SUBJECT : NCM 102

Concepts : Surgery

Surgery – branch of medicine concerned with the treatment of disease, injury

and deformity by operation or manipulation.

- Any procedure that involves entry into the human body usually
performed using instruments.

Operation – procedure itself

Perioperative phase – time before, during and after operation.

Asepsis – freedom from disease or infectious matter.

- Free/absence from microorganisms.

Surgical Asepsis- absence of micro-organism as protection against infection

before, during and following surgery by the use of sterile
techniques.

Indigenous Practice of Surgical Asepsis:

a. Boiling water used in washing wound

b. Ironing linens used in delivery; diapers of babies

c. Heating instruments

d. Soaking in alcohol

Techniques of Surgical Asepsis :

a. Hand washing

b. Scrubbing

c. Gloving

d. Gowning

e. Autoclaving
Common Suffixes Describing Surgical Procedures :

ECTOMY – removal of an organ/gland

OTOMY – cutting into

OSTOMY - creation of permanent opening

OSCOPY – looking into

ORRHAPHY – repair or reconstruction of

Basic Types of Condition Requiring Surgery:

1. Perforation – rupture of an organ, artery or bleb (blister)

2. Obstruction/Blockage – mainly affecting

a. Tubes

b. Arteries

Internal Sites:

a. Blood vessels/lymphatics

b. Ureters

c. Respiratory tract

d. Ventricles – hydrocephally

e. Lacrimal ducts

f. Sinuses – sinusitis

Causes of obstruction

a. Vasoconstriction

b. Tumor
 c. Foreign bodies

3. Tumors – abnormal growth of tissue that form masses

4. Erosions – wearing away or eating away of the surface of a tissue as a

result of:

• Continuous physical irritation – (cancer, tumors,

stones)

• Infection – (stones, AP)

• Ulceration/inflammation – (PUD)

Major Categories of Surgical Procedures :

I. According to Purpose

A. Diagnostic – determining cause of symptoms

B. Curative – removed damaged or disordered part/congenitally

malformed body part
TYPES:

B.1. Ablative – removal of disease organ

B.2. Constructive – repair of congenitally defective organ to

improve its function and appearance so it will
resemble the normal appearance.

- Eg. Cheiloplasty for harelip

B.3. Reconstructive – partial or complete restoration of a

damage organ or tissue to its normal
appearance and function.

- Eg. Vaginal repair, plastic surgery to repair

body part after extensive scarring
from burning.
 C. Palliative – relieves symptom although it doesn’t cure the
disease causing the symptoms.

- Eg. Colostomy

D. Exploratory – to estimate the extent of the disease

- to make or confirm a diagnosis

- eg. Exploratory laparotomy – find the extend/stage

- abd surgeries to find causes – suspected AP, cyst,

kidney stones, etc.

II. According to Urgency

A. Emergency – performed immediately

 Also known as “stat” surgery

B. Imperative/Urent – must be performed within 24-48 hours as

soon as possible if there’s no complication.

C. Planned required surgery – necessary for the patient well being

but not urgent.

o Maybe scheduled weeks/months ahead of

the propose operations because life of
patient is stable.

D. Elective Surgery - performed for patient well being but not

absolutely necessary.

E. Optional Surgery –surgery requested by patient/client not

necessary for physical

Health but for aesthetic or

psychological reasons.

F.Ambulatory – does not require overnight hospital admission.

iii. According to Magnitude/Risk

 A. Minor Surgery

-present little risk to life

- generally not prolonged

- no vital organs involve

- leads to dew serious complications

- performed as opd

-uses loal anesthesia

B. Major Surgery

- involves high risk for patient

- prolonged period of time in OR table

- large amount of blood maybe lost

- high risk of post op complications

- performed in the OR

GENERAL EFFECTS OF SURGERY;

1. Stress response is elicited

2. Vascular system is disrupted

3. Defense against infection is lowered

4. Organ functions are disturbed

5. Body image maybe disrupted

6. Life style maybe changed

RESPONSES to SURGICAL STRESS

1. Peripheral vasoconstriction with increase coagulability

Advantage : blood increased to vital organs

Increased clotting to decrease blood loss

Disadvantage : decrease renal perfusion

Clotting and thrombus formation increase

2. Tachycardia with increase cardiac output, blood pressure and

coronary

artery dilation

advantage : increase perfusion of myocardium

increased oxygen perfusion to vital organs

disadvantage : increased demand on heart possibly leading to

heart

failure, hypertension

3. Sodium and water retention secondary to increase ADH and

aldosterone secretion

Advantage : increase volume to prevent hypovolemia,

maintain blood

pressure and cardiac output

disadvantage : hypervolemia, circulatory overload

hypertension and

heart failure.

