🛌Adult Nursing Care Unit 15 – Perioperative Care

What's This Unit About?

• Focuses on the nursing care provided to adult patients undergoing surgical procedures
• Covers the three phases of perioperative care: preoperative, intraoperative, and postoperative
• Emphasizes the importance of patient safety, infection prevention, and effective communication among healthcare team members
• Discusses common surgical procedures and their potential complications
• Highlights the nurse's role in patient assessment, education, and advocacy throughout the perioperative period

Key Concepts and Definitions

• Perioperative care: the care provided to patients before, during, and after surgical procedures
• Preoperative phase: begins when the decision for surgery is made and ends when the patient is transferred to the operating room
  • Includes patient assessment, education, and preparation for surgery
• Intraoperative phase: begins when the patient is transferred to the operating room and ends when the patient is admitted to the post-anesthesia care unit (PACU)
  • Focuses on maintaining patient safety, monitoring vital signs, and assisting the surgical team
• Postoperative phase: begins with the patient's admission to the PACU and ends with their discharge from the healthcare facility or transfer to another unit
  • Involves monitoring the patient's recovery, managing pain, and preventing complications
• Informed consent: the process by which a patient is provided with information about the risks, benefits, and alternatives to a proposed treatment or procedure and voluntarily agrees to undergo it
• Surgical site infection (SSI): an infection that occurs at the site of surgery within 30 days of the procedure or within 90 days if an implant is placed
• Deep vein thrombosis (DVT): a blood clot that forms in a deep vein, usually in the leg, which can lead to serious complications if it travels to the lungs (pulmonary embolism)

Preoperative Care

• Conduct a thorough patient assessment, including medical history, physical examination, and review of diagnostic tests
• Educate the patient and their family about the surgical procedure, expected outcomes, and potential complications
• Obtain informed consent from the patient or their legal representative
• Ensure the patient is NPO (nothing by mouth) for the appropriate time before surgery to prevent aspiration during anesthesia
• Administer preoperative medications as ordered, such as antibiotics for infection prophylaxis or anxiolytics for relaxation
• Prepare the surgical site by cleaning and shaving (if necessary) to reduce the risk of infection
• Assist with patient positioning and transfer to the operating room, ensuring proper body alignment and pressure point protection

Intraoperative Care

• Collaborate with the surgical team to maintain a sterile field and prevent infection
• Monitor the patient's vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation
• Assist with patient positioning and ensure proper body alignment to prevent nerve damage or pressure injuries
• Manage the patient's airway and ventilation in collaboration with the anesthesia provider
• Administer medications and fluids as ordered by the anesthesia provider or surgeon
• Anticipate the needs of the surgical team and provide instruments, supplies, and assistance as needed
• Document the patient's condition, surgical procedures, and any complications that occur during the intraoperative phase

Postoperative Care

• Assess the patient's level of consciousness, vital signs, and pain level upon arrival to the PACU
• Monitor the patient's surgical site for signs of bleeding, infection, or dehiscence (wound separation)
• Manage the patient's pain using pharmacological and non-pharmacological interventions
• Encourage early ambulation and deep breathing exercises to prevent complications such as DVT and pneumonia
• Provide wound care and dressing changes as needed, using aseptic technique to prevent infection
• Educate the patient and their family about post-operative self-care, including pain management, wound care, and activity restrictions
• Coordinate the patient's discharge planning and follow-up care with the interdisciplinary team

Common Complications and How to Spot Them

• Surgical site infection: signs include redness, swelling, warmth, drainage, and increased pain at the surgical site
  • May also present with fever, chills, and elevated white blood cell count
• Deep vein thrombosis: symptoms include unilateral leg swelling, pain, warmth, and redness
  • Assess for Homans' sign (pain in the calf upon dorsiflexion of the foot) and perform a DVT risk assessment
• Pulmonary embolism: sudden onset of shortness of breath, chest pain, tachycardia, and hypoxia
  • May present with hemoptysis (coughing up blood) and syncope (fainting)
• Hemorrhage: excessive bleeding from the surgical site, characterized by saturated dressings, hypotension, tachycardia, and decreased urine output
• Atelectasis: collapse of lung tissue, leading to decreased oxygen saturation and respiratory distress
  • Encourage deep breathing, coughing, and incentive spirometry to prevent and treat atelectasis

Nursing Interventions and Best Practices

• Perform regular and thorough patient assessments to identify potential complications early
• Maintain strict aseptic technique when handling surgical sites, dressings, and invasive devices to prevent infection
• Encourage early ambulation and provide assistance as needed to prevent DVT and other complications related to immobility
• Use validated pain assessment tools (e.g., numeric rating scale) and provide multimodal pain management, including both pharmacological and non-pharmacological interventions
• Educate patients and their families about the importance of post-operative self-care, including wound care, medication management, and follow-up appointments
• Collaborate with the interdisciplinary team to ensure continuity of care and optimal patient outcomes
• Maintain accurate and timely documentation of patient assessments, interventions, and outcomes to facilitate communication among healthcare team members

Putting It All Together: Case Studies

• Case 1: A 68-year-old male patient undergoes a total knee replacement. On post-operative day 2, he complains of unilateral calf pain and swelling. What steps should the nurse take to assess and manage this potential complication?
  • Assess for signs and symptoms of DVT, including Homans' sign and warmth/redness of the affected leg
  • Notify the physician and request an ultrasound to confirm the diagnosis
  • Administer anticoagulant therapy as ordered and monitor for signs of bleeding
  • Encourage early ambulation and provide compression stockings to improve circulation
• Case 2: A 45-year-old female patient undergoes a laparoscopic cholecystectomy. On post-operative day 1, she develops a fever of 38.5°C (101.3°F) and complains of increased pain at the surgical site. How should the nurse assess and manage this situation?
  • Assess the surgical site for signs of infection, such as redness, swelling, warmth, and purulent drainage
  • Notify the physician and obtain an order for a complete blood count (CBC) to evaluate for leukocytosis
  • Administer antibiotics as ordered and monitor the patient's response to treatment
  • Provide wound care using aseptic technique and educate the patient about signs and symptoms of infection to report
• Case 3: A 72-year-old male patient with a history of COPD undergoes an open prostatectomy. On post-operative day 3, he develops shortness of breath and decreased oxygen saturation. What actions should the nurse take to address this potential complication?
  • Assess the patient's respiratory status, including respiratory rate, depth, and effort
  • Auscultate lung sounds to identify any abnormalities, such as wheezing or diminished breath sounds
  • Administer supplemental oxygen as needed and encourage deep breathing and coughing exercises
  • Notify the physician and request a chest X-ray to evaluate for atelectasis or pneumonia
  • Collaborate with the respiratory therapist to provide additional interventions, such as incentive spirometry or chest physiotherapy