Medical Surgical Nursing

BACHELOR OF
SCIENCE IN NURSING
 CONCEPT IN THE CARE OF AT RISK
AND SICK ADULTS
Health care situation
GLOBAL, NATIONAL AND LOCAL
Top 10 leading cause of deaths in Philippines this 2022
1. Ischemic Heart Disease
2. Heart disease
3. Cerebrovascular disease
4. cancer
5. DM
6. COVID 19, 2021 3RD
7. Pneumonia
8. other heart disease
9. chronic lower respiratory disease
10.genitourinary system
11. respiratory tuberculosis
1. CHRONIC ILLNESS-refers to human experience of
living with a chronic disease or condition. it is the
individuals perception of the experience of having a
chronic disease.

2. CHRONIC DISEASE- are long term health

condition or recurring
 Common problems
• heart disease, chronic lower respiratory disease, stroke,
alzheimers, cancer, obesity, kidney failure, arthritis
CULTURAL AND HEALTH ETHNIC DISPARITIES
AND CULTURALLY COMPETENT CARE
 PERIOPERATIVE NURSING

PERIOD IN THE HEALTH CARE CINTINUUM

THAT FOCUSES MERELY ON THE TIME OF
SURGERY UNTIL RECOVERY OF THE PATIENT

• PRE OPERATIVE NURSING

• INTRA OPERATIVE NURSING
• POST OPERATIVE NURSING
 pre- operative

Phases of the Surgical Experience

1. The perioperative period begins when the patient is
informed of the need for surgery, includes the surgical
procedure and recovery, and continues until the
patient resumes his or her usual activities. The
surgical experience can be segregated into three
phases: (1) preoperative, (2) intraoperative, and (3)
post operative. The word "perioperative" is used to
encompass all three phases. The perioperative nurse
provides nursing care during all three phases.
Preoperative
2. The preoperative phase begins when thepatient,
or someone acting on the patient's behalf, is
informed of the need for surgery and makes the
decision to have the procedure. This phase ends
when the patient is transferred to the operating
room bed.
The preoperative phase is the period that isused to
physically and psychologically prepare the patient
for surgery.
The length of the pre-operative period varies. For the patient
whose surgery is elective, the period may be lengthy. For the
patient whose surgery is urgent, theperiod is brief, the patient
may have no awareness of this period.
4. Diagnostic studies and medical regimens areinitiated in the
preoperative period. Information obtained from preoperative
assessment and interview is used to prepare a plan of carefor
the patient.
5. Nursing activities in the preoperative phase are directed
toward patient support, teaching, and preparation for the
procedure.
PERIOPERATIVE NURSING
Definition of perioperative nursing-Period in the health care
continuum that focuses merely on the time of surgery until the
recovery of the patient.

