Pain and Surgery Lecture Notes PDF

BLACK AND RED - PPT ORANGE - FROM LECTURE Pain Pain Tolerance is DECREASED -​ Whatever person experiencing says it is and -​ With repeated exposure to pain; whenever the person say it does -​...

BLACK AND RED - PPT ORANGE - FROM LECTURE Pain Pain Tolerance is DECREASED -​ Whatever person experiencing says it is and -​ With repeated exposure to pain; whenever the person say it does -​ By fatigue, anger, boredom, apprehension; -​ An unpleasant sensory and emotional anxiety & fear experience associated with actual or -​ Sleep deprivation potential tissue damage or described in terms of such damage Pain Tolerance is INCREASED -​ Mild, moderate, severe -​ By alcohol consumption; -​ Toddler : wong baker -​ Medication, hypnosis; -​ adult : guarding behavior -​ Warmth, distracting activities; Pain Management can be as follows: -​ Strong beliefs or faith -​ Pharmacological -​ Non-pharmacological Misconceptions/ Facts -​ Surgical : Last Option Myths Pain Perception 1. That nurse or 1. Only the client can -​ The conscious experience of discomfort physician is the best judge the level & -​ Children and adults perceive pain judge of a client’s pain. distress of the pain; differently pain management -​ Infant (1-2 days old) are less sensitive 2. Pain is part of aging. should be a team to pain approach. -​ (3-12 months) pain is apparent 3. If a person is asleep Paint Threshold they 2. Pain does not -​ Level at which someone experiences pain are not in pain. accompany aging Pain Tolerance unless a disease -​ the maximum intensity or duration of pain 4. Pain is a result, not a process or ailment is that a person is willing to endure once the cause. present. threshold has been reached. -​ varies greatly among people and in the same 5. Real pain has an 3. People in pain person over time; identifiable become exhausted -​ a decrease in pain tolerance is evident in the cause. and may truly be asleep ELDERLY or merely trying to -​ WOMEN appear to be more tolerant to pain 6. Very young or very sleep. Some people than MEN old people do not have sleep as an escape  5.​ Pain is a valuable diagnostic indicator, it as much pain. mechanism. usually indicates tissue damage or pathology 7. Nurse should rely on 4. Unrelieved pain can 6.​ Pain is usually reported as a severe their own definitions of create other problems discomfort or uncomfortable sensation pain and cultural such as anger, anxiety, Components of Pain beliefs about pain immobility and delay in 1.​ STIMULI healing. 2.​ PERCEPTION 3.​ RESPONSE 5. There is always a 4.​ INTENSITY cause of pain, but it 5.​ THRESHOLD maybe very obscure or 6.​ TOLERANCE unknown & must be assessed carefully. Types of Pain A. According to Source 6. Age is not a 1. Nociceptive Pain determinant of pain, -​ Nociceptive pain is the most common type. but it may influence -​ It’s caused by potentially harmful stimuli expression of pain. being detected by nociceptors around the body. 7. It is a mistake to -​ is believed to be caused by the ongoing impose one’s own activation of pain receptors in either the definitions, cultural surface or deep tissues of the body. beliefs and values -​ is the noxious stimuli that are transmitted to another person’s in an orderly fashion from the point of pain. Let the client tell cellular injury over peripheral sensory you what the pain nerves to pathways between the spinal cord means. and thalamus, and eventually from the thalamus to the cerebral cortex of the brain. Characteristics of Pain A. Somatic Pain 1.​ Pain is subjective and personal -​ Superficial Somatic 2.​ Physiologic pain may sometimes broaden to -​ Deeper Somatic encompass emotional hurt B. Visceral Pain 3.​ Pain is a symptom not a disease entity 4.​ Pain is uniquely experienced by each SOMATIC PAIN individual and can not be adequately define, -​ caused by injury to skin, muscles, bone, identify or measure by an observer; joint, and connective tissues.  -​ Somatic pain often involves inflammation of -​ Neuropathic pain can be a symptom or injured tissue. Although inflammation is a complication of several diseases and normal response of the body to injury, and is conditions. essential for healing, inflammation that -​ pain that is processed abnormally by the does not disappear with time nervous system and usually results from & can result in a chronically painful disease. The damage to either the pain pathways in joint pain caused by rheumatoid arthritis may be -​ peripheral nerves or pain processing centers considered an example of this type of somatic in the brain. nociceptive pain. -​ HERPES ZOSTER - unilateral neuropathic Superficial somatic pain or Cutaneous pain 3. Psychogenic Pain -​ Perceived as sharp or burning discomfort or -​ is a simple label for all kinds of pain that pricking quality. can be best explained by psychological ex. Insect bite, paper cut problems. -​ sometimes occurs in the absence of any Deep somatic pain identifiable disease in the body. More