Surgical Nursing: Classifications of Surgery

Surgical Nursing

• Surgery is a medicine branch treating diseases, injuries, and deformities through physical manipulation or operative measures.
• Activities performed during surgery include elimination of damaged parts, separation of united parts, joining of separated parts and repairing defects in the body.
• Classification is according to purpose, urgency, and risk.

Classification according to the Purpose

• Diagnostic surgery involves biopsy or exploratory laparotomy.
• Curative surgery removes a diseased part in order to cure it (appendectomy).
• Reparative surgery repairs damaged tissues (grafting).
• Reconstructive surgery refigures or reshapes an organ after injury or surgery.
• Cosmetic surgery refigures or reshapes organs, regardless of physical discomfort.
• Palliative surgery relieves pain and improves quality of life without providing a cure.

Classification according to the Degree of Urgency

• Emergency surgery is when a patient requires immediate attention for a life-threatening disorder.
• Urgent surgery is when a patient requires attention within 24-30 hours (ex. gallbladder infection).
• Required surgery is when a patient needs an operation within a few weeks or months (BPH).
• Elective/Ambulatory surgery is when the operation is not a necessity (ex. repair of scars).

Terminology

• Abscess refers to a cavity filled with pus.
• Anastomosis refers to the artificial surgical joining of one or two organs.
• Adhesions refer to the union of two surfaces that are usually separated and are caused by inflammation.
• Algia is related to pain.
• Anesthesia refers to loss of sensation.
• Biopsy refers to the removal of a tissue/part of an organ for pathological examination.
• Calculi refers to the formation of stones.
• Curette refers to scraping.
• Diathermy refers to the production of heat via powerful electric means.
• Dactyl refers to either a finger or a toe.
• Dilate refers to stretch
• Ectomy is a permanent removal
• Excise refers to cut off
• Resect refers to cut off from the middle
• Fissure is a crack or slit.
• Itis refers to inflammation.
• Incise refers to cut into or open into.
• Ligate refers to tie.
• Lumen refers to the interior of an open organ.
• Ostomy refers to a permanent opening into an organ.
• Otomy refers to a temporal incision into an organ
• Oophoro refers to ovaries.
• Oscopy refers to the inspection of an interior of an organ using an instrument
• Osteo refers to bone.
• Ophthalmo refers to the eye.
• Orchi refers to testes.
• Oligo refers to diminished or scanty.
• Oma refers to a tumor or growth.
• Oti refers to ear.
• Megaly refers to enlargement.
• Plasty refers to reconstruction of the diseased part.
• Radical refers to total or complete removal of an organ.
• Phlebo refers to a vein eg. phlebitis.
• Rrhaphy refers to repair of a part.
• Rupture refers to a tear or disruption of a tissue
• Stenosis refers to narrowing of a lumen.
• Subtotal refers to incomplete or partial removal of an organ.
• Tortion refers to twisting.

Perioperative Nursing

• Perioperative Period is the period between a patient's first and last contact with their surgeon.
• The three phases include preoperative, intraoperative and postoperative phases.

Preoperative Care

• It identifies risk factors, which could lead to postoperative complications and hinder recovery.
• It begins when the decision for surgery is made and ends when the patient is transferred to the operative theater.
• It includes physiological, physical, psychological, socio-economic, and spiritual considerations.

Preoperative Assessment

• Age: Young children and older adults have lowest tolerance to stress effect of surgery
• Includes evaluation of pain, nutritional/hydration status, infections (skin, respiratory, systemic, etc.) and drug history(anticoagulants, steroids, hypoglycemics, antibiotics, etc.).
• Cardiopulmonary functioning
• Includes assessment of renal, GIT, liver, endocrine, neurologic, Sensory and perceptual functioning.
• Lifestyle (smoking, alcohol, etc)
• Determination of any deformities

General Preparation for Day of Surgery

• Ensure patient bathes in the morning.
• Skin preparation should be done according to protocol.
• Check and record vital signs.
• Check that the identification band is legible and accurate.
• Ensure that complete informed consent form is signed.
• Check and carry out specific orders (e.g., IV line, administration of enemas, premedication, etc.)
• Ensure the patient is NPO.
• Ask the client to void or pass urethral catheter.
• Remove dentures that could obstruct the airway.
• Remove jewelry, nail polish
• Help patient to put on a gown.
• Put patient on a stretcher and transport to the theater.

Bowel Preparation

• The special preparation of GIT before surgery reduces the possibility of vomiting and aspiration during anesthesia.
• It reduces the possibility of bowel obstruction or injury.
• It prevents contamination from fecal material during intestinal tract or bowel surgery.
• Serve a low residue diet 48 hours before surgery and light diet a day before.
• Increase fluid intake to prevent constipation.
• Ensure NPO 6-8 hours before surgery.
• Provide nutrients using parenteral nutrition.
• Administer stool softeners such as Lactulose and laxatives as prescribed.
• Perform rectal enema the night before surgery, and rectal washout in the morning of surgery.
• Administer prescribed antibiotics to decrease intestinal flora (Neomycin).
• NGT may be passed to reduce intestinal pressure.

Intraoperative Nursing

• Surgery and anesthesia still place patient at risk for several complications.
• It is the duty of the surgical team to protect this patient.

Surgical Environment/Theatre

• Surgical environment is a cool place with access restricted to authorized personnel.
• It is central to all supporting services.
• Air filtration devices screen out contaminating particles, dust, and pollutants.
• Surgical asepsis and traffic control are ensured.

Rooms in the OR and their uses

• Includes: Changing room, Lobby, Scrub-up area, The set-up area, Anesthetic room or office, Operation room, Recovery/ICU, Offices
• Also includes: Sterilization room, Store, sterile pack room and non-sterile, Sluice room, Holding area, CT scanner unit, MR

Surgical Asepsis

• Divided into 4 zones to help decrease microbes.
  • Outer or Unrestricted Zone: Street clothes are allowed.
  • Clean or Semirestricted Zone: Scrub clothes and caps are required attire.
  • Aseptic or Restricted Zone: Requires scrub attire, shoe covers, caps, and masks.
  • Disposal Zone: Area where used instruments and scrubs are decontaminated, washed, dried, and packaged for sterilization.

The Operating Room (OR)

• It is slightly higher pressure.
• Humidity level should be 50-60%.
• Temperature should be 22-24 degrees Celcius.
• Requires special lighting with an overhead source.
• The high-quality lights are bright and shadowless.
  • Control intensity, equipped with reserve light
  • Provides blue-white color similar to daylight.
  • It's freely adjustable with a manipulation fixture.
  • Produces minimum heat (halogen bulb).

The Surgical Team

• Sterile Members
  • The surgeon, First assistant, Scrub nurse
• Non-Sterile Members
  • The patient, Anesthetist/Anesthesiologist, Circulating nurse, Perianesthesia nurse, Others (students, orderlies, lab & X-ray personnel)

The Surgeon

• Leader of the surgical team.
• In charge of performing the operation.
• Helps position the patient on the theater table.
• Marks the surgical site with indelible ink.
• Prepares the patient for the surgical site.
• Drapes the patient.
• Decides on the surgical method.
• Guarantees patient safety with the anesthetist

The Scrub Nurse

• Performs a surgical hand scrub.
• Sets up the sterile tables (Mayo's trolley or tables).
• Prepares sutures, ligatures, and special equipment (e.g. laparoscope).
• Assists the surgeon and the surgical assistant during the procedure.
• Labels the specimen taken from a patient, which is sent to the laboratory by the circulating nurse
• Counts all instruments and sponges before closing the incision to prevent retained foreign bodies.
  • Items are initially counted before the procedure; items are then counted twice after the procedure.

The Circulating Nurse

• Coordinates patient care in the OR.
• Verifies consent for the operation.
• Manages the OR to ensure cleanliness, appropriate temperature, humidity and lighting.
• Facilitates patient positioning.
• Protects patient safety and health by monitoring activities.
• Assesses the patient for injuries and implement interventions.
• Ensures appropriate aseptic practices, while watching surrounding personnel.
• Verifies safe function of equipment.
• Provides supplies and materials.
• Coordinates with the surgical team.
• Confirms the surgical sites, swabs, and instruments with scrub nurse before closing the wound.
• Monitors, verifies, and documents activities.
• Manages surgical specimens.

The Anesthetist/Anesthesiologist

• Evaluates the patient prior to surgery.
• Chooses the anesthesia based on type of surgery required.
• Administers premedication.
• Intubates the patient if/when needed.
• Manages all technical problems connected with the administration of the anesthetic agent.
• Monitors patient's condition (VS, ECG, SPO2 tidal volume, blood gas) throughout surgery.
• Commences patient resuscitation after completion of surgery.

The Patient

• Patients coming for surgery may experience fears and anxiety.
• Primary fears include losing control, the unknown, pain, death, and changes to the body.
• These fears may lead to increased anesthetic requirements, postoperative pain, and overall recovery time.
• Appropriate preparation before surgery is critical.

Surgical Asepsis

• Surgical asepsis prevents contamination of surgical wounds.
• Sources: Patient´s natural skin flora, a prior existing infection, instruments used, the environment or droplet infections from surgical team members.
• Sterile supplies, instruments, needles, sutures, and gloves minimize surgical wounds.
• Surgeons, surgical assistants, and nurses must scrub.
• Surgical team should wear sterile gowns and gloves with a cap to cover the head and hair.
• A mask is to be worn over the nose and mouth to minimize URT droplets.
• The surgical team should only touch sterile objects during surgery.
• The skin must be meticulously cleansed and covered with sterile drapes.
• The surgical team should only move within sterile and unsterile areas.
• All equipment in contact with the body must be sterile.
• Sterilized linens, drapes, and solutions are required.
• Instruments are cleaned and sterilized in nearby units.
• Dispense sterile field items to preserve sterility.
• Individually-wrapped sterile objects must be used.
• Ventilation provides 15 air exchanges per hour to reduce air bacteria.
• Temperature should be 20-24 degrees celcius.
• Humidity level should be 30%-60%.
• Positive pressure relative to adjacent areas should be maintained.

Premedication

• Medication given prior to the administration of the anesthetic agent.
  • Goals: Enhance effectiveness of anesthesia, Reduce side effects (nausea and vomiting), Reduce or relieve anxiety, Dry up mucous secretion, Relax smooth muscles.
• The anesthetist should perform a thorough examination prior to premedication.
• Any underlying disease is to be treated.
• Medications impeding surgery are stopped.
• These medications are usually given a night before and or the morning of surgery: - Barbiturates / Tranquilizers/ Benzodiazepines: Examples are Lorazapine, midazolam, and diazepam to reduce feelings of anxiety. - Opiates: Morphine and meperidine. - Anticholinergics: Atropine to reduce respiratory secretions.

Types of Anesthesia and Sedation

• Anesthesia decreases the central nervous system through pharmacologic agents, analgesia, relaxants, and reflex loss.
• Includes: General, Regional, Moderate and Local anesthesia.

General Anesthesia (GA)

• The administration of anesthetic agent (inhaled or IV) causes a loss of all reflexes.
• The patient requires assistance to maintain a patent airway and a ventilator to maintain cardiovascular and pulmonary function.

Stages of General Anesthesia

• The four stages are beginning/analgesia phase, excitement phase, surgical anesthesia phase, and medullary depression. - Stage 1: Beginning/Analgesia Phase - decreased awareness and amnesia without loss of consciousness - Stage 2: Excitation - Delirium and Excitation
  • Stage 3: Surgical Anesthesia -Unconsciousness with no pain reflexes, regular respiration, and maintained BP.
  • Stage 4: Medullary Depression CV/Respiratory depression or death.

Regional Anesthesia

• Epidural and Spinal Anesthesia - Medication is injected between L4 and L5 (epidural or subarachnoid) surrounding the spinal cord.
• Blocks pain in lower limbs, perineum bladder, and rectum or lower abdomen.

Moderate Sedation / Anesthesia

• The anesthetics agent or sedative is administered intravenously or for short-term surgical procedures (e.g., ketamine).
• Advantages: patient maintains a patent airway, retains protective airway reflexes (e.g., coughing) and responds to verbal and visual stimuli.

Local Anesthesia

• Injection of an anesthetic agent into the tissues at the planned incision site.
• Ideal for short and minor surgical procedures.
• Advantages: simplified, economical, minimal skills and equipment needed, quick recovery, and avoids GA's undesirable effects.

Postoperative Care

• Objective is patient care until full anesthesia recovery.
• Accessories are to be placed on the Operation bed.
• Quickly analyze review instructions and receive the patient.
• Monitor patient's consciousness.
• Lay patient in a supine position with head head turned.
• Reposition to semi-Fowler's or High-Fowler's.
• Record baseline vitals every 15 min for the first hour, then every 30 min until steady, then every 4 hours.
• Look for bleeding signs, dehiscence, and evisceration.
• Strengthen affected area if bleeding is present and alert surgeon if persistent.
• Monitor all drainage tubes, IV infusions or blood transfusions.
• Assess respiratory pattern.
• Suction if required, and provide the patient oxygen.
• If not contraindicated, elevate bed head 15-30 degrees.
• Provide vomit bowl if the patient begins vomiting.
• Watch for shock (hypovolemia).
• Check on blood transfusion if required.
• Administer fluids (PNSS, PLR) as prescribed.
• Check the patient's I&O.
• Administer postoperative medications (antibiotics, analgesics, etc).
• Maintain patient's personal hygiene.
• Watch for bowel sounds to return.
• Begin with sips and progress to liquid then regular diets.
• Give food that high in calories (protein, carbs, vegetables, vitamins).
• Aseptic technique should be employed beginning on the 3rd day post-operation.
• Remove the wound drain as directed.
• Provide education about discharge information: medication, signs of complication, review dates, nutrition, rest, and sleep.

Complications of Surgery

• Infection, bleeding, shock, adhesion, dehydration, overhydration and DVT.