Preoperative Care PDF

Chapter 18 Preoperative Care  Surgery (1 of 2)  Art and science of treating diseases, injuries, and deformities by operation and instrumentation 2  Surgery (2 of 2)  Patients have surgery for ...

Chapter 18 Preoperative Care  Surgery (1 of 2)  Art and science of treating diseases, injuries, and deformities by operation and instrumentation 2  Surgery (2 of 2)  Patients have surgery for  Diagnosis  Cure  Palliation  Prevention  Cosmetic improvement  Exploration 3  Surgical Settings  Elective surgery is carefully planned  Emergency surgery arises with unexpected urgency  Inpatient  Same-day admission  Ambulatory (same day or outpatient)  Minimally invasive  Endoscopy or surgical clinics  Hospital outpatient surgery clinics 4  Case Study (1 of 10) Preoperative Care  J.D., a 45-year-old female, presents to the surgeon’s office for presurgical workup for right breast lumpectomy. 5  Your Role Preop  Identify the reason the patient is having surgery and any co-morbidities  Assess the patient’s response to the stress of surgery  Review the results of preoperative diagnostic tests  Identify potential risks and complications of the surgical procedure 6  Patient Interview (1 of 2)  Check documented information before interview  Avoids repetition  Occurs in advance of or on day of surgery  HCP’s office  Ambulatory surgery center  Hospital 7  Patient Interview (2 of 2)  Purpose  Obtain health information, including drug and food allergies  Provide and clarify information about the surgery and anesthesia  Assess emotional state and readiness  Determine expectations 8  Case Study (2 of 10) Assessment  J.D. is accompanied by her husband.  She tells you she has 2 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. 9  Assessment Goals (1 of 4)  Overall goals  Identify risk factors  Plan care to ensure patient safety 10  Assessment Goals (2 of 4)  Establish baseline data for comparison intraoperative and postoperative  Determine psychologic status to reinforce coping strategies  Determine physiologic factors related to planned procedure contributing to risks 11  Assessment Goals (3 of 4)  Identify and document surgical site  Identify prescription drugs, OTC medications, and herbs taken that may affect surgical outcome  Review results of preoperative diagnostic studies and share with HCPs 12  Assessment Goals (4 of 4)  Identify cultural and ethnic factors that may affect surgical experience  Determine receipt of adequate information from surgeon to make informed decision for surgery  Verify that consent form is signed and witnessed 13  Case Study (3 of 10) Assessment  J.D. states that her mother and aunt have a history of breast cancer resulting in mastectomy.  She appears anxious and you note constant fidgeting. 14  Assessment (1 of 33)  Psychosocial assessment  Excessive stress response can be magnified and affect recovery  Influencing factors Age Experiences with illness and pain Current health Socioeconomic status 15  Assessment (2 of 33)  Use common words and language  Use translators if needed Decreases level of anxiety  Communicate all concerns to surgical team 16  Assessment (3 of 33)  High anxiety level can impair cognition, decision making, and coping abilities  Anxiety can arise from  Lack of knowledge  Uncertainty about outcome  Past experiences and stories  Information lessens anxiety 17  Assessment (4 of 33)  Anxiety may arise from conflict with interventions (i.e., blood transfusions) and religious or cultural beliefs  Identify beliefs and discuss with surgeon and operative staff 18  Assessment (5 of 33)  Common fears  Death or disability May prompt postponement Influence outcome  Pain and discomfort Consult with ACP or surgeon Confirm drugs will be available Teach pain intensity scale  Mutilation/altered body image Assess concerns with an accepting attitude 19  Assessment (6 of 33)  Fears  Anesthesia Loss of control  Disruption of life functioning Range from fear of permanent disability to temporary limiting usual of usual activities Include family and financial concerns Consultations as needed 20  Assessment (7 of 33)  Hope  May be strongest method of coping Never deny or minimize  Assess and support 21  Case Study (4 of 10) Assessment  J.D. tells you she has a history of hypertension.  She recently was diagnosed with type 2 diabetes and is currently controlled with medications and diet. 22  Assessment (8 of 33)  Past health history  Health problems and surgeries  Understanding of reasons for surgery  Problems with previous surgeries  Menstrual/obstetric history 23  Assessment (9 of 33)  Health history  Family health Inherited traits Heart and endocrine diseases  Reactions/problems to anesthesia (patient or family) Malignant hyperthermia 24  Assessment (10 of 33)  Current medications  Prescription and OTC  Herbs  Diet supplements  Antiplatelets/NSAIDs  Recreational Drugs Alcohol Tobacco 25  Assessment (11 of 33)  Drug intolerances and allergies  Latex allergy/ risk factors  Hay fever  Asthma  Food allergies 26  Case Study (5 of 10) Assessment  In addition to HCTZ and glipizide, J.D. is currently taking multivitamin, fish oil, and a daily low-dose aspirin.  She reports an allergy to penicillin, resulting in a rash.  She has had no other surgeries. 27  Assessment (12 of 33)  Review of systems  Body systems review Confirms the presence or absence of diseases Alerts to areas to closely examine Provide essential data to determine specific preoperative tests 28  Assessment (13 of 33)  Cardiovascular system  Report Any cardiac problems so they can be monitored during surgery  Hypertension, angina, dysrhythmias, HF, MI Current treatment for CV conditions Presence of pacemaker/ICD 29  Assessment (14 of 33)  Cardiovascular system  12-lead electrocardiogram (ECG)  Coagulation studies  Possible prophylactic antibiotics  Venous thromboembolism (VTE) prophylaxis 30  Assessment (15 of 33)  Respiratory system  Ask about recent or chronic respiratory disease  Respiratory tract infections Procedure could be cancelled because of increased risk of laryngo/bronchospasm or decreased SaO2 31  Assessment (16 of 33)  Respiratory system  History of dyspnea, coughing, or hemoptysis reported to ACP and surgeon  COPD or asthma High risk for atelectasis and hypoxemia 32  Assessment (17 of 33)  Respiratory system  Encourage smokers to stop smoking at least 6 weeks before surgery Decreases risk of complications  Sleep apnea, obesity, and airway deformities affect respiratory function 33  Assessment (18 of 33)  Neurologic system  Evaluation of neurologic functioning Patient’s ability to respond to questions, follow commands, maintain orderly thought processes  Vision or hearing loss can affect responses Cognitive deficits can affect informed consent and cause adverse outcomes during and after surgery  Especially crucial to assess in older adults  Added stressors may contribute to emergence delirium 34  Assessment (19 of 33)  Genitourinary system  History of renal and urinary tract diseases  Renal problems are associated with Fluid and electrolyte imbalances Coagulopathies Increased risk of infection Impaired wound healing Altered response to drugs and their elimination 35  Assessment (20 of 33)  Genitourinary system  Renal function tests  Note problems voiding, and inform perioperative team  Assess men for prostate problems  Assess women for possibility of pregnancy 36  Assessment (21 of 33)  Hepatic system  Liver detoxifies many anesthetics and adjunctive drugs  Hepatic dysfunction may increase risk of perioperative complications 37  Assessment (22 of 33)  Skin  History of skin problems  History of pressure injuries Extra padding during surgery Affects postoperative healing  Body art such as tattoos, piercings 38  Assessment (23 of 33)  Musculoskeletal system  Identify any joints affected by arthritis  Mobility restrictions may affect positioning and ambulation 39  Assessment (24 of 33)  Musculoskeletal system  Report problems affecting neck or lumbar spine to ACP Spinal anesthesia may be difficult Can affect intubation and airway management 40  Assessment (25 of 33)  Endocrine system  Patients with diabetes are at risk for: Hypo/hyperglycemia Delayed wound healing Infection 41  Case Study (6 of 10) Assessment  Considering her history of diabetes, what assessment is important for J.D. the morning of surgery? 42  Assessment (26 of 33)  Endocrine system  Patients with diabetes Serum or capillary glucose tests morning of surgery (baseline) Clarify with surgeon or ACP about insulin dose 43  Assessment (27 of 33)  Endocrine system  Patients with thyroid problems Hyper/hypothyroidism poses surgical risks because of changes in metabolic rate Verify with ACP about giving thyroid medications Laboratory tests to determine thyroid function 44  Assessment (28 of 33)  Endocrine system  Patients with Addison’s disease Abruptly stopping replacement corticosteroids could cause Addisonian crisis Stress of surgery may require increased dose of IV corticosteroids 45  Assessment (29 of 33)  Immune system  Patients with history of compromised immune system or use of immunosuppressive drugs can have Delayed wound healing Increased risk for infection  Elective surgery may be cancelled for acute infection  Patients with chronic infections may have surgery if needed Take infection control precautions 46  Assessment (30 of 33)  Fluid and electrolyte status  Vomiting, diarrhea, or preoperative bowel preps can cause imbalances  Identify drugs that change F and E status, such as diuretics  Evaluate serum electrolyte levels 47  Assessment (31 of 33)  Fluid and electrolyte status  NPO status Surgery delay may lead to dehydration Patients with or at risk for dehydration may require additional fluids and electrolytes before surgery 48  Assessment (32 of 33)  Nutritional status  Customize care for patients with nutritional problems 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) 49  Assessment (33 of 33)  Nutritional status  Obesity Stresses cardiac and pulmonary systems Increased risk of wound dehiscence, infection, and incisional hernia Slower recovery from anesthesia Slower wound healing 50  Assessment: Exam (1 of 2)  The Joint Commission (TJC) requires a history and physical  Findings enable ACP to rate patient for anesthesia administration  Indicator of perioperative risk and overall outcome 51  Assessment: Exam (2 of 2)  Complete a physical assessment  Record all findings and share with the perioperative team  Obtain and assess results of diagnostic studies  Monitor blood glucose for patients with diabetes 52  Nursing Management (1 of 22)  Preoperative teaching  Patient has the right to know what to expect and how to participate Increases patient satisfaction Reduces fear, anxiety, and stress May decrease complications  pain, and vomiting 53  Nursing Management (2 of 22)  Preoperative teaching  Limited time available Address needs of highest priority Include information focused on safety Provide written material 54  Nursing Management (3 of 22)  Preoperative teaching  Several days before surgery Observe and listen to determine how much teaching is enough Anxiety and fear may limit learning ability Give priority to patient’s concerns 55  Case Study (7 of 10) Nursing 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? 