Perioperative Nursing Care Chapter 50 PDF

50 Perioperative Nursing Care OBJECTIVES Discuss the three phases of perioperative nursing. Identify the benefits of early ambulation for the postoperative Explain the rational...

50 Perioperative Nursing Care OBJECTIVES Discuss the three phases of perioperative nursing. Identify the benefits of early ambulation for the postoperative Explain the rationale for a nursing assessment of a patient’s patient. surgical risk factors. Illustrate how a nurse uses sound clinical judgment when making Identify co-morbid conditions that increase patient risks for an intraoperative assessment and how it promotes patient safety. postoperative complications. Explain the differences between postoperative phases. Explain the approach for assessing a patient’s potential psychological Outline the components of SBAR communication for perioperative response to impending surgery. hand-off. Explain the influence a preoperative teaching plan can have on a Identify nursing care priorities for postoperative patients. patient’s surgical recovery. List the principles for providing education to surgical patients Explain the rationale for postoperative exercises. during the restorative phase of recovery KEY TERMS Ambulatory surgery Conscious sedation Never event American Society of Anesthesiologists Enhanced Recovery After Surgery (ERAS) Obstructive sleep apnea (OSA) (ASA) General anesthesia Oxygen desaturation American Society of PeriAnesthesia Nurses Informed consent Paralytic ileus (ASPAN) Intermittent pneumatic compression (IPC) Perioperative nursing Association of periOperative Registered stockings Postoperative nausea and vomiting (PONV) Nurses (AORN) Laparoscopy Postoperative urinary retention (POUR) Atelectasis Latex sensitivity Preanesthesia care unit (PCU) Bariatric Local anesthesia Preoperative teaching plan Circulating nurse Malignant hyperthermia Regional anesthesia Co-morbid Moribund Scrub nurse MEDIA RESOURCES http://evolve.elsevier.com/Potter/fundamentals/ Skills Performance Checklists Review Questions Audio Glossary Video Clips Content Updates Concept Map Creator Answers to QSEN Activity and Review Questions Case Study with Questions Mr. Cooper is a 72-year-old patient scheduled for admission in 5 days for Perioperative nursing includes a registered nurse’s planned patient- a bowel resection to remove a cancerous tumor. Jeff is the nurse in the centered approach in providing care to patients preoperatively, intraop- preadmission center assigned to Mr. Cooper for his preoperative screening eratively, and postoperatively. Through the application of national and preparation. Jeff has worked in the center for 2 years. During his practice standards, the registered nurse’s role in providing quality patient initial encounter with Mr. Cooper, Jeff learns that the patient is alert and care before, during, and after surgery is crucial in maintaining patient oriented to person, place, and time. He is attentive and answers questions safety. Perioperative nurses apply sound clinical judgment in the use of appropriately. His vision and hearing are normal. The patient has not the nursing process to guide the delivery of care to patients in hospitals, had major surgery before. He lives at home with his wife, to whom he has surgical centers, and/or health care providers’ offices. Nursing goals in been married 42 years. the preoperative area are based on the following: Jeff provides Mr. Cooper with an explanation of what has to be done Quality improvement and evidence-based practices through the before surgery, including bowel prep, diet restrictions, and what time to application of current research and the generation of ideas for new present at the hospital the day of surgery. Jeff also provides Mr. Cooper research knowledge with a brief explanation of what to expect with his surgery. Patient safety through high-quality care 1413 1414 UNIT 7 Physiological Basis for Nursing Practice Teamwork and collaboration lengths of stay. Surgery takes place in a variety of settings, including Effective communication and interactions with a patient, the hospitals, ambulatory surgery centers, health care providers’ offices, and patient’s family members, and the surgical team, fostering shared even mobile units. The principles of caring for perioperative patients are decision making basically the same, regardless of the setting, except for the timing and The nursing process to conduct timely assessment and deliver extent of therapy. interventions in all phases of surgery Advocacy for a patient and the patient’s family Cost containment SCIENTIFIC KNOWLEDGE BASE Perioperative nursing includes multiple intersecting processes guided by theoretical knowledge, ethical principles, ongoing research, special- Classification of Surgery ized clinical skills, and caring practices (Association of periOperative The types of surgical procedures are classified according to serious- Registered Nurses, 2020a). A nurse working within the perioperative ness, urgency, and purpose (Table 50.1). Although surgeries are classi- setting responds to complex and fluctuating clinical needs during a cru- fied as major or minor, any procedure can be considered major from cial period of a patient’s surgical experience. A nurse who works in any the perspective of the patient and/or the family. Some procedures fall perioperative setting relies on clinical reasoning skills to maintain strict into more than one classification. For example, a colon resection to infection control measures, monitor the patient’s physical and psycho- remove a malignant tumor is major in seriousness, urgent in urgency, logical response to the surgical experience, communicate effectively with and ablative in purpose. In many instances, the classifications intersect. members of the surgical team, and emphasize patient safety in each Urgent procedures are major in seriousness. Frequently, the same pro- phase of surgery. Effective teaching and discharge planning involving cedure is performed for different reasons on different patients. For patients and their family members prevent or minimize complications example, a gastrectomy may be performed as an emergency procedure and contribute to quality outcomes. A patient’s smooth transition from to resect a bleeding ulcer or as an urgent procedure to remove a malig- admission into the health care system through recovery is the aim of nant tumor. Knowing the classifications assists in planning appropriate quality perioperative care. perioperative care. The surgical care of patients is evolving as a result of advancements Another type of surgical classification describes the condition in technology, which often result in less invasive surgeries and shortened of a patient facing impending surgery. The American Society of TABLE 50.1 Classification of Surgical Procedures Classification Type Description Example Seriousness Major Involves extensive reconstruction or alteration in body Coronary artery bypass, colon resection, removal of larynx, resection parts; poses great risks to well-being of lung lobe Minor Involves minimal alteration in body parts; designed to Cataract extraction, facial plastic surgery, tooth extraction correct deformities; involves minimal risks to well-being Urgency Elective Performed on basis of patient’s choice; is not essential Bunionectomy; facial plastic surgery; hernia repair; breast and is not always necessary for health reconstruction Urgent Necessary for patient’s health; often prevents development Excision of cancerous tumor; removal of gallbladder for stones; of additional problems (e.g., tissue destruction or vascular repair for obstructed artery (e.g., coronary artery bypass) impaired organ function); not necessarily emergency Emergency Must be done immediately to save life or preserve function Repair of perforated appendix or traumatic amputation; control of of body part internal hemorrhaging Purpose Diagnostic Surgical exploration performed to confirm diagnosis; often Exploratory laparotomy (incision into peritoneal cavity to inspect involves removal of tissue for further diagnostic testing abdominal organs); breast mass biopsy Ablative Excision or removal of diseased body part Amputation; removal of appendix or an organ such as gallbladder (cholecystectomy) Palliative Relieves or reduces intensity of disease symptoms; Colostomy; debridement of necrotic tissue; resection of nerve roots does not produce cure Reconstructive/restorative Restores function or appearance to traumatized or Internal fixation of fractures; scar revision malfunctioning tissues Procurement for transplant Removal of organs and/or tissues from a person Kidney, heart, or liver transplant pronounced brain dead or from living donors for transplantation into another person Constructive Restores function lost or reduced as result of congenital Repair of cleft palate; closure of atrial septal defect in heart anomalies Cosmetic Performed to improve personal appearance Blepharoplasty for eyelid deformities; rhinoplasty to reshape nose  CHAPTER 50 Perioperative Nursing Care 1415 Anesthesiologists (ASA, 2020) assigns classification on the basis of a Age. Very young and older patients are at greater surgical risk. Both age- patient’s physiological condition independent of the proposed surgical groups frequently present problems in temperature control during surgery. procedure (Table 50.2). The classification is a risk assessment that General anesthetics inhibit shivering and cause vasodilation, which results allows surgeons and anesthesia providers to consider factors that influ- in heat loss. These anesthetic changes coupled with age-related physiologi- ence how surgery will