NCM 112A: Medical Surgical Nursing (Unit 1) PDF

NCM 112A: MEDICAL SURGICAL NURSING RLE - SL │ Prof. Mario 7:30 - 9:00 AM ThF (A504) Transes by: Christine Mae Antonio Unit 1: Preoperative Care Perioperative Nursing 2. Intra-operative Phase - a nursing spec...

NCM 112A: MEDICAL SURGICAL NURSING RLE - SL │ Prof. Mario 7:30 - 9:00 AM ThF (A504) Transes by: Christine Mae Antonio Unit 1: Preoperative Care Perioperative Nursing 2. Intra-operative Phase - a nursing specialty that works with patients who are - from the time the patient is received from the having operative or other invasive (involves an operating room until admitted to the post incision under the skin) procedures. This type of anesthesia care unit (PACU) nursing is a specialization that requires additional 3. Postoperative Phase training - begins with the admission of the patient to PACU - used to describe nursing care provided in the total and ends with a follow-up evaluation in the clinical surgical experience of the client before, during and setting or at home after surgical procedures - Perioperative nurses work with surgeons, Instruments and White Board Components anesthesiologists and nurse practitioners in the operating room. - A perioperative nurse is a registered nurse (R.N.) who works in the operating room. Sometimes called a surgical or an operating room nurse. - The perioperative nurse may serve as a scrub nurse (sterile nurse), selecting and passing instruments and supplies used for the operation, or as a circulating nurse managing the overall nursing care in the operating room and helping to maintain a safe, comfortable environment. History of Surgery - Surgery as we know it today wasn't truly invented Phases of Perioperative Nursing until the late 1800s; even then, infection was common, and outcomes were generally poor. 1. Pre-operative Phase - Anesthesia was not used until the mid-1800s. Even - begins when the decision for surgical intervention is so, what was learned from centuries of trial and error, made and ends when the patient is transferred from research, and experimentation led to procedures the unit to the operating room  that are not only commonplace today but highly - 1895: Wilhelm Roentgen takes the first X-rays in effective and safe. Germany - These advances have helped ensure that recovery - 1896: the first successful open heart surgery in times are shorter, hospitalization stays are fewer, Germany to repair a stab wound in the muscle of the outcomes are improved, and complications are right ventricle minimized. - Theodor Billroth: German Billroth (1829-1894) was an early user of antisepsis and was the first to Middle Ages and Renaissance (Before the 19th perform a resection of the esophagus and various Century) surgeries. - Stone age: The oldest known surgery was a leg - Joseph Lister: English surgeon (April 5, amputation performed on a child on the 19TH 1827-February 10, 1912), is considered the father of Century History of Amputations island of Borneo modern surgery for his work developing sterilization around 31,000 year's ago. procedures to prevent deadly postoperative - The first evidence of a surgical procedure is that infections that saved countless lives. Joseph Lister trephining or cutting a small hole in the head pioneered antiseptic surgery; hence called as the probably to allow an evil spirit to scape This father of anitseptic surgery. procedure was practiced as early as 3000 BC and - William Stewart Halsted: (1852 - 1922), an American continued through the middle ages and even into surgeon who pioneered and designed a residency the renaissance. training program for American surgeons. He has - Trephining continued In ancient Egypt as a method been called the most innovative and influential of treating migraines surgeon of USA and also called the father of modern surgery. - Wilhelm Roentgen: takes the first X-rays in Germany on 1895 Surgery - Surgery is the branch of medical practice that treats injuries, diseases, and deformities by the physical removal, repair, or readjustment of organs and tissues, often involving cutting into the body. - It can also serve various purposes, including improving bodily functions, enhancing appearance, or repairing unwanted ruptured areas. - Surgical procedures range from minor, routine operations to complex (major), life-saving interventions. Various Founders of Surgery before 19th Century - -ectomy - means removal (Middle Ages) - -plasty - means repair - Susruta Samhito: Indian national who authored the treatise which details various surgical procedures Indications of Surgery and medical practices. Susruta's expertise included Surgery can be performed for a variety of reasons, each advance techniques like rhinoplasty and plastic aimed at addressing specific health concerns and surgery improving patient outcomes. - Al-Zahrawi: Greatest surgeon of the middle ages, - To Cure an Illness or Disease: This involves wrote a 30 volume encyclopedia of medical practices removing diseased tissue or organs to eliminate the in 1500 pages (Kitab-al Tasrif) which became the underlying cause. reference book among Europeans in 500 years. - To Visualize Internal Structures: During Diagnosis: - John Hunter: The Scotsman (1728-1793) was known This helps in accurately diagnosing conditions by for his scientific, experimental approach to medicine allowing direct examination of internal structures. and surgery. He has been called the father of - To Obtain Tissue for Examination: Biopsies are modern surgery. performed to collect tissue samples for diagnostic - Ambroise Pare: a 16*-century French surgeon, stated evaluation. that to surgery is, "To eliminate that which is - To Prevent Disease or Injury: Prophylactic surgeries superfluous, restore that which has been dislocated, are done to prevent potential health issues. separate that which has been united and repair - To Improve Appearance: Cosmetic surgeries are defects" performed to enhance physical appearance. - To Repair or Remove Traumatized Tissue and Modern Surgery (19th Century) Structures: This includes surgical interventions to - the 19th century was regarded as the birth of address injuries and restore function. modern surgery. It was a century marked by many - To Relieve Symptoms or Pain: Palliative surgeries first discoveries of which many of the surgical aim to alleviate symptoms without necessarily procedures still in use today. curing the disease.  3. Prevent Complications: Implementing strategies to Preoperative Diagnostic Test Requirement avoid potential complications such as infections, - Check informed consent thromboembolism, and respiratory issues. - Check vital signs prior to transportation 4. Alleviate Pain: Managing pain effectively through - Check for skin test - to check if the pt is allergic to an medication and non-pharmacological methods to antibiotic which will used as prophylaxis ensure patient comfort. - Check for allergies 5. Facilitate Recovery Process: Supporting the patient - Check/administer preoperative medications as through the recovery process with appropriate directed interventions and monitoring. - Underwear should be removed (Physical preparation 6. Provide Information: Educating the patient about of the client) the disease process, surgical procedure, prognosis, - Check IVF-D5%LRS and treatment needs to empower them with - NPO - pt must be on NPO 8-12 hours prior to the knowledge and understanding. procedure or usually after dinner the night before (postmidnight) Surgical Site Infection Prevention (SSI) - Preoperative checklist - Carry out bowel preparation, always combined with - Preoperative teaching include post op expectations, administering preoperative oral antibiotics in adult presence of dressings, tubes, oxygen patients undergoing elective colorectal surgery - Action: Surgical Team Complete Blood Count - Supported by Pharmacy/ Procurement - An elevated white blood cell (WBC) count indicates - Consider administering oral or enteral mult-nutrients an inflammatory process, which may be diagnostic enhanced formulas in underweight patients for conditions like appendicitis. - Action: Surgical Team - A decreased WBC count suggests viral processes - Supported by Pharmacy, Procurement, and and may indicate a dysfunctional immune system. Clinical Staff - Low hemoglobin (Hb) suggests anemia or blood - Do not discontinue immunosuppressive loss, impairing tissue oxygenation and reducing the medications Hb available to bind with inhalation anesthetics, - Action: Surgical Team possibly necessitating a crossmatch or blood - Supported by Pharmacy and Clinical Staff transfusion. - Clean and sterilize/ decontaminate surgical - An elevated hematocrit (Hct) may indicate instruments and other equipment dehydration, while decreased Hct suggests fluid - Action: Surgical and Ward Staff overload. Adult: 41% to 50%. - Supported by Procurement, and Clinical Staff - Clean and prepare operating room environment What is a CBC blood test for? - Action: Cleaning Staff - Anemia (low levels of red blood cells or hemoglobin). - Supported by Surgical Team - Erythrocytosis (high concentrations of red blood cells). Staging Surgery - Leukocytosis (high white blood count). Leukopenia Preoperative Phase (low white blood count). - The patient is assisted by an anesthesiologist or - Thrombocytosis (high platelet count). resident to make a specific surgical position, then - Thrombocytopenia (low platelet sterile drapes are used to cover all