med surg chapter 018

Preoperative Care

Chapter 18

Surgery• Art and science of treating diseases, injuries, and deformities by operation and instrumentation

Surgery• Performed for

• Diagnosis• Cure• Palliation• Prevention• Cosmetic improvement• Exploration

Surgical Settings• Elective surgery vs. emergency surgery

• Inpatient • Same-day admission

• Ambulatory (outpatient)

• J.D., a 45-year-old female, presents to the surgeon’s office for presurgical workup for right breast lumpectomy.

Case StudyPreoperative Care

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Your Role Preop• Have knowledge of the nature of the disorder requiring surgery

• Identify the individual patient’s response to the stress of surgery

• Have knowledge of the results of preoperative diagnostic tests

• Identify potential risks and complications associated with surgery

Patient Interview• Check documented information before interview• Avoids repetition

• Occurs in advance of or on day of surgery

Case StudyInterview• J.D. is accompanied by her husband.

• She tells you she has two school-age children.

• She states that she is here because her breast biopsy was positive for cancer and she anticipates that the lumpectomy will remove all cancer.

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Patient Interview• Purpose

• Obtain health information• Determine expectations• Provide and clarify information about the surgery and anesthesia

• Assess emotional state and readiness

Case StudyAssessment• J.D. tells you she has a history of hypertension, for which she takes HCTZ daily.

• She recently was diagnosed with diabetes and is currently controlled with an oral agent and diet.

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Nursing Assessment• Overall goals

• Identify risk factors• Plan care to ensure patient safety

Nursing Assessment Goals• Determine psychologic status to reinforce coping strategies

• Determine physiologic factors of the procedure contributing to risks

• Establish baseline data

Nursing Assessment Goals• Identify and document surgical site

• Identify medications and herbs taken that may affect surgical outcome

• Identify, document, and communicate results of laboratory/diagnostic tests

Nursing Assessment Goals• Identify cultural and ethnic factors that may affect surgical experience

• Determine receipt of adequate information from surgeon to sign informed consent

Nursing Assessment• Psychosocial assessment

• Excessive stress response can be magnified and affect recovery

Nursing Assessment• Influencing factors

• Age• Past experience• Current health• Socioeconomic status

Nursing Assessment• Use common language• Use translators if needed

• Decreases level of anxiety• Communicate all concerns to surgical team

Nursing Assessment• Anxiety can impair cognition, decision making, and coping abilities

• Anxiety can arise from• Lack of knowledge• Unrealistic expectations

Nursing Assessment• Anxiety may arise from conflict with interventions (i.e., blood transfusions) and religious/cultural beliefs• Identify beliefs and discuss with surgeon and operative staff

Case StudyNursing Assessment• J.D. states that her mother and aunt have a history of breast cancer resulting in mastectomy.

• She has two school-age children.

• She appears anxious and you note constant fidgeting.

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Nursing Assessment• Fears

• Death or disability• May prompt postponement• Influence outcome

• Pain• Consult with ACP• Confirm drugs will be available

• Mutilation/alteration in body image• Assess concerns nonjudgmentally

• Anesthesia• ACP for consult

• Disruption of life functioning• Range from fear of permanent disability to temporary loss

• Include family and financial concerns

• Consultations PRN

Nursing Assessment• Hope

• May be strongest positive coping mechanism• Never deny or minimize

• Assess and support

Nursing Assessment• Past health history

• Diagnosed medical conditions (previous and current)

• Previous surgeries and problems

• Menstrual/obstetric history

Nursing Assessment• Health history

• Familial diseases• Conditions

• Reactions/problems to anesthesia (patient or family)

Case StudyNursing Assessment• J.D. states that she is here because her breast biopsy was positive for cancer.

• She anticipates that the lumpectomy will remove all cancer.

• She has had no other surgeries.

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Nursing Assessment• Current medications

• Prescription and OTC• Herbal supplements• Dietary supplements• Antiplatelets/NSAIDs• Recreational

• Drugs• Alcohol• Tobacco

Nursing Assessment• Allergies (drug and nondrug)

• Screen for latex allergy• Risk factors• Contact urticaria or dermatitis

• Aerosol reactions• History of reactions suggesting latex allergy

Case StudyNursing Assessment• J.D. is currently taking HCTZ, glipizide (Glucotrol), a multivitamin, fish oil, and a daily low-dose aspirin.

