My Nursing Mastery
My Nursing Mastery
Surgical Nursing-IntraOp
***=might show up on the NCLEX Hey, it's Cindi from NCLEX Mastery and today we're going to be talking about intra operative nursing.
Cindi:This is the second part in a three part series about OR nursing and we're going to discuss the Circ nurse role. We will also talk in detail about anesthesia as well as conscious sedation. Questions about surgical nursing will show up on the NCLEX. Consider this question: The nurses educating a client before a schedule lumbar fusion. The nurse explains that after the surgery the client will have to maintain bedrest in which position.
:The correct answer is a flat position. After a lumbar fusion the patient should be placed flat in bed rest and repositioned every two hours using the log rolling method.
Cindi:In this our nursing series we will cover a lot of information, key points that will help you do well on the NCLEX or in your clinical practice. Throughout the podcast when you hear this sound***ding*** it is followed by an essential NCLEX concept important for entry level nursing practice. If you're studying for the NCLEX this may come up on the test.
:So let's begin by talking about what goes on in the operating room and the team members. The circulation nurse is an essential resource for the surgical team. The team consists of the surgeon, surgical assistant, scrub nurse or surgical tech. An anesthesiologist or CRNA. A CRNA is a certified registered nurse anesthetist who works under an anesthesiologist. Let's talk about roles and responsibilities. The anesthesiologist monitors levels of anesthesia, assesses cardiopulmonary function and vital signs and hemo dynamic stability. The surgical assistant who may directly assist the surgeon may hold retractors, suction the wound, cut tissue, suture or dress the wound. The scrub nurse or a surgical tech who is scrubbed in on the other hand takes care of draping and hands supplies to the surgeon.
Cindi:The primary concerns for the circulating nurse or Circ nurse include safety and client advocacy. The focus is on preventing infection and protecting the client from harm while they have reduced consciousness. For example, efforts are made to reduce nosocomial or health care acquired infections. Although the circulation nurse does not scrub in, the nurse is alert for breaches and sterile fields. This is part of protecting patient safety. The nurse ensures that grounding pads are properly applied and correct counts of instruments sponges and sharps are documented. The nurse monitors trends and vital signs and takes steps to maintain thermo regulation. Effective padding and monitoring of injury prone tissue prevents skin breakdown.
:***This is an important safety and quality measure. Some important points. The room temperature should be cool, 68 to 73 degrees Fahrenheit. This is 20 to 30 degrees Celsius. The humidity in the air should be low, 30 to 60 percent. This is for protection from fire. The layout includes three zones: an unrestricted zone, a semi restricted zone, and a restricted sterile zone. The CIRC nurse also pays attention to the hygiene of surgical staff. The shedding of microorganisms and skin debris is the greatest immediately after showering so most staff are instructed to bathe a few hours prior to scrubbing in. Microbial cultures may be obtained periodically from all staff as part of a quality control program. Surgical attire includes scrub attire that is clean, but not sterile. All members must cover their hair including any facial hair. Anyone entering the OR where a sterile field is present must wear a mask. Members that are not scrubbed in wear jackets. This includes the anesthesiologist and the circulating nurse. General guidelines include fingernails that are short and clean.***ARTIFICIAL NAILS ARE NOT PERMITTED. Rings, watches, and other jewelry are removed. Let's go over surgical scrub in. It's important to recognize that surgical scrub does not make skin sterile. It merely reduces organisms. The surgeon, all assistants, and the scrub nurse or tech perform scrub in after donning a mask and before donning gown and gloves. The procedure involves using a disposable scrub brush or sponge with an anti-microbial solution and nail cleaner for about three to five minutes followed by a rinse.***After scrub the hands are held higher than the elbows while walking into the OR and they are assisted into gowns and gloves. Important: the area of the gown that is sterile is the front of the gown from 2 inches below the neck to the waist and from the elbow to the wrist. In the next few minutes we'll discuss anesthesia in detail. Anesthesia comes from the Greek word anaesthetise, meaning negative sensation. The definition of anaesthesia is an artificially induced state of partial or total loss of consciousness.***It is important for all nurses to understand that liver or kidney impairment can greatly increase the effects and risk for toxicity. There are four main types of anaesthesia: inhalation, I.V. or intravenous, balanced anesthesia and regional or local anesthesia. Let's talk about general anesthesia first. This is a reversible state of loss of consciousness. It results from inhibition of neuronal impulses in the central nervous system. When clients are under general anesthesia they cannot feel pain. There is also amnesia or memory loss. There is a loss of muscle tone and reflexes. General anesthesia is indicated for head, neck, upper torso or extensive abdominal surgery and it is also helpful for uncooperative clients. There are four stages of general anesthesia. The first stage is sedation and relaxation. It begins upon induction and results in a loss of consciousness. The hearing for the client may be exaggerated. The priorities for the nurse are safety and to maintain dignity. The second stage is excitement or delirium. This begins with loss of consciousness and ends with regular breathing and a loss of eyelid reflex. Some adverse effects can include laryngeal spasm and vomiting. There may be irregular breathing or increased muscle tone during this stage.