MS1-Pain-and-Surgery PDF - Medical-Surgical Nursing 1

NUR1213: MEDICAL-SURGICAL NURSING 1 DEPARTMENT OF NURSING BATCH 2025 2ND SEMESTER / A.Y. 2023 – 2024 MODULE 1: PAIN AND SURGERY LECTURE OUTLINE o “Pain is part of aging” shoul...

NUR1213: MEDICAL-SURGICAL NURSING 1 DEPARTMENT OF NURSING BATCH 2025 2ND SEMESTER / A.Y. 2023 – 2024 MODULE 1: PAIN AND SURGERY LECTURE OUTLINE o “Pain is part of aging” should be a team o “If a person is asleep approach 1. Concept of Pain and its management they are not in pain” o People in pain 2. Concept of Surgery o “Pain is a result, not a become exhausted  Perioperative Care cause” and may truly be  Pre-operative Care asleep or merely  Intra-operative care trying to sleep. Some  Post-operative Care people sleep as an escape mechanism CONCEPT OF PAIN 3H: Hand (apply), Heart (patients), Head (knowledge) DEFINITION OF PAIN American Pain Society CHARACTERISTICS OF PAIN o An unpleasant sensory and emotional Pain is subjective and personal experience associated with actual or Physiologic pain may sometimes broaden to potential tissue damage, or described encompass emotional hurt in terms of such damage. Pain is a symptom not a disease Pain is uniquely experienced by each individual PAIN PERCEPTION and can not be adequately define, identify, or The conscious experience of discomfort measured by an observer Children and elderly perceived pain differently Pain is a valuable diagnostic indicator, it than Adults usually indicated tissue damage or pathology Infants (1-2 days old) are less sensitive to Pain is usually reported as a severe discomfort pain. A full behavioral response to pain is or uncomfortable sensation apparent at 3-12 months of age. PAIN THRESHOLD The level at which someone experiences pain. COMPONENTS OF PAIN High and low pain threshold Stimuli Perception Example: Pag tayo kinurot, lahat tayo marerecognize Response na nakaramdam tayo ng pain but iba-iba ng kakayanan Intensity na kayanin yung pain (pain tolerance) Threshold Tolerance PAIN TOLERANCE Maximum intensity or duration of pain that a person is willing to endure once the threshold TYPES OF PAIN has been reached. ACCORDING TO SOURCE Pain Tolerance is DECREASED” o With repeated exposure to pain Nociceptive Pain o By fatigue, anger, boredom, Neuropathic Pain apprehension, anxiety and fear o Sleep deprivation NOCICEPTIVE PAIN Pain Tolerance is INCREASED Nociceptive pain is the most common type. o By alcohol consumption Cause by potentially harmful stimuli being o Medication, hypnosis detected by nociceptors around the body o Warmth, distracting activities o Strong beliefs or faith SOMATIC PAIN Caused by injury to skin, muscles, bone, joint, and connective tissues. MISCONCEPTIONS AND MYTHS Somatic pain often involves inflammation of injured tissue. Although inflammation is a MISCONCEPTIONS MYTHS normal response of the body to injury, and is o “That nurse or o Only the client can essential for healing, inflammation that does physician is the best judge the level and not disappear with time and can result in a judge of a client’s distress of the pain chronically painful disease. The joint pain pain” o Pain management caused by rheumatoid arthritis may be WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 1  considered and example of this type of Latent somatic nociceptive pain. o DORMANT Classification of Somatic Pain: o Produces no pain except loss of ROM o Superficial somatic pain or Cutaneous pain – perceived as sharp or burning SCLEROTOMIC AND DERMATOMIC PAIN discomfort or pricking quality Deep pain  Ex. Insect bite, paper cut May originate from sclerotomic, myotomic, or o Deep somatic pain – produce localized dermatomic nerve irritation/injury sensations that are sharp, throbbing, Sclerotome: area of bone/fascia that is and intense; usually described as dull supplied by a single nerve root or aching, diffuse discomfort and Myotome: muscle supplied by a single nerve localized in one area. root  Ex. Arthritis. Dermatome: area of skin supplied by a single nerve root VISCERAL PAIN Refers to pain that originates from ongoing injury to the internal organs or the tissues that support them. When the injured tissue is a hollow structure, like the intestine or the gall bladder, the pain often is poorly localized and cramping. When the injured structure is not a hollow organ, the pain may be pressure-like, deep, and stabbing Usually accompanied by ANS symptoms such as nausea and vomiting, pallor, hypotension, and sweating PSYCHOGENIC PAIN A simple label for all kinds of pain that can be best explained by psychological problems Sometimes occurs in the absence of any identifiable disease in the body. More often, there is a physical problem but the psychological cause for the pain is believed to be the major cause for the pain. NEUROPATHIC PAIN Can be a symptom or complication of several diseases and conditions Pain that is processed abnormally by the nervous system and usually results from damage to either the pain pathways in peripheral nerves or pain processing centers in the brain Referred Pain ACCORDING TO CHARACTERSTICS Onset, intensity, and duration REFERRED PAIN Used to describe discomfort that is perceived ACUTE PAIN in a general area of the body, but not in the exact site where an organ is anatomically Usually of short duration (less than 6 months) located. Often described in sensory terms such as” o Sharp o Stabbing TYPES OF REFERRED PAIN o Shooting MYOFASCIAL PAIN Accompanied by observable physical responses Trigger points, small hyperirritable areas within Increased or decreased BP, tachycardia, a muscle in which nerve impulses bombard diaphoresis, tachypnea, focusing on the pain CNS and are expressed at referred pain Active PSYCHOLOGICAL AND BEHAVIORAL RESPONSE o Hyperirritable TO ACUTE PAIN o Causes obvious complaint Fear WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 2  General sense of unpleasantness or unease HOW PAIN WORKS Anxiety PHYSICAL RESPONSE TO ACUTE PAIN Increased heart rate, RR, BP Pallor or flushing, dilated pupils Diaphoresis Increased blood sugar Decreased gastric motility and gastric secretion Decreased blood flow to the viscera, kidneys, and skin Nausea occasionally occurs CHRONIC PAIN A major health concern Divided in 3 types: o Chronic nonmalignant pain  Such as from low back pain to rheumatoid arthritis TRANSMISSION OF PAIN o Chronic intermittent