56  Nursing Management (4 of 22)  Preoperative teaching  Three types of information Sensory Process Procedural 57  Nursing Management (5 of 22)  Preoperative teaching  Must be documented and reported to postoperative nurses Avoid duplication of information Evaluate patient learning 58  Nursing Management (6 of 22)  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 59  Nursing Management (7 of 22)  Ambulatory surgery information  Basic information before arrival Arrival time and place Registration and parking What to wear and bring Responsible adult needed Fluid and food restrictions 60  Nursing Management (8 of 22)  Legal preparation  Check that all required forms are signed and in chart Informed consent Blood transfusions Advance directives Power of attorney 61  Nursing Management (9 of 22)  Consent for surgery  Informed consent must include Adequate disclosure Clear understanding Voluntarily given consent 62  Nursing Management (10 of 22)  Surgeon ultimately responsible for obtaining consent  Nurse may witness signature  Verify patient has understanding  Permission may be withdrawn at any time 63  Nursing Management (11 of 22)  Legally appointed representative of family may consent if patient is  Minor  Unconscious  Mentally incompetent  Emancipated minor is younger than legal age but able to provide legal consent 64  Nursing Management (12 of 22)  Consent for surgery  Medical emergency may override need for consent  Immediate medical treatment needed to Preserve life Prevent serious impairment to life or limb Patient incapable of giving consent 65  Case Study (8 of 10) Nursing Management  J.D. signs her consent in the presence of the surgeon in his office before the day of surgery. 66  Nursing Management (13 of 22)  Day-of-surgery preparation  Final preoperative teaching  Assessment and communication of pertinent findings  Verification of signed informed consent 67  Nursing Management (14 of 22)  Day-of-surgery preparation  Laboratory and diagnostic study results  History and physical examination  Consultations  Baseline vitals  Proper skin preparation  Nursing notes  Surgical site identification 68  Case Study (9 of 10) Nursing 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? 69  Nursing Management (15 of 22)  Day-of-surgery preparation  Hospital gown  Patient should not wear any cosmetics Observation of skin color is important Remove nail polish or artificial nails for pulse oximeter  Identification and allergy bands on wrist 70  Nursing Management (16 of 22)  Day-of-surgery preparation  Valuables are returned to caregiver or locked up  Dentures, contacts, glasses, prostheses are removed  Jewelry and piercings removed if electrocautery devices will be used  Leave hearing aids in place to allow patient to hear instructions 71  Nursing Management (17 of 22)  Void before surgery  Before preoperative drugs  Prevents involuntary elimination under anesthesia  Reduces risk of urinary retention during early postoperative recovery 72  Nursing Management (18 of 22)  Preoperative medication  Benzodiazepines  Anticholinergics  Opioids  Antiemetics  Antibiotics 73  Nursing Management (19 of 22)  Preoperative medication  β-Adrenergic blockers (β-blockers)  Insulin  Eyedrops 74  Nursing Management (20 of 22)  Transportation to the OR  Via stretcher, wheelchair, or bed  Hand-off communication Situation Background Assessment Recommendation  Caregivers directed to waiting room 75  Case Study (10 of 10) Nursing Management  You administer IV midazolam, as ordered, to J.D. and prepare to hand her off to the OR nurse.  Formulate SBAR report. 76  Nursing Management (21 of 22)  Special concerns  Culturally competent care Patient’s expression of pain Family expectations Ability to verbally express needs Decision making 77  Nursing Management (22 of 22)  Special concerns  Geriatric considerations Surgical event may be overwhelming May view hospital as place to die, or stepping stone to nursing home Increased risks with anesthesia and surgery May have sensory deficits or decreased cognitive function 78 Audience Response Question (1 of 2) A 68-year-old male scheduled for hernia repair 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. Which response would the nurse provide? a. “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.” 79 Audience Response Question (2 of 2) Answer: A “Who is available to help you at home after the surgery?” 80 Audience Response Question (1 of 2) Which preoperative instruction is appropriate for all patients? a. Techniques of deep breathing and coughing. b. Descriptions of the planned surgical procedure. c. Physical procedures or preparation required before surgery. d. Withholding of all oral fluids or food after midnight on the day of surgery. 81 Audience Response Question (2 of 2) Answer: C Physical procedures or preparation required before surgery 82