NCM112: MEDICAL SURGICAL

COVERAGE: Tumors
1. Perioperative Nursing  abnormal growth
2. Conditions Requiring Surgery
3. Categories of Surgery
4. Effects of Surgery upon the
Person Obstructions or
5. Factors in the estimation of Blockage
Surgical Risk
6. Preoperative Care
7. Physical Preparation
8. Preoperative Medication  Perforation an injury in which an object enters
9. Intraoperative Phase the body and passes through is called a
10. Stages of General perforating injury. Perforating trauma is
Anesthesia associated with an entrance wound and an exit
11. Types of Anesthesia wound.
12. Side Effects  Bleb-a blister-like protrusion (often
13. Regional Anesthesia hemispherical) filled with serous
14. Types of Block fluid.
15. Specialized Methods of Producing Erosion:
Anesthetics  is a breakdown of the outer layers
16. POTENTIAL ADVERSE of the skin, usually because of a:
EFFECTS OF ANESTHESIA  Cut
17. Basic Guidelines in Surgical  Scrape
Asepsis  Inflammation
18. Patient Positioning
19. POSTOPERATIVE CATEGORIES OF SURGERY
PHASE - According to PURPOSE
20. WOUND CARE AND -According to degree of URGENCY
DRAINAGE -According to degree of RISK
21. Diet
22. Post-operative complications Diagnostic To verify suspected
23. Post-operative Nursing Care diagnosis
Ex. biopsy
Palliative Relieves or reduces pain
or symptoms
Ablative Removes a diseased
PERIOPERATIVE NURSING organ
 Used to describe the nursing care provided in the Ex. Nephrectomy
Constructive Repair of a congenitally
total surgical experience of the patient.
defective organ
Phases of the Perioperative Period: Ex. Cleft palate plastic
1. PRE-OPERATIVE PHASE surgery
 From the time the decision is made Transplant Replaces malfunctioning
for surgical intervention to the structures Ex. Hip
transfer of the patient to the OR. transplant
2. INTRA-OPERATIVE PHASE
 From the time the patient is
received in the OR until admitted
to the recovery room.
3. POST-OPERATIVE PHASE
 From the time of admission to the
PACU (recovery room) to the
follow- up home/ clinic evaluation
and healing is complete.
CONDITIONS REQUIRING SURGERY:
Perforation
 rupture of an organ, artery or
bleb

Erosion
 wearing away of the surface of a tissue

QUIMNO 1
 NCM112: MEDICAL SURGICAL

 Type of drug taken regularly – anticoagulants can

Reconstructive: cause hemorrhage; antibiotics combined with
 partial or complete restoration of a damaged organ anesthesia can produce unfavorable results
Ex. Plastic surgery after  Mental health
severe burn  Economic & occupational status

