Good evening, everyone. Allow me to continue with our discussion on intraoperative nursing.

Now, the intraoperative phase, uh, actually begins when the patient is transferred onto the
operating room table and ends with admission to the, uh, post anesthesia care unit or simply the
recovery room. Well, in this space, the scope of nursing activities includes providing for the
patient's safety.

We're ensuring patient safety, maintaining an aseptic environment, ensuring proper function of
equipment, providing the surgeon with specific instruments and supplies for the surgical field or
surgical environment, completing appropriate documentation, providing emotional support
during induction of general anesthesia.

Assisting in positioning the patient on the operating room table using appropriate principles of
body alignment as well as acting as scrub nurse or circulating nurse or as a registered nurse
first assistant or the RNFA. You see the intraoperative experience has undergone many
changes that make it safer and less disturbing to patients.

However, even with these advances, anesthesia and surgery plays the patient at risk for several
complications or adverse events. Consciousness or full awareness. Mobility, protective biologic
functions, and personal control are totally or partially relinquished or surrendered by the patient
when entering the operating room.

So the staff from the departments of anesthesia, nursing, as well as surgery, work
collaboratively in order to implement professional standards of care. to control iatrogenic or
what we call adverse condition patients resulting from treatment and individual risks to prevent
complications and to promote high quality patient outcomes.

Allow me first to discuss the composition of the surgical team. You see, the surgical team
includes the circulating nurse, also known as the circulator, the scrub person or the scrub nurse.
Having the scrub role, the RNMA, which stands for the registered nurse first assistant, or also
known as Certified Surgical Technologist, and the anesthesiologist or the anesthesia provider.

Every member of the surgical team verifies the patient's name, the procedure and surgical site
using objective documentation and data before beginning the surgery. As mandated by the
Joint Commission, this is what we call timeout or final pause, and these must be performed
prior to incision, preferably with the patient involved.

If the patient's surgical site was marked, the mark should be visible. Now, I have here a table
showing the different, uh, specific responsibilities of the circulating nurse or the circulator, the
scrub person or the scrub nurse. The registered nurse, first assistant, the surgeon, of course,
who is the captain of the ship, and the anesthesia provider.

So as you can see here, the circulating nurse or the circulator, okay, uses the nursing process to
develop individualized plans of care. He or she checks and manages the operating room
conditions, ensuring cleanliness, proper temperature. Humidity, lighting, safe function of
equipment, and availability of supplies and materials.

He or she continually assesses the patient as well for signs of injury and implementing
appropriate interventions, verifies consent, and ensures documentation is correct, coordinates
the team, monitors aseptic practices to avoid breaks in technique, while coordinating the
movement of related personnel, such as the medical, x ray, and laboratory.

Thank you for your time. Implements fire safety precautions and accounts for all surgical counts
in collaboration with scrub nurse or scrub person ensures that the second verification of the
surgical procedure and sits inside rather takes place and is documented and he or she is also
responsible for managing the specimens.

The scrub nurse or the scrub person, on the other hand, performs a surgical hand scrub, okay?
He or she sets up the sterile tables, prepares sutures, ligatures, and special equipment, such
as laparoscope, anticipates the instruments and supplies that will be required, such as
sponges, jeans, and other equipment, And as the surgical incision is closed, he or she counts
all needles, sponges, and instruments with the nurse to be sure that they are accounted for and
not retained as a foreign body.

within the patient's body, eh? The registered nurse first assistant, or the RNFA, is the one who
handles, he or she, is the one who handles the tissue, provides exposure at the operative site,
or operative field. He or she is also responsible for suturing and maintaining hemostasis.
Okay, he or she, the registered nurse first assistant can also be the assistant surgeon.

That's why another term here is certified surgical technologist. The surgeon who is The
licensed physician, okay, he or she can be an osteopath, an oral surgeon, a podiatrist, who is
specially trained and qualified, okay. He or she performs the surgical procedure, heads the
surgical team, so he or she leads the surgical team.

As I said earlier, Captain of the ship. And then we also have the anesthesia provider, not as a
physician, specifically trained in the art and science of anesthesiology. An anesthetist is a
qualified healthcare professional Who administers anesthetics. Most are certified registered
nurse anesthetists.

No, because? Because we also have, in the United States we have nurse anesthetists. Okay,
so what's the responsibility of the anesthesia provider? He or she assesses the patient before
surgery, selects the anesthesia and administers it, intubates the patient if necessary. Manages
any technical problems related to the administration of the anesthetic agent and he or she
supervises the patient's condition throughout the surgical procedure.

So those are the different responsibilities of the members of the surgical team. Now what about
the surgical environment? You see the surgical environment class. is known for its stark
appearance and cool temperature. The surgical suite is behind double doors, usually, and
access is limited to authorized persons.

To provide the best possible conditions for surgery, the operating room is often situated in a
location that is central to all supporting services, like the pathology, x ray, and laboratory. The
operating room often also has special air filtration devices. To screen out contaminating
particles, dust and pollutants.

Now it's important that the surgical environment it has, you have to maintain the environment.
Most of the joint commission's 2015 National Patient Safety, uh, patient safety goals pertain to
the preoperative areas. External precautions include adhering to principles of surgical asepsis.
And strict control of the operating room environment is required, including traffic pattern
restrictions.

Policies governing this environment address such issues such as the health of the staff, the
cleanliness of the rooms, the sterility of equipment and services, and process for scrubbing,
gowning and gloving, and the OR at fire. So it's important that in order to maintain this surgical
environment, We have to prevent surgical fire, also called surgical fire.

You see, fire is a risk to both patients and personnel inside the operating room due to the three
elements of the fire triangle that are necessary for a fire. What are these three elements of the
fire triangle necessary for a fire? We have fuel, oxidizer, and ignition source. Although rare, the
possibility of surgical fires can result in devastating disfigurement, serious injury, and even
death.

It can occur at any time inside the operating room. For example, surgical drapes,

A stray spark could more easily ignite a fire. So to evaluate safety in the facility, electrical
hazards, emergency exit clearances, and storage of equipment and anesthetic gases are
monitored periodically by official agencies such as the State Department of Health and the Joint
Commission. All operating room personnel must also be familiar with and educated about fire
prevention.

