Surgery Presentation

By Ms. Lady Jazzie G. Duldulao, R.N., R.M.

SURGERY 

Branch of medicine concerned with treatment of diseases, deformities and injuries through manual operative procedures

Encompasses: 1. 2.

3.

Pre-operative care Intra-operative judgment and management Post-operative care of clients

Neolithic Age 

TREPANNING – a procedure in which a hole is drilled in the skull to relieve pressure on the brain

EGYPT 

Surgical circumcision – removal of foreskin from the penis and clitoris from female genitalia

EGYPT Operations believed to have been performed: 2. Castration – removal of male’s testicles 3. Lithotomy – removal of stones from bladder 4. Amputation – surgical removal of a limb or other body part

ANCIENT INDIA 



Surgically treated bone fractures and removed bladder stones, tumors and infected tonsils Developed PLASTIC SURGERY as early as 2000 B.C. in response to the punishment of cutting off a criminal’s nose or ears

4 CENTURY B.C. th



HIPPOCRATES

- A Greek physician who published descriptions of various surgical procedures such as treatment of fractures and skull injuries with directions for the proper placement of the surgeon’s hands during operations.

MIDDLE AGES   3.

4.

Practice of surgery declined Its practice was left to BARBERS Cutting hair, removing tumors, pulling teeth, stitching wounds and bloodletting The red and white striped pole that today identifies barbershops derived its design from this practice (red – blood, white – bandages)

GUY DE CHAULIAC 

French surgeon who published CHIRURGIA MAGMA (Great Surgery) in 1316 which describes how to remove growths, repair hernias and great fractures.

GUY DE CHAULIAC A new order of surgeons arose in France: 2. Surgeon of the long robe 3. Surgeons of short robe (BARBERS)

PETER LOWE 

(1550 – 1613)

1597 – made a discourse of the whole art of “CHIRURGERIE” (science or art) – manner how to work on man’s body, exercising all manual operations necessary to heal man or as much as possible arrange healing through:

PETER LOWE 1. 2. 3. 4. 5.

To To To To To

(1550 – 1613)

take away held and add put in place which is out separate join what is separated

PETER LOWE

(1550 – 1613)

CRITERIA OF A SURGEON: 2. He be learned 3. Expert 4. Ingenious 5. Well mannered

AMBROISE PARE  

FATHER OF MODERN SURGERY French surgeon who successfully employed the method of LIGATING (tying off arteries to control bleeding) thus eliminating the old method of cauterizing

WILLIAM HARVEY 

English physician and anatomist who discovered the process of BLOOD CIRCULATION.

MARCELLO MALPIGHI 

Italian anatomist who identified the existence of tiny blood vessels called CAPILLARIES.

JOHN HUNTER 

British anatomist and surgeon who stressed the close relationship between medicine and surgery.

WILLIAM MORTON American dentist often CREDITED WITH THE DISCOVERY OF SURGICAL ANESTHESIA.  In 1846, he used anesthesia as a way to mask pain during surgery. 

CRAWFORD W. LONG 

American surgeon who used anesthesia in 1842 during removal of tumors but did not publish his results until 1849.

LOUIS PASTEUR 

French chemist who discovered FERMENTATION or PUTREFACTION (the decay and death of body tissue is caused by bacteria in the air).

JOSEPH LISTER 

British surgeon who applied Pasteur’s work to surgery by developing ANTISEPTIC TECHNIQUES including the use of carbonic acid spray to kill germs in the OR before surgery.

THEODOR BILLROTH 

Pioneer of abdominal surgery

Austrian IGNAZ SEMMELWEISS and American OLIVER WENDELL HOMES 



Pioneered techniques such as washing of hands and changing into clean clothing before surgery which prevent wounds from being contaminated during surgery. This techniques helped minimize post operative infections.

WILHELM CONRAD K. ROENTGEN 

German physicist who invented X-RAYS in 1895 to “photograph” the inside of the body.

KARL LANDSTEINER 

Austrian pathologist who discovered BLOOD GROUPS A, B and O.

1937 – Blood banks were created  1940s – antibiotics were introduced to further minimized the risk of post operative infection 

JOHN H. GIBBON 

American surgeon who developed a HEART – LUNG MACHINE in 1953, marking the beginning of MODERN CLINICAL HEART SURGERY.



1950s - OPERATING MICROSCOPE was developed - FIRST KIDNEY TRANSPLANT

CHRISTIAAN BARRNARD 

South African physician who performed the FIRST HEART TRANSPLANT.

BRANCHES OF SURGERY 1. 2. 3. 4. 5. 6.

Neurosurgery EENT Thoracic Abdominal Urology Orthopedic

DIVISION OF SURGERY 1. 2. 3. 4.

General surgery Pediatric surgery Oncologic surgery Plastic surgery

SUFFIXES

EXAMPLE

Excision or removal of

appendectomy

- lysis

Destruction of

electrolysis

- rrhaphy

Repair or sutures of

herniorrhaphy

- oscopy

Looking into

endoscopy

- ostomy

Creation of permanent opening into Cutting into or incision of

colostomy

Repair or reconstruction of

mammoplasty

-

ectomy

MEANING

- otomy - plasty

tracheostomy

PREFIXES

SITE OF SURGERY

Hyster -

uterus

Crani -

skull

Mamm -

breast

Nephr -

kidney

Gastr -

stomach

PREFIXES

SITE OF SURGERY

Salping -

fallopian tube

Chole -

gallbladder

Hepat -

liver

Pneum -

lung

Ocul -

eye

1.

2.

Persons who are sterile touch only sterile articles, person who are not sterile touch only non-sterile articles. If in doubt about the sterility of anything, consider it not sterile.

1.

2.

3.

Non-sterile persons avoid reaching over a sterile field. Sterile persons avoid leaning over a non-sterile area. Tables are sterile only at the table level. Gowns are considered sterile only from waist to shoulder level in front and the sleeves.

1.

2.

3.

4.

The edges of anything that encloses sterile contents is not considered sterile. Sterile persons keep well within the sterile area. Sterile persons keep contact with sterile area to a minimum. Moisture may cause contamination.

REASONS FOR SURGICAL PROCEDURES 1. 2. 3. 4. 5.

6.

To undergo diagnostic procedures To preserve life To maintain dynamic bodily equilibrium To prevent infection To obtain comfort and ensure the ability of earning a living For correction of deformities and defects

FOUR MAJOR TYPES OF PATHOLOGIC PROCESSES REQUIRING SURGICAL INTERVENTION: 1.

2. 3.

4.

Obstruction – impairment to the flow of vital fluids Perforation – rupture of an organ Erosion – wearing off of a surface or membrane Tumors – abnormal new growths

MAJOR CATEGORIES OF SURGICAL PROCEDURES: 1. 2. 3.

According to purpose According to extent/magnitude According to urgency

ACCORDING TO PURPOSE: 1. 2. 3. 4. 5. 6.

Diagnostic Curative Palliative Cosmetic Preventive Exploratory

Diagnostic 

2. 3.

Makes it possible to verify a suspected diagnosis or to determine the cause of the symptoms Biopsy Endoscopy

Biopsy

- Excision of a small amount of tissue for pathologic examination

Types: 2. Aspiration biopsy 3. Bone marrow biopsy 4. Excision biopsy 5. Percutaneous biopsy (Punch biopsy) 6. Frozen section biopsy

Endoscopy

- Visual examination of the interior of a body cavity, hollow organs or structure with an endoscope. 1. 2. 3. 4. 5. 6.

Bronchoscopy Esophagoscopy Mediastinoscopy Gastroscopy Cystoscopy Laryngoscopy

Curative 

Perform to remove or repair damaged disease or congenitally malformed organ or tissue.

Curative 1.

2.

3.

Ablative – removal of the disease organ Reconstructive – involves partial or complete restoration of a damaged organ or tissue to it’s normal appearance/functioning Constructive – involves repair of the congenital malformation

Palliative 

Relieves symptoms but does not cure the underlying disease.

Cosmetic 

To improve appearance.

Preventive 

A precautionary, defensive or protective action.

Exploratory 

Enables the surgeon to estimate the extent of the disease and at the same time make or confirm a diagnosis.

