CONCEPT OF SURGERY Flashcards
1
Q
The art of healing by manual operation;
Done for the healing of diseases or injuries of the body;
Its objective is to cure local injuries or diseases, such as wounds or fractures, tumors, etc.
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SURGERY
2
Q
Deviation from normal structure or location in any organ or part of the body that is present from birth
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CONGENITAL ANOMALIES
3
Q
What is VACTERL
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V-ertebral defect
A-nal malformation
C-ardiac Anomaly
T-racheoesophageal fistula
E-sophageal atresia
R-enal Anomaly
L-imb defect
4
Q
What is POET
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Perforation, Obstruction, Erosion, Tumor
5
Q
rupture of an organ
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PERFORATION
6
Q
impairment to the flow of vital fluids
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OBSTRUCTION
7
Q
Wearing off a surface or membrane
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EROSION
8
Q
abnormal new growth
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TUMOR
9
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CLASSIFICATIONS OF SURGERY
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ACCORDING TO PURPOSE
ACCORDING TO URGENCY
ACCORDING TO RISK
10
Q
confirm the disease
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DIAGNOSTIC
11
Q
repairs congenital defect (cheiloplasty)
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CONSTRUCTIVE
12
Q
repairs damaged organ (skin grafting)
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RECONSTRUCTIVE
13
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to relieve pain or correct problem (Gastrostomy, colostomy, ileostomy)
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PALLIATIVE
14
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deformity (arthroplasty)
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RESTORATIVE
15
Q
(without delay); severe bleeding, fractured skull, gunshot wound
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EMERGENCY
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(within 24-30 hours); gall bladder infection
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URGENT
17
Q
(within few weeks or month): cataract
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REQUIRED
18
Q
Failure of surgery is not a catastrophe (e.g., repair of scar, vaginal repair)
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ELECTIVE
19
Q
(personal preference): cosmetic surgery
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OPTIONAL
20
Q
(Ambulatory Surgery): done on Outpatient basis
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DAY
21
Q
Usually involves the use of general anesthesia.
Major surgery often involves opening one of the major body cavities
The surgery is usually performed in an operating room by a team of doctors.
A stay of at least one night in the hospital is usually needed after major surgery.
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MAJOR SURGERY (HIGH RISK)
22
Q
Can involve the use of local, regional, or general anesthesia.
Major body cavities are not opened.
Minor surgery may be performed in an emergency department, an ambulatory surgical center, or a doctor’s office.
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MINOR SURGERY (LOW RISK)
23
Q
3 PHASES
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Preoperative
Intraoperative
Postoperative
24
Q
Begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient into the operating room table
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PREOPERATIVE PHASE
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PREOPERATIVE NURSING ACTIVITIES
Establishing a baseline evaluation of the patient before the day of surgery by carrying out a preoperative interview
Ensuring that necessary tests have been or will be performed (pre admission testing)
Arranging appropriate consultative services
Providing preparatory education about recovery from anesthesia and postoperative care.
On the day of surgery, patient teaching is reviewed, the patient’s identity and the surgical site are verified, informed consent is confirmed and an intravenous infusion is started
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Fears of the unknown
General Fears
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Fear of destruction of body image
Threat of sexuality
Fear of permanent disability
Fear of dying
Fear of pain
Specific Fears
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LEGAL PREPARATION-INFORMED CONSENT
To ensure that the client understand the nature and treatment including the potential complications and disfigurement
To indicate that the client decision was made without pressure
To protect the client against unauthorized procedure
To protect the surgeon and hospital against legal action by a client who claims that an unauthorized procedure was performed
Complete understanding of the procedure, its risk, benefit, complications and alternative as explained by the physician.
It is necessary in all procedures EXCEPT IN EMERGENCY
Adult >18 y/o can sign own consent, unless unconscious or mentally incompetent
Minors (<18 y/o) must have parental guardians consent unless emancipated (married, military service, etc.)
For emergencies, telephone/fax consent will do.
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PHYSIOLOGICAL PREPARATION: AGE
Very young tolerate the trauma of surgery well and recover faster
Elderly tolerate surgery very poorly and chances of complications are more likely
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cause potential complications postoperatively
DEHYDRATION AND MALNUTRITION
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fatty tissues are not resistant to infection: dehiscence and wound infections are common.
OBESITY
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ECG and blood studies are ordered routinely for adults
CVP measurement is ordered if the pt is elderly and fluid overload is a potential prob
Blood typing and cross-matching so that blood can be made available should transfusion becomes necessary postoperatively
CARDIOVASCULAR DISEASES
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Chest x-ray is done routinely
PFT and ABG if interference with pulmonary function is suspected
RESPIRATORY DISEASES
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Urinalysis and kidney function test are routinely done
Presence of diarrhea and constipation should be corrected before surgery
ELIMINATION DISTURBANCES
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DIABETES MELLITUS: hypoglycemia may develop during anesthesia or postoperatively
ENDOCRINE DISTURBANCE
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DRUGS THAT INTERFERE WITH ANESTHESIA OR CONTRIBUTE TO POST-OP COMPLICATIONS
ANTIBIOTICS, ANTICOAGULANTS, ANTIHYPERTENSIVE, DIURETICS, STEROIDS, TRANQUILIZERS, ANTIDEPRESSANTS
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Neomycin, streptomycin, kanamycin when combined with muscle relaxants interrupt nerve transmission, and causes apnea and respiratory paralysis may occur
ANTIBIOTICS
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Increase bleeding, aspirin potentiates action of anticoagulants
ANTICOAGULANTS
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Affect anesthesia and compensatory ability of cardiovascular system
ANTIHYPERTENSIVE
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Such as thiazide causes potassium loss, also cause respiratory depression
DIURETICS
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E.g., dexamethasone, cause anti-inflammatory effect and delay wound healing
STEROIDS
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Potentiates effect of narcotics and barbiturates, can also cause hypotension
TRANQUILIZERS
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Prozac, Elavil, MAO inhibitors increase hypotensive effects of anesthesia
ANTIDEPRESSANTS
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Examples of Post-Op exercises
Deep breathing exercise, coughing, splinting incision, frequent turning and leg exercises
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PHYSICAL PREPARATION: GASTROINTESTINAL
NPO post-midnight
Cleansing enemas
For lower bowel surgery: magnesium citrate, neomycin, Dulcolax
H2 Blockers: Cimetidine, Ranitidine
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PHYSICAL PREPARATION: URINARY
Empty the bladder
Ask the pt to go to the bathroom before pre-medications are given
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PHYSICAL PREPARATION: CIRCULATORY
Antiembolic stocking for elderly to prevent venous stasis, that helps prevent thromboembolism and shock postoperatively
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PHYSICAL PREPARATION: INTEGUMENTARY
Skin cleansing by means of povidone iodine and hexachlorophene
Shaving hair
Remove hairpins, wigs, nail polish
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PHYSICAL PREPARATION: NERVOUS SYSTEM
Barbiturates: commonly phenobarbital and secobarbital
Narcotics: meperidine hydrochloride
Anticholinergic drugs: atropine sulfate
Tranquilize: Phenergan, Diazepam:
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for sedative-hypnotic effect
Barbiturates: commonly phenobarbital and secobarbital and Narcotics: meperidine hydrochloride
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Reduce secretion, and block vagal stimulation to prevent bradycardia and hypotension
Anticholinergic drugs: atropine sulfate
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To allay apprehension and for antiemetic effects
Tranquilize: Phenergan, Diazepam
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OTHER PREPARATION FOR PRE-OP
Removal of Dentures, jewelries, pins
Identification Band
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Begins at the moment of the patient is anesthetized up to the time the last dressing on the incision is placed
The surgical teams take over the responsibility of meeting the patient needs
INTRAOPERATIVE PHASE
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INTRAOPERATIVE NURSING ACTIVITIES
Providing for the patient’s safety
Maintaining an aseptic environment
Ensuring proper function of equipment
Providing the surgeon with specific instruments and supplies for the surgical field
Completing appropriate documentation
Providing emotional support by holding the patient’s hand during general anesthesia induction
Assisting in positioning the patient on the operating room table using basic principles of body alignment
Acting as scrub nurse, circulating nurse, or registered nurse first assistant
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THE SURGICAL TEAM
SURGEON
ANESTHESIOLOGIST
SCRUB NURSE
CIRCULATING NURSE
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Takes responsibility for preventing serious complications
He handles organ and tissue, prevents too much blood loss by tying the blood vessel
SURGEON
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Visits the patient prior to surgery to acquaint him with what to expect from the anesthetic.
During operation he induces anesthesia
He pays particular attention to maintaining a clear or patent airway, adequate breathing and exchange of gases in the lungs, and systemic circulation
ANESTHESIOLOGIST
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Her main responsibility is to anticipate and meet the needs of the surgeon for instruments and supplies during the procedure
Prepares the equipment
Opens the major pack
Prepare the gauze, gloves, mayo table
Serving surgeon-gowning and gloving
Initial counting of the instrument together with the circulating nurse
SCRUB NURSE
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5 LAYERS
Inner to outer
Peritoneum
Muscle
Fascia
Subcutaneous- Final Count
Skin
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Is responsible for the general management of the operating room
She must anticipate and plan to meet the needs of each member of the operating team
She must be alerts to threat to the patient’s safety
She watches for the breaks in aseptic techniques
She saves and counts discarded sponges and instruments
She reminds the team that the patient is awake
She controls the number and behavior of visitors in the operating room
Assists in positioning the patient
Preparing skin for surgery
Managing surgical specimen
Documenting Intraoperative events
CIRCULATING NURSE
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MAIN RESPONSIBILITIES OF A CIRCULATING NURSE
Verifying the consent
Coordinating the team
Ensuring the cleanliness, proper temperature, humidity and lighting
Ensuring the safe functions of the equipment, and the availability of the supplies and materials
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street clothes are allowed
UNRESTRICTED ZONE
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consist of scrub clothes and caps
SEMI-RESTRICTED ZONE
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scrub clothes, shoe cover, masks are allowed
RESTRICTED ZONE
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Is a state of narcosis, analgesia, relaxation and loss of reflexes
ANESTHESIA
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the substance, such as chemical or gas used to induced anesthesia
Anesthetic
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TYPES OF ANESTHESIA
General, Balanced, Local or Regional Block, Spinal or Epidural
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Pain is controlled by general insensibility
Basic elements includes analgesia, interference with undesirable reflexes, and muscle relaxation
GENERAL ANESTHESIA
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The properties of general (hypnosis, analgesia, muscle relaxation) are produced in varying degrees, by combination of agent
BALANCED ANESTHESIA
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Pain is controlled without loss of consciousness
The sensory nerves in one area or region are anesthetized
Sometimes called conduction anesthesia
Acupuncture is sometimes used
LOCAL OR REGIONAL BLOCK ANESTHESIA
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Sensation of pain is blocked at a level below the diaphragm
without a loss of consciousness
The agent is injected in the spinal canal
SPINAL OR EPIDURAL ANESTHESIA
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What are the 4 Stages of Anesthesia
STAGE I - BEGINNING ANESTHESIA
STAGE II – EXCITEMENT
STAGE III - SURGICAL ANESTHESIA
STAGE IV - STAGE OF DANGER/MEDULLARY DEPRESSION
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The stage of induction extends from the beginning of the administration of the anesthetic to the beginning of loss of consciousness
The pt is aware that he is unstable to move his extremities voluntarily.
During this stage even low voices or minor sounds appear loud or distressing.
For this reason, unnecessary noise must be prevented
STAGE I - BEGINNING ANESTHESIA
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Extends from the loss of consciousness to the loss of eyelid reflex.
Characterized by struggling, shouting, talking, singing, laughing or even crying
The pupils of eyes are dilated but when exposed to light will contract
The pulse rate is rapid and respiration irregular
Help need to restraint the patient, strap maybe placed across the thighs
STAGE II – EXCITEMENT
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Reached when too much anesthesia has been given and when the patient has not been observed carefully
Cyanosis develops gradually and unless prompt action is taken, death follows rapidly.
If this stage develops, anesthesia is discontinued and artificial respiration is given.
Stimulants may be administered
STAGE IV - STAGE OF DANGER/MEDULLARY DEPRESSION
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Extends from the loss of lid reflex to cessation of respiratory effort
The patient is unconscious, his muscles are relaxed and most of the reflexes are absent, the pupils are small, but they constrict when they exposed to light
Respiration is regular, pulse rate is of good volume, and skin is pink and slightly flushed.
By proper administration of anesthetic, this stage may be maintained for hours
STAGE III - SURGICAL ANESTHESIA
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METHODS OF ANESTHESIA ADMINISTRATION
INHALATION, INTRAVENOUS, REGIONAL ANESTHESIA, EPIDURAL ANESTHESIA, SPINAL ANESTHESIA
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Barbiturates, benzodiazepine (Midazolam), opioid agent, diazepam (Valium), meperidine HCL (Demerol), promethazine (Phenergan)
INTRAVENOUS
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Administered by mixing vapors with oxygen or nitrous oxide and then having the patient inhale the mixture
The vapors are administered via tube or mask, or laryngeal mask.
Example: Volatile Liquid: Halothane (Fluothane), Methoxyflurane (Penthrane),
Gases: Nitrous oxide
INHALATION
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Another term for Nitrous oxide
Laughing Gas
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Injected around nerves so that area supplied these nerves are anesthetized
REGIONAL ANESTHESIA
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Locks sensory, motor and autonomic functions
ADVANTAGE: absence of headache results from subarachnoid injection
EPIDURAL ANESTHESIA
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anesthesia in the arm
BRACHIAL PLEXUS BLOCK
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A type of extensive conduction nerve block that produced when local anesthetic is introduced into the subarachnoid space at the lumbar level, usually L4 and L5
It produces anesthesia on the lower extremities, perineum and lower abdomen
Common agents used are procaine, tetracaine (Pontocaine), lidocaine (xylocaine) and bupivacaine(Marcaine)
SPINAL ANESTHESIA
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anesthesia on the chest, abdominal wall and extremities
PARAVERTEBRAL ANESTHESIA
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POSITION OF PATIENT FOR SURGERY
The patient should be comfortable
The operative area must be adequately exposed
Circulation must not be obstructed by any body part
There should be no interference with the patient respiration
Nerves should be protected from undue pressure.
Shoulder braces must be well padded to prevent injury
Provide patient privacy by proper draping
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produces anesthesia of the perineum and occasionally lower abdomen
TRANSACRAL (CAUDAL) BLOCK
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MOST COMMONLY USED OPERATIVE POSITIONS
DORSAL RECUMBENT OR SUPINE
PRONE
TRENDELENBURG
LITHOTOMY
LATERAL POSITIONS
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Used for hernia repair, exploratory laparotomy, cholecystectomy, gastric and bowel resection, mastectomy
DORSAL RECUMBENT OR SUPINE
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The arm should be well protected and carefully positioned to prevent ulnar or radial damage
PRONE
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For operation of the lower abdomen and pelvis to obtain good exposure by displacement of the intestine in the upper abdomen
TRENDELENBURG
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Used to obtain better visualization of the biliary tract
REVERSE TRENDELENBURG
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SKIN PREPARATION ON OPERATING TABLE: AREA
Done after the patient has been anesthetized and positioned on the table, skin of the operative site and extensive area surrounding it.
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This position is used for perineal, rectal and vaginal surgery
LITHOTOMY
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This position is used for kidney operation
LATERAL POSITIONS
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SKIN PREPARATION ON OPERATING TABLE: RESPONSIBILITIES
The first assistant is the person who scrubbed the patient after he has scrubbed his own hands and arms.
