UNIT 111: SURGICAL THERAPY AND ANESTHESIA

SURGICAL THERAPY

Surgery is a procedure involving major incisions to remove, repair, or replace a part of

a body. Surgery can also be defined as a medical specialty that uses manual and/or
instrumental techniques to physically reach into a subject's body in order to
investigate or treat pathological conditions such as a disease or injury, to alter bodily
functions (e.g. bariatric surgery such as gastric bypass), to improve appearance
(cosmetic surgery), or to remove/replace unwanted tissues (body fat, glands, scars or
skin tags) or foreign bodies.

Purpose of surgery

Surgery, whether elective or emergency, is done for many reasons. A patient may have
surgery to:

- Further explore the condition for the purpose of diagnosis

- Take a biopsy of a suspicious lump
- Remove or repair diseased tissues or organs
- Remove an obstruction
- Reposition structures to their normal position
- Redirect blood vessels (bypass surgery)
- Transplant tissue or whole organs
- Implant mechanical or electronic devices
- Improve physical appearance

Types of surgery

Surgical procedures are commonly categorized by urgency, type of procedure, body

system involved, the degree of invasiveness, and special instrumentation.

A. Based on severity:

 Major surgeries: Major surgery normally involves opening the body,

 allowing the surgeon access to the area where the work needs to be completed.
It involves major trauma to the tissues, a high risk of infection, and an
extended recovery period. Most major surgeries will leave a large scar.
(Examples include: Cesarean section, Organ replacement, Joint replacement,
Full hysterectomy, Heart surgeries)
 Minor surgeries: Minor surgical procedures are those that are minimally
invasive. In most cases, these are performed laparoscopically or
arthroscopically. Small incisions are made that allow surgical tools and a small
camera to be inserted into the body. This allows the doctor to perform the
procedure without damaging extensive amounts of tissue. The risk of infection
is greatly reduced and the patient's recovery time is much shorter. There are
also surgical procedures that are superficial, only affecting the outermost
portions of the body (examples include Cataract surgery, Dental restoration,
Circumcision, Breast biopsy, Arthroscopy, Laparoscopy, Burn excision and
debridement procedures)

B. Based on timing:

 Elective surgery is done to correct a non-life-threatening condition, and is

carried out at the person's convenience, or to the surgeon's and the surgical
facility's availability.
 Semi-elective surgery is one that is better done early to avoid complications
or potential deterioration of the patient's condition, but such risk are
sufficiently low that the procedure can be postponed for a short period time.
 Emergency surgery is surgery which must be done without any delay to
prevent death or serious disabilities and/or loss of limbs and functions.

C. Based on purpose:

 Exploratory surgery is performed to establish or aid a diagnosis.

 Therapeutic surgery is performed to treat a previously diagnosed condition.
 Curative surgery is a therapeutic procedure done to permanently remove
 pathology.
 Cosmetic surgery is done to subjectively improve the appearance of an
otherwise normal structure.
 Bariatric surgery is done to assist weight loss when dietary and pharmaceutical
methods alone have failed.

D. By type of procedure:

 Amputation involves removing an entire body part, usually a limb or digit;

castration is the amputation of testes; circumcision is the removal of foreskin
from the penis or clitoris (see female circumcision). Replantation involves
reattaching a severed body part.
 Resection is the removal of all or part of an internal organ and/or connective
tissue. A segmental resection specifically removes an independent vascular
region of an organ such as a hepatic segment, a bronchopulmonary segment or
a renal lobe.[2] Excision is the resection of only part of an organ, tissue or
other body part (e.g. skin) without discriminating specific vascular territories.
Exenteration is the complete removal of all organs and soft tissue content
(especially lymphoid tissues) within a body cavity.
 Extirpation is the complete excision or surgical destruction of a body part.
 Ablation is destruction of tissue through the use of energy-transmitting devices
such as electrocautery/fulguration, laser, focused ultrasound or freezing.
 Repair involves the direct closure or restoration of an injured, mutilated or
deformed organ or body part, usually by suturing or internal fixation.
Reconstruction is an extensive repair of a complex body part (such as joints),
often with some degrees of structural/functional replacement and commonly
involves grafting and/or use of implants.
 Grafting is the relocation and establishment of a tissue from one part of the
body to another. A flap is the relocation of a tissue without complete
separation of its original attachment, and a free flap is a completely detached
flap that carries an intact neurovascular structure ready for grafting onto a new
 location.
 Implantation is insertion of artificial medical devices to replace or augment
existing tissue.
 Transplantation is the replacement of an organ or body part by insertion of
another from a different human (or animal) into the person undergoing
surgery. Harvesting is the resection of an organ or body part from a live human
or animal (known as the donor) for transplantation into another patient (known
as the recipient).

