PAIN• a feeling of distress, suffering or agony caused by the stimulation of specialized nerve endings• a blend of physiological and psychological experience of events occurring within the patients body which is always unpleasant and associated with the impression of damage to the tissues
PAIN• First symptom of injury;• Indicator of a disease process• The fifth vital sign
SOURCES OF PAIN STIMULINOCICEPTORS receptors that transmit pain sensation.NOCICEPTION physiologic processes related to pain perception.
PHYSIOLOGY OF PAINFOUR PHASES OF NOCICEPTION2. TRANSDUCTION Noxious stimuli (tissue injury) trigger the release of biochemical mediators (e.g., prostaglandins, bradykinin, serotonin, histamine, stubstance P) that sensitize nociceptors.
Noxious or painful stimulation also causes movement of ions across cell membranes, which excite nociceptors.Pain medication can work at this phase: by blocking production of prostaglandins (e.g., ibuprofen) or by decreasing the movement of ions across the cell membrane (e.g., local anesthetic)
2. TRANSMISSION Neuronal action potential must be transmitted to & through the CNS before pain is perceived. Involves 3 segments before pain impulse is transmitted: 1st Segment – pain impulse travels from the peripheral nerve fiber to the spinal cord 2nd Segment – pain transmission from the spinal cord ascending to the brain via spinothalamic tracts to the brainstem and thalamus. 3rd Segment – transmission of signals between the thalamus to the somatic sensory cortex.
2 Types of nociceptor fibers cause this transmission to the dorsal horn of the spinal cord: a. C fibers – large & myelinated; carry pain impulse at a rapid rate; throbbing, dull, aching pain. b. A-Delta fibers – small & unmyelinated; carry pain sensation at a slower rate; sharp, localized pain
Pain control can take place during this process: Opioid (narcotics) block the release of neurotransmitters, particularly substance P, which stops the pain at the spinal level.
Pain Threshold – the point at which a stimulus is perceived as pain.Pain Tolerance – amount of pain a person is willing to endure; only the person determines tolerance level.
3. PERCEPTION When the client becomes conscious of pain.Pain perception occurs in the cortical structures, which allows for different cognitive-behavioral strategies to be applied to reduce the sensory & afferent components of pain.e.g., nonpharmacologic interventions such as distraction, guided imagery, & music can help direct the client’s attention away from the pain.
4. MODULATIONDescribed as “descending system”Occurs when neurons in the brain stem send signals back down to the dorsal horn of the spinal cord.These descending fibers release substances such as endogenous opioids, serotonin, norepinephrine, which can inhibit the ascending noxious impulses in the dorsal horn.
PAIN MODULATIONENDOGENOUS OPIOIDS – pain inhibiting neurochemicals2. Enkephalins Inhibits the release of substance P - a neurotransmitter that enhances transmission of pain impulses3. Endorphins More potent than enkephalins4. Dynorphins Have analgesic effect, which is 50% more potent than endorphins5. Neuromodulators Modify pain (chemical regulators)
1. SPECIFICITY THEORY There are specific nerve receptors for particular stimuli. e.g., Nociceptors – noxious stimuli (always interpreted as PAIN) Thermoreceptors – heat/cold Mechanoreceptors – pressure, pulling or tearing sensation Chemoreceptors – chemicals
PATTERN THEORYStates that pain is produced by intense stimulation on nonspecific fiber receptors, so any stimulus could be perceived as painful if the stimulation is intense enough.
GATE CONTROL THEORYStates that there is a “gate” in the spinal cord (substantia gelatinosa)When the gate is open, pain stimulus is transmitted thus pain is perceived.When the gate is closed, pain is blocked thus no pain is perceived. The gate is controlled by the balance impulse input from the small and large peripheral nerve fibers
ACCORDING TO DURATION1. ACUTE PAIN• Temporary, immediate onset• Last for less than 6 months• Eventually subside after treatment or sometimes without treatmente.g., headache, postop pain, labor pain, toothache
2. CHRONIC PAIN• Continuous, may begin gradually, persist or recur for an indefinite period of time, more difficult to manage effectively• (last 6 months or longer)
3 TYPES of Chronic Pain:b.Chronic Nonmalignant Pain e.g., low back pain, Rheumatoid A.b. Chronic Intermittent Pain e.g., migraine headachec. Chronic Malignant Pain e.g., cancer
ACCORDING TO SOURCE/ORIGIN1. CUTANEOUS PAIN• Includes superficial somatic structures located in the skin & the subcutaneous tissues• “direct pain” since the pain accurately localizes the point of disturbance• e.g., finger cut, knot hair pulled out while combing, 1st degree burn
2. DEEP SOMATIC PAIN• Includes bones, nerves, muscles & other tissues supporting these structures• Poorly localized; frequently radiates from primary site.• e.g., ankle sprain, jamming a knee
3. VISCERAL PAIN• Includes all body organs located in a body cavity• Diffuse, poorly localized, vague, dull pain• e.g., obstructed bowel, cardiovascular disease
ACCORDING TO INTENSTIY1. MILD• One that is bearable usually tolerated by the client2. SEVERE• One which is intense & usually could not be tolerated by the client
ACCORDING TO LOCATION1. RADIATING PAIN• Perceived at the source of the pain & extends to nearby tissueCardiac pain – chest, left shoulder, down the arm2. REFERRED PAIN• Felt in an area distant from the site of the stimulusMI – left arm, shoulder, or jaw painCholecystitis – back pain & angle of scapula
3. INTRACTABLE PAIN• Pain that is highly resistant to relief• Advanced Malignancy4. NEUROPATHIC PAIN• Result of current or past damage to the peripheral or CNS & may not have a stimulus, such as tissue or nerve damage.• Nerve injury that serves the hand would be perceived a pain-hand even though the injury may be at the spinal cord level.
5. PHANTOM PAIN• Painful sensation perceived in a body part that is missing
FACTORS AFFECTING PAIN PERCEPTION AND RESPONSE1. ETHNIC & CULTURAL VALUES• Filipinos are known to be sufferers who consider pain as sacrifice for sins committed.• Voicing pain – appropriate Italians inappropriate Germans (stoicism)• Mexicans/arabs – moaning/crying use to alleviate pain rather than need for intervention
2.DEVELOPMENTAL STAGES• Infants - sensitivity• Toddlers – cry & anger - threat to security & punishment• School-age – not cry or express much pain so that parents will not get angry• Adolescent – not report pain weakness• Adults – not report pain indicates poor diagnosis, weakness, failure
3. ENVIRONMENT & SUPPORT PEOPLE• Hospital environment can be associated with pain; Places that are noisy & have glaring lights can compound pain sensation4. POST PAIN EXPERIENCES• A person who has witnessed a family member who experienced severe pain may have difficulty enduring the same experience once it arises
5. MEANING OF PAIN• A woman giving birth may tolerate pain infavor of a desired baby• An athlete who undergone knee surgery to prolong his career may tolerate pain better than one who was shot by an enemy6. ANXIETY & STRESS• A person who suffers fatigue may not have a good coping with pain
2. FACES RATING SCALE3. 10 POINT PAIN INTENSITY SCALE
MISCONCEPTION & MYTHS OF PAIN• Myth: Addiction occurs with prolonged use of Morphine and Morphine derivatives• FACT: THE INCIDENCE OF ADDICTION IS LESS THAN 0.1%
• Myth: The nurse or the physician is the best judge of a clients pain.• FACT: ONLY THE CLIENT CAN JUDGE THE LEVEL & DISTRESS OF THE PAIN, THATS WHY CLIENTS SHOULD BE INCLUDED IN PAIN MANAGEMENT.
• Myth: Pain is a result not a cause.• FACT: UNRELIEVED PAIN CAN CAUSE OTHER PROBLEMS SUCH AS ANGER, ANXIETY, IMMOBILITY, RESPIRATORY PROBLEMS, & DELAY IN HEALING.
• Myth: It is better to wait until a client has pain before giving medication.• FACT: IT IS BETTER TO ROUTINELY ADMINISTER ANALGESIA TO MAINTAIN LOW LEVEL OF PAIN THAN TO “CATCH-UP” ONCE PAIN ARISES.
• Myth: Real pain has an identifiable cause.• FACT: THERE ARE ALWAYS CAUSES OF PAIN BUT SOME MAY BE VERY OBSCURE.
