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gooBulacan State University COLLEGE OF NURSING City of Malolos, Bulacan Medical-Surgical Nursing PAIN AND PERIOPERATIVE NURSING Pain:

the 5th Vital Sign An unpleasant sensory and emotional experience associated with actual 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 Classification of Pain A. Classification According to the Cause 1. Nociceptive Pain resulting from noxious (harmful/injurious) stimuli which 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) -

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B. Classification According to Duration and Severity Acute Pain Seconds - < 6 months Short in duration and sudden onset Intensity: mild to severe Localized Sympathetic nervous system Chronic Pain 6 months years Long in duration and remote onset Intensity: mild to severe Generalized Parasympathetic nervous system Dry & warm skin + normal VS

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 stimuli Stimulation of Nociceptors A delta fiber Spinal cord brain stem C Fibers thalamus limbic system Substantia gelatinosaRelease of NOCICEPTION Inhibits Pain /

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 closing mechanism 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

Examples of diseases associated with acetylcholine: i. ii. Myasthenia gravis 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. ii. Narcolepsy Schizophrenia

4. Dopamine Found in the hypothalamus and nerve tracts Excitatory effect For voluntary contraction of muscle fibers Example of associated disorder: i. 5. GABA Found in the hypothalamus and CNS Produces local anesthesia For modulation of pain Generally inhibitory Parkinsonism

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. pain Physical examination of

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)

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;

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) Step 1 (MILD PAIN) Aspirin (ASA) Acetaminophen NSAIDs + Adjuvants Step 2 (MODERATE PAIN) Acet or ASA + Codeine or Hydrocodone or Oxycodone or Dihydrocodeine Tramadol (not available with ASA or Acet) Step 3 (SEVERE PAIN) Morphine Hydromorphon e Methadone Levorphanol Fentanyl Oxycodone + Nonopioid analgesics

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. ii. iii. Assess RR before and after administration to prevent atelectasis Teach DBE and cough exercise using incentive spirometer Management for side effects: a. Sedation raise the side rails, have ambulatory devices, place a call bell b. Constipation - fiber, give laxatives as ordered

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 Nursing Responsibility: i. ii. iii. Give NSAIDs pc because it cause gastric ulcer NSAIDs side effect renal impairment, dyspnea, constipation, headache, dizziness 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 Nursing Responsibility: i. ii. Monitor weight, VS and serum glucose levels Monitor WBC levels

5. Anticonvulsants they are believed to suppress rapid and excessive firing of neurons that start a seizure following pain perception

E.g. diazepam (Valium) it increases GABA Nursing Responsibility: i. ii. iii. Give diazepam with food because of possible ulceration Monitor blood count 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. ii. Give before bedtime for ADHD patients; give on daytime for depressed patients 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. 2. 3. 4. Obtain a written consent Assess for pain level and neurologic status Skin care, position and turn the patient q2h Bowel and bladder management

E. Nonpharmacologic Interventions 1. Heat and cold application 2. TENS and PENS

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

PERIOPERATIVE NURSING Surgical Terminologies Prefix Meaning Root es words a without, adeno ecto absence arthro intro external, auto inter outside blephar intra below cardio pan between cephalo peri within cerebro poly all cheilo pseud around, near chole o many cholecyst retro false choledoch supra behind, o posterior chondro above colpo costo lapar nephro oculo oophoro orchi osteo oto phlebo pyel salpingo Meaning gland joint self eyelid heart head brain lip bile gall bladder common bile duct cartilage vagina rib abdomen kidney eye ovary testis bone ear vein renal pelvis fallopian tube Suffixes algia centesis copy ectomy itis lith logy lysis oma ostomy pexy plasty rrhaphy Meaning pain puncture viewing removal of inflammation of stone, calculus science or study of loose, dissolution tumor artificial opening fixation or suturing repair of repair of

