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- it is the nursing care rendered to the total surgical experience of the patient.
3 Phases
Preoperative phase Intraoperative phase Postoperative phase
A. Physical Effects
B. Psychological Effects
D.
E. F. G.
Corticosteroids
Insulin Diuretics Antidepressant
CLASSIFICATIONS OF SURGERY
According to Urgency:
1. Emergent requires immediate attention; Disorders maybe life-threatening. 2. Urgent- surgical problem requires prompt attention within 24-30hrs 3. Required- condition requires surgery within a few weeks
4. Elective- approximate time for surgery is at the convenience of the patient, failure to have surgery is not catastrophic
5. Optional- is scheduled completely at the preference of the patient.
CLASSIFICATION OF SURGERY
According to Degree of Risk: Major- high degree of risk > maybe complicated/prolonged
CLASSIFICATIONS OF SURGERY
According to Purpose 1. 2. Diagnostic- verifies suspected diagnosis Exploratory- estimates the extent of the disease or injury
3.
4. 5.
Cont.
Constructive- repairing damaged tissue/congenitally defective organ Palliative relieves symptoms but does not cure the underlying diseases
PREOPERATIVE PHASE
5.
6.
The nurse may witness the clients signing of the consent form.
If the patient is unable to write, an X to indicate his sign is acceptable if there is a signed witness to his mark.
3.
4.
PREOPERATIVE TEACHING/VISIT
Physical Preparation
Psychological Preparation
POSTOPERATIVE EXERCISES
Deep breathing - every 2hrs Coughing
Splinting
Turning every 2hrs
INCENTIVE SPIROMETER
Positive Effects - provides stimulus for a spontaneous deep breath
- reduces atelectasis
- opens airways - stimulates coughing
PREOPERATIVE MEDICATIONS
1. 2. Narcotic analgesic Anticholinergics
SURGICAL CHECKLIST
Identification and verification Review of patients record Consent form Patient preparedness 1. NPO status 2.Proper attire (hospital gown) 3. Skin prep, if ordered 4. IV started with correct gauge needle
IV Cannulas
G 22 G 24
G 20
G18
INTRAOPERATIVE PHASE
ASEPTIC TECHNIQUE
A group of procedures that prevent contamination of microorganisms through the knowledge of contain and control.
Sterile Technique Methods by which contamination of an item is prevented by maintaining the sterility of an item/area involved with the procedure.
Tables are sterile at table level only. Sterile persons and items touch only sterile areas; unsterile persons and items touch only unsterile areas. Movement around the sterile field must not contaminate the field. All items and areas of doubtful sterility are considered contaminated.
- refers to the time an item may remain on the shelf and still maintain its sterility.
Spaulding Criteria
RECOMMENDED PRACTICE IV
All items introduced to a sterile field should be opened, dispensed and transferred by methods that maintain item sterility and integrity. 1. The surgical team should practice careful aseptic technique during all invasive surgical procedures. 2. Unscrubbed individuals should open wrapped sterile supplies by opening the wrapper flap farthest away from them first. 3. Sharps and heavy objects should be presented to the scrubbed person/opened on a sterile surface. 4. Peel pouches should be presented to the scrubbed person. 5. Rigid container systems should be opened on a separate surface.
When dispensing solutions, the solution receptacle on the sterile field should be placed near the tables edge, or held by scrubbed person.
Strike- through - contamination of sterile surface by moisture that has originated from a non-sterile surface and penetrated the protective covering of the sterile item
Recommended practice V A sterile field should be maintained and monitored constantly. 1. A sterile field should be prepared in the location in which it will be used. 2. For unsterile personnel, movement around the sterile field should maintain a distance of at least 12 inches from the sterile field. 3. Sterile fields should be prepared as close as possible to the time of use. 4. Sterile field should not be covered. 5. Conversations in the presence of a sterile field should be kept to a minimum.
RECOMMENDED PRACTICE VI
All personnel moving within or around a sterile field should do so in a manner that maintains the sterile field. Unscrubbed personnel - should face sterile fields on approach - should not walk between two sterile fields Scrubbed personnel - should keep their arms and hands above the level of the waist at all times. - arms should not be folded with the hands in the armpits - should avoid changing levels. The number and movements of the surgical team should be kept to a minimum. When a break in the sterile technique occurs, corrective action should be taken immediately.
RECOMMENDED PRACTICES FOR TRAFFIC PATTERNS IN THE PERIOPERATIVE PRACTICE Non- Restricted Area SETTING
Semi-Restricted Area Restricted Area Transition Zone
HEAD COVER
Headgear should be donned before the scrub attire to prevent fall-out from the hair collecting on the scrub attire.
Personnel should cover head and facial hair, including sideburns and necklines, when in the semi-restricted and restricted areas of the surgical suit.
Contaminated headgear must be removed and laundered by the facility.
SURGICAL MASK
Should fully cover both mouth and nose and be secured in a manner that prevents venting. Double mask is unacceptable, doesnt increase filtration. Should be removed by handling only the ties, should be discarded immediately. Should not be saved by hanging them around the neck or tucking them into a pocket for future use
GLOVES
Sterile gloves must be worn when performing sterile procedure. Medical, non sterile gloves are recommended for non-sterile activities.
RECOMMENDED PRACTICES FOR STANDARD AND TRANSMISSION BASED PRECAUTIONS IN THE PERIOPERATIVE PRACTICE SETTING
Standard Precautions to prevent pathogen transmission should be used during all invasive procedures.
Standard Precautions should include use of protective barriers and frequent hand washing to reduce risk of exposure to potentially infectious materials.
Personnel should take precautions to prevent injuries caused by scalpels and other sharp instruments. Personnel should handle specimens as potentially infectious material. Work practices should be designed to minimize risk of occupational exposure to bloodborne and other potentially infectious pathogens.
Transmission based precautions should be used in addition to standard precautions for patients who are known or suspected to be infected with highly transmissible pathogens.
1. Airborne precautions - examples: rubeola, varicella, tuberculosis - respiratory protection to be worn by susceptible persons - placing surgical mask on patients during transport - elective surgical procedures on TB patients should be delayed until patient is no longer infectious. 2. Droplet precautions - examples: diptheria,pertussis,influenza,mumps - wearing a mask when within three feet of patients - positioning patients at a distance of at least three feet
3.
Contact Precautions - wearing gloves when caring for patients/coming in contact with items that may contain high concentrations of microbes. - wearing gowns when it is anticipated that clothing will have substantial contact with patients/items in aegs. environment - precautions are maintained during transport. - adequately cleaning and disinfecting patient care equipment and items before use w/ each patient.
Goals: Mechanical removal of soil and transient microbes from the hands and forearms Chemical reduction of the resident microbial count to as low a level as possible Reduction of potential of rapid rebound growth of SURGICAL HAND SCRUB microbes. Antimicrobial Agents
Iodophors
Chlorhexidine gluconate
Sequence in Removing Soiled Gowns and Gloves at the End of the Procedure
CIRCULATING NURSE
Sets up the Operating room Ensures that necessary supplies and equipment are readily available, safe and functional Receives patient endorsement Assists in the transferring of client in the OR bed Positions patient in the OR bed Performs surgical skin preparation Opens and dispenses additional needed supplies /medications during surgery Manages catheters, tubes, drains and specimens Reviews the results of any diagnostic tests or lab studies
Ensures that the surgical team maintains sterile technique and a sterile field. Monitors traffic in the OR Manages the flow of information to and from the surgical team members scrubbed at the field Manages personnel, equipment, supplies and the environment during surgery
Scrub Nurse Performs scrubbing, gowning and gloving Prepares sterile field for scheduled/emergency surgery Assists with instrumentation, sponges and suture presentation Anticipate needs for surgical team Performs sharps, sponge, and instrument count Prepares sterile dressing w/c will be applied when surgery is completed Aftercare of instruments and other materials
PARAPROFESSIONALS/ANCILLARY POSITIONS
Prepares and maintains supplies, equipment and environment Assists nursing staff before, during and after surgical procedure
-state of depressed level of consciousness that does not impair patients ability to maintain a patent airway and to respond to physical stimulation and verbal commands.
