PERIOPERATIVE NURSING

 Perioperative Period of time that constitutes the surgical experience which include the pre operative, intraoperative and post operative phases of nursing care.

Preoperative Phase Period of time when the decision for surgical intervention is made to when the patient is transferred to the operating room table

CARE OF SURGICAL PATIENT

A.   Definition of Terms

3 Phases

Intraoperative Phase Period of time when the patient is transferred to the operating room table to when he or she is admitted to the PACU (Post anesthesia care unit)

Post operative Phase Period of time that begins with the admission of patient to the PACU and ends after a follow – up evaluation in the clinical setting or home.

B.   Surgical Team

1. Patient

2. Circulating Nurse/ Circulator

o Protects the patient’s safety and health by monitoring the activities of the surgical team

o Coordinates with the other members of the health team

3.The scrub role

• Performs the surgical hand scrub.

• Assisting the surgeon, and the surgical assistants during the procedure

• Tissue specimen obtained must be labeled and sent to the laboratory by the circulator.

4. Surgeon

• Performs the surgical procedure

• Heads the surgical team

• Setting up the sterile tables, preparing sutures, ligatures and equipments

5. Registered nurse 1st assistant

• Responsibilities may include handling tissue, providing exposure at the operative field, suturing, and providing hemostasis

• Another member of the operating room staff

   6. Anesthesiologist

• Physician specifically trained in the art and science of anesthesiology.

• Physician specifically trained in the art and science of anesthesiology.

• An anesthetist is a qualified health care professional who administers anesthetics.

• Most anesthetist are nurses who have graduated from an accredited nurse anesthesia program (American Association of Nurse Anesthetists)

• Interviews and assess the patient prior to surgery

  

• Manages the technical problems related to the administration of anesthetic agents

• Supervises the patient’s condition throughout the surgical procedure.

• Selects the anesthesia, administers it, intubates the patient if necessary.

SURGICAL CLASSIFICATION

   1. Diagnostic

     2. Curative

3. Reconstructive or Cosmetic

4. Palliative

CATEGORIES OF SURGERY BASED ON URGENCY

  1. Emergent

Patient requires immediate attention disorder may be life – threatening

Without a delay

     2. Urgent

Patient required prompt attention

 Within 24 – 30 hours

3. Required

Patient needs to have surgery

Plan within few weeks or months

4. Elective

Patient should have surgery

Failure to have surgery is not catastrophic

  5.  Optional

Decision rests with patient Personal preference

NURSING INTERVENTIONS

A. PRE – OPERATIVE PHASE

Pre admission testing

1. Initiates preoperative assessment

• Nutritional and Fluid Status

• Drug or alcohol use

• Respiratory Status

• Cardiovascular status

• Hepatic function

• Immune Function

• Endocrine function

• Previous medication use

• Psychosocial factors

• Spiritual and Cultural Beliefs

• Instruction for ambulatory surgical patient

• Cognitive coping strategies

• Pain Management

• Mobility and active body movements

• Deep breathing, coughing and incentive spirometers

2. Initiates teaching appropriate to patient’s needs

3. Involves family in interview

4. Verifies completion of pre – operative testing

5. Verifies understanding of surgeon – specific preoperative orders

Managing nutrition and fluids

Preparing the bowel for surgery

Instruction for ambulatory surgical patient

6. Assess patient’s need for post operative transportation and care

Admission to Surgical Center or unit

1. Completes pre – operative assessment

2. Assess for risks for post – operative complications

3. Reports unexpected findings or any deviations from normal

4.Verifies the operative consent has been signed

5. Coordinated patient teaching with other nursing staff

6. Reinforces previous teachings

7. Explain phases in peri – operative period and expectations

8. Answers patient’s and family’s question

9. Develops a plan of care

In the holding area

1. Assess patient’s status (baseline pain and nutritional status)

2.  Reviews chart

3. Identifies patient

4. Verifies surgical site and marks site per institutional policy

5. Establishes intravenous line

6. Administers medication if prescribe

a. Sedatives Given to decrease the patient’s anxiety Lowers BP, and Pulse Reduce the amount of general

anesthetic to be given in surgery Overdose can lead to respiratory

depression

Eg. Pentobarbital Na (Nembutal), Secobarbital (Seconal)

c. Tranquilizers

b. Anticholinergic Given to reduce the amount of

tracheobronchial secretions

Interrupts vagal nerve impulses which acts to slow the heart

Overdose can cause severe tachycardia

Eg. Atrophine Sulfate

• Lowers a patient’s level of anxiety

d. Prophylactic antibiotics

• Causes dangerous hypotension both during and after surgery.

• Eg. Phenergan, Thorazine

• Decrease the number of microorganisms in the system

e. Narcotic Analgesics

Given to relax the patient, to lower anxiety and to reduce the amount of narcotics given during surgery.

8.  Provides psychological support

7. Takes measures to ensure patient’s comfort

They have a tendency to cause vomiting, respiratory depression, and postural hypotension.

