1. The Person Having Surgery
Chapter 32
The Person Having Surgery
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

2. Surgery Surgery is done to: Remove a diseased or injured body part.
Remove a tumor.
Repair an injured body part.
Make a diagnosis.
Improve appearance.
Relieve symptoms.
Restore or improve function.
Replace a body part.
The reasons for surgery are many.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

3. Surgery (cont’d) Surgery often requires a hospital stay.
In-patient—Persons are admitted the morning of surgery or 1 or 2 days before surgery.
Same-day surgery (out-patient, one-day, ambulatory surgery)—The person goes home the same day or the next day.
Some patients go directly to surgery from the emergency department.
In-patient surgery stays are for 1, 2, or more days after surgery.
Same-day surgery is common. Such surgeries are done in hospitals and surgi-centers (surgery centers). Surgi-centers are designed and equipped for certain surgical and diagnostic procedures. The person goes home the same day or the next day.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

4. Surgery (cont’d) Surgeries are elective, urgent, or an emergency.
Elective surgery is done by choice to improve the person’s life or well-being.
The surgery is scheduled in advance.
Urgent surgery is needed for the person’s health.
It is done soon to prevent further damage or disease.
Emergency surgery is done at once to save life or function.
The need is sudden and not expected.
Elective surgery is not life-saving. Joint replacement surgery and cosmetic surgery are examples.
Cancer surgery and coronary artery bypass surgery are examples of urgent surgery.
Vehicle crashes, stabbings, and bullet wounds often require emergency surgery.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

5. Surgery (cont’d)
The person is prepared for what happens before, during, and after surgery.
Pre-operative refers to before surgery.
Post-operative refers to after surgery.
Some people recover from surgery in nursing centers or rehabilitation centers.
Some need home care.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

6. Psychological Care Surgery causes many fears and concerns.
Past experiences affect feelings.
Some people do not share their fears and concerns.
Mental preparation is important.
Respect the person’s fears and concerns.
Review the contents of Box 32-1 on p. 561 in the Textbook.
Show the person warmth, sensitivity, and caring.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

7. Psychological Care (cont’d)
The doctor explains the need for surgery to the patient and family.
They are told about:
The surgical procedure, risks, and possible complications
The risks from not having surgery
Who will do the surgery
The date and time of the surgery
How long the surgery will take
Questions are answered.
Misunderstandings are cleared up.
Care instructions are given.
After surgery, the doctor decides what and when to tell the patient and family about the results.
After surgery, the doctor talks to the patient and family.
Often, the health team knows the results before the person.
Review the Focus on Communication: Patient Information Box on p. 561 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

8. Psychological Care (cont’d)
Your role
Listen to the person.
Refer questions to the nurse.
Explain the care you will give and why it is needed.
Follow communication rules.
Use verbal and nonverbal communication.
Provide care with skill and ease.
Report signs of fear or anxiety.
Report a request to see a member of the clergy.
You can assist in the person’s psychological care.
Communication rules are found in Chapters 6 and 8 of the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

9. Pre-Operative Care
The goal is to prevent complications before, during, and after surgery.
Pre-operative teaching includes:
Pre-operative care
Tests and their purpose
Skin preparation
Personal care
The person learns about the purpose and effects of pre-operative drugs
The pre-operative period may be many days or a few minutes. If time allows, the person is prepared mentally and physically for the effects of anesthesia and surgery.
Review the Teamwork and Time Management: Pre-Operative Care Box on p. 561 in the Textbook.
The nurse explains what to expect before, during, and after surgery.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

10. Pre-Operative Care (cont’d)
Deep breathing, coughing, and incentive spirometry
Leg exercises
Post-anesthesia care unit (PACU)
Vital signs—taken often until stable
Food and fluids
Turning and re-positioning
Early ambulation—is done as soon as possible after surgery
The type and amount of pain to expect
Treatments and equipment
Position restrictions
After surgery, deep breathing, coughing, and incentive spirometry are done every 1 or 2 hours when the person is awake.
After surgery, leg exercises are done every 1 or 2 hours when the person is awake.
The PACU is where the person wakes up after surgery. Care given in the PACU is explained.
The person is NPO and has IV therapy after surgery. Food and oral fluids are ordered when the person’s condition is stable.
Turning and re-positioning are done at least every 1 to 2 hours after surgery.
The nurse explains about pain-relief drugs and how they are given.
Review the Focus on Children and Older Persons: Pre-Operative Care Box on p. 562 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