And how to respond in the event that a fire should occur inside the operating room. A fire risk
assessment should also be completed and communicated to the surgical team prior to the start
of a procedure. Another is donning of proper attire, which is also an important, uh, an important,
uh, consideration in the surgical environment.

You see, to help decrease microbes. The surgical area is divided into three zones. We have
what we call an unrestricted zone where street clothes are allowed. We also have the semi
restricted zone where attire consists of scrub clothes and caps. And the restricted zone where
scrub clothes, shoe covers, caps, and masks are worn.
The surgeons and other surgical team members wear additional sterile clothing. And protective
devices during the surgical operation. Now, according to the Association of Perioperative
Registered Nurses, formerly known as the Association of Operating Room Nurses, they
recommended, you know, specific practices.

or personally to wear surgical attire to promote a high level of cleanliness in a particular

practice setting. Shirts and waist drawstrings should be tucked inside the pants to prevent
accidental contact with sterile areas, and to contain skin shedding. Wet or soiled garments
should also be changed. It's also important to wear a mask, no, at all times, in the restricted
zone of the operating room.

High filtration masks decrease the risk of postoperative wound infection by containing and
filtering microorganisms from the oropharynx and nasopharynx. Masks should be tightly, of
course, should cover the nose and mouth completely and should not interfere with breathing,
speech, or vision. It must also be adjusted to prevent venting from the sides.

Disposable masks have filtration efficiency exceeding 95%. They are changed between patients
and should not be worn outside the surgical department. These masks must be either on or off,
and they must not be allowed to hang around the neck. Also part of surgical attire is the
headgear, which should cover the hair completely.

The head and the neckline, including the beard, so that the single strands of hair, the bobby
pins, clips, and particles of dandruff or dust do not fall on the sterile field. Shoes should also be
comfortable. and supportive. Shoe covers are worn when it is reasonably anticipated that spills
or splashes will occur, or if shoes are worn outside of the operating room suite.

Shoe covers should be changed when they become wet, torn, or soiled. Barriers such as scrub
attire and masks do not entirely protect the patient from microorganisms glass. Upper
respiratory tract detections, sore throats, and skin infections in staff and patients are possible
sources of pathogens and they must be reported because artificial fingernails also harbor
microorganisms and can cause nosocomial or hospital acquired infections or healthcare
associated infections.

A ban on artificial nails by our personnel is supported by the Centers for Disease Control and
Prevention. The Association of Operating Room Nurses and the Association of Professionals
in Infection Control, in short, Natural Finger Needs, are encouraged.

It's also important to make use of environmental controls. In addition to the protocols described
previously, Surgical asepsis requires meticulous cleaning and maintenance of the operating
room environment. Floors and horizontal surfaces are cleaned frequently with detergent, soap
and water, or a detergent germicide.

Sterilizing equipment is also inspected regularly in order to ensure optimal operation and
performance.
Also, Health hazards. Now, there are health hazards associated with the surgical environment.
Safety issues in the operating room include exposure to blood and body fluids, latex and
adhesive substances, exposure to radiation, toxic agents, and laser plumbs. Internal monitoring
of the operating class includes the analysis of surface wide samples or air samples for infectious
and toxic agents.

In addition, there should be policies and procedures that should be established to minimize
exposure to body fluids and reduce the dangers associated with lasers and radiation. You see,
an additional hazard is the unintentional leaving of an object in a person during a surgical
procedure. The risk that foreign objects may be left inside a person increases the following
situations.

Now it increases in the following situations. So when the procedure is performed on an

emergency basis, that's number one. When there is an unplanned change in the procedure. And
the third one is when the patient has a high BMI. You see, many complications can occur from
the retention of an object. And the patient is subjected to the risk of an additional surgical
procedure.

So these health hazards are associated with the surgical environment, as I said, exposure to
blood and body fluids. So you see, that's why O. R. Attire is very important. You know, O. R.
Attire has changed dramatically since the advent, especially since the advent of HIV and AIDS.
Double gloving is routine in trauma and other types of surgery where sharp bone fragments are
present.

Goggles or a wraparound face shield are also worn in order to protect against splashing when
the surgical wound is irrigated or when bone drilling is performed. In hospitals where numerous
total joint procedures are performed, a complete face shield may also be used. This shield
provides full barrier protection from bone fragments and splashes.

Ventilation is also accomplished through an accompanying hood with a separate air filtration
system. Also latex allergy is considered as a health hazard. The Association of Operating
Room Nurses has recommended standards of care for the patient with latex allergy. These
recommendations include early identification of patients with latex allergies, preparation of a
latex allergy supply card, And maintenance of latex allergy precautions throughout the very
operative period.

Because of the increased number of patients with latex allergies, most products Our latex
speed. For safety, manufacturers and hospital material managers need to take responsibility for
identifying the latex containing items used by the patients and healthcare personnel. And the
third one is the laser risk.

You see, the Association of Operating Room Nurses has recommended practices for laser
safety. While lasers are in use, Warning signs must be posted clearly to alert personnel or staff.
Safety precautions are implemented to reduce the possibility of exposing the eyes and skin to
laser beams, to prevent inhalation of the laser plume or the smoke and particulate matter, and
to protect the patient and personnel from fire and electrical hazards.

There are several types of lasers that are available for clinical use. Perioperative personnel,
therefore, should be familiar with the unique features, specific operation, and safety measures
for each type of laser used in the practice setting. All personnel should also wear special
protective goggles specific to the type of laser used in the procedure, and whether protection is
needed to avoid the laser plumb and the effects of inhalation is controversial.

Smoke evacuators are used in some procedures to remove the laser plumb from the operative
feet. You see, in recent years, This technology has been used to protect the surgical team from
the potential hazards associated with the generalized smoke plumb generated by standard
electro quaternary units.

We now proceed to the actual surgical experience. So in the actual surgical experience, one
important consideration, or should I say consideration, is to maintain surgical asepsis.

Surgical asepsis, as we know it in your fundamentals of nursing, prevents the contamination of

surgical wounds. The patient's natural skin flora or a previously existing infection may cause
post operative wound infection. Therefore, rigorous adherence to the principles of surgical
asepsis by OR personnel is basic to preventing surgical site infections or SSIs.

