Three phases of perioperative period – Flashcards

- Immediately prior to the procedure, the patient changes into a hospital gown that is left untied and open in the back. -The patient with long hair may braid it, remove hairpins, and cover the head completely with a disposable paper cap. - The mouth is inspected, and dentures or plates are removed. If left in the mouth, these items could easily fall to the back of the throat during induction of anesthesia and cause respiratory obstruction. - Jewelry is not worn to the OR; wedding rings and jewelry or body piercings should be removed to prevent injury. If a patient objects to removing a ring, some institutions allow the ring to be securely fastened to the finger with tape. All articles of value, including assistive devices, dentures, glasses, and prosthetic devices, are given to family members or are labeled clearly with the patient's name and stored in a safe and secure place according to the institution's policy.

Begins with decision to perform surgery ends when patient is placed on operating table.

Begins when patient is transferred onto operating table and ends when patient is admitted to the post anesthesia care unit PACU.

Begins with admission to PACU and ends with last follow up evaluation with the surgeon.

Informed consent is the patient's autonomous decision about whether to undergo a surgical procedure. - Voluntary and written informed consent from the pt is necessary before non emergent surgery can be performed to protect the pt from unsanctioned surgery and protect the surgeon from claims of unauthorized operation or battery. - Consent is a legal mandate but also helps the pt prepare and understand the surgery being performed. -** The nurse may ask the pt to sign the consent form and witness the signature , however it is the surgeons responsibility to provide a clear and simple explanation of what the surgery will entail prior to the pt giving consent. - Pt signs consent of legal of age otherwise obtained from a surrogate or legal guardian. - In an emergency may be necessary for surgeon to operate without consent, effort must be made to contact family through telephone or other electronic mean to obtain consent. - no pt should should be urged or coerced to give consent - refusing to undergo a surgical procedure is a person's legal right and privilege. - consent form must be signed before psychoactive premedication this can affect judgement making decisions. ** signed consent form is placed in OR in a prominent place on the pt medical records and accompanies the patient to the OR.

Valid consent must be freely given , without coercion. Patient must be at least 18 year of age unless emancipated minor . Physician must obtain consent and staff member witness signature.

Individual who is not autonomous and cannot give or with hold consent. Example: individuals who are cognitively impaired, mentally ill, neurologically incapacitated.

Informed Consent should be in writing .It should contain the following: - Explanation of procedure and risks - Description of benefits and alternatives - An offer to answer questions about the procedure - Instructions that the patient may withdraw consent - A statement informing the pt of the protocol differs from customary procedure

If the pt is non- English speaking, it is necessary to provide consent in a language that is understandable to client. A trained medical interperter may be consulted. Also for hearing and vision impairments.

- 1/3 of pt are 65 years older - older adults are higher risk for complications from anesthesia anesthesia and surgery compared to younger adult patients due to several factors. -There is a progressive loss of skeletal muscle mass in conjunction with an increase in adipose tissue . Comorbidities, advanced systemic disease, and increased susceptibility to illness, even in the healthiest geriatric patient, can complicate perioperative management. - Age alone confers enough surgical risk that it is a clinical predictor of cardiovascular complications

Biologic variations of particular importance include age-related cardiovascular and pulmonary changes. The aging heart and blood vessels have decreased ability to respond to stress. Reduced cardiac output and limited cardiac reserve make the older adult vulnerable to changes in circulating volume and blood oxygen levels (Becker, 2009). Excessive or rapid administration of intravenous (IV) solutions can cause pulmonary edema. A sudden or prolonged decline in blood pressure may lead to cerebral ischemia, thrombosis, embolism, infarction, and anoxia. Reduced gas exchange can result in cerebral hypoxia. Lower doses of anesthetic agents are required in older adults due to decreased tissue elasticity (lung and cardiovascular systems) and reduced lean tissue mass. Older patients often experience an increase in the duration of clinical effects of medications. With decreased plasma proteins, more of the anesthetic agent remains body tissues of the older adult are made up predominantly of water, and those tissues with a rich blood supply, such as skeletal muscle, liver, and kidneys, shrink as the body ages. Reduced liver size decreases the rate at which the liver can inactivate many anesthetic agents, and decreased kidney function slows the elimination of waste products and anesthetic agents. Other factors that affect the older surgical patient in the intraoperative period include the following: • Impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms increase susceptibility to hypothermia. • Bone loss (25% in women, 12% in men) necessitates careful manipulation and positioning during surgery. • Reduced ability to adjust rapidly to emotional and physical stress influences surgical outcomes and requires meticulous observation of vital functions. All of these factors lead to a higher likelihood of perioperative mortality and morbidity in older adult patients.

- Special attention is given to keeping the patient warm, because older patients are more susceptible to hypothermia. - The patient's position is changed frequently to stimulate respirations as well as promote circulation and comfort. - careful monitoring, it is possible to detect cardiopulmonary deficits before signs and symptoms are apparent. -Changes associated with the aging process, the prevalence of chronic diseases, alteration in fluid and nutrition status, and the increased use of medications result in the need for postoperative vigilance and slower recovery from anesthesia due to the prolonged time to eliminate sedatives and anesthetic agents - Postoperative confusion and delirium may occur in up to half of all older patients. Acute confusion may be caused by pain, altered pharmacokinetics of analgesic agents, hypotension, fever, hypoglycemia, fluid loss, fecal impaction, urinary retention, or anemia - Providing adequate hydration, reorienting to the environment, and reassessing the doses of sedative, anesthetic, and analgesic agents may reduce the risk of confusion. Hypoxia can present as confusion and restlessness, as can blood loss and electrolyte imbalances.

Surgical Tesam - patient - circulating nurse - scrub role - Surgeon - RN assistant - Anesthesiologist, anesthetist

- Either a nurse or surgical technician - Performing surgical hand wash scrub really sterile - setting up the sterile table - preparing sutures, ligatures, and special equipment - assisting the surgeon and the surgical assistants during the procedure by anticipating instruments and supplies that will be required (sponges, drains, other equip.) - As surgical inscion closed they count along with the circulating nurse all the instruments and make sure they are all accounted fo and none left inside the pt. - tissue specimens obtained during surgery are labeled by the person in scrub role but sent to the lab by the circulating nurse.

- Has to be an RN is not sterile. coordinates the care of the pt in the OR. - verifying consent - ensures cleanliness, proper temperature, humidity, appropriate lighting, safe function of equipment, and the availability of supplies and materials. - monitors aseptic practices to avoid breaks in technique , implementing fire safety precautions . - documents specific activities throughout the operation to ensure pt safety and well being. - responsible for ensuring that the second check verification of the surgical procedure and site takes place and is documented.

pt enters the OR, he or she may feel either relaxed and prepared or frightful and stressed. - Fears can increase the amount of anesthetic medication needed, the level of postoperative pain , and overall recovery time - The OR nurse is the patients advocate while surgery proceeds

Performs the surgical procedure, heads the surgical team and is a liscensed physician.

- responsibilities include handling tissue, providing exposure at the operative field, suturing, maintaining homeostasis. - role requires a thorough understanding of anatomy , physiology, tissue handling, and principles of surgical asepsis. - must be aware of objectives of the surgery - must be able to handle any emergency situation in the OR.

Anesthesiology is a physician specifically trained n the art and science of anesthesiology. Anesthetist is also a qualified and specifically trained health care professional who administers anesthetic medications. RN plus masters and further training. - The anesthesiologist and anesthetist assess the pt before surgery, selects the anesthesia, administers it, intubates the pt if necessary, manages any technical problem related to the administration of the anesthetic agent - supervises the pt's condition throughout the surgical procedure

surgical asepsis: absence of microorganisms in the surgical environment to reduce the risk of infection -Surgical asepsis prevents the contamination of surgical wounds. The patient's natural skin flora or a previously existing infection may cause postoperative wound infection. Rigorous adherence to the principles of surgical asepsis by OR personnel is basic to preventing surgical site infections. - All surgical supplies, instruments, needles, sutures, dressings, gloves, covers, and solutions that may come in contact with the surgical wound or exposed tissues must be sterilized before use . -Surgical team members wear long-sleeved, sterile gowns and gloves. Head and hair are covered with a cap, and a mask is worn over the nose and mouth to minimize the possibility that bacteria from the upper respiratory tract will enter the wound. During surgery, only personnel who have scrubbed, gloved, and gowned touch sterilized objects. Nonscrubbed personnel refrain from touching or contaminating anything sterile. -An area of the patient's skin larger than that requiring exposure during the surgery is meticulously cleansed, and an antiseptic solution is applied . If hair needs to be removed, this is done immediately before the procedure with clippers (not shaved) to minimize the risk of infection . The remainder of the patient's body is covered with sterile drapes.