• Myth: The same physical stimulus produces the same pain intensity, duration and distress in the same people.• FACT: INTENSITY, DURATION, AND DISTRESS VARY WITH EACH INDIVIDUAL
• Myth: Some clients lie about the existence or severity of their pain.• FACT: VERY FEW PEOPLE LIE ABOUT THEIR PAIN
• Myth: Very young or very old people do no have as much pain.• FACT: ALL CLIENTS WITH INTACT NEUROLOGIC SYSTEM EXPERIENCE PAIN. AGE IS NO A DETERMINANT OF PAIN EXPERIENCE.
• Myth: Pain is a part of aging.• FACT: PAIN DOES NOT ACCOMPANY AGING UNLESS A DISEASE, OR AN AILMENT IS PRESENT
• Myth: If a person is asleep they are not in pain.• FACT: PAIN CAN CAUSE EXHAUSTION WHICH CAN LEAD TO CLIENTS IN PAIN TO SLEEP, BUT THEY ARE IN PAIN. SOME CLIENTS USE SLEEP AS AN ESCAPE FROM PAIN.
• Myth: If the pain is relieved by non- pharmaceutical pain relief techniques, the pain was not real anyway.• FACT: NON-PHARMACEUTICAL METHODS CAN BE EFFECTIVE IN RELIEVING PAIN.
ASSESSMENT• Ask the client about the pain and to describe it in terms of degree, quality, area, and frequency• Observable indicators of pain include: moaning; crying; irritability; restlessness; grimacing or frowning; inability to sleep, rigid posture; increased blood pressure, heart rates, or respirations; nausea; and diaphoresis• Ask the client to use a number-based pain scale (a picture-based scale may be used in children) to rate the degree of pain
PAIN MANAGEMENT Refers to the techniques usedto prevent, reduce, relieve pain.
A. NON-PHARMACOLOGIC PAIN MANAGEMENT1. PHYSICAL INTERVENTION Includes providing comfort, altering physiologic responses & reducing fears associated with pain-related immobility or activity restriction. c. CUTANEOUS STIMULATION Redirects the client’s attention to the tactile stimuli away from the pain stimuli; It releases endorphins; it stimulates large diameter A- beta sensory nerve fibers.
• MASSAGE back rub to reduce pain; stimulate client’s skin by lightly kneading, pulling or pressing with fingers, palms or knuckles.o ACCUPRESSURE Application of pressure to areas or points used in acupuncture known as Meridianso CONTRALATERAL STIMULATION Stimulating the skin opposite to the painful area.
o HEAT & COLD APPLICATION The application of heat and cold or the alternate application can soothe pain resulting from muscle strain Heat applications may include warm- water compresses, warm blankets, Aquathermia pads, and tub and whirlpool baths; may require a physician’s order
b. IMMOBILIZATION Restricting movement of body part may help manage episodes of acute pain e.g., Splint holds joints or fractured bones that maybe painful once moved
C. TRANSCUTANEOUS ELECTRICALNERVE STIMULATION (TENS) (portable, battery operated device) is a method of applying low voltage electrical stimulation directly over identified pain areas. C/I in clients with pacemakers, arrhythmias or in areas of skin breakdown.
D. ACCUPUNCTURE very thin metal needles are skillfully inserted into the body @ designated locations & @ various depths & angles Meridians – accupuncture points distributed patterns disease interrupts energy flow in the body and insertion of needles at specific points will re establish healthy energy flow.
Acupuncture Acupuncture is a traditional Chinese medicine that stimulates specific points in the body in order to restore a proper balance of various chemicals. Some people who suffer from chronic pain find thatacupuncture provides a measure of pain relief where all other methods fail. The way acupuncture suppresses pain remains a mystery. Somescientists now believe that it triggers the release of pain-relieving body chemicals called endorphins and enkephalins. Others argue that acupuncture’s pain-relieving effects are brought about by a patient’s
2. MIND-BODY INTERVENTION (Cognitive-Behavioral)A. DISTRACTION Directs away the attention of the client from the painful sensation or the negative emotional arousal associated with pain TYPES OF DISTRACTION: 1. Visual Distraction – read or watch tv 2. Auditory Distraction – humor, listen to music
MUSIC Physiologic mechanism has not been established in the use of music to relieve pain but possible theories include distraction, release of endogenous opioids, & dissociationHUMOR Believed to help increased the production of endogenous opioids endorphines, which are natural pain killers.
3.Tactile Distraction – massage, slow rhythmic breathing 4. Intellectual Distraction – card games, crossword puzzleB. RELAXATION TECHNIQUES Gradually tighten then deeply relax various muscle groups proceeding systematically from one area to the next Reduce muscle tension & anxiety
C. IMAGERY Help client visualize a pleasant experience Help distract themselves from their pain which may increase pain tolerance; produce relaxation response; diminished the source of pain (e.g.tension headache) D. MEDITATION Client sits comfortably & quietly with focused attention away from pain E.g., flow of the breath; picture image of great spiritual being or peaceful place
E. BIOFEEDBACKBiofeedback in ProgressA patient at a biofeedback clinic sits connected to electrodes on hishead and finger. Biofeedback is a technique in which patients attempt tobecome aware of and then alter bodily functions such as muscle tensionand blood pressure. It is used in treating pain and stress-relatedconditions, and may help some paralyzed patient use of their limbs.
Biofeedback in ProgressA patient at a biofeedback clinic sits connected to electrodes on hishead and finger. Biofeedback is a technique in which patients attempt tobecome aware of and then alter bodily functions such as muscle tensionand blood pressure. It is used in treating pain and stress-relatedconditions, and may help some paralyzed patient use of their limbs.
F. HYPNOSIS Hypnotic state; suggest to alter character of pain or one’s attitude toward itG. THERAPEUTIC TOUCH use hands to rearrange energy field to normalH. MAGNETS Believed that the pull of magnet increased blood flow to the region of pain, opening the NaCl channels in the cell.
1. OPIOID ANALGESICS (NARCOTIC) Derived from natural opium alkaloids & their synthetic derivatives Suppress pain impulses but can suppress respiration and coughing by acting on the respiratory and cough center in the medulla of the brain stem Can produce euphoria and sedation Can cause physical dependence
PHYSICAL DEPENDENCE means that a person experiences physical discomfort, known as withdrawal syndrome, when a drug that client has taken routinely for some time is abruptly discontinued. to avoid withdrawal symptoms, drugs that are known to cause physical dependence are discontinued gradually. Dosage or frequency of adm. is lowered over 1 week or longer.
NARCOTIC ANALGESICS MEPERIDINE HYDROCHLORIDE (Demerol) Can cause respiratory depression, tachycardia, constipation, urine retention, hypotention, and dizziness• Used for acute pain and as a preoperative medication• Contraindicated in head injuries and in the presence of increased intracranial pressure, respiratory disorders, hypotentions, shock and severe hepatic or renal didsease,
• Should not be taken with alcohol or sedative hypnotics; may increase CNS depression• To administer intravenously, dilute in at least 5 ml of sterile water or NSS for injection, then administer dose over 4 to 5 minutes CODEIN SULFATE• Also used in low doses as a cough suppressant• Can cause constipation
MORPHINE SULFATE• Can cause respiratory depression, postural (orthostatic) hypotention, urine retention, constipation, and papillary constriction• May cause nausea and vomiting because of increased vestibular sensitivity• Used to ease acute pain resulting from myocardial infarction or cancer, for dyspnea resulting from pulmonary edema, and as a preoperative medication
• Monitor intake and output and assess client for urine retention• Instruct client to avoid activities that require alertness• Have a narcotic antagonist available (e.g., Naloxone (Narcan), oxygen, and resuscitation equipment available
NARCOTIC ANTAGONISTSDescription• Use to treat respiratory depression from narcotic overdose - Naloxone (Narcan)Interventions• Monitor BP, pulse, & RR q 5 mins. initially, tapering to q 15 minutes, & then q 30 mins. until the client’s condition is stable• Attach a cardiac monitor to the client & observe cardiac rhythm
• Auscultate breath sounds• Have resuscitation equipment available• Do not leave client unattended• Monitor client closely for several hours; when the effects of the antagonist wears off,• the client may again display signs of narcotic overdose
3 Primary Types of Opioids:1. FULL AGONISTS pure opiod drugs producing maximum pain inhibition, an agonists effect. No ceiling on the level of analgesia Dose can be steadily increased to relieve pain No maximum daily dose limit Demerol, Morphine, Codeine
2. MIXED AGONISTS-ANTAGONIST can act like opioids & relieve pain (agonist effect) when given to client who has not taken any pure opioids. block or inactivate other opioid analgesics when given to client who has been taking pure opioids (antagonist effect) have ceiling dose & not recommended for use w/ terminally ill clients. Nubain, Stadol
3. PARTIAL AGONISTS have ceiling effect in contrast to a full agonist. Buprenorphine (Buprenex)Pentazocine (Talwin)
2. NON-OPIOID ANALGESICS They relieve pain by acting on peripheral nerve endings at the injury site& decreasing the level of inflammatory mediators & interfering with the production of prostaglandins at the site of injury.
