Medical Terminology: Perioperative Care

1. What is Perioperative Care?
The care of the surgical patient ideally begins when the patient is first informed of the need for surgery. The surgical procedure may be a sudden, unexpected event for the patient, resulting in stress and anxiety (e.g., necessary surgery following trauma) or may be something that the patient has planned (e.g., a liposuction) far in advance.
The more time the patient has to prepare for surgery, both physically and emotionally, the better able the patient is to cope with the physiological stresses of the surgery. Nurses and other allied health professionals are in a position to care for the patient, provide necessary education, act as patient advocate, and encourage health promotion behaviors.

2. Surgical Classifications
The American Society of Anesthesiology categorizes surgical procedures based on the degree of risk to the patient. The urgency, location, extent, and reason for the procedure are all considered, as well as the patient’s age; preexisting cardiovascular, respiratory, and neurologic statuses; endocrine disorders; malignancies; nutritional, fluid, and electrolyte status; abnormal laboratory findings; abnormal vital signs; and presence of infection. The risks of doing the surgery are weighed against the risks of not doing the surgery.
There are some cases in which the risk of surgery is very high, but the patient may certainly die if the surgery is not performed (patients with uncontrolled internal bleeding following a gunshot or stabbing, for example).
The anatomical location of the surgery affects the degree of risk to the patient. Surgical procedures performed within the thoracic cavity or skull are a greater risk to the patient than procedures performed on the extremities. Surgical procedures involving vital organs such as the heart, lungs, or brain carry a higher risk. The procedures that involve a greater potential for blood loss such as vascular surgery, also involve greater risk.
The degree of urgency of the procedure is described as emergent, urgent, or elective. Emergent procedures need to be performed immediately after identifying the need for surgery. Examples include surgery to stop bleeding from trauma, shooting, or stabbing, or dissection of an aortic aneurysm. Urgent procedures are scheduled after the determination of surgical need is made. Examples include tumor removal and removal of kidney stones. Elective procedures are scheduled in advance at a time that is convenient for both patient and surgeon. Postponement of the surgery for several weeks or even months will not cause harm to the patient. Examples include joint replacement procedures and cosmetic procedures.
The extent of the surgery affects the risk to the patient. The more extensive the surgical procedure, the greater the potential risk to the patient. More extensive surgical procedures cause more physical insult to the body and typically require a longer duration of anesthesia. The anesthesia can also cause stress to the patient’s system, interact with medications in the patient’s system, and must be metabolized out of the body.
The reason for surgery is another way that surgical procedures are classified. The purpose may be diagnostic, curative, restorative, palliative, or cosmetic. Diagnostic procedures are performed to obtain a biopsy for definitive diagnosis of a mass.
Curative procedures are performed to remove a diseased area such as a lumpectomy for breast cancer or an appendectomy. Restorative procedures are performed to restore function such as joint replacements.
Palliative procedures are procedures performed primarily for comfort measures such as tumor debulking. Cosmetic procedures are typically performed at the patient’s request; at times some cosmetic procedures may fall into restorative (repairing damage or a congenital defect), curative, or diagnostic (in the setting of skin cancer).
 

The perioperative period can be broken down into the preoperative (time before the surgery), intraoperative (time during the surgery), and the postoperative (time following the surgery until recovery) periods.

3. Preoperative Period
The preoperative period, the time before surgery, is used to prepare the patient for surgery both physically and psychologically. Ideally there is time to correct as many abnormalities as possible before the surgical procedure.
For patients having a scheduled procedure with a significant anticipated blood loss, this is the time to donate blood to be banked for use in their surgery and begin to take iron, folic acid, vitamin B12, and vitamin C to aid in red blood cell production. Preoperative clearance is given, informed consent is obtained, and preoperative teaching occurs during this time.

4. Preoperative Clearance
This is where the patient’s primary care provider states that the patient is medically able to undergo surgery. The patient’s primary care provider typically gives preoperative clearance for surgery. This physician, nurse practitioner, or physician’s assistant is familiar with the patient’s medical history and current medications and is able to adequately assess the impending risk of the surgery to the patient.
Things to consider when providing clearance for the patient include the type of surgical intervention planned, the potential for blood loss during surgery, the patient’s age, general health and comorbidities, past medical and surgical history, current medications, use of herbal remedies or supplements, alcohol use, smoking history, substance use, allergies, family history including problems with surgery, and diagnostic testing results.
Diagnostic studies often include a CBC (to identify anemia or signs of infection), a chemistry panel (to identify electrolyte imbalance, abnormal glucose, liver or renal function), a urinalysis (to identify infection, protein, glucose), PT/INR/PTT (to identify blood clotting disorders), an ECG (to identify abnormal cardiac rhythms or damage to the myocardium), chest X-ray (to identify pulmonary pathology or enlargement of cardiac silhouette), or pulmonary function testing (for patients with respiratory disorders such as asthma or emphysema).
CT scans, MRIs, or PET scans may be ordered for individual patients depending on their medical history, type of surgical procedure planned, and results of other diagnostic studies.

5. Informed Consent
An informed consent is written approval signed by the patient that is obtained before any invasive or dangerous procedure. The reason for the surgery, type and extent of surgery to be performed, risks of the procedure, the person to perform the procedure, alternative options and their associated risks, and risks associated with anesthesia are all explained to the patient.
It is the surgeon’s responsibility to make sure this information is explained to the patient. The patient must be a competent adult for his or her signature to be valid. If the patient has been given medications that alter his or her ability to reason or make judgments, the consent is not valid. The nurse witnesses the patient’s signature on the consent form.

6. Preoperative Teaching
Explaining normal preoperative routines to the patient can be very helpful, so the patient knows what to expect. The nurse needs to be familiar with the types of surgical procedures and what the expected postoperative course will entail. The extent of the procedure, type of incision, presence of any tubes or drains, and anticipated pain level after the surgery will help guide the type of teaching necessary for the patient.
Preoperatively the patient can expect to be NPO (nothing by mouth), or not allowed to eat or drink anything for several hours before the procedure. The time frame depends on the extent and location of procedure, the type of anesthesia, and the scheduled time of surgery. An exception to this NPO rule would be for patients who need to take oral medications the morning of surgery.
Cardiovascular, diabetic, and certain other medications may need to be taken even though the patient is not to eat or drink anything else. An intravenous access site is obtained before the surgery. Fluids can be administered to the patient in this way. The access also allows for giving the patient medications intravenously for rapid action. Fluids are routinely given in the operating room and the immediate recovery period. The patient may have continued intravenous fluids for more extensive procedures.
Skin preparation may only involve washing of the surgical site in the operating room with an antimicrobial solution. Other patients may need to have removal of hair from the surgical site. This may be with a razor or a depilatory agent. It is important not to cut the skin if you are shaving a surgical site; small cuts or abrasions on the skin allow for potential sites of infection. Depilatory agents can be caustic on the skin of some patients, causing irritation or a rash. A small spot test away from the surgical area is a good idea in a patient with known skin sensitivity or history of allergies.
For patients having planned surgery involving the intestinal tract, a bowel preparation is completed before the surgery. This is done to decrease the bacterial count within the intestinal tract. Cleansing of the bowel is also completed to empty the intestine of stool before the surgeon plans on cutting into either the small or large intestines. Both of these preparations help to reduce the possibility of infection in the postoperative period.
For patients who will have tubes or drains in place in the postoperative period, a simple explanation of what to expect can help to alleviate some anxiety. Availability of pain medication in the postoperative period should be explained to the patient. In many instances, the patient is able to manage his or her own pain medication.
For outpatient procedures, patients may be given a prescription for an oral pain medication before the procedure. This way the medication is available when the patient gets home from the surgery. For postoperative patients in the hospital, many patients have an intravenous patient-controlled analgesia (PCA) for pain management in which pain medication is delivered via a pump.
Typically a small basal dose of narcotic is delivered all the time. These patients also have the ability to press a button whenever they are experiencing pain. The pump monitors the amount and timing of each dose of pain medication. If the patient is due for medication, a dose is administered; if the patient is not due for medication, no dose is administered.

7. Transfer of the Patient
Most facilities have a preoperative checklist to assist the nurse to make sure that all the needed components have been checked before sending the patient to the operating room (OR). All pertinent documentation—the signed consent form, the patient’s chart, and current lab results—accompanies the patient to the OR.

8. Intraoperative Period
Members of the surgical team include the surgeon, a surgical assistant, an anesthesiologist or anesthetist, a circulating nurse, a scrub nurse or surgical tech, and a holding area nurse. The surgeon is the doctor who performs the surgery.
The surgical assistant may be another surgeon, a surgical resident, an RN first assist, or a physician’s assistant. The person providing anesthesia and monitoring the vital signs of the patient is either an anesthesiologist (a physician) or a certified registered nurse anesthetist (CRNA).
The circulating nurse is a registered nurse who acts as the patient advocate, obtains the necessary supplies for the procedure, makes sure diagnostic studies and blood products are available if necessary, prepares the operative table, positions the patient (padding bony prominences if necessary), and cleanses the skin in the operative area before positioning surgical drapes.
The scrub nurse or surgical tech up the sterile field, assists with draping the patient, and hands sterile supplies into the operative field and takes used instruments from the surgeon. The circulating nurse and scrub nurse (or surgical tech) together count all instruments, sponges, and sharps used in the surgical field. The count is performed before, during, and after the procedure.
The holding area nurse cares for the patients who have been brought into the operating room suite but who are not yet ready to go into the operating room. The holding area nurse may be managing several patients at one time and can also help to transport and transfer the patient.
Before entering the operating room, the members of the surgical team scrub at the sink just outside the room in which the surgery will be performed. Before starting the scrub, the team member applies a mask with face shield or goggles.
The surgical scrub is usually timed and covers the area from the fingertips to 2. inches above the elbows. The surgical scrub renders the skin clean, not sterile. After the scrub, the skin is dried with a sterile towel. A sterile gown, then sterile gloves are applied. The front of the gown is considered sterile in the front from two inches below the neck to the waist and from the elbow to the wrist. The circulating nurse puts on the gown and gloves unassisted, and then assists the other members of the team into their gown and gloves as they enter the room.

9. Risk for Injury
During the surgery, the patient is anesthetized and cannot tell you if there is pressure anywhere. The patient is positioned to allow for maximal access to the operative site. This sometimes causes unnatural positioning of the patient or the patient’s extremities. The operative table is padded to decrease pressure on the patient.
There may be additional padding added to areas of flexion or bony prominences to reduce the risk of pressure ulcer formation or nerve damage because of positioning. Heat loss can occur during surgery.
The patient is sent to the operating room in a hospital gown, which may be pulled up or removed depending on the body location of the surgery. The body is draped for privacy so that only the surgical area is exposed. The temperature within the operating room is kept rather cool because the air exchange rate is higher within the operating room than in other rooms (to decrease bacterial counts), and the staff wear double layers of clothes. Warmers can be set up for the patients during certain procedures when heat loss is expected—a large, open operative site or a long duration of surgery.
At the end of the surgical procedure, the wound is closed. The closure is to hold the wound edges together and prevent contamination. Closure may be achieved with sutures (either absorbable or nonabsorbable), staples, or skin closure tape. Nonabsorbable sutures and staples have to be removed in the postoperative period.
Drains may be inserted near the operative site if significant wound drainage is anticipated. Some drains are attached to suction, some have self-suction, and some drain because of gravity. The wound site is covered with a sterile dressing before the patient is transferred out of the operating room.

