Peri-operative care encompasses the care provided to a patient before, during, and after surgery.

Peri-operative care is divided into the following phases:

1. Pre-operative Care: The period before surgery.

2. Intra-operative Care: The period during surgery.

3. Post-operative Care: The period after surgery.

Reasons for Surgery

1. Curative: To eliminate the underlying disease or condition completely.

   • Examples:

     • Appendectomy: Removal of an infected appendix.

     • Tumor Removal: Surgical removal of cancerous growths.

     • Cholecystectomy: Removal of the gallbladder.

2. Diagnostic: To gather information about a suspected medical condition.

   • Examples:

     • Exploratory Laparotomy: Surgical examination of the abdominal cavity to diagnose the cause of symptoms.

     • Biopsy: Removal of a tissue sample for microscopic analysis.

     • Endoscopy: Using a flexible tube with a camera to visualize internal organs.

3. Reconstructive: To restore the function, appearance, or both of a damaged body part.

   • Examples:

     • Plastic Surgery: Repairing facial deformities, burns, or other disfigurements.

     • Hand Surgery: Repairing damaged tendons, ligaments, or bones in the hand.

     • Orthopedic Surgery: Repairing broken bones, performing joint replacements, or correcting spinal deformities.

4. Palliative: To relieve symptoms and improve the quality of life when a cure is not possible.

   • Examples:

     • Gastrostomy: Creating a surgical opening in the stomach for feeding patients with esophageal cancer.

     • Stent Placement: Inserting a tube to open a blocked artery or airway.

     • Pain Management Procedures: Nerve blocks or other interventions to reduce pain.

Types of Surgery

1. Major Surgery: Complex procedures involving significant tissue manipulation, often requiring extended operating times, general anesthesia, a large surgical team, and specialized equipment.

   • Characteristics:

     • Duration: Typically a longer procedure, often lasting several hours.

     • Anesthesia: Usually requires general anesthesia.

     • Team: Involves a large team of surgeons, nurses, and support staff.

     • Equipment: Utilizes sophisticated equipment and instruments.

     • Recovery: Requires an extended hospital stay and a longer recovery period.

   • Examples:

     • Open-heart surgery: Repairing heart valves or coronary arteries.

     • Organ transplantation: Replacing a diseased organ with a healthy donor organ.

     • Major abdominal surgery: Removing a large tumor or performing an extensive bowel resection.

     • Complex orthopedic procedures: Joint replacements, spinal fusion, major bone reconstruction.

2. Elective/Planned Surgery: Surgery that is scheduled in advance and does not address an immediate life-threatening condition. This allows for thorough pre-operative evaluation and preparation.

   • Characteristics:

     • Urgency: Non-urgent, allowing for comprehensive pre-operative assessment and preparation.

     • Timing: Scheduled based on the patient’s convenience and medical appropriateness.

   • Examples:

     • Cataract surgery: Removal of a cloudy lens in the eye.

     • Cosmetic surgery: Procedures performed for aesthetic enhancement.

     • Joint replacement surgery: Replacing a damaged joint with an artificial joint.

     • Laparoscopic cholecystectomy: Removal of the gallbladder through small incisions.

3. Minor Surgery: Less complex and invasive procedures requiring shorter operating times, often performed under local anesthesia with a smaller surgical team.

   • Characteristics:

     • Duration: Typically a shorter procedure, often less than an hour.

     • Anesthesia: May use local anesthesia or sedation.

     • Team: Usually involves a smaller surgical team, potentially a single surgeon and nurse.

     • Equipment: Requires simpler instruments and equipment.

     • Recovery: May involve a shorter hospital stay or be an outpatient procedure.

   • Examples:

     • Incision and Drainage (I&D): Draining an abscess or other fluid collection.

     • Biopsy: Removal of a small tissue sample for diagnostic testing.

     • Skin lesion removal: Excision of moles, cysts, or other skin growths.

     • Tooth extraction: Removal of a tooth.

4. Emergency Surgery: Surgery performed immediately to address a life-threatening condition or severe injury.

   • Characteristics:

     • Urgency: Immediate, requiring swift action to prevent serious complications or death.

