INTERVENTIONS FOR PREOPERATIVE, INTRAOPERATIVE, POSTOPERATIVE CLIENTS CARE.
INTERVENTIONS FOR CLIENTS WITH BURNS AND RENAL DISORDERS
Today’s trends in health care will be tomorrow’s examples of how clients used to be treated. These constant changes reflect multiple advances and society’s needs. The technology explosion is responsible for the development of new diagnostic and interventional devices that provide opportunities for the use and refinement of new surgical techniques. Examples of such technical advances include the GAMMA knife for brain tumor resections, as well as other minimally invasive surgery. Advances in anesthetic agents and techniques also have developed. These changes improve the ways that a surgical client is treated and has made anesthesia safer than ever before.
Cost reduction initiatives by third-party payers are also a driving force as to how the client is managed by the health care community. Shortened stays or outpatient treatment has become the expected. Ambulatory surgical services have rapidly been expanded, with more clients being admitted as in-patients after a procedure, rather than before. Some clients may only be observed after surgery and not admitted as an in-patient. In response to the ongoing health care delivery changes and the use of multiple settings, nurses have modified their interventions, remaining focused on client care before (preoperative), during (intraoperative), and after (postoperative) surgery.
OVERVIEW
The preoperative period begins when the client is scheduled for surgery and ends at the time of transfer to the surgical suite. The nurse acts as an educator, an advocate, and a promoter of health. Perioperative nursing places special emphasis on safety and client education.
Preoperative care consists of education and any interventioeeded before surgery to reduce anxiety and postoperative complications and to promote cooperation in postoperative procedures. In preoperative teaching, the nurse uses adult teaching and learning principles, validating and clarifying information the physician has provided. In addition, during the preoperative assessment it is not uncommon for the nurse to identify situations that warrant further client assessment and/or intervention before surgery. In collaboration with the surgical team, appropriate action is taken to achieve the desired outcome.
Categories and Purposes of Surgery
Surgical procedures are usually categorized according to the following:
• The reason for the surgery
• The urgency of the procedure
• The degree of risk
• The anatomic location
• The extent of surgery required
The primary purposes, or reasons, for surgery can be divided into five general subcategories: diagnostic, curative, restorative, palliative, and cosmetic. Palliative surgery makes the client more comfortable, and cosmetic surgery reconstructs the skin and underlying structures. The urgency of the procedure can be divided into three subcategories: elective, urgent, and emergent. The degree of risk is classified as minor or major. Classification by location is based on the area of the body on which the surgery occurs (e.g., abdominal surgery, intracranial surgery, or heart surgery).
The extent can be simple, modified, or radical. Table 17-1 explains the categories and gives examples of surgical procedures.
Surgical Settings
The term inpatient refers to a client who is admitted to a hospital. The client may be admitted the day before or, more of then, the day of surgery (often termed same-day admission [SDA]), or he or she may already be an inpatient when the need for surgical intervention is identified. In contrast, the terms outpatient and ambulatory refer to a client who goes to the surgical area the day of the surgery and returns home on the same day (i.e., same-day surgery [SDS]). Hospital-based ambulatory surgical centers, freestanding surgical centers, physicians’ offices, and ambulatory care centers are becoming increasingly more common. It is estimated that 70% to 90% of all surgical procedures in the
One of the many advantages of outpatient surgery is that clients are not separated from the comfort and security of their home and family. With continuous improvements in surgical techniques and anesthesia, more procedures are performed safely on an outpatient basis. Changes in the surgical experience, however, present particular challenges for the client who does not have an adequate or available support system. An older spouse may be unable to assist in preoperative and postoperative care. Clients who are primarily responsible for others may be unable to perform their usual tasks within the family. They may try to continue their family role but jeopardize their own health by doing so. As a result, their stress, fears, and anxieties about the surgical experience and about returning home immediately after surgery may be increased.
COLLABORATIVE MANAGEMENT
Assessment
HISTORY
Collection of data about the client before surgery begins in various settings (e.g., the surgeon’s office, the preadmission or admission office, the inpatient unit, and over the telephone). The nurse provides privacy to increase the client’s comfort with the interview process. Anesthesia and surgery are both physical and emotional stressors.
The nurse collects the following data:
• Use of tobacco, alcohol, or illicit substances, including marijuana
• Current medications
• Use of complementary or alternative medicines, such as herbal therapies, folk remedies, or acupuncture
• Medical history
• Prior surgical procedures and experiences
• Prior experience with anesthesia
– Autologous or directed blood donations
• Allergies, including sensitivity to latex products
• General health
• Family history
• Type of surgery planned
• Knowledge about and understanding of events during the perioperative period
• Adequacy and availability of the client’s support system
When taking a history, the nurse screens the preoperative client for conditions that may increase the risk for complications during the perioperative period.
AGE. Older clients are at increased risk for perioperative complications. The normal aging process decreases immune system functioning and delays wound healing. The frequency of chronic illness increases in older clients.
MEDICATION AND SUBSTANCE USE. The use of tobacco products increases the risk of pulmonary complications because of changes they cause to the lungs and thoracic cavity. Excessive alcohol and illicit substance use can alter the effects of anesthesia and response to pain medication. Withdrawal of alcohol in preparation for surgery may precipitate delirium tremens. Prescription and over-the-counter medications may also affect how the client reacts to the perioperative experience.
MEDICAL HISTORY. The nurse asks the client about his or her medical history. The presence of many chronic illnesses increases perioperative risks and is considered when planning care. For example, a client with systemic lupus ery-thematosus may need additional medication to offset the physical and emotional stress of the surgery. A client with diabetes may need a more extensive preoperative bowel preparation because of decreased gastrointestinal motility. An infection may need to be treated before surgery.
AGE
• Older than 65 years
MEDICATIONS
• Antihypertensives
• Tricyclic antidepressants
• Anticoagulants
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
MEDICAL HISTORY
• Decreased immunity
• Diabetes
• Pulmonary disease
• Cardiac disease
• Hemodynamic instability
• Multisystem disease
• Coagulation defect or disorder
• Anemia
• Dehydration
• Infection
• Hypertension
• Hypotension
• Any chronic disease
PRIOR SURGICAL EXPERIENCES
• Less-than-optimal emotional reaction
• Anesthesia reactions or complications
• Postoperative complications
HEALTH HISTORY
• Malnutrition or obesity
• Medication, tobacco, alcohol, or illicit substance use or abuse
• Altered coping ability
FAMILY HISTORY
• Malignant hyperthermia
• Cancer
• Bleeding disorder
TYPE OF SURGICAL PROCEDURE PLANNED
• Neck, oral, or facial procedures (airway complications)
• Chest or high abdominal procedures (pulmonary complications)
• Abdominal surgery (paralytic ileus, deep vein thrombosis)
PRIOR CARDIAC HISTORY.
The nurse obtains a history of cardiac disease because complications from anesthesia could occur in clients with cardiac problems. Cardiac disorders that increase risks associated with surgery include coronary artery disease, angina pectoris, myocardial infarction (MI) within 6 months before surgery, congestive heart failure, hypertension, and dysrhythmias. These disorders impair the ability to withstand and respond to both anesthesia and the hemodynamic changes associated with surgery. The risk of in-traoperative MI is also higher in clients with pre-existing heart problems.
PULMONARY HISTORY. Adults with chronic respiratory problems, older persons, and smokers are at risk for pulmonary complications because of smoking-induced pulmonary changes. Increased rigidity of the thoracic cavity and loss of lung elasticity reduce the efficiency of anesthesia excretion. Smoking increases the level of circulating carboxy-hemoglobin (carbon monoxide in the oxygen-binding sites of the hemoglobin molecule), which in turn decreases oxygen delivery to organs. In addition, mucociliary transport decreases, which leads to increased secretions and predisposes the client to infection (pneumonia) and atelectasis (collapse of alveoli). Atelectasis prevents the exchange of oxygen and carbon dioxide and causes intolerance of anesthesia.
Chronic conditions such as asthma, emphysema, and chronic bronchitis also reduce the elasticity of the lungs, which causes an ineffective exchange of carbon dioxide and oxygen. As a result, clients with these conditions have decreased oxygen diffusion and decreased oxygenation of the tissues.
CARDIOVASCULAR SYSTEM
Decreased cardiac output Increased blood pressure Decreased peripheral circulation
RESPIRATORY SYSTEM
Reduced viral capacity Loss of lung elasticity Decreased oxygenation of blood
RENAL/URINARY SYSTEM
Decreased blood flow to kidneys Reduced ability to excrete waste products
Decline in glomerular filtration rate Nocturia common
NEUROLOGIC SYSTEM
Sensory deficits Slower reaction time Decreased ability to adjust to changes in the surroundings
MUSCULOSKELETAL SYSTEM
Increased incidence of deformities related to osteoporosis or arthritis
Determine normal activity levels and note when the client tires. Monitor vital signs, peripheral pulses, and capillary refill.
Teach coughing and deep breathing exercises. Monitor respirations and breathing effort.
Monitor intake and output. Assess overall hydration. Monitor electrolyte status. Assist frequently with toileting needs, especially at night.
Orient the client to the surroundings. Allow extra time for teaching the client. Provide for the client’s safety.
Assess the client’s mobility. Teach turning and positioning. Encourage ambulation. Place on fall precautions, if indicated.
Knowing limits helps prevent fatigue. Having baseline data helps detect deviations.
Pulmonary exercises help prevent pulmonary complications.
Having baseline data helps detect deviations.
Ongoing assessment helps detect fluid and electrolyte imbalances and decreased renal function.
Frequent toileting helps prevent incontinence and falls.
An individualized preoperative teaching plan is developed on the basis of the client’s orientation and any neurologic deficits.
Safety measures help prevent falls and injury.
Interventions help prevent complications of immobility. Safety measures help prevent injury.
PREVIOUS SURGERY AND ANESTHESIA.
The number and type of previous surgical procedures and previous surgical experiences affect the preoperative client’s readiness for surgery. Previous perioperative experiences, particularly those with complications, may contribute to fears and concerns about the scheduled surgery. The nurse asks about the client’s experience with anesthetic agents and all allergies. These data provide the nurse with information about tolerance of and possible fears about the use of anesthesia. A sensitivity or allergy to certain substances alerts the nurse to a possible reaction to anesthetic agents or to substances that are used for preoperative skin preparation.
For example, povidone-iodine used for skin preparation contains some of the same components found in shellfish. Clients who are allergic to shellfish may have an adverse reaction to povidone-iodine. The family medical history and problems with anesthetics may indicate possible intraoperative needs and reactions to anesthesia, such as malignant hyperthermia.
AUTOLOGOUS OR DIRECTED BLOOD DONATIONS.
Clients may donate their own blood (autologous donations) for a few weeks immediately before the scheduled surgery date. If they need blood during the perioperative period, an autologous blood transfusion can be given. This practice eliminates the possibility of transfusion reactions and the transmission of bloodborne disease.
Clients may be candidates for autologous blood donations up to 5 weeks preoperatively if they are afebrile, have a hemoglobin level greater than 11 g/dL (110 g/L), and have a physician’s recommendation. Usually clients with a history of cardiovascular disease need additional clearance from their cardiologist. The physician may order supplemental iron beginning before the first donation. Autologous donations can be made as frequently as every 3 days if the other criteria are met. Usually a total of 2 to 4 units is donated. The last donation cannot be made within 72 hours before surgery.
A special tag is affixed to the transfusion bag when an autologous blood donation has been made. The blood donor center gives the client a matching tag that he or she brings to the surgical area preoperatively. This procedure helps to ensure that the client receives only his or her own blood. If the blood is not used, it goes to the blood bank to be used as would any other unit of donated blood.
Clients may wish to have family and friends donate blood exclusively for their use, if needed. This practice of directed blood donation is possible only if the blood types are compatible and the donor’s blood is acceptable. Clients may fear disease transmission from unknown blood and feel more comfortable knowing who gave the blood. Increasingly, blood collection centers and other health care personnel are discouraging this practice. Some centers do not accept directed blood, stating that it gives a false sense of security. As with autologous blood donations, a special tag is affixed to the blood. This tag notes the names of the client and the donor and bears the client’s signature.
The nurse asks whether autologous or directed blood donations have been made and documents this information in the chart. It may be important to know the specific blood collection center where the donation was made and whether the blood has arrived before the client goes into surgery.
PLANNING FOR BLOODLESS SURGERY.
Increased use of “bloodless surgery,” or minimally invasive surgery, programs is helping to provide another alternative for clients with religious or medical contraindications to blood transfusions. These programs reduce or eliminate the need for transfusion during and after surgery. Some techniques employed include limiting preoperative blood samples (the number of samples, as well as the volume of blood drawn per sample) and stimulating the client’s own red blood cell production with epoetin alpha (Epogen, Procrit) before, during, and after surgery. The physician may prescribe supplemental iron, folic acid, vitamin B12, and vitamin С preoperatively to further stimulate erythropoiesis. Special equipment and techniques used during the surgical procedure result in less blood loss than with older techniques. Such technologic advances include autotransfusion of suctioned blood during surgery to be recycled and immediately transfused back into the client. The nurse assesses, monitors, teaches, and supports the client during the bloodless surgery process (Vernon & Pfeifer, 1997).
DISCHARGE PLANNING.
