Chapter 9: Concepts of Care for Perioperative Patients

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Welcome to the Deep Dive.

Today, we're diving into something really crucial, that tight critical window around surgery.

We're looking at perioperative care.

Exactly, we're aiming to pull out the absolute must -knows, the things you just can't afford to miss.

Right, moving beyond just textbook facts to what really matters in those, say, 72 hours.

That's a good way to think about it.

Fundamentally, perioperative care splits into three main stages.

You've got a preoperative stage.

Which is from scheduling the surgery right up until they're actually heading into the OR.

Precisely.

Then comes the intraoperative phase that's during the surgery itself.

Okay.

And finally, postoperative.

That starts the minute the surgery ends in recovery and goes all the way until the patient is fully recovered.

And across all of those, the sources really stress two main priorities, don't they?

Gas exchange and pain.

Why those two specifically?

Well, they're fundamental.

Problems with gas exchange

that can lead to severe injury or even death incredibly quickly.

Makes sense.

And pain.

Uncontrolled pain isn't just about comfort.

It really hampers recovery.

It can lead to shallow breathing, reluctance to move.

Which circles back to respiratory issues, right?

Exactly.

And then you have other vital concepts like infection and tissue integrity, how the wound heals.

They're all interconnected.

And it's all underpinned by patient safety.

Like those national patient safety goals, making sure it's the right patient, right procedure, right site, and doing that pre -surgery pause.

Absolutely.

That timeout is critical.

Okay.

Let's dig into that preoperative phase first.

Yeah.

This is all about preparation, getting the full picture of the patient.

It really is.

You need a thorough assessment, their medical background, any previous surgeries, allergies are huge, social factors, how they're coping psychologically, and it needs to be private.

You're essentially looking for potential risks hidden in their history.

You got it.

We're kind of like detectives here.

Take cardiovascular history, for instance.

If someone's had a heart attack in the last, say, six months, or they have heart failure, or even just high blood pressure.

Their risk level goes way up.

Way up.

And it's crucial they continue taking certain prescribed meds, like beta blockers.

They need that protection during the stress of surgery.

And what about the lungs?

Smokers are always a concern, but how immediate is that impact on their oxygen levels for this surgery?

It's pretty immediate, and it's a double whammy, really.

Smoking boosts carboxyhemoglobin levels.

That's carbon monoxide, taking up space where oxygen should be on the red blood cells.

Barving the tissues, basically.

Right, plus it damages the little hairs, the cilia in the airways that normally clear out mucus.

So post anesthesia, their risk for things like pneumonia or atelectasis, collapsed lung tissue is much higher.

Okay, so we've got internal risks.

What about physical safety on the underrating table?

Things like metal implants.

Ah, yes, good point.

Things like joint replacements or pacemakers.

We absolutely have to know about those beforehand.

Why specifically?

Because of the electrocautery tools used in surgery.

If the grounding pad is placed too close to muddle, it can cause a serious electrical burn.

So we need to flag that immediately.

Speaking of serious, let's talk about malignant hyperthermia, MH.

It sounds terrifying.

It is, it's one of the most critical emergencies in anesthesia.

It's an inherited condition.

Certain anesthetic drugs trigger this massive, uncontrolled release of calcium inside skeletal muscle cells.

And that causes?

It kicks off this huge surge in metabolism.

The body goes into overdrive, producing tons of acid, leading to acidosis, heart rhythm problems, muscle rigidity.

It's a metabolic firestorm.

Wow, and the really high fever, like up to 111 degrees Fahrenheit, that's actually a late sign.

That's the crucial part.

The fever is late, you can't wait for that.

So how do we catch it early?

What's the first clue?

The most sensitive, the earliest indicator, is usually an unexpected jump in the patient's end -tidal carbon dioxide level.

That's what the anesthesia provider is constantly monitoring.

Okay, so CO2 rises.

Right, often along with falling oxygen saturation and a raising heart rate, tachycardia.

If you see that pattern, it's an MH crisis until proven otherwise.

And the response has to be immediate.

Absolutely immediate.

The specific antidote is a drug called dantrolene sodium.

It's a muscle relaxant, and getting it administered fast is key to survival.

Okay, so MH is the big emergency.

Before we even get near the OR though, there are standard tests, right?

Like blood work, urine tests.

Yep, usually a urinalysis, a complete blood count, CBC, checking clotting factors, a basic metabolic panel, and often an ECG, especially for older patients or those with known heart risks.

And you mentioned electrolytes.

Is there one that's particularly critical to check before surgery?

Potassium, definitely potassium, whether it's too low hyperkalemia or too high hyperkalemia.

Either one drastically increases the risk of dangerous heart rhythms under anesthesia.

So that has to be corrected beforehand.

Absolutely, non -negotiable.

What about informed consent?

What's the nurse's exact role there?

