legal preparationthe Operative Permit Figure 16-2

It is the surgeons responsibility to explain the surgical procedure, alternatives, risks, and benefits. Purpose is to ensure the patient is not undergoing a procedure without informed consent. Helps protect from liability. Adults must be oriented and not under sedation in order to sign. May take a telephone consent. Consent is witnessed - that is a witness to the signature. Related legal and ethical implications. o Distinguish between paper form and Informed Consent itself. o What to do if theyre not A&O x 3? How is mental competence determined? o Who can sign for a patient (on their behalf)? o When can surgery be performed in the absence of a signed consent? o What about children and emancipated minors? A related ethical issue is DNR status in OR. JCAHO & professional societies (ACS, AANA, ASA) mandate that we take a different approach than "No DNRs in my OR". Another related issue is living wills and advance directives.

INTRAOPERATIVE PHASE Introduction

Transfer to surgery (preop hold or direct to OR room). Floor RN checks chart and makes certain the patient is correctly identified ("What is your name?"). Will be transferred to the OR on a gurney. Family is given instructions. In holding area, final surgical preparations are made. Preop Hold RN repeats checks, abdominal prep. prn, IV. The players & their roles in surgery

Surgeon 1:1 MD or DO Anesthesiologist 1:1 only if acute. 1:2 to 1:4 the usual, serves as resource and supervises care in several rooms. MD or DO Nurse anesthetist CRNA = Certified Registered Nurse Anesthetist 1:1. Directly provides anesthesia care. Trained to function

independently or as team member with anesthesiologist. Masters prepared advanced-practice nurse. Circulating nurse 1:1 almost always RN. Manages environment, gopher, protect pt. Scrub nurse 1:1 RN, LPN, SA, Tech may perform this function. In sterile field, hands tools to surgeon All wear scrub suit to decrease the number of bacteria Anesthesia

Not just drugs- a "process". Mottos: "Watchful Care of the Sleeper" (AANA), "Vigilance" ASA. Agents are continually adjusted to match surgical stimulation and depth "Anesthesia is the half-asleep, watching the half awake, being half-murdered by the half-witted" "A good anesthetic is when the patient is more asleep than you are" Types of anesthesia

Conscious sedation

AKA "local/sed" or "twilight" Patient is conscious with some alteration of mood Airway protective reflexes remain intact (gag, cough) Often combined with local (topical, infiltration, or nerve block) or regional anesthesia.

Regional Anesthesia

Anesthesia to a body region (as opposed to blocking a single nerve). Accomplished by injecting local anesthetics near a nerve Types include: spinal, epidural, axillary block, retrobulbar etc These patients are conscious and need emotional support; they generally receive sedation They need help to maintain position Check for urinary retention after spinal Epidural "You go from chewin your nails, to doin your nails"

General anesthesia

Induced by an IV barbiturate and maintained with inhalation agents. Emergence an active process Anesthesia machine is used to dispense anesthesia and oxygen. Gases will be delivered through a gas mask or ET tube (inserted after asleep). Components: o Hypnosis (implying amnesia & unconsciousness) o Reflex supression o Analgesia o Skeletal muscle relaxation Wound Closure

Contaminated wounds are left open to heal. Otherwise closed in layers. Sutures: absorbable or nonabsorbable - require removal Sterile adhesive strips Retention sutures (provides a secondary suture which relieves undue strain on the suture line. Suture is passed through a small tube or over a plastic bridge that is placed on the skin. Staples: reduces edema and inflammation because manipulation and handling has been reduced.