Peri-Op

The Perioperative Period

• Definitions and Phases

•    Pre-operative Phase:

• This period begins when the decision for surgical intervention is made. It concludes when the patient is transferred to the operating room.

• Nursing Focus: The primary priorities are to reduce patient anxiety and provide thorough teaching regarding the upcoming procedure.  

• Intra-operative Phase: This period begins upon the transfer of the patient to the operating room and ends with their transfer to the Post-Anesthesia Care Unit (PACU).    

• Nursing Focus: The primary priorities are safety, specifically regarding patient positioning, and maintaining asepsis.

• Post-operative Phase: This period begins the moment the patient is admitted to the PACU and concludes with a follow-up evaluation in the home or clinical setting.

• Nursing Focus: The primary priority is promoting recovery.

Pre-operative Assessment and Nursing Interventions

• Pre-operative Assessment Components   

• Pre-admission Testing (PAT).   

• Informed Consent: Includes both surgical and anesthesia consents.    

• Screening Tests: Laboratory and diagnostic tests.    

• Physical Assessment: Comprehensive review of systems.    

• Psycho-socio-cultural Assessment: Understanding the patient’s psychological state, social support, and cultural influences.  

• Skin Antisepsis and Piercings: Evaluation of skin integrity and removal of jewelry/piercings.      Patient Teaching/Readiness: Determining if the patient is prepared for the procedure.

• Pre-operative Nursing Interventions  

• Provide Patient Education:        

• Instruction on coughing and deep breathing techniques.  

• Use of the incentive spirometer.    

• Mobility instructions (early ambulation).   

• Pain management expectations.

• Cognitive Coping Strategies: Helping the patient manage the mental stress of surgery.     * Psychosocial Intervention: Efforts to reduce anxiety and decrease fear.

• Medications Affecting the Surgical Experience  

• Corticosteroids.

• Diuretics.     *

• Phenothiazines.     *

• Insulin.     *

• Antibiotics.     

• Thyroid hormones.  

•    * Anticoagulants.   

•   * Anticonvulsants.  

•    * Anti-anxiety medications.

•     * Opioids.     

• * Over-the-counter (OTC) and herbal supplements.   

•   * Nonsteroidal Anti-inflammatory Drugs (NSAIDS) and vitamins.

• Gerontologic Considerations     * Patients possess less physiologic reserve.     * Cardiac reserves are lower than in younger populations.     * Renal and hepatic functions are depressed.     * Decreased subcutaneous fat.     * Greater overall perioperative risks.

Pre-operative Medical Management and Classifications

• Food and Fluid Guidelines     * Traditional NPO: Nothing by mouth after midnight.     * Clear Liquids: Permitted up to $2$ hours before surgery.     * Light Breakfast: Permitted up to $6$ hours before surgery.     * Heavy or Fatty Foods: Permitted up to $8$ hours before surgery.     * Pre-operative Elimination: May involve an Enema or the insertion of a Urinary Catheter.

• Classification of Surgical Procedures     * Reasons for Surgery:         * Diagnostic.         * Exploratory.         * Cure.         * Repair.         * Reconstructive.         * Palliative.         * Rehabilitative.     * Urgency Levels:         * Emergent.         * Urgent.         * Required.         * Elective.         * Optional.     * Risk Levels: Classified as Minor or Major.

• Surgical Settings     * Acute Care: Hospital setting.     * Ambulatory: Surgery centers.     * Same Day: Patient is admitted on the day of the surgery.

• Pre-Anesthesia Medications     * Opioid Analgesics.     * Sedatives/Hypnotics.     * Antibiotics.     * Anticholinergics.     * Antiemetics.     * Proton Pump Inhibitors (PPIs) or $H2$ Receptor Antagonists.

Patient Psychology and Pre-operative Preparation

• Patient Perceptions of Anesthesia     * Fear of death.     * Fear of the unknown.     * Loss of control.     * Fear of pain.     * Fear of waking up during surgery.     * Fear of having a mask over their face.     * Fear of embarrassing themselves.

• Nursing Diagnoses (Pre-operative)     * Anxiety.     * Fear.     * Pain.     * Deficient knowledge.     * Risk for Infection.     * Disturbed body image.     * Anticipatory grieving.     * Ineffective Coping.

• Assessment Domains     * Chemical, Microbiological, Physical, Physiological, Developmental, and Psycho-sociocultural.

• Pre-operative Nursing Actions (Checklist)     * Verify identity (ID band) and Allergy Band.     * Ensure all CONSENTS are SIGNED (Legal Implications).     * Ensure the patient has voided.     * Remove dentures, jewelry, glasses, hearing aids, and all metal/piercings (including tongue piercings).     * Remove undergarments.     * Secure valuables (sent home or locked in Security).     * Complete skin prep or scrub.     * Verify all diagnostic tests are completed and charted.     * Verify maintenance of NPO status.     * Record Vital signs.     * Administer and chart pre-op meds; ensure side rails are up.     * Apply warming device.