of the patient's count).150,000-450,000 body except for the head and the surgical site or at - WBC = 4,000 to 10,000 cells per mcL (4.0 to 10 k/mcL) least a wide area surrounding the operating field; the - RBC = (4.0 to 5.4 million cells per mcL drapes are clipped to a pair of poles near the head of - HgB - 11.5 to 15.5 g/di the bed to form an "ether screen", which separates - Hemoglobin = 3 to 18 g/dL in adult men and 12 to 16 the anesthetist/anesthesiologist's working area g/dL. in adult women (unsterile) from the surgical site (sterile). - Platelet Count - 150,000 to 400,000 cells per mcL - Anesthesia is administered to prevent pain from - RBC = 4.6 to 6.2 million cells/uL in adult men and 4.2 incision, tissue manipulation and suturing. Based on to 5.4 million cells/uL in adult women. the procedure, anesthesia may be provided locally or - Prothrombin time = 11 to 13.5 seconds. as general anesthesia - With local and spinal anesthesia, the surgical site is anesthetized, but the patient can remain conscious Nursing Priorities or minimally sedated. 1. Reduce Anxiety and Emotional Trauma: Providing - General anesthesia renders the patient unconscious emotional support and reassurance to alleviate and paralyzed during surgery. preoperative and postoperative anxiety. - The patient is intubated and is placed on a 2. Provide for Physical Safety: Ensuring the patient's mechanical ventilator, and anesthesia is produced by safety through proper positioning, monitoring, and a combination of injected and inhaled agents. adherence to sterile techniques.  Conditions Requiring Surgery A. Obstruction - Blockage of a vital flow of substances to the following parts: - Arteries - Tubes - Ducts - Thrombus - blood clot that stays in place; Embolus - blood clot that travels which causes obstruction D. Tumor - Abnormal growth with no physiologic functioning within the body B. Perforation - Rupture of an organ or artery Types of Surgery according to Purpose 1. Diagnostic - done to determine the cause of the disease and confirm a diagnosis - Example: Biopsy - the removal of a small piece of living tissue from an organ or other part of the body for microscopic examination to confirm a diagnosis - Example: Exploratory Laparotomy - surgical incision into the peritoneal cavity to find the cause of a disorder and examine the interior 2. Palliative - Done to relieve symptoms without curing the disease C. Erosion - Examples: mastectomy, colostomy, debridement of - Wearing or eating away of the surface of a tissue as a necrotic tissue result of continuous physical irritation, infection, 3. Curative ulceration, inflammation, wearing away of tissues - Either to remove diseased parts or organs, repair or replace a particular organ or body part. - Types: - Ablative - performed to remove diseased organs. Examples: gastrectomy, thyroidectomy, appendectomy, escharotomy  - Reconstructive - complete or partial restoration - General anesthesia is required of damaged tissue or organ. Example: - Larger incisions are made herniorrhaphy (removal of an hernia) - The duration is usually longer - Constructive - partial or complete repair of a - More risk congenital defect or abnormality. Example: - Danger of bleeding Cheiloplasty - High risk of infection - Cheiloplasty - a surgery to correct a cleft lip, - Longer recovery period also called Cleft repair. Cleft lip is a birth - Examples: cesarean section, cholecystectomy, kidney defect that occurs when the upper lip doesn't transplant, exploratory laparatomy, Hysterectomy, fuse together properly during development. heart surgeroes, cheiloplasty It can look like a small notch in the edge of the lip or it can extend to the nose and gums. 2. Minor Cleft lip can affect one side of the mouth - Can be done in a minor OR suite or at bedside called a unilateral cleft or both sides of the - Regional or local anesthesia mouth called a bilateral cleft. - Simple incisions are made 4. Cosmetic - Done for afew minutes - Done for aesthetic purposes and on the decision of - Lesser risk the patient. - Minimal blood loss - Example: rhinoplasty, breast augmentation - Risk for infection is low 5. Transplant - Shorter recovery time - Replaces malfunctioning structures - Example: incision and drainage (I&D), biopsy, - Example: hip replacement, kidney or liver transplant cataract surgery, dental restorations, circumcision,. 