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BASIC PREPARATION FOR CLEAN AREAS
Don sterile gloves
Scrub skin, starting the site of incision, with a circular motion or over widening circles of periphery. Use enough pressure and friction to remove dirt and microorganism from skin and pores
Discard sponge after reaching the periphery
Repeat scrub with a separate sponge for round and apply antiseptic
Paint area with solution from incision site to periphery with circular motion
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CONTAMINATED AREAS WITHIN THE OPERATIVE FIELD
Umbilicus, stoma, draining sinuses, skin ulcers, vagina, anus
Follow general rule of scrubbing the most contaminated area is last with separate sponge
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ABDOMINAL INCISION 1-10
Kocher
Thoracoabdominal
Midline
Muscle splitting loin
Pfannenstiel
Gable
Transverse muscle splitting
Lanz
Paramedian
McEvedy
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Examples of use includes access of the biliary tract or pancreas in RUQ and access to the LLQ for resection of the sigmoid colon
PARAMEDIAN INCISION
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It begins in the epigastrium at the level of the xiphoid process and may vertically to the suprapubic region.
It offers excellent exposure of and rapid entry into upper abdominal content
LONGITUDINAL MIDLINE INCISION
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It begins in the epigastrium and extends laterally and obliquely just below the lower costal margin
Examples of use includes biliary procedures and splenectomy
SUBCOSTAL UPPER QUADRANT OBLIQUE (KOCHER)
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Made for increased visibility during liver transplant and resection
BILATERAL MODIFIED SUBCOSTAL INCISION (CHEVRON INCISION) OR GABLE
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Located at the right lower quadrant just below the umbilicus
This is a fast easy incision, but exposure is limited
MCBURNEY INCISION
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The patient is placed in in a lateral position, either right or left incision begins at the midway between the xiphoid process and the umbilicus extends across the abdomen to the 7th and 8th costal interspaces into the thorax
Examples of use include esophageal varices
THORACOABDOMINAL INCISION
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Examples of use include choledochojejunostomy and transverse colostomy
MID ABDOMINAL TRANSVERSE INCISION
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It provides access to the inguinal canal and cord structures
Primary use inguinal herniorrhaphy
INGUINAL INCISION (LOWER OBLIQUE/ MCEVEDY)
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NURSING PROCESS APPLICATION
(INTRAOPERATIVE): ASSESSMENT
Assess the anxiety level
Establish rapport
Check chart for the result of laboratory test
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NURSING PROCESS APPLICATION
(INTRAOPERATIVE): INTERVENTIONS
Relief from anxiety
Perform correct procedure to the right patient
Maintain Fluid Balance
Prevent retention of foreign body
Prevent loss of body heat
Prevent infection
Prevent injury
Respect patient ‘s privacy
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Relief from anxiety
Greet patient
Offer comfort measures: raising the head, offering warm blanket
Remain with the patient at all times
Maintain quiet environment to allow preoperative medication to take effect
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Perform correct procedure to the right patient
Name band and OR permit must be checked, the procedure and the surgeon's name must be verified
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Maintain Fluid Balance
Check the chart, the hct and Hgb, amount of blood, maintain accurate input and output, assess blood loss on sponges, and in suction
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Prevent loss of body heat
Give warm blanket
Monitor the OR temperature and patient’s temperature
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Prevent retention of foreign body
The circulating nurse counts, with the assistance of another person, all instruments, sponges, pad and needles before the procedure begin and as the surgeon closes the skin
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Prevent injury
Position carefully and maintain body alignment
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Prevent infection
Monitor breaks in sterile technique and provide corrective action
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Begins from the moment surgeon completes the last stitch and continues until the metabolic and tissues changes resulting from the surgical procedure have returned to normal
POST-OPERATIVE PHASE
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Respect patient ‘s privacy
There should be no unnecessary exposure of the patient, the chart should be only available to authorized personnel, and confidentiality of all information must be maintained
