Surgical Concepts

A. Terms
1. Surgery – a branch of medicine that treats diseases by manual operative
procedure that encompasses pre-operative care intra- operative judgment and
management, and post-operative care of clients
2. Perioperative Nursing Management – refers to activities performed by
nurses during the pre, intra, and post-operative phases through the framework of
the nursing process.
B. Goals of Surgery
1. For diagnosis
2. For preservation of life
3. For maintenance of dynamic bodily equilibrium
4. For prevention of infection and promotion of
healing
5. For alleviation of discomforts
6. For correction of deformities and defects
C. Conditions That Require Surgery

1. Obstruction
2. Perforation
3. Erosion
4. Tumor
D. Major Categories of Surgery

1. According to Purpose
a. Diagnostic
a.1 Biopsy
a.2 Endoscopy

D. Major Categories of Surgery

1. According to Purpose
b. Curative
b.1 Ablative
b.2 Reconstructive
b.3 Constructive
D. Major Categories of Surgery

1. According to Purpose
c. Exploratory
d. Restorative
e. Palliative
f. Cosmetic/Reconstructive
D. Major Categories of Surgery

2. According to Urgency
 a. Emergency
b. Imperative
c. Planned/Required
d. Elective
e. Optional
D. Major Categories of Surgery

3. According to Extent/Magnitude/ Degree of Risk

a. Major
b. Minor
The Pre-operative Nursing Care
I. Assessment
A. Health History
1. Biographical Data
2. Chief Complaint
3. Present Health Concerns or Illness
4. Past Health History
5. Family History
6. Patient Profile
B. Pre-operative Assessment

1. Physical Assessment
a. Nutritional and fluid status
b. Cardiovascular status
c. Respiratory status
B. Pre-operative Assessment

2. Pre-surgical Screening Tests

a. Chest X-ray
b. ECG
c. Electrolytes level
d. Urinalysis
e. Blood studies
B. Pre-operative Assessment

3. Health Factors
a. Hepatic, renal, and endocrine functions
b. Immune functions
c. Psychosocial factors
d. Spiritual and cultural beliefs
II. Analysis
Potential Nursing Diagnoses

1. Anticipatory grieving related to perceived loss of normal body image

2. Anxiety related to the surgical experience and outcome of surgery
 3. Fear related to perceived threat of the surgical procedure and separation from
support systems
4. Knowledge deficit of pre-operative procedures and protocols and post-
operative expectations
III. Planning and Implementation
A. Physiological Preparation for Surgery

1. Managing nutrition and fluids

a. Correct dietary deficiencies
b. Correct fluid and electrolyte imbalance
c. Restore adequate blood volume

A. Physiological Preparation for Surgery

2. Managing infection
a. Treat existing infection
b. Prevent possible infection
3. Managing existing systemic disorders

B. Psychosocial Preparation for Surgery

Reducing Pre-Operative Anxiety/Fear
a. Promote positive coping strategies
a.1. Imagery
a.2. Distraction
a.3. Optimistic self-recitation
b. Provide pre-operative teaching
c. Provide opportunity for visits from family and
friends

Principles of Pre-operative
Teaching and Learning

• Maintain uniformity and accurateness of content.

• Supply what is necessary.
• Use simple terms.
• Do not overwhelm with information.
• Provide chance for patient to ask questions.
• Check patient for comprehension.
• Repeat if necessary.
• Use appropriate teaching strategies.
• Involve significant others.
Pre-operative Teaching

1. Deep-breathing, coughing, and Incentive Spirometer

2. Mobility and Active Body Movement

 3. Pain Management

4. Cognitive Coping Strategies

Pre-operative Teaching
Exercises
1. Deep breathing
• Expands the lungs
• Prevents post-operative pneumonia and atelectasis
2. Coughing
• Helps clear airway of secretions
3. Incentive spirometry
• Expands the lungs
• Provides a visual feedback to patients
Pre-operative Teaching
Exercises
Mobility and Active Body Movement
Purposes:
a. Promotes circulation
b. Prevents circulation stasis which may lead to thrombus
formation

1. Leg Exercises
2. Turning-to-sides Exercises
3. Getting-Out-of-Bed Exercises

C. Spiritual Preparation for Surgery

Respecting spiritual and Religious Beliefs

a. Provide time for prayer

b. Arrange for visit from a spiritual adviser/clergyman as
desired
c. Take into consideration religious beliefs in
the operative care
D. Securing Consent for Surgery

Rationale for Securing Informed Consent

a. Patient ﾁ fs protection from unsanctioned
surgery
b. Doctor ﾁ fs protection against claims of unauthorized
operation
D. Securing Consent for Surgery

Criteria for a Valid Informed Consent

 a. It is done voluntarily.
b. It is made by a competent person.
c. Subject is informed.
d. Information must be written or delivered in a language
understandable to the subject.

D. Securing Consent for Surgery

Criteria for a Valid Informed Consent
e. It should be in writing and should contain the following:
1. Explanation of the procedure and its risks
2. Description of the benefits and alternatives
3. An offer to answer questions about the surgery
4. Instructions that the consent may be withdrawn
5. A statement informing the patient if protocol differs from
the customary procedure

Preparing the Patient on the Eve of Surgery

A. Preparing the skin
- helps reduce the possibility of infection by minimizing the number
of microorganisms through chemical and mechanical
means
1. Washing
2. Scrubbing
3. Shaving

B. Preparing the GI tract

a. Reduces the possibility of vomiting and aspiration
b. Reduces the possibility of bowel obstruction
c. Prevents contamination from fecal material
1. Food and water restriction
2. Enema administration
B. Preparing the GI tract
1. Food and Water Restriction
Guidelines for NPO
a. Explain the reason for the restriction.
b. Remove food and water at bedside.
c. Place an NPO tag on door and on bedside.
d. Mark cardex with NPO.
e. Inform dietician.
f. Inform other health team members of the restriction.

B. Preparing the GI tract

2. Enema Administration
Purposes:
a. Reduces possibility of fecal impaction
 b. Prevents colon injury/trauma
c. Provides adequate surgical site visualization

C. Preparing for Anesthesia

Reduces or totally removes any fear and anxiety to anesthesia
*The anesthesiologist visits the client and assesses client ﾁ fs cardiovascular and
neurological functioning.

Preparing the Patient on the Day of Surgery

A. Immediate Pre-operative Nursing Interventions
1. Administering Pre-Anesthetic Medication
Purposes:
a. to allay anxiety
b. to decrease pharyngeal secretions
c. to reduce amount of anesthetics
d. to create amnesia prior to surgery
2. Maintaining the Pre-operative Record

a. Attachment of consent, clearance, lab reports,

nurse ﾁ fs records
b. Maintenance of NPO status
c. Changing of gown and wearing of cap, etc
d. Removal of dentures, jewelry, nail polish and other
accessory devices

3. Transporting Patient to the Pre-surgical Area

a. Provision of a comfortable stretcher
b. Provision of sufficient number of blankets
c. Provision of safety measures
d. Proper identification of surgical patient
e. Proper greeting of patient
f. Provision of a quiet environment

The Intra-operative Nursing Care

I. Assessment
1. Identification of surgical client
2. Assessment of client ﾁ fs status
a. physiological
b. psychological
c. physical
3. Verification of the information in the pre-
operative checklist
II. Analysis
Potential Nursing Diagnoses

1. Anxiety related to expressed concerns due to surgery

 2. Risk for perioperative injury related to environmental conditions in
the OR
3. Risk for injury related to anesthesia and surgery
4. Disturbed sensory perception related to
general anesthesia
5. Risk for fluid volume deficit related to
bleeding
III. Planning and Implementation
1. Reducing anxiety
a. Introduce yourself.
b. Address patient by name warmly and frequently.
c. Provide explanations.
d. Encourage questions and answer them.
e. Provide comfort measures

2. Preventing Intraoperative Positioning Injury

Factors to Consider in Positioning
a. The patient should be in as comfortable position as
possible, whether asleep or awake.
b. The operative field must be adequately exposed.
c. An awkward position, undue pressure on a body part,
or use of stirrups or traction, should not obstruct the vascular supply.

2. Preventing Intraoperative Positioning Injury

Factors to Consider in Positioning
d. Respiration should not be impeded by pressure of arms on the
chest or by a gown that constricts the neck or chest.
e. Nerves must be protected from undue pressure. Improper
positioning of the arms, legs, or feet may cause serious injury or paralysis.
f. Precautions for patient ﾁ fs safety must be observed.
g. The patient needs gentle restraint before induction in case of
excitement
Surgical Positions
1. Dorsal Recumbent/Supine
• Flat on bed
• One arm is positioned at the side of the table, with the hand placed palm down;
the other hand is carefully positioned on an armboard
• Used for most abdominal surgery
Surgical Positions
2. Trendelenburg
• Flat on bed but head and body are lowered
• The patient is held in position by padded shoulder braces.
• Used for surgery on lower abdomen and pelvis to obtain good exposure by
displacing the intestines into the upper abdomen
Surgical Positions
 3. Lithotomy
• Flat on back with legs and thighs flexed
• Position is maintained by placing stirrups.
• Used for nearly all perineal, rectal, and vaginal surgical procedures
Surgical Positions
4. Sims or Lateral

• Patient is placed on non-operative side with air pillow 12.5 – 15 cm thick under
the loin; the upper leg extended; the lower leg is flexed at the knee
• Used for kidney, chest, and hip surgery
Surgical Positions
5. Prone
• Face-down position
• Head is turned to one side
• Used in back and spine surgery

6. Other positions
• Jackknife
• Thyroidectomy
3. Protecting the Patient From Injury

a. Verifying information
b. Checking chart for completeness
c. Maintaining surgical asepsis
d. Maintaining an optimal environment
Verifying information/Checking of Chart for Completeness
• Correct patient and the planned surgical procedure and type of anesthesia
• Correct informed surgical consent, with patient ﾁ fs signature
• Completed records for health history and physical examinations
• Results of diagnostic studies
• Allergies (including latex)
Maintaining Surgical Asepsis
Basic Principles of Aseptic Technique

– Only sterile items are used within the sterile field.

Practices:
a. Obtain materials from a stock of sterile
packages.
b. Ensure and maintain the sterility of sterile
articles.
c. If in doubt about the sterility of anything,
consider it not sterile.
Maintaining Surgical Asepsis
Basic Principles of Aseptic Technique
– Sterile persons are gowned and gloved.
Practices:
a. Self-gowning and gloving should be done from a
separate sterile surface.
b. Stockinette cuffs of the gown are enclosed beneath
sterile gloves.
c. Sterile persons keep their hands in sight at all times and
at or above the waist level or sterile field.
d. Hands are kept away from face and are never folded
under arms.
e. Sterile persons are aware of the height of team
members in relation to each other and the sterile field.
Maintaining Surgical Asepsis
Basic Principles of Aseptic Technique

– Tables are sterile only at the table level.

Practices:
a. Only the top of a sterile table is considered sterile and
the edges and sides of the drape extending below the
the table level are considered unsterile.
b. Anything falling and extending over the edge is unsterile
and should not be brought back up to the table level.
Maintaining Surgical Asepsis
Basic Principles of Aseptic Technique
4. Sterile persons touch only sterile items or areas;
unsterile persons touch only unsterile items.

Practices:
a. Sterile team members maintain contact with the sterile field
by means of sterile gowns and gloves.
b. Unsterile circulator does not directly contact the sterile field.
Maintaining Surgical Asepsis
Basic Principles of Aseptic Technique
5. Unsterile persons avoid reaching over sterile field,
sterile persons avoid leaning over unsterile area.
Practices:
a. In pouring solutions into a sterile basin the circulator directs
only the lip of the bottle over the basin to avoid reaching over
the sterile area.
b. The circulator stands at a distance from the sterile field to
adjust the light.
c. Surgeon turns away from the sterile field to have perspiration
removed
from brow.
d. Scrub person stands back from the unsterile table when draping it.
Maintaining Surgical Asepsis
Basic Principles of Aseptic Technique
6. Edges of anything that encloses sterile are considered
unsterile.
Practices:
a. In opening sterile packages, the circulator opens the top flap away
from self, then turns the side under. Ends of the flaps secured in the
hand so they don ﾁ ft dangle loosely.
b. Sterile person lifts contents from packages by reaching down and
lifting them straight up, holding their elbows high.
c. Flaps on peel-open packages should be pulled back, not torn, to
expose the sterile contents. Contents should be flipped or lifted
upward and no permitted to slide over edges.
d. Before pouring sterile solution to a sterile basin pour some amount
into the waste receptacle to clean the lid of the bottle.

Maintaining Surgical Asepsis

Basic Principles of Aseptic Technique
7. Sterile field is created as close as possible to
time of use.

Practice:
a. Sterile tables are set up just before surgical
procedure.
It is virtually impossible to uncover a table of sterile contents
without contamination. Covering sterile tables for later use is
not recommended.
Maintaining Surgical Asepsis
Basic Principles of Aseptic Technique
8. Sterile areas are continuously kept in view.
Practices:
a. Sterile persons face the sterile area.
b. When sterile packs are open in a room or a
sterile field is set up, someone must remain in
the room to maintain vigilance. Sterility cannot
be ensured without direct observation.
Maintaining Surgical Asepsis
Basic Principles of Aseptic Technique
9. Sterile persons keep well within sterile area.
Practices:
a. Sterile persons stand back at a safe distance from the table when
draping the patient.
b. Sterile persons pass each other at a 360-degree turn
c. Sterile persons turns back to an unsterile person or area and faces a
sterile area when passing.
d. Sterile person asks an unsterile individual to step aside.
 e. Sterile persons stay within the sterile field. They do not walk around
or go outside the room.
f. Movement within and around the sterile area is kept to a minimum.
Maintaining Surgical Asepsis
Basic Principles of Aseptic Technique
10. Sterile persons keep contact with sterile
areas to minimum.
Practices:
a. Sterile persons do not lean on sterile tables or on
the draped of the patient.
b. Sitting or leaning against an unsterile surface is a
break in technique. If the sterile team sits to operate,
the members do so without proximity to unsterile
areas.
Maintaining Surgical Asepsis
Basic Principles of Aseptic Technique
11. Unsterile persons avoid sterile areas.
Practices:
a. Unsterile persons maintain a distance of at least 1 foot
(30 cm) from any area of the sterile field.
b. Unsterile persons face and observe a sterile area when
passing it to be sure they do not touch it.
c. Unsterile persons never walk between two sterile areas
d. Circulator restricts to a minimum all activity near the sterile
field.

Maintaining an Optimal Environment

• Assess for nonroutine medications, blood components, instrument and other
equipment and supplies
• Determine the following:
a. readiness of the room
b. completeness of the physical setup
c. completeness of the instruments
• Employ injury-preventing measures
a. safety straps
b. proper transferring/positioning
c. proper positioning of grounding pad
4. Monitoring and Managing Potential Complications

a. Being alert to and reporting changes in vital signs, nausea

and vomiting, anaphylaxis, hypoxia and hypothermia, and assisting in
their management
b. Maintaining asepsis
c. Preventing infection
Stages of Anesthesia
Stage I: Beginning Anesthesia
• Warmth, dizziness, feeling of detachment may be experienced
• Ringing , roaring, or buzzing in the ears may be experienced. Noise is
exaggerated.
• Though conscious, client may find it difficult to move extremities easily

NURSING RESPONSIBILITIES:
a. Close OR doors
b. Keep room quiet
Stages of Anesthesia
Stage II: Excitement
• Characterized variously by struggling, shouting, talking, singing, laughing, or
crying
• Respirations are irregular.
• Pulse rate is rapid
• Pupils may dilate

Assist in restraining the client.

Stages of Anesthesia
Stage III: Surgical Anesthesia
• Anesthesia is completely established
• Patient is unconscious and lies quietly on the table.
• Respirations are regular; pulse rate and volume are normal.
a. Assist in positioning the patient.
b. Begin skin prep
c. Prepare operative site
d. Observe for signs and symptoms
Stages of Anesthesia
Stage IV: Medullary Depression
• Reached only when too much anesthesia has been administered.
• Respirations become shallow; pulse is weak and thready, and the pupils become
widely dilated.
• Cyanosis may be observed, death may follow if without prompt treatment.
a. Assist in CPR
b. Provide emergency equipment
c. Establish airway
Responsibilities of A Scrub Nurse
1. Performing surgical hand scrub
2. Setting up the sterile tables
3. Preparing sutures, ligatures, and special instruments
4. Assisting the surgeon and the surgical assistants during the procedure by
anticipating the instruments that will be required
5. Counting all sponges, needles, and instruments to be sure they are all accounted
for and not retained as a foreign body in the patient (together with the circulating nurse)
6. Collecting and labeling of tissue specimen
Responsibilities of A Circulating Nurse
 1. Verifying consent
2. Coordinating the team
3. Ensuring the following:
a. cleanliness
b. proper temperature, humidity, and lighting
c. safe functioning of equipment
d. availability of supplies
4. Monitoring aseptic practices
5. Monitoring the patient and documenting specific activities
The Post-operative Nursing Care
I. Assessment
Nursing Management in the PACU

Assessing the patient

a. Respiratory status
 Rate
 Depth
 Sound
I. Assessment
Nursing Management in the PACU

Assessing the patient

b. Cardiovascular status
 Pulse (rate, rhythm, quality)
 Blood pressure
 Skin (temperature, color, moistness)
 Urine output
 Bleeding
 Mental status
I. Assessment
Nursing Management in the PACU

Assessing the patient

c. Pain
 Level
 Characteristics
 Patient ﾁ fs appearance
 Changes in vital signs
I. Assessment
A – Airway E – Elimination
B – Breathing F – Fluids
C – Circulatory F - Food
C – Consciousness S – Safety/comfort
D – Dressing
D – Drainage
D – Drugs

II. Analysis
Potential Nursing Diagnoses
1. Risk for ineffective airway clearance related to:
a. depressed respiratory function
b. pain
c. bed rest
2. Acute pain related to surgical incision
3. Decreased cardiac output related to hemorrhage
3. Activity intolerance related to:
a. generalized weakness secondary to surgery
b. pain
4. Impaired skin integrity related to surgical incisions and drains
5. Risk for imbalanced nutrition related to:
a. decreased intake
b. increased need for nutrients 2⁰ to
surgery
6. Risk for constipation related to:
a. effects of medication
b. surgery
c. dietary change
d. immobility
7. Risk for urinary retention related to anesthetic agents
8. Risk for injury related to
a. surgery
b. anesthetic agents
9. Anxiety related to surgery
10. Disturbed body image related to surgery
11. Risk for ineffective therapeutic regimen related to insufficient
knowledge about:
a. wound care
b. dietary restriction
c. activity recommendations
d. medications
e. follow-up care
f. signs and symptoms of complications
III. Planning and Implementation
1. Preventing Respiratory Complications
a. Deep-breathing exercises
b. Coughing exercises
c. Incentive spirometry
d. Turning exercises
e. Ambulation
 2. Relieving Pain
a. Opioid analgesics
b. Patient-Controlled Analgesia
c. Epidural/Intrathecal Infusions and Intrapleural Anesthesia
d. Other Pain Relief Measures
2. Promoting Cardiac Output
a. IV therapy
b. Leg exercises/Positioning
c. Early ambulation
d. Intake and output monitoring
3. Encouraging Activity
a. Arm exercises
b. Hand and finger exercises
c. Foot exercises
d. Leg exercises
4. Managing Gastrointestinal Function and Resuming Nutrition
a. Turning exercises
b. Ambulation
c. Nutrition
5. Promoting Bowel Function
a. Early ambulation
b. Dietary intake
c. Stool softeners
6. Managing Voiding
a. Encourage independent voiding
b. Catheterization
7. Maintaining a Safe Environment
a. Safety measures
b. Special positioning
c. Assessment of level of consciousness and
orientation
8. Managing Potential Complications
a. Deep vein thrombosis
b. Hematoma
c. Infection
d. Wound dehiscence and Evisceration