CARE OF CLIENTS REQUIRING SURGERY

FAMADOR ORGE GENALDO, R.N., M.D., USRN

12/03/09

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General Considerations.

1. Conditions Requiring Surgery:  a. Obstruction or blockage  b. Perforation or rupture of an organ, artery, or bleb  c. Erosion or wearing away of the surface of a tissue  d. Tumors or abnormal growth

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2. Categories of Surgical Procedures:  According to Purpose:  a) Diagnostic: to verify suspected diagnosis e.g. biopsy  b) Exploratory: to estimate the extent of the disease e.g. exploratory laparotomy  c) Curative: to remove or repair damaged or diseased organs or tissues
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Types of Curative Surgery:  a) Ablative: removal of diseased organs e.g. nephrectomy, appendectomy  b) Reconstructive: partial or complete restoration of a damaged organ e.g. plastic surgery after burns  c) Constructive: repair of a congenitally defective organ e.g. plastic surgery of a cleft palate: cheiloplasty  d) Palliative: to relieve pain

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According to Degree of Risk to Client:  a) Major surgery  b) Minor surgery  Criteria:  a) Major surgery: High degree of risk  Prolonged intraoperative period  Large amount of blood loss  Extensive: Vital organs may be handled or removed  Great risk of complications  e. g. liver biopsy, colectomy 12/03/09

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b) Minor surgery: Lesser degree of risk to the client  Generally not prolonged; described as “one-day surgery” or outpatient surgery  Leads to few serious complications  Involves less risk  e. g. cyst removal

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According to Urgency:  a) Emergency: must be performed immediately

e.g. gunshot wound

b) Imperative or urgent: must be performed as soon as possible within 24-48 hours

e.g. severe bleeding

c) Planed required: necessary for client well being

e.g. tonsillectomy
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d) Optional: surgery that a client requests  e.g. face lift  e) Elective: should be performed for the client’s well being but which is not absolutely necessary  e.g. hernia repair  f) Required: necessary for the well-being of the client, usually within weeks to months  e. g. cholecystectomy

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• Factors that Affect the Estimation of Surgical Risk:

1. Physical and Mental Condition of the Client a) Age: premature babies and elderly persons are at risk  b) Nutritional status: malnourished and obese are at risk

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Factors that Affect the Estimation of Surgical Risk:
c) State of fluid and electrolytes balance: dehydration and hypovolemia predispose a person to complications  d) General health: infectious process increase operative risk  e) Mental health  f) Economic and occupational status

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Factors that Affect the Estimation of Surgical Risk:

g) Types of drugs taken regularly:  1). Steroids: may improve the body’s ability to response to the stress of anesthesia and surgery  2). Anticoagulants and salicylates: may increase bleeding during surgery  3). Antibiotics: maybe incompatible with or potentiate anesthetic agents

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Factors that Affect the Estimation of Surgical Risk:
 4).

Tranquilizers: potentiate the effect of narcotics and can cause hypotension  5). Antihypertensives: may predispose to shock by the combined effect of blood pressure reduction and anesthetic vasodilation  6). Diuretics: may increase potassium loss  7). Alcohol: will place the surgical client at risk when used chronically
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Factors that Affect the Estimation of Surgical Risk:
 

2. The Extent of the Disease 3. The Magnitude of the Required Operation 4. Resources and Preparation of the Surgeon, Nurses, and the Hospital

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The Three Phases of Perioperative Nursing:  Careful planning by the nurse can help ensure a positive outcome  Because clients experience varying degrees of anxiety and deficient knowledge related to surgery  Refers to activities performed by the professional nurse during these phases

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The Three Phases of Perioperative Nursing:  Encompasses a client’s total surgical experience, including:  Preoperative phase  Intra-operative phase  Postoperative phase

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Phases of Perioperative Nursing

1. Pre-Operative Phase: begins with the decision to perform surgery and ends with the client’s transfer to the operating room table 2. Intra-Operative Phase: begins with the client is received in the OR and ends with his admission to the post-anesthesia recovery room (PARR) or postanesthesia recovery unit (PACU) 3. Post-Operative Phase: begins with the client is admitted to PARR or PACU and extends through follow-up home or clinic evaluation

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The Perioperative Team:
 

The Surgeon Registered Nurse First Assistant  Qualified RNs in place of second or assisting physicians during surgical procedures  An experienced perioperative nurse who has had additional specialized education to perform the role  Works with the primary surgeon during surgery  Activities include:
 Providing

exposure of the operative area  Using instruments to hold and cut  Retracting and handling the tissue  Providing hemostasis and suturing

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The Perioperative Team:

An Anesthesiologist or Nurse Anesthetist (CRNA)  Makes the preoperative assessment to plan for the type of anesthesia to be administered and to evaluate the client’s status  Had 1-2 years of acute or intensive care nursing experience The Professional Registered OR Nurse Manager  Makes preoperative assessment and documents the intra-operative client care 12/03/09 18 plan

The Perioperative Team:

The Circulating Nurse  Manages the OR and protects the safety and health needs of the client by monitoring the activities of the members of the surgical team and monitoring the conditions in the OR

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The Perioperative Team:

The Circulating Nurse  Activities:
all equipment is working properly  Guaranteeing sterility of instruments and supplies  Assisting with positioning  Performing with the surgical skin preparation  Monitoring the room and team members for breaks in sterile technique  Assisting anesthesia personnel with induction and physiologic monitoring  Handling specimens  12/03/09 Documenting care provided 20
 Ensuring

The Perioperative Team:

The Scrub Nurse  Responsible for scrubbing for surgery, including setting up sterile tables and equipment and assisting the surgeon and surgical technicians during the surgical procedure

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The Perioperative Team:

The Scrub Nurse  Activities and responsibilities:
all equipment for the procedure  Preparing all supplies and instruments using sterile technique  Maintaining sterility within the sterile field during surgery  Handling instruments and supplies during surgery  Cleaning up after the case During the surgery, the scrub nurse maintains an accurate count of sponges, sharps, and instruments on the sterile field and counts the same materials with the circulating nurse before and after the surgery
 Gathering

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The Perioperative Team:

The PACU Nurse  Responsible for caring for the client until the client:  Has recovered from the effects of anesthesia  Is oriented  Has stable vital signs  Shows no evidence of hemorrhage

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Principles of Perioperative Asepsis

General Principles  Keep sterile supplies dry and unopened  Check package sterilization expiration date to verify sterility  Maintain general cleanliness in surgical suite  Maintain surgical asepsis: activities designed to keep sites free from the presence of microorganisms) throughout the procedure
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Principles of Perioperative Asepsis

Personnel  Personnel with signs of illness should not report to work  Surgical scrub, a specific handwashing technique used by operating room personnel designed to reduce microorganisms in the hands and arms, is done for the length of time designed by hospital policy
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Surgical Scrub

1) A sensor-controlled or knee- or footoperated faucet allows the water to be turned on and off without the use of the hands 2) Remove all rings and watches 3) Use liquid soaps to prevent the spread of organisms

 

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Surgical Scrub

4) Keep the finger nails short and welltrimmed  Clean fingernails with a nail stick under running water 5) Hold the hands higher than the elbows throughout the handwashing procedure so that run-off goes to the elbows  Allows the cleanest part of the arms to be the hands
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Surgical Scrub

6) A scrub brush facilitates the removal of microorganisms  Clean all areas of skin on the hands and arms in sequence starting at the hands and ending at the elbows 7) After rinsing, dry the hands with paper towels, drying first one arm from the hand to the elbow, then using a second towel to dry the second hand
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Principles of Perioperative Asepsis

Maintaining a Sterile Field (a microorganismfree area)  Create a sterile field using sterile drapes  Use the sterile field to place sterile supplies where they will be available during the procedure  Drape equipment prior to use  Keep drapes dry and out of contact with nonsterile objects  Utilize sterile technique while adding or removing supplies from sterile fields
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Principles of Perioperative Asepsis

Sterile Supplies and Solutions  Check expiration dates for sterility  Don’t use solutions that were opened prior to current use

“Lip” the solution after initial use by pouring a small amount of liquid out of the bottle into a waste container to cleanse the bottle lip
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Principles of Surgical Asepsis

  

1. OR personnel must practice strict Standard Precautions (i.e., blood and body substance isolation) 2. All items used in the sterile field must be sterile 3. Sterile objects become unsterile when touched by unsterile objects 4. Sterile items that are out of vision sterile or below the waist level of the nurse are considered unsterile
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Principles of Surgical Asepsis
 

5. Sterile objects can become unsterile by prolonged exposure to air-born organism 6. The skin can not be sterilized and is unsterile  All personnel must perform a surgical scrub 7. All OR personnel are required to wear specific, clean attire, with the goal of “shedding” the outside environment.
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Principles of Surgical Asepsis

Specific clothing requirements are prescribed and standardized for all ORs  a. OR personnel must wear a sterile gown, gloves, and specific shoe covers  b. Hair must be completely covered

c. Masks must be worn at all times in the OR for the purpose of minimizing airborne contamination and must be changed between operations or more often, if necessary
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Principles of Surgical Asepsis

8. Any personnel who harbors pathogenic organisms must report themselves unable to be in the OR to protect the client from outside pathogens 9. Scrubbed personnel wearing sterile attire should touch only sterile items

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Principles of Surgical Asepsis

10. Sterile gowns and sterile drapes have defined borders for sterility.

Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile. Contact with unsterile objects at any point renders a sterile area contaminated.
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Principles of Surgical Asepsis

11. The circulator and unsterile personnel must stay at the periphery of the of the sterile operating area to keep the sterile area free from contamination 12. Sterile supplies are unwrapped and delivered by the circulator following specific standard protocol so as not to cause contamination

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Principles of Surgical Asepsis

13. The utmost caution and vigilance must be used when handling sterile fluids to prevent splashing or spillage 14. Anything that is used for one client must be discarded or, in some cases, resterilized

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 A.

PRE-OPERATIVE PHASE

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A. Pre-Operative Phase

Begins at the time of decision for surgery and ends when the client is transferred to the OR This period is used to physically and psychologically prepare the client for surgery The nurse plays a major role in client teaching and in relieving the client’s and the family’s anxieties
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Pre-Operative Phase

Goals:  Assessing and correcting physiologic and psychologic problems that might increase surgical risk  Giving the person and significant others complete learning/ teaching guidelines regarding surgery Instructing and demonstrating exercises that will benefits the person during post-op period  Planning for discharge and any projected changes in lifestyle due to surgery

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Pre-Operative Phase

a) Psychologic Preparation for Surgery

Preparation for hospital admission: includes  Explanation of the procedure to be done  Probable outcome  Expected duration of hospitalization  Cost  Length of absence from work  Residual effects
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Pre-Operative Phase

Causes of Fears:  Fear of the unknown  Fear of anesthesia, vulnerability while unconscious  Fear of pain  Fear of death  Fear of disturbance of body image  Worries: loss of finances, employment, social and family roles
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Pre-Operative Phase

Manifestations of Fears:  Anxiousness and bewilderment  Anger  Tendency to exaggerate  Sad, evasive, tearful, clinging  Inability to concentrate  Short attention span  Failure to carry out simple directions  Dazed
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Pre-Operative Phase

Nursing Interventions to Minimize Anxiety:  Assess client’s fears, anxieties, support systems, and patterns of coping  Establish trusting relationship with client and significant others  Explain routine procedures, encourage verbalization of fears, and allow client to ask questions  Demonstrate confidence in surgeon and staff  Provide for spiritual care if appropriate 44 12/03/09

Pre-Operative Phase

b) Legal aspect: “Informed Consent”, operative permit, surgical consent This is to protect the surgeon and the hospital against claims that unauthorized surgery has been performed and that the client was unaware of the potential risks of complications involved  Protects the client from undergoing unauthorized surgery

