PRE OPERATIVE NURSING · 2020. 5. 10. · ECG Identify pre existing cardiac problem. ... The diagnosis and explanation of the condition. Fair explanation of the procedure to be done

PRE OPERATIVE NURSINGMrs. Preethi Ramesh

Senior Nursing Lecturer

BGI

INTRODUCTION Extends from the time the client is a admitted in the surgical unit, to the time he/she is

prepared physically, psychosocially, spiritually, and legally for the surgical procedure, until he is transported into the operating room.

Begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the OR table.

Involves establishing a baseline evaluation of the patient before surgery by carrying out a preoperative interview.

Ensuring that necessary tests have been or will be performed. Arranging appropriate consultations; and providing education about recovery from anesthesia

and postoperative care. On the day of surgery, patient teaching is reviewed, the patient’s identity and surgical site are

verified, informed consent is confirmed, and an IV infusion is started.

GOALS Assessing and correcting physiologic and psychologic problems

that might increase surgical risk. Giving the person and significant others complete

learning/teaching guidelines regarding surgery. Instructing and demonstrating exercises that will benefit the

person during post operative period. Planning for discharge and any projected changes in lifestyle

due to surgery.

AgeAllergiesVital Sign TrendNutritional StatusHabits affecting tolerance to anesthesiaPresence of InfectionsUse of drugs that are contraindicated prior to surgeryCardiovascular functionPulmonary functionRenal functionGastrointestinal functionLiver functionEndocrine functionHematologic function

PHYSIOLOGIC ASSESSMENT OF THE CLIENT UNDERGOING SURGERY

Age:Elderly are at risk >65 years of ageObtain a detailed medical history and health

assessmentAssess for sensory deficitsAssess for overall functional statusUnderstand that there is a decreased physiological

reserve

PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS

Allergies:Assess for known drug, food and substance allergiesAssess what the reaction to the drug or substance is

(is it a true allergy, hives or anaphylaxis)Allergies must be clearly noted on the chart, and

other steps are usually taken per hospital/institutional protocol


Vital Signs Trends:What is normal for thatpatient, and are V/S inthe preoperative periodin line with the normsor deviating?


Nutritional Status: This can be a situation of deficit or excess Assess for individuals who are prone to general nutritional

deficiencies: Aged Cancer patients Gastrointestinal problems Chronic illness/Chronic steriod use Alcoholics/Drug Addicts

Also assess for excess (Obesity): Poor wound healing because of decreased blood supply Hard to access surgical site Decreased lung capacity Anesthesia meds are stored in fat cells


Habits affecting tolerance to anesthesia: Smoking:

alters platelet function...hypercoagulable reduces the amount of functional hemoglobin cilia in the lung are damaged, more difficult to

mobilize secretions in the patient that smokes retards wound healing (especially because of the

decreased functional hemoglobin) Alcoholism:

can have impaired liver function B-vitamin deficiencies

Opioid Addiction have a high tolerance for pain meds


Presence of Infections:

Biggest indicator is the presence of fever above 101 degrees F (38C)

If infection is present, likely surgery will need to be delayed because the risks to the patient are too great.

Goal will be to find and treat the infection, and then reattempt surgery once the infection is cleared


Use of drugs that are contraindicated prior to surgery:

Drugs like aspirin, heparin, warfarin (Coumadin) should be stopped prior to surgery bcoz it affect bleeding time.

ASA is 2 weeks because of the permanent platelet affects.

Heparin, and low molecular weight heparins are usually stopped 24hrs preop, unless there are problems with the liver.

Warfarin is usually 7 days, but the PT/INR is rechecked either the day of or the day before the surgery to check for bleeding.


Use of drugs that are contraindicated prior to surgery: Current use of medications, over the counter agents

and herbal remedies should be assessed and documented.

Some drugs/herbs can interact with the anesthesia Check about antihypertensives, the morning of surgery Need to be clear about home meds (dose, frequency,

timing). Can check with the MD if certain meds should be restarted post operatively.

Want to reinforce that if the patient is to take meds the morning of surgery, they should be taken with sips of water.


General survey- gestures and body movements may reflect decreased energy or weakness caused by illness.

Cardiovascular system- alterations in cardiac status are responsible for as many as 30% of perioperative death.

