intra - operative nursing

7/27/2019 Intra - Operative Nursing

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Jose Leo V. Nastor, Jr. BSN3 B Clinical Group 7

Clinical Instructor: Ms. Louradel M. Ulbata

PERI OPERATIVE NURSING

Surgery

Branch of medicine that is concerned with disease and trauma thatrequires operation procedure

Gave physical means to treat conditions that are difficult or impossibleonly with medications

Nurses in first OR clean rooms and equipments, perform technical taskslike obtaining supplies, accompany patient to the ward

4 MAJOR TYPE OF PATHOLOGIC PROCESS REQUIRING SURGICAL

INTERVENTIONS

a)Obstructionimpairment to the flow of vital fluids (blood, urine, CSF,bile)

b)Perforation rupture of an organc)Erosion wearing off of a surface or membraned)Tumor abnormal growth of cells

CLASSIFICATION OF SURGICAL INTERVENTIONS

I. ACCORDING TO PURPOSEa)Diagnosticconfirm diagnosis; establish presence of diseaseb)Exploratoryestimate the extent of disease and diagnosisc)Curativeto treat disease conditiond)Ablativeremoval of diseased organe)Constructiverepair of congenitally defective organf) Reconstructiverestoration of damaged organg)Pallativerelieve symptoms but does not cure the disease

II.ACCORDING TO URGENCYa)Emergencyrequire immediate attention, without delay to maintain

life

b)Urgent / Imperativeprompt attention; 24 48 hours from the timeof decision

c)Required / Plannedpatient need to have surgery. Time of thesurgery is in a few weeks/months.

d)Electivepatient should have surgery. Convenience of the patient as afailure to have surgery is not life threatening.

e)Optionalsurgery at the preference of the client. III.ACCORDING TO DEGREE OF RISK

a)Majorextensive surgery that includes serious risk or creates a higherrisk for infection, operation is prolonged and large amount of blood

loss is expected. Vital organs may be handled or removed.

b)Minorsurgery that involves minimal complications, operation is notprolonged, decrease risk of infection and less amount of blood loss is

expected.

COMMON VARIATION OF SETTING

Inputpatient is hospitalized for surgery 1 day (Same day)Admitted the day of the schedule of the surgery and

discharged at the same day

Outputpatient is not hospitalized, who is being treated / patient isadmitted 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 complicationsCONCEPT OF PERI OPERATIVE NURSINGproviding continuity of care for

surgical patient/ patient undergoing surgery using the nursing processRESPONSIBILITY: 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)ALLERGIESmedications, chemicals, environment, latex cross reactivefoods

Latex Cross Reactive Foodsbanana, kiwi, papaya, grape, avocado,watermelon, tomato, celery, chestnut

Allergies are reported An allergy band must be place on armB)BLEEDINGuse mediations that interfere the normal clotting factor Herbal Medicationsincrease bleeding time and mark potential blood

related problems

o Gingko biloba, strawberries, garlic, ginger increase level ofsalicylates

C)CORTISONEimmune system is suppressed and patient is at risk ofdeveloping post operative infection and have diminished capacity tofight infection

D)DMdelay wound healingE)EMBOLIprevious embolic events

CLASSIFICATION OF PHYSICAL STATUS

ASA 1patient undergoing surgery is a healthy person without disease,not young and not old

ASA 2patient has mild systemic disease; does not affect activity; mildobesity, smoker, alcoholism

ASA 3multiple system condition but well controlled; limit dailyactivity, without threat

ASA 4with severe disease and poorly controlled, end stage disease ispresent, organ failure is present

ASA 5danger of death, operation is the last attempt for intervention ASA 6declared 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 FEARunstable V/S, decrease pain threshold,anxiousness, bewilderment, anger, inability to concentrate, short

attention span, dazed, sad

o NURSING INTERVENTIONS OF FEARexplore clients feelings- Socioeconomic & Cultural Needs different culture react- Current Medications- Education and Experience

PRE OPERATIVE PHASE

Assess the correcting physiological and psychological problems that mayincrease 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 previousmedical 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 gentamicino Anti hypertensive cause hypotensive crisis,o Steroids delay wound healingo Anticoagulant increase bleedingo Glaucoma Meds (Pilocarpine) cause respiratory and cardiovascular

collapse

o Anti DM insulin needs decrease when client is on NPOo TCA decrease BP, increase risk of shocko Diuretics cause F and E imbalance especially Potassiumo Street drugs increase tolerance to narcotics

-

Psychological History - Social HistoryPHYSICAL 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


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1)Psychological Prep for SurgeryExperience of the procedure, Outcome,Hospital Cost, Length of absence form work