6. Bypass Breast biopsy, arthroscopy, laparoscopy, burn - Redirection of blood or fluid around a section where excision and debridement procedurres, excision, there may be a partial or complete obstruction tonsillctomy, appendectomy - Example: vascular rerouting 7. Drainage Invasive vs. Non-invasive - Removal of blood, fluid or air by making use of tubes 1. Invasive or catheters inserted on a specific location in the - Requires entry into the body cavilty body - All forms of surgery - Example: incision and drainage (I&D) of an abscess, thoracentesis and paracentesis 2. Non-invasive - Pertains to a diagnostic or therapeutic technqe that Types of Surgery based on Indication does not require the skin to be broken 1. Emergency - Usually refers to an excision that does not penetrate - Must be done immediately to preserve the client’s the structure being excised (i.e. laser abation of the life, body part, or body function cornea) or to a radio-surgical procedure (i.e. - Examples: control of hemprrhage, repair of trauma, irradiation of tumor) perforated ulcer, intestinal obstruction, and tracheostomy Classification accroding to Extent 2. Elective 1. Radical - Pre-planned and can be delayed without negative - More extensive procedures because deeper effects structures are explored - Examples: tonsillectomy, hernia repair, catract - Operation goes beyond areas that are obviously extraction, mammoplasty, face lift, removal of wart involved and cesarean section - Example: modified radical mastectomy (MRM), 3. Urgent radical neck dissection (RND), ExLap - Necessary for the client’s health and are usually performed withn 24-48 hours 2. Simple - Example: appendectomy - Invlces ares that are overly affected, less invasive and 4. Required confined to a smaller area - May or may not be an emergency situation but - Example: I&D, excision procedure needs to be operated on in weeks or in month’s time - Example: lumpectomy, mastectomy Terminologies 5. Optional/ Aesthetic 1. ectomy - For aesthetic or personal purposes - Surgical removal, excision - Example: face lift - Example: appendectomy - removal of the appendix 2. tomy - Cutting into, incision Types of Surgery according to Degree of Risk - Example: tracheotomy, cutting into the trachea to 1. Major create a direct airway - Done in the hospital 3. centesis - Puncture into a cavity to remove a fluid 7. A break or destruction of the integrity of microbial - Example: paracentesis - removal of fluid barriers results in contamination. accumulated ascitic fluids in the abdomen 8. Gowns are considered sterile from table level to 4. ostomy chest level in front including sleeves to 2 in above the - Permanent opening elbows. Draped tables are sterile only at table level - Example: colostomy - permanent opening of the 9. As sterile packages are opened, edges of anything colon that encloses sterile items are considered unsterile. 5. plasty 10. Sterile persons keep within sterile areas and - Surgical repair, reshape circulator/s remain at safe distance from the sterile - Example: rhinoplasty - surgical repair of the nose field. 6. pexy 11. A sterile field is created or set up as close to the time - Surgical fixation of use as possible. - Example: nephropexy - surgical fixation of a movable 12. If in doubt of the sterility of something consider it or floating kidney unsterile. 7. tripsy - Crusing or destroying - Example: lithotripsy - process of crushing a stone in the urinary tract 8. rrhaphy - Surgical repair/ suture - Example: herniorrhaphy - surgical repair of hernia 9. lapar - Abdominal region - Example: laparotomy - cutting into the abdominal region 10. scopy - Visualization using scope - Example: endoscopy - visualization of the thrat down to the intestines using an endescobe The Operating Room Team Review of the Principles of Surgical Asepsis - The operating room (OR) team is obligated to - The patient is the center of the sterile field, which promote the general well-being of a patient inside includes the personnel wearing sterile attire and the the OR suite and throughout the procedure. areas of the patient, operating bed, and furniture - There should be coordination with their tasks to that are covered with sterile drapes (Roesler R, et have a successful operation. It is a must that the al.,2010) team should: - Surgical asepsis is the absence of all microorganisms A. Safeguard the patient's privacy. within any type of invasive procedure. Sterile B. Promote safety measures for the patient. technique is a set of specific practices and Preventing infection from the surgical incision procedures performed to make equipment and that will be done. areas free from all microorganisms and to maintain that sterility throughout the surgical procedure (BC Classification of Operating Room Team Centre for Disease Control, 2010). (according to the function of its members) - Aseptic practice is a standard that should be kept in A. Sterile OR team mind by all healthcare personnel as the carry about - Operating surgeon their tasks particularly in the surgical field. - Assistants to the surgeon and scrub person Principles of Aseptic Technique B. Unsterile OR team 1. Unsterile persons avoid sterile areas - Anesthesiologist or nurse anesthetist 2. Sterile persons avoid leaning or reaching over an - Circulator and other OR members that might be unsterile area. Unsterile persons avoid leaning or needed in operating specialized machine or devices reaching over a sterile field. 