2 Introduction to the principles of surgical nursing
The key principles of surgical nursing
We saw in Chapter 1 that there are key words associated with surgery, where it takes place and the roles of various healthcare professionals in the care of patients and their families. Given that you will be learning and working alongside qualified nurses who will be your mentors, it is essential that you familiarise yourself with key aspects of care that a nurse may be involved with.
In this chapter, we provide an overview of the main responsibilities of the nurse in relation to key areas of practice in a surgical placement, and help you to identify what knowledge and skills you will need to ensure best evidence-based practice and patient care. It is important, as with any placement, that you undertake some preliminary reading with regards to patient care, including normal physiology, and, if possible, update some of the key clinical skills required in a surgical placement. The chapter helps you understand how to achieve the NMC Competencies and Essential Skills relevant to your learning experience in a surgical placement, as well as identifying recommended reading prior to the placement. This also helps you to develop your evidence-based practice, an essential part of becoming a competent practitioner on completion of your programme of study (see Ch. 4).
The key areas are the following:
• Assessment, planning, implementing and evaluating care using a nursing model or framework.
• Managing fluid and electrolyte balance.
• Managing wounds and wound care.
It is important to remember that every patient you meet is an individual and so all those you care for during the perioperative period will be unique in their previous experience of hospital, their present illness and their full medical history. It is possible, however, to identify key aspects of care that will be the same for all patients admitted to hospital for surgery.
Assessment, planning, implementing and evaluating care using a nursing model or framework
Admission to hospital, whether it is for a day or longer, is a potentially stressful and anxious experience for patients as well as for their families (Walker 2002). This is one of the main reasons why ensuring patients receive preoperative information about their surgery and their stay in hospital is so important. The development of pre-admission assessment prior to a stay in hospital has become increasingly utilised by the surgical team, which includes nurses as well as surgeons and anaesthetists working together (Fisher & McMillan 2004). This topic is considered in more detail in Chapter 5.
In this chapter, we cover the general principles of assessment of patients, along with planning, implementing and evaluating care; in other words the nursing process as a framework for helping you to learn to care for patients when you begin your placement experience. For some of you, this will be revisiting prior knowledge and experience. Not every surgical ward has a care plan document which clearly states that a nursing model is being used (e.g. Roper, Logan and Tierney's activities of living model [Roper et al 2000]). However, as a student, using the principles of a model helps you to develop a set of skills and knowledge about how to assess, plan, implement and evaluate care as well as focusing on helping you identify gaps in your knowledge and practice. In addition to a nursing model as a framework for applying the nursing process, you also need to be aware of the care delivery model used to deliver care to patients in the surgical placement: for example, is it a team nursing approach or primary nursing?
Find out which nursing model is used in your placement as a framework for care, and if no specific one appears to be used, consider how you could use one to help you learn to assess a patient on admission to hospital and identify needs prior to surgery. (An example of a nursing care plan document can be found in Appendix 3 in Holland et al (2008), as well as a list of questions you may need to ask patients to help ensure best practice and patient safety.) All students need to be able to use a method such as the nursing process to enable them to identify and meet the needs of patients. For those pursuing the adult nursing field of practice (previously known as a branch), the NMC Standards and Competencies in Box 2.1 are particularly relevant.
Box 2.1 Examples of NMC Standards and Competencies (NMC 2010)
Domain: Nursing Practice and Decision Making
Field Standard for Competence (Adult Nursing)
Adult nurses must also be able to carry out accurate health, clinical and nursing assessments across all ages and show the right diagnostic and decision-making skills. They must have the confidence to provide effective adult nursing care in the home, the community and in hospital settings to individuals and communities. They must be able to respond to a range of healthcare needs and levels of dependency including: immediate care, critical care, acute care, intermediate care, long-term conditions, palliative care and end of life care.
Competencies
Generic
1. All nurses must work loosely with individuals, groups and carers, using a range of skills to carry out comprehensive, systematic and holistic assessments. These must take into account current and previous physical, social, cultural, psychological, spiritual, genetic and environmental factors that may be relevant to the individual and their families.
1.1. Adult nurses must safely use a range of diagnostic and clinical skills, complemented by existing and developing technology, to assess the nursing care of individuals undergoing therapeutic or clinical interventions.
