PRE-OPERATIVE

NURSING CARE
K.G.A
 THE PRE-OPERATIVE PHASE
• It begins when the decision to proceed
with surgical intervention is made and
ends with the transfer of the patient
onto the operating room table.
 Cont’
The pre-operative period involves:
a. establishing a baseline evaluation of the patient before
surgery by carrying out a preoperative assessment
b. ensuring that necessary tests have been performed

Thus arranging appropriate consultations with the

multidisciplinary team such as the surgeon, anaesthetist,
radiologist, laboratory technologist, etc.
 CONT’
c. providing education about recovery from
anaesthesia and postoperative care
History is taken from the patient and relatives to
direct the activities of the multidisciplinary team
pre-operatively such as past surgical history,
allergies to drugs, tape, latex, and iodine, existing
infections etc.
 Trends in Pre-operative care
• Gene therapy delivered in utero to help avoid
surgical correction of a range of inherited diseases
• Microsurgical approaches now hasten recovery
from many types of abdominal surgeries.
• Patient controlled analgesia (PCA) devices
allow patients to pace the timing of their own
medication delivery
 SURGICAL RISK FACTORS
1. Nutrition
• Optimal nutrition is an essential factor in
promoting healing and resisting infection and
other surgical complications
• Nutrients important for wound healing are:
protein, vitamin C, vitamin B complex, vitamin A,
vitamin K, magnesium, copper, zinc
 Therapeutic Approach
• Any recent (within 4 to 6 weeks) weight loss of 10%
of the patient's normal body weight should alert the
health care staff of poor nutritional status and the
need to investigate as to the cause of the weight loss.
• Attempt to improve nutritional status before and after
surgery. Unless contraindicated, provide a diet high in
proteins, calories, and vitamins (especially vitamins C
and A); this may require enteral and parenteral
feeding.
 2. Drug or Alcohol Use
• The person with a history of chronic alcoholism
often suffers from malnutrition and other
systemic problems that increase surgical risk.
• The patient may also have an increased tolerance
to anaesthetics.
 Therapeutic Approach
• Anticipate the acute withdrawal syndrome within 72
hours of the last alcoholic drink.
 3. Age
• For healthy older patients, age alone does not mean
that they are at greater surgical risk. However,
complications can occur as a result of previous health
status, immobilization occurring from surgery
• Moreover, normal aging changes may reduce the
effectiveness of deep breathing and coughing, and the
effects of administered medications. Older patients may
need a longer time to recover from anaesthetic agents
because of aging changes in drug metabolism and
elimination.
 Therapeutic approach
• Consider using lesser doses for desired effect.
• Anticipate problems from chronic disorders such
as anemia, obesity, diabetes, hypoproteinemia.
• Adjust nutritional intake to conform to higher
protein and vitamin needs.
 4. Presence of disease/s
• Chronic disorders may increase the patient‟s
surgical risk unless they are well controlled.
• For patients with diabetes, the stress of surgery
can alter blood glucose levels.
• Patients with chronic lung disorders may be at risk
for pulmonary complications from anaesthesia.
 Therapeutic Approach
• Frequently assess heart rate and blood pressure (BP)
• Avoid fluid overload (oral, parenteral, blood products)
because of possible myocardial infarction, angina and
pulmonary edema.
• Prevent prolonged immobilization, which results in venous
stasis. Monitor for potential deep vein thrombosis (DVT) or
pulmonary embolus.
• Encourage position changes but avoid sudden exertion.
• Use antiembolism stockings intraoperatively and
postoperatively.
 5. Obesity
• Increases the difficulty involved in the technical aspects of
performing surgery; risk for wound dehiscence is greater
• Increasesthe likelihood of infection because of
compromised tissue perfusion
• Increases demands on the heart, leading to cardiovascular
compromise
• Increases the risk for airway complications
• Alters the response to many drugs and anesthetics
• Decreases the likelihood of early ambulation
 Therapeutic approach
• Encourage weight reduction if time permits.
• Anticipate postoperative obesity-related complications.
• Be extremely vigilant for respiratory complications.
• Carefully splint abdominal incisions when moving or
coughing.
• Avoid intramuscular injections in morbidly obese individuals
(I.V. or subcutaneous routes preferred).
• Never attempt to move an impaired patient without
assistance or without using proper body mechanics.
 6. Fluid and Electrolyte Imbalance
• Anticipated volume losses associated with surgery,
causing shock and cardiac dysrhythmias
• Patients undergoing major abdominal operations (such
as colectomy-resection of the large intestine) often
experience a massive fluid shift into tissues around the
operative site in the form of edema (as much as 1 L or
more may be lost from circulation). Watch for the fluid
shift to reverse (from tissue to circulation) around the
third postoperative day.
 Therapeutic Approach
• Assess the patient's fluid and electrolyte status.
• Rehydrate the patient parenterally and orally as
prescribed.
• Monitor for evidence of electrolyte imbalance,
especially Na+, K+, Mg++, Ca++.
• Be aware of expected drainage amounts and
composition; report excess and abnormalities.
• Monitor the patient's intake and output; be sure to
include all body fluid losses.
 7. Concurrent or Prior Pharmacotherapy
• Hazards exist when certain medications are given
concomitantly with others (eg, interaction of
some drugs with anaesthetics can lead to
hypotension and circulatory collapse).
• This also includes the use of many herbal
substances. Although herbs are natural products,
they can interact with other medications used in
surgery.
 Therapeutic approach
• An awareness of drug therapy is essential.
• Notify the health care provider and
anaesthesiologist if the patient is taking
anticoagulants, such as warfarin or heparin; or
medications or herbals that may affect
coagulation, such as aspirin.
 Other surgical risk factors
• Nature of condition
• Location of the condition
• Magnitude and urgency of the surgical procedure
• Mental attitude of the person toward surgery
• Caliber of the professional staff and health care
facilities
NURSING MANAGEMENT OF THE PRE-OPERATIVE CLIENT
Goals
• Assessing and correcting physical, physiological and
psychological problems.
• Giving learning/teaching guidelines regarding measures
(such as exercises, dietary restrictions, life-style changes)
to avoid surgical complications and to cope with the
surgical intervention and benefit the patient during the post
operative period.
• Planning for discharge and any projected changes in
lifestyle due to surgery
 Physiological Care
 Involve activities performed to:
 establish a baseline data

