Download Handbook – Nursing Essential Skills

Essential Surgical
Nursing
Handbook
October 2010
Introduction
The Essential Surgical Nursing course is designed to give nurses the tools they need to safely
deliver patient care to the peri-operative patient. This course focuses on caring for the surgical
patient pre-operatively, intra-operatively, and post operatively while building upon the
framework of the nursing process to improve overall peri-operative nursing management.
Important topics covered also include critical thinking, patient/family teaching and education,
coordinating multidisciplinary teams, documentation and evidence based practice.
The Essential Surgical Nursing course takes a creative approach that encourages nurses to
participate as active learners. The course is designed with different teaching methods to meet
the needs of visual, auditory, and hands on learners. We encourage participants to be as
interactive as possible throughout this course.
Although some of this material may be review, it is imperative that nurses continually review
their practice and practice in a way that supports evidence-based care. The field of surgical
nursing is broad, and nurses providing care to surgical patients are required to have a broad
base of knowledge and skill. Only with this knowledge can the nurse thoroughly assess, think
critically, and intervene skilfully and quickly.
We hope that you will find this course enjoyable and valuable to your nursing practice.
Sincerely,
The Nursing Committee
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Table of Contents
Introduction………………………………………………………………………………………………………………
2
Role of the Nurse………………………………………………………………………………………………………
Leadership……………………………………………………………………………………………………..
Teamwork………………………………………………………………………………………………………
Patient-Centered Care……………………………………………………………………………………..
Advocacy…………………………………………………………………………………………………..…..
Nursing Responsibility…………………………………………………………………………………………………
Predict, Prevent, and Manage……………………………………………………………………………
Planning and Prioritizing ………………………………………………………………………………….
Selecting Nursing Interventions…………………………………………………………………………
Communicating the Plan……………………………………………………………………………………
Documentation ……………………………………………………………………………………………….
Evaluation…………………………………………………………………………………………………..…..
Critical Thinking……………………………………………………………………………………………….
Perioperative Nursing………………………………………………………………………………………………….
Preoperative Care…………………………………………………………………………………………….
Intraoperative Care…………………………………………………………………………………………..
Transfer of Patient from Theater to Ward…………………………………………………
Postoperative Care……………………………………………………………………………………………
Postoperative Complications……………………………………………………………….…
Pain…………………………………………………………………………………………..
Nausea and Vomiting…………………………………………………………………..
Bleeding……………………………………………………………………………………..
Fever………………………………………………………….……………………………..
Dizziness and Fainting……………….………………………………………………..
Deep Vein Thrombosis…………………………………………………………………
Fluid and Electrolyte Imbalances…………………………………………………..
Urine Retention…………………………………………………………………………..
Post-Operative Delerium……………………………………………………………..
Wound Care…………………………………………………………………………………………..
Principles of wound care……………………….……………………………………..
Wound Drainage…………………………………….…………………………………..
Dressing Changes………………………………………………………………………..
Patient Teaching………………………………………………………………….……..
Complications……………………………………………………………………………..
Assessment and Prioritization…………………………………………………………………..………..
Signs of an Unstable Patient.…………………………………………………………………..
Priority actions……………………….……………………………………………………………..
Calling the Physician…….………………………………………………………………………..
References………………………………………………………………………………………………………………… 42
Appendices…………………………………………………………………………………………………………………
Head-To-Toe Assessment……………………………………………………………………………………………
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Role of the Nurse
Nurses play an integral part in maintaining and improving the health of different communities.
The function of the nurse is to assist the individual, sick or well, in the performance of those
activities contributing to health (and) its recovery, or to a peaceful death, and to do this in such
a way as to help the client gain independence. Not only do nurses offer care and comfort, but
they also serve as role models for good health care. The practice of nursing requires specialized
knowledge, compassion, and a high level of professional and personal responsibility; therefore,
nurses play a central role in delivering health care.
Nurses advocate for health promotion, educate patients and the public on the prevention of
illness and injury, provide care and assist in cure, participate in rehabilitation, and provide
support. Nurses help families learn to become healthy by helping them understand the range of
emotional, physical, mental, and cultural experiences they encounter during health and illness.
Nurses help people and their families cope with illness and if necessary live with it, so that other
parts of their lives can continue.
Nurses provide ongoing assessment of people's health. Their round-the-clock presence,
observation skills, and vigilance allow doctors to make better diagnoses and propose better
treatments. Many lives have been saved because an attentive nurse picked upon early warning
signs of an upcoming crisis like cardiac arrest or respiratory failure.
Nurses do more than just care for individuals. They are and always have been at the forefront
of change in health care and public health.
Leadership
Powerful leadership skills are needed by all nurses—including those providing direct patient care
to those in top management positions. Anyone who is looked to as an authority (e.g. a nurse
taking care of a patient) or who is responsible for giving assistance to others is considered a
leader.
Building an empowered nursing team begins with leadership. Important strategies for building a
strong team include learning leadership skills such as communication, collaboration, negotiation,
and sharing responsibilities of caring for patients. Leaders learn how to provide support to other
nurses and to advocate for patient safety and care.
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Teamwork
Teamwork is an active process involving two or more healthcare professionals who work
together towards a common healthcare goal. There are many people who make up a team at a
hospital such as the housekeepers, the nurses, doctors, and physiotherapists, just to name a
few. Each health care professional brings with them different skills to contribute to the overall
goal – positive patient outcomes and job satisfaction.
A good team member contributes ideas, communicates clearly, listens to the voices of other
team members and treats others with respect. The patient and their families are all part of the
health care team.
Patient-centered Care
Patient-centered care is based upon communication and involves both patient and their
families. Patient-centered care involves the patient in all aspects of their care and empowers
them to seek the best solution for management or treatment. It encourages the mutual
exchange of information and seeks feedback from the patient to ensure that communication
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has been achieved while addressing the patients’ concerns and questions.
Patient-centered care provides the patient with a physical and emotional environment conducive
to a caring and compassionate experience. It begins from arrival of the patient into the health
care system, to the time the procedure or care is complete and the patient leaves the hospital.
