Interventions for Preoperative Clients Care

Perioperative Care

Three Phases

Preoperative IntraoperativePostoperative

Preoperative

Miss Iman ShaweeshMiss Iman Shaweesh 33

PREOPERATIVE NURSING CARE

CONDUCT A NURSING ASSESSMENT PROVIDE PREOPERATIVE TEACHING PERFORM METHODS OF PHYSICAL

PREPARATION ADMINISTER MEDICATIONS ASSIST WITH PSYCHOSOCIAL

PREPARATION COMPLETE THE SURGICAL CHECKLIST

SURGERY CHECKLIST

Purposes of Surgery

DiagnosticCurativeRestorativePalliative surgery, which makes the

client more comfortableCosmetic surgery, which reconstructs

the skin and underlying structures

Collaborative Management Assessment

History and data collectionAgeDrugs and substance useMedical history, including cardiac and

pulmonary historiesPrevious surgery and anesthesiaBlood donationsDischarge planning

Physical Assessment/Clinical Manifestations

Obtain baseline vital signs.Focus on problem areas identified by

the client’s history on all body systems affected by the surgical procedure.

Report any abnormal assessment findings to the surgeon and to anesthesiology personnel.

System Assessment

Cardiovascular system Respiratory system Renal/urinary system Neurologic system Musculoskeletal system Nutritional status Psychosocial assessment

Laboratory Assessment

Urinalysis Blood type and crossmatch Complete blood count or hemoglobin level and

hematocrit Clotting studies Electrolyte levels Serum creatinine level Pregnancy test Chest x-ray examination Electrocardiogram

Preparing the Client (Continued)

Leg procedures and exercises, antiembolism stockings and elastic wraps, early ambulation, and range-of-motion exercises

DEEP BREATHING, COUGHING, LEG EXERCISES

Deep breathing is a form of controlled ventilation that opens and fills small air passages in the lungs to prevent atelectasis and pneumonia.

Coughing is a natural method of clearing secretions from the airways.

Leg exercises help promote circulation and reduce the risk of forming a thrombus in the veins.

Antiembolism stockings help prevent thrombi and emboli by compressing superficial veins and capillaries redirecting blood to larger and deeper veins, where it flows more effectively toward the heart.

DEEP BREATHING & COUGHING

Pre-Operative EducationDiaphragmatic Breathing Exercises

Pre-Operative EducationSplinting Abdomen while Coughing

Spirometry

Adapt from Smetana GW,et al. New Engl J Med 1999;340:937-944.

Stein 1970

Collin 1968

Appleberg 1974

Fogh 1987

Kispert 1992

10 2 4 6 8 10 12 14 16

Swensson 1991

Use of preoperative spirometry to predicted PPCs

Kroenke 1993

Kocabas 1996

Bando 1997

Jacob 1997

Preoperative Care of Pulmonary Patients: Example

Male 60 yrs. Dx: NSCLC stage Ib , RULUnderlying COPDAssessment

Not urgent surgery, high benefitRisk ; elderly, COPDHistory / Physical examinationLaboratory

Pre-RX(%)

Post –RX(%)

%CHG

FEV1/FVC (%)

55 60

FEV1 (L) 1.31(48)

1.39(53) 5

FVC (L) 2.40(66)

2.50(69) 4

FEF25- 75%

(L/min)

0.43(15)

0.6(22) 22

Spirometry of the patient

Further evaluation PPO-FEV1

RUL : RLL= 0.55: 0.45

RUL = 24.7%

RLL= 20.3%

LL = 55%

Preoperative Care of Pulmonary Patients

Many factors related to PPCsWorking as a team plays major rolesAssessment of the risks ,do appropriated

testing and modifying are the keys of preoperative caring

Recommendation for preoperative CXR

Age > 50 yearsKnown pre-existing cardiopulmonary

diseasesS/S like hoods of cardiopulmonary disease

Smetana GW, et al Med Clin N Am 2003

PFTs and PPCs

Case-control study, elective abdominal surgery:CXR highly associated with PPCs (OR 5.8)Abnormal PE associated with PPCsWhereas PFTs were not predictive

Lawrence VA, et al. Chest 1996;110:744-50.

PFT Diagram in Preoperative Evaluation

PFT(FEV1,MVV,DLCO)

Cleared for any resection

High risk consider exercise

testPerfusion

Scanning PPO-FEV1

Consider “Lesser” resection

Non surgical therapy

Cleared for any resection

High risk consider exercise

test

FEV1 >2 L

MVV >50%DLCO >60%

FEV1 > 2 L

MVV<50%

DLCO <60%

FEV1 <2 L

PPO-FEV1 >1.3

PPO-FEV1 >0.8, <1.3PPO-

FEV1 <0.8

Preoperative PFTs : Summary

Thoracic surgeryUpper abdominal surgery with

respiratory symptoms remain unexplained after careful evaluation

Routine PFTs should not ordered solely without clinical assessment

Risk indices for preoperative assessment

Risk class

Pneumonia Risk

(total point)

Predicted

Prob. pneumonia

(%)

Respiratory

Failure

(total point)

Predicted

Prob.

Res. failure

(%)

1 0-15 0.2 0-10 0.5

2 16-25 1.2 11-19 2.2

3 26-40 4.0 20-27 5.0

4 41-55 9.4 28-40 11.6

5 >55 15.4 >40 30.5

Arozullah AM,et al. Med Clin N Am 2003

Preoperative smoking cessation and PPCs

0

10

20

30

40

50

60

Stop >2 mth Stop<2 mth Stop>6 mth Never smoke

Warner MA,et al. Mayo Clin Proc 1989

Prospective study 200 patients, CABG

% Complication

Preoperative smoking cessation and PPCs

0

10

20

30

40

50

60

Current <2wks Recent2-4wks Exsmoke Never smoke

Nakagawa M, et al Chest 2001;120:705-10

Retrospective study 288 patients, pulmonary surgery

% Complication

Examples of external pneumatic

compression devices used to promote

venous return and prevent deep vein

thrombosis (DVT)

Kendall SCD machine, sleeves, andTED stockings.

Venodyne pneumatic compression system

Flowtron DVT calf garments

Anxiety Interventions

Preoperative teaching

Encouraging communication

Promoting rest

Using distraction

Teaching family and significant others

Preoperative Chart Review

Ensure all documentation, preoperative procedures, and orders are complete.

Check the surgical consent form and others for completeness.

Document allergies

Document height and weight.