Surgical Procedures and Preoperative Nursing

• Surgical procedures serve many purposes and come in various types.

Common Surgical Terms

• Emergency surgery is performed immediately to save a patient's life, limb, or a critical function.
• Urgent surgery must be done within 24 to 48 hours to prevent permanent injury or death.
• Elective surgery is necessary but can be scheduled based on the patient's and surgeon's availability.
• Ambulatory surgery, also known as outpatient surgery, typically occurs in one day at an ambulatory surgical center (ASC).
• Patients are admitted in the morning and discharged after meeting recovery criteria.
• Exploratory surgery, also known as diagnostic surgery, helps in obtaining a diagnosis and potential solutions.
• Ablative surgery involves removing tissue from an organ or body area.
• Palliative surgery alleviates pain or symptoms for patients with incurable diseases.
• Reconstructive surgery restores function or corrects a defect in a body area.
• Cosmetic surgery alters or revises an area or structure of the body.
• Minimally invasive surgery is performed through small skin openings using instruments like a laparoscope for visualization.
• Telesurgery, also known as robotic surgery, takes place remotely using robotic equipment.
• The surgical experience consists of preoperative, intraoperative, and postoperative phases.
• Each phase requires specific nursing care.
• The preoperative phase is the patient's initial exposure to the surgical setting.
• It starts when surgery is decided and ends upon transfer to the surgical suite.
• The preoperative nurse acts as an educator, advocate, and admittance personnel.
• A key responsibility for nurses is completing a preoperative checklist to ensure all patient needs are met.
• Each facility's checklist includes necessary documentation, assessment, physical preparation, and education before surgery.
• A full medical history, including all therapies, is necessary.
• The patient's health status must be assessed.
• Information and paperwork required for intraoperative and postoperative care must be gathered.
• Preoperative orders like IV antibiotics and thromboembolic-deterrent (TED) hose must be completed.
• Patients must receive education about the surgical process.
• Verification that the patient and a witness signed informed consent is required.
• An initial time-out or pause for cause is needed for patient verification of information.
• The patient confirms the information on their identification band.
• Verification of the name of the surgeon is needed.
• The procedure to be performed must be confirmed.
• The correct body side for unilateral procedures must be verified.
• These interventions aim to identify potential issues and ensure procedures are safe and timely.

Informed Consent

• Informed consent is when a patient grants permission for a surgical procedure autonomously after considering alternatives, benefits, and risks.
• While obtaining consent is the provider's responsibility, nurses ensure patients have enough information for an informed decision.
• Addressing educational deficits makes patients comfortable and ensures a better outcome.
• Informed patients are more likely to follow preoperative and postoperative instructions.
• Preoperative nurses must recognize a patient's right to refuse surgery, even if refusal could lead to death.
• Treatment without consent is legally prohibited, even if it risks death.

Components of Informed Consent

• Surgical consent forms are similar across institutions.
• Universal components of consent include:
  • Consent for the procedure, including:
  • Name, type, and reason for surgery.
  • Surgeon's name.
  • Reason for the intervention.
  • Alternative options.
  • Potential outcomes if surgery is not performed.
  • Consent for anesthesia.
  • Consent to administer blood products.
• Anesthesia consent requires a patient's signature.
• The anesthesiologist informs the patient about anesthesia type, medications, and associated risks.
• They also explain the administration method, such as epidural or regional anesthesia.
• The preoperative nurse's role is to advocate for the patient and ensure their understanding.

Blood Products and Consent

• Consent for blood product administration may be part of the general surgical consent or a separate form.
• The surgeon specifies situations requiring blood products and seeks patient consent.
• Nurses must acknowledge cultural and religious beliefs that may prevent patients from consenting to blood products.
• If a patient refuses blood products, the surgeon documents it in the patient's chart.
• The preoperative nurse identifies patients who refuse blood products with a bracelet and chart sign.
• Facilities have blood refusal forms for patients to sign.
• Providers can administer blood without consent only in emergency situations when the patient cannot consent.

