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BUKOVINIAN STATE Medical university




on the methodical conference of department

of patients’ care and higher

nurse education

“ ” ________ 200_ protocol N __

Chief of department, associate professor I.A. Plesh






nursing in surgery

for 3nd year students

of medical faculty №4,

specialty "nurse business''

Methodical instruction was prepared by:

Assistant Riabyi S.I.

Chernivtsi - 2010


(Preparation of patients to planed and urgent operations. A main concept about preoperative period. A purpose of preoperative preparation. Nurse’s function in preoperative period: participation in preparation of organs and systems, hygienic means, preparation of operative field, making of to sensitivity’s tests to medicines. Premedication. Transporting of patients to operation room.).

^ 2. Duration of the class: 2 academic hour.

3. Study aim:

3.1. The student should know:

  • preparation of patients to planed and urgent operations;

  • a main concept about preoperative period;

  • a purpose of preoperative preparation;

  • nurse’s function in preoperative period;

  • participation in preparation of organs and systems;

  • hygienic means;

  • preparation of operative field;

  • making of to sensitivity’s tests to medicines;

  • premedication;

  • transporting of patients to operation room.

^ 3.2. The student should be able:

  • to use modern methods of examination of surgical patients;

  • to analyze results of additional methods of surgical patients’ examination;

  • to take care of surgical patients;

  • to make out of nurse’s documentation.

^ 3.3. The student should master practical skills:

  • to collect complaints of patients;

  • to do observation of skin;

  • to do palpation;

  • to do percussion;

  • to do auscultation;

  • to collect patterns of blood, urine, stomach juice, bile etc;

  • to do enemas;

  • to do preparation of skin;

  • to do premedication;

  • to make out of nurse’s documentation.


^ 4. Advice for students:

Preoperative period – it is the time spent right from patient’s hospitalization to the operation. The duration of this period depends upon the severely of the disease (acute disease or chronic). This depends from the operation invasion type and from the reserves of the body of patient etc. The operation which is threatening to the life of patients could be carried right from the minimal volume of preoperative preparation. If this operation is planned and the disease state does not threaten to the patient, the operation could be carried out from 1 hour till few days. (As usually it is one day and less frequent week or more).

From the medical point of view and from the economical point of view preoperative period should be as minimal as possible. Thus, the least probability of his/her infectioning by intra-hospital infections exists.

The contacts of the patient which supposed to be with pyogenic should be decreased: it means first of all that his preoperative period spent in the hospital will not be so long thanks to successful speed of diagnostics of his disease at home. Thus, speed of diagnostics depends upon the skills of the physician.

Well diagnosed disease at home, using practical knowledge puts surgeons at once on the correct way and does not take excessive time to perform unneeded diagnostic tests. Thus, for the doctor in the hospital the final examination goes with just with questioning of patient and acquaintance with his needed laboratory tests and with putting correct final diagnosis and requirements for operation.

In patients, before operation the carrying out of necessary skin-tests needed: they are first of all the allergic skin-tests with anesthetics (Novocain often, and other) and with antibiotics. The allergic reactions are often caused by the group of Penicillin remedies.

When all instrumental and laboratory tests are performed the final diagnosis could be put. From this moment patient is being prepared for the intervention.

The volume of the preoperative preparation is outlined by the volume of surgical intervention, from the state of his system of organs and from the character of his general state of health. In the case if operational invasion is going to be minimal and the state of his systems of organs is satisfactory one can carry out just psychological preparation and hygienic preparation. The patients supposed to be with big volumes of invasions on internal organs along with profound internal changes in organs associated with the age, the preparations should be multi-profiling and quite deep.

Preoperative preparation of patients is combined from general preparation (necessary for all patients) and individual preparation of patients depending on which organs involved in pathologic process.

The urgency of the separate case influences on the type of preoperational preparation as well. Urgent operation – is the invasion carried immediately after the patient was brought to the hospital, and it’s usually no longer than few hours (The cases which require the urgent hospitalization and, flowingly urgent intervention are: acute appendicitis, hernia necrotic tissues, perforated bleeding ulcer).

Not delaying operation – the surgical intervention carried out during following few days: this could be the mechanical jaundice malignant tumor etc. The planned operation should be performed after full examination of patient and deep and careful preparation.

The examination and preparation of patient for the urgent operation is individual and depends upon the severity of his state. The patient are prepared minimally if they go to the operation with injures of heart and big arterial trunks. In the other case the preparation of patients should be performed in minimal volume. The main tasks of preparation period in these cases are correct putting of diagnosis and signs as for the urgency of operation, definition of functional reserves of organism and rising of its immunity mechanisms for the defense of organism against endogenous infections.

