Care of Client During Surgery

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Care of Client During Surgery

• Helen Barnes MSN, RN

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Members of the Surgical Team

• Physician - surgeon
• Surgeon (1st assistant)- assist the surgeon, RN,
  physicians assistant
• Anesthesiologist- physician
• CRNA- Certified RN Anesthetist
• RN - Circulating Nurse
• Surgical technician- scrub nurse (RN,LVN)

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Scrub Nurse

• Sterile conscience, anticipates needs of the
  surgeon, safeguard the patient.
• Knowledge of the anatomy
• Understand proper positioning, draping of the
  patient
• Prepared for any problems that may arise during
  the operation

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Duties of Scrub Nurse

• Check schedule, type of surgery.
• Check instruments to be used, set-up OR.
• Place instruments in surgeons hands, anticipate
  needs.
• Keep 3 sutures working- one in surgeons hand,
  another on Mayo stand another in process of
  being prepared.
• Do sponge count with circulating nurse.
• Take care of specimens, dirty instruments.

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Circulating Nurse

• Role of leadership, teacher, guide, advisor to
  ancillary personnel.
• Care of client, carry out surgeons order, sound
  judgment.
• Thorough knowledge of ER equipment.
• 4 Important Points Anatomy, comfort, safety,
  and respiratory freedom
• Maintain efficient function of room

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Duties of Circulating Nurse

• Check schedule, type of operation, set-up OR.
• Assist scrub nurse, anesthetist, surgeon.
• Receive client, check identity, assist with
  transfer
• Do prep. Keep floor clean, do sponge count
• Fill out the operating room record.
• Label all specimens, transfer of client to PACU,
  give report to nurse. Clean OR.

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Basic Rules of Surgical Asepsis

• 100 free from microorganisms including spores.
• Surgical scrub prior to donning sterile gown and
  gloves
• Moisture on sterile drapes will contaminate
  set-up
• Instruments are sterilized in autoclave.
• 1 inch border around sterile table not considered
  sterile.

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General Anesthesia

• Intravenous and/or Inhaled
• Advantages
• Good for very anxious and do not want local
  anesthesia clients
• Good for long procedures.
• Good for clients not able to cooperate, head
  disorders, muscle disorders, and impaired
  cognitive function

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Disadvantages

• Laryngospasm - sudden violent
• contractions of the vocal cords
• Laryngeal edema
• Injury to the vocal cords
• Malignant hyperthermia

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Malignant Hyperthermia

• Hereditary
• Caused by inhalation anesthetics halothane and
  enflurane
• Caused by muscle relaxant succinylcholine
• Increased metabolism of muscles, hyperthermia,
  tachycardia, dysrhythmias, tachypnea, cyanosis
• Stop surgery! 100 oxygen Dantrolene
• Sodium and ice to cool

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Stages of Anesthesia

• 1. Beginning- breathes in anesthesia mixture-
  noises are exaggerated. Unnecessary noises must
  be avoided.
• 2. Excitement - Pulse rapid and respirations
  irregular, struggling, singing, talking. Strap
  for safety
• 3. Surgical - Unconscious. VS stable
• 4. Overdosing excessive anesthesia. VS
  depressed. Narcotic antagonist given.

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Inhalation Anesthesia

• Delivered, controlled excreted through
  mechanical ventilation.
• Agents
• Halothane
• Penthrane
• Ethrane
• Forane
• Nitrous oxide
• Cyclopropane

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Inhalation Anesthesia

• Advantages
• Not explosive
• Induction - rapid and smooth
• Potent analgesic
• Low incidence of nausea vomiting
• Muscle relaxant

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Inhalation Anesthesia

• Disadvantages
• Requires skillful administration
• May cause liver, kidney damage
• Unpleasant odor
• May depress respiration, hypoxia
• May cause bronchospasms, depression, disturbance
  in heart rhythm
• Poor relaxant, weak
• Explosive - Cyclopropane

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Intravenous Anesthesia

• Agents
• Barbiturates -Thiopental Sodium
• Opiods - Demerol, Morphine
• Neurolepanalgesics- short-acting agent (fentanyl)
  and butyrophenone (droperidol)
• Dissociative agents- appears not to be asleep or
  anesthetized but dissociative with surroundings.
• Ketamine

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General Anesthesia

• Advantages
• Rapid induction, nonexplosive, onset pleasant
• Duration of action brief, little nausea /
  vomiting
• Useful for short procedures like eye surgery-
  decreases incidence of nausea/vomiting- will
  increase intraocular pressure
• Thiopental often administered with other
  anesthetic agents in prolonged procedures.

