Pre Op

Chapter 18 Preoperative Care Evelyn Robinson, MSN, RN
Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Surgery
Art and science of treating diseases, injuries, and
deformities by operation and instrumentation

2
Surgery
Performed for
Diagnosis Cure Palliation Prevention
Exploration
Cosmetic improvement

3
Surgical Settings
Elective surgery vs. emergency surgery
Inpatient
Same-day admission
Ambulatory (outpatient)

4
Your Role Preop

Have knowledge of the nature of the disorder
requiring surgery. Identify the individual patients response to the stress of surgery. Assess the results of appropriate preoperative diagnostic tests. Provide a baseline by identifying potential risks and complications.

5
Patient Interview
Check documented information prior to interview.
Avoids repetition
Occurs in advance or on day of surgery

6
Patient Interview
Purpose
Obtain health information. Determine expectations. Provide and clarify information on procedure. Assess emotional state and readiness.

7
Nursing Assessment
Overall goals
Identify risk factors. Plan care to ensure patient safety.

8
Nursing Assessment Goals

Determine psychologic status to reinforce coping
strategies. Determine psychologic factors of the procedure contributing to risks. Determine physiologic factors that may contribute to increased surgical risk.

9

Establish baseline data.
Identify medications and herbs taken that may
affect surgical outcome. Identify, document, and communicate results of laboratory/diagnostic tests.

10

Identify cultural and ethnic factors that may affect
surgical experience. Determine receipt of adequate information from surgeon to sign informed consent. Determine informed consent and that informed consent form is signed and witnessed.

11
Nursing Assessment
Psychosocial assessment
Excessive stress response can be magnified and
affect recovery.

12
Nursing Assessment
Influencing factors
Age Past experience Current health Socioeconomic status

13
Nursing Assessment
Use common language.
Use translators if needed.

Decreases level of anxiety
Communicate all concerns to surgical team.

14
Nursing Assessment
Anxiety can impair cognition, decision making,
and coping abilities. Anxiety can arise from

Lack of knowledge Unrealistic expectations
Information lessens anxiety.

15
Nursing Assessment
Anxiety may arise from conflict with interventions
(i.e., blood transfusions) and religious/cultural beliefs.

Identify beliefs and discuss with surgeon and
operative staff.

16
Nursing Assessment
Fears
Death or disability May prompt postponement Influence outcome Pain Consult with ACP. Confirm drugs will be available.

17
Nursing Assessment
Fears
Mutilation/alteration in body image Assess concerns nonjudgmentally. Anesthesia ACP for consult

18
Nursing Assessment
Fears
Disruption of life functioning Range from fear of permanent disability to temporary loss Include family and financial concerns Consultations PRN

19
Nursing Assessment
Hope
May be strongest positive coping mechanism Never deny or minimize. Assess and support.

20
Nursing Assessment
Health history
Diagnosed medical conditions (previous and
current) Previous surgeries and problems Menstrual/obstetric history

21
Nursing Assessment
Health history
Familial diseases
Conditions Reactions/problems to anesthesia
(patient or family)

22
Nursing Assessment
Current medications
Prescription and OTC Herbs Dietary supplements Recreational Drugs Alcohol Tobacco

23
Nursing Assessment
Allergies (drug and nondrug)
Screen for latex allergy:

Risk factors Contact urticaria or dermatitis Aerosol reactions History of reactions suggesting latex allergy

24
Nursing Assessment
Cardiovascular system
Report Any cardiac problems so they can be monitored during the intraoperative period Use of cardiac drugs Presence of pacemaker/ICD

25
Nursing Assessment
Cardiovascular system
Vitals recorded preoperatively for baseline Bleeding/clotting times Laboratory reports Possible prophylactic antibiotics

26
Nursing Assessment
Respiratory system
Inquire about recent airway infections. Procedure could be cancelled because of increased risk of laryngo/bronchospasm or decreased SaO2.

27
Nursing Assessment
Respiratory system
History of dyspnea, coughing, or hemoptysis
reported to operative team COPD or asthma

High risk for atelectasis and hypoxemia

28
Nursing Assessment
Respiratory system
Smokers should be encouraged to quit 6 weeks
before procedure.
Decreases risk of complications Greater years and number of packs = greater risk

29
Nursing Assessment
Nervous system
Evaluation of neurologic functioning Vision or hearing loss can influence results.

30
Nursing Assessment
Nervous system
Cognitive function Determine if any deficits are present.

31
Nursing Assessment
Genitourinary system
History of urinary or renal diseases Renal dysfunction contributes to Fluid and electrolyte Increased risk of infection Impaired wound healing Altered response to drugs and their elimination

32
Nursing Assessment
Genitourinary system
Renal function tests Note problems voiding, and inform operative team.

33
Nursing Assessment
Hepatic system
Liver detoxifies many anesthesics and adjunctive
drugs. Hepatic dysfunction may increase risk of postoperative complications.

34
Nursing Assessment
Integumentary system
History of skin and musculoskeletal problems History of pressure ulcers Extra padding during procedure Affects postoperative healing

35
Nursing Assessment
Musculoskeletal system
Identify joints affected with arthritis. Mobility restrictions may affect positioning and
ambulation. Bring mobility aids to surgery.

36
Nursing Assessment
Musculoskeletal system
Report problems affecting neck or lumbar spine to
ACP.
Can affect airway management and anesthesia delivery

37
Nursing Assessment
Endocrine system
Patients with diabetes mellitus especially at risk for: Hypo/hyperglycemia Ketosis Cardiovascular alterations Delayed wound healing Infection

38
Nursing Assessment
Endocrine system
Patients with diabetes mellitus Serum or capillary glucose tests morning of surgery (baseline) Clarify with physician or ACP regarding insulin dose.