10. Anesthesia
Anesthesia can be administered via general or regional routes (for major procedures) or conscious sedation (for minor procedures). General anesthesia renders the patient unconscious and incapable of breathing on his or her own; pain reception is also blocked. These patients must be intubated and mechanically ventilated for the duration of the anesthesia.
Regional anesthesia can be achieved through nerve blocks, or epidural or spinal anesthesia. Nerve blocks occur when an anesthetic agent is injected into an area immediately surrounding a particular nerve or nerve bundle. The nerve tissue becomes anesthetized, effectively causing the tissue that it supplies to become pain free. With epidural anesthesia, an anesthetic agent is injected into the epidural space surrounding the spinal column, usually in the lower lumbar area.
The nerves become anesthetized as they leave the spinal column, causing the area of the body supplied by these nerves to become pain free. This anesthesia is most commonly associated with childbirth, but is used for many surgical procedures. Spinal anesthesia is not commonly used; the anesthetic agent is injected into the cerebrospinal fluid.
Patient positioning is very important, as gravity will cause the anesthetic agent to travel. The patient must remain flat after the procedure to prevent leakage of cerebrospinal fluid from the puncture site.

11. Postoperative Period
After the surgery, the patient enters the postoperative period. The immediate postoperative period requires close monitoring as the patient emerges from anesthesia. The patient is then transferred to either a same-day surgery area for discharge home that day or an inpatient surgical unit for care. After discharge from the hospital, the patient may need home care. Return to full activities may take several weeks.

2. Postanesthesia Care
The patient is transferred from the operating room to the postanesthesia care unit (PACU) for close monitoring in the immediate postoperative period. Initial assessment is focused on ABC: airway, breathing, and circulation.
The practitioner should monitor the patient’s airway, gas exchange, pulse oximetry, oxygen delivery, accessory muscle use, and breath sounds. The patient can develop stridor because of edema or bronchospasm. The cardiovascular status is checked next. Vital signs are checked every 15. minutes until stabilized; pulse, blood pressure, and cardiac rhythm are monitored.
The surgical wound is checked for signs of drainage or bleeding. The dressing is checked. The drains are checked for output and patency. Tubes that need to be connected to suction (e.g., nasogastric tubes) are connected. Intravenous fluids are monitored. Neurologic assessment is performed to check level of consciousness.
Following general anesthesia, the patient follows a predictable progression in the return to consciousness. Initially there is muscular irritability, and then restlessness followed by pain recognition and the ability to reason and control behavior. Pupil responses are monitored, looking for bilaterally equal responses to light. Motor responses are monitored, looking initially for purposeful response to painful stimuli and later for response to command.
Pain management is begun during this time. As the anesthetic agent wears off, it is important to assess the patient’s level of pain. This may be assessed through subjective information in patients who are conscious, or through more objective signs in patients who are still in semiconscious states.
Monitor for changes in vital signs [elevated pulse and blood pressure (BP)], changes in movement, and moaning. Expected pain levels can be estimated from the type of surgery and give a starting point for those patients as they begin to come out of the anesthesia. Gastrointestinal status is monitored for presence of nausea or vomiting. This may be a reaction or side effect to anesthesia. Check for abdominal distention and presence of bowel sounds.
Monitor drainage from the nasogastric tube; note the amount and color of drainage. Monitor laboratory results as indicated. Electrolyte levels, hemoglobin or hematocrit levels, blood urea nitrogen (BUN) and creati-nine, arterial blood gases (ABGs), or other studies may be necessary in the immediate postoperative period. The necessary diagnostic studies depend on the patient’s history, estimated blood loss during surgery, and type of procedure performed.
After the initial recovery time, the stable patient who is transferred from the PACU to the same-day surgical area continues to be monitored. Vital signs are taken, although not as frequently. Respiratory and cardiovascular functions are monitored. Cardiac rhythm is no longer monitored. The dressing is checked for any drainage. Bowel sounds are checked. Clear fluids are given if the patient is not experiencing nausea.
Patients are monitored for urinary output before being discharged to home. Patients who are admitted to the hospital are transferred from the PACU to a surgical unit. Vital signs, respiration, and cardiovascular status are checked. The dressing is monitored for drainage; drainage tubes are monitored for output. Intravenous lines are monitored for signs of infiltration and proper flow rates.
Bowel sounds are monitored. Patients who are unstable or who have had extensive procedures are transferred to intensive care for close monitoring. Nurses who are used to caring for complex, unstable patients care for these patients. Their vital signs are closely monitored. Some patients will still be on mechanical ventilation.