Appendectomy is classified as:Ablative

Inflamed gallbladder category of surgery based on urgency:Urgent
Pneumonectomy within 24-30 hours - category of surgery based
on urgency:Urgent
Removing her gallbladder (Cholecystectomy):Ablative
Palliative surgery to correct an intestinal obstruction:Done to
relieve symptoms or improve function
 PRE-OP
 Right to information regarding the operation achieved through
informed consent
 Not part of an informed consent for surgery- A guarantee of the
results of the planned surgery
 True about informed consent - The client must be fully informed
regarding treatment, tests, surgery and the risks and benefits prior
to giving informed consent
 Explain the procedure and obtain informed consent by Surgeon
 Emergency surgery - client cannot sign the consent form because of
sedation form narcotic appropriate action
 Obtain telephone consent from a family member and have the
consent witnessed by two persons.
 Criteria for valid consent are -Voluntary, Informed, and Competent
 Patient seems confused about the procedure to be performed appropriate
response by the nurse is to Ask the patient what the physician told him
and then call if necessary
 Thumb mark of a comatose patient in the informed consent is
considered: A not valid signature
 Procedure or practice requires surgical asepsis: IV catheter insertion
 Cleansing enema - position: Left Sim's position
 Administered three enemas and the client is still passing brown liquid
stool next action.
 Notify physician Transfer to the operating room - actions in the care of
this client at this time.
 Ensure that the client has voided
Intraoperative
 The intraoperative phase begins when the patient is
transferred to the operating room bed and ends with transfer
to the postanesthesia care unit (PACU) or another area where
immediate postsurgical recovery care is given. During the
intraoperative period, the patient is monitored, anesthetized,
prepped, and draped, and the procedure is performed.
Nursing activities in the intraoperative period center on
patient safety, facilitation of the procedure, prevention of
infection, and satisfactory physiologic response to anesthesia
and surgical intervention.
Nursing care plan for the client on the day of surgery
Have the client void immediately before surgery.
The worst of all fears among clients undergoing surgery is: Fear of the
unknown
 Preoperative assessment patient is extremely anxious. Notify the surgeon
Appropriate response to a crying client for surgery: Stand by her side and
quietly ask her to describe her feelings
Client expresses anxiety to a nurse about surgery - response by the nurse:
"Can you share with me what you've been told about your surgery?"
Statement about a person's character is evident in the OR team.
 it reflects the moral values and beliefs that are used as guides to personal
behavior and actions
Intervention will allay anxiety and pain among surgical patients:
Assess the client for concerns especially those that can potentially
cause pain
Demonstrates knowledge of the psychological response to the
operation and other invasive procedure when she asks about How is
the post operative pain over the site like?
Clients are at risk for latex allergies if they are allergic to all of the
following, except: Apples
 Allergy to latex-assess allergy to Bananas
Diagnosed with latex allergy - instructs the client to avoid use of
condoms
 Allergy to latex- asks the medical supply personnel to deliver Cotton
pads and silk tape
Latex allergy
 Apply a cloth barrier to the client's arm under a blood pressure
cuff when taking the blood pressure.
 Erythema and itching around her mouth after blowing up a
balloon -- likely due to A latex allergy
Preoperative teaching for a client scheduled for surgery needs
additional teaching if the client states: "I need to continue to
take the aspirin as prescribed until the day of the surgery."
Tonsillectomy most essential for the nurse to ask the mother:
"Does your child have any bleeding tendencies?"
Best time to provide preoperative teaching: During the
preadmission visit & the afternoon or evening before surgery
Given highest priority when receiving patient in the OR Verify patient
identification and informed consent
The nurse notices that the band was missing → immediate action of the
nurse is to: Place a new identification band on the client's wrist before the
client can be transported to the OR
Given sulfasuxidine and neomycin primarily to: reduce the bacterial
content of the colon
 Check for the medical clearance clearance primarily Covers Cardio-
pulmonary system
Tonsillectomy reported:
assessment findings needs to be Presence of loose tooth
Refuses to remove her plain gold wedding band before going to surgery
best action to take. Cover the wedding band with adhesive tape and tape it
to her finger
Primary objective of preoperative skin prep is to:
Prevent postoperative infection by reducing the number
of microorganisms of the skin.
If hair at the operative site is not shaved → done to
make suturing easy and lessen chance of incision
infection Clipped Adrenalectomy - priority nursing
action preoperatively is to monitor Vital signs
Single most important procedure for preventing
hospital-acquired infections Handwashing
Complete scrub should last for how many minutes 10-15
minutes
Meet the safety need of the client after administering
preoperative narcotic put side rails up and ask the client not
to get out of bed INTRAOP
Pre-operative drug is use to decrease salivation and prevent
aspiration: Atropine sulfate & scopolamine
Nursing check that should not be missed before the
induction of general anesthesia is: Check baseline vital signs
Color of the tank which contains laughing gas Blue