4. Increased gastric acidity and decreased peristalsis

Advantage : blood shift from large intestine to more vital

areas

Disadvantage : paralytic ileus and stress ulcers

Clotting and thrombus formation increase

 5. Bronchial dilation

Advantage : increased oxygen exchange, improve ventilation

Disadvantage : none

6. Protein metabolism

Advantage : increased amino acid production-for wound

healing

Disadvantage : result to negative nitrogen balance-eventual

lack

of tissue repair

7. Proliferation of granulation and connective tissue

Advantage : increased wound healing

Disadvantage –development of extensive scar tissue and

adhesions

8. Increased blood sugar and mobilization of fat stores

Advantage : increased energy available

Disadvantage : increased blood sugar detrimental to diabetics

9. Increased cortisol with increased anti- inflammatory response

Advantage : increased blood sugar

Disadvantage : possible infection if anti- inflammatory

effect is prolonged

10. Increased metabolic rate

Advantage : increased energy for adaptation

Disadvantage : increased heat loss can lead to hypothermia

and shivering

with increasing oxygen demand

FACTORS AFFECTING THE DEGREE OF SURGICAL RISK;

1. Physical and mental condition of the patient

a. Age- children/mid.aged to adult generally tolerate surgery

well, pre-mature

aged-poor, because of the ff.

1. Increase sensitivity to sleep(trauma,drug used)

2. Often dehydrated,malnourished

3. Frequently victims of degenerative

disease,resp.,chf,emphysema

4. Blood volume lowered thru normal

b. Nutritional status- major pre-op/ nutritional problems are:

1. Dehydration and malnourishment due to

CHON,Fe,vit.deficiency

2. Obesity- may suffer from HPN,CHF,DM

-perceptible to post op operation(pulmonary)

-fatty tissues is difficult to approximate

-increased wound dehiscense

c. Fluid/electrolytes balance- dehydration; hypovolemia

predisposes pt.to

complications both during/after

surgery

treatment: correct imbalance- IVF

d. General health

The following will increase operative risk:

 a. presence/ absence of infection- CBC is taken

b. inadequacy of function of certain organs

- cardiovascular tx –ECG,X ray done

- pulmonary function- (COPD,emphysema,atelectasis)

-genito-urinary (UTI)

-metabolic liver tx (DM) untreated increase to infection

- neurologic (TIA,embolism,COA)

e. use of drugs/medications

1. anticoagulant (heparin,Coumadin)

-causes hemorrhage during bleeding

2. antibiotics – can combine infavorable effects with

anesthesia

3. tranquilizer – increase hypotension can cause

shock

4. thiozide/ diuretics- create K imbalance

f. mental outlook/attitude – “will to survive”- is an impt.

aspect of pt.

mental outlook bec.pt.will

cooperate to tx

designated to decrease
complication

g.economic/occupation status

-heavy construction workers undergo an amputation

of limb need to seek

for another job

 - minor surgery entails less expenses and only few
days from job than

major surgery

2. Extent of the Disease

a) Nature of the Disease

-whether it is benign or malignant

-importance of tx removed

Eg. Removal of GB not as serious as of removal of

stomach

b) Location – surgical risk decrease in descending order is

the ff.

- heart, thorax,
esophagus,brain,rectum,colon

Stomach,lungs( due to decrease

bld.supply)

c) duration f the disease – the longer the disease process the

greater the

surgical risk involve in

correcting the disorder

3.Extent of Surgical Procedure – more risk involved in major surgery

than minor sx

bec. more bld.loss,prolonged

4.Caliber of the Professional Staff – risk decrease for surgical pt

when hosp.staff are:

- adequate in

- competent and well trained

- hospital well equipped

PRE-OPERATIVE PHASE (general preparation)

1. PSYCHOLOGICAL PREPARATION

a. Patients instruction – explain the reason/ purpose/ procedure to

be done

(how long/ expenses)

