Surgical Procedures and Terminology

• Emergency surgery involves unplanned surgical treatment of trauma or acute illness to preserve life function and control hemorrhage.
• Elective surgery is planned to improve life, examples: cataract extraction and hip replacements.

Purposes of Surgical Procedures:

• Diagnostic surgery confirms or establishes a diagnosis, for example, biopsy of a breast lump.
• Palliative surgery relieves or reduces pain or symptoms of a disease, example: resection of nerve roots.
• Ablative surgery removes a diseased body part, like the removal of a gall bladder (cholecystectomy).
• Constructive surgery restores function or appearance that has been lost or reduced, for example, breast implant.
• Transplant surgery replaces malfunctioning structures, for example, kidney transplant.

Surgical Terminology

• "-ectomy": Excision or removal of, e.g., appendicectomy.
• "-lysis": Destruction of, e.g., electrolysis.
• "-orrhaphy": Repair or suture of, e.g., herniorrhaphy.
• "-oscopy": Looking into, e.g., endoscopy.
• "-ostomy": Creation of opening into, e.g., colostomy.
• "-otomy": Cutting into or incision of, e.g., tracheotomy.
• "-plasty": Repair or reconstruction of, e.g., mammoplasty.

Inpatient and Outpatient Settings:

• Inpatient settings include operating theaters, day surgery units, and cardiac catheter labs.
• Outpatient settings include procedure rooms and ambulatory care units.

Perioperative Patient Journey

• Primary referral GP discusses diagnosis with the patient and decides whether to refer to a specialist surgeon.
• Non-surgical options should also be considered at this stage.
• Operative decision: A specialist reviews the patient and, if surgery is decided, refers the patient to a hospital.
• The specialist completes the Recommendation for Admission (RFA) and consent form.
• Distributes Patient Health Questionnaire (PHQ) and Discharge Planning Questionnaire (DPQ) to the patient.
• Preadmission: PHQ and DPQ are reviewed by a clinical screener who triages for Pre-Procedure Preparation (PPP).
• The PPP process ensures the patient is optimally prepared for their surgery/procedure and hospital resources are efficiently coordinated.
• Admission to hospital: Patient presents to the hospital on the day of surgery/procedure.
• Pre-procedure/surgery preparation is completed, and the patient is reviewed by a procedural anesthetist.

Intraoperative Period

• During the surgery: The patient is wheeled into the anaesthetic bay, information is checked, and anaesthetic is administered.
• The patient is positioned and prepared for surgery/procedure after which, a time out is completed.
• The procedure is undertaken, anaesthetic is switched off, and the patient is wheeled into PACU (recovery).

Postoperative Period

• Recovery in hospital: When the clinical protocol for discharge is satisfied, the patient gets information on post-surgery/procedure care and pain management.
• Emergency contact details are provided along with follow-up appointments and further information as required.

Postoperative Follow-up

• The patient returns home.
• GP is responsible for ongoing care as per the discharge summary and is the main point of contact for addressing concerns, complications, or side effects, post-surgery.

Preoperative (Holding Bay):

• This phase starts when surgery is decided and stops upon transfer to the operating theater.
• It is used for assessing a person's suitability for surgery, identifying risk factors, educating on avoiding complications, and planning to meet needs for safety and recovery.

Intraoperative Phase:

• Begins when a patient enters the operating theatre and stops upon transfer to the post-anaesthetic care unit (PACU).
• Safety is paramount; several checks and procedures are included with administering anaesthetic, performing the procedure, wound closure, and reversing anaesthetic

Postoperative Phase:

• Starts in PACU, ends on discharge or complete recovery.
• OT staff hand over the patient to PACU. Nurses assess airway, breathing, and circulation, manage pain and nausea, and teach/support patients and carers, especially for day surgery cases.

Preop Purpose:

• Goals of preop care include obtaining patient health information, providing and clarifying info about surgery, and assessing the patient's emotional state and readiness for surgery and expectations on outcomes.

Patient Interview:

• Interviews cover current health status, medications, medical conditions, allergies, social habits, cultural and spiritual considerations, discharge planning, and completion of blood tests/diagnostics.

Preoperative Tests and Their Areas Assessed:

• Urinalysis: Renal status, hydration, UTI & disease
• Chest x-ray: Pulmonary disorders & cardiac enlargement
• Blood studies (RBC, WBC, Hb, Hct): Anaemia, immune status, infection
• Electrolytes: Metabolic status, renal function, diuretic side effects
• Blood Gas Analysis (BGA's), oximetry: Pulmonary & metabolic function
• Prothrombin (INR) or partial thromboplastin time: Bleeding tendencies
• Blood glucose: Metabolic status, diabetes mellitus
• Creatinine: Renal function
• Serum urea: Renal function
• Electrocardiogram (ECG): Cardiac disease, electrolyte abnormalities
• Pulmonary function studies: Pulmonary status
• Liver function tests: Liver function
• Blood Type & cross-match: Blood availability for replacement

Legal Considerations

• Ensure all required forms are signed and in the medical record, including: -Informed consent -Blood transfusion consent -Advance directives -Power of attorney.

Special Considerations

• Children's separation anxiety can be addressed by allowing parents in preop and PACU if possible, and using teaching at their developmental level with tools such as dolls with bandages.
• Older adults may have hearing issues, short-term memory loss, higher risk of post-op complications, and functional needs.

Key Points

• Information on surgery and sensory aspects helps patients know what to expect.
• Psychosocial support reduces anxiety through active listening and clarifying misperceptions.
• Staff roles and expectations should be clarified to empower patients.
• Skills training should include moving safely post op, mobilization options, deep breathing, and preventing thrombi/emboli.
• Pain relief options and a plan should be discussed.

Premedications:

• Depending on patient circumstances and prescription, premedications may be used to: provide analgesia, prevent nausea and vomiting, promote sedation and amnesia, decrease anaesthetic requirements, facilitate induction of anaesthesia, relieve apprehension & anxiety, prevent autonomic reflex response, and decrease respiratory and gastrointestinal secretions.

Commonly Used Preoperative Medications:

• Benzodiazepines (Midazolam, Diazepam, Lorazepam): reduce anxiety, induce sedation and amnesia.
• Opioids (Morphine, Pethidine, Fentanyl): reduce anxiety, provide analgesia, decrease the amount of anaesthetic used.
• Histamine H₂-receptor antagonists (Cimetidine, Famotidine, Ranitidine): increase gastric pH.
• Antacids (Sodium citrate): increase gastric pH, decrease gastric volume.
• Antiemetics (Metoclopramide, Droperidol): increase gastric emptying, decrease nausea and vomiting.
• Anticholinergics (Atropine, Glycopyrrolate, Hyoscine): decrease oral and respiratory secretions, prevent bradycardia.

Intraoperative Phases:

• Holding bay, during surgery, completion

Surgical Safety Checklist

• Key items to confirm before induction of anesthesia include patient identity, site and procedure, consent, anesthesia safety check completion, pulse oximeter, and allergies.
• Key items to confirm before skin incision, during the "TIME OUT" include introductions of all team members and verbal confirmation by surgeon, anesthesia professional, and nurse of patient, site and procedure.
• Review anticipated critical events. Nurse confirms sterility and equipment issues, and antibiotic prophylaxis.
• Key items at "SIGN OUT" before the patient leaves the operating room include verbal confirmation by the nurse with the team of the procedure, instrument and sponge counts, labeling of specimens, and equipment problems.
• The team reviews key concerns for recovery and management.

Perioperative Personnel

• Anesthetic nurse/tech duties: Patient ID, advocate, assisting anaesthetist, providing equipment, preparing machines, maintaining airway, applying monitoring devices, and transferring patients.

