Treatment aspects : Pre/Post Operative Care & Pharmacological Aspects
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This document discusses various aspects of pre-operative care for patients undergoing surgery. It covers obtaining informed consent, assessing patient health factors like nutrition and medications, and providing pre-operative education. Key areas of focus include getting consent, evaluating respiratory, cardiac, and immune function, reviewing medications, and addressing psychosocial concerns. The goal is to optimize patient health and prepare them physically and emotionally for surgery.
Treatment aspects : Pre/Post Operative Care & Pharmacological Aspects
- 1. TREATMENT ASPECTS: PHARMACOLOGICAL & PRE/POST OPERATIVE CARE ASPECTS - BY KHYATI CHAUDHARI - I YEAR MSc Student - CMPCON, Gandhinagar.
- 2. INTRODUCTION • Surgery can be defined as the art & science of treating diseases, injuries & deformities by operation and instrumentation. The surgical procedures involve the interaction of a patient, surgeon, anesthesia care provider and nurse. Surgery may be performed for diagnosis, cure, prevention, exploration or cosmetic improvement. • Regardless of what the surgery is, the nurse has a vital role in preparing the patient for surgery, caring for patient during surgery and facilitating the patient’s recovery following surgery. To perform these functions effectively, the nurse must have knowledge requiring surgery and any co-existing disease processes. The nurse must assess the result of appropriate pre-operative diagnostic tests.
- 3. PRE-OPERATIVE CARE Pre-operative care of the patient begins as soon as the surgeon makes a diagnosis and decides that an operation is necessary for the patient.
- 4. INFORMED CONSENT • Voluntary and written informed consent from the patient is necessary before non- emergent surgery can be performed. Such written consent protects patient from, unsanctioned surgery and protects the surgeon from claims of an unauthorized operation. In the best interests of all parties concerned, sound medical, ethical and legal principles are followed. The nurse may ask the patient to sign the form and may witness the patient’s signature. It is the physician’s responsibility to provide appropriate information.
- 5. CRITERIA FOR VALID INFORMED CONSENT Voluntary Consent Valid consent must be freely given, without coercion. Incompetent Patient individual who is not autonomous and cannot give or withhold consent (e.g. individual who are mentally retarded, mentally ill or comatose).
- 6. Informed Subject Informed consent should be in writing. It should contain the following: • Explanation of procedure and its risks. • Description of benefits and alternatives. • An offer to answer questions about procedure. • Instructions that the patient may withdraw consent. • A statement informing the patient if the protocol differs from customary procedure
- 7. PATIENT ABLE TO COMPREHEND
- 8. • Information must be written and delivered in language understandable to the patient. Questions must be answered to facilitate comprehension if material is confusing. • Many ethical principles are integral to informed consent. Before the patient signs the consent form, the surgeon must provide a clear and simple explanation of what the surgery will entail. • The surgeon must also inform the patient of the benefits, alternatives, possible risks, complications, disfigurement, disability and removal of body parts as well as what to expect in the early and late post-operative periods. If the patient needs information to make his or her decision, the nurse modifies the physician about this. Also, the nurse ascertains that the consent form has been signed before administering psychoactive premedication, while the patient was under the influence of medications that can affect judgement and decision-making capacity.
- 9. • Informed consent is necessary in the following circumstances. Invasive procedures, such as surgical incision, a biopsy, a cystoscopy or paracentesis. Procedures requiring sedation and/or anesthesia. A nonsurgical procedure, such as an arteriography, that carries more than slight risk to the patient. Procedure involving radiation.
- 10. • The patient personally signs the consent if he or she is of legal age and is mentally capable. When the patient is a minor or unconscious or incompetent, permission must be obtained from a responsible family member or legal guardian. An emancipated minor may sign his/her own consent form. State regulations and agency policy must be followed. In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without a patient’s informed consent. Every effort, however, must be made to contact the patient’s family. In such a situation, contact can be made by telephone, fax or other electronic means.
- 11. • When the patient has doubts and has not had the opportunity to investigate alternative treatments, a second opinion may be requested. No patient should be urged or pressured to sign an operative permit. Refusing to undergo a surgical procedure is a person’s legal right and privilege. However, such information must be documented and relayed to the surgeon so that other arrangements can be made. For example, additional explanations may be provided to the patient and family or the surgery may be rescheduled. • The consent process can be improved by providing audiovisual materials to supplement discussion, by ensuring that the wording of the consent form is understandable and by using other strategies and resources as needed to help the patient understand its content.
- 12. ASSESSMENT OF HEALTH FACTORS THAT AFFECTS PATIENTS PRE-OPERATIVELY
- 13. • The overall goal in the pre-operative period is for the patient to have as many positives health factors as possible. Every attempt is made to stabilize those conditions that leads to smooth recovery. When negative factors dominate the risks of surgery and post-operative complications may increase. • Before any surgical treatments is initiated, a health history is obtained, a physical examination is performed during which vital sign are noted and a database is established for future comparisons.
