peri operative care

Peri-Operative care

This is the care rendered to a patient before, during and after the surgery. 

It is composed of the following

  • Pre-operative care
  •  Intra-operative care
  •  Post-operative care
REASONS FOR SURGERY
  •  Curative: desired to cause a total healing.
  •  Diagnostic: desired to discover the problem e.g. explorative laparotomy
  •  Reconstructive: More of cosmetology or plastic surgery to improve the look of the damaged
    body part
  •  Palliative: surgery intended to give supportive care with no possibility to cure the real problem
    e.g. gastrostomy for purpose of feeding in people with Ca esophagus.
TYPES OF SURGERY
  1. Major: complex procedures requiring much time, general anesthesia and a bigger team, more
    advanced equipment
  2.  Elective/planned, these are cold cases whose conditions can wait, no emergency. All other
    investigations are done and surgery is done when the patient is ready or desires.
  3.  Minor surgery: Requires less time, simple anesthesia/local anesthesia, no big team, simple
    equipment is used e.g. I&D
  4.  Emergency surgery: This requires urgency. Any delay may result to death.

Summarized Version of perioperative care is below the detailed version, keep scrolling

Pre-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 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 is 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 the 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.  Patient is given explanations or printed information about hospital routines, visiting hours, meal
    times, specific locations and general orientation to the hospital environment.
  2.  Give full explanations of all procedures the patient may undergo
  3.  Patient should have an idea of what the pre-, intra, and post-operative course will entail
  4.  Patient is made aware of the reasons for the various procedures to be done on him and any
    discomfort that may be experienced.
  5.  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.
  6.  Patient should be given chance of asking questions concerning the operation and the postoperative period
  7.  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.
  8.  Patients going for major surgery like mastectomy, colostomy, may benefit from being introduced
    to people who have successfully recovered from these operations
  9.  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.
  10.  Encourage visits from family members and friends to have time with the patient.
  11.  Ascertain the patient’s religious preference and arrange for a priest, minister, or rabbi to visit if
    the patient so desires.
  12.  A child should be told in simple language appropriate to his age and level of development what
    to expect before and after surgery.
  13.  The child should never be told lies. Be honest when telling him about surgery, tests, pain, stitches,
    etc.
  14.  Let the child be with other hospitalized children for easy adjustment.
    NB: 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 post operative nausea and vomiting and fewer post operative complications.

Consent Form

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
  •  It protects the patient against submitting to operations that she or he does not know about or
    does not want.
  •  It also protects the hospital staff and the surgeon from legal action in which the patient or the
    family claim that an operation was performed without the patient’s permission or knowledge.
  •  Sometimes the patient wishes to talk to a close relative before signing the form
Factors to be considered before signing the consent form
  1.  The patient must have the full explanation of the operation before signing the consent form and
    pictures and diagrams may be necessary.
  2.  The patient must be told about any possible complications and the disfigurements that may arise
    from the surgery.
  3.  Explain about procedures and investigations and let him understand before accepting the
    operation.
  4.  Explain about the administration of anesthesia
  5.  Reassure the patient about pain
  6.  Talk to him about disfigurement, e.g. Amputation, inoculation, mastectomy, hysterectomy.
  7.  Encourage the patient to talk about his social, economic background, and talk to him about
    spiritual life.
  8.  The patient needs to know if any organ or body part may be removed.
  9.  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.
  10.  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.
  11.  Make sure this accompanies other medical forms to the operation room.
  12.  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 to 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 pre-operatively 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.

Reasons:
  •  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
    A well-balanced diet is ordered for the patient consisting of proteins, carbohydrates, fats vitamins,
    roughages, and plenty of oral fluids.
    Nurse should know how well the patient is eating, and any problem reported to the surgeon or dietician.
    Patient advised according to his likes and dislikes
    Patient is fed according to his condition and using the appropriate routes.


9. Exercises: Patients need to be instructed pre-operatively concerning the proper way to cough, deep breathe, turn
and move their extremities during the post-operative period. Such instructions, given in sufficient details
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 I 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 encourages wound
    healing due to sufficient blood supply.
    Treatment of existing abnormalities/infections: Abnormalities that have been detected are treated
    according to the diagnostic findings, e.g. mouth infections, dental carries, skin lesions, constipation,
    respiratory and cardiac conditions. Antibiotics, fluids, blood transfusions, pain killers are given as per the
    patient’s condition.


