Comprehensive Perioperative Nursing: Pre-operative and Safety Protocols
Focus of Perioperative Nursing
Scope of Practice: While intraoperative nursing is considered a highly specialized field, the primary focus for general nursing education is on the pre-operative (pre-op) and post-operative (post-op) phases.
Pre-operative Nursing Objectives:
Gathering comprehensive data to determine if the patient is physically and mentally ready for surgery.
Establishing a clinical baseline.
Post-operative Nursing Objectives:
Maintaining life and monitoring the ABCs (Airway, Breathing, Circulation) as the patient recovers from anesthesia.
Identifying and managing complications that arise specifically due to the surgical intervention.
Surgical Care Improvement Project (SCIP) Protocol
Purpose: Created years ago to reduce surgical complications and improve safety by looking at common themes in patient trends (infections, blood clots, etc.).
Infection Prevention:
Prophylactic Antibiotics: All surgical patients now receive an intravenous (IV) antibiotic exactly before surgery begins to lower the rise of surgical site infections.
Urinary Catheter Management:
Catheter-Associated Urinary Tract Infection (CAUTI): Statistics show that within of having a Foley catheter inserted, of patients will develop a UTI.
Financial Implications: Hospitals are responsible for the costs associated with UTIs developed within the facility; insurance and government programs often refuse to pay for these hospital-acquired conditions.
Nurse Responsibility: Remove the Foley catheter ASAP (As Soon As Possible). This may occur on the day of surgery or the following morning to encourage mobility and decrease infection risk.
Venous Thromboembolism (VTE) Prophylaxis:
Also known as Deep Vein Thrombosis (DVT) prevention.
Preventative Measures:
Sequential Compression Devices (SCDs).
TED hose (compression stockings).
Early ambulation (moving the patient out of bed as soon as possible after surgery).
Phases and Categories of Surgery
Three Phases of Perioperative Care:
Pre-operative Phase: Begins when the decision for surgery is made and ends when the patient is wheeled into the Operating Room (OR). This phase can last from hours to weeks.
Intra-operative Phase: Spans the time the patient is in the OR through their transfer to the Post-Anesthesia Care Unit (PACU).
Post-operative Phase: Starts in the PACU and continues until the patient is discharged home or fully recovered. This phase is becoming shorter due to the rise of same-day surgery centers.
Categories of Urgency:
Emergent: Requires immediate intervention to save life or limb. Examples include severe bleeding, major burns, or life-threatening injuries.
Urgent: Required within the next to to prevent complications like sepsis. Notably, kidney or ureteral stones are considered urgent/emergent if they block urine outflow, as waste must be excreted.
Elective: Surgery should be performed, but timing is not critical to survival (e.g., scar repair, joint repairs).
Optional: Surgery based solely on patient preference, such as cosmetic procedures.
Pre-operative Risk Factors and Assessment
Medication History:
Anticoagulants and NSAIDs: These increase bleeding risk. Patients must typically stop taking NSAIDs at least to prior to surgery.
Steroids: Chronic steroid use (common in asthma or COPD patients) suppresses the immune system, leading to delayed wound healing and increased infection risk.
Age-Related Risks (The Elderly):
Increased risk for post-operative confusion and delirium.
Anesthesia takes longer to clear from their system, leading to slower recovery times.
Allergy Assessment:
Latex Allergy: Patients with food allergies to kiwi, avocado, or bananas are at a high risk for cross-reactive latex allergies.
Penicillin: Assessment of antibiotic allergies is mandatory.
Physical and Social Factors:
Obesity: Places extra strain on the heart and respiratory system; increased risk for dehiscence (surgical wound opening) and infection.
Malnutrition: Lack of nutrients prevents proper tissue repair and healing.
Smoking: Causes vasoconstriction, which impairs wound healing and compromises lung function, making it harder to clear anesthesia.
Alcohol and Drug Use: Impacts how the patient reacts to anesthesia and pain medication.
Chronic Health History: Conditions like Diabetes (impairs healing), Heart Disease, and Autoimmune disorders must be documented.
Diagnostic Baseline and Laboratory Evaluation
Fluid and Electrolyte Status: Abnormal levels must be corrected before surgery.
Renal Function (BUN and Creatinine): Critical because kidneys are responsible for excreting anesthesia and other surgical medications.
Liver Function: Necessary for metabolizing medications.
Coagulation Studies: PT and INR to check bleeding and clotting times.
Complete Blood Count (CBC):
White Blood Cell (WBC) Count: If elevated, surgery is cancelled due to active infection.
Hemoglobin and Hematocrit (H&H): If too low (anemia), the patient may require a blood transfusion prior to the procedure.
Imaging and Cardiac Testing:
ECG/EKG: Typically required for any patient over the age of .
Chest X-Ray: Nearly universal requirement for surgical clearance to check lung status.
Pulmonary Function Tests: Required for patients with history of COPD or asthma.
Malignant Hyperthermia
Definition: A rare, life-threatening, often genetic "allergy" or reaction to certain anesthetic gases.
Risk Factors: Documented family history and patients with bulky muscles.
Nursing Role: Monitor if the patient has ever had a previous bad reaction to anesthesia. This is a critical screening question during the pre-op phase.
Outcome: If undetected, it can be fatal. If a risk is identified, the anesthesiologist will use alternative medications.
Legal and Ethical Mandates: Informed Consent
Requirements: Consent must be voluntary, obtained from a patient of sound mind, and not under the influence of mind-altering medications.
MD Responsibility: The surgeon must explain the procedure, risks, and benefits. Nurses do not explain surgical procedures because they are not performing them. If a patient does not understand, the nurse must call the MD back to re-explain.
Nurse Responsibility: The nurse witnesses the signature, confirming the patient is signing of their own free will and understands the doctor's explanation.
Special Signature Circumstances (Requiring Two Nurse Witnesses):
Use of an interpreter (to verify the interpreter relayed the surgeon's words).
Patient signs with an "X" (due to illiteracy).
Telephone/Phone consent from a legal guardian or family member in an emergency.
Pre-operative Nursing Interventions and Teaching
Discharge Planning: Begins in the pre-op phase. Nurses must identify if the patient has support at home (e.g., someone to drive them, help with stairs, or pick up meds).
Patient Teaching (To reduce anxiety and complications):
NPO Status: Ensuring the patient has nothing by mouth to prevent aspiration during anesthesia.
Incentive Spirometer (IS): Demonstrating use before surgery so the patient knows how to use it afterward.
Turn, Cough, Deep Breathe (TCDB): Teaching respiratory hygiene.
Splinting: Showing how to hold a pillow against an abdominal incision when coughing.
Safety: Requiring two patient identifiers (Name/DOB).
Pre-operative Medications (The "Cocktail"):
Benzodiazepines (e.g., Midazolam/Alprazolam): To reduce anxiety ("Lambs are soft and cuddly").
Narcotics (e.g., Morphine): For pain management.
Anticholinergics: To dry up oral secretions and prevent aspiration.
GI Acid Reducers: To prevent nausea/vomiting.
Safety Protocol Post-Medication: Once pre-op sedatives are administered, the patient cannot get out of bed. Side rails should be up and the call light within reach. Consent must be signed before these medications are given.
Surgical Site Marking: The surgeon must mark the surgical site (often with the patient's involvement) to prevent wrong-site surgery. This is not a nursing task.