Peri-Operative Nursing - NCM 112 PDF

**PERI-OPERATIVE NURSING** **Rhizza Gene Mae P. Ragasa, RN** NCM 112 is divided into 5 concepts, namely 1). Care of Clients with Problems in Oxygenation, These concepts will be taught by different educators. I will be teaching the concepts on the **Care of Clients during Per...

**PERI-OPERATIVE NURSING** **Rhizza Gene Mae P. Ragasa, RN** NCM 112 is divided into 5 concepts, namely 1). Care of Clients with Problems in Oxygenation, These concepts will be taught by different educators. I will be teaching the concepts on the **Care of Clients during Peri-Operative Period (Peri-Operative Nursing)**, **Care of Clients with** **Problems in Oxygenation and Immunologic Responses** and **Care of Clients with Cellular Aberration (Oncology Nursing).** To narrow down your focus, this module is further divided into lessons. **Program Outcomes:** By the end of this module, the student will be able to: 1. Apply knowledge of physical, social, natural, and health sciences, and humanities in the practice of nursing. 2. Provide safe, appropriate and holistic care to individuals, families, population group, and community utilizing nursing process 3. Apply guidelines and principles of evidence-based practice in the delivery of care. 4. Practice nursing in accordance with existing laws, legal, ethical and moral principles and standards. 5. Communicate effectively in speaking, writing and presenting using culturally appropriate languages. 6. Document to include up-to-date client care accurately and comprehensively. 7. Work effectively in collaboration with inter-, intra-, and multi-disciplinary and multi-cultural teams. 8. Practice beginning management and leadership skills in the delivery of client care using a systems approach. 9. Conduct research with experienced researcher 10. Engage in lifelong learning with passion to keep current with national and global developments in general, and nursing and health developments in particular. 11. Demonstrate a responsible citizenship and pride of being a Filipino. 12. Utilize techno-intelligent care systems and processes in health care delivery. 13. Enlist nursing core values in the practice of the profession. **Learning Outcomes:** At the end of the discussion, the students will be able to: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. **INSTRUCTION TO LEARNERS** =========================== Unit 3. Intra-Operative Phase: (three hours) Lesson 1. Surgical Environment and Team Lesson 2. Positioning, Incision, Aseptic Techniques Lesson 3. Anesthesia Unit 4. Post-Operative Phase (two hours) Lesson 1. Post Anesthesia Care Unit (PACU) Lesson 2. Nursing Management in Surgical Unit **Table of Contents** ===================== +-----------------------------------+-----------------------------------+ | | **1** | +===================================+===================================+ | | **3** | +-----------------------------------+-----------------------------------+ | | **3** | +-----------------------------------+-----------------------------------+ | | **4** | +-----------------------------------+-----------------------------------+ | | **4** | +-----------------------------------+-----------------------------------+ | | **5** | +-----------------------------------+-----------------------------------+ | | **6** | +-----------------------------------+-----------------------------------+ | | **14** | | | | | | **23** | +-----------------------------------+-----------------------------------+ | | **29** | | | | | | **32** | | | | | | **39** | +-----------------------------------+-----------------------------------+ | | **45** | | | | | | **52** | +-----------------------------------+-----------------------------------+ | | **58** | +-----------------------------------+-----------------------------------+ -------------------------------------------- **Introduction to Peri-Operative Nursing** -------------------------------------------- 1. Define Perioperative nursing practice 2. Differentiate the three phases of perioperative nursing 3. Enlist major pathologic processes requiring surgery 4. Describe the relationship of nursing process in perioperative nursing. 5. Identify different classification of surgery according to degree of risks, urgency, extent, and purpose. 1. Identify the 6 steps of nursing process. **Assessment** **Diagnosis** **Planning** **Implementation** **Evaluation** **Outcome Identification** (sometimes included as a separate step or combined with planning) 2. The nursing process is **dynamic** and continual 3. Nursing Diagnosis is the process of identifying and classifying data collected in the assessment in a way that provides a focus for planning nursing care 4. Outcome describes the desired or favorable patient condition that can be achieved through nursing interventions 1. providing culturally and ethnically sensitive, age- appropriate care; 2. maintaining a safe environment; 3. educating patients and their families; 4. ensuring continuity and coordination of care through discharge planning and referrals; and (5) communicating information. Assessment ---------- Nursing Diagnosis ----------------- Outcome Identification ---------------------- Planning -------- Implementation -------------- Evaluation ---------- I. II. III. 1. Obstruction / blockage - an impairment of flow of vital body fluids. 2. Perforation - a rupture of an organ, artery or bleb. 3. Erosion -- wearing away of the surfaces of a tissue. It can be caused by irritation, infection, ulceration or inflammation. It can damage the walls of blood vessels resulting in serious bleeding. 4. Tumors - abnormal growth of tissue that forms a mass without physiologic function within the body. 1. According to purpose 2. According to timing or urgency 3. According to magnitude / degree of risk / extent ------------------------------------------------------------------------------------------------------------- 1. Diagnostic -- performed to help the physician determine the cause of the symptom experience of a particular patient. 2. Curative -- performed to remove a diseased, damaged or congenitally malformed body organ or part. 3. Restorative (Reconstructive) -- refers to partial or complete reconstruction of a damaged organ or body part by: - Strengthening a weakened area - Rejoining disconnected or injured area - Correcting deformity 4. Constructive -- performed to repair a congenitally defective structure or to improve function and appearance. 5. Palliative -- performed not to cure a patient from a disease but to alleviate signs and symptoms 6. Cosmetic -- performed primarily to alter or enhance personal appearance 7. Preventive -- used to remove a tissue that does not contain cancerous cells but may develop into a malignant tumor 1. Unplanned a. Emergent b. Imperative / urgent 2. Planned c. Planned required d. Optional +-----------------+-----------------+-----------------+-----------------+ | | A surgical | Without delay. | - Severe | | | procedure that | | bleeding, | | | must be | | bladder or | | | performed | | intestinal | | | immediately to | | obstruction | | | save life | | , | | | | | | | | | | - Fractured | | | | | skull | | | | | | | | | | - Gunshot or | | | | | stab wounds | | | | | | | | | | - Extensive | | | | | burns. | +-----------------+-----------------+-----------------+-----------------+ | | Requires prompt | Within 24-30 | - Closed | | | attention to | hours. | fractures | | | prevent serious | | | | | complications. | | - Infected | | | | | wound | | | | | requiring | | | | | exploration | | | | | /irrigation. | +-----------------+-----------------+-----------------+-----------------+ | | Surgery is | Scheduled | - Prostatic | | | necessary but | within weeks or | hyperplasia | | | not immediately | months. | | | | life-threatenin | | - Thyroid | | | g; | | disorders | | | can be planned. | | | | | | | - Cataracts. | +-----------------+-----------------+-----------------+-----------------+ | | Surgery | Based on | - Cosmetic | | | performed at | personal | surgery | | | the patient's | preference. | | | | discretion and | | | | | not necessary | | | | | for survival or | | - liposuction | | | function. | | | | | | | - rhinoplasty | +-----------------+-----------------+-----------------+-----------------+ Classification of Surgery according to Magnitude / Degree of Risk (Ignatavicius, et., al., 2016). 1. Minor surgery - a surgical procedure that presents little risk to life - often done with local anesthesia - Examples: Incision and Drainage (I and D), Implantation of venous access device, muscle biopsy, suturing. 