Category: Nursing The Individual 2

Perioperative Nursing Care

Perioperative nursing care includes:

1. Preoperative Phase: when the patient is prepared and transferred to the theatre prior to undergoing surgery;
2. Intraoperative Phase: during surgery and in the recovery room;
3. Postoperative Phase: from the recovery room to the ward and until discharge, ending completely after being reviewed at the Outpatients Department.

Preoperative Nursing Care

Surgery may be required for the following reasons:

• when further exploration is required to reach a proper diagnosis
• as a preventative measure such as for the prevention of cancer spread
• for treatment purposes
• for palliative purposes such as the removal of tumors
• for cosmetic and reconstructive purposes

PLANNED SURGERY: not an urgent requirement. It is usually scheduled weeks, months and at times years ahead.

EMERGENCY SURGERY: urgent requirement, usually performed for lifesaving purposes, as well as to stop bleeding (eg. internal bleeding) or to preserve an organ or limb (eg. in compound/open fractures where bones are protruding from the skin.

Types of surgeries:

• Minor Surgery (eg. cyst removal or suturing)
• Minimally Invasive (eg. infiltrations, injections)
• Keyhole Surgery (eg. laparoscopy)
• Major Surgery (eg. hysterectomy)

Preoperative Considerations include:

MEDICAL HISTORY: this should include information about the patient’s current health condition, known allergies, current medications list, drug abuse, past surgeries experience if any, and the identification of risk factors especially in the case of past problems with anesthesia.

PSYCHOSOCIAL STATE: evaluating the patient’s situation in relation to psychological and social wellbeing can help identify possible barriers to the recovery phase post-surgery. Reassurance can help alleviate fear, anxiety and stress pre-surgery. If needed, a patient can be referred to a social worker for additional support eg. if patient has left children behind at home, alleviating fears and concerns about their care helps reduce the person’s anxiety and stress.

EDUCATION: the patient should be provided with clear and understandable explanation with regards to what the surgery entails as well as what perioperative nursing care may be required, both verbally and in writing. The patient should also be advised about postoperative monitoring equipment which may be needed, as well as possible tubes, drains and other related equipment use in perioperative nursing care. Pain management should also be discussed with the patient in advance.

INVESTIGATION: blood tests (including CBC, urea, electrolytes and creatinine, INR or APTT and glucose), X-Rays, MRIs and CT Scans, ECG and a crossmatch (a.k.a. X-Match). Wherever possible, preoperative care should include the treatment of any existing infections, monitoring and if possible stabilising existing chronic diseases such as hypertension and diabetes, dietary deficiency and fluid and electrolyte imbalance correction, and if need be, weightloss in obese patients.

RISK FACTORS: can impact surgery success and recovery. Risk factors include age, malnutrition or obesity, pregnancy, as well as infection, diabetes, CVD, renal disease, malignancy, pulmonary disease, hepatic disease, immobility and hypovolaemia (excessive bleeding).

INFORMED CONSENT: patient signature should be acquired by the consultant prior to surgery. The nurse should make sure that information about the procedure or surgery is provided and any questions are addressed so the patient is able to give informed consent; the nurse should also make sure that informed consent has been acquired.

Preoperative Nursing Care:

• address anxiety through communication and if needed adding music therapy, deep breathing, etc; address any body image concerns in relation to the surgery
• nail polish should be remove so SP02 can be monitored correctly
• bathing (4% chlorhexidine solution if patient is MRSA colonised; 2% chlorhexidine solution if undergoing a major operation; soap and water if patient is undergoing minor operation
• shaving should be done using hair clipper so as to avoid skin abrasions, thus minimising the risk of developing a Surgical Site Infection; shaving should be done closest to the surgery time so as to avoid having enough time for bacteria from cultivating within any possible skin abrasions
• make sure surgery site has been pre-marked by surgeon or consultant prior to being transferred to the theatre
• keep patient warm using blankets if needed, as this will help prevent development of SSIs
• surgical site observation
• monitoring and documentation of patient vital signs
• fasting and/or intake restrictions
• possible need of medication restriction eg. drugs affecting coagulation
• checking for dentures and loose teeth
• bowel preparation (if needed)
• tubes eg. nasogastric tube or urinary catheter (although these may be inserted during surgery)
• administration of recommended pre-surgery medication eg. prophylactic antibiotics
• completing pre-op checklist
• if a patient with diabetes is scheduled for surgery, he should be started on the diabetic protocol since being NBM makes him prone to hypoglycaemia
• in the case of an amputation, make sure that the leg to be amputated has been marked by the physician
• if patient has left children behind at home, talk and empathise with the patient to help alleviate any concerns; if need be, refer to a social worker so as to ensure help will be provided during this time and during post-op period
• if spiritual concerns are involved eg. existential problems, referring to a spiritual advisor may also help
• if patient seems to be experiencing psychological issues in relation to surgery, referring to a psychologist may help
• if patient is eager to know, explain the whole procedure eg. where patient is to be transferred to, what to expect right after surgery, recovery area, post-op pain management, etc.

