PAIN AND SURGERYPAIN AND SURGERY

JOCELYN G. GAVIETA, RN

GRADING SYSTEMGRADING SYSTEM

QUIZ 80 %RECITATION 10 %REQUIREMENTS 5 %ATTENDANCE 5 %

---------- 100 %

PAINPAIN• a feeling of distress, suffering or agony

caused by the stimulation of specialized nerve endings

• a blend of physiological and psychological experience of events occurring within the patient's body which is always unpleasant and associated with the impression of damage to the tissues

PAINPAIN

• First symptom of injury;• Indicator of a disease process• The fifth vital sign

SOURCES OF PAIN STIMULISOURCES OF PAIN STIMULI

NOCICEPTORSreceptors that transmit pain

sensation.

NOCICEPTIONphysiologic processes related to

pain perception.

PHYSIOLOGY OF PAINPHYSIOLOGY OF PAIN

FOUR PHASES OF NOCICEPTION1. TRANSDUCTION Noxious stimuli (tissue injury) trigger

the release of biochemical mediators (e.g., prostaglandins, bradykinin, serotonin, histamine, stubstance P) that sensitize nociceptors.

Noxious or painful stimulation also causes movement of ions across cell membranes, which excite nociceptors.

Pain medication can work at this phase: by blocking production of prostaglandins (e.g., ibuprofen) or by decreasing the movement of ions across the cell membrane (e.g., local anesthetic)

2. TRANSMISSION2. TRANSMISSIONNeuronal action potential must be transmitted to &

through the CNS before pain is perceived.

Involves 3 segments before pain impulse is transmitted:

1st Segment – pain impulse travels from the peripheral nerve fiber to the spinal cord

2nd Segment – pain transmission from the spinal cord ascending to the brain via spinothalamic tracts to the brainstem and thalamus.

3rd Segment – transmission of signals between the thalamus to the somatic sensory cortex.

2 Types of nociceptor fibers cause this transmission to the dorsal horn of the spinal cord:

a. C fibers – large & myelinated; carry pain impulse at a rapid rate; throbbing, dull, aching pain.

b. A-Delta fibers – small & unmyelinated; carry pain sensation at a slower rate; sharp, localized pain

Pain control can take place during this process:

Opioid (narcotics) block the release of neurotransmitters, particularly substance P, which stops the pain at the spinal level.

Pain Threshold – the point at which a stimulus is perceived as pain.

Pain Tolerance – amount of pain a person is willing to endure; only the person determines tolerance level.

3. PERCEPTION3. PERCEPTION When the client becomes conscious of

pain. Pain perception occurs in the cortical

structures, which allows for different cognitive-behavioral strategies to be applied to reduce the sensory & afferent components of pain.

e.g., nonpharmacologic interventions such as distraction, guided imagery, & music can help direct the client’s attention away from the pain.

4. 4. MODULATIONMODULATIONDescribed as “descending system”

Occurs when neurons in the brain stem send signals back down to the dorsal horn of the spinal cord.

These descending fibers release substances such as endogenous opioids, serotonin, norepinephrine, which can inhibit the ascending noxious impulses in the dorsal horn.

PAIN MODULATIONPAIN MODULATION

ENDOGENOUS OPIOIDS – pain inhibiting neurochemicals

1. Enkephalins Inhibits the release of substance P - a

neurotransmitter that enhances transmission of pain impulses

2. Endorphins More potent than enkephalins

3. Dynorphins Have analgesic effect, which is 50% more

potent than endorphins4. Neuromodulators

Modify pain (chemical regulators)

PHYSIOLOGICAL PHYSIOLOGICAL THEORIES OF PAIN THEORIES OF PAIN

TRANSMISSIONTRANSMISSION

1. 1. SPECIFICITY THEORYSPECIFICITY THEORYThere are specific nerve receptors for

particular stimuli. e.g.,

Nociceptors – noxious stimuli (always interpreted as PAIN)

Thermoreceptors – heat/coldMechanoreceptors – pressure, pulling or

tearing sensationChemoreceptors – chemicals

PATTERN THEORYPATTERN THEORY

States that pain is produced by intense stimulation on nonspecific fiber receptors, so any stimulus could be perceived as painful if the stimulation is intense enough.

GATE CONTROL THEORYGATE CONTROL THEORYStates that there is a “gate” in the spinal cord

(substantia gelatinosa)

When the gate is open, pain stimulus is transmitted thus pain is perceived.

When the gate is closed, pain is blocked thus no pain is perceived.

The gate is controlled by the balance impulse input from the small and large peripheral nerve fibers

TYPES OF PAINTYPES OF PAIN

ACCORDING TO DURATIONACCORDING TO DURATION

1. ACUTE PAIN• Temporary, immediate onset• Last for less than 6 months• Eventually subside after treatment or

sometimes without treatment

e.g., headache, postop pain, labor pain, toothache

2. CHRONIC PAIN• Continuous, may begin gradually,

persist or recur for an indefinite period of time, more difficult to manage effectively

• (last 6 months or longer)

3 TYPES of Chronic Pain:a.Chronic Nonmalignant Pain

e.g., low back pain, Rheumatoid A.b. Chronic Intermittent Pain

e.g., migraine headachec. Chronic Malignant Pain

e.g., cancer

ACCORDING TO SOURCE/ORIGINACCORDING TO SOURCE/ORIGIN

1. CUTANEOUS PAIN• Includes superficial somatic structures

located in the skin & the subcutaneous tissues

• “direct pain” since the pain accurately localizes the point of disturbance

• e.g., finger cut, knot hair pulled out while combing, 1st degree burn

2. DEEP SOMATIC PAIN• Includes bones, nerves, muscles & other

tissues supporting these structures

• Poorly localized; frequently radiates from primary site.

• e.g., ankle sprain, jamming a knee

3. VISCERAL PAIN• Includes all body organs located in a body

cavity

• Diffuse, poorly localized, vague, dull pain

• e.g., obstructed bowel, cardiovascular disease

ACCORDING TO INTENSTIYACCORDING TO INTENSTIY

1. MILD• One that is bearable usually tolerated by

the client

2. SEVERE• One which is intense & usually could not

be tolerated by the client

ACCORDING TO LOCATIONACCORDING TO LOCATION1. RADIATING PAIN• Perceived at the source of the pain &

extends to nearby tissue

Cardiac pain – chest, left shoulder, down the arm

2. REFERRED PAIN• Felt in an area distant from the site of the

stimulus

MI – left arm, shoulder, or jaw pain

Cholecystitis – back pain & angle of scapula

3. INTRACTABLE PAIN• Pain that is highly resistant to relief• Advanced Malignancy

4. NEUROPATHIC PAIN• Result of current or past damage to the

peripheral or CNS & may not have a stimulus, such as tissue or nerve damage.

• Nerve injury that serves the hand would be perceived a pain-hand even though the injury may be at the spinal cord level.

5. PHANTOM PAIN

• Painful sensation perceived in a body part that is missing

FACTORS AFFECTING PAIN FACTORS AFFECTING PAIN PERCEPTION AND RESPONSEPERCEPTION AND RESPONSE

1. ETHNIC & CULTURAL VALUES• Filipinos are known to be sufferers who

consider pain as sacrifice for sins committed.

• Voicing pain – appropriate Italians

inappropriate Germans (stoicism)• Mexicans/arabs – moaning/crying use to

alleviate pain rather than need for intervention

2.DEVELOPMENTAL STAGES

• Infants - sensitivity• Toddlers – cry & anger - threat to

security & punishment• School-age – not cry or express much

pain so that parents will not get angry• Adolescent – not report pain weakness• Adults – not report pain indicates

poor diagnosis, weakness, failure

3. ENVIRONMENT & SUPPORT PEOPLE• Hospital environment can be associated

with pain; Places that are noisy & have glaring lights can compound pain sensation

4. POST PAIN EXPERIENCES• A person who has witnessed a family

member who experienced severe pain may have difficulty enduring the same experience once it arises

5. MEANING OF PAIN• A woman giving birth may tolerate pain

infavor of a desired baby• An athlete who undergone knee surgery to

prolong his career may tolerate pain better than one who was shot by an enemy

6. ANXIETY & STRESS• A person who suffers fatigue may not have

a good coping with pain

PAIN ASSESSMENT TOOLSPAIN ASSESSMENT TOOLS

Onset

Location

Duration

Characteristics

Aggravating factors

Radiation

Treatment

2. FACES RATING SCALE

3. 10 POINT PAIN INTENSITY SCALE

MISCONCEPTION & MYTHS OF MISCONCEPTION & MYTHS OF PAINPAIN

• Myth: Addiction occurs with prolonged use of Morphine and Morphine derivatives

• FACT: THE INCIDENCE OF ADDICTION IS LESS THAN 0.1%

• Myth: The nurse or the physician is the best judge of a client's pain.

• FACT: ONLY THE CLIENT CAN JUDGE THE LEVEL & DISTRESS OF THE PAIN, THAT'S WHY CLIENTS SHOULD BE INCLUDED IN PAIN MANAGEMENT.

• Myth: Pain is a result not a cause.• FACT: UNRELIEVED PAIN CAN

CAUSE OTHER PROBLEMS SUCH AS ANGER, ANXIETY, IMMOBILITY, RESPIRATORY PROBLEMS, & DELAY IN HEALING.

• Myth: It is better to wait until a client has pain before giving medication.

• FACT: IT IS BETTER TO ROUTINELY ADMINISTER ANALGESIA TO MAINTAIN LOW LEVEL OF PAIN THAN TO “CATCH-UP” ONCE PAIN ARISES.

• Myth: Real pain has an identifiable cause.

• FACT: THERE ARE ALWAYS CAUSES OF PAIN BUT SOME MAY BE VERY OBSCURE.

• Myth: The same physical stimulus produces the same pain intensity, duration and distress in the same people.

• FACT: INTENSITY, DURATION, AND DISTRESS VARY WITH EACH INDIVIDUAL

• Myth: Some clients lie about the existence or severity of their pain.

• FACT: VERY FEW PEOPLE LIE ABOUT THEIR PAIN

• Myth: Very young or very old people do no have as much pain.