Deep Sedation - Drug induced state during which the patient cant be easily aroused but can respond purposefully after repeated stimulation
GENERAL ANESTHESIA
Complete loss of consciousness A reversible state that provides analgesia, muscle relaxation and sedation It depresses the cerebral cortex where conscious interpretation of pain takes place Protective reflexes are lost Produced by IV/inhaled anesthetics
NITROUS OXIDE
Colorless, odorless non-explosive gas Is rarely used alone When combined with other agents and oxygen----it already serves as potentiator for other inhalation agents High concentration nitrous oxide can produce hypoxia induction agent given with oxygen used alone for short procedures used as inhalation analgesic
INHALATION ANESTHESIA
Volatile agents 1. Halothane - safe to use - producing rapid smooth induction - non-flammable/non-explosive - very potent - seldom causes nausea and vomiting - non-irritating to mucous membranes -excellent bronchodilator - hepatotoxic -decreases bp - causes malignant hyperthermia
FORANE (ISOFLOURANE)
Provides rapid induction, rapid emergence
Low incidence of nausea and vomiting Does not stimulate excessive secretions Non-hepatotoxic/non-nephrotoxic Excellent choice for neurosurgery Not recommended for children under 2 years of age------due to longer airway irritation
ENFLURANE
Has similar effects to halothane Muscle relaxation is stronger Hepatotoxicity is not a problem
COMPLICATIONS OF GENERAL
ANESTHESIA
1. 2. 3. Aspiration Oral trauma Hypoventilation
4.
5. 6.
Cardiac dysrrythmias
Hypothermia Malignant Hyperthermia
From
To
Patients response
Drowsy, dizzy, hearing becomes exagerrated, pain sensation is decreased Loss of consciousness,loss of lid reflexes.incresed muscle tone and involuntary motor response Regular respiration,contracted pupils reflexes disappear
Relaxation,light hypnosis
Danger stage, vital Respiratory functions too failure,possible depressed cardiac arrest
OXYGEN TANK
COMPRESSED AIR
NITROUS OXIDE
REGIONAL ANESTHESIA
Production of anesthesia in a specific body part Injecting local anesthetics in close proximity to appropriate nerves Spinal Anesthesia Local anesthetic is injected into lumbar intrathecal space/sub arachnoid space Anesthetic blocks conduction in spinal nerve roots and dorsal ganglia Paralysis and analgesia occur below level of injection Produces excellent analgesia and relaxation to abdominal and pelvic procedures
EPIDURAL ANESTHESIA
Injecting local anesthetic into epidural space by way of a lumbar puncture Associated with obstetric surgery; anorectal and perineal procedure Administered via bolus Peripheral Nerve Blocks Anesthetic is injected around a nerve that supplies sensation to a small area of the body
INTRAVENOUS BLOCK
Involves IV injection of a local agent and the use of an occlusion tourniquet Procedures involving the arm, wrist and hand Local Anesthesia (Infiltration) Used for minors and superficial procedures The agent is injected in the surgical site Topical Anesthesia Anesthetic agent is directly applied to the skin and mucous membranes
Abdominal Incisions
Procedures:
Abdominal Extremity Vascular Chest Neck Facial Ear Breast
Chest Kidney
Kraske (Jacknife)
Procedures:
Rectal Procedures Sigmoidoscopy Colonoscopy
Prone Procedures: Surgeries involving the posterior surface of the body Spine Neck Buttocks Lower extremities
ANTIMICROBIAL SOLUTIONS
1. Povidone /Iodine Betadine 2. Chlorhexidine Gluconate o Rapid acting o Have a broad spectrum of activity o Have minimal harsh effect on skin o Inhibit rapid rebound of microbes o Economical to use o Based on
o
o o
ABDOMINAL PREP
Breastline to upper 3rd of thigh Table line to table line when in supine position
LATERAL/THORACOTOMY
Axilla Chest Abdominal-from neck to iliac crest Area should extend beyond the midline anteriorly and posteriorly
Rectoperineal / Vaginal
SUTURES
Absorbable sutures Examples: Chromic, Plain,Polydiaxone (PDS), Polyglactin 910 (Vicryl),Polyglycolic Acid(Biovek) Used for those who cant return for suture removal/in internal body tissues Non-Absorbable sutures Examples: Silk,Nylon,Prolene (Polypropylene) Used either on skin wound closure/in stressful internal environments where absorbable sutures will not suffice
SUTURES
Is a medical device used to hold tissue together after an injury or surgery till healing takes place. Absorbable Sutures material is digested by body cells and fluids during the healing period. Plain dissolves within 5-10 days, Yellow Chromic- dissolves within 1 month, Brown
Skin
Subcutaneous
Fascia
Muscle
Peritoneum
Organ
20 10 11 12 15
Surgical Blades
Scalpel holder
Metzenbaum
Lister/Bandage Scissors
Suture Scissors
Stitch Scissors
BLADE HANDLE
METZENBAUM
They have serration up to the tips, allowing better grasp of tissue with minimum trauma.
