SRB’s Surgery for Nurses Sriram Bhat M
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Surgery and Nurse1

Surgery is done to a patient to assist the natural healing but not to disturb it. Every admission or out-patients in surgery department need not be for operation. Many surgical conditions are treated by surgeons conservatively by drugs but not surgery.
 
PARTS OF SURGERY
Surgery has three parts—
  • Clinical surgery—where how to diagnose is learnt.
  • Surgical principles—deals with management strategy; how and what treatment given; when and whether surgery is needed or not.
  • Operative surgery—wherein operative procedures are learnt in detail.
Surgery can be emergency, like done for trauma, hemorrhage, perforation, abscess and so on.
Surgery is called as elective when it is planned properly and done with all necessary preparations.
 
NURSING CARE AND DUTIES OF A NURSE IN SURGICAL OUTPATIENT (OP) ROOM
  • Reception of the patient in OP room with kind and affection.
  • Guidance should be given about the OP, surgeons, OP methods and rules of the hospital.
  • Meaning and importance of consent should be explained to the patient and signature of the patient is taken in a consent form.
  • Most often basic blood tests, urine tests, X-rays, and ultrasounds are ordered in the OP room by surgeons. Nurse should guide the patient to get these tests done. Often nurse may have to accompany the ill patient to do these investigations.
  • Surgical gloves, essential instruments like torch, stethoscope, BP apparatus, measuring tape, forceps, dressing materials, proctoscope should be kept ready for the surgeon to examine the patient. Surgery OP room should have a side room for dressings with essential instruments.
  • Many surgery OP room is attached with minor operation theatre (OT) with OT table, OT light, anaesthetic agents for first aid for small procedures like abscess drainage, excisions, wound suturing. As these procedures are done without admissions, such patients should be given proper guidance about the treatment, drugs and review dates.
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  • Once a patient is admitted, admission slip with number and case sheets should be sent to the surgical ward. Often a wheel chair or trolley is required to shift the patient.
  • Many hospitals are having diet department with a dietician. Patient should be discussed about the diet needed.
  • Psychological and moral support to the patient and relatives should be given by the nurse.
  • Nurse should be aware of the surgeon's instructions, team work, application of professional knowledge.
 
SURGICAL DIAGNOSIS
  1. History—History is taken by the surgeon. But, often patient might tell certain history with the nurse only. Its nurse's duty to gain the confidence of a patient and build a good rapport with him. Often in surgical ward, symptoms like pain, its variations, vomiting, malaena, bowel disturbances, micturition, abdominal distension are mentioned with the ward nurse. Menstrual history, gynaecological related history are elicited by the nurse.
  2. Inspection—Examination in general has to be done by the nurse for sweating, breathlessness, cyanosis, bleeding, pallor, swelling and should be informed to the surgeon immediately.
  3. Palpation—Palpation for tenderness, guarding, rigidity; mass, marking of the mass; measurement of abdominal girth is often done by the nurse.
  4. Percussion—For liver dullness, lung note, over the mass, over the sternum, over the distended bladder (dull note), over the kidney is done.
  5. Auscultation—For heart sounds, bowel sounds, breath sounds is done. Appearance of normal bowel sounds after abdominal surgery signifies that patient is recovering well and oral feeding can be started.
 
