Chapter 18 preoperative nursing.pdf

Perioperative Nursing Preoperative phase: period of time from decision for surgery until patient is transferred into operating room Intraoperative phase: period of time from when patient is transferred into operating room to admission to postanesthesia care unit (PACU) Postoperative phas...

Perioperative Nursing Preoperative phase: period of time from decision for surgery until patient is transferred into operating room Intraoperative phase: period of time from when patient is transferred into operating room to admission to postanesthesia care unit (PACU) Postoperative phase: period of time from when patient is admitted to PACU to follow-up evaluation in clinical setting or at home Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins CLASSIFICATIONS OF SURGERY Categories of Surgical Procedures: I. According to Purpose: a. Diagnostic: to verify suspected diagnosis, e.g. biopsy. b. Exploratory: to estimate the extent of the disease, e.g. exploratory laparotomy. c. Curative: to remove or repair damaged or diseased organs or tissues Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Types of Curative Surgery: Ablative: removal of diseased organs. (-ectomy) e.g. appendectomy, hysterectomy Reconstructive: partial or complete restoration of a damaged organ, e.g. plastic surgery after burns iii. Constructive: repair of a congenitally defective organ. iv. Palliative: to relieve pain, relieve distressing S/Sx II. According to Degree of Risk to Client: Major surgery Minor surgery Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Criteria: a. Major surgery: High degree of risk Prolonged intraoperative period Large amount of blood loss Extensive, vital organs may be handled or removed Great risk of complications. b. Minor surgery: Lesser degree of risk to the client Generally not prolonged; described as “one-day surgery” or outpatient surgery Leads to few serious complications Involves less risk. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins III. According to Urgency: Emergency: must be performed immediately without delay, e.g. gunshot wound, severe bleeding, Urgent: must be performed as soon as possible within 24 – 48 hours, e.g. appendectomy Required: necessary for the well-being of the client, usually within weeks to months, e. g. cholecystectomy, cataract extraction, thyriodectomy Elective: should be performed for the client’s well being but which is not absolutely necessary, e.g. simple hernia, vaginal repair, repair of scar Optional: surgery that a client requests, Example: Plastic surgery Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false: Intraoperative phase: the period of time from the decision for surgery until the patient is transferred into the operating room. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. Rationale: The preoperative phase is the period of time from the decision for surgery until the patient is transferred into the operating room. The intraoperative phase is the period of time from when the patient is transferred to the operating room to the admission to postanesthesia care unit (PACU). Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Preadmission Testing Initiates initial preoperative assessment Initiates teaching appropriate to patient’s needs Involves family in interview Verifies completion of preoperative diagnostic testing Verifies understanding of surgeon-specific preoperative orders Discusses, reviews advanced-directive document Begins discharge planning by assessing patient’s need for postoperative transportation, care Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Preoperative Assessment Nutritional, fluid status Dentition Drug or alcohol use Respiratory status Cardiovascular status Hepatic, renal function Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Preoperative Assessment (cont’d) Endocrine function Immune function Previous medication use Psychosocial factors Spiritual, cultural beliefs Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Special Considerations During Preoperative Period Gerontologic considerations Patients who are obese Patients with disabilities Patients undergoing ambulatory surgery Patients undergoing emergency surgery Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Medications that Potentially Affect on Surgical Experience Corticosteroids Anticoagulants Diuretics Antiseizure Phenothiazines Medications Tranquilizers Thyroid Hormone Insulin Opioids Antibiotics Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Types of drugs taken regularly: Steroids: may improve the body’s ability to response to the stress of anesthesia and surgery Anticoagulants and salicylates: may increase bleeding during surgery Antibiotics: maybe incompatible with or potentiate anesthetic agents Tranquilizers: potentiate the effect of narcotics and can cause hypotension Antihypertensives: may predispose to shock Diuretics: may increase potassium loss vii. Alcohol: will place the surgical client at risk when used chronically Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors that Affect Surgical Risk a.Physical and Mental Condition of the Client Age: premature babies and elderly persons are at risk Nutritional status: malnourished and obese are at risk State of fluid and electrolytes balance: dehydration and hypovolemia predispose a person to complications General health: infectious process increase operative risk Mental health Economic and occupational status Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Question Which medication classification must be assessed during the preoperative period because it can cause an electrolyte imbalance during surgery? A. Corticosteroids B. Diuretics C. Phenothiazines D. Insulin Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Diuretics Rationale: Diuretics during anesthesia may cause excessive respiratory depression resulting from an associated electrolyte imbalance. Corticosteroids can cause cardiovascular collapse if discontinued suddenly. Phenothiazines may increase the hypotensive action of anesthetics. Interaction between anesthetics and insulin must be considered when a patient with diabetes mellitus undergoes surgery. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Informed Consent Should be in writing Should contain the following: – Explanation of procedure, risks – Description of benefits, alternatives – Offer to answer questions about procedure – Instructions that patient may withdraw consent – Statement informing patient if protocol differs from customary procedure Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Voluntary Consent Valid consent must be freely given, without coercion Patient must be at least 18 years of age (unless emancipated minor) Consent must be obtained by physician Patient’s signature must be witnessed by professional staff member Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Incompetent Patient Individual who is not autonomous Cannot give or withhold consent – Cognitively impaired – Mentally ill – Neurologically incapacitated Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Teaching Deep breathing, coughing, incentive spirometry Mobility, active body movement Pain management Cognitive Coping strategies Instruction for patients undergoing ambulatory surgery Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  General Preoperative Nursing Interventions Providing psychosocial interventions – Reducing anxiety, decreasing fear – Respecting cultural, spiritual, religious beliefs Maintaining patient safety Managing nutrition, fluids Preparing bowel Preparing skin Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Immediate Preoperative Nursing Interventions Administering preanesthetic medication Maintaining preoperative record Transporting patient to presurgical area Attending to family needs Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Tell whether the following statement is true or false: The primary goal in withholding food before surgery is to prevent aspiration. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True. Rationale: The primary goal in withholding food before surgery is to prevent aspiration. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Preoperative Instructions to Prevent Postoperative Complications Diaphragmatic breathing Coughing Leg exercises Turning to side Getting out of bed Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 3. Physiological Preparation: Respiratory preparation Incentive spirometry Prevent or treat atelectasis Improve lung expansion Improve oxygenation Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Turn, cough, and deep-breathe At least every 2 hours Turn from side-to-back-to-side 2-3 deep breaths Cough 2-3 times (splint abdomen if needed) Contraindicated: surgeries involving intracranial, eye, ear, nose, throat, or spinal). Coughing exercise: deep breath, exhale through the mouth, and then follow with a short breath while coughing; splint thoracic and abdominal incision to minimize pain. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Extremity exercise: prevents circulatory problems and post operative gas pains or flatus. Assure that pain medications will be available post-operative. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Diaphragmatic Breathing and Splinting When Coughing Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Physical Preparation On the Night of the Surgery: Preparing the client’s skin: shave against the grain of the hair shaft to ensure clean and close shave. Skin preparation for surgery on various body areas. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Preparing the GIT: NPO after midnight Administration of enema may be necessary Insertion of gastric or intestinal tubes Preparing for anesthesia Visit done by anesthetist complete respiratory, Neurologic and cardiovascular examination. Promoting rest and sleep: Measures to reduce preoperative sleeplessness and restlessness include: A well ventilated room. Comfortable, clean bed Back rub Warm beverage (if fluids not contraindicated) On the night before surgery sleeping medication Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins On the Day of Operation: a. Early morning care: about 1 hour before the pre-operative medication schedule Vital signs taken and recorded promptly Patient changes into hospital gown that is left untied and open at the back Braid long hair and remove hair pin Provide oral hygiene Prosthetic devices, eyeglasses, dentures removed Remove jewelries Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Remove nail polish Patient should void immediately before going to the OR Make sure that the patient has not taken food for the last 10 hours by asking the client Urinary catheterization may be performed in the OR Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Pre-Operative Medications: Generally administered 60-90 min before induction of anesthesia Purpose: To allay anxiety: the primary reason for pre-operative medications To decrease the flow of pharyngeal secretions To reduce the amount of anesthesia to be given To create amnesia for the events that precedes surgery Types of Pre-Operative Medications: Sedative: Given to decrease client’s anxiety to lower BP and R Reduce the amount of general anesthesia: an overdose can result to respiratory depression e.g. Phenobarbital Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1. Tranquilizer: Lowers the client’s anxiety level ∞ e.g. Thorazine 12.5 - 25 mg IM 1-2 hours prior to surgery Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1. Narcotic analgesia: Given to reduce patients anxiety and to reduce the amount of narcotics given during surgery ∞ e.g. Morphine sulfate 8- 15 mg SC 1 hour prior surgery. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1. Vagolytic or drying agents: To reduce the amount of tracheobronchial secretions ∞ e.g. Atropine sulfate 0.3-0.6 mg IM 45 min before surgery; * An overdose can result to severe tachycardia e. preoperative checklist. f. Recording: all final preparation and emotional response before surgery should be noted down. g. Transportation to the OR, *Woolen or synthetic blankets must never be sent to the OR because they are source of static electricity. - Compare patient’s ID bracelet to the medical record - Assist patient to stretcher - Direct family to appropriate waiting area Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins  Reference; Kindly consult your course book Brunner and Siddharth, The medical and surgical nursing, 14th Edition; 2018 p.no.1206-1250 for more details and exams preparation. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins