PERIOPERATIVE-STUDS.ppt

PERIOPERATIVE NURSING Earl C. Cajandig, RN, RM, MAN Instructor 1  HISTORY OF SURGERY Ancient Surgery Trepanation - is the practice of making a hole in the skull. 2  HISTORY OF SURGERY Ancient Surgery Neolithic times - saws of s...

PERIOPERATIVE NURSING Earl C. Cajandig, RN, RM, MAN Instructor 1  HISTORY OF SURGERY Ancient Surgery Trepanation - is the practice of making a hole in the skull. 2  HISTORY OF SURGERY Ancient Surgery Neolithic times - saws of stone and bone were used to perform amputations. 3  HISTORY OF SURGERY Ancient Surgery Herbs and Remedies- homemade concoction (divine vs. evil). – No knowledge of the germ theory. – Evil -cause of illness 4 5  HISTORY OF SURGERY Ancient Surgery Indus Valley Civilization show evidence of teeth having been drilled. Ancient Egypt, where a mandible shows two perforations just below the root of the first molar, indicating the draining of an abscessed tooth. 6  HISTORY OF SURGERY INDIA Sushruta (Susruta or Sushrutha ) - “Father of Surgery” Sushruta Samhita is a book contains the first known description of surgical instruments & several operations. 7 8  HISTORY OF SURGERY EGYPT Ebers Papyrus - is considered as one of the oldest medical documents on medicine and the most important medical papyri. Imhotep -wrote the first treaty on surgery. Circumcision -oldest recorded engraving of a medical procedure. 9  Ebers Papyrus treatment for cancer 10 Circumcision 11  HISTORY OF SURGERY EGYPT The Egyptians have some knowledge of anatomy from making mummies. The Egyptians used clamps, sutures and cauterization. They had surgical instruments like probes, saws, forceps, scalpels and scissors. Honey– used to disinfect wounds. 12  HISTORY OF SURGERY CHINA Hua Tuo - first person to perform surgery with the aid of anesthesia (mafeisan). Bian Que (Pien Ch'iao) - was a "miracle doctor“. 13  HISTORY OF SURGERY Greece Hippocrates – “father of medicine” Claudius Galen – “father of experimental physiology” The Ancient Greeks bathed wounds with wine. 14 A number of ancient Greek surgical tools. On the left is a trephine; on the right, a set of scalpels. Hippocratic medicine made good use of these tools. 15  HISTORY OF SURGERY Surgery in the Middle Ages Europe in the 13th century a new type of craftsmen emerged in towns (barber- surgeon). They cut hair, pulled teeth and performed simple operations such as amputations and setting broken bones. 16 The barber-surgeon may be cutting a man's boil or shaving his neck. 17  HISTORY OF SURGERY Surgery in the 16th - 18th Century Leonardo Da Vinci - dissected some human bodies and made accurate drawings of what he saw. Andreas Vesalius - published a book called The Fabric of the Human Body contained accurate diagrams of a human body. 18  HISTORY OF SURGERY Surgery in the 16th - 18th Century Syringes were used to irrigate wounds with wine. William Stewart Halsted - introduced rubber gloves in surgery in 1890. 19  HISTORY OF SURGERY Surgery in the 16th-18th Century Ambroise Paré - a leader in surgical techniques and battlefield medicine. Horace Wells and William Morton -American dentists discovered anesthesia. 20  HISTORY OF SURGERY Surgery in the 16th-18th Century John Hunter - invented new procedures such as tracheotomy. Dominique-Jean Larrey - a Frenchman created the first ambulance service for wounded men. 21  HISTORY OF SURGERY Surgery in the 16th-18th Century William Harvey - discovered the process of blood circulation. Marcello Malpighi - an Italian anatomist identified the existence of tiny blood vessels. 22  HISTORY OF SURGERY Surgery in the 16th-18th Century Joseph Lister - discovered antiseptic surgery by spraying carbolic acid over the patient during surgery. Wilhelm Roentgen - discovered x-rays in 1895 Ignaz Semmelweiss and Oliver Wendell Holmes - determined cross contamination of bacteria (patients & doctors) 23  HISTORY OF SURGERY Surgery in the 19th – 20th Century 1900 - different blood types were identified. 1914 - the first successful blood transfusion was made. 1940s - the introduction of antibiotics in the further minimized the risk of postoperative infection. 24  HISTORY OF SURGERY Surgery in the 19th – 20th Century 1950s - the first kidney transplants were performed. 1953 - the development of the heart-lung machine by American surgeon John H. Gibbon allowed surgeons to more easily and successfully perform surgery on these organs. 1958 - the first pacemaker was made. 25  HISTORY OF SURGERY Surgery in the 19th – 20th Century 1960 - the first hip replacement surgery performed. 1960 - the laser was invented. 1962 - the first successful arm reattachment surgery. 26  HISTORY OF SURGERY Surgery in the 19th – 20th Century The first heart transplant was performed by Christiaan Barnard in 1967 The first artificial heart was installed in 1982. The first heart and lung transplant was performed in 1987. In 2008 a laser was used in keyhole surgery to treat brain cancer. 27  INTRODUCTION A person undergoes surgical procedure is likely to experience both psychological and physiological stress. Stressors can be reduced by careful planning and nursing interventions. Patient’s safety and dignity is paramount in surgical nursing. 28  PERIOPERATIVE NURSING Surgery –Defined as the art and science of treating diseases, injuries, and deformities by operation and instrumentation. 29  PERIOPERATIVE NURSING Terminology used to Describe Surgical Procedures Prefixes Meaning Example Angio- Of a vessel Angiography Chol- Bile Cholecystectomy Cysto- Of the bladder Cystectomy Gastro- Of the stomach Gastrostomy Laparo- Abdominal Laparotomy 30  PERIOPERATIVE NURSING Terminology used to Describe Surgical Procedures Suffixes Meaning Example -ectomy Removal of Appendectomy -oscopy Looking of Laparoscopy -ostomy Opening of Ileostomy -otomy Incision into Tracheotomy -orrhaphy Repair of Herniorrhaphy 31  PERIOPERATIVE NURSING Terminology used to Describe Surgical Procedures Suffixes Meaning Example -plasty Reconstruction of Cheiloplasty -pexy Repair of Orchidopexy -lysis Destruction of Hemolysis -therm Heat Diathermy -scopy Visualize Bronchoscopy 32  PERIOPERATIVE NURSING Surgery may be performed for any of the following PURPOSES: 1.Diagnostic – determine the presence and/or extent of pathology. (e.g., lymph node biopsy or bronchoscopy ) Biopsy - Confirms the diagnosis by histologic and cytologic analysis. 33 BIOPSY 34  PERIOPERATIVE NURSING Surgery may be performed for any of the following PURPOSES: 2.Curative – removes or repairs damaged, diseased, or congenitally malformed organs or tissues. 35  Classifications 2.Curative 2.A. Ablative Surgery –involves removal of diseased organs. E.g. (suffix used is “ectomy”) appendectomy, hysterectomy, oophorectomy, salpingectomy, mastectomy, pneumonectomy, tonsillectomy, cholecystectomy 36  Classifications 2.Curative 2.B. Reconstructive - is the partial or complete restoration of a damage organ or tissue to its original appearance or function. (e.g., repairing a severe burn scar, ORIF) 37  Classifications 2.Curative 2.C. Constructive Surgery – repairs a congenitally defective organ, improving its function and appearance. E.g.: Suffixes used are “plasty”, “pexy”, “orrhaphy” C.1. Palatoplasty – repair of the soft palate 38  Classifications C.2. Cheiloplasty – closure of cleft lip with in few days after birth to facilitate feeding and minimize psychologic trauma of patient. C.3. Orchidopexy – repair of undescended testes (cryptorchidism) C.4. Anoplasty – repair of the imperforated anus. C.5. Herniorrhaphy – repair of hernia 39 40  PERIOPERATIVE NURSING Surgery may be performed for any of the following PURPOSES: 3. Palliative – alleviation of symptoms without cure. (e.g., cutting a nerve root (rhizotomy), colostomy to bypass an untreatable bowel obstruction, debridement of necrotic tissues) 41  Nursing Alert Cancer basically is a systemic disease. Therapy is curative if the disease process can be totally eradicated but if NOT possible palliative therapy is used. 42  PERIOPERATIVE NURSING Surgery may be performed for any of the following PURPOSES: 4. Preventive (e.g., removal of the breast (breast Ca), removal of colon in pt. with familial polyposis (colorectal Ca) 5. Explorative – surgical examination to determine the nature or extent of a disease. (e.g. , Exploratory Laparotomy) 43 Explorative 44  PERIOPERATIVE NURSING Categories of Surgery Based on Urgency Classification 1.Emergent – pt. requires immediate attention; (life threatening) Indication for Surgery – w/out delay Examples: severe bleeding, bladder or intestinal obstruction, fractured skull, gunshot or stab wounds, extensive 45 burns, ruptured AP, uterine atony  PERIOPERATIVE NURSING Categories of Surgery Based on Urgency Classification 2. Urgent – pt. requires prompt attention. Indication for Surgery – w/in 24- 30hrs. Examples: kidney or ureteral stones, appendicitis, acute bladder infxn 46  PERIOPERATIVE NURSING Categories of Surgery Based on Urgency Classification 3. Required – patient needs to have surgery Indication for Surgery – plan within a few weeks or months Examples: BPH w/out BO, thyroid disorders, cataracts, uterine fibroids, hemorrhoids 47  PERIOPERATIVE NURSING Categories of Surgery Based on Urgency Classification 4. Elective – (scheduled); patient should have surgery Indication for Surgery – failure to have surgery is NOT catastrophic. Examples: repair of scars, simple hernia, vaginal repair 48  PERIOPERATIVE NURSING Categories of Surgery Based on Urgency Classification Optional – decision rests with patient. Indication for Surgery – personal preferences (cosmetic surgery) 49  PERIOPERATIVE NURSING Examples: E.g. Cosmetic Surgery 1. Rhinoplasty – reshaping of the nose 2. Otoplasty – repair for both external ears as a result of burn or traumatic avulsion. 3. Rhytidoplasty –“face lift”. Repair of facial muscles and skin. 50  PERIOPERATIVE NURSING 4. Blepharoplasty –excision of fats to correct deformities of the upper or lower eyelids of one or both eyes. 5. Mentoplasty – repair of the chin to change its shape and size. 51  PERIOPERATIVE NURSING 6. Soft tissue augmentation - fat transplantation and may be done by miniliposuction. 7. Hair replacement - surgical technique that involves moving individual hair follicles from one part of the body (the donor site) to bald or balding parts (the recipient site). 52 53 54 According to Degree of Risk (Magnitude/Extent) 1.Major Surgery 2.Minor Surgery 55  According to Degree of Risk (Magnitude/Extent) 1. Major Surgery Criteria: -High risk (morbidity, mortality) -Extensive -Prolonged -Large amount of blood loss -Vital organs (handled or removed) -Great risk of complications 56  According to Degree of Risk (Magnitude/Extent) 2. Minor Surgery Criteria: -Generally not prolonged -less complications involve -Involves less risks 57  Common Preoperative Diagnostic Tests/Laboratory Exams 1. Urinalysis -used to assess renal status, hydration, urinary tract infection, and disease. 2. Chest X-ray - used to assess pulmonary disorders, cardiac enlargement. 58  Common Preoperative Diagnostic Tests/Laboratory Exams 3. Blood studies: RBC, Hb, Hct, WBC, WBC differential -used to assess anemia, immune status, infection 4. Electrolytes -used to assess metabolic status, renal function, diuretic side effects. 