Medical-Surgical Nursing: An
Integrated Approach, 2E
Chapter 16
NURSING CARE OF
THE SURGICAL
CLIENT
Surgery
The treatment of injury, disease, or
deformity through invasive operative
methods.
 Surgery is a unique experience, with no
two clients responding alike to similar
operations.

Surgery
Minor: Presenting little risk to life.
 Major: Possibly involving risk to life.

From a Client’s Vantage Point
Surgery is a major stressor for all clients.
 Anxiety and fear are normal.
 Fear of the unknown is the most prevalent
fear prior to surgery and is the fear that is
the easiest for the nurse to help the client
overcome.

Phases of Surgery
Preoperative (before surgery)
 Intraoperative (during surgery)
 Postoperative (after surgery)

Perioperative Nursing
Has one continuous goal: to provide a
standard of excellence in the care of the
client before, during, and after surgery.
 Perioperative nursing is client oriented
and must be geared to meet the client’s
psychosocial needs as well as immediate
physical needs.

Preoperative Phase:
Common Anxieties







Fear of the unknown.
Fear of pain and discomfort.
Fear of mutilation and disfigurement.
Fear of anesthesia.
Fear of disruption of life patterns (separation
from family and significant others; impact on
sexual and financial situation)
Fear of death/not waking up.
Fear of not being in control.
Preoperative Physiologic
Assessment
The outcome of surgical treatment is
tremendously enhanced by accurate
preoperative nursing assessment and
careful preoperative preparation.
 Information gathered through
preoperative assessment and risk
screening is later used for preparation of
the surgical site, for surgical positioning,
and as a comparative basis for
postoperative assessments and
complication screening.

Common Preoperative
Laboratory Tests




Hemoglobin and
hematocrit (Hgb and
Hct)
White blood cell
count (WBC)
Blood typing and
cross matching
(screening)
Serum electrolytes





Prothrombin time
(PT) and partial
thromboplastin time
(PTT)
Bilirubin
Liver enzymes
Urine analysis
Blood urea nitrogen
(BUN) and creatinine
Variables Affecting Surgical
Status





Age
Nutritional status
Fluid and electrolyte
status
Respiratory status
Medications




Cardiovascular status
Renal and hepatic
status
Neurological,
musculoskeletal, and
integumentary status
Endocrine and
immunological status
Client’s Psychological Condition




The psychological condition of a client can have
a stronger influence than does the physical
condition.
Encourage clients to express their feelings and
fears about receiving anesthetic and having
surgery.
Observe the client for nonverbal clues indicative
of anxiety.
To reduce client anxiety, explain to client what
will be happening throughout the surgical
experience.
Psychosocial Health
Assessment
Cultural beliefs can influence a person’s
perception of surgery.
 Clients should be provided the opportunity
to express their spiritual values and
beliefs.

Informed Consent

A legal form signed by the client and
witnessed by another person that grants
permission to the client’s physician to
perform the procedure described by the
physician.
Informed Consent is Required
WHEN:
 Anesthesia is used.
 Procedure is considered invasive.
 Procedure is nonsurgical but has more
than a slight risk of complications.
 When radiation or cobalt therapy is used.
Purposes of Preoperative
Teaching
To answer questions and concerns about
surgery.
 To ascertain client’s present knowledge of
the intended surgery.
 To ascertain the need or desire for
additional information.
 To provide information in a manner most
conducive to learning.

Physical Preparation







Identifying the client and verifying the operative
procedure.
Preparing operative site.
Checking client’s vital signs.
Assisting in putting on hospital gown, cap, and,
if ordered, antiembolic hose.
Verifying allergies.
Verifying NPO (nothing by mouth) status.
Identifying any sensory deficits in the client.
Members of Sterile
Surgical Team



Surgeon.
First assistant (Physician or RN who assists
surgeon in performing hemostasis, tissue
retraction, and wound closure).
Scrub nurse (an LP/VN, RN, or surgical
technologist who prepares and maintains
integrity, safety, and efficiency of the sterile field
throughout the operation).
Sterile Field

The area surrounding the client and the
surgical site that is free from all
microorganisms.
Non-Sterile Members of the
Surgical Team


Anesthesia provider.
Circulating nurse (an RN responsible for
management of personnel, equipment,
supplies, environment, and communication
throughout a surgical procedure).
Asepsis

The absence of pathogenic
microorganisms.
Elements of Aseptic Technique
Sterile gowns and gloves.
 Sterile drapes used to create sterile field.
 Sterilization of items used in sterile field.

Sterile Conscience

The practice of aseptic technique requires
the development of sterile conscience, an
individual’s personal honesty and integrity
with regard to adherence to the principles
of aseptic technique.
Intraoperative Nursing Care
Nurses are responsible for managing six areas
of risk:



Risk of infection related
to invasive procedure
and exposure to
pathogens.
Risk for injury related to
positioning during
surgery.
Risk of injury related to
foreign objects
inadvertently left in the
wound.



Risk for injury related to
chemical, physical, and
electrical hazards.
Risk for impaired tissue
integrity.
Risk for alteration in fluid
and electrolyte balance
related to abnormal
blood loss and NPO
status.
Postoperative Nursing Care
Nurses are responsible for managing seven areas
of risk:




Risk for ineffective
airway clearance.
Risk for ineffective
breathing pattern.
Risk for aspiration.
Risk for decreased
cardiac output.



Risk for fluid volume
deficit.
Risk for
sensory/perceptual
alterations.
Risk for injury and for
altered thought
processes.
Aldrete Score: Defined as:

A means of objectively assessing the
physical status of clients recovering from
anesthesia. Also known as the PostAnesthetic Recovery Score.
Later Postoperative
Nursing Care
Nurses are responsible for managing these risks
and complications:



Risk for ineffective airway
clearance caused by
atelectasis and hypostatic
pneumonia.
Risk for peripheral
neurovascular dysfunction,
fluid volume excess/deficit,
and activity intolerance.
Risk for anxiety or ineffective
individual coping.




Risk for altered nutrition--less
than body requirements
related to nausea and
vomiting, abdominal
distension, constipation and
NPO status.
Risk for urinary retention.
Risk for sensory perceptual
alterations.
Risk for impaired skin integrity
and infection due to surgical
incision.
Ambulatory Surgery
Surgical care performed under general,
regional, or local anesthesia and involving
fewer than 24 hours of hospitalization.
 Also known as same-day, one-day,
outpatient, or short-stay surgery.
 Cost containment, governmental
changes, and technological advances
have all promoted concept of ambulatory
surgery.

Surgery and the Elderly

Because of the physiologic changes and
complex needs of the elderly client
undergoing surgery, the nurse must be
knowledgeable in promoting health and
rehabilitation in the elderly surgical client.