Question

3. Mention the 5 degrees of urgency.

4. Briefly describe the factors that increase the risk of surgery.

5. What estimation data should be assessed in the preoperative phase?

6. What is informed consent?

7. Mention who are the 5 members of the surgical team.

8. What is the purpose of the surgical gown?

9. What is the preparation of the patient's skin?

10. Mention the most commonly used surgical positions.

11. What is the Mesa de Mayo?

12. What is robotic surgery? What advantages and disadvantages does this have for the patient?

13. What aspects are evaluated in the postoperative phase of the patient?

14. What are anti-embolic stockings?

15. What is incentive spirometry?

Answer 1

QUESTION:

3. Mention the 5 degrees of urgency.

4. Briefly describe the factors that increase the risk of surgery.

5. What estimation data should be assessed in the preoperative phase?

6. What is informed consent?

7. Mention who are the 5 members of the surgical team.

8. What is the purpose of the surgical gown?

9. What is the preparation of the patient's skin?

10. Mention the most commonly used surgical positions.

11. What is the Mesa de Mayo?

12. What is robotic surgery? What advantages and disadvantages does this have for the patient?

13. What aspects are evaluated in the postoperative phase of the patient?

14. What are anti-embolic stockings?

15. What is incentive spirometry?

ANSWER

4. BRIEFLY DESCRIBE THE FACTORS THAT INCREASE THE RISK OF SURGERY.

Anaesthesia Complications:

Confusion, nausea, headache, dizziness, sore throat, tiredness, shivering, dry mouth, vomiting or mild hoarseness., severe reactions can include stroke heart attack brain damage death.

Haemorrhage:

Haemorrhage means bleeding. If the patient loses too much blood from the site of surgery it can lead to shock. Treatment for haemorrhage includes IV fluids, blood plasma or blood transfusion or further surgery to stop the bleeding.

DVT/Blood Clots:

During post-op many surgeries have an increased risk of developing a blood clot in the veins of the calf. This is called deep venous thrombosis (DVT). This happens because the body naturally increases its clotting cascade in an attempt to stop the bleeding from surgery. DVTs can cause lung problems including collapsed lungs therefore surgeons will take every step possible to prevent them. Anti-coagulating medications are sometimes prescribed, and patients are encouraged to get up and walk as soon as possible after surgery. Always be sure to follow all post-operative instructions carefully.

Post-Operative Lung Infections:

It is important to exercise the lungs after undergoing any surgery that uses anaesthesia. Lying down for an extended period and some medications taken for surgery can cause an individual to not breathe deeply. When lungs are not working at their full potential it can lead to poor oxygen levels which increase the risk of developing pneumonia.

Wound Infections:

Infections can occur when bacteria enter the body at the site of surgery. They can delay healing and spread to nearby organs and tissue. Wound infections are usually treated with a round of antibiotics. In more serious cases a procedure or surgery may be necessary to clean or drain the infected area.

The following conditions can increase the risk of complications during surgery:

Heart disease:

The stresses of surgery put extra strain on the muscles of the heart to maintain cardiac output. Additionally, the agents in anaesthesia can depress cardiac function.

Hypertension:

It Increases the risk of stroke or respiratory complications with anesthesia.

High blood pressure:

It increases the risk of stroke after surgery.

Stroke:

People who have a history of stroke are more likely to have an additional stroke after surgery. They also have an eight-fold risk increase of mortality within 30 days after surgery.

Bleeding disorders:

Bleeding disorders such as haemophilia increase the risk of haemorrhaging before, during and post-surgery.

Obesity:

Obesity increases the risks of wound infections, more surgical blood loss and a longer operation time.

COPD, asthma or other lung conditions:

Agents found in aesthesia can sometimes decrease respiratory functions, increasing the risk of severe hypoventilation.

Kidney problems:

It increases the risk of stroke after surgery.

Diabetes:

It can increase the susceptibility to infection and when there is an associated circulatory impairment, wound healing is impaired.