It includes activities that maximize privacy and comfort, minimize outside distractions and noise,
and protects a patient’s dignity. It is a way of providing nursing care while being respectful and
professional.
Advocacy
Advocating for patient’s rights and staff rights are an important part of the nurse’s role. The
nurse is able to state information with appropriate persistence until a clear resolution is made.
Advocating can be difficult because of power struggles and hierarchy. A nurse may not feel they
are able to advocate to a doctor, even though she/he is acting in the patient’s best interest.
Advocating includes the following actions:
 Being Respectful, clear and possibly assertive
 Doing your research and making sure you have the facts clear
 Ensuring you have the person’s attention
 Expressing your concern
 Stating the problem
 Stating your proposed action
 Reaching a decision or conclusion
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Nursing Responsibility
What are your Responsibilities as a Nurse?
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Recognize health problems
Anticipate complications
Initiate actions to ensure appropriate and timely treatment
Effective Communication
Documentation
Think CRITICALLY!!!!!
Predict, Prevent and Manage
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Communicating/reporting/reflecting
Focus on early intervention
Predict and anticipate problems
Look for risk factors
Report trends that suggest development of complications
Manage the emerging problem with nurse and physician prescribed measures
Carry out assessments to detect complications
Document and evaluating the outcomes
Planning and Prioritizing
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Planning: A process of identifying measurable goals or outcomes, selecting appropriate
interventions, and documenting the plan of care. The nurse consults with the patient
and family while developing and revising the plan.
Prioritization: Determine problems that require immediate action. Identifying which
patients require immediate care and attention in priority sequence.
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Selecting Nursing Interventions
Planning the measures that the patient and nurse will use to accomplish identified goals
involves critical thinking
 The nurse selects strategies based on the knowledge that certain nursing actions
produce desired effects
 Nursing interventions must be safe, within the scope of nursing practice, and compatible
with medical (doctors) orders
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Communicating the Plan
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Effective communication between healthcare providers is vital for improving patient
safety and providing high quality care
The nurse shares the plan of care with: nursing team members, the patient, and
patient’s family
Shift Handover
Shift handover is defined as the transfer of responsibility and/or accountability for patient care
from one nurse to another. The shift handover forms an important part of the communication
process that takes place between the nurses on a ward.
Two Types of Shift Handover
 Verbal Handover
 Charting (Handover Sheets)
a. Handover sheets should contain individual patient information such as: age,
gender, admitting diagnosis and medical history, social history, discharge
planning, current treatments, and changes in clinical condition
b. Bedside chart should contain components of health record: observation
record, medication record and fluid balance sheet
c. It is crucial that the handover sheet and bedside chart contain the important
patient information and are updated regularly to ensure their accuracy
Documentation
Documentation is any written information about a patient that describes the care or service
provided to that patient. Through documentation nurses communicate their observations,
decisions, actions, and outcomes of these actions for patients. Documentation is an accurate
account of what occurred and when it occurred.
When viewing a patient’s records it is important to maintain confidentiality. This means nurses
must not discuss a patients’ examination, conversations, or treatment with other patients or
staff not involved in their care.
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Reasons for Documentation
1. To facilitate communication
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Nurses communicate to other nurses and care providers their assessments about the
status of clients, nursing interventions that are carried out and the results of these
interventions
Documentation increases the likelihood that the client will receive consistent care
Thorough, accurate documentation decreases the potential for miscommunication
and errors
2. To promote good nursing care
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Documentation encourages nurses to assess client progress and determine which
interventions are effective and which are ineffective, and identify and document
changes as needed
3. To meet professional and legal standards
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Valuable method for demonstrating that within the nurse-patient relationship, the
nurse has applied nursing knowledge, skills and judgment according to professional
standards
Guidelines for Documentation:
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Do not erase, or scratch out any errors
Only use professional language
Correct all errors immediately
Record only facts
Do not leave blank spaces in nursing notes
Use legible writing
If you are unsure of the order/documentation seek clarification
Avoid generalizations or assumptions (i.e. patient slept well, had a good day)
Record time, date, signature and title in records
Be factual (objective), accurate, timely, and organized
What do I need to document as a nurse?
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Vital signs
Medication administration or changes
Patient interactions
Change in patients’ status and nursing actions
Admission, transfer, discharge or death of a patient
Any treatments or procedures completed by nurse or other staff members (i.e.
lumbar puncture, catheter insertion, etc.)
The patient’s response to procedure
Patient education
Interactions with other staff members and nurse re: patient (e.g. doctors phone
call/communication, recommendation from physiotherapist)
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Evaluation
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It is the analysis of the patient’s response
The way the patient determines whether they have reached a goal
Helps to determine the effectiveness of nursing care
Ongoing part of the nursing process
Critical Thinking
Critical thinking is the art of analyzing and evaluating; thinking with a view to improve. Critical
thinking is an active, organized, cognitive process. A critical thinker indentifies and challenges
ideas, considers key aspects of a situation, imagines and explores alternatives, considers ethics,
applies reason and logic and therefore, makes informed decisions
A critical thinker:
 Raises questions and problems, formulating them clearly and precisely
 Gathers and assesses relevant information, using abstract ideas to interpret it effectively
 Comes to well-reasoned conclusions and solutions, testing them against relevant criteria
and standards
 Thinks open-mindedly; recognizing and assessing their assumptions, implications and
consequences
 Communicates effectively with others in figuring out solutions to complex problems

Applying critical thinking allows nurses to focus on options for solving problems and making
decisions rather than hastily forming quick solutions. Thinking critically helps a nurse advocate
for patients and make better informed choices about their care. Critical thinking is more than
just problem solving, it is an attempt to continually improve patient care and leads to best
practice.
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Peri-operative Nursing
Peri-operative nursing addresses the nursing roles relevant to the three phases of the surgical
experience:
1) Pre-operative: beings when the decision to proceed with surgical intervention is
made and ends with the transfer of the patient onto the operating room table. The
nurse is responsible for completion of pre-operative forms, implementing doctor's
orders for pre-operative care, and documentation of all nursing measures.
