Historically, surgery involved rudimentary operations, often amputations, performed without anesthesia and with minimal attention to sterile practices. Patients faced significant risks of pain, infection, and sepsis, leading to fatalities. Surgeons of that era were often untrained individuals relying on physical strength. Modern surgery has addressed these issues through the implementation of anesthesia and strict adherence to aseptic techniques, alongside formalized training for surgeons.

Aims of surgery

1. Diagnostic: To identify a medical condition, such as through a biopsy to examine tissue.

2. Curative: To eliminate a disease or abnormal condition, for instance, by removing a diseased organ.

3. Preventive: To avert a potential future health problem, such as an amputation to prevent the spread of infection.

4. Palliative: To alleviate symptoms and improve quality of life without necessarily curing the underlying disease, for example, radiation therapy to shrink a tumor and relieve pain.

Types of surgery

• Emergency surgery: Required immediately to save life or limb.

• Planned or elective surgery: Scheduled in advance.

• Multistage surgery: A procedure performed in multiple phases.

Principles of surgery

1. Administer anesthesia safely and effectively.

2. Prevent and manage circulatory instability.

3. Promote rapid and effective wound closure.

4. Prevent and manage postoperative complications.

5. Restore the patient’s physiological function.

Surgery can be classified based on invasiveness and urgency:

• Major surgery: Typically requires general anesthesia due to the complexity and invasiveness of the procedure.

• Minor surgery: Often performed under local anesthesia, involving less invasive procedures.

• Emergency surgery: Urgent surgical intervention for life-threatening conditions.

• Planned surgery: Non-urgent surgery scheduled in advance.

Common surgical conditions

• Inflammatory conditions, injuries, and trauma

• Surgical shock

• Burns of varying degrees

• Hemorrhage (excessive bleeding)

• Neoplasms (tumors)

• Bone fractures

• Surgical conditions affecting the neck, thoracic cavity, abdominal cavity, etc.

PRE-OPERATIVE CARE

Preoperative care encompasses all interventions provided to the patient in preparation for their surgical procedure. This care can begin in an outpatient setting or with hospital admission several days prior to the scheduled operation.

Admission: Patients are typically admitted to a surgical unit, placed in a room with adequate ventilation. Room assignments may be further specified based on the patient’s condition.

Rapport: Establishing a positive nurse-patient relationship is crucial. This begins with a courteous greeting, self-introduction by the nurse, and offering the patient a comfortable place to sit or lie down. Building rapport is essential for gaining the patient’s confidence and trust.

History taking: A comprehensive medical history is obtained:

• Demographic data: Basic identifying information about the patient.

• Subjective data: Information reported by the patient or a family member.

• Objective data: Findings observed by the healthcare provider.

Specific histories include:

• Past medical history and previous surgical procedures

• Psychiatric history, including any mental health conditions

• Family history of relevant medical conditions

• Social history, including lifestyle factors

• Obstetrical and gynecological history for female patients

Inform doctor: The physician is notified of the patient’s admission. In the interim, the nurse initiates essential observations. All recorded observations must be documented in the patient’s medical record.

Observations:

1. General observation: A comprehensive visual assessment of the patient from head to toe, noting their overall condition.

2. Vital observations: Measurement and documentation of:

   • Body temperature

   • Pulse rate and rhythm

   • Respiratory rate and pattern

   • Blood pressure

3. Specific observations: Additional assessments relevant to the patient’s particular surgical condition. All observations are meticulously recorded on the patient’s observation chart.

When the physician arrives, they conduct a physical examination, with the nurse assisting by preparing necessary instruments and equipment.

Steps followed during physical examination:

1. Inspection: The physician visually examines the patient from head to toe, noting any apparent abnormalities and documenting all findings.

2. Palpation: Using the fingers to gently feel for any enlarged organs, masses, or areas of tenderness.

3. Percussion: Tapping lightly on body surfaces with the fingertips to assess the sounds produced by underlying organs.

4. Auscultation: Using a stethoscope to listen to internal body sounds for any abnormalities.

The examination typically follows this systematic order, except in the case of the abdomen, where palpation is generally performed last. This is to avoid potentially eliciting pain or guarding that could interfere with other aspects of the abdominal examination.

Investigations:

1. Hematological investigations:

   • Erythrocyte Sedimentation Rate (ESR): An indicator of inflammation, although not specific to any particular condition.

   • White Blood Cell count (WBC): Typically elevated in the presence of infection.

2. Radiological investigations:

   • X-ray imaging

   • Computed Tomography (CT) scan

   • Ultrasound scan

   • Magnetic Resonance Imaging (MRI)

3. Urinalysis:

   • Testing for urine glucose levels.

   • Urine culture and sensitivity to identify any infecting organisms and determine appropriate antibiotic treatment.

4. Sputum for Acid-Fast Bacilli (AAFB): To rule out tuberculosis in relevant cases.

5. Stool for occult blood: To detect hidden blood in the stool, or for culture and sensitivity testing.

N.B. The nurse is responsible for ensuring all ordered investigations are carried out and that the results are accurately recorded in the correct patient’s chart.

Treatment:

Treatment strategies are tailored to the specific surgical condition and may include:

1. Non-pharmacological treatment: Interventions that do not involve medications.

2. Pharmacological treatment: Treatment using medications.

Non-pharmacological treatment Includes:

• Dietary modifications or specific nutritional plans.

• Management of anemia, if present.

• Therapeutic exercises.

• Maintaining personal hygiene.

The day before operation preparation:

• Informed consent: The surgical procedure is thoroughly explained to the patient to ensure understanding and obtain their consent and cooperation.

• Consent form: A written document signed by the patient after a clear explanation of the planned procedure. The patient is then placed on the surgical schedule for the following day.

• Fasting: The patient is instructed to abstain from food and fluids (nil per os – NPO) for a specified period, typically 4-6 hours prior to the scheduled surgery time.

• Reassurance: Addressing patient anxiety and promoting restful sleep. Lights may be dimmed early, or a sedative may be administered as prescribed by the physician.

Morning of operation:

• Site of operation: The surgical site is shaved, if required, and clearly marked according to hospital protocol. The patient takes a bath or shower in the early morning and is provided with a clean surgical gown.

• Insertion of a nasogastric tube (if indicated), insertion of a urinary catheter to drain the bladder, and establishment of an intravenous access line for fluid and medication administration.

• All jewelry and other artificial items are removed and stored safely by a relative or the responsible nurse.

• Pre-medications: Medications such as atropine may be administered as prescribed by the doctor and carefully documented.

• Vital observations are performed and documented on the patient’s chart.

• Confirmation that all necessary investigation results are available in the patient’s chart.

• Preparation of the patient’s transportation trolley. Continuous reassurance is provided to the patient.

• The patient is transported to the operating theater with all necessary documents and preparations.

• Handover of the patient to the theater nurse, along with a verbal report of the patient’s condition and pre-operative care.

• Preparation of a postoperative bed at the patient’s bedside on the ward, ensuring all necessary equipment is readily available.

NB: Preoperative care concludes with the preparation of the postoperative bed, and postoperative care commences with this preparation.

INTRA-OPERATIVE CARE

Intraoperative care is the care provided within the operating theater by the surgical team and the anesthetist during the surgical procedure and immediately afterward, before the patient is transferred back to the ward.

This care includes: continuous monitoring of vital signs, assisting the surgeon during the operation (scrub nurse duties), administering anesthetic agents, ensuring patient cleanliness, and providing care in the post-anesthesia care unit (PACU) or recovery room.

POST-OPERATIVE CARE

Postoperative care is the care provided to the patient following their surgical procedure.

Aim of post-operative care:

1. To prevent or promptly address any postoperative complications.

2. To ensure patient comfort through proper positioning.

3. To facilitate the restoration of normal bodily functions.

Nursing care:

• A postoperative bed is prepared with all the necessary equipment and supplies.

