1. Chapter 18 preoperative nursing management

2. The preoperative phase begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) table.

4. Surgical Classifications
Classification according to reasons:
diagnostic (eg, biopsy, exploratory laparotomy),
curative (eg, excision of a tumor or an inflamed appendix),
or reparative (eg, multiple wound repair).
reconstructive or cosmetic
palliative (eg, to relieve pain).
Surgery may be classified according to the degree of urgency involved:
emergent,
urgent,
required,
elective,
and optional

5. Special Considerations During the Perioperative Period
Gerontologic Considerations
Elderly patients have less physiologic reserve (the ability of an organ to return to normal after a disturbance in its equilibrium) than younger patients.
Respiratory and cardiac complication
Dehydration, constipation, and malnutrition
Sensory limitations,
older people more susceptible to temperature changes

6. Patients Who Are Obese
fatty tissues are especially susceptible to infection.
dehiscence (wound separation) and wound infections are more common.
Increases the risk of hypoventilation and postoperative pulmonary complications.
can make intubation difficult
places increased demands on the heart.

7. Patients With Disabilities
Special considerations for patients with mental or physical disabilities include the need for appropriate assistive devices, modifications in preoperative teaching, and additional assistance with and attention to positioning or transferring.

8. Ambulatory surgery includes outpatient, same-day, or short-stay surgery that does not require an overnight hospital stay but may entail an admission to an inpatient hospital setting for less than 24 hours.
Emergency surgeries are unplanned and occur with little time for preparation for the patient or the perioperative team. (The unpredictable nature of trauma and emergency surgery)

9. Informed consent
Informed consent is the patient’s autonomous decision about whether to undergo a surgical procedure.
Written informed consent is necessary before nonemergent surgery can be performed in order to protect the patient from unsanctioned surgery and protect the surgeon from claims of an unauthorized operation.
it also helps the patient to prepare psychologically, because it helps to ensure that the patient understands the surgery to be performed

11. Informed consent is necessary in the following circumstances:
• Invasive procedures, such as a surgical incision, a biopsy, a cystoscopy, or paracentesis
• Procedures requiring sedation and/or anesthesia
• A nonsurgical procedure, such as an arteriography, that carries more than a slight risk to the patient
• Procedures involving radiation

12. Preoperative Assessment
Preoperative Assessment is performed to address risk factors that otherwise lead to postoperative complications and hinder recovery
It includes health history and physical examination
Blood tests, x-rays, and other diagnostic tests are prescribed when indicated by information obtained from the history and physical examination.

13. Nutritional and Fluid Status
Optimal nutrition is an essential factor in promoting healing and resisting infection and other surgical complications.
nutritional status factors that can affect the patient’s surgical course may be:
obesity or weight loss,
malnutrition, and deficiencies in specific nutrients,
metabolic abnormalities,
and the effects of medications on nutrition.

14. Nutritional needs may be determined by measurement of body mass index and waist circumference

15. Dentition (The condition of the mouth)
Important because decayed teeth or dental prostheses may become dislodged during intubation and occlude the airway.

16. Drug or Alcohol Use
chronic alcoholism often suffers from malnutrition and other systemic problems that increase surgical risk.
long-term alcohol abuse can be contributed to cardiac dysrhythmias, cardiomyopathy, and bleeding tendencies
Alcohol withdrawal syndrome associated with increased in mortality rate
in surgery is postponed Because acutely intoxicated people are susceptible to injury
If emergency surgery is required, local, spinal, or regional block anesthesia is used for minor surgery.
Otherwise, to prevent vomiting and potential aspiration, a nasogastric tube is inserted before general anesthesia is administered.

17. Respiratory Status
Patients with underlying respiratory disease (eg, asthma, chronic obstructive pulmonary disease) are assessed carefully for current threats to their pulmonary status.
Surgery is usually postponed if the patient has a respiratory infection.
The patient is taught breathing exercises and the use of an incentive spirometer
Patients who smoke are urged to stop 4 to 8 weeks before surgery to significantly reduce pulmonary and wound healing complications.

