MINOR SURGICAL

PROCEDURES
• Minor surgical procedures refer to surgery
performed on superficial tissue, usually under local
anesthesia and using minimal equipment. These
procedures can be performed safely and quickly
with few or no complications, and while usually the
patient is conscious throughout the procedure.
Ethico-legal aspects in surgery
• Ethics is the branch of philosophy that defines what
is good for the individual and for society and
establishes the nature of obligation or duties that
people owe themselves and one another.
• The practice of surgery is based on the technical
capabilities of the surgeon, their knowledge and
their capacity of judgment.
• Ethics is an essential discipline in the practice of
surgery.
• Nursing ethics is the formal study of ethical issues that arise
in the practice of nursing and of the analysis used by nurses
to make ethical judgments.
• Any harm that ensues is either unintentional, or is necessary
to facilitate treatment.
• When patients do consent to treatment, surgeons are
provided with a wide discretion.
• The end result may be cure, but disfigurement, disability and
death may also result.
Respect For Autonomy

 Common ethical issues encountered by nurses in daily

practice include:
 cost-containment issues that jeopardize patient
welfare
 end-of-life decisions
 breaches of patient confidentiality
 incompetent, unethical, or illegal practices of
colleagues.
 patients have a right to make choices about proposed surgical
treatment.
 Patients can refuse surgical treatment that will save their
lives, either at present or in the future
Informed Consent
Consent; Voluntary, autonomous permission to proceed with an
agreed-on course of action.
Such information must include:
 Reasons for surgery
Type of surgery
 Prognosis and side effect
Alternative treatment
The consequences of no treatment.
The patient should personally sign the consent unless he or she is a
minor, is unconscious or mentally incompetent, or is in a life-
threatening situation
Consent principles
 Venue- calm and quiet place.

 Consent form- patient’s preferred language

 Patients should be given time and help to come to their own

decision;
 principal person- surgeon
 Attention must be paid to:
☻Information- accurate and reasonably complete.
☻Avoidance – technical languages.
☻Provision of translators.
☻Clarification of doubts.
For consent to be valid
adult patients must:
 Have capacity to give it.
 Not be coerced.
 Be given sufficient information.
Witnessing a Consent
A witness verifies that the consent was signed without
coercion.
 The witnesses may be physicians, nurses, other facility
employees, or family members as established by policy.
The witness signing a consent document attests only to
the following:
‣Identification of the patient or legal substitute
‣Voluntary signature, without coercion
‣Mental state of signatory (i.e., not coerced, sedated, or
confused) at the time of signing
Consent in Emergency Situations
‣In a life-threatening emergency, the consent to treat and
stabilize is not essential.
‣Permission for a lifesaving procedure, especially for a
minor, may be accepted from a legal guardian or
responsible relative by telephone, fax, or other written
communication.
Right to Refuse a Surgical Procedure
Each patient is entitled to receive sufficient information
from which to intelligently base a decision regarding
whether to proceed.
The patient has a right to withdraw written consent at
any time before the surgical procedure.
 The circulating nurse documents the situation in the
patient’s record.
 For legal protection, the surgeon should also obtain
from the patient, parent, or legal guardian a written
refusal for the procedure or other treatment.
Advance Directives
The Patient Self-Determination Act enacted by the
U.S. Congress in December 1991 ensures the patient
has the opportunity to participate in decision making
before a procedure.
Each patient has the right to determine the care
received and to participate in the selection of
delivery methods.
The term advance directive encompasses durable
power of attorney and living wills.
The living will concept allows the patient to refuse
treatment or nonessential measures to prolong life in
a hopeless situation.
 A durable power of attorney document designates the
person authorized to make decisions in the event that the
patient is incapacitated.
On admission to the facility, the patient is asked whether he
or she has an advance directive or durable power of attorney.
Advance directives may also indicate the patient’s
preferences concerning organ donation.
Euthanasia
Good or merciful death.
An act of direct intervention that causes death is
active euthanasia.
Withholding or withdrawing life-prolonging or life-
sustaining measures is passive euthanasia.
Modern technologies can prolong life without
preserving quality.
Matters of life and death
• Patients have a constitutional right to privacy in choosing to
die with dignity.
• living will relieves family members of decision making
when the patient becomes terminally ill, incompetent, or
comatose.
CPR
• If it is the expressed wish of the patient, the physician writes
do-not resuscitate (DNR) orders.
Transplantation
• As a result of the Uniform Anatomical Gift Act of 1968,
many adults carry cards stating that at death they wish to
donate their body organs or parts for transplantation, therapy,
medical research, or education.
Confidentiality
information a patient reveals to a surgeon is private and has
limits on how and when it can be disclosed to a third party.
Breaking confidentiality
☻If the patient is threat to self and others.
☻Other team members –improving treatment options.
☻Public interest.
☻Court order.
Research
• If a proposed innovation passes the criteria for
research, it should be approved by a research ethics
committee.
Beneficence

• The principle of beneficence imposes an obligation to act for

the benefit of the patient.
• Benefit the patient, and balance benefits against risks and
harms.
• Health care professionals Have to follow professional
obligations and standards.
Promote patient best interest by
• Understanding patient perspective
• Address misunderstanding and concern.
• Negotiate a mutually acceptable plan of care.
• Ultimately let the patient decide.
Nonmaleficence(avoid causing harm)

The principle of non-maleficence imposes an obligation not

to inflict harm on others.
Seek not to inflict harm; seek to prevent harm or risk of
harm whenever possible.
If the risks and burdens of a given surgery for a specific
patient outweigh the potential benefits, the surgeon has an
obligation not to operate.
Not do anything that would purposely harm patients without
the action being balanced by proportional benefit.
Justice

 The principle of justice refers to equal access to health care

for all.
 Always seek to distribute the benefits, risks, and costs of
nursing care justly. This may involve recognizing subtle
instances of bias and discrimination.
legal Issues
• The patient is at risk for harm during any surgical
procedure.
Liability
To be liable is to be legally bound and responsible
for personal actions that adversely affect another
person.
The court may rule that a learner or an experienced
practitioner is liable for his or her own acts.
A learner may be held responsible for independent
actions in proportion to the amount and type of
instruction received and judged by the standard of
other learners in training.
An instructor can be named with the learner as partially
liable.
Perioperative nurses make independent nursing decisions
based on their assessments, and they can perform and/or
delegate certain patient care interventions without a
physician’s order.
Assault and Battery

 Assault is an unlawful threat to harm another physically.

 Battery is the carrying out of bodily harm, as by touching
without authorization or consent.
• Lack of informed consent to perform a procedure is an
important aspect of an assault- and-battery charge.
 The purposes of a written, signed, and witnessed consent
are to protect the surgeon, anesthesia provider, perioperative
team members, and facility from claims of unauthorized
procedures and to protect the patient from unsanctioned
procedures.
• Scenario: A patient comes to the emergency room and
refuses to consent to a specific treatment (e.g., a blood
transfusion for religious reasons). The healthcare provider
disregards the refusal and says, “You need this, and I’m
going to do it whether you like it or not,” and then
administers the blood transfusion against the patient’s will.
Invasion of Privacy
The patient’s right to privacy exists by statutory or
common law.
The patient’s chart, medical record, videotapes, x-
rays, and photographs are considered confidential
information for use by physicians and other health
care personnel directly concerned with that patient’s
care.
The patient should give written consent for
videotaping or photographing his or her surgical
procedure for medical education or research.
The patient has the right to refuse photographic
consent.
Have the right to privacy during interview,
examination, and treatment.
Abandonment

• Abandonment consists of leaving the patient for any reason

when the patient’s condition is contingent on the presence of
the caregiver.
• If the caregiver leaves the room knowing there is a potential
need for care during his or her absence, even under the order
of a physician, the caregiver is liable for his or her own
actions.
• A child or disoriented patient left alone or unguarded in a
holding area, for example, may sustain injury by an electric
shock from a nearby outlet or by some other hazard within
reach.
• The circulating nurse should be in attendance during
induction of and emergence from anesthesia and throughout
the surgical procedure to assist as needed.
Perioperative Documentation

Specific care given in the perioperative environment should

be documented on the patient’s chart.
 The circulating nurse should document specific activities
performed to achieve the expected outcomes.
The permanent perioperative record should include but not
be limited to the following:
Preoperative history, physical (H&P) examination,
laboratory reports, consent form(s), and other documents in
the chart per policy.
Any area on the patient’s body with redness or injury before
hands-on care begins must be documented as “present on
admission.”
Patient identification and verification of the surgical site,
intended surgical procedure, allergies, and nothing-by-mouth
(NPO) status..
Significant intraoperative times, such as arrival in and
departure from the OR, anesthesia start and finish, and
incision and closure.
Patient’s condition on transfer to and from the OR, as well as
the method of transport to and from the OR, and by whom.
level of consciousness or anxiety manifested by objective
observation
Patient position, and types of restraints and supports used for
maintaining the patient’s position on the OR bed and for
protecting pressure areas, and by whom.
Personal property disposition, such as religious articles,
hearing aid and dentures
Skin condition and antimicrobials used for skin preparation,
and by whom.
Intravenous (IV) site, time started, type of needle or cannula,
solutions administered IV (including blood products), and by
whom
Medication types and amounts (including local anesthetic
agents), irrigating solutions used and amounts, and given by
whom
Tourniquet cuff location, pressure, inflation duration,
identification of unit, and applied by whom
Estimated blood loss and urinary output, as appropriate
Sponge, sharps, and instrument counts as correct or
incorrect. If inconclusive, state steps taken in remedy of the
situation and notification steps taken.
 Surgical procedure performed, location of the incision
Specific equipment used (e.g., laser), electrosurgical unit,
dispersive and monitoring electrode(s), and prosthetic
devices implanted, if applicable, including the manufacturer
and lot/serial number.
Specimens and cultures sent to the laboratory.
Site and types of drains, catheters, and packing as applicable
Wound classification is documented at the end of the
procedure when all risks for infection have been identified
Any unusual event or complication, and action performed.
 All personnel in the room and their roles, including
physicians, visitors, sales personnel, students, and others as
applicable.