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INTRAOPERATIVE NURSING

VN 122
MODULES A/B

SURGICAL TEAM
PATIENT
SURGEON
ANESTHESIOLOGIST OR ANESTHETIST
CIRCULATING NURSE
SCRUB NURSE
SCRUB TECHS

CIRCULATING NURSE ROLE


1. COORDINATES/MONITORS SURGICAL TEAM
2. CHECKS/ENSURES CONDITION OF O.R., EQUIPMENT
3. VERIFIES CONSENT
MONITORS ASEPTIC TECHNIQUE
DOCUMENTATION

SCRUB NURSE ROLE


1. SETS UP STERILE TABLES
PREPARES SUTURES, LIGATURES, EQUIPMENT
ANTICIPATES ITEMS/EQUIP NEEDED
COUNTS NEEDLES, SPONGES, INSTRUMENTS BEFORE CLOSURE
SPECIMEN LABELING/SENDING

ADVANCED PRACTICE ROLES


1. NURSE ANESTHETIST: INTERVIEWS PT, CHOOSES AND ADMINISTERS
ANESTHESIA, MONITORS PT, INTUBATES PRN
RN FIRST ASSISTANT: UTILIZED AS ASST SURGEON WOULD BE

SURGICAL AREA ZONES


1. UNRESTRICTED: STREET CLOTHES
2. SEMIRESTRICTED: SCRUBS, SHOE COVERS, CAP
RESTRICTED: SCRUBS, SHOE COVERS, CAPS, MASKS, OTHER PROTECTIVE
GEAR AS NEEDED

SURGICAL ASEPSIS
ALL STERILE EQUIPMENT
ALL STAFF SCRUB, PROTECTIVE CLOTHING
ONCE SCRUBBED/GOWNED-TOUCH ONLY STERILE FIELDS/OBJECTS
PT COVERED IN STERILE DRAPES
O.R. VENTILATION MORE OFTEN
LIMITED STAFF
METICULOUS HOUSEKEEPING
PATIENT RISKS FROM SURGERY/ANESTHESIA
CARDIAC DYSRHYTHMIA
CIRCULATORY COLLAPSE
CNS AGITATION, SEIZURES, RESP ARREST
OVER/UNDERSEDATION
AGITATION/DISORIENTATION
HYPOXEMIA/HYPERCARBIA
LARYNGEAL TRAUMA, ORAL TRAUMA
HYPOTHERMIA
HYPOTENSION
INFECTION
THROMBOSIS
MALIGNANT HYPERTHERMIA
NERVE DAMAGE, SKIN BREAKDOWN
ELECTRICAL OR LASER BURNS
DRUG TOXICITY, FAULTY EQUIPMENT, HUMAN ERROR

STAFF RISKS IN SURGERY


1. EXPOSURE TO BLOOD/BODY FLUIDS-USE PPE
LASER RISKS: WEAR PROTECTIVE GOGGLES, PROTECTION FROM LASER
SMOKE VARIES
3. LATEX ALLERGY
ORTHO INJURIES

ANESTHESIA CLASSES
1. THOSE THAT SUSPEND SENSATION IN THE WHOLE BODY: GENERAL,
CONSCIOUS SEDATION
2. THOSE THAT SUSPEND SESATION IN PARTS OF THE BODY: LOCAL,
REGIONAL, EPIDURAL, SPINAL

SEDATION LEVELS
1. MINIMAL SEDATION
MODERATE SEDATION (CONSCIOUS SEDATION)
DEEP SEDATION
ANESTHESIA

MODERATE SEDATION
1. IV ANESTHESIA
USED ALONE OR WITH LOCAL, REGIONAL, SPINAL ANESTHESIA
DEPRESSED LOC, PATENT AIRWAY, ABLE TO RESPOND TO PHYSICAL OR
VERBAL STIMULATION
PROVIDES AMNESIA

MODERATE SEDATION NURSING RESPONSIBILITIES


1. MONITOR FOR DYSRHYTHMIAS, RESPIRATORY, CNS DEPRESSION
2. ADMINISTER O2
RESUSCITATION PRN
NEVER LEAVE PT ALONE
PULSE OXIMETRY, FREQUENT VS, CONTINUOUS ECG
EVALUATE SEDATION LEVEL BY ABILITY TO MAINTAIN PATENT AIRWAY
AND RESPOND TO COMMANDS

