Medical Surgical Nursing Lecture Chapter 1 PDF

NCM 112 MEDICAL SURGICAL NURSING LECTURE CHAPTER 1: CONCEPTS, PRINCIPLES, AND THEORIES eg. heart disease, stroke, cancer, diabetes, obesity, CHAPTER 1...

NCM 112 MEDICAL SURGICAL NURSING LECTURE CHAPTER 1: CONCEPTS, PRINCIPLES, AND THEORIES eg. heart disease, stroke, cancer, diabetes, obesity, CHAPTER 1 arthritis RISK FACTOR HEALTH CARE SITUATIONS a. tobacco use b. poor nutrition THE GLOBAL CAUSES OF DEATH IN ORDER OF TOTAL c. lack of physical activity NUMBER OF LIVES LOST ARE ASSOCIATED WITH THREE d. excessive alcohol use TOPICS: 1. CARDIOVASCULAR: NURSING CARE OF PATIENTS WITH CHRONIC a. ischaemic heart disease CONDITIONS b. stroke 2. RESPIRATORY: alleviate & manage symptoms a. Chronic obstructive pulmonary disease psychologically adjust to physically accommodate (COPD) resulting disability b. Lower respiratory infections prevent and manage crises and complications 3. NEONATAL CONDITIONS: carry out regimens as prescribed a. Birth Asphyxia, and birth trauma validate individual self worth and family functioning a. Prenatal sepsis & infections manage threats to identity b. Preterm birth complications normalize personal and family life as much as possible CAUSED OF DEATH CAN BE GROUPED INTO 3 live with altered time, social isolation, and loneliness CATEGORIES: establish networks of support and resources that a. COMMUNICABLE - infections, parasitic disease, enhance quality of life maternal perinatal, and nutritional conditions return to a satisfactory way of life after an acute b. NON-COMMUNICABLE- injuries & chronic illnesses debilitating episode. die with dignity and comfort LEADING CAUSE OF DEATH (PHILIPPINES, WHO 2019): ischaemic heart disease lower respiratory infections stroke CULTURAL AND HEALTH ETHNIC DISPARITIES AND kidney disease CULTURALLY COMPETENT CARE hypertensive heart disease - awareness of culture in the delivery of nursing care, chronic obstructive pulmonary disease acknowledging one’s cultural knowledge deficit using diabetes mellitus self-reflection, continuous self evaluation, and tuberculosis consultation with others to detect barriers to culturally neonatal conditions competent care and address bias, or lack of interpersonal violence knowledge or skills. - respect one’s culture. Nurses should be aware that MARASMUS: skin and bones patients act and behave in various ways because of KWASHIORKOR: edematous, big, protein-deficiency the influence of culture on behavior and attitudes. CHRONIC ILLNESS & CHRONIC DISEASE CULTURE: defined as the knowledge, belief, art, morals, laws, customs, and any other capabilities and habits acquired by CHRONIC ILLNESS humans as a member of society. CULTURAL CONCEPTS: the concept of culture and its - refers to human experience of living with a chronic relationship to the health care beliefs and practices of patients disease or condition. and their family or significant other provide the foundation for - includes the person’s perception of the experience of transcultural nursing. having a chronic disease or condition. - chronic illness and disability affect people of all ages. - found in all ethnic, cultural, social, socioeconomic, groups. TRANSCULTURAL NURSING - providing care to patients and families across cultural variations - acknowledging, respecting, and adapting to cultural CHRONIC DISEASE needs of patient, families, and communities - refers to noncommunicable disease (conditions not - awareness of culture in the delivery of nursing care caused by an acute infection or injury), chronic conditions, or chronic disorders. 1. respect for cultural diversity/cultural humility - are long-term health conditions that affect one’s well- 2. respect for cultural awareness or sensitivity being and function in an episodic, continuous, or 3. comprehensive care or culturally congruent nursing progressive way over many years of life. care GRACE JOY MALSI BSN3-F 1  NCM 112: Chapter 1 INTRAOPERATIVE PHASE: begins when the patient is CULTURAL HUMILITY transferred onto the (OR) bed and ends with admission to the - acknowledges one’s cultural knowledge deficit using post anesthesia care unit (PACU). nursing responsibilities self reflection, continuous self evaluation and involve; acting as scrub nurse, circulating nurse, or registered consultation nurse first assistant. - delivery