NCM 112A Unit 2 - Medical Surgical Nursing PDF

NCM 112A: MEDICAL SURGICAL NURSING RLE - SL │ Prof. Mario 7:30 - 9:00 AM ThF (A504) Transes by: Christine Mae Antonio Unit 2: Intraoperative Phase Intraoperative Phase Tissue Forceps - From the time the patient is rec...

NCM 112A: MEDICAL SURGICAL NURSING RLE - SL │ Prof. Mario 7:30 - 9:00 AM ThF (A504) Transes by: Christine Mae Antonio Unit 2: Intraoperative Phase Intraoperative Phase Tissue Forceps - From the time the patient is received from the operating room until admitted to the PACU Surgical Instruments - Surgical instruments can be generally divided into six classes by function: - Cutting instruments - Grasping or holding instruments - Haemostatic forceps (instruments used to stop blood flow) - Retractors - Clamps and distractors - Accessories and implants Mayo scissors and Kocher forceps Pean Forceps Richardson I. Cutting and Dissecting - Used to incise, dissect, and excise tissues - Cutting instruments have single or double razor sharp edges  or blades, such as a scalpel, scissors, or osteotome. Dissecting instruments may have a cutting edge and come in a variety of designs. Examples include curettes, cone tip dissectors, and biopsy forceps. - The tips of the scissors should be pointing upwards when cutting a suture (the picture below is wrong) - Metzenbaum Scissors - Used to cut delicate tissue KNIFE HANDLES or Scalpel and blades - Deep knife - Handle 7 with blade 15 Used to cut deep, delicate tissue. - Inside knife - Handle 3 with blade 10 (used to cut superficial tissue. II. Clamping and Occluding - Skin knife - Handle 4 with blade 20 Used to cut skin. - Used to compress vessels and other tubular Blade holder #3 charged to surgical blade structures to impede or obstruct the flow of blood number 10-15-27 and other fluids. Blade holder #4 charged to surgical blade no. - These clamps are atraumatic ratcheted instruments 18-20 that are straight, curved, or angled and have a variety of inner jaw patterns. - The thumb and ring finger are inserted into the rings of the scissors with the index and middle finger used to guide the instrument. - The instrument should remain at the tip of the fingers for maximum control. SCISSORS - Straight Mayo Scissors - Used to cut suture and supplies. Also known as: Suture scissors. Mosquito - Used to clamp small blood vessels. Its jaws may be straight or curved. - Curved Mayo Scissors - Used to cut heavy tissue (fascie, muscle, uterus, and breast) Kelly Forceps - Used to clamp larger vessels and tissue Backhaus towel clip - Used to hold towels and drapes in place Right Angle / Mixter / Ninety - Used to clamp hard-to-reach vessels and to place sutures behind or around a vessel. A right angle with a suture attached is called a "tie on a passer" or stick Forester Sponge Stick / Spong or Ovum forceps - Used to grasp sponges Debakey Vascular Clamp Pickups, thumb forceps, tissue forceps - Available in various lengths, with or without teeth, and smooth or serrated jaws - Should be held like a pencil III. Grasping - Designed to grip and manipulate body tissues Used to stabilize tissue that is to be excised, dissected, repaired, or sutured - Tissue forceps are the non-ratcheted style often referred to as pickups or thumbs, have either smooth, serrated or interlocking teeth, and vary in size and shape according to use Bonney Forceps - Used to grasp tissue. Available in short and long - Used for grasping fascia during the closure of sizes. A "Judd-Allis" holds intestinal tissue; a "heavy abdominal surgery or for clusre and sutring of large allis" holds breast tissue orthopedic procedures, such as total knee and total hip replacement surgery Babock - Used to grasp delicate tissues (intestine, fallopian tube, ovary) - Available in short and long sizes  Rongeur (Bone Cutter) Debakey forceps - Used to grasp delicate tissue, particularly in cardiovascular surgery Laryngoscope Single tooth forceps, many teeth forceps (top to bottom) Thumb forceps are used to grasp tough tissue (fascia, breast); either have many teeth or a single tooth. Single tooth forceps are also called "rat tooth forceps." Randall Needle Holders - Can be short, medium & long (top to bottom) Bone Hook Mayo-Hegar needle holders are used to hold needles when suturing. They may also be placed in the sewing category Oropharyngeal tube Senn Retractor  Trocar Oro/ Nasopharyngeal Tube Hammer (Mallet) Endotracheal tube Bone Curette IV. Retracting and Exposing Instruments - Designed to hold back or pull aside wound edges, organs, vessels, nerves, and other tissues to gain access to the