Management Of Patient Undergoing Surgery

Preoperative care refers to health care provided before a surgical operation. The aim of preoperative care is to do whatever is right to increase the success of the surgery.
At some point before the operation the health care provider will assess the fitness of the person to have surgery.

During the perioperative period, specialised nursing care is needed during each phase of treatment. For nurses to give effective and competent care, they need to understand the full perioperative experience for the patient.

Perioperative refers to the three phases of surgery.
Preoperative stage
Intraoperative stage
Postoperative stage

Within these stages there are many different roles for nurses and different care needed for the patient dependent on which stage they are in.
As with any nursing care, the goal during these stages is to provide holistic and evidence based care as well as support to the individual.

There are different nursing roles throughout the perioperative process including: admissions nurse, anaesthetic nurse, circulating nurse or scout nurse, instrument or scrub nurse, post anaesthesia care unit (PACU) nurse and the surgical ward nurse. Other nurses may be included in the perioperative process such as pain management specialist nurses, diabetes educators.

2. MANAGEMENT OFPATIENT
UNDERGOING SURGERY
Presented by
MrB KalyankumarMsc(N)
Dept Of MSN

3. INTRODUCTION
Surgeryisinvasiveprocedure,canbeperformedelectiveorin
emergencycondition.Surgeryisdoneforavarietyofconditions
thatinclude:
Cosmeticprocedure
Diagnosticprocedures(Laprotomy)
Infectiousdiseaseoftissuesororgans
Repositionandenhancementofbones(ORIF)
Replacementorimplantationofartificialdevices(Knee
replacement)

4. TYPESOFSURGICALMANAGEMENT
Pre-operative
management
Post
operative
management
Intra
operative
management

5. A. PREOPERATIVE MANAGEMENT
Patientcomestosurgicalcarefacilityeitherelectiveor
emergencysurgery.Apatientneedsnursingcarethroughouthis
stayinhospital.Roleofnurseistounderstandtheprocessof
illnessandcontributeskilfullytothepatientsrecovery.Atheatre
nursemustbegentleandempatheticforpatient.
1.Physicalpreparation
2.Psychosocialpreparation
3.Physiologicalpreparation
4.Pre-medications
5.Preoperativepreparation

6. 1. PHYSICALPREPARATION
Assoonassurgicalpatientapproachesnurseinhospital,nurse
initiatespre-operativeassessment.

7. NURSINGASSESSMENT
Medicalhistory:Enquirefrompatientaboutmedicalillnesssuch
asDiabetesmellitus,asthma,tuberculosis,hypertension,
myocardialinfractionetc..Patientmustbeaskedaboutprevious
surgery.EnquireaboutuseofOTCanddrugslikesteroids,anti-
epileptics,insulin.Historyalsoincludesinformationaboutallergy
todrugs,food.
Generalexamination:Aphysicalexaminationisperformed
duringwhichvitalsignsarenotedandadatabaseisestablished
forfuturecomparisons.Takethroughhistoryabouttheorganfor
whichsurgeryisrequired.

8. DrugorAlcoholuse:Personwithhistoryofchronic
alcoholismoftensuffersfrommalnutrition,Systemicproblems
thatincreasethesurgicalrisk.AdditionallyDeliriummaybe
anticipatedupto72hoursafteralcoholwithdrawal.
Nutritionalandfluidstatus:Assessmentofpatients
nutritionalstatusprovidesinformationaboutobesity,weight
loss,malnutrition.Anynutritionaldeficiencysuchas
malnutrition,shouldbecorrectedbeforesurgery.

9. Respiratorystatus:Respiratorystatusisassessedbecause
adequateventilationispotentiallycompromisedduringall
phasesofsurgicaltreatment.Surgeryispostponedwhenthe
patienthasarespiratoryinfection.Patientwhosmokeareurged
tostopsmokingatleastonemonthbeforesurgery.

10. Cardiovascularstatus:Thegoalinpreparinganypatientfor
surgeryistoensurewell-functioningcardiovascularsystemto
meettheoxygen,fluidandnutritionalneeds.Ifthepatienthad
uncontrolledhypertension,surgerymaybepostponeduntiltheBP
inundercontrol.
HepaticandRenalfunction:Thepresurgicalgoalistooptimal
functioningoftheliverandurinarysystem.Sothatmedications,
anaestheticagents,bodywastesandtoxinsareadequately
processedandremovedfromthebody.
Endocrinefunction:Thepatientwithdiabeteswhoisundergoing
surgeryisatriskforhypoglycaemia,Frequentmonitoringof
bloodglucoselevelisimportantbefore,duringandaftersurgery.

11. Localexamination:Inadditiontoroutineabdominalandper
rectalexamination(P/R),conditionoftheskinatthesiteof
incisionshouldbenoted,ifthereisanyinfectionitshouldbe
treatedfirst.
Examinetheclientforjaundice,anaemia,oralhygiene,
hydration,presenceoflooseandartificialteethetc.

12. 2. PSYCHOSOCIAL PREPARATION
Allpatientshavesometypeofemotionalreactionsbeforeany
surgicalprocedure.Fore.g.Pre-operativeanxiety.Thenursemust
beempathetic,listenwellandprovideinformationthathelpsto
reduceanxiety.
Spiritualandculturalbeliefs:Spiritualbeliefsplayanimportant
roleinhowpeoplecopewithfearandanxiety.Everyattemptmust
bemadetohelpthepatientobtainthe,spiritualhealththatheor
sherequests.Faithhasgreatsustainingpower.

13. 3. PHYSIOLOGICAL PREPARATION
Investigations:Ensurethatallinvestigationsareinnormalrange.
Arrangebloodforpatientifrequired,bloodissentforcross-
matching.Followinginvestigationsaregenerallycarriedout.
Haemoglobinlevel,bloodgroup
TotalLeukocyteCount(TLC)
ErythrocytesedimentationRate(ESR)
BloodUreaNitrogen(BUN)
FastingBloodSugarandpostprandial
Bleedingtimeandclottingtime
Urineroutinemicroscopicexamination.

14. ChestX-Ray
Electrocardiogram(ECG)
Specificinvestigations:Ultrasound(USG),CTScan,MRI.

15. 4. PRE-MEDICATIONS
Anesthesianmayprescribeoradministerapre-medicationprior
toadministrationofgeneralanaesthesia.E.galfa-2adrenergic
agonist,aBenzodiazepam(Midazolam)iseffectiveinreducing
anxiety.
Antiemetics,Corticosteroids.Othercommonlyusedpre-
medicationagentsincludeopioidssuchasFentanyl,
Gastrokineticagentssuchasmetaclopramide.
Propranololforhypertensionmaybetaperedpriortooperation,
butshouldbecontinuedinfulldosesforanginapectoris.
Prescribedmedicineifany(Diazepam)isgivenonenightbefore
surgery.Prophylacticantibioticsshouldbegivenafterskin
sensitivitytest.
EnsureIVaccessifintravenousfluidsareindicated.

16. Theuseofprescribedantibiotics,cardiacdrugs,diureticsandthe
patientscurrentmedicationmustbecarefullyconsidered.
Ensurethatsurgeonspecifiedpre-operativeordersarefollowed.
Reviewpatientsrecordtoprovideappropriatetreatment.Assess
theriskforpostoperativecomplications.

17. 5. PREOPERATIVE PREPARATION
Whenthepatientisreadyforoperation,thesurgeonwritesthe
orderforthepreoperativepreparation.IncaseofElective
operation,preoperativeordersarewrittenonedaypriorto
operation.
Shavingandpreparationoflocalparts:Identifypatient.Skin
isshavedbeforeoperation.Completescrubbathwithsavlonor
anantisepticsoapshouldbetakenthenightbeforeoperation.
Relieveanxiety
Enema
PAC(Preanestheticcheckup)
Consent

18. B. INTRAOPERATIVE MANAGEMENT
The Surgeon
The Anesthetist
Operation theatre
technician
Circulating nurse
Scrub nurse

19. TheSurgeon:Surgeonperformstheoperationandleadsthe
surgicalteam.
TheAnesthetist:AnAnesthetistisaqualifiedhealthcare
professionalwhoadministeranesthetics.Heinterviewsand
assessthepatientpriortosurgery,selectstheanesthesia,
administersit.Intubatethepatientifnecessary,supervises
patientsconditionthroughoutsurgicalprocedure.
Operationtheatretechnician:TechnicianarrangestheOTtable,
dressingtable,anesthesiatable,OTlightetc.
Circulatorynurse:Roleofcirculatorynurseincludesverifying
consent,coordinatingtheteam,ensuringcleanliness,proper
temperature,safefunctioningofequipmentandavailabilityof
suppliesandmaterialsanddocumentingintraoperativeevents.

20. Scrubnurse:Nurseperformssurgicalhandscrub,prepares
sutures,assistthesurgeon.Thescrubnurseprovidessterile
instrumentsandsuppliestothesurgeon.

21. NURSESFUNCTIONINOPERATION THEATRE
Reduceanxiety:Addressthepatientbyname,warmlyencourage
friendliness.Attentionpaidtowardsphysicalcomforthelpsthe
patientfeelmorecomfortable.
Preventintraoperativepositioninginjury:ThePatients
positionontabledependsonthesurgicalprocedure.Hyper
extendingjoints,compressingarteries,pressingnervesusually
resultsfromdiscomfortbecausepositiongivenforlongperiod.
Monitorpotentialcomplications:Intraoperativenurseplayvital
roleinreportingchangesinvitalorgansandsymptomsofnausea,
vomiting,hypoxia,hypothermia.

22. MaintainAsepsis:Theatrenurseplayanimportantroleincontrol
andpreventionofinfection.Therearemanyactivitiesinvolved
insafeguardingthepatientagainstinfection.
Continuingeducationofstaffoninfectioncontrol
Correctsterilizationmethods
Allstaffmustbeingoodhealthandfreefrominfection.

23. C. POSTOPERATIVE MANAGEMENT
Thisistheperiodthepatientleavestheoperatingroom.During
postoperativeperiod,nursingcarefocusesonthere-establishing
thepatientsphysiologicequilibrium,preventingcomplications
andteachingthepatientselfcare.
Thepostoperativeanesthesiacareunit(PACU):
Itisalsoknownaspostanesthesiarecoveryroom,itislocated
adjacenttotheoperatingroom.

24. AdmittingthepatienttoPACU:Thenursewhoadmitsthe
patienttoPACUreviewsthefollowinginformationwith
anesthetist.
Medical diagnosis and type of surgery performed
Patients past medical history and allergies
Patients age and general condition, airway patency, vital signs.

25. PHASESOFPACU
PhaseI
PhaseII
InphaseI,PACUisusedinimmediaterecovery,where
intensivecareisprovided.
InphaseII,PACUisreservedforthosepatientswhorequireless
frequentobservationandlessnursingcare.

26. NURSINGMANAGEMENT INTHEPACU
Assessmentofpatient:Checkthesurgicalsitefordrainageor
haemorrhageandmakesurethatalldrainagetubesand
monitoringlinesareconnectedandfunctionwell.
Maintainingapatentairway:Administerhumidifiedoxygen
therapy.Thenurseassistsininitiatingtheuseofventilatorand
weaningprocess.Theheadofthebediselevated15-30degree
unlesscontraindicated.Suctioningshouldbedonethrough
oropharynx.

27. Maintaining the cardiovascular stability: Assess vital signs,
cardiac rhythm, central venous pressure and arterial lines are
monitored.

28. Relievethepain:Asthepatientrecoversfromtheeffectof
anesthesia,he/shefeelsthepain.
Relieveretentionofurine:Retentionofurineshouldbetreated
with
Changeposture
Hotwaterbag
Ifallmeasuresfail,catheterizationmaybedone.

29. Readinessfordischarge:
Stablevitalsigns
Orientationtoperson,place,time
Urineoutputatleast30Ml/h
Nocomplaintofnauseaandvomiting

30. MANAGINGPOST-OPERATIVE COMPLICATIONS
Hypotension and shock
Hemorrhage
Hypertension
Deep vein thrombosis
Infection

31. HYPOTENSION
Thisisresultsfrombloodloss,hypovolemicshockis
characterizedbyafallinvenouspressure.
Signs :
Pallor skin
Rapid breathing, weak pulse
Low blood pressure
Treatment:
Administer IV fluid
Administer humidified oxygen
Administer vasopressordrugs

32. Haemorrhage:Thesurgicalsiteandincisionshouldbe
inspectedforbleeding.Ifbleedingcontinues,asterilegauzepad
isapplied.Thepatientisplacedinthetrendelenburgposition.

33. Deepveinthrombosis(DVT):FormationofbloodClotinvein.
DVTandPulmonaryembolismareseriouscomplicationsof
surgery.
Causes:
Dehydration
Low cardiac output
Prolonged immobility
Treatment:
Heparin
Warfarin
Stockings

34. Infection:Exposureofbodytissuetopathogensplacesthe
patientatriskforinfectionatthesurgicalsite.
Clinical manifestation:
Increased body temperature
Elevated WBC count
Tenderness and Discharge at wound site
Treatment:
Drain is inserted
Antimicrobial therapy
Wound care should be initiated

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