Topic 2: SURGERY - Concept of Illness and PainInstructor: Mrs. Rossana Tasic

HEALTH – state of complete physical, mental and social well being and not merely the absence of a disease or infirmity (WHO 1948)

- viewed as a dynamic, ever changing condition that enables people to function at an optimal potential at any given time

- ideal health status is one in which people are successful in achieving their full potential, regardless of any limitations they might have

- represents successful adaptation to stress – ability to adapt to internal and external environment

ILLNESS – state of having a disease or sickness

DISEASE – abnormal variation, deviation from, or interruption in the normal structure or function of any part, organ, or system of the body causing disruption in function manifested by characteristic set of symptoms or signs and therefore limits freedom of action

- etiology, pathology and prognosis may be known or unknownetiology – causepathology – processprognosis – outcome

- disruption of the normal process

ETIOLOGY – cause of disease- describes what sets the disease process in motion- what triggers – predisposing and precipitating factors

precipitating – triggeringpredisposing – criteria that can make you, later on, develop the disease

ETIOLOGIC AGENTS biologic – bacteria, viruses physical – trauma, burns, radiation chemical – poison, alcohol nutritional excesses or deficits – under/over nourishment

PATHOGENESIS – sequence of cellular and tissue events that take place from the time of initial contact with an etiologic agent till the ultimate expression of diseases

- time of contact until the time that signs and symptoms are evident- describes how the disease process evolves

PATHOLOGY – came from the Greek word “pathos” meaning “disease”- deals with the study of the structural and functional changes in cells, tissues,

organs of the body that cause or are caused by the disease

*you always go back to the cell because it is the smallest unit in the body

PHYSIOLOGY – deals with the normal functions of the body

HOMEOSTASIS – refers to the steady state within the body- State of equilibrium in the body’s internal environment – cells, tissues, organ and

fluids- When a change or stress occurs causing the body function to deviate from its

stable range, processes are initiated to restore and maintain the dynamic balance- If not adequate, homeostasis/steady state is threatened, functions become

disordered and dysfunctional response occurs that can lead to a disease- determined by how body adapts to change

everything boils down to the immune system or how your body responds to stress

PATHOPHYSIOLOGY – physiology of altered health- study of how a disease goes on and what are the changes that go on in the body- deals with the cellular and organ changes that occur with disease and the effects

that these changes have on total body function, focusing on the mechanism of the underlying disease and provides background for preventive as well as therapeutic health care measures and practices

STRESS – defined as a state resulting from a change in the environment that is perceived as threatening to homeostasis

- stimulus is known as “stressor”

EFFECTS OF STRESS1. adaptive – adaptation or adjustment to change or coping with change- you are able to overcome and have a positive results- lead to positive effective/effective – health

2. maladaptive – negative effect/ineffective adaptation – disease and illness develops

MECHANISM OF CELLULAR REPAIR cellular adaptation – cells adapt by undergoing changes in size, number and type

adaptation – desired outcome in managing actual or perceived stress to reestablish equilibrium

regenerative healing – damaged cells and tissues are replaced by new cells and tissues identical to the damaged cell and tissue

replace healing – replacement cells such as connective tissue, resulting in scar formations

FACTORS AFFECTING CELLULAR REPAIR1. age2. nutritional status3. presence of infection you have to correct one illness before you can go to another 4. chronic illness – predisposes cellular injury e.g. secondary disease

5. nature of the wound – incision under aseptic technique vs. traumatic wounds6. extent of wound and associated blood loss7. tissue involved – tissues with good blood supply heal faster8. psychosocial – like stress and fatigue can impair healing

PSYCHOLOGICAL PROCESS OF ILLNESSI. CELL INJURY AND INFLAMMATION

injury – disorder in or the loss of the steady – state regulation- any stressor that alters the ability of the cell or system to maintain

optimal balance of its adjustment process leads to injury causing structural and functional changes which may either be reversible (permits recovery) or irreversible (leading to disability or death)

agents causing injury acts at the cellular level by damaging or destroying the following:1. integrity of the cell membrane necessary for ionic balance2. the ability of the cell to transform energy – e.g. stressor will make you lose your

confidence. Therefore if you lose confidence, you would stay “mumoy” in one side.

3. the ability of the cell to synthesize enzymes and other necessary proteins4. the ability of the cell to grow and reproduce (genetic integrity) – can be related to

ABT

CAUSES OF CELL INJURY1. EXTERNAL

a. Physical agents – duration of exposure and intensity determines severity of damage

i. Temperature extremes – heat stroke, hypothermiaii. Radiation – decrease protective inflammatory response lead to

opportunistic infectioniii. Electrical shock – result to burns ; may over stimulate nerves e.g.

VF1. mechanical trauma – disrupts cells and tissues of the body- outcome depends on severity of wound, amt. of blood loss, and extent of nerve damage

b. chemical agents – poison, drugs (overdose), alcoholc. infectious agents – biological agents e.g. viruses, bacteria, fungi, etc.

2. INTERNALa. Hypoxia – inadequate cellular oxygenation

- respiratory system and efficiency of breathing of patient- do deep breathing or remove secretions

b. Nutritional imbalance – deficiency or excess of 1 or more essential nutrient

c. Immune mechanism – d/o immune response e.g. autoimmune diseases, immunodeficiency

d. Genetic defects – congenital anomalies e.g. Down’s, obesity CA, (hereditary disease)

e. Psychogenic factors – stressf. Chemical agents – e.g. HCl, insulin

WAYS ON HOW BODY RESPONSES TO INJURYI. CELLULAR RESPONSE TO INJURY AND INFLAMMATION

A. CELL ADAPTATIONADAPTATION STIMULUS

hypertrophy – increase in cell size leading to increase in organ size

- increased workload

atrophy – shrinkage/decrease in cell size leading to decrease in organ size

decrease in:1. use2. blood supply3. nutrition4. hormonal

stimulation5. innervations

of the nervehyperplasia – increase in the number of new cells (increased mitosis)- multiplication of cells caused the enlargement

hormonal influence

dysplasia – changes in the appearance of cells after chronic irritation

- reproduction of cells with resulting alternation of their size and shape

metaplasia – transformation of one adult cell type to another cell type (this is reversible)

- stress applied to highly specialized cells

B. BODY DEFENSES AGAINST INJURYINTACT SKIN AND MUCOUS MEMBRANE – body’s first line of defense

oral mucous membranes has many layers; difficult to penetrate skin has acidic (pH < 7) properties that renders some org unable to produce illness

CILIA – hair-like structures lining the upper respiratory tract mucous membrane- protect lungs by trapping mucus, pus, dust, and foreign particles- push trapped particles up the pharynx with wavelike movements

GASTRIC JUICES – found in the stomach’s highly acidic (pH of 1-5) acidic environment destroys most organisms that enter the stomach

IMMUNOGLOBULINS – proteins found in the serum and body fluids- acts antibodies to destroy invading organisms and prevent development of

infectious diseases

ANTIBODY – protein produced by B lymphocytes when foreign antigens of invading cells are detected

ANTIGEN – markers on cell surface that identify cells as being the body’s own (auto antigens) or as being foreign cells (foreign antigen)

antibodies combine with specific foreign antigens on the surface of the invading organisms, such as bacteria or viruses, to control or destroy them

antibodies can destroy or neutralize antigens througho initiating destruction of antigeno neutralize toxins released by bacteriao promote antigen clumping with the antibodyo prevent the antigen from adhering to host cell

LYZOSYMES – bactericidal enzymes present in WBC and most body fluids (tears, saliva, and sweat)

- dissolve the walls of bacteria

INTERFERON – proteins made and released by lymphocytes in response to presence of pathogens: virus, bacteria, parasites, or tumor cells

- aids in the destruction of infected cells and inhibits production of the virus within the infected cells

C. MONOCULAR PHAGOCYTE SYSTEMPHAGOCYTOSIS – engulfing and ingestion of bacteria and other foreign bodies by phagocytes

PHAGOCYTES – cells that ingest and destroy bacteria, damaged or dead cells, cellular debris, and foreign substances

DIFFERENT PHAGOCYTES: LEUKOCYTES (WBC) – primary cells, protect against infection and tissue

damage- 5 types:

o neutrophils – bacteria and small particleso monocytes – become macrophages ; tissue debris and large particleso lymphocytes – functions: antigen recognition and antibody productiono basophils – respond to inflammation from injuryo eosinophils – destroys parasites and response in allergic reactions- increased during allergic reactions or infestation

MACROPHAGES – mature monocytes

INFLAMMATORY RESPONSE – occurs as a result to injury, pathogens, trauma, or any other event that can cause injury to tissue

- infection may or may not be present

STEPS IN THE INFLAMMATORY PROCESSI. VASCULAR RESPONSE – local vasodilation

- increased blood flow in the injured area brings more plasma to nourish tissue and carry waste and debris away

