References:
- Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, 11th Edition, ISBN 9780135428733, by Audrey Berman, Shirlee J. Snyder, and Geralyn Frandsen (Ch. 37, pp. 957)
Surgery is a unique experience of a planned physical alteration encompassing three phases: preoperative, intraoperative, and postoperative. These three phases are together referred to as the perioperative period. Perioperative nursing is the delivery of nursing care through the framework of the nursing process. It also includes collaborating with members of the healthcare team, making nursing referrals, and delegating and supervising nursing care.
Types of Surgery
Surgical procedures are commonly grouped according to (a) purpose, (b) degree of urgency, and (c) degree of risk.
Purpose
| Type | Definition |
|---|---|
| Diagnostic | Confirms or establishes a diagnosis; for example, biopsy of a mass in a breast. |
| Palliative | Relieves or reduces pain or a symptom of a disease; it does not cure; for example, resection of nerve rots. |
| Ablative | Removes a diseased body part; for example, removal of a gallbladder (cholecystectomy). |
| Constructive | Restores function or appearance that has been lost or reduced; for example, cleft palate repair. |
| Transplant | Replaces malfunctioning structures; for example, kidney transplant. |
Degree of Urgency
Surgery is classified by its urgency and necessity to preserve the client’s life, body part, or body function.
- Emergency surgery is performed immediately to preserve function or the life of the client. Surgeries to control internal hemorrhage or repair a fracture are examples of emergency surgeries.
- Elective surgery is performed when surgical intervention is the preferred treatment for a condition that is not immediately life threatening (but may ultimately threaten life or well-being), or to improve the client’s life. Examples of elective surgeries include cholecystectomy for chronic gallbladder disease, hip replacement surgery, and plastic surgery procedures such as breast reduction.
Degree of Risk
Surgery is also classified as major or minor according to degree of risk to the client.
- Major surgery involves a high degree of risk, for a variety of reasons: It may be complicated or prolonged, large losses of blood may occur, vital organs may be involved, or postoperative complications may be likely. Examples are organ transplant, open heart surgery, and removal of a kidney.
- Minor surgery involves a little risk, produces few complications, and is often performed in an outpatient setting. Examples are breast biopsy, removal of tonsils, and cataract extraction.
Factors Affecting the Degree of Risk
- Age: children and older adults have fewer physiologic reserves to meet the extra demands caused by surgery.
- Neonates and infants have a higher metabolic rate, smaller blood volume, limited fluid reserves, large body surface area (heat loss), immature thermoregulation, and altered pharmacodynamics.
- Toddlers and older children are better able to withstand surgery physiologically, but often fear separation from their parents, strangers, bodily injury, mutilation, and death.
- Older adults have a lower percentage of body water, decreased kidney function, decreased thirst response, greater risk for fluid and electrolyte imbalance, changes in liver function, declines in sensory function, and even the presence of poor nutrition, dementia, and other chronic diseases.
- General Health: surgery is least risky when the client’s general health is good. Any infection or pathophysiology increases the risk.
- Respiratory function in particular is of importance—anesthetics used during surgery often affect respiratory status.
- Malnutrition can lead to delayed wound healing, infection, and reduced energy. Protein and vitamins are needed for wound healing; vitamin K is essential for blood clotting.
- Obesity leads to hypertension, impaired cardiac function, and impaired respiratory ventilation. It may also produce delayed wound healing and wound infection.
- Cardiac conditions weaken the heart’s ability to supply the body’s needs.
- Blood coagulation disorders may lead to severe bleeding, hemorrhage, and subsequent shock.
- Upper respiratory tract infection or chronic obstructive pulmonary disease adversely affect pulmonary function, especially when exacerbated by the effects of general anesthesia. They also predispose the client to postoperative lung infections.
- Renal disease impairs regulation of the body’s fluids and electrolytes and excretion of drugs and other toxins.
- Diabetes mellitus predisposes the client to wound infection and delayed healing.
- Liver disease (e.g., cirrhosis) impairs the liver’s abilities to detoxify medications used during surgery, produce the prothrombin necessary for blood clotting, and metabolize nutrients essential for healing.
- Uncontrolled neurologic disease such as epilepsy may result in seizures during surgery or recovery.
- Nutritional Status: Adequate nutrition is required for normal tissue repair. Surgery increases the body’s need for nutrients that help with the tissue healing and prevention of infection required during the postoperative period. Obesity and malnutrition increases surgical risk.
- Obesity contributes to postoperative complications such as pneumonia, wound infections, and wound separation.