• She reports an allergy to penicillin, resulting in a rash.

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Nursing Assessment• Cardiovascular system

• Report• Any cardiac problems so they can be monitored during the intraoperative period

• Use of cardiac drugs• Presence of pacemaker/ICD

Nursing Assessment• Cardiovascular system

• 12-lead electrocardiogram (ECG)

• Coagulation studies• Possible prophylactic antibiotics

Nursing Assessment• Respiratory system

• Inquire about recent airway infections• Procedure could be cancelled because of increased risk of laryngo/bronchospasm or decreased SaO2

• History of dyspnea, coughing, or hemoptysis reported to operative team

• COPD or asthma• High risk for atelectasis and hypoxemia

• Smokers should be encouraged to quit 6 weeks before procedure• Decreases risk of complications

• Greater years and number of packs = greater risk

• Sleep apnea, obesity, and airway deformities affect respiratory function

Nursing Assessment• Nervous system

• Evaluation of neurologic functioning• Vision or hearing loss can influence results

• Cognitive deficits can affect informed consent and cause adverse outcomes during and after surgery

Nursing Assessment• Genitourinary system

• History of urinary or renal diseases

• Renal dysfunction contributes to• Fluid and electrolyte imbalances

• Increased risk of infection• Impaired wound healing• Altered response to drugs and their elimination

Nursing Assessment• Genitourinary system

• Renal function tests• Note problems voiding, and inform operative team

• Assess women for possibility of pregnancy

Nursing Assessment

• Hepatic system • Liver detoxifies many anesthetics and adjunctive drugs

• Hepatic dysfunction may increase risk of postoperative complications

Nursing Assessment• Integumentary system

• History of skin and musculoskeletal problems

• History of pressure ulcers• Extra padding during procedure

• Affects postoperative healing• Body art, tattoos, piercings

Nursing Assessment• Musculoskeletal system

• Identify joints affected with arthritis

• Mobility restrictions may affect positioning and ambulation

• Bring mobility aids to surgery

Nursing Assessment• Musculoskeletal system

• Report problems affecting neck or lumbar spine to ACP• Can affect airway management and anesthesia delivery

Nursing Assessment• Endocrine system

• Patients with diabetes mellitus are especially at risk for:• Hypo/hyperglycemia• Ketosis• Cardiovascular alterations• Delayed wound healing• Infection

Case StudyAssessment• Considering her diabetic history, what assessment is important for J.D. the morning of surgery?

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• Patients with diabetes mellitus • Serum or capillary glucose tests morning of surgery (baseline)

• Clarify with physician or ACP regarding insulin dose

• Patients with thyroid dysfunction• Hyper-/hypothyroidism poses surgical risks because of altered metabolic rate

• Verify with ACP about giving thyroid medications

• Patients with Addison’s disease• Abruptly stopping replacement corticosteroids could cause Addisonian crisis

• Stress of surgery may require increased dose of IV corticosteroids

Nursing Assessment• Immune system

• Patients with history of compromised immune system or use of immunosuppressive drugs can have• Delayed wound healing• Increased risk for infection

Nursing Assessment• Fluid and electrolyte status• Vomiting, diarrhea, or difficulty swallowing can cause imbalances

• Identify drugs that alter F and E status• Diuretics

• Evaluate serum electrolyte levels

Nursing Assessment• Fluid and electrolyte status • NPO status

• May require additional fluids and electrolytes before surgery if dehydration occurs

Nursing Assessment• Nutritional status

• Deficits include over- and under- nutrition

• Obesity• Stresses cardiac and pulmonary systems

• Increased risk of wound dehiscence, infection, and incisional hernia

• Slower recovery from anesthesia

• Slower wound healing

Nursing Assessment• Nutritional status

• Provide extra padding to underweight patients to prevent pressure ulcers

• May be protein and vitamin deficient

• Identify dietary habits that may affect recovery (e.g., caffeine)

