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Medical Surgical Nursing PERIOPERATIVE NURSING By : Lowell P. Bautista, RN.

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Presentation on theme: "Medical Surgical Nursing PERIOPERATIVE NURSING By : Lowell P. Bautista, RN."— Presentation transcript:

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2 Medical Surgical Nursing PERIOPERATIVE NURSING By : Lowell P. Bautista, RN

3 DEFINITION OF TERMS SURGERY -It is the branch of medicine concerned with diseases and conditions which require or are amenable to operative procedures. Surgery is the work done by a surgeon. SURGERY -It is the branch of medicine concerned with diseases and conditions which require or are amenable to operative procedures. Surgery is the work done by a surgeon. -"Surgery can involve cutting, abrading, suturing, laser or otherwise physically changing body tissues and organs." -"Surgery can involve cutting, abrading, suturing, laser or otherwise physically changing body tissues and organs."

4 SURGEON - A physician who treats disease, injury, or deformity by operative or manual methods. A medical doctor specialized in the removal of organs, masses and tumors and in doing other procedures using a knife (scalpel) SURGEON - A physician who treats disease, injury, or deformity by operative or manual methods. A medical doctor specialized in the removal of organs, masses and tumors and in doing other procedures using a knife (scalpel) STERILE - free from living germs or microorganisms; aseptic: sterile surgical instruments. STERILE - free from living germs or microorganisms; aseptic: sterile surgical instruments.

5 ASEPSIS - The state of being free of pathogenic microorganisms. ASEPSIS - The state of being free of pathogenic microorganisms. - The process of removing pathogenic microorganisms or protecting against infection by such organisms. - The process of removing pathogenic microorganisms or protecting against infection by such organisms. SEPSIS - a toxic condition resulting from the spread of bacteria or their toxic products from a focus of infection; especially : septicemia SEPSIS - a toxic condition resulting from the spread of bacteria or their toxic products from a focus of infection; especially : septicemiasepticemia

6 SEPSIS - is a severe illness caused by overwhelming infection of the bloodstream by toxin-producing bacteria. SEPSIS - is a severe illness caused by overwhelming infection of the bloodstream by toxin-producing bacteria. SEPSIS - is caused by bacterial infection that can originate anywhere in the body. - is caused by bacterial infection that can originate anywhere in the body. DISINFECTANT - any chemical agent used chiefly on inanimate objects to destroy or inhibit the growth of harmful organisms. DISINFECTANT - any chemical agent used chiefly on inanimate objects to destroy or inhibit the growth of harmful organisms.

7 ANTISEPTICS - is a substance that prevents or arrests the growth or action of microorganisms either by inhibiting their activity or by destroying them. The term is used especially for preparations applied topically to living tissue ANTISEPTICS - is a substance that prevents or arrests the growth or action of microorganisms either by inhibiting their activity or by destroying them. The term is used especially for preparations applied topically to living tissue STERILIZATION -the destruction of all living microorganisms, as pathogenic bacteria, vegetative forms, and spores. STERILIZATION -the destruction of all living microorganisms, as pathogenic bacteria, vegetative forms, and spores.

8 BACTERIOSTATIC -Capable of inhibiting the growth or reproduction of bacteria. BACTERIOSTATIC -Capable of inhibiting the growth or reproduction of bacteria.reproductionbacteriareproductionbacteria - An agent, such as a chemical or biological material, that inhibits bacterial growth. - An agent, such as a chemical or biological material, that inhibits bacterial growth. BACTERICIDAL - Capable of killing bacteria. BACTERICIDAL - Capable of killing bacteria. bacteria BACTERIOCIDES - is a substance that kills bacteria.Bactericides are either disinfectants, antiseptics or antibiotics. BACTERIOCIDES - is a substance that kills bacteria.Bactericides are either disinfectants, antiseptics or antibiotics.bacteria disinfectantsantisepticsantibioticsbacteria disinfectantsantisepticsantibiotics

9 PREFIXES & SUFFIXES : Prefixes & Suffixes can explain the type of procedure the client will undergo: PREFIXES PREFIXES  Supra – above ; beyond  Ortho – joint  Chole – bile or gall  Cysto – bladder  Encephalo- brain

10  Entero – intestine  Hystero – uterus  Mast – breast  Meningo – membrane; meninges  Myo – muscle  Nephro – kidney  Neuro – nerve  Oophor - ovary

11  Pneumo – lungs  Pyelo – kidney pelvis  Salphingo – fallopian tube  Thoraco – chest  Viscero – organ esp. abdomen

12 SUFFIXES SUFFIXES  Oma – tumor ; swelling  Ectomy – removal of an organ or gland  Rhapy – suturing or stitching of a part or an organ an organ  Scopy – looking into  Ostomy – making an opening or a stoma  Otomy – cutting into

13  Plasty – to repair or restore  Cele – tumor ; hernia ; swelling  Itis – inflammation of

14 PERIOPERATIVE NURSING SURGERY – a branch of Medicine that encompasses preoperative care, intraoperative judgement & management, & postoperative care of patients. SURGERY – a branch of Medicine that encompasses preoperative care, intraoperative judgement & management, & postoperative care of patients. OPERATION – an invasive modality of treatment. OPERATION – an invasive modality of treatment.

15 PERIOPERATIVE NURSING DEFINITION: DEFINITION: a.k.a : OPERATING ROOM NURSING a.k.a : OPERATING ROOM NURSING  The identification of physiological & sociological needs of the client, & the implementation of an individualized program of nursing care in order to restore or maintain the health & welfare of the patient before, during & after surgical intervention.

16 PERIOPERATIVE NURSING PHILOSOPHY : PHILOSOPHY : To give service that aims to provide comprehensive support physically, morally, psychologically, spiritually, & socially to a patient undergoing surgery. To give service that aims to provide comprehensive support physically, morally, psychologically, spiritually, & socially to a patient undergoing surgery.

17 PERIOPERATIVE NURSING GOALS : GOALS : 1. To provide safe, supportive & comprehensive care. 2. To assist the surgeon by functioning effectively as a member of the surgical team. 3. To create & maintain an aseptic / sterile environment.

18 PERIOPERATIVE NURSING Fundamental purposes of the O.R. : Fundamental purposes of the O.R. : It is a place... It is a place... 1. To correlate theory & practice. 2. To develop skills in assisting the surgeon in the operation. 3. To create a suitable sterile field for surgical procedures to prevent complications.

19 Perioperative Patient-Focused Model

20 Period of time that constitutes the surgical experience. Includes three phases: Period of time that constitutes the surgical experience. Includes three phases: Preoperative phase: the period of time from the decision for surgery until the patient is transferred into the operating room. Preoperative phase: the period of time from the decision for surgery until the patient is transferred into the operating room. Intraoperative phase: the period of time from when the patient is transferred to the operating room to the admission to postanesthesia care unit (PACU). Intraoperative phase: the period of time from when the patient is transferred to the operating room to the admission to postanesthesia care unit (PACU). Postoperative phase: the period of time that begins with admission to the PACU and ends with follow- up evaluation in the clinical setting or at home Postoperative phase: the period of time that begins with admission to the PACU and ends with follow- up evaluation in the clinical setting or at home

21 CLASSIFICATIONS OF SURGERY According to Urgency : According to Urgency : 1) EMERGENT – pt. requires immediate attention ; disorder maybe life- threatening. > indications for surgery : without delay. > indications for surgery : without delay. > examples : Severe bleeding, extensive burns, bladder or intestinal obstruction, fractured skull, gunshot or stab wounds. > examples : Severe bleeding, extensive burns, bladder or intestinal obstruction, fractured skull, gunshot or stab wounds.

22 CLASSIFICATIONS OF SURGERY 2) URGENT – pt. requires prompt attention. > indications for surgery : within 24-30 hours. > indications for surgery : within 24-30 hours. > examples : Acute gallbladder infection > examples : Acute gallbladder infection Kidney / Ureteral stones Kidney / Ureteral stones

23 CLASSIFICATIONS OF SURGERY 3) REQUIRED – pt. needs to have surgery. > indications for surgery: plan within few weeks or months. > indications for surgery: plan within few weeks or months. > examples : Prostatic hyperplasia without bladder obstruction, Thyroid disorders, Cataracts. > examples : Prostatic hyperplasia without bladder obstruction, Thyroid disorders, Cataracts.

24 CLASSIFICATIONS OF SURGERY 4) ELECTIVE – pt should have surgery. > indications for surgery: Failure to have surgery not catastrophic. > indications for surgery: Failure to have surgery not catastrophic. > examples : Repair of scars > examples : Repair of scars Simple hernia Simple hernia Vaginal repair Vaginal repair

25 CLASSIFICATIONS OF SURGERY 5) OPTIONAL – decision rests with pt. > indications for surgery : Personal preference > indications for surgery : Personal preference > examples : Cosmetic surgery > examples : Cosmetic surgery

26 CLASSIFICATIONS OF SURGERY Accdg. To Degree Of Risk : Accdg. To Degree Of Risk :  MAJOR – high degree of risk : >maybe complicated / prolonged, large losses of blood may occur, vital organs maybe involved, post-op complications may be likely. >maybe complicated / prolonged, large losses of blood may occur, vital organs maybe involved, post-op complications may be likely. >ex. Organ transplant >ex. Organ transplant Open heart surgery Open heart surgery Removal of a kidney Removal of a kidney

27 CLASSIFICATIONS OF SURGERY  MINOR – little risk with few complications. - often performed in a “day surgery”. - often performed in a “day surgery”. > examples: Breast biopsy > examples: Breast biopsy Tonsillectomy Tonsillectomy Knee surgery Knee surgery

28 CLASSIFICATIONS OF SURGERY Accdg. To Purpose : Accdg. To Purpose : 1. DIAGNOSTIC – verifies suspected diagnosis - ex. Biopsy - ex. Biopsy 2. EXPLORATORY – estimates the extent of the disease or injury. - Ex. Explore laparotomy - Ex. Explore laparotomy 3. CURATIVE – removes or repairs damaged tissues.

29 CLASSIFICATIONS OF SURGERY 4. ABLATIVE – removing diseased organ that can’t wait anymore. - emergency surgery. - emergency surgery. 5. PALLIATIVE – relieves symptoms but does not cure the underlying disease process. 6. RECONSTRUCTIVE – partial or complete restoration of a damaged organ/tissue to bring back the original appearance & function.(mammoplasty, face-lift)

30 7. CONSTRUCTIVE – repairing the damaged tissue or congenitally defective organ. (multiple wound repair)  Accdg. To Location : 1. INTERNAL – inside the body. Ex. Hysterectomy Ex. Hysterectomy 2. EXTERNAL – outside the body. Ex. Skin grafting Ex. Skin grafting

31 FOUR BASIC PATHOLOGIC CONDITIONS THAT REQUIRE SURGERY: FOUR BASIC PATHOLOGIC CONDITIONS THAT REQUIRE SURGERY: 1) OBSTRUCTION – a blockage ; are dangerous because they block the flow of blood, air, CSF, urine & bile through the body. 2) PERFORATION – is a rupture of the organ, artery or bleb.

32 3) EROSION – break in the continuity of tissue surface. It can be caused by irritation, infection, ulceration or inflammation. It can damage the walls of blood vessels resulting in serious bleeding. 4) TUMORS – abnormal growth of tissue that serves no physiologic function in the body.

33 THE SURGICAL RISK PATIENTS Extremes of age ( very young & very old ) Extremes of age ( very young & very old ) Extremes of weight (emaciation, obesity) Extremes of weight (emaciation, obesity) Dehydrated pts. Dehydrated pts. Nutritional deficits Nutritional deficits Pts. with severe trauma or injury, infection/sepsis Pts. with severe trauma or injury, infection/sepsis Pts. with cardiovascular disease Pts. with cardiovascular disease Endocrine dysfunction (diabetes mellitus) Endocrine dysfunction (diabetes mellitus)

34 Hypertensive & hypotensive pts. Hypertensive & hypotensive pts. Hypovolemia Hypovolemia Hepatic disease Hepatic disease Preexisting mental or physical disability Preexisting mental or physical disability

35 PROBLEMS THAT MAY ARISE IN SURGERY: PROBLEMS THAT MAY ARISE IN SURGERY: 1. Surgical risk pts – probability of morbidity or mortality following surgery. 2. Pain 3. Hemorrhage 4. Infection 5. UTI

36 PHASES OF O.R. NURSING : PHASES OF O.R. NURSING : I. PREOPERATIVE PHASE  The rendering of nursing care to the surgical client as soon as he is admitted & the decision to undergo surgery is made.  It ends on the time the client is transferred to the O.R.

37 NURSING ACTIVITIES : NURSING ACTIVITIES :  Assessment of the client (baseline evaluation of the pt. before the day of surgery-interview)  Identification of potential/actual health problems.  PREADMISSION TESTING- ensure necessary tests have been performed  Pre-op teaching involving client & support persons.

38  Day of surgery :  pt. teaching reviewed  informed consent confirmed  pt.’s identity & surgical site verified  IVF started.

39 PREPARATION FOR SURGERY Psychological Support : Psychological Support : a) Assess client’s fears, anxieties, support systems & patterns of coping. b) Establish trusting relationship with client & significant others. c) Explain routine procedures, encourage verbalization of fears & allow client to ask questions.

40 d) Demonstrate confidence in surgeon & staff. e) Provide for spiritual care if appropriate.

41 PREOPERATIVE TEACHING Frequently done on an outpatient basis. Frequently done on an outpatient basis. Assess client’s level of understanding of surgical procedure & its implications. Assess client’s level of understanding of surgical procedure & its implications. Answer questions, clarify & reinforce explanations given by the surgeon. Answer questions, clarify & reinforce explanations given by the surgeon. Explain routine pre- & post-op procedures & any special equipment to be used. Explain routine pre- & post-op procedures & any special equipment to be used.

42 PREOPERATIVE TEACHING Preoperative experience Preoperative experience Preoperative medication Preoperative medication Breathing exercises, coughing, incentive spirometer Breathing exercises, coughing, incentive spirometer Leg exercises Leg exercises Position changes and movement Position changes and movement Pain management Pain management Reducing anxiety and fear, support of coping Reducing anxiety and fear, support of coping Special considerations related to outpatient surgery Special considerations related to outpatient surgery

43 Diaphragmatic Breathing and Splinting When Coughing

44 Leg Exercises and Foot Exercises

45 Preoperative Nursing Interventions  PHYSICAL PREPARATIONS: Patient safety is a primary concern. Patient safety is a primary concern. Obtain history of past medical conditions, surgical procedures, dietary restrictions & medications. Obtain history of past medical conditions, surgical procedures, dietary restrictions & medications. Perform baseline head-to-toe assessment, including VS, height & weight. Perform baseline head-to-toe assessment, including VS, height & weight. Ensure that diagnostic procedures pertinent to surgery are performed as ordered: Ensure that diagnostic procedures pertinent to surgery are performed as ordered:

46 1. CBC 2. Electrolytes 3. PT/PTT (Prothrombin Time;Partial thromboplastin time) 4. Urinalysis 5. ECG 6. Blood typing & crossmatch

47 NPO- to prevent aspiration NPO- to prevent aspiration Bowel prep and skin prep Bowel prep and skin prep - cleansing enema or laxative before surgery to allow satisfactory visualization of the surgical site. - cleansing enema or laxative before surgery to allow satisfactory visualization of the surgical site. - goal of pre-op skin prep is to decrease bacteria without injuring the skin. - goal of pre-op skin prep is to decrease bacteria without injuring the skin.

48 Immediate preoperative preparation Immediate preoperative preparation Complete checklist and chart Complete checklist and chart Hospital gown, voiding, removal of dentures, jewelry, contacts, etc. Hospital gown, voiding, removal of dentures, jewelry, contacts, etc. Preoperative medication Preoperative medication Transporting the pt. to the Presurgical area about 30 to 60 minutes before anesthetics is to be given. Transporting the pt. to the Presurgical area about 30 to 60 minutes before anesthetics is to be given. Attend to family needs Attend to family needs

49  LEGAL PREPARATION:  Surgeon obtains operative permit (informed consent) 1. Surgical procedures, alternatives, possible complications & disfigurements or removal of body parts are explained. 2. It is part of the nurse’s role as client advocate to confirm that the client understands information given.

50  INFORMED CONSENT is necessary in the ff. Circumstances:  Invasive procedures, such as surgical incisions, biopsy, cystoscopy or paracentesis.  Procedures requiring sedation or anesthesia  A non-surgical procedure, such as arteriography  Procedures involving radiation

51 Adult client (over 18 y/o) signs own permit unless unconcious or mentally incompetent. Adult client (over 18 y/o) signs own permit unless unconcious or mentally incompetent. 1. If unable to sign, relative (spouse or next of kin) or guardian will sign. 2. In an emergency, permission via telephone or telegram is acceptable; have a 2 nd listener on phone when telephone permission is given

52 3. Consents are not needed for emergency care if all 4 of the ff. criteria are met: a. There is an immediate threat to life. b. Experts agree that it is an emergency. c. Client is unable to consent. d. A legally authorized person cannot be reached.

53 Minors (under 18 y/o) must have consent signed by an adult (i.e. Parent or legal guardian) Minors (under 18 y/o) must have consent signed by an adult (i.e. Parent or legal guardian) Emancipated minor (married or independently earning his or her own living)may sign his/ her own consent. Emancipated minor (married or independently earning his or her own living)may sign his/ her own consent.

54 Witness to informed consent may be a nurse, another M.D., clerk or any other authorized person. Witness to informed consent may be a nurse, another M.D., clerk or any other authorized person. The nurse witnessing informed consent, specifies whether witnessing explanation of surgery or just signature of the client. The nurse witnessing informed consent, specifies whether witnessing explanation of surgery or just signature of the client.