of interventions that are congruent with a given culture. involves complex integration of attitude, POSTOPERATIVE PHASE: begins with the admission of the knowledge, and skills patient to the PACU and ends with a follow-up evaluation in the - acknowledging one’s cultural differences that might clinical setting or home. be present in the health care process. nurses should go beyond PACU- Post Anesthesia Care Unit CULTURALLY COMPETENT NURSING - effective, individualized care that demonstrates SURGICAL CLASSIFICATION ACCORDING TO PURPOSE respect for dignity, personal rights, preferences, 1. DIAGNOSTIC - to establish the presence of disease beliefs, and practices of person receiving care while condition acknowledging the biases from interfering with the care provided. ex. biopsy, exploratory, laparoscopy or laparotomy, cheiloplasty CULTURAL AWARENESS OF SENSITIVITY - implies awareness of cultural differences might be 2. CURATIVE - to treat disease condition present in healthcare process. - - the nurse should go beyond sensitivity to lewage ex. excision of a tumor or an inflamed appendix awareness of these differences to plan appropriate culturally competent nursing care. ablative - removal of an organ (ectomy) constructive - repair of congenitally defective organ CULTURALLY CONGRUENT NURSING CARE ( “plasty”, “oorhapy”, “pexy”) - customized to fit a person’s cultural values, beliefs, reconstructive- repair of damaged organ traditions, practices and lifestyle. 3. PALLIATIVE - - to relieve distressing signs & effective communication - words, body language, voice, symptoms necessarily to cure the disease. to relieve tone and loudness. (Nurse-Patient Interaction) pain or correct a problem CULTURALLY MEDIATED CHARACTERISTICS: nurse should be aware that the patient acts and behave in various ex. debulking a tumor to achieve comfort, or removal of a ways dysfunctional gallbladder Assessing for patient cultural beliefs 4. REHABILITATIVE - ex. total joint replacement information disclosure surgery to correct crippling pain or progression of space and distance degenerative osteoarthritis eye contact 5. AESTHETIC - to improve physical features that are time within normal range. touch diet ex. breast augmentation biologic variation observance of holiday REASON WHY PATIENT NEED SURGERY CULTURAL NURSING ASSESSMENT to cure illness/disease by removing disease tissue or - refers to a systematic appraisal or examination organs individual, family, or groups to visualize internal structure during diagnostic Nursing Assessment Tools: tools, scales, questionnaires to obtain tissue for examination to prevent disease injury NURSING MANAGEMENT to improve appearance formal education to repair/ remove traumatized tissue and structures in sincere classes feedback and assess to relevant information PERIOPERATIVE NURSING - spans the entire surgical experience. consist of 3 phases that begin and end at particular points in the sequence of surgical experience events. PREOPERATIVE PHASE: begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) bed. GRACE JOY MALSI BSN3F 2  NCM 112: Chapter 1 helps insure patient understands the patient to be performed Doctors = will ask PATIENT TO SIGN Nurses = will be there TO WITNESS ESSENTIAL ELEMENTS OF INFORMED CONSENT a description of benefits is to help expected a description of alternative treatment of procedure the diagnosis & exploration of the condition fair explanation of procedures to be done and used and the consequences the diagnosis and explanation of conditions the prognosis, if recommended care, procedure is refused INFORMED CONSENT IS NECESSARY IN THE FOLLOWING CIRCUMSTANCES: a. invasive procedures such as surgical incision, biopsy, cystoscopy, paracentesis b. procedures requiring sedation or anesthesia ACCORDING TO THE DEGREE OF RISK c. nonsurgical procedure such as an arteriography that causes more than slight risk to patient MAJOR SURGERY MINOR SURGERY d. procedures involving radiation (with contrast medium, ask the patient for allergy of seafood. seafood High risk/Greater risk for Generally not prolonged contains iodine) infection e. blood product administration extensive leads to few serious complications prolonged involves less risk large amount of blood loss vital organ may be handled or removed SPECIAL CONSIDERATIONS DURING