What is surgery?
The art and science of treating diseases, injuries, and deformities by operation and instrumentation.
Define the suffix -ectomy.
incision or removal of
Define the suffix -lysis.
Define the suffix -orrhaphy.
repair or suture of
Define the suffix -oscopy.
Define the suffix -ostomy.
creation of opening into
Define the suffix -otomy.
cutting into or incision of
Define the suffix -plasty.
repair or reconstruction of
What are some (6) purposes of surgery?
- Cosmetic Improvement
Relieving the symptoms of disease.
What are the (5) categories of surgical urgency?
What is emergent surgery?
- Surgery that must be performed without delay.
- Examples: severe bleeding, extensive burns, gunshot/stab wounds, fractured skull, bladder/intestinal obstruction
What is urgent surgery?
- Surgery that must be don within 24-30 hours
- Examples: acute gall bladder infections, kidney or ureteral stones
What is required surgery?
- Surgery that should be planned within the next few weeks or months.
- Examples: prostatic hyperplasia,thyroid disorders, cataracts
What is elective surgery?
- Surgery that if left undone will not be catastrophic.
- Examples: simple hernia, repair of scars
What is optional surgery?
- Surgery that is a personal preference.
- Example: cosmetic surgery
What are the stages of surgery?
List (7) tasks that are a part of preadmission testing.
- Initiates initial preoperative assessment
- Initiates teaching appropriate to patient’s needs
- Involves family in interview
- Verifies completion of preoperative diagnostic testing
- Verifies understanding of surgeon-specific preoperative orders
- Discusses, reviews advanced-directive document
- Begins discharge planning by assessing patient’s need for postoperative transportation, care
List (5) things that put a patient at risk during surgery.
- Greater than 65 years old
- Medical History
- Prior surgical experience
- Family history
- Type of Procedure
List (11) items that are included in the preoperative assessment.
- Informed Consent
- Drug/Alcohol Use
- Respiratory Status
- Cardiovascular Status
- Hepatic/Renal Function
- Immune Function
- Psychosocial Factors
- Spiritual and Cultural Beliefs
List (11) drugs that may affect the surgical experience.
- Antiseizure Medications
- Thyroid Hormone
What are some special considerations of gerontologic patients?
- Have less physiologic reserve
- Decrease ability to perspire
- Sensory limitations – increased risk for falls
What are some special considerations of obese patients?
- Dehiscence and wound infection more common
- Shallow respirations – postop pulmonary complications
- Difficult intubations
- Sleep apnea
What are some special considerations of patients with disabilities?
List (9) items included in preoperative teaching.
- Situational and Procedural Information
- .... General Information
- .... About Surgery
- Sensation and Discomfort information
- Patient’s role
- Skills Training Information
- .... Breathing Exercises
- .... Mobility and ambulation
- Psychosocial Support
What are some nursing interventions in holding area? (8)
- Preop checklist
- Verifies surgical site and marks site
- Establishes intravenous line
- Ensures patient comfort
- Provides psychological support
- Administers medications if ordered
- Communicates patient status to other members of the healthcare team
What is included in the preop checklist?
slide 14 (look in book)
What are the (8) types of medications used preoperatively?
- Anticoagulants, low-dose
- Beta-adrenergic blockers
- Gastric acid blockers
Who are the (6) members of the surgical team?
- Circulating Nurse
- Scrub Nurse
- Registered Nurse First Assistant
- Anesthesiologist and Anesthetist
What are the duties of the Circulating Nurse?
What are the duties of the Scrub Nurse
- What are the duties of the Surgeon
- What are the duties of the Registered Nurse First Assistant
- What are the duties of the Nurse Anesthetist
What are the types of anesthesia?
- General anesthesia
- Regional block
- Peripheral nerve block
Tell me (5) things about local anesthesia?
- Cause loss of sensation in limited areas of the body
- Systemic absorption could cause toxic effects on the nervous system and the heart
- Esters broken down immediately in plasma by enzymes
- Amides metabolized more slowly in liver; serum levels of these drugs can lead to toxicity
- Agent of choice depends on mode of administration, length of time for area to be anesthetized, and potential adverse effects
What are three types of general anesthesia?