     • Preparation: Pre-operative evaluation is often minimal and occurs simultaneously with preparation for the surgical procedure.

   • Examples:

     • Trauma surgery: Repairing severe injuries resulting from accidents or assault.

     • Appendicitis surgery: Removal of an inflamed appendix.

     • Hemorrhagic stroke surgery: Surgery to stop bleeding in the brain.

     • Cardiac arrest surgery: Emergency procedures to restore heart function.

PRE-OPERATIVE CARE OF PATIENTS

Objectives:

1. Identify the requirements for pre- and post-operative care.

2. Prepare necessary materials for pre- and post-operative care.

3. Provide pre- and post-operative care.

Preparation for surgery should commence as soon as the doctor diagnoses the condition and determines that surgery is necessary. From this point forward, the patient and their family must decide whether to accept this treatment and its potential consequences.

The doctor should clearly explain to the patient and their family the reason for the surgery, what will be done, and the likely outcome.

An admission date is scheduled based on the urgency of the illness, the required period of pre-operative care, and the time needed for the patient to make necessary arrangements concerning family, finances, and work.

1. Admission: Patients may be admitted the day before surgery or several days or weeks prior for planned surgeries. This allows for pre-operative treatment, such as addressing nutritional and electrolyte imbalances or managing underlying conditions, particularly in patients with alcoholism or advanced cancer.

2. Rapport: The nurse receives the patient and their family, provides seating, greets them, and introduces themselves. The patient is shown to their bed and introduced to their roommates. The nurse familiarizes the patient with the ward environment, including restrooms, lounges, storage areas, the kitchen, the utility room, and other relevant hospital departments, as well as visiting hours and meal times.

3. Physical Preparation and History: A medical history is obtained, starting with the patient’s primary complaint and any associated symptoms, history of previous illnesses or surgeries, current medications, allergies, dietary restrictions, occupation, religion, and marital status.

4. Vital Signs: Vital signs are measured and recorded to establish a baseline for future comparisons. The patient’s weight is recorded, and the surgeon is informed to review the patient’s case.

5. Psychological Preparation: Preparing the patient psychologically for surgery is crucial as patients often experience fear. This fear is influenced by individual personality, typical responses to stress, overall mental health, and preconceived notions about surgery and anesthesia. Common fears include the fear of the unknown, post-operative pain, the discovery of cancer, the loss of significant organs, the risk of death, concerns based on others’ experiences, the risks of anesthesia, vulnerability while unconscious, the threat of job loss and financial insecurity, changes in social and family roles, and separation from loved ones and usual activities.

   These fears can manifest as various behaviors, such as silence and withdrawal, feelings of hopelessness and helplessness, childlike behavior, aggression and non-compliance, evasiveness, and tearfulness.

   Strategies to Reduce Patient Anxiety:

   1. Information and Orientation: Provide patients with explanations or written materials about hospital routines, visiting hours, meal times, specific locations, and general hospital orientation.

   2. Procedure Explanations: Offer thorough explanations of all procedures the patient will undergo during the pre-operative, intra-operative, and post-operative phases.

   3. Reasoning and Discomfort: Explain the rationale behind various procedures and any potential discomfort, ensuring the patient understands the necessity of the interventions.

   4. Collaborative Communication: Nurses and doctors should communicate to ensure consistent and accurate information is given to the patient.

   5. Questioning and Clarification: Encourage patients to ask questions about the surgery and the post-operative period to address concerns and provide reassurance.

   6. Information Management: Provide information at a pace the patient can handle. Overwhelming the patient with too much information or providing it too close to the surgery can increase anxiety.

   7. Peer Support: Introduce patients facing major surgeries like mastectomies or colostomies to individuals who have successfully recovered from similar procedures.

   8. Occupational Therapy: For patients with extended pre-operative periods, occupational therapy involving games, crafts, or television can provide distraction and alleviate fear and loneliness.