- redness (redness) and heat (calor) manifestedII. INFLAMMAOTRY EXUDATE – increased permeability of blood

vessels- plasma moves out from capillaries to the tissue- swelling (tumor) and pain (dolor) manifested due to compression of nerve endings

*kung ga habok ang IV site, assess if it is:INFILTRATION PHLEBITIS

pale redcold heatpain painsoft swelling hard swelling

III. PHAGOCYTOSIS AND PURULENT EXUDATE – final step- destruction of pathogenic organisms and their toxins by leukocytes- pus containing protein, cellular debris, and dead leukocytes

CARDINAL SIGNS OF INFLAMMATION redness (rubor) - produced by the following chemical mediators: heat (calor) histamine, prostaglandins, leukotrienes, swelling (tumor) bradykinins, platelet activating factors pain (dolor) – prostaglandins and bradykinins loss of function (functio laesa)

ALTERED IMMUNE RESPONSEIMMUNE SYSTEM – body’s final line of defense against infection and/or cellular injury

- finely tuned network that functions together to protect the body form potentially harmful substances by recognizing and responding to antigens

COMPONENTS OF THE IMMUNE SYSTEM1. IMMUNE CELLS

a. Lymphocytes (T cells, B cells, and natural killer cells) have protective functions related to specific antigen

b. Macrophages assist T and B lymphocytes

2. LYMPHOID ORGANSa. Thymus – vital to the development of the immune systemb. Bone marrow – produces leukocytes, which is one of the products of

blood- problems in bone marrow can, later on, cause leukemiac. Spleend. Tonsils e. Intestinal lymphoid tissuef. Lymph Nodes

IMMUNITY – resistance to a disease that is provided by the immune system

- ability of the body to protect itself from diseaseIMMUNE RESPONSE – involves a complex series of interactions between the components of the immune system and the antigens of foreign pathogen

TYPES OF IMMUNITY 1. INNATE IMMUNITY – immunity you are born with involving barriers

that keep harmful materials form entering the body- forms the first line of defense in the immune response- e.g. cough reflex, enzymes in the tears, mucus, skin stomach acid

2. PASSIVE IMMUNITY – antibodies produced in the body other than your own (person or animal)

- transferred from another source (utero transfer from mom to child)- temporary in infants and disappears after 6-12 months

3. ACTIVE IMMUNITY (Acquired) – develop with exposure to various antigens; defense against a specific antigen

- acquired through immunization or actually having a disease4. HUMORAL – consists of protection provided by the B-lymphocyte-

deviated plasma cells, which produce antibodies that travel in the blood and interact with circulating and cell surface antigen

5. CELL-MEDIATED – protects against viruses, intracellular bacteria, and cancer cells

- usually occurs through cytotoxic activity of cytotoxic T cells and the enhanced engulfment and killing by macrophages

CYTOKINES – regulatory proteins produced during all the phases of an immune response

- they regulate response of host to foreign antigens or injurious agents by regulating movement, proliferation and differentiation of leukocytes and other cells

ALTERED IMMUNE RESPONSE- refers to inadequate, inappropriate, or excessive immune response to cellular

injury or infection resulting to immune system disorders that is serious and life threatening

CLASSIFICATION OF DISORDERS due to ALTERED IMMUNE RESPONSE1. IMMUNODEFICIENCY DISEASE- immune response insufficient to protect host- failure of the immune or inflammatory response to function normally, resulting in

increased susceptibility to infection- clinical hallmark:

o tendency to develop unusual or recurrent, severe infection preschools and school-age: 6 to 12 infections/year adult: 2 to 4 infections/year

o recurrent infection w/ short periods of good health with multiple simultaneous infection

2. HYPERSENSITIVITY REACTIONS- excessive or inappropriate activation of the immune system- altered immunologic response to an antigen that results in disease- types:

o ALLERGIC – cause: environmental antigens (medicines, natural products e.g. pollens and bee stings, infectious agents, and any other antigen not naturally foudn in the individual)

Anaphylaxis – most common allergic reaction- occurs within minutes after exposure

o AUTOIMMUNITY – a.k.a. autoimmune disease- disturbance in the immunologic tolerance of self-antigens- occur when the immune system reacts against self antigens to such

a degree that auto-antibodies or autoreactive T cells damage individual’s

o ALLOIMUNITY – occurs when the immune system of one individual produces an immunologic reaction against tissues of another

- e.g. transfusion reactions, transplanted tissue (rejection) or the fetus during pregnancy (Rh), grafting reactions

CONCEPT OF PAIN“Pain is whatever the experiencing person says it is, existing whenever the

experiencing person says it does.” By Margo McCaffery, a well-known pain consultant

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” -1979, International Association for the Study of Pain (IASP)

PAIN- fifth vital sign- most important protective mechanism

- strong motivator for action- one of the body’s most important adaptive mechanisms- protective mechanism or a warning

o congenital analgesia – rare genetic disorder where the individual is unable to feel pain

PAIN EXPERIENCE IS PRODUCED BY THE INTERACTION OF THREE SYSTEMS:

1. SENSORY/DISCRIMINATIVE – process information about the strength, intensity, temporal and spatial aspects of pain

- results in prompt withdrawal from the painful stimulus2. MOTIVATIONAL/AFFECTIVE – determines individual conditioned or learned

approached or avoidance behavior3. COGNITIVE/EVALUATIVE – overlies individual learned behavior- individual’s interpretation of appropriate pain behavior is learned through cultural preferences, male-female roles and life experience

NOCICEPTION – sensory process leading to perception of pain

NOCICEPTORS – free nerve endings that responds to chemical, mechanical dn thermal stimuli

TYPES OF PAIN:I. PHASIC

A. Acute Pain – has identifiable cause and occurs soon after and injury - temporary and subsides as healing takes place as chemical mediators

causing pain are removed- onset: sudden and slow- intensity: varies from mild to severe- severe acute pain activates sympathetic nervous system causing

diaphoresis, increased RR, PR and BP- usually lasts until 6 months- classifications:

o SOMATIC – superficial (comes form the skin or close to the surface of the body)

o VISCERAL – pain in the internal organs, abdomen or skeleton; radiates or referred

o REFERRED – pain present in an area removed or distant form point of origin- supplied by the same spinal segment as actual site since skin

has more receptors, pain is feltB. CHRONIC PAIN – persistent, lasts beyond expected healing phase

- non-protective; related to tissue damage, inflammation or injury of the NS

- lasts for more than 6 months

NEUROPHYSIOLOGICAL TRANSMISSION OF PAIN“ Pain is the result of transduction, transmission, perception and modulation of

painful (nociceptive) impulses.”

STAGES IN THE TRANSMISSION OF PAIN STAGE 1 – TRANSDUCTION

- refers to the conversion of mechanical, chemical or thermal information into electrical activity in the NS

STAGE 2 – TRANSMISSION- transfer electrical impulses to the CNS

CNS – process nociceptive signals to extract relevant information- the processing and extraction of relevant features of sensory input

STAGE 3 – PERCEPTION- awareness of pain that is dynamic, changing in response to person’s

development, environment, disease or injury- can be brief, prolonged, or even permanent

STAGE 4 – MODULATION- also called adjustment- refers to internal and external ways of reducing/increasing the pain

STIMULI (chemical, mechanical, thermal)

Receptor molecules at the tip of nociceptive primary afferent neurons (free nerve endings)

Creation of action potential

Electrical energy (action potential) travels (progresses form the injury site) to the spinal cord

Spinal cord’s dorsal horn (central gray matter)

Transfer of impulses form the nociceptor to the spinothalamic tract (transduction)

Thalamus – acts as relay station sending pain impulses to different areas in the brain for processing

Electrical energy (stimuli) reach the cerebral cortex

Interpretation of stimuli (transmission)

Perception of pain

Somatosensory cortex – identifies location and intensityAssociated cortex – determines how an individual interprets the meaning

Released of neuromodulators (endorphins, serotonin, norepinephrine, GaBa)

This chemicals hinder the transmission of pain producing an analgesic, pain-relieving effect

Inhibition of pain impulse(modulation)

PAIN THRESHOLD – intensity of the stimulus a person needs to sense/feel pain

PAIN TOLERANCE – the duration and intensity of pain that a person tolerates before openly expressing

PAIN THEORIES:1. SPECIFICITY THEORY – intensity of pain is directly

related to the amount of associated injury – DesCartes, 17th century- finger prick against cutting off on one hand- more tissue injury, more painful- useful in specific injuries or acute pain, but not with chronic or cognitive and

psychologic contributions to pain

2. NEUROMATRIX THEORY – Ronald Melzack proposes that a large number of interconnected neurons, a neuromatrix, exists in every person- neuromatrix analyzes the sensory information and gives perception of sensation- tells the brain that the perseptions of sensation are from the “self”- neurosignature tells the brain that your arm is your arm, not someone else’s

3. GATE CONTROL THEORY – first proposed in 1965 by psychologist Ronald Melzack and anatomist Patrick Wall- “gating system” in the CNS that opens and closes to let pain messages through to

the brain or to block them- according to the gate control theory of pain, our thoughts, beliefs, and emotions

may affect how much pain we feel from a given physical sensation- delayed pain perception of athletes

research: Hans Selye

NURSING CARE OF CLIENT EXPERIENCING PAINI. ASSESSMENT- thorough and accurate- highly subjective and needs to be evaluated- always remember the principle of pain assessment:

“Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does.” By Margo McCaffery

JCAHO- a private sector US-based not-for-profit organization that sets standards for

accreditation of health institutions.- helps to improve the quality of patient care by assisting international health care

organizations, public health agencies, health ministries and others evaluate, improve and demonstrate the quality of patient care and enhance patient safety and to demonstrate quality.