59  Common Preoperative Diagnostic Tests/Laboratory Exams 5. ABGs, oximetry -used to assess pulmonary and metabolic function. 6. PT, PTT, INR, platelet count -used to assess bleeding tendencies. 60  Common Preoperative Diagnostic Tests/Laboratory Exams 7. Blood Glucose - used to assess metabolic status and DM. 8. Creatinine - used to assess renal function. 61  Common Preoperative Diagnostic Tests/Laboratory Exams 9. Blood Urea Nitrogen (BUN) - used to assess renal function. 10. Serum Albumin - Used to assess nutritional status. 62  Common Preoperative Diagnostic Tests/Laboratory Exams 11. Electrocardiogram (ECG) -used to assess cardiac diseases, electrolyte abnormalities. 12. Pulmonary Function Studies - used to assess pulmonary status. 13. Liver Function Tests - used to assess liver function. 63  Common Preoperative Diagnostic Tests/Laboratory Exams 14. Type and Crossmatch -used to assess blood availability for replacement. 15. HCG -used to assess pregnancy. 64 THREE PHASES OF SURGICAL EXPERIENCE 65  Perioperative Nursing Describes the nursing functions in the total surgical experience of the patient. Nursing care provided to surgery patients during the entire inpatient period. Surgical conscience must observed. 66  ATTRIBUTES OF A PERIOPERATIVE CAREGIVER EMPATH CONSCIENTIOUSNES Y S EFFICIENC SENSITIVIT Y Y OPEN MINDED 67  ATTRIBUTES OF A PERIOPERATIVE CAREGIVER FLEXIBLE & SUPPORTIV ADAPTABLE E COMMUNICATIV LISTEN E S EVEN TEMPERED 68  ATTRIBUTES OF A PERIOPERATIVE CAREGIVER VERSATIL SENSE OF E HUMOR CREATIV E ANALYTIC MANUAL DEXTERITY 69  ATTRIBUTES OF A PERIOPERATIVE CAREGIVER STAMINA HYGIENE ETHICS CURIOSITY 70 Behaviors: Self-confidence (or diffidence) Interest (or apathy) Proficiency (or incompetence) Authority (or indecisiveness) 71  PERIOPERATIVE NURSING 3 Phases of Surgical Patient 1.Preoperative 2.Intraoperative 3.Postoperative 72  PREOPERATIVE Extends from the time the decision is made for surgical intervention to the transfer of the patient to the operating table. 73  CONSENT General Consent -is signed by patient or pt’s legal guardian on admission. -health care team are authorized to render routine care/treatment. 74  Legal Preparation for Surgery Informed Consent  is a process – not just a document.  surgeon’s responsibility (benefits, risks, alternative therapy, complications, disability) verbally explained to pt’s understanding before the treatment. 75  Legal Preparation for Surgery Validation of Consent -voluntary -informed -legal age (18) -mentally competent -given before premedication or going to OR 76  Legal Preparation for Surgery Validation of Consent (who will sign the consent?) minor unconscious minor mentally (emancipated, incompetent married) Cognitively mentally impaired incapacitated 77  Legal Preparation for Surgery Note: -witnessing (1 or more) a consent by authorized people. -In case of emergency, lifesaving measures are given even w/o IC. -right to refuse a surgical procedure. -signed consent form is placed in a prominent place on the pt’s chart 78  PREOPERATIVE PHASE The aim of preoperative care is to ensure that each patient receives holistic preparation for a safe and dignified surgical experience. 79  PREOPERATIVE PHASE Nursing Responsibilities Preadmission Testing 1.Initiates initial preoperative assessment. 2.Initiates teaching appropriate to pt’s. needs. 3. Involves family in interview. 80  PREOPERATIVE PHASE Nursing Responsibilities Preadmission Testing 4.Verifies understanding of surgeon- specific preoperative orders (e.g. bowel preparation, preoperative shower) 5.Assess pt’s. need for postoperative transportation and care. 81  PREOPERATIVE PHASE Nursing Responsibilities Admission to Surgical Center or Unit 1.Completes preoperative assessment. 