Comprehensive Pre-operative Nursing Care and Surgical Patient Safety Guide

Introduction to Pre-operative Nursing and Surgical Classifications

• Definition of Surgery: Surgery is an intervention categorized by its purpose, body location, extent, and degree of urgency.

• Surgical Settings:   - Hospitals.   - Outpatient ambulatory surgical centers.   - Outpatient office settings.

• Patient Disposition: Surgery may allow for same-day discharge or require the patient to be admitted for post-operative care.

• Primary Goal: Regardless of the setting, patient demographics, or the type of surgery, safety serves as the paramount objective.

• Learning Objectives:   - Define the role of the pre-operative nurse.   - List the specific responsibilities of the pre-operative nurse.   - Identify major concerns regarding pre-operative patient care.   - Explain the critical importance of informed consent.

National Patient Safety Goals and Communication Frameworks

• The Joint Commission’s National Patient Safety Goals (NPSGS): These goals focus on enhancing communication within the surgical team to achieve desired outcomes.

• $2020$ Focus Areas for NPSGS:   - Ensuring the correct procedure is performed on the correct patient at the correct body location.   - Precise marking of the surgical site on the patient's body.   - Implementing a pause before surgery to prevent errors, known as a surgical timeout.

• Role of the Peroperative Nurse: Plays a critical role in identifying the patient, verifying ID band accuracy, and ensuring chart information is current to prevent wrong-site surgeries.

• SBAR Communication System: A standardized handoff and communication tool used among surgical team members. It consists of:   - S: Situation.   - B: Background.   - A: Assessment.   - R: Recommendations or Requests.

Surgical Quality Improvement and Safety Checklists

• Surgical Care Improvement Project (SKIP): Initiated in $2006$, these measures track compliance to reduce surgical complications. Key focus areas include:   - Administration of prophylactic antibiotics.   - Correct hair removal processes.   - Timing for the discontinuation of urinary catheterization post-surgery.   - Venus thrombo embolism ($VTE$) prophylaxis.

• Surgical Safety Checklist: A mandatory list that must be actively completed for every patient, ensuring they are truly ready for the scheduled procedure. Key components include:   - Removal of Jewelry: Prevents items from acting as tourniquets or being lost.   - Removal of Personal Items/Clothing: Prevents loss and minimizes contamination or infection risks in the Operating Room ($OR$).   - Medication Administration: Identifying which medications to give (e.g., antibiotics) and which to withhold (e.g., anti-coagulants).   - Pre-surgery Paperwork: Verification of History and Physical ($HMP$), pre-anesthetic evaluation, $DNR$ suspension status, pregnancy tests, refusals, and imaging.

The Pre-operative Phase: Assessment and Patient History

• Definition of the Pre-operative Phase: This phase commences when the patient is scheduled for a procedure and concludes at the moment of transfer to the surgical suite or $OR$.

• The Pre-operative Assessment: Must be patient-centered and address physical, psychological, psychosocial, cultural, and spiritual needs. It helps identify potential problems, plan care, and anticipate outcomes.

• Patient History Requirements:   - Setting: Conducted in a private setting to ensure confidentiality.   - Timing: May occur immediately before surgery or up to a week in advance, depending on facility policy and physician preference.   - General Data: Includes age, general health status, review of systems ($ROS$), medical history, and current medical problems/treatments.   - Allergies: Specific focus on latex allergies.   - Surgical History: Details on previous surgeries, presence of prosthetics, and prior experiences with anesthesia or pain tolerance.   - Social History: Includes use of tobacco, alcohol, illicit substances, and vaping.   - Medications: Documentation of all current medications, including herbal supplements, vitamins, and over-the-counter ($OTC$) drugs.   - Family History: Relevant familial outcomes, history of malignant hyperthermia, cancer, bleeding disorders, or anesthesia-related complications.   - Psychosocial Status: Assessment of the patient's understanding of the procedure and their support system.   - Cultural and Spiritual Needs: Determining preferences for blood transfusions or specific requests (e.g., blessing by a priest, presence of a shaman in the Post-Anesthesia Care Unit or $PACU$).