10. 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.
11. Pre-operative visits: Visits from theatre nurses and team is important to know the patient, and what he
knows about 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
12. Rest and sleep: Physical exhaustion deteriorates the general health and hinders many body activities
and mental exhaustion aggravates shock. Patient may not relax due to fear for 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 and visiting hours put
  •  Noise of any kind is avoided, i.e., using rubber-soled shoes, talking loudly 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
Preparation of the patient on the eve of surgery (12 hours to operation)
Skin care of the area to be operated:

 The skin site preparation pre-operatively is aimed at removing dirt, oils and micro-organisms, to
prevent the growth of micro-organisms that remained and to leave the skin undamaged with no
irritation from the cleansing and shaving procedure, and the area depends on the type of surgery
to be done.

Principles of skin preparation
  1.  The areas to be prepared should always be larger and wider and longer than the area of the
    proposed incision, because the surgeon may unexpectedly widen or extend the incision line.
  2.  First wash the area with soap and water and start shaving when you are sure of the cleanliness
  3.  Use a strong, light, well-focused and sterile safety razor or blade.
  4.  Shave against the direction of the hair shaft to ensure clean, close shave
  5.  Check the skin for nicks, irritations, and cuts since these are all potential sites for infection
  6.  Use skin antiseptics after shaving to clean the site, like chlorhexidine, iodine and others.
Specific pre-operative preparations;
  1. Abdominal operation: The patient’s gastrointestinal tract needs special preparation on the evening
    before surgery in order to reduce the possibility of vomiting and aspiration during anesthesia and to
    prevent contamination from fecal material during bowel surgery. The measures taken are: the restriction
    of foods and fluids to prevent vomiting during surgery, the aspiration of any vomitus and the resultant
    development of aspiration pneumonia. Solid food must be withheld 7-10 hours before operation, most
    patients receive nothing by mouth (NPO) after midnight; tea, water may be given up to 4 hours before
    surgery. When the surgery is scheduled until late afternoon, the patient may eat a light breakfast in the
    morning. When the patient is on NPO, the nurse should tell the patient not to eat and why; removes
    food and water from the patient’s bedside; places NPO-sign on the door and gives the report to the
    incoming nursing staff; extremely malnourished and debilitated patients are given intravenous infusions
    of glucose, amino acids or plasma up to the moment of surgery; two or three enemas may be given in
    the evening to prevent contamination of the peritoneal cavity from the spillage of fecal content during
    surgery; in some cases, laxatives are given 2-3 days pre-operatively; nasogastric tubes for suction,
    drainage may be inserted in the evening or morning of surgery in order to remove gastric and intestinal
    contents; flatus tubes may as well be inserted to relieve gaseous distension; catheterization is done to
    drain urine and to relieve urine retention post-operatively and intra-operatively to prevent accidental
    injury to the urinary bladder if it is full with urine during abdominal surgery.
  2. Genito-urinary system: The renal functions are often impaired by diseases of the kidneys, prostate,
    urethra, bladder or ureter. The patient should be instructed to take plenty of oral fluids at least 2 liters
    per day and the fluid balance chart be strictly charted; an indwelling catheter be inserted for continuous
    bladder irrigation, washout , drainage post-operatively; intravenous fluids be run to irrigate the bladder
    so as to avoid urine stasis which predispose to calculi formation and bladder wall infection; urine sample
    is removed aseptically for urinalysis; patient is encouraged to pass urine frequently and any
    abnormalities are treated appropriately.
  3. Rectal operation/haemorrhoidectomy: This requires special preparations because it is not easy to render
    the rectum a sterile or aseptic and it is also difficult to control the passage of stool. The bowel may be
    emptied by an aperient’s administration given in the evening before operation and also repeated in the
    morning and 8 hours before operation. Simple enema of soap and water is given followed by washing of
    the rectum and shaving the perineum.
  4. Gynaecological surgery: All patients going for this operation should have antiseptic douche done and no
    spirit or ether are applied on the genital mucosa. Urinary catheter is passed in situ before surgery and
    should continue post-operatively.
  5. Respiratory operation: All patients for respiratory need close respiratory observations and any
    respiratory infections should be treated before surgery and respiratory exercises are taught preoperatively.
    Paired organs: The affected organ of the pair like the eye, ear, limb, breast, should be marked with a tag
    or an adhesive tape to prevent the removal of the normal side.

