AUTHOR: H B SUBARNA
Pre and Post-Operative Nursing Care – Types of Surgery, Phases of Surgery and Nursing Care.
Surgery can be defined as the art and science of treating diseases, injuries and deformities by operation and instrumentation. Most surgical procedures are performed in a hospital operating room, although many simpler procedures are carried out in surgical centres and ambulatory surgical units.
Surgical procedure are grouped according to the
Diagnostic, palliative, ablative, reconstructive or cosmetic, transplant or corrective, curative, repairative and restorative.
Degree of Urgency
Degree of Risk involved
1. Major Surgery
2. Minor Surgery
Types of Surgery and its main features
According to Purpose:
This is an operation in which the diagnosis is unknown and so it confirms or establishes diagnosis. E.g. exploratory laparotomy in which the abdomen is opened to seek the cause of symptoms or biopsy of a mass in the breast.
This is an operation in which symptoms are relieved, but the basic cause remains and so does not cure the disease. E.g. resection of nerve root, or insertion of gastrostomy tube to compensate for the inability to swallow.
This is an operation in which the diseased body part is removed. E.g. removal of gall bladder (Cholecystectomy).
Reconstructive or Cosmetic:
This is an operation which is done to restore function or restore appearance that has been lost or reduced. E.g. mammoplasty, breast implant, face lift etc. repair of cleft lip and cleft palate.
This is an operation in which deformities are corrected and malfunctioning structure are reduced. E.g. hip replacement, replacement of the mitral valve.
This is an operation in which complete cure is ensured by removing the diseased part or organ e.g. removal of an inflamed appendix, total excision of a tumour mass.
This is an operation in which repair of the damaged or injured part is done. E.g. suturing of multiple wounds.
This is an operation involving strengthening of a weakened area. E.g. herniorrhaphy.
Operation is performed to prevent the disease e.g. removal of mole to prevent it turn into malignancy.
Degree of Urgency:
In this, pre-operative period is very short, because of the life threatening situation. E.g. acute appendicitis. Therefore minimum preparation can be done in the pre-operative period.
Immediate (Without Delay): surgery is performed immediately to preserve function or save life of the client. E.g. ruptured aortic aneurysm, gunshot wound, epidural hematoma, acute appendicitis.
Urgent: client requires prompt attention. Surgery is performed within 24 to 48 hours, e.g. ureteral calculi, bleeding uterine fibroids, obstructed duodenal ulcer.
Elective or Planned:
Surgery is performed when surgical intervention is the preferred treatment for a condition that is most immediately life threatening or to improve clients life. Time for surgery is fixed with the mutual consent of the surgeon and the patient. There is enough time left for the per-operative care to be given to the patient.
Required: surgery is required within weeks or months. E.g. cataract extraction, benign prostatic hypertrophy, chronic cholecystitis.
Recommended: client should be operated upon. Failure to do surgery is not catastrophic. E.g. simple haemorrhoids, rectocele, cystocele, simple hernia.
Optional or Cosmetic: decision rest with the client and is the personal preference of the client. Plastic surgery procedures. E.g. face lift.
Degree of Risk:
This involves a high degree of risk to the client, for a variety of reasons. It may be complicated, prolonged, there may be heavy loss of blood, vital organs may be involved, post operative complications are likely, operation may involve large surface area of the body. E.g. open heart surgery, organ transplant, removal of a kidney etc.
This normally involves little risk, produces few complications and usually involves a small area of the body. E.g. breast biopsy, tonsillectomy.
Suffixes Describing Surgical Procedures:
Ectomy – Excision or removal of. E.g. myomectomy.
Lysis – destruction of. E.g. electrolysis.
Orrhaphy – repair or suture of. E.g. colporrhaphy.
Ostomy – creation of opening into. E.g. colostomy.
Otomy – cutting into or incision of. E.g. tracheotomy.
