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102 - Preoperative Care - CH 18
102 - Preoperative Care - CH 18
102 - Preoperative Care - CH 18
SURGICAL SETTINGS
- Surgery
- Elective surgery: carefully planned
- Selective surgery (emergency) : unexpected urgency
- Inpatient → Same-day admission → require at least 1 night
- Ambulatory (same day or outpatient) MEOS
- Minimally invasive (laparoscopic/robotic surgery) → helps with wound dehiscence,
less infection rate, faster healing
- Endoscopy or surgical clinics
- Hospital outpatient surgery clinics
- Surgery center→ mostly healthy pts
Comorbidities?
ASSESSMENT
Psychosocial assessment
- Excessive stress response can be magnified and affect recovery
- Influencing factors : Age, experiences with illness and pain, current health,
socioeconomic status
- can't afford rehabilitation
- insurance doesn't take it
- can they afford meds?
- Help at home?
ASSESSMENT
- Use common words and language
- Use translators if needed → Decreases level of anxiety
- Communicate all concerns to surgical team
- High anxiety level can impair cognition, decision making, and coping abilities
- Anxiety can arise from
- Lack of knowledge
- Uncertainty about outcome
- Past experiences and stories
- Fears
Address any fears the patient may have ( EX: Being exposed on the table)
ASSESSMENT
● Cardiovascular system
○ Any history of hypertension, angina, dysrhythmias, HF, MI
○ Presence of pacemaker, ICD
○ 12 lead electrocardiogram (ECG)
○ Coagulation studies
○ Possible prophylactic antibiotic (antibiotic that prevent infection)
■ May receive before surgery to decrease the risk for infective endocarditis
for patients with prosthetic heart
○ Venous thromboembolism (VTE) prophylaxis → pharmacologic and
nonpharmacologic measures to diminish the risk of deep vein thrombosis (DVT)
and pulmonary embolism (PE)
Signs of DVT
- Calf pain
- red/warm
- Swelling
- Homans sign → pt lying, push foot out, do have pain in back of leg?? (Only do if ordered) (do on
ICU and surg pts)
Prevents → Ted hose, compression socks
Respiratory system
- The procedure could be canceled if patient have any recent respiratory infection
because of an increased risk of Laryngo/Bronchospasm or decrease SAO2
- History of dyspnea, coughing, or hemoptysis (cough up blood in the lung) reported to
the ACP and surgeon
- COPD and asthma are at high risk for atelectasis and hypoxemia
- everyone at risk, collapsed alveoli (USE SPIROMETER; 10x per hour while
awake)
- Sleep apnea, obesity, and airway deformities affect respiratory function
- Cannot operate on someone with a CURREN/recent INFECTION → post op infection risk!!
- Risks:
- Smokers (did you smoke today? How long have you smoked? How much?)
- Sleep apnea, obesity, airway deformities, COPD, Asthma
Neurologic system
- Patient’s ability to respond to questions, follow commands, maintain orderly thought
process (vision and hearing loss can affect responses)
- Cognitive deficits can affect informed consent and cause adverse outcome during and
after surgery
- Crucial to access in older adult (more prone to adverse outcomes during
before and after)
- Added stressors like dehydration, hypothermia, anesthesia and adjunctive drugs
may contribute to emergence delirium
- Anxiety can inhibit
- Neuro assessment
Genitourinary system
● Renal problems are associated with
○ Fluid and electrolyte imbalance
○ Coagulopathies
○ Increased risk of infection
○ Impaired wound healing
○ Altered response to drugs and their elimination
- BUN creatinine GFR
- A lot of drugs cleared through renal/liver system
- Older pts have harder time metabolizing
- May not respond as quickly
Hepatic system
● Liver detoxifies many anesthetics and adjunctive drugs
● Hepatic dysfunction may increase risk of perioperative complications
Skin
● History of pressure injuries
○ Extra padding during surgery
○ Affects postoperative healing
● BODY ART SUCH AS TATTOOS, PIERCINGS → pts hesitant or don't do surgery
- Piercings conduct heat → lead to burns
- Extra padding/support
- Lies on IV tubing?
Musculoskeletal system
● Identify any joints affected by arthritis
● Mobility restrictions may affect positioning and ambulation
● Report problems affecting neck or lumbar spine to ACP
○ Spinal anesthesia may be difficult
○ Can affect intubation and airway management
- assess ROM
- Intubation affected if neck issue
Endocrine system
● Patient with diabetes at risk for
○ Hypo/hyperglycemia
○ Delayed wound healing
○ Infection
○ Serum or capillary glucose test the morning of the surgery
○ Clarify with surgeon or ACT about insulin does
○ Elevated glucose (with surgery as stressor too)→ infection
○ Put on sliding scale
○ Check glucose if diabetic morning of surgery and report to anesthesia
○ Hypoglycemia → jittery, diaphoretic, confused (NPO status)
● Patient with thyroid problems
○ hypo/hyperthyroidism poses surgical risk due to changes in metabolic rate → check lab
test
○ Verify with ACP about given thyroid medications
● Patient with addison’s disease (body doesn't make enough certain hormones)
○ Abruptly stopping replacement corticosteroids could cause addison crisis
○ STRESS OF SURGERY MAY REQUIRE INCREASED DOSE OF IV
CORTICOSTEROIDS
Immune system
● Patient with history of compromised immune system or use of immunosuppressive drugs
can have
○ Delayed wound healing
○ Increased risk for infection
● Elective surgery may be canceled for acute infection
- Cancer, autoimmune, acute infection (UTI)
Nutritional status
● Customize care for patients with nutritional problems
○ May be protein or vitamin deficient
○ Provide extra padding for underweight patient
● Obesity
○ Stress cardiac and pulmonary system
○ Increase risk of wound dehiscence, infection, incisional hernia
○ Slower recovery from anesthesia and wound healing
- YOU NEED PROTEIN FOR WOUND TO HEAL
- Look at obesity sheet
The Joint Commission (TJC) tells surgeon → requires a history and physical (surgeon does)
Nursing management
● Preoperative teaching
○ Patient have the right to know what to expect and how to participate (reduce fear,
anxiety, stress)
○ Teach deep breathing, coughing and early ambulation as appropriate
○ Inform if tubes, drains, monitoring devices, special equipment will be use
postoperative
○ Provide surgery specific information
● Ambulatory surgery information
○ Basic information before arrival
■ Arrival time and place
■ Registration and parking
■ What to wear and bring
■ Responsible adult needed
■ Fluid and food restrictions
■ WHEN YOU CAN EAT (clear ensure → has protein can drink NPO) (also can
drink gatorade → not red ones) (if surg later in day)
■ WHAT MEDS CAN/CANT TAKE
● Legal preparation
○ Check that all required forms are signed and in chart
■ Informed consent
■ Blood transfusion
■ Advance directives
■ Power of attorney
● Consent for surgery
● Informed consent must include
○ Adequate disclosure
○ Clear understanding
○ Voluntarily consent
● Surgeon ultimately responsible for obtaining consent
○ Nurse may witness signature
○ Verify patient understanding
○ Permission may be withdrawn anytime
● Legally appointed representative of family may consent if patient is
○ Minor
○ Unconscious
○ Mentally incompetent
● Emancipated minor is younger than legal age but able to provide legal consent
● Medical emergency may override the need for consent if immediate medical treatment
is needed to
○ Preserve life
○ Prevent serious impairment to life or limb
○ Patient incapable of giving consent
○ HAS TO BE CLEARLY WRITTEN BY DR
○ UNCONSCIOUS PTS ARE SEEN PRIORITY
● Day of surgery preparation
■ Final preoperative teaching
■ Verification of signed informed consent
■ Laboratory and diagnostic study results
■ History and physical examination, baseline vitals
■ Proper skin preparation , functioning IV
■ Surgical identification
■ Hospital gown
■ No cosmetic, remove nail polish
■ Identification and allergy band on wrist
■ Valuables are returned to caregiver or locked up
■ Denture, contacts glasses, prosthesis are removed
■ Jewelry removed if electrocautery devices is used
■ Leave hearing aids in place to allow patient to hear instructions
HR in 30s = BP DOWN
TRANSPORTATION TO THE OR
Special concerns
● Culturally competent
○ Patient’s expression of pain
○ Family expectations
○ Ability to verbally express needs
● Geriatric consideration
○ Surgical may be overwhelming
○ Increase risk with anesthesia and surgery
○ May have sensory deficits or decrease in cognitive function
-
https://www.youtube.com/watch?v=oo4eIbi1vmA&ab_channel=NexusNursing
https://www.youtube.com/watch?v=9aNKPZfyJzE&ab_channel=LevelUpRN
https://www.youtube.com/watch?v=87FBupeZw3s&ab_channel=Thatnursingprof
Pre OP notes
Quiz → pre op and anesthesia, labs
Looking for →
- Baseline vitals
- Meds →
- Anticoagulants: Aspirin, coumadin (stopped 4-5 days before) , eliquis ,
diabetic (insulin) ANYTHING CAUSING BLEEDING
- Cardiac meds
- Steroids → need more of
- ONLY GIVE CRUCIAL MEDS TO PRE OP PTS WHEN NPO
- Opioids → may have tolerance (Narcan/naloxone reverse)
- Benzos → anxiety (tend to double if needs surgery and takes regularly) (anxiety
assessment) (reverse is flumazenil - romazicon)
- Glucose level goes UP in surgery (NPO; take half insulin before)
- Anesthesia provider → does meds!! Answers all questions on that too
- Higher risks for hemorrhage → HYPERTENSION
- DON'T WAIT FOR LABS TO DROP FOR BLEEDING (18-24 hrs)
- BP down, HR up
- Touch patient (roll fingers around incision → feeling for hard spot)
- Hematoma → hard feeling → collection of blood
- Do focused assessment → cardiac, respiratory, surgical area assessment
- BASELINES
- 0-10 scales for ALL
- Labs
- CBC → platelets (bleeding), H/H, WBCs (infection)
- Basic/comprehensive fluid and electrolytes
- Basic → glucose, creatinine (kidney) , Na+, K+, BUN (kidney) GFR (renal function;
less than 60 hang normal saline)
- Comprehensive (don't always need) → pt that takes coumadin/warfarin → Coags (PT
→ INR coumadin/warfarin) (PTT → Heparin)
FORMS
- Consent
- Over 18 unless emancipated or pregnant
- Proxy or power of attorney → mentally ill pts
- Someone else can consent if you're heavily sedated (spouse/friend)
- History and Physical → surgeon writes
- Anesthesia assessment → anesthesia docs
- Asthmatic/COPD → respiratory consult
- Insulin → endocrine consult
- Cardiac problems → cardiac consult
IF UNCONSCIOUS → PRIORITY PT
First exam → meds