Surgery - BSuazo (1) PDF

SURGERY Bobby B. Suazo, MSc, MSN, PGCert, RN Lecturer/Clinical Instructor College of Nursing Liceo de Cagayan University DEFINITION ▪ branch of medicine concerned with the treatment of diseases, deformities, & injuries through manual procedures called operations. TERMS ▪ECTOM...

SURGERY Bobby B. Suazo, MSc, MSN, PGCert, RN Lecturer/Clinical Instructor College of Nursing Liceo de Cagayan University DEFINITION ▪ branch of medicine concerned with the treatment of diseases, deformities, & injuries through manual procedures called operations. TERMS ▪ECTOMY - excision or removal ▪LYSIS - destruction or separation ▪ORRAPHY - repair or suture ▪OSCOPY - looking into ▪OSTOMY - creation of opening ▪PLASTY - repair of scar or tissue  PERIOPERATIVE NURSING OVERVIEW ▪ THE PERIOPERATIVE PERIOD ▪ Encompasses a client’s total surgical experience, including the preoperative and postoperative phases. ▪ THE PERIOPERATIVE NURSING ▪ Refers to activities performed by the professional nurses during these phases.  PHASES ▪ PREOPERATIVE ▪ Begins with the decision to perform surgery and ends with the client’s transfer to the operating room (OR) table. ▪ INTRAOPERATIVE ▪ Begins with the client’s received in the OR and ends with his admission to the Post Anesthesia Care Unit (PACU) or Recovery Room. ▪ POSTOPERATIVE Begins when the client is admitted to PACU/Recovery Room and extends through follow- up home or clinic evaluation. THE PERIOPERATIVE TEAM THE PERIOPERATIVE TEAM ▪ THE ANESTHESIOLOGIST OR NURSE ANESTHETIST ▪ Makes a preoperative assessment to plan the type of anesthetic to be administered and evaluate the client’s physical status. ▪ THE PROFESSIONAL REGISTERED OR NURSE ▪ Makes preoperative nursing assessment and documents the intra-operative client care plan. ▪THE CIRCULATING NURSE ▪ Manages the OR and protects the safety and health needs of the client by monitoring the conditions in the OR. ▪THE SCRUB NURSE ▪ Responsible for scrubbing for surgery, including setting up sterile tables and equipment and assisting the surgeon and surgical technicians during the surgical procedure. ▪ THE PACU NURSE ▪ Responsible for caring for the patient until the patient has recovered from the effects of anesthesia, is oriented, has stable vital signs, and shows no evidence of hemorrhage. CONDITIONS Requiring Surgery ▪Obstruction or blockage ▪Perforation ▪Erosion ▪Tumor  CATEGORIES of Surgical Procedure ▪According to PURPOSE ▪According to URGENCY ▪According to MAGNITUDE or EXTENT of surgery  Classifications According to PURPOSE ▪ DIAGNOSTIC ▪ used to determine the cause of an illness or disorder ▪ verify a suspected diagnosis. ▪ CURATIVE ▪ Tending to overcome disease and promote recovery ▪ Removal of disease organs or tissues. ▪ RECONSTRUCTIVE Restoration, construction, reconstruction, or improvement in the shape and appearance of body structures that are missing, defective, or damaged. ▪ PALLIATIVE Affording relief but not cure  Classification According to URGENCY ▪OPTIONAL SURGERY- done totally at the client’s discretion, e.g., cosmetic surgery ▪ELECTIVE SURGERY- procedures that are scheduled at the client’s convenience, e.g., cyst removal, repair of scars, & simple hernia or vaginal repair ▪ REQUIRED SURGERY - warranted for conditions necessitating intervention within a few weeks, e.g., cataract surgery, thyroid disorder ▪ URGENT OR IMPERATIVE SURGERY - indicated for a problem requiring intervention within 4 to 48 hours, e.g., some cancers, acute gallbladder infection, appendicitis, & kidney stones. ▪EMERGENCY SURGERY - describes a procedure that must be done immediately to sustain life or maintain function, e.g., trauma  Classification According to MAGNITUDE or EXTENT ▪Major surgery ▪ High risk ▪ Extensive ▪ Prolonged ▪ Large amount of blood loss ▪ Great risk of complication ▪Minor surgery ▪Generally, not prolonged ▪Leads to a few serious complications ▪Involves less risk SURGICAL RISK ▪General Risk Factors ▪ Age ▪ Obesity ▪ Immobility ▪ Malnutrition ▪ Emergency ▪ Endocrine related condition ▪ Steroid therapy Major Causes of Death ▪Pneumonia ▪Cardiac arrest ▪Renal failure ▪Stroke ▪Pulmonary emboli ▪Sepsis; peritonitis ▪Hypovolemic shock The degree of SURGICAL RISK depends on: 1. Nature, location, and duration of the condition 2. Type and classification of surgery 3. A person’s mental attitudes 4. Available professional resources NURSING ASSESSMENT A. Physiologic Age Gastrointestinal Presence of pain function Nutritional status Liver function Fluid and Endocrine function electrolyte Neurologic function Infection Hematologic Cardiovascular function function Pulmonary function Use of medications Renal function Presence of trauma  PHYSIOLOGIC ASPECT ▪ Correct dietary deficiencies ▪ Reduce weight ▪ Correct fluid and electrolyte imbalances ▪ Restore adequate blood volume ▪ Treat chronic disease ▪ Cure any infectious disease ▪ IVF fluids if dehydrated NURSING ASSESSMENT B. Psychologic Pre-op Defense Mechanism 1. Regression 2. Denial 3. Intellectualization PSYCHOLOGIC ASPECT ▪ Fear of the unknown ▪ Allow to speak openly about fears. ▪ Provide information about hospital protocols. ▪ Explains the procedures of surgical phases. ▪ Explain all nursing interventions. ▪ Allow the patient to ask questions ▪ Give accurate information. ▪ Introduce to people who had a successful operation. ▪ Give empathetic support. ▪ Include significant others in the discussion. LEGAL ASPECT  INFORMED CONSENT ▪ Purpose ▪ To ensure that the client understands the nature of the treatment, including the potential complications and disfigurement. ▪ To indicate that the client’s decision was made without pressure. ▪ To protect the client against unauthorized procedures. ▪ To protect the surgeon and hospital against legal action by a client claiming an unauthorized procedure was performed.  Circumstances Requiring Consent ▪ Any surgical procedure where a scalpel, scissors, suture, or hemostat of electrocoagulation may be used. ▪ Entrance into a body cavity – e.g., paracentesis, bronchoscopy, cystoscopy, colonoscopy, & proctosigmoidoscopy. ▪ General anesthesia, local infiltration, regional block.  Requisite for the Validity of Informed Consent ▪ Written permission is best and is legally acceptable. ▪ A signature is obtained with the client's complete understanding of what is to occur- adult sign their own consent; it is obtained before sedation. ▪ Secured without pressure or duress ▪ A witness is desirable – a nurse, physician, or another authorized person.  Requisite for the Validity of Informed Consent ▪ In an emergency, permission via telephone or telefax is acceptable. ▪ For minors (below 18), unconscious and psychologically incapacitated, permission is required from responsible family members (parent/legal guardian).  NURSING PEOPLE BEFORE SURGERY ▪Preoperative preparation: Four phases 1. At the physician’s office before admission to the healthcare facility. 2. Upon admission and during days before the operation. 3. The night before the surgery 4. Morning of surgery Preoperative Admission ▪ Depends on the amount of preoperative intervention. ▪ Involve family interview. ▪ A thorough assessment of the body system. ▪ Patient orientation. ▪ Verify info on pre-operative testing. ▪ Initiates teaching appropriate to patient’s needs.  PREOPERATIVE TEACHING ▪Preop Exercises ▪ Coughing ▪ Deep breathing ▪ Turning ▪ Moving ▪ Foot and leg exercise  PREOPERATIVE TEACHING CONT. ▪ Incentive spirometer 10-12x per hour ▪ Early ambulation PREPARATION ON THE EVENING BEFORE SURGERY Four Major Considerations 1. Preparing the skin ▪ Awareness of pre-op preparation protocol of the hospital ▪ On procedure ▪ Proper technique ▪ Location ▪ Size of areas to be prepared ▪ Specific preferences of the surgeon ▪ Document observation of the surgical site 2. Preparing GIT Special Preparation of the Evening Before Surgery ▪ To reduce the possibility of vomiting. ▪ Reduce the possibility of bowel obstruction. ▪ Prevent contamination from fecal material during intestinal or bowel surgery. Preparations include: ▪ Restrict food/ fluids ▪ Administration of enema as needed ▪ Insert gastric tubes/ intestinal tubes If general anesthesia ▪ Foods and fluids are restricted for 8-10 hours before the operations. ▪ NPO/NBM after midnight (8-10 hrs). ▪ Water be given up to 4 hours before surgery, as ordered. ▪ When surgery is not scheduled until late afternoon, the person may eat a light breakfast in AM if permitted. ▪ Extremely malnourished receive IV infusion of amino acids, glucose, and plasma till