13/02/23
SURGERY
WELCOME TO LECTURES IN
SURGERY AND I HOPE THAT YOU
WILL ENJOY THE COURSE DESPITE
THAT ITS QUITE LONG
DATES FOR THE TESTS
•TO BE
COMMUNICATED
Definition of concepts and surgical nursing
concepts
• Surgery: This is the type of
treatment that involves surgical
operation.
• Surgeon: This is a physician who is
trained and qualified to perform
operations and practice surgery.
Definition of concepts and surgical
nursing concepts
• Operation: is a procedure in which
the method of performing anything
with instruments on the patient
follows a definite routine.
• Preoperative Phase: This is a period
from the time when the decision is
made for
Definition of concepts and surgical
nursing concepts
• Intra Operative Phase: This is the period
the patient is brought to the operating
room until admission to the recovery
room.
• Post Operative Phase: This is the period
from the admission to the recovery room
after operation to the follow up clinic for
evaluation and rehabilitation at home.
Definition of concepts and surgical
nursing concepts
• Peri – Operative Phase: This is an
encompassing term that in
cooperates the three phases of the
patient’s surgical experience i.e.
preoperative, intra operative and
post operative periods.
General Principles of Surgery and Surgical
Nursing
• Make sure that all equipment to be used
in a surgical procedure is sterilized or
high level disinfected.
• Start with clean procedures and end with
dirt ones
• Always begin with serious cases then
proceed to the non urgent ones
• Start with children first and end with
adults
………
• All the procedures must be done 30
minutes to an hour after cleaning the
operating environment.
• Wash hands before and after each and
every procedure
• Ensure that you put on protective
garments before entering the operating
room.
………
• Patient should be adequately
prepared for an operation
• Patient should be adequately
cared for during an operation
to avoid loss of life.
………………….
• Patient should be nursed
adequately after an operation
• Maintain clear airway and
effective breathing after an
operation
……
• Control pain as much as
possible
• Maintain adequate circulation
before, during and after
operation.
…..
Have adequate knowledge on
common surgical conditions
affecting various systems of the
body.
Patient need to be rehabilited so
as to live as close to normal life as
possible
Types
1
.
E
surgery
of
m
e
r
g
e
n
c
This is a type of surgery done without delay
in the interest of the patient’s survival.
y
…..
• The patient requires immediate
attention as the disorder may be life
threatening. Examples include severe
bleeding (haemorrhage), intestinal or
urinary bladder obstruction,
fractured skull, gun short or stab
wounds, extensive burns etc
…..
• Surgery must be performed
within a few hours or else
life may be lost.
…..
2.Urgent surgery
• This is the type of surgery done within 24
– 30 hours. The patient requires
• Prompt attention because if delayed a bit
longer may cause worsening
(complications) in the condition
…..
• and thus may require more
complicated procedures; e.g.
acute gallbladder infection,
kidney or ureteral stones.
…
3. Required
Surgery
• This is the type of surgery done
within a few weeks or months.
The patient needs to have surgery
at a coming stage as there is no
immediate threat to life and
…..
• complications are not eminent;
e.g. prostatic hyperplasia without
urinary bladderobstruction,
thyroid disorders, cataracts etc.
….
4. Elective/planned surgery
• An elective surgery is a
planned, non-emergency
surgical procedure.
….
• and whereby failure to do it has
no immediate catastrophic end.
• Thus the patient should be
operated on anyway; e.g.repair of
scars, simple hernia, vaginal
repair etc.
….
5. Optional
Surgery
• This is a type of surgery done for
personal preference.
• The decision entirely rests with
the patient; e.g. cosmetic surgery
…
6.Diagnostic Surgery
• This is a type of surgery done for
diagnostic purposes; e.g. biopsy,
exploratorylaparotomy, etc.
7. Curative Surgery
• This is a type of surgery done for
cure purposes; e.g. tumour
excision, removal of an inflamed
appendix (appendicectomy) etc.