-All equipment that comes into direct contact with the patient must be sterile. Sterilized linens, drapes, and solutions are used. Instruments are cleaned and sterilized in a unit near the OR. Individually wrapped sterile items are used when additional individual items are needed. - A room temperature of 20°C to 24°C (68°F to 73°F), humidity between 30% and 60%, and positive pressure relative to adjacent areas are maintained.

• All materials in contact with the surgical wound or used within the sterile field must be sterile. Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile; contact with unsterile objects at any point renders a sterile area contaminated. • Gowns of the surgical team are considered sterile in front from the chest to the level of the sterile field. The sleeves are also considered sterile from 2 inches above the elbow to the stockinette cuff. • Sterile drapes are used to create a sterile field (Fig. 18-2). Only the top surface of a draped table is considered sterile. During draping of a table or patient, the sterile drape is held well above the surface to be covered and is positioned from front to back. • Items are dispensed to a sterile field by methods that preserve the sterility of the items and the integrity of the sterile field. After a sterile package is opened, the edges are considered unsterile. Sterile supplies, including solutions, are delivered to a sterile field or handed to a scrubbed person in such a way that the sterility of the object or fluid remains intact. • The movements of the surgical team are from sterile to sterile areas and from unsterile to unsterile areas. Scrubbed people and sterile items contact only sterile areas; circulating nurses and unsterile items contact only unsterile areas. • Movement around a sterile field must not cause contamination of the field. Sterile areas must be kept in view during movement around the area. At least a 1-foot distance from the sterile field must be maintained to prevent inadvertent contamination. • Whenever a sterile barrier is breached, the area must be considered contaminated. A tear or puncture of the drape permitting access to an unsterile surface underneath renders the area unsterile. Such a drape must be replaced. • Every sterile field is constantly monitored and maintained. Items of doubtful sterility are considered unsterile. Sterile fields are prepared as close as possible to the time of use. • The routine administration of hyperoxia (high levels of oxygen) is not recommended to reduce surgical site infections.

- Anesthesia is a state of narcosis (severe central nervous system depression produced by pharmacologic agents), analgesia, relaxation, and reflex loss. - The main types of anesthesia are general anesthesia (inhalation, IV), regional anesthesia (epidural, spinal, and local conduction blocks), moderate sedation (monitored anesthesia care [MAC]), and local anesthesia.

general anesthesia: state of narcosis, analgesia, relaxation, and loss of reflexes produced by pharmacologic agents - Patients under general anesthesia are not arousable, not even to painful stimuli. They lose the ability to maintain ventilatory function and require assistance in maintaining a patent airway. Cardiovascular function may be impaired as well. - General anesthesia consists of four stages, each associated with specific clinical manifestations . - Anesthetic agents used in general anesthesia are inhaled or administered IV

Stage 1 : Beginning anesthesia - As pt breathes in the anesthetic mixture, warmth, dizzziness, and a feeling of detachment may be experienced. Pt is having a ringing, buzzing, roaring in the ear and although conscious may sense inability to move extremities easily. - noises are exaggerated, for this reason unnecessary movements or noises are avoided when anesthesia begins. Satge 2: Excitement - struggling, shouting, talking, singing, laughing, or crying, is often avoided if IV anesthetic agents are removed smoothly and quickly. - the pupils dilate but contract if exposed to light , the pulse rate is rapid, and respiration's may be irregular. - anesthesiologisst must be assisted in case of uncontrolled movements of the pt or to apply pressure in case of vomiting to avoid aspirating. Manipulation increases circulation to operative site increasing potential for bleed. Stage 3: Surgical Anesthesia -Surgical anesthesia is reached by administration of anesthetic vapor or gas and supported by IV agents as necessary. -The patient is unconscious and lies quietly on the table. The pupils are small but contract when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. - With proper administration of the anesthetic agent, this stage may be maintained for hours in one of several planes, ranging from light (1) to deep (4), depending on the depth of anesthesia needed. Stage 4: Medullary depression - This stage is reached if too much anesthesia has been administered. -Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer contract when exposed to light. - Cyanosis develops and, without prompt intervention, death rapidly follows. If this stage develops, the anesthetic agent is discontinued immediately and respiratory and circulatory support is initiated to prevent death. Stimulants, although rarely used, may be administered; narcotic antagonists can be used if the overdose is due to opioids.

