Surgical Procedures: Perioperative Considerations

Perioperative Considerations and Surgical Procedures

• Reasons for surgery include diagnostic, palliative, ablative, reconstructive, and transplantation purposes.
• Emergency surgery aims to immediately preserve function or life, without any delay.
• Urgent surgery is typically performed within 24-48 hours to repair or remove a body part or restore health.
• Elective surgery is the preferred treatment for non-life-threatening conditions to restore function, repair, or prevent further damage.
• All OR team members must verify patient identity, surgical site, and procedure in a Time Out.
• Prevent wrong-patient/site errors by conducting a pre-surgery Time Out, marking the surgical site, and double-checking.
• Assess respiratory, circulatory, urinary, gastrointestinal, wound-related, and psychological factors for surgery complications.
• Monitor vital signs, supervise the patient, assess LOC, maintain airway patency, and verify NPO status to ensure the safety of patients sedated with pre-op medications.
• The scrub RN maintains sterility, prepares, passes, and counts supplies.
• The circulating RN is a patient advocate, care coordinator, manages non-sterile duties, monitors the sterile field, and the circulating nurse assists with anesthesia.
• The CRNA administers and adjusts anesthesia, monitors vital signs, maintains the airway, and manages pain control.

Malignant Hyperthermia

• Malignant hyperthermia symptoms include muscle rigidity, rapidly increasing expired CO2, rapidly developing fever (late sign), cola-colored urine (late sign), increased serum creatinine phosphate (late sign), tachycardia, tachypnea, arrhythmia, hypotension, hypertension, cyanosis, metabolic acidosis, hyperkalemia, and coagulopathy.
• Dantrolene at 2.5 mg/kg IV is the treatment for malignant hyperthermia.

Infection Prevention

• Prevent skin infections or surgical site infections with intact, clean, and dry dressings.
• Wound assessments for appearance, size, swelling, pain, and drain tube status are important
• Monitor for inflammation (first 1-3 days), bleeding, infection, and scar formation

Pre- and Post-operative Areas

• The pre-op area prepares the patient for surgery through assessment, pre-op meds, IV placement, monitoring vitals, and patient education.
• The post-op area is for patient recovery, including anesthesia recovery, pain management, vitals monitoring, and identification of complications.

Surgical Procedures and Nursing Process Applications

• In appendicitis, pain begins in the periumbilical area and descends to the RLQ, with the most intense pain at McBurney's Point.
• Appendicitis pain increases with coughing or movement and is relieved by flexing the right hip (side-lying with abdominal guarding).
• Appendicitis may cause nausea, vomiting, diarrhea, or constipation, abdominal muscle rigidity, or rebound tenderness
• Changes in temp, BP and HR including increased WBC, Ultrasound or CT showing inflamed appendix - are further symptoms of appendicitis
• Monitor vital signs for signs of infection, conduct thorough abdominal assessments, and assess for redness, swelling, and pain post-appendectomy.
• NPO status should be maintained post-appendectomy until bowel function returns, and the diet should advance gradually.
• If rupture occurred, expect a drain to be present.
• Post-op appendectomy , the patient should be in a right side-lying or semi-Fowler's position for comfort.
• The nurse should change dressings as ordered, record findings, perform wound irrigation as ordered, maintain NG suction and patency, and administer antibiotics and analgesics as prescribed post appenectomy.
• Cholecystitis causes RUQ abdominal pain triggered by high-fat or high-volume food intake.
• Cholecyctitis includes epigastric pain radiating to the right shoulder or scapula, nausea, vomiting, flatulence, belching, indigestion, abdominal guarding, rigidity, rebound tenderness, Blumberg sign (rebound tenderness)
• Additional cholecystitis symptoms are a mass in the RUQ on palpation, elevated temperature/HR, signs of dehydration, jaundice, steatorrhea(fatty stools), elevated AST and ALT
• Post Cholecystitis, monitor for respiratory complications from pain at the incision site.
• Post Cholecystitis, encurage coughing/deep breathing, teach splinting, encourage ambulation, and administer antiemetics/ analgesics as needed
• After cholecystitis surgery, Maintain NPO and NG suction if ordered, advance diet as ordered, and maintain/monitor drainage from T-tubes and dressings
• Following cholecystitis surgery, monitor drainage for color, amount, consistency, and odor
• Report any sudden, unusual biles to the PCP (primary care provider) to prevent signs of infection and further MD orders
• Avoid irrigation, clamping, or aspiration of T-tubes without a MD order , semi-Fowler position facilitates drainage

Colectomy

• In a colectomy, the VS, Bowel sounds Bowel habits, Stool characteristics, Last bowel movement, Skin Color and a full physical assessment and health history should be taken
• Pre colectomy: Bowel prep should be ensured complete as ordered. A physical assessment and a confirmation of health history should be done
• An enterostomal therapist should assist in placement of the ostomy, along with adminstering antibiotics and providing teaching to prevent any complicaitons post-op colectomy
• Post op: During assessment special attention should be paid to the stoma with emphasis on moisture, color, size, and drainage if present
• Administer antibiotics and analgesics, assessing and monitoring the response
• Finally providing SBAR information upon discharge

