Surgical Risk Factors And Preventive Strategies : Perioperative Nursing

Obesity

Danger

• Increases the difficulty involved in the technical aspects of performing surgery; risk for wound dehiscence is greater
• Increases the likelihood of infection because of compromised tissue perfusion
• Increases the potential for postoperative pneumonia and other pulmonary complications because obese patients chronically hypoventilate
• Increases demands on the heart, leading to cardiovascular compromise
• Increases the risk for airway complications
• Alters the response to many drugs and anesthetics
• Decreases the likelihood of early ambulation

Therapeutic Approach

• Encourage weight reduction if time permits.
• Anticipate postoperative obesity-related complications.
• Be extremely vigilant for respiratory complications.
• Carefully splint abdominal incisions when moving or coughing.
• Be aware that some drugs should be dosed according to ideal body weight versus actual weight (owing to fat content); otherwise, an overdose may occur (digoxin [Lanoxin], lidocaine [Xylocaine], aminoglycosides, and theophylline [Theo-Dur]).
• Avoid intramuscular injections in morbidly obese individuals (I.V. or subcutaneous routes preferred).
• Never attempt to move an impaired patient without assistance or without using proper body mechanics.
• Obtain a dietary consultation early in the patient's postoperative course.

Poor Nutrition

Danger

• Greatly impairs wound healing (especially protein and calorie deficits and a negative nitrogen balance)
• Increases the risk of infection

Therapeutic Approach

• Any recent (within 4 to 6 weeks) weight loss of 10% of the patient's normal body weight or decreased serum albumin should alert the health care staff to poor nutritional status and the need to investigate as to the cause of the weight loss.
• Attempt to improve nutritional status before and after surgery. Unless contraindicated, provide a diet high in proteins, calories, and vitamins (especially vitamins C and A); this may require enteral and parenteral feeding.
• Review a serum prealbumin level to determine recent nutritional status.
• Recommend repair of dental caries and proper mouth hygiene to prevent infection.

Fluid and Electrolyte Imbalance

Danger

Can have adverse effects in terms of general anesthesia and the anticipated volume losses associated with surgery, causing shock and cardiac dysrhythmias

Patients undergoing major abdominal operations (such as colectomies and aortic repairs) often experience a massive fluid shift into tissues around the operative site in the form of edema (as much as 1 L or more may be lost from circulation). Watch for the fluid shift to reverse (from tissue to circulation) around the third postoperative day. Patients with heart disease may develop failure due to the excess fluid “load.”

Therapeutic Approach

• Assess the patient's fluid and electrolyte status.
• Rehydrate the patient parenterally and orally as prescribed.
• Monitor for evidence of electrolyte imbalance, especially Na⁺, K⁺, Mg⁺⁺, Ca⁺⁺.
• Be aware of expected drainage amounts and composition; report excess and abnormalities.
• Monitor the patient's intake and output; be sure to include all body fluid losses.

Aging

Danger

• Potential for injury is greater in older people
• Be aware that the cumulative effect of medications is greater in the older patient
• Medications in the usual dosages, such as morphine, may cause confusion, disorientation, and respiratory depression

Therapeutic Approach

• Consider using lesser doses for desired effect.
• Anticipate problems from chronic disorders such as anemia, obesity, diabetes, hypoproteinemia.
• Adjust nutritional intake to conform to higher protein and vitamin needs.
• When possible, cater to set patterns in older patients, such as sleeping and eating.

Presence of Cardiovascular Disease

Danger

• May compound the stress of anesthesia and the operative procedure
• May result in impaired oxygenation, cardiac rhythm, cardiac output, and circulation
• May also produce cardiac decompensation, sudden arrhythmia, thromboembolism, acute myocardial infarction (MI), or cardiac arrest

Therapeutic Approach

• Frequently assess heart rate and blood pressure (BP) and hemodynamic status and cardiac rhythm if indicated.
• Avoid fluid overload (oral, parenteral, blood products) because of possible MI, angina, heart failure, and pulmonary edema.
• Prevent prolonged immobilization, which results in venous stasis. Monitor for potential deep vein thrombosis (DVT) or pulmonary embolus.
• Encourage position changes but avoid sudden exertion.
• Use antiembolism stockings and/or sequential compression device intraoperatively and postoperatively.
• Note evidence of hypoxia and initiate therapy.

Presence of Diabetes Mellitus

Danger

• Hypoglycemia may result from food and fluid restrictions and anesthesia.
• Hyperglycemia and ketoacidosis may be potentiated by increased catecholamines and glucocorticoids due to surgical stress.
• Chronic hyperglycemia results in poor wound healing and susceptibility to infection.

Therapeutic Approach

• Recognize the signs and symptoms of ketoacidosis and hypoglycemia, which can threaten an otherwise uneventful surgical experience. Dehydration also threatens renal function.
• Monitor blood glucose and be prepared to administer insulin, as directed, or treat hypoglycemia.
• Confirm what medications the patient has taken and what has been held. Facility protocol and provider preference varies, but the goal is to prevent hypoglycemia. If the patient is NPO, oral agents are usually withheld and insulin may be ordered at 75% of the usual dose.
• Reassure the diabetic patient that when the disease is controlled, the surgical risk is no greater than it is for the nondiabetic patient.

Presence of Alcoholism

Danger

The additional problem of malnutrition may be present in the presurgical patient with alcoholism. The patient may also have an increased tolerance to anesthetics.

 

Therapeutic Approach

• Note that the risk of surgery is greater for the patient who has chronic alcoholism.
• Anticipate the acute withdrawal syndrome within 72 hours of the last alcoholic drink.

Presence of Pulmonary and Upper Respiratory Disease

Danger

Chronic pulmonary illness may contribute to hypoventilation, leading to pneumonia and atelectasis. Surgery may be contraindicated in the patient who has an upper respiratory infection because of the possible advance of infection to pneumonia and sepsis.

 

Therapeutic Approach

• Patients with chronic pulmonary problems, such as emphysema or bronchiectasis, should be evaluated and treated prior to surgery to optimize pulmonary function with bronchodilators, corticosteroids, and conscientious mouth care, along with a reduction in weight and smoking and methods to control secretions.
• Opioids should be used cautiously to prevent hypoventilation. Patient-controlled analgesia is preferred.
• Oxygen should be administered to prevent hypoxemia (low liter flow in chronic obstructive pulmonary disease).

Concurrent or Prior Pharmacotherapy

Danger

Hazards exist when certain medications are given concomitantly with others (eg, interaction of some drugs with anesthetics can lead to hypotension and circulatory collapse). This also includes the use of many herbal substances. Although herbs are natural products, they can interact with other medications used in surgery.

 

Therapeutic Approach

• An awareness of drug therapy is essential.
• Notify the health care provider and anesthesiologist if the patient is taking any of the following drugs:
  • Certain antibiotics
  • Antidepressants, particularly monoamine oxidase inhibitors, and St. John's wort, an herbal product
  • Phenothiazines
  • Diuretics, particularly thiazides
  • Steroids
  • Anticoagulants, such as warfarin or heparin; or medications or herbals that may affect coagulation, such as aspirin, feverfew, ginkgo biloba, nonsteroidal anti-inflammatory drugs, ticlopidine (Ticlid), and clopidogrel (Plavix)