THE PERIOPERATIVE PERIOD Reduce surgical complications Gerontologic considerations Bariatric patients Patient with disability Patients undergoing ambulatory surgery Patients undergoing emergency surgery INFORMED CONSENT - is the patient’s autonomous decision about whether to undergo a surgical procedure. PREOPERATIVE PHASE PURPOSE: GOAL assessing and correcting physiologic and psychologic to protect patient from unauthorized surgery problems that may increase surgical risk protect the surgeon from claims of an unauthorized giving the person and significant other complete operation/battery teaming/teaching guidelines regarding surgery GRACE JOY MALSI BSN3F 3  NCM 112: Chapter 1 instructing and demonstrating exercises that will - previous medication use benefit the person during post op period - presence of trauma and infection planning for discharge and any projected changes in - psychosocial factors lifestyle due to surgery - spiritual and cultural belief PRE-OP EXERCISES: ROUTINE PRE-OPERATIVE SCREENING TEST breathing exercises - to expand the lungs during operation splinting & coughing - minimize pain to change position SCREENING TEST RATIONALE ambulation - for circulation RBC Count, hemoglobin, PRE ADMISSION TESTING hematocrit, O2 carrying 1. Performs initial preoperative assessment capacity of blood 2. Initiates education appropriate to patient's needs CBC 3. Involves family in interview Platelet - activate as 4. Verifies completion of preoperative diagnostic testing substance in plasma - forms according to patient's needs as a clot and allow a wound 5. Confirms understanding of surgeon-specific to heal preoperative prescribed therapies (e.g., bowel preparation, preoperative shower) WBC - are indicator of 6. Discusses and reviews advance directive document immune function 7. Begins discharge planning by assessing patient's need for postoperative transportation and care Blood Grouping and determine in carries blood Cross-Matching transfer is required ADMISSION TO SURGICAL CENTER during/after surgery 1. Completes preoperative assessment 2. Assesses for risks for postoperative complications Serum Electrolytes to evaluate fluids and 3. Reports unexpected findings or any deviations from electrolytes status normal 4. Verifies that operative consent has been signed Prothrombin Time (PT) and measure time required for 5. Coordinates patient education and plan of care with Thrombopoietin (PTT) clotting to occur nursing staff and other health team members 6. Reinforces previous education high level indication 7. Explains phases in perioperative period and Fasting Blood Glucose undiagnosed Diabetes expectations Mellitus 8. Answers patient's and family's questions Blood Urea Nitrogen (BUN) to evaluate renal function Creatinine IN HOLDING AREA (PREOPERATIVE AREA) ALT, ALP, AST to evaluate liver function 1. Identifies patient 2. Assesses patient's physical and emotional status, Total Albumin, Total to evaluate nutritional status baseline pain, and nutritional status Protein 3. Reviews medical record 4. Verifies surgical site and that it has been marked per Urinalysis determine urine composition institutional policy 5. Establishes IV line Chest x ray to evaluate respiratory status 6. Administers medications if prescribed & heart size 7. Takes measures to ensure patient's comfort 8. Provides psychological support ECG to identify pre-existing 9. Communicates patient and family's needs to other cardiac problem appropriate members of the health care team PREOPERATIVE NURSING INTERVENTION PRE-OPERATIVE ASSESSMENT prepare the patient physically and psychologically and the goal in the preoperative period is for the patient to be as to maintain safety. healthy as possible. Providing Patient Education - nutritional and fluids and electrolyte balance Deep Breathing, Coughing, and Incentive Spirometry - dentition Mobility and Active Body Movement - drug or alcohol use Pain Management - respiratory status - cardiovascular status EDUCATION FOR PATIENT UNDERGOING AMBULATORY - hepatic and renal function SURGERY - endocrine function - immune function 1. Providing Psychosocial Interventions GRACE JOY MALSI BSN3F 4  NCM 112: Chapter 1 2. Reducing Anxiety and Decreasing Fear 3. Respecting Cultural, Spiritual, and Religious Beliefs 4. Maintaining Patient Safety 5. Managing Nutrition