LEARNING OBJECTIVE: Evaluate the needs of a surgical patient during the preoperative, operative, recovery, and postoperative phases of his treatment.
Surgical procedures are classified into two major categories: emergency and elective. Emergency surgery is that required immediately to save a life or maintain a necessary function. Elective surgery is that which, in most cases, needs to be done but can be scheduled at a time beneficial to both the patient and the provider. Regardless of the type of surgery, every surgical patient requires specialized care at each of four phases. These phases are classified as preoperative, operative, recovery, and postoperative. The following discussion will address the basic concepts of care in each phase.
Before undergoing a surgical procedure, the patient must be in the best possible psychological, spiritual, and physical condition. Psychological preparation begins the moment the patient learns of the necessity of the operation. The physician is responsible for explaining the surgical procedure to the patient, including the events that can be expected after the procedure. Since other staff personnel reinforce the physician’s explanation, all members of the team must know what the physician has told the patient. In this manner, they are better able to answer the patient’s questions. All patients approaching surgery are fearful and anxious. The staff can assist in reducing this fear by instilling confidence in the patient regarding the competence of those providing care. The patient should be given the opportunity and freedom to express any feelings or fears concerning the proposed procedure. Even in an emergency, it is possible to give a patient and the family psychological support. Often this is accomplished simply by the confident and skillful manner in which the administrative and physical preoperative preparation is performed.
The fears of pre-surgical patients derive from their insecurities in the areas of anesthesia, body disfigurement, pain, and even death. Frequently, religious faith is a source of strength and courage for these patients. If a patient expresses a desire to see a clergyman, every attempt should be made to arrange a visit.
ADMINISTRATIVE PREPARATION.— Except in emergencies, the administrative preparation usually begins before surgery. A step-by-step procedure is outlined in Fundamental Skills and Concepts in Patient Care, “Caring for the Patient Undergoing Surgery.” Only the Request for Administration of Anesthesia and for Performance of Operations and Other Procedures (SF 522) will be addressed here. The SF 522 identifies the operation or procedure to be performed; has a statement written for the patient indicating in lay terms a description of the procedure; and includes the signatures of the physician, patient, and a staff member who serves as a witness. An SF 522 must be completed before any preoperative medications are administered. If the patient is not capable of signing the document, a parent, legal guardian, or spouse may sign it. It is customary to require the signature of a parent or legal guardian if the patient is under 21 years of age, unless the patient is married or a member of the Armed Forces. In these latter two cases, the patient may sign his own permit, regardless of age.
Normally, the physical preparation of the patient begins in the late afternoon or early evening the day before surgery. As with the administrative preparation, each step is clearly outlined in Fundamental Skills and Concepts in Patient Care, “Caring for the Patient Undergoing Surgery.”
PREOPERATIVE INSTRUCTIONS.— Preoperative instructions are an important part of the total preparation. The exact time that preoperative teaching should be initiated greatly depends upon the individual patient and the type of surgical procedure. Most experts recommend that preoperative instructions be given as close as possible to the time of surgery. Appropriate preoperative instructions given in sufficient detail and at the proper time greatly reduce operative and postoperative complications.
The operative (or intra-operative) phase begins the moment the patient is taken into the operating room.
Two of the major factors to consider at this phase are positioning and anesthesia.
POSITIONING.—The specific surgical procedure will dictate the general position of the patient. For example, the lithotomy position is used for a vaginal hysterectomy, while the dorsal recumbent position is used for a herniorrhaphy. Regardless of the specific position the patient is placed in, there are some general patient safety guidelines that must be observed. When positioning a patient on the operating table, remember the following:
- Whether the patient is awake or asleep, place the patient in as comfortable a position as possible.
- Strap the patient to the table in a manner that allows for adequate exposure of the operative site and is secure enough to prevent the patient from falling, but that does not cut off circulation or contribute to nerve damage.
- Secure all the patient’s extremities in a manner that will prevent them from dangling over the side of the table.
- Pad all bony prominences to prevent the development of pressure areas or nerve damage.
- Make sure the patient is adequately grounded to avoid burns or electrical shock to either the patient or the surgical team.
ANESTHESIA.—One of the greatest contributions to medical science was the introduction of anesthesia. It relieves unnecessary pain and increases the potential and scope of many kinds of surgical procedures. Therefore, healthcare providers must understand the nature of anesthetic agents and their effect on the human body.
Anesthesia may be defined as a loss of sensation that makes a person insensible to pain, with or without loss of consciousness. Some specific anesthetic agents are discussed in the “Pharmacy” chapter of this manual. Healthcare providers must understand the basics of anesthesiology as well as a specific drug’s usage.
The two major classifications of anesthesia are regional and general.
Regional Anesthesia.—Regional anesthetics reduce all painful sensations in a particular area of the body without causing unconsciousness. The following is a listing of the various methods and a brief description of each.
- Topical anesthesia is administered topically to desensitize a small area of the body for a very short period.
- Local blocks consist of the subcutaneous infiltration of a small area of the body with a desensitizing agent. Local anesthesia generally lasts a little longer than topical.
