Topic 2: SURGERY - Concept of Illness and Pain

Instructor: Mrs. Rossana Tasic

HEALTH – state of complete physical, mental and social well being and not merely the
absence of a disease or infirmity (WHO 1948)
- viewed as a dynamic, ever changing condition that enables people to function at
an optimal potential at any given time
- ideal health status is one in which people are successful in achieving their full
potential, regardless of any limitations they might have
- represents successful adaptation to stress – ability to adapt to internal and external
environment

ILLNESS – state of having a disease or sickness

DISEASE – abnormal variation, deviation from, or interruption in the normal structure or

function of any part, organ, or system of the body causing disruption in function
manifested by characteristic set of symptoms or signs and therefore limits freedom of
action
- etiology, pathology and prognosis may be known or unknown
etiology – cause
pathology – process
prognosis – outcome
- disruption of the normal process

ETIOLOGY – cause of disease

- describes what sets the disease process in motion
- what triggers – predisposing and precipitating factors
precipitating – triggering
predisposing – criteria that can make you, later on, develop the disease

ETIOLOGIC AGENTS
• biologic – bacteria, viruses
• physical – trauma, burns, radiation
• chemical – poison, alcohol
• nutritional excesses or deficits – under/over nourishment

PATHOGENESIS – sequence of cellular and tissue events that take place from the time
of initial contact with an etiologic agent till the ultimate expression of diseases
- time of contact until the time that signs and symptoms are evident
- describes how the disease process evolves

PATHOLOGY – came from the Greek word “pathos” meaning “disease”

- deals with the study of the structural and functional changes in cells, tissues,
organs of the body that cause or are caused by the disease

*you always go back to the cell because it is the smallest unit in the body
PHYSIOLOGY – deals with the normal functions of the body

HOMEOSTASIS – refers to the steady state within the body

- State of equilibrium in the body’s internal environment – cells, tissues, organ and
fluids
- When a change or stress occurs causing the body function to deviate from its
stable range, processes are initiated to restore and maintain the dynamic balance
- If not adequate, homeostasis/steady state is threatened, functions become
disordered and dysfunctional response occurs that can lead to a disease
- determined by how body adapts to change

• everything boils down to the immune system or how your body responds to stress

PATHOPHYSIOLOGY – physiology of altered health

- study of how a disease goes on and what are the changes that go on in the body
- deals with the cellular and organ changes that occur with disease and the effects
that these changes have on total body function, focusing on the mechanism of the
underlying disease and provides background for preventive as well as therapeutic
health care measures and practices

STRESS – defined as a state resulting from a change in the environment that is perceived
as threatening to homeostasis
- stimulus is known as “stressor”

EFFECTS OF STRESS
1. adaptive – adaptation or adjustment to change or coping with change
- you are able to overcome and have a positive results
- lead to positive effective/effective – health

2. maladaptive – negative effect/ineffective adaptation – disease and illness develops

MECHANISM OF CELLULAR REPAIR

• cellular adaptation – cells adapt by undergoing changes in size, number and type
adaptation – desired outcome in managing actual or perceived stress to
reestablish equilibrium
• regenerative healing – damaged cells and tissues are replaced by new cells and
tissues identical to the damaged cell and tissue
• replace healing – replacement cells such as connective tissue, resulting in scar
formations

FACTORS AFFECTING CELLULAR REPAIR

1. age
2. nutritional status
3. presence of infection
• you have to correct one illness before you can go to another
4. chronic illness – predisposes cellular injury e.g. secondary disease
 5. nature of the wound – incision under aseptic technique vs. traumatic wounds
6. extent of wound and associated blood loss
7. tissue involved – tissues with good blood supply heal faster
8. psychosocial – like stress and fatigue can impair healing

PSYCHOLOGICAL PROCESS OF ILLNESS

I. CELL INJURY AND INFLAMMATION
injury – disorder in or the loss of the steady – state regulation
- any stressor that alters the ability of the cell or system to maintain
optimal balance of its adjustment process leads to injury causing
structural and functional changes which may either be reversible
(permits recovery) or irreversible (leading to disability or death)

agents causing injury acts at the cellular level by damaging or destroying the following:
1. integrity of the cell membrane necessary for ionic balance
2. the ability of the cell to transform energy – e.g. stressor will make you lose your
confidence. Therefore if you lose confidence, you would stay “mumoy” in one
side.
3. the ability of the cell to synthesize enzymes and other necessary proteins
4. the ability of the cell to grow and reproduce (genetic integrity) – can be related to
ABT

CAUSES OF CELL INJURY

1. EXTERNAL
a. Physical agents – duration of exposure and intensity determines severity of
damage
i. Temperature extremes – heat stroke, hypothermia
ii. Radiation – decrease protective inflammatory response lead to
opportunistic infection
iii. Electrical shock – result to burns ; may over stimulate nerves e.g.
VF
1. mechanical trauma – disrupts cells and tissues of the body
- outcome depends on severity of wound, amt. of blood loss,
and extent of nerve damage
b. chemical agents – poison, drugs (overdose), alcohol
c. infectious agents – biological agents e.g. viruses, bacteria, fungi, etc.
2. INTERNAL
a. Hypoxia – inadequate cellular oxygenation
- respiratory system and efficiency of breathing of patient
- do deep breathing or remove secretions
b. Nutritional imbalance – deficiency or excess of 1 or more essential
nutrient
c. Immune mechanism – d/o immune response e.g. autoimmune diseases,
immunodeficiency
d. Genetic defects – congenital anomalies e.g. Down’s, obesity CA,
(hereditary disease)
 e. Psychogenic factors – stress
f. Chemical agents – e.g. HCl, insulin

WAYS ON HOW BODY RESPONSES TO INJURY

I. CELLULAR RESPONSE TO INJURY AND INFLAMMATION
A. CELL ADAPTATION
ADAPTATION STIMULUS
hypertrophy – increase in cell size leading - increased workload
to increase in organ size
atrophy – shrinkage/decrease in cell size decrease in:
leading to decrease in organ size 1. use
2. blood supply
3. nutrition
4. hormonal
stimulation
5. innervations
of the nerve
hyperplasia – increase in the number of hormonal influence
new cells (increased mitosis)
- multiplication of cells caused the
enlargement
dysplasia – changes in the appearance of - reproduction of cells with resulting
cells after chronic irritation alternation of their size and shape
metaplasia – transformation of one adult - stress applied to highly specialized cells
cell type to another cell type (this is
reversible)

B. BODY DEFENSES AGAINST INJURY

INTACT SKIN AND MUCOUS MEMBRANE – body’s first line of defense
• oral mucous membranes has many layers; difficult to penetrate
• skin has acidic (pH < 7) properties that renders some org unable to produce illness

CILIA – hair-like structures lining the upper respiratory tract mucous membrane
- protect lungs by trapping mucus, pus, dust, and foreign particles
- push trapped particles up the pharynx with wavelike movements

GASTRIC JUICES – found in the stomach’s highly acidic (pH of 1-5) acidic
environment destroys most organisms that enter the stomach

IMMUNOGLOBULINS – proteins found in the serum and body fluids

- acts antibodies to destroy invading organisms and prevent development of
infectious diseases

ANTIBODY – protein produced by B lymphocytes when foreign antigens of invading

cells are detected
ANTIGEN – markers on cell surface that identify cells as being the body’s own (auto
antigens) or as being foreign cells (foreign antigen)
• antibodies combine with specific foreign antigens on the surface of the invading
organisms, such as bacteria or viruses, to control or destroy them
• antibodies can destroy or neutralize antigens through
o initiating destruction of antigen
o neutralize toxins released by bacteria
o promote antigen clumping with the antibody
o prevent the antigen from adhering to host cell

LYZOSYMES – bactericidal enzymes present in WBC and most body fluids (tears,
saliva, and sweat)
- dissolve the walls of bacteria

INTERFERON – proteins made and released by lymphocytes in response to presence of

pathogens: virus, bacteria, parasites, or tumor cells
- aids in the destruction of infected cells and inhibits production of the virus within
the infected cells

C. MONOCULAR PHAGOCYTE SYSTEM

PHAGOCYTOSIS – engulfing and ingestion of bacteria and other foreign bodies by
phagocytes

PHAGOCYTES – cells that ingest and destroy bacteria, damaged or dead cells, cellular
debris, and foreign substances

DIFFERENT PHAGOCYTES:
• LEUKOCYTES (WBC) – primary cells, protect against infection and tissue
damage
- 5 types:
o neutrophils – bacteria and small particles
o monocytes – become macrophages ; tissue debris and large particles
o lymphocytes – functions: antigen recognition and antibody production
o basophils – respond to inflammation from injury
o eosinophils – destroys parasites and response in allergic reactions
- increased during allergic reactions or infestation
• MACROPHAGES – mature monocytes

INFLAMMATORY RESPONSE – occurs as a result to injury, pathogens, trauma, or any

other event that can cause injury to tissue
- infection may or may not be present

STEPS IN THE INFLAMMATORY PROCESS

I. VASCULAR RESPONSE – local vasodilation
 - increased blood flow in the injured area brings more plasma to nourish tissue and
carry waste and debris away
- redness (redness) and heat (calor) manifested
II. INFLAMMAOTRY EXUDATE – increased permeability of blood
vessels
- plasma moves out from capillaries to the tissue
- swelling (tumor) and pain (dolor) manifested due to compression of nerve endings