Before non-delaying operation the certain sequence of hygienical procedures is recommended: hygienical shower with the following cloth change, broad shaving of hairs in the region of future surgical intervention, the antiseptics preparation, evacuation of the stomach contents, false teeth removal, premedication, injection usage of blood products and transportation to the operational hall, bladder catheterization and operative area preparation.

The planned surgical intervention meant of performance of the next stages of patient preparation:

  • Psychological preparation

  • Cardiovascular system preparation

  • Respiratory system preparation

  • Preparation of digestive system

  • Improving of kidneys and liver functioning

The nervous system preparation and psychics of patient suggests to the attentive attitude to any complaints of the patient, removal of the anxious states, irritated conditions and doubts. The anxiety of future pain, doubts and future bright imagination of the ‘bloody cuts of body’ ruins the defensive resources of the body, decrease the sleep of the patient rising nightmares and horror. Sometimes there are enough of few words of physician or nurse calm down the patient, explaining that everything will be OK.

The attention of doctor along with all staff should be directed to the ‘guarding regimen for patients.’ Right from the moment of hospitalization to the very operation everyone should not to disturb patient’s psychics. Newly hospitalized patient should not be put to the ward with patients who undergone to the heave surgical operations, or those who are on the border of the life and death. So, such patient is better to be with patients who are about to be discharged. The company with recovering patients gives the hope for the good expectations for such patient and with hope to recover. Bad psychic influence on patient causes abrupt change of the day of operation moreover, long expectations to be operated.

^ Preoperational preparation of operation area

On the day of operation the area of operation is shaved with dry method (without use of any shaving cream). The shaver after shaving should be disinfected with appropriate antiseptic and the razor from shave should be trashed after disinfection. One can use single-usage shavers if it is provided with patient. All moves of shaving or washing should be in direction from the wound to decrease the probability of contamination of wound. After the shaving the napkin used to caver the skin should be taken away and the skin should be prepared with solution of antiseptic (betadine, iodobac, iodonat, alcohol soluble chlorhexidine, etc.). Then, the wound should be covered with sterile napkin.

It is prohibited to shave the skin hairs more than six hours before the operation.

^ Sanitation of oral cavity before operation

The patient should wash himself the oral cavity. Dental elixirs could be used for that: (10-15 drops in one glass of water), water solution of common salt (0.5 of teaspoonful per one glass of water), water solution of KMnO4 (1:1000), rivanolum (1:1000), tincture of sage or daisy (1 teaspoonful on one glass of boiled water).

The false (artificial) teeth should be removed, washed and kept for the patient in pot covered with napkin.

If the state of health does not allow performing mentioned above procedures, the nurse should assist him to do it, or do all procedures by herself: When the mouth is opened the tongue should be wrapped with the gauze tissue napkin and taken by the left hand, slightly putted off from the oral cavity. Holding the wad with pincers nurse should wipe the surface of the tongue, and with another wad, letting the tongue in, wipe the internal and external surfaces of teeth. After this procedure patient should wash the mouth with boiled water. It is not wishing to wipe the internal surfaces of cheeks ‘cause there’s exists the risk of infecting the main ducts of saliva glands.

If the patient is not conscious the procedure should be carried in the bed with decreased position of the head and without pillow, to avoid trapping of liquid to the respiratory ways. The oil-cloth should be put under the head of patient to avoid dampening and pollution of bed. The head of the patient should be laid on the side and bean-shaped (kidney-shaped) tray should be put to the lower corner of the mouth. In such position the procedure of wiping with wads of the mouth could be performed safely. The final washing of the mouth could be done with the surgine of with volume of 50-100ml of boiled warm water, pulling a little away by turn left and right cheeks.

^ Digestive system preparation in patient before surgical operation

The day before operation patient’s food should be easily-digestive (liquid soup, etc.). Before underplayed operations if there’s less than 5 hours after meal passed the stomach should be washed via thick catheter. These measures avoid vomiting and dangerous regurgitation under anesthetics. With the help of enema it is necessary to clean the thick bowels 3-4 hours before the operation. But this procedure is not wishing is there’s diseases of bowels such as gangrene or acute appendicitis.

^ Stomach washing with the help of thick catheter

This procedure is prohibited if there’s bleeding from the esophageal veins or ulcer, cancer, aortic aneurism, cardiac pains, cardiac infarction, brain blood supply disturbances.