11. Pre-Operative Care (cont’d)
Before surgery, these tests are commonly ordered (results must be on the chart by the time of surgery):
Chest x-ray
Complete blood count (CBC)
Urinalysis
Electrocardiogram (ECG; EKG)
Other tests depending on the person’s condition and surgery
Nutrition and fluids
The person is NPO for 6 to 8 hours before surgery.
An NPO sign is placed in the person’s room.
The water pitcher and glass are removed.
For expected blood loss, the person’s blood is tested for blood type and compatible blood. This is called type and cross-match.
The person is prepared for the tests as needed.
Food and fluid restrictions and NPO reduce the risk of vomiting and aspiration during anesthesia and after surgery.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

12. Pre-Operative Care (cont’d)
Bowel elimination
Bowel surgeries may require cleansing the bowel of feces. This is called a bowel prep.
Sometimes enemas are given to prevent constipation after surgery.
Urinary elimination
Output is measured and recorded.
The person voids before the nurse gives pre-operative drugs.
If the person has a catheter, the drainage bag is emptied.
A full bladder is easily injured during surgery.
When the intestine is opened, feces can spill into the sterile abdominal cavity. The bowel prep prevents this contamination.
For the bowel prep, the doctor orders special fluids for the person to drink.
Often, catheters are inserted in the operating room (OR). They allow accurate output measurements during and after surgery.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

13. Pre-Operative Care (cont’d)
Personal care before surgery involves:
A complete bed bath, shower, or tub bath
Removing makeup, nail polish, and fake nails
Removing all hairpins, clips, combs, wigs, hairpieces, and other items
Surgical caps are worn to keep hair out of the face and the operative site.
Oral hygiene for comfort
Removing and storing dentures
Provide denture care.
Removing prostheses
Follow agency policy for safe storage.
Often, elastic stockings are put on before transport to the OR.
A special soap or cleanser may be ordered. A shampoo is included. The bath and shampoo reduce the number of microbes on the body. This reduces the risk of a wound infection.
The skin, lips, and nail beds are observed for color and circulation.
The person must not swallow any water during oral hygiene.
Some people do not like to be seen without their dentures. Promote dignity and self-esteem by allowing the person to wear the dentures as long as possible. Store dentures according to agency policy.
Review the Promoting Safety and Comfort: Personal Care Box on p. 563 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

14. Pre-Operative Care (cont’d)
All jewelry is removed and stored for safekeeping.
Record jewelry removal and storage according to agency policy.
Skin preparation
The doctor orders one or more of the following for the skin prep at the operative site:
Cleansing with an anti-microbial soap
Clipping the hair at and around the site
Removing hair at and around the site
The incision site and a large area around it are prepped.
Jewelry is easily lost or broken in the OR and PACU.
Jewelry can cause pressure injuries.
The person may want to wear a wedding ring or religious medal. The item is secured in place with gauze and tape according to agency policy.
Due to swelling of the fingers, wedding rings are removed for hand, arm, shoulder, and breast surgeries.
To reduce the risk of infection, a skin prep is done.
The prep is done in the person’s room or in the OR.
Review the Delegation Guidelines: Skin Preparation Box on p. 565 in the Textbook.
Review the Promoting Safety and Comfort: Skin Preparation Box on p. 565 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

15. Pre-Operative Care (cont’d)
The surgery consent
The person’s consent is needed before surgery.
A surgical consent is signed when the person understands the information given by the doctor.
A parent or legal representative signs for a minor child.
The legal representative signs for a person who is not mentally competent to sign.
The doctor is responsible for securing the written consent. Often, this is delegated to an RN.
You do not obtain the person’s written consent for surgery.
The person’s spouse or nearest relative may be required to sign the consent.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

16. Pre-Operative Care (cont’d)
The pre-operative checklist is completed before surgery.
The nurse may ask you to do some of the things on the list.
Promptly report when you complete each task.
Report any observations.
The checklist is completed before the nurse gives pre-operative drugs.
The doctor marks the surgical site before surgery.
It is done before the pre-operative drugs are given.
Sometimes, the person marks the surgical site.
Marking the site prevents surgery on the wrong body part or area.
Site marking may be part of the pre-operative checklist.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