Field Specific
2.2. Adult nurses must develop and use care pathways and care plans, recognising when standard care pathways are inappropriate and when care should be tailored to individual needs and circumstances. They must understand the physical and psychological impact of long-term conditions, lifestyle, health needs or periods of acute illness. They must then adjust nursing interventions to take account of when people have more than one health need or condition and a person's ability to care for themselves.
5.1. Adult nurses must recognise the early signs of acute illness in young people, adults and older people and accurately assess and start appropriate and timely management of those at risk of clinical deterioration, who are acutely ill or who need emergency care.
Paper to read prior to placement:
Shirey M R (2008) Nursing practice models for acute and critical care: an overview of care delivery models. Critical Care Nursing Clinics of North America 20(4):365–373.
Although this paper is written in the context of a US healthcare system, it is applicable to the UK NHS and compares a range of care delivery options that you will come across in your placements.
Managing fluid and electrolyte balance
Major surgery of any kind will involve a certain amount of blood or fluid loss. To be able to understand what is happening to a patient (with an underpinning knowledge of why this will have an impact on their body) and therefore be able to care for them, it is essential that you understand the management of fluid and electrolytes. It is part of your role as a student, under the supervision of your mentor, to ensure that a fluid balance chart is maintained and be able to interpret this accurately in order to ensure a patient's internal environment is safe.
It is beyond the scope of this book to cover everything you will need to know and we encourage you to read a physiology textbook which explains the way in which the body normally manages fluid and electrolyte balance.
Water is essential to human life, and can be found both within and outwith cells. It makes up around 70% of our total body weight and varies from morning to night by around 2% depending on what we have had to eat or drink (Kindlen 2003). To maintain a balance, it is excreted in urine, faeces, skin and sweat and also exhaled from the lungs.
It is essential to maintain the right ‘ingredients’ in the right amount to manage this balance between enough, too little or too much water. This is why electrolytes are so important in their correct balance. The electrolytes are sodium, potassium and chloride and we consider these in more detail below.
In order to maintain the body's homeostasis (balancing the state of the body's internal environment), different systems have to work together, but for a patient who is ill or has had surgery, this balance may no longer be maintained and signs and symptoms of this will appear. Early detection of these is part of your role as a nurse, and as a student you will need to learn skills and knowledge of how to detect potential problems with fluid balance and thus the balance of electrolytes (see Ch. 20 in Gobbi et al 2006 for a detailed evidence-based approach).
Such skills and knowledge are transferable to other placements, and you may already have experience of detecting possible problems from other placements, which will give you confidence in applying these skills to your surgical placement.
So, how can you be a detective? First, consider Table 2.1 which highlights the different signs and symptoms associated with fluid and electrolyte problems.
Table 2.1 Signs and symptoms associated with fluid and electrolyte problems
| Fluid and electrolyte intake | What could happen and your observations of the effect of this on a fluid balance chart as well as personal observation of the patient |
|---|---|
| A patient has not drunk anything for 12 hours and has been vomiting (they are not being given any intravenous fluid at this time). | If the patient has not been drinking any fluids but is also losing fluid, this means that fluid loss is exceeding intake. This will cause the patient to become dehydrated. You will be able to see this on a fluid balance chart and it is important to measure the amount of vomit if possible (i.e. if the patient has vomited into a vomit bowl and it is mainly liquid, this can be measured). The body will also respond by trying to conserve fluid, and therefore there will be a reduction in urine output, which you will also note on the chart. If this persists without treatment, additional signs will become apparent but these will be visible through personal observation of the patient rather than on the fluid balance chart. It is important to monitor both. |
| An elderly lady has returned from the operating theatre and is not having any oral fluids. Due to lack of close observation of her intravenous fluid intake, she has absorbed 1 litre over 15 minutes instead of the 6 hours prescribed. |
