Care of Clients with Problems in Oxygenation, Fluid and Electrolyte,

Infectious, Inflammatory and Immunologic Response,

Cellular Aberrations, Acute and Chronic

Module #1 Student Activity Sheet

Name: Class number:

Section: _ Date:
Schedule:

Lesson Title: PREOPERATIVE NURSING CARE Materials:

Learning Targets:
At the end of the module, students will be able to:
1. Apply knowledge of safe patient care in the preoperative
setting through case studies and patient care assignments;
2. Apply safe medication administration practices based on
knowledge of interventions and pharmacologic
indications for drugs commonly utilized in the
perioperative setting;
3. Integrate the ethical, moral, and legal responsibilities of
the nurses during the preoperative period; and,
4. Demonstrate ability to appropriately prioritize
preoperative nursing activities relevant to the surgical
setting through case studies, and/or patient care
assignments.
Pen, paper, index card, book, and class List
References:
Hinkle, J. L., Cheever, K. H., & Hinkle, J.
L. (2018). Brunner & Suddarth's
Textbook of Medical-Surgical Nursing.
Wolters Kluwer.
Grinslade, S., Singel, L. J., & Keys, P. L.
(2005). Study Guide for Black & Amp; Hawks
Medical Surgical Nursing: Clinical
Management for Positive Outcomes. Elsevier
Saunders.

Anef, C. D. R. D., & Faan, R. P. L. W. M.

(2012). Medical-Surgical Nursing: Patient-
Centered Collaborative Care, Single Volume
(Ignatavicius, Medical-Surgical Nursing,
Single Vol) (7th ed.). Saunders.

A. LESSON PREVIEW/REVIEW

Your classroom instructor for this subject, Medical – Surgical Nursing 1 - Lecture, is .
Listed below are the additional information vital in orientation:

B. MAIN LESSON

The perioperative period consists of three phases that begin and end at a particular point in the sequence of events in
the surgical experience. period of time that constitutes the surgical experience; includes the preoperative, intraoperative,
and postoperative phases of nursing care.

1. The preoperative phase begins when the decision to proceed with surgical intervention is made and ends with
the transfer of the patient onto the operating room (OR) table.

Goals:
 Assessing and correcting physiologic and psychologic problems that may increase surgical risk
 Giving the person and significant others complete learning/ teaching guidelines regarding surgery
 Instructing and demonstrating exercises that will benefits the person during postop period

THIS DOCUMENT IS THE PROPERTY OF PHINMA EDUCATION 1

 Vasectomy (male sterilization) - Tubal ligation (female sterilization) - fallopian
PACU (POST-ANESTHESIA CARE UNIT) - it is the unit surgical procedure to cut or tubes are permanently blocked, clipped or
where patients are temporarily admitted after any surgical seal the tubes (vas deferens) removed to prevent pregnancy.
procedures to recover and wake up. that carry a man’s sperm to
permanently prevent
pregnancy.

Name: Class number:

Section: _ Date:
Schedule:

 Planning for discharge and any projected changes in lifestyle due to surgery

2. The intraoperative phase begins when the patient is transferred onto the OR table and ends with admission to the
PACU. Nursing duties involve acting as scrub nurse, circulating nurse, or registered nurse first assistant (RNFA)

 Advantages: reduce length of hospital stay; cut cost; reduce stress for the patient; less incidence of hospital
acquired infection; less time lost for work by the patient; minimal disruption on the patient’s activities and
family life
 Disadvantage: less time to assess the patient and perform preoperative teaching, less time to establish
rapport, less opportunity to assess for late postoperative complication.
Examples:
Teeth extraction, circumcision, vasectomy, cyst removal, tubal ligation

Surgical Risk:
 Obesity, poor nutrition, fluid and electrolyte imbalances, age, presence of disease (Cardiovascular disease., DM,
Respiratory disease.), concurrent or prior pharmacotherapy. Serum Electrolytes
> they maintain fluid and pH balance of the body
PREOPERATIVE PHASE > nerve and muscle functioning
> morning samples are preferred since diet and
Physiologic Assessment of the Client Undergoing Surgery exercise can affect electrolyte balance
 Age > test is done if the patient has any condition that can
affect fluid balance in body such as nausea, vomiting,
 Presence of Pain
kidney and heart diseases (arrhythmia), confusion/
 Nutritional & Fluid and Electrolyte Balance cramps
 Cardiovascular/ Pulmonary Function - Sodium
- Potassium > conditions that can decrease electrolytes are kidney
 Endocrine Function diseases, heart diseases, DM, drugs like steroids and
- Chloride
 Hematologic Function - Bicarbonate oral contraceptive pills (increase sodium & chloride),
 Neurologic Function - Calcium antidepressants and diuretics (decrease levels of
 Use of Medication sodium and chloride), barbiturates and loop diuretics
 Presence of Trauma & Infection (increase levels of bicarbonates), tetracycline
(decrease levels of bicarbonates), certain medicines
which are given to lower the blood pressure of the
Routine Preoperative Screening Test patient can result in lowered potassium levels