…..
8. Reparative
Surgery
• This is a type of surgery where
repairing is done due to damage
of the normal structure; e.g.
repair of multiple wounds,
ruptured uterus or urinary
bladder, etc.
…..
9. Palliative Surgery
• This is a type of surgery that is done to
relieve the symptoms or effects of a
surgical problem without necessarily
total removal of the causative
factors;e.g. relief of pain, insertion of a
nasogastric tube for failure to swallow,
gastric distension, etc.
……
1O. Cosmetic/Reconstructive Surgery
• This is a type of surgery done for the
purpose of beautification or alteration in
the natural make up of individuals.
• The indication is recognised by the
person concerned; e.g. mammoplasty,
facelift, etc.
…..
11. According
to the field
• This is a procedure identified by
the field; e.g. gynaecological,
obstetrical, Orthopaedics, etc.
GENERAL MANAGEMENT OF A
PATIENT UNDERGOING SURGERY
• The management of a patient
undergoing surgery involves
three phases namely;
• Preoperative Phase: This is a
period from the time when the
decision is made for surgery.
….
• Intra Operative Phase: This is the
period the patient is brought to
the operating room until
admission to the recovery room.
….
• Post Operative Phase: This is the
period from the admission to the
recovery room after operation to
the follow up clinic for evaluation
and rehabilitation at home.
GENERAL PREPARATION AND CARE OF
CLIENTS UNDERGOING SURGERY
PREOPERATIVE CARE
Defn: Preoperative care
is the care given to the
patient/client before
s/he goes to theatre.
………
AIM
• To decrease anxiety by preparing
patient psychologically and
physically ready for surgery.
EXPLAINATION ABOUT
SURGERY/CONDITION
• Before the patient goes to
theatre for surgery, the nurse
should explain the type of
surgery he/she is going for.
….
• Patient need to be given
adequate disclosure of the
diagnosis.
…..
• The patient is told the nature and
purpose of proposed surgery.
…..
• The patient should be told the
risks, alternative treatment
and their risks and the
prognosis if treatment is not
instituted.
…..
The patient must
demonstrate clear
understanding and
comprehension about
information given to him
before he is requested to
consent.
….. CONSENT
SIGNING
A consent is a legal document
that protects the patient, surgeon
and hospital and its employees.
…..
• Before surgery can be legally
performed, the patient must
sign a voluntary and informed
consent.
…..
• If patient is a minor(below 16
years of age)unconscious or is
mentally incompetent to sign the
consent, the family member
………………..
or legally appointed
representative member can sign
the consent. If no family member
is available and surgery is
emergency, the ED or two senior
surgeons can sign on before of
the patient.
…..
PSYCHOLOGICAL CARE
• This is given to allay anxiety, give
emotional support and reduce
apprehension about surgery.
…..
• The nurse needs to assess
potential stressors that could
negatively affect surgery such
as loss of body part, loss of
friends.
….
• The nurse must explain the
procedure in simple terms and
avoid using medical Jargon
which patient may not
understand.
….
• Allow patient to express himself
or herself about surgery and
answer any questions asked by
the patient to remove
misconceptions.
….
• As a nurse reinforce the
information given to the
patient by the doctor to
promote understanding.
….
• Tell the patient what to
expect during surgery and
after surgery such as
patient will be under GA.
…..
• Correct all misconceptions
before patient goes for
surgery by asking where he
is not clear.
….
• Involve family members in
preoperative care of the patient
and this tend to reduce social
isolation by the patient.
….
• Develop good nursepatient rapport and work
calmly to avoid alarming
the patient.
….
• Listen to the patient’s concern
before patient goes to theatre
and then taking appropriate
nursing care to reduce fear
and anxiety.
LABORATORY WORK
• Blood should be collected for
HCT/HB to detect anaemia.
….
• Grouping and cross matching in
case of need for blood
transfusion should be done.
