Surgery Concept of Illness and Pain

8/3/2019 Surgery Concept of Illness and Pain

1/39

1

Concept of Illness and Pain

HEALTH state of complete physical, mental and social well being and not merely the absence of a

disease or infirmity (WHO 1948)

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

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

- represents successful adaptation to stress ability to adapt to internal and externalenvironment

ILLNESS state of having a disease or sickness

DISEASE abnormal variation, deviation from, or interruption in the normal structure or function of

any part, organ, or system of the body causing disruption in function manifested by characteristic

set of symptoms or signs and therefore limits freedom of action

- etiology, pathology and prognosis may be known or unknownetiology cause

pathology process

prognosis outcome

- disruption of the normal processETIOLOGY cause of disease

- describes what sets the disease process in motion- what triggers predisposing and precipitating factors

precipitating triggering

predisposing criteria that can make you, later on, develop the disease

ETIOLOGIC AGENTS

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

PATHOGENESIS sequence of cellular and tissue events that take place from the time of initial

contact with an etiologic agent till the ultimate expression of diseases

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

PATHOLOGYcame from the Greek word pathos meaning disease

- deals with the study of the structural and functional changes in cells, tissues, organs ofthe body that cause or are caused by the disease

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

PHYSIOLOGY deals with the normal functions of the body

HOMEOSTASIS refers to the steady state within the body

- State of equilibrium in the bodys internal environment cells, tissues, organ and fluids- When a change or stress occurs causing the body function to deviate from its stablerange, processes are initiated to restore and maintain the dynamic balance

- If not adequate, homeostasis/steady state is threatened, functions become disorderedand dysfunctional response occurs that can lead to a disease

- determined by how body adapts to change everything boils down to the immune system or how your body responds to stress


2/39

2

PATHOPHYSIOLOGY physiology of altered health

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

these changes have on total body function, focusing on the mechanism of the

underlying disease and provides background for preventive as well as therapeutic health

care measures and practices

STRESS defined as a state resulting from a change in the environment that is perceived as

threatening to homeostasis

- stimulus is known as stressorEFFECTS OF STRESS

1. adaptive adaptation or adjustment to change or coping with change- you are able to overcome and have a positive results- lead to positive effective/effective health2. maladaptive negative effect/ineffective adaptation disease and illness develops

MECHANISM OF CELLULAR REPAIR

cellular adaptation cells adapt by undergoing changes in size, number and typeadaptation desired outcome in managing actual or perceived stress to

reestablish equilibrium

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

replace healing replacement cells such as connective tissue, resulting in scarformations

FACTORS AFFECTING CELLULAR REPAIR

1. age2. nutritional status3. presence of infection you have to correct one illness before you can go to another4. chronic illness predisposes cellular injury e.g. secondary disease5. nature of the wound incision under aseptic technique vs. traumatic wounds6. extent of wound and associated blood loss7. tissue involved tissues with good blood supply heal faster8. psychosocial like stress and fatigue can impair healing

PSYCHOLOGICAL PROCESS OF ILLNESS

I. CELL INJURY AND INFLAMMATIONinjury disorder in or the loss of the steady state regulation

- any stressor that alters the ability of the cell or system to maintainoptimal balance of its adjustment process leads to injury causing

structural and functional changes which may either be reversible

(permits recovery) or irreversible (leading to disability or death)

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

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

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


3/39

3

CAUSES OF CELL INJURY

1. EXTERNALa. Physical agents duration of exposure and intensity determines severity of

damage

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

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

VF

1. mechanical trauma disrupts cells and tissues of thebody

- outcome depends on severity of wound, amt. of blood loss,

and extent of nerve damage

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

2. INTERNALa. Hypoxia inadequate cellular oxygenation

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

b. Nutritional imbalance deficiency or excess of 1 or more essential nutrientc. Immune mechanism d/o immune response e.g. autoimmune diseases,

immunodeficiency

d. Genetic defectscongenital anomalies e.g. Downs, obesity CA, (hereditarydisease)

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

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

A. CELL ADAPTATIONADAPTATION STIMULUS

hypertrophy increase in cell size leading to

increase in organ size

- increased workload

atrophy shrinkage/decrease in cell size

leading to decrease in organ size

decrease in:

1. use2. blood supply3. nutrition4. hormonal stimulation5. innervations of the nerve

hyperplasia increase in the number of new

cells (increased mitosis)

- multiplication of cells caused the enlargement

hormonal influence

dysplasia changes in the appearance of cells

after chronic irritation

- reproduction of cells with resulting alternation

of their size and shape

metaplasia transformation of one adult cell

type to another cell type (this is reversible)

- stress applied to highly specialized cells

B. BODY DEFENSES AGAINST INJURYINTACT SKIN AND MUCOUS MEMBRANEbodys first line of defense

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

CILIA hair-like structures lining the upper respiratory tract mucous membrane

- protect lungs by trapping mucus, pus, dust, and foreign particles- push trapped particles up the pharynx with wavelike movements


4/39

4

GASTRIC JUICESfound in the stomachs highly acidic (pH of 1-5) acidic environment destroys most

organisms that enter the stomach

IMMUNOGLOBULINS proteins found in the serum and body fluids

- acts antibodies to destroy invading organisms and prevent development of infectiousdiseases

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

detected

ANTIGEN markers on cell surface that identify cells as being the bodys own (auto antigens) or as

being foreign cells (foreign antigen)

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

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

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

- dissolve the walls of bacteriaINTERFERON proteins made and released by lymphocytes in response to presence of pathogens:

virus, bacteria, parasites, or tumor cells

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

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

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

foreign substances

DIFFERENT PHAGOCYTES:

LEUKOCYTES (WBC) primary cells, protect against infection and tissue damage- 5 types:

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

MACROPHAGES mature monocytesINFLAMMATORY RESPONSE occurs as a result to injury, pathogens, trauma, or any other event

that can cause injury to tissue- infection may or may not be present

STEPS IN THE INFLAMMATORY PROCESS

I. VASCULAR RESPONSE local vasodilation- increased blood flow in the injured area brings more plasma to nourish tissue and carry

waste and debris away

- redness (redness) and heat (calor) manifested


5/39

5

II. INFLAMMAOTRY EXUDATE increased permeability of blood vessels- plasma moves out from capillaries to the tissue- swelling (tumor) and pain (dolor) manifested due to compression of nerve endings

assess if it is:

INFILTRATION PHLEBITIS

pale red

cold heat

pain pain

soft swelling hard swelling

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

CARDINAL SIGNS OF INFLAMMATION

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

ALTERED IMMUNE RESPONSE

IMMUNE SYSTEMbodys final line of defense against infection and/or cellular injury

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

COMPONENTS OF THE IMMUNE SYSTEM

1. IMMUNE CELLSa. Lymphocytes (T cells, B cells, and natural killer cells) have protective

functions related to specific antigen

b. Macrophages assist T and B lymphocytes2. LYMPHOID ORGANS

a. Thymus vital to the development of the immune systemb. Bone marrow produces leukocytes, which is one of the products of blood- problems in bone marrow can, later on, cause leukemia

c. Spleend. Tonsilse. Intestinal lymphoid tissuef. Lymph Nodes

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

- ability of the body to protect itself from diseaseIMMUNE RESPONSE involves a complex series of interactions between the components of the

immune system and the antigens of foreign pathogen

TYPES OF IMMUNITY1. INNATE IMMUNITY immunity you are born with involving barriers that keep

harmful materials form entering the body

- forms the first line of defense in the immune response- e.g. cough reflex, enzymes in the tears, mucus, skin stomach acid


6/39

6

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

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

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

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

plasma cells, which produce antibodies that travel in the blood and interact

with circulating and cell surface antigen

5. CELL-MEDIATED protects against viruses, intracellular bacteria, and cancercells

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

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

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


7/39

7

ALTERED IMMUNE RESPONSE

- refers to inadequate, inappropriate, or excessive immune response to cellular injury orinfection resulting to immune system disorders that is serious and life threatening

CLASSIFICATION OF DISORDERS due to ALTERED IMMUNE RESPONSE

1. IMMUNODEFICIENCY DISEASE- immune response insufficient to protect host- failure of the immune or inflammatory response to function normally, resulting in

increased susceptibility to infection

- clinical hallmark:o tendency to develop unusual or recurrent, severe infection

preschools and school-age: 6 to 12 infections/year adult: 2 to 4 infections/year

o recurrent infection w/ short periods of good health with multiplesimultaneous infection

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

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

foudn in the individual)

Anaphylaxis most common allergic reaction- occurs within minutes after exposure

o AUTOIMMUNITY a.k.a. autoimmune disease- disturbance in the immunologic tolerance of self-antigens- occur when the immune system reacts against self antigens tosuch a degree that auto-antibodies or autoreactive T cells damage

individuals

o ALLOIMUNITY occurs when the immune system of one individual producesan immunologic reaction against tissues of another

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

CONCEPT OF PAIN

Pain is whatever the experiencing person says it is, existing whenever the experiencing

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

An unpleasant sensory and emotional experience associated with actual or potential

tissue damage or described in terms of such damage. -1979, International Association for the

Study of Pain (IASP)

PAIN

- fifth vital sign- most important protective mechanism- strong motivator for action- one of the bodys most important adaptive mechanisms- protective mechanism or a warning

o congenital analgesia rare genetic disorder where the individual is unable tofeel pain


8/39

8

PAIN EXPERIENCE IS PRODUCED BY THE INTERACTION OF THREE SYSTEMS:

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

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

or avoidance behavior

3. COGNITIVE/EVALUATIVE overlies individual learned behavior- individuals interpretation of appropriate pain behavior is learned through cultural

preferences, male-female roles and life experience

NOCICEPTION sensory process leading to perception of pain NOCICEPTORS free nerve endings that responds to chemical, mechanical dn thermal

stimuli

TYPES OF PAIN:

I. PHASICA. Acute Pain has identifiable cause and occurs soon after and injury

- temporary and subsides as healing takes place as chemical mediatorscausing pain are removed

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

diaphoresis, increased RR, PR and BP

- usually lasts until 6 months- classifications:

o SOMATIC superficial (comes form the skin or close to thesurface of the body)o VISCERAL pain in the internal organs, abdomen or skeleton;

radiates or referred

o REFERRED pain present in an area removed or distant formpoint of origin

- supplied by the same spinal segment as actual site sinceskin has more receptors, pain is felt

B. CHRONIC PAIN persistent, lasts beyond expected healing phase- non-protective; related to tissue damage, inflammation or injury of the

NS- lasts for more than 6 months

NEUROPHYSIOLOGICAL TRANSMISSION OF PAIN

Pain is the result of transduction, transmission, perception and modulation of painful

(nociceptive) impulses.

STAGES IN THE TRANSMISSION OF PAIN

STAGE 1 TRANSDUCTION- refers to the conversion of mechanical, chemical or thermal information into

electrical activity in the NS

STAGE 2 TRANSMISSION- transfer electrical impulses to the CNS

CNS process nociceptive signals to extract relevant information

- the processing and extraction of relevant features of sensory input


9/39

9

STAGE 3 PERCEPTION- awareness of pain that is dynamic, changing in response to persons development,

environment, disease or injury

- can be brief, prolonged, or even permanent STAGE 4 MODULATION

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

STIMULI (chemical, mechanical, thermal)

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

Creation of action potential

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

Spinal cords dorsal horn (central gray matter)

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

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

processing

Electrical energy (stimuli) reach the cerebral cortex

Interpretation of stimuli (transmission)

Perception of pain

Somatosensory cortexidentifies location and intensity

Associated cortexdetermines how an individual interprets the meaning

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

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

Inhibition of pain impulse(modulation)

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

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

expressing

PAIN THEORIES:

1.

SPECIFICITY THEORY intensity of pain is directly related to the amount of associated injuryDesCartes, 17th

century

- finger prick against cutting off on one hand- more tissue injury, more painful- useful in specific injuries or acute pain, but not with chronic or cognitive and psychologic

contributions to pain


10/39

10

2. NEUROMATRIX THEORY Ronald Melzack proposes that a large number of interconnectedneurons, a neuromatrix, exists in every person

- neuromatrix analyzes the sensory information and gives perception of sensation- tells the brain that the perseptions of sensation are from the self - neurosignature tells the brain that your arm is your arm, not someone elses

3. GATE CONTROL THEORY first proposed in 1965 by psychologist Ronald Melzack andanatomist Patrick Wall

- gating system in the CNS that opens and closes to let pain messages through to thebrain or to block them

- according to the gate control theory of pain, our thoughts, beliefs, and emotions mayaffect how much pain we feel from a given physical sensation

- delayed pain perception of athletes*research: Hans Selye

NURSING CARE OF CLIENT EXPERIENCING PAIN

I. ASSESSMENT- thorough and accurate- highly subjective and needs to be evaluated- always remember the principle of pain assessment:

Pain is whatever the experiencing person says it is, existing whenever the

experiencing person says it does. By Margo McCaffery

JCAHO

- a private sector US-based not-for-profit organization that sets standards foraccreditation of health institutions.

