On completion of this concept, the student will be able to: 1. Define the three phases of the peri- operative period.2. Identify the causes of preoperative anxiety and describe the nursing measures to alleviate it.
3. Identify legal and ethical considerations related to informed consent. 4. Develop a preoperative teaching plan designed to promote the patient’s recoveryfrom anesthesia and surgery, thus preventing postoperative complications.5. Describe the interdisciplinary approach to the care of the patient during surgery.
6. Describe the principles of surgical asepsis. 7. Identify adverse effects of surgery and anesthesia. 8. Identify the use of the nursing process for optimizing patient outcomes during the intra-operative period.9. Identify assessment parameters appropriate for the early detection of postoperative complications.
d. Psychosocial Nursing Assessment and Interventions 1. Alleviating Fear 2. Respecting Spiritual and Cultural Beliefse. General Physical Assessment 1. Nutritional Status – Nutrients important for wound healing and recovery
2. Drug and Alcohol use3. Respiratory status4. Cardiovascular status5. Hepatic and Renal Function6. Endocrine Function7. Immunologic Function8. Previous Medication Therapy
PATIENT EDUCATION1. Deep Breathing and Coughing Exercises2. Mobility and Active Body Movement3. Pain Management4. Cognitive Coping Strategies a. Imagery b. Distraction c. Optimistic Self-recitation
g. Preoperative Nursing Management 1. Managing Nutrition and Fluids 2. Preparing Bowel for Surgery 3. Preparing the skinh. Immediate Preoperative Nursing Interventions 1. Administering pre-anesthetic medications
2. Maintaining the Preoperative Record 3. Transporting the patient to the pre-surgical Suite 4. Attending to Family NeedsII Intraoperative Nursing Management a. The Surgical Environment 1. Physical Layout of the O.R. suite
1. Location 2. Principles in Design 3. Exchange Areas 4. Peripheral Support Areas 5. Operating Roomb. Asepsis, Infection Control and Principles of Sterile Technique 1. Surgical Conscience
2. Infection a. Process of Infection b. Classification of Infection c. Factors Affecting Infection Rates d. Classification of Operative Wounds e. Sources of Contamination f. Infection Control g. Environmental Control
3. Principles of Sterile Technique 4. Methods of sterilization and Disinfectionc. Surgical Scrub, Gowning and Gloving 1. The Surgical Scrub 2. Gowning and Gloving TechniquesThe Surgical Team a. Patient
b. Intraoperative Nurses 1. Circulating Nurse 2. Instrument Nurse 3. Division of Duties: Setup, Procedure, Cleanupc. Anesthesiologist and Anesthetistd. Surgeon / Assistant SurgeonThe Surgical Experience
a. Anesthesia: an overview b. Patients Positions on the Operating table c. Preparation of the Operative Site and DrapingPotential Intra-operative Complications a. Nausea and Vomiting b. Hypoxia and other Respiratory complications
c. Hypothermiad. Malignant HypothermiaPostoperative Nursing ManagementThe Postanesthesia Care Unit a. Admitting Patient to the PACU b. Nursing Mgt. in PACU
1. Assessing the patient2. Maintaining patent airway3. Maintaining Cardiovascular stability4. Relieving Pain and Anxiety5. Determining readiness for discharge from the post-anesthesia care unit
b. The Hospitalized Postoperative Patient a. Receiving the patient in the clinical unit b. Nursing Management during the first hours after surgery 1. Assessing and managing ventilation 2. Assessing and managing hemodynamics
3. Assessing and Managing Surgical Sites4. Assessing and Managing Pain5. Maintaining Normal Body Temperature6. Assessing Mental Status7. Assessing Neurovascular status8. Assessing and Managing Gastrointestinal Status9. Assessing and Managing Voluntary Voiding
10. Encouraging Mobility 11. Maintaining Safe Environment 12. Providing Emotional Support to Patient and Familyc. The First Postoperative day to the day of discharge 1. Relieving Pain 2. Preventing Respiratory Complications 3. Preventing Deep Vein Thrombosis
4. Encouraging Activity and Promoting Self-care5. Preventing wound infection and providing wound care a. Phases of wound healing b. Factors affecting wound healing c. Sterile dressing techniques
6. Managing wound complications a. Hematoma b. Wound Sepsis c. Wound Dehiscence and Evisceration7. Resuming Oral intake and Promoting Bowel Function
Perioperative NursingSurgery – a branch of medicine that deals with disease and trauma through surgical / operative procedures.History of Surgery:- the earliest recorded sign of surgery was found in ancient Egyptian papyri.- they were for treatments of the back, chest , and shoulders.
