Preoperative Nursing Care: Informed Consent and Patient Assessment - PDF

INTRODUCTION There are many different purposes and types of surgical procedures. Common terms associated with the surgical process include the following: Emergency surgery---surgery that must be done immediately to save a patient's life, limb, or ability to function Urgent surgery---surgery tha...

INTRODUCTION There are many different purposes and types of surgical procedures. Common terms associated with the surgical process include the following: Emergency surgery---surgery that must be done immediately to save a patient's life, limb, or ability to function Urgent surgery---surgery that must be done within 24 to 48 hours to prevent permanent injury to the patient or death Elective surgery---surgery that may be necessary but can be planned around the patient's and surgeon's schedule Ambulatory (outpatient) surgery---surgery usually performed in 1 day, with the patient being admitted to the ambulatory surgical center (ASC) in the morning and discharged after acceptable recovery criteria have been met Exploratory (diagnostic) surgery---surgery performed to obtain a diagnosis and possible resolution Ablative surgery---surgery to remove tissue from an organ or area of the body Palliative surgery---surgery performed to decrease pain or symptoms in patients suffering from incurable illnesses Reconstructive surgery---surgery to restore function or a defect in an area of the body Cosmetic surgery---surgery to change or revise an area or structure of the body Minimally invasive surgery---surgery performed through very small openings in the skin, using instruments through which the surgeon can visualize the area such as a laparoscope Telesurgery or robotic surgery---surgery performed from a location other than the surgical suite, by use of robotic equipment The operative experience is broken up into three phases: preoperative, intraoperative, and postoperative. Although each of these phases possesses unique nursing needs, the preoperative phase is a patient's first impression of the surgical setting. The preoperative phase commences when the decision for surgery is made and ends when the patient is transferred to the surgical suite. During this time, the preoperative nurse takes on a multitude of roles, including educator, advocator, and admittance nurse. It is crucial for the nurse to identify any potential needs the patient may have while in their care. The nurse's main priority is to complete a preoperative checklist (Fig. 15.1). Each facility's unique checklist ensures that the necessary documentation, admission assessment, physical preparation, and educational needs have been completed before the patient enters the surgical suite. This includes but is not limited to the following: A full medical history (including prescription, over-the-counter, herbal, and other alternative therapies) Assessment of the patient's health status Collection of information and paperwork necessary for intraoperative and postoperative care Completion of preoperative orders (IV antibiotics, thromboembolic-deterrent \[TED\] hose, etc.) Patient education regarding the entire surgical process Verifying that the patient and a witness signed the informed consent The initial time-out---"pause for cause"---when the patient verifies the following: All information on the identification band as correct The name of the surgeon The procedure that will be completed by the surgeon The correct side of the body on which the surgery will occur if this is a unilateral procedure These interventions not only identify potential issues before surgery but also ensure that all procedures are performed in a timely and safe manner. INFORMED CONSENT Informed consent is when a patient autonomously and cognitively grants permission to a provider to perform a surgical procedure after considering all alternatives, benefits, and risks of the procedure. Although obtaining consent is not the role of the nurse but that of the provider, it is the nurse's responsibility to ensure that the patient has all the information needed to make an informed decision about the procedure being offered. Working with the patient to identify and correct educational deficits not only makes the patient more comfortable about consenting to the surgical experience but also ensures the safest and most successful outcome. An informed patient is more likely to follow instructions preoperatively for preparation and postoperatively for recovery. It is important for the preoperative nurse to understand that every patient has the right to refuse a surgical intervention even when death is a risk of refusal of treatment. In the eyes of the law, treatment without consent is not allowed even at the risk of death. Components of an Informed Consent Surgical consent forms are similar in most institutions. Some may be preprinted; others must be completed to describe each procedure. Whichever form or forms are used, the required components are universal (Fig. 15.2). Components of consents include the following: Consent for the procedure itself, which should include the following information: Name of surgery, type of surgery, and reason for the surgery Name of the surgeon to perform the surgery Reason that intervention will benefit the patient All alternative options to surgery Potential outcomes if surgery is not performed Consent for anesthesia Consent to administer blood products FIGURE 15.1 Preoperative checklist. Anesthesia Anesthesia consent is an additional consent the patient must sign. At this time, the anesthesiologist informs the patient of the type of anesthesia, the medications to be used, and the risks associated with the type of anesthesia planned. The anesthesiologist or nurse anesthetist may also describe how the medication is administered, such as epidural anesthesia or regional block. The role of the preoperative nurse remains the same, one of patient advocate, ensuring that the patient understands the information being presented. Blood Products Consent to administer blood products may be a component of the general surgical consent or a separate form. The surgeon describes what situations will warrant the need for blood products and requests consent from the patient for their use. The nurse must be aware of cultural and religious obligations that prevent the patient from consenting to receive blood products. For example, because of religious beliefs, some patients will not consent to the use of blood products. In that case, the surgeon documents that the patient has refused blood products in the patient's chart. The preoperative nurse is responsible for identifying the patient as "no blood