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Types of Surgical Procedures

• Emergency surgery is done immediately to save a patient’s life, limb, or ability to function.
• Urgent surgery must be done within 24 to 48 hours to prevent permanent injury or death.
• Elective surgery is necessary, but can be planned around the patient’s and surgeon’s schedule.
• Ambulatory (outpatient) surgery is usually performed in one day, with admission to an ambulatory surgical center (ASC) in the morning and discharge after meeting recovery criteria.
• Exploratory (diagnostic) surgery is performed to obtain a diagnosis and possible resolution.
• Ablative surgery is the removal of tissue from an organ or area of the body.
• Palliative surgery decreases pain or symptoms in patients suffering from incurable illnesses.
• Reconstructive surgery restores function or corrects a defect in an area of the body.
• Cosmetic surgery changes or revises an area or structure of the body.
• Minimally invasive surgery is performed through very small openings using instruments for visualization, such as a laparoscope.
• Telesurgery or robotic surgery occurs from a location other than the surgical suite, using robotic equipment.

Preoperative Phase

• The preoperative phase is a patient's first impression of the surgical setting.
• The preoperative phase begins when the decision for surgery is made and concludes when the patient is transferred to the surgical suite.
• Preoperative nurses take on multiple roles, including educator, advocate, and admittance nurse
• A main priority for nurses is to complete a preoperative checklist to ensure necessary documentation, admission assessment, physical preparation, and educational needs are met before the patient enters the surgical suite.
• This includes but is not limited to:
  • Collection of information and paperwork necessary for intraoperative and postoperative care
  • A full medical history including prescription, over-the-counter, herbal, and alternative therapies
  • Assessments of health status
  • Completion of preoperative orders with IV antibiotics and thromboembolic-deterrent [TED] hose
  • Patient education regarding the surgical process
  • Verification that the patient and a witness signed the informed consent
  • Verification of information on the identification band, the surgeon's name, the procedure to be completed, and the correct side of the body for unilateral procedures during the initial time-out or "pause for cause."

Informed Consent

• Informed consent occurs when a patient autonomously and cognitively grants permission to a provider to perform a surgical procedure after considering all alternatives, benefits, and risks.
• Nurses ensure the patient has all necessary information to make an informed decision.
• Nurses identify and correct educational deficits to ensure patient comfort and a safe surgical experience for better preparation and recovery.
• Every patient has the right to refuse surgical intervention, even if refusal could result in death; treatment without consent is illegal.
• Components include:
  • Consent for the procedure which lists name of surgery, type of surgery, reason for the surgery, name of surgeon performing surgery, the intervention's benefits, alternative options, and potential outcomes if surgery is not performed
  • Consent for anesthesia
  • Consent to administer blood products.

Blood Products

• Consent to administer blood products may be part of the general surgical consent or a separate form.
• The surgeon must describe the need for blood products and obtain consent.
• Nurses must understand cultural and religious obligations that may prevent patients from consenting to blood products.
• The preoperative nurse is responsible for identifying the patient as “no blood products” with a bracelet and sign on the chart.
• Facilities offer blood refusal forms to sign.
• Providers can give blood without consent in emergencies when the patient lacks capacity to consent.

Inability to Consent

• Special considerations occur when the patient cannot consent for care.
• These situations include patients who are cognitively impaired or who are cognitively aware but unable to physically sign
• These situations also include a patient who is deaf or speaks another language, minors, or emergency situations
• A medical power of attorney may be established when a patient is impaired
• Patients unable to physically sign can sign with an "x," witnessed by two people.
• For patients who speak another language or are deaf, a hospital interpreter is preferred to avoid bias.
• A legal guardian signs the surgical consent for minors.
• Verbal consent is acceptable in emergencies, with written consent to follow, or two providers can document the need for surgery if the patient is incapable and without support.

Advance Directives

• The Patient Self-Determination Act of 1991 grants all patients the right to determine and direct their care in times of medical emergency via an advance directive.
• An advance directive defines a patient's wishes if the patient cannot express them in a medical emergency.
• Facilities are required to provide the means and guidance to complete an advance directive.
• Within the advance directive, a patient may name a durable medical power of attorney to make medical decisions if the patient becomes incompetent.
• Advance directives allow expression of desires for organ donation and end-of-life issues.
• A living will defines care in cases of cardiac or respiratory failure or when recovery to a functional level is unlikely.
• Patients may elect to take measures or stop life-sustaining procedures in cardiac arrest.
• DNR ("do not resuscitate") or DNI ("do not intubate,") are recorded in the chart.
• Patients can express wishes for feeding tubes or long-term ventilator-assisted breathing.
• If a patient has advance directives or a living will at the time of surgery, the nurse should note it on the chart and place a copy of the documents there, if they brought them to the hospital.

Obtaining Informed Consent

• Surgeons are responsible for obtaining consent in the presence of the patient and one witness.
• Consent for a scheduled procedure must be obtained before premedication or anesthesia administration to ensure an informed decision can be made.
• Surgeons use this time to answer all patient and family questions.
• Preoperative nurse's clarify information and ensures patient understanding, addressing concerns.
• Nurses often serve as witnesses to the consent, witnessing the signature, not the information, and documenting the signed consent.

