Topic 9: The Perioperative Period

Overview of Surgery

  • Definition of Surgery: Surgical procedures are operative or invasive procedures that involve a manual, intentional break in the body's integrity, covering skin, mucous membrane, or epithelial linings.

  • Purpose: Surgery can serve diagnostic purposes or therapeutic purposes, addressing medical issues.

  • Stress Factors: Surgery is a significant stressor, necessitating physical and psychological adaptations from both the patient and their family members.

  • Collaborative Success: The success of surgical outcomes depends on the collaboration and integrated skills of multiple healthcare providers.

Sources and Types of Stress

Stressors Related to Surgery

  • Developmental Stress: Stresses that arise as individuals pass through normal growth and developmental stages.

  • Situational Stress: Unpredictable stressors that can arise from various situations, including:

    • Illness

    • Traumatic injury

    • Marriage

    • Divorce

    • Job changes

    • Loss

Physiologic Stressors

  • Chemical agents

  • Physical agents

  • Infectious agents

  • Nutritional imbalances

  • Hypoxia

  • Genetic or immune disorders

Psychosocial Stressors

  • Accidents and trauma

  • Fear of aggression/mutilation

  • Media representations of historical horrors

  • Rapid global changes

  • Social isolation, political divides (ex: changes from the pandemic)

Physiologic and Psychological Homeostasis

Body’s Response to Stress

  • Involves maintaining homeostasis through adaptive syndromes.

Physiologic Homeostasis

  • Local Adaptation Syndrome (LAS): Short-term responses localized to specific body parts (e.g., inflammation, reflex pain response).

  • General Adaptation Syndrome (GAS): A biochemical model affecting the entire body through three stages:

    1. Alarm Reaction: Initial "fight-or-flight" response; activation of defense mechanisms, rise in hormone levels, potential shock state.

    2. Stage of Resistance: The body tries to adapt; vital signs, hormone levels, and energy may normalize; homeostasis may be restored or fail.

    3. Stage of Exhaustion: Adaptive mechanisms are depleted; leads either to rest and mobilization of defenses or death possibility.

Psychological Homeostasis

  • Involves mind-body interactions leading to psychosomatic disorders. Key responses to stress include:

    • Anxiety: Common stress response characterized by discomfort or dread. Four levels include mild, moderate, severe, and panic.

    • Fear: Response to a known threat.

Clinical Manifestations of Stress

  • Physiological Signs:

    • Pupil dilation

    • Diaphoresis (sweating)

    • Pale skin

    • Dry mouth

    • Increased vital signs and cardiac output

    • Gastrointestinal changes (diarrhea or constipation)

    • Migraines

    • Panic attacks, feelings of isolation, lack of control.

Stress Management and Coping Techniques

Interventions for Stress Relief

  • Coping Strategies:

    • Assist patients with coping methods

    • Decrease anxiety through therapeutic communication

    • Implement relaxation techniques (e.g., massage, meditation, music, guided imagery)

    • Encourage exercise.

    • Teach deep breathing techniques to lessen stress responses.

Coping Mechanisms

Positive Approaches

  • Crying, laughing, sleeping, cursing.

  • Physical activity: Releases endorphins.

  • Mindfulness and deep breathing exercises for calmness.

Negative/ Maladaptive Coping Approaches

  • Substance abuse (smoking, drinking).

  • Withdrawal or lack of eye contact in social situations.

  • Limiting social relationships.

  • Poor nutrition: Either under or overeating.

Defense Mechanisms (Subconscious Reactions)

  • Compensation: Leveraging strengths to balance weaknesses.

  • Denial: Refusal to acknowledge reality.

  • Displacement: Transferring emotions onto a safer target.

  • Dissociation: Detaching from reality to escape stress.

  • Introjection: Adopting beliefs or values from others.

  • Projection: Attaching one’s undesirable feelings to others.

  • Rationalization: Providing logical but false explanations for feelings/behaviors.

  • Reaction Formation: Acting contrary to true feelings.

  • Regression: Reverting to earlier developmental stages during stress.

  • Repression: Blocking unpleasant memories.

  • Sublimation: Redirecting unacceptable impulses into acceptable actions.

  • Undoing: Attempting to reverse feelings through compensatory actions.

Formal Stress Management Techniques

  • Relaxation

  • Mindfulness

  • Anticipatory Guidance

  • Guided Imagery

  • Crisis Intervention

Three Phases of the Perioperative Period

1. Preoperative Phase

  • Definition: From the surgical decision to transfer to the operating room.

2. Intraoperative Phase

  • Definition: From transfer to the operating room bed to transfer to the postanesthesia care unit (PACU).

3. Postoperative Phase

  • Definition: From admission to PACU until complete recovery, including follow-up visits.

Classification of Surgical Procedures

Based on Urgency

  • Elective: Planned in advance (e.g., cosmetic surgery).

  • Urgent: Should occur within 24-48 hours (e.g., appendectomy).

  • Emergency: Necessary for life-saving measures (e.g., bowel obstruction).

Based on Purpose

  • Diagnostic: To gather tissue samples.

  • Reconstructive: To restore function.

  • Palliative: To alleviate symptoms and improve comfort.

  • Cosmetic: Aesthetic surgery.

  • Colostomy/Ostomy: Opening created in the abdominal wall.

Surgical Terminology (Suffixes)

  • -tomy: Cut (e.g., appendectomy).

  • -ectomy: Cut out (e.g., tonsillectomy).

  • -ostomy: Created an opening (e.g., colostomy).

  • -rrhaphy: Suturing (e.g., herniorrhaphy).

  • -desis: Binding two structures (e.g., arthrodesis).

  • -plasty: Reshaping (e.g., rhinoplasty).

  • -oscopy: Viewing with a scope (e.g., endoscopy).

  • -orrhaphy: Suturing (e.g., myorrhaphy).

  • -lysis: Detachment or destruction (e.g., adhesiolysis).

Types of Anesthesia

  • General Anesthesia: Unconsciousness induced through inhaled or intravenous drugs, eliminating pain perception entirely (used for major surgeries).

  • Moderate Sedation/Analgesia (Conscious Sedation): Used for short-term procedures allowing alertness but reduced discomfort.

  • Regional Anesthesia: Injected near nerves to anesthetize an area (commonly for lower-body surgeries).

  • Topical and Local Anesthesia: Numbs specific area without affecting consciousness (used for wounds/burns).

Outpatient/Same Day Surgery

  • Benefits: Reduces hospital stay and costs, lessens stress for patients.

  • Requirements: May necessitate further teaching and home care, especially for older adults or chronically ill patients.

Informed Consent

  • Necessary Information for Patients:

    • Description of procedure and alternative therapies.

    • Information on the disease process and its natural course.

    • Name and qualifications of the performing surgeon.

    • Explanation of risks and their occurrence frequency.

    • Rights to refuse treatment or withdraw consent.

    • Expected outcomes and recovery processes.

Desired Outcomes for the Surgical Patient

  • Respectful Care: Culturally competent and developmentally appropriate.

  • Injury Prevention: Freedom from harm and adverse effects.

  • Infection Prevention: No surgical site infections.

  • Homeostasis Maintenance: Fluid balance, skin integrity, optimal temperature maintenance.

  • Pain Management: Collaboration on pain control.

  • Understanding Responses: Comprehension of physiologic and psychological impacts of surgery.

  • Rehabilitation Participation: Involvement in recovery processes.

Patient Risk Assessment

Risk Factors and Strengths

  • Developmental level.

  • Medical and surgical history.

  • Medication usage history.

  • Nutritional status.

  • Substance use (alcohol, drugs).

  • Activities of daily living (ADLs) and occupation.

  • Coping strategies and support systems.

  • Sociocultural needs.

Surgical Risks Associated with Medications

  • Anticoagulants: Risk of hemorrhage.

  • Diuretics: Electrolyte imbalances, respiratory depression risks.

  • Tranquilizers: Impair anesthetic effects.

  • Adrenal Steroids: Abrupt withdrawal may cause cardiovascular collapse.

  • Antibiotics (mycin group): Risks of respiratory paralysis with certain muscle relaxants.