• FACT: ALL CLIENTS WITH INTACT NEUROLOGIC SYSTEM EXPERIENCE PAIN. AGE IS NO A DETERMINANT OF PAIN EXPERIENCE.

• Myth: Pain is a part of aging.

• FACT: PAIN DOES NOT ACCOMPANY AGING UNLESS A DISEASE, OR AN AILMENT IS PRESENT

• Myth: If a person is asleep they are not in pain.

• FACT: PAIN CAN CAUSE EXHAUSTION WHICH CAN LEAD TO CLIENTS IN PAIN TO SLEEP, BUT THEY ARE IN PAIN. SOME CLIENTS USE SLEEP AS AN ESCAPE FROM PAIN.

• Myth: If the pain is relieved by non-pharmaceutical pain relief techniques, the pain was not real anyway.

• FACT: NON-PHARMACEUTICAL METHODS CAN BE EFFECTIVE IN RELIEVING PAIN.

ASSESSMENTASSESSMENT

• Ask the client about the pain and to describe it in terms of degree, quality, area, and frequency

• Observable indicators of pain include: moaning; crying; irritability; restlessness; grimacing or frowning; inability to sleep, rigid posture; increased blood pressure, heart rates, or respirations; nausea; and diaphoresis

• Ask the client to use a number-based pain scale (a picture-based scale may be used in children) to rate the degree of pain

PAIN MANAGEMENTPAIN MANAGEMENT

Refers to the techniques used Refers to the techniques used to prevent, reduce, relieve pain.to prevent, reduce, relieve pain.

A. NON-PHARMACOLOGIC PAIN A. NON-PHARMACOLOGIC PAIN MANAGEMENTMANAGEMENT

1. PHYSICAL INTERVENTION Includes providing comfort, altering

physiologic responses & reducing fears associated with pain-related immobility or activity restriction.

a. CUTANEOUS STIMULATION Redirects the client’s attention to the tactile

stimuli away from the pain stimuli; It releases endorphins; it stimulates large diameter A-beta sensory nerve fibers.

• MASSAGEback rub to reduce pain; stimulate

client’s skin by lightly kneading, pulling or pressing with fingers, palms or knuckles.

o ACCUPRESSURE

Application of pressure to areas or points used in acupuncture known as Meridians

o CONTRALATERAL STIMULATION

Stimulating the skin opposite to the painful area.

o HEAT & COLD APPLICATION The application of heat and cold or the

alternate application can soothe pain resulting from muscle strain

Heat applications may include warm-water compresses, warm blankets, Aquathermia pads, and tub and whirlpool baths; may require a physician’s order

b. IMMOBILIZATION

Restricting movement of body part may help manage episodes of acute pain

e.g., Splint holds joints or fractured bones that maybe painful once moved

C. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS)

(portable, battery operated device) is a method of applying low voltage electrical stimulation directly over identified pain areas.

C/I in clients with pacemakers, arrhythmias or in areas of skin breakdown.

D. ACCUPUNCTURE

very thin metal needles are skillfully inserted into the body @ designated locations & @ various depths & angles

Meridians – accupuncture points distributed patterns

disease interrupts energy flow in the body and insertion of needles at specific points will re establish healthy energy flow.

Acupuncture Acupuncture is a traditional Chinese medicine that stimulates specific

points in the body in order to restore a proper balance of various chemicals. Some people who suffer from chronic pain find that

acupuncture provides a measure of pain relief where all other methods fail. The way acupuncture suppresses pain remains a mystery. Some scientists now believe that it triggers the release of pain-relieving body

chemicals called endorphins and enkephalins. Others argue that acupuncture’s pain-relieving effects are brought about by a patient’s

expectation of relief.

2. MIND-BODY INTERVENTION2. MIND-BODY INTERVENTION (Cognitive-Behavioral)(Cognitive-Behavioral)

A. DISTRACTION Directs away the attention of the client

from the painful sensation or the negative emotional arousal associated with pain

TYPES OF DISTRACTION:1. Visual Distraction – read or watch tv2. Auditory Distraction – humor, listen to

music

MUSIC Physiologic mechanism has not been

established in the use of music to relieve pain but possible theories include distraction, release of endogenous opioids, & dissociation

HUMOR Believed to help increased the production of

endogenous opioids endorphines, which are natural pain killers.

3.Tactile Distraction – massage, slow rhythmic breathing

4. Intellectual Distraction – card games, crossword puzzle

B. RELAXATION TECHNIQUESGradually tighten then deeply relax various

muscle groups proceeding systematically from one area to the next

Reduce muscle tension & anxiety

C. IMAGERY Help client visualize a pleasant experience Help distract themselves from their pain

which may increase pain tolerance; produce relaxation response; diminished the source of pain (e.g.tension headache)

D. MEDITATION Client sits comfortably & quietly with

focused attention away from painE.g., flow of the breath; picture image of

great spiritual being or peaceful place

E. BIOFEEDBACKE. BIOFEEDBACK

Biofeedback in Progress A patient at a biofeedback clinic sits connected to electrodes on his head and finger. Biofeedback is a technique in which patients attempt to become aware of and then alter bodily functions such as muscle tension and blood pressure. It is used in treating pain and stress-related conditions, and may help some paralyzed patient use of their limbs.

Biofeedback in Progress A patient at a biofeedback clinic sits connected to electrodes on his head and finger. Biofeedback is a technique in which patients attempt to become aware of and then alter bodily functions such as muscle tension and blood pressure. It is used in treating pain and stress-related conditions, and may help some paralyzed patient use of their limbs.

F. HYPNOSIS Hypnotic state; suggest to alter

character of pain or one’s attitude toward it

G. THERAPEUTIC TOUCH use hands to rearrange energy field to normal

H. MAGNETS Believed that the pull of magnet increased

blood flow to the region of pain, opening the NaCl channels in the cell.

PHARMACOLOGIC PAIN PHARMACOLOGIC PAIN MANAGEMENTMANAGEMENT

1. OPIOID ANALGESICS 1. OPIOID ANALGESICS (NARCOTIC)(NARCOTIC)

Derived from natural opium alkaloids & their synthetic derivatives

Suppress pain impulses but can suppress respiration and coughing by acting on the respiratory and cough center in the medulla of the brain stem

Can produce euphoria and sedation Can cause physical dependence

PHYSICAL DEPENDENCE means that a person experiences physical

discomfort, known as withdrawal syndrome, when a drug that client has taken routinely for some time is abruptly discontinued.

to avoid withdrawal symptoms, drugs that are known to cause physical dependence are discontinued gradually. Dosage or frequency of adm. is lowered over 1 week or longer.

NARCOTIC ANALGESICSNARCOTIC ANALGESICSMEPERIDINE HYDROCHLORIDE

(Demerol)Can cause respiratory depression, tachycardia,

constipation, urine retention, hypotention, and dizziness

• Used for acute pain and as a preoperative medication

• Contraindicated in head injuries and in the presence of increased intracranial pressure, respiratory disorders, hypotentions, shock and severe hepatic or renal didsease,

• Should not be taken with alcohol or sedative hypnotics; may increase CNS depression

• To administer intravenously, dilute in at least 5 ml of sterile water or NSS for injection, then administer dose over 4 to 5 minutes

CODEIN SULFATE• Also used in low doses as a cough

suppressant• Can cause constipation

MORPHINE SULFATE• Can cause respiratory depression, postural

(orthostatic) hypotention, urine retention, constipation, and papillary constriction

• May cause nausea and vomiting because of increased vestibular sensitivity

• Used to ease acute pain resulting from myocardial infarction or cancer, for dyspnea resulting from pulmonary edema, and as a preoperative medication

• Monitor intake and output and assess client for urine retention

• Instruct client to avoid activities that require alertness

• Have a narcotic antagonist available (e.g., Naloxone (Narcan), oxygen, and resuscitation equipment available

NARCOTIC ANTAGONISTSNARCOTIC ANTAGONISTS

Description• Use to treat respiratory depression from

narcotic overdose - Naloxone (Narcan)Interventions• Monitor BP, pulse, & RR q 5 mins. initially,

tapering to q 15 minutes, & then q 30 mins. until the client’s condition is stable

• Attach a cardiac monitor to the client & observe cardiac rhythm

• Auscultate breath sounds • Have resuscitation equipment available• Do not leave client unattended• Monitor client closely for several hours;

when the effects of the antagonist wears off,

• the client may again display signs of narcotic overdose

3 Primary Types of Opioids:3 Primary Types of Opioids:

1. FULL AGONISTS pure opiod drugs producing maximum pain

inhibition, an agonists effect. No ceiling on the level of analgesia Dose can be steadily increased to relieve

pain No maximum daily dose limit Demerol, Morphine, Codeine

2. MIXED AGONISTS-ANTAGONIST2. MIXED AGONISTS-ANTAGONIST

can act like opioids & relieve pain (agonist effect) when given to client who has not taken any pure opioids.

block or inactivate other opioid analgesics when given to client who has been taking pure opioids (antagonist effect)

have ceiling dose & not recommended for use w/ terminally ill clients.

Nubain, Stadol

3. PARTIAL AGONISTS3. PARTIAL AGONISTS

have ceiling effect in contrast to a full agonist.

Buprenorphine (Buprenex)Pentazocine (Talwin)

2. NON-OPIOID ANALGESICS2. NON-OPIOID ANALGESICS

They relieve pain by acting on peripheral nerve endings at the injury site

& decreasing the level of inflammatory mediators

& interfering with the production of prostaglandins at the site of injury.

