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Care of the Surgical Patient

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Authors:    Jeff Thompson (Senior Developer) , Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Objectives

After completing this course, the learner will be able to:

  1. Perform a preoperative physical assessment.
  2. Identify the findings of the assessment that may require intervention.
  3. Perform preoperative teaching.
  4. Correctly prepare a patient for transfer to the operating room.
  5. Perform a postoperative assessment.
  6. Identify surgical complications and implement preventive care plans.

Introduction

“Each year, tens of millions of patients in the US undergo a surgical procedure requiring general or spinal/epidural anesthesia. A disproportionate number of these patients are over age 65. Most patients do not suffer complications as a result of the surgical procedure or the anesthetic. However, about 3%-10% of patients do experience significant morbidity, most of which results from cardiac, pulmonary or infectious complications.” 2

Preoperative Physical Assessment

A nursing physical assessment and intervention can prevent or minimize procedure related complications. The initial nursing assessment is usually done before the procedure. This preoperative assessment is essential to identify problems early, and to provide a comparison for postoperative deviations from the norm.

Sometimes, the initial nursing assessment is done in a preadmission visit that may also include preoperative teaching and outpatient testing. However, it is critical that the physical assessment be repeated the morning of surgery. This assessment should include at a minimum, vital signs, respiratory status and assessment of the level of consciousness and orientation. Abnormal results should be called to the physician.

Immunologic function: Is the patient allergic to any foods, medication, latex or soaps? Some allergic reactions can be fatal and some can be serious enough to permanently damage vital organs. It is important that the surgery team know if the patient has an allergy to iodine, seafood, hexachlorophene or latex prior to the procedure.

Pulmonary function: A chest x-ray should be done within 1 year prior to the procedure for older patients (i.e. age 60 and older) and for patients with pulmonary conditions. Patient specific factors that increase the risk of postoperative pulmonary complication are chronic lung disease, morbid obesity and smoking. 2

Is the patient a smoker? If so, how many packs per day and for how long? Smoking increases post-op respiratory complication by decreasing the amount of functional hemoglobin available and impairs oxygen delivery to the tissues. Smoking is associated with the surgical complication of atelectasis, and one study found it doubled the risk of postoperative pneumonia. 2

Does the patient have respiratory allergic conditions, such as asthma or hay fever? Has he had anesthesia-related problems with any previous surgeries? This may affect the choice of anesthetic agents.

Does the patient have chronic obstructive pulmonary disease (COPD)? This disorder increases the risk of complications and may require preoperative interventions to correct electrolyte imbalances, prevent postoperative respiratory infection or remove excess sputum.

Does the patient have an upper or lower respiratory infection? Notify the physician of such an infection, as it may be reason to delay the procedure. Anesthesia produces increased bronchial secretions besides the congestion already present in the case of a respiratory infection. This has a profound effect on ventilation of the patient.

Cardiovascular Function: An EKG must be done within one year prior to the procedure for middle-aged patients (45) and older. Does the patient have a history of cardiovascular disease? If so, additional testing and a Cardiology consult may be needed. 

Anything that causes the heart to pump ineffectively resulting in reduced cardiac output, places the patient at risk for complications. Inadequate blood volume and ineffective vasoconstriction increase the surgical risk. Major abdominal, thoracic and vascular procedures carry a higher risk of postoperative cardiac complications.2

Neurological Function: Does the patient display any signs or symptoms suggesting significant neurological problems? Symptoms may include:

  • Headache
  • Numbness or tingling in an extremity
  • Tremors or weakness in an extremity
  • Unsteady gait
  • Confusion
  • Memory loss

It is important to document any neurological deficits preoperatively for comparison with the post-op assessment. Neurological and behavioral changes can result postoperatively from the effects of anesthetics, analgesic or sedatives. This is especially true in elderly patients.

Is the patient alcoholic? Chronic alcoholism suppresses the adrenocortical response to operative stress. If the patient does not admit to drinking heavily and you are concerned that he might be alcoholic, share these concerns with the physician. Alcoholic patients are at risk for delirium tremens with withdrawal.