2)Legal AspectINFORMED CONSENT

Purpose:o Understand the nature of the treatment including the potential

complication and disfigurement

o Ensure that the clients decision is made without pressureo Protect the client against unauthorized procedureo 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 CONSENTo Written permission is best and legally acceptedo Signature is obtained with the clients complete understanding of what

to occur

o Adult sign their own operative permito Informed consent must be obtained before sedationo Parents or someone standing in their behalf, gives the consento 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 theparents or legal guardian

o If the patient is unable to write, an X is accepted if there is a witnessto his mark

o Secured without pressure and threato When an E situation exist, no consent is necessary because in action

at the same time

3)Physiological Prep laboratory tests and results4)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)Subcostalindicated for biliary and gall bladder surgeries b)Paramediafor splenectomy (L), hiatal hernia, gastrotomyc)Transversegastrectomy (L)d)Midlinefor C/S, laparotomy, appendectomye)McBurneys appendectomyf) Right Rectussmall bowel resection, appendectomyg)Left Rectussigmoid colon resectionh)Pfannenstielfor C/S

INTRA OPERATIVE NURSING

Pre op checklistincluded 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 GITNPO, 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 hoursPrep for anesthesiaavoid alcohol and smoking for at least 24 hours

before the surgery to avoid interaction of substance

Promoting rest and sleepsedatives 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 anxietyCOMMONLY USED PRE OP MEDS

Tranquilizers & Sedativescause hypotension- Diphenhydramide - Diazepam (Valium)- Miazolam - Lorazepam AnalgesicsNalbuphine (to decrease anxiety) Anti cholinergicto decrease respiratory tract secretion and changes

in HR (Atropine Sulfate)

PPIOmeprazole and FamotidineTRANSPORTING PT TO THE OR

Adhere to the principle of maintaining the comfort and safety of thepatient

Accompany OR attendants to the patients bedside for instruction andproper 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 Familyo Direct to the proper waiting roomo Tell the family that the surgeon will probably contact them

immediately after the surgery.

o Explain reason for long interval of waitingo Tell the family what to expect post op

INTRA OPERATIVE PHASE

Transfer onto the OR tablePHYSICAL 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 yetsmall 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 permittedb)Semiresticted Area

- Provide access to the procedure rooms and peripheral support areaswithin 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 maskVESTIBULAR/EXCHANGE AREAS


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PACUOutside the OR suite, or it may be adjacent to the suite so that it

may be incorporated

Conference Room

Support Service

Laboratoryto examine tissues

Radiology ServiceX 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 placedInstrument 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

AAlways face the steile field

SShould be above waist level and on top of the sterile field

EEliminate moisture that cause contamination

PPrevent unnecessary traffic and air current (close door, minimize

talking, dont reach across sterile field)

SSafer to assure contamination when in doubt

IInvolves a team effort

SSterile 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 ofprotective reflexes

Anesthetics can produce muscle relaxation, block the transmission ofpain nerve impulses and suppresses the reflex

Also temporary loss of memoryIn general:

Reversible state consisting of loss of consciousness/ sensation Protective reflexes such as cough and gag reflex Produce amnesia but temporaryTECHNIQUE

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 orapnea

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 beimmediately available in the event of a return to surgery.

b)Immobility of the cervical spine patient with vertebral disease orinjury may not have full ROM necessary for intubation

c)Chin/jaw deformity small jaws/chin may have a difficult airwayd)Dentition can be an issue if the patient has loose teeth of periodontal

disease

e)Short neck/ morbid obesityf) Pathology of the head and neck such as tumors and deformities.g)Previous tracheostomy scar which can cause strictureh)Trauma

DEPTH OF GA

From To Pt Response Pt care

Induction of GA

and beginning

of inhalant and

or IV drug

Begins to lose

consciousness,

will have recall

bispectral

state(RBS)

(100)

Drowsiness,

dizziness,

amnesia

Close doors,

keep room

quiet, stand by

to assist, initate

cricoid pressure

if requested

Loss of

conciousness

(excitement

phase)

Relaxation,

light hypnosis,

low probability

of RBS 50 70

May be excited

with irregular

RR and

movement of

extremities,suspectible to

external stimuli

Restraint pt,

remain at pts

side, quietly

but ready to

assistanesthesia

provider as

needed

Surgical

anesthesia

(state of

relaxation)

Loss of reflexes,

depression of

V/S, RBS of 40

Regular

respiration,

contracted

pupil, reflex

disappears,

muscle

relaxation,

auditory

sensation lost

Position pt

Danger state

(V/S depressed)

Respiratory

failure, cardiac

arrest, RBS 0

No breathing,

little or no HR

Prepare for CPR

EXAMPLE OF GAHalothane, 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 Topicalo 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 siteo IV block In the arm, wrist, hand. Occlusion of tourniquet to prevent

infiltraton

o Caudal caudal or sacral canalo Field block area that is proximal to the incision site can be injected Administration of LAo 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.