18. Cardiovascular Status
The goal in preparing any patient for surgery is to ensure a well-functioning cardiovascular system to meet the oxygen, fluid, and nutritional needs of the perioperative period.
If the patient has uncontrolled hypertension, surgery may be postponed
surgical treatment can be modified to meet the cardiac tolerance of the patient.

19. Hepatic and Renal Function
The presurgical goal is optimal function of the liver and urinary systems so that medications, anesthetic agents, body wastes, and toxins are adequately metabolized and removed from the body.
surgery is contraindicated if a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems

20. Endocrine Function
Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin.
Hyperglycemia, which can increase the risk for surgical wound infection, may result from the stress of surgery, which can trigger increased levels of catecholamine. (acidosis and glucosuria)
Frequent monitoring of blood glucose levels is important before, during, and after surgery
Patients who have received corticosteroids are at risk for adrenal insufficiency.
Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis (with hyperthyroid disorders) or respiratory failure (with hypothyroid disorders).

21. Immune Function
An important function of the preoperative assessment is to determine the presence of allergies.
The patient is asked to identify any substances that precipitated previous allergic reactions, including medications, blood transfusions, contrast agents, latex, and food products, and to describe the signs and symptoms produced by these substances.
Immunosuppression is common with corticosteroid therapy, renal transplantation, radiation therapy, chemotherapy, and disorders affecting the immune system (great care is taken to ensure strict asepsis).

22. Previous Medication Use
A medication history is obtained because of the possible effects of medications on the patient’s perioperative course. (potential effects on coagulation and potentially lethal interactions with other medications).
Side effects of interaction: arterial hypotension and circulatory collapse.
stop aspirin at least 7 to 10 days before surgery.

23. Psychosocial Factors
psychological distress directly influences body functioning.
the nurse must be empathetic, listen well, and provide information that helps alleviate concerns.

24. Spiritual and Cultural Beliefs
Spiritual beliefs play an important role in how people cope with fear and anxiety.
Some areas of assessment include identifying the ethnic group and beliefs the patient holds about illness and health care providers.

25. General Preoperative Nursing Interventions
Providing Patient Teaching
Each patient is taught for any unique concerns or learning needs.
Preoperative teaching is initiated as soon as possible, beginning in the physician’s office, in the clinic, or at the time of PAT
Teaching go beyond descriptions of the procedure and should include explanations of the sensations the patient will experience.
overly detailed descriptions may increase anxiety (provide less detail based on the individual patient’s needs).

26. Deep Breathing, Coughing, and Incentive Spirometry
goal of preoperative nursing care is to teach the patient how to promote optimal lung expansion and resulting blood oxygenation after anesthesia.
The patient assumes a sitting position to enhance lung expansion.
The nurse demonstrates how to take a deep, slow breath and how to exhale slowly.
the patient is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs

27. demonstrates how to use an incentive spirometer, a device that provides measurement and feedback related to breathing effectiveness and may help the patient relax.

28. In the thoracic or abdominal surgeries: the nurse demonstrates how to splint the incision to minimize pressure and control pain.
the patient is informed that medications are available to relieve pain and should be taken regularly for pain relief so that effective deep-breathing and coughing exercises
The goal in promoting coughing is to mobilize secretions so that they can be removed. Deep breathing before coughing stimulates the cough reflex.

29. Mobility and Active Body Movement
The goals of promoting mobility postoperatively are to improve circulation, prevent venous stasis, and promote optimal respiratory function.
The nurse explains the rationale for frequent position changes after surgery and then shows the patient how to turn from side to side and how to assume the lateral position without causing pain or disrupting intravenous (IV) lines, drainage tubes, or other equipment.
Teach Any special position the patient needs to maintain after surgery
Exercise of the extremities includes extension and flexion of the knee and hip joints

30. Pain Management
A pain intensity scale should be introduced and explained to the patient to promote more effective postoperative pain management.
Postoperatively, medications are administered to relieve pain and maintain comfort without suppressing respiratory function.

31. Cognitive Coping Strategies
Cognitive strategies may be useful for relieving tension, overcoming anxiety, decreasing fear, and achieving relaxation.
• Imagery
• Distraction
• Optimistic self-recitation
• Music therapy:

32. Instruction for Patients Undergoing Ambulatory Surgery
Answering questions and describing what to expect,
what to bring (insurance card, list of medications and allergies),
what to leave at home (jewelry, watch, medications, contact lenses), and
what to wear (loose-fitting, comfortable clothes; flat shoes).
The nurse in the surgeon’s office may initiate teaching before the perioperative telephone contact.
The patient is reminded not to eat or drink as directed.

33. Providing Psychosocial Interventions
Reducing Anxiety and Decreasing Fear
Identify coping strategies that patient has previously used to decrease fear.
Discussions with the patient to help determine the source of fears can help with expression of concerns.
The patient benefits from knowing when family and friends will be able to visit after surgery and that a spiritual advisor will be available
Knowing ahead of time about the possible need for a ventilator, drainage tubes, or other types of equipment helps decrease anxiety related to the postoperative period.

34. Respecting Cultural, Spiritual, and Religious Beliefs
Psychosocial interventions include identifying and showing respect for cultural, spiritual, and religious beliefs.

35. Maintaining Patient Safety
Protecting patients from injury is one of

36. Managing Nutrition and Fluids
The major purpose of withholding food and fluid before surgery is to prevent aspiration.

37. Preparing the Bowel
Enemas are not commonly prescribed preoperatively unless the patient is undergoing abdominal or pelvic surgery.
The goals of enemas are to allow satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by fecal material.

38. Preparing the Skin
The goal of preoperative skin preparation is to decrease bacteria without injuring the skin.
the patient may be instructed to use a soap containing a detergent-germicide to cleanse the skin area for several days before surgery to reduce the number of skin organisms
hair is not removed preoperatively unless the hair at or around the incision site is likely to interfere with the operation.

39. Immediate Preoperative Nursing Interventions
Immediately prior to the procedure the patient changes into a hospital gown
The patient with long hair may braid it, remove hairpins
cover the head completely with a disposable paper cap
assistive devices, dentures, glasses, and prosthetic devices, are given to family members or are labeled clearly with the patient’s name and stored in a safe and secure place according to the institution’s policy.
All patients (except those with urologic disorders) should void immediately before going to the OR.

40. Administering Preanesthetic Medication
If a preanesthetic medication is administered, the patient is kept in bed with the side rails raised, because the medication can cause lightheadedness or drowsiness.
the nurse observes the patient for any untoward reaction to the medications.
The immediate surroundings are kept quiet to promote relaxation.

41. Maintaining the Preoperative Record
The completed chart with the surgical consent form attached, along with all laboratory reports and nurses’ records and Preoperative checklists contain critical elements must be accompanied the patient to the OR
Special note are noted prominently at the front of the chart.

42. Transporting the Patient to the Presurgical Area
The patient is transferred to the holding area or presurgical suite in a bed or on a stretcher with a sufficient number of blankets to prevent chilling in an air- conditioned room.
The surrounding area should be kept quiet if the preoperative medication is to have maximal effect.
Use of a standard process or procedure to verify patient identification, the surgical procedure, and the surgical site is imperative to maximize patient safety

43. Attending to Family Needs
Family should be informed that the patient may have certain equipment or devices
When the patient returns to the room, the nurse provides explanations regarding the frequent postoperative observations that will be made.