Gastrointestinal (GI) Function: Does the patient complain GI symptoms? These include:

  • Nausea & vomiting
  • Diarrhea
  • Constipation
  • Spitting up blood or blood in the stool
  • Gastric ulcer disease
  • Inflammatory bowl disorder
  • Diverticular disease

Anesthesia and pain medications affect the GI function. So, a preoperative assessment is needed for comparison postoperatively to determine if any problems were caused by the medication or were preexisting.

Renal Function: Does the patient have any complaints associated with kidney or bladder infection? These include:

  • Frequently
  • Urgency
  • Blood in the urine
  • Burning on urination
  • Fever
  • Back, flank or suprapubic pain

Patients with signs and symptoms of urinary or kidney infection need a more extensive preoperative evaluation. If renal function is severely compromised by infection, the stress of surgery can precipitate renal failure. Lab values that should be monitored in this situation are the urinalysis, BUN and Creatinine.

Endocrine Function: Is the patient diabetic? Diabetics should not have insulin on the morning of surgery due to their NPO (nothing by mouth) status. Do a bedside blood glucose check and notify the physician of abnormal findings before the procedure.

Diabetes puts the patient at risk for delayed wound healing, postoperative surgical infection, hypoglycemia or hyperglycemia.

Lab Results Review: Make sure ordered labs are on the chart. Notify the physician of any abnormal values. Required lab results should be done within a short time (45 days) before the procedure. For major surgery, the required labs are complete blood count (CBC) and urinalysis. A prothrombin time/partial thromboplastin time (PT/PTT) may be ordered if there is a history of aspirin or coumadin use and for spinal anesthesia.

Medication Review: Determine the medications the patient takes regularly, including over the counter and herbal medications. The following are examples of medications that have implications for surgery patients:

  • St. John’s wort, feverfew, ginkgo biloba, ticlid, Plavix anticoagulants and non-steroidal anti-inflammatories effect coagulation and can increase the risk of hemorrhage.
  • Certain antibiotics may interrupt nerve transmission when combined with a curariform muscle relaxant, leading to respiratory paralysis and apnea.
  • Antidepressants and St. John’s wort increase the hypotensive effect of anesthesia.
  • Phenothiazines increase the hypotensive action of anesthesia.
  • Diuretics may cause electrolyte imbalance and respiratory depression during anesthesia.
  • Steroids inhibit wound healing.

 

Preoperative Teaching

Preoperative teaching may have been done and documented in a preadmission visit. If not, you must do the teaching. If it was done, you should reinforce the teaching.

 

If you do the preoperative teaching during a preadmission visit, explain any instructions that require the patient to prepare himself at home, like bowel evacuation for a colonscopy. The morning of the procedure, check to see if the patient complied with the instructions. Failing to execute preoperative preparation may be a reason to postpone the procedure.

 

Explain the meaning of NPO, emphasizing the importance of being compliant to avoiding aspiration. Sometimes, patients will be NPO except for their oral medications, which should be taken with clear water. This variation may be a policy at a specific facility, or the physician’s order will be written as NPO except for medications. Most patients will be NPO after midnight the day before the procedure. A physician may designate a later NPO status if the patient is scheduled late in the day.

Teach the use of the incentive spirometer and splint coughing. Stress that it is important to turn, cough and deep breathe to prevent atelectasis. Instruct him to turn cough and deep breath at least 3 times an hour and to use the incentive spirometer at least every 2 hours, while awake.

Instruct the patient to shower the morning of the procedure with an antimicrobial soap. The patient should wash the operative site for at least five minutes, scrubbing in a circular motion.

Anesthetic will remain in the patient’s body for at least 24 hours post procedure, so caution the patient not to drive, operate dangerous equipment or make important decisions within 24 hours after the procedure. 1

Some procedures have preoperative teaching needs that are specific to that procedure, like how to use a walker if you are going to have a hip replacement. These needs are determined in collaboration with the physician.

 

Preoperative Checklist

Most facilities have a preoperative checklist that must be completed prior to the procedure. This is a prompt to the nurse to complete all the tasks, and a communication tool between the nurse and the operating room (OR) team to assure that everything was done. You generally initial beside an item as you complete it. This allows anyone working with you or after you to know what you completed and avoid rework.

Dentures, glasses, contacts, hearing aides, underwear, make-up, nail polish and jewelry must be removed. The patient should be wearing only a hospital gown.

If there is an operative site that is designated right or left, have the patient mark the correct side with a marking pen the morning of the procedure.