2. Major Surgery - a surgical procedure that carries greater risks - usually longer and more extensive than minor surgery - It could be complicated or may lead to large losses of blood, vital organs maybe involved, postoperative complications maybe likely. - Examples: Caesarean Section, Craniotomy, Lymph node dissection, mitral valve replacement - Inpatient refers to a patient who is admitted to a hospital. The patient may be admitted the day before or, more often, the day of surgery (often termed same-day admission \[SDA\]), or the patient may already be an inpatient when surgery is needed. - Outpatient and ambulatory refer to a patient who goes to the surgical area the day of the surgery and returns home on the same day (i.e., same-day surgery \[SDS\]). Hospital-based ambulatory surgical centers, freestanding surgical centers, physicians\' offices, and ambulatory care centers are common. ------------------------------------------------------------------------ --------------------------------------------------------------------- Patients recover at home, reducing hospital time. Limited home monitoring can miss early complications. Outpatient surgeries are less expensive, easing financial strain. Home recovery adds burden on patients and families for care. Less hospital time lowers infection risk. Emergency response at home is slower than in hospitals. Home recovery offers comfort and may speed up healing Follow-up visits can be inconvenient without easy transport. Outpatient settings optimize hospital resources and reduce congestion. Pain control at home is more difficult without medical supervision. ------------------------------------------------------------------------ --------------------------------------------------------------------- +-----------------+-----------------+-----------------+-----------------+ | | Surgical | | Creation of an | | | puncture to | | opening or | | | remove fluid. | | stoma. (e.g., | | | (e.g., | | colostomy). | | | thoracentesis). | | | +=================+=================+=================+=================+ | | Surgical | | Incision or | | | binding or | | cutting into. | | | fusion. (e.g., | | | | | arthrodesis). | | (e.g., | | | | | tracheotomy). | +-----------------+-----------------+-----------------+-----------------+ | | Surgical | | Fixation of an | | | removal of a | | organ. (e.g., | | | body part. | | nephropexy). | | | | | | | | (e.g., | | | | | appendectomy). | | | +-----------------+-----------------+-----------------+-----------------+ | | Destruction or | | Surgical repair | | | breakdown. | | or | | | | | reconstruction. | | | (e.g., | | (e.g., | | | adhesiolysis). | | rhinoplasty). | +-----------------+-----------------+-----------------+-----------------+ | | Suturing or | | Examination | | | stitching. | | with a scope. | | | | | | | | (e.g., | | (e.g., | | | herniorrhaphy). | | endoscopy). | +-----------------+-----------------+-----------------+-----------------+ | | Washing out or | | Crushing or | | | irrigation. | | breaking down. | | | | | | | | (e.g., | | (e.g., | | | cystolapaxy). | | lithotripsy). | +-----------------+-----------------+-----------------+-----------------+ Adhesion [: Tissue sticking together, usually post-surgery or inflammation.] Amputation : [Surgical removal of a limb or part of it. ] Anastomosis [: Connection between two body structures, like intestines or vessels.] Anoplasty [: Repair or reconstruction of the anus.] Appendectomy [: Removal of the appendix.] Biopsy [: Removal of tissue for diagnostic examination.] Dehiscence [: Surgical wound reopening or separation.] Dissect [: Cutting and separating tissue during surgery.] Enucleation [: Complete removal of an organ or tumor.] Evisceration [: Removal or protrusion of organs.] Excision [: Removal of diseased tissue or organ.] Incision and Drainage [: Cutting to drain an abscess or fluid.] Shunt [ : Tube to redirect fluid flow.] Resection : [Removal of part or all of an organ or tissue.] End of Unit 1 ------------- ------------------------- **Pre-Operative Phase** ------------------------- +-----------------------------------------------------------------------+ | **Introduction to Peri-Operative** | | | | **Lesson 1. Pre-Operative Assessment and Preparation** | +-----------------------------------------------------------------------+ 1. Enumerate goals of pre-operative assessment 2. Identify risk factors for surgical complications 3. Describe routine pre-operative screening test 1. Document the results of all preoperative laboratory and diagnostic tests in the **patient\'s medical record** and communicate this information to appropriate health care providers. 2. True or False. Laboratory tests are prescribed before surgery that serves as a baseline data. [True] 3. **Pre-operative assessment** is used to determine the patient\'s level of anxiety, coping ability, and support systems. Pre -- Operative Assessment --------------------------- - Determine the patient's psychologic status in order to reinforce the use of coping strategies during the surgical experience. - Determine physiologic factors directly or indirectly related to the surgical procedure that may contribute to operative risk factors. - Establish baseline data for comparison in the intraoperative and postoperative period. - Participate in the identification and documentation of the surgical site and/or side (of body) on which the surgical procedure will be performed. - Identify prescription drugs, over-the-counter medications, and herbal supplements taken by the patient that may result in drug interactions affecting the surgical outcome. - Document the results of all preoperative laboratory and diagnostic tests in the patient's record, and communicate this information to appropriate health care providers. - Identify cultural and ethnic factors that may affect the surgical experience. - Determine if the patient has received adequate information from the surgeon to make an informed decision to have surgery and that the consent form is signed and witnessed.  Assignment 1. Identify how the following factors increase surgical complications. 1. Extremes of Age 2. Medications: Antihypertensive Drugs 3. Medications: Anticoagulants 4. Decreased Immunity 5. Diabetes 6. Cardiopulmonary Disease 7. Anemia 8. Dehydration 9. Malnutrition (Obesity) 10. Tobacco and alcohol Use 11. Bleeding disorders 12. Hepatic Diseases Physical Assessment in the Pre-Operative Phase ---------------------------------------------- Laboratory / Diagnostic Assessment in the Pre-Operative Phase ------------------------------------------------------------- ---------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Determines hemoglobin and hematocrit levels, platelet count, and the presence of anemia or infection. This information helps assess whether the patient is anemic, has an infection, or has enough platelets to form clots during and after surgery. Identifies the patient\'s blood type to ensure that, if necessary, a compatible blood transfusion is available during or after the surgery to address excessive blood loss. Assesses levels of important electrolytes such as sodium, potassium, and chloride. Electrolyte imbalances may indicate dehydration, renal function abnormalities, or cardiovascular risks, which are critical to correct before surgery to prevent complications. Assesses coagulation status, ensuring that the patient's blood clotting function is normal. Abnormalities in clotting increase the risk of excessive bleeding during and after surgery. Monitors glucose levels to determine if the patient is hyperglycemic or hypoglycemic, which is crucial for patients with diabetes. Uncontrolled glucose levels can increase the risk of infections, delayed healing, and other complications during and after surgery. BUN Creatinine Evaluates kidney function. It is important to know how well the kidneys are working before surgery, as impaired renal function may affect the patient\'s ability to eliminate anesthetics and medications, requiring adjustments to anesthesia or medications. Assesses liver function to determine the ability of the liver to metabolize medications and anesthesia. Liver dysfunction can increase the risk of complications related to anesthetic clearance and coagulation. Determines nutritional status and the capacity to heal after surgery. Low serum albumin may indicate poor nutritional status, which could impair healing and increase the risk of infections and complications post-surgery. Provides a view of the heart, lungs, and bones. Identifies underlying cardiopulmonary issues such as infections, heart failure, or chronic lung conditions, which could affect anesthesia management and overall risk during surgery. Determines the electrical activity of the heart, identifying any existing arrhythmias, ischemia, or