HIGHLIGHTS OF JCAHO PAIN STANDARDS assess all patients routinely for pain record assessment data in a way that facilitates reassessement and follow-up educate patients and families on the importance of pain management as part of

care do not permit pain to interfere with optimal level of function or rehabilitation include pain and symptom management in discharge planning

ASSESS:Ia. HistoryIa1. Pain characteristics

onset and duration location intensity quality relieveing factors aggravating factors

NOTE: use the alphabet of pain – PQRST P – Provocative or Palliative Q – Quality R – Region and Radiation S – Severity T – Timing

Ia2. Drug History – complete list of medications with allergies

Ia3. Social History – how patient feel about himself- support system

PAIN RATING SCALES The most commonly used Pain assessment scale is the Numeric Pain Rating scale. You ask the patient to rate their pain on a scale from 0 to 10 with “0” being no

pain and “10” being the worst pain they have ever had.

Be sure and let patients rate their own pain, do not be influenced by family members rating the pain.

The Visual Analogue Scale may be easier for some patients to use. Show them the scale and ask them to rate their pain.

The Face Scale may be used for some adults who are unable to use the number scales. Ask the patient to pick a face that matches how they feel and record that # as their pain level.

Brief Pain Inventory(BPI) – pt’s pain in last 24, least & worst Cries Neonatal Postoperative Pain Measurement Scale

FLACC Pain Assessment Tool

Faces Pain Rating Scale - language difficulties such as aged, pedia Oucher Pain Rating Scale

Numerical or Visual Analog Scale

Adolescent, Pain, tool.. :-D Logs and Diaries – Pain Self-monitoring record

POTENTIAL NURSING DIAGNOSIS: physical mobility disturbances nutrition less than body requirement, risk for social interaction, impaired

II. PLAN/IMPLEMENTATION1. Establish therapeutic relationship2. teach patient about pain relief3. reduce anxiety and fears4. provide comfort measures5. manage pain

TYPES OF PAIN MANAGEMENTI. Nonpharmacologic Management – concern on overuse of

drugs

3 MAIN CATEGORIES OF NONPHARMACOLOGIC THERAPY Physical Therapy - use physical agents & methods ease

pain, reduce inflammation, ease muscle spasm, & promote relaxation.a. Hydrotherapyb. Thermotherapyc. Cryotherapyd. Vibratione. TENS f. exerciseg. immobilization

Alternative Therapy - used instead of conventional or mainstream therapy - eg. Acupuncture – analgesics

Complementary - used in conjunction w/ conventional therapy- e.g. Meditation as adjunct to analgesic medication

o Aromatherapyo Music Therapyo Therapeutic Touch and Massage

o Yoga and Meditationo Chiropractic Treatmento Acupunctureo Biofeedbacko Hypnosiso Guided Imageryo Magnet Therapyo Thought Stoppingo Crystal or Gemstone Therapyo Herbal Therapyo Heat and Cold Application

II. PHARMACOLOGICA. ANALGESIS

a. Nonopioid (nonnarcotic) – used to treat pain that’s either nociceptive (injury receptors) or neuropathic (nerves)

effective in somatic pain like joints and muscle pain controls pain, decreased inflammation and fever e.g. acetaminophen, NSAID’s, salicylates

b. opioids (narcotics) – w/ primary effects in the CNSi. opioid agoinist – treat moderate pain w/o loss of consciousness

e.g. Codeine, Fentanylii. mixed agonist – antagonist – decrease risk of toxic effect and

dependency e.g. nalbuphine

iii. opioid antagonist – blocks opioid effectB. METHODS OF ADMINISTRATION

a. Topicalb. Oralc. IMd. IVe. PCA - Patient Controlled Analgesiaf. Conscious Sedationg. Intranasalh. Epidural

PCA – is a means for the patient to self-administer analgesics (pain medications) intravenously by using a computerized pump, which introduces specific doses into an intravenous line.

C. SURGICAL INTERVENTIONS 1. RHIZOTOMY – selective destruction of the dorsal root of the spinal nerve2. NERVE BLOCK OR CORDOTOMY – unilateral or bilateral severe nerve fibers

in the spinal cord3. NEURECTOMY – resection of one or more peripheral branches of the cranial or

spinal

4. SYMPATHECTOMY – destroys nerves in the SNS performed to increase blood flow and decrease long-term

pain in certain diseased that cause narrowed blood vessels can also be used to decrease excessive sweating this surgical procedure cuts or destroys the sympathetic

ganglia, which are collections of nerve cell bodies in clusters along the thoracic or lumbar spinal cord

PERIOPERATIVE NURSING the scrub nurse is always in front of the surgeon

PERIOPERATIVE NURSING CAREa. connotes the delivery of patient care in the:

i. preoperativeii. intra-operative

iii. postoperative …periods of the patients surgical experience through the

framework of the nursing processb. nurse assess the client by:

i. collecting, organizing and prioritizing patient dataii. establishing nursing diagnosis

iii. identifies desired patient outcomes iv. develop and implements a plan of carev. evaluates the care given in terms of outcomes achieved by the

patient

PERIOPERATIVE NURSING CARE PHASES PREOPERATIVE PHASE INTRAOPERATIVE PHASE POSTOPERATIVE

- types:o immediate post-operative/peri-anesthesia phase/PACU nursing/Recovery

Room nursingo post-operative phase – px. is already in the room/ward until the patient

goes home w/o complications

SURGERY – comes from the Greek word “kheirurgus” = “working by hand”

TYPES OF PATHOLOGIC PROCESSES REQUIRING SURGICAL INTERVENTION1. OBSTRUCTION – impaired flow2. PERFORATION – rupture (of a tissue)3. EROSION – wearing off of a membrane4. TUMORS – abnormal growths (w/c can cause your obstruction)

CATEGORIES OF SURGERY1. DEGREE OF RISK

a. MAJOR – high risk, extensive, prolonged, increased blood lossb. MINOR – less risk, less complicated, not prolonged

2. EXTENT – localized or involves the whole system?a. MINIMALLY INVASIVE – usually performed with the use of fiberoptic

endoscopes and does not require traditional or extensive incisions- involves the use of smaller incisions, customized instrumentation, specialized imaging, computerized global navigation system and roboticsb. OPEN – involves traditional opening of body cavity or body part to

perform the surgeryc. SIMPLE – generally limieted to a defined anatomic location and do not

require extensive exposure and dissection of adjacent tissued. RADICAL – usu. Associated w/ malignancies- involves dissection fo tissue and structures beyond the immediate operative site

3. PURPOSE Classification:

a. DIAGNOSTIC – determine cause of symptoms or origin of problemb. CURATIVE – to resolve a health problem or disease state by removing

the involved tissuec. RESTORATIVE/RECONSTRUCTIVE – performed to correct deformity,

repair injury or improve functional statusd. PALLIATIVE – relieve symptoms w/o the intent to curee. ABLATIVE – removal of diseased organf. COSMETIC – performed primarily to alter or enhance personal

appearance4. ANATOMIC SITE – which part of the body?

a. CARDIVASCULAR surgeryb. CHEST surgeryc. INTESTINAL surgeryd. NEUROLOGIC srugery

5. TIMING OR PHYSICAL SETTING – when and where?Classification for timing:

a. ELECTIVE – performed on the basis of clients choice; not essential and may not be necessary for health

b. URGENT – necessary for client’s health- may prevent additional problem from developing (e.g. tissue destruction);

not necessarily emergencyc. EMERGENT – must be done immediately to save life or preserve function

of body partd. REQUIRED – has to be performed at some point can be pre-scheduled

Physical Settings:a. SURGICAL SUITESb. AMBULATORY CARE SETTINGc. CLINICSd. PHYSICIAN’S OFFICESe. COMMUNITY SETTING

f. HOMES

DISADVANTAGES OF OUTPATIENTa. less time for rapportb. less time to assess, evaluate, teach risk of potential complications

ADVANTAGES OF OUTPATIENTa. low costb. low risk of infectionc. less interruption of routined. less stress

6. PROCUREMENT FOR TRANSPLANTATION- removal of organs and/or tissues from a person pronounced brain dead for

transplantation into another person

SUFFIXES DESCRIBING SURGICAL PROCEDURES -ectomy – excision or removal of an organ or gland -orrhaphy – repair or suture of -lysis – destruction of -oscopy – looking into - ostomy – creation of opening into -plasty – repair or reconstruction of

PREOPERATIVE PHASE- begins when the decision for surgical intervention is made and ends with the

transfer of the patient to the operating table

SCOPE OF NURSING ACTIVITIES 1. Establishing the baseline assessment of the patient in the clinical setting or at

home2. Ensuring the necessary laboratory test needed3. Carrying out of preoperative interview4. Preparing the patient for the anesthetic he is to receive and the surgery he is to

undergo5. Focus on assessing the post-operative status of the patient in terms of the effects

of the anesthetic agent.6. Impact of surgery on body image or role function.7. Evaluate the family’s perception of surgery.