3. Postoperative Complications
The focus of care that is common for all postoperative patients is identification of complications. Common complications involve the cardiac, respiratory, and gastrointestinal areas, and infections.

4. Cardiovascular Complications
Patients may develop cardiovascular complications because of the physiologic stress of surgery, side effects of the anesthesia or other medications, or comorbidities. Myocardial infarction (MI), cardiac arrhythmias, or hypotension are likely during or in the immediate postoperative period.
When getting the patient out of bed for the first time after surgery, it is good practice to have the patient sit on the side of the bed for a minute or two before standing up to ascertain if the patient feels dizzy because of a drop in blood pressure associated with position change. Deep vein thrombosis (DVT) is a later vascular complication associated with inflammation and decreased mobility after surgery.

5. Respiratory Complications
Patients with preexisting respiratory disorders, obesity, thoracic or upper abdominal surgical procedures are at greater risk of developing respiratory complications postoperatively. After surgery, patients are not as mobile. This lack of physical activity leads to a diminished chest wall and diaphragmatic movement, resulting in a decreased amount of air exchange. Alveolar sacs can collapse, leading to areas of atelectasis. Pain medications can adversely affect respiratory status by decreasing respiratory drive.
Patients at increased risk for respiratory complications may develop pneumonia in the postoperative period because of diminished airflow, increased respiratory secretions, and inflammatory processes. Patients with increased risk for clotting or DVT, or those with hypercoagulable states are at risk for developing a pulmonary embolism.

6. Infection
The skin is the body’s first line of defense against infection. During surgery this line of defense is penetrated. Even though the surgical procedure is performed in as aseptic an environment as possible, the possibility of infection still exists. Wound infections can develop in the postoperative period.
The wound may be contaminated before surgery such as with penetrating trauma, or may become infected during healing. The surface of the skin has bacteria that are naturally present, referred to as normal flora. These bacteria may enter the wound and cause infection. Nosocomial infections can also occur at the surgical site, caused by bacteria found elsewhere in the hospital. Infection within the surgical wound slow approximation of the wound edges, delaying wound healing.

7. Gastrointestinal Complications
Following administration of anesthesia or pain medication, patients may experience nausea, vomiting, constipation, or paralytic ileus. Nausea is a common side effect of both anesthesia and pain medications. A patient’s reaction to anesthetic agents varies. Some patients have a lot of nausea after anesthesia that may last for several hours.
Abdominal surgery may cause direct visceral afferent stimulation, resulting in nausea and vomiting. Medications may act upon the chemoreceptor trigger zone, located within the medulla outside the blood–brain barrier. Once the patient begins vomiting, antiemetic medication may be necessary to break the cycle.
Opioid-based medications and decreased activity can cause both slowing of peristaltic activity, leading to constipation. Patients having abdominal procedures are at greater risk for paralytic ileus as a postoperative complication.

Basic Questions
Perioperative Care

1. What is an emergent procedure?
An emergent procedure must be performed immediately after identifying the need for surgery. Examples include surgery to stop bleeding from trauma, shooting, or stabbing, or dissection of an aortic aneurysm.

2. What is an urgent procedure?
An urgent procedure is scheduled after the determination of surgical need is made. Examples include tumor or kidney stone removal.

3. What is an elective procedure?
Elective procedures are scheduled in advance at a time that is convenient for both patient and surgeon. Postponement of the surgery for several weeks or even months will not cause harm to the patient. Examples include joint replacement procedures and cosmetic procedures.

