surgery

SURGERYSURGERY

• SURGERYSURGERY – an invasive medical – an invasive medical procedure performed to diagnose or procedure performed to diagnose or treat illness, injury, or deformity.treat illness, injury, or deformity.

• OPERATIONOPERATION – for correction of – for correction of deformities and defects, repair of deformities and defects, repair of injuries, diagnosis and cure disease injuries, diagnosis and cure disease processes, relief of suffering and processes, relief of suffering and prolongation of life.prolongation of life.

• PERIOPERATIVE NURSINGPERIOPERATIVE NURSING – used – used to describe the nursing functions in to describe the nursing functions in the total surgical experience of the the total surgical experience of the patients.patients.

3 Phases of 3 Phases of Perioperative Perioperative

NursingNursing

1.1. PRE OPERATIVE PHASEPRE OPERATIVE PHASE : from the time : from the time the decision is made for surgical the decision is made for surgical intervention to the transference of the intervention to the transference of the patient to the operating room.patient to the operating room.

2.2. INTRA OPERATIVE PHASEINTRA OPERATIVE PHASE : from the : from the time the patient is received in the operating time the patient is received in the operating room, to the time of administration of room, to the time of administration of anesthesia, surgical procedure is done, until anesthesia, surgical procedure is done, until he is admitted in the recovery room/post he is admitted in the recovery room/post anesthesia care unit.anesthesia care unit.

3.3. POST OPERATIVE PHASEPOST OPERATIVE PHASE – from the time – from the time of admission to the recovery room, to the of admission to the recovery room, to the time he is transported back to the surgical time he is transported back to the surgical unit, discharged from the hospital, until the unit, discharged from the hospital, until the follow-up care.follow-up care.

CONDITIONS CONDITIONS REQUIRING SURGERYREQUIRING SURGERY

1.1. ObstructionObstruction

2.2. PerforationPerforation

3.3. ErosionErosion

4.4. TumorTumor

obstructionobstruction

PerforationPerforation

TumorTumor

CLASSIFICATION OFCLASSIFICATION OF SURGICAL PROCEDURES SURGICAL PROCEDURES

I. I. According to PURPOSE:According to PURPOSE:

1.1. DiagnosticDiagnostic2.2. ExploratoryExploratory3.3. CurativeCurative 3.1) Ablative3.1) Ablative 3.2) Constructive3.2) Constructive

3.3) Reconstructive3.3) Reconstructive4. 4. PalliativePalliative5. 5. TransplantTransplant

II. II. According to DEGREE of According to DEGREE of RISK (Magnitude / Extent):RISK (Magnitude / Extent):

1.1. MajorMajor

2.2. MinorMinor

III. According to III. According to URGENCY:URGENCY:

1.1. EmergencyEmergency

2.2. Urgent / ImperativeUrgent / Imperative

3.3. ElectiveElective

4.4. Planned / RequiredPlanned / Required

5.5. OptionalOptional

Abruptio Abruptio placenta,placenta,an an emergencyemergency

VSD needs urgent VSD needs urgent surgerysurgery

Hair transplant – elective Hair transplant – elective surgerysurgery

Required surgery for Required surgery for infected ulcerinfected ulcer

Optional Optional surgery surgery

for for Siamese Siamese

twinstwins

SURGICAL SURGICAL RISK FACTORSRISK FACTORS

1. Aging1. Aging

Nsg. Implications:Nsg. Implications:

1.1. Consider using lesser doses for desired Consider using lesser doses for desired effect.effect.

2.2. Adjust nutritional intake to conform to Adjust nutritional intake to conform to higher protein and vitamin needs.higher protein and vitamin needs.

3.3. Anticipate problems from long standing Anticipate problems from long standing chronic disorders such as diabetes, chronic disorders such as diabetes, anemia, obesity, cardiovascular anemia, obesity, cardiovascular disorders, respiratory disorders.disorders, respiratory disorders.

2. Obesity2. Obesity


1.1. Promote weight reduction if time Promote weight reduction if time permits.permits.

2.2. Monitor closely for wound, Monitor closely for wound, pulmonary, and cardiopulmonary pulmonary, and cardiopulmonary complications postoperatively.complications postoperatively.

3.3. Encourage coughing, turning, and Encourage coughing, turning, and diaphragmatic breathing exercises diaphragmatic breathing exercises and early ambulation.and early ambulation.

