PREOPERATIVE NURSING

• Patients face surgical interaction in different ways

• Fear –• -anticipation or awareness of danger -dependant on individual -intensity of stress• Cultural and Religious Influences

Creates physiological changes

Other Reactions to Illness

• Suspicion• Guilt, shame, punishment• Depression• Withdrawal• Regression• Denial• Anger, Hostility• Shock• Grieving, mourning

Preoperative Interview

• Can discover: – pt. history of surgeries, infections, diseases– pt. allergies– Pt. use of chemicals, alcohol, recreational

substances– Pt. history of smoking

• Can help nsg. anticipate pt. needs, preoperatively, during surgery, and postoperatively

Preoperative Teaching

• Lessening anxiety– Reduces the amount of anesthesia needed– Decreases post-surgical pain– Decreases post surgical complications– Reduces “sympathetic response” and cortico-

steroid production– Wound healing occurs more rapidly

skeletal

Preoperative teaching

• 1-2 days before surgery• decreases fear of the unknown and alleviating

anxiety.• Prepare client/family for the expected events

of the surgical day• What to expect post operatively• Ask client to discuss information known about

upcoming surgery

Preoperative TeachingInstruct about incision(s)

Size and locationType of closureDrains and dressingsGetting out of bed with abdominal incision

Instruct about possibility of tubesNasogastric tubesWound evacuation unitsIVOxygen

When teaching, include family and significant other to promote support.Discharge teaching and expectations

• Leg Exercises• Importance of Early Ambulation and TED hose• Instruct in Assessment and Management of

Pain• Instruct in Splinting Activities with Cough and

Deep Breathing (Exceptions, AHN, pg. 37, Box 2-6)

• Support groups may be available for pre-op visits - eg. Cancer, ostomy or amputation

Patient Special Needs

• Patients of various ages and stages of development have different needs

Developmental Stages

• Birth to 18 months– Dependent on caregivers– Startled easily– View hospital as

abandonment• 18 to 30 months

– Suffers separation anxiety– Fear immediate threats

• 30 months to 5 year olds– Fears, real or imagined– Disfigurement– Fear death or nonexistence– May act out feelings

• 6-12 Year olds– Loss of control– Prefers honesty and

reassurance of safety– Not treated like a baby

• 12-16 Year olds– Body image important– Prefers privacy/confidentiality

• 17-Adult– May feel hostility towards

authority– Torn between dependence and

independence– Demands privacy and

confidentially

PediatricPediatric• May bring toy to O.R.

depending on policy• Use vocabulary compatible

with age• Don’t refer to general

anesthesia as sleeping• Dress dolls as post op

appearance• Be honest-

– Never tell them something won’t hurt

• Priority on schedule– Feeding routine

• Guard against falls• Avoid adhesive tapes

Special Considerationsfor the Elderly

80% of elderly -at least one chronic disease. “Cascade effect” -failure in one system may lead to failure in

another -Late presentation -low health expectations by the patient -failure to recognize the problem -low expectation, fear of treatment/hospitalization. Presentation of a social problem -obscures an underlying disease/complicate its management.Polypharmacy

Special Considerations for the Elderly

• History-taking, diagnosis and management– Complicated by: • intellectual failure • inability to communicate• Depression, confusion and delirium

– Short term memory loss • affects how well your client

absorbs information during teaching.

Preoperative Preparation– Vital Signs– Laboratory tests • Urinalysis• Complete blood count• Blood chemistry profile

– Endocrine, hepatic, renal, and cardiovascular function

• Electrolytes

– Diagnostic imaging• Chest x-ray• Electrocardiogram

– Evaluation by Anesthesiology

Cardiovascular Risk

• Surgical patients are given points to rate them for the possibility of not surviving the surgical procedure

• A risk index of 26 or more points should undergo only life saving surgery

• Scores of 13-25 probably exhibit sufficient cardiac risk to warrant routine preoperative cardiac evaluation.

Cardiovascular Considerations

• Due to blood stasis, encourage LEG EXERCISES post operatively to assist venous flow.– With venous blood slowing ↑ risk for thrombus ↑ risk for embolus ↑ risk for infarct.

• Nursing measures:– Antiembolism stockings – TED hose; sequential

compression device (SCDs)– Leg exercises– Ambulation as soon as MD approves

Informed consent Patient’s Bill of Rights affirms Informed Consent◦ Information clear◦ Requires collaboration between

Patients Physicians Other health care professionals

◦ Risks explained◦ Benefits identified◦ Consequences understood◦ Alternatives discussed

The surgeon is responsible for the informed consent. Nurse may witness the client signing the informed consent but

make sure the client has understood the surgeon’s explanations.

