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Jose Leo V. Nastor, Jr. BSN3 B Clinical Instructor: Ms. Louradel M.

Ulbata

Clinical Group 7

PERI OPERATIVE NURSING Surgery Branch of medicine that is concerned with disease and trauma that requires operation procedure Gave physical means to treat conditions that are difficult or impossible only with medications Nurses in first OR clean rooms and equipments, perform technical tasks like obtaining supplies, accompany patient to the ward 4 MAJOR TYPE OF PATHOLOGIC PROCESS REQUIRING SURGICAL INTERVENTIONS a) Obstruction impairment to the flow of vital fluids (blood, urine, CSF, bile) b) Perforation rupture of an organ c) Erosion wearing off of a surface or membrane d) Tumor abnormal growth of cells CLASSIFICATION OF SURGICAL INTERVENTIONS I. ACCORDING TO PURPOSE a) Diagnostic confirm diagnosis; establish presence of disease b) Exploratory estimate the extent of disease and diagnosis c) Curative to treat disease condition d) Ablative removal of diseased organ e) Constructive repair of congenitally defective organ f) Reconstructive restoration of damaged organ g) Pallative relieve symptoms but does not cure the disease II. ACCORDING TO URGENCY a) Emergency require immediate attention, without delay to maintain life b) Urgent / Imperative prompt attention; 24 48 hours from the time of decision c) Required / Planned patient need to have surgery. Time of the surgery is in a few weeks/months. d) Elective patient should have surgery. Convenience of the patient as a failure to have surgery is not life threatening. e) Optional surgery at the preference of the client. III. ACCORDING TO DEGREE OF RISK a) Major extensive surgery that includes serious risk or creates a higher risk for infection, operation is prolonged and large amount of blood loss is expected. Vital organs may be handled or removed. b) Minor surgery that involves minimal complications, operation is not prolonged, decrease risk of infection and less amount of blood loss is expected. COMMON VARIATION OF SETTING Input patient is hospitalized for surgery 1 day (Same day) Admitted the day of the schedule of the surgery and discharged at the same day Output patient is not hospitalized, who is being treated / patient is admitted either to a short stay unit or directly to the surgical unit. AMBULATORY SURGERY / SAME DAY SURGERY ADVANTAGE: Less length of hospital stay and less cost Less stress to the patient Less incidence of hospital acquired infection Less time to be absent from work or school DISADVANTAGE: Less support Less time to assess the patient for pre operative teaching Less opportunity to assess for late post operative complications CONCEPT OF PERI OPERATIVE NURSING providing continuity of care for surgical patient/ patient undergoing surgery using the nursing process RESPONSIBILITY: safe, consistent, and effective nursing process during each phase FACTORS AFFECTING SURGICAL INTERVENTIONS - Age - Obesity - Altered host - F and E imbalance - Aging Process - Allergies - Presence of disease - Pharmacotherapy DEVICE USED TO ASCERTAIN SERIOUS ILLNESS / TRAUMA (ABCDE) A) ALLERGIES medications, chemicals, environment, latex cross reactive foods

Latex Cross Reactive Foods banana, kiwi, papaya, grape, avocado, watermelon, tomato, celery, chestnut Allergies are reported An allergy band must be place on arm B) BLEEDING use mediations that interfere the normal clotting factor Herbal Medications increase bleeding time and mark potential blood related problems o Gingko biloba, strawberries, garlic, ginger increase level of salicylates C) CORTISONE immune system is suppressed and patient is at risk of developing post operative infection and have diminished capacity to fight infection D) DM delay wound healing E) EMBOLI previous embolic events CLASSIFICATION OF PHYSICAL STATUS ASA 1 patient undergoing surgery is a healthy person without disease, not young and not old ASA 2 patient has mild systemic disease; does not affect activity; mild obesity, smoker, alcoholism ASA 3 multiple system condition but well controlled; limit daily activity, without threat ASA 4 with severe disease and poorly controlled, end stage disease is present, organ failure is present ASA 5 danger of death, operation is the last attempt for intervention ASA 6 declared brain death, patient whose organs are removed for donor SURGICAL RISKS - Obesity - F and E imbalance - Stress / Fear - Nutritional Factors stressful condition need energy to repair tisssues - Psychological Needs fear of the unknown, fear of death, fear of pain, fear of ADL disruption, fear of loss of control due to anesthesia, , fear of disruption of pattern, fear of separation o MANIFESTATIONS OF FEAR unstable V/S, decrease pain threshold, anxiousness, bewilderment, anger, inability to concentrate, short attention span, dazed, sad o NURSING INTERVENTIONS OF FEAR explore clients feelings - Socioeconomic & Cultural Needs different culture react - Current Medications - Education and Experience PRE OPERATIVE PHASE Assess the correcting physiological and psychological problems that may increase surgical risk Give person and SO complete learning guidelines Pre operative exercise and planning of discharge PAST MEDICAL HISTORY Any untoward reaction after the surgery may arise from previous medical conditions such as DM can affect the recovery of the patient Assess for: - ABCDE - F and E imbalance - Lifestyle - Infection - Nutrition - History of chronic disease - Medications: o Antibiotic gentamicin o Anti hypertensive cause hypotensive crisis, o Steroids delay wound healing o Anticoagulant increase bleeding o Glaucoma Meds (Pilocarpine) cause respiratory and cardiovascular collapse o Anti DM insulin needs decrease when client is on NPO o TCA decrease BP, increase risk of shock o Diuretics cause F and E imbalance especially Potassium o Street drugs increase tolerance to narcotics - Psychological History - Social History PHYSICAL EXAM: CV MI, Angina pectoris < 6 months Respi emphysema, if there is DOB notify ASAP! MS fracture, arthritis Skin Integrity lesions, ulcers, and necrotic skin, Renal eliminate CHON waste and removal of drugs Cognitive PD Neuro headache, dizziness, gait abnormalities Hema blood coagulation problems PRE OPERATIVE CARE