44. Expected Patient Outcomes

45. intraoperative phase
The intraoperative phase begins when the patient is transferred onto the OR table and ends with admission to the PACU.
Patient may feel either relaxed and prepared or fearful and highly stressed.
fears can increase the amount of anesthetic medication needed, the level of postoperative pain, and overall recovery time.
The patient is subject to several risks. (Infection, failure of the surgery to relieve symptoms or correct a deformity, temporary or permanent complications related to the procedure or the anesthetic agent, and death)

46. Gerontologic Considerations
Factors that affect the elderly surgical patient in the intraoperative period:
Biologic variations of particular importance include age- related cardiovascular and pulmonary changes.
The aging heart and blood vessels have decreased ability to respond to stress.
Reduced liver size decreases the rate at which the liver can inactivate many anesthetic agents, and decreased kidney function slows the elimination of waste products and anesthetic agents.

47. Impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms increase susceptibility to hypothermia.
Bone loss (25% in women, 12% in men) necessitates careful manipulation and positioning during surgery.
Reduced ability to adjust rapidly to emotional and physical stress influences surgical outcomes and requires meticulous observation of vital functions.

48. Nursing Care
the patient’s emotional state remains a concern, the care initiated by preoperative nurses is continued by the intraoperative nursing staff that provides the patient with information and reassurance.
The nurse supports coping strategies and reinforces the patient’s ability to influence outcomes by encouraging active participation in the plan of care incorporating cultural, ethnic, and religious
intraoperative nurses monitor factors that can cause injury, such as patient position, equipment malfunction, and environmental hazards, and they protect the patient’s dignity and interests while the patient is anesthetized.

49. Additional responsibilities include maintaining surgical standards of care and identifying and minimizing risks and complications.
Cultural Diversity

50. Potential Intraoperative Complications
Potential intraoperative complications include nausea and vomiting, anaphylaxis, hypoxia, hypothermia, and malignant hyperthermia.

51. NAUSEA AND VOMITING (or regurgitation)
If the patient aspirates vomitus, an asthmalike attack with severe bronchial spasms and wheezing is triggered.
Pneumonitis and pulmonary edema can subsequently
develop, leading to extreme hypoxia.If gagging occurs, the patient is turned to the side, the head of the table is lowered, and a basin is provided to collect the vomitus.
Suction is used to remove saliva and vomited gastric contents.
Administers antiemetics preoperatively or intraoperatively to counteract possible aspiration.

52. ANAPHYLAXIS
An anaphylactic reaction can occur in response to many medications, latex, or other substances.
observe the patient for changes in vital signs and symptoms of anaphylaxis when these products are used.

53. HYPOXIA AND OTHER RESPIRATORY COMPLICATIONS
Inadequate ventilation, occlusion of the airway, inadvertent intubation of the esophagus, and hypoxia are significant potential complications associated with general anesthesia.
Respiratory depression caused by anesthetic agents, aspiration of respiratory tract secretions or vomitus, and the patient’s position on the operating table can compromise the exchange of gases.
asphyxia caused by foreign bodies in the mouth, spasm of the vocal cords, relaxation of the tongue, or aspiration of vomitus, saliva, or blood can occur.

54. monitoring of the patient’s oxygenation status
Peripheral perfusion is checked frequently, and pulse oximetry values are monitored

55. HYPOTHERMIA
a core body temperature that is lower than normal (36.6C [98.0F] or less).
Glucose metabolism is reduced, and, as a result, metabolic acidosis may develop.
Causes: a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open body wounds or cavities, decreased muscle activity, advanced age, or the pharmaceutical agents used

56. Environmental temperature in the OR can temporarily be set at 25C to 26.6C (78F to 80F).
IV and irrigating fluids are warmed to 37C (98.6F).
Wet gowns and drapes are removed promptly and replaced with dry materials, because wet materials promote heat loss.
warming must be accomplished gradually
monitoring of core temperature, urinary output, ECG, blood pressure, arterial blood gas levels, and serum electrolyte levels is required.

