PeriOperative Nursing PDF

PERIOPERATIVE NURSING WEEK 9 Mr. Francis Vasquez October 25, 2021 - DAY 1 - 1. Purpose...

PERIOPERATIVE NURSING WEEK 9 Mr. Francis Vasquez October 25, 2021 - DAY 1 - 1. Purpose CLASSIFICATION OF SURGERY PERIOPERATIVE NURSING a. Curative - Identification of the physiological, psychological, social and - perform to remove or repair damaged disease spiritual needs of the client and the formulation of an or congenitally malformed organ tissue individualized plan of care before, during and after surgery. i. Ablative surgery - Pre-operative nurses: Surgical ward - removal of the diseased organ - Intra-operative nurse: Operating room - ectomy - Post-operative nurse: Recovery room / Post anesthesia care Ex: hysterectomy, appendectomy, unit thyroidectomy, gastrectomy ii. Palliative surgery PHYSIOLOGICAL NEEDS OF THE CLIENT PRE-OP (Safety needs) - removal of signs and symptoms a. Informed consent and prevent complications b. Enema - relives symptoms but does not cure c. Hydration the underlying disease d. NPO Ex: Colostomy, Below knee amputation e. Skin preparation b. Diagnostic f. Teaching post-operative exercises - aids the doctor in diagnosing the patient - makes it possible to verify a suspected PSYCOLOGICAL NEEDS OF THE CLIENT PRE-OP diagnosis or to determine the cause of a. Anxiety – without known cause symptoms ▪ Fear of the unknown - -oscopy (visualization) b. Fear – with known cause Ex: Colonoscopy, Endoscopy, Laryngoscopy, ▪ Fear of anesthesia Bronchoscopy, Biopsy (examination of tissue) ▪ Fear of pain c. Exploratory ▪ Fear of death - enables the surgeon to estimate the extent of ▪ Fear of disturbance in body image the disease and at the same time to make or To allay fear and anxiety, educate the patient about the procedure and confirm the diagnosis tell him/her that anesthesia will be administered to prevent pain during Ex: exploratory laparotomy the surgery. -otomy (creation of opening) -ostomy (keeping the opening open; incision) SAFETY NEEDS OF THE CLIENT INTRA-OPERATIVE a. Infection control 2. Location b. Surgical count a. External c. Monitoring vital signs Ex: Skin grafting, wart removal, rhinoplasty d. Monitoring blood loss (circulating nurse and anesthesiologist) b. Internal - Weighing of soaked sponges vs. intake of IV fluid Ex: Cs, hysterectomy, exploratory laparotomy - Check suction bottle - Check for urine output 3. Mode 2 conditions amenable for surgery PSYCOLOGICAL AND SOCIAL NEEDS OF THE CLIENT congenital (inborn defects) a. Separation anxiety acquired (injuries; condition coming from a disease b. Unfamiliar faces in the operating room process) - patient only recognizes the surgeon a. Constructive – covers congenital inborn defects - Pre-operative visit of operating surgeon, Ex: Cleft palate repair, choanal atresia, breast anesthesiologist, and scrub nurse to meet the augmentation psychological and social needs b. Reconstructive – covers acquired Ex: Open reduction due to multiple compound THREE PHASES OF PERI-OPERATIVE NURSING fracture 1. Pre-operative – from admission to OR 2. Intra-operative – from OR to RR/ PACU 4. Degree of risk 3. Post-operative – from RR/PACU to complete wound healing Factors to consider: of patient Organ involved Age of the patient Duration of surgery Expected amount of blood loss  Extent of injury SURGICAL TEAM Type of anesthesia Sterile team members a. Major surgery a. Operating surgeon - extensive reconstruction or alteration in body - graduate of medicine parts - board passer - high risk/ greater risk for infection - undergone residency training on surgery - extensive Roles: - prolonged 1. Pre-operative judgement (he was the one who - large amount of blood loss diagnosed the patient) - vital organ may be handled or removed 2. Intra and post operative management of the Ex: coronary artery bypass, gastric resection patient b. Minor surgery 3. Preoperative medical history and physical - minimal alteration of body parts assessment - generally not prolonged 4. Performance of the operative procedure - leads to few serious complications according to the needs of the patients - involves less risk 5. The primary decision maker regarding surgical Ex: Cataracts, tooth extraction technique to use during the procedure 6. May assist with positioning and prepping the 5. Urgency patient or may delegate this task to other a. Emergency members of the team - surgical procedure must be done ASAP or b. Assistants of the surgeon within 12-24 hrs. i. Physician Ex: Appendectomy, exploratory laparotomy related ii. Non-physician (clerks, interns, senior scrub nurse) to multiple gunshot wound, control of hemorrhage, Roles: intestinal repair perforation, CS related to fetal 1. Clamps bleeding blood vessel distress 2. Cuts the suture b. Urgent 3. Suctions the blood from the operative site - surgery must be done within 48 hours 4. Retracts the operative site Ex: Intestinal surgery, excision of malignant tumor, 5. Places pressure dressing gallbladder 6. Labels specimen (identify the organ, measure the c. Elective dimension) - scheduled based on the time preference of c. Scrub nurse the physician - graduate of BSN Ex: repeat CS - board passer i. Required - in the Philippines, you become an OR nurse based - patient must undergo the surgery but it can on your area of assignment be delayed - in other countries, you will need a certification - delaying it may result to so degree of where you will be trained and undergo skills discomfort, pain or disability assessment: Certified Nurse in Operating Room Ex: Cataract surgery, tumor removal (CNOR) good for 2 years. Examination will be ii. Cosmetic needed for renewal. - done to improve client’s self-worth/ esteem - RNFA (Registered nurse first assistant of the - for aesthetic purposes surgeon) – CNOR needed Roles: VAGINAL BIRTH AFTER CESARIAN SECTION (VBAC) 1. Performs the surgical count - patients with low transverse Cesarean section may undergo VBAC 2. Main concern is patient due to the cut being along the striation of muscle fiber Unsterile team members OBJECTIVE AND PURPOSES OF SURGERY a. Anesthesiologist To cure - MD To relieve pain - undergone residency training in anesthesiology To prolong life (oophorectomy) Roles: To maintain dynamic body equilibrium (removal of cataract) 1. Interprets intake and output To treat and prevent infection (wound debridement) b. Circulating nurse To correct deformities or defects (reconstructive rhinoplasty) - graduate of nursing To ensure the ability of the client to earn a living - board passer (herniorrhaphy)  Roles: b. Chemical 1. Witness and documents the surgical count Alcohol – 70% alcohol dries the protein of 2. Turns on suction machine microorganism. This is the most commonly used 3. Monitors urine output method of disinfection. 4. Maintains communication link inside and Chlorine – is used to disinfect bed linens. outside the OR Iodine – Betadine 5. Monitors aseptic technique of the whole OR ▪ Betadine 7.5% (skin cleanser) – yellowish team solution 6. Overall clinical instructor of the nursing ▪ Betadine 10% (antiseptic) – dark brown students solution. Used in lumbar preparation. c. Other adjunct personnel – enters the OR when needed In abdominal preparation, betadine 7.5% first X-ray technician followed by 10%. Before you apply the 10%, MedTech remove the 7.5% to avoid irritation. Pedia Phenol – for appendectomy. It is used to kill Cardiologist microorganism in the lumen of the appendix. The phenol has a burning effect so it will burn the CONCEPT OF ASEPSIS lumen/ cut of the appendix to stop bleeding. Alcohol Medical asepsis – practices or processes that decrease the number and is the antidote for phenol to stop the burning. limit the spread of microorganisms Phenol promotes coagulation and has an antiseptic Surgical asepsis – practices or processes that render an object or area effect. totally free from microorganisms STERILIZATION a. Medical Asepsis (clean technique) – processes that will a. Physical decrease the number and limit the spread of microorganism. Autoclave To achieve this, disinfection is done. Radiation – UV light Disinfection – killing microorganisms except Gas – there are instruments that cannot be spores autoclaved like sharps because the sharpness Spores might decrease when being subjected to autoclave. - in a vegetative/ dormant stage with Lenses were also not autoclaved because it can protective covering burst inside. An example of gas is ETO (ethylene - encapsulated oxide) - the protective covering is heat and b. Chemical chemical resistant Soaking/ Immersion – Cidex is used most of the - to destroy the protective covering, 130 time. degrees Centigrade or 270 degrees Fahrenheit EARLE SPAULDING’S CLASSIFICATION OF PATIENT CARE ITEMS - Autoclave can destroy microorganism. Its CLASSIFICATION USE STERILIZATION temperature rises beyond 100 C because OR it builds up pressure. Moist heat enters DISINFECTION the autoclave. CRITICAL Cuts intact skin and mucous S b. Surgical asepsis (sterile technique) – practices that will membrane. Enters vascular render an object or area totally free from microorganism. To areas of the body. achieve this, sterilization is done. SEMI-CRITICAL Used on non-intact skin and S or if NA D mucous membrane Sterilization – killing or destroying all NON-CRITICAL Used on intact skin and D microorganisms including spores mucous membrane Critical: surgical instruments, catheters, gauze, needles DISINFECTION Non-critical: Kelly pad, urinal, bed pans, stethoscope, BP app a. Physical Boiling – object is directly submerged in water. Timing starts the moment the water begins to boil. Boiling is done for 10 minutes. Steaming – allow moist heat to come in contact of object being disinfected Sunlight – a weak method of disinfection because the ultraviolet rays from the sun is weak. There are bacteria (tubercle bacilli) that cannot stand the UV light from the sun.  