- 14. Blood tests, x-rays and other diagnostic tests are prescribed when specifically indicated by information obtained from a thorough history and physical examination. These preliminary contacts with the healthcare team provide the patient with the opportunities to ask questions and to become acquainted with those who may be providing care during and after surgery. 1. Nutritional and Fluid status 2. Drug and Alcohol use 3. Respiratory status 4. Cardiovascular function 5. Hepatic and Renal function 6. Endocrine function 7. Immune function 8. Previous Medication use 9. Psychological factors 10. Spiritual and Cultural beliefs
- 15. 1. Nutritional and Fluid status Optimal nutrition is an essential factor in promoting healing and resisting infection and other surgical complications. Assessment of a patient's nutritional status provides information on obesity, under nutrition, weight loss, malnutrition, deficiencies in specific nutrients, metabolic abnormalities, the effects of medications on nutrition, and special problems of the hospitalized patient. Nutritional needs may be determined by measurement of body mass index and waist circumference. Any nutritional deficiency, such as malnutrition, should be corrected before surgery so that enough protein is available for tissue repair. Dehydration, hypovolemia, and electrolyte imbalances can lead to significant problems in patients with present medical conditions or in elderly patients. The severity of fluid and electrolyte imbalances is often difficult to determine.
- 16. Mild volume deficits may be treated during surgery; however, additional time may be needed to correct pronounced fluid and electrolyte deficits to promote the best possible preoperative condition.
- 17. 2. Drug or Alcohol Use People who abuse drugs or alcohol frequently deny or attempt to hide it. In such situations, the nurse who is obtaining the patient's health history needs to ask frank questions with patience, care, and a non-judgmental attitude. Because acutely intoxicated persons are susceptible to injury, surgery is postponed in these patients if possible. If emergency surgery is required, local, spinal, or regional block anesthesia is used for minor surgery. Otherwise, to prevent vomiting and potential aspiration, a nasogastric tube is inserted before administering general anesthesia. The person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase the surgical risk. Additionally, alcohol withdrawal delirium (delirium tremors) may be anticipated up to 72 hours after alcohol withdrawal. Delirium tremors are associated with a significant mortality rate when it occurs postoperatively.
- 18. 3. Respiratory Status The goal for potential surgical patients is optimal respiratory function. Patients are taught breathing exercises and use of an incentive spirometer if compromised during all phases of surgical treatment; surgery is usually postponed when the patient has a respiratory infection. Patients with underlying respiratory disease (e.g., asthma, chronic obstructive pulmonary disease) are assessed carefully for current threats to their pulmonary status. Patient's use of medications that may affect recovery is also assessed. Patients who smoke are urged to stop 2 months before surgery. These patients should be counselled to stop smoking at least 24 hours prior to surgery. Research suggests that counselling has a positive effect on the patient's smoking behaviour 24 hours preceding surgery, helping reduce the potential for adverse effects associated with smoking such as increased airway reactivity, decreased mucociliary clearance, as well as physiologic changes in the cardiovascular and immune systems.
- 19. 4. Cardiovascular Status The goal in preparing any patient for surgery is to ensure a well functioning cardiovascular system to meet the oxygen, fluid, and nutritional needs of the peri- operative period. If the patient has uncontrolled hypertension, surgery may be postponed until the blood pressure is under control. Because cardiovascular disease increases the risk for complications, patients with these conditions require greater- than-usual diligence during all phases of nursing management and care. Depending on the severity of the symptoms, surgery may be deferred until medical treatment can be instituted to improve the patient's condition. At times, surgical treatment can be modified to meet the cardiac tolerance of the patient. For example, in a patient with obstruction of the descending colon and coronary artery disease, a temporary simple colostomy may be performed rather than a more extensive colon resection that would require a prolonged period of anesthesia.
- 20. 5. Hepatic and Renal Function The pre surgical goal is optimal function of the liver and urinary systems so that medications, anesthetic agents, body wastes, and toxins are adequately processed and removed from the body. The liver is important in the biotransformation of anesthetic compounds. Therefore, any disorder of the liver has an effect on how anesthetic agents are metabolized. Because acute liver disease is associated with high surgical mortality, preoperative improvement in liver function is a goal. Careful assessment is made with the help of various liver function tests. Because the kidneys are involved in excreting anesthetic drugs and their metabolites, acid-base status and metabolism are also important considerations in anesthesia administration. Surgery is contraindicated when a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems. The exception is surgery that is performed as a lifesaving measure or that is necessary to improve urinary function, as in the case of an obstructive uropathy.
- 21. 6. Endocrine Function The patient with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or from excessive administration of insulin. Hyperglycemia, which may increase the risk for surgical wound infection, may result from the stress of surgery, which may trigger increased levels of catecholamine. Other risks are acidosis and glycosuria. Although the surgical risk in the patient with controlled diabetes is no greater than in the nondiabetic patient, the goal is to maintain the blood glucose level at less than 200 mg/dL.