products" with a bracelet and sign on the patient's chart. Facilities have blood refusal forms that a patient is asked to sign if this situation presents. Providers can give blood without consent only in an emergency situation where the patient lacks the capacity to consent. Inability to Consent Special considerations occur when the patient is not able to consent for care. These situations include patients who are cognitively impaired or who are cognitively aware but unable to physically sign, a patient who is deaf or speaks another language, minors, or emergency situations. In situations where the patient is impaired, a medical power of attorney may be established for consent purposes. Patients who cannot physically sign but are able to make their own care decisions may sign with an "x." This consent needs to be witnessed by two people instead of just one as normally required. If the patient speaks another language or is deaf, a hospital interpreter may be used. For purposes of consent, this is desirable over a family member. The hospital interpreter is familiar with the medical terms being used. Also, the use of an anonymous interpreter avoids any bias that may occur with a family member during translation. Surgical consent for minors may be signed by the legal guardian of the child. However, if the child is old enough to understand the care, the procedure should still be explained. FIGURE 15.2 Informed consent form. In emergency situations, a verbal consent is acceptable. Written consent should be obtained in a timely manner following the surgery. If the patient is incapable of giving consent, two providers document the need for surgery. This is acceptable only if the patient's medical power of attorney or next of kin is unreachable or the surgery is emergent and the patient has no support present. Other situations require special permits done well before the procedure. An example of this is sterilization procedures. The patient must sign a unique consent 6 weeks before the surgery. 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: the right to create an advance directive. An advance directive defines a patient's wishes should the patient be deemed incompetent to express their wishes in a medical emergency. Facilities are required by law to provide the means and guidance to complete an advance directive if desired before surgery. Within the advance directive, the patient may name a durable medical power of attorney, usually a spouse or adult child, who is designated to make all medical decisions should the patient become incompetent. The advance directive also allows the patient to express desires related to organ donation and end-of-life issues. As part of the advance directive, a living will defines care in the case of cardiac or respiratory failure or when the likelihood of recovery to a quality level of functioning is deemed unlikely. Patients may elect to have all necessary measures taken or may elect to stop life-sustaining procedures in the event of a cardiac arrest. The phrases "do not intubate," DNI, or "do not resuscitate," DNR, are recorded in the patient's chart. The patient also has the opportunity to express wishes in regard to feeding tubes or long-term ventilator-assisted breathing. The patient may select any combination of treatments they feel best matches their values and beliefs. It is imperative that if a patient has advance directives and/or a living will at the time of surgery, the nurse notes that on the chart and places a copy of these documents on the chart if the patient has brought them to the hospital. Obtaining Informed Consent Surgeon The surgeon is solely responsible for obtaining consent in the presence of the patient and one witness. Family members or support persons may be present at this time. Informed consent for a scheduled procedure must be obtained before the administration of pain medications and sedatives or the induction of anesthesia because these medications may alter the patient's ability to make an informed decision. In addition to obtaining informed consent, the surgeon uses this uninterrupted time to ensure that all of the patient's and family member's questions are answered. Preoperative Nurse Many patients admit to not reading the entire consent before signing (Box 15.1). The role of the preoperative nurse is to clarify information and ensure patient understanding. Nurses correct common misconceptions and ease concerns of the patient, family members, or support persons. In addition to reviewing the consent form and validating patient understanding, nurses often serve as the witness to the consent. The nurse is witnessing the physical signature, not the information provided. It is essential that the witness be with the patient as the consent is being signed. The nurse or other witness should never sign the consent form if they did not witness the patient signing the form. As part of preoperative procedures, the nurse is also responsible for documenting that a signed consent has been placed in the patient's chart. Box 15.1 Why Patients Do Not Read the Full Consent The most common reasons patients give for not reading the form: It is too long. There is too much information. It is too intimidating. It is typed in small print. The terms used are too medical or legal. TIME-OUTS/PAUSE FOR CAUSE Surgical errors and wrong-site procedures are a documented occurrence and have been identified by hospital accreditation organizations as an area for improvement. A time-out is a formal process of identification performed by the patient and the healthcare team to identify the correct patient, correct procedure, and correct surgical site. The preoperative nurse is a part of the time-out process. The time-out, or "pause for cause," starts when the patient enters the surgical facility. On admission, the patient receives a wristband containing their identifying information. After reviewing the wristband, the patient confirms that all the information is correct; it is essential that the wristband note accurate information before the patient is moved into the surgical suite. The first responsibility of the preoperative nurse is to review the information on the wristband with the patient and have the patient name the procedure and site. This time-out is performed again by the circulating nurse on transfer to the surgical suite and once more immediately preceding incision by the entire team (Fig. 15.3). The surgeon marks the surgical site with their signature using a permanent marker. Some surgeons may require that, if possible, the patient marks the site themselves. Components of a Time-Out Although the process may vary in different facilities, the components