Chapter 44 PERIOPERATIVE NURSING
Perioperative nursing encompasses the care of a client who is undergoing a surgical procedure. Care takes place from the time the decision is made to have surgery, through to recovery from the procedure. Throughout the perioperative period it is essential that there is a flexible multidisciplinary team approach to ensure continuity of client care from admission, throughout the surgical experience to recovery at home. It is important for the nurse to be familiar with the types of surgery a client is likely to undergo in order to plan and implement adequate and individualised care and to provide appropriate psychological support. This chapter provides an overview of the perioperative period, which comprises the preoperative, intraoperative and postoperative phases as well as the specific physiological and psychological support that each phase requires.
When I went to the operating suite to have my surgical procedure I was frightened, I was naked except for an ill fitting gown that was open down the back and I didn’t know what results the operation would reveal. I felt like I had no control, my husband wasn’t able to be with me, I found the situation overwhelming. I’m a Registered Nurse, I work in the perioperative environment everyday, but this day I was the patient. It was me who looked to the nurse for a smile, a touch, an explanation. When caring for my patients I reflect on my experience and ensure that my patients are cared for with the same professionalism, compassion and respect that I needed.
Perioperative nursing encompasses a wide variety of nursing functions related to the clients’ surgical experience throughout the perioperative period. This period is divided into three phases: preoperative (before), intraoperative (during) and postoperative (after). Perioperative nurses are Registered Nurses (RNs) and Enrolled Nurses (ENs) who fulfil the following roles: circulating nurse (scout), instrument nurse (scrub), anaesthetic and post anaesthesia recovery nurse. The responsibilities of these nurses are specialised and multifaceted. The principal aim is to ensure that holistic, clinically effective, evidence-based care and support is given to the client throughout their perioperative experience. The perioperative nurse provides this care alongside other members of the multidisciplinary team, in an environment that is challenging, changing and fast paced. The nurse acts as the clients advocate and provides continued effective communication with the client, their significant others and the surgical team. The nurse undertakes efficient assessment and intervention, maintains accountability for their own practice, documents care and emphasises client safety in all phases (Crisp & Taylor 2005; Woodhead & Wicker 2005; Farrell 2003).
In Australia professional standards, guidelines and policy statements for perioperative nursing are set by the Australian College of Operating Room Nurses (ACORN). ACORN’s ongoing focus is the improvement and standardisation, education and support of perioperative nursing care (Hamlin 2006).
Undergoing surgery is an experience that is unique to the individual; a client faces numerous stressors when confronting surgery. The anticipation of having a surgical procedure may incite fear and anxiety. Some clients associate having surgery with pain, disfigurement, loss of independence and even death. It is important for the perioperative nurse to quickly establish rapport with clients, listening to them so that their concerns are heard and relieved. Surgical procedures are classified according to risk, urgency or purpose (Crisp & Taylor 2005, Farrell 2003).