Perioperative Nursing- earliest known surgeon used a large amount of tools like: knives, awls, drills, scissors, saws, forceps, clamps, syringes, mirrors, needles, cast, splints, & bandages- surgery has been around since 3,000 B.C. through today.- among the first surgeons were battlefield doctors in the Napoleonic Wars who were primarily concerned with amputations.
Perioperative Nursing- naval surgeons were often barber-surgeons, who combined surgery with their main jobs as barbers.- history of surgery can be divided into three eras: ancient, middle & modern
SUSHRUTAThe “Father ofsurgery” andinventor of PlasticSurgery.
JOSEPH LISTERThe discoverer ofsurgical sepsis andListerine named inhis honor.
ALFRED BLALOCKThe first modernday successfulopen heartsurgery in 1944.
CHRISTIAN BARNARDThe cardiacsurgeon whofirst performedthe hearttransplantationin 1967.
Perioperative NursingPerioperative Nursing – refers to the activities performed by the professional nurse during the client’s total surgical experience.Perioperative period – encompasses a client’s total surgical experience , including the preoperative, intraoperative and postoperative phases.
Phases of Peri-operativeNursing1. Preoperative Phase – begins with the decision to perform surgery and ends with the client’s transfer to the operating room (O.R.).2. Intraoperative Phase – begins when the client is received in the O.R. and ends with his admission to the post-anesthesia care unit (PACU) / Recovery Room.
Phases of Peri-operativeNursing3. Postoperative Phase – begins when the client is admitted to postanethesia care unit and extends through follow-up home or clinic evaluation.Categories of Surgery based on Urgency:1. Emergent / Emergency - patient requires immediate attention, disorder may be life threatening.
indication: without delayexamples: severe bleeding (gunshot or stab wounds), bladder or intestinal obstruction, fractured skull and extensive burns2. Urgent – patient requires prompt attention.indication: within 24-30 hoursexamples: acute gallbladder infection, kidney or ureteral stones, appendicitis
3. Required – patient needs to have surgery.indication: plan within a few weeks or months examples: prostatic hyperplasia (without obstruction), thyroid disorders and cataracts 4. Elective – procedure performed by choice indication: failure to have surgery not essentialexamples: repair of scars, hernia and vaginal repair
5. Optional – decision rest with the patient.indication: personal preferenceexample: cosmetic surgeryClassification of Surgery:1. Diagnostic – e.g. biopsy or exploratory laparotomy (Ex-Lap)2. Curative – e.g. tumor excision & inflamed vermiform appendix
Classification of Surgery3. Reparative / Reconstructive– bringing back to its normal functioning. Repair of damaged organ.4. Palliative – reduce intensity of uncomfortable symptoms but not to produce a cure.
Classification of Surgerya. Ablative – Involves removal of an organ. (suffix used: “ectomy”) appendectomyb. Constructive – Involves repair of congenitally defective organ. (suffixes used are “plasty”, “orrhapy”, “pexy”) cheiloplasty & orchidopexyc. Reconstructive – Involves repair of damaged organ. (plastic surgery)
Classification of SurgeryCategories of Surgery based on Magnitude/Extent:A. Major Surgery Criteria: 1. High risk 4. Large amount of blood loss 2. Extensive 5. Vital organs may be handled 3. Prolonged or be removedB. Minor Surgery Criteria: 1. Generally not prolonged 2. Leads to few serious complications 3. Involves less risk
Informed Consent – permission obtained from a patient to perform a specific test or procedure. Criteria for a Valid Informed Consent:1. Voluntary consent – valid consent must be freely given without coercion.2. Competent patient – individual who is autonomous and can give or withhold consent.3. Patient able to comprehend – information must be written and delivered in language understandable to the patient.
4. Informed subject - consent must be in writing & must contain the following:a. Explanation of the procedure and its risk.b. Description of benefits and alternatives.c. Instructions that the patient may withdraw consent.d. A statement informing the patient if the protocol differs from customary procedure.
