pre and post operative care ppt

Perioperative refers to the three phases of surgery.

Preoperative stage
Intraoperative stage
Postoperative stage

Within these stages there are many different roles for nurses and different care needed for the patient dependent on which stage they are in.

As with any nursing care, the goal during these stages is to provide holistic and evidence based care as well as support to the individual.

There are different nursing roles throughout the perioperative process including: admission nurses; anaesthetic nurse; circulating nurse or scout nurse; instrument or scrub nurse; post anaesthesia care unit (PACU) nurse; and the surgical ward nurse.

For those working in these roles or wishing to work in this specialised area, it is best practice to have an understanding of the complete perioperative process from the patient’s point of view as well as a sound understating of your role requirements.

Day surgery is common practice in Australia.n It involves the patient being admitted and prepared for the procedure, undergoing the procedure and being discharged home on the same day. It is generally done for less complex or less invasive surgical procedures in which limited anaesthesia is required.

Approximately 60% of all procedures are done as day surgery procedures within Australia.(1)

Individual patients will have different psychological and emotional responses to surgery influenced by the type of surgery they are having and why they require that surgery.

Think of Mary as your patient. She is a 63-year-old woman with colorectal cancer who has had a bowel resection with the formation of a stoma. The surgery removed the entire cancerous portion of her bowel and potentially left her cancer free.

Now let’s think of Jane. She is also 63 years old and has had a bowel resection due to severe Crohn’s disease. She was told the resection was necessary for a certain abscess in her bowel and she may experience some relief from her current symptoms but they can’t be certain.

She is also informed there is no cure for her condition and she may require further surgery.

As you can imagine, the psychological and emotional responses of these two women will be vastly different. Mary is most likely relieved and happy about her prognosis whereas Jane may be angry that her disease will be a part of her life forever, she may become depressed, anxious and fear the future.

How do you, as a nurse, respond to these two women?

Providing reassurance and support is one of the most important roles for a nurse during the surgical process.

Providing information to the patient and their family can allay fears. Anxiety of the unknown can be decreased when information is provided. It is also important to encourage the patient to communicate their fears and concerns so

1. Pre and post operative care  TO: DR.BINIYAM. BY: BINIAM.M

2. Outline  Introduction Preoperative preparation   Perioperative management of the high-risk surgical patient  Nutrition and fluid therapy Intraoperative care   Postoperative care  

3. Introduction Surgery is an important treatment option for a wide range of acute and chronic diseases. Around 10 million patients undergo a surgical procedure each year and this number will continue to rise.  For most patients surgery is a success, both in terms of the procedure itself and the care before and afterwards.  However, the population is changing and so must our services.  There are over 250,000 patients at higher risk from surgery and this number is set to rise. So with increasing demand and the increasing complexity of surgical procedures, come new challenges that we must address.

4. Preoperative care 

5. Cont... Preoperative care  refers to  health care  provided before a  surgical operation . The aim of preoperative care is to do whatever is right to increase the success of the surgery. At some point before the operation the health care provider will assess the fitness of the person to have surgery. This assessment should include whatever tests are  indicated , but not include  screening  for conditions without an indication.

6. Benefit of preoperative care   To screen for and properly manage comorbid conditions. To assess the risk of anesthesia and surgery and lower it. To educate patients and families about the objectives and risks of anesthesia and the anaesthesiologist's role in perioperative care. To obtain informed consent.

7. Service in preoperative care  History taking  physical examination Investigation  risk assessment  general and system-specific evaluations.

8. History taking  The history of past surgery and anaesthesia can reveal problems that may present during current hospitalisation (e.g. intraabdominal adhesions and suxamethonium apnoea).  The use of recreational drugs and alcohol consumption should be noted as they are known to be associated with adverse outcomes. Check for allergies and risk factors for deep vein thrombosis (DVT).  Social history, ability to communicate and mobility are important in planning rehabilitation after surgery 

9. Physical Examination Patients should be treated with respect and dignity, receive a clear explanation of the examination undertaken and kept as comfortable as possible A pre-operative physical examination is generally performed upon the request of a surgeon to ensure that a patient is healthy enough to safely undergo anesthesia and surgery.  This evaluation usually includes a physical examination, cardiac evaluation, lung function assessment, abdominal assessment...etc 

10. INVESTIGATIONS

11. Investigations Routine lab tests before are admitted to the hospital or before certain outpatient procedures. The tests help find possible problems that might complicate surgery if not found and treated early. 