Verify that the patient has on the correct identification band.

Note when the patient began to be NPO.

Start an IV if ordered.

Have the patient void immediately before the procedure.

If ordered, shaving should be done as close to the procedure time as possible to reduce the risk of wound infection. An electric clipper is recommended. A disposable razor can be used with a “wet shave,” but it is important to shave in the direction of hair growth. Depilatory creams avoid the possible abrasions and cuts caused by razors, but may cause a skin reaction.

Send the current chart, old chart, addressograph or labels, operative consent and the surgical checklist with the patient to the OR.  The physician’s history and physical assessment must be dated within 30 days before the procedure.

Operative Permit

An operative permit protects a patient from an unwanted procedure. It protects the physician and facility from the liability of performing a procedure without the patient’s permission.

Make sure you have a completed operative permit before you give the patient any narcotic. Once the patient has been given a narcotic, he is under the influence of the medication and is not competent to give consent.

If the operative permit is not signed, have the patient sign and date it. Witness the signature. A nurse’s signature of witness is verifying that the patient signed the form. It does not hold any other legal responsibility. It does not mean that you participated in informed consent. Informed consent is done between the physician and the patient in a discussion. The operative permit has the patient signature to verify that consent. If the patient is unable to write, an “X” to indicate his agreement is acceptable. You should have a second witness to the “X”.

The information that the patient must understand is a definition of the procedure, possible complications and risks of the procedure. If the patient expresses that he has unanswered questions about the procedure, or does not want the procedure, you have the responsibility to contact the physician and let him know.

If the patient is incompetent or incapacitated, permission can be sought from a patient representative. Laws vary from state to state and policy varies from facility to facility. However, the following individuals are commonly recognized as representatives for a patient who lacks decision-making capacity.

  •    Court-appointed guardian of the person or legal guardian of a minor.
  •   The individual named in a Power of Attorney which delegates authority to make decisions regarding health care.
  • Next of kin in the following order or priority: spouse, adult child, parent, and adult sibling.

An incompetent patient is any patient who is mentally or physically incapacitated, as determined by physicians, such that the patient cannot communicate treatment preferences. Facility policy usually dictates the process and how many physicians must be involved in the decision. The patient does not have to be adjudicated incompetent by a court of law for the purposes of consenting for a procedure.

Informed consent can be gotten over the phone. It has to be a 3-way conversation between the physician, the patient representative and a witness.

Most states have statues regarding the treatment of minors. 1 An emancipate minor is usually recognized as one who is not subject to parental control, as in the following situations:

  • Married minor
  • In military service
  • College student under legal age but living away from home
  • Minor who has a child

In an emergency, where the physician feels that delaying a procedure would be an immediate threat to the patient’s life or limb, and the patient cannot give consent, the physician may proceed with the procedure without consent. This process requires extensive documentation and often a consultation with other physicians. Most facilities will have a policy about this.

Surgical Implications of Lab Results

White Blood Cell Count (WBC): An elevated WBC may indicate an infection, which may be an indication to delay the procedure. A decreased WBC may indicate an overwhelming infection or a condition that may impair the patient’s resistance to infection.

Red Blood Cell Count (RBC): An elevated RBC may indicate dehydration, which is an important finding both pre and postoperatively. A decreased RBC may suggest anemia, recent hemorrhage or fluid overload.

Hematocrit (HCT): This is a measure of the percentage of RBCs in the total blood volume. An elevated hematocrit may indicate hemoconcentration from fluid loss and suggest dehydration. A low hematocrit may indicate anemia or hemodilution. This may suggest compensation for blood loss or fluid overload. Report any level less than 33%.

Platelet Count: A decreased platelet count (thrombocytopenia) may be caused by leukemia; platelet loss from hemorrhage; as a sequelae of massive blood transfusion; or increased platelet destruction from drugs or an immune disorder. An elevated platelet count (thrombocytosis) can occur as a compensatory response to severe hemorrhage. It may also indicate leukemia, various malignant disorders, polycythemia vera and postsplenectomy syndrome.

Potassium (K): Elevated serum potassium may be the result of substantial tissue damage. A mild to moderately high level may be expected postoperatively. Elevated potassium levels can cause dangerous cardiac dysrhythmias and should be corrected as soon as they are detected. However, an elevated K can be a false reading caused by hemolysis during a poor or slow venipuncture. If the sample is reported as elevated and hemolyzed, notify the physician so that the test can be reordered.  A low potassium level can cause dysrhythmias. A surgical patient may have low levels from diuretic therapy, steroids or renal problems. Patients with gastric distress and decompensation, diarrhea or vomiting may have low levels from the loss of fluids from the GI tract.

Sodium (NA): An elevated serum sodium level may indicate a state of dehydration caused by water loss. It may also result from impaired renal function. A high sodium level is considered a high risk for surgery. A mild to moderately high level may be expected postoperatively. Low sodium may result from diuretic therapy, renal insufficiency, a plasma or interstitial shift or decreased sodium intake.

Arterial Blood Gas (ABG): This is a measure that helps assess and manage respiratory and metabolic disturbances. An ABG is recommended for patients with known lung disease and suspected hypoxemia or hypercapnia, to evaluate the risk of surgery. It is done for postoperative patients with respiratory complications to make treatment decisions.

Types of Anesthesia

Conscious sedation: The patient remains conscious with some sedation, but the protective reflexes remain intact.

Deep sedation: The patient is asleep but arousable and protective reflexes are mildly depressed.

General anesthesia: The patient experiences a loss of consciousness and the protective reflexes are lost.

Regional Anesthesia: This is a local injection of anesthetics to appropriate nerves, producing anesthesia in a specific body part.

Spinal anesthesia: This is when a local anesthesia is injected into the lumbar intrathecal space. Nerve conduction is blocked in the spinal nerve roots and dorsal ganglia. Paralysis and analgesia occur below the level of injection.

Epidural anesthesia: This is when a local anesthesia is injected into the epidural space. The results are similar to spinal anesthesia.

Peripheral nerve Block: This is an Injection of local anesthetic to anesthetize the surgical site.

Intra-operative Complications

Hypoventilation may be due to inadequate ventilatory support after paralysis of respiratory muscles

Oral trauma is due to a difficult endotracheal intubation. This may include broken teeth, bruising and abrasions.

Hypotension may be due to preoperative hypovolemia or a reaction to anesthetic agents.

Cardiac dysrhythmias may be due to a preexisting cardiovascular compromise, electrolyte imbalance or reaction to anesthetic agents.

Hypothermia may be due to exposure to cool ambient OR environment and loss of the normal thermoregulation capability from anesthetic agents.

Peripheral nerve damage may be due to improper moving or positioning of the patient while they are under anesthesia.

Malignant hyperthermia is a rare reaction to anesthetic inhalants and muscle relaxants. It is an abnormal and excessive intracellular accumulation of calcium resulting in hypermetabolism and increased muscle contractions. Symptoms are tachycardia, pseudotetany, muscle rigidity, high fever, cyanosis, heart failure and central nervous system damage. This is a life-threatening emergency.

Postoperative Assessment

Airway: In the immediate postoperative setting the patency of the airway and chest expansion should be watched closely. Position the patient to facilitate ventilation. Assess and document the rate, rhythm, depth and breath sound. Assess the gag reflex with a tongue blade.

Anesthesia causes the lungs to produce excess secretions which if not expelled could lead to serious complications. During anesthesia, respirations are shallow and the lungs are not well aerated. Secretions pool in the small outer airways, causing them to clog. To counteract this situation, have the patient turn, cough and deep breath 3 times an hour. Have the patient use the incentive spirometer every 2 hours.

Vital Signs: Assess and document the findings. Temperature may be up due to stress reaction, or may be down because of the coldness of the OR and recovery room. Reportable temperatures are over 37.7 C (100F) or under 36.1 C (97 F). 1 The pulse may be up due to jarring during transfer, shock, hemorrhage, hypoventilation, hypoxemia, acute gastric dilation, fluid imbalance or acidosis. The pulse may be down due to cardiac arrhythmias. The respiratory rate may be up due to hypoventilation. It may be decreased due to aesthetics, narcotic, sedatives and abdominal incision. The blood pressure may be up due to anxiety and pain. It may be down due to cardiac arrhythmias, shock, fluid loss and acute gastric dilation.

Neurological Function: You should assess and document the level of consciousness; the ability to follow commands; and the sensation and ability to move extremities following spinal anesthesia. The preoperative neurological assessment should be compared with the postoperative assessment. Anesthetics, narcotics or sedatives may decrease the level of consciousness. The elderly are more likely to experience this type of problem

Urinary Function: Urinary output should be greater than 30 ml/hr. Assess the input versus the output. Preoperative medications and over distention of the bladder can cause loss of bladder tone and urinary retention.

Pain Management: Evaluate the presence, character and severity of pain. Use a 0-10 pain scale. Depending on the route and medication given, followup in 30 minutes to 1 hour to assure that pain medications worked.

Gastrointestinal Function: Does the patient complain of nausea or vomiting? Anesthesia and pain medications affect the GI function. Medication should be given to control the symptoms.

Safety: Use side rails when you give a narcotic, or if the level of conscious is decreased. Make sure the call bell is within reach.

Mobility: Assess the patient’s ability to turn and do leg exercises.

IV: Assess the IV site. If fluids are going, document the type of fluid, rate of infusion and amount of fluid in the bag.

Dressings/Drains: Check any dressings for drainage and bleeding. A dressing may need to be reinforced if actively bleeding, but do not remove the dressing. Notify the physician abnormal bleeding. Many surgeons want the dressing to remain intact until they make the first dressing change, especially with major procedures. If the drainage is visible on the dressing, outline the drainage, date, time and initial it. This will allow for the assessment of progressive drainage. Note any drainage system that the patient has. Document the type, patency of the tubes, character of the drainage and the amount.

Surgical Complication/Interventions

Atelectasis: Incomplete expansion of the lungs or any portion of the lung occurs as a result of plugging and eventual collapse of alveoli by mucous secretions in the terminal bronchi and bronchioles. Signs and symptoms would be diminished breath sounds.

To prevent or resolve atelectasis, instruct the patient to turn cough and deep breath at least 3 times an hour and use the incentive spirometer at least every 2 hours, while awake. Nursing should check and assure the patient is complying at least every 2 hours.

Pneumonia: this is an inflammatory response caused by a viral or bacterial infection, that results in inadequate gas exchange in all or any part of the lung. Obese patients are at a higher risk for post-op pneumonia because they chronically hypoventilate.1 Signs and symptoms are:

  • Dyspnea
  • Tachypnea
  • Complaints of Pleuritic chest pain
  • Productive cough, fever greater then 101F
  • Chills
  • Hemoptysis.

Preventive measures are the same as for atelectasis. In addition, it is important to maintain adequate hydration.

Aspiration: Regurgitation of stomach contents in a heavily sedated patient or a patient with an absent gag reflex can result in aspiration. Aspiration occurs most often in patients who have not been NPO prior to the procedure or who experience GI hemorrhage. In the immediate postoperative period, the aspiration may not be noticeable because of the patient’s inability to cough or protect his airway. Assess the patient’s gag reflex.

Pulmonary Embolism: Pulmonary embolism is a complete or partial obstruction that develops in the pulmonary arterioles. This is caused by the migration of an embolus originating in the venous system or in the right side of the heart. It occurs most frequently in chronically ill patients, or in patients with peripheral vascular disease (PVD).  Symptoms are:

  • Hypotension
  • Diaphoresis
  • Oliguria
  • Dyspnea
  • Tachycardia
  • Rapidly deteriorating level of consciousness
  • Cyanosis
  • Complaints of severe substernal pain

Deep Vein Thrombosis (DVT): This occurs in the pelvic veins or in the deep veins of the lower extremities. Causes are injury to the intimal layer of the vein wall, venous stasis, hypercoagulopathy, and polycythemia. The risk of DVT is increased with obesity, prolonged immobility, cancer, smoking estrogen use, advancing age, varicose veins, dehydration, splenectomy and orthopedic procedures.

To help reduce the risk of DVT, the patient should be asked to do leg exercises 2-3 times a day. For high-risk patients, the physician may order sequential compression stocking (pneumatic stockings) to massage the leg, improving circulation. These should be set to between 35-45 pounds of pressure. The stocking will be ordered from 2-7 days depending on the procedure and mobility of the patient.

Urinary Retention: Preoperative medications and over distention of the bladder can cause loss of bladder tone and urinary retention. Having the patient void before surgery may prevent this. Postoperatively, monitor input and output. Palpate the bladder for distention. Notify the physician if the patient has not voided by 10 hours post procedure.

Urinary Tract Infection (UTI):  This may result from use of a foley catheter and will occur 3-5 days post procedure. Assess the color, amount and odor of the urine output. Keep the foley bag drained and in a dependent position. If urine is allowed to collect in the drainage bag and tubing without proper drainage, bacterial growth will occur over time. Encourage fluids. Maintain an aseptic bladder drainage system.

Paralytic Ilieus: This is an absence of peristalsis in all or part of the bowel. It usually results from disruption of autonomic control of the bowel, electrolyte imbalances or other procedure related events. A paralytic ilieus usually resolves with 48-72 hours post procedure. Signs and symptoms are a slight abdominal distention and absence of bowel sounds.

You should assess for the presence of bowel sounds, abdominal distention, flatus and abdominal cramps. Encourage the patient to ambulate if possible. If there are no bowel sounds 16 hours post procedure, keep the patient NPO and notify the physician.  

Surgical Wound Infection: Assess the skin color around the wound and see if the wound edges are approximated with no gaps. Assess the color, amount and odor of any drainage. Check for bleeding. Assess the skin temperature and the presence of pain around the wound. Document the amount of drainage in any wound drainage systems. Do not remove a surgical dressing unless ordered. If there is copious drainage, just reinforce the dressing and notify the physician.

A patient with diabetes, obesity and the elderly are at higher risk for delayed healing and wound infection.

Wound Dehiscence: This usually occurs between the 5th and 8th day postoperatively when the incision has its weakest tensile strength. It is chiefly associated with abdominal surgery. Dehiscence is usually related to:

  • Inadequate sutures
  • Excessively tight closure that compromises the blood supply to the wound
  • Hematoma
  • Infection
  • Poor nutrition
  • Immunosuppression
  • Uremia
  • Diabetes
  • Steroid use
  • Excessive coughing, hiccups, retching or distention

To help prevent dehiscence, an abdominal binder can be used for obese, elderly or patients with a weak or pendulous abdominal wall. Reinforce splinting of the incision while coughing. Watch for and relieve abdominal distention.

A physician should be notified immediately of dehiscence. If intestine is exposed, cover it with sterile moist saline dressing. Monitor vital signs for symptoms of shock. Position the patient with bent knees and with the head of the bed elevated to relieve tension on the abdomen.

Hemorrhage: Patients with abnormal coagulation factors are at increased risk of hemorrhage, hematoma, delayed wound healing and infections. Abnormal bleeding should be reported to the physician. Early symptoms of hemorrhaging are:

  • Apprehension
  • Restlessness
  • Thirst
  • Cold, pale skin
  • Circumoral pallor

Later symptoms are:

  • Hypotension
  • Tachycardia
  • Decreased level of consciousness

Delirium: Postoperative delirium occurs in about 9% of patients who had major surgery and are over 50 years old. It can be caused by:

  • Prolonged anesthesia
  • Cardiopulmonary bypass
  • Drug reaction
  • Sepsis
  • Electrolyte imbalance
  • Delirium tremens in alcoholics

The symptoms are disorientation, hallucination, paranoia, agitation, and insomnia. Delirium tremens usually occurs within 72 hours of the last alcoholic drink and may include tachycardia, dilated pupils, diaphoresis and fever. You may need to sedate or restrain a patient until the cause for the delirium can be identified and corrected.

Conclusion

Nursing’s preoperative teaching and assessment contribute heavily to the success of a procedure. Postoperative nursing assessment and intervention are essential to avoid, or reduce the impact of complications of the procedure.

References

1. Nettina, S, (et.al.) The Lippincott Manual of Nursing Practice, 7th edition (2001). Philadelphia, PA: Lippincott Williams & Wilkins. pp107-136.

2. Tierneyu, L. M (et.al.) Current Medical Diagnosis and Treatment, 39th edition (2000). New York, NY: Lange Medical Books/McGraw-Hill. pp 35-46.

3. Pagana, K. D. (et. al.) Mosby’s Diagnostic and Laboratory Test Reference, 2nd edition (1995) St. Louis, MO: Mosby. pp 158-159, 344-345, 440-441, 545-546, 622-624, 638-640, 683-689, 744-746, 864-868.