operative site - Generally referred to as retractors and are either manual (handheld) or self-retaining (stay open on their own) - Retractors have one or more blades used for holding back tissues without causing trauma and should not be confused with a cutting blade; usually curved or angled and may be blunt or have sharp or dull prongs; vary in size according to the depth of the wound and the area of placement Deaver retractor - Manual type is used to retractdeep abdominal or chest incisions; available in various widths Skin Hook Richardson Retractor - Manual type is used to retract deepabdominal or chest incisions Gelpi Retractor - Self-retaining type is used to retract shallow incisions Army Navy Retractor / USA / US Army - Manual type is used to retract shallow or superficial incisions Balfour with Bladder Blade - Self-retaining type is used to retract wound edges during deep abdominal procedures Goulet - Manual type is used to retract shallow or superficial incisions Baby Bennette Retractor Malleable or Ribbon Retractor - Elevating and retracting bone; common in the minor - Manual type is used to retract deep wounds; may be orthopedic instrument set bent to various shapes V. Suctioning `Frazier Suction Tip Weitlaner Retractor - Commonly used for orthopedic, neuro, and ENT - Self-retaining type is used to retract shallow incisions surgery Suction pole - Used to evacuate blood and debris in deep abdominal surgery and Cesarean sections Blunt - Round point with no cutting edge that is used in soft, friable tissue, liver, intestine, kidney, muscle and uterine cervix VI. Wound Closing Instruments A. Sutures - materials used to sew together tissues or to hold it together in place. 1. Absorbable Sutures Examples: Surgical gut, Collagen sutures, Synthetic absorbable sutures Skin staples Usually used on fast healing tissues since it - Alternative to suturing absorbs quickly such as stomach, colon, bladder - Frequently used for large skin closure and 2. Nonabsorbable Sutures. Examples: Silk, Cotton, anastomosis of hollow organs Nylon Used for tissues that are slow healing skin, - Does not involve stitching - time saving fascia, tendons - Staples are removed using a special extractor B. Surgical needles - Allows the suture to pass through the tissue. Skin Preparation before Surgery 1. Regular Cutting Cutting edge is in the INNER - Skin preparation is the removal of as many bacteria curvature and is used in skin closure, plastic as possible from the patient's skin, through shaving, surgery, subcutaneous tissue mechanical washing and chemical disinfection. 2. Reverse Cutting Cutting edge is in the OUTER - The purpose of topical skin antiseptic preparation is curvature and it is use for retention sutures skin to reduce the number of microorganisms in the closure fibrous tissue and ligaments field of operation - Prevent infection (SSI) - Skin prep aids in preventing SSIs by removing debris Regular Cutting from, and cleansing, the skin, bringing the resident and transient microbes to an irreducible minimum, and hindering the growth of microbes - Skin is our first line of defense against infection, but surgical incisions leave us vulnerable to microorganisms. That's why pre-operative skin preparation is essential to infection prevention efforts. - Surgical site infections (SSls) are a common and costly complication of surgery. - The goal of surgical site preparation is to remove Reverse Suctioning Cutting bacteria from the skin at the surgical site. - The first use of an antiseptic skin agent in surgery is credited to the English surgeon Joseph Lister (1827-1912). Prior to the mid-19th century, limb amputation was associated with an alarming 50% postoperative mortality from sepsis. (infection/contamination) - The most common skin preparation agents used today include products containing iodophors or chlorhexidine gluconate (CHG). Taper Point - There is recent evidence to suggest that - Pointed needle with no cutting edge and it is used combination alcohol-based antiseptic solutions are for soft tissue closure, GI suture, and fascia  more effective than aqueous solutions at reducing - Rubber sheet the risk of SSls. - Gloves - Head and neck surgery presents a unique challenge for surgical site preparation. Procedure - The proximity of the surgical site to the airway and 1. Introduce self and Identify the patient oxygen increases the risk of surgical fire. All 2. Assess previous knowledge/Ask to change to alcohol-based preparations contain an explicit hospital gown warning not to use for head and neck surgery due to 3. Make it clear at the outset/Explain what to do the risk of fire. 4. Prepare needed materials/equipment - In addition, the eyes, nose, and mouth are mucosal 5. Review patient record surfaces, which means that they are more 6. Enter the room and ensure privacy susceptible to the toxicity of certain antiseptic 7. Perform hand hygiene/Position the patient solutions 8. Exposed the area to be prepared by folding back the cotton blanket and gown 2 inches above and below General Principles of Skin Prep: the surgical site - Start at the surgical site and moves outward in a 9. Assess the area for presence of skin lesions, warts, circular motion Do not go back moles, stoma, etc. and if initial skin prep was done in - Include an area that is larger than the surgical site the ward - Abdominal skin prep pattern for laparoscopy where 10. Open surgical skin prep pack and pour antiseptic surgical site is the umbilicus solution aseptically 11. After surgical hand scrubbing, Don sterile gloves Special Considerations for Skin Prep (shaving is no 12. Drape the area by placing the towel above, below longer a practice in the area): and sides of anticipated surgical site aseptically - To determine the area to be shave, know the 13. If to perform abdominal surgery, solution must be operation to be done, the organ involved and its squeezed to the umbilicus to soften debris and location and the proposed type of incision. cleanse the area with the second iodine ball - Practice modesty and provide privacy 14. Wet the sponge with antiseptic agent but squeeze - Ask the patient permission in cutting eyelashes and out excess solution (antiseptic solution must not run hair off the skin of the patient) - Examine the area to be shaved for any signs of 15. Scrub the skin in widening circles, starting at the site irritation or any abnormal conditions. Report this to of incision going to the peripheral areas with your head nurse adequate pressure and friction - Do not cut the patient's skin 16. Repeat the scrub with separate iodine ball for each round Commonly used for skin preps are Chlorhexidine 17. Discard iodine every after use gluconate and povidone-iodine plus alcohol 70% 18. Remove the drapes - Before any surgical procedure, the patient should 19. Cover the area with a sterile drape towel while have two preoperative showers with chlorhexidine waiting for the surgeon gluconate to reduce the number of microorganisms 20. Cover sterile skin prep pack and do after care on the skin and decrease the risk of contaminating 21. Documentation (by the circulating nurse) the surgical incision. - Alcohol-based agents are likely superior to aqueous Patient Positioning agents. Chlorhexidine may decrease SSI rates - Patient positioning involves properly maintaining a compared with povidone-iodine patient's neutral body alignment by preventing - Benefits of using Chlorhexidine gluconate and hyperextension and extreme lateral rotation to povidone-iodine plus alcohol 70% prevent complications of immobility and injury. - Strong affinity for binding to the skin - High antibacterial activity Goals of Patient Positioning - Prolong residual effects on rebound bacterial 1. Provide patient safety and comfort growth 2. Maintaining patient dignity and privacy - proper - Exhibits excellent activity against gram-positive positioning is a way to respect the patient's dignity. and good activity against gram-negative 3. Allows maximum visibility and access. Proper organism and fungi positioning allows ease of surgical access as well as for anesthetic administration during the Materials and Procedure for Skin Prep perioperative phase. Materials: - Sterile irrigating solution Common Surgical Position - Sterile tubing with drip chamber and clamps 1. Supine - IV pole 2. Prone - 3-way Foley Catheter 3. Lateral - Indwelling catheter drainage set-up 4. Lithotomy - Alcohol swabs Bath blanket Other Surgical Positions 5. Jack knife 6. Fowler's 7. Trendelenburg 8. Reverse Trendelenburg 9. Latera; Desired Position for every Procedure - Spinal Anesthesia Delivery - side lying knee chest and knee chest abdomen - Post-spinal Tap - flat or supine no pillows for 6-8 hours - Saddle Block Anesthesia Delivery - sitting or side lying (between L5-S1) - Female Catheterization - dorsal recumbent - Kidney Operation - Jack knife position Prone Position - Rectal, Perineal and Vaginal Operations - lithotomy - In a prone position, the patient lies on the abdomen - Shock position - trendelenburg with their head turned to one side and the hips are - Rectal Examination, Cleansing enema - sim’s not flexed. position, left