The document discusses the management of patients undergoing surgery. It covers the three main phases of surgical management: pre-operative, intra-operative, and post-operative management. For pre-operative management, the document outlines the physical, psychosocial, physiological preparations and assessments a patient undergoes before surgery including examinations, investigations, pre-medications. It then briefly describes the roles of the surgical team during intra-operative management. Finally, it discusses the immediate post-operative recovery phase in PACU and management of common post-operative complications.

2. MANAGEMENT OF PATIENT
UNDERGOING SURGERY
Presented by
Mr B Kalyan kumar Msc (N)
Dept Of MSN

3. INTRODUCTION
Surgery is invasive procedure, can be performed elective or in
emergency condition. Surgery is done for a variety of conditions
that include:
 Cosmetic procedure
 Diagnostic procedures(Laprotomy)
 Infectious disease of tissues or organs
 Reposition and enhancement of bones(ORIF)
 Replacement or implantation of artificial devices (Knee
replacement )

4. TYPES OF SURGICAL MANAGEMENT
Pre- operative
management
Post
operative
management
Intra
operative
management

5. A. PRE OPERATIVE MANAGEMENT
 Patient comes to surgical care facility either elective or
emergency surgery. A patient needs nursing care throughout his
stay in hospital. Role of nurse is to understand the process of
illness and contribute skilfully to the patients recovery. A theatre
nurse must be gentle and empathetic for patient.
1. Physical preparation
2. Psychosocial preparation
3. Physiological preparation
4. Pre-medications
5. Pre operative preparation

6. 1. PHYSICAL PREPARATION
 As soon as surgical patient approaches nurse in hospital, nurse
initiates pre-operative assessment.

7. NURSING ASSESSMENT
 Medical history : Enquire from patient about medical illness such
as Diabetes mellitus, asthma, tuberculosis, hypertension,
myocardial infraction etc.. Patient must be asked about previous
surgery. Enquire about use of OTC and drugs like steroids, anti-
epileptics, insulin. History also includes information about allergy
to drugs, food.
 General examination: A physical examination is performed
during which vital signs are noted and a database is established
for future comparisons. Take through history about the organ for
which surgery is required.

8.  Drug or Alcohol use: Person with history of chronic
alcoholism often suffers from malnutrition, Systemic problems
that increase the surgical risk. Additionally Delirium may be
anticipated upto 72 hours after alcohol withdrawal.
 Nutritional and fluid status: Assessment of patients
nutritional status provides information about obesity, weight
loss, malnutrition . Any nutritional deficiency such as
malnutrition, should be corrected before surgery.

9.  Respiratory status: Respiratory status is assessed because
adequate ventilation is potentially compromised during all
phases of surgical treatment. Surgery is postponed when the
patient has a respiratory infection. Patient who smoke are urged
to stop smoking at least one month before surgery.

10.  Cardiovascular status: The goal in preparing any patient for
surgery is to ensure well-functioning cardiovascular system to
meet the oxygen, fluid and nutritional needs. If the patient had
uncontrolled hypertension, surgery may be postponed until the BP
in under control.
 Hepatic and Renal function: The pre surgical goal is to optimal
functioning of the liver and urinary system. So that medications,
anaesthetic agents, body wastes and toxins are adequately
processed and removed from the body.
 Endocrine function: The patient with diabetes who is undergoing
surgery is at risk for hypoglycaemia, Frequent monitoring of
blood glucose level is important before, during and after surgery.

11.  Local examination: In addition to routine abdominal and per
rectal examination (P/R), condition of the skin at the site of
incision should be noted, if there is any infection it should be
treated first.
 Examine the client for jaundice, anaemia, oral hygiene,
hydration, presence of loose and artificial teeth etc.

12. 2. PSYCHOSOCIAL PREPARATION
 All patients have some type of emotional reactions before any
surgical procedure. For e.g. Pre-operative anxiety. The nurse must
be empathetic, listen well and provide information that helps to
reduce anxiety.
 Spiritual and cultural beliefs: Spiritual beliefs play an important
role in how people cope with fear and anxiety. Every attempt must
be made to help the patient obtain the, spiritual health that he or
she requests. Faith has great sustaining power.

13. 3. PHYSIOLOGICAL PREPARATION
Investigations: Ensure that all investigations are in normal range.
Arrange blood for patient if required, blood is sent for cross-
matching. Following investigations are generally carried out.
 Haemoglobin level, blood group
 Total Leukocyte Count (TLC)
 Erythrocyte sedimentation Rate(ESR)
 Blood Urea Nitrogen (BUN)
 Fasting Blood Sugar and postprandial
 Bleeding time and clotting time
 Urine routine microscopic examination.

14.  Chest X-Ray
 Electrocardiogram(ECG)
 Specific investigations: Ultrasound (USG), CT Scan, MRI.

15. 4. PRE-MEDICATIONS
 Anesthesian may prescribe or administer a pre-medication prior
to administration of general anaesthesia. E.g alfa-2 adrenergic
agonist, a Benzodiazepam (Midazolam) is effective in reducing
anxiety.
 Anti emetics, Corticosteroids. Other commonly used pre-
medication agents include opioids such as Fentanyl,
Gastrokinetic agents such as metaclopramide.
 Propranolol for hypertension may be tapered prior to operation,
but should be continued in full doses for angina pectoris.
 Prescribed medicine if any (Diazepam) is given one night before
surgery. Prophylactic antibiotics should be given after skin
sensitivity test.
 Ensure IV access if intravenous fluids are indicated.

