Preoperative nursing

when does preoperative period begin?

begins with decision to have surgery

when does preoperative period end?

ends when patient transfers to OR table

when does intraoperative period start?

when client is transferred to OR table

when does postoperative period start?

when patient is admitted to PACU

when does postoperative period end?

ends when healing is complete

degree of urgency for emergency surgery

has to happen to save a life

degree of urgency for elective surgery

patient has to make the choice to have surgery

degrees of risk for surgery

• major (anything with an organ)

• minor

purpose of diagnostic surgery

to look and find a cause

purpose of palliative surgery

to relieve symptoms/pain

purpose of ablative surgery

to remove disease tissue

purpose of constructive surgery

to restore function/appearance

purpose of transplant

to replace organ with another organ

factors contributing to surgical risk

• age/personal habits/allergies

• type of wound/mechanism of injury

• pre-existing conditions

• mental status

• medications

preoperative nursing responsibilities

nursing history

• health history

• client knowledge & understanding of the surgery

physical assessment

• focus on symptoms that indicate risk for surgery

medications

tests to be complete:

• CBC

• Urinalysis

• ECG

surgical consent

• surgeon obtains

• can withdraw anytime

• confirm that it’s complete (witness signing)

nursing assessment for cardiovascular system

assess

• use of cardiac meds

• presence of pacemaker/MI

vitals recorded preoperatively for baseline

bleeding/clotting times

laboratory reports

possible prophylactic antibiotics

• to reduce the incidence of postoperative wound infection

nursing assessment for respiratory system

recent infections

• increased risk of laryngo/brochospasm or decreased SaO2

history of smoking

history of dyspnea

• coughing or hemoptysis

COPD or asthma

• high risk for atelectasis and hypoxemia

Nursing assessment for fluid/electrolytes

any vomiting, diarrhea, or difficulty swallowing

evaluate serum electrolyte levels

NPO status

• may increase need for fluids/electrolytes prior to surgery

• IV fluids

Identifying meds that alter status

• diuretics

Nursing assessment for nervous system

evaluation of neurologic functioning

any vision of hearing loss can influence results

cognitive function?

• assess deficits before surgery

• baseline for assessment of postoperative delirium

• durable power of attorney for health care should be obtained if deficits cannot be corrected

nursing assessment of urinary system

history of urinary or renal diseases

note any problems voiding

history and resulting of renal functions tests

nursing assessment of integumentary system

history of skin problems

• allergies

• history of pressure ulcers (extra padding during surgery)

nursing assessment of musculoskeletal system

joints affected with arthritis

mobility restrictions may affect positioning and ambulation

bring mobility aids to surgery

report problems to neck or lumbar spine to anesthesia care provider (ACP)

can affect airway management and anesthesia delivery

nursing assessment of endocrine system

patients with diabetes mellitus are at risk for:

• hypo/hyperglycemia

• cardiovascular alterations

• delayed wound healing

• infection

serum glucose tests morning of surgery (baseline)

clarify with physician dose of insulin prior to surgery

nursing assessment of immune system

history of compromised immune system or use of immunosuppressive meds can

• delay wound healing

• increased risk of infection

nursing assessment of nutritional status

NPO status

Obesity

• stresses cardiac and pulmonary systems

• increased risk of wound dehiscence and infection

• slower recovery from anesthesia

• slower wound healing

nursing assessment of fears

mutilation/alteration in body image

• assess concerns (nonjudgmental)

• supportive, involve family

disruption of life functioning

anesthesia

• ACP for consult (reactions/problems to anesthesia (patient or family))

Pre-operative teaching of skills

teach deep breathing, coughing

positioning/moving postop

leg exercises

preparing the client physically

NPO

prepare skin: surgical scrub (ID and allergy band)

bowel preparation

facilitate an empty bladder (void before med admin)

administer preoperative meds

apply antiembolism stockings

remove cosmetics, dentures, contacts, prostheses

intraoperative care: physical environment

controlled environment

designed to minimize spread of infection

areas highly restricted e.g. OR room

semi-restricted e.g. peripheral areas and corridors with authorized people in surgical attire

unrestricted areas e.g. personnel in street clothes and in scrubs

intraoperative care: nursing responsibilities

patient advocate

final verification of correct: patient, procedure, site

sterile field

monitor I&O

sponge, sharps, and instrument count

legal requirements for documentation

Postoperative care: the PACU

recovery from anesthesia

airway management

vital signs

LOC

dressing, drains, assessment/drainage

fluid status - I&O

nausea/vomiting

ability to remove extremities

pain control

explain what is happening

  What is the most important reason for controlling postoperative nausea/vomiting in the PACU?

To prevent potential airway issues

Nursing Interventions to prevent respiratory complications

Deep breathing encouraged to facilitate gas exchange and promote return of baseline level of consciousness

Proper positioning to facilitate respiration and protect airway

• Lateral position unless contraindicated

• Patient allowed in supine with HOB elevated once conscious

Nursing interventions to prevent cardiovascular complications

•Frequently monitor vital signs

Notify MD -

*Systolic <90 mm Hg or >160 mm Hg

*Pulse <60 or >120 beats per minute

•Compare to baseline

•Assess skin color, temperature, and moisture

–oxygen therapy as ordered

–IV fluid adjustment to manage fluid volume deficit or shift

–Drug intervention as ordered

–Address/eliminate cause of sympathetic nervous system stimulation 

•Analgesics, voiding, correction of respiratory problems

what is the Likert scale

scale used to assess pain levels

e.g. pain of level 1-10

nursing interventions for pain

IV opioids

Epidural catheters, PCA, or regional anesthetic blockade

comfort measures

what is the normal body temperature

36.1C (97F) - 37.2C (99F)

complications of hypothermia from surgery

compromised immune function

postoperative pain

increased bleeding

myocardial ischemia

delayed drug metabolism

nursing intervention of hypothermia

passive re-warming raises basal metabolism

active re-warming requires application of warming devices

• blankets, heated aerosols radiant warmers, forced air warmers, or heated water

nursing intervention for nausea/vomiting

antiemetic meds

oral fluids as tolerated

suction at bedside

turn patient’s head to side to prevent aspiration (lateral position)

upright position if conscious, allowed, and tolerated

slow, deep breathing

discharge from PACU

ambulatory surgery discharge

• All required teaching is complete

• Verbal & Written information provided

• Patient must be mobile and alert and can provide a degree of self-care

• Pain, nausea, and vomiting must be controlled

respiratory care priority on ALL nursing units

patient conscious and following direction

O2 saturation and effort breathing, RR

trachea central

breath sounds

symmetry of respiration

percussion

use of IS

nursing intervention of cardiovascular

elastic stockings or compressive devices

leg exercises

ambulation

• slow progress

• monitor orthostatic VS

• assess for feelings of faintness

fluid management: nursing unit

accurate I&O

monitor laboratory findings

assessment of infusion rate of fluid replacement and infusion site

adequate and frequent mouth care

nursing interventions of gastrointestinal

auscultate abdomen in all 4 quadrants for presence, frequency, and characteristics of bowel sounds

• can be absent or diminished in immediate postoperative period

• Return of bowel motility accompanied by flatus

• May resume intake upon return of gag reflex

• NPO until return of bowel sounds for patient with abdominal surgery

• NG for decompression

May resume intake upon return of gag reflex

NPO until return of bowel sounds for patient with abdominal surgery

Early and frequent ambulation to prevent abdominal distention

Assess patient regularly for resumption of normal peristalsis

Diet – clear liquids as tolerated advanced to regular diet for pt.