….
• Urinalysis to rule out renal
condition may be done
depending on the condition of
patient.
….
• Other blood tests will
depend on the condition of
the patient.
…..
• E.g patient going for renal
surgery may need to have
creatinine test done before
patient goes for surgery.
…..
RADIOLOGIC STUDIES
These may be done depending on
the diagnosis and type of surgery
to be done .
…..
• This will depend on the condition.
Patient going for chest surgery
may need chest x-ray or patient
going for surgery of another
system but complains of
respiratory problems may need
CXR
BATHING/SKIN PREPARATION
• The patient should take a bath or
shower to remove excess body
dirty and oils.
…..
• The site of operation can be
shaved if ordered by the
doctor.
FOOD AND FLUID RESTRICTION (NPO)
• The doctor will give specific
directions concerning withholding
food and fluid before surgery.
…..
• Ensure that the order is followed
strictly.
• Typically, the patient may eat
solid food until supper, but can
have nothing by mouth (NPO)
beginning at midnight before
surgery.
….
• At least the patient should have
nothing by mouth for about 4-6
hours before surgery and this will
reduce chances of vomiting
during the operation.
……
• Place the NPO sign outside the
patient's room. Instruct the
patient of the importance and
the reason for being NPO.
…..
ELIMINATION
• This consists mainly of bladder
and bowel preparation.
….
Bowel preparation
• The patient should be
encouraged to open bowels
before going for surgery.
….
• If ordered, administer an
enema. The enema cleanses
the colon of fecal material.
…
• Bowel preparation helps to
reduces the possibility of
faecal incontinency during
surgery.
….
Bladder preparation
• Encourage patient to pass urine
before going for surgery and
catheterise the patient if ordered
by the doctor.
….
• Catheterization of patient will
help to prevent urinary
incontinence during an
operation.
observations
VITAL SIGNS
• Record vital signs. Obtain and record
the patient's temperature, pulse,
respiration, and blood pressure
before patient goes to theatre.
….
• The vital signs will act as base line
data and will also help to detect
any deviation from normal so
that appropriate action can be
taken before surgery.
…..
• Observe for any pallor in the
hands and the conjunctiva as this
may indicate presence of
anaemia which may compromise
surgery.
…..
• Observe the reaction of
patient to surgery. Some
patients may be anxious and
worried about surgery.
….
• Observe the general
condition of the patient to
note whether fit for
surgery or not.
…..
PATIENT CHARTS/FILE
• Ensure that all the necessary
patient’s charts/file are in place.
….
• The signed consent should
accompany the patient and
any other relevant papers.
….
• Ensure that the blood test results
such as HCT, blood grouping and
cross matching are available
before patient goes to theatre.
….
• If radiological examinations were
ordered such as chest x-ray
accompany the patient as he/she
goes to theatre.
…..
PRE OPERATIVE MEDICATION
• If ordered, administer
preoperative medications.
…..
• Pre-op medications are usually
administered about 30 to 60
minutes before the patient is
taken to the operating theatre.
…..
• The medications may consist of one,
two, or three drugs: a narcotic or
sedative;
…..
a drug to decrease secretions in the
mouth, nose, throat, and bronchi;
and an antiemetic.
…..
• Explain to the patient the effects
experienced following
administration of the medications
(drowsiness, extreme dry mouth).
…..
• Instruct the patient to remain in
bed. Raise the side rails on the
bed and place the call bell if
available within easy reach.
….
LABELLING OF PATIENT
• The patient should be
well labelled for
identification.
…..
• The name, ward and type
of surgery should be
indicated for easy
identification of patients.
…..
PRE OPERATIVE TEACHING
• Teach the patient what is
expected of him during the
surgery and after surgery.
…
• Tell the patient the importance of
following all the instructions, what
will happen in theatre and after
surgery the need of breathing and
any other type of exercises.
PRE OPERATIVE TEACHING
….