of a time-out are consistent. The patient is asked to state their full name as printed on the identification bracelet and at least one other identifier, which is typically the patient's date of birth, although there are other acceptable identifiers (see Safety Alert). The patient is next asked to state the correct site and the procedure they are receiving. The surgeon then marks the correct site. As stated earlier, the process of identifying the patient, procedure, and site is completed again by the team immediately before incision. Performing a time-out immediately before incision makes an irreversible mistake less likely. FIGURE 15.3 World Health Organization (WHO) surgical safety checklist. Acceptable Patient Identifiers Name Date of birth Social Security number Photo printed on band Address Telephone number Connection Check 15.1 You are preparing a patient for surgery and have asked them to verify their information on their patient identification band. They tell you that the birth date is incorrect on the identification band. The most appropriate action by the nurse at this time is which of the following? A.  Cross out the birth date and put the correct one in its place with the nurse's initials. B.  Ask the family members to validate the patient's birth date. C.  Call the surgeon's office to validate the birth date. D.  Ask the admissions office to please send a corrected identification band. PATIENT ASSESSMENT The surgical patient requires a detailed medical history and assessment to ensure a safe and successful surgery. The preoperative nurse is responsible for obtaining and documenting this history on admission. If a patient has already been admitted to an inpatient unit and has a history on record, the information should be reviewed and documented on the preoperative record. This allows the preoperative nurse and surgeon to identify any patient learning and medical needs that are unique to their surgical experience. Patient History Completed patient medical, social, and surgical histories are the key to a successful surgical experience. These questions may be asked during a preoperative workup or on admission to the surgical facility. As the nurse prepares the patient for surgery, they ask a series of detailed questions. Some of the questions may be very personal and, at times, uncomfortable for the patient to answer. The nurse should remind the patient that this information is important in providing a safe outcome. It is also important to assure the patient that no judgment will be made on their responses and that the information will be used only for medical purposes. Box 15.2 lists the components of a complete patient history. Box 15.2 Components of a Complete Preoperative History Age (see Geriatric/Gerontological Considerations) Allergies and sensitivities to latex Current medications, including over-the-counter medications, vitamins, and herbal supplements Medical history and treatment plans Surgical history Previous anesthesia and responses to anesthesia Last oral intake Any medical implants or devices Any piercings Dental implants Nutrition deficiencies Family history Social history, including smoking and drug and alcohol habits History of mental illness or abuse Support system and living conditions Advance directives Geriatric/Gerontological Considerations Age and Preoperative History The patient's age is important for a multitude of reasons; specifically, the older patient (65 or older) may have many issues that can interfere with a positive surgical outcome. This patient must be assessed carefully for the following issues: Polypharmacy---the use of multiple medications, from multiple providers, purchased at multiple pharmacies. This can lead to medication interactions, which can also affect medications given during the perioperative period. Cardiac status---verify the presence of a preoperative electrocardiogram (ECG); place on the cardiac monitor and establish a baseline cardiac rhythm. Respiratory status---determine whether the patient is having any breathing difficulties. Establish a baseline oxygen saturation on room air if the patient is not on oxygen at home or on the patient's normal administered oxygen level. Cognitive and sensory function---determine whether the patient is capable of giving consent for the procedure; does the patient understand the risks and outcomes of the surgery? Will the patient be able to follow postoperative teaching? Does the patient require postoperative hospitalization because they have no caregivers or is unable to care for themselves after surgery? Muscular function---determine whether the patient is at risk for falls, especially after anesthesia and pain medications. Skin assessment---older patients very often have decreased adipose tissue, which can lead to an increased risk of hypothermia during surgery. They very often also have a change in the epidermis, which can lead to a risk of shearing injury to the skin and delayed healing. Nutritional status---due to the NPO status, this patient must be assessed carefully for dehydration before surgery. Laboratory studies---determine whether decreased renal/hepatic function is noted in the preoperative laboratory studies. Are all laboratory studies within normal range? The elderly patient typically has a decreased number of kidney nephrons and a decrease in the size of the liver, both which can affect how medications are metabolized. Chronic conditions---document all chronic conditions for which the patient is being treated. Support---it is important to ensure that the elderly patient has a strong support system and identify who will be responsible for helping the patient with any care needs they have when returning home. Medical History As the nurse asks questions pertaining to the patient's medical history, they should be taking special note of any conditions that will pose a risk during the surgical experience. For example, a patient with a history of DVT should be receiving coagulation studies before surgery. A patient with a cardiac condition may have an untoward response to anesthesia or may experience harmful hemodynamic changes during the surgical procedure and may require enhanced cardiac monitoring with a cardiologist's input before surgery. Chronic pulmonary conditions such as asthma, emphysema, and chronic bronchitis may complicate the removal of ventilatory support postoperatively and should be monitored with pulse oximetry and arterial blood gas (ABG) testing. These patients may require extended intubation, and admission to the intensive care unit (ICU) postoperatively should be anticipated. The presence of chronic illness such as diabetes or immune deficiencies places the