often, -​ produce localized sensations that are sharp, there is a physical problem but the throbbing and intense psychological cause for the pain is believed -​ usually described as dull or aching, diffuse to be major cause for the pain discomfort and localized in one area. ex. Arthritis B. According to Characteristics (onset, intensity, & duration) VISCERAL PAIN 1. Acute Pain -​ refers to pain that originates from ongoing -​ Less than 6 months injury to the internal organs or the tissues -​ Sharp, stabbing, and shooting that support them. When the injured tissue -​ accompanied by observable physical is a hollow structure, like the intestine or responses the gallbladder, the pain often is poorly -​ increased or decreased BP, localized and cramping. When the injured tachycardia, diaphoresis, tachypnea, structure is not a hollow organ, the pain focusing on the pain may be pressure-like, deep, and stabbing. -​ accompanied by observable physical -​ usually accompanied by ANS symptoms responses such as nausea & vomiting, pallor, MANIFESTATIONS hypotension, & sweating. -​ Sympathetic -​ Increased VS 2. Neuropathic Pain -​ Pallor -​ Diaphoretic  healing stage 2. Chronic Pain - suffering decreases -​ More than 6 months - suffering intensifies -​ Major health concern -​ divided in 3 types Psychological & Behavioral Response to Acute a. Chronic nonmalignant pain Pain -​ such as low back pain to -​ Fear rheumatoid arthritis -​ General sense of unpleasantness or unease -​ Autoimmune diseases -​ Anxiety b. Chronic intermittent -​ such as migraine, headache Physical Response to ACUTE Pain c. Chronic malignant pain -​ Increased Heart rate, RR, BP -​ cancer -​ Pallor or Flushing, dilated pupils -​ Diaphoresis ACUTE PAIN CHRONIC PAIN -​ Increased Blood sugar - sudden onset - remote onset -​ Decreased Gastric motility & gastric secretion - symptomatic of - uncharacteristic of -​ Decreased blood flow to the viscera, kidneys primary injury or primary injury or and Skin disease disease -​ Nausea occasionally occurs - specific & localized - nonspecific and Characteristics of Clients Experiencing generalized CHRONIC Pain - severity assoc. with -​ Depression the acuity or sensitivity - severity out of -​ Increased or decreased appetite and weight of the injury or disease proportion to the stage -​ Poor physical tone process of the injury or -​ Social withdrawal and life role changes disease -​ Decreased concentration - responds favorably to -​ Poor sleep drug therapy. - responds poorly to -​ Preoccupation with physical manifestations drug therapy - requires gradually Intermittent Pain produces a physiologic response decreased drug therapy - requires increasing similar to acute pain drug therapy Persistent pain allows for adaptation (functions of - diminishes with the body are normal but the pain is not relieve) healing - persists beyond REFERRED PAIN -​ used to describe discomfort that is perceived in a general area of the body, but not in the exact site where an organ is anatomically located. -​ NON PLEURITIC -​ Phantom limb : example -​ Rebound tenderness : Appendicitis Types of Referred Pain 1. Myofascial Pain – trigger points, small hyperirritable areas within a m. in which n. impulses bombard CNS & are expressed at referred Pain Pathways and Mechanisms pain -​ Pain begins with noxious signals triggering Active – hyperirritable; causes obvious impulses that travel to the spinal cord, complaint which then relays this information to the Latent – dormant; produces no pain except brain. The brain interprets these signals as loss of ROM pain, localizes the source, and sends instructions to the body to react. 2. Sclerotomic & Dermatomic Pain – deep pain; may originate from sclerotomic, myotomic, or Pain Receptors (Nociceptors) dermatomic nerve irritation/injury Sclerotome: area of bone/fascia that is -​ Pain sensation is mediated by nociceptors, supplied by a single nerve root found in the skin, superficial tissues, and most organs, except the brain. These Myotome: m. supplied by a single n. Root receptors are nerve endings of “first-order neurons” in the pain pathway. Their axons Dermatome: area of skin supplied by a can be: single nerve root ​ Myelinated A fibers: Conduct signals rapidly, causing sharp, immediate pain. ​ Unmyelinated C fibers: Conduct signals slowly, causing dull, persistent pain. Signal Transmission First-order neurons transmit signals via spinal Referred Pain nerves to the spinal cord, synapsing with -​ Referred pain occurs because of the second-order neurons in the dorsal horn. These convergence of pain pathways at the spinal second-order neurons cross to the opposite side of cord level. For instance, during a heart the spinal cord and ascend to the brain. This attack, pain from the heart (innervated by crossover ensures that pain on one side of the body spinal segments T1–T5) may be felt in the is processed by the opposite side of the brain. left shoulder, arm, or back. This happens Pain Pathways to the Brain because the brain misinterprets the source of pain as coming from superficial tissues, 1.​ Spinothalamic Tract:​ which are more frequently injured. Second-order neurons ascend through the spinothalamic tract to the thalamus, TRANSMISSION OF PAIN synapsing with third-order neurons. These 1.​ Transduction project to the somatosensory cortex and are -​ begins a response to a noxious responsible for pain localization. stimuli (painful stimulus) that results 2.​ Spinoreticular Tract:​ in tissue injury, can be mechanical, Second-order neurons ascend to the thermal or chemical. reticular formation in the brainstem and -​ ‘’ IT TRIGGERS THE RELEASE OF then to the thalamus, hypothalamus, and NOXIOUS STIMULI’’. cortex. This pathway mediates the -​ is the conversion of chemical emotional aspects of pain. information in the cellular Pain from the Face environment to electrical impulses that move toward the spinal cord. -​ Pain signals from the face follow a distinct The chemicals that are released by pathway. First-order neurons travel via the the damaged cells stimulate trigeminal nerve to the brainstem, where they specialized pain receptors located in synapse with second-order neurons that the free nerve endings of peripheral ascend to the thalamus. sensory nerves called NOCICEPTORS. Types of Pain -​ Basically ito is from chemical ​ Somatic Pain: Originates from the skin, conversion to electrical impulse muscles, and joints. -​ SENSORY : AFFERENT (SA) ​ Visceral Pain: Originates from internal -​ MOTOR : EFFERENT ( ME) organs and is often perceived at a different 2.​ Transmission location, a phenomenon called referred -​ the phase during which the pain. peripheral nerve fibers form  synapses w/ neurons in the spinal 2. Afferent nerve fibers cord, the pain impulses move from the spinal cord sequentially levels in 3. Spinal Cord network the brain, the impulses ascend to the reticular activating system, the AUTONOMIC NERVOUS SYSTEM limbic system and the thalamus and -​ regulates involuntary functions finally the cerebral cortex. 3.​ Perception 1.​ SYMPATHETIC NERVOUS SYSTEM – ‘’ a -​ Refers to the phase of impulse fight or flight response to stress’’ transmission during which the brain -​ Norepinephrine experiences pain at a conscious level -​ Epinephrine (awareness of pain). -​ adrenaline -​ Subjective 2.​ PARASYMPATHETIC –‘’exhaustion or -​ Conscious experience shock’’ response 4.​ Modulation -​ rest -​ The last phase of pain impulse 3.​ NEUROTRANSMITTERS transmission during which the brain -​ In aid for movement interacts with the spinal nerves in a -​ Dopamine downward fashion to alter the pain -​ acetylcholine experience. The CNS comprises the spinal cord and the brain PERIPHERAL NERVOUS SYSTEM​ -​ Irreversible damage - carries pain impulses to and from the CNS 1.​ The SPINAL CORD – transmits painful 1. Afferent nerve fibers - carry impulses to stimuli to the brain and motor responses the CNS) and pain perception to the periphery. 2. CNS 2.​ The BRAIN – processes and interprets 3. Efferent nerve fibers – carry impulses transmitted pain impulses from the CNS) FACTORS AFFECTING RESPONSE TO PAIN The afferent portion is composed of: 1.​ Physiologic Factors – age, genetics, quality 1. Nociceptors – naked nerve endings (thermal, 2.​ Affective factors – mood, fear, depression, chemical and mechanical) anxiety a. A – Delta fibers – rapid rate, transmit 3.​ Psychosocial factors – family, personal ACUTE SHARP PAIN spiritual, cultural beliefs, occupation b. C – Fibers – slower rate and produce 4.​ Cognitive – past experience, knowledge, chronic type of pain values, expectations PAIN CONTROL THEORIES -​ Smaller, slower n. carry pain 1.​ INTENSITY THEORY impulses -​ State that pain is the result of -​ Larger, faster n. fibers carry other excessive stimulation of sensory sensations receptors. -​ Impulses from faster fibers arriving 2.​ PATTERN THEORY @ gate 1st inhibit pain impulses -​ Describes that painful and (acupuncture/pressure, cold, heat, non-painful sensation are chem. skin irritation) transmitted by nonspecific receptors through a common pathway to Three Factors Involved in Opening and Closing higher centers of the brain the Gate 3.​ SPECIFICITY THEORY 1. The amount of activity in the pain fibers. -​ Describe four types of cutaneous 2. The amount of activity in other peripheral fibers. sensation: touch, warmth, cold and 3. Messages that descend from the brain. pain -​ It focuses on the direct relationship Conditions That Open the Gate between the pain stimulus and 1. Physical conditions perception but does not account for -​ Extent of injury adaptation to pain and the -​ Inappropriate activity level psychosocial factors that modulate 2. Emotional conditions the stimulus -​ Anxiety or worry 4.