MEDICAL AND SURGICAL STUDY GUIDE

BY APRIL MAE LABRADOR

HISTORICAL BACKGROUND
BEGINS: IN SURGERY
HISTORICAL BACKGROUND

Historical development of surgery comes from:

 Babylonian Law  The code of Hammurabi in 1913 B.C.
 According to this law If the patient died after a surgical procedure, retribution would reflected
on the surgeon in the form of amputation of his right hand.

***Or sometimes beheaded.

Another believes that: there be a 3x successful procedures before being pronounced as a competent to
practice surgery.

Claudius Galen-Who considered the father of experimental physiology.

History of International Surgery

 5,000 to 10,000 BC.
 Early medical providers were known as Healers, shamans, priest, barbers and medicine men
 Originally all medical providers were essentially surgeons as they treated wounds, drained
infections, broken bones, and stopped bleeding by applying hot metal or hot oil to wounds.

**Back then, surgical treatment dates back to as early as 10,000 to 5,000 AC.
Originally all medical providers were essentially surgeons as they treated wounds, drained infections,
broken bones, and stopped bleeding by applying hot metal or hot oil to wounds.

In Surgical Instrumentation
Historical Overview:
 Archeologist revealing evidence of a surgical procedure known as trephining ( an opening of the
skull) was performed to release the demons believed to be trapped inside the patient.

TREPANATION
Surgical procedure:
 is the act of drilling openings into skull to release so called evil spirit from the dates back to the
Mesolithic periods.
 While in the period of Hieroglyphic in ancient Egypt and textbooks that were the foundation of
Ayurvedic medicine ( Sushruta Samshita) describe many operations, including CS, rhinoplasty,
craniotomy, and laparoscopy performed while using wine and Cannibis indica as anesthesia.

Trepanation
 the act of drillings into the skull to release so- called evil spirits from the body.
  The act of drilling openings into skull to release so called evil spirit from the dates back to the
Mesolithic periods.
 A sharp flint and hammer were needed to create a hole in the skull, and fine and animal teeth
were used as probes and drainage of abscess.

Definition of Terms:
1. Peri-operative nursing total surgical experience that encompasses with pre-operative, intra-
operative, and post-operative phases of patient care

2. Operating room / Operating theatre  room in a health care facility in which patients are
prepared for surgery, undergo surgical procedures, and recover from the anesthetic procedures
required for surgery.

3. Surgery branch of medicine concerned with disease or conditions requiring or amenable to

operative or manual procedures

4. Surgical procedure invasive incision into body tissues or minimally invasive entrance into a
body cavity for either therapeutic or diagnostic purposes during which protective reflexes or
self-care abilities are potentially compromised

5. Surgical conscience awareness which develops from a knowledge base of the importance of
strict adherence to principles of aseptic and sterile techniques

6. OR nurse duly licensed registered nurse legally responsible for the nature and quality of the
nursing care patients

7. Asepsis freedom from infection or absence of microorganism

8. Sepsis general reaction from the action of bacteria or their products. For sepsis- This need
antibiotics but C/S must be done.

9. Disinfection process of destroying all pathogenic microorganisms except spore bearing ones.

10. Aseptic technique methods by which contamination of microorganism is prevented.

11. Antiseptic substance which combat sepsis and cause bacteriostatic.

12. Anesthesia insensibility to pain and trauma with or without loss of consciousness. Sometimes
GA/Local/Regional

3 Types of Surgery:
1. Elective surgery
 performed when surgery is preferred treatment and improve the client’s life, but not
essential for the health.
  This Elective surgery is a Plan surgery for enhancement / Repair / for a better person.
 Examples: facial plastic surgery to improve or maxillofacial surgery after the accident ,
hernia repair, hip repair surgery that can be waited.

2. URGENT surgery
 essential for the client’s health and may prevent complications.

3. EMERGENCY surgery
 must be done immediately to save the client’s life or preserve function of a body
part.

PURPOSE OF THE SURGERY

1. Diagnostic Surgery
 done to confirm/ establish a diagnosis
 Example- x-ray, biopsy, CT scan
2. Ablative surgery
 done to excise of tissue/ remove a diseased body part.
 Example- amputation, appendectomy, mastectomy, chole
3. Palliative surgery
 done to reduce pain or intensity of symptoms
 Example- salvaging pain or eye remove
4. Reconstruction surgery
 restores appearance of function to traumatized or malfunctioned tissue.
 Example- cosmetic/ plastic surgery- facelift augmentation.
5. Transplant surgery
 malfunctioning structure replaces or organs.
 Example- heart transplantation.