Inability to Consent

• Special considerations apply when patients cannot consent.
• This includes patients who are cognitively impaired, unable to physically sign, deaf, speak another language, are minors, or in emergency situations.
• For impaired patients, a medical power of attorney can be established.
• Patients unable to sign may use an "x," requiring two witnesses instead of one.
• Hospital interpreters are preferred over family for translating to avoid bias.
• Surgical consent for minors is signed by a legal guardian, explaining the procedure if the child is old enough.
• In emergencies, verbal consent is acceptable, with written consent obtained later.
• Two providers must document the need for surgery if the patient cannot consent and their medical power of attorney or next of kin is unreachable.
• Special permits are required for other situations.

Advance Directives

• The Patient Self-Determination Act of 1991 grants patients the right to control their medical care during emergencies and create advance directives.
• An advance directive outlines a patient's wishes if they become unable to express them.
• Facilities must provide the means to complete an advance directive if desired.
• The patient can name a durable medical power of attorney to make medical decisions if they become incompetent.
• Advance directives also allow patients to express desires about organ donation and end-of-life issues.
• A living will defines care preferences in cases of cardiac or respiratory failure or when recovery is unlikely.
• Patients can choose to have all measures taken or stop life-sustaining procedures.
• "Do not intubate" (DNI) or "do not resuscitate" (DNR) orders are recorded in the patient's chart.
• Patients can express wishes regarding feeding tubes or long-term ventilator-assisted breathing.
• Nurses must document advance directives and living wills in the chart, including copies brought by the patient.

Obtaining Informed Consent

• The surgeon is responsible for obtaining consent with the patient and a witness.
• Family members can be present.
• Informed consent for scheduled procedures should occur before administering pain medications, sedatives, or anesthesia.
• These medications may impair the patient's ability to make informed decisions.
• The surgeon uses this time to address the patient's and family's questions.
• Preoperative nurses clarify information and ensure patient understanding, correcting misconceptions and easing concerns.
• Nurses often witness the consent, confirming the signature, not the information provided.
• Witnesses should only sign if they saw the patient sign the form.
• Nurses document that a signed consent is in the patient's chart as part of preoperative procedures.

Time-Outs/Pause for Cause

• Surgical errors and wrong-site procedures are documented occurrences identified by accreditation organizations.
• A time-out is a formal identification process involving the patient and healthcare team to verify the correct patient, procedure, and surgical site.
• The preoperative nurse is part of this time-out process.
• The time-out starts upon entering the surgical facility.
• Patients receive a wristband with identifying information.
• After reviewing the wristband, the patient confirms the accuracy of the information.
• The preoperative nurse reviews wristband information with the patient and verifies the procedure and site.
• The circulating nurse repeats this time-out upon transfer to the surgical suite. The entire team repeats it just before incision.
• The surgeon marks the surgical site with their signature using a permanent marker, or the patient marks the site if the surgeon prefers and if possible.
• The process may vary among facilities, the components of a time-out are consistent.
• The patient states their full name as written on the identification bracelet and another identifier (typically date of birth).
• Verifies the correct site and procedure.
• The surgeon then marks the correct site.
• The team repeats this process before the incision.
• Performing a time-out immediately before incision minimizes irreversible mistakes.

Patient Assessment

• Surgical patients need a detailed medical history and assessment for safe surgery.
• Preoperative nurses document the patient's history upon admission.
• Review and document existing patient histories from inpatient units.
• Complete patient medical, social, and surgical histories ensure a successful surgical experience.
• Nurses ask detailed questions during preoperative workup or admission, some of which may be personal or uncomfortable.
• The nurse should explain that the information is important for a safe outcome and will only be used for medical purposes.