and Fluids 6. Preparing the Bowel 7. Preparing the Skin PREPARING THE PERSON ON THE DAY OF SURGERY PREOPERATIVE NURSING INTERVENTION EARLY MORNING CARE 1. Administering Preop Medication awaken 1 hr before pre-op meds 2. Maintaining the Preoperative Record morning bath and mouthwash 3. Preoperative Patient Warming provide a clean gown 4. Attending to Family Needs remove hairpins, braid long hair and cover with cap if 5. Nursing Care avail remove dentures, colored nail polish, hearing aids, PREPARING THE PATIENT THE EVENING BEFORE SURGERY contact lenses, jewelry take baseline vital signs before preop med preparing the skin by teaching the patient to take a check ID band, skin prep full or half bath. (rationale: to free the skin from check for special orders microorganisms as possible & reduce the risk of have client to void before preop meds (rationale: to infections at the incision site) avoid dizziness and avoid injuries from dizziness) preparing the GI Tract / bowel prep check NPO (rationale: to prevent aspiration) - laxative given or sodium phosphate continue to support emotionally - NPO (nothing by mouth) accomplished “pre-op checklist” - do repeated enema (there will be fluid and electrolytes imbalance developed) PREOPERATIVE MEDICATION - elderly and children patient they ARE NOT ALLOWED TO EAT (rationale: high risk for GOALS: fluid and electrolytes imbalance) preparing for anesthesia: avoid cigarettes and to avoid admission of an anesthetics alcohol at least 24 hrs before surgery (rationale: high to minimize respiratory tract secretion and changes in tolerance in medicine or anesthesia) heart rate promoting rest/sleep: administer sedative to relax the patient and reduce anxiety WHY GIVE PREOP MEDS: COMMONLY USED PREOP MEDS - to reduce anxiety (“pre-anesthesia drug”) - tranquilizers and sedatives - smoother induction of anesthesia - midazolam - to minimize pharyngeal & respiratory secretions & - diazepam gastric secretions - lorazepam - diphenhydramine - analgesic - nalbuphine (nubain) anticholinergics: atropine sulfate proton pump inhibitor: omeprazole, famotidine WHEN TO ADMINISTER PREOP MEDS? 30-45 minutes induction of anesthesia RECAP IN PREOPERATIVE PHASE For giving IV MEDS always INFORM your patients IV Analgesic: we do not give skin testing patient symptoms for anaphylactic shock : drop blood pressure, difficulty of breathing, chills ask client for medical history ask client use of alcohol and drugs patient with substance withdrawal - they develop behavioral changes for FEMALE patients: ask for their pregnancy for MINOR FEMALE patients: ask for their last menstrual period abdominal distention deep breathing exercise - to prevent atelectasis or collapsed lungs GRACE JOY MALSI BSN3F 5  NCM 112: Chapter 1 designed to prevent violation of this area by INTRAOPERATIVE PHASE unauthorized persons peripheral support areas consists of : storage areas for clean and sterile supplies, sterilization - begins when the patient is transferred onto the (OR) equipment and corridors leading to procedure room bed and ends with admission to the post anesthesia care unit (PACU). nursing responsibilities involve; Restricted Area acting as scrub nurse, circulating nurse, or registered nurse first assistant. includes the procedure room where surgery is performed and adjacent substerile areas where the TRANSPORTING THE PATIENT TO THE OR scrub sinks and autoclaves are located personnel working in this area must be in proper Adhere to the principles of maintaining the comfort operating room attire and safety of the patient Accompany OR attendants to the patient's bedside THE SURGICAL TEAM for introduction and proper identification Assist in transferring the patient form bed to Patient stretcher Anesthesiologist/ Certified Complete the chart and preoperative checklist Nurse Anesthetist Make sure that the patient arrive in the OR at the Surgeon proper time Nurses RNFA (Reg. Nurse First Assistant) PATIENT’S FAMILY Surgical Technicians Direct to the proper waiting room SURGEON Tell the family that the surgeon will probably contact them immediately after the surgery Primary responsible for the preoperative medical Explain reason for long interval of waiting: history and physical assessment anesthesia prep, skin prep, surgical procedure, Performance of the operative procedure