Traditionally, the surgical assistants and nurses prepare themselves by scrubbing their hands
and arms with antiseptic soap and water. But this traditional practice is being challenged now by
research in order to investigate the optimal length of time to scrub and the best preparation to
use. Many institutions have now introduced a scrub less process for cleaning the hands prior to
surgery.

Also, we have administration of anesthesia and sedation. You see, anesthesia today is very
safe, and although anesthesia related morbidity and mortality is difficult to quantify, most recent
studies estimate anesthesia related death rate, especially in the United States, to be less than 1
per 10, 000 anesthetics.

So when the patient arrives in the operating room, anesthesiologist or, or the, uh, anesthesia
provider reassess the patient's physical condition immediately prior to initiating anesthesia for
the patient. The anesthesiologist anesthesia experience consists of having an IV line insert,
ma'am, they're going to insert towards an ivy line if it was not inserted earlier.

Receiving a sedating agent prior to induction with an anesthetic agent losing consciousness.
Being intubated, if indicated, and then receiving a combination of anesthetic agents. Typically,
the experience is a smooth one, and the patient has no recall of the events. Now, we have
several types of anesthesia classes.
We have general anesthesia, regional anesthesia, moderate sedation, monitored anesthesia
care, and local anesthesia. And during surgery, dear ladies and gentlemen, the anesthesiologist
monitors the patient's vital signs, including blood pressure, pulse and respiration, as well as the
ECG, blood oxygen saturation level, and tidal volume.

Blood gas levels, blood pH, alveolar gas concentrations, and body temperature. Monitoring by
electroencephalography, or a measure of brain waves, is sometimes also required. Levels of
anesthetics in the body also can be determined. A mass spectrometer can also provide us
instant readouts of critical concentration levels on display terminals.

This information helps personnel assess the patient's ability to breathe unassisted or the need
for mechanical assistance if ventilation is poor and the patient is not breathing well
independently. Even with the availability of automatic monitored equipment. The anesthesia
provider and or the nurse must remain in close contact with the patient to observe any
significant physiologic changes immediately.

Now, let me first discuss general anesthesia. You see, anesthesia is a state of narcosis or a
severe central nervous system depression produced by pharmacologic agents. It's a state of
narcosis, analgesia, relaxation and reflex loss. Patients under general anesthesia are not
arousable class, not even to painful stimuli.

They lose the ability to maintain ventilatory function and require assistance in maintaining a
patent airway. Therefore, their cardiovascular function may also be impaired as well. Now there
are four stages upon receiving general anesthesia. Each stage is associated with specific
clinical manifestations.

Okay. So these are the different stages, uh, by the way, these are the, uh, basic guidelines for
maintaining surgical asepsis. No. So during the surgical experience of the patient during the
surgery, it's important for us, uh, the, or a person or the, or staff to be strict. I thought it was the
highest level, okay.

Maintain surgical asepsis. So all practitioners involved in the intraoperative phase have the
responsibility to provide and maintain a safe environment. Adherence to aseptic practice is part
of this responsibility. And these are the principles, which I'm sure you're all familiar with, okay?
So this is the continuation of the different principles of surgical asepsis.

Now as I was saying, okay, the

anesthetic agents used in general anesthesia are often inhaled. Uh, or administered by IV,
okay? Anesthetics class, you know, they produce anesthesia because they are, um, they're
delivered to the brain at a high partial pressure, enabling them to cross the blood brain barrier.
Relatively large amounts of anesthetic must be administered during induction and the early
maintenance phases because the anesthetic is recirculated and deposited in body tissues.
As these sites become saturated, smaller amounts of the anesthetic agent are required to
maintain anesthesia because equilibrium or near equilibrium has been achieved among brain,
blood, and other tissues. Any condition class that diminishes peripheral blood flow, such as
vasoconstriction or shock, may reduce the amount of anesthetic required.

Conversely, when peripheral blood flow is unusually high, as In a muscularly active or

apprehensive patient, induction is, is lower, and greater quantities of anesthetic are required
because the brain receives a smaller quantity of anesthetic.

Alright, okay. So these are the stages of general anesthesia. So as I said, there are four
stages of general, upon receiving general anesthesia. So the first one is what we call beginning
anesthesia. So as the patient breathes. in the anesthetic mixture, so if the anesthesia was
administered by inhalation, okay?

Warm, dizziness, and a feeling of detachment may be experienced by the patient. The patient
may also experience some ringing, roaring, or buzzing in the ears, and although still conscious,
he or she may sense an inability to move the extremities easily. And during this stage, noises
are exaggerated. Even low voices or minor sounds seem loud and unreal for them, and for this
reason, unnecessary noises and motions are avoided when anesthesia begins.

Stage 2 is what we call the excitement stage. So the excitement stage is characterized variously
by struggling, shouting, talking, singing, laughing, or crying. And this is often avoided if the
anesthetic is administered smoothly and quickly. Because of the possibility of uncontrolled
movements of the patient during this stage, the anesthesia provider must always be assisted by
someone ready.

to help restrain the patient. The patient should not be touched except for purposes of restraint.
But restraints should not be applied over the operative site.

The third stage is what we call the surgical anesthesia stage. The surgical anesthesia is
reached by continued administration of the anesthetic vapor or gas. The patient is unconscious
and lies quietly on the table, you know, in this stage. With proper administration of anesthetic,
this stage may be maintained for hours in one of several planes, ranging from light to deep,
depending on the depth of anesthesia needed.

And finally, the fourth stage is what we call medullary depression. This stage is reached when
too much anesthesia has been administered to the patient. Cyanosis develops, and without
prompt intervention, death follows rapidly. Now, if this stage develops, the anesthesia, or the
anesthetic, is discontinued immediately, and respiratory and circulatory support is initiated to
prevent death.

Stimulants, although rarely used, may be administered. Narcotic antagonists can also be used if
the overdose age is due to opioids. Now, when opioid agents or narcotics and neuromuscular
blockers or relaxants are administered, several of the stages are absent during smooth
administration of an anesthetic.

