MS Handout (Pain and Perioperative Nursing)

7/29/2019 MS Handout (Pain and Perioperative Nursing)

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gooBulacan State UniversityCOLLEGE OF NURSING

City of Malolos, Bulacan

Medical-Surgical NursingPAIN AND PERIOPERATIVE NURSING

Pain: the 5th Vital Sign

- An unpleasant sensory and emotional experience associated withactual or potential tissue damage

- Personal and private sensation of hurt- Harmful stimulus that signals current impending tissue damage- Pattern of response that protects an organism from harm

I. Classification of Pain

A. Classification According to the Cause

1. Nociceptive Pain resulting from noxious (harmful/injurious) stimuliwhich transmits in an orderly manner (e.g. sprains, bone fractures,

burn, bumps, bruises, inflammation, etc.)

Types

a. Somatic Pain caused by mechanical, thermal, chemical,

electrical, etc. affecting voluntarily controlled body tissues (e.g.

skeletal muscles)

b. Visceral Pain caused by ischemia, compression or injury

of the involuntarily controlled body parts (e.g. internal organs)

2. Neuropathic Pain always chronic that occurs or results from injury

or malfunction of PNS/CNS (e.g. cancers, phantom limb pain,

diabetic neuropathy)

B. Classification According to Duration and Severity

Acute Pain Chronic Pain

Seconds - < 6

months Short in duration andsudden onset

Intensity: mild tosevere

Localized

Sympathetic nervoussystem

6 months years

Long in duration andremote onset

Intensity: mild to severe

Generalized

Parasympathetic nervoussystem

Dry & warm skin + normalVS


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Diaphoresis + VS

Dilated pupils

Normal or dilated pupils

C. Classification According to Location

1. Referred Pain pain that comes from detached body parts (e.g.

phantom limb pain)

2. Radiating Pain felt on the source of pain that extends to nearby

tissues (e.g. MI)

3. Intractable Pain pain unresponsive to medical treatment (e.g.

cancers)

II. Pain Transmission

1. Transduction

- The phase wherein noxious stimuli trigger the release of biochemical

mediators (e.g. prostaglandin, bradykinin, serotonin, histamine,

substance P) that sensitize nociceptors.

2. Transmission

- Transmission of pain from cause of pain to the perception of pain

- pain control takes place during transmission pain

3. Perception

- Client becomes conscious of the pain

- Brain interprets the signals and localizes the pain (Nociception)

- Brain relates impulses to past pain experiences

4. Modulation

- descending system

- Neurons of the brain sends signals or pain killers (e.g. endorphins,

GABA) to the area of affectation

- It inhibits painful ascending stimuli

III. Pathophysiology of Pain

Noxious

Stimulation of

C FibersA delta fiberSubstantia gelatinosa

Spinal cord brain stem thalamus limbic system NOCICEPTIONRelease ofInhibits Pain /


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IV. Gate Control Theory

- According to Melzack and Wall, peripheral nerve fibers carrying pain to

the spinal cord can have their input modified at the spinal cord level

before they reach the brain

- Small diameter nerve fibers: carry pain stimuli through a gate

- Large diameter nerve fibers: carry non-pain stimuli through a gate

- Both nerve fibers enters the same gate which explain its gate closingmechanism

- Gate mechanism is thought to be situated in the substantia gelatinosa

in the dorsal horn of the spinal cord

- All pain perception are only mind over matter (Melzack and Wall)

V. Neurotransmitter

- Chemical substances that aids in transmission of pain or any stimuli

1. Acetylcholine

- Found throughout the spinal cord and brain stem

- Excitatory and inhibitory effect

- Responsible for voluntary movement of the muscle fibers


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- Examples of diseases associated with acetylcholine:

i. Myasthenia gravis

ii. Alzheimers disease

2. Norepinephrine

- Found in the brain stem and nerve tracts

- Excitatory and inhibitory effect

- For wakefulness and arousal

- E.g. cocaine, amphetamine, methamphetamine HCl

3. Serotonin

- Found in CNS and brain stem, especially in spinal cord

- Inhibitory effect

- Responsible for memory, emotions, mood, wakefulness, temperature

regulations, sleep, anxiety

- Examples of disorders associated with serotonin:

i. Narcolepsy

ii. Schizophrenia

4. Dopamine

- Found in the hypothalamus and nerve tracts

- Excitatory effect

- For voluntary contraction of muscle fibers

- Example of associated disorder:

i. Parkinsonism

5. GABA

- Found in the hypothalamus and CNS

- Produces local anesthesia

- For modulation of pain

- Generally inhibitory


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- E.g. Ritalin

6. Endorphins

- Found in the CNS widely and PNS

- Calming effects

- Anesthetic/ inhibitory effect

- Natural pain killers

- E.g. Morphine SO4, Opiates

VI. Pain Assessment

A. Characteristics of Pain

1. JCAHO Components of Comprehensive Pain Assessment

a. Intensity

b. Location

c. Quality

d. Onset

e. Duration

f. Variations

g. Patterns

h. Alleviating factors

i. Aggravating factors

j. Present pain management

regimen

k. Pain management history

l. Effects of pain

m. Persons goal for pain

control

n. Physical examination of

pain

O nset (What time?)

P rovoking Factors (What causes and worsens the pain?)

Q uality (is it burning, stabbing, sharp pain?)

R adiation (where do you feel the pain? Did it radiate?)

S everity (pain scale: 0-10)


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T iming (duartion)

Wong Baker FACES Pain Rating Scale: for pediatrics, with language

difficulty and mute which utilizes facial expression or grimaces to assess

pain sensation

0 -1= no pain

2-3 = mild, annoying pain

4-5 = nagging, uncomfortable or troublesome pain

6-7 = distressing, miserable pain

8-9 = intense, dreadful, horrible pain

10 = worst, unbearable, excruciating pain

VII.Pain Management

- It refers to the techniques used to prevent, reduce or relieve pain

A. Methods of Drug Administration

1. Oral (including sublingual)

2. Rectal

3. Transdermal

4. Parenteral

a. Patient controlled analgesia

b. Intraspinal analgesia

B. WHO 3-STEP LADDER

Step 1: mild to moderate pain lasting 3-4hours start with low doses of

nonopioid drugs

e.g. Acetaminophen, NSAIDs, Adjuvants

Step 2: intermediate pain not controlled by nonopioid;


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Use combination of opioid and nonopioid drugs

e.g. Acet/ASA + Codeine or Hydrocodone or Oxycodone,

Tramadol, other related adjuvants

Step 3: For severe pain, add higher dose of opioid to nonopioid or use a

drug that potentiates its analgesic effect

e.g. Morphine, Oxycodone, Hydromorphone, Methadone,

Fentanyl, other adjuvants

A fourth step is being considered for patients with pain associated with

cancer (Nerve blocks, electrical stimulation of the spinal cord,

neurosurgical analgesic techniques)

C. Analgesic Drug Therapy

1. Opioids chemical substance that has morphine like action in the

body. The main use is for pain relief. These agents work by binding

to opioid receptors, which are found principally in the CNS and GIT.

- Examples: Morphine SO4, Meperidine HCl (Demerol)

- Nursing Responsibility:

i. Assess RR before and after administration to prevent atelectasis

ii. Teach DBE and cough exercise using incentive spirometer

iii. Management for side effects:

a. Sedation raise the side rails, have ambulatory devices,

place a call bell

b. Constipation - fiber, give laxatives as ordered

Step 1 (MILD PAIN)

Aspirin (ASA)

Acetaminophen

NSAIDs+ Adjuvants

Step 3 (SEVERE PAIN)

Morphine

Hydromorphone

Methadone

Levorphanol

Fentanyl

Oxycodone+ Nonopioid

Step 2 (MODERATEPAIN)

Acet or ASA +Codeine orHydrocodone orOxycodone orDihydrocodeine

Tramadol (notavailable with ASA


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c. Hypotension move patient slowly, monitor BP q15min

d. Urinary retention insert urinary catheter if indicated

iv. Laugh therapy

2. Nonopioids it inhibits prostaglandin synthesis

- Examples: NSAIDs, ASA, Ibuprofen


i. Give NSAIDs pc because it cause gastric ulcer

ii. NSAIDs side effect renal impairment, dyspnea, constipation,

headache, dizziness

iii. If on ASA, monitor for signs of bleeding occult blood, bleeding

gums, easy bruising, epistaxis

3. Antidepressants effects are believed to be related to their effects

on neurotransmitter.

a. TCA

b. MAOIs

c. SSRI

4. Corticosteroids reduces inflammation and they are therefore

useful in treating pain where inflammation or edema is causing

symptoms.