3.Malnutrition3.Malnutrition

Nsg. Implications:Nsg. Implications:1.1. Promote weight gain by providing Promote weight gain by providing

well-balanced diet high in calories, well-balanced diet high in calories, protein and vitamin C.protein and vitamin C.

2.2. Administer total parenteral nutrition Administer total parenteral nutrition intravenously, nutritional intravenously, nutritional supplements and tube feedings as supplements and tube feedings as prescribed.prescribed.

3.3. Daily weight and calorie counts also Daily weight and calorie counts also may be ordered.may be ordered.

4. Dehydration/Electrolyte 4. Dehydration/Electrolyte ImbalanceImbalance


1.1. Administer intravenous fluids as Administer intravenous fluids as ordered.ordered.

2.2. Keep a detailed input and output Keep a detailed input and output record.record.

3.3. Monitor client for evidence of Monitor client for evidence of electrolyte imbalance (Na+, K+, electrolyte imbalance (Na+, K+, Ca++, etc.).Ca++, etc.).

5. Cardiovascular Disorders5. Cardiovascular Disorders


1.1. Diligently monitor vital signs, Diligently monitor vital signs, especially pulse rate, regularity, and especially pulse rate, regularity, and rhythm, and general condition of the rhythm, and general condition of the client.client.

2.2. Closely monitor fluid intake (oral & Closely monitor fluid intake (oral & parenteral) to prevent circulatory parenteral) to prevent circulatory overload.overload.

3.3. Assess skin color.Assess skin color.

4. Assess for chest pain, lung 4. Assess for chest pain, lung congestion, and peripheral edema.congestion, and peripheral edema.

5. Observe for signs of hypoxia, and 5. Observe for signs of hypoxia, and administer oxygen as ordered.administer oxygen as ordered.

6. Early postoperative ambulation and 6. Early postoperative ambulation and leg exercises reduce the risk of leg exercises reduce the risk of vascular problems, such as vascular problems, such as thrombophlebitis and pulmonary thrombophlebitis and pulmonary embolism.embolism.

7. Encourage change of position but 7. Encourage change of position but avoid sudden exertion.avoid sudden exertion.

6. Respiratory Disorders6. Respiratory Disorders


1.1. Closely monitor respirations, pulse, Closely monitor respirations, pulse, and breath sounds.and breath sounds.

2.2. Assess for hypoxia, dyspnea, lung Assess for hypoxia, dyspnea, lung congestion, and chest pain.congestion, and chest pain.

3.3. Encourage coughing, turning, and Encourage coughing, turning, and diaphragmatic breathing exercises diaphragmatic breathing exercises and early postoperative ambulation.and early postoperative ambulation.

4. Encourage client to quit smoking or 4. Encourage client to quit smoking or at least to reduce the number of at least to reduce the number of cigarettes smoked.cigarettes smoked.

5. Patients with chronic pulmonary 5. Patients with chronic pulmonary problems such as emphysema, problems such as emphysema, bronchiectasis, etc. should be bronchiectasis, etc. should be treated for several days treated for several days postoperatively with postoperatively with bronchodilators, aerosol bronchodilators, aerosol medications, and conscientious medications, and conscientious mouth care.mouth care.

7. Diabetes Mellitus7. Diabetes Mellitus


1.1. Monitor the client closely for signs Monitor the client closely for signs and symptoms of hypoglycemia and and symptoms of hypoglycemia and hyperglycemia.hyperglycemia.

2.2. Monitor blood glucose levels every 4 Monitor blood glucose levels every 4 hrs. as ordered.hrs. as ordered.

3.3. Administer insulin as prescribed.Administer insulin as prescribed.

4.4. Encourage intake of food at the Encourage intake of food at the designated meal and snack times.designated meal and snack times.

8. Renal & Liver 8. Renal & Liver DysfunctionDysfunction

Nsg. Implication:Nsg. Implication:

1.1. Monitor for fluid volume overload, I Monitor for fluid volume overload, I & O, and response to medication.& O, and response to medication.

2.2. Evaluate closely for drug side Evaluate closely for drug side effects and evidence of acidosis or effects and evidence of acidosis or alkalosis.alkalosis.

9. Alcoholism9. Alcoholism


1.1. Monitor closely for signs of Monitor closely for signs of delirium tremens.delirium tremens.

2.2. Encourage well – balanced diet.Encourage well – balanced diet.

3.3. Monitor for wound complications.Monitor for wound complications.

4.4. Administer supplemental nutrients Administer supplemental nutrients parenterally as ordered.parenterally as ordered.

10. Medications10. Medications

A.A. Anticoagulants and SalicylatesAnticoagulants and Salicylates


1.1. Monitor for bleeding.Monitor for bleeding.

2.2. Assess PTT / PT values.Assess PTT / PT values.

B. Diuretics (particularly B. Diuretics (particularly Thiazides)Thiazides)


1.1. Monitor I & O and electrolytes.Monitor I & O and electrolytes.

2.2. Assess cardiovascular and Assess cardiovascular and respiratory status.respiratory status.

C. Antihypertensives (particularly C. Antihypertensives (particularly Phenothiazines)Phenothiazines)


1.1. Closely monitor blood pressure.Closely monitor blood pressure.

D. Antidepressants (particularly MAOD. Antidepressants (particularly MAO inhibitors)inhibitors)


1.1. Closely monitor blood pressure.Closely monitor blood pressure.

E. AntibioticsE. Antibiotics


1.1. Monitor respirations.Monitor respirations.

OTHER FACTORS:OTHER FACTORS:

1.1. Nature of the conditionNature of the condition

2.2. Location of the conditionLocation of the condition

3.3. Magnitude and urgency of the Magnitude and urgency of the surgical proceduresurgical procedure

4.4. Mental attitude of the person Mental attitude of the person toward the surgerytoward the surgery

5.5. Caliber of the professional staff Caliber of the professional staff health care facilities.health care facilities.

COMMON SUFFIXES IN COMMON SUFFIXES IN SURGERYSURGERY

EctomyEctomy – removal of an organ or a – removal of an organ or a glandgland

RrhaphyRrhaphy – repair – repair

OstomyOstomy – providing an opening – providing an opening (stoma)(stoma)

OtomyOtomy – cutting into – cutting into

PlastyPlasty – formation or plastic repair – formation or plastic repair

SScopycopy – looking into – looking into

COMMON COMMON ABBREVIATIONS:ABBREVIATIONS:

TAHBSOTAHBSO – Total Abdominal – Total Abdominal Hysterectomy Bilateral Salphingo Hysterectomy Bilateral Salphingo OophorectomyOophorectomy

TURP TURP – Transurethral Resection of the – Transurethral Resection of the ProstateProstate

TURBTTURBT – Transurethral Resection of – Transurethral Resection of the Bladder Tumorthe Bladder Tumor

STSGSTSG – Split Thicknes Skin Grafting – Split Thicknes Skin GraftingBKABKA – Below Knee Amputation – Below Knee Amputation

AKA AKA – Above Knee Amputation– Above Knee AmputationECCE w/ IOLECCE w/ IOL – Extra Capsular – Extra Capsular

Cataract Extraction w/ Intra-Ocular Cataract Extraction w/ Intra-Ocular Lens ImplantationLens Implantation

CHOLE w/ IOCCHOLE w/ IOC – Cholecystectomy – Cholecystectomy w/ Intra-operative Cholangiogramw/ Intra-operative Cholangiogram

D & CD & C – Dilatationof the cervix & – Dilatationof the cervix & Curettage of the uterusCurettage of the uterus

SMRSMR – Submucous resection of the – Submucous resection of the Nasal SeptumNasal Septum

MRMMRM – Modified Radical Mastectomy – Modified Radical Mastectomy

LCCS LCCS – Low Cervical Cesarean – Low Cervical Cesarean SectionSection

LSTCS LSTCS – Low Segment Transverse – Low Segment Transverse Cesarean SectionCesarean Section

ORIF ORIF – Open Reduction Internal – Open Reduction Internal FixationFixation

BTLBTL – Bilateral Tubal Ligation – Bilateral Tubal Ligation

PRE OPERATIVE PRE OPERATIVE PHASEPHASE

PreparationsPreparations PSYCHOLOGICAL PSYCHOLOGICAL

FearFear• Manifestations:Manifestations:

- Anxious- Anxious

- Bewilderment- Bewilderment

- Anger- Anger

- Tendency to exaggerate- Tendency to exaggerate

- Sad, evasive, tearful, clinging- Sad, evasive, tearful, clinging

- Inability to concentrate- Inability to concentrate

- Short attention span- Short attention span

- Failure to carry out simple directions- Failure to carry out simple directions

Nsg. Interventions to minimize Nsg. Interventions to minimize ANXIETY:ANXIETY:

1.1. Explore client’s feelings.Explore client’s feelings.

2.2. Allow client to speak openly about Allow client to speak openly about fears / concerns.fears / concerns.

3.3. Give empathetic support.Give empathetic support.

4.4. Consider the person’s religious Consider the person’s religious preferences and arrange for visit preferences and arrange for visit by priest / minister as desired.by priest / minister as desired.

