Perioperative Care: Pre, Intra, and Post-operative Phases

Perioperative Care Objectives

• Perioperative care entails preoperative, intraoperative, and postoperative phases.
• Emergency surgery needs to be defined.
• There are different types of surgeries.
• Factors to consider in a preoperative assessment.
• Legal and ethical considerations relate to informed consent and preoperative medications.
• Preoperative measures help decrease postoperative complications.
• Immediate preoperative patient preparation should be described.
• Intraoperative care should be determined.
• Immediate postoperative care should be described.
• Postoperative complications and their management should be identified

Perioperative Care Phases

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

Preoperative phase

• Surgical intervention begins when the decision is made and ends with the client's transfer to the operating room bed.
• This includes nursing activities from a baseline assessment at a clinic or home, and continues with assessment in the surgical suite on the day of surgery.

Intraoperative phase

• The phase starts when the patient is transferred to the operating room.
• The phase ends when the patient is admitted to the recovery area after anesthesia.
• During this phase, nursing interventions range from recognizing improper positioning to implementing corrective measures and evaluating cardiovascular assessment.

Post-operative phase

• This phase begins upon admission to the post anesthesia recovery area.
• The phase ends with a follow-up evaluation in the clinical setting or at home.
• Nursing activities include assessing effects of anesthesia and surgical procedures, vital functions, comfort, pain relief and preventing complications.
• Nursing activities include promoting recovery & initiating teaching, follow up care and rehabilitation after discharge.

Classification of Surgical Procedures

• Surgical procedures are classified according to their purpose, urgency, and seriousness.

Classification by Seriousness:

• Major surgery examples are coronary artery bypass and resection of the lung lobe.
• Minor surgery includes cataract and tooth extraction.

Classification by Urgency:

• Skin grafts and hernia repair are examples of elective surgery.
• Removal of the gallbladder would be considered urgent.
• Repair of traumatic amputation would be considered emergency surgery.

Classification by Purpose:

• Diagnosis, ablative, palliative, reconstructive, and cosmetic surgeries included.
• A biopsy for a breast mass is a diagnostic surgery.
• Colostomy surgery would be considered palliative.

Types of Surgical Procedures

• Emergency surgery requires immediate attention because the disorder may be life threatening.
• Severe bleeding would be an example where emergency surgery is necessary.
• Urgent surgery requires prompt attention in 24-30 hours, such as an acute gallbladder infection.
• For elective surgery, the failure to have surgery may not be catastrophic; an example being simple hernia repair.
• Optional surgery means the decision rests with the patient and is based on patient preference.

Preoperative Care Importance

• Preoperative care helps protect the patient and get them in the best physical and psychological condition for surgery.
• Preoperative care facilitates the patient recovery from surgery.
• Preoperative care helps prevent post-operative complications.

Preoperative Care Steps

• Assessment and psychological assessment come first.
• The next step covers physical assessment.
• II.Preparation covers psychological considerations.
• The final steps prepares the patient physically.

Assessment

Psychological Assessment

• Surgical procedures are always preceded by some type of emotional reaction.
• It doesn't matter whether it's obvious, hidden, normal, or abnormal.
• Everyone fears surgery and may experience preoperative anxiety and fear.
• The extent a client fears surgery depends on their personality, general responses to stress, and preconceptions about surgery and anesthesia.
• Fear of the unknown is a major cause of preoperative anxiety.
• Other fears include pain, death, deformity, and threat to body image.
• Clients respond to fear differently.
• Some may become silent, withdrawn, tearful, or ask many questions.

Alleviating Fear

• Providing a clear explanation of the surgery and expected results is important.
• The nurse should communicate with the doctor and provide patient with support and clarification where needed.
• Unwarranted reassurance should be avoided, and may hinder the patient's coping.
• Communication skills encourage patients to express feelings.
• Preoperative fear is normal and not unusual.
• Ties with religion provide strength and should be maintained.
• Patients should be allowed to ask questions about surgery and postoperative period.
• Respect a patient's spiritual and cultural beliefs.
• Introducing the patient or family to others who have had similar successful surgeries can be beneficial.

