Medical Surgical Nursing

PERIOPERATIVE NURSING By : Lowell P. Bautista, RN

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 can involve cutting, abrading, suturing, laser or otherwise physically changing body tissues and organs."

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.

ASEPSIS - The state of being free of pathogenic microorganisms. - 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 - is a severe illness caused by overwhelming infection of the bloodstream by toxin-producing bacteria. - 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.

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.

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

PREFIXES & SUFFIXES

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

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

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

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

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

PERIOPERATIVE NURSING
SURGERY

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

PERIOPERATIVE NURSING
DEFINITION: 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.

PERIOPERATIVE NURSING

PHILOSOPHY :

To

give service that aims to provide comprehensive support physically, morally, psychologically, spiritually, & socially to a patient undergoing surgery.

PERIOPERATIVE NURSING

GOALS :

1.

2.

3.

To provide safe, supportive & comprehensive care. To assist the surgeon by functioning effectively as a member of the surgical team. To create & maintain an aseptic / sterile environment.

PERIOPERATIVE NURSING
Fundamental purposes of the O.R. : 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.

Perioperative Patient-Focused Model

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. 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 followup evaluation in the clinical setting or at home

 1)

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

CLASSIFICATIONS OF SURGERY

CLASSIFICATIONS OF SURGERY
2)

URGENT pt. requires prompt attention. > indications for surgery : within 24-30 hours. > examples : Acute gallbladder infection Kidney / Ureteral stones

CLASSIFICATIONS OF SURGERY
3)

REQUIRED pt. needs to have surgery. > indications for surgery: plan within few weeks or months. > examples : Prostatic hyperplasia without bladder obstruction, Thyroid disorders, Cataracts.

CLASSIFICATIONS OF SURGERY
4)

ELECTIVE pt should have surgery. > indications for surgery: Failure to have surgery not catastrophic. > examples : Repair of scars Simple hernia Vaginal repair

CLASSIFICATIONS OF SURGERY
5)

OPTIONAL decision rests with pt. > indications for surgery : Personal preference > examples : Cosmetic surgery

CLASSIFICATIONS OF SURGERY
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. >ex. Organ transplant Open heart surgery Removal of a kidney

CLASSIFICATIONS OF SURGERY

MINOR little risk with few complications. - often performed in a day surgery. > examples: Breast biopsy Tonsillectomy Knee surgery

CLASSIFICATIONS OF SURGERY

1.

2.

3.

Accdg. To Purpose : DIAGNOSTIC verifies suspected diagnosis - ex. Biopsy EXPLORATORY estimates the extent of the disease or injury. - Ex. Explore laparotomy CURATIVE removes or repairs damaged tissues .

CLASSIFICATIONS OF SURGERY
4.

5.

6.

ABLATIVE removing diseased organ that cant wait anymore. - emergency surgery. PALLIATIVE relieves symptoms but does not cure the underlying disease process. RECONSTRUCTIVE partial or complete restoration of a damaged organ/tissue to bring back the original appearance & function.(mammoplasty, face-lift)

7.

1.

2.

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

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.

3)

4)

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. TUMORS abnormal growth of tissue that serves no physiologic function in the body.

THE SURGICAL RISK PATIENTS

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

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

1.

2. 3.

4.
5.

PROBLEMS THAT MAY ARISE IN SURGERY: Surgical risk pts probability of morbidity or mortality following surgery. Pain Hemorrhage Infection UTI

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.

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.

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

PREPARATION FOR SURGERY

Psychological Support : a) Assess clients 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.

d)

e)

Demonstrate confidence in surgeon & staff. Provide for spiritual care if appropriate.

PREOPERATIVE TEACHING

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

PREOPERATIVE TEACHING

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

Diaphragmatic Breathing and Splinting When Coughing

Leg Exercises and Foot Exercises

Preoperative Nursing Interventions

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

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4. 5.

6.

CBC Electrolytes PT/PTT (Prothrombin Time;Partial thromboplastin time) Urinalysis ECG Blood typing & crossmatch

NPO- to prevent aspiration Bowel prep and skin prep - 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.

Immediate preoperative preparation

Complete checklist and chart Hospital gown, voiding, removal of dentures, jewelry, contacts, etc. Preoperative medication

Transporting the pt. to the Presurgical area about 30 to 60 minutes before anesthetics is to be given. Attend to family needs

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 nurses role as client advocate to confirm that the client understands information given.

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

1.

2.

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

3.

a. b. c. d.

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

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.

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.

