Perioperative Nursing Care in Critical Care ICU. Legal aspect of ICU nurse, Checklist, Process of Peri-operative period, PACU

1. Dr. Sudhir Khunteta
MD, FCCM, FICCM
Director & Chief Intensivist
SHUBH HOSPITAL
A-35, Vidhyut Nagar
Jaipur- Rajasthan –India
drkhunteta@gmail.com

2.  Define Phases of Perioperative Care
 Describe the scope of Periopeartive Nurse
practice
 Identify members of Team and Role of team
members with special reference to nurse.
 Responsibilty of Periopeartive Nurse

3.  In 1956
 The Association of Operating Room Nurses (AORN)
was formed, to gain knowledge of surgical principles
and explore methods to improve nursing care of
surgical patients.
 The organization is now known as the Association of
periOperative Registered Nurses;

4. Surgery and Complications
• over 230 million surgical procedures
performed annually around the globe
• Interestingly, up to 4% of noncardiac surgery
patients may die and more develop
postoperative Complications.
• Even in groups with a low mortality rate, the
rate of postoperative complications is rather
high with Major surgery

5. A large study showed that
 Lowest frequency of calls occurred between
1:00 AM to 6:59 AM time period.
 The mortality was highest around 7 AM & lowest
during noon hour.
 This indicates that not simply the availability of
such a team makes a difference but also the
alertness of the team is of high importance to
identify deteriorating patients in a timely manner.
 You should not only be alert but able to better
recognize when patients become sicker
and avoid a delayed call.

6. Peri-opeartive Care includes
 1. Pre-Operative Phase
 2. Intra-operative phase
 3. Post operative Care

7. The Preoperative Phase
 begins when the decision for surgical intervention is
made and
 ends when the patient is transferred to the operating
room.

8. Intraoperative Phase
 Begins when the patient is admitted or transferred to
the surgical Area or O. R.
 Ends when he or she is admitted to the recovery
area.

9. Postoperative Phase
 Begins with the admission of the patient to the
recovery area /PACU/ ICU and
 Ends with a follow-up evaluation in the clinical
setting or at home.

10. Study Size : 88,504 surgical patients,
Co-morbidity caused higher hospital mortality
Age (odds ratio (OR) 1.42 per 10 years of age),
Urgency of operation (2.02 for emergency V/S elective),
Thoracic Diseases (OR 1.81),
Cardiovascular (OR 1.25),
Trauma (OR 1.22)
Gastrointestinal surgery (OR 1.71)
Acute kidney injury (OR 1.88)
Pre-existing chronic renal (OR 1.40),
Respiratory (OR 1.20)
Cirrhosis (OR 2.50),
Alcoholism (OR 1.42),
Non-metastatic cancer (OR 1.20)

11.  A modern multidisciplinary critical care team
consists at least of :
An Intensivist,
ICU nurse,
Respiratory therapist & physiotherapist,
Primary team physician.
Based on clinical needs, Inclusion of
oncologists, cardiologists, Pulmonologist, or other
specialties.

12. PURPOSE of Perioperative
Care
 The purpose of a monitoring system is not to
treat but to provide clinical information that
may impact medical decision making and
Improve Surgical Outcome.

13. PURPOSE of Perioperative
Care
 Monitoring will not prevent all adverse
incidents in the perioperative period, it reduces
the risks of accidents by permitting the
continuous recording of core data.
 Monitoring facilitates the detection of the
consequences of human errors, while alerting
physicians that a patient’s condition is
deteriorating for other reasons.

14. The Preoperative Phase
 begins when the decision for surgical intervention is
made and
 ends when the patient is transferred from the
operating room.

15. Pre-operative Phase
 Pre-operative Assessment
 Preoperative History and Clinical profile
 Completion of preoperative Diagnostic
studies.
 Preparing the patient for the anesthetic to be
given
 Preparing the patient for surgery.
 Understanding of surgeon or Surgery-specific
preoperative orders (e.g. bowel preparation,
preoperative shower)
 Assess patient’s need for post-operative
transportation and care.

16.  To identify high-risk individuals and Suggest
treatment strategies that may reduce morbidity and
mortality.
 Assessment of perioperative :
 Assessment of baseline physical status,
 functional reserve of organ systems,
 co-morbid conditions, and their severity
 Co-morbid optimization, and
 Surgery-specific risk.

17. Pre-op Assessment : why
• Proper, adequate, preoperative assessment
should be made of patients’ general health,
and function.
• For patients with compromising disease a
more in depth assessment and optimisation
may reduce the perioperative Morbidity and
Mortality

18. What is to be done: Assessment
Factors may increase surgical risk.
• Assessment of physiological conditions
• Assessing and correcting/ controlling Existing
diseases
• Assessment of psychological problems

19. Physiologic Assessments
in preoperative phase:
• Age
• History: Esp. for IHD, CVA, TB, DMT2, Respiratory disorder, bleeding
disorders etc.
• Allergy History and Immunologic Status/ immunosuppressant use
• Physical examination : vital signs and usual systemic examinations
• Assess usual level of functioning to assist-patient’s care and
rehabilitation plans.
• Assess mouth for dentures, or dental prostheses- note of it
(intubation)
• Nutritional status : Obesity greatly increases the risk and severity of
complications associated with surgery. Record height and weight,
triceps skinfold, serum protein levels and nitrogen balance.
• Fluid and Electrolyte Imbalance – Dehydration, hypovolemia and
electrolyte imbalances : Assess and Correction
• Infection : Preexisting can flare, HIV/ HBsAg/ UTI etc

20. Physiologic Assessments (contd)
in preoperative phase
• Previous Drug history and alcohol use.
• Respiratory status
– Pre-existing pulmonary problems/ Infection
– Pulmonary function studies and blood gas analysis
– Extent of respiratory insufficiency.
• Cardiovascular status –
– Cardiovascular diseases increases the risk of complications.
– If required : medical treatment to improve the patient’s condition.
• Hepatic and renal function –
– Surgery is relatively contraindicated : Acute nephritis, acute renal
insufficiency with oliguria or anuria, or other acute renal problems.
– Hepatic disease : Anesthetic agent metabolism. Choice of agent

21. Physiologic Assessments (contd)
in preoperative phase:
• Presence of trauma: assess
• Endocrine function –
– Diabetes, Controlled status, use of drugs/ insulin
– Corticosteroid intake,
– Hypothyroidism correction
• Immunologic function – Allergies,
Sensitivities to certain medications,
Past adverse reactions to drugs,
Immunosuppression

22. Previous medication therapy
• –The medications that cause particular concern during the
upcoming surgery:
– Adrenal corticosteroids – not to be discontinued abruptly before the
surgery. Once discontinued suddenly, cardiovascular collapse may
result for patients who are taking steroids for a long time. A bolus of
steroid is then administered IV immediately before and after surgery.
– Diuretics – thiazide diuretics may cause excessive
respiratory depression during the anesthesia administration.
– Phenothiazines – increase the hypotensive action of anesthetics.
– Antidepressants – MAOIs increase the hypotensive effects of
anesthetics.
– Tranquilizers – medications such as barbiturates, diazepam and
chlordiazepoxide may cause an increase anxiety, tension and even
seizures if withdrawn suddenly.
– Insulin – Interaction between anesthetics and insulin must be
considered.
– Antibiotics – “Mycin” drugs such as neomycin, kanamycin, may
present problems when combined with curariform muscle relaxant. As
a result nerve transmission is interrupted and apnea due to respiratory
paralysis develops.

23. Psychological Assessment
• Psychological nursing assessment during the
preoperative period:
• Fear of the unknown
• Fear of pain
• Fear of death
• Fear of anesthesia
• Concerns about loss of work, time, job and
support from the family
• Concerns on threat of permanent incapacity
• Spiritual beliefs
• Cultural values and beliefs

24. What is to be done: Pre-op Learning
• Learning and teaching guidelines regarding
the surgery.
• Instructing and demonstrating exercises that
will benefit postoperatively.
• Life Style Modifications: Any projected
changes in lifestyle due to the surgery.