Obstructive sleep apnoea:

Anaesthesia has been shown to increase the upper airway collapsibility in individuals with obstructive sleep apnoea.

Smoking:

Smoking increases the risks of complications from anaesthesia.

Abuse of alcohol and illegal drugs:

Addiction to alcohol and/or drugs can cause an unpredictable reaction when under anaesthesia.

5. WHAT ESTIMATION DATA SHOULD BE ASSESSED IN THE PREOPERATIVE PHASE?

During this phase, emphasis is placed on:

· Assessing and correcting physiological and psychological problems that may increase surgical risk.

· Giving the patient and significant others complete learning and teaching guidelines regarding the surgery.

· Instructing and demonstrating exercises that will benefit the patient postoperatively.

· Planning for discharge and any projected changes in lifestyle due to the surgery.

Physiologic Assessment

The following are the physiologic assessments necessary during the preoperative phase:

· Age

· Obtain a health history and perform a physical examination to establish vital signs and a database for future comparisons.

· Assess patient’s usual level of functioning and typical daily activities to assist in patient’s care and recovery or rehabilitation plans.

· Assess mouth for dental caries, dentures, and partial plates. Decayed teeth or dental prostheses may become dislodged during intubation for anesthetic delivery and occlude the airway.

· Nutritional status and needs – determined by measuring the patient’s height and weight, triceps skinfold, upper arm circumference, serum protein levels and nitrogen balance. Obesity greatly increases the risk and severity of complications associated with surgery.

· Fluid and Electrolyte Imbalance – Dehydration, hypovolemia and electrolyte imbalances should be carefully assessed and documented.

· Infection

· Drug and alcohol use – the acutely intoxicated person is susceptible to injury.

· Respiratory status – patients with pre-existing pulmonary problems are evaluated by means pulmonary function studies and blood gas analysis to note the extent of respiratory insufficiency. The goal for potential surgical patient us to have an optimum respiratory function. Surgery is usually contraindicated for a patient who has a respiratory infection.

· Cardiovascular status – cardiovascular diseases increases the risk of complications. Depending on the severity of symptoms, surgery may be deferred until medical treatment can be instituted to improve the patient’s condition.

· Hepatic and renal function – surgery is contraindicated in patients with acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems. Any disorder of the liver on the other hand, can have an effect on how an anesthetic is metabolized.

· Presence of trauma

· Endocrine function – diabetes, corticosteroid intake, amount of insulin administered

· Immunologic function – existence of allergies, previous allergic reactions, sensitivities to certain medications, past adverse reactions to certain drugs, immunosuppression

· Previous medication therapy – It is essential that the patient’s medication history be assessed by the nurse and anesthesiologist.

Gerontologic Considerations

· Monitor older patients undergoing surgery for subtle clues that indicate underlying problems since elder patients have less physiologic reserve than younger patients.

· Monitor also elderly patients for dehydration, hypovolemia, and electrolyte imbalances.

Diagnostic Tests

These diagnostic tests may be carried out during the perioperative phase:

· Blood analyses such ascomplete blood count, sedimentation rate, c-reactive protein, serum protein electrophoresis with immunofixation, calcium, alkaline phosphatase, and chemistry profile

· X-ray studies

· MRI and CT scans (with or without myelography)

· Electrodiagnostic studies

· Bone scan

· Endoscopies

· Tissue biopsies

· Stool studies

· Urine studies

Psychological Assessment

· Psychological nursing assessment during the preoperative period includes:

· Fear of the unknown

· Fear of death

· Fear of anesthesia

· Concerns about loss of work, time, job and support from the family

· Concerns on threat of permanent incapacity

· Spiritual beliefs

· Cultural values and beliefs

· Fear of pain

Informed consent

· Reinforce information provided by surgeon.

· Notify physician if patient needs additional information to make his or her decision.

· Ascertain that the consent form has been signed before administering psychoactive premedication. Informed consent is required for invasive procedures, such as incisional, biopsy, cystoscopy, or paracentesis; procedures requiring sedation and/or anesthesia; nonsurgical procedures that pose more than slight risk to the patient (arteriography); and procedures involving radiation.

