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• Surgical procedures serve various purposes with associated common terms.

Types of Surgery:

• Emergency surgery is performed immediately to save a patient's life, limb, or function.
• Urgent surgery is done within 24 to 48 hours to prevent permanent injury or death.
• Elective surgery is necessary but can be planned around the patient's and surgeon's schedule.
• Ambulatory (outpatient) surgery is typically performed in one day. The patient are admitted to the ambulatory surgical center (ASC) in the morning and discharged after meeting acceptable recovery criteria.
• Exploratory (diagnostic) surgery is performed to obtain a diagnosis and possible resolution.
• Ablative surgery removes tissue from an organ or area of the body.
• Palliative surgery decreases pain or symptoms in patients with incurable illnesses.
• Reconstructive surgery restores function or corrects a defect.
• Cosmetic surgery changes or revises an area or structure of the body.
• Minimally invasive surgery uses small skin openings and instruments for surgeon visualization, such as a laparoscope.
• Telesurgery or robotic surgery is done from a location other than the surgical suite, using robotic equipment.

Phases

• The operative experience is broken into three phases: preoperative, intraoperative, and postoperative.
• The preoperative phase is the patient’s first impression of the surgical setting.
• The preoperative phase starts with the decision for surgery and ends with patient transfer to the surgical suite.
• During the preoperative phase, nurses take on roles as educators, advocates, and admittance personnel.
• A nurse's main job is completing a preoperative checklist, ensuring necessary documentation, assessments, physical preparation, and education are done before the patient enters the surgical suite.
• Preoperative measures include obtaining a full medical history, including prescription, over-the-counter, herbal, and alternative therapies.
• Assessment of the patient’s health status, collection of information and paperwork needed for intraoperative and postoperative care are key.
• Also include completion of preoperative orders and patient education about the entire surgical process.
• It is key to verify that the patient and a witness have signed informed consent. "Time-out" is initiated to verify the following details, and take a "pause for cause":
• Correct information on the identification band.
• The name of the surgeon.
• The planned procedure.
• The correct side of the body for unilateral procedures before surgery.
• These interventions identify potential issues and ensure procedures are performed safely and on time.

Informed Consent

• Informed consent involves the patient autonomously and cognitively granting permission to a provider to perform surgery after considering all alternatives, benefits, and risks.
• Obtaining consent is the provider's role, while nurses ensure patients have all necessary information to make an informed decision.
• Nurse's role is also to identify and correct any educational shortcomings.
• Patients have the right to refuse surgical intervention.

Components

• Consents include name of surgery, type, and reason, surgeon's name, rationale for intervention, alternatives, and potential outcomes without surgery.
• Consent for anesthesia and blood product administration is required.
• Administering blood products requires consent, and patients can refuse based on cultural or religious beliefs.
• Refusal is documented in the patient's chart, and the patient is identified with a "no blood products" bracelet and sign.
• Blood can be given without consent only in emergencies where the patient lacks capacity.

Inability to Consent

• Special considerations are needed when patients cannot consent, like in cases of cognitive impairment, inability to physically sign, deafness, language differences, minority, or emergency situations.
• Patients who can’t physically sign may use an “x,” which needs witnessing by two people.
• Hospital interpreters are preferred over family members in cases where there is language barrier.
• Surgical consent for a minor can be signed by a legal guardian.
• A verbal consent is acceptable in emergency situations, followed by written consent.
• If patients are incapable of giving consent, two providers document the need for surgery.

Advance Directives

• The Patient Self-Determination Act of 1991 grants patients the right to determine and direct their care during medical emergencies via advance directives.
• Advance directives define a patient's wishes if they become incompetent.
• Facilities must provide the means to complete an advance directive if desired.
• Patients can name a durable medical power of attorney to make medical decisions if they become incompetent. Advance directives can also express desires regarding organ donation and end-of-life issues.
• Living wills define care in cases of cardiac or respiratory failure, documenting choices like "do not intubate" (DNI) or "do not resuscitate" (DNR).
• Nurses should document advance directives and living wills in the chart, with copies of these documents present.

Obtaining Informed Consent:

• Surgeons are responsible for obtaining consent with a witness, before administering medications and sedatives that could alter the patient’s ability to make an informed decision.
• The surgeon makes sure that all of the patient's and family's questions are answered.
• A preoperative nurse clarifies information, corrects misunderstandings, and eases patient concerns.
• Nurses witness only the physical signature, ensuring the witness is present during signing and documenting the signed consent in the patient's chart.

Time Outs

• Wrong-site procedures are documented events which need improvement.
• Time-outs involve identification by the patient and healthcare team to ensure correct patient, procedure, and surgical site.
• A time-out starts upon the patient's admission to the surgical facility.
• Patients receive a wristband which needs reviewing to confirm that the information is correct before moving them to the surgical suite.
• Nurses review wristband information with any patient, and confirms procedure and site.
• This information is confirmed again by the circulating nurse before the patient is moved to the surgical suite.

Patient Assessment

• Surgical patients require a detailed medical history and assessment ensure safe surgery.
• Preoperative nurses obtain and document this history as the patient is admitted.
• The nurse helps the patient by ensuring a safe outcome comes from any answers that aren’t judged with a medical purpose only.
• It is key to include the patient's age, allergies (particularly to latex), current medications, medical history, surgical history, anesthesia experiences, last oral intake, implants/devices, piercings, dental implants, nutrition deficiencies and family/social history, etc.
• The patient’s age should be taken into consideration because patients 65 or older have issues that interfere with a positive surgical outcome.