25. CONSENT
 Informed consent
 Reinforce information provided by surgeon.
 Ascertain that the consent form has been signed
 Informed consent is required for All types of Surgeries,
invasive procedures, such as
Incisional biopsy, Cystoscopy, or paracentesis;
 Procedures requiring sedation and/or anesthesia;
 Procedures involving radiation.
 Arrange for a responsible family member or legal
guardian to be available to give consent when the patient
is a minor or is unconscious or incompetent.
 Preserve the signed consent form.

26. Nursing interventions
And
Optimization

27. Nursing Interventions: What you
should do :Reducing Anxiety and Fear
• Provide psychosocial support.
• Be empathetic, and help alleviate concerns.
• Acknowledge patient concerns or worries about
impending surgery by listening and
communicating therapeutically.
• Explore any fears with patient, and arrange for
the assistance of other health professionals if
required.
• Teach patient cognitive strategies that may be
useful for relieving tension, overcoming anxiety,
and achieving relaxation.

28. Nursing Interventions Contd
Managing Nutrition and Fluids
• Nutritional support : correct any nutrient
deficiency before surgery and provide enough
protein for tissue repair.
• Make NBM. If required
• In dehydrated patients, and especially in older
patients, encourage fluids by mouth, or
administer fluids intravenously as ordered.
• Monitor closely when history of chronic
alcoholism:
– for malnutrition and other systemic problems
– Alcohol withdrawal -delirium tremens up to 72 hours
after alcohol withdrawal.

29. The goal of perioperative fluid therapy
• To maintain body homeostasis
• Administering intravenous solutions to provide
– Adequate intravascular volume, cardiac output and
therefore oxygen to tissues when physiological
functions are altered by surgical stress and
anaesthetic agents.
•

30. Nursing Interventions Contd
Promoting Optimal Respiratory and
Cardiovascular Status
• Urge patient to stop smoking 2 months before surgery
(or at least 24 hours before).
• Teach breathing exercises includes Diaphragmatic
breathing, Coughing and how to use an
incentive spirometer.
• Assess patient with underlying respiratory disease for use
of medications that may affect postoperative recovery.
• In the patient with cardiovascular disease:
– Avoid sudden changes of position,
– Prolonged immobilization,
– hypotension or hypoxia, and overloading of the circulatory
system with fluids or blood.

31. Pre-Op Assessment- 6MWT
• 6 minute walk test (6MWT)
• Approx 720 steps in 6 Minutes.
• Measures distanced walked along flat corridor,
Turing around cones at each end at normal pace
in 6 minutes.
• Distance walked correlates with peak VO2
• Desaturation of >3% suggests impaired gas
exchange
•

32. Nursing Interventions Contd
Supporting Hepatic & Renal Function
• If patient has a disorder of the liver, carefully
assess various liver function tests and acid–
base status.
• Frequently monitor blood glucose levels of the
patient with diabetes before, during, and after
surgery.
• Report the use of steroid medications for any
purpose by the patient during the preceding
year to the anesthesiologist and surgeon.

33. Nursing Interventions Contd
Anemia & Pre-op Intervention
• Anaemia is associated with adverse perioperative
outcomes and is potentially modifiable factor
• Perioperative anaemia is independently associated with
adverse outcomes
increased length of stay,
complications and
mortality.
Treat anaemia if risk of major blood loss (>500ml) in the
perioperative period is expected.
Women with preoperative anaemia have worse outcomes.

34. Nursing Interventions Contd
Promoting Mobility and Active Body
Movement
• Teach Different Positions (how to turn from side to
side and assume the lateral position without causing
pain or disrupting IV lines, drainage tubes, or other
apparatus), as it make post op positioning better (to
improve circulation, prevent venous stasis, and
promote optimal respiratory function)
• Explain and teach any special position needed after
surgery (eg, adduction or elevation of an extremity).
• use leg exercises
• As DVT prophylaxis : Instruct patient in exercises of the
extremities,

35. Nursing Interventions Contd
Remove jewelry, wedding rings etc.
• Give all articles of value, including dentures
and prosthetic devices, to family members, or
if needed label articles clearly with patient’s
name and store in a safe place according
to Hospital policy.
• If patient objects, securely fasten the ring with
tape.