There is no sharp division between stages 1, 2, and 3, and there is no stage 4. The patient
passes gradually from one stage to another, and it is through close observation of the signs
exhibited or displayed by the patient that an anesthesiologist controls the situation. The
responses of the pupils, the BP, the respiratory and cardiac rates are among the most reliable
guides.

to the patient's condition. Now, these are the different routes of administering general
anesthesia. So, as I said earlier, we can administer general anesthesia by inhalation. So,
inhalation anesthetics are commonly used for the provision of general anesthesia with the
addition of a volatile Readily vaporized anesthetic to inspired oxygen, a state of consciousness
and amnesia can be established when combined with additional medications like opioids or
benzodiazepines, further sedation or hypnosis and amnesia are established.

They are considered easy to administer glass, inexpensive and reliable in terms of ability to
monitor their effects with both clinical science and end tidal concentrations. In addition, they are
important in situations where there is lack of venous access and anticipated airway difficulty.

Okay, so these are the different routes of administering general anesthesia by inhalation. So
anesthetic delivery methods are as follows. We have a laryngeal mass airway. We also have
letter B, nasal endotracheal catheter in position we've got updated. And the third one is oral
intubation, the oral and the tracheal intubation, where the tube is in position with the cuff
inflated.

Alright, so as I was saying, another way of administering general anesthesia is by intravenous

administration. You see, general anesthesia can be produced by the IV or intravenous
administration of various substances, such as barbiturates. benzodiazepines, non barbiturate
hypnotics, dissociative agents, and opioid agents. Now, uh, let me share with you the
commonly used intravenous medications.

These table lists commonly use IV anesthetic and analgesic agents, including IV medications
used as muscle relaxants in the intraoperative period. These medications class may be
administered to induce or initiate or maintain anesthesia. Although they are often used in
combination with inhalation anesthetics, they may be used also alone.

They may also be used to produce moderate sedation. Okay, so we have morphine, sulfate,
alfentanil or alfenta, fentanyl, sublimase. ENT or ent. Okay. And then we also have the non
depolarizing muscle relaxants. Okay. So, uh, and so we have here the common usage
advantages, disadvantages, and some comments No by experts regarding these medications.

Okay? So an advantage class of IV anesthesia. Is that the onset of anesthesia is pleasant,

meaning there is none of the buzzing, roaring, or dizziness known to follow administration of an
inhalation anesthetic. That's why induction of anesthesia usually begins with an IV agent, and
often is preferred by some patients who are experienced, or who have experienced rather,
various methods.

The duration of action is also brief, and the patient awakens with little nausea or vomiting. The
IV anesthetic agents are also non explosive, they require little equipment, and are easy to
administer. The low incidence of postoperative nausea and vomiting makes the method useful in
eye surgery because in this setting, vomiting would increase intraocular pressure and endanger
vision in the operated eye.

IV anesthesia is also useful for short procedures, but this is used. less often for the longer
procedures of abdominal surgery. It is not indicated for children plus those who have small
veins or for those who require intubation because of their susceptibility to respiratory
obstruction. Now, a disadvantage of one IV anesthetic such as thiopental or pentotal Is its
powerful respiratory depressant effect.

It must be administered by a skilled anesthesiologist or anesthesia provider. And only when

some method of oxygen administration is available. Immediately in case of difficulty. Sneezing,
coughing, and laryngospasm are sometimes noted with the use of thiopental or pentotal. Okay,
another type of anesthesia is the local anesthesia, which is used to block nerves in the
peripheral nervous system and central nervous system.

You see, local anesthesia provides anesthesia and analgesia by blocking the transmission of
pain sensation along nerve fibers. The degree of blockage depends also on both drug
concentration and volume. It can be used alone or in conjunction with other types of
anesthesia. Usually, it is administered by the surgeon to a specific area of the body by topical
application or local infiltration.

In most cases, the patient will be monitored by a nurse. And in order to ensure safety and
quality of care, as recommended by the American Association of Operating Room Nurses, they
have developed or recommended practices for nurses who monitor patients receiving local care.
Anesthesia. The nurse should also monitor the quantity of medication administered since toxic
reactions are those related.

So under local anesthesia, we have regional anesthesia, spinal anesthesia,

epidural anesthesia, and peripheral nerve blocks. Regional anesthesia is a form of local
anesthesia class, okay, in which an anesthetic agent is injected around nerves. So that the
area supported by these nerves is anesthetized, anesthetized. The most common techniques
are spinal, epidural, and peripheral nerve blocks.

Regional anesthesia is an attractive anesthetic option for many types of operative procedures
and can provide excellent postoperative blocks, post operative pain management in selected
patients. The effect depends on the type of nerve involved. A local anesthetic blocks motor
nerves least readily and sympathetic nerves most readily.

An anesthetic cannot be regarded as having worn off until all three systems Okay. Motor,
sensory, and autonomic are no longer affected. Now, it's important to know that the patient
receiving regional anesthesia is awake and aware of his or her surroundings, unless
medications are given to produce mild sedation.

Or to relieve anxiety. So as a nurse, you must avoid careless conversation, unnecessary noise
in unpleasant wonder, because these may be noticed by the patient inside the operating room
and may contribute to a negative response to the surgical experience. A quiet environment is
therapeutic. The diagnosis must not be stated, also allowed if the patient is not to know it.

At this period or at this now, the spinal anesthesia blasts. It's a, another is an extensive
conduction nerve block that is produced when a local anesthesia is introduced into the
subarachnoid space at the lumbar level, usually between L four and L five, it produces
anesthesia of the lower extremities.

Perineum and even lower abdomen. For the lumbar puncture procedure, for instance, the
patient usually lies on the side in a knee to chest position. Stereotechnique is used as a spinal
puncture. It's made and the medication is injected through the knee. And then as soon as the
injection has been made, the patient is positioned with his or her back.

If a relatively high level of block is sought, the head and shoulders. are lowered.

Epidural anesthesia, on the other hand, commonly used conduction block, is achieved by
injecting a local anesthetic into the epidural space that surrounds the dura mater of the, uh,
spinal cord. In contrast, spinal anesthesia involves injection through the dura mater into the
subarachnoid space surrounding the spinal cord.

the spinal cord. Your epidural anesthesia blocks sensory, motor, and autonomic functions, but it
differs from spinal anesthesia by the site of injection and the amount of anesthetic agent use.
Epidural doses are much higher because the epidural anesthetic does not make direct contact
with the spinal cord.

