The Surgical Patient

• žDiagnostic -
• biopsy

• žCurative -
• appendectomy

• žPalliative –
• debulking of tumor

• žPreventive –
• remove a suspicious mole

• žExplorative –
• look around

• žCosmetic –
• repair, reconstruct, enhance

Inpatient

Same Day Admit

23-Hour

• Psychosocial assessment- situational,
• fear of unknown, body image, past experiences, patient’s knowledge, anesthesia
• awareness

• žMedications – prescribed, OTC, herbal, alcohol,
• recreational drugs

žAllergies and sensitivities – latex

žReview of systems - PE and health history

žAnesthesia interview & ASA rating

ž

• Approximately 750,000 per year leading to increased costs and length of hospital
• stay

žRisk factors:

Age

General health

Nutritional Status

Immune status

Weight

Surgery type

Length of surgery

Foley catheter

žUrinalysis

žChest X-ray

žEKG

• žType &
• Cross

žPregnancy

žCBC

žPT, PTT

žAmount of information: need vs. want to know

žTypes of information:

Sensory – lights, room temperature, smells, sounds

Process – sequence of events

Procedural – specifics about the surgery

žFasting guidelines

• žPractical information: (where to
• park, what to

• wear, prep, waiting area for family, time
• estimate)

• žSurgical
• consent – informed consent

• žHistory &
• Physical Exam

• žBlood
• transfusion consent

žLab Work

žX-Ray Reports

• žLanguage
• barriers

• žCultural
• Considerations

žAge Extremes

• ž
• Disability

ž

žShower

• žClean gown,
• underwear?

žJewelry

žNail polish

• žID band,
• Allergy bracelet

žEmpty bladder

žBody piercings

• žDentures,
• hearing aids, contact lenses

• Benzodiazepines
• (Versed, Valium, Ativan)

Decrease anxiety, promote sedation,

induce amnesia

• žNarcotics
• (Morphine, Demerol, Fentanyl)

Pain relief

žGastric pH drugs (Tagamet, Pepcid,


Zantac, Antacids)

• Increase
• gastric pH, decrease gastric volume

• žAntiemetics
• (Reglan, Inapsine)

• Increase gastric emptying, decrease
• nausea &

vomiting

• žAnticholinergics
• (Atropine, Glycopyrrolate,

Scopalimine)

Decrease secretions, prevent bradycardia

žAntibiotics

• Prophylaxis- need to be given one hour
• before sx.

• Surgical Suite – a controlled environment designed
• to minimize infectious organisms

• 1.
• Unrestricted: Point of
• entry

(Holding, Nursing station, Control Desk).

• 2.
• Semirestricted: Transition
• area

(scrubs, hair and beards covered)

• 3.
• Restricted: Surgical
• room

• (masks are
• worn)

• Last stop
• before OR

• žFinal
• assessment

• žReview of data
• (vitals, labs, H&P, consents)

• Cancellation of
• surgery?

• žSite
• verification and marking

• žMinor
• procedures

• 1. IV, Arterial
• lines, blocks

2. Cast removal

• žPreop
• sedation, other medications

• žControlled
• environment

• 1.
• Geographically – Away from common

areas, restricted traffic of personnel

Close to PACU and ICU

• 2.
• Environmentally
• & Bacteriologically– Airflow
• (positive pressure=outflow of air from room to hall), ventilation and filters;

Temperature (68-73F)

Humidity (30-60%)

žSURGEON

žANESTHESIA PROVIDER (Anesthesiologist or


CRNA)

žFIRST ASSISTANT (RNFA, Surg Tech, Surgeon,

PA, ARNP)

žSCRUB (Surg Tech, RN, PA, ARNP, Private

Scrub)

žCIRCULATOR (RN, Unlicensed personnel)

žOTHER (X-ray Tech, Radiologist, Sales Rep)

žSURGEON – Performs surgery, responsibility

žANESTHESIA PROVIDER – Monitors and

• maintains
• homeostasis, provides anesthesia,

• IV
• fluids, medications, airway management

• žASSISTANT – Retraction, tissue and instrument handling, hemostasis,
• suturing, dressings, may do pre and post op visits

• žSCRUB – Set up and maintain sterile
• field,

• hand and
• maintain instruments

OTHER - Varies

žCIRCULATING NURSE – Team Leader

Patient Advocate!

• Assess,
• confirm, monitor, prepare, direct, anticipate, provide, coordinate, count,
• transport, collaborate, teach, position, skin prep, document, protect, specimen
• handling, secretarial duties, other

• žOnly sterile
• items may enter a sterile field

• žIf sterile
• comes in contact with unsterile, it

is contaminated

• žGown is
• sterile only on the front from chest

• to table level;
• sleeves to 2” above elbow

• žMaintain wide
• margin between sterile and

unsterile

• žContaminated
• items must be removed

immediately

ž

• žTable is
• sterile only at tabletop level

• žEdges of a
• sterile package are considered
• contaminated

• žBacteria
• travel on wind currents

• žBacteria
• travel through moist fabrics

• žBacteria live
• on hair, skin and respiratory

• tracts and must be confined by
• appropriate

attire

And finally……….

žTHE FIVE-SECOND RULE DOES NOT APPLY!

• žBrought in by
• anesthesia provider and circulator - watch noise levels

• žMoved over to
• OR table - safety

• žSafety straps
• and monitors applied

• žPre-oxygenation
• – guided imagery

• žInduction of
• anesthesia

• žInsertion of
• lines, foley

žPositioning

• žSurgeon is
• scrubbing

žSkin prep

žDraping

ž“Time Out”

žGeneral Anesthesia – “Balanced Anesthesia”

Loss of sensation & consciousness

Muscle relaxation

Analgesia

Elimination of somatic, autonomic

and endocrine response (coughing,

gagging, vomiting)

žPhases of General Anesthesia -

Induction-most dangerous time

Maintenance

Emergence-most dangerous time

IV AGENTS (Induction)


žBarbiturates – Pentothal, Brevital

Rapid induction, short duration

Cardiac Side effects

• žNonbarbiturate hypnotics – Amidate,
• Propofol

Rapid onset and elimination

Cardiac Side effects

Propofol may also be used for anesthesia maintenance

INHALATION AGENTS (maintenance)

žVolatile liquids – halothane, enflurane,

isoflurane, desflurane, sevoflurane

(muscle relaxation, bronchodilation,

rapid excretion)

žGaseous agents – nitrous oxide (weaker than volatile liquids, may be used in conjunction with volatile liquids)

žKetamine – Dissociative anesthetic (rarely

used due to hallucinations, nightmares,

increased heart rate, B/P, intraocular

and intracranial pressure)

• žOpoids – Sublimaze, Sufenta, Morphine, Demerol, Alfenta, Altiva, Methadone (used
• in all three phases, causes
• respiratory depression)

žBenzodiazepines – Valium, Versed, Ativan

(Induction and maintenance, conscious

• sedation, sedation during regional or
• local)

• žNeuromuscular Blockers – Anectine,
• Norcuron,

Tracrium, Pavulon, Zemuron (paralysis)

• žAntiemetics – Inapsine, Zofran, Reglan,
• Compazine,

Phenergan

• Beer
• Block for arm to restrict blood.. 2 hour sx. Only with tourniquet

• žOperative
• procedure is performed without loss of consciousness

Topical application – gels, creams

Local infiltration – lidocaine, marcaine

into tissues

• Regional injection
• -

Peripheral nerve block – into or around nerve or group of nerves

Bier block – exsanguination then IV

injection provides anesthesia and bloodless field

Spinal block – into CSF

Epidural block – outside the dura

• žAnaphylactic reaction – hypotension,
• tachycardia, bronchospasm, pulmonary
• edema (antibiotics and latex most common
• causes)

žLatex Allergy –

Type IV – contact dermatitis

Type I – anaphylaxis- (Most serious)

Risk Factors – repeated exposure, hx of

asthma & hay fever, food allergies

• žMalignant hyperthermia – rare but
• deadly

Reaction to Anectine, autosomal dominant

• Muscle rigidity, hyperthermia (late
• sign), hypoxemia, lactic acidosis, cardiac alterations,
• cardiac arrest

Treatment: Dantrolene

žAirway

žParalysis

žSafety

• žTransport to
• PACU

žPACU – Postanesthesia care unit

Critical care area

Transitional

Will be discharged to home or

clinical care area

Phase I – general anesthesia

• Phase II – ambulatory
• surgery

• žAnesthesia
• & Circulator report to PACU nurse

ž Priority:

¡Respiratory – ABC’s

• ¡Circulatory – ECG monitoring, B/P,
• temp, skin color and condition

• ¡Neurological – LOC, orientation,
• sensory & motor

• status,
• pupil size & reaction

• ¡Fluid balance – I&O, IV’s,
• irrigation, drains

• ¡Wound assessment – pain, drainage,
• bleeding

¡Emotional support, reassurance

¡Ongoing assessment

• žObstruction –
• Tongue, laryngospasm, secretions,
• laryngeal edema

• žHypoxemia –
• Atelectasis, secretions, decreased respiratory excursion, hypotension, low cardiac output, fluid

• overload, sepsis,
• aspiration, bronchospasm,
• hypoventilation

TREAT THE CAUSE

• žHypotension –
• decreased fluid volume

• žHypertension –
• pain, anxiety, full bladder,

respiratory compromise, hypothermia,

preexisting hypertension

• žCardiac
• dysfunction – MI, tamponade, PE,

arrythmias, preexisting heart disease




TREAT THE CAUSE

• žEmergence
• delirium – hypoxemia, anxiety,

full bladder, pain, preop anxiety

• žDelayed
• awakening – prolonged drug action

• žPain – may
• prolong PACU stay

• žHypothermia –
• Age extremes at risk, increases recovery time

• žNausea &
• Vomiting – lengthens PACU time

ž


TREAT THE CAUSE

žPOSTANESTHESIA

Patient awake

Vitals stable

No excess bleeding

or drainage

No respiratory depression

Oxygen Sat >90%

Report given

• žAMBULATORY
• SURGERY

All PACU criteria met

No IV narcs for 30 min

Minimal N&V

Has voided

Able to ambulate (if

appropriate)

Responsible caretaker

Discharge instructions

• žSame
• assessment as PACU

• žSame
• complications as PACU plus:

Pneumonia

Urinary retention

Thromboembolism

Hemorrhage

Paralytic ileus

Infection

• žTurning,
• coughing, deep breathing

• žIncentive
• spirometer

žEarly mobility

žPain relief

• žAdequate
• fluids

• žMonitor
• I&O

• žAdequate fluid
• intake

• žAssess for
• bladder distention

• žProper
• positioning for voiding

• žNotify
• physician for no voiding within 6 hrs of surgery

• žAdequate fluid
• intake

• žRange of
• motion/ early ambulation

• žAntiembolism
• stockings (fit)

• žAvoid
• pressure, constriction or pooling and

stasis of blood

• žAssess for
• redness, swelling, pain, heat, edema,
• chest pain, hemoptysis, dyspnea