Plasty – repair or reconstruction of. E.g. tympanoplasty.
Phases of Surgical Experience:
The surgical experience is a unique one and involves three phases
Pre-operative phase. 2. Intra-operative phase. 3. Post-operative phase. These three phases together are referred to as pre-operative period.
Pre-operative Phase: it is the period between the decision to do the surgery and the client being shifted to the operation table.
Nursing Duties in Pre-operative Period:
1. Assessment of the client.
2. Identification of health problems – both actual and potential.
3. Plan of care based on individual health needs.
4. Pre operative health teaching of the client and supportive people.
5. Actual preparation of the client for surgery (physical, psychological, social etc).
Intra-Operative Phase: it is the period from the time the client shifted to the operating table, and later admitted to the post anesthesia care unit or recovery room. The nursing activities during this phase include all the specialized procedures designed to create a safe therapeutic environment for the client.
Post-Operative Phase: it is the period between the admission of the client to the recovery room till the healing is complete. The nursing activities during this phase include
1. Assessment of the client’s response to surgery. (physical and psychological).
2. Care to promote healing process.
3. Activities to prevent complications.
4. Health teaching and post operative exercises.
5. Planning for home care.
PRE-OPERATIVE CARE FOR PATIENTS
Pre-operative care of the patient begins as soon as the surgeon makes a diagnosis and decides that an operation is necessary for the patient.
1. Psychological Preparation:
Discuss with the patient to give full information about the surgery, such as:
Type of surgery
Consequence of surgery (if it is done and if it is not done).
The problems to be faced (disabilities expected)
Expected duration of hospitalization.
Expected time of resuming duty (if employed)
Cost of surgery
Treatment/investigations done before surgery and its purpose.
Necessary arrangements to be made about the family, financial matters, work, hospitalization, etc.
2. Eradicate fear of Operation from the patient:
Allow the patient to ask questions and clear all his doubts.
Introduce the patient to someone who had similar surgeries and have been successfully recovered from the symptoms.
Explain what happens during anaesthesia.
Explain how to get rid of pain after surgery
Tell the patient when he can have meals.
Answer all questions asked by the patient in a language he can understand, so that the patient will have confidence to undergo surgery.
Let the patient see the persons, places and equipment involved in his operation.
Always start the procedures with an explanation, so that it will inspire confidence in the medical team. The patient has to feel that he will be safe in the hands of the competent people during surgery.
For many patients, their admission to the hospital is a first experience in their lives. In such situation, the nurse should them feel at home by eradicating their fear.
3. Meet the Spiritual needs of the patient:
4. Obtain informed consent:
Obtain the consent from the patient/guardian for each operation after explaining the nature of the operation and anaesthesia.
Never compel the patient/guardian to give their consent.
Explain the complications that may occur when the patient is under anaesthesia.
The language used in the consent form should be understood by the patient/guardian, who gives the signature.
Obtain consent for major diagnostic procedure.
5. Build up the general health of the patient and correction of the disease process for speedy recovery:
Assist the doctor to carry out a thorough physical examination from head to foot to assess the physical health of the patient
Ask the patient appropriate questions to obtain past and present medical history in order to exclude anaemia, jaundice, diabetes, asthma, lung infections, hypertension, heart diseases, bleeding tendencies, mental diseases, drug reactions, blood transfusions, previous operations, etc.
Carry out the investigations that the doctor ordered, such as: blood for Hb, TC, DC, ESR, blood urea, blood sugar, BT, CT, HIV, VDRL grouping and typing etc. Urine for albumin, sugar, microscopic examination.
Collect all the baseline data – temperature, pulse rate, respiration, blood pressure, ECG, X-ray chest etc.
6. Pre-Operative Teaching:
7. Surgical Preparation of Skin:
8. Preparaton of Patient on the Evening before Operation:
9. Preparation of Patient on the Day of Surgery:
10. Sending Patient to Operating Room:
Administer the pre-medications to the patient one hour before surgery. These are the drugs that reduce anxiety in the patient, and provide a smoother induction of anaesthesia.