Informed Consent is necessary in the following procedures:1. Invasive procedures – surgical incision, a biopsy, cystoscopy or paracentesis.2. Procedures requiring sedation or anesthesia3. Non-surgical procedure – arteriography, lumbar puncture4. Procedures involving radiation
Nursing Responsibilities:1. The surgeon must provide a clear and simple explanation of the surgical procedure.2. The nurse may ask the patient to sign the consent form.3. The nurse may witness the patient’s signature.
4. If the patient needs additional information about the procedure, nurse notifies the surgeon.5. The nurse ascertains that the consent form has been signed before administering psychoactive drugs.6. If the patient is a minor, unconscious or incompetent, permission must be obtained from a responsible family member or legal guardian.
7. An emancipated minor (married or independently living or earning on his own) may sign his own consent form.8. No patient should be urged or coerced to sign an operative permit.9. In an emergency, a surgeon can operate without the patient’s informed consent.10. Refusing to undergo a surgical procedure is a person’s legal right and privilege.
Preoperative Nursing Problems:1. Anxiety related to the surgical experience (anesthesia & pain) & outcome of surgery. 2. Fear related to perceived threat of the surgical procedure and separation from support system.
3. Knowledge deficit of preoperative procedures and protocols and postoperative expectations Preoperative Nursing Management:1. Teach deep-Breathing, Coughing and Incentive Spirometer2. Encourage mobility and active body movement
3. Pain management – patient-controlled analgesia (PCA), epidural catheter bolus or infusion & patient controlled epidural analgesia (PCEA) 4. Teach cognitive coping strategies a. Imagery – patient concentrates on a pleasant experience or restful scene.b. Distraction – patient thinks of an enjoyable story or recites a favorite poem or song.
PRE-OP NURSINGMANAGEMENTDeep Breathing and Coughing Exercises
LEG and FOOTEXERCISES
c. Optimistic self-recitation – patient recites optimistic thoughts (“I know all will go well”)Instruction for Ambulatory Surgical patients:a. Inform the patient the scheduled date and time of the surgery and where to report. b. Instruct what to bring (insurance card, list of meds) c. Instruct what to leave at home (jewelry, watch )
d. Instruct what to wear (loose-fitting, comfortable clothes & flat shoes)e. Remind the patient not to eat or drink asdirected (fasting period of 8 hours or more is recommended)Preoperative Psychosocial Management: 1. Reducing Preoperative Anxiety – music therapy
2. Decreasing Fear3. Respecting Cultural, Spiritual and Religious Beliefs General Preoperative Nursing Management: 1. Managing Nutrition and Fluids 2. Preparing the Bowel for Surgery 3. Preparing the Skin
Immediate Preoperative Nursing Management: 1. Administering Pre-anesthetic Medication 2. Maintaining the Preoperative Record3. Transporting the Patient to the Pre-surgical Area 4. Attending to Family Needs
Nursing Evaluation: 1. Reports relief of anxiety 2. Reports that fear is decreased 3. Voices understanding of surgical intervention4. Shows no evidence of preoperative complications
Surgical EnvironmentPhysical Layout of the O.R. Suite:1. Location – operating room is situated that is central to all supporting services(laboratory, radiology, pathology & central supply room)2. Principles in Design – a. Exclusion of contamination from outside the suite with sensible traffic patterns within the suite.
b. Separation of clean areas from contaminated areas within the suite.3. Exchange Areas - Surgical Area: a. Unrestricted zone – street clothes are allowed b. Semi-restricted zone – Attire consist of scrub clothes and caps c. Restricted zone – scrub clothes, shoe covers, caps and masks are worn
4. Peripheral Support Areas – a. Central Administrative Control b. Offices c. Conference Room/Classroom d. Laboratory / Radiology Services e. Anesthesia Work & Storage Areas f. Housekeeping Storage Areas g. Utility Room
h. General Workroomi. Storage Roomj. Sterile Supply Roomk. Instrument Rooml. Scrub Room5. Operating Room – surgical suite is behind double doors ( sliding doors, swing doors )
- Access is limited to authorizedpersonnel.- External precautions include adheringto principles of surgical asepsis.- Strict control of the operating roomenvironment is required.- OR has special air filtration devices toscreen out contaminating particles,dust, and pollutants.- Temperature, humidity & airflowpatterns are controlled.
