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COURSE OBJECTIVE:
At the end of the course, the student is expected to: 1. Identify the different phases of surgery.
SUBJECT:
DESCRIPTION
The course focuses on understanding the basic concepts, and principles related to surgery in providing various supportive measures from the members on the health team.
TERMINAL COMPETENCIES:
Providing a client with specific needs during the different phases of surgery, the student will be able to meet the needs of the patients and share the various learned during the learning process
1. Discuss the nursing responsibilities during the different phases of surgery.
PREOPERATIVE PHASE
A. Psychological Preparation
a. 2. Specific Fear
Nursing Process Application a.3. ASSESSMENT a.3.1. Subjective Data a.3.2. Objective Data a.4. Intervention
B. Physiological Preparation
b. 1. Age b. 2. Nutrition b. 3. Presence of Disease Conditions b.3.1. Cardiovascular disease b.3.2. Respiratory disease b.3.3. Elimination disturbances b.3.4. Endocrine disturbances b.3.5. Prior Drug Therapy
C. PHYSICAL PREPARATION C.1. Gastrointestinal C.2. Urinary C.3. Circulatory C.4. Integumentary C.5. Nervous
D. LEGAL CONSIDERATIONS
d. 1.Consent d. 2.Religion d. 3.House Rules
INTRAOPERATIVE PHASE
A.
5 SURGICAL TEAM
a.1. Surgeon a.2. Ass. surgeon a.3. Anesthesiologist a.4. Scrub Nurse a.5. Circulating Nurse
B.
ANESTHESIA
POSTOPERATIVE PHASE
A.
Immediate Postoperative or Postanesthetic Phase. B. Early postoperative Phase ( Return of the patient to the unit) C. Discharge Planning Others: Nursing care Plan:
GRADING SYSTEM:
QUIZZES UNIT
TOTAL=100% STRICLY NO SPECIAL QUIZ / GRADING SYSTEM IS SUBJECT TO CHANGE REQUIREMENTS: TBA ( TO BE ANOOUNCE)
REFERENCE:
Nancymarie Philipps, Berry & Kohn s Operating Room Technique, tenth edition, 2004 by Mosby, Inc. Susan C. Dewit, Keanne s Essentials of MedicalMedicalSurgical Nursing, Third Edition, W. B. Sauders Co., ( ANY EDITION) Heidi C. Dyangko, RN, Ed.D. Operating room Technique Instructional Manual, Fifth edition, Busybook 2003. ANY M-S BOOKS (applicable). MPrepared by: Vergel G. Leonardo RN, MAN
HISTORICAL BACKGROUND
Historical development of surgery comes from: Babylonian law- The code of lawHammurabi (1955-1913 B.C.) (1955 According to this law: If the patient died after a surgical procedure, retribution would reflected on the surgeon in the form of amputation of his right hand.
Another history says : According to the ancient Persians there be a 3x successful procedures before being pronounced as a competent to practice surgery.
Definition of Terms
PeriPeri-operative nursing - total surgical experience that encompasses with pre-operative, preintraintra-operative, and post-operative postphases of patient care Operating room / Operating theatre - room in a health care facility in which patients are prepared for surgery, undergo surgical procedures, and recover from the anesthetic procedures required for surgery
Definition of Terms
Surgery - branch of medicine concerned with disease or conditions requiring or amenable to operative or manual procedures Surgical procedure - invasive incision into body tissues or minimally invasive entrance into a body cavity for either therapeutic or diagnostic purposes during which protective reflexes or self-care selfabilities are potentially compromised
Definition of Terms
Surgical conscience - awareness which develops from a knowledge base of the importance of strict adherence to principles of aseptic and sterile techniques OR nurse - duly licensed registered nurse legally responsible for the nature and quality of the nursing care patients
Definition of Terms
Asepsis - freedom from infection or absence of microorganism Sepsis - general reaction from the action of bacteria or their products.
Definition of Terms
Disinfection - process of destroying all pathogenic microorganisms except spore bearing ones Aseptic technique - methods by which contamination of microorganism is prevented
Definition of Terms
Antiseptic - substance which combat sepsis and cause bacteriostasis Anesthesia - insensibility to pain and trauma with or without loss of consciousness
Biopsy tissue closing of a hernia Foreign body CreationCreation-new breast relief of obstruction
Common Indications For Surgical Procedures Aesthetics facelift Harvest skin grafting Procurement Donor organ Transplant placement of DO
Stabilization Parturition
abor.of pregnancy checking of CA removal of invasive exam. creation of stoma for urine
/ sincere Empathy Efficiency and well organized Conscientious Flexible and adaptable Sensible and perceptive Open-minded Open Supportive and understanding
/ impartial, Versatile, intellectual & curious Sense of humor Ethical Enduring Objective Creative considerate
FOUR MAJOR TYPES OF PATHOLOGIC PROCESSES REQUIRING SURGICAL INTERVENTION. O BSTRUCTION. Impairment to the flow of vital fluids. E.g blood, urine, CSF, bile. P ERFORATION. Rupture of an organ E ROSION. Wearing off of a surface or membrane. T UMOR. Abnormal new growth
c.2 Constructive. Involves repair of Constructive. congenitally defective organ.( suffix used are plasty , orrhaphy , pexy ) e.g. cheiloplasty, cheiloplasty, c.3 Reconstructive. Involves repair of Reconstructive. damaged organ. E.g. plastic surgery after severe burns. d. Palliative. To relieve distressing Palliative. signs and symptoms, not necessarily to cure the disease.
generally not prolonged leads to few serious complications involves less risk
3. According to URGENCY
Emergency. Emergency. To be done immediately to save life.( Limb if affected) Planned Required. Necessary for well Required. being. May be scheduled weeks or months. Elective. Elective. Not absolutely necessary for survival. Delay or omission will not cause adverse effect. Optional. Optional. Requested by the client. Usually for aesthetic purposes. Day ( Ambulatory Surgery). Done on out patient basis.
response is elicited. Defense against infection is lowered. Vascular system is disrupted. Organ function are disrupted. Body image may be disturbed. Lifestyles may change.
Preoperative Phase
Preoperative
nursing care begins with the nurse s initial contact with the surgical patient. The goal of the preoperative patient is to identify individual needs in order that accepted protocols of care can be modified or accepted.
Assessment
would include observing for alteration in : normal physiologic functioning, determining specific nutritional needs, evaluating current pharmacotherapy, and identifying psychosocial patterns of behavior.
This
PREOPERATIVE PHASE
Any
kind of surgery whether major or minor is always preceded by emotional as well as physiological changes hence, the need for extensive preparations. These are presented into:
Preoperative Care
Psychological
A. Psychological Preparation
Fears related to surgery General fear - fear of the unknown-worst fear of all. unknown- what to expect and what are the consequences of surgery - nursing action: allay anxieties by giving the patient opportunities to express his/her fears
A. Psychological Preparation
Fears related to surgery Specific fears - fear of destruction of body image - threat to sexuality - fear of permanent disability - fear of pain - fear of dying
PostPost-op exercises Equipment used during post-op period post- oxygen, pulse oximeter, CVP - ventilator - NGT - IV medications - foley catheter Pain medication and when to request it - Patient-Controlled Anesthesia (PCA) PatientNPO
Preoperative Teaching
B. PHYSIOLOGICAL PREPARATION
Before
surgery is performed, the patient undergoes several tests. There are several factors which may affect the patient s response to surgery, therefore, it is necessary to obtain the essential data to identify potential problems. Factors that affects are as follows:
Physiologic Preparation
Factors that affect surgery 1. Age 2. Nutrition 3. Presence of disease condition 4. Prior drug therapy
1. Age
very young - tolerates trauma of surgery well. - sensitive to temperature changes & rough handling. The elderly - tolerates trauma of surgery poorly.