55 PREOPERATIVE MEDICATIONS PURPOSES: PURPOSES: 1. To relieve fear & anxiety. 2. To reduce dose needed for induction & maintenance of anesthesia. 3. To prevent reflex bradycardia that happens during induction of anesthesia. 4. To minimize oral secretions.

56 PREOPERATIVE MEDICATIONS

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61 II. INTRAOPERATIVE PHASE  Giving nursing care to client undergoing surgery.  It starts from the time the pt. was admitted to the O.R., during operation until it ends & transferred to the PACU.

62 NURSING ACTIVITIES: NURSING ACTIVITIES:  Activities providing for pt’s safety.  Maintenance of aseptic environment.  Ensuring proper function of equipments.  Providing surgeons with specific instruments & supplies for surgical field.  Completing documentation.  Positioning pts.  Acting as scrub/circulating nurse.

63 Members of the Surgical Team Patient Patient Anesthesiologist or anesthetist Anesthesiologist or anesthetist Surgeon Surgeon Nurses (Scrub & Circulating) Nurses (Scrub & Circulating) Surgical technologists Surgical technologists

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65 SCRUB TEAM @ WORK

66 PATIENT – the most important member of the surgical team. May feel relaxed & prepared, or fearful & highly stressed. PATIENT – the most important member of the surgical team. May feel relaxed & prepared, or fearful & highly stressed. - is also subject to several risks. - is also subject to several risks. OPERATING SURGEON – pre-op dx & care. OPERATING SURGEON – pre-op dx & care. - performance of operation. - performance of operation. - post-op mgt & care - post-op mgt & care - assumes all responsibility for all medical acts of judgement & mgt. - assumes all responsibility for all medical acts of judgement & mgt.

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68 SURGEON & ASSISTANTS – scrub & perform the surgery. SURGEON & ASSISTANTS – scrub & perform the surgery. REGISTERED NURSE 1 ST ASST. – practices under the direct supervision of the surgeon. (handling tissue, suturing, maintaining hemostasis) REGISTERED NURSE 1 ST ASST. – practices under the direct supervision of the surgeon. (handling tissue, suturing, maintaining hemostasis) ANESTHESIOLOGIST / ANESTHESIOLOGIST / NURSE ANESTHETIST – administers the anesthetic agent & monitors the pt’s physical status throughout the surgery. NURSE ANESTHETIST – administers the anesthetic agent & monitors the pt’s physical status throughout the surgery.

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70 SCRUB NURSE – provides sterile instruments & supplies to the surgeon during the procedure. SCRUB NURSE – provides sterile instruments & supplies to the surgeon during the procedure. - performs surgical hand scrub. - performs surgical hand scrub. CIRCULATING NURSE – coordinates the care of the pt. in the O.R. CIRCULATING NURSE – coordinates the care of the pt. in the O.R. - care provided includes assisting with pt. positioning, skin prep, managing surgical specimens & documenting intraoperative events. - care provided includes assisting with pt. positioning, skin prep, managing surgical specimens & documenting intraoperative events.

71 SCRUB NURSE SCRUB NURSE

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73 CIRCULATING NURSE :O) anesthesiologist.Assistant surgeon surgeon

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76 Prevention of Infection The surgical environment – stark appearance & cool temperature. Located central to all supporting services. The surgical environment – stark appearance & cool temperature. Located central to all supporting services. Unrestricted zone – where street clothes are allowed. Unrestricted zone – where street clothes are allowed. Semirestricted zone- where attire consists of scrub clothes & caps. Semirestricted zone- where attire consists of scrub clothes & caps. Restricted zone- where scrub clothes, shoe covers, caps & masks are worn. Restricted zone- where scrub clothes, shoe covers, caps & masks are worn.

77 THE OPERATING ROOM

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79 Basic Guidelines for Surgical Asepsis All materials in contact with the wound and within the sterile field must be sterile. All materials in contact with the wound and within the sterile field must be sterile. Gowns are sterile in the front from chest to the level of the sterile field, and sleeves from 2 inches above the elbow to the cuff. Gowns are sterile in the front from chest to the level of the sterile field, and sleeves from 2 inches above the elbow to the cuff. Only the top of a draped table is considered sterile. During draping, the drape is held well above the area and is placed from front to back. Only the top of a draped table is considered sterile. During draping, the drape is held well above the area and is placed from front to back.

80 Basic Guidelines for Surgical Asepsis Items are dispensed by methods to preserve sterility. Items are dispensed by methods to preserve sterility. Movements of the surgical team are from sterile to sterile and from unsterile to sterile only. Movements of the surgical team are from sterile to sterile and from unsterile to sterile only. Movement around the sterile field must not cause contamination of the field. At least a 1- foot distance from the sterile field must be maintained. Movement around the sterile field must not cause contamination of the field. At least a 1- foot distance from the sterile field must be maintained.

81 Basic Guidelines for Surgical Asepsis Whenever a sterile barrier is breached, the area is considered contaminated. Whenever a sterile barrier is breached, the area is considered contaminated. Every sterile field is constantly maintained and monitored. Items of doubtful sterility are considered unsterile. Every sterile field is constantly maintained and monitored. Items of doubtful sterility are considered unsterile. Sterile fields are prepared as close as possible to time of use. Sterile fields are prepared as close as possible to time of use.

82 SURGICAL ASEPTIC TECHNIQUE BEFORE AN OPERATION, it is necessary to sterilize and keep sterile all instruments, materials, and supplies that come in contact with the surgical site. Every item handled by the surgeon and the surgeon's assistants must be sterile. The patient's skin and the hands of the members of the surgical team must be thoroughly scrubbed, prepared, and kept as aseptic as possible. BEFORE AN OPERATION, it is necessary to sterilize and keep sterile all instruments, materials, and supplies that come in contact with the surgical site. Every item handled by the surgeon and the surgeon's assistants must be sterile. The patient's skin and the hands of the members of the surgical team must be thoroughly scrubbed, prepared, and kept as aseptic as possible.