Transduction  Such as migraine, headache Transmission o Chronic malignant pain Modulation  Cancer Perception PSYCHOLOGICAL AND BEHAVIORAL REPONSE TRANSDUCTION TO CHRONIC PAIN Depression Is the conversion of chemical information in Increased or decreased appetite and weight the cellular environment to electrical impulses Poor physical tone that move toward the spinal cord. Social withdrawal and life role changes The chemical that are released by the Decreased concentration damaged cells stimulates specialized pain receptors located in the free nerve endings of Poor sleep peripheral sensory nerves called nociceptors Preoccupation with physical manifestations Begins a response to a noxious stimuli (painful stimulus) that results in tissue injury, can be CHARACTERISTICS OF ACUTE AND mechanical, thermal, or chemical CHRONIC PAIN “It triggers the release of noxious stimuli” ACUTE PAIN CHRONIC PAIN o Sudden onset o Remote onset o Sumptomatic of o Uncharacteristic of primary injury or primary injury or disease disease o Specific and localized o Nonspecific and o Severity associated generalized with the acuity or o Severity out of sensitivity of the proportion to the injury or disease stage of the injury or process disease o Responds favorably to o Responds poorly to drug therapy drug therapy o Requires gradually o Requires increasing decreased drug drug therapy therapy o Persists beyond o Diminishes with healing stage healing o Suffering intensifies o Suffering decreases WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 3  Sympathetic Nervous System o Fight or flight response to stress Parasympathetic o Exhaustion or shock response o “pampakalma” Neurotransmitters CENTRAL NERVOUS SYSTEM The CNS comprises the spinal cord and the brain Spinal Cord o Transmits painful stimuli to the brain and motor responses and pain perception to the periphery TRANSMISSION Brain The phase during which the peripheral nerve o Processes and interprets transmitted fibers form synapses with neurons in the pain impulses spinal cord,, the pain impulses move from the spinal cord sequentially levels in the brain, the impulses ascend to the reticular activating FACTORS AFFECTING RESPONSE TO system, the limbic system and the thalmus and finally the cerebral cortex. PAIN Physiologic Factors PERCEPTION o Age, genetics, quality of life Affective Factors Refers to the phase of impulse transmission o Mood, fear, depression, anxiety during which the brain experiences pain at a Psychological Factors conscious level (awareness of pain) o Family, personal spiritual and cultural beliefs, occupation MODULATION Cognitive The last phase of pain impulse transmission o Past experience, knowledge, values, during which the brain interacts with the spinal expectations nerves in a downward fashion to alter the pain experience. PAIN CONTROL THEORIES INTENSITY THEORY STRUCTURES AND FUNCTIONS OF State that pain is the result of excessive THE PAIN SYSTEM stimulation of sensory receptors PERIPHERAL NERVOUS SYSTEM Carries pain impulses to and from the CNS PATTERN THEORY Afferent Nerve Fibers Describes that painful and non-painful o Carry impulses to the CNS sensations are transmitted by nonspecific Efferent Nerve Fibers receptors through a common pathway to o Carry impulses from the CNS higher centers of the brain AFFERENT NERVE FIBERS Composed of: SPECIFICITY THEORY o Nociceptors Described four types of cutaneous sensation”  Naked nerved endings touch, warmth, cold, and pain (thermal, chemical, and It focuses on the direct relationship between mechanical) the pain stimulus and perception but does not  A – Delta Fibers – rapid rate, account for adaptation to pain and the transmit acute sharp pain psychosocial factors that modulate the  C – Fibers – slower rate and stimulus produce chronic type of pain Nerve fibers carry touch and pain impulses o Afferent Nerve Fibers from receptors on the skin to the spinal cord o Spinal Cord Network Nerve cells in the subcutaneous gelatinosa (SG) of the spinal cord received these touch and pain impulses AUTONOMIC NERVOUS SYSTEM Impulses then proceed through transmission Regulates involuntary functions cells to the brain WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 4  Fibers from the brain send inhibiting Listen carefully to how the client describes the information to the SG in dorsal horn of the pain spinal cord which serves as a gate for control Questions to ask about pain of pain o PAIN  Pattern: onset and duration GATE CONTROL THEORY  Area: location  Intensity: level Gate – located in the dorsal horn of the spinal  Nature: description cord o PQRST Smaller, slower nerve fibers carry pain  Provocation: how the injury impulses occurred and that activities Larger, faster nerve fibers carry other increased/decreases the pain sensations  Quality: characteristics of pain Impulses from faster nerve fibers arrive at  Aching (impingement) gate first inhibit pain impulses  Burning (nerve (acupuncture/pressure, cold, heat, chemical irritation) skin irritation)  Sharp (acute injury) Non-painful stimuli can block pain stimulus  Radiating within kasi mas mabilis makuha ni brain ang non- dermatome (pressure painful stimulus on nerve)  Referral/Radiation THREE FACTORS INVOLVED IN OPENING AND  Referred – site distant CLOSING THE GATE to damaged tissue The amount of activity in the pain fibers that does not follow The amount of activity in other peripheral the course of a fibers peripheral nerve Messages that descend from the brain  Radiation – follows peripheral nerve; May nararamdaman ba talaga akong sakit o wala? diffuse Gate makes you doubt yourself if you’re really in pain.  