Medical History

• Nurses note conditions posing risks during surgery.
• For example, patients with a history of DVT should receive coagulation studies before surgery.
• Cardiac patients may have untoward responses to anesthesia or hemodynamic changes, needing enhanced cardiac monitoring.
• Chronic pulmonary conditions like asthma and bronchitis may complicate ventilator removal postoperatively, requiring monitoring with pulse oximetry and ABG testing.
• These patients may need extended intubation and ICU admission.
• Chronic illnesses like diabetes or immune deficiencies increase the risk of poor wound healing, mandating increased blood glucose monitoring.
• Implants, such as replacement joints and dental work, may interfere with positioning or intubation.
• Patients with pacemakers may need it disabled during surgery due to electromagnetic interference from electrocautery.
• A pacemaker company representative may need to be present.

Surgical and Anesthesia History

• A patient's surgical and anesthesia history provides important information.
• Previous surgeries may have left scar tissue, internal adhesions, or medical implants.
• Nurses inquire about the types of surgery, year performed, indication, incision healing, and anesthesia used.
• Negative responses to anesthesia or wound healing must be considered in patient care planning.

Allergies

• Document all patient allergies to ensure safety.
• Document allergies to medications, food, medical dyes, latex, medical adhesive, and environmental conditions, along with the patient's reaction.
• Place an alert bracelet on the patient and inform the surgical team.
• Antibiotic allergies determine preoperative and postoperative prophylaxis medications.
• Alternative skin preparations must be used if patients are allergic to antiseptic solutions like Betadine or chlorhexidine.
• Latex allergies are a serious concern.
• Facilities must have latex-free equipment.
• Patients with latex allergies are scheduled as first cases in outpatient settings to ensure a latex-free suite.
• Many hospitals are creating latex-free surgical suites.

Medications

• Current medications are important in the preoperative history.
• The use of antihypertensives, anticoagulants, and antiarrhythmics can impact care in the OR.
• Herbal remedies and OTC medications may interact with medications or increase bleeding risk.

Last Oral Intake

• Last oral intake is a essential assessment parameter before anesthesia.
• Patients needing surgery should have nothing to eat or drink (NPO) for at least 8 hours before the procedure to avoid aspiration risk
• Preoperative nurses document the last oral intake.
• Exceptions are sometimes made that allow patients to take essential medications with sips of water before the procedure. A patient may be advised to be NPO 6 to 8 hours for solid foods and 2 hours for clear fluids.
• Preoperative NPO parameters for children and infants:
• No solid food for 8 hours before surgery.
• Infant formula up to 6 hours before surgery.
• Breast milk up to 4 hours before surgery.
• Clear liquids up to 2 hours before surgery.

Alcohol, Smoking, and Drug Use

• The medical team needs to ask uncomfortable but important questions about alcohol, smoking, and drug use.
• Smoking raises the risk of a patient having respiratory depression and DVT.
• Pulmonary changes may complicate intubation and ventilation.
• Smoking can slow wound healing
• Alcohol and drug use may affect a response to anesthesia.
• Postoperative pain management is complicated with recreational drug use.

Special Considerations

• Some questions require patient questions, such as abuse and gynecological or mental illness ones.
• Avoid family or support people when asking these questions.
• Address conflicting medical information from the chart and the patient's responses at this time.

Height and Weight

• Height and weight help determine fluid and medication dosages for anesthesia or antibiotics.
• Patients with a high BMI may need a larger operating table and recovery bed.
• Operating tables include extension, and equipment might need to be adjusted to transfer patients.

Vital Signs

• Nurses obtain vital signs during the initial assessment, including blood pressure, respirations, pulse, temperature, and pulse oximetry.
• Compare admission vital signs include with previous records to identify trends or changes.
• A second set of vital signs should be taken 10 to 15 minutes later if the initial set varies significantly due to patient nervousness.
• The presence of fever may cause the postponement of surgery.
• A second set of vital signs may be needed before transfer if the patient is held in the preoperative room for over 2 hours.
• Vital sign assessment includes pain, the fifth vital sign.
• Rating pain can be done with a scale of 0 to 10 or a series of faces.
• The patient's acceptable pain score needs documenting.
• The postanesthesia nurse and surgeon use this score as a guide for pain management.

