Preoperative Care

1. Surgery The art and science of treating disease, injuries, and

deformities by operation and instrumentation

2. Surgery is pre- - diagnosis, cure, palliation, prevention, cosmetic improve-

formed for ment, exploration

3. Surgical Settings - Elective surgery (carefully planned out) vs. emergency

surgery (arised unexpectancy)
- Inpatient- same-day admission- patient is going to be
admitted to the hospitals on same day of surgery- patients who
are there before are there because of chronic medical
conditions
- Ambulatory: outpatient- same day- may be in clinics,
physicians offices, general, regional or local anesthetic
operative time less than 2 hours and less than 24 hour stay
4. Your Role Pre-op - Have knowledge of the nature of the disorder requiring
surgery
- Identify the individual patient's response to the stress of
surgery
- Have knowledge of the results of the preoperative diag-
nostic tests
- Identify potential risks and complications associated with
surgery
+ get family involved

5. What should - Check documented information before interview to avoid

you do before a repetition
pa- tient - Primary purposes
interview? 1. obtain the patient's health information
2. Provide and clarify information about the planned
surgery
3. Assess the patient's emotional state and readiness for
surgery, including outcomes and expectations
4. Ensure patients consent has been signed and wit- nessed
and appropriate lab data has been ordered or completed

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6. When does the Psycho-

patient
interview occur

7. Purpose of
Pa- tient
Interview

8. Nursing
Assess- ment
goals

9. Nursing
Assess- ment:
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 Preoperative Care

- One day in advance or outcome

on day of surgery - Identify, document, and communicate results of lab/di-
agnostic tests (or when they will get results) good idea to have
patient log 48 hrs pre surgery
- identify cultural and ethnic factors that may affect surgical
- Obtain health experience
information - Determine receipt of adequate information from surgeon to
- Determines sign informed consent
expectations - Determine informed consent and that informed consent for
- Provide and is signed and witnessed
clarify information (you can't do it but document consent is not here and notify
about the surgery physician0 if demeaned needs health care proxy make sure
and anesthesia you have the health care proxy- not always spouse- if patient is
- Assess emotional state alert and oriented the nurse can be a witness)
and readiness
(Surgeon usually rushes - excessive stress response can be magnified and affect
through and you cannot recovery
rush) - this is a subjective assessment

- GOAL= Identify
risk factors AND
Plan care to
ensure patient
safety
+
- determine
psychologic status to
reinforce coping
strate- gies
- Determine
physiologic factors of
the procedure
contribut- ing to risks
- Establish baseline
data****
- identify and document
surgical site + type
- Identify medication
and herbs taken that
may affect sur- gical
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 Preoperative Care

logical assess- - influenced by age, past experience, current health and SES
ment - identify support systems, define current degree of per- sonal
care, decision making and independence, deter- mine presence
of hope and anticipation of positive results
- concerns with unknowns, body image, knowledge deficit,
anxiety, common fears

- age
10. Nursing - past experience
Assess- ment: - current health
Influenc- ing - SES
factors
- use common language
- use translators if needed-- decreases level of anxiety
11. Nursing - communicate all concerns to surgical team
Assess- ment
language - Anxiety can impair cognition, decision making, and cop- ing
abilities
- anxiety can arise from:
12. Nursing 1. Lack of knowledge
Assess- ment: 2. unrealistic expectations
Anxiety - you look anxious, is it because you don't know have you
seen a movie? let surgeon know if over the top anxious
- Information lessens anxiety
- anxiety may arise from conflict with interventions (blood
transfusions) and religious or cultural beliefs- identify be- liefs
and discuss with surgeon and operative staff

1. Death or disability
- may prompt postponement
- influence outcome
- notify surgeon if strong because this can influence the
13. Nursing surgical outcome
Assess- ment: 2. pain
fears - consult with ACP
- Confirm drugs will be available and reassure drugs will be
available
- smokers ensure have narcotic patch
- or chronic smokers or users get pain --> delirium

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 Preoperative Care

3. Mutilation or alteration in body image

- assess concerns nonjudgmental
4. Anesthesia
- ACP for consult
5. Disruption of life functioning
- range from fear of permanent disability to temporary loss
- include family and financial concerns
- consultations PRN- may benefit or may need psych
consult