The nurse assesses the client’s home environment, self-care capabilities, and support systems and anticipates postoperative needs during the preoperative period. All clients, regardless of how minor the procedure, should have discharge planning. Older persons and dependent adults may need referrals for transportation to and from the physician’s office or the surgical setting. A home care nurse may be needed to monitor postoperative recovery and to provide instruction on wound care. All clients with inadequate support systems may need follow-up care at home. Some require a planned direct admission to a rehabilitation hospital or center for extensive physical therapy following surgery, as in the case of total hip arthroplasty. Shortened hospital stays necessitate adequate discharge planning to achieve the desired outcomes after surgery.
PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
The preoperative client may be of any age, with a health status that varies from well to debilitated. The nurse performs a complete preoperative physical assessment to obtain baseline data. During physical assessment the nurse also identifies current health problems, potential complications related to the administration of anesthesia, and potential postoperative complications.
When beginning the assessment, the nurse obtains a complete set of vital signs. The nurse may need to obtain vital signs several times for accurate baseline values. Abnormal vital signs may cause the postponement of surgery until the underlying problem is treated and the client’s condition is stable. The nurse also assesses for anxiety, which could increase blood pressure, pulse, and respiratory rate. These findings are documented in the chart as part of the overall assessment.
Throughout the physical assessment, the nurse focuses on problem areas identified from the client’s history and on all body systems affected directly or indirectly by the surgical procedure. The older adult or chronically ill client is at increased risk for intraoperative and postoperative complications. Perioperative morbidity and mortality are higher in older and chronically ill clients because of their preoperative physical condition.
The nurse reports any abnormalities found on physical assessment to the physician and anesthesiology personnel. In this manner, the nurse functions as a proactive client advocate and is exercising professional legal responsibility. Often, established protocols or care maps identify what interventions are to be performed in the preoperative period.
CARDIOVASCULAR SYSTEM.
Alterations in cardiac status are responsible for as many as 30% of perioperative deaths. The nurse evaluates the client for hypertension, which is common, is often undiagnosed, and can affect the response to surgery. Cardiovascular assessment also includes auscultation of heart sounds for rate, regularity, and abnormalities. The nurse evaluates the client’s extremities for temperature, color, peripheral pulses, capillary refill, and edema. Any physical alterations, such as absent peripheral pulses, pitting edema, or cardiac symptoms, such as chest pain, shortness of breath, and dyspnea, are reported to the physician for further assessment and evaluation.
RESPIRATORY SYSTEM.
In assessing the client’s respiratory status, the nurse considers the client’s age, smoking history, and the presence of any chronic illness. The nurse observes the client’s posture; respiratory rate, rhythm, and depth; overall respiratory effort; and lung expansion. Clubbing of the fingertips (swelling at the base of the nail beds caused by a chronic lack of oxygen) or any cyanosis is noted. The nurse auscultates the lungs to determine the quality and presence of any adventitious (crackles, wheezes, rubs) or abnormal breath sounds.
RENAL/URINARY SYSTEM.
Renal and urinary function affects the filtration and eventual excretion of waste products, including anesthetic and analgesic agents. If renal and urinary function is less than optimal, fluid and electrolyte balance can be altered, especially in the older client. The nurse asks about the presence or absence of symptoms such as urinary frequency, dysuria (painful urination), nocturia (awakening during nighttime sleep because of a need to void), difficulty starting urine flow, and oliguria (scant amount of urine). The client is asked about the appearance and odor of the urine. Equally important is an assessment of usual fluid intake and degree of continence. If the client is suspected of having underlying renal or urinary problems, the nurse consults with the physician about further workup.
Abnormal renal function can decrease the excretion rate of preoperative medications and anesthetic agents. As a result, the drug’s effectiveness may be altered. Scopolamine, morphine, meperidine (Demerol), and barbiturates frequently cause confusion, disorientation, apprehension, and restlessness when administered to clients with decreased renal function.
NEUROLOGIC SYSTEM.
The nurse assesses the client’s overall mental status, including level of consciousness, orientation, and ability to follow commands, before planning preoperative teaching and postoperative care. A deficit in any of these areas affects the type of care required during the perioperative experience. The nurse determines the client’s baseline neurologic status to be able to identify changes that may occur later. The nurse also assesses for any motor or sensory deficits. (See Chapter 41 for complete nervous system assessment.)
The usual neurologic status of a mentally impaired or older client may be difficult to assess. The client who has been independent and oriented while in the home environment may become disoriented in an unfamiliar hospital setting. Family members and significant others can often provide information about what the client was like at home. Often, as part of the neurologic assessment, the nurse assesses the client’s risk for falling, especially in older clients. Factors such as mental status, muscle strength, steadiness of gait, and sense of independence are evaluated to determine the client’s risk. The client’s ability to ambulate and his or her steadiness of gait are noted preoperatively as baseline data.
MUSCULOSKELETAL SYSTEM.
Deformities of the musculoskeletal system may interfere with intraoperative and postoperative positioning.
For example, clients with arthritis may be able to assume conventional intraoperative positions but have unnecessary discomfort postoperatively from prolonged immobilization of joints. Other anatomic characteristics, such as the shape and length of the neck and the shape of the thoracic cavity, may interfere with respiratory and cardiac function or require special positioning during surgery.
The nurse asks about a history of joint replacements and notes the exact location of any prostheses. During surgery the nurse ensures that electrocautery pads, which could cause an electrical burn, are not placed near the area of the prosthesis.
NUTRITIONAL STATUS.
Malnutrition and obesity can increase surgical risk. Surgery usually increases the body’s metabolic rate and consequently depletes potassium, ascorbic acid, and В vitamins, all of which are needed for wound healing and fibrin formation. In malnourished clients, hypoproteinemia slows postoperative recovery. Negative nitrogen balance may result from depleted protein stores. This situation increases the risk for perioperative morbidity and mortality from delayed wound healing, possible dehiscence or evisceration, fluid volume deficit, and sepsis.
Some older clients may have nutritional imbalances because of chronic illness, diuretic or laxative use, poor dietary planning or habits, anorexia, lack of motivation, or financial limitations. Clinical indications of poor fluid or nutritional status include brittle nails, muscle wasting, dry or flaky skin, hair alterations (e.g., dull, sparse, dry), decreased skin turgor, orthostatic (postural) hypotension, decreased serum albumin levels, and abnormal serum electrolyte values.
The obese client is often malnourished because of poor eating habits and an imbalanced diet. Obesity increases the risk for poor or incomplete wound healing because of excessive adipose tissue. Fatty tissue has poor vasculature, little collagen, and decreased nutrients, all of which are important for wound healing. Obesity causes increased stress on the heart and reduces the available lung volumes, which can affect the intraoperative experience and postoperative recovery. In addition, obese clients may require larger doses of medication and retain them longer in their systems postoperatively.
PSYCHOSOCIAL ASSESSMENT
The nurse performs a psychosocial assessment and preparation to determine the client’s level of anxiety, coping ability, and support systems; provide information; and offer support. Most clients scheduled for surgery experience some preoperative anxiety and fear. The extent and type of these reactions vary according to the type of surgery, the perceived effects of the surgery and its potential outcome, and the client’s basic personality. Surgery may be seen as a threat to biologic integrity, body image, self-esteem, self-concept, or lifestyle. Clients may fear death, pain, helplessness, decreased socioeconomic status, a diagnosis of life-threatening conditions, possible disabling or crippling effects, or the unknown.
The client’s anxiety and fear affect his or her ability to learn, cope, and cooperate with preoperative teaching and perioperative procedures. Anxiety and fear may also influence the amount and type of anesthesia needed and may retard postoperative recovery. The nurse is aware of potential fears and anxieties when interviewing the client and planning preoperative teaching.
The nurse assesses coping mechanisms used by the client under similar situations or in the past when confronted with a stressful situation. The nurse asks open-ended questions pertaining to the client’s feelings about the entire perioperative experience. Factors to be assessed that influence coping include age; previous surgical or sick-role experiences; and emotional and physical signs of fear, anxiety, or discomfort. Signs of fear and anxiety include anger, crying, restlessness, diaphoresis (sweating, usually profusely), increased pulse rate, palpitations, sleeplessness, diarrhea, and urinary frequency.
LABORATORY ASSESSMENT
Preoperative laboratory tests provide baseline data about the client’s health and help predict potential complications. The client scheduled for surgery in an ambulatory surgical center or admitted to the hospital on the morning of or day before surgery may have preadmission testing performed from 48 hours to 28 days before the scheduled surgery, depending on the facility’s policy. The results of prior tests are usually valid unless there has been a change in the client’s condition that warrants repeated testing or the client is taking medications that can alter laboratory values (such as warfarin [Coumadin], aspirin, or diuretics).
The choice of routine preoperative laboratory tests varies among facilities and depends on the client’s age and medical history and the type of anesthesia planned. The most common tests are urinalysis, blood type and crossmatch, complete blood count or hemoglobin level and hematocrit, coagulation studies (prothrombin time [PT], International Normalized Ratio [INR], activated partial thromboplastin time [aPTT], and platelet count), electrolyte levels, and serum creatinine level. Depending on a female client’s age and the nature of the planned procedure, a pregnancy test may also be ordered.
A preoperative urinalysis is performed to assess for the presence of protein, glucose, blood, and bacteria, all of which are abnormal constituents of the urine. If renal disease is suspected or the client is older, the physician may order other tests to determine the type and degree of disease present.
The nurse reports electrolyte imbalances or other abnormal results to the anesthesia team and the surgeon before surgery. Hypokalemia (decreased serum potassium level) increases the risk of digoxin toxicity (if the client is taking digoxin), slows recovery from anesthesia, and increases cardiac irritability. Hyperkalemia (increased serum potassium level) increases the risk for cardiac dysrhythmias, especially with the use of anesthesia. Both hypokalemia and hyperkalemia should be corrected before the surgery.
The physician may order other studies, depending on the client’s medical history. For example, baseline arterial blood gas (ABG) values are assessed before surgery for clients with chronic pulmonary problems.
RADIOGRAPHIC ASSESSMENT
A chest x-ray film, ordered by the physician or anesthesiologist, is commonly obtained to determine the size and contour of the heart, lungs, and major vessels and to determine the presence of any infiltrates that could indicate pneumonia or tuberculosis. A chest x-ray study also provides baseline data in the event of postoperative complications. Abnormal x-ray findings alert the physician to potential cardiac or pulmonary complications. The presence of congestive heart failure, cardiomyopathy, pneumonia, or infiltrates may cause cancellation or delay of elective surgery. For emergency surgery, x-ray results assist the anesthesiologist in the selection of anesthesia. In many facilities, chest x-ray results are valid when done within 6 months before surgery, provided that there has not been a change in the client’s condition.
Other radiographic studies are based on individual need, the medical history, and the nature of the surgical procedure. For example, a client with back pain may have computed tomography (CT) or magnetic resonance imaging (MRI) done before a laminectomy (spinal surgery) to identify the exact location of the abnormality.
OTHER DIAGNOSTIC ASSESSMENT
An electrocardiogram (ECG) may routinely be required for all clients older than a specific age who are to have general anesthesia. The age varies among facilities but is often 40 to 45 years. An ECG may also be ordered for clients with a history of cardiac disease or those at risk for cardiovascular complications. An ECG provides baseline information on new or pre-existing cardiac conditions, such as an old anterior wall myocardial infarction (MI). A client with a known cardiac condition may require a preoperative consultation with a cardiologist. Prophylactic medication, such as nitro-glycerin and antibiotics, may be needed during the perioperative period to reduce or prevent stress on the cardiovascular system. Abnormal or potentially life-threatening ECG results may cause the cancellation of surgery until the client’s cardiac status is stable.
Analysis
• COMMON NURSING DIAGNOSES
The following are commoursing diagnoses for preoperative clients:
1. Deficient Knowledge related to a lack of education and lack of exposure to the specific perioperative experience
2. Anxiety related to the threat of a change in health status or fear of the unknown
ADDITIONAL NURSING DIAGNOSES
In addition to the commoursing diagnoses, preoperative clients may have one or more of the following:
• Disturbed Sleep Pattern related to internal sensory alterations (e.g., illness and anxiety)
• Ineffective Coping related to the impending surgery
• Anticipatory Grieving related to the effects of surgery
■ Disturbed Body Image related to anticipated changes in the body’s appearance or function
• Disabled Family Coping related to temporary family disorganization and role changes
• Powerlessness related to the health care environment, loss of independence, and loss of control of one’s body
• Interrupted Family Processes related to situational crisis
Preoperative Coordination: Facilitating preadmission diagnostic testing and preparation of the surgical client
• Review planned surgery.
• Obtain client history, as appropriate.
• Complete a physical assessment, as appropriate.
• Describe and explain preadmission treatments and diagnostic tests.
• Interpret diagnostic tests, as appropriate.
• Determine the client’s expectations about the surgery.
• Provide time for the client and significant other to ask questions and voice concerns.
• Discuss postoperative discharge plans.
• Determine ability of caretakers.
• Planning and Implementation
DEFICIENT KNOWLEDGE
PLANNING: EXPECTED OUTCOMES. The preoperative client is expected to verbalize and comply with preoperative procedures and demonstrate techniques to prevent postoperative complications.
INTERVENTIONS.
Because the perioperative experience is foreign to many people, the nurse focuses on preoperative education of the client and family members. Preoperative teaching usually begins in the surgeon’s office for planned or elective surgery. Pamphlets, written instructions, and videotapes may be given and sent to the client as well. More teaching may occur when the client has preadmission testing. Some facilities conduct preoperative classes for groups of clients or have videos for those who are having the same or similar surgical procedures. A tour of the operating suite and the postanesthesia care unit (PACU) may be included.