- helps to improve the quality of patient care by assisting international health careorganizations, public health agencies, health ministries and others evaluate, improveand demonstrate the quality of patient care and enhance patient safety and to

demonstrate quality.

HIGHLIGHTS OF JCAHO PAIN STANDARDS

assess all patients routinely for pain record assessment data in a way that facilitates reassessement and follow-up educate patients and families on the importance of pain management as part of care do not permit pain to interfere with optimal level of function or rehabilitation include pain and symptom management in discharge planning

ASSESS:

Ia. History

Ia1. Pain characteristics

onset and duration location intensity

quality relieveing factors aggravating factors

NOTE: use the alphabet of pain PQRST

P Provocative or PalliativeQ Quality

R Region and Radiation

S SeverityT Timing

Ia2. Drug History complete list of medications with allergies

Ia3. Social History how patient feel about himself

- support system


11/39

11

PAIN RATING SCALES

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

10 being the worst pain they have ever had.

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

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

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

level.

Brief Pain Inventory(BPI)pts pain in last 24, least & worst Cries Neonatal Postoperative Pain Measurement Scale

NEONATAL INFANT PAIN SCALE

NPS 0 point 1 point 2 points

Facial expression Relaxed Contracted -

Cry Absent Mumbling Vigorous

Breathing Relaxed Different than basal -

Arms Relaxed Flexed/stretched -

legs Relaxed Flexed/stretched -

Alertness Sleeping/clam Uncomfortable -

*Maximal score of seven points, considering pain 4.

FLACC Pain Assessment Tool

DATE/TIMEFace

0 No particular expression or smile

1 Occasional grimace or frown, withdrawn, disinterested

2 Frequent to constant quivering chin, clenched jaw

Legs

0 Normal position or relaxed

1 Uneasy, restless, tense

2 Kicking, or legs drawn up

Activity

0 Lying quietly, normal position, moves easily1 Squirming, shifting back and forth, tense

2 Arched, rigid or jerking

Cry

0 No cry (awake or asleep)

1 Moans or whimpers; occasional complaint

2 Crying steadily, screams or sobs, frequent complaints

Consolability

0 Content, relaxed

1Reassured by occasional touching, hugging or being talked to, distractible

2 Difficult to console or comfortTOTAL SCORE

Faces Pain Rating Scale - language difficulties such as aged, pedia Oucher Pain Rating Scale Numerical or Visual Analog Scale


12/39

12

Not hurting Hurting a whole lotNo discomfort Very uncomfortableNo pain Severe pain Adolescent, Pain, tool.. :-D Logs and Diaries Pain Self-monitoring record

POTENTIAL NURSING DIAGNOSIS: physical mobility disturbances nutrition less than body requirement, risk for social interaction, impairedII. PLAN/IMPLEMENTATION1. Establish therapeutic relationship2. teach patient about pain relief3. reduce anxiety and fears4. provide comfort measures5. manage pain

TYPES OF PAIN MANAGEMENT

I. Nonpharmacologic Management concern on overuse of drugs3 MAIN CATEGORIES OF NONPHARMACOLOGIC THERAPY

Physical Therapy - use physical agents & methods ease pain, reduceinflammation, ease muscle spasm, & promote relaxation.

a. Hydrotherapyb. Thermotherapyc. Cryotherapyd. Vibratione. TENSf. exerciseg. immobilization

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

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

o Aromatherapyo Music Therapyo Therapeutic Touch and Massageo Yoga and Meditationo Chiropractic Treatmento Acupunctureo Biofeedbacko Hypnosiso Guided Imagery


13/39

13

o Magnet Therapyo Thought Stoppingo Crystal or Gemstone Therapyo Herbal Therapyo Heat and Cold Application

II. PHARMACOLOGICA. ANALGESIS

a. Nonopioid (nonnarcotic) used to treat pain thats either nociceptive (injuryreceptors) or neuropathic (nerves)

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

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

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

dependency

e.g. nalbuphineiii. opioid antagonist blocks opioid effect

B. METHODS OF ADMINISTRATIONa. Topicalb. Oralc. IMd. IVe. PCA - Patient Controlled Analgesiaf. Conscious Sedationg. Intranasalh. Epidural

PCA is a means for the patient to self-administer analgesics (pain medications) intravenously by

using a computerized pump, which introduces specific doses into an intravenous line.

C. SURGICAL INTERVENTIONS1. RHIZOTOMY selective destruction of the dorsal root of the spinal nerve2. NERVE BLOCK OR CORDOTOMY unilateral or bilateral severe nerve fibers in the spinal

cord3. NEURECTOMY resection of one or more peripheral branches of the cranial or spinal4. SYMPATHECTOMY destroys nerves in the SNS

performed to increase blood flow and decrease long-term pain in certaindiseased that cause narrowed blood vessels

can also be used to decrease excessive sweating this surgical procedure cuts or destroys the sympathetic ganglia, which are

collections of nerve cell bodies in clusters along the thoracic or lumbar spinal

cord

PERIOPERATIVE NURSING the scrub nurse is always in front of the surgeonPERIOPERATIVE NURSING CARE

a. connotes the delivery of patient care in the:i. preoperative

ii. intra-operativeiii. postoperative


14/39

14

periods of the patients surgical experience through the

framework of the nursing process

b. nurse assess the client by:i. collecting, organizing and prioritizing patient data

ii. establishing nursing diagnosisiii. identifies desired patient outcomesiv. develop and implements a plan of carev. evaluates the care given in terms of outcomes achieved by the

patient

PERIOPERATIVE NURSING CARE PHASES

PREOPERATIVE PHASE INTRAOPERATIVE PHASE POSTOPERATIVE

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

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

home w/o complications

SURGERY comes from the Greek word kheirurgus = working by hand

TYPES OF PATHOLOGIC PROCESSES REQUIRING SURGICAL INTERVENTION

1. OBSTRUCTION impaired flow2. PERFORATION rupture (of a tissue)3. EROSION wearing off of a membrane4. TUMORS abnormal growths (w/c can cause your obstruction)

