GENERAL SURGERY AND SURGICAL NURSING

1. Ms Muleya, a personnel secretary to the Managing Director is admitted to your ward

with a diagnosis of toxic goiter. She is scheduled for partial thyroidectomy.
a) Draw and label the thyroid gland. (20%)
b) Name two other indicators for thyroidectomy. (5%)
c) Describe in detail the pre-operative management of Ms Muleya. (50%)
d) State five complications that may arise following thyroidectomy. (25)

2. Mr. Bombwe, a 50 year old retired security guard is admitted to a surgical ward with a
diagnosis of malignant renal tumour and nephrectomy indicated.
a) Define nephrectomy. (5%)
b) State five other surgical procedures that can be done on kidney apart from the
above. (25%)
c) State five signs and symptoms of kidney cancer. (10%)
d) Describe the pre-operative and post-operative of Mr. Bombwe. (50%)
e) Outline five points you would include in your Information Education
Communication (IEC) to Mr. Bombwe upon discharge. (10%)

3. Mr. Himuyandi, a self employed man aged 65 years is admitted in a surgical ward
with a diagnosis of benign prostatic hypertrophy, suprapubic prostatectomy is indicated.
a) Define prostatectomy. (5%)
b) Mention five predisposing factors to prostatic hypertrophy. (10%)
c) Discuss the pre-operative and post-operative care of Mr. Himuyandi. (50%)
d) State five signs and symptoms Mr. Himuyandi is likely to present with.
e) Outline five points you would include in the Information Education and
Communication (IEC) to Mr. Himuyandi. (25%)

4 Mr. Banda a 30 years old man is admitted to a surgical ward with a history of vomiting blood. A
diagnosis of perforated gastric ulcers is made. He is to undergo gastrectomy.

a) i. Define Peptic ulcer Disease 5%

ii.Mention five (5) predisposing factors to peptic ulcer disease 10%
b) With the aid of a diagram, indicate the common sits for peptic ulcers 20%
c) Describe the pre- operative management you would give Mr. Banda 50%
d) Outline three (3) major complications that are likely to occur due to peptic
ulcers15%

5. Sylvia Muzala a 36 years old woman is admitted to a surgical ward after sustaining burns of the head and
trunk from hot water.

a) Define burns 5%
b) i.Mention five(5) causes of burns 5%
ii.Outline the medical management of Sylvia 10%
c) Discuss the nursing management of Sylvia using the nursing care plan 50%
d) Outline five (5) complications of burns and how they can be prevented 30%
6. Mr Frank Mulenga a 56 year old man is admitted to the eye ward with a history of loss of vision. A
diagnosis of primary angle glaucoma is made. He is scheduled for trabeculectomy.

a) i. Define glaucoma 5%
ii. Mention five (5) clinical manifestations Mr Mulenga may present with 10%

b) State three(3) investigations that may be done on Mr Mulenga to confirm the

diagnosis 15%
c) Discuss the post operative management of Mr Mulenga until discharge.
d) Outline five (5) points you would include in your information education and
communication to Mr Mulenga post operatively
ANSWER SHEET

QUESTION 1
THYROIDECTOMY

The thyroid gland

Indications
1 cosmetic reason
2 When drugs fail to produce a long remission
3 the possibility of malignancy
4 pressure symptoms on the trachea or esophagus

c) Pre-operative care

Investigations
f) Blood for full blood count and hemoglobin, grouping and cross matching
g) Thyroid function test (T3,T4) to determine the degree of thyroxin
 h) EGG-cardiac arrhythmias
i) Indirect laryngoscope for paralysis
j) Neck, chest x-ray for metastasis
k) cardinal signs tachycardia exophthalmia and increased BMR
l) Thyroid biopsy
m) methyl iodine to test activity of thyroxin

Drugs
 Carbimazole weeks before surgery 30mg OD then 10mg TDS and stopped
10days before surgery. Side effects skin rash, hypothyroidism,
constipation
 Glucose iodine 0.3-0.9m/s TDS in milk to reduce vascularity given after
carbimazole and continue till the day of operation
 Beta blockers propranolol up to day of operation 60mg BD. Lowering of
serum thyroxin nervousness ,arterial fibrillation
 Diazepam 5mg.
 Dioxin 0.25mg in arterial fibrillation
 Phenobarbitone to control tremors for 10days before surgery 30-60mg
TDS.