PositioningLateral and Sitting positiono C shapedthe 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 surgeryprocedure.

o Lungs must be adequately ventilated intra operatively and postoperatively

o Assist in recoveringCOMPLICATION 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


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a)Surgeon- Must have knowledge and skills and judgment and prepare for the

unexpected

- Handle tissues and uses instrumentsb)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 fieldB.) Non sterile team - Unsterile team members who DO NOT enter the

sterile fielda)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 protectionc)Other OR TeamSterile Fieldarea 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 equiptmentDUTIES AND PREPATING OF THE STERILE FIELD (BEFORE)

Sure that his or her gown and gloves are open and ready on a surfaceseparate from the sterile field

Perform a complete surgical hand cleansing according to the facilityprocedure

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 procedureor 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 starto Initial performed before the closure of the peritoneumo Final total closure of the skin When counting, must have a loud voice Circu nurse should watch the counting Counting the instrumentso CSBA curves, straight, babcock, allis, Sponges OS, cherry balls,

Needles and blades

Arrange the spongeso Cherries group into 5o 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 surgeonpreference

After draping is completed, bring the mayo stand into position over thepatient

Position the instrument table at a right angle to the OR bed. Assist the surgeon in securing sterile light handles for adjustment of theOR light 4 towels are usedo The 1st 3 towels fold towards youo The last towel fold towards the surgeono Drape near the surgeons bodyo 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 tothe 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 theedges of the incision.

Watch the field and try to anticipate the needs of the surgeon andassistant. 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 sharpsduring 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 theoriginal position

Have a clear, warm, moistened sponge ready to wash blood from thearea surrounding the incision as soon as skin closure is done.

8Ps TO CONSIDER

When preparing for a

surgical procedure

Sterile Field Contact in

Scrub Nurse

Sterile Field Contact in

Circulating Nurse

Proper Placement

pleaced so they will

not be moved

Mayo stand should

not be used during the

procedure. Drapes

may not be used.

Suction, tourniquet

need to be stationary

Proper functiontest

instruments for

usefulness

Test for efficiency of

instruments

Test the materials

Place it onceenergy

and attention should

not be diverted

Each item should be

placed where it will be

used during the

procedure

OR bed should be at

the right place

Point of contact - Should be aware of

passing of the

instruments and nowthey are securely

placed in the waiting

hand of the surgeon

on 1st

assistant

Evaluate the delivery

of items to the sterile

field

Position of function

positioned so they will

be usable during the

procedure

Placed in the

surgeons hand in a

usable way

Should be placed so

they may be

positioned while the

procedure is in

progress

Point of useclose to

the area

Basin should be place

close to the edges

Protected parts

rendered safety of the

patient and the team

Secured appropriately

Prefect picture Should be neat andorderly Should be neat

RESPONSIBILITY OF A CIRCULATING NURSE

Before entering the OR suite, circulating nurse must wash his or herhands 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 thesterile supplies

Test all equipments After the scrub nurse scrubo 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 theinstrument 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


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- 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 gownTime outbefore 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 upstandardized basic set of sterile instruments are selected for

each specific surgical procedure

CLASSIFICATIONS:

a)CUTTING OR DISSECTING Sharpsare used to cut body tissues or surgical supplieso 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) Scissorso Straight mayo scissors cut suture and supplies AKA suture scissorso Curved mayo scissors cut heavy tissues (fascia, muscle)o Metzenbaum cut delicate tissues but not used to cut sutureso 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 Rochesterpean

Burlisher used to clamp deep blood vessels. Burlishers have 2 closedfinger 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 placesuture 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 bloodvessel and ducts which will remain occluded.

c) GRASPING AND HOLDINGHolds 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: spongefoceps

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 stonesd)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 betweenGelpi and Weitlaner is the teeth

Balfour with bladder blade retract wound edges during deepabdominal procedure.

Vein retractor for orthopedic surgerySUTURES

- Holds tissues together Absorbableabsorbed by the body and digested by the bodyo 3 weeks sufficient for the wound to closeo Plain dissolved within 5 10 days, yellow in coloro Chromic dissolved within 1 month, brown in color o Vicryl dissolved within 60 90 days, lavender in coloro PDS dissolve 2 times longer than vicryl, white in color. Nonabsorbableremove after specified timeo Type is divided again by the location of the wound.o Not metabolized in the body, removed by a few weekso Silk animal produced from silk worm cocoonso Cotton long staple cottono Wire greatest strengtho Prolene biosynthetic, non absorbable suture material as substitute

to silk.

