Medical Surgery Reviewer Prelims PDF

MODULE 1- CONCEPT OF PAIN Breakthrough pain - sudden increase Nociception - activation of sensory in pain despite the administration of transduction in nerves by thermal, pain-relieving m...

MODULE 1- CONCEPT OF PAIN Breakthrough pain - sudden increase Nociception - activation of sensory in pain despite the administration of transduction in nerves by thermal, pain-relieving medications mechanical, or chemical energy impinging on specialized nerve Dependence - occurs when a patient endings. The Nerves involved convey who has been taking opioids info about tissue damage to the CNS experiences a withdrawal syndrome when the opioids are discontinued; Nociceptor - a receptor preferentially often occurs with opioid tolerance and sensitive to a noxious stimulus does not indicate an addiction Non- nociceptor - nerve fiber that Dysthesia - the maximum amount and usually does not transmit pain duration of pain that an individual can endure Opioid - A morphine-like compound that produces bodily effects including Endorphins and Enkephalins - pain relief, sedation, constipation, and Pain Terminologies to Remember: morphine like substances produced by respiratory depression. This term is the body. Primarily found in the preferred over narcotic Addiction - a behavioral pattern of central nervous system, they have the substance use characterized by a potential to reduce pain. Placebo - any medication or compulsion to take the drug primarily to procedure, that produces an effect in a experience its psychic effects. Pain threshold/Pain sensation- patient because of its impact or explicit minimum amount of pain stimulation intent and not because of it’s specific Algogenic - causing pain required for a person to feel pain physical or chemical properties Allodynia - Pain due to a stimulus that Pain Tolerance- the maximum amount Placebo Effect - analgesia that results does not normally provoke pain, such and duration of pain that an individual from the expectation that a substance as touch; typically experienced in the can endure will work, not from the actual substance skin around area affects by nerve injury itself and commonly seen with many Hyperalgesia- increased pain from a neuropathic pain syndromes stimulus that usually provokes pain Phantom Pain - perceived pain (type of neuropathic pain) when a person 1 with an amputated limb perceives that the limb still exists and feels burning, itching, deep pain in tissues that have been surgically removed. Prostaglandins - chemical substances that increase the sensitivity of pain receptors by enhancing the pain-provoking effect of bradykinin Radiating pain - a pain (under category of visceral pain) perceived in the source of pain and extended to nearby tissue. Referred pain - a pain (under category of visceral pain) perceived in a general area of the body, usually away from the site of stimulation. E.g., cardiac pain may be felt in the shoulder or left arm, with or without chest pain. TYPES OF PAIN: ACCORDING TO INFERRED PATHOLOGY (SOURCE): TYPES OF PAIN ACCORDING TO DURATION: 2 Concepts of Pain Pain threshold/Pain sensation -amount of pain stimulation required for a person to feel pain Pain Tolerance -the maximum amount and duration of pain that an individual can endure 3 Hyperalgesia Opioid -increased pain from a stimulus that -A morphine-like compound that Endorphins and Enkephalins usually provokes pain produces bodily effects including pain relief, sedation, constipation, and -morphine-like substances produced by Allodynia respiratory depression. This term is the body. Primarily found in the central preferred over narcotic. nervous system, they have the -Pain due to a stimulus that does not potential to reduce pain. normally provoke pain, such as touch; Prostaglandins typically experienced in the skin around Dependence area affects by nerve injury and -chemical substances that increase the commonly seen with many neuropathic sensitivity of pain receptors by -occurs when a patient who has been pain syndromes enhancing the pain-provoking effect of taking opioids experiences a bradykinin withdrawal syndrome when the opioids Dysthesia are discontinued; often occurs with opioid tolerance and does not indicate -the maximum amount and duration of Addiction an addiction pain that an individual can endure -a behavioral pattern of substance use characterized by a compulsion to take Nociception Placebo the drug primarily to experience its -any medication or procedure, that psychic effects -activation of sensory transduction in produces an effect in a patient because nerves by thermal, mechanical, or of its impact or explicit intent and not Algogenic chemical energy impinging on because of it’s specific physical or -causing pain specialized nerve endings.The Nerves chemical properties involved convey info about tissue damage to the CNS Placebo Effect Breakthrough pain -sudden increase in pain despite the Nociceptor -analgesia that results from the administration of pain -relieving expectation that a substance will work, medications -a receptor preferentially sensitive to a not from the actual substance itself noxious stimulus 4  Bradykinin also stimulates the release C fibers- larger, unmyelinated of prostaglandins. nerve fibers, dull aching pain Non-nociceptor A delta – smaller, myelinated Prostaglandin - These compounds fibers, sharp, localized pain -nerve fiber that usually does not sensitize the pain receptors and Messages come out of the transmit pain enhance the effects of bradykinin and spinal cord and travel via motor histamine. nerves to the arm muscles, causing the arm to withdraw Neurophysiological Transmission of Substance P - act as a stimulant to the quickly. Pain nociceptors - Known to be a This is an automatic reflex that neurotransmitter that enhances the does not involve the brain or 1. Transduction movement of impulses across the conscious thought When a pain threshold has nerve synapse from the primary b. From the SC to brain stem and been reached and there is afferent neuron to the second-order thalamus via the spinothalamic tract injured tissue, substances that neuron - pain signals are also sent upwards in stimulate the pain receptors the spinal cord via the Spinothalamic called nociceptors, are released ◻Nociceptors are stimulated: tract (amongst others) to an area in the These pain receptors can be directly - by damage to the brain stem (base of the brain) called stimulated by serotonin, receptor cell, the thalamus. histamine, potassium ions, secondarily - by the release of acids, and some enzymes chemicals such as bradykinin. c. Thalamus to somatic sensory cortex Ibuprofen and local anesthetic ◻ Three types of stimuli that Further processing occurs in can decrease pain excite corresponding types of the thalamus with signals being nociceptors: sent to areas controlling blood Bradykinin - a powerful vasodilator is ○ mechanical pressure, heart rate, breathing, released at the site of an injury ○ thermal and emotions. ○ Chemical causes the release of inflammatory 3. Perception chemicals such as histamine. 2. Transmission when the client experiences These two chemicals (bradykinin and a. Transmission of impulse from the pain histamine) cause the area to redden, peripheral nerves to the spinal cord swell, and become tender. (SC) 5  believed to occur in cortical In order to care for patient structures which allow for experiencing Pain. We need to perform cognitive responses proper Pain Assessment. non-pharmacologic intervention can decrease pain A. Comprehensive pain assessment The pain stimuli transmitted must be conducted upon initial along the nerve fibers as interview. described earlier, enter the spinal cord, and the cord to the B. Physical examination of Pain thalamus reticular formation. The first theory to suggest that CONCEPT OF PAIN Conscious perception of the pain occurs initially at the brain psychological factors play a role in the PART 2 stem and thalamic level. perception of pain and guided Pain Theories Interpretation and localization of research towards the : the pain is in the cerebral cortex Synapses in the dorsal horns act as 1. cognitive behavioral gates that close to keep impulses from 4. Modulation approaches to pain reaching the brain or open to permit neurons send signal back to management. impulses to ascend to the brain. dorsal horn of SC 2. distraction and music causes release of endogenous therapy provide pain relief. opioids, serotonin and NE According to the gate control Tricyclic antidepressant theory: Lesson 2: Pain small-diameter nerve fibers carry pain stimuli through a gate large diameter nerve fibers going through the same gate can inhibit the transmission of 6  those pain impulses-that is, The pain gate in the spinal cord can inhibitory effect (-) on the ascending close the gate be shut in several different ways: control system. A topical anesthetic has an inhibitory effect (-) on nerve Synapses in the dorsal horns act as § Stimulation of touch fibers transmission at the nociceptor level gates that close to keep impulses from and a spinal anesthetic has the same reaching the brain or open to permit § Release of endogenous opioids impact (-) on the ascending nociceptive impulses to ascend to the brain. fibers. § Electrical stimulation § Morphine and other opioid drugs § Normal and excessive sensory stimuli § Cerebral cortex and thalamic inhibition of pain The nervous system is made up of stimulatory and inhibitory fibers. When Factors Influencing Pain Response: nociceptor is stimulated it will stimulate transmission at the next fiber junction 1. Past experiences (represented as +>-). The interneuronal fiber is an inhibitory 2. Anxiety and depression neuron (->-). When it is stimulated it, in turn, inhibits or shuts off transmission 3. Culture at the next junction. So a placebo has a (+) stimulatory effect on the 4. Age descending control system, which has a stimulatory effect (+) on the 5.Gender interneuronal fiber, which has an 7 6. Placebo effect →Women have greater pain intensity, →In other groups, pain may be pain unpleasantness, frustration and Anxiety and depression anticipated as a part of the ritualistic fear than men practices of passage ceremonies, and → Anxiety often accompanies pain. therefore tolerance of pain signifies → Family role can also affect how a strength and endurance. person perceives or responds to pain. →Threat of the unknown and the inability to control the pain or the → The meaning of pain will affect the Placebo effect events surrounding it often augment individual's the pain perception. →When person responds to the perception of pain, tolerance of painful medication or other treatment because → Fatigue also reduces a person's stimuli, of an expectation that the treatment will ability to cope, thereby increasing pain work rather than perception. and the expression of or reaction to pain. →because it actually does so. Results → When pain interferes with from natural (endogenous) production sleep,fatigue and muscle tension often Age of endorphins result and increase the pain; thus a cycle of pain, fatigue, pain develops. → Age is an important variable that →It is a true physiologic response and influences how people admit or it is not an indication that the person describe pain and how they behave does not have pain. Culture ➤ Past experience - Once a person →Values In some cultures, pain maybe experiences severe pain, that person considered a punishment for bad Gender knows just how severe it can be. deeds; the individual is, therefore, to Conversely, someone who has never tolerate pain without complaint in order →In some situations, for example, girls had severe pain may have no fear of to atone for sins. may be permitted to express pain more such pain. openly than boys. →In some Middle Eastern and African ➤ Anxiety - anxiety that is relevant or cultures, self-infliction of pain is a sign related to the pain may increase the of mourning or grief. patient's perception of pain; Anxiety 8 that is unrelated to the pain may PAIN ASSESSMENT distract the patient and may actually ➤ Timing - onset, duration, relationship decrease the perception of pain. between time and intensity, and A. History Taking changes in rhythmic patterns; sudden ➤ Depression Longer durations of pain or gradual increase B. Physical Examination specific to are associated with an increased Pain incidence of depression. ➤ Location - have the patient point to the area of the body involved ➤ Culture - Beliefs about pain and how to respond to it differ from one culture > Quality-patient describes the pain in to the next his or her own words without offering The following are components of a clues comprehensive pain assessment and ➤ Age - The