Preoperative Care • Surgery o Art and science of treating diseases, injuries, and deformities by operation and instrumentation o The surgical experience involves an interprofessional team including the patient, surgeon, anesthesia care provider (ACP), nurse, and other health care team members. • Surgery o Performed for • Diagnosis • Determining the presence and/or extent of pathology (e.g., lymph node biopsy, bronchoscopy) • Cure • Eliminating or repairing pathology (e.g., removing a ruptured appendix, benign ovarian cyst) • Palliation • Alleviating symptoms without cure (e.g., cutting a nerve root [rhizotomy] to remove symptoms of pain, creating a colostomy to bypass an inoperable bowel obstruction) • Prevention • Examples include removing a mole before it becomes malignant or removing the colon in a patient with familial polyposis to prevent cancer • Cosmetic improvement • Examples include repairing a burn scar or breast reconstruction after a mastectomy • Exploration • Conducting a surgical examination to determine the nature or extent of a disease (e.g., laparotomy) • Surgical Settings o Elective surgery • Carefully planned event o Emergency surgery • unexpected surgery o Inpatient • Same-day admission • For inpatient surgery, patients who are going to be admitted to the hospital are usually admitted on the day of surgery o Ambulatory (same day or outpatient) • May be conducted in endoscopy clinics, physicians’ offices, free-standing surgical clinics, and outpatient surgery units in hospitals • Can be performed using general, regional, or local anesthetic • Have an operating time of less than 2 hours • Require less than a 24-hour stay postoperatively • • Your Role Preop o Have knowledge of the nature of the disorder requiring surgery o Identify the individual patient’s response to the stress of surgery o Have knowledge of the results of preoperative diagnostic tests o Identify potential risks and complications associated with surgery Patient Interview Check documented information before interview • Avoids repetition Occurs in advance of or on day of surgery • • • o Patient Interview o Purpose • Obtain health information, including drug and food allergies • Provide and clarify information about the surgery and anesthesia • Assess emotional state and readiness • Determine expectations Nursing Assessment o Overall goals • Identify risk factors • Plan care to ensure patient safety Nursing Assessment Goals Establish baseline data for comparison intraoperative and postoperative Determine psychologic status to reinforce coping strategies Determine physiologic factors of procedure contributing to risks • o Nursing Assessment Goals Identify and document surgical site Identify drugs, OTC medications, and herbs taken that may affect surgical outcome Review results of preoperative diagnostic studies • • o Nursing Assessment Goals o Identify cultural and ethnic factors that may affect surgical experience o Determine receipt of adequate information from surgeon to sign informed consent o Determine that consent form is signed and witnessed Nursing Assessment o Psychosocial assessment • Excessive stress response can be magnified and affect recovery • Even for a procedure considered minor, surgery is a stressful event. Psychologic and physiologic reactions to the surgical procedure and anesthesia may elicit the stress response (e.g., elevated BP and heart rate). • Influencing factors • Age • Past experiences • Current health • Socioeconomic status • Nursing Assessment Use common language Use translators if needed Communicate all concerns to surgical team • o Nursing Assessment Anxiety can impair cognition, decision making, and coping abilities Anxiety can arise from Information lessens anxiety • • o Nursing Assessment o Anxiety may arise from conflict with interventions (i.e., blood transfusions) and religious or cultural beliefs • Identify beliefs and discuss with surgeon and operative staff Nursing Assessment o Fears • Death or disability • May prompt postponement • Influence outcome • Notify the physician if the patient has a strong fear of death, which may prompt postponement. Emotional state influences the stress response, and thus the surgical outcome. o Pain • Consult with ACP • Confirm drugs will be available • For fear of pain, you should encourage the patient to ask for pain medications following surgery, and that taking these medications will not contribute to an addiction. Instruct the patient how to use the pain • • • • • • intensity scale (e.g., 0–10, FACES) and to request pain medication before the pain becomes severe. Nursing Assessment Fears o Mutilation/alteration in body image • Assess concerns nonjudgmentally • Fear of mutilation can occur when the surgery is radical, such as amputation, or minor, such as bunion repair. o Anesthesia • ACP for consult • Fear of anesthesia can result from a prior induction of anesthesia or information about the risks (e.g., brain damage, paralysis). Many patients also fear losing control while under anesthesia. Nursing