LEGAL ConsiderationsLEGAL Considerations

Informed Consent - (Operative Informed Consent - (Operative Permit / Surgical Consent)Permit / Surgical Consent)

- LEGAL document required for - LEGAL document required for certain diagnostic procedures or certain diagnostic procedures or therapeutic measures, including therapeutic measures, including surgery.surgery.

Purposes:Purposes:1.1. To ensure that the client understands To ensure that the client understands

the nature of the treatment including the nature of the treatment including the potential complications and the potential complications and disfigurement.disfigurement.

2.2. To indicate that the client’s decision To indicate that the client’s decision was made without pressure.was made without pressure.

3.3. To protect the client against To protect the client against unauthorized procedure.unauthorized procedure.

4.4. To protect the surgeon and the To protect the surgeon and the hospital against legal action by a hospital against legal action by a client who claims that an unauthorized client who claims that an unauthorized procedure was performed.procedure was performed.

Nursing Responsibilities:Nursing Responsibilities:

1.1. Witnessing the exchange between Witnessing the exchange between the client and the surgeon.the client and the surgeon.

2.2. Witnessing the client’s signature.Witnessing the client’s signature.

3.3. Establishing that the client really did Establishing that the client really did understand.understand.

3 Major Elements of Informed 3 Major Elements of Informed ConsentConsent

1.1. The consent must be given The consent must be given voluntarily.voluntarily.

2.2. The consent must be given to The consent must be given to individual who have the capacity to individual who have the capacity to understand.understand.

3.3. The client must be given The client must be given information to be the ultimate information to be the ultimate decision maker.decision maker.

PHYSIOLOGICALPHYSIOLOGICAL

a. a. CardiovascularCardiovascular – ECG for patient aged – ECG for patient aged 40 yrs. and above and those undergoing 40 yrs. and above and those undergoing gen. anesthesia, or have cardiovascular gen. anesthesia, or have cardiovascular disease.disease.

b. b. Hematologic Hematologic – CBC, Hgb & Hct, WBC, – CBC, Hgb & Hct, WBC, PTT & PT, Platelet count.PTT & PT, Platelet count.

c. c. RespiratoryRespiratory – Chest x-ray, pulmonary – Chest x-ray, pulmonary function test / PFT.function test / PFT.

d. d. MetabolicMetabolic – FBS, Electrolytes(K+,Na+ – FBS, Electrolytes(K+,Na++, etc).+, etc).

e. e. GenitourinaryGenitourinary – routine urine analysis. – routine urine analysis.

PHYSICAL:PHYSICAL:

A. Teaching Post Op Exercises:A. Teaching Post Op Exercises:

1.1. Deep breathing exercise Deep breathing exercise (diaphragmatic)(diaphragmatic)

2.2. Coughing exerciseCoughing exercise

3.3. Turning exerciseTurning exercise

4.4. Leg, ankle, and foot exerciseLeg, ankle, and foot exercise

B. Night Prior to Surgery:B. Night Prior to Surgery:

Preparing the skinPreparing the skin Preparing the GITPreparing the GIT Preparing for anesthesiaPreparing for anesthesia Promoting rest and sleepPromoting rest and sleep

C. On the Day of Surgery:C. On the Day of Surgery:

1.1. Early Am CareEarly Am Care

2.2. Preoperative Medications / Preoperative Medications / Preanesthetic DrugsPreanesthetic Drugs

- generally administered 60-- generally administered 60-90minutes before induction of 90minutes before induction of anesthesia.anesthesia.

INTRAOPERATIVE INTRAOPERATIVE PHASEPHASE

Definition of Terms:Definition of Terms: Surgical ConscienceSurgical Conscience – one’s inner voice for – one’s inner voice for

the conscientious practice of asepsis & the conscientious practice of asepsis & sterile technique at all times.sterile technique at all times.

AsepsisAsepsis – absence of microorganism; – absence of microorganism; freedom from infection; exclusion of freedom from infection; exclusion of microorganism.microorganism.

SterileSterile – free of microorganism, including all – free of microorganism, including all spores.spores.

Spores Spores – inactive but visible sate of – inactive but visible sate of microorganism in the environment.microorganism in the environment.

SterilizationSterilization – process by which all – process by which all pathogenic microorganisms, including spores pathogenic microorganisms, including spores are killed.are killed.

3 Methods of Sterilization3 Methods of Sterilization1.1. Saturated Steam under PressureSaturated Steam under Pressure

e.g. autoclavee.g. autoclave

2.2. Gas Chemical SterilizationGas Chemical Sterilization

e.g. Sterrade.g. Sterrad

3.3. Liquid Chemical SterilizationLiquid Chemical Sterilization

- 2% activated aqueous - 2% activated aqueous glutaraldehyde solution ( e.g. glutaraldehyde solution ( e.g. cidex).cidex).

Sterile FieldSterile Field – area around the site – area around the site of incision into tissue or introduction of incision into tissue or introduction of any instrumentation into the body of any instrumentation into the body orifice that has been prepared for orifice that has been prepared for use of sterile supplies and use of sterile supplies and equipments including all furniture equipments including all furniture covered w/ sterile drapes and covered w/ sterile drapes and personnel who are properly attired.personnel who are properly attired.

Sterile TechniqueSterile Technique – method by – method by which contamination w/ which contamination w/ microorganism is prevented to microorganism is prevented to maintain sterility throughout the maintain sterility throughout the operative procedure.operative procedure.

Surgically CleanSurgically Clean – mechanically – mechanically cleansed but unsterile.cleansed but unsterile.

Disinfection Disinfection – process of destroying – process of destroying all pathogenic microorganism except all pathogenic microorganism except spore – bearing one.spore – bearing one.

AntisepticAntiseptic – used on tissue and skin – used on tissue and skin and the growth of endogenous and the growth of endogenous bacteria.bacteria.

IncisionIncision – the result of cutting into – the result of cutting into a body tissue using sharp a body tissue using sharp instrument.instrument.

Medical AsepsisMedical Asepsis – include all – include all practices intended to confine a practices intended to confine a specific microorganism to a specific specific microorganism to a specific area limiting the new growth and area limiting the new growth and spread of microorganism.spread of microorganism.

Surgical Asepsis (or sterile Surgical Asepsis (or sterile technique)technique) – refers to those – refers to those practices that keep an area or object practices that keep an area or object free of all microorganisms including free of all microorganisms including practices destroying all practices destroying all microorganisms and spores.microorganisms and spores.

PRINCIPLES OF STERILE PRINCIPLES OF STERILE TECHNIQUETECHNIQUE

1.1. Only sterile items are used within Only sterile items are used within the sterile field.the sterile field.

2.2. Gowns are considered sterile only Gowns are considered sterile only from the waist to shoulder level in from the waist to shoulder level in front and sleeves.front and sleeves.

3.3. Tables are sterile only at table level.Tables are sterile only at table level.

4.4. Persons who are sterile touch only Persons who are sterile touch only sterile items or areas; persons who sterile items or areas; persons who are not sterile.are not sterile.

5.5. Unsterile persons avoid reaching Unsterile persons avoid reaching over a sterile field; sterile persons over a sterile field; sterile persons avoid leaning over an unsterile area.avoid leaning over an unsterile area.

6.6. Edges of anything that encloses Edges of anything that encloses sterile contents are considered sterile contents are considered unsterile.unsterile.

7.7. Sterile field is created as close as Sterile field is created as close as possible to time of use.possible to time of use.

8.8. Sterile areas are continuously kept Sterile areas are continuously kept in view.in view.

9.9. Sterile persons keep well within the Sterile persons keep well within the sterile area.sterile area.

10.10.Sterile persons keep contact with Sterile persons keep contact with sterile areas to a minimum.sterile areas to a minimum.

11.11.Unsterile persons avoid sterile Unsterile persons avoid sterile areas.areas.

12.12.Destruction of integrity of Destruction of integrity of microbial barriers results in microbial barriers results in contamination.contamination.