*kung ga habok ang IV site, assess if it is:

INFILTRATION PHLEBITIS
pale red
cold heat
pain pain
soft swelling hard swelling

III. PHAGOCYTOSIS AND PURULENT EXUDATE – final step

- destruction of pathogenic organisms and their toxins by leukocytes
- pus containing protein, cellular debris, and dead leukocytes

CARDINAL SIGNS OF INFLAMMATION

• redness (rubor) - produced by the following chemical mediators:
• heat (calor) histamine, prostaglandins, leukotrienes,
• swelling (tumor) bradykinins, platelet activating factors
• pain (dolor) – prostaglandins and bradykinins
• loss of function (functio laesa)

ALTERED IMMUNE RESPONSE

IMMUNE SYSTEM – body’s final line of defense against infection and/or cellular injury
- finely tuned network that functions together to protect the body form potentially
harmful substances by recognizing and responding to antigens

COMPONENTS OF THE IMMUNE SYSTEM

1. IMMUNE CELLS
a. Lymphocytes (T cells, B cells, and natural killer cells) have protective
functions related to specific antigen
b. Macrophages assist T and B lymphocytes

2. LYMPHOID ORGANS
a. Thymus – vital to the development of the immune system
b. Bone marrow – produces leukocytes, which is one of the products of
blood
- problems in bone marrow can, later on, cause leukemia
c. Spleen
d. Tonsils
e. Intestinal lymphoid tissue
f. Lymph Nodes
IMMUNITY – resistance to a disease that is provided by the immune system
- ability of the body to protect itself from disease
IMMUNE RESPONSE – involves a complex series of interactions between the
components of the immune system and the antigens of foreign pathogen

TYPES OF IMMUNITY
1. INNATE IMMUNITY – immunity you are born with involving barriers
that keep harmful materials form entering the body
- forms the first line of defense in the immune response
- e.g. cough reflex, enzymes in the tears, mucus, skin stomach acid

2. PASSIVE IMMUNITY – antibodies produced in the body other than your

own (person or animal)
- transferred from another source (utero transfer from mom to child)
- temporary in infants and disappears after 6-12 months
3. ACTIVE IMMUNITY (Acquired) – develop with exposure to various
antigens; defense against a specific antigen
- acquired through immunization or actually having a disease
4. HUMORAL – consists of protection provided by the B-lymphocyte-
deviated plasma cells, which produce antibodies that travel in the blood
and interact with circulating and cell surface antigen
5. CELL-MEDIATED – protects against viruses, intracellular bacteria, and
cancer cells
- usually occurs through cytotoxic activity of cytotoxic T cells and the enhanced
engulfment and killing by macrophages

CYTOKINES – regulatory proteins produced during all the phases of an immune

response
- they regulate response of host to foreign antigens or injurious agents by regulating
movement, proliferation and differentiation of leukocytes and other cells
ALTERED IMMUNE RESPONSE
- refers to inadequate, inappropriate, or excessive immune response to cellular
injury or infection resulting to immune system disorders that is serious and life
threatening

CLASSIFICATION OF DISORDERS due to ALTERED IMMUNE RESPONSE

1. IMMUNODEFICIENCY DISEASE
- immune response insufficient to protect host
- failure of the immune or inflammatory response to function normally, resulting in
increased susceptibility to infection
- clinical hallmark:
o tendency to develop unusual or recurrent, severe infection
 preschools and school-age: 6 to 12 infections/year
 adult: 2 to 4 infections/year
o recurrent infection w/ short periods of good health with multiple
simultaneous infection
2. HYPERSENSITIVITY REACTIONS
- excessive or inappropriate activation of the immune system
- altered immunologic response to an antigen that results in disease
- types:
o ALLERGIC – cause: environmental antigens (medicines, natural products
e.g. pollens and bee stings, infectious agents, and any other antigen not
naturally foudn in the individual)
 Anaphylaxis – most common allergic reaction
- occurs within minutes after exposure
o AUTOIMMUNITY – a.k.a. autoimmune disease
- disturbance in the immunologic tolerance of self-antigens
- occur when the immune system reacts against self antigens
to such a degree that auto-antibodies or autoreactive T cells
damage individual’s
o ALLOIMUNITY – occurs when the immune system of one individual
produces an immunologic reaction against tissues of another
- e.g. transfusion reactions, transplanted tissue (rejection) or
the fetus during pregnancy (Rh), grafting reactions

CONCEPT OF PAIN
“Pain is whatever the experiencing person says it is, existing whenever the
experiencing person says it does.” By Margo McCaffery, a well-known pain consultant

“An unpleasant sensory and emotional experience associated with actual or

potential tissue damage or described in terms of such damage.” -1979, International
Association for the Study of Pain (IASP)

PAIN
- fifth vital sign
- most important protective mechanism
 - strong motivator for action
- one of the body’s most important adaptive mechanisms
- protective mechanism or a warning
o congenital analgesia – rare genetic disorder where the individual is unable
to feel pain

PAIN EXPERIENCE IS PRODUCED BY THE INTERACTION OF THREE

SYSTEMS:
1. SENSORY/DISCRIMINATIVE – process information about the strength,
intensity, temporal and spatial aspects of pain
- results in prompt withdrawal from the painful stimulus
2. MOTIVATIONAL/AFFECTIVE – determines individual conditioned or learned
approached or avoidance behavior
3. COGNITIVE/EVALUATIVE – overlies individual learned behavior
- individual’s interpretation of appropriate pain behavior is learned through cultural
preferences, male-female roles and life experience

• NOCICEPTION – sensory process leading to perception of pain

• NOCICEPTORS – free nerve endings that responds to chemical, mechanical dn

thermal stimuli

TYPES OF PAIN:
I. PHASIC
A. Acute Pain – has identifiable cause and occurs soon after and injury
- temporary and subsides as healing takes place as chemical
mediators causing pain are removed
- onset: sudden and slow
- intensity: varies from mild to severe
- severe acute pain activates sympathetic nervous system causing
diaphoresis, increased RR, PR and BP
- usually lasts until 6 months
- classifications:
o SOMATIC – superficial (comes form the skin or close to
the surface of the body)
o VISCERAL – pain in the internal organs, abdomen or
skeleton; radiates or referred
o REFERRED – pain present in an area removed or distant
form point of origin
- supplied by the same spinal segment as actual site since
skin has more receptors, pain is felt
B. CHRONIC PAIN – persistent, lasts beyond expected healing phase
- non-protective; related to tissue damage, inflammation or injury of
the NS
- lasts for more than 6 months
NEUROPHYSIOLOGICAL TRANSMISSION OF PAIN
“ Pain is the result of transduction, transmission, perception and modulation of
painful (nociceptive) impulses.”

STAGES IN THE TRANSMISSION OF PAIN

• STAGE 1 – TRANSDUCTION
- refers to the conversion of mechanical, chemical or thermal information
into electrical activity in the NS

• STAGE 2 – TRANSMISSION
- transfer electrical impulses to the CNS

CNS – process nociceptive signals to extract relevant information

- the processing and extraction of relevant features of sensory input

• STAGE 3 – PERCEPTION
- awareness of pain that is dynamic, changing in response to person’s
development, environment, disease or injury
- can be brief, prolonged, or even permanent

• STAGE 4 – MODULATION
- also called adjustment
- refers to internal and external ways of reducing/increasing the pain

STIMULI (chemical, mechanical, thermal)

Receptor molecules at the tip of nociceptive primary afferent neurons (free nerve
endings)

Creation of action potential

Electrical energy (action potential) travels (progresses form the injury site) to the
spinal cord

Spinal cord’s dorsal horn (central gray matter)

Transfer of impulses form the nociceptor to the spinothalamic tract (transduction)

Thalamus – acts as relay station sending pain impulses to different areas in the brain
for processing

Electrical energy (stimuli) reach the cerebral cortex

Interpretation of stimuli (transmission)

Perception of pain
 Somatosensory cortex – identifies location and intensity
Associated cortex – determines how an individual interprets the meaning

Released of neuromodulators (endorphins, serotonin, norepinephrine, GaBa)

This chemicals hinder the transmission of pain producing an analgesic, pain-relieving

effect

Inhibition of pain impulse

(modulation)

PAIN THRESHOLD – intensity of the stimulus a person needs to sense/feel pain

PAIN TOLERANCE – the duration and intensity of pain that a person tolerates
before openly expressing

PAIN THEORIES:
1. SPECIFICITY THEORY – intensity of pain is directly
related to the amount of associated injury – DesCartes, 17th century
- finger prick against cutting off on one hand
- more tissue injury, more painful
- useful in specific injuries or acute pain, but not with chronic or cognitive and
psychologic contributions to pain

2. NEUROMATRIX THEORY – Ronald Melzack proposes

that a large number of interconnected neurons, a neuromatrix, exists in every person
- neuromatrix analyzes the sensory information and gives perception of sensation
- tells the brain that the perseptions of sensation are from the “self”
- neurosignature tells the brain that your arm is your arm, not someone else’s

3. GATE CONTROL THEORY – first proposed in 1965 by

psychologist Ronald Melzack and anatomist Patrick Wall
- “gating system” in the CNS that opens and closes to let pain messages through to
the brain or to block them
- according to the gate control theory of pain, our thoughts, beliefs, and emotions
may affect how much pain we feel from a given physical sensation
- delayed pain perception of athletes

research: Hans Selye

NURSING CARE OF CLIENT EXPERIENCING PAIN

I. ASSESSMENT
- thorough and accurate
- highly subjective and needs to be evaluated
- always remember the principle of pain assessment:
 “Pain is whatever the experiencing person says it is, existing whenever the
experiencing person says it does.” By Margo McCaffery

JCAHO
- a private sector US-based not-for-profit organization that sets standards for
accreditation of health institutions.
- helps to improve the quality of patient care by assisting international health care
organizations, public health agencies, health ministries and others evaluate,
improve and demonstrate the quality of patient care and enhance patient safety
and to demonstrate quality.