The following equipment needed: thick catheter with 100-120 cm length, rubber drainage (tube) with length 70-80 cm, glass tube – the connector, the ruler (with centimeters degrees), cap, sterile tray, and bucket for used water, pan, rubber sterile gloves and oil-cloth.

Artificial teeth should be removed. The patient should sit on the chair and his knees should be put aside, outstretched. The oil-cloth is on the patient. The big bucket is replaced between the patient’s feet to collect used water.

The distance between navel and the middle of the nose should be measured with the catheter. In this way we can find the length of the catheter which will be used. Along with this one can find different marks on the catheter which indicate different distances. The 45 cm mark is the distance to the cardiac part of the stomach, at the distance of 55 cm – the robe will reach to the bottom of the stomach and 65 cm mark indicates that catheter reached to the exit from the stomach.

Wes should dampen the first 20-30 cm of catheter with warm boiled water and standing from the right side from the patient and ask him/her to open the mouth and pronounce long letter ‘A-a-a-a’. The end of the catheter meanwhile should be put or the root of the tongue, closing the mouth patient should inhale the air and make deep swallow. At the moment of swallowing the catheter should be advanced deeper. Patient should be informed that irritation of the root of the tongue can cause nausea and vomiting. To suppress the vomiting patient should breathe deeply via nasal airways. Patient should not bite the catheter or intent to pull the catheter out.

If the strong cough rose whilst catheter introduction this could be the warning that catheter targeted into the airways – in the pear-shaped pharyngeal sinuses. It means that the catheter should be pulled out by the doctor and inserted again after patient will calm down.

Patient is asked to make swallows. Simultaneously to the swallows the catheter should be introduced achieving needed mark with was printed by manufacturer on catheter or put with the ball pen by surgeon (according to the individual body size of patient). After assuring that the catheter is in the stomach the Zhan’s surgine is connected to the free end of the catheter. The guarantee that the catheter is in the stomach is the appearing of the stomach’s contents in the cylinder of the surgine whilst the aspiration. The plastic water-can then should be connected to the free end of the catheter. Via the broad neck of the water-can 500-600 milliliters of water should be poured, holding the water level (and the water-can) opposite the knees of the patient. Water-can should be slowly lifted vertically. Water could be added in amount not exceeding 1liter, simultaneously with the level decreasing in the water-can while you raise it. When the water-line reaches to the thin neck of the water-can, you should decrease the water-can. Now you may watch appearing water in the water-can mixed with contents on the stomach. (The rule of connected cylinders and their single water-level takes place here.) When the water-can is filled till the up, you may pour down used water with stomach contents and repeat the procedure with new clean water. Such procedure lasts till obtaining of “clean stomach washing water”.

If the blood appeared in the washing water from the stomach the immediate termination of the procedure needed and the nurse should call for a doctor.

When the procedure is finished – the catheter should be disconnected from the water-can and catheter should be pulled from the patient. The catheter as well as water-can should be disinfected.

^ Methodic of putting of enema

This should be carried in the procedure room. For this procedure the Esmarkh’s pot, boiled warm water, sterile enema tip, Vaseline, bed-pan, some piece of tissue, oil-cloth, individual towel, support, with changing height, toilet-paper, and soap needed.

The patient is asked to lie down onto the bad, on its left side with bent knees pressed to the abdomen. The oil-cloth is laid under the patient and the ends of the oil-cloth are directed to the bad-pan. The lower part of the patient body is undressed. The patient could be laid on its back with outstretched legs, if the health-state does not allow for the patient to lie on the side.

The sterile tip of the enema should be connected to the rubber tube. The Esmarkh’s pot now could be filled with water in amount of no more than 1-1.5 liters and with temperature of 30-35 0C. The Esmarkh’s pot is raised up to the height of 1 meter higher than the bed-level and fixed in this position on support. When the tap of Esmarkh’s pot is opened, the system fills with water, letting the air fleeing from the spaces in the tubes. When all air has fled, the Esmarkh’s pot tap should be closed, and the preparation of the enema’s tip is carried out: it should be smeared with the Vaseline oil and inserted into the anus helping with the I-II fingers of the head to broaden the anus. With careful spinning moves of the right hand the tip now could be advanced deeper, to the depth of 10-12 cm. (First 3-4 of centimeters in direction of the umbiculus and remaining 7-8 cm parallel to the spine.) The wall of the rectum could be damaged in case of quick advancing of the enema’s tip.

