4.3 Perioperative Nursing & Wound Care Management
Key Takeaways
- Informed consent must be obtained voluntarily by the surgeon; the nurse's role is to witness the signature and ensure the patient understands.
- Malignant hyperthermia is a life-threatening surgical emergency characterized by a rapid rise in body temperature and severe muscle rigidity; Dantrolene is the antidote.
- Postoperative deep breathing, coughing, and early ambulation are critical for preventing atelectasis and deep vein thrombosis (DVT).
- Wound healing by primary intention involves clean, approximated edges (e.g., surgical incision); secondary intention involves leaving the wound open to heal from the base up (e.g., pressure ulcer).
- Evisceration (protrusion of internal organs through an incision) is a medical emergency requiring immediate covering with sterile saline-soaked dressings.
Perioperative Nursing & Wound Care
Perioperative nursing encompasses the care provided to patients before, during, and after surgery. It requires meticulous assessment, vigilant monitoring for complications, and strict adherence to safety protocols to ensure optimal patient outcomes.
The Three Phases of Perioperative Care
1. Preoperative Phase
This phase begins when the decision for surgery is made and ends when the patient is transferred to the operating room (OR) table.
Key Nursing Responsibilities:
- Assessment: Complete health history, medication review (especially anticoagulants, which must be stopped prior to surgery), and allergy assessment (latex, iodine, shellfish).
- Informed Consent: The surgeon is responsible for explaining the procedure, risks, benefits, and alternatives. The nurse's role is to act as a witness to the signature, ensuring the patient is of legal age, competent, and signing voluntarily without coercion. If the patient has questions about the procedure, the nurse must notify the surgeon.
- Patient Education: Teach postoperative exercises before the surgery (e.g., deep breathing, coughing, incentive spirometry, leg exercises, and splinting the incision). Patients learn better before the stress and pain of the postoperative period.
- Preparation: NPO status verification (usually 6-8 hours for solid food) to prevent aspiration. Baseline vital signs and completion of the preoperative checklist.
2. Intraoperative Phase
Begins when the patient enters the OR and ends with admission to the Post-Anesthesia Care Unit (PACU).
Key Safety Priorities:
- Time-Out: A universal protocol conducted immediately before the procedure starts. The entire surgical team pauses to verify the correct patient, correct procedure, and correct anatomical site.
- Asepsis: Maintaining the sterile field to prevent surgical site infections.
- Positioning: Ensuring proper padding to prevent pressure injuries or nerve damage during prolonged procedures.
Complication Focus: Malignant Hyperthermia (MH)
- MH is a rare, inherited, life-threatening condition triggered by specific inhaled anesthetics (e.g., halothane) and the depolarizing muscle relaxant succinylcholine.
- Signs/Symptoms: Tachycardia (often the earliest sign), severe muscle rigidity (especially jaw), hypercarbia (elevated CO2), and a rapid, extreme rise in body temperature (a late sign, can reach 109°F).
- Intervention: Immediate discontinuation of the triggering agent, hyperventilation with 100% oxygen, cooling measures, and administration of the antidote: Dantrolene sodium (Dantrium).
3. Postoperative Phase
Begins with admission to the PACU and continues through recovery and discharge.
Initial PACU Priorities:
- Airway, Breathing, Circulation (ABCs): This is always the first assessment. Maintain a patent airway, monitor respiratory rate/depth, and check oxygen saturation. Monitor vital signs for signs of hemorrhage/shock (tachycardia, hypotension).
- Neurological Status: Assess level of consciousness and return of sensation/motor function after regional anesthesia.
- Pain and Nausea Management: Administer analgesics and antiemetics as prescribed.
Preventing Postoperative Complications:
| Complication | Prevention/Nursing Interventions |
|---|---|
| Atelectasis / Pneumonia | Encourage deep breathing, coughing (splinting incision), incentive spirometry q1-2h, and early ambulation. |
| Deep Vein Thrombosis (DVT) & Pulmonary Embolism (PE) | Early ambulation, leg exercises, sequential compression devices (SCDs), anti-embolism stockings (TED hose), and prophylactic anticoagulants (e.g., enoxaparin). |
| Paralytic Ileus | Assess bowel sounds and flatus. NPO until bowel sounds return. Encourage ambulation. |
| Wound Infection | Maintain aseptic technique during dressing changes. Monitor for redness, warmth, swelling, and purulent drainage. |
| Urinary Retention | Assess bladder distention. Encourage voiding within 6-8 hours post-op. Bladder scan if necessary; catheterize if ordered. |
Wound Care and Management
Proper wound care is essential for healing and preventing infection.
Wound Healing Processes
- Primary Intention: The wound edges are brought together (approximated) cleanly, such as with sutures, staples, or surgical glue. Healing occurs rapidly with minimal scarring. Example: A surgical incision.
- Secondary Intention: The wound is left open to heal from the "bottom up" via granulation tissue formation. This occurs in wounds with significant tissue loss, trauma, or infection. Healing is slower and scarring is greater. Example: A deep pressure ulcer or infected wound.
- Tertiary Intention (Delayed Primary Closure): The wound is deliberately left open for several days to allow infection or edema to resolve, then it is surgically closed.
Surgical Wound Complications
- Dehiscence: The partial or total separation of wound layers. Often occurs after sudden straining (coughing, vomiting). Intervention: Place the patient in low Fowler's position with knees bent to reduce tension on the wound, cover with a sterile dressing, and notify the provider.
- Evisceration: The protrusion of visceral organs through a wound opening. This is a surgical emergency.
- Immediate Action: Call for help. Stay with the patient. Place the patient in a supine position with hips and knees flexed (low Fowler's). Cover the exposed organs immediately with sterile towels or dressings soaked in sterile normal saline to prevent drying and necrosis. Do not attempt to push the organs back in. Prepare the patient for immediate surgery.
Pressure Injuries (Ulcers)
Pressure injuries occur from prolonged pressure, friction, and shear, leading to tissue ischemia. Prevention involves frequent repositioning (at least q2h), using pressure-relieving devices, keeping skin clean and dry, and optimizing nutrition.
Staging System:
- Stage 1: Intact skin with non-blanchable redness of a localized area, usually over a bony prominence.
- Stage 2: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
- Stage 3: Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present.
- Stage 4: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present.
- Unstageable: Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. The true depth cannot be determined until the slough/eschar is removed.
A patient is scheduled for an elective cholecystectomy. The nurse is preparing the patient for surgery when the patient states, "I don't really understand what the doctor is going to do, but I trust him." What is the most appropriate action for the nurse to take?
On the third postoperative day following abdominal surgery, a patient experiences a sudden fit of coughing and states, "It feels like something just popped open in my stomach." The nurse inspects the incision and notes that a loop of bowel is protruding. Which of the following is the priority nursing intervention?