PREOPERATION CAN TAKE PLACE IN ANY OF THESE TIME AND PLACE:1. In the physician’s office before admission to the health care facility.2. On admission and during the days before the operation.3. The night before the surgery if the client is in the hospital.4. The morning of surgery on admission.

GENERAL PREOPERATIVE PREPARATIONPhysiologic Nursing Assessment of client undergoing surgery

1. AGE older adults have the lowest tolerance to stressful effects of surgery old age produces physiologic changes that increase surgical risk

Interventions for Physical Changes in Older Adults Undergoing SurgeryPHYSICAL CHANGE NURSING INTERVENTIONCARDIOVASCULAR

decreased cardiac output moderate increased in BP decreased peripheral circulation arrythmias

Know what anesthesia is used Monitor V/S carefully Encourage early ambulation & leg

exercises Assess for hypotension or

hypertension or hyperthermia Note any changes to baseline ECG

RESPIRATORY Decreased vital capacity Reduced oxygenation of blood Decreased cough reflex

Assess pulmonary aspiration Monitor respirations carefully Vigorous pulmonary hygiene Post-operative: auscultate lung

sounds Oxygen saturation monitor

RENAL Decreased renal blood flow and

lomerular filtration rate Decreased ability to excrete waste

product

Monitor urine output 1 to 2 hours during Immediate post-surgery

Evaluate intake and output Monitor fluid and electrolyte status

MUSCULOSKELETAL decreased in lean body mass increase in spinal compression increased incidence of osteoporosis

and arthritis

assess level of mobility position on OR table with padding

to reduce trauma to bones and joints spine, limbs and pressure points

must be padded to prevent fractures early ambulation or exercises to

individuals ability provided adequate nutrition provide effective pain management

SENSORIMOTOR decreased reaction time decreased visual acuity decreased auditory acuity

orient client to environment plan individual teaching, allow time

to reinforce teaching provide safe environment

2. PRESENCE OF PAIN

3. NUTRITIONAL STATUS – client who is well nourished is better prepared to handle surgical stress

4. FLUID AND ELECTROLYTE BALANCE – dehydration and hypovolemia (fluid volume deficit) predispose a client to complications during and after surgery- electrolyte imbalance also increased operative risk

5. PRESENCE OF INFECTION6. CARDIOVASCULAR FUNCTION – client should be assessed for elevated BP;

slow, rapid or irregular pulse; edema; cold cyanotic extremities; weakness; and shortness of breath

LABORATORY AND DIAGNOSTIC STUDIES OFTEN ORDERED PRIOR TO SURGERY TO DETERMINE CARDIOVASCULAR FUNCTION:

a. ECGb. CBC

i. Hemoglobinii. Hemcatocrit

iii. WBC – if you are immunosuppressed, you have to strengthen the immune system

- so that the doctor will be able to foresee the crisis that may come and the interventions to be done prior to complication

iv. Plateletc. SERUM ELECTROLYTES – Na, K, Cl

- maintenance of circulating volume, movement of plasma in the cellsd. Urinalysis – kidney functione. BUN – Blood Urea Nitrogen

- high concentration – indicates there’s something wrong with the kidney or renal system

f. Creatinineg. Protime – cardiopulmonary clearanceh. Partial Thromboplastin Time– cardiopulmonary clearancei. Clotting Time/Bleeding Time – cardiopulmonary clearancej. X-Ray

OTHER DIAGNOSTIC TESTS (if needed):1. Pulmonary Function Test – check for capacity of lungs to have oxygen in it- check for amt. of volume the lungs can carry

COPD, emphysema, asthma and bronchitis increase operative risk because they impair CO2 and O2 diffusion in the alveolus and predispose the client to pulmonary infection

Assess client for shortness of breath, wheezing clubbed fingers, chest pain and coughing with expectoration of copious mucous

2. Renal Function Assess for symptoms of frequency, dysuria, anuria (absence of urination)

and observe for the appearance of urine

Includes: Urinalysis, BUN and Creatinine are commonly ordered preoperative tests

3. Gastrointestinal Function4. Liver Function – check if liver is still functioning well- liver is one of those organs that is highly vascular5. Endocrine Function – release of hormones- hypothyroidism – check that they should not be in crisis so that you won’t have

cardiac arrest6. Neurologic Function7. Hematologic Function – clients with coagulation diseases are at risk for

hemorrhage and hypovolemic shock during and surgery

5 FACTORS POINTING TO ABNORMAL HEMATOLOGIC FACTORS: History of bleeding tendencies Symptoms such as easy bruising, excessive bleeding following dental

extraction and severe nosebleed Presence of hepatic and renal disease Use of anticoagulants Abnormal bleeding time, prothrombin time or platelet count

8. Use of medication herbs- Cardiac conditions that increase operative risk include: angina pectoris, MI within

the last 6 month, uncontrolled hypertension, CHF and peripheral vascular disease- Clients take prescribed and non-prescribed medication that may increase

operative risk by increasing coagulation

SOME MEDICATIONS THAT MAY RESULT IN COMPLICAITONS INCLUDE:

ANTICOAGULANTSHeparin sodiumWarfarin sodiumAspirinNSAIDS

cause clotting abnormalities which results to hemorrhage

ANTIBIOTICS w/c is combined with other muscle relaxants

increase postoperative respiratory depression

TRANQUILIZERS decrease blood pressure thus increase the risk of shock

potentiates the effects of narcotics and barbiturates

THIAZIDE DIURETICS can create potassium depletionSTEROIDS cause hypofunction of the adrenal

cortex thus impair physiologic response to stress of anesthesia and surgery

anti-inflammatory effect delay wound healing and increase risk of

infectionMONOAMINE (MOA) INHIBITORS can cause hypertensive crisis when

combined with anesthetic agentsANTIPARKINSON DRUGS cause hypotension or hypertension

when combined with anesthetic agents

STREET DRUGS AND ALCOHOL ABUSE

increase tolerance to narcotics

HYPOGLYCEMICS require dosage alteration and close monitoring of blood sugar

HERBSGARLIC inhibits platelet aggregation

may potentiate warfarin increase INR and PT cause GI upset decrease blood glucose level

GINGER anticoagulant action large doses – increase risk of

bleeding and dysrhythmiasGINSENG tachycardia and hypertension, esp.

w/ the use of cardiac stimulants inhibit platelet aggregation decrease warfarin effectiveness lowers blood glucose potentiate effects of digoxin assess ginseng abuse syndrome:

hypotension, hypotonia and edemaGINGKO BILOBA prolongs bleeding time

increase anticoagulant effect subconjunctival hemorrhage and

spontaneous subdural hemorrhage

9. ALLERGIC REACTIONS

SKIN CONTACT INJECTION INGESTION INHALATION poision

plants animal

dander pollen latex

bee sting medication

medication nuts and

shellfish

pollen dust mold and

mildew animal

dander

10. Presence of Trauma – when surgery must be performed following traumatic incident, details of the event should be documented

11. Health Habits – how much exercise do you do? Do you smoke? Do you make us of drugs?

12. Social Habits

PSYCHOSOCIAL ASPECT OF PREOPERATIVE PREPARATION effectively handling client’s fears can smooth the preoperative experience studies show that client’s who are calm and emotionally prepared for surgery

withstand anesthesia better and experience fewer postoperative complications

PSYCHOLOGIC RESPONSE1. ANXIETY

POTENTIAL SOURCE OF ANXIETYa. anticipation of impending surgeryb. pain and discomfortc. changes in body image or functiond. role changese. loss of controlf. family concernsg. potential alterations in lifestyles

2. FEAR- client’s respond differently to fear – some respond by becoming silent and

withdrawn, childish, belligerent, evasive, tearful and clinging

COMMON FEARS RELATED TO SURGERYa. fear of the unknown

i. first decision to seek medical adviseii. subject to several laboratory tests

iii. first experience-operationb. loss of controlc. loss of love from significant othersd. threat to sexuality