Severity: how bad is it? Pain scale  Timing: when does it occur? PAIN ASSESSMENT Pm, am, before.., during.., after activity, all the time Effective pain management begins with a comprehensive assessment which allows the health care provider to characterize the pain, PAIN ASSESSMENT TOOLS clarify its impact, and evaluate other medical Simple descriptive pain intensity scale and psychosocial problems. The assessment Visual Analog Scale (VAS)/ Linear Scale determines whether additional evaluation is Wong-Baker FACES Pain Rating Scale needed to understand the pain. GOALS OF COMPREHENSIVE PAIN ASSESSMENT Obtain a full description of the pain Determine whether the description fits a well- known pain syndrome Determine whether there is structural disease of the body that may help the pain Try to understand the mechanisms (tissue, nerve, injury, psychological processes) that maintain the pain Describe the negative effects on physical and psychosocial functioning caused by the pain Understand the medical and psychiatric problems that co-exist with the pain and might need treatment at the same time ASSESSMENT HEALTH HISTORY Always believe the client’s account and rating of pain Ask the client about the nature of pain WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 5  PAIN MANAGEMENT Sometimes referred to as a co-analgesic agents Refers to the techniques used to prevent, Comprise the largest group and include reduce, or relieve pain various agents with unique and widely About half of hospitalized patients who have differing MOA pain are under-medicated Examples: Children are at particular risk of poor pain o GABA agonists (baclofen) control methods o N-methyl-D-aspartate (NMDA) Medications are given as: Antagonists – (Dextromethorphan, o PRN - “as needed”; may continuing Ketamine, Amantadine, Memantine) dose o Corticosteroids (Prednisone, o As a prescribed schedule Dexamethasone, Methylprednisone) o Stat – immediately; one dose o Antidepressants (Amitriptyline or Goals in Managing Pain: Elavil, Clomipramine, Desipramine) o Reduce pain o Anticonvulsants (Pregabalin, o Control acute pain Gabapentin, Carbamazepine, o Protect the patient from further injury Phenytoin, Topiramate) while encouraging progressive o Local anesthetic agents (Mexiletine, exercises Tocainide, Flecainide) Pharmacological or Drug Interventions o Adjuvant Drug Therapy NON OPIOID ANALGESICS o Non-opiod analgesics Includes acetaminophen or paracetamol o Opioid Analgesics dipyrone and NSAIDs. Non-drug Interventions NSAIDs are nonspecific analgesics and can o Heat and cold potentially be sued for any type of acute or o Transcutaneous electrical stimulation chronic pain. Because they are both analgesic (TENS) and anti-inflammatory, NSAIDs are particularly o Acupuncture and acupressure useful for pain related to joint problems and o Percutaneous electrical nerve other musculoskeletal disorders. stimulation (PENS) Examples of NSAIDs: Non-Invasive Techniques o Salicylates like aspirin, diflunisal, o Psychological Pain Control trisalicylate and salsalate o Proprionic acids like ibuprofen, 5 GENERAL TECHNIQUES FOR ACHIEVEING PAIN naproxen, ketoprofen, fenoprofen, MANAGEMENT oxaprozin Blocking brain perception o Acetic acids like indomethacin, Interrupting pain transmitting chemicals at the diclofenac, ketorolac, tolmetic, site of injury sulindaca, etodolac. Combing analgesics with adjuvant drugs like o Oxicams like piroxicam (ingredients, methods) to enhance the o Naphthlyalkalonones like nabumetone effectiveness of medical treatment o Fenamates like mefenamic acid, Using gate-closing mechanisms meclofenamic acid Altering pain transmission at the level of the o Pyrazoles like phenylbutazone spinal cord. OPIOID ANALGESICS PHARMACOLOGICAL OR DRUG This includes all drugs that interact with opioid INTERVENTIONS receptors in the nervous system. Routes: Most effective analgesics (Ellsion, 1998) o Intravenous – first line The receptors are the sites of action for the o Rectal – alternative when oral/IV are endorphins, compounds that already exist in not an option the body and are chemically related to the o Topical – e.g. Pathc, Gel formulation opiod drugs that are prescribed for pain. (EMLA) Opioid Antagonists o Intraspinal (Neuraxial) / Epidural o Have no analgesic effect and are used (Perineural) to block the effects of opioid drugs o Oral o Ex. Naloxone, naltrexone, nalmafene Opioid Agonist-antagonist ADJUVANT DRUG THERAPY o Have analgesic effect Defined as drugs that are on the market for o Ex. Buprenorphine, butorphanol, indications other than pain but may be nalbuphine, dezocrine analgesics in selected circumstance WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 6  SIDE EFFECTS o Prior to use, evaluate patient’s ability Constipation to learn and perform necessary Nausea activities. Itch Urinary retention MIND/BODY THERAPY Dry mouth There may be vicious cycle in which pain Sexual dysfunctin causes stress, and stress, in turn, causes more Sleepiness, fatigue, dizziness, and mental pain. clouding Mind/body therapy addresses these issues and provides a variety of benefits including a PATIENT CONTROLEED ANETHESIA greater sense of control, improved coping Interactive method of pain management that skills, decreased pain intensity and distress, allows patients to treat their pain by self- and increased sense of wellbeing and administering doses of analgesic agents relaxation. These approaches may be very valuable for adults and children with pain NONDRUG INTERVENTIONS Nursing Consideration: COGNITIVE-BEHAVIORAL THERAPY (CBT) o Be aware that some of these methods Effective in reducing pain and disability when require a prescription in the inpatient used as a part of therapeutic treatment for setting because inappropriate use can chronic pain. Aquatic Therapy Provides educational information and diffuses feelings of fear and helplessness. HEAT AND COLD Include teaching of life skills and coping skills Heat helps soothe stiff joints and relax that can assist the patient in productive muscles problem solving and the prevention or Cold helps numb shar pain and reduce minimization of future pain episodes. inflammation IMAGERY TRANSCUTANEOUS ELECTRICAL STIMULATION The use of imagine pictures, sounds, or (TENS) sensation for generalized relaxation or for A device, an electrical unit that delivers specific therapeutic goals such as reduction of different frequencies and intensities of pain. stimulation to the skin through electrodes. These images can be initiated by the patient or guided by a practitioner. The sessions in ACUPUNCTURE AND ACUPRESSURE which imagery is used can be individual or Acupuncture is a system of integrative group. medicine that involved pricking the skin or tissues with needles, used to alleviate pain and RELAXATION to treat various physical, mental, and Systematic relaxation of the large muscle emotional conditions. groups. Relaxation therapies include a range of PERCUTANEOUS ELECTRICAL NERVE techniques such as autogenic training, various STIMULATION (PENS) forms of meditation, progressive muscle Combines electro-acupuncture