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SURGERY For Nurses PDF

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SURGERY

SURGERY an invasive medical procedure performed to diagnose or treat illness, injury, or deformity.
OPERATION for correction of deformities and defects, repair of injuries, diagnosis and cure disease processes, relief of suffering and prolongation of life. PERIOPERATIVE NURSING used to describe the nursing functions in the total surgical experience of the patients.

3 Phases of Perioperative Nursing

1.

PRE OPERATIVE PHASE : from the time the decision is made for surgical intervention to the transference of the patient to the operating room. 2. INTRA OPERATIVE PHASE : from the time the patient is received in the operating room, to the time of administration of anesthesia, surgical procedure is done, until he is admitted in the recovery room/post anesthesia care unit. 3. POST OPERATIVE PHASE from the time of admission to the recovery room, to the time he is transported back to the surgical unit, discharged from the hospital, until the follow-up care.

CONDITIONS REQUIRING SURGERY


1. 2. 3. 4. Obstruction Perforation Erosion Tumor

obstruction

Perforation

Tumor

CLASSIFICATION OF SURGICAL PROCEDURES

I. According to PURPOSE:
1. Diagnostic 2. Exploratory 3. Curative 3.1) Ablative 3.2) Constructive 3.3) Reconstructive 4. Palliative 5. Transplant

II. According to DEGREE of RISK (Magnitude / Extent):

1. Major 2. Minor

III. According to URGENCY:


1. 2. 3. 4. 5. Emergency Urgent / Imperative Elective Planned / Required Optional

Abruptio placenta, an emergency

VSD needs urgent surgery

Hair transplant elective surgery

Required surgery for infected ulcer

Optional surgery for Siamese twins

SURGICAL RISK FACTORS

1. Aging
Nsg. Implications: 1. Consider using lesser doses for desired effect. 2. Adjust nutritional intake to conform to higher protein and vitamin needs. 3. Anticipate problems from long standing chronic disorders such as diabetes, anemia, obesity, cardiovascular disorders, respiratory disorders.

2. Obesity
Nsg. Implications: 1. Promote weight reduction if time permits. 2. Monitor closely for wound, pulmonary, and cardiopulmonary complications postoperatively. 3. Encourage coughing, turning, and diaphragmatic breathing exercises and early ambulation.

3.Malnutrition
Nsg. Implications: 1. Promote weight gain by providing wellbalanced diet high in calories, protein and vitamin C. 2. Administer total parenteral nutrition intravenously, nutritional supplements and tube feedings as prescribed. 3. Daily weight and calorie counts also may be ordered.

4. Dehydration/Electrolyte Imbalance
Nsg. Implications: 1. Administer intravenous fluids as ordered. 2. Keep a detailed input and output record. 3. Monitor client for evidence of electrolyte imbalance (Na+, K+, Ca++, etc.).

5. Cardiovascular Disorders
Nsg. Implications: 1. Diligently monitor vital signs, especially pulse rate, regularity, and rhythm, and general condition of the client. 2. Closely monitor fluid intake (oral & parenteral) to prevent circulatory overload. 3. Assess skin color.

4. Assess for chest pain, lung congestion, and peripheral edema. 5. Observe for signs of hypoxia, and administer oxygen as ordered. 6. Early postoperative ambulation and leg exercises reduce the risk of vascular problems, such as thrombophlebitis and pulmonary embolism. 7. Encourage change of position but avoid sudden exertion.

6. Respiratory Disorders
Nsg. Implications: 1. Closely monitor respirations, pulse, and breath sounds. 2. Assess for hypoxia, dyspnea, lung congestion, and chest pain. 3. Encourage coughing, turning, and diaphragmatic breathing exercises and early postoperative ambulation.

4. Encourage client to quit smoking or at least to reduce the number of cigarettes smoked. 5. Patients with chronic pulmonary problems such as emphysema, bronchiectasis, etc. should be treated for several days postoperatively with bronchodilators, aerosol medications, and conscientious mouth care.

7. Diabetes Mellitus
Nsg. Implications: 1. Monitor the client closely for signs and symptoms of hypoglycemia and hyperglycemia. 2. Monitor blood glucose levels every 4 hrs. as ordered. 3. Administer insulin as prescribed. 4. Encourage intake of food at the designated meal and snack times.

8. Renal & Liver Dysfunction


Nsg. Implication: 1. Monitor for fluid volume overload, I & O, and response to medication. 2. Evaluate closely for drug side effects and evidence of acidosis or alkalosis.

9. Alcoholism
Nsg. Implications: 1. Monitor closely for signs of delirium tremens. 2. Encourage well balanced diet. 3. Monitor for wound complications. 4. Administer supplemental nutrients parenterally as ordered.

10. Medications
A. Anticoagulants and Salicylates Nsg. Implications:
1. Monitor for bleeding. 2. Assess PTT / PT values.

B. Diuretics (particularly Thiazides) Nsg. Implications:


1. Monitor I & O and electrolytes. 2. Assess cardiovascular and respiratory status.

C. Antihypertensives (particularly Phenothiazines) Nsg. Implication: 1. Closely monitor blood pressure. D. Antidepressants (particularly MAO inhibitors) Nsg. Implication: 1. Closely monitor blood pressure. E. Antibiotics Nsg. Implication: 1. Monitor respirations.

OTHER FACTORS:
1. Nature of the condition 2. Location of the condition 3. Magnitude and urgency of the surgical procedure 4. Mental attitude of the person toward the surgery 5. Caliber of the professional staff health care facilities.

COMMON SUFFIXES IN SURGERY


Ectomy Rrhaphy Ostomy Otomy Plasty Scopy removal of an organ or a gland repair providing an opening (stoma) cutting into formation or plastic repair looking into

COMMON ABBREVIATIONS:
TAHBSO Total Abdominal Hysterectomy Bilateral Salphingo Oophorectomy TURP Transurethral Resection of the Prostate TURBT Transurethral Resection of the Bladder Tumor STSG Split Thicknes Skin Grafting BKA Below Knee Amputation

AKA Above Knee Amputation ECCE w/ IOL Extra Capsular Cataract Extraction w/ Intra-Ocular Lens Implantation CHOLE w/ IOC Cholecystectomy w/ Intraoperative Cholangiogram D & C Dilatationof the cervix & Curettage of the uterus SMR Submucous resection of the Nasal Septum MRM Modified Radical Mastectomy

LCCS Low Cervical Cesarean Section LSTCS Low Segment Transverse Cesarean Section ORIF Open Reduction Internal Fixation BTL Bilateral Tubal Ligation

PRE OPERATIVE PHASE

Preparations
PSYCHOLOGICAL Fear Manifestations: - Anxious - Bewilderment - Anger - Tendency to exaggerate - Sad, evasive, tearful, clinging - Inability to concentrate - Short attention span - Failure to carry out simple directions

Nsg. Interventions to minimize ANXIETY:


1. Explore clients feelings. 2. Allow client to speak openly about fears / concerns. 3. Give empathetic support. 4. Consider the persons religious preferences and arrange for visit by priest / minister as desired.

LEGAL Considerations
Informed Consent - (Operative Permit / Surgical Consent) - LEGAL document required for certain diagnostic procedures or therapeutic measures, including surgery.

Purposes:
1. To ensure that the client understands the nature of the treatment including the potential complications and disfigurement. 2. To indicate that the clients decision was made without pressure. 3. To protect the client against unauthorized procedure. 4. To protect the surgeon and the hospital against legal action by a client who claims that an unauthorized procedure was performed.

Nursing Responsibilities:
1. Witnessing the exchange between the client and the surgeon. 2. Witnessing the clients signature. 3. Establishing that the client really did understand.

3 Major Elements of Informed Consent


1. The consent must be given voluntarily. 2. The consent must be given to individual who have the capacity to understand. 3. The client must be given information to be the ultimate decision maker.

PHYSIOLOGICAL a. Cardiovascular ECG for patient aged 40 yrs. and above and those undergoing gen. anesthesia, or have cardiovascular disease. b. Hematologic CBC, Hgb & Hct, WBC, PTT & PT, Platelet count. c. Respiratory Chest x-ray, pulmonary function test / PFT. d. Metabolic FBS, Electrolytes(K+,Na++, etc). e. Genitourinary routine urine analysis.

PHYSICAL: A. Teaching Post Op Exercises:


1. 2. 3. 4. Deep breathing exercise (diaphragmatic) Coughing exercise Turning exercise Leg, ankle, and foot exercise

B. Night Prior to Surgery: Preparing the skin Preparing the GIT Preparing for anesthesia Promoting rest and sleep

C. On the Day of Surgery:


1. Early Am Care 2. Preoperative Medications / Preanesthetic Drugs - generally administered 60-90minutes before induction of anesthesia.