E. By organ system: Surgical specialties are traditionally and academically

categorized by the organ, organ system or body region involved. Examples include:

 Cardiac surgery — the heart and mediastinal great vessels;

 Thoracic surgery — the thoracic cavity including the lungs;
 Gastrointestinal surgery — the digestive tract and its accessory organs;
 Vascular surgery — the extra-mediastinal great vessels and peripheral
circulatory system;
 Urological surgery — the genitourinary system;
 ENT surgery — ear, nose and throat, also known as head and neck surgery
when including the neck region;
 Oral and maxillofacial surgery — the oral cavity and midface;
 Neurosurgery — the central nervous system, and;
 Orthopedic surgery — the musculoskeletal system.

F. By degree of invasiveness of surgical procedures:

 Conventional open surgery (such as a laparotomy) requires a large incision to

access the area of interest, and directly exposes the internal body cavity to the
outside.
 Minimally-invasive surgery involves much smaller surface incisions or even
natural orifices (nostril, mouth, anus or urethra) to insert miniaturized
instruments within a body cavity or structure, as in laparoscopic surgery or
 angioplasty.

G. By equipment used:

 Laser surgery involves use of laser ablation to divide tissue instead of a

scalpel, scissors or similar sharp-edged instruments.
 Cryosurgery uses low-temperature cryoablation to freeze and destroy a target
tissue.
 Electrosurgery involves use of electrocautery to cut and coagulate tissue.
 Microsurgery involves the use of an operating microscope for the surgeon to
see and manipulate small structures.
 Endoscopic surgery uses optical instruments to relay the image from inside an
enclosed body cavity to the outside, and the surgeon performs the procedure
using specialized handheld instruments inserted through trocars placed
through the body wall. Most modern endoscopic procedures are video-
assisted, meaning the images are viewed on a display screen rather than
through the eyepiece on the endoscope.
 Robotic surgery makes use of robotics such as the Da Vinci or the ZEUS
robotic surgical systems, to remotely control manipulators under stereotactic
endoscopy.

ANESTHESIA

Anesthesia is a medical treatment that prevents patients from feeling pain during
surgery.