2.Assess for risks for postoperative complications. 3.Report unexpected findings or any deviations from normal. 82  PREOPERATIVE PHASE Nursing Responsibilities Admission to Surgical Center or Unit 4.Verifies that operative consent has been signed. 5.Coordinates pt. teaching with other nursing staff. 6.Reinforces previous teaching. 83  PREOPERATIVE PHASE Nursing Responsibilities Admission to Surgical Center or Unit 7.Explains phases in perioperative period and expectations. 8.Answers pt’s. and family’s questions. 9.Develop a plan of care. 84  PREOPERATIVE PHASE Nursing Responsibilities In the Holding Area 1.Assesses pt’s. status, baseline pain and nutritional status. 2. Review chart. 3. Identifies patient. 4.Verifies surgical site and marks site per institutional policy. 85  PREOPERATIVE PHASE Nursing Responsibilities In the Holding Area 5.Establishes intravenous line. 6.Administers medications if prescribed. 7.Takes measure to ensure pt’s. comfort. 8.Provides psychological support. 86  PREOPERATIVE PHASE Nursing Responsibilities Psychological Assessment and Care Fear of the unknown, anesthesia, pain, death, disturbance of body image, & worries. Nursing Actions: explore client’s feelings, allow pt. to speak openly, give accurate information about surgery, & be empathetic. 87  PREOPERATIVE PHASE Nursing Responsibilities General Physical Preparations Before Surgery -correct any dietary deficiencies -correct fluid and electrolytes imbalances -restore adequate blood volume with BT -treat chronic diseases (DM, HPN) -treat any infectious diseases 88  PREOPERATIVE PHASE Nursing Responsibilities Teaching Preoperative Exercises -Diaphragmatic Deep Breathing Exercise -Incentive Spirometry -Coughing Exercises (splinting of chest) -Turning Exercises -Foot & leg exercises 89 90  PREOPERATIVE PHASE Nursing Responsibilities Preparing the Pt. the Evening Before Surgery -Preparing the skin (full bath) -Preparing the G.I. Tract (NPO, enema) -Preparing for Anesthesia (no alcohol & smoking for @ least 24hrs b4 surgery -Promoting rest & sleep (sedative as ordered) 91  PREOPERATIVE PHASE Nursing Responsibilities Preparing the Pt. on the Day of Surgery Early Morning Care -morning bath, mouth wash -provide clean gown -remove cosmetics, dentures, contact lenses, hearing aid, jewelry and prostheses. 92  PREOPERATIVE PHASE Nursing Responsibilities Preparing the Pt. on the Day of Surgery Early Morning Care -take baseline VS before preop medication -check ID band, skin prep -check for special orders (enema, G.I. tube insertion, IV line) 93  PREOPERATIVE PHASE Nursing Responsibilities Preparing the Pt. on the Day of Surgery Early Morning Care -check NPO -let pt. void before preoperative medication -continue to support emotionally -accomplish “preoperative care checklist” 94  Preoperative Phase Decision Preparation (Holistic and Legal) OR 95 INTRAOPERATIVE PHASE Earl C. Cajandig, RN, RM, MAN Instructor 96  INTRAOPERATIVE Extends from the time the client is admitted to the operating room, to the time of administration of anesthesia, surgical procedure is done, until the patient is transported to the RR/PACU. 97  INTRAOPERATIVE PHASE Physical Environment of OR Operating Room -it is controlled geographically, environmentally, and bacteriologically, and it is restricted in terms of the inflow and outflow of personnel. -it should be adjacent to the PACU, and SICU. 98 99  INTRAOPERATIVE PHASE Anesthesia -in Greek “negative sensation” -absence of all sensation, induced by an anesthetic substance/agent. -it is a state of narcosis, analgesia, relaxation, and reflex loss. 100  INTRAOPERATIVE PHASE Goal of Anesthesia: to facilitate faster return to baseline function and thereby decrease the risk of anesthesia. 