- Perioperative care: A look at perioperative care
- Preoperative care
- Perioperative care: Intraoperative care
- Perioperative care: Postoperative care
- Perioperative care: Medical-surgical unit
- Perioperative care: Postoperative complications
- Perioperative care: Discharge planning
- FURTHER READING/STUDY:
- NCLEX: Health Promotion and Maintenance
- NCLEX-RN: Medical–Surgical Nursing
- NCLEX-RN: Disaster Nursing: Bioterrorism
- NCLEX-RN: Infection Control
- NCLEX-RN: Pharmacology
- NCLEX: Obesity
- NCLEX: Immunologic disorders
- NCLEX: Reproductive system disorders
Perioperative care: A look at perioperative care
Focus topic: Perioperative care
Many technological advances have made operations quicker, safer, and more effective. Even so, surgery remains one of the most stressful experiences a patient can undergo. Before the patient enters the operating room, you must fully address his psychological and physiologic needs. If prepared properly with careful teaching, a surgical patient will experience less pain, fewer postoperative complications, and shorter hospitalization.
Careful, considerate preoperative care will help prevent future complications for the patient and ease anxiety felt by the patient and his family.
A thorough preoperative assessment helps systematically identify and correct problems before surgery and establishes a baseline for postoperative comparison. Begin by confirming the patient’s identity using two identifiers, according to your facility’s policy. Then verify the surgical procedure and surgical site with the patient. Next, focus on problem areas suggested by the patient’s history and on any body system that will be directly affected by the surgery. Consider your findings in relation to the specific age-group norms. Don’t forget to include the patient’s psychological status in your assessment because depression and anxiety can significantly interfere with recovery from surgery.
Your teaching can help the patient cope with the physical and psychological stress of surgery. Preadmission and pre operative teaching are more important than ever in these days of shorter hospital stays and same-day surgeries.
Evaluate, adapt, and consider
Evaluate the patient’s understanding and tell him what to expect before, during, and after the procedure. Adapt your teaching to fit the patient’s age, understanding, and cultural background. Also, consider the needs of the patient’s family or caregivers.
What to teach
Be sure to include these topics in your preoperative patient teaching:
- diagnostic tests
- the need to abstain from food and fluids for a period of time before surgery
- what type of anesthesia is planned, such as general, regional, or balanced
- airway management
- placement of other tubes, such as nasogastric tubes or drains
- operating room procedure
- I.V. therapy
- what to expect on the postanesthesia care unit (PACU)
- pain control
- postoperative care, including diet, mobility, and treatments.
Prepare for postop
Before surgery, teach the patient early postoperative mobility and ambulation techniques and leg exercises. In addition, teach coughing and deep-breathing exercises, including how to use an incentive spirometer. Make it clear that the patient will have to repeat these maneuvers several times after surgery.
Tell the patient that postoperative exercises help prevent such complications as:
- hypostatic pneumonia
- abdominal distention
- venous pooling.
Have the patient perform postoperative exercises to assess whether further teaching is necessary and to support the teaching plan.
To prepare the patient for surgery, you may have to perform skin and bowel preparations and administer drugs.
In most facilities, skin preparation is carried out during the intra-operative phase. However, making sure the skin is as free from microorganisms as possible reduces the risk of infection at the incision site. The patient may be asked to bathe, shower, or scrub a local skin area with an antiseptic the evening before or the morning of surgery. The surgeon will usually specify the site for a local skin scrub if indicated.
Make it big, real big
To reduce the number of microorganisms in areas near the incision site, prepare a much larger area than the expected incision site. Doing so also helps prevent contamination during surgical draping. Document skin preparation, including the area prepared and any unexpected outcomes.
The extent of bowel preparation depends on the type and site of surgery. A patient scheduled for several days of postoperative bed rest who hasn’t had a recent bowel movement may receive a mild laxative or sodium phosphate enema. On the other hand, a patient scheduled for GI, pelvic, perianal, or rectal surgery will undergo more extensive intestinal preparation.
After three, make the call
If enemas are ordered until the bowel is clear and the third enema still hasn’t removed all stool, notify the practitioner because repeated enemas may cause fluid and electrolyte imbalances. Elderly patients, children, and patients who are allowed nothing by mouth and haven’t received I.V. fluids are at particularly high risk for these imbalances.
The practitioner may order preoperative or preanesthesia drugs to:
- ease anxiety
- permit a smoother induction of anesthesia
- decrease the amount of anesthesia needed
- create amnesia for the events preceding surgery
- minimize the flow of pharyngeal and respiratory secretions
- minimize gastric secretions
- reduce the risk of infection.