MAJOR advantage of regional anesthesia is that the client
Remains conscious Spinal anaesthesia - the client will
experience a loss of Motor and sensory function
Fentanyl epidural analgesia → nursing priority care
Assess respiratory rate carefully Norcuron (vercuronium
bromide) - important to monitor Respiration
Third stage of anesthesia, the client is Already
unconscious, has relaxed muscles and the surgery is
started. General anethesia and is in stage II of anesthesia
- intervention to implement during this stage. Restrain
the patient Tonsillectomy and adenoidectomy. General
anesthesia
Closely assess to a client halothane (Fluothane)
Respiratory depression
2 general types of General Anesthesia (GA) Intravenous and
inhalation
Spinal anesthesia → highest priority Complaints of headache
Epidural anesthesia - following administration of the
anesthesia, the nurse should.
1. Priority Monitor the client for respiratory depression
2 priority: hypotension (common side effect) Inherited muscle
disorder chemically induced by anethesia/anesthetic agents:
Malignant hyperthermia is a potential postoperative
complication gathering information on the patient's medical
history, the nurse should ask problems "Has anyone in your
family ever had with general anaesthesia?"
Drug should be available to reverse malignant hyperthermia crisis
dantrolene (Dantrium)
Maintaining the client's safely-circulating nurse. Strap made of
strong non-abrasive materials are fastened securely around the joints
of the knees and ankles and around the 2 hands around an arm board
Behavior in the OR is so lightly controlled is to prevent the cross-
contamination of infection between OR staff and patient
Traffic patterns in the OR suite should Prevent transmission of
pathogenic microorganisms Conversation while in the operation is
ongoing is minimized because it enhances the spread of
microorganism to the incision site
In the OR, "Surgical Conscience" means. Honest adherence to
surgical aseptic techniques all the time
Clear advantage of single-use items is up a
professional ofessional nurse is capable of providing
safe, humane, quality and holistic care to individuals
in alth providers to promote health, prevent illness,
restore health, alleviate suffering and mind alth-
illness status, healthy or at risk families, population
groups and community singly or in who is able to
assume entry-level positions in health facilities or
nurse The Community settings. collaboration with
other varying age, gender and of life carere intra-
operative procedure
 PRINCIPLES OF STERILE TECHNIQUE include except: The
circulating nurse can have a direct contact with the sterile field.
When donning gloves: Pick up the right glove with the left hand
covered with cuff by grasping the fingers, lifting straight up, and
placing on the right palm side down.
Counting of instruments → counting process: From the field, on the
back table and outside the field (FBO) Principles of sterile
technique are strictly applied and doubt might occur when: Change
table levels according to the height level of the surgeon.
Indicates the scrub nurse has broken sterile technique: When the
surgical hair cap is touched. According to Anesthesia OR Nurse
surgical attire intended only for use within the surgical suite should
be worn within the Restricted area only
 Restricted area Head cap, scrub suit, mask, OR shoes
 NOT considered a piece of personal protective equipment (PPE): Sterile gauze
 Personal protective equipment - worn at all times in the restricted zone: Masks
covering the nose and mouth items that come in contact with the intact skin should
be: Disinfected
 Spaulding's classification system - Gastroscopes, bronchoscopes, colonoscopes are:
Semi- critical items
 Instruments introduced directly into the blood stream or into any normally sterile
cavity or area of the body → classified as: Critical
 Instruments that do not touch the patient or have contact only to intact skin is
classified as Non critical
 Classification of endoscopic instruments Sterile instruments
 Items that enter sterile tissue or vascular system are categorized as critical items
and should be: Sterilized
 Missing instruments - appropriate approach to this happening
a place for everything and everything in its place"
 interventions of the surgical team when an instrument was confirmed missing: X-RAY and
incidence report *
Correctly remove a hair that was found on top of the drape: By using a haemostat improve the
effectiveness of clinical afarm systerns:
Implement a regular maintenance and testing of alarm system
Improve the safety of using infusion pumps: Check the functionality of the pump before use •
Ensure quality of these instruments, which criterion is evaluated. Integrity and functionality
after each use & processing
Decontamination
 1. Wiping instruments used in the sterile field
2. pre-rinsing
3. washing
4. rinsing
5. disinfecting /sterilizing
6. wiping for safe handling
Done before using a disinfectant on the instrument: Rinse with sterile water
Black striped autoclave/steam chemical indicator tape
communicates that the instrument tray: is sterile Color of the stripe
produced after autoclaving Black
Ideal setting of the autoclave machine: 121 degrees Celsius for 15
minutes
Considerations for selecting chemical agents for disinfection:
Material compatibility and efficiency
Not an advantage of steam sterilization: Items need not to be
cleaned or freed from the grease and oil.
Liquid sterilizer versus autoclave machine - true: They are both
capable of sterilizing the equipments; however, it is necessary to
soak supplies in the liquid sterilizer for a longer period of time
Types of sterilization Sterilization by boiling not included
Comprise the surgical team: Surgeon, assistants, scrub nurse, circulating
