PRELIM NCM 112-RLE PDF

PRELIM; NCM 112- RLE Question 2 Pretest A client with a chronic lung disorder requires some supplemental oxy...

PRELIM; NCM 112- RLE Question 2 Pretest A client with a chronic lung disorder requires some supplemental oxygen. The nurse ensures consistent and safe To prevent postoperative complications the nurse delivery with which of the following? assists the client with coughing and deep breathing exercises. This is best accomplished by implementing which of the 1. 2 L/min per nasal cannula following? 2. 6 L/min per face mask 1. Coughing exercises 1 hour before meals and deep breathing 1 hour after meals. 3. 8 L/min per partial rebreather mask 2. Forceful coughing as many times as tolerated. 4. 10 L/min per nonrebreather mask 3. Huff coughing every 2 hours or as needed. Rationales 2 4. Diaphragmatic and pursed-lip breathing 5 to 10 times 1. Correct. Clients with chronic lung disease may have four times a day. only low levels of supplemental oxygen, generally not over 2 liters per minute. Rationales 1 2. Incorrect. 1. Deep breathing and coughing should be performed at the same time. Only at meal times is not sufficient. 3. Incorrect. 2. Extended forceful 4. Incorrect. coughing fatigues the Question 3 client. While a client with chest tubes is ambulating, the 3. Correct. Huff connection between the tube and the water seal dislodges. coughing helps keep Which of the following actions by the nurse is most the airways open and appropriate? secretions mobilized. 1. Assist the client to ambulate back to bed. 4. Diaphragmatic and pursed-lip breathing are 2. Reconnect the tube to the water seal. techniques used for 3. Assess the client’s lung sounds with a stethoscope. clients with obstructive airway disease. 4. Have the client cough forcibly several times. Rationales 3 2. This may be true but it would depend on where the infection is located. 1. Assisting the client back to bed is possible actions after the system is reconnected. 3. A fractured rib would interrupt transport of oxygen from the atmosphere to the airways. 2. Correct. The tube should be reconnected to the water seal as quickly as possible. 4. Damage to the medulla would interfere with neural stimulation of the respiratory system. 3. Assessing the client’s lungs is possible actions after the system is reconnected. Question 5 4. Incorrect. Which of the following terms is most descriptive of a client experiencing dyspnea when lying down and must assume an upright or sitting position to breathe more comfortably and effectively? 1. Dyspnea Question 4 2. Hyperpnea Which of the following clients is most at risk for a 3. Orthopnea problem with the transport of oxygen from the lungs to the 4. Acapnia tissues? Rationales 5 1. A client who has anemia. 1. Incorrect. Difficulty of breathing 2. A client who has an infection. 2. Incorrect. Abnormally rapid or deep breathing. 3. A client who has a fractured rib. 3. Correct. Respiratory difficulty related to a reclining 4. A client who has a tumor of the medulla. position without other physical alterations is defined as Rationales 4 orthopnea. 1. Correct. Anemia is a condition of decreased red blood 4. Incorrect. a condition of carbon dioxide deficiency in cells and decreased hemoglobin. Hemoglobin is how blood and tissues. the oxygen molecules are transported to the tissues. Function of the Respiratory System The function of the respiratory system is gas exchange  Oxygen from inspired air diffuses from alveoli in the lung – Pulmonary into the blood in the pulmonary capillaries capillary network Carbon dioxide produced during cell metabolism – Pleural membranes diffuses from the blood into the alveoli and is exhaled. Process of Breathing Inspiration – Air flows into lungs Expiration – Air flows out of lungs Structures of the Respiratory System Inspiration Upper Respiratory Tract Diaphragm and intercostals contract – Mouth Thoracic cavity size increases – Nose Volume of lungs increases – Pharynx Intrapulmonary pressure decreases – Larynx Air rushes into the lungs to equalize pressure Lower Respiratory Tract Exhalation – Trachea Diaphragm and intercostals relax – Bronchi Volume of the lungs decreases – Bronchioles Intrapulmonary pressure rises – Alveoli Air is expelled Gas Exchange Occurs after the alveoli are ventilated  Pressure differences on each side of the respiratory Environment - might have adverse effects on human’s membranes affect diffusion respiratory system, leading to a decline in lung function. For example, exposure to traffic pollutants may cause Diffusion of oxygen from the alveoli into the pulmonary coughing, sneezing, asthma, and decreased lung blood vessels function. Diffusion of carbon dioxide from pulmonary blood Lifestyle - include tobacco smoking (including second- vessels into alveoli hand smoke), Oxygen Transport Stress - Makes you breathe harder (leading to Transported from the lungs to the tissues hyperventilation / panic attack). Leads you to exercise – Leading to an increased metabolism of working 97% of oxygen combines with hemoglobin in red blood muscles. Increasing O2 demands. Tidal volume cells and carried to tissues as oxyhemoglobin increases Remaining oxygen is dissolved and transported in Health Status - Physical inactivity is the obvious cause plasma and cells of the poor development of the respiratory reserve. It results in breathlessness, respiratory deconditioning and Carbon Dioxide Transport chronic respiratory debility. Obesity results in a Must be transported from the tissues to the lungs significant increase in the load on the cardio-respiratory system. Breathlessness is the most common Continually produced in the process of cell metabolism symptom. Gradually, the lungs and the heart are unable 65% is carried inside the red blood cells as bicarbonate to cope up with this burden and tend to fail. While gross obesity itself can lead to respiratory failure, even milder 30% combines with hemoglobin as carbhemoglobin obesity would act as a contributory factor. 5% transported in solution in plasma and as carbonic Medications - Many medicines and substances are acid known to cause lung disease in some people. These include: Antibiotics, such as nitrofurantoin and sulfa Factors that Influence Respiratory Function drugs. Heart medicines, such as amiodarone. Age - has historically been one of the major factors in Chemotherapy drugs such as bleomycin, the evaluation of lung function. Pulmonary maturity is cyclophosphamide, and methotrexate reached at about 20–25 years of age, after which lung Common Manifestations of Impaired Respiratory Function function progressively begins to decline. Hypoxia  Altered breathing patterns Orthopnea Obstructed or partially obstructed airway is the sensation of breathlessness in the recumbent position, relieved by sitting or standing. Hypoxia Dyspnea Condition of insufficient oxygen anywhere in the body is often described as an intense tightening in the chest, air Rapid pulse hunger, difficulty breathing, breathlessness or a feeling of Rapid, shallow respirations and dyspnea suffocation. Increased restlessness or lightheadedness Flaring of nares Substernal or intercostal retractions Cyanosis Altered Breathing Patterns Tachypnea (rapid rate) Bradypnea (abnormally slow rate) Apnea (cessation of breathing) Kussmaul’s breathing- is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) Cheyne-Stokes respirations - disorder characterized by Obstructed or Partially Obstructed Airway recurrent central apneas during sleep alternating with a crescendo-decrescendo pattern of tidal volume Partial indicated by low-pitched snoring during inhalation Biot’s respirations- Abrupt and irregularly alternating periods of apnea with periods of breathing that are Complete indicated by extreme inspiratory effort with no consistent in rate and depth, often the result of IICP chest movement Alterations in Ease of Breathing Nursing Measures to Promote Airway suctioning Respiratory Function Chest tubes Ensure a patent airway Incentive spirometry Positioning Also referred to as SUSTAINED MAXIMAL Encouraging deep breathing, INSPIRATION DEVICES (SMIs) coughing Uses: Ensuring adequate hydration Improve pulmonary ventilation counteracts the effects of anesthesia or hypoventilation loosen respiratory secretions facilitates respiratory gaseous exchange expands collapsed alveoli Client Teaching using an Incentive spirometer 1. hold the spirometer in an upright position 2. exhale normally 3. seal the lips tightly around the mouthpiece Therapeutic Measures to Promote Respiratory Function 4. take in a slow, deep breath for 2 sec Medications initially increasing to 6 sec to keep the ball Incentive spirometry or cylinder elevated as possible. (sustained elevation ensures adequate ventilation of Chest Physiotherapy the alveoli) Postural drainage Oxygen therapy Artificial airways 5. Remove the mouth piece and exhale normally turbulence of the exhaled air thus, loosening secretions. It is done alternately with percussion. 6. Cough after the incentive effort. NURSING CONSIDERATIONS: 7. Relax and take several normal breaths before proceeding a. place hands, palms down on the chest area to be drained, one hand over the other with the fingers together and extended 8. repeat the procedure several times and or the hands may be placed side by side. then 4-5 times hourly b. Ask the client to inhale deeply and exhale slowly through the 9. clean the mouthpiece with water and then nose or pursed lips shake dry. c. During the exhalation, tense all the hand and arm muscles and using mostly the heel of the hand, vibrate the hands moving them downward. Stop during inhalation Percussion, Vibration and Postural Drainage (PVD) Postural Drainage Percussion (clapping) – forceful striking of the skin with cupped Nursing responsibilities: hands. It can mechanically dislodge tenacious secretions from a. monitor vital signs the bronchial walls by trapping air against the chest and sets up vibrations through the chest wall to the secretions. b. assess intolerance – note cyanosis, pallor, diaphoresis, dyspnea, fatigue Nursing Considerations: c. Each position is usually assumed for 10-15 minutes a. cover the area to be percuss with a towel or cloth to reduce discomforts Deep Breathing Exercises and Coughing Exercises b. ask the client to breathe slowly and deeply to promote used to remove secretions in the airways. relaxation Coughing raises secretions allowing the client to expectorate or swallow it. c. alternately flex and extend the wrists rapidly to slap the chest Breathing exercises are indicated for clients with d. percuss each affected lung segments for 1-2 minutes restricted chest expansion (e.g. COPD, post thoracic surgery). Pursed lips create a resistance to the air Vibration – is a series of vigorous quiverings produced flowing out of the lungs, thereby prolonging expiration by hands that are placed flat against the client’s chest and preventing airway collapse. The client usually wall. It is used after percussion to increase the inhales to a count of 3 and exhales. CHEST PHYSIOTHERAPY 6. place the spout 12-18 inches away from the client’s nose 7. render for 10-15 minutes. 8. Inform client to perform DBE and CE after the procedure 9. provide oral hygiene 10. Do after care of the equipment. Oxygen Therapy STEAM INHALATION Adequate Oxygen supply from the environment (man requires 21% of oxygen from the environment in order to survive) Dependent Nursing Action needed when clients have difficulty ventilating all areas of their lungs, impaired gas exchange, with heart failure to prevent Uses: hypoxia. to liquefy mucous secretions Dependent function but nurses may initiate the therapy in an to warm and humidify air emergency situation. to relieve edema of the airways Supplied in a tank or cylinder or piped into wall outlets. to soothe irritated airways Safety precautions: O2 facilitates combustion – fire precautions. to administer medications Can dehydrate Nursing Considerations: respiratory mucous membranes (humidify 1. Explain the procedure and O2). Low liter flows purpose to the client (1-2 lpm) do not 2. Place client in semi-fowler’s position require humidification 3. cover the client’s eyes with washcloth to prevent irritation 4. check the electrical device before use 5. Place care of equipment and document the steam inhalator in a flat stable surface Simple face mask Nonrebreather mask Partial rebreather mask Venturi mask Nasal cannula Cannula (nasal prongs) – most common and inexpensive, easy FACE MASK – covers the client’s nose and mouth. CO2 to apply and most escapes at the exhalation ports. comfortable. Delivers low Types: concentration of – SIMPLE FACE MASK – delivers O2 oxygen (24% - concentrations from 40%-60% at 5-8 liters per 45%) at flow rate minute, respectively. of 2-6 liters per minute. Not – PARTIAL REBREATHER MASK – delivers O2 advisable beyond concentrations of 60%-90% at liter flows of 6-10 6 lpm because lpm. The oxygen reservoir bag allows the client patient tend to to rebreathe about the first third of the exhaled swallow air. air in conjunction with O2. – Non-rebreather mask – delivers the highest concentrations of 95%-100% at liter flows of 10-  15 lpm. It prevents reentry of air through the - to remove secretions that obstruct the airway one-way valve in the mask and the reservoir bag - to facilitate ventilation – Venturi mask – delivers O2 concentration from 24%-40% or 50% at liter flows of 4-10 lpm. It has - to obtain secretions for diagnostic purposes a wide-bore tubing and jet adapter (blue – 24% - to prevent infection due to accumulation of secretions at 4 lpm and green – 35% at 8 lpm) Complications SUCTIONING - hypoxemia aspirating secretions through a catheter connected to a suction machine or wall - trauma to the airway suction outlet. Suction catheters may be - nosocomial infection- an infection acquired at least 72 whistle-tipped (less irritating) or open-tipped hours after hospitalization (more effective in removing thick mucous plugs) - cardiac dysrhythmia Ways on minimizing complications: - hyperinflation – via mechanical ventilation (1-1.5x the tidal volume set on the ventilator). 3-5 breaths are delivered before Oral suction tube or Yankauer device is used to suction and after each pass of suction catheter. the oral cavity. Most suction catheter has a thumb port - hyperoxygenation – increase oxygen flow (100%) before OROPHARYNGEAL OR NASOPHARYNGEAL suctioning and between suction attempts SUCTIONING removes secretions from the upper respiratory tract. ENDOTRACHEAL SUCTIONING removes secretions from the trachea and bronchi. Indications for suctioning: Artificial Airways o Dyspnea Oropharyngeal Airway o bubbling or rattling breath sounds, cyanosis, decreased O2 sat. Purposes:  Nasopharyngeal Airway Pneumostat is an example of a device often used for clients Tracheostomy Tube with a pneumothorax. It uses a one-way valve and has a small collection chamber. Desired Outcomes Maintain a patent airway Improve comfort and ease of breathing Maintain or improve pulmonary ventilation and oxygenation Disposable Chest Drainage System Improve ability to participate in physical activities Prevent risks associated with oxygenation problems Evaluation Collect data to evaluate the effectiveness of interventions If outcomes not achieved, explore the reasons before modifying the care plan PRE-OPERATIVE PHASE Begins when the client decides to have surgery and ends when the client is transferred to the operating bed. Heimlich Chest Drainage Valve Nursing activity:  Assessment of client To provide the client with comprehensive, safe, & effective care during the surgical procedure. Identification of potential or actual health problems. > Assessing the client’s physiologic & psychologic Planning specific care based on the individual’s need status Pre-op teaching including client and support persons > Reviewing the results of the diagnostic tests & A. Types of Surgery laboratory studies a. Was discussed during the lecture b. DO’s & DON’T’s when doing a pre-operative visit > Positioning the client for surgery B. Preoperative Assessment > Performing the surgical skin prep INFORMED CONSENT (Operative Permit/ Surgical Consent) > Assisting in preparing the sterile field - An agreement by a client to accept a course of treatment or a procedure after complete > Opening & dispensing sterile supplies during surgery information, including the risk of treatment & > Monitoring and maintaining a safe, aseptic environment. facts relating to it has been provided by the physician. > Managing catheters, tubes, drains, & specimens. Diagnostic Tests prior to OR: > Performing sponge, sharps, and instrument counts CP clearance > Administering medications & solutions to the sterile field. Urinalysis > Documenting the nursing care provided & the client’s CBC response to the nursing interventions X-ray Abdominal Surgical Incisions FBS TYPES OF INCISION: Begins when the client is transferred to the operating > Two main factors governing incisions are direction & room and ends when the client is admitted to the post location anesthesia area or recovery room. SURGICAL SKIN PREPARATION Activities during Intraoperative phase  This involves cleaning the surgical site, removing hair or > Iodophor in 70% alcohol- an excellent cleansing agent shaving operative site if necessary, & applying an anti- that removes debris from the skin surfaces while slowly bacterial agent. releasing iodine. PURPOSE of skin prep. > Broad- spectrum anti- microbial agent & have some sporicidal activity. Non-toxic & virtually non-irritating to skin or To reduce the risk of post-operative wound infection. mucous membrane. This is done by: 2. Alcohols > Removing soil & transient microbes from the skin. > Isopropyl or Ethyl alcohols are broad spectrum agents > reducing the resident microbial count to sub- that denature proteins in cells. Alcohol coagulates protein, it is pathogenic amounts in a short time & with the least amount of not to be applied to mucous membranes or used in an open tissue irritation. wound. > Inhibiting rapid rebound growth of microbes. > Scrub the skin starting at the site of incision with a Nurse inspects the prospective surgical area for circular motion in ever-widening circles to the periphery. Use growths, mole, rashes, pustules, irritations, abrasions, enough pressure & friction to remove dirt & microorganisms bruises or any broken or ischemic areas: this should be from the skin and pores. recorded & reported to the surgeon. SKIN PREPARATIONS Nurse determines if client is allergic to any solutions ABDOMINAL PREPARATION used in skin preparation. > Area includes breast line to upper third of ANTISEPTICS thighs, from table line with patient in supine position. 1. Iodine & Iodophors Shaded area shows anatomic area to be prepared. Arrows w/in area show direction of motion on operating > 1.5 or 2% in water or in 70% alcohol is an excellent table. antiseptic. > Iodophors (Betadine Surgical scrub) are iodine complexes combined with detergents. > Povidone-iodine has a surfactant, wetting & dispersive agent.  2. RECTOPERINEAL & VAGINAL 6. Knee & Lower Leg preparation PREPARATION > Area includes entire > Area includes circumference of affected leg & extends pubis, vulva, labia, from foot to upper part of thigh. anus, and adjacent area, including inner aspects of upper third of thighs. 3. LATERAL THORACOABDOMINAL PREPARATION Commonly Used Positions > Area includes axilla, chest, & abdomen from 1. Dorsal position the neck to - patient lies on back in a horizontal recumbent position crest of with arms extended at the sides & held in place by draw sheet ilium. Area extends from the midline, 2. Dorsal Lithotomy position anteriorly & > legs are flexed on the abdomen posteriorly. Patient is and held in place by stirrups. in lateral position on operating table. 4. CHEST & BREAST PREPARATION > Area includes shoulder, upper arm down to elbow, axilla, & chest wall to table line & beyond sternum to opposite shoulder. If patient is in lateral position, back is also prepped. 3. Trendelenburg position 5. Hip Preparation - table is tilted so the > Area includes abdomen on affected pelvis is higher than the head. side, thigh to knee, buttock to table line, groin, & pubis  4. Jack knife or ADVANTAGES of General anesthesia: modified knee 1. Client is unconscious, so respiration & cardiac function chest position is readily regulated. - Patient 2. Anesthesia can be adjusted to the length of the lies on his operation & the client’s age & physical status. abdomen with the hip joint over the break of the table 3. Depresses the respiratory & circulatory systems. 5. Lateral/side-lying/ sim’s METHODS OF ADMINISTERING General anesthesia: - body is turned to the side 1. Inhalation - The most common controllable method of administration because uptake & elimination of anesthetic agents are accomplished mainly by pulmonary ventilation ANESTHESIA - The anesthetic vapor of a volatile liquid or anesthetic TYPES OF ANESTHESIA: gas is inhaled & carried to the bloodstream by passing across the alveolar membrane into the general circulation & onto the 1. General anesthesia tissue. - a reversible state of consciousness produced by - Ventilation & pulmonary circulation are the 2 critical anesthetic agents in w/c motor, mental, sensory, & reflex factors involved in the process functions are lost. 1.1 Halothane (Fluothane) - Basic elements include: loss of consciousness, analgesia (insensibility to pain), hypnosis (artificial sleep) & - Halogenated volatile compound relaxation (rendering a part of the body less tense) - Potent, non-irritating, pleasant odor, cardiovascular & - Unconsciousness is produced when blood circulating respiratory depressant. to the brain contains an adequate amount of anesthetic agent. - incomplete muscle relaxation - Results in an immobile, quiet client who does not recall - Useful for patients with bronchial asthma, because it the surgical procedure. induces bronchodilation.  - Used in all types of surgical procedures except routine - Combines with receptors such as opiate obstetrics where uterine relaxation is not desired receptors to initiate drug actions. Disadvantages: > Antagonist - Potentially toxic to the liver - Neutralizes or impedes action of another drug (reverses its effects) - Progressively depressant to respiration - Narcotic produces respiratory depression - Cardiovascular depressant that can cause hypotension can be reversed by opiate antgonists. & bradycardia or cardiac arrest 2.4.1 Naloxone Hydrochloride (Narcan) - 1.2 Enflurane (Ethane) 2.4.2 Nalbuphine Hydrochloride (Nubain) - 1.3 Methoxyflurane (Penthrane) 2.4.3 Butophanol Tartrate (Stadol) - 1.4 Nitrous oxide (N2O) 2.5 Tranquilizers 2. INTRAVENOUS 2.5.1 Diazepam (valium) - injected directly into circulation usually via a peripheral vein. 2.5.2 Midazolam (Versed) - given always with oxygen 3. Local or regional anesthesia 2.1 Barbiturates - loss of sensation in a specific body part or region. 2.2 Ketamine Hydrochloride - produced by blocking conductivity of sensory nerves supplying that area. 2.3 Narcotics - The anesthetic drug is injected around a specific nerve 2.3.1 Morphine sulfate or group of nerves to interrupt pain impulses 2.3.2 Fentanyl (Sublimaze) TECHNIQUES: 2.3.3 Meperidine Hydrochloride (Demerol) A. Topical anesthesia 2.4 Narcotic Agonists- Antagonist > Agonist  - applied directly to the skin mucous membrane, open - Minor blocks involve single nerve (e.g. facial skin surfaces, wounds or burns. Mucous membrane readily nerve) absorbs topical agents because of their vascularity. C.2 Intravenous Block (Bier Block) - acts rapidly - Used most often for procedures involving the COMMONLY USED TOPICAL AGENTS ARE: arm wrist and hand. - Cocaine (4-10%) - an occlusion tourniquet is applied to the extremity to prevent infiltration & absorption of the injected - Lidocaine (Xylocaine) intravenous agent beyond the involved extremity. - Benzocaine 4. SPINAL anesthesia/ intrathecal Block B. Local Anesthesia (Infiltration) - Loss of sensation below the level of the diaphragm, - injection of the anesthetic agent drug produced by intrathecal injection of the anesthetic drug into intracutaneously & subcutaneously into tissues to block the subarachnoid space w/o loss of consciousness. peripheral nerve stimuli at their origin - Requires a lumbar puncture through one of the - Used for minor surgical procedures such as interspace between L4 and L5. suturing a small wound or performing a biopsy. Complication: - Lidocaine or Tetracaine 0.1% may be used. - Postural dependent spinal headache- C. Regional Application Treatment: C.1 Nerve Block - Flat on bed for 6-8 hours - Loss of sensation is produced by injecting - Hydrate patient to replace loss CSF the anesthetic drug around a specific nerve or nerve plexus to interrupt sensory, motor or sympathetic transmission - Give analgesic of impulses. Use of Spinal Anesthesia: - Major block involves multiple nerves or a plexus (e.g. the 1. Abdominal surgery, pelvis surgery & urologic brachial plexus anesthetizes the arm) procedures.  2. It is advised for alcoholics, barbiturate addicts, & very 9. 9 Non-sterile persons keep away from the sterile area. muscular patients. 10. 10. Sterile persons keep in contact with sterile areas in 3. May be used in patients with hepatic, renal and a minimum. metabolic diseases. 11. 11. Moisture may cause contamination. POSITION: 12. 12. When bacteria cannot be eliminated from a field, > Client is usually in a lateral position. Patients back is at they must be kept to an irreversible minimum the edge of the OR table, parallel to it. Knees are flexed onto abdomen & head is flex to knees. Hips & shoulder are vertical to table to prevent rotation of the spine. Surgical conscience OPERATING ROOM TECHNIQUE Inner voice that tells us what is right or wrong should be present to every member of the surgical team. 12 Principle of OR Technique: Inner voice for the conscientious practice of asepsis & 1. All articles in the OR are previously sterilized. sterile technique at all times. 2. Persons who are sterile touch only sterile articles; persons who are unsterile touch only unsterile articles. A surgical conscience is the foundation for the practice of strict asepsis & sterile technique 3. If in doubt of the sterility of something consider it SURGICAL SCRUB unsterile. It is the process of removing as many microorganisms 4. Non-sterile persons avoid reaching over sterile field; sterile persons avoid leaning over unsterile field. as possible from the hands & arms by mechanical washing & chemical asepsis before participating in an 5. 5. Tables are sterile only at table level. operation. 6. 6. Gowns are considered sterile only from the waist to Skin and nails should be kept clean. shoulder in front level, and on the sleeves. Fingernails should not reach beyond the fingertips to 7. 7. Edges of anything that encloses sterile articles is avoid glove puncture. considered unsterile. 8. 8. Sterile persons keep well w/in the sterile area.  Nail polish should not be worn. The lacquer may chip & 1. Sterile team peel providing harbor for microorganisms to get into - team members scrub their hands and arms, put on operative site. sterile gown & gloves, & enter the sterile field. SURGICAL ASEPSIS - consist of: Prevention of microorganisms to enter the client. Operating Surgeon Preparation immediately before scrub: assistant to the surgeon 1. Inspect hands for cuts & abrasions scrub nurse - Skin integrity of hands & forearms should be intact. 2. Unsterile Team 2. Remove all finger jewelry. a. Anesthesiologist - Harbors microorganisms b. circulating nurse 3. Be sure all hair is covered by headgear. c. Others: Medical technician; Transport Aides 4. Adjust disposable mask snugly & comfortably over nose Duties of a scrub nurse & mouth. A. Before the Surgeon Arrives: 1. Do a complete scrub according to accepted practice. GOWNING 2. Put on sterile gown and glove. Gowns should be long enough to completely cover the uniform & once contaminated, it must never be worn 3. Drape tables as necessary. outside the area. 4. Drape the mayo stand. GLOVING TECHNIQUE 5. Count sponges, instruments, needles & sharps. OPEN METHOD is used for minor operations. 6. Arrange the instruments on mayo stand for making & CLOSED METHOD is used for major procedures. opening initial incision. OR TEAM 7. Count surgical needles with circulating nurse. 8. Count all sponges w/ circulating nurse. Circulating nurse c. Staff nurse looks over drapes & under items on the should immediately record it. table & mayo stand. - Counts before the start of the operation. d. Surgeon rechecks field & wound - Counts before the surgeon starts closure of the body e. Circulating nurse should call Head nurse to check the cavity or deep or large incision. count a. Table count f. X-rays must be taken before the patient leaves OR whenever a sponge or instrument count is incorrect - Scrub nurse & circulating nurse count all items in the instrument table & mayo stand. g. Circulating nurse makes an incident report. b. Floor count B. After Surgeon & Assistant scrub - Circulating nurse counts sponges & other 1. Gown & glove the surgeons & assistants as soon as items that are recovered from the floor. Be verified by they enter the room. the staff nurse. 2. Assist in draping the client according to the routine c. Field count procedure - Circulating nurse totals floor & table count. Then - offer towel & towel clips, and drapes. inform surgeon if sponge count is correct. 3. Bring mayo table into position after draping is - Counts all over again before subcuticular closure. If completed. Position the table at right angle to operating sponges are intentionally retained for packing or instrument table. remains with the patient, this should be documented in the C. During the operation patient’s chart. 1. Hand skin knife to surgeon & hemostat to assistant INCORRECT count a. Entire count is repeated immediately. - When handing knife, hold the handle blade down & pointed towards your wrist. Never towards the b. Circulating nurse looks at trash receptacles, under surgeon. furniture, linen hamper or throughout the room. 2. Watch field & anticipate the needs of the surgeon. Keep one step ahead of him in offering instruments, sutures or sponges. Notify circulating nurse quietly for supplies not 1. Count sponges, needles, & instruments w/ circulating in the table. nurse when surgeon begins closure of the wound. - Pass instruments in a positive manner. When 2. Clear off mayo stand as time permits leaving a knife surgeon extends hand, instruments should be slapped handle with blade, tissue forceps, scissor, 4 hemostats & 2 firmly into palm in proper position for use. allis forceps. Hemostat 3. Have a damp sponge ready to wash the blood from the area surrounding the incision as soon as skin closure is - bleeding completed Scissor 4. Have betadine, dressings & plaster ready. - needs to cut tissues Duties of the Circulating nurse Mayo scissors Circulating nurse washes hands & arms 5 minutes at - cuts sutures the beginning of the day before entering the OR but does not use gown or gloves. > Keep instruments clean as possible, wipe blood with moist sponge Circulating nurse must assist the sterile scrub nurse by providing the sterile supplies needed. > Return instruments to mayo stand promptly after use or cleaning. After scrub person/nurse scrubs 3. Save all tissue specimens 1. Fasten back of scrub person’s gown. - Never use a large clamp for small specimens. It may 2. Open packages of sterile supplies like syringes, crash sutures, sponge, gloves. - Put in a specimen bottle, basin, wrapper or towel. - If a sterile package wrapped in porous material NEVER in a sponge. Tell circulating nurse what specimen it drop to the floor, DISCARD, if it can no longer be is, if not sure ask the surgeon. considered sterile. 4. Maintain sterile technique. Watch for any breaks. 3. Flip suture packets onto the instrument table or open over wraps for scrub nurse to take packets. D. DURING CLOSURE  - Do not open sutures unless you are sure patient is 1. Stay in the room & near the patient to provide comfort to be operated on. Just have it on hand & let it be served & assist the anesthesiologist in the event that patient gets when surgeon is about to suture. excited. Patient must be guarded during induction to prevent possible injury or fall from the OR table. 4. Pour Normal Saline (NSS) into the round basin for sponges on the instrument table. 2. Be quiet as much as possible. 5. Count sponges, needles, & instruments with the 3. Excitement may occur during induction from tactile or scrub nurse & record immediately. auditory stimulation especially in alcoholics. B. After the patient arrives D. After the client is anesthesized - Circulating nurse attends to the patient. 1. Reposition patient only after the anesthesiologist says so. 1. Greets & identify the patient. Check wristband. 2. Attach anesthesia screen & other table attachments. 2. Check patients chart for pertinent information including CONSENT. 3. If cautery is to be used, place inactive dispersive electrode plate in contact with patient’s skin to ground the 3. Be sure patient’s hair is covered with cap to prevent patient properly. Avoid scar tissues, hairy or bony areas. dissemination of microorganisms. 5. Expose appropriate area for the skin preparation. 4. Assist the patient in moving from the stretcher to the OR table. Use proper body 6. Turn overhead spotlight over site of incision. mechanics. - Bright light should not be focused on the patient before he/she is asleep because pre-op meds affect the pupils. 5. Apply restraint straps over legs & arms. Keep patient Dim light is less irritating. covered with blanket for privacy & provide warmth. 7. Arrange sterile preparation tray & pour solutions if this a. Patient’s legs should not be crossed. has not been done yet. b. Put arm board on left & right arm if IV is to 8. Cover the preparation tray immediately after use. be infused. E. After Surgeon & assistants scrubs 1. Be alert to anticipate needs of the sterile team. C. During the Induction of General Anesthesia  - Circulating nurse watches closely the operation & - Complete count records. anticipate the needs w/o having the team ask for them. 2. If another patient is scheduled to follow: - Should know where all supplies are to facilitate time & - Circulating nurse should call the ward for the next get them quickly. patient at least 45 minutes before the scheduled time of 2. Stay in the room. Inform scrub nurse if you must operation to request that pre-op medication be given. LEAVE. - Ask transport aide to fetch client from the ward 30 3. Keep discarded sponges carefully collected, separated minutes before operation. by sizes & counted. Use sponge forceps or gloves. NEVER G. After the operation is completed W/ BARE HANDS to handle & count sponges. 1. Open neck & back closures of gowns of surgeons & 4. Assist in monitoring blood loss. Weigh sponges if assistants so they can remove the gowns w/o requested by surgeon. contaminating themselves. - Measure blood volume from suction container. 2. Assist w/ dressing. Scrub nurse should roll drapes off 5. Obtain blood products for transfusion as necessary from the patient before outer laye of dressing is applied. the refrigerator or from the blood bank. 3. Connect all drainage systems as indicated 6. Know the condition of the patient at all times 4. See to it that the client is clean- wash off blood, feces. 7. Prepare & label specimens for transportation to the Put on a clean gown & blanket. laboratory 5. Have transport aide bring a clean recovery room 8. Complete the patient’s chart, permanent operating room stretcher. records, & requisitions for laboratory test, etc.. 6. Help move patient to stretcher or bed. Place patient to 9. Be alert to any break in sterile technique stretcher with a 4-man carry. F. During Closure 7. Be sure chart & proper records accompanying patient. 1. Count sponges, sharps, & instruments with scrub 8. Final completion of the client’s chart should include nurse. documentation of: - report counts as correct or incorrect to surgeon.  a. Assessment of client’s skin condition prior to and 3. Blade handles/ scalpel at completion of operation. - A metal handle w/ a range of single use sterile blade Example: used for incising the skin & for sharp dissection. - skin discoloration GRASPING INSTRUMENTS: - rashes 1. Tissue/ Thumb Forceps - These are used for - pressure sores precision holding. Used to pick up delicate tissue for suturing. - burns - THUMB FORCEPS- b. Urine output & blood loss- I & O Theses are used to grasp tough tissue (fascia, breast) c. Type of dressing used. d. Time patient was discharged from OR 3. Adson Forceps w/ teeth 9. Have nursing assistant help transport patient to - These are used for many recovery room (RR) or post anesthetic care unit(PACU) heavy duty clasping such as w/ the skin & suturing Functions of Basic Instruments 4. Adson Pick- ups CUTTING INSTRUMENTS: - Smooth> Used to grasp delicate tissue 1. Metzenbaum Scissors GRASPING/ CLAMPING - These are used for tissue INSTRUMENTS dissection & are delicate. Tips 1. Babcock - Used to grasp delicate are curved for easy use. tissue (Ovary) 2. Mayo Scissors - Available in long & short - These are used to cut sizes suture materials when suturing, might be straight or curved  2. Kocher ACCESSORY INSTRUMENTS - Used to grasp heavy 1. Needle holder tissue - It is used to hold suture - May also be used as a needles firmly & push them clamp through tissue. - The jaws may be straight - Used to secure scalpel or curved blades to handles. - Other name: Ochsner RETRACTORS 1. Malleable or Ribbon 3. Straight Clamp Retractor (Manual) - It is used to clamp off - Used to retract deep superficial arteries, vessels on the incisions; may be bent to various muscle layers & an all-purposes shapes hemostat. 2. Balfour with Bladder blade (Self 4. Allis forceps retaining) - It has teeth to hold tissue - Used to retract wound firmly but can cause damage. edges during deep abdominal - It is only used on tissue procedures w/c will be excised 3. Deaver retractor - It is used to grasp tissue - is used to retract deep - Available in short & long abdominal or chest incisions. size. - available in various 5. Mosquito Clamps widths - Used to hold sutures aside for pedia patients. 4. Richardson Retractor - it is used to pull layers of 6. Towel Clips tissues aside in deep abdominal or - These are used to keep chest incisions to better visualize towels w/c restricts the surgical the surgery site. field attached to the patient. 6. Army-Navy Retractor (Manual) - A backhaus towel clip is - It is held in one end to used to hold towels & drapes in shallow or superficial incisions place.