CATEGORIES OF SURGERY

1. DEGREE OF RISKa. MAJOR high risk, extensive, prolonged, increased blood lossb. MINOR less risk, less complicated, not prolonged

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

endoscopes and does not require traditional or extensive incisions

- involves the use of smaller incisions, customized instrumentation, specialized

imaging, computerized global navigation system and roboticsb. OPEN involves traditional opening of body cavity or body part to perform

the surgery

c. SIMPLE generally limieted to a defined anatomic location and do notrequire extensive exposure and dissection of adjacent tissue

d. RADICAL usu. Associated w/ malignancies- involves dissection fo tissue and structures beyond the immediate operative site

3. PURPOSEClassification:

a. DIAGNOSTIC determine cause of symptoms or origin of problemb.

CURATIVE to resolve a health problem or disease state by removing theinvolved tissue

c. RESTORATIVE/RECONSTRUCTIVE performed to correct deformity, repairinjury or improve functional status

d. PALLIATIVE relieve symptoms w/o the intent to curee. ABLATIVE removal of diseased organf. COSMETIC performed primarily to alter or enhance personal appearance


15/39

15

4. ANATOMIC SITE which part of the body?a. CARDIVASCULAR surgeryb. CHEST surgeryc. INTESTINAL surgeryd. NEUROLOGIC srugery

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

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

b. URGENTnecessary for clients health- may prevent additional problem from developing (e.g. tissue destruction);

not necessarily emergency

c. EMERGENT must be done immediately to save life or preserve function ofbody part

d. REQUIRED has to be performed at some point can be pre-scheduledPhysical Settings:

a. SURGICAL SUITESb. AMBULATORY CARE SETTINGc. CLINICSd. PHYSICIANS OFFICESe. COMMUNITY SETTINGf. HOMES

DISADVANTAGES OF OUTPATIENT

a. less time for rapportb. less time to assess, evaluate, teach risk of potential complications

ADVANTAGES OF OUTPATIENT

a. low costb. low risk of infectionc. less interruption of routined. less stress

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

transplantation into another person

SUFFIXES DESCRIBING SURGICAL PROCEDURES

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

PREOPERATIVE PHASE

- begins when the decision for surgical intervention is made and ends with the transfer ofthe patient to the operating tableSCOPE OF NURSING ACTIVITIES

1. Establishing the baseline assessment of the patient in the clinical setting or at home2. Ensuring the necessary laboratory test needed3. Carrying out of preoperative interview4. Preparing the patient for the anesthetic he is to receive and the surgery he is to undergo


16/39

16

5. Focus on assessing the post-operative status of the patient in terms of the effects of theanesthetic agent.

6. Impact of surgery on body image or role function.7. Evaluate the familys perception of surgery.

PREOPERATION CAN TAKE PLACE IN ANY OF THESE TIME AND PLACE:

1. In the physicians office before admission to the health care facility.2. On admission and during the days before the operation.3. The night before the surgery if the client is in the hospital.4. The morning of surgery on admission.

GENERAL PREOPERATIVE PREPARATION

Physiologic Nursing Assessment of client undergoing surgery

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

Interventions for Physical Changes in Older Adults Undergoing Surgery

PHYSICAL CHANGE NURSING INTERVENTION

CARDIOVASCULAR

decreased cardiac output moderate increased in BP decreased peripheral circulation arrythmias

Know what anesthesia is used Monitor V/S carefully Encourage early ambulation & leg exercises Assess for hypotension or hypertension or

hyperthermia

Note any changes to baseline ECGRESPIRATORY

Decreased vital capacity Reduced oxygenation of blood Decreased cough reflex

Assess pulmonary aspiration Monitor respirations carefully Vigorous pulmonary hygiene Post-operative: auscultate lung sounds Oxygen saturation monitor

RENAL

Decreased renal blood flow andlomerular filtration rate

Decreased ability to excrete wasteproduct

Monitor urine output 1 to 2 hours duringImmediate post-surgery

Evaluate intake and output Monitor fluid and electrolyte status

MUSCULOSKELETAL

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

and arthritis

assess level of mobility position on OR table with padding to reduce

trauma to bones and joints

spine, limbs and pressure points must bepadded to prevent fractures

early ambulation or exercises to individualsability

provided adequate nutrition

provide effective pain managementSENSORIMOTOR

decreased reaction time decreased visual acuity decreased auditory acuity

orient client to environment plan individual teaching, allow time to

reinforce teaching

provide safe environment


17/39

17

2. PRESENCE OF PAIN3. NUTRITIONAL STATUS client who is well nourished is better prepared to handle

surgical stress

4. FLUID AND ELECTROLYTE BALANCE dehydration and hypovolemia (fluid volumedeficit) predispose a client to complications during and after surgery

- electrolyte imbalance also increased operative risk5. PRESENCE OF INFECTION6. CARDIOVASCULAR FUNCTION client should be assessed for elevated BP; slow, rapid or

irregular pulse; edema; cold cyanotic extremities; weakness; and shortness of breath

LABORATORY AND DIAGNOSTIC STUDIES OFTEN ORDERED PRIOR TO SURGERY TO DETERMINE

CARDIOVASCULAR FUNCTION:

a. ECGb. CBC

i. Hemoglobinii. Hemcatocrit

iii. WBC if you are immunosuppressed, you have to strengthen theimmune system

- so that the doctor will be able to foresee the crisis that may come

and the interventions to be done prior to complication

iv. Plateletc. SERUM ELECTROLYTES Na, K, Cl

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

- high concentrationindicates theres something wrong with the kidney or

renal systemf. Creatinineg. Protime cardiopulmonary clearanceh. Partial Thromboplastin Time cardiopulmonary clearancei. Clotting Time/Bleeding Time cardiopulmonary clearance

j. X-RayOTHER DIAGNOSTIC TESTS (if needed):

1. Pulmonary Function Test check for capacity of lungs to have oxygen in it- check for amt. of volume the lungs can carry