Eg. Morphine, Meperidine HCl

• Reduce anxiety

• Decreasing Fear

9. Communicates patient emotional status to other appropriate members of the health team

Immediate Preoperative Nursing Intervention

• Patient changes into a hospital gown

• Long hair maybe braided

• Remove the hairpins

cover the head with disposable cap

Mouth is inspected for dentures or plates are remove

Remove jewelry, body piercings, contactlens, glasses, prosthetic devices and are given to the family members properly labelled with patient’s name.

• Allow the patient to void

Anesthesia

Factors that influence the Choice of Anesthesia

1. Patient’s wishes and understanding of the types of anesthesia.

2. Patient’s physiologic status

3. Presence and severity of coexisting diseases4.    Patient’s mental and psychologic status

5. Postoperative recovery from various kinds of anesthesia

6. Options for management of postoperative pain

7. Type and duration of the surgical procedure

8. Patient’s position during surgery

9. Any particular requirements of the surgeon

Premedication

Purpose: to sedate the patient and reduce anxiety• administered 60 – 90 mins before

induction of anesthesia

Types of Anesthesia Care

1. General Anesthesia – is a reversible, unconscious state characterized by amnesia, analgesia, depression of reflexes, muscle relaxation and homeostasis of specific manipulation of physiologic systems and functions.

• Inhalation of volatile liquid – ethyl ether, halothane

• Inhalation of gaseous anasthetics – nitrous oxide, ethylene, cycloproprane

• Both inhalation of volatile liquid and gaseous anesthetics causes respiratory and circulatory depression.

• Highly flammable and explosive when mixed with air or oxygen.

Dangers: a. Laryngospasm

b. Hypotension

c. Respiratory Arrest

Stage 2 is from the loss consciousness to the onset of regular breathing and loss of the eyelid reflexStage 3 begins with the onset of a regular breathing pattern and lasts until cessation of respiration

Stage 4 is from cessation of respiration to circulatory failure that leads to death

Stage 1 is from the initial administration of anesthetic agents to loss of consciousness

Levels of General Anesthesia

Phases of General Anesthesia

a. Induction

b. Maintenance

c. Emergence

Types of General Anesthesiaa. IV

technique b. Inhalation technique

c. Combination of IV an inhalation techniques

Muscle Relaxants are used by anesthesia providers primarily to facilitate intubation and to provide good operating conditions at lighter planes of general anesthesia.

2. Regional Anesthesia – (conduction anesthesia) is broadly defined as a reversible loss of sensation in a specific area or region of the body when a local anesthetic is injected to purposefully block or anesthesize nerve fibers in and around the operative site.

Spinal anesthesia – a local anesthetic is injected into the cerebrospinal fluid in the subarachnoid space.

Complications:

Hypotension

Total Spinal Anesthesia

Positioning Problems

Postdural Puncture Headache

• Procaine (Novocaine), Tetracaine (Pontocaine), Lidocaine (Xylocaine)

Epiduaral and Caudal Anesthesia

a. Epidural anesthesia – the local anesthetic is usually injected through the intervertebral spaces in the lumbar region although it can also be injected into the cervical or thoracic regions.

b. Caudal anesthesia – the local anesthetic is also injected into the epidural but the approach is through the caudal canal in the sacrum.

Complications:

Inadvertent Dural puncture

Subarchnoid Injection

Vascular Injection

Peripheral Nerve Blocks – wide variety of peripheral nerves can be effectively blocked by injecting local anesthetic around them to provide adequate surgical anesthesia.

Intravenous Regional Anesthesia (Bier Block) it is often used on the upper extremities. It is highly reliable and easy to accomplish.

Monitored Anesthesia Care – (MAC) is provided when infiltration of the surgical site with a local anesthetic is performed by the surgeon and the anesthesia provider supplements the local anesthesia with IV drugs that provide sedation and systemic analgesia.

Conscious Sedation/Analgesia – is being administered increasingly for specific short-term surgical, diagnostic and therapeutic procedures within a hospital or ambulatory center.

• It refers to the intravenous administration of certain sedatives and analgesics that produce a condition in which the patient exhibits a depressed level of consciousness but retains the ability to independently maintain a patent airway and respond appropriately to verbal commands or physical stimulation.

Local Anesthesia – refers to the administration of an anesthetic agent to one part of the body by local infiltration or topical application.

Postoperative Complications

• Respiratory

o Airway Obstruction

o Laryngospasm

o Bronchospasm

• Cardiovascular

o Hypotension

o Hypovolemia

o Hypertension

o Dsyrhythmias

• Thermoregulation and Temperature Abnormalities

o Hypothermia

o Hyperthermia

• Disturbed Thought Processes

• Nausea and Vomiting• Aspiration

• Acute pain

Stages of Anesthesia

1. Induction of Anesthesia – from the administration of anesthetic agents to loss of consciousness. Pupil Size is normal and reacts to

light

BP is normal

Irregular pulses

2. Excitement of Delirium – from the loss of consciousness to the loss of lid reflex characterized by shouting, struggling and talking.

