pain and surgery
DESCRIPTION
ari na ang gina HULAT HULAT NYO NGA ppt :) enjoy studying! hahahahaha!♥TRANSCRIPT
PAIN AND SURGERYPAIN AND SURGERY
JOCELYN G. GAVIETA, RN
GRADING SYSTEMGRADING SYSTEM
QUIZ 80 %RECITATION 10 %REQUIREMENTS 5 %ATTENDANCE 5 %
---------- 100 %
PAINPAIN• 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 patient's body which is always unpleasant and associated with the impression of damage to the tissues
PAINPAIN
• First symptom of injury;• Indicator of a disease process• The fifth vital sign
SOURCES OF PAIN STIMULISOURCES OF PAIN STIMULI
NOCICEPTORSreceptors that transmit pain
sensation.
NOCICEPTIONphysiologic processes related to
pain perception.
PHYSIOLOGY OF PAINPHYSIOLOGY OF PAIN
FOUR PHASES OF NOCICEPTION1. 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. TRANSMISSION2. TRANSMISSIONNeuronal 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. PERCEPTION3. 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. 4. MODULATIONMODULATIONDescribed 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 MODULATIONPAIN MODULATION
ENDOGENOUS OPIOIDS – pain inhibiting neurochemicals
1. Enkephalins Inhibits the release of substance P - a
neurotransmitter that enhances transmission of pain impulses
2. Endorphins More potent than enkephalins
3. Dynorphins Have analgesic effect, which is 50% more
potent than endorphins4. Neuromodulators
Modify pain (chemical regulators)
PHYSIOLOGICAL PHYSIOLOGICAL THEORIES OF PAIN THEORIES OF PAIN
TRANSMISSIONTRANSMISSION
1. 1. SPECIFICITY THEORYSPECIFICITY THEORYThere are specific nerve receptors for
particular stimuli. e.g.,
Nociceptors – noxious stimuli (always interpreted as PAIN)
Thermoreceptors – heat/coldMechanoreceptors – pressure, pulling or
tearing sensationChemoreceptors – chemicals
PATTERN THEORYPATTERN THEORY
States 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 THEORYGATE 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
TYPES OF PAINTYPES OF PAIN
ACCORDING TO DURATIONACCORDING TO DURATION
1. ACUTE PAIN• Temporary, immediate onset• Last for less than 6 months• Eventually subside after treatment or
sometimes without treatment
e.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:a.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/ORIGINACCORDING TO SOURCE/ORIGIN
1. 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 INTENSTIYACCORDING TO INTENSTIY
1. MILD• One that is bearable usually tolerated by
the client
2. SEVERE• One which is intense & usually could not
be tolerated by the client
ACCORDING TO LOCATIONACCORDING TO LOCATION1. RADIATING PAIN• Perceived at the source of the pain &
extends to nearby tissue
Cardiac pain – chest, left shoulder, down the arm
2. REFERRED PAIN• Felt in an area distant from the site of the
stimulus
MI – left arm, shoulder, or jaw pain
Cholecystitis – back pain & angle of scapula
3. INTRACTABLE PAIN• Pain that is highly resistant to relief• Advanced Malignancy
4. 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 FACTORS AFFECTING PAIN PERCEPTION AND RESPONSEPERCEPTION AND RESPONSE
1. 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 sensation
4. 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 enemy
6. ANXIETY & STRESS• A person who suffers fatigue may not have
a good coping with pain
PAIN ASSESSMENT TOOLSPAIN ASSESSMENT TOOLS
Onset
Location
Duration
Characteristics
Aggravating factors
Radiation
Treatment
2. FACES RATING SCALE
3. 10 POINT PAIN INTENSITY SCALE
MISCONCEPTION & MYTHS OF MISCONCEPTION & MYTHS OF PAINPAIN
• 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 client's pain.
• FACT: ONLY THE CLIENT CAN JUDGE THE LEVEL & DISTRESS OF THE PAIN, THAT'S 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.
ASSESSMENTASSESSMENT
• 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 MANAGEMENTPAIN MANAGEMENT
Refers to the techniques used Refers to the techniques used to prevent, reduce, relieve pain.to prevent, reduce, relieve pain.
A. NON-PHARMACOLOGIC PAIN A. NON-PHARMACOLOGIC PAIN MANAGEMENTMANAGEMENT
1. PHYSICAL INTERVENTION Includes providing comfort, altering
physiologic responses & reducing fears associated with pain-related immobility or activity restriction.
a. 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.
• MASSAGEback 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 Meridians
o 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 ELECTRICAL NERVE 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 that
acupuncture provides a measure of pain relief where all other methods fail. The way acupuncture suppresses pain remains a mystery. Some scientists 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
expectation of relief.