Intra-operative Period and Safety

• National Patient Safety Goals     * Core focus during the intra-operative period.

• Members of the Surgical Team     * Patient.     * Surgeon.     * Surgical assistants.     * Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA).     * Circulating nurse (non-sterile role).     * Scrub nurse or technician (sterile role).

• Safety and Infection Prevention     * Time Out Procedure: Mandatory verification before starting.     * Preventing positioning injuries.     * Accurate administration of blood, IV fluids, and medication.     * Appropriate use of restraints.     * Never leave a sedated patient unattended.     * Maintaining strict surgical asepsis.     * Preventing OR fires and ensuring the patient is grounded.     * Preoperative antibiotic prophylaxis administration.     * Specific safety protocols for Robotics and Lasers.

Anesthesia and Sedation

• Definition of Anesthesia: An artificially induced state of partial or total loss of sensation, occurring with or without loss of consciousness.

• Purpose: To block the transmission of nerve impulses, suppress reflexes, promote muscle relaxation, and achieve loss of consciousness when required.

• General Anesthesia:     * Administered via IV or inhalation.     * Reversible state resulting in CNS depression.     * Characteristics: Loss of protective reflexes, unconsciousness, analgesia, and amnesia.

• Regional Anesthesia Types:     * Topical: Applied to the surface.     * Local: Injected into tissue at the operative site.     * Nerve Blocks: Injected around specific nerves.     * Epidural: Anesthetic injected into the epidural space, outside the dura mater of the spinal cord.     * Spinal: Anesthetic injected into the subarachnoid space around the spinal cord via a lumbar puncture at level $L4/L5$.

• Moderate Sedation:     * Administered via the IV route.     * Induces a decrease in Level of Consciousness (LOC).     * Causes amnesia.     * The patient maintains their own airway.     * The patient remains responsive to verbal stimuli.     * Short-acting and easily reversible.

Intra-operative Complications and Nursing Diagnoses

• Intra-operative Nursing Diagnoses     * Risk for aspiration.     * Impaired skin integrity.     * Risk for perioperative positioning injury.     * Risk for imbalance body temperature.     * Ineffective peripheral tissue perfusion.     * Risk for deficient fluid volume.     * Risk for infection.

• Potential Complications     * Anesthesia awareness (patient waking up or feeling pain during general anesthesia).     * Nausea and vomiting.     * Anaphylaxis.     * Hypoxia and respiratory complications (e.g., airway occlusion, aspiration).     * Hypothermia.     * Malignant Hyperthermia (MH).

• Malignant Hyperthermia (MH)     * Pathophysiology: A rare inherited muscle disorder triggered by inhaled anesthetic gases and succinylcholine.     * Initial Manifestations:         * Increase in $CO_2$ levels.         * Generalized muscle rigidity.         * Cardiac dysrhythmias.         * Tachycardia (recognized as an early sign).         * Spiking temperature (recognized as a late sign).     * Interventions:         * Immediate recognition of symptoms.         * Stop the triggering agents.         * Monitor Arterial Blood Gases (ABGs) to correct acidosis.         * Administer oxygen.         * Administer dantrolene (Dantrium).         * Decrease core body temperature.         * Correct electrolyte imbalances.         * Insert a Foley catheter.

Post-operative Period: PACU Assessment and Management

• PACU Assessment Domains     * Airway: Oxygen therapy and $O_2$ saturation.     * Vital Signs: Temperature ($T$), Pulse ($P$), Respiration ($R$), Blood Pressure ($BP$), and pain intensity.     * Cardiac: Continuous monitoring.     * Neurological: Level of Consciousness (LOC) and mobility.     * Physical: Pressure points, skin color, and wound/dressing status.     * Gastrointestinal: Presence of nausea and vomiting ($N \& V$).     * Fluids: Monitoring IVs and Intake and Output ($I \& O$), specifically urine output.     * Tubes/Drains: Assessment of all surgical tubes.     * Pain Management.

• Respiratory Interventions     * Maintain a patent airway.     * Use an oral airway until the gag reflex returns.     * Provide $O_2$ therapy or maintain endotracheal tube as needed.     * Keep the Head of Bed (HOB) elevated to $15$ to $30$ degrees (unless contraindicated).     * If vomiting occurs, turn the patient to their side to prevent aspiration and suction as needed.

• Cardiovascular Assessment & Interventions     * Assess: VS, cardiac rhythm, skin color/temperature, and urine output.     * Assess: Bleeding and wound drainage.     * Check Estimated Blood Loss (EBL).     * Maintain IV fluids: Ringer's Lactate (RL), Normal Saline (NS), blood products, or colloids.     * DVT prophylaxis: Application of Sequential Compression Devices (SCDs).

• Pain and Anxiety Management     * Perform ongoing assessments.     * Evaluate if the pain level is appropriate for the specific surgical procedure.     * Administer IV opiates or utilize Patient-Controlled Analgesia (PCA) pumps as ordered.     * Provide psychological support.