ACETAMINOPHEN (TYLENOL)ACETAMINOPHEN (TYLENOL)

Description• Inhibits prostaglandin synthesis• Used to decreased pain and feverContraindications• Hepatic or renal disease, alcoholism, and

hypersensitivitySide Effects• Major concern is hepatotoxicity

NSAIDs and ACETYLSALICILIC NSAIDs and ACETYLSALICILIC ACID (Aspirin)ACID (Aspirin)

• NSAIDs are aspirin and aspirin-like medications that inhibit the synthesis of prostaglandins

• Act as analgesics to relieve pain, as antipyretics to reduce body temperature, and as anticoagulants to inhibit platelet aggregation

• Used to relieve inflammation and pain and to treat rheumatoid arthritis, bursitis, tendonitis, osteoarthritis, and acute gout

3. ADJUVANT ANALGESICS3. ADJUVANT ANALGESICS

Is a medication that was developed for other than analgesia but has been found to reduce chronic pain & sometimes acute pain, in addition to its primary action. Muscle Relaxant – muscle spasmAnticonvulsants – nerve injuryCorticosteroids – reduce inflammation &

edema

Concept on surgeryConcept on surgery

CORRECT POSITION OF HANDS AFTER SURGICAL SCRUBBINGCORRECT POSITION OF HANDS AFTER SURGICAL SCRUBBING

SURGERYSURGERYas a science and an art surgery is the branch of medicine that

comprises perioperative patient care encompassing such activities as pre-operative preparation, intra-operative judgement, and post-operative care of patients.

CATEGORIES & PURPOSES CATEGORIES & PURPOSES OF SURGERYOF SURGERY

ACCORDING TO PURPOSE1. Diagnostic

Performed to determine the origin & cause of a disorder or the cell type for cancer

breast biopsy

2. Exploratory Estimation of the extent of disease or

confirmation of a diagnosis exploratory laparotomy, pelvic laparotomy

3. Curative Performed to resolve a health problem by

repairing or removing the cause

Classification:

a.Ablative Includes removal of an organ; e.g., appendECTOMY (suffix)

a.ConstructiveInvolves the repair of congenitally damaged

organe.g., cheiloPLASTY, orchidoPEXY

b.ReconstructiveInvolves repair of damaged organe.g., Total joint replacement

4. Palliative Performed to relieve symptoms of a

disease process, but does not cure Nerve root resection, Colostomy

5. Cosmetic Performed primarily to alter or enhance

personal appearance Rhinoplasty, Blepharoplasty

ACCORDING TO URGENCY1. Emergent

condition is life-threatening that requires surgery at once

e.g., gunshot or stab wound, severe bleeding

2. Urgent performed as soon as client is stable &

infection is under control; life threatening if treatment is delayed more than 24-48H

e.g., appendectomy, intestinal obstruction

3. Required Client should have surgery; planned for a

few weeks or months e.g., Prostatic hyperplasia w/o obstruction,

Cataracts, Simple Hernia

4. Elective Client will not be harmed if surgery is not

performed but will benefit if it is performed e.g., Revision of Scars, Vaginal Repair

5. Optional Personal preference usually for aesthetic

purposes e.g., Cosmetic surgery

ACCORDING TO DEGREE OF RISK1.Minor

Procedure of less risk; generally not prolonged; leads to few complications

2. Major Procedure of greater risk; usually longer &

more extensive; great risk of complications

ACCORDING TO EXTENT OF SURGERY1.Simple

Only the most overtly affected areas involved in the surgery

e.g., Simple or Partial Mastectomy

2.Radical Extensive surgery beyond the area obviously

involved e.g., Radical Mastectomy, Radical

Hysterectomy

SURGICAL SETTINGSURGICAL SETTING

1. INPATIENT Refers to client who is admitted to a hospital Admitted on the day of surgery (Same-day

Admission – SDA)

2. OUTPATIENT & AMBULATORY Refers to a client who goes to the surgical

area the day of the surgery & returns home on the same day (Same-day Surgery – SDS)

PERIOPERATIVE PERIOPERATIVE NURSINGNURSING

PERIOPERATIVE NURSINGPERIOPERATIVE NURSINGAssist clients and their significant others

through the surgical episode, o help promote positive outcomes, and to help clients achieve their optimal level

of function and wellness after surgery.

Emphasis on safety & client education

Use Knowledge, judgement & skills

PREOPERATIVE PREOPERATIVE PERIODPERIOD

Begins when the client is scheduled for Begins when the client is scheduled for surgery & ends at the time of transfer to surgery & ends at the time of transfer to

surgical suitesurgical suite

PREOPERATIVE PERIODPREOPERATIVE PERIOD

Focuses on client’s readiness – client education & any intervention:1. Reduce anxiety2. Reduce complication3. Promote cooperation

Needed before surgery to:1. Validate & clarify information client received from surgeon or members of health team2. Identify problems that warrant further assessment &/or intervention before surgery

PREOPERATIVE ASSESSMENTPREOPERATIVE ASSESSMENT

A. MEDICAL/HEALTH HISTORY Purpose of reviewing medical history is to

determine operative risk.

COLLECT THE FOLLOWING DATA:COLLECT THE FOLLOWING DATA:

1. AGEOlder – risk of complication; immune

system functioning; delays wound healing; frequency of chronic illness; alter operative response/risk

2. DRUGS & SUBSTANCE USEo Tobacco - risk of pulmonary

complications (changes in lungs & cavity)o Alcohol & illicit subs. – alter response to

anesthesia & pain meds. withdrawal before surgery may

lead to delirium tremens

o PRESCRIPTION & OVER THE COUNTER – affect how client reacts to operative experience

o Potential effects for reaction or serious adverse effect with some herbs & specific drugs.

3. MEDICAL HISTORYo Chronic illness increased surgical risk

4. CARDIAC HISTORY

o Complications from anesthesia occur often

o Impair ability to withstand hemodynamic changes & alter response to anesthesia

o Risk for MI during surgery higher with pre-existing cardiac problem

5. PULMONARY HISTORY

o Smoker/Chronic Respiratory Problem - chest rigidity & loss of lung elasticity reduce anesthesia excretion.

o Smoking - blood level of Carboxyhemoglobin which decreases O2 delivery to organs

acts on cilia of pulmonary mucous membrane which lead to retain secretion & predisposes clients to pneumonia & atelectasis (reduce gas exchange & causes intolerance of anesthesia)

Chronic lung problems (asthma, emhysema, chronic bronchitis)

reduce lung elasticity

reduce gas exchange

reduce tissue oxygenation 7. ANESTHESIA

o Affect readiness for surgeryo those w/ complication - fear & concerns of

scheduled surgery

8. DISCHARGE PLANNING

o Assess client’s home, environment, self-care capabilities, support system, & anticipate post-op needs before surgery

Older clients & dependent adult need transport referrals

Home care nurse/health center nurse need to monitor recovery & provide instruction

B. PHYSICAL ASSESSMENTB. PHYSICAL ASSESSMENT

To obtain baseline dataComplete set V/S – abnormal V/S

may postpone surgery until problem is treated & condition is stable

1. CARDIOVASCULAR SYSTEM1. CARDIOVASCULAR SYSTEMCardiac problems – 30% of surgery-related

deathsHPN – common & often undiagnosed affect

response to surgeryAssess cardiac sounds for rate, regularity &

abnormalitiesHands & feet – for temp, color, peripheral

pulses, capillary refill, & edema

REPORT: absent peripheral pulses, pitting edema, cardiac symptoms ( chest pain, dyspnea) for further assessment & evaluation

2. RESPIRATORY SYSTEM2. RESPIRATORY SYSTEM

Age, smoking history (second handsmoke), chronic illness

Overall posture, RR, rhythm & depth, overall respiratory effort & lung expansion

Document clubbing of fingertips ( swelling base nailbeds caused by chronic lack of O2) or cyanosis

3. RENAL/URINARY SYSTEM3. RENAL/URINARY SYSTEMKidney function – affects excretion of drugs &

waste products including ANESTHETIC & ANALGESIC AGENTS

Renal function reduced (Older client) – fluid & electrolyte balance can be altered

KIDNEY IMPAIRED:excretion of drugs & anesthetic agentDrug effectiveness may be altered Buscopan, Morphine, Demerol, Barbiturates

causes confusion, disorientation, apprehension, restlessness with kidney function

4. NEUROLOGIC SYSTEM4. NEUROLOGIC SYSTEMAssess overall mental status – LOC,

orientation, ability to follow commands) before planning preoperative teaching & care

Assess motor & sensory deficits – problems may affect type of care needed during surgical experience

Risk for falling (esp older) – evaluate mental status, muscle strength, steadiness of gait, sense of independence, ability to ambulate

5. MUSKULOSKELETAL SYSTEM5. MUSKULOSKELETAL SYSTEMProblems may interfere with positions during &

after surgery. e.g., w/ Arthritis – may be able to assume surgical position but

have discomfort after surgery from prolonged joint immobilization

History joint replacement & document exact location of prosthesis – ensure that electrocautery pads are not place ON or NEAR area of prosthesis – cause electrical burn

6. NUTRITIONAL STATUS6. NUTRITIONAL STATUS

Malnutrition & Obesity - surgical risk metabolic rate & depletes K, Vit C & B – needed for wound healing & blood clotting

Malnourished - S. CHON slows recovery & negative nitrogen balance may result from depleted CHON store - risk delayed wound healing, possible dehiscence & evisceration, dehydration & sepsis

OBESE CLIENT – often malnourished because of imbalance diet risk poor wound healing – excessive

adipose (fatty) tissue few blood vessels, little collagen, nutrients needed for wound healing

Stresses heart & reduces lung volume – affects surgery & recovery

Need large doses of drugs & may retain them longer after surgery

7. PSYCHOSOCIAL ASSESSMENT7. PSYCHOSOCIAL ASSESSMENT

To determine level of anxiety, coping ability, & support system

– provide information & offer support as neededDegree of Anxiety & Fears varies according:

Type of surgeryPerceived effects of surgery & potential

outcomeClient’s personality

SURGICAL THREAT – life, body image, self-esteem, self-concept, or lifestyle

FEAR of death, pain, helplessness, socio-

economic status, dx of life-threatening conditions, possible disabling/crippling effects or unknown

ANXIETY & FEAR affect client’s ability to learnCope & cooperate w/ teaching & operative

proceduresMay influence amount & type anesthesia

needed & may slow recovery

8. LABORATORY ASSESSMENT8. LABORATORY ASSESSMENT

Provide baseline data about health & help predict potential complications

OUTPATIENT – PAT (preadmission testing) 24-28 days before surgeryvalid unless there’s change in condition or taking drugs that can alter lab values ( Warfarin, Aspirin, Diuretics)