InfectionInfection – is the product of the entrance, growth, metabolic activities & patho- physiologic effects of microorganism in living tissues. Three Stages of infection: 1. Invasion 2. Localization 3. Resolution leading to recovery
Acute Bacterial Infection (most common sepsis in surgical patients) Wound infection begins 4th to 8th postoperative Cellulitis pain, redness & swelling (diffuse inflammatory process) RBC’s, Leukocytes & Macrophages infiltrate the cells (localization & containment of infecting microorganism) Abscess / Pus formation (suppuration) If localization is inadequate Spreading & extension occur causing regional infectionMicroorganism & metabolic products carried into the lymphatic system
Lymphangitis Failure of lymph nodes to hold infection Uncontrolled cellulitis Systemic infection occurs chills, fever, signs of toxicity Septic Thrombophlebitis Septic emboli in circulation causing more infection and abscess in remote tissues Elevates the patient’s metabolic rate 30% to 40% above average (imposing stress on the body’s vital systems) Body’s defenses still not able to overcome the infectious process Septic shock(Fever, restlessness, hypotension, hypoxia, cloudy sensorium, tachycadia) rapid breathing, DIC, metabolic acidosis and oliguria Death
Classification of Infection Classification of Infection:1. Community-Acquired Infections – arenatural disease processes that developed or were incubating before a patient’s admission to the hospital or ambulatory care facility. 2. Communicable Disease – Systemic bacterial, viral or fungal infections may be transmitted from one person to another (HIV, hepatitis & Tuberculosis)
3. Spontaneous Infections – Localizedinfections requiring surgical diagnosis andor treatment for management or that occur as adjuvants to medical therapy (acute appendicitis, cholecystitis & bowel perforation with peritonitis) 4. Nosocomial Infections – are hospital-associated or acquired during the course of health care of the patient.
Types of Nosocomial Infections: 1. Exogenous – infection is acquired from sources outside the body ( personnel & environment ) 2. Endogenous – infection develops from sources within the body.( abdominal sepsis caused from enteric flora due to perforation )
Classification of Surgical Wounds: 1. Clean Wound - No inflammation present- Procedure under ideal O.R. conditions - No break in sterile technique - GIT, respiratory, genitourinary & oropharyngeal cavity not entered Infection rate: 1% to 5%
2. Clean-Contaminated Wound - No inflammation or infection present - Minor break in technique occurred - Primary closure, wound drained- GIT, respiratory, genitourinary tracts & oropharyngeal cavity entered under controlled conditions & no spillage & contamination Infection rate: 8% to 11%
3. Contaminated Wound - Major break in technique occurred- Open fresh traumatic of less than 4 hours - Acute non purulent inflammation present - Gross spillage/contamination from GIT- Entrance to genitourinary or biliary tracts with infected urine or bile present Infection rate: 15% to 20%
4. Dirty and Infected Wound - Organism present in surgical field before procedure - Perforated viscus- Old traumatic wound of more than 4 hours- Existing clinical infection: acute bacterial inflammation encountered, with or without purulence Infection rate: 27% to 40%
Sources ofContamination 1. Skin 2. Hair 3. Nasopharynx 4. Fomites 5. Air 6. Human Error 7. Cross Infection
STERILE / AUTOCLAVE TAPES
PREPARING ASTERILE FIELD
O.R. SCRUB SUIT
Surgical TeamThe Surgical Team / Perioperative Team:1. Circulating Nurse – also known as the “circulator” Responsibilities:a. Manages the operating roomb. Protects patient’s safety and health by monitoring the activities of the surgical team.