2) Intra-operative: period of time from when the patient is transferred to the
operating room table to when he or she is admitted to the ward. The purpose of
intra-operative care is to maintain patient safety and comfort during surgical
procedures.
3) Post-operative: period of time that begins with the admission of the patient to
the ward and ends after a follow-up evaluation on the clinical setting or home. The
goal of post-operative care is to prevent complications such as infection, to promote
healing of the surgical incision, and to return the patient to a state of health.
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Pre-operative Nursing Management
1) Consent
Questions to ask: Does the patient understand the surgery? Has the patient or the family given consent?
If not, it is our role as nurses to ensure that the patient understands the procedure and that the proper
documentation is signed PRIOR to it occurring.
2) Baseline Vitals
These will show us the patient’s “normal” values prior to surgery so we can compare post operatively and
be able to spot any abnormalities or trigger signs that something is wrong.
3) Patient Teaching
Nurses are responsible to teach the patient pre-operatively about the surgery, what activities they can
resume post operatively, what to expect post operatively, and other considerations such as pain
management, ambulation, nutrition etc. Teaching generally involves the patient and their family members
who will be looking after the patient after the surgery.
4) ‘Head to Toe’-Physical Assessment
The nurse should do a generalized assessment and document it so nurses in the post operative phase
know what an abnormal finding is.
5) Allergies
It is important to know what allergies the patient may have. This includes medications, foods, latex,
environmental etc. It is imperative that the nurses and doctors know this prior to surgery.
6) Medications
The doctor may order medications to be given prior to surgery. Medication can be given with small sips of
water. If the patient regularly takes medication at home, the nurse should ask when they last took their
medication (e.g. antihypertensive, antibiotics etc.).
7) Lab work
All lab work should be visible for the nurses and doctors in the theatre to see. It is important to note the
patient’s haemoglobin prior to surgery.
8) Fasting
The patient should be fasting for at least 8 hours prior to surgery. The doctor should order when the
fasting time starts. This includes all solid and fluid food. However, the patient does not need to be fasting
for days prior to surgery. If the surgery is cancelled, the nurse should ask the doctor if the patient can
eat.
9) Skin Preparation
Bath or wash patient focusing on the affected part that is being operated on. Ensure that all jewellery
and clothing are removed prior to surgery.
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Intra-operative Nursing Management
The Role of the Nurse in the OR
Before the patient arrives in the theatre, the operating room nurse helps prepare the room for
surgery. When the patient arrives, the nurse helps to reduce the patient's anxiety. The nurse
explains to the patient what will happen during surgery, and answers questions the patient may
have before the surgery.
The nurse assists with: transferring the patient to the operating room table, attaching
monitoring equipment (blood pressure cuff, oxygen saturation monitor), inserting an IV
cannula. The nurse helps position the patient before and during surgery.
Proper positioning during surgery is very important because the client will not feel discomfort or
pain, and improper positioning results in the risk of pressure ulcers, nerve damage, and muscle
strain. Preparing the surgical site for surgery is usually the responsibility of the theatre nurse.
The nurse uses antimicrobial agents and scrubs the skin in a circular motion from the site of the
upcoming incision to the periphery, cleansing a large area for added aseptic protection. If hair
needs to be removed, the nurse will remove it with scissors or a razor prior to the skin
preparation. After the skin is prepared, a sterile member of the surgical team applies the sterile
drapes.
Depending if the nurse is sterile or unsterile, their role during surgery differs. The unsterile
nurse, known more commonly as the circulating nurse, documents the surgery in detail,
recording any issues/interventions/outcomes. The sterile nurse, known as the scrub nurse,
assists the doctor with the surgery.
Transfer of Patient from Theatre to Ward
It is important for the theatre nurse to give a detailed report to the nurse who will be caring for
the patient after surgery
Report From Theatre Nurse to Ward Nurse
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Identifies patient by name
States type of surgery performed
Identifies type of anaesthetic used
Reports patient’s response to surgical procedure and anaesthetic
Describes intra-operative factors (insertion of drains or catheters; administration of
blood, analgesics, or other medications during surgery; occurrence of unexpected
events)
Describes physical limitations
Reports patient’s pre-operative level of consciousness
Communicates presence of family and/or significant others
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Post-Operative Nursing Management
Post-Operative Complications
PAIN
Pain is
Pain is
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the most common and challenging complications to manage in post-operative patients.
a problem because:
It is unpleasant
It slows recovery
It prevents your patient from performing activities that are important for recovery such
as mobilizing, deep breathing and coughing, etc.
Therefore, we should aim to keep pain at a level that is manageable
How?
1. Assess your patient for pain throughout your shift
2. Give fast acting analgesic ½ hour prior to activities that will cause pain (mobilizing or
dressing changes)
3. Give analgesics at regularly scheduled times (EVERY 3-6 hours [depending on the drug])
 Not just when the patient is really uncomfortable
4. Use an effective combination of analgesics and non-pharmaceutical techniques
Non-opiod analgesics (Paracetamol, Panadol)
· It is useful for mild pain
· In combination with narcotics, it helps relieve moderate-severe pain
· Should be given REGULARLY:
 up to 650 mg PO every 4 hours, or
 up to 1000 mg PO every 6 hours, or
 do not give more than 4000 mg/day
· If your patient has liver disease, the dose may need to be reduced, as this drug is
excreted through the liver
Anti-inflammatories (Buprofen, Analgin)
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Useful for mild-moderate pain
In combination with narcotics, they help to relieve moderate-severe pain
Should be given REGULARLY
Often cause stomach upset:
 Therefore you should give them with food
Monitor your patient for signs of a GIT bleed – which may be precipitated by regular use of
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anti-inflammatories.
They are hard on the kidneys, therefore:
 It is important to check your patient’s most recent kidney function tests
(creatinine)
 Monitor patient’s urine output; if output is less than 30 ml/hr, advise the
Doctor
Narcotics (Pethidine or Morphine)
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Useful for moderate-severe pain
Not useful for mild pain – like headaches – due to the side effects
If the patient has severe pain, these drugs should be given REGULARLY
Right after surgery, narcotics often cause over-sedation. It is important to assess your
patient’s level of consciousness and respirations before AND after narcotic administration
Why is it important to give analgesics regularly?