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Pre-Operative Phase

1) The Surgeon obtains operative permit or informed consent  Surgical procedure, alternatives, possible complications, disfigurements, or removal of body parts are explained

It is part of the nurse’s role as a client advocate to confirm that the client understands information given
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Pre-Operative Phase

2) Informed consent is necessary for each operation performed, however minor  It is also necessary for major diagnostic procedures where major body cavity is entered  e.g. bronchoscopy, thoracentesis

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Pre-Operative Phase

3) Adult client (over 18 years of age) signs own permit unless unconscious or mentally incompetent  If unable to sign, relative, (spouse or next of kin) or guardian will sign  In an emergency, permission via the telephone or telegram is acceptable;  Have a second listener on phone when telephone permission being given
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Pre-Operative Phase

Consents are not needed for emergency care if all four of the following criteria are met:  1. There is an immediate threat to life  2. Experts agree that it is an emergency  3. Client is unable to consent  4. A legally authorized person cannot be reached

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Pre-Operative Phase

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4) Minors (under 18) must have consent signed by an adult (i.e. parent or legal guardian).  An emancipated minor may sign own consent:  Married  College student living away from home  In military service  Any pregnant female or anybody who has given birth
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Pre-Operative Phase

5) Witness to informed consent may be nurse, other physician, clerk, or authorized person 6) If nurse witnesses informed consent, specify whether witnessing explanation of surgery or just signature of client

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Pre-Operative Phase

c) Physiologic Preparation  1) Respiratory preparation:  chest x-ray  2) Cardiovascular preparation:  ECG, CBC, blood typing, cross-matching, PT/PTT (prothrombin time, partial thromboplastin time), serum electrolytes  3) Renal preparation:  Urinalysis
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Pre-Operative Phase

Obtain history of past medical conditions, allergies, dietary restrictions, and medications  A – Allergy to medications, chemicals, and other environmental products such as latex  All allergies are reported to anesthesia and surgical personnel before the beginning of surgery  If allergy exist, an allergy band must be 12/03/09 placed in the client’s arm immediately 53

Pre-Operative Phase

B – Bleeding tendencies or the use of medications that deter clotting, such as aspirin, heparin, and warfarin sodium.  Herbal medications may also increase bleeding time or mask potential bloodrelated problems C – Cortisone and steroid use

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Pre-Operative Phase

D – Diabetes mellitus, a condition that not only requires strict control of blood glucose levels but also known to delay wound healing E – Emboli; previous embolic events ( such as lower leg blood clots) may recur because of prolonged immobility

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Pre-Operative Phase

d) Instructional and preventive aspects:  Frequently done in an out-client basis  Assess the client’s level of understanding of surgical procedure and its implications Answer questions, clarify and reinforce explanations given by surgeon  Explain routine pre and post procedures and any special equipment to be used  Deep breathing exercises: use of diaphragmatic and abdominal breathing

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Pre-Operative Phase
Coughing exercise: deep breath, exhale through the mouth, and then follow with a short breath while coughing; splint thoracic and abdominal incision to minimize pain  Turning exercise: every 1-2 hours post-operative

Extremity exercise: prevents circulatory problems and post operative gas pains or flatus  Assure that pain medications will be available post-op

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Pre-Operative Phase

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e) Physical Preparation  On the night of the surgery  Preparing the client’s skin: shave against the grain of the hair shaft to ensure clean and close shave  Preparing the GIT:  NPO after midnight  Note: the age of the client should be taken in to consideration  Infants and children has a higher metabolic rate than adult
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Pre-Operative Phase makes it essential for the child or infant to receive CHO regularly to prevent acidosis from occurring  Administration of enema  Insertion of gastric or intestinal tubes
 This

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Pre-Operative Phase Preparing for Anesthesia Promoting rest and sleep: use of drugs  Barbiturates: Secobarbital Na (Seconal), Pentobarbital Na (Nembutal)  Non barbiturates: chloral hydrate, Flurazepam (Dalmane)  Note: given after all pre-op treatments have been completed.  If a second barbiturate is needed, it must be given at least 4 hours before the pre12/03/09 medications are due 60 op

Pre-Operative Phase
 

On the Day of Operation Early morning care: about 1 hour before the pre-operative medication schedule  Vital signs taken and recorded promptly  Provide oral hygiene  Remove jewelries and dentures  Remove nail polish  Make sure that the patient has not taken food for the last 10 hours by asking the client
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Pre-Operative Phase
Pre-Operative Medications: Generally administered 60-90 min before induction of anesthesia Purpose:  To allay anxiety: the primary reason for preoperative medications  To decrease the flow of pharyngeal secretions  To reduce the amount of anesthesia to be given  To create amnesia for the events that precedes surgery

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Pre-Operative Phase Types of Pre-Operative Medications: 1) Sedative:  a) Given to decrease the client’s anxiety to lower BP and pulse  b) Reduce the amount of general anesthesia: an overdose can result to respiratory depression  e.g. Phenobarbital (Seconal Na, Nembutal Na)

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Pre-Operative Phase

2) Tranquilizer: lowers the client’s anxiety level (ataractic)  e.g. Thorazine 12.5 - 25 mg IM 1-2 hours prior to surgery  Phenergan 12.5 - 25 mg IM 1-2 hours prior to surgery  * Note: can cause a dangerous hypotension, both during and after surgery

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Pre-Operative Phase

3) Narcotic analgesia: given to reduce patients to reduce anxiety and to reduce the amount of narcotics given during surgery e.g. Morphine sulfate 8-15 mg SC 1 hour prior to preoperative  * Can cause vomiting, respiratory depression and postural hypotension

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Pre-Operative Phase

4) Vagolytic or drying agents: to reduce the amount of tracheobronchial secretions which can clog the pulmonary tree and result in atelectasis and pneumonia  e.g. Atropine sulfate 0.3-0.6 mg IM 45 min before surgery  * An overdose can result to severe tachycardia

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Pre-Operative Phase

Recording: all final preparation and emotional response before surgery should be noted down Transportation to the OR  Woolen or synthetic blankets must never be sent to the OR because they are source of static electricity

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Pre-Operative Phase

f) Nursing Diagnosis for Preoperative Client  Anxiety related to lack of knowledge about preoperative routines, physical preparation for surgery, post operative care and potential body image change

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 B.