Exploratory: PREOPERATIVE CARE

 to estimate the extent A. Pre-op psychological preparation
of the disease  Preparation for hospital admission -
Ex. Laparotomy includes explanation of procedure to be
done, probable outcome, expected
According to the degree of duration of hospitalization, cost, length
Urgency: of absence from work
 Be alert to the client’s anxiety level
Classification: Indication Examples:  Answer questions or concerns
for  Allow time for privacy
Surgery: B. Legal Aspects “Informed Consent”
Emergent or Must be Trauma, gsw
 The surgeon is responsible for obtaining
life threatening performed
without the consent for surgery
delay  No sedation should be administered
Urgent or Must be AP, Cholecystitis before SIGNING the consent
imperative performed  The nurse may serve as witness
within 24-  “This is to protect the surgeon & the
48 hrs hospital against claims that
Required or Plan within Cataracts, unauthorized surgery has been
Planned weeks or thyroid,tonsillectomy performed & that the patient was
months, unaware of the potential risks of
necessary
complications involved”
for patient’s
well-being  “This also protects the patient from
Elective No CS, hernia undergoing unauthorized surgery”
emergency C. Physiologic Preparation: (Asessment)
Optional Personal Cosmetic surgery  Assess for anxiety exhibited as fear or
request worry about financial problem
According to degree of RISK:  2. Obtain baseline data about: height,
Major Surgery Involves high degree of weight, Temp, Pulse, Respiration, BP
risk  3. Obtain health hx including:
Complicated or a. allergies = drugs, food
prolonged b. lifestyle = ex. Sedentary
Minor Surgery Involves low risk c. personal habits = smoking,
Produces few alcohol intake
complications
Performed as day surgery
Pre-operative Screening Test:
CBC Determine Hgb
EFFECTS OF SURGERY UPON THE PERSON
and Hct,
A. Stress response is elicited - increased heart rate infection
,blood pressure and blood sugar; bronchial Blood type Determined in
dilation case of blood
B. Defense against infection is lowered transfusion
C. Vascular system is disrupted Serum Evaluates the
D. Organ functions are distributed electrolytes fluid and
E. Body image may be disturbed electrolyte status
F. Lifestyle may change FBS Evaluates
diabetes mellitus
FACTORS IN THE ESTIMATION OF SURGICAL BUN, Assess the renal
RISK Creatinine function
 Extremes of age- premature baby & elderly persons ALT, AST, Evaluates the
are at risk Bilirubin liver function
Serum albumin Evaluates
 Nutritional status - malnourished & obese at risk
nutritional status
 State of fluid & electrolyte balance - dehydration CXR and ECG Respiratory and
& hypovolemia predispose client to complications Cardiac status
 General health - infections process increase
operative risk

QUIMNO 2
 NCM112: MEDICAL SURGICAL

PHYSICAL PREPARATION - Dentures/partial plates

1. If surgery is scheduled in early am; NO - Glasses/contact lenses
solid food after evening meal. Water may - Appliances/prosthesis
be given up to 4 hrs before surgery. If - Makeup/nail polish
surgery is scheduled in pm, liquid diet for - Hairpins/hairpiece
breakfast – then NPO. - Undergarments
- “The age of the client should always Inform the patient that valuables and jewelry should be
be taken into consideration. Infants given to a family member or friend or locked in the
& children have a higher metabolic cashier's office or patient locker. Wedding rings may
rate than adults, this makes it remain on fingers and will be secured with tape.
essential for the child or infant to (Exception: patients having major head and neck
receive carbohydrate regularly to resection must remove all rings.)
prevent acidosis from occuring. Inform patient's family of the Day of Surgery Lounge
2. Give cleansing enema if ordered and other designated waiting areas.
3. Perform skin prep before surgery. Have Inform patient of postoperative recovery destination.
patient shower with antibacterial soap “(or
CHLORHEXIDINE)” Shave against the Inform the patient of postoperative care:
grain of hair shaft to insure clean close - Vital signs monitored frequently
shave.” - Activity/diet restrictions
4. See that consent is signed - Nursing personnel must assist with first
5. Complete pre-op checklist ambulation
6. Remove jewelry, dentures, hairpins, nail - Medications available for pain and
polish nausea upon request
7. Check identification card - Discharge criteria if anticipate same-day
8. Administer pre-anesthetic meds as ordered discharge
9. Place side rails up & provide a quiet - Document routine preoperative teaching
environment. completed and patient understanding in
Inform outpatients during preoperative visit that the medical record.
they should: Pre-op Nutrition:
- Avoid taking aspirin or aspirin- - Assess order for NPO
containing products for 2 weeks prior to - Solid foods are withheld for about 8
surgery unless approved by physician hours before general anesthesia
- Discontinue nonsteroidal anti- Pre-op Hygiene:
inflammatory medications 48 to 72 - Bath the night before surgery with
hours before surgery antiseptic soap
- Bring a list or container of current - Removal of jewelry and nail polish
medications Pre-op Elimination:
- Bring an adult escort who can drive if - Laxatives, enemas or both may be
they are having an outpatient procedure prescribed the night before surgery
with sedation or general anesthesia - Have the client void immediately
- Wear loose clothing that can easily be BEFORE transferring them to the
removed (eg, avoid clothing that pulls OR
on and off over the head) - Foley catheter may be inserted as
Discuss the type of anesthesia planned (local or ordered
general). The anesthesiologist will evaluate all Pre-operative teachings:
patients receiving general anesthesia preoperatively. - “the best time to instruct the client is
- Instruct the patient to relatively close to the time of surgery”
bathe/shower/shampoo the evening Leg exercises To stimulate blood
before or morning of surgery. Men circulation in the
should be cleanly shaved. extremities to prevent
- Instruct the patient on oral intake thrombophlebitis.
restrictions and medication schedule as - prevents post-op “gas
ordered: pains”
- NPO after midnight (including water) - promotes passage of
flatus
- NPO after clear liquid or light breakfast
Deep breathing and To facilitate lung aeration
if permitted
Coughing and secretion
- AM meds with sip of water if ordered Exercises mobilization to prevent
by physician/anesthesiologist atelectasis and hypostatic
pneumonia (“splint”)
Instruct patient to perform oral hygiene (brush teeth thoracic & abdominal
and rinse mouth) the morning of surgery. Remind incision to minimize pain.
patient not to swallow the rinse. Done every two to four
Inform patient that before going to the operating hours
room he/she will have to remove:
QUIMNO 3
 NCM112: MEDICAL SURGICAL

