Surgery & Surgical Nursing 1 Intro ..pptx

Chest injuries

1. SURGERY AND SURGICAL NURSING

2. SURGICAL NURSING Definition of surgery It is a branch of medicine that treat diseases, injuries and deformities whether in part or whole through physical manipulation or operative measures. Activities performed include Elimination of damaged parts, Separation of united parts, Joining parts that have been separated and Repairing the defects in the body

3. Classification of surgery Surgery is classified according to Purpose of surgery and Degree of urgency surgery Degree of risk

4. A. Classification according to the Purpose Diagnostic surgery : - example taking a biopsy or performing an exploratory laparotomy. Curative: - if a diseased part is removed to cure as in appendicectomy . Reparative : when there is a need to repair damaged tissues as in grafting Reconstructive: when there is a need to refigure or reshape how an organ looks after injury or surgery Cosmetic : when there is a need to refigure or reshape how an organ looks though it may not be causing any physical discomfort. Palliative surgery is done to relieve pain and to improve quality of life but not to produce a cure. Adjuvant :

5. According to the degree of urgency Emergency surgery: when the patient requires immediate attention and the disorder is life-threatening. Urgent s urgery is when patient requires attention within 24 – 30 hours as in gallbladder infection. Required Surgery is when a patient needs to have operation within few weeks or months as in BPH Elective/Ambulatory Surgery is when operation is not a necessity as in repair of scars.

6. Some terminologies used in surgery Abscess : collection of pus in a cavity Anastomosis : the artificial surgical union of one or two organs. Adhesions: the union of two surfaces which are usually separated which is caused or as a result of inflammation Algia : related to pain Anaesthesia : loss of sensation Biopsy: removal of a tissue/part of an organ for pathological examination Calculi: the formation of stones Cele : swelling Curette: to scrape Diathermy: the production of heat by using powerful electric Dactyl: either a finger or a toe Dilate: to stretch Ectomy : a permanent removal Excise: to cut off Resect: to cut off from the middle Fissure: crack or a slit Itis : inflammation Incise: cut into or the open into Hyper: excess Hypo: deficient or scanty Ligate: to tie

7. Terminologies cont’d Lumen: the interior of an open organ Ostomy : permanent opening into an organ Otomy : temporal incision into an organ. Oophoro : ovaries Oscopy : inspection of an interior of an organ using an instrument Osteo : bone Ophthalmo : the eye Orchi : testes Oligo : diminished or scanty Oma : tumor or growth Oti : ear Megaly : enlargement Palpate: manual examination with the hand Plasty : reconstruction of a diseased part Radical: total or complete removal of an organ Phlebo : vein eg . phlebitis Rrhaphy : repair of a part Rupture: tear or disruption of a tissue Stenosis: narrowing of a lumen Subtotal: incomplete or part removal of an organ Torsion: twisting

8. PERIOPERATIVE NURSING CARE

9. PERIOPERATIVE NURSING Perioperative period is the period between the patient’s first and last contact with the surgeon. It consists of three phases namely; The preoperative phase The intraoperative phase The postoperative phase

10. PREOPERATIVE CARE This is done to identify any risk factors that could lead to postoperative complications and hinder recovery It begins when decision for surgery is made and ends when patient is transferred to operative theater We will look at it under Psychological Physiological Physical Socio-economic Spiritual

11. Preoperative Assessment Age: young children and older adults have lowest tolerance to stress effect of surgery Pain: ( socrat ) Nutritional / hydration status Infections (skin, respiratory, systemic etc ) Drug history (anticoagulants, steroids, hypoglycemic, antibiotics, etc ) Cardiopulmonary functioning Renal GIT / Liver functioning tests Endocrine and neurological functioning Sensory and perceptual functioning Lifestyle (smoking, alcohol, etc ) Any other deformities

12. Psychological care Assess patient’s fears and anxiety levels Reassure patient of the competency of the surgical team Educate patient on condition and the surgery Allow patient to ask questions and explain Encourage patient’s participation in decision making and care Show patient to others who have successfully

13. Psychological care cont’d Allow the surgeon to explain the surgical experience to the patient Allow family and other support network to visit Teach patient deep breathing and coughing as well as turning exercises Explain the rationale for frequent position changes Demonstrate to patient how to splint the wound when performing the deep breathing and coughing exercises. Relieve pain before the exercises Discuss how patient’s pain will be managed

14. A consent form is the legal document that indicates the patient informed consent for the procedure Signed consent form is necessary for every invasive procedure Patient/family must have full understanding of the procedure before given consent Alternate treatment must be explained to him He must know of potential risk, complications, and disfigurements or loss of body part. Pain management through anesthesia should be explained to him. Patient should know who will perform surgery, whether or not body part will be remove Doctor can use Durable Power of Attorney in Emergency situations Informed consent form

15. Physiological care Assess patient’s nutritional status Serve high calorie diet to boost nutritional status and promote recovery Assess for dehydration, hypovolemia , shock and electrolyte imbalance Administer prescribed IV fluids for hydration and electrolyte balancing Monitor fluids on intake and output chart Administer prescribed premedication

16. Physiological care cont’d Assess vital signs (T, P, R & BP) and record. Report any abnormality Ensure that all Lab and X-ray examinations are done and reports collected Maintain NPO 6 – 8 hours before surgery Administer prophylactic antibiotics to decrease intestinal flora. All previous medications should be noted or reviewed or stopped prior to surgery. Eg . Aspirin Perform range of motion exercises to improve circulation, prevent venous stasis, DVT and optimal respiratory function.

17. Physical care Let patient have a thorough bath in the morning Inspect the mouth and remove any dentures and keep in safe place Remove all jewelries, watches, contact lenses, pins, etc. and cover hair (for females) Put on identification wrist band Assess skin for abrasions, lacerations or signs of infection at the operative site Prepare the skin by wash the site and with soap and water (shave PRN) Clean with antiseptic lotion ( savlon or povidone -iodine) Cover with sterile towel and hold it in place with adhesive tapes Change patient into theater gown

18. Physical care cont’d Provide bedside rails if premedication is given to prevent falls Pass urethral catheter to monitor urine output or keep the bladder empty Pass NG tube for gastric or intestinal decompression Apply anti-embolic stockings Prepare patient’s bowel by giving enema a night before the surgery and rectal washout the morning of surgery Check and document items for surgery including the folder Transport patient to the theater Direct patient’s relatives to the waiting room

19. GIT needs special preparation before surgery in order to: Reduce the possibility of vomiting and aspiration during anesthesia Reduce the possibility of a bowel obstruction Reduce the possibility of a bowel injury Prevent contamination from fecal material during intestinal tract or dowel surgery . GIT preparation

20. Bowel preparation Serve low residue diet 48 hours before surgery Serve light diet a day before the surgery Increase fluid intake to prevent constipation Ensure nil per os 6 – 8 hours before the surgery Give parenteral nutrition to provide nutrients Administer prescribed stool softeners such as Lactulose Administer laxatives as prescribed The night before the surgery, perform rectal enema In the morning of surgery, perform rectal washout Administer prescribed antibiotics to decrease intestinal flora (neomycin ) N/G Tube may be passed to reduce intestinal pressure

21. To prevent the contamination t o peritoneal cavity Prevent injury to the colon Provide adequate visualization of the surgical site. NB. Some patients may require further bowel cleaning on the morning of surgery N/G tube are usually inserted during surgery if they are use at all Reasons for Enemas

22. Socio-economic care Inform patient of the possible cost of the surgery Enquire whether patient is on NHIS and provide necessary information Allow patient to pay deposits according to hospital protocol Encourage support network to assist in the care of the patient Encourage patient participation in the care Inform social welfare department if patient cannot pay his hospital bills Inform patient of the duration of stay in the hospital

23. Spiritual / Cultural beliefs Assist patient in using religious coping as it helps to reduce anxiety and fear Allow patient to receive spiritual support that he or she requests for The nurse supports the religious beliefs of the patient by praying with him Respect patient’s cultural values as it facilitates rapport and trust between patient and nurse Restrict the intake of any concoction

24. Ensure that patient baths in the morning Skin preparation is done according to protocol Check and record vital signs Check identification band to make sure it is legible, accurate Ensure informed consent form is signed Check and carry out specific orders . eg . IV line, administration of enemas, premed, etc Ensure Nil Per Os General Preparation of client on the day of surgery

25. Ask client to void or pass urethral catheter Remove dentures that could obstruct the airway Remove jewelry Help patient don the gown Remove nails polish Put patient on a Stretcher and transport him to the theater Prepare the patient bed for postoperative care General preop care Cont’d

26. POSTOPERATIVE CARE The postoperative care starts when …… The objective is to provide care until the patient recovers from the effects of anesthesia Prepare operation bed with the accessories Quickly review postoperative instructions and receive the patient Monitor patient’s level of consciousness, Position patient in supine and turn his head

27. Postoperative care cont’d Modify the position to semi-fowlers or high fowlers Document baseline vital signs every 15 minutes for one hour, then every 30 minutes till stable and then 4 hourly Check the surgical site/incision site for bleeding/ dehiscence and evisceration. Reinforce if there is bleeding. Notify the surgeon if bleeding persists Monitor all drainage tubes including IV infusions or blood transfusion Assess respiratory pattern and airway for obstruction Suction patient PRN and administer oxygen as prescribed.

28. Postoperative care cont’d The head of the bed may be elevated to about 15 – 30 degree unless contraindicated If patient vomits, provide vomit bowl and care for the mouth Observe for shock (usually hypovolemia ) Monitor blood transfusion if required Administer IV fluids (R/L and N/S) as prescribed Monitor on Intake and Output chart Administer all postoperative medications such as antibiotics, analgesics, etc.

29. Postoperative care cont’d Maintain personal hygiene of the patient Observe for bowel sounds to return Introduce sips, then liquid and then normal diet. Serve food high in calories (high protein, carbohydrates, vegetables, vitamins) Change wound dressing usually on the third day post operation using aseptic technique. Remove wound drain as indicated Provide education on discharge information covering areas such as medication, identification of possible complications, review dates, nutrition, rest and sleep.

30. Complications of surgery Infection Bleeding Shock Adhesion Dehydration Over-hydration DVT

31. THANK YOU

32. INTRAOPERATIVE NURSING Surgical interventions have improved Surgery and anesthesia still place patient at risk for several complications. It is the duty of the surgical team to protect this patient.

33. THE SURGICAL ENVIRONMENT/THEATER The surgical environment is a cool place and access is limited to authorized personnel only It is located central to all supporting services. It has air filtration devices to screen out contaminating particles, dust, and pollutants. Surgical asepsis and traffic control are ensured.

34. Changing room Lobby Scrub – up area The set-up area Anesthetic room or office Operation room Recovery or ICU Offices Sterilization room Stores, sterile pack room, and non-sterile Sluice room Holding area Others are; CT scanner unit, MIR Rooms in the OR and their uses

35. The theater cont’d To help decrease microbes, the surgical area is divided into four zones: the outer or unrestricted zone, where street clothes are allowed; The clean or semirestricted zone, where attire consists of scrub clothes and caps; and the aseptic or restricted zone, where scrub clothes, shoe covers, caps, and masks are worn. Disposal zone ; where the used instruments and scrubs are decontaminated, washed, dried and packaged for sterilization

36. THE OPERATING ROOM (OR) Slightly higher pressure Humidity 50 – 60 % Temperature 22 – 24 degrees celcius Special lighting Overhead source Has bright and shadowless qualities Can control intensity equipped with reserve light Provide blue- white colour of the day light Freely adjustable, and manipulation fixtures Produce minimum heat (halogen bulb) Easy cleaning, no crevices and uneven surface

37. The Surgical Team It is divided into Sterile and Nonsterile members. The sterile members include The Surgeon, First assistance, The Scrub nurse.   The nonsterile members include The patient The anaesthetist , The circulating nurse, The perianaesthesia nurse, others (students, orderlies, lab & X-ray and account personnel)

38. The Surgeon He is the head of the surgical team He is responsible for carrying out the operation. He also assists in positioning of the patient on the theater table. He marks the surgical site with indelible mark. He prepares the patient surgical site. He drapes the patient. He decides on the surgical method to use Together with the anaesthetist ensures the safety of the patient

39. The scrub nurse The scrub nurse performs a surgical hand scrub She sets up the sterile tables (Mayo’s trolley or Tables) She prepares sutures, ligatures and special equipment eg . Laparoscope. She assists the surgeon and the surgical assistant during the procedure She labels the specimen taken from the patient and the circulating nurse sends it to the laboratory As the incision is closed, the scrub nurse counts the instruments and sponges etc to make sure they are not retained as a foreign body in the patient The items are counted before the procedure and twice after the procedure

40. The Circulating Nurse The circulating nurse coordinates the care of the patient in the OR She is responsible for Verifying consent for the operation Managing the OR and Checking the OR conditions such as ensuring proper cleanliness and temperature, humidity, lighting of the OR Assists in positioning of the patient Protects the patient’s safety and health by monitoring the activities of the surgical team Continually assess the patient for signs of injury and implement appropriate interventions

41. The Circulating Nurse Monitor aseptic practices to avoid break in technique while coordinating movement of related personnel Ensuring safe functioning of equipment Make available supplies and materials Coordinating the team by Anticipating the needs of the surgical team Checks with the scrub nurse the surgical sites, swabs, instruments before wound is closed Monitor activities and documents specific activities throughout the operation Managing surgical specimen Implementing fire safety precautions

42. The anaesthetist / Anaesthesiologist Assesses the patient before the surgery Selects the type of anesthesia based on the type of surgery Prescribes and administers the premedication Intubates the patient when necessary Manages any technical problems related to the administration of anesthetic agent Supervises the patient’s condition (vital signs, ECG, SPO 2 tidal volume, blood gas, ) throughout the surgical procedure They initiates patient’s resuscitation from after the surgery is completed

43. The patient Patient is the individual coming for the surgery and has fears and anxieties Patient’s fears are mainly about Fears about loss of control, The unknown, Pain , Death , Changes in body structure or function . These fears can increase the amount of anesthetic needed, the level of postoperative pain, and overall recovery time.    Hence the need to prepare the patient well before the surgery

44. THANK YOU QUESTIONS AND COMMENTS

45. SURGICAL ASEPSIS Surgical asepsis is the principle of prevention of contamination of surgical wounds. Sources of postoperative wound infection include The patient’s natural skin flora or A previously existing infection The instruments used The environment of the theater or ward Droplet infections from the surgical team members Strict adherence to the principles of surgical asepsis by OR personnel are necessary to reduce the risk of contamination and infection  

46. SURGICAL ASEPSIS cont’d Measures include All surgical supplies such as instruments, needles, sutures, dressings, gloves, must be sterilized before use The surgeon, surgical assistants, and nurses must scrub Surgical team members wear long-sleeved, sterile gowns and gloves The head and hair are covered with a cap, and a mask is worn over the nose and mouth to minimize URT droplets

47. SURGICAL ASEPSIS cont’d During surgery, only sterile personnel touches sterile objects such as instruments Larger than required skin is meticulously cleansed with an antiseptic solution The remainder of the patient’s body is covered with sterile drapes. The movements of the surgical team are from sterile to sterile areas and from unsterile to unsterile areas. Only sterile personnel touch sterile items Circulating nurse touches the unsterile items.