1) Psychological Prep for Surgery Experience of the procedure, Outcome, Hospital Cost, Length of absence form work 2) Legal Aspect INFORMED CONSENT Purpose: o Understand the nature of the treatment including the potential complication and disfigurement o Ensure that the clients decision is made without pressure o Protect the client against unauthorized procedure o Protect surgeon and hospital against legal action CIRCUMSTANCES REQUIRING INFORMED CONSENT - Scalpel, scissors, suture - Entrance into body cavity - Radiologic procedure - Anesthesia GA, SAB ELEMENTS OF INFORMED CONSENT - Assessment and explanation of condition - Fair explanation of procedure - Alternative treatment - Material right (specimen) - Benefits to be expected - Prognosis REQUISITES FOR VALIDITY OF INFORMED CONSENT o Written permission is best and legally accepted o Signature is obtained with the clients complete understanding of what to occur o Adult sign their own operative permit o Informed consent must be obtained before sedation o Parents or someone standing in their behalf, gives the consent o Note: for a married emancipated minor parental consent is not needed anymore, spouse is accepted o For mentally and unconscious patient, consent must be from the parents or legal guardian o If the patient is unable to write, an X is accepted if there is a witness to his mark o Secured without pressure and threat o When an E situation exist, no consent is necessary because in action at the same time 3) Physiological Prep laboratory tests and results 4) Health Teaching Relatively close to the time of the surgey Incentive Spirometry 10 12 times per hour; Cough exercises removal of secretions Repositioning every 1 2 hours to prevent DVT and pressure ulcers 5) Physical Prep Reduction of weight for obese clients Correct dietary allowance of the client Correct F and E imbalance Adequate blood volume for BT Treat chronic disease COMMON SITES USED FOR OPERATION a) Subcostal indicated for biliary and gall bladder surgeries b) Paramedia for splenectomy (L), hiatal hernia, gastrotomy c) Transverse gastrectomy (L) d) Midline for C/S, laparotomy, appendectomy e) McBurneys appendectomy f) Right Rectus small bowel resection, appendectomy g) Left Rectus sigmoid colon resection h) Pfannenstiel for C/S INTRA OPERATIVE NURSING Pre op checklist included in the patients chart if the patient will undergo surgery - IVF - Consent - NPO - Lab results - Presence of tube/drainage - If dentures are removed - Presence of allergy - Jewelry removed - Routine hygiene - In gown - Nail polish removed - V/S taken 4 hours before the operation - Check the chart for competences hx and PE, lab exam - Pre op meds should be given 30 60 minutes before the operation PREPARING THE PATIENT THE EVENING BEFORE THE SURGERY Preparing the skin - Full bath to decrease microorganisms in the skin - Hair should be cut within 1 2 mm of the skin to avoid skin breakdown, use electric clipper if preferable Preparing the GIT NPO, cleansing enema as required ASA GUIDELINES FOR PRE-OP Liquid and food intake minimum fasting period - Clear liquid 2 hours - Breastmilk 4 hours

- Nonhuman milk 6 hours - Light meal 6 hours - Real heavy food 6 hours Prep for anesthesia avoid alcohol and smoking for at least 24 hours before the surgery to avoid interaction of substance Promoting rest and sleep sedatives may be given PREPARING THE PERSON ON THE DAY OF THE SURGERY Early AM care - Should wake the patient 1 hour before the pre op meds are given - Morning bath, mouth wash - Provide clean gown - Remove dentrues, nail polish, hearing aid, contact lens, jewelries, hairpins - Baseline V/S - Check ID band - Check for special orders such as enema, IV line - Check if NPO - Have patient void before the pre op meds - Continue to support emotionally - Accomplish pre op checklist PRE OP MEDS Goals: To aid in the administration of anesthesia To decrease respiratory tract secretion and changes in HR and GI secretion To relax the patient and decrease anxiety COMMONLY USED PRE OP MEDS Tranquilizers & Sedatives cause hypotension - Diphenhydramide - Diazepam (Valium) - Miazolam - Lorazepam Analgesics Nalbuphine (to decrease anxiety) Anti cholinergic to decrease respiratory tract secretion and changes in HR (Atropine Sulfate) PPI Omeprazole and Famotidine TRANSPORTING PT TO THE OR Adhere to the principle of maintaining the comfort and safety of the patient Accompany OR attendants to the patients bedside for instruction and proper identification Assist in transferring the patient from bed to stretcher Complete the chair and pre op checklist Make sure that the patient arrive in the OR at the proper time Patients Family o Direct to the proper waiting room o Tell the family that the surgeon will probably contact them immediately after the surgery. o Explain reason for long interval of waiting o Tell the family what to expect post op INTRA OPERATIVE PHASE Transfer onto the OR table PHYSICAL LAYOUT OF THE OR SUITE Location Located at the center (for easy access and both hospital and OR table) In an area where it is accessible Size of the OR table 20 x 20 x 10 with a minimum floor space of 36 square feet Temperature of OR 68 75 degree F (20 24 degree C) Humidity 50 55% Space Allocation and Traffic Pattern Space is allocated within the OR suite to provide the work to be done, with considerations given to the efficiency which it can be accomplished The OR suite should be large enough to allow for correct technique yet small enough to minimize the movement. SURGICAL ENVIRONMENT a) Unrestircted Area - Provide an entrance and exit from the surgical suite for personnel, equipment, and patient - Street clothes are permitted b) Semiresticted Area - Provide access to the procedure rooms and peripheral support areas within the surgical suite - Street clothes are not allowed - May wear scrub suit but no cap c) Restricted area - Include the procedure room where the surgery is performed and adjacent sub sterile areas where the scrub sinks and autoclaves are located - Scrub suit with cap and mask VESTIBULAR/EXCHANGE AREAS