• Pre-operative teaching helps
to reduces post operative
complications such as
hypostatic.
….
GOWNING OF PATIENT
• Before the patient goes to the
theatre, the patient should be
given clean gown as this will
reduce chances of infection.
….
REMOVAL OF COSMETICS/ prostheses
• Remove all makeup and nail polish.
Numerous areas (face, lips, oral mucosa,
and nail beds) must be observed for
evidence of cyanosis.
….
• Makeup and nail polish
hide true coloration.
….
• Jewelry and other
valuables should be
removed for safe keeping.
…..
• The patient may wear a
wedding band to surgery, but
it must be secured with tape
and gauze wrapping.
…..
• Do not wrap tightly;
circulation may be
impaired.
….
• Do not leave valuables in the
bedside stand or store in the
narcotics container.
…..
• If possible, send these items
home with a relative until the
patient has need of them.
….
• Chart what has been done
with the valuables.
….
• Remove prostheses. Assist the
patient or provide privacy so
that the patient can remove
any prostheses.
….
• These includes artificial limbs,
artificial eyes, contact lenses,
eyeglasses, dentures, or other
removable oral appliances.
…..
• Place small items in a
container and label them with
the patient's name and room
number.
……
• Dentures are usually left
at the bedside.
…..
ESCOTING PATIENT TO THEATRE
• When the patient is read for surgery,
escort the patient to theatre and give
appropriate handover to the theatre
team
…..
• Tell all the necessary
information that has been
done on the patient.
Post operative care
Aim
• To prevent immediate and
subsequent post operative
complications such as airway
obstruction etc.
…..
• Post operative care is usually
divided into immediate and
subsequent post operative
care.
……
Immediate post operative care
Environment
• The post operative bed should be
made before patient arrives in the
ward (when patient is still in
theatre).
….
• The following equipment should
be by the bed side. Suctioning
machine for suctioning any
secretions.
…..
• Pulse-oxymetre for measuring
oxygen saturation.
• Oxygen concentrator/cylinder for
administering oxygen.
…..
• Vital signs tray for
measuring vital signs.
…..
• Intravenous poles for hanging
IV fluids and various fluids that
may be ordered by the doctor
such as normal saline.
…..
• The patient will be nursed near
nurses’s desk for easy monitoring
as he needs vigilant observation
when still under anaesthesia.
…..
• Ensure that the environment is clean
to prevent any infection, warm for
the comfort of the patient and well
lit for easy observation of patient.
….
• Keep the environment quite
to avoid disturbing the patient.
….
Checking of doctor’s orders
• Data from the preoperative and
intraoperative phases is used to
make an initial assessment.
….
• The assessment is often
combined with implementation
of the doctor's postoperative
orders and should include the
following.
….
Position and safety
• Place the patient in the
position ordered by the
doctor.
…..
• The patient who has had spinal
anesthesia may have to remain
lying flat for several hours.
…..
• If the patient is not fully
conscious, place him in a sidelying position(lateral) and raise
the side rails.
…..
Maintaining patent airway and effective
breathing
• The patient from theatre may
present with laryngospasm which is a
sudden, violent contraction of the
vocal cords.
…..
• This complication may happen
after the patient’s endotracheal
tube, is removed.
…..
• Ensure that the oropharyngeal
airway is place till patient is
able to breath on his own.
…..
• The patient may also present with
Swallowing and cough reflexes
problems which usually are
diminished by the effects of
anesthesia and secretions are
retained.
…..
• This results into Ineffective airway
clearance and this can also lead to
aspiration of vomitus resulting into
respiratory distress and patient may
die.
…..
• To prevent aspiration, vomitus or
secretions should be removed
promptly by suctioning as
necessary as possible.
…..
• If possible, an unconscious or
semiconscious patient should be
placed in a lateral position that
allows fluids to drain from the
mouth.
….