83 DURING THE OPERATION, the surgeon, surgeon's assistants, and the scrub nurses must wear sterile gowns and gloves and must not touch anything that is not sterile. DURING THE OPERATION, the surgeon, surgeon's assistants, and the scrub nurses must wear sterile gowns and gloves and must not touch anything that is not sterile. Maintaining sterile technique is a cooperative responsibility of the entire surgical team. Maintaining sterile technique is a cooperative responsibility of the entire surgical team. Each member must develop a surgical conscience, a willingness to supervise and be supervised by others regarding the adherence to standards. Each member must develop a surgical conscience, a willingness to supervise and be supervised by others regarding the adherence to standards.

84 BASIC PRINCIPLES OF SURGICAL ASEPSIS All personnel assigned to the operating room must practice good personal hygiene. This includes daily bathing and clothing change. All personnel assigned to the operating room must practice good personal hygiene. This includes daily bathing and clothing change. Those personnel having colds, sore throats, open sores, and/or other infections should not be permitted in the operating room. Those personnel having colds, sore throats, open sores, and/or other infections should not be permitted in the operating room.

85 Operating room attire (which includes scrub suits, gowns, head coverings, and face masks) should not be worn outside the operating room suite. If such occurs, change all attire before re-entering the clean area. (The operating room and adjacent supporting areas are classified as "clean areas.") Operating room attire (which includes scrub suits, gowns, head coverings, and face masks) should not be worn outside the operating room suite. If such occurs, change all attire before re-entering the clean area. (The operating room and adjacent supporting areas are classified as "clean areas.") All members of the surgical team having direct contact with the surgical site must perform the surgical hand scrub before the operation. All members of the surgical team having direct contact with the surgical site must perform the surgical hand scrub before the operation.

86 All materials and instruments used in contact with the site must be sterile. All materials and instruments used in contact with the site must be sterile. · The gowns worn by surgeons and scrub corpsmen are considered sterile from shoulder to waist (in the front only), including the gown sleeves. · The gowns worn by surgeons and scrub corpsmen are considered sterile from shoulder to waist (in the front only), including the gown sleeves. · If sterile surgical gloves are torn, punctured, or have touched an unsterile surface or item, they are considered contaminated. · If sterile surgical gloves are torn, punctured, or have touched an unsterile surface or item, they are considered contaminated.

87 The safest, most practical method of sterilization for most articles is steam under pressure. The safest, most practical method of sterilization for most articles is steam under pressure. · Label all prepared, packaged, and sterilized items with an expiration date. · Label all prepared, packaged, and sterilized items with an expiration date. · Use articles packaged and sterilized in cotton muslin wrappers within 28 calendar days. · Use articles packaged and sterilized in cotton muslin wrappers within 28 calendar days. Use articles sterilized in cotton muslin wrappers and sealed in plastic within 180 calendar days Use articles sterilized in cotton muslin wrappers and sealed in plastic within 180 calendar days

88 Unsterile articles must not come in contact with sterile articles. Unsterile articles must not come in contact with sterile articles. Make sure the patient's skin is as clean as possible before a surgical procedure. Make sure the patient's skin is as clean as possible before a surgical procedure. Take every precaution to prevent contamination of sterile areas or supplies by airborne organisms. Take every precaution to prevent contamination of sterile areas or supplies by airborne organisms.

89 HANDLING STERILE ARTICLES When you are changing a dressing, removing sutures, or preparing the patient for a surgical procedure, it will be necessary to establish a sterile field from which to work. The field should be established on a stable, clean, flat, dry surface. When you are changing a dressing, removing sutures, or preparing the patient for a surgical procedure, it will be necessary to establish a sterile field from which to work. The field should be established on a stable, clean, flat, dry surface. An article is either sterile or unsterile; there is no in-between. If there is doubt about the sterility of an item, consider it unsterile An article is either sterile or unsterile; there is no in-between. If there is doubt about the sterility of an item, consider it unsterile

90 Any time the sterility of a field has been compromised, replace the contaminated field and setup. Any time the sterility of a field has been compromised, replace the contaminated field and setup. Do not open sterile articles until they are ready for use. Do not open sterile articles until they are ready for use. Do not leave sterile articles unattended once they are opened and placed on a sterile field. Do not leave sterile articles unattended once they are opened and placed on a sterile field.

91 Do not return sterile articles to a container once they have been removed from the container. Do not return sterile articles to a container once they have been removed from the container. Never reach over a sterile field. Never reach over a sterile field. When pouring sterile solutions into sterile containers or basins, do not touch the sterile container with the solution bottle. Once opened and first poured, use bottles of liquid entirely. If any liquid is left in the bottle, discard it. When pouring sterile solutions into sterile containers or basins, do not touch the sterile container with the solution bottle. Once opened and first poured, use bottles of liquid entirely. If any liquid is left in the bottle, discard it.

92 Never use an outdated article. Unwrap it, inspect it, and, if reusable, rewrap it in a new wrapper for sterilization. Never use an outdated article. Unwrap it, inspect it, and, if reusable, rewrap it in a new wrapper for sterilization.

93 SURGICAL HAND SCRUB PURPOSE: To reduce resident and transient skin flora (bacteria) to a minimum. PURPOSE: To reduce resident and transient skin flora (bacteria) to a minimum. Proper hand scrubbing and the wearing of sterile gloves and a sterile gown provide the patient with the best possible barrier against pathogenic bacteria in the environment and against bacteria from the surgical team. Proper hand scrubbing and the wearing of sterile gloves and a sterile gown provide the patient with the best possible barrier against pathogenic bacteria in the environment and against bacteria from the surgical team.

94 1. Before beginning the hand scrub, don a surgical cap or hood that covers all hair, both head and facial, and a disposable mask covering your nose and mouth. 2. Using approximately 6 ml of antiseptic detergent and running water, lather your hands and arms to 2 inches above the elbow. Leave detergent on your arms and do not rinse. 3. Under running water, clean your fingernails and cuticles, using a nail cleaner.

