Preoperative Nursing Care and Postoperative Nursing Care Lecture
Definition and Scope of Perioperative Nursing Care
Definition of Perioperative Nursing:
This specialized field encompassing all nursing care associated with surgical procedures. It is divided into three distinct phases:
- Preoperative Phase: The period before surgery.
- Intraoperative Phase: The period during the surgical procedure. - Postoperative Phase: The period following surgery until recovery is complete.
Purposes of Surgery: Surgical interventions are performed for various clinical reasons, including:
- Diagnostic: To determine the cause of symptoms or confirm a diagnosis. - Curative: To treat a condition, such as removing a cancerous tumor. - Cosmetic: To alter or enhance physical appearance. - Transplant: To replace a diseased organ or tissue.
Direct Clinical Experiences: The instructor shared personal experiences during clinical rotations and teaching: - C-Section Observation: Observed a C-section while being highly stressed after a classmate broke the sterile field. The instructor had to wipe blood off the surgeon's feet because a surgical bag broke. - Robotic Surgery: Taught clinical at Parkview Pascagoski, observing surgeons using robotic technology where techs are instructed to switch tools remotely.
Types of Surgery and Consent
Inpatient vs. Outpatient Surgery: - Ambulatory/Outpatient Surgery: These terms are used interchangeably. The patient has the procedure and is typically discharged to home on the same day. - Inpatient Surgery: The patient is admitted to the hospital and remains for a period of time post-surgery for monitoring and recovery.
Elective vs. Emergent Surgery: - Elective/Necessary: Scheduled procedures where the patient must be fully informed. - Emergent/Trauma: Life-saving procedures where consent is assumed because the patient is unable to sign papers and immediate action is required to maintain life.
Informed Consent: - Crucial for elective procedures. - The surgeon is responsible for providing the primary informed consent (explaining risks, benefits, and alternatives). - The nurse serves as the witness to the signing of the consent form, confirming the surgeon spoke with the patient and the patient agrees.
Safety: Safety remains the primary priority across all phases of perioperative care.
The Preoperative Phase (Pre-op)
Timing: Begins when the surgical procedure is scheduled (could be weeks or minutes before) and officially ends when the patient is transferred to the surgical suite.
Psychosocial and Educational Focus: Preparing the patient involves ensuring they understand the procedure, the risks, and what to expect during their recovery.
Medical History and Assessment: - Past Surgical History: Must identify previous surgeries and specific reactions to anesthesia. - Anesthesia Reactions: Document issues like coding (cardiac arrest) under anesthesia or becoming violent (post-anesthesia emergence delirium). - Medication Review: Identify all current medications and substance abuse. Street drugs can interact fatally with anesthetic agents, requiring the anesthesiologist to adjust the medication cocktail. - Pregnancy Status: Surgery is unsafe for pregnant patients unless absolutely necessary. Patients of childbearing age must have a pregnancy test (urine cup) prior to surgery. - Discharge Planning: This process begins during the pre-op phase. - Baseline Establishment: Obtain baseline vital signs and labs (sometimes done a week in advance) to identify changes during surgery. - Head-to-Toe Assessment: Includes cardiovascular, respiratory, and skin assessments. Skin assessment is vital for surgeries lasting up to $12$ hours to identify risks for pressure wounds.
Preoperative Preparation and Education
Marking the Surgical Site: The surgeon must mark the correct surgical site to prevent wrong-site surgery. Typically, this involves an "X" and the surgeon's initials. This is mandatory even if a patient is not oriented.
Dietary Restrictions (NPO): - Patients are usually NPO (nothing by mouth) starting at midnight before the surgery. - Rationale: To prevent aspiration of stomach contents while under anesthesia. - Risk Factor Example: The instructor's grandmother attempted to drink black coffee before surgery. While some surgeons allow black coffee because it is a thin liquid, substance in the coffee (like creamer) will result in immediate rescheduling of the surgery.
Bowel Preparation: For procedures like colonoscopies, patients must clear the bowels (using medication that causes frequent defecation). If the bowel is not clear, surgeons cannot visualize the colon.
Preoperative Medications: - Reglan (Metoclopramide): Given IV to decrease nausea and the risk of vomiting. - IV Tylenol (Acetaminophen): Often used in orthopedic cases to manage pain before the procedure starts. - IV Antibiotics: Given to decrease the risk of surgical site infection.
Physical Preparation: - CHG Bath/Hibiclens Shower: Patients often perform a Chlorhexidine Gluconate (CHG) bath or shower to reduce skin bacteria. - Mepilex Dressings: Frequently applied to the coccyx before surgery to prevent skin breakdown during long procedures. - Gown only: No underwear, bras, or personal clothing. Identification (ID) bands must include name, date of birth, and a separate allergy band (with specific allergies listed). - Belongings: No fingernail polish or artificial nails (to ensure cleanliness and observe nail bed color). All jewelry and piercings must be removed. Dentures, glasses, and prosthetics are typically removed, though some anesthesiologists prefer dentures stay in to help secure respiratory tubes.