General Preoperative Assessment

History

• Review the patient’s past, present medical and surgical history.
• Review drugs, anesthetic related problems in patient and in immediate family; note alcohol, nicotine, recreational drug use.
• Note current symptoms of discomfort, allergies & dietary restrictions.
• Determine if there is chronic illness such as arthritis or migraines.

Physical assessment

• Conduct a complete physical exam, paying close attention to the cardiac and respiratory systems.
• Assessment of organ / system and airway
• Obtain baseline vital signs.
• Special consideration should be given to the elderly, including cardiac, renal, and musculoskeletal assessments.

American Society of Anesthesiologists (ASA) Grading

• Grade 1: A normal, healthy patient without any clinically significant medical history.
• Grade 2: A patient with mild systemic disease that does not limit activity.
• Grade 3: A patient with severe systemic disease that limits activity.
• Grade 4: A patient with severe systemic disease that is a constant threat to life.
• Grade 5: A moribund patient.

Grading of Surgery (SLCOA National Guidelines)

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

Appropriate lab investigations and diagnostic studies

• Hematologic tests, ABGs, biochemical tests
• Cardiac tests.
• Imaging, Carotid Doppler, Spirometry, and Diseases relevant tests.

Informed Consent (Permission for Operation)

• The patient is asked to sign a statement consenting to the surgery; separate permission is needed for any procedures to be performed.
• Signed consent protects the patient, hospital, doctors, and nurses.

Essential Elements for Consent Validity:

• The person giving consent must know what the treatment is; the doctor explains the reason and recommends the treatment.
• The patient needs to be alert (not affected by morphine/sedatives).
• Consent can be secured over the telephone with one or two witnesses if the guardian or relative is out of state.
• A court can assign a guardian if no relatives are available.

Preoperative Teaching

• Include a teaching plan to help patients actively engage in their own care.
• Teach deep breathing and coughing exercises.
• Exercises for legs to maintain function _ Techniques for controlling pain
• Provide info on post-operative equipment such as drains and tubes.
  • Explain an estimated length of post-operative stay.
    • Teach distraction techniques, such as thinking of enjoyable stories, guided imagery and optimistic thoughts.

Physical Preparation

Preparing skin:

• Use antiseptic cleansers like povidone iodine the night before operation.
• Clipping hair or using electric razors reduces infection rate vs. traditional shaving.

Maintaining Normal Fluid and Electrolyte Balance:

• NPO after midnight before operation
• Remove fluid and solid foods from bedside
• Allow clear liquids up to 3 hours before surgery

Promoting rest, comfort and sleep:

• Nursing measures to include a well ventilated environment.
• A comfortable clean bed, a back rub and warm beverage if appropriate and a client's fears should be addressed.
• Encourage apprehensive clients to take prescribed sleep medication the night before surgery

Preventing bowel and bladder incontinence:

• Enemas for procedures involving gastrointestinal surgery.
• Enemas cleanse the bowel, reducing injury risk to intestines and decreasing contamination during operation.
• Request the patient to void, or insert urinary catheter to prevent bladder injury.

Preparing client on day of surgery

• Early morning care: immediate preoperative preparation begins before surgery for clients in the hospital and as soon as same day admission client come into the hospital.
• Preoperative Intervention helps to promote safety during surgery.
• Take and record vital signs
• Check patient ID
• Ask patient to void, measure and record amount of urine Assist with oral hygiene
• Remove dentures, client jewelry, hairpins, wigs or prosthesis, colored nail polish and make up.
• Check fluid restriction and enema if needed is performed

Preoperative Medications

• Tranquilizers are given 1-2 days before surgery to calm down the patient.
• Barbiturates are given the evening before operation to help the patient to sleep
• Narcotics such as morphine or Demerol are usually administered an hour before surgery.
• Used to relieve apprehension but some physician prefers to use Demerol preoperatively because morphine can depress respiration.
• Atropine is given with general anesthetics and narcotics to lessen respiratory secretion.
• Atropine can make the mouth dry.
• Drugs should not be used as the sole explanation or reassurance.

Explore the comprehensive phases of perioperative care, including preoperative assessment, intraoperative procedures, and immediate postoperative care. Learn about emergency surgery, different types of surgeries, legal and ethical considerations, and measures to decrease postoperative complications. Understand patient preparation and complication management.