95 4. Starting with your fingertips, rinse each hand and arm by passing them through the running water. Always keep your hands above the level of your elbows. 5. From a sterile container, take a sterile brush and dispense approximately 6 ml of antiseptic detergent onto the brush and begin scrubbing your hands and arms. 6. Begin with the fingertips. Bring your thumb and fingertips together and, using the brush, scrub across the fingertips using 30 strokes.

96 7. Now scrub all four surface planes of the thumb and all surfaces of each finger, including the webbed space between the fingers, using 20 strokes for each surface area. 8. Scrub the palm and back of the hand in a circular motion, using 20 strokes each. 9. Visually divide your forearm into two parts, lower and upper. Scrub all surfaces of each division 20 strokes each, beginning at the wrist and progressing to the elbow

97 10. Scrub the elbow in a circular motion using 20 strokes. 11. Scrub in a circular motion all surfaces to approximately 2 inches above the elbow. 12. Do not rinse this arm when you have finished scrubbing. Rinse only the brush. 13. Pass the rinsed brush to the scrubbed hand and begin scrubbing your other hand and arm, using the same procedure outlined above

98 14. Drop the brush into the sink when you are finished. 15. Rinse both hands and arms, keeping your hands above the level of your elbows, and allow water to drain off the elbows. 16. When rinsing, do not touch anything with your scrubbed hands and arms. 17. The total scrub procedure must include all anatomical surfaces from the fingertips to approximately 2 inches above the elbow.

99 18. Dry your hands with a sterile towel. Do not allow the towel to touch anything other than your scrubbed hands and arms. 19. Between operations, follow the same hand- scrub procedure.

100 Gowning and Gloving GOWNING GOWNING 1. Dry one hand and arm, starting with the hand and ending at the elbow, with one end of the towel. Dry the other hand and arm with the opposite end of the towel. Drop the towel. 1. Dry one hand and arm, starting with the hand and ending at the elbow, with one end of the towel. Dry the other hand and arm with the opposite end of the towel. Drop the towel. 2. Pick up the gown in such a manner that hands touch only the inside surface at the neck and shoulder seams. 2. Pick up the gown in such a manner that hands touch only the inside surface at the neck and shoulder seams. 3. Allow the gown to unfold downward in front of you. 3. Allow the gown to unfold downward in front of you.

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102 GLOVING GLOVING 1. Pick up one glove by the cuff using your thumb and index finger. 1. Pick up one glove by the cuff using your thumb and index finger. 2. Touching only the cuff, pull the glove onto one hand and anchor the cuff over your thumb. 2. Touching only the cuff, pull the glove onto one hand and anchor the cuff over your thumb. 3. Slip your gloved fingers under the cuff of the other glove. Pull the glove over your fingers and hand, using a stretching side-to- side motion. 3. Slip your gloved fingers under the cuff of the other glove. Pull the glove over your fingers and hand, using a stretching side-to- side motion.

103 4. Anchor the cuff on your thumb. With your fingers still under the cuff, pull the cuff up and away from your hand and over the knitted cuff of the gown. 4. Anchor the cuff on your thumb. With your fingers still under the cuff, pull the cuff up and away from your hand and over the knitted cuff of the gown. 5. Repeat the preceding step to glove your other hand. 5. Repeat the preceding step to glove your other hand. 6. The gloving process is complete. 6. The gloving process is complete.

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105 To gown and glove the surgeon, follow these steps: 1. Pick up a gown from the sterile linen pack. Step back from the sterile field and let the gown unfold in front of you. Hold the gown at the shoulder seams with the gown sleeves facing you. To gown and glove the surgeon, follow these steps: 1. Pick up a gown from the sterile linen pack. Step back from the sterile field and let the gown unfold in front of you. Hold the gown at the shoulder seams with the gown sleeves facing you.

106 2. Offer the gown to the surgeon. Once the surgeon's arms are in the sleeves, let go of the gown. Be careful not to touch anything but the sterile gown. The circulator will tie the gown. 2. Offer the gown to the surgeon. Once the surgeon's arms are in the sleeves, let go of the gown. Be careful not to touch anything but the sterile gown. The circulator will tie the gown. 3. Pick up the right glove. With the thumb of the glove facing the surgeon, place your fingers and thumbs of both hands in the cuff of the glove and stretch it outward, making a circle of the cuff. Offer the glove to the surgeon. Be careful that the surgeon's bare hand does not touch your gloved hands. (Repeat for left hand) 3. Pick up the right glove. With the thumb of the glove facing the surgeon, place your fingers and thumbs of both hands in the cuff of the glove and stretch it outward, making a circle of the cuff. Offer the glove to the surgeon. Be careful that the surgeon's bare hand does not touch your gloved hands. (Repeat for left hand)

107 TYPES OF ANESTHESIA ANESTHESIA - is a state of narcosis, analgesia, relaxation & reflex loss. ANESTHESIA - is a state of narcosis, analgesia, relaxation & reflex loss. ANESTHESIA involves the use of medications that block pain sensations (analgesia) during surgery and other medical procedures. involves the use of medications that block pain sensations (analgesia) during surgery and other medical procedures. Anesthesia also reduces many of your body's normal stress reactions to surgery. Anesthesia also reduces many of your body's normal stress reactions to surgery.stress reactionsstress reactions

108 TYPES OF ANESTHESIA I. General Anesthesia I. General Anesthesia II. Local Anesthesia II. Local Anesthesia III. Regional Anesthesia III. Regional Anesthesia IV. Moderate Sedation IV. Moderate Sedation V. Monitored Anesthesia Care V. Monitored Anesthesia Care

109 GENERAL ANESTHESIA I. GENERAL ANESTHESIA - affects your entire body and renders you unconscious. I. GENERAL ANESTHESIA - affects your entire body and renders you unconscious. The patient would be completely unaware and not feel pain during the surgery or procedure. The patient would be completely unaware and not feel pain during the surgery or procedure. Also causes forgetfulness (amnesia) and relaxation of the muscles throughout your body. Also causes forgetfulness (amnesia) and relaxation of the muscles throughout your body.