   9. Family and Friends: Encourage visits from family and friends to provide companionship and emotional support.

   10. Religious Support: Determine the patient’s religious preference and arrange visits from a priest, minister, or rabbi if desired.

   11. Age-Appropriate Language: Explain procedures to children using simple language appropriate for their age and developmental level.

   12. Honesty and Clarity: Avoid lying to children. Be honest about what to expect regarding surgery, tests, pain, and stitches.

   13. Socialization: Allow children to interact with other hospitalized children to ease adjustment.

   Note: Addressing fears effectively can improve the patient’s surgical experience. Research indicates that calm, emotionally prepared pre-operative patients tolerate anesthesia better and experience less post-operative nausea, vomiting, and fewer complications.

6. Consent Form: A consent form is a document containing essential information about a medical procedure or treatment, clinical trials, or genetic testing, including potential risks and benefits. By signing the form, the individual provides official consent to participate in the treatment, procedure, trial, or testing. All patients undergoing any surgical procedure, regardless of its complexity, must sign a consent form.

   Importance of the Consent Form:

   • Prevents Unwanted Procedures: Protects patients from undergoing surgery without their knowledge or consent.

   • Ensures Understanding: Guarantees the patient understands the nature of the proposed procedure, including its risks, benefits, and potential complications, allowing them to make an informed and voluntary decision.

   • Legal Protection: Protects healthcare providers, including surgeons and hospital staff, from liability in cases where a patient or their family claims surgery was performed without consent.

   • Respect for Autonomy: Acknowledges and respects the patient’s right to self-determination and control over their body.

   • Encourages Open Dialogue: Promotes communication between the patient and healthcare providers, allowing for questions and concerns to be addressed.

   • Facilitates Family Involvement: Allows family members to be involved in the decision-making process, especially if the patient desires their input.

   Factors to Consider Before Signing the Consent Form:

   1. Clear Explanation: The patient must receive a complete explanation of the operation before signing the consent form. Visual aids like pictures and diagrams may be necessary.

   2. Potential Complications: The patient must be informed about all potential complications and any disfigurement that may result from the surgery.

   3. Procedures and Investigations: Explain all related procedures and investigations to the patient for their understanding before accepting the operation.

   4. Anesthesia: Thoroughly explain the administration of anesthesia, addressing any concerns or questions.

   5. Pain Management: Reassure the patient about pain management strategies during and after surgery.

   6. Disfigurement: If the surgery may cause disfigurement, such as amputation, mastectomy, or hysterectomy, discuss this openly with the patient, acknowledging the potential impact on their body image and self-esteem.

   7. Social and Economic Background: Consider the patient’s social and economic circumstances and discuss any potential challenges related to recovery and daily life. Encourage the patient to discuss their concerns.

   8. Spiritual Life: Acknowledge and address the patient’s spiritual beliefs, offering support or resources if desired.

   9. Organ or Body Part Removal: Clearly and sensitively inform the patient if any organ or body part will be removed.

   10. Simple Explanations: Provide explanations in terms the patient can understand, offering an honest overview of what to expect during and after surgery.

   11. Signature: Adults sign their own consent forms unless they are unconscious or mentally incompetent, in which case a relative or guardian signs on their behalf. For children under 18, a parent or legal guardian must sign. If the parents are unavailable, permission may be obtained by telephone or letter, or the surgeon may sign, depending on local laws or a court order.

   12. Accompanying Medical Forms: Ensure the consent form accompanies other medical documents to the operating room.

   13. Patient Consent: After providing all necessary information, ask the patient to sign the consent form, indicating their agreement to the surgical procedure. This confirms they have received and understood the information necessary to make an informed decision about the procedure and its possible consequences.

7. Investigations: Most pre-operative investigations aim to ensure the patient is in optimal physical condition and to identify any co-existing conditions that might affect their response to surgery or recovery.

   • Routine chest X-rays and sputum examinations are performed to assess lung health and rule out any conditions that could complicate anesthesia or post-operative recovery, particularly issues with oxygen supply and cardiac function. Signs of upper respiratory infections are noted and reported.