TEST RATIONALE
CBC RBC, HGB, HCT are important to the oxygen carrying capacity of blood. WBC is
the indicator of immune function
BLOOD GROUPING/ X-MATCHING Determine in case blood transfusion is required during or after surgery
SERUM ELECTROLYTE To evaluate fluid and electrolyte status
PT, PTT Measure time required for clotting to occur (Prothrombin time) (Partial thromboplastin time)
FASTING BLOOD GLUCOSE High level may indicate undiagnosed DM CBG (Capillary blood glucose monitoring)
BUN/ CREATINIE Evaluate renal function (Blood Urea Nitrogen)
SERUM ALBUMIN AND TOTAL CHON Evaluate nutritional status (Carbon, Hydrogen, Oxygen, Nitrogen)
URINALYSIS Determine urine composition
CHEST XRAY Evaluate respiratory status/ heart size
ECG Identify preexisting cardiac problem (Electrocardiogram)

Psychosocial Assessment and Care Blood typing

Causes of fears of the preoperative clients Type A - A/O

 Fear of the unknown (anxiety) Type B - B/O
 Fear of anesthesia Type AB - A/B/AB/O
 Fear of pain Type O - O

AB (universal recipient)
O (universal donor)
 Name: Class number:
Section: _ Date:
Schedule:

 Fear of death
 Fear of disturbance of boy image
 Worries- loss of finances, employment, social and family roles

Manifestation of fears
 Anxiousness
 Bewilderment
 Anger
 Tendency to exaggerate
 Sad, evasive, tearful, clinging
 Inability to concentrate
 Short attention span
 Failure to carry out simple directions
 Dazed

Nursing Intervention to Minimize Anxiety

 Explore client’s feeling
 Allow clients to speak openly about fears/concerns
 Give accurate information regarding surgery (brief, direct to the point and in simple terms)
 Give empathetic support
 Consider the person’s religious preference and arrange for visit by a priest/minister as desired

Inform Consent

Purposes:
 To ensure that the client understand 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 action by a client who claims that an authorized procedure was
performed.

Essential Elements of Informed Consent

 the diagnosis and explanation of the condition.
 a fair explanation of the procedure to be done and used and the consequences.
 a description of alternative treatment or procedure.
 a description of the benefits to be expected.
 material rights if any.
 the prognosis, if the recommended care, procedure is refused.

Requisites for Validity of Informed Consent

 Written permission is best and legally accepted.
 Signature is obtained with the client’s complete understanding of what to occur.
 adult sign their own operative permit
 obtained before sedation
 For minors, parents or someone standing in their behalf, gives the consent. Note: for a married emancipated minor
parental consent is not needed anymore, spouse accepted
 For mentally ill and unconscious patient, consent must be taken from the parents or legal guardian
 If the patient is unable to write, an “X” is accepted if there is a witness to his mark
 Secured without pressure and threat
 A witness is desirable – nurse, physician or authorized persons.
 When an emergency situation exists, no consent is necessary because inaction at such time may cause
greater injury. (permission via telephone/cellphone is accepted but must be signed within 24hrs.)
 Name: Class number:
Section: _ Date:
Schedule:

Preoperative Medications
Goals:
 To aid in the administration of an anesthetics
 To minimize respiratory tract secretion and changes in heart rate
 To relax the patient and reduce anxiety