The
2. Nutrition
Dehydration
and malnutrition cause potential complications postpostoperatively. It is essential for the nurse to identify these baseline data - nausea, vomiting, anorexia. Parenteral fluids are prescribed to correct fluid & electrolyte deficiencies prior to surgery.
2. Nutrition
Malnutrition
may be corrected by high caloric diet, protein & vitamin supplements. Obesity increases the seriousness of complications to a great extent. Fatty tissues are prone to infection therefore, dehiscence & wound infections are common. Obese people breathe poorly & are prone to pulmonary complications.
3. Presence Of Disease
a. Cardiovascular disease - ECG, 2-D-Echo, Stress tests, Blood tests 2- CVP measurement for elderly, major surgeries - blood typing and cross-matching cross- HPN, Bleeding disorders b. Respiratory disease - CXR, ABGs - PTB, Pneumonia, COPD
3. Presence Of Disease
c. Renal Disease - Urinalysis, BUN/ Creatinine, Creatinine, - Acute nephritis, Acute renal insufficiency, UTI d. Endocrine disease - FBS, Thyroid function tests - Uncontrolled DM, Hypo/hyperthyroidism
4. Prior Drug TherapyTherapycertain medications can interfere with anesthesia or contribute to postoperative complications.
Anticoagulants
increase bleeding - aspirin, heparin, warfarin Antihypertensive- affects anesthesia Antihypertensive Antibiotics e.g neomycin, STSO4, with there will be muscle relaxant interrupt nerve transmission and apnea due to resp. paralysis. *prior to surgery, most of the drugs are
discontinued and new orders are given postpost-op
Diuretics- K loss/ resp. depression Diuretics Steroids- anti-inflam. Effect and delay Steroids- anti-inflam.
wound healing Tranquilizers potentiates effect of narcotics and barbiturates. They cause hypotension. Antidepressants- (monoamine oxide) Antidepressantshypotensive effects *prior to surgery, most of the drugs are discontinued and new orders are given post-op post-
C. PHYSICAL PREPARATION
Patient is prepared the night before the scheduled surgery Common preparations 1. Gastrointestinal Prep: The Eve before OR must have: - light meal the night before surgery - NPO (food & water -post midnight safe is 6hrs - this order should be carefully explained to patients - during anesthesia, reflexes (gag, sphincter) are absent & food in the stomach can easily gain to the tracheobronchial tree, cause aspiration pneumonia & respiratory failure - enemas for GI surgeries / Skin prep/shaving
Nurse s Responsibility
Perform/supervise skin prep & cleansing Notify AMD of drug allergies, severe anxiety, unusual ECG or abnormal lab findings-* note findingsdrug allergy /allergy cannot lessen through nursing intervention while fear, obesity & smoking can be. Ensure all consent forms are signed ( Gen. & Informed) Administer pre-op meds on time-1 hr b4 pretimeanesthesiaanesthesia-to reduce resp.secretions-AtSo4 resp.secretionsComplete pre-op checklist preCheck if history & PE database are on chart Remove dentures, nail polish, hair pins, jewelries
Ensure
all consent forms are signed ( Gen. & Informed) Administer inj. pre-op meds on time-1 hr pretimeb4 OR -to reduce resp.secretions-AtSo4* resp.secretions Premeds tabs given before midnight(optional) Complete pre-op checklist pre Check if history & PE database are on chart Remove dentures, nail polish, hair pins, jewelries
Nurse s Responsibility
Remember: Preparing GIT On The Eve Of Surgery Most common preparation for GIT
Food
restriction for 6 hours or ( NPO after 12mn. Fluid restriction (NPO after 12mn) or for 6 Administration of enema (fleet enema) till clear flow Insertion of nasogastric tube (NGT) if needed FC if needed.
