7 Preparation for and undergoing an anaesthetic prior to surgery
Introduction
The field of anaesthetics is vast and complex. This chapter can only aim to give a brief insight into this complex area of service provision. There are many good texts that you can use to gain more in-depth knowledge on particular aspects which we only touch on. Equally, the experience and expertise of the anaesthetic team are a good source for you to gain further knowledge about caring for the patient who is about to undergo surgery.
At the end of Chapter 6, a patient was transferred to the operating theatre from the ward accompanied by a nurse. The patient is then taken into the anaesthetic room and handed over from the ward nurse to either the anaesthetic nurse or operating department practitioner (ODP). This is a very vulnerable time for patients and, especially if they have never experienced an anaesthetic before, they will rely very much on the security of the familiar nurse from the ward. This may well be you.
Transfer of the patient to the anaesthetic room
If the patient is to undergo major surgery, they will be taken to the anaesthetic room either on their bed, a theatre trolley or, if day surgery, a wheelchair or on foot (Gilmour 2010). Here they will meet new staff, in particular the anaesthetist, the anaesthetic nurse or operating department practitioner. They all have roles to play in caring for the patient and ensuring safe practice in the anaesthetic room (see Box 7.1 for the main functions of staff providing anaesthetic assistance).
Box 7.1 Main functions of staff providing anaesthetic assistance
Adapted from National Occupational Standards for Operating Department Practice (Scottish Government 2003)
In the handover period between ward staff and anaesthetic room staff, it is important that all details about the patient, their surgery and consent form have been checked – this may take place outside the immediate anaesthetic room, in the ‘clean area’ beyond the doors to the main operating theatre suite.
The patient must be treated with respect and dignity at all times. Any cultural or religious needs must be taken into account during this time and reassurance given about such issues as modesty, body fluids and skin
If the operating theatre is your main placement (hub), it is important that you consider what you need to learn in relation to caring for patients during the handover period and also what is going to happen to the patient when they receive anaesthesia and their subsequent management.
Your mentor may already have planned an experience for you during your placement which may include more than a day in this area, working alongside the anaesthetist and others (see Appendix 1 at the end of this chapter for specific learning outcomes that can be achieved).
Specific learning experiences in anaesthetics: a checklist of learning outcomes
Understand importance of communication in relieving patients' anxiety.
Experience of managing the patient handover from ward nurse to anaesthetic practitioner.
Ability to identify different methods of anaesthesia and the effects on patients.
Experience management of patients' airways underpinned by principles of care and knowledge of physiology of airway management.
Understand basic principles underpinning monitoring of patients' cardiac, respiratory and temperature control during anaesthesia.
Ability to recognise the role of members of the multidisciplinary team and demonstrate ability to work within a team.
care as necessary (see Association for Perioperative Practice (2007) for information on respecting cultural diversity in the perioperative setting).
See Box 7.2 for a description of what the anaesthetic nurse has to manage, and identify the areas you need to learn more about. Some of the activities are identified in this chapter as well as resources you can access to learn more.
Box 7.2 The role of the anaesthetic nurse
The anaesthetic nurse will, based on the information known, or relayed by the anaesthetist, prepare the anaesthetic room, anaesthetic machines and all other equipment to ensure the maintenance of a safe environment for the delivery of care during anaesthesia. This will include not only preparing the anaesthetic equipment but also applying knowledge and skills of anaesthesia related to age, medical history and surgical procedure to ensure that the patient's individual needs are being met, e.g. if the patient is elderly, additional precautions are needed when caring for their skin; if the patient has language difficulties, an interpreter may be required.
(From Gilmour 2010:19)
If you are going to spend some time in the perioperative environment of the anaesthetic room as well as caring for the patient both pre- and postoperatively, an understanding of the basics of anaesthesia is essential.
Who else is in the anaesthetic team?
The anaesthetic team includes a number of professionals, including the anaesthetic nurse as described already.
Anaesthetist
The team is led by an anaesthetist, who is a qualified doctor who has undergone further specialty training to be registered as an anaesthetist. The patient will have met the anaesthetist during their pre-admission assessment visit and/or following their admission to hospital either for day surgery or for a longer stay. The anaesthetist will have explained what their role is and also checked a number of safety issues with the patient with regards to any long-term health problems
Watch this video on the NHS Choices website about anaesthesia and the role of the anaesthetist:
http://www.nhs.uk/conditions/Anaesthesia/Pages/Introduction.aspx?url=Pages/What-is-it.aspx (accessed December 2011).