Expect to administer ordered drugs 30 to 75 minutes before induction of anesthesia. Teach the patient about ordered drugs, their desired effects, and their possible adverse effects. These drugs include:
- anticholinergics (vagolytic or drying agents)
- antianxiety drugs
- opioid analgesics
- neuroleptanalgesic agents
- histamine-2 receptor antagonists
Before surgery, follow these important steps:
- Make sure the patient has had no solid food for at least 6 hours and no water for at least 2 hours before surgery.
- Make sure the chart contains all necessary information, such as signed surgical consent, diagnostic test results, health history, and physical examination. Patient allergies should be easily visible.
- Tell the patient to remove jewelry (including body piercings), makeup, and nail polish. Ask the patient to shower with antimicrobial soap, if ordered, and to perform mouth care. Warn against swallowing water.
- Instruct him to remove dentures or partial plates. Note on the chart if he has dental crowns, caps, or braces. Also have him remove contact lenses, glasses, or prostheses (such as an artificial eye). You may remove his hearing aid to make sure it doesn’t become lost. However, if the patient wishes to keep his hearing aid in place, inform operating room and PACU staff of this decision.
- Have the patient void.
- Put on a surgical cap and gown.
- Take and record vital signs.
- Make sure the informed consent form is signed by the patient or a responsible family member. If the surgical site involves a right or left distinction, multiple structures (such as fingers or toes), or multiple levels (such as the spine), the site should be marked with a permanent marker by the person doing the procedure. The site should be marked before the patient is taken to the area where the procedure will be done, and the marking should be visible after the patient is prepped and draped.
- Administer preoperative medication as ordered.
Perioperative care: Intraoperative care
Focus topic: Perioperative care
The intraoperative period begins with the transfer of the patient to the operating room bed and ends with his admission to the PACU. No matter what kind of surgery your patient needs, he’ll receive an anesthetic during this time.
To induce loss of the pain sensation, the anesthesiologist or nurse anesthetist will use some form of anesthesia.
What OR nurses do
Operating room responsibilities are divided between the scrub nurse and the circulating nurse. The scrub nurse scrubs before the operation, sets up the sterile table, prepares sutures and special equipment, and provides help to the surgeon and his assistants throughout the operation. The circulating nurse manages the operating room and monitors cleanliness, humidity, lighting, and safety of equipment. She also coordinates activities of operating room personnel, monitors aseptic practices, assists in monitoring the patient, and acts as a patient safety advocate.
Other nursing responsibilities during the intraoperative period may include positioning the patient, preparing the incision site, draping the patient, and documenting information (such as surgical team information, assessment, the care and handling of specimens, and the count sheet).
Time out for safety
Just before the procedure begins, the entire operative team stops and performs a final verification of the correct patient, procedure, and surgical site. Called a time out, this final step helps prevent serious errors from occurring.
Perioperative care: Postoperative care
Focus topic: Perioperative care
The patient’s recovery from the anesthesia is monitored in the PACU. His ongoing recovery is managed on either an intensive care unit (ICU) or medical-surgical unit. The postoperative period extends from the time the patient leaves the operating room until the last follow-up visit with the surgeon.
What the PACU nurse does
The postoperative period begins when the patient arrives in the PACU, accompanied by the anesthesiologist or nurse- anesthetist. The PACU nurse’s main goal is to meet the patient’s physical and emotional needs, thereby minimizing the development of postoperative complications. Such factors as pain, lack of oxygen, and sudden movement may threaten his physiologic equilibrium. Thanks to the use of short-acting anesthetics, the average PACU stay lasts less than 1 hour. The patient is assessed every 10 to 15 minutes initially and then as his condition warrants.
Whether the patient is discharged from the PACU to the medicalsurgical unit, the ICU, or to the short-procedure unit, safety remains the major consideration. The patient should:
- demonstrate quiet and unlabored respirations
- be awake or easily aroused to answer simple questions
- have stable vital signs with a patent airway and spontaneous respirations
- have a gag reflex
- feel minimal pain
- have return of movement and partial return of sensation to all anesthetized areas if a regional anesthetic was administered.
If the patient had major surgery or has a concurrent serious illness or if complications occurred during or immediately after surgery, he may be discharged to the ICU. Appropriate documentation should accompany the patient on discharge, according to facility policy.
Perioperative care: Medical-surgical unit
Focus topic: Perioperative care
When assessing the patient after he returns to the medical-surgical unit, be systematic yet sensitive to his needs. Compare your findings with intraoperative and preoperative assessment findings, and report significant changes immediately.
Have a system
Follow a systematic approach to your physical assessment in order to make easier comparisons. Facilities typically have protocols for assessing patients postoperatively. Some facilities require assessments every 15 minutes until the patient stabilizes, every hour for the next 4 hours, and then every 4 hours after that.
