Chapter 14 - Preoperative Nursing Management PDF

Chapter 14 – Preoperative Nursing Management ▪ Minimally invasive surgery is a technique used to use specialized tools through natural orifices of the body or tiny incisions. It allows for many procedures to be done as an outpatient but is still considered serious. ▪ Surgery occurs in t...

Chapter 14 – Preoperative Nursing Management ▪ Minimally invasive surgery is a technique used to use specialized tools through natural orifices of the body or tiny incisions. It allows for many procedures to be done as an outpatient but is still considered serious. ▪ Surgery occurs in three phases: preoperative, which is from the moment the surgery is decided to the moment the patient is transferred to the OR table; intraoperative, which is from the time a patient is put on the OR table to the moment surgery is finished and they are transferred to the PACU; and postoperative, which is from the admission to the PACU to the time that the follow-up evaluation is done at home or in a clinical setting. ▪ Each perioperative phase includes many nurse duties that cover four categories: safety, physiologic responses, behavioral responses & healthcare systems. ▪ Robotic surgery is becoming more common in areas such as cardiac, gastrointestinal, urologic, gynecologic, thoracic, orthopedic & ENT. ▪ Surgery can be done based on a diagnosis, a cure, or a repair. It can be reconstructive, cosmetic, or palliative and rehabilitative. ▪ The surgery necessity is based on time: emergent must be done with no delay, it is life- threatening. Urgent must be done promptly, 24-30 hours. Required surgery can be done within weeks or even months, it is not life-threatening but is needed. Elective surgeries should be done, but are not required, and optional surgery is a pure personal choice. ▪ Ambulatory surgery is outpatient surgery where the person is under clinical care for less than 24 hours. To reduce hospital stays and cost, pre-admission testing and pre-op testing are completed prior to the surgery. ▪ Special gerontology considerations anesthesia can dysregulate older adults' physiology, cardiac reserves are lower, renal and hepatic functions are depressed, and gastrointestinal activity is likely reduced. Skin is a big factor, and care must be taken when moving an older adult. Pre-op tests such as EKG, blood pressure, and blood tests will alert to any issues. Memory and cognition also need to be assessed and pain management and communication must be a priority. Providing multiple education formats helps solidify that they have received the information needed. ▪ Bariatric patients, those with obesity special consideration must be taken to pulmonary, cardiovascular, psychological and integumentary. Increase adipose tissue can mean decreased IV access and delayed wound healing. They are also at an increased risk of SSI, joint replacement failure, and OSA which must be undiagnosed. ▪ Patients with disabilities, which could be mental or physical, may need assistive devices such as hearing aids, glasses, braces, prosthetics, and others. Extra care may need to be given in moving and repositioning to prevent pain or injury. Those who have issues such as cerebral palsy, post-polio patients, may need special positioning during surgery. Anesthesia adjustment must be made for those with respiratory problems like MS or muscular dystrophy. ▪ Emergency surgery patients are unplanned and very little prep time to complete the same amount of pre-op prep, communication is key. Usually this is done during resuscitation in the ER. ▪ Required documentation includes informed consent for all surgeries. Surgeon and anesthesiologists are responsible for making sure the patient understands the procedure,  and the nurse must make sure that the consent is signed before any pre-op meds are given. If meds are given, no signatures can be gotten, and it is void if they do. Informed consent is for surgery, anything with sedation, arteriography as it carries a higher risk, and anything that uses radiation or blood products. ▪ Pre-op assessment includes a complete medical history and physical less than 30 days old. Assessment is done to ensure patient is healthy as possible and to catch things that may have been missed prior. Allergies to bananas, kiwi, or avacados could show a latex allergy. Also looks for undiagnosed OSA by using STOP-BANG. o S - snoring o T - tired o O - observed o P - pressure o B - BMI o A - age o N – neck circumference o G – gender ▪ Nutrition and fluids must be on point as any nutritional deficiency should be corrected before surgery to provide adequate protein for wound healing, as long as its possible. People must be NPO before surgery to reduce risks of aspiration, but not so long as to where glycogen stores are depleted and dehydration and electrolyte imbalances start, and chemical imbalances