Preparing The Patient On The Day Of Surgery The nurses awakens the patient before he/she receives pre-op meds, VS is taken & recorded pre Check & make certain that skin preparation has been completed in a thorough manner Ask the patient to void, measure & record the output of urine Oral hygiene, remove nail polish, false dentures, glasses (contact lens, jewelries, & give to responsible person). Narcotics Box ( HN is responsible)
General Consent- forms given during Consentadmission. The physicians and nurses should be knowledgeable about the statements on the form used in their facility. (House Rules). Most facilities require the patient or his or her legal guardian to sign a general consent form on admission. Ex: Rendered day to day treatment, Hosp. charges etc.
The risks of anesthesia should be explained without causing the patient undue stress. Reasonable approach to Informed Consent. Consent. 1. What is your plan or What kind of operation ? This is ask by the client. 2. Why do you want to do this procedure? 3. Are there any alternatives to this plan? 4. What things should I worry about? 5. What are the greatest risks or the worst thing that could happen? * Note* the patient has the right to waive an explanation of the nature and consequences of the procedure and the right to refuse the treatment/ surgery.
*When
a patient signs an agreement, consent is given for the specific procedure indicated on the form. *Additional procedures should be listed and signed separately-not added after the patient separatelyhas already signed the form. *Included in the lists of forms:
A. Who will be performing the procedure or the Surgeon, B. Anesthesiologist C. Residents D. interns or first assistants E. OR nurses during OR procedure
Responsibility for Informed Consent before a surgical procedure: Surgeon / Doctor should include the risks, benefits, and possible complications of all proposed surgical procedures. Documented the procedures and becomes the permanent part of the patient s record.
VALIDATION OF INFORMED CONSENT: Content: Patient s in full name w/ legal age and mentally competent Surgeon s full name Specific procedure to be performed The sig. of the patient and the date of the signature Authorized witness (es) (es)
-parent or legal guardian should sign. 2. Illiterate - may sign with X after which the witness writes Patient THUMB Mark 3. Unconscious 4. Mentally incompetent 5. Mentally incapacitated by alcohol or other chemical substances.
Minor
life threatening emergency the consent to treat and stabilize is not essential. Although, permission for life saving procedures, especially for a minor, may be accepted from a legal guardian or relatives by phone , fax , txt or other written com. then, two nurses must sign the form. And , later or upon arrival at the facility the concern person must sign.
Written consent: Prior to this ,the surgeon must explain everything to the patient. Must have at least two consent ( Gen.& Informed) In case of minor ( < 18), the parents or the guardian sign the consent. If or during emergency, the surgeon may operate if is in life threatening-saving threateningmeasure( house rule / presumed consent) Liability - legally responsible for personal actions
All pertinent data should be recorded: Patient s chart Consent / V/S PrePre-medications Labs / X-rays/IV s, /Bladder/ side rails-up XrailsCheck by the charge nurse Nurse accompanies the pt to the OR. Endorsed.
Date: Last Name First Name MiddleName AMD Hosp PIN Operation Proposed:_________________________________ Date of Operation: _______________ Time__________ Surgeon:_______________ Anesthesiologist Anesthesia________
YES NO YES NO
PrePre-Op Med given IV Fluids Ordered IV Fluids Started Schedule Slip Sent Weight Taken NPO signage on bedside PrePre-op bath or shower Cath, retain & clamp Patient urinated PrePre-anesthesia Eval. Valid consent signed
False Teeth Hair Pins Jewelry Nail Polish Underwear Enema (if ordered Vaginal irrigation Pt. visited by the chaplain History & P.E.
External Prep. Done by:_____________ Checked by:_________________________ Allergies:________________________ Blood Pressure Taken AM PM Laboratory Exams ( if Ordered): DONE NOT YET DONE DONE NOT YET DONE Blood Test ECG Urine Test X-ray If not yet done, w/PLATES Specimen sent to lab
Final Checking done by:___________________________ Printed Name & Signature ( Head Nurse)
- failure to use the proper care or skills. - careless performance of duty - cause damage to a patient who may file lawsuits Malpractice - professional misconduct - illegal or immoral conduct - unreasonable lack of skill or judgment
Borrowed servant rule - captain of the ship - surgeons have supervisory control & right to give orders & is directly liable Doctrine of a reasonable man - patient has the right to expect all personnel & technical nursing personnel will use knowledge, skills, & judgment in performing duties that meet standards exercised by other reasonably prudent persons involve in similar circumstances.
Legal Preparation
Doctrine of res ipsa loquitur - the thing speaks for itself. - court allow the patient s injury to stand as inference of negligence *Before this doctrine can be applied, 3 conditions must exist 1. The type of injury. 2. The injury was caused by the conduct or instrumentality within the exclusive control of the person or persons being sued 3. The injured person could not have contributed to negligence or voluntarily assumed risk
Invasion of privacy
Legal Preparation
& records pertaining to individualized care will be treated as confidential & will not be misused - right to privacy during interview, examination & treatment - NOTE: Surgery schedule bearing the names of the patients should not be posted in a location where the public or other patients can read it. - written consent for videotaping or photographing his/her surgical procedure for medical education or research, w/o a permit is a BIG NO. (just remember the cannester case / u tube.)
Legal Preparation
Doctrine
of respondeat superior - an employer may be liable for an employees negligent conduct Assault - unlawful threat to harm another physically Battery - carrying of bodily harm as by touching without authorization or consent
Legal Preparation
Abandonment
- leaving the patient for any reason when the patient s condition is contingent on the presence of the caregiver - if the caregiver leaves the room knowing there is potential need for care during his/her absence, even under the order of a physician, the caregiver is liable for his/her own action
Legal Preparation
Surgical
team - key elements of perioperative practice caring, conscience, discipline & techniques - optimal patient care requires an inherent surgical conscience, selflessness, selfself-discipline & the application of principles of asepsis & sterile technique
10/13/09
Incisions
a pt has an old incision, is it best to make a subsequent incision next to or through the old incisions. Bec. it has scar Bec. tissue that limits the amount collaterals that would be needed to heal an incision placed next to it. Used to incise the epidermis is the Scalpel blade or the first knife. Used to incise the dermis is the scalpel or electrocautery. electrocautery.
If
Knife Handles
7 handle with 15 blade (deep knife) - Used to cut deep, delicate tissue. 3 handle with 10 blade (inside knife) - Used to cut superfic tissue. 4 handle with 20 blade (skin knife) - Used to cut skin. Firs
INCISIONS
ABDOMINAL INCISION
Abdominal Incisions
Incision Site R-Subcostal incision Paramedian Types of Surgery Gallbladder and billiary tract surgery. Right side billiary tract, gallbladder
Left side splenectomy, gastrectomy, hiatal hernia repair Transverse Rectus gastrectomy Right side small bowel resection Left side Mc Burney incisions Midline Lower Pfannensteil sigmoid colon resection
Abdominal incision
Abdominal incision
Incisions
Sternotomy = Midline sternotomy incision for heart procedures, less painful than a lateral thoracotomy. Thoracotomy= Usually through the 4th or 5th ICS, very painful, but many are performed with muscle sparing ( muscle retraction and not muscle transection). Liver transplant = chevron or MercedesMercedesBenz incision in the upper abdomen.
WOUND CLOSURE
WOUND CLOSURE Methods of wound closure include sutures, clips, staples, tapes, and glue. Suture denotes the acts of sewing by bringing tissues together and holding them until healing has taken place.
WOUND CLOSURE
the material is tied around a blood vessel to occlude the lumen, it is called a LIGATURES or TIE. A suture attached to TIE. a needle for a single stitch for hemostasis is referred to as a STICK TIE or SUTURE LIGATURE. LIGATURE. FREE TIE is a single strand of material handed to the surgeon in the tip of a forceps is referred to as a tie on a passer.
If
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