__________________________________________________________________ Chapter 17 Surgical Care 17
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 17.1
3
DISCUSS
• Discuss ways to lessen patient anxiety about
surgery. Why is it important to include family
members or significant others in
preoperative patient teaching?
p. 259. Ask each group to identify two
nursing interventions for each nursing
diagnosis, goal, and outcome criteria for the
patients in the scenarios below. Have each
group share its findings with the class.
• A 19-year-old pregnant woman who is
scheduled for a cesarean section
• A 65-year-old man who is scheduled to
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Describe
commonly used preoperative medications.
What are some typical nursing
4
DISCUSS
• Discuss the nurse’s responsibilities in
obtaining informed consent from a
preoperative patient.
• Divide the class into small groups. Have
each group outline a teaching plan for each
of the following patients:
• A Mexican-American patient who is able
to speak simple English and is
scheduled to undergo a laminectomy
• A 5-year-old patient scheduled for
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Create a
preoperative teaching plan for a patient
undergoing surgery.
5
DISCUSS
• Invite a nurse anesthetist, a scrub nurse, or
a circulating nurse to discuss the role of
each member of the surgical team. Have the
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Compare and
contrast the roles and responsibilities of
18 Chapter 17 Surgical Care __________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 17.1
6
DISCUSS
• Divide the class into three groups. Assign
one type of anesthesia to each group. Have
each group outline indications, methods, and
complications of that type of anesthesia.
Have each group present its findings to the
class.
• Divide the class into small groups. Have
each group refer to the Nursing Diagnoses,
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Compare and
contrast regional and general anesthesia.
What are some complications of each type
of anesthesia?
Critical Thinking Question
A patient with type 2 diabetes mellitus is scheduled for a hysterectomy in the morning. What
are some special considerations for the nursing care of this patient?
Discussion Guidelines: A person with diabetes mellitus is at higher risk for developing
complications during and after surgery. A patient with a chronic condition, such as diabetes
Instructor Notes/Student Feedback
__________________________________________________________________ Chapter 17 Surgical Care 19
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 17.2
Textbook Objectives Covered
8. List data to be included in the nursing assessment of the postoperative patient.
9. Identify nursing diagnoses, goals, outcome criteria, and interventions for the postoperative
patient.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying surgical care, including:
• Purposes of surgery and the variables affecting surgical outcomes
• Appropriate assessment procedure and interventions during each of the three phases of
surgery
• Providing patient education and guidance as appropriate during each phase of surgery
• Assemble materials and supplies needed for each lesson as indicated below.
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• ablative surgery (p. 256)
• anesthesiologist (p. 267)
• constructive surgery (p. 256)
• cosmetic surgery (p. 256)
• dehiscence (p. 271)
• diagnostic surgery (p. 255)
• evisceration (p. 271)
• palliative surgery (p. 256)
• paralytic ileus (p. 272)
• procurement for transplant (p.
256)
• reconstructive or restorative
surgery (p. 256)
• serous (p. 280)
20 Chapter 17 Surgical Care __________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 17.2
Student Preparation
Assignments 2 hours
7
READ – Textbook (pp. 269-284)
REVIEW
• Figure 17-8: Complications of wound healing (p. 271)
• Figure 17-9: Methods of wound closure (p. 278)
• Table 17-4: Surgical complications (p. 270)
ANSWER – Text
• Review Questions for the NCLEX Examination: 7 (p. 286)
ANSWER – Study Guide
• Part IB: 1-4 (p. 96)
8
READ – Textbook (pp. 272-277)
REVIEW
• Figure 17-10: Wound healing (p. 279)
• Figure 17-11: Types of surgical drains (p. 280)
• Table 17-5: Expected Drainage from Tubes and Catheters (p. 277)
• Box 17-4: Assessment of the Postoperative Patient (p. 276)
ANSWER – Text
ANSWER – Study Guide
• Part IE: 1 (p. 97)
• Part IIJ: 1-4, 29 (pp. 98, 102)
9
READ – Textbook (pp. 277-284)
REVIEW
• Figure 17-12: Splinting supports the incision during coughing (p. 281)
• Figure 17-13: The incentive spirometer is used to promote lung expansion (p. 282)
• Figure 17-14: Postoperative leg exercises promote venous return (p. 282)
• Nursing Care Plan 17-1: Postoperative Patient (p. 275)
ANSWER – Text
• Review Questions for the NCLEX Examination: 6, 8 (p. 286)
ANSWER – Study Guide
10
READ – Textbook (pp. 277-284)
__________________________________________________________________ Chapter 17 Surgical Care 21
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 17.2
50-Minute Lesson Plan
Lecture Outline 20 minutes
7
Slide 42
Surgical Complications
• Shock
• Effect of anesthesia or loss of blood
• Hypoxia
• Inadequate oxygenation of body tissues
• Injury
TALKING POINTS:
• Complications may be related to the surgical procedure itself, to the drugs used before
and during the procedure, or to immobility during and after the procedure.
