Perioperative Care: Pre, Intra, and Post-operative

Perioperative Care Objectives

• Define preoperative, intraoperative, and postoperative care
• Define emergency surgery
• Differentiate between different types of surgery
• List factors to be considered in a comprehensive preoperative assessment
• Identify legal and ethical considerations related to informed consent and preoperative medications
• Describe preoperative measures that decrease post-operative complications
• Describe immediate preoperative preparation of patient
• Determine intraoperative care
• Describe immediate post-operative care
• Identify postoperative complications and management

Background of Perioperative Care

• Perioperative care consists of three phases: preoperative, intraoperative, and post-operative

The Preoperative Phase

• Begins when the decision for surgical intervention is made
• Ends with the transfer of the client to the operating room bed
• Nursing activities include baseline assessment at clinic or home
• Assessment continues in the surgical suite on the day of surgery

The Intraoperative Phase

• Starts when the patient is transferred to the operating room
• Ends when the patient or client is admitted to the post-anesthesia recovery area
• Nursing interventions include recognizing improper positioning and implementing corrective measures
• Interventions also involve evaluating cardiovascular assessments

The Post-operative Phase

• Begins when the patient is admitted to the post-anesthesia recovery area
• Ends with follow-up evaluation in the clinical setting or at home
• Immediate postoperative focus includes assessing anesthesia effects and surgical procedures
• Monitor vital functions, providing comfort and pain relief, and preventing complications
• Nursing activities also include promoting recovery, initiating teaching, follow-up care, and rehabilitation after discharge

Classification of Surgical Procedures

• Classified according to purposes, urgency, and seriousness

Seriousness

• Major: coronary artery bypass, resection of lung lobe, resection of colon
• Minor: cataract extraction, tooth extraction

Urgency

• Elective: skin graft, hernia repair
• Urgent: removal of gallbladder
• Emergency: repair traumatic amputation

Purpose

• Diagnostic: biopsy of breast mass
• Ablative
• Palliative: colostomy
• Reconstructive
• Cosmetics

Types of Surgical Procedures

• Emergency surgery: requires immediate attention due to life-threatening disorders like severe bleeding
• Urgent surgery: requires prompt attention within 24-30 hours, such as acute gallbladder infection
• Elective surgery: failure to have surgery is not catastrophic, like a repair of scar or simple hernia
• Optional surgery: decision rests with the patient, based on their preferences

Importance of Preoperative Care

• Protects the patient and enable them to arrive at the operating room in the best possible physical and psychological condition
• Facilitates patient recovery from surgery
• Prevents post-operative complications

Preoperative Care Steps

• Assessment (psychological, physical)
• Preparation
• Psychological and physical preparation of patient

Psychological Assessment

• Surgical procedures are preceded by emotional reactions, whether obvious, hidden, normal, or abnormal
• Preoperative anxiety and fear are common
• Fear depends on personality, stress responses, mental health, and preconceptions about surgery/anesthesia
• Fear of the unknown is a major cause of preoperative anxiety
• Causes include fear of pain, death, deformity, and threat to body image
• Clients can respond silently, withdrawn, tearfully, or by repeatedly asking questions

Measures to Alleviate Fear

• Surgeons should give careful, clear explanations of the reasons for surgery and expected results
• Nurses should communicate with the doctor to understand what information has been given to patients
• Communication allows nurses to clarify any points that are unclear
• Nurses should avoid unwarranted reassurance, as it can block communication and prevent patients from coping with their worries better

Communication Skills for Alleviating Fear

• Encourage patients to express feelings, especially depression, withdrawal, or apprehension
• Emphasize that preoperative fear is normal
• Explain the plan of preoperative and postoperative nursing care
• Describe ways the patient can participate in their recovery like breathing exercises,
• Maintain ties with religion, as religious faith can provide strength
• Allow patients to ask questions about surgery and the postoperative period
• Respect spiritual and cultural beliefs
• Introduce patient or family to others who have successfully undergone similar surgery