12. Cont. Full blood count . A full blood count (FBC) is needed for major operations, in the elderly and in those with anaemia or pathology with ongoing blood loss. Urea and electrolytes . Urea and electrolytes (U&E) are needed before all major operations, in most patients over 60 years of age especially with cardiovascular, renal and endocrine disease or if significant blood loss is anticipated

13. CONT. It is also needed in those on medications which affect electrolyte levels, e.g. steroids, diuretics, digoxin, NSAIDs (non-steroidal anti-inflammatory drugs), intravenous fluid or nutrition therapy. Electrocardiography. Electrocardiography (ECG) is required for those patients aged over 60 years, cardiovascular, renal and cerebrovascular involvement, diabetes and in those with severe respiratory problems.

14. Cont... Chest radiography . A chest x-ray is not required unless the patient has a significant cardiac history, cardiac failure, severe chronic obstructive pulmonary disease (COPD), acute respiratory symptoms, pulmonary cancer, metastasis or effusions, or is at risk of tuberculosis. Urinalysis. Dipstick testing of urine should be performed on all patients to detect urinary infection, biliuria, glycosuria and inappropriate osmolality.

15. Cont... Human chorionic gonadotrophin. Pregnancy needs to be ruled out in all women of childbearing age Blood glucose and HbA1c. These should be performed in patients with diabetes mellitus and endocrine problems. HbA1c indicates how well diabetes has been controlled over a longer duration.

16. Cardiovascular System/ Cardiac problems Patients with heart disease should be considered high-risk surgical candidates and must be fully evaluated.  At preoperative assessment, it is important to identify the patients who have a high perioperative risk of myocardial infarction (MI) and make appropriate arrangements to reduce this risk. 

17. Cont... These patients include those who have suffered coronary artery disease, congestive cardiac failure, arrhythmias, severe peripheral vascular disease, cerebrovascular disease or renal failure, especially if they are undergoing intra-abdominal or intrathoracic surgery. In patients with ischaemic heart disease (IHD), the left ventricular status can be evaluated using a stress test

18. Cont... For patients with symptomatic valvular heart disease or poor left ventricular function, an echocardiography should be performed.  Pressure gradients across the valves, dimensions of the chambers and contractility can be determined using echocardiography; an ejection fraction of less than 30 per cent is associated with poor patient outcomes.

19. Hypertension Prior to elective surgery, blood pressure should be controlled to near 160/90 mmHg. If a new antihypertensive is introduced, a stabilisation period of at least 2 weeks should be allowed. Elective surgery should be postponed for three to six months after a proven myocardial infarct to reduce the risk of perioperative reinfarction

20. Smoking Information should be provided to indicate perioperative risks associated with smoking. Stopping smoking reduces carbon monoxide levels and the patient is better able to clear sputum. Asthma It is important to establish the severity of the asthma, precipitating causes, frequency of bronchodilator and steroid use, PEFR (peak expiratory flow rate) and any previous intensive care unit admissions. 

21. Chronic obstructive pulmonary disease(COPD) Patients on steroid treatment, or oxygen therapy, or who have a forced expiratory volume in the first second (FEV1) less than 30 per cent of predicted value (for age, weight and height) have severe disease and may have respiratory failure in the postoperative period

22. Cont... Preoperative chest x-ray or scans are useful in patients with known emphysematous bullae, pulmonary cancer, metastasis or effusions. Patients with significant COPD who are undergoing major surgery will need to be referred to the respiratory physicians for optimisation of their condition.  An arterial blood gas analysis may also be useful as it can give an indication of carbon dioxide retention. This is associated with an increased risk of perioperative respiratory complications

23. Liver disease In patients with liver disease, the cause of the disease needs to be known, as well as any evidence of clotting problems, renal involvement, and encephalopathy Elective surgery should be postponed until any acute episode has settled (e.g. cholangitis). The blood tests which need to be performed are liver function tests, coagulation, blood glucose, urea and electrolyte levels. 