-probable income

-expected duration of hospitalization

-cost of hospital

-residual effects

-length of absence in work

b. Psychological Reassurance

-be supportive and understanding

-do not assume judgemental attitude

-recognize fear and anxiety

FEAR- feeling of alarm cause by the expectation of danger/pain

ANXIETY- exaggerated feeling of apprehension,uncertainty and fear

SEVERAL CAUSES OF FEAR AND ANXIETY

1. Fear of the unknown

 2. Fear of pain and death- if operation fails

3. Fear of separation – family and job

4. Fear to control – activities will be resricted

5. Fear of body mutilation

2. PHYSIOLOGICAL PREPARATION

a. Correct dietary deficiency if existing

b. Reduce obese patient – prone to wound dehiscense

c. Restore an adequate fluid volume

d. Treat any specific ailment

e. Cure any infectious process

f. Treat alcoholic patient with vitamin supplementation

3. LEGAL ASPECTS

LEGAL CONSIDERATION

a. Always get a consent from pt./parents/responsible member

b. If patient is alone in case of emergency it maybe necessary

for the surgeon to operate without a permit but a brief statement

of the circumstances must be signed by 2 physicians

- Pt. can signed wihin legal age 21 y/o

- Minor pt. signed by parent/guardian

- If emergency –operate to save pt. life

PURPOSES OF CONSENT;
 1. Ensure pt. understanding to the nature of tx including potential
complication

2. Indicates pt. decision was made without pressure

3. Protect pt.from unauthorized procedure

4. Protect MD and hospital against legal action

CIRCUMSTANCES REQUIRING A CONSENT

1. Any surgical procedures where scalpel,scissors,suture,

hemostasis,electrocoagulation

maybe used

2. Entrance into the body cavity

3. General anesthesia/ local or regional

4. INSTRUCTIONAL AND PREVENTIVE ASPECTS

a. Deep Breathing Exercise

-help expand collapsed lungs and prevent pneumonia and

atelectasis q hour

-done 5-10 times post-operatively/use of diaphragmatic

abd.breathing

Procedure;

-sit on the edge of the bed or lie supine,with knees flexed to relax
the abdominal

Musculature (may lie on either side if lying on the back is

impossible).

-place hands on the abdomen

 -Inhale through the nose until the abdomen balloons outward

-exhale through pursed lips while contracting the abdominal

muscles

b. Coughing Exercises

-deep breath,exhale through the mouth then follow with a short

breath

while coughing

-helps expand collapsed lungs and prevent post-operative

pneumonia

and atelectasis

- done 5-10 times every hour post operatively

-to eliminate anesthesia inhalation

Procedure:

-on sitting or lying position, lace fingers and hold them tightly
across the

incision before coughing (small pillow or folded towel over incision

may do)

-take a deep breath, hold the breath for few seconds then cough
from deep in the

lungs once or twice (encourage client to perform deep breathing

 (exercises before coughing to stimulate
cough reflex)

(cough deeply not just clear the throat)

c. TURNING EXERCISE

-help prevent venous stasis, thrombo-phlebitis, decubitus ulcer

formation and

Expansion uppermost lungs

-promote good circulation

-done every 1-2 hours post operatively

Procedure:

-turn from side to side using the side rails to assist movement for
patient with right abdominal incision or right sided chest incision or
right sided chest incision, turn to left side of bed: by flexing the
knees

-splint the wound by holding left arm and hand or small

pillow against the

Incision

-turn to left side by pushing with right foot and grasp side rail
on left side

of the bed with the right hand

d. Extremity Exercises

- Help prevent circulatory problem ; thrombophlebitis by facilitate

venous return to the heart

- Prevent post op gas pain, flatus, promote circulation

AMBULATION

- Help prevent post operative complications, promote wound healing

 - Started 1st post op day, case to case basis

Discuss the purpose of post operative equipment depending on the

surgery

Tubes: indwelling catheter for bladder drainage nasogastric tube

( NGT)

- To decompress stomach and upper bowel

- To drain stomach content

Drains :Penrose Drain , Wild suction (hemovac or Jackson Pratt drain)

Intravenous Infusion Devices - to administer medication and fluids

during perioperative

period.

