N201 General Surgery

• Causes of altered bowel function

  • Obstruction
  • Colorectal Cancer
  • Diverticulitis
  • Perforation
• Acute abdominal pain


  • Trauma
  • Disease exacerbation (i.e., diverticulitis - peritonitis)
  • Surgery/scope
  • Bowel obstruction/perforation
• Abdominal surgery assessment


  • Wound care
  • NG tube – require increased mouth care and nasal care
  • IV fluids/electrolytes until tolerating po
  • Ice chips to DAT
  • Bowel sounds/passing flatus/distention
  • Antiemetics/analgesics
  • Focused assessment
• Goals of care for abdominal surgery

  • Relief of pain/discomfort
  • No complications (hypovolemia/septic shock)
  • Normal fluid and electrolytes
  • Normal nutritional status
  • Return to pre-injury/disease functioning or supported adaptation to new 'normal'
• Small vs. Large Bowel Obstruction

  Small Intestine: Rapid onset, frequent and large vomiting, colicky, crampy, intermittent pain, feces for a short time, abdominal distention dependent on location of obstruction

  Large Intestine: Gradual onset, late vomiting, crampy pain, absolute constipation, greatly increased abdominal distention
• Diagnosis and Collaborative Care for Intestinal Obstruction

  • CT
  • Sigmoid/colonoscopy
  • CBC, electrolytes, amylase, BUN
  • Stool for OB
  • Decompression (removal of gas/fluid)
  • Correct fluid and electrolytes
  • NG or perc tubes (for neurogenic obstruction)
  • Surgical interventions (for mechanical obstruction)
  • Colonoscope to remove polyps, to dilate structures, remove tumor
  • IV fluids with NS and K
  • TPN/PN for nutritional deficiencies and while bowel healing
• Nursing Management for Intestinal Obstruction

  • Head to toe and pt history
  • Focused abdominal assessment
  • Pain
  • Tenderness/rigidity
  • Vomiting
  • Flatus/BM
  • Auscultation of BC
  • Inspection for scars, palpable masses, distention
  • Guarding
  • Strict I/O, monitor electrolytes, metabolic acidosis/alkalosis, infection, etc.
• Risk Factors and Health Promotion for Colorectal Cancer

  • Age
  • Alcohol use/smoking/obesity
  • GI disease
  • Family history

  Screening – by the time there are obvious symptoms, disease is advanced
• Diagnostic and Collaborative Care for Colorectal Cancer

  • Physical exam, history
  • Rectal/digital exam
  • Fecal OB or FIT test and flexible sigmoidoscopy (screening tools)
  • Sigmoidoscopy/barium enema
  • CBC/liver function/CEA (cancer cells)
  • CT abdomen/US/MRI
  • Surgery/chemo/radiation
• Goals of Care for Colorectal Cancer


  • Best or most appropriate treatment
  • Normal bowel elimination
  • Improved quality of life
  • Adaptation
  • Pain relief
  • Comfort and well being
• Surgical Interventions for Colorectal Cancer

  • Right hemicolectomy
  • Left hemicolectomy
  • Abdominal perineal resection (APR)
  • Low anterior resection

  Wound care – packing or closed suction, assessing and monitoring drainage

  Stoma care

  Discharge planning
• Symptoms and Signs of Diverticulitis

  • Often asymptomatic
  • Crampy, abdominal pain in left lower quadrant
  • Pain relieved by passing flatus or having a BM
  • Anorexia
  • Chills
  • Constipation alternating with Diarrhea
• Diagnostic Studies for Diverticulitis

  • History & physical exam, Stool for OB
  • Lab work (CBC, Lytes, BUN & Creat plus eGFR)
  • Abdominal X-ray
  • CT scan with oral contrast
  • Colonoscopy
  • Barium enema
• Collaborative Care for Diverticulitis

  • Uncomplicated – treat with diet and lifestyle modifications, stool bulking medications

  When acute – allow colon to rest and decrease inflammation, NPO with IV fluids, assess for peritonitis (monitor temp/WBC), IV antibiotics

