The Legal Aspects of Surgical Interventions: Written Informed Consent/ Operative Permit/ Surgical Permit

The purpose of the written informed consent are as follows:

1. To ensure that the client understands the nature of the treatment including the potential complications and disfigurement. These are explained by the surgeon 

2. To indicate that the client’s decision was made without pressure 

3. To protect the client against unauthorized procedure 

4. To protect the surgeon and the hospital against legal action by a client who claims that an unauthorized procedure was performed 

The circumstances requiring written informed consent are as follows:

1. Any surgical procedure where scalpel, scissors, suture, hemostats of electrocoagulation may be used 

2. Any invasive procedure or procedure that involves entry into a body cavity (paracentesis, bronchoscopy, cystoscopy, colonoscopy, proctosigmoidoscopy 

3. Any procedure that involves general anesthesia, local infiltration anesthesia or regional block anesthesia

The requisites for validity of written consent are as follows: 

1. Written permit/ consent is best and legally acceptable 

2. Patient’s signature is obtained with the client’s complete understanding of what is to occur. Adults sign their own consent unless he/ she is physically and mentally incapacitated. If the patient is a child or minor (18years old and below), the parent or guardian will sign the consent 

3. Consent is obtained before sedation 

4. The patient is not under the influence of drugs or alcohol 

5. The consent is secured without pressure or duress 

6. Signature of witness is required. The nurse, physician or other authorized persons may sign as witness 

7. In an emergency, permission via telephone or telefax is acceptable. The physician should document the nature of the emergency situation

8. Emancipated minors are allowed to sign without written consent . Emancipated minors are those who are married, those who live on their own or financially independent from their parents (this is acceptable in US) 

The physical preparation of the patient before surgery include the following: 

1. Correcting any dietary deficiencies 

2. Reducing an obese person’s weight, as time permits 

3. Correcting fluid and electrolyte imbalances 

4. Restoring adequate blood volume with blood transfusion 

5. Treating chronic diseases- DM, heart disease, renal insufficiency, bleeding disorders 

6. Treating any infectious processes 

7. Treating an alcoholic person with vitamin supplementation, IV fluids or oral fluids, if dehydrated 

Preparation of the patient before surgery includes exercise that will prevent postoperative complications. The nurse should provide teachings on the following preoperative exercises: 

1. Deep breathing and coughing exercises. To promote adequate lung expansion and ventilation, and expel mucous secretions 

2. Incentive spirometry. To enhance deep inspiration and promote maximum lung expansion 

3. Turning exercises. To promote lung expansion, promote circulation, and prevent pressure sores 

4. Foot and leg exercises. Flexion and extension exercises of the lower extremities promote circulation; prevent venous stasis, thereby preventing thrombophlebitis 

Preparation of the patient the evening before the surgery include the following:

1. Preparing the Skin

High Impact Concepts: 

1. Human skin normally harbors transient and resident bacterial flora, some of which are pathogenic

2. Skin cannot be sterilized without destroying skin cells 

3. Friction enhances the action of detergent antiseptics 

   • It is ideal for the patient to bathe or shower, using a bacteriostatic soap to reduce microorganisms in the skin 

   • Shaving should be performed as close to the operative time as possible. Hair grows again, overnight. Shaving should be done in the direction of hair growth. 

Preparation of the patient the evening before the surgery include the following:

2. Preparing the Gastrointestinal Tract

• Preparation of the bowel for intestinal surgery to prevent escape of bacteria and sepsis include the following: 

1. Cathartics and enemas (GoLytely) 

2. Oral antimicrobials to reduce bacterial flora 

3. Enemas “until clear” the evening before surgery. No more than three enemas should be given to prevent fluid- electrolyte imbalances

• NPO for 6 hours before surgery. Patients having morning surgery are kept NPO from midnight. Clear fluids, like water may be given up to 4 hours before surgery if ordered to help client swallow medications 

Preparation of the patient the evening before the surgery include the following:

3. Preparing for Anesthesia

The patient should avoid alcohol and cigarette smoking for at least 24 hours before surgery. This can help reduce potential complications of anesthesia 

Preparation of the patient the evening before the surgery include the following:

4. Promoting Rest and Sleep

1. Provide comfort measures (clean gown and linens, correct room temperature, subdued lighting, back rub) 

2. Administer sedative as ordered 

When Preparing the patient on the day of surgery, the nurse should include the following:

1. Awaken the patient, one hour before preoperative medications

2. Provide morning bath and mouthwash. Morning bath reduces microorganisms in the skin. Mouthwash prevents surgical parotitis, (mumps) 

3. Provide clean gown 

4. Remove hairpins, braid long hairs, cover hair with cap 

5. Remove dentures, foreign materials (chewing gum) from patient’s mouth 

6. Remove colored nail polish, hearing aid, contact lens, jewelries. If the patient refuses to remove the wedding ring, tie it with gauze and fasten around the wrist.

7. Take baseline vital signs before administration of preoperative medications 

8. Check patient verification (ID) band and area of “skin prep” as applicable 

9. Check for special orders (enema, gastrointestinal tube insertion, IV line). Ensure that these orders are carried out 

10. Check if NPO is maintained 

11. Have client void before administration of preop medications. Some preoperative medications may cause hypotension and increase risk for falls. For patient safety, put up side rails, put call light within patient’s reach, and instruct patient to ask for help/ she needs to void 

12. Continue to support the patient emotionally. Anxiety level may be high at this time 

13. Accomplish the “Preoperative Care Checklist” 

Preoperative Medications/Preanesthetic Drugs 

Purposes

1. To facilitate the administration of any anesthetic 

2. To minimize respiratory tract secretions and changes in heart rate 

3. To relax the client and reduce anxiety

Preoperative Medications/Preanesthetic Drugs 

Types of Preoperative Medications

1. Opiates - Morphine (Roxanol) and Meperidine (Demerol) are given to relax the patient and potentiate anesthesia 

2. Anticholinergics - Atropine Sulfate, Scopolamine and Glycopyrrolate (Robinul) are given to reduce respiratory tract secretions and to prevent severe reflex slowing of the heart during anesthesia 

3. Barbiturates/Tranquilizers - Phenobarbital (Nembutal) and other Hypnotic Agents are given the night before surgery to help ensure a restful night’s sleep. 

4. Prophylactic Antibiotic - Administered just before or during surgery when bacterial contamination is expected, ideally before skin incision is made. 

Preoperative Medications/Preanesthetic Drugs 

Promote Safety

When transporting the patient to the operating room

Preoperative Medications/Preanesthetic Drugs 

Care of the patient’s family includes the following: 

1. Directing the family to the proper visiting room or waiting lounge 

2. Informing them that they will be contacted by the surgeon immediately 

3. Explaining reason for long interval of waiting. This is due to anesthesia preparation, skin prep, surgical procedure and recovery room/ post anesthesia care unit stay. This action helps prevent unnecessary anxiety by the family 

4. Explaining what to expect during the postoperative period (IV fluids, blood transfusion, oxygen therapy, tubes and other contraptions).