110 Suppresses many of your body’s normal automatic functions, such as those that control breathing, heartbeat, circulation of the blood (such as blood pressure), movements of the digestive system, and throat reflexes such as swallowing, coughing, or gagging that prevent foreign material from being inhaled into your lungs (aspiration) Suppresses many of your body’s normal automatic functions, such as those that control breathing, heartbeat, circulation of the blood (such as blood pressure), movements of the digestive system, and throat reflexes such as swallowing, coughing, or gagging that prevent foreign material from being inhaled into your lungs (aspiration)

111 Monitoring of the heart, breathing, blood pressure, and other vital functions is important. An endotracheal (ET) tube or a laryngeal mask airway is usually used to give an inhalant anesthetic and oxygen, control and assist breathing. An ET tube is used to prevent aspiration. Monitoring of the heart, breathing, blood pressure, and other vital functions is important. An endotracheal (ET) tube or a laryngeal mask airway is usually used to give an inhalant anesthetic and oxygen, control and assist breathing. An ET tube is used to prevent aspiration.endotracheal (ET) tubeendotracheal (ET) tube

112 General anesthesia is commonly begun (induced) with intravenous (IV) anesthetics, but inhalation agents also may be used. Once you are unconscious, anesthesia may be maintained with an inhalant anesthetic alone, with a combination of intravenous anesthetics, or a combination of the two. General anesthesia is commonly begun (induced) with intravenous (IV) anesthetics, but inhalation agents also may be used. Once you are unconscious, anesthesia may be maintained with an inhalant anesthetic alone, with a combination of intravenous anesthetics, or a combination of the two.intravenous (IV) anestheticsintravenous (IV) anesthetics

113 STAGES OF GENERAL ANESTHESIA STAGE I – BEGINNING ANESTHESIA STAGE I – BEGINNING ANESTHESIA  Warmth, dizziness, & feeling of detachment.  Ringing, roaring or buzzing in the ears.  Still conscious but may sense inability to move the extremities easily.  Noises are exaggerated – even low voices or minor sounds seem loud & unreal.  Unnecessary noises & motions should be avoided.

114 STAGE II – EXCITEMENT STAGE II – EXCITEMENT  Struggling, shouting,talking, singing, laughing or crying – (avoided if given smoothly & quickly)  Pupils dilate ( but contract if exposed to light)  PR rapid & RR irregular.  Restraining the patient may be possible.

115 STAGE III – SURGICAL ANESTHESIA STAGE III – SURGICAL ANESTHESIA  Reached by continuous administration of anesthetic vapor or gas.  Pt. is unconscious & lies quietly.  Pupils are small but contract when exposed to light  RR regular, PR & volume WNL, skin pink/flushed

116 STAGE IV – MEDULLARY DEPRESSION STAGE IV – MEDULLARY DEPRESSION  Reached when too much anesthesia has been administered.  Respirations shallow, pulse weak & thready.  Pupils widely dilated & no longer contract when exposed to light.  CYANOSIS develops & w/o prompt intervention  DEATH

117  Anesthetic is discontinued immediately.  Circulatory support initiated.

118 REGIONAL ANESTHESIA REGIONAL ANESTHESIA involves injection of a local anesthetic (numbing agent) around major nerves or the spinal cord to block pain from a larger but still limited part of the body. TYPES : REGIONAL ANESTHESIA involves injection of a local anesthetic (numbing agent) around major nerves or the spinal cord to block pain from a larger but still limited part of the body. TYPES : REGIONAL ANESTHESIA REGIONAL ANESTHESIA 1. EPIDURAL 1. EPIDURAL 2. SPINAL 2. SPINAL 3. LOCAL CONDUCTION BLOCKS 3. LOCAL CONDUCTION BLOCKS

119 EPIDURAL ANESTHESIA EPIDURAL ANESTHESIA EPIDURAL ANESTHESIA EPIDURAL ANESTHESIA  commonly used conduction block  Injecting a local anesthetic into the epidural space that surrounds the dura matter of the SC.  Blocks sensory, motor & autonomic functions.  Doses are much higher than spinal because epidural anesthetic does not make direct contact w/ the SC or nerve roots.

120  ADVANTAGE: absence of headache  DISADVANTAGE: greater technical challenge of introducing the anesthesia in the epidural space.  If (+) accidental puncture of the dura happens & the anesthetic travels toward the head  HIGH SPINAL ANESTHESIA  SEVERE HYPOTENSION, RESPIRATORY DEPRESSION  ARREST

121 SPINAL ANESTHESIA SPINAL ANESTHESIA  Local anesthetic is introduced @ the lumbar level between L4 & L5.  Produces anesthesia of lower extremities, perineum & lower abdomen.  Lumbar puncture done  knee –chest position  As soon as the injection has been made  position pt on his back

122 PERIPHERAL NERVE BLOCKS. A local anesthetic is injected near a specific nerve or group of nerves to block pain from the area of the body supplied by the nerve. Nerve blocks are most commonly used for procedures on the hands, arms, feet, legs, or face. PERIPHERAL NERVE BLOCKS. A local anesthetic is injected near a specific nerve or group of nerves to block pain from the area of the body supplied by the nerve. Nerve blocks are most commonly used for procedures on the hands, arms, feet, legs, or face. PERIPHERAL NERVE BLOCKS PERIPHERAL NERVE BLOCKS Brachial plexus block- arm Brachial plexus block- arm Paravertebral anesthesia- chest, abdo wall & ext. Paravertebral anesthesia- chest, abdo wall & ext. Transacral (Caudal) block- peineum,lower abdomen Transacral (Caudal) block- peineum,lower abdomen

123 LOCAL ANESTHESIA LOCAL ANESTHESIA involves injection of a local anesthetic (numbing agent) directly into the surgical area to block pain sensations. It is used only for minor procedures on a limited part of the body. You may remain awake, though you will likely receive medicine to help you relax or sleep during the surgery LOCAL ANESTHESIA involves injection of a local anesthetic (numbing agent) directly into the surgical area to block pain sensations. It is used only for minor procedures on a limited part of the body. You may remain awake, though you will likely receive medicine to help you relax or sleep during the surgery LOCAL ANESTHESIA LOCAL ANESTHESIA Often administered in combination with Epinephrine. Often administered in combination with Epinephrine.