according RR to the needs of the patients Tell the family what to expect postop when they The primary decision maker regarding surgical see the patient. technique to use during the procedure may assist with positioning and prepping the GOALS: patient or may delegate this task to other members of the team Asepsis Homeostasis ANESTHESIOLOGIST Safe Administration of Anesthesia Hemostasis Selects the anesthesia, administers it, intubates the client of necessary, manages technical problems related to the administration of anesthetics agents, and supervises the client's condition throughout the surgical procedure A physician who specializes in the administration and monitoring of anesthesia while maintaining the overall well-being of the patient SURGICAL SETTING SCRUB NURSE Unrestricted Area Reviews anatomy, physiology and the surgical procedures proves an entrance and exit from the surgical suite Assists with the preparation of the room for personnel, equipment and patient Scrubs, gowns and gloves seld and oher members Street clothes are permitted in this area, and the of the surgical team area provides access to communication with Prepares the instrument table and organizes personnel within the suite and with personnel and sterile equipment for functional use patient's families outside the suite Assist with the drapping procedure Passes instruments to the surgeon and assistants Semi-restricted Area by anticipating their need. Counts sponges, needles and instruments provides access to the procedure rooms and Monitor practices of aseptic technique in self and peripheral support areas within the surgical suite others personnel entering this area must be in proper operating room attire and traffic control must be CIRCULATING NURSE GRACE JOY MALSI BSN3F 6  NCM 112: Chapter 1 Gowns of the surgical team are considered sterile Responsible and accountable for all activities occurring during in front from the chest to the level of the sterile field. a surgical procedure including the management of personnel The sleeves are also considered sterile from 2 inches equipment, supplies and the environment during surgical above the elbow to the procedure stockinette cuff. Sterile drapes are used to create sterile field Only the top surface of a drape is considered sterile. During the draping of a table or patient, the sterile drape is above the surfaces to be covered and is positioned from front to back items are dispensed to a sterile fluid by methods that preserve the sterility of the items and the integrity of the sterile field. After a sterile package is opened the edges are considered unsterile. Sterile supplies, including solutions, are delivered to a sterile field or handed to a scrubbed person in such a way that the sterility of the object or fluid remains intact The movements of the surgical team are from sterile areas and from unsterile to unsterile areas. Scrubbed people and sterile items contact only sterile areas; circulating nurses and unsterile items contact only unsterile areas. Movement around sterile field must not cause contamination of the field. Sterile areas must be kept in view during movement around the area. At least a feet distance from the sterile field must be maintained to prevent inadvertent contamination. Whenever a sterile barrier is breached, the area must be considered contaminated. A ™ tear or puncture of the drape permitting the access to an unsterile surface underneath renders the area unsterile. A drape must be replaced. Every sterile field is constantly monitored and PRINCIPLES OF SURGICAL ASEPSIS maintains items of doubtful sterility are considered unsterile. Sterile fields are prepared as close on the All surgical supplies, instruments, needles, sutures, possible time of dressings, gloves, covers, and solutions that may use. come in contact with the surgical wound or exposed The routine administration of hyperoxia (high levels of tissues must be sterilized before use. oxygen) is not recommended to reduce surgical site The surgeon, surgical assistants, and nurses infection prépare themselves scrubbing their hands and arms with antiseptic soap and water. Surgical team POSITION DURING SURGERY: SUPINE (DORSAL RECUMBENT) members wear long-sleeved, sterile gowns and gloves. Head and hair are covered with a cap and a mask is worn over the