     On the morning of surgery the nurse usually awakens the patient about an hour before preoperative medications are scheduled. During that hour, the nurse does the following tasks:

  • She records the patient’s vital signs as baseline for future observations and comparison, to detect
    abnormalities which may entail postponement of operation, e.g., pyrexia, tachycardia (120b/m
    over), or bradycardia (pulse rate below 60b/m), urine results and weight for future comparison
    and for drug calculation.
  •  She checks for the skin preparation if done well or there is need to be repeated in a thorough
    manner.
  •  She asks the patient to void before going to theatre to avoid bladder injury in the lower
    abdominal and pelvic surgery, incontinence during operation (due to anesthesia), restlessness
    during the early post-operative period, or if the catheter is in situ, the output is emptied and
    recorded.
  •  She carries out special orders like giving enemas, insertion of catheters if not done in the evening,
    NGT, putting infusion lines if not done before and hanging fluids prescribed before anesthesia
    (1litre of normal saline), or checking if the line is patent and the surrounding tissues are not
    infiltrated.
  •  She gives the patient oral hygiene and removes any dentures and safely keeps them
  •  She gathers all the necessary documents like form 5, admission and observation charts,
    laboratory forms, x-ray radiographs, consent form, fluid balance chart, etc, and puts them
    together ready for theatre
  •  She checks if the consent form is signed for and helps the patient if not done.
  •  In privacy, she asks the patient to remove his or her own personal clothing which are safely to be
    kept, she removes and keeps the patient’s jewelry, earrings, but the wedding ring is usually left
    insitu and strapped with an adhesive tape; necklaces, bangles, plastic rings or rubber are too
    removed and kept together with other things.
  •  She dresses the patient in theatre gown which is clean and perhaps support stockings. If the
    patient has long hair, braid them into 2 braids, all hair pins are removed to prevent scalp injury
    during and after surgery, and the head is covered with a protective cap.
  •  Colored nail polish is removed with the nail file to help in easy assessment of cyanosis from the
    nail bed. Anything that is difficult to remove be strapped off.
  •  She questions the patient to make sure that food has not been eaten for the last 8 hours, or
    fluids taken during the preceding 4 hours, and report immediately if the patient has eaten so that
    surgery is postponed.
  •  She makes the patient’s identification band containing his name, age ward, type of surgery to be
    undertaken and attaches it to the patient. She makes sure the information is accurate.
  •  She gives pre-operative medications: this is usually a combination of sedatives and analgesics
    opiates, e.g., morphine 10-15mg, or pethidine 50-100mgs, temazepam 10-20mg, tranquillizers
    such as diazepam 5-10mgs. These drugs are meant to reduce apprehension so as to reduce shock,
    to ensure sleep, and to reduce the amount of anesthetic drugs to be used, and to create amnesia
    for the events that precede surgery
  •  Other drugs sometimes may be prescribed to be given before the patient is transported to
    theatre, such as antibiotics like Metronidazole i.v, + ampicillin+ gentamycin or chloramphenicol
    in some abdominal conditions, gynaecological conditions, head injury, gun shot wounds, etc. give
    according to the prescription.
  •  Anti-secretions like atropine 0.6-1mg is given to dry up secretions or to prevent over production
    when inhalation anesthetics are used especially ether; it improves the heart action and
    suppresses vagal influence on the heart. These drugs must be given half to 45 minutes preoperatively to ensure the above effects. The time of administration should be recorded
    accurately. If omitted or delayed, the anesthetist should be informed. Do not give under the
    maxim “better late than never”.
  •  When all the preparations are ready, and the time of surgery has come, the patient is transported
    to the operating theatre on a couch, rolled by 2 nurses. Minimal noise should be made as hearing
    is very acute after pre-medications. All movements to theatre should be gentle, steady and
    unhurried. The nurse should carry all documents to theatre with the patient.
  •  A full report is given to the theatre nurse, or anesthetist concerning the patient.
  • A post-operative bed is then made with clean linen. The specific bed depends on the type of
    surgery, e.g., divided bed, fracture bed with traction appliances, etc. bed side accessories like bed
    cradles, infusion stands, vital observations tray, mouth care tray, infusion trays, oxygen apparatus
    and cylinder, suction apparatus and suction machines, bed elevators, mosquito nets, etc. this are
    the items necessary for resuscitation immediately post-operatively. The bed should be warm,
    without overheating to prevent shock.
Intra-operative Nursing Care
  1.  Observing a client undergoing surgery may be a component of a nursing student’s experience.
    Doing so will not only give the student a better idea of surgical procedures, but it will also help in
    understanding the client’s feelings and apprehensions. Special training mostly given in OR
    technique and anesthesia Nurses assist surgeons in the operating room.
  2.  The two basic categories of assistant are the sterile assistant and the circulating assistant. The
    sterile assistant (scrub nurse) is scrubbed, gowned and gloved. He/she functions within the sterile
    field. Duties include handling instruments to the surgeon, threading needles, cutting sutures,
    assisting with retraction and suction, and handling specimen.
  3.  The circulating nurse works outside the sterile field. Duties include opening sterile packs,
    delivering supplies and instruments to the sterile team, delivering medications to sterile nurse,
    labeling specimens, and keeping records during the surgical procedure. This person acts as a
    client advocate by monitoring the situation and maintaining safety in the operating room. In most
    cases, the circulating nurse must be registered nurse.