Pupils are dilated by reactive to light Pulse is rapid

Irregular respiration

3. Surgical – From loss of lid reflex to loss of respiration.

Pupils are small and reactive to light Respiration is is regular

BP is normal

4. Medullary or Stage of Danger – from loss of respiration to circulation. Reached when too much anesthesia

has been given

SURGICAL ASEPSIS

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SURGICAL ASEPSIS

A.   Principles of Aseptic Technique

1. Only sterile items are use within the sterile field

2.  Items of doubtful sterility must be considered unsterile

3. Whenever a sterile barrier is permeated it must be considered contaminated

4. Sterile gowns are considered sterile in front from shoulder to level of the sterile field and at the sleeves 2 inches above the elbow cuff

5. Tables are sterile only at table level

6. The edges of sterile enclosure are considered unsterile

7. Sterile persons touch only sterile items or areas; unsterile person touch only unsterile items or areas.

8. Movement within or around sterile field must not contaminate the field.

B. Traffic Control

1. Unrestricted area

        Area includes areas outside of the surgical suite as well as a control point to monitor the entrance of patients, personnel and materials

2. Semi restricted area

   Comprises the peripheral support areas within the surgical suite

  Surgical attire should be worn which includes hair coverings

  Ex. Storage area, work areas, corridors

3. Restricted area

      Includes the operating rooms, procedure rooms, central core, the scrub sink areas

      Surgical attire should be worn which includes hair coverings, and mask

C.   Surgical Attire

1. Surgical gown

2. Sterile Gloves

3. Masks, and googles

D. Scrub Procedure

1. Turn on the faucet. Most scrubs sinks have automatic or knee controls for the faucet.

2. Moisten arms and forearms

3. Using foot control, dispense a few drops of antimicrobial soap or detergent into the palms. Add small amounts of water to make a lather

4. Wash hands and forearms using the antimicrobial soap or detergent. Rinse before beginning the surgical hand scrub. The amount of time needed varies with the amount of soil and effectiveness of the cleansing agent.

5. If a packed scrub brush or sponge is used, open the package. Remove the brush and nail cleaner and discard the package. Hold the brush in one hand while cleaning the nails on the other hand.

6. Rinse the hands and arms thoroughly , exercising care to hold the hand higher than the elbows. Avoid splashing water onto the scrub suit because this moisture can cause subsequent contamination of the sterile gown

7. If the brush or sponge is impregnated with antimicrobial soap, moisten the brush or sponge and begin scrubbing. If the brush or sponge is not impregnated with soap, apply anti – microbial soap or detergent solution to hands. Starting at the fingertips, scrub the nails vigorously holding the brush perpendicular to the nails. Scrub all sides of each digit including the connecting webbed spaces. Scrub the palm of the hand

8. Scrub each side of the forearm with a circular motion upto the elbows

9. Hold the arms and hands away from the body with the hands above the level of the elbows while scrubbing, allowing the water and detritus to flow way from the first scrubbed and cleanest area. Add small amounts of water during the scrub to develop suds and remove detritus.

10. Rinse the hands and arms thoroughly.

11. If the sink is not automatically timed, turn off the faucet by using the knee control or by using the edge of the brush on a hand control. Discard the brush or sponge.

12.  Hold the hands and arms up in front of the body with elbows slightly flexed and enter the operating room

E. Gowning

1. Self – Gowning Procedure

a.      Grasp the sterile gown at the neckline with both hands and lift from the wrapper. Step into the area where the gown maybe opened without risk for contamination.

b. Hold the gown away from the body and allow it to unfold with the inside toward the wearer

c. Keep the hands on the inside of the gown while it completely unfolds

d. Slip both hands into the open armholes, keeping the hands at shoulder level and away from the body.

e. Push the hands and forearms into the sleeves of the gown, advancing the hands only to the proximal edge of the cuff if the close gloving technique will be used.

f. If the open gloving technique will be use. Advance the hands completely through the cuffs of the gown.

The circulating Nurse should do the following:

g. Pull the gown over the scrubbed person’s shoulders touching only the inner shoulder and side seams

h. Tie or clasp the neckline and tie the inner waist ties of the gown touching only the inner aspect of the gown. The gown should be completely fastened by the circulator before the scrub person dons gloves, to prevent contamination from the gown flapping.

To secure the gown the scrubbed person and the circulating nurse should do the following:

i. After gloving the scrub person hands the tab attached to the back tie of the gown to the circulating nurse. The scrub person then makes ¾’s turn to the left while the circulating nurse extends the back tie to its fullest. This action effectively wraps the back panel of the gown around the scrubbed person and covers the previously tied inner waist ties.

j. The scrubbed person retrieves the back tie by carefully pulling it out of the tab held by the circulating nurse and ties it with the other tie, which had been secured to the front tap of the gown.

