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Care of the Preoperative Patient
Chapter 16
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Begins when patient is scheduled for surgery; ends at time of transfer to surgical suite
Nurse functions as educator, advocate, promoter of health and safety
Preoperative Period
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Tubes Drains Vascular access
Patient & Family Teaching
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Nasogastric Tube
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Breathing exercises Incentive spirometry Coughing and splinting
Prevention of Respiratory Complications
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Decreased: Cardiac output, peripheral circulation Vital capacity, blood oxygenation Blood flow to kidneys, glomerular filtration rate
Increased: Blood pressure Risk for skin damage, infection Sensory deficits Deformities related to osteoporosis/arthritis
Older Adults: Changes of Aging as Surgical
Risk Factors
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Chronic illness Malnutrition Impaired self-care ability Allergies Inadequate support systems
Older Adults: Considerations for Preoperative
Care
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Stress from surgery/anesthesia Cardiopulmonary complications after surgery Mental status changes Risk for falls
Older Adults: Considerations for Preoperative
Care
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Diagnostic – determines origin and cause of disorder
Curative – resolves health problem by repairing or removing cause
Restorative – improves patient’s functional ability
Palliative – relieves symptoms of disease process, but does not cure
Cosmetic – alters/enhances personal appearance
Reasons for Surgery
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Urgency: Elective Urgent Emergent
Degree of Risk: Minor Major
Urgency and Degree of Risk of Surgery
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Simple Radical Minimally invasive (MIS)
Extent of Surgery
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Preoperative teaching Encourage communication Promote rest Use distraction Teach family members
Anxiety Interventions
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Break in the skin increases risk for infection Patient may be asked to shower using
antiseptic solution Hair removal by electric clippers, depilatories Shaving of hair creates risk for infection!
Skin Preparation
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Reduce anxiety Promote relaxation Reduce nasal and oral secretions
Preoperative Drugs
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Prevent laryngospasm Reduce vagal-induced bradycardia Inhibit gastric secretion Decrease amount of anesthetic needed for
induction and maintenance of anesthesia
Preoperative Drugs
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History and data collection: Age Drugs, substance use Medical history (including cardiac and pulmonary) Complementary/alternative practices Previous surgical procedures, anesthesia Blood donations Discharge planning
Collaborative Management: Assessment
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Obtain baseline vital signs Focus on problem areas identified in history;
all body systems affected by surgical procedure
Report abnormal assessment findings to surgeon/anesthesiology personnel
Physical Assessment / Clinical Manifestations
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Cardiovascular CAD, MI within 6 months before surgery, angina,
hypertension, dysrhythmias Respiratory
Chronic respiratory problems Smoking increases carboxyhemoglobin blood
level, deceases oxygen delivery Renal/Urinary
Kidney impairment inhibits drugs/anesthetic agent excretion
System Assessment
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Neurologic Determine baseline Assess LOC, ability to follow commands
Musculoskeletal Nutritional status
Malnutrition and obesity increase surgical risk Psychosocial
System Assessment
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Be aware of patients at greater risk for DVT Antiembolism stockings Pneumatic compression devices Leg exercises Mobility
Prevention of Cardiovascular Complications
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Urinalysis Blood type and crossmatch CBC or hemoglobin level and hematocrit Clotting studies (PT, INR, aPTT)
Laboratory Assessment
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Electrolyte levels Serum creatinine level Pregnancy test Chest x-ray ECG
Laboratory Assessment
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Preoperative teaching Informed consent:
Surgeon obtains signed consent before sedation and/or surgery
Nurse clarifies facts and dispels myths about surgery
Nurse not responsible for providing detailed information about procedure!
Insufficient Information Interventions
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Patients may sign with “X” In emergency, telephone authorization is
acceptable Special permits required for some procedures
Informed Consent
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Ensure correct site is selected and wrong site is avoided
Licensed independent practitioner marks site, involving patient if possible
“Time out” procedure adopted by most facilities
NPSGs and Informed Consent
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NPO: Patient not to ingest anything by mouth for 6 to 8 hours before surgery: Decreases risk for aspiration Give patients written/oral directions to stress
adherence Surgery can be canceled if instructions not
followed
Implementing Dietary Restrictions
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Consult with physician and anesthesia provider for instructions
Drugs for certain conditions often allowed with a sip of water: Cardiac disease Respiratory disease Seizures Hypertension
Administering Regularly Scheduled
Medications
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Performed to prevent injury to colon; reduce number of intestinal bacteria
Enema or laxative
Intestinal Preparation
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Patient using Incentive Spirometer
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Obese patients Age 40 or older History of cancer Decreased mobility or immobile Spinal cord injury
Patients at Risk for VTE
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History of VTE, PE, varicose veins, edema Oral contraceptives Smoking History of decreased cardiac output Hip fracture, total hip/knee surgery
Patients at Risk for VTE
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External Pneumatic Compression Devices
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Ensure all documentation, preoperative procedures, orders are complete
Check surgical consent form and others for completeness
Inform patient that area will be marked before procedure begins
Document allergies, height, and weight
Preoperative Chart Review
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Ensure all laboratory and diagnostic test results are in chart
Document/report any abnormal results Report special needs and concerns
Preoperative Chart Review
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Remove most clothing; provide gown Leave valuables with family member or lock
up Tape rings in place if cannot be removed Ensure patient is wearing ID band
Preoperative Patient Preparation
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Remove: Dentures Prosthetic devices Hearing aids Contact lenses Fingernail polish Artificial nails Pierced jewelry
Preoperative Patient Preparation
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Sedatives Hypnotics Anxiolytics Opioid analgesics Anticholinergic agents H2 histamine blockers
Drugs for Preoperative Preparation
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Chapter 16
Audience Response System
Questions
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To ensure safe patient care transition from the perioperative nurse to the intraoperative nurse, optimal hand-off communication includes all of the following except:
A. Providing a recent patient history, vital signs, allergy, and medication updates
B. Verbally verifying that the operating room nurse understands the report
C. Encouraging the operating room nurse to interrupt to ask questions as the perioperative nurse provides report
D. Using a standardized hand-off communication tool to provide report (e.g., SBAR, Five-Ps, PACE)
Question 1
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When assessing the laboratory work of a 65-year-old patient who is scheduled for surgery this morning, which laboratory value may result in cancellation of the surgery?
A. Serum sodium level 149 mEq/L B. Fasting blood glucose 120 mg/dLC. Hemoglobin 10.5 g/dLD. Serum potassium 2.9 mEq/L
Question 2
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During a preoperative assessment, the nurse asks the patient about allergies. Which allergy cited by the patient would be of greatest concern during the surgical procedure?
A. ShellfishB. Sulfa drugsC. CodeineD. Kiwi
Question 3