Time-Outs

• Time-outs, or "pause for cause", are a formal identification process to prevent surgical errors and wrong-site procedures.
• Time-outs are performed by the patient and healthcare team to identify the correct patient, procedure, and surgical site; the preoperative nurse participates in the time-out process.
• The time-out starts upon entry to the surgical facility when the patient receives a wristband with identifying information.
• Nurses review information and ensure the patient confirms accuracy before moving to the surgical suite.
• A time-out is performed again by the circulating nurse on transfer to the surgical suite and once more immediately before incision by the entire team.
• The surgeon marks the surgical site with their signature using a permanent marker and the patient may mark it themselves, if possible.
• The patient states their full name and at least one other identifier, and the correct site and procedure.

Patient History

• A patient history is key to a successful surgical outcome.
• The nurse prepares the patient for surgery by asking detailed questions and assuring that the information is used to provide a safe outcome for medical puropses only.
• The history includes:
  • Medical history notes any conditions that may increase risk during surgery, such as DVT or cardiac conditions and consideration of cardiac monitoring.
  • Chronic pulmonary conditions require close monitoring.
  • Chronic illnesses like diabetes or immune deficiencies impact wound healing.
  • Implants may interfere with positioning or intubation.
  • For pacemakers, a representative of the pacemaker company may need to be present before and after surgery
  • Surgical and anesthesia history assesses previous surgeries, scars, adhesions, implants, types of surgery, year, indications, incision healing, and anesthesia types, considering negative responses.
  • All allergies must be documented to ensure patient safety, which includes allergies to medications, food, dyes, latex, adhesive, and environmental conditions.
  • Latex allergies are a serious concern and requires latex-free equipment.
  • Medications including antihypertensives, anticoagulants, and antiarrhythmics.
  • Oral intake must be documented, with patients typically NPO for at least 8 hours before. Exceptions can be made that allows diabetic patient's to take meds with water before surgery. Recent guidelines say patients may be NPO 6-8 hours for solid foods and 2 hours for clear fluids.
  • Consumption of alcohol, tobacco, and drug use, as smoking can increase risk for DVT during postoperative care.
• Some questions require privacy, particularly psychosocial questions about home abuse, gynecological issues, and mental health.

Physical Examination

• The physical assessment of the surgical patient includes height, weight, vital signs, and systems assessment.
• This assessment includes:
  • Height and weight help determine fluid/medication dosages and appropriate equipment.
  • Vital signs: blood pressure, respirations, pulse, temperature, and pulse oximetry. If initial signs vary significantly from the patient's norm, a second set may be taken 10-15 minutes later.
  • Pain assessment with scaled examples of 0-10, and face charts.
  • Cardiovascular, skin integrity (turgor, capillary refill, edema), pulse, blood pressure, rhythm.
  • Respiratory; Rate, depth, rhytm, breath sounds to assess breathing
  • Neurological assessments baseline. Assessment of general cognition and the ability to understand commands to assess before general anesthesia.
  • Liver/renal assessment to identify signs of dysfunction.
  • Integumentary assessment with consideration to skin integrity.
  • Gastrointestinal assessment of typical bowl movements
  • Genitourinary assessment assessing urinary elimination and any abnormalities.

Lab Tests

• Preoperative laboratory work can be done at an appointment before surgery or the morning of surgery
• Type and screen determine blood type and the presence of antibodies to crossmatch blood.
• A complete metabolic panel assesses renal and liver function, including liver enzymes, electrolytes, BUN, and creatinine.
• Coagulation studies assesses how quickly blood clots
• A CBC measures hemoglobin/hematocrit and white blood cell count.
• Urine tests for glucose, blood, protein, specific gravity, and ketones.
• Pregnancy tests may performed.
• Radiological assessment to identify common preoperative images like MRI, CAT scans, ultrasonography, or x-ray imaging may be needed before surgery.
• An electrocardiogram (ECG) may also be performed before or on admission

Patient Teaching

• Patient teaching decreases anxiety improving outcomes
• Include the patient's family.
• Nurses should discuss the surgical and postoperative experience, PACU stay, and when to expect family updates.

Physical Preparation

• An IV line using an 18-gauge catheter for anesthesia and fluids to administer blood products.
• Patients receiving abdominal, intestinal, gynecological, or rectal surgery may need bowel preparation with laxatives or enemas.
• Skin preparation can prevent infection; patients may shower with Betadine or hexachlorophene soap. A surgical shave, if appropriate, should be made with a sterile electric clipper.
• Shaving may be done in the OR after induction of anesthesia.
• A review should be done to remove body piercings and nail polish.
• Medications should be listed and considered, such as medications for anxiety using benzodiazepines or metoclopramide HCL for nausea.

Transfer

• The final responsibility of the preoperative nurse is preparing the patient for transfer to the OR suite.
• The nurse should ensure that all consents have been signed; the history and assessment have been completed and documented, including vital signs; learning needs have been met; skin and bowel preparation are complete; and preoperative medication has been administered.
• Once transferred, the patient is now considered to be receiving intraoperative care.