Positioning, turning To promote circulation,  ↓ alveolar diffusion, depress respiration

and Ambulation stimulate respiration,  Not given to patient with asthma and
decrease stasis of gas cardiopulmonary disease
 It may cause circulatory depression and
hypotension
PRE-OPERATIVE MEDICATIONS:  Constricts smooth muscles
Generally administered 60-90 mins b4 induction of
 Nausea and vomiting and urinary retention
anesthesia
 Ex:
Pre-op Drugs: Example: Purpose:
 Morphine Sulfate- not given as premeds because
Anti-anxiety; Diazepam To decrease
Sedatives (Valium) nervousness of long duration unless patient is in severe pain
Promote  Meperidine HCl (Demerol)- IM or SQ best
relaxation premed short acting and fewer side effects
Vagolytic;Anti- Atropine SO4 Decreases  Fentanyl (Sablimaze)- IM
cholinergic secretions 3. Antimuscarinics (Adrenergic Effect or
Prevent Sympathetic)
bradycardia  Known also as anti cholinergic
Muscle relaxant Succinylcholine To promote  Inhibits stimulation of vagal nerve ( vagolytic)
muscle
 Prevent reflex slowing of the heart rate (intra
relaxation
thoracic, intra abdominal and extra ocular
Anti-emetic Promethazine To prevent
Plasil nausea and muscle)
vomiting  Bronchodilators and parasympathetic
Antibiotic Cephalosporin To prevent depressants
infection  ↓ mucus secretion (dry mouth observation)
Analgesics Meperidine To decrease  Given IM
Demerol pain and  Ex: Atropine Sulfate- dry mouth and blurred
decrease vision
anesthetic dose  Glycopyrolate (Robinul)
Anti-histamine Diphenhydramine To decrease
 Scopolamine- provides amnesia also
Benadryl occurrence of
allergy  Recording = all final preparation and emotional
H-2 antagonist Cimetidine To decrease response before surgery are noted down.
gastric fluid  Transportation to the OR = woolen or synthetic
and acidity blankets must never be sent to the OR because
they are a source of static electricity.
1. Sedatives and Tranquilizers: Minimal Sedation:
 Dec anxiety, provide comfort, calm and  drug induced state in which a patient can
hypnotic state respond normally in verbal commands
 Benzodiazepines – inhibits transmission to CNS  - cognitive function and coordination may be
 Diazepam (Valium) PO impaired
 Lorazepam (Ativan) PO or IM Moderate Sedation:
 Midazolam (Versed) IM or IV push  depressed level of consciousness that does not
impair ability to maintain a patent airway
 Barbiturates – long duration, not given on day of  calm, sedate a patient combined with analgesic
surgery given night before P.O.  Midazolam/Diazepam
 Secobarbital Na (Seconal) Deep Sedation?:
 Pentobarbital Na (Nembutal)  a drug induced state in which a patient cannot be
 Phenobarbital- hypnotic and sedative effect easily aroused but can respond purposefully
after repeated stimulation
 Antiemetics/ Antinauseants- some sedatives  inhaled or intravenous
have antiemetic  Volatile anesthetic (halothane, Isoflurane)
 Prometrazine HCl (Phenergan)- IM  Gas anesthetic (Nitrous oxide)
 Hydroxyzine HCl (Vistaril)- IM cause dry
mouth INTRAOPERATIVE PHASE
 Droperidol (Inapsine)- IM cause hypotension Terminologies:
and tachycardia Analgesia – decrease pain
2. Narcotics: Analgesic – drug to reduce pain
 Natural alkaloids of opium Anesthesia – loss of sensation
Anesthetic – drug that produces local or general loss of
 Opiates or opoids
sensibility
 They produce analgesia by acting on opiate
Induction – start from anesthetic administration until
receptors in CNS
patient loses consciousness
 ↑ pain threshold and ↓ BMR (↓ amount of
Narcosis – loss of consciousness
analgesia)