• Nausea and Vomiting (N&V) Interventions     * Intervene immediately upon the first report of nausea.     * Turn patient to their side.     * Pharmacologic interventions:         * ondansetron (Zofran).         * prochlorperazine (Compazine).         * metoclopramide (Reglan).         * promethazine (Phenergan).

• Mobility and Positioning     * Options: Supine, HOB elevated, Side-lying, or Log-rolling.

Discharge from PACU and Post-operative Complications

• Readiness for Discharge Criteria     * Stable Vital Signs.     * Patient is oriented and exhibits good muscle strength.     * Adequate respiratory function and $O_2$ saturation.     * Urine output > $30\,mL/hour$.     * Drainage amounts are within expected limits.     * $N \& V$ are controlled.     * Pain is managed effectively.

• Modified Aldrete Score     * Assessment Areas: Activity, Respiration, Circulation, Consciousness, and $O_2$ Saturation.     * Scoring: Each area is scored $0$-$2$. A total score of $7$-$8$ is required for discharge.

• Discharge Instructions for Home     * Provide written and verbal instructions to both caregiver and patient (meds, diet, activity, wound care).     * Strict instruction: No driving for at least $24$ hours.     * Schedule appointment with the surgeon.     * Expect a post-op phone call.

• Receiving Patient from PACU (In-Patient Unit)     * RN-to-RN report.     * Prepare room with equipment.     * Initial head-to-toe assessment and VS documentation.     * Focus on complication prevention and safety (call bell, positioning).

• Common Post-operative Complications     * Respiratory: Atelectasis, Pneumonia, Hypoxemia.     * Pulmonary Embolus (PE):         * Interventions: Administer $O_2$, Fowler's position.         * Diagnostics: V-Q scan, Venous Doppler, CT scan.         * Management: Heparin Drip, analgesics, inferior vena cava filter.     * Cardiovascular:         * Decreased Cardiac Output (CO) causes: Hypovolemia, Hemorrhage, Hypovolemic Shock.         * Prevention: Venous thromboembolism prevention.     * Hypovolemic Shock:         * Definition: A decrease in intravascular volume of $15\%$ ($750\,mL$) or more.         * Surgical risk factors: Hemorrhage and dehydration.         * Manifestations result from blood volume loss and compensatory mechanisms.         * Nursing Actions: Maintain IV line patency, accurate $I \& O$, monitor drainage systems, and surveillance of lab trends.     * Questions for Review (Hypovolemic Shock):         * What are the manifestations of hypovolemic shock?         * What are the gerontological issues associated with shock?         * Identify the priority nursing diagnoses and interventions for this condition.     * Urinary:         * Common complication: Urinary retention.         * Questions for Review: Describe the complication and manifestations. What nursing interventions prevent urinary complications?     * Gastrointestinal:         * $N \& V$.         * Constipation: Defined as no stool within $48$ hours after a solid diet is started.         * Hiccups.         * Postoperative Paralytic Ileus.

Wound Healing and Management

• The Healing Process Timeline     * First few hours: Absence of bleeding; clot binds the wound.     * $1$-$3$ hours: Inflammation begins.     * $7$-$10$ days: Reduction of inflammation.     * $4$ days to $6$ months: Scar formation starts.     * Months or years: Diminished scar appearance.

• Types of Wound Healing     * Primary Intention: Edges are approximated; results in minimal scarring.     * Secondary Intention: Wound bed is visible; results in greater scar formation.     * Third Intention: Used for deep wounds that have not been sutured.

• Factors Influencing Healing     * Infection, Malnutrition, Obesity, Lifestyle, Advanced age, Comorbidities, and Medications.

• Purposes of Wound Dressings     * Protect from physical and microbiological stressors.     * Contain drainage vs. maintaining a moist environment.     * Prevent transfer of microorganisms to the environment.     * Provide psychological comfort.

• Assessment of Surgical Drains     * Types of Drains: Hemovac, Jackson-Pratt (JP), Penrose.     * Drainage Devices:         * Open: (e.g., Penrose).         * Closed: (e.g., Hemovac, Jackson-Pratt).     * Suction Types: Self-suction or Wall suction.

• Surgical Wound Complications     * Infection.     * Dehiscence (splitting open of the wound edges).     * Evisceration (protrusion of internal organs through the wound).     * Hematoma or seroma.     * Delayed healing.

• Wound Infection (Sepsis)     * Risk Factors: Age, nutritional status, diabetes, smoking, obesity, remote infections.     * Timeline: May not be evident until at least Post-operative day $5$.     * Manifestations: Increased pulse and temperature, elevated WBC count, wound swelling, warmth, tenderness, discharge, and increased incisional pain.

• Cleaning Methods     * Surgical wounds are cleaned via specific standardized methods (referenced as steps $A, B, C$).