SERIOUSNESS of the Case:

1. Major surgery involves extensive reconstruction or alteration of body parts.
 Example of High risk: Transplant, cardiac surgery, explore lap. Abdominal trauma during car
accident Etc…

2. Minor surgery minimal risk and minimal alteration of body parts.

FOUR MAJOR TYPES OF PATHOLOGIC PROCESSES REQUIRING SURGICAL INTERVENTION.

 O– BSTRUCTION. Impairment to the flow of vital fluids.
e. g blood, urine, CSF, bile.
 P – ERFORATION. Rupture of an organ
 E – ROSION. Wearing off of a surface or membrane.
 T – UMOR. Abnormal new growth

THE EFFECTS OF SURGERY TO THE CLIENT

 Stress response is elicited.
  Defense against infection is lowered.
 Vascular system is disrupted.
 Organ function are disrupted.
 Body image may be disturbed.
 Lifestyles may change.

** Stress is elicited(draw out). triggering

Defense against infection is lowered. Bacterial wash or removed
Vascular system is disrupted.-amputation
Organ function are disrupted.- R Failure
Body image may be disturbed. mastectomy
Lifestyles may change. # or amputation

EXPECTED BEHAVIOR / ATTITUDE: PERIOPERATIVE NURSE/S

 Honest / sincere
 Communicative / Impartial, Objective
 Efficiency and well organized
 Flexible and adaptable
 Ethical
 Versatile, intellectual & curious
 Sense of humor
 Sensible and perceptive
 Empathy
 Open-minded and creative
 Supportive, understanding and considerate

*** One of the most important things to remember in your career and if possible to stand ALONE AND
BE a successful nurse. Have an expected a very good behavior or attitude in your life.
Empathy- ability to identify oneself or understanding.

PREOPERATIVE PHASE
 Preoperative nursing care begins with the nurse’s initial contact with the surgical patient.
 Objective:
o is to identify individual needs in order that accepted protocols of care can be modified.

Pre-Op Situation:
1. Mrs. Sy, 55yrs old is admitted in the Surgical Ward with the chief complaint of acute right upper
quadrant pain which radiates to the back. She is extremely nauseated and has vomited several
times. She has been diagnosed or tentative diagnosis of Cholelithiasis with Cholecystitis.

Questions:
1. What is Cholelithiasis?
2. What is Cholecystitis?
3. What is open cholecystectomy / laparoscopic cholecystectomy?
4. What are the modifiable and non-modifiable factors?
5. What is/are your Nursing Dx in pre-operative phase / intraoperative / postoperative phase?
6. Labs/Diagnostics/ Operation Performed?

Labs tests/ work up:

1. Leukocytosis may be observed in cholecystitis.
2. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels are used to evaluate for
the presence of hepatitis and may be elevated in cholecystitis or with common bile duct obstruction.
3. Bilirubin and alkaline phosphatase assays are used to evaluate for common bile duct obstruction.
4. Amylase/lipase assays are used to evaluate for the presence of pancreatitis. Amylase may also be
elevated mildly in cholecystitis.
5. An elevated alkaline phosphatase level is observed in 25% of patients with cholecystitis.
6. Urinalysis is used to rule out pyelonephritis and renal calculi.
7. All females of childbearing age should undergo pregnancy testing.
8. Sonography is the preferred initial imaging test for the diagnosis of acute cholecystitis, and
scintigraphy is the preferred alternative.
9. CT is a secondary imaging test that can identify extraciliary disorders and complications of acute
cholecystitis, such as gangrene, gas formation, and perforation.
10. MRI

Assessment : For NCP would include observing for alteration in :

 normal physiologic functioning,
 determining specific nutritional needs, evaluating current pharmacotherapy, and
 identifying psychosocial patterns of behavior.
**This assessment process should result in a detailed nursing care plan.