101  INTRAOPERATIVE PHASE Choice of Anesthesia No ideal agent or technique is suitable for all patients: -is made by the anesthesiologist -low morbidity & mortality -safe agent and technique -produce minimum side effects -potent, rapid onset & easy reversibility 102  INTRAOPERATIVE PHASE Main Types of Anesthesia *General Anesthesia (IV or inhalation) *Regional Block Anesthesia (Spinal, Epidural, & Peripheral nerve blocks) *Local Anesthesia *Moderate sedation 103  INTRAOPERATIVE PHASE Types of Anesthesia 1. General Anesthesia -is the loss sensation with loss of consciousness. -patient isn’t arousable, not even to painful stimuli. 104  INTRAOPERATIVE PHASE Types of Anesthesia 1. General -skeletal muscle relaxation, impaired ventilation and cardiovascular function and elimination of coughing & gagging reflex. -administered IV, or by inhalation (“ane”). 105 106  INTRAOPERATIVE PHASE Types of Anesthesia 1. General (commonly used agents) INTRAVENOUS INHALATION Thiopental Na Nitrous oxide Propofol Halothane Fentanyl Enflurane Ketamine Sevoflurane Diazepam Desflurane 107 INTRAVENOUS 108 Physiologic Monitor Flow- Through Reservoir Vaporizer “Breathin” Bag Flowmeters Ventilator for Gases Carbon Dioxide Canister 109  INTRAOPERATIVE PHASE Types of Anesthesia 1. General Is usually used in pt: Requires significant skeletal muscle relaxant Extremely anxious Uncooperative Refused or contraindicated 110  INTRAOPERATIVE PHASE 1. General Four Stages of General Anesthesia 1.Stage I: Beginning/Induction -extends from administration of anesthetic agent to the time of loss of consciousness. -Nsg. Care: assist during induction, close OR doors, keep OR quiet, no unnecessary motions 111  INTRAOPERATIVE PHASE 1. General Four Stages of General Anesthesia 2. Stage II: Excitement -extends from the time of loss of consciousness to relaxation. -susceptible to external stimuli -Nsg. Care: restrain pt, remain quietly at pt’s side, but ready to assist anes. 112  INTRAOPERATIVE PHASE 1. General Four Stages of General Anesthesia 3. Stage III: Surgical Anesthesia -extends from relaxation to the loss of the most reflexes, depressed vital fxn. -surgical procedure is STARTED. -Nsg. care: position patient and prepare skin only when indicated. 113  INTRAOPERATIVE PHASE 1. General Four Stages of General Anesthesia 4.Stage IV: Danger -too much anesthesia has been given -extends from too depressed vital functions to respiratory & cardiac failure. -Nsg. care: D/C anesthesia, prepare for CPR. 114  INTRAOPERATIVE PHASE 5 Objectives of General Anesthesia 1.Oxygenation -brain tissues must be perfused w/ O2 blood. -Note: color of blood, amnt & kind of bleeding, pulse oximetry, monitor vital fxns. 115  INTRAOPERATIVE PHASE 5 Objectives of General Anesthesia 2.Unconsciousness -pt remains asleep and unaware during the surgical procedure. 3.Analgesia -pt must be free of pain during the surgery. 116  INTRAOPERATIVE PHASE 5 Objectives of General Anesthesia 4.Muscle Relaxation -must be constantly assessed to provide necessary amount of drugs. 5.Control of Autonomic Reflexes -anesthetic agents affect cardiovascular & respiratory systems. 117  INTRAOPERATIVE PHASE 2. Regional Anesthesia -injection of anesthetic agent around a specific/group of nerve to interrupt pain impulses. -Techniques:  Nerve block  Spinal  Epidural 118  INTRAOPERATIVE PHASE 2. Regional Anesthesia -Techniques:  Nerve block -nerve is anesthetized to interrupt sensory, motor and sympathetic transmission. 