be performed. Anesthesia involves risks even in cal factors increase the risk for unintended hypothermia (Barnett, 2020; healthy patients; however, some patients, including but not limited to Black and Maxwell, 2020). Infants also have difficulty in maintaining nor- those with metabolic and cardiac dysfunction, are at higher risk. mal circulatory blood volume, causing risks for dehydration and overhy- dration. A healthy older adult has reduced physiological reserve, and organ Surgical Risk Factors systems may be compromised during illness and/or surgical stress, creating Numerous factors create risks for patients planning surgery. Risk factors a surgical risk (Barnett, 2020). can affect patients in any phase of the perioperative experience. One Older adults account for the majority of surgeries performed in the common risk factor for all patients is the surgical stress response. United States (Barnett, 2020). Their risks are significant. Among per- Physiologically, the stress of surgery causes activation of the endocrine sons age 65 and over, chronic health conditions (co-morbidities) such system, resulting in the release of hormones and catecholamines, which as hypertension, heart disease, cancer, and diabetes are surgical risk increases blood pressure, heart rate, and respiration. Platelet aggrega- factors (Barnett, 2020). Older patients often experience diminished tion also occurs, along with many other physiological responses. All cardiac, pulmonary, and renal function, which decreases older adults’ patients will be affected physiologically by the stress response. Under- ability to maintain homeostasis perioperatively (Table 50.3). Barore- standing the physiology of the stress response (Chapter 37) and risk ceptor function, which regulates blood pressure, may be insufficient factors that affect patients’ responses to surgery is necessary to antici- and cause postural hypotension and dizziness, increasing fall risks. pate patient needs and the types of preparation required preoperatively. Decreased respiratory function, impaired functional reserve of the pulmonary system, and decreased cough reflex increase the risk for Smoking. Surgical patients who smoke are at a higher risk for devel- aspiration, infection, and bronchospasm. Further, dehydration and oping pneumonia, atelectasis, and delayed wound healing (Smetana, fluid imbalance present a need for hydration if the patient is unable to 2020a). Chronic smoking increases the amount and thickness of air- drink before surgery (Barnett, 2020). way secretions, thus increasing the risk of aspiration. After surgery, a patient who smokes has greater difficulty clearing the airways of Nutrition. Tissue repair and resistance to infection depend on adequate mucus, thus contributing to the development of pneumonia. Smoking nutrition. Surgery increases the need for nutrients (Weimann et al., decreases the amount of oxygen that reaches the cells in the surgical 2017). Patients who are thin or obese are often deficient in protein and wound. As a result, the wound may heal more slowly and is more likely vitamins, putting them at greater risk for complications following to become infected (Pachter et al., 2020). Current research suggests surgery (Harding et al., 2020). After surgery, a patient requires at least that surgical patients who use electronic cigarettes, a practice known as 1500 kcal/day to maintain energy reserves. This intake is difficult to “vaping,” are at risk for delayed wound healing and vascular necrosis attain when a patient’s food and/or fluid intake is limited after surgery (Arndt et al., 2020). Although decades of research correlate cigarette or if a patient develops postoperative nausea and vomiting (PONV). smoking to poor patient outcomes in all phases of the perioperative Postoperatively, patients gradually increase their dietary intake (once experience, some preoperative patients are unaware of the surgical gastrointestinal activity returns) over 1 to 2 days or 3 to 5 days after risks associated with smoking. Recent studies suggest the need for surgery until they can tolerate normal meals. Patients who enter surgery health care providers to implement systematic and planned measures malnourished are more likely to have poor tolerance for anesthesia, targeted at educating preoperative patients on the surgical risks of negative nitrogen balance, delayed postoperative recovery, infection, smoking all forms of cigarettes (Arndt et al., 2020; Fracol et al., 2017). and delayed wound healing. Current recommendations suggest the use TABLE 50.2 ASA Physical Status (PS) Classification ASA PS Classification Definition Characteristics ASA I A normal healthy patient Healthy, nonsmoking; no or minimal alcohol use ASA II A patient with mild systemic disease Mild disease only without substantive functional changes (e.g., current smoker, social alcohol drinker, pregnancy, obesity [BMI 30-40], well-controlled DM/HTN, mild lung disease) ASA III A patient with severe systemic disease Substantive functional changes with one or more moderate-to-severe diseases (e.g., poorly controlled DM or HTN, COPD, morbid obesity [BMI 40 or greater], active hepatitis, alcohol dependence or abuse, implanted pacemaker, or moderate reduction of cardiac ejection fraction) ASA IV A patient with severe systemic disease Examples include recent (less than 3 months) MI, CVA, TIA, ongoing cardiac ischemia or severe that is a constant threat to life valve dysfunction, sepsis, disseminated intravascular coagulation, end-stage renal disease not undergoing regularly scheduled dialysis ASA V A moribund patient who is not expected Examples include ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed to survive without the operation with mass effect, ischemic bowel with significant cardiac pathology ASA VI A patient who has been declared brain Wide variety of dysfunctions that are being managed to optimize blood flow to the heart and dead whose organs are being organs (e.g., aggressive fluid replacement and blood pressure medications) removed for donor purpose Modified from American Society of Anesthesiologists: ASA Physical Status Classification System, December 13, 2020, https://www.asahq.org/ standards-and-guidelines/asa-physical-status-classification-system. Accessed September 27, 2021. 1416 UNIT 7 Physiological Basis for Nursing Practice TABLE 50.3 Physiological Factors That Place the Older Adult at Risk During Surgery Alterations Risks Nursing Implications Cardiovascular System Degenerative change in myocardium and Decreased cardiac reserve puts older adults at risk Assess baseline vital signs for tachycardia, fatigue, and arrhythmias valves for decreased cardiac output, especially during (Rosenthal, 2019). A complete, comprehensive cardiac workup times of stress (Rosenthal, 2019; Rothrock, 2019) according to agency policy should be completed before surgery. Rigidity of arterial walls and reduction in Alterations predispose patient to postoperative Maintain adequate fluid balance to minimize stress to the heart. sympathetic and parasympathetic hemorrhage and rise in systolic and diastolic Ensure that blood pressure level is adequate to meet innervation to the heart blood pressure circulatory demands. Increased calcium and cholesterol Predispose patient to clot formation in lower Instruct patient in techniques of leg exercises and proper deposits within small arteries; extremities turning. Apply elastic stockings or intermittent pneumatic thickened arterial walls compression (IPC) devices. Administer anticoagulants as ordered by health care provider. Provide education regarding effects, side effects, and dietary considerations. Integumentary System Decreased subcutaneous tissue and Prone to pressure injuries and skin tears Select appropriate surface for OR table. Assess skin every increased fragility of skin 4 hours; pad all bony prominences during surgery. Turn or reposition at least every 2 hours. Pulmonary System Decreased respiratory muscle strength Increased risk for atelectasis Assess risk factors for postoperative pulmonary complications and cough reflex (Rothrock, 2019) (Rothrock, 2019). Instruct patient in proper technique for coughing, deep breathing, and use of spirometer. Ensure adequate pain control to allow for participation in exercises. Reduced range of movement in Residual capacity (volume of air left in lung after When possible, have patient ambulate and sit in chair diaphragm normal breath) increased, reducing amount of frequently. new air brought into lungs with each inspiration Stiffened lung tissue and enlarged air Blood oxygenation reduced Obtain baseline oxygen saturation; measure throughout spaces perioperative period. Gastrointestinal System Gastric emptying delayed Increases risk for reflux and indigestion and Assess nutritional status and implement preventive measures in Saliva production decreased constipation (Rothrock, 2019) high-risk patients (Rothrock, 2019). (Rothrock, 2019) Position patient with head of bed elevated at least 45 degrees. Reduce size of meals in accordance with ordered diet. Renal System Decreased renal function, with reduced Increased risk of shock when blood loss occurs; For patients hospitalized before surgery, determine baseline blood flow to kidneys increased risk for fluid and electrolyte imbalance urinary output for 24 hours. Reduced glomerular filtration rate and Limited ability to eliminate drugs or toxic Assess for adverse response to drugs. excretory times substances Reduced bladder capacity (Rothrock, Increased risk for urgency, incontinence, and Instruct patient to notify nurse immediately when sensation 2019) urinary tract infections. Increased risk for of bladder fullness develops. Keep nurse call system and postoperative urinary retention (Rothrock, 2019) bedpan within easy reach. Toilet every 2 hours or more frequently if indicated. Neurological System Sensory losses, including reduced tactile Decreased ability to respond to early warning Inspect bony prominences for signs of pressure that patient is sense and increased pain tolerance signs of surgical complications unable to sense. Orient patient to surrounding environment. Observe for nonverbal signs of pain. Febrile response during surgery Increased risk of undiagnosed infection and Ensure careful, close monitoring of patient temperature; provide (Rosenthal, 2019; Rothrock, 2019) hypothermia (Rothrock, 2019) warm blankets; monitor heart function; warm intravenous fluids. Goals are to prevent heat loss (Rosenthal, 2019). Maintain normothermia intraoperatively (Rothrock, 2019). Decreased reaction time Confusion and delirium after anesthesia; Allow adequate time to respond, process information, and increased risk for falls perform tasks. Perform fall-risk screening and institute fall precautions. Screen for delirium with validated tools. Orient frequently to reality and surroundings.  