Surgical

Definition of Terms: •

SURGERY: (Greek term cheirourgia, meaning to cut) - the branch of medicine concerned with diseases and trauma requiring operative procedure. SURGICAL OPERATION: - pertaining to the treatment of disease by manipulative and operative methods. SURGICAL ASISTANCE - a nursing intervention (from Nursing Intervention Classifications (NIC) )defined as assisting the surgeon with operative procedures and care of the surgical patient.

General Considerations : Conditions Requiring Surgery:    

Obstruction or blockage Perforation – rupture of an organ artery or bleb. Erosion – wearing away of the surface of a tissue. Tumor – abnormal growth

CATEGORIES OF SURGICAL PROCEDURE (According to):    

PURPOSE: Diagnostic – to verify suspected diagnosis. Exploratory – to estimate the extent of the disease. Curative – to remove or repair damaged or diseased organs or tissues. a. Ablative - involves removal of diseased organs. e.g.nephrectomy, spleenectomy. b. Reconstructive – partial or complete restoration of a damaged organ. e.g. plastic surgery following severe burn c. Constructive – repair of a congenitally defective organ. e.g. plastic surgery of cleft palate. d. Palliative – relieves symtoms.

CATEGORIES FOR SURGICAL PROCEDURE (cont…)  Degree of risk to Patient 1.) Major Surgery – a surgical procedure that is extensive or life threatening. It can be or often done under or other than general anaesthesia.

2.) Minor Surgery – a surgical procedure for minor problems and injuries that are not considered life threatening or hazardous.

CATEGORIES FOR SURGICAL PROCEDURE (cont….)  According to Urgency: 2. 3. 4. 5. 6.

Emergency – must be performed immediately. e.g. gunshot wound Imperative/Urgent – must be performed as soon as possible within 24-48 hours. e.g. severe bleeding Planned Required – necessary for patient’s well being. e.g. tonsillectomy Optional Surgery – surgery that the patient request. e.g. face lift, liposuction Elective Surgery – should be performed for patient’s well-being but which is not absolutely necessary. e.g. simple hernia repair.

CATEGORIES FOR SURGICAL PROCEDURE (cont….)  Effects of Surgery upon the person.  Stress response is elicited. (increase HR, BP, blood sugar, bronchial dilation).  Defense against infection is lowered.  Vascular system is disrupted.  Organ functions are disturbed.  Body image may be disturbed.  Lifestyle may change.

CATEGORIES FOR SURGICAL PROCEDURE (cont…..)

 2. • d) e) f) g) h)

Factors in the Estimation of Surgical Risk Physical and mental conditions of client: Factors that may affect: Age: premature and elderly person are at risk. Nutritional status: malnourished and obese are at risk. State of fluid and electrolyte imbalance: dehydration and hypovolemia predispose client to complications. General Health: infectious process increases operative risk. Type of medications taken regularly: 

Steroids – may improve the body’s ability to respond to the stress of anesthesia and surgery

CATEGORIES FOR SURGICAL PROCEDURE (cont…..)  Anticoagulants and salicylates – may increased bleeding during surgery  Anitbiotics – may be incompatible with or potentiate anesthetic agents  tranquilizer – potentiate the effect of narcotics and cause hypotension  Antihypertensive – may predispose to shock by the combined effect of blood pressure reduction and anesthetic vasodilation  Diuretics – may increase the potassium loss already begun by the body’s response to stress

CATEGORIES FOR SURGICAL PROCEDURE (cont…..)

 Alcohol – will place the surgical client at risk when used chronically. f.) Mental Health g.) Economic and occupational status 2.) The extent of disease 3.) The magnitude of the required operation 4.) Resources and preparation of the surgeon, nurses, and hospital

PERIOPERATIVE CARE • Perioperative Nursing -(Gk-peri-around + L operari-to work + nutrix- nurse) - Nursing care provided to surgery patients during the entire inpatient period ( preoperative, intraoperative & postoperative) from admission to date of discharge.

PREOPERATIVE CARE • Preoperative Care - the preparation and management of patient before surgery. Begins at the time of the decision for surgery.

PREOPERATIVE CARE (cont…) • Psychologic Preparation for Surgery:  Preparation for hospital admission: includes explanation of procedures to be done, probable outcome, expected duration of hospitalization, cost, length of absence from work and residual effects.  Preoperative visits.