Respiratory system- a decline in ventilator function, assessed through breathing pattern and chest excersion, may indicate a client’s risk for respiratory complications.

Renal system-abnormal renal function can alter fluid and electrolyte balance and decrease the excretion of preoperative medications and anesthetic agents.

Neurologic system- a client’s LOC will change as a result of general anesthesia.


Musculoskeletal system- Deformities may interfere with intraoperative and postoperative positioning. Avoid positioning over an area where the the skin shows signs of pressure, over bony prominences.

Gastrointestinal system- alteration in function after surgery may result in decreased or absent bowel sound and distention.

Head and Neck- the condition of oral mucous membranes reveals the level of hydration.


Causes of fears of the preoperative clients:

Fear of the unknown Fear of anesthesia, vulnerability while

unconscious Fear of pain Fear of death Fear of disturbance of body imageWorries – loss of finances, employment,

social and family roles

PSYCHOSOCIAL ASSESSMENT AND CARE

Manifestations 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 interventions to minimize anxiety: Explore client’s feelings. Assist client to identify coping strategies that he

or she has previously used to decrease fear. Allow client to speak openly about

fears/concerns. Give accurate information regarding surgery. Give empathetic support. Consider the person’s religious preferences and

arrange visit by priest/minister as desired Music therapy.


Test Rationale

CBC RBC, Hgb, Hct are important to know the oxygen carrying capacity of blood.WBC are indicator of immune function.

Blood grouping/ X matching Determined 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.

Fasting Blood Glucose High level may indicate undiagnosed DM

ROUTINE PREOPERATIVE SCREENING TEST

Test Rationale

BUN / Creatinine Evaluate renal function

ALT/AST/LDH and Bilirubin Evaluate liver function

Serum albumin and total CHON

Evaluate nutritional status

Urinalysis Determine urine composition

Chest Xray Evaluate resp.status/ heart size

ECG Identify pre existing cardiac problem.

ROUTINE PREOPERATIVE SCREENING TEST

PATIENT PREPARATION FOR SURGERY

1. Operative consent.

2. Preoperative Teaching.

3. Interventions the day or evening prior to surgery.

4. Interventions the day of surgery.

INFORMED CONSENT (OPERATIVE PERMIT/SURGICAL CONSENT)

Permission obtained from a patient to perform a specific test or procedure

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.


Circumstances Requiring Consent

Any surgical procedure where scalpel, scissors, suture, hemostats of electrocoagulation may be used.

Entrance into body cavity. Radiologic procedures, particularly if a contrast material is required. General anesthesia, local infiltration and regional block.


Essential Elements of Informed Consent The diagnosis and explanation of the condition. Fair explanation of the procedure to be done and the

consequences. Description of alternative treatment or procedure. 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 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 is accepted For mentally ill and unconscious patient, consent must be taken from the parents or

legal guardian


Requisites for Validity of Informed Consent 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.)


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

A statement informing the patient if the protocol differs from customary procedure

PRE OPERATIVE TEACHING

Incentive Spirometer

Diaphragmatic Breathing

Coughing & Splinting

Turning

Foot and Leg Exercise

Early Ambulation

PRE OPERATIVE TEACHING Incentive Spirometer Encouraged to use incentive spirometer about 10 to 12 times per

hour. Deep inhalations expand alveoli, which prevents atelectasis and

other pulmonary complication. 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.

PRE OPERATIVE TEACHING Diaphragmatic Breathing/Deep Breathing Exercises Practice in the same position client would assume in bed after

surgery. Allow hands in a loose fist position to rest lightly on the front of

the lower ribs with your finger tips against lower chest to feel the movement.

Breathe out gently and fully as the ribs sink down and inward toward midline.

Take a deep breath through your nose and mouth, letting the abdomen rise as the lungs fill with air.

Hold this breath for a count of five. Exhale and let out all the air through your nose and mouth.

PRE OPERATIVE TEACHING Coughing exercises 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.

PRE OPERATIVE TEACHING

Turning exercises Turn on your side with the uppermost leg flexed most and supported on a pillow.

Grasp the side rail as an aid to maneuver to the side.

Practice diaphragmatic breathing and coughing while on your side.