HIGHLIGHTS OF JCAHO PAIN STANDARDS

• assess all patients routinely for pain
• record assessment data in a way that facilitates reassessement and follow-up
• educate patients and families on the importance of pain management as part of
care
• do not permit pain to interfere with optimal level of function or rehabilitation
• include pain and symptom management in discharge planning

ASSESS:
Ia. History
Ia1. Pain characteristics
• onset and duration
• location
• intensity
• quality
• relieveing factors
• aggravating factors

NOTE: use the alphabet of pain – PQRST

• P – Provocative or Palliative
• Q – Quality
• R – Region and Radiation
• S – Severity
• T – Timing

Ia2. Drug History – complete list of medications with allergies

Ia3. Social History – how patient feel about himself

- support system

PAIN RATING SCALES

• The most commonly used Pain assessment scale is the Numeric Pain Rating scale.
• You ask the patient to rate their pain on a scale from 0 to 10 with “0” being no
pain and “10” being the worst pain they have ever had.
• Be sure and let patients rate their own pain, do not be influenced by family
members rating the pain.
• The Visual Analogue Scale may be easier for some patients to use. Show them
the scale and ask them to rate their pain.
• The Face Scale may be used for some adults who are unable to use the number
scales. Ask the patient to pick a face that matches how they feel and record that #
as their pain level.
• Brief Pain Inventory(BPI) – pt’s pain in last 24, least & worst
• Cries Neonatal Postoperative Pain Measurement Scale

• FLACC Pain Assessment Tool

• Faces Pain Rating Scale - language difficulties such as aged, pedia

• Oucher Pain Rating Scale
 • Numerical or Visual Analog Scale

• Adolescent, Pain, tool.. :-D

• Logs and Diaries – Pain Self-monitoring record

POTENTIAL NURSING DIAGNOSIS:

• physical mobility disturbances
• nutrition less than body requirement, risk for
• social interaction, impaired

II. PLAN/IMPLEMENTATION
1. Establish therapeutic relationship
2. teach patient about pain relief
3. reduce anxiety and fears
4. provide comfort measures
5. manage pain

TYPES OF PAIN MANAGEMENT

I. Nonpharmacologic Management – concern on overuse of
drugs

3 MAIN CATEGORIES OF NONPHARMACOLOGIC THERAPY

• Physical Therapy - use physical agents & methods ease
pain, reduce inflammation, ease muscle spasm, & promote relaxation.
a. Hydrotherapy
b. Thermotherapy
c. Cryotherapy
d. Vibration
e. TENS
f. exercise
g. immobilization
• Alternative Therapy - used instead of conventional or
mainstream therapy
- eg. Acupuncture – analgesics
• Complementary - used in conjunction w/ conventional therapy
- e.g. Meditation as adjunct to analgesic medication
o Aromatherapy
o Music Therapy
 o Therapeutic Touch and Massage
o Yoga and Meditation
o Chiropractic Treatment
o Acupuncture
o Biofeedback
o Hypnosis
o Guided Imagery
o Magnet Therapy
o Thought Stopping
o Crystal or Gemstone Therapy
o Herbal Therapy
o Heat and Cold Application

II. PHARMACOLOGIC
A. ANALGESIS
a. Nonopioid (nonnarcotic) – used to treat pain that’s either nociceptive
(injury receptors) or neuropathic (nerves)
• effective in somatic pain like joints and muscle pain
• controls pain, decreased inflammation and fever
• e.g. acetaminophen, NSAID’s, salicylates
b. opioids (narcotics) – w/ primary effects in the CNS
i. opioid agoinist – treat moderate pain w/o loss of consciousness
• e.g. Codeine, Fentanyl
ii. mixed agonist – antagonist – decrease risk of toxic effect and
dependency
• e.g. nalbuphine
iii. opioid antagonist – blocks opioid effect
B. METHODS OF ADMINISTRATION
a. Topical
b. Oral
c. IM
d. IV
e. PCA - Patient Controlled Analgesia
f. Conscious Sedation
g. Intranasal
h. Epidural

PCA – is a means for the patient to self-administer analgesics (pain medications)

intravenously by using a computerized pump, which introduces specific doses into an
intravenous line.

C. SURGICAL INTERVENTIONS
1. RHIZOTOMY – selective destruction of the dorsal root of the spinal nerve
2. NERVE BLOCK OR CORDOTOMY – unilateral or bilateral severe nerve fibers
in the spinal cord
 3. NEURECTOMY – resection of one or more peripheral branches of the cranial or
spinal
4. SYMPATHECTOMY – destroys nerves in the SNS
• performed to increase blood flow and decrease long-term
pain in certain diseased that cause narrowed blood vessels
• can also be used to decrease excessive sweating
• this surgical procedure cuts or destroys the sympathetic
ganglia, which are collections of nerve cell bodies in clusters along the
thoracic or lumbar spinal cord

PERIOPERATIVE NURSING
• the scrub nurse is always in front of the surgeon

PERIOPERATIVE NURSING CARE

a. connotes the delivery of patient care in the:
i. preoperative
ii. intra-operative
iii. postoperative
…periods of the patients surgical experience through the
framework of the nursing process
b. nurse assess the client by:
i. collecting, organizing and prioritizing patient data
ii. establishing nursing diagnosis
iii. identifies desired patient outcomes
iv. develop and implements a plan of care
v. evaluates the care given in terms of outcomes achieved by the
patient

PERIOPERATIVE NURSING CARE PHASES

• PREOPERATIVE PHASE
• INTRAOPERATIVE PHASE
• POSTOPERATIVE
- types:
o immediate post-operative/peri-anesthesia phase/PACU nursing/Recovery
Room nursing
o post-operative phase – px. is already in the room/ward until the patient
goes home w/o complications

SURGERY – comes from the Greek word “kheirurgus” = “working by hand”

TYPES OF PATHOLOGIC PROCESSES REQUIRING SURGICAL INTERVENTION

1. OBSTRUCTION – impaired flow
2. PERFORATION – rupture (of a tissue)
3. EROSION – wearing off of a membrane
4. TUMORS – abnormal growths (w/c can cause your obstruction)
CATEGORIES OF SURGERY
1. DEGREE OF RISK
a. MAJOR – high risk, extensive, prolonged, increased blood loss
b. MINOR – less risk, less complicated, not prolonged
2. EXTENT – localized or involves the whole system?
a. MINIMALLY INVASIVE – usually performed with the use of fiberoptic
endoscopes and does not require traditional or extensive incisions
- involves the use of smaller incisions, customized instrumentation,
specialized imaging, computerized global navigation system and robotics
b. OPEN – involves traditional opening of body cavity or body part to
perform the surgery
c. SIMPLE – generally limieted to a defined anatomic location and do not
require extensive exposure and dissection of adjacent tissue
d. RADICAL – usu. Associated w/ malignancies
- involves dissection fo tissue and structures beyond the immediate operative
site
3. PURPOSE
Classification:
a. DIAGNOSTIC – determine cause of symptoms or origin of problem
b. CURATIVE – to resolve a health problem or disease state by removing
the involved tissue
c. RESTORATIVE/RECONSTRUCTIVE – performed to correct deformity,
repair injury or improve functional status
d. PALLIATIVE – relieve symptoms w/o the intent to cure
e. ABLATIVE – removal of diseased organ
f. COSMETIC – performed primarily to alter or enhance personal
appearance
4. ANATOMIC SITE – which part of the body?
a. CARDIVASCULAR surgery
b. CHEST surgery
c. INTESTINAL surgery
d. NEUROLOGIC srugery
5. TIMING OR PHYSICAL SETTING – when and where?
Classification for timing:
a. ELECTIVE – performed on the basis of clients choice; not essential and
may not be necessary for health
b. URGENT – necessary for client’s health
- may prevent additional problem from developing (e.g. tissue
destruction); not necessarily emergency
c. EMERGENT – must be done immediately to save life or preserve function
of body part
d. REQUIRED – has to be performed at some point can be pre-scheduled
Physical Settings:
a. SURGICAL SUITES
b. AMBULATORY CARE SETTING
 c. CLINICS
d. PHYSICIAN’S OFFICES
e. COMMUNITY SETTING
f. HOMES

DISADVANTAGES OF OUTPATIENT
a. less time for rapport
b. less time to assess, evaluate, teach risk of potential complications

ADVANTAGES OF OUTPATIENT
a. low cost
b. low risk of infection
c. less interruption of routine
d. less stress

6. PROCUREMENT FOR TRANSPLANTATION

- removal of organs and/or tissues from a person pronounced brain dead for
transplantation into another person

SUFFIXES DESCRIBING SURGICAL PROCEDURES

• -ectomy – excision or removal of an organ or gland
• -orrhaphy – repair or suture of
• -lysis – destruction of
• -oscopy – looking into
• - ostomy – creation of opening into
• -plasty – repair or reconstruction of

PREOPERATIVE PHASE
- begins when the decision for surgical intervention is made and ends with the
transfer of the patient to the operating table

SCOPE OF NURSING ACTIVITIES

1. Establishing the baseline assessment of the patient in the clinical setting or at
home
2. Ensuring the necessary laboratory test needed
3. Carrying out of preoperative interview
4. Preparing the patient for the anesthetic he is to receive and the surgery he is to
undergo
5. Focus on assessing the post-operative status of the patient in terms of the effects
of the anesthetic agent.
6. Impact of surgery on body image or role function.
7. Evaluate the family’s perception of surgery.