cardiac abnormalities. Abnormal results may indicate increased cardiovascular risk during surgery, prompting additional precautions or further cardiac evaluation. Checks for the presence of infections, proteins, glucose, or other abnormalities in the urine. Urinary tract infections can pose a risk during surgery, while elevated glucose or protein levels might indicate underlying health issues like diabetes or renal dysfunction that could complicate the procedure. Identifies if the patient is pregnant. This is crucial to ensure the safety of both the mother and the fetus, as anesthesia and surgical interventions pose significant risks during pregnancy. Proper planning and modified care are necessary if a pregnancy is confirmed. Evaluates oxygenation, carbon dioxide levels, and blood pH, providing insight into respiratory and metabolic status. Abnormal ABG results may indicate respiratory insufficiency, metabolic acidosis or alkalosis, and may require optimization to improve oxygenation and ventilation during surgery. ---------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Psychosocial Assessment ----------------------- - Pain: Chemical substances are released and nerve endings are stimulated which cause pain, ischemia and distension. - Death: psychologic threat of death may be frightening - Anesthesia: afraid of what they may disclose, awakening during surgery or not awakening after. Allay their fears, anything said is confidential, but rarely say anything (too sleepy). - Disfigurement and Altered Sexuality: If self-perception is affected, patient will experience a grief reaction. Separation and change in roles: feel support systems have lessened. 1. [Increased nervousness or restlessness] 2. [Palpitations or elevated heart rate] 3. [Excessive sweating] 4. [Difficulty focusing or inability to concentrate] 5. [Fear or verbal expressions of concern about the surgery] 6. [Disrupted sleep patterns or insomnia​] - Assess client's fears, anxieties, support systems and patterns of coping ✓ Establish rapport with the patient to decrease feelings of depersonalization. - Use of Humor (sometimes) - Explain the preoperative and postoperative nursing care to decrease fear of the unknown. - Explain that anxiety is a normal reaction. - Enlist patient's active participation in learning and practicing postoperative activities to give control over the environment. - When teaching include family and significant other to promote support. Spiritual and Cultural Beliefs Assessment ----------------------------------------- 1. Showing respect for a patient's cultural values and beliefs facilitates rapport and trust. 2. Identifying the ethnic group to which the patient relates and the customs and beliefs the patient holds about illness and health care providers. 3. Listening carefully to the patient is perhaps the most valuable skill at the nurse's disposal, especially when obtaining the history. 4. An unhurried, understanding, and caring nurse promotes confidence on the part of the patient. - Anticholinergics: Decreases secretion of saliva and gastric juices - Antiulcer (Histamine H2 Antagonists): Prevent aspiration pneumonitis o(Ranitidine (Zantac), Cimetidine (Tagamet), Famotidine (Pepcid) ) - Antiemetics: To increase gastric emptying and decrease Nausea and Vomiting (Metoclopramide (Reglan)) 1. Perform a thorough assessment of the client and necessary laboratory request are done. 2. Dietary restrictions: Regardless of the type of surgery and anesthesia planned, the patient is restricted to NPO status before surgery. NPO means no eating, drinking (including water), or smoking (nicotine stimulates gastric secretions). The exact amount of time a patient must be NPO before surgery is controversial. NPO status ensures that the stomach contains a limited volume of gastric secretions, which decreases the risk for aspiration (Ignatavicius, et., al., 2016). 3. Skin Preparation: decreases bacteria to a minimum. The skin is the body\'s first line of defense against infection. A break in this barrier increases the risk for infection, especially for older patients. Skin preparation before surgery is the first step to reduce the risk for surgical site infection. (Ignatavicius, et., al., 2016). 4. Bowel & Bladder Preparations: Bowel or intestinal preparations are performed to prevent injury to the colon and to reduce the number of intestinal bacteria. Bowel evacuation is needed when a patient is having major abdominal, pelvic, perineal, or perianal surgery. The surgeon\'s preference and the type of surgical procedure determine the type of bowel preparation (Ignatavicius, et., al., 2016). Patient and Family teaching on Postoperative Procedures and Exercises --------------------------------------------------------------------- 1. 2. 3. 5. 6. Procedures and Exercises to Prevent Respiratory Complication ------------------------------------------------------------ 1. [Assume a semi-Fowler or upright position.] 2. [Use diaphragmatic breathing.] 3. [Place the mouthpiece of the spirometer firmly in the mouth, breathe in slowly, and hold the breath for about 3 seconds.] 4. [Exhale slowly through mouthpiece] 5. [Cough during and after each session, splinting the incision when coughing postoperatively.] 6. [Perform the procedure 10 times in succession, repeating hourly during waking hours] **COUGHING** ------------ 1. Lean slightly forward from a sitting position in bed 2. [Interlace your fingers and place your hands across the incision site to act as a splint.] 3. [Breathe with the diaphragm.] 4. [With your mouth slightly open, breathe in fully.] 5. [\"Hack\" out sharply for 3 short breaths.] 6. [Keep your mouth open, take a quick deep breath, and immediately give a strong cough once or twice to clear secretions from the chest​] Splinting --------- 1. [Lean slightly forward while in a sitting position on the bed.] 2. [Interlace your fingers and place your hands over the incision site. ] 3. [Take a deep breath in using diaphragmatic breathing. ] 4. [Hack out sharply for three short breaths, followed by a quick deep breath and a strong cough once or twice.] Procedures and Exercises to Prevent Cardiovascular Complications ---------------------------------------------------------------- Turning Exercise ---------------- -- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- This exercise helps enhance venous return from the legs, preventing venous stasis and reducing the risk of blood clots (deep vein thrombosis). Point toes down, then flex up towards face. Repeat 10-15 times per leg. This exercise strengthens the quadriceps muscles, which support circulation and mobility and helps prevent blood clot formation in the thighs. Tighten thigh muscles by pushing knee into bed. Hold for 5 seconds, relax. Repeat 10-15 times per leg. This exercise promotes circulation in the legs and prevents blood pooling and venous stasis. Lift leg slightly, rotate foot in large circles clockwise, then counterclockwise. 10 reps each direction per foot. This movement helps prevent stiffness and promotes venous return from the lower extremities, reducing the risk of blood clots. Bend knee by sliding foot towards buttocks, then straighten leg. Repeat 10-15 times per leg. The preoperative checklist ensures that the patient is well-prepared for surgery, and it includes activities that reduce the risk of postoperative cardiovascular complications. Verify patient ID, allergies, fasting, consent, and pre-op exercises are completed. This exercise helps enhance venous return from the legs, preventing venous stasis and reducing the risk of blood clots (deep vein thrombosis). Point toes down, then flex up towards face. Repeat 10-15 times per leg. -- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- Transporting the Patient to the Presurgical Area ------------------------------------------------ End of Lesson 1 --------------- +-----------------------------------------------------------------------+ | **Introduction to Pre -- Operative Phase** | | | | **Lesson 2. Ethico-Legal Aspect of Surgery** | +-----------------------------------------------------------------------+ 1. Identify ethico-legal dilemmas in perioperative nursing practice 2. Outline a valid informed consent 3. Identify circumstances that requires informed consent 1. [Informed Consent] the patient's autonomous decision about whether to undergo a surgical procedure 2. True or False. Emancipated minors are legally allowed to give their own consent. [True] 3. Black ink pen should be used in signing the operative permit. [True] - The patient\'s name (and legal guardian, if applicable) - Name of the facility in which the procedure is being performed - Specific name of the surgical procedure (or when multiple procedures are being done, the names of those procedures) in terms the patient understands - Site/side of the planned procedure - Name of the practitioner(s) performing the procedure or important aspects of it - Risks of the procedure - Alternative procedures, treatments, or therapies - Signature of the patient (or legal guardian, if applicable) - Date and time consent is obtained - Statement that the procedure was explained to the patient (or legal guardian or both if applicable) - Name and signature of the person who explained the procedure, usually the primary surgeon or physician performing the procedure - Signature of person witnessing the consent 1. There is an immediate threat of life 2. Experts confirm that there is an emergent need for surgery. 