Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 18: Nursing Management: Preoperative Care Key Points Printable SURGICAL SETTINGS Surgery is performed to diagnose, cure, palliate, prevent, explore, and/or provide cosmetic improvement. The total surgical episode is called the perioperative period. This period in the health care continuum includes the time before surgery (the preoperative period), the time spent during the actual surgical procedure (the intraoperative period), and the period after the surgery is completed (the postoperative period). Surgery may be a carefully planned event (elective surgery) or may arise with unexpected urgency (emergency surgery). The setting in which a surgical procedure may be safely and effectively performed is influenced by the complexity of the surgery, potential complications, and general health status of the patient. The majority of surgical procedures are being performed as ambulatory surgery (also called same-day or outpatient surgery). Regardless of where the surgery is performed, your role is to prepare the patient for surgery, care for the patient during surgery, and facilitate the patients recovery following surgery. PATIENT INTERVIEW One of the most important nursing actions is the preoperative interview. It often occurs in advance or on the day of surgery. The site of the interview and the time before surgery will dictate the depth and the completeness of the interview. The primary purposes of the interview are to obtain the patients health information, provide information regarding the surgical experience, and assess the patients readiness for surgery. It provides the patient and caregiver an opportunity to ask questions. NURSING ASSESSMENT OF THE PREOPERATIVE PATIENT The preoperative nursing assessment is performed to determine the patients psychologic status and physiologic factors that may contribute to operative risk factors; establish baseline detail; identify and document the surgical site and/or side (of body); identify prescription, over-the-counter drugs, and herbal supplements taken by the patient; confirm laboratory and diagnostic test results; note cultural and ethnic factors that may affect the surgical experience; and validate that the informed consent form has been signed and witnessed. Common fears associated with surgery include the potential for death or permanent disability resulting from surgery, pain, change in body image, or

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results of a diagnostic procedure. Your role in psychologically preparing the patient for surgery is to assess the patient for potential stressors that could negatively affect surgery and to provide support during the preoperative period so that stress does not become distress. In the nursing assessment, the nurse should perform a thorough body systems review. Ask specific questions to confirm the presence or absence of any diseases. Information should also be obtained about the patients family concerning any history of adverse reactions to or problems with anesthesia. Patients should be screened for possible latex allergies, as well as history of drug intolerance and drug allergies. All findings on the medication history should be documented and communicated to the intraoperative and postoperative personnel. The Joint Commission requires that all patients admitted to the operating room (OR) have a documented history and physical examination (H&P) in the chart prior to surgery. Findings from the patients H&P will be used to assess the patients perioperative risk and may influence perioperative decisions. The preoperative assessment of the older persons baseline cognitive function is especially crucial for intraoperative and postoperative evaluation. The patient with diabetes is especially at risk for adverse effects of anesthesia and surgery. Obesity stresses both the cardiac and pulmonary system and makes access to the surgical site and anesthesia administration more difficult.

NURSING MANAGEMENT: PREOPERATIVE PATIENT Preoperative nursing interventions are derived from the nursing assessment and must reflect each patients specific needs. Physical preparations will be determined by the pending surgery and the routines of the surgery setting. Preoperative teaching involves the following: o Provision of sensory, process, and procedural information. o Instructions about deep breathing, coughing, and ambulating postoperatively. o Information about pain management, including the use of some type of pain-rating scale. o An understanding that some patients, with varying cultures, backgrounds, and experiences, may need different types of information. o Inclusion of the patients caregiver in the teaching when appropriate. o Documentation of all teaching in the patients medical record. Legal Preparation for Surgery Legal preparation for surgery consists of checking that all required forms have been correctly signed and are present on the chart, and that the patient and caregiver clearly understand what is going to happen. Anyone undergoing an invasive procedure must give informed consent for that procedure to be performed. Informed consent is an active, shared decision-making

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process between the provider and the recipient of care. o A true medical emergency may override the need to obtain informed consent. o The physician is ultimately responsible for obtaining the patients consent for surgical treatment. The nurse may be responsible for witnessing the patients signature on the consent form. o Adults sign their own operative permit. If the patient is a minor, is unconscious, or is mentally incompetent to sign the permit, the written permission may be given by a legally appointed representative or responsible family member. Day-of-Surgery Preparation Day-of-surgery preparation will vary a great deal depending on whether the patient is an inpatient or an ambulatory surgical patient. On the day of surgery, the nurse is responsible for the following: o Final preoperative teaching o Assessment and communication of pertinent findings o Ensuring that all preoperative preparation orders have been completed o Ensuring that records and reports are present and accompany the patient to the OR o Verifying the presence of a signed operative consent o Laboratory and diagnostic data o An H&P report o A record of any consultations o Baseline vital signs o Completed nurses notes and preoperative checklist o Final handoff of communication to the OR nurse receiving the patient to ensure that all pertinent information regarding the patient has been exchanged A variety of preoperative medications may be used, either alone or in combination, depending on the patient and the type of surgery. o These include benzodiazepines for sedation and amnesia, anticholinergics to reduce secretions, and opioids to decrease pain and intraoperative anesthetic requirements. o Additional drugs include antiemetics, antibiotics, insulin, histaminereceptor antagonists, eye drops, and regular prescription drugs. CULTURAL AND GERONTOLOGIC CONSIDERATIONS The nurse should include cultural considerations when assessing and implementing care for the preoperative needs of a patient. Frequently performed procedures in the older adult are cataract extraction, coronary and vascular procedures, prostate surgery, herniorrhaphy, cholecystectomy, and joint repair/replacement. Older adults may have sensory, motor, and cognitive deficits necessitating that more time may be needed to complete preoperative testing and understand
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preoperative instructions. These changes also require attention to promote patient safety and prevent injury.

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.