Perioperative Nursing Care

Perioperative Nursing Care

Surgery

  • Perioperative: The total surgical episode.

  • Performed for:

    • Diagnosis.

    • Cure or repair.

    • Palliation.

    • Prevention.

    • Exploration.

    • Cosmetic improvement.

Surgical Settings

  • Emergency: Unexpected, urgent.

  • Elective: Planned.

  • Inpatient: Same-day admission with a hospital stay after surgery.

  • Ambulatory (same-day surgery):

    • Procedures usually take less than 2 hours.

    • Usually less than 3–4 hours in the post-anaesthesia care unit (PACU).

    • Patient discharged home on the same day of surgery.

Surgical Settings (Cont.)

  • Basic information for nurses in the surgical setting:

    • Know the nature of the disorder necessitating surgery and any coexisting disease processes.

    • Identify the individual client’s response to the stress of surgery.

    • Assess the results of appropriate preoperative diagnostic tests.

    • Consider the bodily alterations and potential risks and complications associated with the surgical procedure and any coexisting medical problems.

Pre-operative Assessment

  • Client interview in advance of surgery.

  • Physical assessment, collection of admission data, review consent forms, pre-anesthesia evaluation, client's weight and airway history, lab tests, and diagnostic tests.

  • Information provided includes:

    • Protocol for taking routine medication on the day of surgery.

    • Which medications (e.g., anticoagulants) or herbal remedies to stop prior to surgery and when to stop them.

    • Nothing-by-mouth (NPO) instructions.

    • Pain management options.

    • Infection prevention and wound care.

    • Postoperative exercise instructions.

    • Postoperative discharge and care.

Nursing Assessment Day of Surgery

  • Overall goals:

    • Confirm and identify changes to physical status.

    • Determine psychological status.

    • Establish baseline data (ex. VS, lab values).

    • Review medications.

    • Ensure preoperative lab and diagnostic tests are completed and documented.

    • Support the client and family.

    • Determine informed decision to have surgery.

    • Understand discharge plan and has postoperative support.

Nursing Assessment Day of Surgery: Subjective Data - Psychosocial Assessment

  • Use interpreter if needed.

  • Meaning of surgery.

  • Client's susceptibility to stress (ex. coping Strategies; age; past experiences, current health; socioeconomic status etc.).

  • Stress negatively affects surgical outcomes.

  • Anxiety: lack of knowledge, uncertain outcomes, lack of control, complications, cultural or religious needs etc.

    • Can impair cognition, decision making, and coping abilities.

    • Information and support lessens anxiety.

  • Common Fears: fear of death, fear of pain and discomfort, fear of mutilation or alteration in body image, fear of disruption of life function or patterns.

  • Remain non-judgmental, provide information and reassurance, consult with other team members, etc.

Nursing Assessment Day of Surgery Subjective Data: Psychosocial assessment Table 20.2

  • Situational Changes

  • Concerns with the Unknown

  • Concerns with Body Image

  • Past Experiences

  • Knowledge Deficit

Nursing Assessment Day of Surgery: Coping with Surgery

  • Transition through the perioperative period affects postoperative recovery.

  • Spirituality, inner peace, and hope.

  • Positive coping mechanism.

  • Never deny or minimize.

  • Assess and support.

  • Implement holistic preoperative approach to client care.

Nursing Assessment Day of Surgery: Subjective Data - Health History

  • Follow hospital policy.

  • Diagnosed medical conditions and current health issues.

  • Reason for surgery.

  • Previous hospitalizations and surgeries

    • Any problems with past surgeries, complications, or reaction to anaesthetics?

  • Menstrual/obstetric history.

  • Familial health history.

  • Cardiac or endocrine diseases

    • Contribute to choice of anaesthetic and impact surgical outcomes.

  • Reactions/problems to anaesthesia (client or family)

    • Ex. adverse reactions, Malignant hyperthermia etc.

Nursing Assessment Day of Surgery: Subjective Data - Current Medications

  • Prescription and over-the-counter (OTC) medications.

  • Herbal, Dietary supplements, and vitamins

    • Specific herbs that can be of concern during the perioperative period are identified in the Complementary & Alternative Therapies box of Chapter 20

  • Recreational drug use

    • Opioids, marijuana, cocaine, amphetamines; Alcohol; Tobacco

    • Ask when last used and what was last used

Nursing Assessment Day of Surgery: Subjective Data - Allergies

  • Pharmaceutical

    • Medication intolerance vs allergies

  • Nonpharmaceutical

    • Foods, metals, chemicals, tape, and pollen

  • Screen areas for possible latex allergies

    • Contact dermatitis and atopic immunological rxns

    • Allergies to nuts, bananas, avocados, kiwi, chestnuts, papayas, pitted fruit (remember from HHNP2!)

    • Repeated exposures to latex

Nursing Assessment Day of Surgery: Review of Systems - Nervous System

  • Evaluation of neurological functioning

  • Vision or hearing loss can influence responses

  • Cognitive function

    • Assess for any deficits before surgery

    • Major importance for older patients

    • For impaired cognitive function, determine whether there are appropriate resources and support to assist the client

Nursing Assessment Day of Surgery: Cardiovascular System

  • Determine pre-existing conditions for effective monitoring during surgery and recovery

  • Use of cardiac drugs

  • Hx of pacemaker, cardiac devises, HTN, angina, HF, MI, etc

  • Vitals recorded preoperatively for baseline

  • Bleeding/clotting times, INR etc.

  • Other laboratory reports as needed

  • Possible prophylactic antibiotics

Nursing Assessment Day of Surgery: Respiratory System

  • Inquire about recent or chronic upper resp. infections

    • Procedure could be cancelled or postponed because of increased risk

  • History of asthma

    • Assess recent use of inhaled or oral corticosteroids and bronchodilators

  • COPD or asthma

    • High risk for bronchospasm, laryngospasm, hypoxemia, and atelectasis

  • Smokers should be encouraged to quit 8 weeks before the procedure

    • Decreases risk of complications

    • Greater pack-years = greater risk for pulmonary complications

Nursing Assessment Day of Surgery: Urinary System

  • History of urinary or renal diseases

  • Renal function tests (creatinine, BUN etc.)

  • Note problems voiding and inform operative team

    • Especially for male pts – enlarged prostate

  • Inform client if catheter will follow surgery

Nursing Assessment Day of Surgery: Integumentary System

  • History of skin rashes, boils, ulcers, or other dermatological conditions

  • History of pressure ulcers

    • Extra padding during procedure

  • Affects postoperative healing

Nursing Assessment Day of Surgery: Musculoskeletal System

  • Identify joints affected with arthritis

    • Mobility restrictions may affect positioning and ambulation

    • Bring mobility aids to surgery

  • Report problems affecting neck or lumbar spine

    • Can affect airway management and anaesthesia delivery

Nursing Assessment Day of Surgery: Endocrine System

  • Clients with diabetes mellitus especially at risk for: Hypo/hyperglycemia, Ketosis, Cardiovascular alterations, Delayed wound healing, Infection

  • Client with Diabetes mellitus: Capillary blood glucose tests morning of surgery (baseline)

  • Clarify with physician or anaesthesiologist if the usual dose of insulin is taken on the day of the surgery

  • Clients with thyroid dysfunction

    • Hyper/hypothyroidism is a surgical risk due to altered metabolic rate

    • Verify with anaesthesiologist about giving medications the day of the surgery

Nursing Assessment Day of Surgery: Immune System

  • Clients with a history of compromised immune system or use of immuno-suppressive drugs can have:

    • Delayed wound healing

    • Increased risk for infection

  • Acute infection (ex. Active skin rash)

    • Elective surgery usually cancelled

Nursing Assessment Day of Surgery: Fluid and Electrolyte Status

  • Vomiting, diarrhea, or difficulty swallowing can cause imbalance

  • Identify drugs that alter status

    • Diuretics

  • Evaluate serum electrolyte levels

  • NPO status

    • May require additional fluids and electrolytes prior to surgery if dehydration occurs

Nursing Assessment Day of Surgery: Nutritional Status

  • Obesity

    • May require certain equipment and instrumentation during surgery

    • Stresses cardiac and pulmonary systems

    • Obstructive sleep apnea

    • Increases risk for DVT and surgical site infection

    • Ventricular arrhythmias and hypertension are potential complications

  • Malnutrition

    • Linked to delayed wound healing and surgical site infections

    • Older clients are at risk

  • Pressure-reducing positioning devises used to prevent pressure ulcers

  • Identify dietary habits that may affect recovery (e.g., caffeine)