INTRAOPERATIVE PHASE

Definition of Terms:
Surgical Conscience ones inner voice for the conscientious practice of asepsis & sterile technique at all times. Asepsis absence of microorganism; freedom from infection; exclusion of microorganism. Sterile free of microorganism, including all spores. Spores inactive but visible sate of microorganism in the environment. Sterilization process by which all pathogenic microorganisms, including spores are killed.

3 Methods of Sterilization
1. Saturated Steam under Pressure e.g. autoclave

2. Gas Chemical Sterilization e.g. Sterrad


3. Liquid Chemical Sterilization - 2% activated aqueous glutaraldehyde solution ( e.g. cidex).

Sterile Field area around the site of incision into tissue or introduction of any instrumentation into the body orifice that has been prepared for use of sterile supplies and equipments including all furniture covered w/ sterile drapes and personnel who are properly attired. Sterile Technique method by which contamination w/ microorganism is prevented to maintain sterility throughout the operative procedure.

Surgically Clean mechanically cleansed but unsterile. Disinfection process of destroying all pathogenic microorganism except spore bearing one. Antiseptic used on tissue and skin and the growth of endogenous bacteria. Incision the result of cutting into a body tissue using sharp instrument.

Medical Asepsis include all practices intended to confine a specific microorganism to a specific area limiting the new growth and spread of microorganism. Surgical Asepsis (or sterile technique) refers to those practices that keep an area or object free of all microorganisms including practices destroying all microorganisms and spores.

PRINCIPLES OF STERILE TECHNIQUE


1. Only sterile items are used within the sterile field. 2. Gowns are considered sterile only from the waist to shoulder level in front and sleeves. 3. Tables are sterile only at table level. 4. Persons who are sterile touch only sterile items or areas; persons who are not sterile.

5. Unsterile persons avoid reaching over a sterile field; sterile persons avoid leaning over an unsterile area. 6. Edges of anything that encloses sterile contents are considered unsterile. 7. Sterile field is created as close as possible to time of use. 8. Sterile areas are continuously kept in view. 9. Sterile persons keep well within the sterile area.

10. Sterile persons keep contact with sterile areas to a minimum. 11. Unsterile persons avoid sterile areas. 12. Destruction of integrity of microbial barriers results in contamination. 13. Microorganisms must be kept to an irreducible minimum.

MEMBERS OF THE SURGICAL TEAM


1. 2. 3. 4. 5. 6. Surgeon Assistant to the surgeon Anesthesiologist Nurse anesthetist (CRNA) Circulating nurse Scrub nurse

ANESTHESIA
Effects of Anesthesia:
1. 2. 3. 4. Analgesia Amnesia Hypnosis Muscle relaxation

Factors considered in choice of Anesthesia:


Physical condition Age Presence of co-existing disease Type, site, duration of surgery Anesthesiologists preference Patients preference

TYPES OF ANESTHESIA
I. General Anesthesia Types: a. Inhalation anesthesia - mask inhalation - endotracheal administration

b. Intravenous anesthesia

Stages of General Anesthesia:


1. 2. 3. 4. Onset / Analgesia / Induction Excitement or Delirium Surgical Excitement / Anesthesia Danger / Medullary

II. Regional Anasthesia Types: 1. Topical anesthesia 2. Infiltration anesthesia 3. Regional application Examples: - Nerve block - Intravenous regional extremity block anesthesia (Bier Block) w/ tourniquet - Spinal anesthesia / Intrathecal anesthesia

Complications & discomforts of Spinal Anesthesia: a. Hypotension b. Nausea & vomiting c. Headache d. Respiratory paralysis e. Neurologic complications
4. Epidural Anesthesia Ex. Cocaine, Novocaine, Xylocaine,Carbocaine

Specialized methods in producing anesthesia:


Muscle relaxants Hypothermia Controlled Hypotension

Intraoperative (ANESTHESIA) Complications:


1. 2. 3. 4. 5. 6. 7. Hypoventilation Oral trauma Hypotension Cardiac dysrhythmia Hypothermia Peripheral nerve damage Malignant hyperpyrexia

Surgical Incisions:
Subcostal Paramedian Midline Transverse Mcburneys Butterfly Pfannenstiel Limbal Halstead / elliptical

Layers of the abdomen:


1. Skin monocryl 3/0 or 2/0, vicryl 4/0, safil 4/0, dexon 4/0, silk 3/0 2. Subcutaneous plain 2/0 3. Fascia vicryl 1 or 0, safil 1 or 0, dexon1 or 0 4. Muscle 5. Peritoneum chromic 2/0, monocryl 2/0 or 3/0

SURGICAL SUTURES
Classification: 1. Absorbable 2. Non-absorbable
Types: 1. Atraumatic 2. Non-atraumatic

Surgical Needles
Types: 1. Cutting 2. Round
Classification of surgical needles: 1. eye needle / free needle / non-atraumatic 2. eyeless / swaged needle / atraumatic

1. Cutting ex. Metzenbaum (metz), mayo scissors, suture scissors, knife. 2. Grasping - divided in the following categories: hemostats occluding clamps graspers and holders forceps or pick ups 3. Retracting 4. Accessory and ancillary instruments

CLASSIFICATION OF INSTRUMENTS

Counting and Reporting of SIN


INITIAL COUNTING before the procedure starts. 1st counting before the closure of peritoneum 2nd counting before the closure of fascia 3rd counting before closure of skin

POSTOPERATIVE PHASE
Immediate post-op nursing care: - avoid exposure - avoid rough handling - avoid hurried movement and rapid changes in position

Assessment
Appraise air exchange and note skin color Verify identify, operative procedure, surgeon Assess neurologic status (LOC) Determine VS and skin temp (CV status) Determine operative site and check dressing Perform safety checks Require briefing on problems encountered in OR

Interventions
1. Ensure maintenance of patent airway and adequate respiratory function. 2. Assess status of circulatory system.
Common cardiovascular complication immediate post-op: 1. Hypotension 2. Cardiac arrhythmias

ALDRETE Scoring in PACU: (ARCCC)


Activity 2 1 0 able to move 4 extremities able to move 2 extremities not able to move
able to cough & deep breath dyspnea or limited breathing apneic

Respiration 2 1 0

Circulation

2 1 0 Consciousness 2 1 0 Color 2 1 0

20% pre anesthesia 20-50% pre anesthesia above 50% pre anesthesia fully awake rousable on calling not responding pink pale, dusky, blotchy cyanotic

Parameters for discharge from RR


Activity score of 2; able to obey commands. Respiration score of 2; easy, noiseless breathing. Circulation 20 of pre anesthesia; BP is within +/-20 mmHg of the pre op level. Consciousness score of 2; responsive. Color score of 2; pinkish skin and mucus membrane.

Nursing Care of the client during the intermediate post op period (RRunit)
Baseline assessment: Respiratory status Cardiovascular status LOC Tubes Position

Goals: 1. Restore homeostasis and prevent complications. 2. Maintain adequate cardiovascular and tissue perfusion. 3. Maintain adequate respiratory function 4. Maintain adequate nutrition and elimination. 5. Maintain adequate fluid and electrolyte balance.

6. Maintain adequate renal function. 7. Promote adequate rest, comfort and safety. 8. Promote adequate wound healing. 9. Promote and maintain activity and mobility. 10. Provide adequate psychological support. Post op discomforts: 1. Nausea and vomiting 2. Pain 3. Thirst 4. Constipation 5. restlessness

Discharge Planning / Teaching 2 3 days after surgery:


Self care activities Wound care activities Activity limitations Diet and medications at home Possible complications Referrals, follow up check - up

POST OP COMPLICATIONS
a. b. c. CIRCULATORY COMPLICATIONS: Shock Hemorrhage Thrombophlebitis / deep thrombophlebitis

PULMONARY COMPLICATIONS a. Atelectasis b. Pneumonia

URINARY DIFFICULTIES a. Urinary retention


GASTROINTESTINAL COMPLICATIONS a. Paralytic ileus b. Gas pain c. Intestinal obstruction d. Hiccups

WOUND COMPLICATIONS a. Wound infections * Rule of thumb - fever 1st 24 hours post op - fever 48 hrs. post op - fever 48-72 hrs. post op - fever 72 hrs. post op b. Hemorrhage / Hematoma c. Wound dehiscence and evisceration

Post Op Psychological Disturbances


a. b. Delirium ACS (Acute Confusional State) Causes: Dehydrartion Insufficient oxygenation Anemia Hypotension Hormonal imbalance Infection Trauma (esp. in nervous person)

THE END GOOD LUCK

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