LICEO DE CAGAYAN UNIVERSITY

BACHELOR OF SCIENCE IN NURSING

LEVEL 3

NCM 112: CARE OF CLIENTS WITH PROBLEMS (Medical Surgical Nursing)

LECTURE PRELIM TERM
Clinical Instructor: Bobby Suazo, MSc, MSN, RN /Clinical Instructor/Lecturer S.Y. 2023 - 2024 1ST SEMESTER
TRANSCRIBE BY: MA. EM CONCEPCION LAGARE (MECTL)

Book reference: Medical – Surgical Nursing 15th Edition, Brunner & Suddarths

MEETING NO. 01

NOTES-August 26, 2023

I. PREOPERATIVE NURSING MANAGEMENT

OVERVIEW

SURGERY
LEARNING OUTCOMES - Is a branch of medicine concerned with the treatment of disease, deformities, and
injuries through manual procedures called OPERATION.
On completion of this chapter, the learner will be able to:
TERMINOLOGIES:
1. Define the phases of perioperative patient care.
Ectomy Excision or removal; Cutting out or off
2. Perform a comprehensive preoperative assessment to identify pertinent health and
surgical risk factors. Lysis Destruction
3. Describe considerations related to preoperative nursing care of older adult patients,
Oma Tumor, excision of fibroma
patients with obesity, and patients with disability.

4. Identify the regulatory documents that are required prior to a patient entering surgery. Orraphy Repair/ suture of

5. Initiate the immediate preoperative preparation and education of the patient Oscopy Looking into

Ostomy Creation of opening; cut into.

Ambulatory Surgery
thoracotomy – cut into the chest cavity
GLOSSARIES
Plasty Repair of scar/ tissue; revision
includes outpatient, same-day, or short-stay surgery
that does not require an overnight hospital stay Pexy Fixation, anchor into place

Bariatrics having to do with patients with obesity

History & physical mandatory form completed by the surgeon that gives PERIOPERATIVE PERIOD
a comprehensive overview of the patient’s history, - encompasses a client’s total surgical experience, including the preoperative and
current physical status, and plan of care postoperative phases.

Informed consent the patient’s autonomous decision about whether to PERIOPERATIVE NURSING
undergo a surgical procedure, based on the nature of - refers to activities performed by the professional nurses during these phases.
the condition, the treatment options, and the risks
and benefits involved THREE PHASES OF PERIOPERATIVE NURSING

Intraoperative phase period of time that begins with transfer of the patient 1.Preoperative phase begins when the decision to proceed with surgical
to the operating room area and continues until the intervention is made and ends with the transfer of the
(PT. is inside the OR) patient is admitted to the postanesthesia care unit patient onto the operating room (OR) bed

Minimally invasive surgery
Perioperative phase
surgical procedures that use specialized instruments 2.Intraoperative phase begins when the patient is transferred onto the OR
inserted into the body either through natural orifices bed and ends with admission to the PACU.
or through small incisions - Intraoperative nursing responsibilities involve acting
as scrub nurse, circulating nurse, or registered nurse
period of time that constitutes the surgical first assistant
experience; includes the preoperative, intraoperative, - involves anesthesia
and postoperative phases of nursing care - “TIME OUT”

Postoperative phase period of time that begins with the admission of the 3.Postoperative phase begins with the admission of the patient to the PACU
patient to the postanesthesia care unit and ends after and ends with a follow-up evaluation in the clinical
(Recovery phase) follow-up evaluation in the clinical setting or home setting or home

Preadmission testing Diagnostic testing performed before admission to the

hospital

Preoperative phase Period of time from when the decision for surgical PREOPERATIVE PHASE
intervention is made to when the patient is
transferred to the operating room table
PERIOPERATIVE NURSING

 Communication, teamwork, and patient assessment are crucial to ensure good

patient outcomes in the perioperative setting.
 Professional perioperative and perianesthesia nursing standards encompass the
domains of behavioral response, physiologic response, and patient safety and are
used as guides toward development of nursing diagnoses, interventions, and plans.
 Perioperative nursing, which spans the entire surgical experience, consists of three
phases that begin and end at particular points in the sequence of surgical
experience events.