36. Nursing Interventions Contd
Pre-anesthetic Intervention
• Assist patients (except those with urologic
disorders) to void immediately before going to
the operating room.
• Administer preanesthetic medication as ordered,
and keep the patient in bed with the side rails
raised.
• Observe patient for any untoward reaction to the
medications.
• Keep the immediate surroundings quiet to
promote relaxation.

37. In Brief: Steps in Pre-operative Phase
• Identify patient.
• Verifies surgical site and marks site per institutional policy.
• Completes preoperative assessment.
• Assess for risk for postoperative complications.
• Reports unexpected findings or any deviation from normal.
• Verify consent signed.
• Explain phase in perioperative period and expectation.
• Assess patient’s status, baseline pain and nutritional status.
• Establishes intravenous line.
• Administers medication if prescribed.
• Takes measures to ensure patient’s comfort.
• Provides psychological support.

38. Intraoperative Phase
 Begins when the patient is admitted or transferred to
the surgical Area or O. R.
 Ends when he or she is admitted to the recovery
area.

39. Postoperative Phase
 Begins with the admission of the patient to the
recovery area and
 Ends with a follow-up evaluation in the clinical
setting or at home.

40. COMMON PROBLEMS IN
PERI-OPERATIVE PERIOD
1. PONV
2. Anaphylaxis
3. Pain
4. Electrolyte imbalances
5. Chills rigor
6. Hypertension /Hypotension
7. Bleed from operative site
8. Cognitive impairment or communication difficulties
9. Malignant hyperthermia due to Anesthetic agents

41. Immediate Care
 PACU- (Post Anaesthesia Care Unit)
Ensures patient is stable before
transfer out from OT
 Shift to ICU, If Patient requires :-
◦ Ongoing Post-operative care
◦ Critical Care- Unstable or
◦ Special needs

42. Initial hours Post-op Care
 Ensure hemodynamic stability
 Ensure adequate ventilation
 Assess for incision pain
 Assess surgical site integrity
 Assess and treat N & V
 Assess neurologic status
 Assess cognitive status (51% of older
adults experience post-op confusion
and delirium)

43. Keep family informed about frequent
assessments and presence of necessary
equipment to appropriately monitor patient.

44. Post Operative Pain Management
• Effective analgesia is an essential part of
postoperative management.
• Important injectable drugs for pain are the
opiate analgesics, Nonsteroidal anti-
inflammatory drugs (NSAIDs), such as
Paracetamol, Tramadol, diclofenac, Ibuprofen
etc. given orally and rectally.

45. Adverse effect of
Poor Post Op Analgesia
Good pain control after surgery is important to
prevent negative outcomes, Like
 Tachycardia,
 Hypertension,
 Myocardial ischemia,
 Decrease in alveolar ventilation,Vital capacity
 Poor wound healing
 Transition to chronic pain,
 Insomnia etc

46. Routes of Analgesic agent
Administration
• Oral
• Intravenous
• Intra-Muscular
• Transdermal-Patches/ Gel application
• Intranasal
• Epidural
• Regional Analgesia
• Rectal

47. Analgesic Modalities
 Multimodal analgesia, a Combination of
Systemic Pharmacologic agent with
a Local/ Intra-articular or Topical Techniques and/or
Regional Anesthetic Techniques (NSAID with Morphine)
 NSAIDs and coxibs and acetaminophen
 Extended-release epidural morphine
 Fentanyl iontophoretic transdermal
system/Patch
 Gabapentin and pregabalin
 Local anesthetics
 Patient-controlled regional analgesia
 Procedure-specific analgesia

48. Both Invasive and Noninvasive
 ECG Monitoring- Continuous
 Pulse Oximetry- continuous
 NIBP Monitoring- Initially Every 15 minutes for 1 hour then...
 Temperature – Every 4 hours for 24 hours
 ABG
 Ultrasound technology
 Invasive BP Monitoring (Radial Arterial BP, Pulmonary
artery catheter )
 EtCO2 monitoring
 TEE
 JVP