occur. ▪ Dentition is decayed teeth and dental prosthesis can become dislodged during intubation and occlude airways. Even infections of the mouth can cause post-op infections. ▪ Drug and alcohol use can cause arrhythmias, infections and withdrawals. Leads to longer hospital stays and increased post-op complications by 50%. Drugs and Alcohol can impede the effectiveness of meds prescribed and if intoxicated when surgery is needed, it will be postponed if possible, if not, NG tube is placed and a spinal block or regional block is given. Those persons also often suffer from malnutrition and metabolic imbalances. ▪ Those with respiratory issues must be encouraged to do breathing exercises and use the incentive spironometer. If a respiratory infection is present, surgery is postponed and if the patient smokes they are more at risk for poor wound healing, higher incidence of SSI, VTE, and pneumonia. ▪ Cardiovascular considerations include supporting oxygen, fluid, and nutritional needs. Patient will be assessed for CHF, SOB, and arrhythmia. Baseline vitals are taken before surgery. ▪ Hepatic and renal function considerations include ensuring medications, anesthetic agents, body wastes, and toxins are adequately metabolized and removed from the body. The liver is important for anesthesia, as acute liver disease is linked to high surgical mortality ▪ Endocrine function is important due to if the body overproduces or underproduces hormones, the dysfunction could be the reason for surgery or cause of organ failure requiring surgery. ▪ Corticosteroids cause adrenal insufficiency therefore any use in past year must be disclosed. ▪ Diabetics are at risk for hypoglycemia due to fasting and hyperglycemia from stress, which can also increase SSIs. ▪ Immune function is considered by checking for infection or allergies. Infection or increased temperature may be a factor to postpone surgery. ▪ Previous medication use including dietary supplements, OTC meds, herbal and prescribed medications must be documented as many interact with anesthesia and can cause circulatory collapse and hypotension. Anti-coagulants should be stopped 7-10 days prior to surgery and no herbal supplements 2 weeks before surgery. ▪ Psychological factors include people reacting different. Fear and anxiety can cause post op complications due to the release of epinephrine and norepinephrine increasing BP & P. Healing issues and infection risk also increase. It is very important to make sure to tell the patient what to expect. ▪ Spiritual and cultural beliefs need to be considered and always shown respect, knowing the beliefs allows holistic approach to be done. Communication with different cultures about pain and feelings may vary and need approached differently. Some view eye contact differently and some view the head as a sacred part of the body, therefore would want to place the surgical cap on themselves. Always listen to the patient to learn what is needed. ▪ Pre-op nursing interventions include making sure to provide patient education. It is imperative to help them understand ways to avoid certain situations o Avoid infection – clean wound and change dressing as directed o Avoid bleeding – care for stitches, no lifting, no exercise, splint incision when needed o Avoid pressure injury – reposition and pad bony prominences o Avoid repiratory issues – Breathing exercises, diaphignatic breathing (belly breathing), pursed lip breathing, incentive spiromether, breath into it 10 times per hour hwile awake and ambulate o Avoid DVT – ambulate ▪ Mobility and active body movements improve circulation, prevent venous stasis and promote optimal respiratory function. Post-op positioning is discussed, ROM completed, and proper body alignment. ▪ Pain management is discussed using acute vs chronic and the pain scale ▪ Cognitive coping skills include guided imagery, distraction, optimistic self talk, music, aromatherapy, Reiki (energy transfer). ▪ Maintaining safety is important ▪ Managing nutrition and fluids by fasting 8 hours prior to surgery and avoiding milk 6 hours prior to surgery. Before elective surgery, healthy people may sometimes be allowed to have clear liquids up to 2 hours prior. Some non-gastrointestinal system procedures do “carb- loading”. ▪ Prepare the bowel if it is an abdominal or pelvic surgery by using enema. ▪ Prepare skin by cleansing all bacteria off the skin, hair removal for incision using an electric razor, and surgeon and patient mark the skin for incisions together. ▪ Immediate pre-op practices include confirming patient identification, donning alert bracelets for allergies, fall risk, and code status. Jewelry, dentures and nail polish is removed. Patients need to void before going to the OR. Antibiotics and preanesthetic meds are given as needed, pre-op checklists and pre-op warming. This is also a time for attending to family needs.