And the other one. The last type of regional anesthesia is the peripheral nerve block. A
blockade of the brachial plexus or arm, lumbar plexus, and specific peripheral nerves. is an
effective means class of providing surgical anesthesia and postoperative analgesia for many
surgical procedures involving the upper and lower extremities.

The advantages of peripheral nerve block include reduced physiologic stress in comparison to
spinal or epidural anesthesia. Avoidance of airway manipulation and the potential complications
associated with endotracheal intubation and avoidance of potential side effects associated with
general anesthesia.
You see, all patient classes receiving peripheral nerve blocks should receive a full, full
perioperative evaluation under the assumption that general anesthesia could be used if the
block is inadequate. Okay?

All right. Now, the third one is What we call moderate sedation. Okay. Or an analgesia and mon
or monitored anesthesia care. It is important to distinguish between moderate sedation or
analgesia and Modi monitored anesthesia care. The Modi, the monitor, uh, sorry, the moderate.
Sedation or analgesia is a term used by the ASA in their practice guidelines for sedation and
analgesia by non anesthesiologists.

The monitored anesthesia care implies the potential for a level of sedation deeper than what is
provided by sedation and analgesia, and this is always administered by anesthesiologists.
Moderate sedation or analgesia, previously referred to as conscious sedation. That's what we
used to call moderate sedation or analgesia, is conscious sedation.

And monitor anesthesia, or forms of anesthesia that involve that. Intravenous administration of
sedatives and analgesic medications to reduce patient anxiety and control pain during
diagnostic or therapeutic procedures. Now, it is being used increasingly for specific short term
surgical procedures in hospitals and even in ambulatory care centers.

The goal is to depress the patient's level of consciousness. During a consciousness to a

moderate level to enable surgical diagnostic or therapeutic procedures to be performed while
ensuring patient's comfort during and cooperation with the procedures. Moderate sedation or
conscious sedation and monitored analgesia allow the patient to maintain a patted airway,
retain protective airway reflexes, respond to stimuli, verbal and physical stimuli, and recover
more rapidly post operatively.

Moderate sedation can be administered by an anesthesiologist, anesthetist, or other specially

trained and credentialed physician or nurse. Or even the nurse anesthetist can also administer
this in the United States. The patient receiving moderate sedation is never left alone and is
closely monitored by a physician or nurse who is knowledgeable and skilled in determining or
detecting arrhythmias, administering oxygen, and performing resuscitation.

Pulse oximetry, ECG monitor, and frequent measurement of vital sites are used to monitor the
patient. The regulations for use and administration of moderate sedation differ from state to
state in the United States. And its administration is addressed in standards issued by the Joint
Commission and by institutional policies and nursing specialty organizations, including the
Association of Operating Room Nurses.

Now what are the intraoperative nursing management activities? You see? The major goals for
care of the patient during surgery are to reduce his or her anxiety, keep the patient free of very
operative injury related to positioning, avoid threat to safety, maintain patient dignity, and avoid
complications associated with operative events.
So. Number one is to reduce anxiety. How do we do this? Okay, I see the OR environment can
seem cold, stark, and frightening to the patient who may be feeling isolated and apprehensive.
And so introductions, addressing the patient by name warmly and frequently, verifying details,
providing explanations, and encouraging answering their questions.

May convey a sense of professionalism and friendliness could help the patient feel secure
when discussing what the patient can expect in surgery. You can use basic communication skills
such as touch and eye contact to reduce anxiety. Attention to physical comfort like providing a
warm blanket, position change may also help the patient feel more comfortable.

Telling the patient who else will be present in the OR, the members of the surgical team, how
long the procedure is expected to take or the duration. And other details may also help the
patient prepare for the surgical experience. They may feel a gain or may gain a sense of control.
Next is preventing intraoperative position injury.

Okay, you see the patient's position on the operating table depends on the surgical procedure to
be performed as well as on the patient's physical condition. The potential for transient
discomfort or permanent injury is present because many positions are hyperextended joints,
compressing arteries. Or pressing on nerves and bony prominences usually result in discomfort
simply because the position must be sustained for a long period of time.

And so there are certain factors that you have to consider. Like the patient should be, uh, in as
comfortable a position as possible, whether conscious or unconscious. The operative field must
be exposed adequately. An awkward position and due pressure on the body.
VIDEO 2
All right, now to continue, okay, these are the factors that you have to consider now in order to
prevent intraoperative positioning injury. Number one is the patient should be in as comfortable
as a position as possible, whether conscious or unconscious. The operative field must be
exposed adequately.

An awkward position, undue pressure on the body part. Or use of stirrups or traction should not
obstruct the vascular supply. Respiration should not be impeded by pressure of arms on the
chest or by a gown that constricts the neck or chest. Nerves must be protected from undue
pressure. Improper positioning of the arms, hands, legs, or feet can cause serious injury or
paralysis.

Shoulder braces must therefore be well padded to prevent irreparable nerve injury, especially
when the Trendelenburg position or head down is necessary. The post operative complication
of compartment syndrome is associated with intraoperative positioning. Precautions for patient
safety must also be observed, particularly with teen, elderly, or obese patients, as well as those
with a physical deformity.
And the patient may need light restraint before induction in case of anxiety. Now let me show
you the different positions. The usual position for surgery is what we call dorsal recumbent,
which is flat on the back. One arm is positioned at the side of the table. With the hand placed
palm down, the other is carefully positioned on an arm board to facilitate IV infusion of fluids,
blood, or medications.

You see this position, which is dorsal recumbent, is used for most abdominal surgeries, except
for surgery of the gallbladder or pelvis. The Trendelenburg position, meanwhile, usually is used
for surgery on the lower abdomen and pelvis to obtain good exposure. by displacing the
intestines into the upper abdomen.

In this position, the head and the upper body are lowered. The patient is held in position by
padded shoulder braces. The lithotomy position, on the other hand, is used for nearly all
perineal, rectal, and vaginal surgical procedures. The patient is positioned on the back with the
legs and thighs flexed.

