(relates to chapter 18, “nursing management: preoperative care,” in the textbook) copyright ©...

(Relates to Chapter 18, “Nursing Management:

Preoperative Care,” in the textbook)

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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• Art and science of treating diseases, injuries, and deformities by operation and instrumentation


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• Performed forDiagnosisCurePalliationPreventionExplorationCosmetic improvement


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• Elective surgery vs. emergency surgery

• Inpatient Same-day admission

• Ambulatory (outpatient)


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• Have knowledge of the nature of the disorder requiring surgery.

• Identify the individual patient’s response to the stress of surgery.

• Assess the results of appropriate preoperative diagnostic tests.

• Provide a baseline by identifying potential risks and complications.


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• Check documented information prior to interview.Avoids repetition

• Occurs in advance or on day of surgery


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• PurposeObtain health information.Determine expectations.Provide and clarify information on

procedure.Assess emotional state and

readiness.


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• Overall goals Identify risk factors.Plan care to ensure patient safety.


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• Determine psychologic status to reinforce coping strategies.

• Determine psychologic factors of the procedure contributing to risks.

• Determine physiologic factors that may contribute to increased surgical risk.


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• Establish baseline data.• Identify medications and herbs

taken that may affect surgical outcome.

• Identify, document, and communicate results of laboratory/diagnostic tests.


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• Identify cultural and ethnic factors that may affect surgical experience.

• Determine receipt of adequate information from surgeon to sign informed consent.

• Determine informed consent and that informed consent form is signed and witnessed.


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• Psychosocial assessmentExcessive stress response can be

magnified and affect recovery.


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• Influencing factorsAgePast experienceCurrent healthSocioeconomic status


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• Use common language.• Use translators if needed.

Decreases level of anxiety

• Communicate all concerns to surgical team.


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• Anxiety can impair cognition, decision making, and coping abilities.

• Anxiety can arise fromLack of knowledgeUnrealistic expectations

• Information lessens anxiety.


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• Anxiety may arise from conflict with interventions (i.e., blood transfusions) and religious/cultural beliefs. Identify beliefs and discuss with

surgeon and operative staff.


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• FearsDeath or disability• May prompt postponement• Influence outcome

Pain• Consult with ACP.• Confirm drugs will be available.


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• Fears Mutilation/alteration in body image• Assess concerns nonjudgmentally.

Anesthesia• ACP for consult


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• FearsDisruption of life functioning• Range from fear of permanent

disability to temporary loss• Include family and financial concerns• Consultations PRN


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• HopeMay be strongest positive coping

mechanism• Never deny or minimize.

Assess and support.


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• Health historyDiagnosed medical conditions

(previous and current)Previous surgeries and problemsMenstrual/obstetric history


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• Health history Familial diseases• Conditions

Reactions/problems to anesthesia (patient or family)


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• Current medicationsPrescription and OTCHerbsDietary supplementsRecreational• Drugs• Alcohol• Tobacco


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• Allergies (drug and nondrug)• Screen for latex allergy:

Risk factorsContact urticaria or dermatitisAerosol reactionsHistory of reactions suggesting latex

allergy


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• Cardiovascular systemReport• Any cardiac problems so they can be

monitored during the intraoperative period

• Use of cardiac drugs• Presence of pacemaker/ICD


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• Cardiovascular systemVitals recorded preoperatively for

baselineBleeding/clotting timesLaboratory reportsPossible prophylactic antibiotics


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• Respiratory system Inquire about recent airway

infections.• Procedure could be cancelled because

of increased risk of laryngo/bronchospasm or decreased SaO2.


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• Respiratory systemHistory of dyspnea, coughing, or

hemoptysis reported to operative team

COPD or asthma• High risk for atelectasis and hypoxemia


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• Respiratory systemSmokers should be encouraged to

quit 6 weeks before procedure.• Decreases risk of complications• Greater years and number of packs =

greater risk


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• Nervous systemEvaluation of neurologic functioning• Vision or hearing loss can influence

results.


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• Nervous systemCognitive function• Determine if any deficits are present.


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• Genitourinary systemHistory of urinary or renal diseasesRenal dysfunction contributes to• Fluid and electrolyte• Increased risk of infection• Impaired wound healing• Altered response to drugs and their

elimination


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• Genitourinary system Renal function testsNote problems voiding, and inform

operative team.


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• Hepatic systemLiver detoxifies many anesthesics

and adjunctive drugs.Hepatic dysfunction may increase

risk of postoperative complications.


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• Integumentary systemHistory of skin and musculoskeletal

problemsHistory of pressure ulcers• Extra padding during procedure• Affects postoperative healing


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• Musculoskeletal system Identify joints affected with arthritis.Mobility restrictions may affect

positioning and ambulation.Bring mobility aids to surgery.


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• Musculoskeletal system Report problems affecting neck or

lumbar spine to ACP.• Can affect airway management and

anesthesia delivery


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• Endocrine systemPatients with diabetes mellitus

especially at risk for:• Hypo/hyperglycemia• Ketosis• Cardiovascular alterations• Delayed wound healing• Infection


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• Endocrine systemPatients with diabetes mellitus • Serum or capillary glucose tests

morning of surgery (baseline)• Clarify with physician or ACP regarding

insulin dose.