ACETAMINOPHEN (TYLENOL)Description• Inhibits prostaglandin synthesis• Used to decreased pain and feverContraindications• Hepatic or renal disease, alcoholism, and hypersensitivitySide Effects• Major concern is hepatotoxicity
NSAIDs and ACETYLSALICILIC ACID (Aspirin)• NSAIDs are aspirin and aspirin-like medications that inhibit the synthesis of prostaglandins• Act as analgesics to relieve pain, as antipyretics to reduce body temperature, and as anticoagulants to inhibit platelet aggregation• Used to relieve inflammation and pain and to treat rheumatoid arthritis, bursitis, tendonitis, osteoarthritis, and acute gout
3. ADJUVANT ANALGESICSIs a medication that was developed for other than analgesia but has been found to reduce chronic pain & sometimes acute pain, in addition to its primary action. Muscle Relaxant – muscle spasm Anticonvulsants – nerve injury Corticosteroids – reduce inflammation & edema
Concept on surgeryCORRECT POSITION OF HANDS AFTER SURGICAL SCRUBBING
SURGERYas a science and an art surgery is the branch of medicine that comprises perioperative patient care encompassing such activities as pre- operative preparation, intra-operative judgement, and post-operative care of patients.
CATEGORIES & PURPOSES OF SURGERYACCORDING TO PURPOSE1. Diagnostic Performed to determine the origin & cause of a disorder or the cell type for cancer breast biopsy2. Exploratory Estimation of the extent of disease or confirmation of a diagnosis exploratory laparotomy, pelvic laparotomy
3. Curative Performed to resolve a health problem by repairing or removing the cause Classification: – Ablative Includes removal of an organ; e.g., appendECTOMY (suffix)
b.Constructive Involves the repair of congenitally damaged organ e.g., cheiloPLASTY, orchidoPEXYc.Reconstructive Involves repair of damaged organ e.g., Total joint replacement
4. Palliative Performed to relieve symptoms of a disease process, but does not cure Nerve root resection, Colostomy5. Cosmetic Performed primarily to alter or enhance personal appearance Rhinoplasty, Blepharoplasty
ACCORDING TO URGENCY1. Emergent condition is life-threatening that requires surgery at once e.g., gunshot or stab wound, severe bleeding2. Urgent performed as soon as client is stable & infection is under control; life threatening if treatment is delayed more than 24-48H e.g., appendectomy, intestinal obstruction
3. Required Client should have surgery; planned for a few weeks or months e.g., Prostatic hyperplasia w/o obstruction, Cataracts, Simple Hernia4. Elective Client will not be harmed if surgery is not performed but will benefit if it is performed e.g., Revision of Scars, Vaginal Repair
5. Optional Personal preference usually for aesthetic purposes e.g., Cosmetic surgery
ACCORDING TO DEGREE OF RISK3.Minor Procedure of less risk; generally not prolonged; leads to few complications2. Major Procedure of greater risk; usually longer & more extensive; great risk of complications
ACCORDING TO EXTENT OF SURGERY2. Simple Only the most overtly affected areas involved in the surgery e.g., Simple or Partial Mastectomy3. Radical Extensive surgery beyond the area obviously involved e.g., Radical Mastectomy, Radical Hysterectomy
SURGICAL SETTING1. INPATIENT Refers to client who is admitted to a hospital Admitted on the day of surgery (Same-day Admission – SDA)2. OUTPATIENT & AMBULATORY Refers to a client who goes to the surgical area the day of the surgery & returns home on the same day (Same-day Surgery – SDS)
PERIOPERATIVE NURSINGAssist clients and their significant others through the surgical episode,o help promote positive outcomes, and to help clients achieve their optimal level of function and wellness after surgery.Emphasis on safety & client educationUse Knowledge, judgement & skills
PREOPERATIVE PERIODBegins when the client is scheduled forsurgery & ends at the time of transfer to surgical suite
PREOPERATIVE PERIOD Focuses on client’s readiness – client education & any intervention: 1. Reduce anxiety 2. Reduce complication 3. Promote cooperation Needed before surgery to: 1. Validate & clarify information client received from surgeon or members of health team 2. Identify problems that warrant further assessment &/or intervention before surgery
PREOPERATIVE ASSESSMENTA. MEDICAL/HEALTH HISTORY Purpose of reviewing medical history is to determine operative risk.
COLLECT THE FOLLOWING DATA:1. AGE Older – risk of complication; immune system functioning; delays wound healing; frequency of chronic illness; alter operative response/risk2. DRUGS & SUBSTANCE USE o Tobacco - risk of pulmonary complications (changes in lungs & cavity) o Alcohol & illicit subs. – alter response to anesthesia & pain meds. withdrawal before surgery may lead to delirium tremens
o PRESCRIPTION & OVER THE COUNTER – affect how client reacts to operative experienceo Potential effects for reaction or serious adverse effect with some herbs & specific drugs.3. MEDICAL HISTORYo Chronic illness increased surgical risk
4. CARDIAC HISTORY o Complications from anesthesia occur often o Impair ability to withstand hemodynamic changes & alter response to anesthesia o Risk for MI during surgery higher with pre-existing cardiac problem
5. PULMONARY HISTORY o Smoker/Chronic Respiratory Problem - chest rigidity & loss of lung elasticity reduce anesthesia excretion. o Smoking - blood level of Carboxyhemoglobin which decreases O2 delivery to organs acts on cilia of pulmonary mucous membrane which lead to retain secretion & predisposes clients to pneumonia & atelectasis (reduce gas exchange & causes intolerance of anesthesia)
Chronic lung problems (asthma, emhysema, chronic bronchitis) reduce lung elasticity reduce gas exchange reduce tissue oxygenation7. ANESTHESIA o Affect readiness for surgery o those w/ complication - fear & concerns of scheduled surgery
8. DISCHARGE PLANNING o Assess client’s home, environment, self- care capabilities, support system, & anticipate post-op needs before surgery Older clients & dependent adult need transport referrals Home care nurse/health center nurse need to monitor recovery & provide instruction
B. PHYSICAL ASSESSMENTTo obtain baseline dataComplete set V/S – abnormal V/S may postpone surgery until problem is treated & condition is stable
1. CARDIOVASCULAR SYSTEMCardiac problems – 30% of surgery-related deathsHPN – common & often undiagnosed affect response to surgery Assess cardiac sounds for rate, regularity & abnormalities Hands & feet – for temp, color, peripheral pulses, capillary refill, & edemaREPORT: absent peripheral pulses, pitting edema, cardiac symptoms ( chest pain, dyspnea) for further assessment & evaluation
2. RESPIRATORY SYSTEMAge, smoking history (second handsmoke), chronic illnessOverall posture, RR, rhythm & depth, overall respiratory effort & lung expansionDocument clubbing of fingertips ( swelling base nailbeds caused by chronic lack of O2) or cyanosis
3. RENAL/URINARY SYSTEMKidney function – affects excretion of drugs & waste products including ANESTHETIC & ANALGESIC AGENTSRenal function reduced (Older client) – fluid & electrolyte balance can be altered
KIDNEY IMPAIRED: excretion of drugs & anesthetic agent Drug effectiveness may be altered Buscopan, Morphine, Demerol, Barbiturates causes confusion, disorientation, apprehension, restlessness with kidney function
4. NEUROLOGIC SYSTEMAssess overall mental status – LOC, orientation, ability to follow commands) before planning preoperative teaching & careAssess motor & sensory deficits – problems may affect type of care needed during surgical experienceRisk for falling (esp older) – evaluate mental status, muscle strength, steadiness of gait, sense of independence, ability to ambulate
5. MUSKULOSKELETAL SYSTEM Problems may interfere with positions during & after surgery. e.g., w/ Arthritis – may be able to assume surgical position but have discomfort after surgery from prolonged joint immobilization History joint replacement & document exact location of prosthesis – ensure that electrocautery pads are not place ON or NEAR area of prosthesis – cause electrical burn
6. NUTRITIONAL STATUSMalnutrition & Obesity - surgical risk metabolic rate & depletes K, Vit C & B – needed for wound healing & blood clottingMalnourished - S. CHON slows recovery & negative nitrogen balance may result from depleted CHON store - risk delayed wound healing, possible dehiscence & evisceration, dehydration & sepsis
OBESE CLIENT – often malnourished because of imbalance diet risk poor wound healing – excessive adipose (fatty) tissue few blood vessels, little collagen, nutrients needed for wound healing Stresses heart & reduces lung volume – affects surgery & recovery Need large doses of drugs & may retain them longer after surgery
7. PSYCHOSOCIAL ASSESSMENTTo determine level of anxiety, coping ability, & support system– provide information & offer support as neededDegree of Anxiety & Fears varies according: Type of surgery Perceived effects of surgery & potential outcome Client’s personalitySURGICAL THREAT – life, body image, self- esteem, self-concept, or lifestyle
FEAR of death, pain, helplessness, socio- economic status, dx of life-threatening conditions, possible disabling/crippling effects or unknownANXIETY & FEAR affect client’s ability to learn Cope & cooperate w/ teaching & operative procedures May influence amount & type anesthesia needed & may slow recovery
