perioperative nursing - original
TRANSCRIPT
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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