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Course: Fundamentals of Nursing

Topic: Perioperative Care

The Nurses International Community

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Module Goals

Learners will be able to:

Describe the purpose of perioperative nursing care.
Apply the nursing process to the perioperative setting.
Discuss the importance of preoperative client education.
Describe the importance of ROM, turning, cough/deep breathing exercises in postoperative care.

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What is Perioperative Care?

CPOC, n.d.

‘Perioperative care, also referred to as perioperative medicine, is the practice of patient-centered, multidisciplinary, and integrated medical care of patients from the moment of contemplation of surgery until full recovery.’

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Perioperative Care

It is care given before, throughout and after surgery.
Aims at making client physically and mentally ready

for the operating procedure
after the surgical treatment

Duration of care depends on the client needs
Includes three stages:

Preoperative
Intraoperative
Postoperative

Journal of Perioperative and Critical Intensive Care Nursing, n,d.

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Preoperative Care

Preoperative care begins when the client or those authorized by the client makes the informed decision to have the surgery.
Client is physically and psychologically prepared for surgery.
Required laboratory tests are performed.
Required preoperative medications, if any, are administered.
Preoperative assessments and interviews are conducted to gather client information for plan of care.

Goodman & Spry, 2017

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Pre-op Assessment and Management

Nutritional status

Assessment and treatment of malnourishment.

Cardiopulmonary considerations

Assessment of cardiac or pulmonary disorders that pose peri/post-operative risks.
Cessation of smoking before surgery improve perioperative outcome.

General screening for medical issues

Serum blood urea nitrogen (BUN).
Serum creatinine, sodium, calcium and full blood count.
Alcohol, prescribed narcotics, & illicit drug use should be assessed.

Cancer Australia, 2018a

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Pre-op Assessment and Management

Garimella & Cellini, 2013
Coluzzi, 2017
Cancer Australia, 2018a

Pain Management

Preoperative evaluation and planning is vital to successful postoperative pain management¹.
Special consideration to opioid-tolerant client².

Psychological impact of surgery³

Psychological preparation linked to shortened hospital stay and decreased need of analgesia.
Provide clients with opportunity to verbalize fears/concerns.
Multidisciplinary team shares the responsibility of pre-operative teaching.

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Pre-operative Education

Positively influences clients’ post-operative outcomes.
Empowers client’s self-management that facilitates recovery.
Comprehensive information vital for informed consent.
Key principles of pre-operative education include:

Consideration of the individuals coping style.
Tailored information which suits their general level of comprehension, education and cultural background.
Communication of the risks involved in their surgery.
Consideration of the timing of education to avoid times of elevated anxiety, such as immediately preceding surgery.

Cancer Australia, 2018a

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Critical Thinking Question:

What are the elements of preoperative?

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Nurse’s role in Preoperative Care

Work collaboratively with doctors to assess clients’ health care needs for the planned procedure or operation.
Nurse is the first point of contact when client is preparing for surgery and when client arrive on the day of their surgery.
Ensure clients are:

Fully informed and have completed an informed consent form.
Prepared for surgery and that it is safe to proceed with surgery.

Are responsible for assessing clients presenting for surgery and ensuring they have made the necessary preparations.
Substantiate data relevant to the client's readiness for surgery.
Communicate pertinent information to the surgical team.

Australian College of Perioperative Nurses, n.d.

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Nurse’s role in Preoperative Care

Provide necessary support and assistance in cessation of smoking before and after surgery.
Provide psychological support to the client appropriately.

Allow client to voice their concerns and ensure they are addressed to the client’s satisfaction.
Ensure/Facilitate timely provision of information of tests and results to client to reduce stress/anxiety of uncertainty.
Provide information on postoperative destination.

Cancer Australia, 2018a;

Cancer Australia, 2018b

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Preoperative Education By Nurse

Restrictions on certain medications as ordered by doctor prior surgery.
Importance of smoking cessation.
‘Nothing by mouth’ status before surgery (when, how, why).
Bathing/shower, oral hygiene required before surgery.
Wearing comfortable clothing, avoid bringing valuables like ornaments.
Need for companion based on type of surgery (drive home same day?).
Postoperative care and activities client should expect:

Frequent vital signs monitoring.
Physical activity/diet requirements and restrictions.
Breathing exercises.
Pain control measures.

University of IOWA Health Care, 2017

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Intraoperative Care

Begins when client is transferred to operating room.
Ends when client is transferred to post-anaesthesia care unit (PACU) or where post-surgical recovery care is provided.
Surgical intervention occurs where client is

Anaesthetized
Monitored
Prepped, draped
Surgical procedure is performed

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Nurse’s Role in Intraoperative Care

Nurse’s responsibilities in intraoperative phase:

Client’s safety
Facilitation of the procedure
Prevention of infection
Satisfactory physiologic response to anaesthesia and surgical intervention

Nurse roles in intraoperative care:

Anaesthetic Nurse
Circulating Nurse
Instrument Nurse

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Nurse’s Role in Intraoperative Care: Anaesthetic Nurse

Assistant to the anesthetist/anesthesia nurse performs:

Prepare environment and equipment for administering anaesthesia.
Receive and identify the correct client in the operating room.
Ask and answer client’s questions and take informed consent.
Communicate relevant client information to the other members of the intraoperative team, both nurses and doctors.
Assist with intra-operative client monitoring and ensure the client’s safety, comfort and warmth.
Assist the anesthetist at the end of the procedure as the client emerges from the effects of anesthesia.

Australian College of Perioperative Nurses, n.d.

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Nurse’s Role in Intraoperative Care: Circulating Nurse

Non-sterile member of the team in operation room who:

Coordinates the activities in the operating room.
Implement the nursing plan of care, supply the sterile team as needed and document all care the client receives.
Advocate for the client and ensure a safe environment.
Undertake and document the count of all accountable items, together with the instrument nurse.
Consistently monitor the intra-operative environment and the aseptic status of the sterile team using their surgical conscience.

Australian College of Perioperative Nurses, n.d.

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Nurse’s Role in Intraoperative Care: Instrument Nurse

Also referred to as ‘Scrub Nurse’.
Scrubs, gowns and gloves for the surgical procedure.
Performs following activities:

Are responsible for setting up and handing sterile supplies.
Are responsible for handing instruments to the surgeon.
Maintain an accurate count of all accountable items throughout the procedure.
Consistently monitor the intra-operative environment and the aseptic status of the sterile team using their surgical conscience.

Australian College of Perioperative Nurses, n.d.

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Critical Thinking Question:

Why is preoperative client education important in surgery?

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Post-operative Care

Begins with the transfer of the client to post-operative care unit (POCU) or PACU.
Ends with the resolution of surgical sequelae.
Currently, many surgical interventions are performed on outpatient basis where possible.

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Immediate Post-operative Care in PACU/POCU

Following assessments are undertaken immediately and frequently:

Respiratory rate;
Oxygen saturation;
Temperature;
Systolic blood pressure;
Pulse rate;
Level of consciousness (consider sedation/opioid analgesia given)
IV Infusions

Clients must be monitored and assessed closely for any deterioration in condition.
Relevant postoperative care plan or pathway must be implemented.

Liddle, 2013a

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Post-operative Care in PACU/POCU

Pain management¹

Indications of pain: Restlessness, immobility, grimacing, increased perspiration, pallor, anxiety, tachycardia, hypertension.
Ensure infusion lines are not disconnected.
Assess/evaluate effectiveness in opioid-tolerant clients.

May need higher doses analgesia compared to other clients.

Assess for haemorrhage and/or shock²:

Assess for excessive bleeding on the surgical wound dressing.
Assess for: tachycardia, lowered systolic reading, cold/clammy skin, and prolonged capillary refill time.

which indicate internal bleeding leading to shock.

Liddle, 2013 b
Coluzzi et al., 2017
Liddle, 2013 a

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Post-operative Care: Further Care

Unless contraindicated, encourage and assist client to upright position supported by pillow².
Assist client in performing:

Deep breathing exercises and coughing, turning frequently^1,2.

Supporting incision firmly with hands/small pillow while doing so
Helps clear lungs and lowers the risk of pneumonia¹.

Provide client teaching and encouragement on performing range of motion exercises of upper and lower extremities.

Flex, extend, rotate feet^1,2.
Reduce risk of embolism^1,2.

Government of Alberta, 2019
Liddle, 2013b

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Post-operative Care: Further Care

American Cancer Society, 2019
Liddle, 2013b

When possible, assist client to ambulate ¹

Improves blood circulation that helps in wound healing.
Helps early return of bowel and bladder function.

Catheterizations must be the last resort to help client urinate².

Introduction of small amounts of fluid²initially, unless contraindicated.

Then progress to solid as appropriate.
Client must be eating full diet by the time they are discharged.

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Nurse’s Role in Post-operative Care

Same perioperative nurse might provide care at postoperative phase where client is expected to return home the same day.
Perioperative nurses are responsible for:

Supporting client recovering from surgery and identifying potential complications.
Keeping up-to-date with guidelines, policies and evidence-based practice pertinent to perioperative care.
Adhering to best practice guidelines.
Skilled at knowing what is normal or abnormal.
Effectively communicating/managing emergency situations.

