Peri-Operative Nursing Review

Peri-Operative Nursing Overview

1. Course Information

  • NURS3212: Peri-Operative Nursing

  • Resource: Brunner & Suddarth's Medical Surgical Nursing

2. Perioperative Phases of the Surgical Experience
A. Three Phases

  • Preoperative Phase:

    • Begins with the decision to have surgery.

    • Ends when the client is transferred onto the operating room (OR) table.

  • Intraoperative Phase:

    • Begins when the client is transferred onto the OR table.

    • Ends with the admission to the Post-Anesthesia Care Unit (PACU).

  • Postoperative Phase:

    • Begins with admission into the PACU.

    • Ends with follow-up evaluation in a clinical setting or at home.

3. Classifications of Operations
A. Type of Operations

  • Diagnostic:

    • Examples: biopsy, laparotomy, laparoscopy.

  • Curative:

    • Examples: excision of a tumor, appendectomy.

  • Reparative:

    • Examples: hernia repair, wound repair.

  • Reconstructive or Cosmetic:

    • Examples: facelift, breast augmentation.

  • Palliative:

    • Examples: gallbladder removal, tumor debulking.

  • Rehabilitative:

    • Example: joint replacement.

B. Purpose and Urgency

  • Emergent:

    • Examples: gunshot wounds, bladder obstructions.

  • Urgent:

    • Requires surgery within 24 to 48 hours to preserve or prevent health issues.

    • Examples: kidney stones.

  • Required:

    • Surgery is needed within weeks to months.

    • Examples: cataracts, thyroid disorders.

  • Elective:

    • Examples: repairing a simple hernia to improve health.

  • Optional:

    • Example: cosmetic surgeries.

  • Degree of Risk:

    • Classifications include major or minor risk procedures.

4. Pre-operative Phase of Care
A. Chart 17-1: Activities

  • Conduct pre-admission testing and preoperative assessments.

  • Ensure completion of preoperative diagnostics.

  • Verify and complete preoperative orders.

  • Begin discharge planning by assessing needs for postoperative care.

  • Admission to surgical center includes:

    • Completing preoperative assessments.

    • Assessing risks for complications.

    • Verifying surgical consent.

    • Reinforcing or coordinating teaching.

    • Admission to the holding area includes:

    • Identifying the client.

    • Assessing baseline pain, vital signs (VS), nutritional status.

    • Reviewing the medical record and identifying the surgical site.

    • Starting IV and administering preoperative medications.

    • Supporting the patient and family.

5. Physiological and Psychological Considerations
A. Gerontological Considerations

  • Physiological Factors:

    • Comorbidities with lower physiological reserves.

    • Renal, hepatic, and gastrointestinal functions may be depressed.

    • Skin is fragile and easily abraded.

    • Decreased muscle mass necessitates lower drug doses.

    • Decreased subcutaneous fat increases hypothermia risk.

    • Altered response to stress of surgery and medication effects.

    • Prolonged healing times.

  • Psychosocial Factors:

    • Surgery can affect coping patterns and induce stress.

    • Assess fears and concerns to alleviate anxiety.

    • Therapeutic communication, e.g., “Tell me about your fears.”

6. Nursing Management
A. Assessment

  • Identify risk factors for postoperative complications and recovery hindrances.

    • Surgical and anesthetic history.

    • Genetic complications such as malignant hyperthermia.

B. Components of Assessment

  • Baseline vital signs, allergies, and pain levels.

  • Laboratory reviews.

  • Nutritional and fluid status:

    • Obesity:

    • More susceptible to infections and wound dehiscence.

    • Increased cardiac demands and respiratory complications.

    • Malnutrition:

    • Should be corrected pre-surgery for optimal healing.

    • Increased risk of hypothermia.

    • Dehydration:

    • Monitor for hypovolemia and electrolyte imbalances.

  • Dentition status.

  • Drug or alcohol abuse history, including potential withdrawal symptoms.

  • Sensory assessment including hearing aids and contact lenses.

  • Respiratory status:

    • Educate on deep breathing and incentive spirometry (IS).

    • Assess for underlying respiratory diseases (e.g., COPD, asthma).

    • Recommend cessation of smoking 4 to 8 weeks pre-surgery.

  • Cardiovascular status:

    • Assess for conditions like CAD, CHF, hypertension, and hemorrhagic disorders.

    • Manage oxygenation and fluid status appropriately.

  • Hepatic and renal function:

    • Importance of liver function tests for medication metabolism.

    • Renal function impacts anesthetic medication excretion.

  • Endocrine health:

    • Diabetes management for pre-, intra-, and postoperative phases.

    • Monitor for thyroid issues and corticosteroid use history.

  • Immune status:

    • Assess allergies and immunocompromised conditions.

    • Be culturally sensitive during assessments.

C. Documentation of Medications

  • Include all medications, even over-the-counter (OTC) and herbal supplements.

  • Special considerations for certain medications include:

    • Corticosteroids: must taper off gradually.

    • Diuretics: can cause respiratory depression.

    • Insulin: may interact with anesthetic drugs.

    • Aspirin: should be stopped 7 days before surgery.

    • Warfarin: increases bleeding risk.

    • Opioids: may alter responses to analgesics.

D. Patient Risk Assessment

  • Evaluate pre-existing diseases that may complicate surgery (e.g., COPD, diabetes, renal failure).

  • Mental and psychological assessment to identify support systems and any disabilities.

  • Identify individuals at highest risk based on existing health conditions.

7. Nursing Diagnoses
A. Common Diagnoses

  • Knowledge deficit

  • Anxiety

  • Risk for infection

  • Pain management requirements

8. Planning and Implementation
A. Preoperative Interventions

  • Nutrition:

    • Typically NPO (nothing by mouth) 6-8 hours prior to surgery.

  • Elimination and Hygiene:

    • Ensure personal hygiene and manage belongings (e.g., valuables, prosthetics).

B. Psychological Preparedness

  • Reduce anxiety and fear. Respect cultural and religious beliefs.

  • Provide instruction on behaviors such as turning, coughing, deep breathing, and pain management techniques (e.g., TCDB, IS).

C. Proactive Respiratory Care

  • Encourage patient mobility, deep breathing, and pain management postoperatively.

9. Evaluation and Documentation
A. Informed Consent

  • The patient's voluntary and written agreement to undergo surgery.

  • Legal requirement; clarification can be provided by the nurse but ultimate responsibility lies with the surgeon.

  • Must be signed before administering preoperative medications.

  • In emergencies, consent may be obtained via phone or court order as per state laws.

B. Surgical Checklist

  • Ensure protocols such as "time-out" procedures to verify patient identity and surgical site, especially in case of discrepancies.

10. Preoperative Patient Teaching
A. Focus Areas

  • Techniques for deep breathing and coughing.

  • Relaxation methods.

  • Turn and active body movement guidance.

  • Pain control measures and medication education.

11. Intraoperative Phase Overview
A. Team Environment

  • Importance of sterile practices and protocols during the operation.

  • Types of attire: unrestricted (street clothes), semi-restricted (scrub clothes), and restricted (surgical attire and masks).

B. Patient Positioning

  • Positioning depends on the surgical procedure and must avoid pressure point injuries.

  • Various positions include:

    • Laparotomy position

    • Trendelenburg position (note padding to prevent brachial plexus injury).

    • Lithotomy position.

    • Patient on unaffected side for procedures on the kidneys.

C. Roles in the OR Team

  • Anesthesiologist and Nurse Anesthetist: Monitor vital signs and respiratory status.

  • Circulating Nurse: Coordinates care and oversees the surgical environment.

  • Scrub Nurse: Provides sterile instruments to the surgeon.

  • Surgeon: Conducts the surgical procedure.

  • All roles require identification of the patient before commencing surgery.

12. Anesthesia Overview
A. Types

  • General Anesthesia:

    • Depresses the central nervous system (CNS) for a non-arousable state in response to painful stimuli.

    • Requires assistance for airway maintenance and may impair cardiovascular function.

    • Drugs include inhalation agents (e.g., halothane, enflurane) and nitrous oxide.

  • IV Anesthesia:

    • Opioids (e.g., fentanyl) and muscle relaxants (e.g., succinylcholine) are used to induce and maintain anesthesia.

    • These agents are not explosive and minimize postoperative nausea/vomiting.

  • Regional Anesthesia:

    • Injected around nerves; patient remains awake.

    • Types include peripheral nerve blocks and spinal anesthesia.

  • Epidural Anesthesia:

    • Involves injecting anesthetic into the epidural space.

    • May lead to hypotension and respiratory depression; interventions include IV fluids and vasopressors.

B. Malignant Hyperthermia

  • A rare inherited muscle disorder chemically induced by anesthetic agents with a mortality rate significantly reduced with prompt treatment.

  • Symptoms can include muscle rigidity, hyperthermia, and cardiac complications.

  • Early signs include tachycardia and rigidity; requires immediate discontinuation of anesthesia and aggressive cooling measures.

13. Intra-Operative Client Assessment
A. Nursing Responsibilities

  • Identify any discrepancies in medical records and monitor for complications (e.g., N/V, anaphylaxis, hypoxia, hypothermia).

  • Plan to manage potential complications, focusing on reducing anxiety and maintaining patient dignity.

B. Implementation and Emotional Support

  • Provide explanations, verify details, and maintain an advocate role for the patient.

  • Assess postoperative outcomes and document all findings.

14. Surgical Asepsis
A. Principles

  • Prevents contamination of surgical wounds.

  • All materials in contact with the surgical site must be sterile.

  • Surgical attire, movement protocols, and maintaining sterile fields are crucial to aseptic practices.

15. Post-Anesthesia Care
A. Assessment

  • Baseline assessment includes airway and respiratory function, cardiovascular function, skin conditions, and awareness.

  • Requires monitoring of surgical sites, lines, and drains.

B. Nursing Interventions

  1. Assess breathing; provide supplemental oxygen if needed.

  2. Monitor vital signs, noting skin warmth, color, and moisture.

  3. Assess surgical site and all drainage systems.

  4. Evaluate level of consciousness and ability to move extremities.

  5. Manage pain effectively and provide comfort measures.

  6. Positioning to enhance safety and lung expansion.

  7. Monitor IV sites for patency.

  8. Reinforce the need for deep breathing and leg exercises.

  9. Provide adequate education to the patient and family.

16. Continuous Care Post-Operatively
A. Prevention of Complications

  • Monitor wound healing, hydration, and nutritional balance.

  • Evaluate for signs of infection or discomfort.

  • Assess urine output and facilitate early mobilization after surgery.

B. Special Considerations for Older Adults

  • Increased risk for complications; require careful monitoring and potential reorientations.

17. Home Care and Discharge Planning
A. Education for Patients and Caregivers

  • Include detailed knowledge of procedures, ongoing regimens, and how to manage potential complications.

  • Reinforce signs of complications to be aware of and schedule follow-ups.

B. Questions to Assess Understanding

  • Explore the significance of preoperative education and recognizing any complications during recovery.