Preoperative Nursing Management
Pre-Op
Intra-Op
Baseline
Safety
Post-Op
Complications
Client’s Reaction
• Surgery is STRESSFUL
• The nurse plays a pivotal role in preparing and supporting the clients
throughout the surgical process
Possible side effects if the client’s stress response to surgery is excessive
• Increased anaesthetic complications
• Increased post-op pain
• Decreased wound healing
Preoperative Phase
• Begins when surgical intervention is decided
• Ends when client is on the operating table
Surgery Classification based on urgency
• Emergency: Broken Hip
• Elective: Cosmetic
Surgery Classification based on the purpose
• Diagnosis/exploration
• Cure or Repair
• Palliation
• Prevention
• Procurement for transplant
• Cosmetic improvement
Goals of Preoperative Nursing Assessment
1. Establish baseline data
a. Vital signs, Diagnostic Imaging, Blood tests
2. Determine physiological operative risk factors
a. Past surgical history (family health history), Current Health Status
3. Determine psychosocial operative risk factors
a. Personal coping strategies (anxiety, fear)
b. Cultural/Ethnic Factors
c. Social Supports
d. Financial Supports
4. Ensure informed consent obtained
a. Informed consent must be obtained pre-op
b. Occurs between the surgeon and the client
5. Pre-op teaching
a. Pre-op fasting
b. Day of surgery
c. Immediately post-op
d. Pre-op teaching of client activities
Important blood and diagnostic tests done before surgery & why
• CBC (RBC, Hgb, Hct)
• Electrolyte panel
• Urea & creatine
• INR/PTT
• Glucose
• EKG
• XR/CT/MRI
Medical Conditions
• Cardiovascular disease
o General anaesthetic agents depress cardiac function, stress of surgery
increases demands on heart to maintain cardiac output
o Spinal (can still breathe) rather than general anaesthesia
o If hx of valvular disease, antibiotic prophylaxis pre-op to decrease risk
of bacterial endocarditis
• Diabetes
o Risk for hypoglycemia for inadequate carb’s or from excessive admin. of
insulin
o Risk for hyperglycemia from stress of surgery
o Impaired wound healing and susceptible to infection
•
Liver Disease
o Alters metabolism and elimination of drugs given during surgery
o Impairs wound healing and clotting time
• Renal Function
o Kidneys involved in excreting anaesthetic drugs and metabolites
o Surgery is contraindicated if acute renal failure present
• Fever
o May indicate underlying infection
o Predisposes patient to fluid and electrolyte imbalances
• Immunologic disorders
o Increase risk of infection and delayed wound healing
• Bleeding disorders
o Risk of hemorrhage
• Chronic pain
o Regular use of pain medication may result in higher tolerance
o Increased dose of analgesics may be required
• Chronic respiratory disease
o Anaesthetic agents reduce respiratory function
o Increase risk for hypoventilation
• Sleep apnea
o Administration of opioids increases the risk of airway obstruction postop
Medication Use
• Previous medication use: Note any side effects to shame or similar drugs
• Current medication use:
o Highlights possible drug interactions with anaesthetic agents
o Herbal medications may interact negatively with anaesthetic agents
§ Many herbal meds may increase post op bleeding, effect BP,
increase sedation, contribute to cardiac effects and electrolyte
alterations.
Medications that may increase surgical risk
• Corticosteroids:
o Long-term use may reduce the body’s ability to withstand stress
o Dosages may be increased pre & post-op
• Diuretics:
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o Potentiate electrolyte imbalances particularly potassium post-op
Tranquilizers:
o May cause anxiety, tension, seizures if withdrawn suddenly
Anticonvulsants:
o Long-term use can alter metabolism of anesthetic agents
Anticoagulants/Antiplatelets:
o Can increase risk of bleeding
o Anticoagulants should be discontinued at least 48h per-op
o Aspirin should be discontinued at least 2 weeks pre-op
Antihypertensives:
o May interact with anesthetic agents to cause bradycardia, hypotension
& impaired circulation
Allergies
• A history of ANY allergy has a greater potential for hypersensitivity
reactions to anaesthesia
• Inquire about drug & nondrug allergies
• Nondrug allergies include:
o Food, chemicals, tape, pollen, latex
o Allergy to shellfish may correspond to an allergy to iodine skin
preparation
Alcohol & Drug Misuse
• Both can increase the client’s tolerance to medications
• Chronic alcoholism is associated with malnutrition which hinders wound healing
and can cause electrolyte imbalances (low albumin = swelling)
• Alcohol withdrawal delirium may be anticipated up to 72 hours after
cessation of consumption
• Delirium tremens (DT’s) is associated with a significant mortality rate when it
occurs postoperatively
Smoking
• Post-op client has greater difficulty clearing the airways of mucous
secretions
• Clients are encouraged to stop smoking 2 months before surgery
Nutritional Status
• Optimal nutrition is essential for healing and resisting infection
• Nutritional deficiencies should be corrected before surgery if possible
Informed Consent
• Four conditions exist for consent to be valid:
1. Must be related to the treatment
2. Must be informed
3. Must be voluntary
4. It cannot be obtained through misrepresentation or fraud
• The surgeon must:
o Clear & simple explanation of the nature and purpose of surgery
o Explain benefits, possible risks, complications, disfigurement, and
disability
o Explain the probability of a successful outcome
o Explain the prognosis if treatment is not instituted
o Notify the client that they can withdrawal consent at any time
Pre-op Fasting
Day of Surgery
• Remove nail polish, jewelry, dentures, prosthetics
• Empty bladder before surgery
Immediately Post-Op
• Prepare client & family about possible tubes, drains, intubation etc.
Pre-op Teaching of Client Activities
• To help prevent some common post-op surgical complications:
o Respiratory infection
§ DB&C (Deep Breathe & Cough)
• Inhale slowly through the nose, hold the breath a few
seconds, and exhale slowly through the mouth, coughing
every 4 to 6 breaths
§ Incentive spirometry
§ Splinting when coughing
• These are the main reasons to teach a patient to do this:
o Dehiscence: means the separation of a surgical
incision or rupture of a wound closure
o Evisceration: is the protrusion of an organ
o VTE (DVT/PE)
§ Mobility & active body movements