lateral - Prone position is often used for neurosurgery in - Post cheiloplasty - side lying to promote drainage most neck and spine surgeries. and patent airway - Male catheterization - supine, flat or dorsal recumbent and stretch penis to 90 degrees - All major surgical cases that undergone major anesthesia - flat on bed (supine) no pillows to prevent orthostatic hypotension, till vital signs are stable and no vomiting Positions Lateral or Side-lying Position Supine or Dorsal Recumbent - In this position, the patient lies on one side of the - Majority of surgical procedures are performed in body with the top leg in front of the bottom leg and supine position such as Exploratory Laparotomy, the hip and knee flexed. This flexion promotes good hernia repair, mastectomy, appendectomy and back alignment. administering general anesthesia - The patient is face-up. The patient's arms should be tucked at the patient's sides with a bedsheet, secured with arm guards to sleds. Lithotomy Position - Used during vaginal repair, D&C, rectal surgeries and deliveries - The arms may be flexed and secured across the body or extended and secured on padded arm boards Fowler’s Position - Fowler's position is used for patients who have difficulty breathing because, in this position, gravity pulls the diaphragm downward, allowing greater chest and lung expansion. The head of the bed is angled between 45 and 60 degrees. Reverse Trendelenburg Position - A variation of the supine position in which the patient's head is tilted upward so that their feet are positioned down. Reverse Trendelenburg may be Modified Lateral Position used for stomach, gallbladder, and biliary tract - The patient lies on an unaffected side for kidney surgeries. surgery. The upper leg is extended, the lower leg is flexed at the knee and the hip joints, a pillow is placed between the knee. Jack knife Position Sitting/ Modified Poisition - Also known as Kraske. The patient’s abdomen lies flat on the bed. The bed is scissored so the hip is lifted and the legs and head are low Common Complications of Intraoperative Positioning Trendelenburg Position 1. Respiratory Compromise - A variation of the supine position in which the - Respiratory function can be decreased by patient's head is tilted down so that the patient's mechanical restriction of the rib cage. abdominal organs are moved towards the head, 2. Circulatory Compromise improving surgical access to the pelvic organs. - Positions can cause redistribution and congestion of Shock position. Insertion of CVP line, Cord the blood supply. 3. Nerve and Muscle Trauma - The patient is at greatest risk of nerve and muscle trauma 4. Skin Injury - Skin injury is a common complication. Anesthesia - A state of depressed CNA activity, temporary loss of sensation or awareness - Marked by depression of consciousness or unconsciousness, amnesia (loss of memory),  paralysis (muscle relaxation), and analgesia loss of - Injectable - Injectable anesthetics are responsiveness to stimulation, relief from or given intravenously (IV). prevention of pain) - Inhaled - Inhaled anesthetics are volatile - From the Greek: an, "without," and aisthesis, gases or vapours/ liquids that are "perception" dissolved in oxygen. - Uses medicines known as anesthetics to control pain - How long does it last? and other sensations during surgeries or any - May last for 45 minutes to 3 to 4 hours medical procedures depending upon the anesthetic drugs used. - A chemical agent that is administered prior to a - A thin breathing tube is in the patient’s throat surgical procedure to induce loss of consciousness, inserted into the windpipe to help patient breathe amnesia, paralysis and/or analgesia. and maintain proper breathing during surgery - Drugs used to cause complete or partial loss of - During the entire procedure, the anesthesiologist sensation will keep monitoring patients’ heart rate, breathing and blood pressure to make sure everything is going Who is an anesthesia provider? well and patient is free of pain - Gives anesthetic drugs to induce and maintain - Anesthesia can be General used for major surgery anesthesia and delivers other drugs as needed to - Gas anesthetics are administered by inhalation and support the patient during surgery. are always combined with oxygen 1. Anesthesiologist or Anesthetist - physician who - General anesthesia renders the patient unconscious specializes in giving anesthetic agents; chooses and and incapable of breathing on his or her own; pain determines the doses of one or more drugs to reception is also blocked. achieve the