Introduction to Surgical Nursing

PRE-OPERATIVE CARE

Preoperative care is the care given to the patient in preparation for the operation.

It can be given in outpatient or the patient may be admitted on the ward some days before the operation

Admission: The patient is admitted in a surgical ward in a well ventilated room. The room can be further described according to which condition.      

Rapport: This is the establishment of a Nurse/patient relationship and it is created by, greeting the patient, self introduction and offering a sit or bed.

• Rapport is very important to attain the confidence and trust from the patient.

History taking:  This is taken as follows: Demographic data i.e. all identification data Subjective data i.e. given by patient or relative. Objective data i.e. what the doctor finds out.    

 Histories taken include the following:-

• Past medical and surgical histories
• Psychiatric history
• Family history
• Social history
• Obstetrical and gynecological if female

 Inform doctor: Doctor is informed but meanwhile, observations are carried out by the nurse. All observations taken must be recorded in the patient’s chart.

Observations:

1. General observation of the patient from head to toe and the general condition of the patien
2.  Vital observations i.e. Take

• Temperature,
• Pulse,
• Respirations
• Blood pressure.

3. Note the specific observations according to the kind of condition you are dealing with. Document them in patients observation chart.

When doctor comes, he/she will examine the patient with the assistance of the nurse who prepares all the necessary equipment.

 Steps followed during physical examination:

1.  Inspection: Doctor will look at the whole patient from head to toe to observe for any abnormalities and document everything.
2.  Palpation: This is by using fingers to feel for enlarged organs.
3.  Percussion: This is by using the finger pads of the middle finger to listen to the sound of an interna organ.
4.  Auscultation: This is by use of a stethoscope to feel for any abnormal sounds.

Examination is done systematically and in that order with the exception of abdomen where palpation is done last. WHY DO YOU THINK SO?

Investigations

1. Hematological investigations like;

• ESR (erythrocyte sedimentary rate) which is raised in case of infection although not diagnostic.
• WBC Which increase in cases of infection

2.  Radiological investigations like;

• X-rays,
• CT scan
• ultrasound scan
• MRI=magnetic resonance imaging

3.  Urinalysis which includes;

• Urine sugar,
• Cultre and sensitivity to find out the causative organism and treatment.

3. Sputum for AAFBs to rule out B
4. Stool for occult blood or culture & sensitivity.

 N.B. The nurse is supposed to carry out all the investigations as ordered and results properly recorded in the right patient’s chart.

Treatment

This will depend on the surgical condition. It includes both

1. non-pharmacological
2. pharmacological treatment .

Non-pharmacological treatment Includes:

• Diet
• Collection of anemia
• Exercises
• Hygiene

The day before operation preparation.

• Informed consent: Thorough explanation of the procedure to the patient is done to obtain consent and cooperation.
• Consent form: This is a paper form signed by the patient after thorough explanation of what is to be done. The patient is then put on theater list for the following day.
• Fasting: Patient should fast or nothing 4-6hrs to time of operation.  
• Reassurance: Alley anxiety, ensure good sleep by early switching off lights or give a sedative as per doctor’s order.

Morning of operation

Site of operation: is shaved if necessary and labeled. Patient should have a bath early morning and a clean theater gown given.

• Nasal gastric tube, catheter passed and an intravenous line established.
• All artificial like rings are removed and safely kept by the relative or in-charge.
• Pre-medications like atropine, given as prescribed by the doctor and documented.
• Observations are carried out and recorded in the patient’s chart.
• Ensure that all results are available in patient’s chart.
• The trolley is prepared and patient is continuously reassured.
• Patient is wheeled to theater with all the requirements.
• Handed over to the theater nurse and give a report.
• Make a post-operative bed with all the necessary requirements at the bed side

NB:  Pre-operative care ends with making of a post-operative bed and post-operative care also begins with the making of the post-operative bed.

 INTRA-OPERATIVE CARE

 It is the care in theater by theater team and anesthetist during the procedure and after but before returning to the ward.

 This care includes: Taking of observations, circulating, assisting doctor during procedure, giving anesthetic drugs, cleaning the patient, care in recovery room

POST-OPERATIVE CARE

It is care given to patient after the operation.

Aim of post operative care:

Nursing care.

• A post-operative bed is made with all the necessary requirements.
• When called upon to fetch the patient, two nurses go for the patient.
• A report is got from the recovery nurse about the patient’s condition.
• Vital observations are carried out before a patient to the ward.
• The operational site is checked for bleeding
• While wheeling patient to the ward, the senior nurse should always be at the head of the patient to observe the airway and condition of the patient.
• On reaching the ward, they put the patient in the post-operative bed and in a proper position.
• The patient should never be left alone. The nurse should observe the airway and ensure it is clear.
• Vital observations should be done 1/4hourly until stable, 1/2hrly then hourly and finally 4 hourly when condition improves.
• Observe the operation site for bleeding but never open it.
• If site is bleeding, add dressings and inform doctor immediately.
• Observe the general condition of the patient and report any abnormality.

 Diet:

• This will depend on the operation done but the patient should be on nourishing fluid diet through the NG-tube during the acute phase. e.g. Milk, diluted porridge, soup
• Diet will be described in detais according to each specific conditions

   Drug treatment: Drugs are given according to surgeon’s prescription. But drugs like analgesics, antibiotics and other supportive treatments are given depending on the condition.

Drugs may include the following:-

1. (i)Pethidine for pain during acute phase (ii). Mild like diclofenac or paracetamol. (iii). Antibiotics to combat infections (iv). v fluids continue until stopped

Exercises:

• Passive, like limb movement by the nurse during the acute phase.
• Active, like deep breathing exercises when condition improves.

Psychotherapy:

• The mind of the patient is cared for by reassuring or occupying her/him, proving radio, news paper etc..

Hygiene:

• A daily bed bath and oral care in acute phase then patient can go to bathroom later if able.

Elimination:

• Bowel: The patient should open the bowel and constipation should be avoided by high fiber diet.
• Bladder: catheter should be draining and urinary bag emptied whenever full & recorded in patient, fluid chart.

Discharging process:

• All gudgets like NG-tube and urinary catheter are removed as patient condition improves.
• Stitches are removed on the seventh day or according to doctor.

               Advice on discharge

Post operative complications

• Respiratory obstruction: due tongue, or vomitus and these are prevented by proper positioning of the patient.
• Respiratory failure: Due to depressing effects of anaesthesia and narcotics and this can be prevented by stumulants.
• Shock and collapse: due to depression of the central nervous system and collapse of the circulation system.
• Heart failure:  relieved by stimulants.
• Kidney failure/renal failure
• Post operative vomiting
• Urine retention
• Haemorrhage
• Flatulence
• Infection and sepsis
• Burst abdomen
• Trauma during the procedure
• Post operative psychosis.