patient at risk for poor wound healing postoperatively and indicates the need for increased blood glucose monitoring. Last, any implants, such as replacement joints and dental work, may interfere with positioning during surgery or intubation. If a patient has a pacemaker, because of possible electromagnetic interference from the use of an electrocautery device to control bleeding during the surgery, it may be necessary for the patient's pacemaker to be disabled during surgery. A representative of the pacemaker company may need to be present before and after surgery to manage the pacemaker. Conditions That Increase Surgical Risks History of cerebral venous thrombosis (CVT) Cardiac disease Diabetes Asthma Emphysema COPD Immune deficiencies Implants Pacemakers Surgical and Anesthesia History A patient's surgical and anesthesia history is a very important part of the patient's history. Previous surgery may have left scar tissue, internal adhesions, or medical implants that need to be considered. The nurse should inquire about types of surgery, the year the surgery was performed, the indication for surgery, any poor incision healing, and what type of anesthesia was used for each procedure. Any negative responses to anesthesia or wound healing must be taken into consideration while planning the patient's care. Allergies All patient allergies must be documented to ensure patient safety. Allergies to medications, food, medical dyes, latex, medical adhesive, and environmental conditions must be documented along with the patient's physical response to exposure to these products. An alert bracelet is placed on the patient, and the surgical team is made aware. Allergies to antibiotics determine what preoperative and postoperative prophylaxis medications are used. If a patient is allergic to antiseptic solutions such as Betadine or chlorhexidine, an alternative skin preparation must be selected. Latex allergies are a serious concern. Each facility must have adequate latex-free equipment available for these cases. In some outpatient settings, patients with latex allergies are scheduled as first cases of the day to ensure that the surgical suite is free of latex contamination. Many hospitals are choosing to create latex-free environments for all surgical suites for this reason. Medications Current medications are an extremely important part of the preoperative history (Table 15.1). The use of antihypertensives, anticoagulants, and antiarrhythmics, to name a few, can have a tremendous impact on the care provided in the operating room (OR). Herbal remedies and over-the-counter medications also may have potential interactions with medications used during the procedure and postoperatively or may increase the risk of bleeding. Last Oral Intake Last oral intake is an essential assessment parameter before anesthesia. The guidelines may be modified for different populations, but typically, all patients requiring surgical intervention should have had nothing to eat or drink (NPO) for at least 8 hours before the procedure. A patient who has eaten within 8 hours is at risk of aspiration, the introduction of food particles into the lungs through emesis. The preoperative nurse is responsible for documenting the last oral intake. Patients who have special needs, such as those with diabetes mellitus, may have altered NPO orders before surgery. Exceptions are sometimes made that allow patients to take essential medications with sips of water before the procedure. According to recent guidelines for elective procedures, the patient may be advised to be NPO 6 to 8 hours for solid foods and 2 hours for clear fluids. There are different preoperative NPO parameters for children and infants: No solid food is allowed for 8 hours before surgery. Infant formula can be given up to 6 hours before surgery. Breast milk can be given up to 4 hours before surgery. Clear liquids can be given up to 2 hours before surgery. Alcohol, Smoking, and Drug Use Alcohol, smoking, and drug use are sometimes uncomfortable but important questions to ask of all patients. Smoking puts patients at risk for respiratory depression during the procedure and DVT during postoperative care. Because of changes in the pulmonary system, intubation and ventilation may also be compromised. Smoking may also increase the healing time for surgical wounds. Alcohol and drug use may compromise the patient's response to anesthesia. Additionally, postoperative pain management is complicated with recreational drug use, and such use must be taken into consideration when making discharge plans. Special Considerations When a patient history is obtained, some questions require privacy because of their sensitive nature. All psychosocial questions, such as questions about abuse at home and gynecological and mental illness, must be asked with no other family or support persons present. Any conflicting medical information from the patient's chart and the patient's responses should also be addressed at this time. Connection Check 15.2 The nurse should report which of the following findings from a patient's history as increasing the risk for DVTs postoperatively? (Select all that apply.) A.  History of smoking B.  Age C.  History of DVTs with previous pregnancy D.  Borderline hypertension E.  Allergies Table 15.1 Current Medications and Possible Implications Medication Classification Mechanism of Action Exemplars Nursing Implications Antiarrhythmics Affect tolerance of anesthesia and potentiate neuromuscular blockers; depress cardiac function, output, and pulse Amiodarone (Cordarone) Sotalol (Betapace) Ibutilide (Covert) Dofetilide (Tikosyn) Dronedarone (Multaq) Obtain baseline: Electrocardiogram Vital signs Monitor: Vital signs during the procedure Communicate: All medications to anesthesia team Antihypertensives Alter response to muscle relaxants and opioids May cause hypotensive crisis during and after the procedure Captopril (Capoten) Clonidine HCl (Catapres) Metoprolol (Lopressor, Toprol XL) Atenolol (Tenormin) Losartan (Cozaar) Olmesartan (Benicar) Telmisartan (Micardis) Valsartan (Diovan, Entresto) Monitor: Blood pressures Communicate: All medications to anesthesia team Corticosteroids Increase need for higher doses of steroids used for replacement therapy May increase healing time because of blockage of collagen formation Increase risk of hemorrhage and may mask signs of infection Dexamethasone (Decadron) Hydrocortisone (Cortef) Prednisone Assess for: Hyperglycemia Infection Bleeding Wound healing Splint incisions to promote healing Continue therapy during the procedure Anticoagulants Inhibit clot formation through interaction in different stages of the coagulation cascade Increase risk of hemorrhage Enoxaparin (Lovenox) Heparin Rivaroxaban (Xarelto) Warfarin (Coumadin) Obtain: Baseline coagulation studies Taper medication at least 48 hours before the procedure Have vitamin K (Coumadin) and protamine sulfate (heparin) available as antidotes if excessive bleeding occurs during the procedure Antiplatelet agents Inhibit platelet aggregation to prevent clot development Aspirin (Bayer aspirin, Ecotin) Clopidogrel (Plavix) Inform physicians if the medication has not been withheld before surgery Monitor for excessive bleeding Nonsteroidal anti-inflammatory drugs (NSAIDs) May prolong bleeding time and may cause intraoperative or postoperative bleeding Ibuprofen (Motrin, Advil) Naproxen (Aleve, Naprosyn, Anaprox) Inform physicians if the medication has not been withheld before surgery Anticonvulsants   May alter the metabolism of anesthesia Phenobarbital (Nembutal) Phenytoin (Dilantin) Be alert for the potential of seizures, which can cause injury during a procedure Maintain medication schedule Have suction and oral airway available Insulin Decreased need for insulin during the preoperative period due to decreased oral intake Increased need postoperatively due to the stress of the surgery increasing glucose release Needs may fluctuate postoperatively because of decreased oral intake   Closely monitor blood glucose levels preoperatively, intraoperatively, and postoperatively Physical Assessment The physical assessment of the surgical patient is another component of the preoperative admission workup. Assessment parameters include height and weight, vital signs, and systems assessment. Height and Weight Height and weight help the anesthesia provider determine fluid needs and medication dosages for anesthesia or antibiotics during the procedure. A patient with a high body mass index (BMI) may also require a larger operating table and recovery bed. Most operating tables have extensions that can meet increased weight requirements. In addition, the OR team may adjust diligence equipment used to transfer the patient. Vital Signs Vital signs are obtained by the nurse during the initial assessment. This includes blood pressure, respirations, pulse, temperature, and pulse oximetry. If available, the nurse should compare the admission vital signs with any previously recorded vital signs to note trends or major changes. If the initial set varies significantly from the patient's normal, a second set of vital signs may be taken 10 to 15 minutes later because many patients may be nervous, which may alter their vital signs. The presence of fever may be an indication of infection. That may necessitate a postponement of the surgical procedure. If the patient is held in the preoperative room for longer than 2 hours, a second set of vital signs may be required before transfer to the surgical suite. Assessment of vital signs must include the fifth vital sign, pain. The patient is asked to rate pain in one of several ways. Examples of pain scales include the following: A scale of 0 to 10, with 10 being the worst pain the patient has ever experienced A series of faces ranging from a smile to a frown for pediatric patients Another required admission question is the documentation of the patient's acceptable pain score. Each patient handles pain differently, and therefore a subjective pain scale is interpreted differently. This score is used by the postanesthesia nurse and surgeon as a guide for adequate pain management. Systems Assessment During the initial assessment, the nurse performs a head-to-toe physical assessment of the preoperative patient. Key elements for the preoperative assessment are presented in the following subsections. Cardiovascular Assessment In addition to pulse and blood pressure, the nurse further assesses the patient's cardiovascular health. Peripheral pulses, color, skin turgor, capillary refill, temperature, and edema are important parameters to assess. The nurse also auscultates the heart for rhythm, rate, and murmurs. Respiratory Assessment The nurse assesses the patient's breathing for rate, depth, rhythm, and adventitious breath sounds such as crackles, rhonchi, or wheezing. Pulse oximetry is used to assess the patient's oxygen saturation on room air. In addition, the nurse should report any clubbing in the fingers, which could indicate long-term oxygen deprivation. The nurse must also ensure that the patient has a clear airway. The patient is asked to stick out their tongue, breathe with the head tilted up and with the chin down, and swallow. This ensures that an airway and any intubation may be safely maintained during the procedure. The anesthesiologist assesses the patient as well during their consultation. Neurological Assessment Before the induction of anesthesia, it is important for the nurse to obtain a baseline neurological evaluation. Assessment of general cognition and the ability to understand commands is important before the induction of general anesthesia. The nurse also assesses the movement, strength, and sensation of the extremities. This is especially important in a patient who will receive some type of regional block for the procedure. The presence of preoperative delirium or confusion may delay or postpone the procedure or necessitate admission to the hospital postoperatively. Liver/Renal Assessment It is important to note potential renal or liver disease in the surgical patient. The effects of anesthesia and other medications used before, during, and after an operation may be altered if the patient has decreased hepatic or renal clearance. A complete metabolic panel helps the team to identify any signs of dysfunction. Integumentary Assessment A general assessment of the patient includes assessing appearance, such as skin integrity and hygiene. Patients with poor skin turgor or fragile skin may heal more slowly than a healthy individual. Also, the team may want to be careful as to the type of dressings that are used to protect the skin from further damage beyond the incision. For example, in an older patient or a patient with fragile skin, the nurse may want to use a leg strap instead of an adhesive to secure a urinary catheter. If hygiene is an issue, the nurse may need to give extra instruction on wound care in an effort to decrease the risk for infection. Gastrointestinal Assessment It is important for the nurse to note typical bowel habits of the patient, especially if the patient will be admitted to the hospital after surgery. The nurse should also document the presence of normal bowel sounds and any areas of tenderness on the abdomen. Genitourinary Assessment The nurse should document any devices noted for urinary elimination, such as an indwelling urinary catheter. The nurse should have the patient void before entering the operating suite and note any unusual odor or color of the urine. The patient may wish to discuss any concerns about urination postoperatively; some patients worry about being able to get into the bathroom without assistance. The nurse should also document any perineal abnormalities on the chart. Connection Check 15.3 Which of the following patients presents the greatest risk for a negative response to anesthesia? A.  A 40-year-old male patient with high blood pressure B.  A 20-year-old female patient with no prior surgical history C.  A 29-year-old female patient with a history of stage II acute renal failure D.  An 85-year-old male patient who drinks one glass of scotch every night CASE STUDY: EPISODE 2 While Maria is interviewed, she expresses concern for her stay at the hospital and her upcoming procedure. Maria states that other than the birth of her children, this is the first time she has been in a hospital, and this is her first surgical procedure. She expresses anxiety over "being put under" and worries about how she will take care of her children after discharge... PATIENT PREPARATION FOR THE SURGICAL EXPERIENCE Laboratory Assessment Preoperative laboratory work is essential in determining the patient's readiness for surgery. This can be done at an appointment before surgery or the morning of surgery. If done on the day of surgery, labs will be drawn as the nurse places an IV line to be used for venous access during surgery. A type and screen to determine blood type and the presence of antibodies is drawn. This sample is used to crossmatch blood in the event the patient needs blood during the surgical procedure. Often, facilities have the patient wear a blood identification bracelet with unique numbers that match the drawn sample for the purpose of easy and safe identification. A complete metabolic panel provides baseline information on renal and liver functions, including liver enzymes, albumin, electrolytes, blood urea nitrogen, and creatinine. This information helps in the selection of medications and dosages for the surgical procedure. Coagulation studies show how quickly the patient's blood clots after injury, determining any bleeding abnormalities. The complete blood count (CBC) measures hemoglobin/hematocrit (blood volume and oxygen-carrying capability) and the white blood cell count for indications of infection. Any deviation from the facility's defined ranges should be reported to the surgeon or anesthesiologist, as appropriate, to be corrected to avoid complications. For example, a low platelet count or hemoglobin/hematocrit will be further decreased by surgery. The surgeon may ask for blood to be typed and crossmatched before the procedure, or the provider may ask for platelet administration before surgery. Clotting abnormalities may also require the administration of fresh frozen plasma before the procedure can begin. Last, urine is measured for the presence of glucose, blood, protein, and specific gravity and the presence of ketones. These measures help determine the presence of infection or the hydration status of the patient. Immediately before surgery, patients may be tested for pregnancy. Radiological Assessment Radiological imaging is sometimes required before surgery. Common preoperative images are magnetic resonance imaging (MRI), computerized axial tomography (CAT scans; more commonly referred to as computed tomography \[CT\]), ultrasonography, or x-ray imaging. Imaging studies may also be required immediately before and during the surgery to monitor progress. An electrocardiogram (ECG) may also be performed before or on admission to the surgical facility, and cardiac monitoring may be ongoing. Patient Teaching It is important at this time to complete any necessary patient teaching. Patient teaching helps decrease anxiety, which has been shown to improve patient outcomes (see Evidence-Based Practice). Anxiety has been shown to increase postoperative pain medication requirements, necessitating more pain medication. This can affect the postoperative recovery by decreasing activity and mobility, which puts the patient at risk for complications such as DVT, pneumonia, and constipation. Anxiety also plays a role in increasing the risk of infection by decreasing the immune system response. Most facilities have a patient teaching record where teaching is documented. The patient's family should be included in the preoperative teaching. At this time, the nurse should take the opportunity to have a discussion with the patient and their family support regarding what to expect during the patient's surgical and postoperative experience. For example, the nurse should discuss how long the procedure will be, how long the patient will be in the postanesthesia care unit (PACU), and how soon the family will receive an update on the patient's status and be able to see the patient. Discharge care may be covered at this time because the patient may be fatigued or drowsy after the procedure. The nurse can address any family concerns at that time as well. Last, the nurse should ensure that the family is guided to the appropriate waiting area where the staff will be able to locate them for updates. See Box 15.3 for a checklist of preoperative learning needs. Evidence-Based Practice Preoperative Anxiety An American Association of Anesthesiologists survey found that up to 60% of preoperative patients experience anxiety. Preoperative anxiety can increase the need for anesthetics, postoperative vomiting, pain, and length of stay; affects the immune system; and contributes to postsurgical complications such as decreased wound healing. Perioperative nurses preparing patients for surgery should address anxiety in conjunction with their other interventions and patient education. Premedication with benzodiazepines should be administered as ordered. Nonpharmacological interventions such as aromatherapy, video distraction, music, and preoperative warming have been shown to reduce preoperative anxiety. Dziadzko, M., Mazard, T., Bonhomme, M. Raffin, M., Pradat, P., Forcione, J., Minard, R., & Aubrun, F. (2022). Preoperative anxiety in the surgical transfer and waiting area: A cross-sectional mixed method study. Journal of Clinical Medicine, 11(9), 2668. Musa, A., Movahedi, R., Wang, J., Safani, D. Cooke, C., Hussain, S. Tajran, J., Hamid, S., & Gucey, G. (2020). Assessing and reducing preoperative anxiety in adult patients: A cross-sectional study of 3661 members of the American Society of Anesthesiologists. Journal of Clinical Anesthesia, 65,109903. Patmon, F., Rylee, T., Holder, D., Woodworth, J., Anderson, M., & Gee, P. (2022). Nurse, parent, and