Psychological care

1. Explain the type of operation, why and to expect post operatively

2. Explain that the scar disappear after some time or to wear a scuff.
3. How to support her head during turning include relatives to avoid excitement to
the patients.
4. Allow patients to verbalize and answer her calmly. Inform patient of temporary
loss of voice after operation

Exercises
 Coughing
 Deep breathing

Nutrition
Diet increased proteins, minerals and vitamins
 Frequent small meals
 Avoid stimulating foods i.e. coffee, tea
 Plenty of fluids

Observations
 Vital signs
 Sleeping pulse 4 hourly
 Eye for ulceration
 Weighing daily
 Side effects of drugs i.e. rash, sweating
Rest
 Provide calm environment
 Stimuli kept at minimal
 Avoid heat as it is poorly tolerated by providing fans, frequent baths, open
windows cool drinks

Immediate Preoperative care
 Consent
 Lab results and X-ray, blood and urine
 Clean from upper chest to chin and shoulder
 Remove any dentures and put in water
 label
 escort patient

d) Complications
hemorrhage due to slippage of one or more sutures
esophageal obstruction due to edema
tetany due to reduced blood calcium
loss or hoarseness of voice due to laryngeal nerve damage
thyroid storm or crisis due to stress

QUESTION 2

NEPHRECTOMY
Definition
The surgical removal of kidney, usually done to remove a tumor, drain an
abscess or treat hydronephrosis.
e) Procedures
1. Insertion of a tube in a kidney for drainage of pus or urine
2. Pyloplasty an operation done to repair hydronephrosis
3. Nephropexy a surgical attachment of floating kidney in place
4. Nephrourectomy the removal of kidneys and ureters

f) Signs and symptoms

1. Painless haematuria
2. Dull pain in the loins due to uretro compression by back pressure
3. Palpable mass in the flank of kidney
4. Weight loss due to anorexia
5. General bogy malaise

g) Pre-operative care

Investigations
1. Kidney function test
2. X-Ray of the kidney, ureters, bladder
 3. Blood for urea and electrolytes, grouping and cross matching, HB,FBC
4. Urinalysis
5. Ultrasound of the pelvis
6. Intravenous pyelography
7. 24 hour specimen of urine
8. Renal biopsy

Psychological care
 Explain importance of surgery
e) Explain the necessity of removing one rib
f) Let patient verbalize freely and answer his questions precisely
g) Tell patient that the other kidney will maintain the normal functions
h) Reinforce what the surgeon has taught about the type of operation
i) Tell patient to expect some aches post operatively of muscles due to increased
extension

Fluid and nutrition

 Plenty fluids to promote hydration and remove waste
 Increased protein, vitamins in diet
 Avoid high fat diet

Immediate
 Signed consent form
 Nasogastric tube inserted for decompression and relief of distention
 Investigation results
 Catheterize and give suppositories to cleanse bowel
 Bath and gown patient

Post-operative care
 Patient to lie on operated side to allow free drainage
 Prop up for lung ventilation

Observations
 Urine for RBC
 Vital signs
 Sign and symptoms of renal failure
 Intake and output charting and reporting deviations from normal
 Degree of pain
 Drainage leakage

Relief of pain
 Pethidine 75 mg PRN
 Provide a calm environment for rest
 Provide a bed cradle to remove weight of blankets

Fluid and nutrition

  IV therapy 48 hours of Normal saline and dextrose 5%
 Plenty fluids when free from anesthesia to promote peristalsis
 Provide a bland diet

Wound care
1. Check for kinking of sutures on day 8
2. Aseptic technique during wound dressing to prevent infection
3. First dressing removed by doctor
4. Third day remove drains
5. Change of dressing everyday

Hygiene
a) Bed bath first day post- op
b) Oral care to promote appetite, lessen nausea and promote salivation
c) Catheter toilet to prevent assertion of infection

Elimination
 Assess amount of drainage
 Assess amount of urine and record
 Assess bowel opening

Medication
 Antibiotics to prevent infection i.e. crystapen 4 mega units QID
 Cytotoxic to clear the cancer cells i.e. vincristine 1.5 mg IV weekly
 Urinary antiseptic i.e. nitrofuratoin 100mg TDS
 Analgesics i.e. paracetamol 500- 1000mg TDS

h) IEC
 Diet to contain less proteins to allow remaining kidney to cope up
 Rest and avoid strenuous activities
 Wound care
 Signs and symptoms of renal failure eg anuria and to seek prompt medical
advice
 To come for follow up and to take medication as prescribed.

