Perioperative Nursing

• Perioperative nursing involves caring for patients before, during, and after surgery.

Surgical Classifications

• Urgency-based surgery classifications include urgent, emergent and elective.
• Risk-based surgery classifications include minor and major.

Anesthesia Phases

• Induction is the first phase of anesthesia, beginning with administration and continuing until the patient is ready for incision.
• Maintenance is the second phase of anesthesia, spanning from the point of incision to near the procedure's completion.
• Emergence is the third phase of anesthesia, starting as the patient begins to wake up and ending when they are ready to leave the operating room.

Roles in the Surgical Team

• Scrub nurses are sterile team members who maintain surgical asepsis when draping and handling instruments/supplies.
• Circulating nurses coordinate care activities, collaborate with health care providers and nurses in all phases of perioperative and postanesthesia care, assess the patient in the operating room, ensure safety, integrate case management, critical paths, and research into care of the surgical patient, and assist with monitoring the patient during surgery plus provide supplies while maintaining environmental safety.
• RNFAs actively assist surgeons with exposure, hemostasis, and wound closure.

Key Perioperative Concepts

• Informed consent is a patient's voluntary agreement to undergo a procedure or treatment after receiving appropriate information.
• Advance directives allow patients to specify healthcare treatment instructions should they be unable to communicate these wishes postoperatively.
• The "Universal Protocol" (Joint Commission) involves surgical team members agreeing on patient identity, surgical site, and procedure.
• After surgery and emergence from anesthesia, the patient is transferred to PACU (Post-Anesthesia Care Unit).
• The skin is the body's first line of defense against infection.

Anesthesia and Airway Management

• An endotracheal tube may be inserted during general anesthesia to administer anesthetic gases and maintain patent air passages.

Postoperative Patient Monitoring

• Interventions include measuring inspiration via incentive spirometer, monitoring white blood cell counts, measuring output of drainage devices, observing for calf swelling, assessing for tachycardia and hypotension, and auscultating for crackles in the lung fields include monitoring.
• Pneumonia, thrombophlebitis, shock, wound infection, and atelectasis are potential complications.

Perioperative Phases

• The preoperative phase begins when the patient is scheduled for surgery and ends with transfer to the operating room bed.
• The intraoperative phase begins when the patient enters the operating room and ends when transferred to PACU.
• The postoperative phase begins with admission to PACU and continues through follow-up and rehabilitation.

Types of Surgery (Purpose)

• Diagnostic is a type of surgery.
• Ablative is a type of surgery.
• Palliative is a type of surgery
• Reconstructive is a type of surgery.
• Transplantation is a type of surgery.
• Constructive is a type of surgery.

Essential Information for Informed Consent

• A description of the procedure and alternatives must be given.
• The underlying disease process and its typical course must be given.
• The name and qualifications of the provider must be given.
• The known risks and benefits must be given.
• An explanation of the patient's right to refuse treatment must be given.
• The expected outcome, process, and rehabilitation must be given.

Risks for Postoperative Complications

• Cardiovascular problems increase the risk for hemorrhage, shock, venous stasis, thrombus, and overhydration with IV fluids.
• Pulmonary disorders increase the risk for respiratory depression, postoperative pneumonia, atelectasis, and alterations in acid-base balance.
• Kidney and liver dysfunction affect fluid/electrolyte balance, alter drug metabolism and excretion, and impair healing.
• Endocrine disorders increase the risk for hypoglycemia or acidosis, slow wound healing, and increase cardiovascular complications.

Addressing Patient Fears

• Help patients overcome the fear of the unknown by encouraging expression, identifying correct and incorrect knowledge, and reminding them of strengths.
• To address the fear of pain and death, teach pain management strategies and support the patient's spiritual needs.
• To address fears about changes in body image and self-concept, identify the patient's needs and offer support.

Nurse's Role in Preoperative Screening

• The nurse ensures that all required tests are ordered and performed, results are recorded, and that any abnormal findings are reported.

Postoperative Care: Hygiene and Elimination

• Follow orders made by the provider, it is no longer routine to empty the bladder.

Factors Increasing Surgical Risk

• Developmental considerations mean that infants are at risk.
• Infants are at an increased risk of infection/respiratory and temperature problems.
• A medical history of past and current pathology can increase surgical and postoperative complications.
• Medications like anticoagulants/diuretics/tranquilizers can increase problems.
• Previous surgeries can have physical implications/surgical complications/ and psychological experiences.
• Lifestyle choices mean licit and illicit substances like alcohol and drugs can affect healing.
• Nutrition affects risk due to malnutrition or obesity.
• Certain activities may need to be discontinued for healing.
• Sociocultural needs/ reactions to surgery and pain are influenced by patient and experience.

PACU Assessment

• Vital signs (temperature, BP, pulse, respiratory rate) should be assessed, noting tachycardia, hypotension, and deviations from pre-op values.
• Skin color and temperature should be assessed noting pallor, cyanosis, and diaphoresis.
• Level of consciousness (orientation to time, place, and person) should be assessed, as well as movement and reaction to stimuli, and movement.
• For IV fluids, type and amount, flow rate, security/patency of tubing, and infusion site should be assessed.
• The surgical site should be assessed including, dressing, drainage, drains, and twines.
• Tubes and drains (urinary catheter, GI suction) should be assessed for drainage, patency, and amount.
• Pain management (assessment, time of analgesic administration) should be assessed, plus N/V.
• Position and safety (ordered position, side-lying until conscious, elevated rails) should be assessed.
• Patient comfort (warmth, assess for hypothermia) and making considerations for family should be done.

Postoperative Interventions

• Nursing interventions include administering prescribed medication and avoiding large amounts of fluid if a patient is experiencing nausea and vomiting.
• Nursing interventions include offering sips of water or ice chips when NPO is permitted, and maintaining oral hygiene if a patient is experiencing thirst
• Nursing interventions include taking swallows of water while holding breath, or rebreathing into a paper bag if a patient is experiencing hiccups
• Nursing interventions include administering prescribed medication and reinforcing preoperative teaching regarding pain management if a patient is experiencing surgical pain.
• Nursing interventions involves listening to patients, establishing trust, and preparing to answer questions if a patient needs comfort.

Actions Expected in PACU

• Actions expected include admitting, and assessing for complications as the patient emerges from anesthesia.

Teaching Deep Breathing and Coughing

• To teach deep-breathing: place patient in semi-Fowler's with neck/shoulders supported, have the patient place their hands over rib cage, ask them to inhale through the nose completely and slowly, then exhale completely (repeat 3 times).
• In teaching effective coughing place the patient in semi-Fowler's leaning forward + splint the incision, have the patient take a quick breath with open mouth, ask patient to "hack out" for three short breaths, then cough deeply once or twice and take another deep breath.
• To teach leg exercises for increased venous return from the legs, provide appropriate leg exercises 10 times each waking hour.
• The nurse must be able to recognize signs of increasing anxiety.
• Patients express fears during surgery due to lack of sleep and concerns about surgery.
• A nurse can implement a plan of care in a manner that respects the human dignity, addresses and concerns the surgical experience by practicing presence with the patient, actively listening, establishing trust and prepared to answer the questions.
• Patient is free from infection at discharge.
• Patient receives proper care for pain management.
• Intellectual, interpersonal, ethical, and legal competencies are most likely to bring about the desired.
• Psychosocial responses/pain interventions and medication are necessary.
• Developing trust, advocating, validating and completing checklists, plus updating are necessary.

Nursing Considerations

• Nurses should be competent and knowledgeable about equipment.
• Nurses should understand the procedure.
• Nurses should know the expected outcomes.
• Nurses should have the patient's best interest in mind.
• Nurses promote patient safety and well-being.
• The perioperative nurse is responsible for the care of the surgical patient.
• A nurse in the perioperative setting acts as a patient advocate.
• A nurse can prevent potential issues or complications from becoming fatal.
• The nurse must be observant of the patient's body language and verbal cues.
• The nurse should be familiar with equipment.
• The nurse must have knowledge of anatomy and physiology.
• The nurse should provide a holistic care approach that includes physical, psychosocial, environmental, safety, and comfort.
• The nurse must be accountable for their actions.
• The nurse must use a multidisciplinary approach.
• The nurse must be willing to ask for help from peers.
• Document nursing care and patient data.
• The nurse must consider age, nutritional status, fluid and electrolyte balance, medical diagnosis, drugs.
• The nurse must collaborate and communicate with entire team members.
• The nurse must follow infection prevention protocols and maintain asepsis
• The goal of perioperative nursing care is to assist patients throughout the surgical experience