- E.g. Dexamethasone, Betamethasone


i. Monitor weight, VS and serum glucose levels

ii. Monitor WBC levels

5. Anticonvulsants they are believed to suppress rapid and excessive

firing of neurons that start a seizure following pain perception


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- E.g. diazepam (Valium) it increases GABA


i. Give diazepam with food because of possible ulceration

ii. Monitor blood count

iii. Safety precautions (use of side rails, tongue guard)

6. Psychostimulants used as adjuvant to analgesic therapy to

increase effect to pain

- E.g. Ritalin for ADHD and depressed patients

- Nursing responsibility:

i. Give before bedtime for ADHD patients; give on daytime for

depressed patients

ii. Avoid caffeinated beverages if on Ritalin treatment

D. Neurosurgical Management

1. Cordotomy division of certain tracts of the spinal cord to interrupt

transmission of pain.

2. Rhizotomy sensory nerve roots are destroyed where they enter

the spinal cord.

Nursing Responsibility:

1. Obtain a written consent

2. Assess for pain level and neurologic status

3. Skin care, position and turn the patient q2h

4. Bowel and bladder management

E. Nonpharmacologic Interventions

1. Heat and cold application

2. TENS and PENS


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3. Acupuncture and acupressure

4. Imagery

5. Biofeedback

6. Breathing exercise

7. Hypnosis

8. Massage

9. Yoga/ meditation

10.Music Therapy

F. General Nursing Responsibility for Pain Management

1. Maintain a therapeutic relationship

2. Assess and document systematically

3. Intervene using a multidisciplinary team approach for maximum

relief

4. Advocate for the patient

5. Educate patient and family

6. Clarify orders


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PERIOPERATIVE NURSING

Surgical TerminologiesPrefixes

Meaning Root words

Meaning Suffixes Meaning

aectointrointerintrapanperipolypseudoretrosupra

without,absenceexternal,outsidebelowbetweenwithinallaround, nearmanyfalsebehind,posteriorabove

adenoarthroautoblepharcardiocephalocerebrocheilocholecholecystcholedochochondrocolpocostolaparnephrooculooophoroorchiosteootophlebopyelsalpingo

glandjointselfeyelidheartheadbrainlipbilegall bladdercommon bileductcartilagevaginaribabdomenkidneyeyeovarytestisboneearveinrenal pelvisfallopian tube

algiacentesiscopyectomyitislithlogylysisomaostomypexyplastyrrhaphy

painpunctureviewingremoval ofinflammation ofstone, calculusscience or study ofloose, dissolutiontumorartificial openingfixation or suturingrepair ofrepair of

Preoperative Phase extends from the time the client is admitted in the surgicalunit, to the time he/she is prepared physically, psychosocially, spiritually and legallyfor the surgical procedure, until he/she is transported into the operating roomIntraoperative Phase extends from the time the client is admitted to theoperating room, to the time of administration of anesthesia, surgical procedure isdone, until he/she is transported to the recovery room/post-anesthesia care unitPostoperative Phase extends from the time the client is admitted to therecovery room, to the time he/she is transported back into the surgical unit,discharged from the hospital, until follow-up care.


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I. Four Major Types of Pathologic Processes Requiring Surgical Interventions1. Obstruction impairment to the flow of vital fluids. E.g. blood, urine,

CSF, bile2. Perforation rupture of an organ3. Erosion wearing off of a surface or membrane4. Tumors abnormal new growths

II. Classification of Surgical ProcedureA. Classification According to Degree of Risk (Magnitude/Extent)

1. Major Surgery

High risk

Extensive

Prolonged

With large amount of blood loss

Vital organs may be handled or removed

Great risk of complications2. Minor Surgery

Generally not prolonged Leads to few serious complications

Involves less risk

Some minor operations exceeding 2hours is considered majoroperation

B. Classification According to Purpose1. Diagnostic Surgery to establish the presence of a disease

condition. E.g. biopsy2. Exploratory Surgery to determine the extent of the disease

condition. E.g. exploratory laparotomy3. Curative Surgery to treat the disease condition

a. Ablative Surgery involves removal of an organ (suffix used isectomy). E.g. appendectomy

b. Constructive Surgery involves repair of congenitally defectiveorgan (suffixes used are plasty, orrhaphy, pexy). E.g.cheiloplasty, orchidopexy

c. Reconstructive Surgery also called restorative surgery;involves repair of damaged organ (suffixes used are plasty,orrhaphy, pexy). E.g. plastic surgery after severe burns

