Chapter 17 Nursing Management: Preoperative Care KEY POINTS SURGICAL SETTINGS • Surgery is performed to diagnose, cure, palliate, prevent, explore, and/or provide cosmetic improvement. • The total surgical episode is called the perioperative period. This period in the health care continuum includes the time before surgery (preoperative period), the time spent during the actual surgical procedure (intraoperative period), and the period after the surgery is completed (postoperative period). • Surgery may be a carefully planned event (elective surgery) or may arise with unexpected urgency (emergency surgery). • The setting in which a surgical procedure may be safely and effectively performed is influenced by the complexity of the surgery, potential complications, and general health status of the patient. • Most surgical procedures are being performed as ambulatory surgery (also called same-day or outpatient surgery). • Regardless of where the patient has surgery, your role is to prepare the patient for surgery, care for the patient during surgery, and aid the patient’s recovery after surgery. PATIENT INTERVIEW • One of the most important nursing actions is the preoperative interview. It often occurs in advance or on the day of surgery. The site of the interview and the time before surgery will dictate the depth and the completeness of the interview. Copyright © 2020 by Elsevier, Inc. All rights reserved. • The primary purposes of the interview are to obtain the patient’s health information, provide information about the surgical experience, and assess the patient’s readiness for surgery. It gives the patient and caregiver an opportunity to ask questions. NURSING ASSESSMENT OF THE PREOPERATIVE PATIENT • The preoperative nursing assessment is performed to determine the patient’s psychologic status and physiologic factors that may contribute to operative risk factors; establish baseline detail; identify and document the surgical site; identify prescription, over-the-counter drugs, and herbs taken by the patient; confirm laboratory and diagnostic study results; note cultural and ethnic factors that may affect the surgical experience; and validate that the informed consent form has been signed and witnessed. • Common fears associated with surgery include the potential for death or permanent disability resulting from surgery, pain, change in body image, or results of a diagnostic procedure. • Your role in psychologically preparing the patient for surgery is to assess the patient for potential stressors that could negatively affect surgery and to provide support during the preoperative period so that stress does not become distress. • In the nursing assessment, you should perform a thorough body systems review. Ask specific questions to confirm the presence or absence of any diseases. Obtain information about any family history of adverse reactions to or problems with anesthesia. Screen patients for possible latex allergies, as well as history of drug intolerance and drug allergies. • Record and share all findings on the medication history, including allergies, with the intraoperative and postoperative personnel. • Findings from the patient’s preoperative assessment are used to assess the patient’s perioperative risk and may influence perioperative decisions. Copyright © 2020 by Elsevier, Inc. All rights reserved. • The preoperative assessment of the older person’s baseline cognitive function is essential for intraoperative and postoperative evaluation as well as for choice of type of anesthesia. • The patient with diabetes is especially at risk for adverse effects of anesthesia and surgery. • Obesity stresses the heart and lung system and makes access to the surgical site and anesthesia administration more difficult. NURSING MANAGEMENT: PREOPERATIVE PATIENT • The Association of periOperative Registered Nurses (AORN) provides perioperative standards and recommended practices to guide nursing practice in the perioperative setting. • Derive preoperative nursing interventions from the nursing assessment, based on each patient’s specific needs. Physical preparations depend on the type of surgery and routines of the surgery setting. • Preoperative teaching involves the following: • Provision of sensory, process, and procedural information • Instructions about deep breathing, coughing, and ambulating postoperatively • Information about pain management, including the use of a pain-rating scale • An understanding that some patients, with varying cultures, backgrounds, and experiences, may need different types of information • Inclusion of the patient’s caregiver in the teaching when appropriate • Documentation of all teaching in the patient’s chart Legal Preparation for Surgery • Legal preparation for surgery consists of checking that all required forms have been correctly signed and are present on the chart and that the patient and caregiver clearly understand what is going to happen. Copyright © 2020 by Elsevier, Inc. All rights reserved. • Anyone undergoing an invasive procedure must give informed consent for the procedure to be performed. Informed consent is an active, shared decision-making process between the provider and the recipient of care. • A true medical emergency may override the need to obtain informed consent. • The surgeon is ultimately responsible for obtaining the patient’s consent for surgical treatment. As a nurse, you may witness the patient’s signature on the consent form. • Adults and emancipated minors sign their own operative permit. • If the patient is a minor, is unconscious, or is mentally incompetent to sign the permit, a legally appointed representative or responsible family member gives permission. Day-of-Surgery Preparation • Day-of-surgery preparation will vary a great deal depending on whether the patient is an inpatient or an ambulatory surgical patient. • On the day of surgery, you are responsible for the following: • Final preoperative teaching • Assessment and communication of pertinent findings • Ensuring that all preoperative orders have been completed • Ensuring that records and reports are present and go with the patient to the OR • Verifying the presence of a signed operative consent • Laboratory and diagnostic data • A history and physical report • A record of any consultations • Baseline vital signs • Completed nurses’ notes and preoperative checklist Copyright © 2020 by Elsevier, Inc. All rights reserved. • Final “hand-off” communication to the OR nurse receiving the patient to ensure that all pertinent information about the patient has been exchanged • A variety of preoperative drugs may be used, either alone or in combination, depending on the patient and the type of surgery. • Drugs include benzodiazepines for sedation and amnesia, anticholinergics to reduce secretions, and opioids to decrease pain and intraoperative anesthetic requirements. • Other drugs include antiemetics, antibiotics, insulin, histamine-receptor antagonists, eyedrops, and regular prescription drugs. CULTURAL AND GERONTOLOGIC CONSIDERATIONS • You should include cultural considerations when assessing and implementing care for the preoperative patient. • Frequently performed procedures in the older adult are cataract extraction, coronary and vascular procedures, prostate surgery, herniorrhaphy, cholecystectomy, and joint repair/replacement. • Older adults may have sensory, motor, and cognitive deficits. They may need more time to complete preoperative testing and understand preoperative instructions. These changes need attention to promote patient safety and prevent injury. Copyright © 2020 by Elsevier, Inc. All rights reserved.