Make notes of key points of the process which you can further investigate when you are on your placement.
The video is also useful as it shows the actual physical environment of the operating theatre. The website also has many more short video clips of a wide range of surgical interventions from the perspective of patients and health professionals.
and medication being taken and will answer any questions they and their family might ask.
The anaesthetist ensures that patient safety is maintained during surgery, whether minor or major, and if a patient is having a general anaesthetic and is unconscious throughout the procedure, they ensure they wake up with as few problems as possible.
Operating department practitioner
Another key role in the team is that of the operating department practitioner, who provides anaesthetic assistance to the anaesthetist. The role of ODPs is multifaceted and they also contribute to the care of the patient during the actual surgery as well as during the anaesthesia. They undertake a similar period of training and education to either diploma or degree level that a student nurse does. See the NHS careers information in Box 7.3.
Box 7.3 NHS careers information
Working as an operating department practitioner
Operating department practitioners (ODPs) are an important part of the operating department team working with surgeons, anaesthetists and theatre nurses to help ensure every operation is as safe and effective as possible.
ODPs provide high standards of patient care and skilled support alongside medical and nursing colleagues during perioperative care. The ODP's role involves the application of theory to practice in a variety of clinical settings. The ODP therefore needs a broad knowledge and skill base, including management and communication skills, and will be involved with the assessment, delivery and evaluation of perioperative care.
The anaesthetic phase
During this phase, the ODP will:
assist the patient prior to surgery and provide individualised care
need an ability to communicate and work effectively within a team
undertake a role which will also involve many clinical skills such as the preparation of a wide range of specialist equipment and drugs. This includes anaesthetic machines, intravenous equipment and devices to safely secure the patient's airway during anaesthesia.
The surgical phase
ODPs will participate, as part of the operative team, in a number of roles, including the ‘scrubbed’ role, application of aseptic technique, wound management and infection control.
wear sterile gown and gloves and prepare all the necessary instruments and equipment for the procedure. This may involve complex machinery such as microscopes, lasers and endoscopes
work alongside the surgeon, providing correct surgical instruments and materials in order to ensure safe and efficient completion of surgical procedures
have a role in the promotion of health and safety and are therefore responsible for ensuring that surgical instruments, equipment and swabs are all accounted for throughout the surgical procedure
undertake the circulating role, utilising communication and management skills, preparing the environment, equipment and acting as the link between the surgical team and other parts of the theatre and hospital
be able to anticipate the requirements of the surgical team and to respond effectively.
The recovery phase
receive, assess and deliver patient care on their arrival into the recovery unit
monitor the patient's physiological parameters and support them, providing appropriate interventions and treatment until the patient has recovered from the effects of the anaesthesia and/or surgery and is stable
assess the patient in order to ensure they can be discharged back to a surgical ward area
evaluate the care given during the perioperative phases (anaesthetics, surgery, recovery).
(From http://www.nhscareers.nhs.uk/details/Default.aspx?Id=255 (accessed December 2011).
Definition of anaesthesia and anaesthetic
The NHS Choice website (http://www.nhs.uk/conditions/anaesthesia/Pages/Introduction.aspx (accessed May 2011) states that:
Anaesthesia means ‘loss of sensation’. Medications that cause anaesthesia are called anaesthetics. Anaesthetics are used for pain relief during tests or surgical operations so that you do not feel:
As seen in the NHS Choices video of the anaesthetist (see above), there are three main overarching types of anaesthesia, namely local, regional and general.
To consider how the team works in the operating room and related areas access and read the article by Silen-Lipponen et al (2004) (see References).
Local anaesthesia
Local anaesthesia ‘blocks the transmission of pain from a specific area of the body. Where only the sensory receptors are blocked, it is more correctly termed local analgesia’ (Gibson 2006:918).
Regional anaesthesia
'is used for larger or deeper operations where the nerves are harder to reach. Local anaesthetic is injected near the nerves in order to numb a larger area, but the patient remains conscious.' (Patient Information
Familiarise yourself with the effects of anaesthesia before you start your placement, or if you intend to include spending time in this environment as part of your insight learning days (spokes), and read Chapter 2, Gilmour (2010) (see References).
leaflet, NIHCE, accessed 25th May 2011). One type of regional anaesthetic is an epidural, which affects the lower half of the body, and is used in childbirth and also surgery where a general anaesthetic may not be advisable.