Assessing postoperative status
Pay special attention to the patient’s breathing. Make sure the patient has a patent airway and check his respiratory rate, rhythm, and depth. Additional assessment measures include:
- assessing the patient’s level of consciousness by testing his ability to follow commands
- observing for tracheal deviation from the midline
- noting chest symmetry, lung expansion, or use of accessory muscles
- obtaining the patient’s blood pressure (systolic pressure shouldn’t vary more than 15% from the preoperative reading except in patients who experience preoperative hypotension)
- taking the patient’s apical pulse rate for 1 minute and assessing the rate and quality of radial and pedal pulses, noting any dependent edema
- taking the patient’s temperature, which may be low (due to slowing of basal metabolism associated with anesthesia or to the cold operating room or I.V. solution) or high (due to the body’s response to the trauma of surgery).
Encourage deep breathing to promote elimination of the anesthetic and optimal gas exchange and acid-base balance.
Encourage coughing if the patient has secretions. Excessive sedation from analgesics or a general anesthetic can cause respiratory depression. Respiratory depression can also occur if reversal agents wear off.
Examining the surgical wound
When examining the surgical wound, follow the practitioner’s orders. Don’t remove dressings from a surgical wound without permission. Some dressings provide pressure to the wound; others keep skin grafts intact. If the dressing is stained by drainage, estimate the quantity and note its color and odor. Reinforce wet dressings with additional sterile dressings. If the patient has a drainage device, record the amount and color of drainage. Make sure the device is secure and free from kinks. If the patient has an ileostomy or colostomy, describe output. If the wound isn’t dressed, note the wound’s location and describe its length, width, and type (horizontal, transverse, or puncture). Describe the sutures, staples, or adhesive strips used to close the wound and assess approximation of wound edges.
Assessing the abdomen
When assessing the abdomen, first observe for changes in abdominal contour. Abdominal dressings, tubes, or other devices may distort this contour. To detect asymmetry, view the abdomen from the foot of the patient’s bed. Also, observe for Cullen’s sign, a bluish hue around the umbilicus that commonly accompanies intra-abdominal or peritoneal bleeding.
Auscultate bowel sounds for at least 1 minute in each of the four quadrants. You probably won’t be able to detect bowel sounds for 6 hours or more after surgery because general anesthetics slow peristalsis. If the surgeon handled the patient’s intestines during surgery, bowel sounds will be absent even longer.
If the patient has a nasogastric tube, regularly check its patency. Confirm proper tube placement by checking the pH of gastric aspirate (normal pH is from 1 to 4), or by X-ray. Document findings for a baseline assessment and for future reference.
The postsurgical patient may be unable to assume a comfortable position because of incisional pain, activity restrictions, immobilization devices, or an array of tubes and monitoring lines. Assess the patient’s pain by having him rate his pain on a scale of 0 to 10 (with 0 being no pain and 10 being the worst pain imaginable) and offer analgesics as ordered. Although most patients will tell you when they experience severe pain, some may suffer silently. Increased pulse rate and blood pressure may provide the only clues to their condition.
Support, promote, and discuss
Although emotional support can do much to relieve pain, it doesn’t replace adequate analgesia. Physical measures, such as positioning, back rubs, and creating a comfortable environment in the patient’s room, can also promote comfort and enhance the effectiveness of analgesics. Discuss specific measures the patient can take to prevent or reduce incisional pain.Encourage the patient to request analgesics or use patient-controlled analgesia before pain is severe.
Recording intake and output
Measure postoperative intake of food and fluids, including ice chips, I.V. fluids, blood products, and irrigation fluid. Measure postoperative output of urine, tube drainage, and wound drainage.
Acting like an adult
An adult should have a minimum urine output of 0.5 to 1 ml/kg/ hour. Report an output of less than 30 ml/hour for more than 2 consecutive hours. After surgery, the patient may have difficulty voiding; this occurs when medications, such as atropine, depress parasympathetic stimulation. In order to assess for catheterization, monitor the patient’s intake and palpate his bladder or use a bladder scanner regularly. Because some anesthetics slow peristalsis, the patient may not defecate until his bowel sounds return.
When documenting output, note the source of output; its quantity, color, and consistency; and the duration over which the output occurred. Notify the practitioner of significant changes, such as a change in the color and consistency of nasogastric contents from dark green to “coffee grounds” or a larger volume of output than expected.
Perioperative care: Postoperative complications
Focus topic: Perioperative care
After surgery, take steps to avoid complications. Be ready to recognize and manage them if they occur.
Reducing the risk of complications
To avoid extending the patient’s hospital stay and to speed his recovery, perform these measures to prevent postoperative complications.