5. PHYSICAL PREPARATION

On the eve of surgery

a. Skin preparation defillatory, clipping, wet shave

- To decrease minimum bacteria on the pts. skin by

-bathing if possible
 -mechanical means by shaving against the groin of hair, shaft to
ensure clean,

close shave

-OB case –shaving and antiseptic douche

-Surgical case-rectal/bowel surgery, water by saline enema

PRINCIPLES IN SHAVING

1. Area of prep should should always be wider and longer than the
area of the proposed incision

2. Use strong light, well paysed and sterile razor with a new blade

3. Shave against the groin of the hair to ensure close clean shave

b. Gastro-intestinal tract (GIT) preparation

Purpose:

- Reduce possibility of vomiting and aspiration during anesthesia

- Reduce possibility of a bowel obstruction

- Prevent contamination from fecal material during intestinal tract or

bowel surgery

b.1 Restrict food and fluid

- NPO post midnight( solid food withheld 7-10 hrs. however water
maybe given

4 hours before, local anesthesia light breakfast)

- light breakfast for late afternoon surgery

When a client on NPO:

- Explain the reasons for the restriction

- Remove food and water from the bedside stand

- Place an NPO sign on the door and on the bed

- Mark the kardex or nursing care plan NPO

- Inform the dietitian or diet list patient is NPO

- Inform caretaker that a client is NPO

b.2 Administer IV fluids for debilitated/ malnourished as ordered

b.3 Give enema as ordered – not routinely done except for intestinal
colon operation

2-3 enemas given evening/ early morning

Reasons:

- Prevent contamination of peritoneal cavity by feces

- Prevent colon surgery

- Provide adequate visualization of surgical site

b.4 Insert NGT as ordered (done usually by physician)

c. Anesthesia preparation – anesthesiologist visits the patient evening

prior to surgery

-examine for evidence of pulmonary

problem as URTI and

Investigate patient smoking habit

Responsibility – anesthesiologist :

- Discuss type of anesthesia

- Explain sensation

- Discuss fear

d. Promoting Rest and Sleep

- Tranquilizer

- Well ventilated room

- Clean comfortable bed

- Back rub

- Warm milk,tea

- Talk to patient

On the Day of Surgery

a. Early morning care - 1-2 hours before surgery

- Assist in bath or shower, provide oral hygiene, give clean gowns

- Check consent signed, laboratory results reading

- Give oral hygiene

- Record allergies

- Remove jewelries, dentures

- Remove colored polish

- Remove make up

- Check ID band

- Remind NPO

- Check skin preparation

- IV fluids. Catheter, NGT, administered as ordered

- Ask client to void (empty bladder to prevent incontinence,

accidental injury)

- Assist in donning hosp. gown and protective cap

- Take v/s
b. Administer pre-operativemedications

- Administer 60-90 mins before induction of anesthesia

Purpose:

- Allay anxiety

- Decrease pharyngeal secretions

- Reduce side effects of anesthetic agents

- Inducee amnesia

Nursing Responsibilities:

- Raise bed side rails

- Do not leave patient alone

- Lower window shades and turn off lights

- Let patient void before administration pre-op medicine

- Instruct patient not to get up without assistance

- Disturb the lient only when necessary, briefly and quietly after
administering

pre-op medicine

TYPES OF PRE OP MEDS;

1. Tranquilizer- relax smooth muscle, decrease anxiety eg. Phenergan

2. Sedatives- promote relaxation, decrease patient anxiety, decrease

amt. of anesthesia given, given at night to ensure good sleep eg.
Phenobarbital

3. Analgesics- eg. Morphine, butorphanol, dormicum, midazolam

4. Vagolytic/ anticholinergics- decrease secretions and interrupt vagal

nerve stimulation eg. Atrophine sulfate
c. Recording

d. Transport the Client to OR

Responsibilities:

- Gently transfer client to the stretcher

- Cover patient for protection from draft

- Place side rails up and secure restraining belt 2 inches above the
knee

- Records/chart brought to Or with the patient

- Avoid rapid walking and swinging the cart around corners

- Arrange room for post operative case

-keep furnitures away so that stretcher is easily brought in the

bedside

-make a surgical bed

-set up necessary equipment : emesis basin, IV stand, suction

Oxygen set up

e. Care of Significant Others

- Inform where to wait and when surgery completed

- In case no relative during operation get telephone number or

contact when necessary

- Give psychological report