Post-Surgery Patient Care Instructions

Care of Preoperative and Intraoperative Surgical Patients

• This chapter discusses the care of preoperative and intraoperative surgical patients
• It'll go over the theory and clinical practices of the nurses in these contexts

Lesson 4.1 Care of Preoperative and Intraoperative Surgical Patients Theory Objectives (1 of 2)

• Advances in surgery technology will be discussed
• The preparation of patients physically, emotionally, and psychosocially for surgical procedures will be gone over
• Identification of what patient types are most at risk for surgical complications and why will be shown

Theory Objectives (2 of 2)

• Planning and implementation of patient and family teaching to prevent postoperative complications
• Comparing the roles of the scrub nurse and the circulating nurse
• Analyzing the differences in various types of anesthesia and list the advantages and disadvantages of each to the surgeon and the patient will be examined

Clinical Practice Objectives

• Perform a thorough nursing assessment for a preoperative patient
• Teaching the patient postoperative exercises during the preoperative period
• Prepare a patient for surgery using a preoperative checklist.
• Document preoperative care and assessment data
• Observe during a patient's surgery

Types of Surgery

• Diagnostic surgery determines the origin and cause of a disorder or the cell type for cancer
• Curative surgery resolves a health problem by repairing or removing the cause
• Restorative surgery improves a patient's functional ability
• Palliative surgery relieves symptoms of a disease process but does not cure
• Cosmetic surgery primarily alters or enhances personal appearance

Urgency of Surgery

• Elective surgery is planned for the correction of a nonacute problem
• Urgent surgery requires prompt intervention and may be life-threatening if treatment is delayed more than 24 to 48 hours
• Emergent surgery requires immediate intervention because of life-threatening consequences

Degree of Risk of Surgery

• Minor surgery is a procedure without significant risk and is often done with local anesthesia
• Major surgery is a procedure of greater risk and is usually longer and more extensive than a minor procedure

Extent of Surgery

• Simple surgery only involves the most overtly affected areas
• Radical surgery is extensive surgery beyond the area obviously involved aimed at finding a root cause

Trends in Surgery

• There are technological advances in surgery, autologous blood for transfusion, bloodless surgery, and cultural considerations

Audience Response Question 1

• In discussing options for fluid resuscitation during major surgery, the physician indicates the availability of bloodless surgery
• The nurse would include Administration of erythropoietin, Provision of postoperative hyperbaric oxygen therapy, Induction of hypothermia, Banking blood before surgery, Autologous transfusion

Perioperative Nursing Management

• Perioperative nursing refers to the care of the patient before, during, and after surgery Assessment involves data collection, latex allergy consideration, surgical risk factors, and learning needs

Cultural Considerations

• Beliefs regarding surgery and what issues and interventions need to be conveyed to the surgical team must be considered
• Cultural taboos and blood transfusion considerations should be taken into account

Consent for Surgery

• Written permission signed by the patient, guardian, or whoever holds power of attorney is required
• Written consent protects the surgeon against claims of unauthorized surgery and provides the patient an opportunity to exercise the right of informed consent
• The surgeon explains the procedure, risks, and benefits; the nurse only witnesses the patient's signature
• The patient must be mentally competent and give consent freely and without coercion
• The consent form is attached to the patient's chart and is sent to the operating room with the patient
• The nurse must always check that a consent form has been signed before giving the preoperative medication

Food and Fluids

• Restrict food for 8 hours before surgery with nothing per mouth (NPO) status
• A light meal such as toast and clear fluids may be allowed up to 6 hours before surgery
• Clear liquids such as black coffee, tea, apple juice, or carbonated beverages may be consumed up to 3 hours before surgery in elective cases
• Always check the physician's order before giving anything by mouth in the immediate preoperative period
• Oral restriction's purpose is to prevent nausea, vomiting, and aspiration
• Confirm with the patient that the NPO order has been needed
• Usual insulin may or may not be given
• If a patient has not remained NPO for the prescribed period, surgery may be canceled

