Concept of Illness and Pain HEALTH state of complete physical, mental and social well being and not

t merely the absence of a disease or infirmity (WHO 1948) viewed as a dynamic, ever changing condition that enables people to function at an optimal potential at any given time ideal health status is one in which people are successful in achieving their full potential, regardless of any limitations they might have represents successful adaptation to stress ability to adapt to internal and external environment ILLNESS state of having a disease or sickness DISEASE abnormal variation, deviation from, or interruption in the normal structure or function of any part, organ, or system of the body causing disruption in function manifested by characteristic set of symptoms or signs and therefore limits freedom of action etiology, pathology and prognosis may be known or unknown etiology cause pathology process prognosis outcome disruption of the normal process ETIOLOGY cause of disease describes what sets the disease process in motion what triggers predisposing and precipitating factors precipitating triggering predisposing criteria that can make you, later on, develop the disease ETIOLOGIC AGENTS biologic bacteria, viruses physical trauma, burns, radiation chemical poison, alcohol nutritional excesses or deficits under/over nourishment PATHOGENESIS sequence of cellular and tissue events that take place from the time of initial contact with an etiologic agent till the ultimate expression of diseases time of contact until the time that signs and symptoms are evident describes how the disease process evolves PATHOLOGY came from the Greek word pathos meaning disease deals with the study of the structural and functional changes in cells, tissues, organs of the body that cause or are caused by the disease *you always go back to the cell because it is the smallest unit in the body PHYSIOLOGY deals with the normal functions of the body HOMEOSTASIS refers to the steady state within the body State of equilibrium in the bodys internal environment cells, tissues, organ and fluids When a change or stress occurs causing the body function to deviate from its stable range, processes are initiated to restore and maintain the dynamic balance If not adequate, homeostasis/steady state is threatened, functions become disordered and dysfunctional response occurs that can lead to a disease determined by how body adapts to change everything boils down to the immune system or how your body responds to stress 1

PATHOPHYSIOLOGY physiology of altered health study of how a disease goes on and what are the changes that go on in the body deals with the cellular and organ changes that occur with disease and the effects that these changes have on total body function, focusing on the mechanism of the underlying disease and provides background for preventive as well as therapeutic health care measures and practices STRESS defined as a state resulting from a change in the environment that is perceived as threatening to homeostasis stimulus is known as stressor EFFECTS OF STRESS 1. adaptive adaptation or adjustment to change or coping with change you are able to overcome and have a positive results lead to positive effective/effective health 2. maladaptive negative effect/ineffective adaptation disease and illness develops

MECHANISM OF CELLULAR REPAIR cellular adaptation cells adapt by undergoing changes in size, number and type adaptation desired outcome in managing actual or perceived stress to reestablish equilibrium regenerative healing damaged cells and tissues are replaced by new cells and tissues identical to the damaged cell and tissue replace healing replacement cells such as connective tissue, resulting in scar formations FACTORS AFFECTING CELLULAR REPAIR 1. age 2. nutritional status 3. presence of infection you have to correct one illness before you can go to another 4. chronic illness predisposes cellular injury e.g. secondary disease 5. nature of the wound incision under aseptic technique vs. traumatic wounds 6. extent of wound and associated blood loss 7. tissue involved tissues with good blood supply heal faster 8. psychosocial like stress and fatigue can impair healing PSYCHOLOGICAL PROCESS OF ILLNESS I. CELL INJURY AND INFLAMMATION injury disorder in or the loss of the steady state regulation any stressor that alters the ability of the cell or system to maintain optimal balance of its adjustment process leads to injury causing structural and functional changes which may either be reversible (permits recovery) or irreversible (leading to disability or death) agents causing injury acts at the cellular level by damaging or destroying the following: 1. integrity of the cell membrane necessary for ionic balance 2. the ability of the cell to transform energy e.g. stressor will make you lose your confidence. Therefore if you lose confidence, you would stay mumoy in one side. 3. the ability of the cell to synthesize enzymes and other necessary proteins 4. the ability of the cell to grow and reproduce (genetic integrity) can be related to ABT

CAUSES OF CELL INJURY 1. EXTERNAL a. Physical agents duration of exposure and intensity determines severity of damage i. Temperature extremes heat stroke, hypothermia ii. Radiation decrease protective inflammatory response lead to opportunistic infection iii. Electrical shock result to burns ; may over stimulate nerves e.g. VF 1. mechanical trauma disrupts cells and tissues of the body - outcome depends on severity of wound, amt. of blood loss, and extent of nerve damage b. chemical agents poison, drugs (overdose), alcohol c. infectious agents biological agents e.g. viruses, bacteria, fungi, etc. 2. INTERNAL a. Hypoxia inadequate cellular oxygenation respiratory system and efficiency of breathing of patient do deep breathing or remove secretions b. Nutritional imbalance deficiency or excess of 1 or more essential nutrient c. Immune mechanism d/o immune response e.g. autoimmune diseases, immunodeficiency d. Genetic defects congenital anomalies e.g. Downs, obesity CA, (hereditary disease) e. Psychogenic factors stress f. Chemical agents e.g. HCl, insulin WAYS ON HOW BODY RESPONSES TO INJURY I. CELLULAR RESPONSE TO INJURY AND INFLAMMATION A. CELL ADAPTATION ADAPTATION STIMULUS hypertrophy increase in cell size leading to - increased workload increase in organ size atrophy shrinkage/decrease in cell size decrease in: leading to decrease in organ size 1. use 2. blood supply 3. nutrition 4. hormonal stimulation 5. innervations of the nerve hyperplasia increase in the number of new hormonal influence cells (increased mitosis) - multiplication of cells caused the enlargement dysplasia changes in the appearance of cells - reproduction of cells with resulting alternation after chronic irritation of their size and shape metaplasia transformation of one adult cell - stress applied to highly specialized cells type to another cell type (this is reversible) B. BODY DEFENSES AGAINST INJURY INTACT SKIN AND MUCOUS MEMBRANE bodys first line of defense oral mucous membranes has many layers; difficult to penetrate skin has acidic (pH < 7) properties that renders some org unable to produce illness CILIA hair-like structures lining the upper respiratory tract mucous membrane protect lungs by trapping mucus, pus, dust, and foreign particles push trapped particles up the pharynx with wavelike movements 3

GASTRIC JUICES found in the stomachs highly acidic (pH of 1-5) acidic environment destroys most organisms that enter the stomach IMMUNOGLOBULINS proteins found in the serum and body fluids acts antibodies to destroy invading organisms and prevent development of infectious diseases ANTIBODY protein produced by B lymphocytes when foreign antigens of invading cells are detected ANTIGEN markers on cell surface that identify cells as being the bodys own (auto antigens) or as being foreign cells (foreign antigen) antibodies combine with specific foreign antigens on the surface of the invading organisms, such as bacteria or viruses, to control or destroy them antibodies can destroy or neutralize antigens through o initiating destruction of antigen o neutralize toxins released by bacteria o promote antigen clumping with the antibody o prevent the antigen from adhering to host cell LYZOSYMES bactericidal enzymes present in WBC and most body fluids (tears, saliva, and sweat) dissolve the walls of bacteria INTERFERON proteins made and released by lymphocytes in response to presence of pathogens: virus, bacteria, parasites, or tumor cells aids in the destruction of infected cells and inhibits production of the virus within the infected cells C. MONOCULAR PHAGOCYTE SYSTEM PHAGOCYTOSIS engulfing and ingestion of bacteria and other foreign bodies by phagocytes PHAGOCYTES cells that ingest and destroy bacteria, damaged or dead cells, cellular debris, and foreign substances DIFFERENT PHAGOCYTES: LEUKOCYTES (WBC) primary cells, protect against infection and tissue damage 5 types: o neutrophils bacteria and small particles o monocytes become macrophages ; tissue debris and large particles o lymphocytes functions: antigen recognition and antibody production o basophils respond to inflammation from injury o eosinophils destroys parasites and response in allergic reactions - increased during allergic reactions or infestation MACROPHAGES mature monocytes INFLAMMATORY RESPONSE occurs as a result to injury, pathogens, trauma, or any other event that can cause injury to tissue infection may or may not be present STEPS IN THE INFLAMMATORY PROCESS I. VASCULAR RESPONSE local vasodilation increased blood flow in the injured area brings more plasma to nourish tissue and carry waste and debris away redness (redness) and heat (calor) manifested 4

II. INFLAMMAOTRY EXUDATE increased permeability of blood vessels plasma moves out from capillaries to the tissue swelling (tumor) and pain (dolor) manifested due to compression of nerve endings assess if it is: INFILTRATION PHLEBITIS pale red cold heat pain pain soft swelling hard swelling III. PHAGOCYTOSIS AND PURULENT EXUDATE final step destruction of pathogenic organisms and their toxins by leukocytes pus containing protein, cellular debris, and dead leukocytes

