The preoperative phase begins when the decision for surgery is made and ends when the patient is transferred to the operating room table. The preoperative evaluation and teaching typically takes place several days before surgery in an outpatient setting. Today, most perioperative patients are admitted to the hospital the morning of their surgical procedure. However, there are times when the preoperative phase will begin on the medical-surgical units or in the emergency department.
The first step of the preoperative phases begins with a patient and chart assessment on all patients scheduled for an operative and/or invasive procedure prior to transportation to the Surgical Suites. This ensures accurate identification of the patient, using two identifiers, identification and marking of the surgical site, adequacy of the preoperative patient preparation, and completeness of the documentation. This assesses the patient’s actual and potential health problems and facilitates implementation and communication of the perioperative plan of care.
The intraoperative phase extends from the time the client is admitted to the operating room, to the time of anesthesia administration, performance of the surgical procedure and until the client is transported to the recovery room or postanethesia care unit (PACU). Throughout the surgical experience the nurse functions as the patient’s chief advocate. The nurse’s care and concern extend from the time the patient is prepared for and instructed about the forthcoming surgical procedure to the immediate preoperative period and into the operative phase and recovery from anesthesia.
The patient needs the security of knowing that someone is providing protection during the procedure and while he is anesthetized because surgery is usually a stressful experience. The postoperative period of the surgical experience extends from the time the client is transferred to the recovery room or past-anesthesia care unit (PACU) to the moment he or she is transported back to the surgical unit, discharged from the hospital until the follow-up care. During the postoperative period, reestablishing the patient’s physiologic balance, pain management and prevention of complications should be the focus of the nursing care.
To do these it is crucial that the nurse perform careful assessment and immediate intervention in assisting the patient to optimal function quickly, safely and comfortably as possible. Postoperative complications may either be general or specific to the type of surgery undertaken and should be managed with the patient’s history in mind. Common general postoperative complications include postoperative fever, atelectasis, wound infection, embolism and deep vein thrombosis (DVT). The highest incidence of postoperative complications is between one and three days after the operation.
However, specific complications occur in the following distinct temporal patterns: early postoperative, several days after the operation, throughout the postoperative period and in the late postoperative period. [1] General postoperative complications include: Immediate: Primary hemorrhage: either starting during surgery or following postoperative increase in blood pressure – replace blood loss and may require return to theatre to re-explore the wound, basal atelectasis: minor lung collapse.
Shock, blood loss, acute myocardial infarction, pulmonary embolism or septicemia, low urine output: inadequate fluid replacement intra-operatively and postoperatively. Early: acute confusion: exclude dehydration and sepsis, nausea and vomiting: analgesia or anesthetic-related; paralytic ileus, fever, secondary hemorrhage: often as a result of infection, pneumonia, wound or anastomosis dehiscence, DVT, acute urinary retention, Urinary tract infection (UTI), postoperative wound infection, bowel obstruction due to fibrous adhesions, paralytic Ileus.
Late: bowel obstruction due to fibrous adhesions, incisional hernia, persistent sinus, and recurrence of reason for surgery – eg, malignancy. General principles of preoperative teaching include reinforcing what the patient has been told about surgery. Find out patient’s understanding of procedure first. Know enough basic information about common procedures to anticipate and answer the common questions. Balance telling too little vs. too much. Avoid anxiety producing words “pain” (discomfort).
Include family members, if possible. Have the patient explain, give return demonstrations. Prepare for situations (cold, bright light, never left alone) Patient teaching about postoperative care include therapeutic devices: indwelling catheter, n/g tube, chest tube. Assure that medication will be available, PCA devices. Postoperative self-care procedures: C & DB, splinting, leg exercises, turning. Ambulation- don’t bound OOB, don’t do a sit up, sit at BS for a moment to check dizziness.