COMMON: Urinalysis, Blood type, crossmatching, CBC, Hgb, Hct, Clotting studies (PT, platelet count), electrolyte levels, s. creatinine

Urinalysis – assess abnormal subs.- CHON, glucose, blood, bacteria

Report Electrolyte imbalance to surgeon & anesthesiologist before surgery

♠ K - risk toxicity if taking digoxin - slow recovery from anesthesia

- cardiac irritability ♠ K - risk dysrhythmias esp. w/ use of

anesthesia K must be corrected before surgery Baseline ABG – w/ chronic pulmonary problem

9. RADIOGRAPHIC ASSESSMENT9. RADIOGRAPHIC ASSESSMENTCHEST XRAY – often young healthy adults

not required

Determine size & shape of heart, lungs, & major vessels

Determine presence of pneumonia or TB

Provides baseline data in care of complication

Results assist anesthesiologist in selecting anesthesia for emergency surgery

Abnormal findings alert for potential cardiac or pulmonary complication

Cardiac failure, cardiomyopathy, pneumonia or infiltrates may cause cancellation or delay of elective surgery

CT SCAN OR MRI

Electrocardiogram (ECG)Electrocardiogram (ECG)

• Common non-invasive diagnostic test that aids evaluation of heart function by recording electrical activity

• Abnormal findings alert for potential cardiac or pulmonary complication

Preoperative CarePreoperative Care

Obtaining Informed ConsentObtaining Informed Consent

• The surgeon is responsible for obtaining the client’s consent for surgery

• Ensure that informed consent has been signed and that any additional necessary consents (e.g., limb disposal) have been obtained & you serve as a WITNESS to the signature, not to the fact that the client is informed

• Sedation should not be administered to the client before he or she signs the consent

Nurse:Not responsible for providing detailed

information about the surgical procedureROLE: to clarify facts that have been

presented by the physician & dispel myths that the client or family may have about the surgical procedure

• The patient should personally sign the consent unless she/he:

• MINOR – A PARENT OR LEGAL GUARDIAN

• EMANCIPATED MINOR (married or independently earning a living – he/she may sign

A MINOR WHO HIS THE PARENT OF AN INFANT OR CHILD WHO IS HAVING A PROCEDURE -

he or she may sign for his/her child

ILLITERATE- HE/SHE MAY SIGN WITH AN “X”, AFTER WHICH THE WITNESS WRITE “PATIENT MARK”

CANNOT WRITE:Sign w/ an X with 2 witnessessEmergency:Phone or telegram authorization but follow-up

with written consent ASAPLifethreatening:With effort to contact person w/ medical power of

atty., consent is desired but not essentialWritten consultation by 2 physician not assoc. w/

the case ( formal consultation legally supports decision for surgery until appropriate person signs the consent)

No family:Courts appoints legal guardian

Blind:May sign his own consent with 2 witnessess

Other language:Translator and a 2nd witness

A WITNESS VERIFIES THAT THE CONSENT WAS SIGNED WITHOUT COERCION AFTER THE SURGEON EXPLAINED THE DETAILS OF THE PROCEDURE ( physician, nurse, facility employee, family members (as established by policy)

Advance DirectiveAdvance DirectiveProvides legal instruction to healthcare

providers about the client’s wishes & are to be followed.

Encompasses durable power of attorney and living will

Living will or durable power of attorney as mandated by The Patient self-determination act. (USA)

NutritionNutrition• Assess the surgeon's orders regarding the intake of

food and fluids before surgery and for the administration of intravenous fluids

• NPO - NO eating, drinking & smoking (nicotine stimulates gastric secretion) for 8 hours before the surgical procedure – to decrease risk of aspiration

• Fasting > 8H – possible fluid & electrolyte imbalance & blood glucose levels

• Emphasize the IMPORTANCE OF ADHERENCE - failure result in cancellation or increase risk of aspiration during surgery

EliminationElimination • If the client is to undergo intestinal or abdominal

surgery, an enema, a laxative, or both may be prescribed for the night before surgery – to prevent injury to colon & reduce number of intestinal bacteria

• The client should void immediately before surgery• FC is in place, it should be emptied immediately

before surgery & the amount & quality of UO documented

Surgical SiteSurgical Site• Prepare to clean the surgical site with a mild

antiseptic soap the night before surgery, as prescribed

• – reduces contamination & no. of organism @ site

• Hair should be shaved only if it will interfere with the surgical procedure and only if prescribed

• Skin prep is the first step in prevention of surgical wound infection.

MedicationsMedications• Note medications client is taking, including herbal

products; some medications (e.g., antihypertensives and antidysrhythmics) can interact with anesthetic agents

• Check with the surgeon regarding administration of prescribed medications; some medications (e.g., cardiac medications) may be administered with a sip of water

• If the client has diabetes mellitus, check with the surgeon regarding administration of an oral hypoglycemic or insulin

Preoperative TeachingPreoperative Teaching• Reduce apprehension and fear

• Increased cooperation & participation in care after surgery

• Decrease complications

Client TeachingClient Teaching • Describe what client should expect after surgery

• Instruct client to notify nurse of pain after surgery and reassure client that pain medication will be prescribed, to be given as the client requests

• Instruct client not to smoke for at least 24 hours before surgery

• Instruct client in deep-breathing and coughing techniques, the use of incentive spirometry and its importance

Incentive Spirometer – promote complete lung Incentive Spirometer – promote complete lung expansion & prevent pulmonary problemsexpansion & prevent pulmonary problems

Chest PhysiotherapyChest Physiotherapy

Chest PhysiotherapyChest Physiotherapy

Percussion and vibration over the thorax to loosen secretions in the affected area of the lungs

Contraindications• When bronchospasm occurs by its use stop the

procedure • Rib fracture• History of pathological fractures • Chest

incisions

LEG AND FOOT EXERCISESLEG AND FOOT EXERCISES

Instruct client in leg and foot exercises to prevent venous stasis of blood and facilitate venous blood return [Figure]  

SplintingProvide support, promotes a feeling of

security, & reduces pain during coughing

CoughingMay be performed along with deep

breathing q 1-2H after surgeryTo expel secretions, keep lungs clear,

allow full aeration, prevent pneumonia & atelectasis

“Do Not Cough” – hernia repair

• Inform client of any invasive devices that may be needed after surgery (e.g., nasogastric tube, drain, Foley catheter, epidural catheter, intravenous or subclavian line)

• Instruct client not to pull on invasive devices and reassure client that they will be removed as soon as possible

• Early AmbulationStimulates intestinal motility, enhance lung

expansion, mobilizes secretion, promotes venous return, prevents joint rigidity, relieves pressure

• ROME – prevent joint rigidity & muscle contracture

Psychosocial PreparationPsychosocial Preparation

• Assess client's anxiety level

• Address client's questions and concerns regarding surgery

• Give client privacy to prepare psychologically for surgery

Preoperative ChecklistPreoperative Checklist • Review checklist to ensure that each item is

addressed before client is transported to surgery

• Ensure that client is wearing an identification bracelet

• Assess client for allergies • Ensure that prescribed laboratory-test results

and electrocardiography and chest-radiography reports are documented in the client's record

• Remove client's jewelry, makeup, dentures, hairpins, nail polish, glasses, and prostheses as appropriate

• Document that valuables have been given to client's family members or locked in the hospital safe

• Monitor and document client's vital signs

3. Prosthesis or Dentures-3. Prosthesis or Dentures- should be removed to should be removed to prevent obstruction in the airway prevent obstruction in the airway

2. GIT /Elimination- insertion of indwelling catheter (foley catheter), administration of cleansing enema- this is to ensure that neither of the bladder, nor the bowel is distended during surgery- nutrition/ hydration-- NPO 8 hours before surgery, but some institution may allow clear liquids 3-4 hours before-- IVF infusion may be started to ensure adequate hydration

Pre operative medicationsPre operative medicationsAnticholinergics - Atropine SO4, Scopolamine Glycopyrrolate - control secretions• Antiemetics - Dropiridol, Thorazine - prevents vomiting• Tranquilizers- Diazepam, Lorazepam - decrease anxiety• - Sedatives- Medazolam, Phenobarbital - induce sleep and decrease anxiety• Opioids- Morphine SO4, Meperidine Hcl - relieve pain, decrease anxiety

• Tell the client that he or she will feel drowsy shortly after the medications are administered

• After administering the preoperative medications, keep the client in bed with the side rails up and place the call bell next to the client

• Instruct the client not to get out of bed and to call for assistance if needed

Transporting the client to the operating Transporting the client to the operating roomroom

• Per stretcher – enough help for safety• Cover with blanket – protect from drafts• Place side rails and restraint above knee• Record accompanies client• Smooth as possible – sedated- to prevent

nausea vomiting• Avoid rapid walking or swinging around

corners• Prepare room for post operative care

Arrival in the Operating RoomArrival in the Operating Room• When the client arrives in the operating

room, the operating-room nurse will check the identification bracelet against the client's verbal response

• The client's chart will be checked for completeness and reviewed for informed consent

• The surgeon's orders will be reviewed to ensure that they were carried out

INTRAOPERATIVEINTRAOPERATIVE PERIODPERIOD

begins when the client is transferred to the operating room bed and ends when the client is transferred to an area for recovery from anaesthesia

Key words of OR practiced areKey words of OR practiced are::1. Caring 3. Discipline2. Conscience 4. Technique

Optimal client care requires an inherent surgical conscience, self-discipline & the application of principles of aseptic & sterile technique

SURGICAL CONSCIENCE – “Surgical Golden SURGICAL CONSCIENCE – “Surgical Golden Rule” Rule”

““Do unto the patient as you would have Do unto the patient as you would have others others do unto you.”do unto you.”

Surgical ConscienceSurgical ConscienceOne’s inner voice for the conscientious

practice of asepsis & sterile technique @ all times.

Conscience dictates that appropriate action to be taken, whether the person is with others or alone & unobserved

Foundation for the practice of strict aseptic & sterile technique

ASEPTIC TECHNIQUEASEPTIC TECHNIQUE

– to maintain asepsis (absence of microorganism that caused diseased)

STERILE TECHNIQUEMethod by which contamination which

microorganism is prevented to maintain sterility throughout the operative procedure.