QUIMNO 4
 NCM112: MEDICAL SURGICAL
STAGES OF GENERAL ANESTHESIA
STAGE ONE:
 STAGE OF INDUCTION OR ANALGESIA
- The patient experiences analgesia or a loss of
pain sensation but remains conscious and can
carry on a conversation.
- Noises are exaggerated therefore provide a
QUIET environment
- The sensation of pain is not lost
STAGE TWO:
 STAGE OF DELIRIUM OR EXCITEMENT
- The patient may experience delirium or
become violent.
- Blood pressure rises and becomes
irregular, and breathing rate increases.
- Client is very sensitive to outside
stimuli. “Shouting, crying, laughing and
singing may be experienced.”
- This stage is typically bypassed by
administering a barbiturate, such as
sodium pentothal, before the anesthesia.
STAGE THREE:
 STAGE OF SURGICAL ANESTHESIA
- During this stage, the skeletal muscles
relax, and the patient's breathing
becomes regular. Eye movements slow,
then stop, and surgery can begin.
STAGE FOUR:
 STAGE OF MEDULLARY PARALYSIS
RESPIRATORY PARALYSIS / TOXIC
STAGE
- This stage occurs if the respiratory
centers in the medulla oblongata of the
brain that control breathing and other
vital functions cease to function. Death
can result if the patient cannot be
revived quickly. This stage should never
be reached. Careful control of the
amounts of anesthetics administered
prevent this occurrence.
TYPES OF ANESTHESIA:
A. GENERAL ANESTHESIA – state of anagesia,
amnesia and unconsciousness characterized by loss of
reflexes & muscle tone.
Types:
1. INHALATION ANESTHESIA:
 Advantage: prevention of pain and anxiety
 Disadvantage: circulatory & respiratory
depression. Highly flammable & explosive.
 Safety rules:
 Do not wear slips, nylons, wool or any material
which can set off sparks.
 Do not touch the breathing area to prevent
sparks
 Do not wear shoes that are not conductive
 Do not use bed materials that are not bed
conductive
 Ex. Gas Anesthetic:
Nitrous Oxide,
Cyclopropane
 Ex. Volatile liquid:
Halothane, Ether
Halothane
(Fluothane):
- is a powerful anesthetic and can easily
be over administered. This drug causes
unconsciousness but little pain relief so
it is often used with other agents to
control pain. Very rarely, it can be toxic
to the liver in adults, causing death. It
also has the potential for causing serious
cardiac dysrhythmias. Halothane has a
pleasant odor, and was frequently the
anesthetic of choice for use with
children, but since the introduction of
sevofluorane in the 1990s, halothane use
has declined.
Enflurane (Ethrane):
- is less potent and results in a more rapid
onset of anesthesia and faster awakening
than halothane. In addition, it acts as an
enhancer of paralyzing agents.
Enflurane has been found to increase
intracranial pressure and the risk of
seizures; therefore, its use is
contraindicated in patients with seizure
disorders
Isoflurane (Forane):
- is not toxic to the liver but can cause
some cardiac irregularities. Isofluorane
is often used in combination with
intravenous anesthetics for anesthesia
induction. Awakening from anesthesia is
faster than it is with halothane and
enfluorane.
Desfluorane (Suprane):
- may increase the heart rate and should
not be used in patients with aortic valve
stenosis; however, it does not usually
cause heart arrhythmias. Desflurane may
cause coughing and excitation during
induction and is therefore used with
intravenous anesthetics for induction.
Desflurane is rapidly eliminated and
awakening is therefore faster than with
other inhaled agents.
Sevofluorane (Ultane):
- may also cause increased heart rate and
should not be used in patients with
narrowed aortic valve (stenosis);
however, it does not usually cause
heart arrhythmias. Unlike desfluorane,
sevofluorane does not cause any
coughing or other related side effects,
and can therefore be used without
intravenous agents for rapid induction.