3. Persons who are sterile touch only sterile The members of the OR sterile team will do the items/areas. Unsterile persons touch only nonsterile following: items or spaces. - Perform surgical hand washing (arms are included) 4. Sterile areas are continuously kept in view, scrub - Don sterile gowns and gloves person does not turn her/his back from her /his - Enter the sterile field sterile instruments. - Haldles sterile items only 5. Only sterile items are used within a sterile field. - Functions only within a limited area (sterile field) 6. Microorganisms must be kept to an irreducible - Wear mask minimum The unsterile operating room members are not allowed - the elderly due to degeneration of body system to enter the sterile field to prevent contamination. The functioning; and the young which may be attributed responsibilities of the members of this team are the to premature body system following: - Handle supplies and equipment that are considered 2. Nutritional Status / Obese / Malnourished unsterile. 3. Fluid and Electrolyte status - Touches unsterile surfaces only. 4. General Condition in relation to major systems - Keep the sterile team supplied with supplies affected like Respiratory, Cardio, Immunologic, handled aseptically. Hepatic, and Renal status - Give direct patient care. E. Assist the sterile team member's need with strict observation of avoiding B. EXTENT OF THE DISEASE contact to the sterile field. 1. Nature of the disease - Handles other requirements arising during the - pertains to the severity of the clients condition in surgical procedure. relation to the surgical procedure. 2. Site of the disease - dependent on the location of the Three Areas of the OR for Staff and Visitors operative site. A. Unrestricted area 3. Length of time that the patient is ill This area has following characteristics: - The patient is prone to more complications due to - Traffic among staff and visitors is not limited. the length of time of not being treated. - Street clothes are allowed in this area. - This area is separated by doors from the main C. EXTENT OF SURGICAL PROCEDURE hospital corridor. - it may be a major or a minor procedure; it also - This area allows access for communication with pertains to the duration of the surgical procedure department and hospital personnel. which may range from a few minutes to hours. The examples of this area include: - Operating room supervisor's office. D. CALIBER OF THE PROFESSIONAL STAFF - Locker rooms. - Expertise of the surgical team - Surgical scheduling office. Assessment B. Semi-restricted area 1. Current medical diagnosis This area has following characteristics: a. Preexisting medical conditions - obesity, fluid and - Traffic is not allowed to everyone. You must wear electrolyte imbalance, presence of Diabetes mellitus, scrub attire and caps to enter in this area. presence of pulmonary and upper respiratory tract - This area includes the support areas of the surgical infection suite. b. Nutritional status - poor nutrition such as - Examples of this area include: preoperative malnutrition greatly impairs wound - Clean cores and sub-sterile rooms as designated healing. It may increase the risk for hypovolemic by the facility shock and infection. - Corridors outside the operating room c. Current medications - notify health care provider - Storage areas for clean and sterile supplies and anesthesiologist if the patient is taking any of the following medications: C. Restricted area - Antibiotics - may cause interruption in nerve This area has following characteristics: transmission if given with some forms of muscle - You have to wear scrub attire, caps and masks in this relaxant area. - MAO inhibitors - increases hypotensive effects of - Areas where unwrapped sterile supplies are provided anesthesia to carry out procedures are carried out are included - Phenothiazines - increases hypotensive actions in this section. of anesthesia - Examples of this area include: - Thiazide diuretics - may cause respiratory - Operating room and Procedure room depression and fluid and electrolyte imbalance - Sterile preparation area with anesthesia - Scrub area - Steroids impair wound healing - Gowning area - Anticoagulants increase risk for intra-operative - Clean cores and sub-sterile rooms as designated and postonerative bleeding by the facility 2. Diagnostic and