• Why is the postoperative patient at risk for hypoxia?
Slide 43
Surgical Complications (cont.)
• Wound complications
• Dehiscence, evisceration, and infection
• Dehiscence and evisceration
• Dehiscence: reopening of the surgical wound
• Evisceration: body organs protrude through open wound
Surgical Complications (cont.)
• Gastrointestinal disturbances
• Nausea, vomiting, impaired peristalsis, and constipation
TALKING POINTS:
• Factors that cause peristalsis to be impaired after surgery include anesthesia, immobility,
opioid analgesics, and handling of the bowel during surgery.
• What is a paralytic ileus?
22 Chapter 17 Surgical Care __________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 17.2
Slide 45
Surgical Complications (cont.)
• Urinary retention and renal failure
• Urinary retention: kidneys produce urine, but the patient is unable to empty the
bladder
TALKING POINTS:
• Urinary retention can be caused by the effects of anesthesia or opioids, trauma to the
urinary tract, or anxiety about voiding.
• How do dehydration and blood loss affect urine output?
Slide 46
Surgical Complications (cont.)
• Thrombophlebitis
• Inflammation of veins; formation of blood clots
• Most often in legs after a period of immobility
• Emboli: thrombi that break loose and flow with the blood
TALKING POINTS:
• Patients who have very lengthy surgical procedures or who must be immobilized are
8
Slide 47
Immediate Postoperative Nursing Care in the PACU
• Assess patient’s status (level of consciousness, vital signs) and inspect the wound or
dressing
• Check and set up equipment (suction devices, oxygen, urinary drainage, intravenous
lines)
• Interventions
TALKING POINTS:
• Vital signs are monitored every 5 to 15 minutes in the postanesthesia care unit (PACU).
• What are the signs and symptoms of impending shock?
• Measures to reduce the risk of shock include prompt recognition and treatment of
__________________________________________________________________ Chapter 17 Surgical Care 23
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 17.2
Slide 48
Immediate Postoperative Nursing Care in the PACU (cont.)
• Acute pain
• Decisions to medicate for pain in the early postoperative phase are based on
physician’s orders and nursing judgment
• Acute confusion
• Simple explanations calm and reassure
• Many surgeons speak with the family after surgery
Slide 49
Immediate Postoperative Nursing Care in the PACU (cont.)
• Discharge from the PACU when
• Vital signs are stable
• Respiratory and circulatory functions are adequate
9
Slide 50
Assessment: Health History
• Review preoperative assessment noting long-term conditions, disabilities, prostheses,
drugs, and allergies
• When the patient is able to respond, ask about significant symptoms, including pain,
nausea, and altered sensations
Assessment: Physical Examination
• Vital signs
• Compare results with preoperative readings
TALKING POINTS:
• How often are the vital signs taken until they are stable?
• Note spontaneous movements and the patient’s ability to move affected parts on
command.
Slide 52
Assessment: Physical Examination (cont.)
