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18 Preoperative Nursing Management1/29/2012 3:05:00 PM

Perioperative Nursing Periop period consists of 3 phases that begin & end at a particular point in sequence of events in the surgical experience. o Preop phase- when decision to proceed w/ surgical intervention is made & ends w/ transfer of pt onto the OR o Intraop phase begins when pt is transferred onto OR table & ends w/ admission to PACU (postanesthesia care unit) o Postop phase begins w/ admission of pt to PACU & ends w/ a follow-up evaluation in clinical setting or home. o The Perioperative Nursing Data Set (PNDS) categorizes practice of perioperative nursing practice into four domains: safety, physiological responses, behavioral responses, & health care systems. Surgical Classification Surgical procedure may be diagnostic (biopsy, exploratory laparotomy), curative (excision of a tumor or an inflamed appendix), or reparative (multiple wound repair). May be reconstructive or cosmetic (mammoplasty, facelift) or palliative (to relieve pain or correct a problem) May be classified according to degree of urgency involved: emergent, urgent, required, elective, & optional. o Emergent- Patient requires immediate attention; disorder may be life-threatening (w/out delay) Ex: Severe bleeding, bladder/intestinal obstruction, fractured skull, gunshot/ stab wounds, extensive burns o Urgent- Pt requires prompt attention (w/in 24-30 hrs) Ex: Acute gallbladder infection, kidney/ureteral stones o Required- Pt needs to have surgery ( w/in a few wks/months) Ex: Thyroid disorders, cataracts, prostatic hyperplasia w/out bladder obstruction o Elective- Pt should have surgery (failure not catastrophic) Ex: Repair of scars, simple hernia, vaginal repair o Optional- Decision rests w/ pt (personal preference) Ex: Cosmetic surgery

Preadmission Testing Pressure to reduce hospital stays & contain costs has resulted in diagnostic preadmission testing (PAT) & preop preparation prior to admission Special Considerations During the Perioperative Period Gerontology Considerations o Elderly pts have less physiologic reserve (ability of an organ to return to normal after a disturbance in its equilibrium) than younger pts. Patients Who Are Obese o Obesity risk & severity of complications associated w/ surgery. Difficult to care for because of excessive weight. o Fatty tissues are especially susceptible to infection. o Dehiscence (wound separation) & wound infections are more common o Pt tends to have shallow respirations when supine, which risk of hypoventilation & postop pulmonary complications. o Short thick necks, large tongues, & redundant pharyngeal tissue, along w/ increased demand for oxygen & decrease reserves, can make intubation difficulty Patients With Disabilities o Pts w/ mental/physical disabilities include need for appropriate assistive devices, modifications in preoperative teaching, assistance w/ & attn to positioning or transferring o Pt w/ disability that affects body positioning (cerebral palsy, postpolio syndrome, & other neuromuscular disorders) may need special positioning during surgery to prevent pain/injury o Pts w/ respiratory problems related to a disability (multiple sclerosis, muscular dystrophy) may experience difficulties unless problems are made known to anesthetist & adjustments are made. Patients Undergoing Ambulatory Surgery o Ambulatory surgery- outpatient, same-day, or short-stay surgery that does not require overnight hospital stay but may

entail an admission to an impatient hospital setting for less than 24 hrs. Patients Undergoing Emergency Surgery o Emergency surgeries are unplanned & occur w/ little time for preparation for pt or perioperative team o Only opportunity for preoperative assessment may take place at same time as resuscitation in emergency dept. o For the unconscious pt, informed consent & essential info, such as pertinent past medical history & allergies, need to be obtained from a family member, if one is available.

Informed Consent Informed consent- pts autonomous decision about whether to undergo a surgical procedure. Voluntary & written informed consent from pt is necessary before nonemergent surgery can be performed in order to protect pt from unsanctioned surgery & protect surgeon from claims of an unauthorized operation While nurse may ask pt to sign consent form & witness signature, it is surgeons responsibility to provide a clear & simple explanation of what the surgery will entail prior to pt giving consent. Nurse clarifies information provided, & if additional info is requested, nurse notifies physician. Signed consent form is placed in a prominent place on pts chart & accompanies patient to OR. Informed consent is necessary in following: o Invasive procedures (surgical incision, biopsy, paracentesis) o Procedures requiring sedation &/or anesthesia o Nonsurgical procedure (arteriography) o Procedures involving radiation In emergency, it may be necessary for surgeon to operate as a lifesaving measure w/out pts informed consent. However, every effort must be made to contact pts family (telephone, fax, other)

Preoperative Assessment Goal in preoperative period is for pt to be as healthy as possible.

