2. Perioperative care
Diane Gilmour
CHAPTER CONTENTS
Preoperative care18
Care during anaesthesia19
Intraoperative care21
Immediate postoperative care27
Conclusion32
The aim of this chapter is to provide a broad introduction to the holistic care given by nurses within the perioperative environment during the patient’s immediate preoperative, intraoperative and postoperative phases of their surgical experience.
This chapter will:
• give a definition of the perioperative period
• describe the various roles of the nurses and other healthcare workers within the perioperative environment
• explore in depth the needs of patients during these phases of their surgical experience, and how care for the individual physical and psychological needs can be adapted
• illustrate how technology and innovation has changed perioperative patient care.
Introduction
Historically, for patients, student nurses and other hospital staff, the perioperative or theatre area has been seen as one of high drama and action, as portrayed regularly by the media, many having preconceived ideas about the roles and contribution made by those within the environment. Yet, for many individuals, it is a time when they are most vulnerable or scared. For patients, they are asleep, unsure if they will wake up and what will happen to them; for student nurses, it is a strange experience, which to begin with they feel unable to relate to other environments; and for other hospital staff, they feel as if they are entering an environment where everything is different and goes on behind closed doors. Ensuring that the highest standard of patient care is delivered to each individual patient throughout their journey within the perioperative environment is fundamental to the perioperative nurse’s role. Patient interaction and communication is essential, although covert if the patient is asleep, as perioperative nurses assess, prepare, plan and implement care. This chapter will demonstrate that perioperative nursing care is patient orientated and that nurses must have a thorough knowledge and understanding of the environment. This will enable them to deliver patient care safely, effectively and without harm to that patient.
Elective or emergency surgery
Surgical procedures can be broadly categorized as either elective (that which is planned) or emergency (that which is unplanned). Elective surgery aims to be performed when the patient is in optimal health but before the surgery affects the quality and threatens their life: e.g. an inguinal hernia can become life threatening if the bowel becomes obstructed within the sac. Clinicians decide if a planned procedure is ‘urgent’ or can be arranged at a time convenient for the surgeon and patient (Phillips, 2004).
Emergency surgery may be as a result of trauma or an accident, gastrointestinal obstruction, or from perforated viscera. The injury may be immediately life threatening, and therefore the procedure will be carried out within 1–2 hours from admission. Other emergencies may require procedures within 24–48 hours following the injury, but in both instances the preoperative time for preparing the patient is significantly reduced and changes in the patient’s condition occur rapidly. Information may be limited; the perioperative nurse must be prepared for any event or occurrence and therefore communication within the perioperative team is essential to coordinate the delivery of safe patient care during this potentially traumatic period (MacDonald, 2005).
For this chapter the emphasis will be on the care of the patient for elective surgery, as many of the principles discussed apply to any patient undergoing any surgical procedure.
Preoperative care
Patient preparation
The perioperative environment is dynamic and ever changing with developments in anaesthesia and surgical technologies, but underpinned by practitioners promoting and maintaining a safe environment for each individual patient (Association for Perioperative Practice (AfPP), 2005). Preparing the perioperative environment starts before the patient arrives and the only information that may be available for the staff is retrieved from the operating theatre list, which is written daily and produced 16–24 hours before the scheduled surgery (AfPP, 2007a). At a minimum, this should detail the patient’s name, age, gender and procedure. This will enable the perioperative nurse to prepare their own area to ensure a safe working environment. For example, knowing the patient’s age allows the anaesthetist and recovery nurses to prepare the correct equipment for the management of that patient’s airway; the procedure will identify how this patient will be positioned and potentially how long they may be in that position for (AfPP, 2007a and Smith, 2005). However, liaison with the preassessment clinic may also have highlighted specific needs for that patient, such as latex allergy (requiring special preparation of the theatre environment), immobility problems, hearing impairment or medical history requiring additional interventions from the clinicians (Oakley, 2010).