INTRA-OPERATIVE PHASE

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• B. Intra-Operative Phase

Begins the moment the client is anesthesized and ends when the last stitch or dressing is in place Anesthesia  An artificially induced state of partial or total loss of sensation with or without loss of consciousness

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Intra-Operative Phase

Effects of Anesthetic Agents:  Produce muscle relaxation  Block transmission of pain nerve impulses (Analgesia)  Suppress reflexes  Temporarily decrease memory retrieval and recall

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Intra-Operative Phase

The depth and effect of anesthesia are monitored by observing changes in:  Respiration  O2 saturation, and end-tidal CO2 levels  BP and CR  Urine output

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Intra-Operative Phase

Client’s concern about anesthesia:  Adequacy of pain-blocking effects  Being put to sleep with a drug  Whether client will talk during anesthesia  The presence of nausea and vomiting postoperatively Nursing responsibility:  Providing reassurance about the capability of the anesthesia provider and  About the availability of other drugs to reduce any unpleasant side effects of the 12/03/09 73 anesthesia

Intra-Operative Phase

The decision about the type of anesthesia to be used is made by:  The anesthesia provider  The surgeon  The client  The surgical procedure

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Intra-Operative Phase

The Two Major Techniques of Anesthesia Administration:  I. General Anesthesia  Intravenous Anesthesia  Inhalation Anesthesia

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Intra-Operative Phase

Mechanism of Action of General Anesthetics  Block pain stimulus at the cerebral cortex and  Induce depression of the CNS  Reversion of effect either by:  Metabolic change and elimination from the body or  Pharmacologic means

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Intra-Operative Phase

Effects of General Anesthesia:  Analgesia  Amnesia  Unconsciousness  Loss of reflexes and muscle tone

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Intra-Operative Phase

Indications of GA:  Surgery of the head and neck  Upper torso and back  For prolonged surgical procedures  For clients unable to lie for quietly for a long period

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Intra-Operative Phase

II. Regional Anesthesia:  Spinal Anesthesia  Epidural Anesthesia  Caudal Anesthesia  Topical  Local infiltration  Field block  Peripheral nerve block  IV nerve block
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Intra-Operative Phase

Regional Anesthetics  Given to block the pain stimulus at its origin, along afferent neurons, or along the spinal cord  Produces a loss of painful sensation in only one region of the body and does not result in unconsciousness  Sedative agents may be given to produce drowsiness
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Intra-Operative Phase

a) Four Stages of Anesthesia:  Stage I Onset  Stage II Excitement  Stage III Surgical Anesthesia  Stage IV Danger Stage (Death)

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Intra-Operative Phase
 

Last sense to be depressed: Auditory The client can hear and may remember conversations on awakening Nursing Responsibility: Ensures that all conversation during induction and throughout the case is appropriate

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Intra-Operative Phase

Clients emerge into consciousness backward through all three stages of anesthesia after the anesthetic agents are discontinued Therefore, hearing is the first sense to return

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 Four
Stage Start-point

Stages of Anesthesia
Physical Reactions Nursing Interventions

End-point

I. Anesthetic Loss of Client maybe Close operating Onset administration consciousness drowsy, or dizzy room doors, Possible auditory keep room quiet and visual Stand by to assist hallucinations the client

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 Four

Stages of Anesthesia
Physical Reactions Nursing Interventions Remain quietly at client’s side Assist anesthetist, as needed

Stage

Start-point

End-point

II. Loss of Loss of eyelid Increase in Excitemen consciousness reflexes autonomic t activity Irregular breathing Client may struggle

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 Four

Stages of Anesthesia
Physical Reactions Nursing Interventions

Stage

Start-point

End-point

III. Surgical Loss of eyelid anesthesia reflexes

Loss of most Client is Begin preparation (if reflexes unconscious indicated) only when anesthesia indicates Depression of Muscles are stage III has been vital functions relaxed No blink or gag reached and client is breathing well, with reflexes stable vital signs

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 Four

Stages of Anesthesia
Physical Reactions Nursing Interventions

Stage

Start-point

End-point

IV. Danger Functions Respiratory excessively and (death) depressed circulatory failure

Client is not If arrest occurs, respond breathing immediately to assist in establishing airway, A heartbeat may or may notprovide cardiac arrest tray, drugs syringes, be present long needles Assist surgeon with closed or open cardiac massage

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 Four
Stage I. Onset Start-point

Stages of Anesthesia
Physical reactions Client maybe drowsy, or dizzy Possible auditory and visual hallucinations Nursing interventions Close operating room doors, keep room quiet Stand by to assist the client

End-point

Anesthetic Loss of administration consciousness

II. Excitement Loss of Loss of eyelid consciousness reflexes

Increase in Remain quietly at client’s side autonomic activity Assist anesthetist, as needed Irregular breathing Client may struggle

III. Surgical Loss of eyelid anesthesia reflexes

Loss of most Client is unconscious Begin preparation ( if indicated) reflexes Muscles are relaxed only when anesthesia indicates stage III has been reached and Depression of vital No blink or gag client is breathing well, with functions reflexes stable vital signs

IV. Danger (death)

Functions excessively depressed

Respiratory and circulatory failure

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Client is not breathing A heartbeat may or may not be present

If arrest occurs, respond immediately to assist in establishing airway, provide cardiac arrest tray, drugs syringes, long needles 88 Assist surgeon with closed or open cardiac massage

• Intra-Operative Phase

b) Types of Anesthesia:  1. General Anesthesia:  A state of analgesia, amnesia, and unconsciousness characterized by the loss of reflexes and muscle tone