Diagnostic Testing, Pre-surgical Teaching, and Discharge Planning

• Laboratory and Diagnostic Labs:   - Type and screen.   - Complete Blood Count ($CBC$).   - Clotting studies.   - Metabolic panel.   - Pregnancy tests (when applicable).   - Urinalysis ($UA$) or drug screens.   - Electrocardiogram ($EKG$).   - Identification of pacemakers or Internal Cardioverter Defibrillators ($ICD$).

• Pre-operative Teaching: Information should be provided while the patient is in a receptive state, rather than just before use. Subjects include:   - Use of the incentive spirometer ($IS$).   - Training on aid devices such as crutches, braces, or wheelchairs.

• Discharge Planning: This process begins during the initial assessment. The nurse evaluates the home environment and support system to proactively address anticipated needs.

Nursing Diagnoses and Informed Consent

• Common Pre-operative Nursing Diagnoses:   - Fear and anxiety.   - Knowledge deficit.   - Impaired coping.   - Hypovolemia.

• Informed Consent Definitions:   - Informed: The patient must be educated on the process and procedure. This education is the responsibility of the surgeon/proceduralist.   - Consent: The patient agrees or gives permission for the procedure after being educated.   - Obtain: The nurse’s role is to ensure the patient is educated and to witness the conversation where consent is given without coercion.

• Legal Requirements for Consent:   - Must be obtained prior to the administration of any sedative medications.   - Patient must be of sound mind.   - If the patient is not of sound mind, a legal Power of Attorney ($POA$) with paperwork on file must sign.   - Minors (under $18$ years old) require a parent or guardian's signature unless they are legally emancipated.   - A patient may rescind consent at any time up to the induction of anesthesia, even if refusal results in death or complications.

Questions & Discussion

• Scenario: You are on the day shift receiving a report from the night shift. A patient is scheduled for a $9:30$ laparoscopic appendectomy (‘lap appy’). The night shift nurse states they witnessed the consent but did not sign the form.   - Question: What is the correct action?   - Response: The night shift nurse must sign the consent before leaving. If a nurse did not personally witness the conversation between the physician and the patient, they cannot legally sign as a witness.

Clinical Preparation: Advanced Directives and NPO Status

• Advanced Directives: Mandated by the Patient Self-Determination Act. Includes living wills or durable power of attorney. These instructions must be followed during surgery and cannot be ignored.

• NPO Status (Nothing Per Os):   - Definition: No food, drink, smoking, or unapproved medications.   - Rationale: Anesthesia relaxes gastric muscles; anything in the stomach increases the risk of aspiration exponentially.   - Standard Recommendations:     - Nothing fatty, fried, or protein-based for $8\,hours$ prior.     - No other foods within $6\,hours$.     - Clear liquids limited to within $2\,hours$ of surgery.     - Note: Always follow specific facility policy or surgeon orders.

Medication Management and Physical Prep

• Pre-operative Medication Management:   - Most routine medications are held the morning of surgery.   - Exceptions (usually given with a small sip of water): Cardiac medications (Beta blockers), seizure medications, respiratory treatments (Albuterol), and hypertension medications.   - Diabetic Patients: Critical thinking is required. Avoid medications that drop blood sugar if the patient is $NPO$ for a long procedure. Conversely, severely elevated glucose may require treatment. Consult the surgeon or anesthesia team.

• Intestinal Preparation: Used for major abdominal, pelvic, or perianal surgeries to reduce bacteria and prevent colon injury.   - Methods: Enemas or potent laxatives.   - Risks: Electrolyte imbalance, fluid volume imbalance, vagal stimulation, or postural hypotension.   - Safety: Include fall prevention teaching during bowel prep.   - Compliance: Lack of compliance must be reported as it may cancel the procedure.

• Skin Preparation: The body's first line of defense. Surgical incisions create pathways for microbes.   - Procedure: Washing with antimicrobial soap/solution ($1$ to $2$ days prior).   - Common Agent: Chlorhexidine gluconate, used according to facility policy or physician orders.