 detect abnormalities

 correct imbalance and

 determine the fitness of the patient

 Cont’
 Laboratory investigations
 Blood analysis: grouping & x-matching, FBC (RBC, Hb,
WBC)
 Urinalysis (Color, pH, etc..)

 Prothrombin/ Bleeding time (test)

 RBS/FBS

 Radiographic examinations
 X-rays

 Electrocardiography

 Barium meal/enema
 CONT’
Routine monitoring
 Blood pressure

 Temperature

 Pulse

 Respiration

 Oxygen saturation (SpO2)

 Assess for the signs of dehydration (dry skin and mucous

membrane, loss of skin turgor) and over-hydration (orbital
oedema). Observe the site of IV therapy for any swelling
and intervene appropriately.
 CONT’
Assist the doctor to insert a cannula and administer
prescribed intravenous (IV) fluids to hydrate the patient
(ensure you calculate the drop per minute).
 Maintain accurate input and out record.
Depending on the type of surgery such as abdominal or
pelvic surgery, the patient may be catheterized or a
naso-gastric (NG) tube may be passed to decompress
the stomach. Ensure that right size of urethral catheter
or NG tube is used for the patient and the procedure
should be done aseptically.
 Psychological Care
The main aim of psychological preparation is to allay fears from
the patient and family
Manifestations of fears
• Anxious
• Anger
• Tendency to exaggerate
• Sad, evasive, tearful
• Inability to concentrate
• Short attention span
• Failure to carry out simple instructions/directions
 How to allay fears
1. Establish Rapport: this will involve warm reception of
patient, exchanging greetings and other preliminary
conversations
2. Asses for causes of fears of the preoperative clients OR
Allow client to speak openly about fears/concerns
• Fear of the unknown
• Fear of anaesthesia, vulnerability while unconscious
• Fear of pain
• Fear of death
• Fear of disturbance of body image
 CONT’
• Worries – loss of finances, employment, social and
family roles
3. Assist client to identify coping strategies that he or she
has previously used to decrease fear
4. Give accurate information regarding surgery
5. Introduce patient and family to another patient who
has undergone a similar surgery successfully and
encourage an interaction between the patients or family
members to help relieve anxiety.
 Cont’
5. Address patient‟s pain concerns (use of anaesthesia and
analgesics)
6. Address self-care concerns
7. Orient patient to theatre environment and equipment
8. Educate patient and relatives on what to expect after
surgery e.g. catheter, drainage tubes etc.
NOTE: Spiritual care may be incorporated in the
psychological preparation to give the client a sense of
hope. The Clergy or Imam or any significant other may be
invited to have a discussion with the client based on their
religious affiliations.
 PHYSICAL PREPARATION
 Skin preparation

1. Patient is encouraged to
bath with antibacterial soap
2. If indicated, shaving is done
using hair clippers or
depilatory cream.
NOTE: Mostly surgical hair
clippers blades are disposable
CONT’
3. Clean the area with antiseptic lotion and
dry with sterile towel
4. Drape the patient with sterile towel
Depilatory cream shaving:
The best practice is to refrain from hair
removal unless it interferes with the
surgical procedure or wound closure,
however if shaving is indicated, depilatory
cream is preferred to shaving with sharps
(Karegoudar et al., 2011)
Rationale
• Depilatory has an advantage in areas where shaving is difficult
(Karegoudar et al., 2011).
• It is effective, atraumatic, non-toxic and can be self-administered
(Karegoudar et al., 2011)
• It is associated with significant decrease in skin-surface bacteria
compared with shaving (Karegoudar et al., 2011).
Procedure
• Apply cream on the skin and wait for 10 minutes
• Wash with soap and water to remove all hair after the 10 minutes
• Rinse, dry and apply antiseptic lotion to the area to be prepared
and cover with sterile towel
 Cont’
 Bowel preparation
 Purpose: reduce bacteria load, ensure satisfactory
visualization of the surgical site
 Enemas may be administered to remove gross collections
of stool. If ordered, enema is given the night before
surgery.
 Oral antimicrobial agents (e.g., neomycin, erythromycin)
suppress the colon's potent microflora ie. for colonic
surgeries
 Ensure nil per os (nothing by mouth) for 6 to 8 hours
before surgery. In emergencies, gastric lavage (stomach
wash out) is done when patient has eaten and patient is
sent to the theatre without waiting for 6 to 8 hours.
• However, patients not at
risk for aspiration can be
allowed to ingest 150 ml
water 2 h prior to surgery
(Dalal, Rajwade, &
Suchak, 2010).
• A Cochrane review indicated
that there was no evidence
supporting the standard „nil
by mouth from midnight‟
fasting compared to a
shortened fluid fast (2–4
hours).
NOTE: It is important to note that these recommendations
were accompanied by a very vital caveat; thus in patients
considered to be at increased risk of anaesthesia related
regurgitation, there is little to no data available regarding
the best preoperative fasting times (Nason, 2015).
• Conditions such as large paraesophageal hernia, achalasia
and obstructing esophageal cancers requires consideration
of several days of clear or full liquid diet, considering the
poor emptying and possibility of retained solid food
associated with these conditions (Nason, 2015).
 Cont’
 Promote rest and sleep by:
 Ensuring a quite environment

 Massage

 Sedation

 Use of diversion therapy etc.

 Socio-economic preparation
 Role performance concerns
Assess the patient„s social roles and responsibilities and
address concerns expressed regarding effects of the illness
on him and others. Some of these role concerns include
breadwinning, governance etc.
 Job

Assess the impact of the operation on patient„s job and

offer solutions where necessary
 Family support

The patient„s family members are educated to recognize

the impact of their support on the well-being of the patient
 CONT’
Hospital bills
• The nurse establishes patient„s ability to pay for the
cost of the care.
• The social welfare may be contacted if patient cannot
pay bill.
• More importantly, the patient should be encouraged to
register with the national health insurance scheme.
 Pre-operative patient teaching