General anaesthesia
General anaesthesia is used where the patient is required to be unconscious for a period of time, sometimes for as much as 10 hours if it is a very complicated surgery. In this situation, the patient must not be able to feel anything, and this condition is ‘characterised by loss of consciousness, analgesia and muscle relaxation’ (Gibson 2006:918). There are considered to be three stages to general anaesthesia:
• Stage 1: pain relief, heavy sedation and some muscle relaxation.
• Stage 2: patient loses consciousness but may ‘exhibit wild movements and irrational behaviour but, with intravenous induction of anaesthesia, this stage is passed very quickly and may be more evident when the patient is recovering from anaesthesia’ (Gibson 2006:918).
• Stage 3: total muscle relaxation, loss of reflexes and consciousness, and the patient needs airways maintained. An endotracheal tube is introduced through the larynx, which is completely relaxed, and the patient's respiration is artificially maintained for the entire surgery.
It is beyond the scope of this book to explore all the drugs and procedures involved in anaesthesia. You are advised to read about the physiology of the nervous system and pain pathways and management as well as making a list of key drugs you are likely to encounter in the perioperative period. You can also ask your mentor and the operating theatre team any questions you may have. This information will help you explain to patients why they are experiencing some of the side effects of the procedures they have undergone as well as the drugs given to them.
Some of the more common side effects during the recovery period are seen in Box 7.4.
Box 7.4 Common side effects of anaesthesia
Feeling sick or vomiting – about one in three people feel sick after an operation.
Feeling cold and shivering for up to half an hour – this is possible after a general anaesthetic, or during, or after, a regional anaesthetic.
(taken from NIHCE Patient information leaflet)
It is essential that you refresh your understanding of normal physiology of all the body systems plus some of the disordered physiology prior to your surgical placement. Surgery of any kind impacts on many different systems.
Patients undergoing general anaesthetic can be in the third stage prior to leaving the anaesthetic room, and as soon as they are transferred into the operating room they will immediately be attached to an anaesthetic machine, which not only delivers the appropriate anaesthetic but also manages the mechanical ventilation of the patient during the operation.
Throughout the stages of general anaesthesia, it is vital that the nurse maintains communication with the patient, be it verbal or through touch. The patient must remain the focus of the procedures being carried out around them and their dignity maintained at all times. Patients are at their most vulnerable during the transition from the conscious to unconscious state. By staying with them throughout their whole experience, you will not only be able to answer their queries postoperatively but, most importantly, they will know that you have stayed with them throughout their surgery.
Your experience of the patient journey now enters its next phase of what happens in the operating theatre.
Association for Perioperative Practice. Respecting cultural diversity in the perioperative setting. Harrogate: Association for Perioperative Practice; 2007.
Gibson C. The patient facing surgery. Alexander M., Fawcett J.N., Runciman P.J. Nursing practice hospital and home: the adult, third ed., Edinburgh: Churchill Livingstone, 2006.
Gilmour D. Perioperative care. Pudner R., ed. Nursing the surgical patient, 3rd ed., Edinburgh: Baillière Tindall, 2010. 17–34
Scottish Government. Anaesthetic assistance: a strategy for training, recruitment and retention and the promulgating of safe practice. Online. Available at: http://www.scotland.gov.uk/Publications/2003/05/17153/21988, 2003. (accessed December 2011)
Silen-Lipponen M., Tossavainen K., Turunen H., Smith A. Learning about teamwork in operating room clinical placement. British Journal of Nursing. 2004;13(5):244–253.
Eart L., Huntington S. The peri-operative phase. In: McArthur-Rouse F., Prosser S. Assessing and managing the acutely ill adult surgical patient. Oxford: Blackwell, 2007.
Hughes S.J., Mardell A. Oxford handbook of perioperative practice. Oxford: Oxford University Press; 2009.
Wicker P., O'Neill J. Caring for the perioperative patient, second ed. Oxford: Wiley-Blackwell; 2010.
NHS Choices website: http://www.nhs.uk/conditions/anaesthetic-local/pages/introduction.aspx (accessed December 2011).