perioperative nursing - original

PERI OPERATIVE PERI OPERATIVE NURSINGNURSING

Presented by:Presented by:Ms. Monica L. Añonuevo, RN, MANMs. Monica L. Añonuevo, RN, MAN

Course ObjectivesCourse Objectives

To develop an understanding of the To develop an understanding of the principles of sterile and aseptic technique principles of sterile and aseptic technique and the necessity of their application in all and the necessity of their application in all operative procedures or phases.operative procedures or phases.

To acquire basic knowledge and skills To acquire basic knowledge and skills about OR nursing in order to provide about OR nursing in order to provide better and efficient care to surgical pts.better and efficient care to surgical pts.

To develop confidence, alertness and To develop confidence, alertness and competence among students in meeting competence among students in meeting the patient’s needs – physical or the patient’s needs – physical or psychological.psychological.

Introduction

Definition of Terms

Operating room / Operating theatre - room in a health care facility in which patients are

prepared for surgery, undergo surgical procedures, and recover from the anesthetic procedures required for surgery

Surgery- branch of medicine concerned with disease or conditions requiring or amenable to operative or manual procedures

Peri-operative nursing- total surgical experience that encompasses pre-operative, intra-operative, and post-operative phases of patient care

OR nurse - duly licensed registered nurse legally responsible for the nature and quality of the nursing care patients

Surgical conscience- awareness which develops from a knowledge base of the importance of strict adherence to principles of aseptic and sterile techniques

Asepsis- freedom from infection or absence of microorganism

Sepsis- general reaction from the action of bacteria or their products

Disinfection- process of destroying all pathogenic microorganisms except spore bearing ones

Aseptic technique- methods by which contamination of microorganism is prevented

Antiseptic- substance which combat sepsis and cause bacteriostasis

Anesthesia- insensibility to pain and trauma with or without loss of consciousness

Terminologies

SUFFIX MEANINGCele - tumor, herniaCenthesis - punctureEctomy - surgical excision Itis - inflammationLitho - stone / calculusOstomy - creation of a new openingRhapy - repairOscopy - examination w/ a lighted instrumentPlasty - plastic repairPexy - to fix or suture in place

FOUR MAJOR TYPES OF PATHOLOGIC PROCESSES REQUIRING SURGICAL

INTERVENTION.

O – BSTRUCTION. Impairment to the flow of vital fluids. E.g. blood, urine, CSF, bile.

P – ERFORATION. Rupture of an organ

E – ROSION. Wearing off of a surface or membrane.

T – UMOR. Abnormal new growth

Objectives of SurgeryObjectives of Surgery

a.a. Correction of deformities and defects;Correction of deformities and defects;

b.b. Repair of injuries;Repair of injuries;

c.c. Diagnosis and cure of disease Diagnosis and cure of disease process;process;

d.d. Relief of suffering;Relief of suffering;

e.e. Prolongation of lifeProlongation of life

Reasons why Patients Reasons why Patients submit to Surgical submit to Surgical

InterventionIntervention To preserve lifeTo preserve life To maintain dynamic body To maintain dynamic body

equilibriumequilibrium To undergo diagnostic proceduresTo undergo diagnostic procedures To prevent infection and to To prevent infection and to

promote healingpromote healing To obtain comfort and to ensure To obtain comfort and to ensure

the ability to earn a livingthe ability to earn a living

Conditions treated by Conditions treated by SurgerySurgery

CONGENITALCONGENITAL – inborn deformity – inborn deformity

ACQUIREDACQUIRED – conditions resulting – conditions resulting from trauma or injuryfrom trauma or injury

Peri operative Care Peri operative Care (SURGERY)(SURGERY)

PERIOPERATIVE PERIOPERATIVE – is a term used to – is a term used to describe the entire span of surgery, describe the entire span of surgery, including before and after the actual including before and after the actual operation.operation.

SURGERYSURGERY – a branch of medicine that – a branch of medicine that encompasses pre-operative care, intra encompasses pre-operative care, intra operative judgment and management and operative judgment and management and post operative care of patients.post operative care of patients.

Perioperative Nursing or Perioperative Nursing or Operating Room NursingOperating Room Nursing

Perioperative nursing includes those Perioperative nursing includes those activities performed by the activities performed by the professional registered nurse in the professional registered nurse in the preoperative (preoperative (beforebefore) , intraoperative ) , intraoperative ((duringduring) and postoperative () and postoperative (afterafter) ) phases of surgery. phases of surgery.

What is a PERIOPERATIVE What is a PERIOPERATIVE NURSE?NURSE?

A perioperative nurse is a nurse who A perioperative nurse is a nurse who provides patient care, manages, provides patient care, manages, teaches and studies the care of teaches and studies the care of patients undergoing operative or patients undergoing operative or other invasive proceduresother invasive procedures

Provides specialized nsg. Care to patients before, during and after their surgical & invasive procedure

Helps plan, implement and evaluate treatment of the patient

Acts as a patient advocate for patients undergoing surgical & invasive procedures

Works closely w/ all members of the surgical team

What is does a PERIOPERATIVE What is does a PERIOPERATIVE NURSE do?NURSE do?

Expected Behavior of an OR Expected Behavior of an OR PersonnelPersonnel

EmphaticEmphatic ConscientiousConscientious Efficient and well organizedEfficient and well organized Flexible and adaptableFlexible and adaptable Sensitive and perceptiveSensitive and perceptive Understanding, supportiveUnderstanding, supportive Skilled listener, keen observer and Skilled listener, keen observer and

able communicatorable communicator ConsiderateConsiderate Informative and sincereInformative and sincere

Expected Behavior of an OR Expected Behavior of an OR PersonnelPersonnel

VersatileVersatile Analytical – knows the how and the Analytical – knows the how and the

why of surgical procedures.why of surgical procedures. Creative / resourcefulCreative / resourceful HumanisticHumanistic With sense of humorWith sense of humor EnduringEnduring Intellectually eager and curiousIntellectually eager and curious Ethical – knows the ethical principles, Ethical – knows the ethical principles,

moral values and professional moral values and professional conductsconducts

Three Phases of Three Phases of Perioperative CarePerioperative Care

Preoperative phasePreoperative phase – begins with the – begins with the decision to perform surgery and continues decision to perform surgery and continues until the client reaches the operating area.until the client reaches the operating area.