Checks and verifies the consent form. Ensure fire safety precautions, cleanliness, proper temperature, humidity and lighting of the O.R. Monitors safe functioning of the equipments. Coordinates with the surgical / peri- operative team and monitors aseptic practices. Documents O.R. surgical activities
3. Scrub Nurse – responsible for scrubbing for the surgery. Responsibilities: a. Setting up sterile tables b. Preparing sterile sutures, ligatures & special equipments c. Assisting the surgeon & assistant surgeon, taking care tissue specimens d. Count all needles, sponges & instruments together with the circulating nurse
4. Surgeon – head of the surgical teamResponsibilities a. Performs the surgical procedure5. RN/INTERN/Co-Surgeon First Assistant – practices under the supervision of the surgeonResponsibilities: a. Suturing and handling of tissues b. Providing exposure at the operative field c. Providing homeostasis
6. Anesthesiologist – is a physician specifically trained in the art and science of anesthesiology. - Anesthetist is a qualified health care professional who administer anesthetics. Responsibilities: a. Interviews and assesses the patient b. Select & administer appropriate anesthesia c. Monitors V/S, ECG, ABG & anesthesia levels
7. Post Anesthesia Care Unit (PACU) Nurse – responsible for caring for the patient until the patient has recovered from the effects of anesthesia. Responsibilities: a. Monitors V/S and post-operative complications (bleeding, respiratory distress etc) b. Carry out postoperative orders c. Refer any abnormalities to the physician
AnesthesiaAnesthesia – a state of narcosis, analgesia, relaxation and loss of reflexes.Levels of Sedation and Anesthesia:1. Minimal sedation – is a drug-induced state wherein patient can respond normally to verbal command. Cognitive & coordination is impaired but respiratory & cardiovascular is not affected.
2. Moderate Sedation – a depressed level of consciousness that does not impair the patient’s ability to maintain patent airway & respond to physical stimulation and verbal commands, often called “ monitored anesthesia care” ( intravenous drugs: midazolam & diazepam )
3. Deep sedation – is a drug induced state which a patient cannot be easily aroused but can respond purposely after repeated stimulation.• Difference of deep sedation and anesthesia is that the anesthetized patient is not arousable.
Types of AnesthesiaTypes of Anesthesia:1. General anesthesia – (inhaled or intravenously) refers to drug-induced depression of the central nervous system that produces analgesia, amnesia and unconsciousness. volatile liquids – Halothane, Isofluorane, methoxyflurane, enflurane
2. Regional Anesthesia – is a form of local anesthesia that suspends sensation and motion in a body region or part, the patient is awake and continuous monitoring is required.3. Spinal Anesthesia – is a local anesthetic injected into the subarachnoid space at the lumbar level to block nerves and suspend sensation and motion to the lower extremities, perineum and lower abdomen.
4. Conduction Blocks – suspend sensation and motion on various groups of nerves. Types of conduction blocks: a. Epidural block – anesthetic into space the dura mater b. Brachial plexus – produces anesthesia on the arm c. Paravertebral block – produces anesthesia of the chest, abdominal wall & ext. d. Transacral (caudal) – anesthesia of the perineum
Spinal AnesthesiaGeneral Anesthesia
Local Anesthetics Agents1. Lidocaine (xylocaine) – topical or injectionAdvantages: Rapid, longer duration of action compared with procaine & free from local irritation effect2. Bupivacaine (sensorcaine) – infiltration, peripheral nerve block & epiduralAdvantages: Duration is 2-3 times longer than lidocaine
Stages of General Anesthesia:Stage I Beginning anesthesia – feeling of warmth, dizziness & detachment may be experienced, unable to move extremities easily, experiences roaring, ringing & buzzing in the ears.Stage II Excitement – characterized by struggling, shouting, laughing, crying, increased pulse and irregular respirations. Pupils dilate but contract to light.
Stages of AnesthesiaStage III Surgical Anesthesia– patient is unconscious and lies quietly on the table, surgical procedure begins. Pupils are small but contract when exposed to light. Respirations are regular, pulse rate normal, skin is pink and slightly flushed.
Stages of AnesthesiaStage IV Medullary Depression/Danger – this stage is reached when too much anesthesia has been administered. Respiration is shallow, pulse is weak & thready, pupils dilated & non-reactive, cyanosis develops & without prompt intervention death rapidly follows.
Types of Anesthesia2. Regional Anesthesia – is a form of local anesthesia that suspends sensation and motion in a body region or part, the patient is awake and continuous monitoring is required.3. Spinal Anesthesia – is a local anesthetic injected into the subarachnoid space at the lumbar level to block nerves and suspend sensation and motion to the lower extremities, perineum and lower abdomen.
Intraoperative ComplicationsPotential Intraoperative Complications:Nausea and Vomiting – if it occurs, turn patient to side, the head of the table is lowered and a basin is provided to collect vomitus. - Suction saliva and vomited gastric contents. - Administration of anti-emetics.
