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OXFORD MEDICAL PUBLICATIONS

Oxford Handbook of
Surgical Nursing
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Oxford Handbook of
Surgical
Nursing

Edited by

Alison Smith
Lecturer,
University of Birmingham, UK

Maria Kisiel
Formerly Head of Department of Adult
and Critical Care Nursing,
Birmingham City University, UK

Mark Radford
Chief Nursing Officer,
University Hospitals Coventry
and Warwickshire NHS Trust,
and Professor,
Birmingham City University, UK

1
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 v

Foreword

Florence Nightingale stated that ‘Apprehension, uncertainty, waiting,

expectation, fear of surprise, do a patient more harm than any exertion.’
The prospect of surgery can and does generate these emotions. This
Handbook offers nurses with an interest in and passion for surgical nurs-
ing a holistic perspective that can help to address not only these emo-
tions but also the physical and practical elements of practice.
The pace, scale, and sophistication of new treatments and technolo-
gies make surgery one of the fastest changing and exciting special-
ties. The ability to perform surgery on patients with complex medical
problems and chronic illness means that the skills required to provide
competent and compassionate care for these patients must extend
well beyond the fundamentals of pre-​and post-​operative care. Surgical
nurses require both a broad and deep knowledge and the necessary skills
if they are to be able to confidently assess patients’ needs and pre-​empt
potential complications. This is more important than ever now that many
nurses are also undertaking more advanced procedures as part of the
multidisciplinary team.
This Handbook will both act as an aide-​memoire and help to build
a knowledge base that will enable surgical nurses to understand their
core role and their contribution to the modern surgical team. It will be
of benefit to nurses and allied health professionals working on surgical
wards and also in the many settings in which surgical care is delivered,
including day-​surgery, high-​dependency, outpatient, and pre-​operative
assessment clinics. It can be used by clinicians at different stages in their
professional development, including pre-​and post-​registration, as well
as those undertaking specialist and advanced practice.
This evidence-​based, easily accessible, concise Handbook, which can
be used at the bedside, offers practical advice on how to effectively
assess, plan, implement, and evaluate surgical care. It also explains the
wider role of the surgical nurse in effective ward management and lead-
ership, and the implications for patient care.
Patients and their families deserve and expect a high-​quality, digni-
fied, and safe experience when they have surgery. This requires skilled,
compassionate, and competent surgical clinicians who strive to con-
tinue to enhance and develop their knowledge, skills, and practice. This
Handbook without doubt supports the attainment of this. It is packed
with a wealth of information, and has the benefit of being written and
edited by credible, respected, and experienced clinicians and academics,
all of whom understand the challenges that face nurses and allied health
professionals working today in this dynamic and fast-​moving field.

Janice Stevens CBE MA RGN

Director for Midlands and East
Health Education England
vi

Preface

Contributing to the writing and editing of this book has been both chal-
lenging and rewarding, and the end result is a product of the passion
and expertise of the many contributors for improving the care of the
surgical patient. It is hoped that, by using this key resource, the reader
will gain an insight into the diverse nature of surgical nursing and develop
confidence in their clinical practice. Each chapter has been written by
healthcare professionals with a passion for and expertise in their subject
area. The key references and suggestions for further reading at the end
of each section provide the reader with opportunities to supplement
their knowledge further.
Surgery is a complex and varied specialty that has seen significant
changes and technical advances in recent years. Central to this has been
the skill and support of the surgical nurse in ensuring improved outcomes
and compassionate care for patients. From the operating theatre to the
hospital bed, the surgical nursing specialty has developed and diversi-
fied to keep pace with the many advances and improvements in surgery.
Many textbooks in this subject area provide comprehensive information
in an attempt ‘to cover all bases’, which often means that these text-
books are large and not easily transportable to the bedside.
In developing the Oxford Handbook of Surgical Nursing, the editors have
aimed to adhere to the Oxford Handbook philosophy of providing high-​
quality, quick-​reference, pocket-​sized resources that enable nurses to
easily check key clinical facts. It is hoped that this Handbook will also
complement and build upon other publications, while enabling nurses
and other allied healthcare professionals to quickly access concise rele­
vant information to support their clinical practice.