CARDINAL SIGNS OF INFLAMMATION redness (rubor) - produced by the following chemical mediators: heat (calor) histamine, prostaglandins, leukotrienes, swelling (tumor) bradykinins, platelet activating factors pain (dolor) prostaglandins and bradykinins loss of function (functio laesa) ALTERED IMMUNE RESPONSE IMMUNE SYSTEM bodys final line of defense against infection and/or cellular injury finely tuned network that functions together to protect the body form potentially harmful substances by recognizing and responding to antigens COMPONENTS OF THE IMMUNE SYSTEM 1. IMMUNE CELLS a. Lymphocytes (T cells, B cells, and natural killer cells) have protective functions related to specific antigen b. Macrophages assist T and B lymphocytes 2. LYMPHOID ORGANS a. Thymus vital to the development of the immune system b. Bone marrow produces leukocytes, which is one of the products of blood - problems in bone marrow can, later on, cause leukemia c. Spleen d. Tonsils e. Intestinal lymphoid tissue f. Lymph Nodes

IMMUNITY resistance to a disease that is provided by the immune system ability of the body to protect itself from disease IMMUNE RESPONSE involves a complex series of interactions between the components of the immune system and the antigens of foreign pathogen TYPES OF IMMUNITY 1. INNATE IMMUNITY immunity you are born with involving barriers that keep harmful materials form entering the body forms the first line of defense in the immune response e.g. cough reflex, enzymes in the tears, mucus, skin stomach acid

PASSIVE IMMUNITY antibodies produced in the body other than your own (person or animal) transferred from another source (utero transfer from mom to child) temporary in infants and disappears after 6-12 months 3. ACTIVE IMMUNITY (Acquired) develop with exposure to various antigens; defense against a specific antigen acquired through immunization or actually having a disease 4. HUMORAL consists of protection provided by the B-lymphocyte-deviated plasma cells, which produce antibodies that travel in the blood and interact with circulating and cell surface antigen 5. CELL-MEDIATED protects against viruses, intracellular bacteria, and cancer cells usually occurs through cytotoxic activity of cytotoxic T cells and the enhanced engulfment and killing by macrophages

2.

CYTOKINES regulatory proteins produced during all the phases of an immune response they regulate response of host to foreign antigens or injurious agents by regulating movement, proliferation and differentiation of leukocytes and other cells

ALTERED IMMUNE RESPONSE refers to inadequate, inappropriate, or excessive immune response to cellular injury or infection resulting to immune system disorders that is serious and life threatening CLASSIFICATION OF DISORDERS due to ALTERED IMMUNE RESPONSE 1. IMMUNODEFICIENCY DISEASE immune response insufficient to protect host failure of the immune or inflammatory response to function normally, resulting in increased susceptibility to infection clinical hallmark: o tendency to develop unusual or recurrent, severe infection preschools and school-age: 6 to 12 infections/year adult: 2 to 4 infections/year o recurrent infection w/ short periods of good health with multiple simultaneous infection 2. HYPERSENSITIVITY REACTIONS excessive or inappropriate activation of the immune system altered immunologic response to an antigen that results in disease types: o ALLERGIC cause: environmental antigens (medicines, natural products e.g. pollens and bee stings, infectious agents, and any other antigen not naturally foudn in the individual) Anaphylaxis most common allergic reaction - occurs within minutes after exposure o AUTOIMMUNITY a.k.a. autoimmune disease disturbance in the immunologic tolerance of self-antigens occur when the immune system reacts against self antigens to such a degree that auto-antibodies or autoreactive T cells damage individuals o ALLOIMUNITY occurs when the immune system of one individual produces an immunologic reaction against tissues of another e.g. transfusion reactions, transplanted tissue (rejection) or the fetus during pregnancy (Rh), grafting reactions CONCEPT OF PAIN Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does. By Margo McCaffery, a well-known pain consultant An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. -1979, International Association for the Study of Pain (IASP) PAIN fifth vital sign most important protective mechanism strong motivator for action one of the bodys most important adaptive mechanisms protective mechanism or a warning o congenital analgesia rare genetic disorder where the individual is unable to feel pain

PAIN EXPERIENCE IS PRODUCED BY THE INTERACTION OF THREE SYSTEMS: 1. SENSORY/DISCRIMINATIVE process information about the strength, intensity, temporal and spatial aspects of pain results in prompt withdrawal from the painful stimulus 2. MOTIVATIONAL/AFFECTIVE determines individual conditioned or learned approached or avoidance behavior 3. COGNITIVE/EVALUATIVE overlies individual learned behavior - individuals interpretation of appropriate pain behavior is learned through cultural preferences, male-female roles and life experience NOCICEPTION sensory process leading to perception of pain NOCICEPTORS free nerve endings that responds to chemical, mechanical dn thermal stimuli

TYPES OF PAIN: I. PHASIC A. Acute Pain has identifiable cause and occurs soon after and injury temporary and subsides as healing takes place as chemical mediators causing pain are removed onset: sudden and slow intensity: varies from mild to severe severe acute pain activates sympathetic nervous system causing diaphoresis, increased RR, PR and BP usually lasts until 6 months classifications: o SOMATIC superficial (comes form the skin or close to the surface of the body) o VISCERAL pain in the internal organs, abdomen or skeleton; radiates or referred o REFERRED pain present in an area removed or distant form point of origin supplied by the same spinal segment as actual site since skin has more receptors, pain is felt B. CHRONIC PAIN persistent, lasts beyond expected healing phase non-protective; related to tissue damage, inflammation or injury of the NS lasts for more than 6 months NEUROPHYSIOLOGICAL TRANSMISSION OF PAIN Pain is the result of transduction, transmission, perception and modulation of painful (nociceptive) impulses. STAGES IN THE TRANSMISSION OF PAIN STAGE 1 TRANSDUCTION refers to the conversion of mechanical, chemical or thermal information into electrical activity in the NS STAGE 2 TRANSMISSION - transfer electrical impulses to the CNS CNS process nociceptive signals to extract relevant information the processing and extraction of relevant features of sensory input

STAGE 3 PERCEPTION awareness of pain that is dynamic, changing in response to persons development, environment, disease or injury can be brief, prolonged, or even permanent STAGE 4 MODULATION also called adjustment refers to internal and external ways of reducing/increasing the pain STIMULI (chemical, mechanical, thermal) Receptor molecules at the tip of nociceptive primary afferent neurons (free nerve endings) Creation of action potential Electrical energy (action potential) travels (progresses form the injury site) to the spinal cord Spinal cords dorsal horn (central gray matter) Transfer of impulses form the nociceptor to the spinothalamic tract (transduction) Thalamus acts as relay station sending pain impulses to different areas in the brain for processing Electrical energy (stimuli) reach the cerebral cortex Interpretation of stimuli (transmission) Perception of pain Somatosensory cortex identifies location and intensity Associated cortex determines how an individual interprets the meaning Released of neuromodulators (endorphins, serotonin, norepinephrine, GaBa) This chemicals hinder the transmission of pain producing an analgesic, pain-relieving effect Inhibition of pain impulse (modulation)

PAIN THRESHOLD intensity of the stimulus a person needs to sense/feel pain PAIN TOLERANCE the duration and intensity of pain that a person tolerates before openly expressing PAIN THEORIES: SPECIFICITY THEORY intensity of pain is directly related to the amount of associated injury DesCartes, 17th century finger prick against cutting off on one hand more tissue injury, more painful useful in specific injuries or acute pain, but not with chronic or cognitive and psychologic contributions to pain

1.

2.

NEUROMATRIX THEORY Ronald Melzack proposes that a large number of interconnected neurons, a neuromatrix, exists in every person neuromatrix analyzes the sensory information and gives perception of sensation tells the brain that the perseptions of sensation are from the self neurosignature tells the brain that your arm is your arm, not someone elses GATE CONTROL THEORY first proposed in 1965 by psychologist Ronald Melzack and anatomist Patrick Wall gating system in the CNS that opens and closes to let pain messages through to the brain or to block them according to the gate control theory of pain, our thoughts, beliefs, and emotions may affect how much pain we feel from a given physical sensation delayed pain perception of athletes *research: Hans Selye

3.