laboratory tests results 3. Physical status and physiological response to The Preoperative Phase surgery 4. Spiritual needs, ethnic and cultural background Factors for a Surgical Risk Patient 5. Previous surgery that the client has undergone - it A. PHYSICAL AND MENTAL CONDITION may be possible that upcoming surgery that the 1. Age patient will undergo is related to previous operations. - Extremes of age 6. Psychosocial status - since surgery is a powerful 9. NPO Maintained in NPO stressor, psychological support from the family and to prevent pt from being nauseous since 12 midnight, friends, nurses and the rest of the surgical team is and at risk for aspiration pneumonia last meal (LM) 8 pm Preoperative Checklist 10. Drainage tube Not indicated - This checklist is a comprehensive tool that is utilized insertion not only by the nurse, but also the surgical team where it is used to determine, document, and 11. Bladder and LV - 7am, LB - 7am communicate varied risk factors or vulnerabilities of bowel emptying patients. - It is a risk assessment where potential positive and 12. Spiritual care Done with patient negative outcomes are anticipated in relation to the administration of anesthesia and the outcome of the 13. Oral care/ Done by patient surgical procedure. bathing 14. Nail polish Removed removal 15. Intravenous Hooked D5LRS 1Lx8 fluids hours at 7:15 AM 16. Documentation Completed The Consent - When filling up the consent box, the nurse will place who signed the consent. If the patient himself signed the consent, the nurse places "by patient". - If a relative signs the consent the nurse places the name of the person, relationship to the patient and the age. Special RN Remarks - Example: Consent By patient or Consent by Juan Consideration signature dela Cruz (husband) 30 y/o 1. Consent for Signed by patient if a relative signs the consent, put The Cardio Pulmonary (CP) Clearance operation signed the name of the person, relationship to the pt and the age - A form which contain remarks of cardiologist and 2. Cleared by Dr. pulmonologist regarding patient's risk to Cardiopulmonary Jimenez intra-operative and postoperative complications (CP) clearance remarks: high, mod., or low risk or no contraindication based on their physical assessment, history taking and laboratory and diagnostic tests results of the 3. Procedure Explained by Dr. Yu patient. explanation (surgeon) and Dr. Sy (Anesthesiologist) - Can be: - High risk - Hgb 4. Laboratory and - Hct Hgb - 123 - Moderate riks - cbc diagnostic test - cbcp Platelet - 250 - Low risk - blood type - clotting time Hct -.674 - No contraindication - bleeding time (ctbt) - serum elec Blood type - A+ - ecg, xray, utz 5. Vital signs BP - 110/70, RR-24, Procedure Explanation PR-78, Temp- 36.8 - The person responsible for explaining the surgical procedure and taking of consent from the patient is 6. Preoperative Cefuroxime 750mg the surgeon, while the anesthesiologist explains the medications loading dose given anesthesia that will be utilized. at 6am IV 7. Jewelry, makeup Assisted patient For laboratory and diagnostic test and denture - Pertinent laboratory and diagnostic test that will be removal taken are the following: - Hemoglobin(Hgb) and hematocrit(Hct) 8. Provision of Gowned or by - complete blood count and platelet(CBCP) gown patient - Blood type  - clotting time - bleeding time (CTBT) - Explain what to expect in the operating room - Serum electrolytes and in the recovery room without introducing - and other pertinent blood values needed. fear or worries. - ECG, Xray, Ultrasound (UTZ) B. To reduce the incidence of post-op wound Preoperative Medications infection - Antibiotics are used for prophylaxis or as a loading 1. Skin preparation dose 2. Practice aseptic technique - Antihistamines are used to prevent histaminic 3. Physical set-up reactions - Anticholinergics are used to suppress bodily secretions C. To reduce the risk of intra-operative - For eye operations like Extracapsular cataract contamination of lungs and surgical field by the extraction(ECCE) usually a mydriatic is given to dilate gastrointestinal contents. the pupil. - And other drugs that are prescribed for the patient D. To prepare for anesthesia: prior to the surgery. 1. Provide physical, mental and emotional relaxation Jewelry, make-up and denture removal 2. Reduce sensory input and antagonize adverse ANS - Jewelry is removed due to instances where burns stresses may occur, it may also get lost during the procedure or be left in a cavity. It may also be a source of Additional Assessment and Interventions contamination. Piercings and jewelry can block 1. Explain the purpose important structures in imaging studies. 