PREOPERATIVE PHASE
 Any kind of surgery whether major or minor is always preceded by emotional as well as
physiological changes hence, the need for 3 extensive preparations.
 Psychological Care Preparation
 Preoperative Teaching Preparation
 Physical Care Preparation
 Nurses Responsibility with preparation

A. Psychological Preparation
Fears related to surgery ( 2 Types)
1. General fear
 fear of the unknown-worst fear of all.
 what to expect and what are the consequences of surgery
 nursing action: allay anxieties by giving the patient opportunities to express his/her fears.

2. Specific fears
 fear of destruction of body image
 threat to sexuality
  fear of permanent disability
 fear of pain
 fear of dying
 Body image- mastectomy=asset losses, keloids, contractures.
 Sexuality-infertility.
 Permanent disability – amputation, loss of vision. Loss of job
 Fear of pain= pain threshold is weak. Especially the injection, postop
 Fear of dying= because of age, be loss in the family children were all young.,

Application Of Nursing Process / NCP

Assessment:
 Subjective
o know the level of understanding of the patient
o type of surgery
o site
o information from surgeon regarding extent of hospitalization
o limitations
o tests
o cost of hospitalization
o support from family, religion, & friends
 Objective
o *signs of anxiety differ from person to person
o increased PR, RR, BP (physical signs)
o restlessness, constant hand movement, sweating
o frequent voiding, changes in sleep patterns
o angry, resentful & aggressive behaviors

** In taking objective cue: Note PQR highly anxious person may talk rapidly, ask too many questions,
repeat same questions, deny worries, or withdraw & refuse to talk to people, & avoid topics related to
feelings.

Application Of Nursing Process / Intervention:

 Goal: (Nursing Diagnosis )
 Ex: To decrease the level of anxiety / fear  conclusions based on analysis & interpretation of
human response patterns revealed by the assessment data

Application Of Nursing Process

 Outcome Identification
o Realistic, attainable, & consistent with medical regimen
o Results of care should be documented in standardized language
o Examples:
 absence of physical injury
 maintenance of skin integrity
 maintenance of fluids & electrolytes balance
** Expected perioperative outcomes are the desired patient objectives after a surgical intervention.
Patient’s rights and preferences are the cornerstone for expected outcomes

 Planning
o Should reflect current standards, facilitates the prescribed medical care, & work toward
attainment of desired outcomes
o The scope of plan is determined by assessment data
o Example
 patient will demonstrate understanding of the procedure
 patient will be injury-free
 patient will be infection-free

*** - patient will remain physiologically stable

- patient will demonstrate psychologic comfort
- patient will return to normal activities of daily living

 Implementation
o Plan of care is implemented throughout the perioperative period
o Scientific principles provide the basis for patient care interventions that are consistent
with the plan for continuity of patient care in the perioperative environment
o Suggested interventions
 identify concerns if he/she is given opportunities to talk about

** Suggested intervention:
- allowing the patient & the family to participate in decision-making concerning his/her care helps the
patient meet his/her need for control
- fear of the unknown can be partly relieved by providing information

 Evaluation
- Continual process of reassuring the patient and his/her responses to implementation of
the plan of care
- Examples
 Risk for deficient knowledge – patient verbalizes understanding

** Risk for deficient knowledge – patient verbalizes understanding

-Risk for impaired skin integrity – patient’s skin remains intact
- Risk for hypothermia – patient is normothermic
- Risk for injury – patient is free from injury

Preoperative Teaching Exercise:

 Post-op exercises
- Equipment used during post-op period
 oxygen, pulse oximeter, CVP
  MV care
 NEBU/NGT care
 IV medications
 FC care
- Pain medication and when to request it
 Patient-Controlled Anesthesia (PCA)
- NPO

** PCA common @ St lukes

Inform the patent about the gadgets, meds etc…

B. PHYSIOLOGICAL PREPARATION
 Before surgery is performed, the patient undergoes several tests. There are several factors
which may affect the patient’s response to surgery, therefore, it is necessary to obtain the
essential data to identify potential problems. Factors that affects are as follows:

Physiologic Preparation: Factors that affect surgery

1. Age
2. Nutrition
3. Presence of disease condition
4. Prior drug therapy

The very young

- tolerates trauma of surgery well.
The elderly
- tolerates trauma of surgery poorly.

