1. The Perioperative Experience

2. Perioperative Nursing – 3 phases

3. Preoperative phase: – From decision to have surgery to – Transfer into OR

4. Intraoperative phase: – From transfer to OR  admit to PACU

5. Postoperative phase – From PACU (Recovery Room)  DC from facility

6. Places where surgery can take place Hospital Surgical center attached to hospital Free-standing surgical center Physician’s office

7. Knightsbridge Surgery Center

8. Outpatient/Same-day Surgery l Also called ambulatory surgery ↓ length of hospital stay ↓ costs ↓ stress May ↑ need for: – extra teaching – home care services

9. Surgery based on : Urgency – Elective surgery – Urgent – Emergency

10. Surgery based on: Degree of Risk – Major – Minor

11. Surgery based on: Purpose – Diagnostic – Curative – Preventive – Ablative – Palliative – Reconstructive – Transplant – Constructive

12. Surgery based on: Extent of Surgery – Simple – Radical – Minimally invasive

13. Nurse’s roles Significant roles! – Educator – Promotes health and safety – Prevent complications after surgery, and – Patient advocate

14. P REOPERATIVE P HASE

15. Preparation for Surgery Includes Pre-admission Testing (P.A.T.): – Initial preop assessment – Teaching to fit patient’s needs – To verify pre-op diagnostic testing – To verify that patient understands pre-op orders

16. – Advanced-directive documents are completed and available

17. Patient is interviewed for P.A.T. Can take place: – By phone – Physician’s office – Anesthetic clinics – Pre-admission Testing Dept.

19. Purpose of Interview Obtain patient information Provide information to patient Get patient’s consent for surgery Assess patient’s (and family) emotional state and readiness for surgery Explore patient’s expectations

20. Roles of the Nurse in Preoperative Nursing Assessment Teaching patient and family

21. Assessment of Pre-op Patient

22. Assess Patient Risk Factors and Strengths Developmental level Medical history – Lung/heart conditions Medications Previous surgeries – reaction to anesthesia?

23. Nutritional status – Diabetes, obese, malnourished Use of alcohol, illicit drugs, or nicotine ADL and occupation Coping patterns, support systems Sociocultural needs

24. Assess Surgical Risks of Medications Anticoagulants Diuretics Tranquilizers – ↑ hypotensive effects of anesthetic agents

25. Steroids – abrupt withdrawal may cause cardiovascular collapse OTC-ASA – bleeding

26. Assess History of Substance Abuse Alcoholics - ETOH – poor liver function – poor metabolism of anesthesia/meds Smokers - should stop 2-6 weeks ahead

27. Psychosocial Assessment Common fears include: –

28. Nursing Interventions to Meet Psychological Needs of Surgical Patients Allow patient to verbalize fears and concerns. Use active listening skills to identify anxiety and fear. Use of touch. Answer questions.

29. Physical Exam Prior to the day of surgery or on the day of surgery Completed by anesthesiologist or advanced practitioner

30. Weigh patient Vital Signs Basic head-to-toe assessment

31. Usual Presurgical Screening Tests Chest x-ray Electrocardiography Complete white blood count (WBC) Electrolyte levels Urinalysis

32. Nurse’s Role in Presurgical Testing Ensure tests are explained to the patient Ensure results are recorded in patient records before surgery Ensure that abnormal results are reported

33. Nurse’s Role …. Preoperative teaching. Informed consent: – Surgeon obtaines signed consent before sedation and/or surgery. – The nurse: clarifies facts presented by the physician dispels myths that the patient or family may have about surgery.

