Perioperative Care Overview

Perioperative Care Overview

• Perioperative care encompasses preoperative, intraoperative, and postoperative phases of surgery
• Each phase involves distinct procedures and considerations for patient safety and well-being

Preoperative Care

• Involves activities prior to surgical intervention
• Includes patient interview for health history, assessment of emotional state, and readiness for surgery
• Aims to identify and mitigate potential risk factors
• Includes obtaining informed consent
• Medical testing (CMP, CBC, PT/PTT/INR, LFTs, T&S, blood glucose, albumin, hCG, EKG, ECHO, chest x-ray)
• Preoperative teaching

Surgical Settings

• Majority of surgeries are performed as ambulatory (same-day) procedures
• Some complex procedures are done in-hospital
• Reasons for surgery include diagnosis, cure, palliative care, prevention, or cosmetic improvement

Patient Interview

• Gathering patient health information
• Clarifying information regarding surgery and anesthesia
• Assessing patient's emotional state and readiness for the procedure

Risk Factors

• Age (young or old)
• Coagulation/hemorrhages
• Obesity
• Sleep apnea and airway concerns
• Pregnancy
• Immunodeficiency
• Nutritional status (delayed wound healing)
• Fluid and electrolyte imbalances
• Negative outcomes (Sepsis, DVT, PE, PNA, Ileus, delirium, death)

Health History

• Gathering patient's past medical and surgical history
• Previous surgical complications
• Menstrual and obstetric (for women) history
• Family history of anesthesia complications
• Medication reconciliation (identifying important meds)
• Allergies
• Review of systems (head-to-toe)
• Physical assessment
• Diagnostics (substance use, drug use)

Common Preoperative Diagnostic Studies

• Complete metabolic profile (CMP)/Basic metabolic profile (BMP)
• Complete blood count (CBC)
• Prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR)
• Liver function tests (LFTs)
• Type and screen/crossmatch (T&S)
• Blood glucose
• Albumin
• Human chorionic gonadotropin (hCG)
• Electrocardiogram (EKG)
• Echocardiogram (ECHO)
• Chest radiography

Preoperative Teaching

• Improves patient satisfaction
• Reduces postoperative fear, anxiety, and stress
• Addresses patient concerns throughout surgery process
• Emphasizes safety, sensory process, and procedural knowledge

Informed Surgical Consent

• Patient understanding of diagnosis, proposed treatment, risks and complications, probability of success, alternatives, and prognosis if surgery is not successful
• Patient consent must be voluntary
• Obtained by the surgeon, witness signature by the nurse
• Medical emergency may override the need for consent if life is threatened

Preparation Day of Surgery

• Verifying informed consent
• Confirming Non-Fasting (NPO) status (with aspiration precautions)
• Vital sign measurements
• Skin preparation
• Removing prosthetics
• Administering pre-op medications (antibiotics, pain/anxiety meds)
• Safe transportation (if same-day)
• Patient marking the site for surgeons

Preoperative Preparation for People with IDD

• Using visual aid like pictures and videos to explain the process
• Tours of the OR facility
• Identifying close contacts to offer support
• Utilizing a communication aid like a PECS board or talking mat during the preparation

Informed Surgical Consent for IDD

• Evaluating cognitive capacity and adaptive skills
• Assessing patient's ability to make decisions at a particular time
• Involving individuals closest to the patient
• Identifying a surrogate if patient is unable to make a decision

Preference order for surrogate selection

• Spouse (unless separated)
• Adult child
• Parent/step-parent
• Adult sibling
• Other adult relative
• Other adult who displays care and concern for the patient

Preoperative Phase: Gerontologic Considerations

• Decreased skin elasticity
• Complications from pre-existing medical conditions
• Varying response to medications
• Decreased kidney function for waste excretion

Nursing Management: Intraoperative

• Preparation of the operating room
• Positioning the patient (after administration of anesthesia)
• Preparing surgical site (antimicrobial cleansing and draping)
• Completing a time-out and surgical checklist