Obviously, it is essential that any patient returning from theatre should be closely observed for signs of physiological and other changes. This is part of the NMC Code (NMC 2009) However, occasionally, and for valid reasons such as positioning of the arm or restlessness of the patient, IV fluids may ‘run through’ the tubing at a faster rate than it should If this does happen, it could have serious consequences due to circulatory overload, especially if the patient is elderly or there is another underlying health problem where a sudden overload of fluid is not advisable. It is important to notify the doctor in charge of the patient's care initially, who will advise certain protocols and also close observation of the patient. Key signs of fluid overload include tachycardia, raised blood pressure, wheezing or other signs of respiratory distress. There may also be restlessness. |
| A man has returned from theatre having lost a great amount of blood and the surgeon has ordered 4 units of blood to be given over 24 hours. He has already received 2 units of blood in theatre. |
During blood transfusion, key observations to make are pulse rate, blood pressure, temperature and general observation of the patient. Normally, the nurse should remain with the patient for at least 5–10 minutes after a unit has been started to ensure any unexpected reaction is monitored (Torrance & Serginson 1999). Record carefully his intake of blood, any additional fluid given and his urine output. Check for any increase in pulse rate (tachycardia), lowering of his blood pressure (hypotension), any allergic response such as a sudden rash and, most importantly, any increase in temperature, or shivering and rigors. All these could indicate a reaction to the blood but symptoms such as increased pulse rate and lower blood pressure could also indicate further blood loss. |
| A patient has returned from theatre and has had 2 litres of fluid over 24 hours, has not yet started to take fluids orally and has only passed 200 ml of urine in 24 hours. | Having a reduced urinary output is not uncommon in postoperative surgical patients (Torrance & Serginson 1999). This patient is experiencing what is known as low urine output or oliguria, as the flow of urine is less than 400 ml in 24 hours. Careful monitoring of his urine output on an hourly basis may be necessary. |
| A 60-year-old man has had major abdominal surgery. He has progressed to being allowed to eat as well as drink but he is reluctant to do either and his wound is not healing as well as anticipated. |
It is important to encourage him to eat and drink as there is a correlation between good nutrition and wound healing. It is important to explain this to the patient and also find out why he is reluctant to eat and drink after his surgery. He may have fears about his wound bursting due to eating too much or he may still be feeling nauseated due to the effects of the anaesthetic. Whatever the reason, close observation and reassurance are essential in order for his wound to heal properly and for him to have any fears allayed postoperatively. |
Ensuring you are familiar with how fluid and electrolyte balance works will support your achievement of many NMC Essential Skills and Competencies. For example, as an Essential Skill at Progression Point 2 (probably at the end of year 2) on the NMC regulations (NMC 2010:131), it is expected that:
‘People can trust a newly registered graduate nurse to assess and monitor their fluid status and, in partnership with them, formulate an effective care plan:
We will return to how you can manage learning opportunities to achieve these later in the book.
Managing nutrition
There is clear evidence that patients can become malnourished in hospital (Edwards 1998, Brogden 2004). The majority of patients undergoing elective surgery should be ‘well nourished and able to cope with a short period of pre- and postoperative starvation’ (Torrance & Serginson 1999:103) but, as seen in The Essence of Care (Department of Health 2001, NHS Modernisation Agency 2003) it is evident that malnutrition is a problem in hospitals.
The possible causes of malnutrition in a patient undergoing surgery can be seen in Box 2.2.
Box 2.2 Causes of malnutrition in the surgical patient
An underlying disease process causing a reduction in food intake and/or increased nutrient losses.
The metabolic response to trauma/surgery.
Enforced periods of nil by mouth.
Reduced appetite: may be further affected by pain/nausea/depression/anxiety.
(From: Ord H, Baker M (2010) Nutrition and the surgical patient. In: Pudner R, Nursing the surgical patient. Baillière Tindall, Edinburgh)
You may already have considered that Mrs Gold will need care in a number of areas:
• Physical preparation for undergoing surgery.
Consider Case history 2.1 as an experience you may have in a specific adult nursing placement or an exposure to other fields of practice clinical placement.
Mrs Gold, aged 56 years, has been admitted to hospital for surgery. She has had ulcerative colitis for 20 years which has been progressively affecting her quality of life. She has been admitted to hospital on numerous occasions over this period of time for palliative treatment, medication changes and surgery. Her nutritional status has become compromised, she has lost weight and has become depressed because of this and the constant exacerbation of her condition.
• Nutritional needs during the whole of the perioperative period.
This is an example of the type of learning experiences you might plan with your mentor to meet the NMC Standard in Box 2.3.
Box 2.3 Developing learning plans with your mentor
Domain: Nursing Practice and decision making (NMC 2010)
Generic Standard for Competence (for all fields of practice)
Nurses must demonstrate a knowledge and understanding of how lifestyle, diversity and socioeconomic factors can affect health and illness and public health priorities.
They must meet the needs of people of all ages who may have overlapping physical and mental health problems, such as children and young people with addiction problems, eating disorders; and learning disabilities; adults with depression, eating disorders, dementia and drug and alcohol abuse; and older people with dementia, restricted lifestyles due to disability, and long-term illness.
NMC 2010 Standards of Competence (NMC 2010)
Paper to read prior to placement:
Fletcher J (2009) Identifying patients at risk of malnutrition: nutrition screening and assessment. Gastrointestinal Nursing 7(5):12–17.
Prior to any practice placement experience, it is very important that you find out about the kinds of learning experiences you are likely to have and the health problems of the patients you are likely to come across. This will enable you to plan your pre-placement reading and also consider the kind of clinical skills that you may encounter to add to your increasing levels of competence and confidence.
Managing pain
It must not be assumed that all patients undergoing surgery will experience pain or that it is an expected outcome. However, for many patients, and again depending on the surgery that has taken place, a certain level of pain or discomfort may be anticipated. Kitcatt (2010:103) states that ‘pain is a complex, multidimensional experience and it is unique to the patient experiencing it … It is also a warning sign that something is wrong’. This applies to any patient and not just those undergoing surgery. It is important, therefore, to understand the principles underpinning pain and why patients experience it, as well as the mental and physical effects on an individual.
Managing infection control
Infection control is an essential aspect of a nurse's role in any field of practice and none more so than in a perioperative environment, especially in the operating theatre (see Ch. 8). Handwashing, for example, will have been introduced early in your nursing course, and many of you will have undertaken either formative or summative assessment in a clinical simulation laboratory in this essential nursing practice. Handwashing should be a normal day-to-day activity for adults and children, with more and more environments now adopting good practice in infection-free areas and the use of special antibacterial gels. Hospitals, nursing homes and other areas now ensure that visitors are also included in their good practice, with many hospitals setting up ‘hand protection’ stations at key points in hospital corridors and outside wards. You may, as a student, be given your own small bottle of gel to place in your pocket for daily use. Students in certain placements, such as mental health, have to adopt other mechanisms for infection control and handwashing due to the risk to patient safety and possibe self-harm if patients obtain access to these types of gels.
Paper to read prior to placement:
Col M (2007) Infection control: worlds apart primary and secondary care. British Journal of Community Nursing 12(7):301–306.
Make sure you are familiar with the infection control policies and practice of your placement. Check that you are confident in handwashing technique and that you are aware of the possible consequences of not adopting good handwashing techniques and practices. Most of you will have undertaking handwashing as a key skill to learn prior to your first placement and some of you will have been assessed in this practice as well.
All students are expected to meet the standards for Essential Skills in Infection Control (see NMC 2010 Essential Skills Cluster: Infection Prevention and Control 21, 22–26).
Consider the NMC Standard and Competency Statement in Box 2.4 which includes generic statements and those applied specifically to mental health field of practice.
Box 2.4 Domain 3: Nursing Practice and Decision Making (NMC 2010)
Generic standard for competence
All nurses must practise autonomously, compassionately, skilfully and safely, and must maintain dignity and promote health and wellbeing. They must assess and meet the full range of essential physical and mental health needs of people of all ages who come into their care. Where necessary, they must be able to provide safe and effective immediate care to all people prior to accessing or referring to specialist services irrespective of their field of practice. All nurses must also meet more complex and coexisting needs for people in their own nursing field of practice, in any setting including hospital, community and at home. All practice should be informed by the best available evidence and comply with local and national guidelines.
Decision making must be shared with service users, carers and families and informed by critical analysis of a full range of possible interventions, including the use of up-to-date technology. All nurses must also understand how behaviour, culture, socioeconomic and other factors, in the care environment and its location, can affect health, illness, health outcomes and public health priorities and take this into account in planning and delivering care.
Field standard for competence
Mental health nurses must draw on a range of evidence-based psychological, psychosocial and other complex therapeutic skills and interventions to provide person-centred support and care across all ages, in a way that supports self-determination and aids recovery. They must also promote improvements in physical and mental health and wellbeing and provide direct care to meet both the essential and complex physical and mental health needs of people with mental health problems.
Competencies
1. All nurses must use up-to-date knowledge and evidence to assess, plan, deliver and evaluate care, communicate findings, influence change and promote health and best practice. They must make person-centred, evidence-based judgements and decisions, in partnership with others involved in the care process, to ensure high-quality care. They must be able to recognise when the complexity of clinical decisions requires specialist knowledge and expertise, and consult or refer accordingly.
1.1.Mental health nurses must be able to recognise and respond to the needs of all people who come into their care including babies, children and young people, pregnant and postnatal women, people with physical health problems, people with physical disabilities, people with learning disabilities, older people, and people with long-term problems such as cognitive impairment.
2. All nurses must possess a broad knowledge of the structure and function of the human body, and other relevant knowledge from the life, behavioural and social sciences as applied to health, ill health, disability, ageing and death. They must have an in-depth knowledge of common physical and mental health problems and treatments in their own field of practice, including co-morbidity and physiological and psychological vulnerability.
1. How could you use what you know about infection control policy and practices to enable you to meet the generic outcomes for any field of practice?
2. If you are following a mental health pathway, how could this help you to achieve your field-specific competency while undertaking a mental health-specific placement?
If undertaking the pathway to become a qualified mental health nurse, negotiating a short learning opportunity in a surgical placement could offer an insight into a client with mental health problems who has had a surgical procedure or intervention. Some of you will already have had this experience as part of a placement learning pathway (as described by the NMC [2010]) as good practice in developing a holistic view of client care.
Cole (2007:24) explores some of the differences between infection control practice in primary and secondary care and examines the reasons for this.
Managing wounds and wound care
Surgical interventions lead to some kind of wound, whether it is a small incision as for a laparoscopy or insertion of an implant, or a major incision into the abdomen in order to reach major abdominal organs. They are usually made in ‘a clean environment where asepsis is maintained at all times’ (Pudner 2010).
Pudner (2010:51) states that the following are the ‘main principles of surgical wound management’:
• To achieve healing of the wound.
• To avoid complications, e.g. infection.
• To achieve good pain control.
• To ensure a cosmetically acceptable scar.
• To allow the individual to return to a normal lifestyle as soon as possible.
The kind of surgical placement you undertake will determine the experience you will gain in wound care and management, but these principles should be considered as a guide to determine learning experiences to obtain and skills to develop. Knowledge of wound healing, infection control and pain management are prerequisites for preparation for practice experience in a surgical placement (see Section 3 for integration of learning).
Read about the physiology of wound healing (surgical) and consider the factors that are essential for effective wound healing.
Re-visit the principles of asepsis and consider the key competences to achieve to meet the Essential Skills Cluster on Infection Control (see NMC 2010 Essential Skills Cluster: Infection Prevention and Control 21, 22–26).
Revise and re-visit your handwashing skills prior to placement and find out what kind of policy is in place with regards to use of antibacterial hand gel.
Managing stress and anxiety
Being anxious before undergoing a surgical procedure is a normal reaction for patients. However, there is research to show that although a certain level of anxiety is to be expected, higher levels can have a more profound impact on a patient's wellbeing. For example, Pritchard (2009:417) states that ‘Anxious patients, particularly post-operative patients, appear to suffer more pain and can become more distressed by the presence of wound drains or urinary catheters’ and that ‘the role of nurses is to ensure that the patient is fully prepared for the normal post-operative care a surgical operation may entail’.
Managing anxiety and alleviating possible stress is a major part of caring for patients who are to undergo surgery (see Chs 6 and 9). Given that in the future, a significant number of surgical procedures will be experienced as day surgery, identifying patients at risk and offering them the support they need in the short term will become an important aspect of learning in any kind of surgical placement. It might form the basis of one of your main goals to achieve, for example: ‘To determine the evidence base for preoperative and postoperative anxiety and to offer support to a patient during the perioperative period with the supervision of my mentor’ (see Ch. 4 for goal statements).