Meeting and greeting the patient
The patient is escorted to the operating theatre by either a porter or ward nurse, or both. Ward staff must check the patient’s identity, operating consent form, patient notes and appropriate marking and ensure that all documentation is completed before the patient is transferred to theatre (AfPP, 2007a). The patient may be transported by wheelchair or on their bed, or in some hospitals, particularly within a day surgery unit, they are given the choice of walking (Oakley, 2010). Depending on the facilities within each unit, the patient is either admitted to the holding area (this may be part of recovery) or waits in reception. The patient at this time may have their stress and anxiety heightened due to the unknown environment and unfamiliar staff. It is therefore essential that the perioperative nurse communicates effectively with patients, to ensure that they understand the actions being performed, and that they are able to question and challenge these at any time (Reid, 2005). An accurate assessment at this time by the perioperative nurse will promote an individualized plan for delivering high standards of patient care (AfPP, 2005).
An adult or parent may accompany a child to the operating department and therefore the perioperative care extends to the whole family. Parents themselves may be anxious as they relinquish care of their child to strangers and consideration of their needs as well as the child’s has to be defined (AfPP, 2007a).
Adolescents too have different needs to children and adults; they may have concerns about their surgery but be too embarrassed or scared to articulate those fears and may request their own privacy away from parents (Donnelly, 2005).
An elderly patient may be confused and require additional explanations and reassurance. The nurse with experience will assess the patient’s skin condition, mobility and general appearance as an indication of the patient’s health and well-being (Hehir, 2005).
The patient should be greeted by name and then the nurse should introduce themselves to the patient. A preoperative checklist should be completed in accordance with hospital policy (Table 2.1). This documentation ensures that the correct operation is carried out on the correct patient, who has been prepared to enable the safe administration of anaesthesia and continuation of the surgical procedure. At all times the patient must be treated with privacy, dignity and respect.
| To check | Rationale |
|---|---|
| Name/date of birth of patient | To ensure that this is the correct patient with the correct notes. The date of birth acts as an additional check, as patients with the same name may be on the same ward |
| Consent | Written consent is preferred as it provides documentary evidence (AfPP, 2007a and Hind, 2005). The consent form should clearly state without abbreviations the operative procedure and should be signed by the patient (exceptions apply such as minors, life-threatening situation, legally or mentally incompetent) (Hind, 2005) and by a qualified practitioner competent to carry out the procedure. For consent to be valid, the patient must be informed of the procedure, its expected outcomes, benefits, potential risks and alternatives (AfPP, 2007a and Hind, 2005). The perioperative nurse must check the patient’s understanding of the procedure to safeguard their autonomy (Reid, 2005) |
| Procedure site is marked | Side or site is clearly marked with an indelible marker to avoid confusion. This should then be confirmed with the patient’s notes, X-rays and the operating list. It is the responsibility of the person performing the procedure to ensure that the correct side/site is marked (AfPP, 2007a) |
| Last ate or drank | Patients must fast preoperatively to minimize the risk of inhaling gastric contents whilst undergoing general anaesthetic, which could prove fatal (AfPP, 2007a and RCN, 2005). The Royal College of Nursing (RCN) recommend the oral intake for adults be restricted – clear fluids (water, tea and coffee without milk) may be taken up to 2 hours before surgery and a fasting time of 6 hours for solid foods or drinks with milk Chewing gum and sweets are not recommended on the day of surgery (RCN, 2005). Patients must be given enough information to understand and realize the importance of preoperative fasting and the consequences if these instructions are not followed, i.e. the operation will be delayed or cancelled (AfPP, 2007a) Chand and Dabbas (2007) identified that prolonged fasting preoperatively can result in dehydration, anxiety, electrolyte imbalances and glycaemic disturbances. Certain groups of patients are particularly susceptible to such complications, including the elderly, pregnant women, children and the critically ill. Reducing fasting times will reduce Postoperative nausea and vomiting (PONV) and improve wound healing, comfort and postoperative outcomes |
| Allergies | Identify allergies to minimize risk for patient during surgery. These should include Elastoplast, specific drugs (antibiotics, suxamethonium, or any that contain eggs or nuts), fluids such as iodine, and latex, and also note patients’ adverse reactions to anaesthetic or blood transfusions (AfPP, 2007a and Phillips, 2004) |
| State of teeth | Caps, crowns, dentures or loose teeth can become dislodged or damaged during intubation and may compromise the airway. Dentures, if tight fitting, and if the patient does not normally remove them routinely, may be left in place throughout the procedure at the anaesthetist’s discretion |