Alison Smith
Maria Kisiel
Mark Radford
2016
 vii

Contents

Contributors ix
Symbols and abbreviations xi

1 Introduction to the surgical patient    1

2 Managing the surgical ward   29
3 Surgical care models   53
4 Pre-​operative assessments and preparation   61
5 Pre-​operative optimization 103
6 Transfer to other departments or theatre 115
7 Intra-​operative care 123
8 Ward post-​operative care 149
9 Pain management 167
10 Nutrition and hydration 193
11 Transfusion of blood products 213
12 Wound care 241
13 Skin assessment 257
14 Infection: prevention, control, and treatment 265
15 Post-​operative complications 313
16 Surgical nursing procedures 335
17 Ophthalmology 361
18 Upper gastrointestinal and hepatobiliary surgery 395
19 Colorectal and lower gastrointestinal surgery 419
20 Trauma and orthopaedics 439
21 Vascular surgery 519
22 Urology and renal surgery 547
23 Neurological and spinal surgery 581
24 Burns and plastic surgery 613
viii CONTENTS

25 Thoracic surgery 651

26 Cardiac surgery 667
27 Breast surgery 695
28 Gynaecological surgery 725

Index 747

Contributors
Debra Adams
(Chapter 14)
Head of Infection Prevention and
Control (Midlands and East)
NHS Trust Development
Authority, UK
Ann-​Marie Cannaby
(Chapter 2)
Executive Director of Nursing
Hamad Medical
Corporation, Qatar
Ruth Capewell
(Chapter 28)
MacMillan Gynaecology Clinical
Nurse Specialist (Oncology)
University Hospitals Coventry
and Warwickshire NHS Trust, UK
Anna Casey
(Chapter 14)
Clinical Research Scientist
University Hospitals Birmingham
NHS Foundation Trust, UK
Kirsty Cotterill
(Chapter 28)
Gynaecology Clinical
Nurse Specialist
University Hospitals Coventry
and Warwickshire NHS Trust, UK
Kevin Crimmons
(Chapter 25)
Head of Adult Nursing
Birmingham City University, UK
Patricia Davies
(Chapter 12, Chapter 13)
Senior Lecturer
Birmingham City University, UK
Suzanne Davies
(Chapter 21)
Vascular Nurse Specialist
University Hospitals Coventry
and Warwickshire NHS Trust, UK
ix
Helen Gibbons
(Chapter 17)
Senior Lecturer
City University, London, UK
Suzanne Hammond
(Chapter 28)
Urogynaecology Clinical
Nurse Specialist
University Hospitals Coventry
and Warwickshire NHS Trust, UK
Kim Harley
(Chapter 20, Chapter 23)
Formerly Senior Lecturer
Birmingham City University, UK
Suzanne Harrington
(Chapter 28)
Modern Matron— ​Gynaecology
University Hospitals Coventry
and Warwickshire NHS Trust, UK
Helen Holder
(Chapter 10)
Senior Lecturer
Birmingham City University, UK
Louise Jennings
(Chapter 28)
Clinical Nurse Specialist
Gynaecology Outpatient
Department,
University Hospitals Coventry
and Warwickshire NHS Trust, UK
Sue Jones
(Chapter 23)
Formerly Senior Lecturer
Birmingham City University, UK
Aaron Kisiel
(Chapter 1)
CT1 General Surgery
University Hospitals Birmingham
NHS Foundation Trust, UK
x CONTRIBUTORS

Maria Kisiel Anna Rudkin

(Chapter 1, Chapter 26) (Chapter 28)
Formerly Head of Department of Gynaecology Clinical Nurse
Adult and Critical Care Nursing Specialist
Birmingham City University, UK University Hospitals Coventry
and Warwickshire NHS Trust, UK
Alison Kite
(Chapter 21) Debbie Shreeve
Clinical Nurse Specialist—​ (Chapter 22)
Vascular Surgery Urology Nurse Specialist
University Hospitals Coventry University Hospitals Coventry
and Warwickshire NHS and Warwickshire NHS Trust, UK
Trust, UK
Alison Smith
Jane Leaver (Chapter 1, Chapter 6, Chapter 8,
(Chapter 24) Chapter 11, Chapter 18,
Senior Lecturer Chapter 26)
Birmingham City University, UK Lecturer
University of Birmingham, UK
Lorraine Marsons
(Chapter 25) Dion Smyth
Senior Lecturer (Chapter 27)
Birmingham City University, UK Senior Lecturer
Birmingham City University, UK
Ross Palmer
(Chapter 8) Richard Stock
Modern Matron—​Trauma and (Chapter 20)
Orthopaedics Senior Lecturer
University Hospitals Coventry Birmingham City University, UK
and Warwickshire NHS
Trust, UK Meriel Swann
(Chapter 9)
Claire Perkins Senior Lecturer
(Chapter 15, Chapter 16) Birmingham City University, UK
Senior Lecturer
Birmingham City University, UK Iain Wharton
(Chapter 22)
Mike Phillips Consultant Urologist
(Chapter 5) University Hospitals Coventry
Lead Anaesthesia Practitioner and Warwickshire NHS Trust, UK
Heart of England NHS
Foundation Trust, UK Maddie White
(Chapter 19)
Mark Radford Colorectal Nursing Team Leader
(Chapter 3, Chapter 4, Chapter 7) University Hospitals Birmingham
Chief Nursing Officer NHS Foundation Trust, UK
University Hospitals Coventry
and Warwickshire NHS Trust, Annette Wye
and Professor (Chapter 21)
Birmingham City University, UK Vascular Nurse Specialist
University Hospitals Coventry
and Warwickshire NHS Trust, UK
 xi

Symbols and abbreviations

2 important
3 act quickly
E cross-​reference
M website
AAA abdominal aortic aneurysm
ABPI Ankle Brachial Pressure Index
ACE angiotensin-​converting enzyme
ACS acute coronary syndrome
ADH antidiuretic hormone
AED automated external defibrillator
AF atrial fibrillation
AFP alpha-​fetoprotein
AIDS acquired immunodeficiency syndrome
AKI acute kidney injury
ALI acute lung injury
ALT alanine transaminase
ANTT aseptic non-​touch technique
AP anteroposterior
APC activated protein C
APTT activated partial thromboplastin time
ARDS acute respiratory distress syndrome
ASA American Society of Anesthesiologists
ASI acute spinal injury
AST aspartate transaminase
ATP adenosine triphosphate
AUR acute urinary retention
AV atrioventricular
AVPU Alert, Voice, Pain, Unresponsive
BAPEN British Association for Parenteral
and Enteral Nutrition
BCC basal-​cell carcinoma
BMI body mass index
xii SYMBOLS AND ABBREVIATIONS

BMT best medical therapy

BPH benign prostatic hyperplasia
BSE bovine spongiform encephalopathy
CABG coronary artery bypass graft
CAPD continuous ambulatory peritoneal dialysis
CBT cognitive behavioural therapy
CD controlled drug
CJD Creutzfeldt– ​Jakob disease
CK creatinine kinase
CMV cytomegalovirus
CNS central nervous system
COPD chronic obstructive pulmonary disease
CPAP continuous positive airway pressure
CPE carbapenemase-​producing Enterobacteriaceae
CPET cardiopulmonary exercise testing
CPR cardiopulmonary resuscitation
CQC Care Quality Commission
CRP C-​reactive protein
CSF cerebrospinal fluid
CT computed tomography
CUR chronic urinary retention
CVA cerebrovascular accident
CVP central venous pressure
DAI diffuse axonal injury
DBS deep brain stimulation
DCIS ductal carcinoma in situ
DIC disseminated intravascular coagulopathy
DKA diabetic ketoacidosis
DVT deep vein thrombosis
DXA dual-​energy X-​r ay absorptiometry
ECF extracellular fluid
ECG electrocardiogram
ED erectile dysfunction
EDTA ethylene diamine tetra-​acetic acid
EEG electroencephalography
 SYMBOLS AND ABBREVIATIONS xiii

