COSMETIC</li></ul>An extensive means used to diagnosed a medical problem.<br />Cholecystectomy<br />Surgery to change a physical feature.<br />
4. Laparoscopy<br />5. Removal of tissue for diagnostic purposes.<br />6. Replacement of defective tissue to restore function<br />7. Appendectomy<br />8. Removal of tumor that relieves symptoms but doesn’t cure a problem.<br />9. Noselifting<br />10. Below knee amputation<br />
CARE OF PATIENT REQUIRING SURGERY<br />OPERATING ROOM CONCEPTS<br /> <br />1. PRINCIPLES OF STERILE TECHNIQUE<br />The patient is the center of the sterile field, which includes the areas of the patient, the<br /> operating table and furniture covered with sterile drapes, and the personnel wearing the OR attire. Strict adherence to sound principles of sterile technique and recommended practices is mandatory for the safety of the patient. This adherence reflects one’s surgical conscience.<br /> <br />Delfin,s<br />
PRINCIPLES:<br />Sterile persons have scrubbed and are gowned and gloved; unsterile persons have not.<br />Only sterile items are used within the sterile field.<br />Gowns are considered sterile only from the waist to shoulder level in front and the sleeves.<br />Tables are sterile only at table level.<br />Delfin,s<br />
5. Persons who are sterile touch only sterile items or areas; Persons who are not sterile touch only unsterile items or areas.<br />6. Edges of anything that encloses sterile contents are considered unsterile.<br />7. Sterile field is created as close as possible to time of use.<br />8. Sterile areas are continuously kept in view.<br />9. Sterile persons keep well within the sterile area.<br />Delfin,s<br />
10. Sterile persons keep contact with sterile areas to a minimum.<br />11. Unsterile persons avoid sterile areas.<br />12. Destruction of integrity of microbial barriers results in contamination.<br />13. Microorganisms must be kept to an irreducible minimum<br />
SURGICAL CATEGORIES <br />Surgical procedures are categorized according to their purpose, the degree of risk to the person, and their urgency. Risk factors are also taken into consideration.<br />
PURPOSE<br />Diagnostic Surgery– makes it possible to verify a suspected diagnosis (ex. Biopsy)<br />Exploratory Surgery– makes it possible to estimate the extent of disease to confirm a diagnosis (ex. Exploratory laparotomy)<br />
Curative Surgery – involved removing or repairing of diseased, damaged or congenitally malformed organs or tissues. <br />Ablative surgery – involves removing diseased organs (ex. Kidney)<br />Reconstructive surgery – is a partial or complete restoration of a damaged organ or tissue to its original appearance and function. (Ex. Plastic surgery of the face following a major burn)<br />Constructive Surgery – repairs a congenitally defective organ improving its function or appearance.<br />
Palliative Surgery– relieves symptoms but does not cure the underlying disease. <br />(Ex. Nerve supplying a diseased organ may be remove to alleviate severe pain)<br /> <br />
DEGREE OF RISK<br />Major Surgery – extensive, may be prolonged, and may involve a significant loss of blood and involves the greatest risk of complications. (Ex. Nephrectomy)<br />Minor Surgery – generally not prolonged, leads to few serious complication and involves less risk. (Ex. Skin biopsy and Excision of digital cystic neuroma) <br />
URGENCY<br />Emergency Surgery –done immediately to:<br />Maintain life<br />Maintain organ or limb function<br />Remove a damaged organ or limb<br />Stop hemorrhage<br />Imperative OR Surgery – needs to be completed within 24 hours.<br />Planned or elective – is necessary for the person’s well being but is not urgent.<br />Optional – requested by the person generally for aesthetic or psychological reasons.<br /> <br />
SURGICAL RISK<br />Surgical risk is the probability of morbidity or death from surgery. This extends<br /> throughout the perioperative period from preoperative preparation through postoperative <br /> convalescence.<br />
GENERAL RISK FACTORS:<br />Age<br />Obesity<br />Immobility<br />Malnutrition<br />Emergencies requiring surgery<br />Endocrine related conditions<br />
The degree of surgical risk depends on:<br /><ul><li>Nature, occasion and duration of the condition
Available professional resources</li></li></ul><li>ASSESSMENT<br />Both surgery and anesthesia produce changes in the body and the patient must be in the best possible physical condition to withstand these changes. A history of the patient’s past and present illness is obtained and a complete physical examination including laboratory tests is made to ascertain that patient’s physical status and to discover coexisting diseases that might alter the patient’s response to surgery. <br /> <br /> <br /> <br />