2.  Assisted Gowning Procedure

a. A gowned and gloved person may assist another person in donning a sterile gown

b. The gown is opened in the manner previously describe.

c. The inner side with the open armholes is turned towards the individual who is to be gowned.

d. A cuff is made of the neck and shoulder area of the gown to protect the gloved hands. The gown is held until the person’s hand and forearms are in the sleeves of the gown.

e. The circulating nurse assist in pulling the gown onto the shoulders, adjusting the back and tying the tapes. The wrap around back on the gown is fixed into position by the scrubbed person after the gloving is completed.

F.   Gloving

Donning Gloves 1. Closed Gloving Technique

a. The gloves are handled through the fabric of gown sleeves.

b. The hands are not extended from the sleeves and cuff when the gown is put on.

c. The hands are pushed through the cuff openings as the gloves are pulled into place.

2.   Open Gloving technique

a. The everted cuff of each glove permits a gowned person to touch the glove’s inner side with ungloved fingers and to touch the gloves outer side with gloved fingers.

b. Keep the hands in direct view, not lower than the waist level.

c. The gowned person flexes the elbow.

d. Exerting a light even pull on the glove brings it over the hand and using a rotating movement brings the cuff over the wristlet.

3.   Assisted gloving technique

a. Grasp the glove under the everted cuff.

Be sure the palm of the glove is turned toward the ungloved individual’s hand with the thumb of the glove directly opposed to the thumb of the person’s hand

b. Using the fingers stretch the cuff to open the glove.

c. The ungloved individual can then insert his/her hand into the glove.

d. The procedure is repeated for the other hand.

G.   REMOVING SOILED GOWN, GLOVES AND MASK

1. Wipe gloves clean with a wet sterile towel.

2. Untie surgical gown. Circulator must unfasten back closures.

3. Grasp gown at one shoulder seam without touching scrub clothing.

4. Bring neck and sleeves of the gown forward, over, and off the gloved hand, turning the gown inside out and everting the cuff of the gown

5. Repeat steps 3 – 4 for the other side.

6. Keep arms and gown away from body while turning the gown inside out and discarding carefully in the designated receptacle.

7. Using the gloved fingers of one hand to secure the everted cuff, remove the glove turning it inside out. Discard appropriately.

8. Using the ungloved hand, grasp the fold of the everted cuff of the hand of the other glove and remove the glove inverting the glove as it is removed. Discard appropriately.

9. After leaving the restricted area remove the mask by touching the ties or elastic only

10. Discard in the designated receptacle.

11. Wash hands and forearms.

H.   Universal Precaution

1. Hand hygiene – hands are to be washed whenever they are visibly soiled, after contact with body fluids and upon glove removal.

2. Gloves – gloves are to be worn when touching blood, body fluids, secretions, excretions and contaminated items.

3. Masks, eye protection, and face shields – mask and eye protection or a face shields are to be worn at any time patient care activities are likely to generate sprays or splashes of blood or body fluids, secretions and excretions

4. Gowns- gowns are to be worn at any time patient care activities are likely to generate sprays or splashes of blood and body fluids, secretions and secretions.

5. Sharps – needles, scalpels, and other sharps are to be handled in a manner to avoid injury. Needles should never be recapped using any technique that directs the point of the needle toward any body part. If recapping is necessary, it should be done using a mechanical device or a one handled scoop technique.

6. Patient Care equipment – single use items are to be discarded after use. Reusable equipment must be cleaned and reprocessed to ensure safe use for another patient.

7. Linens – linens soiled with blood, body fluids, secretions or excretions should be handled in a manner to avoid skin and mucous membrane exposure. Clothing contamination and transfer of microorganism to another patients, personnel, and the environment.

8. Environmental control – adequate procedures or routine care and cleaning of environmental surfaces, beds, and associated equipment are to be developed and the use of this procedure is monitored on a regular basis.

9. Patient Placement – patients who contaminate the environment or who are unable to maintain appropriate hygiene or environmental control are to be housed in a private room with appropriate handling and ventilation.

CHARACTERISTICS OF SUTURE MATERIALThe ideal suture material is one that causes minimal inflammation and tissue reaction while providing maximum strength during the lag phase of wound healing.

THREE MAIN FEATURESPhysical characteristics a. Physical configuration – single stranded (monofilament) or multistranded (multifilament) containing a number of fibers rendered into a single thread by twisting or braiding.

b. Capiliarity – defined as ability to transmit fluid along the strand. c. Diameter – determined in millimeters and expressed in USP sizes with zeroes; the smaller the cross section diameter the more zeroes; sizes range from # 7, the largest, to 11 – 0, the smallest; sizes 0 to 4 – 0 are the most commonly used suture in general surgery.

d. Tensile strength – amount of weight necessary to break a suture; varies with type of suture material.

e. Knot strength – the force necessary to cause a given type of knot to slip, either partially or completely.f. Memory – the capacity of a suture to return to its former shape after being reformed, as when tied; high memory yields less knot security.