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 LICEO DE CAGAYAN UNIVERSITY
BACHELOR OF SCIENCE IN NURSING
LEVEL 3

NCM 112: CARE OF CLIENTS WITH PROBLEMS (Medical Surgical Nursing)

LECTURE PRELIM TERM
Clinical Instructor: Bobby Suazo, MSc, MSN, RN /Clinical Instructor/Lecturer S.Y. 2023 - 2024 1ST SEMESTER
TRANSCRIBE BY: MA. EM CONCEPCION LAGARE (MECTL)

 Many patients enter the hospital 90 minutes prior to surgery and have necessary missing, defective, damages, or misshapen.
medical assessments and analyses preceding the surgical intervention. The
surgery is followed by a recovery period in the postanesthesia care unit (PACU). 4. Palliative  Affording relief but nor cure.
 Each perioperative phase includes the many diverse activities a nurse performs,
using the nursing process, and is based on the recommended practice standards of Classification according to URGENCY:
the Association of periOperative Registered Nurses (AORN), formerly known as the
Association of Operating Room Nurses (AORN, 2019) and the American Society of 1. Optional Surgery  Is done totally at the client’s discretion
PeriAnesthesia Nurses (ASPAN, 2019).  E.g: cosmetic surgery
THE PERIOPERATIVE TEAM:
2. Elective surgery  Refer to procedures that are scheduled at the
client’s convenince.
1. Anesthesiologist or Nurse Anesthetist
 E.g: cyst removal, repair of scars, simple hernia
 “King of airway”
or vaginal repair
 Makes a preoperative assessment to plan the type of anesthetic to be administered
and to evaluate the client’s physical status.
3. Required surgery  Is warranted for conditions necessitating
2. Professional Registered OR nurse intervention within a few weeks
 makes preoperative nursing assessment and documents the intra – operative  E.g: cataract surgery, thyroid disorder
client care plan.
4. Urgent or  Is indicated for a problem requiring intervention
3. The circulating nurse imperative withing 4 to 48 hours
 manages the OR and protects the safety and health needs of the client by surgery  E.g: some cancers, acute gallbladder infection,
monitoring the conditions in the OR appendicitis, kidney stones.

4. Scrub nurse 5. Emergency  Describes procedure that must be done

 responsible for scrubbing for surgery, including setting u sterile tables and surgery immediately to sustain life or maintain function
equipment and assisting the surgeon and surgical techniques during the surgical
procedure. Classifications according to MAGNITUDE or EXTENT:

5. PACU nurse 1. Major Surgery  High risk; extensive; prolonged; large amount of
 responsible for caring for the client until the client has recovered from the effects of blood loss; great risk of complication
anesthesia, is oriented, has stable vital signs, and show no evidence of
hemorrhage 2. Minor Surgery  Generally not prolonged; leads to few serious
complications; involves less risk

CONDITIONS REQUIRING SURGERY

1. Obstruction or Intestinal obstruction is a blockage that keeps food or liquid SURGICAL RISK
blockage from passing through your small intestine or large intestine
(colon). Causes of intestinal obstruction may include fibrous General Risk factors:
bands of tissue (adhesions) in the abdomen that form after
surgery; hernias; colon cancer; certain medications; or 1. Age
strictures from an inflamed intestine caused by certain 2. Obesity
conditions, such as Crohn's disease or diverticulitis. 3. Immobility
4. Malnutrition
2. Perforation is a hole that develops through the wall of a body organ. This 5. Emergency
problem may occur in the esophagus, stomach, small 6. Endocrine related condition
intestine, large intestine, rectum, or gallbladder. 7. Steroid therapy

3. Erosion Is a breakdown of the outer layers of the skin, usually MAJOR CAUSES OF DEATH
because of a: Cut; Scrape; Inflammation
1. Pneumonia
4. Tumor an abnormal mass of tissue that may be benign, 2. Cardiac arrest
premalignant, or cancerous. 3. Renal failure
4. Stroke
5. Pulmonary emboli
6. Sepsis; peritonitis
CATEGORIES OF SURGICAL PROCEDURES 7. Hypovolemic shock

1. According to PURPOSE DEGREE OF SURGICAL RISK DEPENDS ON:

2. According to URGENCY
1. Nature, Location, And Duration of The Condition
3. According to MAGNITUDE or EXTENT of surgery
2. Type and Classification of Surgery
3. Person’s Mental Attitudes
Classifications according to PURPOSE:
4. Available Professional Resources
1. Diagnostic  Is used to determine the cause of an illness or IDENTIFICATION OF POTENTIAL RISK:
disorder.
 Makes it possible to verify a suspected 1. Elicitation of stress response
diagnosis. 2. Decreased resistance to infection
3. Description of the vascular system
2. Curative  Tending to overcome disease and promote 4. Disturbance of body image
recovery
 Removal of disease organ or tissues.

3. Reconstructive  Concerned with the restoration, construction,

reconstruction, or improvement in the shape
and appearance of body structures that are NURSING ASSESSMENT

A. PHYSIOLOGIC

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 LICEO DE CAGAYAN UNIVERSITY
BACHELOR OF SCIENCE IN NURSING
LEVEL 3

NCM 112: CARE OF CLIENTS WITH PROBLEMS (Medical Surgical Nursing)

LECTURE PRELIM TERM
Clinical Instructor: Bobby Suazo, MSc, MSN, RN /Clinical Instructor/Lecturer S.Y. 2023 - 2024 1ST SEMESTER
TRANSCRIBE BY: MA. EM CONCEPCION LAGARE (MECTL)

was performed.

Circumstances  Any surgical procedure where scalpel, scissors, suture,

1. Age Requiring Permit: hemostat of electrocoagulation may be used.
2. Presence of pain
 Entrance into a body cavity – E.g: Paracentesis,
3. Nutritional status
bronchoscopy, cystoscopy, colonoscopy, and
4. Fluid & electrolyte
proctosigmoidoscopy
5. Infection
 General anesthesia, local infiltration, regional block.
6. Cardiovascular function
7. Pulmonary function
8. Renal function Requisite for validity of A. Written permission is best and is legally acceptable.
9. Gastrointestinal function informed consent: B. Signature is obtained with clients complete
understanding of what to occur – adult sign their own
10. Liver function
operative permit; it is obtained before sedation.
11. Endocrine function
C. Secured without pressure or duress
12. Neurologic function
D. A witness is desirable – nurse, physician, or other
13. Hematologic function
authorized person.
14. Use of medications
E. In an emergency, permission via telephone or telefax is
15. Presence of trauma
acceptable.
***Carbon dioxide – potent vasodilator of our brain F. For minor (below 18 yrs. Old), unconscious,
psychologically incapacitated, permission is required
B. PSYCHOLOGIC from responsible family members (parent/ legal guardian)

Pre – op Defense Mechanism C. PHYSIOLOGIC ASPECT

1. Regression 1. Correct dietary deficiencies

2. Denial 2. Reduce weight
3. Intellectualization 3. Correct fluid and electrolyte imbalances
4. Restore adequate blood volume
NURSING INTERVENTIONS: 5. Treat chronic disease
Help RELIEVE ANXIETY 6. Cure any infection diseases
1. Explore feelings 7. Treat alcoholic person with vitamin supplement
2. Allow to speak openly about fears
3. Give accurate information D. PREOPERATIVE TEACHING
4. Give emphatic support
 Preop Exercise
C. ASSESSMENT OF ECONOMIC AND DEVELOPMENTAL STATUS 1. Coughing
2. Deep breathing – expand alveoli, prevent atelectasis, &other complication,
NURSING PEOPLE BEFORE SURGERY: 4 phases less pain in inspiration than expiration.
3. Turning
1. At the physician’s office before admission to health care facility 4. Moving
2. Upon admission and during days before operation 5. Foot & leg exercise
3. Night before the surgery
4. Morning of surgery

PREOPERATIVE ADMISSION PREPARATION ON THE EVENING BEFORE SURGERY

1. Depend on the amount of preoperative intervention 4 Major Considerations:

2. Involve family interview
3. Thorough assessment of the body system 1. Preparing the skin
4. Patient orientation
5. Verify info on pre operative testing  Awareness of preop preparation protocol of the health care facility
6. Initiates teaching appropriate to patient’s needs  On procedure:
1. Proper technique
A. PSYCHOLOGIC ASPECT 2. Location
3. Size of areas to be prepared.
1. Fear of the unknown 4. Specific preferences of the surgeon
2. Provide information about hospital protocols 5. Document observation of the surgical sit
3. Explains procedures of surgical phases
2. Preparing GIT
4. Explain all nursing intervention
5. Allow pt to ask question
 Special preparation of the evening before surgery
6. Introduce to people who had successful operation
1. To reduce the possibility of vomiting
7. Arrange occupational therapy on extended post op
2. Reduce the possibility of bowel obstruction
3. Prevent contamination from fecal material during intestinal or bowel
surgery
4. Restrict food/fluid
B. LEGAL ASPECT
5. Administration of enema as needed
6. Insert gastric tube/ intestinal tube
 Informed Consent (Operative permit/ Surgical consent)

Purpose:  To ensure that the client understands the nature of the

treatment including the potential complication and
disfigurement.
 To indicate that the client’s decision was made without
pressure.
 To protect that client against unauthorized procedures.
 To protect the surgeon and hospital against legal action
by a client who claims that an unauthorized procedure

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 LICEO DE CAGAYAN UNIVERSITY
BACHELOR OF SCIENCE IN NURSING
LEVEL 3

NCM 112: CARE OF CLIENTS WITH PROBLEMS (Medical Surgical Nursing)

LECTURE PRELIM TERM
Clinical Instructor: Bobby Suazo, MSc, MSN, RN /Clinical Instructor/Lecturer S.Y. 2023 - 2024 1ST SEMESTER
TRANSCRIBE BY: MA. EM CONCEPCION LAGARE (MECTL)

PREADMISSION TESTING

 Incentives to reduce hospital stays and contain costs have resulted in diagnostic
preadmission testing (PAT) and preoperative preparation prior to admission.
 During the PAT visit, patients learn what to expect on the day of surgery and
receive answers to questions they may have mission.
 Nurses in the PAT department are responsible for communicating information
related to the surgical procedure and the effect that the surgical procedure and
anesthetic may have on the patient’s health status, functional status, and family
dynamics
If General Anesthesia:
EXAMPLES OF NURSING ACTIVITIES IN THE PERIOPERATIVE PHASES OF CARE
1. Foods and fluid restricted for 8-10 hours before the operation
Preoperative Phase
2. NPO after midnoc (8-10 hrs)
3. Water be given up to 4 hours before surgery as ordered
Preadmission Testing
4. When surgery is not scheduled until late afternoon, person may eat light
breakfast in AM if permitted. 1. Performs initial preoperative assessment
5. Extremely debilitated or malnourished receive IV infusion, amino acid, 2. Initiates education appropriate to patient’s needs Involves family in
glucose, plasma ‘till moment of surgery. interview
6. Edema as needed 3. Verifies completion of preoperative diagnostic testing according to
patient’s needs
Liquid & food intake Minimum fasting period 4. Confirms understanding of surgeon-specific preoperative prescribed
therapies (e.g., bowel preparation, preoperative shower)
Clear liquid 2 5. Discusses and reviews advance directive document Begins discharge
planning by assessing patient’s need for postoperative transportation and
Breastmilk 4 care

Non – human milk 6 Admission to Surgical Center

Light meals 6 1. Completes preoperative assessment

2. Assesses for risks for postoperative complications
Regular meals/ heavy meal 8 3. Reports unexpected findings or any deviations from normal
4. Verifies that operative consent has been signed
3. Preparing for anesthesia 5. Coordinates patient education and plan of care with nursing staff and
other health team members
1. Done evening before surgery to complete respiratory, cardiovascular, 6. Reinforces previous education
neurologic examination 7. Explains phases in perioperative period and expectations
2. Determine the type of anesthesia used during surgery 8. Answers patient’s and family’s questions
3. Discuss type of anesthesia plans, sensation the person will experience.
4. Address fears. A calm, confident person undergoes anesthesia more In the Preoperative Area
smoothly than someone who is nervous is frightened
1. Identifies patient
4. Promoting rest & sleep 2. Assesses patient’s physical and emotional status, baseline pain, and
nutritional status
1. Physically comfortable; mentally ease; adequate sedated 3. Reviews medical record
2. Measure to reduce sleeplessness and restlessness 4. Verifies surgical site and that it has been marked per institutional policy
3. Have a well-ventilated room, comfortable and clean bed 5. Establishes IV line
4. Give back rub 6. Administers medications if prescribed
5. Warm beverage if fluid is not contraindicated 7. Takes measures to ensure patient’s comfort
8. Provides psychological support
9. Communicates patient and family’s needs to other appropriate members
of the health care team
PREPARATION ON THE DAY BEFORE SURGERY
Intraoperative phase
A. EARLY MORNING CARE
Maintenance of safety
1. Record V/S – slight increase due to anxiety
2. Check ID band 1. Maintains aseptic, controlled environment
3. Skin prep thoroughly/ oral hygiene 2. Effectively manages human resources, equipment, and supplies for
4. Check order if carried out individualized patient care
5. Identify if not eaten within 4-10 hours 3. Transfers patient to operating room bed or table
6. Remove jewelry, hearing aid, prosthesis 4. Positions patient based on functional alignment and exposure of surgical
7. Remove colored nail polish site
5. Applies grounding device to patient
Before Administration of Anesthesia: 6. Ensures that the sponge, needle, and instrument counts are correct
7. Completes intraoperative documentation
1. Get the BP and record
Physiologic Monitoring
2. if given to early – induction is more difficult to administered, put side rails up, turn off
lights, instruct to not get up without resistance to prevent dizziness, speak only when 1. Communicates amount of fluid instillation and blood loss Distinguishes
necessary, just before the person goes to surgery “ON CALL” if tentative schedule for normal from abnormal cardiovascular data
surgery. 2. Reports changes in patient’s vital signs Institutes measures to promote
normothermia

Psychological Support (Before Induction and When Patient is Conscious)

Additional Notes from Book
1. Provides emotional support to patient

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 LICEO DE CAGAYAN UNIVERSITY
BACHELOR OF SCIENCE IN NURSING
LEVEL 3

NCM 112: CARE OF CLIENTS WITH PROBLEMS (Medical Surgical Nursing)

LECTURE PRELIM TERM
Clinical Instructor: Bobby Suazo, MSc, MSN, RN /Clinical Instructor/Lecturer S.Y. 2023 - 2024 1ST SEMESTER
TRANSCRIBE BY: MA. EM CONCEPCION LAGARE (MECTL)

2. Stands near or touches patient during procedures and induction. but never replaces asking patients if they feel sufficiently warm and attending to
3. Continues to assess patient’s emotional status their needs.
4. Notifies the patient’s family or significant others of updates throughout the  The older adult is at a higher risk of cardiovascular complications. Of all the body
procedure systems, the cardiovascular system exerts the most influence on anesthesia. The
older adult patient usually has decreased or slow circulation to the rest of the body.
Postoperative Phase A preoperative assessment, including blood tests, blood pressure, and EKG, can
identify potential risks including anemia, hypertension, and arrhythmias.
Transfer of Patient to Post anesthesia Care Unit  The older adult should be assessed for poor memory and cognition. When older
adults are in a vulnerable and stressful state, such as preparing for surgery, they
1. Communicates intraoperative information: may show poor concentration, confusion, and disorganized thought patterns
a) Identifies patient by name  Nurses must educate patients and caregivers about appropriate pain management
b) States type of surgery performed and encourage good communication to obtain greater postoperative pain relief.
c) Identifies type and amounts of anesthetic and analgesic agents used Older adults may need multiple education formats (verbal and print) along with
d) Reports patient’s vital signs and response to surgical procedure and extra time in order to understand and retain what is communicated.
anesthesia
e) Describes intraoperative factors (e.g., insertion of drains or catheters,
administration of blood, medications during surgery, or occurrence of BARIATRICS PATIENTS
unexpected events)
f) Describes physical limitations
g) Reports patient’s preoperative level of consciousness Bariatrics is a specialty that revolves around diagnosing, treating, and managing PATIENTS
h) Communicates necessary equipment needs WITH OBESITY.
i) Communicates presence of family or significant others
 Obesity increases the risk and severity of complications associated with surgery.
Postoperative Assessment Recovery Area  Preoperative assessment of the patient with obesity should pay careful attention to
pulmonary, cardiovascular, psychological, and integumentary systems.
1. Determines patient’s immediate response to surgical intervention  Patients with obesity have more subcutaneous fat. The increase in adipose tissue
2. Monitors patient’s vital signs and physiologic status can result in difficult intravenous (IV) access and delayed wound healing at the
3. Assesses patient’s pain level and administers appropriate pain-relief incision site. They are also associated with increased SSIs and joint replacement
measures failure.
4. Maintains patient’s safety (airway, circulation, prevention of injury)  Patients with BMI >45 – are at increased risk for total joint replacement failure and
5. Administers medications, fluid, and blood component therapy, if post operative infection.
prescribed  Obese patients tend to have shallow respirations when supine – increasing the risk
6. Provides oral fluids if prescribed for ambulatory surgery patient of hypoventilation and postoperative pulmonary complications.
7. Assesses patient’s readiness for transfer to inhospital unit or for discharge  Obstructive Sleep Apnea (OSA) – diagnosed/ undiagnosed is common to obese
home based on institutional policy patients.

Surgical Nursing Unit

1. Continues close monitoring of patient’s physical and psychological

response to surgical intervention
2. Assesses patient’s pain level and administers appropriate pain-relief
measures
3. Provides education to patient during immediate recovery period
4. Assists patient in recovery and preparation for discharge home
5. Determines patient’s psychological status
6. Assists with discharge planning

Home or Clinic

1. Provides follow-up care during office or clinic visit or by telephone contact

2. Reinforces previous education and answers patient’s and family’s
questions about surgery and follow-up care
3. Assesses patient’s response to surgery and anesthesia and their effects
on body image and function
4. Determines family’s perception of surgery and its outcome

SPECIAL CONSIDERATIONS DURING THE PERIOPERATIVE PERIOD

 In an effort to reduce surgical complications, The Joint Commission and the Patients with Disability
Centers for Medicare and Medicaid Services (CMS) developed National Patient
Safety Goals. The goals are updated yearly and identify performance measures
aimed at preventing surgical complications, including venous thromboembolism  Special considerations for patients with mental or physical disability include the
(VTE), surgical site infections (SSIs), and wrong-site surgery related to positive need for appropriate assistive devices, modifications in preoperative education, and
patient identification additional assistance with and attention to positioning or transferring.
 On the day of surgery, the preoperative nurse should verify the list of home  Assistive devices include hearing aids, eyeglasses, braces, prostheses, and other
medications with the patient and, if applicable, confirm which medications the devices.
patient discontinued and when they were last taken.  If the patient relies on signing or speech (lip) reading and their eyeglasses or
contact lenses are removed or the health care staff wears surgical masks, an
GERONTOLOGIC CONSIDERATIONS alternative method of communication will be needed.
 In the preoperative period, the nurse pays careful attention to the integumentary
system of the patient as it can reveal pertinent data about the patient’s health
status.
PATIENTS UNDERGOING AMBULATORY SURGERY
 Assessment includes the overall condition of the skin, and determination of any
bruises, abrasions, and discolorations.
 Precautions are taken when moving an older adult. Decreased subcutaneous fat
Ambulatory surgery includes outpatient, same-day, or short-stay surgery not requiring admission
makes older adults more susceptible to temperature changes. A lightweight cotton
for an overnight hospital stay but may entail observation in a hospital setting for 23 hours or less.
blanket is an appropriate cover when an older patient is moved to and from the OR

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 LICEO DE CAGAYAN UNIVERSITY
BACHELOR OF SCIENCE IN NURSING
LEVEL 3

NCM 112: CARE OF CLIENTS WITH PROBLEMS (Medical Surgical Nursing)

LECTURE PRELIM TERM
Clinical Instructor: Bobby Suazo, MSc, MSN, RN /Clinical Instructor/Lecturer S.Y. 2023 - 2024 1ST SEMESTER
TRANSCRIBE BY: MA. EM CONCEPCION LAGARE (MECTL)

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