EMDR eye movement desensitization and reprocessing

ERAS enhanced recovery after surgery
ERCP endoscopic retrograde cholangiopancreatography
ERP Enhanced Recovery Programme
ERPOC evacuation of retained products of conception
ERV expiratory reserve volume
ESBL extended-​spectrum β-​lactamase
ESR erythrocyte sedimentation rate
ETF enteral tube feeding
FAP familial adenomatous polyposis
FAST focused assessment with sonography for trauma
FBC full blood count
FDP fibrin degradation product
FES fat embolism syndrome
FEV1 forced expiratory volume in 1 s
FFP fresh frozen plasma
FRC functional residual capacity
FRCA Fellow of the Royal College of Anaesthetists
FRCS Fellow of the Royal College of Surgeons
FVC forced vital capacity
FVD fluid volume deficit
GALS gait, arms, legs, and spine
GCS Glasgow Coma Scale
GI gastrointestinal
GMC General Medical Council
GORD gastro-​oesophageal reflux disease
GTN glyceryl trinitrate
HAART highly active antiretroviral therapy
Hb haemoglobin
HbA1c glycated haemoglobin
HCAI healthcare-​a ssociated infection
HER2 human epidermal growth factor receptor-​2
HHS hyperosmolar hyperglycaemic state
HIV human immunodeficiency virus
HPV human papilloma virus
xiv SYMBOLS AND ABBREVIATIONS

HRT hormone replacement therapy

HSDU Hospital Sterilization and Disinfection Unit
HSV herpes simplex virus
IABP intra-​aortic balloon pump
IBD inflammatory bowel disease
IC inspiratory capacity
ICF intracellular fluid
ICP intracranial pressure
IHD ischaemic heart disease
IM intramuscular
INR international normalized ratio
IOL intra-​ocular lens
IOP intra-​ocular pressure
IPC infection prevention and control
IPH inadvertent peri-​operative hypothermia
IPPV intermittent positive pressure ventilation
IRV inspiratory reserve volume
IV intravenous
JVP jugular venous pressure
LBO large bowel obstruction
LDH lactate dehydrogenase
LFT liver function test
LMA laryngeal mask airway
LV left ventricle
MAP mean arterial pressure
MDT multidisciplinary team
MET metabolic equivalent
MHRA Medicines and Healthcare products
Regulatory Agency
MI myocardial infarction
MODS multiple organ dysfunction syndrome
MRI magnetic resonance imaging
MRSA meticillin-​resistant Staphylococcus aureus
MSSA meticillin-​sensitive Staphylococcus aureus
MUST Malnutrition Universal Screening Tool
 SYMBOLS AND ABBREVIATIONS xv

NAI non-​accidental injury

NBM nil by mouth
NCEPOD National Confidential Enquiry into Patient Outcome
and Death
NEWS National Early Warning Score
NICE National Institute for Health and Care Excellence
NIPPV non-​invasive positive pressure ventilation
NMC Nursing and Midwifery Council
NPA nasopharyngeal airway
NPSA National Patient Safety Agency
NRS numerical rating scale
NSAID non-​steroidal anti-​inflammatory drug
NSTEMI non-​ST-​segment-​elevation myocardial infarction
NYHA New York Heart Association
ODP operating department practitioner
OGTT oral glucose tolerance test
ONS oral nutrition supplements
OPA oropharyngeal airway
ORIF open reduction and internal fixation
PA posteroanterior
PaCO2 partial pressure of carbon dioxide
PAD peripheral artery disease
PaO2 partial pressure of oxygen
PCA patient-​controlled analgesia
PCI percutaneous coronary intervention
PEEP positive end-​expiratory pressure
PEG percutaneous endoscopic gastrostomy
PEJ percutaneous endoscopic jejunostomy
PET positron emission tomography
PET-​C T positron emission tomography with computed
tomography
PGD patient group direction
PICC peripherally inserted central catheter
PID pelvic inflammatory disease
PII period of increased incidence
PMC pseudomembranous colitis
xvi SYMBOLS AND ABBREVIATIONS