PRE OPERATIVE TEACHING Foot and leg exercises Lie in a semi-Fowler’s position. Bend your knee and raise your foot – hold

it a few seconds, then extend the leg and lower it to the bed.

Do this five times with each leg. Then trace circles with the feet by bending

them down, in toward each other, up, and then out.

PREPARING THE PATIENT THE EVENING BEFORE SURGERY

Preparing the Skin Have a full bath to reduce microorganisms in the skin. Hair should be removed within 1 to 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 atleast 24 hours before surgery.

Promoting rest and sleep Administer sedatives as ordered.


Preparing the Skin For abdominal surgery, the male patient's

skin is shaved and cleaned from the nipple line to the upper third of the thigh, including the pubes (hair over the pubic regions) from side to side anteriorly (see figure A). For a female, the upper boundary is the breast fold on the chest wall (see figure B).


Preparing the Skin For kidney operations and

surgery of the proximal third of the ureters, the skin is shaved from the axilla (which is prepped) to the groin (see figures C and D).


Preparing the Skin For chest surgery, the skin is

shaved and cleansed on the affected side from mid hip over the shoulder, including the axilla, to the shoulder on the unaffected side (see figures E and F).


Preparing the Skin For rectal surgery, support the legs

and thighs in the lithotomy position. Shave the pubic, perineal, thigh, and anal areas (in a radius of about 10 inches from the anus) (see figures G and H).


Preparing the Skin For gynecological surgery (perineal prep)

(see figure I), support legs and thighs in the lithotomy position and shave the anterior surface from the umbilicus down: the pubic area, the external genitalia, the perineum, including the area around the anus, and the buttocks. Shave inner thighs halfway to the knees from the middle of anterior to middle of posterior thighs.


Preparing the Skin For surgery of the cranium (see figure J), follow

the outline indicated by the surgeon. Clip the hair before attempting to shave the scalp. Find out if long hair is to be saved for the patient. If so, follow local procedures. The actual shaving is often done in the surgical suite just before surgery, and the preparation done on the ward may be limited to cutting or clipping the hair close to the scalp.


Preparing the Skin For surgery of the limbs (see figures K, L, M,

and N), the area includes the entire circumference. The extent of the prep varies depending upon the type of operation. As an example, for surgery of the hand, the prep would normally extend distally from the elbow. A manicure or pedicure is also necessary. Fingernails or toenails must be clipped short, cleaned, and scrubbed.

ASA (American Society of Anesthesiologists) Guidelines for Preoperative Fasting

Liquid and Food Intake Minimum Fasting Period

Clear Liquids 2

Breast Milk 4

Nonhuman Milk 6

Light Meal 6

Regular / Heavy Meals 8

Pre Anesthesia Management Physical Status Categories


Diet Restrictions Historical guidelines to prevent aspiration were NPO after

midnight the night before. Educating the patient about the reason for NPO status may

help with adherence Information of what to wear for the surgeryPatient will likely need to be there 1 to 2 hours prior to

scheduled procedure

PATIENT PREPARATION ON THE DAY OF SURGERY

Awaken1hourbeforepre-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, jewelries. Take baseline vital sign before pre-op medication. Check ID band, skin prep Check for special orders – enema, IV line Check NPO Have client void before pre-op medication Continue to support emotionally Accomplished “pre-op care checklist”

PATIENT PREPARATION ON THE DAY OF SURGERY

OPERATIVE SITE IDENTIFICATION

PRE-OPERATIVE CHECKLIST

PRE-OPERATIVE MEDICATIONS

Benzodiazepines/Barbituates: used for their sedative and amnesic properties

Anticholinergics: reduce secretions, and can reduce cramping Opioids: decrease need for intraoperative analgesics and decrease pain Antiemetics: decrease nausea/Vomiting Antibiotics: to prevent infective endocarditis, or where wound

contamination is a risk (GI surgery) or where woundinfection would cause significant postoperative morbidity, usually given IV

Eyedrops: especially with eye surgery (lasik, cataract surgery)

PRE-OPERATIVE MEDICATIONS

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.

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.

Tell the family what to expect postop when they see the patient.

PRE-OPERATIVE PHASE

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PRE OPERATIVE NURSING · 2020. 5. 10. · ECG Identify pre existing cardiac problem. ... The diagnosis and explanation of the condition. Fair explanation of the procedure to be done