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Toxic level
6
When a medication is given,
it has an onset, peak and duration
5
During this time, the drug is
having its therapeutic effect
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2
Critical
concentration
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1
0
0
1
2
3
4
5
6
7
8
9
Time in hours
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In order for a medication to reach its maximum effective concentration, approximately 5
regularly administered doses must be given
In order for the medication to remain at a constant level in the blood, the nurse must
continue to administer the medication regularly
If a medication is administered at irregular intervals, or if the nurse waits until the
medication begins to wear off before administering the next dose, an effective level of
analgesic is not maintained
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NAUSEA AND VOMITING
Another issue for many postoperative patients is nausea and vomiting. Nausea and vomiting are
problems because:
· They are unpleasant for the patient
· They prevent the patient from mobilizing
· They present a risk of aspiration
· They increase the risk of having a surgical wound dehisce (especially abdominal wounds)
Therefore, aim to prevent nausea or keep it at a level that is manageable for your patient
How?
1. Assess your patient for nausea throughout your shift
2. Administer anti-nausea medications when your patient complains of nausea
3. Utilize non-pharmaceutical methods of preventing nausea (e.g. fresh air, cold cloth etc.)
Non-pharmaceutical methods of preventing or managing nausea:
· Have your patient change position slowly. Suddenly standing up may precipitate vomiting.
· Encourage your patient to take slow, deep breaths
· A cool, damp cloth to the forehead or back of the neck may help decrease nausea
· Severe nausea and vomiting may be managed by inserting a nasogastric tube (with a
doctor’s order)
What are some of the causes of nausea?
1. Gastric stasis
· Both surgery and anaesthetics may temporarily paralyze the GIT. The more that the
surgeon handles the bowels, the more likely a patient is to develop an ileus (paralysis).
Therefore, abdominal surgeries often result in serious nausea and vomiting.
The nausea and gastric stasis caused by anaesthesia agents is usually short-lived and wears
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off as the drugs are cleared from the patient’s system.
2. The Chemoreceptor Trigger Zone (CTZ) and the Vomiting Center in the brain. These centers
may be stimulated by:
· Fear, anticipation, memory
· Senses (sight, smell, pain)
· Motion sickness or sudden changes in position
· A drop in blood pressure
· Substances in the blood (opiods, anaesthetics, chemotherapy drugs)
Some of the neurotransmitters involved with nausea and vomiting:
· Histamine
·Dopamine
·Serotonin
When using medication to manage post-op nausea and vomiting:
1.
2.
3.
4.
Administer the medication that you think is most likely to be effective
Wait 20-30 minutes for the medication to take effect
Assess your patient for nausea and vomiting
If the patient is still nauseated, select a medication that works on a DIFFERENT
neurotransmitter
5. Check your medication guide to make sure that the two medications do not interact
together in a negative way
6. Repeat the process
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What if your patient is vomiting bile (green, slimy stuff)?
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Bile enters the GIT in the small intestine. If bile is backing up into the stomach, this is
an indicator of gastric stasis. It is possible that your patient has paralytic ileus (or
possibly an obstruction)
Discuss this situation with the Doctor, document and measure how much
Monitor your patient closely. If the amount of vomited bile is small and decreasing, the
situation will likely resolve with time. If the amount of vomited bile is large and
increasing, the patient may need a nasogastric tube (with a doctor’s order).
What if your patient is vomiting coffee ground emesis (brown, grainy, looks
like coffee grounds)?
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Coffee ground emesis is an indication of blood in the upper GIT
If your patient has had surgery on his/her esophagus, stomach or small intestine, it
would not be unusual to have a small amount of blood in the stomach, which might be
vomited soon after surgery. You should tell the Doctor and monitor the patient’s
condition closely
Whenever you encounter coffee ground emesis, it is important to inform the nurse in
charge or doctor immediately
Large amounts of bright red blood indicate complications – notify doctor and document
Diet and postoperative nausea and vomiting
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Surgery and anaesthetic agents often cause nausea and vomiting, so it is common to
restrict a patient’s diet after surgery
Always check the doctor’s orders regarding a patient’s postoperative diet
For short, minor procedures, the patient may not have any restrictions. Use common
sense. Give the patient sips of water first. If this is tolerated, the patient may be able to
eat small amounts of solid food
For longer surgical procedures, it is usual to keep the patient on clear fluids for the first
evening after surgery, followed by full fluids and then advance to a regular diet, if
tolerated
For surgical procedures involving the abdomen (and particularly the GIT), the patient is
much more likely to experience a paralytic ileus, and the patient usually has more strict
dietary restrictions. The patient may be fasting, or only allowed sips of clear fluids. The
doctor will advance the patient’s diet when the patient has little or no nausea and when
he/she begins to pass wind (indicating that peristalsis has returned)
No matter what the patient’s ordered diet, if the patient is experiencing nausea and
vomiting, it is prudent for the nurse to reduce the patient’s diet. For example, if the
patient has only fluids for breakfast and then vomits, the nurse would not give them a
full meal at lunch. It is up to the nurse to judge the most appropriate diet that the
patient will tolerate.
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BLEEDING
Another possible complication is postoperative bleeding. In this section, we will consider only
postoperative wounds (not chronic wounds) in the first 24 hours after surgery.
It is important to check for significant bleeding on a regular basis including:
· When the patient first returns from the theatre
· ½ hour after surgery
· Then every hour afterward
How much bleeding is “significant”?
Every type of surgical wound will bleed a different amount, so there is no general rule.
However, one rough guide is that bleeding is a concern when you need to change a dressing
(because it gets saturated with blood) more than 2 or 3 times per shift (8 hour period or less).
How to know what to expect:
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In order to assess your patient correctly and intervene appropriately, you must know
approximately how much drainage to expect.
When the surgeon anticipates a lot of drainage, he/she will usually put in place a
surgical drain.
Some general guidelines:
· Open abdominal surgeries (e.g. open appendectomy, bowel resection) usually drain a
moderate amount of serosanguinous fluid. The dressing might need to be changed a few
times per shift
· Orthopaedic surgeries usually drain a moderate amount of blood after surgery, and the
dressing may need to be reinforced with abdominal pads.
How do we manage excessive bleeding?
1. Non-emergency
· Immediately observe how much bleeding/drainage the patient has experienced (number
of dressing changes, or amount of drain output). This will provide guidance on the best
strategy to deal with the bleeding.
· Often excessive bleeding can be slowed with direct pressure to the wound. This can be
accomplished by:
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Putting several gauzes on top of the wound and apply pressure with a gloved hand until
the bleeding slows down or stops
Using a stretchy bandage. For example, a knee can be wrapped with a tensor bandage. A
chest or abdominal wound can have elastic tape stretched over a bulky gauze dressing
Take your patient’s vital signs and monitor them closely. Excessive bleeding may cause
decreased blood pressure and elevated heart rate. Report any changes to the doctor
The doctor may order a transfusion of red cells to replace the blood loss
Document amount of estimated blood loss and interventions
2. Emergency, life-threatening
· Immediately tell the doctor about the bleeding. If the bleeding is severe, you will need
to get other nurses to help
· Apply direct pressure to the wound to slow the bleeding
· Make sure the patient is lying down in bed
· If the bleeding is severe, the surgeon may need to take the patient back to the theatre
to control the bleeding
· Be prepared to assist in administering a transfusion or bolus of intravenous fluids or
blood
· Monitor the patient’s vital signs more frequently and report a drop in blood pressure or
increase in heart rate
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FEVER
Many post-operative patients will develop a fever. This fever may simply be part of the
patient’s normal physiological response to surgery, or it may indicate a potential
complication.
Normal physiological response to surgery:
· Causes a low grade (usually <38°) fever during the first 48 hours after surgery
· Caused by:
 Normal inflammatory response to surgery
 Increase in metabolism, to meet increased metabolic demands from body in order to
heal
· Usually requires no treatment
Malignant hyperthermia
· Rare complication
· Causes a severe, life-threatening fever
· Usually occurs in the operating room, but may still occur up to 10 hours post-operatively
· Genetic predisposition which causes some patients to react to anaesthetic medications (e.g.
succinylcholine)
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Fever in a post-operative patient
The 4 W’s
· WIND ·WALKING
·WATER ·WOUND
Wind:
· Occurs most commonly on post-operative day 1-2
· Wind refers to atelectasis (collapsing of the small airways at the bottom of the lungs
· Fever due to atelectasis is treated by encouraging the patient to deep breathe and cough,
and encouraging the patient to mobilize
Water:
· Occurs most commonly after postoperative day 3-5
· Water refers to urinary tract infections (UTI’s) – particularly in patients who have been
catheterized
· If you suspect a UTI, obtain a sterile urine specimen for ‘culture and sensitivity’
22
Walking:
· Occurs most commonly after post-operative day 4-6
· The development of deep vein thrombosis (DVT), which may cause a low-grade fever
· To prevent DVT, encourage patients to ambulate as soon as possible, at least 3 times per day
Wound:
· Most wound infections do not cause fever until 5-7 days after surgery
· If your patient will be discharged home before this time, you need to teach your patient how
to recognize the signs of a wound infection. It is important to carefully assess the wound for
redness, swelling, pain and purulent drainage
· If you suspect a wound infection, take a wound culture. (Cleanse the wound with normal
saline, and then roll a sterile swab over the wound bed for about 30 seconds)
Other important causes of fever:
Septicemia/Septic Shock (serious, system-wide infection)
· Typically causes a moderate to high fever… but in some cases, patients may not develop a
fever with sepsis
· May occur at any time, depending on the cause
· The risk is increased in patients who have experienced trauma, or patients who have had a
leakage of GI contents into the peritoneum
· The risk is increased in patients who have invasive procedures
Dehydration
23
· Causes a low-grade fever
· May occur in patients who have been fasting or who have been vomiting
· Urine output may be decreased and urine may be concentrated
· Skin turgor may be reduced and mucous membranes dry
What to do about a fever:
· When your patient has a fever, look at the ‘big picture’:
 Are his/her vital signs stable?
 Does he/she feel well otherwise?
 How does his/her chest sound?
 What does his/her urine look/smell like?
 What does his/her wound look like?
 Is he/she mobilizing? Any signs of a DVT?
 What medications is he/she taking?
 Are there any other potential sources of infection (like an IV, urinary catheter)?
· Identify the most likely cause of the fever
· Decide if the physician needs to be notified
Select an appropriate intervention, such as:
· Administer anti-infective medications as ordered
· Provide non-pharmacological measures
o Cool cloth to the head or neck
o Use fan to circulate the air
o Remove extra bed covers
o If the patient is allowed, provide increased fluids
· If the patient has a high fever, or if the fever is causing the patient discomfort, administer an
24
anti-pyretic medication, as ordered:
o Panadol
o Analgin
· For a low-grade fever, an appropriate intervention may be to do nothing more than to closely
monitor the patient’s condition
Other considerations for patients with a fever:
· Patients with a fever need increased fluids (due to increased metabolic rate and loss of water
through sweat)
· Patients with a fever need more calories (due to increased metabolic rate)
· Not every fever needs medication. Low grade fevers rarely need to be treated with an antipyretic medication unless the patient experiences a headache or other bothersome symptom
of the fever
· Some serious infections DO NOT always cause a fever
o Some patients – particularly those with a compromised immune system – may
not get a fever when they get an infection. Some examples include patients
receiving chemotherapy, elderly patients, patients with HIV/AIDS, certain types
of cancer, diabetes, etc
25
DIZZINESS AND FAINTING
For the first 24-48 hours, post-operative patients often experience dizziness when they sit or
stand up and may faint.