PMPS post-​mastectomy pain syndrome

PN parenteral nutrition
PONV post-​operative nausea and vomiting
PPE personal protective equipment
PPV positive pressure ventilation
PSA prostate-​specific antigen
PSC primary sclerosing cholangitis
PT prothrombin time
PTSD post-​traumatic stress disorder
PTT partial thromboplastin time
PVL Panton–​Valentine leucocidin
RAS renal artery stenosis
RCA root cause analysis
RCC renal-​cell carcinoma
REMS regional examination of the musculoskeletal system
RICP raised intracranial pressure
RIG radiologically inserted gastrostomy
RN registered nurse
RRT renal replacement therapy
RSI rapid sequence induction
RTT referral to treatment time
RV residual volume
SA sinoatrial
SAH subarachnoid haemorrhage
SALT speech and language therapy
SBAR Situation– ​Background–​A ssessment– ​Recommendation
SBC standard bicarbonate concentration
SBO small bowel obstruction
SCC squamous-​cell carcinoma
SGOT serum glutamic oxaloacetic transaminase
SHOT Serious Hazards of Transfusion
SICP Standard Infection Control Precautions
SIGN Scottish Intercollegiate Guidelines Network
SIRS systemic inflammatory response syndrome
SSI surgical site infection
 SYMBOLS AND ABBREVIATIONS xvii

STEMI ST-​segment-​elevation myocardial infarction

STI sexually transmitted infection
SUFE slipped upper femoral epiphysis
TBI traumatic brain injury
TBP Transmission-​Based Precautions
TBSA total body surface area
TBW total body water
TCI target-​controlled infusion
TENS transcutaneous electrical nerve stimulation
TIPS transjugular intrahepatic portosystemic shunt
TIVA total intravenous anaesthesia
TLC total lung capacity
TNF tumour necrosis factor
TNP topical negative pressure
TPN total parenteral nutrition
TRALI transfusion-​related acute lung injury
TSH thyroid-​stimulating hormone
tTGA tissue transglutaminase
TV tidal volume
U&E urea and electrolytes
UTI urinary tract infection
VAD venous access device; ventricular assist device
VAS visual analogue scale
VATS video-​a ssisted thoracic surgery
VC vital capacity
V/​Q ventilation/​perfusion
VRE vancomycin-​resistant enterococci
VTE venous thromboembolism
WCC white cell count
WFNS World Federation of Neurological Surgeons
WHO World Health Organization
 Chapter 1 1

Introduction to the
surgical patient

The surgical patient 2

The surgical team 4
The role of the surgical nurse 6
Classification of surgery 7
Terminology in surgery 9
Basic anatomy of the chest 11
Basic anatomy of the abdomen 13
Basic anatomy of the upper limb 15
Basic anatomy of the lower limb 17
Basic anatomy of the head and neck 19
Basic anatomy of the gastrointestinal tract 21
Basic anatomy of the vascular system 24
Basic anatomy of the genito-​urinary system 25
2 Chapter 1 Introduction to the surgical patient

The surgical patient

Surgical patients receive physical treatment in the form of operative
procedures to remove or replace diseased organs and/​or tissues. This
means that specific aspects of the care of these patients may differ from
those of medical patients. In addition, surgical patients are at risk of com-
plications following a surgical procedure.
Psychological support
Psychological support is required throughout the peri-​operative period,
in order to ensure that the patient:
• is able to express any fears and anxieties
• has a clear understanding of the processes involved in the pre-​operative
assessment and preparation for surgery
• understands the surgical procedure that is being undertaken and the
potential risks and complications
• is aware of the interventions and monitoring required in the
post-​operative period
• has access to specialist nursing teams in order to discuss any
concerns and anxieties they may have relating to altered body image
(e.g. scarring, prosthesis)
• knows who to contact if they have a query or concern after discharge
from hospital.
Pain management
Surgical patients require good-​quality pain management interventions
both following surgical procedures and prior to surgery. If a patient’s pain
is poorly controlled, the following complications may occur:
• emotional and physical suffering, which can result in the breakdown
of the nurse–​patient relationship
• cardiovascular effects, tachycardia, and hypertension
• increased oxygen demand
• reduced respiratory function, and consolidation or collapse of the
alveoli
• reduced mobility, which increases the risk of developing a venous
thromboembolism
• sleep disturbance
• delayed discharge.
Wound care and infection control
Surgical site infections represent 16% of all healthcare-​a ssociated infec-
tions, and can have both physical and psychological effects on the patient.1
Most surgical site infections are preventable, and it is the responsibility
of all members of the multidisciplinary team (MDT) to ensure that meas-
ures are taken to reduce the risk of infection. Best practice should be
adhered to at all times, while also taking into consideration the patient’s
individual needs and preferences.
 The surgical patient 3