4. Palliative Surgery to relieve distressing signs and symptoms, notnecessarily to cure the disease

5. Cosmetic Surgery improves appearance. E.g. facelifting

C. Classification According to Urgency1. Emergency Surgery

Done without any delay and requires immediate attention

Usually life-threatening

E.g. ruptured appendicitis, VA, gunshot wound, stabbedwound, fractured skull, CS for labor arrest

2. Urgent / Imperative Surgery

Done within 24 30 hours requiring prompt attention


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E.g. CAD, kidney stones, appendicitis (if not ruptured)3. Required Surgery

Patient needs to have surgery for well-being

Weeks months plans

E.g. cataract, thyroid disorder, prostatic hyperplasia,

scheduled CS4. Elective Surgery

Not absolutely necessary for survival; even without surgery itwill not be life-threatening

E.g. circumcision, cyst (non-malignant)5. Optional Surgery

Decision rest on the patient; usually for aesthetic purposes

E.g. plastic / cosmetic surgery

D. The Effects of Surgery to the Client1. Stress response is elicited2. Defense against infection is lowered

3. Vascular system is disrupted4. Organs function are disturbed5. Body image may be disturbed6. Lifestyle may change

III. PREOPERATIVE PHASEA. Goals

1. Assessing and correcting physiologic and psychological problemsthat might increase surgical risk

2. Giving the person and significant others complete learning/teachingguidelines regarding surgery

3. Instructing and demonstrating exercises that will benefit the person

during postop period4. Planning for discharge and any projected changes in lifestyle due to

surgeryB. Assessment

1. Age

Too young and too old are at high risk for surgery2. Fluids and Nutrition

Nutritional deficiency should be corrected preop

Dehydration and electrolyte imbalances

Obesity

NPO post midnight

3. Drugs or alcohol use Alcoholic patients requires higher dose of anesthesia

Prone to malnutrition and hepatotoxicity4. Respiratory Function

Assess RR perioperatively

Respiratory function may be depressed during surgery

Teach DBCT

Instruct to stop smoking at least 24h preop


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5. Cardiovascular Function

Assess PR, perform ECG as ordered

If with uncontrolled hypertension, surgery may postponeduntil corrected

6. Immune system

Assess for allergies on drugs, blood products, contrastagents, latex, etc.

Interview if on corticosteroids7. Hepatic Function

Secure result of liver enzyme test, function test

History of hepatitis8. Endocrine function

Monitor blood glucose level

Assess thyroid function9. Previous Medications Used

Assess for history of aspirin use

To prevent possible antagonistic effect of drugs during

surgery10.Neurologic Function

Assess LOC

Assess for fear and anxiety about the procedure and addressit therapeutically

Nursing Responsibility to Minimize Anxiety:i. Explore clients feelingsii. Allow client to speak openly about fears and concernsiii. Give accurate information regarding surgery (no false

reassurance)iv. Give empathetic supportv. Consider the persons religious preferences and

arrange for visit by priest/minister as desired11.Spiritual Concerns

Jehovahs witnesses no blood transfusion

Protestants avoid seafoods and vertebral animals

C. Informed Consent

Purposes:i. To ensure that the client understands the nature ofthe treatment including the potential complicationsii. To indicate that the clients decision was madewithout pressure

iii. To protect the client against any unauthorizedprocedureiv. To protect the surgeon and hospital against legalaction by a client who claims that an unauthorizedprocedure was performed

Circumstances Requiring a Permiti. Any surgical procedure where scalpels, scissors,suture, hemostats of electrocoagulation may be used


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ii. Entrance into a body cavity e.g. paracentesis,bronchoscopyiii. General anesthesia, local infiltration, regional block

Requisites for Validity of Informed Consenti. Written permission is best and is legally acceptableii. Signature is obtained with clients complete

understanding of what to occuriii. Obtained before sedationiv. Secured without pressure or duressv. A witness is desirable nurse, physician, or otherauthorized personsvi. In an emergency, permission via telephone ortelefax is acceptablevii. For minor (below 18yrs), unconscious,psychologically incapacitated, permission is requiredfrom responsible family member (parent/legalguardian)

D. Physical Preparation1. Before the Surgery

Correct any dietary deficiencies

Reduce an obese persons weight

Correct fluid and electrolyte imbalance

Prepare blood products for possible blood transfusion

Treat chronic diseases DM, heart disease, renalinsufficiency

Halt or treat any infectious process

Treat an alcoholic person with vitamin supplements, IVFs ororal fluids, if dehydrated