Is the responsibility of everyone caring for the client in the OR.

PRINCIPLES OF STERILE TECHNIQUE ARE PRINCIPLES OF STERILE TECHNIQUE ARE APPLIEDAPPLIED::

1. In preparation for operation by sterilization of necessary materials & supplies

2. In preparation of operating team to handle sterile supplies & intimately contact wound

3. In maintenance of sterility & asepsis throughout operative procedure

4. In terminal sterilization & disinfection at conclusion of operation

PRINCIPLES OF STERILE TECHNIQUEPRINCIPLES OF STERILE TECHNIQUE

1. ONLY STERILE ITEMS ARE USED WITHIN STERILE FIELDIf you are in doubt about the sterility of anything, consider it not sterile.

a. If sterilized package is found in a nonsterile workroom.

b. If uncertain about actual timing or operation of sterilizer. Items processed in a suspect load are considered unsterile.

c. If unsterile person comes into close contact with a sterile table & vice versa.

d. If sterile table or unwrapped sterile items are not d. If sterile table or unwrapped sterile items are not under constant observation.under constant observation.

a. If sterile package wrapped in material other than plastic or moisture-resistant barrier becomes damp or wet. Humidity in storage area or moisture on hand may seep into package.

b. If the integrity of the packaging material is not intact.

c. If sterile package wrapped in a pervious muslin or other woven material drops to the floor or other area of questionable cleanliness. These material allow implosion of air into package. A dropped package is considered contaminated.

If the wrapper is impervious & the area of contact If the wrapper is impervious & the area of contact is dry, the item may be transferred to the sterile is dry, the item may be transferred to the sterile field. Packages that have been dropped on the field. Packages that have been dropped on the floor should not be put back into sterile storage.floor should not be put back into sterile storage.

2. GOWNS ARE CONSIDERED STERILE ONLY INFRONT FROM CHEST TO LEVEL OF STERILE FIELD & THE SLEEVES FROM ABOVE ELBOWS TO CUFF

a. Self-gowning & gloving should be done from a sterile surface for this purpose only to avoid dripping water onto sterile supplies or sterile field.

b. Stockinet cuffs of gown are enclosed beneath sterile gloves. Stockinet is absorbent & will retain moisture, thus this part of gown does not provide a microbial barrier.

c. Sterile persons keep hands in sight @ all times & at or above level of waist or sterile field.

d. Hands are kept away from face. Elbows are kept close to sides. Hands are never folded under arms because of perspiration in axillary region. Neckline, shoulders, & back also may become contaminated with perspiration.

e. Sterile persons are aware of height of team members in relation to each & the sterile field. Changing levels @ sterile field is avoided. Gown is considered sterile only down to highest level of sterile tables. If a sterile person must stand on a platform to reach operative field, platform should be positioned before this person steps up to draped area. Sterile person should sit only when entire procedure will be performed @ this level.

3. 3. TABLES ARE STERILE ONLY AT TABLE TABLES ARE STERILE ONLY AT TABLE LEVELLEVEL

a. Only top of a sterile draped table considered sterile. Edges & sides of drapes extending below table level are considered unsterile.

b. Anything falling or extending over table edge, such as a piece of suture, is unsterile. Scrub person does not touch part hanging below table level.

c. If unfolding a sterile drape, the part that drops below table surface is not brought back up to table level. Once placed, draped is not moved or shifted.

d. Cords, tubings, etc., are secured on the sterile field with a non-perforating device to prevent them from sliding over the table edge.

4. PERSON WHO ARE STERILE TOUCH ONLY 4. PERSON WHO ARE STERILE TOUCH ONLY STERILE ITEMS OR AREAS; PERSONS WHO ARE STERILE ITEMS OR AREAS; PERSONS WHO ARE NOT STERILE TOUCH ONLY UNSTERILE ITEMSNOT STERILE TOUCH ONLY UNSTERILE ITEMS

a. Sterile team members maintain contact with sterile field by means of sterile gowns & gloves.

b. Non-sterile circulating nurse does not directly contact the sterile field.

c. Supplies are brought to sterile team members by the circulating nurse who opens the wrappers on sterile packages. The circulating nurse ensures sterile transfer to the sterile field. Only sterile items touch sterile surface.

5. UNSTERILE PERSONS AVOID REACHING OVER A 5. UNSTERILE PERSONS AVOID REACHING OVER A STERILE FIELD; STERILE PERSONS AVOID LEANING STERILE FIELD; STERILE PERSONS AVOID LEANING OVER AN UNSTERILE AREAOVER AN UNSTERILE AREA

a. Unsterile circulating nurse NEVER reaches over a sterile field to transfers sterile items.

b. In pouring solution into sterile basin, circulating nurse holds only lip of bottle over basin to avoid reaching over a sterile area.

c. Scrub person sets basins or glasses to be filled @ edge of the sterile table; circulating nurse stands near this edge fo the table to fill them.

d. Circulating nurse stands @ a distance from the sterile field to adjust light over it to avoid microbial fallout over field.

e.e. SurgeonsSurgeons turns away from sterile turns away from sterile field to have perspiration removed from field to have perspiration removed from brow.brow.

f. Scrub persons drapes a nonsterile table towards self first to protect gown. Gloved hands are protected by cuffing draped over them

g. Scrub persons stands back from nonsterile table when draping it to avoid leaning over an unsterile area.

6. EDGES OF ANYTHING THAT ENCLOSES STERILE 6. EDGES OF ANYTHING THAT ENCLOSES STERILE CONTENTS ARE CONSIDERED UNSTERILECONTENTS ARE CONSIDERED UNSTERILE

a. In opening sterile packages, a margin of safety is always maintained. The inside of wrappers is considered sterile within 1 inch of the edges. The circulating nurse opens top flap away from self, then turns the sides under. Ends of flaps are secured in hand so they do not dangle loosely. The last flap are secured in pulled toward person opening package, thereby exposing package contents away from nonsterile hand.

b. Sterile person lifts contents away from packages by reaching down & lifting them straight up, holding elbows high

c. Steam reaches only area within the gasket of a sterilizer. Instrument trays should not touch edge of the sterilizer outside the gasket.

d. Flaps on peel-open packages should be pulled back not torn, to expose sterile contents. Contents should be flipped or lifted upward & not permitted to slide over edges. Inner edge of the heat seal is considered the line of demarcation between sterile & unsterile.

e. If a sterile wrapper is used as a table cover, it should amply cover the entire table surface. Only the interior & surface level of the cover are considered sterile.

f. After a sterile bottle is opened, contents must be f. After a sterile bottle is opened, contents must be used or discarded. Cap can be replaced without used or discarded. Cap can be replaced without contaminating pouring edges.contaminating pouring edges.

7. STERILE FIELD IS CREATED AS CLOSE AS POSSIBLE TO TIME OF USE

a. Sterile tables are set up just before the operation.

b. It is virtually impossible to uncover a table of sterile contents without contamination. Covering sterile tables for later use is not recommended.

8. STERILE AREAS ARE CONTINUALLY KEPT8. STERILE AREAS ARE CONTINUALLY KEPT IN VIEW IN VIEW

a. Sterile person face sterile areas.

b. When sterile packs are open in a room, or a sterile field set up, someone must remain in the room to maintain vigilance. Sterility cannot be ensured without direct observation. An unguarded sterile field should be considered contaminated.

9. STERILE PERSONS KEEP WELL WITHIN 9. STERILE PERSONS KEEP WELL WITHIN THE STERILE AREATHE STERILE AREA

a. Sterile persons stand back at a safe distance from the operating table when draping the client.

b. Sterile persons pass each other back to back at 360° turn.

c. Sterile person turns back to nonsterile person or area when passing.

d. Sterile person face sterile area to pass it.e. Sterile person asks nonsterile individual to step

aside rather than risk contamination.f. Sterile persons stay within the sterile field. They

do not walk around or go outside the room.

g. Movement within & around a sterile areas is g. Movement within & around a sterile areas is kept to a minimum to avoid contamination of sterile kept to a minimum to avoid contamination of sterile items or persons.items or persons.

10. STERILE PERSONS KEEP CONTACT WITH STERILE AREAS TO A MINIMUM

a. Sterile persons do not lean on sterile tables & on the draped client.

b. Sitting or leaning against a nonsterile surface is a break in technique. If the sterile team sits to operate, they do so without proximity to nonsterile areas.

11. UNSTERILE PERSON AVOID STERILE AREAS

a. Unsterile persons maintain a distance of at 1 foot (30 cm) from any area of the sterile field.

b. Unsterile persons face & observe a sterile area when passing it to be sure they do not touch it.

c. Unsterile persons never walk between two sterile areas, e.g., between sterile instrument tables.

d. Circulating nurse restricts to a minimum all activity near sterile field.

12. DESTRUCTION OF INTEGRITY OF MICROBIAL BARRIERS RESULTS IN CONTAMINATION

a. Sterile packages are laid on dry surfaces.b. If sterile package wrapped in absorbent

material becomes damp or wet, it is resterilized or discarded. The package is considered nonsterile if any part of it comes in contact with moisture.

c. Drapes are placed on a dry field.d. If solution soaks through sterile drape to

nonsterile area, the wet area is covered with impervious sterile draped or towels.

e. Packages wrapped in muslin or paper are permitted to cool after removal from a sterilizer & before being placed on cold surface to prevent steam condensation & resultant contamination.

f. Sterile items are stored in clean dry areas.g. Sterile package are handled with clean dry

hands.h. Undue pressure on sterile packs is avoided to

prevent forcing sterile are out & pulling unsterile air into the pack.

13. MICROORGANISM MUST BE KEPT TO AN IRREDUCIBLE MINIMUM

A. Skin cannot be sterilized. Skin is a potential source of contamination in every operation.

1. Transient & resident flora are removed from skin around operative site of client & hands & arms of sterile team members by mechanical washing & chemical antisepsis.

2. Gowning & gloving of operating team is accomplished without contamination of exterior of gowns & gloves.

3. Sterile gloved hands do not directly touch skin & then deeper tissues. Instruments uses in contact with skin are discarded & not reused.