Presurgical Screening and Nursing Role

Usual Presurgical Screening Tests

  • Chest X-ray.

  • Electrocardiography (EKG).

  • Complete blood count (CBC).

  • Basic (BMP) or complete (CMP) metabolic profile.

  • Urinalysis.

  • Clotting studies (PT, PTT, INR).

Nurse’s Role in Testing

  • Explain tests to patients.

  • Ensure proper collection of specimens.

  • Record and report results before surgery.

Nursing Interventions in the Preoperative Phase

Meeting Psychological Needs

  • Intentional presence to care for patient.

  • Establish and maintain a therapeutic relationship.

  • Active listening to understand anxieties and fears.

  • Appropriate touch for empathy.

Patient Teaching

  • Prepare patients about surgical experiences and sensations.

  • Discuss pain management strategies.

  • Explain physical activities (deep breathing, coughing, incentive spirometry, leg exercises, turning in bed, early ambulation).

General Preparation

  • Hygiene and skin preparation.

  • Elimination.

  • Nutrition and fluid management.

  • Rest and sleep needs.

  • Safety preparations for the surgery day.

Error Prevention Protocols

  • Patient Identification Verification: Confirm correct patient before surgery.

  • Marking Operative Site: Physical identification of the correct site.

  • Final Verification (Time-out): Confirm patient, procedure, and site before starting surgery.

Intraoperative Phase: In the Operating Room

Major Concerns

  • Safety and Asepsis: Essential to prevent infections and complications.

Nursing Activities

  • Perform assessments, positioning, maintaining asepsis, patient monitoring, and error prevention.

Postoperative Phase: Recovery and Complication Management

Immediate Postoperative Concerns

  • Maintain core physiological functions, summarized by the ABCs:

    • Airway: Ensure it is patent and that gag reflex is intact.

    • Breathing: Evaluate adequacy of breathing (Rate, depth, quality).

    • Circulation: Monitor circulation by frequent vital signs assessments.

Nursing Activities

  • Perform patient assessments, monitor for complications, ensure safety, and maintain asepsis.

  • Frequent Assessments (every 10-15 minutes):

    • Respiratory Status: Airway function and pulse oximetry.

    • Cardiovascular Status: Blood pressure tracking.

    • Temperature: Monitor changes.

    • CNS Status: Alertness, movement, shivering monitoring.

    • Fluid Status: Monitoring inputs/outputs.

    • Wound Care: Assess wound for complications.

    • Pain Management: Address patient discomfort.

Managing Patient’s Health

  • Pain Management: Supporting recovery from pain.

  • Oxygenation and Circulation Stability: Ensure rich oxygen levels and consistent circulation.

  • Fluid Balance: Monitor and maintain fluid input and output.

  • Wound Care: Implement appropriate dressing and care.

  • Mobility Support: Facilitate patient mobility to enhance recovery.

  • Complication Prevention: Stay vigilant against potential complications (e.g., infections, thromboembolism).

Potential Postoperative Complications

Cardiovascular Complications

  • Hemorrhage: Excessive bleeding.

  • Shock: Life-threatening condition due to inadequate blood flow.

  • Thrombophlebitis: Inflammation of veins resulting from blood clots.

  • Thromboembolism Risks: Include Deep Vein Thrombosis (DVT) and Pulmonary Embolus.

  • Interventions: Leg exercises to enhance venous return and prevent clots.

Respiratory Complications

  • Atelectasis: Collapse of lung tissue.

  • Pneumonia: Lung infection risks post-surgery.

  • Pulmonary Embolism: Blockage of a pulmonary artery.

  • Interventions include:

    • Monitor vital signs.

    • Implement deep breathing exercises, encouraging coughing.

    • Utilize incentive spirometers, turning patients every two hours.

    • Promote early ambulation, maintain hydration, avoid restrictive positioning, monitor narcotic responses.

Additional Postoperative Complications

  • Managing surgical site infections.

  • Ensuring return to health and comfort needs.

  • Addressing elimination and nutritional needs.

  • Fostering overall comfort and rest for the patient.

  • Helping patients cope with the surgical experience and recovery process.