QUESTION 3
PROSTATECTOMY

1. Definition

Surgical procedure in which the entire prostate gland or portion of it is removed as a

result of either benign or malignant growth.

2. Predisposing factors
1. Prostatic enlargement
2. Advanced age (80 and above)
3. Increased levels of testosterone
4. Positive family history
5. Cancer of the colon

3. Clinical features
 Reduced urine flow
 Frequency of micturation
 Voiding difficulties
 Terminal dribbling
 Urine obstruction
 Weight loss

4. Pre-operative care
Admission
 2-3 weeks before surgery in order to put patient in his best physical,
psychological, social state and for investigations
Investigations
 Digital rectal exam may show a hard, irregular prostate
 Transrectal ultrasound and biopsy to define the size of the gland and
staging
 Bone x-ray may appear as osteosclerotic,lesions
 Digital palpation through rectum will feel a hard prostate
 Midstream urine to rule out infection
 Blood for HB, urea and electrolytes, grouping and cross-matching

Drug therapy
 Urinary antiseptics ie Nitrofuratoin 100mg tds
Side effects-discoloration of urine
Implication- take copious fluids
 Feso4 200mg tds
Side effects- nausea, vomiting and dark stool
Implication- take with meals
 Vitamin c 200mg od
 Antibiotics ie crystalline penicillin 2 mega unit qid
To combat secondary infection
Side effects- hypersensitivity reaction
Implication- give a test dose
 Beta-blockers ie tamsolusin 400mg /24 hours oral to reduce smooth muscle tone
Side effects – drowsiness, depression, dizziness, dry mouth and
ejaculatory failure
Nutrition
Increase protein, vitamin and carbonhydrate in the diet
 Copious fluids to wash out the bladder

Observations
 Vital signs 4 hourly to rule any infections , BP 6 hourly
 Bladder distention
 Urinalysis for blood, sugar
 Skin turgor for hydration
Consent
 Center on risk of procedure eg
 Haematuria/haemorrhage
 Hypothermia, urethral trauma and stricture
 Infection ie prostatitis
 Impotence and retrograde ejaculation

POST- OPERATIVE CARE

i. Bladder drainage with two catheters
ii. Normal saline to run full blast to clean the bladder free of clots
Observations
 2 hourly urine output recording
 Avoid kinking of tubes
 Avoid the bag to overfill causing pain due to backflow
 Bladder irrigation stopped after 24 hours, if blocked flush the tube
 Observe drain for amount, color and consistence and record
 Wound for bleeding
Pain relief
 Pethidine 50-75mg for 4 doses Qid
 Ensure patency of cather to reduce pain
 Empty bag when half full to avoid back pressure
Drugs
 Antibiotics
 Analgesics
 Antiseptics

Fluids/nutrition
 IV fluids of normal saline and dextrose 2l/24 hours when patient is still
nil orally first day post -op
 Provide a high calorie protein and vitamin diet
 Serve small frequent meals starting wih oral sips of liquids, then semi-
solid to solid foods
Wound care
 First 48 hours observe for bleeding if any reinforce the dressing to
reduce bleeding
  Clean wound with antiseptic
 Apply dressing around the drain to absorb secretions
 First dressing to be removed after 24-48 hours
Exercises
 Early ambulation
 Perineal exercises to strengthen the muscles
 Bladder training
 Deep breathing and coughing to prevent hypostatic pneumonia
 Limb extension and flexion to prevent joint deformities
IEC
1. Urine control
 After removal of catheter dribbling and frequency is common. Tell patient that it
will disappear after some time involve wife
 To micturate at first urge and expect to pass blood in urine for the first 2 weeks,
do not be alarmed
 Plenty fluids until bladder control is achieved

2. Exercises

 Continue perineal exercises to control dribbling

 Avoid long journey to avoid sitting and driving for 2 weeks after operation
 Avoid acidic foods and smoking
3. Sexual potency
e) Avoid sex for 2 weeks after surgery, then go back to normal
f) Caution of semen excretion which may cloud the urine
g) Warn of infertility after surgery and impotence
4. Review
 If feverish or if urination hurts, take a sample of urine to doctor

1. Drug adherence

QUESTION 4

GASTRECTOMY

a) Definition of peptic ulcer disease

Is an erosion of the gastrointestinal tract mucosa common in the esophagus, stomach
and the duodenum usually resulting from digestive action of hydrochloric acid.

b) Predisposing factors of peptic ulcer disease

 stress
 excessive alcohol intake
 use of non steroidal antinflamatory drugs
 eractic meals
 smoking
  infection by helicobacter pylori (H. pylori)
C) COMMON SITES FOR PEPTIC ULCER DISEASE

Pre- operative management

Psychological care
1. Explain condition and procedure to the patient and relatives.
2. Explain risks and benefits e.g. risk of peritonitis and need for arresting
hemorrhage due to perforation.
3. Reassure patient about treatment modalities.

Informed consent
 Make sure that the patient and relative understands reasons for operations
 Make patient or next of kin sign consent form
 Witness the consent form

Assessment
 Take history and conduct physical examination to assess client’s condition
Check the following:
 The presence of pain
 Nutritional status
 Hydration status
 Vomiting
 Signs of shock e.g. If shock is present , elevate foot end of bed, give
intravenous infusion

Ensure the following laboratory tests are done:

 Full blood count
 Haemoglobin level
 Partial prothrombin or bleeding time to identify coagulation deficiencies
 Grouping and cross match in case of need for transfusion of blood
Observations
Check and record the following
 Temperature, Pulse Respirations and Blood Pressure every 15 – 30 minutes until
patient is stable
 vomitus for blood and amount
 urine output and amount
 intake and output chart
 abdominal distention
 stool for blood and amount
 level of consciousness using the Glasgow coma scale

Pain control
Do measures to relieve pain e.g.
 diversional therapy
 imagery
 putting patient in a comfortable position
 giving analgesics such as pethdine

Nutrition
 Patient is kept nil per oral
 Total Parentral Nutrition is maintained using intravenous infusion e.g. dextrose
saline
 Nasogastric tube is inserted to compress the stomach

Hygiene /Skin preparation

 wipe if stable before being taken to theatre to reduce the presence of
microorganisms on the body.
 Do mouth swabbing with wet swabs to keep the moth moist
 Shaving is not done unless if preferred by surgeon
Elimination
 Insert urinary catheter to prevent injury to the bladder during operation
 Provide emesis bowl for vomiting
Immediate pre- operative care
 Put identification band
 Gown the patient
 Put patient items in safe hands e.g. with the in-charge
 Take and record Temperature, Pulse Respirations and Blood Pressure to
act as baseline data
 Remove jewellery to prevent injury during surgery
 Remove all prosthesis e.g. dentures, eye glasses to prevent airway
blockage or dislodging.
 Escort patient to the theater
 Carry all unnecessary documents and equipments e.g. patient’s notes,
laboratory results, x-rays etc
 Handover to theater nurse

d) 3 major complications of Peptic ulcer disease

iii. Haemorrhage
 bleeding from the ulcers due to severe ulceration of the stomach wall
 Can be life threatening and requires immediate measures to stop the bleeeding &
replace lost blood
 signs and symptoms include heamoptisis and malena stool

iv. Pyloric stenosis

 narrowing of the pyloric sphincter
 results from build up of fibrous tissue by healing ulcers
 symptoms include;feeling of fullness after meals, anorexia and vomiting

v. Perforation
 a break in the wall of the stomach or duodenum due an eroded ulcer
 symptoms include severe epigastric pain, haemoptisis,later abdominal pains
becomes generalised and abdominal tenderness occurs
 secretions may leak into the peritoneum causing peritonitis