nurse, anaesthesiologist
Coordinates the activities outside, including the family Circulating Nurse
Circulating nurse must do the following except Passing an instrument to
the surgeon. Count and identify the number of sponges, sharps and
instruments use in a surgical procedure
Scrub nurse Responsibility of the scrub nurse
Account for the number of sponges, needles, supplies, used during the
surgical procedure. .
Counting during the pre-incision phase, the operative phase and closing
phase - counts the sponges, needle and instruments: Scrub nurse and the
circulating nurse
Daily monitoring the standards of safe, nursing practice in the operating
suite
Monitor the status of the client like urine output, blood loss Anaesthesiologist
Administers anesthetics and monitors the patient's status throughout the
procedure Anesthesiologist Report any discrepancy of counts to the Surgeon
Nurse in charge for scheduling surgical cases - important information needed to
be asked: Who are your assistant and anesthesiologist, and what is your
preferred time and type of surgery?
First sponge instrument count reported after an abdominal surgery Before
peritoneum is closed
Sutured with long tensile strength such as cotton or nylon or silk suture Fascia
Closure of the abdominal layers begins with the peritoneum followed by
Muscle, fascia, subcutaneous tissue, skin
Prone to keloid formation and has low threshold of pain needle: Atraumatic
needle
Another alternative "suture" for skin closure is the use of: Staple
POST-OP IMMEDIATE in the PACU, the nurse will monitor his
vital signs. Every 15 minutes
 Continue with postoperative assessment activities Every 15
minutes for the first half hour, every 30 minutes for 2 hours, every
hour for 4 hours, and then every 4 hours as needed. AIRWAY
Post-anesthesia - transferred to the surgical unit -- first on arrival
of the client: Assess the patency of the airway.
Positioning a client for surgical procedure - priority Access to the
airway
MOST effective in promoting adequate respiratory function in an
unconscious client recently admitted to the PACU with no
contraindications to movement: care: Extending client's chin while
on his side and pillow at the back
Endoscopic examinations - anesthetized with xylocaine
(Lidocaine) spray-interventions for post- endoscopic examination
include: Keeping patient NPO until gag reflex returns
 General anesthesia in PACU - signs that may indicate his
artificial airway should be removed is: Gagging
Following a pneumonectomy, deep tracheal suction should be
done with extreme caution because: The bronchial suture line
maybe traumatized
Inhalation anesthesia - experienced severe shivering
postoperatively: Provide oxygen as prescribed
Unconscious on admission to the post-anesthesia care unit
(PACU)-position the client: In a lateral position
Spleenectomy -- nursing priority assessment: The
quality of the client's respiration
Assessment would prevent the patient's transfer to
ward: Pulse oximeter reading is 80% (Abnormal)
Pulse oximeter and gets a reading of 85% - next action
should be to Awaken the patient and have him cough
and deep breathe BREATHING
 Incentive spirometer The best results are achieved when
the head of the bed is elevated 45-90 degrees.incentive
spirometry has been effective if the patient has Clear
breath sounds
Postoperative
The postoperative phase begins with the patient's transfer to
the recovery unit and ends with the resolution of surgical
phase. the perioperative nurse may not provide care beyond
patient transfer to the PACU, where post anesthesia care
nurses assume responsibility for the patient. In an effort to
better utilize nursing resources, many perioperative nurses,
particularly in smaller hospitals, have been trained in post
anesthesia care and are assuming responsibility for providing
care in both the operating room and PACU. Care at home, if
required, is delivered by home healthcare nurses.
POST-OP IMMEDIATE in the PACU, the nurse will monitor his
vital signs. Every 15 minutes
Continue with postoperative assessment activities Every 15
minutes for the first half hour, every 30 minutes for 2 hours,
every hour for 4 hours, and then every 4 hours as needed.
AIRWAY
Post-anesthesia - transferred to the surgical unit -- first on arrival
of the client: Assess the patency of the airway. *Positioning a
client for surgical procedure - priority Access to the airway
MOST effective in promoting adequate respiratory function in an
unconscious client recently admitted to the PACU with no
contraindications to movement: care:
Extending client's chin while on his side and pillow at the back
Endoscopic examinations - anesthetized with xylocaine
(Lidocaine) spray-interventions for post- endoscopic examination
include: Keeping patient NPO until gag reflex returns
General anesthesia in PACU - signs that may indicate his artificial
airway should be removed is: Gagging
 Following a pneumonectomy, deep tracheal suction should be
done with extreme caution because: The bronchial suture line
maybe traumatized * Inhalation anesthesia - experienced severe
shivering postoperatively: Provide oxygen as prescribed
Unconscious on admission to the post-anesthesia care unit
(PACU)-position the client: In a lateral position
Spleenectomy -- nursing priority assessment: The
quality of the client's respiration
Assessment would prevent the patient's transfer to
ward: Pulse oximeter reading is 80% (Abnormal)
Pulse oximeter and gets a reading of 85% - next
action should be to Awaken the patient and have him
cough and deep breathe BREATHING
Incentive spirometer The best results are achieved
when the head of the bed is elevated 45-90 degrees.
Incentive spirometry has been effective if the patient