way an older person ways on how to elicit the information responds to pain may differ from ➤ Personal meaning - effect of pain in from the patient. person's daily life. the way a younger person responds. If 1. Location pain perception is diminished in the ➤ Aggravating, alleviating factors - elderly person, it is most likely anything makes the pain worse and 2. Intensity secondary to a disease process (eg, what makes it better; relationship diabetes) rather than to aging between activity and pain - mild, moderate, severe (American Geriatrics Society, 1998) ➤ Pain behaviors - nonverbal and 3. Quality ➤ Gender - Women had higher pain behavioral expressions of pain are not intensity, pain unpleasantness, consistent or reliable indicators of the 4. Timing-onset, duration, pattem frustration, and fear compared to men. quality or intensity of pain, and they Robinson, Riley, Meyers et al. (2001); should not be used to determine the 5. Aggravating and alleviating factors men being more anxious about their presence of or the degree of pain pain (Edwards, Auguston and Fillingim experienced (grimace, cry, rub the 6. Comfort-function (pain intensity goal) (2000) affected area, guard the affected area, or immobilize it moaning, groaning, 7. Personal Meaning ➤ Intensity - none to mild discomfort to grunt, or sigh.) excruciating. 1. Location of Pain: 9  Tools To Assess Intensity of Pain: Ask the patient to point the areas of "0" - happy face that indicates no pain. pain on the body. There are many different tools available to help nurses assess a "10" - tearful sad face and indicates the client's level of pain. It is important to worst pain. choose the tool that will work best for the client. The faces in between reflect differing levels of pain. A. NRS: Numeric Rating Scale To assess you will inform the pedia Uses number to assess a person's client what each face represents. Then severity to pain from 0 to 10. he can pick the face that best represents how he is feeling. Score of 0 means that the patient is not experiencing any pain, while 10 means the worst pain. 2. Intensity of Pain: - Simple and works well for patients Ask the patient to rate the severity who can cognitively rate pain intensity. of pain using these tools: But what about if the client is 5 yrs old, C. Faces Pain Scale - Revised he might not understand how to score (FPS-R) the pain on such an abstract scale therefore we use other tools. a self-report measure of pain intensity developed for children Has 6 faces B. Wong- Baker FACES pain rating range from neutral facial expressions scale: to one of intense pain and are numbered 0,2,4,6,8,10 Best tool for young patients. Consists of six pictures of faces The faces correlate to a number. 10 D. Verbal Descriptor Scale (VDS) 3. Quality of Pain: Allow patient to uses different words or phrases to describe how the pain feels. - "sharp", describe the intensity of pain, such as "shooting", "burning” "no pain, mild pain, moderate pain, very severe pain & worst possible pain" the patient is asked to select the phrase that best describes pain intensity E. Visual Analog Scale (VAS) 5. Aggravating and relieving factors: A 10cm line with word anchors at the ends. "no pain" & "pain as bad as it - Ask patient what makes the pain could possibly be" worse and what makes it better 4. Onset & Duration: Patient is asked to mark on the line to 6. Effect of pain on function and indicate the intensity of pain Impractical - Ask patient when the pain started and quality of life: for use in daily clinical practice & rarely whether it is constant or intermittent. used - Effect of pain on the ability to perform recovery activities should be regularly evaluated. 11 6. Comfort function (pain intensity) goal: - Identification of short term functional goals and reinforce to the patient that good pain control will more likely lead to successful achievement of goal. § varies from one person to another § verbal, non-verbal and behavioral expressions may not be reliable Sample Nursing Diagnoses ✓ Acute Pain ✓ Chronic Pain 12 ✓ Ineffective airway clearance r/t poor § Severity of Pain as judge by the coughing secondary to incisional pain patient § refers to the use of more than one analgesia to obtain more pain relief ✓ Anxiety r/t past experiences of poor § Anticipated harmful effects of pain and fewer side effects pain control and anticipation of pain § Anticipated duration of pain 2. Pre Re Nata (PRN)- as needed ✓Self care deficit r/t poor pain control PAIN MANAGEMENT 3. Preventive Approach Management of Pain INTERVENTIONS: 4. Individualized dosage Nurse's Role: I. Pharmacologic 5. Patient Controlled Analgesia (PCA) 1. Administering Pain relieving II. Non- Pharmacologic intervention § for post-operative and chronic pain III. Neurologic and Neurosurgical 2. Assessing effectiveness of Interventions allows patients to control administration intervention of their pain medication with in I. PHARMACOLOGIC predetermined safety limits 3. Monitoring for adverse effects INTERVENTIONS I. ANALGESIC AGENTS 4. Advocate for the patient when the 1. Premedication Assessment prescribed treatment is ineffective can be categorized into 3 main groups § ask for allergies Identifying the Goals of Pain A. Non opioid Management: § medication history Includes Paracetamol and NSAIDS § to determine the type of intervention § other health problems needed and to establish a target NSAIDS: Decrease pain by inhibiting Approaches for using analgesic cyclo- oxygenase (enzyme involved in Consider the ff: agents: production of prostaglandin) 1. Balanced Anesthesia NSAIDS 13  goal is to relieve pain and occur in patients over large decrease pain by inhibiting COX improve quality of life doses of opioids pathway; the rate limiting step in prostaglandin production can be administered by various tolerance does not occur routes combined with opioids 4. Inadequate pain relief Side Effects: nephrotoxic due to inadequate dose or Respiratory depression and shifting route of administration COX-1 sedation 5. Tolerance and addiction mediates prostaglandin formation most serious adverse effects involved in maintenance of physiologic the need to increase the dose function increases with age and concomitant to achieve same effect use of other opioids 6. Other effects platelet aggregation and increase mucosal blood flow decrease RR and shallow respiration - pruritus, urinary retention COX-2 Nausea and vomiting - decreased excretion in liver and kidney disease mediates prostaglandin occur after the initial dose formation that results in - varying effects in patients with thyroid symptom of pain, inflammation triggered by sudden change in position disease and fever Side Effects: - hypotension in dehydrated patients B. Opioid (Narcotic)Analgesic 1. Heading - may be potentiated by other Agents medications e.g. MAO inhibitors, 2. Head Phenothiazines - act on CNS to inhibit activity of ascending nociceptive pathways 3. Constipation 14  Opioid Tolerance and Addiction Approaches for Using Analgesic Tolerance Agents ➤ Maximum safe opioid dosage must ➤ Balanced analgesia - use of more be individually assessed than one form of analgesia concurrently to obtain more pain relief ➤Tolerance develops in all patients with fewer side effects. who take opioids for prolonged periods ➤ "PRN" medications (pro re ➤With tolerance, increased usage nata(PRN), or "as needed." needed to effect pain relief ➤ Routine administration: around the ➤Dependence (body adapts to drugs) clock (ATC) or preventive approach; analgesic agents are administered at ➤occurs with tolerance, physical set intervals so that the medication symptoms occur when opioid is acts before the pain becomes severe discontinued and before the serum opioid level falls to a subtherapeutic level. Addiction ➤Individualized dosage - The dosage ➤Behavioral pattern ( compulsive drug and the I interval between doses use) characterized by need to take should be based on the patient's drug for psychic effects requirements rather than on an inflexible standard or routine. People ➤Addiction from therapeutic use of metabolize and absorb medications at opioid is negligible different rates and experience different levels of pain. C. Local Anesthetic Agents - (Topicals, patches, sprays) ➤ PCA: patient-controlled analgesia 15 ➤ Rapidly absorbed into bloodstream, resulting to dec. availability at the Respiratory depression surgical or injury site and an inc anesthetic level in the blood, increasing Sedation the risk of toxicity Nausea, vomiting ➤ Blocks nerve conduction when applied directly to the nerve fibers. Constipation ➤ A vasoconstrictive agent (eg, Pruritus epinephrine or phenylephrine) is added to the anesthetic agent to decrease its Routes of Administration: systemic absorption and to maintain its concentration at the surgical or injury 1. Oral - preferred route of analgesic site. administration D. Local Anesthetic Agents higher dose. a. Topical Easiest route, least expensive; best tolerated - applied to the site of injury w/ a 2. Rectal vasoconstricting agent alternative when oral and IV is not an -EMLA (eutectic mixture of local option anesthetic) rectum allows passive diffusion of b. Intraspinal (epidural) medications and absorption into the systemic circulation - local anesthetic is directly applied to the nerve root through an Epidural catheter Adverse Effects of Analgesic Agents 16 Keep in mind: drug absorption is Two commonly used medications are unreliable due to rectal tissue health preservative-free morphine sulfate and and administration technique fentanyl. 3. Topical and Transdermal Route The major benefit of intraspinal drug absorbed through the skin and fat layer therapy is that it exerts a lesser slowly sedative effect than do systemic opiates. 4. Parenteral Route Intraspinal analgesics IM, IV or SQ § intrathecal space contains - Rapid onset with shorter duration cerebrospinal fluid (CSF) and directly surrounds the spinal cord, opiates act 5. Transmucosal quickly on the dorsal horn. - lozenges or nasal spray § Very little drug is absorbed by blood vessels into the systemic circulation. 6. Intraspinal- intrathecal/spinal or epidural - for persistent, severe, unresponsive pain may cause spinal h/a, respiratory depression, vomiting Intraspinal analgesics - act directly on opiate Epidural analgesics - The epidural receptors in the dorsal horn of the space is most com- monly used spinal cord. because the dura mater acts as a protective barrier against infection, including meningitis. 17  ➤ The placebo effect results from the II. NON PHARMACOLOGIC natural (endogenous) production of INTERVENTIONS endorphins in the descending control system. It is a true physiologic II. Non-Pharmacologic Pain response that can be reversed by Interventions: naloxone, an opioid antagonist (Wall, 1999). 1. Cutaneous stimulation and Massage ➤ "placebos (tablets or injections with proposes stimulation of fibers that no active ingredients) should not be transmit non-painful sensations can used to assess or manage pain in any block or dec pain transmission patient regardless of age or diagnosis" impulses The American Society of Pain Management Nurses (1996) 2. Ice and Heat Therapies Placebo effect Gerontologic Considerations ice should be applied no longer than 20 minutes at a time; ➤ Any medication/procedure that ➤ More likely to have adverse drug produces an effect in a patient effects, drug interactions Heat because of it's implicit or explicit intent & not bec of it's specific physical or ➤ Increased likelihood of chronic chemical properties. illness ➤ occurs when a person responds to May need to have more time between the medication or other treatment doses of medication due to decreased because of an expectation that the excretion, metabolism related to aging 3. Transcutaneous Electrical Nerve treatment will work rather than changes stimulation- uses battery operated unit because it actually does so with electrodes applied to the skin to 18 produce a tingling, vibrating or buzzing - (Music therapy, touch therapy, §- pain suppression by application of sensation in the area of pain reflexology, magnetic therapy, low- voltage electrical pulses to the electrotherapy, acupressure, different parts of the NS 4. Distraction aromatherapy) § thought to relieve pain by blocking focusing the patient's attention on III. NEUROLOGIC & painful stimuli something other than the pain NEUROSURGICAL INTERVENTIONS (cognitive techniques) TV, I music, §-spinal cord or deep brain stimulation mental exercises III. Neurologic & Neurosurgical Pain Interventions: §- reversible 5. Relaxation Techniques ➤ indicated for Intractable pain (pain ➤ indicated for Intractable pain (pain - abdominal breathing at a slow, that cannot be relieved