The Perioperative Experience

1. Preoperative preparation
   
1. Assessment:
1. Subjective data:
   1. Understanding of proposed surgery - site,type, extent of hospitalization
   2. Previous experiences with hospitalization
   3. Age-related factors
   4. Allergies - iodine, latex, adhesive tape, cleansing solutions, medications.
   5. Medication/substance use - prescribed, OTC, smoking, alcohol, recreational drugs.
   6. Cultural and religious background
   7. Concerns of feeling about surgery:
      1. Exaggerated ideas of surgical risk, e.g., fear of colostomy when none is being considered.
         
      2. Nature of anesthesia, e.g., fears of going to sleep and not waking up, saying or revealing things of a personal nature.
      3. Degree of pain, i.e., may be incapacitating.
      4. Misunderstandings regarding prognosis.
   8. Identification of significant others as a source of patient support or care responsibilities postdischarge.
2. Objective data:
   1. Speech patterns indicating anxiety - repetition, changing topics, avoiding talking about feelings.
   2. Interactions with others - withdrawn or involved.
   3. Physical signs of anxiety, i.e., increased pulse, respirations; clammy palms, restlessness.
   4. Baseline physiological status: vital signs; breath sounds; peripheral circulation; weight; hydration status (hematocrit, skin turgor, urine output); degree of mobility; muscle strength.
      