Types of Anesthesia

• General anesthesia (GA) involves a loss of sensation and consciousness, suppression of protective airway reflexes, amnesia, analgesia, hypnosis, and relaxation; administered via IV or inhaled gases.
• Benefits of GA include suppression of psychological stress and pain.
• Disadvantages of GA include the need for close monitoring when unconscious and patient anxiety.
• Three phases of GA: induction, maintenance, and emergence.

IV Technique Example:

• Induction agent: propofol with 30-40% O2 and nitrous oxide (N2O).
• Amnesic drug: midazolam.
• Analgesic: fentanyl or morphine sulfate.
• Muscle relaxant: rocuronium.

Regional Anesthesia:

• Regional anesthesia temporarily interrupts nerve impulse transmission from a specific body region, resulting in loss of sensation and movement in the targeted area, while the patient remains conscious.
• Types of regional anesthesia: topical, local, and peripheral nerve blocks.
• Topical anesthesia involves using aerosols or sprays (cophenylcaine forte spray), nebulizers, gels, and ointments (amethocaine).
• Local anesthesia involves blocking conduction when applied locally to nerve tissue.
• Peripheral nerve blocks: involves injecting LA near a nerve trunk or group, such as the brachial plexus block or pudenal block.

IV Block:

IV block (Bier's block) procedures must be performed within arm, wrist and hand. It applies occlusion tourniquet to extremity.

Central Nerve Block:

Central Nerve Blocks includes epidurals and spinal and LA injected into spinal roots that emerge from the spinal canal.

Spinal Blocks:

LA injected into subarachnoid space.

Epidural:

Epidural is used for anaesthesia/opioid to the epidural space (outside dura mater.

Conscious Sedation

• Can be used alone in certain tests and procedures- the patient remains awake, with a patent airway (e.g. midazololpam for sedation) along with an analgesic (fentanyl/morphine).
• Examples include endoscopes and some angioplasties.
• Nursing management for local and regional anaesthetic include: History of prior anaesthetics and outcomes, Chest fasting status, Monitor vitals
• Observe for signs of autonomic NS blockage (hypertension, bradycardia, nausea and vomiting) and supervise ambulation

Airway Management Considerations

• Unconsciousness leads to muscle tone loss in the upper airway Tongue and epiglottis fall back on the posterior wall of pharynx → obstruct airway

Artificial Airways:

Helps to prevent obstructions.

Mallampati Classification

• The Mallampati classification to assess the difficulty of intubation.

Airway Equipment:

• Includes laryngoscopes, endotracheal tubes (ETT), oral airways, nasopharyngeal airways, Yankauer sucker, McGill forceps, face masks, syringes, carbon dioxide detector/filter, and bag valve mask.

Anaesthetic Induction:

• Apnoea may temporarily occur.Eyelash reflex gone and the eyes taped shut
• Ventilated patient with mask to check airway patency, and head position or artificial airway should be used to maintains patient airway.

Guedel's (oropharyngeal) airway and Nasopharyngeal airway:

• Are important for these processes Laryngeal mask airway (LMA) minimise aspiration risk for short procedure with the surgery site below the head and neck.
• Intubation allows for facilittaion on ventillation, prevents asiration with a 7.5mm ETT. Insertion of ETT helps maintains good operations on Operations on head, neck, mouth, throat and nose.

ETT:

• Controlled ventillation and facilitates ventilation while preventing possible aspiration with a 7.5mm endotracheal tube.
• ETT Insertion can ensure the patient is sniffing the air, has a flexed neck and a straight head.
• Ensures air dilivered goes nto the lungs and not the oesophagus
• Airway cuff manometer used to inflate cuff to correct cmH20 pressure.
• Liste for beathing sounds bilaterally, watch for movement and confirm placement when cuff is infalted.

Rapid Sequence Induction (RSI):

• Decreases the risk of pulminary aspiration when certain conditions exist.
• Indicatons include: unknown fasting, pregnancy, hiatus hernia, bowel obstruction, bleeding, or gastirc reflux etc.

Cricoid Pressure:

• To help the esophagus by posterior cricoid cartilage and 6th vertebra. Prevent regurgitation and aspiration when ETT cuff not inflated.