- Nerve blocks consist of injecting the agent into the region of a nerve trunk or other large nerve branches. This form of anesthesia blocks all impulses to and from the injected nerves.
- Spinal anesthesia consists of injecting the agent into the subarachnoid space of the spinal canal between the third and fourth lumbar space or between the fifth lumbar and first sacral space of the spinal column. This form of anesthesia blocks all impulses to and from the entire area below the point of insertion, provided the patient’s position is not changed following injection of the agent. If the patient’s position is changed, for example, from dorsal recumbent to Trendelenburg’s, the anesthetic agent will move up the spinal column and the level of the anesthesia will also move up. Because of this reaction, care must be exercised in positioning the patient’s head and chest above the level of insertion to prevent paralysis (by anesthesia) of the respiratory muscles. In general, spinal anesthesia is considered the safest for most routine major surgery.
- Epidural blocks consist of injecting the agent into the epidural space of the spinal canal at any level of the spinal column. The area of anesthesia obtained is similar to that of the subarachnoid spinal method. The epidural method is frequently used when continuous anesthesia is desired for a prolonged period. In these cases, a catheter is inserted into the epidural space through a spinal needle. The needle is removed, but the catheter is left in place. This provides for continuous access to the epidural space.
- Saddle blocks consist of injecting the agent into the dural sac at the third and fourth lumbar space. This form of anesthesia blocks all impulses to and from the perineal area of the body.
- Caudal blocks consist of injecting the agent into the sacral canal. With this method, anesthesia is obtained from the umbilicus to the toes.
General Anesthesia.—General anesthetics cause total loss of sensation and complete loss of consciousness in the patient. They are administered by inhalation of certain gases or vaporized liquids, intravenous infusion, or rectal induction. The induction of inhalation anesthesia is divided into four stages. These stages and the body’s main physiological reaction in each phase are explained below and depicted in figure 2–1.
Figure 2–1.—Stages of anesthesia.
For purposes of this discussion, the recovery phase consists of the period that begins at the completion of the operation and extends until the patient has recovered from anesthesia. The recovery phase generally takes place in a specialized area called the recovery room. This unit is usually located near the operating room and has access to the following:
From the time of admission to patient discharge, routine care in the recovery room consists of the following:
After the patient’s condition has been stabilized in the recovery room, a physician will order the patient’s transfer to another area of the facility. Generally, this transfer is to the unit that the patient was assigned to preoperatively. Since both surgery and anesthesia have unavoidable temporary ill effects on normal physiological functions, every effort must be made to prevent postoperative complications.
POSTOPERATIVE GOALS.—From the time the patient is admitted to the recovery room to the time recovery from the operation is complete, there are definite goals of care that guide the entire postoperative course. These goals are as follows:
- Promoting respiratory function
- Promoting cardiovascular function
- Promoting renal function
- Promoting nutrition and elimination
- Promoting fluid and electrolyte balance
- Promoting wound healing
- Encouraging rest and comfort
- Encouraging movement and ambulation
- Preventing postoperative complications
The physician will write orders for postoperative care that are directed at accomplishing the above goals. Although the orders will be based on each individual patient’s needs, there will be some common orders that apply to all patients. These orders will center around the promotion of certain physiological functions and areas addressed in the following paragraphs.
Respiratory function is promoted by encouraging frequent coughing and deep breathing. Early movement and ambulation also help improve respiratory function. For some patients, oxygen therapy may also be ordered to assist respiratory function. Cardiovascular function is assisted by frequent position changes, early movement and ambulation, and, in some cases, intravenous therapy. Renal function is promoted by adequate fluid intake and early movement and ambulation. Nutritional status is promoted by ensuring adequate oral and correct intravenous intake and by maintaining accurate intake and output records. Elimination functions are promoted by adequate diet and fluid intake. Postoperative patients should be advanced to a normal dietary regimen as soon as possible, since this, too, promotes elimination functions. Early movement and ambulation also help to restore normal elimination activities.
In addition to various medications and dressing change procedures ordered by the physician, wound healing is promoted by good nutritional intake and by early movement and ambulation. Rest and comfort are supported by properly positioning the patient, providing a restful environment, encouraging good basic hygiene measures, ensuring optimal bladder and bowel output, and promptly administering pain-relieving medications. Early movement and ambulation are assisted by ensuring maximum comfort for the patient and providing the encouragement and support for ambulating the patient, particularly in the early postoperative period. As indicated in the above discussion, the value of early movement and ambulation, when permissible, cannot be overemphasized.
POSTOPERATIVE COMPLICATIONS.— During the early postoperative phase, the major complications to be guarded against are respiratory obstruction, shock, and hemorrhage. As the patient progresses in the postoperative period, other complications to avoid are the development of pneumonia, phlebitis and subsequent thrombophlebitis, gastrointestinal problems ranging from abdominal distention to intestinal obstruction, and, finally, wound infections. Accurate implementation of the physician’s orders and careful observation, reporting, and recording of the patient’s condition will contribute markedly to an optimal and timely postoperative recovery course for the patient.