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Care of the Preoperative Patient

Chapter 16

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Begins when patient is scheduled for surgery; ends at time of transfer to surgical suite

Nurse functions as educator, advocate, promoter of health and safety

Preoperative Period

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Tubes Drains Vascular access

Patient & Family Teaching

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Nasogastric Tube

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Breathing exercises Incentive spirometry Coughing and splinting

Prevention of Respiratory Complications

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Decreased: Cardiac output, peripheral circulation Vital capacity, blood oxygenation Blood flow to kidneys, glomerular filtration rate

Increased: Blood pressure Risk for skin damage, infection Sensory deficits Deformities related to osteoporosis/arthritis

Older Adults: Changes of Aging as Surgical

Risk Factors

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Chronic illness Malnutrition Impaired self-care ability Allergies Inadequate support systems

Older Adults: Considerations for Preoperative

Care

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Stress from surgery/anesthesia Cardiopulmonary complications after surgery Mental status changes Risk for falls

Older Adults: Considerations for Preoperative

Care

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Diagnostic – determines origin and cause of disorder

Curative – resolves health problem by repairing or removing cause

Restorative – improves patient’s functional ability

Palliative – relieves symptoms of disease process, but does not cure

Cosmetic – alters/enhances personal appearance

Reasons for Surgery

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Urgency: Elective Urgent Emergent

Degree of Risk: Minor Major

Urgency and Degree of Risk of Surgery

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Simple Radical Minimally invasive (MIS)

Extent of Surgery

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Preoperative teaching Encourage communication Promote rest Use distraction Teach family members

Anxiety Interventions

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Break in the skin increases risk for infection Patient may be asked to shower using

antiseptic solution Hair removal by electric clippers, depilatories Shaving of hair creates risk for infection!

Skin Preparation

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Reduce anxiety Promote relaxation Reduce nasal and oral secretions

Preoperative Drugs

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Prevent laryngospasm Reduce vagal-induced bradycardia Inhibit gastric secretion Decrease amount of anesthetic needed for

induction and maintenance of anesthesia

Preoperative Drugs

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History and data collection: Age Drugs, substance use Medical history (including cardiac and pulmonary) Complementary/alternative practices Previous surgical procedures, anesthesia Blood donations Discharge planning

Collaborative Management: Assessment

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Obtain baseline vital signs Focus on problem areas identified in history;

all body systems affected by surgical procedure

Report abnormal assessment findings to surgeon/anesthesiology personnel

Physical Assessment / Clinical Manifestations

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Cardiovascular CAD, MI within 6 months before surgery, angina,

hypertension, dysrhythmias Respiratory

Chronic respiratory problems Smoking increases carboxyhemoglobin blood

level, deceases oxygen delivery Renal/Urinary

Kidney impairment inhibits drugs/anesthetic agent excretion

System Assessment

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Neurologic Determine baseline Assess LOC, ability to follow commands

Musculoskeletal Nutritional status

Malnutrition and obesity increase surgical risk Psychosocial

System Assessment

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Be aware of patients at greater risk for DVT Antiembolism stockings Pneumatic compression devices Leg exercises Mobility

Prevention of Cardiovascular Complications

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Urinalysis Blood type and crossmatch CBC or hemoglobin level and hematocrit Clotting studies (PT, INR, aPTT)

Laboratory Assessment

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Electrolyte levels Serum creatinine level Pregnancy test Chest x-ray ECG

Laboratory Assessment

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Preoperative teaching Informed consent:

Surgeon obtains signed consent before sedation and/or surgery

Nurse clarifies facts and dispels myths about surgery

Nurse not responsible for providing detailed information about procedure!

Insufficient Information Interventions

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Patients may sign with “X” In emergency, telephone authorization is

acceptable Special permits required for some procedures

Informed Consent

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Ensure correct site is selected and wrong site is avoided

Licensed independent practitioner marks site, involving patient if possible

“Time out” procedure adopted by most facilities

NPSGs and Informed Consent

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NPO: Patient not to ingest anything by mouth for 6 to 8 hours before surgery: Decreases risk for aspiration Give patients written/oral directions to stress

adherence Surgery can be canceled if instructions not

followed

Implementing Dietary Restrictions

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Consult with physician and anesthesia provider for instructions

Drugs for certain conditions often allowed with a sip of water: Cardiac disease Respiratory disease Seizures Hypertension

Administering Regularly Scheduled

Medications

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Performed to prevent injury to colon; reduce number of intestinal bacteria

Enema or laxative

Intestinal Preparation

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Patient using Incentive Spirometer

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Obese patients Age 40 or older History of cancer Decreased mobility or immobile Spinal cord injury

Patients at Risk for VTE

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History of VTE, PE, varicose veins, edema Oral contraceptives Smoking History of decreased cardiac output Hip fracture, total hip/knee surgery

Patients at Risk for VTE

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External Pneumatic Compression Devices

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Ensure all documentation, preoperative procedures, orders are complete

Check surgical consent form and others for completeness

Inform patient that area will be marked before procedure begins

Document allergies, height, and weight

Preoperative Chart Review

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Ensure all laboratory and diagnostic test results are in chart

Document/report any abnormal results Report special needs and concerns

Preoperative Chart Review

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Remove most clothing; provide gown Leave valuables with family member or lock

up Tape rings in place if cannot be removed Ensure patient is wearing ID band

Preoperative Patient Preparation

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Remove: Dentures Prosthetic devices Hearing aids Contact lenses Fingernail polish Artificial nails Pierced jewelry

Preoperative Patient Preparation

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Sedatives Hypnotics Anxiolytics Opioid analgesics Anticholinergic agents H2 histamine blockers

Drugs for Preoperative Preparation

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Chapter 16

Audience Response System

Questions

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To ensure safe patient care transition from the perioperative nurse to the intraoperative nurse, optimal hand-off communication includes all of the following except:

A. Providing a recent patient history, vital signs, allergy, and medication updates

B. Verbally verifying that the operating room nurse understands the report

C. Encouraging the operating room nurse to interrupt to ask questions as the perioperative nurse provides report

D. Using a standardized hand-off communication tool to provide report (e.g., SBAR, Five-Ps, PACE)

Question 1

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When assessing the laboratory work of a 65-year-old patient who is scheduled for surgery this morning, which laboratory value may result in cancellation of the surgery?

A. Serum sodium level 149 mEq/L B. Fasting blood glucose 120 mg/dLC. Hemoglobin 10.5 g/dLD. Serum potassium 2.9 mEq/L

Question 2

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During a preoperative assessment, the nurse asks the patient about allergies. Which allergy cited by the patient would be of greatest concern during the surgical procedure?

A. ShellfishB. Sulfa drugsC. CodeineD. Kiwi

Question 3