SPECIFIC FEARSa. diagnosis of malignancyb. anesthesiac. dyingd. paine. disfigurementf. permanent limitations

ASSESSMENT OF PREOPERATIVE ANXIETYSUBJECTIVE DATA

1. understanding of proposed surgerya. siteb. type of surgery

c. information from surgeon regarding extent of hospitalization, postoperative limitations

d. preoperative routines – what will happen postoperatively?- let px. know that after surgery, px. will be staying in RRe. postoperative routinesf. tests

2. previous surgical experiencea. type, natureb. time interval

3. any specific concerns or feelings about present surgery4. religion, meaning for patient5. significant others

a. geographic distanceb. perception as source of support

6. changes in sleep pattern

OBJECTIVE DATA1. speech patterns

a. repetition of themesb. change topicc. avoidance of topics related to feelings

2. degree of interaction with others3. physical

a. pulse and respiratory ratesb. hand movement and perspirationc. activity leveld. voiding frequency

PREOPERATIVE TEACHINGS TO DECREASE ANXIETY1. Preoperative test

a. Reasonsb. Explanations of the test

2. Preoperative routines3. Schedules

a. Time of surgeryb. Probable lengthc. Time in the recovery room

4. Recoverya. Place where px. will awakenb. Close nsg. Supervisionc. Frequent monitoring of VSd. Return to room when VS are stable

5. Family Directionsa. Time px. will leave for surgeryb. Where the family may wait during surgeryc. Procedure for notification of results of surgery (by the Physician)

d. Procedure for notification of px. return to unit

PROBABLE POST-OPERATIVE THERAPIES1. Anticipate treatment (VI, NGT)2. Need for increased mobility as soon as possible3. Need fro breathing and coughing routines, even though these are uncomfortable4. Pain medication routines (timing, sequence-PRN status)

PREOPERATIVE PSYCHOLOGIC SUPPORT1. Asses client’s fears, anxieties, support systems and patterns of coping2. Establish trusting relationship with client and significant others3. Explain routine procedures, encourage verbalization of fears, and allow client to

ask questions4. Demonstrate confidence in surgeon and staff5. Provide for spiritual care if appropriate

PREOPERATIVE ASSESSMENT HISTORY TAKING - plays a large part in determining the degree of preoperative

and postoperative anxiety the client experiences- allows the nurse to:

o Establish rapport with cliento Begin psychosocial assessmento Reassure client and significant others and answer general questions about

surgery, the health-care facility etc.- Specific information to obtain during reoperative history concerns:

o Previous surgery and experience with anesthesiao Responses of significant others to previous surgery and anesthesiao Whether the client had any serious illnesso Previous and current medication (prescribed/over-the-counter)o Allergies and reactions and dietary restrictionso Alcohol, nicotine or recreational drug useo Current symptoms and discomfortso Occupationo Religious affiliationo Significant otherso Whether client has question about the surgeryo Chronic illnesses such as arthritis, migraines, backpains

PHYSICAL EXAMINATION

PREOPERATIVE DIAGNOSTIC TESTS1. Serum potassium 2. Hemoglobin3. Serum sodium 4. Hematocrit5. Serum chloride

6. Prothrombin time 7. Glucose 8. Partial thrombo-plastin time9. Blood Urea 10. Nitrogen 11. Chest X-ray12. Electrocardiogram13. Creatinine

PREOPERATIVE TEACHINGBasic areas that must be covered:

1. deep breathing and coughing exercise2. turning and extremity exercises3. pain control methods that will be offered – splinting, DBE, medications4. postoperative equipment

teach coughing and breathing exercise, splinting of incision, turning side to side on bed and leg exercises: explain the importance in preventing complications; provide for opportunity for return demonstration

COUGHING EXERCISE may be done sitting or lying down splinting the incision minimizes pressure and helps control pain when coughing client is instructed to interlace fingers across the incision to and hold them when

coughing a small pillow or folded towel may be held over the incision to facilitate splinting

LEG AND ANKLE EXERCISES – prevent deep vein thrombosis and embolism

POSTOPERATIVE EQUIPMENTa. wound drain and suction devicesb. penrose drain – used for post AP, ruptures where there are discharges

- acts as a route for all discharges to pass through so that it will be absorbed by the gauze

- tied to the skinc. Jackson-Pratt drain or reservoird. T-tube draine. Hemovac drainage system

PHYSICAL PREPARATION1. Preparing the Skin2. Preparing the GIT – some surgery require special bowel preparation (enema)3. Preparing for anesthesia4. Promoting rest and sleep

PREPARING THE CLIENT ON THE DAY OF THE SURGERY1. Early morning care

a. Begins at least 1-2 hours before surgeryi. Take vital signs and record

ii. Check identification band Consent form is signed and the surgical procedure is written correctly Check for and carry out any special orders such as administering

enemas or starting an IV line Verify that the client has not eaten for the last 8 hours Assist client with oral hygiene –if necessary Remove dentures or bridgework that could obstruct the airway if left

in place Have the client remove jewelry If client is wearing hearing aid, notify OR personnel Assist client in donning a hospital gown, protective head cap, ace

wraps or antiembolic socks Remove colored nail polish, remove make-up so skin color can be

observedPrior to administering preoperative medications, the nurse should check for:

1. Preoperative permit2. Transfusion permit (if require)

PURPOSE OF PREPOERATIVE MEDICATION1. allay anxiety2. decrease pharyngeal secretions3. reduce side-effects of anesthetic agent4. create amnesia

COMMONLY USED PREOPERATIVE MEDICATIONSGENERIC NAME TRADE NAME DESIRE EFFECT UNDESIRED

EFFECTSTRANQUILIZERSdiazepam droperidol

ValiumInapsine

Decrease anxietyDecrease anxietyProduce antiemetic effect

May cause dizziness, clumsiness or confusionAnxietyHypotension during and after surgery

SEDATIVESmidazolam Hcl

promethazine

Dormicum

Phenergan

Induces undesired sleepiness and reduces anxietyDecreases anxietyProduces an antiemetic effect

Hypotension, undesired respiratory depression Hypotension during and after surgery

secobarbital Napentobarbital Na

Seconal NaNembutal Na

Decreases anxietyPromotes sedation

Disorientation, especially in elderly patients

ANALGESICSmorphine sulfatemeperidine Hcl Demerol

Relieves painDecreases anxiety sedation

Respiratory depressionHypotensionCirculatory depressionDecreased gastric motility causing potential vomiting

ANTICHLINERGICatropine sulfatealycopyrrolate Robinul

Controls secretions Excessive dryness of mouth; tachycardia

HISTAMINE H2-RECEPTOR ANTAGONISTcimetidine Tagamet Inhibits gastric acid

productionSome mild dizziness, diarrhea, somnolence, and rash

LEGAL AND ETHICAL ISSUESA. Informed Consent

A statement consenting to the operative procedure Protect’s px. rights to self determination and autonomy regarding surgical

intervention Surgeon must explain the procedure in terms the client readily understand Implies that the patient has been given the information necessary to understand

the nature of the procedure and its known and possible consequence

PURPOSE OF SIGNED CONSENT ensure client understands nature of treatment including potential

outcome and disfigurement indicate px. decision was made w/o pressure protect client against unauthorized procedure protect surgeon and hospital against legal action when client

claims unauthorized procedure was performed

CIRCMSTANCES REQUIRING CONSENT any surgical procedure where scalpel, scissor, suture and hemostats

of electrocoagulation may be used entrance into a body cavity : paracentesis, cystoscopy,

pericardiocentesis, etc.

using anesthesia

NECESSARY COMPONENTS OF CONSENT patient’s full legal name surgeon’s name specific procedure (s) to be performed signature fo the patient, next of kin or legal guardian witnesses date it was signed

And adult sign their own consent unless they are unconscious or mentally incompetent. A parent or legal guardian usually provides consent for a minor

Emancipated minors, that is, minors who are married or earning their own livelihood and retaining the earnings can sign their own consent

If no legal guardian can be contacted, two phsycians who are not associated with the procedure amy make the decision for surgical intervention

Illiterate patients must understand the verbal explanation of the consent process and may sign the form with an X_ . This process must be witnessed by two persons.

The patient has the right to refuse surgical intervention Px. has the right to withdraw consent at anytime before the procedure is that

decision is reached voluntarily

At least 2 px. identifiers must be used to identify px. identityConfirm and verify the ff:

px. and name on ID band date of birth medical record number consent forms availability of blood radiologic examinations

Patient response must match: marked site ID band Consent forms Radiologic examinations Scheduled procedures

SITE MARKINGSSite verification is required for all procedures that involve laterality, multiple structures or multiple level.

