subject ncm 102
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SUBJECT : NCM 102
Concepts : Surgery
Surgery – branch of medicine concerned with the treatment of disease, injury
and deformity by operation or manipulation.
- Any procedure that involves entry into the human body usually
performed using instruments.
Operation – procedure itself
Perioperative phase – time before, during and after operation.
Asepsis – freedom from disease or infectious matter.
- Free/absence from microorganisms.
Surgical Asepsis- absence of micro-organism as protection against infection
before, during and following surgery by the use of sterile
techniques.
Indigenous Practice of Surgical Asepsis:
a. Boiling water used in washing wound
b. Ironing linens used in delivery; diapers of babies
c. Heating instruments
d. Soaking in alcohol
Techniques of Surgical Asepsis :
a. Hand washing
b. Scrubbing
c. Gloving
d. Gowning
e. Autoclaving
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Common Suffixes Describing Surgical Procedures :
ECTOMY – removal of an organ/gland
OTOMY – cutting into
OSTOMY - creation of permanent opening
OSCOPY – looking into
ORRHAPHY – repair or reconstruction of
Basic Types of Condition Requiring Surgery:
1. Perforation – rupture of an organ, artery or bleb (blister)
2. Obstruction/Blockage – mainly affecting
a. Tubes
b. Arteries
Internal Sites:
a. Blood vessels/lymphatics
b. Ureters
c. Respiratory tract
d. Ventricles – hydrocephally
e. Lacrimal ducts
f. Sinuses – sinusitis
Causes of obstruction
a. Vasoconstriction
b. Tumor
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c. Foreign bodies
3. Tumors – abnormal growth of tissue that form masses
4. Erosions – wearing away or eating away of the surface of a tissue as aresult of:
• Continuous physical irritation – (cancer, tumors,stones)
• Infection – (stones, AP)
• Ulceration/inflammation – (PUD)
Major Categories of Surgical Procedures :
I. According to Purpose
A. Diagnostic – determining cause of symptoms
B. Curative – removed damaged or disordered part/congenitallymalformed body part
TYPES:
B.1. Ablative – removal of disease organ
B.2. Constructive – repair of congenitally defective organ toimprove its function and appearance so it willresemble the normal appearance.
- Eg. Cheiloplasty for harelip
B.3. Reconstructive – partial or complete restoration of adamage organ or tissue to its normalappearance and function.
- Eg. Vaginal repair, plastic surgery to repairbody part after extensive scarringfrom burning.
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C. Palliative – relieves symptom although it doesn’t cure thedisease causing the symptoms.
- Eg. Colostomy
D. Exploratory – to estimate the extent of the disease
- to make or confirm a diagnosis
- eg. Exploratory laparotomy – find the extend/stage
- abd surgeries to find causes – suspected AP, cyst,kidney stones, etc.
II. According to Urgency
A. Emergency – performed immediately
Also known as “stat” surgery
B. Imperative/Urent – must be performed within 24-48 hours assoon as possible if there’s no complication.
C. Planned required surgery – necessary for the patient well beingbut not urgent.
o Maybe scheduled weeks/months ahead of
the propose operations because life of patient is stable.
D. Elective Surgery - performed for patient well being but notabsolutely necessary.
E. Optional Surgery –surgery requested by patient/client notnecessary for physical
Health but for aesthetic or
psychological reasons.
F.Ambulatory – does not require overnight hospital admission.
iii. According to Magnitude/Risk
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A. Minor Surgery
-present little risk to life
- generally not prolonged
- no vital organs involve
- leads to dew serious complications
- performed as opd
-uses loal anesthesia
B. Major Surgery
- involves high risk for patient
- prolonged period of time in OR table
- large amount of blood maybe lost
- high risk of post op complications
- performed in the OR
GENERAL EFFECTS OF SURGERY;
1. Stress response is elicited
2. Vascular system is disrupted
3. Defense against infection is lowered
4. Organ functions are disturbed
5. Body image maybe disrupted
6. Life style maybe changed
RESPONSES to SURGICAL STRESS
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1. Peripheral vasoconstriction with increase coagulability
Advantage : blood increased to vital organs
Increased clotting to decrease blood loss
Disadvantage : decrease renal perfusion
Clotting and thrombus formation increase
2. Tachycardia with increase cardiac output, blood pressure and
coronary
artery dilation
advantage : increase perfusion of myocardium
increased oxygen perfusion to vital organs
disadvantage : increased demand on heart possibly leading to
heart
failure, hypertension
3. Sodium and water retention secondary to increase ADH and
aldosterone secretion
Advantage : increase volume to prevent hypovolemia,
maintain blood
pressure and cardiac output
disadvantage : hypervolemia, circulatory overload
hypertension and
heart failure.