Assessment o Fears • Disruption of life functioning • Range from fear of permanent disability to temporary loss • Include family and financial concerns • Consultations PRN Nursing Assessment o Hope • May be strongest positive coping mechanism • Never deny or minimize • Some surgeries are hopefully anticipated. These can be the surgeries that repair (e.g., plastic surgery for burn scars), rebuild (e.g., total joint replacement to minimize pain and improve function), or save and extend life (e.g., repair of aneurysm, organ transplant). • Assess and support Nursing Assessment o Past health history • Diagnosed medical conditions (previous and current) • You will need to determine if the patient understands the reason for surgery. For example, the patient scheduled for a total knee replacement may indicate that increasing pain and immobility are the reasons for the surgery. • Previous surgeries and problems • Menstrual/obstetric history • For menstrual history, you should ask the date of the last menstrual period, the number of pregnancies, and history of cesarean section. Nursing Assessment o Health history • Familial diseases • • • Inherited traits • Conditions • Reactions/problems to anesthesia (patient or family) • With regard to reactions to anesthesia, the genetic predisposition for malignant hyperthermia is well documented, and measures can be taken to limit complications associated with this condition. Nursing Assessment o Current medications • Prescription and OTC • In many ambulatory surgery centers, patients are asked to bring their medications with them when reporting for surgery, to facilitate accurate assessment and documentation of both the name and dosage of current medications. In addition, assess and evaluate the patient’s compliance with the medication regimen to identify other concerns. • Herbs • You should ask specifically about the use of herbs and dietary supplements because their use is so prevalent. Many patients do not think to include supplements in their list of medications. • Dietary supplements • Antiplatelets/NSAIDs • Antiplatelet and nonsteroidal antiinflammatory drugs (NSAIDs) inhibit platelet aggregation and may contribute to postoperative bleeding. Surgeons may instruct patients to withhold these medications before surgery. • Recreational • Drugs • Alcohol • Tobacco • Under recreational drugs, the substances most likely to be abused include tobacco, alcohol, opioids, marijuana, cocaine, and amphetamines. Ask questions in a frank manner about the use of these substances. • You should stress that recreational drug use may affect the type and amount of anesthesia that will be needed. When patients become aware of the potential interactions of these substances with anesthetics, most patients will respond honestly about their using them. Nursing Assessment Allergies (drug and nondrug) Screen for latex allergy • Risk factors • Contact urticaria or dermatitis • Aerosol reactions • History of reactions suggesting latex allergy • o o Ask the patient about drug intolerances and drug allergies. • Drug intolerance usually results in side effects that are unpleasant for the patient but not life threatening, including nausea, constipation, diarrhea, or idiosyncratic (opposite than expected) reactions. • A true drug allergy produces hives and/or an anaphylactic reaction, causing cardiopulmonary compromise (e.g., hypotension, tachycardia, bronchospasm). o Also inquire about nondrug allergies, specifically food and environmental (e.g., latex, pollen, animals) allergies. The patient with a history of any allergic reactions has a greater potential for having hypersensitivity reactions to drugs given during anesthesia. o Risk factors for latex allergy include long-term, multiple exposures to latex products, such as those experienced by health care and rubber industry workers. Additional risk factors include a history of hay fever, asthma, and allergies to certain foods. Nursing Assessment o Review of systems • Body systems review • Confirms the presence or absence of diseases • • • • • Alerts to areas to closely examine • Provide essential data to determine specific preoperative tests Nursing Assessment o Cardiovascular system • Report • Any cardiac problems so they can be monitored during the intraoperative period • Use of cardiac drugs • Presence of pacemaker/ICD • In reviewing the CV system, you may find a history of hypertension, angina, dysrhythmias, heart failure, and/or myocardial infarction. • You should inquire about the patient’s current treatment for the CV condition (e.g., medications) and the level of functioning. • If the patient has a significant CV history (e.g., recent myocardial infarction, valvular heart disease, or implanted cardioverter-defibrillator), a cardiology consult is often required before surgery. Nursing Assessment o Cardiovascular system • 12-lead electrocardiogram (ECG) • Coagulation studies • Results of diagnostic studies and laboratory findings should be on the chart before surgery. • Possible prophylactic