Client profile.<br />Age: Elderly clients are more likely to have chronic health problems, as well as age-related factors; and infants have more difficulty maintaining homeostasis than adults and children.<br />Obesity: predisposes client to postoperative complications of infection and wound dehiscence.<br />
OLDER ADULTS CARE FOCUS<br />Preoperative and Postoperative Considerations<br /> Elderly clients are at increased risk because of the decreased response of the immune system (which delays healing) and the increased incidence of chronic diseases.<br />Cardiovascular: decreased cardiac output and peripheral circulation along with arrhythmias and increased incidence of arteriosclerosis and atherosclerosis can lead to hypotension or hypertension, hypothermia, and cardiac problems<br />
Respiratory: decreased vital capacity, reduced oxygenation, and decreased cough reflex can lead to an increased risk of atelectasis, pneumonia, and aspiration.<br />Renal: decreased renal excretion of wastes and renal blood flow along with increased incidence of nocturia can lead to fluid overload, dehydration, and electrolyte imbalance.<br />Musculoskeletal: increased incidence of arthritis and osteoporosis can lead to trauma on bones and joints with positioning in the operating room, of pressure points and limbs that are not padded.<br />Sensory: decreased visual acuity and reaction time can lead to safety problems associated with falls and injuries<br />
The older client may require repeated explanation, clarification, and positive reassurance. Elderly clients often have poor nutritional status, which can directly influence healing and postoperative recovery.<br />
Preoperative interview.<br />a. Chronic health problems and previous surgical procedures<br />b. Past and current drug therapy, including over-the-counter medications.<br />c. History allergies and dietary restrictions.<br />d. Client's perception of illness and impending surgery.<br />e. Discomfort or symptoms client is currently experiencing.<br />f. Religious affiliation.<br />g. Family or significant others.<br />
Psychosocial needs:<br />Fear of the unknown is the primary cause of preoperative anxiety.<br />Spiritual needs: ask for clergy or priest for guidance.<br />
Medications: may predispose client to operative complications.<br />a. Anticoagulants: potentiate bleeding.<br />b. Antidepressants: Monoamine oxidase inhibitors increase hypotensive effects of anesthetic agents.<br />c. Tranquilizers: increase the risk of hypotension may be used to enhance anesthetic agent.<br />d. Thiazide diuretics: create electrolyte imbalance, particularly in potassium level.<br />e. Steroids: prolonged use impairs the physiological response of the body to stress.<br />
Check results of routine laboratory studies.<br />a. Complete blood count; chemistry profile.<br />b. Urinalysis.<br />c. Venereal Disease Research Laboratory (VDRL) or florescent treponemal antibody (FTA). <br />d. chest x-ray<br />e. Electrocardiogram for clients over 40 years old.<br />f. coagulation studies for clients with unknown problems or to establish a baseline.<br /> <br />
Preoperative teaching: <br />Goal is to decrease the client's anxiety and prevent postoperative complications.<br />Preoperative teaching content.<br /> a. Deep breathing and coughing exercises.<br /> b. turning and extremity exercises.<br /> c. pain medication policy.<br /> d. Adjunct equipment used for breathing: nebulizer, oxygen mask spirometer.<br /> e. Explanation of NPO (nothing by mouth) policy.<br /> f. Anti-embolic stockings and/or pneumatic compression device to decrease venous stasis.<br />
Pediatric implications in preoperative teaching.<br />a. Plan the teaching content around the child's developmental level and previous experiences.<br />b. Use concrete terms and visual aids.<br />c. Plan teaching session at a time in the child's schedule when he or she will be most receptive to learning.<br />d. Use correct terms for body parts and clarify terms with which the child's is unfamiliar.<br />e. Introduce anxiety-provoking information last (increase anxiety may decrease comprehension)<br />f. Use role playing to either explain procedures to the child or to allow the child to do a return demonstration.<br />g. Fear of anesthesia is very common in children.<br />h. Include the parents in the teaching process<br />
PHYSIOLOGIC PREPARATION<br />RESPIRATORY PREPARATION<br /><ul><li>Routine radiographs of the chest are taken to be sure that the patient does not have any lung disease that would complicate the operative course or be aggravated by anesthesia. If the patient is an elderly, a measure of the vital capacity may be taken. This precaution is taken because it is sometimes difficult for the elderly patient to obtain enough oxygen, the rib cage having become firmer and alterations have occurred in all the tissues of the respiratory tract, particularly the lung parenchyma.
