Medical Surgery Chapter 17 (preoperative nursing care)

the preoperative phase

begins when a decision is made to perform surgical procedure and ends when the pt enters the operating room, during this phase the goals of nursing care are to inform the pt of what to expect,reduce pt anxiety,and decrease the risk of complications during and after surgery.

assessment

when non emergency surgery is scheduled, a thorough assessment is made that starts with the pts health history and physical examination.the Lpn often assists by collecting specific,relevant data, this assessment is usually performed before admission to the nursing care unit,lab studies,urine studies,blood grouping/crossmatching,chest radiography,pulmonary function test,and EKG. in many instances, these and other procedures are performed on an outpatient basis before admission

assessment of preoperative pts

Health History

-identifying data

-history of present illness

-past medical history

-review of symptoms

-functional assessment

Physical Examination

-general survey

-ht/wt

-Vital signs

-skin

-thorax

-abdomen

-extremities

-prostheses

identifying data

age,marital status

history and present illness

problem being treated surgically

past medical history

acute and chronic conditions,previous hospitalizations and surgeries,allergies,recent and current medications(include recreational and herbal medications)

review of symptoms

disabilities and limitations;hearing or vision loss,paralysis,stiffness,weakness, cognitive impairment; any current health deviations

functional assessment

occupation,roles,responsibilities,diet and fluid intake,exercise,tobacco and alcohol use, sources of stress and support,coping strategies,expectations of surgery

general survey

emotional state,ability to communicate,response to directions

height and weight

height and weight

vital signs

all vitals

skin

color,lesions,brusises,warmth,turgor,moisture

thorax

respiratory pattern and effort,breath sounds,apical pulse

abdomen

distention,scars,bowel sounds

extremities

color,hair distribution,lesions,deformities,range of motion,crepitus,pain,weakness

prostheses

hearing aids,eyeglasses,contact lenses,dentures,artificial limbs,other devices

anxiety interventions

determine presense and level of anxiety, the contributing factors,and the need for interventions.determine pts previous experience if any with hospitalization and surgery. if pt seems excessively nervous or fearful about surgery,report this behavior to the surgeon or anesthesia personnel.

deficient knowledge

pt teaching may be performed in the physicians office, the clinic,during pre admission workup,or after admission to the hospital. a cost saving trend is to admit pts very early in the morning on the day of surgery, in this case the burden of preoperative teaching rest heavily on the physician, the office nurse,the admission nurse,or the clinic nurse. teaching should include the pt and those who will be with the pt.tell pt and family what to expect,verbal instructions and written instructions

teaching methods

depend on situation. some hospitals have group classes, books,pamphlets,audiotapes,videotapes,reading level may be above pts ability,or too many technical terms used.

preparation for surgery

starts before or shortly after admissiion

informed consent

pt must sign legal document called consent forms. it states the pt has been informed of procedure to be performed, the alternative treatments, and the risks involves and that the pt agrees to the procedure.this is responsibilty of the physicians but the nurse might witness it. always done before pt is given preoperative meds, it becomes part of patients record.

preparation of the digestive tract

it depends on type of anesthesia and surgery,for surgery of the abdomen or digestive tract laxatives and enemas are generally given to empty the bowel.they sometimes must empty the bowel at home at home before being admitted to the hospital.

bowel cleansing purposes

1. reduce the risk of contamination from fecal matter during the operation.

2.helps prevent postoperative distention until normal bowel function returns

3.prevents constipation and strainning in the postoperative period,strainning can create pressure on the surgical wound, surgery may be canceled if bowel preparation is inadequate

food and fluid restriction

1.clear liquids,water,clear tea,black coffee,carbonated beverages, and fruit juice without pulp---- min fasting period is 2 hours.

2. breast milk----min fasting period is 4 hours

3.non human milk,including infant formula----min fasting period is 6 hours

4.light meal,toast and clear liqiuid---min fasting period is 6 hours

5.reg or heavy meal,fried or fatty food,meat----min fasting period is 8 hours

this is done to prevent the risk of vomiting and aspiration during or after anesthesia

skin preparation

intended to reduce the number or organism near the incision site. the process usually includes scrubbing and removing hair from a wide marging around the planned surgical site, is ordered by the physician or procedure manual.shaving causes tiny nicks that shelter organisms, therefore shaving is often delayed until shortly before surgery to allow less time for organisms to multiply.

dress and grooming

on the morning of surgery provide a clean gown,instruct the pt to remove all undergarments unless agency policy dictates otherwise, jewelry should be remove, body piercing. document the disposition of jewelry and dentures, should not be left at bed side. braid or secure long hair,remove hairpins or clips,provide a cap,remove nail polish,acrylic nails consult with the anesthesiologist or preoperative nurse, atleast one acrylic nail is usually remove,make up including mascara is also remove.pt must have identification band on wrist,allergie bands,blood type band.

preoperative medications

usually ordered to be given shortly before the pt is transported to surgery or when pt is in a holding area. may include opioids,antiemetic,anticholinergic drug (decreade secretions).must be given at time they are ordered because they interact with the anesthetic agent,ask pt to void immediately before the preoperative medication is given,medication will cause drowsiness and dry mouth. raise the side rails, call bell within reach,instruct the pt to remain in bed.

preoperative checklist

most agencies have a preoperative checklist that must be completed and signed before the pt leaves the unit.check to be sure that all lab,radiology,reports are with the chart. that jewelry,prostheses, and nail polish,have been removed,that the pt has voided,that premeds has been given,that vs has been recorded,and consent form signed.SBAR is frequently used.

the info communicated for a surgical pt should include:

-pt diagnosis

-surgical procedure to be performed

-relevant medical history

-any medication given

-blood administered

-latest vs

-any drains

-iv access lines