What some advantages of inhalation anesthesia?
- Most controllable
- Induction and reversed via pulmonary ventalation
- Few side efffects
What some advantages of IV anesthesia?
- Rapid and pleasant induction
- Low postop N/V
- Little equipment
What some advantages of balanced anesthesia?
- Minimal disturbance to physiological function
- Minimal side-effects
- Can be used with older and high risk patients
What some advantages of regional or local anesthesia?
- Gag and couch reflex is left intact
- Participation and cooperation by patient
- Decreased disruption of physiological and emotional effects
- Decreased sensitivity to agent
- Decreased itraop stress.
What some disadvantages of inhalation anesthesia?
- Need combination agents
- Limited muscle relaxant
- Postop nausea & shivering common
What some disadvantages of IV anesthesia?
- Must be metabolized and excreted tor reverse effects
- Contraindicated in renal and hepatic patients
- Increased cardiac and resp, depression
- Retained by fat cells
What some disadvantages of balanced anesthesia?
- Drug interactions
- Pharmacological effects my be unpredictable
What some disadvantages of regional or local anesthesia?
- Difficult to administer to upset or uncooperative patients
- No way to control agent after administration
- absorbs rapidly in blood - cardiac depression/overdose
- Increased nervous system stimulation
- Nit practical for extensive procedures
List (4) modes of administering local anesthesia.
- Infiltration – injecting anesthetic directly into tissues
- Prevents nerve endings form transmitting impulses to the brain
- Nerve Block – inject along the nerve or nerves that run to and from the region in which loss of pain or muscle paralysis is desired
- Regional Anesthetic
- .... spinal
- .... epidural
What is the therapeutic action of local anesthesia?
- Affect permeability of nerve membranes to sodium ions
- Stops nerve from depolarizing
- Particular section of nerve cannot be stimulated and nerve impulses directed toward that section are lost when they reach that area
What are contraindications of local anesthesias?
- Allergy to any one of these agents or parabens
- Heart Block
- Shock – could alter local delivery and absorption
- Decreased plasma esterases – could result in toxic levels of ester-type
What are adverse and interactions of local anesthesias?
- CNS: H/A, restlessness, anxiety, dizziness, tremors, blurred vision, & backache
- GI – N/V
- Cardiovascular – peripheral vasodilation, myocardial depression, arrhythmias, & BP changes, cardiac and respiratory arrest
- Succinylcholine: increased and prolonged neuromuscular blockade
- Epinephrine: less risk of systemic absorption & increased local effects
Nursing? slide 36
- .... VS
- .... localized blanching
- .... LOC
- .... therapeutic effects
- .... Promptly report adverse effects
- .... Monitor continued effects
- .... Patient education
- .... Ensure patient safety
What is conscious sedation?
- IV sedative/hypnotic/opiod meds used to decrease LOC but allow client to maintain patent airway and follow commands
- Short acting/ rapid recovery
- Nurses administer with special training
Tell me about conscious sedation.
- No oral intake x 30 min
- Can’t drive post op
- IV Administration
- .... Useful for short procedures
- .... Easy to administer
What are some medications used for conscious sedation?
- diazepam (Valium)
- midazolam (Versed)
- meperidine (Demerol)
- fentanyl (Sublimaze)
What are some uses of conscious sedation?
- cardiac catheterization
What must be monitored during conscious sedation?
- O2 sat
- VS q15-30 min
What are the (4) Stages of Anesthesia
- Stage 1: Beginning Stage
- Stage 2: Excitement
- .... most dangerous and distressing
- Stage 3: Surgical anesthesia
- Stage 4: Medullary depression
- .... too much anesthesia
Tell me about general anesthesia.
- Lipid soluble --> distributed widely throughout body
- Cross placenta
- Wait 4-6 hrs after recovery before nursing baby
What are some contraindications and cautions of general anesthesia?
- Status asthmaticus
- No IV access
What are some cautions of general anesthesia?
