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Chapter 7 Lecture Outline

Nursing Care of Clients Having Surgery
I. Background:
A. Definitions
1. Surgery: invasive medical procedure
2. Nurse: collaborative and independent role in providing care during all
phases of surgical experience
B. Phases
1. Preoperative Phase: time from when client and surgeon make decision
to have surgery until client enters operating room
2. Intraoperative Phase: time from entry of operating room until client is
admitted to postanesthesia unit
3. Postoperative Phase: time from admittance to postanesthesia unit to
time when client is completely recovered from surgery
C. Types of surgery (classified according to purpose)
1. Diagnostic: determine seriousness of alteration in health
2. Curative: cure a health problem
3. Palliative: relief of symptoms
4. Cosmetic: improve physical appearance
5. Preventative: prevent a more serious condition from developing
6. Elective surgery: surgery that can be done at a time convenient for
client and surgeon
7. Emergency surgery: must be done as soon as possible to save clients
life or ability to function
8. Inpatient surgery: client has been in hospital prior to having surgery
done, begins recovery as inpatient client
9. Outpatient surgery: client enters hospital or free standing surgical
facility to have surgery done and then is discharged after recovering
and stable from anesthesia and surgical procedure
(Many variations of in and outpatient surgery with clients being
admitted the morning of surgery and then being inpatients; 23 hour
stays post op, etc. in attempt to control costs)
II. Preoperative Phase:
A. Diagnostic Testing
1. Purpose: determine clients present health status and ability to tolerate
surgical procedure and anesthesia
2. Generally the more involved the surgery: more involved the diagnostic
testing
3. More involved testing with clients who are elderly and/or have
multiple pre-existing health problems
4. Nursing advocacy role to make sure physicians aware of any
significant abnormalities and follow-up is done
B. Common Diagnostic Tests prior to Surgery
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1. Complete Blood Count: hemoglobin and hematocrit: clients ability to