has Clear breath sounds
Breathing technique inhale through the mouth and
hold the breath for 5 seconds and exhale through the
mouth CIRCULATION
Open reduction and internal fixation (ORIF) -
observation would prompt you to call the doctor Left
foot is cold to touch and pedal pulse is absent
Avoid dangling of foot- done primarily to prevent:
Nerve and muscle damage
SAFETY
Transferred out a post-op client to her room - instruction to prevent accidents:
Make sure the side rails are up DRAINAGE
 Action would the nurse avaid in the care of the drain. XCurl the drain tightly
and tape firmly to the body.
Interpreted as a normal finding at the surgical site: Serous drainage * Facilitate
drainage of secretions from the operative site, the nurse should Turn the client
to the operative side every 2-3 hours NUTRITION Tonsillectomy and
adenoidectomy - food to prepare and give Soft diet when fully awake
Purpose of NGT IMMEDIATELY after an operation is For gastric
decompression ELIMINATION
Hasn't voided since before surgery, which took place 8 hour ago nurse do first
Assess the client for bladder fullness
Nurse plans to monitor which of the following parameters most carefully.
Urinary output of 20 ml/hr.
POSITIONING
Unconscious on admission to the post-anesthesia care unit (PACU)-
position the client: In a lateral position Postoperative I and A
(Tonsillectomy & Adenoidectomy) position. Prone with the head on
pillow and turned to the side
Position who just underwent pneumonectomy On the side of surgery
COMPLICATIONS AND MGNT
Reduce pain during the deep breathing and coughing exercises by
Splinting the patient's chest with both hands during the exercises
 Smokes 3 packs of cigarettes a day for the past 10 years increased risk for
Postoperative respiratory complications
 Incentive spirometer - accurate understanding of the technique: Slow,
deep breaths to elevate the spirometer ball Become MOST concamed
indicate an evolving complication: Increasing restlessness
Monitor and promote the respiratory status of postop chent, the
nurse would do: Instruct the client and monitor the use of the
incentive spirometer.
Retained pulmonary secretions in a postoperative cliant may lead:
Pneumonia
inserted vaginally to prevent postoperative bleeding Vaginal
packing Most common postoperative complication of tonsillectomy
Hemorrhage
Blood pressure is 90/60 mmHg and apical pulse is 122. The nurse's
first action would be to: Check the dressing for bleeding
Homan's Sign Pain with dorsiflexion of the foot Contributing
factors would the nurse recognize as important on recent pelvic
surgery
Indication of a developing thrombophlebitis would be: Tender, painful
area on the leg
Prevent deep vein thrombosis (DVT)- ensure that the patient
Ambulates frequently
Sign alerts the nurse to wound evisceration: Pink serous drainage
 Wound has eviscerated. The nurse assesses his respiratory status
because: Coughing increases the risk of evisceration
Dehiscence of the wound occurred → first action should be to: Cover
the wound with sterile dressings saturated with normal saline W Signs
of impending infection: Localized heat and redness
Sterile surgical dressing, the nurse must first Wash hands
Risk of developing wound infection: Clients who are undernourished *
Normal finding at the surgical site: Serous drainage
Assessment
Nursing assessment of the patient may take place in a
number of settings and time frames.
Assessment may be performed a week or more before
surgery or just prior to the procedure.
It may occur in the patient's inpatient hospital unit, the
surgeon's office, the pre admission testing unit of the
surgical facility, or the same day/ambulatory surgery
unit In some instances, the assessment process is
initiated in a telephone conversation with the patient
prior to surgery, and completed on the
Nursing Diagnoses
Assessment data provide information that the
perioperative nurse uses to formulate nursing diagnoses
and identify desired outcomes. Several nursing
diagnoses, such as knowledge deficit andhigh risk for
infection, are typical for the surgical patient.
Assessment data form the foundationfor patient-specific
nursing diagnoses and planning individualized care
tailored to meet each patient's individual and unique
need
Often the initial nursing assessment is performed by a
nurse who is not a perioperative nurse. It is more likely
that the perioperative nurse's assessment of the patient
will take place justprior to the patient's entry into the
operatingroom. This assessment will include a brief
interview, a quick physical inspection of the patient, and
a review of the patient's record, including the results of
diagnostic testing and assessment data obtained
previously by other caregivers.
Planning The perioperative nurse uses knowledge of the patient,
the proposed procedure, identified patient needs, related nursing
diagnoses, and desired outcomes to planeare foreach patient.
The perioperative nurse begins care planning before the patient is
seen, based on knowledge of the planned procedure, the
resourcesrequired, and the common nursing diagnoses related to
surgical intervention. Knowledge of the individual patient
obtained during the assessment process is combined with this
previous planning to prepare for meeting theunique needs of the
patient and providing care that is individually tailored to each
patient.
Intervention
In the intervention stage of the nursing process. the
perioperative nurse provides, coordinates, supervises, and
documents are within the of accepted standards of nursing
care,
Evaluation.
In the final evaluation stage of the nursing press, the
perioperative nurse evaluates the results of nursing care in
relation to the extent that expected patient outcomes have
been met