Surgical Team: Registered Nurse

• Circulating Nurse (not sterile)
• Supports intraoperative procedures
• Maintains a sterile environment
• Documentation of supplies in the surgical field

Surgical Team: Surgeon

• Physician who performs the surgical procedure.
• Responsibility for surgical patient care
• Assessment of preoperative medical history
• Directs preoperative testing
• Obtaining informed consent
• Marking the surgical site
• Ensuring patient safety
• Manages postoperative care

Surgical Team: Surgeon's Assistant

• MD, RNFA, PA, Resident/fellow, medical student
• Assists the surgeon
• Holds retractors
• Helps with hemostasis and suturing
• May perform designated surgical procedures under direct supervision

Surgical Team: Anesthesia Care Provider

• Anesthesiologist or CRNA
• Administers anesthetic agents
• Manages airway, vitals and anesthesia
• Maintains physiological homeostasis throughout surgery

Anesthesia Types

• Moderate sedation (conscious sedation) includes administering anti-anxiety and pain medication and maintaining patent airway
• General anesthesia is usually a combination of gases and IV meds that cause loss of consciousness. It requires advanced airway management

Gerontologic Anesthetic Considerations

• Anesthetic drugs need careful titration due to possible impaired absorption, metabolism and excretion
• Poor communication may alter patient response to anesthesia
• Increased risk of complications from tape, electrodes, and warming/cooling blankets
• Need appropriate precautions for osteoporosis and perioperative hypothermia

Postoperative Surgical Phase: Phase 1

• Airway management: checking for stridor, cough, gag, swallowing, breathing patterns, respiratory rate, oxygen saturation(SpO2), work of breathing (WOB), and absence of apnea
• Assess vital signs (q15min or more frequently)
• Physical exam
• Neurological assessment
• Dressing assessment

Postoperative Surgical Phase: Phase 2

• Preparing patients for discharge
• Reviewing written post-op instructions, teachings, and medication instructions
• Ensuring patients/family fully understand instructions and verbalize their comprehension
• Post anesthesia recovery precautions
• Discharge instructions (driving, alcohol, activities)
• Patient discharge to responsible adult

Postoperative Assessment

• Assess vital signs and conduct focused assessment (respiratory, cardiac, wound) for potential complications.
• Examine skin integrity and wound condition for any issues
• Observe metabolic/glucose functioning
• Evaluating gastrointestinal and genitourinary functioning
• Watch for pain/comfort; encourage reporting of pain.
• Identify potential postoperative complications (airway obstruction, hypoxemia, etc.)

Common Postoperative Complications

• Airway obstruction (tongue falling back, secretions, laryngospasm, stridor)
• Hypoxemia (low SpO2)
• Atelectasis, pulmonary edema, PE, aspiration, bronchospasm
• Hypoventilation
• Pain

Postoperative Complications and Nursing Interventions

• DVT/PE: Anticoagulants & ambulation
• Gastric Ulcers: PPI
• Pneumonia/atelectasis: Pulmonary toilet, oral care, and ambulation
• Electrolyte Imbalance: Monitor I&O, and electrolytes levels
• Hemorrhage/bleeding: Monitor BP, HR, I&O

Postoperative Assessment

• Respiratory function (patency, rate, rhythm, symmetry, mucus membranes)
• Preventing circulatory complications (heart rate, rhythm, blood pressure, capillary refill, urine output, and peripheral pulses)
• Achieving rest and comfort (pain control, side effects, and temperature regulation)
• Neurological function (LOC, delirium, gag reflex, and pupil reflexes)

Postop Care: Implementation

• Maintaining fluid and electrolyte balance (IV, I&O, baseline lab values)
• Promoting normal bowel elimination and adequate nutrition (monitor bowel movement and prevent ileus)
• Promoting urinary elimination (monitor urine output)
• Promoting wound healing (checking skin for rashes, abrasions, burns, and drainage).
• Maintaining/enhancing self-concept (observe patients for behaviors that reflect any alteration in self-concept after hospitalization)

Restorative and Continuing Cares

• Preparing for Discharge
• Wound care
• Diet/activity restrictions
• Medications and complications
• Home care or rehab facility needs