Chapter 2
Care of the Surgical Patient
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Introduction to Operative Care
• Perioperative care is care that clients receive
before, during, and after surgery
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Slide 2
Introduction to the Surgical
Patient
• Classification of surgical procedures

Seriousness
• Major surgery

Extensive reconstruction of or alteration in body parts
o Examples: Coronary artery bypass, gastric resection
• Minor surgery

Minimal alteration in body parts
o Examples: Cataracts, tooth extraction
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Slide 3
Introduction to the Surgical
Patient
• Type of surgery according to urgency

Elective
• Patient’s choice or convenience


Example: Plastic surgery, removal of superficial cyst
Urgent
• Necessary for patient’s health


Examples: Excision of malignant tumor, gallstones
Emergency
• Must be done immediately to save life or preserve
function

Example: Control of hemorrhage, repair of intestinal
perforation
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Slide 4
Introduction to the Surgical
Patient
• Purpose of Surgery

Diagnostic
• Confirm diagnosis


Example: Exploratory laparotomy (large abdominal
incision to examine abdominal organs), tumor biopsy
Ablation
• Excision or removal of diseased body part or removal of
a growth or harmful substance


Examples: Amputation (diabetes), cholecystectomy
Palliative (will not produce cure)
• Relieves or reduces intensity of disease symptoms

Example: Colostomy
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Slide 5
Introduction to the Surgical
Patient
• Purpose of Surgery (continued)

Reconstructive
• Restores function or appearance to traumatized or
malfunctioning tissue


Example: Internal fixation of fractures, breast
reconstruction, scar revision
Transplant
• Replaces malfunctioning organs or structures


Examples: Kidney, cornea transplant
Constructive
• Restores function lost or reduced as result of congenital
anomalies

Example: Repair of cleft palate, closure of atrial-septal
defect in the heart
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Slide 6
Perioperative Care – Pre-operative
• Inpatient surgery: procedures performed on a
client who is admitted to the hospital, expected to
remain at least overnight, and needs nursing care
for more than 1 day after surgery
• Outpatient surgery: operative procedures
performed on clients who return home the same
day
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Slide 7
Preoperative Period (cont’d)
• Outpatient surgery (cont’d)

Clients remain in the outpatient surgical suite
for a brief time and get discharged by
midafternoon or early evening when:
o The client is awake and alert
o Vital signs are stable
o Oral fluids are retained
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Slide 8
Preoperative Period
• Laser surgery

Used as an alternative to many previously
conventional surgical techniques such as
reattaching the retina, removing skin tattoos,
and revascularizing ischemic heart muscle
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Slide 9
Preoperative Period (cont’d)
• Laser surgery (cont’d)

Advantages
o Cost effectiveness
o Reduced need for general anesthesia
o Minimal blood loss
o Less time recuperating
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Slide 10
Perioperative Nursing
• Phases of the operative process which includes:


Preoperative
• Before surgery
Intraoperative
• During surgery

Postoperative
• Following surgery
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Slide 11
Perioperative Nursing
• Factors influencing patient outcomes:

Age (altered body response to physiological
changes, altered metabolic needs)


Young patients
Older patients
• Physical condition
• Healthy patients
• Coexisting health problems

Nutritional factors
• Carbohydrates and fat—energy producers
• Proteins—build and repair
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Slide 12
Perioperative Nursing
• Factors influencing patient outcomes:

Psychosocial Needs
• Fear of loss of control (anesthesia)
• Fear of the unknown (outcome, lack of knowledge)
• Fear of anesthesia (waking up)
• Fear of pain (pain control)- let patient know
availability of pain medication
• Fear of death (surgery, anesthesia)
• Fear of separation (support group)
• Fear of disruption of life patterns (ADLs, work)
• Fear of detection of cancer
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Slide 13
Perioperative Nursing
• Factors Affecting Patient’s Outcomes

Socioeconomic and cultural needs
•
•
•
•
•

Social
Economic
Religious
Ethnic
Cultural
Education and experience
• Age
• Life experiences
• Educational level
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Slide 14
Preoperative Assessment
• Preoperative assessment must include home
medications in use