2. Assess patient's understanding about the surgical - Make up and nail polish is also removed for the intervention reason that it" masks" natural skin color and the nail 3. Instruct patient about: beds which serves as a window for oxygenation, it may also contain flammable ingredients and it may be a medium for infection. A. Bowel preparation - Laxative and enema - to decompress the bowel prior What is a preoperative visit? to surgery and reduce the possibility of bowel - To obtain patient's medical history and physical perforation examination II. "Nothing per orem" (NPO) - nothing per mouth - Perioperative care and pain management to reduce III. NGT anxiety - To determine which lab test or further medical B. Skin preparation consultation are needed - To choose care plan guided by patient's choice and I. Hygiene/bathing - instruct the client to take a bath on risk factors the night before surgery which promotes relaxation and - To educate about anesthesia better sleep. II. Shaving if still ordered and allowed by institution III. Goals of Preoperative Phase Removal of make-ups, cosmetics, nail polish A. To promote rest and comfort IV. The need to wear gown before transport to OR 1. Psychological Preparation - assess anxiety, fear, and patient reactions C. Pain Management - Sources of anxiety: 1. Pain Process- transduction, transmission, perception, - Fear of unknown modulation - Fear of death and disability - Fear of body image destruction D. Splinting techniques - Fear of pain - Fear of separation from a loved one E. Improvement of circulation - Fear of anesthesia I. Ambulation - To promote circulation, prevent Management contractures and post operative adhesions. - Encourage verbalization of thoughts and feelings II. Passive and active range of motion (ROM) activities - Accept patient and his behavior Ill. Turning from side to side (log rolling schedule) to - Keep lines of communication open promote circulation. - Provide spiritual preparation - Communicate a feeling of calmness F. Breathing and coughing - Keep contact unhurried  I. Pursed lip - instruct patient to take a few sips, inhale - Do this 5 times with one leg then repleat with the deeply and slowly, hold breath, then exhale like other leg blowing a candle. II. Diaphragmatic - hands or palms must be at the Surgical Procedures requiring Consent diaphragm level or abdominal area, inhale deeply 1. All surgical procedures while you feel for the rise of the abdominal area, 2. All procedures requiring entrance to body cavitiy hold breath, and exhale slowly while you contract 3. Radiologic procedures particularly those that use the abdominal muscles contrast medium III. Controlled coughing exercises - Cascade Cough - inhale, aoid, and ask patient to Other important considerations: cough seculively until the end of breath instead of - Must be signed by a patient of legal age, with exhaling mental capacity to understand information - Huff cough - same instruction with cascade cough, about the procedure but instead of coughing, you pronounce the word - A witness is required - nurse, health care huff, reduces pain and discomfort of the surgical site provider, or other authorized person; indicates - Quad Cough- hands must be at the level of the that the signature of the person who consents is diaphragm. then instructions same as cascade authentic and signed without coercion cough, but as the patient is coughing hands should - Must be obtained before patient receives evert a quick downward or pressing motion then sedation and is secured without pressure upward to stimulate a more forceful cough - Incentive spirometry Preparation prior to Surgery On the evening prior to surgery Emancipated Minors a. Skin preparation - A person under the age of majority-adulthood —who b. Gastrointestinal preparation is regarded in the eyes of the law as being old c. Preparation for anesthesia enough-usually by virtue of marriage or financial d. Promoting rest and sleep independence-to make adult decisions and exercise On the day of the surgery general control over his or her own life. a. Verification of NPO status - ask for the last meal - Who are to be considered emancipated minors? and what type of meal taken - Married b. Check completeness of skin preparation - Those in military service c. Take vital signs - College student below 18 but living away from d. Instruct on oral and body hygiene home e. Check for and carry out any special orders from - Minor with a child the doctor f. Ask the person to void - measure and document Preoperative Instruction to Prevent the amount Postoperative Complication g. Assess the bladder and bowel time h. Remove unnecessary attachments on the Diaphragmatic Breathing patient - dentures, jewelries, nain polish and - Done in semi-fowler’s