SURGERY

SURGERY - designates the branch of medicine that encompasses pre-operative care,

intra-operative judgement, and post-operative care of patients
OPERATION - for correction of deformities and defects, repair of injuries, diagnosis and cure
of disease processes, relief of suffering and prolongation of life.
PERIOPERATIVE NURSING
- describes the nursing functions in the total surgical experience of the patients
- Specialise area of practice providing care to surgical clients

3 PHASES OF PERIOPERATIVE NURSING:

1. Pre-operative Phase - from the time the decision is made for surgical intervention to
the transference of the patient to the operating.
START: When decision was made
ENDS: Transference of the patient to OR
a. Informed consent
b. Demographic data
- Check personal information- name, age, history of illness or allergies,
previous surgery
c. Health teaching
d. Physical assessment and emotional assessment is performed
e. Laboratory Phase
2. Intra Operative Phase - from the time the patient is received in the operating room,
to the time of administration of anaesthesia, surgical procedure is done, until
admitted to the RR/PACU
BEGINNING: starts once transferred to OR and given with anaesthesia
END: admitted to PACU (POST-ANAESTHETIC CARE UNIT)
a. Maintain aseptic technique to provide safety (sterile environment)
b. note - surgical site infection (SSI)
c. Surgical positioning
d. Equipments are properly functioning, also provide necessary equipments
3. Post Operative Phase - from time of admission to the RR, to the time he is
transported back to the surgical unit, discharges from the hospital, until the follow up
care.
BEGINNING: admission to RR
END: discharge

CONDITIONS REQUIRING SURGERY: (OPET)

1. Obstruction - blockage to any organ
2. Perforation - fracture or hole in organ, PPUD (perforated peptic ulcer disease)
3. Erosion - wearing OFF
4. Tumour - any abnormal new growth that has no physiologic function (benign or
malignant)
Under diagnostic
- Melena - Blood in stool

CLASSIFICATION OF SURGICAL PROCEDURES:

According to PURPOSE
1. Diagnostic - Process of determining the nature of the disease
 a. Bronchoscopy - viewing of pulmonary System
b. Colonoscopy - viewing of the colon
2. Exploratory - an investigative operation on a wound, tissue or cavity
a. otomy- incision
b. example to know what organ is affected (ruptured appendix - so need siyag
laparotomy)
3. Curative - to treat the disease condition
a. Ablative - removal of a diseased organ
i. ectomy - removal
ii. Eg. appendectomy, amputation
b. Constructive - repair of congenitally defective organ
i. plasty- surgical repair
ii. Eg. cheiloplasty, herniorrhaphy, orchiopexy
c. Reconstructive - to treat disease conditions, restore the partially or
completely damaged organ and tissue.
I. eg. skin graft after a burn, total joint replacement, rhinoplasty,
perineorrhaphy, ORIF (Open Reduction Internal Fixation)
NOTE:
Perineorrhaphy and episiorrhaphy is the same but performed in different conditions
Perineorrhaphy - cause of tear is accidental on the perineum area during childbirth
Episiorrhaphy - cause is intentional for example during giving birth after episiotomy
4. Palliative - alleviates symptoms without curing the disease condition
a. remove the affective area and suture back the health are of the patient, will
not cure it just relieve symptoms
b. Eg. bowel resection in patient with terminal cancer
5. Transplant - to replace/ organs tissue
a. Heart, lungs, liver, kidney, cornea
NOTE:
Eyeball removal is impossible due to nerve that is connected such as the optic nerve,
removal of the said organ causes total blindness

According to DEGREE of RISK (Magnitude/extent)

1. MAJOR
- major cavities are opened (chest, abdomen, skull)
- so much blood loss and usually would last for 8 to 12 hours. (Cataract surgery
is considered a major surgery)
- Extensive critical assault to the area
- High risk for mortality and morbidity
- Prolonged hours of procedure
- Vital organs are affected
a. Transplant
b. Caesarean
c. Total hip replacement
d. cholecystectomy
e. joint replacement
2. MINOR
- only superficial tissues are opened and does not open major cavities of the
body - can be done in a ambulatory surgery
 - Ambulatory surgery means, after the surgery the patient can go home or be
discharge on the same day without being admitted to the hospital
a. A minor surgery can become a major surgery if prolonged 4-5 hrs (due to
complication)
b. Examples
i. Debridement
ii. RASPA OR D & C (dilatation and curettage)
iii. SKIN LESION REMOVAL
iv. BREAST BIOPSY
v. Removal of warts

According to URGENCY
1. Emergency - to be done immediately
- Done without delay to save the life of the patient
- This events are LIFE-THREATENING scenarios
a. fetal distress, excessive
b. ruptured appendix it is emergency
c. Obstetric emergencies
d. ruptured aneurysm
e. life threatening trauma
f. Intestinal obstruction
g. Multiple injury
2. Urgent/Imperative - to be done within 24 to 30 hours (or 24 - 48)
- It is urgent and requires immediate attention within the given time frame
a. essential to perform surgery but not an emergency
b. Eg. amputation resulting from gangrene, fractured hp, heart bypass surgery,
appendectomy
3. Elective - performed for the patient’s well being
a. depending on the assessment and findings of the surgeon
b. the doctor will schedule the surgery
c. but the time of surgery depending on the assessment of the doctor
4. Planned/Required - necessary surgery, needed by the patient but the time of the
surgery is scheduled by the physician or surgeon
a. Cataract surgery
5. Optional - performed for patients aesthetic purposes, personal preferences
a. plastic surgery like rhinoplasty
NOTES:
- Emergency/ Stat performed immediately
- Scheduled / Elective

SURGICAL RISK FACTORS (MAMDOCRARD)

1. AGE - extreme ages :< 2 years or ? 65 years have higher risks
- Infant (young age group) blood depletion due to their low fluid reserves which
can cause (such as) hypovolemic shock
- Old - cognitive problems that involves age related changes, Less physiologic
reserves due to old age, diminish blood flow thus there will be inadequate
tissue perfusion
Nsg. Implications:
 ● Consider using lesser doses of anaesthesia for desired effect.
- general anaesthesia (GA) for children
- Epidural anaesthesia for adults bc lesser ang side effects
● Adjust nutritional intake to conform to higher protein and vitamin needs.
- protein for tissue or antibody repair esp in patients who undergone surgical
procedure
- vit c for immune booster referring to surgical patient for antibody formation
- Vit a for wound healing; food sources are dairy products
- Vit k for blood clotting hemostan, soybean, broccoli
● Anticipate problems from long standing chronic disorders such as DM, anaemia,
obesity, CV disorders, respiratory disorders. For ex, if pt has severe anemia need
muna mag BT before undergoing surgery bc there will be blood loss. For DM, it
should be corrected bc there will be a wound; di magheal if may DM
2. OBESITY
- Poor vascularity causing tearing in the suture site can thus can delay wound
healing ay tama ba baahahahahahh lei nawala nako
- full of adipose tissue there is a possibility that the wound will open
- dehiscence is greater due to secretion
- Difficulty in breathing causing respiratory disorder and they move less that
can cause circulatory problems that will cause thrombophlebitis
- Unable to breathe or breathe poorly and difficulty moving esp in supine
position
Nsg. Implications:
● Promote weight reduction if time permits (anticipate several problems like poor
wound healing when performing surgery on a obese patient)
● Monitor closely for wound and cardiopulmonary complications postoperatively. Prone
to atelectasis or respiratory problems
● Encourage coughing, turning, and diaphragmatic breathing exercise and early
ambulation
3. MALNUTRITION
- Body reserve is not sufficient to respond satisfactory organ failure and shock
may result
- vulnerable to pressure ulcers due to surgical positioning (there is pressure on
bony prominences tissues
- Poor inadequate nutrition result in delay wound healing