Information about informed consent, dietary restrictions, preoperative preparation (bowel and skin preparations), postoperative exercises, and plans for pain management promote clients’ participation and help achieve the desired outcome in their health care (see the Evidence-Based Practice for Nursing box on p. 248). A sample preoperative educational checklist is shown in Table 17-5. Because education occurs in a variety of settings, coordination of client teaching efforts is particularly challenging. The nurse who cares for the client immediately before surgery (same-day, ambulatory surgery [outpatient] unit or inpatient hospital unit) assesses the client’s and family member’s knowledge and provides additional information as needed.
The physician is responsible for having the consent form signed before preoperative sedation is given and before surgery is performed. The nurse is not responsible for providing detailed information about the surgical procedure. Rather, the nurse clarifies facts that have been presented by the physician and dispels myths that the client or family may have about the perioperative experience.
Consider the following items when planning individualized preoperative teaching for clients and families:
• Fears and anxieties
• Surgical procedure
• Preoperative routines (e.g., NPO, enemas, blood samples, showering)
• Invasive procedures (e.g., lines, catheters)
• Coughing, turning, deep breathing
• Incentive spirometer
How to use
How to tell when used correctly
• Lower extremity exercises
• Stockings and pneumatic compression devices
• Early ambulation
• Splinting
• Pain management
The surgeon is contacted and requested to see the client for clarification of information if the nurse believes that the client has not been adequately informed. The nurse documents this action in the chart.
Clients who cannot write may sign with an X, which must be witnessed by two persons. In an emergency, telephone or telegram authorization is acceptable and should be followed with written consent as soon as possible. The number of witnesses (usually two) and the type of documentation vary according to the facility’s policy. In a life-threatening situation in which every effort has been made to contact the person with medical power of attorney, consent is desired but not essential. In place of written or oral consent, written consultation by at least two physicians who are not associated with the case may be requested by the physician. This formal consultation legally supports the decision for surgery until the appropriate person can sign a consent form. If the client is not capable of giving consent and has no family, the court can appoint a legal guardian to represent the client’s best interests.
A blind client is capable of signing his or her own consent form, which usually needs to be witnessed by two persons. Clients who speak a language other than the general language of the agency require a translator and a second witness. Some facilities have consent forms written in more than one language.
Some surgical procedures require a special permit in addition to the standard consent. National and local governing bodies and the individual surgical facility determine which procedures require a separate permit. Intraocular lens implants, sterilization, and experimental procedures are examples of procedures for which the extra form is usually required. Separate consents for anesthesia and the administration of blood products may be required as well.
CLIENT SELF-DETERMINATION ACT.
All individuals receiving medical care have the right to have or initiate advance directives, such as living wills and durable power of attorney, as mandated by the Patient Self-Determination Act. Advance directives provide legal instructions to the health care providers about the client’s wishes and are to be followed. Surgery does not provide an exception to a client’s advance directives or living will tricted to nothing by mouth (NPO) for 6 to 8 hours before surgery. NPO means no eating, drinking (including water), or smoking (nicotine stimulates gastric secretions). It is common practice to begin NPO status for all preoperative clients at midnight on the night before surgery. This extra precaution ensures that the stomach contains a limited volume of gastric secretions, which helps decrease the possibility of aspiration. Outpatients and clients who are scheduled for admission to the hospital on the same day that surgery is performed must receive written and oral instructions about remaining NPO after midnight. The nurse emphasizes the importance of compliance; failure to comply can result in cancellation of surgery or an increased risk of intraoperative or postoperative aspiration.
ADMINISTERING REGULARLY SCHEDULED MEDICATIONS.
On the day of surgery, the client’s usual medication schedule may need to be altered. The nurse consults the medical physician and the anesthesiologist for instructions about administration of medications, such as those taken for diabetes mellitus, cardiac disease, or glaucoma, as well as regularly scheduled anticonvulsants, antihypertensives, anticoagulants, antidepressants, or corticosteroids. The physician may order some medications, including over-the-counter medications, such as aspirin, to be stopped until after surgery. The physician may order other medications to be administered by the intravenous (IV) route to maintain the level of the medication in the blood. Medications for cardiac disease and hypertension are commonly allowed with a sip of water if taken at least 2 hours before surgery. Some antihypertensive or antidepressant medications may be withheld on the day of surgery because of a possible adverse effect on the blood pressure intraoperatively.
The client with diabetes who is taking insulin may be given a reduced dose of intermediate- or long-acting insulin on the basis of the serum glucose level, or he or she may be given regular (fast-acting) insulin subcutaneously in divided doses on the day of surgery. An alternative method of diabetes management is an IV infusion of 5% dextrose in water given with the insulin to prevent hypoglycemia intraoperatively. Because of numerous treatment approaches to diabetes, the nurse clarifies medication and IV orders with the physician. (More information about the client with diabetes is found in Chapter 65.)
GASTROINTESTINAL PREPARATION.
Bowel or gastrointestinal (GI) preparation procedures are performed to prevent injury to the colon and to reduce the number of intestinal bacteria. Evacuation of the GI tract is done when a client is having major abdominal, pelvic, perineal, or perianal surgery. The surgeon’s preference and the type of surgical procedure determine the type of bowel preparation.
An enema ordered to be given until return flow is clear is a physically stressful procedure for anyone, but especially for the older client. Repeated enemas can cause electrolyte imbalance (especially potassium depletion), fluid volume deficit, vagal stimulation, and postural (orthostatic) hypotension. Enemas also cause severe anorectal discomfort in clients with hemorrhoids. To prevent complications, some physicians prescribe potent laxatives (e.g., polyethylene glycol electrolyte solution instead of enemas, especially for older clients. Bowel preparation procedures can be exhausting, and the nurse takes safety precautions to prevent falls.
SKIN PREPARATION.
The skin preparation may be embarrassing or uncomfortable for the client, especially if the surgical site is in a sensitive or generally private body area. The nurse provides a warm, comfortable, and private environment during the procedure.
The skin is the body’s first line of defense against infection. A break in this protective mechanism increases the risk of infection, especially for older clients. Preoperative skin preparation is the initial step in the prevention of wound infection. One or two days before the scheduled surgery, the surgeon may require the client to shower using an antiseptic solution such as povidone-iodine (Betadine) or hexachlorophene. The physician may want the client to be especially attentive to cleaning around the proposed surgical site. If the client is hospitalized before surgery, the showering and cleaning is often repeated the night before surgery or in the morning before transfer to the surgical suite. This cleaning reduces contamination of the surgical field, as well as the number of microorganisms on the surgical field. After the final cleaning procedure, especially for an orthopedic surgical procedure, the area may be covered with sterile towels or drapes to prevent contamination.
A controversial step in preoperative skin preparation after the cleaning or showering is the shave. Many health care practitioners believe that the shaving procedure itself is a possible source of contamination of the surgical area and traumatizes the skin around the area where the incision will be made. Those factors believed to predispose the client to wound contamination include bacteria found in hair follicles, disruption of the normal protective mechanisms of the skin, and nicks in the skin (e.g., from shaving). Shaving of hair creates the potential for infection. Clipping of the hair with electrical surgical clippers is becoming increasingly popular to decrease the complications associated with traditional razors. In the
Figure • Skin preparation of common surgical sites.
Shaded areas indicate areas of hair removal.
PREPARING THE CLIENT FOR TUBES, DRAINS, AND INTRAVENOUS ACCESS.
The nurse prepares the client for possible insertion of tubes, drains, and IV access devices. Preparation reduces the client’s postoperative anxiety and fear, and the family’s negative reaction. The nurse is careful not to scare the client while providing information about the purpose of each tube.
TUBES.
The client may require an indwelling urinary (Foley) catheter before, during, or after surgery to keep the bladder empty and to enable monitoring of renal function. The client having major abdominal or genitourinary surgery usually has a Foley catheter.
A nasogastric tube may be inserted before emergency surgery or major abdominal surgery for decompressing or emptying the stomach and the upper bowel. More often, however, the tube is inserted after the induction of anesthesia, when insertion is less disturbing to the client and is easier to perform.
DRAINS.
Drains are frequently inserted during surgery to promote the evacuation of fluid from the surgical site. Some drains are under the dressing, whereas others are visible and require emptying. Drains come in various shapes and sizes (see Chapter 19). The nurse informs the client that drains are often used routinely and that generally they are not painful but may cause some discomfort. The nurse further discusses the reasons why they should not kink or pull on the drain.
INTRAVENOUS ACCESS.
An IV access (line) is placed by the nurse or anesthesia personnel for all clients receiving general anesthesia and most clients receiving other types of anesthesia. An access is needed to administer medication and fluids before, during, and after surgery. Clients who are dehydrated or who are at risk for dehydration, such as older clients, may receive fluids before surgery.
The IV access is usually placed in the arm or the posterior aspect of the hand using a large, short catheter (e.g., 18-gauge, 1-inch catheter). This type of catheter provides the least resistance to fluid or blood infusion, especially in an emergency when rapid infusions may be necessary. Depending on the individual client’s needs and the facility’s policies and practices, the IV access can be placed before surgery when the client is in the hospital room, in the holding or admission area of the surgical suite, or in the OR.
TEACHING ABOUT POSTOPERATIVE PROCEDURES AND EXERCISES.
The nurse instructs the client and family members about postoperative exercises and procedures (e.g., checking dressings and obtaining vital signs frequently). Preoperative teaching reduces apprehension and fear, increases cooperation and participation in postoperative care, and decreases the incidence and severity of postoperative complications. When the fear or anxiety level is high, however, the nurse explores the client’s attitudes and feelings before discussing procedures (Cipperley, Butcher, & Hayes, 1995). Discussion, demonstration, and return demonstration and practice by the client aid in the ability to perform various breathing and leg exercises during postoperative recovery. The nurse emphasizes the need to begin exercises early in the recovery phase and to continue them, with five to ten repetitions each, every 1 to 2 hours after surgery for at least the first 48 hours. The nurse also explains that the client may need to be awakened for these activities.
BREATHING EXERCISES.
In deep, or diaphragmatic, breathing, the diaphragm flattens during inspiration, enlarging the upper abdominal cavity. During expiration the abdominal muscles and diaphragm contract, which completely expands the lungs. After the nurse demonstrates and explains the technique, the client is encouraged to practice the five steps of deep breathing.
For clients with chronic pulmonary disease or limited upper chest expansion, as seen in older clients because of the aging process, expansion breathing exercises are useful. For the client having thoracic surgery, expansion breathing exercises strengthen accessory muscles and should be initiated preoper-atively. Expansion breathing may be used postoperatively during chest physiotherapy (percussion, vibration, and postural drainage) to assist with loosening secretions and maintaining an adequate air exchange.
Positions for Postural Drainage
INCENTIVE SPIROMETRY. Incentive spirometry is another way to encourage the client to take deep breaths. Its purpose is to promote complete lung expansion and to prevent respiratory complications. Various types of incentive spirometers are available; some examples are shown in Figure 17-3.
With all types, the client must be able to seal his or her lips tightly around the mouthpiece, inhale spontaneously, and hold his or her breath for 3 to 5 seconds to achieve effective lung expansion. Goals (e.g., attaining specific volumes) can be set according to the client’s ability and the type of incentive spirometer. Visualization through seeing a light move up a column or a bellows expanding often reinforces and motivates the client to continue performance.
COUGHING AND SPLINTING. Coughing may be performed in conjunction with deep breathing every 1 to 2 hours postoperatively. The purposes of coughing are to promote expectoration of secretions, keep the lungs clear, allow full aeration, and prevent pneumonia and atelectasis. Coughing may be uncomfortable for the client, but when performed correctly, it should not harm the surgical area. Splinting (e.g., holding) the incision area provides support, promotes a feeling of security, and reduces pain during coughing. A folded bath blanket is helpful to use as a splint.
Some practitioners think that coughing exercises should no longer be encouraged routinely. Their belief is that coughing has the potential to harm the surgical wound and that it would be better to emphasize other, safer measures for pulmonary hygiene, such as deep breathing and incentive spirometer exercises. When routine coughing exercises are contraindicated for a client, such as after a hernia repair, the physician usually writes a “do not cough” order.
LEG PROCEDURES AND EXERCISES. Antiembolism stockings (TED or Jobst stockings), elastic (Ace) wraps, or pneumatic compression devices (e.g., “sequentials” or “boots”) may be used perioperatively in combination with leg exercises and early ambulation to promote venous return. Venous stasis can lead to deep vein thrombosis (DVT) or a pulmonary embolus (PE) if the blood clot breaks off and travels to the lungs. Interventions depend on the client’s risk factors. Clients at greater risk for DVT:
• Are obese
• Are older than 40 years of age
• Have a concurrent diagnosis of cancer
• Have decreased mobility or immobility
• Have a fracture or leg trauma
• Have a history of
• Are taking estrogen or oral contraceptives
• Smoke
• Have decreased cardiac output
• Are undergoing pelvic surgery
Antiembolism Stockings and Elastic Wraps. Stockings and elastic wraps provide graduated compression of the lower extremities, starting distally at the foot and ankle. The nurse measures the client’s leg length and circumference and orders the appropriate stocking size. Elastic wraps are used when the legs are too large or too small for the stockings. The nurse assists the client in applying the devices and ensures that they are neither too loose (are ineffective) nor too tight (inhibit blood flow). They also need to be worn as ordered to be effective and should be removed one to three times per day for 30 minutes for skin care and inspection.