After the tip is inserted, the tap of Esmarkh’s pot could be opened now, letting the water into the bowels. The jet of infused water should not cause the ‘heavily’ feeling and the painful feelings, so the speed of infused water should be regulated. If the feeling of heavily or pain will rise, the Esmarkh’s pot should be lowered on the support, to make pressure of infused water lowering too. If the strong pain rises, the doctor should be informed. If the water cannot pass in to the bowel, the tip of the enema should be changed in position, or pulled out on 1-2 cm. The tip of the enema may happen to be impassable due to fecal masses inside its cavity. In this case, the tip should be pulled off, washed, and applied again. Sometimes the concernments from the fecal could be large, making the enema becomes impossible: in this case the manual removing of the concernments should be done. The rubber glove finger should be smeared with Vaseline oil in this case too, and after this the enema is possible.

To take away the enema one should do the following sequence: The tap of Esmarkh’s pot is closed, letting some water on the bottom of the enema, with the aim of air trapping prevention to the rectum. After the tip of enema is pulled out some water could flee out from the anus. To prevent this, the buttocks of the patient should be pressed together, closing the anus. The hold of buttocks lasts for 5-7 min.

The water in the bowels should be hold for 5-10 minutes, and patient is asked to do so. The position on the back is best fitting for this. On the defecation need the patient is led to the rest room or the bad-pan is given for him. The tip of the enema should be disinfected in the correct way.

^ Catheterization of the bladder

This is performed before operation if the patient cannot urinate by himself unless it’s required in accordance with methodic of operation (i. e. operations on urinary system).

For the catheterization it is wishing to have single-usage rubber catheter, two sterile pincers, sterile Vaseline oil, sterile napkins, the solution of Furacilin (1:5000), or the solution of Dekasan. All these things should be put on the sterile tray. The patient should be laid on his back with outstretched legs twisted in the joints. Between the legs the tray for the urine collection is put. The head of the penis and the end of the urination channel on it is smeared with the napkin with antiseptics. The catheter on the distance of 2-3 cm is taken and the tip of the catheter and few following centimeters should be smeared with Vaseline oil. With the left hand between III and IV fingers the penis is taken in the region of the its neck and with I and II fingers the external urination channel is broadened with pressing on the head. The catheter now could be inserted on the depth of 2-3 cm. Then, the pincers should let the catheter and catch it few centimeters higher, letting the next part of the catheter in. The appearing urine from the catheter means that the bladder was reached. After evacuation of urine the catheter should be pulled out. If the procedure of urine evacuation fails, the attempt should be repeated again, but this procedure requires skills and doctor who will do it.

The catheterization in women should be carried with the laying position of the patient with bent in knees and outstretched legs. With the running water the external sex organs washed, napkin should be applied to wipe the external urination channel. With the right hand which holds the pincer with catheter the catheterization is performed. The catheter is commonly easy could be moved forwards, and after the urine is let out the catheter is pulled out.

^ Transportation of patient to the operation room

The transportation to the operation room is carried out with the wheeled carrier, which is covered with the oil-cloth and wiped with 3% solution of hydrogen peroxide with 0.5% solution of washing stuff. The transportation of patient should be mild, excluding all sharp moves.

The patient could be fetched to the carrier with no less than 3 or 2 people. If there’s two men carrying the patient – one should hold the body with hands in the region of scapulae near the neck and the second should hold the patient in the area of hips. If the patient is quite heavy or in bad state, the participation of three people recommended: One holds the head and chest, the second holds waist and pelvis, the third one holds legs. In case if the medical dropper installed for the intravenous remedies injection – the nurse should help with it, carrying the support with bottle or just bottle (plastic bag) along with carried patient. The nurse is in response for the workability of this dropper. In preoperational room the carrier is changed to the operational room’s carrier (with is more clear) and the patient with this carrier delivered to the operation hall.

^ 5. Study questions:

  1. A main concept about preoperative period;

  2. A purpose of preoperative preparation;

  3. Preparation of patients to planed and urgent operations;

  4. Nurse’s function in preoperative period;

  5. Participation in preparation of organs and systems;

  6. Hygienic means;

  7. Preparation of operative field;

  8. Making of to sensitivity’s tests to medicines;

  9. Premedication;

  10. Transporting of patients to operation room.

^ 6. The literature:

6.1. Basic :

  1. Textbook of basic nursing / Caroline Bunker Rosdahl. – J. B.Lippincott Company. Philadelphia. - 6th ed. –1995.– 1518 p.

  2. Fundamentals of nursing /Taylor Mary Carol, Mary Carol, Lillis Carol– J. B.Lippincott Company. Philadelphia. - 1989.– 1356 p.