-When opioid agents (narcotics) and neuromuscular blockers (relaxants) are administered, several of the stages are absent. During smooth administration of an anesthetic agent, there is no sharp division between stages I, II, and III, and there is no stage IV. The patient passes gradually from one stage to another, and it is through close observation of the signs exhibited by the patient that an anesthesiologist or anesthetist controls the situation.

- Inhaled anesthetic agents include volatile liquid agents and gases. Volatile liquid anesthetic agents produce anesthesia when their vapors are inhaled.All are administered in combination with oxygen and usually nitrous oxide as well. -

-General anesthesia can also be produced by the IV administration of various substances, such as barbiturates, benzodiazepines, nonbarbiturate hypnotics, dissociative agents, and opioid agents -An advantage of IV anesthesia is that the onset of anesthesia is pleasant; there is none of the buzzing, roaring, or dizziness known to follow administration of an inhalation anesthetic agent. The duration of action is brief, and the patient awakens with little nausea or vomiting. The IV anesthetic agents are nonexplosive, require little equipment, and are easy to administer. The low incidence of postoperative nausea and vomiting makes the method useful in eye surgery, because in this setting vomiting would increase intraocular pressure and endanger vision in the operated eye. IV anesthesia is useful for short procedures but is used less often for the longer procedures of abdominal surgery. It is not indicated for children who have small veins or for those who require intubation because of their susceptibility to respiratory obstruction. The combination of IV and inhaled anesthetic agents produce an effective and smooth experience for the patient, with a controlled emergence following surgery.

regional anesthesia: an anesthetic agent is injected around nerves so that the area supplied by these nerves is anesthetized -The patient receiving regional anesthesia is awake and aware of his or her surroundings unless medications are given to produce mild sedation or to relieve anxiety. The health care team must avoid careless conversation, unnecessary noise, and unpleasant odors; these may be noticed by the patient in the OR and may contribute to a negative response to the surgical experience. A quiet environment is therapeutic. The diagnosis must not be stated aloud if the patient is not to know it at this time.

- Epidural anesthesia is achieved by injecting a local anesthetic agent into the epidural space that surrounds the dura mater of the spinal cord ). The administered medication diffuses across the layers of the spinal cord to provide anesthesia and pain relief). In contrast, spinal anesthesia involves injection through the dura mater into the subarachnoid space surrounding the spinal cord. -Epidural doses are much higher because the epidural anesthetic agent does not make direct contact with the spinal cord or nerve roots - An advantage of epidural anesthesia is the absence of headache that can result from spinal anesthesia. A disadvantage is the greater technical challenge of introducing the anesthetic agent into the epidural space rather than the subarachnoid space. If inadvertent puncture of the dura occurs during epidural anesthesia and the anesthetic agent travels toward the head, high spinal anesthesia can result; this can produce severe hypotension and respiratory depression and arrest. Treatment of these complications includes airway support, IV fluids, and the use of vasopressors.

- Spinal anesthesia is an extensive conduction nerve block that is produced when a local anesthetic agent is introduced into the subarachnoid space at the lumbar level, usually between L4 and L5 . - It produces anesthesia of the lower extremities, perineum, and lower abdomen. - For the lumbar puncture procedure, the patient usually lies on the side in a knee-chest position. Sterile technique is used as a spinal puncture is made and the medication is injected through the needle. As soon as the injection has been made, the patient is positioned on his or her back. - A few minutes after induction of a spinal anesthetic agent, anesthesia and paralysis affect the toes and perineum and then gradually the legs and abdomen. If the anesthetic agent reaches the upper thoracic and cervical spinal cord in high concentrations, a temporary partial or complete respiratory paralysis results - Paralysis of the respiratory muscles is managed by mechanical ventilation until the effects of the anesthetic agent on the cranial and thoracic nerves have worn off. - Nausea, vomiting, and pain may occur during surgery when spinal anesthesia is used. As a rule, these reactions result from manipulation of structures within the abdominal cavity. Adequate hydration and the IV administration of appropriate medications may prevent such reactions. -Headache may be an aftereffect of spinal anesthesia. Several factors are related to the incidence of headache: the size of the spinal needle used, the leakage of fluid from the subarachnoid space through the puncture site, and the patient's hydration status - This technique allows greater control of the dosage; however, there is greater potential for postanesthetic headache because of the large-gauge needle used.

