The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [598]
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Chapter 14
Perioperative Care
Overview
This chapter relates to the care provided to the patient in the three stages of surgery:
preoperative care
intraoperative care
postoperative care.
Preoperative care
Definition
Preoperative care is the physical and psychological care provided to the patient to help them prepare to undergo surgery.
Related theory
Venous thromboembolism (VTE) is a condition where a blood clot is formed inside a vein. This is normally due to stasis of blood within the vessel, trauma to the vessel or an increase in the ability of the blood to clot. This most frequently happens in the deep veins of the leg which is termed a deep vein thrombosis or DVT. If one of these clots dislodges from the leg and travel to the lung via the bloodstream, it is called a pulmonary embolus or PE. This is a potentially fatal complaint (NICE 2010) (Box 14.1).
Box 14.1 Signs of DVT/PE
Complaints of calf or thigh pain.
Erythema, warmth, tenderness and abnormal swelling of the calf or thigh in the affected limb.
Numbness or tingling of the feet.
Dyspnoea, chest pain or signs of shock.
Pain in the chest, back or ribs which gets worse when the patient breathes in deeply.
Coughing up blood.
Patients should be assessed for the individual risk factors for VTE when hospitalized in order to determine the most appropriate thromboprophylaxis (HoCHC 2005, NICE 2010). Patients at higher risk include those with major illness, for example acute cardiac or respiratory failure, major surgery, older patients, patients who are obese or with a previous history of DVT or PE (NICE 2010, SIGN 2002) (Box 14.2). All patients requiring an inpatient stay for surgery should have prophylactic treatment to reduce the risk of DVT, which may include anticoagulation and mechanical compression methods, for example antiembolic stockings and intermittent pneumatic compression methods (NICE 2010, Roderick et al. 2005, SIGN 2002).
Box 14.2 Venous thrombus risk factors
Patient undergoing major surgery or abdominal/pelvic surgery.
Immobility, for example prolonged bed rest.
Active cancer.
Severe cardiac failure or recent myocardial infarction.
Acute respiratory failure.
Elderly.
Previous history of DVT or PE.
Acute infection/inflammation.
Diabetes.
Smoker.
Obesity.
Gross varicose veins.
Paralysis of lower limbs.
Clotting disorders.
Hormone replacement therapy.
Oral contraceptives.
(HoCHC 2005, NICE 2010, Rashid et al. 2005, SIGN 2002)
Patients should be given verbal and written information before surgery about the risks of VTE and the effectiveness of prophylaxis (NICE 2010). It is estimated that 20% of patients undergoing major surgery will develop a DVT with the risk increasing to 40% of patients undergoing major orthopaedic surgery (SIGN 2002). Mechanical compression methods reduce the risk of DVT by about two-thirds when used as monotherapy and by about half when added to pharmacological methods (Roderick et al. 2005). Graduated compression (antiembolic) stockings promote venous flow and reduce venous stasis not only in the legs but also in the pelvic veins and inferior vena cava (Hayes et al. 2002, Rashid et al. 2005, Roderick et al. 2005). See Chapter 4 for more information.
Evidence-based approaches
Rationale
To ensure patient safety at all times and minimize intra/postoperative complications by:
delivering the required nursing care for the preoperative patient
minimizing potential problems by ensuring patients have carried out certain procedures and are prepared safely for theatre. These include:
– preoperative fasting
– skin preparation
– marking skin for surgery
– preoperative pregnancy testing
– preventing toxic shock syndrome from tampons (female only)
– patient education
– application of antiembolic stockings (graduated elastic compression stockings)
– assessment for latex allergy
– consent.
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