Study Guide: Perioperative Medicine PDF

 **Team Roles**: - The surgical team typically includes a surgeon, anesthesia provider, circulating nurse, and surgical technician. Other specialists may also be involved depending on the complexity of the surgery.  **Preoperative Phase**: - This phase starts when surgery is schedul...

 **Team Roles**: - The surgical team typically includes a surgeon, anesthesia provider, circulating nurse, and surgical technician. Other specialists may also be involved depending on the complexity of the surgery.  **Preoperative Phase**: - This phase starts when surgery is scheduled and ends when the patient is transferred to the operating room. The focus is on preparing the patient physically, mentally, and emotionally for the procedure.  **Preoperative Assessment**: - This is a thorough evaluation that includes: - **Health history**: Age, general health, past surgeries, allergies (especially to latex, anesthesia, and medications). - **Risk factors**: Chronic diseases, obesity, smoking, alcohol or substance abuse, and medications that may increase surgical risk (e.g., anticoagulants, immunosuppressants). - **Anesthesia history**: Any past issues with anesthesia, family history of reactions like malignant hyperthermia (a rare but serious reaction to certain anesthetic agents). - **Medications and supplements**: Understanding current medications is essential, especially those that may affect bleeding or anesthesia response.  **National Patient Safety Goals**: - Ensure correct patient identification, correct surgical site marking, and correct procedure performance.  **Communication and Hand-offs**: - SBAR (Situation, Background, Assessment, Recommendation) is an effective communication tool for transferring patient information between health care providers, ensuring safe hand-offs.  **Surgical Risk Factors**: - Age (particularly older adults), chronic conditions (e.g., pulmonary issues, diabetes), substance use, and certain medications are all factors that can increase surgical risk.  **Malignant Hyperthermia (MH)**: - A critical concern in anesthesia, especially for patients with a family history of the condition. Early detection of symptoms, such as rapid heart rate, muscle rigidity, or respiratory changes, is vital for preventing severe complications.  **Discharge Planning**: - Begins before the surgery, considering the patient\'s home environment, support system, and postoperative needs. This ensures smooth recovery and proper follow-up care.  **Physical Assessment**: - Nurses must assess vital signs, respiratory function, cardiovascular status, and any history of venous thromboembolism (VTE) or implantable devices like pacemakers. Abnormal findings should be promptly reported to the surgical and anesthesia teams. - **Study Guide: Preoperative Assessment & Anesthesia Reactions** - **1. Preoperative Assessment** - The preoperative phase begins when the patient is scheduled for surgery and ends at the time of transfer to the surgical suite. Proper assessment is essential for identifying risk factors and preparing the patient for surgery. - **Key Components of Preoperative Assessment** - **Patient History**: - **Age**: Older adults are at increased risk for complications due to age-related changes in organs and systems. - **Medical History**: Chronic conditions (e.g., diabetes, hypertension, respiratory or cardiac disease) can increase surgical risks. - **Surgical History**: Past surgeries, especially with complications, should be noted. - **Anesthesia History**: Patients who have had complications with anesthesia or have a family history of anesthesia reactions (e.g., **malignant hyperthermia**) need special precautions. - **Medication History**: Current medications, particularly anticoagulants, immunosuppressive drugs, and chronic disease medications, should be documented. - **Allergies**: Allergies to anesthetic agents (e.g., propofol, latex), food (e.g., bananas, avocados), and medications should be documented. - **Substance Use**: Smoking, alcohol, and illicit drug use can affect anesthesia and healing. - **Preoperative Screening for Risk Factors** - **Age**: Older than 65 years is a risk factor for complications. - **Anticoagulant Use**: Increases the risk of bleeding. - **Immunosuppressive Drugs**: Can increase susceptibility to infections. - **Chronic Diseases**: Such as asthma, diabetes, heart disease, or obesity. - **Nutritional Status**: Both **malnutrition** and **obesity** can increase surgical risks. - **Substance Use**: Smoking increases the risk of pulmonary complications, and alcohol/substance use can alter responses to anesthesia. - - **2. Malignant Hyperthermia (MH)** - **Overview of Malignant Hyperthermia** - **Malignant Hyperthermia (MH)** is a rare, life-threatening condition triggered by certain anesthetic agents (e.g., **volatile anesthetics** like halothane, isoflurane, and the muscle relaxant **succinylcholine**). - **Genetic**: It is an inherited muscle disorder that can cause a hypermetabolic state during or after anesthesia. - **Signs and Symptoms of MH** - **Early Signs**: Tachycardia, hypercapnia (elevated CO₂), and muscle rigidity (especially in the jaw and upper chest). - **Later Symptoms**: - **Severe muscle rigidity**. - **Tachypnea** and **hypoxemia**. - **Hyperthermia** (elevated body temperature, but may not be present early). - **Arrhythmias**. - **Acidosis** and **elevated creatine kinase** (muscle breakdown). - **Management of MH** - **Immediate Intervention**: - **Discontinue triggering agents** (e.g., volatile anesthetics). - **Administer dantrolene sodium** (the antidote for MH). - **Supportive care**: Oxygen, fluids, cooling measures. - **Notify the surgical and anesthesia team** immediately if MH is suspected. - - **3. Anesthesia Reactions and Allergies** - **Types of Anesthesia Reactions** - **Anaphylactic Reactions**: Can occur with medications used during surgery (e.g., antibiotics, anesthetics). Symptoms include rash, difficulty breathing, and hypotension. - **Anesthesia Drug Sensitivities**: Some patients may react to specific anesthetic agents. Examples include: - **Propofol**: Contains egg lecithin and soybean oil, so patients with egg or soy allergies may have a reaction. - **Latex Sensitivity**: Patients allergic to latex (often those with allergies to certain fruits like bananas, avocados, and chestnuts) may react to latex-containing equipment. - **Preoperative Allergy Screening** - **Latex Sensitivity**: A history of fruit allergies (e.g., bananas, avocados, chestnuts) may indicate a latex sensitivity. - **Egg, Soy, Peanut Allergies**: Can indicate potential reactions to propofol, a common anesthetic agent. - **Medication History**: Assess for allergies to anesthetic agents, antibiotics, and analgesics. - **Tobacco Use and Anesthesia** - **Tobacco Use** increases the risk of respiratory complications due to its effects on the lungs, blood vessels, and oxygen exchange. - Smokers may need additional monitoring during anesthesia due to impaired lung function. - - **4. Preparing for Surgery: Key Considerations** - **Patient Education**: - Explain the importance of providing a complete medical and family history, especially regarding any reactions to anesthesia (e.g., malignant hyperthermia). - Discuss the **potential risks** based on their health history (e.g., diabetes, heart disease, substance use). - Inform the patient about the preoperative fasting requirements and what medications they should take before surgery. - **Lab and Diagnostic Tests**: - Ensure necessary tests (e.g., blood work, ECG, chest X-ray) are completed and reviewed prior to surgery. - Report any **critical lab values** (e.g., abnormal electrolytes, elevated white blood cell count) to the surgical team immediately. - **Discharge Planning (Begins Preoperatively)** - **Assess Home Environment**: Determine if the patient will need assistance with activities of daily living post-surgery. - **Support Systems**: Ensure the patient has family or friends available to help with recovery after surgery. - **Self-Care Capabilities**: Assess the patient's ability to manage their care, including medication adherence and follow-up appointments. - - **5. Nursing Interventions for Preoperative Patients** - **Physical Assessment**: Ensure vital signs are stable before surgery. Assess for any cardiovascular or respiratory issues that may complicate anesthesia. - **Informed Consent**: Confirm the patient understands the surgical procedure, anesthesia risks, and alternatives. - **Anxiety Management**: Offer reassurance, education, and relaxation techniques to alleviate preoperative anxiety. - **Report Abnormal Findings**: Immediately notify the surgeon or anesthesia team about any abnormal findings (e.g., abnormal vital signs, lab results). - - **6. Special Considerations for Older Adults** - **Anesthesia Risks**: Older