NURSING CARE OF CLIENT EXPERIENCING PAIN I. ASSESSMENT thorough and accurate highly subjective and needs to be evaluated always remember the principle of pain assessment: Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does. By Margo McCaffery JCAHO -

a private sector US-based not-for-profit organization that sets standards for accreditation of health institutions. helps to improve the quality of patient care by assisting international health care organizations, public health agencies, health ministries and others evaluate, improve and demonstrate the quality of patient care and enhance patient safety and to demonstrate quality.

HIGHLIGHTS OF JCAHO PAIN STANDARDS assess all patients routinely for pain record assessment data in a way that facilitates reassessement and follow-up educate patients and families on the importance of pain management as part of care do not permit pain to interfere with optimal level of function or rehabilitation include pain and symptom management in discharge planning ASSESS: Ia. History Ia1. Pain characteristics onset and duration location intensity NOTE: use the alphabet of pain PQRST P Provocative or Palliative Q Quality R Region and Radiation

quality relieveing factors aggravating factors

S Severity T Timing

Ia2. Drug History complete list of medications with allergies Ia3. Social History how patient feel about himself support system 10

PAIN RATING SCALES The most commonly used Pain assessment scale is the Numeric Pain Rating scale. You ask the patient to rate their pain on a scale from 0 to 10 with 0 being no pain and 10 being the worst pain they have ever had. Be sure and let patients rate their own pain, do not be influenced by family members rating the pain. The Visual Analogue Scale may be easier for some patients to use. Show them the scale and ask them to rate their pain. The Face Scale may be used for some adults who are unable to use the number scales. Ask the patient to pick a face that matches how they feel and record that # as their pain level. Brief Pain Inventory(BPI) pts pain in last 24, least & worst Cries Neonatal Postoperative Pain Measurement Scale NEONATAL INFANT PAIN SCALE NPS 0 point 1 point Facial expression Relaxed Contracted Cry Absent Mumbling Breathing Relaxed Different than basal Arms Relaxed Flexed/stretched legs Relaxed Flexed/stretched Alertness Sleeping/clam Uncomfortable *Maximal score of seven points, considering pain 4. FLACC Pain Assessment Tool DATE/TIME Face 0 No particular expression or smile 1 Occasional grimace or frown, withdrawn, disinterested 2 Frequent to constant quivering chin, clenched jaw Legs 0 Normal position or relaxed 1 Uneasy, restless, tense 2 Kicking, or legs drawn up Activity 0 Lying quietly, normal position, moves easily 1 Squirming, shifting back and forth, tense 2 Arched, rigid or jerking Cry 0 No cry (awake or asleep) 1 Moans or whimpers; occasional complaint 2 Crying steadily, screams or sobs, frequent complaints Consolability 0 Content, relaxed 1 Reassured by occasional touching, hugging or being talked to, distractible 2 Difficult to console or comfort TOTAL SCORE Faces Pain Rating Scale - language difficulties such as aged, pedia Oucher Pain Rating Scale Numerical or Visual Analog Scale

2 points Vigorous -

11


Not hurting No discomfort No pain Adolescent, Pain, tool.. :-D Logs and Diaries Pain Self-monitoring record POTENTIAL NURSING DIAGNOSIS: physical mobility disturbances nutrition less than body requirement, risk for social interaction, impaired II. 1. 2. 3. 4. 5. PLAN/IMPLEMENTATION Establish therapeutic relationship teach patient about pain relief reduce anxiety and fears provide comfort measures manage pain

Hurting a whole lot Very uncomfortable Severe pain

TYPES OF PAIN MANAGEMENT I. Nonpharmacologic Management concern on overuse of drugs 3 MAIN CATEGORIES OF NONPHARMACOLOGIC THERAPY Physical Therapy - use physical agents & methods ease pain, reduce inflammation, ease muscle spasm, & promote relaxation. a. Hydrotherapy b. Thermotherapy c. Cryotherapy d. Vibration e. TENS f. exercise g. immobilization Alternative Therapy - used instead of conventional or mainstream therapy - eg. Acupuncture analgesics Complementary - used in conjunction w/ conventional therapy - e.g. Meditation as adjunct to analgesic medication o Aromatherapy o Music Therapy o Therapeutic Touch and Massage o Yoga and Meditation o Chiropractic Treatment o Acupuncture o Biofeedback o Hypnosis o Guided Imagery 12

o o o o o II. A.

Magnet Therapy Thought Stopping Crystal or Gemstone Therapy Herbal Therapy Heat and Cold Application

B.

PHARMACOLOGIC ANALGESIS a. Nonopioid (nonnarcotic) used to treat pain thats either nociceptive (injury receptors) or neuropathic (nerves) effective in somatic pain like joints and muscle pain controls pain, decreased inflammation and fever e.g. acetaminophen, NSAIDs, salicylates b. opioids (narcotics) w/ primary effects in the CNS i. opioid agoinist treat moderate pain w/o loss of consciousness e.g. Codeine, Fentanyl ii. mixed agonist antagonist decrease risk of toxic effect and dependency e.g. nalbuphine iii. opioid antagonist blocks opioid effect METHODS OF ADMINISTRATION a. Topical b. Oral c. IM d. IV e. PCA - Patient Controlled Analgesia f. Conscious Sedation g. Intranasal h. Epidural

PCA is a means for the patient to self-administer analgesics (pain medications) intravenously by using a computerized pump, which introduces specific doses into an intravenous line. C. 1. 2. 3. 4. SURGICAL INTERVENTIONS RHIZOTOMY selective destruction of the dorsal root of the spinal nerve NERVE BLOCK OR CORDOTOMY unilateral or bilateral severe nerve fibers in the spinal cord NEURECTOMY resection of one or more peripheral branches of the cranial or spinal SYMPATHECTOMY destroys nerves in the SNS performed to increase blood flow and decrease long-term pain in certain diseased that cause narrowed blood vessels can also be used to decrease excessive sweating this surgical procedure cuts or destroys the sympathetic ganglia, which are collections of nerve cell bodies in clusters along the thoracic or lumbar spinal cord

PERIOPERATIVE NURSING the scrub nurse is always in front of the surgeon

PERIOPERATIVE NURSING CARE a. connotes the delivery of patient care in the: i. preoperative ii. intra-operative iii. postoperative 13

b.

periods of the patients surgical experience through the framework of the nursing process nurse assess the client by: i. collecting, organizing and prioritizing patient data ii. establishing nursing diagnosis iii. identifies desired patient outcomes iv. develop and implements a plan of care v. evaluates the care given in terms of outcomes achieved by the patient

PERIOPERATIVE NURSING CARE PHASES PREOPERATIVE PHASE INTRAOPERATIVE PHASE POSTOPERATIVE types: o immediate post-operative/peri-anesthesia phase/PACU nursing/Recovery Room nursing o post-operative phase px. is already in the room/ward until the patient goes home w/o complications SURGERY comes from the Greek word kheirurgus = working by hand TYPES OF PATHOLOGIC PROCESSES REQUIRING SURGICAL INTERVENTION 1. OBSTRUCTION impaired flow 2. PERFORATION rupture (of a tissue) 3. EROSION wearing off of a membrane 4. TUMORS abnormal growths (w/c can cause your obstruction) CATEGORIES OF SURGERY 1. DEGREE OF RISK a. MAJOR high risk, extensive, prolonged, increased blood loss b. MINOR less risk, less complicated, not prolonged 2. EXTENT localized or involves the whole system? a. MINIMALLY INVASIVE usually performed with the use of fiberoptic endoscopes and does not require traditional or extensive incisions - involves the use of smaller incisions, customized instrumentation, specialized imaging, computerized global navigation system and robotics b. OPEN involves traditional opening of body cavity or body part to perform the surgery c. SIMPLE generally limieted to a defined anatomic location and do not require extensive exposure and dissection of adjacent tissue d. RADICAL usu. Associated w/ malignancies - involves dissection fo tissue and structures beyond the immediate operative site 3. PURPOSE Classification: a. DIAGNOSTIC determine cause of symptoms or origin of problem b. CURATIVE to resolve a health problem or disease state by removing the involved tissue c. RESTORATIVE/RECONSTRUCTIVE performed to correct deformity, repair injury or improve functional status d. PALLIATIVE relieve symptoms w/o the intent to cure e. ABLATIVE removal of diseased organ f. COSMETIC performed primarily to alter or enhance personal appearance

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5.

