Peri-Operative care

PRE-OPERATIVE CARE OF PATIENTS

Objectives

1. Identify the requirements for pre and post operative care.
2. Prepare requirements for pre and post operative care.
3. Perform pre and post operative care.

Preparation for surgery should begin as soon as the  doctor makes a diagnosis and decides that an operation is necessary. From that moment on, the patient and relatives are faced with the decision of accepting this treatment and its consequences or not.
The  doctor should tell the patient and family why an operation must happen, what will be done and what the probable outcome will be.
An appointment for admission is now arranged depending on the acuteness of the illness, period of preoperative care and the amount of time the patient requires to make necessary arrangements regarding his family, financial matters and work.

1. Admission: patient may be admitted a day before or several weeks or days in a surgical ward for a planned surgery, depending on the extent of the pre-operative treatment, e.g., alcoholics, wasted cancer patients, so that their nutritional and electrolyte status and underlying conditions are treated before
surgery.

2. Rapport: Patient and significant others are received by the nurse, given seats, greeted, and introduction of names done by the nurse. Patient is showed a bed, and he is introduced to the ward or room-mates, he is showed the ward environment, i.e. the latrines, shelters, stores, kitchen, sluice room and other
departments within the hospital that are necessary for him to know, visiting hours, meal times.

3. Physical preparations and History: History of the disease is taken, starting from the present main complaint, and other associated complaints presently, history of previous illness, or operation done is noted, any drugs taken by the patient, any allergy to any drug, any dietary restrictions, patient’s occupation, religion, marriage status, etc.

4. Vital Observations are taken and recorded to provide a baseline for future comparisons, weighing is done and the surgeon is informed to come and review the patient.

5. Psychological preparation: There is need to prepare the patient before surgery psychologically because patients always have fears when faced with the fact of undergoing an operation, and this depends on the individual basic personalities, habitual reactions to stress over the years, general state of mental health, and the preconceptions that they have concerning surgery and anesthesia. These fears include; fear of unknown, post-operative pain, discovery of cancer, the loss of organs that have special meaning
for them, the hazard of death or fear of what other friends have been telling them about surgery, hazards of anesthesia, vulnerability while unconscious, threat of loss of job and financial security, loss of social and familial roles, and the problem of being separated from family members and former activities.
These fears cause anxiety in patients going for surgery and these can be expressed in a variety of behaviors such as: becoming silent and withdrawn, hopeless and helpless, childish, aggressive and disobedient, evasive, tearful.

Measures to alley the patient’s anxiety

1. Information and Orientation: Patient is given explanations or printed information about hospital routines, visiting hours, meal times, specific locations and general orientation to the hospital environment.
2. Procedure Explanations: Give full explanations of all procedures the patient may undergo, covering the pre-operative, intra-operative, and postoperative phases.
3. Reasoning and Discomfort: Patient is made aware of the reasons for the various procedures to be done on him and any discomfort that may be experienced, ensuring the patient understands the reasons for the intervention.
4. Collaborative Communication: There must be prior consultation between a nurse and the  doctor in order to maintain the uniformity and accuracy of the information to be given to the patient.
5. Questioning and Clarification: Patient should be given a chance to ask questions concerning the operation and the postoperative period, providing reassurance and addressing any concerns.
6. Information Management: Give only as much information as the patient wishes to know, as too much information given in a short time may create more anxiety or when given at a wrong time, like some few hours to operation.
7. Peer Support: Patients going for major surgery like mastectomy, colostomy, may benefit from being introduced to people who have successfully recovered from these operations.
8. Occupational Therapy: Occupational therapy can be arranged for patients who are facing an extended preoperative period, e.g. games, handicrafts, television to distract the patient and ease the fear and loneliness.
9. Family and Friends: Encourage visits from family members and friends to have time with the patient, to provide companionship and emotional support.
10. Religious Support: Ascertain the patient’s religious preference and arrange for a priest, minister, or rabbi to visit if the patient so desires.
11. Age-Appropriate Language: A child should be told in simple language appropriate to his age and level of development what to expect before and after surgery.
12. Honesty and Clarity: The child should never be told lies. Be honest when telling him about surgery, tests, pain, stitches, etc.
13. Socialization: Let the child be with other hospitalized children for easy adjustment.

• Note: handling fears in this way can smooth the patient’s operative course. Studies show that the calm,emotionally prepared pre-operative patient is able to withstand the induction of anesthesia better and also experiences less postoperative nausea and vomiting and fewer postoperative complications.