PACU Outside the OR suite, or it may be adjacent to the suite so that it may be incorporated Conference Room Support Service Laboratory to examine tissues Radiology Service X Ray and images Work and Storage Areas cleaning the supplies Anesthesia Work placing of the anesthesia Housekeeping Areas cleaning the supplies Utility Room soiled/ contaminated instruments that are washed. Sterile Supply Room where the sterile instruments and things are placed Instrument Room usually a cupboard Scrubroom for scrubing Suture nurse must have a suture booklet Free tie thread Sponges OS, lap packs, long narrow packs, square packs, cherry balls, peanuts Sponge forceps pick up and dressing forceps Black silk thread White cotton thread SCIENTIFIC PRINCIPLES INVOLVED IN THE OR TECH - Anatomy and Physiology - Chemistry - Microbiology - Pharmacology - Psychology - Sociology - Physics PRINCIPLES OF SURGICAL ASPEPSIS A Always face the steile field S Should be above waist level and on top of the sterile field E Eliminate moisture that cause contamination P Prevent unnecessary traffic and air current (close door, minimize talking, dont reach across sterile field) S Safer to assure contamination when in doubt I Involves a team effort S Sterile articles and opened are no longer sterile after the procedure ANESTHESIA GENERAL ANESTHESIA Loss of feeling or sensation especially loss sensation of pain with loss of protective reflexes Anesthetics can produce muscle relaxation, block the transmission of pain nerve impulses and suppresses the reflex Also temporary loss of memory In general: Reversible state consisting of loss of consciousness/ sensation Protective reflexes such as cough and gag reflex Produce amnesia but temporary TECHNIQUE IV rapid effect; after 30 minutes Inhalation volatile liquid/ gas and oxygen, administered through mask and ETT INDUCTION OF GA a) Pre oxygenation May have the patient breathe pure 100% oxygen by facemask for a few minutes. This provides a margin of safety in the event of airway obstruction or apnea b) Loss of consciousness Induced by IV administration of a drug or by inhalation of an agent mixed with O2. Because the technique is rapid and simple, and IV drug usually is preferred by anesthesia provides and often requested by patient. c) Intubation Patent airway must be established to provide adequate O2 and control breathing of the unconscious patient. PHYSIOLOGIC INDICATORS OF DIFFERENT AIRWAY INCLUDE THE FF: a) Inability to open mouth previous jaw injury, wine cutters, should be immediately available in the event of a return to surgery. b) Immobility of the cervical spine patient with vertebral disease or injury may not have full ROM necessary for intubation c) Chin/jaw deformity small jaws/chin may have a difficult airway d) Dentition can be an issue if the patient has loose teeth of periodontal disease e) Short neck/ morbid obesity f) Pathology of the head and neck such as tumors and deformities. g) Previous tracheostomy scar which can cause stricture h) Trauma DEPTH OF GA

From Induction of GA and beginning of inhalant and or IV drug

Loss of conciousness (excitement phase)

To Begins to lose consciousness, will have recall bispectral state(RBS) (100) Relaxation, light hypnosis, low probability of RBS 50 70

Pt Response Drowsiness, dizziness, amnesia

May be excited with irregular RR and movement of extremities, suspectible to external stimuli Regular respiration, contracted pupil, reflex disappears, muscle relaxation, auditory sensation lost No breathing, little or no HR

Surgical anesthesia (state of relaxation)

Loss of reflexes, depression of V/S, RBS of 40

Pt care Close doors, keep room quiet, stand by to assist, initate cricoid pressure if requested Restraint pt, remain at pts side, quietly but ready to assist anesthesia provider as needed Position pt

Danger state (V/S depressed)

Respiratory failure, cardiac arrest, RBS 0

Prepare for CPR

EXAMPLE OF GA Halothane, Nitrous oxide, Evaflurane, Slevoflorane LOCAL/ REGIONAL ANESTHESIA Temporary interruption of nerve impulses Most commonly used are lidocaine Reduce all painful sensation in one region of the body without loss of conciousness Technique: o Topical o Subarachnoid into the subarachnoid space; via lumbar puncture between L2 S1 - Low spinal perineal - Mid spinal T10 appenedectomy - High spinal T4 for C/S Fetal or C shaped position o Epidural epidural space C shaped (chlorprocaine, lidocaine) o Peripheral Nerve Block in the surgical site o IV block In the arm, wrist, hand. Occlusion of tourniquet to prevent infiltraton o Caudal caudal or sacral canal o Field block area that is proximal to the incision site can be injected Administration of LA o If no surgeon, a RN is responsible for monitoring the pts physiological state and safety during LA. This should be the only act assigned to the nurse. Positioning Lateral and Sitting position o C shaped the nurses hand must support the neck and thigh part SPEED OF EMERGENCE Recovery from anesthesia, depending on the type of anesthesia, length of time, and many other factors. A very critical part Induction anesthetic agent has been injected CARE OF THE ANESTHESIZED PATIENT Safety factors: o Pts position is changed slowly and gently to allow the circulation to readjust o Proper positioning is very important to avoid pressure points, stretching of the nerves, or interference in the circulation o Pts chest must be free of adequate respiratory exertion during surgery procedure. o Lungs must be adequately ventilated intra operatively and post operatively o Assist in recovering COMPLICATION AND DISCOMFORT - Hypoventilation - Oral Trauma - Cardiac dysrhythmia -N&V - Hypotension - Hypothermia - Peripheral Nerve Damage - Headache SURGICAL TEAM A.) Sterile - Scrub their hands and arms - Wear sterile gown and gloves - Enter sterile field - Function within the limited area and the only sterile area