- Both clients with obesity and those who are underweight are vulnerable to perioperative pressure injuries due to the positioning required for surgery.
- Vitamin A: promotes epithelialization and enhances collagen synthesis
- Vitamin B complex: cofactor of the enzyme system
- Vitamin C (ascorbic acid): Essential for collagen synthesis affecting wound tensile strength
- Vitamin K: Essential in the synthesis of prothrombin and thus coagulation
- Iron, zinc, and copper: Involved in collagen synthesis
- Obstructive Sleep Apnea: Partial or complete obstruction of the upper airway during sleep briefly interrupts breathing, lasting at least 10 seconds. Many diagnosed with OSA go undiagnosed. Patients with OSA have been shown to be at increased risk for perioperative complications.
- The STOP-Bang Questionnaire is a screening test for OSA, which is diagnosed by polysomnography (an often expensive sleep study). STOP-Bang is a mnemonic for Snores, Tired during the day, Observed apnea during sleep, Body mass index, Age, Neck circumference, and Gender.
- Medications can increase surgical risk. Examples include:
- Anticoagulants enhance bleeding by increasing blood coagulation time.
- Tranquilizers can interact with anesthetics, increasing risk for anesthesia-related complications.
- Corticosteroids may interfere with wound healing and increase infection risks.
- Diuretics may disrupt fluid and electrolyte balance.
- Mental Status: Disorders that affect cognitive function, such as mental illness, intellectual disability, or developmental delay, affect the client’s ability to understand and cope with the stresses of surgery.
- Some disorders may require medications such as anticonvulsants and antipsychotics. These may also interact with anesthetic and analgesic agents.
- Dementia can make understanding proposed surgical procedures difficult. Confusion, disorientation, and agitation may be worsened by the change of environment in the hospital, and interfere with the patient’s ability to cooperate with care.
- Extreme anxiety can increase surgical risk by interfering with the patient’s ability to process information and respond correctly o instructions. Professional counseling may become advisable.
Preoperative Phase
Preoperative Consent
Prior to any surgical procedure, informed consent is required from the client or legal guardian. Informed consent implies that the client has been informed and involved in decisions affecting his or her health. The surgical consent form, provided by the health-care facility where the surgery will be performed, protects the client from incorrect or unwanted procedures and the surgeon and facility from litigation related to unauthorized surgeries or uninformed clients.
- The surgeon is responsible for obtaining the informed consent by following information to the client or legal guardian:
- The nature of and the reason for the surgery
- All available options and the risks associated with each option
- The risks of the surgical procedure and its potential outcomes
- Name and qualifications of the surgeon performing the procedure
- The right to refuse consent or later withdraw consent
- The surgeon documents the informed consent conversation with the client or legal guardian in the preoperative progress note.
- This consent form becomes part of the client’s medical record and goes to the operating room (OR) with the client. The RN ensures consent is in the client’s chart prior to releasing the client to surgery.
- Although the surgeon maintains legal responsibility for ensuring that the client has given informed consent, the nurse may witness the client’s signature on the consent form. In doing so, the nurse ensures that the consent form is signed and serves as a witness to the signature, not to the fact that the client is informed.
- If the nurse assesses that the client does not understand the procedure to be performed, the surgeon is contacted and requested to speak with the client before surgery can proceed.
- Informed consent is only possible when the client understands the provided information, that is, speaks the language and is conscious, mentally competent, and not sedated. A minor may not give informed consent. Specific guidelines regarding consent for minors vary among countries.
Nursing Management
Preoperative assessment includes collecting and reviewing physical, psychologic, and social client data to determine the client’s needs throughout the three perioperative phases.
- The client’s mobility and ability to function should also be assessed in the preoperative phase. The perioperative nurse collects the data by interviewing the client in the presurgical care unit or by telephone prior to the day of surgery. When data cannot be collected directly, the perioperative nurse uses other data sources such as the nursing admission assessment. Although forms vary considerably among agencies, the following are essential preoperative information that should be included:
- Current health status: general health status, chronic disease, physical limitations, and prostheses
- Allergies: drugs, food, tape, latex, soaps, antiseptic agents
- Medications. All current and recent medications both prescription and nonprescription drugs, supplements, and herbs. Some medications may need to be maintained at a certain blood level throughout the surgery, such as anticonvulsants. Some, like anticoagulants and aspirin, increase surgical risk.
- Previous surgeries
- Mental status
- Understanding of the surgical procedure and anesthesia
- Smoking
- Obstructive sleep apnea
- Alcohol and other mind-altering substances
- Coping
- Social resources
- Cultural and spiritual considerations