8. LABORATORY ASSESSMENT Provide baseline data about health & help predict potential complications OUTPATIENT – PAT (preadmission testing) 24-28 days before surgery valid unless there’s change in condition or taking drugs that can alter lab values ( Warfarin, Aspirin, Diuretics) COMMON: Urinalysis, Blood type, crossmatching, CBC, Hgb, Hct, Clotting studies (PT, platelet count), electrolyte levels, s. creatinine
Urinalysis – assess abnormal subs.- CHON, glucose, blood, bacteria Report Electrolyte imbalance to surgeon & anesthesiologist before surgery ♠ K - risk toxicity if taking digoxin - slow recovery from anesthesia - cardiac irritability ♠ K - risk dysrhythmias esp. w/ use of anesthesia K must be corrected before surgery Baseline ABG – w/ chronic pulmonary problem
9. RADIOGRAPHIC ASSESSMENTCHEST XRAY – often young healthy adults not required Determine size & shape of heart, lungs, & major vessels Determine presence of pneumonia or TB Provides baseline data in care of complication Results assist anesthesiologist in selecting anesthesia for emergency surgery
Abnormal findings alert for potential cardiac or pulmonary complication Cardiac failure, cardiomyopathy, pneumonia or infiltrates may cause cancellation or delay of elective surgeryCT SCAN OR MRI
Electrocardiogram (ECG)• Common non-invasive diagnostic test that aids evaluation of heart function by recording electrical activity• Abnormal findings alert for potential cardiac or pulmonary complication
Obtaining Informed Consent• The surgeon is responsible for obtaining the client’s consent for surgery• Ensure that informed consent has been signed and that any additional necessary consents (e.g., limb disposal) have been obtained & you serve as a WITNESS to the signature, not to the fact that the client is informed• Sedation should not be administered to the client before he or she signs the consent
Nurse: Not responsible for providing detailed information about the surgical procedure ROLE: to clarify facts that have been presented by the physician & dispel myths that the client or family may have about the surgical procedure
• The patient should personally sign the consent unless she/he:• MINOR – A PARENT OR LEGAL GUARDIAN• EMANCIPATED MINOR (married or independently earning a living – he/she may sign A MINOR WHO HIS THE PARENT OF AN INFANT OR CHILD WHO IS HAVING A PROCEDURE - he or she may sign for his/her child ILLITERATE- HE/SHE MAY SIGN WITH AN “X”, AFTER WHICH THE WITNESS WRITE “PATIENT MARK”
CANNOT WRITE: Sign w/ an X with 2 witnessess Emergency: Phone or telegram authorization but follow-up with written consent ASAP Lifethreatening: With effort to contact person w/ medical power of atty., consent is desired but not essential Written consultation by 2 physician not assoc. w/ the case ( formal consultation legally supports decision for surgery until appropriate person signs the consent)
No family: Courts appoints legal guardianBlind: May sign his own consent with 2 witnessessOther language: Translator and a 2nd witness A WITNESS VERIFIES THAT THE CONSENT WAS SIGNED WITHOUT COERCION AFTER THE SURGEON EXPLAINED THE DETAILS OF THE PROCEDURE ( physician, nurse, facility employee, family members (as established by policy)
Advance DirectiveProvides legal instruction to healthcare providers about the client’s wishes & are to be followed.Encompasses durable power of attorney and living willLiving will or durable power of attorney as mandated by The Patient self- determination act. (USA)
Nutrition• Assess the surgeons orders regarding the intake of food and fluids before surgery and for the administration of intravenous fluids• NPO - NO eating, drinking & smoking (nicotine stimulates gastric secretion) for 8 hours before the surgical procedure – to decrease risk of aspiration• Fasting > 8H – possible fluid & electrolyte imbalance & blood glucose levels• Emphasize the IMPORTANCE OF ADHERENCE - failure result in cancellation or increase risk of aspiration during surgery
Elimination• If the client is to undergo intestinal or abdominal surgery, an enema, a laxative, or both may be prescribed for the night before surgery – to prevent injury to colon & reduce number of intestinal bacteria• The client should void immediately before surgery• FC is in place, it should be emptied immediately before surgery & the amount & quality of UO documented
Surgical Site• Prepare to clean the surgical site with a mild antiseptic soap the night before surgery, as prescribed• – reduces contamination & no. of organism @ site• Hair should be shaved only if it will interfere with the surgical procedure and only if prescribed• Skin prep is the first step in prevention of surgical wound infection.
Medications• Note medications client is taking, including herbal products; some medications (e.g., antihypertensives and antidysrhythmics) can interact with anesthetic agents• Check with the surgeon regarding administration of prescribed medications; some medications (e.g., cardiac medications) may be administered with a sip of water• If the client has diabetes mellitus, check with the surgeon regarding administration of an oral hypoglycemic or insulin
Preoperative Teaching• Reduce apprehension and fear• Increased cooperation & participation in care after surgery• Decrease complications
Client Teaching• Describe what client should expect after surgery• Instruct client to notify nurse of pain after surgery and reassure client that pain medication will be prescribed, to be given as the client requests• Instruct client not to smoke for at least 24 hours before surgery• Instruct client in deep-breathing and coughing techniques, the use of incentive spirometry and its importance
Chest Physiotherapy Percussion and vibration over the thorax to loosen secretions in the affected area of the lungsContraindications• When bronchospasm occurs by its use stop the procedure • Rib fracture• History of pathological fractures • Chest incisions
LEG AND FOOT EXERCISES• Instruct client in leg and foot exercises to prevent venous stasis of blood and facilitate venous blood return [Figure]
• SplintingProvide support, promotes a feeling of security, & reduces pain during coughing • CoughingMay be performed along with deep breathing q 1-2H after surgeryTo expel secretions, keep lungs clear, allow full aeration, prevent pneumonia & atelectasis“Do Not Cough” – hernia repair
• Inform client of any invasive devices that may be needed after surgery (e.g., nasogastric tube, drain, Foley catheter, epidural catheter, intravenous or subclavian line)• Instruct client not to pull on invasive devices and reassure client that they will be removed as soon as possible
Psychosocial Preparation• Assess clients anxiety level• Address clients questions and concerns regarding surgery• Give client privacy to prepare psychologically for surgery
Preoperative Checklist• Review checklist to ensure that each item is addressed before client is transported to surgery• Ensure that client is wearing an identification bracelet• Assess client for allergies• Ensure that prescribed laboratory-test results and electrocardiography and chest- radiography reports are documented in the clients record
• Remove clients jewelry, makeup, dentures, hairpins, nail polish, glasses, and prostheses as appropriate• Document that valuables have been given to clients family members or locked in the hospital safe• Monitor and document clients vital signs
3. Prosthesis or Dentures- should be removed to prevent obstruction in the airway
2. GIT /Elimination- insertion of indwelling catheter (foleycatheter), administration of cleansing enema- this is to ensure thatneither of the bladder, nor the bowel is distended during surgery- nutrition/ hydration-- NPO 8 hours before surgery, but some institution may allow clearliquids 3-4 hours before-- IVF infusion may be started to ensure adequate hydration
• Tell the client that he or she will feel drowsy shortly after the medications are administered• After administering the preoperative medications, keep the client in bed with the side rails up and place the call bell next to the client• Instruct the client not to get out of bed and to call for assistance if needed
Transporting the client to the operating room• Per stretcher – enough help for safety• Cover with blanket – protect from drafts• Place side rails and restraint above knee• Record accompanies client• Smooth as possible – sedated- to prevent nausea vomiting• Avoid rapid walking or swinging around corners• Prepare room for post operative care
Arrival in the Operating Room• When the client arrives in the operating room, the operating-room nurse will check the identification bracelet against the clients verbal response• The clients chart will be checked for completeness and reviewed for informed consent• The surgeons orders will be reviewed to ensure that they were carried out
INTRAOPERATIVE PERIODbegins when the client is transferred tothe operating room bed and ends whenthe client is transferred to an area forrecovery from anaesthesia
Key words of OR practiced are: 1. Caring 3. Discipline 2. Conscience 4. Technique Optimal client care requires an inherent surgical conscience, self-discipline & the application of principles of aseptic & sterile techniqueSURGICAL CONSCIENCE – “Surgical Golden Rule”“Do unto the patient as you would have others do unto you.”