Preoperative Phase extends from the time the client is admitted in the surgical unit, to the time he/she is prepared physically, psychosocially, spiritually and legally for the surgical procedure, until he/she is transported into the operating room Intraoperative Phase extends from the time the client is admitted to the operating room, to the time of administration of anesthesia, surgical procedure is done, until he/she is transported to the recovery room/post-anesthesia care unit Postoperative Phase extends from the time the client is admitted to the recovery 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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Four Major Types of Pathologic Processes Requiring Surgical Interventions 1. Obstruction impairment to the flow of vital fluids. E.g. blood, urine, CSF, bile 2. Perforation rupture of an organ 3. Erosion wearing off of a surface or membrane 4. Tumors abnormal new growths Classification of Surgical Procedure A. 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 complications 2. Minor Surgery Generally not prolonged Leads to few serious complications Involves less risk Some minor operations exceeding 2hours is considered major operation B. Classification According to Purpose 1. Diagnostic Surgery to establish the presence of a disease condition. E.g. biopsy 2. Exploratory Surgery to determine the extent of the disease condition. E.g. exploratory laparotomy 3. Curative Surgery to treat the disease condition a. Ablative Surgery involves removal of an organ (suffix used is ectomy). E.g. appendectomy b. Constructive Surgery involves repair of congenitally defective organ (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, not necessarily to cure the disease 5. Cosmetic Surgery improves appearance. E.g. facelifting C. Classification According to Urgency 1. Emergency Surgery Done without any delay and requires immediate attention Usually life-threatening E.g. ruptured appendicitis, VA, gunshot wound, stabbed wound, 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 CS 4. Elective Surgery Not absolutely necessary for survival; even without surgery it will 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 Client 1. Stress response is elicited 2. Defense against infection is lowered 3. Vascular system is disrupted 4. Organs function are disturbed 5. Body image may be disturbed 6. Lifestyle may change III. PREOPERATIVE PHASE A. Goals 1. Assessing and correcting physiologic and psychological problems that might increase surgical risk 2. Giving the person and significant others complete learning/teaching guidelines regarding surgery 3. Instructing and demonstrating exercises that will benefit the person during postop period 4. Planning for discharge and any projected changes in lifestyle due to surgery B. Assessment 1. Age Too young and too old are at high risk for surgery 2. 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 hepatotoxicity 4. Respiratory Function Assess RR perioperatively Respiratory function may be depressed during surgery Teach DBCT Instruct to stop smoking at least 24h preop

5. Cardiovascular Function Assess PR, perform ECG as ordered If with uncontrolled hypertension, surgery may postponed until corrected 6. Immune system Assess for allergies on drugs, blood products, contrast agents, latex, etc. Interview if on corticosteroids 7. Hepatic Function Secure result of liver enzyme test, function test History of hepatitis 8. Endocrine function Monitor blood glucose level Assess thyroid function 9. Previous Medications Used Assess for history of aspirin use To prevent possible antagonistic effect of drugs during surgery 10.Neurologic Function Assess LOC Assess for fear and anxiety about the procedure and address it therapeutically Nursing Responsibility to Minimize Anxiety: i. Explore clients feelings ii. Allow client to speak openly about fears and concerns iii. Give accurate information regarding surgery (no false reassurance) iv. Give empathetic support v. Consider the persons religious preferences and arrange for visit by priest/minister as desired 11.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 of the treatment including the potential complications ii. To indicate that the clients decision was made without pressure iii. To protect the client against any unauthorized procedure iv. To protect the surgeon and hospital against legal action by a client who claims that an unauthorized procedure was performed Circumstances Requiring a Permit i. Any surgical procedure where scalpels, scissors, suture, hemostats of electrocoagulation may be used

ii. Entrance into a body cavity e.g. paracentesis, bronchoscopy iii. General anesthesia, local infiltration, regional block Requisites for Validity of Informed Consent i. Written permission is best and is legally acceptable ii. Signature is obtained with clients complete understanding of what to occur iii. Obtained before sedation iv. Secured without pressure or duress v. A witness is desirable nurse, physician, or other authorized persons vi. In an emergency, permission via telephone or telefax is acceptable vii. For minor (below 18yrs), unconscious, psychologically incapacitated, permission is required from responsible family member (parent/legal guardian) D. Physical Preparation 1. 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, renal insufficiency Halt or treat any infectious process Treat an alcoholic person with vitamin supplements, IVFs or oral fluids, if dehydrated 2. Teaching Preop Exercises DBCT Incentive spirometry Turning exercises Foot and leg exercise 3. Preparing the Person the Evening Before the Surgery Preparing the skin have full bath to reduce microbes on the skin Preparing the GIT NPO; cleansing enema as required Preparing for Anesthesia avoid alcohol and smoking at least 24h preop Promoting rest and sleep administer sedatives as ordered 4. Preparing the Person on the Day of Surgery Early AM care i. Awaken 1h before preop medications ii. Morning bath and mouth wash iii. Provide clean gown iv. Remove hairpins, braid long hairs, cover hair with cap v. Remove dentures, foreign materials, colored nail polish, hearing aid, contact lenses

