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TABLE OF CONTENTS

Definition of terms............................................

Introduction...................................................

Review of Anatomy and Physiology of the Uterus and Cervix......

Pathophysiology................................................

Discussion of the Procedure....................................

Instrumentation................................................

Nursing Management.............................................

Drug Study..

Reference......................................................

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INTODUCTION

Total Abdominal Hysterectomy and Bilateral Salphingo

Oopherectomy,this is the removal of the uterus including the cervix

as well as the tubes and ovaries using an incision in the abdomen.

Terectomy is the surgical removal of the uterus. Hysterectomy may be

total, as removing the body and cervix of the uterus or partial, also

called supra-cervical.

Salphingo refers specifically to the fallopian tubes which

connect the ovaries to the uterus. Oophorectomy is the surgical

removal of an ovary or ovaries. Hysterectomy is also referred to as

sugical menopause. Indications OF TAH-BSO Hysterectomy is often

performed on cancer patients or to relieve severe pelvic pain from

things like, endometriosis or adenomyosis.

A hysterectomy is a surgical procedure whereby the uterus (womb)

is removed. Hysterectomy is the most common non-obstetrical surgical

procedure of women in the United States. Approximately 300 out of

every 100,000 women will undergo a hysterectomy.

A hysterectomy is also performed to treat uterine cancer or very

severe pre-cancers(called dysplasia, carcinoma in situ, or CIN III,

or micro-invasive carcinoma of the cervix).A hysterectomy

for endometrial cancer (uterine lining cancer) has an obvious

purpose, that of removal of the cancer from the body. This procedure

is the foundation of treatment for cancer of the uterus. Therefore, a

premenopausal (still having regular menstrual periods) woman whose

uterine fibroids are causing bleeding but no pain is generally first

offered medical therapywith hormones. Non-hormonal treatments are

also available, such as tranexamic acid and more moderate surgical

procedures, such as ablations (removal of the lining of the uterus).

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If she still has significant bleeding that causes major

impairment to her daily life, or the bleeding continues to cause

anemia (low red blood cell count due to blood loss), and she has no

abnormality on endometrial sampling, she may be considered fora

hysterectomy. This is the most common type of hysterectomy. During a

total abdominal hysterectomy, the doctor removes the uterus,

including the cervix. The scar may be horizontal or vertical,

depending on the reason the procedure is performed, and the size of

the area being treated. Cancer of the ovary(s) and uterus,

endometriosis, and large uterine fibroids are treated with total

abdominal hysterectomy. Total abdominal hysterectomy may also be done

in some unusual cases of very severe pelvic pain, after a very

thorough evaluation to identify the cause of the pain, and only after

several attempts at non-surgical treatments. Clearly a woman cannot

bear children herself after this procedure, so it is not performed on

women of childbearing age unless there is a serious condition, such

as cancer. Total abdominal hysterectomy allows the whole abdomen and

pelvis to be examined, which is an advantage in women with cancer or

investigating growths of unclear cause.

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ANATOMY AND PHYSIOLOGY

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Physiology

Vagina

The vagina is a fibro muscular tubular tract leading from the uterus

to the exterior of the body in female mammals, or to the cloaca in

female birds and some reptiles. Female insects and other

invertebrates also have a vagina, which is the terminal part of the

oviduct.

The vagina is the place where semen from the anatomic male is

deposited into the anatomically female person's body at the climax of

sexual intercourse, commonly known as ejaculation. Around the vagina,

pubic hair protects the vagina from infection and is a sign of

puberty. The vagina is mainly used for sexual intercourse.

Cervix

The cervix is the lower, narrow portion of the uterus where it joins

with the top end of the vagina. It is cylindrical or conical in shape

and protrudes through the upper anterior vaginal wall. Approximately

half its length is visible, the remainder lies above the vagina

beyond view. The vagina has a thick layer outside and it is the

opening where baby comes out during delivery. The cervix is also

called the neck of the uterus.

Uterus

The uterus or womb is the major female reproductive organ of humans.

The uterus provides mechanical protection, nutritional support, and

waste removal for the developing embryo (weeks 1 to 8) and fetus

(from week 9 until the delivery). In addition, contractions in the

muscular wall of the uterus are important in ejecting the fetus at

the time of birth.

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The uterus contains three suspensory ligaments that help stabilize

the position of the uterus and limits its range of movement. The

uterosacral ligaments, keep the body from moving inferiorly and

anteriorly. The round ligaments, restrict posterior movement of the

uterus. The cardinal ligaments, also prevent the inferior movement of

the uterus.