Types of Anesthesia

There are four main categories of anesthesia used during surgery and other
procedures: general anesthesia, regional anesthesia, sedation (sometimes called
"monitored anesthesia care"), and local anesthesia. Sometimes patients may choose
which type of anesthesia will be used.
 General anesthesia is what people most often think of when they hear the
word "anesthesia". During general anesthesia, the patient is unconscious and
has no awareness or sensations. Many different medications may be used
during general anesthesia. Some are anesthetic gases or vapors that are given
through a breathing tube or a mask. Some medications are given through the
IV to induce sleep, relax muscles, and treat pain. The most frequent side effect
of general anesthesia is drowsiness afterward. This typically goes away within
the first hour or two after surgery ends. Some patients may experience a sore
throat or nausea. Serious reactions to general anesthesia are very rare although
the surgical team will monitor vital signs of the patient continuously
throughout surgery and recovery.
 Regional anesthesia makes an area of the body numb to prevent the patient
from feeling pain. It can completely block sensation to the area of the body
that requires surgery. The anesthesiologist injects local anesthesia (numbing
medication) near the cluster of nerves that provides sensation to that area. wo
very common types of regional anesthesia are spinal and epidural anesthesia.
Either one may be used for childbirth, or for orthopedic procedures such as
total knee and total hip replacement. Sometimes, an epidural catheter is left in
place to allow continuous pain relief to be given for one or more days after
surgery. This is common after surgery on the chest or abdomen, even when
general anesthesia is used during the operation. Nerve blocks are another type
of regional anesthesia that can provide pain relief to a smaller area, such as an
arm or leg. Examples include femoral nerve block to numb the thigh and knee,
or a brachial plexus block to numb the shoulder and arm. Having regional
anesthesia for surgery doesn't mean that you have to be completely awake.
Many patients prefer to receive sedation so that they can relax and doze off
during the procedure. Sometimes regional anesthesia is used in combination
with general anesthesia for major surgery on the chest or abdomen. This
 technique has the advantage that patients don't need as much opioid pain
medication after surgery.
 Sedation, also known as "monitored anesthesia care", is what people have
often referred to in the past as "twilight". Medications are given, usually
through an IV, to make the patient feel drowsy and relaxed. Different levels of
sedation are possible, depending on the type of procedure and the patient's
preference. Under mild sedation, often used for eye surgery, a patient is awake
and can respond to questions or instructions. With moderate sedation, the
patient may doze off but awakens easily. Deep sedation is nearly the same as
general anesthesia, meaning that the patient is deeply asleep though able to
breathe without assistance. Deep sedation with a medication called propofol is
often used for procedures such as upper endoscopy or colonoscopy.
 Local anesthesia is the term used for medications such as lidocaine that are
injected through a needle or applied as a cream to numb a small area. Local
anesthesia alone may provide enough pain relief for limited procedures such
as sewing up a deep cut or filling dental cavities. It is often used along with
sedation during minor outpatient surgery. At the end of many operations, the
surgeon may inject local anesthesia to provide additional pain relief during
recovery.

Assignment: Complications of Anesthesia

CARE OF THE PATIENT UNDERGOING SURGERY

Introduction

For most people, an operation is a worrying event, regardless of the procedure or

whether they have had surgery before. Good pre-operative care improves the patient
experience by minimizing anxiety and promoting recovery. Improving pre-operative
care is one of three key elements of the ‘Enhanced Recovery after Surgery’ initiative
to improve outcomes and speed up recovery. Patients should be fully informed about
the procedure, recovery and discharge.
Anxiety
Many factors contribute to anxiety in patients about to undergo surgery, such as the
anaesthetic, the procedure itself and the potential outcome of the surgery. Patients
may value detailed information and opportunities for discussion. If they are to reduce
anxiety, nurses should be able to recognize its signs; these may be physical, such as
raised vital signs, sweating, nausea and heightened senses or physiological such as
behaviour change, aggression, wanting constant attention, or becoming withdrawn or
uncharacteristically emotional. The most difficult time is waiting for the surgery. If
possible, having someone to sit with patients before surgery – perhaps a relative –
may help to reduce anxiety. Patients with learning disabilities or mental health
problems can find new environments stressful, so it is preferable if the person with
them is familiar. Children are usually accompanied by parents, and play therapists can
also help to distract them.
Pre-admission assessment
Elective patients usually attend a pre-admission clinic, which is often a
multidisciplinary team approach. The appointment will involve a medical history, a
nursing assessment; the provision of written or verbal information and tests, as well as
ensuring the consent for the procedure is obtained.
For patients with a learning disability or mental health problems, it is advisable that a
relative or carer is present so consent, capacity and reasonable adjustments can be
discussed. A ward visit for these patients may make the ward less daunting on the day
of surgery.
Admission to the clinical area
On admission to the clinical area, a case file/note/folder should be created for the
patient (an identity band should be placed on the patient’s dominant arm with printed
information as it applies to the facility). Any assessments not performed at the pre-
assessment clinic will need to be undertaken and documented. The following risk
assessments should be included, in line with local policy:
  Pressure ulcer;
 Venous thromboembolism (VTE);
 Falls;
 Malnutrition screening

Baseline observations are required and should be recorded:

 Blood pressure;
 Pulse;
 Respirations;
 Temperature;
 Oxygen saturations;
 Blood glucose (if appropriate).