• Maintain the position of the patient's
head to one side and place an emesis
basin under the cheek, extending
from just below the eye to the lower
edge of the bottom lip.
….
• Wipe vomitus or secretions from
the nose or mouth in order to
avoid possible aspiration of these
fluids into the lungs.
….
• Monitor respiratory status as
frequently as prescribed. For
example every hour till condition is
stable.
….
• Respiratory function is assessed
by monitoring the patient's
respiratory rate, rhythm, and
depth, and by observing skin
color.
……
The following observations
indicate ineffective ventilation:
• Restlessness and
apprehension.
….
• Unequal chest expansion with
use of accessory muscles.
• Shallow, noisy respirations.
….
• Cyanosis.
• Rapid pulse rate.
…..
• Ensure that patient is receiving
adequate oxygen and if not on
oxygen therapy administer oxygen as
ordered.
….
Maintaining adequate circulation
• When there is an alteration in
circulatory control or a loss of
circulating fluid, the body's reaction
is shock.
…..
• The most common type of shock
seen in the postoperative patient is
hypovolemic shock which occurs
with a decrease in blood volume..
…..
• Hemorrhage, which is an
excessive blood loss, may lead to
hypovolemic shock.
…..
• Postoperative hemorrhage may
occur from a slipped suture, a
dislodged clot in a wound, or stress
on the operative site.
Severe bleeding after surgery
…..
• The primary nursing care goal is to
maintain tissue perfusion by
eliminating checking if patient is
bleeding and any remove the cause.
…..
• Administer fluids or blood
as ordered by the surgeon.
…..
• The primary purposes of care for
the patient having a hemorrhage
include stopping the bleeding and
replacing blood volume.
……
observations
Vital signs.
• Take vital signs and note alterations
from postoperative and recovery
room data, as well as any symptoms
of complications.
….
• The vital signs should be taken as
follows: every 15 minutes for the first
30minutes and then half hourly for
the next hour, then hourly for the
next 2hours and finally every 4hours.
…..
• Level of consciousness. Assess the
patient's reaction to stimuli and
ability to move extremities.
…..
• Help the patient become oriented
by telling him that his surgery is
over and that he is back in his
room.
….
• Intravenous fluids. Assess the type
and amount of solution in the bag,
the tubing, and the infusion site.
…..
• Count the rate at which the
intravenous fluid is infusing.
…..
Wound.
• Check the patient's
dressing for bleeding. Note
the color and amount, if
any.
…..
• If there is a large amount
or bright red bleeding,
report this immediately to
the supervisor.
……
Drains and tubes.
• Assess indwelling urinary catheter,
gastrointestinal suction (NTG), and
other tubes for drainage, patency,
and amount of output.
….
• Be sure drainage bags are hanging
properly and suction is functioning.
• If the patient is receiving oxygen, be
sure that the application and flow
rate is as ordered.
…..
• Color and temperature of skin. Feel
the patient's skin for warmth and
perspiration. Observe the patient for
paleness or cyanosis.
….
Comfort.
• Assess the patient for pain, nausea,
and vomiting. If the patient has pain,
note the location, duration and
intensity.
…..
• Determine from recovery room
data if analgesics were given and
at what time.
…..
• Make sure that the patient is warm
and comfortable, and allow family
members to visit after you have
completed the initial assessment.
….
Prevention of hypothermia
This is a possible complication
immediately patient comes
back from theatre.
….
• Keep the room warm, close
near by windows and cover
patient with extra linen.
….
Subsequent care
• This mainly starts after patient
has recovered from anaesthesia
and condition of patient is stable.
….
Position
• The patient now can be put in any
comfortable position and ensure that
this does not cause any pain or un
due pressure on the wound.
…..
Observation
• The nurse continues monitoring
the vital signs and this case the
are done 4 hourly for the
following rationales.
….
• Temperature is done to detect
any fever which may indicate
presence of infection especially
after 24hours.
….