Post-Operative Nursing Care

Aims or principles of post-operative care

  1.  By skillful observation and application of knowledge to prevent, recognize and treat
    complications during unconsciousness and up to the time of discharge from hospital.
  2.  To ensure patient’s comfort
  3.  To restore patient to individual maximum health and independence.
Immediate care of a patient recovering from anesthesia
  1.  Transporting the patient from the operating room to the recovery room.
  2.  Following the completion of the operation, the operating room staff generally dresses the patient
    in a clean gown and moves the patient to the stretcher, while avoiding exposing the patient which
    predisposes him to respiratory infections and shock; rough handling which may place a strain on
    the sutures; hurried movements and rapid position changes which predisposes the patient to
    hypotension.
    Recovery room care:
  3.  After arriving, the patient is either put to a bed from a stretcher, or left on the couch.
  4.  The patient is made to lie supine with the head turned to one side with the chin extended forward
    since the patient is unconscious or semi-conscious from anesthesia to avoid respiratory
    obstruction from a relaxed tongue falling back into the throat, or by aspiration of mucus, blood
    and/or vomitus and to allow secretions to flow out, or for easy suctioning.
  5.  Baseline assessment of the patient is done, i.e., vital signs- bp and pulse, respiratory rate, airway
    patency, depth of respirations, chest expansion, and the color of the skin, visual assessment of
    the patient , presence of i.v infusions, drains, or special equipment.  
  6.  The time of admission to the recovery room. Check for the following.
  1. The absence of reflexes, e.g. pharyngeal or swallowing reflex for proper positioning of the head,
    i.e., lateral head position with the neck extended forward until the patient is swallowing.
  2.  The patient’s level of responsiveness upon admission, e.g. touch, pain, sound, movement, etc.
  3.  The temperature and vital signs, which are taken ¼ hourly until stable, then ½ hourly for the next
    2-3 hours, and the temperature is taken 2-4 hourly, depending upon recovery policy.
  4.  The quality and rate of respirations, and if in distress, oxygen is given, anesthetist informed in
    respiratory depression or change in ventilatory pattern and arterial blood gas is determined,
    while mechanical breathing aids are employed to resuscitate the patient, e.g., intubation,
    tracheostomy, ambu- ventilation, suctioning, etc
  5.  The presence of an airway/mouth piece meant to keep the tongue from falling back. Sometimes
    the patient may push this away as he regains consciousness.
  6.  Skin color and dryness. A pale, cold sweating, skin is one of the sign of shock. Also notice the lips
    and nail bed for pallor and cyanosis. Run the fluids as prescribed.
  7.  The condition of the dressing, i.e. dry or soiled. If soiled, note the color, type and amount of
    drainage.
  8. The presence of the drainage tubes, e.g., the thoracic, abdominal, gastric, catheters. Check if
    patent, clamped whether to be connected to suction apparatus, and whether they are draining.
  9.  The i.v infusions: note the type of i.v infusion solutions, amount left in the bottle, the rate of the
    drip, infiltrations, and orders for any other fluid to follow. Check if medications have to be added
    to the i.v or if there are orders for any to be added.
  10.  The presence of blood transfusion: note if BT is running or if one is ordered. Watch the rate of
    the drip and carefully for signs of a reaction.
  11. Any unusual symptoms like airway obstruction, arrhythmias, signs of shock, hemorrhage, marked
    temperature elevation and signs of circulatory overload from excess i.v fluids.
  12.  After the patient stabilizing, i.e., in 2-3 hours, and recovering from anesthesia, he is discharged
    from the recovery room by the anesthetist, or surgeon and the ward nursing staff are informed
    to come and collect the patient.
    Patient is collected from the recovery room back to the ward:
  13.  The ward nurses are informed about the patient to be collected from the recovery room after
    stabilizing.
  14.  A verbal report is given by the recovery room nurse to the 2 nurses who have come to collect the
    patient. This covers the type of operation done, vital signs, the level of consciousness, wound
    status and drainages, infusions and blood transfusions, resuscitation done, anesthesia, problems
    patient had during surgery such as vomiting or stoppage of breathing, urinary drainage and
    others and other post-operative instructions.
  15.  Brief taking of vital parameters is done by the ward nurses to confirm the report from theatre
    and to prove that the patient is alive.
  16.  Patient is rolled back to the ward with the legs in front and the head behind for easy resuscitation
    by the behind nurse should there be any problem.
  17.  The patient is gently lifted from the stretcher to the bed prepared before and care of
    anesthetized patient is instituted immediately.
Immediate post-operative care in the ward

Care of anesthetized patient in the ward:
The patient should not be left alone during this period because of danger of asphyxiation, shock, falls
and hemorrhage.

  1. Position: This varies with the type of surgery. It can be supine with the head turned to one side, to prevent
    the bulky tongue falling back by gravity over the pharynx and blocking the air way, and to
    promote drainage of saliva from the mouth.
    – The head can be made lower than the shoulders to prevent the flow of fluids into the trachea
    and allows secretions to pool in the check, thus making removal easier, and preventing
    obstruction and pneumonia. The usual position is modified Sims.
  2.  Respiratory status: assess the quality, depth, and rate of respirations, the skin color and
    temperature which are indications of adequate oxygen exchange.
  3.  Neurologic status/level of responsiveness: whether the patient is alert and oriented or
    unconscious, confused , restless, etc.
  4.  Cardiovascular status: obtain vital signs and color and temperature of the skin.
  5.  Wound: check for drainage, bleeding and connect any drainage tubes to the suction machine or
    to the collection bag.
    – See if the dressings are soiled, look and feel under the patient to detect pooling of blood.
  6.  Tubes: catheters, NGTs, infusion lines for patency, rate and amount, drainage or blockage, or
    kinked, proper attachment to drainage systems, etc.
Discharge advice/health education on home care of the patient:

 The length of time needed for a patient to recover from surgery depends upon the patient’s physical and mental condition prior to surgery, the magnitude of surgery and development of any post-operative complications