NOTE: If patient is on Steroids pre-op for inflammation, consider that steroid side-effects include hyperglycaemia (attn. if patient is diabetic), affecting the immune system (attn. if patient is immunocompromised), and affecting the peripheral nervous system (attn. if patient has been or is being amputated or has existing issues with his arms and legs).

Transferring patient from ward to the theatre:

1. Check patient ID
2. Check allergy bracelet
3. Explain procedure
4. Ensure patient safety
5. Provide accurate handover to the theatre nurse

Postoperative Nursing Care

This period starts right after surgeons finish the operation (an anesthetist and a theatre nurse stays with the patient after surgeon leaves), up until the 1st review after discharge as an outpatient.

Patient Assessment Right After Surgery

PULSE: monitor pulse volume and regularity

SKIN: check for any signs of cyanosis and monitor SPO2

CONSCIOUSNESS: is the patient conscious or semi-conscious? Prior to transfer to ward, patient should be fully conscious

AIRWAY: assess respiratory rate and depth

Patient Assessment In Recovery Room

• understand and follow up on anesthetist and surgeon’s instructions
• pain management: PCA pump if provided; prescribed medication, including PRN medication if needed
• monitor vital signs and level of consciousness
• assess level of pain, at rest and when ambulating; if noticing increased pain during ambulation, prophylactic pain medication may be administered pre-ambulation so as to reduce the pain and increase effectiveness of ambulation
• monitor surgical site for bleeding and signs of infection
• monitor input and output for urinary retention and/or for renal function indications
• assess for signs of complications post-surgery, especially in relation to cardiovascular and pulmonary related comorbidities eg. Pneumonia (see pneumonia prevention section in link for preventative measures)
• monitor for fluid imbalance (possible loss of fluid during surgery)
• report any changes in patient condition and document changes
• keep NBM for a couple of hours due to relaxed reflexes as an effect of anaesthesia
• for diabetic patients, keep monitoring for hypoglycaemia especially whilst NBM

Patient Transfer From Theatre to Ward

Patient needs to be fully conscious and stabilised before being transferred to the ward. Monitor for any neurological impairment such as lack of movement of limbs, IV fluids and drip rate, drains, as well as same monitoring undergone in the recovery room.

Post-Surgery Investigations

• check CBC (haemoglobin due to bleeding during and post-surgery, white cells, platelets, sodium, potassium, urea [to monitor for kidney function], creatinine and glucose [in diabetic patients, glucose status should be checked routinely])
• X-Rays
• MRI
• CT Scan

Patient Care In The Ward

• Observe IV Infusion,IV Pumps and Cannula Site
• Assess For Nausea: patient may be administered an antiemetic drug to prevent nausea and vomiting
• Personal Hygiene: bathing and mouth care
• Patient Repositioning: to avoid pressure sores
• Monitor for Confusion and Delirium
• In case of Altered Level of Consciousness post-op, provide safety eg. side rails pulled up, personal items at reach etc
• Monitor for Drug Allergy Symptoms
• Patient Mobilisation: earliest possible ambulation if not contraindicated as it helps prevent complications in relation to respiration, deep vein thrombosis and pulmonary oedema; assist during ambulation
• Encourage Deep Breathing and Coughing Exercises
• Promote Exercise and Movement
• Ensure Adequate Fluid Intake: start with encouraging small sips if not contraindicated
• Wound Care: assess for infection and change dressings as required
• Tracheostomy Care: including suctioning if present
• Monitor for Urinary Retention: can cause restlessness, bladder distension, suprapubic discomfort and confusion; insert catheter to eliminate retention and confusion
• If Increased Wound Bleeding is noticed, DO NOT remove the existing bandages, but apply extra pressure with another bandage on top and inform physician

Tackling Loss in Perioperative Nursing – Stages of Loss / Stages of Grief

Below you can find a collection of videos that can help provide a more visual approach to perioperative nursing – preoperative, intraoperative and postoperative care.

Preoperative Nursing Care

Intraoperative Nursing Care

Postoperative Nursing Care

Types of Wound Drainage

Caring for a Post-Surgery Wound Drainage System and Gauze Dressing

Suture Removal & Steri-Strips Application

Surgical Staples Removal

Delirium Simulation and Care

Patient Discharge Planning

Special thanks to the creators of the featured videos on this post, specifically Youtube Channel NCLEX Study Guide, RN Kid, MD Anderson Cancer Center, RegisteredNurseRN, Western Australian Clinical Training Network and Oakwood Healthcare.

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