Prescription medications
 Over the counter medications
 Herbal remedies
• Allergies
• Past surgeries
• Infection and disease history
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Slide 15
Preoperative Phase
• Preoperative teaching – Ideally 1 to 2 days prior to
surgery when anxiety is not as high

Include patient and family
 Clarify preoperative and postoperative events
 Surgical procedure
 Informed consent
 Skin preparation
 Gastrointestinal cleanser
 Time of surgery
 Area to be transferred, if applicable
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Slide 16
Preoperative Phase
• Preoperative teaching (continued)




Frequent vital signs
Dressings, equipment, etc.
Turning, coughing, and deep-breathing exercises
Pain medication (PRN)
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Slide 17
Preoperative Phase
• Preoperative preparation

Laboratory tests – eg: serum potassium levels – to prevent
dysrhythmias related to anesthesia
• Urinalysis
• Complete blood count
• Blood chemistry profile

Endocrine, hepatic, renal, and cardiovascular function
• Electrolytes

Diagnostic imaging
• Chest x-ray
• Electrocardiogram
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Slide 18
Preoperative Phase
• Patient Bill of Rights - Informed consent

Permission that a client gives after an
explanation of the risks benefits, and
alternatives for any specific test or procedure
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Slide 19
Preoperative Phase
• Informed consent

Competent
• Mentally able to understand







Should not be under the influence of pain medications
Agrees to the procedure
Information clear
Risks explained
Consequences understood
Alternatives discussed
Ability to understand (language, disabilities)
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Slide 20
Surgical Consent Form – must be signed by the
patient
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Slide 21
Preoperative Phase
• Gastrointestinal preparation

NPO after midnight (6 to 8 hours)
• Documentation (in-patient – sign over bed, fluids
removed from the room)
• Comfort measures to reduce patient’s feelings of
“dryness” (wet cloth on patient’s lips)

Bowel cleanser (GoLYTELY)
• Rationale for use (anesthesia relaxes bowel, lessen
postoperative GI problems)
• Contraindications (GI obstruction, bowel perforation)
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Slide 22
Preoperative Phase
• Skin preparation

Removal of hair (lesser rate of infection with
clip/depilatory)
• Shave (performed close to time of surgery)
• Electric clippers
• Depilatory

Assess for skin impairment
•
•
•
•

Infection
Irritation
Bruises
Lesions
Scrub with antiseptic solution applied (Hibiclens)
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Slide 23
Preoperative Period (cont’d)
• Preoperative blood donation

Autologous transfusion: self-donated blood
 Directed donors: blood donors chosen from
among the client’s relatives and friends. If
directed donation not used, it is available
for use by other clients
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Slide 24
Latex Allergies
• Increased incidence of latex allergies presenting in
the health care environment


Categories – irritant (most common), Type I (true
allergic reaction to proteins present) and Type IV
(systemic reaction when latex is touched, inhaled or
ingested)
Risk factors- hx of allergies/asthma, multiple surgical
procedures, food allergies
• Nursing interventions to reduce risk to the latexsensitive patient – latex free crash cart, pre-op
medications corticosteroids, antihistamines
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Slide 25
Preoperative Phase
• Respiratory preparation

Incentive spirometry
• Prevent or treat atelectasis
• Improve lung expansion
• Improve oxygenation

Turn, cough, and deep-breathe
•
•
•
•
•
At least every 2 hours
Turn from side-to-back-to-side
Two to three deep breaths
Cough two to three times (splint abdomen if needed)
Contraindicated: surgeries involving intracranial, eye,
ear, nose, throat, or spinal areas
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Slide 26
Figure 2-3
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2008]. Nursing interventions and clinical skills. [4th ed.]. St. Louis: Mosby.)
Volume-oriented spirometer.
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Slide 27
Preoperative Phase
• Cardiovascular considerations

Prevents thrombus, embolus, and infarct
• Leg exercises
• Antiembolism stockings (TEDS)
• Sequential compression devices
• Vital signs



Blood pressure, temperature, pulse, and respiration
Frequency depends on hospital and physician
protocol and stability of patient
Needed for baseline to compare with postoperative
vital signs
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Slide 28
Figure 2-4
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2008]. Nursing interventions and clinical skills. [4th ed.]. St. Louis: Mosby.)
Applying antiembolism stockings.
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Slide 29
Preoperative Phase
• Genitourinary concerns

Normal bladder habits
 Instruct patient about postoperative palpation of
bladder
 Urinary catheter may be inserted
• Surgical wounds

Teach patient about incision(s)
• Size and location
• Type of closure
• Drains and dressings
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Slide 30
Preoperative Phase
• Pain

Nontraditional analgesia
• Imagery
• Biofeedback
• Relaxation

Traditional analgesia
•
•
•
•
Intermittent injections
Patient-controlled analgesia (PCA)
Epidural
Oral analgesics (when oral intake allowed)
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Slide 31
Preoperative Phase
• Tubes

Teach patient about possibility of tubes
•
•
•
•
Nasogastric tubes
Wound evacuation units
IV
Oxygen
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Slide 32
Preoperative Phase
• Preoperative medication

Reduces anxiety
• Valium, Phenobarbital

Decreases anesthetic needed
• Valium, meperidine, morphine

Reduces respiratory tract secretions
• Anticholinergics—atropine

If given on nursing unit, use safety measures
• Bed in low position and side rails up
• Monitor every 15 to 30 minutes
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Slide 33
Preoperative Phase
• Anesthesia

General
• Analgesia, amnesia, muscle relaxation, and
unconsciousness occur
• Inhalation, oral, rectal, or parenteral routes

Regional (patient is sedated)
• Renders only a specific region of the body insensitive to
pain
• Nerve block, spinal, or epidural anesthesia (for urologic
procedures)
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Slide 34
Preoperative Phase
• Anesthesia (continued)

Local
• Topical application (Lidocaine) or infiltration into tissues
of an anesthetic agent that disrupts sensation at the
level of the nerve endings
• Immediate area of application
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Slide 35
Conscious Sedation –depressed
level of consciousness
• The administration of drugs to depress the CNS
provides analgesia
Primary uses – bronchoscopy, pulmonary biopsy,
cosmetic surgery
 Advantages – minimal risk, rapid recovery, stable vital
signs
 Nursing assessment for possible reactions – close
access to resuscitation equipment

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Slide 36
Preoperative Phase
• Preoperative checklist


Permits signed and on chart
Allergies
 ID band(s) on patient
 Skin prep done
 Removal of dentures, glasses/contacts, jewelry, nail
polish, hairpins, makeup
 TED stockings applied
 Preoperative vital signs
 Preoperative medications
 Physical disabilities and/or diseases
 History and physical and lab reports on chart
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Slide 37
Preoperative Checklist
Nurse signs to acknowledge that all pre-op nursing interventions have
been done
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Slide 38
Preoperative Phase
• Eliminating errors—wrong site or procedure

Joint Commission guidelines to prevent error
• Preoperative verification
• Site marking
• Verification by surgical team members during a “timeout”
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Slide 39
Preoperative Phase
• Transport to the operating room



Compare patient’s ID bracelet to the medical record
Assist patient to stretcher
Direct family to appropriate waiting area
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Slide 40
Preoperative Phase
• Preparing for the postoperative patient

Sphygmomanometer (blood pressure cuff),
stethoscope, and thermometer
 Emesis basin
 Clean gown, washcloth, towel, and tissues
 IV pole and pump
 Suction equipment
 Oxygen equipment
 Extra pillows and bed pads
 PCA pump, as needed
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Slide 41
Preoperative Period (cont’d)
• Immediate preoperative care

Nursing assessment
o Surgical risk factors
 Low hemoglobin and red cells
 Cardiopulmonary disease
 Malnutrition
 Dehydration
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Slide 42
Preoperative Period (cont’d)
• Immediate preoperative care (cont’d)

Preoperative teaching
o Deep breathing
o Coughing
o Leg exercises
o Postoperative pain management
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Slide 43
Preoperative Period (cont’d)
• Immediate preoperative care (cont’d)

Physical preparation
o Skin preparation
o Elimination
o Food and fluid restrictions
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Slide 44
Preoperative Period (cont’d)
• Immediate preoperative care (cont’d)

Physical preparation (cont’d)
o Care of valuables
o Surgical attire
o Disposition of dentures and prostheses
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Slide 45
Preoperative Period (cont’d)
• Immediate preoperative care (cont’d)

Preoperative medications

Psychosocial preparation

Preoperative checklist
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Slide 46