Nutrition
Following surgery the patient may have a reduced appetite due to nausea
and vomiting, which are side effects of analgesic and anaesthetic drugs.
It is important that the surgical patient has a diet rich in protein and
vitamins, to promote wound healing. The body has an increased meta-
bolic demand for protein following surgery, due to the stress response
releasing catecholamines such as cortisol. A diet rich in fibre is also
required to prevent constipation, which can occur as a result of reduced
mobility or after the administration of opioid analgesia.

Reference
1 National Institute for Health and Care Excellence (NICE). Surgical Site Infection. QS49.
NICE: London, 2013. M www.nice.org.uk/​g uidance/​q s49
4 Chapter 1 Introduction to the surgical patient

The surgical team

The surgical team consists of a range of healthcare professionals who
are involved in the patient’s care throughout the peri-​operative period.
Patient safety is at the centre of care provision, and requires effective
leadership and teamworking by all clinical staff. The surgical team and
wider members of the MDT have an obligation to support each other
while delivering patient care in wards, theatre, clinics, and community
settings following discharge. It is imperative that there is effective com-
munication between all team members with regard to the patient’s care,
in order to maintain high standards of patient care and reduce the risk
of errors.
Key members of the general intra-​operative team include the following:
• surgeon
• surgical care practitioner
• anaesthetist
• anaesthetic practitioner
• advanced scrub practitioner
• circulating practitioner
• recovery practitioner.
Surgeon
In the operating department, the surgeon is the lead member of the MDT.
He or she is responsible for performing the surgery safely and effectively,
while at the same time maintaining a good level of communication with
the scrub practitioner and the anaesthetist. The consultant surgeon is
responsible for the patient’s care throughout the peri-​operative period.
Surgical care practitioner
The surgical care practitioner was defined by the Royal College of
Surgeons of England2 as ‘a registered non-​medical practitioner who has
completed a Royal College of Surgeons accredited programme (or other
previously recognized course) working in clinical practice as a member
of the extended surgical team, who performs surgical intervention, pre-​
operative and post-​operative care under the direction and supervision
of a consultant surgeon.’
The role includes the provision of care and appropriate interventions
within the peri-​operative, ward, and clinic settings.
Anaesthetist
The anaesthetist administers the anaesthetic, maintains the patient’s air-
way, and monitors and acts upon the patient’s vital signs throughout the
intra-​operative period. He or she is responsible for assessing the patient
prior to surgery and putting in place a plan of pain management interven-
tions for the initial post-​operative period.
 The surgical te am 5

Anaesthetic practitioner
The anaesthetic practitioner provides skilled assistance to the anaesthe-
tist. He or she may be an operating department practitioner (ODP) or
a nurse who has undertaken further training. Such nurse training may be
an in-​house competency-​based programme or a university degree-​level
anaesthetics course.
Advanced scrub practitioner
A nurse or ODP undertakes post-​registration training to enable them
to take on the role of advanced scrub practitioner, which is defined
by the Perioperative Care Collaboration3 as ‘the role undertaken by a
registered peri-​operative practitioner providing competent and skilled
assistance under the direct supervision of the operating surgeon while
not performing any form of surgical intervention.’ They are responsible
for draping the patient and handling sterile instruments and supplies. The
scrub practitioner is also responsible for ensuring that all swabs, needles,
and instruments are accounted for at the end of the procedure.
Circulating practitioner
The circulating practitioner acts as a ‘runner’, ensuring that adequate sup-
plies are available and providing the scrub practitioner with any equip-
ment that is not available on the scrub trolley. They need to have a good
knowledge of where equipment is stored, in order to minimize delays
in treatment during surgery. Circulating practitioners also assist with
positioning of the patient and repositioning of equipment (e.g. lighting,
cameras) for the surgical team.
Recovery practitioner
The recovery practitioner works in the recovery area of the operating
theatre, and may be an ODP or a nurse who has undertaken further
training. They ensure that the post-​operative patient is able to maintain
his or her airway and is receiving adequate analgesia. They also monitor
the patient’s vital signs, wound site, and wound drain, and complete all
documentation according to trust policy. They will hand over to the ward
nurse, providing details of the patient’s intra-​operative care and specific
instructions from the surgeon and anaesthetist for patient care during
the post-​operative period.