satisfactorily that cannot be rhythmic rate. rhythmic inhalation an by the usual approaches, including exhalation medications; usually is the result of relieved satisfactorily by the usual malignancy (especially of the cervix, approaches, including medications; 6. Guided Imagery bladder, prostate, and lower bowel) ➤ usually is the result of malignancy indicated for prolonged and severe (especially of the cervix, bladder, - using one's imagination in a special intractable pain prostate, and lower bowel), way to achieve a specific positive effect; consist of combining slow, 1. Stimulation procedures - intermittent 1. Stimulation procedures - intermittent rhythmic breathing with a mental electrical stimulation of a tract or electrical stimulation of a tract or image of relaxation and comfort center to inhibit the transmission of center to inhibit the transmission of pain impulses (TENS, Spinal Cord pain impulses (TENS, Spinal Cord 7. Hypnosis stimulation) stimulation) 8. Alternative therapies Stimulation Procedures 2. administration of intraspinal opioids 19 2. Interruption of pain pathways - permanent 1. Severity of the pain, as judged by B.RISK INVOLVED the patient C.URGENCY Cordotomy division of certain tracts of the SC interrupt the transmission of 2. Anticipated harmful effects of pain. According to Purpose: pain A high risk patient is at much greater risk for the harmful effects of pain than 1. DIAGNOSTIC Rhizotomy a young healthy patient. 2. EXPLORATORY sensory nerve roots are destroyed 3. Anticipated duration of the pain. 3. ABLATIVE when they enter the SC reducing nociceptive input ➤ Always establish nurse-patient 4. PALLIATIVE relationship, teaching 5. RECONSTRUCTIVE ➤ Provide physical care COSMETIC/AESTHETIC ➤ Manage anxiety/ related to pain I CURATIVE ➤ Evaluate all the pain management strategies done to patient PROCUREMENT FOR TRANSPLANT M2: Concept of Surgery REMOVAL – TO REMOVE A FOREIGN BODY Lesson 1 : PREOPERATIVE Nursing DIAGNOSTIC- removal and study of tissue to Nursing Process Framework for Pain Surgical procedures are classified make a diagnosis. Management according to: EXPLORATORY -to estimate the extent of Factors to consider for pain A.PURPOSE the disease management: 20  Prolonged /complicated ABLATIVE- to remove a diseased organ Blood loss - ↑ Urgent/Imperative- patient requires prompt attention PALLIATIVE- done to relieve symptoms of Examples: disease without treating or correcting the Within 24-30 hours disease itself Less important body structure – removed/in 1.Acute gallbladder RECONSTRUCTIVE -to repair tissue/organ Risk - less risk infection CONSTRUCTIVE - to repair a congenitally malformed tissue/organ. Complications - few 2.Kidney or ureteral stones COSMETIC/AESTHETIC- to improve perso Done under local anesthesia Required/Planned- patient needs to appearance have surgery. Often performed in a da CURATIVE - elimination or repair of patholo Plan within few weeks or months REMOVAL- Removal of foreign body Examples 1.Prostatic hyperplasia without bladder obstruction Emergency Without delay Classification of Surgery Based on the 2.Thyroid disorders 1.Severe bleeding Degree of Risk involved 3.Cataracts 2.Bladder or intestinal MAJOR SURGERY: obstruction Elective- patient should have surgery Major organ – removed /surgical 3.Fractured skull Failure to have surgery not catastrophic manipulated 4.Gunshot or stab wounds 1.Repair of scars Risk - high degree 5.Extensive burns 2.Simple Hernia 21  Less risk of nosocomial infection. 3.Vaginal Repair Less decrease in patient’s productiv Less costly to the patient Risk assessment Optional- the decision rest with the patient Disadvantages Medical Conditions that Increase the Risks of Surgery Less time to monitor and assess Personal preference Patient Type of Condition 1.Cosmetic Surgery Less time to establish holistic care Bleeding Disorders Patient will be responsible for 1. Thrombocytopenia - ↓ platelet count, Assessing complications SURGICAL SETTING 2. haemophilia - ability of the blood to clot is severely reduced ( little or no clotting factor) Elective Surgery– carefully planned event GOALS: PREOPERATIVE PHASE: Reason for Risk Emergency Surgery– may arise with Increase risk of hemorrhage unexpected urgency Assess and correct physiologic and Same-day admission– patient most often problems - surgical risk. admitted on the day of surgery for in patien Type of Condition surgery. Give the person and significant othe Diabetes Mellitus Ambulatory Surgery- is done on an out-pa learning/teaching guidelines regarding surg Reason for Risk basis. Instruct and demonstrate exercises Increases susceptibility to infection Impaired wound healing Ambulatory Surgery operative) Type of Condition Advantages Plan for discharge /any projected ch Diabetes Mellitus - Strict glycemic control Less stress to the patient due to surgery. (80-110 mg/dl) 22  Type of Condition chemotherapeutic drugs or Hypoglycemia – anesthesia, Fever immunosuppressive agents) ↓ COOH, ↑insulin use Reason for Risk Increased risk of infection and Hyperglycemia - stress Predisposes - fluid and electrolyte delayed wound healing after imbalances Stress of surgery - ↑ cardiac demands surgery. May indicate underlying infection General anesthetic agents - ↓cardiac functions Type of Condition Reason for Risk Type of Condition Type of Condition Reason for Risk Drug abuse Upper respiratory infection Person Chronic respiratory abusing drugs Reason for Risk disease (emphysema, ↑ risk of HIV/Hepatitis Increases risk of respiratory bronchitis, asthma) complications Anesthetic agents reduce respiratory Type of Condition Type of Condition Reason for Risk Liver disease function Chronic pain Reason for Risk Higher tolerance. Type of Condition Alters metabolism and elimination Reason for Risk of drugs Assessment Immunological disorders Considerations for Clients Impairs wound healing and (leukemia, AIDS, bone marrow clotting time undergoing Surgery depression and use of 23  healing and preventing infection. 