nose and mouth' to minimize Abdominal, extremity, vascular, chest, neck, facila, ear, breast the possibility that bacteria from the upper respiratory surgery. tract will enter the wounds During Surgery, only scrubbed, gloved, and gowned patient lies flat on back with arms either extended personnel can touch sterilized objects. Non-scrubbed on arm board or placed along side of body personnel refrain from touching or contaminating any Small padding placed under patient's head, neck sterile. and under knees Environment control- surgical asepsis requires Vulneravle pressure points should be padded meticulous cleaning and maintenance of the OR Safety strap applied 2 inches aboive knees environment. Floor and horizontal surfaces are Eyes should be protected by using eye patch and cleaned between cases with detergent, soap, and ointment watèr of detergent germicide. Sterile equipments are inspected regularly to ensure optimal operation and performance Unnecessary personnel and physical movement POSITION DURING SURGERY: PRONE POSITION may be restricted to minimize bacteria in the air. Surgeries involving posterior surface of the body (spine, neck, BASIC PRINCIPLES OF ASEPTIC TECHNIQUE buttocks and lower extremities) Chest rolls or bolster are placed on operating table All materials in contact with the surgical wound or prior to positionning used within the sterile field must be sterilized Foam head rest, head turned to side or facing downward. GRACE JOY MALSI BSN3F 7  NCM 112: Chapter 1 Patient's arms are rotated to the padded arm boards that face the head, bringing them through their normal ROM ANESTHESIA Padding for knees and pillow for lower extremities to grevent toes from touching the mattress. Safety strap applied 2 inches above the knees A state of narcosis or severe CNS depression POSITION DURING SURGERY: REVERSE TRENDELENBURG produced by pharmacologic agents, analgesia, and POSITION reflex loss. Anesthetics can produce muscle relaxation, block Surgeries involving upper abdominal, head, neck and facial transmission of pain nerve impulses and suppress surgery. reflexes It can also temporarily decrease memory retrieval Patient is supine with head higher than feet. and recall. Small pillow under neck and knees. Well-padded footboard should be used to prevent The effects of anesthesia are monitored by considering the slippage of foot of the table following parameters: Anti-embolic hose should be used of position is to be maintained for an extended period of time. respiration Patient should be returned slowly to supine 02 saturation CO2 levels POSITION DURING SURGERY: LITHOTOMY HR and BP Urine output Perineal, vaginal, rectal surgeries; combined abdominal vaginal procedure TYPES OF ANESTHESIA: GENERAL Patient is supine with buttocks near lower break in the table. feet are placed in stirrups, stirrups height should reversible state consisting of complete loss of consciousness be excessively high or low, but even on both sides. and sensation Knee brace must not compress vascular structures or nerves in the popliteal space. Protective reflexes such as cough and gag are lost Pressure from metal stirrups against the upper Provides analgesia, muscle relaxation, and inner aspect of the thigh and calf should be avoided. sedation leg should be raised and lowered slowly and Produces amnesia and hypnosis simultaneously TECHNIQUES USED IN GENERAL ANESTHESIA A. Intravenous Anesthesia POSITION DURING SURGERY: MODIFIED FOWLER (SITTING POSITION) This is being administered IV and extremely rapid Its effect will immediately take place after 30 Otorhinology (ear and nose), neurosurgery minutes of introduction It prepares the client for smooth transition to the Patient is supine position over the upper break surgical anesthesia table backrest is elevate, knees flexed B. Inhalation Anesthesia Arms rest on pillow, placed in lap; safety strap 2 inches above the knees. This comprises of volatile liquids or gas and Slow movement in and out of position must be oxygen used to prevent drastic changes in blood volume administered through a mask or endotracheal tube movement. commonly used inhalation agents: oxygen and Anti-embolic hose should be used to assist venous nitrous oxide (combined) return when using special neurologic headrest, eyes must Stages of General Anesthesia be protected