Nursing Assessment: Client About to Undergo Surgery: Objective Data - Physical examination

  • Each province/territory and health authority may have its own policies on preoperative health assessments, but it is important to have a physical examination documented on the chart in case surgical complications arise

  • Includes: neurological system, cardiovascular system, respiratory system, urinary system, hepatic system, endocrine and hematological systems, integumentary system, MSK system, Gastrointestinal-nutritional system

  • Table 20.5

Nursing Assessment: Client About to Undergo Surgery: TABLE 20-4 ASA PHYSICAL STATUS CLASSIFICATION SYSTEM

  • ASA I: Healthy normal patient. Examples: Healthy, nonsmoking, no or minimal alcohol intake

  • ASA II: Patient with mild systemic disease. Examples: Mild disease, minimal functional limitations (e.g., currently smoking, social alcohol intake, pregnancy, obesity, controlled diabetes, controlled hypertension, mild lung disease)

  • ASA III: Patient with severe systemic disease. Substantial functional limitations with one or more moderate to severe diseases (e.g., poorly controlled diabetes, hypertension, COPD, active hepatitis, premature infant, myocardial ischemia, CVA)

  • ASA IV: Patient with severe systemic disease that is a constant threat to life. Examples: Recent (<3 months) myocardial infarction, CVA, ongoing cardiac ischemia, sepsis, acute respiratory disease, DIC

  • ASA V: Moribund patient not expected to survive without surgery. Examples: Ruptured abdominal/thoracic aneurysm, massive trauma, massive intracranial bleed, ischemic bowel plus cardiac or multiple organ failure

  • ASA VI: Brain-dead patient. Organs being removed for donation

Nursing Assessment: Client About to Undergo Surgery: Objective Data - Laboratory and Diagnostic Testing

  • The need for preoperative laboratory and electrocardiogram testing is determined based on the client’s history

  • Common tests Table 20.6

  • Nurses:

    • Document relevant findings and report to perioperative team

    • Obtain and evaluate the results of laboratory tests

    • Ensure results are on the chart

Nursing Management: Preoperative Education

  • Empowers client to make informed health decisions and allows participation

  • Increases adherence to instructions and client satisfaction

  • Reduces fear, anxiety, stress, duration of hospitalization, and recovery time following discharge

  • Challenges

    • Language barrier

    • Cultural perceptions of health, hospitals and surgery

    • Individualized time

    • Limited time available

    • Address needs of highest priority

    • Include information focused on safety

    • Provide written material

Nursing Management: Preoperative Education (Cont.)

  • Identify client's education needs by determining:

    • Age, language, reading level, emotional status, and motivation to understand the surgery

  • Education is a team effort and should be documented

  • Three types of information (Table 20.7)

    • Sensory information (what client hear, see, smell, feel etc.)

    • Process information (general flow of what will happen)

    • Procedural information (more specific details: ex. clothing to wear, when IV will be inserted, pain control, etc.)

Nursing Management: Preoperative Education (Cont.): General Surgery Information

  • Information specific to surgery and education needs of the client

  • Table 20.8

  • All patients receive teaching on:

    • Nutrition: NPO guidelines; post-op nutrition and nausea plans

    • Ambulation (to help post-op)

    • Breathing (deep breathing, coughing, incentive spirometer)

    • Grooming needs

    • Medication guidelines

    • Pain control plan

    • If tubes, drains, monitoring devices, or special equipment will be used postoperatively

    • Where family can wait and expected length of stay

Nursing Management: Preoperative Education (Cont.): Ambulatory Surgery Information

  • Basic information before arrival

    • Time and place (arrival time and surgery time)

    • Registration

    • What to wear and bring

    • Fluid and food restrictions

    • Need for bowel prep or medications

    • Need for shower/grooming

    • Transportation after surgery

Legal Preparation For Surgery

  • All required forms are signed and in chart

  • Consent forms for surgical procedure, anaesthesia interventions, blood transfusions

  • Advance directives and Power of attorney

  • Informed consent: client at all times has the right to autonomously make own health decisions

    • Client assesses information and makes informed decision

  • Informed consent must include:

    • Voluntary consent

    • Mental capacity to consent

    • Properly informed

    • Typically signed in the presence of a witness

Legal Preparation For Surgery: Informed Consent - Voluntary Consent

  • Surgeon is legally responsible for obtaining consent

  • Nurse can be a patient advocate, by verifying that the patient voluntarily signed the consent and understands the consent and its implications.