ACCORDING TO EXTENT/MAGNITUDE: 1. -

-

-

MAJOR Involves extensive reconstruction or alteration in body parts Poses great risks to well-being with significant blood loss May cause tissue and organ trauma

ACCORDING TO EXTENT/MAGNITUDE: 1. -

-

-

MINOR Involves minimal alteration in body parts often designed to correct deformities Involves minimal risks compared with the major surgery Few complications, less blood loss

ACCORDING TO URGENCY: 1. 2.

3.

4.

5.

EMERGENCY – requires immediate attention URGENT or IMPERATIVE – requires prompt attention (24 to 30 hours) REQUIRED/PLANNED – few weeks or months, necessary for the person’s wellbeing but is not urgent ELECTIVE – performed for the person’s well-being but is not urgent OPTIONAL – decisions rest with patient

1.

2.

3.

Stress response is elicited. Defense against infection is lowered. Vascular system is disrupted.

1.

2.

3.

Organ functions are disturbed. Body image may be disturbed. Lifestyles may change.

SURGICAL RISK 

Probability of morbidity or death from surgery

A. Nature of condition  2.

3.

Maybe benign or malignant Location – depends on the location of the disease and the organ requiring surgery Duration – length of the time the patient has been exposed to the illness dictates the degree of risk involved.

B. Magnitude/urgency of the surgical procedure 

Operative risk is proportional with the magnitude of the operation

C. Physical and Mental conditions 

Based on health status and person’s mental attitude toward surgery

C. 1. Physical Condition a.

b.

Age – infants and elderly have the lowest tolerance to the stressful effects of surgery. Nutritional status – a well-nourished preop client is better prepared for surgical stress and return to optimal health after surgery. A. Obesity B. Malnutrition

C. 1. Physical Condition a.

b.

Fluid and electrolyte problems – fluid volume deficit leads to possible intra and post-op complications. Presence of diseases – increases the operative risk

Presence of diseases a.

b.

Pulmonary – impairs ability to exchange oxygen and carbon dioxide. Cardiovascular – a heart that pumps effectively and blood vessels that constrict well is necessary for prevention of shock and fluid and electrolyte imbalance.

Presence of diseases a.

b.

c.

Hematologic – blood coagulation problem causes severe hemorrhage Genito-urinary – difficulty in eliminating wastes from the body and preserve fluid and electrolyte balance Endocrine – affect clients response to surgery

Presence of diseases a.

b.

Liver – unable to detoxify medications or metabolize carbohydrates, fats and amino acids. Neurologic – for possible effect of anesthetic meds which is to depress CNS

Presence of diseases a.

b.

c.

Gastrointestinal – changes in GI status. Integumentary – bleeding tendencies. Disabilities – influences response to surgery including those that affect and limit activity.

C. 1. Physical Condition a.

Use of medications 1.

2. 3.

Tranquilizers – causes anxiety, tension and even seizures if withdrawn suddenly Insulin Adrenal corticosteroids – cardiovascular collapse might occur if discontinued suddenly

C. 1. Physical Condition a.

Use of medications 1.

2.

3.

Diuretics – thiazide may cause excessive respiratory depression during anesthesia Phenothiazines and antidepressants (MAO) – may increase hypotensive action of anesthetics Antibiotics – when combined with muscle relaxant, nerve transmission is interrupted.

C. 2. Mental Condition  2. 3. 4. 5. 6. 7.

FEAR Fear of the unknown Fear of anesthesia Fear of pain Fear of death Fear of disturbance of body image Worries

Manifestations of Fear 1. 2. 3. 4. 5.

Anxiousness Bewilderment Anger Tendency to exaggerate Sad, evasive, tearful, clingy

Manifestations of Fear 1. 2. 3.

4.

Inability to concentrate Short attention span Failure to carry out simple instructions Dazed

Three types of defense mechanism: 1.

2. 3.

Regression – behaves in a childlike manner. Denial – appears unalarmed Intellectualization – would discuss operation and illness rationally but without emotion

D. Professional Resources 

Caliber of the professional staff and health care facilities

PREOPERATIVE PHASE Begins when the decision of the surgical intervention is made and ends with the transfer of the patient to the OR. FOUR PHASES



 1. 2.

3. 4.

Doctor’s clinic Upon admission and during the days before surgery Night before surgery Morning before surgery

1. Nursing Assessment a. b.

c. d. e.

