Sutures sizes:

(very large, used to close abdominal wall)

Sutures sizes:

(very tiny, used for microvascular anastomoses)

Method of suturing:

• Each stitch is tied and knotted separately

• e.g. Simple interrupted suture, mattress suture

Method of suturing:

• One thread runs in a series of stitches

• Tied only at the beginning and at the end of the run

a. Simple continuous suture

b. Blanket suture

c. Subcuticular suture

Method of suturing:

• Very large sutures used in addition to skin suture

• Attach underlying tissues of fat, muscle and skin

• Support incision in obese individuals or wound with prolonged healing

• Left in place ~ 14 – 21 days (maybe removed at the same time as the skin sutures in some instances).

• Rubber tubings are placed over tension suture to prevent irritating the incision

Removal of suture / staples:

Clean the suture line and the healed incision ? suture /staples removal

Removal of suture / staples:

Should I lift the staple remover when squeezing the handles?

Removal of intermittent stitches:

Cut suture as ? to skin as possible

Wound drain:

1. Penrose drain

2. Yeast drain

3. Corrugated drain

Wound drain:

1. Latex drain

2. Tubal drain

3. Jackson-Pratt (JP) drain

4. Redivac drain

Wound drain:

• Hollow, open-ended rubber tube commonly used after a surgical procedure or for drainage of an abscess

• Not sutured; a large safety pin is usually placed in the part outside the wound to prevent the drain from slipping back into the incised area

• Promotes drainage passively, with the drainage moving from an area of greater pressure, in the wound or surgical site, to the area of less pressure, the absorbent dressings

Wound drain:

• Rubber corrugated sheet

• Can be cut to the required size

• Does not get blocked easily

• Usually a safety pin is attached to the drain to prevent it from migrating into the wound

Wound drain:

Round drain, Robinson drain (R/D)

• Some may have holes on the sides of the inner end

• Most commonly used closed passive drainage

Wound drain:

• A bulblike device that is compressed to create gentle suction

• Consists of perforated tubing connected to a portable vacuum unit

Wound drain:

• Either an evacuated bottle or a compressible container.

• Designed to be attached to a fine tube with multiple holes at the proximal end that permit drainage of blood beneath the skin.

• Can be used in deep internal spaces such as around a vascular anastomosis.

Detect any complications after removal of drain

1. Bleeding

2. Haematoma

3. Infection

4. Retained drainage tube

Prevent recurrence of urinary tract infection:

Drink ? mL of fluids / day if not contraindicated

Which are urinary incontinence type?

1. Stress urinary incontinence (SUI)

2. Urge urinary incontinence (UUI)

3. Overflow incontinence

4. Mixed urinary incontinence

Types of urinary catheters:

• Single lumen tube with opening about 1.25cm from the insertion tip

• Inserted to drain the bladder and then the removed immediately

• Purposes:

- Relieve discomfort due to bladder distention

- Assess amount of residual urine if bladder empties incompletely

- Obtain sterile urine specimen

- Empty bladder completely prior to surgery

Types of urinary catheters:

• Double/ tripple lumen catheter

• Outside end of the catheter is bifurcated:

- One opening to drain urine

- The other to inflate the balloon

- – The third one to bladder irrigation fluid (in 3-way)

Types of urinary catheters:

• The larger lumen drains urine from the bladder

• The second smaller lumen is used to inflate the balloon near the tip of the catheter to hold the catheter in place within the bladder

• Usually connected to a closed drainage system

- reduce the risk of microorganisms entering the system and infecting the urinary tract

Urinary catheterization:

Dorsal recumbent position with knees flexed and hip joints externally rotated (Sims’ position if patient unable to lie supine)

Urinary catheterization:

Supine position with thighs slightly abducted or apart

Urinary catheterization:

Female

- Clean (Use a new swab each stroke):

1) One side of (a); another side of (a)

2) One side of (b); another side of (b)

3) Lastly the center of (c)

Responses of the body to immobility: Urinary system

when client is in supine position, gravity impedes the emptying urine from kidneys and urinary bladder. To urinate, the client must push upward, against gravity. The renal pelvis may then fill with urine before it is pushed into the ureters.

Responses of the body to immobility: Urinary system

with immobility and the resulting excessive amounts of calcium in urine, the urine becomes alkaline and calcium salts precipitate to form renal calculi.

Responses of the body to immobility: Urinary system

decreased muscle tone of urinary bladder inhibits its ability to empty completely.

Responses of the body to immobility: Urinary system

static urine provides an excellent medium for bacterial growth.