INVESTIGATIONS
  • Plain conventional chest X-ray is used to visualize heart shadow, lung diseases like pneumonia, collapse, tuberculosis, carcinoma, effusion, pneumothorax, trauma to chest, mediastinal tumours.
  • Plain X-ray abdomen with lower chest is used to find out gas under diaphragm (bowel perforation), multiple air-fluid levels (intestinal obstruction), pancreatic stones, radiopaque gallstones (10% radiopaque).
  • Plain X-ray KUB (kidney, ureter, bladder) is done to visualize kidney outline, psoas shadow, renal stones (ninety per cent radiopaque), soft tissue shadows, calcification.
  • X-ray bone is done in fractures, tumours, infection, secondaries.
  • Contrast X-rays like barium meal, barium meal follow through, small bowel enema X-ray, barium enema, intravenous urogram (IVU), angiogram, cholecystogram, cholangiogram are done often.
  • Ultrasound examination—To visualize abdominal contents, mass lesions, pus collection.
  • Doppler scan to find out pathology in arterial and venous system.
  • Radioisotope imaging using technetium or radioiodine.
  • CT scan is used in trauma, tumours, sepsis, space occupying lesions.
  • MRI is more sensitive and specific investigation.
  • Endoscopy, either gastroscopy or colonoscopy.
  • ERCP
  • Intervention radiology—It is the diagnostic and therapeutic methods done using radio imaging technique like X-ray, ultrasound, CT scan. It is done using needles, guide wire and catheters of specific areas.
Procedure is always done with the help of a radiologist or by a radiologist himself. It is a procedure that demands technical expertise. Nurse in charge of this 3should have a clear idea and training about the interventional radiology.
 
NURSE AND DIAGNOSIS
  • Nurse should observe the patient for bedsore, oedema, rash, drug reaction, pallor, colour changes, breathing, pulse etc.
  • Haemorrhage in the ward, which may be in postoperative period like after thyroidectomy or other causes like haematemesis may get aggravated, and the nurse should observe, identify and inform the doctor about the same.
  • A nurse should be aware of the care of an unconscious patient by proper monitoring of vital signs, care of urination and bowel, feeding, prevention of bedsores. Pupil size, its reaction should also be observed.
  • Drowsiness, irritability, disorientation in postoperative period should be observed. It may be due to hyponatraemia, hypocalcaemia, dehydration, anaemia, hypoproteinaemia.
  • Pain and its severity should be observed. Analgesics and response to analgesic drugs should be noted. Often diclofenac suppository is a very useful analgesic. Persistent pain if present, one should think of presence of infection, pus formation, haematoma and so on.
  • Ryle's tube aspiration should be observed and measured properly.
  • Continuous irrigation of bladder is done after bladder and prostate surgery. Colour of the fluid, its flow should be observed.
  • Leak from the drain site, its colour (it may be either bile, pus, faecal matter), quantity, should be observed.
  • Passing a flatus tube in postoperative period is often required. Amount of gas getting deflated should be observed once it is passed.
  • Patient should have adequate leg exercise to improve venous circulation so as to prevent deep venous thrombosis. DVT may dislodge a thrombus which may block the pulmonary artery causing life threatening acute pulmonary embolism. Patient may suddenly collapse, become breathless and die. It can be prevented by leg exercises, elevation of the limb and prophylactic heparin therapy.
  • When a patient is on anticoagulant therapy or cytotoxic drugs, patient should be observed for sudden bleeding, hematological changes, sudden deterioration of kidney function, breathing difficulties.
 
NURSE AND PATIENT'S IDENTITY
  • Proper naming, labelling and identifying the patient is absolutely essential otherwise it may create legal problems.
  • Two persons with same names but with different diseases may get admitted. Unless proper labelling is done, it results in confusion while treating the patient and while giving drugs. Often unknowingly other person may be shifted to the operation theatre for a wrong surgery. Patient's address and date of birth and identification marks should be noted to differentiate.
  • The diseased site and side of the patient should be correctly labelled before a surgery. Exampleside of the inguinal hernia, side of the craniotomy.
  • Collection of specimens like blood, pus, urine, sputum in proper bottles and correct labelling with name, age, and number has to be done. Purpose of sending the specimen and tests that is required should be mentioned clearly. Biopsy and surgical specimens should be properly labelled while sending to the pathology department.
  • Proper blood grouping, cross matching and labelling of the blood sample is essential. Nurse should check the cross matching slip attached to the blood properly before transfusion.
  • Different gas cylinders are indexed with different colours. White for oxygen, blue for nitrous oxide. The nurse should have clear knowledge about this.