The uterus is a pear-shaped muscular organ. Its major function is to

accept a fertilized ovum which becomes implanted into the

endometrium, and derives nourishment from blood vessels which develop

exclusively for this purpose. The fertilized ovum becomes an embryo,

develops into a fetus and gestates until childbirth. If the egg does

not embed in the wall of the uterus, an anatomically female person

begins menstruation and the egg is flushed away.

Fallopian Tube

The Fallopian tubes or oviducts are two tubes leading from the

ovaries of female mammals into the uterus.

On maturity of an ovum, the follicle and the ovary's wall rupture,

allowing the ovum to escape and enter the Fallopian tube. There it

travels toward the uterus, pushed along by movements of cilia on the

inner lining of the tubes. This trip takes hours or days. If the ovum

is fertilized while in the Fallopian tube, then it normally implants

in the endometrium when it reaches the uterus, which signals the

beginning of pregnancy.

Ovaries

The ovaries are small, paired organs that are located near the

lateral walls of the pelvic cavity. These organs are responsible for

the production of the ova and the secretion of hormones. ovaries are

the place inside the anatomically female body where ova or eggs are

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produced. The process by which the ovum is released is called

ovulation. The speed of ovulation is periodic and impacts directly to

the length of a menstrual cycle.

After ovulation, the ovum is captured by the oviduct, after traveling

down the oviduct to the uterus, occasionally being fertilized on its

way by an incoming sperm, leading to pregnancy and the eventual birth

of a new human being.

The Fallopian tubes are often called the oviducts and they have small

hairs (cilia) to help the egg cell travel.

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PATHOPHYSIOLOGY

TOTAL ABDOMINAL HYSTERECTOMY BILATERAL SALPHINGO OOPHORECTOMY

Total abdominal hysterectomy is utilized for benign and

malignant disease where removal of the internal genitalia is

indicated. The operation can be performed with the preservation or

removal of the ovaries on one or both sides. In benign disease, the

possibility of bilateral and unilateral oophorectomy should be

thoroughly discussed with the patient. Frequently, in malignant

disease, no choice exists but to remove the tubes and ovaries, since

they are frequent sites of micrometastases. Endometrial carcinoma is

the third most common cause of gynecologic cancer death (behind

ovarian and cervical cancer). A total abdominal hysterectomy

(surgical removal of the uterus) with bilateral salpingo-oophorectomy

is the most common therapeutic approach.

In general, the modified Richardson technique of intrafascial

hysterectomy is used. The purpose of the operation is to remove the

uterus through the abdomen, with or without removing the tube and

ovaries.

Indications OF TAH-BSO

-Hysterectomy is often performed on cancer patients or to relieve

severe pelvic Pain from things like, endometriosis or adenomyosis.

-Hysterectomy is also used as a last resort for postpartum

obstetrical hemorrhage or uterine fibroids that cause heavy or

unusual bleeding and discomfort in some women.

-Transsexuals undergoing sex reassignment surgery as part of a

female-to-male

(FTM) transition commonly have hysterectomies and oophorectomies to

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remove

the primary sources of female hormone production.

Cancer prevention

Oophorectomy can significantly improve survival for women with high

risk BRCA mutations.

For women with high risk BRCA1 mutations prophylactic oophorectomy

around age 40 reduces the risk of ovarian and breast cancer and

provides significant and substantial long-term survival advantage.

Earlier intervention does not, on average, provide any additional

benefit but increases risks and adverse effects.

For women with high risk BRCA2 mutations, oophorectomy around age 40

has a relatively modest benefit on survival; the positive effect of

reduced breast and ovarian cancer risk is nearly balanced by adverse

effects. The survival advantage is more substantial when oophorectomy

is performed together with prophylactic mastectomy

Endometriosis

In rare cases, oophorectomy can be used to treat endometriosis by

eliminating the menstrual cycle, which will reduce or eliminate the

spread of existing endometriosis as well as reducing the pain. Since

endometriosis results from an overgrowth of the uterine lining,

removal of the ovaries as a treatment for endometriosis is often done

in conjunction with a hysterectomy to further reduce or eliminate

recurrence.

Oophorectomy for endometriosis is used only as last-resort often in

conjunction with a hysterectomy, as it has rather severe side effects

for women of reproductive age and low success rate.

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Oophorectomy at age 40 or later might also be used to prevent ovarian

cancer although there is currently no evidence that cancer prevention

alone is a sufficiently strong indication to justify the surgery.

Partial oophorectomyovarian cyst removal not involving total

oophorectomyis often used to treat milder cases of endometriosis

when non-surgical hormonal treatments fail to stop cyst formation.

Removal of ovarian cysts through partial oophorectomy is also used to

treat extreme pelvic pain from chronic hormonal-related pelvic

problems.

Physiologic Changes. The predominant physiologic change from

removal of the uterus is the elimination of the uterine disease and

the menstrual flow. If the ovaries are removed with the specimen, the

predominant physiologic change noted is loss of the ovarian steroid

sex hormone production.

Points of Caution. The predominant point of caution in

performing abdominal hysterectomy is to ensure that there is no

damage to the bladder, ureters, or rectosigmoid colon.

Mobilization of the bladder with a combination of sharp and

blunt dissection frees the bladder from the lower uterine segment and

upper vagina. This reduces the incidence of damage to the bladder.

By exercising extreme care in management of the uterine artery

pedicle, the surgeon may minimize the risk of injury to the ureter.

The same is true of the management of the cardinal and uetrosacral

ligament pedicles. If the vaginal cuff is left open with the edges

sutured, the incidence of postoperative pelvic abscess is

dramatically reduced.

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DISCUSION OF THE PROCEDURE:

A transverse, Pfannenstiel, midline, or paramedian incision is

employed, depending on the diagnosis, anatomical considerations, and

preference of the surgeon. The peritoneal cavity is entered, and a

self retaining retractor is placed. The table is placed in

Trendelenburg position to facilitate viewing the pelvic contents. The

intestines are protected with warm moist (saline) lap pads. The

fundus of the uterus is grasped with a multi-toothed tenaculum for

manipulation this, too, facilitates pelvic exposure. The abdomen is

explored. If adhesions are present, a hydroids sector may be

employed. When the affected fallopian tube is blocked, a laser fiber

may be used to open it and a stent may be placed to maintain patency.

For excision, the infundibulopelvic ligament is ligated and divided,

as are the broad ligament attachment and the blood vessels of the

affected tube and ovary. The tube and ovary are excised. The site of

adnexal excision maybe reperitonealized.

A free raytec sponge (soaked in prep solution) may be placed in

the vagina with long smooth forceps prior to closure. Hemostasis is

secured. The vaginal cuff is closed with a continuous absorbable

suture; a drain may be placed (infrequently).The stumps of the

uterosacral and round ligaments are sutured to the angles of the

vaginal closure. The peritoneum is approximated, and the wound is

closed in layers. Dressings are placed. The free raytec sponge is

removed transvaginally; in order for the sponge count to be correct,

the free raytec sponge must be retrieved before the patient is taken

from the OR to PACU.

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Technique

The patient is placed in the

dorsal lithotomy position, and an

adequate pelvic examination is

performed with the patient under

general anesthesia. This is

extremely important because it

allows the surgeon to become

acquainted with the anatomy of the

internal genitalia. This is

frequently impossible when the

patient is examined in the

gynecologic clinic. The patient is

then put in approximately a 15

Trendelenburg position. A Foley

catheter is left in the bladder

and connected to straight

drainage. In general, midline

incisions are preferred for

Self-retaining retractors are

placed in the abdominal incision,

and the bowel is packed off with

warm, moist gauze packs. A 0

synthetic absorbable suture is

placed in the fundus of the

uterus and used for uterine

traction. The uterus is deviated

to the patient's right. The left

round ligament is placed on

stretch and incised between

clamps.

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malignant disease, since they

allow accurate staging and

exposure to the upper abdomen and

aortic lymph nodes. If

investigation of the upper abdomen

and aortic lymph nodes is needed,

the midline incision should be

extended around and above the

umbilicus for appropriate

exposure.

For benign disease, the

Pfannenstiel incision is an

adequate alternative to the

midline incision.

After the abdomen is entered, it

should be thoroughly explored;

including the liver, gallbladder,

stomach, kidneys, and aortic lymph

nodes.

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The distal stump of the round

ligament is ligated with 0

synthetic absorbable suture. The

proximal stump is held with a

straight Ochsner clamp. At this

point the leaves of the broad

ligament are opened both

anteriorly and posteriorly. This

is performed by delicate

dissection with the Metzenbaum

scissors.

While retracting the uterus

cephalad, the surgeon opens the

anterior lead of the broad

ligament to the vesicouterine

fold. Steps 2-4 are carried out

on the opposite side.

