Quiz #3: Perioperative Care
Reason(s) for Surgery
- Diagnostic Surgery - Curative Surgery - Restorative Surgery - Palliate Surgery - Cosmetic Surgery
Urgency of Surgery
- Elective - Urgent - Emergent
Types of Anesthesia
- General ANesthesia - Monitored Anesthesia Care (MAC) - Regional Anesthesia - Moderate Sedation
What are some Patient Safety measures that are important in perioperative care?
- Marking the Site - The Surgical Pause - Don't Skip the SCIP
Degree of Risk of Surgery
- Minor Procedure - Major Procedure
Extent of Surgery
- Simple - Radical - Minimally Invasive Surgery (MIS)
The Surgical Team
- Surgeon - Anesthesia Care Provider - Surgeon's Assistant - Scrub Nurse - Circulating Nurse
Diagnostic Surgery Examples
- breast biopsy - exploratory laparotomy
Elective Surgery Examples
- cataract removal - hernia repair - total joint replacement
Curative Surgery Examples
- cholecystectomy - appendectomy - hysterectomy
Radical Surgery
- extensive surgery beyond the area obviously involved - is directed at finding a root cause
Emergent Surgery Exampls
- gunshot wound - stab wound - ruptured abdominal aortic aneurysm - appendectomy
Minor Procedure Examples
- incision & drainage (I & D) - implantation of a venous access device
Urgent Surgery Examples
- intestinal obstruction - kidney or ureteral stones - acute cholecystitis
Minimally Invasive Surgery (MIS) Examples
- laparoscopy cholecystectomy
Major Procedure Examples
- mitral valve replacement - pancreas transplant
Major Procedure
- of greater risk - usually longer & more extensive than a minor procedure
How are surgical procedures classified?
- purpose - body location - extent - degree of urgency
Radical Surgery Examples
- radical prostatectomy - radical hysterectomy
Circulating Nurse
- stays in the unsterile field area of the operating room, records/documents intraoperative care, coordinates all intraoperative activities with team members & other departments, prepares & labels intraoperative specimens, gives hand-off report ot PACU nurse
Palliative Surgery Examples
- tumor debulking - colostomy
Minor Procedure
- without significant risk - often done with local anesthesia
Common Labs & Diagnostics Required for Pre-Op Clearance
1. Urinalysis 2. Blood type and screen 3. CBC or hemoglobin level and hematocrit 4. Clotting studies (PT, INR, aPTT) 5. Electrolyte levels 6. Serum creatinine level 7. Pregnancy test 8. Chest x-ray 9. ECG
What right does a competent adult have regarding the surgical consent?
As a competent adult, it is the patient's right to refuse treatment for any reason, even when refusal might lead to death. For example, in the case of Jehovah's Witnesses, some patients will not accept blood transfusions because of their religious convictions.
The Surgical Pause
Before starting the operative procedure, facilities use a "time-out" procedure to verify the correct site, correct patient, and correct procedure.
SCIP Infection-4 (SCIP Inf-4)
Cardiac Surgery Patients with Controlled 6 AM Postoperative Blood Glucose (applies to cardiac surgery patients only) The purpose is to avoid hyperglycemia (which is defined as blood glucose levels above 200 mg/dL and is associated with increased complications and mortality) in cardiac surgery patients, especially patients undergoing coronary artery bypass graft surgery and patients with diabetes who are having cardiac surgery.
What is the purpose of the preoperative checklist?
Checklists promote safety by ensuring nothing is omitted
What does consent imply?
Consent implies that the patient has sufficient information to understand: 1) The nature of and reason for surgery 2) Who will be performing the surgery & whether others will be present during the procedure (ie: students) 3) All available options & the risks associated with each option 4) The risks associated with the surgical procedure & its potential outcomes 5) The risks associated with the use of anesthesia
How is consent obtained in a life-threatening situation?
For a life-threatening situation in which every effort has been made to contact the person with medical power of attorney, consent is desired but not essential. In place of written or oral consent, written consultation by at least two physicians who are not associated with the case may be requested by the surgeon.
Restricted Area of the Surgical Department
Found within the semi-restricted zone. Surgical suite (i.e. OR) where the invasive procedure takes place. In addition to clean surgical attire, masks must be worn and traffic minimized whenever sterile supplies are open.
Marking the Site
In an effort to avoid wrong-site surgery, the Joint Commission requires marking of site prior to surgical procedures that are site-specific, such as left, right. Marking must be done with an indelible marker should take place when the patient is awake and before the patient leaves the pre-op hold area. Except in an emergency, the patient should not enter the anesthetic/procedure room until this has been completed.
Surgical Settings
Inpatient Outpatient/Ambulatory
Implementing Dietary Restrictions
NPO Regardless of the type of surgery and anesthesia planned, the patient is restricted to NPO status before surgery. NPO means no eating, drinking (including water), or smoking (nicotine stimulates gastric secretions). NPO status ensures that the stomach contains a limited volume of gastric secretions, which decreases the risk for aspiration. The exact amount of time a patient must be NPO before surgery is controversial. The American Society of Anesthesiologists (ASA) recommends a reduced NPO time - 6 or more hours for easily digested solid food and at least 2 hours for clear liquids (Crenshaw, 2011; Sendelbach, 2010).
Semi-restricted Area of the Surgical Department
Only authorized staff in clean surgical attire (i.e. scrubs laundered in an accredited laundry facility, long-sleeved jacket, shoes dedicated for surgery use or shoe covers, surgical head cover, and mask that covers all facial hair.
Palliative Surgery
Performed to relieve symptoms of a disease process, but does NOT cure
Curative Surgery
Performed to resolve a health problem by repairing or removing the cause of problem
Elective Surgery
Planned for correction of a nonacute problem
SCIP Infection-1 (SCIP Inf-1)
Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision The purpose is to use short-duration antibiotics to establish bactericidal blood and tissue levels by the time the surgical incision is made.
SCIP Infection-2 (SCIP Inf-2)
Prophylactic Antibiotic Selection for Surgical Patients The purpose is to ensure that prophylactic antibiotics are used for patients who are at increased risk for surgical site infections. The guidelines for risk and for the exact antibiotic to be used are specific to each type of surgical procedure and follow evidence-based published recommendations.
SCIP Infection-3 (SCIP Inf-3)
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time The purpose is to ensure that prophylactic antibiotic therapy provides benefit without risk. Prolonged prophylactic antibiotic therapy has not been shown to increase benefit and is known to increase the risk for C. difficile infection and the development of microorganisms that are resistant to antimicrobial drugs.
SCIP Venous thromboembolism-2 (SCIP VTE-2)
Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery The purpose is to reduce the complications from postoperative venous thromboembolism (VTE), particularly among patients undergoing the types of surgeries in which the risk is highest.
SCIP CARD-2
Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period The purpose is to ensure that patients with specific medical conditions receive beta-blocker therapy before surgery and continue the therapy in the immediate postoperative period. This evidence-based action has resulted in a significant reduction in coronary events, cardiovascular mortality, and overall mortality.
SCIP Infection-6 (Inf-6)
Surgery Patients with Appropriate Hair Removal The purpose is to avoid hair removal procedures, specifically shaving, that cause skin abrasions & increase the risk for surgical site infections. If hair must be removed from the surgical site, removal is performed with electric clippers or chemical depilatories.
SCIP Infection-10 (SCIP Inf-10)
Surgery Patients with Perioperative Temperature Management The purpose is to prevent prolonged hypothermia, which is associated with impaired wound healing, serious cardiac complications, altered drug metabolism, coagulation problems, and a higher incidence of surgical site infections. Temperature must be measured within 15 minutes from the end of anesthesia administration. Intentional hypothermia must be documented.
SCIP Venous thromboembolism-1 (SCIP VTE-1)
Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered The purpose is to reduce the complications from postoperative venous thromboembolism (VTE). Surgery is a major risk factor responsible for VTE formation and subsequent pulmonary embolism. Although VTE prophylaxis is effective, it is underused. Specific preoperative and postoperative VTE prophylaxis strategies are recommended on the basis of patient risk, type and duration of surgery, and extent of expected postoperative immobilization.
Surgical Consent
Surgery of any type involves invasion of the body and requires informed consent from the patient or legal guardian
What is the nurse's responsibility in the surgical consent?
The nurse is responsible to witness that 1) the patient was actually the one who signed the consent and that 2) the patient was competent to sign the consent at the time it was signed (e.g. not under the influence at the time).
Skin Preparation
The skin is the body's first line of defense against infection. A break in this barrier increases the risk for infection. Skin preparation before surgery is the first step to reduce the risk for surgical site infection. One or two days before the scheduled surgery, the surgeon may ask the patient to shower using an antiseptic solution (e.g. chlorhexidine gluconate (CHG) cloths). If the patient is hospitalized before surgery, showering and cleaning are repeated the night before surgery or in the morning before transfer to the surgical suite. This cleaning reduces contamination of the surgical field and reduces the number of organisms at the site.
Surgical Department Layout
The surgery department is a controlled environment designed to minimize the spread of pathogens & allows a smooth flow of patients, staff, & equipment Divided into 3 Areas: - Unrestricted - Semirestricted - Restricted
What does perioperative mean?
The term perioperative includes: - preoperative phase - intraoperative phase - postoperative phase
Don't Skip the SCIP
Therefore, the Joint Commission (TJC) has collaborated with other groups and agencies and developed a plan for the reduction and eventual elimination of preventable surgical complications known as the Surgical Care Improvement Project (SCIP). Implementation of these core measures is now mandatory for patient safety. The current plan focuses on 1) infection prevention, 2) prevention of serious cardiac events, and 3) prevention of venous thromboembolism (VTE) (also known as deep vein thrombosis [DVT]).
SCIP Infection-9 (SCIP Inf-9)
Urinary Catheter Removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with Day of Surgery Being Day Zero The purpose is to avoid urinary catheter-associated urinary tract infections, which increase with longer duration indwelling catheters. It is unacceptable to have an indwelling urinary catheter in place longer than 48 hours after surgery unless there is a documented specific and medically validated reason for it
Surgeon's Assistant
Usually holds the retractors to expose surgical areas & helps with hemostasis & suturing May be another physician, a registered nurse first assistant (RNFA), physician's assistant (PA), or surgical resident or fellow
Postoperative Phase
after surgery nursing care delivered in the post-anesthesia care unit (PACU); prior to transfer to the inpatient unit or discharge home
Preoperative Phase
before surgery patient is in the pre-op area
Intraoperative Phase
during surgery patient is in the operating room
When is preparation for post-op started?
in Pre-Operative Provide patient education prior to surgery about post-operative procedures to prevent respiratory complications (i.e. cough, turn, deep breath, IS) and cardiovascular complications (i.e. ankle exercise, early mobility to prevent DVT)
General Anesthesia
loss of consciousness, sensation, & skeletal muscle relaxation requires advanced airway management (intubation w/ mechanical ventilation) administered by ACP
Regional Anesthesia
loss of sensation to region of body without loss of consciousness Example: epidural anesthesia in child birth
Simple Surgery
only the most overtly affected areas involved in the surgery
Monitored Anesthesia Care (MAC)
patient less responsive & may need some airway management Ex: endoscopy or colonoscopy
Cosmetic Surgery
performed primarily to alter or enhance personal appearance
Diagnostic Surgery
performed to determine the origin & cause of a disorder or the cell type for cancer
Restorative Surgery
performed to improve a patient's functional ability
Anesthesia Care Provider (ACP)
person responsible for administering anesthetic agents during the procedure & managing vital life functions (ie: breathing, blood pressure, etc) during the perioperative period May be an anesthesiologist or nurse anesthetist (CRNA)
Scrub Nurse
prepares and manages the sterile field and instrumentation
Outpatient/Ambulatory
refers to a patient who goes to the surgical area the day of the surgery and returns home on the same day (same-day surgery) Hospital based ambulatory surgical centers, freestanding surgical centers, physicians' offices, & ambulatory care centers are common. More than half of all surgical procedures in N. America are performed in ambulatory centers (Ambulatory Surgery Center Association, 2013).
Inpatient
refers to a patient who is admitted to a hospital The patient may be admitted the day before or more often, the day of surgery (same-day admission [SDA]), or the patient may already be an inpatient when surgery is needed
Emergent Surgery
requires immediate intervention because of life-threatening consequences
Urgent Surgery
requires prompt intervention; may be life threatening if treatment is delayed more than 24-48 hr
Cosmetic Surgery Examples
rhinoplasty for cosmetic reason
Simple Surgery Examples
simple/partial matectomy
Minimally Invasive Surgery (MIS)
surgery performed in a body cavity or body area through one or more endoscopes - can correct problems, remove organs, take tissue for biopsy, re-route blood vessels & drainage systems; - is a fast-growing type of surgery
Surgeon
the physician who does the surgical procedure Primarily responsible for the preoperative medical history and physical assessment, ordering pre-op tests, obtaining informed consent, and leading the surgical team during the procedure.
Who is responsible for explaining the procedure to the patient and answer any questions the patient has?
the surgeon
Restorative Surgery Examples
total knee replacement
Moderate Sedation
used for procedures done outside of the OR (ie: reduction of fracture in ER) Patient remains awake & breathes independently Does NOT require an anesthesiologist
Unrestricted Area of the Surgical Department
where people in street clothes interact with those in scrub attire. These areas typically include the point of entry for patients (e.g. pre-op holding area), staff locker rooms, and nurses station.
