Ch_18_19_8_Notes

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Ch 18 Intraoperative Notes Positive air pressure in the OR room prevent air from entering the OR from the halls and corridors Holding area can be called the AOD unit (Admission, Observation, and Discharge) Duties of the OR RN during surgery: Maintain patient’s safety, dignity, and confidentiality. Communicating with the patient, surgical team, and other dept. Providing nursing care Surgeon is responsible for: Preoperative medical history and physical assessment, directing preoperative testing, and postoperative management Obtaining informed consent Leading the surgical team and directing the course of a procedure When at the floor ask about where to put padding for the supine, prone, lateral, lithotomy, and sitting surgical positions? When the patient’s head is elevated what are some typical things to consider for the patient? Ask about blood pooling, venous return, and padding. Specific Surgical Care Improvement Project (SCIP) measures to consider: A prophylactic antibiotic startedwithin 30 – 60 mins before the surgical incision to decrease infection. Applying a warming blanket to prevent unintended hypothermia Applying intermittent pneumatic compression devices to reduce risk for VTE Universal protocol is used to prevent wrong site, wrong procedure, and wrong surery. The surgeon marks the procedure site. When the patient finishes from surgery, they are brought back to awareness/wakefulness, what is the reason for that? Besides checking to make sure they are alive and are aware that they are done with surgery? Anesthesia Techniques: Moderate to Deep Sedation – can be done by any RN Monitored Anesthesia Care – must have an ACP General Anesthesia – used for patients that require extensive surgical procedures (long duration), need skeletal muscle relaxation, require uncomfortable operative positions because

of the location of the incision site, require control of ventilation, patient refusal of local or regional techniques, contraindications to other techniques, and uncooperative patients. What is the difference between Moderate/Deep Sedation and MAC since in the book it was noted that MAC was used for endoscopic procedures, but I saw a patient receive a moderate/deep sedation but they have an EGD? General differences in the anesthesias? Ketamine given to patients with asthma problems since it promotes bronchodilation. It also increases HR and maintain CO in trauma patients. However, it can cause hallucinations and nightmares. It can be noted that concurrent use of Versed can reduce or eliminate the hallucinations. Ask about local anesthetic systemic toxicity (LAST)? Malignant Hyperthermia typically occurs during general anesthesia, but may occur during the recovery period as well. Ch 19 Postoperative Care Notes Main duties of a nurse in the postoperative period: Support ventilation and perfusion Maintain fluid and electrolyte imbalance Promote comfort Reduce infection Promote safety There are multiple phases of postanesthesia care, namely 3. Phase I, Phase II, and Extended Observation. First things to do as a PACU nurse is to assess the patient’s Airway, Circulation, and Breathing (ABC). CO2 is used for monitoring high risk patients for respiratory depression. Hearing is the first sense to return in an unconscious patient. Areas near the site of injections are the last to return. First are the areas distal to the site. Patients that are high risk for respiratory problems are: Have had general anesthesia Older than 55 years of age Hx of tobacco use Have preexisting lung disease and/or sleep-disordered breathing

Obese Have co-morbidities Have undergone airway, thoracic, or abdominal surgery What happens to the tongue when you are asleep? Does it actually fall back? Common causes of respiratory problems are atelectasis and pneumonia especially in patients with co- morbidities and after abdominal and thoracic surgery. Manifestations of hypoxemia include tachypnea, gasping, anxiety, restlessness, confusion, and rapid or thread pulse. If a patient has had abdominal or chest surgery and has a splint, would we still want to encourage deep breathing exercises? Or use of an IS? Even if at risk for dehiscence? Clinical signs of hypotension  hypoperfusion are disorientation, loss of consciousness, chest pain, and oliguria. Treatment is aimed towards restoring circulating volume, but if no response to fluid administration, then heart dysfunction may be a potential cause. Primary heart dysfunction results in a drop of cardiac output. Common cause of hypotension is fluid and blood loss which can lead to hypovolemic shock. Fluid retention during postop day 1 – 3 can result from the stress response, which maintains blood volume and BP. Both ADH and ACTH help retain fluids in the body in times of stress response. Hypokalemia can result from urinary and gastrointestinal tract losses. Know that potassium replacement can be at 40 mEq/day but needs to be indicated by proper renal function at 0.5 mL/kg/hr. The stress of surgery increases the clotting factors in the body so a patient may be at risk for VTE. Observe vitals every 15 minutes in Phase I of post anesthesia care. Systolic BP <90 or >160, Pulse <60 or >120, pulse pressure (diff between systolic and diastolic) narrows, BP trending up or down, or a change in heart rhythm. Hypotension with rapid or weak pulse and cold, clammy, pale skin may indicate hypovolemic shock. Early ambulation is most significant general nursing measure to prevent complications. Walking benefits are: Increase muscle tone Stimulates circulation, which prevents venous stasis and VTE and speeds up wound healing Increases vital capacity and supports normal respiratory function

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Emergence delirium is short-term neurologic change manifested by behaviors such as restlessness, agitation, disorientation, thrashing, and shouting. If delirium occurs, first suspect hypoxia. Two types of cognitive impairments in surgical patients are: Postoperative cognitive dysfunction caused by older age, preexisting cognitive impairment, duration of anesthesia, complications during surgery, and infection. Delirium caused by older age, but can occur in any age, severe pain, fluid and electrolyte imbalance, hypoxemia, drug effects, sleep deprivation, and sensory deprivation/overload. Patient’s self-report on pain is most reliable for indication of pain. Assess for any pain related side effects such as constipation, nausea and vomiting, respiratory and cough depression, and hypotension. If it is gas pain, opioids can worsen the pain. Patients who are at a higher risk for postoperative hypothermia are: Patients with low preoperative core body temperature Patients with systolic BP less than 140 Older patients Female patients Patients who receive epidural or spinal anesthesia When using any external warming device, make sure to record body temperature and comfort level at 15 minute intervals. Make sure to prevent skin injuries. Postoperative ileus is the temporary impairment of gastric and bowel motility after surgery and it is common in abdominal surgeries, but can occur after nonabdominal surgery. Large intestine motility may be reduced for 2 – 7 days and small intestine resumes within several hours after surgery. Gas pains tend to become pronounced on the 2 nd or 3 rd postoperative day. Low urine output in the first 24 hours after surgery is to be expected regardless of fluid intake. Most patients void within 6 – 8 hours of surgery. Surgical site infection can result from 3 major sources: Exogenous flora present in the environment and on the skin Oral flora Intestinal flora Assess the surgical wound every 15 – 30 minutes. Skin graft dressings may stay in place for 3 – 5 days to avoid disturbing the graft site and promote graft acceptance.

PACU Discharge Criteria: Phase I Patient awake, easily arousable (or baseline) Vital signs at baseline or stable No excess bleeding or drainage No respiratory depression O2 saturation >90% Pain control acceptable Nausea and Vomiting controlled Report given Phase II All PACU Phase I discharge criteria No IV opioid drugs for last 30 minutes Voided if appropriate to surgical procedure or orders Able to ambulate if not contraindicated Responsible adult present to accompany and drive patient home Written discharge instructions given and patient and caregiver understanding confirmed The patient leaving ambulatory surgery setting must be hemodynamically stable, mobile, alert, and able to provide a degree of self-care when discharged to home. Make sure patient and caregiver have access to pharmacy for prescriptions, a phone in case of emergency, and follow-up care. Ch 8 Pain Notes