13.13.Microorganisms must be kept to an Microorganisms must be kept to an irreducible minimum.irreducible minimum.

MEMBERS OF THE MEMBERS OF THE SURGICAL TEAMSURGICAL TEAM

1.1. SurgeonSurgeon

2.2. Assistant to the surgeonAssistant to the surgeon

3.3. AnesthesiologistAnesthesiologist

4.4. Nurse anesthetist (CRNA)Nurse anesthetist (CRNA)

5.5. Circulating nurseCirculating nurse

6.6. Scrub nurseScrub nurse

ANESTHESIAANESTHESIA

Effects of Anesthesia:Effects of Anesthesia:

1.1. AnalgesiaAnalgesia

2.2. AmnesiaAmnesia

3.3. HypnosisHypnosis

4.4. Muscle relaxationMuscle relaxation

Factors considered in choice of Factors considered in choice of Anesthesia:Anesthesia:• Physical conditionPhysical condition• AgeAge• Presence of co-existing diseasePresence of co-existing disease• Type, site, duration of surgeryType, site, duration of surgery• Anesthesiologist’s preferenceAnesthesiologist’s preference• Patient’s preferencePatient’s preference

TYPES OF ANESTHESIATYPES OF ANESTHESIA

I.I. General AnesthesiaGeneral Anesthesia

Types:Types:

a. Inhalation anesthesiaa. Inhalation anesthesia

- mask inhalation- mask inhalation

- endotracheal administration- endotracheal administration

b. Intravenous anesthesiab. Intravenous anesthesia

Stages of General Stages of General Anesthesia:Anesthesia:

1.1. Onset / Analgesia / InductionOnset / Analgesia / Induction

2.2. Excitement or DeliriumExcitement or Delirium

3.3. Surgical Excitement / AnesthesiaSurgical Excitement / Anesthesia

4.4. Danger / MedullaryDanger / Medullary

II.II. Regional AnasthesiaRegional Anasthesia

Types:Types:

1.1. Topical anesthesiaTopical anesthesia

2.2. Infiltration anesthesiaInfiltration anesthesia

3.3. Regional applicationRegional application

Examples:Examples:

- Nerve block- Nerve block

- Intravenous regional extremity - Intravenous regional extremity block anesthesia (Bier Block) w/ block anesthesia (Bier Block) w/ tourniquettourniquet

- Spinal anesthesia / Intrathecal - Spinal anesthesia / Intrathecal anesthesiaanesthesia

Complications & discomforts of Complications & discomforts of Spinal Anesthesia:Spinal Anesthesia:

a. Hypotensiona. Hypotension

b. Nausea & vomitingb. Nausea & vomiting

c. Headache c. Headache

d. Respiratory paralysisd. Respiratory paralysis

e. Neurologic complicationse. Neurologic complications

4.4. Epidural AnesthesiaEpidural Anesthesia

Ex. Cocaine, Novocaine, Ex. Cocaine, Novocaine, Xylocaine,CarbocaineXylocaine,Carbocaine

Specialized methods in Specialized methods in producing anesthesia:producing anesthesia:

• Muscle relaxantsMuscle relaxants• HypothermiaHypothermia• Controlled HypotensionControlled Hypotension

Intraoperative Intraoperative (ANESTHESIA) (ANESTHESIA) Complications:Complications:

1.1. Hypoventilation Hypoventilation

2.2. Oral traumaOral trauma

3.3. HypotensionHypotension

4.4. Cardiac dysrhythmiaCardiac dysrhythmia

5.5. HypothermiaHypothermia

6.6. Peripheral nerve damagePeripheral nerve damage

7.7. Malignant hyperpyrexiaMalignant hyperpyrexia

Surgical Incisions:Surgical Incisions:• SubcostalSubcostal• ParamedianParamedian• MidlineMidline• TransverseTransverse• McburneysMcburneys• ButterflyButterfly• PfannenstielPfannenstiel• LimbalLimbal• Halstead / ellipticalHalstead / elliptical

Layers of the abdomen:Layers of the abdomen:

1.1. Skin Skin – monocryl 3/0 or 2/0, vicryl – monocryl 3/0 or 2/0, vicryl 4/0, safil 4/0, safil 4/0, dexon 4/0, dexon 4/0, silk 3/04/0, silk 3/0