It's important to be clear.

The surgeon explains the procedure, the risks, the benefits, the alternatives.

The nurse's role is primarily to witness the patient's signature, confer they understand what they heard from the surgeon, maybe clarify some facts or dispel myths, but not to give the primary explanation.

Got it, witness and clarify.

An NPO status, nothing by mouth.

That's purely about preventing aspiration during anesthesia.

That's the main goal, yes.

Stomach contents getting into the lungs is a major complication.

Generally no solid food for about six to eight hours beforehand.

And clear liquids.

Usually allowed up to two hours before.

But always follow specific facility protocols.

We also hear about alternatives to standard blood transfusions now.

Things like autologous donation or cell savers.

You put it in alpha, what are those?

Good question.

Autologous donation is when patients donate their own blood weeks before surgery.

Directed donation is when family or friends donate specifically for that patient.

And bloodless surgery techniques are becoming more common.

A cell saver is a machine used during the operation.

It collects blood lost by the patient, washes the red cells, and returns them right back to the patient.

Recycling their own blood in real time.

Exactly.

And epiwatin alpha is a medication given before surgery to boost the patient's own red blood cell production.

Both aim to reduce the need for donor blood transfusions and their associated risks.

Makes sense.

Now that pre -op teaching piece, it seems heavily focused on preventing lung problems after surgery.

It is, because anesthesia and immobility really increase that risk.

We teach deep breathing exercises.

Sometimes called expansion breathing.

And using that incentive spirometer device.

Yes.

Critically important.

Teaching to get a good seal with their lips, inhale slowly and deeply to raise the piston, and then hold that breath for about three to five seconds.

That really helps pop open the air sacs.

And coughing.

Seems counterintuitive if you have an incision.

It does.

But clearing secretions is vital.

So unless it's a type of surgery where coughing is bad, like maybe a hernia repair or a brain surgery, we teach them how to cough effectively.

By splinting the incision.

They need to hold a pillow or a folded blanket firmly over the surgical site while they cough.

It provides support, reduces pain, and lets them give a good strong cough to clear their lungs.

And preventing blood clots, VTEs.

Also key, we teach simple leg exercises like making circles with their feet or pushing the balls of their feet down against the bed like pressing a gas pedal.

Simple stuff.

Simple but effective.

But the most crucial teaching point for VTE is recognizing the warning signs.

If they suddenly develop swelling in one leg, maybe with a dull ache in the calf.

They need to report that immediately.

Immediately, that could be a DVT.

And it needs urgent attention from the surgeon.

Okay, we've prepped them, they've had the surgery, now they're coming out.

Let's shift to the post -operative phase.

Starts in the PCU, right?

The post -anesthesia care unit.

That's phase one, yes.

Very intensive monitoring right after the OR.

Then there's usually a phase two where they're getting ready for discharge or transfer to a regular room.

And phase three is more about extended recovery, maybe at home or in a rehab setting.

When they hit the regular med -surg floor, what's the absolute first thing we're assessing?

Airway and breathing.

Always.

Gas exchange is still priority number one.

We need continuous pulse oximetry, SpO2 monitoring.

What are the red flags there?

A respiratory rate dropping below 10 breaths per minute is a big one.

Could be residual anesthesia or opioid effects.

Listening to their breathing, any stridor, that high -pitched squeak or loud snoring can mean airway obstruction.

And the oxygen saturation number?

If that SpO2 drops below 95 % or whatever the patient's baseline is, you need to notify the surgeon or anesthesia provider right away.

That's a critical rescue cue.

Okay, airway secured.

Next up, cardiovascular.

Yep, checking blood pressure and heart rate against their baseline.

We're looking for big deviations, say, more than the 25 % change from their pre -op numbers.

Could signal bleeding, hypovolemia, or fluid overload.

And we continue VTE prevention.

Stockings, compression devices.

Yeah, absolutely.

Keep those measures going and encourage early mobilization as soon as it's safe.

But there's a common mistake with positioning.

What's that?

Never, ever put pillows directly under the patient's knees or raise the knee gatch of the bed sharply.

Why not?

Because bending the knees like that can kink the veins in the legs, slow down blood flow,

and significantly increase the risk of a DVT forming.

Keep the legs relatively straight or only slightly elevated.

Good tip.

Now, what about neurochecks, especially if they had spinal or epidural anesthesia?

You're assessing their level of consciousness, orientation, just like any post -op patient.

But with regional anesthesia, you're also checking sensory and motor function return in the legs.

What's the major warning sign with an epidural or spinal?

Okay, so a headache when they sit up is common.

That's often a postural puncture headache, needs management, but isn't usually an emergency.

The real emergency sign is if they have delayed or absent return of motor function, especially combined with increasing back pain, maybe worse when they cough or strain.

What could that mean?

