Perioperative Nursing Care: Phases, Complications, and Management

Key Risk Factors: Patients at higher risk for complications include those with advanced age, obesity, malnutrition, dehydration, electrolyte imbalances, diabetes, or renal/liver dysfunction.

Nursing Responsibilities: Education and Physical Prep

Nursing interventions in this phase aim to reduce anxiety and prepare the body for the stress of surgery.

Psychological Support: Use therapeutic communication to relieve anxiety and fear, but avoid providing false reassurance.

Preoperative Education: Teaching patients how to manage their recovery before they enter surgery improves outcomes. Key topics include:

• Respiratory Care: Deep breathing exercises, coughing, and the use of an incentive spirometer (e.g., Voldyne).
• Incisional Care: Teaching the patient to splint the incision with a pillow while coughing to prevent pain and dehiscence.
• Mobility: Leg exercises and the use of Sequential Compression Devices (SCDs).

Physical Preparation: This is guided by physician orders and hospital policy. It includes skin cleansing with antimicrobial solutions (like chlorhexidine), ensuring the patient has voided or has a catheter, and hair removal via clipping rather than shaving to minimize skin trauma.

Pharmacology: Common preoperative medications include:

• Sedatives (e.g., diazepam, lorazepam) to alleviate anxiety.
• Anticholinergics (e.g., atropine) to decrease secretions and prevent laryngospasms.
• Opioid agonists (e.g., morphine, fentanyl) for sedation and relaxation.
• Antihistamines (e.g., cimetidine) to decrease gastric acid.

Intraoperative Nursing Functions

Once the patient is in the operating room, the nurse often functions as a circulating nurse. Responsibilities include managing equipment (cardiac monitors, pulse oximeters, warming devices), ensuring IV lines are attached, and introducing the staff to the patient.

Prevention of Surgical Site Infections (SSI)

Preventing infection is a multi-phase effort:

• Before Surgery: Patient education, chlorhexidine showers, and clipping hair instead of shaving.
• During Surgery: Minimizing OR traffic, maintaining normal body temperature, controlling blood glucose, and ensuring correct timing of antibiotic administration.
• After Surgery: Removing catheters as soon as possible and practicing strict hand hygiene.

Postoperative Care and Complications

Monitoring Physiological Stability

Postoperative nursing care focuses on the return of homeostasis across multiple systems:

• Cardiovascular: Monitor vital signs, electrolytes, and ECG. Note that tachycardia is an early sign of shock.
• Respiratory: Assess oxygenation via pulse oximetry, breath sounds, and respiratory rate.
• Fluid Status: Monitor skin turgor, urine output, and wound drainage.
• Neurological: Monitor for the return of consciousness.

Managing Respiratory Complications

Postoperative patients are at risk for several respiratory issues:

1. Atelectasis: Collapse of alveoli due to retained mucus. Signs include diminished lung sounds and dyspnea. Intervention: Activity, positioning, and incentive spirometry.
2. Pneumonia: Inflammation or infection of the alveoli. Signs include fever, chills, and productive cough. Intervention: Antibiotics and elevated head of bed (30 degrees).
3. Pulmonary Embolism (PE): A life-threatening blood clot in the lungs. Signs include sudden dyspnea, chest pain, and tachycardia. Intervention: Notify the physician immediately and apply oxygen.

Wound Complications and Healing

Nurses must monitor the incision for:

• Dehiscence: The separation of the layers of the incisional wound.
• Evisceration: The protrusion of body organs through a dehisced wound.

Clinical Tip: Surgical dressings usually remain intact for the first 24 hours. If a dressing becomes saturated with blood, the nurse should reinforce it and notify the surgeon.

Other Critical Complications

• Hemorrhage and Shock: Excessive blood loss can lead to hypovolemic shock (inadequate organ perfusion due to low blood volume). Signs include hypotension, increased pulse, and cold, clammy skin.
• Deep Vein Thrombosis (DVT): Inflammation of a vein associated with a clot, common in the legs. Signs include calf pain, redness, and swelling.
• Nutrition Issues: Inadequate nutrition slows wound healing. Diet progression (from NPO to clear liquids to solids) should be based on the return of GI function, such as the presence of bowel sounds and the passing of flatus.

Clinical Tool: ABG Interpretation

Postoperative patients may experience acid-base imbalances. When interpreting Arterial Blood Gases (ABGs), use the ROME mnemonic:

• Respiratory Opposite: pH and $PaCO_2$ move in opposite directions.
  • If pH is low ($\downarrow$) and $PaCO_2$ is high ($\uparrow$), it is Respiratory Acidosis.
  • If pH is high ($\uparrow$) and $PaCO_2$ is low ($\downarrow$), it is Respiratory Alkalosis.
• Metabolic Equal: pH and $HCO_3$ move in the same direction.
  • If pH is low ($\downarrow$) and $HCO_3$ is low ($\downarrow$), it is Metabolic Acidosis.
  • If pH is high ($\uparrow$) and $HCO_3$ is high ($\uparrow$), it is Metabolic Alkalosis.

Normal Reference Values:

• pH: 7.35 – 7.45
• $PaCO_2$: 35 – 45 mmHg
• $HCO_3$: 22 – 26 mEq/L
• $SaO_2$: 92 – 100%