ch. 18 preoperative nursing management

7/29/2019 Ch. 18 Preoperative Nursing Management

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Ch. 18 Preoperative Nursing Management 1/29/2012 3:05:00 PM

Perioperative Nursing Periop period consists of 3 phases that begin & end at a particular

point in sequence of events in the surgical experience.o Preop phase- when decision to proceed w/ surgical

intervention is made & ends w/ transfer of pt onto the ORo Intraop phase begins when pt is transferred onto OR table &

ends w/ admission to PACU (postanesthesia care unit)o Postop phase begins w/ admission of pt to PACU & ends w/ a

follow-up evaluation in clinical setting or home.o The Perioperative Nursing Data Set (PNDS) categorizes

practice of perioperative nursing practice into four domains:safety, physiological responses, behavioral responses, & health care systems.

Surgical Classification Surgical procedure may be diagnostic (biopsy, exploratory

laparotomy), curative (excision of a tumor or an inflamedappendix), or reparative (multiple wound repair).

May be reconstructive or cosmetic (mammoplasty, facelift) orpalliative (to relieve pain or correct a problem)

May be classified according to degree of urgency involved:

emergent, urgent, required, elective, & optional.o Emergent- Patient requires immediate attention; disorder

may be life-threatening (w/out delay) Ex: Severe bleeding, bladder/intestinal obstruction,

fractured skull, gunshot/ stab wounds, extensive burnso Urgent- Pt requires prompt attention (w/in 24-30 hrs)

Ex: Acute gallbladder infection, kidney/ureteral stoneso Required- Pt needs to have surgery ( w/in a few wks/months)

Ex: Thyroid disorders, cataracts, prostatic hyperplasiaw/out bladder obstruction

o Elective- Pt should have surgery (failure not catastrophic) Ex: Repair of scars, simple hernia, vaginal repair

o Optional- Decision rests w/ pt (personal preference) Ex: Cosmetic surgery


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Preadmission Testing Pressure to reduce hospital stays & contain costs has resulted in

diagnostic preadmission testing (PAT) & preop preparation prior toadmission

Special Considerations During the Perioperative Period Gerontology Considerations

o Elderly pts have less physiologic reserve (ability of an organto return to normal after a disturbance in its equilibrium) thanyounger pts.

Patients Who Are Obeseo Obesity risk & severity of complications associated w/

surgery. Difficult to care for because of excessive weight.o Fatty tissues are especially susceptible to infection.o Dehiscence (wound separation) & wound infections are more

commono Pt tends to have shallow respirations when supine, which

risk of hypoventilation & postop pulmonary complications.o Short thick necks, large tongues, & redundant pharyngeal

tissue, along w/ increased demand for oxygen & decreasereserves, can make intubation difficulty

Patients With Disabilitieso Pts w/ mental/physical disabilities include need for

appropriate assistive devices, modifications in preoperativeteaching, assistance w/ & attn to positioning or transferring

o Pt w/ disability that affects body positioning (cerebral palsy,postpolio syndrome, & other neuromuscular disorders) mayneed special positioning during surgery to prevent pain/injury

o Pts w/ respiratory problems related to a disability (multiplesclerosis, muscular dystrophy) may experience difficultiesunless problems are made known to anesthetist & adjustments are made.

Patients Undergoing Ambulatory Surgeryo Ambulatory surgery- outpatient, same-day, or short-stay

surgery that does not require overnight hospital stay but may


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entail an admission to an impatient hospital setting for lessthan 24 hrs.

Patients Undergoing Emergency Surgeryo Emergency surgeries are unplanned & occur w/ little time for

preparation for pt or perioperative teamo Only opportunity for preoperative assessment may take place

at same time as resuscitation in emergency dept.o For the unconscious pt, informed consent & essential info,

such as pertinent past medical history & allergies, need to beobtained from a family member, if one is available.

Informed Consent Informed consent- pts autonomous decision about whether to

undergo a surgical procedure. Voluntary & written informed consent from pt is necessary before

nonemergent surgery can be performed in order to protect pt fromunsanctioned surgery & protect surgeon from claims of anunauthorized operation

While nurse may ask pt to sign consent form & witness signature, itis surgeons responsibility to provide a clear & simple explanation of what the surgery will entail prior to pt giving consent.

Nurse clarifies information provided, & if additional info isrequested, nurse notifies physician.

Signed consent form is placed in a prominent place on pts chart & accompanies patient to OR.

Informed consent is necessary in following:o Invasive procedures (surgical incision, biopsy, paracentesis)o Procedures requiring sedation &/or anesthesiao Nonsurgical procedure (arteriography)o Procedures involving radiation

In emergency, it may be necessary for surgeon to operate as alifesaving measure w/out pts informed consent. However, everyeffort must be made to contact pts family (telephone, fax, other)

Preoperative Assessment Goal in preoperative period is for pt to be as healthy as possible.


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Before any surgical treatment, a health history is obtained, physicalexamination is performed during which vital signs are noted, & adatabase is established for future comparisons.

Blood tests, x-rays, & other diagnostic tests are prescribed when

indicated by info obtained from history & physical examination

Nutritional and Fluid Statuso Optimal nutrition is essential factor in promoting healing &

resisting infection & other surgical complications.o Any nutritional deficiency (malnutrition) should be corrected

before surgery to provide adequate protein for tissue repair. Dentition

o Dental caries, dentures, & partial plates are significant toanesthesiologist/anesthetist, because decayed teeth/dentalprostheses may become dislodged during intubation & occlude airway.

Drug or Alcohol Useo Surgery is postponed if possible because acutely intoxicated

people are susceptible to injuryo Alcohol w/drawal syndrome may be anticipated between 48-

72 hrs after alcohol w/drawal & associated w/ significant

mortality rate when it occurs postoperatively Respiratory Status

o Goal- optimal respiratory functiono Usually postponed if pt has respiratory infectiono Pts who smoke are urged to stop 4-8 wks before surgery to

reduce pulmonary & wound healing complications. Cardiovascular Status

o Goal- ensure a well-functioning cardiovascular system tomeet oxygen, fluid, & nutritional needs

Hepatic & Renal Functiono Goal- optimal function of liver & urinary systems so that

meds, anesthetic agents, body wastes, & toxins areadequately metabolized & removed from body.


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o Liver important in biotransformation of anestheticcompounds. Any disorder of the liver has an effect on howanesthetic agents are metabolized.

o Kidneys- involved in excreting anesthetic meds & their

metabolites. Surgery is contraindicated if pt has acutenephritis, acute renal insufficiency w/ oliguria or anuria orother acute renal problems.

Endocrine Functiono Pt w/ diabetes who is undergoing surgery is at risk for

hypoglycemia & hyperglycemia.o Hypoglycemia may develop during anesthesia or postop from

inadequate carbohydrates/excessive administration of insulin.o Hyperglycemia (can risk for surgical wound infection) may

result from stress of surgery, which can trigger increasedlevels of catecholamine.

o Other risks: acidosis & glucosuriao Pts who have received corticosteroids are at risk for adrenal

sufficiency. Must be reported.o Pts w/ uncontrolled thyroid disorders are at risk for

thyrotoxicosis (w/ hyperthyroid disorders) or respiratoryfailure (w/ hypothyroid disorders).

Immune Functiono Determine presence of allergies.o Immunosuppression common w/ corticosteroid therapy, renal

transplantation, radiation therapy, chemotherapy, & disordersaffecting immune system, such as acquired immunodeficiencysyndrome (AIDS) & leukemia.

o Mildest symptoms/ slightest temp must be investigated Previous Medication Use

o Med history obtained because of possible effects of meds onpts periop course, including possibility of drug interactions

o Aspirin- a common OTC med that inhibits plateletaggregation; therefore it is prudent to stop aspirin at least 7-10 days before surgery if possible

o Nursing Alert: Because of possible adverse interactions, nursemust assess & doc pts use of prescription meds, OTC meds


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(aspirin), herbal agents, & frequency w/ which meds areused. Nurse must clearly communicate this info toanesthesiologist or anesthetist.

o Herbal products be discontinued 2-3 wks before surgery

Psychosocial Factorso Preoperative anxiety may be an anticipatory response to an

experience viewed by the pt as a threat to his/her customaryrole in life, permanent incapacity, body integrity, increasedresponsibilities or burden on family members, or life itself.

Spiritual & Cultural Beliefso Play an important role in how people cope w/ fear & anxiety.o Spiritual beliefs can be as therapeutic as medication.

General Preoperative Nursing Interventions Providing Patient Teaching

o Multiple teaching strategies should be used (verbal, written,return demonstration), depending on pts needs & abilities

o Teaching initiated as soon as possible, beginning inphysicians office, clinic, or at time of PAT when diagnostictests are performed.

o Teaching should include sensations the pt will experience.o o Deep Breathing, Coughing, & Incentive Spirometer

Goal- teach pt how to promote optimal lung expansion& resulting blood oxygenation after anesthesia

Pt assumes sitting position to enhance lung expansion.Nurse demonstrates how to take a deep, slow breath & how to exhale slowly. After practicing several times, ptis instructed to breathe deeply, exhale through mouth,take a short breath, & cough from deep in the lungs.

Incentive Spirometer- a device that providesmeasurement & feedback r/t breathing effectiveness.

If thoracic/abdominal incision is anticipated, nursedemonstrates how to splint incision to minimizepressure & control pain.


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Pt should put palms of both hands together.Placing hands across incision site acts as aneffective splint when coughing.

Goal in promoting cough- to mobilize secretions so that

they can be removed. Deep breathing before coughingstimulates cough reflex.

o Mobility & Active Body Movement Goals- improve circulation, prevent venous stasis, &

promote optimal respiratory function.o Pain management

Pain assessment should include differentiation betweenacute & chronic pain.

Anticipated methods of administration of analgesicagents for inpatients include patient-controlledanalgesia (PCA), epidural catheter bolus or infusion, orpatient-controlled epidural analgesia (PCEA).

o Cognitive Coping Strategies Useful for relieving tension, overcoming anxiety,

decreasing fear, & achieving relaxation. Ex: Imagery, Distraction, Optimistic self-

recitation, Music therapyo Instruction for Patients Undergoing Ambulatory Surgery

Major difference in outpatient preop education isteaching environment.

Preop teaching content may be presented in a groupclass, videotape, at PAT, by telephone in conjunction w/preop interview.

When & where to report, what to expect, what tobring, what to leave at home, what to wear

Providing Psychosocial Interventionso Reducing Anxiety & Decreasing Fear

Knowing ahead of time about possible need forventilator, drainage tubes, or other types of equipmenthelps decrease anxiety r/t postop period.

o Respecting Cultural, Spiritual, & Religious Beliefs


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Psychosocial interventions include identifying & showingrespect for cultural, spiritual, religious beliefs.

o Maintaining Patient Safety Major role- protecting pts from injury

o Managing Nutrition & Fluids Major purpose of w/holding food/fluid before surgery is

to prevent aspiration. Fast 8 hrs after eating fatty food, 4 hrs after ingesting

milk products Many pts currently allowed clear liquids up to 2 hrs

before an elective procedureo Preparing the Bowel

Enemas not commonly prescribed preop unless pt isundergoing abdominal or pelvic surgery.

Goals- allow satisfactory visualization of surgical site & to prevent trauma to intestine or contamination of peritoneum by fecal material

Toilet or bedside commode, rather than bedpan, is usedfor evacuating enema if pt is hospitalized at this time.

o Preparing Skin Goal- Decrease bacteria w/out injury to skin

Hair is not removed preop unless hair at/around incisionsite is likely to interfere w/ operation.

Immediate Preoperative Nursing Interventions Immediately prior to procedure pt changes into hospital gown that

is left untied & open in back. Mouth inspected, & dentures/ plates removed Jewelry not worn to the OR All pts (except those w/ urologic disorders) should void

immediately before going to the OR

Administering Preanesthetic Medicationo Minimal w/ ambulatory or outpatient surgeryo Often, surgery is delayed or OR schedules change, & becomes

impossible to request a med be given at a specific time


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In these situations, preop med is prescribed on call toOR. Nurse can have med ready to administer as soonas call is received from OR staff. Usually takes 15-20min to prepare to pt for OR.

Maintaining the Preoperative Recordo Completed chart (w/ preop checklist & verification form)

accompanies pt to OR w/ surgical consent form attached,along w/ all lab reports & nurses records.

Transporting the Patient to the Presurgical Areao Pt transferred to holding area/presurgical suite in a bed or on

a stretcher about 30-60 min before anesthetic is to be given.o Patient safety in preoperative area is a priority.

Attending Family Needso Pt may be in OR much longer than actual operating time for

several reasons: Pts are routinely transported well in advance of actual

operating time. Anesthesiologist/anesthetist often make additional

preparations that may take 30-60 min. Surgeon may take longer than expected w/ preceding

case, which delays start of next surgical procedure.o It is the surgeons responsibility, not the nurse, to relay

surgical findings & the prognosis, even when findings arefavorable.

Expected Patient Outcomes Relief of anxiety, decreased fear, understanding of surgical

intervention, no evidence of preop complications


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1/29/2012 3:05:00 PM


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1/29/2012 3:05:00 PM

ch. 18 preoperative nursing management

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