Handling characteristics - are related to both pliability (how easily the material bends) and coefficient of friction (how easily the suture slips through the tissue).Tissue reaction characteristics – all suture material causes tissue reaction. Tissue reaction begins when the suture inflicts injury to the tissue during insertion and reacts to the suture material itself.

TYPES OF SUTURE MATERIALAbsorbable sutures – are collagen derived from healthy mammals or synthetic polymer. They can be digested (enzyme activity) or hydrolyzed (by reaction with water in tissue fluids to breakdown) and assimilated by the tissues during healing.

Surgical gut – is obtained from the collagen of the sub mucosal layer of the small intestine of sheep or the intestinal serosa of cattle or hogs. They can either be untreated (plain, type A) or treated with chromium salts (chromic type C).

Chromatization delays absorption of the suture in the living mammalian tissues. Absorption takes place by digestion of the gut by tissue. Wet packed with alcohol.Collagen sutures – are derived from tendons of cattle. They are superior to surgical gut used most often as a fine suture material for the eye.

Synthetic absorbable suture – to produce synthetic absorbable sutures, specific polymers are extruded into suture strands. The base material for synthetic absorbable suture is a combination of lactic and glycolic acid polymers (vicryl, dexon, polysorb) – 2 to 3 weeks.

Newer synthetic polymers (PDS, MAXON,MONOCRYL) provide wound support for 3 months. They are absorbed by slow hydrolysis in the presence of tissue fluid. They are dry packed.Non – absorbable sutures – are strands of material that effectively resist enzymatic digestion in living animal tissues.

Silk – is prepared from thread spun by silkworm larvae in making its cocoon. Silk is processed to remove natural waxes and gum, manufactured into threads and colored with a vegetable dye. Silk handles well, is soft and forms a secure knot. Wet silk looses 20 % in strength – scrub person should keep the silk dry.

Cotton – are made from individual cotton fibers that are combed, aligned, and twisted to form a finished strand. Nylon – a synthetic polymer material. Most common are DERMALON, ETHYLON, SURGILON. Frequently used in ophthalmology and microsurgery because it is manufactured in fine sizes ( 11 – 0 ).

Polyester Fiber – it has greater tensile strength, minimal tissue reaction and maximum visibility and does not absorb tissue fluids. Polypropylene – is a clear or pigmented polymer. This monofilament suture material is used for cardiovascular, general and plastic surgery. It may be used in the presence of infection and causes minimal tissue reaction.Stainless steel – is formulated to be compatible with stainless steel implants and prosthesis.

This formula, 316L (L for low carbon) ensures absence of toxic elements, optimal strength, flexibility and uniform size. Kinks in the wire can render it practically useless.

` PACKAGING, STORAGE AND SELECTION OF SUTURESTypes of packaging – suture material is sealed in a primary inner, which may or may not contain fluid then placed inside the dry, outer, peel – back packet then sterilized. This method permits easy dispensing onto the sterile field.

Various forms of foil, plastic, and special paper are used in both the inner and outer packets. The needle may be permanently attached to the suture (SWAGED) and may need to be cut off for removal.

Color codes – Color coded packaging based on suture fiber is used by most companied to make identification quicker and easier.

Fiber color codePlain gut yellowChromic gut tanGlycolic acid polymers violet*Silk medium blueCotton pink, whitePolypropylene royal bluePolyester medium green *Nylon light greenStainless steel mustard*

*May change form one manufacture to another

Selection of Sutures – the choice of suture material, size, and type depends on the procedure, the tissue being sutured and type of reapproximation required, general condition of the patient and the surgeon’s preference.

HEMOSTASISan ongoing process during surgery. In addition to the damaging physiologic effects of blood loss for the patient bleeding from cut vessels obscures visualization of the operative site for the surgeon and must be controlled.

a. Methods of ligating vesselsa ligature is a strand of suture material used to encircle and close off the lumen of a vessel to effect hemostasis, close off a structure, or prevent leakage of materials.

Techniques used to secure a ligature in deep tissues: A hemostat is placed at the end of the structure; the ligature is then placed around the vessel. The knot is tied and tightened with the surgeon’s finger or with the aid of forceps.

Slip knot is made and its loop is placed over the involved structure by means of a forcep or clamp. Deeper cavities, ties are often placed with the long end extending from the tip these are called tie on a pass or bow ties.

Suture ligature, stick tie or transfixion ligature is a strand of suture material threaded or swaged on a needle. This is usually placed through the vessel and then around it to prevent the ligature from slipping at the end.

Ligating clipsare small v- shaped, staple like devices that are placed around the lumen of a vessel or a structure to close it.

SKIN STAPLESare one of the most frequently chosen method of skin closure. They are disposable and reduces both operating time and tissue trauma, allowing uniform tension along the suture line and less distortion from the stress of individual suture points. They are usually removed in 5 – 7 days using an extractor.