​ GATE CONTROL THEORY -​ Tension -​ Nerve fibers carry touch and pain -​ Depression impulses from receptors on the skin 3. Mental Conditions to the spinal cord -​ Focusing on pain -​ Nerve cells in the SG of the spinal -​ Boredom cord receive these touch and pain Conditions That Close the Gate impulses 1. Physical conditions -​ Impulses then proceed through -​ Medications transmission cells to the brain -​ Counter stimulation (e.g., heat, message) -​ Fibers from the brain send 2. Emotional conditions inhibiting information to the -​ Positive emotions Substantia Gelatinosa (SG) in dorsal -​ Relaxation, Rest horn of spinal cord w/c serves as a 3. Mental conditions gate for control of pain -​ Intense concentration or distraction -​ Gate - located in the dorsal horn of the -​ Involvement and interest in life activities spinal cord Pain Management GOALS 5 General Techniques for Achieving Pain Mgt: 1.​ Reduce Pain 1. Blocking brain perception. 2.​ Control Pain 2. Interrupting pain transmitting chemicals at the 3.​ Protect Patient from further injury site of injury. 3. Combining analgesics with adjuvant drugs like A: full description of pain {ingredients, methods} to enhance the effectiveness B: Determine if part of structural disease of medical treatment. C: understand mechanisms 4. Using gate-closing mechanisms. D: Note Negative Effects 5. Altering pain transmission at the level of the E: Coexist between medical and psychological spinal cord. QUICK ASSESSMENT 1. Pharmacological or Drug Interventions P: Pattern * Adjuvant Drug Therapy A: Area * Non opioid Analgesics I: Intensity * Opioid Analgesics N: Nature 2. Non drug Interventions a. Heat and Cold PATTERN b. Transcutaneous Electrical Stimulation -​ Onset (TENS) -​ Duration c. Acupuncture & Acupressure d. Percutaneous Electrical Nerve AREA Stimulation (PENS) -​ Location e. Non invasive Techniques * Mind / Body Therapy INTENSITY * Cognitive – Behavioral Therapy -​ 1 to 10 * Imagery * Relaxation NATURE * Biofeedback -​ Description of pain * Progressive relaxation -​ Dull, sharp, stabbing * Distraction P: Provocation * Hypnosis Q: Quality; Characteristics * Prayer R: Referral/ Radiation * Breathing Exercises S: Severity ( using pain scale) Routes: T: Timing Intravenous- first line  Rectal- alternative when Oral/IV are not an ✓ Constipation option ✓ Nausea Topical – eg. Patch, Gel formulation (EMLA) ✓ Itch Intraspinal (Neuraxial) / Epidural (Perineural) ✓ Urinary retention Oral ✓ Dry mouth ✓ Sexual Dysfunction Drug Interventions for Pain ✓ Sleepiness, fatigue, dizziness and mental clouding 1. Patient Controlled Anesthesia -​ Interactive method of pain management 3. Non- Opioid Analgesics that allows patients to treat their pain by -​ includes acetaminophen or paracetamol, self-administering doses of analgesic agents. dipyrone and nonsteroidal anti-inflammatory drugs or NSAIDs). 2. Opioid Analgesics -​ The NSAIDs are nonspecific analgesics and -​ The most effective analgesics (Ellison, 1998). can potentially be used for any type of acute -​ All drugs that interact with opioid receptors or chronic pain. Because they are both in the nervous system. analgesic and anti- inflammatory, NSAIDs -​ These receptors are the sites of action for are particularly useful for pain related to the endorphins, compounds that already joint problems and other musculoskeletal exist in the body and are chemically related disorders. to the opioid drugs that are prescribed for pain. a. Opioid antagonists – have no analgesic effect and Examples of NSAIDs are used to block the effects of opioid drugs. * Salicylates like Aspirin, Diflunisal,Trisalicylate & Ex. Naloxone, Naltrexone, Nalmafene Salsalate b. Opioid Agonist -antagonist - have analgesic * Proprionic acids like ibuprofen, naproxen, effect. ketoprofen, fenoprofen, oxaprozin Ex. Buprenorphine, Butorphanol, * Acetic acids like indomethacin, diclofenac, Nalbuphine, Dezocine ketorolac, tolmetin, sulindac, etodolac * Oxicams like piroxicam * Naphthlyalkanones like nabumetone * Fenamates like mefenamic acid, meclofenamic acid * Pyrazoles like phenylbutazone 4. Adjuvant Analgesics -​ Sometimes referred to as coanalgesic agents Side Effects associated with Opioid Drugs  -​ Comprise the largest group and include PAIN AND SURGERY various agents with unique and widely Phase 1: Preoperative differing MOA Phase 2: Intraoperative Phase 3: Post-operative Examples of Adjuvant Analgesics 1. GABA Agonists (Baclofen) Objectives of surgery 2. N-methyl-D-aspartate (NMDA) 1.​ Alter form or structure Antagonists - (Dextromethorphan, 2.​ Repair of injuries Ketamine, Amantadine, Memantine) 3.​ Correction of deformities 3. Corticosteroids (prednisone, 4.​ Prolong life Dexamethasone, Methylprednisolone) 5.​ Relief suffering Antidepressants (Amitriptyline or Elavil, 6.​ Diagnosis and cure of disease Clomipramine, Desipramine) Reasons for Surgery 4. Anticonvulsants (Pregabalin, Gabapentin, 1.​ To preserve Life Carbamazepine, Phenytoin, Topiramate) 2.​ Maintain dynamic equilibrium 5. Local Anesthetic Agents (Mexiletine, 3.​ Undergo diagnostic procedure Tocainide, Flecainide) 4.​ Prevent further infection 5.​ Promote healing 6.​ For comfort 7.​ Restore or reconstruct part of the body 8.​ For aesthetic reasons Indication of Surgery ​ Incision ​ Reconstruction ​ Transplant ​ Excision ​ Palliation ​ By-pass / shunt ​ Diagnostics ​ Aesthetics ​ Drainage/ ​ evacuation ​ Repair ​ Stabilization ​ Harvest  ​ Removal Procurement Staging -​ Closed fracture, infected wound, ​ Parturition exploration, irrigation ​ Extraction 3.​ Required ; AMBULATORY ​ Exploration -​ Needs surgery ​ Diversion -​ Planned within a few weeks or months Classification of Surgical Procedures -​ Thyroid disorders, prostatic hyperplasia, cataracts According to DEGREE OF RISK 4.​ Elective ; AMBULATORY 1.​ Minor -​ Should i have surgery? -​ life threatening high risk, extensive, -​ Client will not be harmed if not prolong, large amount of blood loss, performed but will benefit from it major or vital organs are involved, -​ Repair of scars, simple hernia, great risk of complications vaginal repair 2.​ Minor 5.​ Optional ; AMBULATORY -​ Non-life threatening less serious, -​ Personal preference but not required generally not prolong, few serious -​ Cosmetic surgery complications. According to LOCATION According to PURPOSE 1.​ Internal 1.​ Diagnostic -​ Inside the body 2.​ Exploratory -​ Surgery of tissues, organs involved 3.​ Curative beyond subcutaneous tissue 4.​ Palliative - to extend life 2.​ External 5.​ Cosmetic -​ Surgery within the dermis and epidermis According URGENCY 1.​ Emergent Classification based on INVASIVENESS -​ Without delay condition is life- 1.​ Non-invasive Surgery threatening requiring surgery -​ Closed reduction of fractured bone immediately 2.​ Minimally invasive surgery -​ Severe bleeding, bladder or intestinal -​ Laparoscopic surgery obstruction, fractured skull, gunshot 3.​ Invasive or stab wounds, extensive burns -​ Cesarean section 2.​ Urgent -​ Within 24 hours -​ Client requires prompt attention PREFIXES be familiar with greek/ latin name of organs 7.​ Appendectomy: Surgery to take out the a ** - absence of appendix. intra** -within 8.​ Transsphenoidal Hypophysectomy: angio** - vessel Removing a pituitary tumor through the vaso**- blood vessel nose. arhtro** - joint -​ Supratentorial extra** - outside -​ Infratentorial hemi**- half -​ Transsphenoidal baro** - pressure 9.​ Total Abdominal Hysterectomy: Removing para** - beside the uterus through the belly. endo** - inside trans** - across SUFFIXES **centesis- to puncture **ectomy - removal of **lysis- break up/ to destroy **opsy- to look at **oscopy- to view using a scope **ostomy- make an opening **otomy - to cut or make an incision **tripsy- to crush or break **plasty -to repair 1.​ Gastroscopy: A camera is used to check your stomach and food pipe. 2.​ Abdominal Paracentesis: Removing fluid from the belly with a needle. 3.​ Laparoscopic Cholecystectomy: Keyhole surgery to remove the gallbladder. 4.​ Lithotripsy: Breaking kidney or gallstones into smaller pieces. 5.​ Rhinoplasty: Surgery to reshape the nose. 6.​ Colostomy: Creating an opening in the belly Preoperative for stool to pass.  -​ Starts when a patient and the doctor agree -​ Relative; immediate, competent to make that a surgery will be performed decisions, underage -​ Ends when a patient is transferred to the OR table PREOPERATIVE CARE​ 1. Skin preparation Assessment -​ shaving -​ Demographic Data 2. Dietary restrictions -​ Health History -​ Nothing Per Orem -​ Clearances -​ 8 hours prior to general anesthesia -​ Relevant diagnostics and laboratory tests -​ 4 hours prior to epidural anesthesia -​ Allergies -​ No restrictions on local anesthesia -​ Current medications -​ Insurance What to expect inside the Operating Room -​ Vital signs 1.​ Difficulty to identify staff -​ Social support 2.​ Relatives are restricted -​ Baseline functional patterns - GORDONS 3.​ Cold room 4.​ Hear instruments and machines Diagnosis -​ What could happen if… Planning -​ Who should explain the surgical consent to the patient - SURGEON -​ NURSE is the witness Informed Consent 1.​ Name of patient 2.​ Name of surgical procedure 3.​ Name of surgeon 4.​ Potential risks 5.​ Potential benefits 6.​ Signature of the patient 7.​ Signature of the witness WHO SHOULD SIGN THE SURGICAL CONSENT? -​ Patient; is conscious and mentally fit Types of Anesthesia GOLDEN RULE IN OR : Sterile to Sterile, Clean to 1.​ Epidural Anesthesia Clean -​ Insertions of a spinal needle in to the lumbar spine before attaching the epidural catheter 2.​ Spinal Anesthesia -​ Side Lying position -​ Insertion of medicine in the lumbar area using a spinal needle -​ NO CATHETER 3.​ Regional Block Anesthesia -​ A certain region is numbed by anesthesia that affects across the body region -​ example : arm block anesthesia below the armpit 4.​ Local Anesthesia -​ Anesthesia injected into the muscles around the surgical site PATIENT EDUCATION What to expect during surgery? 1.​ Anesthesia or deep sleep 2.​ Numbness 3.​ No pain What to expect after surgery 1.​ Post-anesthesia Care Unit 2.​ Limitations in Movement 3.​ Post-Operative Pain 4.​ Post-Operative Medication 5.​ Early Ambulation 6.​ Dressing change and wound healing 7.​ Advance directives 8.​ Pain control 9.​ Surgical complications Intra-Operative -​ Head cover or Cap Turban -​ The intraoperative phase extends from the -​ Shoe cover or OR shoes time the client is admitted to the operating -​ Face mask room, to the time of anesthesia -​ Protective eye cover or goggles administration, and performance of the -​ Sterile gloves surgical procedure until the client is -​ Surgical gown transported to the recovery room or -​ Lead apron postanesthesia care unit (PACU) Surgical Hand Scrubbing Principles of Aseptic Technique -​ is the process of removing as many All materials in contact with the surgical wound microorganisms as possible from the hands or used within the sterile field must be sterile. and arms by mechanical washing & Gowns of the surgical team are considered sterile chemical antisepsis before participating in in front from the chest to the level of the sterile surgery. field. Sterile drapes are used to create a sterile field. PURPOSES: Only the top surface of a draped table is considered -​ to help prevent possibility of contamination sterile. of the operative wound by bacteria on the Items are dispensed to a sterile field by methods hands and arms. that preserve the sterility of the items and the integrity of the sterile field. Materials: The movements of the surgical team are from Scrub Sink sterile to sterile areas and from unsterile to Scrub Brush unsterile areas. Antiseptic Agents Movement around a sterile field must not cause -​ Chlorhexidine Gluconate contamination of the field. -​ Povidone-iodine Whenever a sterile barrier is breached, the area -​ Triclosan must be considered contaminated. -​ Alcohol Every sterile field is constantly monitored and -​ Parachlorometaxylenol maintained. Items of doubtful sterility are -​ Hexachlorophene considered unsterile. The routine administration of hyperoxia (high 3 Types of Scrub Method levels of oxygen) is not recommended to reduce 1.​ Time method surgical site infections. -​ Complete scrub (5-7 minutes) -​ Short Scrub (3 minutes) OR Attire 2.​ Brushless Method -​ Body Cover or Scrub Suit -​ Uses surgical hand scrub solution  3.​ Brush-stroke method or counted method The Scrub Nurse a.​ 20 strokes method ​ Performs the activities of the scrub role, 30 fingernails including performing hand hygiene 30 downward strokes for digits ​ Setting up the sterile equipment, tables and 30 circular strokes for hands and sterile field; preparing sutures, ligatures, forearms and special equipment (e.g., a laparoscope, b.​ 15 strokes method which is a thin endoscope inserted through 15 strokes on each 6 parts of each a small incision into a cavity or joint using hand fiber-optic technology to project live images of structures onto a video monitor); Surgical Team ​ Assisting the surgeon and the surgical The Patient assistants during the procedure by -​ As the patient enters the OR, he or she may anticipating the instruments and supplies feel either relaxed and prepared or fearful that will be required, such as sponges, and highly stressed. These feelings depend drains, and other equipment. to a large extent on the amount and timing ​ As the surgical incision is closed, the scrub of preoperative sedation, preoperative person and the circulating nurse count all education, and the individual patient. needles, sponges, and instruments to be sure that they are accounted for and not The Circulating Nurse retained as a foreign body in the patient ​ Manages the OR and protects the patient’s ​ Standards call for all sponges used in safety and health surgery to be visible on x-ray and for sponge ​ Monitoring the activities of the surgical counts to take place at the beginning of team, checking the OR conditions surgery and twice at the end (when wound ​ Assessing the patient for signs of injury and closure begins and again as the skin is being implementing appropriate interventions. closed). Tissue specimens obtained during ​ Verifying consent; if not obtained, surgery surgery are labeled by the person in the 1262 may not commence. The team is scrub role and sent to the laboratory by the coordinated by the circulating nurse, who circulating nurse. ensures cleanliness, proper temperature, humidity, appropriate lighting, safe function The surgeon of equipment, and the availability of -​ The surgeon performs the surgical supplies and materials. procedure, heads the surgical team, and is a licensed physician (MD or DO), oral surgeon (DDS or DMD), or podiatrist (DPM) who is specially trained and qualified. Qualifications and training must adhere to  Joint Commission standards, hospital standards, and local and state admitting practices and procedures (Rothrock, 2014) The Registered Nurse First Assistant -​ Practices under the direct supervision of the surgeon. RNFA responsibilities may include handling tissue, 1263 providing exposure at the operative field, suturing, and maintaining hemostasis (rothrock, 