- Moderate sedation, previously referred to as conscious sedation, is a form of anesthesia that involves the IV administration of sedatives or analgesic medications to reduce patient anxiety and control pain during diagnostic or therapeutic procedures. - It is being used increasingly for specific short-term surgical procedures in hospitals and ambulatory care center - The goal is to depress a patient's level of consciousness to a moderate level to enable surgical, diagnostic, or therapeutic procedures to be performed while ensuring the patient's comfort during and cooperation with the procedures. With moderate sedation, the patient is able to maintain a patent airway, retain protective airway reflexes, and respond to verbal and physical stimuli. - he patient receiving moderate sedation is never left alone and is closely monitored by a physician or nurse who is knowledgeable and skilled in detecting dysrhythmias, administering oxygen, and performing resuscitation. The continual assessment of the patient's vital signs, level of consciousness, and cardiac and respiratory function is an essential component of moderate sedation. Pulse oximetry, an ECG monitor, and frequent measurement of vital signs are used to monitor the patient.

- Monitored anesthesia care, also referred to as monitored sedation, is moderate sedation administered by an anesthesiologist or anesthetist who must be prepared and qualified to convert to general anesthesia if necessary. - The skills of an anesthesiologist or anesthetist may be necessary to manage the effects of a level of deeper sedation to return the patient to the appropriate level of sedation. - MAC may be used for healthy patients undergoing relatively minor surgical procedures and for some critically ill patients who may be unable to tolerate anesthesia without extensive invasive monitoring and pharmacologic support (Rothrock, 2010).

Local anesthesia is the injection of a solution containing the anesthetic agent into the tissues at the planned incision site. Often it is combined with a local regional block by injecting around the nerves immediately supplying the area. Advantages of local anesthesia are as follows: • It is simple, economical, and nonexplosive. • Equipment needed is minimal. • Postoperative recovery is brief. • Undesirable effects of general anesthesia are avoided. • It is ideal for short and minor surgical procedures. - Local anesthesia is often administered in combination with epinephrine. Epinephrine constricts blood vessels, which prevents rapid absorption of the anesthetic agent and thus prolongs its local action and prevents seizures. - Local anesthesia is the preferred anesthetic method in any surgical procedure. However, contraindications include high preoperative levels of anxiety, because surgery with local anesthesia may increase anxiety. For some surgical procedures, local anesthesia is impractical because of the number of injections and the amount of anesthetic medication that would be required (e.g., breast reconstruction) and might result in toxic doses.

-Goal is for the patient to be as health as possible , address and and asses for risk factors that may contribute to postoperative complications and delay recovery. - health history is obtained - physical examination is performed which vital signs are noted and data base is established for future comparisons. - many factors that that have potential to affect the pt undergoing surgery are considered such as joint and mobility - genetic considerations are taken into account during assessment to prevent complications with anesthesia. - Asking pt about use of prescription and OTC, and herbal drugs provides useful info. - Activity level should be determined , including that involving regular anaerobic exercise . - Known allergies to drugs, food, latex, could avert anaphylactic response. - should be alert to signs of abuse , and findings need to be reported accordingly. - Blood test, X-rays , and other diagnostic testing

During the postoperative period, nursing care focuses on reestablishing the patient's physiologic equilibrium, alleviating pain, preventing complications, and educating the patient about self-care . - Careful assessment and immediate intervention assist the patient in returning to optimal function quickly, safely, and as comfortably as possible. - Ongoing care in the community through home care, clinic visits, office visits, or telephone follow-up facilitates an uncomplicated recovery.

Optimal nutrition is essential factor for promoting healing and resisting infection and other surgical complications. - Assessment of a patient's nutritional status identifies factors that can affect the patient's surgical course, such as obesity, weight loss, malnutrition, deficiencies in specific nutrients, metabolic abnormalities, and the effects of medications on nutrition. - Nutritional needs may be determined by measurement of body mass index and waist circumference . * Any nutritional deficiency should be corrected before surgery to provide adequate protein for tissue repair. - Protein, Arginine (Amino Acids), Carbs, H20, Vit C Vit B Vit A Vit K, magnesium, copper, Zinc.