Clients’ positioning:

• Use in thoracic surgery, severe respiratory conditions

Clients’ positioning:

• To Promote oxygenation, maximum chest expansion

• For oral or nasal gastric feeding, prevent aspiration

Clients’ positioning:

• For cardiac, respiratory, neurological conditions

Clients’ positioning:

• To promote skin integrity, client comfort

Clients’ positioning:

• Lie on one side of body

• Flex top hip and knee, place this leg in front of body

• To create a wider, triangular base of support for greater stability

• To promote good alignment of back

• It helps to relieve pressure on the sacrum and heels

Clients’ positioning:

• Lie on the abdomen with head turn to one side

• One or both arm flex over head

• Hip and knee joint are fully extended

• To promote drainage from mouth for unconscious clients, recovering from surgery of mouth/throat

Clients’ positioning:

• A posture halfway between the lateral and the prone position

• Position the lower arm behind the client, flex the upper arm at the shoulder and elbow

• Flex both legs in front of the client

• For clients who are unconscious, paralyzed, receiving enemas, undergoing examination or treatment of perineal area

Loss - Types of loss:

can by recognized by others

Loss - Types of loss:

losing one’s job, the death of child, and losing functional ability

Loss - Types of loss:

the departure of grown children from the home, retirement from a career, and the death of aged parents

Loss - Types of loss:

experienced by one person but cannot be verified by others

• Reaction to loss

• Total response to the emotional experience related to loss

• Encompasses thoughts and feelings, physical, behavioral and spiritual responses

• Subjective response experienced by the surviving loved ones

• Related to death-related losses

• Behavioral process thorough which grief is eventually resolved or altered

• Influenced by culture, spiritual beliefs and custom.

Behavioral Responses:

1. Refuses to believe that loss is happening

2. Is unready to deal with practical problems, such as prosthesis after the loss of a leg.

May assume artificial cheerfulness to prolong denial

Behavioral Responses:

Client or family may direct anger at nurse or staff

Behavioral Responses:

Seeks to bargain to avoid loss (e.g. ‘Let me just live until (a certain time) and then I will be ready to die.’)

Behavioral Responses:

1. Grieves over what has happened and what cannot be.

2. May talk freely (e.g. reviewing past losses such as money or job), or may withdraw

Behavioral Responses:

1. Comes to terms with loss

2. May have decreased interest in surroundings and support people

3. May wish to begin plans (e.g. will, prosthesis, altered living arrangement)

Nursing Implication:

1. Verbally support client but do not reinforce denial

2. Examine your own behavior to ensure that you do not share in client’s denial.

Nursing Implication:

• Help client understand that anger is a normal response to feelings of loss and powerlessness.

• Avoid withdrawal or retaliation; do not take anger personally

• Deal with needs underlying any angry reaction

• Provide structure and continuity to promote feelings of security

• Allow clients as much control as possible over their lives

Nursing Implication:

Listen attentively, and encourage client to talk to relieve guilt and irrational fear. If appropriate, offer spiritual support.

Nursing Implication:

1. Allow client to express sadness

2. Communicate nonverbally by sitting quietly without expecting conversation

3. Convey caring by touch

Nursing Implication:

1. Help family and friends understand client’s decreased need to socialize

2. Encourage client to participate as much as possible in the treatment program

Does not understand the concept of death

Infant’s sense of separation forms basis for later understanding of loss and death.

Believe death is reversible, a temporary departure, or sleep.

Emphasizes immobility and inactivity as attributes of death.

Understands that death is final.

Believes own death can be avoided.

Associates death with aggression or violence.

Believes wishes or unrelated actions can be responsible for death.

Understands death as the inevitable end of life.

Begins to understand own mortality, expressed as interest in afterlife or as fear of death.

Fears as lingering death. May fantasize that death can be defined, acting out defiance through reckless behaviors (e.g. dangerous driving, substance abuse)

Seldom thinks about death, but views it in religious and philosophic terms.

May seem to reach “adult” perception of death but be emotionally unable to accept it.

May still hold concepts from previous developmental stages.

Has attitude toward death influenced by religious and cultural beliefs.

Accepts own mortality.

Encounters death of parents and some peers.

Experiences peaks of death anxiety.

Death anxiety diminishes with emotional well- being.

Fears prolong illness.

Encounters death of family members and peers.

See death as having multiple meanings (e.g. freedom from pain, union with already deceased family members).

Which is the last sense lost

• Stiffening of the body that occurs about 2-4 hours after death

• Starts in the involuntary muscles, then progresses to the head, neck and trunk and finally reaches the extremities

• Usually leaves the body about 96 hours after death

• Gradual decrease of the body’s temperature after death

• Body temperature falls about 1∘C / hour until reach the room temperature

• Skin loses its elasticity and can easily be broken when removing the dressings and adhesive tape

• Blood circulation stopped -> RBC break down -> release Hemoglobin

• Appears in the lowermost or dependent areas of the body

rapid respirations

abnormally slow respiratory rate

difficulty breathing or the feeling of being short of breath (SOB)

absence of any breathing

marked rhythmic waxing and waning of respirations from very deep to very shallow with

short periods of apnoea

inability to breathe easily unless sitting upright or standing

Properties of oxygen:

Constitutes ?% of the atmospheric air.

Oxygen Therapy:

ranging from 1 to 6 liters per minute (L/min),

Oxygen Therapy:

ranging from 6 to10 liters per minute (L/min),

Oxygen Therapy:

ranging from 24% to 50%

Oxygen Therapy:

ranging from 10 to 15 L/min

Artificial Airways:

1. For unresponsive patient only

2. Cause vomiting and aspiration in responsive patient (gag reflex)

3. Keeping the airway open during BVM ventilation

4. Allow suction of the throat & mouth

5. Prevent patient from biting the ETT

6. Proper size: measure the length from client’s opening of mouth to the back angle of jaw.

Artificial Airways:

1. are tolerated better by alert clients

2. should be well lubricated with water or saline

3. Proper size:

• measure the length from tip of the client’s nostril to the earlobe.

