Interventions for Preoperative Clients Care

Perioperative Care Three Phases Preoperative Intraoperative Postoperative

Miss Iman Shaweesh 3

PREOPERATIVE NURSING CARE CONDUCT A NURSING ASSESSMENT PROVIDE PREOPERATIVE TEACHING PERFORM METHODS OF PHYSICAL PREPARATION ADMINISTER MEDICATIONS ASSIST WITH PSYCHOSOCIAL PREPARATION COMPLETE THE SURGICAL CHECKLIST

SURGERY CHECKLIST

Purposes of Surgery Diagnostic Curative Restorative Palliative surgery, which makes the client more comfortable Cosmetic surgery, which reconstructs the skin and underlying structures Sentences and phrases

Collaborative Management Assessment History and data collection Age Drugs and substance use Medical history, including cardiac and pulmonary histories Previous surgery and anesthesia Blood donations Discharge planning

Physical Assessment/Clinical Manifestations Obtain baseline vital signs. Focus on problem areas identified by the client’s history on all body systems affected by the surgical procedure. Report any abnormal assessment findings to the surgeon and to anesthesiology personnel. Sentences and phrases

System Assessment Cardiovascular system Respiratory system Renal/urinary system Neurologic system Musculoskeletal system Nutritional status Psychosocial assessment

Laboratory Assessment Urinalysis Blood type and crossmatch Complete blood count or hemoglobin level and hematocrit Clotting studies Electrolyte levels Serum creatinine level Pregnancy test Chest x-ray examination Electrocardiogram

Preparing the Client (Continued) Leg procedures and exercises, antiembolism stockings and elastic wraps, early ambulation, and range-of-motion exercises

DEEP BREATHING, COUGHING, LEG EXERCISES Deep breathing is a form of controlled ventilation that opens and fills small air passages in the lungs to prevent atelectasis and pneumonia. Coughing is a natural method of clearing secretions from the airways. Leg exercises help promote circulation and reduce the risk of forming a thrombus in the veins. Antiembolism stockings help prevent thrombi and emboli by compressing superficial veins and capillaries redirecting blood to larger and deeper veins, where it flows more effectively toward the heart.

DEEP BREATHING & COUGHING

Pre-Operative Education Diaphragmatic Breathing Exercises

Pre-Operative Education Splinting Abdomen while Coughing

Spirometry

Use of preoperative spirometry to predicted PPCs Jacob 1997 Bando 1997 Kocabas 1996 Kroenke 1993 Kispert 1992 Swensson 1991 Fogh 1987 Appleberg 1974 Stein 1970 Collin 1968 1 2 4 6 8 10 12 14 16 Adapt from Smetana GW,et al. New Engl J Med 1999;340:937-944.

Preoperative Care of Pulmonary Patients: Example Male 60 yrs. Dx: NSCLC stage Ib , RUL Underlying COPD Assessment Not urgent surgery, high benefit Risk ; elderly, COPD History / Physical examination Laboratory

Spirometry of the patient Pre-RX(%) Post –RX(%) %CHG FEV1/FVC (%) 55 60 FEV1 (L) 1.31(48) 1.39(53) 5 FVC (L) 2.40(66) 2.50(69) 4 FEF25- 75% (L/min) 0.43(15) 0.6(22) 22 Irreversible airway obstruction

Further evaluation PPO-FEV1 Rt=0.45(45%) Lt=0.55(55%) RUL = 24.7% LL = 55% RLL= 20.3% RUL : RLL= 0.55: 0.45 Acceptable, See Mx PPO-FEV1=1.04(39%)

Preoperative Care of Pulmonary Patients Many factors related to PPCs Working as a team plays major roles Assessment of the risks ,do appropriated testing and modifying are the keys of preoperative caring

Recommendation for preoperative CXR Age > 50 years Known pre-existing cardiopulmonary diseases S/S like hoods of cardiopulmonary disease Smetana GW, et al Med Clin N Am 2003

PFTs and PPCs Case-control study, elective abdominal surgery: CXR highly associated with PPCs (OR 5.8) Abnormal PE associated with PPCs Whereas PFTs were not predictive Lawrence VA, et al. Chest 1996;110:744-50.

PFT Diagram in Preoperative Evaluation PFT(FEV1,MVV,DLCO) FEV1 >2 L MVV >50% DLCO >60% FEV1 > 2 L MVV<50% DLCO <60% FEV1 <2 L High risk consider exercise test Cleared for any resection Perfusion Scanning PPO-FEV1 PPO-FEV1 >1.3 PPO-FEV1 >0.8, <1.3 PPO-FEV1 <0.8 High risk consider exercise test Cleared for any resection Consider “Lesser” resection Non surgical therapy

Preoperative PFTs : Summary Thoracic surgery Upper abdominal surgery with respiratory symptoms remain unexplained after careful evaluation Routine PFTs should not ordered solely without clinical assessment

Risk indices for preoperative assessment Risk class Pneumonia Risk (total point) Predicted Prob. pneumonia (%) Respiratory Failure Prob. Res. failure 1 0-15 0.2 0-10 0.5 2 16-25 1.2 11-19 2.2 3 26-40 4.0 20-27 5.0 4 41-55 9.4 28-40 11.6 5 >55 15.4 >40 30.5 Arozullah AM,et al. Med Clin N Am 2003

Preoperative smoking cessation and PPCs % Complication Prospective study 200 patients, CABG Warner MA,et al. Mayo Clin Proc 1989

Preoperative smoking cessation and PPCs % Complication Retrospective study 288 patients, pulmonary surgery Nakagawa M, et al Chest 2001;120:705-10

Examples of external pneumatic compression devices used to promote venous return and prevent deep vein thrombosis (DVT)

Kendall SCD machine, sleeves, and TED stockings.

Venodyne pneumatic compression system

Flowtron DVT calf garments

Anxiety Interventions Preoperative teaching Encouraging communication Promoting rest Using distraction Teaching family and significant others

Preoperative Chart Review Ensure all documentation, preoperative procedures, and orders are complete. Check the surgical consent form and others for completeness. Document allergies Document height and weight. Most institution have some sort of preop check list. Surgical consents forms filled out without abbreviations. Make sure consent for anesthesia and blood consent filled out before sedation given. 38