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 nutrition.

• Managing pain.

• Managing infection control.

• Managing wounds and wound care.

• Managing stress and anxiety.

• Managing possible altered body image.

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?

Activity

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

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.