The position is maintained by placing the fitted stirrups. The seams or lateral position,
meanwhile, is used for renal surgery. The patient is placed on the non operative side with an air
pillow or beanbag, okay? The beanbag is about 12. 5 to 15 cm or 5, around 5 to 6 inches. Stick
under the loin or on a table with a kidney or back lift.

Other procedures such as neurosurgery or abdominal thoracic surgery may require unique
positioning and supplemental apparatus depending on the operative approach. Okay, now the
third, uh, priority one. Third, uh, nursing responsibility is to protect the patient from injury. You
see, a variety of activities are used to address the diverse patient safety issues arising inside
the operating room.

As a nurse, you have to protect the patient from injury by providing a safe environment.
Verifying information, checking the chart for completeness, and maintaining surgical asepsis in
an optimal environment are critical nursing responsibilities. Verifying that all required
documentation is completed is one of the first.

Functions of the intraoperative nurse, the patient is identified, and the planned surgical
procedure, correct surgical site, and the type of anesthesia are also verified. It's also important
to review the patient's record for the following, okay? Correct informed surgical consent with
patient's and surgeon's signatures.

Completed records for health history and physical examination. Results of diagnostic studies
and allergies. Now, in addition to checking that all necessary patient data are complete, as a
perioperative nurse, you have to obtain the necessary equipment specific to the procedure. The
need for non routine medications, blood components, instruments, and other equipment and
supplies is assessed.
And the readiness of the room, completeness of physical setup, and completeness of the
instrument, suture, and dressing setups are determined. Any aspects of the operating room
environment. That may negatively affect the patient are identified. These can include the
physical features such as room temperature and humidity, electrical hazards, potential
contaminants like dust, blood, and discharge on floor or surfaces, uncovered hair, faulty attire of
personnel, jewelry worn by personnel, and unnecessary traffic.

The circulating nurse also sets up and maintains suction equipment in working order, sets up
invasive monitoring equipment, assists with insertion of vascular access and monitoring devices,
such as the arterial swans guns, central venous pressure, IV lines, and the circulating nurse
also initiates appropriate physical comfort measures for the patient.

Now, preventing physical injury class includes using safety straps and side rings and not leaving
the sedated patient unattended. Transferring the patient from the stretcher to the operating
room table or OR table requires safe transferring practices. Other safety measures include
properly positioning the grounding pad under the patient to prevent electrical burns and shock,
removing excess antiseptic solution from the patient's skin, and promptly and completely
draping exposed areas after the sterile field has been created to decrease the risk of
hypothermia.

The importance of nursing measures. to prevent never events in surgery such as prevention of
retained foreign objects, wrong side surgery, and pressure ulcers cannot be over emphasized.
The Joint Commission and the Association of Operating Room Nurses have developed
guidelines that should be implemented in each facility to prevent these from occurring.

There are also technologic devices that can support the safe counting of surgical instruments
and supplies to prevent retention of foreign objects. The un, the unintended retention of foreign
objects or the UR echo. Unintended, unintended retention of foreign objects, also called
retained surgical items, or RSIs after invasive procedures can cause death.

Okay, and surviving patients may sustain both physical and emotional harm depending on the
type of object retained, depend government. Okay. And the length of time it is written, the risk
of the unintended retention of foreign objects increases during certain surgical conditions.
Nursing measures to prevent injury from excessive blood loss include blood conservation using
equipment such as cell saver, which is a device for recirculating the patient's own blood cells, as
well as administration of blood products.

Few patients undergoing an elective procedure require blood transfusions. But those patients
undergoing higher risk procedures, such as orthopedic or cardiac surgeries, may require an
interoperative transfusion. The circulating nurse, hence, anticipates this need, checks that
blood has been cross matched and filled, held in reserve, and is prepared to support the
anesthesiologist with administration.
Of course, let us not forget our role as patients. Okay, because the patient undergoing general
anesthesia or moderate sedation experiences temporary sensory, perceptual alteration or loss,
he or she has not increased, has an increased need for protection and advocacy. Patient
advocacy in the OR entails maintaining the patient's physical and emotional comfort, privacy,
rights, and dignity.

Patients, whether conscious or unconscious, should not be subjected to excessive noise.

Inappropriate conversation, or most of all, derogatory comments, as surprising as these
sounds, bantered in the operating room occasionally includes jokes about the patient's physical
appearance, job, personal history, and so forth.

Cases have been reported in which seemingly deeply anesthetized patients recall the entire
surgical experience. including disparaging personal remarks made by the Kumar personnel. As
an advocate, never engage in this conversation and discourage others from doing so. Other
advocacy activities may include minimizing the clinical dehumanizing aspects of being a surgical
patient by making sure the patient is treated as a person, respecting cultural and spiritual
values, providing physical privacy, and maintaining confidentiality.

And the last one is, of course, monitoring and managing potential complications. It is the
responsibility of the surgeon, anesthesiologist or anesthesia provider, and the circulating nurse
to monitor and manage complications. Important nursing functions include being alert to and
reporting changes in vital signs and symptoms of nausea and vomiting, anaphylaxis, hypoxia,
hypothermia, malignant hyperthermia, and even disseminated intravascular coagulation.

And assisting with the management of those complications. These post operative
complications. It is the responsibility of all members of the healthcare team to maintain asepsis.
Okay, so that concludes our session on intraoperative nursing.

VIDEO 3
Now to continue we have the post operative nursing. The post operative phase actually begins
when the patient is transferred to the post anesthesia care unit or the recovery room and the
report is given by the anesthesiologist and circulating nurse to the perianesthesia nurse. The
post operative phase ends when the patient is discharged from all phases.

of post operative care. The scope of nursing care in this phase covers a wide range of activities
including maintaining the patient's airway, monitoring vital signs, assessing the effects of the
anesthesia or anesthetic agents, assessing the patient for post operative complications, and
providing comfort and pain relief.

Nursing activities also focus on promoting the patient's recovery and initiating the teaching,
follow up care, and referrals essential for recovery and rehabilitation after discharge.