2.2. Subcutaneous Subcutaneous – plain 2/0– plain 2/0

3.3. FasciaFascia – vicryl 1 or 0, safil 1 or 0, – vicryl 1 or 0, safil 1 or 0, dexon1 or 0dexon1 or 0

4.4. MuscleMuscle

5.5. Peritoneum Peritoneum – chromic 2/0, – chromic 2/0, monocryl 2/0 or monocryl 2/0 or 3/03/0

SURGICAL SUTURESSURGICAL SUTURES

• Classification:Classification:

1. Absorbable1. Absorbable

2. Non-absorbable2. Non-absorbable

• Types:Types:

1. Atraumatic1. Atraumatic

2. Non-atraumatic2. Non-atraumatic

Surgical NeedlesSurgical Needles

• Types:Types:

1. Cutting1. Cutting

2. Round2. Round

• Classification of surgical needles:Classification of surgical needles:

1. eye needle / free needle / non-1. eye needle / free needle / non-atraumaticatraumatic

2. eyeless / swaged needle / atraumatic2. eyeless / swaged needle / atraumatic

CLASSIFICATION OF CLASSIFICATION OF INSTRUMENTSINSTRUMENTS

1.1. CuttingCutting ex. Metzenbaum (metz), mayo scissors, ex. Metzenbaum (metz), mayo scissors,

suture scissors, knife.suture scissors, knife.22. . GraspingGrasping - divided in the following categories:- divided in the following categories:

hemostatshemostats occluding clampsoccluding clamps graspers and holdersgraspers and holders forceps or pick – ups forceps or pick – ups

3. Retracting3. Retracting4. Accessory and ancillary 4. Accessory and ancillary

instrumentsinstruments

Counting and Reporting Counting and Reporting of SINof SIN

• INITIAL COUNTINGINITIAL COUNTING – before the – before the procedure starts.procedure starts.

• 11stst counting – counting – beforebefore the closure of the closure of peritoneumperitoneum

• 22ndnd counting – counting – before before the closure of the closure of fasciafascia

• 33rdrd counting – counting – beforebefore closure of skin closure of skin

POSTOPERATIVE PHASEPOSTOPERATIVE PHASE

• Immediate post-op nursing care:Immediate post-op nursing care:

- avoid exposure- avoid exposure

- avoid rough handling- avoid rough handling

- avoid hurried movement and - avoid hurried movement and rapid rapid changes in positionchanges in position

AssessmentAssessment

• Appraise air exchange and note skin colorAppraise air exchange and note skin color• Verify identify, operative procedure, Verify identify, operative procedure,

surgeonsurgeon• Assess neurologic status (LOC)Assess neurologic status (LOC)• Determine VS and skin temp (CV status)Determine VS and skin temp (CV status)• Determine operative site and check Determine operative site and check

dressingdressing• Perform safety checksPerform safety checks• Require briefing on problems encountered Require briefing on problems encountered

in ORin OR

InterventionsInterventions

1.1. Ensure maintenance of patent airway Ensure maintenance of patent airway and adequate respiratory function.and adequate respiratory function.

2.2. Assess status of circulatory system.Assess status of circulatory system.

Common cardiovascular Common cardiovascular complication immediate post-op:complication immediate post-op:

1.1. HypotensionHypotension

2.2. Cardiac arrhythmiasCardiac arrhythmias

ALDRETE Scoring in PACU: ALDRETE Scoring in PACU: (ARCCC)(ARCCC)

• ActivityActivity 22 able to move 4 extremitiesable to move 4 extremities

11 able to move 2 extremitiesable to move 2 extremities

00 not able to movenot able to move

• RespirationRespiration 22 able to cough & deep able to cough & deep breathbreath

11 dyspnea or limited breathingdyspnea or limited breathing

00 apneicapneic

• CirculationCirculation 22 20% pre anesthesia20% pre anesthesia

11 20-50% pre 20-50% pre anesthesiaanesthesia

00 above 50% pre above 50% pre anesthesiaanesthesia

• Consciousness Consciousness 22 fully awakefully awake

11 rousable on callingrousable on calling

00 not respondingnot responding• ColorColor 22 pinkpink

11 pale, dusky, blotchypale, dusky, blotchy

0 0 cyanoticcyanotic

Parameters for discharge Parameters for discharge from RRfrom RR

• Activity Activity – score of 2; able to obey commands.– score of 2; able to obey commands.• RespirationRespiration – score of 2; easy, noiseless – score of 2; easy, noiseless

breathing.breathing.• CirculationCirculation – 20 of pre anesthesia; BP is – 20 of pre anesthesia; BP is

within within +/-20 mmHg of the pre op level.+/-20 mmHg of the pre op level.• ConsciousnessConsciousness – score of 2; responsive. – score of 2; responsive.• ColorColor – score of 2; pinkish skin and mucus – score of 2; pinkish skin and mucus

membrane.membrane.