Before any surgical treatment, a health history is obtained, physical examination is performed during which vital signs are noted, & a database is established for future comparisons. Blood tests, x-rays, & other diagnostic tests are prescribed when indicated by info obtained from history & physical examination Nutritional and Fluid Status o Optimal nutrition is essential factor in promoting healing & resisting infection & other surgical complications. o Any nutritional deficiency (malnutrition) should be corrected before surgery to provide adequate protein for tissue repair. Dentition o Dental caries, dentures, & partial plates are significant to anesthesiologist/anesthetist, because decayed teeth/dental prostheses may become dislodged during intubation & occlude airway. Drug or Alcohol Use o Surgery is postponed if possible because acutely intoxicated people are susceptible to injury o Alcohol w/drawal syndrome may be anticipated between 4872 hrs after alcohol w/drawal & associated w/ significant mortality rate when it occurs postoperatively Respiratory Status o Goal- optimal respiratory function o Usually postponed if pt has respiratory infection o Pts who smoke are urged to stop 4-8 wks before surgery to reduce pulmonary & wound healing complications. Cardiovascular Status o Goal- ensure a well-functioning cardiovascular system to meet oxygen, fluid, & nutritional needs Hepatic & Renal Function o Goal- optimal function of liver & urinary systems so that meds, anesthetic agents, body wastes, & toxins are adequately metabolized & removed from body.

o Liver important in biotransformation of anesthetic compounds. Any disorder of the liver has an effect on how anesthetic agents are metabolized. o Kidneys- involved in excreting anesthetic meds & their metabolites. Surgery is contraindicated if pt has acute nephritis, acute renal insufficiency w/ oliguria or anuria or other acute renal problems. Endocrine Function o Pt w/ diabetes who is undergoing surgery is at risk for hypoglycemia & hyperglycemia. o Hypoglycemia may develop during anesthesia or postop from inadequate carbohydrates/excessive administration of insulin. o Hyperglycemia (can risk for surgical wound infection) may result from stress of surgery, which can trigger increased levels of catecholamine. o Other risks: acidosis & glucosuria o Pts who have received corticosteroids are at risk for adrenal sufficiency. Must be reported. o Pts w/ uncontrolled thyroid disorders are at risk for thyrotoxicosis (w/ hyperthyroid disorders) or respiratory failure (w/ hypothyroid disorders). Immune Function o Determine presence of allergies. o Immunosuppression common w/ corticosteroid therapy, renal transplantation, radiation therapy, chemotherapy, & disorders affecting immune system, such as acquired immunodeficiency syndrome (AIDS) & leukemia. o Mildest symptoms/ slightest temp must be investigated Previous Medication Use o Med history obtained because of possible effects of meds on pts periop course, including possibility of drug interactions o Aspirin- a common OTC med that inhibits platelet aggregation; therefore it is prudent to stop aspirin at least 710 days before surgery if possible o Nursing Alert: Because of possible adverse interactions, nurse must assess & doc pts use of prescription meds, OTC meds

(aspirin), herbal agents, & frequency w/ which meds are used. Nurse must clearly communicate this info to anesthesiologist or anesthetist. o Herbal products be discontinued 2-3 wks before surgery Psychosocial Factors o Preoperative anxiety may be an anticipatory response to an experience viewed by the pt as a threat to his/her customary role in life, permanent incapacity, body integrity, increased responsibilities or burden on family members, or life itself. Spiritual & Cultural Beliefs o Play an important role in how people cope w/ fear & anxiety. o Spiritual beliefs can be as therapeutic as medication.