Now, the post anesthesia period, okay, or the post operative period provides a monitored
transition from the intraoperative Our procedure period to assess and manage the patient's
hemodynamic, analgesic, and general preparedness for rapid and optimal recovery. The PACU,
or Separate Post Anesthesia Recovery Area, such as a Surgical Intensive Care Unit, provides
resources appropriate for patients who receive sedation, regional anesthesia, Even general
anesthesia now prior to anesthesia or during the inoperative period when decision to meet the
patient in the back or intensive care area is discussed by the surgeon and the anesthesiologist.

Some procedures and anesthesia techniques also allow transition from the operating or
procedure room, no operating room, to directly return to the patient room for phase two
recovery based on facility. Policy and criteria. Now, the post anesthesia care during the
postoperative period in some hospitals and ambulatory surgical centers is divided into two
phases.

Generally, two phases. We have the phase one PACU, which is the immediate recovery phase.
Intensive nursing care is provided here. In phase two PACU, the patient is prepared for self
care or care in the hospital. An extended care setting or discharge recliners rather than
stretchers or beds are standard in many phase two units.

In facilities without separate bases, the patient remains in the PACU and may be discharged
home directly from this unit. Now the nursing management objectives for the nurse in the PACU
or post anesthesia care unit are to provide care until the patient has recovered from the effects
of anesthesia. For instance, until resumption of motor and sensory functions.

Okay. Is oriented or returns to baseline cognition, has a stable vital signs and adequate pain
control, and shows no evidence of hemorrhage or other complications. Therefore, all PACO
nurses have special, should have special skills, including strong assessment skills. The PACO
nurse provides frequent monitoring.

Ideally, every 15 minutes of the patient's pulse, ECG, respiratory rate, blood pressure, and pulse
oximeter, blood oxygen level. In some cases, the N tidal carbon dioxide level is monitored as
well. Patients airway may become obstructed because of the latent effects of recent
anesthesia, and the PACO nurse must be prepared to assist in re intubation and in handling
other emergencies that may occur.

Nurses, in fact, must also possess excellent patient teaching skills. Now, as shown on this
slide, there are three phases in the post anesthesia care. The post anesthesia period, as I said,
may be separated into three levels of care. We have phase one, phase two, and we also have
now the extended care for the phase three.

In each phase, each phase of recovery may occur in one PACU or in multiple locations, which
may include the patient's room. In a critical care area, anesthesia and procedural transitions
are integrated into the routine care and monitoring of the patient. So what do we have in each
phase? In Phase 1, during Phase 1, the focus is on the patient's recovery from anesthesia and
the return to baseline vital signs.
Consideration is given to the procedure, anesthesia care, patient comorbidities, and the
patient's physical status to recognize, minimize, and manage any issues or complications.
Phase 1 includes, but is not limited to, applying PAHU scoring criteria on admission. In each
vital signs assessment, managing respiratory and hemodynamic changes, monitoring the
effects of the procedure like bleeding and circulation, and providing necessary analgesia and
anesthetics.

It's antiemetics, rather. While monitoring requirements are facility specific, they are also based
on the patient's condition. Now, according to the ASPAN, A S P A N, they recommended
assessing and documenting vital signs at least every 15 minutes during Phase 1, during the first
hour, and then Every 30 minutes until discharge from phase one back to care, the patient is then
transitioned to phase two, the inpatient setting, or the intensive care unit for continued.

Now, in phase two, before a patient is transitioned to phase two care, phase one priorities
should be met. Phase 2 care focuses on continued recovery, and this is based on facility policy
and the needs of the patient. Phase 2 care most often applies to the ambulatory or same day
admission. The goal of this phase is to prepare the patient to be transferred in or to an
extended care facility.

The goal of this phase is to prepare the patient to be transferred home or to an extended care
facility. During this phase, the patient is able to ambulate. Take nutrition and receive education
instructions necessary for self management of care at home. Now, um, in some instances,
there's what we call fast tracking.

Some anesthesia techniques and surgeries allow the patient to bypass phase one care and go
directly from the operating or procedure room to phase two. A process known as fast tracking.
Fast tracking allows the anesthesia, anesthesiologist, and the surgical team to determine that
the patient has adequately recovered and has met the criteria to be transitioned to phase two
care immediately in the post anesthesia period.

Criteria for determining whether a patient is able to be fast tracked is developed by the
interdisciplinary team and documented in facility policy. Criteria for bypass of phase one PACU
may include but are not limited to the PACU scoring criteria. Patient physical and mental status,
vital signs, type of surgery, procedure, and many complications.

Age alone is not used as a criterion to fast track a patient. Adequate staffing resources on the
receiving phase 2 team is an important consideration in fast track. Communication from the
procedure team to the phase 2 team. is also essential for successful transition of care. And the
last one is phase three or the so called extended care.

Extended care, otherwise known as phase three, occurs in the same physical location as care
provided to phase one and phase two patients. This phase is for patients who have met the
criteria to leave phase one but are not able to go to another location, like there are no available
inpatient beds. These patients are assessed and managed as inpatients.
And these are the nursing management during the post anesthesia care. Of course, admitting
PACU, okay? We already know that transferring the post op patient from the OR to the PACU is
the responsibility of the anesthesiologist. During the transport from the OR to the PACU, the
anesthesiologist remains at the head of the stretcher to maintain the airway, and the surgical
team member remains at the opposite end.

Transporting the patient involves special consideration of the incision site, potential vascular
changes, and exposure. The surgical incision is considered every time the post op patient is
moved. Many wounds are closed under considerable tension, and every effort should be made
to prevent further strain on the incision site.

Patient is positioned so that he or she is not lying on or obstructing drains or drainage tubes.
Serious ortho, orthostatic, or postural hypotension may occur when the patient is moved too
quickly from one position to another, let's say from lithotomy to horizontal position, or from
lateral to sine position.

So the patient must be moved slowly and carefully, and as soon as the patient is placed on the
stretch stretcher bed, the soil gown is removed and replaced with a dry gown. Patient is covered
with lightweight blankets and warmth. Three side rails must also be raised. to prevent, uh, to
prevent falls. Next is, of course, assessing the patient, okay?