  • Document in client chart

  • Verify client has understanding

  • Client’s permission may be withdrawn at any time

  • Operative consent must be signed before any preoperative medication is given

Legal Preparation for Surgery: Informed Consent - Capacity to Consent

  • Physician makes sure client can comprehend consent discussion

  • A patient has the capacity to consent if they understand the nature and effects of the proposed treatment, the consequences of refusing the treatment, and any alternatives to the treatment

  • Consent determined by maturity, not age

  • Additionally, capable minors must give permission (consent) to have their parents involved in health care decisions.

  • Unconscious client or diminished capacity: consent signed by a family member or legally appointed representative

  • Medical emergency may override need for consent - physician does what is immediately necessary and then obtains consent as soon as possible

Legal Preparation for Surgery: Informed Consent - Properly Informed

  • Physician discusses:

    • Diagnosis

    • Proposed treatment

    • Risks and consequences

    • Probability of successful outcome

    • Consequences of no treatment

  • The patient must know the availability, benefits, and risks of alternative treatments

Day-of-Surgery Preparation Nursing Role

  • Communication – check understanding, answer questions etc.

  • Preoperative Checklist: all pertinent documentation and actions required prior to surgery

  • Nurses must ensure:

    • Final preoperative teaching

    • Readiness assessment

    • Assessment and report of pertinent findings

    • Verify signed consent

    • The chart should include a patient history, physical examination, lab results, type and screen, baseline vitals, informed consent, consultation records, and nurses’ notes. All critical documentation must accompany the patient or be accessible electronically in the OR

Day-of-Surgery Preparation (Cont.)

  • Client needs to showered or bathed before surgery and is dressed in hospital gown

  • Client should not wear any cosmetics

    • Observation of skin colour is important

  • Remove nail polish for pulse oximeter

  • Identification and allergy bands on wrist

  • Valuables returned to family member or locked up

  • Jewelry, dentures, contacts, glasses, and prostheses are removed to prevent loss or damage; Hearing aids usually left in place

  • Void before surgery

    • Prevents involuntary elimination under anaesthesia or urinary retention during early postoperative recovery

  • Before medication administration

  • Documented on patient record

Preoperative Medications

  • Can be given oral, IV, subcutaneous, or IM

  • May be used for a variety of reasons (single or combination)

    • Benzodiazepines and barbiturates (for sedative and amnestic properties)

    • Anticholinergics (to reduce secretions)

    • Opioids (to decrease intraoperative anaesthetic requirements and pain)

    • Antiemetics (to decrease postoperative nausea and vomiting)

    • Other medications may be administered preoperatively

      • Antacids

      • Antibiotics

      • Eye drops

      • Routine prescription drugs – depends on type of drug, and client health history

Transportation to the Operating Room

  • Inpatients transported by stretcher to the operating room from the room

    • Side rails raised and secured

    • Chart and preoperative equipment with client

  • Outpatients transported by stretcher or wheelchair, or may walk (accompanied)

  • Method of transport documented by nurse responsible for transfer, per hospital policy

  • Family instructed on the waiting area where they can be informed of progress

Culturally Competent Care

  • Aware of and supportive of cultural perceptions and beliefs of clients when preparing them for surgery

  • Decisions made because of cultural variations must be respected and valued

  • Consider cultural considerations for pain, coping, and family expectations

Age-Related Considerations

  • Nurse must be alert in assessing and caring for older-adult surgical clients

  • An event that has little effect on a younger client may be overwhelming to the older client

  • Greater risks associated with anaesthesia and surgery

  • Greater risk for postoperative complications

  • Consider client’s physiological condition, not just their chronological age

  • Knowledge of family support

  • Consider sensory deficits

  • Threat to independence, lifestyle, and self-esteem may result in ineffective coping