Professional Documents
Culture Documents
Preop Chapter 1
Preop Chapter 1
Surgical classifications
1. 2. 3. 4. 5.
Diagnostic ( biopsy) Curative ( excision of tumor) Reparative (multiple wound repair) Reconstructive or cosmetic ( mamoplasty) Palliative (relief pain or correct a problem)
Assist the pt in understanding the physical and psychosocial aspects of the surgical experience Acquaint the pt and his family with the environment, protocol, and expectations as surgery. Teach the pt certain procedures that will help in reducing post operative complications Prepare the physically and psychologically for the operation Collaborative with other members of the health team in coordinating all preoperative procedures.
Miss Iman Shaweesh 7
10
Preoperative Teaching
The goal of preoperative teaching is to familiarize the pt with the expected post operative outcomes such as:
Facilitation of recuperative period. Attainment of a sense of well-being with minimal fear wellof the unknown. Decreased need for analgesics Absence of complications Decrease time for hospitalization
11
12
Teaching the pt how to promote optimal lung expansion and consequent bloody oxygenation after anesthesia. The goal in promoting coughing is to mobilize secretions so they can be removed .If the pt doesnt cough effectively, Atelectasis (lung collapse), pneumonia, and other lung complications may occur.
Miss Iman Shaweesh 13
Beliefs
Include identifying and showing respect for cultural, spiritual, and religious beliefs, such as in pain control, or in blood transfusion.
15
Purpose for: to reduce bleeding at the operative site espicially in brain surgery.
Malignant hyperthermia:
Due to biochemical disturbances in skeletal muscle involving calcium distribution. we use hypothermia blanket, infusion of ice saline solution high concentration of oxygen, and NaHCO3 to correct metabolic acidosis
Miss Iman Shaweesh 16
17
Intra operative Nursing Positions: Dorsal Recumbent position Trendelenburg position Lithotomy position For kidney operation For chest and abdominothoracic operation Operation on the neck Operation on the skull and brain.
Miss Iman Shaweesh 18
Trendelenburg position
19
20
Lithotomy position
21
kidney operation
22
Preoperative: Preoperative:
Preoperative sterilization of surgical materials Placement of the operation room Scrubbing of health team Cleansing the patients skin with antiseptic agents Covering the rest of pts body with sterile drapes
23
2.
Intraoperative: Intraoperative: Asepsis techniques in surgical practice Post operative: Protect the wound from contamination by sterile dressing Heat compresses at site of surgery Antimicrobial agents in infected wounds
24
3.
Environmental control: Meticulous housekeeping in the operating room Sterilizing equipment Laminar air flow system to filter out high percentage of dust and bacteria. Constant surveillance and conscientiousness in carrying out aseptic practice
Miss Iman Shaweesh 25
26
Headgear Completely cover the hair, clips or dandruff or dust dont fall in sterile field Shoes Comfortable and supportive Tennis shoes, sandals and boots are not permitted unsafe and difficult to be cleaned Must be worn one time only and removed upon leaving the restricted area Gloves
Miss Iman Shaweesh 27
28
2- Scrub activities
Scrubbing of the operation room Setting up the sterile table, preparing sutures and special equipment Assisting the surgeon and the surgical assistance Keeping the time the patient is under anesthesia Check all equipments used in operation are accounted Send specimens to lab
29
The site of operation should be kept in mind every time. Check positioning of the head ; extension, lying on unaffected site , Check blood pressure; arterial hypotension Remove the wet gown, keep the pt warm
31
32
The pt remains in this room until he has full recovery from the anesthetic agents, stable blood pressure, good air passage, and reasonable degree of consciousness.
33
34
Invaded of skin and mucous membrane by tubes and catheters, by the disease process Effect of surgery and anesthesia reduce resistance of the body
Miss Iman Shaweesh 36
Continuous health education about infection control policy Deep breathing exercise to prevent accumulation of secretions Sterilization of equipments Antibiotics therapy
Miss Iman Shaweesh 37
Ambulation increase respiratory exchange Prevent stasis of bronchial secretions Reduce distension Prevent thrombophlebitis Increase rate of wound healing Ambulation done gradually
Miss Iman Shaweesh 38
39
8-Document all phases of nursing process and report data Any slight symptoms that can increase in severity Any progressive and steady change for the worse in the general condition of the pt The pts complaints
Miss Iman Shaweesh 40
41
2-Abdominal distension Loosing of normal peristalsis within 24-48 hours post 24operatively is due to trauma in abdomen. he was swallowed mucous and secretions during operation, so he needs to evacuate these things . 3-Thirst. (atropine).