1. Age
 Factors that affect surgery under physiological preparation.

The very young

- tolerates trauma of surgery well.
- sensitive to temperature changes & rough handling.
The elderly
- tolerates trauma of surgery poorly.

2. Nutrition
 Dehydration and malnutrition cause potential complications post-operatively.
 Parenteral fluids are prescribed to correct fluid & electrolyte deficiencies prior to surgery.
o It is essential for the nurse to identify these baseline data
o nausea, vomiting, anorexia
 Malnutrition may be corrected by high caloric diet, protein & vitamin supplements.
 Obese people breathe poorly & are prone to pulmonary complications.
 o Obesity increases the seriousness of complications to a great extent. Nursing
intervention is diet only to come after a month for possible OR.
o Fatty tissues are prone to infection therefore, dehiscence & wound infections are
common.

3. Presence Of Disease
 Cardiovascular disease
o ECG, 2-D-Echo, Stress tests, Blood tests
o CVP measurement for elderly, major
 Surgeries
o blood typing and cross-matching
o HPN, Bleeding disorders

 Respiratory disease
o CXR, ABGs
o PTB, Pneumonia, COPD

**Prepare for the dx exam/ procedures:

 Renal Disease
o Urinalysis, BUN/ Creatinine,
o Acute nephritis, Acute renal insufficiency, UTI
 Endocrine disease
o FBS, Thyroid function tests
o Uncontrolled DM, Hypo/hyperthyroidism

** Infection caused UTI, STD.

4. Prior Drug Therapy

 *certain medications can interfere with anesthesia or contribute to postoperative

complications. Like…
o Anticoagulants
o Antihypertensive
o Antibiotics
 *prior to surgery, most of the drugs are discontinued and new orders are given post-op

** Anticoagulants – increase bleeding

- Example: aspirin, heparin, warfarin
Antihypertensive- affects anesthesia
Antibiotics e.g neomycin, ATSO4, with there will be muscle relaxant interrupt nerve transmission and
apnea due to resp. paralysis.
Allergies cannot be a nursing intervention Dr. should treat the pt.
*infection like nosocomial infection acquired in the hospital stay.
  certain medications can interfere with anesthesia or contribute to postoperative complications.
o Diuretics
o Steroids
o Tranquilizers
o Antidepressants

** Diuretics- K loss/ resp. depression

-Steroids- anti-inflammation. Effect and delay wound healing
-Tranquilizers potentiates effect of narcotics and barbiturates. They cause hypotension.
-Antidepressants- (monoamine oxide) hypotensive effects
*prior to surgery, most of the drugs are discontinued and new orders are given post-op

C. PHYSICAL PREPARATION
Common preparations:
1. Gastrointestinal Prep: The Eve before OR must have:
 light meal the night before surgery
 NPO (food & water -post midnight – safe is 6hrs-2 hours b4 is still possible to give a sips
of water.
 this order should be carefully explained to patients

** *The Patient is prepared the night before the scheduled surgery

- during anesthesia, reflexes (gag, sphincter) are absent & food in the stomach can easily gain to the
tracheobronchial tree, cause aspiration pneumonia & respiratory failure
- enemas for GI surgeries / Skin prep/shaving

2. Completed early morning of surgery

 Final skin prep: shaving, topical antiseptics (esp. in ortho cases)
 GIT preparation, enema as ordered
 Foley catheter, NGT, IV as ordered

** *Administer preop medications( 1 hour before going to OR)

- Always with side rails up
- Blood glucose if ordered esp DM case

3. Urinary
 Empty bladder before patient is sent to the OR*
 Before giving pre-meds. Pt. must empty his bladder.

4. Circulatory
 Anti-embolic stockings for elderly & for long surgeries
 skin prep, shaving, oral & body hygiene
o * can reduce the no. of microorganism.
** Circulatory
- stockings or bandages compress superficial veins & increase blood flow through deep vein
pressure preventing venous stasis & thromboembolism.

Nurse’s Responsibility:
 Perform/supervise skin prep & cleansing
 Notify AMD of drug allergies, severe anxiety, unusual ECG or abnormal lab findings-
 Ensure all consent forms are signed ( Gen. & Informed)
 Administer pre-op meds on time-1 hour before anesthesia.
 Complete pre-op checklist
 Check if history & PE database are on chart
 Remove dentures, nail polish, hair pins, jewelries

** note drug allergy /allergy cannot lessen through nursing intervention while fear, obesity & smoking
can be.

Next is the legality during surgery.