CHAPTER 50 Perioperative Nursing Care 1417 TABLE 50.3 Physiological Factors That Place the Older Adult at Risk During Surgery—cont’d Alterations Risks Nursing Implications Metabolic System Lower basal metabolic rate Reduced total oxygen consumption Ensure adequate nutritional intake when diet is resumed but avoid intake of excess calories. Reduced number of red blood cells and Reduced ability to carry adequate oxygen to Administer necessary blood products as needed. Monitor blood hemoglobin levels tissues test results and oxygen saturation. Change in total amounts of body Greater risk for fluid or electrolyte imbalance Monitor electrolyte levels and supplement as necessary. Provide potassium and water volume cardiac monitoring (telemetry) as needed. Rosenthal L, Association of periOperative Registered Nurses (AORN): Perioperative assessment of the older adult. The Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, 2019; Rothrock JC: Alexander’s care of the patient in surgery, ed 16, St Louis, 2019, Elsevier. of immune-enhancing nutritional supplements as needed to address by a huge increase in sympathetic output, which causes a significant deficiencies before scheduled surgery (Askari, 2020; Weimann et al., increase in blood pressure (Wickramasinghe, 2019). 2017). Some studies indicate that recovery can also be enhanced by Patients with OSA who are to undergo surgery present a significant regulating the metabolic status of a patient before surgery (e.g., mini- risk. Receiving sedatives, opioid analgesics, and general anesthesia mizing metabolic stress and insulin resistance by giving carbohydrate- causes relaxation of the upper airway and may worsen OSA. The risk based drinks and fluid loading) and after surgery (e.g., early oral is higher when a patient is sedated and lying on the back. Patients have feeding and giving prokinetic medications to enhance gastric motility, experienced severe apnea and hypoxemia, leading to death after surgi- resulting in improved enteral feeding tolerance) (Kim et al., 2018; cal and diagnostic procedures under conscious sedation. Careful Weimann et al., 2017). screening of patients at risk or symptomatic for OSA is essential before surgery (Olson et al., 2020a). Obesity. According to the World Health Organization (WHO) there Patients with OSA often have co-morbid conditions such as asthma, are approximately 650 million obese adults and 42 million obese chil- atherosclerosis, myocardial infarction, heart failure, hypertension, atrial dren under the age of 5 years. In the United States, 35% of adults and fibrillation, chronic kidney disease, and behavioral disorders, such as 17% of children are obese (Lim, 2020). As weight increases, a patient’s decreases in attention, vigilance, concentration, motor skills, and verbal ventilatory and cardiac function diminish, increasing the risk for post- and visuospatial memory (Kline, 2020; National Institute of Health, operative atelectasis, pneumonia, and death. Obstructive sleep apnea n.d.). Some evidence suggests that the lack of sleep (for various reasons) (OSA), hypertension, coronary artery disease, diabetes mellitus, and may play a role in some older adults’ mental decline (National Institute heart failure are co-morbid conditions in the bariatric population. of Health, n.d.). The disorder hinders daily functioning because of Patients who are obese often have difficulty resuming normal physical chronic fatigue and sleepiness and adversely affects health and longev- activity after surgery because of the pain and fatigue caused by surgery ity. Patients who suffer from OSA develop numerous complications, in addition to preexisting impaired physical mobility. This combination including hypertension, heart disease, vascular disease, neurological of factors increases the risk of developing venous thromboembolism disease, and type 2 diabetes (Kline, 2020). (VTE). Obesity is also a significant risk factor for wound infections, surgical blood loss, and pulmonary embolism (Inge, 2020). Immunosuppression. Patients with conditions that alter immune Excess weight placed on skin over bony prominences restricts blood function (e.g., primary immune deficiency, acquired immunodefi- flow and poses risks for pressure injuries to form when patients lie on ciency syndrome [AIDS], cancer, bone marrow alterations, and organ operating tables. Obesity also increases the risk of poor wound healing, transplants) are at an increased risk for developing infection after wound infection, dehiscence, and evisceration because fatty tissue con- surgery. The risk for infection increases when patients receive radia- tains a poor blood supply, slowing the delivery of essential nutrients tion or chemotherapy for cancer treatment, take immunosuppressive and antibodies needed for wound healing (see Chapter 48). In addition, medications, or require steroids to treat a variety of inflammatory or surgeons often have difficulty closing surgical wounds because of the autoimmune conditions (Anderson and Sexton, 2020a). Radiation thick adipose layer. sometimes is given before surgery to reduce the size of a cancerous tumor so that it can be removed surgically. Ideally, a surgeon waits to Obstructive Sleep Apnea. Obstructive sleep apnea (OSA) is a perform surgery until 4 to 6 weeks after the completion of radiation chronic sleep disorder characterized by periodic episodes of narrowing treatments because of the unavoidable effects that radiation has on or collapse of the upper airway (Kline, 2020). It occurs when muscles in normal tissue. Radiation thins the layers of the skin, destroys collagen, the throat relax during sleep, causing soft tissue in the back of the throat and impairs tissue perfusion. Otherwise, the patient may face serious to collapse and block the upper airway. These structural and neuromus- wound-healing problems. cular changes can cause OSA, which results in pauses in breathing (apnea) that last at least 10 seconds during sleep. Most apneic episodes Fluid and Electrolyte Imbalance. The body responds to surgery as a last from 10 to 30 seconds, but some may continue for 1 minute or form of trauma. Severe protein breakdown causes a negative nitrogen longer, leading to significant oxygen desaturation. During an episode balance (see Chapter 45) and hyperglycemia. Both of these effects de- of apnea there is increasing negative intrathoracic pressure (down crease tissue healing and increase the risk of infection. As a result of the to !80 mm Hg), which makes it difficult for the heart to pump effectively; adrenocortical stress response, the body retains sodium and water and thus cardiac output decreases. In response to the oxygen desaturation, loses potassium in the first 2 to 5 days after surgery. The severity of the there is an arousal, which ends the apnea. The arousal is accompanied stress response influences the degree of fluid and electrolyte imbalance. 1418 UNIT 7 Physiological Basis for Nursing Practice Extensive surgery results in a greater stress response. A patient who is after surgery, Medicare and some private insurance companies with- hypovolemic before surgery or who has serious electrolyte alterations is hold payment to the hospital for the costs associated with treating at significant risk during and after surgery. For example, an excess or DVT because DVTs are typically preventable. The Joint Commission depletion of potassium increases the chance of dysrhythmias during or (2020) has an updated set of accountability measures (i.e., quality after surgery. The risk of fluid and electrolyte alterations is even greater measures that produce the greatest positive impact on patient out- in patients with preexisting diabetes mellitus, renal disease, or gastroin- comes when hospitals demonstrate improvement in them). One of the testinal (GI) or cardiovascular abnormalities (see Chapter 42). accountability measures is treatment and prevention of venous throm- boembolism (VTE). Some VTEs are subclinical (without symptoms), Risks for Postoperative Nausea and Vomiting (PONV). The expe- whereas others present as sudden pulmonary embolus or symptomatic rience of having nausea and vomiting after surgery is uncomfortable DVT. Patients most at risk for developing VTE are those who undergo and often immobilizing. PONV affects approximately 30% of patients surgical procedures with a general anesthetic and undergo a surgical in recovery rooms after surgery (Feinleib et al., 2020). It can lead to time of more than 90 minutes, or 60 