For this reason, sevofluorane is
replacing halothane for induction in
pediatric patients. Like desfluorane,
QUIMNO 5
 NCM112: MEDICAL SURGICAL
this agent is rapidly eliminated and
allows rapid awakening.
Nitrous oxide (laughing gas):
- is a weak anesthetic and is used with
other agents, such as thiopental, to
produce surgical anesthesia. It has the
fastest induction and recovery and is
the safest because it does not slow
breathing or blood flow to the brain.
However, it diffuses rapidly into air-
containing cavities and can result in a
collapsed lung (pneumothorax) or
lower the oxygen contents of tissues
(hypoxia).
2. Intravenous Anesthesia:
 usually employed as an induction prior to
administration of the more potent inhalation
anesthetic agents. Commonly used in minor
procedures.
 Advantages:
 rapid pleasant induction
 absence of explosive hazards
 low incidence of N&V
 Disadvantage:
 Laryngeal spasm & bronchospasm
 Hypotension
 Respiratory arrest
 Examples:
 Thiopental Na ( Pentothal Na), Methohexital
(Brevital), Etomidate, Propofol (Diprivan)
3. Rectal Anesthesia:
 rarely used today; useful during the induction of
anesthesia of pediatrics
Ex. Pentothal Na
Miscellaneous General Anesthesia:
A. Dissociative anesthesia
Ex. Ketamine (Ketalar)
- used for short diagnostic procedures in
combination with other anesthetics
- has no analgesic or muscle relaxing
properties
B. Neuroleptics
Ex. Innovar (Fentanyl)
- causes psychological apathy &
tranquilization without inducing sleep or
analgesia
- used for pts. Undergoing surgery & dx
procedures when cooperation &
responsiveness are necessary
SIDE EFFECTS:
 Headache
 Vision problems, including blurred or double
vision
 Shivering or trembling
 Muscle pain
 Dizziness, lightheadedness, or faintness
 Drowsiness
 Mood or mental changes
 Nausea or vomiting
 Sore throat
 Nightmares or unusual dreams
Precautions:
 A complete medical history including a history
of allergies in family members, is an important
precaution.
 Patients may have a potentially fatal allergic
response to anesthesia known as malignant
hyperthermia, even if there is no previous
personal history of reaction.
Induction of GA:
KEY POINTS DURING INDUCTION!
1. Circulator should remain
2. Gentle and rapid approach
3. Avoid stimulation of the patient (mandatory)
“noise avoidance”
4. Do not touch patient until anesthesiologist says
it is safe to do so
5. Precaution: ECG, defib, chest stet, BP
6. Positioning: if obese elevate head to avoid
pressure (protect diaphragm)
7. If hypotensive- flat
8. Children: circulator- to be less frightening stay
close to the child
REGIONAL ANESTHESIA:
- the injection or application of a local
anesthetic agent to produce a loss of
painful sensation in only one region of
the body and does not result to
unconsciousness.
Types:
1. Topical Anesthesia Ex. Cocaine, Lidocaine
2. Infiltration Anesthesia
Types:
1. Nerve Block 3. Epidural block
2. Caudal Block 4. Pudendal block
TOPICAL Applied directly on the
skin
INFILTRATION Injected into a specific
area of skin
NERVE BLOCK Injected around a nerve
SPINAL Subarachnoid Low spinal anesthesia
EPIDURAL Epidural space is injected
with anesthesia
Spinal Anesthesia:
 Spinal anaesthesia is induced by injecting small
amounts of local anaesthetic into the cerebro-
spinal fluid (CSF).
 The injection is usually made in the lumbar
spine below the level at which the spinal cord
ends (L2).
Indications for Spinal Anesthesia:
 Spinal anaesthesia is best reserved for operations
below the umbilicus
 Examples: hernia repairs, gynaecological and
urological operations and any operation on the
perineum or genitalia.
 Spinal anesthesia is particularly suitable for
older patients and those with systemic disease
such as chronic respiratory disease, hepatic,
renal and endocrine disorders such as diabetes
QUIMNO 6
 NCM112: MEDICAL SURGICAL

Local Anaesthetics for Spinal Anaesthesia:  Nausea and vomiting

 Bupivacaine (Marcaine).  anaphylaxis
 Lidocaine/Lignocaine (Xylocaine).  CNS agitation, seizures, respiratory arrest
 Cinchocaine (Nupercaine, Dibucaine, Percaine,  Over sedation or under sedation
Sovcaine).  Agitation and disorientation
 Tetracaine (Amethocaine, Pantocaine,  Hypothermia
Pontocaine, Decicain, Butethanol, Anethaine,  Hypotension
Dikain).  Malignant hyperthermia
 Mepivacaine (Scandicaine, Carbocaine,
Meaverin).
 Pethidine/Meperidine
 Ropivacaine (Naropin)

TYPES OF BLOCK
SADDLE BLOCK
BASIC GUIDELINES IN SURGICAL ASEPSIS
 OPERATIONS OF GENITALIA &
1. All materials that enter the sterile must
PERINEUM
be sterile.
 Also used for vaginal delivery
2. If a sterile item comes in contact with an
LUMBAR BLOCK unsterile item, it is contaminated.
 OPERATIONS ON LEGS, GROIN, HERNIAS 3. Contaminated items should be removed
MID-THORACIC BLOCK immediately from the sterile field.
 OPERATIONS ON HYSTERECTOMY 4. Sterile team members must wear only
sterile gowns and gloves.
C. Local Anesthesia 5. Once dressed for the procedure, they
Ex. should recognize that the only parts of
 Procaine (Novocaine) the gown considered sterile are the front
 Cocaine (Tetracaine) from chest to table level and the sleeves
 Lidocaine (Xylocaine) to 2 inches above the elbow
6. A wide margin of safety must be
SPECIALIZED METHODS OF PRODUCING maintained between the sterile and
ANESTHETICS: unsterile fields.
Types: 7. Tables are considered sterile only at
. Muscle Relaxants – neuromuscular blocking table top level.
agent used to provide muscle relaxation 8. The edges of a sterile package are
Uses: Endotracheal Intubation considered contaminated once the
Ex. Pancuronium Bromide (Pavulon) package has been opened.
D-Tubo Curarine Chloride (Curare) 9. Bacteria travel on airborne particles and
2. Hypothermia – refers to the deliberate reduction of will enter the sterile with excessive air
the patient’s body temperature between 28 degrees & 30 movement and currents.
degrees (82 and 84 degrees F) 10. Bacteria travel by capillary action
Uses: through moist fabrics and contamination
1. Heart Surgery occurs.
2. Brain surgery 11. Bacteria harbor on the patient’s and
3. Surgery on large vessels supplying major organs team members hair, skin and respiratory
Methods: Ice water immersion, Ice bags, Cooling tracts must be confined by appropriate
blanket, Extra corporeal cooling devices attire.
Complications: Cardiac Arrest and Respiratory arrest INTRA OPERATIVE:
 Coordinated roles of scrub person & circulator
 Positioning the pt.
 Skin prep & draping of site
 Hemostasis and blood loss replacement
 Wound closure materials
OPERATING ROOM TEAM:
– direct patient care team
 The team is like a symphony orchestra
 Each person is an integral entity in harmony
with his colleagues
1. THE STERILE TEAM
POTENTIAL ADVERSE EFFECTS OF 2. THE UNSTERILE TEAM
ANESTHESIA THE STERILE TEAM:
 Operating surgeon
 Myocardial depression, bradycardia  Assistants to the surgeon