PREOPERATION CAN TAKE PLACE IN ANY OF THESE TIME AND PLACE:

1. In the physician’s office before admission to the health care facility.
 2. On admission and during the days before the operation.
3. The night before the surgery if the client is in the hospital.
4. The morning of surgery on admission.

GENERAL PREOPERATIVE PREPARATION

Physiologic Nursing Assessment of client undergoing surgery
1. AGE
• older adults have the lowest tolerance to stressful effects of surgery
• old age produces physiologic changes that increase surgical risk

Interventions for Physical Changes in Older Adults Undergoing Surgery

PHYSICAL CHANGE
CARDIOVASCULAR
• decreased cardiac output
• moderate increased in BP
• decreased peripheral circulation
• arrythmias
RESPIRATORY
• Decreased vital capacity
• Reduced
• oxygenation of blood
• Decreased cough reflex
RENAL
• Decreased renal blood flow and
lomerular filtration rate
• Decreased ability to excrete waste
product
MUSCULOSKELETAL
• decreased in lean body mass
• increase in spinal compression
• increased incidence of osteoporosis
and arthritis
SENSORIMOTOR
• decreased reaction time
NURSING INTERVENTION
• Know what anesthesia is used
• Monitor V/S carefully
• Encourage early ambulation & leg
exercises
• Assess for hypotension or
hypertension or hyperthermia
• Note any changes to baseline ECG
• Assess pulmonary aspiration
• Monitor respirations carefully
• Vigorous pulmonary hygiene
• Post-operative: auscultate lung
sounds
• Oxygen saturation monitor
• Monitor urine output 1 to 2 hours
during Immediate post-surgery
• Evaluate intake and output
• Monitor fluid and electrolyte status
• assess level of mobility
• position on OR table with padding
to reduce trauma to bones and joints
• spine, limbs and pressure points
must be padded to prevent fractures
• early ambulation or exercises to
individuals ability
• provided adequate nutrition
• provide effective pain management
• orient client to environment
 • decreased visual acuity • plan individual teaching, allow time
• decreased auditory acuity to reinforce teaching
• provide safe environment

2. PRESENCE OF PAIN
3. NUTRITIONAL STATUS – client who is well nourished is better prepared to
handle surgical stress
4. FLUID AND ELECTROLYTE BALANCE – dehydration and hypovolemia
(fluid volume deficit) predispose a client to complications during and after
surgery
- electrolyte imbalance also increased operative risk
5. PRESENCE OF INFECTION
6. CARDIOVASCULAR FUNCTION – client should be assessed for elevated BP;
slow, rapid or irregular pulse; edema; cold cyanotic extremities; weakness; and
shortness of breath

LABORATORY AND DIAGNOSTIC STUDIES OFTEN ORDERED PRIOR TO

SURGERY TO DETERMINE CARDIOVASCULAR FUNCTION:
a. ECG
b. CBC
i. Hemoglobin
ii. Hemcatocrit
iii. WBC – if you are immunosuppressed, you have to strengthen the
immune system
- so that the doctor will be able to foresee the crisis that may come
and the interventions to be done prior to complication
iv. Platelet
c. SERUM ELECTROLYTES – Na, K, Cl
- maintenance of circulating volume, movement of plasma in the
cells
d. Urinalysis – kidney function
e. BUN – Blood Urea Nitrogen
- high concentration – indicates there’s something wrong with the kidney
or renal system
f. Creatinine
g. Protime – cardiopulmonary clearance
h. Partial Thromboplastin Time– cardiopulmonary clearance
i. Clotting Time/Bleeding Time – cardiopulmonary clearance
j. X-Ray

OTHER DIAGNOSTIC TESTS (if needed):

1. Pulmonary Function Test – check for capacity of lungs to have oxygen in it
- check for amt. of volume the lungs can carry
• COPD, emphysema, asthma and bronchitis increase operative risk because
they impair CO2 and O2 diffusion in the alveolus and predispose the client
to pulmonary infection
 • Assess client for shortness of breath, wheezing clubbed fingers, chest pain
and coughing with expectoration of copious mucous
2. Renal Function
• Assess for symptoms of frequency, dysuria, anuria (absence of urination)
and observe for the appearance of urine
• Includes: Urinalysis, BUN and Creatinine are commonly ordered
preoperative tests
3. Gastrointestinal Function
4. Liver Function – check if liver is still functioning well
- liver is one of those organs that is highly vascular
5. Endocrine Function – release of hormones
- hypothyroidism – check that they should not be in crisis so that you won’t have
cardiac arrest
6. Neurologic Function
7. Hematologic Function – clients with coagulation diseases are at risk for
hemorrhage and hypovolemic shock during and surgery

5 FACTORS POINTING TO ABNORMAL HEMATOLOGIC FACTORS:

• History of bleeding tendencies
• Symptoms such as easy bruising, excessive bleeding following dental
extraction and severe nosebleed
• Presence of hepatic and renal disease
• Use of anticoagulants
• Abnormal bleeding time, prothrombin time or platelet count

8. Use of medication herbs

- Cardiac conditions that increase operative risk include: angina pectoris, MI within
the last 6 month, uncontrolled hypertension, CHF and peripheral vascular disease
- Clients take prescribed and non-prescribed medication that may increase
operative risk by increasing coagulation

SOME MEDICATIONS THAT MAY RESULT IN COMPLICAITONS INCLUDE:

ANTICOAGULANTS
Heparin sodium • cause clotting abnormalities which
Warfarin sodium results to hemorrhage
Aspirin
NSAIDS
ANTIBIOTICS w/c is combined with other • increase postoperative respiratory
muscle relaxants depression
TRANQUILIZERS • decrease blood pressure thus
increase the risk of shock
• potentiates the effects of
narcotics and barbiturates
THIAZIDE DIURETICS • can create potassium depletion
STEROIDS • cause hypofunction of the adrenal
cortex thus impair physiologic
response to stress of anesthesia and
surgery
• anti-inflammatory effect delay
wound healing and increase risk of
infection
MONOAMINE (MOA) INHIBITORS • can cause hypertensive crisis when
combined with anesthetic agents
ANTIPARKINSON DRUGS • cause hypotension or hypertension
when combined with anesthetic
agents
STREET DRUGS AND ALCOHOL • increase tolerance to narcotics
ABUSE
HYPOGLYCEMICS • require dosage alteration and close
monitoring of blood sugar
HERBS
GARLIC • inhibits platelet aggregation
• may potentiate warfarin
• increase INR and PT
• cause GI upset
• decrease blood glucose level
GINGER • anticoagulant action
• large doses – increase risk of
bleeding and dysrhythmias
GINSENG • tachycardia and hypertension, esp.
w/ the use of cardiac stimulants
• inhibit platelet aggregation
• decrease warfarin effectiveness
• lowers blood glucose
• potentiate effects of digoxin
• assess ginseng abuse syndrome:
hypotension, hypotonia and edema
GINGKO BILOBA • prolongs bleeding time
• increase anticoagulant effect
• subconjunctival hemorrhage and
spontaneous subdural hemorrhage

9. ALLERGIC REACTIONS

SKIN CONTACT INJECTION INGESTION INHALATION

• poision • bee sting • medication • pollen
plants • medication • nuts and • dust
 • animal shellfish • mold and
dander mildew
• pollen • animal
• latex dander

10. Presence of Trauma – when surgery must be performed following traumatic

incident, details of the event should be documented
11. Health Habits – how much exercise do you do? Do you smoke? Do you make us
of drugs?
12. Social Habits

PSYCHOSOCIAL ASPECT OF PREOPERATIVE PREPARATION

• effectively handling client’s fears can smooth the preoperative experience
• studies show that client’s who are calm and emotionally prepared for surgery
withstand anesthesia better and experience fewer postoperative complications

PSYCHOLOGIC RESPONSE
1. ANXIETY
POTENTIAL SOURCE OF ANXIETY
a. anticipation of impending surgery
b. pain and discomfort
c. changes in body image or function
d. role changes
e. loss of control
f. family concerns
g. potential alterations in lifestyles
2. FEAR
- client’s respond differently to fear – some respond by becoming silent and
withdrawn, childish, belligerent, evasive, tearful and clinging