Intraoperative Phase (Inter-op)
Roles in the Operating Room (OR): - Circulating Nurse: A non-sterile role. Acts as the primary patient advocate. Coordinates supplies, maintains the environment, and facilitates communication. - Scrub Nurse: A sterile role. Sets up equipment, hands instruments to the surgeon, and is responsible for the manual count of all sponges and instruments to ensure nothing is left inside the patient. - Clinical Lead: Oversees the quality and safety of surgical procedures across the facility, ensuring adherence to high-standard protocols.
Postoperative Phase (Post-op)
Phase 1: Immediate Recovery: - This occurs in the PACU (Post-Anesthesia Care Unit) or sometimes the ICU. - Nurses are ACLS (Advanced Cardiac Life Support) trained and ICU-skilled. - Nursing ratios are usually $1:1$ or $1:2$. - Monitoring: Vital signs are checked every $5$ minutes at minimum. - Blood Pressure: A significant drop in blood pressure is a primary indicator of internal bleeding. - Urinary Output: Monitored for retention. Bladder scans or straight catheterization may be used if the patient cannot urinate. - Hand-off Report: Includes types of anesthesia used, as many complications are drug-related.
Post-op Risk Factors and Complications
Smoking: Increases risks for clotting and bleeding. Also indicates potential COPD or emphysema, increasing respiratory risks.
Age: Older adults ( years) have higher rates of chronic diseases, decreased organ function, and reduced skin elasticity, making them prone to incision dehiscence (opening).
Nutrition: Poor nutrition significantly delays the healing process.
Obesity: Increases the risk of DVT (Deep Vein Thrombosis), infections, and respiratory strain due to weight on the chest. Obstructive Sleep Apnea (OSA) is a major concern when patients are flat on their backs.
Immunosuppression: Leads to increased infection rates and prolonged healing times.
Fluid and Electrolyte Balance: - Meds are hard on the kidneys; renal function must be monitored. - Electrolyte imbalances can cause seizures or cardiac complications.
Specific Complications: - PONV: Postoperative Nausea and Vomiting. Must be controlled with meds to prevent abdominal muscle strain. - PUR: Postoperative Urinary Retention. Often caused by anesthesia or recent catheter use ("lazy bladder"). - VTE: Venous Thromboembolism. Prevented by SCDs (Sequential Compression Devices) and early mobility.
Phase 2: Recovery and Maintenance
Ambulatory Phase: Monitoring frequency reduces as the patient stabilizes. - Standard Monitoring Protocol: Every minutes for the first hour, every minutes for the next hours, and then hourly.
Respiratory Maintenance: - Atelectasis: Partial or focal collapse of the lung. Prevented by using the incentive spirometer, deep breathing, and early walking to keep alveoli open. - Oxygenation: Patients may need supplemental $O_2$ to wean off anesthesia.
Cardiac Monitoring: - Notify the surgeon if blood pressure changes by (higher or lower) from the patient's baseline.
Dietary Progression: Start with liquids and gradually increase based on tolerance (juice/pizza vs. liquids).
Incision Care: - Pressure Dressings: DO NOT remove the initial pressure dressing placed by the surgeon, even if blood is visible. Monitor the drainage and wait for the surgeon to perform the first dressing change.
Malignant Hyperthermia (MH): - A life-threatening reaction to certain anesthetic agents. - Facilities maintain an "MH Cart" with specific medications (e.g., Dantrolene). - Requires manual temperature monitoring, as it is often not continuously measured via electronic monitors.
Safety Guidelines and Discharge
Coughing Restrictions: While coughing and deep breathing are generally encouraged, they are CONTRAINDICATED for patients following brain, spinal, head, neck, or eye surgeries because coughing increases intracranial and ocular pressure.
Promoting Peristalsis: Listen for bowel sounds; though they may be absent initially, hydration and mobility help them return. Patients often must pass gas or urinate before discharge.
Medication Teaching: - Narcotics side effects: Sleepiness, nausea. - Instruct patients to take pain meds with food to prevent sickness and not to overdose. - Narcan may be sent home with some patients as a safety precaution.
Home Care: Educate on handwashing, proper showering, and managing drains/catheters (some patients remove their own catheters days later).
Discharge Prerequisite: Follow-up appointments should be scheduled on the patient's calendar before they leave the hospital.
Questions & Discussion: Final Exam
Final Exam Timing: Wednesday at AM.
Exam Format: - Total points: . - The instructor is giving a -point exam on ATI and doubling the score to equal a -point weight (e.g., scoring becomes ). - Types of questions: Approximately to questions. - Select-All-That-Apply (SATA): These questions are worth more than point (some or points based on size/complexity).
Rationale: To prevent "killing the brain" with a -question test that would take too much time.