SKIN TAPESwounds that are subjected to minimal static and dynamic tension are approximated with skin tape. Tapes are applied perpendicularly to the wound edge first on one side and then the other, so that the edges can be pulled together.

SURGICAL NEEDLE varies considerably in size, shape, point design and wire diameter. Needle is selected depending on the type and location of tissue being sutured. Made from either stainless steel or carbon steel.

THREE BASIC PARTS:EYE – the eye of the surgical needle falls into 3 general categories Eyed Needles, in which the needle must be threaded with suture strands, and 2 strands of suture must be pulled through the tissue.

Spring or French, eyed needles in which the suture is placed or snapped through the spring.Eyeless needles, a needle – suture combination in which a needle is swaged (permanently attached) onto one or both ends of the suture material.

BODY – the body or shaft of the needle may be round, flattened triangular. Surgical needles may also be straight or curved.

Needle point – relates to density of tissue to be penetrated. Delicate tissue such as bowel or kidney requires a taper or blunted point. Skin, which is dense in structure requires a cutting edge.

SUTURING METHODS:Closure of wounds The primary suture line refers to suture that obliterate dead spaces, prevent serum from accumulating in the wound and hold the wound edges in approximation until healing takes place.

The secondary suture line refers to suture that supplement the primary suture. It helps eliminate tension on the primary sutures and reduces the risk of evisceration or dehiscence. Retention sutures are type of secondary suture line.Interrupted suture is inserted into tissues or vessels in such a way that each stitch is placed and tied individually. This is generally used on skin and may be used in any underlying tissue layer.

Continuous suture consist of series of stitches which only the first and last are tied. With this type of suture a break at any point may mean a disruption of the entire suture line. Used to close tissue layers where there is little tension but tight closure is required. E.g. peritoneum

Retention (Stay) sutures are placed at a distance from the primary suture line to provide a secondary suture line to relieve undue strain and help obliterate dead space.

Subcuticular sutures referred to as buried are those placed completely under epidermal layer of skin.

HOLDING A DRAIN IN PLACEa drainage tube is inserted into the wound, the tube may be anchored to the skin with a non absorbable suture so that it will slip in or out. A tube left in a hollow viscus, such as the gallbladder or common bile duct, may be secured to the wall of that organ with an absorbable suture.

KNOT – TYING TECHNIQUEthe completed knot should be firm to prevent slipping and should be small with ends cut short, to minimize the bulk of suture material in the wound.

PERIOPERATIVE NURSING CONSIDERATIONSGENERAL CONSIDERATIONS

Precautions must be taken to keep the suture sterile, to prevent prolonged exposure and unnecessary handling and to avoid wasting.

OPENING PRIMARY PACKETSThe scrub person tears the foil packet across the notch near the hermetically sealed edge and removes the suture.

HANDLING SUTURE MATERIALS To remove suture strands to be used for ties when they are not on a reel or disc, the loose end is pulled out with one hand while the folder is grasped with one hand.

To straighten a long suture, the free end is grasped (using the thumb and forefinger of the free hand), the kinks, caused by the package memory are removed by gently pulling with free hand secured, one in each hand, and then the arms are slowly abducted to strengthen the strands.

Kinks should never be removed by running gloved fingers over the strand because this action causes fraying.Tensile strength of a gut suture should not be tested before it is handed to the surgeon. Sudden pulls or jerks used to test the tensile strength may damage the suture so that it will break when used.

To remove a suture – needle combination from the package, the scrub person grasps the needle with the needle holder and gently pulls.

The jaws of the needle holder grasp the flattened surface of the needle to prevent breakage and bending.To facilitate suturing, the needle is secured about 1/8 inch down from the tip of the needle holder.

The holder is placed on the needle about a third of the distance in from the eye or swaged end.Suture or free ligature should not be too long or too short.

THREADING SURGICAL NEEDLESFree needles that come packaged separately from the suture must be threaded by the scrub person for the surgeon. Curved – needle is threaded within its curvature to prevent accidental pull out.

COUNTING NEEDLESInitial counts before the start of the procedure provide the basis for subsequent counts.Items added during the procedure should be counted and documented.The count should be performed audibly and with each sharp scrub person and circulator.

During the procedure the scrub person should be aware of the location of sharps on the sterile field.

If subsequent counts should be performed by the scrub person and circulator before closure of the body cavity, or deep, large incision after closure of the body cavity when either person is relieved by other personnel and immediately before completion of surgical intervention.

Recording of the count is the responsibility of the circulator.To facilitate counting, needles are counted according to the number indicated on the package; the scrub person verifies this number with the circulating nurse when the package is opened.

INSTRUMENTSINSTRUMENTAL CATEGORIESDISSECTORS – they are sharp or dull instruments used to separate tissues. Scalpels are the oldest of the surgical instruments.