2. MIND-BODY INTERVENTION2. MIND-BODY INTERVENTION (Cognitive-Behavioral)(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 tv2. 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, & dissociation
HUMOR 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 puzzle
B. RELAXATION TECHNIQUESGradually 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 painE.g., flow of the breath; picture image of
great spiritual being or peaceful place
E. BIOFEEDBACKE. BIOFEEDBACK
Biofeedback in Progress A patient at a biofeedback clinic sits connected to electrodes on his head and finger. Biofeedback is a technique in which patients attempt to become aware of and then alter bodily functions such as muscle tension and blood pressure. It is used in treating pain and stress-related conditions, and may help some paralyzed patient use of their limbs.
Biofeedback in Progress A patient at a biofeedback clinic sits connected to electrodes on his head and finger. Biofeedback is a technique in which patients attempt to become aware of and then alter bodily functions such as muscle tension and blood pressure. It is used in treating pain and stress-related conditions, 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 it
G. THERAPEUTIC TOUCH use hands to rearrange energy field to normal
H. MAGNETS Believed that the pull of magnet increased
blood flow to the region of pain, opening the NaCl channels in the cell.
PHARMACOLOGIC PAIN PHARMACOLOGIC PAIN MANAGEMENTMANAGEMENT
1. OPIOID ANALGESICS 1. OPIOID ANALGESICS (NARCOTIC)(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 ANALGESICSNARCOTIC ANALGESICSMEPERIDINE 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 ANTAGONISTSNARCOTIC ANTAGONISTS
Description• 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: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-ANTAGONIST2. 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 AGONISTS3. PARTIAL AGONISTS
have ceiling effect in contrast to a full agonist.
Buprenorphine (Buprenex)Pentazocine (Talwin)
2. NON-OPIOID ANALGESICS2. 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)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 NSAIDs and ACETYLSALICILIC ACID (Aspirin)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 ANALGESICS3. ADJUVANT ANALGESICS
Is 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 spasmAnticonvulsants – nerve injuryCorticosteroids – reduce inflammation &
edema
Concept on surgeryConcept on surgery
CORRECT POSITION OF HANDS AFTER SURGICAL SCRUBBINGCORRECT POSITION OF HANDS AFTER SURGICAL SCRUBBING
SURGERYSURGERYas 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 CATEGORIES & PURPOSES OF SURGERYOF SURGERY
ACCORDING TO PURPOSE1. Diagnostic
Performed to determine the origin & cause of a disorder or the cell type for cancer
breast biopsy
2. 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:
a.Ablative Includes removal of an organ; e.g., appendECTOMY (suffix)
a.ConstructiveInvolves the repair of congenitally damaged
organe.g., cheiloPLASTY, orchidoPEXY
b.ReconstructiveInvolves repair of damaged organe.g., Total joint replacement
4. Palliative Performed to relieve symptoms of a
disease process, but does not cure Nerve root resection, Colostomy
5. 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 bleeding
2. 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 Hernia
4. 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 RISK1.Minor
Procedure of less risk; generally not prolonged; leads to few complications
2. Major Procedure of greater risk; usually longer &
more extensive; great risk of complications
ACCORDING TO EXTENT OF SURGERY1.Simple
Only the most overtly affected areas involved in the surgery
e.g., Simple or Partial Mastectomy
2.Radical Extensive surgery beyond the area obviously
involved e.g., Radical Mastectomy, Radical
Hysterectomy
SURGICAL SETTINGSURGICAL SETTING
1. 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 PERIOPERATIVE NURSINGNURSING
PERIOPERATIVE NURSINGPERIOPERATIVE 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 education
Use Knowledge, judgement & skills
PREOPERATIVE PREOPERATIVE PERIODPERIOD
Begins when the client is scheduled for Begins when the client is scheduled for surgery & ends at the time of transfer to surgery & ends at the time of transfer to
surgical suitesurgical suite
PREOPERATIVE PERIODPREOPERATIVE PERIOD
Focuses on client’s readiness – client education & any intervention:1. Reduce anxiety2. Reduce complication3. Promote cooperation
Needed before surgery to:1. Validate & clarify information client received from surgeon or members of health team2. Identify problems that warrant further assessment &/or intervention before surgery
PREOPERATIVE ASSESSMENTPREOPERATIVE ASSESSMENT
A. MEDICAL/HEALTH HISTORY Purpose of reviewing medical history is to
determine operative risk.
