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OPERATING ROOM

NURSING: SURGERY
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SURGERY TODAY !!!


Many

surgical procedures that were once performed in an inpatient setting now take place in an Ambulatory or Outpatient setting.
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Approximately

60% of elective surgeries are now performed in an ambulatory or outpatient setting.

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PERIOPERATIVE PHASE

Pre-operative Phase begins when decision to proceed with surgical intervention is made and ends with the

transfer into the operating table

Intra-operative Phase starts from the transfer of patient to the operating table and ends with the admission of the patient to the PACU (post-anesthesia care unit) Post-operative Phase begins with admission to the PACU and ends with follow-up evaluation in the clinical setting or home

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SURGICAL CLASSIFICATIONS
Diagnostic Eg. Biopsy or explorative laparotomy Curative Eg. Excision of a tumor or inflamed appendix Reparative Eg. Multiple Wound Repair Reconstructive / Cosmetic Eg. Mammoplasty or facelift Palliative Eg. To relieve pain, a PEG tube is inserted to compensate for dysphagia

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PREPARATION FOR SURGERY

Voluntary and written INFORMED consent from the patient is necessary before nonemergent surgery can be performed. Consent must be signed before administration of ANY PSYCHOactive medications .

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CRITERIA FOR VALID INFORMED CONSENT


Voluntary Consent given FREELY Incompetent Patient (those who are mentally ill, and comatose CANNOT give consent) Informed Subject should be in WRITING. Includes explanation of risks, procedure. Description of benefits & alternatives An EMANCIPATED Minor may sign his consent form

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CLASSIFICATION ACCDG. TO URGENCY

Brunner & Suddarths Textbook

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NURSING ALERT!!!

signed consent form is placed in a prominent place on the patients chart and accompanies the patient to the operating room.
The

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PRE-OPERATIVE ASSESSMENT

The

overall goal in the pre-operative period is for the patient to have as many positive health factors as
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NUTRITIONAL & FLUID STATUS


obesity, undernutrition, weight loss,

malnutrition, deficiencies in specific nutrients,

metabolic abnormalities, the effects of medications on nutrition, and special problems of the hospitalized patient (Quinn, 1999) measurement of body mass index and waist circumference (National Institutes of Health,
2000)
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NUTRIENTS
Protein Calories Water Vitamin C Thiamin, Niacin, Riboflavin, Folic Acid, Vit. B12 Vitamin A Vitamin K Iron Zinc

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DRUG OR ALCOHOL ABUSE


People who abuse drugs attempt to HIDE and DENY it Acutely intoxicated persons are susceptible to injury Alcohol withdrawal delirium (delirium tremens) may be anticipated up to 72 hours after alcohol withdrawal.

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RESPIRATORY STATUS
Goal : Optimal Respiratory Function Breathing Exercises

Use of Incentive Spirometry

Surgery is USUALLY postponed if patient have a Respiratory INFECTION SMOKING urged to STOP 2 Months before surgery (Counseling has a positive effect 24 hours before operation)

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EFFECTS OF SMOKING
increased airway reactivity decreased mucociliary clearance, physiologic changes in the cardiovascular

and immune systems

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CARDIOVASCULAR STATUS
GOAL

: to ensure a well functioning cardiovascular system to meet the oxygen, fluid, and nutritional needs of the perioperative period.

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HEPATIC AND RENAL FUNCTION


GOAL

:optimal function of the liver and urinary systems so that medications, anesthetic agents, body wastes, and toxins are adequately processed and removed from the body.
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ENDOCRINE FUNCTION
Hypoglycemia and Hyperglycemia Acidosis Glucosuria GOAL : Maintain the blood glucose level at less than 200 mg/dl Adrenal insufficiency for those who have received corticosteroids Thyrotoxicosis (hyperthyroid disorders) Respiratory failure (hypothyroid disorders)

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IMMUNE FUNCTION
Existence of Allergies Latex Allergy Immunosuppression The mildest symptoms or slightest temperature elevation must be investigated. Great care is taken to ensure strict asepsis

