focus on preoperative care

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

(Relates to Chapter 18, “Nursing Management:

Preoperative Care,” in the textbook)


Art and science of treating diseases, injuries, and deformities by operation and instrumentation


Performed for◦ Diagnosis◦ Cure◦ Palliation◦ Prevention◦ Exploration◦ Cosmetic improvement


Inpatient ◦ Same day admission

Ambulatory (outpatient)◦ Usually less than 3 to 4 hours in PACU


Check documented information prior to interview◦ Avoids repetition

Occurs in advance or on day of surgery


Purpose◦ Obtain health information◦ Determine expectations◦ Provide and clarify information on procedure◦ Assess emotional state and readiness


Overall goal◦ Identify risk factors◦ Plan care to ensure patient safety


Determine psychologic status to reinforce coping strategies

Determine psychologic factors of procedure contributing to risks


Establish baseline data Identify medications and herbs taken that

may affect surgical outcome Identify, document, and communicate

results of laboratory/diagnostic tests


Identify cultural and ethnic factors that may affect surgical experience

Determine receipt of adequate information from surgeon in order to sign informed consent


Psychosocial assessment◦ Excessive stress response can be magnified and

recovery affected


Influencing factors◦ Age◦ Past experience◦ Current health◦ Socioeconomic status


Use common language Use translators if needed

◦ Decreases level of anxiety Communicate all concerns to surgical team


Anxiety can impair cognition, decision making, and coping abilities◦ Lack of knowledge◦ Unrealistic expectations◦ Information lessens anxiety


Anxiety may arise from conflict with interventions (e.g., blood transfusions) and religious/cultural beliefs ◦ Identify beliefs and discuss with surgeon and

operative staff


Fears◦ Death or disability

May prompt postponement Influence outcome

◦ Pain Consult with ACP Reassure that drugs will be available


Fears ◦ Mutilation/alteration in body image

Assess concerns nonjudgmentally◦ Anesthesia

ACP for consult Assess malignant hyperthermia risk


Fears◦ Disruption of life functioning

Range from fear of permanent disability to temporary loss

Include family and financial concerns Consultations PRN


Hope◦ May be strongest positive coping mechanism

Never deny or minimize◦ Assess and support


Health history◦ Diagnosed medical conditions◦ Previous surgeries and problems◦ Menstrual/obstetric history


Health history ◦ Familial diseases

Conditions◦ Reactions/problems to anesthesia (patient or

family)


Current medications◦ Prescription and OTC◦ Herbs◦ Vitamins◦ Recreational

Drugs Alcohol Tobacco


Allergies (drug and nondrug) Screen areas:

◦ Risk factors◦ Contact urticaria◦ Aerosol reactions◦ History of reactions suggesting latex allergy


Cardiovascular system◦ Report

Problems for effective monitoring Use of cardiac drugs Presence of pacemaker/MI


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


Respiratory system◦ Inquire about recent airway infections

Procedure could be cancelled because of increased risk of laryngo/bronchospasm or decreased SaO2


Respiratory system◦ History of dyspnea, coughing, or hemoptysis

reported to operative team◦ COPD or asthma

High risk for atelectasis and hypoxemia


Respiratory system◦ Smokers should be encouraged to quit 6 weeks

before procedure Decreases risk of complications Greater years and number of packs = greater risk


Nervous system◦ Evaluation of neurologic functioning

Vision or hearing loss can influence results


Nervous system◦ Cognitive function

Assess or correct any deficits before surgery Durable power of attorney for health care should be

obtained if deficits cannot be corrected


Nervous system◦ Cognitive function

Postoperative delirium (falsely labeled senility or dementia) can occur with dehydration, hypothermia, and adjunctive medications


Urinary system◦ History of urinary or renal diseases◦ Renal dysfunction contributes to

Fluid and electrolyte imbalances Increased risk of infection Impaired wound healing Altered response to drugs and their elimination


Urinary system ◦ Renal function tests◦ Note problems voiding and inform operative team


Integumentary system◦ History of skin and musculoskeletal problems◦ History of pressure ulcers