2. Teaching Preop Exercises DBCT

Incentive spirometry

Turning exercises

Foot and leg exercise3. Preparing the Person the Evening Before the Surgery

Preparing the skin have full bath to reduce microbes on theskin

Preparing the GIT NPO; cleansing enema as required

Preparing for Anesthesia avoid alcohol and smoking at least24h preop

Promoting rest and sleep administer sedatives as ordered4. Preparing the Person on the Day of Surgery

Early AM carei. Awaken 1h before preop medicationsii. Morning bath and mouth washiii. Provide clean gowniv. Remove hairpins, braid long hairs, cover hair with capv. Remove dentures, foreign materials, colored nail

polish, hearing aid, contact lenses


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vi. Take baseline VS before preop medicationsvii. Check id band, skin prepviii. Check for special orders enema, GI tube insertion, IV

line (g.18)ix. Check NPOx. Have client void before preop medication

xi. Continue to support emotionallyxii. Accomplish preop care checklist

5. Preoperative Medications / Preanesthetic Drugs

Goals:i. To facilitate the administration of any anestheticii. To minimize respiratory tract secretions and change in

HRiii. To relax the client and reduce anxiety

Commonly Used Preop Meds:1. Sedatives

Given to anxiety

Lowers BP and pulse

Lowers the administration of anesthetics

E.g. barbiturates, Phenobarbital, nubain, Demerol

Overdose: respiratory depression2. Anticholinergics

To tracheobronchial secretions

To bowel motility and fluid retention

Interrupts vagal nerve impulses HR

E.g. Atropine Sulfate

Overdose: severe tachycardia, arrhythmias3. Tranquilizers

To anxiety and BP

E.g. Phenergan, Thorazine4. Narcotics / Analgesics

Relaxes patient and anxiety

E.g. morphine, meperidine HCl (Demerol)

Side Effects: RR, n & v, hypotension5. Prophylactic Antibiotic to flora in the bowel

Transporting the client to the OR

Patients Familyi. Direct proper visiting roomii. Doctor informs family immediately after surgeryiii. Explain reason for long interval of waiting: anesthesia

prep, skin prep, surgical procedure, RRiv. Explain what to expect postop

IV. INTRAOPERATIVE PHASEA. Members of the Surgical Team

1. Scrub Teama. Operating Surgeon

Leader of Operating Team


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Doer of the operationb. Assistant to the Surgeon

Clerk, intern, resident or another surgeon

Holds retractors

Exposes surgical area

Clamps all the bleeders or sutures bleeders

Tying clamped vessels

Assist surgeons in ligating bleedersc. Scrubbed Nurse (Instrument and Suture Nurse)

Prepares and arrange instruments and supply

Checks the completeness of instruments and preliminarycount

Passes sponges

Assist scrub team during gowning and gloving

Assist in draping the patient2. Unscrubbed Team

a. Anesthesiologist (either MD or RN)

Monitor VS during the surgical procedure

Keeps the surgeon aware of the patients condition

Determines if the patient is viable to be transferred to PACUb. Pathologists

Consulted by the surgeon on the diagnosis of the removedtissue or organ

Consulted for possible treatmentc. Circulating Nurse

Overseer of the OR

Maintains sterility of the OR

Assist all the scrubbed for their needs

Checks the completeness of the chart Ties the gowns of members stoop and swing method

Maintain lightings

Provide footstools for the team

Carries and opens lap packs

B. Parts of the Operating Unit1. Unrestricted Area

Provides an entrance to and exit from surgical suite

Contains the holding or admission area, hospital lobby andPACU

Street clothes are permitted here2. Semi restricted area

Provides an access to the procedure rooms and peripheralsupport areas within the surgical suite

PACU, Anesthesia room, packing area (autoclave area) withwindow

3. Restricted Area

Includes the procedure room in which surgery is performed


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Personnel in OR attire + surgical masks

C. OR Attires (Protective Barriers)1. Scrub suits2. Head coverings (cap/hood)3. Shoe coverings

4. Masks5. Lead aprons and thyroid shield

D. Principles of Surgical Asepsis1. Patient is the center of the sterile field2. Only sterile items are used within the sterile field3. Sterile persons are gowned, gloved, masked and with bonnet or cap