Again, you start every 15 minutes and then afterwards every 30 minutes, okay? Patency of the
airway and respiratory function should be evaluated first, followed by assessment of
cardiovascular function, condition of surgical site, and function of the central nervous system.
Any surgical procedure As the potential for injury due to disrupted neurovascular integrity
resulting from surgical procedure, prolonged awkward position in the OR, manipulation of
tissues, inadvertent severing of nerves, or tight bandages.

Any orthopedic surgery or surgery involving the extremities carries a risk of peripheral nerve
damage. So assessment of circulation, sensation, mobility is also important. And that includes
having the patient move the hand or foot distal to the surgical site through a full range of motion,
assessing all surfaces for impact sensation, okay, or an assessing peripheral, uh, pulses and
capillary refill.

Third is to maintain a patent airway. You see, the primary objective in the immediate post
operative period is to maintain pulmonary ventilation, and thus, prevent hypoxemia or reduce
oxygen in the blood, not only hypoxemia, prevent hypercapnia or excess carbon dioxide in the
blood. These two, hypoxemia and hypercapnia can occur if the airway is obstructed and
ventilation is reduced, or if there is hyperventilation.

Besides checking the provider's orders or the physician's orders for and administering
supplemental oxygen, you also have to assess. respiratory rate and depth, ease of respirations,
oxygen saturation, and breath sounds, because patients who have experienced prolonged
anesthesia usually they are unconscious with all muscles relaxed.

This relaxation extends to the muscles of the pharynx. When the patient lies on his or her back,
the lower jaw and the thumb fall backward and the air passages may become obstructed and
that condition is what we call hypopharyngeal obstruction. LA and . Signs of hyperreal
obstruction or occlusion, which can include joking, noisy and irregular respirations, decreased
oxygen saturation, and within minutes, a blue dusky color or cyan to the skin can be observed in
the patient.

What is to maintain cardiovascular? Activity. Okay, so it's important to monitor cardiovascular

stability. So you have to assess patient's mental status, vital signs, cardiac rhythms, skin
temperature, color and moisture, and , CVP or central venous pressure, pulmonary artery
pressure and arterial lines are the patient's condition requires such assessment.

So you also have to assess the patency of all the IV lines. Okay. See, the primary
cardiovascular complications seen in the include hypotension and shock hemorrhage.
Hypertension is also possible and arrhythmia. Okay. Another is to, uh, relieve pain and anxiety.
Now the , so, uh, IV opioid analgesics are administered judiciously and often in the, uh, post
anesthesia care unit, IV opioids.

Provide immediate pain relief and a short acting, thus minimizing the potential for drug
interactions or prolonged respiratory depression, while there are anesthetics still active in the
patient's system. So, as a nurse, no, as a back home nurse, you have to monitor the patient's
physiologic status, have to manage pain and provide psychological support in an effort to relieve
the patient's fears and concerns.

You also have to check the medical record, you know, for special needs and concerns of the
patient. And when the patient's condition permits, a close member of the family may visit in the
park. This will also decrease family's anxiety and could make the patient feel more secure.
Another is to control nausea and vomiting.

We call this post anus, post operative, and post discharge nausea. Post operative and post
discharge nausea and vomiting, which is one of the most commonly occurring post operative
complications, uh, frequently resulting in prolonged post operative stay, unanticipated
admission, and increased healthcare costs.

So healthcare providers have yet to reach consensus regarding an evidence based

multidisciplinary multi treatment model approach to this one. So as a nurse, you have to
intervene at the patient's first report of nausea to control the problem rather than wait for it to
progress to vomiting. Okay. Now there are many, many medications now available to control
nausea and vomiting without over sedating the patient.
They're commonly administered during surgery now, as well as in the PA medications like
Metoclopramide or lan. Okay. Prochlorperazine or Compazine or Methazine Magazine or fan or
gun. Hy di Diamond ate or drumin, Orin, hydroxyzine, er, aax and scopolamine. They are
commonly prescribed to, uh, control, nausea and vomiting, although it is costly on Danone or
Zofran, is frequently used as an effective antiemetic agent with few side effects.

Okay. And finally, of course, preparing the patient for discharge from the pack. You see, a
patient remains in the pack until fully recovered from the anesthetic agent. Indicators. No
indicators of recovery includes stable bp, unstable in the patient if there is adequate respiratory
function, adequate oxygen saturation level pass of measures of 95 to 100%.

Okay, consistently compared with baseline and spontaneous movement or movement on

command. Discharge criteria actually should be developed collaboratively with anesthesia,
anesthesiologists using these standards like stable vital signs, return to baseline level of
consciousness. uncompromised pulmonary function and adequate airway, pulse oximetry
readings indicating adequate blood oxygen saturation, intake and output, nausea and vomiting
are absent or under control, pain level, sensory and motor function, and condition of surgical
site.

Ngayon, karamiyan ng mga hospital gumagamit ng scoring system tinatawag na ALDRIT score.
Okay, ALDRIT score, perhaps you have encountered this already, okay, the ALDRIT score.
Ginagamit itong ALDRIT score to determine the patient's general condition and readiness for
transfer from the PACU, okay? Throughout the recovery period, the patient's physical signs are
observed and evaluated by means of this scoring system based on a set of objective criteria
that includes consciousness.

activity, breathing, pulse oximetry, and circulation. Those are the standards or criteria that we
look at using Aldrich's scoring system. Patient is also assessed at regular intervals, as I said,
every 15 minutes and the total score is calculated and recorded on the assessment record.
Now the patient remains in the PACU until their condition improves or they can be transferred
safely to an ICU or surgical unit or discharged depending on their preoperative baseline score.

The patient is discharged from the Phase 1 PACU by the anesthesiologist. to the critical care
unit, the medical surgical unit, and then the phase two or home with the responsible family.
Okay. So I hope, uh, I was able to clearly discuss with you the important highlights in each, uh,
in each phase. Okay. So these are the details for each, uh, Nursing management during the
post operative care, okay?

Assessing the patient, maintaining a patent airway, maintaining cardiovascular activity,

relieving pain and anxiety, controlling nausea and vomiting, as well as preparing for discharge
from PAH, okay? So, uh, prepare for an assessment. Should you have questions, feel free to
raise them before our next meeting, before the start of our session.
Okay. And also again, prepare for a graded recitation. Okay. So thank you so much and have a
lovely day.