COLLECT THE FOLLOWING DATA:COLLECT THE FOLLOWING DATA:
1. AGEOlder – risk of complication; immune
system functioning; delays wound healing; frequency of chronic illness; alter operative response/risk
2. DRUGS & SUBSTANCE USEo 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 experience
o 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 oxygenation 7. ANESTHESIA
o Affect readiness for surgeryo 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 ASSESSMENTB. PHYSICAL ASSESSMENT
To obtain baseline dataComplete set V/S – abnormal V/S
may postpone surgery until problem is treated & condition is stable
1. CARDIOVASCULAR SYSTEM1. CARDIOVASCULAR SYSTEMCardiac problems – 30% of surgery-related
deathsHPN – common & often undiagnosed affect
response to surgeryAssess cardiac sounds for rate, regularity &
abnormalitiesHands & feet – for temp, color, peripheral
pulses, capillary refill, & edema
REPORT: absent peripheral pulses, pitting edema, cardiac symptoms ( chest pain, dyspnea) for further assessment & evaluation
2. RESPIRATORY SYSTEM2. RESPIRATORY SYSTEM
Age, smoking history (second handsmoke), chronic illness
Overall posture, RR, rhythm & depth, overall respiratory effort & lung expansion
Document clubbing of fingertips ( swelling base nailbeds caused by chronic lack of O2) or cyanosis
3. RENAL/URINARY SYSTEM3. RENAL/URINARY SYSTEMKidney function – affects excretion of drugs &
waste products including ANESTHETIC & ANALGESIC AGENTS
Renal function reduced (Older client) – fluid & electrolyte balance can be altered
KIDNEY IMPAIRED:excretion of drugs & anesthetic agentDrug effectiveness may be altered Buscopan, Morphine, Demerol, Barbiturates
causes confusion, disorientation, apprehension, restlessness with kidney function
4. NEUROLOGIC SYSTEM4. NEUROLOGIC SYSTEMAssess overall mental status – LOC,
orientation, ability to follow commands) before planning preoperative teaching & care
Assess motor & sensory deficits – problems may affect type of care needed during surgical experience
Risk for falling (esp older) – evaluate mental status, muscle strength, steadiness of gait, sense of independence, ability to ambulate
5. MUSKULOSKELETAL SYSTEM5. MUSKULOSKELETAL SYSTEMProblems 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 STATUS6. NUTRITIONAL STATUS
Malnutrition & Obesity - surgical risk metabolic rate & depletes K, Vit C & B – needed for wound healing & blood clotting
Malnourished - 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 ASSESSMENT7. PSYCHOSOCIAL ASSESSMENT
To determine level of anxiety, coping ability, & support system
– provide information & offer support as neededDegree of Anxiety & Fears varies according:
Type of surgeryPerceived effects of surgery & potential
outcomeClient’s personality
SURGICAL 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 unknown
ANXIETY & FEAR affect client’s ability to learnCope & cooperate w/ teaching & operative
proceduresMay influence amount & type anesthesia
needed & may slow recovery
8. LABORATORY ASSESSMENT8. LABORATORY ASSESSMENT
Provide baseline data about health & help predict potential complications
OUTPATIENT – PAT (preadmission testing) 24-28 days before surgeryvalid 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 ASSESSMENT9. 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 surgery
CT SCAN OR MRI
Electrocardiogram (ECG)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
Preoperative CarePreoperative Care
Obtaining Informed ConsentObtaining 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 procedureROLE: 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 witnessessEmergency:Phone or telegram authorization but follow-up
with written consent ASAPLifethreatening:With effort to contact person w/ medical power of
atty., consent is desired but not essentialWritten 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 guardian
Blind:May sign his own consent with 2 witnessess
Other 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 DirectiveAdvance DirectiveProvides legal instruction to healthcare
providers about the client’s wishes & are to be followed.
Encompasses durable power of attorney and living will
Living will or durable power of attorney as mandated by The Patient self-determination act. (USA)
NutritionNutrition• Assess the surgeon's 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
EliminationElimination • 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 SiteSurgical 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.
MedicationsMedications• 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 TeachingPreoperative Teaching• Reduce apprehension and fear
• Increased cooperation & participation in care after surgery
• Decrease complications
Client TeachingClient 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
Incentive Spirometer – promote complete lung Incentive Spirometer – promote complete lung expansion & prevent pulmonary problemsexpansion & prevent pulmonary problems
Chest PhysiotherapyChest Physiotherapy
Chest PhysiotherapyChest Physiotherapy
Percussion and vibration over the thorax to loosen secretions in the affected area of the lungs
Contraindications• When bronchospasm occurs by its use stop the
procedure • Rib fracture• History of pathological fractures • Chest
incisions
LEG AND FOOT EXERCISESLEG 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
• Early AmbulationStimulates intestinal motility, enhance lung
expansion, mobilizes secretion, promotes venous return, prevents joint rigidity, relieves pressure
• ROME – prevent joint rigidity & muscle contracture
Psychosocial PreparationPsychosocial Preparation
• Assess client's anxiety level
• Address client's questions and concerns regarding surgery
• Give client privacy to prepare psychologically for surgery
Preoperative ChecklistPreoperative 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 client's record
• Remove client's jewelry, makeup, dentures, hairpins, nail polish, glasses, and prostheses as appropriate