4. If glove is torn or punctured by needle or 4. If glove is torn or punctured by needle or instrument, gloved is changes immediately. Needle instrument, gloved is changes immediately. Needle or instrument is discarded from sterile field.or instrument is discarded from sterile field.

5. Sterile dressing should be applied before draped are removed to reduce risk of the incision being touched by contaminated hands or objects.

B. Some areas cannot be scrubbed. (Operative includes mouth, nose throat, or anus in various parts of the body such as GIT & vagina) to reduce number of microorganism & prevent them from scattering:

1. Surgeons makes an effort to use a sponge only once, then discards it.

2. GIT, especially colon, is contaminated. Measure are used to prevent spreading this contamination.

C. Infected areas are grossly contaminated. The C. Infected areas are grossly contaminated. The teams avoids disseminating the contamination.teams avoids disseminating the contamination.

D. Air is contaminated by dust & droplets1. Drapes over anesthesia screen or attached to IV

poles separate anesthesia area from sterile field.2. Talking is kept to minimum in OR. Moisture

droplets expelled with force into mask during process of articulating words.

3. Movement around sterile field is kept to minimum to avoid air turbulence.

4. Drapes are not flipped, fanned or shaken to avoid dispersion of lint & dust.

MEMBERS OF THS SURGICAL TEAMMEMBERS OF THS SURGICAL TEAM

1. SURGEON – is a physician who assumes responsibility for the surgical procedure & any surgical judgments about the client

2. SURGICAL ASSISTANT – might be another surgeon (or physician, resident or intern) or nurse, surgical technologist

3. ANESTHESIOLOGIST – is a physician who specializes in giving anesthetic agents

Anesthesia provider monitors the client Anesthesia provider monitors the client during surgery by assessing & monitoring the during surgery by assessing & monitoring the

following:following:

1. The level of anesthesia

2. Cardiopulmonary function & hemodynamic monitoring

3. Vital signs

4. Intake & Output

*Gives Intravenous fluids, including blood & blood products

OPERATING ROOM STAFFOPERATING ROOM STAFF

A. Circulating Nurse – sets up OR & ensure that supplies, including blood products & diagnostic support, are available as needed;

1. assists the anesthesia provider with the induction 2. 2.“prep” (scrub) the surgical site3. notifies PACU of client’s estimated time of arrival &

any special needs

Throughout the surgery, the circulating Throughout the surgery, the circulating nurse:nurse:

1. Monitors traffic around the room2. Assesses the amount of urine & blood loss3. Reports findings to the surgeon & anesthesia

provider4. Ensures that the surgical team maintains sterile

technique & a sterile team5. Anticipates the client’s & surgical team’s needs,

providing supplies & equipment as needed.6. Communication information regarding the client’s

status w/ family members during long or unique procedures

7. Document care, events, interventions & findings

B. Scrub Nurse – sets up sterile field, drapes the client, & hands sterile instruments to the surgeon & the assistant place; maintains accurate count of sponges, sharps, instruments & amount of irrigation fluid & drugs used

Knowledge duration of anesthesia

anticipation surgeon’s anxiety & tension

PREPARATION OF THE SURGICAL SUITE & PREPARATION OF THE SURGICAL SUITE & TEAM SAFETYTEAM SAFETY

A. LAYOUT Surgical areas are divided in 3 zones to

ensure proper movement of clients & personnel:a. Unrestrictedb. Semirestrictedc. Restricted

STERILIZATIONSTERILIZATION

• PROCESS BY WHICH ALL PATHOGENIC AND NON PATHOGENIC MICROORGANISMS INCLUDING SPORES ARE DESTROYED OR KILLED.

METHODS OF STERILIZATIONMETHODS OF STERILIZATIONTHERMAL (PHYSICAL)• STEAM UNDER PRESSURE• Hot/Dry air

CHEMICAL• ETHYLENE OXIDE GAS• FORMALDEHYE SOLUTION OR GAS

• HYDROGEN PEROXIDE/PLASMA VAPOR• OZONE GAS• GLUTARALDEHYDE SOLUTION

RADIATION• MICROWAVE (NON IONIZING)• X-RAY (IONIZING)

B. B. HEALTH & HYGIENE OF THE HEALTH & HYGIENE OF THE SURGICAL TEAMSURGICAL TEAM

Anyone who has open wound, cold or any infection should not participate in surgery

Shedding of organisms & skin debris is greatest immediately after showering – bathe few hours before changing into OR attire

Jewelries carries organisms – minimalHandwashing Routine Culture q 3-6 monthsSurgical attire & surgical scrub help

contamination

CC. SURGICAL ATTIRE. SURGICAL ATTIRE

Clean, not sterile Worn to reduce contamination from home & areas

outside of the surgical setting.

a. Body cover (shirt & pants)

b. Head cover (cap or hood)

c. Shoe coverings/inside shoes

d. Protective attire: mask, eyewear, glove, gown & shoe covers

Change in the locker rooms, not at home

D. SURGICAL SCRUBD. SURGICAL SCRUB

Process of removing as many microorganisms as possible from the hands & arms by mechanical washing & chemical antisepsis before participating in a surgical procedure.

E. GOWNING Puts on a sterile gown

F. GLOVING Puts on sterile gloves

1. Open gloving technique2. Closed gloving technique

G. ANESTHESIAG. ANESTHESIA

“Negative Sensation” Is an induced state of partial or total loss of

sensation, occurring with or without loss of consciousness.

PURPOSES:

1. Block nerve impulse transmission

2. Promote muscle relaxation

3. Achieve a controlled level of unconsciousness

SELECTION OF ANESTHESIA SELECTION OF ANESTHESIA INFLUENCED BY THE FOLLOWING:INFLUENCED BY THE FOLLOWING:

a. Client’s health problem – major factor

b. Type & duration of the procedure

c. Area of the body having surgery

d. Safety issues to reduce injury – airway mgt.

e. Whether the procedure is an emergency

f. Options for management of pain after surgery

g. How long it has been since the client ate, had any liquid, or any drugs

h. Client’s position needed for the surgical procedure

TYPES OF ANESTHESIATYPES OF ANESTHESIA

1. GENERAL ANESTHESIA Depresses CNS resulting:

♠ amnesia ♠ unconsciousness

♠ analgesia ♠ loss of muscle tone & reflexes

1. LOCAL ANESTHESIA OR REGIONAL Disrupts sensory nerve impulse transmission from

a specific area or region

STAGES OF GENERAL ANESTHESIASTAGES OF GENERAL ANESTHESIA

STAGE I – STAGE OF INDUCTIONFrom the beginning of administration of

drugs/gas to loss of consciousnessClient appear drowsy & dizzy

Nursing Action: Close OR doors & keep room quiet Standby the client & assist if necessary

STAGE II – STAGE OF EXCITEMENTSTAGE II – STAGE OF EXCITEMENT

From loss of consciousness to relaxationClient appear excited, breathing is irregularClient moves extremities or bodyClient very sensitive to external stimuliNURSING ACTION:

Restrain client if needed Remain at client’s side Be quiet & alert Assist anesthesiologist if needed

STAGE III – SURGICAL ANESTHESIA & STAGE III – SURGICAL ANESTHESIA & RELAXATIONRELAXATION

Loss of reflexesDepression of vital functionsRespiration – regular, pupils contractedEyelids reflexes disappearLoss of auditory senses

NURSING ACTION: Begin final prep – client is under control

STAGE IV – DANGER STAGESTAGE IV – DANGER STAGE

Vital functions are to depressed Respiratory failure & possible cardiac arrest Not breathing, little or no pulse & heartbeat

NURSING ACTION: Be ready to resuscitate

ADMINISTRATION OF GENERAL ADMINISTRATION OF GENERAL ANESTHESIAANESTHESIA

1. INHALATION Inhales anesthetic gas or vapor through

a mask, endotracheal or nasotracheal

a. GASEOUS AGENTS – Nitrous oxide

b. VOLATILE AGENTS – Liquid agent vaporized for inhalation

cause shivering after surgery – effect on hypothalamus

2. INTRAVENOUS INJECTION2. INTRAVENOUS INJECTION

a. BARBITURATES – mild sedation to deep loss of consciousness.

a. KETAMINE (KETALAR) – dissociative anesthetic agent (one that promote a feeling of separation or dissociation from the env’t.)

Emergence reaction during recovery – combative or restless

b. PROPOFOL (DIPRIVAN) – short actin; hypnosis occur less than 1 minute & responsive within 8 minutes after infusion ends

3. ADJUNCTS TO GENERAL ANESTHESIA3. ADJUNCTS TO GENERAL ANESTHESIA

a. HYPNOTICS – Midazolam or Diazepam (Benzodiazepines)

Hypnotic, sedative, muscle relaxant & amnesic effect

May be used as part of IV conscious sedation

b. OPIOID ANALGESICS – used during surgery helps provide pain relief after surgery

MSO4, Demerol, Sublimaze All opioids depressed respiration

c. NEUROMUSCULAR BLOCKING AGENTSUsed to relax the jaw & vocal cords

immediately after induction so that the ET can be placed.

May be used during surgery to provide continued muscle relaxation

Tracium, Anectine

4. COMPLICATIONS OF INTUBATIONS

– broken or injured teeth, swollen lip, vocal cord trauma

Difficult intubation – small oral cavity, tight jaw joint, present of tumor

Improper neck extension during intubation – may cause injury

ET PLACEMENT – tracheal irritation & edema, sore throat

REGIONAL ANESTHESIAREGIONAL ANESTHESIA

Produces a loss of painful sensation in only one region of the body & does not result in unconsciousness

1. TOPICAL ANESTHESIA – directly applied onto the area to be disensitized

2. LOCAL INFILTRATION ANESTHESIA – injection of an anesthetic agent into the skin & SQ tissue of the area to be anesthetized.

3. NERVE BLOCK – injection of the local anesthetic agent into or

around a nerve or group of nerves in the involved area.