42
RX.of hiccups
Remove of cause by applying NGT Finger pressure on the eyeball for several minutes Induced vomiting Gastric lavage IV injection of atropine Inhalation of CO2
43
44
Remove the impaction Enema of liquid petrolatum (oil enema) Gloved finger Injection of 30-60cc of H2O2 into the rectum 308- Diarrhea After operation diarrhea is rare. Fecal impaction is the main cause
46
47
Pathophysiology:
Catecholamines (epinephrine and norepinephrene) are elevated during shock, cause constrict arterioles in the skin, subcutaneous tissue, and kidney; thus dilate arterioles of skeletal muscles and liver. Heart output is increased due to tachycardia and increased myocardial contractibility. The great veins are constricted, increased venous return. Shock stimulates (ACTH) release from the pituitary gland, increased plasma level of glucocorticoids.
48
Glucagons is released and antidiuritic hormone (ADH) released Due to high level of epinephrine, cortisol and glucagons and lower level of insulin stimulate catabolism, decreased oxygen utilization, decreased cardiac output, and insulin insufficiency.
49
Classification of Shock:
1-Hypovolemic shock:
is cause by decreased fluid volume due to loss of blood, plasma or water. Fluid volume usually decreased post surgery due to local trauma to tissues and loss of blood and plasma from circulation, which creates a decrease in the circulating blood volume. It characterized by a fall in venous pressure, rise in peripheral resistance and tachycardia.
50
2- Cardiogenic shock:
It results from cardiac failure or an interference with heart function, (poor heart pump function, and causing diminished cardiac output) as in MI, arrhythmias, tamponate, pulmonary embolism, epidural or general anesthesia. The signs are increased pressure in the venous bed and an increase in peripheral resistance.
51
3-Neurogenic shock:
It occurs as a result of a failure of arterial resistance due to spinal anesthesia, quadriplegia. It characterized by fall in blood pressure, increase heart activity to maintain normal output (stroke volume); this helps in filling the dilated vascular system.
52
4-Septic shock: It results from gram negative septicemia ( infection , peritonitis, etc) The pt exhibit fever, rapid strong pulse, rapid respiration, and normal or slightly decreased blood pressure, flushed , warm, dry skin,, then hypovolemia develops.
53
Clinical manifestation:
The classical signs of shock are pallor ,cool , moist skin, rapid breathing, ischemia to eyelids, lips, gums and tongue , weak, thready pulse, small pulse pressure, low blood pressure.
Central venous pressure: It has a value on the volume pressure: of blood returning to the heart and the ability of the right heart to propel blood. Average CVP is 5-12 cm 5water, near zero indicate hypovolemia Arterial blood gases: an arterial pressure of oxygen below 60 mm Hg indicates respiratory acidosis. A PCO2 over 45 mmHg indicated hypoventilation. In shock PCO2 remain normal. Serum lactate: lactate elevation and oxygen dept, the lactate: higher the lactate level, the greater the oxygen need.
Miss Iman Shaweesh 56
Hematocrite: Hematocrite: to determine the kind of fluid in replacement. HCT over 55, plasma and normal saline are given. HCT less than 20, blood is needed Level of consciousness: alert in mild shock, to mental consciousness: cloudiness immoderate shock. Failure to react or stimuli is irreversible shock.
57
Prevention:
Adequate preparation of pt physically. Anticipation of complication Preparation of special emergency equipments e.g. blood studies, BP device, catheters, suction, oxygen, CVP line, IV, defibrillator, solutions. Decrease any operative trauma during surgery Control pain Thermal regulation after surgery Control of blood loss, if the amount of blood loss exceeds 500 ml, replacement is usually indicated Positioning dorsal recumbent position to facilitate circulation.
58
Treatment:
The pt must kept warm, infusions of Ringer lactate is started, placed in shock position, monitor respiratory and circulatory status. The basic approach of treatment of shock is to determine its cause and correct it if possible. 1-Ensure adequacy of the airway. 2- Restore blood volume. .
59
3-Administer vasodilators. Vasopressors are not used for the pts in shock because they have vasoconstriction in the microcirculation which may cause irreversible damage to kidney, lungs, liver, and GIT tissues Vasodilators are given to reduce peripheral resistance, which decrease in turn the work of the heart and increase cardiac output and tissue perfusion. They use Nipride which stimulate cardiac contractibility and lower peripheral resistance
60
4-Provide psychological support and minimize the pts energy expenditure. 5-Prevent complications: Avoid peripheral and pulmonary edema due to fluid overload from administering fluid faster than the body can accommodate them.
61
62
Hemorrhage
Hemorrhage is classified as 1) primary, when it occurs at the time of the primary, operation. 2) Intermediary, it occurs within the first few Intermediary, hours after an operation. 3) Secondary, it occurs some time after the Secondary, operation, as result of slipping of a ligature because of infection.