1. Anxiolytics (Tranquilizers & Sedatives) - used to reduce anxiety

 Diazepam (Valium) - treat anxiety, muscle spasms, seizures
 Lorazepam (Ativan) - treat anxiety and sleeping problems
 Diphenhydramine - relieves the symptoms of allergies
2. Analgesics - relieve pain
3. Nalbuphine (Nubain) - relieve pain
4. Anticholinergics - treat Parkinson’s disease, chronic obstructive pulmonary disease (COPD), overactive bladder
5. Atropine Sulfate - to increase heart rate, reduce secretions, treat the effects of certain poisons
6. Anti-•‐Ulcer (Proton Pump Inhibitors) - treat ulcers
 Omeprazole (Losec) - treat certain stomach and esophagus problems such as acid reflux and ulcers
 Famotidine - treat stomach ulcers, acid reflux and heartburn
7. Antibiotics - treat or prevent types of bacterial infection

PREOPERATIVE CARE

Before surgery
 Correct any dietary deficiencies
 Reduce an obese person’s weight
 Correct fluid and electrolyte imbalances
 Restore adequate blood volume with BT (bleeding time)
 Treat chronic disease Atelectasis - complete/partial collapse of the
 Halt or treat any infectious process entire lung or area (lobe) of the lung
 Treat an alcoholic person with vitamin supplementation, IVF or fluids if dehydrated
Incentive spirometer - device that measures the - Helps prevent mucus and fluids from
Preoperative Teachings volume of air inhaled into the lungs during inspiration building up in your lungs
 Incentive Spirometry – deep inhalations expand alveoli, which prevents atelectasis and other pulmonary complications
 Diaphragmatic Breathing – flattening of the dome of the diaphragm during inspiration, with resultant enlargement
of upper abdomen as air rushes in. During expirations, abdominal muscles contract
 Coughing – promotes removal of chest secretions
 Turning – stimulates circulation, encourages deeper breathing and relieve pressure areas
 Foot and Leg exercise – improves circulation and muscle tone
 Teaching should be done morning/afternoon before the day of surgery
 Best Method: Return Demonstration

Evening Before Surgery

 Preparing the skin
 Full bath to reduce microorganisms in the skin
 Hair should be removed within 1-2 mm of the skin to avoid skin breakdown, use of electric clipper is preferable
 Preparing the GI tract
 NPO, cleansing enema as required
 Preparing for anesthesia
 Avoid alcohol and cigarette smoking for at least 24 hours before surgery
 Promoting rest and sleep
 Administer sedatives as ordered
Preparing the Patient on the Day of the Surgery
 Name: Class number:
Section: _ Date:
Schedule:

 Early A.M care

 Morning bath, mouth wash
 Provide clean gown
 Remove hairpins, braid long hair, cover hair with cap if available
 Remove dentures, colored nail polish, hearing aid, contact lenses, jewelries.
 Take baseline vital sign before pre-op medication
 Take baseline vital signs before pre op medication
 Check ID band, skin prep
 Check for special orders-enema, IV line
 Check NPO
 Have client void before preop medication
 Continue to support emotionally, accomplished pre-op care check list

Transporting the Patient to the OR

 Adhere to the principle of maintaining the comfort and safety of the patient
 Accompany OR attendants to the patient’s bedside for introduction and proper identification
 Assist in transferring the patient from bed to stretcher
 Complete the chart and preoperative checklist
 Make sure that the patient arrives in the OR at the proper time.

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.

Case Study: Case Study: Read and examine the case thoroughly.

Patient Profile: C.J., a 49-year-old construction worker, is scheduled for a bronchoscopy for biopsy of a right lung lesion.
He initially sought medical care for hemoptysis and increasing fatigue. When the nurse asked him to sign the operative
permit, he stated that he was not certain if he should go ahead with the procedure because he fears a diagnosis of
cancer.

Subjective Data
 Has never been hospitalized
 Has had no medical problems except mild obesity
 Has a cigarette smoking history of 40 pack-years
 Is married with two children, ages 6 and 8; both children have cystic fibrosis
 Is fearful that his wife will not be able to manage without him

Objective Data
 Diagnostic studies: chest x-ray revealed mass in upper lobe of right lung
 Hematocrit: 31%

Discussion Questions:
1. What factors in C.J.’s background or personal situation might influence his emotional response and physical
reactions to this surgery?
Answer:

2. What should C.J. know if his consent for surgery is to be truly informed?
 Name: Class number:
Section: _ Date:
Schedule:

Answer:

3. Priority Decision: C.J. will be an outpatient for this procedure. What is the priority preoperative teaching that should
be done to prepare him for surgery?
Answer:

4. What risk factors for surgical and anesthetic complications might you anticipate for C.J.? What are the potential
interventions that might minimize the risks?
Answer:

5. Priority Decision: Based on the assessment data provided, what are the priority nursing diagnoses? Are there
any collaborative problems?
Answer:

Multiple Choice

1. As a nurse, what is the importance of a thorough preoperative assessment?

a. To identify and correct problems before surgery and establish a baseline for postoperative comparison
b. To save time doing an assessment after the patient returns from surgery
c. To provide the doctor with information that may have been missed during the preadmission assessment
d. To ensure that postoperative complications don’t occur
Answer:
Rationale:

2. Before administering preoperative medication to a client, nurse Jonalyn should plan to:
a. Verify the consent
b. Check the vital signs
c. Have the client void
d. Remove the client’s dentures
Answer:
Rationale:
 Name: Class number:
Section: _ Date:
Schedule:

3. A client with Cataract is about to undergo surgery. Nurse Princess is preparing plan of care. Which of the
following nursing diagnosis is most appropriate to address the long term need of this type of patient?
a. Anxiety related to the operation and its outcome
b. Sensory perceptual alteration related to lens extraction and replacement
c. Knowledge deficit related to the pre-operative and post-operative self-care
d. Body Image disturbance related to the eye packing after surgery
Answer:
Rationale:

4. On the morning of Mrs. Sy’s planned cholecystectomy, she awakens with a pain in her right scapular area and thinks
she slept in poor position. While doing the pre-op check list you note that on her routine CB report her WBC is 15,000.
Your responsibility at this point is:
a. To notify the surgeon at once; this is an elevated WBC indicating an inflammatory reaction
b. To record this finding in a prominent place on the pre-op checklist and in your pre-op notes
c. To call the laboratory for a STAT repeat WBC
d. None. This is not an unusual finding
Answer:
Rationale:

5. Mrs. Sy is scheduled for surgery 2 days later and is to be given atropine 0.3 mg IM and Demerol 50 mg IM one
hour preoperatively. Which nursing actions follow the giving of the pre-op medication?
a. Have her void soon after receiving the medication
b. Allow her family to be with her before the medication takes effect
c. Bring her valuables to the nursing station
d. Reinforce pre-op teaching
Answer:
Rationale:

6. A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses
coagulation? SATA.
a. Partial thromboplastin time.
b. Prothrombin time.
c. Platelet count.
d. Hemoglobin
Answer:
Rationale:

7. A client with a perforated gastric ulcer is scheduled for emergency surgery. The client cannot sign the operative
consent form because he has been sedated with opioid analgesics. The nurse should take which of the following
actions in the care of this client?
a. Obtain a telephone consent from the family member witnessed by two persons.
b. Obtain a court order for the surgery.
c. Send the client to surgery without the consent form being signed.
d. Have the hospital chaplain sign the informed consent immediately
Answer:
 Name: Class number:
Section: _ Date:
Schedule:

Rationale:

8. A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which of the following responses by
the nurse is most likely to stimulate further discussion between the client and the nurse?
a. “I will be happy to explain the entire surgical procedure to you.”
b. “Let me tell you about the care you’ll receive after surgery and the amount of pain you can anticipate.”
c. “If it’s any help, everyone is nervous before surgery.”
d. “Can you share with me what you’ve been told about your surgery?”
Answer:
Rationale:

9. A nurse is preparing the client for transfer to the operating room (OR). The nurse should take which of the
following actions in the care of this client at this time?
a. Administer all the daily medications.
b. Ensure that the client has voided.
c. Verify that the client has not eaten for the last 24 hours.
d. Practice postoperative breathing exercises.
Answer:
Rationale:

10. A nurse is reviewing the physician’s order sheet for the preoperative client, which states that the client must be on
nothing per mouth (NPO) status after midnight. The nurse would clarify whether which of the following medications should
be given to the client and not withheld?
a. Conjugated estrogen (Premarin)
b. Atenolol (Tenormin)
c. Cyclobenzaprine (Flexeril)
d. Ferrous sulfate
Answer:
Rationale:

C. LESSON WRAP-UP

AL Activity: CAT: 3-2-1

Instructions:
1. As an exit ticket at the end of the class period
2. Record three things you learned from the lesson.
3. Next, two things that you found interesting and that you’d like to learn more about.
4. Then, record one question you still have about the lesson.

Three things you learned:

1.
2.
 Name: Class number:
Section: _ Date:
Schedule:

3.

Two things that you’d like to learn more about:

1.
2.

One question you still have:

1.