General Preoperative Assessment

• History taken: review patient's past and present medical/surgical history, drugs, anesthetic-related problems, alcohol, nicotine, and recreational drug use; note current symptoms of discomfort, chronic illnesses, allergies, and dietary restrictions
• Physical assessment: complete physical exam with attention to cardiac and respiratory function
• Assess organ/system and airway assessment from head to toe
• Obtain baseline vital signs, special considerations for elderly patients

American Society of Anesthesiologists (ASA) Grading

• Grade 1: Normal healthy patient without clinically important medical history
• Grade 2: Patient with mild systemic disease that does not limit activity
• Grade 3: Patient with severe systemic disease that limits activity
• Grade 4: Patient with severe systemic disease that is a constant threat to life
• Grade 5: Moribund patient

Grading of Surgery (SLCOA National Guidelines)

• Grade 1 (Minor): excision of skin lesions, incision and drainage of skin abscess
• Grade 2 (Intermediate): repair of inguinal hernia, stripping of varicose veins, adeno-tonsillectomy, arthroscopies
• Grade 3 (Major): thyroidectomy, total abdominal hysterectomy, lumbar discectomy, endoscopic resection of prostate
• Grade 4 (Major+): total joint replacement, lung surgery, colonic, radical neck resection

General Preoperative Investigations

• Appropriate lab investigations and diagnostic studies should be done
• Include hematologic tests, arterial blood gases (ABGs), biochemical tests
• Cardiac tests
• Imaging (CXR, C spine X-ray)
• Carotid Doppler
• Spirometry
• Disease-relevant tests

Informed Consent

• Also known as permission for operation
• Patient must sign indicating consent to have surgery performed
• If multiple procedures, patient should sign for each separately
• Signed informed consent protects patient, hospital, doctors, and nurses
• Requires person giving consent to understand what they agree to, with doctor explaining reason and treatment
• Patient should be alert and not under the influence of morphine or sedatives
• Consent can be secured over the telephone with one or two witnesses if guardian is out of state
• If no guardian is available, the court can appoint one

Preoperative Teaching

• Teach the patient to actively participate in self-care, including deep breathing, coughing exercises, and leg exercises
• Explain the turning to maintain physical functioning
• Teach pain control methods
• Explain post-operative equipment like drains and tubes
• Provide information about length of post-operative stay
• Teach coping strategies, such as guided imagery to concentrate on pleasant experiences or restful events
• Encourage distraction by thinking of enjoyable stories
• Encourage optimistic thought and affirmation that all will go well

Physical Preparation

• Operative site should be cleansed the night before with antiseptic such as povidone-iodine to decrease microorganisms
• Use clipping hair or electric razors to prevent infection better than shaving
• NPO after midnight or according to hospital policy, for major operations
• Remove fluid and solids from bedside
• Emptying stomach before surgery lowers risks of vomiting or aspiration
• Clear liquids can be allowed up to 3 hours before surgery

Physical Preparation cont.

• Nursing measures include providing a well-ventilated room and comfortable bed
• Nurse can provide a back rub and warm beverage if not contradicted
• Listen to patient doubts
• Encourage sleep medication if needed
• Enemas for bowel preparation in surgeries involving the gastrointestinal system
• Enemas cleanse bowel reducing injury and preventing contamination
• Ask patient to void or insert catheter to reduce bladder injury

Preparing Client on day of surgery

• Early morning care is the immediate preparation before surgery, begins once the clients gets to the hospital
• Includes taking and recording vital signs
• Checking patient ID
• Asking patient to void and measuring urine
• Assisting with hygiene
• Remove dentures, client jewelry, hairpins, wigs and nail polish to observe skin color
• Check fluid restriction and administer enema if needed

Preoperative Medications

• Tranquilizers are given 1-2 days before surgery to help patients remain calm
• Barbiturates are given the evening before operation to help patients sleep
• Narcotics such as morphine or Demerol can be administered an hour prior to relieve apprehension, however physicians prefer Demerol
• Atropine is used with general anesthetics to lessen respiratory secretion and will make the mouth dry

Preoperative Drugs

• Drugs should not be used as a substitute to explanation & reassurance.

Understand perioperative care's phases: preoperative, intraoperative, and postoperative. Learn nursing activities, assessments and preparations involved in each stage. Identify potential post-operative complications and their management.