Intraoperative phaseIntraoperative phase – includes the entire – includes the entire surgical procedure until transfer of the client surgical procedure until transfer of the client to the recovery roomto the recovery room

Postoperative phasePostoperative phase – begins with – begins with admission to the recovery area and continues admission to the recovery area and continues until the client receives a follow – up until the client receives a follow – up evaluation at home or is discharged to a evaluation at home or is discharged to a rehabilitation unit. rehabilitation unit.

Abdominal Incisions

Incision Site Types of Surgery

Subcostal Gallbladder and billiary tract surgery.

Paramedian Right side – billiary tract, gallbladder

Left side – splenectomy, gastrectomy, hiatal hernia repair

Transverse gastrectomy

Rectus Right side – AP, small bowel resection

Left side – sigmoid colon resection

Mc Burney AP

Midline Lower Female reproductive tract

Pfannensteil Gynecologic surgery

CLASSIFICATION of CLASSIFICATION of SurgicalSurgical ProceduresProcedures

I.I. According to PurposeAccording to Purpose

Type of Type of surgerysurgery

PurposePurpose ExampleExample

Diagnostic Diagnostic To establish the presence To establish the presence of a disease conditionof a disease condition

a. Breast biopsya. Breast biopsy

b. Biopsy of skin lesion b. Biopsy of skin lesion

Exploratory Exploratory To determine the extent of To determine the extent of the disease condition the disease condition

a. Exploration of abdomen for unexplained painb. Exploratory laparoscopy

CurativeCurative a. Ablativea. Ablative – involves – involves removal of an organ removal of an organ (suffix used is (suffix used is ‘’ectomy”)‘’ectomy”)

b. b. ConstructiveConstructive – involves – involves repair of congenitally repair of congenitally defective organ defective organ (suffixes use are (suffixes use are orrohaphy’’, pexy)orrohaphy’’, pexy)

c. c. ReconstructiveReconstructive – – involves repair of involves repair of damaged organdamaged organ

Cholecystectomy/Appendectomy

Total Hip Replacement, orchipexy

Plastic surgery after burns

Type of Type of surgerysurgery

PurposePurpose ExampleExample

PalliativePalliative Diagnostic Diagnostic

To relieve distressing To relieve distressing signs and symptoms, not signs and symptoms, not necessarily to cure the necessarily to cure the diseasedisease

Resection of a tumor Resection of a tumor to relieve pressure to relieve pressure and pain and pain

CosmeticCosmetic Correction of defects, Correction of defects, improvement of improvement of appearance or change to appearance or change to a physical featurea physical feature

a. Rhinoplastyb. Cleft lip repair

c. Mammoplasty

II. According to URGENCYII. According to URGENCY

Classification Classification Conditions Conditions ExampleExample

Emergency Emergency ImmediateImmediate: condition is : condition is life – threatening requiring life – threatening requiring surgery at once surgery at once

Gunshot woundGunshot wound

Severe bleedingSevere bleeding

Small bowel obstruction Small bowel obstruction

Urgent Urgent Within 24 to 30 hoursWithin 24 to 30 hours: : client requires prompt client requires prompt attention attention

Kidney stonesKidney stones

Acute gallbladder infectionAcute gallbladder infection

Fractured hip Fractured hip

RequiredRequired Planned for a few weeks Planned for a few weeks oror months after decisionmonths after decision: : client requires surgery at client requires surgery at some point. some point.

Benign Prostatic HypertrophyBenign Prostatic Hypertrophy

CataractsCataracts

Hernia w/o StrangulationHernia w/o Strangulation

ElectiveElective Client will not be harmed if Client will not be harmed if surgery is not performed surgery is not performed but will benefit if it if but will benefit if it if performed performed

Revision of scarsRevision of scars

Vaginal repairs Vaginal repairs

OptionalOptional Personal preference Personal preference Cosmetic surgery Cosmetic surgery

III. According to LOCATIONIII. According to LOCATION

INTERNALINTERNAL – inside the body – inside the body

ex. Hysterectomyex. Hysterectomy

EXTERNALEXTERNAL – outside the body – outside the body

ex. Skin Graftingex. Skin Grafting

IV. According to DEGREE OF RISK IV. According to DEGREE OF RISK TO THE PERSON / PHYSIOLOGIC TO THE PERSON / PHYSIOLOGIC

HAZARDHAZARD

MAJORMAJOR – life threatening – life threatening

- when major or vital - when major or vital organs are involved and those organs are involved and those surgeries that may involve surgeries that may involve serious bleeding.serious bleeding.

MINORMINOR – non life threatening, – non life threatening, less seriousless serious

ex. biopsyex. biopsy

Surgical RisksSurgical Risks

General Risks FactorsGeneral Risks Factors ObesityObesity Fluid, electrolyte and nutritional Fluid, electrolyte and nutritional

problemsproblems AgeAge Presence of diseasePresence of disease Concurrent or prior Concurrent or prior

pharmacotheraphy (patient taking up pharmacotheraphy (patient taking up medication for treatment, ex. Heparin, medication for treatment, ex. Heparin, coumadin, etc.)coumadin, etc.)

Other FactorsOther Factors Nature of conditionNature of condition Location of the conditionLocation of the condition Magnitude and urgency of the Magnitude and urgency of the

surgical proceduresurgical procedure Mental attitude of the person Mental attitude of the person

toward surgerytoward surgery Caliber of the professional staff and Caliber of the professional staff and

health care facilitieshealth care facilities

Effects of Surgery to the Effects of Surgery to the ClientClient

Stress response is elicitedStress response is elicited Defense against infection is Defense against infection is

loweredlowered Vascular system is disruptedVascular system is disrupted Organ functions are disturbedOrgan functions are disturbed Body image may be disturbedBody image may be disturbed Lifestyles may changeLifestyles may change

Preoperative Care

Psychological Care Preoperative Teaching Physical Care Nurses Responsibility

Psychological Preparation

Fears related to surgery General fear

- fear of the unknown- what to expect and what are the consequences of surgery- nursing action: allay anxieties by giving the patient opportunities to express his/her fears

Specific fears- fear of destruction of body image- threat to sexuality- fear of permanent disability- fear of pain- fear of dying

Preoperative Teaching

Post-op exercises Equipment used during post-op period

- oxygen, pulse oximeter, CVP- ventilator- NGT- IV medications- foley catheter

Provide client and family teaching, Provide client and family teaching, instruct the client in:instruct the client in:

deep breathing and coughing deep breathing and coughing exerciseexercise

relaxation techniquerelaxation technique Post op Exercises of Post op Exercises of

extremitiesextremities turning and moving techniquesturning and moving techniques pain – control techniquespain – control techniques INCENTIVE SPIROMETRY USEINCENTIVE SPIROMETRY USE

Pain medication and when to request it- Patient-Controlled Anesthesia (PCA)

NPO Ancillary tests

Physiologic Preparation

Factors that affect surgery Age Nutrition Presence of disease Prior drug therapy

Age

The very young- tolerates trauma of surgery well. - sensitive to temperature changes & rough handling.

The elderly- tolerates trauma of surgery poorly.

Nutrition

Dehydration and malnutrition cause potential complications post-operatively.

Obese people breathe poorly & are prone to pulmonary complications.

AssessmentAssess respiratory status, Assess respiratory status,

including history of including history of pulmonary problems to pulmonary problems to identify risk factors for identify risk factors for postoperative postoperative complications complications

Assess cardiovascular statusAssess cardiovascular status

Assess for and report evidence of F/E imbalance Assess for and report evidence of F/E imbalance

Assess emotional status of client.Assess emotional status of client.

Examine the client’s record for endocrine or Examine the client’s record for endocrine or metabolic problems that could affect his metabolic problems that could affect his response to surgery (DM).response to surgery (DM).

Assess immunologic and hematologic functionsAssess immunologic and hematologic functions history of allergieshistory of allergies previous reactions to blood transfusionsprevious reactions to blood transfusions history of substance abusehistory of substance abuse

Assess neurologic functionsAssess neurologic functions

Assess integumentary systemAssess integumentary system

Evaluate medication history for drugs that could Evaluate medication history for drugs that could increase operative risk for affecting coagulation increase operative risk for affecting coagulation time or interacting anestheticstime or interacting anesthetics

Assess the client for any type of prosthetic device Assess the client for any type of prosthetic device or metal implants.or metal implants.

Assess the client and his family’s knowledge base Assess the client and his family’s knowledge base to guide the preoperative teaching program.to guide the preoperative teaching program.

Assess the laboratory and diagnostic results of Assess the laboratory and diagnostic results of the patient (x-ray, cbc, wbc, etc.)the patient (x-ray, cbc, wbc, etc.)

B. NURSING DIAGNOSISB. NURSING DIAGNOSIS

AnxietyAnxiety

Deficient knowledgeDeficient knowledge

C. PLANNING AND OUTCOME C. PLANNING AND OUTCOME IDENTIFICATIONIDENTIFICATION

Major goals:Major goals:1.1. Decreased anxiety and increased Decreased anxiety and increased

knowledge of the surgical experience.knowledge of the surgical experience.

2. Promote measures that help decrease 2. Promote measures that help decrease anxiety for the client and his family.anxiety for the client and his family.

Discuss the surgical experience Discuss the surgical experience with the client and his family to minimize with the client and his family to minimize anxiety and increase knowledge.anxiety and increase knowledge.

Provide GI preparation as prescribed, w/c Provide GI preparation as prescribed, w/c may include:may include:

restricting solid food and fluid for restricting solid food and fluid for 8 to 10 hours before surgery 8 to 10 hours before surgery

posting NPO sign posting NPO sign administering an enema and inserting administering an enema and inserting

a NGT as prescribeda NGT as prescribed

Informed Consent (Operative Informed Consent (Operative Permit/Surgical Consent)Permit/Surgical Consent)

Purposes:Purposes: to ensure that the client understands the to ensure that the client understands the

nature of the treatment including the potential nature of the treatment including the potential complications and disfigurement (explained by complications and disfigurement (explained by AMD)AMD)

to indicate that the client’s decision was made to indicate that the client’s decision was made without pressurewithout pressure

to protect the client against unauthorized to protect the client against unauthorized procedureprocedure

to protect the surgeon and hospital against to protect the surgeon and hospital against legal action by a client who claims that an legal action by a client who claims that an authorized procedure was performedauthorized procedure was performed

Circumstances Requiring a Circumstances Requiring a Permit:Permit:

Any surgical procedure where scalpel, Any surgical procedure where scalpel, scissors, suture, hemostats of scissors, suture, hemostats of electrocoagulation may be used.electrocoagulation may be used.

Entrance into a body cavity – e.g. Entrance into a body cavity – e.g. paracentesis, bronchoscopy, paracentesis, bronchoscopy, cystoscopy, colonoscopy, cystoscopy, colonoscopy, proctosigmoidoscopyproctosigmoidoscopy

Preparing the person the evening Preparing the person the evening before surgerybefore surgery

PREPARING THE SKINPREPARING THE SKIN shaving the skin in and around the surgical area shaving the skin in and around the surgical area

(most often it is done in the operating room)(most often it is done in the operating room) using an electric razorusing an electric razor applying scrub to the surgical areaapplying scrub to the surgical area

PREPARING THE G.I. TRACTPREPARING THE G.I. TRACT PREPARING FOR ANESTHESIAPREPARING FOR ANESTHESIA

Avoid alcohol and cigarette smoking for at least 24 Avoid alcohol and cigarette smoking for at least 24 hours before surgeryhours before surgery

PROMOTING REST AND SLEEPPROMOTING REST AND SLEEP

PREPARING THE PERSON ON PREPARING THE PERSON ON THE DAY OF SURGERYTHE DAY OF SURGERY

Early A.M. careEarly A.M. care Awaken one hour before preop medicationsAwaken one hour before preop medications Morning bath, mouth washMorning bath, mouth wash Provide clean gownProvide clean gown Remove hairpins, braid long hairs, cover hair Remove hairpins, braid long hairs, cover hair

with capwith cap Remove dentures, foreign materials (chewing Remove dentures, foreign materials (chewing

gum), colored nail polish, hearing aid, contact gum), colored nail polish, hearing aid, contact lens (wedding ring – tie with gauze and fasten lens (wedding ring – tie with gauze and fasten around the wrist)around the wrist)

Take baseline VS before preop medicationTake baseline VS before preop medication Check ID band, skin prepCheck ID band, skin prep Check for special orders – enema, GI tube Check for special orders – enema, GI tube

insertion, IV lineinsertion, IV line Check NPOCheck NPO Have client void before preop medicationHave client void before preop medication Continue to support emotionallyContinue to support emotionally

Accomplish: Accomplish: ’’PREOP CARE CHECKLIST’’ (includes:)PREOP CARE CHECKLIST’’ (includes:)