Stage 1: Onset/ Induction dizziness and a feeling of detachment POSITION DURING SURGERY: JACK KNIFE POSITION Patient may have ringing, roaring, or buzzing in the ear although still unconscious rectal procedures, sigmoidoscopy and colonoscopy Sense an inability to move the extremities easily Table is flexed at center break Stage 2: Excitement/ Delirium All precautions taken with prone position are taken with Jack knife position Table strap applied over thighs. GRACE JOY MALSI BSN3F 8  NCM 112: Chapter 1 Struggling, shouting, talking, singing, laughing, or C. Epidural Anesthesia crying is often avoided if IV anesthetics agents are given smoothly and quickly. achieve by injecting a local anesthetic into the Pupils dilate but they constrict if exposed to light, epidural space into space that surrounds the dura the PR is rIpid and respirations may be irregular matter of the spinal cord. because of the uncontrolled movements of the patient result similar to spinal analgesia agents use are chloroprocaine, lidocaine and Stage 3: Surgical bupivacaine. reached by administration of anesthetic vapor or D. Peripheral Nerve Block gas and supported by IV agents The patient is unconscious and lies quietly on the achieve by injecting a local anesthetic to table anesthetize the surgical site the pupils are small but constrict when exposed to agents used are chloroprocaine, lidocaine and light, respiration is regular, the PR and volume and bupivacaine. the skin is pink and slightly flushed E. Intravenous Block (Beir Block) Stage 4: Medullary/ Stage of Danger Often used for arnwrist, and hand procedure reached if too much anesthesia. an occlusion tomiquet is applied to the extremity to Respiration becomes shallow, the pulse is weak prevent infiltration and absorption of the injected IV and thready and the pupils become widely dilated and agents beyond the involved extremity. no longer constrict when exposed to light. Cyanosis develops and without prompt F. Caudal Anesthesia intervention death rapidly follows. If this stage develops, an anesthetic agent is discontinued is produced by injection of the local anesthetic into immediately and respiratory and circulatory support is the caudal or sacral canal. initiated to prevent death 1. General: c the entire 2. Local: treat the local of the p TYPES OF ANESTHESIA: REGIONAL G. Field Block Anesthesia Types of Anesthesia: Regional The area proximal to a planned incision can be temporary interruption of the transmission of nerve impulses injected and infiltrated with local anesthetic agents. to and from specific area or region of the body H. Monitored Anesthesia Care Achieve by injecting local anesthetics in close proximity to appropriate nerves referred to as monitored sedation reduce all painful sensation in one region of the used for healthy patients undergoing minor surgical body without inducing unconsciousness procedures and some critically ill patients who are agents used are lidocaine and bupivacaine unable to tolerate anesthesia TECHNIQUES USED IN REGIONAL ANESTHESIA PATHOPHYSIOLOGY OF MALIGNANT HYPERTHERMIA A. Topical Anesthesia During anesthesia --- agents such as: applied directly to the skin and mucous inhalation anesthetic agents (e.g. halothane, membrane, open skin surfaces, wounds, and burns enflurane, isoflurnae) readily absorbed and act rapidly muscle relaxants (succinylcholine) used topical agents are benzocaine Stress and some medication such as: sympathominetics (epinophrine) B. Spinal Anesthesia (SAB) Theophylline, Aminophylline, anticholinergic (atrophine) local anesthetics are injected through a lumbar Cardiac glycosides(digitalis) puncture, between L2 and S1 Anesthetic agent is injected into the subarachnoid space surrounding the spinal, cord Low spinal- perineal/ rectal areas Mid spinal T10 (below level if umbilicus) - hernia repair and appendectomy High spinal T4 (nipple line) for CS Agents used are procaine, tetracaine, lidocaine and bupivacaine. GRACE JOY MALSI BSN3F 9  NCM 112: Chapter 1 Nursing Process: The patient during surgery intraoperative, focus on Nursing Diagnosis, interventions and outcomes that surgical patients and their families experience. Priorities include collaborative problems and expected goals: Assessment: Nursing assessment obtain data from the patient and the patient's medical