Disrupts motor & sensory impulse transmission If injected bloodstream seizure, cardiac &

respiratory depression, dysrhythmias

NERVE BLOCKNERVE BLOCK

Radial, Medial & Ulnar nerve (elbow, wrist, hands, & fingers)

Intercostal nerves (chest & abdominal wall)Brachial plexus (upper arm)Cervical plexus (betweem jaw & clavicle)

4. SPINAL ANESTHESIA – injecting an anesthetic agent into the CSF on the subarachnoid space

Lower abdominal & pelvic surgery

6. EPIDURAL ANESTHESIA -Anesthetic agent 6. EPIDURAL ANESTHESIA -Anesthetic agent injected into the epidural space & spinal cord injected into the epidural space & spinal cord areas are never enteredareas are never entered

• Spinal needles

Epidural anesthesia setEpidural anesthesia set

Local infiltrationLocal infiltration

COMPLICATIONS OF REGIONAL ANESTHESIA:

1. Sensitivity to anesthetic agent2. Overdosage3. Systemic absorption4. Cardiac arrest (rare – spinal)5. Edema & inflammation (local)6. Abscess formation – contamination during injection7. Necrosis & gangrene (rare - prolonged blood vessel

constriction injected area)

NURSE’S ROLE IN THE DELIVERY OF NURSE’S ROLE IN THE DELIVERY OF ANESTHESIA:ANESTHESIA:

1. Assisting the anesthesia provider

2. Observing for breaks in the sterile technique

3. Providing emotional support for the client

4. Staying with the client

5. Offering information & reassurance

6. Positioning the client comfortable & safely

POSITIONINGPOSITIONING PUTTING CIENT IN PROPER BODY PUTTING CIENT IN PROPER BODY

ALIGNMENT TO EXPOSE THE OPERATIVE SITE ALIGNMENT TO EXPOSE THE OPERATIVE SITE OR AREA.OR AREA.

• QUALIFICATION OF A GOOD POSITION:

1. free respiration

2. Free circulation

3. No pressure on nerve

4. hand or feet properly supported

5. No undue postoperative discomfort

6. accessible operative site

Supine position/dorsal Supine position/dorsal - laparotomy, appendectomy - laparotomy, appendectomy

Reverse modified trendelenburg positionReverse modified trendelenburg position - face and neck surgery - face and neck surgery

Modified fowler’s positionModified fowler’s position for neurosurgery for neurosurgery

Prone positionProne position - surgery on the posterior part of the body - surgery on the posterior part of the body

- laminectomy - laminectomy

Lithotomy positionLithotomy position - perineal approach - perineal approach

- cystoscopy, vaginal hysterectomy - cystoscopy, vaginal hysterectomy

Lateral positionLateral position - kidney, lungs or hip - kidney, lungs or hip

Jacknife positionJacknife position - rectal surgery - rectal surgery

SUTURESSUTURES Any strand of materials used for ligating or

approximating tissue, bringing tissues together & holding them until healing takes place.

1. ABSORBABLEa. Surgical gut – is collagen derived from

submucosa of sheep intestine or serosa of beef intestine.

b. Collagen sutures – extended from a homogenous dispersion of pure collagen from the flexor tendons of beefs (opthalmic surgery)

c. Synthetic Absorbable Polymers – Polydiaxanone suture (PDS), monocryl. Maxon, vicryl, dexon

2. NONABSORBABLE2. NONABSORBABLE

♥Silk ♥Cotton ♥Steel ♥Synthetic nonabsorbable polymers – nylon, prolene, novafil

TENSILE STRENGTH Amount of weight or pull necessary to break

suture material.LIGATURE OR TIE Material is tied around a blood vessel to occlude

the lumenSUTURE LIGATURE/STICK TIE A suture attached to a needle for a single stitch

for hemostasis.TIE ON A PASSER A tie handled to the surgeon in the tip of a forcep

5 LAYERS OF THE ABDOMEN5 LAYERS OF THE ABDOMEN

1. skin2. subcutaneous3. fascia4. muscle5. peritoneum

DRAPINGProcedure of covering the client & surrounding

areas with a sterile barrier to create & maintain an adequate sterile field.

Sternal split, oblique subcostal, upper vertical Sternal split, oblique subcostal, upper vertical midline , thoracoabdominal, McBurney, lower midline , thoracoabdominal, McBurney, lower vertical midline, pfannensteilvertical midline, pfannensteil

Scrubbing, Gowning and Gloving

SURGICAL SURGICAL HANDHAND SCRUBBINGSCRUBBING

• IS THE PROCESS OF REMOVING AS MANY MICROORGANISMS AS POSSIBLE FROM THE HANDS AND ARMS BY MECHANICAL WASHING AND CHEMICAL DISINFECTION BEFORE PARTICIPATING IN A SURGICAL PROCEDURE.

MECHANICALMECHANICAL – PROCESS OF – PROCESS OF REMOVING DIRT, SOIL AND REMOVING DIRT, SOIL AND TRANSIENT ORGANISM BY TRANSIENT ORGANISM BY FRICTIONFRICTION

• CHEMICAL – PROCESS REDUCES RESIDENT FLORAE AND INACTIVATES MICROORGANISMS WITH AN ANTIMICROBIAL OR ANTISEPTIC AGENT

TYPES OF ANTIMICROBIAL TYPES OF ANTIMICROBIAL SKIN-CLEANSING AGENTSSKIN-CLEANSING AGENTS

• CHLORHEXIDINE GLUTANATE• IODOHORS• TRICLOSAN• ALCOHOL• HEXACHLOROPHENE• PARACHLOROMETAXYLENOL

GOWNING – DONNING OF GOWNING – DONNING OF STERILE GOWNSTERILE GOWN

• GLOVING – WEARING OF STERILE GLOVES TO COMPLETE THE ATTIRE.

CLOSED/ OPEN TECHNIQUE

GOWNS ANS GLOVES ARE WORN TO EXCLUDE SKIN FROM POSSIBLE CONTAMINATION AND TO CREATE A BARRIER BETWEEN THE STERILE AND UNSTERILE AREA

Surgical instruments are designed to provide the tools the surgeon needs for each maneuver

• Whether they are small or large, short or long, straight or curved or sharp or blunt, all instruments can be classified by their function.

• All instruments should be used only for their intended purpose and they should not be abused.

SURGICAL INSTRUMENTATIONSURGICAL INSTRUMENTATION

CUTTING & DISSECTING

CLAMPING & OCCLUDINGCLAMPING & OCCLUDING

GRASPING & HOLDINGGRASPING & HOLDING

EXPOSING & RETRACTINGEXPOSING & RETRACTING

Basic instruments are essential to accomplish most types of general surgery.  Each instrument can be placed into one of the four following basic categories:Cutting and DissectingClamping and OccludingGrasping and HoldingRetracting and Exposing

MEASURING Ruler, depth gauges, caliperACCESSORY INSTRUMENTS Mallet, screw drivers, hudson braceMICROINSTRUMENTATION Powered surgical instruments – saw, drill,

dermatone

SPONGESSPONGES

Are used for absorbing blood & fluids, protecting tissues, applying pressure or traction, & dissecting tissues.

Gauze sponges, lap packs, peanuts, tonsil balls, cottonoids, cherries

SPONGE, SHARPS, & INSTRUMENT SPONGE, SHARPS, & INSTRUMENT COUNTSCOUNTS

ACCOUNTABILITYIs a professional responsibility that rests primarily

on the scrub nurse & the circulator.

COUNTING PROCEDURESIs a method of accounting for items put on the

sterile table for use during the surgical procedure.Counts are performed for client & personnel safety,

infection control, & inventory purposes.

1. BASELINE COUNT DURING SET- UP FOR 1. BASELINE COUNT DURING SET- UP FOR THE SURGICAL PROCEDURETHE SURGICAL PROCEDURE

Count all item before the surgical procedure begins & during the surgical procedure as each additional package is opened & added to the sterile field.

2. CLOSING COUNT (FIRST CLOSING COUNT)Counts are taken before the surgeon starts the

closure of a body cavity or a deep or large incision. Field count table floor

3. FINAL COUNT (SECOND CLOSING COUNT)Performed before any part of a cavity or a cavity

within a cavity is closed.

WOUND CLOSUREWOUND CLOSURE1. Continuous suture (running stitch) – peritoneum

& vessels because it provides leak proofs suture line.

2. Interrupted suture – each stitch is taken & tied separately.

3. Buried suture – suture is placed under the skin, buried either continuous or interrupted.

4. Purse-string method – a continuous suture is placed around a lumen & tightened, drawing fashion, to close the lumen.

5. Subcuticular suture – a continuous suture is placed beneath epithelial layers of skin I short lateral stitches

B. DRAINS – is placed in a separate small incision B. DRAINS – is placed in a separate small incision parallel to the operative incisions to drain blood & parallel to the operative incisions to drain blood & serum from the operative site.serum from the operative site.

MONITORING MONITORING BODY TEMPERATURE OR standard cool level – inhibit bacterial growth

& allow optimal performance of surgical team

keep client warm w/o causing vasodilation (more bleeding) – warm blankets, booties/socks, warmed IV solution

CARDIAC & RESPIRATORY ARRESTCARDIAC & RESPIRATORY ARREST

No need for code blue Surgeon talk to family in case of death

ALLERGIC REACTION Ideally not occur if adequate history taken Some do not recall an allergy - Identify allergy only

if occurrence of 2nd allergic reaction to triggering agent during surgery (e.g., latex)

DOCUMENT INTRAOPERATIVE CARE

MOVING & TRANSPORTING THE MOVING & TRANSPORTING THE CLIENT CLIENT

Clean the client Avoid rapid movement when changing position –

develop hypotension During emergency (revival) from anesthesia,

client prone to: nausea, confusion, hypotension Check tubes Modesty maintained SAFETY: warm blankets, body straps, side rails

up Notify family of client status

POSTOPERATIVE POSTOPERATIVE PERIODPERIOD

BEGINS WITH THE ADMISSION OF THE BEGINS WITH THE ADMISSION OF THE CLIENT TO THE POSTANESTHESIA AREA CLIENT TO THE POSTANESTHESIA AREA AND ENDS WHEN HEALING IS COMPLETEAND ENDS WHEN HEALING IS COMPLETE

Stages of RecoveryStages of Recovery

• Immediate postoperative stage The period 1 to 4 hours after surgery.