COMMON FEARS RELATED TO SURGERY

a. fear of the unknown
i. first decision to seek medical advise
ii. subject to several laboratory tests
iii. first experience-operation
b. loss of control
c. loss of love from significant others
d. threat to sexuality

SPECIFIC FEARS
a. diagnosis of malignancy
b. anesthesia
c. dying
d. pain
e. disfigurement
f. permanent limitations
ASSESSMENT OF PREOPERATIVE ANXIETY
SUBJECTIVE DATA
1. understanding of proposed surgery
a. site
b. type of surgery
c. information from surgeon regarding extent of hospitalization,
postoperative limitations
d. preoperative routines – what will happen postoperatively?
- let px. know that after surgery, px. will be staying in RR
e. postoperative routines
f. tests
2. previous surgical experience
a. type, nature
b. time interval
3. any specific concerns or feelings about present surgery
4. religion, meaning for patient
5. significant others
a. geographic distance
b. perception as source of support
6. changes in sleep pattern

OBJECTIVE DATA
1. speech patterns
a. repetition of themes
b. change topic
c. avoidance of topics related to feelings
2. degree of interaction with others
3. physical
a. pulse and respiratory rates
b. hand movement and perspiration
c. activity level
d. voiding frequency

PREOPERATIVE TEACHINGS TO DECREASE ANXIETY

1. Preoperative test
a. Reasons
b. Explanations of the test
2. Preoperative routines
3. Schedules
a. Time of surgery
b. Probable length
c. Time in the recovery room
4. Recovery
a. Place where px. will awaken
b. Close nsg. Supervision
 c. Frequent monitoring of VS
d. Return to room when VS are stable
5. Family Directions
a. Time px. will leave for surgery
b. Where the family may wait during surgery
c. Procedure for notification of results of surgery (by the Physician)
d. Procedure for notification of px. return to unit

PROBABLE POST-OPERATIVE THERAPIES

1. Anticipate treatment (VI, NGT)
2. Need for increased mobility as soon as possible
3. Need fro breathing and coughing routines, even though these are uncomfortable
4. Pain medication routines (timing, sequence-PRN status)

PREOPERATIVE PSYCHOLOGIC SUPPORT

1. Asses client’s fears, anxieties, support systems and patterns of coping
2. Establish trusting relationship with client and significant others
3. Explain routine procedures, encourage verbalization of fears, and allow client to
ask questions
4. Demonstrate confidence in surgeon and staff
5. Provide for spiritual care if appropriate

PREOPERATIVE ASSESSMENT
• HISTORY TAKING - plays a large part in determining the degree of preoperative
and postoperative anxiety the client experiences
- allows the nurse to:
o Establish rapport with client
o Begin psychosocial assessment
o Reassure client and significant others and answer general questions about
surgery, the health-care facility etc.
- Specific information to obtain during reoperative history concerns:
o Previous surgery and experience with anesthesia
o Responses of significant others to previous surgery and anesthesia
o Whether the client had any serious illness
o Previous and current medication (prescribed/over-the-counter)
o Allergies and reactions and dietary restrictions
o Alcohol, nicotine or recreational drug use
o Current symptoms and discomforts
o Occupation
o Religious affiliation
o Significant others
o Whether client has question about the surgery
o Chronic illnesses such as arthritis, migraines, backpains
• PHYSICAL EXAMINATION
PREOPERATIVE DIAGNOSTIC TESTS
1. Serum potassium
2. Hemoglobin
3. Serum sodium
4. Hematocrit
5. Serum chloride
6. Prothrombin time
7. Glucose
8. Partial thrombo-plastin time
9. Blood Urea
10. Nitrogen
11. Chest X-ray
12. Electrocardiogram
13. Creatinine

PREOPERATIVE TEACHING
Basic areas that must be covered:
1. deep breathing and coughing exercise
2. turning and extremity exercises
3. pain control methods that will be offered – splinting, DBE, medications
4. postoperative equipment

• teach coughing and breathing exercise, splinting of incision, turning side to side
on bed and leg exercises: explain the importance in preventing complications;
provide for opportunity for return demonstration

COUGHING EXERCISE
• may be done sitting or lying down
• splinting the incision minimizes pressure and helps control pain when coughing
• client is instructed to interlace fingers across the incision to and hold them when
coughing
• a small pillow or folded towel may be held over the incision to facilitate splinting

LEG AND ANKLE EXERCISES – prevent deep vein thrombosis and embolism

POSTOPERATIVE EQUIPMENT
a. wound drain and suction devices
b. penrose drain – used for post AP, ruptures where there are discharges
- acts as a route for all discharges to pass through so that it will be
absorbed by the gauze
- tied to the skin
c. Jackson-Pratt drain or reservoir
d. T-tube drain
e. Hemovac drainage system

PHYSICAL PREPARATION
 1. Preparing the Skin
2. Preparing the GIT – some surgery require special bowel preparation (enema)
3. Preparing for anesthesia
4. Promoting rest and sleep

PREPARING THE CLIENT ON THE DAY OF THE SURGERY

1. Early morning care
a. Begins at least 1-2 hours before surgery
i. Take vital signs and record
ii. Check identification band
• Consent form is signed and the surgical procedure is written
correctly
• Check for and carry out any special orders such as administering
enemas or starting an IV line
• Verify that the client has not eaten for the last 8 hours
• Assist client with oral hygiene –if necessary
• Remove dentures or bridgework that could obstruct the airway if
left in place
• Have the client remove jewelry
• If client is wearing hearing aid, notify OR personnel
• Assist client in donning a hospital gown, protective head cap, ace
wraps or antiembolic socks
• Remove colored nail polish, remove make-up so skin color can be
observed
Prior to administering preoperative medications, the nurse should check for:
1. Preoperative permit
2. Transfusion permit (if require)

PURPOSE OF PREPOERATIVE MEDICATION

1. allay anxiety
2. decrease pharyngeal secretions
3. reduce side-effects of anesthetic agent
4. create amnesia

COMMONLY USED PREOPERATIVE MEDICATIONS

GENERIC NAME TRADE NAME DESIRE EFFECT UNDESIRED
EFFECTS
TRANQUILIZERS
diazepam Valium Decrease anxiety May cause
droperidol Inapsine Decrease anxiety dizziness,
Produce antiemetic clumsiness or
effect confusion
Anxiety
Hypotension during
and after surgery
SEDATIVES
midazolam Hcl Dormicum Induces undesired Hypotension,
sleepiness and undesired
reduces anxiety respiratory
promethazine Phenergan Decreases anxiety depression
Produces an Hypotension during
antiemetic effect and after surgery
secobarbital Na Seconal Na Decreases anxiety Disorientation,
pentobarbital Na Nembutal Na Promotes sedation especially in elderly
patients
ANALGESICS
morphine sulfate Relieves pain Respiratory
meperidine Hcl Demerol Decreases anxiety depression
sedation Hypotension
Circulatory
depression
Decreased gastric
motility causing
potential vomiting
ANTICHLINERGIC
atropine sulfate Controls secretions Excessive dryness
alycopyrrolate Robinul of mouth;
tachycardia
HISTAMINE H2-
RECEPTOR
ANTAGONIST
cimetidine Tagamet Inhibits gastric acid Some mild
production dizziness, diarrhea,
somnolence, and
rash

LEGAL AND ETHICAL ISSUES

A. Informed Consent
• A statement consenting to the operative procedure
• Protect’s px. rights to self determination and autonomy regarding surgical
intervention
• Surgeon must explain the procedure in terms the client readily understand
• Implies that the patient has been given the information necessary to understand
the nature of the procedure and its known and possible consequence

PURPOSE OF SIGNED CONSENT

• ensure client understands nature of treatment including
potential outcome and disfigurement
• indicate px. decision was made w/o pressure
• protect client against unauthorized procedure
 • protect surgeon and hospital against legal action when
client claims unauthorized procedure was performed

CIRCMSTANCES REQUIRING CONSENT

• any surgical procedure where scalpel, scissor, suture and
hemostats of electrocoagulation may be used
• entrance into a body cavity : paracentesis, cystoscopy,
pericardiocentesis, etc.
• using anesthesia

NECESSARY COMPONENTS OF CONSENT

• patient’s full legal name
• surgeon’s name
• specific procedure (s) to be performed
• signature fo the patient, next of kin or legal guardian
• witnesses
• date it was signed

• And adult sign their own consent unless they are unconscious or mentally
incompetent. A parent or legal guardian usually provides consent for a minor
• Emancipated minors, that is, minors who are married or earning their own
livelihood and retaining the earnings can sign their own consent
• If no legal guardian can be contacted, two phsycians who are not associated with
the procedure amy make the decision for surgical intervention
• Illiterate patients must understand the verbal explanation of the consent process
and may sign the form with an X_ . This process must be witnessed by two
persons.
• The patient has the right to refuse surgical intervention
• Px. has the right to withdraw consent at anytime before the procedure is that
decision is reached voluntarily

At least 2 px. identifiers must be used to identify px. identity

Confirm and verify the ff:
• px. and name on ID band
• date of birth
• medical record number
• consent forms
• availability of blood
• radiologic examinations

Patient response must match:

• marked site
• ID band
• Consent forms
 • Radiologic examinations
• Scheduled procedures