Administered by using a combination of agents based on the client's need with consideration of the type of surgery to be performed
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Intra-Operative Phase

Most common way of administering GA: Neuroleptic or Balanced Anesthesia  Achieved by using a combination of an inhalation agent, O2, an opioid, and a neuromuscular blocking agent (muscle relaxant) Neuromuscular blocking agents:  Given mainly to facilitate intubation by easing laryngospasm and relaxing muscles for controlled ventilation  Succinylcholine (Anectine)  Tubocurarine 12/03/09 90  Pancuronium (Pavulon)

• Intra-Operative Phase

a). Intravenous Anesthesia:  Usually employed as an induction prior to administration of the more potent inhalation anesthetic agents.  Used commonly in minor procedure  Dental extraction  Unconsciousness generally occurs 30 seconds after administration  Rapid and smooth transition from conscious stage to surgical anesthesia stage
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Intra-Operative Phase

Advantage of IV Anesthesia:

1. Rapid pleasant induction 2. Absence of explosive hazards 3. Low incidence of nausea and vomiting

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• Intra-Operative Phase

Disadvantage of IV Anesthesia:  1. Laryngeal spasm and bronchospasm  2. Hypotension  3. Respiratory arrest

Examples:  Thiopental Na (Pentothal Na)  Ketamine (Ketalar)  Fentanyl (Innovar)
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Intra-Operative Phase

b). Inhalation Anesthesia  A mixture of volatile liquids or gas and O2 is used  Usually used to maintain the client in stage III anesthesia following induction The mixture is given through a mask or through an endotracheal tube which is inserted once the client is paralyzed and unconscious  O2 tank: green color 12/03/09 94  CO2 tank: gray color

Intra-Operative Phase

Administration by a mask:  The gases flow into the mask via a finely calibrated vaporizer that is controlled by a machine Administration by ETT:  The gases flow directly into the client’s tracheobronchial tree, resulting in a quick response
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Endotracheal Intubation

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Intra-Operative Phase

Advantage:  Ease of administration and elimination through the respiratory system  Rapid onset  Prevention of pain and anxiety Disadvantage: circulatory and respiratory depression  * Highly flammable and explosive
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Intra-Operative Phase

Two commonly used Inhalation Anesthetics:  Halothane  Isoflurane Commonly used Gas Anesthetic:  Nitrous oxide (Blue tank)

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• Intra-Operative Phase

Safety rules:  Do not wear slips, nylons, wool, or any material which can set-off sparks  Do not touch the vicinity of the breathing area to prevent sparks  No smoking 12 hours after the operation  Do not wear shoes that are nonconductive

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• Intra-Operative Phase

c. Rectal Anesthesia:  Rarely used today  Useful during the induction of anesthesia of pediatric clients  e.g. Pentothal Na

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• Intra-Operative Phase

2. Regional Anesthesia:  It is the injection or application of a local anesthetic agent to produce a loss of painful sensation in only one region of the body  Does not result to unconsciousness  Blocks the conduction of impulses in the nerve fibers without depolarizing the cell membrane
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Intra-Operative Phase

Epinephrine as an additive to local anesthetics:  To prolong the effect of anesthesia through vasoconstriction thus, delaying the absorption of the anesthetic agent  To cause vasoconstriction thus reducing bleeding during the procedure

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Intra-Operative Phase

a). Spinal Anesthesia  Often the anesthetic technique of choice of older adults  Can be used for almost any type of major procedure performed below the level of the diaphragm  Cholecystectomy, appendectomy

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103

Intra-Operative Phase

Spinal Anesthesia is achieved by injecting local anesthetics into the subarachnoid space Position of client: genu-pectal or knee-chest position Level of anesthesia: Intervertebral space between
 

L2 and L3 L3 and L4

Autonomic nerve fibers are affected first and also the last to recover
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Intra-Operative Phase

After blockade of the ANS, spinal anesthesia blocks the following fibers in this order:  1) Touch  2) Pain  3) Motor  4) Pressure  5) Proprioceptive fibers (sensory fibers for movement and position)

Touch ► Pain ►Motor ►Pressure ►Proprioception
105

12/03/09

Intra-Operative Phase

Within minutes of administration the client experiences a loss of sensation and paralysis of the of the toes, feet, legs, and then abdomen

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106

Meninges and Spaces of the Brain and Spinal Cord

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107

The Vertebral Column and Space

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108

Spinal Anesthesia

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109

Spinal Anesthesia

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110

The Distribution of the Spinal Nerves and its Dermatomes

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111

Intra-Operative Phase

Complications of SA:  Hypotension  Paralysis of vasomotor nerves, occurring shortly after induction of anesthesia  Rapid IVF administration before the block  Administer O2 by inhalation  Trendelenburg position 10-20 min after induction  Vasoactive drugs: Ephedrine
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Intra-Operative Phase

Nausea and vomiting  Occurs mainly from abdominal surgery because of traction placed on various structures within the abdomen or from hypotension  Drugs used: antiemetics

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113

Intra-Operative Phase

Headache  Can be extremely painful and may last a week  CSF, which cushions the brain, is lost through dural hole  Leakage of fluid with loss of cushioning effect is increased by:  Use of large spinal needle  Poor hydration  Keep client flat 6-8 hours postoperatively 12/03/09 114

Intra-Operative Phase

Respiratory paralysis  Occurs when drug reaches upper thoracic or cervical spinal levels in large amounts or in heavy concentrations  Do artificial respiration  Avoid extreme T-position after induction

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115

Intra-Operative Phase

Neurologic complications:  Paraplegia  Severe muscle weakness in legs  Postoperative paralysis may be due to:  Unsterile needles, syringes and anesthetic agent  Pre-existing diseases of the CNS  Transient response to anesthetics  Position during surgery
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Intra-Operative Phase

Advantages of SA:  Relatively safe  Excellent lower-body muscle relaxant  Absence of effect on consciousness  Doe not require empty stomach