Consent for Surgery

• Voluntary and informed act • Mentally able to understand

– Should not be under the influence of pain medications

• Agrees to the procedure

• Granting party must have authority– Competent adult – Parent or legal guardian of a minor– Legal Guardian (permanent, temp.)– Courts

Written Informed Consent

• Patient’s legal name• Surgeon’s name• Procedure to be performed• Patient’s legal signature• Signature of witness(es)• Date and time of signatures

Latex Allergy Considerations

• Nsg. - focused assessment of risk factors:– Hx. anaphylactic reaction of unknown etiology

during a medical or surgical procedure– Hx. reaction to latex (blowing up/handling balloons,

gloves, condoms/condom catheters)– Multiple surgical procedures– Food allergies – esp. kiwi, bananas, avocado,

chestnuts– Allergy to poinsettia plant– Hx. of allergies and/or asthma

Latex Allergy Considerations

• Pt. with suspected or known latex allergy:– All latex is avoided– Admitted directly to the OR– 1st case of the day– Some are returned to a converted isolation room

(with reverse flow ventilation) that is latex-safe– Medic-Alert bracelet– Prep meds with latex-free measures– Latex-free supplies on the Crash Cart

Latex Allergy Considerations

• Preeoperative Prophylaxis– Treat with glucocorticosteroids and antihistamines

• Reference: AHN p. 28 Box 2-5

Sleep Promotion the Night before Surgery

Sleep gives neurons a chance to shut down and

repair themselves. Without sleep, neurons may

become so depleted in energy or so polluted with

byproducts of normal cellular activities that they

begin to malfunction.

Anesthesia Sleep

Preoperative medication

Reduces anxietyValium, Versed, Ativan

Facilitate induction of anesthesiaMorphine, Fentanyl (Sublimaze) and sufentanil (sulenta)

Minimize some of the undesirable after effects of anesthetics such as excessive salivation, laryngospasm, bradycardia and vomiting

Anticholinergics—atropineSide effect: skin flush and fever, urinary retention

If given on nursing unit, use safety measuresBed in low position and side rails upMonitor every 15-30 minutes

Preoperative checklist

Permits signed and on chartAllergies (don’t forget Latex)ID band(s) on patient (remember, once patient is sedated, they

don’t talk)Skin prep doneRemoval of dentures, glasses/contacts, jewelry, nail polish, hairpins,

makeupTED stockings appliedPreoperative vital signsPreoperative medicationsPhysical disabilities and/or diseasesHistory and physical and lab reports on chart

Skin PreparationSkin preparation◦ Check Policy and Procedure book◦ Shower and wash hair the night before◦ All nail polish and make up should be removed◦ Removal of body hair in general wide zone of surgery

Clipping only◦ Assess for skin impairment

Infection Irritation Bruises Lesions

◦ All rings, bracelets and necklaces need to be removed Intravenous Therapy initiated

Skin Prep

Gastrointestinal preparation

NPO after midnight (6-8 hrs for general surg., 2-3 hours for local anesthesia)

Sign on door and over bedMay have oral careMoist cloth to lipsVoid immediately or empty Foley bag before surgery

Bowel cleanser night before, if GI procedureEnemaLaxativeGI lavage (GoLYTELY)Medication to detoxify and sterilize bowel

Respiratory Considerations

• SMOKERS– May have impaired alveoli and reduced lung

capacity, what is the ciliary “elevator?”– Mucous and anesthesia by-products may get

trapped in the lungs atelectasis and pneumonia

• Post operative breathing exercise and treatment is aimed at increasing lung expansion

Respiratory Considerations

• Incentive Spirometer- what is the goal?– Keep at the bedside– Increase, maintain tidal capacity

• See AHN p. 28-29 Skill 2-2

• Turn, Cough, Deep Breathing Exercises– Staff to turn q 2 hours (unless MD restricts movement)– Coughing: contraindicated after brain, neck, spinal, and eye

surgery– Teach the pt. how to ‘splint’ the operative site during DB

and coughing. What is splinting for thoracic procedures?– Perform respiratory exercises q2 hrs and prn

GU Considerations• After general anesthesia - ↓ urinary bladder tone• Preoperatively, assess the pt. nrml. bladder habits

and identify when pt. experiences fullness and distention of bladder

• Inform the pt. of frequent lower abdominal palpation by nurse post operatively

• Inform pt. of possible catheter placement• I and O• Most common complications: urinary retention

and bladder infection

Holding area

• Pre-anesthesia care unit– Compare patient’s ID bracelet to the medical record– Preoperative preparations

• IV• Preoperative medications• Skin prep (hair removal)

– Transport to the operating room– Direct family to appropriate waiting area

Transportation MethodsTransportation Methods

• Standard stretcher

• Gurney

• Crib

• Ward bed

• Stryker Frame