References
2 Royal College of Surgeons of England. The Curriculum Framework for the Surgical Care
Practitioner, 2nd edn. Royal College of Surgeons of England: London, 2014.
3 Perioperative Care Collaborative. The Role and Responsibilities of the Advanced Scrub
Practitioner. Perioperative Care Collaborative: London, 2007.
6 Chapter 1 Introduction to the surgical patient

The role of the surgical nurse

Surgical nurses are skilled in preparing patients for surgical procedures
and caring for them after surgery. They need to have a good theoretical
knowledge of the following:
• anatomy and physiology
• complications associated with surgical procedures
• asepsis
• infection control
• pharmacology, including pain management
• anxiety and coping mechanisms
• patient education
• discharge planning.
All surgical nurses should be competent to provide care for patients in
the pre-​operative and post-​operative period. Nursing care should be
evidence-based and comply with local or national policy, to ensure that
the patient receives optimum care in order to reduce the risks associated
with surgery.
When further developing their skills, the surgical nurse should consider
whether:
• the skill will benefit the quality of patient care that they deliver
• they are the best person to develop this skill
• when they have acquired the skill they will use it often enough in
clinical practice to remain competent.
A good knowledge of ethical, legal, and professional issues is essential
within surgical nursing. The Nursing and Midwifery Council (NMC) Code
of Conduct4 is a professional document that is based on ethical prin-
ciples within the laws of the UK. The four key ethical principles within
healthcare are:
• beneficence—​balancing the benefits of treatment against the risks
and costs that it incurs
• non-​maleficence—​avoiding harm; all treatment incurs a small
amount of harm, but the harm should not be disproportionate to the
benefits of treatment
• autonomy—​enabling an individual to make reasoned and informed
decisions about their care
• justice—​the act of being just and fair.
A good working knowledge of consent is imperative for surgical
nurses, particularly in special circumstances (e.g. when the patient is
unconscious).

Reference
4 Nursing and Midwifery Council (NMC). The Code: professional standards of practice and behav-
iour for nurses and midwives. NMC: London, 2015.
 Cl assification of surgery 7

Classification of surgery
In December 2004, the National Confidential Enquiry into Patient
Outcome and Death (NCEPOD)5 issued new classifications of interven-
tions. These are as follows:
• immediate
• urgent
• expedited
• elective.
They replace the old categories of surgery, which were as follows:
• emergency
• urgent
• scheduled
• elective.
These classifications exist to ensure that patients receive surgery within
the time frame necessary for their condition, and also to ensure that
medical staff only perform surgery out of hours when it is appropriate to
do so. The classification should be assigned by the consultant caring for
the patient, at the time when the decision to operate is taken. Specific
conditions or types of surgery cannot be pre-​a ssigned to these catego-
ries, as individual patient need will vary on a case-​by-​case basis.
Immediate surgery
Surgery takes place within minutes of the decision to operate, in order
to save life, an organ, or a limb. It should take place in the next available
operating theatre, and can necessitate interrupting existing theatre lists.
Examples of this category include:
• a ruptured aortic aneurysm that requires repair
• a myocardial infarction that requires a coronary angioplasty to
restore the blood supply to the myocardium.
Urgent surgery
The surgical intervention normally takes place within hours of the deci-
sion to operate, in order to treat the acute onset or the clinical dete-
rioration of a potentially life-​threatening condition. It also includes the
fixation of fractures, and the relief of pain or other distressing symptoms.
Patients who are to undergo this category of surgery should be added to
the emergency theatre list. Examples include:
• a laparotomy for a perforated large bowel
• the debridement and fixation of a compound fracture.
Expedited surgery
The surgical intervention takes place within days of the decision to oper-
ate for a condition that requires early intervention but which does not
pose an immediate threat to life, a limb, or an organ. The patient should
either be added to an elective theatre list which has spare capacity, or be
included on a daytime emergency list. Examples include:
• a developing large bowel obstruction that requires excision of a tumour
• surgery to correct a retinal detachment that could lead to loss of
vision in the affected eye.
8 Chapter 1 Introduction to the surgical patient