Anxiety has physiological effects, which may result in hypertension, tachycardia and
a rise in temperature, so observations should be performed when the patient has
settled in and has been resting. For accuracy, it is advised that recordings are
performed manually, especially if a reading is abnormal; readings that remain
abnormal should be reported to medical staff.
Preoperative Nursing care - Preparing the patient for theatre
Nutrition and hydration – it is recommended that clear fluids up to two hours and
food up to six hours before induction in healthy patients of all ages. Many clinical
areas have set fasting times for patients. Nurses need to be aware of patient comfort
and hydration, and enable them to access food and drink for as long as is possible, in
line with local policy. All staff should know when patients are on Nil per Oral (NPO),
and this should be documented in patients’ records. Once patients are fasting, mouth
care should be available or administered to those unable to perform it themselves.
When operations are cancelled, poor communication between operating departments
and wards may mean patients’ NPO status is prolonged. This issue needs to be
addressed by senior nursing and medical staff, and decisions passed to ward and
operating department staff.
Other actions
- Patients should wash or shower using soap and water the evening before
surgery.
- Prescribed medication should be reviewed pre-operatively and only essential
medicines given - those taken orally should be swallowed with the smallest
amount of water possible;
- Medicines that will cause drowsiness should be administered once the patient
has been prepared for theatre and the patient should be advised to stay on the
bed with a call bell;
- Hair around the incision site should be removed on the day of surgery if
necessary, using electric clippers or shave without causing injury at the sight
of injury
- Patients’ comfort and dignity should be maintained when they are changing
into their theatre gown; - provide privacy.
- Depending on the surgery, patients may wear pants, but women should be
asked to remove bras before surgery;
- Jewellery should be removed where possible, although local policy may allow
tape to be applied around jewellery that is difficult to remove;
- Dentures and hearing aids should be removed, and patients may prefer this to
be done in the anaesthetic room – these items should be taken to the recovery
area, and stored and labelled;
- Wristband details should be checked with patients and to ensure they match
those on patient records, medicine records, X-rays and test results;
- Vital signs should be recorded and abnormal readings reported;
- Allergies should be documented;
- The site of surgery should be marked on the ward or day unit before patients
go to theatre or receive premeds
- Consent should have been obtained in line with hospital policy, and checked
immediately before surgery. This involves ensuring patients understand the
 procedure and that they are happy to go ahead with it. How consent is gained
and confirmed will depend on age and mental capacity.
- Transfer to theatre - before patients leave for theatre, a final pre-operative
checklist may be appropriate for patients with a learning disability or mental
health problems to be accompanied by someone familiar to them.
Intra-operative nursing care

- The patient is received in the receiving bay of OR.

- The nurse from the ward may remain with the patient (otherwise, the nurse in
the OR is responsible for the patient after handing over is done)
- The nurse will help in transporting the patient from the receiving bay to the
pre-anaesthesia room and may assist in interventions such as intravenous
cannulation, shifting to OR table, catheterisation and providing anaesthesia.
- The nurse will also communicate with other team members regarding any care
alterations.
- The physical presence of a familiar nurse itself will boost the confidence of
patients, promote a feeling of security and ensure comfort.
- The nurse will ascertain the safety of the patient by adhering to the WHO
Surgical Safety Checklist through the involvement of sign in, sign out and
time out.

Postoperative nursing care

Postoperative care is the management of a client’s health during the postoperative

period. This begins right after the surgical procedure is complete, and lasts until the
client is discharged from the healthcare facility. Postoperative care promotes the
client’s recovery after surgery by managing pain, supporting oxygenation and
cardiovascular stability, maintaining fluid balance, providing wound care, monitoring
bowel function, assisting with mobility, and preventing complications.

Postoperative care typically begins when the client is transferred from the operating
suite to the postanesthesia care unit. How long they’re being cared for in this setting
depends on the client’s health status, the type of procedure, and the type of anesthesia,
as well as the rate of progression to alertness and hemodynamic stability. The goal of
this phase of care is to stabilize the client for transfer to the next level of care, which
could be an intensive care unit or another inpatient care unit; as well as being
discharged home in the case of ambulatory surgery. In order for clients to transition to
a different level of care, they should meet certain criteria such as responding easily to
stimuli, having stable vital signs, and adequate pain control.

Now, the most common complications during the postoperative period include pain,
hemorrhage, hypothermia, and infections at the site of the surgery, called surgical site
infection, as well as wound dehiscence and evisceration. There can also be respiratory
complications, like airway obstruction, laryngospasm, pneumonia, atelectasis, and
pulmonary embolism.