Liddle, 2013a; Liddle, 2013b

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Nurse’s Role in Immediate Post-operative Care

Liddle, 2013a

PACU/POCU nurse receives client and provide immediate care which include:

Ensure client safety from any kind of injury.
Ensuring client is in recovery position with patent airway.
Undertake respiratory, cardiovascular and neurological assessment.
Assess for signs of external/internal bleeding.
Incase client deteriorates, immediately call for help and carry out management interventions according to the agency protocol.

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Nurse’s Role in Post-operative Care in the Ward/Daycare Units

Liddle, 2013b

Monitoring of vital signs, pain, active bleeding, wound dehiscence.
Administration of appropriate medications:

Antibiotics
Pain medications
IV fluids
Anticoagulants

Provide client education and assistance in:

Deep breathing, coughing exercise.
Range of motion exercises of feet.
Early ambulation bowel movement and Urination.
Wound care.

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Nurse’s Role in Post-operative Care

Client education before discharge:

Physical activities, exercises that can be done safely.

To prevent wound dehiscence and promote wound healing.

Nutritional diet for wound healing.
Hygienic habits to care for wound at home,

Signs of infection to be aware of, and seek medical care immediately if present.

Date and time for follow-up.

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What Would the Nurse Do?

The nurse is caring for a client in the recovery room who has had abdominal surgery. What assessments would be specific in this case?

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Red Flags

Tachycardia
Increased blood or drainage on dressing
Low blood pressure
Prolonged capillary refill
Lower level of consciousness
Fever ( may indicate life threatening reaction to anesthesia)
Anxiousness, restlessness, grimacing
Urinary retention
Low Oxygen saturation readings
Decreased respirations

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Cultural Considerations

Tolerance and expression of pain differs across cultures.
Maintenance of privacy in pre op and recovery areas.

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References:

American Cancer Society (2019, October 2). Risks of Cancer Surgery. https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/surgery/risks-of-cancer-surgery.html

Australian College of Perioperative Nurses (n.d.). Nurses roles. Retrieved on September 7, 2021 from https://www.acorn.org.au/nursing-roles

CPOC (n.d.). What is perioperative care?. Retrieved on September 7, 2021 from https://cpoc.org.uk/about-cpoc/what-perioperative-care

Cancer Australia. (2018a). EdCaN module: Fundamentals of cancer surgery/Individual Assessment. version 2.1. Retrieved on September 7, 2021 from https://www.edcan.org.au/edcan-learning-resources/supporting-resources/surgery/care-of-person/pre-op-assessment

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References:

Cancer Australia. (2018b) EdCaN module: Fundamentals of cancer surgery/Pre-operative education. version 2.1. Retrieved on September 7, 2021 from https://www.edcan.org.au/edcan-learning-resources/supporting-resources/surgery/care-of-person/pre-op-education

Coluzzi, F., Bifulco, F., Cuomo, A., Dauri, M., Leonardi, C., Melotti, R.M., Natoli, S., Romualdi, P., Savoia, G., & Corcione, A. (2017).The challenge of perioperative pain management in opioid-tolerant patients. Ther Clin Risk Manag, 13,1163-1173. https://doi.org/10.2147/TCRM.S141332

Garimella, V., & Cellini, C. (2013). Postoperative pain control. Clinics in colon and rectal surgery, 26(3), 191–196. https://doi.org/10.1055/s-0033-1351138

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Reference:

Goodman, T., & Spry, C. (2017). Essentials of Perioperative Nursing (6th ed.). Jones & Bartlett Learning.

Government of Alberta. (2019, May). Deep Breathing, Coughing, and Moving After Surgery. https://myhealth.alberta.ca/Alberta/Pages/deep-breathing-coughing-after-surgery.aspx

Journal of Perioperative & Critical Intensive Care Nursing (n.d.). Perioperative care. Retrieved on September 7, 2021 from https://www.longdom.org/scholarly/perioperative-care-journals-articles-ppts-list-1504.html

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Reference:

Liddle, C. (2013a). Postoperative care 1: principles of monitoring postoperative patients. Nursing Times, 109 (22): 24-26. https://www.nursingtimes.net/clinical-archive/critical-care/postoperative-care-1-principles-of-monitoring-postoperative-patients-31-05-2013/

Liddle, C. (2013b). Postoperative nursing care 2: how to reduce the risk of deterioration after surgery. Nursing Times; 109 (23):16-17. https://www.nursingtimes.net/clinical-archive/perioperative-nursing/postoperative-care-2-how-to-reduce-the-risk-of-deterioration-after-surgery-07-06-2013/

University of IOWA Health Care. (2017, July 16 ). Routine preoperative teaching for the adult patient. https://medicine.uiowa.edu/iowaprotocols/routine-preoperative-teaching-adult-patient

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