   • Urinalysis is conducted to detect urinary tract infections or other conditions that could pose problems, especially regarding drug elimination after anesthesia, or the presence of glucose, protein, or ketones, which may indicate diabetes mellitus, chronic kidney disease, starvation, or dehydration, respectively. These findings can influence the necessary pre-, intra-, and post-operative care.

   • Blood tests, including a complete blood count, hemoglobin levels, blood typing and cross-matching, and bleeding and clotting times, help identify chronic infections, anemia, or other blood disorders that could cause complications during surgery or interfere with wound healing and recovery. Low hemoglobin levels can increase the risk of intra-operative shock, and bleeding problems can cause issues during and after surgery.

   • Specific investigations like ECGs and plain abdominal radiographs are performed to evaluate cardiac function and guide pre-operative care or to ensure the patient’s condition is stable before surgery.

8. Treatment: Antibiotics are administered based on investigation results and pre-existing conditions. Any other identified conditions, such as heart, blood, respiratory, urinary, or digestive issues, are treated appropriately before the patient is cleared for surgery.

9. Nutrition: Ensuring the patient is in the best possible nutritional state before anesthesia and surgery is crucial because:

   • Dehydration and poor nutrition can negatively impact post-operative outcomes, especially in infants and the elderly, and can lead to electrolyte imbalances, particularly if caused by excessive vomiting or diarrhea, often exacerbated by chronic illness and poor appetite.

   • Protein deficiency can slow wound healing and lower resistance to infection.

   • Vitamin C deficiency can delay wound healing.

   • Interventions:

     • Balanced Diet: Provide a well-balanced diet tailored to the patient’s needs, including adequate protein, carbohydrates, fats, vitamins, fiber, and plenty of fluids.

     • Monitoring and Reporting: Nurses monitor the patient’s food intake and report any concerns to the surgeon or dietitian.

     • Individualized Approach: Consider the patient’s food preferences when planning meals to encourage intake and ensure optimal nutrition.

     • Appropriate Feeding Routes: Select feeding methods based on the patient’s condition and needs to ensure adequate nutrition via the most suitable route.

10. Exercises: Patients receive pre-operative instruction on proper coughing and deep breathing techniques, as well as how to turn and move their extremities post-operatively. Detailed instructions provided at the appropriate time can significantly reduce both operative and post-operative complications.

    • Deep breathing exercises: Involve slow inhalation through the nose, expanding the abdomen, and slow exhalation through the mouth, pulling the abdomen in to expel all air. This should be repeated 5-10 times hourly to effectively aerate the lungs, allow for full expansion in thoracic surgery, expel secretions, and prevent pneumonia and atelectasis.

    • Coughing exercises: Patients are instructed to sit or lie down, take a deep breath, exhale, and then follow with a short, forceful cough from deep in the lungs. Deep breathing should precede coughing to stimulate the cough reflex. Patients undergoing thoracic or abdominal surgery should learn how to splint their incision with a pillow or rolled towel to minimize pressure on the sutures and control pain during coughing.

    • Turning exercises: Patients practice turning from side to side, using bed rails for support if available. This helps prevent venous stasis and the pooling of secretions in the lower lungs, reducing the risk of pulmonary complications. This should be done every 1-2 hours post-operatively.

    • Extremity exercises: Include range of motion exercises for all joints, such as flexing and extending, and circular foot movements. These exercises help prevent circulatory problems like deep vein thrombosis, muscle wasting, and promote wound healing by ensuring sufficient blood supply.

11. Treatment of Existing Abnormalities/Infections: Any detected abnormalities or infections, such as mouth infections, dental caries, skin lesions, constipation, and respiratory or cardiac conditions, are treated according to diagnostic findings. Antibiotics, fluids, blood transfusions, and pain relievers are administered as needed.

12. Hygiene: Maintaining hygiene ensures the cleanliness of the skin, nails, and umbilicus (for abdominal surgeries), as well as oral care, which is crucial given its connection to the respiratory and digestive systems. The goal is to minimize the number of microbes introduced into deeper tissues during the surgical incision. Patient gowns, bed linens, utensils, and care equipment, including tables and beds, are kept clean.