position underwear - Refers to flattening of the dome of the diaphragm during inspiration with reluctant enlargement of the Guidelines for the Prevention of upper abdomen as air rushes in Surgical Site Infection - During expiration, the abdominal muscles contract - Alcohol-based antiseptic solutions based on CHG for surgical site skin preparation should be used in Splintin when Coughing patients undergoing surgical procedures. - Lean forward slightly from sitting positionn bed - Adult patients undergoing general anesthesia with - Interlace your finger together and place your hand endotracheal intubation for surgical procedures across the incisional site to act as a splintlike support should receive 80% fraction of inspired oxygen when coughing intraoperatively and, if feasible, in the immediate postoperative period for 2-6 h. Leg Exercises - Lie in semi-fowlers position Conditional Guideline Recommendations - Bend your knee and raise your foot, hold it a fw 1. Immuno-suppresive medications seconds then extend the leg and lower it to bed - Immunosuppressive medication should not be  discontinued prior to surgery for the purpose of antimicrobial properties should not be used for the preventing SSI. purpose of preventing SSI. 2. Nutritional Formula 12. Wound protector - Consider the administration of oral or enteral - Consider the use of wound protector devices in multiple nutrient-enhanced nutritional formulas for clean-contaminated, contaminated and dirty the purpose of preventing SSI in underweight abdominal surgical procedures for the purpose of patients who undergo major surgical operations. reducing the rate of SSI. 3. Bathing before Surgery 13. Saline Wound irrigation - It is good clinical practice for patients to bathe or - There is insufficient evidence to recommend for or shower before surgery. Either a plain soap or an against saline irrigation of incisional wounds for the antiseptic soap could be used for this purpose. purpose of preventing SSl. 4. Intranasal Mupirocin 14. Povidone iodine irrigation - Consider treating patients with known nasal carriage - Consider the use of irrigation of the incisional wound of S. aureus undergoing other types of surgery with with an aqueous povidone iodine solution before perioperative intranasal applications of mupirocin 2% usee for the purnose of preventing SSI, particularly in ointment with or without a combination of CHG clean and clean-contaminated wounds. body wash 15. Antibiotic irrigation X 5. Antibiotics and MBP - Antibiotic incisional wound irrigation before closure - Preoperative oral antibiotics combined with MBP should not be used for the purpose of preventing should be used to reduce the risk of SSI in adult SSI. patients undergoing elective colorectal surgery 16. Negative pressure wound therapy 6. Antimicrobial sealants X - Prophylactic negative pressure wound therapy may - Antimicrobial sealants should X not be used after Neg pressure wound therapy be used on primarily surgical site skin preparation for the purpose of closed surgical incisions in high-risk wounds and, reducing SSI. taking resources into account, for the purpose of preventing SSI. 7. Warming devices - Warming devices should be used in the operating 17. Coated sutures room and during the surgical procedure for patient - Triclosan-coated sutures may be used for the body warming with the purpose of reducing SSl. purpose of reducing the risk of SSI, independent of the type of surgery 8. Blood glucose control - Protocols for intensive perioperative blood glucose 18. Laminar flow ventilation X control should be used for both diabetic and - Laminar airflow ventilation systems should not be non-diabetic adult patients undergoing surgical used to reduce the risk of SSI for patients procedures. undergoing total arthroplasty surgery. 9. Fluid therapy 19. Peri-op antibiotics - Goal-directed fluid therapy should be used - Perioperative surgical antibiotic prophylaxis should intraoperatively for the purpose of reducing SSI. not be continued due to the presence of a wound drain for the purpose of preventing SSI. 10. Drapes and gown - Either sterile disposable non-woven or sterile 20. Wound drains reusable woven drapes and surgical gowns can be - The wound drain should be removed when clinically used during surgical operations for the purpose of indicated. No evidence was found to allow making a preventing SSI. recommendation on the optimal timing of wound drain removal for the purpose of preventing SSI. 11. Adhesive drapes X - Plastic adhesive incise drapes with or without 21. Advanced dressings X - Advanced dressing of any type should not be used over a standard dressing on primarily closed surgical wounds for the purpose of preventing SSI.