3. Client is unable to provide consent and, 4. In some situations that a legally authorized person cannot be located or reached in any means. **What if the patient is blind?**  **What if the patient has mental problems?**  Maintaining the Preoperative Record ----------------------------------- 1. Ensure that the client is wearing an ID bracelet. 2. Assess for allergies 3. Review the preoperative checklist to be sure that each item is addressed before the client is transported to surgery. 4. Ensure that informed consent forms were signed for the operative procedure, for any blood transfusion, for disposal of limb, or for surgical sterilization procedures. 5. Ensure that the history and Physical Exam were completed and documented in the client's record 6. Ensure that consultations prescribed were completed and documented in the client's record. 7. Ensure the prescribed laboratory results are documented in the client's record 8. Ensure that ECG and Chest radiograph reports are documented in the client's record. 9. Ensure that a blood type and screening test and cross match is performed and documented in the client's record. 10. Remove jewelry, makeup, dentures, hairpins, nail polish, glasses and prosthesis. 11. Document that valuables were given to the client's family members or locked in the hospital safe. 12.Document the last time the client ate or drank 13.Document that the client has voided prior to surgery 14. Document that the prescribed pre-op meds were given. 15. Monitor and document client's vital signs 16. Preoperative medications are given to allay anxiety, to decrease pharyngeal secretions, to reduce side effects of anesthetic agents and to induce amnesia. 17. Prepare to administer preoperative mediations as prescribed, or on call to the OR immediately before surgery 18. Inform the client that he/she will drowsy shortly after the medications are administered. 19. Turn off bright lights to avoid glare. 20. After administering pre-op meds, keep the client in bed with the side rails up. The Association of peri-Operative Registered Nurses (AORN) ---------------------------------------------------------- +-----------------------------------------------------------------------+ | **Intra-Operative Phase** | | | | **Lesson 1. The Surgical Environment and Team** | +-----------------------------------------------------------------------+ 1. Differentiate types of surgical environment 2. Identify members of the surgical team 3. Outline the roles and responsibilities of the surgical team 1. The surgical suite should be designed to minimize the spread of infectious organisms. [True] 2. Members of the surgical team are all qualified to be in the operating room. [True] 3. Scrub nurses do not perform sterile work in the operative site. [False] 1. Unrestricted Area - provides an entrance and exit from the surgical suite for personnel, equipment and patient. Characterize further about this area: [ ] 2. Semi-restricted Area - provides access to the procedure rooms and peripheral support areas within the surgical suite. Characterize further about this area: [It includes corridors leading to the operating rooms and storage areas for sterile supplies.] 3. Restricted Area - includes the procedure room where surgery is performed and adjacent substerile areas where the scrub sinks and autoclaves are located. Characterize further about this area: [This area includes the actual procedure or operating rooms where surgeries are performed.] [Scrub sinks and autoclaves are also located in the adjacent substerile areas.] [Personnel must wear complete scrub attire, including masks, to maintain a sterile environment.] [The restricted area is the most sterile part of the surgical suite and must maintain a high standard of asepsis.] [Surgical procedures are performed here, requiring all personnel and equipment to adhere strictly to sterile protocols.] Surgeon ------- 1. [Assess the patient before surgery.] 2. [Select and administer anesthesia.] 3. [Intubate the patient if necessary.] 4. [Manage any technical problems related to the administration of anesthetic agents.] 5. [Supervise the patient's condition throughout the surgical procedure​The Scrub Role ] 1. [Setting up sterile equipment, tables, and sterile fields.] 2. [Preparing sutures, ligatures, and special equipment.] 3. [Assisting the surgeon and the surgical assistants.] 4. [Counting all needles, sponges, and instruments along with the circulating nurse.] 5. [Maintaining sterility throughout the procedure.] **CIRCULATING NURSE** --------------------- 1. [Manage the operating room (OR).] 2. [Protect the patient's safety and health by monitoring the activities of the surgical team.] 3. [Check the OR conditions.] 4. [Verify consent and ensure that the surgical procedure and site verification is conducted.] 5. [Monitor aseptic practices and coordinate personnel movement​ ] Safety in the Operating Room ---------------------------- End of Lesson 1 =============== +-----------------------------------------------------------------------+ | **Intra-Operative Phase** | | | | **Lesson 2. Positioning, Incisions and Aseptic Techniques** | +-----------------------------------------------------------------------+ 1. Identify common positioning techniques in preparation for surgery 2. Differentiate common surgical incisions 3. Outline basic principles of aseptic techniques employed in the OR 1. True or False. A surgical hand scrub should be performed by healthcare personnel before donning sterile gloves for surgical or other invasive procedures. [True] 2. True or False. In positioning the patient for surgery, nerves must be protected from undue pressure. [True] 3. Surgical aseptic practices are based on the premise that most infections are caused by [ contamination] to the surgical patient\'s body. - The client should be as comfortable as possible. - The operative field must be exposed. - The position should not obstruct vascular supply. - Respiration should not be impeded by pressure of arms on the chest or by a gown that constricts the neck and chest. - Nerves must be protected by undue pressure. - Precautions for safety must be observed. - The client needs gentle restraints in case of excitement. Position ------------------------ -- --------------------------------------------------------------------------------------------------------------------- -- **Surgery**: Abdominal surgeries, cardiovascular surgery, and any surgeries involving the chest or neck.  **Surgery**: Pelvic surgeries, lower abdominal surgeries, such as urological or gynecological procedures. **Surgery**: Upper abdominal surgeries, gallbladder surgery, head and neck surgery. **Surgery**: Shoulder surgery, head and neck surgery, breast surgery, neurological surgery, facial surgery.  **Surgery**: Gynecologic surgery, urologic surgery, colorectal surgery (e.g., vaginal hysterectomy, prostatectomy). **Surgery:** Rectal surgeries, hemorrhoidectomy, pilonidal sinus procedures. +-----------------------------------+-----------------------------------+ |  | S**urgery**: Lung surgery, | | | esophageal surgery, thoracic | | | aorta surgery, pleural surgeries. | +===================================+===================================+ | | **Surgery**: Hip fracture repair, | | | femoral nailing, certain types of | | | pelvic and lower extremity | | | fractures. | +-----------------------------------+-----------------------------------+ | +--------------+--------------+ | **Surgery**: Kidney surgery, | | | ---------- | | | thoracic surgery, hip | | | ------------ | | | replacement. | | | ------ | | | | | | Lateral or | | | | | | kidney posi | | | | | | tion | | | | | | ---------- | | | | | | ------------ | | | | | | ------ | | | | | +--------------+--------------+ | | +-----------------------------------+-----------------------------------+ |  | **Surgery**: Rectal surgery, | | | lower spine surgeries (e.g., | | | laminectomy). | +-----------------------------------+-----------------------------------+ Surgical Incision ----------------- ---------------------------------- ------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------ **Type of Incision** **Definition** **Surgery** **Butterfly** A V-shaped incision that resembles a butterfly. Often used for facial surgeries to improve cosmetic outcomes. Facial surgery, skin grafts **Limbal** An incision made at the limbus (the junction between the cornea and sclera) in the eye. Cataract surgery, glaucoma surgery **Halstead / Elliptical** An elliptical incision commonly used to excise tissue while minimizing tension. Excision of skin lesions or tumors **Subcostal / Kocher Incisions** An oblique incision below the costal margin, generally used for access to the upper abdomen, particularly on the right side. Cholecystectomy, liver surgery **Para-median** A vertical incision made just to the side of the midline of the abdomen. Exploratory laparotomy, bowel surgery **Transverse** A horizontal incision across the abdomen, generally used in pediatric surgery or lower abdominal surgeries. Cesarean section, colostomy **Rectus** An incision along the rectus muscle, used for better access in abdominal surgeries. General abdominal surgery, hernia repair **McBurney / Gridiron Incision** An oblique incision made at the right lower quadrant, commonly used for appendectomies. Appendectomy **Pfannenstiel** A low transverse incision made above the pubic symphysis, commonly used for obstetric and gynecological procedures. Cesarean section, hysterectomy **Lumbotomy** An incision made in the flank area, used to access the retroperitoneal space. Kidney surgery, adrenal gland surgery ---------------------------------- ------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------ ---------------------------- ----------------------------------------------------------------------------------- --------------------------------------------------------------------------------------- **Factor** **Medical Asepsis** **Surgical Asepsis** **Goal of action** Reduce the number of pathogens and prevent the spread of infection. Eliminate all microorganisms to prevent contamination during surgical procedures. **Reservoir of infection** Non-sterile environment, common areas where people and equipment move freely. Sterile environment, operating room with controlled conditions. **Equipment and supplies** Clean and disinfected, but not necessarily sterile. All equipment and supplies must be sterile. **Hand hygiene** Routine hand washing with soap and water or use of alcohol-based hand sanitizers. Surgical scrubbing for several minutes to ensure all bacteria are eliminated. **PPE** Gloves, gown, and mask as necessary to prevent spread of infection. Sterile gloves, gown, mask, and sometimes additional coverings for maximal sterility. **Field** Clean, non-sterile working area. Sterile field is maintained, where only sterile equipment is allowed. ---------------------------- ----------------------------------------------------------------------------------- --------------------------------------------------------------------------------------- Basic Guidelines for Maintaining Surgical Asepsis ------------------------------------------------- 1. Only sterile items are used within the sterile field. 2. Sterile persons are gowned and gloved; gowns are sterile from table to chest level in front including sleeves to 2 inches above the elbow. 3. Tables are sterile only at table level 4. Sterile persons touch only sterile items or areas. Unsterile persons touch only unsterile items or areas 5. Unsterile persons avoid reaching over the sterile field. Sterile persons avoid leaning over unsterile areas 6. Edges of anything that encloses sterile content are considered unsterile 7. Unsterile persons avoid sterile areas 8. The sterile field is created as close as possible to the time of use 9. Sterile areas are continuously kept in view 10. Sterile persons keep well within the sterile area 11. Sterile persons keep contact with sterile area to a minimum 12. Microorganisms must be kept to an irreducible minimum 13. Destruction of the integrity of microbial barriers results in contamination Surgical Attire ---------------  1. Remove jewelry from hands and wrists 2. Apply the amount of alcohol-based hand rub recommended by the manufacturer to cover all surfaces of the hand 3. Rub hands together covering all surfaces of the hands and fingers until dry. - - - - - - End of Lesson 2 =============== +-----------------------------------------------------------------------+ | **Intra-Operative Phase** | | | | **Lesson 3. Anesthesia** | +-----------------------------------------------------------------------+ 1. List the effects of anesthesia 2. Outline the stages of anesthesia 3. Enumerate anesthetic drugs 4. Develop a drug study utilizing the nursing process Pre test -------- 1. True or False. Balanced Anesthesia is a term applied to anesthesia produced by the combination of two or more drugs for induction [True] 2. [Regional] anesthesia temporarily interrupts the transmission of nerve impulses to and from a specific area or region. 3. Optimal anesthesia produces [ ] **hypnosis** (sleep); **analgesia** [ ] (freedom from pain); [ ] **amnesia** (lack of recall or awareness); 4. True or False. Patient\'s mental and psychologic status may affect the selection of anesthetic agent. [True] 1. Patient\'s wishes and understanding of the types of anesthesia that could be used 2. Patient\'s physiologic status 3. Presence and severity of coexisting conditions 4. Patient\'s mental and psychologic status 5. Postoperative recovery from various kinds of anesthesia 6. Options for management of postoperative pain 7. Type and duration of surgical procedure 8. Patient\'s position during surgery 9. Surgeon\'s particular requirements ----------- -------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Stage** **Name** **Description / Signs and Symptoms** **Nursing Interventions** I Induction or Stage of Analgesia Patient progresses from awake to drowsy and loses pain sensation; responses to stimuli are slower. Mild respiratory depression. Monitor vital signs, assist with induction, reassure the patient, and provide emotional support. Ensure equipment is functioning properly. II Stage of Delirium/Excitement Patient may have irregular breathing, involuntary movement, and increased muscle tone. Reflexes are active, and vomiting or struggling can occur. Increased risk of laryngospasm. Protect patient from self-injury, maintain a calm environment, secure airway, suction secretions if needed, and prepare to assist anesthetist if necessary. III Stage of Surgical Anesthesia Regular breathing resumes, muscle relaxation occurs, and eye movements stop. Patient is ready for surgery with adequate anesthesia depth. Loss of gag and cough reflexes. Monitor depth of anesthesia and vital signs continuously. Assist in patient positioning, maintain sterility, and ensure surgical site access. IV Stage of Danger/Medullary Depression Severe respiratory and cardiovascular depression; pupils dilate, and pulse becomes weak and irregular. Can be fatal if not addressed. Immediate intervention is necessary. Immediate support of vital functions, including resuscitation as needed. Ensure emergency drugs and equipment are ready for use. Monitor closely for signs of recovery. ----------- -------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1. Preinduction begins with the administration of premeds and ends when anesthesia induction begins. 2. Induction begins with administration of anesthetic agents and continues until the patient loses consciousness and is ready for positioning or surgical prepping (surgical prep), surgical manipulation, or incision. 3. Maintenance continues from this point until near completion of the procedure; the anesthesia provider achieves this phase either with inhalation agents, with IV medications given in titrated doses, or by continuous infusion. 4. Emergence as surgery is completed (patient starts to wake up), restoration of gag reflex, extubation. a. Inhalation: Inhaled anesthetic agents include volatile liquid agents and gases. Volatile liquid anesthetic agents produce anesthesia when their vapors are inhaled. Write down some anesthetic agents delivered via inhalation by completing the table below. -- --------------- Nitrous Oxide Xenon -- --------------- b. Intravenous: General anesthesia can also be produced by the IV administration of various substances, such as barbiturates, benzodiazepines, nonbarbiturate hypnotics, dissociative agents, and opioid agents. [ 1. **Barbiturates**: Thiopental, Methohexital] [2. **Benzodiazepines**: Midazolam, Diazepam] [3. **Nonbarbiturate Hypnotics**: Propofol, Etomidate] [4. **Dissociative Agents**: Ketamine] [5. **Opioid Agents**: Fentanyl, Sufentanil, Remifentanil] ### CLINICAL MANIFESTATIONS 1. **Rapid increase in CO₂ levels** (early sign) - Indicates increased metabolism. 2. **Tachycardia (fast heart rate)** - Body\'s response to the crisis. 3. **Muscle rigidity** - Especially in the jaw; due to excessive calcium in muscles. 4. **High fever** - Body temperature rises quickly. 5. **Acidosis** - Increased acid levels from fast metabolism. 6. **Hyperkalemia (high potassium)** - From muscle breakdown. 7. **Dark urine** - Due to muscle breakdown products in urine. ### **NURSING INTERVENTIONS** 1. [**Stop triggering agents** (anesthesia gases and succinylcholine)] - [*Rationale:* Prevents worsening of symptoms.] 2. **[Give 100% oxygen]** - [*Rationale:* Helps with high CO₂ and low oxygen.] 3. [**Administer Dantrolene** (specific treatment for MH)] - [*Rationale:* Reduces muscle rigidity and controls temperature.] 4. **[Monitor vital signs continuously]** - [*Rationale:* Allows for early detection and quick response.] 5. [**Cool the patient** (cooling blankets, ice packs, cold IV fluids)] - [*Rationale:* Lowers body temperature to prevent further harm.] 6. **[Check electrolytes and blood gases regularly]** - [*Rationale:* Helps detect and treat acidosis and high potassium.] 7. **[Give IV fluids to support kidneys]** - [*Rationale:* Prevents kidney damage from muscle breakdown.] ### **EMERGENCY MANAGEMENT** 1. **[Give Dantrolene immediately]** - [Initial dose: 2.5 mg/kg IV, repeat until stable.] - [*Rationale:* Key drug to stop the MH reaction.] 2. **[Hyperventilate with 100% oxygen]** - [*Rationale:* Lowers CO₂ and supports oxygen needs.] 3. [**Active cooling** (cooling blankets, ice packs, cold fluids)] - [*Rationale:* Controls the high body temperature.] 4. **[Correct metabolic issues]** - [Give bicarbonate for acid levels and treat high potassium.] - [*Rationale:* Prevents complications like irregular heartbeat.] 5. [**Insert Foley catheter** to monitor urine] - [*Rationale:* Checks kidney function.] 6. **[Transfer to ICU for further monitoring]** - [*Rationale:* MH can recur, so continued monitoring is essential.] Anesthesia Machines - Models and Pricing - Avante Health Solutions 2. Regional Anesthesia ---------------------- Techniques used in Regional Anesthesia -------------------------------------- **Topical Anesthesia** **Field Block** **Nerve Block** **Spinal Anesthesia (Subarachnoid Block)** **Epidural Anesthesia** - - - - - - +-----------------------------------------------------------------------+ | **Postoperative Phase** | | | | **Lesson 1. Post Anesthesia Care Unit (PACU)** | +-----------------------------------------------------------------------+ 1. Describe the responsibilities of the post-anesthesia care unit nurse in the prevention of immediate postoperative complications. 2. Identify common immediate post-operative problems and their management. 3. Identify nursing interventions in the prevention / management of post-operative 4. Outline parameter criteria in receiving and admitting patient in the PACU 1. Transferring the postoperative patient from the OR to the PACU is the responsibility of the [ Anesthesia provider (anesthesiologist or CRNA) and the circulating nurse**.**] 2. **[Aldrete Score]** is a well-established scoring system that has been used to determine when patients can be safely discharged from the post anesthesia care unit (PACU). 3. True or False. The surgeon speaks to the family after surgery and relates the general condition of the patient. [True] 4. Postoperatively, the nurse must make careful assessment and immediate intervention to the patient in returning to optimal function quickly, safely, and as comfortably as possible. [True] 5. The primary intervention for hypovolemic shock is volume replacement. [True] 1. Phase I care occurs immediately after surgery, most often in a PACU, although care in an ambulatory care unit is becoming common. For those patients who have very complicated procedures or many serious health problems, phase I care may occur in an intensive care unit (ICU). The length of time the patient remains at a phase I level of observation depends on his or her health status, the surgical procedure, anesthesia type, and rate of progression to complete alertness and hemodynamic stability. 2. Phase II postoperative recovery focuses on preparing the patient for care in an extended care environment, such as a medical-surgical unit, step-down unit, skilled nursing facility, or home. This phase can occur in a PACU, on a medical-surgical unit, or in the same-day surgery (SDS) unit (ambulatory care unit) and may last only 15 to 30 minutes, although 1 to 2 hours is more typical. 3. Phase III known as the extended-care environment, most often occurs on a hospital unit or in the home. For patients who have continuing care needs that cannot be met at home, discharge may be from the hospital unit to an extended-care facility. Although vital signs continue to be monitored in this type of environment, the frequency ranges from several times daily to just once daily. During the postoperative period, nursing care focuses on reestablishing the patient's physiologic equilibrium, alleviating pain, preventing complications, and teaching the patient selfcare. Careful assessment and immediate intervention assist the patient in returning to optimal function quickly, safely, and as comfortably as possible (Smeltzer, at., al., 2010). Post-anesthesia Care Unit (PACU) -------------------------------- Transferring Patient from OR to PACU ---------------------------------------------------------- Transferring the postoperative patient from the OR to the PACU is the Suddarth\'s6Smeltzer, S., Bare, B., Hinkle, J. and Cheever, K. Textbook of Medical-Surgical Nursing 12(2010)th Edition.. Brunner and Lippincott Nursing Management in the PACU ------------------------------ 2. Maintaining a Patent Airway and Respiration ---------------------------------------------- **Clinical Manifestations**: 1. Allow the airway (ET tube) to remain in place until the patient begins to waken and is trying to eject the airway. 2. Aspirate excessive secretions when they are heard in the nasopharynx and oropharynx. 3. Maintaining Cardiovascular Stability --------------------------------------- 7Smeltzer, S., Bare, B., Hinkle, J. and Cheever, K. (2010). Brunner and Suddarth\'s Textbook of Medical-Surgical Nursing 12th Edition. Hemorrhage and Shock ------------------------------------------ MedicalSmeltzer,-Surgical Nursing 12th Edition. Lippincott Williams & Wilkins S., Bare, B., Hinkle, J. and Cheever, K. (2010). Brunner and Suddarth\'s Textbook of 1. [Hypotension (low blood pressure)] 4.[Tachycardia (increased heart rate)] 2. [Cold, clammy skin] 5.[Decreased urine output] 3. [Altered mental state (e.g., confusion, agitation, anxiety)]. 6.[Rapid, shallow breathing] The primary intervention for hypovolemic shock is volume replacement, with an infusion of lactated Ringer's solution, 0.9% sodium chloride solution, colloids, or blood component therapy. Hypovolemic shock can be avoided largely by the timely administration of IV fluids, blood, blood products, and medications that elevate blood pressure (Smeltzer, at., al., 2010). 1. **[Positioning the Patient Flat with Elevated Legs (Modified Trendelenburg)]** 2. **[Maintain Airway Patency and Administer Oxygen if Needed]** 3. **[Apply Direct Pressure to Bleeding Site if Accessible]** 4. **[Keep the Patient Warm]** 4. Managing Thermoregulation ---------------------------- - [Provide Warm Blankets] - [Adjust Room Temperature] - [Encourage Use of Socks or Head Covers] - [Monitor Patient Temperature Frequently] - [Limit Skin Exposure During Assessments] 5. Managing Pain ---------------- 1. [Position the Patient for Comfort] 2. [Encourage Deep Breathing and Relaxation Techniques] 3. [Provide Distraction Techniques (e.g., Music, TV, Guided Imagery)] 4. [Support the Surgical Site When Coughing or Moving] 5. [Maintain a Calm and Quiet Environment] [ ] 6. Managing neuromuscular stability ----------------------------------- Observe for lethargy, restlessness, or irritability, and test coherence and orientation. Determine awareness by observing responses to calling the patient\'s name, touching the patient, and giving simple commands such as "Open your eyes" and "Take a deep breath." (Ignatavicius, et., al., 2016). 7. Controlling Nausea and Vomiting -------------------------------------------------------- *10Smeltzer, S., Bare, B., Hinkle, J. and Cheever, K. (2010). Brunner and Suddarth\'s Textbook of Medical-Surgical Nursing 12th Edition.* Parameter for Discharge from PACU/RR ------------------------------------ Admission to the Surgical Unit ------------------------------ Prepare for a Quiz on Lesson 1 of Unit 4. End of Lesson1 +-----------------------------------------------------------------------+ | **Postoperative Phase** | | | | **Lesson 2. Nursing Management in the Surgical unit** | +-----------------------------------------------------------------------+ 1. 2. 3. 1. [True.]Dressings are selected based on the characteristics of the surgical site, depth, and area, and the patient\'s overall condition 2. [Secondary dressings] are placed directly over the primary dressing. 3. [Drains]control ecchymosis and provide exits through which air and fluids 4. [Third Intention]This healing process occurs when approximation of wound edges is intentionally delayed by 3 or more days after injury or surgery. 2. Second Intention (Granulation and Contraction) When surgical wounds are characterized by tissue loss with an inability to approximate wound edges, healing occurs through second intention. This type of wound is usually not closed; instead, it is allowed to heal from the inside toward the outer surface. 3. Delayed Primary Closure or Third Intention As the name delayed primary closure implies, this healing process occurs when approximation of wound edges is intentionally delayed by 3 or more days after injury or surgery. These wounds may require debridement and usually require a primary and secondary suture line, such as when retention sutures are used. Phases of Wound Healing ----------------------- 1. **Inflammatory Phase**: 2. **Proliferative Phase**: 3. **Remodeling Phase** (Maturation Phase): Factors Affecting Wound Healing ------------------------------- ### Patient\'s Age 2. Handling of Tissues 3. Drainage Accumulation [Fluid buildup in wounds creates pressure and encourages infection. Proper drainage prevents ] [complications and supports healing.] ### ### Nutritional Status ### Medications (Corticosteroids) ### Oxygenation Level Surgical site and Dressing -------------------------- 1. Primary dressings are placed directly over or in the wound. A variety of primary dressing materials are available on the market. Their function is to absorb drainage and then wick it away from the wound edge. Cotton gauze or synthetic dressings may be used for this purpose. The layer of primary dressing directly contacting the wound should be nonadherent, unless debridement is desired. 2. Secondary dressings are placed directly over the primary dressing. These function to absorb excessive drainage, provide hemostasis by compression, and protect the wound from further trauma. These functions usually are accomplished with a bulky dressing, such as an abdominal pad. These pads have a cotton filling that provides extra absorbency. 1. [Dressings are designed to absorb wound exudate and wick moisture away from the wound edge, thereby maintaining a clean and dry environment that is conducive to healing.] 2. [Secondary dressings can help provide hemostasis, or the control of bleeding, through compression.] 3. [Dressings protect the wound from external contaminants, including bacteria and other harmful agents that could cause infection, and provide a physical barrier against further trauma.] 4. [When debridement is necessary, a primary dressing may be used to assist with the removal of dead or infected tissue, aiding in the wound healing process.] 5. [Secondary dressings often offer cushioning to protect the wound from mechanical injury or irritation and can provide additional comfort to the patient.] 6. [Dressings maintain a controlled moist environment, which promotes efficient wound healing.] 1. [Wash hands and put on clean gloves. Carefully remove the old dressing.] [**Rationale:** Prevents infection and protects both the nurse and patient.] 2. [Observe the wound for drainage, odor, or signs of infection] [**Rationale:** Ensures early identification of complications and tracks wound healing] 3. [Clean the wound from the center outwards using sterile gauze.] 4. [Place a primary dressing on the wound (nonadherent if debridement is not required). Apply a secondary dressing over it.] 5. [Secure the dressing with tape or bandages.] Drains 1. [Assess drain function during vital sign checks and every 8 hours afterward.] 2. [Track drainage volume, color, and type regularly] [**Rationale:** Changes may indicate bleeding or infection.] 3. [Use sterile techniques when handling drains.] [**Rationale:** Prevents introducing infections to the wound.] 4. [Ensure drains are well-secured to avoid dislodgement] [**Rationale:** Prevents complications and ensures proper function.] 5. [Empty drains each shift or when nearly full; record output] [**Rationale:** Prevents backflow and tracks healing progress.] 6. [Look for redness, warmth, or unusual drainage.] [**Rationale:** Early detection prevents serious complications] 1. Helps the patient move gradually from the lying position to the sitting position by raising the head of the bed and encourages the patient to splint the incision when applicable. 2. Positions the patient completely upright (sitting) and turned so that both legs are hanging over the edge of the bed. 3. Helps the patient stand beside the bed Wound Infection --------------- "Something popped" or "I feel as if I just split open." *^/dehiscence^* +-------------+-------------+-------------+-------------+-------------+ | **Pneumonia | Infection | Immobility, | Fever, | Encourage | | ** | of the lung | aspiration, | productive | deep | | | tissue | weak cough, | cough, | breathing | | | after | decreased | crackles, | and | | | surgery. | lung | difficulty | coughing | | | | expansion. | breathing, | exercises, | | | | | chest pain. | | | | | | | use of | | | | | | incentivesp | | | | | | irometer, | | | | | | | | | | | | early | | | | | | ambulation, | | | | | | elevate | | | | | | | | | | | | head of bed | | | | | | 30-45 | | | | | | degrees, | | | | | | | | | | | | monitor | | | | | | respiratory | | | | | | status. | +-------------+-------------+-------------+-------------+-------------+ | **Atelectas | Partial or | Immobility, | Difficulty | Encourage | | is** | complete | mucus plug, | breathing, | coughing, | | | collapse of | anesthesia, | decreased | deep | | | the lung. | shallow | lung | | | | | breathing. | sounds, low | breathing, | | | | | oxygen | use of | | | | | levels, | incentive | | | | | low-grade | | | | | | fever. | spirometer, | | | | | | early | | | | | | mobilizatio | | | | | | n, | | | | | | repositioni | | | | | | ng. | +-------------+-------------+-------------+-------------+-------------+ | **Thromboph | Inflammatio | Immobility, | Swelling, | Encourage | | lebitis** | n | hypercoagul | redness, | early | | | of a vein | ability, | warmth, | ambulation, | | | with a | dehydration | pain in the | use of | | | blood clot. |. | leg. | compression | | | | | | stockings, | | | | | | elevate | | | | | | extremity, | | | | | | administer | | | | | | anticoagula | | | | | | nts | | | | | | if | | | | | | prescribed. | +-------------+-------------+-------------+-------------+-------------+ | **Urinary | Inability | Anesthesia, | Leakage of | Assess for | | Incontinenc | to control | immobility, | urine, | bladder | | e** | urination. | bladder | inability | distention, | | | | distention. | to void, | | | | | | bladder | assist to | | | | | discomfort. | bathroom, | | | | | | provide | | | | | | privacy, | | | | | | ensure | | | | | | hydration, | | | | | | | | | | | | use bladder | | | | | | scan if | | | | | | needed. | +-------------+-------------+-------------+-------------+-------------+ | **Intestina | Blockage in | Adhesions | Abdominal | NPO | | l | the | from | distention, | (nothing by | | Obstruction | intestines. | surgery, | vomiting, | mouth), | | ** | | hernias, or | absence of | | | | | decreased | bowel | insert | | | | bowel | movements, | nasogastric | | | | motility. | cramping | tube, | | | | | pain. | | | | | | | administer | | | | | | IV fluids, | | | | | | | | | | | | monitor for | | | | | | bowel | | | | | | sounds. | +-------------+-------------+-------------+-------------+-------------+ | **Constipat | Difficulty | Decreased | Infrequent | Encourage | | ion** | in passing | mobility, | bowel | fluid | | | stools. | opioids, | movements, | intake, | | | | decreased | straining, | | | | | fluid and | hard | high-fiber | | | | fiber | stools. | diet, early | | | | intake. | | | | | | | | ambulation, | | | | | | administer | | | | | | stool | | | | | | softeners | | | | | | if | | | | | | prescribed. | +-------------+-------------+-------------+-------------+-------------+ | **Paralytic | Temporary | Anesthesia, | Absent | NPO, insert | | Ileus** | cessation | manipulatio | bowel | nasogastric | | | of bowel | n | sounds, | tube, | | | movement. | of the | abdominal | | | | | bowel | distention, | encourage | | | | during | nausea, | early | | | | surgery. | vomiting. | ambulation, | | | | | | | | | | | | monitor | | | | | | bowel | | | | | | sounds. | +-------------+-------------+-------------+-------------+-------------+ | **Post-Oper | Psychologic | Pain, | Withdrawal, | Offer | | ative | al | immobility, | sadness, | emotional | | Depression* | response | loss of | loss of | support, | | * | after | function, | interest, | | | | surgery. | previous | changes in | encourage | | | | mental | sleep or | talking | | | | health | appetite. | about | | | | issues. | | feelings, | | | | | | involve | | | | | | family, | | | | | | refer to | | | | | | | | | | | | mental | | | | | | health | | | | | | services if | | | | | | needed. | +-------------+-------------+-------------+-------------+-------------+ **Generic Name:** Alfentanil **Brand Name:** Alfenta **Dosage / Route / Frequency:** 500 mcg IV, adjusted as needed during surgery **Pharmacologic Classification:** Opioid analgesic **Physiologic Classification:** Analgesic **Mechanism of Action:** Alfentanil is a potent, short-acting opioid agonist that binds to opioid receptors in the central nervous system (CNS), resulting in analgesia and sedation. It has a rapid onset of action due to high lipid solubility and is typically used in anesthesia for its potent pain-relieving effects. **Indication:** Primarily used as an anesthetic adjunct for induction and maintenance of anesthesia, particularly in surgeries that require rapid, short-acting pain relief. **Desired Effect:** To provide rapid and effective pain relief and sedation during surgical procedures. **Contraindications:** - Hypersensitivity to alfentanil or other opioids - Respiratory depression or severe asthma - Paralytic ileus **Side Effects:** - Nausea - Vomiting - Dizziness - Respiratory depression **Adverse Effects:** - CNS: Sedation, confusion - CV: Hypotension, bradycardia - Respiratory: Respiratory depression, apnea - GI: Constipation - Other: Muscle rigidity +-----------------------------------+-----------------------------------+ | **NURSING** | **RATIONALE** | | | | | **RESPONSIBILITIES** | | +===================================+===================================+ | 1.Monitor respiratory rate, blood | 1.To detect any signs of | | pressure, and oxygen saturation | respiratory depression or | | throughout administration. | hypotension. | | | | | 2.Have resuscitation equipment | 2.To ensure prompt intervention | | readily available in case of | if adverse reactions occur. | | overdose or severe respiratory | | | depression. | 3.To evaluate effectiveness and | | | adjust dosage if needed. | | 3.Assess patient's pain level | | | before and after administration. | 4.Rapid administration can | | | increase risk of muscle rigidity | | 4.Administer slowly and monitor | and respiratory complications. | | for muscle rigidity. | | | | 5.To increase understanding and | | 5.Educate the patient or family | cooperation with treatment. | | on the potential side effects and | | | the need for monitoring. | 6.To prevent potential overdose | | | due to opioid tolerance. | | 6.Check patient history for | | | opioid use or abuse. | 7.To promptly address any | | | hypersensitivity reactions. | | 7.Evaluate for signs of an | | | allergic reaction (rash, itching, | 8.To prevent accidents or | | swelling). | injuries due to impaired | | | cognitive function. | | 8.Advise patient to avoid | | | operating heavy machinery or | | | making critical decisions after | | | the procedure due to sedation | | | effects. | | +-----------------------------------+-----------------------------------+ **\"Fame's Fragile Balance: Michael Jackson's Journey Through Stardom, Struggle, and the Boundaries of Medicine\"** Michael Jackson's life was an extraordinary tapestry of talent, creativity, and ultimately, tragic decline. With a unique brilliance and an insatiable ambition, he was ready to reclaim his place on the global stage with the "This Is It" tour---a series of performances meant to cement his legacy. Yet, behind the scenes and away from public adoration, Jackson battled an invisible but relentless foe. He wasn't haunted by fame or past missteps; rather, he was prey to insomnia---a torment that stalked him night after night, slowly breaking him down. In his urgent quest for relief, Jackson's path took a fatal turn with Propofol---a powerful anesthetic strictly for hospital use. This was no mere choice, but a last-ditch effort by a mind deprived of rest for far too long. Jackson didn't seek Propofol to escape life but simply to find peace in sleep. Yet, this fundamental human need had become elusive, buried beneath layers of exhaustion and turmoil.However, Jackson's struggle wasn't a solitary one. In his circle was Dr. Conrad Murray---a physician committed to upholding medical ethics but ultimately compromised by proximity to Jackson's world of fame and influence. Bound by his duty yet swayed by his connection to this legendary figure, Dr. Murray succumbed to Jackson's desperate requests rather than upholding his professional obligations. With every dose, he chose expedience over caution, compliance over care, until finally, that decision proved fatal. Jackson's passing sent shockwaves around the world, but beneath the headlines lay a sobering truth about the collision of fame, medicine, and human vulnerability. His death was more than the loss of an icon; it revealed the profound failures of a system that should have protected him. Jackson's life underscored the fragility of those who, trapped in fame and personal turmoil, find themselves stretched between the unforgiving demands of an industry and the exhaustion of the mind. The great irony in Jackson's life is that he, a man who inspired joy in millions, could not find his own peace. His insomnia became a symbol of deeper unrest---a life so externally controlled by managers, fans, and critics that he lost command over even his most basic needs. The sleep he longed for symbolized a quest for freedom from the confines of fame. Using Propofol as a sleep aid was a desperate and ultimately tragic act, a misguided attempt to create sanctuary in a life that afforded him none. This final attempt to regain control over his own body and mind led him down a fatal path. Bringing such a potent medical tool into his personal realm set into motion the tragic events that ultimately claimed his life. Jackson's story conveys an essential lesson for the medical field: no patient, regardless of status, should be allowed to undermine the boundaries of medical ethics. The doctor-patient relationship is a deeply rooted trust, dedicated to life and well-being. Jackson's story highlights the peril of blurring the line between empathy and compliance, care and complicity. Dr. Murray's compliance with Jackson's requests was no act of compassion; it was a betrayal of his ethical duty. Jackson's death leaves a legacy that extends far beyond his musical achievements. It's a stark reminder of the isolation that fame can foster and the pressures that can lead a person down a path of self-destruction in the pursuit of something as essential as sleep. His story urges us to rethink how we perceive celebrity, the toll we expect stars to pay for their success, and the ethical obligations of those who support them. It also calls the medical profession to reassert its commitment to ethical principles, prioritizing patient safety above all else. As we reflect on Michael Jackson's life and loss, it may be tempting to remember only his musical contributions. Yet the deeper lesson is found in the quiet shadows of his life---the nights without sleep, the ignored cries for help, and the tragic decisions that culminated in his untimely death. His story reminds us that even the brightest stars are human, susceptible to the same struggles as anyone else. In the end, Jackson's life is not merely a cautionary tale about fame, insomnia, or missteps in medical practice. It's a story of the precarious balance between power and vulnerability, a balance that, when tipped, can lead even the most remarkable lives into quiet suffering. His story underscores the importance of boundaries, ethical integrity, and the duty to protect life---not just for the famous but for anyone who seeks medical care. And may we remember that behind every celebrated figure lies a person who, in their darkest moments, may need rest as much as they ever needed fame.