COPD, emphysema, asthma and bronchitis increase operative risk because theyimpair CO2 and O2 diffusion in the alveolus and predispose the client topulmonary infection

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

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

observe for the appearance of urine

Includes: Urinalysis, BUN and Creatinine are commonly ordered preoperativetests

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

arrest

6. Neurologic Function7. Hematologic Function clients with coagulation diseases are at risk for hemorrhage and

hypovolemic shock during and surgery


18/39

18

5 FACTORS POINTING TO ABNORMAL HEMATOLOGIC FACTORS:

History of bleeding tendencies Symptoms such as easy bruising, excessive bleeding following dental extraction

and severe nosebleed

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

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

last 6 month, uncontrolled hypertension, CHF and peripheral vascular disease

- Clients take prescribed and non-prescribed medication that may increase operative riskby increasing coagulation

SOME MEDICATIONS THAT MAY RESULT IN COMPLICAITONS INCLUDE:

ANTICOAGULANTSHeparin sodium

Warfarin sodium

Aspirin

NSAIDS

cause clotting abnormalities which results to hemorrhage

ANTIBIOTICS w/c is combined with other

muscle relaxants

increase postoperative respiratory depression

TRANQUILIZERS decrease blood pressure thus increase the risk of shock

potentiates the effects of narcotics and barbiturates

THIAZIDE DIURETICS can create potassium depletion

STEROIDS cause hypofunction of the adrenal cortex thus impair physiologic

response to stress of anesthesia and surgeryanti-inflammatory effect delay wound healing and increase risk

of infection

MONOAMINE (MOA) INHIBITORS can cause hypertensive crisis when combined with anesthetic

agents

ANTIPARKINSON DRUGS cause hypotension or hypertension when combined with

anesthetic agents

STREET DRUGS AND ALCOHOL ABUSE increase tolerance to narcotics

HYPOGLYCEMICS require dosage alteration and close monitoring of blood sugar

HERBS

GARLIC inhibits platelet aggregation

may potentiate warfarinincrease INR and PT

cause GI upset

decrease blood glucose level

GINGER anticoagulant action

large doses increase risk of bleeding and dysrhythmias

GINSENG tachycardia and hypertension, esp. w/ the use of cardiac

stimulants

inhibit platelet aggregation

decrease warfarin effectiveness

lowers blood glucose

potentiate effects of digoxin

assess ginseng abuse syndrome: hypotension, hypotonia andedema

GINGKO BILOBA prolongs bleeding time

increase anticoagulant effect

subconjunctival hemorrhage and spontaneous subdural

hemorrhage


19/39

19

9. ALLERGIC REACTIONSSKIN CONTACT INJECTION INGESTION INHALATION

poision plants animal dander pollen latex

bee sting medication medication nuts and shellfish pollendust

mold and mildewanimal dander

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

11. Health Habits how much exercise do you do? Do you smoke? Do you make us ofdrugs?

12. Social HabitsPSYCHOSOCIAL ASPECT OF PREOPERATIVE PREPARATION

effectively handling clients fears can smooth the preoperative experience studies show that clients who are calm and emotionally prepared for surgery withstand

anesthesia better and experience fewer postoperative complications

PSYCHOLOGIC RESPONSE

1. ANXIETYPOTENTIAL SOURCE OF ANXIETY

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

2. FEAR- clients respond differently to fear some respond by becoming silent and withdrawn,

childish, belligerent, evasive, tearful and clinging

COMMON FEARS RELATED TO SURGERY

a. fear of the unknowni. first decision to seek medical advise

ii. subject to several laboratory testsiii. first experience-operation

b. loss of controlc. loss of love from significant othersd. threat to sexuality

SPECIFIC FEARS

a. diagnosis of malignancyb. anesthesiac. dyingd. paine. disfigurementf. permanent limitations


20/39

20

ASSESSMENT OF PREOPERATIVE ANXIETY

SUBJECTIVE DATA

1. understanding of proposed surgerya. siteb. type of surgeryc. information from surgeon regarding extent of hospitalization, postoperative

limitationsd. preoperative routines what will happen postoperatively?- let px. know that after surgery, px. will be staying in RR

e. postoperative routinesf. tests

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

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

a. geographic distanceb. perception as source of support

6. changes in sleep patternOBJECTIVE DATA

1. speech patternsa. repetition of themesb. change topicc. avoidance of topics related to feelings

2. degree of interaction with others3. physicala. pulse and respiratory ratesb. hand movement and perspirationc. activity leveld. voiding frequency

PREOPERATIVE TEACHINGS TO DECREASE ANXIETY

1. Preoperative testa. Reasonsb.

Explanations of the test

2. Preoperative routines3. Schedules

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

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

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


21/39

21

PROBABLE POST-OPERATIVE THERAPIES

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

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

questions

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

PREOPERATIVE ASSESSMENT

HISTORY TAKING - plays a large part in determining the degree of preoperative andpostoperative anxiety the client experiences- allows the nurse to:

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

surgery, the health-care facility etc.

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

PHYSICAL EXAMINATIONPREOPERATIVE DIAGNOSTIC TESTS

1. Serum potassium2. Hemoglobin3. Serum sodium4. Hematocrit5. Serum chloride6. Prothrombin time7. Glucose8. Partial thrombo-plastin time9.

Blood Urea10. Nitrogen

11. Chest X-ray12. Electrocardiogram13. Creatinine


22/39

22

PREOPERATIVE TEACHING

Basic areas that must be covered:

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

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

return demonstration

COUGHING EXERCISE

may be done sitting or lying down splinting the incision minimizes pressure and helps control pain when coughing client is instructed to interlace fingers across the incision to and hold them when coughing a small pillow or folded towel may be held over the incision to facilitate splintingLEG AND ANKLE EXERCISES prevent deep vein thrombosis and embolism

POSTOPERATIVE EQUIPMENT

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

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

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

PHYSICAL PREPARATION

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

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

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

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

enemas or starting an IV line

Verify that the client has not eaten for the last 8 hours Assist client with oral hygieneif necessary Remove dentures or bridgework that could obstruct the airway if left in

place

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

or antiembolic socks

Remove colored nail polish, remove make-up so skin color can beobserved


23/39

23

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

1. Preoperative permit2. Transfusion permit (if require)

PURPOSE OF PREPOERATIVE MEDICATION

1. allay anxiety2. decrease pharyngeal secretions3. reduce side-effects of anesthetic agent4. create amnesia