13. Pre-operative Visits: Visits from the operating room nurses and team are important for them to meet the patient, understand their knowledge about the surgery, inform them about the approximate duration of the procedure, and describe what they might see, hear, and smell before going to sleep and what to expect in the recovery room.

14. Rest and Sleep: Physical exhaustion weakens the body and impairs its functions, while mental exhaustion intensifies shock. Patients may struggle to relax due to pre-operative anxiety.

    • Ensure a comfortable, freshly made bed in a well-ventilated room.

    • Nurses should avoid engaging in lengthy conversations with tired patients.

    • Limit visitors to minimize disturbances.

    • Reduce noise levels by using rubber-soled shoes, avoiding loud talking, keeping radio volumes low, and preventing doors from slamming and noisy trolleys.

    • Sedation may be necessary to aid sleep or manage pain that interferes with sleep.

Preparing the Patient on the Eve of Surgery (12 Hours Before the Operation)

Skin Care of the Area to Be Operated On: Pre-operative skin preparation aims to remove dirt, oils, and microorganisms, inhibit the growth of remaining microorganisms, and ensure the skin is intact without irritation from cleansing or shaving. The area prepared depends on the type of surgery.

Principles of Skin Preparation:

1. The preparation area should be larger and wider than the anticipated incision site, as the surgeon may need to extend the incision unexpectedly.

2. Wash the area with soap and water before shaving to ensure cleanliness.

3. Use a new, sharp, well-lit, and sterile safety razor or blade.

4. Shave against the direction of hair growth for a closer shave.

5. Inspect the skin for nicks, irritations, and cuts, as these are potential sites for infection.

6. Apply a skin antiseptic like chlorhexidine or iodine after shaving.

Specific Pre-operative Preparations:

1. Abdominal Operation: Special preparation of the gastrointestinal tract is needed the evening before surgery to reduce the risk of vomiting and aspiration during anesthesia and to prevent fecal contamination during bowel surgery.

   • Restrict food and fluids to prevent vomiting and subsequent aspiration pneumonia. Solid foods are typically withheld for 7-10 hours before surgery, with most patients receiving nothing by mouth (NPO) after midnight. Clear liquids may be allowed up to 4 hours before surgery. For surgeries scheduled later in the day, a light breakfast might be permitted. When a patient is NPO, the nurse must inform them of this restriction and the reasons, remove food and water from the bedside, place an NPO sign, and communicate this information to the incoming nursing staff. Severely malnourished or debilitated patients may receive intravenous infusions of glucose, amino acids, or plasma until the time of surgery.

   • Two or three enemas may be administered in the evening to prevent contamination of the peritoneal cavity from fecal spillage during surgery. In some cases, laxatives are given 2-3 days pre-operatively.

   • Nasogastric tubes may be inserted the evening before or morning of surgery to remove gastric and intestinal contents. Flatus tubes may also be used to relieve gaseous distension.

   • Catheterization is performed to drain urine and prevent post-operative urinary retention and accidental bladder injury during surgery.

2. Genito-urinary System: Renal function can be compromised by conditions affecting the kidneys, prostate, urethra, bladder, or ureters. Patients should be encouraged to drink at least 2 liters of fluid daily, with strict monitoring of their fluid balance. An indwelling catheter may be inserted for continuous bladder irrigation and drainage post-operatively. Intravenous fluids may be administered to irrigate the bladder, preventing urine stasis and subsequent calculi formation and bladder infections. Aseptic urine samples are collected for urinalysis. Patients are encouraged to urinate frequently, and any abnormalities are treated.

3. Rectal Operation/Hemorrhoidectomy: These procedures require special preparation due to the difficulty in achieving a sterile environment in the rectum and controlling bowel movements. The bowel may be emptied with an aperient the evening before and again in the morning, 8 hours before surgery. A simple soap and water enema is administered, followed by washing of the rectum and shaving of the perineum.