17. Pre-Operative Care (cont’d)
Pre-operative drugs are given before the person is transported to the OR.
They are given to:
Help the person relax and feel drowsy.
Reduce respiratory secretions to prevent aspiration.
Prevent nausea and vomiting.
Falls and accidents are prevented after drugs are given.
Bed rails are raised.
The person is not allowed out of bed.
The person is transported to the OR by OR staff.
Identification checks are made.
The person’s chart is given to the OR staff member.
After receiving pre-operative drugs, the person feels sleepy and light-headed.
The person voids before the drugs are given. After they are given, the person uses the bedpan or the urinal to void.
After the drugs are given, move furniture to make room for the stretcher, clean off the overbed table and the bedside stand, and raise the bed to its highest level to transfer the patient from the bed to a stretcher.
The patient is transferred to the stretcher and covered with a bath blanket for warmth and to prevent exposure.
The family may be allowed to go as far as the OR entrance.
Review the Focus on Children and Older Persons: Transport to the Operating Room Box on p. 567 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

18. Sedation and Anesthesia
Sedation is a state of quiet, calmness, or sleep produced by a drug. Three levels of sedation include:
Minimal
Moderate (conscious)
Deep
Some procedures only require sedation.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

19. Sedation and Anesthesia (cont’d)
Anesthesia is the loss of feeling or sensation produced by a drug.
General anesthesia—loss of consciousness and all feeling or sensation
A drug is given IV.
A gas is inhaled.
Regional anesthesia—loss of feeling or sensation in a large area of the body
The person is awake.
A drug is injected into a body part.
Local anesthesia—loss of feeling or sensation in a small area
A drug is injected at the site.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

20. Sedation and Anesthesia (cont’d)
Sedation and anesthesia are given by specially trained doctors and nurses.
An anesthesiologist is a doctor who specializes in giving anesthetics.
An anesthetist is an RN with advanced study in giving anesthetics.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

21. Post-Operative Care After surgery, the person is taken to the PACU.
The doctor allows the person to be transported to his or her room when:
Vital signs are stable.
Respiratory function is good.
The person can respond and call for help.
The room must be ready for the person.
After the person is transported to the OR, you can do the following:
Make a surgical bed. (Lower the bed rails and raise the bed to its highest position.)
Place equipment and supplies in the room.
Move furniture out of the way for the stretcher.
The person recovers from anesthesia in the PACU. The person is watched very closely. Vital signs are taken and observations are made often.
The person usually remains in the PACU for 1 to 2 hours after surgery.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

22. Post-Operative Care (cont’d)
The PACU staff calls the nursing unit when the person is ready for transfer.
The transport is done by PACU nurses.
The person is transferred from the stretcher to bed.
You assist and help position the person as needed.
Vital signs are measured and observations made.
The nurse checks the incision for bleeding.
Catheter, IV, and other tube placements and functions are checked.
Bed rails are raised.
The signal light is placed within the person’s reach.
Necessary care and treatments are given.
Then the family can be with the person.
A nurse meets the PACU nurses and patient in the person’s room.
Vital signs are compared with those taken in the PACU.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

23. Post-Operative Care (cont’d)
Measurements and observations
Your role in post-operative care depends on the person’s condition.
Often, you will measure vital signs, pulse oximetry, and the person’s condition.
Vital signs are usually measured:
Every 15 minutes until the person’s condition is stable
Every 30 minutes for 1 to 2 hours
Every hour for 4 hours
Then every 4 hours
The nurse tells you how often to check the person.
Report signs and symptoms to the nurse at once.
Many serious complications can result from surgery. Be alert for the signs and symptoms in Box 32-2 on p. 568 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

24. Post-Operative Care (cont’d)
Positioning
The person is usually positioned:
For easy and comfortable breathing
To prevent stress on the incision
To prevent aspiration
Re-positioning is done at least every 1 to 2 hours.
Turning may be painful.
Provide support.
Use smooth, gentle motions.
Place pillows and positioning devices as the nurse directs.
The nurse tells you when to re-position the person and the positions allowed.
Depending on the surgery, position restrictions may be ordered.
When supine, the head of the bed is usually raised slightly. The person’s head may be turned to the side.
Re-positioning every 1 to 2 hours prevents respiratory and circulatory complications.
Usually you assist the nurse with re-positioning.
Review the Focus on Children and Older Persons: Positioning Box on p. 569 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

25. Post-Operative Care (cont’d)
Preventing respiratory and circulatory complications
The following help prevent respiratory complications:
Coughing and deep-breathing exercises
Incentive spirometry
See Box 32-2 on p. 568 in the Textbook for respiratory system and circulatory complications.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

26. Post-Operative Care (cont’d)
Circulation must be stimulated for blood flow in the legs.
If blood flow is sluggish, blood clots may form.
Blood clot (thrombus)—can break loose and travel through the bloodstream
Embolus—a blood clot that travels through the vascular system until it lodges in a blood vessel
Pulmonary embolism—embolus from a vein lodges in the lungs. Severe respiratory problems and death may occur.
Report the following at once: swollen area of a leg, pain or tenderness in a leg, warmth in the part of the leg that is swollen or painful, red or discolored skin, chest pain, or shortness of breath.
Review Focus on Children and Older Persons: Preventing Respiratory and Circulatory Complications Box on p. 569 in the Textbook.
Review Promoting Safety and Comfort: Preventing Respiratory and Circulatory Complications Box on p. 569 in the Textbook.
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27. Post-Operative Care (cont’d)
Circulation is stimulated and thrombi prevented by:
Leg exercises
A doctor’s order is needed.
The nurse tells you when to do the exercises.
Ambulation as soon as possible
Blood pressure and pulse are measured.
If stable, the person is assisted out of bed.
Elastic stockings
The nurse measures the person for the correct size.
Elastic bandages
Have the same purpose as elastic stockings
Sequential compression devices (SCD)
Wraps around the leg
Attached to a pump that inflates the device with air
SCDs are worn post-operatively until doctor orders removal.
No prolonged standing or sitting
Leg exercises are done at least every 1 or 2 hours while the person is awake. Assist if the person is weak.
Elastic stockings exert pressure on the veins and promote venous blood return to the heart. They are also called AE stockings (anti-embolism or anti-embolic) or TED hose (thrombo-embolic disease).
Review the Delegation Guidelines: Elastic Stockings Box on p. 570 in the Textbook.
Review the Promoting Safety and Comfort: Elastic Stockings Box on p. 572 in the Textbook.
Review the Delegation Guidelines: Elastic Bandages Box on p. 572 in the Textbook.
Review the Promoting Safety and Comfort: Elastic Bandages Box on p. 572 in the Textbook.
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28. Post-Operative Care (cont’d)
Wound healing
The incision needs protection.
Healing is promoted and infection prevented.
Sterile dressing changes are done by the doctor or nurse.
Your agency may let you do simple dressing changes.
Nutrition and fluids
The person returns from the OR with an IV.
Diet progresses from NPO to clear liquids, to full liquids, to a regular diet.
Frequent oral hygiene is important when the person is NPO.
Some patients have naso-gastric tubes (NG tubes).
A dressing may be over the incision. See Chapter 33 for wound care.
Continued IV therapy depends on the type of surgery and the person’s condition.
Anesthesia may cause nausea and vomiting.
The doctor orders the diet.
Often, the NG tube is attached to suction to keep the stomach empty. The person is NPO and has an IV.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

29. Post-Operative Care (cont’d)
Elimination
Anesthesia, the surgery, and being NPO affect normal bowel and urinary elimination.
Pain-relief drugs can cause constipation.
Intake and output are measured.
Report the time and amount of the first voiding.
Some patients have a catheter after surgery.
Fluid intake and regular diet are needed for bowel elimination.
Suppositories or enemas may be ordered for constipation.
Provide measures to promote elimination as directed by the nurse and the care plan.
If the person does not void within 8 hours, a catheter may be needed.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

30. Post-Operative Care (cont’d)
Comfort and rest
The degree of pain after surgery depends on:
The extent of the surgery
The incision site and size
If drainage tubes, casts, or other devices are present
Positioning during surgery
For pain relief:
The doctor orders drugs.
The nurse uses the nursing process to promote comfort and rest.
Follow the measures in the person’s care plan.
Personal hygiene is important for physical and mental well-being.
Pain is common after surgery.
Refer to the pain-relief measures listed on p. 514 in Chapter 28 of the Textbook.
Frequent oral hygiene, hair care, and a complete bed bath after surgery help refresh and renew the person. The gown and linens are changed whenever wet or soiled.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.