63
Management: Positioning in shock position Administer morphine to keep pt quiet Inspect wound for bleeding Giving transfusion of blood and determine the cause. Giving fluids but too rapid to avoid fluid overload
65
The first symptom is pain or cramps in the calf, followed by swelling of the entire legs due to a soft edema that pits easily on pressure, slight fever, chills and perspiration, tenderness. Phlebitis: Phlebitis: indicate intravascular clotting without marked inflammation of the veins. The clotting occurs on the calf. The major sign is slight soreness of the calf.
67
68
2) Active treatment
Ligation of the femoral veins , to prevent pulmonary embolism by eliminating the cause ( thrombi that could become detached from femoral veins and circulate in the blood) Anticoagulant therapy. Heparin given IV by drip method or SC to reduce the coagulability of the blood rapidly Wrapping the legs from the toes to groin with elastic stockings, these prevent swelling and stagnation of venous blood in the legs and to relief pain with leg elevation and legs exercises
Miss Iman Shaweesh 69
4- Pulmonary Embolism
Emboli: Emboli: foreign body in the blood stream. Formed by blood clot that becomes dislodged from its original site and is carried along in the blood. When it is carried to the heart, it is forced by the blood into the pulmonary artery, where it plugs its artery of the one of its branches. The signs are: Sharp, stabbing pains in the chest. Breathless, cyanotic, and anxious. Pupils dilated, cold perspiration appears. Rapid, irregular pulse.
Miss Iman Shaweesh 70
Respiratory Complications
1- Atelectasis: When mucous is plug it closes one of the bronchi, which make collapse of the pulmonary tissue, and massive atelectasis is result. 2- Bronchitis: it occurs within the first 5-6 days. A simple 5bronchitis is characterized by a cough that produces considerable mucopus, with marked elevation in temperature and pulse. 3- Bronchopneumonia: beside a productive enough, elevation of temperature, with an increase in pulse and the respiratory rate.
Miss Iman Shaweesh 71
4- Lobar pneumonia: is less frequent complication after pneumonia: operation. It begins with chill, high temperature pulse, and respiration. Little or no cough, flushed cheeks.
5- Hypostatic Pulmonary Congestion: In old or very Congestion: weak pts, due to weak heart and vascular system that permit a stagnation of secretions at the base of the lungs. There is elevation of temperature, pulse and respiratory rate, dullness in chest and crackles at the base of the lungs, if it is untreated, it is fatal.
72
Medical and Nursing Management of Pulmonary Complications: 1- Measures to promote the full Aeration of the lung.
Ask the pt to have at least 10 deep breaths every hour Use incentive Spiro meter to expand the lungs fully Turning the pt from side to side Suction when needed. Early ambulation
73
To treat bronchitis; inhalation of a mist or steam In lobar and bronchopneumonia; take fluids, expectorant and antibiotics drugs For pleurisy; analgesics or cold applications
74
75
A small warm enema Catheterization: this procedure can be delayed after 121218 hours. Catheterization can be avoided due to: (1) Possibility of infecting the bladder and cause cystitis. (2) Experience that the pt has once catheterization; he will have recurrent. 2- Urinary incontinence It is due to weakness with loss of tone of the bladder sphincter 3- Urinary Infection
Miss Iman Shaweesh 76
77
The obstruction is due to kinking of loop of intestine from inflammatory adhesions or is involved with peritonitis or irritation of the peritoneal surface. No temperature or pulse elevation, localized pain, distension, vomiting, hiccups proceed the vomiting. Enemas return clean, showing small amount of intestinal content has reached the bowel. Treatment: Constant suction drainage or simple NGT Operation IV fluids
Miss Iman Shaweesh 78
7- Wound Complications
1- Hematoma (Hemorrhage) The nurse should know the location of the pts incision to inspect the site of operation for bleeding at intervals for the first 24 hours. Any undue amount of bleeding should be reported. 2- Infection (Wound Sepsis) Staphylococcus aureus, E. Coli, Aerobacter aerogenes and pseudomonas aeroginosa. The main important area of prevention lies on aseptic techniques in wound care, cleanliness and environmental disinfection are important. The symptoms appear within 36-48 hours. 36Miss Iman Shaweesh 79
The temperature and pulse increase, wound become tender, swollen, and warm. Use of warm antiseptic solutions to flush the wound. Take culture at site of operation. Specific antibiotics. 3-Disruption, Evisceration (protrusion of wound center), or Dehiscence (distruption of surgical wound or incision). It results from sutures giving way and from infection, and after marked distention or cough. It occurs because of increasing age and the presence of pulmonary or cardiovascular diseases in abdominal surgical pts.
Miss Iman Shaweesh 80
The sign is usually a gush of serosanguineous peritoneal fluid from the wound, rupture of wound, coils of intestine escaping onto the abdominal wall, pain, vomiting. When disruption of a wound occurs, the surgeon is notified at once. The protruding coils of intestine should be covered with sterile dressing moistures with sterile saline.
81
Thank You
82
83