Activated Cidex is the cheapest therefore it is commonly used Automate endoscopic high-level disinfector – can be used as gas sterilizer for fogging. One time used only. Cidex OPA 0.55% is only used for emergency cases. Low level disinfection kills some fungi and some viruses but not bacteria Intermediate level disinfection kills fungi, viruses and some bacteria High level disinfection – all are destroyed except spores Sterilization – all including spores  - functionality of the operating room. This also keeps - DAY 2 - tract of the items that are near expiration. PACKING MATERIALS 1. Muslin/ Linen SOAKING - these have micro holes which can be penetrated by Ideally, 3 soaking trays will be used in the operating room. dust and microorganisms - If you have already soaked items in the soaking tray, soaking - 3 layers of Muslin must be used to delay entrance a new set while there are still soaked ones in place promotes of dust recontamination. - labeling is needed for the packed instrument - make sure to dry the equipment before placing them in the - most widely used because it is reusable tray. The water on wet equipment may dilute the Cidex, 2. Paper therefore the potency and efficacy will be reduced. Always - special paper that has wax to decrease absorption soak a dry instrument of water - As long as you don’t mix the Cidex, expiration will take years. 3. Plastic But the moment you activate the Cidex, it will only be available - most ideal packing material but this can’t be used for 14 days (regular use) and 30 days (full use) as a sterile field - In mixing the Cidex, use laundry gloves and goggles because - pouch type with sealer it is a very potent solution and make sure that you are away - individual instruments can be packed using a plastic from the electric fan so that it will not enter your eyes (can - expensive cause blindness) or be inhaled (can cause pneumonia) - non-absorbent - transparent so there is an easy identification of equipment inside CABINET ORGANIZATION 1. Closed cabinet - with sliding glass door - a sterile pack placed inside a CLOSED cabinet will be considered sterile for 28-30 days (most correct: 30 days) Newly soaked Partially soaked Fully soaked - heaviest pack at the bottom so whenever - if you soak - if there are - if the newly soaked physician is earthquakes will occur, the heavy items would not new sets of asking for equipment, ones, transfer fall and destroy the shelves the previously another place here - the newly packed autoclaved gowns must be placed instrument, soaked here. get here under so that the previously autoclaved gowns will The previously partially be placed on top because its expiration rate is much soaked will sooner (use the principle of First In, First Out) then be - First In, First Out is used for the rational and transferred to efficient use of supply especially consumable items. fully soaked Consumable items are items that will expire and is needed to be used before reaching the expiration PRINCIPLES OF STERILE TECHNIQUE rate. 1. Only sterile items are used within the sterile field - The management can charge unnecessary wastage - Sterile to sterile of items, adhering to the principle of inventory. - Unsterile to unsterile - Inventory provides a list of items, keep tract of 2. Sterile personnel are gowned and gloved materials and monitor the items that have been - Gowns are considered sterile from shoulder to used and how any were replaced to ensure the waist in front only 2. Open Cabinet - The part of the sleeves that is considered sterile is - a sterile pack placed inside an OPEN cabinet will 2 inches above the elbow (from the cuff up to 2 be considered sterile for 21 days inches below the elbow). - Due date must be placed on top of the sterile - The back and axillary area is considered unsterile. pack. If the pack reached the expiration date, - In folding the gown for autoclaving, hide the right laundry will be performed again, repack then side to remain sterile. The right side will face the autoclave. table, the wrong side will touch your scrub suit. - The sterile pack is sealed with an autoclave tape/ - To fold the gown, the neckline and the bottom will steri tape that has diagonal lines in it. The lines will meet at the center. Since in government hospitals, turn into black after being autoclaved a spare towel is not provided, the bottom of the gown is also used for wiping the hands after  surgical scrub. To ensure that the bottom will fall once the gown in unfold, use the FOLD-BY-THREE technique (Fold neck line by three, then fold