surgery presentation

ByMs. 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. Pre-operative care2. Intra-operative

judgment and management

3. 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

EGYPTOperations believed to have been

performed:1. Castration – removal of male’s

testicles2. Lithotomy – removal of stones

from bladder3. 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

4th CENTURY B.C. 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 Practice of surgery declined Its practice was left to BARBERS1. Cutting hair, removing tumors, pulling

teeth, stitching wounds and bloodletting

2. 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 CHAULIACA new order of surgeons

arose in France:1. Surgeon of the long robe2. 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 (1550 – 1613)

1. To take away2. To held and add3. To put in place which is out4. To separate5. To join what is separated

PETER LOWE (1550 – 1613)

CRITERIA OF A SURGEON:1. He be learned2. Expert3. Ingenious4. 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. Neurosurgery2. EENT3. Thoracic4. Abdominal5. Urology6. Orthopedic

DIVISION OF SURGERY

1. General surgery2. Pediatric surgery3. Oncologic surgery4. Plastic surgery

SUFFIXES

MEANING EXAMPLE

- ectomy 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

colostomy

- otomy Cutting into or incision of

tracheostomy

- plasty Repair or reconstruction of

mammoplasty

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. Persons who are sterile touch only sterile articles, person who are not sterile touch only non-sterile articles.

2. If in doubt about the sterility of anything, consider it not sterile.

3. Non-sterile persons avoid reaching over a sterile field. Sterile persons avoid leaning over a non-sterile area.

4. Tables are sterile only at the table level.

5. Gowns are considered sterile only from waist to shoulder level in front and the sleeves.

4. The edges of anything that encloses sterile contents is not considered sterile.

5. Sterile persons keep well within the sterile area.

8. Sterile persons keep contact with sterile area to a minimum.

9. Moisture may cause contamination.

REASONS FOR SURGICAL PROCEDURES

1. To undergo diagnostic procedures2. To preserve life3. To maintain dynamic bodily

equilibrium4. To prevent infection5. To obtain comfort and ensure the

ability of earning a living6. For correction of deformities and

defects

FOUR MAJOR TYPES OF PATHOLOGIC PROCESSES REQUIRING SURGICAL INTERVENTION:

1. Obstruction – impairment to the flow of vital fluids

2. Perforation – rupture of an organ3. Erosion – wearing off of a

surface or membrane4. Tumors – abnormal new growths

MAJOR CATEGORIES OF SURGICAL PROCEDURES:

1. According to purpose2. According to

extent/magnitude3. According to urgency

ACCORDING TO PURPOSE:

1. Diagnostic2. Curative3. Palliative4. Cosmetic5. Preventive6. Exploratory

Diagnostic Makes it possible to verify

a suspected diagnosis or to determine the cause of the symptoms

1. Biopsy2. Endoscopy

Biopsy- Excision of a small amount of tissue for pathologic examination

Types:1. Aspiration biopsy2. Bone marrow biopsy3. Excision biopsy4. Percutaneous biopsy (Punch

biopsy)5. Frozen section biopsy

Endoscopy- Visual examination of the interior of a body cavity, hollow organs or structure with an endoscope.

1. Bronchoscopy2. Esophagoscopy3. Mediastinoscopy4. Gastroscopy5. Cystoscopy6. Laryngoscopy

Curative Perform to remove or repair

damaged disease or congenitally malformed organ or tissue.

Curative1. Ablative – removal of the disease

organ2. Reconstructive – involves partial

or complete restoration of a damaged organ or tissue to it’s normal appearance/functioning

3. 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:

2. 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. EMERGENCY – requires immediate attention

2. URGENT or IMPERATIVE – requires prompt attention (24 to 30 hours)

3. REQUIRED/PLANNED – few weeks or months, necessary for the person’s well-being but is not urgent

4. ELECTIVE – performed for the person’s well-being but is not urgent

5. OPTIONAL – decisions rest with patient

1. Stress response is elicited.

2. Defense against infection is lowered.

3. Vascular system is disrupted.

4. Organ functions are disturbed.

5. Body image may be disturbed.

6. Lifestyles may change.

SURGICAL RISK Probability of morbidity

or death from surgery

A. Nature of condition Maybe benign or malignant1. Location – depends on the

location of the disease and the organ requiring surgery

2. 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. Age – infants and elderly have the

lowest tolerance to the stressful effects of surgery.

b. Nutritional status – a well-nourished pre-op client is better prepared for surgical stress and return to optimal health after surgery.