adults are at higher risk for complications related to anesthesia due to decreased organ function and comorbidities. - **Preoperative Care**: Pay close attention to **polypharmacy**, the risk of **delirium**, and potential for slower recovery from anesthesia. - - **Key Points to Remember** - **Malignant Hyperthermia** is a genetic condition that requires special attention during anesthesia. Prompt recognition and intervention (dantrolene sodium) are critical. - Always **assess for allergies**, especially to anesthetic agents, latex, and foods (e.g., avocados, bananas). - **Substance use (smoking, alcohol, illicit drugs)** can significantly affect surgical outcomes and anesthesia. - **Older adults** have an increased risk of anesthesia complications. - **Comprehensive preoperative assessments** help identify potential complications and prepare the patient for surgery. - **Patient education and communication** are vital for ensuring a safe and successful surgical experience. - **Study Guide: Preoperative Patient Preparation and Safety Protocols** - This section of the study guide will focus on key preoperative procedures, including surgical site identification, NPO (nothing by mouth) status, medication management before surgery, and patient safety protocols to ensure the correct site and procedures. - - **1. Surgical Site Identification** - **Importance of Correct Site Identification**: - **Site-specific surgeries** (e.g., left, right, or bilateral procedures) require strict identification before surgery to avoid **wrong-site surgery**. - According to **The Joint Commission's National Patient Safety Goals (2023)**, surgical site marking is a critical safety measure to prevent such errors. - **Process for Site Marking:** - **Responsibility**: The **surgeon** is responsible for marking the surgical site. - **Patient involvement**: When the patient is alert and able, they should be involved in confirming the surgical site. - **Timing**: The site is marked **before the first incision** and should be verified by all operative team members, including the surgeon and surgical assistants. - **Team Responsibility**: Every member of the surgical team must verify the site marking to ensure accuracy. - - **2. NPO (Nothing by Mouth) Status** - **Definition of NPO**: The patient must remain **NPO (nothing by mouth)** before surgery, which includes: - **No food**, **no liquids** (including water), **no smoking**, and **no intake of oral medications**. - **Rationale**: This restriction reduces the risk of **aspiration** during surgery, as it ensures the stomach is empty when anesthesia is administered. - **Importance of Adhering to NPO Guidelines:** - **Risk of Aspiration**: Eating or drinking before surgery increases the risk of **aspiration pneumonia** and **gastric acid aspiration** into the lungs during surgery. - **Surgical Postponement**: Failure to comply with NPO restrictions can result in **postponing or canceling the surgery**. - **Increased Risk of Complications**: Adherence to NPO status is essential to prevent **complications** during anesthesia administration and surgery. - - **3. Medication Management on the Day of Surgery** - **Changes to Usual Drug Schedule**: - Many patients have regular medications that may need to be altered on the day of surgery. - **Consultation with the surgeon and anesthesia provider** is required to determine whether to administer or withhold medications. - **Common Medications and Their Management:** - **Diabetes Medications**: - **Insulin**: Insulin doses may be adjusted or withheld depending on the type of surgery and the patient's blood glucose levels. - **Cardiac Medications**: - **Beta-blockers**: These medications may be continued to maintain stable heart rates and blood pressure. - **Antihypertensive Medications**: - **Antihypertensives**: May be withheld before surgery to avoid **hypotension** or low blood pressure during anesthesia. - **Anticoagulants**: - **Blood thinners** (e.g., warfarin, aspirin) may need to be discontinued to reduce the risk of excessive bleeding during surgery. - **Anticonvulsants**: - Medications used for seizures may need to be adjusted to ensure the patient's safety and prevent complications during surgery. - **Drugs Typically Allowed with a Sip of Water:** - Medications related to **cardiac disease**, **respiratory conditions**, **seizures**, and **hypertension** are commonly allowed to be taken with a small sip of water