Patients with chronic obstructive pulmonary disease will usually have pulmonary function test and blood gas studies prior to surgical intervention</li></li></ul><li>CARDIOVASCULAR PREPARATION<br />An electrocardiogram (ECG) is usually ordered for adult surgical patient and particularly for patients with a history of cardiac diseases. The ECG is especially helpful in determining cardiac damage or in interpreting arrhythmias. <br />Blood tests such as CBC, Hgb determination and bleeding and clotting time determination will help ascertain whether the patient has chronic infection or signs of anemia or other blood dyscracia. If major surgery is anticipated, blood typing and cross matching including determination of the Rh factors is always done so that a transfusion of blood may be given at once if needed.<br />A blood sugar test is done beyond middle age to rule out the presence of mild or incipient diabetes such if present and untreated may lead to such post-operative complication as delayed wound healing and infections.<br />
RENAL PREPARATION<br />The patient’s urine is always examined preoperatively to detect the presence of urinary tract infection or any other disease condition that may become a serious problem during and after the operation. <br />(Ex. Presence of sugar – may indicate Diabetes Mellitus)<br />
Physical preparation of client.<br />1. Skin preparation: purpose is to reduce bacteria on the skin (may be done in surgical suite or in the unit).<br /> a. area of preparation is always longer and wider than area of incision.<br /> b. Antiseptic soap is used to cleanse area.<br /> c. Area may or may not be shaved.<br />2. Gastrointestinal preparation.<br /> a. Food and fluid restriction: 6 to 8 hours surgery or NPO at midnight before surgery.<br /> b. Enemas or cathartics: may be administered the evening before surgery to prevent fecal contamination in the peritoneal cavity.<br />3. Promote sleep and rest: sleeping medication may be given to promote rest (e.g., barbiturate).<br />
Legal implications.<br />Each surgical procedure must have the voluntary informed, and written consent of the client or the person legally responsible for the client.<br />Physician: gives the client a full explanation of the procedure, including complications, risks, and alternatives.<br />Client's informed consent record (permit) must be signed by the physician, the client,and a witness (e.g., usually the staff nurse).<br />
The signed consent record (permit) is part of the permanent chart record and must accompany the client to the operating room <br />The signed consent protects that hospital and the surgeon against claims that unauthorized surgery has been performed and that the patient was unaware of the potential risk of complication involved. This also protects the patient from undergoing unauthorized surgery.<br />Signed consent is necessary for each procedure. However, adults sign their own operative permit unless they are unconscious or mentally incompetent. In such case a guardian or relative signs the form. If the relative or guardian is out of state, the physician can secure consent over the telephone in the presence of one or two witnesses on the same line. If no relative can be found, the facility administrator will take responsibility. <br />Children and patients under 18 are considered minor and must be signed for by an adult, preferably a relative. <br />
Day of Surgery <br />A. Nursing responsibilities.<br />Routine hygiene care.<br /><ul><li> Vital signs within 4 hours of surgery.
Remove jewelry; wedding bands may be taped on finger.
Determine whether dentures and removable bridge work need to be removed before surgery.
Continue NPO status.</li></li></ul><li><ul><li>Check client's identification for two identifiers.</li></ul> a. The first identifier should reliably identify the patient for whom service or treatment is intended, for example, the client's name.<br /> b. The second identifier is used to match the service or treatment to that individual, for example, the client's hospital identification number.<br /><ul><li>Check skin preparation.
Identify family and significant others who will be waiting information regarding client's progress.
Check the chart for completeness regarding laboratory reports, consent form, significant client observations, history, and physical exam records.