tolerate blood loss involved with surgery; white blood count: general
assessment of immune system and healing potential
2. Electrolyte Studies: normal range for proper heart and neuromuscular
functioning
3. Coagulation Studies: ability to clot normally post-surgery
4. Urinalysis: general screening for disease such as renal problems or
diabetes
5. Chest Xray and electrocardiogram: gives basic information about
lungs and heart; determine whether clients cardiac and respiratory
systems are healthy enough for client to tolerate surgery and anesthesia
6. Blood type and cross match: done if blood transfusion anticipated
(For some elective surgeries clients may opt for autologous blood
transfusion: client donates own blood ahead of time; blood prepared
for transfusion during surgery)
7. Other diagnostic tests may be ordered if indicated
8. Preop History and Physical exam is done by surgeon or medical
physician; medical specialists may also be consulted
C. Informed Consent
1. Surgeon performing procedure is responsible for obtaining clients
informed consent (operative permit)
2. Legal document that includes description and purpose of procedure
with possible benefits and risks, right to refuse treatment and withdraw
consent; document placed on chart after signed
3. Nurse has advocate role to assist client in getting questions answered
and concerns addressed
4. Nurse acts as witness to clients signature on consent; indicates correct
person signed consent and was aware of what was signed (not sedated
or coerced)
D. Other preoperative interventions
1. Physicians, including surgeon and consultants, give orders to prepare
client night before or day of surgery.
2. Inpatient clients receive care from nurse; outpatient clients need to
understand instructions to prepare for surgery independently
3. Teaching about surgical and postsurgical routines; interventions for
pain control and for decreasing the risk of postoperative complications
4. Planning for recovery needs post discharge
5. Common orders
a. Clients routine medications
1. Specific instructions regarding medications routinely
taken (i.e. diabetic meds, antihypertensives,
anticoagulants)
2. Nurse needs to clarify in advance
3. Clients often bring meds from home, or a list if
outpatient case.
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b. Specific preparations ordered by physician (e.g. showering or
scrubbing the surgical area with a bacteriostatic cleaner; taking
an enema).
c. NPO status (Nothing by mouth): decreases the likelihood of
vomiting and decreases the risk of aspiration (serious
complication)
1. Often 6 8 hours depending on time surgery is
scheduled
2. If NPO for several hours, client usually has intravenous
fluids ordered to maintain client fluid balance.
3. May be allowed liquids depending on time and type of
surgery
d. Preoperative Medications
1. Ordered at specific time, or on call, or in surgical
holding area
2. Used to sedate, reduce anxiety, reduce gastric acidity
and volume, decrease nausea and vomiting, reduce
incidence of aspiration by drying oral and respiratory
secretions, or prevent incidence of infection
6. Preop-Checklist
a. Nurse completes for inpatient and outpatient surgery clients
b. Nurse signs that client is fully prepared for surgery
c. Nurse places documentation on chart and includes
1. Client has identification and allergy bracelet on
2. Informed Consent form is signed and witnessed
3. Diagnostic tests have results documented
4. History and physical including current height and
weight
5. Preoperative interventions completed as ordered
6. Preoperative medications administered as ordered
7. Vital signs documented within 2 hours
8. Client voided
9. Family members present with client
10. Disposition of dentures, glasses, hearing aides per
institution policy
11 Proper attire according to institution policy (jewelry off,
nail polish and makeup removed)
II. Intraoperative Nursing Phase
A. Anesthesia
1. Medications given to produce unconsciousness, analgesia, reflex loss
and muscle relaxation, amnesia
2. Type determined by condition and type of surgery
3. Types
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a. General
1. Given by inhalation and intravenous
2. CNS depressed: client loses consciousness
3. Risks for cardiac and respiratory systems
4. Phases
a. Induction: tracheal intubation for airway
patency
b. Maintenance: positioned, surgery performed
c. Emergence: anesthesia reversed; extubation
b. Regional
c. Conscious Sedation
B. Surgical Team Members
1. Surgeon
2. Surgical assistant
3. Anesthesiologist or CRNA
4. Nursing Roles
a. Circulating nurse: surgery coordinator; assists other team
members; documentation; ensures counts of sponges and
instruments are correct; client advocate
b. Scrub nurse: scrubbed in and assists surgeon in surgical
procedure
c. Certified registered nurse anesthetist (CRNA): works with
anesthesiologist to maintain anesthesia, and to monitor and
maintain physiological status with medications, fluids, blood
d. Specialty team: nurses specialize for complex surgeries, e.g.
open heart surgical team, transplant team
C. Care of client (especially elderly)
1. Positioning: minimize risk for pressure sores
2. Communication: client may have sensory impairment being without
hearing aides or glasses
D. Operating room protocols: Scrubbing, maintaining sterile fields
III. Postoperative Phase
A. Admittance to post-anesthesia recovery unit
1. Immediate and continuous assessment per protocol; initially every 15
minutes
2. Monitor patency of airway, vital signs, surgical site, recovery from
anesthesia, fluid status, pain control, other post-operative orders, e.g.
lab tests, intravenous fluids, etc.
3. When stable, discharge to hospital room or home
B. Care focus: prevention of postoperative complications
1. Cardiovascular
a. Hemorrhage, shock (hypovolemic most common)
1. Client restless or less responsive
2. Monitor post-operative hematocrit/hemoglobin
3. Hypotension, tachycardia
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4. Pressure for obvious bleeding
5. Notify surgeon
b. Deep venous thrombosis (DVT)
1. Thrombus in deep veins of leg
2. Client has pain, edema usually in one leg
3. Bedrest
4. Contact physician immediately
5. After diagnosis: anticoagulation
6. Prevention
a. Support stockings
b. Use of intermittent pressure devices on lower
legs (e.g. external pneumatic compression
machine)
c. Early ambulation
d. Adequate hydration
c. Pulmonary embolism
1. DVT dislodges, moves, and lodges in pulmonary
circulation
2. Client has chest pain, dyspnea, tachycardia
3. Bedrest
4. Contact physician immediately
5. Prevention includes adequately treating DVT
2. Respiratory
a. Atelectasis, pneumonia
b. Prevention: cough and deep breathe, instruction incentive
spirometry
3. Elimination
a. Problems associated with effects of anesthesia, lack of activity,
pain medications
b. Urine elimination
1. Should urinate within 7 to 8 hours post surgery
2. Methods to assist people to void
3. Obtain catheterization order from physician, if
indicated
c. Bowel elimination
1. Promote activity
2. Adequate fluid intake
4. Wound
a. Healing
1. Primary Intention: incision edges well-approximated
2. Secondary Intention: wound gaping, irregular;
granulation tissue fills in, some scarring
3. Tertiary Intention: not sutured, tissue heals by
granulation process, wide scar
b. Wound drainage