24. Urinary tract infection Urinary tract infection Uncomplicated urinary infections are common in women, while outflow uropathy with chronically infected urine is common in men.  These infections should be treated before embarking on elective surgery where infection carries dire consequences,              e.g. joint replacement. For emergency procedures, antibiotics should be started and care taken to ensure that the patient maintains a good urine output before, during and after surgery

25. Preoperative assessment in emergency surgery In urgent or emergency surgery, the principles of preoperative assessment should be the same as in elective surgery, except that the opportunity to optimise the condition is limited by time constraints.  Medical assessment and treatments should be started (e.g. according to the Advanced Trauma Life Support (ATLS) guidelines) even if there is no time to complete those before the surgical procedure is started. Some risks may be reduced, but some may persist and whenever possible these need to be explained to the patient

26. Cont... Start: Similar principles to that for elective surgery  constraints: Time, facilities available  Consent: May not be possible in life-saving emergencies  Organisational efforts: For example, local/national algorithms for treatment of multi-trauma patient

27. RISK ASSESSMENT AND CONSENT All life- or limb-threatening complications and all complications with an incidence of 1 per cent or more should be discussed with the patient The risk of death doubles with every seven years of adult life lived. The presence of peripheral vascular disease, stroke, heart failure, myocardial infarction or renal failure each independently increases the risk of death by

28. Cont... -About 1.5 times the baseline. The risks of the surgical procedure itself are then to be added on separately.  Valid consent implies that it is given voluntarily by a competent and informed person who is not under duress  In emergency situations or in an unconscious patient, consent may not be obtained and the procedure carried out ‘in the best interests of the patient’.

29. Cont... Adults are presumed to have capacity to consent unless there is contrary evidence. For adults who are not deemed competent to give consent, treatment can still proceed in their best interests by filling in an inability to consent form.  Those under 16 years who demonstrate the ability to appreciate the risks and benefits fully are deemed competent. This is known as Gillick competence 

30. Risk assessment and consent Risks: Related to the comorbidities, anaesthesia and surgery  ■ Explain: Advantages, side effects, prognosis ■ Language: Simple, use daily life comparisons to explain risks ■ Consents: Valid consent is necessary except in life-saving circumstances

31. Nutrition and fluid therapy Fluid therapy and nutritional support are fundamental to good surgical practice. Accurate fluid administration demands an understanding of maintenance requirements and an appreciation of the consequences of surgical disease on fluid losses.  This requires knowledge of the consequences of surgical intervention and, in particular, intestinal resection. Malnutrition is common in hospital patients.

32. Cont... The success or otherwise of nutritional support should be determined by tolerance to nutrients provided and nutritional end points, such as weight.  It is unrealistic to expect nutritional support to alter the natural history of disease. It is imperative that nutrition-related morbidity is kept to a This necessitates the appropriate selection of feeding method, careful assessment of fluid, energy and protein requirements, which are regularly monitored, and the avoidance of overfeeding.

33. Intraoperative care

34. Definition  The term "intraoperative" refers to the time during surgery. Intraoperative care is patient care during an operation and ancillary to that operation. Activities such as monitoring the patient's  vital signs  ,  blood  oxygenation levels, fluid therapy, medication transfusion, anesthesia , radiography, and retrieving samples for laboratory tests, are examples of intraoperative care.

35. Cont... The purpose of intraoperative care is to maintain patient safety and comfort during surgical procedures. Some of the goals of intraoperative care include maintaining homeostasis during the procedure, maintaining strict sterile techniques to decrease the chance of cross-infection, ensuring that the patient is secure on the operating table, and taking measures to prevent hematomas from safety strips or from positioning.

36. Complications Intraoperative complications are surgery related, anesthesia related, or position related. One complication occurring during the intraoperative period that is not common but can be life threatening is an anaphylactic (allergic) reaction to anesthesia . The intraoperative staff is trained extensively in the treatment of such a reaction, and emergency equipment should always be available in the event it is needed for this purpose.

37. Cont... Another anesthesia -related complication is called "awareness under anesthesia ." This occurs when the patient receives sufficient muscle relaxant (paralytic agent) to prohibit voluntary motor function but insufficient sedation and analgesia to block pain and the sense of  hearing  . Patients are aware

38.       Post operative        care

39. Cont... The aim of postoperative care is to provide the patient with as quick, painless and safe recovery from surgery as possible.  Trainees should acquire knowledge and skills to manage surgical, as well as medical, postoperative problems.