COMMONLY USED PREOPERATIVE MEDICATIONS

GENERIC NAME TRADE NAME DESIRE EFFECT UNDESIRED EFFECTS

TRANQUILIZERS

diazepam

droperidol

Valium

Inapsine

Decrease anxiety

Decrease anxiety

Produce antiemetic

effect

May cause dizziness,

clumsiness or

confusion

AnxietyHypotension during

and after surgery

SEDATIVES

midazolam Hcl

promethazine

secobarbital Napentobarbital Na

Dormicum

Phenergan

Seconal NaNembutal Na

Induces undesired

sleepiness and

reduces anxiety

Decreases anxiety

Produces an

antiemetic effect

Decreases anxietyPromotes sedation

Hypotension,

undesired respiratory

depression

Hypotension during

and after surgery

Disorientation,

especially in elderlypatients

ANALGESICS

morphine sulfate

meperidine Hcl Demerol

Relieves pain

Decreases anxiety

sedation

Respiratory depression

Hypotension

Circulatory depression

Decreased gastric

motility causing

potential vomiting

ANTICHLINERGIC

atropine sulfatealycopyrrolate Robinul

Controls secretions Excessive dryness ofmouth; tachycardia

HISTAMINE H2-

RECEPTOR

ANTAGONIST

cimetidine Tagamet Inhibits gastric acid

production

Some mild dizziness,

diarrhea, somnolence,

and rash

LEGAL AND ETHICAL ISSUES

A. Informed Consent A statement consenting to the operative procedure Protects px. rights to self determination and autonomy regarding surgical intervention Surgeon must explain the procedure in terms the client readily understand Implies that the patient has been given the information necessary to understand the

nature of the procedure and its known and possible consequence


24/39

24

PURPOSE OF SIGNED CONSENT

ensure client understands nature of treatment including potentialoutcome and disfigurement

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

claims unauthorized procedure was performed

CIRCMSTANCES REQUIRING CONSENT

any surgical procedure where scalpel, scissor, suture andhemostats of electrocoagulation may be used

entrance into a body cavity : paracentesis, cystoscopy,pericardiocentesis, etc.

using anesthesiaNECESSARY COMPONENTS OF CONSENT

patients full legal name surgeons name specific procedure (s) to be performed signature fo the patient, next of kin or legal guardian witnesses date it was signed

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

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

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

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

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

reached voluntarily

At least 2 px. identifiers must be used to identify px. identity

Confirm and verify the ff:

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

Patient response must match:

marked site

ID band Consent forms Radiologic examinations Scheduled procedures


25/39

25

SITE MARKINGS

Site verification is required for all procedures that involve laterality, multiple structures or multiple

level.

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

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

Site is marked with patient participation (verbal confirmation or pointing) A patient has the right to refuse to mark the site. Each institution will

determine policy for these situation

PHYSICAL (P) STATUS CLASSIFICATION SYSTEM

Classification Description

P1 Normal healthy patient

P2 Patient with mild systemic disease

P3 Patient with severe systemic disease

P4 Patient with systemic disease that poses a constant threat to life (ex. MI)P5 Moribund patient not expected to survive w/o surgery

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

INTRAOPERATIVE PHASE

Intraoperative Nursing

- 2nd Phase of the Perioperative Period

- OR Nursing

- OR table to PACU

NURSING ACTIVITIES

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

environment

PERIOPERATIVE TEAM

a. Preoperative team Pre-op nurse Physician, nurse practitioner or physician assistant Clinical nurse specialist Advanced Practice Nurse, a MSN holder w/ Major in

their field of specialty

b. Surgical/Operating Team

Sterile Unsterile

c. Post Operative Team

Post anesthesia nurse Medical-surgical nurse

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

the welfare & safety of the client

Sterile Team Non-Sterile Team


26/39

26

STERILE MEMBERS

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

produre

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

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

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

-suctioning and retracting

-cutting sutures

-may do suturing

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

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

& after surgery

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

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

5. CERTIFIED REGISTERED NURSE 1ST ASSISTANTUNSTERILE MEMBERS

- work outside the sterile area1. ANESTHESIOLOGIST maintenance of physiologic stability

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


27/39

27

CERTIFIED NURSE ANESTHETIST nurse who has a minimum of two years

additional education specializing in anesthetic administration

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

2. CIRCULATING NURSE responsible for the overall running of the OR in the wholeintraoperative period

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

intervention

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

addition

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

pathology departments

minimizing conversation and traffic within the OR suite documentation

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

OR DIVIDED INTO THREE AREAS:

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

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

CLOTHING ATTIRE

basic scrub suit

shoes with shoe cover

4. RESTRICTED AREA operating rooms sub-sterile areas connected to the ORs (typically houses the autoclave, scrub

sinks and blanket warmers)

where a sterile area/field is open


28/39

28

CLOTHING ATTIRE

sterile gown and sterile gloves mask

SURGICAL SUITE ENVIRONMENTAL HAZARDS

1. PHYSICAL back injury, fall, noise, pollutions, radiations, electricity fire2. CHEMICAL anesthetic gases, toxic fumess antineoplastic drugs and cleaning agents3. BIOLOGIC patients as a host for or source of pathogenic microorganism, infectious

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

PREPARATION OF THE PATIENT IN THE OPERATING ROOM

greet patient and try to promote relaxation never leave the patient unattended check the chart for pre-operative orders and preparations report any significant changes in the patient

SURGICAL ATTIRE

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

BASIC SCRUB ATTIRE

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

PROTECTIVE ATTIRE

objective follows the principles of the UNIVERSAL PRECAUTION- precaution that protects health care workers form contact with blood and

body fluids of all patients not just those diagnosed or suspected of being

infected by Hepa B, HIV or other blood borne pathogens

- minimum precaution for all invasive proceduresINVASIVE PROCEDURES entry into the tissue, organs or body cavities in the OR, DR, ER physician

or dentist office, radiologist department, clinal laboratory- attire:

1. APRON should be fluid resistant2. EYE WEAR/FACE SHIELD3. GLOVES

a. STERILE GLOVES used on a sterileprocedure

b. CLEAN GLOVES only used for unsterileprocedures (e.g. washing instruments, MIO,

handling specimens)