| Jewellery | Some items of jewellery are worn for religious or cultural reasons and may cause offence if removed, so perioperative nurses must respect patient needs. Muslim and Sikh women may wear gold or glass bangles or nasal stones and a wedding ring to signify marriage and the AfPP recommend that these remain in place if they do not compromise venous or surgical access (AfPP, 2007b). Some body piercing may interfere with the surgery or compromise the airway and may be removed if required Secure all rings and other jewellery to ensure that they are not lost during positioning or moving of the patient (AfPP, 2007a) |
| Wearing of any prosthesis | Hearing aids are essential for the patient to communicate with theatre staff, so can be left in until the patient reaches the anaesthetic room and is about to be anaesthetized. The hearing aid should then be removed and given to recovery staff so that they can insert it once the patient regains consciousness Glasses can also be worn to theatres for the same reason Contact lenses should not be worn, because during the procedure there is a risk that they can become dry and may scratch the cornea Other prostheses such as wigs, false eyes and artificial limbs should be removed prior to surgery and retained on the ward for safe-keeping. However, patients may express anxiety and every effort should be made to preserve a patient’s dignity and respect during the perioperative period (AfPP, 2007a) |
| Medical and nursing records | All medical and nursing records should accompany the patient to the operating theatre so that an accurate assessment of the patient’s history can be made for the delivery of safe perioperative care Documentation should include results from investigations completed at preoperative assessment, blood tests, X-rays and baseline observations (AfPP, 2007a) |
Perioperative nurses also need to provide equitable and appropriate care with respect to cultural, religious, ethnic and racial beliefs. Perioperative nurses must acknowledge the differences in beliefs and consider the patient’s wishes when greeting, planning and providing care. This will involve a knowledge and understanding of religious practices, family role and cultural orientation. Hindu, Muslim and Sikh women may wish to keep their legs and arms covered, as physical contact and exposure can be distressing; Muslim women must be attended by female practitioners where possible; Hindus also consider body fluids offensive, so nurses must ensure that all traces of blood are removed at the end of the operation; and Sikh men do not cut their hair or beard and wear a turban. Perioperative nurses need to discuss with Sikh men the potential need for shaving the diathermy plate site and seek their permission first (AfPP, 2007b).
Care during anaesthesia
The anaesthetic nurse will, based on the information known or relayed by the anaesthetist, prepare the anaesthetic room, anaesthetic machines and all other equipment to ensure the maintenance of a safe environment for the delivery of care during anaesthesia. This will include not only preparing the anaesthetic equipment but also applying knowledge and skills of anaesthesia related to age, medical history and surgical procedure to ensure that the patient’s individual needs are met: e.g. if the patient is elderly, then additional precautions are needed when caring for their skin; if the patient has language difficulties, an interpreter may be required.
An anaesthetic nurse must hold an appropriate, recognized qualification. The nurse must also continue to demonstrate continuing knowledge, skills and understanding in the field of anaesthesia (Nursing and Midwifery Council, 2008).
The role of an anaesthetic nurse has many dimensions and involves technical, communication, clinical and supervisory skills. Patients may be frightened or anxious, which can inhibit communication at this point. Barriers, such as the wearing of a mask when greeting the patient, undue background noise such as talking and telephones, and lack of explanations when performing tasks, must be removed. It is therefore essential to support and reassure the patient, offer appropriate explanations and provide care based on their needs at the time (Oakley and Van Limborgh, 2005). Communication is not always verbal and the use of touch, holding the patient’s hand and just being a physical presence can offer additional support for the patient. The anaesthetic nurse may also need to remove dentures, glasses, prostheses or wigs in preparation for surgery. Reassurance, comfort and sensitivity about the patient’s potential loss of dignity are essential in reducing the patient’s anxiety further (AfPP, 2007a).
‘ Anaesthesia’ is a Greek word and reflects a state where there is a loss of sensation because drugs have been administered (Pollard, 2005). When making a decision about the type of anaesthesia to be administered – i.e. general, regional or local – the anaesthetist will be influenced by the type and technique of the planned surgery, the patient’s risk factors, their personal skills and the patient’s preference. Most anaesthetists assess their patients preoperatively to decide on the type of anaesthetic and any additional requirements required for each individual, and will ensure that anaesthesia together with analgesia is such that the patient does not feel or react to any operative stimulation.