  Surgery to drain abscess, resection if obstruction or perforation

  Colostomy can be temporary or permanent, depends on findings
• Peritonitis


  Local or general inflammation of the peritoneal lining

  Bacterial peritonitis occurs when foreign material leaks into the peritoneal cavity

  Symptoms include abdominal tenderness/pain, rebound tenderness, spasms, abdominal distention, fever, nausea/vomiting, and tachypnea

  Complications such as paralytic ileus, hypovolemic shock, or sepsis may occur leading to death
• Surgical stress


  Body's metabolic response to injury
• Stress response


  1. Hormonal and metabolic changes

  2. Hematological, immunological, and endocrine responses
• Insulin resistance


  Associated with post operative complications and morality
• Surgical stress response


  1. Catecholamine release

  2. Hyper inflammation

  3. Immunosuppression
• Surgical stress management


  • Multidisciplinary approach required
  • Patient is one of the main players
• Preoperative stage


  Begins prior to the patients surgical experience
• Patient teaching


  1. Patients need to understand what to expect throughout the surgical phases

  2. Teaching needs to involve what will happen in the pre and post operative phases

  3. Discharge teaching should also begin prior to surgery
• Preoperative fasting


  • Patients need to stop eating food 6 hours prior to surgery
  • Patients can however drink clear fluids up to 2 hours before surgery
• Carbohydrate loading


  1. Reduces metabolic stress

  2. Reduces post operative N&V

  3. Raise insulin sensitivity by 50% resulting in less insulin resistance
• Bowel prep


  • Previously colorectal patients had mechanical bowel prep to clean the colon
  • Use of mechanical bowel preps leads to dehydration and electrolyte imbalances
  • Prep was associated with post-operative ileus
• Warming the patient


  1. Starts while the patient is waiting to enter the operating room

  2. Goal is to maintain normothermia
• Intraoperative stage


  • Maintaining normothermia helps maintain homeostasis
  • Hypothermic surgeries have higher risk of wound infections, cardiac events, and bleeding
• Maintaining normothermia


  Prevents shivering in recovery which increases oxygen consumption
• Adapting and limiting IV fluids

  1. Use crystalloids over NS

  2. Use vasopressors to manage intra and post op epidural induced hypotension (if the patient is normovolemic)
• Regional anesthesia


  • Epidurals and spinal anesthesia minimize opioid use post-operatively
  • Regional blocks can reduce the bodies response to surgical stress
• Laparoscopic approaches


  • Improve recovery by decreasing pain and complications
  • Can be used in combination with GA
• Nasogastric tubes


  Studies show they can cause an increase in complications such as pyrexia, atelectasis, and pneumonia
• Other intraoperative interventions


  • Prophylaxis antibiotics
  • Prophylaxis chemical and mechanical venous thromboembolism
  • Pre-emptive antiemetics
• Postoperative stage


  Want to promote comfort after surgery, provide teaching to decrease anxiety
• Goals in the post-operative period

  1. Day 0: pain control, push oral fluids, reduce IV fluids, do not bolus just for low urine output, mobilize the patient, provide gum for chewing, prevent N&V

  2. Day 1: mobilization, gum chewing, providing solid food diets, removing foleys, and saline locking patients

  3. Day 2: continued mobilization and gum chewing

  4. Day 3-5: discharge home
• Limiting opioids


  Using opioids alongside side NSAIDs and acetaminophen helps manage postoperative pain and decrease complications
• Preventing fluid overload


  1. Limiting the use of IV fluids

  2. Saline locking patients once they are drinking adequately
• Early mobilization


  1. Patients need to be mobilized post op day 0

  2. Patients should be up in chair for all meals
• Gum chewing


  • Simple intervention to improve GI functioning and promote bowel activity
  • Patients postoperative flatus and defecation times are shortened
• Prevention of N&V


  1. One of the main ways to promote comfort after surgery

  2. Need to treat N&V as quickly as possible to allow patients to resume oral intake and mobilize