Nursing History Health history – development consideration, medical history, medications, occupation Lifestyle Coping pattern and support system Preoperative physical assessment

1. Nursing Assessment a.

Pre-surgical screening tests – CXR, ECG, CBC, Blood grouping and crossmatching, Electrolyte levels, U/A, FBS, BUN and Crea

2. Analysis 1. 2. 3. 4. 5. 6. 7. 8.

Anxiety Fear Knowledge deficit Sleep pattern disturbance Anticipatory grieving Ineffective individual coping Ineffective airway clearance Risk for infection

3. Plan/Implementation a.

Physiologic preparation 1.

2. 3.

Introduce patient and SO to health care facility. Data collection Interview the patient

B. Psychologic/Psychosocial preparation 1. 2.

3.

4. 5.

Explore client’s feelings. Allow client to speak openly about fears/concerns. Give accurate information regarding the surgery. Give empathetic support. Consider the person’s religious preferences and arrange for visit by priest/minister as desired.

C. Legal aspect of the informed consent PURPOSES: 







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 procedure. To protect the surgeon and hospital against legal action by a client who claims that an unauthorized procedure was performed.

Circumstances requiring a permit: 

 

Any surgical procedure where scalpel, scissors, suture, hemostats or electrocoagulation may be used. Entrance into a body cavity General anesthesia, local infiltration, regional block

Requisites for Validity of Informed Consent: 





Written permission is best and is legally acceptable. Signature is obtained with the client’s complete understanding of what is to occur. (Adults sign their own operative permit and obtained before sedation) Secured without pressure.

Requisites for Validity of Informed Consent:  



A witness is desirable. In an emergency, permission via telephone or telefax is acceptable. For minor, unconscious, psychologically incapacitated, permission is required from a responsible family member.

Introductional and Preventive aspects Deep breathing  Coughing exercises  Turning exercises  Foot and leg exercises 

Physical preparations    

  

Correct any dietary deficiencies. Reduce an obese person’s weight. Correct fluid and electrolyte imbalances. Restore adequate blood volume with blood transfusion. Treat chronic diseases. Halt or treat infectious process. Treat an alcoholic person with vitamin supplementation, IVF or oral fluids if dehydrated.

On the Night of Surgery Preparing the skin  Preparing the GI tract  Preparing for anesthesia  Promoting rest and sleep 

On the Day of Surgery 

Early AM care 1.

2. 3. 4.

Awaken an hour before pre-op medications. Morning bath, mouth wash Provide clean gown Remove hairpins, braid long hairs, cover hair with cap.

On the Day of Surgery 

Early AM care 1.

2. 3. 4.

Remove dentures, foreign materials, colored nail polish, hearing aid, contact lens (wedding ring secured to waist). Take baseline VS before pre-op meds. Check ID band Skin prep

On the Day of Surgery 

Early AM care 1.

2. 3. 4. 5.

Check for special orders – enema, IV line Check NPO Have client void before pre-op meds. Continue to support emotionally. Accomplish “pre-op checklist.”

Preop meds  2.

3.

4.

GOALS: To facilitate administration of any anesthetic. To minimize respiratory tract secretions and change in HR. To relax the client and reduce anxiety.

Preop meds  2. 3. 4. 5. 6.

Commonly used: Tranquilizers Sedatives Analgesics Anticholinergics Histamine 2 receptor antagonists

Transporting the client to the OR

Patient’s family  





Direct proper waiting room. Doctor informs family immediately after surgery. Explain reason for long interval of waiting. Explain what to expect.

INTRAOPERATIVE PHASE 

Begins when the patient is transferred to the O.R. and ends when he is admitted to the PACU.

1. ASSESSMENT a. b.

c.

Identify surgical client Assess the emotional and physical status. Verify information in the preoperative checklist.

2. ANALYSIS/POTENTIAL NURSING DIAGNOSIS a. b. c. d.

Impaired skin integrity Risk for fluid volume deficit Risk for injury Knowledge deficit

3. PLAN/IMPLEMENTATION  b. c.

d.

SURGICAL TEAM Surgeon Intra-operative nurses (Circulating and Scrub nurse) Anesthesiologist/Anesthetist

CIRCULATING NURSE 

Manages the OR and protects the safety and health needs of the patient by monitoring activities of members of the surgical team and checking the conditions in the OR.

Main responsibilities of the Circulating Nurse: 1. 2. 3. 4.

5.

Verifying consent Coordinating the team Ensuring cleanliness Proper temperature, humidity and lighting Safe functioning of equipment

Main responsibilities of the Circulating Nurse: 1.

2.

Availability of supplies and materials Monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel

SURGICAL SKIN PREPARATION: Involves cleaning the surgical site, removing hair only if necessary and applying an antimicrobial agent  Purpose is to reduce the risk of post-op wound infection 

SCRUB NURSE 1. 2. 3. 4.

Scrubbing for surgery Setting up the sterile tables Preparing sutures, ligatures and special equipment Assisting the surgeon during the procedure by anticipating the required instruments, sponges, drains and other equipment

SCRUB NURSE 1.

2.

3.

Keeping track of time the patient is under anesthesia and the time the wound is open Counts all needles, sponges and instruments Label specimens and send to lab

ANESTHESIOLOGIST Interviews and assesses the patient  Selects anesthesia and administers it 

ANESTHESIOLOGIST Intubates patient if necessary  Manages technical problems relating to anesthesia administration 

ANESTHESIOLOGIST 

Supervises patient’s condition throughout surgery (monitors BP, pulse, RR, ECG, oxygen saturation, tidal volume, blood gas levels, blood pH, alveolar gas concentrations and body temp)

POSITIONING 

Nurses needs to know the various positions used in surgery and understands the physiologic changes that occur when placed in that position.

Factors to consider when positioning a client: 1. 2. 3. 4.

5.

Site of operation Age and size of the patient Type of anesthetic used Pain normally experienced by the patient upon movement Must not hinder respiration and circulation

General considerations in positioning a client: 1. 2.

3. 4. 5.

Explain purpose of position. Operative site must be adequately exposed. Avoid undue exposure. Strap the person to prevent falls. Maintain adequate respiratory and respiratory function.

General considerations in positioning a client: 1. 2.

3.

Maintain good body alignment. Do not allow the persons extremity dangle over the sides of the table and lead to nerve muscle damage caused by circulatory impairment. Avoid excessive muscle strain.

General considerations in positioning a client: 1.

2.

3.

Avoid person resting on hands which may impede circulation. Precautions for patient’s safety must be observed, particularly with thin, elderly or obese patients. The patient may need a gentle restraint before induction in case of excitement.

Surgical positions: 1.

2.

DORSAL RECUMBENT – hernia repair, mastectomy, bowl resection, abdominal surgeries except for gallbladder and pelvis TRENDELENBURG – lower abdomen and pelvis to obtain good exposure by displacing the intestines into the upper abdomen (padded shoulder braces)

Surgical positions: 1.

2.

3. 4. 5.

LITHOTOMY – exposes perineal and rectal areas PRONE – spinal surgeries, alminectomy LATERAL – kidney, chest and hip JACKNIFE – hemorrhoidectomy LOMBOTOMY - kidney

ANESTHESIA Once anesthesia is administered, this signifies the start of the intra-op phase.  Produces temporary or total loss of sensation 

ANESTHESIA 1. 2. 3. 4.

5.

To produce muscle relaxation Analgesia Loss of memory Artificial sleep (unconsciousness) Relieves fear and anxiety

Stages of Anesthesia: 1. 2. 3. 4.

Beginning Excitement Surgical Medullary

1. BEGINNING (ONSET/INDUCTION) from anesthetic administration to loss of consciousness Assessment:  Drowsy or dizzy  Experience auditory/visual hallucination 

1. BEGINNING (ONSET/INDUCTION) INTERVENTION  Close OR doors  Keep room quiet  Standby person to assist if necessary

2. EXCITEMENT (DELIRIUM) Loss of consciousness to loss of eyelid reflexes ASSESSMENT  Increase in automatic activity  Irregular breathing, shouting, struggling 

2. EXCITEMENT (DELIRIUM) INTERVENTIONS:  Strap the thighs.  Secure hand on armboard  Do not apply restraint on operative site

3. SURGICAL Loss of eyelid reflexes to loss of most reflexes  Depression of vital function  Surgical procedure is started 

3. SURGICAL ASSESSMENT:  Unconscious  Muscles are relaxed INTERVENTIONS:  Assist in positioning the patient.  Begin prep long upon the signal of the anesthesiologist

4. MEDULLARY (DANGER) Vital function too depressed until respiratory and circulatory failure  Due to overdose of anesthesia  Resuscitation must be done. 

4. MEDULLARY (DANGER) ASSESSMENT:  Not breathing  May or may not have a heartbeat INTERVENTION:  Establish an airway  Provide emergency equipment/material  Assist in CPR

Types of anesthesia: 1. 2.

GENERAL ANESTHESIA REGIONAL ANESTHESIA

GENERAL ANESTHESIA  





Blocks the pain stimulus at the cortex Total loss of consciousness and sensation Produces amnesia, analgesia, hypnosis and relaxation Administered by IV INFUSION or by INHALATION

GENERAL ANESTHESIA ADVANTAGES:  Respiration and cardiac function are readily regulated since client is unconscious.  Anesthesia is adjusted to the length of the operation and the client’s age and physical status DISADVANTAGE:  Depresses the respiratory and circulatory system

Inhalation A mixture of anesthetic liquid in volatized form or gases with oxygen  BY MASK or ENDOTRACHEAL TUBE 

IV (INTRAVENOUS) 





Commonly used as an induction agent before a more patent type is given Unconsciousness occurs about 30 seconds after initial IV administration Brief duration of action

REGIONAL ANESTHESIA 



Produces loss of sensation in only one region of the body and does not cause loss of consciousness Blocks pain stimulus at its: 1. 2. 3.

Origin Along afferent neurons Along the spinal cord

Block pain stimulus at its ORIGIN 1.

2.

TOPICAL – directly applied into the area to be desensitized with the use of a solution LOCAL INFILTRATION BLOCK – blocks only peripheral nerves around the area of incision

ALONG AFFERENT NEURONS 1.

2.

FIELD BLOCK – areas proximal to the incision site is injected and infiltrated a barrier (“WALL IN”) PERIPHERAL NERVE BLOCK – anesthesizes individual nerves or nerve plexuses rather than all the nerves anesthesized by a field block

ALONG SPINAL CORD: 

Blocks impulses along the spinal cord and nerve roots and may occur either in the subarachnoid or epidural space

ALONG SPINAL CORD: 1.

2.

3.

SPINAL – produces a nerve block in the subarachnoid space EPIDURAL – injection of local anesthetic into the spinal canal in the space surrounding the dura mater CAUDAL (TRANS-SACRAL) – produces anesthesia of the perineum and occasionally, the lower abdomen

LOCAL ANESTHETIC AGENTS: 1.

2. 3. 4. 5.

Lidocaine (Xylocaine) and Mepivacaine (Carbocaine) Bupivacaine (Marcaine) Etidocaine (Duranest) Procaine (Novocaine) Tetracaine (Pontocaine)

REGIONAL ANESTHETIC AGENTS: 1. 2. 3. 4.

Procaine (Novocaine) Tetracaine (Pontocaine) Lidocaine (Xylocaine) Bupivacaine (Marcaine)

Complications/ Discomforts of Regional Anesthesia: HYPOTENSION PREVENTION:  Infuse 500-800 mL of IV if not prone to CHF INTERVENTION:  Oxygen administration  Vasoconstrictive drugs  Trendelenburg position 10-20 mins after induction 1.

Complications/ Discomforts of Regional Anesthesia: NAUSEA AND VOMITING INTERVENTION:  Oxygen administration  Give ephedrine, anti-emetics  IVF 1.

Complications/ Discomforts of Regional Anesthesia: 1.

HEADACHE – excessive loss of CSF due to: a. Loss of large spinal fluid b. Poor hydration

PREVENTION:  Use of small needle  Administer IV before and after induction  Flat on bed for 6 to 8 hours

INTERVENTION:  Apply tight abdominal binder  IV administration  Analgesic  Inject 10 mL of patient’s blood to plug hole (in severe loss)

Complications/ Discomforts of Regional Anesthesia: 1.

RESPIRATORY PARALYSIS – happens when drug reaches upper thoracic and cervical cord in large amount or in heavy doses

PREVENTION:  Avoid extreme trendelenburg position before level of anesthesia sets INTERVENTION:  Artificial airway

Complications/ Discomforts of Regional Anesthesia: 1.

NEUROLOGIC COMPLICATIONS – post operative paralysis due to: a. Unsterile needles, syringes and anesthetic medications b. Pre-existing disease of the CNS which cause the paralysis rather than the anesthesia itself

PREVENTION:  Strict aseptic technique and careful neurologic examination to ascertain existing neurologic diseases

INHALATION ANESTHETIC AGENTS: VOLATILE LIQUIDS:

1.

a. b. c. d. e. f.

Halothane (Fluothane) Methoxyflurane (Penthrane) Enflutane (Ethrane) Isoflurane (Forane) Sevoflurane (Ultrane) Desflurane (Suprane)

INHALATION ANESTHETIC AGENTS: 1.

GASES: a. Nitrous oxide

INTRAVENOUS ANESTHETIC AGENTS: 1.

TRANQUILIZERS AND SEDATIVE HYPNOTICS (Benzodiazepines) a. Midazolam (Dormicum) b. Diazepam (Valium) c. Chlordiazepoxide (Librium) d. Droperidol (Inapsine) e. Lorazepam (Ativan)

INTRAVENOUS ANESTHETIC AGENTS: 1.

OPIOIDS (Narcotics) a. Morphine b. Meperidine HCl (Demerol)

INTRAVENOUS ANESTHETIC AGENTS: 1.

2.

NEUROLEPANALGESICS a. Fentanyl (Sublimaze) b. Sufentanil DISSOCIATIVE AGENTS a. Ketamine (Ketaralac; Ketajact)

INTRAVENOUS ANESTHETIC AGENTS: 1.

2.

BARBITURATES a. Thiopental Na (Pentothal) b. Methohexital Na (Brevital) NONBARBITURATES HYPNOTICS a. Etomidate (Amidate) b. Propofol (Diprivan)

Major Complications of General Anesthesia: 1. 2.

CARDIAC ARREST RESPIRATORY DEPRESSION a. Excessive mucus b. CNS depression c. Bronchospasm/laryngospasm

Major Complications of General Anesthesia: 1. 2.

3.

HYPOTENSION AND SHOCK LOSS OF PROTECTIVE RESPONSE TO PAIN VOMITING AND ASPIRATIONS

Supplementary agents 

MUSCLE RELAXANTS – administered through IV and given mainly to supplement GA agents

Supplementary agents ADVANTAGES:  Early rapid induction (5 minutes)  Reduction of pre-op anxiety  Ease of administration

Supplementary agents DISADVANTAGES:  Decrease in respiratory rate and depth  Mild hypotension is produced  Central hepatic necrosis

DOCUMENTATION 

 

Received this 35 y.o., female, drowsy from ward per stretcher with IVF of PNSS 1L at 100 cc/hr at the level of 800cc, infusing well on left metacarpal vein for cholecystectomy under the service of Dr. Cruz. Pre-op checklist reviewed; complete. Placed on OR table comfortably.

DOCUMENTATION   



Oxygen administration at 2 LPM. Loosened gown. Attached leads for cardiac monitor, BP cuff and finger probe for pulse oximetry reading. Placed well padded straps on hips to prevent falls.

DOCUMENTATION   

  

Arms placed on board, strapped well. Placed cap on head. Placed on knee-chest side lying position Induction of SAB - CEB by Dr. Rabe. Placed on trendelenburg position. Skin prep done.

DOCUMENTATION    

Incision done. All bleeders clamped and cauterized. Gall bladder out. All layers sutured, done aseptically.

TRANSFERRING TO PACU Responsibility of the anesthesiologist New gown Transferred to stretcher Avoid the following during transfer:

    1. 2. 3.



Undue exposure Rough handling Hurried movements and rapid changes in position

Side rails up

POSTOPERATIVE PHASE 

Admission of the patient from the PACU or RR and ends when patient discontinues follow-up or upon discharge

STAGES OF POST-OP PHASE: 1. 2. 3.

IMMEDIATE – admission to PACU INTERMEDIATE – in patient’s room EXTENDED – follow-up at doctor’s clinic (removal of sutures)

IMMEDIATE PACU (POST ANESTHESIA CARE UNIT)  

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Located adjacent to OR Quiet, clean, painted with soft pleasing colors and have indirect lighting Has equipment that controls noise (plastic emesis basins, rubber bumpers on beds and tables)

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Isolated but with visible quarters to disruptive patients Should be ventilated Beds should provide easy access to the patient, safe and easily movable, can be readily placed in shock position and has features that facilitates care (IV poles, side rails, wheel brakes and chart storage rack)

ARRIVING AT PACU 

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Position with the head to the side and the chin extended forward on a lateral Sims position. If required to lie flat, carefully monitor respiratory status. Elevate client’s upper arm on a pillow.

ARRIVING AT PACU 

Immediately make baseline: 1. Check airway patency 2. VS, visual assessment (general color, IV infusion, drains, special equipment, condition of the dressing) 3. LOC

ARRIVING AT PACU Attach apparatus  Communicates intra-op info (name, surgical procedure, anesthesia, response to surgery)  Arouse clients 

ARRIVING AT PACU 

DOCUMENTATION: 1. 2. 3. 4. 5. 6.

Time of admission Absence of reflexes LOC Skin color and dryness, VS Condition of dressing IV infusion, BT, drainage tubes, bladder catheter

NURSING RESPONSIBILITIES: MAINTENANCE OF PULMONARY VENTILATION – to prevent hypoxemia and hypercapnea ASSESSMENT:  Noisy and irregular respirations  cyanotic 1.

INTERVENTION:  Leave plastic oral airway in the mouth.  Assess RR, Oxygen saturation and breath sounds  Check the order and apply supplemental oxygen  Prevent choking

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Maintain patent airway (prevent aspiration)  

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Turning from one side Elevate head of bed unless contraindicated Prepare emesis basin always at bedside Open mouth manually but cautiously with padded tongue depressor Suction as necessary

NURSING RESPONSIBILITIES: 1.

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PROTECTION AND PREVENTION OF INJURY Provide side rails, place up Turn patient frequently and placed in good alignment Never leave the patient alone

NURSING RESPONSIBILITIES: 1.  

PROMOTION OF COMFORT Never leave the patient alone Administer narcotic analgesic to relieve pains

ALDRETE POST ANESTHESIA RECOVERY SCORING SYSTEM AREA OF ASSESSMENT: 2. Muscle activity 3. Respiration 4. Circulation 5. Consciousness level 6. Oxygen saturation *Required for discharge from PACU = 7 to 8 points

Clients are discharged from PACU when (FAIRCHILD):  

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Conscious and coherent Able to maintain a clear airway and deep breathe and cough freely VS stable and/or consistent with preop VS for at least 30mins Protective reflexes are active

Clients are discharged from PACU when (FAIRCHILD):   

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Able to move four extremities Urinary output is adequate Afebrile or a febrile condition has been attended to Dressings are dry and intact, no overt drainage

ON-GOING POST OPERATIVE CARE  

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Obtain special equipment Check physician’s stat orders before conducting initial assessment Consult surgeon’s post-op orders Check PACU record Assessment Document client’s arrival and all assessments

ASSESSMENT A – AIRWAY

Maintain patent airway Head turned to side Suctioning Administer oxygen B – BREATHING DBE Coughing Administer oxygen

ASSESSMENT C – CIRCULATION VS q15 for 2h, q30 for 2h, q hour for the first 24 hours or until stable CRT not > 2-3s Skin color Monitor BT

ASSESSMENT C – CONSCIOUSNESS D – DRESSING D – DRAINAGE D – DRUGS

LOC Ability to command Keep it dry and intact Tubings attached, keep it patent and intact Antibiotics Pain reliever

ASSESSMENT E – ELIMINATION

F – FLUIDS F – FOOD

Monitor I & O Monitor passing of flatus IVF 30 gtts/min NPO until peristalsis returns (clear liquid → full liquids → soft diet → full diet/DAT

ASSESSMENT S – SAFETY/COMFORT  Side rails up  Turn to sides, early ambulation  Relief from discomforts  Prevent complications

ANALYSIS / POST-OP NURSING DIAGNOSIS      

High risk for infection High risk for injury High risk for fluid volume deficit Pain Impaired physical mobility Altered family process r/t loss of economic stability

ANALYSIS / POST-OP NURSING DIAGNOSIS     

Ineffective airway clearance Ineffective breathing pattern Self-care deficit Altered health maintenance Self-esteem disturbance