Pneumatic Compression Devices. Pneumatic compression devices enhance venous blood flow by providing intermittent periods of compression on the lower extremities. The nurse measures the client’s legs and orders the appropriate size. The nurse places the boots on the client’s legs and sets and checks the prescribed or recommended compression pressures (often 35 to
Leg Exercises. Leg exercises also promote venous return. The nurse teaches the postoperative leg exercises and then encourages the client to practice these exercises preoperatively. The exercises are important, even when the other devices are being used.
EARLY AMBULATION. Mobility soon after surgery (early ambulation) stimulates gastrointestinal motility, enhances lung expansion, mobilizes secretions, promotes venous return, prevents rigidity of joints, and relieves pressure. In general, the nurse instructs the client that he or she should turn at least every 2 hours after surgery while confined to bed. To aid clients, the nurse teaches them how to use the bed siderails safely for turning and how to protect the surgical wound (splinting) when turning. The nurse assures clients that assistance and pain medication will be given as needed to alleviate any anxiety and pain they may have in relation to this activity.
CLIENT EDUCATION GUIDE
Postoperative Leg Exercises
For certain surgical procedures, such as some brain, spinal, and orthopedic procedures, the physician may order turning restrictions. The nurse discusses with the physician other interventions to prevent complications associated with immobility in clients with turning restrictions. The nurse informs the client of anticipated turning restrictions during preoperative teaching.
Many clients are allowed and encouraged to get out of bed the day of or the day after surgery. The nurse assists the client into a chair or with ambulation after the surgery or the next day, depending on the type and time of surgery and the physician’s preference. If a client must remain in bed, he or she must turn, deep breathe, and perform leg exercises at least every 2 hours to prevent the complications of postoperative immobility.
RANGE-OF-MOTION EXERCISES. Passive or active range-of-motion (ROM) exercises help prevent joint rigidity and muscle contracture. The client should do these exercises three to five times each, three to four times a day while bedridden. The nurse instructs the client in these procedures and informs the client that he or she will receive assistance as needed postoperatively.
ANXIETY
PLANNING: EXPECTED OUTCOMES.
The preoperative client is expected to verbalize decreased or manageable preoperative anxiety and demonstrate evidence of relaxation when at rest.
Figure 17-3 • Examples of volume incentive spirometers for lung expansion. A, A volume displacement incentive spirometer. B, A volumetric incentive spirometer. (Courtesy DHD Healthcare, Canastota, NY.)
INTERVENTIONS.
Preoperative anxiety frequently causes physical symptoms such as a threat to biopsychosocial integrity. The nurse first assesses the client’s level of anxiety, as discussed earlier under Psychosocial Assessment. Interventions such as teaching and communicating with the client preoperatively, enabling the client to use previously successful coping mechanisms, and administering antianxiety agents help to reduce the anxiety and subsequent complications. The nurse incorporates appropriate and available support systems into the plan of care.
PREOPERATIVE TEACHING.
The nurse assesses the client’s knowledge about the perioperative experience that he or she has acquired from prior surgical experiences and procedures and from other sources. Factual information about the surgery and the perioperative experience is provided to promote the client’s understanding. Ample time is allowed for questions. The nurse responds to the questions appropriately and accurately and refers unanswered questions to the proper person. During the discussion, the nurse continually assesses the client’s responses and anxiety level. The nurse must be careful not to provide information that might increase anxiety. Clients have ranked psychosocial support as the most important component during preoperative teaching. The informed, educated client is better able to anticipate events and maintain self-control and is thus less anxious.
ENCOURAGING COMMUNICATION. Stating feelings, fears, and concerns is an appropriate way to reduce anxiety. The nurse develops a trusting relationship with the client so that he or she can express feelings freely without fear of ridicule or judgment. The nurse keeps the client informed, clarifies information, answers questions, and allays some apprehensions about the surgery.
PROMOTING REST. The stress and anxiety of impending surgery frequently interfere with the client’s ability to sleep and rest the night before surgery. The preoperative experience is physically and emotionally stressful. To assist the client in relaxing, the nurse determines what the client usually does to relax and fall asleep. If permitted and able, the client is encouraged to continue these methods of relaxation. A back rub is a relaxing and therapeutic measure and can be performed by a nurse or family member. The physician may prescribe a sedative or short-acting hypnotic to ensure that the client is well rested for surgery.
USING DISTRACTION. The nurse may plan distraction as an intervention for anxiety. Especially in the 24 hours immediately before surgery, listening to music or audiotapes may decrease anxiety, as may watching television, reading, or visiting with family members.
TEACHING FAMILY AND SIGNIFICANT OTHERS. The nurse assesses the readiness and desire of the family or significant others to take an active part in the client’s care. The involved family provides support and helps reduce anxiety. A positive sign of family interest is members’ initiation of questions about the perioperative experience. After family readiness is determined, the nurse keeps family members informed and encourages their involvement in all aspects of preoperative education. The nurse emphasizes the important role of the family preoperatively but guides discussions and practice sessions so that family members do not dominate the sessions. Family members can encourage and help the client practice postoperative exercises.
The nurse informs the family of the time for surgery, if known, and of any schedule changes. If the client is an outpatient, he or she and the family need clear directions regarding any specific night-before procedures, what time and where to report, and what to bring with them. The family is encouraged to stay with the client preoperatively for support.
Most families are anxious about the surgery planned for their loved one. To reduce their anxiety, the nurse explains the intraoperative and postoperative routine to them. The nurse explains that after the client leaves the hospital room or admission area, there is usually a 30- to 60-minute preparation period in the operating area (holding room, treatment area, and so on) before the surgery actually begins. After surgery, the client is taken to the postanesthesia care unit (PACU) for 1 to 2 hours before returning to the hospital room or discharge area. The nurse instructs the family about the best place to wait for the client or surgeon according to the facility’s policy and the physician’s preference. Many hospitals and surgical centers have designated surgical waiting areas so that families can wait in comfortable surroundings and be easily located when the procedure is completed.
PREOPERATIVE CHART REVIEW
The nurse reviews the client’s chart to ensure that all documentation, preoperative procedures, and orders are completed. The nurse checks the surgical informed consent form and, if indicated, any other special consent forms to see that they are signed and dated, and that they contain the witnesses’ signatures. The nurse confirms that the scheduled procedure, including the identification of left versus right wheecessary, is what is listed on the consent form. Allergies must be noted according to facility policy. Accurate documentation of height and weight is important for proper dosage calculation of the anesthetic agents.
The results of all laboratory, radio-graphic, and diagnostic tests should be on the chart; any abnormal results are documented and reported to the physician and the anesthesiologist or anesthetist. If the client is an autologous blood donor or has had directed blood donations made, those special slips must be included in the chart. The nurse records a current set of vital signs (within 1 to 2 hours of the scheduled surgery time) and documents any significant physical or psychosocial observations. The nurse reports special needs, concerns, and instructions (advance directives) to the surgical team. For example, the nurse advises the surgical team whether the client is a member of Jehovah’s Witnesses and does not accept blood products or whether the client is hard of hearing and does not have his or her hearing aid. This information assists the surgical team in providing continuity of care while the client is in the surgical area.
The removal of fingernail polish or artificial nails is controversial. Polish is flammable, and artificial nails may affect the accuracy of pulse oximetry readings. In some facilities at least one artificial nail must be removed for this reason.
After the client is prepared for surgery and the operating suite is ready to receive him or her, the nurse asks the client to empty his or her bladder to prevent incontinence or overdistention and to provide a starting point for intake and output measurement. An overly full bladder may hinder access to the surgical site. The nurse answers any final questions, offers reassurance as needed, and administers any ordered preoperative medication.
Practice nursing care for Intraoperative Clients
Safety and advocacy for the client during surgical interventions are the primary concerns of perioperative nurses. Outcomes and numerous hazards can be managed, prevented, reduced, and controlled by deliberate actions and observations. The client entering the perioperative environment is at risk for infection, impaired skin integrity, increased anxiety, altered body temperature, and injury related to positioning and other hazards present. The intraoperative phase begins with unfamiliar experiences involving uncertain or nonguaranteed outcomes. Nursing care during the intraoperative period is critical, because all of the client’s physical needs, comfort, safety, dignity, and psychologic status are dependent on the perioperative nurse. Specific procedures and policies may differ among agencies, but similarities are evident and reflect the standards and recommended practices for perioperative nursing, as published by AORN, the Association of perioperative Registered Nurses (formerly the Association of Operating Room Nurses).
OVERVIEW
Members of the Surgical Team
The surgical team consists of the surgeon, one or more surgical assistants, the anesthesiologist and/or nurse anesthetist, and perioperative staff.
Perioperative, or operating room (OR), nurses include the holding area nurse, circulating nurse, scrub nurse, and any specialty nurses. The number of assistants, circulating nurses, and scrub nurses depends on the complexity and projected length of the surgical procedure. For some minor diagnostic or outpatient procedures, only a scrub nurse or a circulating nurse may be required in addition to the surgeon. The more complex procedures may require additional nursing staff to either circulate or scrub.
SURGEON AND SURGICAL ASSISTANT
The surgeon is a physician who assumes responsibility for the surgical procedure and any surgical judgments about the client. The surgical assistant might be another surgeon (or physician, such as a resident or intern) or a physician’s assistant, nurse, or surgical technologist. Under the direction of the surgeon and within the legal scope of practice within each state, the assistant may hold retractors, suction the wound (to allow visualization of the operative site), cut tissue, suture, and dress wounds. Regulating agencies determine who may qualify to be a surgical assistant and delineate the functions of the surgical assistant.
ANESTHESIOLOGIST AND NURSE ANESTHETIST
The anesthesiologist is a physician who specializes in the administration of anesthetic agents. A certified registered nurse anesthetist (CRNA) is a specially trained registered nurse with additional credentials who administers anesthetic agents under the supervision of an anesthesiologist, surgeon, dentist, or podiatrist. The anesthesiologist or CRNA administers anesthetic drugs to induce and maintain anesthesia and administers other medications as indicated to support the client’s physical status during surgery.The anesthesiologist or nurse anesthetist usually monitors the client intraoperatively by measuring, assessing, and monitoring the following:
• The level of anesthesia (i.e., by using a peripheral nerve stimulator or bispectral analysis)
• Cardiopulmonary function (using electrocardiographic [ECG] monitoring, pulse oximetry, end-tidal carbon dioxide monitoring, arterial blood gases, and hemodynamic monitoring via arterial lines and/or pulmonary artery catheters)
• Vital signs
• Intake and output
Depending on the client’s needs, anesthesia personnel administer intravenous (IV) fluids, including blood and blood components, to maintain physiologic homeostasis.
PERIOPERATIVE STAFF
Perioperative, or OR, staff assume several roles within the operating suite, depending on their education, experience, skill, and job responsibilities.
HOLDING AREA NURSE.
Some operating suites feature a presurgical holding area next to the main ORs. The client waits in this area until the OR is ready. The holding room nurse manages the client’s care while he or she is in this area. This nurse greets the client on arrival, reviews the medical record and preoperative checklist, and ensures that the operative consent forms are signed. The nurse assesses the client’s physical and emotional status, gives emotional support, answers questions, and provides additional education as needed.
The holding area can be very busy, with many staff members performing a number of preoperative procedures (e.g., establishing IV lines or inserting epidural catheters). The holding area nurse maintains an atmosphere conducive to the client’s overall well-being and intervenes on his or her behalf to maintain comfort, privacy, and confidentiality. Depending on the facility’s policy, family members may be invited to wait with the client.
CIRCULATING NURSE.
The circulating nurse, or circulator (who should be a registered nurse), coordinates, oversees, and participates in the client’s nursing care while he or she is in the OR. The circulating nurse’s actions are vital to the smooth flow of events before, during, and after the operation. This nurse is responsible for the activities within that particular OR. The circulator sets up the OR and ensures that necessary supplies, including blood products, are available as needed. All anticipated equipment is gathered and inspected by the circulator to make certain that all equipment is safe and functional before the surgery. Depending on the procedure and position required, the circulator makes up the operating bed (formerly called the OR table) with gel pads (to prevent pressure sores) and heating pads (to prevent hypothermia) under the sheets as indicated.
If there is no holding room nurse, the circulator assumes the responsibilities of that nursing role as well. Even when there is a holding room nurse, the circulator also greets the client and reviews findings with the holding area nurse, because the circulator is responsible for continuity of care.
Once the client is ready to move into the OR, the circulating nurse assists the OR team in the transfer to the operating bed. The nurse then positions the client, protecting bony prominences with extra padding as indicated while providing comfort and reassurance. While comforting and observing the client, the circulating nurse also assists the anesthesiologist or CRNA with the induction of anesthesia. The circulator then may “prep” (scrub) the surgical site before the client is draped with sterile drapes.
Throughout the surgery, the circulating nurse:
• Monitors traffic in the room
• Assesses the amount of urine and blood loss
• Reports findings to the surgeon and anesthesia personnel
• Ensures that the surgical team maintains sterile technique and a sterile field
• Anticipates the client’s and surgical team’s needs, providing supplies and equipment as needed
• Communicates information regarding the client’s status with family members during long and unique procedures
• Documents care, events, interventions, and findings
Depending on facility policy, the circulating nurse may obtain and record medications, blood, and blood components. (This may be partially a function of anesthesia personnel.)