49. ABG: indispensible tool of Periop
monitoring
• Advances in the interpretation of
arterial blood gases-
Multiple New Parameters
• Aids in evaluating the anion gap value
while taking into account its
dependence on the concentrations of
the nonvolatile weak acids, which in
turn has improved our understanding
regarding metabolic acidosis

50.  Pneumonia – due to aspiration, depressed cough
reflex, increased secretions from anesthesia,
dehydration and immobilization.
Clinically : Increased temp, chills, a productive cough
with rusty or purulent sputum, crackles, wheezes,
dyspnea, and chest pain
 Atelectasis – due to incomplete expansion or collapse
of alveoli with retained mucus, involving a portion of
lung and resulting in poor gas exchange
Clinically : Decreased lung sounds over affected area,
dyspnea, cyanosis, crackles, restlessness, and
apprehension

51. Ways to
Prevent Respiratory Complications
 HOB in Semi-Fowler’s position
 Administer Oxygen Therapy as needed
 Administering analgesics for pain
 Use of incentive spirometry (deep breathing)
 Coughing while splinting

52. Post Op Pulmonary edema:
A rapid diagnosis
• The fusion of lung ultrasound and
echocardiographic applications into general
chest ultrasound with cardiorespiratory
monitoring protocols enhance our ability to
detect early pulmonary edema.

53. Important development and NonInvasive Tool
 Available Bedside
 Relatively cheap technology
 Helps in hemodynamic monitoring
(echocardiography),
 Early Detection of Internal Bleed/collections
 Neuromonitoring (transcranial color coded Doppler
and ocular ultrasound), and
 Guided procedures (vascular access and nerve
blockade)

54. ROLE OF ECMO
 ExtraCorporeal Membrane Oxygenation (ECMO) has been
upgraded in the management of severe respiratory and
circulatory failure.
 Bedside ECMO provides support to critically ill patients
requiring
 Cardiac or Respiratory (venovenous ECMO) or
 Cardiopulmonary support (Venoarterial ECMO)
 Now Portable - allowed for intra- and interhospital transport of
otherwise unstable patients.
 VA ECMO is ideally placed in cardiogenic shock from
postcardiac surgery with the inability to wean off bypass, early
graft failure following heart transplantation or trauma to the
great vessels.

55.  Standard choice Postoperatively :
 Lung-protective ventilation with the use of low
tidal volumes and
 Patients undergoing
 Major abdominal surgery,
 Transplants,
 Cardiac surgery,
 Pulmonary surgery,
 PostTraumatic,
 Neurosurgery

56. Post Op. Sodium Homeostasis
 Hyponatremia is common
 Serum sodium is the most common Post
Operative electrolyte disturbance in children,
approximately 30%

57. Ongoing Postoperative Care
 Frequent Assessment – post-op checklist or flow
sheet, compare with initial assessment,
 Carry out Post-op physician orders
 Diagnosing – Actual problems
 Continue plan of care- Defined in pre-operative
phase
 specific outcomes are individualized - based on
 risk factors,
 the surgical procedure, and
 the patient’s unique needs.

58. Preventing post-op cardiovascular complications
 Hypertension - Common in the immediate
postoperative period
secondary to sympathetic nervous system
stimulation from pain, hypoxia, or bladder
distention
Dysrhythmias : associated with electrolyte
imbalance, altered respiratory function, pain,
hypothermia, stress, and anesthetic agents

59. Preventing post-op cardiovascular complications-
contd
 Hemorrhage –monitor drainage/Operative site,
and urine output
 Shock -hypovolemic shock- monitor output & vital
signs and replenish fluid loss – IV ± Oral
 Thrombophlebitis - venous stasis in legs/clot
formation – applying TED hose, CPMs, leg exercises,
early ambulation, and anticoagulant medications
 Pulmonary embolism - dislodged blood clot or
foreign substance that travels to the pulmonary
vessels

60. Urinary Elimination
 Monitor I/ O
 Assist in normal positioning for voiding
 Assess for bladder distention – If not voided
within 8 hours post-op or less than 50 cc/hr
, Inform consultant
 Maintain IV infusion fluid infusion rates
 Provide privacy
 Catheter, if ordered but keep Measures to
Prevention of Urinary Tract Infections