SITE MARKINGS
Site verification is required for all procedures that involve laterality, multiple structures
or multiple level.
 Site is marked with a permanent marker that is visible after the
skin is prepped and draped
 Operating surgeon should mark the site with his or her initials
before the patient enters the OR suites
 Site is marked with patient participation (verbal confirmation or
pointing)
 A patient has the right to refuse to mark the site. Each institution
will determine policy for these situation

PHYSICAL (P) STATUS CLASSIFICATION SYSTEM

Classification Description

P1 Normal healthy patient

P2 Patient with mild systemic disease
P3 Patient with severe systemic disease

P4 Patient with systemic disease that poses a

constant threat to life (ex. MI)
P5 Moribund patient not expected to survive w/o
surgery

P6 Patient declared brain dead whose organs are

being removed for donation

INTRAOPERATIVE PHASE
Intraoperative Nursing
- 2nd Phase of the Perioperative Period
- OR Nursing
- OR table to PACU

NURSING ACTIVITIES
• Psychological Support – emotional well-being
• Physiologic support - assessment of patient status
• Maintenance of patient safety - positioning, maintain asepsis, & control of
surgical environment
PERIOPERATIVE TEAM
a. Preoperative team
 Pre-op nurse
 Physician, nurse practitioner or physician assistant
 Clinical nurse specialist – Advanced Practice Nurse, a MSN holder
w/ Major in their field of specialty
b. Surgical/Operating Team
 Sterile
 Unsterile

c. Post Operative Team

 Post anesthesia nurse
 Medical-surgical nurse

MEMBERS OF THE SURGICAL TEAM

- group of highly trained & educated professionals who coordinate their efforts to
ensure the welfare & safety of the client
 Sterile Team
 Non-Sterile Team

STERILE MEMBERS
1. SURGEON
• The team leader & main decision maker
• Performs the operative procedure safely and correctly
• Performed draping of the patient and checks all other needed for
the produre
• Secures dressing In place
• Assist in moving the patient to PACU
• Do the post operative orders
2. ASSISTANT TO THE SURGEON
• Assist to the surgeon in operative procedure
• Assist in positioning the patient and draping
• Assist in closing the incision and dressing
• Assist in moving patient to pacu
• MAY DO POST OPERATIVE ORDERS.
3. 2ND ASSISTANT TO THE SURGEON
• Assist the surgeon and the assistant surgeon
-suctioning and retracting
-cutting sutures
-may do suturing
• Assist in positioning, draping and dressing
• Assist in moving patient to pacu.
4. SCRUB NURSE/SURGICAL TECHNICIAN
• Gathers all equipment for the procedure
 • Prepares supplies & instruments using sterile technique
• Maintain sterility w/in the sterile field
• Set up back table, mayo tray and prep tray
• Handles instruments & supplies during surgery
• Do the sponge count and instrument count with the circulating
nurse before & after surgery
• Maintain accurate count
• Assist the surgeon through out the operation with proper
anticipation
• Assist in draping and securing the suction and the cautery machine
• Responsible for cleaning patient before transferring to the pacu
• Responsible in cleaning up the back table and instrument
• Anticipates the needs of the sterile team
• Establishes baseline counts with circulating nurse
5. CERTIFIED REGISTERED NURSE 1ST ASSISTANT

UNSTERILE MEMBERS
- work outside the sterile area

1. ANESTHESIOLOGIST – maintenance of physiologic stability

• Administer anesthetic to the patient
• Checks operative condition preoperatively
• Checks the chart (laboratory results and availability of the blood)
• Helps positioning the patient properly
• Monitor vital signs
• Gives IVF and blood transfusion
• Determines when to transfer patient to PACU

CERTIFIED NURSE ANESTHETIST – nurse who has a minimum of two

years additional education specializing in anesthetic administration
• Administer anesthetic to the patient
• Checks operative condition preoperative
• Helps positioning the patient properly
• Monitor vital signs
• Works under the direction of an anesthesiologist

2. CIRCULATING NURSE – responsible for the overall running of the OR in the

whole intraoperative period
• does not scrub but good hand washing techniques must be carried
out
• assess client preoperatively, planning for optima care during the
surgical intervention
• ensures all equipment is working properly
 • guaranty sterility of instrument and supplies – esp. those that is
given in addition
• assists with positioning
• performs skin preparation
• monitors the room and team members for breaks in sterile
technique
• anticipates sequence of operation
• assisting anesthesia personnel w/ induction and physiologic
monitoring
• handles specimen
• coordinates activities with other departments, such as radiology
and pathology departments
• minimizing conversation and traffic within the OR suite
• documentation

SENSE OF HEARING – last sense lost and first sense gained in anesthesia

OR DIVIDED INTO THREE AREAS:

2. UNRESTRICTED AREA
• main entrance to the surgical suite
• pre-operative holding area/admission area
• PACU
• Anesthesia Office
• Staff Lounge and locker rooms
3. SEMI RESTRICTED AREAS
• peripheral support areas
• corridors leading to OR’s
• storage and supply areas
• work room
• sterilization and processing areas

CLOTHING ATTIRE
• basic scrub suit
• shoes with shoe cover

4. RESTRICTED AREA
• operating rooms
• sub-sterile areas connected to the OR’s (typically houses the
autoclave, scrub sinks and blanket warmers)
• where a sterile area/field is open

CLOTHING ATTIRE
• sterile gown and sterile gloves
• mask
SURGICAL SUITE ENVIRONMENTAL HAZARDS
1. PHYSICAL – back injury, fall, noise, pollutions, radiations, electricity fire
2. CHEMICAL – anesthetic gases, toxic fumess antineoplastic drugs and cleaning
agents
3. BIOLOGIC – patients as a host for or source of pathogenic microorganism,
infectious waste, surgical plumes, latex sensitive, cuts and needle prick

PREPARATION OF THE PATIENT IN THE OPERATING ROOM

• greet patient and try to promote relaxation
• never leave the patient unattended
• check the chart for pre-operative orders and preparations
• report any significant changes in the patient

SURGICAL ATTIRE
• provide effective barrier that prevent dissemination of microorganism to patient
• prohibits contamination of surgical wound and sterile field by direct contact
• protects personnel from infected persons

BASIC SCRUB ATTIRE

1. shirt and pants (scrub suit) –used before entering a semi restricted area
2. head cover/hood/cap – put on before the scrub suit
3. shoe/shoe covers – unprotected shoe surfaces increase floor contamination
4. mask – restricted area

PROTECTIVE ATTIRE
• objective follows the principles of the “UNIVERSAL PRECAUTION”
- precaution that protects health care workers form contact with blood and
body fluids of all patients not just those diagnosed or suspected of being
infected by Hepa B, HIV or other blood borne pathogens
- minimum precaution for all invasive procedures

INVASIVE PROCEDURES – entry into the tissue, organs or body cavities in the OR,
DR, ER physician or dentist office, radiologist department, clinal laboratory
- attire:
1. APRON – should be fluid resistant
2. EYE WEAR/FACE SHIELD
3. GLOVES
a. STERILE GLOVES – used on a sterile procedure
b. CLEAN GLOVES – only used for unsterile
procedures (e.g. washing instruments, MIO,
handling specimens)

ATTIRE IN STERILE FIELD

• sterile gown and sterile gloves
ASEPSIS – absence of infectious or disease-producing microorganism
- two types:
1. MEDICAL ASEPSIS – exclude or reduce the number and
transfer of pathogens
- clean technique (hand washing)
2. SURGICAL ASEPSIS – renders and keep objects and areas
free from microorganism
- sterile technique
ASEPTIC TECHNIQUES – practices that restricts microorganisms in the environment,
equipment and supplies
- goal:
• prevent surgical infections
• minimizes length of recover from surgery
• prevents transfer of microorganism into body tissues

STERILE TECHNIQUE
- required in the ff:
• all surgical procedures
• all procedures that invade the blood stream
• complex dressing and wound care
• tube insertions
• care of the high risk groups of patients

INFECTION – invasion and proliferation of microorganism into the body tissue

SEPSIS –

TWO TYPES OF MICROORANISM THAT INHIBITS THE SKIN

• TRANSIENT- acquire by direct contact
• RESIDENT-below the skin surface

SURGICAL CONSCIENCE – inner voice for conscientious practice of asepsis and

sterile techniques at all times
- self regulation in practice according to a deep personal commitment to the
highest value
- sometimes called the GOLDEN RULE OF SURGERY
- includes all activity and interventions, personal hygiene and health
- involves a concept of self inspection coupled with moral obligation,
involving both scientific and intellectual honesty

PROCESSES INVOLVED IN REMOVING MICROORGANISMS

• MECHANICAL
• CHEMICAL
- Remove soil, debris, natural skin oil or hand lotions present on skin.
 - Reduced the number of resident microorganism on skin to irreducible minimum
especially during surgical procedures
- Reduce hazard of microbial contamination of the surgical wound by skin flora

HAND WASHING – single most important infection control practice

SURGICAL HAND SCRUBBING – process of removing as many microorganisms as

possible from the hands and arms by mechanical washing and chemical asepsis before a
particular surgical procedure
- done before donning in the sterile gown and sterile gloves