before surgery. - - **4. Discontinuation of Certain Medications Before Surgery** - Some drugs may need to be stopped several days before surgery to reduce risks associated with anesthesia or surgery: - **Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors**: - These medications should be stopped **3-4 days before surgery** to reduce the risk of **ketoacidosis** and other complications during surgery. - - **5. Surgical Safety Protocols** - **The Role of the Surgical Team**: All members of the surgical team must confirm: - The correct **surgical site** has been marked. - The patient's **NPO status** is being strictly followed. - All necessary **medications** are being managed appropriately. - **Preoperative Verification Process:** - **\"Time-Out\"**: Before the surgical procedure begins, a **\"time-out\"** is conducted to verify: - The patient's identity. - The correct surgical site and procedure. - The presence of all necessary equipment and personnel. - - **Practice Questions** - **1. A patient is scheduled for surgery to remove a mass from their right kidney. Which of the following actions is required by the surgical team before beginning the procedure?** - A\) The surgeon must mark the surgical site with the patient's input. - B\) The anesthesia provider must confirm the surgical site. - C\) The nurse must confirm the surgical site before the patient enters the operating room. - D\) The surgical assistant is responsible for marking the site. - **Answer**: **A) The surgeon must mark the surgical site with the patient's input.**\ The surgeon is responsible for marking the surgical site, and the patient should be involved in the process when possible. - - **2. A patient is scheduled for surgery and has not followed the NPO guidelines, having eaten a light breakfast. What is the nurse's best action?** - A\) Proceed with the surgery if the patient feels fine. - B\) Inform the surgical team, as the surgery may need to be postponed. - C\) Administer an anti-nausea medication to prepare the patient for surgery. - D\) Allow the patient to have a sip of water and proceed. - **Answer**: **B) Inform the surgical team, as the surgery may need to be postponed.**\ Failure to follow NPO guidelines can increase the risk of aspiration, and the surgery may need to be postponed if the patient has eaten. - - **3. The nurse is preparing a patient who takes SGLT2 inhibitors for diabetes. When should these medications be stopped before surgery?** - A\) 1-2 days before surgery. - B\) The night before surgery. - C\) 3-4 days before surgery. - D\) These medications should not be stopped before surgery. - **Answer**: **C) 3-4 days before surgery.**\ SGLT2 inhibitors should be stopped 3-4 days before surgery to reduce the risk of complications like ketoacidosis. - - **4. Which of the following statements about marking the surgical site is true?** - A\) The surgical assistant should mark the site before surgery. - B\) The patient is not involved in marking the surgical site. - C\) The surgeon is responsible for marking the surgical site. - D\) Only the anesthesia provider is responsible for marking the surgical site. - **Answer**: **C) The surgeon is responsible for marking the surgical site.**\ The surgeon is responsible for marking the surgical site, and the patient should be involved if they are alert and able to participate. - - **Conclusion** - Proper **preoperative preparation** is essential for ensuring patient safety during surgery. The **surgical site** must be marked accurately to prevent errors, and patients must adhere to **NPO status** to reduce the risk of complications. Medication management, especially for chronic conditions, is a critical part of preoperative care. Understanding these protocols ensures a safer surgical experience for patients. - Top of Form - Bowel or intestinal preparations are necessary for surgeries that involve the **abdomen**, **pelvis**, **perineum**, or **perianal** areas. - **Primary goal**: To **prevent injury to the colon** and to **reduce intestinal bacteria** that could lead to infections. - **Bowel evacuation** is typically done through a **laxative regimen**, **enemas**, or **oral antibiotics** to clear the intestines of stool and bacteria. - The surgeon will determine the **specific bowel preparation method** based on the nature of the surgery and the patient's condition. - **Surgical Site Infections (SSIs)** are among the most common and costly