Unit 3- Perioperative Care

Surgery

The art and science of treating diseases, injuries, and deformities by operation and instrumentation

Perioperative

3 Stages

-Preoperative

-Intraoperative

-Postoperative

Preoperative

1st phase of surgery

Begins when patient decides to have surgery

Intraoperative

2nd phase of surgery

begins when patient enters the operating room

Postoperative

3rd phase of surgery

Begins when patient is admitted to the PACU and ends when patient has completely recovered- May be several months

Diagnosis Surgery

Determine the presence and extent of pathologic condition (e.g. lymph node biopsy, bronchoscopy)

Cure Surgery

Eliminate or repair a pathologic condition (e.g. remove a ruptured appendix or benign ovarian cyst)

Palliation Surgery

Alleviate symptoms without cure (e.g. cutting nerve root to reduce pain)

Prevention Surgery

Reduce risk of developing a condition (e.g. removal of a mole before it becomes malignant, prophylactic mastectomy due to BRCA1/2 genes)

Cosmetic Surgery

Alter physical appearance (e.g. repairing a burn scar, breast reconstruction)

Exploration Surgery

Determine the nature or extent of a disease (e.g. laparotomy)

Often less common due to being able to identify most problems noninvasively

Elective Surgery

Planned/optional event preformed to improve patients quality of life

Emergency Surgery

Surgery that must be preformed immediately to save the person’s life or a body organ

Ambulatory/Outpatient Surgery

Most common type of surgery

Patient comes in and goes in less than 24 hours of procedure

Minimally invasive

Done at clinics/ HCP office/outpatient

Ambulatory Surgery’s often use what types of anesthetics

General, Regional and Local

Preoperative Nursing role

-have knowledge of the nature of the disorder requiring surgery and any comorbidities
-identify the individual patient's response to the stress of surgery
-have knowledge of the results of preoperative diagnostic tests
-identify potential risk and complications associated with surgery

Factors effecting surgery outcome

-age
-past experience
-current heath status (cardiac conditions, blood coagulation disorders, respiratory & renal disorders, DM)
-use of illicit drugs & nicotine
-family Hx
-socioeconomic status

Preoperative patient interview

1. Obtain health info including drug/food allergies

2. Provide and clarify information about planned surgery including anesthesia

3. Assess the patients emotional state and readiness for surgery, including their expectations about surgery

Preoperative History assessment

-menstrual/obstetric history
-familial diseases (DM, stroke & malignant hyperthermia)
-reactions/problems with anesthesia

Preoperative psychosocial assessment

• Fears & anxiety-death or disability; may prompt postponement or influence outcome

• Fears of Pain-consult with ACP or surgeon and confirm drugs will be available

Preoperative Medication assessment

-prescribed and OTC
-herbal supplements
-dietary supplements
-antiplatelet/NSAIDS
-latex allergy or sensitive
-recreational; (drugs, alcohol, tobacco)

Preoperative Cardiovascular assessment

• Cardiac acute or chronic problems (angina, HTN, HF, recent MI)

• Use of cardiac drugs (including herbs) that could affect coagulation

• Presence of pacemaker/ICD or Heart valve

• Risk for VTE

• Assess for edema

• Obtain baseline BPs

• Check cap refill and pulses for rate, rhythm, and quality

Cardiovascular Preop

-Echo

-ECG or EKG

-Coagulation studies (PT,PTT, INR)

-Possible stress test or clearance from cardiologist

-Prophylactic antibiotics

Preoperative GI Assessment

• determine patterns of food and fluid intake

• Any recent changes in weight

• Last BM or any issues with BM

• Assess for presence of dentures and bridges

• Auscultate abdomen for Bowel sounds

Preoperative Respiratory Assessment

-recent airway infections
-hx of dyspnea, coughing or hemoptysis (coughing up blood)
-COPD or asthma (increased risk for atelectasis)
-smoking hx
-sleep apnea, obesity and airway deformities that affect respiratory function

Respiratory Preop

-Baseline pulmonary function tests

-ABG

Preoperative Neuro Assessment

Neuro functioning (mini cog, Glasgow coma scale)

Vision or hearing loss

Cognitive deficits

Preoperative GU assessment

Hx of urinary or renal diseases

Assess for glomerulonephritis(inflammation of kidney’s filtering units), CKD, or repeated UTIs

Assess creatine and BUN levels

Preoperative Renal dysfunctions

contributes to fluid and electrolyte imbalances

and altered response to drugs and elimination

GU preop

• renal function tests

• note providing voiding

• assess women for pregnancy

Preoperative Hepatic assessment

• hepatic dysfunction may increase risk of postoperative complications (metabolism of anesthesia)

• Jaundice

• Hepatitis

• Alcohol abuse

Hepatic Preop

AST & ALT labs

Preoperative integumentary Assessment

• Hx of skin problems

• Hx of pressure ulcers

• Hx of tattoos and piercings

Preoperative Musculoskeletal Assessment

• Assess mobility functions

• Identify joints affected with arthritis (intraoperative positioning+ Post op Mobility)

• Problems with neck for lumbar spine (intubation or spinal anesthesia)

Preoperative Immune Assessment

Compromised immune system or use of immunosuppressive drugs can have

• decreased wound healing

• increased risk for infection

Preoperative Fluid and Electrolyte Assessment

• Vomiting, Diarrhea, or difficulty swallowing (can cause imbalances)

• Identify drugs that may alter (diuretics)

• Evaluate serum electrolytes

Preoperative Nutrition Assessment

• NPO prior to surgery

• Overnutrition (dehiscence and eviscerations)

• Undernutrition (healing and pressure ulcer)

• Underweight (provide extra padding, may be protein + vitamin deficient)

• Identify dietary habits that may affect recovery

Obesity Surgery

• Or may need special equipment

• Stresses heart + lungs, making surgical site & anesthesia more difficult

• Predisposes pt to wound dehiscence (opening of surgical incision)

• Wound infection

Preoperative teaching

• preop preparation*

• NPO status preop

• pain management

• physical activities

• deep breathing & coughing

• incentive spirometer

• leg exercises

• repositioning Q2H

• early ambulation

• prevention of nausea/constipation

• prophylactic DVT prevention

Informed Consent

• adequate disclosure

• understanding & comprehension

• voluntarily given consent

Day of Surgery

• labs

• H&P

• baseline vitals

• consult records

• nurses notes

• the site & side of surgery will be identified & marked with an indelible marker by the surgeon

• hospital gown

• valuables

• dentures, contacts and prosthetics removed

• pt may not wear cosmetics

• final teaching

Preop Medications

Benzodiazepines- used for sedative and amnesic properties

Anticholinergics-sometimes given to reduce secretions

Opiods- may be given to decrease pain and anesthetic requirements

Antiemetics- can decrease N&V

Antibiotics- infection prophylaxis

Transportation to OR

Via stretcher or wheelchair

Communication to Intraoperative nurse using SBAR

Caregivers directed to waiting room

Preoperative Specials considerations

-culturally competent care (family members may be included in decision making, consider ELS)
-geriatric considerations (vision/hearing deficits, slowed cognitive processes, caregiver support may be needed)