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 Interactions with others - withdrawn or involved.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).

2. Intraoperative preparation - anesthesia: blocks transmission of nerve impulses, suppresses reflexes, promotes muscle relaxation, and in some instances achieves reversible unconsciousness.
   1. Intravenous conscious sedation - produces sedation and amnesia in ambulatory procedures, short surgical or diagnostic procedures. Allays fear and anxiety, elevates pain threshold, maintains consciousness and protective reflexes, and returns patient quickly to normal activities. Commonly used agents are benzodiazepines (midazolam, diazepam) and narcotics (fentanyl, meperidine, morphine).
   2. Regional anesthesia - purpose is to block pain reception and transmission in a specified area. Commonly used drugs are lidocaine HCI, tetracaine HCI, cocaine HCI, and procaine HCI. Types of regional anesthetics:
      1. Topical - applied to mucous membranes or skin; drug anesthetizes the nerves immediately below the area. May be used for bronchoscopic or laryngoscopic examinations. Side effects: rare anaphylaxis.
      2. Local infiltration - used for minor procedures; anesthetic drug is injected directly into the area to be incised, manipulated, or sutured. Side effects: rare anaphylaxis.
      3. Peripheral nerve block - regional anesthesia is achieved by injecting drug into or around a nerve after it passes from vertebral column; procedure is named for nerve involved, such as brachial-plexus block. Requires a high degree of anatomical knowledge. Side effects: may be absorbed into bloodstream. Observe for signs of excitability, twitching, changes in vital signs, or respiratory difficulties.
      4. Field block - a group of nerves is injected with anesthetic as the nerves branch from a major or main nerve trunk. May be used for dental procedures, plastic surgery. Side effects: rare.
      5. Epidural anesthesia - anesthetizing drug is injected into the epidural space of vertebral canal; produces a bandlike anesthesia around body. Frequently used in obstetrics. Rare complications. Slower onset than spinal anesthesia, not dependent on patient position for level of anesthesia, no postoperative headaches.
      6. Spinal anesthesia - anesthetizing drug is injected into the subarachnoid space and mixes with spinal fluid; drug acts on the nerves as they emerge from the spinal cord, thereby inhibiting conduction in the autonomic, sensory, and motor systems.
         1. Advantages: rapid onset; produces excellent muscle relaxation.
         2. Utilization: surgery on lower limbs, inguinal region, perineum, and lower abdomen.
         3. Disadvantages:
            1. Loss of sensation below point of injection for 2-8 hours - watch for signs of bladder distention; prevent injuries by maintaining alignment, keeping bedclothes straightened.
            2. Patient awake during surgical procedure - avoid light or upsetting conversations.
            3. Leakage of spinal fluid from puncture site - keep flat in bed for 24-48 hours to prevent headache. Keep well hydrated to aid in spinal-fluid replacement.
            4. Depression of vasomotor responses - frequent checks of vital signs.
      7. Intravenous regional anesthesia - used in an extremity whose circulation has been interrupted by a tourniquet; the anesthetic is injected into vein, and blockage is presumed to be achieved from extravascular leakage of anesthetic near a major nerve trunk. Precautions as for peripheral nerve block.
   3. General anesthesia - a reversible state in which the patient loses consciousness due to the inhibition of neuronal impulses in the brain by a variety of chemical agents; may be given intravenously, by inhalation, or rectally.
      1. Side effects:
         1. Respiratory depression.
         2. Nausea, vomiting.
         3. Excitement.
         4. Restlessness.
         5. Laryngospasm.
         6. Hypotension.
      2. Nursing care plan/implementation - Goal: prevent hazardous drug interactions.
         1. Notify anesthesiologist if patient is taking any of the following drugs:
            1. Antidepressants, such as Prozac - long half-life; monitor renal and liver function.
            2. Antihypertensives, such as reserpine, hydralazine, and methyldopa - potentiate the hypotensive effects of anesthetic agents.
            3. Anticoagulants, such as heparin, warfarin (Coumadin) - increase bleeding times, which may result in excessive blood loss or hemorrhage.
            4. Aspirin and NSAIDs - decrease platelet aggregation and may result in increased bleeding.
            5. Steroids, such as cortisone - anti-inflammatory effect may delay wound healing.
         2. Stages o f inhalation anesthesia and nursing goals:
         1. Stage I - extends from beginning of induction to loss of consciousness. Nursing goal: reduce external stimuli, because all movement and noises are exaggerated for the patient and can be highly distressing.
         2. Stage II - extends from loss of consciousness to relaxation; stage of delirium and excitement. Nursing goal: prevent injury by assisting anesthesiologist to restrain patient if necessary; maintain a quiet, nonstimulating environment.
         3. Stage III - extends from loss of lid reflex to cessation of voluntary respirations. Nursing goal: reduce risk of untoward effects by preparing the operative site, assisting with procedures, and observing for signs of complications.
         4. Stage IV - indicates overdose and consists of respiratory arrest and vasomotor collapse due to medullary paralysis. Nursing goal: promote restoration of ventilation and vasomotor tone by assisting with cardiac arrest procedures and by administering cardiac stimulants or narcotic antagonists as ordered.
