3.1 Perioperative Care Flashcards
Perioperative Care
- Includes preoperative, intraoperative, and postoperative care
Pre-operative phase
- Begins with the decision to proceed with surgery until the patient is transferred to the operating room or bed
Intraoperative Care
- Begins after patient is transferred to the OR bed and ends with admission to PACU (post anesthesia care unit)
Postoperative Care
- Begins with admission to PACU and ends with follow up evaluation in the clinical setting or home
Surgery
- Categories are based on anatomical location, procedure to be preformed, and purpose of the surgery.
Diagnosis/Exploration Surgery
- Determines origin and cause of a disorder
- These include laparoscopy/laparotomy (opening of abdomen to investigate tumors, bleeding, obstruction and gangrene)
Curative Surgery
- Resolving the issue by repairing or removing the cause
- An example is appendectomy or removal of inflamed/infected tissue
Palliative Surgery
- Relieves symptoms but does provide a cure
- Example is debulking a tumor to provide relief of symptoms
Prevention Surgery (prophylactic)
- Removing tissue that does not yet contain cancer but may in the future
- Example is a mastectomy in high risk patients (removal of breast)
Rehabilitative or Restorative Surgery
- To improve function or decrease pain.
- To restore your body after an injury or disease
- Example includes joint replacement to improve functional ability
Reconstructive surgery
- Often a form of cosmetic surgery
- Also includes surgeries used to rebuild an area after surgery
- Example includes breast reconstructive surgery following mastectomy
Cosmetic Improvements
- Alters/Enhances personal appearance
- Example is a face lift
Surgical Classifications
- Based on how urgent the surgery is
Emergent - Requires immediate intervention
Urgent - Requires prompt attention (no more than 24 hours)
Required - Needs surgery but is not time critical
Elective - Should have the surgery but is not required
Optional - Decision is on the patient (most common is cosmetic surgery)
Emergent Surgery Examples
- Severe Bleeding
- Bladder or intestinal obstruction
- Fractured skull
- Gunshot/stab wound
- Extensive burn
- Need surgery without delay
Urgent Surgery Examples
- Acute bladder infection
- Kidney/Ureteral stones
- Needs surgery within 24-30 hours
Required Surgery Examples
- Prostatic hyperplasia without bladder obstruction
- Thyroid disorders
- Cataracts
- Plan within a few weeks to months
Elective Surgery Examples
- Repair of scars
- Simple hernia
- Vaginal repair
- Failure to have surgery is not catastrophic
Optional Surgery Examples
- Cosmetic Surgery
- Personal preference
Preoperative Care
- Most important components are assessment and teaching
- Begins with initial contact which is often a phone call to schedule surgery or discussion about the surgery at a physicians office
Role of a nurse in Preoperative Care
- Education of patient and family
- Clarifying understanding of patient and family
- Ensuring family understands risks and benefits of surgery
General Surgery
NPO - Nothing to drink or eat for a prescribed amount of time. This is generally 6-8 hours before surgery and decreases the risk of aspiration. Give patients oral or written directions to stress adherence
Cough/Deep Breathing - Importance of this to reduce respiratory complications. May involve demonstration of incentive spirometry.
Tubes/Drains/Monitors/IV - Inform patient about equipment they may encounter following surgery.
Paralytic Drugs - Inform use of paralytic and anesthetic drugs and their inability to move
Ambulatory Surgery
- Ensure they know to remain in recovery area for a few hours
- Assure they have a ride home
- Determine if they have a plan for at home post-op recovery
Admission Data (Pre-Op Assessment)
- Demographics, health history, and all other information pertinent to surgery
- Verification of completion of preoperative diagnostic tests with results
- Comprehensive medical/surgical history
- Full review of systems
- This also begins discharge planning for patient by assessing the patients knowledge of their postoperative care.
Medications (Pre-Op Assessment)
- Ask specifically for prescribed medications that can potentially affect surgical experience
- Corticosteroids, diuretics, phenothiazines, tranquilizers, insulin, antibiotics, anticoagulants, anticonvulsants, opioids, aspirin, NSAID’s vitamins, dietary supplements, herbal supplements. (May need to stop taking these 3 weeks prior to surgery)
Allergies (Pre-Op Assessment)
- Drug hypersensitivities, latex, food allergies, chemicals, pollen
Health History
- Patient and Family History
- Ask about patient or family history of complications from anesthesia
Malignant Hyperthermia (MH)
- Potentially fatal that is associated with administration of certain general anesthetics or succinylcholine
- Caused by acceleration of metabolism in skeletal tissue .
- Due to abnormally high levels of cell calcium in skeletal muscle.
- Signs include muscle rigidity, rapid heart rate, high body temperature, muscle breakdown and increased acid content.
- Treatment is dantrolene
Review of Systems
Cardiovascular - ECG, rhythm disturbances (pacemaker requires cardiologist), history of HTN, MI, Angina
Respiratory - Oxygenation, use of steroids, cough or SOB, ABG’s
Integumentary - Rashes, pressure ulcers, wounds, bruises
Nervous System - LOC, Cognitive Function, CNS diseases
Urinary - Renal Dysfunction, fluid/electrolyte imbalance, frequent UTI, prostate enlargement, altered response to drug and/or elimination
GI - Pattern of elimination
Endocrine (diabetes are high risk) - Blood glucose, hypoglycemia, hyperglycemia, risk of infection, thyroid (risk of altered metabolic rate)
Immune (immunocompromised) - Risk of infection, patients with active infection should cancel surgery
Nutritional status (over/under) - Adipose tissue is less vascular, obesity increased risk for cardiac risk, wound dehiscence, infection, incisional herniation. Under nutrition can come with vitamin deficiency, protein deficiency, delayed healing. Also note high caffeine
Laboratory Diagnostic Testing
- Completed before or day of surgery (sooner is better)
- CBC
- Basic/Comprehensive Metabolic Panel (BMP/CMP)
- Urinalysis
- Beta Human Chorionic Gonadotropin (for pregnancy)
- Chest X-ray (CXR)
- ECG
- Tests based on age, history, surgery type, and anesthesia.
- Nurse responsibility is to ensure results are charted and to notify of any abnormal findings.
Older Adults Risk for Surgery
- Decreased cardiac output, cardiac reserve, peripheral circulation, lung vital capacity, blood oxygenation, blood flow to kidneys, GFR, hepatic function, SubQ tissue which makes them more susceptible to temperature change.
- Increased blood pressure, risk of skin damage/infection.
- Sensory deficit, chronic illness, malnutrition, impaired self-care ability, inadequate support systems, mental status change, risk of falls, deformities from osteoporosis and arthritis.
- Need for multiple explanations to understand and retain communication
Informed Consent
- Patient has been educated about the procedure, risks and benefits, alternatives.
- Surgeon should be the one explaining the procedure
- Nurse clarifies information and witnesses patient signature.
- Signature must be obtained before administering psychoactive medications.
3 conditions for validity - adequate disclosure, clear understanding/comprehension, voluntary consent
Possible Nursing Diagnosis
- Knowledge Deficit
- Anxiety
- Acute Pain
- Risk of Ineffective Thermoregulation
- Impaired home maintenance (understanding discharge information)
- Risk for perioperative position injury
Nursing Interventions for Pre-Op
- Education on deep breathing, coughing, spirometry, mobility and body movement, pain management.
- Psychosocial interventions to decrease anxiety and fear
- Managing nutrition and fluids
- Maintaining safety
- Preparing bowel as appropriate
- Preparing skin
Bowel Preparation for Surgery
- Prevents injury to colon and reduce intestinal bacteria
- Enemas or laxatives
Skin preperation
- Hair removal around incision site (generally not removed
- Goal is to decrease bacteria without damage to skin so electric clippers are often used.
- Instruct patient to cleanse area before surgery
“Time Out”
- Verification of correct surgery site
Anxiety Interventions
- Encourage open communication and provide clear teaching
- Promote adequate rest prior to surgery
Imagery - Concentrate on pleasant experience or restful scene
Distraction - Think of enjoyable story or recite favorite song
Optimistic Self-Recitation - Recite “I know all will go well”
Music - Listen to soothing music. Easy, inexpensive, non-invasive
Expected outcomes for pre-operative patients
- Relief of anxiety
- Decreased fear
- Understanding of the surgical intervention
- No evidence of preoperative complications
Patient Interview Prior to Surgery
- Review patient health information and health history
- Determine patients expectations of the surgery and anesthesia
- Clarify information about the surgical experience
- Assess emotional state and readiness for surgery
- Risk Factors
Preparation for Surgery
- Check for hospital ID band and validate information
- Patient changes into gown
- Ensure dentures, jewelry, and valuables are removed (make sure tape rings are in place if they cannot be removed)
- Pierced jewelry must be removed because they can cause burns during cautery and they can also promote infection
- Prosthetic devices and hearing aides must be removed and labeled
- Contact lenses and glasses also to be removed.
- Nail polish and artificial nails must be removed.
Surgical Site Marking
- Mark the site when there is more than 1 possible location for procedure
- Try to involve patient in the marking process
- Site is marked by licensed practitioner who is ultimately accountable for the procedure
Administration of Scheduled Drugs
- Consult with physician/anesthesiologist for instructions
- Certain drugs are allowed with a sip of water
- Administer pre-anesthetic medications
- Maintain preoperative records
- Direct family to waiting area
Pre-Operative Drugs
- IV’s can be inserted in pre-operative holding area or sometimes in OR
- Medications include sedatives, hypnotics, anxiolytics, opioid analgesics, anticholinergic medication, antiemetics, histamine blockers.
- These medications relieve anxiety, promote relaxation, reduce nasal/oral secretions, prevent laryngospasm, reduce vagal bradycardia, inhibit gastric secretions, decrease anesthetics needed.
- Antibiotics may also be given
Prevention of Cardiovascular Complications
High Risk for DVT - Obese - Age 40+ - History of Cancer - Immobile/Decreased Mobility - Spinal Cord Injury Interventions - Antiembolism Stockings - Sequential (pneumatic) Compression Device (SCD's) - Leg Exercise, Mobility, Enoxaparin (Lovenox)
Time Out
- Immediate pause by entire surgical team to verify correct patient, procedure, and site.
- Prevents harm as a result of wrong patient, procedure, and site.
Special Population Considerations during Pre-operative Care
- Obese
- Disabled
- Older Adults
- Ambulatory Surgery Patients
- Emergency Surgery Patients
