Perioperative Care Overview

Perioperative Care

• Perioperative care encompasses preoperative, intraoperative, and postoperative care
• Preoperative care is the time before surgery
• Intraoperative care is the time during surgery
• Postoperative care is the time after surgery

Surgical Settings

• Most surgeries are ambulatory (outpatient)
• Some surgeries are inpatient
• Surgical purposes include diagnosis, cure, palliative care, prevention, and cosmetic improvement

Patient Interview

• Obtain health information, including specific details
• Provide and clarify information related to surgery and anesthesia
• Assess the patient's emotional state and readiness for surgery
• Goal is risk stratification to reduce complications

Risk Factors

• Age (young or old)
• Coagulation/Hemorrhages
• Obesity/Airway
• Sleep Apnea/Airway Concerns
• Pregnancy
• Immunosuppression
• Fluid and Electrolyte
• Nutrition/delayed wound healing

Health History

• Past medical and surgical history
• Previous surgical complications
• Menstrual and obstetric history (women)
• Family history of anesthesia complications
• Medication reconciliation
• Allergies
• Review of systems
• Physical assessment (head-to-toe)
• Diagnostics (including substance use and drug use)

Common Preoperative Diagnostic Studies

• Complete Metabolic Profile (CMP) or Basic Metabolic Profile (BMP)
• Complete Blood Count (CBC) (H/H, WBC) - active infection risk/possible transfusion
• Prothrombin Time (PT), Partial Thromboplastin Time (PTT), International Normalized Ratio (INR) - blood clotting
• Liver Function Tests (LFTs) - drug metabolism
• Type and Screen/Crossmatch (T&S)
• Blood Glucose
• Albumin (post-op healing)
• Human Chorionic Gonadotropin (hCG) (pregnancy test)
• Electrocardiogram (EKG)
• Echocardiogram (ECHO)
• Chest Radiograph (chest x-ray)

Preoperative Teaching

• Increases patient satisfaction
• Reduces postoperative fear, anxiety, and stress
• Teaching occurs throughout the entire surgical process
• Focuses on safety
• Includes sensory, process, and procedural aspects

Informed Surgical Consent

• Required before non-emergency surgery
• Patient must understand diagnosis, proposed treatment, risks/complications, probability of successful outcome, alternatives, and prognosis if surgery is unsuccessful
• Patient must consent voluntarily
• Consent is obtained by the surgeon; a nurse may witness the signature
• Permission may be withdrawn at any time
• Medical emergencies may override the need for consent to preserve life or prevent limb impairment

Preparation Day of Surgery

• Verify informed consent
• Confirm NPO status (patients are typically NPO after midnight for aspiration precautions)
• Monitor vital signs
• Perform skin prep
• Remove prostheses
• Administer pre-op medications
• Arrange safe ride home (if ambulatory procedure)
• Surgeon marks surgical site
• Patient verifies information
• Nurse ensures all is complete before sending the patient to the operating room

Preoperative Preparation for People with IDD

• Use communication aids (PECS boards, talking mats, sign language)
• Use pictures and visuals to ease anxiety and fear
• Provide a tour of the unit and operating room
• Identify individuals closest to the patient to assist in preparation and provide support
• Talk to the patient

Informed Surgical Consent for People with IDD

• Individuals with cognitive disabilities require consideration of their capacity to make decisions
• Cognitive ability to give informed consent can vary; should be re-evaluated as needed
• Involve those who know the patient best
• Identify a surrogate if the patient is unable to give consent
• Preference for surrogate selection: spouse (unless legally separated), adult child, parent/step-parent, adult sibling, other adult relative, other adult exhibiting special care and concern.

Preoperative Phase: Gerontologic Considerations

• Decreased skin elasticity
• Pre-existing medical conditions can complicate the surgical process
• Varying responses to medications
• Decreased kidney function affecting waste excretion

Nursing Management: Intraoperative

• Room preparation
• Patient positioning (after anesthesia administration)
• Preparing the surgical site using antimicrobial cleansing and draping
• Time-out and surgical checklist to ensure patient safety

Surgical Team: Registered Nurse

• Circulating Nurse (not sterile) — Facilitates surgical progress, remains in unsterile area, documents information
• Scrub Nurse (sterile) — Remains in sterile area, prepares and manages the sterile field, instruments, documents sponge/sharps utilization

Surgical Team: Surgeon

• Physician performing the procedure
• Responsible for the preoperative medical history
• Physical assessment
• Directing preoperative testing
• Obtaining informed consent
• Marking the surgical site
• Ensuring patient safety
• Postoperative management