There is a degree of risk with any surgical procedure. Various factors and conditions increase a client’s risk during surgery. Knowledge of the risk factors allows the nurse to appropriately plan client care. Some of these risk factors include:
|Degenerative change in myocardium and valves||Reduced cardiac reserve.||Assess baseline vital signs. Recognise the longer time period required for heart rate to return to normal following stress on the heart, and evaluate the occurrence of tachycardia accordingly (Eliopoulos 2004).|
|Rigidity of arterial walls and reduction in sympathetic and parasympathetic innervation to heart||Alterations predispose client to postoperative haemorrhage and rise in systolic and diastolic blood pressure.||Maintain adequate fluid balance to minimise stress to the heart. Ensure blood pressure level is adequate to meet circulatory demands.|
|Increase in calcium and cholesterol deposits within small arteries; thickened arterial walls||Predispose client to clot formation in lower extremities.||Instruct client in techniques for performing leg exercises and proper turning. Apply elastic stockings, sequential compression devices (SCDs). Administer anticoagulants as prescribed by health care provider. Provide education regarding effects, side effects and dietary considerations.|
|Decreased subcutaneous tissue and increased fragility of skin||Prone to pressure ulcers and skin tears.||Assess skin every 4 hours; pad all bony prominences during surgery. Turn or reposition at least every 2 hours.|
|Rib cage stiffened and reduced in size||Reduced vital capacity.||Instruct client in proper technique for coughing, deep breathing and use of spirometer.|
|Reduced range of movement in diaphragm||Greater residual capacity (volume of air is left in lung after normal breath) increases, reducing amount of new air brought into lungs with each inspiration.||When possible, have client ambulate and sit in chair frequently.|
|Stiffened lung tissue and enlarged air spaces||Alteration reduces blood oxygenation.||Obtain baseline oxygen saturation; measure as indicated throughout perioperative period.|
|Reduced blood flow to kidneys||Increased risk of shock when blood loss occurs.||For clients hospitalised before surgery, determine baseline urinary output for 24 hours.|
|Reduced glomerular filtration rate and excretory times||Limits ability to eliminate drugs or toxic substances.||Assess for adverse response to drugs.|
|Reduced bladder capacity||Voiding frequency increases, and larger amount of urine stays in bladder after voiding.||Instruct client to notify nurse immediately when sensation of bladder fullness develops. Keep call light and bedpan within easy reach. Toilet every 2 hours or more frequently if indicated.|
|Sensation of need to void often does not occur until bladder is filled.|
|Sensory losses, including reduced tactile sense and increased pain tolerance||Decreased ability to respond to early warning signs of surgical complications.||Inspect bony prominences for signs of pressure that client is unable to sense. Orient client to surrounding environment. Observe for nonverbal signs of pain.|
|Decreased reaction time||Confusion after anaesthesia.||Allow adequate time to respond, process information and perform tasks. Institute fall precautions.|
|Lower basal metabolic rate||Reduced total oxygen consumption.||Ensure adequate nutritional intake when diet is resumed, but avoid intake of excess calories.|
|Reduced number of red blood cells and haemoglobin levels||Ability to carry adequate oxygen to tissues is reduced.||Administer necessary blood products.|
|Monitor blood test results and oxygen saturation.|
|Change in total amounts of body potassium and water volume||Greater risk for fluid or electrolyte imbalance occurs.||Monitor electrolyte levels, and supplement as necessary.|
|Cardiac monitoring (telemetry) as needed.|
|Impaired thermoregulatory mechanisms||Cold operating rooms; exposure of body parts during procedure, IV fluids, medications.||Ensure careful, close monitoring of client temperature; provide warm blankets; monitor cardiac function; warm IV fluids.|
In response to surgical invasion, the body mobilises defences to maintain homeostasis. Most of these mechanisms are generally favourable to survival and healing. If, however, the mechanisms are prolonged or uncontrolled, they may contribute to the development of complications. Table 44.2 outlines the physiological responses to the stress of surgery.
|Increased peripheral vasoconstriction and blood coagulation||Prevents excessive blood and fluid loss|
|Increased rate and strength of heart beat, and dilation of the coronary arteries||Maintains cardiac perfusion and oxygenation|
|Increased reabsorption of sodium ions from the kidneys, causing retention of sodium and water||Maintains blood volume, blood pressure and cardiac output|
|Decreased peristalsis in the gastrointestinal tract||Reduces metabolic activity which is non-essential in the short-term emergency|
|Relaxation of smooth muscle that promotes dilation of the bronchioles||Improves gas exchange and tissue oxygenation|
|Increased breakdown of protein||Increases the availability of amino acids for repair of tissues|
|Proliferation of connective tissue||Promotes wound healing|
|Increased circulation of glucose and mobilisation of stored fat||Provides required energy|
|Increased basal metabolic rate||Provides required energy and nutrients for the tissues|
After injury, local inflammatory reactions occur to promote healing. A surgical incision, even though created under sterile and controlled conditions, still constitutes injury or insult. The inflammatory response begins with the creation of a surgical wound, and the normal sequence of tissue replacement and wound healing must occur to ensure tissue recovery. The physiology of wound healing involves a specific sequence of events and is discussed in Chapter 37, as are influences on healing, and the specific care of wounds.
