Perio operative notes

Perioperative Nursing: Comprehensive Overview

UNIT 1

Reference: Lewis Chapters 18-20

Perioperative Phases

• Pre-operative
• Intra-operative
• Post-operative

Suffixes Describing Surgical Procedures

Classification of Surgical Procedures

Admission Status

• Ambulatory
• Same day admit
• Inpatient admit

Urgency

• Elective: Delay has no ill effects; can be scheduled in advance based on patient's choice.
• Urgent: Usually scheduled within 24-48 hours.
• Emergency: Done immediately to remove/repair a body part, preserve life, or prevent further tissue damage.

Degree of Risk

• Major: May be elective, urgent, or emergency; aims to preserve life or improve health.
• Minor: Primarily elective; less invasive procedures.

Purpose of Surgery

• Diagnostic: To make or confirm a diagnosis (e.g., breast biopsy, exploratory laparotomy).
• Ablative: To remove a diseased body part (e.g., appendectomy).
• Palliative: To relieve or reduce intensity of an illness (e.g., colostomy).
• Reconstructive: To restore function to malfunctioning tissue (e.g., breast reconstruction).
• Transplantation: To replace organs that are diseased (e.g., kidney, liver).
• Constructive: To restore function in congenital anomalies (e.g., cleft palate repair).

Risks for Surgery

• Age
• Illness (Co-Morbidities):
  • Diabetes
  • Respiratory disorders
  • Congestive Heart Failure (CHF), Myocardial Infarction
  • Renal & Liver Disease
  • Obesity
  • Alcoholism
  • Previous surgery

Anesthesia Assessment

• Airway assessment
• Mallampati Score: A classification system for assessing airway.
• Phrase: “The more you see, the easier it will be.”

Pre-Op Considerations

1. Labs
2. Consent
3. Allergies
4. Blood
5. Vitals
6. Personal Items:
   • Dentures, contacts, prostheses, jewelry removed, hearing aids
7. Fears (address any pre-operative anxieties)

Advance Directives

• Living Will: Medical decision preferences.
• Power of Attorney: Person designated to make medical decisions.
• Health Care Wishes: Nature of treatment, risks, and alternatives involved.

Pre-Op Medications

• Sedatives
• Anti-anxiety
• Anti-hypertensives
• Anti-diabetics
• Aspirin, NSAIDs, anti-platelets
• Anticoagulants
  • Focus on: Warfarin (Coumadin), Heparin, Apixaban (Eliquis), Rivaroxaban (Xarelto), Enoxaparin (Lovenox), Dabigatran (Pradaxa)
• Herbs & Supplements
• Recreational drug use and addiction
• Tobacco
• Alcohol
• Narcotics

Common Preoperative Agents

• Benzodiazepines:
  • Midazolam (↓ anxiety, amnesia)
• Opioids:
  • Fentanyl, Morphine (pain control, monitor respiratory rate)
• Anticholinergics:
  • Atropine, Glycopyrrolate (decrease secretions)
• Antiemetics:
  • Ondansetron (Zofran); Prochlorperazine (Compazine); Promethazine (Phenergan); Metoclopramide (Reglan)
• Antibiotics:
  • Cefazolin (Surgical Site Infection prevention)

Pre-Op Checklist for Day of Surgery

1. Informed consent signed
2. NPO (nothing by mouth) status confirmed
3. Bowel preparation completed
4. Skin prep shower in anti-microbial soap
5. Documentation of valuables
6. Voided prior to transfer
7. Administered preoperative medications and charted
8. Side rails up after pre-op
9. Bed in low position
10. Hospital gown properly worn
11. Allergy band in place
12. ID band on
13. Valuables left in place or removed (dentures, eyeglasses, hearing aids)
14. Makeup and nail polish removed
15. Vital signs taken before transfer
16. Pre-op lab work noted in chart
17. Surgeon notified of abnormal values

Intra-Op: Surgical Team

• Roles:
  • Scrub RN or tech
  • Circulating RN
  • Anesthesiologist or CRNA
• Surgical Time Out: A crucial safety procedure
• Preparing the surgical site and hair removal

World Health Organization Surgical Safety Checklist

Before Induction of Anesthesia

• SIGN IN Checkpoints:
  • Confirm patient identity and surgical site
  • Verify consent and mark site
  • Assess anesthesia safety and evaluate blood loss risk
• TIME OUT: Confirm all team members have introduced themselves and confirm patient, site, and procedure
• Review anticipated critical events and confirm sterility

Before Patient Leaves Operating Room

• SIGN OUT Checkpoints:
  • Verify procedure name and confirm counts of instruments
  • Confirm specimen labeling and address any equipment problems
  • Review key concerns for recovery and patient management

Understanding Surgical Zones

• Unrestricted Area: Street clothes allowed; regular clothing interaction.
• Semi-restricted Area: Surgical attire required; head and facial hair covered.
• Restricted Area: Includes OR, sterile core, and scrub sink; surgical attire + masks required for higher sterility.

Surgical Care Improvement Project (SCIP) Measures

• Antibiotics: Given 30–60 minutes before incision
• Warming Blankets: Applied preoperatively
• Intermittent Pneumatic Compression Devices (IPCs): Prevent venous thromboembolism (VTE)

Types of Anesthesia

1. General Anesthesia
   • Intravenous
   • Inhalation
   • Adjunctive agents: Opioids, Benzodiazepines, Neuromuscular blocking agents
2. Regional Anesthesia
   • Spinal Epidural, Peripheral nerve block
3. Local Anesthesia
4. Sedation: Decreased consciousness level or relaxed state

Intra-Operative Considerations

• Hypothermia
• Controlled Hypotension
• Airway Management
• Positioning
• Anaphylaxis
• Malignant Hyperthermia: Triggered by succinylcholine; characterized by rapid increase in end-tidal CO₂, muscle rigidity, and high body temperature
  • Only medication that reverses: DANTROLENE

Reversal Agents

• Naloxone (Narcan): Reverses opioids
• Flumazenil (Romazicon): Reverses benzodiazepines
• Kcentra & Protamine Sulfate: Control bleeding from anticoagulant use

Post-Op Recovery

• Post Anesthesia Care Unit (PACU): Phases
  • Phase I: Immediate recovery
  • Phase II: Prepare for discharge
• Modified Aldrete Scoring System: Determines discharge readiness
  • Ability to move extremities
  • Breathing
  • Blood pressure monitoring
  • Consciousness
  • Oxygen saturation

Post-Op Immediate Concerns

• Airway patency and airway obstruction
• Respiratory Rate, O2 saturation, Capnography
• Blood Pressure monitoring
• Drain management

Assessment Areas and Interventions

• Respiratory: Breathing exercises, Oxygen therapy
• Cardiovascular: Vital signs monitoring, Compression devices
• Neurological: Consciousness checks, Pain assessment
• Fluid Balance: IV fluids, Intake/output monitoring

- Wound Care: Dressing changes, Infection prevention