a) Surgeon - Must have knowledge and skills and judgment and prepare for the unexpected - Handle tissues and uses instruments b) Assistant to the Surgeon - Require formal education program and must have additional surgical training c) Scrub Person - Pt care, staff member, work in a sterile field B.) Non sterile team - Unsterile team members who DO NOT enter the sterile field a) Anesthesia Provider - Responsible for monitoring V/S, status of the patient during the procedure b) Circulator (Circu nurse) - Smooth flow of events before, during, and after the surgical procedure - Pt advocate and protection c) Other OR Team Sterile Field area surrounding the client and the surgical field is free from micro-organisms DUTIES AND RESPONSIBILITIES OF A SCRUB NURSE - Set up the room and position the equiptment DUTIES AND PREPATING OF THE STERILE FIELD (BEFORE) Sure that his or her gown and gloves are open and ready on a surface separate from the sterile field Perform a complete surgical hand cleansing according to the facility procedure Gown and gloves are closed gloving method Drape unsterile tables according to standard set up procedure with drapes from the drape pad. A 2nd instrument table may be needed for extensive surgical procedure or special types of instruments (e.g. tables for preparation of an implant) Drape both the tray and the mayo table Arrange on the mayo table the instruments and accessory items to create a primary precision arrange Place the instrumens and items on the mayo table Do not overload the sponged and sharps Count sponges, surgical needles, other sharps and instruments with the circu according to established facility policy and procedure o Baseline count before the operation will start o Initial performed before the closure of the peritoneum o Final total closure of the skin When counting, must have a loud voice Circu nurse should watch the counting Counting the instruments o CSBA curves, straight, babcock, allis, Sponges OS, cherry balls, Needles and blades Arrange the sponges o Cherries group into 5 o Peanuts group into 5 (small cherry balls) In serving peanuts attach it with Allis or Babcock Never drop the peanuts in the tray, leave it to the side of the mayo table Secure surgical needles and all other sharps including the knife needle. They should never be loose on the mayo stand Prepare suture in the table when the surgeon will use them After the surgeon and assistant scrubs, gown and glove the surgeon and assistant ASAP as they enter the OR table Assist in draping according to the type of procedure with the surgeon preference After draping is completed, bring the mayo stand into position over the patient Position the instrument table at a right angle to the OR bed. Assist the surgeon in securing sterile light handles for adjustment of the OR light 4 towels are used o The 1st 3 towels fold towards you o The last towel fold towards the surgeon o Drape near the surgeons body o After the 3 towels are placed, prepare 2 towel clips o After placing the last towel, prepare the last 2 clips. DURING THE SURGICAL PROCEDURE Pass the skin knife to the surgeon and pass a hemostat and suction to the assistant. When passing the knife, take care to direct the blade away from yourself and other personnel.

Hand up sterile towel or sponges if requested for covering skin at the edges of the incision. Watch the field and try to anticipate the needs of the surgeon and assistant. Keep one step ahead of them in passing instruments, sutures, and sponges in handling. Return instruments to the mayo stand or instrument table after use Keep instrument as clean as possible Have scissors ready when the knot is tied. Remove waste ends of suture material from the field, mayo stand, and instrument table and place them in the trash disposal container Follow established institutional policy and procedure for securing sharps during the surgical procedure Keep specimen table on the field. Before the closing of the skin or peritoneum, may request amount of fresh, warm irrigation solution to rinse the abdomen or smaller amount to irrigate the surgical wounds Alert the circu nurse that closure is about to begin In accordance with established procedure, count material as the surgeon begins closure of the wound. Place unneeded instruments and supplies on the instrument table in the original position Have a clear, warm, moistened sponge ready to wash blood from the area surrounding the incision as soon as skin closure is done. 8Ps TO CONSIDER When preparing for a Sterile Field Contact in Sterile Field Contact in surgical procedure Scrub Nurse Circulating Nurse Proper Placement Mayo stand should Suction, tourniquet pleaced so they will not be used during the need to be stationary not be moved procedure. Drapes may not be used. Proper function test Test for efficiency of Test the materials instruments for instruments usefulness Place it once energy Each item should be OR bed should be at and attention should placed where it will be the right place not be diverted used during the procedure Point of contact Should be aware of Evaluate the delivery passing of the of items to the sterile instruments and now field they are securely placed in the waiting hand of the surgeon on 1st assistant Position of function Placed in the Should be placed so positioned so they will surgeons hand in a they may be be usable during the usable way positioned while the procedure procedure is in progress Point of use close to Basin should be place the area close to the edges Protected parts Secured appropriately rendered safety of the patient and the team Prefect picture Should be neat and Should be neat orderly

RESPONSIBILITY OF A CIRCULATING NURSE Before entering the OR suite, circulating nurse must wash his or her hands and arms as required by institutional policy and procedure, but he or she does not wear sterile gowns and gloves Assist the sterile scrub nurse by opening the sterile by opening the sterile supplies Test all equipments After the scrub nurse scrub o Fasten the back of scrub nurse gown o Check with the scrub nurse to see if additional supplies or instruments After patient arrives - Attend to the patient while the scrub nurse continue to prepare the instrument table - Greet the patient - Verify any allergies - Be sure patients hair is covered by cap - Placing the restraints - Apply and connect or monitoring devices - Check IVF and level of IV - Time of the patient arrives - Check the presence of FBC - Check for the labs - Check for the consent During induction of anesthesia - Remain patients side during the induction of anesthesia - Assist the anesthesia provider during induction and intubation