61. Bowel elimination
 Auscultate for peristalsis q 4 hours
 Assess abdominal distention, especially if
bowel sounds are not audible or high-
pitched– indicates possible paralytic ileus
 Assist movement in bed and ambulation to
relieve gas pain
 Maintain privacy while pt is on bedpan or
bedside commode
 Administer suppositories, enemas, or
medications such as stool softeners as
prescribed

62. Wound Care
 Monitor wound for dehiscence and
evisceration
 Manage drains and document output
 Monitor wound and dressing for infectious
drainage or excessive bleeding
 The nurse will instruct and teach patient and
family members how to perform dressing
changes for post dischrge.

63. Some Facts to know

64. Factors related to Nutrition
 Malnutrition: increased risk for poor wound
healing
 Obesity:
 Increased risk for wound infection
 Increased risk for respiratory, cardiovascular,
and gastrointestinal problems (GERD)
 Fatty tissue has a poor blood supply-
increased risk for infection and possible
delayed wound healing
 Disruption in integrity of wound
(evisceration/dehiscence)

65. Infant related facts
 Lower total blood volume, More risk
for dehydration and increased oxygen
needs during surgery.
 Due to increased surface area- Prone
to hypothermia and hyperthermia
 Lower GFR and creatinine clearance
which leads to slower metabolism of
drugs
 Longer effect of muscle relaxants and
narcotics - Immature liver.

66. Old age related facts
 Decrease in metabolism and renal
functioning which puts them at risk for
anesthesia complications.
 More Postop cognitive imbalance
(51%)
 The older adult may also have
prolonged or altered wound healing
 Chronic illnesses are more common in
older adults, keep consideration.

67.  The professional nurse’s obligation to protect
the patient’s right to safety.
 Role as the patient advocate, protecting the
patient from incompetent, unethical, or illegal
actions/practices.
 Your’s qualifications relating to the
administration of proficient patient care.
 You are obliged to maintain the highest level
of competency in nursing practice, through
continuing education activities.

68. Nursing care providers are and includes
anyone licensed, registered, or certified by
the state to practice in the field of Nursing
Care.
Registration with INC or state Nursing council
is a MUST for Practice

69. Captain of the ship doctrine
 An analogy of the responsibility of a
navy captain.
 The surgeon has full responsibility for the
care and efficiency of the procedure room
and the welfare of all the persons present.

70. The respondent superior doctrine
 A subordinate acts according to his/her
superior’s direction therefore, the hospital is
liable for the negligence actions of a nurse.

71. Res ipsa loquitur (the thing speaks for
itself)
Applied to the perioperative nurse’s
 As the`re practice much more frequent than
to any other area of nursing practice.
 According to this doctrine, the nurses must
show that the standard of care was not
breached, rather than the usual requirement
that the injured party shows the standard was
breached.

72.  Consistent adherence to uniform policy,
procedures, and protocols provides safer
patient care, thus decreasing the likelihood
that the patient will injured.
 If an injury does occur and suit is filled, it will
be easier to show that the nurse complied
with the policy and procedures of the
institution.

73. Regarding informed consent
Ensuring that consent has been
Obtained,
Documented, and
Placed in the health record
in accordance with the policy of the hospital.

74. FINAL WORDS

75. Skill requirements for a Perioperative
Nurse
• Perioperative Nurse serve many roles—
– Assisting doctors,
– serving as patient liaisons,
– Communicating with patients and their families.
• Most common skill requirements:
– Technically sound
– Detail-oriented
– A critical thinker
– Able to work in a challenging, fast-paced environment
– Flexible
– A good multi-tasker
– An effective communicator with solid interpersonal skills
– A team player
– Possess a great deal of emotional stamina

76. Logic Of Peri-Operative care
• We should develop systems that can avoid the
complications.
• But thereafter early identification and treating
complications whenever they arise, represent
the basic logic of modern perioperative
monitoring.

77. Achieve the triple aim
Delivering a high-quality service with better
patient outcomes.
Better and more efficient use of resources.
Better patient experiences.