• Intermediate postoperative stage The period 4 to 24 hours after surgery.

• Extended postoperative stage The period at least 1 to 4 days after surgery.

POST-ANESTHESIA NURSINGPOST-ANESTHESIA NURSING

GOAL: to assist uncomplicated return to safe physiologic function after an anesthetic procedure by providing safe, knowledgeable, individualized nursing care for clients & their family members in the immediate post-anesthesia phase.

UPON RECEIVING:UPON RECEIVING:

1. AIRWAY PATENCY/POSITION SAFELY/STABLEUnconscious adult – extend neck & thrust jaw

forwardPreferred position – (lateral sim’s position)

sidelying allows the client’s tongue to fall forward & mucous or vomitus to drain from the mouth.

2. ENDORSEMENT – verbal detailed report of events from OR.

IMMEDIATE ASSESSMENT INIMMEDIATE ASSESSMENT IN PACU PACU

AIRWAY – tubes/ respiratory assistive deviceBREATHING – RR & depth, breath sounds, stay

beside til gag reflex returnsCIRCULATION – PR, BP, skin color, ECG,

O2Sat, dressing, wound statusOTHERS – LOC, muscle strength, ability to

follow command, IV, drains, tubes, inspect skin (burns, bruises, temperature)

POSTOPERATIVE POSTOPERATIVE NURSING CARENURSING CARE

ASSESSMENT

1. ASSESS RESPIRATORY STATUS

Patent airway ♠ HYPOXIA

2. ASSESS CIRCULATION• V/S, skin, color, temperature• Weakness, numbness, pressure ulcers• Early ambulation – leg exercise if not tolerated

3. ASSESS NEUROLOGIC STATUS

LOC, orientation, lingering effects of anesthesia

4. MONITOR WOUND4. MONITOR WOUND

a. Assess dressing amount & charac. Drainage, wound appearance

b. Measure drainage – drains, ostomy bag

c. Wound dressing DEHISCENCE & EVISCERATION

5. MONITOR IV LINESCheck IV lines – patency, I & O,

Infiltration – mild heat to decreased local pain

6. MONITOR DRAINAGE TUBES6. MONITOR DRAINAGE TUBES

• Drainage tube to suction/gravity drain• Note amt, color, consistency of drainageNGT – decompression, removal of intestinal

secretion, promote GI rest, allow GIT to heal, monitor GI bleeding, prevent intestinal obstruction

Until peristalsis begin – may remove w/ orderBowel sounds NGT clamp & removed

Passage of flattus if tolerated w/o N/Vhunger

7. PROMOTE COMFORT7. PROMOTE COMFORT

• Pain meds

Oral – reassess after 30 minutes

IV – reassess after 5-10 minutes

8. REDUCE NAUSEA & VOMITING

Vomiting – is a reflex stimulated

♥CTZ (chemoreceptor trigger zone) ♥ ICP

♥GIT distention or irritation ♥Pain

♥vagal stimulation ♥centers in cerebrum

♥disequilibrium -vestibular labyrinth ear

Atelectasis and PneumoniaAtelectasis and Pneumonia

• Collapse of the alveoli with retained mucous secretions

• The most common postoperative complication; usually occurs 1 to 2 days after surgery

Assessment• Dyspnea, increased respiratory rate, productive

cough, chest pain • Crackles over involved lung area • Increased temperature

Interventions

• Reposition client every 1 to 2 hours; encourage deep breathing, coughing, and use of the incentive spirometer

• Encourage fluid intake

• Encourage early ambulation

• Perform suctioning to clear secretions if client is unable to cough

HypoxiaHypoxia • An inadequate concentration of oxygen in

arterial blood

Assessment• Restlessness• Dyspnea• Diaphoresis• Cyanosis

Interventions

• Monitor client for signs of hypoxia

• Eliminate cause of hypoxia

• Monitor lung sounds and pulse oximetry

• Administer oxygen as prescribed

Pulmonary EmbolismPulmonary Embolism • An embolus blocking the pulmonary artery

and disrupting blood flow to one or more lobes of the lung

Assessment• Dyspnea• Sudden, sharp chest or upper-abdominal pain• Cyanosis• Tachycardia and tachypnea• Anxiety

Interventions• Notify surgeon immediately• Monitor vital signs• Administer oxygen and medications as

prescribed

Hemorrhagic and ShockHemorrhagic and Shock • Loss of circulatory fluid volume as a result of

losing a large amount of blood externally or internally in a short period

Assessment• Restlessness• Weak, rapid pulse• Hypotension• Tachypnea• Cool, clammy skin• Reduced urine output

Interventions• Put pressure on site of bleeding & elevate legs • If client has had spinal anesthesia, do not elevate

legs any higher than placing them on the pillow; otherwise the diaphragm muscles could be impaired

• Notify surgeon immediately• Adm. intravenous fluids , oxygen & blood as

prescribed• Monitor LOC, vital signs, and intake & output• Prepare client for surgery, if necessary

ThrombophlebitisThrombophlebitis• Inflammation of a vein (most commonly in the

leg), often accompanied by clot formation

Assessment• Vein inflammation • Aching or cramping pain • Vein feels hard and cordlike and is tender to

touch  • Increased temperature • Homans' sign

InterventionsInterventions• Prevention measures include ROME every 2H if

the client is restricted to bed rest & early ambulation as prescribed; instruct client not to sit in one position for an extended period

• Monitor legs for swelling, inflammation, pain, tenderness, venous distention, & cyanosis

• Elevate leg 30° w/o placing any pressure on popliteal area

• Maintain an intermittent pulsatile compression device or use antiembolism stockings, as prescribed

• Administer heparin sodium or warfarin sodium (Coumadin), as prescribed 

Urine RetentionUrine Retention • Caused by anesthetics & narcotic analgesics

• Usually appears 6 to 8 hours after surgery

Assessment

• Inability to void

• Restlessness and diaphoresis

• Lower-abdominal pain & a distended bladder

• On percussion, bladder sounds like a drum

InterventionsInterventions• Monitor client for voiding and assess for

distended bladder• Encourage fluid intake, unless contraindicated• Assist client in voiding by helping him or her

stand; provide privacy• Pour warm water over the perineum or allow the

client to hear running water to promote voiding• Catheterize client as prescribed after all

noninvasive techniques have been attempted

Paralytic IleusParalytic Ileus

Description• Failure of bowel contents to move along

appropriately• May occur as a result of anesthetic

medications or manipulation of the bowel during surgery

Assessment• Nausea & vomiting immediately after surgery• Abdominal distention• Absence of bowel sounds, bowel movement,

or flatus

Interventions• First treated nonsurgically by means of bowel

decompression through the insertion of a nasogastric tube attached to intermittent-to-constant suction

• Keep client from eating or drinking until bowel sounds return; administer intravenous fluids as prescribed

• Encourage walking

• Administer medications, as prescribed, to increase gastrointestinal motility and secretions 

ConstipationConstipation

Description

• When client resumes a solid diet after surgery, failure to pass stool within 48 hours is a cause for concern

Assessment

• Abdominal distention

• Absence of bowel movements

• Anorexia, headache, and nausea

Interventions• Encourage fluid intake up to 3000 mL/ day, unless

contraindicated

• Encourage early ambulation

• Encourage consumption of fiber-rich foods, unless contraindicated

• Administer stool softeners and laxatives as prescribed

• Provide privacy and adequate time for elimination

Wound InfectionWound Infection

Description• Wound becomes contaminated with a

microorganism

Assessment• Fever and chills• Warm, tender, painful, inflamed incision site• Edematous skin at incision and tight skin sutures• Increased white blood cell count

Interventions• Monitor client’s temperature• Monitor incision site for approximation of suture

line, edema, or bleeding, signs of infection• Maintain patency of drains and assess drainage

amount, color, and consistency• Change dressing as prescribed; maintain

asepsis• Administer antibiotics as prescribed

Wound DehiscenceWound Dehiscence

Description • Separation of the wound

edges at the suture lineAssessment• Increased drainage • Opened wound edges • Appearance of

underlying tissues through the wound

Interventions• Place the client in low Fowler's position with the

knees bent to prevent abdominal tension on an abdominal suture line

• Notify surgeon immediately 

• Cover wound with a sterile normal saline dressing

EVISCERATIONEVISCERATION• Abdominal wound becomes infected &

abdominal incision opens, the fascia or internal organs may be visible.

• Preceded gush of serosanguinous drainage

Interventions• cover wound sterile NS dressing• Monitor V/S• Keep client as calm as possible• Notify surgeon

Criteria for Client Discharge • Client is alert and oriented• Client has voided• Client has no respiratory distress• Client can walk, swallow, and cough• Client tolerates a small amount of fluid and food• Pain is minimal• Client is not vomiting• Bleeding from incision site, if any, is minimal• A responsible adult is available to drive the client

home• The surgeon has signed a release form

Discharge TeachingDischarge Teaching • Should be performed before date of scheduled

procedure• Provide written instructions to client and family

regarding specifics of care• Instruct client & family about possible

postoperative complications • Provide appropriate resources for home-care

support• Instruct client to call surgeon, ambulatory center,

or emergency department if postoperative problems occur

• Instruct client to keep follow-up appointments with surgeon

• Demonstrate care of incision & how to change dressing , provide extra dressings for home use

• Instruct client on importance of returning to surgeon's office for follow-up

• Instruct client that sutures are usually removed in surgeon's office 7 to 10 days after surgery

• Inform client that staples are removed 7-14 days after surgery & that skin may become slightly reddened when they are ready to be removed

• Instruct client on use of medications: purpose, doses, administration, side effects

• Instruct client on diet and remind him or her to drink six to eight glasses of liquid a day

• • Instruct client on activity levels; tell him or her to

resume normal activities gradually

• Instruct client to avoid lifting for 6 weeks (or as prescribed by the surgeon) if a major surgical procedure has been performed

• Instruct client with an abdominal incision not to lift anything weighing 10 pounds or more (or as prescribed by surgeon)

• Instruct client on signs and symptoms of complications and when to call surgeon

Generally client can return to work in 6 to 8 weeks, as prescribed by surgeon