antibiotics • Venous thromboembolism (VTE) prophylaxis • Postoperative venous thromboembolism (VTE), a condition that includes deep vein thrombosis and pulmonary embolism, is a concern for any surgical patient. Patients at high risk for VTE include those with a history of previous thrombosis, bloodclotting disorders, cancer, varicosities, obesity, smoking, heart failure, or chronic obstructive pulmonary disease (COPD). Antiembolism stockings or sequential compression devices (SCDs) may be applied to the legs preoperatively. Nursing Assessment o Respiratory system • Inquire about recent airway infections • Procedure could be cancelled because of increased risk of laryngo/bronchospasm or decreased SaO2 Nursing Assessment o Respiratory system • History of dyspnea, coughing, or hemoptysis reported to operative team • COPD or asthma • High risk for atelectasis and hypoxemia Deep breathing, coughing, early ambulation – most important • • • • • Upper airway infections increase the risk of bronchospasm, laryngospasm, decreased oxygen saturation, and problems with respiratory secretions. Nursing Assessment o Respiratory system • Smokers should be encouraged to stop smoking 6 weeks before procedure • Decreases risk of complications • Sleep apnea, obesity, and airway deformities affect respiratory function • Conditions likely to influence or compromise respiratory function (e.g., sleep apnea, obesity, and spinal, chest, and airway deformities) should also be reported. • Depending on the patient’s history and physical examination, baseline pulmonary function tests and arterial blood gases (ABGs) may be ordered preoperatively. Nursing Assessment o Nervous system • Evaluation of neurologic functioning • Vision or hearing loss can influence results • Alterations in the patient’s hearing and vision may affect responses and ability to follow directions throughout the perioperative assessment and evaluation. The patient’s ability to pay attention, concentrate, and respond appropriately in the preoperative phase must be documented to establish an accurate baseline for postoperative comparison. • Cognitive deficits can affect informed consent and cause adverse outcomes during and after surgery • For patients with cognitive deficits, involve a legal guardian or person with durable power of attorney to assist patient and provide informed consent. Nursing Assessment o Genitourinary 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 Nursing Assessment o Genitourinary system • Renal function tests • Renal function tests, such as serum creatinine and blood urea nitrogen, are commonly ordered preoperatively. • • • • • • Note problems voiding, and inform operative team • Male patients may have physical alterations, such as an enlarged prostate, which can interfere with the insertion of a urinary catheter during surgery or can impair voiding in the postoperative period. • Assess women for possibility of pregnancy • For women of child-bearing age, determine if they are pregnant or think they could be pregnant. The surgeon should be informed immediately if the patient states that she might be pregnant, because maternal and subsequent fetal exposure to anesthetics should be avoided during the first trimester. Nursing Assessment o Hepatic system • Liver detoxifies many anesthetics and adjunctive drugs • Hepatic dysfunction may increase risk of postoperative complications • The patient with hepatic dysfunction may have increased perioperative risk for clotting abnormalities and adverse responses to medications. Consider the presence of liver disease if the history includes jaundice, hepatitis, alcohol abuse, or obesity. Nursing Assessment o Integumentary system • History of skin and musculoskeletal problems • Assess the current condition of the skin, especially at the incision site, for rashes, breakdown, or other dermatologic conditions. • History of pressure ulcers • Extra padding during procedure • Affects postoperative healing • Body art such as tattoos, piercings • Body art such as tattoos, and piercings are increasingly common. When possible, select pigment free areas for injections, IV sites, and lab draws. Nursing Assessment o Musculoskeletal system • Identify joints affected with arthritis • Mobility restrictions may affect positioning and ambulation Nursing Assessment o Musculoskeletal system • Report problems affecting neck or lumbar spine to ACP • Can affect airway management and anesthesia delivery • Spinal anesthesia may be difficult if the patient cannot flex the lumbar spine adequately to allow easy needle insertion. Nursing Assessment o Endocrine system • Patients with diabetes mellitus are especially at risk for: • • • • • Hypo/hyperglycemia • Ketosis • Cardiovascular alterations • Delayed wound healing • Infection Nursing Assessment o Endocrine system • Patients with diabetes mellitus • Serum or capillary glucose tests morning of surgery (baseline) • Clarify with physician or ACP regarding insulin dose • ACP practitioners may vary the usual insulin dose based on the patient’s current status and history of glucose control. • Regardless of the preoperative insulin or oral hypoglycemic orders, determine serum or capillary glucose levels the morning of surgery to establish baseline levels. • Assess the patient’s glucose levels periodically and manage, if necessary, with regular (short-acting, rapidonset) insulin. Nursing Assessment o Endocrine system • Patients with thyroid dysfunction • Hyper/hypothyroidism poses surgical risks because of altered metabolic rate • Verify with ACP about giving thyroid medications • Laboratory test may also be ordered to determine current levels of thyroid function. Nursing Assessment o Endocrine system • Patients with Addison’s disease • Abruptly stopping replacement corticosteroids could cause addisonian crisis • Stress of surgery may require increased dose of IV corticosteroids Nursing Assessment o Immune system • Patients with history of compromised immune system or use of immunosuppressive drugs can have • Delayed wound healing • Increased risk for infection • Corticosteroids used in immunosuppressive doses may be tapered before surgery. • If the patient has an acute infection (e.g., acute upper respiratory tract infection, sinusitis, influenza), elective surgery is often cancelled. • • • • • Patients with active chronic infections such as hepatitis B or C, acquired immunodeficiency syndrome, and tuberculosis may have surgery if indicated. • However, when preparing the patient for surgery, remember to take infection control precautions for the protection of the patient as well as the staff. Nursing Assessment o Fluid and electrolyte status • Vomiting, diarrhea, or preoperative bowel preps can cause imbalances • Identify drugs that alter F and E status such as diuretics • Evaluate serum electrolyte levels Nursing Assessment o Fluid and electrolyte status • NPO status • Surgery delay may also lead to dehydration • Patients with or at risk for dehydration may require additional fluids and electrolytes before surgery • Although a preoperative fluid balance history should be completed for all patients, it is especially critical for older adults because their reduced adaptive capacity leaves a narrow margin of safety between over- and underhydration. Nursing Assessment o Nutritional status • Deficits include overnutrition and undernutrition • Provide extra padding to underweight patients to prevent pressure ulcers • May be protein and vitamin deficient • Identify dietary habits that may affect recovery (e.g., caffeine) • If the nutritional problem is severe, surgery may be postponed. Protein and vitamins A, C, and B complex deficiencies are particularly significant because these substances are essential for wound healing. • Supplemental nutrition may be administered during the perioperative period to patients who are malnourished. • Caffeine withdrawal headaches can be confused with spinal headaches. Giving caffeinated beverages postoperatively, when possible, may prevent caffeine withdrawal headaches. • The older adult is often at risk for malnutrition and fluid volume deficits. Nursing Assessment o Nutritional status • Obesity • Stresses cardiac and pulmonary systems • Increased risk of wound dehiscence, infection, and incisional hernia • • • • • • Notifying the team that a patient is severely obese (body mass index [BMI] > 40 kg/m2) to allow time to obtain special equipment needed for the care of this patient (e.g., longer instruments for abdominal surgery). • Slower recovery from anesthesia • The patient may be slower to recover from anesthesia because inhalation agents are absorbed and stored in adipose tissue, thus leaving the body more slowly. • Slower wound healing Nursing Assessment: Exam o The Joint Commission (TJC) requires a history and physical o Findings enable ACP to rate patient for anesthesia administration • Indicator of perioperative risk and overall outcome Nursing Assessment: Exam o Complete a physical examination • In addition, you will complete a physical examination of the patient before surgery and document and communicate all relevant findings immediately to the ACP or surgeon. o Document relevant findings and share with the perioperative team o Obtain and evaluate results of laboratory tests • Obtain and assess laboratory and diagnostic test results. For example, if the patient is taking an antiplatelet medication (e.g., aspirin), a coagulation profile will be ordered. If a patient is on diuretic therapy, a potassium level is assessed. If a patient is of child-bearing age, a pregnancy test should be ordered. If a patient is taking medications for dysrhythmias, a preoperative electrocardiogram (ECG) is obtained. o Monitor blood glucose for patients with diabetes Nursing Management o Preoperative teaching • Patient has the right to know what to expect and how to participate • Increases patient satisfaction • Reduces fear, anxiety, stress, pain, and vomiting • Teaching may also decrease the development of complications, the length of hospitalization, and the recovery time