• Document that valuables have been given to client's family members or locked in the hospital safe
• Monitor and document client's vital signs
3. Prosthesis or Dentures-3. Prosthesis or Dentures- should be removed to should be removed to prevent obstruction in the airway prevent obstruction in the airway
2. GIT /Elimination- insertion of indwelling catheter (foley catheter), administration of cleansing enema- this is to ensure that neither of the bladder, nor the bowel is distended during surgery- nutrition/ hydration-- NPO 8 hours before surgery, but some institution may allow clear liquids 3-4 hours before-- IVF infusion may be started to ensure adequate hydration
Pre operative medicationsPre operative medicationsAnticholinergics - Atropine SO4, Scopolamine Glycopyrrolate - control secretions• Antiemetics - Dropiridol, Thorazine - prevents vomiting• Tranquilizers- Diazepam, Lorazepam - decrease anxiety• - Sedatives- Medazolam, Phenobarbital - induce sleep and decrease anxiety• Opioids- Morphine SO4, Meperidine Hcl - relieve pain, decrease anxiety
• 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 Transporting the client to the operating roomroom
• 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 RoomArrival in the Operating Room• When the client arrives in the operating
room, the operating-room nurse will check the identification bracelet against the client's verbal response
• The client's chart will be checked for completeness and reviewed for informed consent
• The surgeon's orders will be reviewed to ensure that they were carried out
INTRAOPERATIVEINTRAOPERATIVE PERIODPERIOD
begins when the client is transferred to the operating room bed and ends when the client is transferred to an area for recovery from anaesthesia
Key words of OR practiced areKey words of OR practiced are::1. Caring 3. Discipline2. Conscience 4. Technique
Optimal client care requires an inherent surgical conscience, self-discipline & the application of principles of aseptic & sterile technique
SURGICAL CONSCIENCE – “Surgical Golden SURGICAL CONSCIENCE – “Surgical Golden Rule” Rule”
““Do unto the patient as you would have Do unto the patient as you would have others others do unto you.”do unto you.”
Surgical ConscienceSurgical ConscienceOne’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 TECHNIQUEASEPTIC TECHNIQUE
– to maintain asepsis (absence of microorganism that caused diseased)
STERILE TECHNIQUEMethod 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 PRINCIPLES OF STERILE TECHNIQUE ARE APPLIEDAPPLIED::
1. In preparation for operation by sterilization of necessary materials & supplies
2. In preparation of operating team to handle sterile supplies & intimately contact wound
3. In maintenance of sterility & asepsis throughout operative procedure
4. In terminal sterilization & disinfection at conclusion of operation
PRINCIPLES OF STERILE TECHNIQUEPRINCIPLES OF STERILE TECHNIQUE
1. ONLY STERILE ITEMS ARE USED WITHIN STERILE FIELDIf you are in doubt about the sterility of anything, consider it not sterile.
a. If sterilized package is found in a nonsterile workroom.
b. If uncertain about actual timing or operation of sterilizer. Items processed in a suspect load are considered unsterile.
c. If unsterile person comes into close contact with a sterile table & vice versa.
d. If sterile table or unwrapped sterile items are not d. If sterile table or unwrapped sterile items are not under constant observation.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 If the wrapper is impervious & the area of contact is dry, the item may be transferred to the sterile is dry, the item may be transferred to the sterile field. Packages that have been dropped on the field. Packages that have been dropped on the floor should not be put back into sterile storage.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 CUFF
a. 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. 3. TABLES ARE STERILE ONLY AT TABLE TABLES ARE STERILE ONLY AT TABLE LEVELLEVEL
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 ONLY 4. PERSON WHO ARE STERILE TOUCH ONLY STERILE ITEMS OR AREAS; PERSONS WHO ARE STERILE ITEMS OR AREAS; PERSONS WHO ARE NOT STERILE TOUCH ONLY UNSTERILE ITEMSNOT STERILE TOUCH ONLY UNSTERILE ITEMS
a. 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 A 5. UNSTERILE PERSONS AVOID REACHING OVER A STERILE FIELD; STERILE PERSONS AVOID LEANING STERILE FIELD; STERILE PERSONS AVOID LEANING OVER AN UNSTERILE AREAOVER AN UNSTERILE AREA
a. 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.e. SurgeonsSurgeons turns away from sterile turns away from sterile field to have perspiration removed from field to have perspiration removed from brow.brow.
f. Scrub persons drapes a nonsterile table towards self first to protect gown. Gloved hands are protected by cuffing draped over them
g. Scrub persons stands back from nonsterile table when draping it to avoid leaning over an unsterile area.
6. EDGES OF ANYTHING THAT ENCLOSES STERILE 6. EDGES OF ANYTHING THAT ENCLOSES STERILE CONTENTS ARE CONSIDERED UNSTERILECONTENTS 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 packages by reaching down & lifting them straight up, holding elbows high
c. 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 f. After a sterile bottle is opened, contents must be used or discarded. Cap can be replaced without used or discarded. Cap can be replaced without contaminating pouring edges.contaminating pouring edges.
7. STERILE FIELD IS CREATED AS CLOSE AS POSSIBLE TO TIME OF USE
a. Sterile tables are set up just before the operation.
b. 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 KEPT8. STERILE AREAS ARE CONTINUALLY KEPT IN VIEW 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 9. STERILE PERSONS KEEP WELL WITHIN THE STERILE AREATHE STERILE AREA
a. 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 g. Movement within & around a sterile areas is kept to a minimum to avoid contamination of sterile kept to a minimum to avoid contamination of sterile items or persons.items or persons.