2014). The role requires a thorough understanding of anatomy and physiology, tissue handling, and the principles of surgical asepsis. The Anesthesiologist -​ A physician specifically trained in the art and science of anesthesiology. a crna is a qualified and specifically trained health care professional who administers anesthetic agents, has graduated from an accredited nurse anesthesia master’s program, and has passed examinations sponsored by the american association of nurse anesthetists. the anesthesiologist or crna assesses the patient before surgery, selects the anesthesia, administers it, intubates the patient if necessary, manages any technical problems related to the administration of the anesthetic agent. Post-Operative Major Goals Extends from the time the patient leaves the OR Restoration of optimal respiratory function until the follow up visit with the surgeon Relief of pain Nursing care focuses on reestablishing the Optimal cardiovascular function patient’s physiologic equilibrium, alleviating pain, Increased activity tolerance preventing complications, and teaching the patient Unimpaired wound healing self care. Maintenance of body temperature Maintenance of nutritional balance PACU - Post Anesthesia Care Unit Resumption of usual bowel and bladder Also called the recovery room or postanesthesia elimination recovery room Acquisition of sufficient knowledge to manage Kept clean, quiet, free of unnecessary equipment, self-care after discharge with indirect lighting, and well ventilated to help Absence of complications patients decrease anxiety and promote comfort Should be equipped with necessary facilities Initial Nursing Interventions 1.​ Maintaining a Patent Airway Phases of PostAnesthesia Care -​ Prevents aspiration Phase 1 -​ Put rubber, plastic or metal in the -​ Used during the immediate recovery phase, airway intensive nursing care is provided -​ Place patient in lateral position w/ Phase 2 neck extended -​ The patient is prepared for self-care or care -​ Deep breathing exercise in the hospital or an extended care setting -​ Auscultate lung sounds Phase 3 -​ Administer oxygen -​ Patient is prepared for discharge -​ Use of mechanical ventilator Contraptions COMMON RESPIRATORY COMPLICATIONS -​ IV Lines -​ Atelectasis ( alveolar collapse: inadequate -​ Jackson Pratt Drain lung expansion) -​ Chest Tube Drain -​ Pneumonia -​ Foley Catheter -​ Hypostatic pulmonary congestion -​ Central Line Access -​ Subacute hypoxemia -​ Endotracheal Tube -​ Episodic hypoxemia 2.​ Maintaining Cardiovascular stability -​ Take v/s (BP) every four hours -​ Monitor i&o COMMON CARDIO COMPLICATIONS -​ Post op dressing should be done by a 1.​ Hypotension member of the surgical team 2.​ Shock 3.​ Hypertension Reasons for application of dressing: 4.​ Dysrhythmias ​ To provide a proper environment for wound 5.​ Deep Vein Thrombosis healing ​ To absorb drainage 3. Promote Wound Healing ​ To splint or immobilize the wound FIRST INTENTION HEALING ​ To protect the wound and new epithelial -​ incision is a clean, straight and all layers of tissue from mechanical injury the wound are well approximated by ​ To protect the wound from bacterial suturing contamination and from soiling from feces, -​ If the wounds remain free from infection, it vomitus, and urine will not separate, heal quickly with a ​ To promote hemostasis; as in pressure minimum scarring dressing ​ To provide mental and physical comfort for SECOND INTENTION HEALING the patient -​ Occurs in infected wounds (abscess) or in wounds in which the edges have not been WOUND DEHISCENCE approximated. disruption of surgical incision or wound -​ When the post op wound is allowed to heal Management: by secondary intention, it is usually packed Apply a sterile non adherent (such as Telfa) or with a saline moistened sterile dressing, and saline dressing to the wound and notify the surgeon covered with a dry sterile dressing THIRD INTENTION HEALING WOUND EVISCERATION -​ Used for deep wounds that either have not protrusion of wound contents been sutured early or break down and are Management: resutured later, thus bringing together two Provide emotional support by explaining what opposing granulation surfaces happened and reassuring the client that the -​ Results in deeper and wider scars emergency will be handled competently Prepare the client for surgery to close the wound Prevention Examine the client’s skin for areas of redness or lost integrity Document and report abnormalities Use padding and positioning to relieve pressure CHANGING OF DRESSING  Treat any open areas according to the facility the bases, and changes in heart sounds (e.g. S3 guidelines and the surgeon’s prescription gallop) increase CVP. Ensure that information about the client’s skin -​ Monitor intake and output, excluding all condition in the PACU is communicated to the drains observe for bladder distention. medical-surgical nurse. -​ Inspect skin and tissue surrounding maintenance lines to detect early 4. Assessing Thermoregulation infiltration. Restart line immediately to -​ Monitor temperature hourly to be alert from maintain fluid volume. malignant hyperthermia or to detect hypothermia. 