Take baseline VS before preop medications Check id band, skin prep Check for special orders enema, GI tube insertion, IV line (g.18) ix. Check NPO x. Have client void before preop medication xi. Continue to support emotionally xii. Accomplish preop care checklist 5. Preoperative Medications / Preanesthetic Drugs Goals: i. To facilitate the administration of any anesthetic ii. To minimize respiratory tract secretions and change in HR iii. 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 depression 2. Anticholinergics To tracheobronchial secretions To bowel motility and fluid retention Interrupts vagal nerve impulses HR E.g. Atropine Sulfate Overdose: severe tachycardia, arrhythmias 3. Tranquilizers To anxiety and BP E.g. Phenergan, Thorazine 4. Narcotics / Analgesics Relaxes patient and anxiety E.g. morphine, meperidine HCl (Demerol) Side Effects: RR, n & v, hypotension 5. Prophylactic Antibiotic to flora in the bowel Transporting the client to the OR Patients Family i. Direct proper visiting room ii. Doctor informs family immediately after surgery iii. Explain reason for long interval of waiting: anesthesia prep, skin prep, surgical procedure, RR iv. Explain what to expect postop IV. INTRAOPERATIVE PHASE A. Members of the Surgical Team 1. Scrub Team a. Operating Surgeon Leader of Operating Team

vi. vii. viii.

Doer of the operation b. 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 bleeders c. Scrubbed Nurse (Instrument and Suture Nurse) Prepares and arrange instruments and supply Checks the completeness of instruments and preliminary count Passes sponges Assist scrub team during gowning and gloving Assist in draping the patient 2. 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 PACU b. Pathologists Consulted by the surgeon on the diagnosis of the removed tissue or organ Consulted for possible treatment c. 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 Unit 1. Unrestricted Area Provides an entrance to and exit from surgical suite Contains the holding or admission area, hospital lobby and PACU Street clothes are permitted here 2. Semi restricted area Provides an access to the procedure rooms and peripheral support areas within the surgical suite PACU, Anesthesia room, packing area (autoclave area) with window 3. Restricted Area Includes the procedure room in which surgery is performed

Personnel in OR attire + surgical masks C. OR Attires (Protective Barriers) 1. Scrub suits 2. Head coverings (cap/hood) 3. Shoe coverings 4. Masks 5. Lead aprons and thyroid shield D. Principles of Surgical Asepsis 1. Patient is the center of the sterile field 2. Only sterile items are used within the sterile field 3. 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 position 4. Tables are sterile at the topmost level only 5. Sterile persons touches sterile items and unsterile persons touches unsterile only For sterile persons, avoid overreaching over the unsterile fields For unsterile persons, avoid overreaching over the sterile fields 6. All edges of the mayo table are considered unsterile 7. Sterile items are always kept in view 8. Microbes are kept irreducibly minimum E. Types of Anesthesia 1. General Anesthesia Total loss of consciousness and sensation Produces amnesia Methods of administration: i. Inhalation ii. 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:

Cardiopulmonary complications: Cardiac arrhythmias Cardiac arrest Bronchospasm and laryngospasm Respiratory obstruction and failure Vomiting and aspiration Shock and Hypotension ii. Cerebral Complications: CVA Convulsions iii. Renal Complucations: Renal ischemia 2. Regional Anesthesia Reduce all painful sensation without in one region of the body 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 point Examples: Digital block Axillary block Radial block Intercostals nerve block Cervical block iv. Field block blocking off the operative site with wall of anesthetic solution by series of injection into proximal and surrounding tissues v. Spinal and Epidural Block solution is injected either in spinal space or epidural space; for surgeries below the diaphragm Components of Spinal Anesthesia: a. Pontocaine main anesthetic agent b. Dextrose 10% in water diluents c. 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 Anesthesia i. Hypotension ii. N&V

i.

