Perioperative Nursing: Surgical Phases & Anesthesia

• Perioperative nursing covers the nursing care of patients before, during, and after surgery.

Three Phases of Perioperative Period

• The preoperative phase starts when the decision for surgery is made and ends when the patient is transferred to the operating room.
• The intraoperative phase begins when the patient enters the operating room and ends upon transfer to the post-anesthesia care unit (PACU).
• The postoperative phase lasts from PACU admission through recovery and the final follow-up with the healthcare provider.

Classification of Surgical Procedures

• Surgical procedures are classified by urgency, risk, and purpose.
• Urgency classifications include elective, urgent, and emergency surgeries.
• Risk is classified as either minor or major.
• Purpose classifications are diagnostic, curative, preventive, ablative, palliative, reconstructive, transplantation, and constructive.

Types of Anesthesia

• General anesthesia involves the administration of drugs through inhalation or intravenously.
• Moderate sedation/analgesia (conscious sedation/analgesia) is used for short-term, minimally invasive procedures.
• Regional anesthesia involves injecting an anesthetic agent near a nerve or nerve pathway.
• Topical and local anesthesia are used on mucous membranes, open skin, wounds, and burns.

Three Phases of General Anesthesia

• Induction is the period from the administration of anesthesia to when the patient is ready for incision.
• Maintenance is the phase from incision to near completion of the procedure.
• Emergence begins when the patient starts to wake up from anesthesia and is ready to leave the operating room.

States of Anesthesia

• Anesthesia induces loss of consciousness.
• Amnesia is induced during anesthesia.
• Analgesia (pain relief) is induced by anesthesia.
• Skeletal muscles are relaxed.
• Reflexes are depressed under anesthesia.

Types of Regional Anesthesia

• Nerve blocks are a type of regional anesthesia.
• Spinal anesthesia involves injecting local anesthesia into the subarachnoid space.
• Epidural anesthesia involves injecting anesthesia into the epidural space around the spine.

Informed Consent Information

• Informed consent includes a description of the procedure and alternative therapies.
• It covers the underlying disease process and its natural course.
• The name and qualifications of the person performing the procedure should be included.
• The risks of the procedure and how often they occur must be explained.
• The patient has the right to refuse treatment or withdraw consent, and this must be explained.
• An explanation of the expected outcome, recovery, rehabilitation plan, and treatment course is part of the consent.

Advance Directives

• Advance directives include living wills.
• A durable power of attorney for healthcare is an advance directive.
• Extending a "Do Not Resuscitate" (DNR) order during surgery should be discussed beforehand.
• Actions to resuscitate are integral to the surgical process.
• Surgery poses specific risks where reversible cardiopulmonary arrest may occur.

Outpatient/Same-Day Surgery

• Outpatient surgery reduces the length of hospital stays and associated costs.
• It also reduces the patient's stress.
• This approach may require additional teaching and home care services for certain patients.
• Older, chronically ill, and patients without support systems are examples of patients who may need additional support.

Outcomes for the Surgical Patient

• Patients should receive respectful, culturally sensitive, and age-appropriate care.
• Patients should be free from injury and adverse effects.
• Prevention of infection and deep vein thrombosis (DVT) are key outcomes.
• Maintaining fluid and electrolyte balance, skin integrity, and normal temperature is important.
• Postoperative pain should be well-managed.
• Patients should demonstrate an understanding of their physiological and psychological responses to surgery.
• Participation in the rehabilitation process is expected.

Patient Risk Factors and Strengths

• Infants and older adults are at greater risk during surgery.
• Medical and surgical history can indicate possible postoperative risks.
• Medication history, including anticoagulants and diabetic medications, is important.
• Nutritional status impacts healing and medication effects.
• Alcohol, illicit drugs, and nicotine use can affect intra- and post-operative medications.
• Activities of daily living and regular occupation, including rest, exercise, and work, should be considered.
• Coping patterns and available support systems are important factors.
• Sociocultural needs influence perception and should be considered.

Surgical Risks of Medications

• Anticoagulants can precipitate hemorrhage.
• Diuretics can cause electrolyte imbalances and respiratory depression from anesthesia.
• Tranquilizers can increase the hypotensive effects of anesthetic agents.
• Abrupt withdrawal of adrenal steroids may cause cardiovascular collapse.
• Antibiotics in the "mycin" group can cause respiratory paralysis when combined with muscle relaxants.

Usual Presurgical Screening Tests

• A chest x-ray is a common presurgical screening test.
• Electrocardiography is a usual presurgical screening tests.
• A complete white blood cell count is part of presurgical screening.
• Electrolyte levels are checked.
• Urinalysis may be required.

Nurse’s Role in Presurgical Testing

• Nurses are responsible for explaining tests to patients.
• Nurses must ensure that appropriate specimens are collected during presurgical testing.
• Recording test results in patient records before surgery is a nursing responsibility.
• Abnormal results must be reported.

Nursing Interventions to Meet Psychological Needs of Surgical Patients

• Establish a therapeutic relationship to allow patients to verbalize their fears and concerns.
• Utilize active listening skills to identify anxiety and fear.
• Genuine empathy and caring can be demonstrated with touch.
• Being prepared to answer common patient questions about surgery provides reassurance.

Preparing the Patient Through Teaching

• Surgical events and sensations should be explained to the patient before surgery.
• Pain management strategies should be taught.
• Patients should learn physical activities like:
  • Deep breathing exercises
  • Coughing techniques
  • How to use incentive spirometry
  • Perform leg exercises
  • Practice turning in bed
  • Early ambulation

Nursing Interventions for Surgical Patients

• Focus on hygiene and skin preparation before surgery.
• Support elimination needs.
• Provide appropriate nutrition and fluids.
• Facilitate rest and sleep.
• Ensure preparation and safety of the patient on the day of surgery.

Typical Preoperative Medications

• Sedatives are often given preoperatively.
• Anticholinergics may be used.
• Narcotic analgesics can be administered preoperatively.
• Neuroleptanalgesic agents (combo tranquilizers and antipsychotics) could be used.
• Histamine-2 receptor antihistamines may be administered.

TJC Protocol to Prevent Wrong Site, Wrong Procedure, and Wrong Person Surgery

• A preoperative patient identification verification process is required.
• The surgeon must mark the operative site.
• Final verification, known as the "time-out," occurs just prior to starting the procedure.

Postoperative Assessments and Interventions (Every 10 to 15 Minutes)

• Assess respiratory status, including airway and pulse oximetry.
• Monitor cardiovascular status by checking blood pressure.
• Checks should be made for temperature.
• Assess central nervous system status (level of alertness, movement, shivering).
• Assess fluid status.
• Monitor wound status.
• Check gastrointestinal status (nausea and vomiting).
• Assess general condition.

Return of Consciousness

• Postoperative state can vary through:
  • Unconsciousness
  • Responsiveness to touch and sounds
  • Drowsiness
  • Awake but not oriented
  • Awake and oriented

Cardiovascular Complications

• Postoperative cardiovascular complications may include:
  • Hemorrhage
  • Shock
  • Thrombophlebitis
  • Pulmonary embolus

Interventions to Prevent Respiratory Complications

• Regular monitoring of vital signs is mandatory.
• Deep breathing exercises should be implemented.
• Support patients to cough effectively.
• Use of incentive spirometry.
• Turning in bed every 2 hours.
• Early ambulation.
• Maintain adequate hydration.
• Proper positioning to avoid decreased ventilation.
• Careful monitoring of patient responses to narcotic analgesics.