2. Analysis/nursing diagnosis:
1. Anxiety related to proposed surgery.
2. Knowledge deficit (learning need) related to incomplete teaching or lack of understanding.
3. Fear related to threat of death or disfigurement.
4. Risk for injury related to surgical complications.
5. Ineffective individual coping related to anticipatory stress.
3. Nursing care plan/implementation:
   1. Goal: reduce preoperative and intraoperative anxiety and prevent postoperative complications.
      1. Preoperative teaching:
         1. Provide information about hospital nursing routines and preoperative procedures to reduce fear of unknown.
         2. Explain purpose of diagnostic procedures to enhance ability to cooperate and tolerate procedure.
         3. What will occur and what will be expected in the postoperative period:
            1. Will return to room, postanesthesia care unit, or intensive care unit.
            2. Special equipment - monitors, tubes, suction equipment.
            3. Pain control methods.
      2. Management of latex allergy if present. Three forms: immediate reaction (most serious, life threatening) - flushing, diaphoresis, pruritus, nausea, vomiting, cramping, hypotension, dyspnea; delayed response (most common, discomfort) - localized symptoms 18-24 hours after contact; and contact dermatitis. Exposure to latex through skin, mucous membranes, inhalation, internal tissue, and intravascular; sources include: anesthesia masks, tourniquets, ECG electrodes, adhesive tape, warming blankets, elastic bandages, gloves, tubes/catheters, irrigation syringes. Nursing goal: provide latex-free environment.
   2. Goal: instruct in exercises to reduce complications.
      1. Diaphragmatic breathing - refers to flattening of diaphragm during inspiration, which results in enlargement of upper abdomen; during expiration the abdominal muscles are contracted, along with the diaphragm.
         1. The patient should be in a flat, semiFowler’s, or side position, with knees flexed and hands on the midabdomen.
         2. Have the patient take a deep breath through nose and mouth, letting the abdomen rise. Hold breath 3-5 seconds.
         3. Have patient exhale through nose and mouth, squeezing out all air by contracting the abdominal muscles.
         4. Repeat 10-15 times, with a short rest after each five to prevent hyperventilation.
         5. Inform patient that this exercise will be repeated 5-10 times every hour postoperatively.
      2. Coughing - helps clear chest of secretions and, although uncomfortable, will not harm incision site.
         1. Have patient lean forward slightly from a sitting position, and place patient’s hands over incisional site; this acts as a splint during coughing.
         2. Have patient inhale and exhale slowly several times.
         3. Have patient inhale deeply, hold breath 3 seconds, and cough sharply three times while exhaling - patient’s mouth should be slightly open.
         4. Tell patient to inhale again and to cough deeply once or twice. If unable to cough deeply, patient should “huff” cough to stimulate cough.
      3. Turning and leg exercises - help prevent circulatory stasis, which may lead to thrombus formation, and postoperative flatus or “gas pains,” as well as respiratory problems.
         1. Tell patient to turn on one side with uppermost leg flexed; use side rails to facilitate the movement.
         2. In a supine position, have patient do five repetitions every hour of: ankle pumps, quad sets, gluteal tightenings, and straight-leg raises.
         3. Apply intermittent pulsatile compression device or sequential compression device to promote venous return.
   3. Goal: reduce the number of bacteria on the skin to eliminate incision contamination. Skin preparation:
   1. Prepare area of skin wider and longer than proposed incision in case a larger incision is necessary.
   2. Gently scrub with an antimicrobial agent.
      1. Note possibility of allergy to iodine.
      2. Hexachlorophene should be left on the skin for 5-10 min.
      3. If benzalkonium Cl (Zephiran) solution is ordered, do not soap skin before use; soap reduces effectiveness of benzalkonium by causing it to precipitate.
   3. Hair should remain unless it interferes with surgical procedure.
      1. Note any nicks, cuts, or irritations, potential infection sites.
      2. Depilatory creams or clipping of hair is preferred to shaving with a razor; nick may result in cancellation of surgery.
      3. Skin prep may be done in surgery.
   4. Goal: reduce the risk of vomiting and aspiration during anesthesia; prevent contamination of abdominal operative sites by fecal material. Gastrointestinal tract preparation:
   1. No food or fluid at least 6-8 hours before surgery.
   2. Remove food and water from bedside.
   3. Place NPO signs on bed or door.
   4. Inform kitchen and oncoming nursing staff that patient is NPO for surgery.
   5. Give IV infusions up to time of surgery if dehydrated or malnourished.
   6. Enemas: two or three may be given the evening before surgery with intestinal, colon, or pelvic surgeries; 3 days of cleansing with large-intestine procedures.
   7. Possible antibiotic therapy to reduce colonic flora with large-bowel surgery.
   8. Gastric or intestinal intubation may be inserted the evening before major abdominal surgery.
      1. Types of tubes:
         1. Levin: single lumen; sufficient to remove fluids and gas from stomach; suction may damage mucosa.
         2. Salem-sump: large lumen; prevents tissue-wall adherence.
         3. Miller-Abbott: long single or double lumen; required to remove the contents of jejunum or ileum.
      2. Pressures: low setting with Levin and intestinal tubes; high setting with Salem-sump; excessive pressures will result in injury to mucosal lining of intestine or stomach.
   5. Goal: promote rest and facilitate reduction of apprehension.
   1. Medications as ordered: on evening before surgery may give barbiturate— pentobarbital (Nembutal), secobarbital (Seconal).
   2. Quiet environment: eliminate noises, distractions.
   3. Position: reduce muscle tension.
   4. Back rub.
   6. Goal: protect from injury; ensure final preparation for surgery. Day of surgery:
   1. Operative permit signed and on chart; physician responsible for obtaining informed consent.
   2. Shower or bathe.
      1. Dress: hospital pajamas.
      2. Remove: hair pins (cover hair); nail polish, to facilitate observation of peripheral circulation; jewelry (tape wedding bands securely); pierced earrings; contact lenses; dentures (store and give mouth care); give valuable personal items to family; chart disposition of items.
   3. Proper identification - check band for secureness and legibility.
   4. Vital signs - baseline data.
   5. Void, to prevent distention and possible injury to bladder.
   6. Give preoperative medication to ensure smooth induction and maintenance of anesthesia - antianxiety (e.g., midazolam, diazepam, lorazepam); narcotics (e.g., meperidine, morphine, fentanyl); anticholinergics (e.g., atropine, glycopyrrolate).
      1. Administered 45-75 min before anesthetic induction.
      2. Side rails up (client will begin to feel drowsy and light-headed).
      3. Expect complaint of dry mouth if anticholinergics given.
      4. Observe for side effects - narcotics may cause nausea and vomiting, hypotension, arrhythmias, and/or respiratory depression.
      5. Quiet environment until transported to operating room.
   7. Note completeness of chart:
      1. Surgical checklist completed.
      2. Vital signs recorded.
      3. Routine laboratory reports present.
      4. Preoperative medications given.
      5. Significant patient observations.
   8. Assist patients family in finding proper waiting room.
      1. Inform family members that the surgeon will contact them after the procedure is over.
      2. Explain length of time patient is expected to be in recovery room.
      3. Prepare family for any special equipment or devices that may be needed to care for patient postoperatively (e.g., oxygen, monitoring equipment, ventilator, blood transfusions).