- Maintain safe environment After the patient is anesthesized - Repositions the patient only after the anesthesia provider says go. - Prepare for skin prep - Turn on the off spotlight over the site of incision - Bag and discord the sponges from a reusable prep tray immediately after use After the scrub nurse is finished scrubbing - Fasten the waistline, assist in gowning the team - Should stand by to help with back flip tie in the gown - Observe for any break in the sterile technique - No touching of the drapes - Place steps or platform of team members - Connect suction and other equipment to be used - Place foot pedals within easy reach of the surgeons right foot - Confirm and document the desired setting on the machines During the surgical procedure - Be alert to anticipate needs of sterile team - Stay in the room - Use and care of the supplies - Know the condition of the patient at all times - Keep discarded sponges carefully collected - Assist surgeon/ anesthesia provider monitor blood loss - Prepare and label specimens - Communicate periodically with patient family and SO - Correlate the documentation in the patients chart During closure - Count sponges, sharps, and instruments with the scrub nurse - Obtain the washer sterilizer tray, instruments and other items necessary or the clean up - Send to PACU or ICU After surgical procedure is complete - Assess dressings - Open the gown Time out before the operation will start, start the surgeon will identify the patient LAYERS OF THE ABDOMEN AND THE SUTURES USED - Uterus (1st) Chromic 2.O - Uterus (2nd) Chromic 2.O - Peritoneum Chromic 2.O - Muscle Chromic 2.O - Fascia Vicryl O - SQ fat Plain 2.O - Skin Vicryl 3.O 5.O BASIC SURGICAL INSTRUMENTS OR Set up standardized basic set of sterile instruments are selected for each specific surgical procedure CLASSIFICATIONS: a) CUTTING OR DISSECTING Sharps are used to cut body tissues or surgical supplies o No. 7 handle with blade no. 15 cute deep delicate tissue (deep knife) o No. 3 handle with blade no. 10 cut superficial tissue but not skin (inside knife or 2nd knife) o No. 4 handle with blade no. 20 cut skin (1st knife or skin knife) Scissors o Straight mayo scissors cut suture and supplies AKA suture scissors o Curved mayo scissors cut heavy tissues (fascia, muscle) o Metzenbaum cut delicate tissues but not used to cut sutures o Electrocautery machine electrocautery pad attach to patient to a large surface area. Uses electricity b) CLAMPING AND OCCLUDING - Used for compress blood vessels or hollow organs for hemostasis or to prevent spillage of contents Hemostat used to clamp blood vessels. May be straight or curved Mosquito clamp small blood vessels. Used in thyroidectomy and mastectomy Kelly used to clamp large blood vessels in the tissue. AKA Rochester pean Burlisher used to clamp deep blood vessels. Burlishers have 2 closed finger rings. Open finger rings are also called hemostat. Other names are Adson forceps and Scnidt tonsil forceps. Right angle clamp used to clamp hard to reach vessels and to place suture behind or around the vessel. Right angle with a suture attached is called tie on a passer. Other names are Mixler. Hemoclip applier with hemoclips, applies netal chips onto the blood vessel and ducts which will remain occluded. c) GRASPING AND HOLDING Holds tissues and sponges Allis grasp tissues.available in short and long sizes. A Judd Allis holds intestinal tissue

Babcock grasp delicate tissues (intestine, fallopian tube, ovary) Kocher grasp heavy tissue. Used as a clamp, straight or curved. Other name is Ochsner Foerster sponge forceps used to grasp sponges. Other name: sponge foceps Dissector hold peanuts Towel clip hold towels and drapes in place. Tissue forceps pick up or thumb forceps Russian used to grasp tissues Adson pick up forceps Bonney grasping fascia during the closure of abdominal surgery Thumb forceps grasp tissues DeBakey grasp tissues, used particularly in cardiovascular surgery Needle holder holds needles Tenaculum used for D and C Randall Stones to grasp stones d) RETRACTING AND EXPOSING Deavor retract deep abdominal or chest incision.available in various widths Richardson deep abdominal or chest incision Army Navy (skin retractor) retract superficial tissue Goulet retract shallow incisions, self retracting Malleable or ribbon retract deep wounds Weitlaner retract shallow incisions, self retaining, adjustable and for orthopedic surgery Gelpi retract shallow incision (self retaining), the difference between Gelpi and Weitlaner is the teeth Balfour with bladder blade retract wound edges during deep abdominal procedure. Vein retractor for orthopedic surgery SUTURES - Holds tissues together Absorbable absorbed by the body and digested by the body o 3 weeks sufficient for the wound to close o Plain dissolved within 5 10 days, yellow in color o Chromic dissolved within 1 month, brown in color o Vicryl dissolved within 60 90 days, lavender in color o PDS dissolve 2 times longer than vicryl, white in color. Nonabsorbable remove after specified time o Type is divided again by the location of the wound. o Not metabolized in the body, removed by a few weeks o Silk animal produced from silk worm cocoons o Cotton long staple cotton o Wire greatest strength o Prolene biosynthetic, non absorbable suture material as substitute to silk. SUTURE NEEDLES Traumatic with holes or eyes, which are supplied to the hospital separate from their suture thread o Must be threaded on site, as is done when sewing at home. Atraumatic comprise a eyeless needle attached to a specific length of suture thread GENERAL CONSEQUENCES a) Handle loose instruments separately to prevent interlocking or crushing - Never pile on top of another. Microsurgery are vulnerable to damage through rough handling b) Inspect instruments for alignment, imperfection, cleanliness and wanking cord - Scalpel blades should not be properly set in handles using a heavy instrument. - Tips should be straight and in alignment - Teeth and serrations should align exactly - Scissors should be sharp - Cannula should be clear c) Sort instruments d) Leave retractor in a tray or container e) Protect sharp blade edges and tips POST OP PHASE Maintenance or maintaining adequate body system function Restore homeostasis State of emergence anesthesia is wearing off Alleviate pain discomfort Post operative teaching Prevent post operative complication PACU CARE