QUESTION 5
BURNS
a) Definition
A burn is a tissue injury caused by a thermal, electrical, chemical or radio active agents.

b) i. Causes of burns
 Themal
 Electricity
 Chemicals such as caustic acids and alkali
  Radiation such as ultra violet, X-rays
 Friction from contact with moving objects.

ii. Medical management

1. History taking
2. Physical examination
6. assess airway for obstruction
7. breathing for signs of respiratory distress
8. circulation for pulse, skin colour, skin temperature
3. Laboratory tests
n) Haemoglobin levels
o) Urea and electrolytes
p) Urinalysis
q) X-ray
4. Tetanus toxoid
5. Analgesics
6. Topical antimicrobial agents e.g flamazine, silver sulphadiazine
7. Systemic antibiotics

c) Nursing management/ nursing care plan

Problem Nursing Goal/obj Intervention Outcome

diagnosis ectives
1. Fluid Fluid volume Client -Give fluids according to Baxter’s Client is
volume deficit related to will formula by giving ringer lactate or adequately
deficit electrolyte have normal saline to replace fluids and rehydrated
Or electrolytes.
imbalance and restored -Monitor and document fluid intake
evidenced
Loss of excessive fluid fluid and by normal
fluids and output using fluid balance chart
loss from electroly to prevent complications like over urine output
wound te hydration. and reduced
evidenced by balance -Assess fluid replacement status; thirstiness.
inadequate (skin turgor, increased
signs of within pulse, decreased urine output, or
dehydration e.g. six change in mental status) or excessive
thirsty. hours. (pulmonary congestion or pulmonary
edema) to recognize appropriate fluid
balance.
-Monitor laboratory results to
identify fluid and electrolyte
imbalance( serum potassium,
phosphorus and magnesium)
-Monitor mental status to access
cerebral perfusion.
2.Pain Pain related to Client -Provide adequate bed rest in a Patient
exposed nerve will be quite environment. exhibits
endings relived -Provide comfort and use a bed reduction of
evidenced by of pain cradle to avoid wound being in pain by
contact wit linen.
verbalization within verbalisation
 six -Provide diversional therapy
hours. e.g.watching television.
-Provide analgesics 30 minutes
before dressing the wound e.g.
paracetamol.
-Explain any procedure before
intervention to prevent to provide
reassurance.
3.Risk for Risk for Client -Nurse the patient in a well-heated The
ineffective hypothermia will room by using heaters and keep patient’s
thermoregu related to heat maintain windows closed. temperature
-Keep the patient warm by covering
lation loss and normal her with adequate blankets.
remains
regulation disruption of body -Keep the linen dry to prevent heat within the
or skin’s defense temperat loss by conduction. normal
ineffective mechanism to ure - Clean the wounds as quickly as limits of 36
temperature maintain body range 36 possible (using saline) to prevent to 37.5C..
exposure.
control temperature. to 37.5 -Monitor temperature to identify and
Or risk for C. treat hypothermia
hypothermia
.

4. Risk of High risk of Clients -Implement and maintain Patient is

infection infection related will be infection precautions free of signs
to loss of skin free of according to unit policy. of local or
barrier and infection -Use aseptic techniques in all aspects systemic
altered immune . of patient care e.g. washing before infection.
and after patient care, use aseptic
response. techniques in wound care, change
tubing and intravenous line.
-Change linen PRN to avoid
contaminating wound.
-Monitor temperature 4 hourly.
-Administer topical and systemic
antibiotics to help combat infection.
-Avoid patient contact with persons
who have upper respiratory or skin
infections.
-Cover the wound or patient
according o protocol of the unit to
provide a barrier to organisms e.g.
use of Vaseline.
-Isolate patient
5. risk for Risk for altered The -Maintain NGT for the patients who Client’s
altered nutrition less client’s can not easily swallow to supply high nutritional
nutritive needs.
nutrition than body optimu -Maintain IV fluid balance charts.
status has
or loss of requirement m -Provide a high protein diet, high improved as
weight related to nutrition caloric diet in order to provide evidenced
increased al status nutrition necessary for healing. by weight
nutritional to be -Explain to the patient why eating is gain.
important.
requirements maintain -Give small frequent meals
and poor ed .-Make meals a pleasant time, un
appetite associated with treatments and
 interruptions.