The preoperative phase begins when surgical intervention is first considered, and ends when the individual is transferred to the operating table. This phase may be of short duration if the client is taken directly to an operating room from the emergency department or transferred soon after admission to a surgical unit.
The duration depends on a number of factors, such as the amount of time required to prepare the client adequately for surgery. The preoperative phase may begin with the individual as an outpatient in a designated pre-admission clinic, where preoperative investigations are undertaken prior to the client’s procedure.
In Australia it is now common practice for an individual, depending on the type of surgery to be performed, to be admitted for same-day surgery. In this instance the client is admitted in the early or late morning depending on if the client is on the AM or PM theatre list. The client is prepared for and undergoes surgery, is recovered from the anaesthetic, is cared for in the Day Surgery Unit (DSU) after the procedure, and is discharged home on the same day. Clients undergoing surgery who will require in-patient care are also, in most cases, admitted through the DSU as a day of surgery admission (DOSA). DOSA clients are taken to theatre from the DSU and are taken to the ward from the recovery room. DOSA clients require comprehensive preparation and teaching about home recovery. Follow-up at home (often by telephone) must be available for continuity of care to occur. Day-stay surgery is suitable for less complex surgical procedures, or invasive techniques for which some anaesthesia is required (e.g. endoscopy). These units are staffed by RNs and ENs.
Day surgery is now well established throughout Australia, in both the public and private sectors. Currently up to 60% of all procedures are undertaken as day patient procedures. At present, day surgery is widely practised; in over 240 freestanding day surgery centres, many large public hospitals and over 320 private hospitals around Australia have designated DSUs in place (Australian Day Surgery Council 2004). The advantages to the client and their relatives include considerable reduction in cross-infection risk compared with clients who remain in hospital; decreased risk of thrombo-embolism associated with early ambulation; less anxiety for the client as an overnight stay in hospital is avoided, particularly in the instance of children where minimal separation from parents is beneficial, and for the older client who may become disorientated when subjected to unfamiliar surroundings for extended periods of time. The client will have a quicker return to normal activities with less time off work, less stress for their relatives, a saving in time, travel and in some cases a need for accommodation required to visit an in-patient in hospital (Australian Day Surgery Council 2004).
Another trend is that overall length of stay in hospital after surgical procedures is decreasing. With this practice of earlier discharge comes the implication that clients may go home with complex medical and nursing needs and will require suitable follow-up with visiting nurses, or involvement in a ‘Hospital in the Home’ or a ‘Rehabilitation in the home’ program.
The overall aim of preoperative preparation is to ensure that the individual is in the best physical and psychological condition possible before undergoing surgery. It is essential to gather appropriate data concerning the client’s health status through the taking of baseline observations and a detailed and accurate nursing history. Nursing assessment is based on the data collected and includes the identification of actual and potential problems that may be faced by the individual throughout any phases of the perioperative period. Although certain aspects of preoperative preparation are similar for most surgical procedures, other factors are specific, depending on the individual client’s condition and on the type of operation to be performed.
Initial assessment of each client’s knowledge base should be undertaken; even if the person’s past surgical experiences are extensive. The client needs to be informed about all pre- and postoperative procedures and care because knowledge and understanding promote feelings of being in control, and a sense of control helps to relieve anxiety. Research has demonstrated that preoperative education has resulted in positive improvements on the levels of fear, anxiety and pain experienced by clients (Joanna Briggs Institute 2000). The information given to clients and, as appropriate, to their significant others should include:
The information must be provided in such a way that the individual can understand it, and it should be repeated if necessary. This is essential, as anxiety about hospitalisation and/or the surgical procedure may influence the client’s ability to process and retain information. The most helpful teaching program is designed so that all clients receive the same information.
Preoperative teaching can help to reduce anxiety and stress, and teaching specific activities that the individual can undertake to promote their own recovery gives them a positive role to play. In some cases the client may visit a specialty postoperative area; that is, an Intensive Care Unit (ICU) as familiarity with environments that will be encountered during or after surgery may help reduce the stress associated with the surgical experience.