Systems Assessment

• During the initial assessment, the nurse does a head-to-toe physical assessment.
• The nurse assesses cardiovascular health, including peripheral pulses, color, skin turgor, capillary refill, temperature, and edema, in addition to pulse and blood pressure.
• Auscultate the heart for rhythm, rate, and murmurs.
• Assess the patient's breathing for rate, depth, rhythm, and sounds like crackles or wheezing.
• Use pulse oximetry to check oxygen saturation on room air.
• Report any finger clubbing.
• Ensure the patient has a clear airway.
• Check their tongue, breathing with the head tilted up and chin down, and swallowing.
• Anesthesiologists also assess the patient during their consultation.
• Nurses need to check the baseline neurological function before anesthesia.
• Assess cognition and ability to understand commands.
• Evaluate movement, strength, and sensation in the extremities, an assessment particularly important for regional blocks.
• Preoperative delirium or confusion may necessitate admission postoperatively.
• It is essential to note potential renal or liver disease.
• Anesthesia effects may be altered.
• A complete metabolic panel can help the team identify any signs of dysfunction.
• A general assessment includes appearance, skin integrity, and hygiene.
• Healing may be slower for patients with poor skin turgor or fragile skin.
• Careful choice of dressings is needed, as well as giving extra wound care instructions.

Gastrointestinal and Genitourinary Assessments

• Nurses should note typical bowel habits and sounds.
• Nurses must document any urinary devices and make the patient void just before entering the operating suite, noting any unusual urine color.
• Addressing any patient concerns is also important.

Laboratory Assessment

• Preoperative laboratory work is essential in determining the patient's readiness for surgery.
• Labs may be done before surgery or the morning of.
• Type and screen determines blood type and antibodies to crossmatch blood.
• Blood identification bracelets with unique numbers are used.
• A complete metabolic panel provides baseline information on renal and liver function.
• Coagulation studies show how quickly blood clots.
• Complete blood count (CBC) tests blood volume, oxygen-carrying capacity, and white blood cell count.
• Any deviation should be reported to avoid complications.
• Urine is measured for glucose, blood, protein, specific gravity, and ketones to check for infection or hydration.
• Pregnancy tests may be done.

Radiological Assessment

• Common preoperative images are MRI, CT, ultrasonography, or x-ray imaging.
• Imaging may monitor progress before and during surgery.
• An ECG may be performed before or during admission, and cardiac monitoring may be ongoing.

Patient Teaching

• Patient teaching helps decrease anxiety and improve outcomes.
• Anxiety increase pain medication requirements and affect postoperative recovery.
• It also increase risk of infection.
• Teaching is documented.
• Include the patient's family in teaching, explaining the surgical and postoperative experience.
• Describe the procedure length, PACU stay, and how soon the family will receive updates.
• Ensure the family knows where to wait and if the nurse can address any family concerns, as well as guiding the family to the waiting area.

Physical Preparations

• An IV line is inserted for anesthesia and fluids, with an 18-gauge catheter preferred for blood product administration.
• Label the IV with gauge, time, date, and nurse's initials.
• Administer preoperative antibiotics.
• Patients needing abdominal, intestinal, or rectal surgery may self-administer bowel preparation at home.
• The nurse should confirm preparation is complete.
• Skin preparation prevents infection at the surgical site.
• Patients may shower with Betadine or hexachlorophene soap.
• A surgical shave may be necessary, using a sterile electric clipper.
• Remove piercings, and ensure nails are clear of polish.
• Preoperative medications may be given for anxiety or antiemetics.
• Preoperative medications may be prescribed like benzodiazepine such as midazolam HCI, diazepam, or lorazepam.
• Antiemetics may be prescribed such as metoclopramide HCI or ondansetron HCI.

Transfer

• Preparing the patient for transfer is the preoperative nurse's final responsibility before transport, including confirming signed consents, completed assessments, learning needs, skin and bowel preparation, and preoperative medication administration.
• The intraoperative nurse or anesthesia team may accompany the patient.
• After transfer, the patient now under intraoperative care.