Allis Clamp
Tenaculum
Babcock Clamp
Richardson
US Army Navy
Senn
Deaver
Malleable
Vein Retractor
Volkmann Rake
Green Goiter
Weitlaner
Langenbeck
Skin Hooks
Vaginal Speculum
RICHARDSON RETRACTOR
VEIN RETRACTOR
SENN RETRACTOR
Straight Mosquito
Crile Clamp
Kelly Clamp
Suturing Instruments
POSTOPERATIVE PHASE
3 Stages Immediate Stage
Position
CARDIOVASCULAR
Cardiovascular Assess skin and check capillary refill Assess peripheral edema Monitor for bleeding Assess pulse rate and rhythm Monitor for hypo/hypertension Monitor for cardiac dysrhythmias Assess for Homans Sign
Vital signs are stable for at least 30mins and are within normal range
Patient is breathing easily Reflexes has returned to normal Patient is responsive and oriented to time and place
POST-OPERATIVE COMPLICATIONS
Atelectasis - a collapse of the alveoli with retained mucus secretions - Usually develop 1-2days post-op Aspiration
POST-OPERATIVE COMPLICATIONS
- caused by inhalation of food, gastric contents, water or blood into the tracheobronchial system.
- anesthetics and narcotics depress the CNS,causing inhibition of cough and gag reflex
3. PNEUMONIA
an inflammatory response in which cellular material replaces alveolar gas. Assessment: Dyspnea, increased RR Crackles over involved lung area Elevated temp Productive cough and chest pain Hypotension - may develop 3-5days post-op
PULMONARY EMBOLISM
-An embolus blocking the pulmonary artery disrupting blood flow to one or more lobes of the lungs
Assessment:
Dyspnea Sudden sharp chest/upper abdominal pain Cyanosis Tachycardia A drop in blood pressure
CARDIOVASCULAR COMPLICATIONS
Thrombophlebitis Inflammation of the vein, often accompanied by clot formation 7-14 days post-op Assessment: Vein inflammation Aching or cramping pain Vein feels hard and cordlike and is tender to touch Elevated temperature Positive Homans sign
INTERVENTION
hydrate patient adequately Avoid massaging to calves or thighs Avoid standing or sitting in one pace or crossing legs Avoid inserting IVs into legs Assess for Homans Sign
CIRCULATORY COMPLICATIONS
Hemorrhage
-The loss of a large amount of blood externally/internally for a short period of time Shock -Loss of circulatory fluid volume caused by hemorrhage Assessment: Restlessness Weak rapid pulse Hypotension
Tachypnea
Cool clammy skin Reduced urine output
9. CONSTIPATION
URINARY RETENTION
-Involuntary accumulation of urine in the bladder as a result of loss of muscle tone - Due to effects of anesthetics/narcotics Assessment:
Inability to void
Restlessness and diaphoresis Lower abdominal pain, distended bladder Elevated BP
Medications
Diet Follow-up visit removal of sutures in 7-10 days/ removal of staples in7-14 days Activity levels-no lifting for 6 weeks - not to lift anything (>10lbs)
DRAINS
are placed in wounds only when abnormal fluid collections are present/expected Are placed near the incision site: In compartments that are intolerant to fluid accumulation In areas with large blood supply In infected draining wounds Areas that have sustained large superficial tissue dissection
TYPES OF DRAINS
G R AV I T Y MECHANIC
B. MECHANICAL
- these are portable self contained closed wound mechanical devices that suction fluid after collapsing them and closing the valve thus forcing the fluid to be pulled into the collection chamber. examples: Hemovac Jackson- Pratt
First Intention Healing - Wounds are made aseptic by minor debridement and irrigation with a minimum tissue damage and tissue reaction - Wound edges are properly approximated with suture
- Wounds are left open to heal spontaneously or surgically closed at a later date - Examples include burns, traumatic injuries, ulcers and suppurative infected wounds - Cavity of the wound fills with a red, soft, sensitive tissue (granulation tissue), which bleeds easily, a scar eventually forms. - In infected wounds, drainage may be accomplished by use of special dressings and drains. - Produces deeper wider scar
2.DIAGNOSTIC SPECIMEN
Frozen Section Requires special handling and immediate examination by the pathologist With verbal report of the findings communicated to the surgeon during the surgical procedure Examples include breast biopsy/any organ, tumor or lesion Specimen is sent dry and is properly labeled.
CULTURES
Are taken on a patient who comes to the OR with a known/suspected infection 2 types: aerobic and anaerobic, requires different medium for growth This will determine the antibiotic that will specifically affect the microbes