10. STERILE PERSONS KEEP CONTACT WITH STERILE AREAS TO A MINIMUM
a. Sterile persons do not lean on sterile tables & on the draped client.
b. 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 AREAS
a. 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 OF MICROBIAL BARRIERS RESULTS IN CONTAMINATION
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 TO AN IRREDUCIBLE MINIMUM
A. Skin cannot be sterilized. Skin is a potential source of contamination in every operation.
1. Transient & resident flora are removed from skin around operative site of client & hands & arms of sterile team members by mechanical washing & chemical antisepsis.
2. Gowning & gloving of operating team is accomplished without contamination of exterior of gowns & gloves.
3. 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 or 4. If glove is torn or punctured by needle or instrument, gloved is changes immediately. Needle instrument, gloved is changes immediately. Needle or instrument is discarded from sterile field.or 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:
1. Surgeons makes an effort to use a sponge only once, then discards it.
2. GIT, especially colon, is contaminated. Measure are used to prevent spreading this contamination.
C. Infected areas are grossly contaminated. The C. Infected areas are grossly contaminated. The teams avoids disseminating the contamination.teams avoids disseminating the contamination.
D. Air is contaminated by dust & droplets1. Drapes over anesthesia screen or attached to IV
poles separate anesthesia area from sterile field.2. Talking is kept to minimum in OR. Moisture
droplets expelled with force into mask during process of articulating words.
3. Movement around sterile field is kept to minimum to avoid air turbulence.
4. Drapes are not flipped, fanned or shaken to avoid dispersion of lint & dust.
MEMBERS OF THS SURGICAL TEAMMEMBERS OF THS SURGICAL TEAM
1. SURGEON – is a physician who assumes responsibility for the surgical procedure & any surgical judgments about the client
2. SURGICAL ASSISTANT – might be another surgeon (or physician, resident or intern) or nurse, surgical technologist
3. ANESTHESIOLOGIST – is a physician who specializes in giving anesthetic agents
Anesthesia provider monitors the client Anesthesia provider monitors the client during surgery by assessing & monitoring the during surgery by assessing & monitoring the
following:following:
1. The level of anesthesia
2. Cardiopulmonary function & hemodynamic monitoring
3. Vital signs
4. Intake & Output
*Gives Intravenous fluids, including blood & blood products
OPERATING ROOM STAFFOPERATING ROOM STAFF
A. Circulating Nurse – sets up OR & ensure that supplies, including blood products & diagnostic support, are available as needed;
1. assists the anesthesia provider with the induction 2. 2.“prep” (scrub) the surgical site3. notifies PACU of client’s estimated time of arrival &
any special needs
Throughout the surgery, the circulating Throughout the surgery, the circulating nurse: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 procedures
7. 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 & PREPARATION OF THE SURGICAL SUITE & TEAM SAFETYTEAM SAFETY
A. LAYOUT Surgical areas are divided in 3 zones to
ensure proper movement of clients & personnel:a. Unrestrictedb. Semirestrictedc. Restricted
STERILIZATIONSTERILIZATION
• PROCESS BY WHICH ALL PATHOGENIC AND NON PATHOGENIC MICROORGANISMS INCLUDING SPORES ARE DESTROYED OR KILLED.
METHODS OF STERILIZATIONMETHODS OF STERILIZATIONTHERMAL (PHYSICAL)• STEAM UNDER PRESSURE• Hot/Dry air
CHEMICAL• ETHYLENE OXIDE GAS• FORMALDEHYE SOLUTION OR GAS
• HYDROGEN PEROXIDE/PLASMA VAPOR• OZONE GAS• GLUTARALDEHYDE SOLUTION
RADIATION• MICROWAVE (NON IONIZING)• X-RAY (IONIZING)
B. B. HEALTH & HYGIENE OF THE HEALTH & HYGIENE OF THE SURGICAL TEAMSURGICAL 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 – minimalHandwashing Routine Culture q 3-6 monthsSurgical attire & surgical scrub help
contamination
CC. SURGICAL ATTIRE. 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 shoes
d. Protective attire: mask, eyewear, glove, gown & shoe covers
Change in the locker rooms, not at home
D. SURGICAL SCRUBD. 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 gown
F. GLOVING Puts on sterile gloves
1. Open gloving technique2. Closed gloving technique
G. ANESTHESIAG. ANESTHESIA
“Negative Sensation” Is an induced state of partial or total loss of
sensation, occurring with or without loss of consciousness.