4. Increased gastric acidity and decreased peristalsis
Advantage : blood shift from large intestine to more vital
areas
Disadvantage : paralytic ileus and stress ulcers
Clotting and thrombus formation increase
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FACTORS AFFECTING THE DEGREE OF SURGICAL RISK;
1. Physical and mental condition of the patient
a. Age- children/mid.aged to adult generally tolerate surgery
well, pre-mature
aged-poor, because of the ff.
1. Increase sensitivity to sleep(trauma,drug used)
2. Often dehydrated,malnourished
3. Frequently victims of degenerative
disease,resp.,chf,emphysema
4. Blood volume lowered thru normal
b. Nutritional status- major pre-op/ nutritional problems are:
1. Dehydration and malnourishment due to
CHON,Fe,vit.deficiency
2. Obesity- may suffer from HPN,CHF,DM
-perceptible to post op operation(pulmonary)
-fatty tissues is difficult to approximate
-increased wound dehiscense
c. Fluid/electrolytes balance- dehydration; hypovolemia
predisposes pt.to
complications both during/after
surgery
treatment: correct imbalance- IVF
d. General health
The following will increase operative risk:
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a. presence/ absence of infection- CBC is taken
b. inadequacy of function of certain organs
- cardiovascular tx –ECG,X ray done
- pulmonary function- (COPD,emphysema,atelectasis)
-genito-urinary (UTI)
-metabolic liver tx (DM) untreated increase to infection
- neurologic (TIA,embolism,COA)
e. use of drugs/medications
1. anticoagulant (heparin,Coumadin)
-causes hemorrhage during bleeding
2. antibiotics – can combine infavorable effects with
anesthesia
3. tranquilizer – increase hypotension can cause
shock
4. thiozide/ diuretics- create K imbalance
f. mental outlook/attitude – “will to survive”- is an impt.
aspect of pt.
mental outlook bec.pt.will
cooperate to tx
designated to decrease
complication
g.economic/occupation status
-heavy construction workers undergo an amputation
of limb need to seek
for another job
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- minor surgery entails less expenses and only few
days from job than
major surgery
2. Extent of the Disease
a) Nature of the Disease
-whether it is benign or malignant
-importance of tx removed
Eg. Removal of GB not as serious as of removal of
stomach
b) Location – surgical risk decrease in descending order is
the ff.
- heart, thorax,
esophagus,brain,rectum,colon
Stomach,lungs( due to decrease
bld.supply)
c) duration f the disease – the longer the disease process the
greater the
surgical risk involve in
correcting the disorder
3.Extent of Surgical Procedure – more risk involved in major surgery
than minor sx
bec. more bld.loss,prolonged
4.Caliber of the Professional Staff – risk decrease for surgical pt
when hosp.staff are:
- adequate in
- competent and well trained
- hospital well equipped
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PRE-OPERATIVE PHASE (general preparation)
1. PSYCHOLOGICAL PREPARATION
a. Patients instruction – explain the reason/ purpose/ procedure to
be done
(how long/ expenses)
-probable income
-expected duration of hospitalization
-cost of hospital
-residual effects
-length of absence in work
b. Psychological Reassurance
-be supportive and understanding
-do not assume judgemental attitude
-recognize fear and anxiety
FEAR- feeling of alarm cause by the expectation of danger/pain
ANXIETY- exaggerated feeling of apprehension,uncertainty and fear
SEVERAL CAUSES OF FEAR AND ANXIETY
1. Fear of the unknown
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2. Fear of pain and death- if operation fails
3. Fear of separation – family and job
4. Fear to control – activities will be resricted
5. Fear of body mutilation
2. PHYSIOLOGICAL PREPARATION
a. Correct dietary deficiency if existing
b. Reduce obese patient – prone to wound dehiscense
c. Restore an adequate fluid volume
d. Treat any specific ailment
e. Cure any infectious process
f. Treat alcoholic patient with vitamin supplementation
3. LEGAL ASPECTS
LEGAL CONSIDERATION
a. Always get a consent from pt./parents/responsible member
b. If patient is alone in case of emergency it maybe necessary
for the surgeon to operate without a permit but a brief statement
of the circumstances must be signed by 2 physicians
- Pt. can signed wihin legal age 21 y/o
- Minor pt. signed by parent/guardian
- If emergency –operate to save pt. life
PURPOSES OF CONSENT;
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1. Ensure pt. understanding to the nature of tx including potential
complication
2. Indicates pt. decision was made without pressure
3. Protect pt.from unauthorized procedure
4. Protect MD and hospital against legal action
CIRCUMSTANCES REQUIRING A CONSENT
1. Any surgical procedures where scalpel,scissors,suture,
hemostasis,electrocoagulation
maybe used
2. Entrance into the body cavity
3. General anesthesia/ local or regional
4. INSTRUCTIONAL AND PREVENTIVE ASPECTS
a. Deep Breathing Exercise
-help expand collapsed lungs and prevent pneumonia and
atelectasis q hour
-done 5-10 times post-operatively/use of diaphragmatic
abd.breathing
Procedure;
-sit on the edge of the bed or lie supine,with knees flexed to relaxthe abdominal
Musculature (may lie on either side if lying on the back is
impossible).
-place hands on the abdomen
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-Inhale through the nose until the abdomen balloons outward
-exhale through pursed lips while contracting the abdominal
muscles
b. Coughing Exercises
-deep breath,exhale through the mouth then follow with a short
breath
while coughing
-helps expand collapsed lungs and prevent post-operative
pneumonia
and atelectasis
- done 5-10 times every hour post operatively
-to eliminate anesthesia inhalation
Procedure:
-on sitting or lying position, lace fingers and hold them tightly
across the
incision before coughing (small pillow or folded towel over incision
may do)
-take a deep breath, hold the breath for few seconds then cough
from deep in the
lungs once or twice (encourage client to perform deep breathing
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(exercises before coughing to stimulate
cough reflex)
(cough deeply not just clear the throat)
c. TURNING EXERCISE
-help prevent venous stasis, thrombo-phlebitis, decubitus ulcer
formation and
Expansion uppermost lungs
-promote good circulation
-done every 1-2 hours post operatively
Procedure:
-turn from side to side using the side rails to assist movement for
patient with right abdominal incision or right sided chest incision or
right sided chest incision, turn to left side of bed: by flexing the
knees
-splint the wound by holding left arm and hand or small
pillow against the
Incision
-turn to left side by pushing with right foot and grasp side rail
on left side
of the bed with the right hand
d. Extremity Exercises
- Help prevent circulatory problem ; thrombophlebitis by facilitate
venous return to the heart
- Prevent post op gas pain, flatus, promote circulation
AMBULATION
- Help prevent post operative complications, promote wound healing
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- Started 1st post op day, case to case basis
Discuss the purpose of post operative equipment depending on the
surgery
Tubes: indwelling catheter for bladder drainage nasogastric tube
( NGT)
- To decompress stomach and upper bowel
- To drain stomach content
Drains :Penrose Drain , Wild suction (hemovac or Jackson Pratt drain)
Intravenous Infusion Devices - to administer medication and fluids
during perioperative
period.