Site is marked with a permanent marker that is visible after the skin is prepped and draped

Operating surgeon should mark the site with his or her initials before the patient enters the OR suites

Site is marked with patient participation (verbal confirmation or pointing)

A patient has the right to refuse to mark the site. Each institution will determine policy for these situation

PHYSICAL (P) STATUS CLASSIFICATION SYSTEMClassification Description

P1 Normal healthy patient

P2 Patient with mild systemic disease

P3 Patient with severe systemic disease

P4 Patient with systemic disease that poses a constant threat to life (ex. MI)

P5 Moribund patient not expected to survive w/o surgery

P6 Patient declared brain dead whose organs are being removed for donation

INTRAOPERATIVE PHASEIntraoperative Nursing

- 2nd Phase of the Perioperative Period- OR Nursing- OR table to PACU

NURSING ACTIVITIES Psychological Support – emotional well-being Physiologic support - assessment of patient status Maintenance of patient safety - positioning, maintain asepsis, & control of

surgical environment

PERIOPERATIVE TEAMa. Preoperative team

Pre-op nurse Physician, nurse practitioner or physician assistant Clinical nurse specialist – Advanced Practice Nurse, a MSN holder w/

Major in their field of specialty b. Surgical/Operating Team

Sterile Unsterile

c. Post Operative Team Post anesthesia nurse Medical-surgical nurse

MEMBERS OF THE SURGICAL TEAM- group of highly trained & educated professionals who coordinate their efforts to

ensure the welfare & safety of the client Sterile Team Non-Sterile Team

STERILE MEMBERS1. SURGEON

The team leader & main decision maker Performs the operative procedure safely and correctly Performed draping of the patient and checks all other needed for the

produre Secures dressing In place Assist in moving the patient to PACU Do the post operative orders

2. ASSISTANT TO THE SURGEON Assist to the surgeon in operative procedure Assist in positioning the patient and draping Assist in closing the incision and dressing Assist in moving patient to pacu MAY DO POST OPERATIVE ORDERS.

3. 2ND ASSISTANT TO THE SURGEON• Assist the surgeon and the assistant surgeon

-suctioning and retracting-cutting sutures-may do suturing

• Assist in positioning, draping and dressing• Assist in moving patient to pacu.

4. SCRUB NURSE/SURGICAL TECHNICIAN Gathers all equipment for the procedure Prepares supplies & instruments using sterile technique Maintain sterility w/in the sterile field Set up back table, mayo tray and prep tray Handles instruments & supplies during surgery Do the sponge count and instrument count with the circulating nurse

before & after surgery Maintain accurate count Assist the surgeon through out the operation with proper anticipation Assist in draping and securing the suction and the cautery machine Responsible for cleaning patient before transferring to the pacu Responsible in cleaning up the back table and instrument

Anticipates the needs of the sterile team Establishes baseline counts with circulating nurse

5. CERTIFIED REGISTERED NURSE 1ST ASSISTANT

UNSTERILE MEMBERS- work outside the sterile area

1. ANESTHESIOLOGIST – maintenance of physiologic stability Administer anesthetic to the patient Checks operative condition preoperatively Checks the chart (laboratory results and availability of the blood) Helps positioning the patient properly Monitor vital signs Gives IVF and blood transfusion Determines when to transfer patient to PACU

CERTIFIED NURSE ANESTHETIST – nurse who has a minimum of two years additional education specializing in anesthetic administration

• Administer anesthetic to the patient• Checks operative condition preoperative• Helps positioning the patient properly• Monitor vital signs• Works under the direction of an anesthesiologist

2. CIRCULATING NURSE – responsible for the overall running of the OR in the whole intraoperative period

does not scrub but good hand washing techniques must be carried out assess client preoperatively, planning for optima care during the surgical

intervention ensures all equipment is working properly guaranty sterility of instrument and supplies – esp. those that is given in

addition assists with positioning performs skin preparation monitors the room and team members for breaks in sterile technique anticipates sequence of operation assisting anesthesia personnel w/ induction and physiologic monitoring handles specimen coordinates activities with other departments, such as radiology and

pathology departments minimizing conversation and traffic within the OR suite documentation

SENSE OF HEARING – last sense lost and first sense gained in anesthesia

OR DIVIDED INTO THREE AREAS:

2. UNRESTRICTED AREA main entrance to the surgical suite pre-operative holding area/admission area PACU Anesthesia Office Staff Lounge and locker rooms

3. SEMI RESTRICTED AREAS peripheral support areas corridors leading to OR’s storage and supply areas work room sterilization and processing areas

CLOTHING ATTIRE basic scrub suit shoes with shoe cover

4. RESTRICTED AREA operating rooms sub-sterile areas connected to the OR’s (typically houses the autoclave,

scrub sinks and blanket warmers) where a sterile area/field is open

CLOTHING ATTIRE sterile gown and sterile gloves mask

SURGICAL SUITE ENVIRONMENTAL HAZARDS1. PHYSICAL – back injury, fall, noise, pollutions, radiations, electricity fire2. CHEMICAL – anesthetic gases, toxic fumess antineoplastic drugs and cleaning

agents3. BIOLOGIC – patients as a host for or source of pathogenic microorganism,

infectious waste, surgical plumes, latex sensitive, cuts and needle prick

PREPARATION OF THE PATIENT IN THE OPERATING ROOM greet patient and try to promote relaxation never leave the patient unattended check the chart for pre-operative orders and preparations report any significant changes in the patient

SURGICAL ATTIRE provide effective barrier that prevent dissemination of microorganism to patient prohibits contamination of surgical wound and sterile field by direct contact protects personnel from infected persons

BASIC SCRUB ATTIRE1. shirt and pants (scrub suit) –used before entering a semi restricted area2. head cover/hood/cap – put on before the scrub suit3. shoe/shoe covers – unprotected shoe surfaces increase floor contamination4. mask – restricted area

PROTECTIVE ATTIRE objective follows the principles of the “UNIVERSAL PRECAUTION”

- precaution that protects health care workers form contact with blood and body fluids of all patients not just those diagnosed or suspected of being infected by Hepa B, HIV or other blood borne pathogens

- minimum precaution for all invasive procedures

INVASIVE PROCEDURES – entry into the tissue, organs or body cavities in the OR, DR, ER physician or dentist office, radiologist department, clinal laboratory

- attire:1. APRON – should be fluid resistant2. EYE WEAR/FACE SHIELD3. GLOVES

a. STERILE GLOVES – used on a sterile procedureb. CLEAN GLOVES – only used for unsterile

procedures (e.g. washing instruments, MIO, handling specimens)

ATTIRE IN STERILE FIELD sterile gown and sterile gloves

ASEPSIS – absence of infectious or disease-producing microorganism- two types:

1. MEDICAL ASEPSIS – exclude or reduce the number and transfer of pathogens- clean technique (hand washing)

2. SURGICAL ASEPSIS – renders and keep objects and areas free from microorganism

- sterile techniqueASEPTIC TECHNIQUES – practices that restricts microorganisms in the environment, equipment and supplies

- goal: prevent surgical infections minimizes length of recover from surgery prevents transfer of microorganism into body tissues

STERILE TECHNIQUE- required in the ff:

all surgical procedures all procedures that invade the blood stream

complex dressing and wound care tube insertions care of the high risk groups of patients

INFECTION – invasion and proliferation of microorganism into the body tissue

SEPSIS –

TWO TYPES OF MICROORANISM THAT INHIBITS THE SKIN• TRANSIENT- acquire by direct contact• RESIDENT-below the skin surface

SURGICAL CONSCIENCE – inner voice for conscientious practice of asepsis and sterile techniques at all times

- self regulation in practice according to a deep personal commitment to the highest value

- sometimes called the GOLDEN RULE OF SURGERY- includes all activity and interventions, personal hygiene and health- involves a concept of self inspection coupled with moral obligation,

involving both scientific and intellectual honesty

PROCESSES INVOLVED IN REMOVING MICROORGANISMS MECHANICAL CHEMICAL

- Remove soil, debris, natural skin oil or hand lotions present on skin.- Reduced the number of resident microorganism on skin to irreducible minimum

especially during surgical procedures- Reduce hazard of microbial contamination of the surgical wound by skin flora

HAND WASHING – single most important infection control practice

SURGICAL HAND SCRUBBING – process of removing as many microorganisms as possible from the hands and arms by mechanical washing and chemical asepsis before a particular surgical procedure