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The vesicoperitoneal fold is

elevated, and the fine filmy

attachments of the bladder to the

pubovesical cervical fascia are

visible. The bladder can be

dissected off the lower uterine

segment of the uterus and cervix

by either blunt or sharp

dissection. If there has been

extensive lower segment disease,

previous cesarean sections, or

pelvic irradiation, blunt

dissection of the bladder off the

cervix is dangerous, and a sharp

dissection technique should be

performed.

If the ovaries are to be

preserved, the uterus is

retracted toward the pubic

symphysis and deviated to one

side with the infundibulopelvic

ligament, tube, and ovary on

tension. A finger should be

inserted through the peritoneum

of the posterior leaf of the

broad ligament under the

suspensory ligament of the ovary

and Fallopian tube. The tube and

suspensory ligament are doubly

clamped, incised, and tied with 0

synthetic absorbable suture. The

distal stump of this structure is

best doubly tied, first with a

single tie of 0 synthetic

absorbable suture and then with a

ligature of 0 synthetic

absorbable suture. The same

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procedure is carried out on the

opposite side.

The uterus is then retracted

cephalad and deviated to one side

of the pelvis with the lower broad

ligament on stretch. The filmy

tissue surrounding the uterine

vessels is skeletonized by

elevating the round ligament and

dissecting the tissue away from

the uterine vessels. Three curved

Ochsner clamps are placed at the

junction of the lower uterine

segment on the uterine vessels.

This is best performed by placing

the tips of the curved Ochsner

clamps onto the uterus and

allowing them to slide off the

body of the uterus, thus ensuring

complete clamping of the uterine

vessels. An incision is made

The uterus is held in traction in

the cephalad position, and the

handle of the knife is used to

dissect the pubovesical cervical

fascia inferiorly. This step

mobilizes the ureter laterally

and caudally.

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between the upper Ochsner clamp

and the two lower Ochsner clamps.

This is suture-ligated with two 0

synthetic absorbable sutures,

placing the first suture at the

tip of the lower Ochsner clamp and

tying the suture behind the base

of the clamp. The middle Ochsner

clamp is left in place and is

similarly suture-ligated by a

second ligature placed at the tip

of the Ochsner clamp and tied

behind the base of the clamp. No

attempt is made to place a suture

in the middle of the pedicle,

since it contains blood vessels

and a pedicle hematoma can be

created.

The same procedure is carried out

on the opposite side.

A delicate, transverse, curved

incision is made in the

pubovesical cervical fascia

overlying the lower uterine

segment. The separation of the

pubovesical cervical fascia from

the underlying cervical stroma is

facilitated by placing traction on

the uterus in the cephalad

position.

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Two straight Ochsner clamps are

applied to the cardinal ligament

for a distance of approximately 2

cm. The cardinal ligament is

incised between the two clamps,

and the distal stump is ligated

with 0 synthetic absorbable

suture. The suture is tied at the

base of the clamp; no attempt is

made to place this suture within

the body of the pedicle because

vessels can be torn and hematomas

created.

The same procedure is carried out

on the opposite cardinal ligament.

The posterior leaf of the broad

ligament is incised down to the

uterosacral ligaments and across

the posterior lower uterine

segment between the rectum and

cervix.

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The uterosacral ligaments on both

sides are clamped between straight

Ochsner clamps, incised, and

ligated with 0 synthetic

absorbable suture.

The uterus is placed on traction

cephalad, and the lower uterine

segment and upper vagina are

palpated between the thumb and

first finger of the surgeon's

hand to ensure that the ligaments

have been completely incised. The

vagina is entered by a stab wound

with a scalpel and is cut across

with either a scalpel or

scissors. The uterus is removed.

The edges of the vagina are

picked up with straight Ochsner

clamps in a north, south, east,

and west direction.

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a. The vaginal cuff is never

closed in our clinic. This alone

has accounted for a radical

decrease in postoperative febrile

morbidity and abscess formation.

The edges of the vaginal mucosa

are sutured with a running locking

0 synthetic absorbable suture

starting at the midpoint of the

vagina underneath the bladder and

carried around to the stumps of

the cardinal and uterosacral

ligaments, which are sutured into

the angle of the vagina.

b. The running locking suture is

carried around the posterior wall

of the vagina ensuring that the

rectovaginal space is obliterated.

c. The cardinal and uterosacral

The pelvis is reperitonealized

with running 2-0 synthetic

absorbable suture from the

anterior to the posterior leaf of

the broad ligament. The stumps of

the tubo-ovarian round,

suspensory ligament of the ovary,

and the cardinal and uterosacral

ligaments are buried

retroperitoneally.