· Arrange for a responsible family member or legal guardian to be available to give consent when the patient is a minor or is unconscious or incompetent (an emancipated minor [married or independently earning own living] may sign his or her own surgical consent form).

· Place the signed consent form in a prominent place on the patient’s chart.

Nursing Interventions

   1. Preparing Patient for Surgery

· Instruct patient to use detergent–germicide for several days at home (if the surgery is not an emergency).

· If hair is to be removed, remove it immediately before the operation using electric clippers.

· Dress patient in a hospital gown that is left untied and open in the back.

· Cover patient’s hair completely with a disposable paper cap; if patient has long hair, it may be braided; hairpins are removed.

· Inspect patient’s mouth and remove dentures or plates.

2. Reducing Anxiety and Fear

3. Managing Nutrition and Fluids

4. Promoting Optimal Respiratory and Cardiovascular Status

5. Supporting Hepatic and Renal Function

6. Monitor patient for signs of adrenal insufficiency.

7. Promoting Mobility and Active Body Movement

8. Respecting Spiritual and Cultural Beliefs

9. Providing Preoperative Patient Education

10. Teaching the Ambulatory Surgical Patient

11. Teaching Deep Breathing and Coughing Exercises

12. Explaining Pain Management

13. Remove jewellery, including wedding rings

14. Preparing the Bowel for Surgery

15. Transporting Patient to Operating Room

16. Attending to Special Needs of Older Patients

17. Attending to the Family’s Needs

6. WHAT IS INFORMED CONSENT?

Informed consent:

· It is the process by which a patient learns about and understands the purpose, benefits, and potential risks of a medical or surgical intervention, including clinical trials, and then agrees to receive the treatment or participate in the trial. Informed consent generally requires the patient or responsible party to sign a statement confirming that they understand the risks and benefits of the procedure or treatment.

· Reinforce information provided by surgeon.

· Notify physician if patient needs additional information to make his or her decision.

· Ascertain that the consent form has been signed before administering psychoactive premedication. Informed consent is required for invasive procedures, such as incisional, biopsy, cystoscopy, or paracentesis; procedures requiring sedation and/or anesthesia; nonsurgical procedures that pose more than slight risk to the patient (arteriography); and procedures involving radiation.

· Arrange for a responsible family member or legal guardian to be available to give consent when the patient is a minor or is unconscious or incompetent (an emancipated minor [married or independently earning own living] may sign his or her own surgical consent form).

· Place the signed consent form in a prominent place on the patient’s chart.

· An informed consent is necessary to be signed by the patient before the surgery.

Purposes of an informed consent:

· Protects the patient against unsanctioned surgery.

· Protects the surgeon and hospital against legal action by a client who claims that an unauthorized procedure was performed.

· To ensure that the client understands the nature of his or her treatment including the possible complications and disfigurement.

· To indicate that the client’s decision was made without force or pressure.

Criteria for a Valid Informed Consent:

· Consent voluntarily given. Valid consent must be freely given without coercion.

· For incompetent subjects, those who are NOT autonomous and cannot give or withhold consent, permission is required from a responsible family member who could either be apparent or a legal guardian. Minors (below 18 years of age), unconscious, mentally retarded, psychologically incapacitated fall under the incompetent subjects.

The consent should be in writing and should contain the following:

· Procedure explanation and the risks involved

· Description of benefits and alternatives

· An offer to answer questions about the procedure

· Statement that emphasizes that the client may withdraw the consent

· The information in the consent must be written and be delivered in language that a client can comprehend.

· Should be obtained before sedation.

7. MENTION WHO ARE THE 5 MEMBERS OF THE SURGICAL TEAM

The surgical team consists of:

1. The surgeon

Surgeons are medical school graduates that complete surgery residency and receive all certifications required for practicing general or specialised surgery. They often specialise in a particular area of study such as trauma surgery, colorectal surgery, breast, vascular, endocrine, transplant, oncology. Key requirements are the full knowledge of the instruments required, on-going training in new procedures, the ability to make close call decisions to save a patient’s life and the overall management of the OR.