119  INTRAOPERATIVE PHASE 2. Regional Anesthesia -Techniques:  Nerve block -Ex.: paravertebral anesthesia (chest & abdominal wall), radial or ulnar block (elbow or wrist), brachial plexus block/axillary block (arm), penile block, transsacral (caudal) block (perineum & lower abdomen) 120 121  INTRAOPERATIVE PHASE 2. Regional Anesthesia -Techniques: (Spinal & Epidural) SPINAL EPIDURAL SITE SITE injection of drug injection of @ subarachnoid anesthetic agent space (L 4-5) @ epidural space 122 Upper needle lies in the subarachnoid space for the injection of the anesthetic..A small catheter is inserted through the needle into the epidural space after which the needle is removed leaving the catheter in place. 123 SPINAL 124 EPIDURAL 125  INTRAOPERATIVE PHASE 2. Regional Anesthesia -Techniques: (Spinal & Epidural) SPINAL EPIDURAL USE USE abdominal, pelvic, SAME; post inguinal, lower operative pain extremity, & management urologic 126 procedures  INTRAOPERATIVE PHASE 2. Regional Anesthesia -Techniques: (Spinal & Epidural) SPINAL EPIDURAL ABSORPTION ABSORPTION anesthetic is anesthesia is becoming “fixed” prolonged (CSF – BS) (DM– CSF –BS) rapid onset(2-5mins) slow onset(15-20mins) 127  INTRAOPERATIVE PHASE 2. Regional Anesthesia -Techniques: (Spinal & Epidural) SPINAL EPIDURAL Identification of Identification of the subarachnoid the epidural space space When CSF Using the loss of appears resistance technique 128  INTRAOPERATIVE PHASE 2. Regional Anesthesia -Techniques:  Spinal or Epidural Anesthesia -position pt into knee-chest/C or sitting. -Note: inform pt site prep. (aseptic technique) & possible outcome of insertion. Monitor BP pre-intra-post operative. 129 Knee-Chest Position Sitting Position 130  INTRAOPERATIVE PHASE 2. Regional Anesthesia -Techniques: (Spinal & Epidural) SPINAL EPIDURAL ADVANTAGES ADVANTAGES pt is conscious Decreased case of: throat reflexes are hypotension maintained headache no respiratory neurological depression complications 131  INTRAOPERATIVE PHASE 2. Regional Anesthesia -Techniques: (Spinal & Epidural) SPINAL EPIDURAL DISADVANTAGES DISADVANTAGES circulatory more difficult depressant effect technique hypotension unpredictable stasis of blood time consuming sensitivity to agent large dose of agent 132  INTRAOPERATIVE PHASE 3. Local Anesthesia -is the injection of anesthetic agent into the tissues at the planned incision site. -it is combined w/ a local regional block (injection around the nerve) 133  INTRAOPERATIVE PHASE 3. Local Anesthesia -agents used ends w/ “caine” -technique: simple local infiltration and topical -often given in combination w/ epinephrine -LAST may develop when bolus of LA is accidentally injected in the blood vessels 134  INTRAOPERATIVE PHASE 3. Local Anesthesia 135  INTRAOPERATIVE PHASE 3. Local Anesthesia Advantages:  Simple, economical & nonexplosive  Less equipment to be used  Postoperative recovery is brief 136  INTRAOPERATIVE PHASE 3. Local Anesthesia Advantages:  No loss of consciousness  Suitable for pt who ingested food or fluids  Ideal for short and minor surgical procedures 137  INTRAOPERATIVE PHASE 3. Local Anesthesia Disadvantages:  not practical for all procedures  rapid absorption of drug in the bloodstream (harmful)  apprehension may increase 138  INTRAOPERATIVE PHASE 3. Local Anesthesia Contraindication:  Allergic sensitivity  Local infection or malignancy @ the site of injection  Extreme nervousness or inability to cooperate 139  INTRAOPERATIVE PHASE 4. Moderate Sedation -previously referred to as conscious sedation -involves the IV administration of sedatives or analgesics -reduce pt anxiety and control pain 140  INTRAOPERATIVE PHASE 4. Moderate Sedation -commonly used in short-term surgical procedures (diagnostic or therapeutic) 141  INTRAOPERATIVE PHASE Complications of Anesthesia 1.Anesthesia Awareness -Patient may experienced partially awake