Nsg. Implications:
● Promote weight gain by providing a well-balanced diet high in calories, protein and
vitamin C.
● Administer total parenteral nutrition, nutritional supplements and tube feedings as
prescribed.
● Daily weights and calorie counts may be ordered.
4. DEHYDRATION/ ELECTROLYTE IMBALANCE
- Depending on the degree of dehydration or depending on type of imbalance
cardiac failure may occur
Nsg. Implications:
● Assess patient esp fluid status
 ● Administer IV fluid as ordered. If severely dehydrated ang pt, hydrate pt first before
surgery. Probably 2L or 3L fast drip
● Keep a detailed I&O record
● Monitor for evidence of electrolyte imbalance (Na+, K+, Ca++, etc.). if taas ang
potassium, more than 3.5mg/dl, pt is prone to have a cardiac arrest. For calcium it is
important for nerve conduction as well as conduction for heart muscles
5. CARDIOVASCULAR DISORDER
- Increases risk of DVT or hypovolemic shock and pulmonary embolism and
fluid overload
Nsg. Implications:
● Diligently monitor VS, especially PR, regularity and rhythm, and general condition of
the client
● Closely monitor fluid intake bc if too much fluid it will affect functioning of your heart
● Assess skin color esp if dehydrated, cyanotic (assess lips, nail beds) if pt has dark
skin, check upper palate
● Assess for chest pain, lung congestion, and peripheral edema
● Observe signs of hypoxia and administer oxygen as ordered
● Early postoperative ambulation and leg exercises
● Encourage change of position but avoid sudden exertion. 24 hrs after surgery or if
already awake, pt has to ambulate or to move in bed so as not to have respiratory
problems. Kasi if magkaresp problem, magkaroon ng fluid in the lungs of pt esp in
the alveoli then pt will have difficulty of breathing
● Sudden change of position might cause hypotension
6. RESPIRATORY DISORDER
- High risk to contribute to another respiratory disorder
Nsg. Implications:
● Closely monitor RR, PR, and breath sounds
● Assess for hypoxia, dyspnea, lung congestion and chest pain
● Encourage coughing, turning, and diaphragmatic breathing exercises and early
postoperative ambulation
● Encourage client to quit smoking or at least to reduce the number of cigarettes
smoked
● Patients with chronic pulmonary problems such as emphysema, bronchiectasis, etc.
should be treated for several days preoperatively with bronchodilators, aerosol
medications, and conscientious mouth care.
7. DIABETES MELLITUS
- increased risk for surgery due to fluctuating blood glucose levels
- can develop cardiovascular disorder
- susceptible to delay in wound healing
Nsg. Implications:
● Monitor the client closely for signs and symptoms of hypo/hyperglycemia. If pts have
diabetes then may medications, meds should be continued even during surgery esp
when they have insulin bc pt is under stress so the more that endocrine system will
cope up with the stress so magincrease use ng sugar
● Monitor blood glucose levels every 4 hours as ordered
● Administer insulin as prescribed given even intraoperatively; as circulating nurse,
check if may insulin para di madelay
● Encourage intake of food at the designated meal and snack times
 8. RENAL AND LIVER DYSFUNCTION
- decrease metabolism and decrease excretion of drugs causing anaesthesia
to not work
- Kidney for elimination of anaesthetic drug
- Anaesthetic drug has Side Effects
Nsg. Implications:
● Evaluate closely for drug side effects and evidence of acidosis or alkalosis.
● Monitor for fluid volume overload, I&O, and response to medication.
● decrease wound healing check
9. ALCOHOLISM
- Accompanied with problems in malnutrition such as delay wound healing and
increased risk for infection
- Require high dose in anaesthetic drugs since they are immune to normal
levels due to alcohol intake
Nsg. Implications:
- Monitor closely for signs of delirium tremens (form of psychosis caused by alcohol
withdrawal in the body) so pts will have seizures, hypotension
- Encourage a well-balanced diet. Esp rich in vitamin B complex bc liver produces this
vitamin so if diseased na ang liver, iheal muna bago sched ng surgery
- Monitor for wound complications.
- Administer supplemental nutrients parenterally as ordered.
- monitor the patient intake

10. MEDICATIONS
- Obtained even info such as medications that the pt is currently taking to
determine appropriate drugs to be given
a. Anticoagulants/ Salicylates
- Known as to prevent blood clot formation
- Cause intra and post op bleeding
Nsg implications:
● Monitor for bleeding. Post-op check if may good wound closure, dry dressing and no
blood
● Assess PTT/PT values.
● PTT - partial thromboplastin time, PT - prothrombin time
● values will tell the clotting time of patient; determine if long or normal
b. Diuretics (Thiazides)
- Cause fluid and electrolyte imbalance
- Produce altered cardiovascular problems
- And causes respiratory depression
Nsg Implications:
● Monitor I&O and electrolytes.
● Assess cardiovascular and respiratory status.
c. Antihypertensive (phenothiazine)
- Can increase the hypotensive effect of anaesthesia that result in
hypovolemic shock
Nsg. Implications:
- Closely monitor blood pressure.
 d. Antidepressant (MOA inhibitors)
- monoamine oxidase inhibitors; increase hypotensive effect of
anaesthesia
Nsg. Implications:
● Closely monitor blood pressure.
e. Antibiotics
- Incompatible with anaesthetic agent and potentiate the hypotensive
effect of anaesthesia
Nsg. Implication
- Monitor Respirations

11. OTHER FACTORS

1. Nature of the condition – what is the surgery all about, or para saan ang gagawin
for pt, would it be beneficial for the pt to do the surgery or not
2. Location of the condition – location: heart, brain; and what type of brain surgery
are they going to have, is it only evacuation or clipping of aneurysm
3. Magnitude and urgency of the surgical procedure – for ex. clipping of
aneurysm – it is very urgent bc there is pooling of blood sa brain which may cause to
have bleeding, seizure, hypotension, also cause death
4. Mental attitude of the person toward the surgery – if patient is psychologically
prepared, does the pt experiences anxiety
5. Calibre of the professional staff health care facilities – how good the surgeon,
number of times that the surgeon have done this procedure, facilities if kaya ba ng
hosp to have that procedure

PREOPERATIVE PHASE

PSYCHOLOGICAL PREPARATION
- surgery can be distressing to the family and the patient

Fear - an emotion marked by dread, apprehension and alarm caused by anticipation or

awareness of danger and manifested by anxiety. Distress emotion that is aroused

Types of Fear (Cause of FEAR of the Preoperative client)

1. Fear of the UNKNOWN - most common
a. the expected is less traumatic than the unexpected
2. Fear of ANAESTHESIA - fear of loss consciousness is closely aligned with fear of
death
3. Fear of PAIN and DISCOMFORT - pain is powerful emotion than sensation brought
by anxiety
4. Fear of DEATH - a very valid fear
5. Fear of DISFIGUREMENT, MUTILATION LOSS OF A VALUED BODY PART -
Hard to accept the possible outcomes after surgery. Real suffering psychologically
6. Fear of loss of LIVELIHOOD - due to financial instability, or loss of finances due to
surgery

MANIFESTATION OF FEAR:
● Bewilderment
 ● Anxiousness
● Anger
● Tendency to exaggerate
● Sad, evasive, tearful, clinging
● Inability to concentrate
● Short attention span
● Failure to carry out simple directions

NURSING INTERVENTIONS to minimise ANXIETY:

1. Explore the client's feelings.
2. Allow clients to speak openly about fears/concerns.
3. Give empathetic support.
4. Consider the person’s religious preferences and arrange for visit by priest/minister as
desired.

