CARE OF CLIENTS REQUIRING SURGERY

General Considerations.

1. Conditions Requiring Surgery:

a. Obstruction or blockage

b. Perforation or rupture of an organ, artery, or bleb

c. Erosion or wearing away of the surface of a tissue

d. Tumors or abnormal growth

2. Categories of Surgical Procedures:

According to Purpose:

a) Diagnostic: to verify suspected diagnosis (e.g. biopsy)

b) Exploratory: to estimate the extent of the disease e.g. exploratory laparotomy

c) Curative: to remove or repair damaged or diseased organs or tissues

Types of Curative Surgery:

a) Ablative: removal of diseased organs e.g. nephrectomy, appendectomy

b) Reconstructive: partial or complete restoration of a damaged organ e.g. plastic surgery (burns

c) Constructive: repair of a congenitally defective organ e.g. plastic surgery of a cleft palate:

d) Palliative: to relieve pain

According to Degree of Risk to Client:

a) Major surgery

b) Minor surgery

Criteria:

a) Major surgery: High degree of risk; prolonged intraoperative period; Large amount of blood loss

Extensive: Vital organs may be handled or removed; Great risk of complications

e. g. liver biopsy, colectomy

b) Minor surgery: Lesser degree of risk to the client

Generally not prolonged; described as “one-day surgery” or outpatient surgery

Leads to few serious complications; Involves less risk e. g. cyst removal

According to Urgency:

a) Emergency: must be performed immediately e.g. gunshot wound

b) Imperative or urgent: must be performed as soon as possible within 24-48 hours e.g. severe bleeding

c) Planed required: necessary for client well being e.g. tonsillectomy

d) Optional: surgery that a client requests e.g. face lift

e) Elective: should be performed for the client’s well being but which is not absolutely necessary

e.g. hernia repair

f) Required: necessary for the well-being of the client, usually within weeks to months e. g. chole

Factors that Affect the estimation of Surgical Risk:

1. Physical and Mental Condition of the Client

a) Age: premature babies and elderly persons are at risk

b) Nutritional status: malnourished and obese are at risk

c) State of fluid and electrolytes balance: dehydration and hypovolemia predispose a person to complications

d) General health: infectious process increase operative risk

e) Mental health

f) Economic and occupational status

g) Types of drugs taken regularly:

1). Steroids: may improve the body’s ability to response to the stress of anesthesia and surgery

2). Anticoagulants and salicylates: may increase bleeding during surgery

3). Antibiotics: maybe incompatible with or potentiate anesthetic agents

4). Tranquilizers: potentiate the effect of narcotics and can cause hypotension

5). Antihypertensives: may predispose to shock by the combined effect of blood pressure reduction and anesthetic vasodilation

6). Diuretics: may increase potassium loss

7). Alcohol: will place the surgical client at risk when used chronically

2. The Extent of the Disease

3. The Magnitude of the Required Operation

4. Resources and Preparation of the Surgeon, Nurses, and the Hospital

The Three Phases of Perioperative Nursing:

Careful planning by the nurse can help ensure a positive outcome

Because clients experience varying degrees of anxiety and deficient knowledge related to surgery

Refers to activities performed by the professional nurse during these phases

Phases of Perioperative Nursing

1. Pre-Operative Phase: begins with the decision to perform surgery and ends with the client’s transfer to the operating room table

2. Intra-Operative Phase: begins with the client is received in the OR and ends with his admission to the post-anesthesia recovery room (PARR) or post-anesthesia recovery unit (PACU)

3. Post-Operative Phase: begins with the client is admitted to PARR or PACU and extends through follow-up home or clinic evaluation

The Perioperative Team:

The Surgeon

Registered Nurse First Assistant

Qualified RNs in place of second or assisting physicians during surgical procedures

An experienced perioperative nurse who has had additional specialized education to perform the role

Works with the primary surgeon during surgery

Activities include:

Providing exposure of the operative area; Using instruments to hold and cut; Retracting and handling the tissue; Providing hemostasis and suturing

An Anesthesiologist or Nurse Anesthetist (CRNA)

Makes the preoperative assessment to plan for the type of anesthesia to be administered and to evaluate the client’s status; Had 1-2 years of acute or intensive care nursing experience

The Professional Registered OR Nurse Manager

Makes preoperative assessment and documents the intra-operative client care plan

The Circulating Nurse

Manages the OR and protects the safety and health needs of the client by monitoring the activities of the members of the surgical team and monitoring the conditions in the OR

Activities:

Ensuring all equipment is working properly; Guaranteeing sterility of instruments and supplies; Assisting with positioning; Performing with the surgical skin preparation; Monitoring the room and team members for breaks in sterile technique; Assisting anesthesia personnel with induction and physiologic monitoring; Handling specimens; Documenting care provided

The Scrub Nurse

Responsible for scrubbing for surgery, including setting up sterile tables and equipment and assisting the surgeon and surgical technicians during the surgical procedure

The Scrub Nurse

Activities and responsibilities:

Gathering all equipment for the procedure; Preparing all supplies and instruments using sterile technique; Maintaining sterility within the sterile field during surgery; Handling instruments and supplies during surgery; Cleaning up after the case

During the surgery, the scrub nurse maintains an accurate count of sponges, sharps, and instruments on the sterile field and counts the same materials with the circulating nurse before and after the surgery

The PACU Nurse

Responsible for caring for the client until the client:

Has recovered from the effects of anesthesia; Is oriented; Has stable vital signs; Shows no evidence of hemorrhage

Principles of Perioperative Asepsis

General Principles

Keep sterile supplies dry and unopened

Check package sterilization expiration date to verify sterility

Maintain general cleanliness in surgical suite

Maintain surgical asepsis: activities designed to keep sites free from the presence of microorganisms) throughout the procedure

Personnel

Personnel with signs of illness should not report to work

Surgical scrub, a specific handwashing technique used by operating room personnel designed to reduce microorganisms in the hands and arms, is done for the length of time designed by hospital policy

Surgical Scrub

1) A sensor-controlled or knee- or foot-operated faucet allows the water to be turned on and off without the use of the hands

2) Remove all rings and watches

3) Use liquid soaps to prevent the spread of organisms

4) Keep the finger nails short and well-trimmed

Clean fingernails with a nail stick under running water

5) Hold the hands higher than the elbows throughout the handwashing procedure so that run-off goes to the elbows

Allows the cleanest part of the arms to be the hands

6) A scrub brush facilitates the removal of microorganisms

Clean all areas of skin on the hands and arms in sequence starting at the hands and ending at the elbows

7) After rinsing, dry the hands with paper towels, drying first one arm from the hand to the elbow, then using a second towel to dry the second hand

Maintaining a Sterile Field (a microorganism-free area)

Create a sterile field using sterile drapes

Use the sterile field to place sterile supplies where they will be available during the procedure

Drape equipment prior to use

Keep drapes dry and out of contact with nonsterile objects

Utilize sterile technique while adding or removing supplies from sterile fields

Sterile Supplies and Solutions

Check expiration dates for sterility

Don’t use solutions that were opened prior to current use

“Lip” the solution after initial use by pouring a small amount of liquid out of the bottle into a waste container to cleanse the bottle lip

1. OR personnel must practice strict Standard Precautions (i.e., blood and body substance isolation)

2. All items used in the sterile field must be sterile

3. Sterile objects become unsterile when touched by unsterile objects

4. Sterile items that are out of vision sterile or below the waist level of the nurse are considered unsterile

5. Sterile objects can become unsterile by prolonged exposure to air-born organism

6. The skin can not be sterilized and is unsterile

All personnel must perform a surgical scrub

7. All OR personnel are required to wear specific, clean attire, with the goal of “shedding” the outside environment.

Specific clothing requirements are prescribed and standardized for all ORs

a. OR personnel must wear a sterile gown, gloves, and specific shoe covers

b. Hair must be completely covered

c. Masks must be worn at all times in the OR for the purpose of minimizing air-borne contamination and must be changed between operations or more often, if necessary

8. Any personnel who harbors pathogenic organisms must report themselves unable to be in the OR to protect the client from outside pathogens

Scrubbed personnel wearing sterile attire should touch only sterile items

10. Sterile gowns and sterile drapes have defined borders for sterility.

Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile.

Contact with unsterile objects at any point renders a sterile area contaminated.

11. The circulator and unsterile personnel must stay at the periphery of the of the sterile operating area to keep the sterile area free from contamination

12. Sterile supplies are unwrapped and delivered by the circulator following specific standard protocol so as not to cause contamination

13. The utmost caution and vigilance must be used when handling sterile fluids to prevent splashing or spillage

14. Anything that is used for one client must be discarded or, in some cases, resterilized

A. PRE-OPERATIVE PHASE

A. Pre-Operative Phase

Begins at the time of decision for surgery and ends when the client is transferred to the OR

This period is used to physically and psychologically prepare the client for surgery

The nurse plays a major role in client teaching and in relieving the client’s and the family’s anxieties

Goals:

Assessing and correcting physiologic and psychologic problems that might increase surgical risk

Giving the person and significant others complete learning/ teaching guidelines regarding surgery

Instructing and demonstrating exercises that will benefits the person during post-op period

Planning for discharge and any projected changes in lifestyle due to surgery

a) Psychologic Preparation for Surgery

Preparation for hospital admission: includes

Explanation of the procedure to be done

Probable outcome

Expected duration of hospitalization

Cost

Length of absence from work

Residual effects

Causes of Fears:

Fear of the unknown

Fear of anesthesia, vulnerability while unconscious

Fear of pain

Fear of death

Fear of disturbance of body image

Worries: loss of finances, employment, social and family roles

Manifestations of Fears:

Anxiousness and bewilderment

Anger

Tendency to exaggerate

Sad, evasive, tearful, clinging

Inability to concentrate

Short attention span

Failure to carry out simple directions

Dazed

Nursing Interventions to Minimize Anxiety:

Assess client’s fears, anxieties, support systems, and patterns of coping

Establish trusting relationship with client and significant others

Explain routine procedures, encourage verbalization of fears, and allow client to ask questions

Demonstrate confidence in surgeon and staff

Provide for spiritual care if appropriate

b) Legal aspect: “Informed Consent”, operative permit, surgical consent

This is to protect the surgeon and the hospital against claims that unauthorized surgery has been performed and that the client was unaware of the potential risks of complications involved

Protects the client from undergoing unauthorized surgery

1) The Surgeon obtains operative permit or informed consent

Surgical procedure, alternatives, possible complications, disfigurements, or removal of body parts are explained

It is part of the nurse’s role as a client advocate to confirm that the client understands information given

2) Informed consent is necessary for each operation performed, however minor

It is also necessary for major diagnostic procedures where major body cavity is entered

e.g. bronchoscopy, thoracentesis

3) Adult client (over 18 years of age) signs own permit unless unconscious or mentally incompetent

If unable to sign, relative, (spouse or next of kin) or guardian will sign

In an emergency, permission via the telephone or telegram is acceptable;

Have a second listener on phone when telephone permission being given

Consents are not needed for emergency care if all four of the following criteria are met:

1. There is an immediate threat to life

2. Experts agree that it is an emergency

3. Client is unable to consent

4. A legally authorized person cannot be reached

4) Minors (under 18) must have consent signed by an adult (i.e. parent or legal guardian).

An emancipated minor may sign own consent:

Married

College student living away from home

In military service

Any pregnant female or anybody who has given birth

5) Witness to informed consent may be nurse, other physician, clerk, or authorized person

6) If nurse witnesses informed consent, specify whether witnessing explanation of surgery or just signature of client

c) Physiologic Preparation

1) Respiratory preparation:

chest x-ray

2) Cardiovascular preparation:

ECG, CBC, blood typing, cross-matching, PT/PTT (prothrombin time, partial thromboplastin time), serum electrolytes

3) Renal preparation:

Urinalysis

Obtain history of past medical conditions, allergies, dietary restrictions, and medications

A – Allergy to medications, chemicals, and other environmental products such as latex

All allergies are reported to anesthesia and surgical personnel before the beginning of surgery

If allergy exist, an allergy band must be placed in the client’s arm immediately

B – Bleeding tendencies or the use of medications that deter clotting, such as aspirin, heparin, and warfarin sodium.

Herbal medications may also increase bleeding time or mask potential blood-related problems

C – Cortisone and steroid use

D – Diabetes mellitus, a condition that not only requires strict control of blood glucose levels but also known to delay wound healing

E – Emboli; previous embolic events ( such as lower leg blood clots) may recur because of prolonged immobility

d) Instructional and preventive aspects:

Frequently done in an out-client basis

Assess the client’s level of understanding of surgical procedure and its implications

Answer questions, clarify and reinforce explanations given by surgeon

Explain routine pre and post procedures and any special equipment to be used

Deep breathing exercises: use of diaphragmatic and abdominal breathing

Coughing exercise: deep breath, exhale through the mouth, and then follow with a short breath while coughing; splint thoracic and abdominal incision to minimize pain

Turning exercise: every 1-2 hours post-operative

Extremity exercise: prevents circulatory problems and post operative gas pains or flatus

Assure that pain medications will be available post-op

e) Physical Preparation

On the night of the surgery

Preparing the client’s skin: shave against the grain of the hair shaft to ensure clean and close shave

Preparing the GIT:

NPO after midnight

Note: the age of the client should be taken in to consideration

Infants and children has a higher metabolic rate than adult

This makes it essential for the child or infant to receive CHO regularly to prevent acidosis from occurring

Administration of enema

Insertion of gastric or intestinal tubes

Preparing for Anesthesia

Promoting rest and sleep: use of drugs

Barbiturates: Secobarbital Na (Seconal), Pentobarbital Na (Nembutal)

Non barbiturates: chloral hydrate, Flurazepam (Dalmane)

Note: given after all pre-op treatments have been completed.

If a second barbiturate is needed, it must be given at least 4 hours before the pre-op medications are due

On the Day of Operation

Early morning care: about 1 hour before the pre-operative medication schedule

Vital signs taken and recorded promptly

Provide oral hygiene

Remove jewelries and dentures

Remove nail polish

Make sure that the patient has not taken food for the last 10 hours by asking the client

Pre-Operative Medications:

Generally administered 60-90 min before induction of anesthesia

Purpose:

To allay anxiety: the primary reason for pre-operative medications

To decrease the flow of pharyngeal secretions

To reduce the amount of anesthesia to be given

To create amnesia for the events that precedes surgery

Types of Pre-Operative Medications:

1) Sedative:

a) Given to decrease the client’s anxiety to lower BP and pulse

b) Reduce the amount of general anesthesia: an overdose can result to respiratory depression

e.g. Phenobarbital (Seconal Na, Nembutal Na)

Pre-Operative Phase

2) Tranquilizer: lowers the client’s anxiety level (ataractic)

e.g. Thorazine 12.5 - 25 mg IM 1-2 hours prior to surgery

Phenergan 12.5 - 25 mg IM 1-2 hours prior to surgery

* Note: can cause a dangerous hypotension, both during and after surgery

3) Narcotic analgesia: given to reduce patients to reduce anxiety and to reduce the amount of narcotics given during surgery

e.g. Morphine sulfate 8-15 mg SC 1 hour prior to preoperative

* Can cause vomiting, respiratory depression and postural hypotension

4) Vagolytic or drying agents: to reduce the amount of tracheobronchial secretions which can clog the pulmonary tree and result in atelectasis and pneumonia

e.g. Atropine sulfate 0.3-0.6 mg IM 45 min before surgery

* An overdose can result to severe tachycardia

Recording: all final preparation and emotional response before surgery should be noted down

Transportation to the OR

Woolen or synthetic blankets must never be sent to the OR because they are source of static electricity

f) Nursing Diagnosis for Preoperative Client

Anxiety related to lack of knowledge about preoperative routines, physical preparation for surgery, post operative care and potential body image change

B. INTRA-OPERATIVE PHASE

Begins the moment the client is anesthesized and ends when the last stitch or dressing is in place

Anesthesia

An artificially induced state of partial or total loss of sensation with or without loss of consciousness

Effects of Anesthetic Agents:

Produce muscle relaxation; Block transmission of pain nerve impulses (Analgesia)

Suppress reflexes; Temporarily decrease memory retrieval and recall

The depth and effect of anesthesia are monitored by observing changes in:

Respiration; O2 saturation, and end-tidal CO2 levels; BP and CR; Urine output

Client’s concern about anesthesia:

Adequacy of pain-blocking effects; Being put to sleep with a drug; Whether client will talk during anesthesia; The presence of nausea and vomiting postoperatively

Nursing responsibility:

Providing reassurance about the capability of the anesthesia provider and About the availability of other drugs to reduce any unpleasant side effects of the anesthesia

The decision about the type of anesthesia to be used is made by:

The anesthesia provider; The surgeon; The client; The surgical procedure

The Two Major Techniques of Anesthesia Administration:

I. General Anesthesia

Intravenous Anesthesia; Inhalation Anesthesia

Mechanism of Action of General Anesthetics

Block pain stimulus at the cerebral cortex and Induce depression of the CNS

Reversion of effect either by:

Metabolic change and elimination from the body or Pharmacologic means

Effects of General Anesthesia:

Analgesia; Amnesia; Unconsciousness; Loss of reflexes and muscle tone

Indications of GA:

Surgery of the head and neck; Upper torso and back; For prolonged surgical procedures; For clients unable to lie for quietly for a long period

II. Regional Anesthesia:

Spinal Anesthesia; Epidural Anesthesia; Caudal Anesthesia; Topical; Local infiltration; Field block

Peripheral nerve block; IV nerve block

Regional Anesthetics

Given to block the pain stimulus at its origin, along afferent neurons, or along the spinal cord

Produces a loss of painful sensation in only one region of the body and does not result in unconsciousness

Sedative agents may be given to produce drowsiness

a) Four Stages of Anesthesia:

Stage I Onset

Stage II Excitement

Stage III Surgical Anesthesia

Stage IV Danger Stage (Death)

Last sense to be depressed: Auditory

The client can hear and may remember conversations on awakening

Nursing Responsibility: Ensures that all conversation during induction and throughout the case is appropriate

Clients emerge into consciousness backward through all three stages of anesthesia after the anesthetic agents are discontinued

Therefore, hearing is the first sense to return

b) Types of Anesthesia:

1. General Anesthesia:

A state of analgesia, amnesia, and unconsciousness characterized by the loss of reflexes and muscle tone

Administered by using a combination of agents based on the client's need with consideration of the type of surgery to be performed

Most common way of administering GA: Neuroleptic or Balanced Anesthesia

Achieved by using a combination of an inhalation agent, O2, an opioid, and a neuromuscular blocking agent (muscle relaxant)

Neuromuscular blocking agents:

Given mainly to facilitate intubation by easing laryngospasm and relaxing muscles for controlled ventilation

Succinylcholine (Anectine)

Tubocurarine

Pancuronium (Pavulon)

a). Intravenous Anesthesia:

Usually employed as an induction prior to administration of the more potent inhalation anesthetic agents.

Used commonly in minor procedure

Dental extraction

Unconsciousness generally occurs 30 seconds after administration

Rapid and smooth transition from conscious stage to surgical anesthesia stage

Advantage of IV Anesthesia:

1. Rapid pleasant induction

2. Absence of explosive hazards

3. Low incidence of nausea and vomiting

Disadvantage of IV Anesthesia:

1. Laryngeal spasm and bronchospasm

2. Hypotension

3. Respiratory arrest

Examples:

Thiopental Na (Pentothal Na)

Ketamine (Ketalar)

Fentanyl (Innovar)

b). Inhalation Anesthesia

A mixture of volatile liquids or gas and O2 is used

Usually used to maintain the client in stage III anesthesia following induction

The mixture is given through a mask or through an endotracheal tube which is inserted once the client is paralyzed and unconscious

O2 tank: green color

CO2 tank: gray color

Administration by a mask:

The gases flow into the mask via a finely calibrated vaporizer that is controlled by a machine

Administration by ETT:

The gases flow directly into the client’s tracheobronchial tree, resulting in a quick response

Endotracheal Intubation

Advantage:

Ease of administration and elimination through the respiratory system

Rapid onset

Prevention of pain and anxiety

Disadvantage: circulatory and respiratory depression

* Highly flammable and explosive

Two commonly used Inhalation Anesthetics:

Halothane

Isoflurane

Commonly used Gas Anesthetic:

Nitrous oxide (Blue tank)

Safety rules:

Do not wear slips, nylons, wool, or any material which can set-off sparks

Do not touch the vicinity of the breathing area to prevent sparks

No smoking 12 hours after the operation

Do not wear shoes that are non-conductive

c. Rectal Anesthesia:

Rarely used today

Useful during the induction of anesthesia of pediatric clients

e.g. Pentothal Na

2. Regional Anesthesia:

It is the injection or application of a local anesthetic agent to produce a loss of painful sensation in only one region of the body

Does not result to unconsciousness

Blocks the conduction of impulses in the nerve fibers without depolarizing the cell membrane

Epinephrine as an additive to local anesthetics:

To prolong the effect of anesthesia through vasoconstriction thus, delaying the absorption of the anesthetic agent

To cause vasoconstriction thus reducing bleeding during the procedure

a). Spinal Anesthesia

Often the anesthetic technique of choice of older adults

Can be used for almost any type of major procedure performed below the level of the diaphragm

Cholecystectomy, appendectomy

Spinal Anesthesia is achieved by injecting local anesthetics into the subarachnoid space

Position of client: genu-pectal or knee-chest position

Level of anesthesia: Intervertebral space between

L2 and L3

L3 and L4

Autonomic nerve fibers are affected first and also the last to recover

After blockade of the ANS, spinal anesthesia blocks the following fibers in this order:

1) Touch

2) Pain

3) Motor

4) Pressure

5) Proprioceptive fibers (sensory fibers for movement and position)

Touch ► Pain ►Motor ►Pressure ►Proprioception

Within minutes of administration the client experiences a loss of sensation and paralysis of the of the toes, feet, legs, and then abdomen

Meninges and Spaces of the Brain and Spinal Cord

The Vertebral Column and Space

Spinal Anesthesia

Spinal Anesthesia

The Distribution of the Spinal Nerves and its Dermatomes

Complications of SA:

Hypotension

Paralysis of vasomotor nerves, occurring shortly after induction of anesthesia

Rapid IVF administration before the block

Administer O2 by inhalation

Trendelenburg position 10-20 min after induction

Vasoactive drugs: Ephedrine

Nausea and vomiting

Occurs mainly from abdominal surgery because of traction placed on various structures within the abdomen or from hypotension

Drugs used: antiemetics

Headache

Can be extremely painful and may last a week

CSF, which cushions the brain, is lost through dural hole

Leakage of fluid with loss of cushioning effect is increased by:

Use of large spinal needle

Poor hydration

Keep client flat 6-8 hours postoperatively

Respiratory paralysis

Occurs when drug reaches upper thoracic or cervical spinal levels in large amounts or in heavy concentrations

Do artificial respiration

Avoid extreme T-position after induction

Neurologic complications:

Paraplegia

Severe muscle weakness in legs

Postoperative paralysis may be due to:

Unsterile needles, syringes and anesthetic agent

Pre-existing diseases of the CNS

Transient response to anesthetics

Position during surgery

Advantages of SA:

Relatively safe

Excellent lower-body muscle relaxant

Absence of effect on consciousness

Doe not require empty stomach

b) Epidural Anesthesia

Introduction of anesthetic agent into the epidural space

The needle is carefully positioned in the epidural space without penetrating the dura and without entering the subarachnoid space

Epidural block produces a blockade of the autonomic nerves and can result to hypotension

If the level of block is too high and respiratory muscles are affected, respiratory depression or paralysis may occur

The epidural space is generally entered by a needle at a thoracic, lumbar, sacral, or caudal interspace

c) Caudal Anesthesia

A variation of epidural anesthesia

Produced by injection of the local anesthetic into the caudal or sacral canal

This method is commonly used with obstetric clients

d) Topical Anesthesia

Application of the agent directly to the skin, mucous membranes, or open surface to be desensitized

The anesthetic may be a solution, an ointment, a gel, a cream, or a powder

A short-acting form of anesthesia can block peripheral nerve endings in the mucous membranes of the vagina, rectum, nasopharynx, and mouth

Used in minor procedures: rectal examination with painful hemorrhoids, and bronchoscopy

Commonly used topical anesthesia:

Solution of 4-10% cocaine

For topical used only primarily to anesthetize the eye and the mucous membrane of nose, mouth, and urethra

Highly toxic agent

Accidental injection: can cause severe excitement or seizures; followed by shock, respiratory failure, and cardiac arrest

Nursing Responsibility:

Emergency resuscitation equipment must be available

Other topical anesthetic agents:

Tetracaine

Procaine

Mepivacaine

Lidocaine (Xylocaine)

e) Local Infiltration Anesthesia

Involves the injection of an anesthetic agent into the skin and subcutaneous tissue of the area to be anesthesized

Blocks the peripheral nerves around the area of the incision

During administration of the agent, aspiration should be done to ensure that the needle is not in the blood vessel

Inadvertent intravenous injection of the agent can result to cardiovascular collapse or convulsions

f) Field Block Anesthesia

The area proximal to a planned incision can be injected and infiltrated with local anesthetic agents to produce field block.

The block forms a barrier between the incision and the nervous system

A field block actually walls in the area around the incision and prevent transmission of sensory impulses to the brain from that area

g) Peripheral Nerve Block Anesthesia

Anesthetizes individual nerves or nerve plexuses

Examples:

Digital nerve block: fingers

Brachial plexus nerve block: entire upper arm

Intercostal nerve block: chest or abdominal wall

Peripheral Nerve Block Anesthesia

Injection of anesthetic agents along the nerve rather done into the nerve in an effort to decrease the risk of nerve damage

Agents commonly used: lidocaine, bupivacaine, and Mepivacaine

Epinephrine-containing agents are not used for surgery involving the extremities, like below the wrist and ankle, because of vasoconstriction

IV Regional Extremity Block Anesthesia (Bier Block)

Regional anesthesia of a limb can be achieved with an agent when it is injected into a vein of the limb to be anesthetized

A pneumatic dual-cuff tourniquet applied to the anesthetized area prevents the lidocaine from circulating beyond the area undergoing the procedure

This type of anesthesia is used most commonly for procedures of the extremities that are of short duration

Agent used: lidocaine

Specialized methods of producing anesthesia:

1. Muscle relaxants: It is a neuromuscular blocking agent used to provide muscle relaxation

Use: For endotracheal intubation

Pancuronium bromide (Pavulon)

Curarine chloride (Curare)

2. Hypothermia: it refers to the deliberate reduction of the patient’s body temperature between 28°-30° C

Uses:

Heart surgery

Brain surgery

Surgery on large vessels supplying major organs

Methods:

a) Ice water immersion

b) Ice bags

c) Cooling blanket

d) Extracorporeal cooling devices

Complications:

a) Cardiac arrest

b) Respiratory depression

Positioning the Client

Commonly used operative positions:

Dorsal recumbent / Supine: hernia repair, exploratory laparotomy, cholecystectomy, mastectomy, CABG,

Prone: spine surgery, rectal surgery, rectal, posterior leg surgery

Trendelenburg: surgery of the lower abdomen and the pelvis

Reverse Trendelenburg

Lithotomy position: vaginal repairs, dilation and curettage, rectal surgery

Lateral position: kidney, chest, and hip surgery

For thyroidectomy - head hyperextended

Nursing responsibility: Promote Safety

C. POST-OPERATIVE PHASE

A) Post Anesthetic Care

Nursing responsibilities:

1) Maintenance of Pulmonary Ventilation:

Position the client to side lying or semi-prone position to prevent aspiration

Oropharyngeal or nasopharyngeal airway:

Is left in place following administration of general anesthetic until pharyngeal reflexes have returned

It is only removed as soon as the client begins to awaken and has regained the cough and swallowing reflexes

All clients should received O2 at least until they are conscious and are able to take deep breaths on command

Shivering of the client must be avoided to prevent an increase in O2, and should be administered until shivering has ceased

2) Maintenance of Circulation:

Most common cardiovascular complications:

a) Hypotension

Causes:

Jarring the client during transport while moving client from the OR to his bed

Reaction to drug and anesthesia

Causes:

Loss of blood and other body fluids

Cardiac arrhythmias and cardiac failure

Inadequate ventilation

Pain

b) Cardiac arrhythmias

Causes:

Hypoxemia

Hypercapnea

Interventions:

O2 therapy

Drug administration:

Lidocaine

Procainamide (Pronestyl)

3) Protection from injury and promotion of comfort

Provide side rails

Turning frequently and placed in good body alignment to prevent nerve damage from pressure

Administration of narcotic analgesics to relieve incisional pain

Post-operative dose usually reduced to half the dose the patient will be taking after fully recovered from anesthesia

B) Dismissal of client from recovery room: Modified Aldrete Score for Anesthesia Recovery Criteria

The Five Physiological Parameters:

1. Activity

2. Respiration

3. Circulation

4. Consciousness

5. Color

The Five Physiological Parameters:

1. Activity - able to move four extremities voluntarily on command

2. Respiration - able to breath effortlessly and deeply, and cough freely

3. Circulation - BP is (+ 20%) or (- 20%)

of pre-anesthetic level

4. Consciousness - fully awake, oriented to time, place and person

5. Color- pink (lips), (for blacks: tongue)

Post Anesthesia Care Unit

MODIFIED ALDRETE SCORE

Post-Operative Complications

1. Respiratory Complications: atelectasis and pneumonia

Suspected whenever there is a sudden rise of temperature 24-48 hours after surgery

Collapse of the alveoli is highly susceptible to infection: pneumonia

Occurs usually in high abdominal surgery when prolonged inhalation anesthesia has been necessary and vomiting has occurred during the operation or while the patient has recovered from anesthesia

Nursing Management:

1. Measures to prevent pooling of secretions

Frequent changing of position

High Fowler’s position

Moving out of bed

2. Measures to liquefy and remove secretions

Increase oral fluid intake

Breathing moist air

Deep breathing followed by coughing is contraindicated in cases of brain, spinal, or eye surgeries

Administer analgesics before coughing is attempted after thoracic and abdominal surgery

Splint operative area with draw sheet or towel to promote comfort while coughing

3. Other measures to increase pulmonary ventilation

Blow bottle exercise

Rebreathing tubes: increase CO2 stimulates the respiratory center to increase the depth of breathing thus increasing the amount of inspired air

CO2 tank: gray color

IPPB: intermittent positive pressure breathing apparatus

Incentive spirometer: encourage sustained maximal inspiration

2. Circulatory Complication

Causes of venous stasis:

Muscular inactivity

Respiratory and circulatory depression

Increased pressure on blood vessels due to tight dressing

Intestinal distention

Prolonged maintenance of sitting

Contributing factors for venous stasis:

Obesity

CV disease

Debility

Malnutrition

Old age

Most common circulatory complications:

Phlebothrombosis

Thrombophlebitis: (+) Homan’s sign

Nursing Measures:

Limbs must never be massaged for a post-op client

If possible, client should lie on his abdomen for 30 min several time a day to prevent pooling of blood in the pelvic cavity

Do not allow the client to stand unless pulse has returned close to baseline to prevent orthostatic hypotension

Wear elastic bandages or stockings when in bed and when walking for the first time.

Can be removed at least once a day to permit washing of the legs

3. Fluids and Electrolytes Imbalance:

Causes:

1) Blood loss

2) Increased insensible fluid loss through the skin after surgery:

Form vomiting,

From copious wound drainage, and

From the tube drainage as in NGT

3) Since surgery is a stressor, there is an increased production of ADH for the first 12-24 hours following surgery resulting to fluid retention by the kidney

The potential for over hydration therefore exists since fluids being given IV may exceed fluid output by the kidney

Electrolyte Imbalance: Particularly Na and K imbalance as a result of blood loss

Stress of surgery increases adrenal hormonal activity resulting to increased aldosterone and glucocorticoids, resulting in sodium reabsorption by the kidney

And as Na is reabsorbed, K coming from tissue breakdown is excreted

Action: IV of D5W alternate with D5NSS or half strength NSS to prevent Na excess

4. Complications of Surgery

a. GIT complications:

1) Paralytic ileus

Cessation of peristalsis due to excessive handling of GI organs

Nursing management:

NPO until peristalsis has returned as evidenced by auscultation of bowel sounds or by passing out of flatus

2) Vomiting: usually the effect of certain anesthetics on the stomach, or eating food or drinking water before peristalsis returns

Psychologic factors also contribute to vomiting

Nursing management:

Position the client on the side to prevent aspiration

When vomiting has subsided, give ice chips, sips of ginger ale or hot tea, or eating small frequent amounts of dry foods thus relieving nausea

Administer anti-emetic drugs as ordered:

Trimethobenzamide Hcl (Tigan)

Prochiorperasine dimaleate (Compazine)

3) Abdominal distention: results from the accumulation of non-absorbable gas in the intestine

Causes:

Reaction to the handling of the bowel during surgery

Swallowing of air during recovery from anesthesia

Passage of gases from the blood stream to the atonic portion of the bowel

4) Gas pains: results from contraction of the unaffected portion of the bowel in order to move accumulated gas in the intestinal tract

Nursing management:

Aspiration of fluid or gas: with the insertion of an NGT

Ambulation: stimulates the return of peristalsis and the expulsion of flatus

Fleet enema

Rectal tube insertion: inserted just passed the anal sphincter and removal after approximately 20 minutes

Adult: 2-4 inches, children: 1-3 inches

Prolonged stimulation of the anal sphincter may cause in a loss of neuromuscular response, and pressure necrosis of the mucous surface

5) Constipation: due to decreased food intake and inactivity

Regular bowel movement will return 3-4 days after surgery with resumption of regular diet and adequate fluid intake and ambulation

5. GUT Complications

a) Return of urinary function

Usually after 6-8 hours

First voiding may not be more than 200 ml, and total out put may not be more than 1500ml

Due to the loss of fluids during surgery, perspiration, hyperventilation, vomiting, and increased secretion of ADH

Complication: urinary retention

Causes:

Prolonged recumbent position

Nervous tension

Effect of anesthetics interfering with bladder sensation and the ability to void

Use of narcotics that reduce the sensation of bladder distention

Pain at the surgical site and on movement

b) Urinary tract infection

Management:

Instruct the client to empty the bladder completely during voiding

Catheterize if necessary, done by sterile non-traumatic technique

6. Post-operative Discomforts

a) Post-operative pain

Narcotics can be given every 3-4 hours during the first 48 hours post-operatively for severe pain without danger of addiction

b) Hiccup (Singultus)

Brought about by the distention of the stomach, irritation of the diaphragm, peritonitis and uremia causing a reflex or stimulation of the phrenic nerve

Management for hiccups:

Paper bag blowing

CO2 inhalation: 5% CO2 and 95% O2 x 5 minutes every hour

7. Wound Complications:

Sutures are usually removed about 5th-7th day post-op with the exception of wire retention sutures placed deep in the muscles and removed 14-21 days after surgery

a) Hemorrhage from the wound

Most likely to occur within the first 48 hours post-op or as late as 6th-7th post-op day

Causes:

1) Hemorrhage occurring soon after operation: slipping of the ligatures or mechanical dislodging of a blood clot or caused by the reestablished blood flow through the vessel

2) Hemorrhage after few days: Sloughing off of blood clot or of a tissue

3) Infection

4) Erosion of a blood vessel by a drainage tube

Assessment:

Bright red blood

Decreased BP

Increased PR and RR

Restlessness and Pallor

Cold, moist skin

Weakness

b) Infection

Cause: streptococcus and staphylococcus

Assessment: from 3-6 days after surgery, the client begins to have a low grade fever, and the wound becomes painful and swollen

There maybe purulent drainage on the dressing

c) Dehiscence and Evisceration

Dehiscence or wound disruption:

Refers to a partial-to-complete separation of the wound edges

Evisceration:

Refers to protrusion of the abdominal viscera through the incision and onto the abdominal wall

Assessment:

Complain of a “giving” sensation in the incision

Sudden, profuse leakage of fluid from the incision

The dressing is saturated with clear, pink drainage

Management:

Position the client to low Fowler’s position

Instruct the client not to cough, sneeze, eat or drink, and remain quiet until the surgeon arrives

Protruding viscera should be covered warm, sterile, saline dressing

8. Post-op psychological disturbances

Delirium (mental aberration)

ACS (acute confusional state)

Causes:

Dehydration and Insufficient O2

Anemia

Hypotension

Hormonal imbalances

Infection and Trauma

Manifestations:

Poor memory

Restlessness

Inattentiveness

Inappropriate behavior

Wild excitement, hallucinations, delusions, depression

Disoriented

Sleep disturbance

Nursing Interventions:

Sedatives given as ordered, to keep the client quiet and comfortable

Explain reasons for interventions

Listen and talk to the client and significant others

Provide comfort

Treat the underlying cause

Discharge Instructions:

Early discharge, which has become common, typically increases client teaching needs

Be sure to provide information about wound care, activity restrictions, dietary management, medication administration, symptoms to report, and follow-up care

A client recovering from same-day surgery in an outpatient surgical unit must be in stable condition before discharge

This client must not drive home, make sure a responsible adult takes the client home