QUIMNO 7
 NCM112: MEDICAL SURGICAL

 Scrub person  Provides optimal access for assessing and

 They:
 Scrub their hands and arms
 Don sterile gloves and gown
 Enter the sterile field (all items for the surgical
procedure are sterilized
THE UNSTERILE TEAM:
 Anesthesiologist or anesthetist
 Circulating nurse
 Technicians
 They:
 Don’t enter the sterile field
 Function outside of it
 Maintain sterile technique
SCRUB NURSE:
 Maintain safety of the sterile field
 Knows the sterile and aseptic technique
 Prepares the instruments
 Assists the surgeon with the instruments
CIRCULATING NURSE:
 Monitors/coordinates all activities
 Controls the physical and emotional atmosphere
in the room
maintaining anesthesia and function
 Protects patient from harm
1. Supine – for hernia repair, explore lap,
cholecystectomy, mastectomy, etc.
2. Prone – for back supine and rectal surgery
Note: After surgery, the patient will be returned to the
supine position. This should be done gradually and
slowly to adjust the cardiovascular system to any change
in position. Rapid turning can cause a drop in BP.
3. Trendelenburg – head and body are flexed by
“breaking” the table.
4. Reverse Trendelenburg – head is elevated and feet
are lowered
5. Lithotomy position – thighs and legs are flexed at
right angles and then simultaneously placed in stirrup
6. Lateral position – used in kidney and chest surgery
7. Other positions:
a. Thyroidectomy – head hyperextended, a
small sand bag or neck pillow to provide
exposure of thyroid gland.
Position Patient during Surgery:
Abdominal Surgeries Supine
Bladder Surgery Slightly trendelenburg
Perineal Surgery Lithotomy
Brain Surgery Semi-fowler’s
Spinal Cord Surgeries Prone mostly
Lumbar Puncture Side lying, flexed body
Abdominal Surgical Incisions:
Paramedian – vertical incision
Longitudinal midline

FUNCTIONS OF THE NURSE DURING OR  Begins at the level of xiphoid to supra-

PROCEDURE: pubic region

SCRUB NURSE  Assists the  For gastrectomy & intestinal resection

surgeon
Subcostal
 Maintains
sterility  begins at the epigastrium and extends
 Handles laterally and obliquely just below the
instruments lower costal margin
 Drapes patient
 Counts sponges  biliary, spleen, liver
CIRCULATING  Assists the Scrub  bilateral subcostal – CHEVRON
NURSE nurse
incision – liver transplant
 Positions the
patient for  Paramedian – vertical incision
 surgery
 Positions any  Longitudinal midline
equipments  Begins at the level of xiphoid to supra-
pubic region
PATIENT POSITIONING
 For gastrectomy & intestinal resection
 Provides optimal visualization  Subcostal

QUIMNO 8
 NCM112: MEDICAL SURGICAL

 begins at the epigastrium and extends  Deep breathing and coughing exercises Q2
laterally and obliquely just below the hours- to remove secretions
lower costal margin  Leg exercises Q 2 hours - to promote
circulation
 biliary, spleen, liver
 Ambulation ASAP- prevents respiratory,
 bilateral subcostal – CHEVRON circulatory, urinary and gastrointestinal
incision – liver transplant complications
 Hydration after NPO- to maintain fluid
POSTOPERATIVE PHASE
balance
Activities in the POST-op:  Suction, either gastro or respiratory-to relieve
distention, to remove respi secretions
 Assessing responses  Diet-progressive, usually given when bowel
to surgery
sounds and a gag reflex return
 Performing
interventions to Post-operative Interventions
promote healing
Some Examples of Position Post Op:
 Prevent
complications Mastectomy Semi-fowlers’, affected
 Planning for home-care arm elevated
 Assist the client to achieve optimal recovery Thyroidectomy Semi fowlers’ , head
midline
Hemorrhoidectomy Semi-prone, side-lying
Laryngectomy Fowler’s
Pneumonectomy Lateral, affected side
POST OPERATIVE INTERVENTIONS Lobectomy Lateral, unaffected side
Aneurysmal repair Fowler’s 45 degrees
 Maintain patent airway
(abdomen)
 Monitor vital signs and note for early Amputation of lower Flat, with stump elevated
manifestations of complications extremities with pillow
Cataract surgery Fowler’s 45 degrees
 Monitor level of consciousness Supratentorial Fowlers’
craniotomy
 Maintain on PROPER position Infratentorial Flat on bed, supine
 NPO until fully awake, with passage of flatus craniotomy
and (+) gag reflex Spina bifida repair Prone