A general anaesthetic can be divided into three components, called the triad of anaesthesia. These three elements are hypnosis (sleep), analgesia and relaxation (usually of the muscles). Different surgical procedures require differing degrees of each. Surgical stimulation and pain can cause a series of physiological responses such as tachycardia, hypertension, sweating and vomiting. Analgesics reduce the body’s response to such stimulation (Hughes, 2002). Anaesthetic techniques and drug therapy have evolved, which allow the anaesthetist to adjust the proportions of each part of the triad of anaesthesia to suit individual requirements. For procedures requiring little or no muscle relaxation, the anaesthetist may induce anaesthesia using an intravenous agent (although a gas induction can be used with patients with a needle phobia), and maintain anaesthesia with a volatile agent, allowing the patient to breathe the gases spontaneously via a mask or a laryngeal mask airway attached to the appropriate breathing system. Where muscle relaxation is required after anaesthesia is induced, a muscle relaxant is given and the patient’s airway maintained via an endotracheal tube or a laryngeal mask airway, and the patient is connected to a ventilator. The third part of the triad of anaesthesia is analgesia. This is achieved using differing categories of drugs, which block the stimulation of pain at the nerve impulses. Opioid analgesics such as fentanyl are used intraoperatively because of their short duration of action and can be titrated to meet the patient’s needs (Oakley and Spiers, 2004a).
Regional and local anaesthesia provide the patient with excellent analgesia and avoid the side-effects from general anaesthesia (Russon and Thomas, 2007). Such techniques include peripheral nerve blocks (injection of a local anaesthetic agent into a plexus of nerves); central neuroaxial blocks (injection of local anaesthetic into the subarachnoid space or epidural space for surgery on lower abdomen or lower limbs and postoperative analgesia); and infiltration anaesthesia (injection of local anaesthetic around the surgical incision site or prior to cannulation) (Avidan et al., 2003 and Russon and Thomas, 2007). Table 2.2 gives information on agents used for anaesthesia.
| Type of drug | Names | Functions and side-effects |
|---|---|---|
| Induction agent | Propofol | Administered in a rapid bolus. Patient unconscious within a few seconds. Maintained in this state until maintenance anaesthesia has taken over May also be administered as a continuous infusion to maintain anaesthesia or sedation in intensive care Reduces cardiovascular, respiratory and nervous system activity |
| Inhalation agent | Isoflurane, sevoflurane | Possess relaxing, sleep-inducing and minor analgesic properties May be used for induction as well as for maintenance Colourless liquids, but become gases when bubbled through oxygen Affects heart rate and blood pressure. Relaxes skeletal muscle |
| Local anaesthetic | Lidocaine, bupivacaine, cocaine | Localized action around site of administration Drug diffuses into neural sheaths and axonal membranes, then combines with nerve receptor and blocks nerve conduction Also has a vasodilatory effect, so may be combined with a vasoconstrictor. Duration of action, strength and toxicity is dependent on each drug and patient’s age, vascular supply and general health |
| Muscle relaxants: depolarizing | Suxamethonium | Drug that induces paralysis to facilitate intubation Inhibits neuromuscular transmission by preventing muscle being polarized through chemical interference. Blood enzymes break the drug down and muscle becomes repolarized. Rapid onset time and has a short action Reduced amount of blood enzyme leads to suxamethonium apnoea |
| Muscle relaxants: non-depolarizing | Atracurium, rocuronium, vecuronium, mivacurium, pancuronium | Drugs that induce paralysis to assist surgical intervention and easier ventilation Compete at nerve receptor sites and build up as body’s response continues to break down competing acetylcholine Reversal agents such as neostigmine enable rapid build up of acetylcholine to displace muscle relaxant |
| Analgesics | Morphine, diamorphine, fentanyl, codeine, diclofenac, ketorolac, alfentanil, remifentanil | Basic constituent of anaesthesia. They do not induce sleep These drugs block nerve responses to painful stimuli by action on receptors, or inhibit chemicals associated with pain Personal perception of pain based on several factors (sociological and physiological influences) as well as own threshold Opioids cause respiratory depression, nausea and vomiting, and hypotension Non-opioid analgesics can combine both methods of action and be more effective with reduced side-effects Non-steroidal anti-inflammatory drugs provide anti-inflammatory action, but can cause gastrointestinal disturbances and defective coagulation |
During regional anaesthesia the patient is awake or sedated, therefore requiring additional reassurance and support from all perioperative staff. Diligence by clinical staff is essential in maintaining confidentiality of other patients and ensuring that minimal noise and interference occurs during the procedure, which may distract the patient and so cause them to move. Conversely, if the procedure is long, it may be difficult for the patient to stay still on an uncomfortable table/bed and therefore sedation may be administered or a combination of general and regional anaesthesia may also be a considered option (Avidan et al, 2003).