Consent Form

A consent form is a document with important information about a medical procedure or treatment, a clinical trial, or genetic testing. It also includes information on possible risks and benefits. If a person chooses to take part in the treatment, procedure, trial, or testing, he or she signs the form to give official consent. Any patient undergoing a surgical procedure, however minor, must sign a consent form.

Indications of Consent form

• Avoiding Unwanted Procedures: Safeguards the patient from undergoing surgery they are unaware of or do not consent to.It protects the patient against submitting to operations that she or he does not know about or does not want. 
• Ensures the patient understands the nature of the proposed procedure, including its risks, benefits, and potential complications, empowering them to make an informed and voluntary decision. 
• Legal protection: Protects healthcare providers, including surgeons and hospital staff, from liability in cases where a patient or their family alleges that surgery was performed without consent.
• Respect for Autonomy: Acknowledges and respects the patient’s right to self-determination and bodily integrity.
• Open Dialogue: Encourages open communication between the patient and healthcare providers, allowing for any questions, concerns, or anxieties to be addressed before proceeding with the procedure.
• Family Involvement: Facilitates the involvement of family members or loved ones in the decision-making process, particularly when the patient desires their input or support. Sometimes the patient wishes to talk to a close relative before signing the form

Factors to be considered before signing the consent form

1. Clear Explanation: The patient must have the full explanation of the operation before signing the consent form and pictures and diagrams may be necessary.
2. Potential Complications: The patient must be told about any possible complications and the disfigurements that may arise from the surgery.
3. Procedure and Investigations: Explain about procedures and investigations and let him understand before accepting the operation.
4. Anesthesia: Explain about the administration of anesthesia, addressing any concerns or questions the patient may have.
5. Pain Management: The patient should be reassured about pain management strategies during and after the surgery.
6. Disfigurement: If the surgery involves the possibility of disfigurement, such as amputation, mastectomy, or hysterectomy, this should be openly discussed with the patient, acknowledging the potential impact on their body image and self-esteem.
7. Social and Economic Background: The patient’s social and economic background should be considered, understanding potential challenges or concerns related to recovery, finances, and daily life.Encourage the patient to talk about his social, economic background, and talk to him about spiritual life.
8. Spiritual Life: The patient’s spiritual beliefs and practices should be acknowledged and addressed, offering appropriate support or resources if desired.
9. Organ or Body Part Removal: If any organ or body part is to be removed, the patient should be informed of this in a clear and sensitive manner.
10. Simple Explanations are given in terms that the patient can understand- the patient needs an honest and fair statement of what may be faced both in surgery and following the operation.
11. Signature: Adults sign their consent forms unless unconscious or mentally incompetent, thus making a relative or a guardian to sign on his behalf. Children under 18 years must be signed for by an adult and preferably a relative. If a child’s parents can not be present, permission be got by telephone or letter or the surgeon may sign the form personally, depending on the laws of the state or court order may have to be obtained permitting the operation.
12. Make sure this accompanies other medical forms to the operation room.
13. After all the above details, a patient is asked to sign the consent form which indicates that he consents to have the operative procedure performed. This implies that he has been provided with the knowledge necessary to understand the nature of the procedure to be carried out as well as the known and possible consequences of the operation.

6. Investigations: Most of these investigations are done to make sure that the patient’s physical status is at maximum fitness and to ensure that coexisting diseases that might alter the patient’s response to surgery or his recovery are treated.

• Routine radiographs of the chest are taken, including sputum examinations: to be sure that the patient does not have any lung problem that would complicate anesthesia or recovery after surgery, especially difficulties with inadequate oxygen supply through the lungs and cardiac function. Signs of upper respiratory infections are noted and reported.
• Urinalysis is done: to detect urinary tract infection or any other disease that may become a serious problem especially when it comes to drug elimination after anesthesia or presence of sugar or proteins or acetone which may indicate the presence of diabetes mellitus, chronic kidney disease, starvation or dehydration respectively: for any of these may alter the treatment that is
  needed before, during and after surgery.
• Blood tests such as, complete blood count, hemoglobin, blood grouping and cross matching bleeding and clotting time: these will help to make sure that the patient has a chronic infection, anaemia or any blood problems, which may bring problems during surgery, or interfere with wound healing and prolong a period of recovery. If Hb is low, shock may ensure intra-operatively,
  or bleeding problems may cause problems intra or post-operatively.
• Specific investigations like ECG, Plain abdominal radiographs: are done to assess the cardiac functions so as to influence the care to be given to the patient preoperatively or for his condition to stabilize first before surgery.