16.  The use of prescribed antibiotics, cardiac drugs, diuretics and the
patients current medication must be carefully considered.
 Ensure that surgeon specified pre-operative orders are followed.
 Review patients record to provide appropriate treatment. Assess
the risk for post operative complications.

17. 5. PRE OPERATIVE PREPARATION
 When the patient is ready for operation, the surgeon writes the
order for the pre operative preparation . In case of Elective
operation, pre operative orders are written one day prior to
operation.
 Shaving and preparation of local parts: Identify patient. Skin
is shaved before operation. Complete scrub bath with savlon or
an antiseptic soap should be taken the night before operation.
 Relieve anxiety
 Enema
 PAC (Pre anesthetic checkup )
 Consent

18. B. INTRA OPERATIVE MANAGEMENT
The Surgeon
The Anesthetist
Operation theatre
technician
Circulating nurse
Scrub nurse

19.  The Surgeon: Surgeon performs the operation and leads the
surgical team.
 The Anesthetist : An Anesthetist is a qualified health care
professional who administer anesthetics. He interviews and
assess the patient prior to surgery, selects the anesthesia,
administers it. Intubate the patient if necessary, supervises
patients condition throughout surgical procedure.
 Operation theatre technician: Technician arranges the OT table,
dressing table, anesthesia table, OT light etc.
 Circulatory nurse: Role of circulatory nurse includes verifying
consent ,coordinating the team, ensuring cleanliness, proper
temperature, safe functioning of equipment and availability of
supplies and materials and documenting intra operative events.

20.  Scrub nurse: Nurse performs surgical hand scrub, prepares
sutures, assist the surgeon. The scrub nurse provides sterile
instruments and supplies to the surgeon.

21. NURSES FUNCTION IN OPERATION THEATRE
 Reduce anxiety: Address the patient by name, warmly encourage
friendliness. Attention paid towards physical comfort helps the
patient feel more comfortable.
 Prevent intra operative positioning injury: The Patients
position on table depends on the surgical procedure. Hyper
extending joints, compressing arteries, pressing nerves usually
results from discomfort because position given for long period.
 Monitor potential complications: Intra operative nurse play vital
role in reporting changes in vital organs and symptoms of nausea,
vomiting, hypoxia, hypothermia.

22. Maintain Asepsis: Theatre nurse play an important role in control
and prevention of infection. There are many activities involved
in safeguarding the patient against infection.
 Continuing education of staff on infection control
 Correct sterilization methods
 All staff must be in good health and free from infection.

23. C. POST OPERATIVE MANAGEMENT
 This is the period the patient leaves the operating room. During
post operative period, nursing care focuses on the re-establishing
the patients physiologic equilibrium, preventing complications
and teaching the patient self care.
 The post operative anesthesia care unit(PACU) :
 It is also known as post anesthesia recovery room, it is located
adjacent to the operating room.

24. Admitting the patient to PACU: The nurse who admits the
patient to PACU reviews the following information with
anesthetist.
 Medical diagnosis and type of surgery performed
 Patients past medical history and allergies
 Patients age and general condition, airway patency, vital signs.

25. PHASES OF PACU
Phase I
Phase II
 In phase I , PACU is used in immediate recovery , where
intensive care is provided.
 In phase II, PACU is reserved for those patients who require less
frequent observation and less nursing care.

26. NURSING MANAGEMENT IN THE PACU
 Assessment of patient: Check the surgical site for drainage or
haemorrhage and make sure that all drainage tubes and
monitoring lines are connected and function well.
 Maintaining a patent airway: Administer humidified oxygen
therapy. The nurse assists in initiating the use of ventilator and
weaning process. The head of the bed is elevated 15- 30 degree
unless contraindicated. Suctioning should be done through
oropharynx.

27.  Maintaining the cardiovascular stability: Assess vital signs,
cardiac rhythm, central venous pressure and arterial lines are
monitored.

28. Relieve the pain: As the patient recovers from the effect of
anesthesia, he/she feels the pain.
Relieve retention of urine: Retention of urine should be treated
with
 Change posture
 Hot water bag
 If all measures fail, catheterization may be done.

29. Readiness for discharge:
 Stable vital signs
 Orientation to person , place, time
 Urine output at least 30 Ml/h
 No complaint of nausea and vomiting

30. MANAGING POST-OPERATIVE COMPLICATIONS
 Hypotension and shock
 Hemorrhage
 Hypertension
 Deep vein thrombosis
 Infection

31. HYPOTENSION
 This is results from blood loss, hypovolemic shock is
characterized by a fall in venous pressure.
Signs :
 Pallor skin
 Rapid breathing, weak pulse
 Low blood pressure
Treatment:
 Administer IV fluid
 Administer humidified oxygen
 Administer vasopressor drugs

32.  Haemorrhage: The surgical site and incision should be
inspected for bleeding. If bleeding continues, a sterile gauze pad
is applied. The patient is placed in the trendelenburg position.

33.  Deep vein thrombosis (DVT): Formation of blood Clot in vein.
DVT and Pulmonary embolism are serious complications of
surgery.
Causes:
 Dehydration
 Low cardiac output
 Prolonged immobility
Treatment:
 Heparin
 Warfarin
 Stockings

34. Infection: Exposure of body tissue to pathogens places the
patient at risk for infection at the surgical site.
Clinical manifestation:
 Increased body temperature
 Elevated WBC count
 Tenderness and Discharge at wound site
 Treatment:
 Drain is inserted
 Antimicrobial therapy
 Wound care should be initiated

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