ANATOMIC SITE which part of the body? a. CARDIVASCULAR surgery b. CHEST surgery c. INTESTINAL surgery d. NEUROLOGIC srugery TIMING OR PHYSICAL SETTING when and where? Classification for timing: a. ELECTIVE performed on the basis of clients choice; not essential and may not be necessary for health b. URGENT necessary for clients health may prevent additional problem from developing (e.g. tissue destruction); not necessarily emergency c. EMERGENT must be done immediately to save life or preserve function of body part d. REQUIRED has to be performed at some point can be pre-scheduled Physical Settings: a. SURGICAL SUITES b. AMBULATORY CARE SETTING c. CLINICS d. PHYSICIANS OFFICES e. COMMUNITY SETTING f. HOMES

DISADVANTAGES OF OUTPATIENT a. less time for rapport b. less time to assess, evaluate, teach risk of potential complications ADVANTAGES OF OUTPATIENT a. low cost b. low risk of infection c. less interruption of routine d. less stress 6. PROCUREMENT FOR TRANSPLANTATION removal of organs and/or tissues from a person pronounced brain dead for transplantation into another person

SUFFIXES DESCRIBING SURGICAL PROCEDURES -ectomy excision or removal of an organ or gland -orrhaphy repair or suture of -lysis destruction of -oscopy looking into - ostomy creation of opening into -plasty repair or reconstruction of PREOPERATIVE PHASE begins when the decision for surgical intervention is made and ends with the transfer of the patient to the operating table SCOPE OF NURSING ACTIVITIES 1. Establishing the baseline assessment of the patient in the clinical setting or at home 2. Ensuring the necessary laboratory test needed 3. Carrying out of preoperative interview 4. Preparing the patient for the anesthetic he is to receive and the surgery he is to undergo 15

5. 6. 7.

Focus on assessing the post-operative status of the patient in terms of the effects of the anesthetic agent. Impact of surgery on body image or role function. Evaluate the familys perception of surgery.

PREOPERATION CAN TAKE PLACE IN ANY OF THESE TIME AND PLACE: 1. In the physicians office before admission to the health care facility. 2. On admission and during the days before the operation. 3. The night before the surgery if the client is in the hospital. 4. The morning of surgery on admission. GENERAL PREOPERATIVE PREPARATION Physiologic Nursing Assessment of client undergoing surgery 1. AGE older adults have the lowest tolerance to stressful effects of surgery old age produces physiologic changes that increase surgical risk

Interventions for Physical Changes in Older Adults Undergoing Surgery PHYSICAL CHANGE NURSING INTERVENTION CARDIOVASCULAR Know what anesthesia is used decreased cardiac output Monitor V/S carefully moderate increased in BP Encourage early ambulation & leg exercises decreased peripheral circulation Assess for hypotension or hypertension or arrythmias hyperthermia Note any changes to baseline ECG RESPIRATORY Decreased vital capacity Assess pulmonary aspiration Reduced Monitor respirations carefully oxygenation of blood Vigorous pulmonary hygiene Decreased cough reflex Post-operative: auscultate lung sounds Oxygen saturation monitor RENAL Decreased renal blood flow and Monitor urine output 1 to 2 hours during lomerular filtration rate Immediate post-surgery Decreased ability to excrete waste Evaluate intake and output product Monitor fluid and electrolyte status MUSCULOSKELETAL decreased in lean body mass assess level of mobility increase in spinal compression position on OR table with padding to reduce trauma to bones and joints increased incidence of osteoporosis and arthritis spine, limbs and pressure points must be padded to prevent fractures early ambulation or exercises to individuals ability provided adequate nutrition provide effective pain management SENSORIMOTOR decreased reaction time orient client to environment decreased visual acuity plan individual teaching, allow time to reinforce teaching decreased auditory acuity provide safe environment

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2. 3. 4.

5. 6.

PRESENCE OF PAIN NUTRITIONAL STATUS client who is well nourished is better prepared to handle surgical stress FLUID AND ELECTROLYTE BALANCE dehydration and hypovolemia (fluid volume deficit) predispose a client to complications during and after surgery electrolyte imbalance also increased operative risk PRESENCE OF INFECTION CARDIOVASCULAR FUNCTION client should be assessed for elevated BP; slow, rapid or irregular pulse; edema; cold cyanotic extremities; weakness; and shortness of breath

LABORATORY AND DIAGNOSTIC STUDIES OFTEN ORDERED PRIOR TO SURGERY TO DETERMINE CARDIOVASCULAR FUNCTION: a. ECG b. CBC i. Hemoglobin ii. Hemcatocrit iii. WBC if you are immunosuppressed, you have to strengthen the immune system - so that the doctor will be able to foresee the crisis that may come and the interventions to be done prior to complication iv. Platelet c. SERUM ELECTROLYTES Na, K, Cl maintenance of circulating volume, movement of plasma in the cells d. Urinalysis kidney function e. BUN Blood Urea Nitrogen - high concentration indicates theres something wrong with the kidney or renal system f. Creatinine g. Protime cardiopulmonary clearance h. Partial Thromboplastin Time cardiopulmonary clearance i. Clotting Time/Bleeding Time cardiopulmonary clearance j. X-Ray OTHER DIAGNOSTIC TESTS (if needed): 1. Pulmonary Function Test check for capacity of lungs to have oxygen in it check for amt. of volume the lungs can carry COPD, emphysema, asthma and bronchitis increase operative risk because they impair CO2 and O2 diffusion in the alveolus and predispose the client to pulmonary infection Assess client for shortness of breath, wheezing clubbed fingers, chest pain and coughing with expectoration of copious mucous 2. Renal Function Assess for symptoms of frequency, dysuria, anuria (absence of urination) and observe for the appearance of urine Includes: Urinalysis, BUN and Creatinine are commonly ordered preoperative tests 3. Gastrointestinal Function 4. Liver Function check if liver is still functioning well liver is one of those organs that is highly vascular 5. Endocrine Function release of hormones hypothyroidism check that they should not be in crisis so that you wont have cardiac arrest 6. Neurologic Function 7. Hematologic Function clients with coagulation diseases are at risk for hemorrhage and hypovolemic shock during and surgery 17

5 FACTORS POINTING TO ABNORMAL HEMATOLOGIC FACTORS: History of bleeding tendencies Symptoms such as easy bruising, excessive bleeding following dental extraction and severe nosebleed Presence of hepatic and renal disease Use of anticoagulants Abnormal bleeding time, prothrombin time or platelet count 8. Use of medication herbs Cardiac conditions that increase operative risk include: angina pectoris, MI within the last 6 month, uncontrolled hypertension, CHF and peripheral vascular disease Clients take prescribed and non-prescribed medication that may increase operative risk by increasing coagulation

SOME MEDICATIONS THAT MAY RESULT IN COMPLICAITONS INCLUDE:

ANTICOAGULANTS Heparin sodium Warfarin sodium Aspirin NSAIDS ANTIBIOTICS w/c is combined with other muscle relaxants TRANQUILIZERS THIAZIDE DIURETICS STEROIDS

cause clotting abnormalities which results to hemorrhage

increase postoperative respiratory depression decrease blood pressure thus increase the risk of shock potentiates the effects of narcotics and barbiturates can create potassium depletion cause hypofunction of the adrenal cortex thus impair physiologic response to stress of anesthesia and surgery anti-inflammatory effect delay wound healing and increase risk of infection can cause hypertensive crisis when combined with anesthetic agents cause hypotension or hypertension when combined with anesthetic agents increase tolerance to narcotics require dosage alteration and close monitoring of blood sugar inhibits platelet aggregation may potentiate warfarin increase INR and PT cause GI upset decrease blood glucose level anticoagulant action large doses increase risk of bleeding and dysrhythmias tachycardia and hypertension, esp. w/ the use of cardiac stimulants inhibit platelet aggregation decrease warfarin effectiveness lowers blood glucose potentiate effects of digoxin assess ginseng abuse syndrome: hypotension, hypotonia and edema prolongs bleeding time increase anticoagulant effect subconjunctival hemorrhage and spontaneous subdural hemorrhage

MONOAMINE (MOA) INHIBITORS ANTIPARKINSON DRUGS STREET DRUGS AND ALCOHOL ABUSE HYPOGLYCEMICS HERBS GARLIC

GINGER GINSENG

GINGKO BILOBA

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ALLERGIC REACTIONS INJECTION bee sting medication INGESTION medication nuts and shellfish INHALATION pollen dust mold and mildew animal dander

SKIN CONTACT poision plants animal dander pollen latex

10. Presence of Trauma when surgery must be performed following traumatic incident, details of the event should be documented 11. Health Habits how much exercise do you do? Do you smoke? Do you make us of drugs? 12. Social Habits PSYCHOSOCIAL ASPECT OF PREOPERATIVE PREPARATION effectively handling clients fears can smooth the preoperative experience studies show that clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications PSYCHOLOGIC RESPONSE 1. ANXIETY POTENTIAL SOURCE OF ANXIETY a. anticipation of impending surgery b. pain and discomfort c. changes in body image or function d. role changes e. loss of control f. family concerns g. potential alterations in lifestyles 2. FEAR clients respond differently to fear some respond by becoming silent and withdrawn, childish, belligerent, evasive, tearful and clinging COMMON FEARS RELATED TO SURGERY fear of the unknown i. first decision to seek medical advise ii. subject to several laboratory tests iii. first experience-operation loss of control loss of love from significant others threat to sexuality SPECIFIC FEARS diagnosis of malignancy anesthesia dying pain disfigurement permanent limitations

a.

b. c. d.