Anaphylaxis – is a life threatening acute allergic reaction that causes vasodilation, hypotension and bronchial constriction. - carefully observe the patient for changes in V/S and symptoms of anaphylaxis.
Hypoxia & other Respiratory Complications – inadequate ventilation, occlusion of the airway, inadvertent intubation of the esophagus and hypoxia are potential problems of general anesthesia- Peripheral perfusion & pulse oximetry are monitored continuously. - Vigilant assessment of the patient’s oxygenation status is a primary function of the anesthesiologist or anesthetist or circulating nurse.
Hypothermia – body temperature below 36.6- caused by low temperature in OR, infusion of cold fluids, inhalation of cold gases, open body wounds, decreased muscle activity and advanced age.Malignant Hyperthermia – is an inherited muscle disorder chemically induced by anesthetic agent. - Susceptible people include those with strong and bulky muscles, a history of muscle cramps or muscle weakness and unexplained temperature elevation.
Pathophysiology of Malignant HyperthermiaHalothane, Enflurane (GA gases), Succinylcholine (muscle relaxant), Stress Muscle cell activity Muscles cells composed of inner fluid (sarcoplasm) and Outer surrounding membraneCalcium (essential factor in muscle contraction) is normally stored in sarcoplasm Nerve impulses stimulate the muscle Calcium is released, allowing contraction to occur Pumping action mechanism return calcium to the sac so that muscle can relax
Pathophysiology of Malignant HyperthermiaMalignant Hyperthermia, this mechanism is disruptedCalcium ions accumulate causing clinical symptoms of hypermetabolismIncreases muscle contraction (rigidity), hyperthermia Damage to the Central Nervous system
Clinical Manifestation:1. Tachycardia >150 beats/min. (earliest sign)2. Hypotension3. Decreased cardiac output4. Oliguria5. Body temperature >40 Celsius (late sign)6. Cardiac arrest
Medical Management:1. Discontinuing the anesthesia and surgery2. Administration of a muscle relaxant and Sodium Bicarbonate3. Decrease body temperature4. Correct electrolyte imbalanceNursing Management:- Identify patient’s at risk, recognize the signs & symptoms, have appropriate medications and equipment available.
Disseminated Intravascular Coagulopathy( DIC )- is a life-threatening condition characterized by thrombus formation and depletion of select coagulation proteins.
Patient Position on the Operating Table:1. Dorsal recumbent – flat on the back, used for most abdominal surgeries.2. Trendelenberg position - the head & body are lowered, used for surgery on the lower abdomen and pelvis.
3. Lithotomy position – patient positioned at the back with the legs and thighs flexed used for perineal, rectal and vaginal surgical procedures.4. Sims or lateral position – patient positioned on the non- operative side, used for renal surgery.
Preparation of the Operative Site-Skin preparation (skin prep) beginsbefore the patient arrive in the OR.Purpose:- is to render the surgical site as free aspossible from transient and residentmicroorganisms, dirt, and skin oil so theincision can be made through the skinwith minimal danger of infection from this source.
DRAPINGDraping - is the procedure of covering the patient and surrounding areas with a sterile barrier to create and maintain an adequate sterile field.
Surgical InstrumentsImportant Nursing Consideration: Surgical instruments are designed to provide the tools the surgeon needs for its maneuver, they are classified by their functions whether small, short, long, straight, curve, sharp or blunt. All surgical instruments should be used for their intended purposes only and should not be abused.