Elective surgery
This type of surgery is planned in advance of a routine admission, at a
time to suit the patient and the hospital. It takes place on an elective
theatre list, having been booked in advance. Examples include:
• a knee replacement for a patient with degenerative knee joint disease
• varicose vein surgery.

Reference
5 National Confidential Enquiry into Patient Outcome and Death. The NCEPOD Classification
of Intervention. NCEPOD: London, 2004.
 Terminology in surgery 9

Terminology in surgery
Many different terms are used within surgery, and some of the main
terms are defined here. Other surgical terminology will be discussed in
subsequent chapters.
Abscess
An accumulation of pus that forms within a tissue when the body tries
to fight an infection.
Adhesion
A band of scar tissue that joins together organs or tissues that would
normally be separate.
Amputation
The removal of all or part of a limb or body extremity (e.g. a finger),
either by surgery or as a result of trauma.
Anastomosis
The joining of two structures that would not normally be connected.
Biopsy
The process of taking a sample of living tissue to be examined under the
microscope.
Debridement
The removal of dead, damaged, contaminated, or infected tissue from
a wound.
Diathermy
A surgical technique in which heat produced by electric currents is used
to cut body tissue or seal bleeding vessels.
-​ectomy
The surgical removal of an anatomical structure (e.g. appendectomy is
the surgical removal of the appendix).
Excision
The surgical removal of all or part of an anatomical structure by cutting
it out.
Fistula
An abnormal connection consisting of a passage or duct between an
organ, vessel, or tissue and another anatomical structure.
Hernia
The abnormal bulging or protrusion of a tissue or organ through a weak-
ened area in the muscle or other tissue that normally surrounds it.
Incision
A cut made through skin or other tissue in order to expose the underly-
ing tissue, organ, or bone.
10 Chapter 1 Introduction to the surgical patient

Laparoscopy
A surgical procedure in which a viewing instrument (laparoscope) is used
to visualize the organs and tissues in the abdomen without the need to
make a large incision.
Laparotomy
A surgical procedure in which a large incision is made through the
abdominal wall to provide access to the abdominal cavity.
Microsurgery
The use of a microscope and specialized instruments to allow very small
structures to be visualized and operated on.
Minimally invasive
A surgical technique that is considered to be less traumatic than the tra-
ditional technique. Keyhole surgery is a widely used minimally invasive
technique.
Necrosis
The death of cells within a tissue. Necrotic tissue cannot be treated and
must be excised.
-​oscopy
The use of a viewing instrument to examine an organ or tissue (e.g. bron-
choscopy of the lungs).
-​ostomy
A surgically created opening in the body to allow the discharge of body
waste (e.g. colostomy).
Paralytic ileus
Obstruction of the intestine caused by paralysis of the intestinal muscles.
Peri-​operative
Relating to a procedure or treatment that occurs at or around the time
of a surgical operation.
-​plasty
The surgical repair, restoration, or reshaping of a tissue, organ, or ana-
tomical structure (e.g. rhinoplasty following nasal surgery).
Resection
The surgical removal of part or all of an organ or anatomical structure.
Sigmoidoscopy
A minimally invasive procedure that is used to examine the large intestine
from the rectum to the colon.
Stricture
An abnormal narrowing of a tubular structure in the body (e.g. urethral
stricture).
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