- Severe cardiovascular disease
- Conditions where hypnotic effects may be prolonged or potentiated (IICP, myasthenia gravis)
What are some adverse effects & interactions of general anesthesia.
- Circulatory depression, hypotension, shock, decreased CO, arrhythmias
- respiratory depression (apnea, laryngospasm, bronchospasm, hiccups, coughing), H/A, N/V, prolonged somnolence, delirium, malignant hyperthermia
- skin breakdown r/t immobility
- Ketamine & Halothane --> severe cardiac depression
- Ketamine may potentiate muscular blocking of NMJ blockers requiring prolonged period of respiratory support
What are some general properties of gases for general anesthesia?
- Enter bronchi and alveoli, rapidly pass into capillary system, and are transported to heart to be pumped through body
- High affinity for fatty tissue
- Pass quickly into brain and cause severe CNS depression
What are some general properties of nitrous oxide?
- Weakest and least toxic of gas anesthetics
- Rapid onset (1-2 min) and recovery
- Does not produce complete LOC or relaxation of skeletal muscle
- Usually combined with other agents
- Can block reuptake of oxygen after surgery, causing hypoxia
- Always given in combination with oxygen
- Nausea/vomiting common
What are some general properties of the volatile liquid, halothane (Fluothane)?
- Unstable at room temp. and release gases
- Primarily used with other anesthetic agents
- Associated with vomiting, bradycardia, hypotension, and hepatic toxicity
- Recovery syndrome (rare) – fever, anorexia, nausea, vomiting, and eventual hepatitis and hepatic necrosis
- Not used more frequently than every 3 weeks to reduce risk
What are adverse effects of halothane (Fluothane)?
- Dysrhythmias are a concern
- Lowers blood pressure and respiratory rate
- Overcomes reflex mechanisms that normally keep contents of stomach from entering lungs
- Malignant hyperthermia
- Increased intracranial pressure
What are some interactions of halothane (Fluothane)?
- Excessive hypotension with antihypertensive drugs
- Potentiates action of nondepolarizing neuromuscular blocking agents
- Aminoglycosides – skeletal muscle weakness, resp. depression, or apnea
- Levadopa – increases level of dopamine in CNS
- Discontinue 6-8 hours prior to surgery
What are some general properties of succinylcholine?
- Depolarizing NMJ blocker
- Attaches to Ach receptor site on muscle cell, depolarizing the muscle
- Inhibits neuromuscular transmission, causing flaccid paralysis
- Indications – adjunct to general anesthesia, facilitate endotracheal intubation, induce skeletal muscle relaxation during surgery or mechanical ventilations
What are the pharmocokinetics of succinylcholine?
- onset 30-60 secs
- duration 4-6 min
- Half life- 2-3 min
- metabolized in tissues
- excreted unchanged in urine
What are the contraindications & cautions of succinylcholine?
- Crosses placenta, but accurate timing prevents serious effects on fetus
- Effects during lactation not known
- Allergy, myasthenia gravis, renal or hepatic disease
- Family or personal history of malignant hyperthermia
- Pulmonary or cardiovascular dysfunction, altered fluid and electrolyte, patients with fractures, narrow angle glaucoma, penetrating eye injuries, paraplegia or spinal cord injuries, conditions causing low plasma cholinesterase levels
What are the adverse effects of succinylcholine?
- Profound and prolonged muscle paralysis
- Never use without anesthesiologist or nurse anesthetist
- Histamine release can cause respiratory obstruction with wheezing and bronchospasm
- Hypotension and cardiac arrhythmias
- GI – constipation, vomiting, regurgitation, and aspiration
- Decubitus ulcers
- Malignant hyperthermia
What are the interactions of succinylcholine?
- NMJ blockers & aminoglycoside antibiotics – increased neuromuscular blockage, increased risk of dysrhythmias
- Lower dose of NMJ blocker and prolonged support and monitoring
- Calcium channel blockers increase paralysis r/t effect on calcium channels in muscle
- Decrease NMJ blocker dose and close monitoring
- Cholinesterase inhibitors- effectiveness of NMJ blocker decreased r/t buildup of Ach in synaptic cleft
- Xanthines (theophylline) – could result in reversal of neuromuscular blockage
What are some Intraoperative Complications
- Nausea, vomiting
- Hypoxia, respiratory complications
- Malignant hyperthermia
- Disseminated intravascular coagulation (DIC)
What is Malignant Hyperthermia?