Before giving the pre-medications, check the vital signs of the patient such as blood pressure, temperature, pulse, respirations etc. record the vital signs in the patient’s charts as baseline data.
Change the patient’s dress and put on hospital gown.
Write the patient’s name, age, ward, bed number, diagnosis, hospital number etc. on the identification card and fasten it onto the dress or on the arm to prevent mistaken identity.
Ask the patient to void just before sending the patient to operating room.
Transfer the patient onto a patient trolley and cover him with clean sheets to prevent draught.
Never leave the patient alone on a trolley without any person near-by to prevent falls and injuries.
Always send the patient’s charts will all reports , such as lab reports/medication chart/X-ray/ECG reports/and other investigations done on the patient. Check the consent form for the operation and anaesthesia.
Always send the patient with an attendant up to the operation theatre. It is preferable to have female attendant to accompany the female patient.
NURSING DIAGNOSIS OF THE PRE-OPERATIVE CLIENT
1. Anxiety related to lack of knowledge about pre-operative routines and post-operative care.
2. Fear related to effect of surgery and ability to function in usual roles.
3. Fear related to the risk of death.
4. Anxiety related to the outcome of exploratory surgery for malignancy.
5. Fear related to loss of control during anaesthesia.
6. Anxiety related to the perceived inadequate post operative analgesia.
7. Sleep pattern disturbance related to hospital routines and psychological stress.
8. Anticipatory grieving related to perceived loss of body part associated with planned surgery.
9. Ineffective individual coping related to conflicting values (e.g. need for blood transfusion verses the religious values for Jehovah’s witness)
10. Ineffective individual coping related to lack of clear out-come of surgery.
11. Ineffective individual coping related to unresolved past negative experience with surgery.
Intra-operative nurses are responsible for the safety and well being of the patient, the co-ordination of the operating room personnel and activities of the circulating nurse and the scrub nurse.
Intra Operative Nursing Functions:
The Circulating Activities: it include assuring cleanliness, proper equipment, humidity and lighting, the safe functioning of the equipment and the availability of the supplies and materials. The circulating nurse also monitors the aseptic practices of the related personnel (Medical, X-ray and Laboratory) besides monitoring the safety of the patient throughout the surgical procedure.
The Scrub Activities: it includes scrubbing for surgery, setting up the sterile tables, preparing sutures, ligatures and special equipments and assisting surgeons during the procedure.
Nursing Diagnosis of Intra Operative Clients:
1. Potential for risk of aspiration related to the position used for surgery and anaesthesia.
2. Potential for risk for perioperative positioning injury related to improper positioning and inadequate support while positioning.
3. Potential for impaired skin integrity related to surgical incision and infection.
4. Potential for altered tissue perfusion related to anaesthetic drugs.
5. Potential for risk of fluid volume deficit related to loss of body fluid during surgery.
6. Potential for risk of altered body temperature related to
Lowered room temperature of operation theatre.
Infusion of cold fluids.
Inhalation of cold gases.
Decreased muscle activity.
Use of pharmaceutical agents.
1. Preparation of Post-anaesthetic Bed and Reception of the Patient:
After sending the patient to operating room prepares a bed to receive the patient who has undergone surgery and anaesthesia.
There should be adequate number of people to transfer the patient without disturbing the functioning of the devices attached with the patient: such as : i.v. infusion set, self retaining suction set, blood transfusion set, naso-gastric tube, oxygen, urinary catheter, cardiac monitoring, water seal drainage system, plaster casts, traction sets.
Receive the patient without disturbing the devices attached to the patient. The recovery room nurse-incharge may give the necessary instructions to the personnel before transferring the patient.
Ask the theatre staff who has accompanied with the patient about any complications that has occurred in the operation room during surgery.