Allow parent to accompany child as far as possible</li></li></ul><li>B. Preoperative medications<br />1. Purpose.<br /> a. Induce anesthesia rapidly and pleasantly.<br /> b. Reduce anxiety.<br />2. Nursing responsibilities.<br /> a. confirm that all consent forms are signed and that the client understands the procedure.<br /> b. Ask client to void before administration of medication.<br /> c. Obtain baseline vital signs.<br /> d. Administer medication 45 minutes to 1 hour before surgery or as ordered.<br /> e. raise the side rails and instruct the client not to get out of bed.<br /> f. Observe for side effects of medication<br />
C. The “time out” or protocol for preventing wrong site, wrong procedure, wrong person surgery must occur in the location where the procedure is done. All members of the surgical team are involved in the positive identification of the client, the intended procedure, and the site of the procedure <br />
TRANSPORTATION TO THE OPERATING ROOM<br />The surgical patient is usually transported to the operating room on a stretcher or in some instances in a bed. The stretcher should be well maintained and in good working condition at all times. To protect the patient from falling, each stretcher should have restraint straps for over the body and side rails.<br />
POSITIONING<br />The responsibility for positioning the patient on the operating room table is one shared by the nurse, surgeon and anesthesiologist. The nurse must be aware of the position required for each surgical procedure and understand the many physiologic changes that occur as the anesthetized patient is placed in a particular operative position.<br />
Good positioning is important to:<br /><ul><li>Adequately expose the operative area.
Make the patient accessible for induction of anesthesia and administration of intravenous solution.
Minimize interference of circulation due to pressure on a body part.
Provide protection from injury to nerves due to improper positioning of arms, hands.
Provide for the maintenance of respiratory function by avoiding pressure on the chest to allow for adequate ventilation of the lungs and by holding the jaw forward to keep it from dropping on the chest.
Provide for the patient’s individuality and privacy by proper draping.</li></ul> <br />
DRAPING<br />Draping is the procedure of covering patient and surrounding areas with a sterile barrier to create and maintain an adequate sterile field during operation.<br />
DOCUMENTING<br />The patient chart is sent to the OR with the patient. The chart must be accurate and complete and should contain all pertinent information that may be needed during or after surgery. All recent vital signs are graphed to provide baseline data to compare with post-operative findings. The operative permit is attached to the chart and all laboratory, radiograph, and ECG reports must be included. All final preparations for surgery are noted such as the time the pre-operative medication was given, the time the patient voided and removal of dentures or other prosthesis. The patient’s emotional response is also noted.<br />
Anesthesia <br />A. General Anesthesia.<br />Intravenous anesthesia: used as an induction agent before the inhalation agent is administered.<br />Inhalation anesthesia: used to progress client from stage II to stage III of anesthesia.<br />
B. Regional Anesthesia: used to anesthetize one region of the body; client remains awake and alert throughout the procedure.<br /><ul><li>Topical: anesthetizing medication applied to mucous membrane or skin; blocks peripheral nerve endings.
Localinfiltration: injection of anesthetic agent; only blocks peripheral nerves around area.
Peripheralnerveblock: anesthetizes individual nerves or nerve plexuses (digital, brachial plexus); does not block the autonomic nerve fiber; medication is injected to block peripheral nerve fibers.</li></li></ul><li><ul><li>Spinalanesthesia: local anesthetics are injected into the subarachnoid space; may be used with almost any type of major procedure performed below the level of the diaphragm.
