This document discusses guidelines for taking medical notes and history, including: - Write clearly in blue or black ink and sign/date all entries - Record a patient's presenting complaint, medical history, social history, and conduct a systematic inquiry of body systems - Take an accurate history of the presenting complaint and past medical history - Present cases in a clear, organized, and chronological manner It also summarizes guidelines for preoperative, intraoperative, and postoperative nursing care including assessing patient risk factors, providing education, and addressing psychological needs to reduce anxiety.

1. General surgery
Perioperative care
Dr. Walaa El- Leithey
PhD Medical Surgical Nursing
Alexandria University

2. History taking and making notes
• Making medical notes --basic rules.
• Write in blue or black ink; other colors do not photocopy well.
• Date, time, and sign all entries; always identify retrospective
entries.
• Be accurate.
• •Make it clear which diagnoses are provisional.
• •Abbreviations are lazy and open to misinterpretation; avoid them.
• • Clearly document information given to patients and relatives.
• • Avoid non-medical judgments of patients or relatives.

3. History taking and making notes
• medical notes --basic rules.
• • Always record name, age, occupation, and method
of presentation.
• Presenting complaint and past history relevant
to it.
• • Other past medical history, drug history, and
systematic enquiry.
• • Previous operations/allergies/drugs.
• • Family history, social history, and environment.

4. History taking and making notes
• Making medical notes --basic rules.
• Write in blue or black ink; other colors do not photocopy well.
• Date, time, and sign all entries; always identify retrospective
entries.
• Be accurate.
• •Make it clear which diagnoses are provisional.
• •Abbreviations are lazy and open to misinterpretation; avoid them.
• • Clearly document information given to patients and relatives.
• • Avoid non-medical judgments of patients or relatives.

5. Presenting complaint
• This is a one- or two-word summary of the
patient's main symptoms, e.g. abdominal pain,
nausea and vomiting, swollen leg, PR bleeding.
• • In emergency admissions, do not write a
diagnosis here (e.g. ischemic leg). The diagnosis of
referral may well turn out to be wrong.
• • In elective admissions ‫ختيارى‬ ‫ا‬, it is reasonable
to write: elective admission for varicose vein
surgery’.

6. History of presenting complaint
• This is a detailed description of the main symptoms and relevants
• • Try to put the important positives first, e.g. right-sided lower
abdominal pain, sharp, worse with moving, and coughing, anorexia
24h.
• • Include the relevant negatives, e.g. no vomiting, no PR bleeding.
• • Be very clear about the chronology of events ‫تاريخها‬.
• • In a complicated history or with multiple symptoms, use headings, e.g.
Current episode’, ‘Previous operations for this problem’, ‘Results of
investigations’.
• • Summarize the results of investigations performed prior to admission
• systematically: bedside tests, blood tests, histology or cytology, X-rays,
cross-sectional imaging, specialized tests.

7. Past medical history
• • Ask about thyroid problems, tuberculosis (TB),
hypertension, rheumatic fever, epilepsy, asthma,
diabetes, ischemic heart disease, stroke, and previous
surgery, specifically.
• • List and date all previous operations.
• • Ask about previous problems with an anaesthetic.
• • Asking ‘Have you ever had any medical problem
or been to hospital for anything?’

8. Systematic enquiry
• This is extremely important and often neglected.
• A genitourinary history is highly relevant in young
females with pelvic pain.
• A good cardiovascular and respiratory systems enquiry will
help avoid patients being cancelled because they have
undiagnosed anaesthetic risks.
• Older patients may have pathology in other systems that
may change management, e.g. the patient with
prostatism should be warned about urinary retention.

9. Systematic enquiry
• • Cardiovascular. Chest pain, effort dyspnoea, orthopnoea,
nocturnal dyspnea, palpitations, swollen ankles, strokes,
transient ischaemic attacks, claudication.
• • Respiratory. Dyspnoea, cough, sputum, wheeze,
haemoptysis.
• • Gastrointestinal. Anorexia, change in appetite, weight
loss (quantify how much, over how long).
• • Genitourinary. Sexual activity, dyspareunia (pain on
intercourse), abnormal discharge, last menstrual period.
• • Neurological. 3 Fs: fits; faints; funny turns.

10. Social history
• • At what time did they last eat or drink?
• • Ask who will look after the patient. Do they need
help to mobilize?
• • Smoking and alcohol history

11. Tips for case presentation
• Practice.
• Always ‘set the scene’ properly. Start with name, age, occupation,
and any key medical facts together with the main presenting
complaint(s).
• Be chronological. Start at the beginning of any relevant or associated
symptoms.
• Be concise with the past medical history. be relevant either to the
diagnosis or management, e.g. risks of general anesthesia.
• Always summarize the general appearance and vital signs first.
• be systematic—‘inspection, palpation, percussion, and auscultation’..
• Finally, summarize and synthesize—don't repeat.
• • Finish with a proposed diagnosis or differential list and be
prepared to discuss what diagnostic or further evaluation tests might
be necessary.

12. Perioperative nursing
• Perioperative Nursing – used to describe the nursing care provided
of the patient: preoperative, intraoperative and postoperative.
• Preoperative Phase, extends from the time the client is admitted in
the surgical unit, to the time he/she is prepared for the surgical
procedure, until he is transported into the operating room.
• Intraoperative Phase, extends from the time the client is admitted
to the OR, to the time of administration of anesthesia, surgical
procedure is done, until he/she is transported to the RR.
• Postoperative Phase, extends from the time the client is admitted to
the recovery room, to the time he is transported back into the
surgical unit, discharged from the hospital, until the follow-up
care.