57. MALIGNANT HYPERTHERMIA
Susceptible people include those with strong and bulky muscles, a history of muscle cramps or muscle weakness and unexplained temperature elevation, and an unexplained death of a family member during surgery that was accompanied by a febrile response
Tachycardia (heart rate greater than 150 bpm) is often the earliest sign.
Sympathetic nervous stimulation also leads to ventricular dysrhythmia, hypotension, decreased cardiac output, oliguria, and, later, cardiac arrest.

58. rigidity or tetanuslike movements occur, often in the jaw.
Generalized muscle rigidity is one of the earliest signs.
The rise in temperature is actually a late sign

59. Medical Management
Recognizing symptoms early and discontinuing anesthesia
Goals of treatment are to decrease metabolism, reverse metabolic and respiratory acidosis, correct dysrhythmias, decrease body temperature, provide oxygen and nutrition to tissues, and correct electrolyte imbalance.
Anesthesia and surgery should be postponed.

60. NURSING PROCESS Nursing Diagnoses Based on the assessment data:
Anxiety related to surgical or environmental concerns
Risk of latex allergy response due to possible exposure to latex in OR environment
Risk for perioperative positioning injury related to positioning in the OR
Risk for injury related to anesthesia and surgical procedure
Disturbed sensory perception (global) related to general anesthesia or sedation

61. potential complications may include the following:
• Nausea and vomiting
• Anaphylaxis
• Hypoxia
• Unintentional hypothermia
• Malignant hyperthermia
• Infection

62. Planning and Goals
The major goals for care of the patient during surgery include reduced anxiety, absence of latex exposure, absence of positioning injuries, freedom from injury, maintenance of the patient’s dignity, and absence of complications.

63. Nursing Interventions
Reducing Anxiety
Introducing yourself,
addressing the patient by name warmly
verifying details,
providing explanations,
and encouraging and answering questions
provide a sense of professionalism and friendliness.

64. uses basic communication skills, such as touch and eye contact, to reduce anxiety.
Attention to physical comfort (warm blankets, padding, and position changes) helps the patient feel more comfortable.
Telling the patient who else will be present in the OR,
how long the procedure is expected to take,

65. Reducing Latex Exposure
maintenance of latex allergy precautions throughout the perioperative period must be observed.

66. Preventing Intraoperative Positioning Injury
The patient’s position on the operating table depends on the surgical procedure to be performed as well as on the patient’s physical condition
The usual position for surgery, called the dorsal recumbent position, is flat on the back.
Figure 19-5 Positions on the operating table. Captions call attention to safety and comfort features. All surgical patients wear caps to cover the hair completely.

67. Protecting the Patient From Injury
Verifying information, checking the chart for completeness, and maintaining surgical asepsis and an optimal environment
It is important to review the patient’s record for the following:
• Correct informed surgical consent, with patient’s signature
• Completed records for health history and physical examination
• Results of diagnostic studies
• Allergies (including latex)

68. obtains the necessary equipment specific to the procedure.
The need for nonroutine medications, blood components, instruments, and other equipment and supplies is assessed, and the readiness of the room, completeness of physical setup, and completeness of instrument, suture, and dressing setups are determined.
Preventing physical injury includes using safety straps and side rails and not leaving the sedated patient unattended.
checks that blood has been cross-matched and is prepared to administer blood.

69. Serving as Patient Advocate
Patient advocacy in the OR entails maintaining the patient’s physical and emotional comfort, privacy, rights, and dignity.

70. - Monitoring and Managing Potential Complications
monitor and manage complications.

71. Evaluation
Expected Patient Outcomes: 1. Exhibits low level of anxiety while awake during the intraoperative phase of care 2. Has no symptoms of latex allergy 3. Remains free of perioperative positioning injury 4. Experiences no unexpected threats to safety 5. Has dignity preserved throughout OR experience 6. Is free of complications