Before the surgical procedure is over, the circulating nurse completes documentation (Figure 18-2; see also Figure 18-1). The nurse notes drains or catheters in place, the length of the surgery, and a count of all sponges, “sharps” (needles, blades), and instruments. The nurse notifies the postanesthe-sia care unit (PACU) of the client’s estimated time of arrival and any special needs.
SCRUB NURSE AND SURGICAL TECHNOLOGIST.
The scrub nurse and/or the surgical technologist sets up the sterile field (Figure 18-3), assists with draping the client, and hands sterile supplies, sterile equipment, and instruments to the surgeon and the assistant. Knowledge of anatomy and physiology, as well as familiarity with the surgical procedure, allows the scrub nurse to anticipate the progression of the procedure and determine which instruments and types of sutures the surgeon will need. The nurse’s ability to anticipate these needs reduces the duration of anesthesia for the client. Furthermore, the surgeon’s anxiety and tension can be minimized with a scrub nurse who is familiar with the procedure and demonstrates the ability to anticipate and respond accordingly. Throughout the surgical procedure, the scrub nurse (with the circulating nurse) maintains an accurate account of the sponges, sharps, instruments, and amounts of irrigation fluid and medication used.
A specially trained person who is not a nurse may perform the scrub role. Such people are called operating room technicians (ORTs) or surgical technologists. Increasingly, certified surgical technologists (CSTs) are used in the perioperative environment.
Figure 18-3 • Setting up the sterile table.
SPECIALTY NURSE. The specialty coordinator nurse is educated in a particular type of surgery (e.g., orthopedic, cardiac, ophthalmologic) and is responsible for intraoperative nursing care specific to clients needing that type of surgery. The specialty coordinator nurse serves a critical role by assessing, maintaining, and recommending equipment, instruments, and supplies used in that specialty. They also typically are responsible for orienting and evaluating staff members to this service. During surgery the specialty nurse may function as the scrub or circulating nurse.
If the facility has laser technology, nurses specially trained in the use, care, and maintenance of the laser should be on hand. Such a nurse may be called a laser specialty nurse or a laser nurse coordinator.
Laser is an acronym for light amplification by the stimulated emission of radiation. A laser emits a high-powered beam of light that cuts tissue cleaner than do scalpel blades. This process produces intense heat for rapid coagulation of blood vessels or tissue and can turn tissue (such as a tumor) into vapor. It is essential for all personnel to observe safety measures (e.g., eye shields, door signs) during laser procedures. Improper laser use and inadequate safety measures increase the risk for injury to both the client and staff.
Preparation of the Surgical Suite and Team Safety
During the intraoperative phase, when the client is unable to protect himself or herself, all members of the surgical team must provide protection. The operating room (OR) layout is designed to prevent infection by limiting the source of contaminants by air exchanges in the room and limiting the traffic and extraneous activities in the OR. Safety straps are used for the client, and the operating bed is locked in place. Heating pads are used to prevent hypothermia, and interventions are instituted to prevent skin breakdown.
The nurse ensures electrical safety through proper placement of grounding pads and use of electrical equipment that meets safety standards. All equipment that might be used during surgery must be functional and in proper working condition, checked per safety procedure of that facility, and appropriately cleaned and, when required, sterilized so that it can be used as a part of the procedure. The scrub and circulating nurses together ensure a correct count of surgical instruments, sharps, and sponges immediately before the beginning of the procedure, during the procedure, and immediately after the close of the surgical incision.
Fire prevention is of utmost concern to OR personnel, as is prevention of complications associated with the use of hazardous and potentially toxic substances. A cool room temperature (between 68° and 73° F [20° to 30° C]), with a low relative humidity of 30% to 60% is optimal, and staff and clients must be protected against thermal or chemical burns caused by fire or spills. The nurse is aware of appropriate emergency measures to take in the event of a fire or spill.
LAYOUT
The surgical suite should be located out of the mainstream of the hospital or facility and adjacent to the postanesthesia care unit (PACU) and support services (e.g., blood bank, pathology and laboratory departments). Traffic flow should be patterned to ensure minimal contamination from outside the suite. Within the suite, clean and contaminated areas must be separate. According to AORN, the Association of periOpera-tive Registered Nurses, designation of the surgical area into three zones as unrestricted, semirestricted, and restricted facilitates appropriate movement of clients and personnel.
The size of a surgical suite depends on the size and surgical capabilities of the facility. The average suite contains staff changing rooms (staff locker rooms) and staff lounges, an admission or preoperative holding area, a scrub area for staff, a number of ORs, designated cabinets for sterile supplies, separate utility rooms for clean and soiled equipment, and a clean linen room.
Figure 18-4 shows a typical OR. The exact number of tables and specialized equipment used in the room is based on the needs of each client. A reliable communication system links the OR and the main desk of the surgical unit or suite to ensure safe client care. The system should include an intercom and the capability to differentiate between routine and emergency calls.
HEALTH AND HYGIENE OF THE SURGICAL TEAM
People are a major source of bacteria in the surgical setting. Everyone has a large number of potentially pathogenic bacteria on the skin and hair and in the respiratory tract. Because these pathogens can be transmitted to the client, special health standards and dress are required. Every surgical environment has written policies and procedures regarding personnel and acceptable attire. Health standards require that all members of the surgical team and other support personnel in the surgical suite be free from communicable diseases. Anyone who has an open wound, cold, or other infection should not participate in surgery.
Good personal hygiene aids in the prevention and control of infection, as does frequent and appropriate handwashing. Shedding of microorganisms and skin debris is greatest immediately after showering, so surgical staff should bathe a few hours before changing into OR attire. Jewelry, which can carry multiple microorganisms, should be minimal. In preparing for surgery, all personnel must wash their hands between procedures and more frequently when indicated. Microbial specimens from the hands of surgical personnel may be obtained for culture periodically to maintain an awareness of the potential for nosocomial (hospital-acquired) infections and to identify the source of pathogenic invasion. Further interventions or cultures are necessary if quality reports (e.g., through the facility’s quality improvement program or quality reviews) indicate
Figure 18-4 A, A typical operating room
Figure 18-4 B, A typical anesthesia station with an anesthesia machine.
SURGICAL ATTIRE
All members of the surgical team and all OR personnel must wear scrub attire. Scrub attire is clean, not sterile. It is worn to decrease contamination from microorganisms. The basic attire of personnel entering the operating suite consists of a shirt and pants, a cap or hood (Figure 18-5), and shoe coverings. Staff change into clean surgical attire in the operating suite locker rooms, not at home. All members of the surgical team must cover their hair, including facial hair when present. In addition to basic attire, everyone must wear appropriate protective body attire depending on the situation. This includes a mask, eyewear, gloves, gown, and shoe covers. Everyone who enters an OR where a sterile field is present must wear a mask. Members of the surgical team who are scrubbed to be at the bedside of the client during the surgical procedure must also be in a sterile fluid-resistant gown, with sterile gloves and eye protectors (Figure 18-6). Members of the surgical team in the OR who are not scrubbed (e.g., anesthesiologist and circulating nurse) usually wear cover scrub jackets to prevent shedding of organisms from bare arms and eyewear, as warranted.
Figure 18-5 • An example of a hood-type hair covering that adequately covers facial and scalp hair.
Figure 18-6 • Typical attire for all scrubbed personnel. Note complete hair covering, eye shields, mask, sterile gloves over the sleeves of the sterile gown, and shoe coverings. Note that wheot in use, the hands are typically folded in front of the body, never below the waist.
SURGICAL SCRUB
The surgeon, all assistants, and the scrub nurse perform a surgical scrub after putting on a mask and before putting on the sterile gown and gloves (Figure 18-7). The scrub does not make the hands and forearms sterile; however, when it is effectively carried out, it reduces the number of microorganisms from the hands, arms, and nails. Rings, watches, and bracelets are removed before scrubbing.
A disposable scrub brush or sponge, impregnated with an antimicrobial solution, and a nail cleaner are used. As with handwashing, the effectiveness of the scrub depends on the application of friction from the fingertips to the elbow. The surgical scrub usually continues for 3 to 5 minutes, followed by a rinse. During the rinse, surgical personnel position their hands and arms in such a way that water runs off, rather than up or down, their arms. After scrubbing, personnel enter the OR with their hands held higher than the elbows and thoroughly dry their hands and forearms with a sterile towel. The scrubbed staff member is then assisted into a sterile gown (“gowning”) and puts on sterile gloves (“gloving”).
Gowns, gloves, and materials used at the operative field must be sterile and are changed between surgical procedures and as they become contaminated. The areas of the surgical gown considered sterile are the front of the gown from
Anesthesia
The word anesthesia comes from the Greek word anesthesis, meaning “negative sensation.” Administration of anesthesia is an exact and sophisticated science. It requires the skill of a licensed anesthesiologist, a certified registered nurse anesthetist (CRNA) working under the direction of an anesthesiologist or another physician, or an anesthesiologist’s assistant (AA)—which is similar to a physician’s assistant—working under the direction of an anesthesiologist.
Figure 18-7 • The scrubbing, gowning, and gloving process.
A, The surgical scrub.
B, Rinsing. Note the water falling off the hands and arms. Also note the foot-operated handle that controls the water flow. (After scrubbing and rinsing, the scrub nurse dries his hands and arms with a sterile towel inside the operating room and then is assisted into a sterile gown.)
C, The scrub nurse prepares sterile gloves. Note that the scrub nurse’s hands are inside the sleeves of the gown and that he is touching the sterile gloves only with the sterile sleeves.
D, The scrub nurse puts on his first sterile glove while the sterile gown is being tied in the back. Note again that his hand never emerges from under the sterile sleeve.
E, The scrub nurse puts on his second sterile glove.
Anesthesia is an artificially induced state of partial or total loss of sensation, occurring with or without loss of consciousness. The purpose of anesthesia is to block the transmission of nerve impulses, suppress reflexes, promote muscle relaxation, and in some cases, achieve a controlled level of unconsciousness. Anesthesia providers use a separate anesthesia record for documentation.
Usually the anesthesia provider determines the choice of anesthesia after consultation with the client and surgeon, and after consideration of specific client-related factors. The nurse or client or both communicate the preference and fears related to a particular type of anesthesia to the anesthesia provider. Specific problems noted in the client’s history or preoperative physical examination are major factors in the selection and dosage of anesthesia. Selection is also influenced by the following:
• Type and duration of the procedure
• Area of the body being operated on
• Whether the procedure is an emergency
• Options for management of postoperative pain
• How long it has been since the client ate, had any liquids, or any medications
• Client positioeeded for the surgical procedure
The administration of anesthesia begins with the selection and administration of preoperative medication, if any. The nurse must know the pharmacologic characteristics of commonly used agents and their effects during and after surgery. Anesthesia produces multiple systemic effects, which can affect the client’s care and can compound other coexisting problems. For example, most anesthetics are metabolized by the liver and excreted by the kidneys. Liver or kidney impairment can increase anesthetic effects and the risk for toxicity. In addition, drug interactions may occur between the anesthetic agents and other medications the client has been receiving.
The state of anesthesia may be produced in a number of ways (Table 18-1):
• General or balanced anesthesia
• Local or regional anesthesia
• Hypnosis or hypnoanesthesia
• Cryothermia
• Acupuncture
Hypnosis or hypnoanesthesia (which induces a passive, trancelike state), cryothermia (use of cold [e.g., ice] to lower the surface temperature of the surgical site), and acupuncture are not commonly used in the
Most controllable method
Induction and reversal accomplished with pulmonary
ventilation Few side effects
Rapid and pleasant induction
Low incidence of postoperative nausea and vomiting
Requires little equipment
Minimal disturbance to physiologic function
Minimal side effects
Can be used with older and high-risk clients
Gag and cough reflexes stay intact
Allows participation and cooperation by the client
Less disruption of physical and emotional body functions
Decreased chance of sensitivity to the agent Decreased intraoperative stress
Must be used in combination with other agents for painful or prolonged procedures Limited muscle relaxant effects Postoperative nausea and shivering common Explosive
Must be metabolized and excreted from the body for complete reversal Contraindicated in presence of hepatic or renal Disease
Increased cardiac and respiratory depression Retained by fat cells
Drug interactions can occur Pharmacologic effects on the body may be unpredictable
Difficult to administer to an uncooperative or upset client
No way to control agent after administration Absorbs rapidly into the blood and causes cardiac depression (hypotension) or overdose Increased nervous system stimulation (overdose) Not practical for extensive procedures because of the amount of drug that would be required to maintain anesthesia
GENERAL ANESTHESIA
General anesthesia is a reversible state in which the client loses consciousness as a result of the inhibition of neuronal impulses in the several areas of the central nervous system (CNS). The administration of a single agent or a combination of chemical agents achieves this state. The anesthetic agents used induce CNS depression, characterized by analgesia (pain relief or pain suppression), amnesia (memory loss of the surgery), and unconsciousness, with loss of muscle tone and reflexes. The client is unconscious, unaware, and anesthetized. Indications for general anesthesia include surgery of the head, neck, and upper torso; extensive abdominal surgery; and situations in which clients are unable to cooperate.
STAGES OF GENERAL ANESTHESIA.
Four stages of general anesthesia are classically described.