Endorse: Name, Operation, Surgeon, Anesthesia, V/S, Presence of drains, IV, General Status Transfer of patient from OR RR Avoid exposure and rough handling Avoid hurried movement and rapid changes in position INITIAL NURSING ASSESSMENT Verify patient identity Evaluate the surgeons sign and evaluate the level of stability with anesthesiologist Respi status, pulse, O2 sat, Circulatory status, temp, hemodynamic values Determine swallowing reflex and gag response, LOC, and response to stimuli. Evaluate tubes or drainage, estimate blood loss Evaluate patients level of comfort and safety side rails up Evaluate activity status Check the doctors order 1st priority maintain a patent airway o Allow ET tube to remain until the patient begins to be awake and is trying to eject the airway o Keep passage open and prevent the tongue from falling backward o Aspirate excessive secretions when sounds are head in the nasopharynx and oropharynx Assessing the status of the circulatory system o V/S per protocol (V/S every 15 minutes) o I and O o Assess for early s/sx of hemorrhage or shock cool extremities, decrease urine output, decrease BP, slow capillary refill, narrow pulse pressure o Place patient in shock position with his feet elevated (unless contraindicated) Maintain adequate Respi function o Place the patient in a lateral position, with neck extended o Turn the patient every 1 2 hours to facilitate breathing and ventilation o Assess lung fields o Administer humidified oxygen Assess thermoregulation status monitor temperature Minimizing complications o Turn the patient from side to side o Handwashing o Inspect dressing o Record the amount of drainage Maintain adequate fluid volume IV solution and watch out for F and E imbalance Maintaining safety side rails up and avoid nerve damage and muscle cramps Promoting comfort analegics PARAMETERS FOR DISCHARGE FROM PACU OR RR Activity able to obey commands Respiration easy and noiseless breathing Circulation BP within normal range Conciousness or Responsiveness Color pinkish skin COMPLICATIONS: a) Shock response of the body to a decrease in the circulating blood volume, tissue perfusion is impaired culminating in cellular hypoxia and death. Preventive Measures: o Have blood available if there is any indication that it may needed o Measure accurately any blood loss and monitor all fluid I and O o Anticipate progression of symptoms on earliest manifestation o Monitor V/S per protocol until they are stable o Assess V/S deviation; evaluate blood pressure in relation to other physiological parameters of shock and patients premorbid values. Orthostatic pulse and BP are important indicators of hypovolemic shock o Prevent infection because this will minimize the risk of septic shock b) Hemorrage copious escape of blood from the blood vessels. Classifications of hemorrhage are as follows: i. General a. Primary occurs at the time of the operation b. Intermediary occurs within the first few hours after surgery. BP returns to normal and causes loosening of some ligated sutures and flushing out of weak clots from unligated vessels.

c. Secondary occurs some time after surgery due to ligated slip from blood vessels and eroson of blood vessels. ii. According to blood vessels a. Capillary slow, general oozing from capillaries b. Venous bleeding that is dark in color and bubble out. c. Arterial bleeding that spurts and is bright red in color iii. According to location a. Evident or external visible bleeding on the surface b. Internal (concealed) bleeding that cannot be seen Clinical Manifestations: Apprehension; restlessness; thirst; cold, moist, pale skin; and circumoral pallor Pulse increases; respiration becomes rapid and deep (air hunger), temperature drops With progression of hemorrhage. o Decrease in CO and narrowed pulse pressure o Rapidly decreaseing BP, AWA Hct and Hgb o Patient grows weaker until death occurs Nursing Responsibilities: Inspect the wound as a possible site of bleeding. Apply pressure dressing over extent bleeding site. Increase IVF infusion rate and administer blood if necessary an ASAP. Ligation of bleeders by the surgeon as necessary. c) DVT occurs in pelvic veins or in deep veins of the LE in postoperative patients. DVT is most common after hip surgery, followed by retropubic prostatectomy; and general thoracic or abdominal surgery. Venous thrombi located above the knee are considered the major source of pulmonary emboli. Causes: o Injury to the intimal layer of the vein wall. o Venous stasis o Hypercoagulopathy, polycythemia o High risks include obesity, prolonged immobility, cancer, smoking, estrogen use, advancing age, varicose veins, DHN, splenectomy and orthopedic procedures Clinical Manifestations: o Pain or cramps in the calf (+ Homans sign) or thigh, progressive to painful swelling of the entire leg. o Slight fever, chills, perspiration o Marked tenderness over anteromedial surface of thigh o Intravascular clotting without marked inflammation may develop, leading to phlebothrombosis o Circulation distal to DVT may be compromised if sufficient swelling is present. NURSING INTERVENTIONS: Hydrate the client adequately postoperatively to prevent hemoconcentration Encourage leg exercises and ambulate the patient ASAP by surgeon. Avoid any restricting devices such as tight straps that can constrict and impair circulation Avoid rubbing or massaging calves and thighs Instruct patient to avoid standing or sitting in one place for prolonged periods or crossing legs when seated Refrain from inserting IV catheters into legs or feet of adults Assess distal peripheral pulses, capillary refill, and sensation of LE Check for + Homans sign calf pain on dorsiflexion of the foot. Prevent the use of bed rolls or knee gatches in patients at risk because there is danger of constricting the vessels under the knee. Initiate anticoagulant therapy either intravenously, SQ, or orally as prescribed Prevent swelling and stagnation of venous blood by applying appropriately fitting elastic stockings or wrapping the legs from the toes to the groin with elastic bandage Apply pneumatic stockings, intraoperatively to patients at highest risk of DVT. d) Pulmonary complications a. Atelectasis o Incomplete expansion of lung or portion of it occurring within 48 hours of surgery. o Attributed to absence of periodic deep breaths. o A mucus plug closes to bronchiole, causing alveoli distal to the plug to collapse o Symptoms are often absent may compromise mild to severe tachypnea, tachycardia, cough, fever, hypotension, and decreased breath sounds and chest expansion of affected side. b. Aspiration