Surgical Conscience One’s inner voice for the conscientious practice of asepsis & sterile technique @ all times. Conscience dictates that appropriate action to be taken, whether the person is with others or alone & unobserved Foundation for the practice of strict aseptic & sterile technique
ASEPTIC TECHNIQUE– to maintain asepsis (absence of microorganism that caused diseased) STERILE TECHNIQUE Method by which contamination which microorganism is prevented to maintain sterility throughout the operative procedure. Is the responsibility of everyone caring for the client in the OR.
PRINCIPLES OF STERILE TECHNIQUE ARE APPLIED:1. In preparation for operation by sterilization of necessary materials & supplies2. In preparation of operating team to handle sterile supplies & intimately contact wound3. In maintenance of sterility & asepsis throughout operative procedure4. In terminal sterilization & disinfection at conclusion of operation
PRINCIPLES OF STERILE TECHNIQUE1. ONLY STERILE ITEMS ARE USED WITHIN STERILE FIELD If you are in doubt about the sterility of anything, consider it not sterile.c. If sterilized package is found in a nonsterile workroom.d. If uncertain about actual timing or operation of sterilizer. Items processed in a suspect load are considered unsterile.e. If unsterile person comes into close contact with a sterile table & vice versa.
d. If sterile table or unwrapped sterile items are not under constant observation.a. If sterile package wrapped in material other than plastic or moisture-resistant barrier becomes damp or wet. Humidity in storage area or moisture on hand may seep into package.b. If the integrity of the packaging material is not intact.c. If sterile package wrapped in a pervious muslin or other woven material drops to the floor or other area of questionable cleanliness. These material allow implosion of air into package. A dropped package is considered contaminated.
If the wrapper is impervious & the area of contact is dry, the item may be transferred to the sterile field. Packages that have been dropped on the floor should not be put back into sterile storage.2. GOWNS ARE CONSIDERED STERILE ONLY INFRONT FROM CHEST TO LEVEL OF STERILE FIELD & THE SLEEVES FROM ABOVE ELBOWS TO CUFFa. Self-gowning & gloving should be done from a sterile surface for this purpose only to avoid dripping water onto sterile supplies or sterile field.
b. Stockinet cuffs of gown are enclosed beneath sterile gloves. Stockinet is absorbent & will retain moisture, thus this part of gown does not provide a microbial barrier.c. Sterile persons keep hands in sight @ all times & at or above level of waist or sterile field.d. Hands are kept away from face. Elbows are kept close to sides. Hands are never folded under arms because of perspiration in axillary region. Neckline, shoulders, & back also may become contaminated with perspiration.
e. Sterile persons are aware of height of team members in relation to each & the sterile field. Changing levels @ sterile field is avoided. Gown is considered sterile only down to highest level of sterile tables. If a sterile person must stand on a platform to reach operative field, platform should be positioned before this person steps up to draped area. Sterile person should sit only when entire procedure will be performed @ this level.
3. TABLES ARE STERILE ONLY AT TABLE LEVEL a. Only top of a sterile draped table considered sterile. Edges & sides of drapes extending below table level are considered unsterile. b. Anything falling or extending over table edge, such as a piece of suture, is unsterile. Scrub person does not touch part hanging below table level. c. If unfolding a sterile drape, the part that drops below table surface is not brought back up to table level. Once placed, draped is not moved or shifted. d. Cords, tubings, etc., are secured on the sterile field with a non-perforating device to prevent them from sliding over the table edge.
4. PERSON WHO ARE STERILE TOUCH ONLYSTERILE ITEMS OR AREAS; PERSONS WHO ARENOT STERILE TOUCH ONLY UNSTERILE ITEMSa. Sterile team members maintain contact with sterile field by means of sterile gowns & gloves.b. Non-sterile circulating nurse does not directly contact the sterile field.c. Supplies are brought to sterile team members by the circulating nurse who opens the wrappers on sterile packages. The circulating nurse ensures sterile transfer to the sterile field. Only sterile items touch sterile surface.
5. UNSTERILE PERSONS AVOID REACHING OVER ASTERILE FIELD; STERILE PERSONS AVOID LEANINGOVER AN UNSTERILE AREAa. Unsterile circulating nurse NEVER reaches over a sterile field to transfers sterile items.b. In pouring solution into sterile basin, circulating nurse holds only lip of bottle over basin to avoid reaching over a sterile area.c. Scrub person sets basins or glasses to be filled @ edge of the sterile table; circulating nurse stands near this edge fo the table to fill them.d. Circulating nurse stands @ a distance from the sterile field to adjust light over it to avoid microbial fallout over field.
e. Surgeons turns away from sterilefield to have perspiration removed frombrow.f. Scrub persons drapes a nonsterile table towards self first to protect gown. Gloved hands are protected by cuffing draped over themg. Scrub persons stands back from nonsterile table when draping it to avoid leaning over an unsterile area.
6. EDGES OF ANYTHING THAT ENCLOSES STERILECONTENTS ARE CONSIDERED UNSTERILE a. In opening sterile packages, a margin of safety is always maintained. The inside of wrappers is considered sterile within 1 inch of the edges. The circulating nurse opens top flap away from self, then turns the sides under. Ends of flaps are secured in hand so they do not dangle loosely. The last flap are secured in pulled toward person opening package, thereby exposing package contents away from nonsterile hand.
b. Sterile person lifts contents away from packagesby reaching down & lifting them straight up, holdingelbows highc. Steam reaches only area within the gasket of a sterilizer. Instrument trays should not touch edge of the sterilizer outside the gasket.d. Flaps on peel-open packages should be pulled back not torn, to expose sterile contents. Contents should be flipped or lifted upward & not permitted to slide over edges. Inner edge of the heat seal is considered the line of demarcation between sterile & unsterile.e. If a sterile wrapper is used as a table cover, it should amply cover the entire table surface. Only the interior & surface level of the cover are considered sterile.
f. After a sterile bottle is opened, contents must be used or discarded. Cap can be replaced without contaminating pouring edges.7. STERILE FIELD IS CREATED AS CLOSE AS POSSIBLE TO TIME OF USE• Sterile tables are set up just before the operation.• It is virtually impossible to uncover a table of sterile contents without contamination. Covering sterile tables for later use is not recommended.
8. STERILE AREAS ARE CONTINUALLY KEPT IN VIEW a. Sterile person face sterile areas. b. When sterile packs are open in a room, or a sterile field set up, someone must remain in the room to maintain vigilance. Sterility cannot be ensured without direct observation. An unguarded sterile field should be considered contaminated.
9. STERILE PERSONS KEEP WELL WITHIN THE STERILE AREAa. Sterile persons stand back at a safe distance from the operating table when draping the client.b. Sterile persons pass each other back to back at 360° turn.c. Sterile person turns back to nonsterile person or area when passing.d. Sterile person face sterile area to pass it.e. Sterile person asks nonsterile individual to step aside rather than risk contamination.f. Sterile persons stay within the sterile field. They do not walk around or go outside the room.
g. Movement within & around a sterile areas is kept to a minimum to avoid contamination of sterile items or persons.10. STERILE PERSONS KEEP CONTACT WITH STERILE AREAS TO A MINIMUMb. Sterile persons do not lean on sterile tables & on the draped client.c. Sitting or leaning against a nonsterile surface is a break in technique. If the sterile team sits to operate, they do so without proximity to nonsterile areas.
11. UNSTERILE PERSON AVOID STERILE AREASa. Unsterile persons maintain a distance of at 1 foot (30 cm) from any area of the sterile field.b. Unsterile persons face & observe a sterile area when passing it to be sure they do not touch it.c. Unsterile persons never walk between two sterile areas, e.g., between sterile instrument tables.d. Circulating nurse restricts to a minimum all activity near sterile field.
