Operative care

13 Operative care


Operative care is the care that takes place when a patient undergoes a surgical procedure. It begins before admission and often continues following discharge.




Phases of operative care



image Preoperative care
• Occurs from the decision to operate until the patient enters the operating suite

image Intraoperative care
• Occurs while the patient is in the operating suite, until the patient reaches the ward

• Three distinct phases:
image Preoperative
– From the time the patient enters the operating suite until they enter the operating room (OR)

– Includes holding bay and anaesthetic room

image Intraoperative
– From the time the patient enters the OR until they are transferred to recovery/post-anaesthetic care unit (PACU) or intensive care unit (ICU)

image Postoperative
– From the time the patient enters recovery until they are transferred to the ward

image Postoperative care
• Occurs from the ward until the patient goes home. It can include hospital in the home and rehabilitation.


Preoperative care


Many operations are done as day-procedures, which means that admission data can be collected days or even weeks in advance.



Data collected in advance



image Past history, including previous anaesthetics and allergies

image Medication history
• Some prescribed, OTC and herbal remedies can interact with anaesthetic medications and patient’s coagulation status. Always check with the surgeon or anaesthetist about what medications may need to be ceased prior to surgery.



image Aspirin should be stopped at least seven days prior to surgery, as it takes this amount of time for new platelets to form.



image Physical assessment—may need to redo on day of surgery

image Height and weight—necessary for anaesthetic dose

image Blood tests:
• Full blood examination (FBE)/full blood count (FBC)—including Hb, WCC and platelets

• Urea, creatinine and electrolytes (UCE or U&E)—to assess renal function

• Coagulation studies—to assess clotting ability

• Possibly liver function tests (LFT)—especially if suspected alcohol use

• X-match—in the event that a blood transfusion is required

• Autologous blood donation—prior to major surgery where a transfusion is likely

image ECG—especially for patients with a cardiac history

image X-ray, CT, MRI—to diagnose exact locations
• These need to be with the patient on the day of surgery

image Social history, including smoking and support at home—to assess what support services may be required postoperatively.


Factors that may affect surgery



image Cardiovascular system
• If BP is too high or too low, the surgery may be postponed until the patient is stable, unless it is an emergency

• Arrythmias may need to be treated or stabilised

image Respiratory system
• A respiratory disorder such as asthma or emphysema can lead to conditions such as atelectasis and pneumonia, which may prolong the patient’s hospital stay

image Gastrointestinal system
• Poor nutrition and/or hyperglycaemia can lead to poor wound healing and lower resistance to infection

• Poor hepatic function can lead to drugs not being metabolised effectively and remaining in the circulation longer
image Can also lead to clotting problems, as the clotting factors are not being produced in satisfactory quantities

• Patients with alcohol or drug use may have malnutrition
image These patients may also have withdrawal post-op, slowing recovery and placing more stress on the body

image Immune system
• The patient may not heal as quickly if they:
image Are taking anti-rejection medications post transplant

image Are undergoing chemotherapy or radiotherapy treatment

image Are on certain medications, e.g. steroids

image Culture/religion
• For example, Jehovah’s Witnesses do not usually accept blood products, and therefore other means (e.g. autologous blood salvage units (cell savers)) may be used to replace blood lost during major surgery.


Preop assessment (on day of surgery)



image Ensure patient has signed the consent form
• It is the duty of the medical team to obtain valid consent
image Ensure an interpreter is present if the patient does not understand English

image Ensure patient has fasted for 8 hours prior to surgery, to prevent aspiration of food and fluids
• For morning surgery, the patient should fast from 2400 hours the night before. Patients having afternoon surgery can have an early breakfast at 0600 hours.

image Enquire as to whether patient has taken any medication that morning
• Some patients will still require their daily medications, e.g. cardiac patients are often told to take their antihypertensive medications (to prevent rebound hypertension)

• Pre-medications are not used regularly but can be ordered if patient is overly anxious or in pain



image Always check with the surgical team or anaesthetist prior to giving ‘regular’ medication.



image Ensure that, if ordered, the patient has completed their bowel workup—that is, taken the prescribed medication to ‘flush’ out the bowel
• This allows better visualisation of the bowel during surgery.


Nursing care on the day of surgery



image Ensure that the patient has had adequate skin preparation prior to surgery, e.g. an antibacterial skin wash or shave to the surgical area

image Nail polish should be removed from fingernails and toenails, to enable pulse oximetry readings

image All jewellery should be removed
• Wedding rings are the exception and, if left on, should be taped

• Ensure jewellery is taken home by relatives or locked in the hospital safe

image Dentures should remain in, as they will be removed by the anaesthetist prior to intubation
• A labelled denture container should be sent with the patient history and the patient

image Ensure the patient has an ID band on a wrist and another on an ankle, as sometimes bands may be removed for procedures

image Patient education should start in the preoperative phase
• Deep breathing and coughing (DB&C)
image To prevent atelectasis and pneumonia

• Leg exercises, e.g. calf pumping and leg circles
image To prevent deep vein thrombosis (DVT)

• Education about expected outcomes including pain and, if appropriate, use of a patient-controlled analgesia (PCA) device.


Intraoperative care



Intraoperative clothing


Once inside the theatre complex, all staff must wear:


image Clean scrubs
• Staff may leave theatre in their scrubs but must change into new scrubs upon re-entering restricted areas

image Sterile gowns and gloves
• All staff in the sterile operating field must wear sterile gowns and gloves, e.g. surgeons, assistants, scrub nurses

image Shoe covers for temporary staff. Permanent staff will have ‘theatre’ shoes.

image Hats or scarves
• Staff must ensure that their hair is tied back and completely covered by a hat or a scarf

• Facial hair must be covered with a balaclava

image Masks
• Must be worn by everyone in the operating room once the sterile theatre packs are opened

image Eye protection
• Must be worn by everyone in the operating field.


The surgical team


The surgical team consists of:


image The surgeon and their assistants

image The anaesthetist

image The scrub (or instrument) nurse, the anaesthetic nurse and the circulating nurse.


On admission to the holding room


The anaesthetic nurse:


image Greets the patient

image Checks:
• ID bands

• Consent

• That the patient is scheduled for the correct procedure

• Allergies

• Whether the patient has fasted and had skin and/or bowel preparations

image Reassures the patient and stays with them until they enter the theatre.


Patient positioning


Patients can receive muscle injuries/pressure sores if:


image Their limbs are hyperextended for a long time

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Oct 22, 2016 | Posted by in NURSING | Comments Off on Operative care

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