SUTURE NEEDLES

Traumaticwith holes or eyes, which are supplied to the hospitalseparate from their suture thread

o Must be threaded on site, as is done when sewing at home. Atraumaticcomprise 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 andwanking cord

- Scalpel blades should not be properly set in handles using a heavyinstrument.

- Tips should be straight and in alignment - Teeth and serrations should align exactly- Scissors should be sharp- Cannula should be clearc)Sort instrumentsd)Leave retractor in a tray or containere)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


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Endorse: Name, Operation, Surgeon, Anesthesia, V/S, Presence ofdrains, 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 tostimuli.

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 airwayo 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 backwardo Aspirate excessive secretions when sounds are head in the

nasopharynx and oropharynx

Assessing the status of the circulatory systemo V/S per protocol (V/S every 15 minutes)o I and Oo 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 (unlesscontraindicated)

Maintain adequate Respi functiono Place the patient in a lateral position, with neck extendedo Turn the patient every 1 2 hours to facilitate breathing and

ventilation

o Assess lung fieldso Administer humidified oxygen Assess thermoregulation statusmonitor temperature Minimizing complicationso Turn the patient from side to sideo Handwashingo Inspect dressingo Record the amount of drainage Maintain adequate fluid volumeIV solution and watch out for F and E

imbalance

Maintaining safetyside rails up and avoid nerve damage and musclecramps

Promoting comfort analegicsPARAMETERS FOR DISCHARGE FROM PACU OR RR

Activityable to obey commands Respirationeasy and noiseless breathing CirculationBP within normal range Conciousness or Responsiveness Colorpinkish skinCOMPLICATIONS:

a)Shockresponse of the body to a decrease in the circulating bloodvolume, 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 manifestationo Monitor V/S per protocol until they are stableo 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)Hemorragecopious escape of blood from the blood vessels. Classifications of hemorrhage are as follows:

i. Generala.Primaryoccurs at the time of the operation b.Intermediaryoccurs 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. Secondaryoccurs some time after surgery due to ligated slip fromblood vessels and eroson of blood vessels.

ii. According to blood vesselsa.Capillaryslow, general oozing from capillariesb.Venousbleeding that is dark in color and bubble out. c. Arterialbleeding that spurts and is bright red in color

iii. According to locationa.Evident or externalvisible bleeding on the surfaceb.Internal (concealed)bleeding that cannot be seen

Clinical Manifestations:

Apprehension; restlessness; thirst; cold, moist, pale skin; andcircumoral 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 Hgbo Patient grows weaker until death occurs

Nursing Responsibilities:

Inspect the wound as a possible site of bleeding. Apply pressuredressing over extent bleeding site.

Increase IVF infusion rate and administer blood if necessary an ASAP. Ligation of bleeders by the surgeon as necessary.

c)DVToccurs in pelvic veins or in deep veins of the LE in postoperativepatients.

DVT is most common after hip surgery, followed by retropubicprostatectomy; and general thoracic or abdominal surgery.

Venous thrombi located above the knee are considered the majorsource of pulmonary emboli.

Causes:o Injury to the intimal layer of the vein wall.o Venous stasiso Hypercoagulopathy, polycythemiao 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, perspirationo 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 ispresent.

NURSING INTERVENTIONS:

Hydrate the client adequately postoperatively to preventhemoconcentration

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 asprescribed

Prevent swelling and stagnation of venous blood by applyingappropriately fitting elastic stockings or wrapping the legs from the

toes to the groin with elastic bandage

Apply pneumatic stockings, intraoperatively to patients at highest riskof DVT.

d)Pulmonary complicationsa.Atelectasiso 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 severetachypnea, tachycardia, cough, fever, hypotension, and decreased

breath sounds and chest expansion of affected side.

b.Aspiration


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o Distress and fatigueo Vomitingo Wound dehiscence in severe cases Nursing Interventions:o Identify and resolve the cause, if possibleo 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 10cm or 3 4 inches); rotate gently and jiggle back and forth

For rare, intractable hiccups, an extreme procedure is surgicalalteration of the phrenic nerve.

i) Wound infection2nd most common nosocomial infection. Theinfection 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 postoperativelyo 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, warmtho Red streaks in the skin near the woundo 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 woundo Generalized body chills or fevero Elevated temperature and pulseo 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:

oAtelectasis within the 1

st

48 hourso Wound infections in 5 7 dayso Urinary infections in 5 8 dayso 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 avoidacquiring 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 salineavailable

A drain may be inserted, or the wound may be packed with sterilegauze

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 surgeryo 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 distentiono 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 resto 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; attemptto keep patient quiet and relaxed

o Prepare the client for surgery and repair of the wound.jlnastor16

intra - operative nursing

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