• Aim
• To help the patient understand the surgical
experience
• To minimize anxiety
• To promote full recovery from surgery and
anesthesia.
1. Deep Breathing and coughing exercise
(diaphragmatic abdominal exercise)
• Purpose: It triggers the release of endorphins, which
helps create a pleasure effect (“good feeling”)
experience and also combats pain.
• the patient slowly inhales air through the nostrils
until the abdomen is ballooned
• He then slowly exhales through the mouth until the
abdomen pulls in.
• this is repeated several times before the surgery.
 Cont’
2. Coughing and splinting exercise:
• Purpose: to promote expectoration, prevents
pneumonia and atelectasis.
• Before coughing, the wound area is firmly
supported with the palms padded by a folded
sterile towel.
Cont’
 Cont’
• Have client sit up and lean forward
• Show client how to splint incision with hands, pillow, or
blanket
• Have client inhale and exhale deeply three times through
mouth
• Have client take in deep breath and cough out the breath
forcefully with three short coughs using diaphragmatic
muscles.
• Take in quick deep breath through mouth, cough deeply,
and deep breathe
 3. Turning exercises
Purpose: Changing positions from back to side-lying (vice
versa) stimulates circulation, encourages deeper breathing
and relieve pressure areas.
Assist patient to move onto his side if assistance is needed.
Place the uppermost leg in a more flexed position than that
of the lower leg and place a pillow comfortably between the
legs.
Make sure that the patient is turned from one side to the
back and onto the other side every 2 hours.
Cont’
 4. Foot and leg exercises
• Purpose: Moving the legs helps to improve circulation and
muscle tone.
• Assist patient to lie in the supine position
• Instruct patient to bend a knee and raise the foot – hold it a few
seconds and lower it to the bed. Repeat if for about 5 times
with one leg and then with the other.
• Repeat the set 5 times every 3-5 hours. Then have the patient
lie on one side and exercise the legs by pretending to pedal a
bicycle.
• For foot exercise, trace a complete circle with the great toe.
Cont’
Cont’
 5. Incentive spirometry
Purpose: It promotes complete lung expansion.
• Let client sit upright, at 45 degrees minimum
• Take two normal breaths. Place mouthpiece of
spirometer in mouth
• Inhale until target, designated by spirometer light or
rising ball is reached, and hold breath for 3 to 5
seconds
• Exhale completely
• Perform 10 sets of breaths each hour
Cont’
Legal preparation for surgery: Informed Consent
(Surgical Consent)
 Informed consent is the patient‟s autonomous
decision about whether to undergo a surgical
procedure.
 This is part of the legal preparation for surgery.
 It is an active, shared decision making process
between the provider and recipient of care
 It is necessary before non emergent surgery can
be performed
 Cont’
There are components that make an informed
consent valid:
1. Adequate Disclosure: of the diagnosis, nature
and purpose of the proposed treatment,
probability of successful outcome, risks and
consequences of moving forward with treatment
or alternatives, the prognosis if treatment is not
instituted.
2. Understanding and Comprehension of
point 1
 Cont’
3. Voluntary Consent: should not be
coerced into going through with a procedure.
• Thus consent can be revoked at any point
leading up to a surgical procedure.
 Informed consent should contain the following:
 explanation of procedure and its risks
 description of benefits and its alternatives
 an offer to answer questions about procedure
 instructions that the patient may withdraw
consent
 Circumstances requiring a consent
 Any surgical procedure where scalpel, scissors, or
sutures may be used
 Any invasive procedure such as surgical incision, a
biopsy, a cystoscopy, or paracentesis
 Who has the legal responsibility of obtaining
consent?
 The physician/surgeon obtains consent
 The nurse is not legally required to obtain consent
however, the nurse:
 must make sure the consent was signed