PREOPERATIVE MEDICATIONS

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PURPOSES: To relieve fear & anxiety. To reduce dose needed for induction & maintenance of anesthesia. To prevent reflex bradycardia that happens during induction of anesthesia. To minimize oral secretions.

PREOPERATIVE MEDICATIONS

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.

NURSING ACTIVITIES: Activities providing for pts 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.

Members of the Surgical Team

Patient Anesthesiologist or anesthetist Surgeon Nurses (Scrub & Circulating) Surgical technologists

SCRUB TEAM @ WORK

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

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

SCRUB NURSE provides sterile instruments & supplies to the surgeon during the procedure. - performs surgical hand scrub. 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.

SCRUB NURSE

CIRCULATING

NURSE

Prevention of Infection

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

THE OPERATING ROOM

Basic Guidelines for Surgical Asepsis

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. 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.

Basic Guidelines for Surgical Asepsis

Items are dispensed by methods to preserve sterility. 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 1foot distance from the sterile field must be maintained.

Basic Guidelines for Surgical Asepsis

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. Sterile fields are prepared as close as possible to time of use.

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.

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. Each member must develop a surgical conscience, a willingness to supervise and be supervised by others regarding the adherence to standards.

BASIC PRINCIPLES OF SURGICAL ASEPSIS

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.

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 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. If sterile surgical gloves are torn, punctured, or have touched an unsterile surface or item, they are considered contaminated.

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. 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

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. Take every precaution to prevent contamination of sterile areas or supplies by airborne organisms.

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. 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

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 leave sterile articles unattended once they are opened and placed on a sterile field.

Do not return sterile articles to a container once they have been removed from the container. 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.

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

SURGICAL HAND SCRUB

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.

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2.

3.

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. 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. Under running water, clean your fingernails and cuticles, using a nail cleaner.

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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. 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. Begin with the fingertips. Bring your thumb and fingertips together and, using the brush, scrub across the fingertips using 30 strokes.

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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. Scrub the palm and back of the hand in a circular motion, using 20 strokes each. 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

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

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

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Dry your hands with a sterile towel. Do not allow the towel to touch anything other than your scrubbed hands and arms. Between operations, follow the same handscrub procedure.

Gowning and Gloving

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. 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.

GLOVING 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. 3. Slip your gloved fingers under the cuff of the other glove. Pull the glove over your fingers and hand, using a stretching side-toside motion.

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. 6. The gloving process is complete.

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.

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)

TYPES OF ANESTHESIA

ANESTHESIA - is a state of narcosis, analgesia, relaxation & reflex loss. 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.

TYPES OF ANESTHESIA

I. General Anesthesia II. Local Anesthesia III. Regional Anesthesia IV. Moderate Sedation V. Monitored Anesthesia Care

GENERAL ANESTHESIA

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. Also causes forgetfulness (amnesia) and relaxation of the muscles throughout your body.

Suppresses many of your bodys 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)

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.

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.

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.

STAGES OF GENERAL ANESTHESIA

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.

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

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

Anesthetic is discontinued immediately. Circulatory support initiated.

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 : 1. EPIDURAL 2. SPINAL 3. LOCAL CONDUCTION BLOCKS

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.

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

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

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.

Brachial plexus block- arm Paravertebral anesthesia- chest, abdo wall & ext. Transacral (Caudal) block- peineum,lower abdomen

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 Often administered in combination with Epinephrine.

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

Intraoperative Complications

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

Potential Adverse Effects of Surgery and Anesthesia

Allergic reactions and drug toxicity or reactions Cardiac dysrhythmias CNS changes and oversedation or undersedation Trauma: laryngeal, oral, nerve, and skin, including burns Hypotension Thrombosis

Gerontologic Considerations

Elderly patients are at increased risk for complications due to surgery and anesthesia because of:
Increased likelihood of coexisting conditions. Aging heart and pulmonary systems. 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.

Nursing Goals for the Patient in the Intraoperative Period

Reducing anxiety Preventing positioning injuries Maintaining patient safety Maintaining the patient's dignity Avoiding complications

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

Protecting the Patient from Injury

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

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

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.

Post-Anesthesia Care Unit

The PACU environment Beds and other equipment Three phases:

Phase I Phase II Phase III

Nursing Management in the PACU

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. Frequent skilled assessment of the patient is vital

Responsibilities of the PACU Nurse

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. 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.

Outpatient Surgery/Direct Discharge

Discharge planning and discharge assessment 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.

Outpatient Surgery/Direct Discharge

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.

Maintaining a Patent Airway

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

Head and Jaw Positioning to Open Airway

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