Perioperative Nursing: Care and Case Study Part 1

• Perioperative nursing involves care provided before, during, and after surgery
• This spans from the pre-operative phase, through the intra-operative and post-anesthesia care unit (PACU) stages, to the post-operative phase.

Course Student Learning Outcomes

• Provide safe, patient-centered, evidence-based nursing care guided by the Caritas philosophy.
• Demonstrate intermediate levels of critical thinking and clinical reasoning to provide quality patient care.
• Relate the impact of quality improvement measures to improved patient care.
• Explain management of care concepts for adult patients.

Case Study: Mr. J.

• Mr. J, a 74-year-old male, is scheduled for an elective colon resection due to recurring diverticulitis.
• His medical history includes hypertension (HTN), diabetes mellitus type II (DM II), chronic obstructive pulmonary disease (COPD), atrial fibrillation (A fib), and a myocardial infarction (MI) with stent placement in 2013, osteoarthritis, and hypothyroid.
• Current medications: Glucophage, Lantus at night, lisinopril, metoprolol, warfarin, clopidogrel, and albuterol prn.
• Subjective Data: Excellent health pre-op, walks at the mall 4 times a week for 20-30 minutes, uses hearing aids and glasses, concerned about the surgery's impact on his lifestyle, and does not smoke or drink alcohol.
• Mr. J has a Pre-Admission Testing appointment 4 days before surgery and will arrive at the Pre-op Area two hours before the scheduled surgery time.

Purposes for Surgical Intervention

• Diagnostic: To determine the nature of a disease or condition.
• Curative/Ablative: To remove diseased tissue or correct a problem.
• Restorative/Reconstructive: To restore function or appearance.
• Palliative: To relieve symptoms without curing the underlying disease.
• Cosmetic: To improve appearance.
• Transplant/Procurement: To transplant organs or tissues.
• Preventive: To prevent a disease or condition from developing.
• Exploration: To examine a body area.

Classification of Surgeries

• Surgeries can be classified by degree of severity and degree of urgency.

Settings

• Settings include hospital or ambulatory setting

Nurse’s Role During the Perioperative Period

• Pre-op: Includes pre-admission testing/admission and teaching.
• Intra-op: The time during which surgery is performed.
• Post-op: Includes the immediate hours in PACU to 24-48 hours post-op and the convalescent period.

Nursing Care of the Patient in the Pre-Operative Phase

• The nursing care includes:
  • Review preoperative laboratory and diagnostic studies.
  • Review the client's health history and preparation for surgery.
  • Assess physical needs.
  • Assess psychological needs.
  • Assess cultural needs.

Pre-Operative Assessment: History and Physical

• Includes history, interview, physical assessment, establish patient’s preoperative function, identify risk factors and creating plan of care

Patient History- Interview

• In a patient interview obtain patient information and health history
• Collect baseline data to determine potential risk factors, assess emotional state, expectations of patient, baseline knowledge
• Physician and Nurse answer questions

Subjective Data

• Is what the patient shares
• Health History: Focus on current, past, and family history.
• Medications: Includes daily medications, allergies, and any anesthesia problems.

Subjective Data: Psychological Assessment and Considerations

• Assess emotional state, stress response, common fears, past experiences, and knowledge deficit.

Review of Systems (ROS)

• Differs from the regular head-to-toe physical assessment.
• Focuses on identifying any pre-existing conditions.
• Includes a review of pre-op tests like labs and X-rays.

Additional Assessments

• Baseline assessment: Identify any current or chronic medical issues.
• Be aware of conditions like stroke/TIA/GCS, MS, Parkinson's, Spinal cord injury.
• Elder patientsare more prone to negative effects post-op
• Surgery stressors: Includes dehydration, hypothermia, anesthesia, narcotics

Physical Assessment

• Objective data collected by the physician or advanced care provider.
• The assessment involves a head-to-toe systems review and adhering to Joint Commission requirements.

Medications with Potential for Increased Intra-op & Postop Risk

• Steroids, Anticoagulants/, Anti-platelet aggregates/NSAIDS/Salicylates, Antibiotics, Tranquilizers/Sedatives, Anti-hypertensives, Diuretics, ETOH/Recreational drugs, Insulin/Anti-Diabetic agents, Cardiac meds, Eye Drops/Inhalers, Herbals

Latex Allergies

• Determine the kind of reaction, and identify latex allergy risk factors.
• Risk factors: long-term, multiple exposures to latex, hay fever, and asthma.
• Allergies to avocados, bananas, chestnuts, and kiwi.

Anesthesia Assessment

• Anesthesia Rating (ASA) is based on history and physical exam and performed by anesthesia care provider.

Patients with High-Risk Diagnoses

• Extremes of age, chronic diseases, and obesity.

Pre-Op Testing

• Test depend on the type of surgery, and the patient's age/medical history.

Pre-Op Consent, Teaching and Medications

• Involves discussing expectations for the day of surgery, PACU, intra-op, and post-op expectations/routines
• Includes ensuring pre-op preparation, understanding medication use
• Dietary restrictions must be observed
• Discharge teaching as relevant

Informed Consent

• The responsibility to obtain informed consent lies with the surgeon.
• The consent must be signed in the presence of a witness, with the nurse acting only as a witness to the patient's signature.
• The nurse is responsible for ensuring the signed consent is on the chart before pre-medication and serves as a patient advocate.

Three Aspects of Informed Consent

• Adequate disclosure by the physician.
• The patient must demonstrate sufficient comprehension and understanding of the information provided.
• The patient must give consent voluntarily, this is required before pre-op meds are given.

Exceptions to Informed Consent

• Emergencies
• Patients who are minors, unconscious, or mentally incompetent
• Administrative consent
• Patients with a Durable POA, Living Will, or DNR

Perioperative Cultural Aspects of Perioperative Care

• Include emotional support and cultural considerations

Adequate Nutrition/Hydration

• Focus on nutritional status weeks to 1-2 days pre-op.
• Patients are usually NPO (nothing by mouth) after midnight the evening, or 8 hours prior
• Clear liquids can be ingested up to 2 hours before procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia.
• Check institution policy.

Teaching for Every Post-Op Patient

• Should include importance of coughing, deep breathing, incentive spirometer use, turning, leg exercises, and using anti-embolic stockings/Teds.

Decreasing Risk for Post-Op Complications

• Atelectasis and Pneumonia are major risks of surgery
• Education on breathing exercises and movement can alleviate these risks

VTE Prophylaxis

• Prevention methods focus on leg exercises using low dose anticoagulants, SCD's/TEDS

Preventing Post-Op Infection

• Handwashing and skin preparation
• Remove hair only when necessary
• Scrubs should include Betadine, Hibiclens, PhisoHex, or Chlorhexidine
• Antibiotics

Pre-Op Checklist Ensures patient safety

• Verify name, allergy bands are correct.
• Administer meds and ensure side rails are up, with the call light within reach.
• Patient must void prior to pre-op meds.
• Remove all piercings.
• No clothing except the gown.
• No dentures.
• No prosthesis.
• Remove all cosmetics, nail polish
• Tape rings and lock up patient's valuables.

Pre-Op Medications

• Benzodiazepines, Barbiturates, Anticholinergics, Opioids (Narcotics), Histamine (H2)-receptor antagonists, Antiemetics, Phenothiazine derivatives