the moment of surgery. ▪ ENEMA as ordered. Guidelines for Preop Fasting The American Society of Anesthesiologists (ASA) 2-4-6-8 Rule Liquid & Food Intake Minimum Fasting Period Clear liquid, e.g., water, tea or coffee without 2 hours milk Breastmilk 4 hours Non-human milk 6 hours Light meals 6 hours Fatty food or meats 8 hours 3. Preparing for anesthesia ▪ Done the evening before surgery to complete respiratory, cardiovascular, and neurologic examinations. ▪ Determine the type of anesthesia used during surgery. ▪ Discuss the type of anesthesia planned and the sensation the person will experience. ▪ Address fears – a calm, confident person undergoes anesthesia more smoothly than someone nervous is frightened. 4. Promoting rest and sleep ▪ Physically comfortable; mentally ease; adequately sedated. ▪ Measure to reduce sleeplessness and restlessness, have a well-ventilated room, comfortable and clean bed, give back rub, warm beverage if fluid not contraindicated.  PREPARATION ON THE DAY OF SURGERY A. EARLY MORNING CARE ▪ Record vital signs- slight increase due to anxiety ▪ Check ID band ▪ Skin prep thoroughly/oral hygiene ▪ Check order if carried out ▪ Identify if not eaten within 4-10 hours ▪ Remove jewelry, hearing aid prosthesis ▪ Remove colored nail polish B. Pre-Operative Medication ▪To allay anxiety, reduce pharyngeal secretions, reduce the effect of anesthesia, and create amnesia.  C. Transporting the Patient to Surgery ▪Gently move the patient to the stretcher and transport smoothly and gently to prevent nausea and vomiting. ▪ Cover the patient with a blanket to avoid exposure. INTRAOPERATIVE PHASE ▪Goals of Care ▪ Asepsis ▪ Homeostasis ▪ Safe administration of anesthesia INTRAOPERATIVE PHASE BASIC RULES ▪Only sterile materials can be used within a sterile field. If there is any doubt about the sterility of the item, it’s considered UNSTERILE. ▪ The gowns are sterile in the front from shoulder to waist level, and the sleeves are 2 inches above the elbow. ▪Draped tables are considered to be sterile on top only. INTRAOPERATIVE PHASE BASIC RULES: ▪Sterile surfaces should contact only sterile areas. ▪Edges of any sterile package or container are considered unsterile. ▪The sterile field should be created as close to the time it is going to be used as possible. SAFETY MEASURES ▪ OR tables are securely locked. ▪ Muscles, nerves, and bony prominences are positioned or padded to avoid injury. ▪ Heavily sedated patients and the elderly are moved slowly & gently. ▪ Ensure tubings are not dislodged or obstructed. ▪ Straps should not interfere with blood circulation. ▪ Sterile team members should not lean on any part of the patient’s body. POSITION DURING SURGERY Dorsal Recumbent Hernia repair, mastectomy, & bowel resection Trendelenburg’s Lower abdomen and pelvic surgeries  Lithotomy Vaginal repairs, D & C, rectal surgery, & abdominal– perineal resection Prone Spinal surgeries and laminectomy  Lateral Kidney, chest, & hip surgeries NURSING RESPONSIBILITIES ▪ Explain the purpose of the position ▪ Avoid undue exposure ▪ Strap the person to prevent falls ▪ Maintain adequate respiratory and circulatory function ▪ Maintain good body alignment  TYPES OF ANESTHESIA GENERAL ANESTHESIA ▪Total loss of consciousness and sensation ▪Produces amnesia ▪IV, inhalation,& rectal  REGIONAL ▪Reduce all painful sensations in one region of the body without inducing unconsciousness.  LEVELS OF SEDATION AND ANESTHESIA ▪Minimal sedation – ▪ Cognitive and coordination may be impaired, but ventilatory & cardiovascular functions are not affected. ▪Moderate sedation – ▪ It depressed the level of consciousness that does not impair the patient’s ability to maintain a patent airway and to respond appropriately to physical stimulation and verbal command. LEVELS OF SEDATION AND ANESTHESIA CONT. ▪Deep Sedation a drug induced state during which patient cannot be easily aroused but can responds purposefully after repeated stimulation.  STAGES OF ANESTHESIA Stage 1: Analgesia/Induction Stage Initiated at the preoperative holding area Patient is given medication and begins to feel its effects but is not unconscious (loss of pain sensation) Patient is sedated but conversational Breathing is slow but regular This stage comes to an end with the loss of consciousness.  STAGES OF ANESTHESIA Stage 1: Analgesia/Induction Stage Noises are exaggerated; even low voices or a low or minor sound seem loud and unreal. The nurse should avoid making unnecessary noises or motions when anesthesia begins. Stage 2 : Excitement/Delirium Periods of excitement & often combative behavior Signs of sympathetic stimulation Tachycardia, increased RR, hypertension, uncontrolled movements Airway remains intact but hypersensitive to stimulation Airway manipulation should be avoided (placement or removal of ET or LMA) Stage 3 : Surgical Relaxation of skeletal muscles Return of regular respirations Respiration is regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. Airway manipulation is safe. Surgery can be safely performed. The goal is to keep in stage 3 for the duration of the operation. Stage 4: Medullary/Stage of Danger It is characterized by respiratory/cardiac depression or arrest due to an overdose of anesthesia. Very deep CNS depression Loss of respiratory and vasomotor Pupils are fixed and dilated, hypotension, weak and thready pulses Lethal stage.!  METHODS OF ANESTHESIA ADMINISTRATION Inhalation-  administered by mixing the vapor with oxygen or nitrous oxide-oxygen and then having the patient inhale the mixture.  Administered through a tube or a mask.  It can also be administered using a laryngeal mask.  It can be also administered using the endotracheal technique. When it is in place, the tube seals off the lung from the esophagus so that if the patient vomits, the stomach does not enter the lungs. Intravenous Intravenous anesthetic agents are non-explosive; they require little equipment and are easy to administer. Intravenous anesthesia is useful for short periods but less often used for longer abdominal surgery procedures. Intravenous cont. Advantageous because the onset of anesthesia is pleasant; there is none of buzzing, roaring, or dizziness known to follow the administration of an inhalation anesthetic. Duration of action is brief, and the patient awakens with little nausea or vomiting. Thiopental is the agent of choice, but it causes powerful respiratory depressant. Regional anesthesia Is a form of local anesthesia in which an anesthetic agent is injected around the nerve. The patient is awake and aware of his or her surroundings unless medication is given to produce mild sedation or to relieve anxiety Nurses must avoid careless conversation, unnecessary noise, and unpleasant odors. Conduction Block and Spinal Anesthesia There are many types of conduction block Epidural Anesthesia  Achieved by injecting a local anesthetic into the spinal canal in the space surrounding the dura mater  Block sensory, motor and autonomic functions. Epidural Anesthesia Are much higher in doses because it is not in direct contact with the cord or nerve roots Advantage: absence of headaches Disadvantage: greater technical challenge of introducing the anesthetic into the epidural matter than the subarachnoid. Spinal Anesthesia Type of extensive conduction nerve block that is introduced into the subarachnoid space at the lumbar level between L4 and L5. Anesthesia of the lower extremities, perineum, and lower abdomen. Spinal Anesthesia cont. Nausea, vomiting, & pain may occur during surgery due to the manipulation of those structures. Administration of a weak solution of thiopental and inhalation of nitrous oxide may prevent such reactions. Spinal Anesthesia cont. Headache may be an after-effect due to many factors, such as: a spinal needle is used the leakage of fluid from the subarachnoid space through the puncture site patient’s hydration status Keep the patient lying flat on the bed and well-hydrated. Local Infiltration Anesthesia Injection of the local anesthetic into the tissue at the planned incision site combined with the local regional block. Local anesthesia is administered with epinephrine Constrict blood vessels and prevent rapid absorption of anesthetic agent, thus it prolongs its effect. POTENTIAL INTRAOPERATIVE COMPLICATIONS Nausea and Vomiting Anaphylaxis Hypoxia and other respiratory complications Hypothermia POSTOPERATIVE PHASE ▪Maintain adequate body system function ▪Restore homeostasis ▪Alleviate pain and discomfort ▪Prevent post-op complications ▪Ensure adequate discharge planning and teaching Nursing Care: Immediate Postop Care (PACU/RR) ASSESSMENT ▪ Appraise air exchange status and note skin color ▪ Verify identity, operative procedure, surgeon ▪ Assess Neurologic status (LOC) ▪ Determine VS and skin temperature (CV status) Nursing Assessment & Interventions ▪ Examine the operative site and check dressings. ▪ Perform safety checks: position for good body alignment; side rails; restraints for IVF’s, Blood transfusion; ▪ Require briefing on problems encountered in OR INTERVENTIONS (RR) ✓Ensure maintenance of patent airway and adequate respiratory function: ✓lateral position with neck extended ✓Keep airway in place until fully away ✓Suction secretions ✓Encourage deep breathing ✓Administer humidified oxygen as ordered Assess Status of Circulatory System ✓Monitor vital signs and report abnormalities. ✓Observe signs and symptoms of shock and hemorrhage. ✓Promote comfort and maintain safety. ✓Continuous, constant patient surveillance until he is completely out of anesthesia. Transfer of Patients from PACU to the Surgical Unit/Ward ✓Parameters for discharge from RR ✓Activity- able to obey commands, e.g., deep breathing, & coughing ✓Respiration – easy, noiseless breathing ✓Circulation – BP is within 20 mmHg of the preop level ✓Consciousness – responsive ✓Color – pinkish skin and mucus membrane Surgical Assessment Continue ✓Vital signs ✓Level of consciousness ✓Breath sounds ✓Bowel sounds ✓Wound dressing ✓Tubings Pain Management What is Pain? An “unpleasant, subjective, sensory and emotional experience associated with actual or potential tissue damage or described in terms of such tissue” (The International Association for the Study of Pain, 2005). PATIENT’S RIGHTS oIt is every person’s right to have their pain appropriately and aggressively managed (Agency for Health Care Research Joint Commission, 2004). oPain relief is a “basic human right” (The American Pain Society, 2005). oIt is “not the responsibility of patients to prove they are in pain; it is the nurses’ responsibility to accept the client’s report of pain” (The American Pain Society, 2005).  PAIN ASSESSMENT / INTERVENTION / RE- ASSESSMENT (AIR) CYCLE INDICATOR oPain Assessment: oComprehensive evaluation of pain. oHow do you assess pain? oPain Intervention: oSelection and implementation of various measures to facilitate pain relief. oWhat nurse interventions could be used to manage pain? oWhat non-nursing interventions could be used to manage pain? oPain Reassessment: oSubsequent evaluation of the effectiveness of pain relief measures following the interventions. NON-PHARMACOLOGIC INTERVENTIONS WHAT ARE THE EXAMPLES OF NON- PHARMACOLOGIC / NURSING INTERVENTIONS? oSplinting of a fracture oImmobilization of an inflamed joint oRepositioning oApplication of therapeutic heat oCooling of an area of inflammation oDistraction oReassurance and psychological support  UNRELIEVED PAIN HAS SERIOUS SIDE EFFECTS, WHICH CAN RESULT HARMFUL MULTISYSTEM EFFECTS ENDOCRINE METABOLIC CARDIOVASCULAR RESPIRATORY GENITOURINARY GI Increase the Increase in the following: following:. ACTH. Hyperglycaemia. Heart rate. Atelectasis. Decreased urinary. Decreased output gastric motility. Cortisol. Glucose. Cardiac output. Hypoxaemia. Urinary retention. Decreased bowel intolerance motility. Antidiuretic. Insulin. Hypertension. Decrease cough. Fluid overload hormone resistance. Epinephrine. Myocardial oxygen. Sputum. Hypokalaemia consumption retention. Norepinephrine. DVT. Infection. Renin. Angiotensin. Aldosterone. Glucagon  UNRELIEVED PAIN HAS SERIOUS SIDE EFFECTS, WHICH CAN CAUSE HARMFUL MULTISYSTEM EFFECTS MUSCULOSKELETAL COGNITIVE IMMUNE DEVELOPMENTAL FUTURE PAIN QUALITY OF LFE. Muscle spasm. Reduction in. Depression of. Altered. Post-mastectomy. Sleeplessness cognitive immune temperaments pain function response. Fatigue. Mental. Infant distress. Phantom pain. Anxiety confusion behaviour. Immobility. Anxiety states. Fear. Hopelessness Ref: Last two slides. Pain and Comfort Management, PeriAnesthesia Nursing Core Curriculum, 2004 OVERALL MESSAGE Pain relief is a “basic human right” (American Pain Society, 2005). “Pain is the enemy, not the patient” (Greg Holmquist, 2008). Golden Rule: Good assessment, intervention, and reassessment (AIR cycle).