Geriatric Considerations

• Polypharmacy requires consideration due to potential medication interactions.
• Cardiac status needs verification through preoperative ECG and monitoring to establish a baseline.
• Respiratory status includes assessing breathing difficulties and establishing baseline oxygen saturation.
• Cognitive and sensory assessment determines the patient’s understanding of risks and ability to follow instructions.
• Nurses need to assess muscular function and fall risk, especially after anesthesia and pain medications. Skin assessment is also needed because older patients often have decreased adipose tissue and epidermis changes, increasing risk of hypothermia, shearing, and delayed healing.
• Nutritional status assessment prevents dehydration, and the lab studies help determine renal/hepatic function.
• Any chronic conditions needs documenting, along with level of support, and who will be responsible for helping when the patient returns home.
• Nurses need to note conditions that have risks during surgery, plus any surgeries that leave scar tissue, internal adhesions, or medical implants which need considering.
• Nurses ask about types of surgery, year, indication, incision healing, and type of anesthesia used.

Allergies

• All allergies must be documented to ensure patient safety.
• Patients receive an alert bracelet.
• If patients are allergic to Betadine or chlorhexidine, an alternative skin preparation is chosen.
• It is key that facilities have adequate latex-free equipment, and latex allergen patients be first cases of the day.

Medications

• It is key to get current medications because antihypertensives, anticoagulants, and antiarrhythmics can impact operating room care.
• Herbal remedies and "over the counter" options may have potential interactions with medications which could be used or increase risk of bleeding.

Last Oral Intake

• Last oral intake must be determined before anesthesia.
• Ideally, patients undergoing surgery should not eat or drink at least 8 hours before. The nurse documents the last oral intake. Patients like those with diabetes mellitus may have altered orders. Recent guidelines advise fasting of 6 to 8 hours for solid foods and 2 hours for clear liquids for elective procedures.
• No solid food is allowed for 8 hours before surgery, infant formula can be given up to 6 hours before, breast milk up to 4 hours before, and clear liquids up to 2 hours before surgery.
• Smoking puts patients at risk for respiratory depression and DVT during postoperative care.
• Smoking may also increase healing time.

Patient History

• Social questions like those based on abuse and mental illness are asked with no family member or support person present.
• Any different medical information gets addressed.

Physical Assessment:

• A physical assessment parameters include height and weight, vital signs, and systems assessment.

Height and Weight

• Height and weight assist the anesthesia provider in determining fluid needs and medication dosages.

Vital Signs

• Vital signs includes blood pressure, respirations, pulse, temperature, and pulse oximetry, and are obtained during the initial assessment.
• Another admission question, acceptable pain scores are asked.

Systems Assessment

• During the initial session, the nurse performs a physical assessment.
• Peripheral pulses, color, skin turgor, capillary refill, temperature, and edema are all important factors for assessment.
• The nurse auscultates the heart for rhythm, rate, and murmurs.
• The nurse assess the patient's breath pattern to see if their breathing rate, depth, rhythm, and other adventitious breath sounds like crackles, rhonchi, or wheezing or not.
• Neurological needs assessing the ability to understand commands is important before anesthesia induction.

Liver/Renal Assessment

• It's crucial for potential renal or liver disease to need noting in the surgical patient.

• The effects of anesthesia and different medications must be documented as it is used before, during, and after an operation.

• The nurse should document any devices noted for urinary elimination.

• Preoperative lab work helps to properly to determine the patient’s readiness to perform and have and blood work done correctly.

• A complete metabolic panel provides blood analysis.

• Labs show how quickly a patient's blood clots after an injury that may have occurred due to and if there is bleeding abnormalities.

• Deviation alerts the surgeon.

Radiological Assessment

• Radiological imaging before any surgery.
• If any imaging tools are required, the tools have been selected and provided to surgeons appropriately on time.

Patient Teaching

• Patient education helps decrease patient’s anxiety which helps prevent future issues.
• The patient’s family members should be included for guidance during discussions.
• Patient can fatigue or be drowsy after a procedure.
• IV’s must be clear and administered correctly.
• Nonpharmacological interventions such as aromatherapy video distractions, music, and preoperative warming may occur.

Preparations

• An IV is used for anesthesia and administers fluids.
• Bowel preperations is a consultation.
• Skin prep is to also prepare the surgical site.
• Patients may need to shower to wash properly at surgical sites.

Medications

• Preoperative medications might be needed.
• For example patients may receive something for preoperative anxiety.

Transfer

• Nurses should ensure patient has completed all paper work; assessments, vital signs, learning needs, skin and bowel cleaning, and preoperative medication has been completed.

Final nurse notes

• Patient identification physical check completion.
• Complete medical paper work with a good set of vital signs.
• Allergy bracelet is good.
• Educate patient on the known details. Ensure all questions have been answered.
• Nurses must access and preform proper vitals and oxygen checks. Ensure proper documentation is in chart through any exams that are performed.
• Ensure to prep skin and bowel.
• Ensure complete tasks are completed.
• Help patients manage pain.
• Know what they can do prevent future issues. Have a way to keep external stimuli like heat, ice and the timing of the medicating, if applicable.