Preoperative teaching of activities involves instructing the client how to perform deep breathing and coughing techniques, leg exercises and how to move and change position. The person is informed how important these activities are in the prevention of postoperative complications and is encouraged to practise them so that the techniques will be familiar when they are necessary postoperatively. Some clients will have postoperative pain relief medication administered by a self-operated infusion pump. This is called patient-controlled analgesia (PCA). Clients who are expected to return from surgery with a PCA will need to understand the purpose of the pump and will require preoperative education about how to use the device correctly. This teaching is generally the role of an RN, but the EN caring for a client using a PCA will need to monitor that the client is using it correctly and that pain relief is effective.
Deep breathing and coughing techniques are performed to facilitate gas exchange and expectoration of accumulated mucus. The client assumes a sitting position and takes several deep breaths followed by a short breath and cough. Alternatively, the client may be taught to take a deep breath, hold it for 2–3 seconds, then cough several times while exhaling. The client is informed that if coughing is likely to be painful, for example, due to a thoracic or abdominal incision, the provision of analgesia and external support (placing the hands over the incision, or splinting with a pillow) reduces pain and therefore may help facilitate coughing and deep breathing.
Leg exercises are performed to stimulate blood circulation thereby prevent venous thrombosis. The client is instructed how to bend the knees and contract the hamstring and quadricep muscles, and how to dorsiflex and plantarflex the feet (see Chapter 36). Such exercises also act to prevent general muscle stiffness and soreness.
Moving and changing position helps to prevent complications such as skin breakdown and deep vein thrombosis. The nurse should inform clients that they will be assisted to move if they are unable to do so independently, or if special restrictions will be in place. If specialised techniques are required to facilitate movement in the postoperative period such as the use of a rolling or turning frame after total hip replacement, an opportunity to practise these techniques should be provided in the preoperative phase.
The anaesthetist and a medical officer each perform a thorough physical examination of the client. The anaesthetist pays particular attention to the client’s cardiovascular and respiratory systems to evaluate the general level of function and to identify any problems that may cause difficulty during induction or maintenance of anaesthesia, such as an upper airway abnormality, which may make placement of an endotracheal tube difficult, or a spinal condition which may hinder regional anaesthesia. The anaesthetist also evaluates possible sites for peripheral or central venous cannulation. After assessing the client, the anaesthetist may prescribe any preoperative medications deemed necessary to be administered prior to surgery.
Laboratory tests and diagnostic studies help detect any risk factors or possible issues. Specific tests and studies performed depend on the client’s condition and on the nature and complexity of the operation. Ideally, diagnostic tests are carried out with sufficient time before the scheduled procedure to allow for correction of any detected problems.
Before an operation is performed, the client must give informed consent which should be freely given without coercion. Informed consent involves the surgeon providing the client with enough information to understand the nature and consequences of the proposed procedure and informing the client about the facts and possible risks relating to the surgery concerned, in terms that ensures understanding by the client. The client then consents, in writing, to have the operation. The surgeon and the client must both sign a consent form, an important part of the documentation process that formalises the client’s agreement to undergo surgery. The nurse is not responsible for obtaining the individual’s consent, but the nursing role includes checking that informed consent has been obtained and making appropriate notifications if this is found not to be the case. In some agencies, nurses are asked to witness consent forms, but the act of witnessing only verifies that this is the person who signed the consent, and that it was given voluntarily. It does not relate to the client’s actual knowledge or understanding of the procedure. (Further information on informed consent is provided in Chapters 3 and 4.)
To minimise anxiety and prepare the client psychologically for the proposed procedure, the nurse must ensure that all relevant information is provided. People generally experience anxiety when they are facing the unknown, and anxiety is usually reduced somewhat when accurate and relevant information is supplied. The nurse must ensure that the client and the significant others are given opportunities to ask questions and to express any concerns they may have. It is important for the nurse to recognise that procedures that seem relatively minor or routine may not appear that way to clients or to their significant others. The prospect of any surgical intervention raises many fears about body image alteration, loss of control, pain or even the possibility of death. Some of the many factors that the client may be worried about include: