Care of Preoperative Patients – Chapter 14

Preoperative period
• Begins when patient is scheduled for surgery; ends at time of transfer to surgical suite
• Nurse functions as educator, advocate, promoter of health and safety

Reasons for surgery

• Diagnostic – determines origin and cause of disorder
• Curative – resolves health problem by repairing or removing cause
• Restorative – improves patient’s functional ability
• Palliative – relieves symptoms of disease process, but does not cure
• Cosmetic – alters/enhances personal appearance

Urgency and degree of risk of surgery

• Urgency:
- Elective
- Urgent
- Emergent
• Degree of Risk:
- Minor
- Major

Patient Safety:
• Core Safety measures
• Infection Prevention
• Abx before incision
• Hair removal
• Urinary catheter
• Controlled BG in cardiac Pts
• Prevention of Cardiac Events
• Beta Blockers
• DVT Prevention
• Assessment-History
• Risk factors for complications
• >65 years (Chart 14-2)
• Chronic conditions
• Tobacco/drug use
• Herbal supplements
• Assessment-Physical
• Provides baseline
• Report abnormal findings
• Risk for falls
• Prosthetics
• Skin
• Psychosocial assessment
• NPSG Correct site
• Time out
• Patient
• Correct side/site
• Correct position
• Procedure

Older Adults Pediatric Patients

• Changes of aging as surgical risk factors • Informed consent
- Decreased: - Age of majority and competence
o Cardiac output, peripheral circulation - Requirements for obtaining informed consent
o Vital capacity, blood oxygenation - Eligibility for giving informed consent
o Blood flow to kidneys, glomerular filtration - Treatment without parental consent
rate - Adolescent consent and confidentiality
- Increased: - Parental rights to see the child’s medical chart
o Blood pressure • Psychological and physical preparation
o Risk for skin damage, infection • Parental presence
o Sensory deficits • Preoperative sedation
o Deformities related to - Reduces anxiety
osteoporosis/arthritis - Amnesia
 • Considerations for preoperative care - Sedation
- Chronic illness
- Malnutrition
- Impaired self-care ability
- Allergies
- Inadequate support systems
- Stress from surgery/anesthesia
- Cardiopulmonary complications after surgery
- Mental status changes
- Risk for falls

Patient and Family Teaching

• What to expect
- Begins before admission (NPSG)
- Informed consent
 What and Why
 Who
 Other options
 Risks and outcomes
 Risks of anesthesia
- Diet restrictions before and after surgery (ex. NPO)
- Tubes, drains, vascular access
- Medications (what to take or not take before procedure)
- Pre-op preparations: skin/bowel
- Preadmission testing
- Person to care for patient
- Anxiety interventions
- The effects of smoking
 Smoking  the blood level of carboxyhemoglobin (carbon monoxide on oxygen-binding sites of the
hemoglobin molecule), which  oxygen delivery to organs
- Autologous blood donation
 Can be made by the patient a few weeks before surgery – so if blood is needed during surgery it
will be available
• Pain control methods after surgery
- Use of pain scales, PCA
• Prevention of complications
- Use of Incentive Spirometer, coughing, splinting
- TEDs, SCDs, early ambulation (DVT prevention)
 External pneumatic compression devices
- Exercises

Patients at risk for VTE

• VTE or DVT can lead to a PE if the blood clot breaks off and travels to the lungs.
• Patients at greater risk for VTE:
o Obese patients o History of VTE, PE, varicose veins,
o Age 40 or older edema
o History of cancer o Oral contraceptives
o Decreased mobility or immobile o Smoking
o Spinal cord injury o History of decreased cardiac output
o Hip fracture, total hip/knee surgery
• Always assess for VTE before surgery.
• Sudden swelling in one leg is a common physical finding of VTE caused by DVT.
• A patient may feel a dull ache in the calf area that becomes worse with ambulation.
• A careful assessment and timely intervention may prevent the potentially fatal complication of pulmonary embolism.

Physical Assessment/Clinical Manifestations

• Obtain baseline vital signs
• Focus on problem areas identified in history; all body systems affected by surgical procedure
• Report abnormal assessment findings to surgeon/anesthesiology personnel

System Assessment
• Cardiovascular
- CAD, MI within 6 months before surgery, angina, hypertension, dysrhythmias
 • Respiratory
- Chronic respiratory problems
- Smoking increases carboxyhemoglobin blood level, deceases oxygen delivery
• Renal/Urinary
- Kidney impairment inhibits drugs/anesthetic agent excretion
• Neurologic
- Determine baseline
- Assess LOC, ability to follow commands
• Musculoskeletal
• Nutritional status
- Malnutrition and obesity increase surgical risk
• Psychosocial

Laboratory Assessment
• Urinalysis
• Blood type and crossmatch
• CBC or hemoglobin level and hematocrit
• Clotting studies (PT, INR, aPTT)
• Electrolyte levels
- Hyperkalemia: dysrhythmias
- Hypokalemia: slows recovery and risk of digoxin toxicity
• Serum creatinine level
• Pregnancy test
• Chest x-ray
• ECG

Implementing dietary restrictions

• NPO: Patient not to ingest anything by mouth for 6 to 8 hours before surgery:
- Decreases risk for aspiration
- Give patients written/oral directions to stress adherence
- Surgery can be canceled if instructions not followed

Anxiety Interventions
• Preoperative teaching
• Encourage communication
• Promote rest
• Use distraction
• Teach family members

Skin Preparation
• Break in the skin increases risk for infection
• Patient may be asked to shower using antiseptic solution
• Hair removal by electric clippers, depilatories
• Shaving of hair creates risk for infection!