Hands above the waist

Keep your hands away from the face

Remove all jewelries

Gowns are considered sterile at the front area

Sit only if the operation requires or allows sitting position4. Tables are sterile at the topmost level only5. Sterile persons touches sterile items and unsterile persons touches

unsterile only

For sterile persons, avoid overreaching over the unsterilefields

For unsterile persons, avoid overreaching over the sterilefields

6. All edges of the mayo table are considered unsterile7. Sterile items are always kept in view8. Microbes are kept irreducibly minimum

E. Types of Anesthesia1. General Anesthesia

Total loss of consciousness and sensation

Produces amnesia

Methods of administration:i. Inhalationii. Intravenous

Anesthetic agent given through inhalation:i. Halothane (Fluothane)ii. Enflurane (Ethrane)iii. Isoflurane (Forane)iv. Sevoflurane (Sevorane)

Anesthetic agent given via IV (sometimes via IM):i. Thiopental Na (Pentothal Na)ii. Propofol (Diprivan)iii. Ketamine HCl (Ketalar)iv. Fentanyl (Sublimaze)v. Diazepam (Valium)vi. Midazolam (Dormicum)

Complications of General Anesthesia:


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i. Cardiopulmonary complications:

Cardiac arrhythmias

Cardiac arrest

Bronchospasm and laryngospasm

Respiratory obstruction and failure

Vomiting and aspiration

Shock and Hypotensionii. Cerebral Complications:

CVA

Convulsionsiii. Renal Complucations:

Renal ischemia2. Regional Anesthesia

Reduce all painful sensation without in one region of thebody without inducing unconsciousness

Methods of Administration:i. Topical application via spray or instillation; e.g.

xylocaine (Lidocaine)ii. Local Infiltration agent injected into the tissue around

the incisional area; e.g. Xylocaine 1-2%iii. Nerve Block anesthetizing a group of nerve of nerve at a

given pointExamples:

Digital block

Axillary block

Radial block

Intercostals nerve block

Cervical block

iv. Field block blocking off the operative site with wall ofanesthetic solution by series of injection into proximal andsurrounding tissues

v. Spinal and Epidural Block solution is injected either inspinal space or epidural space; for surgeries below thediaphragm

Components of Spinal Anesthesia:a. Pontocaine main anesthetic agentb. Dextrose 10% in water diluentsc. Ephedrine vasoconstrictor (to prolong anesthetic

effect)

Anesthetic agent given through spinal anesthesia:

i. Procaine (Novocaine)ii. Tetracaine (Pontocaine)iii. Lidocaine (Xylocaine)iv. Mepivacaine (Carbocaine)v. Bupivacaine (Marcaine)

Complications of Spinal Anesthesiai. Hypotensionii. N & V


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iii. Headacheiv. Respiratory paralysisv. Paraplegia or severe muscle weakness

vi. Cryoanesthesia produced by marked cooling

F. Stages of Anesthesia

Stage I (Induction Stage) Extends from the administration of anesthesia to the time of loss

of consciousness

Reaction: dizzy, drowsy

Nursing Responsibility: keep the room quiet and standby toassist

Stage II (Excitement/Delirium Stage)

Extends from the loss of consciousness to the loss of lid reflex

Reaction: shouting, struggling, uncontrolled muscle movement

Nursing Responsibility: secure the patient properly and assistanesthesiologist

Stage III (Surgical Anesthesia Stage) Extends from the loss of lid reflex to the loss of most reflexes

Reaction: reflexes disappear, all senses

Surgical procedure is started

Nursing Responsibility: skin prep, insert catheter, position theclient properly

Stage IV (Medullary/Danger Stage)

Characterized by respiratory/cardiac arrest due to anesthesiaoverdose

Nursing Responsibility: assist in resuscitation

G. Common OR Instruments/Equipment1. Lap Pack

Army Navy (2)

Thumb or TissueForceps (2)

Straight clamps (3)

Curved clamps (3)

Allis (1)

Sharps:

- Metzenbaumscissor (1)

- Mayo scissor (1)- Bandage scissor (1)

Scalpel (1)

Blade holder (1)

Needle holders (2)

Towel clips (4)2. Needles and Sutures

Types of Sutures:

a. Absorbable Sutures Types:

i. Plain Gut used to ligate small vessels andsubcutaneous tissue

ii. Chromic / Catgut used to ligate larger vesselsiii. Vicryl Plus used in reproductive tractiv. Vicryl Rapide used to close mucosa in the mouthv. Coated Vicryl used in reproductive tractvi. Monocryl used in urinary bladder; GIT