- 22. Frequent monitoring of blood glucose levels is important before, during, and after surgery. Patients who have received corticosteroids are at risk for adrenal insufficiency. Therefore, the use of corticosteroids for any purpose during the preceding year must be reported to the anesthesiologist or anesthetist and surgeon. Additionally, the patient is monitored for signs of adrenal insufficiency. Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis (with hyperthyroid disorders) and respiratory failure (with hypothyroid disorders). Therefore, the patient is assessed for a history of these disorders.
- 23. 7. Immune Function An important function of the preoperative assessment is to determine the existence of allergies, including the nature of previous allergic reactions. It is especially important to identify and document any sensitivity to medications and past adverse reactions to these agents. The patient is asked to identify any substances that precipitated previous allergic reactions, including medications, blood transfusions, contrast agents, latex, and food products, and to describe the signs and symptoms produced by these substances. Immunosuppression is common with corticosteroid therapy, renal transplantation, radiation therapy, chemotherapy, and disorders affecting the immune system, such as acquired immunodeficiency syndrome (AIDS) and leukemia. The mildest symptoms or slightest temperature elevation must be investigated. Because patients who are immunosuppressed are highly susceptible to infection, great care is taken to ensure strict asepsis.
- 24. 8. Prepare Medication Care Unit A medication history is obtained from each patient because of the possible effects of medications on The patient's perioperative and perianesthesia course and the possibility of drug interactions. Any medication the patient is using or has used in the past is documented, including over-the-counter (OTC) preparations and herbal agents and the frequency with which they are used. Potent medications have an effect on physiologic functions; interactions of such medications with anesthetic agents can cause serious problems, such as arterial hypotension and circulatory collapse.
- 25. The potential effects of prior medication therapy are evaluated by the anesthesiologist or anesthetist, who considers the length of time the patient has used the medications, the physical condition of the patient, and the nature of the proposed surgery. Many patients take self-prescribed or OTC medications. Aspirin is a common OTC medication prescribed by physicians or taken independently by patients to prevent myocardial infarction, stroke, and other disorders. Because of the effects of aspirin or other OTC medications and possible interactions with other medications and anesthetic agents, it is important to ask a patient about their use. The information is noted in the patient's chart and conveyed to the anesthesiologist or anesthetist and surgeon.
- 26. • The use of herbal medications is widespread among patients. Patients with chronic illnesses may be using herbal medications to supplement their prescribed medications or in place of them. Certain herbal medications, such as Ephedra, Gingko, Ginseng, Garlic, Kava kava are used.
- 28. GINKGO EPHEDRA
- 29. 9. Psychosocial Factors All patients have some type of emotional reaction before any surgical procedure, be it obvious or hidden, normal or abnormal. For example, preoperative anxiety may be an anticipatory response to an experience the patient views as a threat to his or her customary role in life, body integrity, or life itself. Psychological distress directly influences body functioning. Therefore, it is imperative to identify any anxiety the patient is experiencing. By taking a careful health history, the nurse elicits patient concerns that can have a hearing on the course of the surgical experience. Undoubtedly, a patient about to undergo surgery is faced with various fears, including fears of the unknown, of death, of anesthesia, pain, or cancer. Concerns about loss of work time, loss of job, increased responsibilities or burden on family members, and the threat of permanent incapacity further contribute to the emotional strain created by the prospect of surgery. Less obvious concerns may occur because of previous experiences with the health care system and people the patient has known with the same condition.
- 30. People express fear in different ways. For example, one patient may repeatedly ask a lot of questions, even though answers were given previously. Another person may withdraw, deliberately avoiding communication, perhaps by reading or watching television. Still others may talk about trivialities. Consequently, the nurse must be empathetic, listen well, and provide information that helps alleviate concerns. An important outcome of the psychosocial assessment is the determination of the extent and role of the patient's support network. The value and reliability of all available support systems are assessed. Other information, such as usual level of functioning and typical daily activities, may assist in the patient's care and rehabilitation plans. Assessing the patient's readiness to learn and determining the best approach to maximize comprehension will provide the basis for preoperative patient education.
- 31. 10. Spiritual and Cultural Beliefs Spiritual beliefs play an important role in how people cope with fear and anxiety. Regardless of the patient's religious affiliation, spiritual beliefs can be as therapeutic as medication. Every attempt must be made to help the patient obtain the spiritual help that he or she requests. Faith has great sustaining power. Thus, the beliefs of each patient should be respected and supported. Some nurses avoid the subject of a clergy visit lest the suggestion alarm the patient. Asking if the patient's spiritual advisor knows about the impending surgery is a caring, nonthreatening approach. Showing respect for a patient's cultural values and beliefs facilitates rapport and trust Some areas of assessment include identifying the ethnic group to which the patient relates and the customs and beliefs the patient holds about illness and health care providers.