Elimination

• Enemas may be ordered to clear the bowel
• Oral GOLYTELY solution may be given
• A Soft or liquid diet for the 3 days before surgery to decrease the contents of the bowel may be ordered
• Have patient empty the bladder prior to sedation

Tubes and Equipment

• If a nasogastric tube will be inserted during surgery for postoperative use, one should explain its purpose, its care, and what it will feel like to the patient
• One should explain the function of other tubes such as drains, an intravenous (IV) line, oxygen delivery and monitoring devices, a chest tube, and a urinary catheter, as well as their care and probable duration of use

Rest and Sedation

• Rested is important before surgery so the body is not compromised in meeting the stresses of anesthesia and the surgical procedure
• Patients scheduled for same-day surgery should take the sedative at home and retire early the night before because it may be necessary to arise early to enter the hospital

Pain Control

• A Patient-controlled analgesia (PCA) pump may be used for postoperative pain. Injections for pain control are ordered on an as-needed basis every 3 to 4 hours; patients must ask for it
• Oral pain medication is ordered every 4 to 6 hours as needed
• Inform that asking for pain medication before the pain becomes severe makes it easier to control the pain level

Skin Preparation

• The night or morning before surgery, shower with a special antibacterial cleanser to remove microorganisms
• On the morning of the surgery, hair may be removed from the operative site
• Explaining to the patient the hair removal area to be prepared, the hair removal process, and the timing for hair removal is important
• Nail polish is removed so that the pulse oximeter can function correctly when attached to the finger
• Makeup is removed; note the presence of permanent makeup on the preoperative checklist
• Ask about contact lenses and have them removed as well

Preoperative Teaching

• Correct breathing, coughing, turning, and leg exercises is a high priority during the preoperative period
• Instruct patients about what to expect before, during, and after surgery
• Help the same-day surgery patient devise a schedule for doing the necessary exercises

Turning

• Show patients how to turn in bed by flexing their legs to relax their abdominal muscles, placing a pillow between the legs, grabbing onto the side of the bed, and slowly turning to the side
• This maneuver is also used for getting up out of bed
• Trapeze bars for orthopedic patients help with turning and repositioning

Family Instructions

• Advise families to come to the hospital 1 to 1½ hours before surgery
• Families are told about the usual routines, where to wait, the approximate time before patients may be expected to return, and what to anticipate in the way of tubes, equipment, and patient appearance after surgery

Immediate Preoperative Care

• Patients wear Clean hospital gowns, without underwear, for the OR. Hair is covered with a surgical paper cap
• All jewelry must be removed. Jewelry and other valuables should be given to a family member or secured according to facility policy
• Dentures are removed, placed in a labeled cup, and kept in a designated place, according to hospital policy
• If a hearing aid is left in place, note its placement on the preoperative checklist sheet.
• Verify the identification bracelet matches the chart to avoid any error or mix-up of patients. Verify that the procedure site indicated on the surgical consent form is the same as what the patient states
• The procedure site is verified and marked on the patient before transport to surgery or in the preoperative holding area
• Attend to all items on the preoperative checklist that can be handled ahead of time, to prevent hurrying and increasing mistakes.
• Administration of any preoperative medication should occur when the list is completed.

Preoperative Medications

• Preoperative medications may be given to: reduce anxiety and promote a restful state, decrease secretion of mucus and other body fluids, counteract nausea and reduce emesis, and enhance the effects of anesthetics

Preventing Falls

• If patients have received a sedative preoperatively, the side rails of the bed are remembered to put up, per facility protocol, and lower the bed
• Patients are reminded not to get up without assistance
• These measures are important patient safety after administering sedatives

Cultural Variances in Drug Metabolism

• Asians, particularly Chinese individuals, metabolize psychotropic drugs differently than other ethnic groups
• Valium causes greater sedation with normal doses
• Atropine is also metabolized differently and can greatly accelerate the heart rate
• Asian patients should be monitored closely when receiving these drugs