12. DESTRUCTION OF INTEGRITY OFMICROBIAL BARRIERS RESULTS INCONTAMINATION a. Sterile packages are laid on dry surfaces. b. If sterile package wrapped in absorbent material becomes damp or wet, it is resterilized or discarded. The package is considered nonsterile if any part of it comes in contact with moisture. c. Drapes are placed on a dry field. d. If solution soaks through sterile drape to nonsterile area, the wet area is covered with impervious sterile draped or towels.
e. Packages wrapped in muslin or paper are permitted to cool after removal from a sterilizer & before being placed on cold surface to prevent steam condensation & resultant contamination.f. Sterile items are stored in clean dry areas.g. Sterile package are handled with clean dry hands.h. Undue pressure on sterile packs is avoided to prevent forcing sterile are out & pulling unsterile air into the pack.
13. MICROORGANISM MUST BE KEPT TOAN IRREDUCIBLE MINIMUMA. Skin cannot be sterilized. Skin is a potential source of contamination in every operation.2. Transient & resident flora are removed from skin around operative site of client & hands & arms of sterile team members by mechanical washing & chemical antisepsis.3. Gowning & gloving of operating team is accomplished without contamination of exterior of gowns & gloves.4. Sterile gloved hands do not directly touch skin & then deeper tissues. Instruments uses in contact with skin are discarded & not reused.
4. If glove is torn or punctured by needle orinstrument, gloved is changes immediately. Needleor instrument is discarded from sterile field.5. Sterile dressing should be applied before draped are removed to reduce risk of the incision being touched by contaminated hands or objects.B. Some areas cannot be scrubbed. (Operative includes mouth, nose throat, or anus in various parts of the body such as GIT & vagina) to reduce number of microorganism & prevent them from scattering:3. Surgeons makes an effort to use a sponge only once, then discards it.• GIT, especially colon, is contaminated. Measure are used to prevent spreading this contamination.
C. Infected areas are grossly contaminated. Theteams avoids disseminating the contamination.D. Air is contaminated by dust & droplets2. Drapes over anesthesia screen or attached to IV poles separate anesthesia area from sterile field.3. Talking is kept to minimum in OR. Moisture droplets expelled with force into mask during process of articulating words.4. Movement around sterile field is kept to minimum to avoid air turbulence.5. Drapes are not flipped, fanned or shaken to avoid dispersion of lint & dust.
MEMBERS OF THS SURGICAL TEAM• SURGEON – is a physician who assumes responsibility for the surgical procedure & any surgical judgments about the client• SURGICAL ASSISTANT – might be another surgeon (or physician, resident or intern) or nurse, surgical technologist• ANESTHESIOLOGIST – is a physician who specializes in giving anesthetic agents
Anesthesia provider monitors the clientduring surgery by assessing & monitoring the following: 2. The level of anesthesia 3. Cardiopulmonary function & hemodynamic monitoring 4. Vital signs 5. Intake & Output *Gives Intravenous fluids, including blood & blood products
OPERATING ROOM STAFF A. Circulating Nurse – sets up OR & ensure that supplies, including blood products & diagnostic support, are available as needed;• assists the anesthesia provider with the induction• 2.“prep” (scrub) the surgical site• notifies PACU of client’s estimated time of arrival & any special needs
Throughout the surgery, the circulating nurse:1. Monitors traffic around the room2. Assesses the amount of urine & blood loss3. Reports findings to the surgeon & anesthesia provider4. Ensures that the surgical team maintains sterile technique & a sterile team5. Anticipates the client’s & surgical team’s needs, providing supplies & equipment as needed.6. Communication information regarding the client’s status w/ family members during long or unique procedures7. Document care, events, interventions & findings
B. Scrub Nurse – sets up sterile field, drapes the client, & hands sterile instruments to the surgeon & the assistant place; maintains accurate count of sponges, sharps, instruments & amount of irrigation fluid & drugs used Knowledge duration of anesthesia anticipation surgeon’s anxiety & tension
PREPARATION OF THE SURGICAL SUITE & TEAM SAFETYA. LAYOUT Surgical areas are divided in 3 zones to ensure proper movement of clients & personnel: a. Unrestricted b. Semirestricted c. Restricted
STERILIZATION• PROCESS BY WHICH ALL PATHOGENIC AND NON PATHOGENIC MICROORGANISMS INCLUDING SPORES ARE DESTROYED OR KILLED.
METHODS OF STERILIZATIONTHERMAL (PHYSICAL)• STEAM UNDER PRESSURE• Hot/Dry airCHEMICAL• ETHYLENE OXIDE GAS• FORMALDEHYE SOLUTION OR GAS• HYDROGEN PEROXIDE/PLASMA VAPOR• OZONE GAS• GLUTARALDEHYDE SOLUTIONRADIATION• MICROWAVE (NON IONIZING)• X-RAY (IONIZING)
B. HEALTH & HYGIENE OF THE SURGICAL TEAM Anyone who has open wound, cold or any infection should not participate in surgery Shedding of organisms & skin debris is greatest immediately after showering – bathe few hours before changing into OR attire Jewelries carries organisms – minimal Handwashing Routine Culture q 3-6 months Surgical attire & surgical scrub help contamination
C. SURGICAL ATTIRE Clean, not sterile Worn to reduce contamination from home & areas outside of the surgical setting.a. Body cover (shirt & pants)b. Head cover (cap or hood)c. Shoe coverings/inside shoesd. Protective attire: mask, eyewear, glove, gown & shoe covers Change in the locker rooms, not at home
D. SURGICAL SCRUB Process of removing as many microorganisms as possible from the hands & arms by mechanical washing & chemical antisepsis before participating in a surgical procedure.E. GOWNING Puts on a sterile gownF. GLOVING Puts on sterile gloves 1. Open gloving technique 2. Closed gloving technique
G. ANESTHESIA “Negative Sensation” Is an induced state of partial or total loss of sensation, occurring with or without loss of consciousness.PURPOSES:4. Block nerve impulse transmission5. Promote muscle relaxation6. Achieve a controlled level of unconsciousness
SELECTION OF ANESTHESIAINFLUENCED BY THE FOLLOWING:a. Client’s health problem – major factorb. Type & duration of the procedurec. Area of the body having surgeryd. Safety issues to reduce injury – airway mgt.e. Whether the procedure is an emergencyf. Options for management of pain after surgeryg. How long it has been since the client ate, had any liquid, or any drugsh. Client’s position needed for the surgical procedure
TYPES OF ANESTHESIA1. GENERAL ANESTHESIA Depresses CNS resulting:♠ amnesia ♠ unconsciousness♠ analgesia ♠ loss of muscle tone & reflexes6. LOCAL ANESTHESIA OR REGIONAL Disrupts sensory nerve impulse transmission from a specific area or region
STAGES OF GENERAL ANESTHESIASTAGE I – STAGE OF INDUCTION From the beginning of administration of drugs/gas to loss of consciousness Client appear drowsy & dizzyNursing Action: Close OR doors & keep room quiet Standby the client & assist if necessary
STAGE II – STAGE OF EXCITEMENT From loss of consciousness to relaxation Client appear excited, breathing is irregular Client moves extremities or body Client very sensitive to external stimuliNURSING ACTION: Restrain client if needed Remain at client’s side Be quiet & alert Assist anesthesiologist if needed
STAGE III – SURGICAL ANESTHESIA & RELAXATION Loss of reflexes Depression of vital functions Respiration – regular, pupils contracted Eyelids reflexes disappear Loss of auditory sensesNURSING ACTION: Begin final prep – client is under control
STAGE IV – DANGER STAGE Vital functions are to depressed Respiratory failure & possible cardiac arrest Not breathing, little or no pulse & heartbeatNURSING ACTION: Be ready to resuscitate
ADMINISTRATION OF GENERAL ANESTHESIA1. INHALATION Inhales anesthetic gas or vapor through a mask, endotracheal or nasotrachealc. GASEOUS AGENTS – Nitrous oxided. VOLATILE AGENTS – Liquid agent vaporized for inhalation cause shivering after surgery – effect on hypothalamus
2. INTRAVENOUS INJECTIONa. BARBITURATES – mild sedation to deep loss of consciousness.c. KETAMINE (KETALAR) – dissociative anesthetic agent (one that promote a feeling of separation or dissociation from the env’t.) Emergence reaction during recovery – combative or restlessd. PROPOFOL (DIPRIVAN) – short actin; hypnosis occur less than 1 minute & responsive within 8 minutes after infusion ends
3. ADJUNCTS TO GENERAL ANESTHESIAa. HYPNOTICS – Midazolam or Diazepam (Benzodiazepines) Hypnotic, sedative, muscle relaxant & amnesic effect May be used as part of IV conscious sedationb. OPIOID ANALGESICS – used during surgery helps provide pain relief after surgery MSO4, Demerol, Sublimaze All opioids depressed respiration
c. NEUROMUSCULAR BLOCKING AGENTS Used to relax the jaw & vocal cords immediately after induction so that the ET can be placed. May be used during surgery to provide continued muscle relaxation Tracium, Anectine
4. COMPLICATIONS OF INTUBATIONS– broken or injured teeth, swollen lip, vocal cord trauma Difficult intubation – small oral cavity, tight jaw joint, present of tumor Improper neck extension during intubation – may cause injuryET PLACEMENT – tracheal irritation & edema, sore throat
REGIONAL ANESTHESIA Produces a loss of painful sensation in only one region of the body & does not result in unconsciousness1. TOPICAL ANESTHESIA – directly applied onto the area to be disensitized2. LOCAL INFILTRATION ANESTHESIA – injection of an anesthetic agent into the skin & SQ tissue of the area to be anesthetized.