  1. Assess the knowledge and understanding of the patient about the surgery and the preventive
    measures.
  2.  Look for learning readiness and the ability of the patient and/or family members to provide care
    and skills needed to perform procedures at home.
  3.  Teach the patient to report pain in any area, temperature elevation, cough and sputum of
    abnormal color, loss of energy, nausea and vomiting, change in urine characteristics, difficulty in
    breathing, abnormal drainage, sudden weight loss. These are signs of complications.
  4.  Tell the patient the importance of hand washing prior to meals, performing any procedure of
    care, and toileting.
  5.  Practice together with the patient coughing, breathing, exercises to prevent pulmonary
    complications.
  6.  Let the patient avoid smoking or contact with people with RTIs,
  7.  Let him continue with physical exercises and increase when necessary and stop when tired.
    Exercises promote activity to maintain circulation and for normal functioning of the systems.
  8.  Patient is told to take plenty of fluids and vitamins, electrolytes to maintain fluid/nutritional
    status for health (wound healing, skin integrity, elimination, liquefy secretions).
  9.  Teach the patient how to care for the wound: dressing change, cleansing, and skin care and allow
    practicing aseptic technique in wound care, protection of the wound when bathing. This
    maintains the wound clean, dry, healing wound.
  10.  Teach the patient how to take drugs: checking their actions, dose, route, frequency, side effects,
    and food and drug interactions. This ensures compliance.
  11.  Tell him to modify his home environment to clear pathways of rugs, provide good lighting and
    articles to hold onto when walking, firm and good fitting shoes. This will ensure safety and
    prevents accidents.
  12.  Talk to him about the care of appliances such as fixators, plaster of paris, prostheses for the
    purpose of safe usage and optimal effect of supportive aids.
  13.  Give him information of where to find supplies and equipment for home care.
  14.  Give the patient information and phone number of the doctor or other staffs for the purpose of
    easy follow up or emergency calls.

PERI-OPERATIVE CARE (Summary)

  1. Admission
  2.  Explanation to the patient the nature of the surgery and the possible outcomes.
  3.  Informed Consent for admission and surgery.
  4. Vital observations and other lab investigations, radiological investigations to get a baseline.
  5. Preparation of the body and mind through counselling and continuous reassurance. This helps to allay anxiety as well.
  6. Talk to the patient and answer questions of their concerns to reduce fear/anxiety.
  7. Spiritual care if one so wishes, respective church leaders are allowed to come and see the patient.
  8. A baseline Physical examination for example weight, height, nutritional status needs to be assessed prior. Site preparation; involves marking/labelling,48 hours shaving if hairy.
  9. Removal of jewelries, rings
  10. Removal dentures, prosthesis
  11. Putting an Iv line
  12. Rehydration with iv fluids
  13. Administration of premedication drugs.
  14. Perform required procedures like putting NGT, Catheterization, bowel irrigation
  15. Ensure enough rest and sleep
  16. Educate on anticipated activity post operatively.
  17. Starve the patient prior as per order (nil per os).
  18. Make a post op bed with all the necessary accessories required e.g. oxygen, suction apparatus
POST-OPERATIVE CARE
  1. Reception from theatre with all the necessary instructions.
  2.  Vitals parameters monitoring
  3.  Monitoring for bleeding, signs of shock
  4.  Admission in a warm post-operative bed from theatre.
  5.  Intravenous infusion with fluids and prescribed drugs.
  6.  Fluid balance chart recording and monitoring.
  7.  Ongoing post op-medication
  8.  Bowel and bladder care.
  9.  Rest and sleep
  10.  Proper management of drainages e.g abdominals etc.
  11.  Proper positioning to relieve pains.
  12.  Diet/nutrition
  13.  Wound care
  14.  Pain management.
  15.  Bed hygiene
  16.  Body/skin hygiene
  17.  Physiotherapy e.g breathing exercises.
  18.  Psychological care.
POST-OPERATIVE COMPLICATIONS
  •  Hemorrhage; can be primary or secondary.
  •  Pain
  •  Shock
  •  Wound infection/sepsis
  • Hypostatic pneumonia due to constant lying on bed.
  • Delayed healing
  • Paralytic ileus
  • Adhesions
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5 thoughts on “Peri-Operative care”

    1. Oh well, the only reason we didn’t include that is because nurses roles stop after handing the patient over to theatre staff, that means the roles are taken over by the circulating and scrub nurse. Then the roles resume after surgery

  1. Thank you so much for this,
    I still think Nurses roles can be included intraoperatively because they still have roles to play while in the O.R.

    Thanks again.

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