- 32. For example, patients from some cultural groups are unaccustomed t expressing feelings openly. Nurses need to consider this pattern of communication when assessing pain. As a sign of respect, people from other cultural groups may not make direct eye contact with others. The nurse needs to know that this lack of eye contact is not avoidance or a lack of interest. Perhaps the most valuable skill at the nurse's disposal is listening carefully to the patient, especially when obtaining the history. Invaluable information and insights may be gained by engaging in conversation and using communication and interviewing skills. An unhurried, understanding, and caring nurse invites confidence on the part of the patient.
- 34. Pre-operative teaching Nurses have long recognized the value of preoperative instruction . Each patient is taught as an individual , with consideration for any unique concerns or needs ; the program of instruction should be based on the individual's learning needs . Multiple teaching strategies should be used ( e.g. , verbal , written , return abilities demonstration ) , depending on the patient's needs and abilities. Preoperative teaching is initiated as soon as possible . It should start in the physician's office and continue until the patient arrives in the operating room.
- 35. When and What to Teach Ideally, instruction is spaced over a period of time to allow the patient to assimilate information and ask questions as they arise . Frequently, teaching sessions are combined with various preparation procedures to allow for an easy and timely flow of information. The nurse should guide the patient through the experience and allow ample time for questions. Some patients may feel too many descriptive details will increase their anxiety level and the nurse should respect their wish for less detail. Teaching should go beyond descriptions of the procedure and should include explanations of the sensations the patient will experience. For example, telling the patient only that preoperative medication will relax him or her before the operation is not as effective as also noting that medication may result in light headedness and drowsiness.
- 36. • Knowing what to expect will help the patient anticipate these reactions and thus attain a higher degree of relaxation than might otherwise is expected. The ideal timing for preoperative teaching is not on the day of surgery but during the preadmission visit when diagnostic tests are performed. At this time, the nurse or resource person answers questions and provides important patient teaching. During this visit. patient can meet and ask questions of the pre-operative nurse, view audiovisuals, receive written materials and be given the telephone number to call as questions arise closer to the date of surgery. Most institutions provide written instructions (designed to be copied and given to patients) about many types of surgery.
- 37. Deep-Breathing, Coughing, and Incentive Spirometers One goal of preoperative nursing care is to teach the patient how to promote optimal lung expansion and consequent blood oxygenation after anesthesia, The patient assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and how to exhale slowly. After practicing deep breathing several times, the patient is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs. The nurse also demonstrates how to use an incentive spirometer, a device that provides measurement and feedback related to breathing effectiveness. In addition to enhancing respiration, these exercises may help the patient to relax.
- 38. • If there will be a thoracic or abdominal incision, the nurse demonstrates how the incision line can be splinted to minimize pressure and control pain. The patient should put the palms of both hands together, interlacing the fingers snugly. Placing the hands across the incisional site act as an effective splint when coughing. Additionally, the patient is informed that medications are available to relieve pain and should be taken regularly for pain relief so that effective deep- breathing and coughing exercises can be performed. The goal in promoting coughing is to mobilize secretions so they can be removed. Deep breathing before coughing stimulates the cough reflex. If the patient does not cough effectively, atelectasis (lung collapse), pneumonias, and other lung complications may occur.
- 39. Mobility and Active Body Movement The goals of promoting mobility postoperatively are to improve circulation, prevent venous stasis, and promote optimal respiratory function The nurse explains the rationale for frequent position changes after surgery and then shows the patient how to turn from side to side and how to assume position without causing pain or disrupting intravenous lines, drainage tubes, or other equipment. Any special position the individual patient will need to maintain after surgery(e.g. adduction or elevation of an extremity) is discussed, as is the importance of maintaining as much possible despite restrictions. Reviewing the process before surgery is helpful because the patient may be too uncomfortable after surgery to absorb new information.
- 40. • Exercises of the extremities include extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side). The foot is rotated as though tracing the largest possible circle with the great toe. The elbow and shoulder are also put through range of motion. At first, the patient is assisted and reminded to perform these exercises. Later, the patient is encouraged to do them independently. Muscle tone is maintained so that ambulation will be easier. The nurse should remember to use proper body mechanics and to instruct the patient to do the same. Whenever the patient is positioned, his or her body needs to be properly aligned.
- 41. Pain Management An assessment should include a determination between acute and chronic pain so that the patient may differentiate postoperative pain from a chronic condition. It is at this point that a pain scale should be introduced and its use explained to the patient. Postoperatively, medications are administered to relieve pain and maintain comfort without increasing the risk for inadequate air exchange. The patient instructed to take the medication as frequently as prescribed during the initial postoperative period for pain relief. Anticipated methods of administration of analgesic agents for inpatients include patient- controlled analgesia (PCA), epidural catheter bolus or infusion, or patient controlled epidural analgesia (PCEA). A patient who is expected to go home would receive oral analgesic agents. These are discussed with the patient before surgery, and the patient's interest and willingness to use those methods are assessed The patient is instructed in use of a pain intensity rating scale to promote effective postoperative pain management.