Potential Postoperative Problems

• Atelectasis and Pneumonia present with dyspnea, diminished breath sounds, crackles, low-grade fever, tachypnea, and cough.
• Atelectasis and Pneumonia prevention includes incentive spirometry, early ambulation, deep breathing/coughing exercises, and adequate pain control.
• Patient education for Atelectasis and Pneumonia involves demonstrating incentive spirometer use and encouraging deep breathing/coughing.
• Nursing implementation for Atelectasis and Pneumonia consists of frequent respiratory assessments, encouraging mobility, and administering oxygen if needed.
• A pulmonary embolism presents with sudden dyspnea, chest pain, tachycardia, hypotension, cyanosis, and anxiety. Early ambulation, leg exercises, using sequential compression devices (SCDs), and anticoagulation prevent PE
• Avoid prolonged immobilization for pulmonary emblious prevention and to perform ankle pumps and report sudden shortness of breath.
• Nursing implementation for prevent pulmonary embolism, monitor oxygen saturation, assess for DVT, and ensure anticoagulation therapy adherence.
• Hypovolemia and Hemorrhage exhibit hypotension, tachycardia, pallor, cool/clammy skin, dizziness, and decreased urine output.
• Prevent hypovolemia by closely monitoring vital signs, assessing active bleeding, and ensuring IV fluid replacement.
• Patients should report dizziness, excessive bleeding, or lightheadedness as a part of hypovolemia patient education.
• Frequent assessments, monitoring surgical drains, maintaining IV access, and administering fluids/blood support hypovolemia prevention.
• Urinary retention presents with the inability to void, bladder distension, discomfort, restlessness, and low urine output.
• Early ambulation, monitoring fluid intake/output, running water, or using a bedside commode can prevent urinary retention..
• Educate the patient to attempt to urinate every few hours and notify the RN if unable to void and assess the bladder.
• A UTI causes dysuria, cloudy/foul-smelling urine, urgency, fever, and lower abdominal pain.
• Increased hydration, avoiding unnecessary catheter use, and proper hygiene prevent UTI.
• Patients need to be educated on the importance of of drinking plenty of fluids, wiping from front to back and when they should notify their doctor
• RN Implementation for UTI's is to implement early catheter removal, monitor peri care and monitor urine characteristics
• Nausea and Vomiting has dizziness and abdominal discomfort symptoms
• To prevent, provide slow advancement of diet and meds per-prescribed, as well as maintaining proper hydration
• Educate patient to eat small, light meals and immediately communicate if signs of nausea occur
• Implementation for N&V, assess the bowels and administer anti-nausea meds
• Constipation presents with decreased bowel movements, bloating, straining, and abdominal discomfort.
• Encourage fluid intake, a fiber-rich diet, and early ambulation can prevent constipation
• Educate patients to maintain hydration as well as a high-fiber diet, while preventing prolonged bed rest
• As the RN, monitor bowel sounds and encourage stool softeners/laxatives as needed.
• Postoperative Ileus has absent bowel sounds, abdominal dissension, nausea/vomiting
• This condition can be prevented with ambulation, less opioid use, and bowel stimulation techniques
• Patients should be diligent to report anything bloating, nausea, and abnsence of bowel sounds
• If these conditions are met, the RN must montiro the bowels, maintain a NPO and administer prescribed meds Wound infections have warmth, fever/ puss discharge
• This can be prevented/ treated with proper cleaning/ meds and aseptic techniques
• Be sure the patient is aware how to keep it dry and what the tell tale signs are
• As the RN continue to montior, as well as teaching these protocols Wound dehiscence and evisceration symptoms are sudden wound openings/ visible organs
• This can be reduced by proper healing as well as preventing straining
• Support with a nurse monitor while applying a sterilized saline

Diabetes

• Type 1 diabetes is characterized by autoimmune destruction of pancreatic beta cells, leading to no insulin production, sudden onset, and genetic/environmental risk factors.

• Type 1 diabetes will need insulin as therapy, in addition to having complications of DKA (ketoacidosis), retinopathy, and neuropathy DMII - Insulin resistance and/or decreased insulin production, Gradual, usually in adulthood (but increasing in younger individuals), Initially normal or high, then decreases over time insulin production, risks Obesity, sedentary lifestyle, poor diet, family history, metabolic syndrome, Often asymptomatic in early stages; later symptoms include fatigue, frequent infections, slow wound healing, increased thirst & urination, treatment Lifestyle changes (diet & exercise), oral medications, insulin (in advanced cases), Can be managed and sometimes reversed with lifestyle changes, complications Cardiovascular disease, stroke, neuropathy, nephropathy, retinopathy.

• Common signs for diabetes are constant thirst, peeing, hungry (also named the 3 P's)

• Complications include: Poor circulation, severe pain, cool skin tone with limb

• Proper treatment for bad circulation can be done with regular health monitoring, and restoring blood flow if needed

• Insulin can be inserted through rapid acting, shots , as well as pumps

• Rotate injection sites to prevent lipodystrophy (fat tissue changes) Avoid injecting into scar tissue or bruised areas

• HgbA1c are readings with long term indicators and glucose is for short term indicators

• For hyperglycemia, frequent urination with blurred vision, is a common sign

• For hypoglycemia, frequent urination with blurred vision, is a common sign

• Check for Glucose side effects (common symptoms are boating, nausea, diarrhea, with long term effects of heart issues, as well as infections) Skin care is import as diabetic nephrotpathy (also leading to protein loss)

• A = Good skin, being free of any sores and any open cut
• B = Good circulation for skin. C Sensation (Neuropathy Check) Numbness, tingling, burning pain Loss of sensation to touch, temperature, or pain

DM 2- causes nerve damage (Neuropathy) , kidney damage (Nephropathy), eye damage (Retinopathy)