The Association of Anaesthetists recommends minimum standards of monitoring during anaesthesia and recovery. During induction of anaesthesia, this will include pulse oximetry, non-invasive blood pressure monitoring, electrocardiogram and capnography (measurement of CO 2 in expired air at end of respiration) (AfPP, 2007a). For those patients undergoing complex procedures, or who are high risk due to co-morbidities, monitoring of urine output, body temperature and invasive monitoring such as central venous pressure and arterial pressure are essential.
During the induction of anaesthesia it is important that all personnel are calm and that noise, disruption and disturbance are minimal, as hearing is the last sense to go when the patient loses consciousness.
During the maintenance of anaesthesia the anaesthetic nurse will observe and monitor the patient’s well-being. Eye pads may be applied over the eyes to prevent corneal abrasions and to maintain closure of the eyelids to prevent drying of the corneas due to a reduced eye reflex.
Intraoperative care
Patient and staff safety is paramount throughout the perioperative environment and a proactive clinical risk management strategy involves identifying and adopting strategies to reduce the risk and evaluating their effectiveness (Fulbrook, 2005). Within the intraoperative phase, the patient is vulnerable and totally reliant on perioperative nurses and other members of the team to ensure that they come to no harm. Some of these risks have already been addressed with patient identification, informed consent and patient monitoring in the anaesthetic room. Intraoperatively, such clinical risks are associated with patient positioning, the risk of infection, risk of deep vein thrombosis, risk of hypothermia, and the risk to both staff and patients from the use of equipment (Parker, 2004). This list is not exhaustive, but identifies those potential risks to each patient undergoing surgery. For each risk, strategies are discussed to minimize the risk to patients and staff.
Surgical access and positioning
Positioning the patient correctly to enable easy surgical access requires coordination and cooperation from the whole team (Table 2.3). Manual handling regulations recommend that the team involved undertake a risk assessment for the moving and positioning of each individual patient, and that relevant aids and methods are used to reduce patient movement and potential injury to both staff and patients. An assessment will include the physical condition of the patient, nature of the intervention and individual patient needs. When positioning patients, consideration should be given to avoiding nerve and joint injury, avoiding mechanical trauma such as shearing, friction burns and damage to soft tissue, and ensuring that at all times the anaesthetized patient is physically well supported (AfPP, 2007a).
| Surgical position | Description and potential risks | Procedures performed |
|---|---|---|
| Supine | Patient lies on their back, with their arms folded and secured across their chest, or on an arm board at less than 90° to the body to prevent brachial plexus injury, or at their side A lumbar support should be used to prevent postoperative backache Pressure-relieving devices for the ankles should not hyperextend the knee as this may result in injury | Administration of general anaesthesia Patient transfer to and from the operating table Abdominal, breast and lower limb surgery |
| Lateral | Patient is turned onto their side and the head, rear of chest and pelvis is supported with padded table attachments. Arms are secured to allow venous access. A pillow should be placed between the knees to prevent pressure on bony contact | Hip surgery Some kidney procedures Thoracic surgery |
| Prone | Patient lies on their stomach with their head supported on a ring or turned to one side, and their arms positioned to prevent extension and abduction at the shoulder, either above their head or by their side. The chest must be supported to allow movement of the abdomen for respiration | Spinal surgery Neurosurgery |
| Trendelenburg | Patient is in a supine position with a head-down tilt. Abdominal organs fall towards diaphragm due to gravity, allowing greater surgical access. Legs may be bent at the knee to add stability | Lower abdominal surgery, e.g. abdominal hysterectomy Lower limb surgery, e.g. varicose veins |
| Lithotomy | Patient lies supine with their legs raised in supporting poles. These may support the calf to ankle or just the ankles are secured. The patient’s arms are secured across their chest while the end of the table is removed. The legs are elevated, lowered and positioned simultaneously to prevent lower back injury, sacroiliac ligament damage and pelvic asymmetry
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