13. 4 Major Types of Pathologic Process Requiring Surgical
Intervention (OPET)
• Obstruction – impairment to the flow of vital fluids
• (blood, urine, CSF, bile)
• Perforation – rupture of an organ.
• Erosion – wearing off of a surface or membrane.
• Tumors – abnormal new growths

14. Classification of Surgical Procedure
According to PURPOSE:
• Diagnostic – to establish the presence of a disease condition.
(e.g biopsy )
• Exploratory – to determine the extent of disease condition
• (e.g Ex-Laproscopy)
• Curative – to treat the disease condition.
* Ablative – removal of an organ
* Constructive – repair of congenitally defective organ.
* Reconstructive – repair of damage organ
• Palliative ‫تخفيفى‬/ ‫–مسكن‬ to relieve distressing sign and symptoms,
not necessarily to cure the disease.
•

15. Classification of Surgical Procedure
According to Urgency
Classification Indication for Surgery Examples
Emergent – patient requires
immediate attention,
life threatening condition.
Without delay - severe bleeding
- gunshot/ stab wounds
- Fractured skull
Urgent ‫عاجل‬ / Imperative ‫ملح‬ –
patient requires prompt attention.
Within 24 to 30 hours - kidney /
Ureteral stones
Required – patient needs to have
surgery.
Plan within a
few weeks or months
- cataract
- thyroid d/o
Elective – patient should have
surgery.
Failure to have surgery not
catastrophic
- repair of scar
- vaginal repair
Optional – patient’s decision.
‫الزامى‬ ‫غير‬
Personal preference Cosmetic surgery

16. Classification of Surgical Procedure
According to degree of risk
• Major Surgery
• - High risk / Greater Risk for Infection
• - Extensive
• - Prolonged
• - Large amount of blood loss
• - Vital organ may be handled or removed
• Minor Surgery
• - Generally not prolonged
• - Leads to few serious complication
• - Involves less risk
• Ambulatory Surgery/ Same-day Surgery / Outpatient Surgery

17. Ambulatory Surgery/ Same-day Surgery / Outpatient Surgery
Example of Ambulatory Surgery: Teeth extraction; Circumcision;
Vasectomy; Cyst removal; Tubal ligation
Advantages:
• - Reduces length of hospital stay and
cuts costs
• - Reduces stress for the patient
• - Less incidence of hospital acquired
infection
• - Less time lost from work by the
patient; minimal disruptions on the
patient’s activities and family life.
Disadvantages:
• - Less time to assess the patient
and perform preoperative
teaching.
• - Less time to establish rapport
• - Less opportunity to assess for
late postoperative complication.

18. Preoperative phase
• Goals
• Assessing and correcting physiologic and psychologic problems
that may increase surgical risk.
• Giving the person and significant others complete learning /
teaching guidelines regarding surgery.
• Instructing and demonstrating exercises that will benefits the
person during postop period.
• Planning for discharge and any projected changes in lifestyle due
to surgery

19. Physiologic Assessment of the Client Undergoing Surgery
• Age
• Presence of Pain
• Nutritional & Fluid and Electrolyte Balance
• Cardiovascular / Pulmonary Function
• Renal Function
• Gastrointestinal / Liver Function
• Endocrine Function
• Neurologic Function
• Hematologic Function
• Use of Medication
• Presence of Trauma & Infection

20. Routine Preoperative Screening Test
Test Rationale
CBC RBC, Hgb,Hct are important to the oxygen carrying
capacity of blood.
WBC is indicator of immune function.
Blood grouping/
X matching
Determined in case blood transfusion is required during
or after surgery
Serum Electrolyte To evaluate fluid and electrolyte status
PT,PTT Measure time required for clotting to occur.
Fasting Blood Glucose High level may indicate undiagnosed DM
BUN / Creatinine Evaluate renal function
ALT/AST/LDH
and Bilirubin
Evaluate liver function
Serum albumin
and total CHON
Evaluate nutritional status
Urinalysis Determine urine composition
Chest Xray Evaluate respiratory status/ heart size

21. Psychosocial Assessment and Care
Causes of Fears of the Preoperative Clients
 Fear of Unknown ( Anxiety )
 Fear of Anesthesia
 Fear of Pain
 Fear of Death
 Fear of disturbance on Body image
 Worries – loss of finances, employment, social and family roles.
Manifestation of Fears
 anxiousness
 anger
 tendency to exaggerate
 sad, evasive ‫متهرب‬, tearful, clinging
 inability to concentrate
 short attention span
 failure to carry out simple directions

22. Nursing Intervention to Minimize Anxiety
 Explore client’s feeling
 Allow client’s to speak openly about fears/concerns
 Give accurate information regarding surgery (brief, direct to the point
and in simple terms)
 Give empathetic support ‫تعاطف‬
 Consider the person’s religious preference and arrange for visit by a
priest / minister as desired.

23. Informed Consent
Purposes:
 To ensure that the client understand the nature of the treatment
including the potential complications and disfigurement
 To indicate that the client’s decision was made without pressure.
 To protect the client against unauthorized procedure.
 To protect the surgeon and hospital against legal action by a
client who claims that an authorized procedure was performed.

24. Appendix