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b. Non-Absorbable Sutures

Types:i. Silk used in serosa of the GITii. Cottoniii. Nylon used by ophthalmologistiv. Polyester fiber

v. Polythylenevi. Stainless steel use of staple wires

Common Colors of Suture Packaging:

Plain gut (yellowish tan)

Chromic (tan)

Silk (medium blue)

Cotton (pink and white)

Polyester (medium green)

Nylon (light green)

Classification of Needles:

According to the Eye

a. Eyedb. Eyeless/Swayed/Atraumatic

Single arm 1 needle on suture end onlyDouble arm both ends of suture have needles

c. Spring/French

According to the Shapea. Non-cutting rounded body or shaft + pointed endb. Cutting sharp edge of the body or shaft + pointed end

According to Shaft or Bodya. Straightb. Curved

H. Samples of Surgical Incisions1. Butterfly for craniotomy2. Limbal for eye surgeries3. Halstead / elliptical for breast surgeries4. Abdominal for abdominal surgeries5. McBurneys for appendectomy6. Lumbotomy / Transverse for kidney surgeries

I. Positions during Surgery1. Dorsal Recumbent hernia repair, mastectomy, bowel resection2. Trendelenburg lower abdomen, pelvic surgeries3. Lithotomy vaginal repairs, D and C, rectal surgery, APR4. Prone spinal surgeries, laminectomy5. Lateral kidney, chest, hip surgeries

Nursing Responsibility:i. Explain purpose of the procedureii. Avoid undue exposureiii. Strap the person t prevent fallsiv. Maintain adequate respiratory and circulatory functionv. Maintain good body alignment


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V. POSTOPERATIVE PHASEA. Goals

To maintain adequate body system functions

Restore homeostasis

Alleviate pain and discomfort

Prevent postop complications

Ensure adequate discharge planning and teaching

B. Transport of the Client from the OR to RR

Avoid exposure

Avoid rough handling

Avoid hurried movement and rapid changes in positionB.1 Nursing Assessment1. Appraise air exchange status and note the skin color2. Verify identity, operative procedure, surgeon3. Assess neurologic status (LOC)

4. Determine VS and skin temperature if with fever, suspectinfection

5. Examine operative site and check dressing6. Perform safety checks:

Position for good body alignment

Side rails

Restraints for IVFs, BT7. Require briefings on problems encountered in ORB.2 Nursing Interventions1. Ensure patent airway and adequate respiratory function

Lateral position with neck extended

Keep airway in place until fully awake

Suction secretions

DBE

O2 therapy2. Assess status of circulatory system

Monitor VS and report abnormalities

Observe for signs of shock and hemorrhage

Continuous care until patient is completely out of anesthesia

C. Transfer of the Client from RR to the Surgical UnitC.1 Parameters for Discharge from RR

Activity able to obey commands, e.g. DBCT

Respiration Easy, noiseless Circulation BP is within the normal range

Consciousness responsive

Color pinkish skin and mucous membraneC.2 Nursing Intervention

Maintain adequate fluid and electrolytes

Maintain adequate renal function

Promote rest, comfort and safety


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Promote adequate wound healing

Promote and maintain activity and mobility

Provide adequate psychological support

D. Postoperative Complications1. Shock a circulatory collapse due to specific factors (e.g. blood

volume, bleeding, cardiac dysfunction, etc.)2. Femoral Phlebitis / Deep thrombophlebitis inflammation/injury of

the blood vessels due to prolonged immobility, obesity, hemorrhage3. Pulmonary complications:

a. Atelectasis lung collapseb. Bronchitisc. Bronchopneumonia and lobar pneumoniad. Pleurisy

4. Urinary difficultiesa. Retentionb. Incontinence

5. Intestinal obstruction6. Hiccups7. Wound Infection

Rule of Thumb:1. Fever 1st 24hours pulmonary infections2. Within 48hours UTI3. Within 72hours wound infection

8. Wound complications

Kinds:1. Hemorrhage / Hematoma2. Wound Dehiscence disruption in the coaptation of wound

edges (wound breakdown)

3. Wound Dehiscence dehiscence + outpouching of abdominalorgans9. Delirium (Mental Aberration)

Prepared by:JOHN PAUL E. MENDOZA

R.N.

MS Handout (Pain and Perioperative Nursing)

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