• Pulse may be done to detect any
tachycardia which may indicate
prolonged primary concealed
haemorrhage or secondary
haemorrhage.
….
• Blood pressure may be done to
detect any hypotension which may
indicate prolonged primary
concealed haemorrhage or
secondary haemorrhage.
…..
• Respirations are mainly to detect
any respiratory problems such as
dyspnoea which may indicate
aspiration or hypostatic
pneumonia.
……
• The wound is observed for any
signs of infection and
secondary haemorrhage.
…..
• Observe the general condition
of the patient depending on
the type of surgery done.
Pain management
I. Analgesics
…..
• If the patient is in severe pain,
give prescribed analgesics such as
Pethidine.
…..
• If patient is not in severe pain, mild
analgesics such as panadol can be
given to the patient.
….
• Ensure that patient is not
pressing on the wound site
as this can cause pain.
…..
• Keep room quite and
provide diversional therapy
especially when condition
is so stable.
…..
Medication
• The patient may be on certain
drugs especially intravenous
antibiotics . Ensure that these
drugs are given as per doctor’s
advice
…..
Maintaining Nutrition and fluid
status
• When the patient has just come
back from theatre,
…..
he/she will be initially nil per oral
until when bowel sounds are
heard.
….
• The patient will initially start with
sips of water and when bowel
sounds are heard, he can be
graduated to fluids, light diet and
finally to full diet.
….
• The diet should be well balanced but
rich in proteins for repair of worn out
tissues, rich in vitamins for
promotion of immunity and thus
promote quick recovery.
…..
• Save attractive meals to
promote adequate food
intake.
….
• Avoid resumption of oral feeds too
early as this can lead to nausea and
vomiting.
….
• Depending on the nature of surgery,
the patient may resume oral intake
as soon as the gag reflex returns
…..
• The patient who had abdominal
surgery is usually allowed nil by
mouth (NPO) until the presence of
bowel sounds which indicate the
return of peristalsis.
…..
• When the patient is NPO, IV fluids
are given to maintain fluids and
electrolyte balance.
……
Hygiene
• The patient should be given a bed
bath depending on the condition.
….
• Bathing will promote comfort and of
the patient, blood circulation and
remove bacterial from the body that
can have access through the open
wounds.
….
• Soiled linen especially from urine,
blood and vomitus should be
changed as soon as possible to
reduce
….
chances of infection, pressure sore
development and promote comfort
of the patient.
……
• Regular mouth care is essential
for comfort and stimulation of
salivary glands when patient is
still NPO.
….
Wound care
the amount, color and odour of
the drainage from the wound
should be recorded.
…..
• Carry out dressings as per
surgeon’s advice.
• Maintain aseptic technique
during dressing to prevent cross
infection.
…..
• Advise patient to avoid touching
the wounds to prevent
contaminating the wound with
bacteria leading to local infection.
……
• During dressing check the wound
for signs of infection such as pus,
redness and healing and any
abnormalities should be reported
to the surgeon.
….
• If patient has drains, take care
of them so that they are not
accidentally removed.
…..
Activities
• This will depend on type of
surgery.
• Encourage early ambulation of
patient to prevent hypostatic
pneumonia as well as promote
quick healing.
…..
• Breathing and coughing
exercises are encouraged to
prevent hypostatic
pneumonia.
…..
• Passive exercises also done to
promote blood circulation.
…..
Psychological care
• Work calmly to avoid alarming
the patient
• Explain every procedure done
to promote cooperation.
…..
• Tell patient the progress of
wound healing
• Allow patient to ask questions so
that misconceptions can be
cleared
…..
Catheter care.
• Done for every patient who
has a catheter in-sutu to
prevent ascending infection.
• Mainly done twice a day
Elimination
• Provide patient with bedpan
and urinal whenever need
arises.
• Monitor intake and output
strictly to detect any fluid over
load or dehydration
…….
(Plus any other specific
care as per condition).