AssessmentAssessment Preoperative MedicationsPreoperative Medications IVIV Preoperative PreparationsPreoperative Preparations ChartChart OTHER Information – as required by agency OTHER Information – as required by agency

policypolicy SignatureSignature

PRE - OPERATIVE PRE - OPERATIVE MEDICATIONSMEDICATIONS

A single drug or a combination of A single drug or a combination of various drug usually given IM, 30 various drug usually given IM, 30 – 60 mins. Before surgery– 60 mins. Before surgery

purpose:purpose: to allay anxietyto allay anxiety Help the patient to relaxHelp the patient to relax to minimize respiratory tract secretions to minimize respiratory tract secretions

and changes in HR (heart rate)and changes in HR (heart rate)

Commonly used Commonly used Preoperative MedicationsPreoperative Medications

I. ANTICHOLIGERNICS I. ANTICHOLIGERNICS Action: Action: SIDE EFFECTSSIDE EFFECTS:: EXAMPLES:EXAMPLES:

ATROPINE SULFATEATROPINE SULFATE SCOPOLAMINESCOPOLAMINE GLYCOPYRROLATE GLYCOPYRROLATE

II. ANTIEMETICSII. ANTIEMETICS ActionAction Side EffectsSide Effects EXAMPLE:EXAMPLE:

DroperidolDroperidolPromethazine (phenerganPromethazine (phenergan) )

III. TRANQUILIZERSIII. TRANQUILIZERS Action Action S/E S/E EXAMPLEEXAMPLE

- - Hypnotics (diazepam)Hypnotics (diazepam)

- - Valium (flurazepam)Valium (flurazepam)

- Dalmane torazepam,- Dalmane torazepam,

(ativan(ativan) )

IV. SEDATIVESIV. SEDATIVES Action Action S/E: S/E: EXAMPLE:EXAMPLE:

MidazolamMidazolamBarbituratesBarbituratesPhenobarbital (Nembutal)Phenobarbital (Nembutal)secobarbital (seconalsecobarbital (seconal) )

V. OPIODS (NARCOTICS)V. OPIODS (NARCOTICS) ACTION ACTION S/E: S/E: EXAMPLE:EXAMPLE:

Morphine,Morphine,

Meperidine (Demerol)Meperidine (Demerol)

THE OPERATING ROOMTHE OPERATING ROOM

OR Furniture & Other OR Furniture & Other EquipmentsEquipments

OR TableOR Table Instrument table or Back tableInstrument table or Back table Mayo tableMayo table Small tableSmall table Anesthesia tableAnesthesia table Anesthesia machineAnesthesia machine Sitting stools and foot stoolSitting stools and foot stool IV standsIV stands

OR Furniture & Other OR Furniture & Other Equipments ( cont…)Equipments ( cont…)

Suction machine, bottles and tubingsSuction machine, bottles and tubings Cautery machineCautery machine Kick buckets in wheeled basesKick buckets in wheeled bases Basin in wheeled bases for soiled Basin in wheeled bases for soiled

sponges and glovessponges and gloves Communication system / IntercomCommunication system / Intercom

OR Furniture & Other OR Furniture & Other Equipments (cont.)Equipments (cont.)

Board for recording of sponge, Board for recording of sponge, instrument and sharps countinginstrument and sharps counting

DefibrillatorDefibrillator Blood warmer machine attached to IV Blood warmer machine attached to IV

polepole Other monitoring machinesOther monitoring machines Cabinets / carts Cabinets / carts

Transition ZoneTransition Zone

Operating Room UnitOperating Room Unit

1.1. Semi restricted / Semi restricted / semi sterile areasemi sterile area

Operating Room UnitOperating Room Unit

Semirestricted AreaSemirestricted Area

OR SuiteOR Suite

33. Restricted / sterile area. Restricted / sterile area

The Surgical TeamThe Surgical Team

SurgeonSurgeon First AssistantFirst Assistant Scrub nurseScrub nurse AnesthesiologistAnesthesiologist Circulating NurseCirculating Nurse

Sterile

Unsterile

The Surgeon The Surgeon

Surgeon Surgeon – heads the – heads the surgical team, he or surgical team, he or she is a physician she is a physician

AnesthesiologistAnesthesiologist

AnesthesiologisAnesthesiologist – t – makes a makes a preoperative preoperative assessment to plan the assessment to plan the type of anesthetic to be type of anesthetic to be administered and to administered and to evaluate the client’s evaluate the client’s physical status. physical status.

Circulating nurseCirculating nurse – managing – managing the overall nursing care in the the overall nursing care in the operating room and helping to operating room and helping to maintain a safe, comfortable maintain a safe, comfortable environment. environment.

Scrub NurseScrub Nurse

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

THE INTRAOPERATIVE THE INTRAOPERATIVE PERIODPERIOD

a. ASSESSMENTa. ASSESSMENT

1.1. classify the client’s physical status classify the client’s physical status for for

anesthesiaanesthesiaTotal or partial loss of sensation to

touch or pain, caused by nerve injury or diseased, or induced intentionally, especially by the administration of

anesthetic drugs, to provide medical treatment

GENERAL ANESTHESIAGENERAL ANESTHESIA – – ((inhaled or I.V.) refers to drug – induced depression of the inhaled or I.V.) refers to drug – induced depression of the

CNS that produces analgesia, amnesia and unconsciousness CNS that produces analgesia, amnesia and unconsciousness (affects whole body)(affects whole body)

Stages:Stages: stage I – BEGINNING stage I – BEGINNING from. from. Anesthetic administration to loss of consciousnessAnesthetic administration to loss of consciousness drowsy, dizzydrowsy, dizzy

stage II – EXCITEMENT stage II – EXCITEMENT from from Loss of consciousnessLoss of consciousness to to Loss of EYELID REFLEXLoss of EYELID REFLEX Increase in autonomic activity, irregular breathingIncrease in autonomic activity, irregular breathing

Types of AnesthesiaTypes of Anesthesia

Stage III – surgical anesthesiaStage III – surgical anesthesia From Loss of EYELID REFLEX to Loss of From Loss of EYELID REFLEX to Loss of

most reflexes, depression of vital most reflexes, depression of vital functionsfunctions

Stage IV – dangerStage IV – danger From Functions excessively depressed From Functions excessively depressed

to Respiratory and circulatory failure to Respiratory and circulatory failure

REGIONAL anesthesiaREGIONAL anesthesia

is a form of local anesthesia that suspends sensation and is a form of local anesthesia that suspends sensation and motion in a body region or part; the client remains motion in a body region or part; the client remains awake.awake.