• When called to retrieve the patient from the recovery area, two nurses typically go together.

• A verbal report is obtained from the recovery nurse regarding the patient’s current condition.

• Vital signs are assessed and documented before transporting the patient back to the ward.

• The surgical site is visually inspected for any signs of bleeding.

• During transport back to the ward, the senior nurse should be positioned at the patient’s head to closely monitor their airway and overall condition.

• Upon arrival on the ward, the patient is carefully transferred to the prepared postoperative bed and positioned appropriately.

• The patient should never be left unattended immediately post-surgery. The nurse continuously monitors the patient’s airway to ensure it remains patent.

• Vital signs are monitored frequently: every 15 minutes until the patient is stable, then every 30 minutes, then hourly, and finally every four hours as their condition improves.

• The surgical site is observed for bleeding, but the dressing should not be opened. If bleeding is observed, additional dressings are applied, and the doctor is immediately informed.

• The patient’s general condition is continuously monitored, and any abnormalities are promptly reported.

Diet:

The dietary progression depends on the type of surgery performed. During the initial acute phase, the patient may receive nourishing fluids via a nasogastric tube, such as milk, diluted porridge, or broth. Specific dietary guidelines will be detailed based on the individual surgical procedure.

Drug treatment: Medications are administered according to the surgeon’s prescriptions. This often includes analgesics for pain management, antibiotics to prevent or treat infections, and other supportive treatments as indicated by the patient’s condition.

Common drug categories include:

1. Analgesics:

   • Stronger opioids like pethidine for acute postoperative pain.

   • Milder analgesics such as diclofenac or paracetamol for less severe pain.

2. Antibiotics: To prevent or treat surgical site infections or other infections.

3. Intravenous fluids: Continued until the patient can tolerate oral intake adequately.

Exercises:

• Passive exercises: During the acute phase, the nurse assists with limb movements to promote circulation and prevent stiffness.

• Active exercises: As the patient’s condition improves, they are encouraged to perform active exercises, such as deep breathing exercises to prevent respiratory complications.

Psychotherapy:

Providing emotional support and distraction is important. This can involve reassurance, providing access to radio or newspapers, and creating a calming environment.

Hygiene:

• During the acute phase, a daily bed bath and oral care are provided. As the patient’s mobility improves, they can ambulate to the bathroom for personal care.

Elimination:

• Bowel: Promoting regular bowel movements is important. Constipation should be avoided by encouraging a high-fiber diet.

• Bladder: If a urinary catheter is in place, it should be draining freely. The drainage bag should be emptied regularly, and the output recorded on the patient’s fluid balance chart.

Discharging process:

• Medical devices such as nasogastric tubes and urinary catheters are removed as the patient’s condition improves.

• Skin sutures or staples are typically removed around the seventh postoperative day or as directed by the physician.

Advice on discharge:

• Instructions to continue prescribed medications.

• Scheduled follow-up appointment information.

• Guidance on avoiding undue pressure on the surgical site.

• Recommendations for a well-balanced diet rich in Vitamin C to promote healing.

Post operative complications

• Respiratory obstruction: May be caused by the tongue falling back or by vomitus. Prevented by proper patient positioning.

• Respiratory failure: Can occur due to the depressant effects of anesthesia and narcotic pain medications. May be managed with respiratory stimulants.

• Shock and collapse: Resulting from central nervous system depression and circulatory system failure.

• Heart failure: May be addressed with cardiac stimulants.

• Kidney failure/renal failure

• Post operative vomiting

• Urinary retention

• Hemorrhage: Excessive bleeding at the surgical site or internally.

• Flatulence: Accumulation of gas in the intestines.

• Infection and sepsis: Infection at the surgical site or a systemic infection.

• Burst abdomen: Wound dehiscence, where the surgical incision reopens.

• Trauma during the procedure: Unintended injury to tissues or organs during surgery.

• Post operative psychosis: Mental disturbance following surgery.