• Integument
• Skin color and temperature; inspect the surgical area
24 Chapter 17 Surgical Care __________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 17.2
Slide 53
Acute Pain
• Pain receptors stimulated because tissues are cut and stretched during surgery
• Most severe during first 48 hours after surgery
• Administer intravenous opioid analgesics
• Patient-controlled analgesia
• Ask patient to rate pain on a scale of 1 to 10
TALKING POINTS:
• Muscle spasms in the area around the incision add to the patient’s discomfort.
• When do most patients need less medication for pain relief?
• Pain medication should be given before activities that normally cause pain.
Impaired Tissue Integrity
• Incision closed with sutures, staples, tape
TALKING POINTS:
• Although the wound appears to be healed after about 10 days, complete healing may
Slide 55
Impaired Tissue Integrity (cont.)
• Drains
• “Stab” wound: Penrose drain
• Hemovac and the Jackson-Pratt drain
• Create negative pressure when they are compressed
TALKING POINTS:
• Drains remove fluids from the operative site.
• A Penrose drain is a soft tube that permits the passive movement of fluids from the
wound.
• What is an “active” drain?
__________________________________________________________________ Chapter 17 Surgical Care 25
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 17.2
Dehiscence, Evisceration, and Infection
• Avoid strain on the suture line
TALKING POINTS:
• Patients who have had abdominal surgery should not use trapeze bars to move
themselves.
• What are the causes of wound dehiscence and evisceration?
Slide 57
Risk for Infection
• Signs and symptoms of wound infection usually do not develop until the third to fifth day
after surgery
• Include pain, fever, redness, swelling, and purulent drainage
TALKING POINTS:
• What techniques can be used to decrease exposure to microorganisms?
• If wound care is needed at home, make sure the patient or a family member is able to do
it before the patient leaves the hospital.
Slide 58
Impaired Gas Exchange
• Document respiratory status every hour for the first 24 hours
• Signs and symptoms of pneumonia include dyspnea, fatigue, fever, cough, purulent or
bloody sputum, and “wet” breath sounds
TALKING POINTS:
• Assist the patient to turn at least every 2 hours.
• Early ambulation has been found to reduce greatly the respiratory complications of
surgery.
• How should the patient be instructed to cough and deep-breathe?
Slide 59
Urinary Retention
• Carefully monitor urinary output after surgery
• In the first 24 hours, urinary output is reduced because of the stress response
• Monitor urinary function by measuring intake and output and by checking for bladder
distention
TALKING POINTS:
• Patients who have had perineal or abdominal surgery are most likely to have difficulty
voiding.
• What sensory stimuli may encourage voiding?
26 Chapter 17 Surgical Care __________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 17.2
Slide 60
Constipation
• Inspect and palpate for abdominal distention and auscultate for bowel sounds
• Flatus means digestive tract is functioning again
• Measures to promote flatus may be ordered
TALKING POINTS:
• Document the passage of flatus and the first bowel movement.
• What is the best way to prevent gastrointestinal discomfort?
• Severe abdominal distention develops if normal bowel activity does not resume within a
few days.
Slide 61
Deficient Fluid Volume and Imbalanced Nutrition: Less Than Body
Requirements
• Usually clear liquids first, then full liquids
• If liquids retained, soft, then regular foods
Impaired Physical Mobility
• Help patient sit on the bedside, press the feet on the floor, stand, and then walk
increasingly greater distances
Slide 63
Disturbed Body Image
• Effects of surgery (scars, loss of body organs, altered physical functions) can be
traumatic
• A sense of loss can be demonstrated by anger, depression, or even denial
10
Discharge Teaching
• Prescribed medications
__________________________________________________________________ Chapter 17 Surgical Care 27
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 17.2
Activities
Classroom Choose from below to make 30 minutes
Online
7
DISCUSS
• Discuss Table 17-5. What are the nurse’s
responsibilities for prevention and treatment
of each complication?
• As a class, discuss and identify possible
surgical complications and list them on the
board. Divide the class into small groups
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Divide the
class into groups. Provide each group with
the following scenarios. Have each group
determine the type of postoperative
complication and outline nursing
8
DISCUSS
• Discuss the assessment of and nursing
interventions for a patient admitted to the
PACU.