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PREVIOUS MEDICATION USE


OTC Meds Aspirin, HPN meds, Insulin Herbal Meds echinacea, ephedra, garlic (Allium sativum), ginkgo, ginseng kava kava (Piper methysticum), St. Johns wort (Hypericum perforatum) licorice (Glycyhiza glabra) valerian (Valeriana officinalis)

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PSYCHOSOCIAL FACTORS
Emotional Reaction Psychological Distress Anxiety Anticipatory response Different responses of persons to FEAR: 1. Repeatedly asking questions 2. Withdrawal, avoiding communication 3. Some talk about it *** NURSE Must be an EMPHATETIC listener

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MEDS THAT MAY AFFECT SURGERY


Corticosteroids Prednisone(Deltasone) Diuretics Hydrochlorothiazide(HydroDIURIL)

PhenoThiazines Chlorpromazine (Thorazine) Tranquilizers Diazepam (Valium) Insulin Antibiotics Erythromycin (Ery-tab) Anticoagulants Warfarin (Coumadin) Antiseizure Phenytoin (Dilantin) MAO Inhibitors Phenelzine sulfate (Nardil)
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ELDERLY PATIENTS
Less physiologic Reserve Sensory limitations vision, hearing and reduced tactile sensitivity Arthritis may affect mobility Dental assessment impt to Anesthesiologist Ability to perspire fragile skin (dry)

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OBESE PATIENTS
Fatty Tissues susceptible to infection Technical & Mechanical Problems Wound dehiscence(separation) and wound infections are more common. For Every 30 lbs excess weight, additional 25 miles of blood vessels needed, thus increasing workload of the heart.

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PREOPERATIVE TEACHING
IDEAL timing Pre-admission visit not ON the DAY of SURGERY GOAL Promote OPTIMAL Lung Expansion after ANESTHESIA USE of Incentive SPIROMETER Splinting of Incision line if possible GOAL Coughing, mobilizes secretions Deep Breathing Promote Mobility POST-OP

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DIAPHRAGMATIC BREATHING

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SPLINTING WHEN COUGHING

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LEG EXERCISES

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FOOT EXERCISES

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PAIN MANAGEMENT
Identification of ACUTE and CHRONIC Pain PAIN Scale Patient Controlled Analgesia (PCA) Epidural Catheter (Bolus/Infusion) P.Controlled Epidural Analgesia (PCEA) Oral Meds for Home Meds Cognitive Coping Strategies Imagery, Distraction, Optimistic Self-recitation

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PREOPERATIVE FASTING GUIDELINES


Watch out! UNNECESSARY LONG FASTINGS Warn Patients they might feel thirsty and teach strategies(as permitted):brushing teeth, rinsing the mouth, and chewing gum 8 hours fasting after eating fatty foods 4 hours after ingesting milk products 2 hours for clear liquids in an elective procedure

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PRE-OP NURSING INTERVENTIONS


Gown left Untied,OPEN in the BACK Mouth Inspected, Dentures removed Jewelries not WORN, If patient refuse, some allow ring to be taped in finger All Patients should VOID immediately(except those with UROLOGIC D/O) to promote continence and make abdominal organs more accessible

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PRE-OPERATIVE CHECKLIST

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PRE-OP NURSING DIAGNOSES


Anxiety related to the surgical experience (anesthesia, pain) and the outcome of surgery Fear related to perceived threat of the surgical procedure and separation from support system Knowledge deficit of preoperative procedures and protocols and postoperative expectations

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CRITICAL THINKING EXERCISES


1.During the preoperative assessment of a man scheduled for hand surgery in an ambulatory setting, you think that the patients responses indicate that he does not understand the procedure and that he has not made plans for postoperative care. What further assessment and teaching is indicated? What nursing interventions are warranted?
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CRITICAL THINKING EXERCISES

2.A patient with a long history of the use of several herbal supplements is scheduled for major surgery. What effect would this information have on your preoperative care of this patient?

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CRITICAL THINKING EXERCISES


3. Two patients are admitted to the same-day surgery unit for bilateral knee replacements. One patient is a 30-year-old who ambulates with crutches and the other is a 75-year-old who lives alone. How would your assessments, preoperative teaching, and preparation differ for these two patients?

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