Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Chapter 16Care of Preoperative Patients

2Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Preoperative Period

Begins when patient is scheduled for surgery; ends at time of transfer to surgical suite

Nurse functions as educator, advocate, promoter of health and safety

3Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Patient & Family Teaching

Tubes Drains Vascular access

4Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Nasogastric Tube

5Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Prevention of Respiratory Complications

Breathing exercises Incentive spirometry Coughing and splinting

6Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Older Adults: Changes of Agingas Surgical Risk Factors

Decreased: Cardiac output, peripheral circulation Vital capacity, blood oxygenation Blood flow to kidneys, glomerular filtration rate

Increased: Blood pressure Risk for skin damage, infection Sensory deficits Deformities related to osteoporosis/arthritis

7Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Older Adults: Considerations for Preoperative Care

Chronic illness Malnutrition Impaired self-care ability Allergies Inadequate support systems

8Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Older Adults: Considerations for Preoperative Care (cont’d)

Stress from surgery/anesthesia Cardiopulmonary complications after surgery Mental status changes Risk for falls

9Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Reasons for Surgery

Diagnostic – determines origin and cause of disorder

Curative – resolves health problem by repairing or removing cause

Restorative – improves patient’s functional ability

Palliative – relieves symptoms of disease process, but does not cure

Cosmetic – alters/enhances personal appearance

10Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Urgency and Degree of Risk of Surgery

Urgency: Elective Urgent Emergent

Degree of Risk: Minor Major

11Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Extent of Surgery

Simple Radical Minimally invasive (MIS)

12Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Anxiety Interventions

Preoperative teaching Encourage communication Promote rest Use distraction Teach family members

13Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Skin Preparation

Break in the skin increases risk for infection Patient may be asked to shower using

antiseptic solution Hair removal by electric clippers, depilatories Shaving of hair creates risk for infection!

14Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Preoperative Drugs

Reduce anxiety Promote relaxation Reduce nasal and oral secretions

15Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Preoperative Drugs (cont’d)

Prevent laryngospasm Reduce vagal-induced bradycardia Inhibit gastric secretion Decrease amount of anesthetic needed for

induction and maintenance of anesthesia

16Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Collaborative Management: Assessment

History and data collection: Age Drugs, substance use Medical history (including cardiac and pulmonary) Complementary/alternative practices Previous surgical procedures, anesthesia Blood donations Discharge planning

17Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Physical Assessment/Clinical Manifestations

Obtain baseline vital signs Focus on problem areas identified in history;

all body systems affected by surgical procedure

Report abnormal assessment findings to surgeon/anesthesiology personnel

18Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

System Assessment

Cardiovascular CAD, MI within 6 months before surgery, angina,

hypertension, dysrhythmias Respiratory

Chronic respiratory problems Smoking increases carboxyhemoglobin blood

level, deceases oxygen delivery Renal/Urinary

Kidney impairment inhibits drugs/anesthetic agent excretion

19Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

System Assessment (cont’d)

Neurologic Determine baseline Assess LOC, ability to follow commands

Musculoskeletal Nutritional status

Malnutrition and obesity increase surgical risk Psychosocial

20Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Prevention of Cardiovascular Complications

Be aware of patients at greater risk for DVT Antiembolism stockings Pneumatic compression devices Leg exercises Mobility

21Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Laboratory Assessment

Urinalysis Blood type and crossmatch CBC or hemoglobin level and hematocrit Clotting studies (PT, INR, aPTT)

22Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Laboratory Assessment (cont’d)

Electrolyte levels Serum creatinine level Pregnancy test Chest x-ray ECG

23Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Insufficient Information Interventions

Preoperative teaching Informed consent:

Surgeon obtains signed consent before sedation and/or surgery

Nurse clarifies facts and dispels myths about surgery

Nurse not responsible for providing detailed information about procedure!

24Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Informed Consent

Patients may sign with “X” In emergency, telephone authorization is

acceptable Special permits required for some procedures

25Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

NPSGs and Informed Consent

Ensure correct site is selected and wrong site is avoided

Licensed independent practitioner marks site, involving patient if possible

“Time out” procedure adopted by most facilities

26Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Implementing Dietary Restrictions

NPO: Patient not to ingest anything by mouth for 6 to 8 hours before surgery: Decreases risk for aspiration Give patients written/oral directions to stress

adherence Surgery can be canceled if instructions not

followed

27Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Administering Regularly Scheduled Medications

Consult with physician and anesthesia provider for instructions

Drugs for certain conditions often allowed with a sip of water: Cardiac disease Respiratory disease Seizures Hypertension

28Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Intestinal Preparation

Performed to prevent injury to colon; reduce number of intestinal bacteria

Enema or laxative

29Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Patient Using Incentive Spirometer

30Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Patients at Risk for VTE

Obese patients Age 40 or older History of cancer Decreased mobility or immobile Spinal cord injury

31Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Patients at Risk for VTE (cont’d)

History of VTE, PE, varicose veins, edema Oral contraceptives Smoking History of decreased cardiac output Hip fracture, total hip/knee surgery

32Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

External Pneumatic Compression Devices

33Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Preoperative Chart Review

Ensure all documentation, preoperative procedures, orders are complete

Check surgical consent form and others for completeness

Inform patient that area will be marked before procedure begins

Document allergies, height, and weight

34Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Preoperative Chart Review (cont’d)

Ensure all laboratory and diagnostic test results are in chart

Document/report any abnormal results Report special needs and concerns

35Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Preoperative Patient Preparation

Remove most clothing; provide gown Leave valuables with family member or lock

up Tape rings in place if cannot be removed Ensure patient is wearing ID band

36Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.

Preoperative Patient Preparation (cont’d)

Remove: Dentures Prosthetic devices Hearing aids Contact lenses Fingernail polish Artificial nails Pierced jewelry