Nursing Assessment: Exam• The Joint Commission (TJC) requires an H&P

• Findings enable ACP to rate patient for anesthesia administration• Indicator of perioperative risk and overall outcome

Nursing Assessment: Exam• Document relevant findings, and report to perioperative team

• Obtain and evaluate results of laboratory tests

• Monitor blood glucose for patients with diabetes

Nursing Management• Preoperative teaching

• Patient right to know what to expect and how to participate• Increases patient satisfaction• Reduces fear, anxiety, stress, pain, and vomiting

• Limited time available• Address needs of highest priority

• Include information focused on safety

• Provide written material

• Several days before surgery• Observe and listen to determine amount of teaching for each session

• Anxiety and fear can hinder learning

• Give priority to patient’s concerns

Case StudyNursing Management• What teaching should be given to J.D. before the day of surgery?

• What does she need to know on the day of surgery?

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• Three types• Sensory• Process• Procedural

• Must be documented and reported to postoperative nurses• Avoid duplication of information

• Assess learning

Nursing Management

• Preoperative teaching • Teach deep breathing, coughing, and early ambulation as appropriate

• Inform if tubes, drains, monitoring devices, or special equipment will be used postoperatively

• Provide surgery-specific information

• Basic information before arrival• Time and place• Fluid and food restrictions• Need for enema• Need for shower

Nursing Management• Legal preparation

• All required forms are signed and in chart• Informed consent• Blood transfusions• Advance directives• Power of attorney

Nursing Management• Consent for surgery

• Informed consent must include• Adequate disclosure• Understanding and comprehension

• Voluntarily given consent

Nursing Management• Surgeon responsible for obtaining consent• Nurse may obtain and witness signature

• Verify patient has understanding

• Permission may be withdrawn at any time

Nursing Management• Consent for surgery

• Medical emergency may override need for consent

Nursing Management• Legally appointed representative of family may consent if patient is• Minor• Unconscious• Mentally incompetent

Case StudyNursing Management• J.D. signs her consent in the presence of the surgeon in his office before the day of surgery.

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Nursing Management• Day-of-surgery preparation• Final preoperative teaching • Assessment and report of pertinent findings

• Verification of signed consent

Nursing Management• Day-of-surgery preparation• Labs • History and physical examination

• Baseline vitals• Consultation records• Nurse’s notes

Case StudyNursing Management• J.D. reports to the outpatient ambulatory surgical center on the day of her surgery.

• How will you help to get her ready for the OR?

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Nursing Management• Day-of-surgery preparation • Hospital gown• Patient should not wear any cosmetics• Observation of skin color is important

• Remove nail polish for pulse oximeter

Nursing Management• Day-of-surgery preparation• Valuables are returned to family member or locked up

• Dentures, contacts, prostheses are removed

• Identification and allergy bands on wrist

Nursing Management• Void before surgery

• Prevents involuntary elimination under anesthesia or during early postoperative recovery

• Before medication administration

Nursing Management• Preoperative medication

• Benzodiazepines• Anticholinergics• Opioids• Antiemetics• Antibiotics

Nursing Management• Transportation to the OR

• Via stretcher or wheelchair• Communication “handoff”

• Situation• Background• Assessment• Recommendation

Case StudyNursing Management• You administer IV medazolam (Versed), as ordered, to J.D. and prepare to hand her off to the OR nurse.

• Formulate SBAR report.

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Nursing Management• Special concerns

• Culturally competent care• Geriatric considerations

Audience Response Question A 68-year-old male scheduled for a herniorrhaphy at an ambulatory surgical center expresses concern that he will not have enough care at home and asks if he can stay in the hospital after the surgery. The best response by the nurse isa.“Who is available to help you at home after the

surgery?”b.“I’m sure you will be able to manage at home after

surgery. It is a simple procedure.” c.“We will teach you everything you need to know to

be able to care for yourself after surgery.”d.“Your health insurance will pay for inpatient care

only if complications develop during surgery.”

Audience Response Question Preoperative instruction that is appropriate for all patients includesa. Techniques of deep breathing and

coughingb. Descriptions of the planned surgical

procedurec. Physical procedures or preparation

required before surgeryd. Withholding of all oral fluids or food

after midnight on the day of surgery

med surg chapter 018

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