Nursing Care of the client Nursing Care of the client during the intermediate during the intermediate post op period (RRunit)post op period (RRunit)

• Baseline assessment:Baseline assessment:Respiratory statusRespiratory statusCardiovascular statusCardiovascular statusLOCLOCTubesTubesPositionPosition

• Goals:Goals:

1.1. Restore homeostasis and prevent Restore homeostasis and prevent complications.complications.

2.2. Maintain adequate cardiovascular Maintain adequate cardiovascular and tissue perfusion.and tissue perfusion.

3.3. Maintain adequate respiratory Maintain adequate respiratory functionfunction

4.4. Maintain adequate nutrition and Maintain adequate nutrition and elimination.elimination.

5.5. Maintain adequate fluid and Maintain adequate fluid and electrolyte balance.electrolyte balance.

6.6. Maintain adequate renal function.Maintain adequate renal function.7.7. Promote adequate rest, comfort and Promote adequate rest, comfort and

safety.safety.8.8. Promote adequate wound healing.Promote adequate wound healing.9.9. Promote and maintain activity and Promote and maintain activity and

mobility.mobility.10.10.Provide adequate psychological support.Provide adequate psychological support.Post op discomforts:Post op discomforts:1.1. Nausea and vomitingNausea and vomiting2.2. PainPain3.3. ThirstThirst4.4. ConstipationConstipation5.5. restlessnessrestlessness

Discharge Planning / Discharge Planning / Teaching 2 – 3 days after Teaching 2 – 3 days after

surgery:surgery:• Self – care activitiesSelf – care activities• Wound care activitiesWound care activities• Activity limitationsActivity limitations• Diet and medications at homeDiet and medications at home• Possible complicationsPossible complications• Referrals, follow – up check - upReferrals, follow – up check - up

POST OP POST OP COMPLICATIONSCOMPLICATIONS

CIRCULATORY COMPLICATIONS:CIRCULATORY COMPLICATIONS:a.a. ShockShockb.b. HemorrhageHemorrhagec.c. Thrombophlebitis / deep Thrombophlebitis / deep

thrombophlebitisthrombophlebitis

PULMONARY COMPLICATIONSPULMONARY COMPLICATIONSa.a. AtelectasisAtelectasisb.b. PneumoniaPneumonia

URINARY DIFFICULTIESURINARY DIFFICULTIES

a.a. Urinary retentionUrinary retention

GASTROINTESTINAL GASTROINTESTINAL COMPLICATIONSCOMPLICATIONS

a.a. Paralytic ileusParalytic ileus

b.b. Gas painGas pain

c.c. Intestinal obstructionIntestinal obstruction

d.d. HiccupsHiccups

WOUND COMPLICATIONSWOUND COMPLICATIONS

a.a. Wound infectionsWound infections

* Rule of thumb* Rule of thumb

- fever 1- fever 1stst 24 hours post op 24 hours post op

- fever 48 hrs. post op- fever 48 hrs. post op

- fever 48-72 hrs. post op- fever 48-72 hrs. post op

- fever 72 hrs. post op- fever 72 hrs. post op

b.b. Hemorrhage / HematomaHemorrhage / Hematoma

c.c. Wound dehiscence and eviscerationWound dehiscence and evisceration

Post Op Psychological Post Op Psychological DisturbancesDisturbances

a.a. DeliriumDelirium

b.b. ACS (Acute Confusional State)ACS (Acute Confusional State)• Causes:Causes:- DehydrartionDehydrartion- Insufficient oxygenationInsufficient oxygenation- AnemiaAnemia- HypotensionHypotension- Hormonal imbalanceHormonal imbalance- InfectionInfection- Trauma (esp. in nervous person)Trauma (esp. in nervous person)

THE ENDTHE END

GOOD LUCK…GOOD LUCK…

surgery

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