Handles with one end suited to the attachment of disposable blades.Scissors are designed in various shapes and sizes for different purposes in cutting body tissues and surgical materials.

a. Mayo scissors – for heavy tissuesb. Metzenbaum scissors – for dissection of delicate tissuesc. Straight scissors – for cutting suturesd. Bandage scissors – for uterusOther dissectors include drills, saws, and osteotomes

a. Sharp or blunt dissecting instruments include curettes, and periosteal elevatorsCLAMPS – are instruments specifically designed for holding tissues or other materials, and must have an easily recognizable design.

CATEGORIES OF CLAMPS:Hemostats – are used to close several ends of a vessel with minimum tissue damage. They prevent excessive blood loss in the course of dissectionThey have deep transverse cuts so that bleeding vessels may be compressed with sufficient force to stop bleeding

Occluding clamps – are used to prevent leakage and to minimize trauma when clamping bowel, vessels, or ducts that are to be re - anastomosed. This is due to vertical serrations or special jaws that have finally meshed, multiple rows of longitudinally arranged teeth.

Graspers and Holders – are used for tissue extraction and generally have jaws of specific design based on their use.Allis clamp – has multiple teeth on tip so as not to crush or damage tissue.Babcock clamp – has curved fenestrated tips with no teeth and grips on enclosed delicate structures.

Kochner or Ochsner – transverse serrations as well as large teeth at its tip to grasp tightly on tough slippery tissues such as the fascia.Non clamp graspers and holders – are known as forceps or pick ups used to lift or hold tissues.

Non toothed forceps – create minimal damage and hold delicate thin tissuesToothed forceps – hold thick and slippery tissues that need extra gripGrasper and holder clamps – sponge holding forceps are used to grasp or handle tissues but are commonly used as sponge holders

A gauze sponge is folded and placed in the jaws and is then used to retract tissues, to absorb blood in the field and occasionally to perform blunt dissection.Needle holders – it holds the needle firmly.

Towel clamps – are considered holding instruments used for holding draping materials in place.RETRACTORS – are used to hold back the wound edges, structures, or tissues to provide exposure of the operative site.

TWO TYPES OF RETRACTORS: A. Self - retaininga.1 With frames to which various blades may be attached.

a.2 With two blades held apart with a ratchet.B. Manually held retractors

ACCESSORY AND ANCILLARY INSTRUMENTS – are designed to enhance the use of basic instrumentation or to facilitate the procedure.Suction tips and tubings, irrigators – aspirators, eloctrosurgical devices and special use devices (probes, dilators, and screw drivers)

BASIC TABLE SETUPSInstruments are set up on mayo stands and back tables in a planned standardized, organized, functional manner to maintain continuity, when the original scrub person is replaced by another.

Each item used by the scrub person should have its own placement on the table to prevent the mass clutter that would occur if instruments and supplies are randomly placed.

Know the instruments and its functions, the physicians glove size, the preferred skin preparation solution, specific draping instructions and instruments.

Before an operative procedure, the scrub person assists the circulator in gathering the needed supplies, equipment and sutures.

He then dons gown and gloves and begin to set up sterile table with drapes, instruments, supplies and sutures.Mayo stand contains most frequently used instruments and is placed across the lower part of the patient’s legs after draping.

One or two back tables depending upon the instruments and supplies.The scrub person places the blade on the handle, prepares the suture and ligature.Instruments must be placed or slapped firmly on the surgeon’s palm in such a manner that it is ready for immediate use.Curved instrument should be pointing in the direction of intended use.

Physiologic Monitoring

1. Calculates effects on patient of excessive fluid loss or gain

2. Distinguishes normal from abnormal cardio – pulmonary data

3. Reports changes in patient’s vital signs.

  4. Institutes measures to promote normothermia

Psychological Support (Before Induction and when the patient is conscious)

1.     Provides emotional support to patient

2. Distinguishes normal from abnormal cardio – pulmonary data

3. Reports changes in patient’s vital signs.

4. Institutes measures to promote normothermia

Psychological Support (Before Induction and when the patient is conscious)

1. Provides emotional support to patient

2. Stands near or touches patient during procedures and induction

C. POST – OPERATIVE PHASE

Transfer of patient to post anesthesia care unit

1.   Assessment of the patient

2. Maintaining patent airway

3.  Maintaining cardiovascular Stability

Hypotension and shock (dec BP, pallor, widening pulse pressure, cold clammy skin)

• Hemorrhage

• HPN and dysrhythmias

4. Relieving pain and anxiety

5. Controlling nausea and vomiting

6. Communicates intra-operative information

• Identifies patient by name

• States type of surgery performed

• Identify type of anesthetic used

• Reports patient’s response to surgical procedure and anesthesia

• Describes intra-operative factors

Insertion of drainage

Catheters

Administration of blood

Analgesic

Occurrence of unexpected events

• Describes physical limitation

• Reports patient’s pre – operative levels of consciousness

• Communicates necessary equipment needed

• Communicates presence of family and or significant others

Determining Readiness to PACU

• Stable vital signs

• Orientation to person, place, event and time

• Uncompromised pulmonary function

• Pulse oximetry reading indicating adequate O2 saturation

• Nausea and vomiting absent or undercontrol

• Minimal pain

Post operative assessment (Recovery Area)