- done before donning in the sterile gown and sterile gloves

EQUIPMENT FOR SURGICAL SCRUBBING1. SCRUB SINK2. STERILIZED REUSABLE SCRUB BRUSHES3. SCRUBBING SOLUTION

CRITERIA FOR ANTI MICROBIAL SOLUTION USED IN SURGICAL SCRUBBING broad spectrum fast effecting and effective non irritating and non sensitizing prolonged acting

independent of cumulative action

EFFECTIVNESS OF SURGICAL SCRUBBING DEPENDS ON THE FF. VARIABLE Mechanical Factors, Chemical factors and differences in individual skin flora Everyone should scrub according to a standardized written procedure Prolonged scrubbing raises residual microbes from deep dermal layers. Care

should be done not to abrade the skin. Denuded areas allow entry microbes Too short scrubbing would be equally ineffective

TYPES OF ANTISEPTICA. CHLORHEXIDINE GLUCONATE antimicrobial effects against gram (+) and gram (-) microorganisms residual effect is more than 6 hoursB. IODOPHORES rapid against gram (+) and gram (-) microorganism can’t sustain for a prolonged period of time – at least two hours only skin irritantC. TRICLOSAN non toxic, non irritating that inhibits growth of a wider range of both gram (+) and

gram (-) microorganism good for sensitive skin develops prolonged cumulative suppressive action if used routinelyD. ALCOHOL ethyl or isopropyl rapid acting anti-microbial non toxic but has a drying effectE. HEXACHLOROPHENE available by prescription only has a high potential for toxicity

METHOD OF SURGICAL HAND SCRUBBING1. ANATOMIC TIMED SCRUB

Scrub from the nails, fingers each side and web space, palmar, dorsal surface and forearm for a specific time

2. COUNTED BRUSH STROKEStarting from the fingertips, scrub each anatomical area for the designated number of strokes according to policy.

12 PRINCIPLES OF SURGICAL ASEPSIS/ASEPTIC TECHNIQUE1. Only sterile items are used within the sterile field.2. Sterile gowns are considered sterile only in front, from shoulder to the level of the

sterile field and at sleeves from 2 inches above the elbow to the cuff.3. Tables are sterile only up to the table level. 4. Sterile persons touch only sterile items or areas; unsterile person touch only

unsterile items or areas.

5. Unsterile persons avoid reaching over a sterile field; Sterile persons avoid leaning over unsterile area.

6. The edges of anything that encloses sterile content are considered unsterile.7. Sterile areas are continuously kept in view. In passing always face the sterile

field.8. Sterile persons keep well within sterile areas. Unsterile persons avoid sterile

areas.9. Sterile persons keep contact with sterile areas to a minimum.10. When in doubt, consider it unsterile.11. Moisture causes contamination. 12. Microorganisms must be kept to an irreducible minimum

SURGICAL INSTRUMENTATIONClassification of items according to purpose and body contact:

1. Critical – items that enter body tissues, underlying skin and mucuous membrane.- must be sterile and maintained sterile

2. Semi-critical – items that come in contact w/ intact skin or mucous membrane- mechanically cleaned & disinfected to reduce microorganisms- e.g. ET tube guide, metal tongue depressor

3. Non-critical – items that come in contact only with intact skin or in areas remote from the surgical site

- may be cleaned, terminally disinfected & stored unsterile- e.g straps, ground, BP cuff

FOUR CATEGORIES OF SURGICAL INSTRUMENTS1. Sharps – usable part has a sharp, or cutting edge

a. Scalpel- incising tissues; dissection b. Dissecting scissors - dissection

i. Curved mayo ( heavy ) - heavy or tough tissue- Used to prevent puncturing

ii. Metzembaum ( narrow ) - delicate tissueiii. Straight Mayo ( suture scissors) - to cut

sutures2. Clamps – used for hemostasis. May be used as graspers or

retractors.a. Straight Clamps – used for hemostasis

- Stop bleedingb. Curved clampsc. Graspers or Holding instruments

- commonly used to grasp and hold tissues- as in retraction or for suturing

d. Retractors - Retractors – used to hold tissues away from the operative site.

a. self retaining- can maintain it’s own positione.f.

PRINCIPLES OF COUNTING1. All item are counted initially by the circulating nurse and the scrub nurse together

(aloud) as the scrub person touches each item.2. The number (count) of each type of item is immediately recorded in the sponge

count form by the circulating nurse3. If there is any uncertainty regarding the initial count, it is repeated.4. As additional items are added to the sterile field during the procedure, the scrub

nurses counts the items with the circulator who adds the count to the records form and initial it.

5. If possible there should be no interruptions while counting6. After the final sponge and instrument count, the circulating nurse and the scrub

nurse will inform the surgeon by saying aloud “sponge count, instruments count and needle count complete.”

7. The circulating nurse signed the sponge count form with the time and term correct.

POSITIONING• essential that each patient be considered as an individual.

- A good position must provide maximum safety for the duration of the operative procedure. Maximum safety includes:

a. Maintaining good respiratory function.b. Maintaining good circulationc. Preventing pressure on muscles and nerves.d. Good exposure and accessibility of the operative field – maximum

visualizatione. Good access for the administration of anesthetic and observation of effects

EQUIPMENTS FOR POSITIONING1. Operating table

- Are versatile at adaptable to a number diversified positions for all surgical specialties. However orthopedics, urologic and fluoroscopic tables are utilized frequently for specialized procedures.

2. SAFETY BELT (body, knee, hard strap)- -a sturdy, wide strap of conductive material such as nylons, cotton or

rubber webbing to protect the safety of the patient3. ANESTHESIA SCREEN

- metal bar holds the drapes form the patients face and separates the non-sterile area from the sterile area

4. ARM BOARD- self locking board to support the arm resting at patient side

5. STIRRUPS- Supports legs in lithotomy position

6. PILLOWS AND SANDBAGS- support or immobilize a body part- various size and shape to fit anatomic structures

7. SHOULDER ROLL- placed under each side of the patients chest to raises it off the table to

facilitate operation8. KIDNEY REST

- concave metal piece with groove notches at the base are place under the mattress on the elevator part of the table

9. DONUT- used for procedures on head and face - circular or donut shape rubber foam pad

10. METAL FOOTBOARD

- to support the feet, the soles resting securely against - can be flat as horizontal extension of the table or raised perpendicular to

the table

DIFFERENT POSITIONS DURING SURGERY1. SUPINE2. PRONE3. LATERAL4. KIDNEY POSITION5. PRONE POSITION6. KRASKE (JACKKNIFE) POSITION7. MODIFIED TRENDELENBERG – those in the lower

pelvis is pushed up so you can visualize what is in the lower pelvic cavity

8. REVERSE TRENDELENBERG – everything in the lower abdomen is pushed down so you can visualize the upper abdomen

9. LITHOTOMY10. ORTHOPEDIC POSITION

SKIN PREPARATION decreases the number of bacteria on the patient’s skin, thus decreasing the

chance of the patient acquiring a post operative wound infection. duration usually is 5 min depending on the size of the area to be prepped. always start the prep at the incision site, working to the outer boundaries.

Boundaries are Bedside to bedside; nipple line to mid thigh new sponges should be used when returning to incision site ( cleanest to dirtiest ) should be done with firm but not rough movements. Observe for skin reactions. skin prep is institutional. Latest practice is the 12 ball technique. Nurse must not reach over the prepped area. Draping of the operative area is done immediately after the skin preparation is

completed.

COMMONLY USED SKIN PREPARATIONa. Abdominal skin preparation includes the area of the breast line to the upper third of thighs. From Table line to table line with patient in supine position

b. Back Preparation Includes the area of the breast line to the upper third of the thighs with the patient in prone position.

c. Rectoperineal and vaginal preparation includes pubis, vulva, labia, anus and adjacent areas, including inner aspects of upper third thigh.

STERILIZATION - complete destruction of microorganism.- complete sterilization of instruments and equipments is used in the surgical practice.- there is no midway between sterile and unsterile.

Sterilization by Heat

1. Autoclaving (moist heat) or steam under pressure - most effective means of sterilization- Steam kills organism by coagulations of the cell protein.- suitable for fabrics e.g. gowns, towels, dressings, and instruments- A process by which there is a direct steam contact with specific

temperature and time contained in a chamber with a saturated steam pressure.

PRINCIPLES OF AUTOCLAVING• Temperature – 250f to 270f• Timing – depending upon the loads and the type of autoclave but usually 15-30

minutes.• Loading – all articles must be properly wrapped with indicators• Drying the load- all articles should be dry at the end of the sterilization process.

2. Dry Heat- kills micro-organisms by oxidation (exposed at 160 C or 320 F for 1 hr.)- suitable for all types of glassware and some instruments.