The speed of emergence, or recovery from the anesthesia, depends on the type of anesthetic agent, the length of time the client is anesthetized, and whether a reversal agent for the neuromuscular blocking agent has been administered. Although they are not as common as they once were (because of advances made in the pharmacology of anesthesia), retching, vomiting, and restlessness may occur during emergence. The nurse has suction equipment available to prevent aspiration. During recovery, shivering, rigidity, and slight cyanosis are not uncommon. These phenomena may reflect a temporary disturbance in the body’s temperature control. The nurse provides the client with warm blankets, radiant light, and oxygen to decrease the undesirable effects of emergence.
ADMINISTRATION OF GENERAL ANESTHESIA.
The two methods of administering general anesthesia are inhalation and IV injection.
INHALATION.
Inhalation is the most controllable method of administering general anesthesia because intake and elimination of the anesthetic are accomplished primarily by respiration. The lungs act as a passageway for entrance and exit of the anesthetic agent. The client inhales the anesthetic vapor of a volatile liquid or the anesthetic gas via a mask. The anesthetic then passes across the alveolar membrane to the general circulation. The agent is transported through the bloodstream to the various tissues, where it is metabolized.
To improve ventilation and control the anesthesia, respiration may be assisted or controlled. With assisted respiration, an endotracheal (ET) tube is inserted. The ET tube is then connected to a reservoir (breathing) bag of the anesthesia machine (see Figure 18-4). The anesthesiologist overrides, or “assists,” the client’s own respiratory effort to initiate the respiratory cycle by manually compressing the reservoir bag.
Controlled respiration is accomplished with the use of a mechanical device, such as a mechanical ventilator, that automatically and rhythmically inflates the lungs with intermittent positive pressure; the client is not required to participate. Controlled ventilation is initiated after the anesthesiologist has produced apnea (absence of spontaneous respiratory effort) either through hyperventilation or by administering a respiratory depressant or neuromuscular blocking agent.
The anesthesiologist or certified registered nurse anesthetist (CRNA) inserts the ET tube with the assistance of the circulating nurse. A laryngoscope is used to visualize the vocal cords, and the tube is placed in the trachea (Figure 18-9).
Figure 18-9 • An oral endotracheal tube in position. The cuff of the tube was placed just below the vocal cords, then inflated to seal off the airway.
With the ET tube safely in place, the client has an open airway (through the tube) and an avenue for the safe administration of the inhaled anesthetic and oxygen.
Inhalation anesthetic agents are divided into two categories: gases and volatile agents.
GASEOUS AGENTS. In the past, gaseous agents included ether and cyclopropane gas. Nitrous oxide (N2O) is now the most commonly used gaseous anesthetic agent and is usually administered with oxygen. It is a colorless, odorless, nonirri-tating gas that provides analgesia equivalent to 10 mg of morphine sulfate.
VOLATILE AGENTS. Liquids vaporized for inhalation are considered volatile agents. Oxygen acts as a carrier, flowing over or bubbling through the liquid in the vaporizer system on the anesthesia machine. All volatile agents can produce postoperative shivering in the client because of their effect on the hypothalamus. Awakening is usually rapid, within 15 to 20 minutes.
Halothane (Fluothane). Halothane is a halogenated hydrocarbon that depresses the cardiovascular system. The intraoperative use of epinephrine to control bleeding may increase or precipitate a dysrhythmia when halothane is used. Clients can have memory impairment for up to 24 hours after halothane is used.
Enflurane (Ethrane). Enflurane is an inhalation anesthetic agent that reduces ventilations and decreases blood pressure as the depth of anesthesia increases.
Isoflurane (Forane). Isoflurane is another halogenated compound and appears to be a preferred inhalation agent.
Desflurane (Suprane). Desflurane produces a rapid induction of anesthesia but can cause coughing and excitation during the process. The rapid elimination of desflurane produces awakening in 8 to 10 minutes. Cardiopulmonary depressant effects and malignant hyperthermia are the most common adverse effects.
Sevoflurane (Sevorane). Sevoflurane is like desflurane, except less coughing and laryngospasm occur with sevoflurane. Adverse effects are similar to those associated with desflurane.
INTRAVENOUS INJECTION.
IV anesthetic agents are injected, usually through a peripheral IV line, into the circulation. A pleasant, rapid, and smooth dissipation of the agent occurs. The drug is diluted by the blood, but still travels in high concentration to the organs of high blood flow (brain, liver, and kidneys). The reversal and removal of the agent from circulation are not possible with IV injection, and the recovery from the agent is directly related to the client’s metab-olism.
BARBITURATES. Barbiturates are often used for IV induction of anesthesia. These drugs act directly on the central nervous system (CNS), producing a reaction ranging from mild sedation to unconsciousness. The principal barbiturate used is thiopental sodium (Pentothal), which can also be used for rectal induction. Intravenously, it acts rapidly, resulting in unconsciousness within 30 seconds of administration. Because thiopental is a potent respiratory and cardiovascular system depressant, the client’s vital signs must be monitored continuously during administration.
KETAMINE (KETALAR). Ketamine is a dissociative anesthetic agent (one that promotes a feeling of dissociation from the environment). It acts by selectively interrupting various pathways in the brain. Rapid onset of a trancelike, analgesic state occurs. Ketamine is commonly used for diagnostic and short surgical procedures or to supplement weaker agents, such as nitrous oxide.
Emergence reactions are expected during recovery from ketamine. The operating room (OR) nurse reports the use of the drug to the postanesthesia nurse so that safety precautions can be implemented. If the client is combative or restless, the nurse pads the siderails of the bed to prevent injury. The nurse minimizes external stimuli until the client awakens naturally.
For severe reactions during the recovery phase, small doses of diazepam (Valium, Vivol, Novo-Dipam) may be given as needed. The medical-surgical nurse continues interventions until the effects of the drug have worn off.
PROPOFOL (DIPRIVAN). Propofol is in a newer classification of IV anesthetic agents, the alkylphenols. Its short action makes it desirable as an anesthetic agent. Hypnosis occurs in less than 1 minute from the time of injection, and because the drug is so rapidly metabolized, it does not accumulate during maintenance of the anesthesia. The client becomes responsive quickly after the infusion is ended (within 8 minutes). Propofol is also used to supplement nitrous oxide during short procedures and is used as a hypnotic agent with regional anesthesia.
ADJUNCTS TO GENERAL ANESTHETIC AGENTS.
Other drugs, such as hypnotics, opioid analgesics, and neuromuscular blocking agents, may be used as part of the anesthesia regimen.
HYPNOTICS. The benzodiazepines may be used for various effects. Common drugs in this classification include mi-dazolam (Versed), lorazepam (Ativan, Novolorazem), and diazepam (Valium, Vivol, Novo-Dipam). All have hypnotic, sedative, antianxiety, muscle relaxant, and amnesic effects. Generally, lower doses are ordered for preoperative sedation. Each drug may be used as part of an IV conscious sedation regimen for diagnostic or endoscopic procedures. Higher doses of midazolam may be used to induce general anesthesia. The benzodiazepines may also be used intraoper-atively in conjunction with regional or local anesthesia. Adverse reactions include respiratory depression, apnea, and oversedation.
OPIOID ANALGESICS. Common opioid analgesics used to supplement inhalation anesthesia include morphine sulfate (Statex+0, meperidine hydrochloride (Demerol), fentanyl citrate (Sublimaze), and sufentanil (Sufenta). The use of opioids during surgery contributes to postoperative analgesia. All opioid analgesics are respiratory depressants and decrease alveolar ventilation. The nurse monitors respirations and maintains an open airway. Reduced dosages are prescribed for older clients, clients with a circulatory problem (e.g., heart failure), and debilitated clients.
Fentanyl and sufentanil induce analgesia in lower doses, but at higher doses they can be used as the anesthetic agent. Fentanyl has a potency 75 to 125 times greater than that of morphine. Sufentanil has five to seven times the analgesic potency of fentanyl and produces a more rapid onset of CNS effects than does fentanyl. It is often used in open heart surgery when the sternum must be opened. The nurse monitors the client who has received sufentanil for bradycardia and decreased cardiac output.
NEUROMUSCULAR BLOCKING AGENTS.
The neuromuscular blocking agents are used to relax the jaw and vocal cords immediately after induction so that the anesthesiologist or certified registered nurse anesthetist (CRNA) can place the endotracheal (ET) tube. These drugs are also used throughout the surgical procedure to provide continued overall muscle relaxation. Neuromuscular blocking agents act on the skeletal muscles of the body by interfering with impulse transmission at the neuromuscular junction. The drugs are administered intravenously in small amounts and may cause circulatory alterations, decreased respirations, or apnea from muscle paralysis. The nurse ensures the client’s safety by securing him or her on the operating bed with safety straps and assists the anesthesiologist or CRNA with intubation. Throughout the surgery, the anesthesiologist or CRNA checks the effectiveness of the blocking agent by using a peripheral nerve stimulator. There are two types of neuromuscular blocking agents: nondepolarizing and depolarizing.
NONDEPOLARIZING BLOCKING AGENTS. The non-depolarizing blocking agents block acetylcholine at the neuromuscular junction. Only skeletal muscles are blocked, and the drug is easily reversed with an antidote of neostigmine and atropine. Examples of nondepolarizing blocking agents include pancuronium (Pavulon), atracurium (Tracrium), ve-curonium (Norcuron), doxacurium (Nuromax), tubocurarine (Tubarine), and mivacurium (Mivacron). Pancuronium has a relatively long effect (45 to 60 minutes) compared with ve-curonium (25 to 30 minutes) or mivacurium (6 to 16 minutes). The longer the duration of drug action, the longer it takes for the client to recover.
DEPOLARIZING BLOCKING AGENTS. The depolarizing blocking agents, also called “noncompetitive” blocking agents, depolarize the motor end plate at the neuromuscular junction. In the process, potassium is forced out of the muscle cells and into general circulation, which can cause hyperkalemia. Clients often experience transient intraoperative muscle twitching, which can result in generalized muscle aches after awakening. Other side effects include increased salivation (increasing the risk for aspiration) and increased intraocular pressure (thus the agents may be contraindicated with glaucoma). An example of a commonly used depolarizing blocking agent is succinylcholine (Anectine). There is no specific antidote for these agents.
BALANCED ANESTHESIA.
In the past, the term balanced anesthesia was used when various combinations of IV medications were balanced to provide complete anesthesia. Today, the term is used to describe a combination of both IV medication and inhalation agents employed to obtain specific effects. Balanced anesthesia provides a safe and controlled anesthetic experience, especially for older and high-risk clients. A combination is used to provide hypnosis, amnesia, analgesia, muscle relaxation, and relaxation of reflexes with minimal disturbance of physiologic function. An example of balanced anesthesia is the use of a barbiturate (such as thiopental) administered intravenously for induction, nitrous oxide administered by inhalation for amnesia, morphine for analgesia, and a muscle relaxant (such as pancuronium) administered intravenously to provide additional muscle relaxation.
A second example of balanced anesthesia is the use of 70% nitrous oxide for induction and maintenance (to prevent awareness throughout the procedure and to prevent recall afterward), 30% oxygen to maintain oxygenation saturation at greater than 90%, an opioid, and a muscle relaxant. Many combinations are possible, and selection reflects assessment of the individual client and the specific surgical procedure.
COMPLICATIONS FROM GENERAL ANESTHESIA OR ANESTHESIA MANAGEMENT.
Complications can range from minor and annoying (sore throat) to the most severe and irreversible—death. Despite surgical procedures being performed on increasingly sicker and higher-risk clients, however, there has been a significant decline in anesthesia-related deaths during the last 30 years (Voelker, 1995).
MALIGNANT HYPERTHERMIA.
Malignant hyperthermia (MH) is an acute, life-threatening complication of general anesthesia that may be triggered by drugs commonly used in anesthesia. Inhalational anesthetics and succinyl-choline are the most frequently implicated triggering agents. MH is a multifactorial disease and is genetically transmitted as an autosomal dominant trait. The client with a genetic predisposition for MH is at risk for this complication from agents such as halothane, enflurane, isoflurane, desflurane, sevoflu-rane, and succinylcholine. Stressors such as severe fatigue, strenuous exercise, trauma or muscle injury, and emotional stress may also trigger this crisis.
This rare but potentially deadly syndrome is most common in children and young adults. A biochemical reaction begins with a defect in skeletal muscle calcium regulation, and exposure to specific triggering stimuli results in intracellular hy-percalcemia leading to increased metabolism. This hypermetabolic condition results in an increase in the circulating calcium level, an increase in the metabolic rate, hyper-kalemia, metabolic and respiratory acidosis, cardiac dysrhythmias, and rapid elevation of the body temperature.
Onset of MH may occur immediately after induction of anesthesia, several hours into the procedure, or rarely, once the anesthetic has been terminated. Clinical features reflect the increased intracellular muscle calcium concentration and the greatly increased body metabolism. Common manifestations include tachycardia or other dysrhythmias; muscle rigidity (apparent in 75% of all MH cases), especially of the jaw and upper chest; hypotension; tachypnea; and skin mottling, cyanosis, and myoglobinuria (cola-colored urine). The most sensitive indication is an unexpected rise in the end-tidal carbon dioxide level with a decrease in oxygen saturation (Dunn, 1997). The second indication may be unexplained sinus tachycardia. Extremely elevated temperature, perhaps as high as 111.2° F (44° C), is a late sign ofMH. Treatment and survival of the client depend on early diagnosis and the cooperation of the entire surgical team. Time is crucial when MH is diagnosed. Dantrolene sodium, a skeletal muscle relaxant, is the medication of choice along with other interventions.