14. Nursing - May be strongest positive coping mechanism- NEVER

Assess- ment: deny or minimize
Hope - Assess and support

- Diagnosed medical conditions- previous and current

15. Nursing
Assess-
ment: Past Health - Previous surgeries and problems
History - Menstrual/obstetric history
*especially fi they or family had trouble with anesthesia
- Familial diseases- conditions
- reactions/problems to anesthesia patient or family
- when obtaining a family history as BOTH patient and
caregiver about any inherited traits

16. Nursing - Prescription and OTC

Assess- ment: - Herbal supplements
Current - Dietary supplements
medications - Antiplatelts/NSAIDs
- Recreational- drugs, alcohol, tobacco
- if patient taking antidepressants- don't want to discontin- ue
those
- nicotine patient put patch on because of withdrawal
- document ALL findings and communicate to periopera- tive
team

- drug and non-drug allergies

17. Nursing - screen for latex allergy: risk factors, contact urticaria or
Assess- ment- dermatitis, aerosol reactions, history of reactions suggest- ing
Allergies latex allergy
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 Preoperative Care

- may be
idiosyncratic-
opposite than
expected effect
therefore ask
ALL

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 Preoperative Care

18. Nursing Assess- Report

ment- - any cardiac problems so they can be monitored during the
Cardiovas- cular intraoperative period- history of hypertension, MI, may need
system cardiolog consult or 12 lead
- use of cardiac drugs
- presence of pacemaker/ ICD
*Anticoagulants and surgery DO NOT mix must initiates
surgeons implementation
- pacemakers are usually full code and turn off with mag- net
if has defibrillator
- 12 lead ECG
- Coagulation studies
- Possible prophylactic antibiotics
(possible cardio consult- remember diet can influence drug
interactions so if go off medication before surgery tell them to
stick to normal diet)

- Inquire about recent airway infections- procedure could

19. Nursing Assess-
ment: respiratory be canceled because of increased risk of laryngo/bron-
system chospasm or decreased SaO2
- any respiratory infection you must call the surgeon
- protect immune system before your surgery- example
encouraging them not to see their grandchildren
- history of dyspnea, coughing, hemoptysis reported to
operative team- know baseline!
- COPD or asthma- high risk for atelectasis and hypoxemia
- smokers should be encouraged to quit 6 weeks before
procedure- decrease risk of complications - especially warn
against right before surgery on the way use nicotine patch to
make them comfortable after
- sleep apnea, obesity, and airway deformities affect res-
piratory function- sleep apnea can go unknown too so ask by
does your sig other say you snore do you not feel well rested
after sleeping?
- may need pulmonary function test based on these results

20. Best time to pre-operatively and the importance of it

teach IS
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21. Nursing - Evaluation of neurologic functioning- follow commands,

Assess- ment- maintain orderly throughout patterns
Nervous system - vision or hearing loss can influence results: as soon as get
hearing aid back surgery is better
- cognitive deficits can affect informed consent and cause
adverse outcomes during and after surgery
- if issues cannot be corrected, may need witness or
attorney for legal reasons
- inquire about history of strokes, transient ischemic at- tacks,
SC injury, neurological diseases- Parkinsons, MS + treatments

- History or urinary or renal disease

22. Nursing - Renal dysfunction contributes to:
Assess- ment- 1. Electrolyte and Fluid imbalances
Genitouri- nary 2. Increased risk of infection
system- genitals 3. Impaired wound healing
and uri- nary 4. Altered response to drugs and their elimination
- drugs stay in system longer with renal dysfunction- must
know base line- may not be able to take narcotic day before
surgery
- Renal function tests- BUN creatine to calculate GFR
- frequent kidney stones do renal ultra sounds
- note problems voiding, and inform operative team
- assess women for possibility of pregnancy
- for women of childbearing years determine if they are
prego or think that they could be

- Liver detoxifies many anesthetics and adjunctive drugs

23. Nursing - hepatic dysfunction may increase risk of postoperative
Assess- ment- complications
Hepatic system - Lab tests- ALT, LST
- liver and gallbladder work closely with bilirubin tree- total
bilirubin lab
- liver is involved in glucose hemostasis, fat metabolism,
protein synthesis drug and hormone metabolism
- ask about liver disease, jaundice etc.