and TENS relaxation, deep breathing, and paced which uses acupuncture like needle probes as respiration. electrodes place dermatomal levels The goal of these therapeutic approaches is corresponding local pathology. overall relaxation and stress reduction Practice can produce a set of physiologic NON-INVASIVE TEHCNIQUES changes that result in slowed respiration, PSYCHOLOGICAL PAIN CONTROL METHODS lowered pulse and blood pressure, and Mind/body therapy reduction in the body’s inflammatory response Cognitive-behavioral therapy mechanisms. Imagery This can have a positive impact on health and Biofeedback improve symptoms in many acute and chronic Progressive relaxation illnesses and conditions, including pain. Distraction BIOFEEDBACK Hypnosis Prayer Provides biophysiological feedback to patient Breathing Exercises about some bodily process the patient is Nursing Consideration unaware of (e.g. forehead muscle tension) WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 7  Use of electronic monitoring instruments to o REASONS FOR SURGERY provide patients with immediate feedback on To preserve life heart rate, blood pressure, muscle tension, or Maintain dynamic equilibrium brain wave activity. This allows the patient to Undergo diagnostic procedure learn how to influence these bodily responses Prevent further infection through conscious control and regulation. Promote healing For comfort HYPNOSIS Restore or reconstruct part of the body Relaxation + suggestion + distraction + For aesthetic reasons altering the meaning of pain. ***XLAP (Exploratory Laparotomy) During hypnosis, changes like those found in meditation can occur, such as a slowing of the INDICATIONS OF SURGERY pulse and respiration, and an increase in alpha brain waves. Incision Medical hypnosis has been shown to be helpful Excision in reducing both acute and chronic pain Diagnostics Repair PRAYER Removal Reconstruction Not usually considered a mind-body or Palliation psychological approach, but it is worthwhile Aesthetics considering it in this context of mind/body Harvest treatmetns Procurement Changes in the concept of health and illness, a Transplant broadening view of healing and curing, and By-pass/shunt interest in other cultural systems of medicine Drainage/evacuation have created a growing openness to the Stabilization spiritual dimensions of health Staging PHYSICAL THERAPY Parturition Extraction Is useful in teaching patients to control pain, Exploration to move in safe and structurally correct ways, Diversion to improve range of motion, and to increase flexibility, strength, and endurance “Active” and “Passive” modalities can both be CLASSIFICATIONS OF SURGICAL sued, but active modalities, such as PROCEDURE therapeutic exercise are particularly important Degree of risks when the goal is to improve both comfort and Purpose function Urgency Location Invasiveness EXERCISE It may reduce the risk of secondary pain CLASSFICATION BASED ON DEGREE OF RISK problems like muscle strains and may also lead MAJOR to improved confidence and sense of well- being. Life threatening High risk, extensive, prolong, large amount of blood loss, major or vital organs are involved, great risk of complications CONCEPT OF SURGERY Objectives of surgery MINOR Reasons for surgery Non-life threatening Indications of surgery Less serious, generally not prolong, few Classifications of surgical procedure serious complications. Prefix and suffixes in surgical procedure CLASSIFICATION BASED ON PURPOSE OBJECTIVES OF SURGERY Diagnostic Surgery Alter form or structure o To establish the presence of a disease Repair of injuries condition Correction of deformities o Enables the surgeon to verify a Prolong life suspected diagnosis Relief of suffering o E.g. breast biopsy, biopsy of skin Diagnosis and cure of disease lesions WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 8  Exploratory Optional o To determine the extent of the o Personal preference, not required disesase condition and at times to o Ex. Cosmetic surgery make or confirm a diagnosis Ambulatory surgery – required, elective, optional o E.g. exploration of abdomen for unexplained pain, exploratory CLASSIFICATION BASED ON LOCATION laparotomy Inside the body Curative o Surgery of tissues, organs o Ablative o Involves beyond subcutaneous tissue  Removal of decreased organ (hypodermis) (suffixed used is “ectomy”) Skin/Outside the body  E.g. cholycystectomy, o Surgery within dermis, epidermis appendectomy o Constructive CLASSIFICATION BASED ON INVASIVENESS  Repair of congenitally defective organs (suffixes Non-invasive surgery used are “plasty”, “orrhapy”, o Ex. Closed reduction of a fractured “pexy”) bone  E.g. total hip replacement, Minimally invasive surgery orchiopexy (surgery for o Ex. Laparoscopic surgery undescended testes) Invasive o Reconstructive o Ex. Cesarean section  Repair of damaged organs  E.g. plastic surgery after burns PREFIXES SUFFIXES Palliative Surgery A Absence of Centesis To puncture o To relieve distressing signs and Angio vessel Ectomy Removal of symptoms, not necessarily to cure the Vaso Blood Lysis Break up/to disease vessel destroy o E.g. resection of tumor to telieve Arhtro joint Opsy To look at pressure and pain Baro Pressure Escopy To view Cosmetic using a o Correction of defects, improvement of scpe appearance or change to a physical Endo inside Ostomy Make an feature opening o E.g. rhinoplasty, cleft lip repair, Intra Within Otomy To cut or mammoplasty make an incision CLASSIFICATION BASED ON URGENCY Extra Outside Tripsy To crush or Emergent break o Without delay Hemi Half Plasty To repair o Condition is life-threatening requiring Para Beside surgery immediately Trans across o Severe bleeding, bladder or intestinal obstruction, fractured skull, gunshot or stab wounds, extensive burns PERIOPERATIVE Urgent o Within 24-30 hours Refers to the nursing management of surgical o Client requires prompt attention patients which begins when the time decision o Closed fracture, infected wound, is made to undergo surgery (pre-operative), exploration, irrigation and continues while the patient is on the Required operating room table (intra-operative) until the o Needs surgery follow-up and evaluation in the clinical and o Planned within a few weeks or month home-care setting (post-operative) o Thyroid disorders, prostatic 3 Phases of Perioperative Nursing