C. Legal Preparation

TWO TYPES OF CONSENT-under legality

1. General Consent
 forms given during admission. The physicians and nurses should be knowledgeable
about the statements on the form used in their facility or hospital policy.

2. INFORMED CONSENT
 SURGICAL / INFORNMED CONSENT- is a process-not necessary a mere document.
Explanations of the procedure, risks, benefits, and alternative therapy are made verbally
to the patient’s level of understanding.

** A surgeon or anesthesia provider may be held liable for negligence if the patient can prove failure to
disclose significant information that would have influenced a reasonable person’s decision to consent.

Hospital of choice:
This General consent form (House Rules). require the patient or his or her legal guardian to sign a
general consent form on admission. Ex: Rendered day to day treatment, Hosp. charges, info about the
surg, or even package, or medic card etc.

Preparing The Patient On The Day Of Surgery:

 The nurses awakens the patient before he/she receives pre-op meds, VS is taken & recorded
 Check & make certain that skin preparation has been completed in a thorough manner
 Ask the patient to void, measure & record the output of urine
 Oral hygiene, remove nail polish, false dentures, glasses (contact lens, jewelries, & give to
responsible person). Narcotics Box ( HN is responsible).
** The nurse should prepare the patient: in many ways like: The HN/charge nurse is responsible for
checking together with the ward nurse: the pre-op checklist.

Right to Refuse a Surgical Procedure

 The patient has the right to withdraw consent at any time before the surgical procedure. Notify
the doctor and obtain a form for refusal to operation.
o The patient has the right to decide what will or will not be done to him or her. Only after
making this decision is the patient asked to sign a written consent for a surgical
procedure.
o Pt can refused to not touch the other organs.
 *When a patient signs an agreement, consent is given for the specific procedure indicated on
the form.
o *Included in the lists of forms:
A. Who will be performing the procedure or the Surgeon,
B. Anesthesiologist
C. Ass. Surgeon/Resident
D. Circulating nurse
E. Scrub nurse
 *Additional procedures should be listed and signed separately-not added after the patient has
already signed the form.

Reasonable approach to Informed Consent. by the client.

1. What is your plan or What kind of operation ? This is ask by the client.
2. Why do you want to do this procedure?
3. Are there any alternatives to this plan?
4. What things should I worry about?
5. What are the greatest risks or the worst thing that could happen?

* Note* the patient has the right to waive an explanation of the nature and consequences of the
procedure and the right to
refuse the treatment/ surgery.

Responsibility for Informed Consent before a surgical procedure:

 Surgeon / Doctor – should include the risks, benefits, and possible complications of all proposed
surgical procedures. Documented the procedures and becomes the permanent part of the
patient’s record.
o VALIDATION OF INFORMED CONSENT:
o Content:
1. Patient’s in full name w/ legal age and mentally competent
2. Surgeon’s full name
3. Specific procedure to be performed
4. The sig. of the patient and the date of the signature
5. Authorized witness (es) nurse.
VALIDATION OF CONSENT: for
1. Minor
 parent or legal
 guardian should sign.
2. Illiterate
 may sign with X “ after which the witness writes ” Patient THUMB Mark”.
3. Unconscious
 Big no
4. Mentally incompetent
 Big no
5. Mentally incapacitated by alcohol or other chemical substances
 Big no

CONSENT IN EMERGENCY SITUATIONS:

 In life threatening emergency
 The consent to treat and stabilize is not essential.

** Although, permission for life saving procedures, especially for a minor, may be accepted from a legal
guardian or relatives by phone , fax , txt or other written com. then, two nurses must sign the form. And,
later or upon arrival at the facility the concern person must sign.

Legal Preparation / Considerations:

1. Written consent: Prior to this ,the surgeon must explain everything to the patient.
2. Must have at least two consent ( Gen.& Informed)
3. In case of minor ( < 18), the parents or the guardian sign the consent.
4. If or during emergency, the surgeon may operate if is in life threatening-saving measure( house
rule / presumed consent)
5. Liability
 legally responsible for personal actions

Things to remember in the day of surgery (Pre op Phase) Checked!