PREOPERATIVE CARE (cont…) • LEGAL ASPECTS: INFORMED CONSENT: permission obtained from the patient to perform specific test or procedure. 1.This is to protect the surgeon and the hospital against claims that unauthorized surgery has been performed and that the patient was unaware of the potential risks of complications involved. 2.Protects the patient from undergoing unauthorized surgery.

PREOPERATIVE CARE (cont…) • PHYSIOLOGIC PREPARATIONS: 2. Respiratory preparation – includes x-ray ordered by the surgeon. 3. Cardiovascular preparation – ECG, Blood test: CBC, Hgt, and others 4. Renal preparation – routine urinalysis

PREOPERATIVE CARE (cont…) • INSTRUCTIONAL AND PREVENTIVE ASPECTS: note: The best time to instruct the client is relatively close to the time of the surgery. 3. Deep breathing exercise – use of diaphragmatic abdominal breathing. Done 5-10 times every hour in post-op period. 4. Coughing exercise – deep breathing, exhale to the mouth and then follow with a short breath while coughing. 5. Turning Exercise – every 1-2 hours post-op. 6. Extremity exercise – prevents circulatory problems and post-op gas pains or flatus.

PREOPERATIVE CARE (CONT..) • PHYSICAL PREPARATION 2. On the night of the surgery: c. Preparing patient’s skin. Shave against the grain of hair shaft to insure clean, close shave. d. Preparing the GIT:  Patient is on NPO after midnight: note: the age of the client should always be taken into consideration. Infant and children has a higher metabolic rate than adult, this makes it essential for the child or infant to receive carbohydrate regularly to prevent acidosis from occurring.  Administration of enema.  Insertion of gastric or intestinal tubes.

PREOPERATIVE CARE (cont…) Preparing for anesthesia:  Promoting rest and sleep: use of drugs. - Barbiturates – sedative or hypnotic that depresses RR, BP, and CNS. secobarbital Na (seconal), pentobarbital Na (nembutal). -Non-barbiturates – chloral hydrate, flurazefam (dalmane) *given after all preoperative treatment have been completed. If a second barbiturate is needed, it must be given at least 4 hours before the pre- op medication is due. c.

PREOPERATIVE CARE (cont…) 2. The patient on the day of the surgery: b. Early morning care ( about 1 hour before the preoperative medication is schedule)     

Vital signs taken and recorded promptly. Provide oral hygiene Remove jewelry and dentures Remove nail polish Make sure that the patient has not taken food for the last 10 hours by asking the patient.

PREOPRATIVE CARE (cont…) b. Pre-operative medication: generally administered 60-90 minutes

before induction of anesthesia. 1. Purposes:  To allay anxiety  To decrease the flow of pharyngeal secretions.  Reduce the amount of anesthesia to be given  Create amnesia for the events that precede surgery. 2. Types of pre-operative medications:  Sedatives – given to decrease the patient’s anxiety, to lower BP and PR and to reduce the amount of general anesthesia. An overdose can lead to respiratory depression. ex. Dormicum, Nubain  Tranquilizer – lowers the patient’s anxiety level. ex. Valium, phenergan  Narcotic Analgesia – given to reduce anxiety and the amount of narcotics given during surgery. ex. Morphine Sulfate.

PREOPERATIVE CARE (cont…)

•

 Vagolytic or Drying Agent: ex. Atropine Sulfate Given:  To reduce he amount of tracheobronchial secretions which can clog the pulmonary tree and result in atelectasis or pneumonia.  To interrupt vagal nerve impulses which acts to slow the heart. 3. Recording – all final preparation and emotional response before surgery are noted down. 4. Transportation to the OR woollen or synthetic blankets must never be sent to the OR because they are sources of static electricity. Nursing diagnosis for Preoperative client: Anxiety related to: lack of knowledge about preoperative routines, physical preparation for surgery, post operative care and potential body image change.

INTRAOPERATIVE NURSING CARE

• INTRAOPERATIVE CARE pertaining to the period during a surgical procedure. Begins at the moment when the patient is anesthetized and ends when the last stitch and dressing is in place.

INTRAOPERATIVE CARE (CONT…) • ANALGESIA – pain relief by insensibility production without loss of consciousness. • ANESTHESIA – loss of sensation, usually produced in order to permit a painless surgical operation.