PURPOSES:
1. Block nerve impulse transmission
2. Promote muscle relaxation
3. Achieve a controlled level of unconsciousness
SELECTION OF ANESTHESIA SELECTION OF ANESTHESIA INFLUENCED BY THE FOLLOWING:INFLUENCED BY THE FOLLOWING:
a. Client’s health problem – major factor
b. Type & duration of the procedure
c. Area of the body having surgery
d. Safety issues to reduce injury – airway mgt.
e. Whether the procedure is an emergency
f. Options for management of pain after surgery
g. How long it has been since the client ate, had any liquid, or any drugs
h. Client’s position needed for the surgical procedure
TYPES OF ANESTHESIATYPES OF ANESTHESIA
1. GENERAL ANESTHESIA Depresses CNS resulting:
♠ amnesia ♠ unconsciousness
♠ analgesia ♠ loss of muscle tone & reflexes
1. LOCAL ANESTHESIA OR REGIONAL Disrupts sensory nerve impulse transmission from
a specific area or region
STAGES OF GENERAL ANESTHESIASTAGES OF GENERAL ANESTHESIA
STAGE I – STAGE OF INDUCTIONFrom the beginning of administration of
drugs/gas to loss of consciousnessClient appear drowsy & dizzy
Nursing Action: Close OR doors & keep room quiet Standby the client & assist if necessary
STAGE II – STAGE OF EXCITEMENTSTAGE II – STAGE OF EXCITEMENT
From loss of consciousness to relaxationClient appear excited, breathing is irregularClient moves extremities or bodyClient 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 & STAGE III – SURGICAL ANESTHESIA & RELAXATIONRELAXATION
Loss of reflexesDepression of vital functionsRespiration – regular, pupils contractedEyelids reflexes disappearLoss of auditory senses
NURSING ACTION: Begin final prep – client is under control
STAGE IV – DANGER STAGESTAGE IV – DANGER STAGE
Vital functions are to depressed Respiratory failure & possible cardiac arrest Not breathing, little or no pulse & heartbeat
NURSING ACTION: Be ready to resuscitate
ADMINISTRATION OF GENERAL ADMINISTRATION OF GENERAL ANESTHESIAANESTHESIA
1. INHALATION Inhales anesthetic gas or vapor through
a mask, endotracheal or nasotracheal
a. GASEOUS AGENTS – Nitrous oxide
b. VOLATILE AGENTS – Liquid agent vaporized for inhalation
cause shivering after surgery – effect on hypothalamus
2. INTRAVENOUS INJECTION2. INTRAVENOUS INJECTION
a. BARBITURATES – mild sedation to deep loss of consciousness.
a. KETAMINE (KETALAR) – dissociative anesthetic agent (one that promote a feeling of separation or dissociation from the env’t.)
Emergence reaction during recovery – combative or restless
b. PROPOFOL (DIPRIVAN) – short actin; hypnosis occur less than 1 minute & responsive within 8 minutes after infusion ends
3. ADJUNCTS TO GENERAL ANESTHESIA3. ADJUNCTS TO GENERAL ANESTHESIA
a. HYPNOTICS – Midazolam or Diazepam (Benzodiazepines)
Hypnotic, sedative, muscle relaxant & amnesic effect
May be used as part of IV conscious sedation
b. OPIOID ANALGESICS – used during surgery helps provide pain relief after surgery
MSO4, Demerol, Sublimaze All opioids depressed respiration
c. NEUROMUSCULAR BLOCKING AGENTSUsed 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 injury
ET PLACEMENT – tracheal irritation & edema, sore throat
REGIONAL ANESTHESIAREGIONAL ANESTHESIA
Produces a loss of painful sensation in only one region of the body & does not result in unconsciousness
1. TOPICAL ANESTHESIA – directly applied onto the area to be disensitized
2. 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 BLOCKNERVE 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 agent 6. EPIDURAL ANESTHESIA -Anesthetic agent injected into the epidural space & spinal cord injected into the epidural space & spinal cord areas are never enteredareas are never entered
• Spinal needles
Epidural anesthesia setEpidural anesthesia set
Local infiltrationLocal infiltration
COMPLICATIONS OF REGIONAL ANESTHESIA:
1. Sensitivity to anesthetic agent2. Overdosage3. Systemic absorption4. Cardiac arrest (rare – spinal)5. Edema & inflammation (local)6. Abscess formation – contamination during injection7. Necrosis & gangrene (rare - prolonged blood vessel
constriction injected area)
NURSE’S ROLE IN THE DELIVERY OF NURSE’S ROLE IN THE DELIVERY OF ANESTHESIA:ANESTHESIA:
1. Assisting the anesthesia provider
2. Observing for breaks in the sterile technique
3. Providing emotional support for the client
4. Staying with the client
5. Offering information & reassurance
6. Positioning the client comfortable & safely
POSITIONINGPOSITIONING PUTTING CIENT IN PROPER BODY PUTTING CIENT IN PROPER BODY
ALIGNMENT TO EXPOSE THE OPERATIVE SITE ALIGNMENT TO EXPOSE THE OPERATIVE SITE OR AREA.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
Supine position/dorsal Supine position/dorsal - laparotomy, appendectomy - laparotomy, appendectomy
Reverse modified trendelenburg positionReverse modified trendelenburg position - face and neck surgery - face and neck surgery
Modified fowler’s positionModified fowler’s position for neurosurgery for neurosurgery
Prone positionProne position - surgery on the posterior part of the body - surgery on the posterior part of the body
- laminectomy - laminectomy
Lithotomy positionLithotomy position - perineal approach - perineal approach
- cystoscopy, vaginal hysterectomy - cystoscopy, vaginal hysterectomy
Lateral positionLateral position - kidney, lungs or hip - kidney, lungs or hip
Jacknife positionJacknife position - rectal surgery - rectal surgery
SUTURESSUTURES Any strand of materials used for ligating or
approximating tissue, bringing tissues together & holding them until healing takes place.