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• Endocrine systemPatients with thyroid dysfunction• Hyper/hypothyroidism are surgical

risks due to altered metabolic rate.• Verify with ACP about giving thyroid

medications.


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• Endocrine systemPatients with Addison’s disease• Abruptly stopping replacement

corticosteroids could cause addisonian crisis.

• Stress of surgery may require increased dose of corticosteroids.


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• Immune systemPatients with history of compromised

immune system or use of immunosuppressive drugs can have• Delayed wound healing• Increased risk for infection


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• Fluid and electrolyte statusVomiting, diarrhea, or difficulty

swallowing can cause imbalances. Identify drugs that alter F and E

status.• Diuretics

Evaluate serum electrolyte levels.


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• Fluid and electrolyte status NPO status• May require additional fluids and

electrolytes before surgery if dehydration occurs


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• Nutritional statusObesity• Stresses cardiac and pulmonary

systems• Increased risk of wound dehiscence

and infection• Slower recovery from anesthesia• Slower wound healing


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• Nutritional status Provide extra padding to

underweight patients to prevent pressure ulcers.

Identify dietary habits that may affect recovery (e.g., caffeine).

May be protein and vitamin deficient


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• Findings enable ACP to rate patient for anesthesia administration. Indicator of perioperative risk and

overall outcome


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• Document relevant findings, and report to perioperative team.

• Obtain and evaluate results of laboratory tests.

• Monitor blood glucose for patients with diabetes.


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• Preoperative teachingPatient has right to know what to

expect and how to participate.• Increases patient satisfaction• Reduces fear, anxiety, stress, pain, and

vomiting


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• Preoperative teaching Limited time available• Address needs of highest priority.• Include information focused on safety.• Provide written material.


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• Preoperative teaching Several days before surgery• Observe and listen to determine

amount of teaching for each session.• Anxiety and fear can hinder learning.• Give priority to patient’s concerns.


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• Preoperative teachingThree types• Sensory• Process• Procedural


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• Preoperative teaching Must be documented and reported to

postoperative nurses• Avoid duplication of information.• Assess learning.


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• Preoperative teachingTeach deep breathing, coughing, and

early ambulation as appropriate. Inform if tubes, drains, monitoring

devices, or special equipment will be used postop.

Provide surgery-specific information.


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• Preoperative teachingBasic information before arrival• Time and place• Fluid and food restrictions• Need for enema• Need for shower


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• Legal preparationAll required forms are signed and in

chart:• Informed consent• Blood transfusions• Advance directives• Power of attorney


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• Consent for surgery Informed consent must include• Adequate disclosure• Understanding and comprehension • Voluntarily given consent


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• Surgeon responsible for obtaining consentNurse may obtain and witness

signature.Verify patient has understanding.Permission may be withdrawn at any

time.


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• Consent for surgeryMedical emergency may override

need for consent.


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• Legally appointed representative of family may consent if patient isMinorUnconsciousMentally incompetent


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• Day-of-surgery preparationFinal preoperative teaching Assessment and report of pertinent

findingsVerify signed consent.


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• Day-of-surgery preparationLabs History and physical examinationBaseline vitalsConsultation recordsNurse’s notes


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• Day-of-surgery preparation Patient should not wear any

cosmetics.• Observation of skin color is important.• Remove nail polish for pulse oximeter.


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• Day-of-surgery preparationValuables are returned to family

member or locked up.Dentures, contacts, prostheses are

removed. Identification and allergy bands on

wrist


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• Void before surgeryPrevents involuntary elimination

under anesthesia or during early postoperative recovery

Before medication administration


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A 68-year-old scheduled for a herniorrhaphy at an ambulatory surgical center expresses concern that he will not have enough care at home and asks if he can stay in the hospital after the surgery. The best response by the nurse is:

1. “Who is available to help you at home after the surgery?”

2. “I’m sure you will be able to manage at home after surgery. It is a simple procedure.”

3. “We will teach you everything you need to know to be able to care for yourself after surgery.”

4. “Your health insurance will pay for inpatient care only if complications develop during surgery.”

Audience Response Question


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Preoperative instruction that is appropriate for all patients includes1. Techniques of deep breathing and coughing.2. Descriptions of the planned surgical procedure.3. Physical procedures or preparation required before surgery.4. Withholding of all oral fluids or food after midnight on the day of surgery.

Audience Response Question


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• 45-year-old woman presents to holding area for presurgical workup for right breast lumpectomy.

• The nurse notes constant fidgeting.


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• She is unable to articulate details about what the surgeon will do or her disease process.

• She reacts angrily when asked if she would consent to transfusion, if needed.


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1. What do you think is happening with her?

2. What can you do to help her and prepare her for the procedure?


(relates to chapter 18, “nursing management: preoperative care,” in the textbook) copyright ©...

Documents

affiliate of elsevier

instrumentation copyright

psychologic factors

ethnic factors

physiologic factors

stress of surgery

surgical risk

informed consent form