39
Nursing Assessment
Endocrine system
Patients with thyroid dysfunction Hyper/hypothyroidism are surgical risks due to altered metabolic rate. Verify with ACP about giving thyroid medications.

40
Nursing Assessment
Endocrine system
Patients with Addisons disease Abruptly stopping replacement corticosteroids could cause addisonian crisis. Stress of surgery may require increased dose of corticosteroids.

41
Nursing Assessment
Immune system
Patients with history of compromised immune
system or use of immunosuppressive drugs can have

Delayed wound healing Increased risk for infection

42
Nursing Assessment
Fluid and electrolyte status
Vomiting, diarrhea, or difficulty swallowing can
cause imbalances. Identify drugs that alter F and E status.

Diuretics
Evaluate serum electrolyte levels.

43
Nursing Assessment
Fluid and electrolyte status
NPO status May require additional fluids and electrolytes before surgery if dehydration occurs

44
Nursing Assessment
Nutritional status
Obesity Stresses cardiac and pulmonary systems Increased risk of wound dehiscence and infection Slower recovery from anesthesia Slower wound healing

45
Nursing Assessment
Nutritional status
Provide extra padding to underweight patients to
prevent pressure ulcers. Identify dietary habits that may affect recovery (e.g., caffeine). May be protein and vitamin deficient

46
Nursing Assessment: Exam

Findings enable ACP to rate patient for
anesthesia administration.
Indicator of perioperative risk and overall outcome

47
Nursing Assessment: Exam

Document relevant findings, and report to
perioperative team. Obtain and evaluate results of laboratory tests. Monitor blood glucose for patients with diabetes.

48
Nursing Management
Preoperative teaching
Patient has right to know what to expect and how to
participate.
Increases patient satisfaction Reduces fear, anxiety, stress, pain, and vomiting

49
Nursing Management
Limited time available Address needs of highest priority. Include information focused on safety. Provide written material.

50
Nursing Management
Several days before surgery Observe and listen to determine amount of teaching for each session. Anxiety and fear can hinder learning. Give priority to patients concerns.

51
Nursing Management
Three types Sensory Process Procedural

52
Nursing Management
Must be documented and reported to postoperative
nurses
Avoid duplication of information. Assess learning.

53
Nursing Management
Teach deep breathing, coughing, and early
ambulation as appropriate. Inform if tubes, drains, monitoring devices, or special equipment will be used postop. Provide surgery-specific information.

54
Nursing Management
Basic information before arrival Time and place Fluid and food restrictions Need for enema Need for shower

55
Nursing Management
Legal preparation
All required forms are signed and in chart: Informed consent Blood transfusions Advance directives Power of attorney

56
Nursing Management
Consent for surgery
Informed consent must include Adequate disclosure Understanding and comprehension Voluntarily given consent

57
Nursing Management
Surgeon responsible for obtaining consent
Nurse may obtain and witness signature. Verify patient has understanding. Permission may be withdrawn at any time.

58
Nursing Management
Consent for surgery
Medical emergency may override need for consent.

59
Nursing Management
Legally appointed representative of family may
consent if patient is
Minor Unconscious Mentally incompetent

60
Nursing Management
Day-of-surgery preparation
Final preoperative teaching Assessment and report of pertinent findings Verify signed consent.

61
Nursing Management
Labs History and physical examination Baseline vitals Consultation records
Nurses notes

62
Nursing Management
Patient should not wear any cosmetics. Observation of skin color is important. Remove nail polish for pulse oximeter.

63
Nursing Management
Valuables are returned to family member or locked
up. Dentures, contacts, prostheses are removed. Identification and allergy bands on wrist

64
Nursing Management
Void before surgery
Prevents involuntary elimination under anesthesia
or during early postoperative recovery Before medication administration

65
Audience Response Question

A 68-year-old scheduled for a herniorrhaphy at an ambulatory surgical center expresses concern that he will not have enough care at home and asks if he can stay in the hospital after the surgery. The best response by the nurse is: 1. Who is available to help you at home after the surgery? 2. Im sure you will be able to manage at home after surgery. It is a simple procedure. 3. We will teach you everything you need to know to be able to care for yourself after surgery. 4. Your health insurance will pay for inpatient care only if complications develop during surgery.
66
Audience Response Question

Preoperative instruction that is appropriate for all patients includes 1. Techniques of deep breathing and coughing. 2. Descriptions of the planned surgical procedure. 3. Physical procedures or preparation required before surgery. 4. Withholding of all oral fluids or food after midnight on the day of surgery.

67
Case Study
68
Case Study
45-year-old woman presents to holding area for
presurgical workup for right breast lumpectomy.

The nurse notes constant fidgeting.

69
Case Study
She is unable to articulate details about what the
surgeon will do or her disease process.

She reacts angrily when asked if she would
consent to transfusion, if needed.

70
Discussion Questions
1. What do you think is happening with her? 2. What can you do to help her and prepare her
for the procedure?

71

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Chapter 18 Preoperative Care Evelyn Robinson, MSN, RN

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

deformities by operation and instrumentation

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Your Role Preop

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Occurs in advance or on day of surgery

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Goals

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Goals

Identify medications and herbs taken that may

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Goals

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Use translators if needed.

Communicate all concerns to surgical team.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

and coping abilities. Anxiety can arise from

Information lessens anxiety.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

(i.e., blood transfusions) and religious/cultural beliefs.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

current) Previous surgeries and problems Menstrual/obstetric history

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Screen for latex allergy:

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

reported to operative team COPD or asthma

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

drugs. Hepatic dysfunction may increase risk of postoperative complications.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

ambulation. Bring mobility aids to surgery.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

system or use of immunosuppressive drugs can have

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

cause imbalances. Identify drugs that alter F and E status.

Evaluate serum electrolyte levels.