2. Anaesthesiologist

Similar to surgeons, anaesthesiologists complete 4 years of medical school and 4 years of anaesthesia residency. There are certain areas of anaesthesia that require special certification and training, such as cardiac anaesthesia. They are present before, during and after the surgery. It’s necessary that they’re informed about the entire medical condition and history of the patient before the procedure, in order for them to choose the best anaesthetic option. During the surgery, he/she will monitor the critical life functions – breathing, heart rate, blood pressure – and take any necessary precautions.

3. Certified registered nurse anaesthetist (CRNA)

The nurse anaesthetist is an advanced practice registered nurse (APRN). In order to become one, he/she has to complete one year of full-time nursing experience in a medical or surgical intensive care unit, followed by a master’s degree in anaesthesia and/or nursing, with a post-masters certification in anaesthesia. Nurse anaesthetists work under the supervision of a licensed physician, dentist or podiatrist and assist in anaesthesia care before, during and after surgery, labour and delivery.

4. Operating room nurse

The OR nurses have various responsibilities in making sure everything is well organised and the surgery can be performed under the highest operating standards.

• Scrub nurses ensure that all instruments are sterilised and layered out for the operation. They provide care for the patient before and during the surgery, attach equipment and monitors and pass instruments to the surgeon.

• Circulating nurses take care of all the documents required before the surgery and handle the procurement of instruments and surgical supplies.

• Registered nurse first assistants play a higher role in assisting the surgeons during the operation: they administer medication, control the bleeding, suture incisions, monitor vital signs, and perform CPR.

5. Surgical technologist

The surgeon needs to concentrate on the patient, not on finding instruments. This is where the surgical techs chime in: they’re trained in hundreds of types of surgery and are able to anticipate next steps in the procedure, in order to provide the surgeon with the required instruments and equipment. In the US, they are graduates of surgical technology programs and can specialise in a vast array of surgeries.

8. WHAT IS THE PURPOSE OF THE SURGICAL GOWN?

A surgical gown is a personal protective garment intended to be worn by health care personnel during surgical procedures to protect both the patient and health care personnel from the transfer of microorganisms, body fluids, and particulate matter.

Surgical isolation gowns are used when there is a medium to high risk of contamination and a need for larger critical zones than traditional surgical gowns.

9. WHAT IS THE PREPARATION OF THE PATIENT'S SKIN?

Human skin is colonised by a large number of microorganisms known as the ‘resident’ or ‘normal’ flora which tend to live deep in the skin folds, sebaceous glands and hair follicles. The surfaces of the skin can also be contaminated with microorganisms from body excretions/secretions, dirt or from contact with contaminated surfaces or items (‘transient’ flora). Whilst all these microorganisms are harmless on the surface of the skin, if they get into a surgical incision they can cause a surgical site infection. Cleansing of the skin prior to surgery is therefore required to remove as many microorganisms as possible from the skin surface. Soap and water physically removes dirt and secretions, and with it the transiently located microorganisms. Antiseptic agents such as alcohol, chlorhexidine, triclosan and iodine contain agents that can rapidly kill both resident and transient microorganisms. Some agents are also able to suppress their regrowth for the duration of the surgical procedures.

Surgical Skin Preparation includes:

1 .Patient Washing

2 .Hair Removals

3 .Skin Disinfection

4 .Incise Drapes

1 .Patient Washing

The aim of pre-operative washing is to ensure the skin is clean before surgery. Patients should be encouraged (or if necessary assisted) to have a shower or bath with soap.

Soap solutions are recommended to physically remove dirt and remove transient microorganisms from the surface of the skin. Using antiseptic in the soap solution is a strategy for reducing skin flora

2. Hair Removal

The removal of hair from the site of incision may be necessary to access the surgical site. The perception that the presence of hair at the site increases microbial contamination and therefore risk of SSI is not supported by evidence.