6.​ Promoting Comfort -​ A temperature over 37.7 c (100F) or under -​ Assess pain by observing behavioral and 36.1 c (97F) is reportable. physiologic manifestation -​ Monitor for post anesthesia shivering (PAS) -​ Administer analgesics (change in V/S maybe it is most significant in hypothermic result in pain) and document efficacy. patients 30 to 45 minutes after admission to -​ Position the patient to maximize comfort. the PACU. It represents a heat gain mechanism and relates to regaining thermal 7.​ Maintaining Safety balance. -​ Keep side rails up until the patient is fully -​ Provide a therapeutic environment with awake. proper temperature and humidity, when -​ Protect the extremity to which IV fluids are cold, provide the patients with warm running so the needle will not become blanket. accidentally dislodged. -​ Avoid nerve damage and muscles train by 5. Maintaining Adequate Fluid Volume properly supporting and padding pressure -​ Administer IV solution as ordered. areas. -​ Monitor electrolytes and recognize evidence -​ Recognize that the patient may not be able of imbalance such as nausea and vomiting, to complain of injury such as the pricking of weakness. an open safety pin or clamp that is exerting -​ Evaluate mental status, skin color and pressure. turgor and body temperature. -​ Check dressing for constriction. -​ Recognize signs of fluid imbalance -​ Determine return of motor control -​ Hypovolemia (decreased BP and following anesthesia indicated by how the urine output, decrease central patient responds to a pinprick or a request venous pressure (CVP), increase to move a part. pulse. -​ Hypervolemia – increase BP change in lungs such as crackles in  8.​ Managing Elimination 9. Minimizing the stress factors of sensory Complications: deficits a.​ Urinary retention- inability to urinate as a 1. Know that the ability to hear returns more result of the recumbent position, effects of quickly than other senses as the patient emerges anesthesia and narcotics, inactivity, altered from anesthesia. fluid balance, nervous tension or surgical 2. Avoid saying anything in the patient’s presence manipulation of the pelvic area. that may be disturbing, patients may appear to be Nsg Mgt: sleeping but still consciously hears what is being a.1 assess for bladder distension said. a.2 monitor I & O 3. Explain procedures and activities at the patient’s a.3 maintain IVF as prescribed level of understanding. a.4 increase daily oral intake 2500-3000L 4. Minimize the patient’s exposure to emergency of a.5 insert straight or IFC nearby patients by drawing lowering voice and a.6 promote normal urinary elimination noise level 5. Treat the patient as a person who needs as much b.​ Bowel elimination- frequently altered after attention as the equipment and monitoring devices. pelvic or abdominal surgery and sometimes 6. Respect the patient’s feeling of sensory after other surgery. Return to normal GI deprivation and over stimulation make adjustment function may be delayed by general to minimize this fluctuation of stimuli. anesthesia, narcotic analgesia, decreased 7. Demonstrate concern for and understanding of mobility or altered fluid and food intake the patients and anticipate needs and feelings. during perioperative period. 8. Tell the patients repeatedly that the surgery is over and that he or she is in the recovery room. Nursing Care: 1. Assess for return or normal peristalsis: 10. Relieving Pain dn Anxiety a. auscultate bowel sounds every 4 hours while the -​ Opioids are administered judiciously and client is awake often by IV in the PACU b. assess the abdomen for distention -​ The nurse monitors the patient’s c. determine whether the client is passing flatus physiologic status, manages pain, and d. monitor for passage of stool including provides psychological support consistency -​ If the patient’s condition permits, a close 2. Encourage ambulation within prescribed limits member of the family is allowed inside the 3. Facilitate a daily intake of fluids 2.5-3L PACU 4. Provide privacy when the patient is using the bedpan, commode or bathroom 5. If no BM has occurred for 3-4 days post op, a suppository or an enema may be ordered. 11. Controlling Nausea and Vomiting ​ N and V are common complaints in the PACU ​ The should intervene on the first complaint of nausea to prevent the progress of vomiting ​ Medicate for N and V such as metoclopramide(Plasil) ​ At the slightest indication of nausea, the patient is turned completely to one side to promote mouth drainage and prevent aspiration of vomitus. MEASURES TO DETERMINE READINESS FOR DISCHARGE IN THE PACU ​ Stable V/S ​ Orientation to person, place, events and time ​ Uncompromised pulmonary fxn ​ Adequate O2 saturation ​ UO at least 30ml/hr ​ N and V absent or under control ​ Minimal pain