Parts of the Surgical Instrument Finger Ring JawsRatchets Tip Shank Boxlock/Hinge Joint
Classification of Instruments:1. Cutting and Dissecting – instruments that have sharp edges, used to dissect, incise, separate, cut and excise tissues.Nursing Responsibilities: 1. These instruments should be kept separate from other instruments. 2. Demand careful handling at all times.Examples: Scalpels, Blades, Scissors, Knives, Bone cutters, Curettes and Biopsy forceps
2. Grasping and Holding – instruments used to grasp or hold tissues (soft or hard) during the surgical operation.Examples: Thumb forceps, Tissue forceps, Allis forceps, Babcock forceps, Tenaculum, Bone holders
3. Clamping or Occluding – instrumentsused to apply pressure or occluding blood vessels to prevent bleeding.Examples: Kelly/Clamps, Pean, Ochsner, Vascular mixter
Mosquito Clamp Kelly / Clamp Vascular Mixter
4. Retracting or Exposing – instruments used to pull aside tissues, muscles & other structures for exposure of the surgical site. Types: a.) Handheld retractor b.) Self-retaining retractor Examples: Balfour, Army/Navy, Richardson, Malleable, Hooks and Deaver
Army-Navy Balfour / Self-retaining
Deaver Richardson Double-ended Richardson
5. Suturing and stapling– instruments used to close/suture the tissues and other structures of the operative site.Examples: Needle holder, free needles (round or cutting), Atraumatic needle and staplers
6. Viewing Instruments – used to view the operative site.Examples: Speculum and Endoscopes
7. Suctioning and Aspirating – instruments used to suction blood and other body fluids on the operative site.Examples: Poole Suction, Cannula, Trocar, Yankeur suction, Frazier Suction
Yankeur SuctionFrazier Poole Suction
8. Dilating and Probing – dilating instruments are used to enlarge orifice and ducts while a probe is used to explore a structure or to locate an obstructionExamples: Common bile duct dilators, esophageal dilators, Probes
Hegars Probes Dilators
9. Accessory instruments – used in addition to basic instruments.Examples: Towel clips, Bovie pencil, Ruler
Towel Clips Cautery Pad Surgical Ruler Cautery CordKidney Basin Bipolar Cautery Tip
Key Points in handling the instrument:1. Scrub person counts all instruments & sharps with circulating nurse (before and after) in the procedure.2. Never pile the instruments on top of each other.3. Know the name & use of the instrument.4. Handle the instrument individually.5. Hand the surgeon/asst. surgeon the correct instrument.6. Pass the instrument firmly & decisively.7. Careful handling of sharp instruments at all times.
Objective of Postoperative Period:1. Maintain adequate body system functions.2. Restore homeostasis3. Alleviate pain and discomfort4. Prevent postoperative complications5. Ensure adequate discharge planning and teaching
Post-Anesthesia Care UnitPostanesthesia Care Unit (PACU) – is located adjacent to the operating rooms, patients under anesthesia are placed in this unit for easy access to experienced, highly skilled nurse, anesthesiologists, nurse anesthetist, surgeons and special equipments & medications. - PACU is kept quiet, clean & free of unnecessary equipments & well ventilated.
Phases of PACU:1. Phase I PACU – used during the immediate recovery phase and intensive nursing care is provided2. Phase II PACU – is reserved for patients who requires less frequent observation and less nursing care - the patient is prepared for discharge.
Admitting Patient to PACU:1. Anesthesiologist or anesthetist is responsible in transferring the patient from the O.R. to the PACU2. Avoid unnecessary body exposure.3. Avoid rough handling4. Avoid hurried movement & rapid changes in position
5. Nurse who admits patient to the PACU reviews the following information: a. Medical diagnosis and type of surgery performed b. Pertinent past medical history & allergies c. Patient’s age and general condition, airway patency & vital signs d. Anesthetics & other medication used in the procedure
Nursing Management in the PACU:Assessing the Patient a. Appraise air exchanges status & note skin color. b. Verify & identify operative status & surgeon. c. Assess neurologic status (LOC) d. Examine operative site & check dressings
e. Perform safety checks– good body alignment, side rails &restraints for IVF & blood transfusionf. Require briefing on problemsencountered in ORMaintaining a Patent Airwaya. Lateral position with neck extendedb. Keep airway in place until fully awakec. Suction secretions
d. encourage deep breathinge. administer humidified oxygen as ordered Maintaining Cardiovascular Stability a. Monitor VS and report abnormalities b. Observe signs & symptoms of shock and hemorrhage
Classic signs/symptoms of shock: 1. Pallor 2. Cool & moist skin 3. Rapid Breathing 4. Cyanosis of the lips, gums & tongue 5. Rapid, weak, thready pulse 6. Decreasing pulse pressure 7. Hypotension & concentrated urinec. Promote comfort & maintain safetyd. Continuous monitoring until patient iscompletely out of anesthesia
e. Recognize & minimize factors that may affect the patient in PACU.Relieving Pain & Anxiety a. Opioid analgesics administration b. Allow family member to visit PACU Controlling Nausea & Vomiting a. Administration of anti-emetics( metoclopramide (plasil), promethazine )
Determining Readiness for Discharge from the PACU:1. Stable vital signs2. Orientation to person, place, events and time3. Uncompromised pulmonary function4. Pulse oximetry readings indicating adequate blood oxygen saturation5. Urine output at least 30 cc/hr6. Nausea & vomiting absent or under control7. Minimal pain
Modified Aldrete Scoring System – determine the patient’s general condition and readiness for transfer from PACU, it allows more objective assessment at regular interval.