- Rare & inherited muscle disorder
- Susceptible people
- R/T hypermetabolic condition involving altered mechanisms of calcium function in skeletal muscle cells
- Clinical Manifestations
How is Malignant Hyperthermia Managed?
- D/C anesthesia, dantrolene sodium
- .... decrease metabolism
- .... reverse acidosis
- .... correct dysrrhythmias
- .... decrease temp
- .... correct electrolyte imbalance
Potential Adverse Effects
- Allergic reactions, drug toxicity or reactions
- Cardiac dysrhythmias
- CNS changes, oversedation, undersedation
- Trauma: laryngeal, oral, nerve, skin, including burns
- Refer to Chart 19-1
What are some intraoperative nursing interventions
- Reducing anxiety
- Reducing latex exposure
- Preventing intraoperative positioning injuries
- Protecting patient from injury
- Serving as patient advocate
- Monitoring, managing potential complications
What tasks are part of PACU Management?
- Assessment – airway, respiratory & cardiovascular function, skin color, LOC, and ability to respond to commands, surgical site, VS, postop analgesia
- Maintain patent airway
- Maintain cardiovascular stability
- Hypotension and shock
- HTN & dysrhythmias
- Relieve pain and anxiety
- Gerontologic – change position frequently
Classification of Hemorrhage
- Secondary or delayed
- (slide 59)
What is primary hemorrhaging?
Hemorrhaging that occurs at the time of surgery
What is intermediary hemorrhaging?
Hemorrhaging that occurs a few hours after surgery when the BP rises to its normal level.
What is secondary or delayed hemorrhaging?
- Hemorrhaging that occurs some time after surgery
- Delayed occurs 7-10 days after surgery
What is capillary hemorrhaging?
Slow general ooze
What is venous hemorrhaging?
Dark colored bubbles out quickly.
What is arterial hemorrhaging?
- Bright red
- appears in spurts with each heart beat
What is evident hemorrhaging?
What is concealed hemorrhaging?
- In a body cavity
- Cannot be seen
Inpatient Nsg Management Postop
- Initial primary concerns – adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, N/V, neuro status, & spontaneous voiding
- Then regaining independence
- Surgical drains
- Managing potential complications
- .... DVT
- .... Infection
- .... Wound dehiscence
Outpatient Surgery/Direct Discharge
- Discharge planning, discharge assessment
- Provide written, verbal instructions regarding:
- .... follow-up care
- .... complications
- .... wound care
- .... activity
- .... medications
- .... diet
- Give prescriptions, phone numbers
- Discuss actions to take if complications occur
- Give instructions to patient, responsible adult who will accompany patient
- Patients are not to drive home or be discharge to home alone
- Sedation, anesthesia may cloud memory, judgment, effect ability
List common postop complications.
- Fluid Retention
- Fluid deficit
- Abdominal Distention
- Orthostatic hypotension
- Urinary Retention
- Deep Vein Thrombosis
When is atelectasis likely to occur (postop)?
When is a postop fever likely to occur?
What is wound dehiscence?
A closed wound that has reopened
What is wound evisceration?
a protrusion of wound contents
List postop teaching topics.
- Incision and Drain care
- .... Inspect daily
- .... Site care
- .... Sutures and Steristrips
- .... Note color of drainage from drains. Empty as needed.
- .... Assess needs, follow-up appts, and wound checks
- Pain Control
- .... Assess environment for safety
- .... Medication education
- .... Fatigue may last several weeks.
- .... Avoid strenuous exercise
- .... Assess support systems and need for home care
When to Call Physician?
- Fever with chills
- Increased pain or pain not adequately controlled by medications
- Incision is re, painful, or has drainage
- Difficulty voiding or unable to void
- Painful urinations