24. 24.

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 Preoperative Care

Nursing - History of skin and musculoskeletal problems

Assess- ment: - History of pressure ulcers: extra padding during proce-
integu- mentary dure, affects post operative hearing, after surgery must make
system sure patient skin is dry
- Body art, tattoos, piercings

- identify joints affected with arthritis

25. Nursing - mobility restrictions may affect positioning and ambula-
Assess- ment:
Muscu-
loskeletal system tion
- bring mobility aids to surgery (females that had a lot of kids
may have back problems) that should be brought with the
patient the day of surgery
- report problems affecting neck or lumbar spine to ACP- can
affect airway management and anesthesia delivery

26. Nursing Assess- ment- Endocrine System: Addi- son's

Assess- ment- disease
Endocrine
System- DM

27. Nursing
Assess- ment-
Endocrine
System: Thyroid
disease

28. Nursing
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 Preoperative Care

- patients with DM are or ACP regarding insulin dose

especially at risk for - patient must be NPO midnight before come in- but if
- Hypo or diabetic need to know if to continue with medications etc.
hyperglycemia must be done pre-operatively
- Ketosis
- Cardiovascular - hyper-hypothyrodisum poses risk because of altered
alterations metabolic rate
- delayed wound - verify with ACP about giving thyroid medications
healing - post operative complications from thyroid abnormalities can
- infection be missed- make sure correct dosage is in there and last if took
- Serum or capillary night before
glucose tests
morning of surgery - abruptly stopping replacement of corticosteroids could
for baseline cause Addison crisis
- Clarify with physician - Stress of surgery may require increased dose of IV
corticosteroids

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 Preoperative Care

29. Nursing - patients with history of compromised immune system or use

Assess- ment: of immunosuppressive drugs can have-
immune system 1. delayed wound healing
2. increased risk of infection
- know baseline of cell counts
- cancer pt on chemo is immunocompromised unless
proven otherwise
8-11 WBC is normal <1 is low- if WBC is low patient should
be on neutropec
30. Nursing Assess- - Vomiting, diarrhea, or difficulty swallowing can cause
ment: fluid and imbalances- if this is occurring night before must call
electrolyte - identify drugs that alter F and E status- diuretics
status - evaluate serum electrolyte levels
- NPO stats: may require additional fluids and electrolytes
before surgery if dehydration occurs

- Deficits include over and under nutrition

31. Nursing Assess- - obesity
ment- Nutritional -- stresses cardiac and pulmonary systems ( if BMI >40
status HUGE RF- might not even fit onto able must be document- ed
to prepare)
- - increased risk of wound dehiscence, infection, and
incisional hernia
-- slower recovery from anesthesia
-- slower wound healing
* try to keep belly off chest can obstruct respirations- side
lying is best
- provide extra padding to UNDERwt patients to prevent
pressure ulcers
- may be protein and vitamin deficient
- ID dietary habits that may affect recovery eg. caffeine
- ID patients with large caffeine- could lead to severe
withdrawal headaches that could be confused with spinal
headaches if not documented

- The Joint Commission- TJC requires an H&P

32. Nursing - may be one day in advance or day of
Assess- ment- - Findings enable ACP to rate patient for anesthesia ad-
EXAM
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 Preoperative Care

ministration- indicator of perioeraptive risk and overall out- come

- document relevant findings, and report to perioeraptive
team
- obtain and evaluate results of lab tests
- monitor BG for patients with DM

- Preoperative teaching
33. Nursing Man- --patient right to know what to expect and how to partici-
agement pate
Teach- ing ---increases patient satisfaction
General ---reduces fear, anxiety, stress, pain and vomiting
- Limited time available- address needs of highest priority,
include information focused on safety, provide written ma-
terial
- ideally this is several days before surgery- observe and
listen to determine amount of teaching for session
- anxiety and fear can hinder learning
- give priority to patient's concerns
- must be documented and reported to postoperative nurs- es
- avoid duplication of information, assess learning- make sure
they are comfortable with the information or know where to
find it