Once a client or family history of MH is known, close family members can undergo a muscle biopsy to determine whether they are at risk. In the case of a known history or predetermination, the client can be treated preoperatively, intra-operatively, and postoperatively with dantrolene to prevent this complication.
OVERDOSE.
An anesthesia overdose can occur if the client’s metabolism and drag elimination do not react or respond as expected. Drugs (e.g., antihypertensive medications) also alter anesthesia metabolism, and drug interactions can occur between the anesthetic agents and other regularly administered medications. Accurate, accessible information about the client, such as height, weight, and history, is vital in determining the anesthetic type and dosage. Intraoperative death, however, is more often related to pre-existing health problems than to overdose of anesthetics.
UNRECOGNIZED HYPOVENTILATION.
The respiratory system is most frequently involved when the client experiences an anesthesia-induced complication. Failure to ventilate adequately can lead to cardiac arrest, central nervous system (CNS) damage (e.g., permanent brain damage), and death. Monitoring standards include the use of an end-tidal carbon dioxide monitor to confirm carbon dioxide in the client’s expired gas and a breathing system disconnect monitor to detect any break in the breathing circuit equipment.
COMPLICATIONS RELATED TO SPECIFIC ANESTHETIC AGENTS.
Specific complications are discussed earlier in the chapter. The older or debilitated client may be more susceptible to complications of anesthesia because of intolerance to the agent, decreased metabolism, or his or her general physical condition. (For preoperative risk factors, see Chapter 17.)
COMPLICATIONS OF INTUBATION. Many complications can occur from intubation (e.g., broken or injured teeth and caps, swollen lip, or vocal cord trauma). Intubation may be difficult because of the individual anatomy or disease process (e.g., small oral cavity, tight mandibular joint, or presence of tumor). Improper extension of the neck during intubation also may cause injury. The surgeon should be in the operating room (OR) during the intubation process in case an emergency arises (e.g., a tracheostomy is needed) when the endotracheal (ET) tube is placed. Placement of the ET tube causes some degree of irritation and edema of the trachea and accounts for the client’s sore throat postoperatively.
LOCAL OR REGIONAL ANESTHESIA
Local or regional anesthesia temporarily interrupts the transmission of sensory nerve impulses from a specific area or region. Motor function may or may not be affected, and the client does not lose consciousness. Thus the client is able to follow instructions throughout the procedure. Because the gag and cough reflexes remain intact, there is little risk of aspiration or complications from hypoventilation. Local or regional anesthesia is typically supplemented with sedatives, opioid analgesics, and/or hypnotics to reduce anxiety and increase comfort.
The OR nurse provides the client with information, directions, and emotional support before, during, and after the procedure. Table 18-5 describes various local and regional anesthetic agents and related nursing implications.
LOCAL ANESTHESIA.
Techniques used to administer local anesthesia include topical anesthesia and local infiltration. Sometimes when the term local is used, it means any form of anesthesia that is not general anesthesia.
TOPICAL ANESTHESIA.
Topical anesthesia involves use of an anesthetic agent applied directly to the surface of the area to be anesthetized. Often the anesthetic is an ointment or spray. This method is often used for respiratory intubation and for diagnostic procedures, such as laryngoscopy, bron-choscopy, or cystoscopy. The onset of action is 1 minute, and the duration is 20 to 30 minutes. Collapse or depression of the cardiovascular system is a potential complication of topical anesthetic agents applied to the respiratory tract.
LOCAL INFILTRATION.
Local infiltration is the injection of an anesthetic agent intracutaneously and subcuta-neously into the tissue surrounding an incision, wound, or lesion. The anesthetic agent blocks peripheral nerve stimulation at its origin. Local infiltration is commonly used during the suturing of superficial lacerations.
REGIONAL ANESTHESIA
Regional anesthesia, a type of local anesthesia, may be used as follows:
· When general anesthesia is contraindicated because of the presence of medical problems (e.g., dysrhythmias and respiratory disease)
· When the client has experienced previous adverse reactions to general anesthesia
· When the client has a preference and a choice is possible
· When pain management postoperatively is enhanced by regional anesthesia
If the client has eaten and the surgery is an emergency, it may be possible to perform the procedure with the client under regional anesthesia (depending on the procedure) to decrease the risks associated with gastric contents (e.g., aspiration). Types of regional anesthesia include field block, nerve block, spinal, and epidural.
FIELD BLOCK.
A field block is produced by a series of injections around the operative field. Injecting around a specific nerve or group of nerves depresses the entire sensory nervous system of a localized area. This type of blocking is used for thoracic procedures, herniorrhaphy (hernia repair), dental procedures, and plastic surgery.
NERVE BLOCK.
A nerve block is achieved by injection of the local anesthetic agent into or around a nerve or group of nerves supplying the involved area. Nerve blocks interrupt sensory, motor, and sympathetic transmission. They are used surgically to prevent pain during a procedure, diagnos-tically to identify the cause of pain, and therapeutically to relieve chronic pain and increase circulation in some vascular diseases.
Figure 18-10 shows commoerve block sites. Lido-caine (Xylocaine) or bupivacaine (Marcaine) is frequently the agent used. A nerve block takes effect within minutes after the injection, and the anesthesia lasts longer than that achieved with local infiltration. Epinephrine added to the anesthetic agent potentates the drug, causing a prolonged effect. Seizures, cardiac depression, dysrhythmias, and/or respiratory depression may occur if the nerve-blocking agent is injected accidentally into the bloodstream. The nurse observes for signs of systemic absorption, sensitivity, or overdose.
Figure 18-10 • Nerve block sites.
SPINAL ANESTHESIA.
Spinal anesthesia—intrathecal block—is achieved by injection of the anesthetic agent into the cerebrospinal fluid in the subarachnoid space (Figure 18-11). The drug acts on the nerves as they emerge from the spinal cord and before they leave the spinal canal, thereby inhibiting conduction in the autonomic, sensory, and motor systems. The drag is rapidly absorbed into the nerve fibers and produces analgesia with relaxation, which is effective for lower abdominal and pelvic surgical procedures.
EPIDURAL ANESTHESIA. The anesthetic agent is injected into the epidural space so that the protective coverings of the spinal cord (dura mater and arachnoid mater) are never entered. Because the anesthetic can diffuse or float up the vertebral column, the client can achieve anesthetic effects as high as the T4 level; however, potential respiratory complications may make injection at this high a level undesirable.
Epidural anesthesia is used for anorectal, vaginal, and per-ineal procedures, as well as for hip and lower extremity oper-ations, such as total hip or knee replacements. Two important advantages are associated with this type of anesthesia:
• Decreased cardiopulmonary complications, which is particularly important for the older client
• Ability to retain the epidural catheter for postoperative analgesic administration
COMPLICATIONS OF LOCAL OR REGIONAL ANESTHESIA.
Major intraoperative complications of local or regional anesthesia are usually related to client sensitization to the anesthetic agent (anaphylaxis), incorrect administration technique, systemic absorption, or overdosage. The nurse observes for signs of a systemic toxic reaction, manifested by central nervous system (CNS) stimulation followed by CNS and cardiovascular depression. The nurse assesses for initial behaviors indicating a problem, such as restlessness, excitement, incoherent speech, headache, blurred vision, metallic taste, nausea, vomiting, tremors, seizures, and increased pulse, respirations, and blood pressure. Nursing interventions include establishing and maintaining an open airway, administering oxygen, and notifying the surgeon. Usually it is necessary to administer a fast-acting and short-acting barbiturate. If the client’s toxic reaction remains untreated, unconsciousness, hypotension, apnea, cardiac arrest, and death may result.
A cardiac arrest may occur as a rare complication of spinal anesthesia, possibly related to unknown autonomic nervous system effects. Administration of epinephrine to a client who develops sudden, unexplained bradycardia may prevent cardiac arrest (Biddle, 1994).
Local complications include edema and inflammation, as early problems, with possible abscess, necrosis, and/or gangrene later. Inflammation and abscess usually result from a break in sterile technique occurring at the time of injection of the anesthetic agent. Necrosis and gangrene are rare but may occur as a result of prolonged vasoconstriction in the area of the injection.
The nurse’s role in the administration of regional anesthesia consists of the following:
· Assisting the anesthesia provider
· Observing for breaks in sterile technique
· Providing physical and emotional support for the client
· Staying with the client
· Offering information, encouragement, and reassurance
· Positioning the client comfortably and safely
Figure 18-11 • Administration of spinal and epidural anesthesia.
A, Spinal or epidural anesthesia is administered by inserting a spinal needle between the second and third or the third and fourth lumbar vertebrae (L2-3 or L3-4). The client is placed in the flexed lateral (fetal) position (shown here) or seated on the edge of the operating bed with the back arched and the chin tucked to the chest.
B, Spinal anesthesia (viewed from the side). A large needle is inserted to the surface of the dura mater, and a second, smaller needle is passed through the first to penetrate the dura mater and arachnoid mater. An anesthetic in injected, sometimes through an indwelling catheter, directly into the cerebrospinal fluid in the sub-arachnoid space.
C, Epidural anesthesia (viewed from the side). The needle is inserted to the surface of the dura mater, and the anesthetic is injected, usually through an indwelling catheter, into the epidural space.
CONSCIOUS SEDATION
Conscious sedation refers to the IV administration of sedative, hypnotic, and opioid medications to produce a condition in which the client has a depressed level of consciousness but retains the ability to independently maintain a patent airway and respond appropriately to verbal commands or physical stimulation. A rapid, safe return to activities of daily living is usually achieved with some degree of amnesia with conscious sedation. Diazepam (Valium, Vivol4*, Novo-Dipam^), mida-zolam (Versed), meperidine (Demerol), fentanyl (Sublimaze), alfentanil (Alfenta), and morphine sulfate are the most commonly used drugs. Conscious sedation is typically used for procedures such as endoscopy, cardiac catheterization, closed fracture reduction, percutaneous transluminal cardiac angiog-raphy (PTCA), cardioversion, and other special but relatively short procedures.
Selection of clients for conscious sedation is based on established criteria developed by an interdisciplinary team. The physician determines whether the client is a candidate. In most states, a credentialed registered nurse may administer conscious sedation under physician supervision and within the state-defined scope of nursing practice (
The nurse monitors the client during and after the procedure for his or her response to the procedure and drag administration. Specific responsibilities include careful monitoring of the client’s airway, level of consciousness, oxygen saturation via pulse oximetry, electrocardiographic (ECG) status, and vital signs every 15 to 30 minutes until he or she is fully awake, alert, and oriented, and vital signs have returned to preprocedural levels.
The client receiving IV conscious sedation may be discharged to go home with a responsible adult. If the client returns to the general medical-surgical nursing unit, the unit staff nurses continue to monitor him or her. The client is expected to be sleepy but arousable for several hours after the procedure. The nurse usually does not permit oral intake until 30 minutes after the client has received medication or according to the physician’s orders. When fluids are permitted, the nurse makes sure that the client is awake and positioned to avoid aspiration.
On arrival in the surgical suite, the client is taken to the holding area or directly into the operating suite. The holding area nurse and/or the circulating nurse greets the client on arrival. Correct identification of the client is the responsibility of every member of the health care team. The nurse verifies the client’s identity with his or her identification bracelet and asks, “What is your name?” This practice prevents errors that may occur. For example, if a client is asked, “Are you Mr. James?” He may respond inappropriately if he is drowsy, anxious, or sedated. The nurse always validates the identification obtained using the medical record and the client’s name and identification number.
After completing the identification process, the nurse validates that the surgical consent form has been signed and witnessed. The nurse asks the client, “What kind of operation are you having today?” to ascertain that his or her perception of the procedure, the operative permit, and the operative schedule coincide. This practice is especially important when the nurse is validating the side on which a procedure is to be performed (e.g., for amputation, cataract extraction, or hernia repair). Some facilities have the client and/or nurse initial the appropriate surgical site. Before proceeding, the nurse thoroughly investigates any discrepancy in information and notifies the surgeon and anesthesia provider.
The nurse asks the client about any allergies and determines if any autologous blood was donated. A red allergy bracelet on the client’s wrist and the medical record must be verified with what has been communicated.
The nurse checks the client’s attire to ensure compliance with facility policy. Dentures and dental prostheses (e.g., bridges and retainers), jewelry, eyeglasses, contact lenses, hearing aids, wigs, and other prostheses are removed for safety during surgery. The nurse pays special attention to the removal of dentures, because the denture plate could become loose and obstruct the airway during surgery. Occasionally the anesthesiology team may request that the dentures be left in place to ensure a snug fit of the anesthesia mask. In some facilities, clients may be permitted to retain their eyeglasses and hearing aids until after the induction phase of anesthesia.
MEDICAL RECORD REVIEW
The circulating nurse and anesthesia personnel review the client’s medical record in the holding area (or in the operating room [OR] if there is no holding area). The medical record provides informatioeeded to identify potential and actual needs of the client during the intraoperative period and allows the circulating nurse to assess and plan for his or her needs during and after surgery. The medical record is a primary source of information on the type and location of the planned surgical procedure. A check of the medical record ensures that all required data are present before the procedure is started.