***It's important to note that clients may be susceptible to external stimuli. Nurses should avoid stimuli and use suctioning when needed. Stage 3 is called operative anesthesia. This begins with generalized muscle relaxation and ends with loss of reflexes and vital function depression. The jaw becomes relaxed and breathing is quiet and regular. There is a loss of pain sensation nurses may assist with intubation during this stage and prepped a surgical site. Stage 4 anesthesia should be avoided. It begins with depression of vital functions and ends with system failure or even death. Respiratory muscles may become paralyzed and result in apnea. Pupils are fixed and dilated. There are two methods of general anesthesia: inhalation and I.V. injection. Let's talk about inhalation agents for a moment. Inhalation agents offer advantages because they're modifiable. Because intake and elimination of the agent occurs by breathing which can be assisted and controlled. This is done manually through the endotracheal tube. The Circ nurse often assists the anesthesiologist with intubation. Intubation maintains a Pétain airway and provides safe delivery of the agent as well as oxygen. Inhalation agents are gases. Historically this included ether, but currently the most common is nitric oxide. This is a colorless odorless non-irritating gas it's used for short periods of time and reduces concentration required for other agents. It may produce hypoxia, but it has minimal effect on vital signs. Another popular agent is Fluothane. This is metabolized by the liver. It has a sweet smell and children can tolerate it well. Shivering post op is common and there is a risk for dysrhythmia. Isoflurane is another agent, these agents carry a risk for malignant hyperthermia. We will discuss this later in detail. IV injectables include barbiturates, ketamine, and diprivan. These agents are diluted in the blood, but travel to organs of high blood flow including the brain, liver, and kidneys. Although these agents provide amnesia, fentanyl is often used in addition to provide pain relief. Inhalants are excreted from the body by respiration but I.V. injectables are removed via metabolism. This is an important distinction between the two. There are other drug classes that are commonly used. Hypnotics include benzodiazepines. These are commonly given with a regional or local anesthetic. They are used for I.V. sedation for endoscopies. Opioid analgesics, as mentioned with fentanyl, are used during surgery and help with pain post-op.***A major side effect is respiratory depression. It is important to note that fentanyl has a potency 75 to 125 times that of morphine. Atropine Narcan and vasopressors as well as a crash cart should always be on hand. The last class of medications that's commonly found in the OR are neuro muscular blocking agents. These drugs interfere with the impulse that is transferred at the neuro muscular junction. They are used to relax the jaw and vocal cords for intubation. There is a risk for apnea due to muscle paralysis. There are two types of neuro muscular blocking agents: non depolarizing and depolarizing. Non depolarizing neuro muscular blocking agents block acetylcholine at the neuro muscular junction. They are reversed with atropine and Neostigmine. Agents can be long acting or short acting. Examples are pancuronium and vecuronium. De polarizing agents depolarize the motor plate at the junction and can result in Hyperkalemia. There is no antidote for these agents. Succinylcholine is one example. Let's talk briefly about complications for general anesthesia. The main complication is malignant hyperthermia. We covered this in detail in part one of our series. This is an increased risk with inhalation meds or succinylcholine which act as triggers. Signs include an elevated body temperature, cola colored urine, an increase in end tidal carbon dioxide and a decrease in oxygen saturation as well as sinus tachycardia. It's important to note that the antidote for malignant hyperthermia is Dantrium which is a skeletal muscle relaxant. Another risk for general anesthesia is unrecognized hypo ventilation. Monitoring standards include end tidal carbon dioxide to monitor expired gas and detect inadequate ventilation.***Older adults are at higher risk for any complications complications can result from intubation. Another type of anesthesia is called balanced anesthesia. This is a combination of IV medications and inhalation medications to obtain a specific effect. An example would be 70 percent nitrous oxide for induction and maintenance and oxygen plus an opioid and a muscle relaxant. When anesthesia is completed, this is called emergence. Its recovery from anesthesia. The speed at which this happens depends on the agents used and whether a reversal agent for neuro muscular blocking agent has been given. Patients may have a sore throat post-op due to intubation, this is common. Side effects during emergence may include retching or vomiting, restlessness, and shivering. Nursing interventions include suction, warm blankets, radiant light if needed, and oxygen. We won't go into detail about conscious sedation, but it's fairly common and it's worth mentioning a few important points. Conscious sedation usually involves several drugs including a sedative hypnotic and an opioid. It leads to a reduced level of consciousness. But clients retain the ability to independently breathe and also respond to verbal commands or physical stimulation clients will have a rapid return of normal function, but not remember the surgery. This is particularly helpful for short procedures like endoscopy, cardiac catheterization, a closed