 Monitor the patency of the drainage

WOUND CARE
 Maintain intake and output monitoring
 Inspect dressing hourly
 Care of the tubes, drains and wound  Change dressing daily
 Ensure safety by side rails up  Inspect for signs of infection🡪 redness,
swelling, purulent exudate
 Pain medication given as ordered  Maintain wound drainage
 Drainage can be (1) serous (clear and thin; may
 Measures to PREVENT post-op
be present in a
Complications
healthy,
PAIN MANAGEMENT : healing
wound),
 Pain is usually greatest during the 12-36 hours
after surgery (2)serosanguineous (containing blood; may also
 Narcotic analgesics and NSAIDS may be be present in a healthy, healing wound), (3)
prescribed together for the early period of sanguineous (primarily blood), or (4) purulent
surgery (thick, white, and pus-like; may be indicative of
 Provide back rub, massage, diversional infection and should be cultured).
activities, position changes
DIET
POSITIONING:
 NPO usually immediately after surgery
 Clients who have spinal anesthesia is usually  Progressive diet
placed FLAT on bed for 8-12 hours
 Unconscious client is placed side lying to drain  Assess the return of the bowel sounds ( passage
secretions of flatus)
 Other positions are utilized BASED on the type
of surgery Liquid Diet Vs Soft diet:

QUIMNO 9
 NCM112: MEDICAL SURGICAL

Constipation Infrequent  High fiber

passage of diet
stool  Increased
fluid
 Ambulation

Paralytic ileus Absent  Encourage

bowel ambulation
sound  NPO until
peristalsis
returns

Wound Occurs  Daily

infection about 3 wound
days after dressing
Urinary Elimination: surgery  Antibiotics
 Offer bedpans  Maintain
drain
 Allow patient to stand at the bedside commode
if allowed
Wound Separation  Cover the
 Report to surgeon if NO URINE output noted dehiscence of wound wound with
within 8 hours post-op edges at the sterile
POST-OPERATIVE COMPLICATIONS suture line normal
saline
Atelectasis Collapsed  Assess dressing
alveoli due breath  Place in
to secretions sounds low-
 Repositioni Fowler’s
ng  Notify MD
 Deep
breathing Wound Protrusion  Cover the
and evisceration of the wound with
coughing internal saline pad
Pneumonia Inflammatio  Chest organs and  Place in
n of alveoli physio tissues low-
 Suctioning through Fowler’s
 Ambulation wound  Notify MD

Thrombophlebit Inflammatio  Leg

is n of the exercises
POST-OPERATIVE NURSING CARE
veins  Monitor for
swelling To emphasize:
 Elevated
extremities  The over-all goal of nursing care during the
PRE-OPERATIVE phase is to prepare the
Hypovolemic Loss of  Shock patient mentally and physically for the surgery
Shock circulatory position  The over-all goal of nursing care during the
fluid  Determine INTRA-OPERATIVE phase is to maintain client
volume cause and safety
prevent  The over-all goals of nursing care during the
bleeding POST-OPERATIVE phase are to promote
 O2, IVF healing and comfort, restore the highest possible
wellness and prevent associated risk.
Urinary Involuntary  Encourage
retention accumulatio ambulation
n of urine  Provide
privacy
 Pour warm
water
 Catheterize

Pulmonary Embolus  Notify

embolism blocking the physician
lung blood  Administer
flow O2w

QUIMNO 10