3. NERVE BLOCK– injection of the local anesthetic agent into or around a nerve or group of nerves in the involved area. Disrupts motor & sensory impulse transmission If injected bloodstream seizure, cardiac & respiratory depression, dysrhythmias
NERVE BLOCK Radial, Medial & Ulnar nerve (elbow, wrist, hands, & fingers) Intercostal nerves (chest & abdominal wall) Brachial plexus (upper arm) Cervical plexus (betweem jaw & clavicle)4. SPINAL ANESTHESIA – injecting an anesthetic agent into the CSF on the subarachnoid space Lower abdominal & pelvic surgery
6. EPIDURAL ANESTHESIA -Anesthetic agentinjected into the epidural space & spinal cordareas are never entered
NURSE’S ROLE IN THE DELIVERY OFANESTHESIA:1. Assisting the anesthesia provider2. Observing for breaks in the sterile technique3. Providing emotional support for the client4. Staying with the client5. Offering information & reassurance6. Positioning the client comfortable & safely
POSITIONING PUTTING CIENT IN PROPER BODYALIGNMENT TO EXPOSE THE OPERATIVE SITE OR AREA.• QUALIFICATION OF A GOOD POSITION: 1. free respiration 2. Free circulation 3. No pressure on nerve 4. hand or feet properly supported 5. No undue postoperative discomfort 6. accessible operative site
SUTURES Any strand of materials used for ligating or approximating tissue, bringing tissues together & holding them until healing takes place.1. ABSORBABLE• Surgical gut – is collagen derived from submucosa of sheep intestine or serosa of beef intestine.• Collagen sutures – extended from a homogenous dispersion of pure collagen from the flexor tendons of beefs (opthalmic surgery)• Synthetic Absorbable Polymers – Polydiaxanone suture (PDS), monocryl. Maxon, vicryl, dexon
2. NONABSORBABLE♥Silk ♥Cotton ♥Steel ♥Synthetic nonabsorbable polymers – nylon, prolene, novafilTENSILE STRENGTH Amount of weight or pull necessary to break suture material.LIGATURE OR TIE Material is tied around a blood vessel to occlude the lumenSUTURE LIGATURE/STICK TIE A suture attached to a needle for a single stitch for hemostasis.TIE ON A PASSER A tie handled to the surgeon in the tip of a forcep
5 LAYERS OF THE ABDOMEN1. skin2. subcutaneous3. fascia4. muscle5. peritoneumDRAPINGProcedure of covering the client & surrounding areas with a sterile barrier to create & maintain an adequate sterile field.
SURGICAL HAND SCRUBBING• IS THE PROCESS OF REMOVING AS MANY MICROORGANISMS AS POSSIBLE FROM THE HANDS AND ARMS BY MECHANICAL WASHING AND CHEMICAL DISINFECTION BEFORE PARTICIPATING IN A SURGICAL PROCEDURE.
MECHANICAL – PROCESS OFREMOVING DIRT, SOIL ANDTRANSIENT ORGANISM BYFRICTION• CHEMICAL – PROCESS REDUCES RESIDENT FLORAE AND INACTIVATES MICROORGANISMS WITH AN ANTIMICROBIAL OR ANTISEPTIC AGENT
GOWNING – DONNING OF STERILE GOWN• GLOVING – WEARING OF STERILE GLOVES TO COMPLETE THE ATTIRE.CLOSED/ OPEN TECHNIQUEGOWNS ANS GLOVES ARE WORN TO EXCLUDE SKIN FROM POSSIBLE CONTAMINATION AND TO CREATE A BARRIER BETWEEN THE STERILE AND UNSTERILE AREA
Surgical instruments are designed to providethe tools the surgeon needs for each maneuver• Whether they are small or large, short or long,straight or curved or sharp or blunt, allinstrumentscan be classified by their function.• All instruments should be used only for their
Basic instruments are essential to accomplish most types ofgeneral surgery.Each instrument can be placed into one of the four followingbasic categories:Cutting and DissectingClamping and OccludingGrasping and HoldingRetracting and Exposing
SPONGESAre used for absorbing blood & fluids, protecting tissues, applying pressure or traction, & dissecting tissues.Gauze sponges, lap packs, peanuts, tonsil balls, cottonoids, cherries
SPONGE, SHARPS, & INSTRUMENT COUNTSACCOUNTABILITY Is a professional responsibility that rests primarily on the scrub nurse & the circulator.COUNTING PROCEDURES Is a method of accounting for items put on the sterile table for use during the surgical procedure. Counts are performed for client & personnel safety, infection control, & inventory purposes.
1. BASELINE COUNT DURING SET- UP FOR THE SURGICAL PROCEDURE Count all item before the surgical procedure begins & during the surgical procedure as each additional package is opened & added to the sterile field.2. CLOSING COUNT (FIRST CLOSING COUNT) Counts are taken before the surgeon starts the closure of a body cavity or a deep or large incision. Field count table floor3. FINAL COUNT (SECOND CLOSING COUNT) Performed before any part of a cavity or a cavity within a cavity is closed.
WOUND CLOSURE• Continuous suture (running stitch) – peritoneum & vessels because it provides leak proofs suture line.• Interrupted suture – each stitch is taken & tied separately.• Buried suture – suture is placed under the skin, buried either continuous or interrupted.• Purse-string method – a continuous suture is placed around a lumen & tightened, drawing fashion, to close the lumen.• Subcuticular suture – a continuous suture is placed beneath epithelial layers of skin I short lateral stitches
B. DRAINS – is placed in a separate small incisionparallel to the operative incisions to drain blood &serum from the operative site.
MONITORINGBODY TEMPERATURE OR standard cool level – inhibit bacterial growth & allow optimal performance of surgical team keep client warm w/o causing vasodilation (more bleeding) – warm blankets, booties/socks, warmed IV solution
CARDIAC & RESPIRATORY ARREST No need for code blue Surgeon talk to family in case of deathALLERGIC REACTION Ideally not occur if adequate history taken Some do not recall an allergy - Identify allergy only if occurrence of 2nd allergic reaction to triggering agent during surgery (e.g., latex) DOCUMENT INTRAOPERATIVE CARE
MOVING & TRANSPORTING THE CLIENT Clean the client Avoid rapid movement when changing position – develop hypotension During emergency (revival) from anesthesia, client prone to: nausea, confusion, hypotension Check tubes Modesty maintained SAFETY: warm blankets, body straps, side rails up Notify family of client status
POSTOPERATIVE PERIODBEGINS WITH THE ADMISSION OF THECLIENT TO THE POSTANESTHESIA AREAAND ENDS WHEN HEALING IS COMPLETE
Stages of Recovery• Immediate postoperative stage The period 1 to 4 hours after surgery.• Intermediate postoperative stage The period 4 to 24 hours after surgery.• Extended postoperative stage The period at least 1 to 4 days after surgery.
POST-ANESTHESIA NURSINGGOAL: to assist uncomplicated return to safe physiologic function after an anesthetic procedure by providing safe, knowledgeable, individualized nursing care for clients & their family members in the immediate post- anesthesia phase.