6.2. Аdditional:

  1. Gostishev V.K. "Guidance to practical employments on general surgery". M., "Medicine" - 1987.

  2. P. of Brown. Operating block. Operating brigade. – Kharkov, 1997. – with. 1-32.

Methodical instruction was prepared by

Assistant Riabyi S.I.

A review is positive, associate professor Chomko O.J.

Regarding to the terms of time the operations are classified as:

A). Urgent*

B). Appropriate

C). Not postponing*

D). Palliative

E). Radical

Regarding to the terms of time the operations are classified as:

A). Single-staged

B). Diagnostic



E). Symptomatic

Regarding to the terms of time the operations are classified as:

A). Two-staged

B). Urgent*

C). Not in time operated

D). Radical

E). Not postponing*

Preoperative measures, which decrease the risk of infection of operative wound, are following:

A). Hygienic bath*

B). Hairs shaving in the region of operation 1 day before operation

C). Enema (Clysters)*

D). Bed regimen

E). Hunger during one day after operation

Preoperative measures, which decrease the risk of infection of operative wound, are following:

A). Hairs shaving in the region of operation 2 hours before operation*

B). Alcohol compresses in the area of operation area

C). Soporifics administering before the operation

D).Bed regimen

E). Sanitation of oral cavity before operation*

Digestive tract preparations in patient who will undergo the operation under general anesthetics include:

A). Feeding via probe

B). Washing of stomach if this is needed via thick drainage*

C). Putting of enema if is possible for him*

D). Hunger during 3 days before operation

E). Rubber bag with ice putted on the abdominal wall

During the preparation of patient to the urgent surgical intervention can be used following:

A). Hygienical shower with following cloth change of patient*

B). Dental false teeth removal*

C). Inhalation with medicines which cure the cough

D).Preparation of future operative area with 1% chloramine

E). Carrying out the lesson of physical training

For the urgent surgical intervention what could be done from following to prepare the patient?

A). Stomach washing with thick catheter*

B). Inserting into the rectum of gas freeing drainage

C). Preparation of operative area with 5% alcohol solution of iodine

D). Psychiatric training of patient

E). Bladder catheterization*

For the planned operative intervention what could be done to prepare the patient?

A). Hygienic shower with cloth change the day before operation*

B). Bed regimen the day before operation

C). Psychological training of patient*

D). Hairs shaving in the operative area two days before operation

E). Carrying out the lesson of physical training

Why patients are not allowed to eat before operation?

A). Eaten food hardens inserting the catheter into the stomach

B). Eaten food hardens the breathing regulation during the operation

C). Eating of food could cause vomiting when patient is under general anesthetics*

D). Any meal before operation can cause the rising of pH+ of blood

E). The regurgitation can happen during the intervention if something in the stomach could be during operation*

What should be done for the allergic reactions prophylaxis before surgical intervention?

A). Skin-test for Novocain*

B). Skin-test with antibiotic which will be used before and after operation*

C).Skin-test with Analgin

D).Skin-test with chemical antiseptics

E). Skin-test test with antihistamine remedies

The patient is going to be operated in planned order. How you may need to empty the bladder?

A). There’s no need to do that

B). Patient can do it himself before operation*

C). Patient could do that 2 hours before the operation

D).If it is hard for patient to urinate, there’s the need to insert the catheter into the bladder*

E). Gas emptying drainage should be inserted into rectum

How correctly the transportation of patient to the operative hall should be performed?

A). If the state of health allows patient to walk, he may go by himself

B). Carrier, with laid position on it*

C). Carrier with wheels where the patient lays*

D). Nurse brings him in operation room

E). Specific chair with wheels

With the aim of digestive tract preparation for the planned surgical operation it is necessary to do:

A). Put an enema in the evening the day before operation*

B). Put an enema before the very operation

C). The hunger is assigned for patient for 3 days

D). Advising for the patient to empty the bowels by himself

E). Forbidding for the patient to drink water and eating in the day of operation*

With the aim of operative area preparation for the patient who goes to operation it is necessary to do:

A). The day of operation one should take a shower and to change the clothes*

B). The evening of the day before operation the operative area should be prepared with solution of hlorhexidin and with shaving

C). In the morning of the day, 2-3 hours before operation it is necessary to shave the operative area*

D). Preparation of skin with concentrated solution of alcohol (96%) should be performed

E). 1% Decametoxin after hygienical shower to make operative area ready.


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Higher nurse education iconHigher nurse education

Higher nurse education iconHigher nurse education

Higher nurse education iconHigher nurse education

Higher nurse education iconHigher nurse education

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Higher nurse education iconHigher nurse education

Higher nurse education iconHigher nurse education

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