Intra-Op

Begins when the pt is received in the OR and ends with admission to post anesthesia recovery room (PARR).

• Surgeon - performs operation, talks with patient
• Anestheiologist - can be MD or nurse, starts IV, central line
• Perioperative staff - RN, scrub tech, support staff, instrument personnel

Does all checks & balances

• Responsible to stay with pt
• Gets equipment
• Sponge count
• NCP while pt is in OR
• Safety & security
• Charting
• Monitors traffic
• Assess urine & blood loss
• Must be RN

• Can be RN or surg tech
• Assist with draping
• Hands instruments to MD

Educated for a particular type of surgery

High power beam of light that cuts thru tissue - intense heat. Must wear eye protectors.

• Layout of suite
• Electrical safety
• Health of team
• Attire/scub
• Surgical awareness

• Hand washing - surgical scrub - wash for 2 minutes for everyone who goes in
• Droplet contamination - sneeze in sleeve
• Avoid spilling
• Open packages correctly - look to see where to peel
• Sterile items
• Clothing - scrubs, shoes kept in OR if working there

• Team meets with patient
• Anesthesiologist makes an assessment
• RN makes assessment & documents the intraoperative NCP

• General - reversible state - pt loses consciousness as a result of inhibition of neural impulses in several areas of the CNS
• Analgesia - pain relief
• Amnesia - memory loss of surgery

Analgesia & sedation, relaxation

Begins with induction & ends with loss of consciousness. Pt feels drowsy & dizzy. Hearing is exaggerated.

Nursing interventions - close OR door, dim lights, control traffic, position pt securely with safety belts,

Rationales - avoids external stimuli & promotes relaxation

Excitement, delirium

Begins with loss of consciousness & ends with relaxation & loss of eyelid reflux. May have irregular breathing, increased muscle tone & involuntary movements. Laryngospasm or vomiting may occur.

Nursing Interventions - Stay with pt & protect. Avoid auditory & physical stimuli.

Rationales - staying with pt is emotionally supportive & safety measures help to prevent injury

Operative anesthesia, surgical anesthesia

Begins with generalized muscle relaxation & ends with loss of reflexes & depression of vital functions. Jaw is relaxed & there is quit, regular breathing. Pt cannot hear. Sensations are lost.

Nursing Interventions - assist anesthesiologist with intubation. Place into operative position. Prep the operative site as directed.

Rationales - providing assistance helps promoste smooth intubation & prevent injury. Performing procedures asap promotes time management to minimize total anesthesi time for pt.

DANGER

Begins with depression of vital functions & ends with respiratory failure, cardiac arrest, & possible death. Pupils are fixed & dilated. Respiratory muscles are paralyzed; apnea occurs.

Nursing Interventions - prepares for & assists in treatment of cardiac/pulmonary arrest. Document occurrence.

• Inhalation
• Gaseous agents - nitrous oxide
• Endotracheal tube
• Intravenous - barbiturates
• Balanced - combination inhaled/intravenous
• Adjuncts - opioids/neuromusc. blocking agents

• Sore throat
• Overdose
• Unrecognized hypoventilation
• Complications of intubation - knock out tooth, vocal cords injury...
• Malignant hyperthermia

• Inherited disorder resulting in chemical reaction causing an increased metabolic rate
• Deficit in cell membrane - increased circulating calcium level
• S/S - muscles get rigid, increased HR, arrythmias, coke-colored urine related to muscle contraction, skin-mottled, increased temp (111 F)
• Death, renal failure
• TX - dantrolene sodium (Dantrium), cooling measures, fluids

Local/Topical - agents applied directly to skin

Local infiltration - injection of an agent directly into tissue around an incision, wound, or lesion. Used for suturing.

May be used when general anesthesia cannot be used because of a disease, pt has had reaction to general anesthesia, pt's choice, or pain management is enhanced by regional anesthesia -- still have gag reflex.

Occurs with a series of injections around the operative field. Used for chest procedures, hernia repairs, dental surgery & some plastic surgeries.

Occurs with injection of local anesthetic agent into or around a nerve or group of nerves. Used for example after rotator cuff repair.

AKA intrathecal block. Occurs by injecting an anesthetic agent into cerebrospinal fluid in subarachnoid space. It is used for lower abdominal & pelveic surgery.

Injected into epidural space & spinal cord areas are never entered. Use for vaginal, hip & lower extremity surgeries. Two advantages are decreased cardiac & pulmonary complications which are especially important for older pt & use of epidural catheter for pain control after surgery.

• Incorrect placement or delivery technique
• Nurse assesses for CNS stimulation followed by CNS & cardiac depression which are signs of a system toxic reaction.
• Nurse observes for blurred vision, H/A, incoherent speech, metallic taste, N/V, siezures, & an increase in vital signs.
• If untreated, death may occur.

Interventions - establish an airway, giving oxygen, notify surgeon

Administration of sedative, hypnotic, & opiod meds to produce a condition in which the pt has a depressed level of consciousness but retains ability to independently maintain a patent airway & respond appropriately to verbal commands & physical stimulation

Versed (midazolam), Valium

• Name
• Chart
• Pre-op checklist
• Informed consent
• Allergies
• Labs
• Hx/physical
• Autologous blood transfusion

• R/F infection R/T break in skin integrity
• R/F disuse syndrome R/T immobilization
• Ineffective thermoregulation R/T medications
• R/F injury

• Staff health
• Pause
• Traffic
• Draping
• Grounding
• Positioning - pad under bony prominances, maintain good alignment
• Interventions - skin prep night before, wound closure (staples, absorbable, non), documenting
• To PARR - anesthesiologist & circulating nurse accompany pt