UPON RECEIVING:1. AIRWAY PATENCY/POSITION SAFELY/STABLEUnconscious adult – extend neck & thrust jaw forwardPreferred position – (lateral sim’s position) sidelying allows the client’s tongue to fall forward & mucous or vomitus to drain from the mouth.2. ENDORSEMENT – verbal detailed report of events from OR.
POSTOPERATIVE NURSING CAREASSESSMENT1. ASSESS RESPIRATORY STATUS Patent airway ♠ HYPOXIA2. ASSESS CIRCULATION• V/S, skin, color, temperature• Weakness, numbness, pressure ulcers• Early ambulation – leg exercise if not tolerated3. ASSESS NEUROLOGIC STATUS LOC, orientation, lingering effects of anesthesia
4. MONITOR WOUNDa. Assess dressing amount & charac. Drainage, wound appearanceb. Measure drainage – drains, ostomy bagc. Wound dressing DEHISCENCE & EVISCERATION5. MONITOR IV LINESCheck IV lines – patency, I & O, Infiltration – mild heat to decreased local pain
6. MONITOR DRAINAGE TUBES• Drainage tube to suction/gravity drain• Note amt, color, consistency of drainageNGT – decompression, removal of intestinal secretion, promote GI rest, allow GIT to heal, monitor GI bleeding, prevent intestinal obstructionUntil peristalsis begin – may remove w/ orderBowel sounds NGT clamp & removedPassage of flattus if tolerated w/o N/Vhunger
7. PROMOTE COMFORT• Pain medsOral – reassess after 30 minutesIV – reassess after 5-10 minutes8. REDUCE NAUSEA & VOMITINGVomiting – is a reflex stimulated ♥CTZ (chemoreceptor trigger zone) ♥ ICP ♥GIT distention or irritation ♥Pain ♥vagal stimulation ♥centers in cerebrum ♥disequilibrium -vestibular labyrinth ear
Atelectasis and Pneumonia• Collapse of the alveoli with retained mucous secretions• The most common postoperative complication; usually occurs 1 to 2 days after surgeryAssessment• Dyspnea, increased respiratory rate, productive cough, chest pain• Crackles over involved lung area• Increased temperature
Interventions• Reposition client every 1 to 2 hours; encourage deep breathing, coughing, and use of the incentive spirometer• Encourage fluid intake• Encourage early ambulation• Perform suctioning to clear secretions if client is unable to cough
Hypoxia• An inadequate concentration of oxygen in arterial bloodAssessment• Restlessness• Dyspnea• Diaphoresis• Cyanosis
Interventions• Monitor client for signs of hypoxia• Eliminate cause of hypoxia• Monitor lung sounds and pulse oximetry• Administer oxygen as prescribed
Pulmonary Embolism• An embolus blocking the pulmonary artery and disrupting blood flow to one or more lobes of the lungAssessment• Dyspnea• Sudden, sharp chest or upper-abdominal pain• Cyanosis• Tachycardia and tachypnea• Anxiety
Interventions• Notify surgeon immediately• Monitor vital signs• Administer oxygen and medications as prescribed
Hemorrhagic and Shock• Loss of circulatory fluid volume as a result of losing a large amount of blood externally or internally in a short periodAssessment• Restlessness• Weak, rapid pulse• Hypotension• Tachypnea• Cool, clammy skin• Reduced urine output
Interventions• Put pressure on site of bleeding & elevate legs• If client has had spinal anesthesia, do not elevate legs any higher than placing them on the pillow; otherwise the diaphragm muscles could be impaired• Notify surgeon immediately• Adm. intravenous fluids , oxygen & blood as prescribed• Monitor LOC, vital signs, and intake & output• Prepare client for surgery, if necessary
Thrombophlebitis• Inflammation of a vein (most commonly in the leg), often accompanied by clot formationAssessment• Vein inflammation• Aching or cramping pain• Vein feels hard and cordlike and is tender to touch• Increased temperature• Homans sign
Interventions• Prevention measures include ROME every 2H if the client is restricted to bed rest & early ambulation as prescribed; instruct client not to sit in one position for an extended period• Monitor legs for swelling, inflammation, pain, tenderness, venous distention, & cyanosis• Elevate leg 30° w/o placing any pressure on popliteal area• Maintain an intermittent pulsatile compression device or use antiembolism stockings, as prescribed• Administer heparin sodium or warfarin sodium (Coumadin), as prescribed
Urine Retention• Caused by anesthetics & narcotic analgesics• Usually appears 6 to 8 hours after surgeryAssessment• Inability to void• Restlessness and diaphoresis• Lower-abdominal pain & a distended bladder• On percussion, bladder sounds like a drum
Interventions• Monitor client for voiding and assess for distended bladder• Encourage fluid intake, unless contraindicated• Assist client in voiding by helping him or her stand; provide privacy• Pour warm water over the perineum or allow the client to hear running water to promote voiding• Catheterize client as prescribed after all noninvasive techniques have been attempted
Paralytic IleusDescription• Failure of bowel contents to move along appropriately• May occur as a result of anesthetic medications or manipulation of the bowel during surgeryAssessment• Nausea & vomiting immediately after surgery• Abdominal distention• Absence of bowel sounds, bowel movement, or flatus
Interventions• First treated nonsurgically by means of bowel decompression through the insertion of a nasogastric tube attached to intermittent-to- constant suction• Keep client from eating or drinking until bowel sounds return; administer intravenous fluids as prescribed• Encourage walking• Administer medications, as prescribed, to increase gastrointestinal motility and secretions
ConstipationDescription• When client resumes a solid diet after surgery, failure to pass stool within 48 hours is a cause for concernAssessment• Abdominal distention• Absence of bowel movements• Anorexia, headache, and nausea
Interventions• Encourage fluid intake up to 3000 mL/ day, unless contraindicated• Encourage early ambulation• Encourage consumption of fiber-rich foods, unless contraindicated• Administer stool softeners and laxatives as prescribed• Provide privacy and adequate time for elimination
Wound InfectionDescription• Wound becomes contaminated with a microorganismAssessment• Fever and chills• Warm, tender, painful, inflamed incision site• Edematous skin at incision and tight skin sutures• Increased white blood cell count
Interventions• Monitor client’s temperature• Monitor incision site for approximation of suture line, edema, or bleeding, signs of infection• Maintain patency of drains and assess drainage amount, color, and consistency• Change dressing as prescribed; maintain asepsis• Administer antibiotics as prescribed
Wound Dehiscence Description • Separation of the wound edges at the suture line Assessment • Increased drainage • Opened wound edges • Appearance of underlying tissues through the wound
Interventions• Place the client in low Fowlers position with the knees bent to prevent abdominal tension on an abdominal suture line• Notify surgeon immediately• Cover wound with a sterile normal saline dressing
EVISCERATION• Abdominal wound becomes infected & abdominal incision opens, the fascia or internal organs may be visible.• Preceded gush of serosanguinous drainageInterventions• cover wound sterile NS dressing• Monitor V/S• Keep client as calm as possible• Notify surgeon
Criteria for Client Discharge• Client is alert and oriented• Client has voided• Client has no respiratory distress• Client can walk, swallow, and cough• Client tolerates a small amount of fluid and food• Pain is minimal• Client is not vomiting• Bleeding from incision site, if any, is minimal• A responsible adult is available to drive the client home• The surgeon has signed a release form
Discharge Teaching• Should be performed before date of scheduled procedure• Provide written instructions to client and family regarding specifics of care• Instruct client & family about possible postoperative complications• Provide appropriate resources for home-care support• Instruct client to call surgeon, ambulatory center, or emergency department if postoperative problems occur• Instruct client to keep follow-up appointments with surgeon
• Demonstrate care of incision & how to change dressing , provide extra dressings for home use• Instruct client on importance of returning to surgeons office for follow-up• Instruct client that sutures are usually removed in surgeons office 7 to 10 days after surgery• Inform client that staples are removed 7-14 days after surgery & that skin may become slightly reddened when they are ready to be removed
• Instruct client on use of medications: purpose, doses, administration, side effects• Instruct client on diet and remind him or her to drink six to eight glasses of liquid a day•• Instruct client on activity levels; tell him or her to resume normal activities gradually• Instruct client to avoid lifting for 6 weeks (or as prescribed by the surgeon) if a major surgical procedure has been performed
• Instruct client with an abdominal incision not to lift anything weighing 10 pounds or more (or as prescribed by surgeon)• Instruct client on signs and symptoms of complications and when to call surgeonGenerally client can return to work in 6 to 8 weeks, as prescribed by surgeon