7. Treatment: Antibiotics are given according to the results of the investigations and pre-existing conditions. Any other condition discovered is treated appropriately before the patient is considered ready for surgery: heart conditions, blood conditions, respiratory, urinary, digestive, etc.
8. Nutrition: The patient should be in the best possible state nutritionally before undergoing anesthesia and surgery. This is because;

• Dehydration and poor nutrition affects the prognosis post-operatively, particularly in infants and elderly especially if caused by excessive vomiting or diarrhea and this may cause electrolyte imbalance, coupled with chronic illness and poor appetite
• Protein deficiency leads to slow wound healing and low resistance to infection
• Lack of vitamin C retards wound healing.
• Interventions
• Balanced Diet: A well-balanced diet tailored to the individual patient’s needs should be provided, including adequate protein, carbohydrates, fats, vitamins, roughages, and plenty of fluids.
• Monitoring and Reporting: Nurses play a role in monitoring the patient’s food intake and reporting any concerns to the surgeon or dietician.
• Individualized Approach: The patient’s likes and dislikes should be considered when planning meals to encourage food intake and ensure optimal nutrition.
• Appropriate Feeding Routes: Feeding methods should be chosen based on the patient’s condition and needs, ensuring they receive adequate nutrition through the most appropriate route.

9. Exercises: Patients need to be instructed pre-operatively concerning the proper way to cough, deep breathe, turn and move their extremities during the postoperative period. Such instructions, given in sufficient detail and at the correct time, greatly reduce operative and post-operative complications.

• Deep breathing exercise: this is done by inhaling slowly through the nose, distending the abdomen and exhaling slowly through the mouth, pulling the abdomen in until all air has been expelled. This should be done at least 5-10 times every hour. This is important for effective aeration of the lungs and the tissues to allow full lung expansion in thoracic surgery, to expel secretions, to prevent pneumonia and Atelectasis.
• Coughing exercise: patient is instructed to sit or lie, take a deep breath, exhale through the mouth and then follow with a short breath while coughing from deep in the lungs. Deep breathing exercise should be done before coughing exercise to stimulate coughing reflex. Patients who will go for thoracic or abdominal surgery should be showed how to splint their incision before
  coughing in order to minimize pressure on the sutures and to control pain. A small pillow or rolled towel may be held against the incision to facilitate splinting.
• Turning exercises: the patient will need to practice turning from side to side using the side rails if available. This prevents venous stasis and pooling of secretions in the lower lobes of the lungs, predisposing to pulmonary complications. This should be done every 1-2 hours post-operatively.
• Extremity exercises: range of movement exercises of all the joints, flexing and extending the joints and to move each foot in a circular motion. These help to prevent circulatory problems, such as deep venous thrombosis, prevent muscle wasting and disuse, and encourage wound healing due to sufficient blood supply.
  
  

10. Treatment of existing abnormalities/infections: Abnormalities that have been detected are treated according to the diagnostic findings, e.g. mouth infections, dental caries, skin lesions, constipation, respiratory and cardiac conditions. Antibiotics, fluids, blood transfusions, painkillers are given as per the patient’s condition.
11. Hygiene: Hygiene ensures cleanliness of the skin, nails, umbilicus in case of abdominal surgery, oral care since this is the entrance to the respiratory system and digestive. It is aimed at minimizing the number of microbes that will be carried into the deeper tissues from the skin when the surgeon makes the incision. Patient’s gowns, bed linen, utensils and equipment of care are made clean including the tables, bed, etc.
12. Pre-operative visits: Visits from theater nurses and team are important to know the patient, and what he knows about the operation, to tell him the approximate length of surgery, to tell him what he will see , hear, and smell before he goes to sleep and what to expect in the recovery room.
13. Rest and sleep: Physical exhaustion deteriorates the general health and hinders many body activities and mental exhaustion aggravates shock. Patients may not relax due to fear of the forthcoming operation.

• Prepare a comfortable freshly made bed and in a well-ventilated room.
• Nurse avoids talking to a tired patient.
• Visitors are restricted from always disturbing the patient.
• Noise of any kind is avoided, i.e., using rubber-soled shoes, talking loudly is not allowed, radio sounds put at low tones, banging doors and using trolleys that make a lot of noise are avoided.
• Sedation may be necessary to induce sleep or to reduce the pain that may interfere with sleep,