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

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ASSESSMENT OF PREOPERATIVE ANXIETY SUBJECTIVE DATA 1. understanding of proposed surgery a. site b. type of surgery c. information from surgeon regarding extent of hospitalization, postoperative limitations d. preoperative routines what will happen postoperatively? - let px. know that after surgery, px. will be staying in RR e. postoperative routines f. tests 2. previous surgical experience a. type, nature b. time interval 3. any specific concerns or feelings about present surgery 4. religion, meaning for patient 5. significant others a. geographic distance b. perception as source of support 6. changes in sleep pattern OBJECTIVE DATA 1. speech patterns a. repetition of themes b. change topic c. avoidance of topics related to feelings 2. degree of interaction with others 3. physical a. pulse and respiratory rates b. hand movement and perspiration c. activity level d. voiding frequency PREOPERATIVE TEACHINGS TO DECREASE ANXIETY 1. Preoperative test a. Reasons b. Explanations of the test 2. Preoperative routines 3. Schedules a. Time of surgery b. Probable length c. Time in the recovery room 4. Recovery a. Place where px. will awaken b. Close nsg. Supervision c. Frequent monitoring of VS d. Return to room when VS are stable 5. Family Directions a. Time px. will leave for surgery b. Where the family may wait during surgery c. Procedure for notification of results of surgery (by the Physician) d. Procedure for notification of px. return to unit

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PROBABLE POST-OPERATIVE THERAPIES 1. Anticipate treatment (VI, NGT) 2. Need for increased mobility as soon as possible 3. Need fro breathing and coughing routines, even though these are uncomfortable 4. Pain medication routines (timing, sequence-PRN status) PREOPERATIVE PSYCHOLOGIC SUPPORT 1. Asses clients fears, anxieties, support systems and patterns of coping 2. Establish trusting relationship with client and significant others 3. Explain routine procedures, encourage verbalization of fears, and allow client to ask questions 4. Demonstrate confidence in surgeon and staff 5. Provide for spiritual care if appropriate PREOPERATIVE ASSESSMENT HISTORY TAKING - plays a large part in determining the degree of preoperative and postoperative anxiety the client experiences allows the nurse to: o Establish rapport with client o Begin psychosocial assessment o Reassure client and significant others and answer general questions about surgery, the health-care facility etc. Specific information to obtain during reoperative history concerns: o Previous surgery and experience with anesthesia o Responses of significant others to previous surgery and anesthesia o Whether the client had any serious illness o Previous and current medication (prescribed/over-the-counter) o Allergies and reactions and dietary restrictions o Alcohol, nicotine or recreational drug use o Current symptoms and discomforts o Occupation o Religious affiliation o Significant others o Whether client has question about the surgery o Chronic illnesses such as arthritis, migraines, backpains PHYSICAL EXAMINATION PREOPERATIVE DIAGNOSTIC TESTS 1. Serum potassium 2. Hemoglobin 3. Serum sodium 4. Hematocrit 5. Serum chloride 6. Prothrombin time 7. Glucose 8. Partial thrombo-plastin time 9. Blood Urea 10. Nitrogen 11. Chest X-ray 12. Electrocardiogram 13. Creatinine

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PREOPERATIVE TEACHING Basic areas that must be covered: 1. deep breathing and coughing exercise 2. turning and extremity exercises 3. pain control methods that will be offered splinting, DBE, medications 4. postoperative equipment teach coughing and breathing exercise, splinting of incision, turning side to side on bed and leg exercises: explain the importance in preventing complications; provide for opportunity for return demonstration

COUGHING EXERCISE may be done sitting or lying down splinting the incision minimizes pressure and helps control pain when coughing client is instructed to interlace fingers across the incision to and hold them when coughing a small pillow or folded towel may be held over the incision to facilitate splinting LEG AND ANKLE EXERCISES prevent deep vein thrombosis and embolism POSTOPERATIVE EQUIPMENT a. wound drain and suction devices b. penrose drain used for post AP, ruptures where there are discharges acts as a route for all discharges to pass through so that it will be absorbed by the gauze tied to the skin c. Jackson-Pratt drain or reservoir d. T-tube drain e. Hemovac drainage system PHYSICAL PREPARATION 1. Preparing the Skin 2. Preparing the GIT some surgery require special bowel preparation (enema) 3. Preparing for anesthesia 4. Promoting rest and sleep

PREPARING THE CLIENT ON THE DAY OF THE SURGERY 1. Early morning care a. Begins at least 1-2 hours before surgery i. Take vital signs and record ii. Check identification band Consent form is signed and the surgical procedure is written correctly Check for and carry out any special orders such as administering enemas or starting an IV line Verify that the client has not eaten for the last 8 hours Assist client with oral hygiene if necessary Remove dentures or bridgework that could obstruct the airway if left in place Have the client remove jewelry If client is wearing hearing aid, notify OR personnel Assist client in donning a hospital gown, protective head cap, ace wraps or antiembolic socks Remove colored nail polish, remove make-up so skin color can be observed 22

Prior to administering preoperative medications, the nurse should check for: 1. Preoperative permit 2. Transfusion permit (if require) PURPOSE OF PREPOERATIVE MEDICATION 1. allay anxiety 2. decrease pharyngeal secretions 3. reduce side-effects of anesthetic agent 4. create amnesia COMMONLY USED PREOPERATIVE MEDICATIONS GENERIC NAME TRADE NAME TRANQUILIZERS diazepam Valium droperidol Inapsine

DESIRE EFFECT Decrease anxiety Decrease anxiety Produce antiemetic effect

UNDESIRED EFFECTS May cause dizziness, clumsiness or confusion Anxiety Hypotension during and after surgery Hypotension, undesired respiratory depression Hypotension during and after surgery Disorientation, especially in elderly patients Respiratory depression Hypotension Circulatory depression Decreased gastric motility causing potential vomiting Excessive dryness of mouth; tachycardia

SEDATIVES midazolam Hcl

Dormicum

promethazine

Phenergan

secobarbital Na pentobarbital Na ANALGESICS morphine sulfate meperidine Hcl

Seconal Na Nembutal Na

Induces undesired sleepiness and reduces anxiety Decreases anxiety Produces an antiemetic effect Decreases anxiety Promotes sedation Relieves pain Decreases anxiety sedation

Demerol

ANTICHLINERGIC atropine sulfate alycopyrrolate HISTAMINE H2RECEPTOR ANTAGONIST cimetidine

Controls secretions Robinul

Tagamet

Inhibits gastric acid production

Some mild dizziness, diarrhea, somnolence, and rash

LEGAL AND ETHICAL ISSUES A. Informed Consent A statement consenting to the operative procedure Protects px. rights to self determination and autonomy regarding surgical intervention Surgeon must explain the procedure in terms the client readily understand Implies that the patient has been given the information necessary to understand the nature of the procedure and its known and possible consequence

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PURPOSE OF SIGNED CONSENT ensure client understands nature of treatment including potential outcome and disfigurement indicate px. decision was made w/o pressure protect client against unauthorized procedure protect surgeon and hospital against legal action when client claims unauthorized procedure was performed

CIRCMSTANCES REQUIRING CONSENT any surgical procedure where scalpel, scissor, suture and hemostats of electrocoagulation may be used entrance into a body cavity : paracentesis, cystoscopy, pericardiocentesis, etc. using anesthesia NECESSARY COMPONENTS OF CONSENT patients full legal name surgeons name specific procedure (s) to be performed signature fo the patient, next of kin or legal guardian witnesses date it was signed And adult sign their own consent unless they are unconscious or mentally incompetent. A parent or legal guardian usually provides consent for a minor Emancipated minors, that is, minors who are married or earning their own livelihood and retaining the earnings can sign their own consent If no legal guardian can be contacted, two phsycians who are not associated with the procedure amy make the decision for surgical intervention Illiterate patients must understand the verbal explanation of the consent process and may sign the form with an X_ . This process must be witnessed by two persons. The patient has the right to refuse surgical intervention Px. has the right to withdraw consent at anytime before the procedure is that decision is reached voluntarily

At least 2 px. identifiers must be used to identify px. identity Confirm and verify the ff: px. and name on ID band date of birth medical record number consent forms availability of blood radiologic examinations Patient response must match: marked site ID band Consent forms Radiologic examinations Scheduled procedures

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SITE MARKINGS Site verification is required for all procedures that involve laterality, multiple structures or multiple level. Site is marked with a permanent marker that is visible after the skin is prepped and draped Operating surgeon should mark the site with his or her initials before the patient enters the OR suites Site is marked with patient participation (verbal confirmation or pointing) A patient has the right to refuse to mark the site. Each institution will determine policy for these situation PHYSICAL (P) STATUS CLASSIFICATION SYSTEM Classification Description P1 Normal healthy patient P2 Patient with mild systemic disease P3 Patient with severe systemic disease P4 Patient with systemic disease that poses a constant threat to life (ex. MI) P5 Moribund patient not expected to survive w/o surgery P6 Patient declared brain dead whose organs are being removed for donation INTRAOPERATIVE PHASE Intraoperative Nursing 2nd Phase of the Perioperative Period OR Nursing OR table to PACU

NURSING ACTIVITIES Psychological Support emotional well-being Physiologic support - assessment of patient status Maintenance of patient safety - positioning, maintain asepsis, & control of surgical environment PERIOPERATIVE TEAM a. Preoperative team Pre-op nurse Physician, nurse practitioner or physician assistant Clinical nurse specialist Advanced Practice Nurse, a MSN holder w/ Major in their field of specialty b. Surgical/Operating Team Sterile Unsterile c. Post Operative Team Post anesthesia nurse Medical-surgical nurse MEMBERS OF THE SURGICAL TEAM group of highly trained & educated professionals who coordinate their efforts to ensure the welfare & safety of the client Sterile Team Non-Sterile Team

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STERILE MEMBERS 1. SURGEON The team leader & main decision maker Performs the operative procedure safely and correctly Performed draping of the patient and checks all other needed for the produre Secures dressing In place Assist in moving the patient to PACU Do the post operative orders 2. ASSISTANT TO THE SURGEON Assist to the surgeon in operative procedure Assist in positioning the patient and draping Assist in closing the incision and dressing Assist in moving patient to pacu MAY DO POST OPERATIVE ORDERS. 3. 2ND ASSISTANT TO THE SURGEON Assist the surgeon and the assistant surgeon -suctioning and retracting -cutting sutures -may do suturing Assist in positioning, draping and dressing Assist in moving patient to pacu. 4. SCRUB NURSE/SURGICAL TECHNICIAN Gathers all equipment for the procedure Prepares supplies & instruments using sterile technique Maintain sterility w/in the sterile field Set up back table, mayo tray and prep tray Handles instruments & supplies during surgery Do the sponge count and instrument count with the circulating nurse before & after surgery Maintain accurate count Assist the surgeon through out the operation with proper anticipation Assist in draping and securing the suction and the cautery machine Responsible for cleaning patient before transferring to the pacu Responsible in cleaning up the back table and instrument Anticipates the needs of the sterile team Establishes baseline counts with circulating nurse 5. CERTIFIED REGISTERED NURSE 1ST ASSISTANT UNSTERILE MEMBERS work outside the sterile area 1. ANESTHESIOLOGIST maintenance of physiologic stability Administer anesthetic to the patient Checks operative condition preoperatively Checks the chart (laboratory results and availability of the blood) Helps positioning the patient properly Monitor vital signs Gives IVF and blood transfusion Determines when to transfer patient to PACU

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CERTIFIED NURSE ANESTHETIST nurse who has a minimum of two years additional education specializing in anesthetic administration Administer anesthetic to the patient Checks operative condition preoperative Helps positioning the patient properly Monitor vital signs Works under the direction of an anesthesiologist 2. CIRCULATING NURSE responsible for the overall running of the OR in the whole intraoperative period does not scrub but good hand washing techniques must be carried out assess client preoperatively, planning for optima care during the surgical intervention ensures all equipment is working properly guaranty sterility of instrument and supplies esp. those that is given in addition assists with positioning performs skin preparation monitors the room and team members for breaks in sterile technique anticipates sequence of operation assisting anesthesia personnel w/ induction and physiologic monitoring handles specimen coordinates activities with other departments, such as radiology and pathology departments minimizing conversation and traffic within the OR suite documentation

SENSE OF HEARING last sense lost and first sense gained in anesthesia OR DIVIDED INTO THREE AREAS: 2. UNRESTRICTED AREA main entrance to the surgical suite pre-operative holding area/admission area PACU Anesthesia Office Staff Lounge and locker rooms 3. SEMI RESTRICTED AREAS peripheral support areas corridors leading to ORs storage and supply areas work room sterilization and processing areas CLOTHING ATTIRE basic scrub suit shoes with shoe cover 4. RESTRICTED AREA operating rooms sub-sterile areas connected to the ORs (typically houses the autoclave, scrub sinks and blanket warmers) where a sterile area/field is open

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CLOTHING ATTIRE sterile gown and sterile gloves mask SURGICAL SUITE ENVIRONMENTAL HAZARDS 1. PHYSICAL back injury, fall, noise, pollutions, radiations, electricity fire 2. CHEMICAL anesthetic gases, toxic fumess antineoplastic drugs and cleaning agents 3. BIOLOGIC patients as a host for or source of pathogenic microorganism, infectious waste, surgical plumes, latex sensitive, cuts and needle prick PREPARATION OF THE PATIENT IN THE OPERATING ROOM greet patient and try to promote relaxation never leave the patient unattended check the chart for pre-operative orders and preparations report any significant changes in the patient

SURGICAL ATTIRE provide effective barrier that prevent dissemination of microorganism to patient prohibits contamination of surgical wound and sterile field by direct contact protects personnel from infected persons BASIC SCRUB ATTIRE 1. shirt and pants (scrub suit) used before entering a semi restricted area 2. head cover/hood/cap put on before the scrub suit 3. shoe/shoe covers unprotected shoe surfaces increase floor contamination 4. mask restricted area PROTECTIVE ATTIRE objective follows the principles of the UNIVERSAL PRECAUTION precaution that protects health care workers form contact with blood and body fluids of all patients not just those diagnosed or suspected of being infected by Hepa B, HIV or other blood borne pathogens minimum precaution for all invasive procedures INVASIVE PROCEDURES entry into the tissue, organs or body cavities in the OR, DR, ER physician or dentist office, radiologist department, clinal laboratory attire: 1. APRON should be fluid resistant 2. EYE WEAR/FACE SHIELD 3. GLOVES a. STERILE GLOVES used on a sterile procedure b. CLEAN GLOVES only used for unsterile procedures (e.g. washing instruments, MIO, handling specimens)

ATTIRE IN STERILE FIELD sterile gown and sterile gloves

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ASEPSIS absence of infectious or disease-producing microorganism two types: 1. MEDICAL ASEPSIS exclude or reduce the number and transfer of pathogens clean technique (hand washing) 2. SURGICAL ASEPSIS renders and keep objects and areas free from microorganism - sterile technique ASEPTIC TECHNIQUES practices that restricts microorganisms in the environment, equipment and supplies goal: prevent surgical infections minimizes length of recover from surgery prevents transfer of microorganism into body tissues STERILE TECHNIQUE required in the ff: all surgical procedures all procedures that invade the blood stream complex dressing and wound care tube insertions care of the high risk groups of patients INFECTION invasion and proliferation of microorganism into the body tissue SEPSIS TWO TYPES OF MICROORANISM THAT INHIBITS THE SKIN TRANSIENT- acquire by direct contact RESIDENT-below the skin surface SURGICAL CONSCIENCE inner voice for conscientious practice of asepsis and sterile techniques at all times self regulation in practice according to a deep personal commitment to the highest value sometimes called the GOLDEN RULE OF SURGERY includes all activity and interventions, personal hygiene and health involves a concept of self inspection coupled with moral obligation, involving both scientific and intellectual honesty PROCESSES INVOLVED IN REMOVING MICROORGANISMS MECHANICAL CHEMICAL Remove soil, debris, natural skin oil or hand lotions present on skin. Reduced the number of resident microorganism on skin to irreducible minimum especially during surgical procedures Reduce hazard of microbial contamination of the surgical wound by skin flora HAND WASHING single most important infection control practice SURGICAL HAND SCRUBBING process of removing as many microorganisms as possible from the hands and arms by mechanical washing and chemical asepsis before a particular surgical procedure done before donning in the sterile gown and sterile gloves

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EQUIPMENT FOR SURGICAL SCRUBBING 1. SCRUB SINK 2. STERILIZED REUSABLE SCRUB BRUSHES 3. SCRUBBING SOLUTION CRITERIA FOR ANTI MICROBIAL SOLUTION USED IN SURGICAL SCRUBBING broad spectrum fast effecting and effective non irritating and non sensitizing prolonged acting independent of cumulative action EFFECTIVNESS OF SURGICAL SCRUBBING DEPENDS ON THE FF. VARIABLE Mechanical Factors, Chemical factors and differences in individual skin flora Everyone should scrub according to a standardized written procedure Prolonged scrubbing raises residual microbes from deep dermal layers. Care should be done not to abrade the skin. Denuded areas allow entry microbes Too short scrubbing would be equally ineffective TYPES OF ANTISEPTIC A. CHLORHEXIDINE GLUCONATE antimicrobial effects against gram (+) and gram (-) microorganisms residual effect is more than 6 hours B. IODOPHORES rapid against gram (+) and gram (-) microorganism cant sustain for a prolonged period of time at least two hours only skin irritant C. TRICLOSAN non toxic, non irritating that inhibits growth of a wider range of both gram (+) and gram (-) microorganism good for sensitive skin develops prolonged cumulative suppressive action if used routinely D. ALCOHOL ethyl or isopropyl rapid acting anti-microbial non toxic but has a drying effect E. HEXACHLOROPHENE available by prescription only has a high potential for toxicity METHOD OF SURGICAL HAND SCRUBBING 1. ANATOMIC TIMED SCRUB Scrub from the nails, fingers each side and web space, palmar, dorsal surface and forearm for a specific time 2. COUNTED BRUSH STROKE Starting from the fingertips, scrub each anatomical area for the designated number of strokes according to policy. 12 PRINCIPLES OF SURGICAL ASEPSIS/ASEPTIC TECHNIQUE 1. Only sterile items are used within the sterile field. 2. Sterile gowns are considered sterile only in front, from shoulder to the level of the sterile field and at sleeves from 2 inches above the elbow to the cuff. 3. Tables are sterile only up to the table level. 30

4.

Sterile persons touch only sterile items or areas; unsterile person touch only unsterile items or areas. 5. Unsterile persons avoid reaching over a sterile field; Sterile persons avoid leaning over unsterile area. 6. The edges of anything that encloses sterile content are considered unsterile. 7. Sterile areas are continuously kept in view. In passing always face the sterile field. 8. Sterile persons keep well within sterile areas. Unsterile persons avoid sterile areas. 9. Sterile persons keep contact with sterile areas to a minimum. 10. When in doubt, consider it unsterile. 11. Moisture causes contamination. 12. Microorganisms must be kept to an irreducible minimum

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SURGICAL INSTRUMENTATION Classification of items according to purpose and body contact: 1. Critical items that enter body tissues, underlying skin and mucuous membrane. must be sterile and maintained sterile 2. Semi-critical items that come in contact w/ intact skin or mucous membrane mechanically cleaned & disinfected to reduce microorganisms e.g. ET tube guide, metal tongue depressor 3. Non-critical items that come in contact only with intact skin or in areas remote from the surgical site may be cleaned, terminally disinfected & stored unsterile e.g straps, ground, BP cuff FOUR CATEGORIES OF SURGICAL INSTRUMENTS 1. Sharps usable part has a sharp, or cutting edge a. Scalpel- incising tissues; dissection b. Dissecting scissors - dissection i. Curved mayo ( heavy ) - heavy or tough tissue - Used to prevent puncturing ii. Metzembaum ( narrow ) delicate tissue iii. Straight Mayo ( suture scissors) - to cut sutures 2. Clamps used for hemostasis. May be used as graspers or retractors. a. Straight Clamps used for hemostasis - Stop bleeding b. Curved clamps c. Graspers or Holding instruments - commonly used to grasp and hold tissues - as in retraction or for suturing d. Retractors - Retractors used to hold tissues away from the operative site. a. self retaining- can maintain its own position PRINCIPLES OF COUNTING 1. All item are counted initially by the circulating nurse and the scrub nurse together (aloud) as the scrub person touches each item. 2. The number (count) of each type of item is immediately recorded in the sponge count form by the circulating nurse 3. If there is any uncertainty regarding the initial count, it is repeated. 4. As additional items are added to the sterile field during the procedure, the scrub nurses counts the items with the circulator who adds the count to the records form and initial it. 5. If possible there should be no interruptions while counting 6. After the final sponge and instrument count, the circulating nurse and the scrub nurse will inform the surgeon by saying aloud sponge count, instruments count and needle count complete. 7. The circulating nurse signed the sponge count form with the time and term correct. POSITIONING essential that each patient be considered as an individual. - A good position must provide maximum safety for the duration of the operative procedure. Maximum safety includes: a. Maintaining good respiratory function. b. Maintaining good circulation c. Preventing pressure on muscles and nerves. d. Good exposure and accessibility of the operative field maximum visualization e. Good access for the administration of anesthetic and observation of effects 32

EQUIPMENTS FOR POSITIONING 1. Operating table Are versatile at adaptable to a number diversified positions for all surgical specialties. However orthopedics, urologic and fluoroscopic tables are utilized frequently for specialized procedures. 2. SAFETY BELT (body, knee, hard strap) -a sturdy, wide strap of conductive material such as nylons, cotton or rubber webbing to protect the safety of the patient 3. ANESTHESIA SCREEN metal bar holds the drapes form the patients face and separates the nonsterile area from the sterile area 4. ARM BOARD self locking board to support the arm resting at patient side 5. STIRRUPS Supports legs in lithotomy position 6. PILLOWS AND SANDBAGS support or immobilize a body part various size and shape to fit anatomic structures 7. SHOULDER ROLL placed under each side of the patients chest to raises it off the table to facilitate operation 8. KIDNEY REST concave metal piece with groove notches at the base are place under the mattress on the elevator part of the table 9. DONUT used for procedures on head and face circular or donut shape rubber foam pad 10. METAL FOOTBOARD to support the feet, the soles resting securely against can be flat as horizontal extension of the table or raised perpendicular to the table DIFFERENT POSITIONS DURING SURGERY SUPINE PRONE LATERAL KIDNEY POSITION PRONE POSITION KRASKE (JACKKNIFE) POSITION MODIFIED TRENDELENBERG those in the lower pelvis is pushed up so you can visualize what is in the lower pelvic cavity REVERSE TRENDELENBERG everything in the lower abdomen is pushed down so you can visualize the upper abdomen LITHOTOMY ORTHOPEDIC POSITION SKIN PREPARATION decreases the number of bacteria on the patients skin, thus decreasing the chance of the patient acquiring a post operative wound infection. duration usually is 5 min depending on the size of the area to be prepped. always start the prep at the incision site, working to the outer boundaries. Boundaries are Bedside to bedside; nipple line to mid thigh new sponges should be used when returning to incision site ( cleanest to dirtiest ) should be done with firm but not rough movements. Observe for skin reactions. 33

skin prep is institutional. Latest practice is the 12 ball technique. Nurse must not reach over the prepped area. Draping of the operative area is done immediately after the skin preparation is completed.

COMMONLY USED SKIN PREPARATION a. Abdominal skin preparation includes the area of the breast line to the upper third of thighs. From Table line to table line with patient in supine position b. Back Preparation Includes the area of the breast line to the upper third of the thighs with the patient in prone position. c. Rectoperineal and vaginal preparation includes pubis, vulva, labia, anus and adjacent areas, including inner aspects of upper third thigh. STERILIZATION - complete destruction of microorganism. - complete sterilization of instruments and equipments is used in the surgical practice. - there is no midway between sterile and unsterile. Sterilization by Heat 1. Autoclaving (moist heat) or steam under pressure most effective means of sterilization Steam kills organism by coagulations of the cell protein. suitable for fabrics e.g. gowns, towels, dressings, and instruments A process by which there is a direct steam contact with specific temperature and time contained in a chamber with a saturated steam pressure. PRINCIPLES OF AUTOCLAVING Temperature 250f to 270f Timing depending upon the loads and the type of autoclave but usually 15-30 minutes. Loading all articles must be properly wrapped with indicators Drying the load- all articles should be dry at the end of the sterilization process.

2. Dry Heat - kills micro-organisms by oxidation (exposed at 160 C or 320 F for 1 hr.) - suitable for all types of glassware and some instruments. 3. Boiling water sterilization -a process by which there is a direct heat immersion contact but only destroy vegetative bacteria, thereby this process is discouraged. - Principle: 5. Timing the recommended time is 2 minutes or longer from the start of boiling point

Gas Sterilizaiton (anprolene) A process of heat sensitive gaseous sterilization under pressure. PRINCIPLES: Temperature 140f Timing-12 hours anpprolene gas sterilization and 24 hours aeration Highly inflammable A vesicant it is come in contact with the skin Toxic if inhaled 6. Chemical disinfectant A process by which chemical agents is used to prevent and to kill the growth of bacteria. A. Cidex - a 2% activated aqueous glutaraldehyde soln B. Alcohol solution 70% isopropyl or ethyl alcohol solution 34

C. D.

Providone iodine (betadine) anaqueous solution that coagulates albuminous substance Phenols (Lysol) effective in the presence of organic matter

DRAPE provide sterile environment 1. Laparotomy sheet/lap sheet - a large sheet with longitudinal opening which is place over the operative site on the abdomen, or comparable area. 2. towels - A small sheet used to outline the operative site(green towel) also used for drying of hands (blue towel) 3. large sheet - a plain large sheet used to drape under legs as in added protection above or below the operative area or for draping areas in which a sheet with an opening cannot used. 4. towel with hole -a small sheet with a circular hole used to drape or cover a small operation such as excision of cyst or mass. 5. eye sheet -a small sheet with an openning like a shape of an eye used to drape a very small operation and eye operations. 6. thyroid sheet -a large sheet with an opening fitted in the neck area to drape in the neck operation. 7. single sheet/sterilizing sheet/ss -a regular size sheet without opening which is folded lengthwise and placed above operative field. 8. perineal sheet - A special design large sheet with an opening and used to create an adequate sterile field with the patient in lithotomy position such as d & c, hemorroidectomy and others. 9. cystoscopy sheet -a special design large sheet with an opening and pockets used to drape patient in a lithotomy position such as cystoscopy operation and others. 10. instrument tray cover (ITC) - A fitted sheet used to drape or cover the mayo stand. SURGICAL INCISIONS The choice of the incision is made by the surgeon with the following considerations: Type of surgery (anatomical location) Maximum exposure Ease and speed of entering (for emergency surgery) Possibility of extending the incision Maximal postoperative wound strength Minimum postoperative discomfort Cosmetic surgery

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LAYERS OF THE ABDOMINAL TISSUE 1. skin 2. subcuticular 3. subcutaneous 4. fascia superficial deep 5. muscle 6. peritoneum ANESTHESIOLOGY -

a branch of Medicine concerned with the administration medications or anesthetic agents to relieve pain and support physiologic function during a surgical procedure

ANESTHESIA is an artificially induced state of partial or total loss of sensation, occurring with or without loss of consciousness. Purpose: to block the transmission of nerve impulses, suppress reflexes, promote muscle relaxation and in some cases, achieve a controlled level of unconsciousness. formed from the Greek word meaning negative sensation loss of feeling or sensation; esp. loss of sensation of pain with loss of protective reflexes

Analgesia lessening of or insensibility to pain Amnesia loss of memory; indifference to pain Analgesic drug that relieves pain by altering perception of painful stimuli w/o producing loss of consciousness; acts on specific receptors in NS. Anesthetics drug that produces local or general loss of sensibility Pain perceptual phenomenon, a disturbed sensation causing suffering/distress

3 Types of Pain 1. 2. 3. Phasic of short duration as a needlestick. Acute up to six months as postoperative pain from tissue trauma Chronic six months and above duration as a chronic disease.

FACTORS THAT AFFECT THE CHOICE OF ANESTHESIA 1. Provide maximum comfort &safety for the patient with low index of toxicity 2. Provide maximum operating conditions for the surgeon 3. Provide potent, predictable analgesia extending to postop period. 4. Produce adequate muscle relaxation and provide amnesia 5. Have rapid onset & easy reversibility w/ minimum side effects 6. Patients physiologic status w/ Presence & severity of co-existing dcs. 7. Patients mental and psychologic status 8. Options for management of postoperative pain 9. Posoperative recovery from various kinds of anesthesia 10. Type and duration of the surgical procedure 11. Client position needed for the surgical procedure 12. Any particular requirement of the surgeon and patients preference

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TYPES OF ANESTHESIA 1. GENERAL ANESTHESIA / GENERAL ENDOTRACHEAL ANESTHESIA / GETA block pain stimulus at the cerebral cortex induce depression of the CNS that is reversed either by metabolic change and elimination from the body or by pharmacologic means produces analgesia, amnesia, unconsciousness and loss of reflexes and muscle tone best suited for surgeries of the ff: head, neck, upper torso, back prolonged surgical procedure used in all clients who are unable to lie quietly for long periods of time types: INTRAVENOUS ANESTHESIA extremely rapid induction Uncosciousness occurs 30 sec. after administration Promotes rapid transition form the conscious to surgical anesthesia stage Acts as calming agent Sufficiently potent to be used alone in some minor procedures as dental extraction and pelvic exams Ex. Thiopental Sodium and Ketamine (has a great effect on px. ; increases BP ; not given to px. with hx. Of hypertension ; usually px. who have hx. Of low BP due to depression of CNS which may be increased by Ketamine) INHALATION ANESTHESIA uses a mixture of volatile liquids or gas and oxygen advantage: ease in administration and elimination through the respiratory system used ot maintain client in stage III anesthesia mixture is given through a mask or ET tube which is inserted once the client is paralyzed and unconscious (intubation) examples: a. INHALATION ANESTHETICS (volatile agents) liquids vaporized for inhalation with O2 as carrier cause post operative shivering hypothalamus effect halothane and isoflurane b. GAS ANESTHETIC (gaseous agent) nitrous oxide- most commonly used odorless, colorless, non-irritating gas that provides analgesia equivalrent to 10 mg of morphine sulfate 2. REGIONAL ANESTHESIA reversible loss of sensation in a specific area or region of the body when local anesthetic is injected to purposely block or anesthetize nerve fibers in and around the operative site agents blocks conduction of impulses in the nerve fibers

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EPINEPHRINE added to many local anesthetics adjunct medication given with another medication to potentiate effect of the medication purpose: prolonged anesthetic effect delay absorption of anesthetic by constriction of local blood vessels TYPES OF REGIONAL ANESTHESIA a. SPINAL SUB ARACHNOID BLOCK / SAB anesthetic technique of choice for older adults and for clients undergoing surgical procedures in the lower half of the body achieved by injecting local anesthetics into the subarachnoid space autonomic nerve fibers 1st affected and last to recover after blockade of the ANS spinal anesthesia blocks the following fibers in these order and recovers in reverse order: a. touch b. pain c. motor d. pressure and e. proprioreceptive fibers (alerts brain of physical orientation) within minutes of administration, client experience a loss of sensation and paralysis of the toes, feet, legs, then abdomen benefits: safe, excellent lower body muscle relaxation, absence of effect of consciousness b. EPIDURAL CLEB / CONTINUOUS LUMBAR EPIDURAL BLOCK achieved by introduction of anesthetic agent into the epidural space (thoraxic, lumber, sacral, or caudal interspace) w/o penetrating the dura and w/o entering the subarachnoid space blocks autonomic nerves and cause hypotension respiratory depression or paralysis may occur if block done is too high that may affect respiratory muscle c. CAUDAL ANESTHESIA d. TOPICAL ANESTHESIA short acting applied directly to the area to be sesensitized blocks peripheral nerve endings in the mucous membrane of the vagina, rectum, nasopharynx, and the mouth preparation: solution, ointment, gel, cream or powder LOCAL INFILTRATION ANESTHESIA involves injection of anesthetic agent such as lidocaine into the skin and subcutaneous tissue of the area blocks only the peripheral nerves around the area of incision when administered, aspirate that no blood vessel was hit before injecting to ensure and prevent systemic reaction causing cardiovascular collapse or convulsion FIELD BLOCK ANESTHESIA areia proximal to a planned incision can be injected and infiltrated to produce a field block this block forms a barrier between incision and the nervous system walls the area around the incision and prevents transmission of sensory impulse to the brain from this area 38

e.

f.

g.

PERIPHERAL NERVE BLOCK / PNB injects along the nerve rather than into the nerve to decrease risk fo nerve damage anesthetize individual nerve or nerve plexus rather than all local nerves anesthetized by a field block prevent accidental injection into the blood vessel

TYPES OF PERIPHERAL NERVE BLOCK Digital nb- for a finger Brachial plexus nb- entire upper arm Intercostals nb chest or abdominal wall h. MONITORED ANESTHESIA surgeon infiltrates surgical site with local anesthesthetics and the anesthesia provider supplements local anesthetics w/ IV drugs to provide sedation and systemic analgesia ACUPUNCTURE Ancient chinese killing technique that works by insertion of long, thin needles into specific acupuncture points CRYOTHERMIA use of cold to induce anesthesia

i. -

j. -

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