GENERAL ANESTHESIA
1. IV OR INHALATION
ADMINISTERED WITH O2
3. MOST COMMON: NITROUS OXIDE
MASK OR ENDOTRACHEAL TUBE
LARGER AMOUNTS DURING INDUCTION, THEN DECREASES

STAGES OF ANESTHESIA
1. I: BEGINNING ANESTHESIA
2. II: EXCITEMENT
III: SURGICAL ANESTHESIA
IV: MEDULLARY DEPRESSION
NORMALLY NO SHARP SEPARATION OF STAGES, AND NO STAGE IV.
MAY NOT HAVE ALL STAGES IF OPIOIDS OR NEUROMUSC. BLOCKERS
GIVEN

IV ANESTHESIA
1. BARBITURATES, BENZODIAZEPINES, NONBARBITURATE HYPNOTICS,
DISSOCIATIVE AGENTS, OPIOIDS
USED FOR INDUCTION OR MAINTENANCE OF ANESTHESIA
USED ALONE OR WITH INHALATION ANESTHESIA
USED FOR CONSCIOUS SEDATION

BENEFITS OF IV ANESTHESIA
1. PLEASANT ONSET
DURATION OF ACTION BRIEF
EASY TO ADMINISTER, LITTLE EQUIPMENT NEEDED
DECREASED POSTOP N/V

COMMON INHALATION ANESTHESIA AGENTS


NITROUS OXIDE
HALOTHANE (FLUOTHANE)
METHOXYFLURANE (PENTHRANE)
ENFLURANE (ETHRANE)
ISOFLURANE (FORANE)
SEVOFLURANE (ULTRANE)
DESFLURANE (SUPRANE)

COMMON IV ANESTHESIA AGENTS


1. TRANQUILIZERS/SEDATIVE HYNOTICS
MIDAZOLAM (VERSED)
DIAZEPAM (VALIUM)
DROPERIDOL (INAPSINE)
LORAZEPAM (ATIVAN)

IV ANESTHESIA AGENTS
1. OPIOIDS
2. MORPHINE
MEPERIDINE HYDROCHLORIDE (DEMEROL): IV,SC, IM

IV ANESTHESIA AGENTS
1. NEUROLEPTANALGISICS: COMBINATION OF SHORT ACTING OPIOID
AND A BUTYROPHENONE
FENTANYL (SUBLIMAZE) IV OR TD AND DROPERIDOL

IV ANESTHESIA AGENTS
DISSOCIATIVE AGENT: KETAMINE, IM, IV. APPEARS AWAKE BUT
DISSOCIATED. HTN, HALLUCINATIONS, DEPRESSED RESP
BARBITURATE: PENTOTHAL: IV, RECTAL. RAPID INDUCTION, RESP
DEPRESSION COMMON
NONBARBITURATE HYPNOTICS: DIPRIVAN (PROPOFOL), IV. MYOCARDIAL
DEPRESSION RISK, HYPOTENSION

NEUROMUSCULAR BLOCKERS
1. NONDEPOLARIZING: TUBARINE-RAPID ACTING AND EXCRETION.
DON’T GIVE IF ALLERGY, ASTHMA
2. DEPOLARIZING: SUCCINYLCHOLINE (ANECTINE, SUCOSTRIN)-RAPID
ONSET/SHORT DURATION. TXS STATUS ASTHMATICUS & TOXIC
REACTIONS TO LOCAL ANESTHETIC

REGIONAL ANESTHESIA
INJECTED AROUND NERVES THAT SUPPLY AREA TO BE CUT
BLOCKS MOTOR NERVES MOST READILY
3. NOT RECOVERED UNTIL MOTOR, SENSORY, AND AUTONOMIC
SYSTEMS ARE NO LONGER AFFECTED

SPINAL ANESTHESIA
1. CONDUCTION NERVE BLOCK PRODUCING ANESTHESIA OF LOWER
EXTREMITIES, PERINEUM, LOWER ABDOMEN
LUMBAR PUNCTURE USU BETWEEN L4/L5-PT IN KNEE/CHEST POSITION,
AFTER INJECTION, ON BACK
NOVOCAINE, PONTOCAINE, XYLOCAINE, MARCAINE

RISKS WITH SPINAL


HIGH ANESTHESIA-TEMPORARY RESPIRATORY PARALYSIS-NEED
MECHANICAL VENTILATION TILL WEARS OFF
N/V
PAIN
POSTOP HEADACHE: KEEP PATIENT FLAT, QUIET, AND HYDRATED TO
DECREASE RISK
HYPOTENSION
RARE: MENINGITIS, PARALYSIS