Types:Types:a. a. Local anestheticLocal anesthetic – provides loss of sensation, used – provides loss of sensation, used

primarily for dental, eye and minor surgeriesprimarily for dental, eye and minor surgeries

b. b. Spinal anestheticSpinal anesthetic – local anesthetic injected into the – local anesthetic injected into the subaracnoid space of the lumbar area (usually L4 or L5), subaracnoid space of the lumbar area (usually L4 or L5), which contains cerebrospinal fluid) suspend sensation which contains cerebrospinal fluid) suspend sensation and motion in the lower extremities, perineum and lower and motion in the lower extremities, perineum and lower abdomenabdomen e.g. lidocaine, procainee.g. lidocaine, procaine

c. c. Epidural blockEpidural block – local anesthetic injected into – local anesthetic injected into the extradural space near the spinal cordthe extradural space near the spinal cord

d. d. Peripheral nerve blockPeripheral nerve block – injected in a – injected in a specific body region and directed at a specific body region and directed at a particular nerveparticular nervee.g. lidocaine e.g. lidocaine

Positions During Positions During SurgerySurgery

Nursing interventions:Nursing interventions: Explain purpose of positionExplain purpose of position Strap the person to prevent fallsStrap the person to prevent falls Maintain adequate respiratory and Maintain adequate respiratory and

circulatory functioncirculatory function Maintain good body alignmentMaintain good body alignment

FIVE TYPES OF SURGERY FIVE TYPES OF SURGERY POSITIONSPOSITIONS

Dorsal RecumbentDorsal Recumbent – hernia repair, – hernia repair, mastectomy, bowel resection, mastectomy, bowel resection, cholecystectomycholecystectomy

Trendelenburg Trendelenburg – lower abdomen, pelvic – lower abdomen, pelvic surgeriessurgeries

LithotomyLithotomy – vaginal repairs, D and C, – vaginal repairs, D and C, rectal surgery, APR – Abdomino – Perineal rectal surgery, APR – Abdomino – Perineal Resection)Resection)

ProneProne – spinal surgeries, laminectomy– spinal surgeries, laminectomy LateralLateral – kidney, chest, hip surgeries– kidney, chest, hip surgeries

NURSING PROCESS OVERVIEW FOR NURSING PROCESS OVERVIEW FOR THE INTRAOPERATIVE PERIODTHE INTRAOPERATIVE PERIOD

A.A. ASSESSMENTASSESSMENT Classify the client’s physical status for anesthesiaClassify the client’s physical status for anesthesia

Assess the client’s record for appropriate documentationAssess the client’s record for appropriate documentation

Verify client identification and that the correct surgery is Verify client identification and that the correct surgery is scheduledscheduled

Assess for surgical consideration and precautionsAssess for surgical consideration and precautions

Assess the client’s risk for accidentalAssess the client’s risk for accidental hypothermia or hypothermia or malignant hyperthermiamalignant hyperthermia

NURSING MANAGEMENT NURSING MANAGEMENT intra operative periodintra operative period

SURGICAL ASEPSISSURGICAL ASEPSIS

CLIENT’S FASETY AND PROTECTION FROM CLIENT’S FASETY AND PROTECTION FROM SURGERYSURGERY

POSSIBLE INTRAOPERATIVE POSSIBLE INTRAOPERATIVE COMPLICATIONSCOMPLICATIONS

InfectionInfection – strict aseptic – strict aseptic technique is absolutely technique is absolutely necessary before and during necessary before and during surgery.surgery.

Fluid volume excess or deficitFluid volume excess or deficit – proper recording and keeping a – proper recording and keeping a running total of IV fluids running total of IV fluids administered.administered.

Injury related to positioningInjury related to positioning

HypothermiaHypothermia – due to low temperature in the OR– due to low temperature in the OR Malignant hyperthemiaMalignant hyperthemia - - occurs when body temp. muscle, occurs when body temp. muscle,

metabolism and heat production increase rapidly and metabolism and heat production increase rapidly and uncontrollable response to stress and some anesthetic agents, with uncontrollable response to stress and some anesthetic agents, with the following s/sx:the following s/sx: TachycardiaTachycardia Tachypnea, cyanosis,Tachypnea, cyanosis, Fever, muscle rigidityFever, muscle rigidity Diaphoresis, mottled skin,Diaphoresis, mottled skin, Hypotension, irregular heart rateHypotension, irregular heart rate Decreased urine output and cardiac arrest).Decreased urine output and cardiac arrest).

NURSING DIAGNOSISNURSING DIAGNOSIS

RISK FOR FLUID VOLUME DEFICIT OR EXCESSRISK FOR FLUID VOLUME DEFICIT OR EXCESS

RISK FOR HYPOTHERMIA AND HYPERTHEMIARISK FOR HYPOTHERMIA AND HYPERTHEMIA

RISK FOR INFECTION AND INJURYRISK FOR INFECTION AND INJURY

PLANNINGPLANNING

Maintenance of fluid Maintenance of fluid balancebalance

Maintenance of Maintenance of normothermianormothermia

Prevention of infectionPrevention of infection Absence of injuryAbsence of injury

IMPLEMENTATIONIMPLEMENTATION

PROMOTE MEASURES THAT MAINATAIN PROMOTE MEASURES THAT MAINATAIN ADEQUATE FLUID AND ELECTROLYTE ADEQUATE FLUID AND ELECTROLYTE BALANCEBALANCE

Monitor I/O accuratelyMonitor I/O accurately Assess for dehydrationAssess for dehydration Assess for circulatory overload (assess Assess for circulatory overload (assess

breath sounds, peripheral edema and breath sounds, peripheral edema and jugular vein distention)jugular vein distention)

Monitor electrolyte valuesMonitor electrolyte values PROMOTE MEASURES THAT MAINTAIN A PROMOTE MEASURES THAT MAINTAIN A

CLIENT’S NORMAL TEMP.CLIENT’S NORMAL TEMP. (36.6 – 37.5)(36.6 – 37.5)