nurse leader perspective on adoption of iPads for pediatric preoperative anxiety reduction. Journal of PeriAnesthesia Nursing, 37(3), 393--397. Physical Preparations Intravenous Line (IV Line) An IV line is inserted during the preoperative admission, typically for the purpose of the administration of anesthesia and fluids during the surgery. An 18-gauge catheter is preferred because this size is required for the administration of all blood products. Factors to consider when placing the IV line include the location of the procedure and whether multiple sites are required. The IV should be labeled with gauge, time and date of placement, and the nurse's initials. The nurse may also administer any preoperative antibiotics at this time. Bowel and Bladder Preparation Patients receiving abdominal, intestinal, gynecological, or rectal surgery may be asked to perform a bowel preparation. This may be done by use of an enema or gentle laxatives that the patient self-administers at home the night before the procedure. The nurse should confirm and document that this preparation has been performed. Box 15.3 Checklist of Preoperative Learning Needs Reason for procedure Nature of procedure Members of the surgical team Length of the procedure Location of the procedure Components and use of the pain scale Anesthesia plan Postoperative pain management plan Location of the incisions Presence of postoperative drains and dressings Surgical site preparation Ambulation guidelines after surgery Coughing and deep breathing exercises Splinting incisional area when coughing to decrease the pain Family instructions---the patient should not be alone for the first 24 to 48 hours Patients scheduled for abdominal, gynecological, or long procedures may also require the insertion of an indwelling catheter to drain urine. This will keep the bladder empty during a procedure, preventing injury to the bladder. It also allows the surgical team to monitor output in the operating room and PACU. Connection Check 15.4 During the initial assessment and admission questions, the nurse asks Maria for the time of her last oral intake. The patient replies, "I had dinner last night at 8 p.m., but I took a few sips of water this morning with my vitamins." The nurse's best response is which of the following? A.  Explain to the patient that just a sip of water should not be a problem for anesthesia but that the vitamins may be a problem. That information will be passed on to the anesthesiologist. B.  Tell the patient that the sip of water is not an issue because it was only a sip. C.  Inform the patient that her surgery will not be performed today because the risk is too high for a negative outcome. D.  Inform the patient that taking her vitamins before surgery was a good plan. Skin Preparation Before surgery, skin preparation is done to help prevent infection at the surgical site. Patients may be instructed to shower and wash with Betadine or hexachlorophene soap before admission. A surgical shave may be necessary depending on the patient's skin type and the location of the incision. If a shave is appropriate, the nurse uses a sterile electric clipper. A razor is not recommended because of the risk of infection caused by small nicks in the skin that may occur with a razor. Shaving may be done in the OR after the induction of anesthesia. In addition, the nurse should confirm that all body piercings have been removed and that nails are clear of polish. Medications Preoperative medications may be required. Patients with preoperative anxiety may be prescribed a benzodiazepine such as midazolam HCl, diazepam, or lorazepam. Antiemetics such as metoclopramide HCl or ondansetron HCl may be used preoperatively if a patient has a history of nausea and vomiting due to anesthesia. Transfer Preparing the patient for transfer to the OR suite is the final responsibility of the preoperative nurse. Before transport, the nurse should make sure 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. The intraoperative nurse may accompany the patient to the surgical suite, or the anesthesia team may be responsible for this transport depending on the surgical suite's policies. Once transferred, the patient is now considered to be receiving intraoperative care. Transfer of Patient to Surgical Suite The preoperative nurse must ensure that the following have been completed before transfer to intraoperative care: Patient identification Physical preparations Confirmation of NPO status Documentation of complete medical history and admission vital signs and laboratory work Allergy bracelet visible Documentation of initial time-out Copies of all appropriate documentation are in patient's file Patient education with verbalized return of information Family and patient questions answered Connection Check 15.5 Maria's surgeon has asked that thromboembolic-deterrent (TED) stockings be placed on the patient before surgery as well as sequential compression devices on both legs to the knees. Maria asks the nurse what these devices will do for her. Which response by the nurse is most appropriate? A.  "They work together to make sure that you do not have a decrease in arterial blood flow in your legs during the surgery." B.  "They complement each other to prevent blood from backing up in your legs and causing a deep vein thrombosis due to your immobility during the surgery." C.  "They prevent deep tissue clotting during the surgery." D.  "The two devices do the same thing, but one is better during the surgery, and the other is better postoperatively." NURSING MANAGEMENT Nursing Diagnoses/Problem List Fear and anxiety related to loss of control and the unknown Knowledge deficit: treatment procedure Postoperative pain management Risk of postoperative infection Nursing Interventions Assessments Vital signs/oxygen saturation Initial vital signs provide a base to determine the patient's condition during and after the procedure. Increased or decreased heart rate, increased or decreased blood pressure, increased temperature, and decreased oxygen saturation may necessitate a postponement of the procedure, if elective. Physical examination/laboratory analysis Evaluation of the physical examination and laboratory values determines readiness for the procedure, indicates necessary adjustments to be made before the procedure, and provides a baseline for comparison in the OR and postoperatively. Last oral intake NPO before the procedure is essential to guard against aspiration during intubation and extubation due to decreased gag reflexes. Confirm appropriate skin prep and bowel prep have been completed. Prepping the skin with a special soap before surgery helps reduce the risk of infection; a bowel prep before some abdominal, gynecological, or rectal surgeries is necessary to clear the bowel, which prevents the risk of peritoneal contamination if the bowel is compromised during surgery. Actions Complete the preoperative checklist. Completing the checklist ensures that all necessary information and actions have been obtained or completed before the patient enters the surgical suite. Ensure removal of jewelry and prosthetics. An electrocautery unit is used during operative procedures to decrease bleeding. Electricity may travel to any metal on the body, causing a burn. There is also a risk during positioning that the patient's ring may get caught in a piece of equipment, causing injury to the finger. Inform anesthesia and surgical personnel of the presence of any implants. A patient with a pacemaker may need to have the pacemaker disabled; the pacemaker company or a representative of the hospital needs to assume responsibility for this action. Personnel must also be aware of items such as central IV lines or Mediports, typically used for long-term medication therapy. Time-out Establishing the right patient, procedure, and site is essential to avoid operative errors. IV insertion An IV is necessary for fluid and medication administration. Teaching What to expect of the OR experience An understanding of what to expect of the OR experience helps control anxiety and increase patient comfort. How to prevent postoperative complications Knowledge of postoperative teaching, such as coughing, deep breathing, early ambulation, and leg and ankle exercises, significantly reduces the risk of postoperative complications. How to manage postoperative pain Knowledge of nonpharmacological pain management techniques such as heat, ice, and decreasing external stimuli, as well as knowledge of proper pain medication use and timing, to ensure effective pain management and reduce the risk of addiction. Connection Check 15.6 When planning discharge education for a 65-year-old male patient who is having a hip replacement, it is appropriate for the nurse to consider which of the following? (Select all that apply.) A.  The patient's resources at home for completing activities of daily living B.  The number of stairs in the patient's home C.  Transportation to follow-up appointments D.  Preexisting medical conditions E.  The number of bathrooms in the home Making Connections CASE STUDY: WRAP-UP Maria's nurse completes the preoperative preparation. An IV line is inserted, and normal saline is started. The anesthesia provider is reminded of Maria's allergies to penicillin and latex and her smoking history. Once completed, the nurse spends time with Maria, attempting to allay her fears by explaining what to expect in the OR and when she wakes up. They review potential plans for childcare postoperatively. Case Study Questions 1\. Maria expresses her anxiety about the procedure and anesthesia to her nurse. Which is the most appropriate response? A. Tell her, "It's okay; we do this every day." B. Assure her that her fears are normal and encourage her to use her consultation time with the surgeon and anesthesiologist to address her concerns. C. Share a story about your friend who had similar fears before her surgery. D. Document her concerns in the chart so that the PACU nurse will expect her to be anxious during recovery. 2\. Maria is allergic to latex. What is the appropriate action to prevent an allergic reaction in the patient who is having surgery? A. Terminally clean the OR before her case and remove all latex products. B. Maria should be the first case of the day, and only nonlatex items should be used. C. All surgical suites are latex-free, so this is not a concern. D. Anesthesia should be prepared to intubate and treat her if a reaction occurs because there is no way to ensure a latex-free environment. 3\. Because of Maria's smoking history, the nurse understands she is at great risk for which of the following? (Select all that apply.) A. Increased postoperative pain B. Difficulty with anesthesia C. Respiratory depression during the procedure D. Increased healing time after the procedure E. Deep vein thrombosis after the procedure 4\. The nurse recognizes teaching has been effective by which of the following statements? A. "My neighbor was able to eat right up to the time of her procedure." B. "I know there is nothing you can do about nausea after the procedure." C. "So that IV line will stay in throughout the procedure?" D. "I know I will need blood during this procedure." 5\. What is the priority responsibility of Maria's nurse before the procedure? A. Explaining the procedure and having Maria sign the consent form B. Reviewing the risks of anesthesia C. Marking the surgical site with the patient D. Ensuring completion of the preoperative assessment CHAPTER SUMMARY The preoperative phase of the surgical experience begins when the decision for surgery is made and ends when the patient is transferred to the surgical suite. During this time, the preoperative nurse takes on a multitude of roles, including educator, advocator, and admittance nurse. Priority assessments include patient history and medications (prescribed and over the counter), physical assessment, allergies, alcohol and drug use, and advance directives. The nurse must assess older adults for specific concerns that may affect their surgical experience. It is essential to get a baseline for comparison in the intraoperative and postoperative periods, specifically with vital signs, cardiac rhythm, and oxygen saturation. Also, the assessment may identify a patient who requires additional monitoring to avoid complications associated with the procedure or anesthesia. Patient preparation includes education about the operative experience, IV insertion, labs, postoperative teaching, and family support. The patient should be aware of the potential for IV lines or drains that may be present postoperatively. The nurse is involved in all aspects of preoperative care: patient education, time-outs, and confirmation of informed consent and family support. Education must include the many facets of the surgical experience, including postoperative care that will be vital to preventing complications, specifically coughing, deep breathing, and early mobility after surgery, as well as pain management. The nurse must also be sure the patient is clear about postoperative medications and the regimen for taking these medications. Teaching is a vital aspect of the preoperative nurse's care, to ensure that the transition to the operative suite and subsequent postanesthesia care unit (PACU) is seamless and without adverse outcomes.