(Things to remember in the day of Surgery)!!
 NPO  Nail polished removed
 Consent form signed  Client teaching completed
 Pre-op meds given  Voiding prior to transfer
 Skin prep done  Contact lenses out
 In gown  Dentures out
 Allergy NOTED /ID band on  VS within 4 hours of surgery or 30 mins
 Side-rails up after pre-op meds pre-op
 No jewelry  Pre-op lab work ups and plates
 NURSE’S PRE-OPERATIVE CHECKLIST-DAY OF SURGERY in the WARD
Date:
Last Name First Name MiddleName AMD Hosp PIN
Operation Proposed:_________________________________
Date of Operation: _______________ Time__________
Surgeon:_______________ Anesthesiologist Anesthesia________
YES NO YES NO
Pre-Op Med given False Teeth
IV Fluids Ordered Hair Pins
IV Fluids Started Jewelry
Schedule Slip Sent Nail Polish
Weight Taken Underwear
NPO signage on bedside Enema (if ordered
Pre-op bath or shower Vaginal irrigation
Cath, retain & clamp Pt. visited by the chaplain
Patient urinated History & P.E.
Pre-anesthesia Eval.
Valid consent signed

External Prep. Done by:_____________ Checked by:_________________________

Allergies:________________________
Blood Pressure Taken AM PM
Laboratory Exams ( if Ordered):
DONE NOT YET DONE DONE NOT YET DONE
Blood Test ECG
Urine Test X-ray
If not yet done, w/PLATES
Specimen sent to lab

Patient prepared for O.R by_____________________________________

Printed Name & Signature
(Staff Nurse)

Final Checking done by:__________________________

Printed Name & Signature
( Nurse Manager / Head Nurse)
Legal aspect and Liability from Clients & Health Workers

Legal Preparation w/ Liability

 Negligence
o failure to use the proper care or skills.
o careless performance of duty
o cause damage to a patient who may file lawsuits

 Malpractice
o professional misconduct
o illegal or immoral conduct
o unreasonable lack of skill or judgment
o professional misconduct
o illegal or immoral conduct
o unreasonable lack of skill or judgment

Legal Preparation / Liability

 Borrowed servant rule
- “captain of the ship”
- surgeons have supervisory control & right to give orders & is directly liable.

**Doctrine of a Reasonable Man

 patient has the right to expect all personnel & technical nursing personnel will use knowledge,
skills, & judgment in performing duties that meet standards exercised by other reasonably
prudent persons involve in similar circumstances.

Legal Preparation
 Doctrine of res ipsa loquitur
o “the thing speaks for itself.”
 Court allow the patient’s injury to stand as inference( witness) of negligence
 *Before this doctrine can be applied, 3 conditions must exist
1. The type of injury.
2. The injury was caused by the conduct or instrumentality within the exclusive control of
the person or persons being sued
3. The injured person could not have contributed to negligence or voluntarily assumed risk

Legal Preparation
 Invasion of privacy
o patient has the right to expect that all communications & records pertaining to
individualized care will be treated as confidential & will not be misused
o right to privacy during interview, examination & treatment
**Example: - NOTE: Surgery schedule bearing the names of the patients should not be posted in a
location where the public or other patients can read it.
- written consent for videotaping or photographing his/her surgical procedure for medical
education or research, w/o a permit is a BIG NO. (just remember the canister case / u tube.)

Legal Preparation
 Doctrine of Respondent Superior
o an employer may be liable for an employee’s negligent & conduct.
 Assault
o unlawful threat to harm another physically
 Battery
o carrying of bodily harm as by touching without authorization or consent
 Abandonment
o Leaving the patient for any reason when the patient’s condition is contingent on the
presence of the caregiver

**Abandonment of post  if the caregiver leaves the room knowing there is potential need for care
during his/her absence, even under the order of a physician, the caregiver is liable for his/her own
action

Legal Preparation
 Surgical conscience for the surgical team
o key elements of perioperative practice caring, conscience, discipline & techniques.

**Be honest. Optimal patient care requires an inherent surgical conscience, selflessness, self-discipline
& the application of principles of asepsis & sterile technique.

-END of Pre-op preparation…

Thanks!