types and degree of anesthesia - These patients must be intubated and mechanically characteristics appropriate for the type of procedure ventilated for the duration of the anesthesia. and the particular patient - Nitrous oxide is the most commonly used gas 2. Nurse Anesthetist - A certified and qualified anesthetic registered nurse practitioner in anesthesia (CRNA), - Ex: GETA - general endotracheal anesthesia has additional education and credentials and who delivers anesthetic agents under the supervision of Inhalation Anesthetics Agent an anesthesiologist or surgeon. Nitrous Oxide - Volatile Agents: Desflurane, Isoflurane, Sevoflurane, Types of Anesthesia Halothane 5. General Anesthesia - Uses: sedation - A reversible loss of consciousness induced by - Adverse effects: Malignant hyperthermia; All inhibiting neuronal impulses in several areas of the inhalation agents increase the risk of postoperative central nervous system (CNS) \ nausea and vomiting - Causes loss of pain sensation, consciousness, and reflexes Can cause central nervous system (CNS) During Administration of anesthetics, adjunct depression medications are also given. These substances are used - Makes patient unconscious and unaware (unable to to achieve further reactions as listed below: remember anything happening during the process) and body functions are slowed downs with loss of Induction Agents: Propofol (Lipophilic), Barbiturates muscle tone and reflexes (Thiopental, Methohexital), Etomidate, Ketamine - A reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the Benzodiazepines central nervous system (CNS) - Diazepam (Valium), Midazolam (Versed) - Causes loss of pain sensation, consciousness, and - Uses: reflexes - Reduces anxiety preoperative - Can cause central nervous system (CNS) depression - Promote amnesia - Makes patient unconscious and unaware (unable to - Produce mild sedation (unconsciousness) with remember anything happening during the process) moderate to very little respiratory depression and body functions are slowed downs with loss of when titrated muscle tone and reflexes - Adverse effects: Can result in cardiac and - Intended Surgical Procedures: respiratory arrest if not administered slowly ar if - For patients undergoing long procedures with doses are administered without waiting for the significant blood loss requiring amnesia, full effect to develop sedation, analgesia, muscle relaxation and reflex control Muscle Relaxants or Neuromuscular Blocking Agents - Used for major surgeries - Depolarizing: Succinylcholine (anectine) - fastest - Knee and hip replacements, heart surgeries or to acting treat cancer - Nondepolarizing - Vecuronium (Norcuron), - How are anesthetics administered? Atracurium - short acting - Anesthetics used during GA are classified as: - Uses:  - Skeletal muscle relaxation for surgery - Airway placement 2. Stage 2: Excitement Stage - In conjunction with IV anesthetic agents - From loss of consciousness to loss of eyelid reflexes (Propofol, Opioids, Benzodiazepines) - Nursing intervention: remain quiet at patient’s side - Adverse effects: - Total flaccid paralysis 3. Stage 3: Surgical Anesthesia - Requires mechanical ventilation because it - From loss of consciousness to loss of eyelid reflexes. blocks contraction of all muscles including the Surgical anesthesia is reached by contrinued diaphragm and respiratory system administration of the anesthetic vapor or gas - The patient is unconscious and lies quietly on the Opioids table - Fentanyl (Sublimaze), Sufentany| (Sufenta), - Nursing interventions Alfentany! (Alfenta), Hydromorphone (Dilaudid), - Remain quiet at patient’s side Meperidine HCI (Demerol), Morphine - Begin skin prep anaesthesiologist indicates stage - Uses: 3 has been reached and patient is in good control - sedation, - Analgesic to relieve preoperative and Surgical Incisions postoperative pain - Surgical Incision is a cut made through the skin to - Adverse Effects: facilitate an operation or procedure. It should be the - Depresses the central nervous system, resulting aim of the surgeon to employ the type of incision in respiratory depression or distress considered to be the most suitable for the - Delays awakening following surgery or a procedure. procedure - Layers of the Abdominal wall - Can result in postoperative constipation and - Skin urinary retention. Can trigger nausea and - Subcutaneous tissue vomiting - Muscles - Bradycardia - Fascia - Seizures - Peritoneum - Hypotension from histamine release - Regions of the Abdomen Isoflurane - Administration: inhalation - Advantages - Rapid