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(Relates to Chapter 18, “Nursing Management:
Preoperative Care,” in the textbook)
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Art and science of treating diseases, injuries, and deformities by operation and instrumentation
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Performed for◦ Diagnosis◦ Cure◦ Palliation◦ Prevention◦ Exploration◦ Cosmetic improvement
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Inpatient ◦ Same day admission
Ambulatory (outpatient)◦ Usually less than 3 to 4 hours in PACU
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Check documented information prior to interview◦ Avoids repetition
Occurs in advance or on day of surgery
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Purpose◦ Obtain health information◦ Determine expectations◦ Provide and clarify information on procedure◦ Assess emotional state and readiness
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Overall goal◦ Identify risk factors◦ Plan care to ensure patient safety
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Determine psychologic status to reinforce coping strategies
Determine psychologic factors of procedure contributing to risks
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Establish baseline data Identify medications and herbs taken that
may affect surgical outcome Identify, document, and communicate
results of laboratory/diagnostic tests
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Identify cultural and ethnic factors that may affect surgical experience
Determine receipt of adequate information from surgeon in order to sign informed consent
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Psychosocial assessment◦ Excessive stress response can be magnified and
recovery affected
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Influencing factors◦ Age◦ Past experience◦ Current health◦ Socioeconomic status
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Use common language Use translators if needed
◦ Decreases level of anxiety Communicate all concerns to surgical team
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Anxiety can impair cognition, decision making, and coping abilities◦ Lack of knowledge◦ Unrealistic expectations◦ Information lessens anxiety
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Anxiety may arise from conflict with interventions (e.g., blood transfusions) and religious/cultural beliefs ◦ Identify beliefs and discuss with surgeon and
operative staff
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Fears◦ Death or disability
May prompt postponement Influence outcome
◦ Pain Consult with ACP Reassure that drugs will be available
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Fears ◦ Mutilation/alteration in body image
Assess concerns nonjudgmentally◦ Anesthesia
ACP for consult Assess malignant hyperthermia risk
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Fears◦ Disruption of life functioning
Range from fear of permanent disability to temporary loss
Include family and financial concerns Consultations PRN
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Hope◦ May be strongest positive coping mechanism
Never deny or minimize◦ Assess and support
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Health history◦ Diagnosed medical conditions◦ Previous surgeries and problems◦ Menstrual/obstetric history
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Health history ◦ Familial diseases
Conditions◦ Reactions/problems to anesthesia (patient or
family)
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Current medications◦ Prescription and OTC◦ Herbs◦ Vitamins◦ Recreational
Drugs Alcohol Tobacco
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Allergies (drug and nondrug) Screen areas:
◦ Risk factors◦ Contact urticaria◦ Aerosol reactions◦ History of reactions suggesting latex allergy
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Cardiovascular system◦ Report
Problems for effective monitoring Use of cardiac drugs Presence of pacemaker/MI
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Cardiovascular system◦ Vitals recorded preoperatively for baseline◦ Bleeding/clotting times◦ Laboratory reports◦ Possible prophylactic antibiotics
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Respiratory system◦ Inquire about recent airway infections
Procedure could be cancelled because of increased risk of laryngo/bronchospasm or decreased SaO2
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Respiratory system◦ History of dyspnea, coughing, or hemoptysis
reported to operative team◦ COPD or asthma
High risk for atelectasis and hypoxemia
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Respiratory system◦ Smokers should be encouraged to quit 6 weeks
before procedure Decreases risk of complications Greater years and number of packs = greater risk
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Nervous system◦ Evaluation of neurologic functioning
Vision or hearing loss can influence results
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Nervous system◦ Cognitive function
Assess or correct any deficits before surgery Durable power of attorney for health care should be
obtained if deficits cannot be corrected
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Nervous system◦ Cognitive function
Postoperative delirium (falsely labeled senility or dementia) can occur with dehydration, hypothermia, and adjunctive medications
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Urinary system◦ History of urinary or renal diseases◦ Renal dysfunction contributes to
Fluid and electrolyte imbalances Increased risk of infection Impaired wound healing Altered response to drugs and their elimination
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Urinary system ◦ Renal function tests◦ Note problems voiding and inform operative team
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Integumentary system◦ History of skin and musculoskeletal problems◦ History of pressure ulcers
Extra padding during procedure Affect postoperative healing