   4. Intravenous agents - rapid and pleasant induction of anesthesia. Three categories: barbiturates (thiopental), narcotics, and neuromuscular blocking agents (succinylcholine, curare, pancuronium). Ketamine also used - may produce emergence delirium. IV drugs require liver metabolism and renal excretion.
   5. Hypothermia - a specialized procedure in which the patient’s body temperature is lowered to 28°-30°C (82°-86°F).
   1. Reduces tissue metabolism and oxygen requirements.
   2. Used in heart surgery, brain surgery, and surgery on major blood vessels.
   3. Nursing care plan/implementation:
      1. Goal: prevent complications:
         1. Monitor vital signs for shock.
         2. Note level of consciousness.
         3. Record intake and output accurately.
         4. Maintain good body alignment; reposition to prevent edema, pressure, or discoloration of skin.
         5. Maintain patent IV.
      2. Goal: promote comfort.
      1. Apply blankets to rewarm and prevent shivering.
      2. Mouth care.
      3. Goal: observe for indications of malignant hyperthermia - common during induction; may occur 24-72 hours postoperatively. Genetic defect of muscle metabolism; early sign is unexplained ventricular dysrhythmia, tachypnea, cyanosis, skin mottling; elevated temperature is not reliable indicator.
      1. Administer 100% O₂.
      2. Cool with ice packs or cooling blankets.
      3. Give dantrolene (muscle relaxant) per order.
   6. Evaluation/outcome criteria: complete reversal of anesthetic effects (e.g., spontaneous respirations, pupils react to light). No indication of intraoperative complications - cardiac arrest, laryngospasm, aspiration, hypotension, malignant hyperthermia.

3. Postoperative experience
   1. Assessment:
      1. Subjective data:
         1. Pain: location, onset, intensity.
         2. Nausea.
      2. Objective data:
         1. Operative summary:
            1. Type of operation performed.
            2. Pathological findings if known.
            3. Anesthesia and medications received.
            4. Problems during surgery that will affect recovery, e.g., arrhythmias, bleeding (estimated blood loss).
            5. Fluids received: type, amount.
            6. Need for drainage or suction apparatus.
         2. Observations:
            1. Patency of airway.
            2. Vital signs.
            3. Skin color and dryness.
            4. Level of consciousness.
            5. Status of reflexes.
            6. Dressings.
            7. Type and rate of IV infusion and blood transfusion.
            8. Tubes/drains: urinary, chest, Penrose, Hemovac; note color and amount of drainage.
   2. Analysis/nursing diagnosis:
      1. Ineffective breathing pattern related to general anesthesia.
      2. Ineffective airway clearance related to absent or weak cough.
      3. Risk for aspiration related to vomiting.
      4. Pain related to surgical incision.
      5. Altered tissue perfusion related to shock.
      6. Risk for fluid volume deficit related to blood loss.
      7. Risk for injury related to disorientation.
      8. Risk for infection related to disruption of skin integrity.
      9. Urinary retention related to anesthetic effects.
      10. Constipation related to decreased peristalsis.
   3. Nursing care plan/implementation - immediate postanesthesia nursing care: refers to time following surgery that is usually spent in the recovery room ( 1-2 hours).
      1. Goal: promote a safe, quiet, nonstressful environment.
         1. Side rails up at all times.
         2. Nurse in constant attendance.
      2. Goal: promote lung expansion and gas exchange.
      3. Goal: Prevent aspiration and atelectasis.
         1. Position: side or back, with head turned to side to prevent obstruction of airway by tongue; allows for drainage from mouth.
         2. Airway: leave the oropharyngeal or nasopharyngeal airway in place until patient awakens and begins to eject; gagging and vomiting may occur if not removed before pharyngeal reflex returns.
         3. After removal of airway: turn on side in a lateral position; support upper arm with pillow.
         4. Suction: remove excessive secretions from mouth and pharynx.
         5. Encourage coughing and deep breathing: aids in upward movement of secretions.
         6. Give humidified oxygen as necessary: reduces respiratory irritation and keeps bronchotracheal secretions soft and moist.
         7. Mechanical ventilation: respirators if needed.
      4. Goal: promote and maintain cardiovascular function.
         1. Vital signs, as ordered: usually q15mins until stable.
            1. Compare with preoperative vital signs.
            2. Immediately report: systolic blood pressure that drops 20 mm Hg or more, a pressure below 80 mm Hg, or a pressure that continually drops 5-10 mm Hg over several readings; pulse rates under 60 or over 110 beats/min, or irregularities; respirations over 30/min; becoming shallow, quiet, slow; use of neck and diaphragm muscles (symptoms of respiratory depression).
         2. Observe for other alterations in circulatory function - pallor; thready pulse; cold, moist skin; decreased urine output, restlessness.
            1. Immediately report to physician.
            2. Initiate oxygen therapy.
            3. Place patient in shock position unless contraindicated - feet elevated, legs straight, head slightly elevated to increase venous return.