following discharge. Nursing Management o Preoperative teaching • Limited time available • Address needs of highest priority • Include information focused on safety • Provide written material • Preoperative teaching for these patients is generally done in the surgeon’s office or the preadmission surgical clinic and is reinforced on the day of surgery. Nursing Management • • • o Preoperative teaching • Several days before surgery • Observe and listen to determine amount of teaching for each session • When providing preoperative teaching for a patient several days before surgery, provide a balance between telling so little that the patient is unprepared and explaining so much that the patient is overwhelmed. • Anxiety and fear can hinder learning • Give priority to patient’s concerns Nursing Management o Preoperative teaching • Three types of information • Sensory • With sensory information, patients want to know what they will see, hear, smell, and feel during the surgery. For example, you may tell them that the OR will be cold, but they can ask for a warm blanket; the lights in the OR are very bright; or they will hear lots of sounds that are unfamiliar and may notice specific smells. • Process • Patients wanting process information may not want specific details but desire to know the general flow of what is going to happen. This information would include the patient’s transfer to the holding area, visits by the nurse and ACP before transfer to the OR, and waking up in the PACU. • Procedural • With procedural information, desired details are more specific. For example, this information would include that an IV line will be started while the patient is in the holding area, and the surgeon will mark the operative area with an indelible marker to verify surgical site. Nursing Management o Preoperative teaching • Must be documented and reported to postoperative nurses • Avoid duplication of information • Assess learning Nursing Management o Preoperative teaching • Teach deep breathing, coughing, and early ambulation as appropriate • Inform if tubes, drains, monitoring devices, or special equipment will be used postoperatively • Provide surgery-specific information • • • • • The patient should also receive accurate surgery-specific information. For example, a patient having a total joint replacement may have an immobilizer following surgery, or a patient having heart surgery should be told about waking up in the intensive care unit. Nursing Management o Ambulatory surgery information • Basic information before arrival • Time and place • Arrival time is usually 1 to 2 hours before the scheduled time of surgery to allow for completion of the preoperative assessment and paperwork. • What to wear and bring • Responsible adult needed • Fluid and food restrictions • Traditionally, patients having elective surgery are told to have nothing by mouth (NPO) starting at midnight on the night before surgery. • Evidence-based guidelines published by the American Society of Anesthesiologists are less strict. Restriction of fluids and food is designed to minimize the potential risk of pulmonary aspiration and to decrease the risk of postoperative nausea and vomiting. The patient who has not followed the NPO instructions may have surgery delayed or cancelled, so it is critical that the surgical patient understands and adheres to these restrictions. Nursing Management o Legal preparation • Check that all required forms are signed and in chart • Informed consent • Blood transfusions • Advance directives • Power of attorney Nursing Management o Consent for surgery • Informed consent must include • Adequate disclosure • First, information must include adequate disclosure of the diagnosis; the nature and purpose of the proposed treatment; the risks and consequences of the proposed treatment; the probability of a successful outcome; the availability, benefits, and risks of alternative treatments; and the prognosis if treatment is not instituted. • Understanding and comprehension • • • • • • • Second, the patient must demonstrate clear understanding and comprehension of the information being provided before receiving sedating preoperative medications. If a patient is sedated prior to signing the consent, surgery may be cancelled or delayed. Voluntarily given consent • Third, the recipient of care must give consent voluntarily. The patient must not be persuaded or coerced in any way by anyone to undergo the procedure. Nursing Management o Surgeon responsible for obtaining consent • Nurse may witness signature • Verify patient has understanding • Permission may be withdrawn at any time • You can be the patient advocate, verifying that the patient (or caregiver) understands the information presented in the consent form, the implications of consent, and that consent for surgery is truly voluntary. Nursing Management o Legally appointed representative of family may consent if patient is • Minor • Unconscious • Mentally incompetent • An emancipated minor is one who is younger than the