fracture reduction, cardioversion, or PTCA. Common agents include diazepam, midazolam, and fentanyl as well as morphine. Nursing responsibilities during conscious sedation include vital signs every 15 minutes, oxygen saturation, monitoring and ECG, and the level of consciousness. The client remains sleepy but arousable for several hours after conscious sedation. Okay let's talk about local and regional anesthesia. This type of anesthesia temporarily interrupts sensory impulses from a specific body region. The nurse's role during local or regional anesthesia is to assist the provider, observe for breaks and sterile technique, provide physical and emotional support, provide reassurance, and position the client comfortably and safely. Local anesthesia can be one of two types: topical or infiltration. Topical local anesthesia is often used for diagnostic procedures like a cystoscopy. Local infiltration involves intra cutaneous or subcutaneous injection into surrounding tissues. This blocks the peripheral nerve stimulation. Regional anesthesia is used when general anesthesia is contra indicated. This can happen when there is a history of previous sensitivity to general anesthesia or a history of malignant hyperthermia. Sometimes patients will choose regional anesthesia. Pain management can be enhanced post-operatively with this type. An example would be an epidural. Regional anesthesia can be helpful if the client has eaten and requires emergency surgery. One type of regional anesthesia is a field block. This is a series of injections around a nerve group or near the area. This can include thoracic procedures, dental procedures, and plastic surgery. Nerve block involves providing anesthesia to a specific nerve. Common nerves include the brachial, cervical plexus, and intercostal nerves. An example of this agent would be lidocaine or bupivacaine. This type of anesthesia takes effect within minutes and lasts longer than local infiltration. Nursing responsibilities include watching for signs of systemic absorption of the drug, sensitivity, or overdose. Spinal anesthesia is also called an intrathecal block. This is accomplished at the L2 L3 or L3 L4 level. The injection is into the cerebral spinal fluid in the subarachnoid space. This type of anesthesia acts nerves before they leave the spinal canal. And lastly we have the epidural. This is accomplished by injecting into the epidural space. The needle does not enter the protective coverings of the spinal cord. Epidural anesthesia can take effect as high as the T4 level. So there is a slight risk for respiratory complications. This type of anaesthesia is commonly used for total hip and total knee replacement surgeries. Advantages to epidural anesthesia include decreased cardiopulmonary complications, especially in older adults, and post-op pain relief. So complications for all local and regional anesthesia include a toxic reaction. This happens when the central nervous system is stimulated, followed by cardiovascular depression.***Signs to watch for include restlessness, excitement, incoherent speech, blurred vision, a metallic taste, vomiting, tremors, seizures, or tachycardia. Priority interventions include the APCs and alerting the surgeon. Rarely spinal anesthesia can result in an autonomic response and result in sudden or unexplained bradycardia and even cardiac arrest. Another complication of local or regional anesthesia is necrosis or gangrene, resulting from prolonged vasoconstriction. Nurse must collaborate with team members to perform key assessments in the peri operative period. The nurse must correctly identify the client, the nurse must validate the surgical consent. This can be done by asking what kind of operation are you having today. Clients may be permitted to wear eyeglasses and hearing aids until anesthesia induction. The nurse should assess the Advanced Directives. Any DNR orders must be clearly communicated. The nurse should assess allergies prior to surgery; priorities include latex allergy and any previous anesthesia experiences that have gone poorly such as malignant hyperthermia. The nurse should be aware of autologous blood donation, be aware of any cell processing methods, make sure containers are labelled, assist with the sterile setup and reinfusion, and monitor vital signs. The Circ nurse checks lab work prior to surgery. One example is hemoglobin. A low hemoglobin will effect oxygen transport and will affect the anesthesia type and amount used.***Never leave the client unattended. The client will have impaired skin integrity. The nurse should be familiar with wound closures. This includes sutures and staples as well as glue. Retention sutures stay in the skin. Sterile strips are closure tapes that are put on top of the skin. These are used for superficial wounds or to reinforce glue. Sutures come in many types of materials. Retention sutures are made of nylon, silk, or Lycra. They may be braided or twisted. Absorbable sutures are digested by enzymes of the body, this includes cat gut, plain gut, or chromic gut. Non-absorbable sutures are encapsulated by the tissue and remain embedded. This may include silk, cotton, steel, or nylon. These materials may be used to wire the sternum together after open heart surgery, for example. Lastly let's review some evaluation outcomes for the nurse. Number one: is the client safely anesthetized without any complications? Number two: does the client not experience injury due to positioning? Number three: is the client free of tissue contamination?
Cindi:Lastly, check the client's pressure points for bruises, redness, or abrasions. This concludes our close up look at intra operative nursing. Be sure to listen to the other two parts in this series. For more podcasts and tips to pass the NCLEX go to nclexmastery.com or go to flo.buzzsprout.com. Or check us out on Facebook at Nursing and NCLEX Mastery.