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Musculoskeletal system◦ Identify joints affected with arthritis◦ Mobility restrictions may affect positioning and
ambulation◦ Bring mobility aids to surgery
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Musculoskeletal system ◦ Report problems affecting neck or lumbar spine to
ACP Can affect airway management and anesthesia
delivery
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Endocrine system◦ Patients with diabetes mellitus especially at risk
for: Hypo/hyperglycemia Ketosis Cardiovascular alterations Delayed wound healing Infection
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Endocrine system◦ Patients with diabetes mellitus
Serum glucose tests morning of surgery (baseline) Clarify with physician or ACP if usual dose of insulin
is taken
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Endocrine system◦ Patients with thyroid dysfunction
Hyper/hypothyroidism are surgical risks due to altered metabolic rate
Verify with ACP about giving medications
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Endocrine system◦ Patients with Addison’s disease
Abruptly stopping replacement corticosteroids could cause addisonian crisis
Stress of surgery may require increased dose of corticosteroids
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Immune system◦ Patients with history of compromised immune
system or use of immunosuppressive drugs can have Delayed wound healing Increased risk for infection
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Fluid and electrolyte status◦ Vomiting, diarrhea, or difficulty swallowing can
cause imbalance◦ Identify drugs that alter status
Diuretics◦ Evaluate serum electrolyte levels
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Fluid and electrolyte status ◦ NPO status
May require additional fluids and electrolytes before surgery if dehydration occurs
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Nutritional status◦ Obesity
Stresses cardiac and pulmonary systems Increased risk of wound dehiscence and infection Slower recovery from anesthesia Slower wound healing
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Nutritional status ◦ Provide extra padding to underweight patients to
prevent pressure ulcers◦ Identify dietary habits that may affect recovery
(e.g., caffeine)
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Findings enable ACP to rate patient for anesthesia administration◦ Indicator of perioperative risk and overall
outcome
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Document relevant findings and report to perioperative team
Obtain and evaluate results of laboratory tests
Monitor blood glucose for diabetics
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Preoperative teaching◦ Patient has right to know what to expect and how
to participate Increases patient satisfaction Reduces fear, anxiety, stress, pain, and vomiting
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Preoperative teaching ◦ Limited time available
Address needs of highest priority Include information focused on safety Provide written material
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Preoperative teaching ◦ Several days before surgery
Observe and listen to determine amount of teaching for each session
Anxiety and fear can hinder learning Give priority to patient’s concerns
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Preoperative teaching ◦ Must be documented and reported to
postoperative nurses Avoid duplication of information Assess learning
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Preoperative teaching◦ Teach deep breathing, coughing, and moving for
postop◦ Inform if tubes, drains, monitoring devices, or
special equipment will be used postop
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Preoperative teaching◦ Basic information before arrival
Time and place Fluid and food restrictions Need for enema Need for shower
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Legal preparation◦ All required forms are signed and in chart
Informed consent Blood transfusions Advance directives Power of attorney
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Consent for surgery◦ Informed consent must include
Adequate disclosure Understanding and comprehension Voluntarily given consent
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Surgeon responsible for obtaining consent◦ Nurse may obtain and witness signature◦ Verify patient has understanding◦ Permission may be withdrawn at any time
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Consent for surgery◦ Medical emergency may override need for
consent
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Legally appointed representative of family may consent if patient is◦ Child◦ Unconscious◦ Mentally incompetent
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Day-of-surgery preparation◦ Final preoperative teaching ◦ Assessment and report of pertinent findings◦ Verify signed consent
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Day-of-surgery preparation◦ Labs ◦ History and physical examination◦ Baseline vitals◦ Consultation records◦ Nurse’s notes
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Day-of-surgery preparation ◦ Patient should not wear any cosmetics
Observation of skin color is important Remove nail polish for pulse oximeter
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Day-of-surgery preparation◦ Valuables returned to family member or locked up◦ Dentures, contacts, prostheses are removed◦ Identification and allergy bands on wrist
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Void before surgery◦ Prevents involuntary elimination under anesthesia
or early postoperative recovery◦ Before medication administration
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45-year-old woman presents to holding area for presurgical workup for lumpectomy
The nurse notes consistent fidgeting
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She is unable to articulate details about what surgeon will do or her disease process
She reacts angrily when asked if she would consent to transfusion, if needed