Peri - operative care

Pre - Operative Care

Care may vary depending on type of surgery, eg. major or minor and if the surgery is elective or emergency

Reduction of anxiety

Give a warm personal welcome

Introduce yourself, other team members and other patients by name

Explain ward layout and nurse call system

Explain procedures before starting them

Encourage patient to express fears and anxieties

Encourage patient to ask questions

Give appropriate answers

Take time to communicate with significant others

Gain information

Complete admission documents

Record patients weight

Record baseline TPR BP

Note any significant medical history

Possible ECG

Carry out ward based urinalysis

Check for any allergies, clearly record on notes and drug charts

Patient education

Education may help prevent some post - op complications

Giving information may help reduce post operative pain

Teach how pain will be controlled

Teach deep breathing exercises

Teach how to hold the wound to cough

Teach importance of foot and leg movements

Involve MDT as appropriate

Fasting

Nil by mouth for 4 - 6 hours before operation

Patient Identification

Check out of ward - name, address, DOB

Check identity bracelet

Check site of operation is marked if appropriate

Send notes, X rays, blood results etc with patient

Consent

Patient must sign a consent form, consent must be informed

General measures

TED stockings and s/c heparin

Operation site preparation

Ask patient to empty bowels and bladder

Shower and gown

Give pre-medication

Tape or remove jewellery

Remove nail varnish and make up

Remove prostheses spectacles/contact lenses and hearing aid

Note if dentures are in situ and any loose teeth or crowns, (all late removal)

Ensure any specific preparation is carried out eg. bowel preparation

Optimise the physical condition of the patient, eg good nutrition, lose weight, stop smoking, make sure the patient is not febrile

Post - Operative Care

The aim of post operative care is to allow a full recovery after surgery without the patient suffering from any complications

A lot of post - op care is therefore directed at the prevention of potential complications

As in all clinical situations the immediate priorities are to maintain airway, breathing and circulation ABC

Airway and breathing

If the airway is not maintained at all times the patient may asphyxiate

Usually the patient will be intubated or have an oral airway in situ, these are left in place until the patient regains consciousness after the anaesthetic.

This is gauged in the case of an oral airway by asking the patient to pull the airway out themselves.

Nurse in a semi - prone position till fully conscious, or turn head to the side, clearly position will depend on type of operation

Keep the patients chin up

Monitor airway by feeling the flow of air over your hand

Observe for cyanosis

Circulation

This may be monitored by palpation of a pulse and recording of blood pressure

A fast weak thready pulse with reduced BP may indicate the patient is going into shock

After surgery the 3 possible forms of shock are hypovolaemic, neurogenic and anaphylactic, all may be detected by a fast pulse and low BP

Pulse and BP should be recorded as soon as the patient returns to the ward and at regular intervals for a few hours

15 minutes, half an hour, hourly, 2 hourly, 4 hourly, reducing as the patient is seen to stabilise

How the patient is feeling should be monitored

Skin colour

As with all observations comparison should be made with the baseline observations and trends should be noted

Haemorrhage

External - monitor dressings for oozing and underneath the body for pooling

Internal - monitor volumes from wound drains and observe for signs of shock

Primary - occurs at the time of the operation

Reactionary - occurs after surgery as the BP starts to rise

Secondary - a few days after surgery due to infection

Hypo and/or hyperthermia

Immediately after surgery patient may be hypothermic - warm them up

Low grade pyrexia is normal after surgery due to tissue damage

Higher grade pyrexia may indicate an infection somewhere

Pain

Assess the amount of pain the patient has using an assessment tool

Anticipate pain and treat before the pain becomes too bad

Help the patient into a position where pain is lessened

Give analgesic drugs and assess their effectiveness

Strong analgesia may be given by iv or im injection

Use PCA where appropriate

Monitor epidurals if in place

Do not worry about addiction when patient is in pain

Ensure pain is regularly assessed for as long as required

Dehydration

Fluids may have been lost during surgery

Patient may well be unable to eat or drink

This may be associated with electrolyte imbalance

Administer IVI as prescribed - make sure it runs to time

Observe venflon site for tissuing or inflammation

Start oral fluids as prescribed - determine how fluids are tolerated

Check for bowel sounds and flatulence

Record all fluids on a fluid balance chart

Urinary complications

Ensure patient has passed urine post - op

If catheterised check for anuria/oliguria - monitor urine output hourly for first few hours, later record 4 hourly

Ensure at least 30 mls of urine per hour

Retention

Infection

Catheter care if in situ, eg ensure patency

Provide handy bed bottles or bed pans if not catheterised

Nausea and vomiting

Nasogastric tube may be in situ to allow aspiration of gastric contents to prevent vomiting - 2 - 4 hourly aspiration

Provide vomit bowels and tissues

Record volumes and character of vomit or NG aspirate

Provide mouth washes

Give anti-emetics

Wound care

Observe wound site for adherence

Observe wound site for oozing, inflammation and signs of infection

Send swab for culture if infection suspected

Keep wound covered for 48 hours then leave open if clean and dry

Remove wound drains as instructed by doctor

Remove clips/suitures at 10 days or as directed

Complications of immobility

These may occur as the patients mobility is reduced after surgery

Assess risk of pressure sores and prevent - relief of pressure, 2 hourly

turns, aids

Thrombo - embolic complications - encourage foot and leg movements, active or passive and deep breathing exercises

Use of anti-embolic stockings TED, sc. heparin 5 000 iu twice a day

Hypostatic pneumonia - encourage deep breathing exercises, coughing - sputum pots and tissues

Refer to physiotherapists as required

Encourage early mobilisation - give analgesic cover to improve early mobilisation

ADL/Self care defecit

Help with washing, mouth care, shaving etc

Encourage independence and mobility

Ensure privacy

Anxiety

Keep informed about patients management and any required procedures

Inform patients about their progress

Encourage and answer questions

Involve friends and family

Sepsis

Wound infection

Haematoma

Wound opening

Abcess formation

Septicaemia

Bowel complications

Vomiting

Illeus

Constipation

Herniation

Nervous system complications

Peripheral nerve damage eg. ulna, radial or brachial nerve injuries - may spread to brachial plexus adversely effecting breathing

CVA - following hypoperfusion

Pulmonary complications

Asphyxia

Atelectasis

Bronchitis

Pneumonia

Infarct

Abcess

Cardiovascular complications

Myocardial infarction

Cardiac failure

Cardiac arrhythmias

Embolism - fat, venous, arterial

Recovery phase

Nutrition

Activity and rest periods

Avoid stress

Pre op questions

How will you reduce a patients anxiety prior to surgery

What physiological/medical information should be collected

before surgery

What information/education do patients require before

surgery

How long should patients be fasted for

Why are patients fasted before surgery

How are surgical patients identified

When and where is patient identity checked

How can you reduce the possibility of post op DVT

Why is nail varnish removed

Why is jewellery not allowed

Why are false teeth removed

What pre op skin prep may be required

Why is the consent form filled in

Why should the patient shower before surgery

Why should the bladder and bowels be emptied before surgery

Why should patients be advised to stop smoking before

elective surgery

Why is it important to know if patients may be pregnant

In what ways will preparation for emergency surgery vary from elective cases

Post op questions

How may the airway be compromised in the post op situation

How will the airway be protected

What may adversely effect the circulation post op

How will haemorrhage be recognised

How will immediate post op hypothermia be managed

What might post op pyrexia indicate

How will the amount of pain be assessed

How will pain be treated

What is PCA

Why is PCA helpful

Which patients will have dietary restrictions

How and when will a patient be allowed to eat again

How will you recognise dehydration

How is dehydration prevented and treated

Why is it important to ensure a patient has PU after surgery

What is acute renal failure

Which patients will have a urinary catheter

Why might nausea be a problem

How will nausea be treated

What observations will be made of the wound site

What observations will be made of wound drains

How will wound infection be prevented

How will wound infection be recognised

How will DVT be prevented

Why are DVTs life threatening

What is hypostatic pneumonia

How will hypostatic pneumonia be prevented

How will pressure sores be prevented

What are UTIs

How will UTIs be prevented

When are sutures/clips normally removed

What psychological problems may complicate recovery

How will local circulatory problems be identified

How will local neurological problems be identified