SURGERY

• SURGERY – an invasive medical

procedure performed to diagnose or
treat illness, injury, or deformity.

• OPERATION – for correction of

deformities and defects, repair of
injuries, diagnosis and cure disease
processes, relief of suffering and
prolongation of life.

• PERIOPERATIVE NURSING – used

to describe the nursing functions in
the total surgical experience of the
 3 Phases of
Perioperative
Nursing
• PRE OPERATIVE PHASE : from the time
the decision is made for surgical
intervention to the transference of the
patient to the operating room.
• INTRA OPERATIVE PHASE : from the
time the patient is received in the
operating room, to the time of
administration of anesthesia, surgical
procedure is done, until he is admitted in
the recovery room/post anesthesia care
unit.
• POST OPERATIVE PHASE – from the
time of admission to the recovery room,
to the time he is transported back to the
surgical unit, discharged from the
 CONDITIONS REQUIRING
SURGERY
2. Obstruction
3. Perforation
4. Erosion
5. Tumor
obstruction
Perforation
Tumor
 CLASSIFICATION OF
SURGICAL PROCEDURES
 I. According to PURPOSE:
1. Diagnostic
2. Exploratory
3. Curative
3.1) Ablative
3.2) Constructive
3.3) Reconstructive
4. Palliative
5. Transplant
 II. According to DEGREE of
RISK (Magnitude / Extent):

3. Major
4. Minor
 III. According to
URGENCY:
1. Emergency
2. Urgent / Imperative
3. Elective
4. Planned / Required
5. Optional
Abruptio
placenta,
an
emergency
VSD needs urgent
surgery
Hair transplant – elective
surgery
Required surgery for
infected ulcer
Optional
surgery
for
Siamese
twins
 SURGICAL
RISK FACTORS
 1. Aging
Nsg. Implications:
2. Consider using lesser doses for
desired effect.
3. Adjust nutritional intake to conform
to higher protein and vitamin
needs.
4. Anticipate problems from long
standing chronic disorders such as
diabetes, anemia, obesity,
cardiovascular disorders,
 2. Obesity
Nsg. Implications:
2. Promote weight reduction if time
permits.
3. Monitor closely for wound,
pulmonary, and cardiopulmonary
complications postoperatively.
4. Encourage coughing, turning, and
diaphragmatic breathing exercises
and early ambulation.
 3.Malnutrition
Nsg. Implications:
2. Promote weight gain by providing
well-balanced diet high in calories,
protein and vitamin C.
3. Administer total parenteral nutrition
intravenously, nutritional
supplements and tube feedings as
prescribed.
4. Daily weight and calorie counts also
may be ordered.
 4. Dehydration/Electrolyte
Imbalance
Nsg. Implications:
2. Administer intravenous fluids as
ordered.
3. Keep a detailed input and output
record.
4. Monitor client for evidence of
electrolyte imbalance (Na+, K+,
Ca++, etc.).
5. Cardiovascular Disorders
Nsg. Implications:
2. Diligently monitor vital signs,
especially pulse rate, regularity,
and rhythm, and general condition
of the client.
3. Closely monitor fluid intake (oral &
parenteral) to prevent circulatory
overload.
4. Assess skin color.
4. Assess for chest pain, lung
congestion, and peripheral edema.
5. Observe for signs of hypoxia, and
administer oxygen as ordered.
6. Early postoperative ambulation and
leg exercises reduce the risk of
vascular problems, such as
thrombophlebitis and pulmonary
embolism.
7. Encourage change of position but
avoid sudden exertion.
 6. Respiratory Disorders
Nsg. Implications:
2. Closely monitor respirations, pulse,
and breath sounds.
3. Assess for hypoxia, dyspnea, lung
congestion, and chest pain.
4. Encourage coughing, turning, and
diaphragmatic breathing exercises
and early postoperative ambulation.
4. Encourage client to quit smoking or
at least to reduce the number of
cigarettes smoked.
5. Patients with chronic pulmonary
problems such as emphysema,
bronchiectasis, etc. should be treated
for several days postoperatively with
bronchodilators, aerosol medications,
and conscientious mouth care.
 7. Diabetes Mellitus
Nsg. Implications:
2. Monitor the client closely for signs
and symptoms of hypoglycemia and
hyperglycemia.
3. Monitor blood glucose levels every
4 hrs. as ordered.
4. Administer insulin as prescribed.
5. Encourage intake of food at the
designated meal and snack times.
8. Renal & Liver Dysfunction
Nsg. Implication:
2. Monitor for fluid volume overload, I
& O, and response to medication.
3. Evaluate closely for drug side
effects and evidence of acidosis or
alkalosis.
 9. Alcoholism
Nsg. Implications:
2. Monitor closely for signs of delirium
tremens.
3. Encourage well – balanced diet.
4. Monitor for wound complications.
5. Administer supplemental nutrients
parenterally as ordered.
 10. Medications
A. Anticoagulants and Salicylates
Nsg. Implications:

4. Monitor for bleeding.

5. Assess PTT / PT values.
B. Diuretics (particularly
Thiazides)
Nsg. Implications:

4. Monitor I & O and electrolytes.

5. Assess cardiovascular and
respiratory status.
C. Antihypertensives (particularly
Phenothiazines)
Nsg. Implication:
3. Closely monitor blood pressure.
D. Antidepressants (particularly MAO
inhibitors)
Nsg. Implication:
• Closely monitor blood pressure.
E. Antibiotics
Nsg. Implication:
• Monitor respirations.
 OTHER FACTORS:
1. Nature of the condition
2. Location of the condition
3. Magnitude and urgency of the
surgical procedure
4. Mental attitude of the person
toward the surgery
5. Caliber of the professional staff
health care facilities.
 COMMON SUFFIXES IN
SURGERY
Ectomy – removal of an organ or a
gland
Rrhaphy – repair
Ostomy – providing an opening
(stoma)
Otomy – cutting into
Plasty – formation or plastic repair
Scopy – looking into
 COMMON ABBREVIATIONS:
 TAHBSO – Total Abdominal
Hysterectomy Bilateral Salphingo
Oophorectomy
 TURP – Transurethral Resection of
the Prostate
 TURBT – Transurethral Resection of
the Bladder Tumor
 STSG – Split Thicknes Skin Grafting
 BKA – Below Knee Amputation
 AKA – Above Knee Amputation
 ECCE w/ IOL – Extra Capsular
Cataract Extraction w/ Intra-Ocular
Lens Implantation
 CHOLE w/ IOC – Cholecystectomy w/
Intra-operative Cholangiogram
 D & C – Dilatationof the cervix &
Curettage of the uterus
 SMR – Submucous resection of the
Nasal Septum
 MRM – Modified Radical Mastectomy
 LCCS – Low Cervical Cesarean
Section
 LSTCS – Low Segment Transverse
Cesarean Section
 ORIF – Open Reduction Internal
Fixation
 BTL – Bilateral Tubal Ligation
PRE OPERATIVE
PHASE
 Preparations
 PSYCHOLOGICAL
Fear
• Manifestations:
- Anxious
- Bewilderment
- Anger
- Tendency to exaggerate
- Sad, evasive, tearful, clinging
- Inability to concentrate
- Short attention span
- Failure to carry out simple directions
Nsg. Interventions to minimize
ANXIETY:
1. Explore client’s feelings.
2. Allow client 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

Informed Consent - (Operative

Permit / Surgical Consent)
- LEGAL document required for
certain diagnostic procedures or
therapeutic measures, including
surgery.
 Purposes:
1. To ensure that the client
understands the nature of the
treatment including the potential
complications and disfigurement.
2. To indicate that the client’s decision
was made without pressure.
3. To protect the client against
unauthorized procedure.
4. To protect the surgeon and the
hospital against legal action by a
client who claims that an
 Nursing Responsibilities:
1. Witnessing the exchange between
the client and the surgeon.
2. Witnessing the client’s signature.
3. Establishing that the client really did
understand.
 3 Major Elements of Informed
Consent
1. The consent must be given
voluntarily.
2. The consent must be given to
individual who have the capacity to
understand.
3. The client must be given
information to be the ultimate
decision maker.
 PHYSIOLOGICAL
a. Cardiovascular – ECG for patient
aged 40 yrs. and above and those
undergoing gen. anesthesia, or have
cardiovascular disease.
b. Hematologic – CBC, Hgb & Hct, WBC,
PTT & PT, Platelet count.
c. Respiratory – Chest x-ray, pulmonary
function test / PFT.
d. Metabolic – FBS,
Electrolytes(K+,Na++, etc).
e. Genitourinary – routine urine
 PHYSICAL:
A. Teaching Post Op Exercises:

4. Deep breathing exercise

(diaphragmatic)
5. Coughing exercise
6. Turning exercise
7. Leg, ankle, and foot exercise
B. Night Prior to Surgery:

 Preparing the skin

 Preparing the GIT
 Preparing for anesthesia
 Promoting rest and sleep
C. On the Day of Surgery:

3. Early Am Care
4. Preoperative Medications /
Preanesthetic Drugs
- generally administered 60-
90minutes before induction of
anesthesia.
INTRAOPERATIVE
PHASE
 Definition of Terms:
 Surgical Conscience – one’s inner voice
for the conscientious practice of asepsis &
sterile technique at all times.
 Asepsis – absence of microorganism;
freedom from infection; exclusion of
microorganism.
 Sterile – free of microorganism, including
all spores.
 Spores – inactive but visible sate of
microorganism in the environment.
 Sterilization – process by which all
pathogenic microorganisms, including
 3 Methods of Sterilization
1. Saturated Steam under Pressure
e.g. autoclave

4. Gas Chemical Sterilization

e.g. Sterrad

7. Liquid Chemical Sterilization

- 2% activated aqueous
glutaraldehyde solution ( e.g.
cidex).
 Sterile Field – area around the site
of incision into tissue or introduction
of any instrumentation into the body
orifice that has been prepared for
use of sterile supplies and
equipments including all furniture
covered w/ sterile drapes and
personnel who are properly attired.
 Sterile Technique – method by
which contamination w/
microorganism is prevented to
maintain sterility throughout the
operative procedure.
 Surgically Clean – mechanically
cleansed but unsterile.
 Disinfection – process of destroying
all pathogenic microorganism except
spore – bearing one.
 Antiseptic – used on tissue and skin
and the growth of endogenous
bacteria.
 Incision – the result of cutting into a
body tissue using sharp instrument.
 Medical Asepsis – include all
practices intended to confine a
specific microorganism to a specific
area limiting the new growth and
spread of microorganism.
 Surgical Asepsis (or sterile
technique) – refers to those
practices that keep an area or object
free of all microorganisms including
practices destroying all
microorganisms and spores.
 PRINCIPLES OF STERILE
TECHNIQUE
1. Only sterile items are used within
the sterile field.
2. Gowns are considered sterile only
from the waist to shoulder level in
front and sleeves.
3. Tables are sterile only at table level.
4. Persons who are sterile touch only
sterile items or areas; persons who
are not sterile.
1. Unsterile persons avoid reaching
over a sterile field; sterile persons
avoid leaning over an unsterile
area.
2. Edges of anything that encloses
sterile contents are considered
unsterile.
3. Sterile field is created as close as
possible to time of use.
4. Sterile areas are continuously kept
in view.
5. Sterile persons keep well within the
1. Sterile persons keep contact with
sterile areas to a minimum.
2. Unsterile persons avoid sterile
areas.
3. Destruction of integrity of microbial
barriers results in contamination.
4. Microorganisms must be kept to an
irreducible minimum.
 MEMBERS OF THE
SURGICAL TEAM
1. Surgeon
2. Assistant to the surgeon
3. Anesthesiologist
4. Nurse anesthetist (CRNA)
5. Circulating nurse
6. Scrub nurse
 ANESTHESIA
Effects of Anesthesia:

3. Analgesia
4. Amnesia
5. Hypnosis
6. Muscle relaxation
Factors considered in choice of
Anesthesia:
• Physical condition
• Age
• Presence of co-existing disease
• Type, site, duration of surgery
• Anesthesiologist’s preference
• Patient’s preference
 TYPES OF ANESTHESIA
• General Anesthesia
Types:
a. Inhalation anesthesia
- mask inhalation
- endotracheal administration

b. Intravenous anesthesia
 Stages of General
Anesthesia:

2. Onset / Analgesia / Induction

3. Excitement or Delirium
4. Surgical Excitement / Anesthesia
5. Danger / Medullary
I. Regional Anasthesia
Types:
3. Topical anesthesia
4. Infiltration anesthesia
5. Regional application
Examples:
- Nerve block
- Intravenous regional extremity
block anesthesia (Bier Block) w/
tourniquet
- Spinal anesthesia / Intrathecal
anesthesia
 Complications & discomforts of
Spinal Anesthesia:
a. Hypotension
b. Nausea & vomiting
c. Headache
d. Respiratory paralysis
e. Neurologic complications

8. Epidural Anesthesia
Ex. Cocaine, Novocaine,
Xylocaine,Carbocaine
 Specialized methods in
producing anesthesia:
• Muscle relaxants
• Hypothermia
• Controlled Hypotension
 Intraoperative
(ANESTHESIA)
Complications:
1. Hypoventilation
2. Oral trauma
3. Hypotension
4. Cardiac dysrhythmia
5. Hypothermia
6. Peripheral nerve damage
7. Malignant hyperpyrexia
 Surgical Incisions:
• Subcostal
• Paramedian
• Midline
• Transverse
• Mcburneys
• Butterfly
• Pfannenstiel
• Limbal
• Halstead / elliptical
 Layers of the abdomen:
• Skin – monocryl 3/0 or 2/0, vicryl
4/0, safil 4/0, dexon
4/0, silk 3/0
• Subcutaneous – plain 2/0
• Fascia – vicryl 1 or 0, safil 1 or 0,
dexon1 or 0
• Muscle
• Peritoneum – chromic 2/0,
monocryl 2/0 or 3/0
 SURGICAL SUTURES
• Classification:
1. Absorbable
2. Non-absorbable

