Module 1 - Peri-Operative

preoperative phase

time the decision for surgery is made → beginning of surgery

What should be obtained during a patient interview in pre-op?

• health information (drug/food allergies, review of systems, PMH, etc.)

• provide and clarify information about surgery and/or anesthesia

• assess patient’s emotional state and readiness about surgery

• determine patient/caregiver outcomes

What should be obtained during a patient’s assessment in pre-op?

• baseline data (psychological, physical)

• ID patient and surgical site

• review all meds/supplements

• review informed consent

• obtain ALL medical/surgical history (anesthesia, co-morbidities, risk factors, etc.)

Why is a pre-op assessment important?

IDs risk factors and plans care to ensure patient safety

Describe informed consent and ways it can be obtained.

active, shared decision-making process between the healthcare provider and recipient of care

obtained by the surgeon; nurse can witness, but surgeon is responsible

What specific condition overrides informed consent?

medical emergencies

What are some situations in which the patient can’t give informed consent? Who signs in their place?

patient is a minor, unconscious, or mentally incompetent

a legally appointed representative, or responsible family member may give written permission

What should a nurse be aware of during pre-op teaching?

• Has the patient been NPO?

• ensure patient has voided

• review pre-op meds and at-home medication list

• culturally competent care

• age-related considerations

What must be included for informed consent to be valid?

adequate disclosure of…

• diagnosis, nature, and purpose of proposed treatment

• risks and consequences

• probability of success

• availability of alternative treatments

• prognosis if not treated

- patient must demonstrate a clear understanding

- patient must give consent voluntarily

Describe a nurse’s role in the overall pre-op stage.

pre-op teaching - patient ID, allergy bands, diet restriction before procedure day

legal prep - review informed consent (unless emergent)

day of surgery teaching - verify documentation (H&P, procedure, etc.)

OR transport - taking patient to procedure area

What is a nurse’s responsibility during patient teaching in pre-op?

• importance of early post-op ambulation, breathing exercises, and use of incentive spirometry

• educating patient on rating of pain and use of PCA pumps

• communication with other nurses so teaching is not repeated

• assessing patient’s understanding and filling gaps as needed

• record all teaching in patient’s charts

• explaining equipment being used, smells, and/or sounds the patient may see/experience**

• explaining the surgery in Layman’s terms**

** only if patient requests

What is a “Pre-Op Checklist”?

a checklist completed as a final check before the procedure outlining a “quick checklist” of important last minute reminders before entering the OR such as vitals and allergies, signed consent, blood products, labs, scans, surgery/procedure review, and patient valuables

What are the pre-op fasting recommendations? (Give descriptions of food and minimum fasting periods)

regular meals → 8 hrs

light meals or nonhuman milk/formula → 6 hrs

• toast, clear liquids, etc.

breast milk → 4 hrs

clear liquids → 2 hrs

• water, tea, black coffee, no-pulp juices, carbonated beverages

What medications are usually given prior to surgery? How soon?

antibiotics; within 30—60 minutes of the incision

unrestricted zone

street clothes interacting with scrub attire; “holding area” where patient ID and assessment take place

semi-restricted zone

peripheral support areas and corridors with only authorized staff; should wear clean surgical attire and/or appropriate PPE

restricted zone

surgical site (OR); STERILE; masks worn and traffic minimized whenever sterile supplies are open

What is done in the “Holding Area”?

• prophylactic antibiotics within 30—60 mins before surgical incision

• patient warming

• applying intermittent pneumatic compression devices (SCDs)

The “Holding Area” requires a pre-procedure verification. What does this include?

• verification of relevant documentation

• results of diagnostic studies

• availability of needed blood products, implants, special equipment

• procedure is marked by surgeon

Explain the role of the circulating nurse.

implements plan of care and collaborates with the team

patient advocate, maintains safety, privacy, dignity, and confidentiality; provides physical and emotional care for the patient

documents care (surgical time out, surgical instrument count)

The circulating nurse remains where in relation to the sterile field?

outside the sterile field

The circulating nurse is always what kind of healthcare provider?

RN

Explain the role of the scrub nurse.

maintains aseptic technique, handing equipment to surgeons and first assists

preps the sterile field, gowned and gloved

does surgical count/manages sterile field

The scrub nurse is always what kind of healthcare provider?

LPN, RN, or surgical tech

Explain the role of the 1st assist.

hold retractors, helps with hemostasis and suturing

may perform some parts of the procedure under surgeon’s direct supervision

The 1st assist is always what kind of healthcare provider?

physician/specially trained RN, certified surgical tech, or med student

What is the surgeon responsible for?