Surgical Team: Surgeon's Assistant

• May be an MD, RNFA, PA, resident/fellow, or medical student
• Assists the surgeon
• Holds retractors
• Assists with hemostasis and suturing
• May perform portions of the procedure under direct supervision

Surgical Team: Anesthesia Care Provider

• Anesthesiologist or CRNA
• Administers anesthetic agents
• Manages airway
• Monitors vital signs
• Maintains homeostasis throughout intraoperative procedures

Anesthesia Types

• Moderate (conscious sedation): Combination of anti-anxiety and analgesia; patient maintains airway, and spontaneous breathing; no advanced airway needed; no anesthesia care provider needed (examples: wisdom teeth extraction)
• General: Usually a combination of gas and IV medications; eliminates cough/gag reflex; requires advanced airway (breathing tube); risk of aspiration due to impaired gag reflex
• Local: Loss of sensation at the site; no loss of consciousness (examples: cavity filling)
• Regional: Loss of sensation in an area of the body; no loss of consciousness (example: epidural during labor)

Gerontologic Considerations (Anesthesia)

• Anesthetic drugs must be carefully titrated due to potential organ dysfunction (absorption, metabolism, excretion)
• Assess for potential communication issues
• Be aware of risks from tape, electrodes, and warming/cooling blankets
• Consider positioning needs due to osteoporosis
• Be aware of the risk for perioperative hypothermia and use warming devices

Postoperative Surgical Phase: Phase 1 (Hand-off from OR to PACU)

• Assess airway (cough, gag, swallowing, absence of stridor; narrow airway is a concern)
• Assess breathing (respiration rate, SpO2, work of breathing, apnea)
• Assess circulation (blood pressure, pulse, color)
• Monitor vital signs every 15 minutes or more frequently
• ECG
• Neurological assessment (including reflexes, lines, drains, airways, etc.)
• Observe dressing

Postoperative Surgical Phase: Phase 2 (Discharge Preparation)

• Prepare patients for discharge to home or extended care facilities
• Review post-operative instructions and medications, ensuring understanding
• Provide post-anesthesia care (no driving, no major decisions, no alcohol or drugs for 24 hours)
• Discharge patients to responsible adult/driver

Postoperative Assessment

• Vital signs and focused assessments (respiratory, cardiac, wound, CMS, etc)
• Skin integrity and wound condition
• Metabolism (blood glucose levels)
• Genitourinary function (spontaneous void)
• Gastrointestinal function (prevent paralytic ileus; ambulate if gas pain occurs)
• Pain/comfort

Common Postoperative Complications

• Airway obstruction (tongue falling back, secretions, laryngospasms)
• Hypoxemia (low oxygen levels) (atelectasis, pulmonary edema, PE, aspiration, bronchospasm)
• Hypoventilation (shallow breathing; depression of central respiratory drive or poor muscle tone from anesthesia)
• Pain

Postoperative Complications (Risk and Interventions)

• Risk Factors: DVT/PE, Gastric Ulcers, Pneumonia/atelectasis, electrolyte imbalance, hemorrhage/bleeding
• Interventions: Anticoagulants and ambulation, PPI, Pulmonary toilet, oral care and ambulation, BP, HR, I&O, Lab values, surgical site assessment

Postoperative Assessment (Detailed)

• Respiratory function (patency, rate, rhythm, chest symmetry, breath sounds, accessory muscles, mucous membranes)
• Preventing circulatory complications (heart rate, rhythm, blood pressure, hypotension risk with fluid/blood loss or anesthesia, capillary refill, urine output, peripheral pulses)
• Achieving rest and comfort (efficacy of pain control, minimizing side effects of modalities; potential for malignant hyperthermia)
• Temperature regulation
• Neurological function (LOC, assessing for delirium, gag reflexes and pupils).

Postoperative Care: Implementation

• Maintaining fluid and electrolyte balance (IV, I&O, compare baseline lab values)
• Promoting normal bowel elimination and adequate nutrition (anesthesia slows motility; monitor for bowel movements, ileus; ambulation is encouraged)
• Promoting urinary elimination (monitor output, 6-8 hours expected)
• Promoting wound healing(monitor skin for rashes, petechiae, abrasions, burns; watch for wound drainage.)
• Maintaining/enhancing self-concept (observe patients for behaviors reflecting alterations in self-concept)

Implementation: Restorative and Continuing Care

• Preparation for discharge (wound care, diet and activity restrictions, medications, and complications)
• Home care or rehabilitation facility as needed (for patients who need additional support following surgery)

This quiz covers the key concepts of perioperative care, including the stages of care such as preoperative, intraoperative, and postoperative. It also discusses surgical settings, risk factors, and the importance of patient interviews for effective surgical outcomes. Test your understanding of these essential components in perioperative management.