EQUIPMENT FOR SURGICAL SCRUBBING

1. SCRUB SINK
2. STERILIZED REUSABLE SCRUB BRUSHES
3. SCRUBBING SOLUTION

CRITERIA FOR ANTI MICROBIAL SOLUTION USED IN SURGICAL SCRUBBING

• broad spectrum
• fast effecting and effective
• non irritating and non sensitizing
• prolonged acting
• independent of cumulative action

EFFECTIVNESS OF SURGICAL SCRUBBING DEPENDS ON THE FF. VARIABLE

• Mechanical Factors, Chemical factors and differences in individual skin flora
• Everyone should scrub according to a standardized written procedure
• Prolonged scrubbing raises residual microbes from deep dermal layers. Care
should be done not to abrade the skin.
• Denuded areas allow entry microbes
• Too short scrubbing would be equally ineffective

TYPES OF ANTISEPTIC
A. CHLORHEXIDINE GLUCONATE
• antimicrobial effects against gram (+) and gram (-) microorganisms
• residual effect is more than 6 hours
B. IODOPHORES
• rapid against gram (+) and gram (-) microorganism
• can’t sustain for a prolonged period of time – at least two hours only
• skin irritant
C. TRICLOSAN
• non toxic, non irritating that inhibits growth of a wider range of both gram (+) and
gram (-) microorganism
• good for sensitive skin
• develops prolonged cumulative suppressive action if used routinely
D. ALCOHOL
 • ethyl or isopropyl
• rapid acting anti-microbial
• non toxic but has a drying effect
E. HEXACHLOROPHENE
• available by prescription only
• has a high potential for toxicity

METHOD OF SURGICAL HAND SCRUBBING

1. ANATOMIC TIMED SCRUB
Scrub from the nails, fingers each side and web space, palmar, dorsal
surface and forearm for a specific time
2. COUNTED BRUSH STROKE
Starting from the fingertips, scrub each anatomical area for the designated
number of strokes according to policy.

12 PRINCIPLES OF SURGICAL ASEPSIS/ASEPTIC TECHNIQUE

1. Only sterile items are used within the sterile field.
2. Sterile gowns are considered sterile only in front, from shoulder to the level of the
sterile field and at sleeves from 2 inches above the elbow to the cuff.
3. Tables are sterile only up to the table level.
4. Sterile persons touch only sterile items or areas; unsterile person touch only
unsterile items or areas.
5. Unsterile persons avoid reaching over a sterile field; Sterile persons avoid leaning
over unsterile area.
6. The edges of anything that encloses sterile content are considered unsterile.
7. Sterile areas are continuously kept in view. In passing always face the sterile
field.
8. Sterile persons keep well within sterile areas. Unsterile persons avoid sterile
areas.
9. Sterile persons keep contact with sterile areas to a minimum.
10. When in doubt, consider it unsterile.
11. Moisture causes contamination.
12. Microorganisms must be kept to an irreducible minimum
SURGICAL INSTRUMENTATION
Classification of items according to purpose and body contact:
1. Critical – items that enter body tissues, underlying skin and mucuous membrane.
- must be sterile and maintained sterile
2. Semi-critical – items that come in contact w/ intact skin or mucous membrane
- mechanically cleaned & disinfected to reduce microorganisms
- e.g. ET tube guide, metal tongue depressor
3. Non-critical – items that come in contact only with intact skin or in areas remote
from the surgical site
- may be cleaned, terminally disinfected & stored unsterile
- e.g straps, ground, BP cuff

FOUR CATEGORIES OF SURGICAL INSTRUMENTS

1. Sharps – usable part has a sharp, or cutting edge
a. Scalpel- incising tissues; dissection
b. Dissecting scissors - dissection
i. Curved mayo ( heavy ) - heavy or tough
tissue
- Used to prevent puncturing
ii. Metzembaum ( narrow ) - delicate tissue
iii. Straight Mayo ( suture scissors) - to cut
sutures
2. Clamps – used for hemostasis. May be used as graspers or
retractors.
a. Straight Clamps – used for hemostasis
- Stop bleeding
b. Curved clamps
c. Graspers or Holding instruments
- commonly used to grasp and hold tissues
- as in retraction or for suturing
d. Retractors - Retractors – used to hold tissues away
from the operative site.
a. self retaining- can maintain it’s own position
e.
f.

PRINCIPLES OF COUNTING
1. All item are counted initially by the circulating nurse and the scrub nurse together
(aloud) as the scrub person touches each item.
2. The number (count) of each type of item is immediately recorded in the sponge
count form by the circulating nurse
3. If there is any uncertainty regarding the initial count, it is repeated.
4. As additional items are added to the sterile field during the procedure, the scrub
nurses counts the items with the circulator who adds the count to the records form
and initial it.
 5. If possible there should be no interruptions while counting
6. After the final sponge and instrument count, the circulating nurse and the scrub
nurse will inform the surgeon by saying aloud “sponge count, instruments count
and needle count complete.”
7. The circulating nurse signed the sponge count form with the time and term
correct.

POSITIONING
• essential that each patient be considered as an individual.
- A good position must provide maximum safety for the duration of the operative
procedure. Maximum safety includes:
a. Maintaining good respiratory function.
b. Maintaining good circulation
c. Preventing pressure on muscles and nerves.
d. Good exposure and accessibility of the operative field – maximum
visualization
e. Good access for the administration of anesthetic and observation of effects

EQUIPMENTS FOR POSITIONING

1. Operating table
- Are versatile at adaptable to a number diversified positions for all surgical
specialties. However orthopedics, urologic and fluoroscopic tables are
utilized frequently for specialized procedures.
2. SAFETY BELT (body, knee, hard strap)
- -a sturdy, wide strap of conductive material such as nylons, cotton or
rubber webbing to protect the safety of the patient
3. ANESTHESIA SCREEN
- metal bar holds the drapes form the patients face and separates the non-
sterile area from the sterile area
4. ARM BOARD
- self locking board to support the arm resting at patient side
5. STIRRUPS
- Supports legs in lithotomy position
6. PILLOWS AND SANDBAGS
- support or immobilize a body part
- various size and shape to fit anatomic structures
7. SHOULDER ROLL
- placed under each side of the patients chest to raises it off the table to
facilitate operation
8. KIDNEY REST
- concave metal piece with groove notches at the base are place under the
mattress on the elevator part of the table
9. DONUT
- used for procedures on head and face
- circular or donut shape rubber foam pad
10. METAL FOOTBOARD
 - to support the feet, the soles resting securely against
- can be flat as horizontal extension of the table or raised perpendicular to
the table

DIFFERENT POSITIONS DURING SURGERY

1. SUPINE
2. PRONE
3. LATERAL
4. KIDNEY POSITION
5. PRONE POSITION
6. KRASKE (JACKKNIFE) POSITION
7. MODIFIED TRENDELENBERG – those in the lower
pelvis is pushed up so you can visualize what is in the
lower pelvic cavity
8. REVERSE TRENDELENBERG – everything in the lower
abdomen is pushed down so you can visualize the upper
abdomen
9. LITHOTOMY
10. ORTHOPEDIC POSITION

SKIN PREPARATION
 decreases the number of bacteria on the patient’s skin, thus decreasing the
chance of the patient acquiring a post operative wound infection.
 duration usually is 5 min depending on the size of the area to be prepped.
 always start the prep at the incision site, working to the outer boundaries.
Boundaries are Bedside to bedside; nipple line to mid thigh
 new sponges should be used when returning to incision site ( cleanest to dirtiest )
 should be done with firm but not rough movements. Observe for skin reactions.
 skin prep is institutional. Latest practice is the 12 ball technique.
 Nurse must not reach over the prepped area.
 Draping of the operative area is done immediately after the skin preparation is
completed.

COMMONLY USED SKIN PREPARATION

a. Abdominal skin preparation includes the area of the breast line to the upper third of
thighs. From Table line to table line with patient in supine position
b. Back Preparation Includes the area of the breast line to the upper third of the
thighs with the patient in prone position.
c. Rectoperineal and vaginal preparation includes pubis, vulva, labia, anus and
adjacent areas, including inner aspects of upper third thigh.

STERILIZATION - complete destruction of microorganism.

- complete sterilization of instruments and equipments is used in the surgical practice.
- there is no midway between sterile and unsterile.

Sterilization by Heat
1. Autoclaving (moist heat) or steam under pressure
- most effective means of sterilization
- Steam kills organism by coagulations of the cell protein.
- suitable for fabrics e.g. gowns, towels, dressings, and instruments
- A process by which there is a direct steam contact with specific
temperature and time contained in a chamber with a saturated steam
pressure.

PRINCIPLES OF AUTOCLAVING
• Temperature – 250f to 270f
• Timing – depending upon the loads and the type of autoclave but usually 15-30
minutes.
• Loading – all articles must be properly wrapped with indicators
• Drying the load- all articles should be dry at the end of the sterilization process.

2. Dry Heat
- kills micro-organisms by oxidation (exposed at 160 C or 320 F for 1 hr.)
- suitable for all types of glassware and some instruments.