ATTIRE IN STERILE FIELD

sterile gown and sterile gloves


29/39

29

ASEPSIS absence of infectious or disease-producing microorganism

- two types:1. MEDICAL ASEPSIS exclude or reduce the number and

transfer of pathogens

- clean technique (hand washing)2. SURGICAL ASEPSIS renders and keep objects and areas

free from microorganism- sterile technique

ASEPTIC TECHNIQUES practices that restricts microorganisms in the environment, equipment and

supplies

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

STERILE TECHNIQUE

- required in the ff: all surgical procedures all procedures that invade the blood stream complex dressing and wound care tube insertions care of the high risk groups of patients

INFECTION invasion and proliferation of microorganism into the body tissue

SEPSIS

TWO TYPES OF MICROORANISM THAT INHIBITS THE SKIN

TRANSIENT- acquire by direct contact RESIDENT-below the skin surface

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

all times

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

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

both scientific and intellectual honesty

PROCESSES INVOLVED IN REMOVING MICROORGANISMS

MECHANICAL CHEMICAL

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

during surgical procedures

- Reduce hazard of microbial contamination of the surgical wound by skin floraHAND WASHING single most important infection control practice

SURGICAL HAND SCRUBBING process of removing as many microorganisms as possible from the

hands and arms by mechanical washing and chemical asepsis before a particular surgical procedure

- done before donning in the sterile gown and sterile gloves


30/39

30

EQUIPMENT FOR SURGICAL SCRUBBING

1. SCRUB SINK2. STERILIZED REUSABLE SCRUB BRUSHES3. SCRUBBING SOLUTIONCRITERIA FOR ANTI MICROBIAL SOLUTION USED IN SURGICAL SCRUBBING

broad spectrum fast effecting and effective non irritating and non sensitizing prolonged acting independent of cumulative action

EFFECTIVNESS OF SURGICAL SCRUBBING DEPENDS ON THE FF. VARIABLE

Mechanical Factors, Chemical factors and differences in individual skin flora Everyone should scrub according to a standardized written procedure Prolonged scrubbing raises residual microbes from deep dermal layers. Care should be

done not to abrade the skin.

Denuded areas allow entry microbes Too short scrubbing would be equally ineffective

TYPES OF ANTISEPTIC

A. CHLORHEXIDINE GLUCONATE antimicrobial effects against gram (+) and gram (-) microorganisms residual effect is more than 6 hours

B. IODOPHORES rapid against gram (+) and gram (-) microorganism cant sustain for a prolonged period of time at least two hours only skin irritant

C. TRICLOSAN non toxic, non irritating that inhibits growth of a wider range of both gram (+) and gram

(-) microorganism

good for sensitive skin develops prolonged cumulative suppressive action if used routinely

D. ALCOHOL ethyl or isopropyl rapid acting anti-microbial non toxic but has a drying effect

E. HEXACHLOROPHENE available by prescription only has a high potential for toxicity

METHOD OF SURGICAL HAND SCRUBBING

1. ANATOMIC TIMED SCRUBScrub from the nails, fingers each side and web space, palmar, dorsal surface

and forearm for a specific time

2.

COUNTED BRUSH STROKEStarting from the fingertips, scrub each anatomical area for the designated

number of strokes according to policy.

12 PRINCIPLES OF SURGICAL ASEPSIS/ASEPTIC TECHNIQUE

1. Only sterile items are used within the sterile field.2. Sterile gowns are considered sterile only in front, from shoulder to the level of the

sterile field and at sleeves from 2 inches above the elbow to the cuff.

3. Tables are sterile only up to the table level.


31/39

31

4. Sterile persons touch only sterile items or areas; unsterile person touch only unsterileitems or areas.

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

6. The edges of anything that encloses sterile content are considered unsterile.7. Sterile areas are continuously kept in view. In passing always face the sterile field.8. Sterile persons keep well within sterile areas. Unsterile persons avoid sterile areas.9. Sterile persons keep contact with sterile areas to a minimum.10. When in doubt, consider it unsterile.11. Moisture causes contamination.12. Microorganisms must be kept to an irreducible minimum


32/39

32

SURGICAL INSTRUMENTATION

Classification of items according to purpose and body contact:

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

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

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

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

FOUR CATEGORIES OF SURGICAL INSTRUMENTS

1. Sharps usable part has a sharp, or cutting edgea. Scalpel- incising tissues; dissectionb. Dissecting scissors - dissection

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

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

2. Clamps used for hemostasis. May be used as graspers or retractors.a. Straight Clamps used for hemostasis

- Stop bleeding

b. Curved clampsc. Graspers or Holding instruments

- commonly used to grasp and hold tissues

- as in retraction or for suturingd. Retractors - Retractors used to hold tissues away from the operative

site.

a. self retaining- can maintain its own position

PRINCIPLES OF COUNTING

1. All item are counted initially by the circulating nurse and the scrub nurse together (aloud) asthe scrub person touches each item.

2. The number (count) of each type of item is immediately recorded in the sponge count formby the circulating nurse

3.

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

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

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

inform the surgeon by saying aloud sponge count, instruments count and needle count

complete.

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

essential that each patient be considered as an individual.- A good position must provide maximum safety for the duration of the operative procedure.

Maximum safety includes:

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

visualization

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


33/39

33

EQUIPMENTS FOR POSITIONING

1. Operating table- Are versatile at adaptable to a number diversified positions for all surgical

specialties. However orthopedics, urologic and fluoroscopic tables are

utilized frequently for specialized procedures.