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iii. Headache iv. Respiratory paralysis v. Paraplegia or severe muscle weakness 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 to assist 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 assist anesthesiologist 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 the client properly Stage IV (Medullary/Danger Stage) Characterized by respiratory/cardiac arrest due to anesthesia overdose Nursing Responsibility: assist in resuscitation G. Common OR Instruments/Equipment 1. Lap Pack Army Navy (2) Thumb or Tissue Forceps (2) Straight clamps (3) Curved clamps (3) Allis (1) Sharps:

Metzenbaum scissor (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 and subcutaneous tissue ii. Chromic / Catgut used to ligate larger vessels iii. Vicryl Plus used in reproductive tract iv. Vicryl Rapide used to close mucosa in the mouth v. Coated Vicryl used in reproductive tract vi. Monocryl used in urinary bladder; GIT

b. Non-Absorbable Sutures Types: i. Silk used in serosa of the GIT ii. Cotton iii. Nylon used by ophthalmologist iv. Polyester fiber v. Polythylene vi. 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. Eyed b. Eyeless/Swayed/Atraumatic Single arm 1 needle on suture end only Double arm both ends of suture have needles c. Spring/French According to the Shape a. Non-cutting rounded body or shaft + pointed end b. Cutting sharp edge of the body or shaft + pointed end According to Shaft or Body a. Straight b. Curved H. Samples of Surgical Incisions 1. Butterfly for craniotomy 2. Limbal for eye surgeries 3. Halstead / elliptical for breast surgeries 4. Abdominal for abdominal surgeries 5. McBurneys for appendectomy 6. Lumbotomy / Transverse for kidney surgeries I. Positions during Surgery 1. Dorsal Recumbent hernia repair, mastectomy, bowel resection 2. Trendelenburg lower abdomen, pelvic surgeries 3. Lithotomy vaginal repairs, D and C, rectal surgery, APR 4. Prone spinal surgeries, laminectomy 5. Lateral kidney, chest, hip surgeries Nursing Responsibility: i. Explain purpose of the procedure ii. Avoid undue exposure iii. Strap the person t prevent falls iv. Maintain adequate respiratory and circulatory function v. Maintain good body alignment

V.

POSTOPERATIVE PHASE A. 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 position B.1 Nursing Assessment 1. Appraise air exchange status and note the skin color 2. Verify identity, operative procedure, surgeon 3. Assess neurologic status (LOC) 4. Determine VS and skin temperature if with fever, suspect infection 5. Examine operative site and check dressing 6. Perform safety checks: Position for good body alignment Side rails Restraints for IVFs, BT 7. Require briefings on problems encountered in OR B.2 Nursing Interventions 1. Ensure patent airway and adequate respiratory function Lateral position with neck extended Keep airway in place until fully awake Suction secretions DBE O2 therapy 2. 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 Unit C.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 membrane C.2 Nursing Intervention Maintain adequate fluid and electrolytes Maintain adequate renal function Promote rest, comfort and safety

Promote adequate wound healing Promote and maintain activity and mobility Provide adequate psychological support D. Postoperative Complications 1. 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, hemorrhage 3. Pulmonary complications: a. Atelectasis lung collapse b. Bronchitis c. Bronchopneumonia and lobar pneumonia d. Pleurisy 4. Urinary difficulties a. Retention b. Incontinence 5. Intestinal obstruction 6. Hiccups 7. Wound Infection Rule of Thumb: 1. Fever 1st 24hours pulmonary infections 2. Within 48hours UTI 3. Within 72hours wound infection 8. Wound complications Kinds: 1. Hemorrhage / Hematoma 2. Wound Dehiscence disruption in the coaptation of wound edges (wound breakdown) 3. Wound Dehiscence dehiscence + outpouching of abdominal organs 9. Delirium (Mental Aberration)

Prepared by: JOHN PAUL E. MENDOZA R.N. Clinical Instructor