Pre Operative Nursing Care

Dr. Ravi Kant Millan

M.S., MRCS (England)
PERIOPERATIVE NURSING

used to describe the nursing care provided in the total surgical experience of the
patient:
a. preoperative
b. intraoperative
c. postoperative.
 Classification of Surgical Procedure
According to PURPOSE:

DIAGNOSTIC–to establish the presence of a disease/condition.

(e.g- biopsy, endoscopy, laparoscopy, bronchoscopy)

EXPLORATORY–to determine the extent of disease condition

( e.g Exploratory Laparotomy, wound debridement, deep infection )

CURATIVE– to treat the disease condition.

*Ablative–removal of an organ“ectomy” ( appendectomy, cholecystectomy,
* Constructive–repair of congenitally defective organ “plasty,oorhaphy,pexy”
*Reconstructive–repair and restore function of traumatised or malfunctioning organ : all
fracture surgeries, plastic surgeries
*Transplantation : surgeries to replace diseased organ structures. Eg: lung,liver,kidney,
heart

PALLIATIVE–to relieve distressing sign and symptoms, not necessarily to cure the disease.
Eg: Colostomy, nerve root resection, tumour debulking
 According to Urgency

Classification Timing for Surgery Examples

Emergent –patient requires Without delay severe bleeding

immediate attention, life -gunshot/ stab
threatening condition. wounds
-Fractured skull
-EDH,SDH, stroke

Urgent –patient requires Within 24 to 30 hours kidney/ureteral stones

prompt attention. Amputation

Required –patient Plan within a few weeks or cataract

needs to have surgery months -thyroid d/o

Elective–patient should have Failure to have surgery not repair of scar

surgery. catastrophic -vaginal repair

Optional –patient’s decision. Personal preference cosmetic surgery

 According to Degree of risk/complexity
MINOR excising skin lesion
Draining abscess
-short
-Leads to few serious complication
-Involves less risk

INTERMEDIATE Tendon repair

MAJOR/COMPLEX
-High risk for Infection
-Extensive- major exposure
-Prolonged—
-Large amount of bloodloss
-Vital organ may be handled or removed
Small Wound debridement
knee arthroscopy
Tracheostomy
primary repair of inguinal hernia
excising varicose veins in the leg
Craniotomy, decompression
All orthopedics surgeries of hip,
shoulder, spine, fractures around joints
Tumour excision
 Ambulatory surgery/ Day care surgery/
Outpatient surgery
Advantages :
-Reduces length of hospital stay and cuts costs
-Reduces stress for the patient
-Less incidence of hospital acquired infection
-Less time lost from work by the patient; minimal disruptions on the patient’s
activities and family life.

Disadvantages:
-Less time to assess the patient and perform preoperativeteaching.
-Less time to establish rapport
-Less opportunity to assess for late postoperative complication.

Eg: Hernia surgery, abcess, hydrocoele, cyst excision, biopsy, circumcision,

hemorrhoidectomy, teeth extraction
 ASA Physical Status Classification System
ASA I A normal healthy patient Healthy, non-smoking, no or minimal alcohol use

ASA II A patient with mild systemic Mild diseases only without substantive functional limitations.
Eg: current smoker, social alcohol drinker, pregnancy, obesity
disease (30 < BMI < 40), well-controlled DM/HTN, mild lung disease

ASA III A patient with severe systemic One or more moderate to severe diseases. Examples include
(but not limited to): poorly controlled DM or HTN, COPD,
disease morbid obesity (BMI ≥40), active hepatitis, alcohol
dependence or abuse, implanted pacemaker, moderate
reduction of ejection fraction, ESRD undergoing regularly
scheduled dialysis, premature infant PCA < 60 weeks, history
(>3 months) of MI, CVA, TIA, or CAD/stents.
ASA IV A patient with severe systemic recent ( < 3 months) MI, CVA, TIA, or CAD/stents, ongoing
cardiac ischemia or severe valve dysfunction, severe
disease that is a constant threat reduction of ejection fraction, sepsis, DIC, ARD or ESRD not
to life undergoing regularly scheduled dialysis

ASA V A moribund patient who is not
expected to survive without the
operation
ASA VI A declared brain-dead patient
whose organs are being
removed for donor purposes
Examples include (but not limited to): ruptured
abdominal/thoracic aneurysm, massive trauma, intracranial
bleed with mass effect, ischemic bowel in the face of
significant cardiac pathology or multiple organ/system
dysfunction
 Surgical Risk
 Obesity
 Poor Nutrition
 Fluid and Electrolyte Imbalances
 Age
 Presence of Disease (Cardiovascular disease, DM, Respiratory conditions. )
 Concurrent or Prior Chemotherapy/Radiotherapy
 other factors

nature of condition
-location of the condition
-magnitude / urgency of the surgery
-mental attitude of the patient
-caliber of the health care team
 Pre operative Phase: 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.

 Planning for discharge and any projected changes in lifestyle due to surgery.
 Physiological assessment of patient undergoing
surgery
 Presence of Pain

 Nutritional & Fluid and Electrolyte Balance- Anthropometry, Sr proteins,

 Cardiovascular / Pulmonary Function – CXR,ECG, 2D Echo, Pulmonary Function tests

 Renal Function – Electrolytes, Creatinine, Urea, Urine analysis

 Gastrointestinal / Liver Function- liver function tests

 Endocrine Function- Thyroid function, HbA1C, Fasting PP glucose

 Neurologic Function- Higher mental functions, sight, smell, reflexes, gait

 Hematologic Function- CBC, PT INR

 Use of Medication
 Presence of Trauma & Infection
Recommendations relevant for all types of surgery
• Communication : When offering tests before surgery, give people information in line with
recommendations (including those on consent and capacity)
• Considering existing medicines
• Pregnancy tests: On the day of surgery, sensitively ask all women of childbearing potential whether there
is any possibility they could be pregnant. Make sure women who could possibly be pregnant are aware of the
risks of the anaesthetic and the procedure to the fetus. Document all discussions with women about whether or
not to carry out a pregnancy test. Carry out a pregnancy test with the woman's consent if there is any doubt
about whether she could be pregnant.

• Sickle cell disease or sickle cell trait tests : Take personal and family history. Refer to specialist if
known positive.

• HbA1c testing for people with diabetes :if they have not been tested in the last 3 months. Avoid in
non diabetics
• Urine tests: Do not routinely offer urine dipstick tests before surgery, Consider microscopy and culture of
midstream urine sample before surgery if the presence of a urinary tract infection would influence the decision
to operate.

• Chest X-ray: Do not routinely offer chest X-rays before surgery

• Echocardiography : Do not routinely offer resting echocardiography before surgery. Consider resting
echocardiography if the person has: • a heart murmur and any cardiac symptom (including breathlessness, pre-
syncope, syncope or chest pain) or • signs or symptoms of heart failure.
 Psychosocial Assessment and Care
Causes of Fear in Preoperative patients Manifestations of fear

• Fear of Unknown ( Anxiety ) • Anxiousness

• Fear of Anesthesia • Bewilderment
• Fear of Pain • Anger
• Fear of Death • Tendency to exaggerate
• Fear of disturbance on body image • Sad, evasive, tearful, clinging
• Worries –loss of finances, employment, • Inability to concentrate/short
social and family roles. attention span
• Failure to carry out simple directions
• dazed
 Nursing Interventions to Minimize Anxiety
 Explore client’s feeling

 Allow client’s to speak openly about fears/concern.

 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.
 Informed Consent
Purpose
• To ensure that the patient understand the nature of
the treatment including the potential complications
• To indicate that the patient’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.
• 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 patient’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 is accepted
• For mentally ill and unconscious patient, consent must be taken from the parents or
legal guardian.
• 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)
Pre Operative Care
 Physical Preparation
Before Surgery
 Correct any dietary deficiencies
 Reduce an obese person’s weight
 Correct fluid and electrolyte imbalances
 Restore adequate blood volume with blood transfusion
 Treat chronic diseases
 Halt or treat any infectious process
 Treat an alcoholic person with vit. supplementation, IVF or fluids if
 dehydrated

Pre Operative Teaching

 Incentive Spirometer
 Diaphragmatic Breathing
 Coughing and Splinting
 Turning
 Foot and Leg Exercises
 Early Ambulation
 Incentive Spirometer

Encourage to use incentive spirometer

about 10 to 12 times per hour.

Deep inhalations expand alveoli, which

prevents atelectasis and other pulmonary
complication.

There is less pain with inspiratory

concentration than with expiratory
concentration.
 Coughing and Splinting
Promotes removal of chest secretions.
Interlace his fingers and place hands over the proposed incision site, this will act as
a splint and will not harm the incision.
Lean forward slightly while sitting in bed.
Breath, using diaphragm
Inhale fully with the mouth slightly open.
Let out 3-4 sharp hacks.
With mouth open, take in a deep breath and quickly give 1-2 strong coughs.

Foot and Leg exercises

Moving the legs improves circulation and muscle tone.
Have the patient lie supine, instruct patient to bend a knee and raise the foot –hold it a
few seconds and lower it to the bed.
Repeat above 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
 Evening before surgery
Preparing the Skin-have a 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 G.I 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.

ASA guidelines for Pre

operative fasting:
Rule: 2, 4, 6, 8 rule
applies to all ages
No clear liquids within 2 hours
of surgery
No breast milk within 4 hours
of surgery
No solid foods within 6 hours
of surgery
No fried foods, fatty foods or
meats within 8 hours of
surgery.
 On the day of Surgery
• Awaken 1 hour before pre-op medications
• 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, jewelleries.
• Take baseline vital sign before pre-op medication.
• Check ID band, skin prep
• Check for special orders –enema, IV line
• Check NPO
• Have patient void before pre-op medication
• Continue to support emotionally
• Accomplished “preop care checklist
 Pre Operative Medication
Continue in morning of Sx Do NOT take Avoid

• All Cardiovascular Diuretics NSAIDS

medications ( except Potassium Short acting: Stop 1 day before (Diclofenac,
ibuprofen,Indomethacin)
Antihypertensives) supplements Mid-acting-Stop 3days before (Naproxen, Sulindac)
• Anti-reflux Diabetes Long acting-Stop 10 days before (Piroxicam,
medications  medications Miloxicam)
• Seizure and anti- COX 2 inhibitors- stop 2 days before
parkinson medications Antiplatelets: Do not stop antiplatelet agents
• Psychiatric drugs without carefully reviewing indications and minimum
duration from stenting.Clopidogrel ,Ticlopidinee:5
• Bronchodilators days, Prasugrel 7 days
• Oral Contraceptives Aspirin,Warfarin : 5 days
(unless stoped for AntiHT: Avoid diuretics, CCBs, ACEI,ARBs
prevention of DVT) Parkinson agents: MAO inhibitors should be
• Levothyroxine tapered off 2-3 weeks before the procedure
• Corticosteroids DMARDS and Anti TNF agents: stopped 1-2
• HIV Medications weeks before procedure and resumed 1-2 weeks after
surgery
• Pain Medication Estrogen replacement/OCPs: Ideal to stop at
s(except Aspirin, least 1 month before surgery-Weigh risk versus
NSAIDS) benefit-If agent continued, consider DVT Prophylaxis
 measures
 Surgical Site Marking
When : before patient transfer to theatre and ideally before sedatve pre-medication
How : carried out after all the available information concerning the patient’s identity, the
procedure and the surgical site/ intended side (provided by the patient, medical file, notes,
imaging, consent, etc.) has been checked and cross-referenced.
Who : surgeon who will be performing the operation. The person who marks the site is
identified in the medical file (preferably in the pre-op verification checklist*).Delegation to a
doctor or nurse is possible if this person is involved in the operation or is directly involved in
the patient preparation process.
Where : at the intended site of the incision or as near as possible to the intended site.
The mark must be made with a skin marker that is sufficiently permanent to remain visible
a`er prepara'on of the pa'ent (skin prepara'on and applica'on of theatre drapes)
 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 arrive in the OR at the proper time.
SOP : safe transfer of a patient from a bed to a
transportation device
Specific needs of the patient should be considered when selecting the method
of transport:

A. Need for IV pole(s)

B. Need to transport oxygen tank
C. Mobility of the patient
D. Conscious, semi-conscious or unconscious patient
E. Size of patient
F. Age of patient
G. Determining the physical abilities and state of health of the patient.
Knowing the patient’s state of health and abilities will help in the choice
of mode of transportation, decrease the possibility of accidents to the patient and
hospital personnel, and aid in determining the number of hospital personnel needed to
help move the patient.
Parameters to be considered when identifying the mode of
transportation
A. Wheels can be locked
B. Safety straps available
C. Side rails are high enough
D. Rails on crib are high enough to prevent pediatric patient from falling out
E. IV poles can be easily transferred with the chosen method of transport
F. Shelf or rack is available in order to transport oxygen tank and/or monitoring devices
G. Method of transport is large enough to accommodate size of patient
H. Ability to accommodate positioning needs of the patient
I. Mattress on gurney is held in place
J. Ability to use patient transfer devices
K. Maneuverability of transportation device
L. The transportation device has undergone scheduled inspections,
maintenance and repair to ensure proper functioning
Patient care concepts to be implemented during the transfer
of the patient
A. Individual who is transporting the patient should introduce and identify
herself/himself to lessen patient anxiety.

B. Correctly identify the patient to prevent wrong-patient surgery.

C. If the patient is conscious, explain the transfer procedure prior to implementation to

reduce the anxiety of the patient and promote safety. Verbally communicate to the
patient which staff member will indicate that they are ready for the patient to move over
to the transportation device. Instruct the patient to move slowly to avoid severe
physiological alterations; assist the patient with transfer.

D. Maintain the patient’s dignity during the transfer by keeping him/her covered. This will
aid in decreasing the patient’s anxiety and ensure his/her personal and moral rights.
SOP : safely transport a patient to the preoperative
holding area or operating room
A. Elevate the side rails.
B. Apply safety strap.
C. Confirm IV lines, indwelling catheters, monitoring system lines and drains, and any other lines are
secure and patent, and IV bag and collection containers are hanging away from the patient’s head.
D. Ensure head, arms and legs are protected, adequately padded, and patient
is comfortable as possible.
E. The patient should be transported feet first; rapid movements, particularly when going around a
corner should be avoided. Rapid movements, especially if the patient has received preoperative
medications, can cause the patient to become disoriented, dizzy, and nauseated, and induce vomiting.
F. The staff person moving the transportation device should be positioned at the patient’s head in
order to look forward for potential hazards. This also allows immediate access to the patient’s airway
in case of respiratory distress or vomiting. If two staff members are available for transport, the second
person should be positioned at the foot of the stretcher. It is the responsibility of the person at the
head of the bed to communicate any
upcoming potential hazards to the other staff person.
G. Never use the transportation device to force open any doors.
H. When using an elevator, the elevator doors should be locked, and the
patient is transported headfirst into the elevator.
I. The patient should never be left unattended during the transportation process. Abandonment of
the patient increases the risk of patient injury. Additionally, remaining with the patient at all times will
lessen patient anxiety.
J. During the transportation process, remain observant of the patient for signs of physical or emotional
distress.
 Patient’s Family
 Direct to the proper waiting room.
 Tell the family that the surgeon will probably contact them immediately after the
surgery.
 Explain reason for long interval of waiting: anesthesia prep, skin prep, surgical
procedure, RR.
 Tell the family what to expect postop when they see the patient