Extra padding during procedure Affect postoperative healing


Musculoskeletal system◦ Identify joints affected with arthritis◦ Mobility restrictions may affect positioning and

ambulation◦ Bring mobility aids to surgery


Musculoskeletal system ◦ Report problems affecting neck or lumbar spine to

ACP Can affect airway management and anesthesia

delivery


Endocrine system◦ Patients with diabetes mellitus especially at risk

for: Hypo/hyperglycemia Ketosis Cardiovascular alterations Delayed wound healing Infection


Endocrine system◦ Patients with diabetes mellitus

Serum glucose tests morning of surgery (baseline) Clarify with physician or ACP if usual dose of insulin

is taken


Endocrine system◦ Patients with thyroid dysfunction

Hyper/hypothyroidism are surgical risks due to altered metabolic rate

Verify with ACP about giving medications


Endocrine system◦ Patients with Addison’s disease

Abruptly stopping replacement corticosteroids could cause addisonian crisis

Stress of surgery may require increased dose of corticosteroids


Immune system◦ Patients with history of compromised immune

system or use of immunosuppressive drugs can have Delayed wound healing Increased risk for infection


Fluid and electrolyte status◦ Vomiting, diarrhea, or difficulty swallowing can

cause imbalance◦ Identify drugs that alter status

Diuretics◦ Evaluate serum electrolyte levels


Fluid and electrolyte status ◦ NPO status

May require additional fluids and electrolytes before surgery if dehydration occurs


Nutritional status◦ Obesity

Stresses cardiac and pulmonary systems Increased risk of wound dehiscence and infection Slower recovery from anesthesia Slower wound healing


Nutritional status ◦ Provide extra padding to underweight patients to

prevent pressure ulcers◦ Identify dietary habits that may affect recovery

(e.g., caffeine)


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

outcome


Document relevant findings and report to perioperative team

Obtain and evaluate results of laboratory tests

Monitor blood glucose for diabetics


Preoperative teaching◦ Patient has right to know what to expect and how

to participate Increases patient satisfaction Reduces fear, anxiety, stress, pain, and vomiting


Preoperative teaching ◦ Limited time available

Address needs of highest priority Include information focused on safety Provide written material


Preoperative teaching ◦ Several days before surgery

Observe and listen to determine amount of teaching for each session

Anxiety and fear can hinder learning Give priority to patient’s concerns


Preoperative teaching ◦ Must be documented and reported to

postoperative nurses Avoid duplication of information Assess learning


Preoperative teaching◦ Teach deep breathing, coughing, and moving for

postop◦ Inform if tubes, drains, monitoring devices, or

special equipment will be used postop


Preoperative teaching◦ Basic information before arrival

Time and place Fluid and food restrictions Need for enema Need for shower


Legal preparation◦ All required forms are signed and in chart

Informed consent Blood transfusions Advance directives Power of attorney


Consent for surgery◦ Informed consent must include

Adequate disclosure Understanding and comprehension Voluntarily given consent


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


Consent for surgery◦ Medical emergency may override need for

consent


Legally appointed representative of family may consent if patient is◦ Child◦ Unconscious◦ Mentally incompetent


Day-of-surgery preparation◦ Final preoperative teaching ◦ Assessment and report of pertinent findings◦ Verify signed consent


Day-of-surgery preparation◦ Labs ◦ History and physical examination◦ Baseline vitals◦ Consultation records◦ Nurse’s notes


Day-of-surgery preparation ◦ Patient should not wear any cosmetics

Observation of skin color is important Remove nail polish for pulse oximeter


Day-of-surgery preparation◦ Valuables returned to family member or locked up◦ Dentures, contacts, prostheses are removed◦ Identification and allergy bands on wrist


Void before surgery◦ Prevents involuntary elimination under anesthesia

or early postoperative recovery◦ Before medication administration


45-year-old woman presents to holding area for presurgical workup for lumpectomy

The nurse notes consistent fidgeting


She is unable to articulate details about what surgeon will do or her disease process

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


1. What do you think is happening with her?

2. What can you do to help her and prepare her for the procedure?

3. What should you not ask the patient to do?

focus on preoperative care

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