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16. PERIOPERATIVE CARE

WHO The World Health Organization (WHO) published the WHO Surgical Safety Checklist in 2008 in order to increase the safety of patients undergoing surgery. The checklist serves to
SURGICAL remind the surgical team of important items to be performed before and after the surgical procedure in order to reduce adverse events such as surgical site infections or retained
SAFETY instruments. It is one affordable and sustainable tool for reducing deaths from surgery in low and middle-income countries.
CHECKLIST
https://en.wikipedia.org/wiki/WHO_Surgical_Safety_Checklist
https://apps.who.int/iris/bitstream/handle/10665/44186/9789241598590_eng_Checklist.pdf

CONSENT -Consent may be expressed by a person verbally, in writing or by implying. The nurse should ensure that the person has understood what examination or treatment is intended and
why for the consent to be valid.
-Written consent is usually obtained from the patient by the person undertaking the procedure. Sometimes a nurse who has had the necessary consent training and is competent to
do so may seek to obtain consent. e.g. Advanced Nurse Practitioner.
-For consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to make the decision.
-A patient who has the mental capacity can give consent.
-The age of consent for organ donation is above 18 in the UK.

1. INFORMED Informed consent in medicine is the consent given by a person who has a clear appreciation and understanding of the facts, implications, and future
CONSENT consequences of an action. The term is also used in other contexts, such as in social scientific research, when participants are asked to affirm that they
understand the research procedure and consent to it, or in sex, where informed consent means each person engaging in sexual activity is aware of any positive
statuses (for sexually transmitted infections and/or diseases) they might expose themselves to.

Informed consent is when a person agrees to the test or treatment they have been offered, knowing the details, benefits, risks and expected outcome.

2.EXPRESSED It may be oral or in writing. Though both these categories of consent are of equal value, written consent can be considered superior because of its evidential
CONSENT value.

Oral -Oral consent should be taken in the presence of an uninterested thor party.
-Mainly in cases where intimate examination of females is required.
-Tests necessitating removal of body fluids, the radiological examination can be done after securing oral consent

Written -It is advisable to take written consent in the presence of a disinterested third party (this third party is only to attest the signature of the patient)

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-Consent should be taken in the patient's language.

-Written consent is mandatory in every invasive diagnostic/therapeutic procedure or any medicolegal examination.

3.IMPLIED Not all consent has to be written or documented fully. In much of clinical practice, where the patient is seeking medical help to relieve his suffering or pain,
CONSENT consent is implied consent. Implied consent is measured by the actions of the patient: stretching out his hand for blood taking, or taking off clothes and lying on
the couch when requested for a clinical examination. Implied consent is not implied or informed compliance.
In implied consent, the patient must be informed of what is to be done and be allowed to refuse.
In many other clinical situations where implied consent is exercised, consent could be recorded in the clinical notes under the plan of action, for example:
“Discussed options with the patient, he preferred delaying surgery for a trial of conservative medical treatment. Risk and benefits explained and understood.
Condition to be reviewed in one week.”

4.TACIT Tacit consent is often used to describe the opt-out system, or by an act of omission and silently not objecting. Here a patient or person not agreeing to a
CONSENT procedure has to take active action to refuse, if he does not want the procedure done on him. For example, some hospitals practice opt-out consent for HIV
testing, while some countries have moved to an opt-out system for the donation of organs at death. However, tacit consent, like all consent processes, must fulfil
three basic features, namely:
1. Capacity: understand the information, retain and consider (weigh the choices) and make a decision.
2. Disclosure: adequate information must be given to make the decision.
3. Voluntariness: must be done out of free will and under no coercion.

5.SURROGATE A surrogate decision maker, also known as a health care proxy or an agent, is an advocate for incompetent patients. If a patient is unable to make decisions for
CONSENT themselves about personal care, some agent must make decisions for them. If there is a durable power of attorney for health care, the agent appointed by that
document is authorized to make health care decisions within the scope of authority granted by the document.