124 ADVANTAGES : ADVANTAGES : Simple, economical, non-explosive Simple, economical, non-explosive Equipment needed is minimal Equipment needed is minimal Post-op recovery is brief Post-op recovery is brief Undesirable effects of Gen. Anesthesia are avoided. Undesirable effects of Gen. Anesthesia are avoided. Ideal for short & superficial surgical procedures. Ideal for short & superficial surgical procedures.

125 Intraoperative Complications Nausea and vomiting Nausea and vomiting Anaphylaxis Anaphylaxis Hypoxia and respiratory complications Hypoxia and respiratory complications Hypothermia Hypothermia Malignant hyperthermia Malignant hyperthermia Disseminated intravascular coagulation (DIC) Disseminated intravascular coagulation (DIC)

126 Potential Adverse Effects of Surgery and Anesthesia Allergic reactions and drug toxicity or reactions Allergic reactions and drug toxicity or reactions Cardiac dysrhythmias Cardiac dysrhythmias CNS changes and oversedation or undersedation CNS changes and oversedation or undersedation Trauma: laryngeal, oral, nerve, and skin, including burns Trauma: laryngeal, oral, nerve, and skin, including burns Hypotension Hypotension Thrombosis Thrombosis

127 Gerontologic Considerations Elderly patients are at increased risk for complications due to surgery and anesthesia because of: Elderly patients are at increased risk for complications due to surgery and anesthesia because of: Increased likelihood of coexisting conditions. Increased likelihood of coexisting conditions. Aging heart and pulmonary systems. Aging heart and pulmonary systems. Decreased homeostatic mechanisms. Decreased homeostatic mechanisms. Changes in responses to drugs and anesthetic agents due to aging changes such as decreased renal function, and changes in body composition of fat and water. Changes in responses to drugs and anesthetic agents due to aging changes such as decreased renal function, and changes in body composition of fat and water.

128 Nursing Goals for the Patient in the Intraoperative Period Reducing anxiety Reducing anxiety Preventing positioning injuries Preventing positioning injuries Maintaining patient safety Maintaining patient safety Maintaining the patient's dignity Maintaining the patient's dignity Avoiding complications Avoiding complications

129 Laparotomy Position, Trendelenburg Position, Lithotomy Position, and Sidelying Position for Kidney Surgery

130 Protecting the Patient from Injury Patient identification Patient identification Correct informed consent Correct informed consent Verification of records of health history and exam Verification of records of health history and exam Results of diagnostic tests Results of diagnostic tests Allergies (include latex allergy) Allergies (include latex allergy) Monitoring and modifying the physical environment Monitoring and modifying the physical environment

131 Safety measures such as grounding of equipment, restraints, and not leaving a sedated patient Safety measures such as grounding of equipment, restraints, and not leaving a sedated patient Verification and accessibility of blood Verification and accessibility of blood

132 III. POSTOPERATIVE PHASE  Begins with the admission of the client to PACU & ends with discharge of client from hospital or facility providing continuity of care.

133 Post-Anesthesia Care Unit The PACU environment The PACU environment Beds and other equipment Beds and other equipment Three phases: Three phases: Phase I Phase I Phase II Phase II Phase III Phase III

134 Nursing Management in the PACU Provide care for the patient until he/she has recovered from the effects of anesthesia. Provide care for the patient until he/she has recovered from the effects of anesthesia. Patient has resumption of motor and sensory function, is oriented, has stable VS, and shows no evidence of hemorrhage or other complications of surgery. Patient has resumption of motor and sensory function, is oriented, has stable VS, and shows no evidence of hemorrhage or other complications of surgery. Frequent skilled assessment of the patient is vital Frequent skilled assessment of the patient is vital

135 Responsibilities of the PACU Nurse Review pertinent information and baseline assessment upon admission to the unit. Review pertinent information and baseline assessment upon admission to the unit. Assessments include airway and respirations, cardiovascular function, surgical site, function of the central nervous system; also assess IVs and all tubes and equipment. Assessments include airway and respirations, cardiovascular function, surgical site, function of the central nervous system; also assess IVs and all tubes and equipment. Reassess VS and patient status every 15 minutes or more frequently as needed. Reassess VS and patient status every 15 minutes or more frequently as needed. Provide report and transfer the patient to another unit or discharge the patient to home. Provide report and transfer the patient to another unit or discharge the patient to home.

136 Outpatient Surgery/Direct Discharge Discharge planning and discharge assessment Discharge planning and discharge assessment Provide written and verbal instructions regarding follow-up care, complications, wound care, activity, medications, and diet. Provide written and verbal instructions regarding follow-up care, complications, wound care, activity, medications, and diet. Give prescriptions and phone numbers. Discuss actions to take if complications occur. Give prescriptions and phone numbers. Discuss actions to take if complications occur.

137 Outpatient Surgery/Direct Discharge Give instructions to the patient and a responsible adult who will accompany the patient. Give instructions to the patient and a responsible adult who will accompany the patient. Patients are not to drive home or be discharged to home alone. Sedation and anesthesia may cloud memory and judgment and affect ability. Patients are not to drive home or be discharged to home alone. Sedation and anesthesia may cloud memory and judgment and affect ability.

138 Maintaining a Patent Airway A primary consideration: necessary to maintain ventilation and oxygenation! A primary consideration: necessary to maintain ventilation and oxygenation! Provide supplemental oxygen as indicated. Provide supplemental oxygen as indicated. Assess breathing by placing hand near face to feel movement of air. Assess breathing by placing hand near face to feel movement of air. Keep head of bed elevated 15-30 o unless contraindicated. Keep head of bed elevated 15-30 o unless contraindicated. May require suctioning. May require suctioning. If vomiting occurs, turn patient to the side If vomiting occurs, turn patient to the side

139 Head and Jaw Positioning to Open Airway

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142 Use of Oral Airway Note: Do not remove oral airway until evidence of gag reflex returns


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