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

webbing to protect the safety of the patient

3. ANESTHESIA SCREEN- metal bar holds the drapes form the patients face and separates the non-

sterile area from the sterile area

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

5. STIRRUPS- Supports legs in lithotomy position

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

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

facilitate operation

8. KIDNEY REST- concave metal piece with groove notches at the base are place under the

mattress on the elevator part of the table

9. DONUT- used for procedures on head and face- circular or donut shape rubber foam pad10. METAL FOOTBOARD- to support the feet, the soles resting securely against- can be flat as horizontal extension of the table or raised perpendicular to the

table

DIFFERENT POSITIONS DURING SURGERY

SUPINE PRONE LATERAL KIDNEY POSITION PRONE POSITION KRASKE (JACKKNIFE) POSITION MODIFIED TRENDELENBERG those in the lower pelvis is pushed up so you can visualize what

is in the lower pelvic cavity

REVERSE TRENDELENBERG everything in the lower abdomen is pushed down so you canvisualize the upper abdomen

LITHOTOMY ORTHOPEDIC POSITION

SKIN PREPARATION decreases the number of bacteria on the patients skin, thus decreasing the chance of

the patient acquiring a post operative wound infection.

duration usually is 5 min depending on the size of the area to be prepped. always start the prep at the incision site, working to the outer boundaries. Boundaries

are Bedside to bedside; nipple line to mid thigh

new sponges should be used when returning to incision site ( cleanest to dirtiest ) should be done with firm but not rough movements. Observe for skin reactions.


34/39


35/39

35

C. Providone iodine (betadine) anaqueous solution that coagulatesalbuminous substance

D. Phenols (Lysol) effective in the presence of organic matterDRAPE provide sterile environment

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

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

3. large sheet - a plain large sheet used to drape under legs as in addedprotection above or below the operative area or for draping areas in which a

sheet with an opening cannot used.

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

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

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

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

8. perineal sheet - A special design large sheet with an opening and used tocreate an adequate sterile field with the patient in lithotomy position such as

d & c, hemorroidectomy and others.

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

and others.

10. instrument tray cover (ITC) - A fitted sheet used to drape or cover the mayostand.SURGICAL INCISIONS

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

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

Minimum postoperative discomfort Cosmetic surgery


36/39

36

LAYERS OF THE ABDOMINAL TISSUE

1. skin2. subcuticular3. subcutaneous4. fascia

superficial deep

5. muscle6. peritoneum

ANESTHESIOLOGY

- a branch of Medicine concerned with the administration medications oranesthetic agents to relieve pain and support physiologic function during a

surgical procedure

ANESTHESIA

- is an artificially induced state of partial or total loss of sensation, occurringwith or without loss of consciousness.

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

loss of protective reflexes

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

producing loss of consciousness; acts on specific receptors in NS.

Anesthetics drug that produces local or general loss of sensibility Pain perceptual phenomenon, a disturbed sensation causing suffering/distress

3 Types of Pain

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

FACTORS THAT AFFECT THE CHOICE OF ANESTHESIA

1. Provide maximum comfort &safety for the patient with low index of toxicity2. Provide maximum operating conditions for the surgeon3. Provide potent, predictable analgesia extending to postop period.4. Produce adequate muscle relaxation and provide amnesia5. Have rapid onset & easy reversibility w/ minimum side effects6. Patients physiologic status w/ Presence & severity of co-existing dcs.7. Patients mental and psychologic status8. Options for management of postoperative pain9. Posoperative recovery from various kinds of anesthesia10. Type and duration of the surgical procedure11. Client position needed for the surgical procedure12. Any particular requirement of the surgeon and patients preference


37/39

37

TYPES OF ANESTHESIA

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

elimination from the body or by pharmacologic means

- produces analgesia, amnesia, unconsciousness and loss of reflexes andmuscle tone

- best suited for surgeries of the ff: head, neck, upper torso, back prolonged surgical procedure used in all clients who are unable to lie quietly for long periods

of time

- types: INTRAVENOUS ANESTHESIA extremely rapid induction

- Uncosciousness occurs 30 sec. after administration- Promotes rapid transition form the conscious to surgical

anesthesia stage- Acts as calming agent- Sufficiently potent to be used alone in some minor

procedures as dental extraction and pelvic exams

- Ex. Thiopental Sodium and Ketamine (has a great effecton px. ; increases BP ; not given to px. with hx. Of

hypertension ; usually px. who have hx. Of low BP due to

depression of CNS which may be increased by Ketamine)

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

through the respiratory system

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

inserted once the client is paralyzed and unconscious

(intubation)

- examples:a. INHALATION ANESTHETICS (volatile agents)

- liquids vaporized for inhalation withO2 as carrier

- cause post operative shiveringhypothalamus effect- halothane and isoflurane

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

that provides analgesia equivalrent to

10 mg of morphine sulfate

2. REGIONAL ANESTHESIA reversible loss of sensation in a specific area or region of thebody when local anesthetic is injected to purposely block or anesthetize nerve fibers in

and around the operative site- agents blocks conduction of impulses in the nerve fibers


38/39

38

EPINEPHRINE added to many local anesthetics

- adjunct medication given with another medication to potentiate effect ofthe medication

- purpose: prolonged anesthetic effect delay absorption of anesthetic by constriction of local blood

vessels

TYPES OF REGIONAL ANESTHESIA

a. SPINAL SUB ARACHNOID BLOCK / SAB- anesthetic technique of choice for older adults and for clients undergoing

surgical procedures in the lower half of the body

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

these order and recovers in reverse order:

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

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

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

of consciousness

b. EPIDURAL CLEB / CONTINUOUS LUMBAR EPIDURAL BLOCK

- achieved by introduction of anesthetic agent into the epidural space(thoraxic, lumber, sacral, or caudal interspace) w/o penetrating the dura andw/o entering the subarachnoid space

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

may affect respiratory muscle

c. CAUDAL ANESTHESIA

d. TOPICAL ANESTHESIA short acting- applied directly to the area to be sesensitized- blocks peripheral nerve endings in the mucous membrane of the vagina,rectum, nasopharynx, and the mouth- preparation: solution, ointment, gel, cream or powder

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

subcutaneous tissue of the area

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

ensure and prevent systemic reaction causing cardiovascular collapse or

convulsion

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

produce a field block

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

impulse to the brain from this area


39/39

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

damage

- anesthetize individual nerve or nerve plexus rather than all local nervesanesthetized by a field block

- prevent accidental injection into the blood vesselTYPES OF PERIPHERAL NERVE BLOCK

- Digital nb- for a finger- Brachial plexus nb- entire upper arm- Intercostals nb chest or abdominal wallh. MONITORED ANESTHESIA- surgeon infiltrates surgical site with local anesthesthetics and the anesthesia provider

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

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

specific acupuncture points

j. CRYOTHERMIA- use of cold to induce anesthesia

Surgery Concept of Illness and Pain

Documents

Transcript of Surgery Concept of Illness and Pain