ADVANCE DIRECTIVES AND DO-NOT-RESUS-CITATE ORDERS. The perioperative nurse is subject to ethical dilemmas in the surgical environment. As a client advocate, the perioperative nurse may have to intervene on behalf of the client’s rights and wishes. The perioperative nurse must be familiar with the advance directives and do-not-resuscitate (DNR) orders for each client.
The 1990 Patient Self-Determination Act requires health care providers to ask clients if they have advance directives. These directives are to be honored in the surgical environment regardless of the situation. It is difficult for some health care providers not to treat the client in the OR for an emergency situation, and they ignore advance directive or living will. In addition, it is a common practice to suspend DNR orders while a client is undergoing a surgical procedure. The position statement of AORN, the Association of periOperative Registered Nurses, regarding the perioperative care of clients with DNR orders states that automatically suspending a DNR order during surgery undermines a client’s right to self-determination (AORN, 1999b). Many institutions are addressing this issue along with advance directives in a way that protects the client’s rights in all environments.
ALLERGIES AND PREVIOUS REACTIONS TO ANESTHESIA OR TRANSFUSIONS.
In reviewing the medical record, the nurse asks about allergies and previous reactions to anesthesia or blood transfusions. Allergies or sensitivity to iodine products or shellfish may indicate the potential for a reaction to the antimicrobial agents used to clean the surgical area. Latex allergies or sensitivities must be assessed with all clients. Induced anaphylaxis accounts for about 10% of the life-threatening anaphylactic reactions that occur during surgery. Latex-free equipment and supplies must be used when allergies, sensitivity, or a familial history of latex allergy exists and poses a potential risk to the client. The nurse clearly indicates the allergies in the medical record and notifies the OR team.
The client’s previous experience with anesthesia helps the nurse and anesthesia provider plan and anticipate needs. For example, if a client is restless or agitated as a reaction to anesthesia, the nurse can have padding for the stretcher siderails and protective restraints available. The use of blood and blood products during surgery may be influenced by the client’s history, religious beliefs or preferences, and type of transfusion reaction in the past.
AUTOLOGOUS BLOOD TRANSFUSION.
Increasingly, autologous blood transfusion (reinfusing the client’s own blood) is being used for surgery. This method of blood transfusion eliminates the risk of acquiring bloodborne infections, such as hepatitis В and human immunodeficiency virus (HIV), from another person.
LABORATORY AND DIAGNOSTIC TEST RESULTS.
The OR nurse assesses the most recent preoperative laboratory and diagnostic test results to inform the surgical team about the client’s medical condition and to alert them to potential intraoperative and postoperative interventions. The most recent results are usually obtained within 24 to 28 hours before surgery for hospitalized clients and within 4 weeks for ambulatory surgery clients. The nurse reports all abnormalities to the surgeon and anesthesia provider. Laboratory values significantly greater than or less than the normal range are potentially life threatening for any client, but are especially so for the client undergoing surgery.
For example, if the hemoglobin concentration is less than 10 g/dL, oxygen transport capacity is reduced, affecting the amount and type of anesthesia used as well as the potential impact of blood loss during surgery.
MEDICAL HISTORY AND PHYSICAL EXAMINATION FINDINGS.
The OR nurse checks that the medical history and examination findings, including usual pulse and blood pressure, are recorded. This information provides the circulating nurse, surgeon, anesthesia provider, and postanesthesia care unit (PACU) nurse with baseline data to assess the client’s reaction to the surgical procedure and anesthesia. Medications the client has routinely taken preoperatively may affect the reaction to surgery and wound healing.
Knowing the client’s medical history and age allows the nurse to take special precautions and plan appropriate interventions for the care and safety of high-risk clients. The nurse carefully monitors older clients and those with cardiac disease for potential fluid overload, which can be life threatening.
After completing the medical record review, the nurse may insert an IV catheter and perform a surgical shave. The circulating nurse provides additional emotional support and explains procedures to the client. The client is never left unattended. If the client is in the holding area, he or she is transferred to the OR after the preoperative routine is completed.
Analysis
COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
The following are commoursing diagnoses for intraoperative clients:
1. Risk for Perioperative Positioning Injury related to immobilization and effects of anesthesia
2. Impaired Skin Integrity and Impaired Tissue Integrity related to the surgical incision
ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
In addition to the commoursing diagnoses and collaborative problems, intraoperative clients may have one or more of the following:
• Risk for Infection related to a break in skin integrity (i.e., incision, invasive lines)
• Risk for Injury related to fire and electrical hazards within the operating environment
• Risk for Disuse Syndrome related to a decreased level of consciousness or to immobilization
• Hypothermia related to evaporation from skin and exposed tissue in a cool environment, body heat loss, alteration in the hypothalamus from anesthetic agents, inadequate body covering, or aging
• Ineffective Thermoregulation related to sedation, fluctuating environmental temperature, medications, or age extremes
• Fear related to the threat of death, actual or perceived, or to anticipation of events posing a threat to self-esteem
• Anxiety related to loss of control or the threat of death
• Deficient Fluid Volume related to decreased intake, evaporative fluid loss through the skin and exposed tissue, or blood loss
• Potential for Peripheral Neurovascular Dysfunction related to intraoperative positioning
Planning and Implementation
RISK FOR PERIOPERATIVE POSITIONING INJURY
PLANNING: EXPECTED OUTCOMES.
The intraoperative client is expected to be free of injury.
INTERVENTIONS.
Interventions are directed toward preventing injury resulting from intraoperative positioning. Because of preoperative medication, anesthetic agents, and the narrowness of the bed, the client’s normal defense mechanisms cannot guard against nerve or joint damage and muscle stretch and strain. Proper positioning, therefore, is important. In addition, the incidence of pressure ulcer formation is greater in the postoperative client population than for those hospitalized clients who do not undergo surgery. The circulating nurse pads the operating bed with foam and/or silicone gel pads, properly places the grounding pads, coordinates the transfer to the operating bed, and helps th°- client obtain a comfortable position. The circulating nurse assesses the skin, especially of older clients, for bruising or injury, placing extra padding as indicated. A newer product designed to reduce pressure injury in the operating room (OR) is a mattress overlay made of urethane foam having a 25% indentation load deflection (ILD) of
The client is usually in a dorsal recumbent (supine) position after transfer to the operating bed. Anesthesia may be administered with the client supine, and he or she may be repositioned for surgery. When general anesthesia is used, the nurse assists with repositioning (Figure 18-12).
The circulating nurse coordinates repositioning of the client for surgery and modifies the position according to the client’s safety and special needs. Factors influencing the timing of repositioning include the following:
· • The surgical site
· The age and size of the client
· The anesthetic administration technique
· Pain experienced by the conscious client on movement
· Factors influencing the actual position include the following:
· The specific procedure being performed
· The surgeon’s request
· The client’s age, size, and weight
· Any respiratory, skeletal, or neuromuscular limitations, such as rheumatoid arthritis, joint replacements, or emphysema
Table 18-6 presents possible complications related to prolonged surgical immobility and preventive nursing actions.
The dorsal recumbent, prone, lithotomy, and lateral positions are commonly used for surgery.
Figure 18-12 illustrates common surgical positions and the use of protective padding.
When general anesthesia is used, the nurse positions the client slowly to prevent blood vessel dilation that may produce hypotension. The nurse ensures proper positioning by assessing for the following:
· Physiologic alignment
· Minimal interference with circulation and respiration
· Protection of skeletal and neuromuscular structures
· Optimal exposure of the operative site and IV line
· Adequate access to the client for the anesthesia provider
· The client’s comfort and safety
· Preservation of the client’s dignity
The nurse must be aware of potential complications related to specific positions and modify care as indicated.
For example, clients in the lithotomy position may develop leg swelling, pain in the legs or back, and diminished sensation or pulses. The nurse ensures proper padding and position changes at regular intervals. Throughout the intraoperative period, the nurse assists in preventing obstruction of circulation, respiratory efforts, or nerve impulse conduction caused by tight straps, improperly placed pads and pillows, or the position of the bed.
IMPAIRED SKIN INTEGRITY AND IMPAIRED TISSUE INTEGRITY
PLANNING: EXPECTED OUTCOMES.
The intraoperative client is expected to experience minimal skin and tissue impairment and contamination as a result of surgery.
INTERVENTIONS. Surgery is an invasive procedure that places the client at risk for complications related to the surgical wound (such as incisional tears and lacerations), bacterial contamination, and loss of body fluids from the wound during and after surgery. Sterile surgical technique and the use of protective drapes, skin closures, and dressings help to minimize complications and promote wound healing.
PLASTIC ADHESIVE DRAPE. If a sterile plastic adhesive drape is used, the scrub nurse helps the surgical assistant apply the drape after the surgical site has been cleaned and dried. The plastic drape is applied directly to the client’s skin to prevent shifting and exposure of skin edges. The surgeon makes the incision through the plastic drape. The cut edge sticks to the skin and keeps the surgical incision sealed from the movement of bacteria into the wound. The scrub nurse and surgical assistant gently remove the drape after closure of the surgical incision. The nurse pays special attention to older clients and those with fragile skin to prevent skin tearing when the adhesive drape is removed.
SKIN CLOSURES.
Skin and tissue closures, such as sutures and staples, are used to:
• Approximate wound edges until wound healing is complete
• Occlude blood vessels, preventing hemorrhage and fluid loss
• Prevent wound contamination
The quality of the wound edges and the type of closure material are two factors that determine the strength and integrity of . the closure. The wound is usually closed in layers to maintain tissue integrity and promote healing with minimal scarring. The surgeon selects the method and type of closures to be used on the basis of the surgical site, the tissue involved, the size and depth of the surgical wound, and the age and medical history of the client. A combination of sutures and clips is commonly used for closure of internal layers of the wound. Staples, retention (stay) sutures, and skin closure tapes (Steri-Strips) are used for closure of superficial wounds of the epidermis.
Figure 18-13 illustrates commonly used wound closures.
A suture consists of one or more strands of material and is designated by its size, or gauge. The size designation sequence, from largest diameter to smallest, is 5, 4, 3, 2, 1, 0, 00 (2-0), 000 (3-0), 0000 (4-0), and so forth, to 11-0. Size 0 may be used to close the deep layers of an abdominal wound; 11-0 is the smallest-diameter suture and is used in plastic surgery and eye surgery. Other characteristics of the suture material, such as type (e.g., nylon, silk, Vicryl), color (e.g., green, blue, black, white, violet), and structure (e.g., twisted, braided), are listed on the package.
Suture material can be absorbable or nonabsorbable.
Absorbable sutures are digested over time by body enzymes. These sutures first lose strength and then gradually disappear from the tissue. Catgut suture, such as “plain gut” and “chromic gut,” is a type of natural absorbable suture material still in use today, although not as frequently as in the past. Other absorbable sutures are made of synthetic materials. The client’s physical status, the presence of inflammation, and the type of suture used all influence the time for absorption, which is usually up to about 2 weeks.
Nonabsorbable sutures become encapsulated in the tissue during the healing process and remain embedded in the tissue unless they are removed. These sutures are made of silk, cotton, steel, nylon, polyester, or other synthetic material. Body enzymes do not affect nonabsorbable sutures. Nonabsorbable sutures are used for vascular anastomosis, “wiring” the sternum together after open heart surgery, and closing external wounds. The surgeon may use a double or interlocking stitch to increase the integrity of the closure. Retention (stay) sutures may be used in addition to standard suture material for clients at high risk for impaired wound healing (those having major abdominal surgery, obese clients, clients with diabetes, and clients taking steroids, which inhibit wound healing).
After the incision is closed, the physician may inject a local anesthetic or instill an antibiotic into the wound. A gauze or spray dressing may be applied to protect it from contamination. A variety of dressings may also be used to absorb drainage and provide support to the incision. A pressure dressing may be applied to prevent or stop a vascular area from bleeding postoperatively. One or more drains (see Chapter 19) may be inserted to prevent the accumulation of secretions and fluids within tissues around the surgical area. These secretions, if not drained, slow healing and promote bacterial growth, which could result in wound infection.
After the dressing is secure, the nurse coordinates the surgical team in repositioning and transfer. A roller board or a lift sheet is used for safe transfer from the operating bed to a stretcher or bed. Some clients are able to move themselves back over to the stretcher. The circulating nurse and anesthesia provider accompany the client to the postanesthesia care unit (PACU) and give a report of the client’s intraoperative experience to the PACU nurse.
POTENTIAL FOR HYPOVENTILATION
PLANNING: EXPECTED OUTCOMES. The intraoperative client is expected to be free of damaging events related to hypoventilation.
INTERVENTIONS.
Interventions are directed toward preventing injury resulting from anesthesia (see earlier discussion). The nurse, physician, and anesthesia provider monitor the client according to official standards. These standards, which have been adopted by both the American Society of Anesthesiologists and the American Association of Nurse Anesthetists, include continuous monitoring of ventilation, circulation, and cardiac rhythms; blood pressure and heart rate recordings every 5 minutes; and the continuous presence of an anesthesiology practitioner during the case (Biddle, 1994).
Evaluation: Outcomes
The nurse evaluates the care of the intraoperative client on the basis of the identified nursing diagnoses and collaborative problems.
The expected outcomes are that the client:
• Is safely anesthetized without complications
• Does not experience any injury related to intraoperative positioning or equipment
• Is free of skin or tissue contamination during surgery
• Is free of skin tears, bruises, redness, abrasion, or mac eration over pressure points and elsewhere.