48. SURGICAL ASEPSIS cont’d Floors and horizontal surfaces are cleaned between cases Sterile equipment are inspected regularly to ensure optimal performance . All equipment that comes into direct contact with the patient must be sterile. Sterilized linens, drapes, and solutions are used. Instruments are cleaned and sterilized in a unit near the OR. Items are dispensed to a sterile field by methods that preserve the sterility of the items

49. SURGICAL ASEPSIS cont’d Individually wrapped sterile items are used when additional individual items are needed. Unnecessary personnel and physical movement are also restricted to minimize bacteria in the air To decrease the amount of bacteria in the air, Ventilation provides about 15 air exchanges per hour, A room temperature of 20_C to 24_C (68_F to 73_F), humidity between 30% and 60%, and Positive pressure relative to adjacent areas are maintained.

50. THANK YOU QUESTIONS AND COMMENTS

51. PREMEDICATION This is the medication given prior to the administration of anesthetic agent for surgery to commence . The main goals are to : Enhance effectiveness of anesthesia Reduce side effects such as nausea and vomiting Reduce or relieve anxiety Dry up mucous secretion Relax smooth muscles A thorough examination by the anesthetist is carried out before the premed is given Any underlying disease is treated Other medications that might impede surgery are stopped

52. Types of medications given Barbiturates / Tranquilizers or benzodiazepaines . Examples are lorazepine , Midaxolam and diazepam are given to reduce or relieve anxiety. Opiates : examples are Morphine, Meperidine for patients with severe pain in the preoperative period . Anticholinergics are also given to reduce respiratory tract secretions. Example is Atropine Timing: these are usually given a night before and morning of surgery.

53. TYPES OF ANESTHESIA AND SEDATION Anesthesia is a state of narcosis (central nervous system depression produced by pharmacologic agents, analgesia, relaxants and reflex loss). We have; General anesthesia Regional Moderate sedation Local anesthesia

54. General Anesthesia (GA) G.A is the administration of anesthetic agent (through Inhalation or IV) that makes patients lose all reflexes especially response to pain. Patient requires assistance in maintaining patent airway Patient requires a ventilator to maintain cardiovascular and pulmonary functioning Stages of General Anesthesia The Beginning phase The Excitement phase Surgical anesthesia phase Medullary Depression

55. Regional Anesthesia Epidural and Spinal anesthesia In epidural anesthesia, In spinal anesthesia, The drug is injected at the lumber level usually L4 or L5 into the epidura or subarachnoid space surrounding the spinal cord respectively. It blocks pain sensations in the lower limbs, perineum bladder and rectum or lower abdomen

56. Moderate Sedation / Anesthesia The anesthetic agent or sedative is administered IV to reduce patient’s anxiety and control pain during diagnostic or therapeutic short-term surgical procedures. E.g. Ketamine Advantages Patient maintains patent airway Retains protective airway reflexes eg . coughing Responds to verbal and physical stimuli Patient is however, monitored closely to prevent over sedation.

57. Local anesthesia This is the injection (infiltration) of an anesthetic agent into the tissues at the planned incision site. Advantages It is simple, economical and non-expensive Equipment and skill needed are minimal Postoperative recovery is brief Undesirable effects of GA are avoided It is ideal for short and minor surgical procedures

58. Examples of anesthetic agents Lidocaine , Bupivacaine , Tetracaine . Diazepam (Valium) Ketamine ( Ketalar ) Midazolam (Versed) Thiopental sodium (Pentothal) Propofol ( Diprivan ) Morphine sulphate

59. Intra-operation Complications Bleeding Shock Nausea and Vomiting Anaphylaxis to anesthetic agent Hypoxia from cyanosis or asphyxia Hypothermia Malignant hyperthermia

60. THANK YOU