1. sensory- prepare if the or will be really bright, smells

they might smell, hear lots of beeps
2. Process- patient transfer to the holding area, vists the
34. Nursing manage- nurse, and waking up in PACU
ment-- types of 3. Procedural- an IV line will be started while in the holding
teaching area

- teach deep breathing, coughing, and early ambulation as

appropriate
- inform if tubes, drains, monitoring devices, or special
35. Specific preoper- equipment will be used post- operatively
ative teaching - provide surgery-specific information: IV, foleys different
lines etc.
*unless contraindicated, all patients should receive in-

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 Preoperative Care

40. Surgeon and Consent vs. nurse

36. Preoperative
teaching-
basic
information
before arrival

37. Nursing man-

agement- legal
preparation

38. Before
nonemer- gency
surgery can be
legal-
ly performed,
pa- tient must

39. Consent for

surgery- in-
formed
consent must
include

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 Preoperative Care

struction about deep successful outcome- avail- ability of benefits- risks of

breathing, coughing, alternative treatments and the prognosis if the treatment is not
and early am- instituted
bulation 2. Patient must demonstrate clear understanding of this
postoperatively information
3. The recipient of care must give consent voluntarily
- time and palce- where *RN may be responsible for witnessing the patient's sig-
to park nature- can be advocate, verify patient caregiver under-
- fluid and food stands and if not tell surgeon need more information
restrictions
- need for enema 1. Adequate disclosure
- need for shower 2. Understanding and comprehension
3. Voluntarily given consent
- all required forms are (if knew information comes into play after consent, they can
signed and in chart: say forget this its ok)
1. Informed consent
2. Blood transfusions - the surgeon is responsible for obtaining consent
3. Advance directives -Nurse may obtain and witness signature
4. Power of attorney

voluntarily sign an
informed consent form
in the presence of a
witness
Informed consent-
active, shared decision
making process
between HCP and
patient receiving care
- 3 conditions must be
met for consent to be
valid
1. Must be adequate
disclosure of the
diagnosis- the na-
ture and purpose of
the treatment- the
risks and conse-
quences- the
possibility of a
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 Preoperative Care

- verify patient has understanding

- permission may be withdrawn

41. Medical emer- - medical emergency may override need for consent
gency and con- - if patient is unavailable next kin may give consent, if
sent reaching the next kin is not possible the physician may begin
treatment without written consent but needs docu- mentation
(closest living blood relative)

42. Legally - a minor

appoint-
ed representative - unconscious
of family may - mentally incompetenet
consent i patient
is

43. Emancipated MI- - has legal capacity too provide consent despite age
NOR

44. Nursing Manage- - Final preoperative teaching

ment- Day of - Assessment and report of patient findings
Surgery Prepara- - Verification of signed consent
tion - Labs- ensure all orders are done and labs
- History and physical examination verify and informed
conset, baseline VS
- Baselien vitals
- Consultation record's
- Nurses's notes
- Hospital gown- nothing under
- Patient should not wear any cosmetics- observation of
skin color is important! remove nail polish for pulse ox
*document items on patient so you are not responsible if
lost before this point

45.
46. Day of surgery - valuables are retuned to family member or locked up
and valuables - dentures, contacts, prostheses are removed
- identification and allergy bands on wrist

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 Preoperative Care

47.

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 Preoperative Care

Day of surgery - void before surgery --> prevents involuntary elimination

and voidiing under anesthesia or during early postoperative recovery
- before medication administration
48. Preoperative - Benzodiazepines- sedeative and amnesic properties
Medications - Anticholinergics
- Opioids
- Antiemetics- decrease N/V
- Antibiotics
*if accidentally given meds before consent obtain consent
from health care proxy
Preoperative medication should be ordered PO IV or subQ
- PO small sip pf water 60-90 min before patient goes to OR

- Via stretcher or wheelchair

49. Nursing Man- - Communication handoff SBAR (situation, background,
agement- assessment, recommendation)
Trans- - you are responsible for the handoff
portation to the
OR

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