INTRAOPERATIVE CARE (CONT…) • 1. Anesthesia: Stages of Anesthesia:  Stage I: Stage of Analgesia – this stage extends from the beginning of administration of an anaesthetics to the beginning of the loss of consciousness, the sensation of pain is not lost.  Stage II: Stage of Delirium or Excitement – extends from the loss of consciousness to the loss of eyelid reflexes. Any stimulation has the potential to cause the client to become difficult to control. Characterized by increased muscle tone, irregular respiration, REM.  Stage III: Stage of Surgical Anesthesia – extends from the loss of eyelid reflexes to cessation of respiratory effort. Characterized by completely dilated and unresponsive pupils and absence of reflexes.  Stage IV: Stage of Danger/ Medullary Stage – vital functions become too depressed and respiratory failure occurs due to high concentration of anaesthetic in the CNS.

INTRAOPERATIVE CARE (CONT…) • 2 Types of Anesthesia: Main Classification: c. General Anesthesia – it is a state of analgesia, amnesia and unconsciousness characterized by the loss of reflexes and muscle tone. Types: Inhalation Anesthesia : surgical narcosis achieved by the inhalation of an anesthetic gas or vapor. Endotracheal: G.A. administered through a tube, placed through the mouth or nose, directly into the trachea or windpipe.  Advantage: prevention of pain and anxiety.  Disadvantage: circulatory and respiratory depression. Highly inflammable and explosive.

INTRAOPERATIVE CARE (CONT…)  Safety Rules: b. Do not wear slips, nylons, wool, or any material which can set-off sparks. c. Minimized use of cautery. d. Do not touch the vicinity of the breathing area to prevent sparks. e. Do not use bed materials that are not conductive.

INTRAOPERATIVE CARE (cont…) b. Intravenous Anesthesia : usually employed as an induction prior to administration of more potent inhalation anesthetic agents. Commonly use in minor procedure.  Advantage:  Rapid pleasant induction.  Absence of explosive hazards.  Low incidence of nausea and vomiting.

 Disadvantage:  Laryngeal spasm and bronchospasm  Hypotension  Respiratory arrest

 Examples: Thiopental Na pentothal Na), Ketamine (ketalar), Fentanyl (sublimaze)

INTRAOPERATIVE CARE (cont…) c. Rectal Anesthesia : rarely used today, useful during the induction of anesthesia for pediatric patient, e.g. pentothal Na. d. Regional Anesthesia: it is the injection or application of a local anesthetic agent to produce loss of painful sensation in only one region of the body and does not result to unconsciousness.

INTRAOPERATIVE CARE (cont…)  2. 3.

Types of Regional Anesthesia: Topical Anesthesia – application of an anesthetic agent on a body surface; as with a spray or a cotton swab. e.g. cocaine, lidocaine, novocaine Infiltration Anesthesia     

Nerve block – injection of an anesthetic agent into or around the nerve to produce loss of sensation to the area supplied by the nerve. Epidural block – injection of anesthetic agent into the space just outside of the spinal canal. Caudal block – injection of an anesthetic agent into the lower caudal (spinal) canal near the end of the vertebral column. Pudendal block – injection of an anesthetic agent into the perineum. Field block – applied directly to the area to be operated upon.

3. Spinal Anesthesia – injection of an anesthetic agent directly into the spinal fluid within the spinal canal (between the spaces of L3 & L4 or L4 & L5). 

Saddle block – spinal anesthesia given so as to affect only the genital region, buttocks and thighs.

INTRAOPERATIVE CARE (cont…) • 3. Specialized Methods of Producing Anesthesia: Types:  Muscle Relaxants - a neuromuscular blocking agent used to provide muscle relaxation. Used in Endotracheal intubation. e.g. Tracrium, pancronium  Hypothermia – refers to the deliberate reduction of the patient’s body temperature between 28-30 degree Celsius. Uses:  Heart surgery, brain surgery, surgery on large vessels supplying major organs.

Methods:  Ice water immersion, Icebags, cooling blanket, Extracorporeal cooling devices.

Complications: Cardiac arrest, respiratory depression.

INTRAOPERATIVE CARE (CONT…) • 4. Positioning the Patient: Commonly used Operative Positions:  Supine – for hernia repair, explore lap, cholecystectomy, mastectomy, etc.  Prone – for back supine and rectal surgery. note: After surgery, the patient will be returned to supine position. This should be done gradually and slowly to adjust cardiovascular system in position. Rapid turning can cause drop in BP.  Trendelenberg – head and body are flexed by breaking the table.  Reverse Trendelenberg – head is elevated and feet are lowered.  Lithotomy Position – thighs and legs are flexed at right angle then simultaneously placed in stirrups.  Lateral Position – used in kidney and chest surgery.  Thyroidectomy Position – head hyperextended, with small sand bag , pillow on the neck and shoulders to provide exposure of the thyroid gland.

POSTOPERATIVE NURSING CARE Postoperative Care: pertaining to the period of time after surgery. Begins with the patient’s emergence from anesthesia and continues through the time required for the acute effects of anesthetic and surgical procedures to abate ( begins when the client returns from the Recovery Room/Surgery Suite to the nursing limit and ends when the client is discharged.)

POSTOPERATIVE CARE (cont…) • Post Anesthesia Care (P.A.C.): monitoring and management of the patient who has recently undergone general or regional anesthesia. • Nursing priorities:  Get the baseline assessment of the patient.  Vital Signs (PR, T, RR, BP)  Level of consciousness

POSTOPERATIVE CARE cont…) • 2.

Nursing Responsibilities during P.A.C.: Maintenance of Pulmonary Ventilation:  

 

Position the patient to side lying or semi-prone position to prevent aspiration. Oropharyngeal or nasopharyngeal airway is left on place following administration of G.A. until pharyngeal reflexes have returned. Airway should be removed as soon as the patient begins to regain consciousness and coughing and swallowing reflexes returned. All patients should receive O2 at least until they are conscious and are able to take deep breaths on command. Shivering of the patient must be avoided to prevent an increase in O2 demand. O2 should be administerd until shivering ceased.

POSTOPERATIVE CARE (cont..) 2. Maintenance of Circulation: most common complication during post anesthetic period:  Hypotension: Causes: d. Moving the patient fro OR to bed, jarring during transport. e. Reaction to drug and anesthesia. f. Loss of blood and other body fluids. g. Cardiac arrhythmias and cardiac failure. h. Inadequate ventilation i. Pain.

POSTOPERATIVE CARE (cont…) Assessment: b. Weak thready pulse with a significant drop in BP may indicate hemorrhage or circulatory failure. c. Skin: cold, moist, pale, or cyanotic. d. Restlessness or apprehension. Nursing Responsibilities:  Monitor v/s every 15 minutes for the first 4 hours or until stable.  Cardiac Arrhythmias: Causes: i. Hypoxemia – abnormal deficiency in the concentration of oxygen in the arterial blood. j. Hypercapnea – excess carbon dioxide in the arterial blood. (common causes of premature beats and sinus tachycardia) Management: m. Oxygen Therapy n. Drug Administration: lidocaine,procainamide, prostigmine

POSTOPERATIVE CARE (cont…) 3. Protection from Injury and Promotion of Comfort: 2. Provide side rails, placed up until the patient is fully awake. 3. Patient is turned frequently and placed in good body alignment to prevent nerve damage from pressure. 4. Administration of narcotic analgesic to relieve incisional pain. Post operative dose usually reduced to half until the patient is fully recovered from anesthesia.

POSTOPERATIVE CARE (cont…) •

Dismissal of client from the Recovery Room: Five (5) Physiological Parameters: 3. Activity – able to move extremities voluntarily on command. 4. Respiration – able to breath deeply and cough freely. 5. Circulation – BP is +20% or -20% of pre-anesthetic level. 6. Consciousness – fully awake. 7. Color - pinkish

POSTOPERATIVE CARE (cont…) • Prevention of Postoperative Complications: 2. Respiratory complication: e.g. atelectasis, pneumonia  Atelectasis is suspected whenever there is sudden rise in temperature 24-48 hours after surgery. Collapsed lung are highly susceptible to infection.  Pneumonia occurs usually in high abdominal surgery when prolonged inhalation anesthesia ha s been necessary and vomiting has occurred during the operation or while the patient is recovering from anesthesia.

POSTOPERATIVE CARE (cont…) Nursing Management for respiratory complication: Measures to prevent polling of secretions: a. Includes changing of position. b. Altering height of bed from low to high fowlers c. Moving out of bed or walking activity stimulates deeper breathing and prevents pooling of secretions. 3. Measures to liquefy and remove secretions: a. Encourage patient to increase fluid intake. b. Breathing in moist air provided by moist tents or ultrasonic mist. c. Deep breathing followed by coughing may be contra indicated in cases of brain surgery, spinal or eye surgery. Administer analgesic before coughing is attempted after thoracic or abdominal surgery. d. Splint operative area with a draw sheet or towel to promote comfort while coughing.  2.

POSTOPERATIVE CARE (cont…) (Nursing mgt. for resp. complication cont…) 3. Other measures to increase pulmonary ventilation: a. Blow bottle exercise. b. Incentive spirometer – designed to encouraged sustained maximal inspiration (SMI). c. Rebreathing tubes – increase CO2 stimulates the respiratory center to increase the depth of breathing thus increasing the amount of inspired air. d. Intermittent Positive-Pressure Breathing (IPPB) – a form of assisted or controlled respiration produced by a ventilatory apparatus in which compressed gas is delivered under positive pressure into a person’s airway until a preset pressure is reached.

POSTOPERATIVE CARE (cont…) 2. Circulatory Complication: e.g. venous stasis: a disorder in which the normal flow of blood through a vein is slowed or halted.  Causes of venous stasis: 1. Muscular inactivity. 2. Respiratory and circulatory depression 3. Increased pressure on blood vessels due to tight dressing. 4. Intestinal distension. 5. Prolonged maintenance of sitting position. 6. Contributing factors: a) Obesity b) Cardiovascular disease c) Debility d) Malnutrition e) Old age

POSTOPERATIVE CARE (cont…) 

Most common circulatory complications: 1. 2.



Phlebothrombosis: a clot forms within the vein Thrombophlebitis: inflammation of a vein accompanied by the formation of blood clot. (positive homan’s sign: pain on dorsiflexion of the foot).

Nursing Measures: 1. 2. 3. 4.

Limbs must never be massage for a post operative patient. If possible patient should lie on the abdomen for 30 mins, 2-3 times a day to prevent pooling of blood on pelvic cavity. Do not allow patient to stand unless pulse has returned close to baseline to prevent orthostatic hypotension. Wear elastic bandage or support stockings when in bed and when walking for the first time. Remove at least once daily to permit washing of the legs.

POSTOPERATIVE CARE (cont…) 3. Fluid and Electrolyte Imbalance: Particularly Na & K imbalance as a result of blood loss. Stress of surgery increases adrenal hormonal activity resulting to increase aldosterone and glucocortioids resulting to Increase Na reabsorpstion by the kidney and as Na is reabsorbed, K is excreted. Increase K loss from tissue breakdown.  Causes: Blood loss Increase insensible fluid loss through skin, after surgery through vomiting, copious wound, drainage from tubes like NGT. Since surgery is a stressor, there is increase production of ADH for 1st 12-24 hours following surgery which results to fluid retained by the kidney. The potential for over hydrating therefore exist since fluid being given IV may exceed fluid output by the kidney.



Action: IV of D5W alternated with D5NSS or PNSS to prevent Na excess.

POSTOPERATIVE CARE (cont…) 4. Gastrointestinal Complications:  Paralytic Ileus – cessation of peristalsis due to extensive handling of GI organs. Nursing Management: No fluids or food are given until peristalsis has returned as evidenced by auscultation of bowel sounds or by passing of flatus.  Vomiting – usually a result of certain anesthetics on the stomach or eating food or drinking H2O before peristalsis returns. Psychologic factors also contribute to vomiting. Nursing Management: 1. 2. 3.

Position the patient on his side to prevent aspiration. When vomiting has subsided, give ice chips, sips of ginger ale, or hot tea or eating small amounts of dry solid foods may relieve nausea. Anti-emetic Drugs: Metochlopromide HCl (Pasil),

POSTOPERATIVE CARE (cont…) • GI complications (cont…)  Abdominal Distention: results from the accumulation of non- absorbable gas in the intestine. Causes: 1. Reaction to the handling of bowel during surgery. 2. Swallowing of air during recovery from anesthesia. 3. Passes of gases from the blood stream to the atonic portion of the bowel. 4. Gas pain: results from contraction of unaffected portion of the bowel in order to move accumulated gas in intestinal tract..

POSTOPERATIVE CARE (cont…) Management: 1. 2. 3.

4.

Aspiration of fluid or gas with a NGT. Ambulation stimulates the return of peristalsis and expulsion of flatus. Rectal tube insertion- inserted just past the rectal sphincter and removal after approximately 20 mins (2-4 inches for adult, 1-3 inches for children) prolonged stimulation of the anal sphincter may result in a loss of neuromuscular response. It may cause pressure necrosis of the mucous surface. Fleet enema.

 Constipation : due to decrease food intake and decrease activity. Management: Drinking adequate amounts of fluid and ambulating will have a bowel movement within 3-4 days after surgery.

POSTOPERATIVE CARE (CONT…) 5. Urinary Complications:  Return of Urinary Function: usually after 6-8 hours. 1st voiding may not be more than 200ml and total output may not be more than 1500ml. This is due to the loss of fluids during surgery and to perspiration, hyperventilation, vomiting and increase secretion of ADH.  Complications: 4. Urinary retention Causes: a) b) c) d) e)

Prolonged recumbent position Nervous tension. Effect of anesthetic that interfere with bladder sensation and the ability to void. Use of narcotics that reduce the sensation of bladder distention. Pain at the site or by movement.

POSTOPERATIVE CARE (cont…)  Management (Urinary retention) 1. Force fluid intake. 2. Place patient on bed pan at regular interval. 3. Pouring warm H2O over the perineum. 4. Assuring patient’s privacy 5. Assuming proper position. 6. Catheterization if bladder is palpable over the suprapubic bone, because pressure causes discomfort, this is done to prevent stretching of the vesical wall.

POSTOPERATIVE CARE (cont…) Complications (Urinary comp…cont….) 2. Urinary Tract Infection:  Management: 1. Instruct the patient to empty the bladder completely each voiding. 2. Use sterile non-traumatic technique in catheterization if necessary.

POSTOPERATIVE CARE (cont…) 6. Post-operative discomforts:  Post-operative pain: Management: narcotics can be given every 3-4 hours during the 1st 48 hours post-op for severe pain without the danger of addiction.  Hiccoughs: brought about by the dilation of the stomach, irritation of the diaphragm, peritonitis and uremia cause either reflex or CNS stimulation of the phrenic nerve. Management: 1. Paper bag blowing. 2. CO2 inhalation, 5% CO2 and 95% O2, 5 mins every hour.

POSTOPERATIVE CARE (cont…) 7. Wound Complications: sutures are usually removed about the 5-7th day post-op with the exception of wire retention sutures placed deep in muscles and removed usually 14-21 days after.

POSTOPERATIVE CARE (cont…) Wound complications: Hemorrhage from the wound: most likely to occurs within the 1st hours post-op or as late as 6th or 7th post-op day. Causes: a. Hemorrhage occurring soon after operation: slipping of ligature or mechanical dislodging of a blood clot or caused by the re-established blood flow through vessel. b. Hemorrhage after a few days: sloughing of a clot or tissue, infection, erosion of blood vessel by a drainage tube. Assessment: a. Bright red blood b. Decrease BP c. Increase PR & RR d. Restlessness e. Pallor f. Weakness g. Cold, moist skin  

POSTOPERATIVE CARE (cont…) 2. Infection: Causes: streptococcus, staphylococcus Assessment: a. From 3- 6 days after surgery, the patient begins to have low grade fever and the wound becomes painful and swollen. There maybe purulent drainage on dressing.

3. Dehiscence and Evisceration: a. Dehiscence- (wound disruption) refers to a partial to complete the separation of the wound edges. b. Evisceration- refers to the protrusion of the abdominal viscera through the incision and onto the abdominal wall.

POSTOPERATIVE CARE (cont…) Assessment: a. b. c.

Complaint of giving sensation in the incision Sudden, profuse leakage of fluid from the incision Dressing saturated with clear , pink drainage.

Management: a. b. c. d. e.

Position the patient to low fowler’s position; instruct not to cough, sneeze , eat or drink, and remain quiet until the surgeon arrives. Protruding viscera should be covered with warm, sterile saline dressing. Apply slight pressure on the bleeding site. Dressing should be change frequently Administer antibiotic as ordered