PROMOTE MEASURES THAT DECREASE PROMOTE MEASURES THAT DECREASE RISK OF INFECTIONRISK OF INFECTION

ENSURE THE CLEINT’S SAFETY IN THE ENSURE THE CLEINT’S SAFETY IN THE OROR

promote measures that ensure tissue promote measures that ensure tissue perfusion in the client during surgeryperfusion in the client during surgery

assess the client’s vital signsassess the client’s vital signs assess the client’s respiratory status and assess the client’s respiratory status and

assist with mechanical ventilationassist with mechanical ventilation assess the client’s peripheral vascular status assess the client’s peripheral vascular status

minimumminimum

Types of Surgical Incisions

ButterflyButterfly – for craniotomy – for craniotomy LimbalLimbal – for eye surgeries – for eye surgeries Halstead/ ellipticalHalstead/ elliptical – for breast – for breast

surgeriessurgeries AbdominalAbdominal – for abdominal surgeries – for abdominal surgeries Mc burneysMc burneys – for appendectomy – for appendectomy Lumbotomy/transverseLumbotomy/transverse – for kidney – for kidney

surgeriessurgeries

POST OPERATIVE CLIENT

PACU (POST ANESTHESIA CARE UNIT)

2 PHASES OF CARE:

I: IMMEDIATE RECOVERY - REQUIRES INTENSE NURSING

II: CLIENT PREPARED FOR DISCHARGE HOME OR TO OTHER CARE AREA

TRANSFER TO THE PACU

WHO’S RESPONSIBLE ??

ANESTHESIOLOGIST OR ANESTHETIST

REMAINS AT HEAD OF BED DURING TRANSFER….THINK AIRWAY !!!

THINGS TO CONSIDER ….

SURGICAL INCISION

POSITIONING (DRAINS & DRAINAGE TUBES MAY BE PRESENT)

WARM THE CLIENT

SIDE RAILS (ALWAYS THINK SAFETY !!!)

TRANSFER REPORT .. WHAT INFORMATION IS NEEDED ?

DIAGNOSIS & TYPE OF SURGERY

CLIENT’S GENERAL CONDITION

PROBLEMS / PATHOLOGY FLUIDS / PRESENCE OF DRAINS &

TUBES

ANY OTHER SPECIFIC INFORMATION

NURSING MANAGEMENT

CLIENT ASSESSMENT

VITAL SIGNS ARE VITAL !!!! SKIN COLOR LEVEL OF CONSCIOUSNESS INCISIONAL SITE AIRWAY PATENTCY CLIENT’S PREVIOUS HEALTH HISTORY

AIRWAY - AIRWAY - AIRWAY

MAINTAIN PULMNORAY VENTILATION

PREVENT HYPOXEMIA PREVENT HYPERCAPNIA ( EXCESS CO2)

ASSESS RESPIRATORY RATE - O2 ORDERS ASSESS DEPTH / EASE OF / O2 SATS / AND BREATH SOUNDS

PROLONGED ANESTHESIA

CLIENTS USUALLY UNCONSCIOUS ALL MUSCLES RELAXED TONGUE MAY OBSTRUCT AIR

PASSAGE

SIGNS: CHOKING / NOISY & IRREGULAR RESPIRATIONS / CYANOSIS

AIRWAY DEVICES PLASTIC - MAY LEAVE TIL GAG REFLEX

RETURNS

ENDOTRACHEAL TUBE - MECHANICAL VENTILATION ( MAY NEED ICU TRANSFER)

THINK SAFETY

CLIENT VOMITS ……

TURN CLIENT TO THE SIDE

MAY ELEVATE HEAD OF BED IF NOT CONTRAINDICATED

PHARYNGEAL SUCTIONING

ASSESS: MENTAL STATUS (THINK HYPOXIA) VITAL SIGNS CARDIAC RHYTHM SKIN PARAMETERS URINE OUTPUT AMOUNT OF BLOOD LOSS

HYPOTENSION

MAY RESULT FROM:

LOSS OF BLOOD (> 500ML = REPLACE) HYPOVENTILATION POSITION CHANGES SIDE EFFECTS OF MEDS

SHOCK

SERIOUS COMPLICATION CAN RESULT FROM HYPOVOLEMIA

INADEQUATE CELLULAR VENTILATION & INABILITY TO EXCRETE METABOLIC WASTE PRODUCTS

SHOCK - CLASSIC SIGNS

PALLOR COOL, MOIST SKIN RAPID BREATHING CYANOSIS (LIPS/ GUMS) WEAK & THREADY PULSE PULSE USUALLY B/P & CONCENTRATED URINE

TREATMENT

TREATMENTS: IV FLUIDS BLOOD MEDS ( B/P) MANAGE PAIN BODY TEMPERATURE

(NORMOTHERMIA)

VOLUME REPLACEMENT

PRIMARY INTERVENTION LACTATED RINGERS SOLUTION

OXYGEN

CONTINUOUS CLIENT ASSESSEMENT

HEMORRHAGE

CLIENT IS APPREHENSIVE & RESTLESS

PULSE RATE TEMPERATURE AIR HUNGER (RAPID & DEEP

RESPIRATIONS)

IF HEMORRHAGE CONTINUES….

CARDIAC OUTPUT

BLOOD PRESSURE & HEMOGLOBIN RAPIDLY

USE SHOCK POSITION - (FLAT ON BACK - KNEES STRAIGHT - LEGS )

ADMINISTER FLUIDS- BUT BE CAREFUL!

HYPERTENSION & DYSRHYTHMIAS

HYPERTENSION: THINK PAIN / HYPOXIA

DYSRHYTHMIAS: THINK ELECTROLYTE IMBALANCE / PAIN / HYPOTHERMIA / STRESS/

GASTROINTESTINAL FUNCTION

ASSESS GASTRIC ACTIVITY BOWEL SOUNDS NAUSEA PRESENCE OF NG TUBE

SKIN: DRESSINGS / DRAINS

GENITOURINARY: I&O / FOLEY/ AMOUNT& COLOR OF URINE / BLADDER FULLNESS & DISTENTION

POSITIONING (PREVENTING CIRCULATORY STASIS)

OLDER CLIENTS….

THINK SAFETY .. TRANSFER GENTLY.. CAN AFFECT B/P & VENTILATION

KEEP WARM CHANGE POSITION FREQUENTLY

POSTOPERATIVE CONFUSION SOMETIMES COMMON

MOVING OUT OF PACU ....WHEN TO TRANSFER

(PARAMETERS)

STABLE VITAL SIGNS ADEQUATE PULMONARY

FUNCTION…..HOW WILL YOU KNOW? NEUROLOGICALLY “ADEQUATE”…

HOW WILL YOU KNOW? ADEQUATE URINE OUTPUT NAUSEA/ VOMITING & PAIN

CONTROLLED

PULMONARY COMPLICATIONS

GOALS: PREVENT ATELECTASIS & PNEUMONIA

TEACH SPLINTING

ENCOURAGE D – B – C – T exercise

TEACH IMPORTANCE OF APPROPRIATE PAIN CONTROL

TEACH IMPORTANCE OF AMBULATION

INCENTIVE SPIROMETER?

THE SURGICAL SITE

MONITOR & OBSERVE FOR:

BLEEDINGTYPE & INTEGRITY OF DRESSING

PRESENCE OF DRAINS / TUBESLABEL MULTIPLE DRAINS

Nursing Interventions: Stay w/ patient and have some one notify

surgeon immediately If intestines are exposed, cover with STERILE

MOIST DRESSINGS Keep patient on absolute bedrest – low fowler’s Instruct patient to bend his knees – relieves

tension on abdomen Instruct not to cough, sneeze, eat, drink and

remain quiet Assure patient that wound will be properly taken

cared for Prepare for surgery and repair of wound

PAIN

PSYCHOLOGICAL FACTORS MAY INFLUENCE

PAIN STIMULATES STRESS RESPONSE … (VASOCONSTRICTION) CAN THUS CONTRIBUTE TO COMPLICATIONS

ASSESS ADEQUATELY

PAIN CONTROL MEASURES

OPIODS

PATEINT-CONTROLLED ANALGESIC

COMFORT MEASURES

URINARY ELIMINATION

URINARY RETENTION: ANESTHESIA/ OPIOIDS / ABDOMINAL, PELVIC, HIP SURGERY (PAIN)

VOID WITHIN 6-8 HOURS OF SURGERY (INCLUDE PACU TIME)

Nursing Interventions:a. assist patient to sit or

stand up (if permissible)b. provide privacyc. use psychological aid of

running tap water ( relaxes bladder sphincter spasm)

d. catheterize when all measures are unsuccessful

ACTIVITY

EARLY AMBULATION: REDUCES LIKELIHOOD OF: ATELECTASIS PNEUMONIA GI DISCOMFORT CIRCULATORY PROBLEMS SHORTER HOSPITAL STAYS

MONITOR FOR ORTHOSTATIC HYPOTENSION!

OTHER CONSIDERATIONS

MAINTAIN SAFE ENVIRONMENT

PROVIDE EMOTIONAL SUPPORT

CONTINUE TO MONITOR FOR COMPLICATIONS

RESPIRATORY: BREATH SOUNDS- CRACKLES - FEVER - TACHYCARDIA - COUGH

DEEP VEIN THROMBOSIS (DVT) positive HOMAN’S SIGN ( pain on

the calf or thigh upon dorsiflexion of the foot)

PULMONARY EMBOLISM DEHYDRATION / LOW CARDIAC

OUTPUT/ BLOOD POOLING IN EXTREMITIES /

BED REST

WOUND INFECTION

SURGICAL WOUNDS DISRTUPT SKIN INTEGRITY!

MONITOR LAB VALUES…WBC CLASSIFIED ACCORDING TO

DEGREE OF CONTAMINATION OTHER RISK FACTORS: AGE/

NUTRITIONAL STATUS / SMOKING/ OBESITY/ DIABETES

PROMOTING BOWEL FUNCTION(BM – 2nd – 3rd day post op.)

CONSTIPATION COMMON AFTER SURGERY

ASSESS BOWEL SOUNDS ADEQUATELY!!!

ASSESS FOR ABDOMINAL DISTENTION

PARALYTIC ILEUS & INTESTIONAL OBSTRUCTION CAN OCCUR

HICCUPS or SINGULTUS - spasmodic closure of the glottis following a sudden involuntary intake of breath causing an abrupt cough

Causes:a. irritation of phrenic nerve

* distended stomach, peritonitis, surgery performed near diaphragm

* indirect – toxemia, uremia* reflex – exposure to cold, drinking

very cold or very hot liquids, intestinal obstruction

Abdominal Distention or PARALYTIC ILEUS:

Causes:a. resection and handling of the bowel during

surgeryb. swallowing of air during recovery from

anesthesiac. passing gases from the blood stream to bowel

PHASES OF WOUND PHASES OF WOUND HEALINGHEALING

First Phase – ‘’INFLAMMATORY PHASE’’ First Phase – ‘’INFLAMMATORY PHASE’’ blood clot formation with swelling (lasts fr.1 – 4 days).blood clot formation with swelling (lasts fr.1 – 4 days).

Second phase – ‘’ PROLIFERATIVE’’Second phase – ‘’ PROLIFERATIVE’’ formation granulated tissue (occurs from 5 – 20days).formation granulated tissue (occurs from 5 – 20days).

third phase – ‘’MATURATION or REMODELING third phase – ‘’MATURATION or REMODELING PHASE’’PHASE’’

lasts up to 21 days to several months and even 1 to 2 yearslasts up to 21 days to several months and even 1 to 2 years (remodeling of new tissue)(remodeling of new tissue)

Three modes of wound Three modes of wound healinghealing

Primary intentionPrimary intention – heals in 8 – 10 – heals in 8 – 10 days, with minimal scarringdays, with minimal scarring

Secondary intentionSecondary intention – wound healing – wound healing is slowis slow

Tertiary intentionTertiary intention – the resulting scar – the resulting scar is wider than primary intentionis wider than primary intention

POSTOP PSYCHOLOGICAL POSTOP PSYCHOLOGICAL DISTURBANCES:DISTURBANCES:

DELIRIUM (MENTAL ABERRATION)/ ACS DELIRIUM (MENTAL ABERRATION)/ ACS (ACUTE CONFUSIONAL STATE)(ACUTE CONFUSIONAL STATE)

CAUSES:CAUSES: Dehydration, insufficient oxygenation, anemiaDehydration, insufficient oxygenation, anemia Hypotension, hormonal imbalances, infectionHypotension, hormonal imbalances, infection traumatrauma

manifestations:manifestations: poor memory ,restlessness, inattentivenesspoor memory ,restlessness, inattentiveness inappropriate behavior, wild excitement, hallucinations, inappropriate behavior, wild excitement, hallucinations,

delusions, depressiondelusions, depression disoriented, sleep disturbancesdisoriented, sleep disturbances

nursing interventions:nursing interventions: sedatives to keep client quiet and comfortablesedatives to keep client quiet and comfortable explain reasons for interventionsexplain reasons for interventions listen and talk to the client and significant otherslisten and talk to the client and significant others provide physical comfortprovide physical comfort treat the underlying causetreat the underlying cause

2 – 3 days after surgery (discharge 2 – 3 days after surgery (discharge planning/teaching)planning/teaching)

Self- care activitiesSelf- care activities

Activity limitationActivity limitation

Diet and medication at homeDiet and medication at home

Possible complicationsPossible complications

Referrals, follow – up check – upReferrals, follow – up check – up

AMBULATORY SURGERYAMBULATORY SURGERY(OUTPATIENT SURGERY)(OUTPATIENT SURGERY)

A surgery that requires fewer than 24 hours of A surgery that requires fewer than 24 hours of hospitalizationhospitalization

Criteria for ambulatory surgeryCriteria for ambulatory surgery

a. the client is not critically illa. the client is not critically ill surgical procedure is not extensive and does not surgical procedure is not extensive and does not

require many hours of general anesthesiarequire many hours of general anesthesia recovery is expected to be quickrecovery is expected to be quick the client or family can provide adequate the client or family can provide adequate

postoperative carepostoperative care

Surgical HandscrubSurgical Handscrub

2 types of scrubbing method2 types of scrubbing method

a.a. Time methodTime method

b.b. Scrub/brush stroke methodScrub/brush stroke method

15 Strokes 15 Strokes

• • 15 palmar15 palmar

• • 15 back of hand15 back of hand

• • 15 interdigital space15 interdigital space

• • 15 lower forearm15 lower forearm

• • 15 upper forearm15 upper forearm

• • 15 above elbow15 above elbow

Gowning & GlovingGowning & Gloving

two techniques:two techniques:

- Closed Method- Closed Method

- Open Method- Open Method

Principles & Practices of Principles & Practices of Surgical AsepsisSurgical Asepsis

Principles & Practices of Principles & Practices of Surgical AsepsisSurgical Asepsis

STERILE

Principles & Practices of Principles & Practices of Surgical AsepsisSurgical Asepsis

Principles & Practices of Principles & Practices of Surgical AsepsisSurgical Asepsis

4 Categories of Instruments4 Categories of Instruments

SharpsSharps• • Scalpels/ Knife/Scalpels/ Knife/

Blade holder – Blade holder – for for

incising and incising and dissectingdissecting

#7, #3, #4(left to right)

SharpsSharps

• ScissorsScissors

Straight Mayo scissor - Used to cut suture and supplies.  Also known as Suture scissors.

SharpsSharps

Curved Mayo scissor - Used to cut heavy or tough tissue (fascia, muscle, uterus, breast).  Available in regular and long sizes.

4 Categories of 4 Categories of InstrumentsInstruments

Scalpel No. 3 , 7 , 9 – blade no. 10, 11, 12, 15 Scalpel No. 4 – blade no. 20, 21, 22, 23,

SharpsSharps

Metzenbaum scissors - Used to cut delicate tissue. 

SharpsSharps

IRIS OPERATING STICH

SharpsSharps

KILNER BANDAGE – uterus / umbilicus

Grasping & HoldingGrasping & HoldingInstrumentsInstruments

Adson ForcepsDebakey Tissue Forcep

Russian Tissue ForcepFerris Smith Tissue Forcep

Grasping & HoldingGrasping & HoldingInstrumentsInstruments

Thumb Forcep – holds delicate tissues as in GIT

Toothed Tissue Forcep or Rat Tooth-for tougher tissues

Grasping & HoldingGrasping & HoldingInstrumentsInstruments

Bobcocks- hold delicate tissues Allises-for tough tissues

Clamping & Occluding Clamping & Occluding InstrumentsInstruments

Crile Hemostat “aka” Stet or Tag – for shallow layers of tissue

Clamping & Occluding Clamping & Occluding InstrumentsInstruments

Kelly Hemostats – for deep layers of tissue or cavity

Clamping & Occluding Clamping & Occluding InstrumentsInstruments

Kocher Hemostats

Clamping & Occluding Clamping & Occluding InstrumentsInstruments

Right Angle Hemostats or Mixters

Clamping & Occluding Clamping & Occluding InstrumentsInstruments

Tonsil Hemostat

RetractorsRetractors

• • Handheld Retractors or Non self Handheld Retractors or Non self retaining retractorsretaining retractors

Army Navy Retractors

RetractorsRetractors

Deaver Retractors

RetractorsRetractors

Harrington Retractor

RetractorsRetractors

Malleable Ribbon

RetractorsRetractors

Richardson Retractors

RetractorsRetractors

Goulet Retractor

RetractorsRetractors

• Self-Retaining Retractor Self-Retaining Retractor

Balfour abdominal Retractor Bladder Retractor

Types of needles and Types of needles and DrapesDrapes

A. NeedleA. Needle Hypo needleHypo needle Suture needleSuture needle

B. B. DRAPESDRAPES Towel, st. Mary’s, lap sheet, eye sheet, Towel, st. Mary’s, lap sheet, eye sheet,

thyroid sheet, breast sheet, kidney sheetthyroid sheet, breast sheet, kidney sheet Quarter (head/foot)Quarter (head/foot) FenestratedFenestrated Mayo table drapeMayo table drape

ACRONYMS USED ACRONYMS USED DURING SURGERYDURING SURGERY

MRM – modified radical mastectomyMRM – modified radical mastectomy ECCE c PCIOL – extra capsular cataract ECCE c PCIOL – extra capsular cataract

extraction w/ posterior chamber intraocular extraction w/ posterior chamber intraocular lenslens

TAHUSO – total abdominal hysterectomy w/ TAHUSO – total abdominal hysterectomy w/ unilateral salpingo oophorectomyunilateral salpingo oophorectomy

ORIF – open reduction internal fixationORIF – open reduction internal fixation LSCS – low segment caesarean sectionLSCS – low segment caesarean section EGD – esophago gastroduodenoscopyEGD – esophago gastroduodenoscopy CSOM – chronic suppurative otitis mediaCSOM – chronic suppurative otitis media

FBE – foreign body extractionFBE – foreign body extraction TURP – trans urethral resection of prostateTURP – trans urethral resection of prostate BKA – below knee amputationBKA – below knee amputation OD – right eye (ocularis dexter)OD – right eye (ocularis dexter) PHRA – partial hip replacement arthrplastyPHRA – partial hip replacement arthrplasty PFC – peritoneal fluid cytologyPFC – peritoneal fluid cytology ESS – endoscopic sinus surgeryESS – endoscopic sinus surgery FNB – fine needle biopsyFNB – fine needle biopsy

FUTURE OPERATING FUTURE OPERATING ROOMROOM

RECOVERY ROOM

WARD

END OF PRESENTATIONEND OF PRESENTATION

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