Patients who have had spinal anaesthetic are especially susceptible to dizziness. The spinal
anaesthetic “freezes” motor nerves (so the person can’t move), sensory nerves (so the person
can’t feel pain) and autonomic nerves (which maintain the muscle tone in blood vessels). When
a person stands up, the walls of the blood vessels in the lower body should contract – to keep
your patient’s blood from draining to his feet. However, after having a spinal anaesthetic, this
mechanism doesn’t work for several hours. All their blood drains to their feet, blood pressure
drops, and then the patient faints.
To prevent your patient from fainting when mobilizing:
·
·
·
·
·
·
If your patient has had a spinal anaesthetic, make sure he/she can feel his feet prior to
attempting to mobilize
Ask your patient to change position slowly
When your patient sits up, have him/her sit up straight and take several deep breaths
Check your patient’s skin colour. If he becomes pale, have him/her remain seated until
his colour returns and the dizziness fades. If the patient becomes very pale/gray and
sweaty, help him to lie down immediately
Remember, nausea is often a sign of a sudden drop in blood pressure
Remain at your patient’s side until you find out how he tolerates standing
When is it safe for your patient to walk to the bathroom?
·
It depends…


How big was the surgery?
How many drugs/which drugs did the patient receive during surgery?
26


·
·
·
·
·
How alert/awake is the patient?
How well did the patient mobilize before the surgery?
Check the doctor’s orders to make sure that your patient is allowed to ambulate
Use your judgment – depending on the patient’s condition, and the type of surgery
Sometimes it is OK for the patient to get up within hours of the surgery – sometimes
you should wait until the next morning
ALWAYS walk with your patient to the bathroom the first time
Make sure you have any necessary mobility aids (e.g. wheelchair) at the bedside
BEFORE you get the patient up
What should you do if your patient faints?
·
·
·
·
·
·
·
·
Call for help
Check the ABC’s (airway, breathing, circulation)
Check for injuries
Once you have adequate help, assist your patient back into bed
Check your patient’s vital signs and complete a head-to-toe assessment
Administer first aid, as necessary
Advise the physician
Document
What is a vasovagal episode?
·
·
·
“Vaso” refers to blood vessels – in this case, it usually means that the patient’s
peripheral blood vessels are dilated, so that when the patient stands up, all his blood
rushes from his brain to his feet.
“Vagal” refers to the vagus nerve. When the vagus nerve is stimulated, it slows down
the heart (decreasing cardiac output). Some activities that may stimulate the vagus
nerve include:
o Holding the breath and ‘bearing down’ – as when having a bowel movement.
o Inserting a rectal suppository
o Inserting an IV catheter or administering an injection
When a surgical patient faints, the combination of factors leading to this event are often
referred to as a vasovagal episode.
The series of events that may typically occur in a vasovagal episode include:
 As the patient sits or stands, there is a slow decrease in the patient’s blood pressure
 The patient begins to experience symptoms of hypotension (faintness, dizziness,
confusion, nausea, dyspnea, becoming pale and sweaty)
 After a variable period of time (5-20 minutes), there is a sudden drop in blood pressure
and heart rate
 The patient may suddenly lose consciousness
 Some patients experience mild jerking of the limbs (which might appear like a seizure –
although there is no actual seizure activity in the brain)
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DEEP VEIN THROMBOSIS (DVT)
Deep vein thrombosis is a serious complication that can lead to additional life-threatening
complications, such as pulmonary embolus
Some authorities suggest that (without prevention) up to 20% of patients undergoing general
surgery will develop a DVT
Most DVTs occur in the lower extremities – particularly in the lower leg
Three causes of DVT:
1. Blood pooling in the veins or moving sluggishly
 Patients not mobilizing adequately after surgery
2. Damage to blood vessels
 Blood vessels cut during surgery
3. Blood that clots too easily
 Dehydration
 Clotting cascade activated during surgery
Signs and symptoms of DVT:
It may be difficult to identify a DVT, because patients may experience some of the following
signs and symptoms – but up to ½ of patients have no symptoms at all.
· Redness, tenderness, swelling on the affected limb
· Low grade fever
· Homan’s sign (pain in the calf on dorsiflexion)
Preventing DVT after surgery:
· Ambulation, ambulation, ambulation!
· Adequate hydration
28
FLUID AND ELECTROLYTE IMBALANCES
Surgical patients are at a high risk for several fluid and electrolyte imbalances
Hypovolemia
There are several factors that contribute to the development of hypovolemia in surgical
patients:
· Reduced fluid intake prior to surgery (patient is often fasting prior to surgery)
· Fluid loss during surgery
 Bleeding
 Evaporation from the open body cavity
· Reduced fluid intake after surgery
· Fluid loss after surgery
 Wound drainage
 Sweating
 vomiting
Some Common Signs and Symptoms of Hypovolemia:
·
·
·
·
·
·
Decreased blood pressure
Increased heart rate
Decreased level of consciousness, dizziness, light headedness
Nausea
Skin and mucous membranes are pale
Peripheral vasoconstriction (hands and feet cool and pale)
Nursing Management of Hypovolemia:
·
·
·
·
·
Monitor vital signs closely for decreased blood pressure and increased heart rate
Use caution when mobilizing patient – due to possible dizziness
Administer supplemental oxygen as necessary
Administer intravenous fluids
For severe hypovolemia, blood transfusions may be necessary
Fluid Volume Excess/Hypervolemia
Several factors that may contribute to the development of fluid volume excess:
· Administration of excessive intravenous fluids during surgery
· Reduced kidney function in susceptible patients, leading to retention of fluids
· Hormonal mechanisms:
 Increased secretion of anti-diuretic hormone (ADH), leading to fluid retention
 Increased secretion of aldosterone, leading to fluid retention
29
Some Common Signs and Symptoms of Fluid Volume Excess:
·
·
·
·
·
·
·
Elevated blood pressure
Elevated heart rate
Elevated respiratory rate
Decreased oxygen saturation
Dyspnea
Crackles – often loud, wet-sounding crackles that can be heard without a stethoscope
Edema – often starts in the lower extremities but may extend throughout the body as
more fluid accumulates
Nursing Management of Fluid Volume Excess:
· Monitor vital signs closely for elevated blood pressure and increased heart rate
· Monitor lungs for signs of dyspnea, crackles, elevated respiratory rate and decreased
·
·
·
·
·
oxygen saturation
Administer supplemental oxygen as necessary
Elevate the head of the bed
Monitor intake and output closely
If the patient is tolerating the excess fluid, the doctor is likely to wait for the patients’
hormones to normalize. After 2-3 days, the patient will usually experience a sudden
increase in urine output and excrete the excess fluid.