3. Boiling water sterilization-a process by which there is a direct heat immersion contact but only destroy

vegetative bacteria, thereby this process is discouraged.- Principle:

- Timing – the recommended time is 2 minutes or longer from the start of boiling point

5. Gas Sterilizaiton (anprolene)- A process of heat sensitive gaseous sterilization under pressure.- PRINCIPLES:

• Temperature – 140f• Timing-12 hours anpprolene gas sterilization and 24 hours aeration• Highly inflammable• A vesicant it is come in contact with the skin• Toxic if inhaled

6. Chemical disinfectant• A process by which chemical agents is used to prevent and to kill the growth of

bacteria.A. Cidex - a 2% activated aqueous glutaraldehyde solnB. Alcohol solution – 70% isopropyl or ethyl alcohol solutionC. Providone iodine (betadine) – anaqueous solution that coagulates

albuminous substanceD. Phenols (Lysol) – effective in the presence of organic matter

DRAPE – provide sterile environment

1. Laparotomy sheet/lap sheet - a large sheet with longitudinal opening which is place over the operative site on the abdomen, or comparable area.

2. towels - A small sheet used to outline the operative site(green towel) also used for drying of hands (blue towel)

3. large sheet - a plain large sheet used to drape under legs as in added protection above or below the operative area or for draping areas in which a sheet with an opening cannot used.

4. towel with hole -a small sheet with a circular hole used to drape or cover a small operation such as excision of cyst or mass.

5. eye sheet -a small sheet with an openning like a shape of an eye used to drape a very small operation and eye operations.

6. thyroid sheet -a large sheet with an opening fitted in the neck area to drape in the neck operation.

7. single sheet/sterilizing sheet/ss -a regular size sheet without opening which is folded lengthwise and placed above operative field.

8. perineal sheet - A special design large sheet with an opening and used to create an adequate sterile field with the patient in lithotomy position such as d & c, hemorroidectomy and others.

9. cystoscopy sheet -a special design large sheet with an opening and pockets used to drape patient in a lithotomy position such as cystoscopy operation and others.

10. instrument tray cover (ITC) - A fitted sheet used to drape or cover the mayo stand.

SURGICAL INCISIONSThe choice of the incision is made by the surgeon with the following considerations:

Type of surgery (anatomical location) Maximum exposure Ease and speed of entering (for emergency surgery) Possibility of extending the incision Maximal postoperative wound strength Minimum postoperative discomfort Cosmetic surgery

LAYERS OF THE ABDOMINAL TISSUE1. skin2. subcuticular3. subcutaneous4. fascia

• superficial• deep

5. muscle6. peritoneum

ANESTHESIOLOGY- a branch of Medicine concerned with the administration medications or

anesthetic agents to relieve pain and support physiologic function during a surgical procedure

ANESTHESIA- is an artificially induced state of partial or total loss of sensation, occurring

with or without loss of consciousness.- Purpose :

to block the transmission of nerve impulses, suppress reflexes, promote muscle relaxation and in some cases, achieve a controlled level of unconsciousness. formed from the Greek word meaning “negative sensation” loss of feeling or sensation; esp. loss of sensation of pain with

loss of protective reflexes

• Analgesia – lessening of or insensibility to pain• Amnesia – loss of memory; indifference to pain• Analgesic – drug that relieves pain by altering perception of painful stimuli w/o

producing loss of consciousness; acts on specific receptors in NS.• Anesthetics – drug that produces local or general loss of sensibility• Pain – perceptual phenomenon, a disturbed sensation causing suffering/distress

3 Types of Pain1. Phasic – of short duration as a needlestick.2. Acute – up to six months as postoperative pain from tissue trauma3. Chronic – six months and above duration as a chronic disease.

FACTORS THAT AFFECT THE CHOICE OF ANESTHESIA1. Provide maximum comfort &safety for the patient with low index of toxicity2. Provide maximum operating conditions for the surgeon3. Provide potent, predictable analgesia extending to postop period.4. Produce adequate muscle relaxation and provide amnesia5. Have rapid onset & easy reversibility w/ minimum side effects6. Patients physiologic status w/ Presence & severity of co-existing dcs.7. Patients’ mental and psychologic status8. Options for management of postoperative pain9. Posoperative recovery from various kinds of anesthesia10. Type and duration of the surgical procedure11. Client position needed for the surgical procedure 12. Any particular requirement of the surgeon and patients preference

TYPES OF ANESTHESIA1. GENERAL ANESTHESIA / GENERAL

ENDOTRACHEAL ANESTHESIA / GETA- block pain stimulus at the cerebral cortex- induce depression of the CNS that is reversed either by metabolic change

and elimination from the body or by pharmacologic means- produces analgesia, amnesia, unconsciousness and loss of reflexes and

muscle tone- best suited for surgeries of the ff:

head, neck, upper torso, back prolonged surgical procedure used in all clients who are unable to lie quietly for long periods

of time- types:

INTRAVENOUS ANESTHESIA – extremely rapid induction - Uncosciousness occurs 30 sec. after administration- Promotes rapid transition form the conscious to surgical

anesthesia stage- Acts as calming agent

- Sufficiently potent to be used alone in some minor procedures as dental extraction and pelvic exams

- Ex. Thiopental Sodium and Ketamine (has a great effect on px. ; increases BP ; not given to px. with hx. Of hypertension ; usually px. who have hx. Of low BP due to depression of CNS which may be increased by Ketamine)

INHALATION ANESTHESIA- uses a mixture of volatile liquids or gas and oxygen- advantage: ease in administration and elimination through the

respiratory system- used ot maintain client in stage III anesthesia- mixture is given through a mask or ET tube which is inserted

once the client is paralyzed and unconscious (intubation)- examples:

a. INHALATION ANESTHETICS (volatile agents)- liquids vaporized for inhalation with O2 as

carrier- cause post operative shivering – hypothalamus

effect- halothane and isoflurane

b. GAS ANESTHETIC (gaseous agent)- nitrous oxide- most commonly used- odorless, colorless, non-irritating gas that

provides analgesia equivalrent to 10 mg of morphine sulfate

2. REGIONAL ANESTHESIA – reversible loss of sensation in a specific area or region of the body when local anesthetic is injected to purposely block or anesthetize nerve fibers in and around the operative site

- agents blocks conduction of impulses in the nerve fibers

EPINEPHRINE – added to many local anesthetics- adjunct – medication given with another medication to potentiate effect of

the medication- purpose:

prolonged anesthetic effect delay absorption of anesthetic by constriction of local blood

vessels

TYPES OF REGIONAL ANESTHESIAa. SPINAL – SUB ARACHNOID BLOCK / SAB

- anesthetic technique of choice for older adults and for clients undergoing surgical procedures in the lower half of the body

- achieved by injecting local anesthetics into the subarachnoid space- autonomic nerve fibers 1st affected and last to recover- after blockade of the ANS spinal anesthesia blocks the following fibers in

these order and recovers in reverse order:

a. touch b. pain c. motor d. pressure ande. proprioreceptive fibers (alerts brain of physical orientation)

- within minutes of administration, client experience a loss of sensation and paralysis of the toes, feet, legs, then abdomen

- benefits: safe, excellent lower body muscle relaxation, absence of effect of

consciousness

b. EPIDURAL – CLEB / CONTINUOUS LUMBAR EPIDURAL BLOCK- achieved by introduction of anesthetic agent into the epidural space

(thoraxic, lumber, sacral, or caudal interspace) w/o penetrating the dura and w/o entering the subarachnoid space

- blocks autonomic nerves and cause hypotension- respiratory depression or paralysis may occur if block done is too high that

may affect respiratory muscle

c. CAUDAL ANESTHESIA

d. TOPICAL ANESTHESIA – short acting- applied directly to the area to be sesensitized- blocks peripheral nerve endings in the mucous membrane of the vagina,

rectum, nasopharynx, and the mouth- preparation: solution, ointment, gel, cream or powder

e. LOCAL INFILTRATION ANESTHESIA- involves injection of anesthetic agent such as lidocaine into the skin and

subcutaneous tissue of the area- blocks only the peripheral nerves around the area of incision- when administered, aspirate that no blood vessel was hit before injecting

to ensure and prevent systemic reaction causing cardiovascular collapse or convulsion

f. FIELD BLOCK ANESTHESIA- areia proximal to a planned incision can be injected and infiltrated to

produce a “field block”- this block forms a barrier between incision and the nervous system- walls the area around the incision and prevents transmission of sensory

impulse to the brain from this area

g. PERIPHERAL NERVE BLOCK / PNB- injects along the nerve rather than into the nerve to decrease risk fo nerve

damage- anesthetize individual nerve or nerve plexus rather than all local nerves

anesthetized by a field block- prevent accidental injection into the blood vessel

TYPES OF PERIPHERAL NERVE BLOCK- Digital nb- for a finger- Brachial plexus nb- entire upper arm- Intercostals nb – chest or abdominal wall

h. MONITORED ANESTHESIA - surgeon infiltrates surgical site with local anesthesthetics and the anesthesia

provider supplements local anesthetics w/ IV drugs to provide sedation and systemic analgesia

i. ACUPUNCTURE- Ancient chinese killing technique that works by insertion of long, thin needles

into specific acupuncture points

j. CRYOTHERMIA- use of cold to induce anesthesia