- 42. Cognitive Coping Strategies Cognitive strategies may be useful for relieving tension, overcoming anxiety, decreasing fear, and achieving relaxation. Examples of such strategies include the following: • Imagery-The patient concentrates on a pleasant experience or restful scene. • Distraction-The patient thinks of an enjoyable story or recites a favorite poem or song. • Optimistic self-recitation-The patient recites optimistic thoughts ("I know all will go well").
- 43. Instruction for Ambulatory Surgical Patients Preoperative education for the same-day ambulatory surgical patient comprises all the material presented earlier in this chapter as well as collaborative planning with discharge and follow-up home care. The major difference in outpatient preoperative education is the teaching environment. Preoperative teaching content may be presented in a group meeting, on a videotape, during night classes, at preadmission testing, or by telephone in conjunction with the preoperative patient and family for interview.
- 44. • In addition to answering questions and describing what to expect, the nurse tells the patient when and where to report, what to bring (insurance card, list of medications and allergies), what to leave at home (jewelry, watch, medications, contact lenses), and what to wear (loose fitting, comfortable clothes; flat shoes). The nurse in the surgeon's office may initiate teaching before the perioperative telephone contact. The last preoperative phone call is designed to remind the patient to cat and drink as directed. A fasting period of 8 hours or more is recommended after a meal that includes fried or fatty foods or meat. The anesthesiologist or anesthetist may restrict foods and fluids for longer periods of time depending on the patient's fluid status, age, and pulmonary status and the nature of the surgical procedure. The purpose of withholding food before surgery is to prevent aspiration.
- 45. • Aspiration occurs when food or n regurgitated from the stomach and enters is pulmonary system. Such inhaled material which is a foreign substance, is irritating and causes an inflammatory reaction that interferes with adequate air exchange. Aspiration is a serious problem and mortality is high (60% to 70%). If the patient is assessed as being at high risk for aspiration and stringent food and fluid restrictions. Fluids may be administered intravenously in some patients to ensure an adequate fluid volume when oral fluids restricted.
- 47. Reducing Preoperative Anxiety Cognitive strategies useful for reducing anxiety were addressed previously in this chapter. In addition to these strategies, music therapy is an easy-to- administer, inexpensive, non-invasive intervention that can reduce anxiety in the perioperative patient. The patient should be allowed to choose his or her own addressed earlier in this section will also help decrease anxiety in many patients. Knowing ahead of time music and be provided with quiet uninterrupted listening time. The general preoperative teaching about the possible need for a ventilator, drainage tubes, or other types of equipment will help decrease anxiety in the postoperative period.
- 48. Decreasing Fear During the preoperative assessment the nurse should assist the patient to identify coping strategies that he or she previously used to decrease fear. The patient benefits from knowing when family and friends will be able to visit after surgery and that a spiritual advisor will be available if desired. Research suggests that hypnosis may be a useful strategy for reducing surgery.
- 49. Respecting Cultural, Spiritual, and Religious Beliefs Psychosocial interventions include identifying and showing respect for cultural, spiritual, and religious beliefs. In some cultures, for example, individuals are stoic in regard to pain, whereas others are more expressive. These responses should be recognized as normal for those patients and families and respected by perioperative personnel. When patients decline blood transfusions for religious reasons, this information needs to be clearly identified in the preoperative period, documented, and communicated to the appropriate personnel.
- 50. GENERAL & PREOPERATIVE NURSING INTERVENTIONS
- 51. Managing Nutrition and Fluid The major purpose of withholding food and fluid before surgery is to prevent aspiration. However, studies demonstrate that in patients who do not have a compromised airway or coexisting diseases or disorders that affect gastric emptying or fluid volume (e.g. pregnancy, obesity, diabetes, gastroesophageal reflux, enteral tube feeding, ileus or bowel obstruction), lengthy restriction of fluid and food is unnecessary. Until recently, fluid and food were restricted preoperatively overnight and often longer. However, recent review of this practice by the American Society of Anesthesiologists has resulted in new recommendations for persons undergoing elective surgery who are otherwise healthy. The recommendations depend on the age of the patient and type of food eaten. For example, adults are advised to fast for 8 hours after eating fatty food and 4 hours after ingesting milk. Most patients are currently allowed clear liquids up to 2 hours before an elective procedure.
- 52. Preparing the Bowel for Surgery Enemas are not commonly ordered preoperatively unless the patient is undergoing abdominal or pelvic surgery. In this case, a cleansing enema or laxative may be prescribed the evening before surgery and may be repeated the morning of surgery. The goals of this preparation are to allow satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by faeces. Unless the condition of the patient presents some contraindication, the toilet or bedside commode, rather than the bedpan, is used for evacuating the enema if the patient is hospitalized during this time. Additionally, antibiotics may be prescribe to reduce intestinal flora.
- 53. Preparing the Skin The goal of preoperative skin preparation is to decrease bacteria without injuring the skin. If the surgery is not performed as an emergency, the patient may be instructed to use a soap containing a detergent germicide to cleanse the skin area for several days, before surgery to reduce the number of skin organisms this preparation may be carried out at home. Generally, hair is not removed preoperatively unless the hair at or around the incision site is likely to interfere with the operation If hair must be removed, electric clippers are used for safe hair removal immediately before the operation.
- 55. patient changes into a hospital gown that is left untied and open at the back. The patient with long hair may braid it, remove hairpins, and cover the head completely with a disposable paper cap. The mouth is inspected, and dentures or plates are removed. If left in the mouth, these items could easily fall to the back of the throat during induction of anesthesia and cause respiratory obstruction. Jewelry is not worn to the operating room; wedding rings and jewelry of body piercings should be removed to prevent injury.
- 56. If patient objects to removing a ring, some institutions allow the ring to be securely fastened to the finger with tape. All articles of value, including assistive devices, dentures, glasses, and prosthetic devices, are given to family members or are labelled clearly with to the institution's policy. All patients (except those with urologic disorders) should void immediately before going to the operating room to promote continence during low abdominal surgery and to make abdominal organs more accessible. Urinary catheterization is performed in the operating room as necessary.
- 57. Administering Pre anesthetic Medication The use of pre-anesthetic medication is minimal with ambulatory or outpatient surgery. If prescribed, it is usually administered in the preoperative holding area. If a pre anesthetic medication is administered, the patient is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. During this time, the nurse observes the patient for any untoward reaction to the medications. The immediate surroundings are kept quiet to promote relaxation. Often, surgery is delayed or operating room schedules are changed, and it becomes impossible to request that a medication be given at a specific time. In these situations, the preoperative medication is prescribed "on call from operating room." The nurse can have the medication ready to give and administer it as soon as a call is received from the operating room staff
- 58. It usually takes 15 to 20 minutes to prepare the patient for the operating room. If the nurse gives the medication before attending to the other details of preoperative preparation, the patient will have at least partial benefit from the preoperative medication and will have a smoother anesthetic and operative course.
- 59. Maintaining the Preoperative Record A preoperative checklist contains critical elements that need to be checked preoperatively. The completed chart accompanies the patient to the operating room with the surgical consent form attached, along with all laboratory reports and nurses' records. Any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted at the front of the chart in a prominent place.
- 60. Transporting the Patient to the Pre-surgical Area The patient is transferred to the holding area or pre- surgical suite in a bed or on a stretcher about 30 to 60 minutes before the anesthetic is to be given. The stretcher should be as comfortable as possible, with a sufficient number of blankets to prevent chilling in air- conditioned rooms. A small head pillow is usually provided. The patient is taken to the preoperative holding area, greeted by name and positioned comfortably on the stretcher or bed. The surrounding area should be kept quiet if the preoperative medication is to have maximal effect. Unpleasant sounds or conversation should be avoided because a sedated patient who overhears them might misinterpret them, Patient safety in the preoperative area is a priority. Using a process to verify patient identification, the surgical procedure and the surgical site maximizes patient safety and allows for early identification and intervention if any discrepancies are identified.
- 61. Attending to Family Needs Most hospitals and ambulatory surgery centers have a waiting room where the family and significant others can wait while the patient is undergoing surgery. This room may be equipped with comfortable chairs, television, telephones, and facilities for light refreshment. Volunteers may remain with the family, offer them coffee, and keep them informed of the patient's progress. After surgery, the surgeon may meet the family in the waiting room and discuss the outcome. The family and significant others should never judge the seriousness of an operation by the length of time the patient is in the operating room.
- 62. A patient may be in surgery much longer than the actual operating time for several reasons: Patients are routinely transported well in advance of the actual operating time. The anesthesiologist or anesthetist often makes additional preparations that may take 30 to 60 minutes. The surgeon may take longer than expected with the preceding case, which delays the start of the next surgical procedure.
- 63. After surgery, the patient is taken to the PACU to ensure safe emergence from anesthesia. Family members and significant others waiting to see the patient after surgery should be informed that the patient may have certain equipment or devices (e.g., intravenous lines, indwelling urinary catheter nasogastric tube, oxygen lines, monitoring equipment and blood transfusion lines) in place when he or she returns from surgery. When the patient returns to the room, the nurse provides explanations regarding the frequent postoperative observations that will be made However, it is the responsibility of the surgeon, not the nurse, to relay the surgical findings and the prognosis, even when the findings are favorable.
- 64. POST-OPERATIVE CARE Postoperative care is the care you receive after a surgical procedure.
- 65. 1. Immediate Post-operative stage • It is described as the period of 1-4 hours after surgery. Respiratory system - Monitor vital signs - Monitor airway patency & adequate ventilation because prolonged mechanical ventilation during anesthesia may affect post-operative lung function. - The intubated client who are lethargic may not be able to maintain an airway - Monitor for secretions; if the client is unable to clear the airway by coughing, suction the secretions from the client’s airway.