1.AGE (opening of the suture line) Malnourished clients have: Infant - normal body temperature must be m Risk in mortality and morbidity - potential 4.Immunocompetence Elderly patients - risk during surgery for multiple organ failure. Cancer patients: Surgeon waits for 4-6 weeks AGE 3.Obesity/Bariatric (ideally) Polypharmacy Reduced ventilator and cardiac after completion of radiation treatments before surgery. Mouth Condition function. CAD, DM, CHF 5. Fluid and electrolyte imbalance - Dentures Postoperative complications : Excess body fluid can overload the heart Embolus 2.Nutritional Status 5. Fluid and electrolyte imbalance Post-op: needs at least 1500 kcal/day to ma 3.Obesity/Bariatric- Postoperative complications : Normal serum potassium concentration is 3.5 – 5.0 Increase in CHON, Vitamin A & C and Zinc to facilitate healing Atelectasis mEq/L. Pneumonia Notify anesthesiologist Malnutrition 3.Obesity/Bariatric ↓ or ↑serum potassium Weight loss of 10% within 6 weeks before surgery must be investigated Susceptible to poor wound healing – fatty concentration (risk for arrhythmia when tissues (poor blood under general anesthesia ) may cancel surgical procedure. supply) 2.Nutritional Status 6.Pregnancy Often difficult to close surgical wound – Brittle nails – indicate poor nutrition thick adipose layer. Surgery - emergent or urgent basis. Optimum nutrition is required for wound At risk for dehiscence General Anesthesia is administered with 24 caution. Effects During Surgery The client : General Anesthesia increases the risk for Antibiotics fetal death and preterm labor. is misinformed or unaware of potentiate action of anesthetic agents. 6.Pregnancy the reason for surgery. MOST EFFECTIVE IN PREVENTING INFECTION IF IT IS GIVEN 30 – 60 MIN before the operative C/S – PREOP DIAGNOSIS has inaccurate perception or incision is made. Abruptio placenta knowledge of the surgical Ex. If surgery scheduled at 7:00 am/give it 6:30 am Active maternal gonorrhea procedure. P.I.H. Drug Class BTL Effects During Surgery CPD 8.Perception and understanding of surge Antidysrhythmics Breech Can reduce cardiac contractility and impair cardiac Psychosocial integrity issues Placenta previa – conduction during anesthesia. Fetal bradycardia cosmetic surgery Drug Class Cord coil Effects During Surgery Coping mechanism Anticoagulants Situational role changes 7. Previous Surgery alter normal clotting factors and thus increase risk of hemorrhaging. Body image changes Client’s past experience with surgery can influence physical and psychological They should be discontinued BREAST responses to a procedure. at least 48 hours REDUCTION prior to 9.MEDICATION HISTORY surgery. 8.Perception and understanding of Aspirin surgery Drug Class is a commonly used medication that can 25 alter clotting mechanisms.– 10.Allergies would ALERT the nurse if used by the Drug class Effects During Surgery An allergy to shellfish is also allergic to- patient days before surgery for pain IODINE management. Diuretics Diuretics potentiate electrolyte imbalances SKIN PREPARATIONS Drug Class (Iodophor and Betadine) Effects During Surgery (particularly potassium) after surgery. or any other products containing iodine such Anticonvulsants NSAID’s as dyes. Long term use - e.g. Phenytoin [Dilantin] and Phenobarbital can alter metabolism NSAIDS inhibit platelet aggregation and Note: allergic to shellfish do not necessarily of anesthetic agents May prolong bleeding time, increasing have an allergy to seafood susceptibility to postoperative bleeding. EDUCATION HISTORY LATEX ALLERGY - Assessment Considerations for Clients allergic undergoing Surgery reactions to natural Drug Class rubber Effects During Surgery Herbal therapies; ginger, ginkgo, ginseng latex Antihypertensives affect platelet activity and increase suscepti and synthetic rubber - interact with anesthetic agents to cause bradycardia, hypotension and to postoperative bleeding. At risk for latex allergy, if allergic to: impaired circulation. Ginseng may increase hypoglycemia with Bananas Drug class insulin therapy Avocados Effects During Surgery Garlic Kiwi Corticosteroids (anticoagulant properties) that help With prolonged use, may cause adrenal hyp Apricots control BP – be alert if too much in the which reduces the body’s ability to withstan diet Peaches Insulin →↑bleeding Diabetic client’s need for insulin after Potatoes surgery is altered. 26 Tomatoes Cramping Identify client’s source of support. Grapes Dyspnea Family presence should be encouraged Guava DELAYED RESPONSE – 18 -24 hrs. After (client’s coach) Hazelnuts contact Latex-fruit syndrome CONTACT DERMATITIS Assessment Considerations for Clients undergoing Surgery GOAL: PROVIDE A LATEX FREE ENVIRO ADHESIVE TAPE 13.Review of Emotional Health. 11.Smoking Habits ANESTHESIA MASKS Surgery is psychologically stressful. Increase amount and thickness of mucous Feelings about the surgery. TOURNIQUET secretions- smokers. Fears and concerns. IRRIGATION SYRINGES General Anesthesia -↑ airway irritation and Anger and anxiety. SPEND TIME LISTENING TO stimulates pulmonary secretions CATHETERS (retained ↓ ciliary activity during THE CLIENT anesthesia).→ Ineffective Airway ANSWER QUESTIONS LATEX ALLERGY Clearance PHYSICAL EFFECTS OF SURGERY IMMEDIATE REACTION (life threatening) Post- operative deep breathing and Pruritus and flushing coughing is vital. ON THE CLIENT Diaphoresis Surgery Stress response is activated. Nausea and vomiting 12. Family Support Resistance to infection is lowered due to surgical 27 incision. Toddler Age Group Severing of blood vessels and blood loss. Specific Fears School-age Organ function maybe altered due to manip Fear of separation Specific Fears Body image maybe disturbed. Nursing Actions Loss of control Lifestyle may be change. Teach parents to expect regression, Nursing Actions e.g. in toilet training, and difficult PSYCHOLOGICAL EFFECTS OF separations 1.Explain procedures in simple SURGERY ON THE CLIENT terms. FEARS OF SURGERY AT DIFFERENT 2. Allow choices when FEAR DEVELOPMENTAL STAGES possible. Manifestations: Age Group FEARS OF SURGERY AT DIFFERENT Anxiety Preschooler DEVELOPMENTAL STAGES Avoids communication Specific Fears Sad, evasive, tearful, Fear of Mutilation Age Group clinging Nursing Actions Adolescence Inability to concentrate 1.Allow child to play with models of equipme Specific Fears Dazed 2.Encourage expression of feelings(.e.g. Anger Loss of independence being different anger) Tendency to exaggerate from peers e.g. alterations in body image. FEARS OF SURGERY AT DIFFERENT Age Group DEVELOPMENTAL STAGES 28 Nursing Actions 16. Coping Resources abnormalities. 1. Involve adolescence in procedures and th Be aware of the responses Electrolytes to assess for 2. Expect resistance. Assist in stress management imbalances. 