BENEFITS OF SPINAL
EASILY ADMINISTERED
2. INEXPENSIVE
3. MINIMUM EQUIPMENT
4. RAPID ONSET
5. MUSCULAR RELAXATION

EPIDURALS
1. LOCAL ANESTHESIA INTO SPACE SURROUNDING DURA MATER
2. BLOCKS SENSORY, MOTOR, AUTONOMIC FUNCTION
3. DOSE HIGHER THAN WITH SPINAL
4. BENEFIT: NO SPINAL HEADACHE
5. RISKS: SIMILAR TO SPINAL

LOCAL ANESTHESIA
INJECTION INTO TISSUES AT INCISION SITE
SIMPLE, ECONOMICAL, NONEXPLOSIVE
SHORT ACTING, NO GEN’L ANESTHESIA
GOOD FOR SHORT/SUPERFICIAL SURGERY

COMMON SURGICAL POSITIONS


1. DORSAL RECUMBENT-MOST COMMON
2. TRENDELENBURG
3. LITHOTOMY
4. SIMS OR LATERAL

SAFETY IN POSITIONING
1. COMFORTABLE AS POSSIBLE
2. OPERATIVE AREA EXPOSED
3. VASCULAR SUPPLY UNOBSTRUCTED
4. NO UNDUE PRESSURE ON A PART
NO INTERFERENCE WITH RESPIRATION
PROTECT NERVES FOR PRESSURE
GENTLE RESTRAINT PRN
SPECIAL CARE WITH ELDERLY, FRAIL, OBESE

INTRAOPERATIVE COMPLICATIONS
NAUSEA/VOMITING
ANAPHYLAXIS
HYPOXIA/RESPIRATORY DEPRESSION
HYPOTHERMIA
MALIGNANT HYPERTHERMIA

MALIGNANT HYPERTHERMIA (MH)


POTENTIALLY FATAL, GENETIC
SUCCINYLCHOLINE AND HALOTHANE REACTION, EARLY IN INDUCTION
BUT UP TO 24 HOURS POSTOP
EARLY SIGNS: TACHYCARDIA, VENTRICULAR DYSRHYTHMIAS,
HYPOTENSION, TACHYPNEA, HYPERCARBIA, MUSCLE RIGIDITY,
TETANUS-LIKE MOVEMENTS, METABOLIC/RESP ACIDOSIS, DECREASED
CARDIAC OUTPUT, OLIGURIA, CARDIAC ARREST

PREVENTION OF MH
EARLY SCREENING/IDENTIFICATION
ASK RE: FAMILY/PERSONAL HX OF THIS OR SUDDEN HIGH FEVER ASSOC WITH
A SURGICAL PROCEDURE
BULKY STRONG MUSCLES, STRESS
CONTINUOUS EVALUATION OF VITAL SIGNS

TREATMENT OF MH
DC TRIGGERING AGENT
DC SURGERY
HYPERVENTILATION W/100% O2
IV DANTROLENE SODIUM
IV COOL SALINE
TOPICAL COOLING BLANKET
GASTRIC OR PERINEAL LAVAGE
ICE BAGS IN AXILLAE AND GROIN
POSSIBLY CARDIOPULMONARY BYPASS

REDUCING ANXIETY IN OPERATIVE PATIENT


TALK TO PATIENT, INTRODUCTIONS
ANSWER QUESTIONS CLEARLY
TELL PATIENT WHAT TO EXPECT
PILLOWS/BLANKETS PRN
STAY WITH PATIENT

SAFETY IN SURGERY
ENSURE PROPER INFORMATION, DOCUMENTATION
SURGICAL ASEPSIS
EQUIPMENT WORKING PROPERLY
O.R. AND EQUIPMENT AVAILABLE
SAFETY STRAPS, PROPER GROUNDING, STAY WITH PATIENT
SPONGE/INSTRUMENT COUNT
POSITIONING
PHYSICIAN DECIDES
NURSE ASSISTS WITH POSITIONING, ENSURE PROPER PADDING, NO PRESSURE
ON NERVES, CIRCULATION
CHECK PERIPHERAL PULSES

MONITORING FOR COMPLICATIONS


HYPOTHERMIA
HYPOTENSION
RESPIRATORY DEPRESSION
MALIGNANT HYPERTHERMIA
HYPOVOLEMIA