4. Gynecological Surgery: Patients undergoing gynecological surgery should receive an antiseptic douche, and spirit or ether should not be applied to the genital mucosa. A urinary catheter is inserted before surgery and remains in place post-operatively.

5. Respiratory Operation: Patients undergoing respiratory surgery require close respiratory monitoring, and any respiratory infections should be treated pre-operatively. Patients are taught respiratory exercises before surgery.

   For paired organs (eyes, ears, limbs, breasts), the affected side should be marked with a tag or adhesive tape to prevent surgery on the incorrect side.

   On the morning of surgery, the nurse typically wakes the patient about an hour before pre-operative medications are scheduled to be given. During this time, the nurse performs the following:

   • Records vital signs to establish a baseline for comparison and to detect any abnormalities (e.g., fever, tachycardia, bradycardia) that might necessitate postponing the surgery. Urine test results and weight are also noted for future comparison and medication dosage calculations.

   • Checks the skin preparation to ensure it was done correctly and whether it needs to be repeated.

   • Asks the patient to void to prevent bladder injury during lower abdominal and pelvic surgery, incontinence during the operation due to anesthesia, or post-operative restlessness. If a catheter is in place, the output is emptied and recorded.

   • Carries out specific orders such as administering enemas, inserting catheters or nasogastric tubes (if not done the previous evening), initiating intravenous infusions if not already in place, and ensuring the patency of existing IV lines without infiltration.

   • Assists with oral hygiene, removes dentures, and stores them safely.

   • Gathers all necessary documents, including consent forms, admission and observation charts, laboratory forms, X-rays, and fluid balance charts, and prepares them for transport to the operating room.

   • Verifies that the consent form is signed and assists the patient if needed.

   • In private, asks the patient to remove their personal clothing and stores it securely, along with any jewelry (earrings, necklaces, bangles, plastic or rubber rings). Wedding rings are usually left on and secured with adhesive tape.

   • Dresses the patient in a clean operating room gown and possibly support stockings. If the patient has long hair, it is braided into two braids, and all hairpins are removed to prevent scalp injury. The head is covered with a protective cap.

   • Removes colored nail polish to facilitate the assessment of cyanosis. Items difficult to remove can be taped over.

   • Confirms with the patient that they have not eaten in the past 8 hours or had fluids in the past 4 hours and reports immediately if this is not the case, which may lead to the postponement of surgery.

   • Applies an identification band with the patient’s name, age, ward, and the type of surgery to be performed, ensuring the information is accurate.

   • Administers pre-operative medications, which typically include a combination of sedatives and analgesic opiates like morphine (10-15mg) or pethidine (50-100mg), temazepam (10-20mg), and tranquilizers like diazepam (5-10mg). These medications aim to reduce anxiety, thereby reducing the risk of shock, ensure sleep, decrease the amount of anesthetic needed, and cause amnesia for the events preceding surgery. Other pre-operative medications may include antibiotics (e.g., intravenous metronidazole with ampicillin, gentamicin, or chloramphenicol for abdominal or gynecological conditions, head injuries, or gunshot wounds) and anti-secretory drugs like atropine (0.6-1mg) to reduce secretions, especially when ether is used as an anesthetic, improve heart action, and suppress vagal influence on the heart. These medications should be given 30-45 minutes before surgery, and the time of administration should be accurately recorded. If a dose is missed or delayed, the anesthetist must be informed.

   • Once all preparations are complete and it is time for surgery, the patient is transported to the operating room on a trolley by two nurses. Noise should be kept to a minimum due to heightened sensitivity after pre-medication. Movements should be gentle, steady, and unhurried. The nurse accompanies the patient with all necessary documents and provides a full report to the operating room nurse or anesthetist.

   A post-operative bed is then prepared with clean linen. The specific type of bed depends on the surgery (e.g., divided bed, fracture bed with traction). Necessary bedside equipment for immediate post-operative care includes bed cradles, infusion stands, a vital signs monitoring tray, a mouth care tray, infusion trays, oxygen and suction apparatus. The bed should be warm to prevent shock but not overheated.

Preparation for Pre-operative Care