record. include: Physiologic status (anxiety level, verbal communication problems, coping mechanism) Psychological status (surgical site, skin condition, and effectiveness of preparation, mobility of joints) Ethnical concerns Diagnosis: Nursing diagnosis may include: Anxiety related to surgical or environmental concerns Clinical Manifestation: Risk of latex Initial symptoms of Malignant Hyperthermia are cardiovascular, Planning / Goals respiratory and abnormal musculoskeletal activity. Reduced anxiety, absence of latex exposure, absence of > Tachycardia (heart rate greater than 15 bpm) positioning injuries, freedom from > Sympathetic nervous stimulation leads to ventricular injury maintenance of the patient dignity and absence of dysrhythmia hypotension complication. > Decreased cardiac output oliguria and cardiac arrest. > Hypercapnia, increase in carbon dioxide(CO,) early respiratory sign > Abnormal transport of Calcium, Rigidity or Tetanus like Nursing Interaction movement, often in the jaw - muscle rigidity early sign. Reducing anxiety Reducing latex exposure > Late sign develops rapidly the rise of body temperature can Preventing perioperative positioning injury increase I'C to 2°C (2°F Protecting the patient to 4°F) every minutes and core body temperature can exceed 42°C (107"F) POSTOPERATIVE CARE POTENTIAL INTRAOPERATIVE COMPLICATION POST OPERATIVE PERIOD -extends from the time the Intraoperative Complication patient leaves the operating room until the last follow up visit with the surgeon Anesthetic Awarenessess nausea and vomiting regurgitation GOALS: Anaphylaxis Restore homeostasis and prevent complication Hypoxia and other Respiratory Complication Maintain adequate cardiovascular and tissue perfusion Hypothermia Maintain adequate respiratory function Malignant Hyperthermiamia Maintain adequate nutrition and elimination Maintain adequate fluid and electrolye balance So, how do we protect our patients? assessment, diagnosis, Maintain adequate renal function planning, implementation, evaluation Promote adequate rest, comfort and safety GRACE JOY MALSI BSN3F 10  NCM 112: Chapter 1 Promote adequate wound healing GERONTOLOGIC CONSIDERATIONS: Promote and maintain activity and mobility Provide adequate psychological support Post operative Nursing care: > Keep patient warm, older adults are more susceptible to PACU CARE hypothermia Transport of client from OR to RR > Position is changed frequently to stimulate respiration; promote circulation and comfort Avoid exposure > Careful monitor it is possible to detect cardio pulmonary Avoid rough handling deficits before signs and symptoms are apparent Avoid hurried movement and rapid changes in position > Changes associated with the aging process, the prevalence of chronic disease, Initial Nursing Assessment - alteration in fluid and nutritional status - the increased use of medication result in the need for Verify the patient's identity, operative procedure, and the postoperative vigilant surgeon who performed the procedure - older adults may have slower recovery from anesthesia due Evaluate the following signs and verify their level of stability to prolonged time to eliminate sedative and anesthetic agent with the anesthesiologist: > Post operative confusion and delirium may occur in up to half - respiratory status of older adult - circulatory status - pulses PARAMETERS FOR DISCHARGE FROM - temperature PACU/RR - oxygen saturation Activity= Able to obey command - hemodynamic values Respiratory= Easy, noiseless breathing Determine swallowing and gag reflex, LOC, and patient's Circulation= BP within 20mmHg of preop level response to stimuli Consciousness= responsive Color= Pinkish skin and mucus membrane Initial Nursing Assessment Evaluate lines, tubes, or drains, estimate blood loss, condition of wound, medication used, transfusions and output. Evaluate the patient's level of comfort and safety Perform safety check; siderails up and restraints are properly in placed Evaluate activity status, movement of extremities Review the healthcare provider's orders. Nursing Management PACU Assess the patient Maintain a patent airway Assess Status of Circulatory System Maintaining Adequate Respiratory Function Assessing thermoregulatory Status Maintaining adequate fluid volume Hypotension and Shock GRACE JOY MALSI BSN3F 11