Epiduralanesthesia: anesthetic agent is introduced into the epidural space; cerebral spinal fluid cannot be aspirated.</li></li></ul><li>NURSING CARE OF THE CLIENT UNDERGOING REGIONAL ANESTHESIA<br />Problem<br />Preparation for procedure<br />Hypotension<br />Nursing Interventions<br />Explain procedure.<br />Do preoperative preparation and have surgical client sign consent form.<br />Asses client for effectiveness as anesthesia is initiated.<br /> client will remain awake throughout procedure.<br />Report BP less than 100 mm Hg systolic or any significant decrease.<br />Place client flat<br />Administer oxygen<br />Increase IV rate if client is not prone to CHF.<br />
NURSING CARE OF THE CLIENT UNDERGOING REGIONAL ANESTHESIA<br />Avoid extreme Trendelenburg position before level of anesthesia is set.<br />Evaluate client's respiratory status.<br />Have ventilatory support equipment available.<br />Antiemetics.<br />Anticipate nausea if client becomes hypotensive.<br />Suction, or position client to prevent aspiration.<br />Respiratory Paralysis<br />Nausea and Vomiting<br />
NURSING CARE OF THE CLIENT UNDERGOING REGIONAL ANESTHESIA<br />Loss of Bladder Tone<br />Trauma to Extremities<br />Headache<br />Evaluate for bladder distention.<br />Support extremity during movement.<br />Remove legs from stirrups simultaneously.<br />Ensure adequate hydration before, during, and after procedure.<br />Maintain recumbent position 6 to 12 after procedure.<br />
D. Conscious sedation: the administration of an IV medication to produce sedation, analgesia and amnesia.<br />Characteristics.<br />a. Client can respond to commands, maintains protective reflexes, and does not need assistance in maintaining an airway.<br />b. Amnesia most often occurs after the procedure.<br />c. Slurred speech and nystagmus indicate the end of conscious sedation.<br /> <br />
Nursing implications.<br />a. perform baseline assessment before procedure; implications for care are the same as those for a client receiving general anesthesia.<br />b. Client is assessed continuously; vital signs are recorded every 5 to 15 minutes.<br />c. Monitor level of consciousness; client should not be unconscious, but relaxed and comfortable.<br />d. client should respond to physical and verbal stimuli; protective airway reflexes should remain intact.<br />e. Potential complications include loss of gag reflex. Aspiration, hypoxia, hypercapnia, and cardiopulmonary depression.<br />Does not require extensive Postoperative recovery time.<br /> <br />
TRANSFERRING TO THE PACU<br />POST-OPERATIVE NURSING CARE<br />
IMMEDIATE POST-OPERATIVE CARE IN THE PACU<br /><ul><li>When the patient arrives in the post anesthesia recovery area the nurse checks the patient immediately and reports the vital information to the anesthesiologist or the surgeon. The nurse must totally evaluate the patient and record the findings. This evaluation is done every 15 minutes or more often, depending on the patient’s condition.</li></ul> <br />
AIRWAY<br />The airway is the most important item to check when the patient arrives in the recovery area. The nurse places a hand slightly above the artificial airway or the patient’s nose and mouth to feel for air exchange. The patient’s chest movements are no guarantee that adequate ventilation is occurring. If there is airway obstruction due to mucus accumulation, suction may be needed. <br /> <br />
VITAL SIGNS<br />Blood pressure and pulse rate should be compared with the intraoperative record and preoperative readings. If possible, the blood pressure cuff should be placed on the arm of the patient in a lateral position, or, if the patient has had hand, arm, or breast surgery, on the opposite arm. <br />
COLOR<br /> The nurse checks the nails, ears, lips, and general overall skin color. If pigmentation prevents an accurate evaluation, the color of the oral mucosa is checked. <br />The patient should be evaluated for the following:<br />Cyanosis<br />Pallor<br />Flushing<br />Jaundice<br />Dusky hue<br />Blotchy discoloration<br />
LEVEL OF CONSCIOUSNESS<br />The nurse should speak in normal tones and orient the patient to person, place, and time. The patient should be reassured that the operation is over and that his family knows where he is (if that is hospital policy). The nurses must watch what they say and how they say it. <br />Following are some descriptions that may be used:<br /><ul><li>Unconscious without reflexes
Conscious, alert (oriented)</li></li></ul><li>FLUID & ELECTROLYTE BALANCE<br />The nurse should know what intravenous solutions the patient has been given: amount, type, rate of administration, and any drugs added. <br />The nurse must observe the site of injection for infiltration, disconnected tubings, allergic reactions, or kinks in tubing and should know the type of needle used. The nurse should double-check the preoperative laboratory values just to be sure something was not overlooked (if so, notify the physician).<br />
DRESSINGS, TUBES, DRAINS, OR CASTS<br /><ul><li>The nurse should note the type, color, location, amount, and texture of any drainage. Dressings are usually reinforced but not changed in the recovery room unless ordered or necessary.
The physician’s orders must be followed concerning whether tubes or drains should be connected, draining, or irrigated. The nurse must know where the other end of the tube or drains is placed.
The patient’s urinary output must be checked (amount and color). At least 30 ml of urine should be excreted per hour to ensure proper kidney functioning in the average adult with no complications.