General Preoperative Nursing Interventions Providing Patient Teaching o Multiple teaching strategies should be used (verbal, written, return demonstration), depending on pts needs & abilities o Teaching initiated as soon as possible, beginning in physicians office, clinic, or at time of PAT when diagnostic tests are performed. o Teaching should include sensations the pt will experience. o o Deep Breathing, Coughing, & Incentive Spirometer Goal- teach pt how to promote optimal lung expansion & resulting blood oxygenation after anesthesia Pt assumes sitting position to enhance lung expansion. Nurse demonstrates how to take a deep, slow breath & how to exhale slowly. After practicing several times, pt is instructed to breathe deeply, exhale through mouth, take a short breath, & cough from deep in the lungs. Incentive Spirometer- a device that provides measurement & feedback r/t breathing effectiveness. If thoracic/abdominal incision is anticipated, nurse demonstrates how to splint incision to minimize pressure & control pain.

Pt should put palms of both hands together. Placing hands across incision site acts as an effective splint when coughing. Goal in promoting cough- to mobilize secretions so that they can be removed. Deep breathing before coughing stimulates cough reflex. o Mobility & Active Body Movement Goals- improve circulation, prevent venous stasis, & promote optimal respiratory function. o Pain management Pain assessment should include differentiation between acute & chronic pain. Anticipated methods of administration of analgesic agents for inpatients include patient-controlled analgesia (PCA), epidural catheter bolus or infusion, or patient-controlled epidural analgesia (PCEA). o Cognitive Coping Strategies Useful for relieving tension, overcoming anxiety, decreasing fear, & achieving relaxation. Ex: Imagery, Distraction, Optimistic selfrecitation, Music therapy o Instruction for Patients Undergoing Ambulatory Surgery Major difference in outpatient preop education is teaching environment. Preop teaching content may be presented in a group class, videotape, at PAT, by telephone in conjunction w/ preop interview. When & where to report, what to expect, what to bring, what to leave at home, what to wear Providing Psychosocial Interventions o Reducing Anxiety & Decreasing Fear Knowing ahead of time about possible need for ventilator, drainage tubes, or other types of equipment helps decrease anxiety r/t postop period. o Respecting Cultural, Spiritual, & Religious Beliefs

Psychosocial interventions include identifying & showing respect for cultural, spiritual, religious beliefs. o Maintaining Patient Safety Major role- protecting pts from injury o Managing Nutrition & Fluids Major purpose of w/holding food/fluid before surgery is to prevent aspiration. Fast 8 hrs after eating fatty food, 4 hrs after ingesting milk products Many pts currently allowed clear liquids up to 2 hrs before an elective procedure o Preparing the Bowel Enemas not commonly prescribed preop unless pt is undergoing abdominal or pelvic surgery. Goals- allow satisfactory visualization of surgical site & to prevent trauma to intestine or contamination of peritoneum by fecal material Toilet or bedside commode, rather than bedpan, is used for evacuating enema if pt is hospitalized at this time. o Preparing Skin Goal- Decrease bacteria w/out injury to skin Hair is not removed preop unless hair at/around incision site is likely to interfere w/ operation. Immediate Preoperative Nursing Interventions Immediately prior to procedure pt changes into hospital gown that is left untied & open in back. Mouth inspected, & dentures/ plates removed Jewelry not worn to the OR All pts (except those w/ urologic disorders) should void immediately before going to the OR Administering Preanesthetic Medication o Minimal w/ ambulatory or outpatient surgery o Often, surgery is delayed or OR schedules change, & becomes impossible to request a med be given at a specific time

In these situations, preop med is prescribed on call to OR. Nurse can have med ready to administer as soon as call is received from OR staff. Usually takes 15-20 min to prepare to pt for OR. Maintaining the Preoperative Record o Completed chart (w/ preop checklist & verification form) accompanies pt to OR w/ surgical consent form attached, along w/ all lab reports & nurses records. Transporting the Patient to the Presurgical Area o Pt transferred to holding area/presurgical suite in a bed or on a stretcher about 30-60 min before anesthetic is to be given. o Patient safety in preoperative area is a priority. Attending Family Needs o Pt may be in OR much longer than actual operating time for several reasons: Pts are routinely transported well in advance of actual operating time. Anesthesiologist/anesthetist often make additional preparations that may take 30-60 min. Surgeon may take longer than expected w/ preceding case, which delays start of next surgical procedure. o It is the surgeons responsibility, not the nurse, to relay surgical findings & the prognosis, even when findings are favorable.

Expected Patient Outcomes Relief of anxiety, decreased fear, understanding of surgical intervention, no evidence of preop complications

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1/29/2012 3:05:00 PM