 can "witness" the consent, and sign it as such

 Can give clarifications to the patient if there are

questions that he/she can answer.
 Who can give consent?
• the patient
• next of kin (in order of kinship): Spouse, Adult
Child, Parent, Sibling
• Can be designated with a durable power of
attorney in case of medical incapacitation
 What about emergency treatment?
 A true medical emergency may override the need
to obtain consent.
 When medical care is needed to protect the life
of an individual, the next of kin/POA (Power of
Attorney) can give consent.
 Also, if there is a known and available Advanced
Directive with healthcare decision making
instructions, that can be used to assist in
justifying consent.
 Cont’
• If they are not available, and the doctor deems
the procedure necessary for life, the doctor can
document that it was necessary, and go ahead
with the procedure.
• The nurse may need to write up an incident
report and state that the emergency caused a
deviation in the normal policy to obtain consent
on everyone.
 Purposes of informed consent
 to ensure that the client understands the nature of the
treatment including the potential complications and
disfigurement
 to indicate that the client‟s decision was made without
pressure
 to protect the client against unauthorized procedure
 to protect the surgeon and hospital against legal actions
by a client who claims that an unauthorized procedure
was performed
 IMMEDIATE PRE OP PREPARATION
a. Ensure patient„s personal hygiene is maintained
b. b. Ensure patient is still NPO. In an emergency pass NG
tube
c. Check baseline vital signs: report any deviation to the
anaesthetist
d. Ensure patient has signed the consent form
e. File all pre- operative laboratory reports, history and
physical examination reports in patient„s folder
 Cont’
f. Contraindicated items such as cosmetics, nail polish, hair
pins, wigs, dentures etc on the patient should be removed
and kept in a safe place or given to the relative to keep
g. Hearing aids may be left in place to allow patient
understand instructions better
h. Encourage patient to empty the bladder; pass catheter
when necessary
i. Place an identification band on patient„s wrist indicating
age, name, diagnosis etc
 Cont’
j. Administer pre OP medication as ordered to relax patient,
dry up secretions and reduce the risk of infection.
k. Complete the pre OP checklist
l. Gown patient, cover the hair and transfer patient to theater
on a stretcher with side rails 30-60mins before anaesthesia
begins
m. Accompany patient with the folder and all relevant
documents.
 EMERGENCY PRE OPERATIVE CARE
• Reassure patient.
• Explain in brief the procedure and its essence.
• Obtain an informed consent from patient.
• Provide warmth (patient may be in shock).
• Check baseline vital signs.
• Blood analysis (HB, grouping and cross matching).
Note: the surgery may be started even before the
results are in. check with the lab for standby blood
donors.
 Cont’
• Ensure patient NPO: pass NGT if patient has recently ingested
food.
• Set up IV line and administer IV fluids as ordered.
• Pass urethral catheter and attach it to a drainage bag.
• Remove all jewelry and prosthesis, label and keep them safely
for patient.
• Do skin preparation if possible or clean up only the surgical area
with soap and water and apply an antiseptic lotion.
• Gown patient and accompany him to the theater with on a
trolley with folder and necessary documents.
 Transporting the Patient to the Operating Room
• Adhere to the principle of maintaining the comfort and safety of the
patient.
• Accompany operating room attendants to the patient's bedside for
introduction and proper identification.
• Assist in transferring the patient from bed to stretcher (unless the
bed goes to the operating room floor).
• Complete the chart and preoperative checklist; include laboratory
reports and X-rays as required by facility policy or the health care
provider's directive.
• Make sure that the patient arrives in the operating room at the
proper time.
 Preoperative Medications/ Pre-anaesthetic Drugs
Goals:
• To facilitate the administration of any anaesthetic
• To minimize respiratory tract secretions and
changes in heart rate
• To relax the client and reduce anxiety
 Pre-anaesthetic drugs
 Opioids
 Morphine sulfate

 Fentanyl (Sublimaze)

 Meperidine (Demerol)

Analgesia; enhancement of postoperative pain relief

 Cont’
 Antianxiety and sedative hypnotics
 Diazepam (Valium)

 Lorazepam (Ativan)

 Midazolam (Versed)

 Phenobarnital sodium

Reduce the symptoms of anxiety such as worry,

fear and panic attacks.
 Cont’
 Anticholinergic
 Atropine sulfate

 Scopolamine hydrobromide

Respiratory secretion reduction

 Cont’
 Antiemetic
 Ondansetron (Zofran)

 Metoclopramide (Reglan)

 Promethazine hcl (Phenergan)

Control nausea and vomiting; may be effective into the

postoperative period
 Cont’
 H2 antagonist
 Cimetidine (Tagamet)

 Ranitidine (Zantac)

 Famotidine (Pepcid)

Reduction of acidic gastric secretions in case aspiration

occurs
 Cont’
 Antibiotic
 Cefazolin

 Ampicillin

Prevention of postoperative infection

 References
• LeMone, P. Burke, K. (2004) Clinical handbook for medical-
surgical nursing: critical thinking in client care. Prentice Hall
Inc. New Jersey

• Lewis, S. M., Heitkemper, M. M. Dirksen, S. R. Goldsworthy, S.,

& Barry, M. (2006). Medical-Surgical Nursing in Canada:
Assessment and Management of Clinical, Mosby, Canada

• Smeltzer, S. C. & Bare, B. G., Hinkle, J. L., & Cheever, K. H.

(2010) Brunner & Suddarth‟s Textbook of Medical-Surgical
Nursing, 11th Ed. Lippincott Williams & Wilkins, Philadelphia
 Articles
• Karegoudar, J., Prabhakar, P., Vijayanath, V., Anitha, M.,
Surpur, R., & Patil, V. (2011). Shaving Versus Depilation Cream
for Pre-operative Skin Preparation. Indian Journal Of Surgery,
74(4), 294-297. doi: 10.1007/s12262-011-0368-5
• Walker, J. A. (2002). Emotional and psychological preoperative
preparation in adults. British journal of nursing, 11(8), 567-
575.
• Dalal, K. S., Rajwade, D., & Suchak, R. (2010). “Nil per oral
after midnight”: is it necessary for clear fluids?. Indian journal
of anaesthesia, 54(5), 445.