34. Informed Consent Should be in writing Should contain: – Explanation of procedure, risks – Description of benefits, alternatives – Offer to answer questions about procedure – Instructions that patient may withdraw consent – Statement informing patient if protocol differs from customary procedure

35. Voluntary Consent Valid consent freely given, without coercion Patient must be at least 18 years of age (unless emancipated minor) Consent must be obtained by physician Patient’s signature must be witnessed by professional staff member

36. Incompetent Patient Individual who is not autonomous Cannot give or withhold consent – Cognitively impaired – Mentally ill – Neurologically incapacitated

37. General Preoperative Nursing Interventions Provide psychosocial interventions – Reduce anxiety, decrease fear – Respect cultural, spiritual, religious beliefs Maintain patient safety Manage nutrition, fluids Prepare bowel Prepare skin

38. Provide Preoperative Teaching Very important! Include: – Day-of-surgery events – Time to arrive, time of surgery

39. Teach: What to expect in each phase

40. Teach Coughing & Deep Breathing (C & DB): Purpose:

42. Some Key Points: Sit up as straight as possible Breathe in through nose, out through mouth Take approximately 3 breaths, then cough Splint! Praise your patient!

45. Teach about Incentive Spirometer (IS) Increases lung volume Inflates alveoli Prevents atelectasis

47. Teach other ways to prevent respiratory complications: Turn in bed every 2 hours Ambulate Maintain hydration Avoid positioning that decreases ventilation

48. Prevent Cardiovascular Complications Be aware of patients at greater risk for DVT Antiembolism stockings Pneumatic compression devices Leg exercises Mobility

49. Teach how to Prevent blood clots Teach leg exercises: – 5-10 repetitions each extremity every 1-2 hours – Gastrocnemius (calf) pumping While lying in bed, pull your toes back toward your knees, then point your toes down.

51. – Quadriceps (thigh) setting While lying in bed, tighten thigh muscles and press knee into bed. Count to 5 and relax

52. Apply External Pneumatic Compression Devices

54. Promote Turning and Active Body Movements Improves respiratory air exchange Improves circulation Decreases venous stasis

55. Increases peristalsis: – Prevents constipation or paralytic ileus – Relieves gas pain Turn side to side, up in chair, walk in hall

57. Implement Dietary Restrictions NPO: Patient advised not to ingest anything by mouth for 6 to 8 hours before surgery: – Decreases the risk for aspiration. – Patients should be given written and oral directions to stress adherence. – Surgery can be cancelled if not followed.

58. Administering Regularly Scheduled Medications Consult with MD and anesthesia provider re: meds taken regularly – Should patients take them or not?

59. Preoperative Drugs Reduce anxiety Promote relaxation Reduce nasal and oral secretions Prevent laryngospasm Reduce vagal-induced bradycardia Inhibit gastric secretion Decrease the amount of anesthetic needed for the induction and maintenance of anesthesia

60. Preop drugs that might be prescribed: Handout

61. After preanesthetic med is given: Keep patient in bed with side rails up Watch for adverse effects Keep environment quiet Medication may be “on call” if surgery is delayed or schedule changes

62. Intestinal Preparation Bowel or intestinal preparations performed: – to prevent injury to the colon – to reduce number of intestinal bacteria. Enema or laxative may be ordered by the physician.

63. Skin Preparation A break in the skin increases risk for infection. Patient may be asked to shower using antiseptic solution.

64. Skin Preparation for Common Surgical Sites

65. Other Use of bedpan or urinal post-operatively Pain control

66. Nursing Interventions just prior to patient going to OR: Administer preanesthetic medication Maintain preoperative record Verify that patient has followed food/fluid restrictions Have patient empty bladder Transport patient to presurgical area Attend to family needs After patient leaves, prepare room and make a postoperative bed

68. Voiding Pre-Operatively Immediately before pre-op med

69. Patient Transfer to Surgical Suite (Preoperative Holding area)

70. Nursing Diagnoses for Preoperative Patient Anxiety Risk for Infection Knowledge Deficit And more…

71. Outcomes for the Surgical Patient Be free from injury and adverse effects Be free from infection and DVT Maintain fluid and electrolyte balance; skin integrity, normal temperature

72. Have pain managed Demonstrate understanding of physiologic and psychological responses to surgery Participate in rehabilitation process Be educated on what to do after surgery – In the hospital – At home