induction and recovery - Muscle relaxants are markedly potentiated - Disadvantages - Profound respiratory depressant - Consideration: respirations must be monitored closely and supported when necessary 6. Local Anesthesia - Used for minor Procedures Epidural Anesthesia - An anesthetic agent is injected into the epidural space surrounding the spinal column, usually in the lower lumbar area. - The nerves become anesthetized as they leave the Common Surgical Incisions spinal column, causing the area of the body supplied Pfannenstiel Incision by these nerves to become pain-free. - Use frequently by gynecologist and urologist for - This anesthesia is most commonly associated with access to pelvic organ bladder, prostate and childbirth but is used for many surgical procedures. cesarean section - Between lumbar 4 and 5 - Access to pelvic organs, bladder, prostate and cesarean section Stages of Anesthesia - Incision made in the abdomen and another one in 1. Stage 1: Onset the uterus - From anesthetic administration to loss of consciousness - Nursing intervention: - Close OR door - Keep room quiet - Standby to assist if necessary  Right Lower Paramedian - Provides laterally to the midline incision, allowing access to lateral structures (e,g. kidney, adrenals, spleen) Left Lower Oblique / Inguinal Midline Incision - Use for inguinal herniorrhaphy - Almost all operations in the abdomen and retroperitoneum McBurney’s Incision - Common use: appendectomy, cecostomy Subcostal Incision / Kocker - Right Subcostal Incision Common - Cholecystectomy, Liver, Biliary - Left Sided Subcostal Incision (Splenectomy) Modified blair incision - commonly used for parotic surgery Weber-Ferguson Incision - Used for tumors involving the maxilla Median Sternotomy - Used for open heart surgery; access to anterior mediastinal structures Documentation Tracheotomy (C) and Thyroidectomy (B) Surgical Sutures - Suture is a strand used to ligate the blood vessels and approximate the tissues  scope of practice of the RNFA depends on each state's nurse practice act, - The RNFA practices under the direct supervision of the surgeon. RNFA responsibilities may include handling tissue, providing exposure at the operative field, suturing, and providing hemostasis. - The entire process requires a thorough understanding of anatomy and physiology, tissue handling, and the principles of surgical asepsis. - The competent RNFA needs to be aware of the objectives of the surgery, needs to have the knowledge and ability to anticipate needs and to work as a skilled member of a team, and needs to be able to handle any emergency situation in the operating room (Fortunato, 2000; Rothrock, 1999). 4. Surgeon - The surgeon performs the surgical procedure and heads the surgical team. - He or she is a licensed physician (MD), osteopath (DO), oral surgeon (DDS or DMD), or podiatrist (DPM) who is specially trained and qualified. - Qualifications may include certification by a specialty board, adherence to Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Roles and Responsibilities standards, and adherence to hospital standards and of the Scrub and Circulating Nurse admitting practices and procedures. 1. Scrub Nurse - Activities of the scrub role include performing a surgical hand scrub; setting up the sterile tables; preparing sutures, ligatures, and special equipment (such as a laparoscope); and assisting the surgeon and the surgical assistants during the procedure by anticipating the instruments that will be required, such as sponges, drains, and other equipment (Phippen & Wells, 2000). - As the surgical incision is closed, the scrub person and the circulator count all needles, sponges, and instruments to be sure they are accounted for and not retained as a foreign body in the patient. - Tissue specimens obtained during surgery must also be labeled by the scrub person and sent to the laboratory by the circulator. 2. Circulating Nurse - The main responsibilities include verifying consent, coordinating the team, and ensuring cleanliness, proper temperature, humidity, and lighting; the safe functioning of equipment; and the availability of supplies and materials. - The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel (medical, radiography, and laboratory) as well as implementing fire safety precautions (Phippen & Wells, 2000). - Nursing activities directly relate to preventing complications and achieving optimal patient outcomes. 3. Registered Nurse First Assistant (RNFA) - The registered nurse first assistant (RNFA) is another member of the operating room staff. Although the