• Divide the class into three groups. Have
each group describe nursing care provided
in the OR, PACU, or ICU/medical-surgical
unit after surgery. In a class discussion,
compare and contrast the care provided.
• In a class discussion, ask students how
they would respond in the following
situation:
• A patient, who is in the PACU following
repair of a right lung lobectomy, is
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Discuss the
conditions that must be met before a patient
can be moved from the PACU.
28 Chapter 17 Surgical Care __________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 17.2
9
DISCUSS
• Discuss nursing care for the postoperative
patient.
• Discuss appropriate interventions for acute
postoperative pain.
• Discuss appropriate interventions for
share its findings with the class.
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Create a
teaching plan to prevent postoperative
complications of surgery.
10
Discuss
• Community resources available to the
patient
POST AND COMMENT
• Create and post a discharge teaching plan
for a surgical patient.
Critical Thinking Question
A 74-year-old man who underwent bowel resection surgery 2 days ago develops a low-grade
fever and refuses to deep-breathe and cough because of incisional pain. The nurse
auscultates his lung sounds and hears bilateral basilar crackles. Why might the patient have
a low-grade fever and how should the nurse intervene?
Discussion Guidelines: The patient’s fever is most likely related to atelectasis and stasis of
secretions from general anesthesia. Fever within 48 hours of surgery is typically related to
Instructor Notes/Student Feedback
__________________________________________________________________ Chapter 17 Surgical Care 29
Introduction to Medical-Surgical Nursing, 6th ed.
17
Assessments for
Surgical Care
CHAPTER OBJECTIVES
Lesson 17.1:
2. List data to be included in the nursing assessment of the preoperative patient.
4. Outline a preoperative teaching plan.
6. Explain the nursing implications of each type of anesthesia.
Lesson 17.2:
8. List data to be included in the nursing assessment of the postoperative patient.
9. Identify nursing diagnoses, goals, outcome criteria, and interventions for the postoperative patient.
Assessments by Lesson & Objective
Lesson 17.1
1
Study Guide
• Part IA: 1-7 (p. 95)
• Part IIJ: 8 (p. 99)
Evolve Instructor Resources
• Test Bank: 16
Evolve Student Resources
• NCLEX Review: 1
2
Evolve Instructor Resources
• Test Bank: 17, 22, 28
3
Study Guide
• Part IC: 1-3 (p. 96)
• Part IH: 1-10 (p. 97)
Evolve Instructor Resources
• Test Bank: 7, 14, 23
Evolve Student Resources
• NCLEX Review: 2, 5, 6
• Prioritization: 6
4
Evolve Instructor Resources
• Test Bank: 29
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
5
Evolve Instructor Resources
• Test Bank: 18, 31
6
Study Guide
Evolve Instructor Resources
• Test Bank: 15, 26, 27, 32
Evolve Student Resources
• NCLEX Review: 7
Lesson 17.2
7
Study Guide
• Part IB: 1-4 (p. 96)
• Part IF: 1 (p. 97)
• Part IG: 1 (p. 97)
• Part II: 1-15 (pp. 97-98)
• Part IIJ: 5-7, 9, 10, 12, 13, 24-26, 27 (pp. 98-102)
Evolve Instructor Resources
• Test Bank: 2, 3, 5, 6, 13
• Prioritization: 3, 4
8
Study Guide
• Part IE: 1 (p. 97)
• Part IIJ: 1-4, 29 (pp. 98, 102)
Evolve Instructor Resources
• Test Bank: 3, 8, 9, 11, 21, 25, 30
9
Study Guide
• Part IIJ: 31-42, 44, 45 (pp. 102-103)
• Part IIIK: 2-13 (pp. 103-104)
Evolve Instructor Resources
• Test Bank: 1, 4, 12, 19, 20, 24
Evolve Student Resources
• NCLEX Review: 4, 10
• Prioritization: 1, 2, 5
Evolve Instructor Resources
__________________________________________________________________ Chapter 17 Surgical Care 31
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
Instructor’s Notes/Student Feedback