A. ObesityB. Malnutrition

C. 1. Physical Condition

c. Fluid and electrolyte problems – fluid volume deficit leads to possible intra and post-op complications.

d. Presence of diseases – increases the operative risk

Presence of diseases

a. Pulmonary – impairs ability to exchange oxygen and carbon dioxide.

b. Cardiovascular – a heart that pumps effectively and blood vessels that constrict well is necessary for prevention of shock and fluid and electrolyte imbalance.


c. Hematologic – blood coagulation problem causes severe hemorrhage

d. Genito-urinary – difficulty in eliminating wastes from the body and preserve fluid and electrolyte balance

e. Endocrine – affect clients response to surgery


f. Liver – unable to detoxify medications or metabolize carbohydrates, fats and amino acids.

g. Neurologic – for possible effect of anesthetic meds which is to depress CNS


h. Gastrointestinal – changes in GI status.

i. Integumentary – bleeding tendencies.

j. Disabilities – influences response to surgery including those that affect and limit activity.

C. 1. Physical Conditione. Use of medications

1. Tranquilizers – causes anxiety, tension and even seizures if withdrawn suddenly

2. Insulin3. Adrenal corticosteroids –

cardiovascular collapse might occur if discontinued suddenly

C. 1. Physical Condition

e. Use of medications4. Diuretics – thiazide may cause

excessive respiratory depression during anesthesia

5. Phenothiazines and antidepressants (MAO) – may increase hypotensive action of anesthetics

6. Antibiotics – when combined with muscle relaxant, nerve transmission is interrupted.

C. 2. Mental Condition FEAR1. Fear of the unknown2. Fear of anesthesia3. Fear of pain4. Fear of death5. Fear of disturbance of body image6. Worries

Manifestations of Fear1. Anxiousness2. Bewilderment3. Anger4. Tendency to exaggerate5. Sad, evasive, tearful,

clingy

Manifestations of Fear6. Inability to concentrate7. Short attention span8. Failure to carry out

simple instructions9. Dazed

Three types of defense mechanism:

1. Regression – behaves in a childlike manner.

2. Denial – appears unalarmed3. 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 PHASES1. Doctor’s clinic2. Upon admission and during the days

before surgery3. Night before surgery4. Morning before surgery

1. Nursing Assessmenta. Nursing Historyb. Health history – development

consideration, medical history, medications, occupation

c. Lifestyled. Coping pattern and support systeme. Preoperative physical assessment

1. Nursing Assessmentf. Pre-surgical screening tests –

CXR, ECG, CBC, Blood grouping and cross-matching, Electrolyte levels, U/A, FBS, BUN and Crea

2. Analysis1. Anxiety2. Fear3. Knowledge deficit4. Sleep pattern disturbance5. Anticipatory grieving6. Ineffective individual coping7. Ineffective airway clearance8. Risk for infection

3. Plan/Implementationa. Physiologic preparation

1. Introduce patient and SO to health care facility.

2. Data collection3. Interview the patient

B. Psychologic/Psychosocial preparation

1. Explore client’s feelings.2. Allow client to speak openly about

fears/concerns.3. Give accurate information regarding

the surgery.4. Give empathetic support.5. 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. Awaken an hour before pre-op medications.

2. Morning bath, mouth wash3. Provide clean gown4. Remove hairpins, braid long hairs,

cover hair with cap.


5. Remove dentures, foreign materials, colored nail polish, hearing aid, contact lens (wedding ring secured to waist).

6. Take baseline VS before pre-op meds.

7. Check ID band8. Skin prep


9. Check for special orders – enema, IV line

10. Check NPO11. Have client void before pre-op

meds.12. Continue to support emotionally.13. Accomplish “pre-op checklist.”

Preop meds GOALS:1. To facilitate administration of

any anesthetic.2. To minimize respiratory tract

secretions and change in HR.3. To relax the client and reduce

anxiety.

Preop meds Commonly used:1. Tranquilizers2. Sedatives3. Analgesics4. Anticholinergics5. 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. ASSESSMENTa. Identify surgical clientb. Assess the emotional

and physical status.c. Verify information in the

preoperative checklist.

