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Care of Surgical Patients
B260: Fundamentals of
Nursing
History of Surgical Nursing
• Association of periOperative Registered Nurses
(AORN)
• Established in 1956
• Focus on clinical practice, professional
practice, administrative practice, patient
outcomes, and quality improvement
• Ambulatory surgery
• Hospital-based or freestanding
• Many laparoscopic surgeries, such as
gallbladder removal (cholecystectomy)
Classification of Surgery
• Seriousness
• Major or minor
• Urgency
• Elective, urgent, emergency
• Purpose
• Diagnostic, ablative, palliative,
reconstructive/restorative, procurement
for transplant, constructive, or cosmetic
Risk Factors
Age
Nutrition
Obesity
Sleep apnea
Immunocompetence
Fluid and
electrolyte
imbalance
Pregnancy
Surgical Phases
• Pre-operative – Before surgery
• Intra-operative – During surgery
• Post-operative – After surgery
Pre-Operative: Assessment
• Medical history
• Past illnesses
• Surgeries
• Reasons for surgery
Peri-Operative: Assessment (cont’d)
• Perceptions and knowledge
• Medication history
• Prescription
• Over the counter
• Herbs
• Street drugs
• Allergies
• Drugs, latex, food, and contact
Peri-Operative: Assessment (cont’d)
• Smoking
• Cigarettes or packs per day
• Alcohol ingestion and substance
use/abuse
• Use per day or week
• Support sources
• Family, friends, home environment
Peri-Operative: Assessment (cont’d)
• Occupation
• Preoperative pain assessment
• Emotional health
• Self-concept
• Body image
• Coping resources
• Culture and religion
Peri-Operative: Assessment (cont’d)
Physical Examination
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General survey
Head and neck
Integument
Thorax and lungs
Heart and vascular system
Abdomen
Neurological status
Diagnostic screenings
Nursing Diagnosis and Planning
Nausea
Ineffective airway
clearance
Deficient knowledge
(specify)
Impaired physical
mobility
Anxiety
Fear
Delayed
Risk for deficient
surgical
fluid volume
recovery
Risk for
Acute pain
infection
Risk for perioperative positioning
injury
Pre-Operative: Implementation
• Informed consent: legal issue
• Preoperative teaching:
• Reasons for preoperative Instructions and
exercises; time of surgery
• Postoperative unit and location of family during
surgery and recovery; anticipated
postoperative monitoring and therapies
• Surgical procedures and postoperative
treatment; postoperative activity resumption
• Patient verbalizes pain relief measures.
• Patient expresses feelings regarding surgery.
Pre-Operative: Implementation (cont’d)
• Physical preparation
• Maintaining normal fluid and
electrolyte balance
• Reducing risk of surgical site
infection
• Preventing bladder and bowel
incontinence
• Promoting rest and comfort
Pre-Operative: Implementation (cont’d)
• Preparation on day of surgery
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Hygiene
Hair and cosmetics
Removal of prostheses
Safeguarding valuables
Preparing the bowel and bladder
Vital signs
Documentation
Other procedures
Administering preoperative medications
Eliminating wrong site and wrong
procedure surgery
Pre-Operative: Evaluation
• Evaluate whether the patient’s
expectations were met with respect to
surgical preparation.
• During evaluation, include a discussion
of any misunderstandings, so patient
concerns can be clarified.
• When patients have expectations about
pain control, this is a good time to
reinforce how pain will be managed after
surgery.
Intraoperative Surgical Phase
• Transport to the operating room
• Preoperative (holding) area
• IV placement
• Anesthesia assessment
• Admission to the operating room
• Nursing process
• Assessment
• Nursing diagnosis
• Planning
Intraoperative: Implementation
• Physical preparation
• Monitoring
• Graded compression stockings
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Latex sensitivity/allergy
Introduction of anesthesia
Positioning the patient for
surgery
Documentation of intraoperative
care
Introduction of Anesthesia
• General
• Loss of all sensation and consciousness
• Induction, maintenance, and emergence
• Regional
• Loss of sensation in one area of the
body
• Local
• Loss of sensation at a site
• Conscious sedation/moderate sedation
• Used for procedures that do not require
complete anesthesia
Intraoperative: Evaluation
• The circulating nurse conducts an ongoing
evaluation to ensure that interventions
such as patient position are implemented
correctly during the intraoperative phase of
surgery.
• Circulating nurse
• Scrub nurse
• Evaluate the patient’s ongoing clinical
status. Continuously monitor vital signs
and intake and output.
Postoperative Surgical Phase
• Immediate postoperative recovery (phase
1)
• Arrival
• Hand-off: OR to PACU
• Systems assessment
• Discharge and hand-off: PACU to
Acute Care
Postoperative Surgical Phase
• Recovery in ambulatory surgery
(phase 2)
• Postanesthesia recovery score for
ambulatory patients (PARSAP)
• Observation
• Discharge
• Postoperative convalescence
Postoperative: Assessment
• Airway and respiration
• Circulation
• Temperature control
• Malignant hyperthermia
• Fluid and electrolyte balance
• Neurological functions
Postoperative Assessment
• Skin integrity and condition of the
wound
• Metabolism
• Genitourinary function
• Gastrointestinal function
• Paralytic ileus
• Comfort
Postoperative Nursing Diagnosis and
Planning
• Determine status of preoperative diagnosis.
• Revise or resolve preoperative diagnosis;
identify relevant new diagnoses.
• Goals and outcomes:
• Patient’s incision remains closed and
intact.
• Patient’s incision remains free of
infectious drainage.
• Patient remains afebrile.
• Setting priorities
• Teamwork and collaboration
Acute Postop Care: Implementation
Maintaining
Respiratory
Function
Patency, rate, rhythm, symmetry, breath
sounds, color of mucous membranes
Preventing
Circulatory
Complications
Heart rate, rhythm, BP, capillary refill, nail
beds, peripheral pulses
Achieving Rest and Enhance the efficacy of pain control,
Comfort
minimize side effects of each modality
Temperature
Regulation
Malignant hyperthermia
Maintaining
Neurological
Function
LOC, gag and pupil reflexes
continued…
Postop Care: Implementation
Maintaining Fluid and
Electrolyte Balance
IV, I&O, compare baseline lab
values
Promoting Normal Bowel
Elimination and Adequate
Nutrition
Anesthesia slows motility.
Promoting Urinary
Elimination
Urinary function returns in 6 to
8 hours.
Promoting Wound Healing Check skin for rashes,
petechiae, abrasions, or burns;
wound for drainage.
Maintaining/Enhancing
Self-Concept
Observe patients for behaviors
reflecting alterations in selfconcept.
Implementation: Restorative and
Continuing Care
• Preparation for discharge
• Continue wound care.
• Follow diet or activity restrictions.
• Continue medication therapy.
• Watch for complications.
• Some patients need home care after
discharge; others require discharge to a
skilled nursing facility.
Evaluation
• Examples of evaluation questions:
• “Are you satisfied with the way we are
managing your pain?”
• “Do you feel you have learned enough to
be able to follow your diet at home?”
• “Are you having any ongoing issues,
questions, or concerns that we can
address for you at this time?”
• Evaluate whether the patient and the family
have learned self-care measures.