3. Skin Disinfection

Cleaning the skin with soap and water removes dirt, skin secretions such as sweat and sebum, together with superficial microorganisms. However, microorganisms that live in the folds of the skin, sebaceous glands and hair follicles are not removed by washing. The aim of skin disinfection is to apply antiseptic solutions to rapidly kill or remove skin microorganisms at the site of the incision and reduce the risk of contamination of the surgical sit.Preparation of the surgical site should occur as close to the point of surgery as possible and immediately prior to draping. There is no evidence to suggest that multiple applications of different skin antiseptics increases efficacy.

4. Reducing Skin Recolonisation/use an incise drape

Surgeons report that an incise drape secures and protects the incisional area. It ensures the area is protected from other surgical drapes shifting and it allows limb mobilisation without disturbing the sterile field and can support heavy retraction with reduced tension. The benefits of using an incise drape to reduce the risk of SSI has not been proven .The incise drape is part of creating the sterile field and is applied following skin disinfection and prior to incision. As with all medical devices the application and use must be in compliance with the manufacturer’s instructions.

10. MENTION THE MOST COMMONLY USED SURGICAL POSITIONS.

1.Supine position

It is the most common surgical position. The patient lies with back flat on operating room bed.

2.Fracture Position

For hip fracture surgery, upper torso is in supine position with unaffected leg raised. Affected leg is extended with no lower support. The leg is strapped at the ankle and there is padding in the groin to keep pressure on the leg and hip.

3.Lithotomy position

Used for gynaecological, anal, and urological procedures. Upper torso is placed in the supine position, legs are raised and secured, and arms are extended.

4.Prone position

Patient lies with stomach on the bed. Abdomen can be raised off the bed.

5.Lloyd-Davies position

It is a medical term referring to a common position for surgical procedures involving the pelvis and lower abdomen. The majority of colorectal and pelvic surgery is conducted with the patient in the Lloyd-Davis position.

6.Jackknife position

It is also called the Kraske position. Patient's abdomen lies flat on the bed. The bed is scissored. So the hip is lifted and the legs and head are low.

7.Lateral position

Also called the side-lying position, it is like the jackknife except the patient is on his or her side. Other similar positions are Lateral chest and Lateral kidney.

8.Kidney position

The kidney position is much like the lateral position except the patient's abdomen is placed over a lift in the operating table that bends the body to allow access to the retroperitoneal space. A kidney rest is placed under the patient at the location of the lift.

9.Sims' position

The Sims' position is a variation of the left lateral position. The patient is usually awake and helps with the positioning. The patient will roll to his or her left side. Keeping the left leg straight, the patient will slide the left hip back and bend the right leg. This position allows access to the anus.

10.Trendelenburg position

Same as supine position but the upper torso is lowered.

11.Reverse Trendelenburg position

Same as supine but upper torso is raised and legs are lowered.

12.Fowler's position

It begins with patient in supine position. Upper torso is slowly raised to a 90 degree position.

13.Semi-Fowlers position

Lower torso is in supine position and the upper torso is bent at a nearly 85 degree position. The patient's head is secured by a restraint.

12. WHAT IS ROBOTIC SURGERY? WHAT ADVANTAGES AND DISADVANTAGES DOES THIS HAVE FOR THE PATIENT?

Robotic Surgery

Robotic surgery is surgery that is carried out by a robot. It's a minimally invasive surgery, which means it's capable of performing complicated surgical techniques through tiny incisions, leaving very little scar tissue behind. The robot is the tool here, just like a scalpel or a set of forceps would be a tool for a skilled surgeon. The surgeon will sit at the robot's controls, guiding the surgical instruments at the end of the robot's arms with high definition 3-D cameras.

Advantages

1: Smaller Incisions and Less Trauma

2: Higher Surgical Accuracy

3: Reduced Surgeon Fatigue

Disadvantages

1: The Expense of Surgery

2: Movement Latency