• The diameter should be slightly smaller than the diameter of the nostril.

4. Reinsert the airway in the other naris every 8 hours or as ordered to prevent necrosis of the mucosa

Artificial Airways:

1. commonly inserted in clients who have had general anesthetics or for those in emergency situations where mechanical ventilation is required

2. inserted through the mouth or the nose and into the trachea, using a laryngoscope as a guide

3. terminates just superior to the bifurcation of the trachea into the bronchi

4. have an air-filled cuff to prevent air leakage around it

Artificial Airways:

1. a surgical procedure to create an artificial opening and insert a tube through the neck into the trachea.

2. It may be described as short-term or long-term tracheostomy depending on patient’s condition and treatment.

3. End Tracheostomy is a permanent artificial opening created surgically into the trachea. The trachea is brought out to the surface of the skin and sutured to the neck.

Types of Drug Preparation:

Powdered drug compressed into a particular shape for administration

Types of Drug Preparation:

A gelatinous container to hold a drug in various form (powder, oil or liquid)

Types of Drug Preparation:

One or more drugs mixed with a cohesive material, in oval, round, or flattened shapes

Types of Drug Preparation:

Clear fluid containing water and alcohol with flavour added

Types of Drug Preparation:

Medication dissolved in concentrated sugar solution

Types of Drug Preparation:

Finely dissolved drug particles in liquid medium; must be shaken before administration. When

left standing, particles settle to bottom of container

Dosage Calculation:

• Dose strength on hand: - Lanoxin 0.125mg / tablet

• Ordered dosage: Lanoxin 0.25mg

How many tablet should be administered?

Dosage Calculation:

• Dose strength on hand: - Syrup panadol 250mg / 5mL

• Desired dosage: Syrup panadol 500mg

How many mL should be administered?

Administering Medications via Nasogastric / Gastrostomy Tube:

Crush a tablet into a fine powder and dissolve in at least ?mL of warm water (Rationale: Cold liquid may cause client discomfort)

Administration of Eye Medication:

Instill the correct number of drops onto the outer third of the ? conjunctival sac

Parenteral Medications:

subcutaneous (S.C.)

? degree angle

Parenteral Medications:

intramuscular (I.M.)

? degree angle

Parenteral Medications:

intradermal (I.D.)

? degree angle

Syringe from 1 to 3 mL in size usually for ? injection

1. intradermal (I.D.)

2. subcutaneous (S.C.)

3. intramuscular (I.M.)

4. intravenous (I.V.)

Needles:

Longer bevels for?

1. intradermal (I.D.)

2. subcutaneous (S.C.)

3. intramuscular (I.M.)

4. intravenous (I.V.)

Needles:

Short bevels for?

1. intradermal (I.D.)

2. subcutaneous (S.C.)

3. intramuscular (I.M.)

4. intravenous (I.V.)

Needles:

The ? the gauge number, the ? diameter of the shaft

Preparing Medications from Vials:

Mix the solution by rotating the vial between the palms of the hands, not by shaking

The rationale is?

Preparing Medications from Vials:

Remove the protective cap, or clean the rubber cap of a previously opened vial with an antiseptic wipe by rubbing in a circular motion

The rationale is?

Preparing Medications from Vials:

Inject the air into the vial, keeping the bevel of the needle above the surface of the medication

The rationale is?

Preparing Medications from Vials:

Tap the syringe barrel to dislodge any air bubbles present in the syringe if necessary

The rationale is?

Preparing Medications from Ampoules:

Flick the upper stem of the ampoule several times with a fingernail

The rationale is?

Preparing Medications from Ampoules:

Use an ampoule opener or place a piece of sterile gauze or alcohol wipe between your thumb & the ampoule neck and break off the top by bending it toward you to ensure the ampoule is broken away from yourself and others

The rationale is?

Preparing Medications from Ampoules:

Alternative method: Place the antiseptic wipe packet over the top of the ampoule before

breaking off the top

The rationale is?

Which are the common sites for intradermal injections?

1. ventral forearm

2. upper chest

3. inner lower arm

4. back beneath the scapulae

Procedures for Intradermal Injection:

With the non-dominant hand, pull the skin at the site until it is taut

The rationale is?

Procedures for Intradermal Injection:

Enter the skin at 5 to 15 degree angle

The rationale is?

Procedures for Intradermal Injection:

Do not massage the area

The rationale is?

Subcutaneous (S.C.) Injection:

?° angle is used when 1 inch of tissue can be grasped at the site

Subcutaneous (S.C.) Injection:

?° angle is used when 2 inch of tissue can be grasped at the site

Special Considerations for Insulin & Heparin Injections:

Do not aspirate for checking any puncturing of needle into blood vessel for administering insulin

The rationale is?

Special Considerations for Insulin & Heparin Injections:

Do not massage the site after insulin and heparin injection

The rationale is?

Administration of Subcutaneous Injection:

Select a site free of tenderness, hardness, swelling, scarring, itching, burning, or localized inflammation

The rationale is?

Administration of Subcutaneous Injection:

Inject the medication by holding the syringe steady and depressing the plunger with a slow,

even pressure until full dose of medication is administered

The rationale is?

Administration of Subcutaneous Injection:

Remove the needle smoothly, pulling along the line of insertion while depressing the skin with your non-dominant hand

The rationale is?

Injection:

- oral route is unavailable or inappropriate, either because the client cannot swallow the medication or the medication would be adversely affected or inactivated by gastric secretions

- intravenous access is difficult

- a reasonably rapid systemic uptake of the drug is needed by the body

Intramuscular (I.M.) Injection:

I.M. injection can be completed using ?-track method, which creates a zig-zag channel that

reduces leakage of irritating medications into subcutaneous tissue

Intramuscular (I.M.) Injection:

Angle of insertion is?

Intramuscular (I.M.) Injection:

Need to aspirate the syringe?

Intramuscular (I.M.) Injection:

If blood appears during aspiration

Intramuscular (I.M.) Injection, Ventrogluteal Site:

Recommended volume

Intramuscular (I.M.) Injection, Deltoid Site:

Recommended volume, no more than?

Intramuscular (I.M.) Injection, Ventrogluteal Site:

Client can be in what position?

1. back

2. prone

3. side lying

Intramuscular (I.M.) Injection, Vastus Lateralis Site:

Client can be in what position?

1. back-lying

2. sitting

3. standing

Landmark for Ventrogluteal Site:

Place your left hand on client’s ? hip, or your right hand on client’s ? hip

Administration of Intramuscular Injection:

Assist client to a supine, lateral, prone or sitting position, depending on the chosen site

The rationale is?

Administration of Intramuscular Injection:

Clean the site with an antiseptic swab. Using circular motion, start at the centre of the site and

move outward about 5 cm. Allow the area to dry thoroughly

The rationale is?

Administration of Intramuscular Injection:

If using a prefilled unit-dose medication, take caution to avoid dripping medication on the

needle prior to injection

The rationale is?

Administration of Intramuscular Injection:

Using the ulnar side of non-dominant hand to pull the skin approximately 2.5 cm to the side

The rationale is?

Administration of Intramuscular Injection:

Holding syringe between the thumb and forefinger (as if holding a pen), pierce the skin quickly and smoothly at a 90-degree angle and insert the needle into the muscle

The rationale is?

Administration of Intramuscular Injection:

Aspirate for 5-10 seconds gently to check any blood is present in order to ensure the needle is not entering into blood vessel

The rationale is?

Administration of Intramuscular Injection:

If blood does not appear, inject the medication steadily and slowly (〜10 seconds per mL) while holding the syringe steady

The rationale is?

Administration of Intramuscular Injection:

After injection, wait 10 seconds if using the ventrogluteal site

The rationale is?

Administration of Intramuscular Injection:

Withdraw the needle smoothly at the same angle of insertion

The rationale is?

Administration of Intramuscular Injection:

Apply gentle pressure at the site with dry gauze

The rationale is?

Administration of Intramuscular Injection:

It is not necessary to massage the area at the site of injection

The rationale is?

IVF:

• Do not administer to clients with kidney or heart disease or who are dehydrated

• Watch for signs of hypervolemia.

Intravenous (IV) Catheters:

It is most frequently used for short-term therapy (e.g. less than 24 hours) such as administering

bolus injection, or blood sample retrieval

Intravenous (IV) Catheters:

• Inserted in the basilic or cephalic vein just above or below the antecubital space of the right arm

• Tip of the catheter rests in the superior vena cava

Intravenous (IV) Catheters:

• Defined by the location of the catheter tip in a central vein

• The catheter tip should reside in the lower one third of the superior vena cava, above the right atrium

• At greater risk of complication including haemothorax or pneumothorax, cardiac perforation, thrombosis and

infection

Procedure of Peripheral Line Insertion:

Do I need to remove the tourniquet after use?

Procedure of Peripheral Line Insertion:

Can I use gloves as tourniquet?

Precautions in Administering High Alert IV Medications (Concentrated KCl):

Concentrated potassium chloride do not need to be DILUTED before use

Precautions in Administering High Alert IV Medications (Concentrated KCl):

Concentrated potassium chloride should NOT be ordered when pre-mixed potassium chloride

solution with required dosage is available

Precautions in Administering High Alert IV Medications (Concentrated KCl):

It should be locked and separated from the usual drug storage

Precautions in Administering High Alert IV Medications (Concentrated KCl):

Infusion rate and infused volume must be closely monitored and regulated

Precautions in Administering High Alert IV Medications (Concentrated KCl):

A rate controlled infusion pump should be used if the infusion rate of potassium chloride is faster than 10mmol/hour

Precautions in Administering High Alert IV Medications (Concentrated KCl):

Concentration higher than 40mmol/L (i.e. 4 mmol per 100ml) of potassium must be used with extreme caution and closely monitored

Precautions in Administering High Alert IV Medications (Concentrated KCl):

In case where a client complains of severe pain at the injection site, continuses the infusion

Phlebitis – Inflammation of A Vein, Prevention:

Assess the length of time needed for infusion therapy

The rationale is?

Phlebitis – Inflammation of A Vein, Prevention:

Choose smallest IV catheter for insertion and stable the catheter

The rationale is?

Phlebitis – Inflammation of A Vein, Prevention:

Use infusion pump to administer infusion with additive (e.g. potassium chloride)

The rationale is?