health care--associated infections. - SSIs can lead to significant morbidity, increased length of hospital stay, additional treatments, and **increased health care costs**. - **Preoperative bathing**: Showering or bathing with an antiseptic solution (e.g., chlorhexidine gluconate) 1-2 days before surgery can help reduce bacteria on the skin. - **Hand hygiene**: Proper hand washing and sanitizing by the surgical team before the procedure is essential to prevent the introduction of pathogens. - **Hair removal**: Removing hair from the surgical site, when necessary, should be done carefully to avoid cuts or nicks that can introduce bacteria. - **Shaving** creates microscopic nicks in the skin, which increases the risk of infection. - If hair removal is needed, **electrical clippers** or **depilatory agents** (chemical hair removers) should be used, following **aseptic techniques** immediately before surgery. - **Antibiotic administration** is an important part of infection prevention. - Antibiotics should be administered so that they reach **peak effectiveness** in the patient\'s bloodstream and tissues before the incision is made. - This can help reduce the risk of **bacterial contamination** during the procedure. - Antibiotics should be given within **1 hour** before the surgical incision to maximize their effectiveness in preventing infection. - The choice of antibiotic will depend on the type of surgery being performed and the patient\'s risk factors. - **Hair removal** is sometimes required for surgeries involving areas where hair may interfere with the procedure (e.g., abdominal, pelvic, or perineal surgeries). - **Shaving** the area is **not recommended** because it increases the risk of cuts and nicks, which can become entry points for bacteria, leading to SSIs. - If hair removal is necessary, it should be done with the **least traumatic method**, using **electrical clippers** or a **depilatory agent**. - **Use electrical clippers** immediately before surgery, ensuring **aseptic techniques** are followed. - If **depilatory agents** (chemical hair removers) are used, they should be applied **in a sterile manner** to reduce contamination. - **Showering or bathing** with antiseptic solutions (e.g., **chlorhexidine gluconate**) before surgery can help reduce the microbial load on the skin and reduce the likelihood of SSIs. - Patients are typically asked to perform this **1-2 days before surgery** to optimize the antiseptic effect. - Ensure that the skin is completely dry before dressing the patient to prevent any irritation or further contamination. - **Purpose**: To **keep the bladder empty** and to monitor **urine output**. - **When it\'s used**: It may be placed **before**, **during**, or **after** surgery depending on the type of surgery and the patient\'s condition. - **Purpose**: To provide medications, fluids, and nutrients. - **Common Placement**: - **Arm**: A large-bore, short catheter (e.g., 18-gauge, 1-inch catheter) is often placed in the arm. - **Back of the hand**: A smaller-bore catheter (20-gauge) may be used in the hand. - **Purpose**: These exercises help **enlarge the chest cavity** and **expand the lungs** to improve oxygenation and prevent complications like pneumonia and atelectasis. - **How to teach**: 1. **Demonstrate** deep breathing (diaphragmatic breathing). 2. **Allow the patient** time to practice the technique. 3. **Return demonstration**: Have the patient show that they can do the breathing correctly. - **Purpose**: **Promotes complete lung expansion** and helps to prevent **pulmonary problems**, such as atelectasis and pneumonia. - **How to use**: The patient inhales deeply into the device, which encourages lung expansion. - **Purpose**: Coughing helps to **expel secretions**, **clear the lungs**, and prevent complications like **pneumonia** and **atelectasis**. - **Technique**: - Patients should cough **every 1 to 2 hours** after surgery. - **Splinting**: Support the surgical incision site (using a pillow, towel, or folded blanket) while coughing to reduce pain and provide stability. - Some patients, such as those who have had a **hernia repair** or **craniotomy**, may be instructed to **avoid coughing** by the surgeon to prevent complications. - In such cases, the surgeon will issue a **\"do not cough\"** order. - **Classic Finding**: **Sudden swelling in one leg** with a **dull ache in the calf** that worsens with walking. - DVT can lead to