Turn and reposition the patient
Turn and reposition the patient every 2 hours to promote circulation and reduce the risk of skin breakdown, especially over bony prominences. When the patient is in a lateral recumbent position, tuck pillows under bony prominences to reduce friction and promote comfort. Each time you turn the patient, carefully inspect the skin to detect redness or other signs of breakdown.
Don’t turn ’em all
Keep in mind that turning and repositioning may be contraindicated in some patients such as those who have undergone neurologic or musculoskeletal surgery that demands immobilization postoperatively.
Encourage coughing and deep breathing
Deep breathing promotes lung expansion, which helps clear anesthetics from the body. Coughing and deep breathing also lower the risk of pulmonary and fat emboli and of hypostatic pneumonia associated with secretion buildup in the airways.
Encourage the patient to deep-breathe and cough every hour while he’s awake. (Deep breathing doesn’t increase intracranial pressure.) Also, show him how to use an incentive spirometer.
Monitor nutrition and fluids
Adequate nutrition and fluid intake is essential to ensure proper hydration, promote healing, and provide energy to match the increased basal metabolism associated with surgery. If the patient has a protein deficiency or compromised immune function preoperatively, expect to deliver supplemental protein via parenteral nutrition to promote healing. If he has renal failure, this treatment would be contraindicated because his inability to break down protein could lead to dangerously high blood urea nitrogen levels.
Promote exercise and ambulation
Early postoperative exercise and ambulation can significantly reduce the risk of thromboembolism. They can also improve ventilation and brighten the patient’s outlook.
Passive, okay; active, better
Perform passive range-of-motion (ROM) exercises better yet, encourage active ROM exercises to prevent joint contractures and muscle atrophy and to promote circulation. These exercises can also help you assess the patient’s strength and tolerance.
Before encouraging ambulation, have the patient sit and dangle his legs over the side of the bed and perform deep-breathing exercises. How well the patient tolerates this step is usually a key predictor of out-of-bed tolerance. Document frequency of movement, the patient’s tolerance, use of analgesics, and any other relevant information.
Detecting and managing complications
Despite your best efforts, complications sometimes occur. These may include atelectasis, pneumonia, and pulmo nary embolism and thrombophlebitis. By knowing how to recognize and manage them, you can limit their effects.
Perioperative care: Discharge planning
Focus topic: Perioperative care
Begin planning for the patient’s discharge at your first contact with him. Include his family or other caregivers in your planning to ensure proper home care. The discharge plan should include:
- home care procedures and referrals
- potential complications
- return appointments.
Recognizing potential problems early on will help your discharge plan succeed. The initial nursing history and preoperative assessment as well as subsequent assessments can provide useful information. Tailor the contents of your plan to the patient’s individual needs. Assess the strengths and limitations of the patient and his family. Consider several factors, including:
- physiologic factors — general physical and functional abilities, current medications, and general nutritional status
- psychological factors — self-concept, motivation, and learning abilities
- social factors — duration of care needed, types of services available, and family involvement in the patient’s care.
Can I get that in writing?
Provide written materials as a reference for the patient at home. Assess your patient’s reading and comprehension level and always make sure that readings are reinforced by personal teaching. Include information on these topics:
- Medications—Teach the patient the purpose of drug therapy, proper dosages and routes, special instructions, potential adverse effects, and when to notify the practitioner. Try to establish a medication schedule that fits in with the patient’s lifestyle.
- Diet—Teach the patient and, if appropriate, the family member or caregiver who will prepare his meals. Refer the patient to a dietitian i f appropriate.
- Activity—After surgery, the patient is commonly advised not to lift a heavy weight such as a basket of laundry. Restrictions usually last 4 to 6 weeks after surgery. Let him know when he can return to work, drive, and resume sexual activity.
- Home care procedures—After the patient watches you demonstrate a procedure, have him (or his caregiver) perform a return demonstration. If the patient needs to rent or purchase special equipment, such as a hospital bed or walker, give him a list of suppliers in the area.
- Wound care—Teach the patient about changing his wound dressing. Tell him to keep the incision clean and dry, and teach proper hand-washing technique.
- Potential complications—Make sure the patient can recognize signs and symptoms of wound infection and other potential complications, and provide this information in writing. Advise the patient to call the practitioner with any questions.
- Return appointments—Stress the importance of the follow-up appointment in your teaching, and make sure the patient has the practitioner’s office telephone number. If the patient has no means of transportation, refer him to an appropriate community resource.
- Referrals—Reassess whether the patient needs referral to a home care agency or other community resource. In some hospitals, the responsibility for making referrals falls to a home care coordinator, discharge planning nurse, or case manager.