• Types:
1. Atraumatic
2. Non-atraumatic
 Surgical Needles
• Types:
1. Cutting
2. Round

• Classification of surgical
needles:
1. eye needle / free needle / non-
atraumatic
2. eyeless / swaged needle /
 CLASSIFICATION OF
INSTRUMENTS
1. Cutting
ex. Metzenbaum (metz), mayo
scissors, suture scissors, knife.
2. Grasping
- divided in the following categories:
hemostats
occluding clamps
graspers and holders
forceps or pick – ups
3. Retracting
4. Accessory and ancillary
Counting and Reporting
of SIN
• INITIAL COUNTING – before the
procedure starts.
• 1st counting – before the closure of
peritoneum
• 2nd counting – before the closure of
fascia
• 3rd counting – before closure of skin
 POSTOPERATIVE PHASE

• Immediate post-op nursing care:

- avoid exposure
- avoid rough handling
- avoid hurried movement and
rapid changes in position
 Assessment
• Appraise air exchange and note skin
color
• Verify identify, operative procedure,
surgeon
• Assess neurologic status (LOC)
• Determine VS and skin temp (CV
status)
• Determine operative site and check
dressing
• Perform safety checks
 Interventions
1. Ensure maintenance of patent
airway and adequate respiratory
function.
2. Assess status of circulatory system.

Common cardiovascular
complication immediate post-
op:
5. Hypotension
 ALDRETE Scoring in PACU:
(ARCCC)
• Activity 2 able to move 4
extremities
1 able to move 2
extremities
0 not able to move

• Respiration 2 able to cough &

deep breath
1 dyspnea or limited
• Circulation 2 20% pre
anesthesia
1 20-50% pre
anesthesia
0 above 50% pre
anesthesia
• Consciousness 2 fully awake
1 rousable on calling
0 not responding
• Color 2 pink
1 pale, dusky, blotchy
 Parameters for discharge
from RR
• Activity – score of 2; able to obey
commands.
• Respiration – score of 2; easy,
noiseless breathing.
• Circulation – 20 of pre anesthesia; BP
is within +/-20 mmHg of the pre
op level.
• Consciousness – score of 2;
responsive.
• Color – score of 2; pinkish skin and
 Nursing Care of the client
during the intermediate
post op period (RRunit)
• Baseline assessment:
 Respiratory status
 Cardiovascular status
 LOC
 Tubes
 Position
• Goals:
2. Restore homeostasis and prevent
complications.
3. Maintain adequate cardiovascular
and tissue perfusion.
4. Maintain adequate respiratory
function
5. Maintain adequate nutrition and
elimination.
6. Maintain adequate fluid and
electrolyte balance.
1. Maintain adequate renal function.
2. Promote adequate rest, comfort and
safety.
3. Promote adequate wound healing.
4. Promote and maintain activity and
mobility.
5. Provide adequate psychological
support.
Post op discomforts:
7. Nausea and vomiting
8. Pain
9. Thirst
 Discharge Planning /
Teaching 2 – 3 days after
surgery:
• Self – care activities
• Wound care activities
• Activity limitations
• Diet and medications at home
• Possible complications
• Referrals, follow – up check - up
 POST OP
COMPLICATIONS
 CIRCULATORY COMPLICATIONS:
b. Shock
c. Hemorrhage
d. Thrombophlebitis / deep
thrombophlebitis

 PULMONARY COMPLICATIONS
g. Atelectasis
h. Pneumonia
 URINARY DIFFICULTIES
b. Urinary retention

 GASTROINTESTINAL
COMPLICATIONS
e. Paralytic ileus
f. Gas pain
g. Intestinal obstruction
h. Hiccups
 WOUND COMPLICATIONS
b. Wound infections
* Rule of thumb
- fever 1st 24 hours post op
- fever 48 hrs. post op
- fever 48-72 hrs. post op
- fever 72 hrs. post op
h. Hemorrhage / Hematoma
i. Wound dehiscence and evisceration
 Post Op Psychological
Disturbances
a. Delirium
b. ACS (Acute Confusional State)
• Causes:
- Dehydrartion
- Insufficient oxygenation
- Anemia
- Hypotension
- Hormonal imbalance
- Infection
- Trauma (esp. in nervous person)
 THE END

GOOD LUCK…