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117

Intra-Operative Phase

b) Epidural Anesthesia  Introduction of anesthetic agent into the epidural space  The needle is carefully positioned in the epidural space without penetrating the dura and without entering the subarachnoid space

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118

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119

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120

Epidural block produces a blockade of the autonomic nerves and can result to hypotension If the level of block is too high and respiratory muscles are affected, respiratory depression or paralysis may occur The epidural space is generally entered by a needle at a thoracic, lumbar, sacral, or caudal interspace

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121

Intra-Operative Phase

c) Caudal Anesthesia  A variation of epidural anesthesia  Produced by injection of the local anesthetic into the caudal or sacral canal  This method is commonly used with obstetric clients

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122

Intra-Operative Phase

d) Topical Anesthesia  Application of the agent directly to the skin, mucous membranes, or open surface to be desensitized  The anesthetic may be a solution, an ointment, a gel, a cream, or a powder

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123

A short-acting form of anesthesia can block peripheral nerve endings in the mucous membranes of the vagina, rectum, nasopharynx, and mouth Used in minor procedures: rectal examination with painful hemorrhoids, and bronchoscopy

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124

Commonly used topical anesthesia:  Solution of 4-10% cocaine  For topical used only primarily to anesthetize the eye and the mucous membrane of nose, mouth, and urethra  Highly toxic agent

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125

Accidental injection: can cause severe excitement or seizures; followed by shock, respiratory failure, and cardiac arrest

Nursing Responsibility:  Emergency resuscitation equipment must be available

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126

Other topical anesthetic agents:  Tetracaine  Procaine  Mepivacaine  Lidocaine (Xylocaine)

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127

Intra-Operative Phase

e) Local Infiltration Anesthesia  Involves the injection of an anesthetic agent into the skin and subcutaneous tissue of the area to be anesthesized

Blocks the peripheral nerves around the area of the incision During administration of the agent, aspiration should be done to ensure that the needle is not in the blood vessel
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Intra-Operative Phase

Inadvertent intravenous injection of the agent can result to cardiovascular collapse or convulsions

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129

Intra-Operative Phase

f) Field Block Anesthesia  The area proximal to a planned incision can be injected and infiltrated with local anesthetic agents to produce field block.

The block forms a barrier between the incision and the nervous system

A field block actually walls in the area around the incision and prevent transmission of sensory impulses to the 12/03/09 130 brain from that area

Intra-Operative Phase

g) Peripheral Nerve Block Anesthesia  Anesthetizes individual nerves or nerve plexuses  Examples:  Digital nerve block: fingers  Brachial plexus nerve block: entire upper arm  Intercostal nerve block: chest or abdominal wall
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Intra-Operative Phase
Peripheral Nerve Block Anesthesia  Injection of anesthetic agents along the nerve rather done into the nerve in an effort to decrease the risk of nerve damage  Agents commonly used: lidocaine, bupivacaine, and Mepivacaine

Epinephrine-containing agents are not used for surgery involving the extremities, like below the wrist and ankle, because of vasoconstriction 12/03/09

132

Intra-Operative Phase

IV Regional Extremity Block Anesthesia (Bier Block)  Regional anesthesia of a limb can be achieved with an agent when it is injected into a vein of the limb to be anesthetized

A pneumatic dual-cuff tourniquet applied to the anesthetized area prevents the lidocaine from circulating beyond the area undergoing the procedure
133

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Intra-Operative Phase
This type of anesthesia is used most commonly for procedures of the extremities that are of short duration  Agent used: lidocaine

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Intra-Operative Phase

Specialized methods of producing anesthesia: 1. Muscle relaxants: It is a neuromuscular blocking agent used to provide muscle relaxation  Use: For endotracheal intubation  Pancuronium bromide (Pavulon)
 Curarine

chloride (Curare)

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135

• Intra-Operative Phase

2. Hypothermia: it refers to the deliberate reduction of the patient’s body temperature between 28°-30° C  Uses:  Heart surgery  Brain surgery  Surgery on large vessels supplying major organs

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• Intra-Operative Phase

Methods:

a) Ice water immersion b) Ice bags c) Cooling blanket d) Extracorporeal cooling devices

Complications:  a) Cardiac arrest  b) Respiratory depression 12/03/09

137

• Intra-Operative Phase
 

Positioning the Client Commonly used operative positions: Dorsal recumbent / Supine: hernia repair, exploratory laparotomy, cholecystectomy, mastectomy, CABG,

Prone: spine surgery, rectal surgery, rectal, posterior leg surgery Trendelenburg: surgery of the lower abdomen and the pelvis

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138

 

Reverse Trendelenburg Lithotomy position: vaginal repairs, dilation and curettage, rectal surgery Lateral position: kidney, chest, and hip surgery For thyroidectomy - head hyperextended Nursing responsibility: Promote Safety
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 C.

POST-OPERATIVE PHASE

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140

• C. Post-Operative Phase
 

A) Post Anesthetic Care Nursing responsibilities:  1) Maintenance of Pulmonary Ventilation:  Position the client to side lying or semiprone position to prevent aspiration

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141

C. Post-Operative Phase

Oropharyngeal or nasopharyngeal airway:  Is left in place following administration of general anesthetic until pharyngeal reflexes have returned

It is only removed as soon as the client begins to awaken and has regained the cough and swallowing reflexes

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142

C. Post-Operative Phase

All clients should received O2 at least until they are conscious and are able to take deep breaths on command Shivering of the client must be avoided to prevent an increase in O2, and should be administered until shivering has ceased

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143

C. Post-Operative Phase

2) Maintenance of Circulation:  Most common cardiovascular complications:  a) Hypotension  Causes:  Jarring the client during transport while moving client from the OR to his bed  Reaction to drug and anesthesia
12/03/09 144

C. Post-Operative Phase
Causes:  Loss of blood and other body fluids  Cardiac arrhythmias and cardiac failure  Inadequate ventilation  Pain

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145

Post-Operative Phase

b) Cardiac arrhythmias  Causes:  Hypoxemia  Hypercapnea  Interventions:  O2 therapy  Drug administration:  Lidocaine  Procainamide (Pronestyl)
12/03/09 146

Post-Operative Phase

3) Protection from injury and promotion of comfort  Provide side rails Turning frequently and placed in good body alignment to prevent nerve damage from pressure  Administration of narcotic analgesics to relieve incisional pain

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Post-operative dose usually reduced to half the dose the patient will be taking after fully recovered from anesthesia

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148

Post-Operative Phase

B) Dismissal of client from recovery room: Modified Aldrete Score for Anesthesia Recovery Criteria The Five Physiological Parameters:  1. Activity  2. Respiration  3. Circulation  4. Consciousness  5. Color 12/03/09

149

The Five Physiological Parameters: 1. Activity - able to move four extremities voluntarily on command 2. Respiration - able to breath effortlessly and deeply, and cough freely 3. Circulation - BP is (+ 20%) or (- 20%)

of pre-anesthetic level

4. Consciousness - fully awake, oriented to time, place and person 5. Color- pink (lips), (for blacks: tongue)
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 

Post Anesthesia Care Unit MODIFIED ALDRETE SCORE
Point Score 1 hour

After 2 hours 3 hours

Area of assessment Muscle activity: Moves spontaneously or on command  Ability to move all extremities  Ability to move 2 extremities  Unable to control any extremity

2 1 0 2 1 0 2 1 0 2 1 0

  

Respiration: Ability to breath deeply and cough Limited respiratory effort (dyspnea and splinting) No spontaneous effort

  

Circulation: BP +/- 20% of pre-anesthetic level BP +/- 20%-40% of pre-anesthetic level BP +/- 50% pre-anesthetic level
 

Consciousness Level:

  

Fully awake Arousable on calling Not responding O2 Saturation: Unable to maintain O2 sat >92% on room air Needs O2 inhalation to maintain O2 sat >90% O2 sat <90% even with O2 supplement

2 1 0 Total Points

  

12/03/09

Required for discharge from PACU: 7-8

151

Post-Operative Phase

C. Post-operative Care  Begins when the client returns from the recovery room or surgical suite to the nursing unit and ends when the client is discharged  It is directed toward prevention of complication and post-operative discomfort

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Post-Operative Phase

Post-Operative Complications 1. Respiratory Complications: atelectasis and pneumonia  Suspected whenever there is a sudden rise of temperature 24-48 hours after surgery  Collapse of the alveoli is highly susceptible to infection: pneumonia

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153

Post-Operative Phase

Occurs usually in high abdominal surgery when prolonged inhalation anesthesia has been necessary and vomiting has occurred during the operation or while the patient has recovered from anesthesia Nursing Management: 1. Measures to prevent pooling of secretions  Frequent changing of position  High Fowler’s position  Moving out of bed
12/03/09 154

 

Post-Operative Phase

2. Measures to liquefy and remove secretions  Increase oral fluid intake  Breathing moist air

Deep breathing followed by coughing is contraindicated in cases of brain, spinal, or eye surgeries

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155

Administer analgesics before coughing is attempted after thoracic and abdominal surgery Splint operative area with draw sheet or towel to promote comfort while coughing

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156

Post-Operative Phase

3. Other measures to increase pulmonary ventilation  Blow bottle exercise  Rebreathing tubes: increase CO2 stimulates the respiratory center to increase the depth of breathing thus increasing the amount of inspired air

CO2 tank: gray color
157

12/03/09

IPPB: intermittent positive pressure breathing apparatus Incentive spirometer: encourage sustained maximal inspiration

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158

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159

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160

Post-Operative Phase

2. Circulatory Complication  Causes of venous stasis:  Muscular inactivity  Respiratory and circulatory depression  Increased pressure on blood vessels due to tight dressing  Intestinal distention  Prolonged maintenance of sitting

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161

Post-Operative Phase

Contributing factors for venous stasis:  Obesity  CV disease  Debility  Malnutrition  Old age Most common circulatory complications:  Phlebothrombosis  Thrombophlebitis: (+) Homan’s sign
12/03/09 162

Post-Operative Phase

Nursing Measures:  Limbs must never be massaged for a post-op client  If possible, client should lie on his abdomen for 30 min several time a day to prevent pooling of blood in the pelvic cavity

Do not allow the client to stand unless pulse has returned close to baseline to prevent orthostatic hypotension
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12/03/09

Wear elastic bandages or stockings when in bed and when walking for the first time.  Can be removed at least once a day to permit washing of the legs

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164

Post-Operative Phase

3. Fluids and Electrolytes Imbalance:  Causes:  1) Blood loss  2) Increased insensible fluid loss through the skin after surgery:  Form vomiting,  From copious wound drainage, and  From the tube drainage as in NGT
12/03/09 165

Post-Operative Phase

3) Since surgery is a stressor, there is an increased production of ADH for the first 1224 hours following surgery resulting to fluid retention by the kidney  The potential for over hydration therefore exists since fluids being given IV may exceed fluid output by the kidney

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166

Post-Operative Phase

Electrolyte Imbalance: Particularly Na and K imbalance as a result of blood loss  Stress of surgery increases adrenal hormonal activity resulting to increased aldosterone and glucocorticoids, resulting in sodium reabsorption by the kidney

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167

And as Na is reabsorbed, K coming from tissue breakdown is excreted  Action: IV of D5W alternate with D5NSS or half strength NSS to prevent Na excess

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168

Post-Operative Phase

4. Complications of Surgery  a. GIT complications:  1) Paralytic ileus  Cessation of peristalsis due to excessive handling of GI organs  Nursing management:  NPO until peristalsis has returned as evidenced by auscultation of bowel sounds or by passing out of flatus
12/03/09 169

Post-Operative Phase
2) Vomiting: usually the effect of certain anesthetics on the stomach, or eating food or drinking water before peristalsis returns  Psychologic factors also contribute to vomiting  Nursing management:  Position the client on the side to prevent aspiration