3. Express understandings of concerns. Identify sources of support. PT/PTT( Pro 4. Point out strengths. 17. Culture Blood type & cross match The nurse should acquire Assessment Considerations for Clients If a transfusion is anticipated knowledge of the client’s undergoing Surgery If the patient refuses to cultural and ethnic heritage. 14. Self Concept accept blood transfusions, 18. Client Expectations Assess and identify personal strengths and documentation it. Assess expectations weaknesses. NO BLOOD TRANSFUSION – Provide accurate information Jehovah’s 15. Body Image and clarify misconceptions. Witnesses Response is determined by CHEST X-RAY PREPARING CLIENTS FOR SURGERY culture, self concept, degree to assess patient with cardiac or of self esteem. PRE-OPERATIVE PREPARATION OF pulmonary disease Nurse should encourage THE PATIENT for smokers expressions of concerns Common tests are: person age 60 and older about sexuality. CBC to check for 29 for cancer patients Biographic information Anesthesia provider will visit ECG Physical findings Encourage patient /family to discuss their feelings or anxieties. known suspected heart disease. Special therapy 40 years of age or older by Emotional status Identify any special needs of the patient. policy. Choose an optimal time and place - A pad of paper and pencil - unable to speak DOPPLER ULTRASOUND - without interruptions. or hear. test uses reflected sound waves to evaluate PRE OP VISIT – O.R. NURSE - Ask - wears any type of prosthetic device. blood flow (blood vessel). Walk in, sit down, maintain eye Preoperative vital signs - shows blocked or reduced blood flow throu contact, and introduce yourself. Elevated temperature (underlying infection) - arteries of the neck Explain - purpose postpone the surgery until infection has been - reveals blood clots in leg veins Assess - understanding of the treated. THE NURSE INTERVIEW surgical procedure. PHYSICAL ASSESSMENT KEY POINTS to make a preoperative assessment. Orient to the environment of the OR Inspect bony prominences of the skin – prolonged to provide emotional support surgery may increase the risk of pressure ulcers. suite and interpret policies and to teaches how to prepare for Inform surgeon skin disease (pimple) near the site of postoperative recovery routines surgery, increase risk of infection. – videotape PRE Ex. LAMINECTOMY – skin problem on the lower OPERATIVE back, might cancel surgery. Review the patient’s chart and VISIT Inspect bony prominences of the skin – prolonged records. Review the preoperative preparations surgery may increase the risk of pressure ulcers. 30 PHYSICAL ASSESSMENT KEY POINTS The patient with individualized needs: determine the most appropriate type and Older adult – positioning and sliding on Eyeglasses should be permitted to be amount of anesthetic agent/s. worn 3.Investigates patient’s cardiac reserve the OR table, may cause shear and If a general anesthetic is used, glasses sho and observes signs of dyspnea. pressure Contact lenses must be removed 4. Asks about teeth. If indicated before the administration of a general Peripheral pulses are not explains the dental work may be anesthetic, because they may dry on the cornea or become dislodged. damage inadvertently palpable – use of a Doppler during airway instrument for assessment of PRE OP VISIT ANESTHESIOLOGIST insertion. their 1.Takes a history pertinent to administration 5.Evaluates physique of the patient for technicalities The patient with individualized needs: in administration of anesthesia: anesthetic agents Language Barrier - a. A short stout neck Get an interpreter past anesthetic experiences may cause respiratory problems or difficult intubation. Hearing Impairment/Deafness – Allergies b. Active athletic and obese persons require more anesthetic than inactive -sign language Adverse reactions to drugs persons. -hearing aid Habitual drug usage. c. Accurate body weight - dosage of many medications is calculated from Visual Impairment/Blindness body weight. PREOPERATIVE VISIT BY Make some noise ANESTHESIOLOGIST gives reason for this I.V. therapy is explained. as you approach so as not to startle the patient. 2.Evaluates the patient’s physical, mental 8. Discusses preoperative sedation in and emotional status to 31 relation to Voluntary signature, without coercion. 9. Reassures - constant observation If the patient is : Mental state of signatory (i.e. not coerced, 10. Explains risks of anesthesia sedated, or confused) at the time of Legal age -18 y/o ,if minor, a parent or lega signing. l guardian 11. Answers the questions of the patient an should sign. anesthesia. Purposes of Informed Consent An emancipated minor (not subject to parental INFORMED CONSENT CLIENT- control), It is an agreement by a client to : understands the nature of the treatment married, or independently earning a living he/she including the potential complications and may sign. (not in the Philippines) accept a course of treatment or disfigurement. decision was made without pressure. is protected against Unconscious, a responsible relative or guardian procedure after being provided unauthorized procedure. should sign. complete information SURGEON AND HOSPITAL- protected Validation of consent against legal action by a client The surgeon who claims that an unauthorized If the patient is : has the ultimate procedure was performed. Illiterate, he/she may sign it with an X, after which the responsibility for obtaining informed Circumstances requiring a permit witness writes “Patient’s mark”. consent Any surgical procedure where scalpel, scissors, suture, hemostats of Mentally incompetent, the legal guardian should sign. INFORMED CONSENT electrocoagulation may be used. Mentally incapacitated by alcohol or other chemical The witness signing a consent document Entrance into a body cavity- thoracic attest only to parecentesis, bronchoscopy substance the spouse or responsible relative of legal the following: age may sign Use of general anesthesia, local infiltration Identification of the patient or legal regional Consent in Emergency Situations substitute Validation of consent Permission for a lifesaving procedure 32  can undermine a person’s mental and - by telephone, fax, or other written physical health and become harmful. When the body is threatened or suffers communication. an