Managing possible altered body image
Bob Price's (1990) explanation and model of body image is an excellent way of examining the way in which we normally see ourselves. When undergoing surgery, that normal perception of ourselves may be altered. Price considers that body image is actually made up of three different concepts: body ideal, body reality and body presentation. In brief, body reality ‘refers to our body as it really is – tall, short, fat, thin, spotty, sallow, coarse’ and ‘it is not how we would like our body to look, nor whether we find it pleasant or disagreeable. It is the body as seen and measured as objectively as humanly possible’ (Price 1990:4).
Body ideal, on the other hand, is when the body reality ‘is measured constantly against an ideal of what we think the body should look like and how it should act. This ideal is carried in our head and may be applied not only to our own body reality, but that of others near and dear to us’ (Price 1990:6).
Body presentation is then related to how we dress and adorn our bodies but also, most importantly, ‘the way in which it might move and pose its limbs were it to come to life’ (Price 1990:10). It is how we present ourselves and our body appearance to the social world.
Consider minor surgery involving the insertion of two or three sutures. For most people, this would not necessarily be problematic. Imagine if those sutures were to be inserted into the facial skin of a photographic model whose work was dependent on having a ‘flawless’ appearance, would their response be the same as someone whose work was not dependent on this? It is easy to see how concerns about body image can also have an effect on anxiety levels pre- and postoperatively.
It is important to consider the impact that any surgical intervention may have on a person regardless of anticipated disfigurement resulting from it. Learning about this prior to placement will give you knowledge to be able to consider a patient's needs during their perioperative care and also demonstrate your awareness of the links between physical aspects of care and social and psychological aspects.
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Department of Health. The essence of care: patient-focused benchmarking for healthcare practitioners. London: DH; 2001.
Edwards S.L. Malnutrition in hospital patients: where does it come from? British Journal of Nursing. 1998;7(16):971–974.
Fisher A., McMillan R. Integrated care pathways for day surgery patients. London: British Association of Day Surgery; 2004. Online. Available at: http://www.daysurgeryuk.net/bads/joomla/files/Handbooks/IntegratedCarePathways.pdf (accessed September 2011)
Gobbi M., Cowen M., Ugboma D. Fluid and electrolyte balance. In: Alexander M., Fawcett J.N., Runciman P.J. Nursing practice hospital and home: the adult. Edinburgh: Churchill Livingstone; 2006:763–785.
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Kindlen S. Physiology for health care and nursing. Edinburgh: Churchill Livingstone; 2003.
Kitcatt S. Concepts of pain and the surgical patient. In: Pudner R., ed. Nursing the surgical patient. 3rd ed. Edinburgh: Baillière Tindall; 2010:103–123.
NHS Modernisation Agency. Essence of care; patient-focused benchmarks for clinical governance. London: NHS; 2003.
Nursing and Midwifery Council. The code: standards of conduct, performance and ethics for nurses and midwives. London: NMC; 2008.
Nursing and Midwifery Council. Standards for pre-registration nursing education. Online. Available at: http://standards.nmc-uk.org/PreRegNursing/statutory/background/Pages/introduction.aspx, 2010. (accessed May 2011)
Price B. Body image – nursing concepts and care. London: Prentice Hall; 1990.
Pritchard M.J. Managing anxiety in the elective surgical patient. British Journal of Nursing. 2009;18(7):416–419.
Pudner R. Wound healing in the surgical patient. In: Pudner R., ed. Nursing the surgical patient. Edinburgh: Baillière Tindall; 2010:51–76.
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The Breast Cancer Care UK website has some excellent resources on topics such as body image, surgical intervention and post-surgical expectations. There are also some excellent audio and video clips of women talking about their experiences: http://www.breastcancercare.org.uk/breast-cancer-breast-health/treatment-side-effects/surgery/ (accessed December 2011).
These links takes you to many different pages where you can discover not only patient stories of their experiences (http://www.nhs.uk/Planners/Yourhealth/Pages/Realstories.aspx) but also explanations of different kinds of surgical interventions such as removal of cataracts (http://www.nhs.uk/Search/Pages/Results.aspx?___JSSniffer=true&q=Cataract+surgery) and bowel cancer (http://www.nhs.uk/conditions/cancer-of-the-colon-rectum-or-bowel/pages/realsstoriesbowelcancer.aspx) (accessed December 2011).