That could signal an epidural hematoma, bleeding in the epidural space or an infection.

It's rare, but it can cause permanent paralysis if not treated immediately, needs urgent notification.

Wow, okay, moving down to the gut.

Nausea and vomiting PONV, super common, right?

Probably the most common post -op complaint, yeah.

Especially if they have risk factors like obesity or a history of motion sickness, we have meds to manage it.

And assessing bowel function return.

We often hear about listening for bowel sounds.

Is that reliable?

That's the classic teaching, but honestly, it's not the best indicator.

You can have bowel sounds even if things aren't moving properly.

So what is the reliable sign?

The true sign that peristalsis is back is the patient passing flattus or having a bowel movement.

That's the definitive proof.

And if they don't, if their belly gets distended and uncomfortable.

And they aren't passing gas or stool, then you start thinking about a paralytic ululias where the bowel has temporarily stopped working.

That needs attention.

Okay.

And you're an output.

What's the minimum we need to see?

We need to see at least 30 milliliters per hour.

Anything less than that needs to be reported.

Could be dehydration, hypovolemia, or even early kidney injury.

Got it.

Let's talk about the incision itself.

Tissue integrity.

How should wound healing look?

Initially, you might see some bloody drainage that's sanguineous.

Then it typically transitions to pale pinkish -yellow serosanguineous.

And finally, to a clearer, straw -colored fluid serous drainage.

That progression is normal.

And signs of infection?

Increasing redness around the incision, more pain or tenderness,

warmth, maybe swelling, and definitely purulent drainage.

Thick yellowish or greenish pus.

There are more serious wound complications than just infection, right?

Like dehiscence.

Right, dehiscence is when the outer layers of the wound separate.

It often happens between day five and 10 post -op.

The patient might even say they felt a pop.

Not good, but not the worst case.

No, the absolute worst case scenario is evisceration.

That's when the wound separates completely and internal organs actually protrude out.

That's a surgical emergency.

A true surgical emergency.

If that happens, your first actions are critical.

What do you do?

First, stay with the patient.

Call for help immediately.

The rapid response team, the surgeon,

don't leave them alone.

Position them lying flat on their back, supine, with their hips and knees bent.

This helps reduce tension on the abdomen.

Makes sense.

And the organs.

You need to cover the protruding organs immediately with sterile dressings that have been moistened with warm sterile saline solution.

Never try to push the organs back in.

Just cover them and keep those dressings continuously moist until the surgeon arrives.

Wow, critical steps.

Okay, finally, let's circle back to our other core priority.

Patients often worry about getting addicted to opioid pain meds after surgery.

That's a very common fear, and it's important we address it.

We need to reassure patients that using opioids for acute short -term pain after surgery is very, very unlikely to lead to addiction or substance abuse problems.

So managing the pain effectively is the priority.

Absolutely, and often the best way is through scheduled, around -the -clock dosing, or using a PCA, patient -controlled analgesia pump.

Keeping a steady level of medication is usually better than waiting for the pain to get severe before treating it.

And if someone does get too much opioid, leading to respiratory depression.

The reversal agent is naloxone, but there's a big safety point here.

Which is?

Naloxone often wears off faster than the opioid does.

So you can reverse the respiratory depression, but then an hour later, as the naloxone is eliminated, the patient can slip back into it.

Or they might experience sudden severe rebound pain.

So close monitoring is essential after giving naloxone.

Continuous monitoring, absolutely.

And don't forget non -drug methods, too.

Repositioning, distraction, sometimes gentle massage on the back, or stiff joints can help.

But not the calves, right?

Definitely never massage the calves.

That could dislodge a DVT if one is present.

Sending it to the lungs is a pulmonary embolism.

Hashtag tag tag outro.

So, wrapping this all up, if you think about the whole perioperative journey, the nurse is constantly vigilant.

The absolute bedrock is monitoring gas exchange, managing pain proactively, and being hyper aware of those big potential complications.

Malignant hyperthermia during surgery, VTEs, and wound disasters like evisceration afterwards.

It really highlights that the nurse's power isn't just in doing tasks, but in synthesizing all that information.

Connecting the dots from that pre -op history, remembering the MH risk factor, knowing about that pacemaker.

Exactly.

And then picking up on those subtle post -op changes, that slight rise in end -tidal CO2, the unexplained back pain after an epidural, that sudden increase in wound drainage on day six.

Recognizing those early signs is what makes the difference.

It's communication and early recognition.

It really is.

And we emphasize surgical safety checklists and the timeout before incision, and those are vital.

But maybe the most important safety check is a continuous, thoughtful assessment the nurse performs long after the patient leaves the OR, that constant vigilance.

That's a really powerful way to think about it, the ongoing assessment as the ultimate safety measure.

Well, that's all the time we have for this deep dive.

Thanks so much for joining us.