injury, its response may involve Unit I. Introductory Concepts TELEPHONE – 2 nurses should functional and structural changes; Homeostasis-Stress & Adaptation these changes may be adaptive monitor the call and sign the form TYPE of STRESSORS: (having a positive effect) or maladaptive (having a negative effect). M3: Inflammation The defense mechanisms that the Physical stressors body Cold Stress is a natural feeling of not being uses determine the difference between Heat able to cope with specific demands adaptation and maladaptation—health Chemical agents and events. However, stress can and disease. This module discusses Physiologic stressors become a chronic condition if a person homeostasis, stress, adaptation, Pain does not take steps to manage it. health Fatigue These demands can come from work, problems associated with Psychosocial stressors relationships, financial pressures, and maladaptation, and ways nurses can Fear of failing an examination other situations, but anything that intervene to reduce stress and its Losing a job poses a real or perceived challenge or health-related effects. Waiting for a diagnostic test threat to a person’s well-being can Types of illness/disease result cause stress. acc. to duration: Classification of Stress Stress can be a motivator, and it can even be essential to survival. The Acute- abrupt onset and short duration, body’s fight-or-flight mechanism tells a may not require intervention the day-to-day stressors person when and how to respond to danger. However, when the body Ex. Common colds includes such common occurrences becomes triggered too easily, or there as getting caught in a traffic jam, Chronic – insidious onset and usually last experiencing computer downtime, and are too many stressors at one time, it for an extended period of time usually Characterized By remissions and exacerba 33 having an argument with a spouse or Chronic illness and its effect job loss or divorce daily hassle chronic roommate illness, a disability, or poverty Classification of Stress according to have a greater health impact duration Let’s Differentiate: major complex occurrences Acute, time limited stressor- Adaptation involving large groups such as studying for final exams a change or alteration designed to These include events of history, such A stressor sequence a series assist in adapting to a new situation or as terrorism and war. The of stressful event from an environment This is the process of demographic, initial events- job loss or coping with the stress, a economic, and technologic changes divorce compensatory process that has occurring in society A chronic intermittent physiologic and psychological stressors- daily hassles components The tension produced by any stressor Chronic enduring stressors is a result not only of the change itself, that persists over time- Adaptation is a constant, ongoing but also of the speed with which the chronic illness, a disability, or process that requires a change in change occurs. poverty. structure, function, or behavior so that a person is better suited to the stressors that occur less frequently environment; it involves an interaction and involve fewer people A stressor between the person and the Sequence—a series of stressful events environment. This category includes the influence that result from an initial event of life events such as death, birth, Homeostasis marriage, divorce, and retirement. It A chronic intermittent stressor chronic also includes the psychosocial crises enduring stressor that persists over a steady state within the body; the that occur in the life cycle stages of time such as studying for Final stability of the internal environment. the human experience. examinations When a change or stress occurs that causes a body function to deviate from 34 its stable range, processes are initiated Response Based Model to restore and maintain dynamic FIGURE 6-1 Constellation of systems. balance. Each system is a subsystem of the Transaction Based Model larger system (suprasystem) of which it When these adjustment processes or is a part. In this figure the cell is the Stimulus-Based Model of compensatory mechanisms are not smallest system, being a subsystem of Stress adequate, steady state is threatened, all other systems. function becomes disordered, and dysfunctional responses occur The goal of the interaction of the Stimulus Based Model body’s Holmes and Rahes advanced Subsystems is to produce a dynamic this theory Balance or steady state (even in the It proposed that life changes presence of change), so that all (LIFE EVENTS) or subsystems Are in harmony with each (STRESSORS), either positive other. or negative, are stressors that tax the adaptation capacity of Four concepts—constancy, an individual, causing Constellation of systems Homeostasis, Stress, and physiological and adaptation— are key to the psychological strains that lead understanding of steady state to health problems. They developed the Social Readjustment Rating Scale (SRRS). Models of Stress Let’s Differentiate: Stimulus Based Model 35  and somatic changes and Resistance Phase finally disruption of homeostasis. adaptation to the noxious stressor occurs A. Psychological Response to Stress cortisol activity is still increased B. Physiologic Response to Stress Exhaustion Phase Endocrine activity increases and has a negative effects on the body They hypothesized that people with RESPONSE BASED MODEL systems that can lead to death higher scores in the SRRS, - that is major life changes-are more likely to GENERAL ADAPTATION experience physical or mental illness. SYNDROME (GAS) Response Based Model of Stress Alarm Phase It is represented in the Sympathetic “fight-flight” well-known theory of Hans Response activated with the release of Selye catecholamine It is similar to the “Fight or Flight” response, which occurs onset of the adrenocorticotropic in situation that perceived as hormone (ACTH)-adrenal cortical very threatening. response The response is a physiological one in which arousal of the defensive and anti-inflammatory but sympathetic nervous system self-limited results in many physiological 36  thus revenging its spread and 2.The response is adaptive, meaning promotes healing. The inflammatory that a stressor is necessary to response may produce localized pain, stimulate it swelling, heat, redness and changes in functioning.