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ligaments of the opposite side

have been included in the running

locking 0 synthetic absorbable

suture, and the reefing process

has been completed to the midpoint

of the anterior vaginal wall. At

this point, meticulous care should

be taken to ensure that the

lateral angle of the vagina is

adequately secured and that

hemostasis is complete between the

lateral angle of the vagina and

the stumps of the cardinal and

uterosacral ligaments. This can be

a site of hemorrhage.

At this point, the pelvis is

thoroughly washed with sterile

saline solution. Meticulous care

is taken to ensure that hemostasis

is present throughout the

dissected area.

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Drains are rarely needed. If they

are indicated, they are placed

through the open vaginal cuff and

carried along the lateral pelvic

wall retroperitoneally.

If the tube and ovary are to be

removed, they are removed at Step

6 in the operation. Instead of

placing a finger underneath the

tube and suspensory ligament of

the ovary, a finger is placed

under the infundilbulopelvic

ligament on that side. Care is

taken to ensure that the ureter

is not included. In various forms

of pelvic disease (endometriosis,

pelvic inflammatory disease,

etc.), the ureter can be deviated

close to the infundibulopelvic

ligament.

The infundibulopelvic ligament is

doubly clamped and incised, and

the distal stump of the ligament

is doubly ligated with a tie of 0

synthetic absorbable suture plus

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a ligature of 0 synthetic

absorbable suture.

For a bilateral salpingo-

oophorectomy, the same procedure

is carried out on the opposite

infundibulopelvic ligament.

The tube and ovary have been

mobilized medially with the

uterine specimens. The remainder

of the operation is carried out as

described in Steps 7-13.

The peritoneum of the pelvis has

been reestablished with the tube

and ovary removed. The stump of

the infundibulopelvic ligament is

buried retroperitoneally.

Postoperatively, no vaginal

packing is left in the vagina,

and no Foley catheter drainage of

the bladder is indicated.

The open vaginal cuff closes

without difficulty. Rarely, a

small bit of granulation tissue

is noted in the upper vagina and

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is adequately treated by

application of silver nitrate 4

weeks postoperatively in the

clinic or office. The patient is

allowed to resume sexual

intercourse 4 weeks after

examination in the clinic and is

allowed to resume work 5 weeks

postoperatively.

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PREPARATION OF THE PATIENT:

Antiembolitic hose are put on the legs, as requested. The

patient is supine; arms may be extended on padded armboards. A pillow

may be placed under the lumbar spine and/or under the knees to avoid

straining back muscles. Padded shoulder braces are secured to the

table. The table may be placed in Trendelenburg position. Pad all

bony prominences and areas vulnerable to skin and neurovascular

trauma or pressure. Apply electrosurgical dispersive pad.

SKIN PREPARATION:

A vaginal and an abdominal prep (separate trays) are required.

The patient legs are placed in a froglike position; prep as for D&C,

Insert a Foley catheter and connect to continuous drainage unit.

Return the patients legs to their original position, place the

drainage unit below the level of the table, and replace the safety

belt.

For the abdominal preparation, begin at the intended site of

incision (usually Pfannenstiel), extending from nipples to mid-thighs

and down to the table at the sides.

ANESTHESIA:

General Endotracheal Anaesthesia (GETA) induced the patient with

gases through a mask worn over the nose and mouth.

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NURSING MANAGEMENT:

Assess perception of change in structure or function of body part

(also proposed change). The extent of the response is more related to

the value or importance the patient places on the part or function

than the actual value or importance. Even when an alteration improves

the overall health of the individual (e.g., an ileostomy for an

individual with pre cancerous colon polyps), the alteration results

in a body image disturbance.

Assess perceived impact of change on activities of daily living

(ADLs), social behavior, personal relationships, and occupational

activities.

Assess impact of body image disturbance in relation to patients

developmental stage. Adolescents and young adults may be particularly

affected by changes in the structure or function of their bodies at a

time when developmental changes are normally rapid, and at a time

when developing social and intimate relationships is particularly

important.

Note patients behavior regarding actual or perceived changed body

part or function. There is a broad range of behaviors associated with

body image disturbance, ranging from totally ignoring the altered

structure or function to preoccupation with it.

Note frequency of self-critical remarks

Acknowledge normalcy of emotional response to actual or perceived

change in body structure or function. Stages of grief over loss of a

body part or function are normal, and typically involve a period of

denial, the length of which varies from individual to individual.

Help patient identify actual changes. Patients may perceive changes

that are not present or real, or they may be placing unrealistic

value on a body structure or function.

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Encourage verbalization of positive or negative feelings about

actual or perceivedchange. It is worthwhile to encourage the patient

to separate feelings about changes inbody structure and/or function

from feelings about self-worth.

Assist patient in incorporating actual changes into ADLs, social

life, interpersonalrelationships, and occupational activities.

Opportunities for positive feedback andsuccess in social situations

may hasten adaptation.

Demonstrate positive caring in routine activities. Professional

caregivers represent amicrocosm of society, and their actions and

behaviors are scrutinized as the patient plansto return to home, to

work, and to other activities.

Teach patient about the normalcy of body image disturbance and the

grief process.

Teach patient adaptive behavior (e.g., use of adaptive equipment,

wigs, cosmetics,clothing that conceals altered body part or enhances

remaining part or function, use ofdeodorants). This compensates for

actual changed body structure and function.

Help patient identify ways of coping that have been useful in the

past. Asking patients toremember other body image issues (e.g.,

getting glasses, wearing orthodontics, beingpregnant, having a leg

cast) and how they were managed may help patient adjust to thecurrent

issue.

Refer patient and caregivers to support groups composed of

individuals with similar alterations.

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DRUG STUDY:

1.NIFEDIPINECLASSIFICATION: Anti-anginals

INDICATION: Vasopastic angina, classic chronic stable angina pectoris

CONTRAINDICATION: contraindicated in patients hypertensive to drugs

ADVERSE EFFECTS:dizziness, light- headedness, somnolence, headache,

weakness,syncope,nervousness

MODE OF ACTION: thought to inhibit calcium ion influx across cardiac

and smoothmuscle cells, decreasing contractility and oxygen demand.

Also may dilate coronaryarteries and arterioles.

PATIENT TEACHING:

Tell patient that chest pain may occur or may worsen brieflywhen beginning drug orwhen dosage increased.

Instruct patient to swallow extended release tablets withoutbreaking, crushing, orchewing them.

Advise patient to avoid taking drug with grape fruit juice.

2.VITAMIN KCLASSIFICATION: vitamins and minerals

INDICATION:RDA, HYPOPROTHROMBONEMIA caused by effect of

oralanticoagulants

CONTRAINDICATION: contraindicated to patients hypertensive to drugs

ADVERSE EFFECTS: dizziness, flushing, transient hypotension after IV

administration,rapid and weak pulse

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MODE OF ACTION: An antihemorraghic factor that promotes hepatic

formation ofactive coagulation factors.

PATIENT TEACHING:

Explain purpose of drugs. Tell the patient to avoid hazardous activities if dizziness

occurs.

Tell patient that foods that provide vitamin K include cabbage,cauliflower, spinach, fish,liver, eggs, meats, and dairy

products.

3.KETOROLACCLASSIFICATION: NSAID

INDICATION: short term management of moderately severe acute pain for

single dosetreatment

CONTRAINDICATION: contraindicated asprophylactic analgesic before

surgery orintraoperatively when homeostasis is critical and in

patients currently receiving aspirin,NSAID or probenecid.

ADVERSE EFFECTS: drowsiness, sedation, dizziness, headache

MODE OF ACTION: may inhibit prostaglandin synthesis to produce anti-

inflammatory,analgesic, and anti-pyretic effects

PATIENT TEACHING:

Correct hypovolemia before giving. Carefully observe patients with coagulopathies and those taking

anticoagulants.

NSAID may mask signs and anti inflammatory actions.

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4.TRAMADOL HClCLASSIFICATION: opiod analgesic

INDICATION: moderate to moderately severe pain

CONTRAINDICATION: contraindicated in patients with acute intoxication

from alcohol,hypnotics, centrally acting analgesics, opiods or

psychotropic drugs.

ADVERSE EFFECTS: dizziness, vertigo, headache, somnolence, CNS

stimulation,asthma, anxiety, confusion, coordination disturbance,

euphoria, nervousness, sleepdisorder, seizures

MODE OF ACTION: A centrally acting synthetic analgesic compound not

chemicallyrelated to opiods. Thought to bind to opiate receptors and

inhibit reuptake ofnorepinephrine and serotonin

PATIENT TEACHING:

Tell patient to take drug as prescribed and not to increase doseor dosage intervalunless ordered by physician.

Advise patient to check with prescriber before taking OTC drugsbecause interactionscan occur.