Phlebitis – Inflammation of A Vein, Prevention:

Avoid insertion of a peripheral IV catheter in an area of joint flexion

The rationale is?

Phlebitis – Inflammation of A Vein, Prevention:

Use transparent dressing such as tegaderm on the IV exit site and assess IV insertion site at least every 4 hours

The rationale is?

Phlebitis – Inflammation of A Vein, Prevention:

Practice good hand hygiene with strict aseptic technique when inserting IV catheter, adding

medications and changing of IV bottle

The rationale is?

Phlebitis – Inflammation of A Vein, Prevention:

Change the IV catheter at least every 72-96 hours according to hospital guidelines and never

hang IV fluid for more than 24 hours

The rationale is?

Management:

- Stop infusion immediately

- Remove the IV catheter

- Do not rub or massage the affected area to avoid dislodging clots

Cause:

• Frequent disconnection of tubing

• A generalized reaction due to invasion of bacteria through the broken skin, contaminated equipment or solution when solutions are changed, a medication is added or the solution is infused for an extended period

• Inadequate/improper decontamination of hub prior to use

unintentional administration of non-vesicant medications or fluids (e.g. D5W, NS) into the

subcutaneous tissue

unintentional administration of vesicant medications or fluids into subcutaneous tissue (e.g.

dopamine, chemotherapeutic agents, D10, D20)

S/S:

• Coolness of skin around site

• Skin blanching, tautness

• Oedema at, above, or below the insertion site

• Absence of or “pinkish” blood return

• Leakage at insertion site

• Difference in size of opposite limb

S/S:

• Burning, stinging pain

• Redness followed by blistering, tissue necrosis and ulceration

Infiltration & Extravasation, Prevention:

Avoid the insertion of IV access site at the areas of joint flexion such as wrist and antecubital fossa

The rationale is?

Infiltration & Extravasation, Prevention:

Select the smallest gauge of IV catheter with adequate fixation that can deliver the prescribed therapy in an appropriate size vein

The rationale is?

Infiltration & Extravasation, Prevention:

Recognise the osmolality and pH of medications and fluids

The rationale is?

Infiltration & Extravasation, Prevention:

Observe the infusion site and flow rate frequently

The rationale is?

Infiltration & Extravasation, Prevention:

Secure the IV catheter firmly; apply splint as required

The rationale is?

Infiltration & Extravasation, Prevention:

Instruct client to be cautious during movement, not to bend the arm or perform heavy exertion on the limb with IV drip

The rationale is?

Infiltration & Extravasation, Prevention:

Assess the patency of IV catheter and vein regularly by normal saline flushing

The rationale is?

Venous Access Device – Related Infection, Prevention:

Use clear equipment and solution

Venous Access Device – Related Infection, Prevention:

Perform hand hygiene before and after palpating catheter insertion sites; before and after inserting, replacing, accessing and dressing a venous access device

Venous Access Device – Related Infection, Prevention:

Never administer same pack of IV fluid for more than 48 hours

Venous Access Device – Related Infection, Prevention:

Remove peripheral venous catheter at least every 72 – 96 hours in adult or no longer indicated. If sites for venous access are limited, catheter can be maintained for longer period but close monitoring of insertion sites is necessary

Venous Access Device – Related Infection, Prevention:

Leave the catheter in place until therapy is completed unless a complication occurs in paediatric clients

Management:

• Prompt actions are required

• Pinch off catheter or secure system to prevent entry of air

• Turn client to left side in Trendelenburg position

which will slow the flow of air into the vein and pulmonary artery

• Administer oxygen as ordered

• Monitor vital signs and pulse oximetry

Cause:

• Excessive or rapid infusion especially in children, elderly or clients with heart or renal disease

Prevention:

• Adjust the flow rate as prescribed, never speed up the rate to catch up the required infused volume

• Identify high risk groups (e.g. infant, elderly, clients with heart or renal diseases)

• Keep strict I&O chart, observe the urine output and report if the amount is decreasing

Management:

• Slow down infusion rate just to keep vein open

• Inform doctor

• Arrange client in a sitting position to ease breathing

• Administer oxygen and diuretics if prescribed

• Monitor vital signs

Phases of perioperative period:

▸ Begins when the decision to have surgery is made;

▸ Ends when the client is transferred to operating table.

▸ Nursing activities include:

- assessing the client

- identifying potential / actual health problem

- planning specific care based on individual’s needs

- providing preoperative teaching for the clients and significant others

Phases of perioperative period:

▸ Begins when client is transferred to operating table and ends when client is transferred to recovery room.

▸ Nursing activities included interventions that:

- providing client’s safety

- maintaining an aseptic environment

- ensure proper functioning of equipment

- providing surgical team with the instruments and supplies needed during the procedure.

Phases of perioperative period:

▸ Begins with admission of client to recovery room and ends when the healing is completed.

▸ The goal is to assist client to achieve the most optimal health status.

▸ Nursing activities include:

- assessing client’s responses (physiological and psychological) to surgery

- performing intervention to facilitate healing and prevent complications

- teaching and providing support to the client

- planning for home care

Types of surgery, Degree of urgency:

▸ Performed immediately to preserve function or life of the client.