- 66. - Monitor oxygen administration if prescribed - Monitor pulse oximetry - Encourage deep breathing and coughing exercises as soon as possible - Note the rate, depth and quality of respirations and the respiratory rate should be more than 10 breaths per minute and less than 30 breaths per minute - Assess breath sounds for stridor, wheezing, which can indicate partial obstruction, bronchospasm, laryngospasm. Crackles or rhonchi may indicate pulmonary edema.
- 67. Cardiovascular system - Assess skin and check capillary refill. - Assess peripheral pulses. - Assess for peripheral edema. - Monitor for bleeding - Assess pulse for rate and rhythm. - Monitor for cardiac dysrhythmias. - Assess for homan's sign.
- 68. Musculoskeletal system - Assess the client for the movement of the extremities. - Review physician's order regarding client positioning and restrictions. - Unless contraindicated place the patient in low Fowler's position after surgery to increase the size of thorax for lung expansion. - Avoid positioning the client in a supine position until pharyngeal reflexes have returned. - If the client is comatose or semi-comatose, position on side and keep an oral airway in place.
- 69. Neurological system - Assess the level of consciousness. - Frequent periodic attempts to awaken the client should continue till the client awakens. - Orient the client to the environment. - Speak in a soft tone, filter out extraneous noises in the environment. - Maintain bodily temperature and prevent heat by providing the client with warm blanket raising the room temperature as necessary.
- 70. Temperature control - Monitor temperature. - Monitor for signs of hypothermia that may result from anesthesia, a cool operating room exposure of the skin and internal organs during surgery. - Apply warm blankets and continue oxygen as prescribed if the client is shivering.
- 71. Integumentary system - Assess surgical site, drains and wounds. - Monitor for and document any drainage or bleeding from the surgical site - Assess the skin for redness, abrasions or breakdown that may have resulted from surgical positioning.
- 72. Fluid and electrolyte imbalance - Monitor I.V fluid administration as prescribed. - Record intake and output. - Monitor for signs of hypocalcaemia, hyperglycemia, and metabolic or respiratory acidosis or alkalosis.
- 73. Gastro intestinal system - Monitor for nausea and vomiting. - Maintain patency of the nasogastric tube if present. - Monitor for abdominal distension. - Monitor for return of bowel sounds.
- 74. Renal system - Assess the bladder for distension. - Monitor color, quality and quantity of urine if a Foley's catheter is present. - Expect the client to void 6-8 hours after the surgery, depending on the anesthesia used.
- 75. Pain management - Assess for pain. - Assess for type of anesthesia used and pre-operative medication, that the client received and note whether the client received any pain medications in the post anesthesia period. - Enquire about the type and location of pain. - Ask the patient to rate the pain on the scale. - Monitor for objective data related to pain such as facial expression, body gestures, increased pulse rate, increased blood pressure and increased & Enquire about the effectiveness of the last pain medication.
- 77. - Administer pain medication, as prescribed. - Ensure that the client with client controlled analgesia pump understand how to use it. - If an opioid has been prescribed during the initial administration, assure the client every 30 minutes for respiratory rate and pain relief. - Use non-invasive measures to relief pain including distraction, comfort measures, positioning, and back rub and providing a quiet and peaceful environment respiration.
- 78. 2. Intermediate post-operative stage • It is the period of 4-24 hours after surgery. Respiratory system • Monitor vital signs. • Continue the same assessments as during immediate stage. • Monitor for patency airway, verifying that the lungs are clear on auscultation or describe sounds heard. • Encourage deep breathing and coughing.
- 79. Cardiovascular system • Monitor circulatory status such as peripheral pulses, capillary refill and the absence of edema, numbness and tingling. • Encourage use of anti-embolisms stockings, if prescribed to promote venous return, strengthen muscle tone and prevent pooling of blood in the extremities.
- 80. Musculoskeletal system • Assess for range of motion an all extremities. • Encourage ambulation; before ambulation instruct the client to sit at the edge of the bed with his or her feet supported to assume balance. • If the client is unable to get out of bed, turn the client every 1 to 2 hours.
- 81. Neurological system • Assess level of consciousness. • Maintain orientation to the environment.
- 82. Integumentary system • Assess surgical site and drains. • Monitor body temperature and wounds for signs of infection. • Maintain a dry and intact dressing. • Reinforce the wound with a sterile dressing necessary and notify the physician if bleeding occurs from the site • Change dressings as prescribed. notify the amount of bleeding or drainage, odor and intactness of sutures or staples.
- 83. • Use the abdominal binder for obese and debilitated individuals to prevent dehiscence of the incision • Drains should be patent with minimal bleeding or drainage. • Prepare to assist with the removal of drains (as by the physician) when the drainage prescribed amount becomes insignificant. • Turn the client to a side lying position, if vomiting occurs and have suctioning equipment available and ready to use. • Administer frequent oral care, at least every two hours. • Maintain the NPO (nil per oral) status until the gag reflex and the peristalsis return.
- 84. • Continue IV fluids as prescribed until the client can tolerate fluids. • When oral fluids are permitted, start with ice chips and water. • Ensure that the client advances to clear liquids and then to a regular diet as prescribed. • Assess for bowel sounds in all the four quadrants. • Monitor the clients for passing of flatus and encourage ambulation.