Airway Complications:

• The obstructive sleep apnoea needs to be managed in PACU.
• Aspiration is caused by: decreased throat reflexes under GA → acidic contents enter lung → residual effects impede lung function and gas exchange → oedema → alveolar collapse → hypoxia

Catastrophic Events- Anaphylactic reactions

• Manifestation may be masked by anaesthesia- Vigi.lance and rapid intervention are essential! Symptoms include hypotension, tachycardia, bronchospasm and pulmonary oedema.
• Antibiotics and latex main instigators.

Malignant hyperthermia:

• Muscle rigidity.
• Tachycardia.
• Tachypnoea- Elevated body temperature - 41°C or higher (NOT an early sign).
• Respiratory & metabolic acidosis.
• Ventricular arrhythmias.
• Can result in cardiac arrest and death.

Recovery/ PACUA

• Close monitoring
• Reliant on nurse depending on LOC Situational awareness – need for recognising deterioration and acting quickly with immediate A-E

Patency and adequacy of airway and breathing:

• Arterial oxygen saturation needs check to make sure it has an adequate ventilation.

Cardiovascular Status

• Heart rate and rhythm should be checked along with blood pressure to check circulation .

Skin color

• Monitor to make sure there are no signs dehydration or fluid overload every 5-15 mins

Lifespan Considerations:

• Infants and young children- may not state their pain levels-can use other signs-crying, fussiness, increased heart rate and BP, agitation- Good pain control help facilitate healing process and recovery

Bariatric Patients:

• Bariatric patient need to have the most risk mitigation since they are at a higher risk/ Difficulty clearing anaesthetic medications from system-pain control more complex with possible Pressure areas and the need for some pressure areas management of all types.

Airway complications list-

• Laryngospasm- Partial or complete closure of the vocal cords as an involuntary reflex action

Bronchospasm-

• Contraction of the smooth muscle in the walls of the bronchi and bronchioles, causing narrowing of lumen

Post-op Risk Mitigation

• look listen and feel the patients
• check the count and record respirations to give more ease to respirations

Priority action when there is failure to breathe-

• CAUSES-Airway obstruction- Persistient muscle relaxant

Risks for these patients are- Haemiomdynamic instability and altered perfusion from blood pooling- Peripheral vasodilation, hypothermia and hypovolaemia – check drains and wounds for bleeding

• Consider type of surgery (musculoskeletal (watch for compartment syndrome)
• The goal is Disability- to watch consciuous state when is is postioning on the left lateral side

Pacu Transistion

• Patient should be drowsy but easily roused and able to answer questions
• Monitor high HR of possible Hypothermia → risk to homeostasis → impaired coagulation → risk of bleeding- Related to Prolonged surgical treatment and anaesthesia
• Watch out for pain and provide the analgesia for it.

Wound assessment in Post-Op Care

• Assess drain patency, amount and type of drainage, and dressing adherence; watch for complications.

PONV

• Postoperative Nausea and Vomiting should be mitigated by encouraging deep breaths and using prophylactic medications.

Under Water Drainage Seal

• Follow each haspital protocol with its own paramenters with criteria

Chest Injurries

• A chest drain must be inserted

Chest Drain insertion

• inserted following cardiothoracic surgery or after chest trauma; following a spontaneous pneumothorax; or from any conditions resulting in accumulation of content in the pleural space.

Chest Tube Drainage System

• Water seal (one way valve) prevents air from re-entering chest on inspiration. chest tube end sits 2cm below sterile water line

UwSd

• is monitored with the patient for: •Swinging the fluid in tubing as they breathe •Draining fluid from patient site •Bubbling when their air is escaping out of that area

Complication with this seal

• Secure all connections Secure dressing site- Encorage the partint to exhale and cough if they need the drainage

Complication in Alveoli and tissue-

• pneummonia, inflammation if there are toxins
• signs temp, productive cough with blood, purulent sputum, dyspnoea, chest pain
• Preventative management: deep breathing and coughing, early moving in bed and ambulation