Administering Regularly Scheduled Medications

• Consult with physician and anesthesia provider for instructions
• Drugs for cardiac disease, respiratory disease, seizures, and hypertension are commonly allowed with a sip of water
before surgery.
• Some antihypertensive or antidepressant drugs are withheld on the day of surgery to reduce adverse effects on blood
pressure during surgery.
• Even when beta blockers are not part of a patient's usual medications, they may be prescribed for some patients who
are at risk for cardiac problems
• The patient who takes insulin for diabetes may be given a reduced dose of intermediate- or long-acting insulin based
on the blood glucose level or may be given regular (fast-acting) insulin in divided doses on the day of surgery.
• As an alternative, an IV infusion of 5% dextrose in water may be given with the insulin to prevent low blood sugar
during surgery.

Informed Consent
• Surgeon obtains signed consent before sedation and/or surgery
• Nurse clarifies facts and dispels myths about surgery
• Nurse not responsible for providing detailed information about procedure!
• Patients may sign with “X”
• In emergency, telephone authorization is acceptable, requires 2 witnesses
• Special permits required for some procedures
NPSG’s and informed consent
• Ensure correct site is selected and wrong site is avoided
• Licensed independent practitioner marks site, involving patient if possible
• “Time out” procedure adopted by most facilities

Preoperative Chart Review

• Ensure all documentation, preoperative procedures, orders are complete
• Check surgical consent form and others for completeness
• Inform patient that area will be marked before procedure begins
• Document allergies, height, and weight
• Ensure all laboratory and diagnostic test results are in chart
• Document/report any abnormal results
• Current vital signs
• Report special needs and concerns

Preoperative Patient Preparations

• Remove most clothing; provide gown
• Leave valuables with family member or lock up
• Tape rings in place if cannot be removed
• Ensure patient is wearing ID band
• TED/SCD
• “on call” drugs – typically antibiotics
• pre-op checklist
• Remove: Dentures, prosthetic devices, hearing aids, contact lenses, fingernail polish, artificial nails, pierced jewelry

Preoperative Drugs
• Reduce anxiety
• Promote relaxation
• Reduce nasal and oral secretions
• Prevent laryngospasm
• Reduce vagal-induced bradycardia
• Inhibit gastric secretion
• Decrease amount of anesthetic needed for induction and maintenance of anesthesia

Drugs for Preoperative Preparation

• Sedatives
• Hypnotics
• Anxiolytics
• Opioid analgesics
• Anticholinergic agents
• H2 histamine blockers
Pain assessment tools
Adolescent and pediatric pain tool (APPT) 8-17
- Three-part tool composed of a body outline, an intensity scale, and a pain descriptor word list
CRIES pain scale neonates – 6 months
- Five behavioral categories: Crying, Requires oxygen for SaO2 < 95%, Increased vital
signs, Expression, Sleepless; 0-2 for each with total score from 0-10. A higher score indicates greater pain
or distress
Comfort behavior scale infants and children in critical care settings
- Six categories are scored: Alertness, Calmness/Agitation, Respiratory response (if on ventilator) or Crying (if
breathing spontaneously), Physical Movement, Muscle Tone, Facial Tension; 1-5 for each category with
total score from 6-30. A higher score indicates greater pain or distress
FLACC infants and preverbal or nonverbal children
- Five behavioral categories: Face, Legs, Activity, Cry, Consolability. Each scored from 0-2, resulting in a total
score from 0-10. A higher score indicates higher pain or distress
FACES pain rating scale 3 and up
- Six cartoon faces with neutral to gradually increasing painful expressions, corresponding to an analog scale
with words ranging from a happy face (0; No Hurt) to a crying face (5 or 10; Hurts Worst). Accommodates a
0-5 or 0-10 system
Numeric pain scale 9 and up
- Patient is asked to give a number that reflects the pain level: 0 = no pain; 1-3 = mild; 4-6 = moderate; 7-10 =
severe
The oucher 3-12
- A poster with a 0-100 scale for older children and a six-picture photographic scale for young children who
cannot count to 100; 0 is no pain and 100 is the greatest pain. Five versions available: Caucasian/white,
Asian (boy or girl), First Nations (boy or girl), Hispanic, and African-American/black
Poker chip tool 4-12
- Four poker chips are used, with each chip representing a piece of hurt. One poker chip represents a little
hurt, and four chips represent the most hurt the child could have
Visual analog scale (VAS) 7-18
- Usually a 10-cm line with one end representing “no pain” and the opposite end “the worst pain”