- 85. Renal system • Monitor urinary output (should be more than 30 ml per hour). • If the client does not have a Foley's catheter, the client is expected to void within 6 to 8 hours post operatively, ensure that the amount is at least 200 ml.
- 86. Pain management • Continue with the assessments and the interventions as during the immediate stage.
- 87. 3. Extended post-operative stage • This is the period of at least 1 to 4 days’ post operatively. • Continue to assess and observe the client’s body systems during this stage. • Monitor for signs of infection, such as redness, swelling and tenderness at the surgical site, fever and leukocytosis. • Encourage active range of motion exercises every two hours.
- 88. • Continue to encourage ambulation to promote peristalsis and the passage of flatus. • Increase ambulation every day to increase muscle strength. • Encourage the client to perform as many as activities of daily living as possible. • Instruct the client to have foods that are high in protein and vitamin C content to promote wound healing
- 89. POST-OPERATIVE COMPLICATIONS • Constipation • Hemorrhage • Hypoxia • Paralytic ileus • Pneumonia and atelectasis • Pulmonary embolism • Shock • Thrombophlebitis • Urinary retention • Wound dehiscence • Wound evisceration • Wound infection
- 91. 1. Constipation • Constipation can be defined as a decrease in frequency of bowel movements from what is normal tor the individuals, hard difficult to pass stools, a decrease in fluid volume and/or retention of faces in the rectum. In many cases, the condition can be tackled by: - Increase in fluid intake up to 3000 ml/day. - Early ambulation. - Consumption of fiber rich diet. • Laxatives and enemas can be used to treat acute constipation. The choice of laxatives depends on severity of the condition. Bisacodyl tablets and suppositories, milk of magnesia, lactulose are the more potent drugs used, but are likely to cause dependence. Tegascrod can be used for management of chronic constipation. Enemas that can be used are sodium phosphate enemas, soapsuds enema etc.
- 92. 2. Pneumonia & Atelectasis • Pneumonia is an inflammation of the alveoli by an infectious process that may develop 3 to 5 days’ post operatively as a result of infection, aspiration or immobility. Atelectasis is a collapse of the alveoli with retained mucous secretions, the most common post-operative complication usually occurring 1 to 2 days post operatively. • In such case, Encourage the client to deep Breathing exercise, coughing and use of spirometer. Prescribe chest physiotherapy and postural drainage AS needed. Use suction to clear secretions if the client is unable to cough. Encourage fluid intake and early ambulation. Antibiotics can be given as the doctor prescribes.
- 93. 3. Hypoxia • It is the inadequate concentration of oxygen in the atrial blood. • The vital signs should be monitored, the physician should be notified and eliminate the cause of hypoxia • The lung sounds and pulse oximetry should be assessed. Oxygen should be administered as prescribed. The breathing and coughing exercises should be encouraged. Turn and reposition the client.
- 94. 4. Pulmonary Embolism • An embolus blocking the pulmonary artery and disrupting blood flow to one or more lobes of the lung, presence of the pulmonary embolism can be life threatening and requires emergency action. The physician should be notified in case of emergency. The vital signs should be monitored. Administer oxygen and medications such as anticoagulants as prescribed.
- 95. 5. Hemorrhage • The loss of large amount of blood externally or internally in a short time period is called hemorrhage. Pressure should be provided to the site of bleeding. The physician should be notified in case of emergency. Blood and IV fluids should be a administered as prescribed.
- 96. 6. Urinary Retention • Urinary retention is an involuntary accumulation of urine in the bladder as a result of loss of muscle tone. It is caused by the effects of anesthesia or opioid analgesics and appears after 6 to 8 hours after surgery. The voiding should be monitored. The client should be assessed for distension of bladder. Encourage ambulation and increase fluid intake, Catheterize the client as prescribed after all non-invasive techniques have been attempted.
- 97. 7. Wound Infection • It is caused by poor aseptic techniques or a contaminate wound before surgical exploration. Infections usually occur 3 to 6 days after surgery. Purulent material may exit from the drains or separated wound edges. In such cases, the temperature should be monitored; incision site should be inspected for the signs of infection. The dressings should be changed frequently. Antibiotic therapy should be administered as per physician’s order.
- 98. Bibliography 1. Navdeep kaur brar “Text book of advanced nursing practice”, 2015, Jaypee Brothers publication, New Delhi. 2. Shabeer P. Basheer and S. Yaseen khan, “A Concise text book of advanced nursing practice”, 2018, Emmess publisher. 3. Neelam Mann, “Advanced Nursing Practice”, student edition, kumar publication house nursing books. 4. Rajesh G. Konnur and Sangita Singh, “Textbook of Advanced Nursing Practice”, Lotus Publishers. 5. George Castedine and Paula McGee, “Advanced Nursing Practice”, Second edition, Blackwell Publishing house.