Shock – response of the body to a decrease in the circulating blood volume which results to poor tissue perfusion & inadequate tissue oxygenation (tissue hypoxia)1. Hemorrhage – copious escape of blood from the blood vessel Capillary: slow, generalized oozing Venous: dark in color and bubble out Arterial: spurts & is bright red in color
Clinical Manifestations: 1. Apprehension, restlessness, thirst, cold, moist, pale skin 2. Deep & rapid RR, low body temperature 3. Low cardiac outputMedical Management: 1. Vitamin K, Hemostan 2. Ligation bleeders, pressure dressing, BT & IV fluids
2. Femoral Phlebitis / Deep Thrombophlebitis – often occurs after operation on the lower abdomen or during the course of septic conditions as ruptured ulcer or peritonitis. Etiologic factors: 1. Injury: damage to vein 2. Hemorrhage 3. Prolonged immobility 4. Obesity / Debilitation
Nursing Management: (Active Intervention)1. Bed rest, elevate affected leg with pillow support2. Wear anti-embolic support hose from the toes to the groin3. Avoid massage on the calf of the leg4. Initiate anticoagulant therapy as ordered
Preventions:1. Hydrate adequately (to prevent hemoconcentration)2. Leg exercises and ambulate early3. Avoid any restricting devices4. Preventing use of bed rolls, knee gatches, dangling over the side of the bed with pressure on popliteal area
3. Wound Infections Etiologic Factors: a. Staphylococcus aureus b. Escherichia coli c. Proteus vulgaris d. Pseudomonas aerogenosa e. Anaerobic bacteria
Clinical Manifestations:1. Redness, swelling, pain, warmth2. Pus or other discharges on the wound3. Foul smell from the wound4. Elevated temperature, chills5. Tender lymph nodes on the axilla or groin
Rule of thumb1. Fever 1st 24 hours – Pulmonary infection2. Within 48 hours – Urinary Tract Infection3. Within 72 hours – Wound InfectionPreventive Interventions:1. Housekeeping cleanliness in the OR2. Strict Aseptic Technique3. Antibiotic therapy
4. Wound Complications Kinds 1. Hemorrhage / Hematoma 2. Wound dehiscence – disruption in the coaptation of wound edges 3. Wound Evisceration – dehiscence with outpouching of abdominal organs
Nursing Management:1. Apply abdominal binder2. Encourage proper nutrition3. Keep in Bed4. Stay with client, have someone call M.D.5. Cover exposed intestine with sterile, moist saline dressing6. Supine or semi-fowlers, bend knees torelieve tension on abdominal muscle
6. Intestinal Obstruction (3rd – 5th Postop day) – Loop of intestine may kink due to inflammatory adhesionClinical Manifestation: 1. Intermittent sharp, colicky abdominal pains 2. Nausea and vomiting (fecaloid) 3. Abdominal distention, hiccups 4. Diarrhea, shock & death
Nursing Management: 1. NGT insertion 2. Administer electrolyte / IV as ordered 3. Prepare for possible surgical intervention7. Hiccups – intermittent spasms of the diaphragm causing a sound “hic” that result from the vibration of closed vocal cords as air suddenly into the lungs
Etiologic Factor: 1. irritation of phrenic nerve between the spinal cord and terminal ramifications on undersurface of the diaphragm.Nursing Management: 1. Remove the cause 2. NGT for abdominal distention 3. Hold breath while taking a large swallow of water / Metoclopramide administration 4. Breath in and out paper bag (CO2)
Promoting Home and Community-Based Care:1. Teaching Patient’s self care a. Give written instructions on medications, medical check-ups, wound care, activity & diet. b. Provide the nurse and surgeon’s number2. Continuing Care a. Assess patient’s physical status (surgical incision, respiratory, cardiovascular & pain management)
3. Previous teachings is reinforced as needed4. Change the wound dressings, monitor the drainage system & administer medications5. Patient reminded of the importance of follow-up appointments.