6.ADVANCE Advance consent is a recognised method of obtaining informed consent for participation in research, whereby a potential participant provides consent for future
CONSENT involvement in a study contingent on qualifying for the study’s inclusion criteria at a later date. The goal of this study is to map the existing literature on the use
of advance consent for enrolment in randomised controlled trials (RCTs) for emergency conditions.

7.PROXY Proxy consent is the process by which people with the legal right to consent to medical treatment for themselves or for a minor or a ward delegate that right to
CONSENT another person. There are three fundamental constraints on this delegation:
1. The person making the delegation must have the right to consent.
2. The person must be legally and medically competent to delegate the right to consent.
3. The right to consent must be delegated to a legally and medically competent adult.

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8.INFORMED Informed choice is when a person is given options to choose from several diagnostic tests or treatments, knowing the details, benefits, risks and expected
CHOICE outcome of each.

https://en.wikipedia.org/wiki/Consent
https://www.slideshare.net/NcDas/consent-11741896
https://www.sma.org.sg/UploadedImg/files/Publications%20-%20SMA%20News/4506/CMEP.pdf
https://en.wikipedia.org/wiki/Surrogate_decision-maker
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9906254/
https://biotech.law.lsu.edu/books/lbb/x302.htm

EARLY
AMBULATION DOESN’T PREVENTS DEVELOPING THE INFECTION OF THE WOUND PREVENTS DEEP VEIN THROMBOSIS PREVENTS MUSCLE WASTING / ATROPHY
BENEFITS
PREVENTS CHEST INFECTION / RESPIRATORY INFECTIONS PREVENTS LUNG COLLAPSE PREVENTS VENOUS THROMBOEMBOLISM

INFORMED -A decision to participate in research, taken by a competent individual who has received the necessary information; who has adequately understood the information, and who, after
CONSENT considering the information, has arrived at a decision without having been subjected to coercion, undue influence or inducement, or intimidation.
-A process for getting permission before conducting a healthcare intervention on a person.
-The process by which the treating health care provider discloses appropriate information to a competent patient so that the patient may make a voluntary
the choice to accept or refuse treatment.
-The principle of informed consent is gaining permission from a patient who is competent to give it, by providing information in understandable terms prior to surgery, allowing time
for answering questions and inviting voluntary participation.
-For consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to make the decision.

INTRAOPERA- -Safe moving and handling of an anaesthetised patient are imperative to reduce harm to both the patient and staff.
TIVE CARE -To prevent patient injury during the transfer between the trolley and the operating table. There must be adequate staff (a minimum of four is recommended) to transfer the
patient onto the operating table.

NEWS2 Accurate postoperative observations are key to assessing a patient's deterioration or recovery. The Modified Early Warning Score (MEWS) is a scoring system that supports that aim.
The primary purpose of NEWS is to identify patients at risk of deterioration.

POST -A patient’s blood pressure, pulse and respiratory rate should be monitored and recorded every 5 minutes (not continuously).
ANAESTHETIC -The patient is expected to pass urine 6-8 hours after the surgery.
CARE UNIT
(PACU)

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INTENSIVE Mechanical ventilated patients must have a registered nurse/patient ratio of a minimum 1:1 to deliver direct care. A greater ratio than 1:1 may be required to safely meet the
CARE UNIT needs of some critically ill patients, such as unstable patients requiring various simultaneous nursing activities and complex therapies used in supporting multiple organ failure.

https://www.britishjournalofnursing.com/content/focus/changes-to-nurse-to-patient-ratios-in-intensive-care-during-the-pandemic/#:~:text='Ventilated%20patients%20must%20have%20a,1%20to%20deliver%20direct%20care.

EATING / The amount of time you have to go without food or drink (fast) before you have your operation will depend on the type of operation you're having.
DRINKING However, it is usually at least 6 hours for food, and 2 hours for fluids. You'll be told how long you must not eat or drink for before your operation.
PRIOR TO THE
https://www.nhs.uk/common-health-questions/operations-tests-and-procedures/can-i-eat-or-drink-before-an-operation/#:~:text=Usually%2C%20before%20having%20a%20general,up%20food%20into%20your%20throat.
SURGERY