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1. Serous: clear or slightly yellow, serum (plasma) of
blood
2. Sanguineous: thick, reddish, contains red blood cells
and serum
3. Purulent: result of infection; contains white blood cells,
tissue debris, and bacteria; thick, color varies with
causative organism
c. Wound disruptions
1. Dehiscence: separation of layers of incision wound
2. Evisceration: protrusion of body organs through area
where incision came apart (with abdominal wounds,
may see intestines); cover with sterile dressings soaked
in sterile saline; notify physician for surgical close
d. Suture (stitches) or staple removal
1. Some sutures need to be removed; some dissolve
2. Removed 5 to 10 days post surgery if wound is healing
3. Often removed at time of clients visit to physician
office or removal ordered if inpatient
5. Acute Pain
a. Adequate pain control allows client to participate in recovery
and avoid complications
b. Client participation in pain assessment and relief
1. Use of pain scale, administer and evaluate medication
effectiveness
2. Obtain alternate medications or routes if pain control
ineffective
3. Teach client how to splint (brace) incision with
movement
4. Ways of changing position that lessen pull on incision
C. Promotion of recovery from surgery
1. Discharge instructions
2. Follow-up plans
3. Home care, outpatient physical therapy
4. Wound care; activity restrictions
5. Prescriptions for medications, lab tests
6. Supply contact source if client has questions
7. Follow up appointment with surgeon

Suggestions for Clinical Experience

Assign the students to follow a client who is scheduled for surgery on the day of the
clinical experience in a hospital or free standing outpatient surgery facility. Assist the
student to meet the client in the pre-surgical area or hospital unit. Students should review

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or complete the Preop-Checklist. As clinical time allows, arrange for the student to
observe the clients surgery and follow the client to the post-anesthesia recovery unit.
Assign the students to care for hospital clients who are returning to the floor after surgery.
Assist the student to participate in the care of the client post-operatively, including
assessment and management of the clients pain. Assist the client to review the postoperative orders, post-anesthesia recovery unit record, and surgeons operative note.
Assign the students to hospital clients who have undergone surgery recently. Assist
students to identify risks for postoperative complications specific to the assigned client,
based on the clients health history and type of surgery. What interventions are being
employed to decrease the likelihood of the complications?
Arrange for the students to have clinical experience in a surgeons office. Students should
follow several clients through office visits, including preoperative and postoperative
visits. Have the students observe office personnel coordinating surgery schedules and
preoperative testing. What assessment data do the office personnel measure during visits?
Students should review the educational materials available to the clients. Are the
materials written in terms that are easily understood by clients?
Nursing Care Plan
Present the following client situation for discussion:
A 47-year-old man has undergone abdominal surgery and has returned to the hospital
surgical unit six hours ago. The nurse receives a report from the nurse on the previous
shift. The client has been sleeping off and on, while maintaining his pain level at a 3 on a
1 to 10 scale with PCA (Patient Controlled Analgesia). Vital signs have been stable and
he has not yet voided. The clients wife comes to the desk and states that her husband
just woke up and seems to be feeling bad. She wants the nurse to check on him. The
nurse goes to the clients bedside, questions the client and performs a physical
examination.
What should the nurse include in her assessment and what questions should she ask of
the client?
The client states he is having lower abdominal discomfort different from the pain he has
been experiencing since surgery. Pain level is at a 6. Skin is warm and dry. Color is pink.
His midline abdominal dressing is dry, intact. Bowel sounds are absent. Abdomen is soft
and non- tender to gentle palpation in all quadrants.
The clients vital signs: T:37.0o C P:104 R:22 BP: 136/76 RA
What aspects of this assessment are normal for a client who underwent abdominal
surgery earlier in the day? How can the nurse determine that this set of vital signs are
within the normal range for this client?
How could the nurse assess if the client is experiencing discomfort from a distended
bladder?
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The nurse gives the client a urinal but he is unable to void.

What strategies could the nurse employ to assist the client to urinate?
The client voids 240 ml. and the nurse rechecks his vital signs. Vital signs are T:37.2o C
P:96 R:22 BP: 120/60 RA . Pain level is at a 4. The client is resting and dozing off.
His wife asks the nurse how one would know if her husband was bleeding inside.
What should the nurse explain to the wife?

Joyce Hammer
11/5/2014