4. What is the extent of the surgery?
The extent of the surgery affects the risk to the patient. The more extensive the surgical procedure, the greater the potential risk to the patient. More extensive surgical procedures cause more physical insult to the body and typically require a longer duration of anesthesia. The anesthesia can also cause stress to the patient’s system, interact with medications in the patient’s system, and must be metabolized out of the body.

5. What is a curative procedure?
A curative procedure is performed to remove a diseased area such as a lumpectomy for breast cancer or an appendectomy.

6. What is a palliative procedure?
Palliative procedures are procedures performed primarily for comfort measures such as tumor debulking.

7. What is a cosmetic procedure?
Cosmetic procedures are typically performed at the patient’s request; at times some cosmetic procedures may fall into restorative (repairing damage or a congenital defect), curative, or diagnostic (in the setting of skin cancer).

8. What is the perioperative period?
The perioperative period is the time before surgery through the time following surgery when the patient is recovered.

9. What is the preoperative period?
The preoperative period is the time before surgery.

10. What is the intraoperative period?
The intraoperative period is the time during surgery.

11. What is the postoperative period?
The postoperative period is the time following surgery until recovery.

12. What occurs during the preoperative period?
The preoperative period, the time before surgery, is used to prepare the patient for surgery both physically and psychologically. Ideally there is time to correct as many abnormalities as possible before the surgical procedure.

13. What is preoperative clearance?
The patient’s primary care provider states that the patient is medically able to undergo surgery.

14. What is purpose of the CBC test before surgery?
The CBC test is used to identify anemia and signs of infection before surgery.

15. What is the purpose of the PT/INR/PTT test before surgery?
The PT/INR/PTT test identifies blood clotting disorders.

16. What is an informed consent?
An informed consent is written approval signed by the patient that is obtained before any invasive or dangerous procedure. It explains the reason for the surgery, the type and extent of surgery to be performed, the risks of the procedure, the person to perform the procedure, alternative options and their associated risks, and the risks associated with anesthesia.

17. What is preoperative teaching?
The medical provider explains normal preoperative routines to the patient so the patient knows what to expect. Also explained are the extent of the procedure, type of incision, presence of any tubes or drains, and anticipated pain level after the surgery.

18. Who is a surgical assistant?
The surgical assistant may be another surgeon, a surgical resident, an RN first assist, or a physician’s assistant.

19. What is a circulating nurse?
A circulating nurse is a registered nurse who acts as the patient advocate, obtains the necessary supplies for the procedure, makes sure diagnostic studies and blood products are available if necessary, prepares the operative table, positions the patient (padding bony prominences if necessary), and cleanses the skin in the operative area before positioning surgical drapes.

20. What might be a cause of nausea and vomiting following abdominal surgery?
Direct visceral afferent stimulation.

21. What is a scrub nurse or surgical tech?
The scrub nurse or surgical tech sets up the sterile field, assists with draping the patient, and hands sterile supplies into the operative field and takes used instruments from the surgeon. The circulating nurse and scrub nurse (or surgical tech) together count all instruments, sponges, and sharps used in the surgical field.

22. What is a holding area nurse?
The holding area nurse cares for patients who have been brought into the operating room suite but who are not yet ready to go into the operating room. The holding area nurse may be managing several patients at one time and can also help to transport and transfer the patient.

23. What is a surgical scrub?
The surgical scrub is usually timed and covers the area from the fingertips to 2. inches above the elbows. The surgical scrub renders the skin clean, not sterile.

24. What is general anesthesia?
General anesthesia renders the patient unconscious and incapable of breathing on his or her own; pain reception is also blocked. These patients must be intubated and mechanically ventilated for the duration of the anesthesia.

25. What is regional anesthesia?
Regional anesthesia can be achieved through nerve blocks, or epidural or spinal anesthesia. Nerve blocks occur when an anesthetic agent is injected into an area immediately surrounding a particular nerve or nerve bundle. The nerve tissue becomes anesthetized, effectively causing the tissue that it supplies to become pain free.