2. ANALYSIS/POTENTIAL NURSING DIAGNOSIS

a. Impaired skin integrityb. Risk for fluid volume

deficitc. Risk for injuryd. Knowledge deficit

3. PLAN/IMPLEMENTATION

SURGICAL TEAMa. Surgeonb. Intra-operative nurses

(Circulating and Scrub nurse)

c. 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. Verifying consent2. Coordinating the team3. Ensuring cleanliness4. Proper temperature,

humidity and lighting5. Safe functioning of

equipment

Main responsibilities of the Circulating Nurse:

6. Availability of supplies and materials

7. 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 NURSE1. Scrubbing for surgery2. Setting up the sterile tables3. Preparing sutures, ligatures

and special equipment4. Assisting the surgeon during

the procedure by anticipating the required instruments, sponges, drains and other equipment

SCRUB NURSE5. Keeping track of time the

patient is under anesthesia and the time the wound is open

6. Counts all needles, sponges and instruments

7. 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. Site of operation2. Age and size of the patient3. Type of anesthetic used4. Pain normally experienced by

the patient upon movement5. Must not hinder respiration

and circulation

General considerations in positioning a client:

1. Explain purpose of position.2. Operative site must be

adequately exposed.3. Avoid undue exposure.4. Strap the person to prevent falls.5. Maintain adequate respiratory

and respiratory function.


6. Maintain good body alignment.7. Do not allow the persons

extremity dangle over the sides of the table and lead to nerve muscle damage caused by circulatory impairment.

8. Avoid excessive muscle strain.


9. Avoid person resting on hands which may impede circulation.

10. Precautions for patient’s safety must be observed, particularly with thin, elderly or obese patients.

11. The patient may need a gentle restraint before induction in case of excitement.

Surgical positions:1. DORSAL RECUMBENT – hernia

repair, mastectomy, bowl resection, abdominal surgeries except for gallbladder and pelvis

2. TRENDELENBURG – lower abdomen and pelvis to obtain good exposure by displacing the intestines into the upper abdomen (padded shoulder braces)

Surgical positions:3. LITHOTOMY – exposes perineal

and rectal areas4. PRONE – spinal surgeries,

alminectomy5. LATERAL – kidney, chest and hip6. JACKNIFE – hemorrhoidectomy7. LOMBOTOMY - kidney

ANESTHESIA Once anesthesia is

administered, this signifies the start of the intra-op phase.

Produces temporary or total loss of sensation

ANESTHESIA1. To produce muscle relaxation2. Analgesia3. Loss of memory4. Artificial sleep

(unconsciousness)5. Relieves fear and anxiety

Stages of Anesthesia:1. Beginning2. Excitement3. Surgical4. 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. SURGICALASSESSMENT: Unconscious Muscles are relaxedINTERVENTIONS: 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 heartbeatINTERVENTION: Establish an airway Provide emergency

equipment/material Assist in CPR

Types of anesthesia:1. GENERAL ANESTHESIA2. REGIONAL 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

GENERAL ANESTHESIAADVANTAGES: 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. Origin2. Along afferent neurons3. Along the spinal cord

Block pain stimulus at its ORIGIN

1. TOPICAL – directly applied into the area to be desensitized with the use of a solution

2. LOCAL INFILTRATION BLOCK – blocks only peripheral nerves around the area of incision

ALONG AFFERENT NEURONS

1. FIELD BLOCK – areas proximal to the incision site is injected and infiltrated a barrier (“WALL IN”)

2. 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. SPINAL – produces a nerve block in

the subarachnoid space2. EPIDURAL – injection of local

anesthetic into the spinal canal in the space surrounding the dura mater

3. CAUDAL (TRANS-SACRAL) – produces anesthesia of the perineum and occasionally, the lower abdomen

LOCAL ANESTHETIC AGENTS:

1. Lidocaine (Xylocaine) and Mepivacaine (Carbocaine)

2. Bupivacaine (Marcaine)3. Etidocaine (Duranest)4. Procaine (Novocaine)5. Tetracaine (Pontocaine)

REGIONAL ANESTHETIC AGENTS:

1. Procaine (Novocaine)2. Tetracaine (Pontocaine)3. Lidocaine (Xylocaine)4. Bupivacaine (Marcaine)

Complications/ Discomforts of Regional Anesthesia:

1. HYPOTENSIONPREVENTION: Infuse 500-800 mL of IV if not

prone to CHFINTERVENTION: Oxygen administration Vasoconstrictive drugs Trendelenburg position 10-20

mins after induction


2. NAUSEA AND VOMITINGINTERVENTION: Oxygen administration Give ephedrine, anti-

emetics IVF


3. HEADACHE – excessive loss of CSF due to:

a. Loss of large spinal fluidb. 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)


4. 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


5. 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:

1. VOLATILE LIQUIDS:a. Halothane (Fluothane)b. Methoxyflurane (Penthrane)c. Enflutane (Ethrane)d. Isoflurane (Forane)e. Sevoflurane (Ultrane)f. Desflurane (Suprane)

INHALATION ANESTHETIC AGENTS:

2. 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)


2. OPIOIDS (Narcotics)a. Morphineb. Meperidine HCl

(Demerol)


3. NEUROLEPANALGESICSa. Fentanyl (Sublimaze)b. Sufentanil

4. DISSOCIATIVE AGENTSa. Ketamine (Ketaralac;

Ketajact)


5. BARBITURATESa. Thiopental Na (Pentothal)b. Methohexital Na (Brevital)

6. NONBARBITURATES HYPNOTICS

a. Etomidate (Amidate)b. Propofol (Diprivan)

Major Complications of General Anesthesia:

1. CARDIAC ARREST2. RESPIRATORY DEPRESSION

a. Excessive mucusb. CNS depressionc. Bronchospasm/

laryngospasm

Major Complications of General Anesthesia:

3. HYPOTENSION AND SHOCK

4. LOSS OF PROTECTIVE RESPONSE TO PAIN

5. VOMITING AND ASPIRATIONS

Supplementary agents MUSCLE RELAXANTS –

administered through IV and given mainly to supplement GA agents

Supplementary agentsADVANTAGES: Early rapid induction (5

minutes) Reduction of pre-op

anxiety Ease of administration

Supplementary agentsDISADVANTAGES: 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. Undue exposure2. Rough handling3. 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. IMMEDIATE – admission to PACU

2. INTERMEDIATE – in patient’s room

3. EXTENDED – follow-up at doctor’s clinic (removal of sutures)

IMMEDIATEPACU (POST ANESTHESIA CARE

UNIT) 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)

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 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 patency2. 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. Time of admission2. Absence of reflexes3. LOC4. Skin color and dryness, VS5. Condition of dressing6. IV infusion, BT, drainage tubes,

bladder catheter

NURSING RESPONSIBILITIES:

1. MAINTENANCE OF PULMONARY VENTILATION – to prevent hypoxemia and hypercapnea

ASSESSMENT: Noisy and irregular respirations cyanotic

INTERVENTION: Leave plastic oral airway in the

mouth. Assess RR, Oxygen saturation

and breath sounds Check the order and apply

supplemental oxygen Prevent choking

Maintain patent airway (prevent aspiration) 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


2. PROTECTION AND PREVENTION OF INJURY

Provide side rails, place up Turn patient frequently and

placed in good alignment Never leave the patient alone


3. PROMOTION OF COMFORT Never leave the patient alone Administer narcotic analgesic to

relieve pains

ALDRETE POST ANESTHESIA RECOVERY SCORING SYSTEM

AREA OF ASSESSMENT:1. Muscle activity2. Respiration3. Circulation4. Consciousness level5. Oxygen saturation*Required for discharge from PACU = 7

to 8 points

Clients are discharged from PACU when (FAIRCHILD):

Conscious and coherent Able to maintain a clear airway

and deep breathe and cough freely

VS stable and/or consistent with pre-op VS for at least 30mins

Protective reflexes are active

Clients are discharged from PACU when (FAIRCHILD):

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 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

ASSESSMENTA – AIRWAY Maintain patent airway

Head turned to sideSuctioningAdminister oxygen

B – BREATHING DBECoughingAdminister oxygen

ASSESSMENTC – CIRCULATION VS q15 for 2h,

q30 for 2h, q hour for the first 24 hours or until stable

CRT not > 2-3sSkin colorMonitor BT

ASSESSMENTC – CONSCIOUSNESS LOC

Ability to commandD – DRESSING Keep it dry and intactD – DRAINAGE Tubings attached, keep

it patent and intactD – DRUGS Antibiotics

Pain reliever

ASSESSMENTE – ELIMINATION Monitor I & O

Monitor passing of flatus

F – FLUIDS IVF 30 gtts/minF – FOOD NPO until

peristalsis returns (clear liquid → full liquids → soft diet → full diet/DAT

ASSESSMENTS – 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

surgery presentation

Documents

practice of surgery

removal of tumors

plastic surgery

chauliac french surgeon

long american surgeon

amputation surgical

surgery branch of medicine

joseph lister british