40. GENERAL MANAGEMENT Patient’s vital parameters, consciousness, pain and hydration status are monitored in the recovery room and supportive treatment is given .  Specific monitoring, such as Doppler flow for a free flap, observations like neurological evaluation and laboratory tests such as blood gas analysis may also be requested where necessary

41. Cont... The patient can be discharged from the recovery room when they fulfil the following criteria:   Patient is fully conscious.  Respiration and oxygenation are satisfactory. Patient is normothermic, not in pain nor nauseous.  Cardiovascular parameters are stable.

42. SYSTEM-SPECIFIC POSTOPERATIVE COMPLICATIONS The presentation of complications may be similar for more than one underlying condition. Shortness of breath can be due to respiratory or cardiac problems, abdominal pain can be due to surgical causes or sepsis, while chest pain may be present in cardiac, respiratory and even in gastrointestinal problems. 

43. Respiratory complications The most common respiratory complications in the recovery room are hypoxaemia, hypercapnia and aspiration. Pneumonia and pulmonary embolism tend to appear later in the postoperative period.

44. Cardiovascular complications Hypotension in the immediate postoperative period may be due to inadequate fluid replacement, vasodilatation from subarachnoid and epidural anaesthesia or rewarming of the patient.  However, other causes of hypotension such as surgical bleeding, sepsis, arrhythmias, myocardial infarction, cardiac failure, tension pneumothorax, pulmonary embolism, pericardial tamponade and anaphylaxis should be also sought

45. Cont... Patients with hypotension are likely to have cold clammy extremities, tachycardia and a low urine output ≤0.5 mL/kg per hour and low CVP.  Hypovolaemia should be corrected with intravenous crystalloid or colloid infusions (see below under Bleeding).

46. Urinary retention Inability to void after surgery is common with pelvic and perineal operations or after procedures performed under spinal anaesthesia. Pain, fluid deficiency, problems in accessing urinals and bed pans, and lack of privacy on wards may contribute to the problem of urine retention. The diagnosis of retention may be confirmed by clinical examination and by using ultrasound imaging. Catheterisation should be performed prophylactically when an operation is expected to last 3 hours or longer or when large volumes of fluid are administered.

47. Urinary infection Urinary infection is one of the most commonly acquired infections in the postoperative period. Patients may present with dysuria and/or pyrexia. Immunocompromised patients, diabetics and those patients with a history of urinary retention are known to be at higher risk.  Treatment involves adequate hydration, proper bladder drainage and antibiotics depending on the sensitivity of the microorganisms.

48. GENERAL POSTOPERATIVE PROBLEMS AND MANAGEMENT Hypothermia and shivering Anaesthesia induces loss of thermoregulatory control. Exposure of skin and organs to a cold operating environment, volatile skin preparation (which cool by evaporation), and the infusion of cold i.v. fluids all lead to hypothermia.  .

49. fever About 40 per cent of patients develop pyrexia after major surgery; however, in most cases no cause is found. The inflammatory response to surgical trauma may manifest itself as fever, and so pyrexia does not necessarily imply sepsis. However, in all patients with a pyrexia, a focus of infection should be sought.

50. Cont... Patients with a persistent pyrexia need a thorough review. Relevant investigations include full blood count, urine culture, sputum microscopy and blood cultures

51. Enhanced recovery Enhanced recovery is an approach to the perioperative care of patients undergoing surgery. It is designed to speed clinical recovery of the patient, and reduce the cost and the length of stay of the patient in the hospital. It is achieved by optimising the health of the patient before surgery and then delivering evidence-based best care in the perioperative period. 

52. Cont... Postoperative strategies for enhanced recovery include:  Early planned physiotherapy and mobilisation.  Early oral hydration and nourishment.   Good pain control using regular paracetamol with nonsteroidal anti-inflammatory drugs (NSAIDs). Epidurals and nerve blocks are managed by acute pain teams.

53. Cont... Discharge planning is started before the patient is even admitted to hospital and involves support from stoma care nurses, physiotherapists and other community care workers

54. Cont... Early mobilisation is encouraged to reduce the risks of DVT, urinary retention, atelectasis, pressure sores and faecal impaction. Telephone follow up is carried out to make sure that the patient is recovering well once discharged.

55. Reference  Bailey and Loves: Short practice of Surgery, 26ed. Hardy’s Textbook of Surgery 

56. Thank you