hyperplasia, cataracts o Preoperative nursing Elective o Intraoperative nursing o Should have surgery o Post-operative nursing o Client will not be harmed if surgery is not performed but will benefit from it o Repair of scars, simple hernia, vaginal repair WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 9  Patient education (advance directives, pain PRE-OPERATIVE control, post-op complications) STARTS when patient and the doctor agree Availability of equipment, supplies, prosthetics, that a surgery will be performed and ENDS blood products, etc. when patient is transferred to the OR table BE GUIDED BY THESE: INFORMED CONSENT o Caring, conscience, discipline, 1. Name of patient technique, and FEU (fortitude, 2. Name of surgical procedure excellence, uprightness) 3. Name of surgeon 4. Potential risks 5. Potential benefits PRE-OPERATIVE NURSING CARE 6. Signature of patient ASSESSMENT 7. Signature of witness Patient information and history – co- Who should sign the SURGICAL morbidities, allergies, previous hospitalizations, CONSENT? etc. o PATIENT – conscious and mentally fit Clearance – neuro , CP, Endo, Pedia, etc. o RELATIVE – immediate, competent to Diagnostic and laboratory result – blood, x-ray, make decision, legal age CT scan, MRI NURSE will act as witness; SURGEONS will explain the Allergies procedure Current medications How can the nurse help patients to Insurance; discount benefits consent properly to surgery? Vital signs o Skin preparation Baseline functional patterns (gordon)  Shaving examples: Social support  Cranial surgery Demographic data  Abdominal surgery Health history  Leg surgery DIAGNOSIS DIETARY RESTRICTIONS Anxiety NOTHING PER OREM (NPO) Fear o 8 hours prior to surgery under Pain GENRAL ANESTHESIA Risk for infection o 4 hours prior to surgery under Hypovolemia EPIDURIAL ANESTHESIA Hypothermia o No restrictions for LOCAL Risk for injury and others ANAESTHESIA What could happen to the patient if…? o These includes no food and drinks, o Patient do not understand the medications as instructed by procedure and what to expect anesthesiologist o Patient is wearing patient gown only and transferred to a very cold OR ***Bakit NPO? If stomach ay may laman pa pag o Patients’s immune system is naginstill ng anesthesia, stomach will relax so may (1) compromised risk for aspiration kasi yung pagkain mapupunta sa o No blood products was prepared lungs. If pagkain is nasa intestine na, pwedeng before surgery; patient not hydrated magspoil during surgery which can (2) cause infection. well before surgery ***Ensure safety when transferring patient o Patient in pain or with fracture is not careful in transferring patient from INTERVENTION hospital bed to OR table Transfer and patient safety o OR nurse preparing the Preparation of equipment, instruments, and instruments/supplies is not sure of its supplies strerility PLANNING EVALUATION Documentation in chart Surgical consent Skin preparation Pre-op dietary instructions Instructions about what to expect during and after surgery WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 10  PRE-OP PATIENT EDUCATION No pain o There will be no sensation, hence, no WHAT TO EXPECT INSIDE OR pain as the surgeon performs the Difficult to identify staff procedure o Staff are wearing masks and hair cap; staff will introduce themselves WHAT TO EXPECT AFTER SURGERY Relatives are restricted o Relatives may enter until certain point Post-anesthesia care unit – PACU only (ex. anteroom); nurse will (recovery room) accompany them throughout o When the patient wakes up from Cold room sedation, she will see a different room o Machines and medications in the OR and some new staff and hear should be stored in cool temperature; machines beeping warm blanket will be provided Limitations in movement You will see and hear machines and o Due to anesthesia and surgery, instruments movements may be limited. Movement o The surgeon and surgical team need will return once anesthesia subsides certain machines and equipment; staff Post-operative pain are trained to use it safely to perform o When anesthesia wears off, you will surgery; anesthesia will be given so start to feel the pain on the surgery you will not feel while these are used site. Pain medicatinos will be given Post-operative medications REINFORCE PATIENT’S KNOWLEDGE ON THE o Pain medications, antibiotics and other ANESTHESIA TO BE USED prescription medicines General anesthesia Early ambulation o Inhalation gas will be given to put the o Early movement and ambulation patient to sleep endotracheal tube promote circulation and early return to may be given for risky and prolonged functioning surgery Dressing change & wound healing IV sedation o Dressing should be changed daily; o The patient is put to sleep for a short observe for positive/negative post-op period of time using IV medication outcomes  Epidural anesthesia o The anesthesiologist will ask the OTHER INFORMATION patient to sit while the spinal needle is Advance directives injected to the lubar spine before o A legal document duly signed by the attaching the epidural catheter patient that indicates his/her  Spinal anesthesia preference in his/her health o Side lying fetal position. management should he/she be unable anesthesiologist inserts the medication to decide due to the health condition in the lumbar area using a spinal Pain control needle (no catheter to attach) o Pain medications will be given thru IV  Regional block anesthesia in the first few hours. When the pain o A certain nerve region is numbed by becomes mild to moderate and patient anesthesia that affects acrosss the can tolerate food intake, oral pain body region. medications can be given as necessary  Ex. arm block – injected Surgical complications below the armpit and its effect o Depending on the patient’s co- runs down the affected morbidities and characteristics, he/she  Local anesthesia may have low to high level of srugical o Anesthesia is injected to the muscles risks and complications. Clearance around the surgical site prior to surgery and close monitoring pre, intra and post-op is important WHAT TO EXPECT DURING SURGERY Anesthesia/deep sleep o To further relax your mind and your PRE-OP NURSING INTERVENTIONS muscles, you will be may be put to TEACH HOW TO PREVENT POST-OP sleep COMPLICATION Numbness Diaphragmatic breathing o Surgeon will not start the procedure if Splinting of chest when coughing you still have sensation if you still Leg exercieses – down, straighten then flex have sensation in the surgical site WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 11  Foot exercises Early ambulation Turning on the sides – prevent bed sore o Turning schedule Incentive spirometer – lungs capacity TRANSFER AND ENDORSEMENT Ambulatory or via wheelchair Relaxed via stretcher Critical on stretcher Accompish and endorse preoperative checklist Chart and document the condition of patient as indicated in the checklist Document time of endorsement of patient to the OR nurse Surgical safety checklist includes: o Sign in – before induction of anesthesia o Time out – before skin incision o Sign out – before patient leaves OR Sterile package indicators Prepare sterile packages and instruments CLASSIFICATION OF INSTRUMENTS CUTTING AND DISSECTING Have sharp edges UseD to dissect, incise, separate, and excise tissues Should be protected during cleaning, sterilizing and storing ; Should be kept separate from other instruments and demand careful handling at all times. SETTING UP FOR SURGERY SCALPELS  GOLDEN RULE: sterile to sterile; clean to clean; if clean instrument/supply touches the sterile area, it is considered contaminated, remove contaminated filed/instruments  Surgical set up - https://youtu.be/JaSnvS- XNas?si=cJ3jFK9p2-jhQQsN SURGICAL INSTRUMENTS PARTS OF THE INSTRUMENT a. Tip b. Serrated jaws c. Box lock d. Shank e. Ring handle f. Ratchets Made of brass & the blade is made of carbon steel; Most frequently used has a reusable handle with a disposable blade; May also be available in disposable type. WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 12  SCISSORS Blades of the scissors maybe straight, angled or curved , pointed or blunt a the tips and the handles maybe long or short ; Used only to cut or dissect tissues ; To maintain the sharpness of the scissors, it should be used ONLY for their intended purpose. METZENBAUM SCISSORS Used to cut delicate tissue; also known as TISSUE OR OPERATING SCISSOR May be curved or straight Handle # 3, 7, 9 – Blade # 10 , 11, 12, 15 Handle # 4 – Blade # 20, 21, 22, 23 Blade # 10 – most frequently use; has a rounded cutting edge along one side. Blades # 20, 21, 22 have the same shape but larger. Blade # 11 – has a straight edge that comes to a sharp point; known as the STAB KNIFE. Blade # 12 – is shaped like a hook with the STRAIGHT MAYO SCISSORS cutting edge on the inside curvature. Used to cut sutures and supplies ; also known Blade # 15 – has a smaller and shorter as SUTURE SCISSOR. curved cutting edge than no. 10 blade. Blade # 23 – has a curved cutting edge that comes to more of a point than no. 20, 21, and 22 blades. Standard used in hospitals: Handle 3 and 10, Handle 4 – Blade 20 KNIVES Comes in various sizes and configurations ; Usually have a blade at one end & the blade have one or two cutting edges. Some have detachable and replaceable blades like adenotome & dermatome May be also known as scalpels CURVED MAYO SCISSORS Used to cut heavy and tough tissues (fascia, muscles, uterus & breast) Available in regular and long sizes. WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 13 WIRE SCISSORS Have short, heavy blades They are used instead of suture scissors to cut stainless steel sutures Heavy wire cutters are used to cut bone fixation wires. CAUTERY TIP AND MACHINE Electronic instruments used to cut the skin, tissues, and vessels (yellow button) DRESSING / BANDAGE SCISSORS Also used to coagulate bleeding vessels by Used to cut drains and dressings and to open heat (blue button) items such as plastic packets. Bandage is used to cut the uterus and umbilicus during CS operation. BONE CUTTERS GRASPING AND HOLDING TISSUE FORCEPS Used often in pairs, to pick up or hold soft tissues and vessels THUMB / SMOOTH / NON-TOOTHED FORCEPS Used to hold delicate tissues ; are tapered with serrations at the tip ; maybe straight or angled, short or long and delicate or heavy. DISSECTORS (BLUNT/SHARP) Includes biopsy forceps and punches, curettes (has a sharp edge with loop, ring or scoop on the end), snares (a loop of wire may be put around a pedicle to dissect tissue such as a tonsil, then the wire cuts the pedicle as it retracts into the instrument and the wire is replaced after use). WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 14 TOOTHED / PICK UP / RAT TOOTH FORCEPS DEBAKEY ALTRAUMATIC TISSUE FORCEPS Have a single tooth on one side that fits between two teeth on the opposing side; use to hold tough tissues. ADSON BIPOLAR FORCEPS ALLIS FORCEPS Has a scissor action. Each jaw curves slightly inward with a row of teeth at the end ; Holds tough tissue gently but securely SPONGE FORCEPS BABCOCK FORCEPS The end of each jaw is rounded to fit around a structure or to grasp tissue without injury. STONE FORCEPS Used to grasp calculi such as kidney stones or gall stones; Either curved or straight forceps ; Have blunt loops or cups at the end of the jaws WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 15  TENACULUM Curved or angled points on the ends of the jaws penetrate tissue to grasp firmly; May have a single tooth or multiple teeth KELLY FORCEPS For deep layers of tissues or cavity BONE HOLDERS Includes vice-grip, pliers and other types of heavy holding forceps use to stabilize the bone. MOSQUITO CLAMP CLAMPING AND OCCLUDING HEMOSTATIC FORCEPS Usually have two opposing serrated jaws that are stabilized by a box lock and controlled by ringed handles. When closed, the handles remain locked on ratchets; Most commonly used surgical instruments; Used primarily to clamp blood vessels; Either straight or curved slender jaws that taper to a fine point KOCHER OR OSHNER FORCEPS CRILE / STET / TAG FORCEPS For shallow layers of tissues WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 16  CRUSHING CLAMPS Used to crush tissues or clamp blood vessels; ARMY-NAVY RETRACTOR Fine tips are used for small vessels and Abdominal operation structures while longer and sturdier jaws are needed for larger vessels, dense structures and thick tissues. DEAVER RETRACTOR For deeper retraction Exploratory in abdominal surgery HARRINGTON RETRACTOR NON CRUSHING VASCULAR CLAMPS To protect the organ Used to occlude peripheral or major blood Minimizes trauma vessels TEMPORARILY; Minimizes tissue trauma; Jaws, either straight, curved or S shaped, have opposing rows of finely serrated teeth SINGLE END RICHARDSON RETRACTOR Used in cesarean section EXPOSING AND RETRACTING HANDHELD OR NON SELF-RETAINING RETRACTORS Usually used in pairs and held by the first or second assist - some have blades on one end, either curved or angled, dull or sharp while some have blades on both ends. WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 17 DOUBLE END RICHARDSON RETRACTOR BALFOUR ABDOMINAL RETRACTOR GOULET RETRACTOR Intended for the abdominal procedure BLADDER RETRACTOR MALLEABLE RIBBON RETRACTOR Straight, thin, bendable RIB RETRACTOR SELF-RETAINING RETRACTORS May have shallow or deep blades, some have ratchets or spring locks to keep the device open, while others have wing to secure the blades; - some holding devices have two or more blades that can be inserted to spread the edges of incision and hold them WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 18 BRAIN RETRACTOR SMOOTH JAWS NEEDLE HOLDER Needle holders that have jaws without serrations which are used for small needles like in plastic and microsurgery SUTURING OR STAPLING NEEDLE HOLDER Used to grasp and hold curved surgical needles; Resembles hemostatic forceps but the basic CASTROVIEJO NEEDLE HOLDER difference is the jaws; Intended for sututres Has a short, sturdy jaws for grasping a needle For smaller needles without damaging it or the suture material. Blood vessel repair The size of the needle holder should match the size of the needle; Either long or short, with serrations on jaws, some are non; STAPLERS Available in reusable and disposable type TUNGSTEN CARBIDE JAWS Jaws with an insert of solid tungsten carbide with diamond cut precision teeth designed to eliminate twisting and turning of the needle in the needle holder; Can be identified by the gold plating on the handles. Intended for handling needles VIEWING INSTRUMENTS SPECULUM Has a hinged, blunt blades that enlarges and holds a canal open such as the vagina, or a cavity, such as the nose WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 19  SUCTIONING AND ASPIRATING SUCTION is the application of pressure (less than atmospheric pressure) to withdraw blood or fluids, usually for visibility at the surgical site; made of style tip and sterile tubing; NASAL SPECULUM style of the suction tip depends where it is to Is like a funnel used to visualize the inner be used and the surgeon’s preference. parts of the nose POOLE ABDOMINAL TIP EAR SPECULUM Is a straight hollow tube with a perforated Is like a funnel used to visualize the inner outer filter shield that prevents the adjacent parts of the ear tissues from being pulled into the suction apparatus. Used during abdominal laparotomy or within any cavity in which copious amount of fluid or pus are encountered ENDOSCOPES Made of a round or oval sheath that is inserted into a body orifice or through a small skin incision Used for viewing in a specific anatomical FRAZIER TIP locations Is a right angle tube with a small diameter; Usually have two opposing serrated jaws that Used when little or no fluid except capillary are bleeding and irrigating fluid is encountered, such as brain, spinal, plastic and ortho procedures Keeps the field dry without the need for sponging WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 20  Has a fitted blunt end cannula inside to keep fluid or gas from escaping until the cannula is removed. YANKAUER TIP Is a hollow tube that has an angle for use in the mouth or throat. CANNULA Has a blunt end and perforations around the tip to aspirate fluid without cutting into tissues; Also used to open blocked vessels or ducts for drainage or to shunt blood flow from the surgical site ASPIRATION Done manually to obtain a specimen like blood, body fluid, or tissue for laboratory examination or to obtain bone marrow for transplantation which is frequently done with a syringe and needle. ASPIRATING TUBE DILATING AND PROBING A long straight tube used through an DILATORS endoscope Used to enlarge orifices and ducts HEGAR DILATORS TROCAR Has a sharp cutting edge at the end of a hollow tube intended to cut through tissues for PROBES access to fluid or a body cavity. Used for Used to explore a structure or to locate an bone marrow and laparoscopy obstruction WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 21  ROUND NEEDLE ACCESSORY INSTRUMENTS MALLET TIES SCEW DRIVERS 4 MAJOR CATEGORIES OF INSTRUMENTS 1. Sharps 2. Grasping and Holding 3. Clamping and Occluding 4. Retractors HANDLING OF INSTRUMENTS BEFORE SURGICAL PROCEDURE 1. Surgical nurse should be the one to prepare the instruments on the mayo and back table o Avoid as much as possible preparing the instruments wearing only sterile SUTURES gloves Absorbable sutures 2. Uncovered, exposed instruments are never Non-absorbable sutures transported through corridors 3. The scrub should not go beyond the confines NEEDLES of the room CUTTING NEEDLE 4. The scrub nurse together with the circulating nurse should person counting of instruments, sharps, and sponges. They must be accounted for through every procedure o Counting Procedure – a method of accounting for items put on the sterile table for use during the surgical procedure i. Sponges, sharps, and instruments should be counted on all procedure. ii. Counting that expensive instrument like towel clips and WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 22  scissors are not accidentally c. Select appropriate instruments for thrown away with the drapes location of surgical site; short iii. Counts are also performed for instruments for superficial work and infection control and inventory long ones for deep in a body cavity. control purposes Experience will facilitate instrument selection according to the surgeon’s KEY POINTS IN HANDLING INSTRUMENTS preference and need 1. Handle loose instruments separately to d. Many instruments are used in pairs or prevent interlocking or crushing in sequence a. Never pile one instrument on top of 4. Pass instruments decisively and firmly. The another on an instrument; lay them instrument should be slapped or placed firmly side by side into the surgeon’s palm in the proper position b. Microsurgical, ophthalmic, and other for use. delicate instruments are vulnerable to a. Generally, when passing a curved damage through rough handling instrument, the curve of the c. Metal to metal contact should be instrument aligns with the direction of avoided or minimized the curve of the surgeon’s hand. 2. Inspect instruments such as scissors and forceps for alignment, imperfections, IN PASSING AN INSTRUMENT TO THE SURGEON cleanliness, and working conditions If the surgeon is on the opposite side of the a. Blades must be properly set table, pass across right hand to right hand or b. Exact alignment of teeth and with the left hand to a left handed surgeon serrations is necessary If the surgeon or assistant is on the same side c. Set aside or remove any defective of the table and to the right, pass with your instruments left hand; if the surgeon is to your left, pass 3. Sort instruments nearly by classifications with your right hand 4. Keep ring – handled instruments together, with curvatures and angles pointed in the same 5. Watch the sterile field for loose instruments. direction Remove them promptly after use to the mayo a. Hang ring handles over a rolled towel table. The weight of the instruments can injure or over the edge of the instrument the patient or cause post-op discomfort. tray or container Keeping instruments off the field also b. Remove instrument pins or holders if decreases the possibility of falling to the floor. used to keep box locks open 6. Wipe the blood and organic debris off the c. Close box locks on the 1st ratchet instruments promptly after each use with a 5. Leave retractors and other heavy instruments moist sponge in a back table a. Dried blood and debris on instruments 6. Protect sharp blades, edges, and tips. They surface like in box lock and in crevices, should not touch anything increase bioburden that could be a. Some orthopaedic instruments can carried into the surgical site remain the racks during the initial 7. Flush the suction tip and tubing with sterile table set up and until they are needed distilled water periodically to keep the lumens during the surgical procedure patent. Keep a tally of the amount of fluid used to clear the suction line and deduct this DURING SURGICAL PROCEDURE amount from the total sued to irrigate the surgical site. This is to have an accurate 1. Know the name and use of each instrument accounting of blood loss from the operation. 2. Handl instruments individually 8. Remove debris from electrosurgical tips to 3. Hand the surgeon or assistant the correct ensure electrical contact. Disposable abrasive instrument for each particular task. Remember tip cleaners are helpful for maintaining the the principle: “use for intended purpose conductivity and effectiveness of the surface of only” the tup. Avoid using the scalpel blade because a. Avoid placing fingers in the ring the debris may become airborne and handle as the instrument is passed contaminate the surgical field. because it may inadvertently drop or 9. Place used instruments not needed again into snag on drapes a tray or basin during or at the end of the b. Many surgeons use hand signals to surgical procedure indicate the type of instrument a. Blood and gross debris must be needed. An understanding of what is removed first taking place at the surgical site makes b. Careless dropping, tossing or throwing these signals meaningful. of instruments into a basin is highly prohibited WILLIAM, A.R.A, LUGARES, J.R.K., PAHUTAN, K.F.C., CULLARIN, M.J.B. 23  c. Keep instruments accessible for final SOLUTIONS FOR SHORT IMMERSION PERIOD counts Proteolytic Enzymatic Detergent dissolves d. Bloody instruments should not be blood and protein and removes dissolved soaked in a basin of solution for a debris from crevices. This is effective in a wide prolonged period. Instruments that range of water qualities. have been wiped can be immersed in OR nurse should wear protecting gloves, a basin of sterile demineralized waterproof apron and face shields to prevent distilled water, not saline solution. accidental spray from contaminated solutions NaCl in saline solution and blood is DONTs corrosive. o BLEACH – corrosive solution should e. Never place heaving instruments like not be used retractors on top of tissue and o CHLORINE COMPOUNDS hemostatic forceps and other clamps. o IODOPHOR – soaking should not Place them in a separate tray. exceed 1 hour AFTER SURGICAL PROCEDURE WASHING 1. Check all the drapes, towels, and table covers Done to remove residual blood and debris to be sure that no instruments will to the before terminal sterilization or high-level laundry or into the trash. A final quick count is disinfection. a safeguard. Clean, warm water with noncorrosive, free 2. Collect all the instruments from the mayo, rinsing detergent back table and other small tables including o Regardless of the water content, the those have been dropped or passed off the detergent should be anionic or sterile field. nonionic with a pH close to neutral 3. Separate delicate, small instruments and those  Alkaline detergent (>8.5 pH with sharp and semi sharp edges for special level) will stain instruments handling  Acidic detergent (< 6 pH 4. Disassemble all instruments with parts to level) will corrode or pit the expose all surfaces for cleaning. instruments 5. Open all hinged instruments to expose box o Wash instruments carefully to guard locks and serrations. against splashing and creating 6. Separate instruments of dissimilar metals. aerosols Clean the instruments per type to prevent  Use soft-bristled brush to electrolyte deposition of other metals. clean serrations and box locks 7. Flush with cold distilled water through hollow  Keep instruments submerged instruments or channels like suction tips or while brushing to minimize endoscopes to prevent drying of organic aerosolizing microorganisms debris.  Use a soft cloth to wipe 8. Rinse off blood and debris with demineralized surfaces or a non-fibrous distilled water or any enzymatic detergent cellulose sponge to prevent solution. damage to delicate tips 9. Follow procedures for preparing the  Remove bone, tissue, and instruments for decontamination or terminal other debris from cutting sterilization. Procedure varies depending on instruments the type of instrument and its components and  Never scrub surfaces with the equipment available and its location. steel wool, wire brushes, scouring pads, or powders to protect the protective finish on DECONTAMINATION PROCESS OF metal (this protects the base metal from oxidation) INSTRUM