         3. Intravenous infusions: time, rate, orders for added medications.
         4. Monitor blood transfusions if ordered: observe for signs of reaction (chills, elevated temperature, urticaria, laryngeal edema, and wheezing). Table 7-22 illustrates the nursing care plan implementation.
         5. If reaction occurs, immediately stop transfusion and notify physician. Send stat urine to lab.
      5. Goal: promote psychological equilibrium.
         1. Reassure on awakening - orient frequently.
         2. Explain procedures even though patient does not appear alert.
         3. Answer patient’s questions briefly and accurately.
         4. Maintain quiet, restful environment.
         5. Comfort measures:
            1. Good body alignment.
            2. Support dependent extremities to avoid pressure areas and possible nerve damage.
            3. Check for constriction: dressings, clothing, bedding.
            4. Check IV sites frequently for patency and signs of infiltration (swelling, blanching, cool to touch).
      6. Goal: maintain proper function of tubes and apparatus.
   4. General postoperative nursing care: refers to period of time from admission to the general nursing unit until anticipated recovery and discharge from the hospital.
      1. Goal: promote lung expansion, gaseous exchange, and elimination of bronchotracheal secretions.
         1. Turn, cough, and deep breathe q2h.
         2. Use incentive spirometer as ordered to enable patient to observe depth of ventilation.
         3. Administer nebulization as ordered to help mobilize secretions.
         4. Encourage hydration to thin mucous secretions.
         5. Assist in ambulation as soon as allowed.
      2. Goal: provide relief of pain.
         1. Assess type, location, intensity, and duration; possible causative factors, such as poor body alignment or restrictive bandages.
         2. Observe and evaluate reaction to discomfort.
         3. Use comfort measures, such as back rubs and proper ventilation, staying with patient and encouraging verbalization.
         4. Reduce incidence of pain: change position frequently; support dependent extremities with pillows, sandbags, and footboards; keep bedding dry and straight.
         5. Give analgesics or tranquilizers as ordered; assure patient that they will help.
         6. Observe for desired and untoward effects of medication.
      3. Goal: promote adequate nutrition and fluid and electrolyte balance.
      1. Parenteral fluids, as ordered.
      2. Monitor blood pressure, I&O to assess adequate, deficient, or excessive extracellular fluid volume.
      3. Diet: liquid when nausea and vomiting stop and bowel sounds are established, progress as ordered.
      4. Goal: assist patient with elimination.
      1. Encourage voiding within 8-10 hours after surgery.
         1. Allow patient to stand or use commode, if not contraindicated.
         2. Run tap water or soak feet in warm water to promote micturition.
         3. Catheterization if bladder is distended and conservative treatments have failed.
      2. Maintain accurate I&O records.
      3. Expect bowel function to return in 2-3 days.
      5. Goal: facilitate wound healing and prevent infection.
      1. Incision care: avoid pressure to enhance venous drainage and prevent edema.
      2. Elevate injured extremities to reduce swelling and promote venous return.
      3. Support or splint incision when coughing.
      4. Check dressings q2h for drainage.
      5. Change dressings on draining wounds prn; aseptic technique; protective ointments to reduce skin irritation may be ordered.
      6. Carefully observe wound suction (e.g., Jackson-Pratt), if applied, for kinking or twisting of the tubes.
      6. Goal: promote comfort and rest.
      1. Recognize factors that may cause restlessness - fear, anxiety, pain, oxygen lack, wet dressings.
      2. Comfort measures: analgesics or barbiturates; apply oxygen as indicated; change positions; encourage deep breathing; massage back to reduce restlessness.
      3. Allow rest periods between care - group activities.
      4. Give antiemetic for relief of nausea and vomiting, as ordered.
      5. Vigorous oral hygiene (brushing) to prevent “surgical mumps” or parotitis from preop atropine or general anesthesia.
      7. Goal: encourage early movement and ambulation to prevent complications of immobilization.
      1. Turn or reposition q2h.
      2. ROM: passive and active exercises.
      3. Encourage leg exercises.
      4. Use preventive treatments - antiembolic stockings, graduated compression stockings, or external pneumatic compression sleeves:
         1. With compression stockings, highest pressure (100%) at ankles, lowest pressure (40%) at midthigh.
         2. Compression sleeves, three chambers sequentially inflated-deflated to stimulate venous return.
      5. Assist with standing or use of commode if allowed.
      6. Encourage resumption of personal care as soon as possible.
      7. Assist with ambulation in room as soon as allowed. Avoid chair sitting because it enhances venous pooling and may predispose to thrombophlebitis.
   5. Evaluation/outcome criteria:
   1. Incision heals without infection.
   2. No complications, e.g., atelectasis, pneumonia, thrombophlebitis.
   3. Normal bowel and bladder functions resume.
   4. Carries out activities of daily living, self-care.
   5. Accepts possible limitations: dietary, activity, body image (e.g., no depression, complies with treatment regimen).

TABLE 7-22 Postoperative Complications