3. Boiling water sterilization

-a process by which there is a direct heat immersion contact but only destroy
vegetative bacteria, thereby this process is discouraged.
- Principle:

- Timing – the recommended time is 2 minutes or longer from the start of boiling
point

5. Gas Sterilizaiton (anprolene)

- A process of heat sensitive gaseous sterilization under pressure.
- PRINCIPLES:
• Temperature – 140f
• Timing-12 hours anpprolene gas sterilization and 24 hours aeration
• Highly inflammable
• A vesicant it is come in contact with the skin
• Toxic if inhaled

6. Chemical disinfectant
• A process by which chemical agents is used to prevent and to kill the growth of
bacteria.
A. Cidex - a 2% activated aqueous glutaraldehyde soln
B. Alcohol solution – 70% isopropyl or ethyl alcohol solution
C. Providone iodine (betadine) – anaqueous solution that
coagulates albuminous substance
D. Phenols (Lysol) – effective in the presence of organic
matter
DRAPE – provide sterile environment
1. Laparotomy sheet/lap sheet - a large sheet with longitudinal
opening which is place over the operative site on the abdomen, or
comparable area.
2. towels - A small sheet used to outline the operative
site(green towel) also used for drying of hands (blue towel)
3. large sheet - a plain large sheet used to drape under legs as
in added protection above or below the operative area or for draping areas
in which a sheet with an opening cannot used.
4. towel with hole -a small sheet with a circular hole used to
drape or cover a small operation such as excision of cyst or mass.
5. eye sheet -a small sheet with an openning like a shape of an
eye used to drape a very small operation and eye operations.
6. thyroid sheet -a large sheet with an opening fitted in the
neck area to drape in the neck operation.
7. single sheet/sterilizing sheet/ss -a regular size sheet without
opening which is folded lengthwise and placed above operative field.
8. perineal sheet - A special design large sheet with an
opening and used to create an adequate sterile field with the patient in
lithotomy position such as d & c, hemorroidectomy and others.
9. cystoscopy sheet -a special design large sheet with an
opening and pockets used to drape patient in a lithotomy position such as
cystoscopy operation and others.
10. instrument tray cover (ITC) - A fitted sheet used to drape or
cover the mayo stand.

SURGICAL INCISIONS
The choice of the incision is made by the surgeon with the following considerations:
 Type of surgery (anatomical location)
 Maximum exposure
 Ease and speed of entering (for emergency surgery)
 Possibility of extending the incision
 Maximal postoperative wound strength
 Minimum postoperative discomfort
 Cosmetic surgery
LAYERS OF THE ABDOMINAL TISSUE
1. skin
2. subcuticular
3. subcutaneous
4. fascia
• superficial
• deep
5. muscle
6. peritoneum

ANESTHESIOLOGY
- a branch of Medicine concerned with the administration medications or
anesthetic agents to relieve pain and support physiologic function during a
surgical procedure

ANESTHESIA
- is an artificially induced state of partial or total loss of sensation, occurring
with or without loss of consciousness.
- Purpose:
• to block the transmission of nerve impulses, suppress
• reflexes, promote muscle relaxation and in some cases, achieve
• a controlled level of unconsciousness.
• formed from the Greek word meaning “negative sensation”
• loss of feeling or sensation; esp. loss of sensation of pain with
loss of protective reflexes
 • Analgesia – lessening of or insensibility to pain
• Amnesia – loss of memory; indifference to pain
• Analgesic – drug that relieves pain by altering perception of painful stimuli w/o
producing loss of consciousness; acts on specific receptors in NS.
• Anesthetics – drug that produces local or general loss of sensibility
• Pain – perceptual phenomenon, a disturbed sensation causing suffering/distress

3 Types of Pain
1. Phasic – of short duration as a needlestick.
2. Acute – up to six months as postoperative pain from tissue trauma
3. Chronic – six months and above duration as a chronic disease.

FACTORS THAT AFFECT THE CHOICE OF ANESTHESIA

1. Provide maximum comfort &safety for the patient with low index of toxicity
2. Provide maximum operating conditions for the surgeon
3. Provide potent, predictable analgesia extending to postop period.
4. Produce adequate muscle relaxation and provide amnesia
5. Have rapid onset & easy reversibility w/ minimum side effects
6. Patients physiologic status w/ Presence & severity of co-existing dcs.
7. Patients’ mental and psychologic status
8. Options for management of postoperative pain
9. Posoperative recovery from various kinds of anesthesia
10. Type and duration of the surgical procedure
11. Client position needed for the surgical procedure
12. Any particular requirement of the surgeon and patients preference

TYPES OF ANESTHESIA
1. GENERAL ANESTHESIA / GENERAL
ENDOTRACHEAL ANESTHESIA / GETA
- block pain stimulus at the cerebral cortex
- induce depression of the CNS that is reversed either by metabolic change
and elimination from the body or by pharmacologic means
- produces analgesia, amnesia, unconsciousness and loss of reflexes and
muscle tone
- best suited for surgeries of the ff:
• head, neck, upper torso, back
• prolonged surgical procedure
• used in all clients who are unable to lie quietly for long periods
of time
- types:
• INTRAVENOUS ANESTHESIA – extremely rapid induction
- Uncosciousness occurs 30 sec. after administration
- Promotes rapid transition form the conscious to surgical
anesthesia stage
- Acts as calming agent
 - Sufficiently potent to be used alone in some minor
procedures as dental extraction and pelvic exams
- Ex. Thiopental Sodium and Ketamine (has a great effect on
px. ; increases BP ; not given to px. with hx. Of
hypertension ; usually px. who have hx. Of low BP due to
depression of CNS which may be increased by Ketamine)
• INHALATION ANESTHESIA
- uses a mixture of volatile liquids or gas and oxygen
- advantage: ease in administration and elimination through
the respiratory system
- used ot maintain client in stage III anesthesia
- mixture is given through a mask or ET tube which is
inserted once the client is paralyzed and unconscious
(intubation)
- examples:
a. INHALATION ANESTHETICS (volatile agents)
- liquids vaporized for inhalation with O2 as
carrier
- cause post operative shivering –
hypothalamus effect
- halothane and isoflurane
b. GAS ANESTHETIC (gaseous agent)
- nitrous oxide- most commonly used
- odorless, colorless, non-irritating gas that
provides analgesia equivalrent to 10 mg of
morphine sulfate
2. REGIONAL ANESTHESIA – reversible loss of sensation in a specific area or
region of the body when local anesthetic is injected to purposely block or
anesthetize nerve fibers in and around the operative site
- agents blocks conduction of impulses in the nerve fibers

EPINEPHRINE – added to many local anesthetics

- adjunct – medication given with another medication to potentiate effect of
the medication
- purpose:
• prolonged anesthetic effect
• delay absorption of anesthetic by constriction of local blood
vessels

TYPES OF REGIONAL ANESTHESIA

a. SPINAL – SUB ARACHNOID BLOCK / SAB
- anesthetic technique of choice for older adults and for clients undergoing
surgical procedures in the lower half of the body
- achieved by injecting local anesthetics into the subarachnoid space
- autonomic nerve fibers 1st affected and last to recover
 - after blockade of the ANS spinal anesthesia blocks the following fibers in
these order and recovers in reverse order:
a. touch b. pain c. motor d. pressure and
e. proprioreceptive fibers (alerts brain of physical orientation)
- within minutes of administration, client experience a loss of sensation and
paralysis of the toes, feet, legs, then abdomen
- benefits:
• safe, excellent lower body muscle relaxation, absence of effect of
consciousness

b. EPIDURAL – CLEB / CONTINUOUS LUMBAR EPIDURAL BLOCK

- achieved by introduction of anesthetic agent into the epidural space
(thoraxic, lumber, sacral, or caudal interspace) w/o penetrating the dura
and w/o entering the subarachnoid space
- blocks autonomic nerves and cause hypotension
- respiratory depression or paralysis may occur if block done is too high that
may affect respiratory muscle

c. CAUDAL ANESTHESIA

d. TOPICAL ANESTHESIA – short acting

- applied directly to the area to be sesensitized
- blocks peripheral nerve endings in the mucous membrane of the vagina,
rectum, nasopharynx, and the mouth
- preparation: solution, ointment, gel, cream or powder

e. LOCAL INFILTRATION ANESTHESIA

- involves injection of anesthetic agent such as lidocaine into the skin and
subcutaneous tissue of the area
- blocks only the peripheral nerves around the area of incision
- when administered, aspirate that no blood vessel was hit before injecting
to ensure and prevent systemic reaction causing cardiovascular collapse or
convulsion

f. FIELD BLOCK ANESTHESIA

- areia proximal to a planned incision can be injected and infiltrated to
produce a “field block”
- this block forms a barrier between incision and the nervous system
- walls the area around the incision and prevents transmission of sensory
impulse to the brain from this area

g. PERIPHERAL NERVE BLOCK / PNB

- injects along the nerve rather than into the nerve to decrease risk fo nerve
damage
- anesthetize individual nerve or nerve plexus rather than all local nerves
anesthetized by a field block
 - prevent accidental injection into the blood vessel

TYPES OF PERIPHERAL NERVE BLOCK

- Digital nb- for a finger
- Brachial plexus nb- entire upper arm
- Intercostals nb – chest or abdominal wall

h. MONITORED ANESTHESIA
- surgeon infiltrates surgical site with local anesthesthetics and the anesthesia
provider supplements local anesthetics w/ IV drugs to provide sedation and
systemic analgesia

i. ACUPUNCTURE
- Ancient chinese killing technique that works by insertion of long, thin needles
into specific acupuncture points

j. CRYOTHERMIA
- use of cold to induce anesthesia