Cardiovascular complications can also occur, such as hypotension, hypertension, and

dysrhythmias. Clients can also develop nervous system complications, including
delirium and delayed emergence from anesthesia.

On the other hand, gastrointestinal complications include postoperative nausea and

vomiting, constipation, postoperative ileus, and hiccups; while urinary complications
can manifest as urinary retention and urinary tract infections. Finally, fluid and
electrolyte imbalances can also occur following surgical procedures.

Nursing responsibility

The priority goals of care are to facilitate a smooth transition of care from the
postanaethesia care unit, monitor for postoperative complications, and provide
supportive care.

- Obtain a complete handoff/handover report from the postanaethesia care unit

nurse, including the client’s name; age; the names of the surgeon and
anesthesia care providers; the procedure performed and type of anesthesia
 used; as well as airway status, pain management; NPO status; and orders that
need to be implemented and note the time.
- Obtain information about the intraoperative course, including medications
administered; length of time the client was under anesthesia and reversal
agents used; estimated blood loss and total volume of fluids replaced; any
unexpected events and how they were managed; and results of diagnostic tests.
- Then, along with the postanaethesia care unit nurse, check the incision site and
dressing, and locate any drains, tubes, or catheters that were placed during
surgery.
- Also check the IV site, solutions, and infusion rate.
- Obtain information about the client’s medical history, medications, allergies,
the use of assistive devices such as glasses, hearing aids, or walkers, as well as
their primary language, emotional status, available social support, and cultural
or spiritual preferences (although these information may have been collected
prior to surgery during the preoperative nursing car phase).
- Monitor and document vital signs of the patient.
- Begin a focused assessment, starting with their respiratory status. Check their
airway patency, and adequacy of gas exchange. Encourage them to take deep
breaths, and show them how to splint their incision while coughing.
- Report to the health care provider if the client has signs of airway obstruction
such as inspiratory stridor; signs of atelectasis like decreased breath sounds or
a SpO2 less than 95%; or other indications of respiratory compromise such as
tachypnea, dyspnea, or chest wall retractions. As prescribed, administer
supplemental oxygen, reposition them to allow for full chest expansion, and
monitor their response to treatment.
- Next, assess your client’s cardiovascular status. Report to the healthcare
provider if there’s a systolic blood pressure less than 90 mmHg or greater than
160 mmHg; a heart rate is less than 60 beats per minute or greater than 120
beats per minute; a narrow pulse pressure; or any changes to the heart rhythm.
 Administer corrective medications as prescribed and implement advanced
cardiovascular life support measures if needed.
- Report any signs of hemorrhage or shock, such as a weak, rapid, thready
pulse; hypotension; or cool, clammy skin. Apply pressure to sites of active
external bleeding; administer supplemental oxygen; increase the IV flow rate;
and administer blood products as prescribed. Elevate their legs unless
contraindicated; and prepare your client for surgery if indicated.

NOTE: The recovering patient is fit for the ward when he or she is:

- Awake, opens eyes

- Extubated
- Breathing spontaneously, quietly and comfortably
- Can lift head on command
- Not hypoxic
- Blood pressure and pulse rate are satisfactory
- Appropriate analgesia has been prescribed and is safely established
Care of surgical site/incision site: Attend to surgical with the aim of promoting
healing and preventing infection.
- Observe site for swelling and discharge or drains, it may be an indication for
an infection
- Maintain aseptic techniques during dressing.
- Change dressing as prescribe
- Teach patient how to protect site and clean site after discharge
Relieving pain and anxiety: Administer opioid analgesic as prescribed

Encourage activity: Most surgical patients are encouraged to be out of bed as soon as
possible. Early ambulation reduces the gastrointestinal discomfort and circulatory
problem.