5. PHYSICAL PREPARATION
On the eve of surgery
a. Skin preparation defillatory, clipping, wet shave
- To decrease minimum bacteria on the pts. skin by
-bathing if possible
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-mechanical means by shaving against the groin of hair, shaft to
ensure clean,
close shave
-OB case –shaving and antiseptic douche
-Surgical case-rectal/bowel surgery, water by saline enema
PRINCIPLES IN SHAVING
1. Area of prep should should always be wider and longer than the
area of the proposed incision
2. Use strong light, well paysed and sterile razor with a new blade
3. Shave against the groin of the hair to ensure close clean shave
b. Gastro-intestinal tract (GIT) preparation
Purpose:
- Reduce possibility of vomiting and aspiration during anesthesia
- Reduce possibility of a bowel obstruction
- Prevent contamination from fecal material during intestinal tract or
bowel surgery
b.1 Restrict food and fluid
- NPO post midnight( solid food withheld 7-10 hrs. however water
maybe given
4 hours before, local anesthesia light breakfast)
- light breakfast for late afternoon surgery
When a client on NPO:
- Explain the reasons for the restriction
- Remove food and water from the bedside stand
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- Place an NPO sign on the door and on the bed
- Mark the kardex or nursing care plan NPO
- Inform the dietitian or diet list patient is NPO
- Inform caretaker that a client is NPO
b.2 Administer IV fluids for debilitated/ malnourished as ordered
b.3 Give enema as ordered – not routinely done except for intestinal
colon operation
2-3 enemas given evening/ early morning
Reasons:
- Prevent contamination of peritoneal cavity by feces
- Prevent colon surgery
- Provide adequate visualization of surgical site
b.4 Insert NGT as ordered (done usually by physician)
c. Anesthesia preparation – anesthesiologist visits the patient evening
prior to surgery
-examine for evidence of pulmonary
problem as URTI and
Investigate patient smoking habit
Responsibility – anesthesiologist :
- Discuss type of anesthesia
- Explain sensation
- Discuss fear
d. Promoting Rest and Sleep
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- Tranquilizer
- Well ventilated room
- Clean comfortable bed
- Back rub
- Warm milk,tea
- Talk to patient
On the Day of Surgery
a. Early morning care - 1-2 hours before surgery
- Assist in bath or shower, provide oral hygiene, give clean gowns
- Check consent signed, laboratory results reading
- Give oral hygiene
- Record allergies
- Remove jewelries, dentures
- Remove colored polish
- Remove make up
- Check ID band
- Remind NPO
- Check skin preparation
- IV fluids. Catheter, NGT, administered as ordered
- Ask client to void (empty bladder to prevent incontinence,
accidental injury)
- Assist in donning hosp. gown and protective cap
- Take v/s
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b. Administer pre-operativemedications
- Administer 60-90 mins before induction of anesthesia
Purpose:
- Allay anxiety
- Decrease pharyngeal secretions
- Reduce side effects of anesthetic agents
- Inducee amnesia
Nursing Responsibilities:
- Raise bed side rails
- Do not leave patient alone
- Lower window shades and turn off lights
- Let patient void before administration pre-op medicine
- Instruct patient not to get up without assistance
- Disturb the lient only when necessary, briefly and quietly after
administering
pre-op medicine
TYPES OF PRE OP MEDS;
1. Tranquilizer- relax smooth muscle, decrease anxiety eg. Phenergan
2. Sedatives- promote relaxation, decrease patient anxiety, decrease
amt. of anesthesia given, given at night to ensure good sleep eg.Phenobarbital
3. Analgesics- eg. Morphine, butorphanol, dormicum, midazolam
4. Vagolytic/ anticholinergics- decrease secretions and interrupt vagal
nerve stimulation eg. Atrophine sulfate
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c. Recording
d. Transport the Client to OR
Responsibilities:
- Gently transfer client to the stretcher
- Cover patient for protection from draft
- Place side rails up and secure restraining belt 2 inches above the
knee
- Records/chart brought to Or with the patient
- Avoid rapid walking and swinging the cart around corners
- Arrange room for post operative case
-keep furnitures away so that stretcher is easily brought in the
bedside
-make a surgical bed
-set up necessary equipment : emesis basin, IV stand, suction
Oxygen set up
e. Care of Significant Others
- Inform where to wait and when surgery completed
- In case no relative during operation get telephone number or
contact when necessary
- Give psychological report