If the patient is not tolerating the excess fluid (e.g. dyspnea or chest pain), the doctor is
likely to order diuretic therapy (ex: furosemide)
30
URINARY RETENTION
Many patients experience urinary retention after surgery. If the patient does not have a urinary
catheter in place, it is important to monitor for this complication.
Why? What usually causes urinary retention?
· Anaesthetic agents – particularly spinal anaesthetics
· Narcotics
· Enlarged prostate in men
Monitoring urinary output after surgery
·
·
·
·
As soon as your patient returns from surgery, find out:
 When did the patient void (pass water) last?
 How much fluid did the patient receive in the theatre?
 How fast is the patient’s IV running? – Remember, what goes in must come out!
Assess for bladder distension and ask if the patient needs to void
If the patient had a spinal anaesthetic:
 The effects of the spinal anaesthetic may prevent the patient from feeling the urge
to void, even when the bladder is full
 As the spinal anaesthetic wears off, sometimes the patient will suddenly discover
that his/her bladder is uncomfortably full, yet be unable to release the urinary
sphincter to void
If the patient does not need to void right away, and the patient’s bladder is not yet full,
re-assess the patient every 1-2 hours until the patient voids
When is ‘full’ too full?
An average bladder holds about 300-600 ml.
31
·
·
Whenever possible, it is best to simply wait and allow any perioperative medications to
wear off, in order to allow the patient to void normally after surgery
However, once you establish that the patient’s bladder is full it may be necessary to
insert a urinary catheter to drain the bladder. There is no absolute rule about how long
to wait before inserting a catheter. Here are some factors to consider:
 You must have a doctor’s order to insert a urinary catheter
 If a patient has not voided within 6-8 hours, you should re-assess the patient
frequently and provide opportunities to void (e.g. provide a urinal, assist the patient
to the bathroom etc.)
 If you anticipate that the patient may need to be catheterized, prepare your supplies
and review the procedure
 When the patient’s bladder is slightly distended, use your judgement about the right
time to insert a catheter:
o How big is the patient?
o Is the patient experiencing any bladder pain or discomfort?
o Is the patient continuing to receive medications that cause urinary retention?
 If the patient’s bladder is distended, and the patient is not able to void, it is usually
necessary to insert a urinary catheter
32
POSTOPERATIVE DELIRIUM
Postoperative delirium is a common – and serious – complication experienced by many surgical
patients
What does delirium look like?
Delirium symptoms include:
 Acute onset of symptoms (a change from the patient’s previous cognitive function)
 Fluctuating symptoms (gets better and worse throughout the day)
 Difficulty focusing attention
 Disorganized thinking
 Illogical or rambling
 Altered level of consciousness
Hyperactive (agitated) or hypoactive (drowsy)
Is it possible to be “alert and oriented” and to have a mild level of
postoperative delirium...YES!
What are the causes of delirium?
There are many factors that may lead to delirium:
· Long or complicated surgery
· Fluid or electrolyte imbalance
· Pain
· Use of narcotics
· Use of multiple medications
· Use of anticholinergic medications
· Sleep deprivation
· Urinary retention
33
·
·
·
·
·
·
·
·
Use of a urinary catheter
Use of restraints
Constipation
Malnutrition
Infection
Fever
Hypoxia
Old age
What should the nurse do about delirium?
1. The first step is to recognize when the patient has had a change in cognition
a. Report the change to the nurse in charge and doctor
b. Chart your findings: Document specific findings with narrative charting
2. Seek out possible causes of the delirium and attempt to remove the cause. For example,
if the patient has not had a BM for several days, give them a laxative
3. Assist the patient to eat adequate and nutritious meals
4. Reduce stimulation in the patient’s environment (e.g. noise)
5. Assist the patient to mobilize soon after surgery
What if the patient is very confused and at risk for injuring him/her self?
1. Ensure that the other nurses and the in-charge are aware of the patient’s status. It may
be necessary to have a nurse sit with the patient to prevent harm
2. Some patients may be calmer if a family member sits with them
3. Avoid physical restrains whenever possible – they often make delirium worse
4. If the patient is very agitated or disruptive, it may be necessary to administer an
antipsychotic/ neuroleptic medication
Disruptive behaviours:
·
·
·
·
·
·
·
·
·
Impulsiveness
Wandering
Climbing out of bed
Pulling at tubes
Hallucinating
Picking
Resistance to care
Combativeness
Hitting, pinching, biting
34
Wound Care
Principles of Wound Care
Types of surgeries
Know the type of surgery performed and the body structures involved
Abdominal surgery versus thoracic surgery
Abdominal surgery– abdominal cavity, intestines, pancreas, liver, and
stomach
Thoracic surgery – lungs, pleural cavity, and rib cage
 Support the patients concerns
Talk to patient and find out their concerns
 For many post operative patients pain management and mobilization are
concerns
Enhance local wound care
Aseptic technique
Dressing changes
Types of Surgery
Example:
Abdominal surgery
Questions to ask yourself:
1. What organs and body structures are involved?
2. How much drainage is there from the wound? Is there a drain?
A small amount of serous or sanguineous drainage is normal from any
wound
Your wound is draining heavy sanguineous drainage, what are your
priorities?
 Stop the bleeding
 Assess blood pressure and other vital signs
35
Wound Drainage
Types
Description
Color and Consistency
Serous
Clear or light yellow
Thin and watery
Sanguineous
Red (with fresh blood)
Thin
Serosanguineous
Pink to light red
Thin
Watery
Purulent
Creamy yellow, green, white or light
brown
Thick and opaque
Amount
If a drain is in place you can expect a moderate to large amount of drainage
Amount decreases with time
Drainage transitions from sanguineous to serous
Support Patient Concerns
Pain Control
Is your patient comfortable? How do you know?