• pre-op medical history, physical assessment, and directing pre-op testing

• obtaining informed consent

• post-op management

local anesthesia

loss of sensation to a specific area

peripheral anesthesia

targeted block of a specific nerve

epidural anesthesia

injected into epidural space (not in CSP) to block sensation, not motor fibers

spinal anesthesia

injected into L2 subarachnoid space to block ALL senses (autnomic, sensory, motor)

general anesthesia

hypnotic, anxiolytic, or dissociative agent; requires airway management

What are some serious potential complications of anesthesia?

anaphylaxis, malignant hyperthermia

What are the manifestations of anesthesia anaphylaxis? How do you treat them?

• HYPOtension

• tachycardia

• bronchospasms - treat with bronchodilators and O₂

• pulmonary edema - treat with O₂, medications, and mechanical ventilation (if necessary)

What’s an important consideration when monitoring for anesthesia anaphylaxis?

initial manifestations may be masked by anesthesia

malignant hyperthermia

rare disorder characterized by hyperthermia with skeletal muscle rigidity; usually occurs during general anesthesia but can occur after

Why is malignant hyperthermia so dangerous?

it can result in cardiac arrest and death

What are the signs of malignant hyperthermia?

• tachycardia

• tachypnea

• stiff muscles (specifically the jaw)

• unexplained increase in CO₂ levels

• rapid rise in temp (up to 109^oF)

How is malignant hyperthermia treated?

prompt administration of Dantrolene, provide 100% oxygen and actively cool patient

Can malignant hyperthermia be prevented?

YES. Prevention is key. Obtain a family history and genetic testing

Explain a nurse’s role in the post-operative phase.

• support ventilation and perfusion

• maintain fluid and electrolyte imbalances

• monitor and manage vitals/pain levels frequently

• encourage early ambulation

• promote comfort and safety

• reduce and prevent infection

Describe the phases of the PACU.

stage I - immediate post OR; stable and recovering well, 1-on-1; obtain ABCs

stage II - consciousness has returned, vitals are stable

stage III - extended; ongoing care (home, inpatient, observation)

What are some potential post-op neurological complications?

• emergence delirium

• fever

• hypothermia

• pain

Explain a nurse’s role on preventing post-op neuro complications.

• know patient’s baseline to accurately compare

• monitor SpO₂

• keep patient safe and report any/all alterations to provider IMMEDIATELY

• know difference between CVA and delirium

What are some potential post-op respiratory complications?

• atelectasis

• bronchospasm

• pulmonary edema

Why can atelectasis occur after surgery?

may result from bronchial obstruction caused by retained secretions, decreased respiratory excursion, or general anesthesia

atelectasis

alveolar collapse

Explain a nurse’s role on preventing post-op respiratory complications.

• airway clearance

• positioning/splinting

• incentive spirometry/deep breathing exercises

• ambulation

Explain a nurse’s role on preventing post-op cardiovascular complications.

• monitor vitals frequently

• monitor intake/output

• obtain labs (potassium, magnesium, Hgb/Hct, BUN/Creatinine)

• notify provider of assessment outside of ordered parameters

What are some potential post-op cardiovascular complications?

• dysrhythmias

• fluid/electrolyte imbalance

• hypo/hypertension

• venous thromboembolism (VTE)

What are some potential post-op GI/GU complications?

• nausea/vomiting

• constipation

• urinary retention

• urinary infection

Explain a nurse’s role on preventing post-op GI complications.

• appropriate diet (NPO, clear liquid, based on assessment/provider orders)

• early ambulation

• obtain last void time

• bladder scan

• intervene as needed (catheter, etc.)

Explain nursing management to prevent post-op pain.

• OLDCART assessment

• splinting

• medications/PCA pump

• early ambulation

Explain nursing management to prevent post-op surgical site complications.

• DO NOT CHANGE FIRST DRESSING (done by surgeon or resident to assess

• if oozing/bleeding, only reinforce or hold pressure to stop; notify provider and document

What should be taught to a patient prior to discharge?

• what symptoms to report

• when and how to take medications

• adverse effects of medications and when to call provider

• incision care

• activity/dietary restrictions

• follow-up adherence

What circumstances should a patient by told to notify their provider?

• unrelieved/excruciating pain

• medication questions

• abnormal wound drainage and/or bleeding

• increased drainage from drainage device (if applicable)

• fever per discharge instructions

• CALL 911 FOR SHORTNESS OF BREATH AND/OR CHEST PAIN