If the patient has a cast, it should be checked for pressure by noting color and temperature of the distal end of the extremity. When the patient is responsive, sensation of the extremity can be checked. </li></li></ul><li>POSITION<br />The safest position for most unconscious patient is the lateral position (if permitted). This permits more control if the patient vomits.<br />
SAFETY MEASURE<br />The side rails of the stretcher must always be up and the stretcher in the locked position. If the patient is disoriented as he wakes up, the nurse must stay with him. If this is impossible, he must be moved to a bed with padded rails. Wrist or ankle restraints are seldom used unless the arm or leg must be straight because of IV therapy. Arm boards are generally used, if possible.<br />
PHYSICIAN’S ORDERS<br />The nurse will carry out all the stat orders or orders for the patient while he is in post anesthesia recovery.<br />
COMFORT OF THE PATIENT<br />The RR or PACU nurse is extremely concerned about the patient’s comfort. Three postoperative discomforts or complaints the patient may have while in the post anesthesia recovery room are pain, vomiting, and restlessness. The nurse must first assess the nature of the problem before it can be treated. Sometimes changing the patient’s position, adjusting the dressing, or relieving the pressure area will decrease pain enough so that medication is not needed. At other times pain medication is needed but may be given in decreased dosages depending on the patient’s condition and other medications he has received. <br /> <br /> <br /> <br /> <br />
TRANSFERRING FROM PACU<br /><ul><li> Discharge of the patient from the post anesthesia care unit or recovery room is usually determined by:
Effect of surgery (some operations are more difficult for the body to adjust to)</li></li></ul><li> The patient is transported to the ward on a stretcher, or hospital bed by one ore more persons with post anesthesia recovery experience. This individual must give a complete report of the patient’s status to the ward nurse. This includes the following:<br /><ul><li>Patient’s name
Auscultate breath sounds.</li></li></ul><li>Nursing management during recovery.<br />Goal: To maintain cardiovascular stability.<br /><ul><li>Check vital signs every 15 minutes until condition is stable.
Report blood pressure that is continually dropping 5 to 10 mm Hg with each reading.
Evaluate quality of pulse and presence of dysrhythmia.
Evaluate adequacy of cardiac output and tissue perfusion.</li></li></ul><li>Nursing management during recovery.<br />Goal: To maintain adequate fluid status.<br /><ul><li>Evaluate blood loss in surgery and response to fluid replacement.
Observe amount and character of drainage on dressing or drainage in collecting containers.
Assess amount and character of gastric drainage if nasogastric tube is in place.
Evaluate amount and characteristics of any emesis.</li></ul> <br />
Nursing management during recovery.<br />Goal: To maintain incisional areas.<br /><ul><li>Evaluate amount and character of drainage from incision and drains.
Check and record status of Hemovac, Jackson-Pratt, Penrose, or any other wound drains.</li></li></ul><li>Nursing management during recovery.<br />Goal: To maintain psychological equilibrium.<br /><ul><li>Speak to client frequently in calm, unhurried manner.
Continually orient client; it is important to tell client that surgery is over and where he or she is.
Dressings are intact with no evidence of excessive drainage.
Client can maintain a patient airway without assistance.</li></li></ul><li>GENERAL POSTOPERATIVE CARE<br />Goal: To promote comfort.<br /><ul><li>Determine nonpharmacological pain relief measures.
Administer analgesic</li></li></ul><li>THANK YOU!!<br />
POSTTESTIN 10 MINUTESPREPARE YOUR QUIZ NOTEBOOK<br />
POST TEST<br />Matching type:<br />Match the term in column II to its correct definition in column I<br />Actual time or duration of the surgical procedure.<br />Clot formation with minimal or absent inflammation<br />Partial or complete loss of pain sensation with or without loss of consciousness.<br />Paralyzed intestines with absence of peristalsis<br />
5. Separation of wound edges without the protrusion of organs.<br />6. Physician who administers anesthesia and assess the client during the perioperative period.<br />7. Term used to describe the entire span of surgery.<br />8. State in which clients are free of pain, fear and anxiety while awake during a procedure.<br />9. Complete separation of wound edges with the protrusion of organs.<br />10. Rapid and progressive rise in body temperature in response to stress of surgery and some anesthetic agents.<br />