1. ABSORBABLEa. Surgical gut – is collagen derived from
submucosa of sheep intestine or serosa of beef intestine.
b. Collagen sutures – extended from a homogenous dispersion of pure collagen from the flexor tendons of beefs (opthalmic surgery)
c. Synthetic Absorbable Polymers – Polydiaxanone suture (PDS), monocryl. Maxon, vicryl, dexon
2. NONABSORBABLE2. NONABSORBABLE
♥Silk ♥Cotton ♥Steel ♥Synthetic nonabsorbable polymers – nylon, prolene, novafil
TENSILE 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 ABDOMEN5 LAYERS OF THE ABDOMEN
1. skin2. subcutaneous3. fascia4. muscle5. peritoneum
DRAPINGProcedure of covering the client & surrounding
areas with a sterile barrier to create & maintain an adequate sterile field.
Sternal split, oblique subcostal, upper vertical Sternal split, oblique subcostal, upper vertical midline , thoracoabdominal, McBurney, lower midline , thoracoabdominal, McBurney, lower vertical midline, pfannensteilvertical midline, pfannensteil
Scrubbing, Gowning and Gloving
SURGICAL SURGICAL HANDHAND SCRUBBINGSCRUBBING
• 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.
MECHANICALMECHANICAL – PROCESS OF – PROCESS OF REMOVING DIRT, SOIL AND REMOVING DIRT, SOIL AND TRANSIENT ORGANISM BY TRANSIENT ORGANISM BY FRICTIONFRICTION
• CHEMICAL – PROCESS REDUCES RESIDENT FLORAE AND INACTIVATES MICROORGANISMS WITH AN ANTIMICROBIAL OR ANTISEPTIC AGENT
TYPES OF ANTIMICROBIAL TYPES OF ANTIMICROBIAL SKIN-CLEANSING AGENTSSKIN-CLEANSING AGENTS
• CHLORHEXIDINE GLUTANATE• IODOHORS• TRICLOSAN• ALCOHOL• HEXACHLOROPHENE• PARACHLOROMETAXYLENOL
GOWNING – DONNING OF GOWNING – DONNING OF STERILE GOWNSTERILE GOWN
• GLOVING – WEARING OF STERILE GLOVES TO COMPLETE THE ATTIRE.
CLOSED/ OPEN TECHNIQUE
GOWNS 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 provide the tools the surgeon needs for each maneuver
• Whether they are small or large, short or long, straight or curved or sharp or blunt, all instruments can be classified by their function.
• All instruments should be used only for their intended purpose and they should not be abused.
SURGICAL INSTRUMENTATIONSURGICAL INSTRUMENTATION
CUTTING & DISSECTING
CLAMPING & OCCLUDINGCLAMPING & OCCLUDING
GRASPING & HOLDINGGRASPING & HOLDING
EXPOSING & RETRACTINGEXPOSING & RETRACTING
Basic instruments are essential to accomplish most types of general surgery. Each instrument can be placed into one of the four following basic categories:Cutting and DissectingClamping and OccludingGrasping and HoldingRetracting and Exposing
MEASURING Ruler, depth gauges, caliperACCESSORY INSTRUMENTS Mallet, screw drivers, hudson braceMICROINSTRUMENTATION Powered surgical instruments – saw, drill,
dermatone
SPONGESSPONGES
Are 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 SPONGE, SHARPS, & INSTRUMENT COUNTSCOUNTS
ACCOUNTABILITYIs a professional responsibility that rests primarily
on the scrub nurse & the circulator.
COUNTING PROCEDURESIs 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 1. BASELINE COUNT DURING SET- UP FOR THE SURGICAL PROCEDURETHE 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 floor
3. FINAL COUNT (SECOND CLOSING COUNT)Performed before any part of a cavity or a cavity
within a cavity is closed.
WOUND CLOSUREWOUND CLOSURE1. Continuous suture (running stitch) – peritoneum
& vessels because it provides leak proofs suture line.
2. Interrupted suture – each stitch is taken & tied separately.
3. Buried suture – suture is placed under the skin, buried either continuous or interrupted.
4. Purse-string method – a continuous suture is placed around a lumen & tightened, drawing fashion, to close the lumen.
5. Subcuticular suture – a continuous suture is placed beneath epithelial layers of skin I short lateral stitches
B. DRAINS – is placed in a separate small incision B. DRAINS – is placed in a separate small incision parallel to the operative incisions to drain blood & parallel to the operative incisions to drain blood & serum from the operative site.serum from the operative site.