6. Anxiety Anxiety related The -Explain the disease process to The client
to pain client the patient relaxes, rests
hospitalization will be - Explain every procedure carried out and
and treatment relieved so as to reduce anxiety. cooperates.
- Be calm and use the language that
evidenced by of the patient understand because a
restlessness, anxiety. well informed mother /client copes
fear and well with the condition.
cleaving to the -Allow the patient to ventilate her
mother. fears because a calm patient cope
well.
-Allow visitors to visit during
visiting hours.

d) Complications

5. Contractures
due to lack of exercises and poor healing of wound result from inappropriate
would care
prevention; promote e.g deep breathing & range of motion exercises, use aseptic
technique when cleaning wounds, saline soak or use of Vaseline gauze

6. Shock
due to exessive loss of fluids and electrolytes, pain & fear
prevention; adequate hydration, control pain e,g give analgesics

7. Malnutrition
due to increased metabolic rate
prevention; small frequent balanced diet

8. Anemia
due to red cells haemolysis resulting from haemoconcetration
prevetion; give adequate fuids, give haematinics

9. Infection
due to altered defense mechanism (loss of skin)& poor use of aseptic techniques
prevention; isolate patient,use aseptic techniques,give balanced diet, antibiotic
prophylaxis

10. Renal failure

due to severe loss of fluids causing reduced renal perfusion
prevention; provide adequate hydration orally & IVF
QUESTION 6
GLAUCOMA
a) Definition
Glaucoma is an eye disorder characterized by raised intra ocular pressure, optic nerve
hypertrophy and peripheral loss of vision.

b) Clinical manifestations
 Raised intra ocular pressure greater than 24 months
 Slow loss of vision
 Persistent dull eye pain
 Difficulty in adjusting to darkness
 Failure to detect color changes

c) Investigations
 Tonometry to measure the inter ocular pressure if more than 24mm Hg
 Topography to estimate the resistance in the flow channels of acqeous humour by
recording intra ocular pressure over 2-4 minutes
 Opthalmoscopy to evaluate color and configuration of the optic cup
 Visual activity to assess loss of vision
 Gonuiscopy to examine the angle structure of the eye
 Fundus photography.

d) Post operative management

Immediate post operative care
i) Receive verbal report regarding surgery e. name type of operation, doctor’s
orders etc.
j) Position patient in recovery or semi prone position to allow easy drainage of
position on the un operated side

Assess the following:

1. Airway patency
2. Breathing circulation
3. Level of consciousness

Observations
 Take and record temperatures, pulse, respiration and blood pressure every 15
mins till stable
 Eye pad or dressing for bleeding
 Observe the intravenous fluid flow, rate site and line for kinking
 Measure intraocular pressure as observed

Pain relief
5. Put patient in a comfortable position on un operated eye or back
 6. Nurse patient in dim light to prevent photophobia
7. Cover the operated eye with eye pad
8. Give prescribed analgesics

Medication
f) Give prescribed drugs e.g. antibiotics, steroids, mydriatic e.g.cycloplegic
Nutrition
g) Nil per oral a few hours after surgery
h) Intravenous fluids
i) Give balanced diet
j) Plant oral fluids and high fibre diet to prevent constipation that may strain the
eyes

Hygiene
 Eye care dressing three times a day
 Daily bath
 Oral care at least twice a day
 Nail/hair care

Patient education (IEC)

medication
 Self administration of eye drops
 drug adherence
 side effects
 avoid herbal drugs & self priscribed drugs
infection prevention
 hand washing before and after drug instillation
 cleaning of the face
 avoid communal towel & basins
check ups
 follow review dates
 frequent eye check ups

Eye protection
 covering with eye pad
 use of eye shields e.g gogles
 avoid bright lights e.g weilding

prevention of complications
 avoid strenous activities e.g lifting heavy items and constipation
 teach patient early sign of complications e.g pain, headache, blurred vision
reduced visual field with halos