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Post-Operative Phase
 When

vomiting has subsided, give ice chips, sips of ginger ale or hot tea, or eating small frequent amounts of dry foods thus relieving nausea anti-emetic drugs as

 Administer

ordered:  Trimethobenzamide Hcl (Tigan)  Prochiorperasine dimaleate (Compazine)
171

12/03/09

Post-Operative Phase
3) Abdominal distention: results from the accumulation of non-absorbable gas in the intestine  Causes:  Reaction to the handling of the bowel during surgery  Swallowing of air during recovery from anesthesia  Passage of gases from the blood stream to the atonic portion of the bowel

12/03/09 172

Post-Operative Phase

4) Gas pains: results from contraction of the unaffected portion of the bowel in order to move accumulated gas in the intestinal tract

Nursing management:  Aspiration of fluid or gas: with the insertion of an NGT  Ambulation: stimulates the return of peristalsis and the expulsion of flatus 12/03/09 173  Fleet enema

Post-Operative Phase
 Rectal

tube insertion: inserted just passed the anal sphincter and removal after approximately 20 minutes  Adult: 2-4 inches, children: 1-3 inches stimulation of the anal sphincter may cause in a loss of neuromuscular response, and pressure necrosis of the mucous surface
174

 Prolonged

12/03/09

Post-Operative Phase

5) Constipation: due to decreased food intake and inactivity  Regular bowel movement will return 34 days after surgery with resumption of regular diet and adequate fluid intake and ambulation

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Post-Operative Phase

5. GUT Complications

a) Return of urinary function
 Usually

after 6-8 hours  First voiding may not be more than 200 ml, and total out put may not be more than 1500ml  Due to the loss of fluids during surgery, perspiration, hyperventilation, vomiting, and increased secretion of ADH
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Post-Operative Phase
 

Complication: urinary retention Causes:  Prolonged recumbent position  Nervous tension  Effect of anesthetics interfering with

bladder sensation and the ability to void

Use of narcotics that reduce the sensation of bladder distention Pain at the surgical site and on movement
177

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Post-Operative Phase
 

b) Urinary tract infection Management:  Instruct the client to empty the bladder completely during voiding  Catheterize if necessary, done by sterile non-traumatic technique

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178

Post-Operative Phase

6. Post-operative Discomforts  a) Post-operative pain  Narcotics can be given every 3-4 hours during the first 48 hours postoperatively for severe pain without danger of addiction

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179

Post-Operative Phase
b) Hiccup (Singultus)  Brought about by the distention of the stomach, irritation of the diaphragm, peritonitis and uremia causing a reflex or stimulation of the phrenic nerve  Management for hiccups:  Paper bag blowing  CO2 inhalation: 5% CO2 and 95% O2 x 5 minutes every hour

12/03/09 180

Post-Operative Phase
 

7. Wound Complications: Sutures are usually removed about 5th-7th day post-op with the exception of wire retention sutures placed deep in the muscles and removed 14-21 days after surgery

a) Hemorrhage from the wound

12/03/09

Most likely to occur within the first 48 hours post-op or as late as 6th-7th post-op day

181

Post-Operative Phase
 

Causes: 1) Hemorrhage occurring soon after operation: slipping of the ligatures or mechanical dislodging of a blood clot or caused by the reestablished blood flow through the vessel 2) Hemorrhage after few days: Sloughing off of blood clot or of a tissue

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Post-Operative Phase
  

3) Infection 4) Erosion of a blood vessel by a drainage tube Assessment:  Bright red blood  Decreased BP  Increased PR and RR  Restlessness and Pallor  Cold, moist skin  Weakness
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Post-Operative Phase

b) Infection  Cause: streptococcus and staphylococcus  Assessment: from 3-6 days after surgery, the client begins to have a low grade fever, and the wound becomes painful and swollen  There maybe purulent drainage on the dressing

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184

Post-Operative Phase

c) Dehiscence and Evisceration  Dehiscence or wound disruption:  Refers to a partial-to-complete separation of the wound edges

Evisceration:  Refers to protrusion of the abdominal viscera through the incision and onto the abdominal wall
185

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Post-Operative Phase

Assessment:  Complain of a “giving” sensation in the incision  Sudden, profuse leakage of fluid from the incision  The dressing is saturated with clear, pink drainage

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Post-Operative Phase

Management:  Position the client to low Fowler’s position  Instruct the client not to cough, sneeze, eat or drink, and remain quiet until the surgeon arrives  Protruding viscera should be covered warm, sterile, saline dressing

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188

Post-Operative Phase

8. Post-op psychological disturbances  Delirium (mental aberration)  ACS (acute confusional state) Causes:  Dehydration and Insufficient O2  Anemia  Hypotension  Hormonal imbalances  Infection and Trauma
12/03/09 189

Post-Operative Phase

Manifestations:  Poor memory  Restlessness  Inattentiveness  Inappropriate behavior  Wild excitement, hallucinations, delusions, depression  Disoriented  Sleep disturbance
12/03/09 190

Post-Operative Phase

Nursing Interventions:  Sedatives given as ordered, to keep the client quiet and comfortable  Explain reasons for interventions  Listen and talk to the client and significant others  Provide comfort  Treat the underlying cause
12/03/09 191

Post-Operative Phase

Discharge Instructions:  Early discharge, which has become common, typically increases client teaching needs

Be sure to provide information about wound care, activity restrictions, dietary management, medication administration, symptoms to report, and follow-up care
192

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Post-Operative Phase

A client recovering from same-day surgery in an outpatient surgical unit must be in stable condition before discharge This client must not drive home, make sure a responsible adult takes the client home

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Maraming Salamat Po

194

References:  Textbook of Medical Surgical Nursing 7th Edition by Joyce Black  Lippincott Manual of Nursing Practice 8th Edition  NCLEX-RN Review Materials 12/03/09 195

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