Assignment:

Post Operative complications

 - Shock
- Hemorrhage
- Deep vein thrombosis. (DVT).
- Pulmonary embolism.
- Urinary Retention
- Intestinal obstruction.
- Wound infection, dehiscence, hemorrhage evisceration.
PRINCIPLES OF ASEPTIC TECHNIQUES APPLIED TO THEATRE
NURSING

Asepsis refers to the absence of infectious material or infection. Surgical asepsis is the
absence of all microorganisms within any type of invasive procedure. Sterile
technique is a set of specific practices and procedures performed to make equipment
and areas free from all microorganisms and to maintain that sterility. Principles of
sterile technique help control and prevent infection, prevent the transmission of all
microorganisms in a given area, and include all techniques that are practised to
maintain sterility.

Principles of Surgical Asepsis

These principles must be strictly applied when performing any aseptic procedures,
when assisting with aseptic procedures, and when intervening when the principles of
surgical asepsis are breached. It is the responsibility of all health care workers to
speak up and protect all patients from infection.

Safety considerations:

 Hand hygiene is a priority before any aseptic procedure.

 When performing a procedure, ensure the patient understands how to
prevent contamination of equipment and knows to refrain from sudden
movements or touching, laughing, sneezing, or talking over the sterile
field.
  Choose appropriate PPE to decrease the transmission of microorganisms
from patients to health care worker.
 Review hospital procedures and requirements for sterile technique prior to
initiating any invasive procedure.
 Health care providers who are ill should avoid invasive procedures or, if
they can’t avoid them, should double mask.

Steps

1. All objects used in a sterile field must be sterile –

 Commercially packaged sterile supplies are marked as sterile; other packaging
will be identified as sterile according to agency policy.
 Check packages for sterility by assessing intactness, dryness, and expiry date
prior to use.
 Any torn, previously opened, or wet packaging, or packaging that has been
dropped on the floor, is considered non-sterile and may not be used in the
sterile field.
2. A sterile object becomes non-sterile when touched by a non-sterile object.
 Sterile objects must only be touched by sterile equipment or sterile gloves.
 Whenever the sterility of an object is questionable, consider it non-sterile.
 Fluid flows in the direction of gravity. Keep the tips of forceps down during a
sterile procedure to prevent fluid travelling over entire forceps and potentially
contaminating the sterile field.

3. Sterile items that are below the waist level, or items held below waist level, are
considered to be non-sterile.

 Keep all sterile equipment and sterile gloves above waist level.
 Table drapes are only sterile at waist level.

4. Sterile fields must always be kept in sight to be considered sterile.

  Sterile fields must always be kept in sight throughout entire sterile procedure.
 Never turn your back on the sterile field as sterility cannot be guaranteed.

5. When opening sterile equipment and adding supplies to a sterile field, take care to
avoid contamination.

 Set up sterile trays as close to the time of use as possible.

 Stay organized and complete procedures as soon as possible.
 Place large items on the sterile field using sterile gloves or sterile transfer
forceps.
 Sterile objects can become non-sterile by prolonged exposure to airborne
microorganisms.

6. Any puncture, moisture, or tear that passes through a sterile barrier must be
considered contaminated.

 Keep sterile surface dry and replace if wet or torn.

7. Once a sterile field is set up, the border of one inch at the edge of the sterile drape
is considered non-sterile.

 Place all objects inside the sterile field and away from the one-inch border.

8. If there is any doubt about the sterility of an object, it is considered non-sterile.

 Known sterility must be maintained throughout any procedure.

9. Sterile persons or sterile objects may only contact sterile areas; non-sterile persons
or items contact only non-sterile areas.

 The front of the sterile gown is sterile between the shoulders and the waist,
and from the sleeves to two inches below the elbow.
 Non-sterile items should not cross over the sterile field. For example, a non-
sterile person should not reach over a sterile field.
  When opening sterile equipment, follow best practice for adding supplies to a
sterile field to avoid contamination.
 Do not place non-sterile items in the sterile field.

10. Movement around and in the sterile field must not compromise or contaminate the
sterile field.

 Do not sneeze, cough, laugh, or talk over the sterile field.

 Maintain a safe space or margin of safety between sterile and non-sterile
objects and areas.
 Refrain from reaching over the sterile field.
 Keep operating room (OR) traffic to a minimum, and keep doors closed.
 Keep hair tied back.
 When pouring sterile solutions, only the lip and inner cap of the pouring
container is considered sterile. The pouring container must not touch any part
of the sterile field. Avoid splashes.