Before the theatre staff (including anaesthetist) return to operation theatre, check the vital signs – blood pressure, pulse rate, respiration, colour of the skin and nails for any cyanosis etc. compare it with the baseline data recorded data recorded before sending to operating theatre.
Check the operation site for bleeding, discharge etc., if drainage tubes are lifted.
Keep the patient well covered to prevent draught.
Never leave the patient alone to prevent injury from falls.
Observe the patient for swallowing reflexes. If not present, keep the patient in a sidelying position to prevent the tongue falling back and obstructing the airway. After tonsillectomy the patient may be kept in prone position to prevent blood aspirating into the lungs. The patient who has spinal anaesthesia, the foot end may be raised on bed blocks.
Quickly observe the functioning of all devices and make sure they are in its functioning order e.g., the drainage tubes are connected with drainage bottle, the IV sets are patent etc.
Check the doctor’s orders for other instructions and treatments.
2. Care of the Patient who in under the Effects of Anaesthesia:
Patient needs close and diligent observation until the patient fully recover from anaesthesia. This will help to detect the early signs of complications after surgery and the nurse will be able to respond immediately.
A noisy breathing is indicative of airway obstruction that can occur due to the tongue falling back and obstructing the pharynx, or fluid collected in the airway passages or fluids aspirated into the lungs. Apply suction immediately, send and call the surgeon and the anaesthetist.
Keep the patient in a suitable position that will be helpful to drain out the vomitus, blood and secretions collected in the mouth and will prevent them aspirating into the lungs. This position is maintained until protective reflexes are returned.
The oro-pharyngeal airway left in the mouth of the patient should be removed as soon as the patient has regained the cough and swallowing reflexes.
Excessive secretions in the mouth or anywhere in the respiratory passage can lead to airway obstruction. It should be sucked out. If intra-tracheal suctioning is necessary, always use sterile technique.
If the patient is cyanosed, administer oxygen inhalation. At the same time, find out the cause and remove the cause. Prolonged oxygen therapy should be guided by arterial blood gas determinations.
A weak thread pulse with a significant fall in blood pressure may indicate circulatory failure. It may also indicate blood loss from the body. The surgeon and the anaesthetist should be informed.
In order to prevent injury from falls from bed put the side rails on the bed. Till the patient recover from the effects of anaesthesia, the nurse should not leave the patient alone. Even when the patient has recovered from the effects of anaesthesia, entrust the patient to someone responsible for the care.
While awakening from anaesthesia, patients need frequent orientation as to where they are, what has been done to them, and reassurance that they are safe in the hands of the medical team. They also need to know that the operation is over and they are recovering from anaesthesia.
Although these patients, while they are under the effects of anaesthesia, appear to the unconscious, the nurses should be careful, not to make any statement about the paitent or his disease conditions that may create anxiety in the patient.
When the patients under the effects of anaesthesia complain pain in the operation site, the narcotics/sedatives may be ordered by the surgeon and it should be given with caution. The first post operative dose of a narcotic is usually reduced to half the dose the patient will be receiving after being fully recovered from anaesthesia. This is because it can cause pronounced depression of the respiratory/circulatory/central nervous system that may follow.
Patient recovering from anaesthesia may ask for drinking water. Unless the patient has fully regained the swallowing reflex, drinking water may choke the patient: it should not be given.
As the patient is recovering from the effects of anaesthesia, the patient may become restless due to the discomfort caused by the presence of those devices attached to the patient, such as i.v. sets, urinary catheters, and drainage tubes etc. The nurse should help the patient by giving adequate explanations.
Keep the family informed of the successful completion of surgery, transfer of the patient from the operating room to recovery room etc. This information will reduce their anxiety. If possible, allow the relatives to meet surgeon to clear their doubts.
3. Observation of the Patient in the Post Operative Period:
Close and diligent observation by the nurses are important to detect complications in the early stages, and thus, save the patient.