while under GA Greatest risk: cardiac, obstetric, major trauma pt Prevention: premedication w/ anesthetic agents and avoidance of muscle paralytics 142  INTRAOPERATIVE PHASE Complications of Anesthesia 2.Nausea, Vomiting, and Pain Cause: manipulation of the abdominal cavity, cerebral ischemia Management: turn head to side, suctioning, antiemetics, citric acid or antacids 143  INTRAOPERATIVE PHASE Complications of Anesthesia 3.Spinal Headache Cause: large needle, CSF leakage Management: quiet environment, supine bed rest, keep hydrated 144  INTRAOPERATIVE PHASE Complications of Anesthesia 4.Severe Hypotension and Respiratory Depression Cause: vigorous movement, high spinal anesthesia (total spinal) Management: avoid vigorous movement, O2 support or mechanical ventilation, IV fluids 145  INTRAOPERATIVE PHASE Complications of Anesthesia 5.Anaphylaxis (life-threatening acute allergic reaction) Cause: exposure to antigen or substance (meds or latex gloves) Management: discontinue, epinephrine (vasoconstriction), Diphenhydramine (Benadryl), intubation (cardiac and respiratory arrest) 146  INTRAOPERATIVE PHASE Complications of Anesthesia 6.Hypoxia, Respiratory and Cardiac Arrest, Urinary retention, Paralysis Cause: ↑ anesthetic agent, aspiration, nerve damage Management: monitoring of VS & O2 sat, mechanical ventilation, IV therapy, CPR, rehabilitation, catheterization 147  INTRAOPERATIVE PHASE Complications of Anesthesia 7.Hypothermia -body temp. lower than 36.6ºC Cause: low temp in the OR, infusion of cold flds, open body wounds, advanced age, meds Management: OR temp is set at 25-26.6ºC, warm solution to be used, use thermal blanket & minimize body exposure 148  INTRAOPERATIVE PHASE Complications of Anesthesia 7.Malignant Hyperthermia -rare inherited muscle disorder that is chemically induced by anesthetic agents Cause: triggered by inhalation of anesthetic agents and muscle relaxants Management: Goal: decrease metabolism, reverse metabolic and respiratory acidosis, dec. temp, provide 02, use of dantrolene 149  INTRAOPERATIVE PHASE Types of Surgical Incision 1. Butterfly – for craniotomy 2. Limbal – for eye surgeries 3. Halstead/Elliptical – for breast surgeries 4. Abdominal – for abdominal surgeries 5. McBurney’s – for appendectomy 6. Lumbotomy/Transverse – for kidney surgeries. 150  INTRAOPERATIVE PHASE Types of Surgical Incision 7. Subcostal – GB, biliary tract surgery 8. Paramedian Right side – biliary tract, GB Left side – splenectomy, gastrectomy 9. Midline (lower) – female reproductive tract 10. Pfannestiel – gynecologic surgery. 151 152 153 154  INTRAOPERATIVE PHASE Positioning the Client for Surgery Remember: - explain the purpose - avoid undue pressure on body parts - strap to prevent falls - maintain adequate respiratory & circulatory function, and ensure good body alignment. 155  INTRAOPERATIVE PHASE Positioning the Client for Surgery 1. Supine (Back-lying position) -recommended for mastectomy, herniorrhaphy, abdominal surgeries 2. Lithotomy -supine with legs flexed and supported on stirrups (e.g., D&C, perineal/vaginal repair) 156 Supine Lithotomy 157  INTRAOPERATIVE PHASE Positioning the Client for Surgery 3. Trendelenburg -head positioned downward -abdominal & gynecological surgery 4. Reverse Trendelenburg -head positioned upward -abdominal & gynecological surgery 158 Trendelenburg Reverse Trendelenburg 159  INTRAOPERATIVE PHASE Positioning the Client for Surgery 5. Modified Fowler’s/Sitting Position -may lead to hypotension 6. Lateral/Side Lying -kidney and thoracic surgery 7. Prone -respiration is restricted 8. Jacknife (Kraske Position) 160 Sitting Jacknife (Kraske Position) 161  Intraoperative Phase OR Induction of Anesthesia Surgical Procedure PACU/RR 162