Transfer to the Operating Room

• Assist in transferring patients to the stretcher when the transport person comes to take patients to surgery
• Compare patients' identification bracelet names and numbers with the transport request sheet for accuracy
• Check the chart to make certain that everything ordered has been done and complete final documentation

Preparation of the Patient Unit

• While patients are in surgery preparation should be made for their return which includes fresh linens, the bed raised to the height of the stretcher, and the IV pole at the head of the bed
• Emesis basins, tissues, frequent vital signs sheets or postoperative records, intake and output sheets, small towels and washcloths, and pens should be gathered and placed on the bedside table or console
• Oxygen and suction equipment should be connected if they need is anticipated Thermometers, sphygmomanometers, pulse oximeters, and stethoscopes should be close at hand
• If a PCA pump, sequential pneumatic compression devices, or passive range-of-motion machine will be needed, make sure they are obtained and ready

Audience Response Question 2

• Interventions critical in preoperative preparation of the patient include no oral intake for at least 6 hours, allow clear liquids up to 2 h before major procedures, ensure timely administration of insulin injections at all times, withhold all cardiac medications, antihypertensives, and anticonvulsants, confirm patient compliance with the NPO status

Surgical Team

• The surgical team consists of the surgeon, physician's assistant, surgical assistants, anesthesia care provider, circulating nurse, and scrub person or scrub technician
• The surgeon may be a physician, oral surgeon, or podiatrist

Surgical Suite

• The unrestricted zone is essentially the control desk area, where street clothes may be permitted
• Semi-restricted zones include the hallways and outer regions of the ORs, where the circulating nurse and anesthesia care providers work in clean scrub clothes and caps
• The restricted zone is the area surrounding the operating table and instrument trays/table, where personnel wear scrub cloths, sterile gowns, caps, shoe covers, masks, and sterile gloves; asepsis is the responsibility of all surgical personnel

Roles of the Circulating Nurse and the Scrub Person

• The scrub person is a surgical technician or nurse, and functions within the sterile area of the operating room
• The circulating nurse maintains the safety and dignity of the patient, brings needed items to the operating team, and serves as a communication link between the OR and those outside the surgical suite

Intraoperative Care

• Before surgery begins, a "time out" occurs during which final verification of the correct patient, procedure, site, and implants (if applicable) is performed, and any questions or concerns must be resolved

Anesthesia

• Anesthesia is the loss of sensory perception
• Goals of anesthesia administration are the prevention of pain, achievement of adequate muscle relaxation, and calming fear, easing anxiety, and inducing forgetfulness of unpleasant experience

General Anesthesia

• Stages of general anesthesia include induction, where unconsciousness is induced; maintenance, which is the period during which the surgical procedure is performed; and emergence, where surgery is completed and the patient is prepared to return to consciousness; neuromuscular blocking agents are reversed

Older Adult Care Points

• Accurate elder height and weight are very important for the calculation of anesthetic agents and medication dosages
• Kidney function is declining in older persons, and drugs are not eliminated from the body as quickly
• Reduced dosages are often needed

Regional Anesthesia

• Regional anesthesia is accomplished by administering a nerve block by injecting the spinal, epidural, caudal, or peripheral nerve area.
• The block anesthetizes the local area or the area distal to the block
• Spinal or epidural blocks are frequently used for high-risk patients undergoing pelvic or lower extremity surgery
• Epidural blocks are widely used in obstetric procedures

Procedural Sedation Anesthesia (Moderate Sedation)

• A local anesthetic agent or regional anesthesia to numb the area, plus IV sedation, are used to provide systemic analgesia and sedation during a surgical procedure
• The combination can be used for any procedure that can be done with local or regional anesthesia and is being used more frequently

Local Anesthesia

• Local anesthesia is used for minor procedures such as superficial tissue biopsies, surface cyst excision, insertion of pacemaker, and insertion of venous access devices.
• The patient who has had local anesthesia is transferred directly to the nursing unit and does not need care in the postanesthesia care unit (PACU).

Potential Intraoperative Complications

• Potential intraoperative complications include infection, fluid volume excess or deficit, hypothermia, malignant hyperthermia, and injury related to positioning