On the first post operative day the patient needs close and frequent observations: e.g. the vital signs are checked every 15 minutes or more frequently (during the period when the patient is in the recovery room). Once the vital signs are stabilized, the observations may be made every 2 hourly or 4 hourly according to the progress made by the patient.
Vital signs-blood pressure, pulse rate, respiratory rate, skin colour, skin temperature.
Intake and output – I.V. fluids, oral fluids taken by the patient, naso-gastric aspiration, wound discharge, blood loss.
Abdominal girth in patients with abdominal distension.
Urinary output – time and amount.
Signs of hypo/hypervolaemia.
Any breathing difficulties.
Pain over the calf muscles.
Operation site for bleeding, drainage.
Any specific observation as told by the surgeon and according to the operation done.
4. Care of the Wound:
This is the most important nursing care regarding control of infections.
5. Diet of the Patient:
All patients, except patients who had abdominal surgery, may start the normal diet, if desired so, on the first day. Remember to exclude nausea and vomiting due to the effect of anaesthesia.
Patient who had abdominal surgery, but did not involved the intestine or stomach, can have the clear fluids on the day after the surgery.
Gradually, it can change into soft diet and then normal diet.
Patients who are with specific diseases, for which they were taking special diets, should continue to observe the control of their diet as ordered by the doctor (e.g. a diabetic patient).
Remember, the patient who had undergone any type of surgery need a diet rich in vitamins and minerals.
6. Post Operative Health Teaching:
All patients need health teaching according to the educational background of the patient.
Maintenance of personal hygiene.
Diet that is allowed for the patient: any control on the diet.
Ambulation: activities that are permitted, as well as restricted.
Any adjustments to be made in the occupation of the patient.
Any drugs to be taken post operatively: the side effects and precautions.
Date on which the patient may resume duty.
Learning of any particular procedure to be carried out postoperatively, e.g. care of the colostomy. When the patient is unable to perform the procedure, teach the patient’s relatives.
Future treatment that may be needed for the patient in any other hospital e.g. radiation therapy for cancer patients.
NURSING DIAGNOSIS OF POST OPERATIVE CLIENTS
1. Ineffective airway clearance related to effects of medication and anaesthetic agents.
2. Ineffective breathing pattern related to pain, surgical incision and medications.
3. Risk for altered body temperature, hypothermia – related to the use of drugs, infusion of cold fluids, inhalation of cold gases etc.
4. Risk for injury related to post anaesthetic status.
5. Pain related to surgical incision and reflex muscle spasm.
6. Altered nutrition, less than body requirements.
7. Risk for fluid volume deficit related to loss of fluid during surgery and inadequate intake of fluid after surgery.
8. Nausea and vomiting related to gastrointestinal distension medication, anaesthetic effect and stimulation of vomiting centre or chemoreceptors trigger zone.
9. High risk for infection related to surgical incision, inadequate nutrition and fluid intake, presence of environmental pathogens, invasive catheter and immobility.
10. Altered urinary elimination related to decreased activity, effects of medication and reduced intake of fluid.
11. Constipation related to decreased gastric and intestinal motility during intra operative period.
12. Impaired physical mobility related to depressant effects of anaesthesia, decreased activity tolerance and prescribed activity restrictions.
13. Potential for haemorrhage related to ineffective vascular closure.
14. Potential for thromboembolism related to dehydration, immobility, vascular manipulation or injury.
15. Potential for urinary retention related to horizontal positioning, pain, fear or analgesia and anaesthetic medications.
16. Self care deficit related to anaesthesia and surgery.
17. Potential for paralytic ileus related to bowel manipulation, immobility, pain, medication and anaesthesia.
18. Anxiety about post-operative diagnosis, possible changes in life style, and alternation in self-concept.
19. Potential for body image disturbance related to surgery.
20. Impaired home management related to lack of knowledge about follow-up care.