legal age of consent but is recognized as having the legal capacity to provide consent. Nursing Management o Consent for surgery • Medical emergency may override need for consent • Immediate medical treatment needed to • Preserve life • Prevent serious impairment to life or limb • When immediate medical treatment is needed to preserve life or to prevent serious impairment to life or limb and the patient is incapable of giving consent, the next of kin may give consent. • If reaching the next of kin is not possible, the physician may begin treatment without written consent. Nursing Management o Day-of-surgery preparation • Final preoperative teaching • Assessment and report of pertinent findings • Verification of signed consent • You will also ensure that all preoperative orders are done and that the chart is complete and accompanies the patient to the OR. Nursing Management o Day-of-surgery preparation • • • • • • • • • • Labs History and physical examination Baseline vitals Proper skin preparation Nursing notes In addition, the surgical site is identified and marked with an indelible marker by the surgeon and documented to indicate that the patient agrees. Nursing Management o Day-of-surgery preparation • Hospital gown • Sometimes no underwear in most cases • Patient should not wear any cosmetics • Observation of skin color is important • Remove nail polish for pulse oximeter Nursing Management o Day-of-surgery preparation • Valuables are returned to family member or locked up • Dentures, contacts, glasses, prostheses are removed • Return glasses to the patient as soon as possible after surgery. • All prostheses, including dentures, contact lenses, piercings, and glasses, are generally removed to prevent loss or damage. • Identification and allergy bands on wrist • Hearing aids should be left in place to allow the patient to better follow directions. • If electrocautery devices will be used during surgery, jewelry and piercings will need to be removed as a safety measure. Nursing Management o Void before surgery • Before medication administration • Prevents involuntary elimination under anesthesia • Reduces risk of urinary retention during early postoperative recovery • Many preoperative medications interfere with balance and increase the risk for a fall when ambulating, in which case the patient may need to use a bedpan. Nursing Management o Preoperative medication • Benzodiazepines (chills them out) • Used for sedative and amnesic properties • Anticholinergics (dry everything up; saliva, eyes, cant spit, cant pee, etc) • Reduce secretions • Opioids • Given to decrease pain and intraoperative anesthetic requirements • • • • Antiemetics (to keep from vomiting so they don’t aspirate) • May be given to decrease the risk of endocarditis in patients with a history of congenital or valvular heart disease, and for patients with previous joint replacement. They may also be ordered for the patient undergoing surgery where wound contamination is a potential risk (GI surgery) or where wound infection could have serious post-operative consequences • Antibiotics • Administered IV Nursing Management o Preoperative medication • β-Adrenergic blockers (β-blockers) • β-Adrenergic blockers (β-blockers) are sometimes used in people with known hypertension or coronary artery disease to control BP or reduce the chances of MI and cardiac arrest. • Insulin • People with diabetes are also carefully monitored and may receive insulin in the preoperative period. • Eye drops • Eye drops are often ordered and given preoperatively for the patient undergoing cataract and other eye surgery. Nursing Management o Transportation to the OR • Via stretcher or wheelchair • Inpatients are transported via stretcher to the OR. • In an ambulatory surgical center, the patient may be transported to the OR by stretcher or wheelchair, or may even walk if no sedatives have been given. • Communication “handoff” • Situation: patient name, age, surgical procedure, surgeon, surgical site, etc. • Background: significant patient history, allergies, medications • Assessment: baseline vital signs, findings relative to the surgical procedure, coping strategies • Recommendation: preoperative care still needed, such as IV antibiotics, positioning concerns, etc • Caregivers directed to waiting room Nursing Management o Special concerns • Culturally competent care • Cultural aspects to consider include the patient’s experience of pain, family expectations, and ability to verbally express needs. • One’s culture may require that the family be included in any decision making. • • If the patient or caregiver does not speak English, it is mandated that a qualified interpreter or translator communication system be used. Geriatric considerations • Surgery on older adults (over 65 years of age) requires careful evaluation • Vision and/or hearing deficits may be present. • Thought processes and cognitive abilities may be slowed or impaired. • Caregiver support may be needed. • Greater the risk of complications after surgery.