complications like **pulmonary embolism (PE)** if a clot travels to the lungs. - **Compression stockings**: Help improve circulation and prevent blood from pooling in the legs. - **Pneumatic compression devices**: These devices provide intermittent pressure to the legs to promote venous return and prevent clot formation. - **Early mobilization** after surgery is crucial to preventing VTE. It has multiple cardiovascular benefits, including: - **Stimulating intestinal motility** and reducing the risk of **constipation**. - **Enhancing lung expansion** and improving oxygenation. - **Promoting venous return** to the heart. - **Preventing joint rigidity** and **relieving pressure** in the legs. - **Purpose**: These exercises help to reduce the risk of complications like **venous stasis**, **DVT**, and **VTE**. - **Teaching the patient**: 1. **Demonstrate** leg exercises (e.g., flexing and extending the ankles). 2. Allow the patient time to practice the exercises and provide **return demonstrations** to ensure proper technique. - **Assess the patient's respiratory status** frequently after surgery to ensure they are able to clear secretions and maintain proper oxygenation. - **Monitor for signs of VTE**, such as **swelling** or **pain in the legs**. - **Instruct the patient** on the importance of using devices like **incentive spirometers** and performing **deep breathing exercises** to promote lung expansion. - **Document** and report any **abnormal findings** (e.g., signs of infection, impaired mobility, or respiratory distress). - **Encourage open communication**: It\'s essential to create a safe environment for patients to express their feelings, concerns, and fears without judgment. An honest and open approach builds trust and encourages dialogue. - **Address patient anxieties**: By explaining each step of the process and addressing any concerns the patient may have, the nurse can help alleviate anxiety and prepare the patient mentally for the procedure. - **Rings**: If the patient wears rings that cannot be removed, the nurse should **assess the risk for swelling** and may need to take precautions (e.g., marking the rings or using special removal techniques). - **Prosthetic Devices**: Items like **artificial eyes**, **limbs**, **contact lenses**, **wigs**, and **toupees** should be **removed** and safely stored or given to a family member or caregiver. - **Dentures**: The anesthesia provider may determine whether **dentures** should be removed before surgery. If left in place, there is a risk that they could become dislodged and obstruct the airway. The decision is made by the anesthesia provider based on the patient\'s specific needs. - **Fingernail Polish or Artificial Nails**: - Some hospitals have **policies** regarding the use of **fingernail polish** or **artificial nails**. - Studies have shown that **red nail polish** does not affect **oxygen saturation readings** from pulse oximetry. However, other colors may obscure readings, so hospitals may request that nail polish be removed to ensure accurate monitoring during surgery. - **Timing of Antibiotic Administration**: - **Prophylactic antibiotics** are typically administered within **30 minutes** before the surgical incision. - In some cases, antibiotics may be given between **31 and 60 minutes** before the incision, depending on the surgeon\'s protocol and the specific medication used. - **Prophylactic antibiotics** are typically given within **30 minutes** before the incision. If the surgery has been delayed for **3 hours**, the original timing of the antibiotic administration (at 0800) will no longer be within the ideal window. - The nurse should contact the **surgeon or anesthesia provider** to **reassess** whether the antibiotic should be **administered again** or if the first dose is still effective. Some guidelines recommend **re-dosing** the antibiotic if the surgical procedure is delayed significantly to ensure that the medication reaches peak efficacy in the tissues and bloodstream at the time of the incision. 1. **Airway and Breathing:** - **Initial Assessment**: When the patient is admitted post-surgery, assess for a patent airway immediately. - **Continuous Monitoring**: Use pulse oximetry to monitor oxygen saturation (SpO2), aiming for levels above 95% or the patient's pre-surgical baseline. Check lung sounds every 4 hours for the first 24 hours, then every 8 hours. - **Breathing Patterns**: Watch for slow (\