▸ e.g. control internal haemorrhage, repair of rupture.

Types of surgery, Degree of urgency:

▸ Performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening, or to improve the client’s life.

▸ e.g. hip replacement surgery, plastic surgery such as breast reduction.

Types of surgery, Degree of risk:

▸ Involves a high degree of risk for a variety of reasons:

- It may be complicated or prolonged

- Large losses of blood may occur

- Vital organs may be involved

- Postoperative complications

▸ e.g. organ transplant, open heart surgery

Types of surgery, Degree of risk:

▸ Involves little risk

▸ Produces few complications

▸ Often performed at bedside/outpatient setting

▸ e.g. breast biopsy, cataract extraction

Types of consent form:

▸ For a minor (under 18 years of age) with no parent or guardian and who cannot consent to the proposed operation/procedure/treatment.

▸ For a mentally incapacitated adult within the meaning of Mental Health Ordinance (MHO) with no legal guardian

vested with power to consent to treatment and who cannot consent to the proposed operation/procedure/treatment.

Usually completed by?

Physical preparation:

▸ Firm elastic hose that compress the veins of the legs and thus facilitate the return of venous blood to the heart, improve circulation to the feet and prevent oedema of the legs and feet.

Physical preparation:

▸ Promote venous return from the legs.

▸ It inflates and deflates plastic sleeves wrapped around legs to promote venous flow.

Surgical Safety Protocol:

▸ The “SIGN IN” checking is performed before the induction of anaesthesia

▸ Operating surgeon and anaesthesist explain and obtain a written informed consent from client

▸ Perform site marking for procedure involving laterality by doctor. Mark a “↑” at the operating site with indelible marker pen. For eye operations, mark an “R” for right operating eye and an “L” for left operating eye.

▸ Check the client identity, the procedure, the relevant site marked against the consent form and the client. Check client’s blood group, the availability of client’s blood and/or blood products if appropriate.

▸ Theatre nursing team shall check the availability of specific consumables.

▸ The “SIGN IN” safety checking should be performed at least by a nurse and anaesthetist.

Surgical Safety Protocol:

▸ The team should confirm aloud with each other about all required and relevant information. They should clarify any discrepancy during the process and decide appropriate action(s).

▸ Information such as client identity, validity of informed consent on the procedure and type of anaesthesia, side and site with appropriate markings, known alerts, blood group should be checked.

▸ Ensure the correct client has received the correct procedure at the correct site as stated in the consent.

▸ If an interruption or distraction occurs during the “TIME OUT”, the whole process must be restarted.

▸ “TIME OUT” checking process(es) should be performed for each individually consented procedure(s) which is/ are to be performed on the same patient.

▸ If repositioning of patient is required in order to proceed for a new, separately consented procedure, "TIME OUT" safety check should be conducted for the new procedure after repositioning.

Surgical Safety Protocol:

▸ Before discharging the patient from the operation room, the staff should confirm the following “SIGN OUT” checking with the operating doctor, anaesthetist and operation room nurse:

- Correct counting and checking of the integrity of all countable surgical/interventional items.

- Correct labelling of the specimen(s).

- Review key concerns for recovery/ post-surgical management.

Types of anaesthesia:

▸ Applied directly to skin and mucous membrane, open skin surface, wound and burns

▸ Readily absorbed and act rapidly

▸ e.g. lidocaine (Xylocaine)

Types of anaesthesia:

▸ Injected to a specific area

▸ Used for minor surgical procedures

▸ e.g. suture small wound or perform a biopsy

▸ e.g. Lidocaine

Types of anaesthesia:

▸ Anesthetic agent is injected into and around a nerve or small nerve group that supplies sensation to a small area of the body

▸ Major blocks involve multiple nerves or a plexus (e.g. brachial plexus anesthetizes the arm)

▸ Minor block involve a single nerve (e.g. facial nerve)

Types of anaesthesia:

▸ Injection into cerebral spinal fluid (CSF)

▸ Low spinal: surgeries involve perineal or rectal areas

▸ Mid spinal: hernia repairs / appendectomies

▸ High spinal: cesarean sections

Types of anaesthesia:

▸ Injection of an anesthetic agent into the epidural space, the area inside the spinal column but outside the dura mater

Implementation:

? coordinates activities and manages client care by continually assessing client safety (e.g. client positioning), monitoring aseptic practice and the environment (e.g. temperature, humidity and lighting).

Implementation:

? wears sterile gowns, gloves, caps and eye protection. Their roles are to assist the surgeon by:

- Controlling bleeding

- Using equipment

- Handling the cutting tissues and suturing during the procedure

Implementation:

? are responsible for accounting for all sponges, needles and instruments at the closure phase of surgery to prevent foreign bodies from being left inside the client’s body.

- Perform Initial count for all accountable items before the procedure to establish a baseline for subsequent counts

- Perform Change over count for all accountable items at the relief of the scrub nurse

Implementation:

Perform ? for all accountable items prior to closure of a cavity

Implementation:

Perform ? for all accountable items before wound closure begins

Implementation:

Perform ? for all accountable items at skin closure or the end of the operative procedure.

Positioning:

Clients who have spinal anaesthetics usually lie flat for ? hours.

According to the Time of Occurrence:

- Occurs immediately at the time of injury or operation

According to the Time of Occurrence:

- Occurs after injury and within 24 hours due to loosening of ligatures / sutures

According to the Time of Occurrence:

-Occurs in 7-10 days after injury due to infection or erosion of a vessel from a spreading infection

According to the Site:

- Similar to hypovolaemic shock

- Have evidence of blood loss

- Rapid & thread pulse

- Shallow & rapid respiration

- Drop in blood pressure

- Cold & clammy skin

- Pale face & lips

- Thirst & dry mouth

- Faint & blurred vision

- Restless, confused & altered consciousness

- Pain

According to the Site:

- Initially pale, cold, clammy skin. If bleeding continues, the skin may turn cyanosis

- Rapid, weak pulse

- Thirst

- Rapid, shallow breathing

- Confusion, restlessness and irritability

- Possible collapse and casualty may become unresponsive

- Bleeding from orifices of body

- In cases of violent injury, “pattern bruising” – an area of discoloured skin with a shape that matches the pattern of clothes or crushing or restraining objects

- Pain

Measures to Control External Bleeding:

By slowing the blood flow by gravity

X if a fracture is suspected

X if elevation causes the client pain or discomfort.

Measures to Control External Bleeding:

1. Apply pressure located between the site of injury and the heart where a main artery passes over a bone or underlying muscle mass.

2. Only use if direct pressure and elevation fails

- MUST NOT be applied for > 10 min

Classification of shock:

When blood is lost in such amount that remaining blood cannot fill the circulatory system

Classification of shock:

Circulatory blood volume remain normal, but there is massive vasodilatation leading to acute reduction of systemic blood pressure resulting from the disruption of autonomic pathways within the spinal cord

Classification of shock:

Inadequate cardiac pumping function resulted from impaired heart muscle, disorder of heart rate & rhythm, mechanical obstruction of blood flow

Classification of shock:

Toxins of bacteria act on blood vessels resulting in vasodilatation, easily causing a sudden blood pressure drop

Classification of shock:

Allergic reaction affects blood vessels & other tissues, causing acute blood pressure drop & severe dyspnoea

Stages of shock:

Anaerobic respiration may lead to metabolic acidosis

Stages of shock:

Rapid pulse, rapid and shallow respiration, anxiety, decreased urine output

Stages of shock:

When compensatory mechanism fails to cope with reduced cardiac output, client may develop decreased blood pressure, disoriented, oliguria

Stages of shock:

Myocardial depression & damage to other organs may occur. Client may have extremely low blood pressure, loss of consciousness, damage to other organs

Clinical manifestations of shock:

• A rapid pulse

• Pale, cold and clammy skin

• sweating

Clinical manifestations of shock:

• Rapid, shallow breathing

• A weak, “thread” pulse.

• Grey-blue skin (cyanosis), especially inside the lips.

• A fingernail or earlobe, if pressed, will not regain its colour immediately

• Weakness and dizziness

• Nausea and possibly vomiting

• Thirst

Clinical manifestations of shock:

• Restlessness and aggressive behavior

• Yawning and gasping for air

• Client becomes unresponsive

• Finally the heart will stop

CPR- Compression-ventilation ratios:

Adult

CPR- Compression-ventilation ratios:

Adult

CPR- Compression-ventilation ratios:

Children

CPR- Compression-ventilation ratios:

Children and Infant

CPR- Compression-ventilation ratios:

Infant

High quality CPR, Compression depth:

Adults & adolescents

High quality CPR, Compression depth:

Children

High quality CPR, Compression depth:

Infants

High quality CPR:

Push fast give chest compression at a rate of ?

life-threatening arrhythmias:

The heart’s electrical activity becomes disordered. The heart muscles quiver in a fast and unsynchronized way, so the heart does not pump blood.

life-threatening arrhythmias:

a rapid heart rate when the ventricles (lower chambers) of heart begin contracting at a very fast pace. The ventricles pump so quickly and inefficiently that no pulse can be detected.

Application of adhesive AED pad, Adult & child pads:

Adult can use child pads

Application of adhesive AED pad, Adult & child pads:

Infants/children can use adult pads

Com m on laboratory tests for sputum:

To identify a specific m icroorganism.

To identify the microorganism’s drug resistance and sensitivities.

Specimen Bottle used: Sterile Plastic Container for Sputum Culture

Com m on laboratory tests for sputum:

To screen for the presence of AFB and detection of tuberculosis (TB).

Serial collection for 3 consecutive EARLY MORNING.

Specimen Bottle used: Plastic Container

Common laboratory tests for sputum:

To identify lung cancer.

Serial collection for 3 consecutive days.

Specimen Bottle used: Plastic Container

Common laboratory tests of urine:

• To identify urinary tract infection (UTI).

• To determine the most effective antibiotic for treatment (sensitivity).

• Types of tests:

 Midstream urine (MSU).

 Catheterized-saved urine (CSU).

Specimen Bottle Used: Urine culture bottle (with boric acid preservative).

Common laboratory tests of urine:

• To measure kidney excretion of certain substances, which include total urine protein, creatinine, urobilinogen, uric acid, electrolytes, and hormones during 24 hours’ period.

Specimen Bottle Used: 24-hour urine container.

Bottle content: Plain: Na/K, Urea, Creatinine, Protein, Free Cortisol.

5g NaHCO3: Urate.

Hydrochloric acid (HCL): Calcium, Phosphate, Metanephrines.

Common laboratory tests of urine:

To identify cancer cells.

Specimen bottle used: Plain urine bottle.

Common laboratory tests of urine:

To screen for the presence of AFB for detection of TB.

For 3 consecutive early mornings.

Specimen bottle used: 500ml Plastic bottle.

Common laboratory tests of urine:

To detect for drug overdose

Specimen bottle used: 20 mL spot urine in plain bottle

Types of stool specimen collection:

• To identify a specific micro-organism growing in the stool.

• To identify the microorganism’s drug resistance and sensitivities.

Types of stool specimen collection:

• To screen for the presence of invisible blood in the stool which is difficult to detect in naked eye inspection.

• For conditions such as colon cancer, bleeding gastrointestinal ulcers, and localized gastric or intestinal irritation.

• Required for 3 consecutive days.

Types of stool specimen collection:

- To look for any ova and parasites

Types of stool specimen collection:

- Save mainly for doctor's naked eye inspection

- Usually collected in bedpan or napkin

Types of stool specimen collection:

- To detect globin moiety of human hemoglobin only

- Not appropriate for the detection of upper gastrointestinal tract bleeding

Removal of suture/staples, Assessment:

1. client’s identity

2. physician’s orders

3. risk for impaired wound healing

4. comfort level (pain scale)

Removal of staples:

• Place lower tips of sterile staple remover ? the staple

• Squeeze the handles together until they are completely closed

Removal of staples:

• Place removed staples on a sterile gauze

• Remove ? staple to ensure the wound edges are healed

Removal of suture/staples, Documentation:

1. The number of sutures/ staples removed

2. appearance of the incision

3. Type of dressing applied

4. Client’s response

Patient education:

● Instruct client to try to keep the wound dry for the first ? days. Showers are preferable to baths, to avoid soaking the wound; use a shower cap if the wound is on the head, and pat the wound dry if it gets wet. Do not rub the wound.

Wound drain:

• Without a drain, some wounds would heal on the surface and trap the discharge inside and abscess might form

• Generally, the suction is discontinued from ? days postoperatively or when drainage is minimal.

Special considerations when performing drainage tube removal:

● Do not carry out wound drain removal procedure and clarify with doctor if ? hours drain output remains high or suddenly increases drain output, or change in patient’s general condition and nature of drainage.

Prevent recurrence of urinary tract infection:

- These substances can be irritating to the urethra and encourage inflammation and bacterial infection

Prevent recurrence of urinary tract infection:

- Accumulation of perineal moisture facilitates bacterial growth. Cotton enhances ventilation of the perineal area

Prevent recurrence of urinary tract infection:

- This creates irritation of the urethra and prevents ventilation of the perineal area

Prevent recurrence of urinary tract infection:

- Prevent introduction of gastrointestinal bacteria into the urethra

Prevent recurrence of urinary tract infection:

- Bacteria present in bath water can readily enter the urethra

Manage urinary incontinence:

Goals:

• Gradually lengthen intervals between urination to correct client’s frequent urination, stabilize the bladder and diminish urgency

• Delayed voiding provides larger voided volume and longer intervals between voiding

• Instructs client to practice deep, slow breathing every time client has a premature urge to void, until the urge diminishes or disappears.

• Encourage voiding every 2 – 3 hours initially except during sleeping

• Gradually increase voiding to every 4 – 6 hour

Manage urinary incontinence:

Goals:

• Keep clients dry by having them void at regular intervals (e.g. 2 – 4 hours)

Hazard of urinary catheterization:

• Occurs while indwelling catheter in place or within 48 hours of its removal

• Most frequent health care-associated infection

• Introduce microorganisms into the bladder

• Signs and symptoms: foul-smell urine, cloudy urine, haematuria, renal inflammation, kidney infection, bladder spasms, elevated levels of WBCs and fever, be aware that client may be asymptomatic

Hazard of urinary catheterization:

• Particularly in male, whose urethra is longer and more tortuous

• Damage to urethra if the catheter is forced through strictures or at an incorrect angle

Materials of urinary catheters:

• Resistant to encrustation

• Can stay in place up to 12 weeks (depending on the manufacturer instruction)

• Used for clients with latex hypersensitivity

Materials of urinary catheters:

• For intermittent use

• e.g. Nelaton catheter

Lubricate the tip of the catheter:

?cm for female

Lubricate the tip of the catheter:

?cm for male

Urinary catheterization:

• Gently pull back the catheter until resistance is felt

- Ensure the balloon has inflated and to place it in the trigone of the bladder

• Reposition the foreskin for ? client if indicated

- Prevent paraphimosis or even gangrene

Nursing Care to prevent catheter - associated urinary tract infection:

• Drink up to ?ml/ day if not contraindicated to ensure large urine output:

- Keeps bladder flushed out

- Decrease likelihood of urinary stasis and subsequent infection

- Minimize the risk of sediment or other particles from obstructing the drainage tubing

Removal of an Indwelling Urinary Catheter:

• Check if there is any lower abdominal distension & failure to pass urine ? hours after catheter removal. Take appropriate actions accordingly