minutes if the surgery involves the serious complications, including pulmonary aspiration, dehydration, pelvis or lower limb; acute surgical admissions with inflammatory and arrhythmias resulting from fluid and electrolyte imbalance. A or intraabdominal conditions; and those expected to have significant patient who vomits frequently after surgery runs the risk of dehiscing reduction in mobility after surgery. In addition, patients are at higher surgical sutures. Patients at risk for developing PONV are women, indi- risk if they have one or more risk factors (Bauer and Lip, 2020): viduals with a history of PONV or motion sickness, nonsmoking status, Active cancer or cancer treatment and younger age. Anesthesia-related risk factors include the use of vola- Age over 55 years tile anesthetics (e.g., nitrous oxide), duration of anesthesia, and periop- Prior venous thromboembolism erative opioid use. Certain types of surgery (e.g., abdominal procedures Recent surgery [cholecystectomies] and gynecological surgery) are also associated with Dehydration PONV (Feinleib, 2020). Ambulatory surgery patients generally have less Known clotting disorders PONV. However, nausea and vomiting may occur after an ambulatory Obesity (body mass index [BMI] of 40 kg/m2 or greater) patient has left a surgical setting. This post-discharge nausea and/or vomiting (PDNV) may be particularly hazardous for ambulatory sur- gery patients because they no longer have immediate access to fast-on- REFLECT NOW set intravenous antiemetic medications (Feinleib, 2020). Screening for PONV is crucial for nurses to be able to take precautions needed to A nurse conducts a preoperative assessment for an 85-year-old patient prevent PONV and possible pulmonary aspiration. Patients with four who is accompanied by a caregiver. The patient’s caregiver assists the or more risk factors have a higher incidence of PONV (Rothrock, 2019). patient with ambulation and answers the nurse’s questions. A review of Management of PONV begins before surgery. the patient’s medical record reveals recent episodes of sleep apnea. What questions should the nurse ask to assess this patient’s risks for Risks for Postoperative Urinary Retention (POUR). Postoperative surgical complications? Which risk factors place this patient at risk for urinary retention (POUR) is common following anesthesia, affecting up surgical complications? to 70% of patients. Usually the inability to void is temporary, but it may be prolonged in some patients. Common risk factors are (Glick, 2020): Patient-specific: Older age, male gender, history of POUR, neurological disease, or prior pelvic surgery. NURSING KNOWLEDGE BASE Procedure-specific: Anorectal surgery, joint arthroplasty, hernia repair, or incontinence surgery. Perioperative Communication Anesthesia-specific: Excessive intraoperative fluid administration, Continuity of care is important when caring for surgical patients. In medication-related (e.g., use of opioids, anticholinergic agents, most cases a different nurse cares for a patient during each surgical sympathomimetics), prolonged anesthesia, or type of anesthesia. phase, which requires clear and accurate communication between Patients who are unable to void in the postanesthesia care unit nurses. However, based on the delivery of care model utilized in the (PACU) may not complain of bladder fullness, and physical assessment perioperative setting, some nurses may follow patients through the may fail to detect an overdistended bladder. Bladder scanning is noninva- preoperative and intraoperative phases of surgery. In some instances, sive and can usually confirm an overdistended bladder. Bladder scanning perioperative nurses follow patients through the postanesthesia care is used when a patient has risk factors for POUR or is unable to void unit (PACU), assessing a patient’s health status before surgery, identify- 4 hours postoperatively. ing specific patient needs, providing teaching and counseling, preparing A single-time catheterization is recommended when "600 mL of for the operating room (OR), and following a patient’s recovery. Other urine is measured on bladder scan. A patient in ambulatory surgery health care providers such as respiratory therapists and physical thera- may not spontaneously void prior to discharge. Ambulatory surgery pists also care for patients during each phase of the surgical experience. patients should be instructed to seek medical assistance if they are still A smooth communication “hand-off ” between caregivers is needed to unable to void 8 hours after discharge. ensure continuity of care and reduce risk of medical errors (Rothrock, 2019). Transitions from one care provider to another place patients at Risks for Venous Thromboembolism (VTE). In 2008, the Centers risk for injuries, missed care, and errors in translating information. The for Medicare and Medicaid Services ruled that deep vein thrombosis World Health Organization (WHO, n.d.) offers a Surgical Safety (DVT) (clot formed in the deep veins) after total knee and hip surgery Checklist that ensures effective communication and safe practices dur- is a never event and thus refused to pay medical expenses for hospital- ing three perioperative periods: prior to administration of anesthesia, acquired DVTs (AHRQ, 2019; CMS, 2020). In addition, the CDC prior to skin incision, and prior to the patient leaving the operative area. found that between 2007 and 2009 over 550,000 patients had a dis- Hospitals and surgical outpatient centers can modify or add to the charge diagnosis of VTE (CDC, 2020a). If a patient develops a DVT checklist based on their practice guidelines. TJC National Patient Safety  CHAPTER 50 Perioperative Nursing Care 1419 Goals address the importance of accurate patient identification and Several methods have been suggested to provide preoperative edu- communication (TJC, 2021). cation. The use of videos allows the patient to reflect on an upcoming surgery, but videos are less effective than verbal communication. Verbal Glycemic Control and Infection Prevention communication allows the patient to ask questions and clarify concerns Perioperative nurses play a key role in monitoring patients throughout about the surgical process. Other commonly used methods include the perioperative experience. When a patient has diabetes or prediabetes, preadmission group classes, booklets and brochures, and individual monitoring of blood glucose levels is imperative. Evidence supports a preoperative meetings with a nurse (Burgess et al., 2019). relationship between wound and tissue infection and surgical patients’ Current evidence demonstrates improved patient outcomes from blood glucose levels. Poor control of blood glucose levels (specifically preoperative education, including a reduced length of stay, a decrease hyperglycemia) during and after surgery increases patients’ risks for in anxiety, and a reduced risk for postoperative complications (Burgess adverse outcomes, such as wound infection and mortality. Controlling et al., 2019; Iqbal et al., 2019). In addition, preoperative education has blood sugars perioperatively reduces mortality in patients with or with- been shown to lessen postoperative pain, reduce agency costs, and out diabetes who have general surgery and in patients who have cardiac lessen postoperative depression (Burgess et al., 2019). Education about surgery (van den Boom et al., 2018). Perioperative assessment of patients the surgical experience increases patient satisfaction and knowledge, coupled with appropriate insulin administration is a critical standard speeds up the recovery process, and facilitates a return to functioning of care. (Harding et al., 2020). Pressure Injury Prevention Patients who have surgery pose a unique challenge in pressure injury prevention (Joseph et al., 2019). Nursing research reveals that patients CRITICAL THINKING are at risk intraoperatively for pressure injuries as a result of intrinsic, Successful critical thinking applied with nursing judgment requires a extrinsic, and specific OR risk factors (EPUAP, NPIAP, PPPIA, 2019): synthesis of knowledge, experience, environmental conditions, criti- Intrinsic risks (patient’s tolerance to a pressure injury insult)— cal thinking attitudes, and intellectual and professional standards. altered nutrition (albumin levels #3 g/dL), decreased mobility, Clinical judgment requires you to reflect on the knowledge you have older age, decreased mental status, infection, incontinence, im- in order to anticipate what to assess about a patient, such as knowing paired sensory perception, and co-morbidities such as diabetes, common surgical risk factors, the type of surgery, and what questions malnutrition, and weight (Kim et al., 2017; Saghaleini et al., 2018). should patients address preoperatively. Clinical judgment involves Extrinsic risks (variables that increase tissue susceptibility to sustain analyzing patient assessment findings, recognizing patterns of data, external pressure)—temperature, friction and shearing forces, and forming accurate nursing diagnoses, and then planning and deliver- moisture. ing a patient-centered plan of care. During assessment, consider all OR risk factors—length and type of surgery, position on OR table, elements that build toward making an appropriate nursing diagnosis positioning devices used, warming devices, anesthetic agents, intra- (Fig. 50.1). operative hemodynamics, and length of time on the OR bed. When caring for a surgical patient, integrate your knowledge Although there are numerous potential risk factors, more research is regarding the patient’s specific clinical situation and type of surgery needed to determine which type(s) of