o Caused by inhalation of food, gastric contents, water, or blood into the tracheobronchial system o Anesthetic agents and narcotics depress the CNS, causing inhibition of gag or cough reflexes o NGT insertion renders both upper and lower esophageal sphincters partially incompetent o Usually, evidence of atelectasis occurs within 2 minutes of aspiration. Other symptoms include tachypnea, dyspnea, cough, bronchospasm, wheezing, rhonci, crackles, hypoxia and frothy sputum c. Pneumonia o This is an inflammatory response in which cellular material replaces alveolar gas. o In post operative patient, most often caused by gram - negative bacilli due to impaired oropharyngeal defense mechanisms o Predisposing factors include atelectasis, URTI, copious secretions, aspiration, DHN, prolonged intubation or tracheostomy, hx of smoking, impaired normal host defenses (cough relfex, mucociliary system, alveolar macrophage activity) o Symptoms include dyspnea, tachypnea, pleuritic chest pain, fever, chills, hemoptysis, cough (rusty or purulent sputum), and decreased breath sounds over involved area. Preventive Measures: Report any evidence of URTI to the surgeon. Suction nasopharyngeal or bronchial secretions if patient is unable to clear own airway. Prevent regurgitation and aspiration through proper patient positioning Recognize predisposing causes of pulmonary complications o Infection - mouth, nose, throat, sinuses o Aspiration of vomitus o History of heavy smoking, chronic pulmonary disease o Obesity o Avoid oversedation NURSING INTERVENTIONS: Monitor the pt's progress carefully on a daily basis to detect early signs of respiratory difficulties o Slight temperature, pulse and respiration elevation o Apprehension and restlessness or a decreased level of consciousness o Complaints of chest pain, signs of dyspnea or cough Promote full aeration of the lungs o Turn the patient frequently o Encourage the patient to take 10 deep breaths hourly, holding each breath to a count of 5 and exhaling o Use a spirometer or any device that encourages the patient to ventilate more effectively o Assist the patient in coughing in an effort to bring up mucus secretions. Have patient splint chest or abdominal wound to minimize discomfort associated with DBE and coughing o Encourage and assist the patient to ambulate as early as the HCP will allow Initiate specific measures for particular pulmonary problems o Provide cool mist or heated nebulizer for the patient exhibiting signs of bronchitis or thick secretions. o Encourage patient to take fluids to help liquefy secretions and facilitate expectoration (in pneumonia) o Elevate HOB and ensure proper administration of prescribed oxygen o Prevent abdominal distention NGT insertion may be necessary o Administer prescribed antibiotics for pulmonary infections e) Pulmonary Embolism CAUSES: o Caused by the obstruction of one or more pulmonary arterioles by an embolus originating somewhere in the venous system or in the right side of the heart o Postoperatively, the majority of emboli develop in the pelvic or iliofemoral veins before becoming dislodged and travelling to the lungs. Clinical Manifestations: o Sharp, stabbing pain in the chest o Anxiousness and cyanosis o Pupillary dilation, profuse respiration o Rapid and irregular pulse become imperceptible leads rapidly to death o Dyspnea, tachypnea, hypoxemia o Pleural fiction rub (occasionally) Nursing Management: o Administer oxygen with the patient in an upright/sitting position o Reassure and keep the patient calm o Monitor V/S, ECG, and ABG

o Treat for shock or heart failure as needed o Give analgesics or sedatives to control pain or apprehension o Prepare for anticoagulant or thrombolytic therapy or surgical interventions f) Urinary Retention This is accumulation of 500 mL of urine or more, in the urinary bladder due to relaxation of its detrusor muscles. Causes: o Occurs postoperatively, especially after operations of the rectum, vagina, or lower abdomen o Caused by spasm of the bladder sphincter o More common in male clients due to inherent increase in urethral resistance to urine flow o Can lead to UTI and possible renal failure Clinical Manifestations: o Inability to void o Voiding small amounts at frequent intervals (e.g., voiding 30 60 mL every 15 30 minutes. This indicates overdistended bladder with overflow of urine o Palpable bladder o Lower abdominal discomfort Nursing Interventions: o Assist the client to sit or stand (if permissible) because many patients are unable to void while lying down o Provide client with privacy o Run the tap water frequently; the sound or sight of running water relaxes spasm of the bladder sphincter o Use warmth to relax sphincters o Notify physician if pt does not regulate regularly after surgery o Administer bethanol chloride (Urecholine) IM if prescribed o Catheterize only when all other measures are unsuccessful Urinary retention results in a partial or complete impairment to the forward flow of bowel contents. Loop of intestine may kink due to inflammatory adhesions. Most obstructions occur in the small bowel especially at its narrowest pint the ileum. g) Intestinal Obstructions Due to decreased or absent peristalsis, causing accumulation of gas and feces in the intestines. Clinical manifestations: o Intermittent sharp colicky abdominal pains o N&V. Vomitus is fecaloid due to reverse peristalsis o Abdominal distention, hiccups o Diarrhea for partial obstruction; absence of bowel movement for complete obstruction o High pitched for partial obstruction; absent bowel sounds for complete obstruction o Shock and death occurs Nursing Interventions: o Monitor for adequate bowel sound return after surgery. Assess bowel sounds and degree of abdominal distention (may need to measure abdominal girth) o Monitor and document characteristics of emesis and NG drainages o Relieve abdominal distention by passing a nasoenteric suction tube, as ordered. o Replace F and E o Monitor fluids, electrolytes (especially Na and K) and acid base imbalance o Administer narcotics judiciously because the medication may further suppress peristalsis o Prepare the client for surgical intervention if obstruction continues unresolved o Closely monitor patient for signs of shock o Provide frequent reassurance to patient; use nontraditional methods to promote comfort(touch, relaxation, imagery) h) Hiccups intermittent spasms of the diaphragm causing a sound (hic) that result from the vibration of closed vocal cords as air rushes suddenly into the lungs. Causes: o Irritation to the phrenic nerve between the spinal cord and the terminal ramification on undersurface of the diaphragm a. Direct distended stomach, peritonitis, abdominal distention, pleurisy, tumors pressing on nerves b. Indirect toxemia, uremia c. Reflex exposure to cold, drinking very hot or very cold liquids, intestinal obstruction Clinical Manifestations: o Audible hic

o Distress and fatigue o Vomiting o Wound dehiscence in severe cases Nursing Interventions: o Identify and resolve the cause, if possible o When removal of the cause is not possible, remedies may include if appropriate: Have client swallow a large gulp of water. Place tablespoon of coarse, granulated sugar on the back f clients tongue and have client swallow it. Administer a phenothiazine drug such as prochlorperazine (Compazine) or Chlorpromazine (Thorazine) as directed. Introduce a small catheter into the patients pharynx (about 8 10 cm or 3 4 inches); rotate gently and jiggle back and forth For rare, intractable hiccups, an extreme procedure is surgical alteration of the phrenic nerve. i) Wound infection 2nd most common nosocomial infection. The infection may be limited to the surgical site (60 80%) or may affect the patient systematically Causes: o Drying tissues by long exposure, operations on contaminated structures, gross obesity, old age, chronic hypoxemia and malnutrition are directly related to an increased infection rate. o The patients own flora is most often implicated in wound infections (S. Aureus) o Other causative agents in wound infection include E. coli, Klebsiella, Enterobacter, and Proteus. o Wound infections typically present 5 7 days postoperatively o Factors affecting the extent of infection include: Kind, virulence and quantity of contaminating MO Presence of foreign bodies or devitalized tissues Location and nature of the wound Amount of dead space or presence of hematoma Immune response to the patient Presence of adequate blood supply to the wound Presurgical conditions of the patient (e.g., elderly, alcoholism, DM, malnutrition) Clinical Manifestations: o Redness, excessive swelling, tenderness, warmth o Red streaks in the skin near the wound o Pus or other discharge from the wound o Tender, enlarged lymph nodes in axillary region or groin close to the wound o Foul smell from wound o Generalized body chills or fever o Elevated temperature and pulse o Increasing pain from incision care. NURSING PRIORITY: Mild transient fever appears postoperatively due to tissue necrosis, hematoma, or cauterization. Higher sustained fever arises with the following for most common postoperative complications: o Atelectasis within the 1st 48 hours o Wound infections in 5 7 days o Urinary infections in 5 8 days o Thrombophlebitis in 7 14 days Nursing Interventions: o Preoperative Encourage the pt to achieve n optimal nutritional level. Enteral or parenteral alimentation may be ordered preoperatively to reduce hypopoteinemia with weight loss Reduce postoperative hospitalization to a minimum to avoid acquiring nosocomial infections o Operative Follow strict asepsisthroughout the operative procedures When a wound has exudates, fibrin dessicated fat, or nonviable skin, it is not approximated by primary closure but approximation is delayed (secondary closure) o Postoperative Keep dressing intact, reinforcing if necessary, until prescribed otherwise Use strict asepsis when dressings are changed Monitor and document amount, type and location of drainage. Ensure that all drains are working properly o Postoperative care of an infected wound The surgeon removes one or more stitches, separates wound edges, and examines for infection using a hemostat or probe A culture is taken and sent to the laboratory for bacterial analysis

Wound irrigation may be done; have asepto syringe ad saline available A drain may be inserted, or the wound may be packed with sterile gauze Antibiotics are prescribed Wet-to-dry dressing may be applied. If deep infection is suspected, the patient may be taken back to the OR for debridement. j) Wound Dehiscence and Evisceration Wound Dehiscence disruption in the coaptation/approximation of wound edges. It is wound breakdown Wound Evisceration dehiscence with protrusion of intestines. CAUSES: o Commonly occurs between 5th 8th day postoperatively when incision has weakest tensile strength; greatest strength is found between 1st and 3rd postoperative day. o Chiefly associated with abdominal surgery o This catastrophe is often related to the following: Inadequate sutures or excessively tight sutures (the latter compromises blood supply) Hematomas, seromas Infections Excessive coughing, hiccups, retching Poor nutrition, immunosuppression Uremia, DM Steroid use Preventive Measures: o Apply abdominal binder for heavy or elderly patients or those with weak or pendulous abdominal walls. o Encourage patient to splint incision while coughing o Monitor for and relieve abdominal distention o Encourage proper nutrition with emphasis on adequate amounts of CHON and Vitamin C Nursing Interventions: o Stay with the patient and have someone notify the surgeon immediately o If intestines are exposed, cover with sterile moist saline dressings o Monitor V/S and watch out for shock o Keep the patient on absolute bed rest o Instruct patient to bend knees, with head of bed elevated in semi fowlers position to relieve tension on abdomen o Assure the patient that the wound will be properly cared for; attempt to keep patient quiet and relaxed o Prepare the client for surgery and repair of the wound. jlnastor16