1. Determines patient’s immediate response to surgical intervention

2. Monitors patient’s physiologic status

3. Assess patient’s pain level and administer appropriate pain relief.

4. Maintains patient’s safety

5. Administers medication, fluid and blood component therapy if prescribe.

7. Assess patient’s readiness for transfer to in – hospital unit or for discharge home based on institutional policy.

Surgical Unit

1. Continuous close monitoring of patients physical and psychological response to surgical intervention.

6. Provides oral fluids if prescribe for ambulatory surgery patient

4. Assist patient in recovery and preparation for discharge home.

5. Determines patient’s psychological status

6. Assists with discharge planning

3. Provides teaching to patient during immediate recovery period

2. Assess patient’s pain level and administers appropriate pain relief measures.

2. Reinforces previous teaching and answers patient’s and family’s questions about surgery and follow – up care

3. Assess patient’s response to surgery and anesthesia and their effects on body image and function

4. Determines family’s perception of surgery and its outcome.

1. Provides follow – up care during office or clinic visit or by telephone contact

Home or Clinic

POST OPERATIVE DISCOMFORTS

1. Nausea and vomitingCauses: • Most often related to inhalation

anesthetics, which may irritate the stomach lining and stimulate the vomiting center of the brain

• Accumulation of fluid or food in the stomach

Nsg Mngt:

• Deep breathing – facilitiates elimination of anesthetics

• Side effect of narcotics

• Small sip of carbonated beverages

• Support the wound • Turn patient’s head to one side to

prevent aspiration

2. Constipation and Gas Cramps

Cause:

• Trauma and manipulation of the bowel during surgery as well as narcotic use will retard peristalsis

Nsg. Mngt:

• Early ambulation

• Laxatives, enema and stool softeners as ordered

3. Thirst

Causes:

• Side Effect of atrophine sulfate

• Fluid restriction

Nsg Mngt:

• Administer fluid by vein or mouth if permitted

• Allow patient to rinse mouth with mouthwash

• Hot tea with lemon, gum or hard candies

4. Pain

Cause: Stimulation to or trauma to nerve endings

Nsg Mngt: Comfort measures

POST OPERATIVE COMPLICATIONS

1. Respiratory Complications

Signs: Sudden rise in temp 24 – 48 hours after surgery

Likely to occur after high abdominal operations when prolonged inhalation anesthesia has been necessary and vomiting has occurred during the operation.

Eg. Atelectasis and Pneumonia

Interventions

a. Deep breathing and coughing except when contraindicated. (eye, brain and spinal surgery)

b. Comfort during coughing by splinting operative side with a draw sheet or supporting both sides of the incision by hand.

c. Increase pulmonary ventilation by using blow bottles, incentive spirometer

2. Fluid and Electrolyte Imbalance

Causes: blood loss, vomiting, copius round drainage or drainage from tubes such as NGT’s

3. Circulatory Complications (Thrombophlebitis, phlebothrombosis)

Causes: muscular inactivity, post – op circulatory and respiratory depression, increase pressure of blood vessels from tight dressings.

4. Gastrointestinal Complications

No patient should be urged to eat solid food 1 to 2 days following anesthesia or surgery

a. Paralytic Ileus

Cessation of peristalsis due to excessive handling of bowel during surgery

Interventions

No fluid or food until (+) peristalsis

b. Abdominal Distention

Accumulation of gas due to excessive handling of bowel during surgery

Swallowing of air during recovery from anesthesia

Interventions

a. Rectal tube is inserted just pass the rectum (2-4 inches) for approximately 20 minutes.

5. Urinary Complications

Urinary functions usually return 8 hours post op

If bladder is palpable over the pubic bone and suprapubic pressure cause discomfort then catheterization is ordered to prevent stretching of vesical wall.

5. Wound Complications

o Sutures are removed on about 5 – 7th day post op

a. Hemorrhage from the wound

• Most likely to occur within first 48 hours

• Assessment – bright red blood, decrease BP, increase RR and PR, cold and moist skin, pallor, weakness and restlessness

b. Infection

• Assessment – low grade fever 3 – 6 days post op, wound is painful and swollen, purulent discharge on the dressings

c. Dehiscence and Evisceration

Dehiscence – is a partial to complete separation of the wound edges

Evisceration – protrusion of the abdominal viscera through the incision onto the abdominal wall.

Assessment – sudden profuse leakage of fluid from the incision, dressings saturated with clear, pink drainage.

Intervention

a. Low fowler’s position, remain quiet, not to cough, not to drink or eat anything until the surgeon arrives

b. Protruding viscera should be covered with warm sterile saline dressing.