surgery contribute to the develop- along with your previous experiences in caring for surgical patients. ment of pressure injuries and which clinical condition(s) most likely This enables you to form questions to ask about the patient’s expecta- contribute to the development of pressure injuries in the postoperative tions and familiarity with the surgery. Apply this knowledge using a period (Bulfone et al., 2018). patient-centered care approach, partnering with your patient to make A preoperative assessment should include screening for these risk clinical decisions. Using critical thinking attitudes (see Chapter 15) factors. Registered nurses assist in preventing pressure injuries intraop- ensures that your assessment and plan of care are comprehensive and eratively by carefully positioning patients and using pressure-relieving incorporates evidence-based principles for successful perioperative surfaces. Positioning is a shared responsibility among the surgeon, the care. A key attitude for a perioperative nurse is responsibility (i.e., anesthesia provider, and OR nurses. The optimal position often involves being responsible not only for standards of care but being a patient a compromise between the best position for surgical access and the posi- advocate as well). Professional perioperative standards developed by tion a patient can tolerate (Welch, 2020). After surgery, perform a careful the Association of periOperative Registered Nurses (AORN, 2020a) skin assessment and use appropriate pressure-reduction strategies (see (http://www.aorn.org) and the American Society of PeriAnesthesia Chapter 48). Nurses (ASPAN, 2019) (http://www.aspan.org/) provide valuable Jeff reviews his knowledge of the surgical process and knows that Mr. guidelines for perioperative management and the evaluation of Cooper has never undergone surgery before this admission. Jeff uses his process and outcomes. TJC Hospital National Patient Safety Goals previous knowledge of surgery and surgical risk factors to identify areas to include two sets of recommendations for perioperative care—to pre- assess and lab results to review. He also knows that Mr. Cooper has been vent infection and to prevent mistakes in surgery (TJC, 2021). Always calling the surgical center with questions, so Jeff wants to ensure that he review these guidelines within the context of emerging evidence- allows time to answer all of Mr. Cooper’s questions. based practice, agency policies, and the scope of practice of the state in which you practice. Preoperative Education Preoperative education has been linked through research to improved patient outcomes in the postoperative phase of care (Koivisto et al., REFLECT NOW 2020). Current evidence suggests that patients who receive preoperative education demonstrate reduced anxiety levels and more realistic postop- Think about a patient you cared for during his or her surgical experience. erative expectations (Burgess et al., 2019). In addition, education allows Develop a communication hand-off for your patient that you would use to for preoperative collaborative decision making that allows the patient to report to the nurse on the next shift. make better choices (Burgess et al., 2019). 1420 UNIT 7 Physiological Basis for Nursing Practice Knowledge Base Anatomy and physiology of affected body systems Type of surgical procedure to be performed Pathophysiology of selected surgical conditions Surgical stress response Surgical risk factors Infection control practices n Ass atio Attitudes valu es sm Environment E en t Use discipline to obtain Evaluate Recognize complete and correct history outcomes cues Impact of surgical medical devices and procedures Use perseverance to ensure a on time and task comprehensive assessment complexity tation Clinical Display humility in Take Decision Analyze Resources for other recognizing limitations in action Making cues therapies (e.g., urinary D knowledge men catheter equipment and iagn Be responsible; display respect additional personnel) ple os for patients' cultural preferences Generate Prioritize Interruptions is Im solutions hypotheses Standards Experience Planning ANA Standards and Scope of Nursing Practice Caring for patients who have had surgery Clinical Practice Guidelines and Standards Caring for patients at risk for surgical of Practice complications Intellectual standards in measurement Personal experience with surgery Agency policies and procedures Professional ° Standards of Care (Association of periOperative Nurses [AORN], American Society of PeriAnesthesia Nurses [ASPAN]) ° Ethical standards FIG. 50.1 Critical thinking model for surgical patient assessment. (Clinical Judgment Measurement Model copyright © NCSBN. All rights reserved.) nursing interventions, and establish outcomes in collaboration with PREOPERATIVE SURGICAL PHASE patients and their families. It is a nurse’s responsibility to communicate pertinent data and the plan of care to surgical team members. NURSING PROCESS Many hospitals have developed Enhanced Recovery After Surgery The nursing process provides a clinical decision-making approach that (ERAS) protocols that are implemented in the preoperative, intraopera- involves the application of critical thinking and sound clinical judg- tive, and postoperative phases of care (Ricciardi et al., 2020). The proto- ment. Patients having surgery enter the health care setting in different cols are interprofessional and based on published scientific evidence. levels of health. For example, a patient may enter the hospital or ambu- Elements of an ERAS protocol might include minimally invasive surgical latory surgery center (ASC) on a predetermined day feeling relatively approaches instead of large incisions, management of fluids to seek fluid healthy and prepared to face elective surgery, while another person in balance rather than large volumes of intravenous fluids, avoidance of a motor vehicle crash will face emergency surgery with no time to or early removal of drains and tubes, early mobilization, and the serving prepare. The ability to establish rapport and maintain a professional of drinks and food the day of an operation (Ljungqvist et al., 2017; relationship with a patient and the patient’s family is essential during Ricciardi et al., 2020). An ERAS protocol will include evidence-based the preoperative phase. Patients having surgery meet many health care standards for preoperative and postoperative care as well as clinical personnel, including surgeons, nurse anesthetists, anesthesiologists, guidelines established by an agency. Clinical judgment is needed even surgical technologists, and nurses. All play a role in a patient’s care and when a patient is placed on an ERAS protocol. The appropriateness of recovery. Family members attempt to provide support through their the various components of an ERAS protocol and any unexpected clini- presence but face many of the same stressors as the patient. As a nurse cal changes a patient might experience need to be monitored to make you need to form a caring relationship (see Chapter 7) and effectively clinical decisions about completing interventions. communicate (see Chapter 24) with the patient and family to gain the patient’s trust. This helps you to assess in-depth the information needed Assessment to accurately identify nursing diagnoses and problems and provide a During the assessment process, thoroughly assess each patient and patient-centered plan of care. Cultural sensitivity is equally important critically analyze findings to ensure that you make patient-centered in developing a patient-centered plan of care reflecting the patient’s clinical decisions required for safe nursing care. The goal of the preop- physical, psychological, emotional, sociocultural, and spiritual well- erative assessment is to consider what is normal for a planned surgical being (see Chapter 9). You will learn to recognize a patient’s degree of procedure, including the anticipated physiological effects, and to com- surgical risk, coordinate diagnostic tests, identify nursing diagnoses and pare with a patient’s baseline preoperative status. Your assessment will  CHAPTER 50 Perioperative Nursing Care 1421 also reveal the presence of any surgical risks so that you can recognize, medical conditions that increase the risk of complications during or prevent, and minimize possible postoperative complications. The after surgery (Table 50.4). This information allows you to anticipate extent of a nurse’s assessment depends on the patient’s condition, what some of the preliminary treatments will be before surgery. For the surgical setting (outpatient versus inpatient), the time the nurse example, a patient who has a history of heart failure is at risk for a has with a patient, and the urgency of a procedure. Ambulatory and further decline in cardiac function during and after surgery. The same-day surgical programs offer challenges in gathering a complete patient with heart failure in the preoperative period often requires assessment in a short time. In these settings, an interprofessional team beta-blocker medications, intravenous (IV) fluids infused at a slower approach is essential. Patients are admitted only hours before surgery; rate, or administration of a diuretic after blood transfusions. Box 50.1 consequently, it is important for a nurse to organize and verify data provides a list of assessment questions for a patient with a cardiac obtained before surgery and implement a perioperative plan of care. history. If a patient has surgical risks from medical conditions, surgery This occurs both in ASCs and with patients who require a hospital stay. as an outpatient may be inadvisable, or special precautions will be Most surgical assessments begin before admission in the health care necessary. In addition, the history includes questions about a family provider’s office, a preadmission clinic, an anesthesia clinic, or by tele- history of anesthetic complications such as malignant hyperthermia phone. Some patients answer a self-report inventory before arriving at a (an inherited disorder and life-threatening condition) that may occur center. Other times a health care provider performs a physical examina- during surgery. tion or orders laboratory tests. Nurses begin to teach, answer questions, and complete paperwork before surgery to streamline patient care on Surgical History. A review of a patient’s past experience with surgery the day of surgery. When surgery is emergent with little time available, reveals physical and potential psychological responses that may occur you prioritize an assessment based on the patient’s presenting clinical during the planned procedure. Complications such as anaphylaxis or condition and risk factors. malignant hyperthermia during previous surgeries alert you to the need for preventive measures and the availability of appropriate emergency Through the Patient’s Eyes. When possible, it is important to deter- equipment. For example, if a patient experienced an allergic reaction to mine a patient’s expectations of surgery and recovery. Ask a patient latex during a previous surgery, you would document the patient’s his- what is hoped to be gained as a result of surgery. Explore with questions tory and ensure that a latex-free environment is provided for the patient such as “Tell me the type of surgery you are having in your own words” during hospitalization. or “Do you understand the expected care and how long you will stay in A history of postoperative complications such as persistent vomit- the hospital after surgery? If not, what do you want to know?” or “Do ing or uncontrolled pain will lead to the selection of more appropriate you expect full pain relief or simply to have your pain reduced after medications (as ordered by the medical team). Reports of severe anxiety surgery?” and “Do you expect to be independent immediately after before a previous surgery identify the need for additional emotional surgery, or do you expect to be fully dependent on the nurse or your support, medications, and preoperative teaching. Always inform the family?” These are only a few of the questions to ask to establish a plan surgeon and/or anesthesiologist of these findings, especially when of care that matches a patient’s needs and expectations. Listen to the medications may be indicated. patient’s explanation, be attentive, and explain expectations of surgery. Form a relationship with each patient to foster collaboration and shared Risk Factors. Knowledge of potential surgical risk factors and risk decision making. Assessing patient expectations gives you a better factors for complications (e.g., pressure injuries) provides focus for the understanding of the patient’s health and health care needs. preoperative assessment. The assessment data from careful screening As Jeff begins his assessment of Mr. Cooper, he uses knowledge of the of patients will contain information useful for necessary precautions in surgical process, including knowledge of cancer and the gastrointestinal planning perioperative care. Consider any risk factors described earlier system. He always includes his past experience with patients with surgical that may contribute to negative outcomes, and collaborate closely with procedures. When Jeff talks with Mr. Cooper, he finds out that Mr. Cooper the health care provider to identify necessary therapies. has talked with his surgeon and learned that he is going to need a colos- A patient’s risk for developing pressure injuries intraoperatively tomy. Jeff asks Mr. Cooper additional history questions regarding what he cannot be adequately assessed using the standard Braden Scale, as the understands about his preoperative preparations and any concerns he Braden was not developed to target intraoperative risk factors. The might have about his impending surgery. Munro Pressure Ulcer Risk Assessment Scale for Perioperative Patients and the Scott Triggers Risk Assessment Tool are two scales recom- Nursing History. A preoperative nursing history includes informa- mended by AORN (n.d.). The Munro Scale is a cumulative scale that tion about all body systems, similar to that described in Chapter 30. If assesses risk factors present in each of the different operative phases a patient is unable to relay all of the necessary information, rely on (Munro, 2019). The preoperative scale includes mobility, nutritional family members (if appropriate) as resources. As with any admission state, weight loss, BMI, and co-morbidities (Munro, 2019). The intra- to a health care agency, include information about advance directives. operative scale includes physical status classification according to the Ask whether a patient has a durable power of attorney for health care American Society of Anesthesiologists (ASA) scale, type of anesthesia, or a living will (see Chapter 23), and include a copy in the patient’s moisture, surface/motion, hypotension, and body temperature (Munro, medical record. Often directives are modified before surgery but are 2019). The postoperative component of the scale includes length of the reestablished after postoperative stabilization. To help ensure a thor- surgical procedure and occurrence of hemorrhage (AORN, n.d.). The ough and accurate nursing assessment, electronic health records benefit of the Munro tool is that it allows nurses to complete the tool at (EHRs) provide standardized documentation forms for data. Be sure each surgical phase, increasing the frequency of risk assessments. The to use all drop-down menus to portray a patient’s history most clearly, Scott Triggers tool is a single preoperative measure that assesses a pa- but also be willing to enter full-text descriptions as needed. tient’s age, albumin or BMI values, ASA classification, and estimated duration of the surgery (Park et al., 2019). Medical History. A review of a patient’s medical history includes Preoperatively, some patients need to stop taking medications (e.g., past illnesses and surgeries and the primary reason for seeking medi- anticoagulants) that may affect surgical outcomes and medications cal care. The medical history screens surgical candidates for major that may pose risks based on a potential for drug-to-drug interaction 1422 UNIT 7 Physiological Basis for Nursing Practice TABLE 50.4 Medical Conditions That Increase Risks of Surgery Type of Condition Reason for Risk Bleeding disorders (thrombocytopenia, hemophilia) Increases risk of hemorrhage during and after surgery. Diabetes mellitus Increases susceptibility to infection and impairs wound healing from altered glucose metabolism and associated circulatory impairment. Stress of surgery often results in hyperglycemia (Harding et al., 2020). Heart disease (recent myocardial infarction, dysrhythmias, Stress of surgery causes increased demands on myocardium to maintain cardiac output. General heart failure) and peripheral vascular disease anesthetic agents depress cardiac function. Hypertension Increases risk for cardiovascular complications during anesthesia (e.g., stroke, inadequate tissue oxygenation). Obstructive sleep apnea Administration of opioids increases risk of airway obstruction after surgery. Patients desaturate as revealed by drop in oxygen saturation by pulse oximetry. Upper respiratory infection Increases risk of respiratory complications during anesthesia (e.g., pneumonia and spasm of laryngeal muscles). Renal disease Alters excretion of anesthetic drugs and their metabolites, increasing risk for acid-base imbalance and other complications. Liver disease Alters metabolism and elimination of drugs administered during surgery and impairs wound healing and clotting time because of alterations in protein metabolism. Fever Predisposes patient to fluid and electrolyte imbalances and sometimes indicates underlying infection. Chronic respiratory disease (emphysema, bronchitis, Reduces patient’s means to compensate for acid-base alterations (see Chapter 42). Anesthetic agents asthma) reduce respiratory function, increasing risk for severe hypoventilation. Immunological disorders (leukemia, acquired Increases risk of infection and delayed wound healing after surgery. immunodeficiency syndrome [AIDS], bone marrow depression, and use of chemotherapeutic drugs or immunosuppressive agents) Abuse of alcohol, opioid addiction Alcohol abuse is associated with liver dysfunction and may interfere with the effects of anesthesia. Opioid addiction may result in health care and self-care neglect. Consequently, patients may have underlying diseases that may affect wound healing. Chronic pain Regular use of pain medications often results in higher tolerance. Increased doses of analgesics are sometimes necessary to achieve postoperative pain control. Data from Mohabir PK: Preoperative evaluation, 2021, Merck manual professional version. https://www.merckmanuals.com/professional/special- subjects/care-of-the-surgical-patient/preoperative-evaluation. Last revised November 2020. Accessed September 2021; and Harding M, et al: Lewis’s medical-surgical nursing: assessment and management of clinical problems, ed 11, St Louis, 2020, Elsevier. BOX 50.1 Nursing Assessment Questions: Cardiac History Nature of the Problem When do your feet swell (all the time, end of the day, only after a busy day)? Do you have a history of heart attack, heart failure, angina (chest pain), When do you become short of breath? irregular heartbeat, or valve disease? Which medications do you take? Severity Tell me about any vitamins or other supplements you are taking. On a scale of 0 to 10 (with 0 being no pain and 10 the worst pain), what Have you had any recent medical testing or procedures on your heart (e.g., number do you give your chest pain? cardiac catheterization or echocardiogram)? Describe your usual activity level. Can you climb stairs; can you do housework? Do you smoke cigarettes, including e-cigarettes? If so, how often and how Describe the amount of physical activity you have daily. Tell me about the many per day? types of exercise you perform. Signs and Symptoms Self-Management and Culture Are you having any chest pain? Have you changed your activity level, sleep patterns, diet, or fluid intake How do you sleep at night (position, use of pillows, awakened with chest recently? pain)? Are you taking any herbal or over-the-counter medications? Do your feet swell? Are you short of breath, or do you have any difficulty breathing? Through the Patient’s Eyes How are you feeling about your upcoming surgery? Has it affected your Onset and Duration symptoms? How often do you have chest pain, when does it start, how long does it last, Are you currently having any additional stress? what alleviates it?  CHAPTER 50 Perioperative Nursing Care 1423 BOX 50.2 The STOP-BANG Questionnaire TABLE 50.5 Medications With Special To determine whether a patient has obstructive sleep apnea (OSA) many agencies Implications for the Surgical Patient use the STOP-Bang assessment tool (below). (Any question answered Yes is Drug Class Effects During Surgery a risk factor.) Antibiotics Potentiate (enhance action of) anesthetic agents. If taken within 2 weeks before surgery, aminoglycosides STOP (gentamicin, neomycin, tobramycin) may cause mild Do you SNORE loudly (louder than talking or loud enough to be heard respiratory depression from depressed neuromuscular through closed doors)? transmission. Do you often feel TIRED, fatigued, or sleepy during the daytime? Has anyone OBSERVED you stop breathing during your sleep? Antidysrhythmics Medications (e.g., beta blockers) can reduce cardiac Do you have or are you being treated for high blood PRESSURE? contractility and impair cardiac conduction during anesthesia. BANG Anticoagulants Medications such as warfarin or aspirin alter normal BMI greater than 35 kg/m2 clotting factors and thus increase risk of hemorrhaging. AGE over 50 years old Discontinue at least 48 hours before surgery. NECK circumference "40 cm (16 inches) Anticonvulsants Long-term use of certain anticonvulsants (e.g., GENDER: Male phenytoin and phenobarbital) alters metabolism Modified from Kawada T: Screening ability of STOP-Bang questionnaire of anesthetic agents. for obstructive sleep apnea, Anesthesia & Analgesia 128(3): e48, 2019; Antihypertensives Medications such as beta blockers and calcium Olson E, et al: Surgical risk and the preoperative evaluation and channel blockers interact with anesthetic agents management of adults with obstructive sleep apnea, UpToDate, to cause bradycardia, hypotension, and impaired 2020a, https://www.uptodate.com/contents/surgical-risk-and-the- circulation. They inhibit synthesis and storage preoperative-evaluation-and-management-of-adults-with-obstructive- of norepinephrine in sympathetic nerve endings. sleep-apnea. Corticosteroids With prolonged use, corticosteroids cause adrenal atrophy, reducing the ability of the body to withstand stress. Before and during surgery, (Muluk et al., 2020). Carefully screen patients who have signs and dosages are often increased temporarily. symptoms of suspected OSA. Include the patient’s sleeping partner as Insulin A patient’s insulin requirements fluctuate after appropriate to assess for signs of OSA such as snoring. Also, determine surgery. For example, some patients need the patient’s use of continuous positive airway pressure (CPAP), non- increased doses due to the stress response from invasive positive-pressure ventilation (NIPPV), or apnea monitoring surgery. Other patients need less insulin due to at home. Instruct a patient who uses CPAP or NIPPV to bring the decreased nutritional intake following surgery. machine to the hospital or surgery center. Many health care agencies Diuretics Diuretics such as furosemide potentiate electrolyte are now making OSA screening mandatory, using evidence-based tools imbalances (particularly potassium) after surgery. such as the STOP-Bang sleep apnea assessment tool (Box 50.2) (Kawada, 2019; Olson et al., 2020a). If the STOP-Bang is unavailable, Nonsteroidal NSAIDs (e.g., ibuprofen) inhibit platelet aggregation screen patients with simple questions regarding snoring, apnea during antiinflammatory and prolong bleeding time, increasing susceptibility sleep, frequent arousals during sleep, morning headaches, daytime drugs (NSAIDs) to postoperative bleeding. somnolence, and chronic fatigue (Kawada, 2019). Herbal therapies: These herbal therapies have the ability to affect Some patients need a detailed nutritional assessment to determine ginger, ginkgo, platelet activity and increase susceptibility to surgical risk. If a patient presents with signs of malnutrition, perform a ginseng postoperative bleeding. Ginseng increases nutritional screening using your agency’s tool, or confer with a registered hypoglycemia with insulin therapy. dietitian (see Chapter 45). Data from Kuwajerwala K: Perioperative medication management, 2021, Merck manual professional version. https://www.merckmanuals. Medications. Review a patient’s medications to determine whether com/professional/special-subjects/care-of-the-surgical-patient/ any medications may increase the risk for surgical complications preoperative-evaluation. Last reviewed November 2020. Accessed (Table 50.5). Include all prescribed, OTC, and herbal medications September 27, 2021; Muluk V, et al.: Perioperative medication in your assessment. Many medications interact unpredictably with management, UpToDate, 2020, https://www.uptodate.com/contents/ anesthetic agents during surgery (Burchum and Rosenthal, 2019). perioperative-medication-management. Sometimes surgeons temporarily discontinue or adjust doses of a patient’s prescription, over-the-counter (OTC) medications, and/or herbal supplements before surgery. For example, there are various automatically after surgery unless reordered. It is important that as a medical opinions about when to hold an oral anticoagulant and patient moves through different areas (e.g., from the holding area to whether to continue therapy through certain surgical procedures the OR), a complete list of medications is communicated accurately (Douketis and Lip, 2020). Nurses in an outpatient setting should during the hand-off report (TJC, 2021). verify with surgeons which, if any, medications patients should take or withhold on the morning of surgery. Often preprinted instruction Allergies. Allergies to medications, latex, and topical agents used to sheets given to patients in physician offices contain this information. prepare the skin for surgery create significant risks for patients and When working in an acute care setting, confirm with the surgeon all staff during surgery. An allergic response to any agent is potentially discontinued medications. If a patient is having inpatient surgery, fatal, depending on severity. Latex allergies affect 8% to 12% of the all prescription medications taken before surgery are discontinued health care workforce (OSHA, n.d.). Patients most at risk for a latex 1424 UNIT 7 Physiological Basis for Nursing Practice allergy include people with a genetic predisposition to latex allergy, patient has surgery only on an emergent or urgent basis. Because all of a children with spina bifida, patients with urogenital abnormalities or mother’s major systems are affected during pregnancy, the risk for intra- spinal cord injury (because of a long history of urinary catheter use), operative complications increases. General anesthesia is administered patients with a history of multiple surgeries, health care professionals, with caution because of the increased risk of fetal death and preterm and workers who manufacture rubber products. Patients with an labor. Regional anesthesia is used in preference to general anesthesia allergy to certain foods such as bananas, chestnuts, kiwifruit, avocados, when appropriate (Sviggum, 2020). Psychological assessment of mother potatoes, tomatoes, and wheat often have a cross-sensitivity to latex and family is also essential. (Hamilton, 2020). Symptoms of a latex allergy vary in severity (e.g., contact dermatitis with redness, inflammation, and blisters; contact Perceptions and Knowledge Regarding Surgery. A patient’s past urticaria with pruritus, redness, and swelling; hay fever–like symp- experience with surgery influences potential physical and psychologi- toms; and anaphylaxis). When you identify a patient allergy, provide cal responses to a procedure. Assess the patient’s previous experiences an allergy identification band at the time of admission that remains on with surgery as a foundation for anticipating and identifying needs until discharge. List all allergies in the patient’s medical record. It is and selecting appropriate interventions, including teaching, addressing also common to list allergies on the front of paper charts. fears, and clarifying concerns. Ask the patient to discuss the previous type of surgery, level of discomfort, extent of disability, and overall Smoking Habits. Screen all patients for a history of smoking, includ- level of care required. Review any past medical records, if available, for ing cigarettes, cigars, electronic cigarettes, and pipes. This is usually surgical complications. Address any complications that the patient included in the nursing health history. Use “pack-years” as a guide to experienced. Prior anesthesia records are also a useful source of infor- determine the number of cigarette packs smoked per day and the mation if previous surgical problems occurred. number of years the patient has smoked. In addition, ask the patient The surgical experience affects the family unit as a whole. Under- about the use and frequency of other nicotine products such as snuff standing a patient’s and family’s knowledge and expectations (following and chewing tobacco. Use this information to plan for aggressive pul- discharge) allows you to plan teaching and provide individualized emo- monary hygiene, including more frequent turning, deep breathing, tional support measures. In many instances, patients fear surgery. Some coughing, and the use of incentive spirometry after surgery. fears are the result of past hospital experiences, warnings from friends and family, or lack of knowledge. Assess the patient’s understanding of Alcohol Ingestion and Substance Use and Abuse. Habitual use planned surgery, its implications, and planned postoperative activities. of alcohol or illegal drugs and the misuse of prescription drugs predis- Ask questions, such as “Tell me what you think will happen before and pose patients to adverse reactions to anesthetic agents. Some patients after surgery” or “Explain what you know about surgery.” Nurses face experience a cross-tolerance to anesthetic agents and analgesics, result- ethical dilemmas when patients are misinformed or unaware of the ing in the need for higher-than-usual doses. Patients with a history of reason for surgery. Confer with the surgeon if a patient has an inaccu- excessive alcohol ingestion are often malnourished, which delays rate perception of the surgical procedure before the patient is sent to the wound healing. These patients are also at risk for liver disease, portal surgical suite. Further, determine whether the health care provider ex- hypertension, and esophageal varices (which increase the risk of bleed- plained routine preoperative and postoperative procedures, and assess ing). A patient who habitually uses alcohol and is required to remain the patient’s readiness and willingness to learn. Reinforce the patient’s in the hospital longer than 24 hours is also at risk for acute alcohol knowledge of the surgical procedure and postoperative expectations. withdrawal and its more severe form, delirium tremens (DTs). It is important to assess all age-groups because there is a high preva- Support Sources. Have your assessment include the identification of the lence of at-risk drinking and binge drinking in adults ages 18 years and patient’s primary family caregiver or family support person. The patient older (CDC, 2019). It is common for patients to not disclose their use of usually cannot immediately assume the same level of physical activity en- alcohol or illegal drug use. Begin the assessment by asking the patient joyed before surgery. With ambulatory surgery, patients and/or family about the consumption of wine, beer, whiskey, or other forms of alcohol. caregivers assume responsibility for postoperative care immediately. The Assess the number of drinks the patient has during a typical day or week. family caregiver is an important resource for a patient with physical limita- Also ask about the use of illegal drugs and the use of prescription drugs, tions and provides the emotional support needed to motivate the patient including the type, frequency, and method of delivery. Some health care to return to the previous state of health. Ask the family caregiver about the agencies require the use of screening tools such as the Alcohol, Smoking type of support provided. Is it sufficient to meet the patient’s needs? What and Substance Involvement Screening Test (ASSIST) to assess a patient’s level of instruction or support is required? use of illegal drugs, smoking, and/or misuse of prescription drugs or the Sometimes the family caregiver remembers preoperative and postop- Alcohol Use Disorders Identification Test (AUDIT) to screen for alcohol erative teaching better than the patient. Patients having ambulatory use problems (National Institute on Alcohol Abuse and Alcoholism, n.d.; surgery will receive a postdischarge phone call to evaluate their recovery. Saitz, 2020). Your findings will help in the planning of anesthetic and Sometimes patients, especially older adults, are unable to hear or reach a pain management. In addition, it is important postoperatively to con- phone after surgery. Ask whether a family member will be staying with sider opportunities to counsel those patients whose use of alcohol or the patient to answer the phone. The nurse’s responsibility is to fully illicit drugs is excessive. prepare a patient and any family caregiver for patient self-care if the patient returns home. This includes providing information that allows Pregnancy. During preoperative assessment, routinely ask women of the patient to anticipate any problems, know the activity level to assume, childbearing age who are scheduled for surgery about their last men- and be able to perform care measures (e.g., medication administration, strual period and whether it was “typical” for them. Also ask whether dressing changes, prescribed exercises). Often a family member becomes they have had unprotected sex in the past month. Because many women the patient’s coach, offering valuable support after surgery when a do not know they are pregnant early in the first trimester, many institu- patient’s participation in care is vital. tions require a pregnancy test when a patient is scheduled for surgery. If a woman is pregnant, the perioperative plan of care addresses not Occupation. Surgery often results in physical changes and restrictions one, but two patients: the mother and the developing fetus. A pregnant that prevent a person from immediately returning to work. Assess the  CHAPTER 50 Perioperative Nursing Care 1425 patient’s occupational history to anticipate the possible effects of sur- sexual dysfunction requires understanding and support. Hold discus- gery on recovery, the time it will take to return to work, and eventual sions about the patient’s sexuality with the patient’s sexual partner so work performance. Knowing the type of surgery, anticipate the post- that the partner gains a shared understanding of how to cope with operative restrictions that will be set by the health care provider (e.g., limitations in sexual function (see Chapter 34). limits on lifting or walking), and assess the patient’s perceptions of Coping Resources. Assessment of patients’ feelings and self-concept the extent this will affect the ability to return to work. This will help reveals whether they have the ability to cope with the stress of surgery. establish realistic expectations for the patient postoperatively. Thus, ask a patient about perceptions of the upcoming surgery and whether there are other sources of stress in the patient’s life. How is the Preoperative Pain Assessment. Surgical manipulation of tissues, stress affecting life currently? How does the patient typically deal with treatments, and positioning on the OR table contribute to postoperative stressful situations? If your patient has limited coping resources, your pain. However, patients also often present preoperatively with painful assessment findings will guide you in planning for stress management conditions. Conduct a comprehensive pain assessment before surgery postoperatively by offering healthy coping strategies (see Chapters 32 (see Chapter 44), including the character of any existing pain and the and 37), initiating more frequent or comprehensive discussions about patient’s and family’s expectations for pain management after surgery. surgery, knowing how to involve family, and involving social work or Ask patients to describe their perceived tolerance to pain, past experi- clergy as needed. ences, and prior successful interventions, especially nonpharmacological therapies. Cultural and Spiritual Factors. Culture is a system of beliefs and values developed over time and passed on through many generations Review of Emotional Health. Surgery is psychologically stressful (see Chapter 9). Each patient is unique in perceptions and reactions to and creates anxiety in patients and their families. Patients often feel the surgical experience. If you do not acknowledge and plan for cultural powerless over their situation. Potential disruptions in lifestyle, a and spiritual differences in the perioperative plan of care, your patient lengthy recovery period at home, and uncertainty about the long-term may not achieve desired surgical outcomes (Box 50.3). To bridge effects of surgery on a patient’s life place stress on patients and their cultural differences, listen to a patient’s story, and explore and respect families. When a patient has a chronic illness, the family is either fear- the patient’s beliefs as well as their meaning of illness, preferences, and ful that surgery will result in further disability or hopeful that it will needs. Understanding a patient’s cultural and ethnic heritage helps the improve the patient’s lifestyle. To understand the effect of surgery on a nurse care for a patient having surgery. Although it is important patient’s and family’s emotional health, assess the patient’s feelings about surgery, self-concept, body image, and coping resources. It is difficult to assess a patient’s feelings thoroughly when ambula- tory surgery is scheduled because