the bottom. The small fold signifies the bottom while the thick fold indicates the neck line) - In wearing the gown, the NECKLINE SHOULD BE FACING YOU (to ensure that the wrong side will touch your scrub suit) and arm holes away - In serving the gown, the NECKLINE SHOULD BE FACING THE SURGEON then put YOUR HANDS BELOW THE ARMHOLE (so that when the surgeon inserts his hands into the armhole, your glove will not become contaminated) 3. Tables are sterile only at table level - Anything below the table level is considered unsterile - If the linen was long on the other side of the table, avoid pulling it upward (unsterile goes up, sterile - open the sterile package AWAY FROM YOU to maintain goes down). This only brings up the unsterile sterility surface of the linen. Instead, get another sterile - If the mayo table and the nurse’s gown get in contact, the linen and cover the uncovered area. TABLE will be the point of reference of the sterility. - Fold the linen using the fan fold method - Changing the height of the mayo table during surgery is not recommended. But if we can’t avoid adjusting the height of the mayo table during surgery, nurses are only allowed to adjust it UPWARD. - The height of the mayo table is higher than the waist level of the gown. 4. Sterile personnel touch only sterile items or areas; Unsterile personnel touch only unsterile items of areas - an unsterile person can get in contact with a sterile item using an OVUM FORCEP - always hold the ovum forceps down to avoid the solution from dripping in the handle. - Never leave the ovum forceps unlocked 5. Unsterile personnel avoid reaching over the sterile field and sterile personnel avoid leaning over an unsterile area 6. The edges of anything that encloses sterile contents are considered unsterile 7. The sterile field is created as close as possible to the time of use. 8. Sterile areas are continuously kept in view. - Nurses are not allowed to pass between sterile tables because the back of the gown is considered unsterile. You should only face one sterile field. 9. Sterile personnel keep well within the sterile area - Sterile persons pass each other back-to-back 10. Sterile personnel keep contact with sterile areas to a minimum 11. Destruction of the integrity of microbial barriers results in contamination - To pour sterile water on the sterile kidney basin, - The SIDE NEAREST TO YOU SHOULD BE DRAPED open the bottle and discard some amount of water FIRST so that when you reach for the farther side, in the kick bucket to wash the mouth of the bottle. your gown will touch a sterile field. Pour the sterile water directly into the kidney basin. - Flap method needs a square linen to make a Be sure that the bottle will not touch he basin. If diamond. accidental spilling occurs, the damp part will be - In packing a kidney basin, it should be PRONE. considered unsterile (due to the moisture in the wet part of the linen, the microorganisms may be  absorbed upward via the tiny holes in the linen. This - Right-handed surgeons (needle eye on right breaks the sterile field). Changing of the whole side of needle holder) drape is not required; instead place the stainless - Left-handed surgeons (needle eye on left side tray on the wet part. The moment the tray is placed, of needle holder) it is no longer allowed to be transferred to another i. Straight – for tough (skin) area. ii. Curved ▪ Cutting – tough (skin and fascia). This has a DOFFING OF GOWN AND GLOVES pointed triangular tip to cut through tough layers Remove the GOWN FIRST and then the GLOVES. of the skin, therefore allowing the needle to pass - In removing the gown and gloves, you have to protect yourself through. from being contaminated with the patient’s body fluids. ▪ Round – delicate (subcutaneous, muscle, - In removing the gloves (GLOVE TO GLOVE, SKIN TO SKIN) to peritoneum and most of the internal organs) avoid contamination. - In performing close gloving technique, the nurse will place the 4 TYPES OF SUTURE PREPARATION glove in a prone position, fingers pointing towards her. 1. Free tie – a strand of suture material. For superficial bleeders. 2. Stick tie/ suture with carrier – needle holder + suture. Handle ABDOMINAL LAYERS of the needle holder served to the surgeon; end of the suture 1. Skin Tough served to the assistant. Prepare suture scissor. 2. Subcutaneous (avascular) Delicate 3. Suture ligature (sut lig) – suture + needle holder + eyed needle 3. Fascia Tough 4. Atraumatic (atrau) - suture + needle holder + eyeless needle ▪ Anterior (above (needle that has an attached suture) muscle) a. Single arm attachment ▪ Posterior b. Double arm attachment – can be round-round, cutting- (between the cutting, round-cutting muscle and peritoneum) SURGICAL COUNT ON A MAJOR ABDOMINAL SURGERY 4. Muscle Delicate 1. First count – before start of surgery 5. Peritoneum Delicate 2. Second count – before closing of peritoneum 3. Third count – before closing the fascia Other tough tissue: Bones, tendons, ligaments 4. Fourth count – before closing the skin Tough tissue = tough instrument Delicate tissue = delicate instruments This will become 5 counts during a double cavity operation like CS SURGICAL INSTRUMENTS 1. First count – before start of surgery 1. Sharps – dissecting and cutting supplies (cut tissue, materials 2. Second count – before closing the uterus and supplies) 3. Third count – before closing of peritoneum a. Knife (scalpel) 4. Fourth count – before closing the fascia - surgical blade (disposable) and blade holder 5. Fifth count – before closing the skin (reusable) - to assemble the knife, you will need a NEEDLE Nursing Responsibilities if there is a discrepancy in the HOLDER count - BH no. 3: 10, 11, 12, 15 (all with 1) 1. Report to the surgeon - BH no. 4: 20, 21, 22, 25 (all with 2) 2. Surgeon will order for a recount - use kidney basin to serve the knife to avoid 3. Surgeon orders for search injury ▪ Scrub nurse – mayo table, back table, patient’s i. 1st knife – skin area ii. 2nd knife – remaining layers ▪ Assistant surgeon – area closest to them b. Scissors ▪ Circulating nurse – on the floor i. Mayo – short and snout. This is used for tough 4. If needle is not found, surgeon orders for an x-ray tissue like fascia. 5. If needle is not inside the body of the patient, close ii. Metz – long and slender. This is used for the the patient peritoneum which is delicate. 6. Scrub nurse makes an incident report c. Needles - the tip of the needle holder should be 2. Graspers – holding instruments grasping near the eye of the needle a. Thumb forceps – toothless. Used for delicate tissue - needle should be side lying  b. Babcock – for delicate tubular organs like Fallopian ORDER OF INSTRUMENTS tube, ureter, vas deferens. Not used on peritoneum, Opening muscle or SQ. 1. 1st knife – skin c. Allis – toothed. Used for tough tissues particularly 2. 2nd knife - SQ skin and fascia. 3. Army Navy retractor to retract the skin and SQ d. Tissue forceps – toothed. Used for tough tissue (Retractor retracts layers above the layer to be dissected) 3. Clamps – occluding instruments (control or minimize 4. Tissue forceps (surgeon) and 2 allis forceps (one for each bleeding). In the absence of a grasper, use a clamp surgeon) for the fascia Serration – tooth 5. 2nd knife a. Mosquito clamp – 100% serrated small 6. Mayo scissor b. Crile clamp – 50% serrated 7. Clamp (Crile/Kelly – depends on the body fat) c. Kelly clamp – toothless. 100% serrated large 8. Handle of scalpel can be used to open the muscle d. Ochsner forceps – toothed Kelly for tough tissue 9. Thumb - Muscle e. Mixter forceps – 90-degree Kelly to reach deeply 10. 2 Kelly located organs 11. 2nd Knife 4. Retractors – exposing instrument 12. Metz a. Self-retaining Closing i. Balfour – has screw and lock that is 13. The 2 assistants must assure that the two edges of the included in the lock peritoneum are well approximated b. Non-self-retaining – manually held and pulled by the 14. 4 Kelly – to hold the peritoneum in four areas assistant surgeons 15. Assistant on the other side holds the 2 Kelly vertically away i. Army navy from the center ii. Richardson 16. Surgeon hold Kelly horizontal towards the center ▪ Single bladed – with handle 17. Give suture scissors to assistant across the surgeon ▪ Double bladed 18. Give thumb forceps to surgeon iii. Beaver – for fat patients 19. Suturing set with round needle 20. 4 Allis to hold fascia in four areas 21. Tissue forceps SHARP GRASPER NEEDLE 22. Cutting needle TOUGH Knife Tissue forceps Cutting needle 23. In SQ, thumb forcep (skin, fascia) Mayo scissor Allis DELICATE Knife Thumb Round needle (SQ, muscle, Metz Kelly peritoneum) Babcock ▪ During dissection, at the start of the surgery use SHARP and GRASPER ▪ During suturing or closing, use GRASPER and NEEDLE Clampers – start in fascia 1. Curved mosquito first to follow the contour of the abdomen 2. Crile 3. Kelly 4. Straight mosquito – if other clamps are used  - DAY 3 - QUADRANTS AND REGIONS OF THE BODY SURGICAL INCISIONS ▪ The surgeon determines the type of incision of the patient. 1. Upper midline incision - below the xyphoid, above the umbilicus - Procedures: Gastrectomy, Billroth 1, Billroth 2, Exploratory Laparotomy 2. Lower midline incision  - Procedures: Hysterectomy, TAHBSO, CS, Tubal - Right Subcostal/ Right Upper Oblique, Left ligation (if small), Exploratory Laparotomy Subcostal/ Left Upper Oblique, Right Inguinal/ 3. Longitudinal Midline Incision Right Lower Oblique, Left Inguinal/ Left Lower Oblique - There is no subcostal below and no inguinal above - This is not frequently used due to poor wound healing - Procedures: Operation of the Liver, Gallbladder 8. McBurney’s Incision - largest and longest incision that could be created in the abdomen - Procedures: Exploratory Laparotomy 4. Paramedian Incision - Procedures: Appendectomy (if appendix is still intact) - If appendix is ruptured, right lower paramedian will be used because peritoneal lavage (Betadine 10% 50/50 200 mL: (1) Betadine 10% 100 mL mix with - To follow the contour of the organ for maximum PNSS (2) Betadine 10% 100 mL followed by 500 exposure mL pure NSS for washing to remove excess and - vertical pus) is done to decrease the possibility of - Procedures: Resection and end-to-end peritonitis post-op anastomosis of the end section of the ascending - In peritoneal lavage, circulating nurse will colon document the solution and blood loss. 5. Mid-abdominal Transverse Incision 9. Pfannenstiel Incision - To follow the contour of the organ - Procedures: Surgeries on the starting section of the transverse colon - the only curved incision 6. Thoracolumbar - Procedures: CS SURGICAL POSITIONS ▪ The position of the patient must benefit both the surgeon and anesthesiologist. ▪ Benefit to the Surgeon: Positioning allows maximum exposure of the operative side, ease of entry and exit from operative site and minimum tissue trauma. - Diagonal incision is more frequently used ▪ Benefit to the Anesthesiologist: The position should not - Procedures: Nephrectomy impede the respiration and circulation 7. Oblique Incision ▪ Prone position is the hardest position to assume during a surgery because it restricts chest expansion ▪ Breaking the table – position the table by segment ▪ Straps are used to secure the patient ▪ Pillow – If supine, use donut pillow to immobilize the head of the patient ▪ Footboards – to prevent foot drop - can also be called as Subcostal Incision and Inguinal Incision 1. Supine Position 6. Kraske or Jackknife position (old) - Procedures: CS, Open heart, Open reduction, Cataract surgery 2. Prone position 7. New Jackknife position - shoulder roll is placed under the should blade for ample chest expansion - Procedures: Surgery of the back, lumbar laminectomy - Procedures: Hemorrhoidectomy, Prostate 3. Semi-Fowler’s position surgeries 8. Trendelenburg position - Procedure: Abdominal paracentesis, insertion of close tube thoracostomy, bronchoscopy 4. Lateral position - seldom used in surgery because the abdominal organs are moving towards the diaphragm. The diaphragm will have a hard time contracting and relaxing. - used to locate the organ temporarily - Procedures: Bilateral tubal ligation (low sec) 9. Reverse Trendelenburg position - Procedures: Endoscopy 5. Lithotomy position - Procedures: Nose and Neck surgery, Rhinoplasty - To direct the flow of blood downward 10. Kidney position - Procedures: Perineal surgery, Vaginorraphy, Episiotomy, Episiorraphy, Hemorrhoidectomy (can also be in this position)  - Affected will be exposed 2. Sedative - Right nephrectomy – Right kidney position / Left - Phenergan lateral jackknife 3. Anticholinergic - Left nephrectomy – Left kidney position / Right - decreases production of secretions lateral jackknife - Number 1 side effect is dry mouth and throat - Wet cotton ball with water applied to patient’s lips DUTIES AND RESPONSIBILITIES OF OR NURSES - Atropine sulfate A. CIRCULATING NURSE ▪ Client preparation before the surgery 1. Receive patient from surgical ward nurse Scheduled surgery – client is prepared at least a day ▪ Endorsement – Pre-operative checklist (to ensure or a night before the surgery or the morning of the that everything is thoroughly and completely surgery checked) Emergency surgery – no preparation. This increases PRE-OPERATIVE CHECKLIST the risk for post-operative complications V Client ID band and allergy (right patient and schedule) a. The day and night before the surgery V Informed consent is signed and witnessed - Pre-operative visit (to allay patient’s V Diagnostic and laboratory test anxiety and to become familiar with other V Client voided personnel) V Documented height and weight - Client education on post-op activities (leg V Vital signs before exiting the ward exercises, deep breathing and coughing V Pre-op meds given exercises, positioning and ambulation, V Document allergy proper wound dressing) - Ensure all lab and diagnostic exam results Consent – signifies patient’s willingness to undergo a are in and reported to MD (especially procedure CBC) General consent – secured upon admission/covers routine - Check cardiopulmonary clearance (for procedures elderly; Cardio: ECG, stress test, BUN, creatinine; Pulmo: X-ray, ABG, pulmonary Informed consent function test) Purpose: “Protects the patient from any unwanted procedure to be done on him and protects the hospital from any claim of - Check blood products the patient that an unwanted procedure was done on him.” - Monitor VS and I&O - Secure consent Surgeon: gives informed consent - Bathing PRN (Triclosan – skin Patient: signs the informed consent disinfectant; remove microorganism and Nurse: witnesses the signing of consent limit the growth of organism overnight) The consent is secured before pre-op meds are given. - Light evening meal Pre-op meds are administered after the consent is secured. - NPO post-midnight (until OR transfer) - Psychological & spiritual support Considerations: - Administer laxative drug if ordered (if a. Legal age ordered a night before surgery, no need b. Timing for enema) c. Who is qualified to sign d. Coverage: - Removal of nail polish (for pulse ▪ each surgical operation oximeter) ▪ any entrance into the body cavity b. The morning of the surgery ▪ hazardous treatment or therapy - Ensure NPO ▪ anesthesia - Oral care - Enema if ordered (Low cleansing enema Pre-operative Medications until return flow is clear: 2-3 times) - prepares client for anesthesia - Shaving (not performed a night before - potentiates effect of anesthesia surgery because minor cuts are created - allays patient’s anxiety and it can become infected overnight) - Review post-op exercises 1. Narcotic analgesic - Per-op medication - Morphine – most potent; can cause post-op - Monitoring constipation - Demerol Meperidine – most commonly used - Removal of dentures - Nalbuphine – least potent; causes post-op - Endorsement to OR constipation  2. Establish rapport with client Time method: allotting a number of minutes for brushing a specific part 3. Place patient on OR table and never leave patient alone (place of the upper extremities arm board) - 10 minutes scrub 4. Position for anesthesia (supine for general anesthesia or Brush-stroke method: counting the number of strokes that you will do quasi fetal position for spinal/epidural) in a particular part of the extremity 5. Perform lumbar prep (10%) for Spinal/ Epidural - Palm, back, tip: 10 - Circular motion, inner to outer, lumbosacral area - Side: 3 Induction of anesthesia - Sterilium 6. Supine position 7. Perineal prep with proper positioning. Catheterization PRE-REQUISITES IN SURGICAL SCRUBBING 8. Supine 1. No skin disease on upper extremity 9. Surgical positioning 2. No open wound or cuts 10. Abdominal skin prep 3. Short fingernails and no nail polish 11. Draping (4 OR towels outline the incision site, foot drape to 4. No persistent cough cover the lower extremities, laparotomy sheet to cover the entire patient; has fenestration/ hole) ANESTHESIA 12. Cutting time - loss of sensibility to pain Analgesia – lessening of sensibility to pain B. SCRUB NURSE 1. Receives patient from surgical ward nurse Stages: 2. Prepare and organize the OR unit based on the case 1. Induction (prepare suction machine, OR pack, complete drapes – - time patient is prepared for anesthesia until the should be strategically located) anesthetic agent is given 3. Open sterile packs and add sterile supplies and 2. Excitement instruments - involuntary movements of the patient 4. Perform surgical scrubbing, gowning and gloving 3. Surgical anesthesia 5. Organize sterile field - best time to perform the surgery 6. Serve gowns and gloves to surgeons 4. Medullary 7. Instrument count - old term is overdose 8. Draping - the anesthesia affects the CNS in which medulla 9. Cutting time oblongata (respiratory center) is located. - Time-out: check for spontaneous breathing, check for SURGICAL SCRUBBING (SURGICAL CONSCIENCE) nail beds, check for color of the lips - In cases of emergency, scrub nurse should remain sterile because if stabilization of patient is finished, the surgery may continue - Assistant of the surgeon will do chest compression - Circulating nurse should prepare medication (Epinephrine, Amiodarone) Types: 1. General - produces sensory, motor, reflex and mental block - inhalation gas (mixed with oxygen) or liquid (anesthetic agent will be placed on the vaporizer of the anesthesia machine then mix with oxygen) - IV Inhalation agents A. Non-halogenated gas 1. Nitrous oxide (Blue) – initial restlessness 2. Cyclopropane (Orange) – for short procedure B. Halogenated fluid – they are placed inside the vaporizer of the anesthesia machine. It could be anesthesia mask or via ET tube. 1. Halothane (Red) – hypotension 2. Enflurane (Yellow) – muscle relaxation 3. Sevoflurane (Pedia) – sweet taste  Intravenous barbiturates - the client will not feel the pain but the uterus will continue to - Thiopental Na contract Neuroleptic Agents - cannot be used for CS - Fentanyl – decreases motor - used for painless vaginal delivery Dissociative agents - Ketamine - hallucinations WOUND CLOSURE MATERIALS 2. Regional - sutures - Spinal - Epidural ABSORBABLE SUTURES - Nerve block-plexus 1. Non-synthetic sutures - Local – infiltration, application, spray - derived from the natural source - Ex: Cut-gut – derived from the intestine of the sheep. This is made up of protein that is why it is absorbable because it has gone enzymatic digestion. a. Chromic – brown. It is a plain suture that is treated with chromium salt solution. Usually, the absorption rate of the plain suture would take around 70 days. If a plain suture will be treated by chromium salt solution, the absorption rate of chromic suture becomes 90 days. The purpose of the chromium solution is to delay the enzymatic digestion of the plain suture. This is used on all layers (under the skin, fascia, muscle, peritoneum and almost all internal organs) except subcutaneous layer. b. Plain – light yellowish. The absorption rate of the plain suture would take around 70 days. This is only used in the subcutaneous layer. Handling Characteristic: Peel the outer package to drop the inner package into the sterile field. The scrub nurse will place it on a kidney basin. The alcohol will evaporate in the kidney basin, therefore the suture dries. The dry suture is not allowed to be soaked in the sterile water because they are made up of protein. The protein will absorb water if these two would interact so the suture will swell and loses its tensile strength. IF NOT IN USE, DO NOT SOAK IN STERILE WATER. ONLY WET USING STERILE WATER JUST BEFORE SERVING IT TO THE SURGEON to lubricate the suture EMLA- for warts before cautery to decrease tissue trauma. CSF – can be found in the subarachnoid space Spinal Headache – most common complication of spinal anesthesia The absorption of both chromic and plain suture Management is flat on bed without pillow in the next 6-8 hours. starts one week after placement. Gradually elevate the head after 8 hrs. 2. Synthetic suture SPINAL VS EPIDURAL ANESTHESIA - from artificial source Spinal anesthesia a. Dexon – green in color. It will take 90 days for - motor and sensory nerves are affected the tissue to fully absorb this suture. - patient cannot feel any pain b. Vicryl – violet in color. It will take 110-120 days - the uterus will not contract before absorption. - for CS Epidural anesthesia ▪ Wound dehiscence might occur if the wound is not healed - affect only sensory nerves but not motor nerves while the suture is fully absorbed. Later, evisceration happens  which is the protrusion of internal organs due to wound blood vessels will be constricted. It can be sprayed or dehiscence. applied. ▪ Primary suture line – directly closes the operative wound b. Electrocautery – mostly used in general hospitals. It ▪ Secondary suture line – supports the primary suture line uses heat though electric current. This can be used to ▪ We are not allowed to wet the synthetic sutures cut (higher electric current) tissue or as clamp to coagulate the blood vessel. there is a black rubber pad SUTURE SIZES which is the ground of the patient. Apply KY jelly on the 1 black rubber pad to be placed under the body (buttocks 1-0 or leg/ gastrocnemius) of the patient. Eschar will remain 2 in the spatula which is the nurse’s responsibility to 2-0 remove by scraping it on a gauze pad. ▪ 1-9 ▪ 1 to 2-0 for abdominal surgery ▪ 8 to 8-0 for eye surgery NON-ABSORBABLE SUTURES 1. Non-synthetic a. Silk suture – navy blue (true color)/ black (description). Used over the skin. This is derived from silk worms’ saliva. DO NOT WET as it loses its tensile strength. This is used over the skin only and covered with a dressing. Easy contamination is possible that might become a source of infection leading now to SUTURE ABCESS. Silk suture is only good to stay on the skin for 7 days then after 1 week is removed. b. Cotton suture – light pink (true color)/ white (description). This is derived from cotton. CAN BE WET. This can take years of absorption. 2. Synthetic a. Nylon – absorption rate is 25% per year so it will take 4 years for it to be fully absorbed. HEMOSTASIS - control or arrest of bleeding to minimize blood loss, to prevent the hypovolemic shock of the patient CLASSIFICATIONS 1. Mechanical a. Hemostat – clamps b. Sutures – ligates bleeding blood vessels c. Pressure – manual (hand)/ digital (fingers) d. Dressing e. Gel foam – derived from dried seaweeds. This comes in different sizes, according to the desired size of the surgeon. Gel foam swells as it absorbs the blood. When it becomes large, it creates a pressure therefore bleeding stop. Overtime, this will be absorbed by the body because it is made up of protein. 2. Chemical a. Coagulant drugs – Vitamin K, Hemostan (Tranexamic aicd), Oxytocin (not a coagulant but promotes uterine contraction therefore preventing bleeding), bone wax (for fractured bones) 3. Thermal a. Cryosurgery – mostly used in aesthetic clinics. Liquid nitrogen is used that has a freezing effect therefore,