MONITORING MONITORING BODY 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 ARRESTCARDIAC & RESPIRATORY ARREST
No need for code blue Surgeon talk to family in case of death
ALLERGIC 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 MOVING & TRANSPORTING THE CLIENT 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 POSTOPERATIVE PERIODPERIOD
BEGINS WITH THE ADMISSION OF THE BEGINS WITH THE ADMISSION OF THE CLIENT TO THE POSTANESTHESIA AREA CLIENT TO THE POSTANESTHESIA AREA AND ENDS WHEN HEALING IS COMPLETEAND ENDS WHEN HEALING IS COMPLETE
Stages of RecoveryStages 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 NURSINGPOST-ANESTHESIA NURSING
GOAL: 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: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.
IMMEDIATE ASSESSMENT INIMMEDIATE ASSESSMENT IN PACU PACU
AIRWAY – tubes/ respiratory assistive deviceBREATHING – RR & depth, breath sounds, stay
beside til gag reflex returnsCIRCULATION – PR, BP, skin color, ECG,
O2Sat, dressing, wound statusOTHERS – LOC, muscle strength, ability to
follow command, IV, drains, tubes, inspect skin (burns, bruises, temperature)
POSTOPERATIVE POSTOPERATIVE NURSING CARENURSING CARE
ASSESSMENT
1. ASSESS RESPIRATORY STATUS
Patent airway ♠ HYPOXIA
2. ASSESS CIRCULATION• V/S, skin, color, temperature• Weakness, numbness, pressure ulcers• Early ambulation – leg exercise if not tolerated
3. ASSESS NEUROLOGIC STATUS
LOC, orientation, lingering effects of anesthesia
4. MONITOR WOUND4. MONITOR WOUND
a. Assess dressing amount & charac. Drainage, wound appearance
b. Measure drainage – drains, ostomy bag
c. Wound dressing DEHISCENCE & EVISCERATION
5. MONITOR IV LINESCheck IV lines – patency, I & O,
Infiltration – mild heat to decreased local pain
6. MONITOR DRAINAGE TUBES6. 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 obstruction
Until peristalsis begin – may remove w/ orderBowel sounds NGT clamp & removed
Passage of flattus if tolerated w/o N/Vhunger
7. PROMOTE COMFORT7. PROMOTE COMFORT
• Pain meds
Oral – reassess after 30 minutes
IV – reassess after 5-10 minutes
8. REDUCE NAUSEA & VOMITING
Vomiting – 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 PneumoniaAtelectasis and Pneumonia
• Collapse of the alveoli with retained mucous secretions
• The most common postoperative complication; usually occurs 1 to 2 days after surgery
Assessment• 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
HypoxiaHypoxia • An inadequate concentration of oxygen in
arterial blood
Assessment• 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 EmbolismPulmonary Embolism • An embolus blocking the pulmonary artery
and disrupting blood flow to one or more lobes of the lung
Assessment• 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 ShockHemorrhagic and Shock • Loss of circulatory fluid volume as a result of
losing a large amount of blood externally or internally in a short period
Assessment• 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
ThrombophlebitisThrombophlebitis• Inflammation of a vein (most commonly in the
leg), often accompanied by clot formation
Assessment• Vein inflammation • Aching or cramping pain • Vein feels hard and cordlike and is tender to
touch • Increased temperature • Homans' sign
InterventionsInterventions• 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 RetentionUrine Retention • Caused by anesthetics & narcotic analgesics
• Usually appears 6 to 8 hours after surgery
Assessment
• Inability to void
• Restlessness and diaphoresis
• Lower-abdominal pain & a distended bladder
• On percussion, bladder sounds like a drum
InterventionsInterventions• 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 IleusParalytic Ileus
Description• Failure of bowel contents to move along
appropriately• May occur as a result of anesthetic
medications or manipulation of the bowel during surgery
Assessment• 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
ConstipationConstipation
Description
• When client resumes a solid diet after surgery, failure to pass stool within 48 hours is a cause for concern
Assessment
• 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 InfectionWound Infection
Description• Wound becomes contaminated with a
microorganism
Assessment• 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 DehiscenceWound Dehiscence
Description • Separation of the wound
edges at the suture lineAssessment• Increased drainage • Opened wound edges • Appearance of
underlying tissues through the wound
Interventions• Place the client in low Fowler's 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
EVISCERATIONEVISCERATION• Abdominal wound becomes infected &
abdominal incision opens, the fascia or internal organs may be visible.
• Preceded gush of serosanguinous drainage
Interventions• 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 TeachingDischarge 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 surgeon's office for follow-up
• Instruct client that sutures are usually removed in surgeon's 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 surgeon
Generally client can return to work in 6 to 8 weeks, as prescribed by surgeon