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Intravenous Anesthesia

• Disadvantages
• Thiopental powerful respiratory depressant.
  Oxygen must be available immediately.
• Must be administered by skilled anesthesiologist
  / nurse anesthetist.
• Causes sneezing, coughing, laryngospasm.

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Adjunct Agents

• To improve outcome of surgery
• Medications used with primary anesthetic agents
• Narcotics- control pain
• Muscle relaxers - avoid movement of muscles
  during surgery
• Antiemetics - control nausea or vomiting
• Sedatives - supplement anesthesia

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Neuromuscular Blockers

• Blocks the transmission of nerve impulses at
  neuromuscular junction of skeletal muscles.
• Muscle relaxants
• Relaxes muscles in abdominal/thoracic surgery,
  certain types of eye surgery
• Facilitate ET intubation- treat laryngospasm
• Agents Tubarine, Flaxedil, Pavulon, Norcuron,
  Anectine, Sucostrin, Syncurine

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Spinal Anesthesia

• Introduction of local agent into lumbar space -
  L4 L5. Blocks motor/sensory
• Produces anesthesia on lower abdomen, lower
  extremities, and perineum.
• Agents
• Novocaine
• Pontocaine
• Xylocaine

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Spinal Anesthesia

• Advantages
• Easily administered
• Inexpensive
• Minimum equipment required
• Rapid onset
• Excellent muscular relaxation

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Spinal Anesthesia

• Disadvantages
• Hypotension
• Respiratory depression
• Spinal headache
• Rarely paralysis or meningitis

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Conduction Blocks

• Epidural
• Local anesthetic injected into epidural space
• Blocks sensory,motor, autonomic functions
• Does not make direct contact with spinal cord or
  nerve roots
• Brachial Plexus- Produces anesthesia of arm
• Paravertebral -Chest, abdomen and extremities
• Transsacral (Caudal)
• Blocks perineum and lower abdomen

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Local Anesthesia

• Injected into tissues at planned incision site.
• Simple, economical, non-explosive
• Short postoperative recovery
• Surgeon can administer anesthetic
• Agents
• Marcaine Novocaine
• Xylocaine Pontocaine
• Nupercainal

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Local Anesthesia

• Local infiltration- incision site
• Regional block - along nerve that carry impulses
  to region where anesthesia is desired
• Nerve block- injection of a nerve at a specific
  point
• Bier block - placing a tourniquet on an extremity
  to remove blood, then inject anesthetic
• Field block-surrounding the site
• Epidural-around spinal nerves

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Positioning

• Dorsal Recumbent
• Flat on back, arms on side. Used in abdominal
  surgeries.
• May cause pressure on posterior bony prominences,
  compression of blood vessels.
• Use padding. Insure knees are not flexed to
  promote circulation.

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Positioning

• Semi-sitting
• Thyroid/ neck surgery
• May lead to postural hypotension, venous pooling
  on legs.
• Possible sciatic nerve injury.
• Assess for hypotension, use soft padding
• Make sure knees are not sharply flexed

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Positioning

• Prone
• Spinal fusion, hemorrhoids
• Causes pressure on face, knees, thighs, anterior
  ankles, toes, corneal abrasion
• Raise clients chest/abdomen to promote
  respiratory function
• Close and pad eyes

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Positioning

• Lateral chest
• Thoracic surgeries hip replacement, kidney
  surgery.
• May cause excessive pressure on bony prominences.
  
• Upper leg may cause peroneal nerve injury on
  downside leg.
• Adequate padding/support on downside arm.
• Pad both legs.

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Positioning

• Lithotomy
• Gynecological, perineal, rectal
• Causes 18 decrease in vital capacity
• Monitor respirations, assess for hypoxia, dyspnea
• Can lead to perineal nerve damage, joint damage,
  peripheral blood vessels damage
• Adequate padding, manipulate both legs to
  stirrups simultaneously

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Positioning

• Jacknife
• Proctologic and spinal surgeries
• Causes 12 decrease in vital capacity
• Monitor respirations, assess for hypoxia, dyspnea
• Greatest pressure felt at bends on the table
• Pad groin/ knees/chest
• Pad/proper positioning - prevent pressure on ear,
  neck, nerves of upper arm

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The End