Ask them and look for body language
Assessment (use faces card or number scale)
36
Has the patient taken pain medication?
Effective pain control will promote wound healing, prevent complications
and allow patients to participate in activities
Mobilization
Early and frequent mobilization leads to improved wound healing
How?
Improves circulation and oxygenation throughout the body
Wound care with aseptic technique
Goal: keep the wound as clean as possible!
Steps:
1. Remove soiled dressing
2. Inspect the dressing and wound
Note the color, amount, and odor of drainage
3. Clean the wound
Sterile field
Clean to dirty
Use a new piece of gauze for each cleaning swipe
4. Dry the wound
Using gauze
5. Reassess the condition of the skin and wound
Note the surrounding skin and wound bed
6. Document any significant findings
Dressing Changes
Frequency
Depends on the type of wound and every patient will be different
Basic principle:
change when soiled and as ordered by the doctor
 Types of dressings
Assess drainage from previous dressing and this will be your indicator as
to which dressing to use
For moderate to large drainage you will need an absorbent dressing
For scant drainage you will need a less absorbent dressing
37
Surgical Skin Closures
Sutures
Ask what kind of suture your patient has so you know whether or not they need to be
removed or if they will dissolve
If you are unsure, ask the doctor
What to teach your patient about surgical wound care
Signs and symptoms of wound infection to report immediately
See below
Proper wound care, such as keeping the incision clean and dry and the importance of
hand-washing
Wound dressings and proper application
Activity restrictions (especially for abdominal surgeries)
No heavy lifting
Splinting and protecting abdominal muscles when coughing or sneezing
Complications
1. Infection
Redness
Purulent drainage
Foul odor
Warmth
Swelling
2. Wound dehiscence
Separation and disruption of wound edges
3. Wound evisceration
Protrusion of the visceral organs through a wound opening (considered a medical
emergency)
38
Documentation
The standard is that wound care should be documented
Why?
To establish whether or not the wound is healing
This will guide care
Provides communication of care between healthcare professionals
39
Assessment and Prioritization
When to transfer a patient to the Critical Care Unit
Signs of an Unstable Patient: (What to Watch For)
Acute
Acute
Acute
Acute
Acute
change
change
change
change
change
in
in
in
in
in
heart rate <40 or >130
systolic BP <8 or >30
RR <8 or >30
conscious state
urinary output to <30 ml/hr
Signs of an Unstable Patient: (Your Assessment Findings)
CNS: restlessness, anxiety, confusion, changes in LOC
CVS: ↑ HR, ↓ BP, ↓ peripheral pulses
Resp: ↑ respiratory rate, ↑ oxygen requirements
GIT: ↓ blood sugar (especially in non-diabetics), nausea and vomiting
GU: ↓ Urine output (less than 30m ml/hr and dropping)
Skin: dry, warm, flushed (early sign), pale, cool, mottled (late sign)
Priority Actions:






Notify physician of findings and concerns
Apply oxygen (if needed)
Establish IV lines
Fluid support
Frequent vital signs and Foley catheter (if needed)
Lab work
Prior to calling the physician, follow these steps:




Have I seen and assessed the patient before calling?
Has the situation been discussed with the nurse in-Charge?
Know the admitting diagnosis and date of admission
Have I read the most recent Doctor's progress notes and notes from the nurse who
worked the last shift ahead of me?
 Have the following in front of you when speaking with the physician
◦
Patient's chart
◦
List of current medications, allergies, IV fluids, and lab work
◦
Most recent vital signs
40
References
Day, R.A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. G. (2010). Brunner &
Suddarth’s textbook of Canadian medical-surgical nursing (2nd ed.). Philadelphia:
Lippincott, Williams & Wilkins.
Canadian Health Services Research Foundation. (2008) “How can we improve
communication between healthcare providers? Lessons from the SBAR
technique.”
Chaboyer, W., McMurray, A. & Wallis, M. (2010) “Bedside Nursing handover: A case
study.” International Journal of Nursing Practice; 16, 27-34.
College of Registered Nurses of British Columbia. 2007 “Nursing Documentation.”
Garrett, K., Tsuruta, K., Walker, S., Jackson, S. & Sweat, M. (2003). Managing nausea
and vomiting: Current strategies. Critical Care Nurse 23(1), 31-52.
Kjorven, M. (2010). Postoperative Delirium [PowerPoint slides from NRSG 221].
Retrieved from https://www.elearning.ubc.ca
McKerns,L. (n.d.). What is Patient Centered Care and How is it better. Retrieved
September 1, 2010, from
http://www.selfgrowth.com/articles/What_is_Patient_Centered_Care_and_how_i
s_it_Better.ht ml .
Springhouse. (2008). Fluid & electrolytes made incredibly easy (4rd ed.). Pennsylvania:
Springhouse.
Pop, BB., Rodzen, L & Spross, G. (2008) “Raising the SBAR: How better communication
improves patient outcomes.” Nursing, 38(3), 41-43.
Potter, P.A. & Perry, A.G. (2006). Canadian fundamentals of nursing (3rd ed.). Toronto,
ON: Elsevier Mosby.
The American Academy of Otolaryngology – Head and Neck Surgery Foundation.
(2005). Chapter 3: Postoperative fevers. Primary Care Otolaryngology (2nd ed.).
Retrived 26 December 2006 from http://www.entnet.org/education/upload
/Chapter-3-Postoperative-Fevers.pdf
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Wakefield, T. W. & Messina, L. M. (2006). Chapter 36. Veins & Lymphatics (Chapter).
Doherty GM, Way LW: CURRENT Surgical Diagnosis and Treatment, 12e:
http://www.accessmedicine.com/content.aspx?aID=2063677.
Wikipedia. Teamwork. Retrieved September 1, 2010, from
http://en.wikipedia.org/wiki/Teamwork.
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