LEGAL CONSIDERATIONS (OPERATIVE PERMIT/ SURGICAL CONSENT)

Informed consent
- is a LEGAL document required for certain diagnostic procedures or therapeutic
measures, including surgery
- Written in simple words and sentences
- Medico required and will serve as evidence

PURPOSES: (MADE TO PROTECT PATIENT DOCTOR AND THE SURGICAL TEAM)

1. To ensure that the client understands the nature of the treatment including the
potential complications and disfigurement.
- The patient has to be informed what would be the benefits and risks.
2. To indicate that the client’s decision was made without pressure.
- Not under any medication and under the influence of drugs when making the
decision, pt needs to be aware when making the decision, to avoid legal
problems.
3. To protect the client against unauthorized procedure.
- To know that the person doing the surgery is a certified surgeon - knows what
that surgeon is doing. If the procedure is not stated in the consent, then the
doctor cannot do such additional procedures. E.g., BTL during caesarean
section.
4. To protect the surgeon and the hospital against legal action by a client who
claims that an unauthorized procedure was performed.
- Two-way protection to the doctor and the hospital

NURSING RESPONSIBILITY
●

3 MAJOR ELEMENTS of the INFORMED CONSENT

1. VOLUNTARY
2. INFORMED (ultimate decision maker)
3. Patient must be competent to understand the information and alternatives
NOTE:
- the patient will sign a waiver if he or she does not want to get the surgery so when
something happens to the patient it was his and her decision to not accept the
surgery

“OBTAINING THE INFORMED CONSENT IS THE RESPONSIBILITY OF THE SURGEON“

- the surgeon will ask the patient to sign
- the nurse will witness the signing of the waiver from the surgeon and patient

WHO SIGNS THE CONSENT?

1. Adults
2. Next of Kin (if married: spouse)
3. Parent or Legal Guardian
4. Emancipated minors - earning married minors
5. Emergency Situation - next of kin/create a surgical board to decide for the px
- the attending physician will sign the consent when the situation is emergency
6. Illiterate - making an x then the witness writes “patient’s mark” - pt who cannot read/write
pwede thumb mark

NURSING RESPONSIBILITY:
- Witnessing the exchange of information b/w the client and the surgeon
 - Witnessing the client’s signature
- Establishing that the client really did understand. Nurses should not explain, only the
surgeon. As a nurse, we should just make sure that the patient really did understand
what's going to happen during the surgery.

PHYSIOLOGICAL PREPARATIONS
LABORATORY AND DIAGNOSTIC TESTS
1. Cardiovascular - Ecg
- For patients aged 40 years and above
2. Hematologic - CBC, Hgb, and Hct, WBC, PTT, and PT, Platelet count
3. Respiratory - Chest X-ray, Pulmonary function Test/PFT
4. Metabolic - FBS, Electrolytes (K+, Na++, etc.)
5. Genitourinary - routine urine analysis

PHYSICAL PREPARATIONS:
TEACHING POST OP EXERCISES
1. Deep breathing exercise (diaphragmatic)
- To promote lung expansion and ventilation and enhance blood oxygenation
- Patient should be fully awake and conscious
- Position the patient in fowlers or semi fowler. Inhale thru the nose and hold for
at least 5 seconds. Exhale thru the mouth and repeat every 2 hours.
2. Coughing exercises
- Incentive spirometer
- Contraindicated to pt with head or eye surgery; can increase intraocular
pressure and intracranial pressure
- To loosen, mobilize and remove pulmonary secretions
3. Turning Exercises
- Performed 5 times every hours
- Tas wa ko kabalo diri ahhahaha
4. Leg, Ankle, and Foot exercises
- Purpose of leg exercises is to promote venous blood return from the
extremities
- Wala nako naminaw diri:< HHHAHAHAHAHAHA

NIGHT PRIOR TO SURGERY:

● Preparing the skin
- Includes shaving the hair of the affected area to ensure the close clean shave
- Upon shaving we can injure the site thru shaving with small cuts thus
increasing risk for infection or unsa ba
- Changes in skin prep is done during itnra op hindi na in pre op
● Preparing GIT (GASTROINTESTINAL TRACT)
- Bowel preparation (cleansing enema)
- Place the patient in NPO post midnight
- according to ASA there is no need for npo post midnight
- To prevent help reduce incidence post op N/V and may develop post op
bleeding
- placing a patient on npo can give satisfactory viewing of the operating site
 - We place pt on npo to decrease risk of aspiration pneumonia under while
anaesthesia
- If we are the pre op nurse we must ensure that the patient is being reminded
to stay under npo till surgery to reduce risk of aspiration
● Preparing for anaesthesia
- Remind the patient to avoid alcohol at least 24 hours
- anaesthesia consent check if the anesthesiologist has obtained consent prior
to surgery
● Promoting rest and sleep
- By administering sedatives as ordered

ON THE DAY OF SURGERY:

EARLY AM CARE:
● Awaken on hour before pre op medications
-
● Morning bath, mouth wash
-
● Provide clean gown
- so there will be no cross contamination.
● Remove hairpins, braid long hair, cover hair wash cap
- To prevent contamination
● Remove dentures, foreign materials, colored nail polish, hearing aid, contact lens,
wedding ring , underwear
- Remove Dentures to avoid aspiration that may cause airway obstruction
- Remove colored nail polish to check capillary refill
● Take baseline VS before pre op medication
- Sometimes before transporting the patient
● Check ID band, skin prep
- Check id band to confirm identification of the patient this is to avoid the
“wrong patient, wrong procedure”
- if you don’t check it mag incident report ka
● Check special orders- enema, tube insertion, IV line (in the morning)
-
● Check NPO- ensure that patient has not taken food for the last 10 hours
-
● Have client void before pre op medication
- Allow the pt to void; anes is a sedative thus pt is at risk of accidents
- To avoid any bladder injury

SURGICAL CHECKLIST
● Certain things that need to be done before surgery to make sure everything is
accomplish and to reduce risk of accidents
● Pink sheet (checklist)
PREOPERATIVE MEDICATIONS/ PREANESTHETIC DRUGS
- It must be administer 60-90 minutes before surgery
GOALS:
1. To allay anxiety
- Either give barbiturates or tranquilliser to alleviate anxiety
2. To minimize respiratory tract secretions to prevent incidence of aspiration and
changes in HR
- Anticholinergics
3. Create amnesia for the events that precede surgery
-
4. To decrease body metabolism so less anaesthetic will be used
- We need to give analgesics preoperatively to decrease metabolism that
created by your anaesthetic agent

PRE-OP MEDS:
1. Sedatives and Hypnotics (Versed (Midazolam) Phenergan (Promethazine,
- Reduce pt anxiety
- Decrease BP and HR
2. Barbiturates/ TranquilizersRe
- Same effect of sedatives
- Calming effect administered a night prior to surgery
- Valium (Diazepam) most common; Inapsine (Droperidol)
3. Narcotic Analgesics(Valium (DiazepamP,)
- It can be given pre op if pre op pain is anticipated
- Morphine sulfate (most common)
- Fentanyl (sublimaze)
- Demerol (meperidine hcl)
 4. Anticholinergics
- Drugs that block the action of acetylcholine
- To reduce oral resp unsa daw to??
- Interrupts vagal unsa daw
- Atropine sulfate(most common)
- Glycopyrrolate (Robinul)
- Scopolamine
-
5. Histamine- H2 Receptor Antagonist
- Inhibits gastric acid production to reduce gastric ulcer so even w/o food our
GIT keeps producing
6. Anxiolytics - eg. diazepam (valium)
- Drug used to reduce anxiety
- Most common is Diazepam (Valium)
7. Antiemetics
- Drug used to treat N/V
- Reduce incidence of N&V intra or post operatively
8. Prophylactic Antibiotics
- Cephalosporins (Cefazolin)
- Surgical prophylaxis

PRE-OP NURSING DIAGNOSIS

● Anxiety related to the surgical experience (anaesthesia, pain) and the outcome of
surgery
● Fear related to perceived threat of the surgical procedure and separation from
support system
● Knowledge deficit of preoperative procedures and protocols and postoperative
expectation

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