Chapter 14: Preoperative Nursing Management

Perioperative Nursing Phases

Perioperative nursing is a comprehensive field that encompasses the entire surgical experience for a patient. It is divided into three distinct phases based on the timing and location of care:

• Preoperative Phase: This phase begins the moment the decision is made to proceed with a surgical intervention. It encompasses all preparatory steps and ends when the patient is physically transferred onto the operating room ($OR$) bed.

• Intraoperative Phase: This phase starts when the patient is moved onto the $OR$ bed and continues through the duration of the surgical procedure. It concludes when the patient is admitted to the Postanesthesia Care Unit ($PACU$).

• Postoperative Phase: This phase begins with the patient's admission to the $PACU$. It extends through the recovery process and concludes with a follow-up evaluation, which may occur in a clinical setting or at the patient's home.

Surgical Classification Systems

Surgeries are classified based on their underlying purpose and the urgency of the situation.

Purpose-Based Classifications:

• Diagnostic: Performed to facilitate a diagnosis (e.g., biopsy).

• Curative: Performed to cure a disease or condition (e.g., excision of a tumor).

• Repair: Performed to fix a specific injury or defect (e.g., multiple wound repair).

• Reconstructive: Performed to restore function or appearance (e.g., breast reconstruction).

• Cosmetic: Performed to improve appearance (e.g., rhinoplasty).

• Palliative: Performed to relieve symptoms or improve quality of life without curing the underlying disease (e.g., debulking a tumor for pain relief).

• Rehabilitative: Performed to restore function (e.g., total joint replacement).

Urgency-Based Classifications:

• Emergent: Requires immediate attention; life-threatening (e.g., severe hemorrhage).

• Urgent: Requires prompt attention within $24$ to $30$ hours.

• Required: Patient needs to have the surgery, planned within a few weeks or months.

• Elective: Patient should have surgery, but failure to do so is not catastrophic.

• Optional: Decision rests with the patient; personal preference.

Preadmission Testing (PAT)

Preadmission testing is the crucial first step in the nursing assessment process for surgical candidates. Its functions include:

• Initiation of Nursing Assessment: Gathers initial clinical data.

• Collection of Admission Data: Includes demographics, comprehensive health history, and any other information specific to the planned surgical procedure.

• Verification of Diagnostic Testing: Ensures all required preoperative tests (labs, imaging, etc.) are completed and reviewed based on the patient's specific needs.

• Discharge Planning: Begins early by assessing the patient's post-surgical needs, including transportation and the availability of care at home.

Comprehensive Preoperative Assessment

A thorough assessment is vital to ensure patient safety and optimal outcomes. The assessment is divided into several key areas:

Physical and Medical History (Part 1):

• Health History and Physical Exam: Baseline data for comparison.

• Medications and Allergies: Identification of current drugs and any hypersensitivities.

• Nutritional and Fluid Status: Assessment for dehydration or malnutrition which can affect healing.

• Dentition: Inspection for loose teeth, dentures, or decay that could be dislodged during intubation.

• Drug or Alcohol Use: Assessment for potential withdrawal or tolerance to anesthesia.

• Respiratory and Cardiovascular Status: Ensuring the systems can handle the stress of anesthesia and surgery.

• Hepatic and Renal Function: Vital for the metabolism and excretion of anesthetic agents and medications.

Additional Assessment Factors (Part 2):

• Endocrine Function: Monitoring conditions such as diabetes mellitus.

• Immune Function: Assessing for immunosuppression or autoimmune disorders.

• Previous Medication Use: Reviewing long-term therapy that might interact with surgery.

• Psychosocial Factors: Assessing the patient’s mental state and support systems.

• Spiritual and Cultural Beliefs: Taking into account any religious or cultural requirements regarding medical treatment (e.g., blood transfusions).

Medications and Their Surgical Impact

Various classifications of medications must be carefully assessed during the preoperative phase as they can significantly impact the surgical experience:

• Corticosteroids: If discontinued suddenly, they can cause cardiovascular collapse.

• Diuretics: Can cause electrolyte imbalances, leading to excessive respiratory depression during anesthesia.

• Phenothiazines: May increase the hypotensive (blood pressure lowering) action of anesthetic agents.

• Tranquilizers: May contribute to respiratory depression or excessive sedation.

• Insulin: Interactions between anesthetics and insulin must be managed, especially for patients with diabetes mellitus ($DM$).

• Antibiotics: Certain antibiotics can have nerve-blocking properties that interact with muscle relaxants.

• Anticoagulants: Increase the risk of intraoperative and postoperative bleeding.

• Anticonvulsant Medications: Vital for maintaining seizure control; may interact with anesthetics.

• Thyroid Hormone: Necessary for metabolic stability.

• Opioids/Analgesics: Long-term use may affect pain management requirements postoperatively.

• Over-the-counter ($OTC$) and Herbals: Many can increase bleeding risks or interact with other medications.

Gerontologic Considerations in Surgery

Elderly patients represent a high-risk population due to physiological changes associated with aging:

• Lower Cardiac Reserves: The heart is less able to respond to increased demands.

• Depressed Renal and Hepatic Functions: This slows the metabolism and clearance of anesthetics and other drugs.

• Reduced Gastrointestinal ($GI$) Activity: Slower transit times and decreased absorption.

• Respiratory Compromise: Reduced lung elasticity and vital capacity.

• Decreased Subcutaneous Fat: Makes the elderly more susceptible to hypothermia and temperature changes.

• Communication and Education: Older adults may require more time and various educational formats (visual, auditory, written) to fully comprehend and retain preoperative instructions.

Special Patient Populations

Certain groups require specialized attention during the preoperative period:

• Patients with Obesity: Increased risk for respiratory issues, poor wound healing, and technical surgical challenges.

• Patients with Disabilities: May require specialized equipment or communication methods (e.g., sign language, assistance with physical positioning).

• Patients undergoing Ambulatory Surgery: Focus on rapid education and ensuring the home environment is prepared for recovery.

• Patients undergoing Emergency Surgery: Often lack the time for thorough preparation; requires rapid assessment and prioritization.

Informed Consent and Legal Mandates

Informed consent is a vital legal and ethical requirement before any nonemergent surgery.

• Mandate: Informed consent must be in writing.

• Surgeon's Responsibility: The surgeon is legally obligated to explain the procedure, its benefits, potential risks, and possible complications.

• Nurse's Role: The nurse clarifies the information provided by the surgeon and acts as a witness to the patient's signature.

• Validity: The consent is only valid if signed before the administration of any psychoactive premedication (sedatives, amnesics).

• Documentation: The signed consent form must accompany the patient to the $OR$.

• Purpose: It protects the patient from unsanctioned or unauthorized surgery and protects the surgeon from legal claims of battery or unauthorized operation. It also assists in the patient's psychological preparation by ensuring they understand what will happen.

Preoperative Patient Education

Effective education is linked to better postoperative outcomes. Key topics include:

• Respiratory Exercises: Instruction on deep breathing, coughing, and the use of an incentive spirometer to prevent pneumonia and atelectasis.

• Mobility: Teaching active body movements and early ambulation to prevent deep vein thrombosis ($DVT$).

• Pain Management: Educating the patient on pain scales and the importance of reporting pain early.

• Cognitive Coping Strategies: Helping the patient manage anxiety and stress related to the surgery.

• Ambulatory Surgery Instructions: Specific guidance for patients returning home on the same day as the procedure.

Immediate Preoperative Nursing Interventions

Just before the patient is moved to the surgical area, the nurse must ensure the following:

• Preparation for Surgery: The patient changes into a hospital gown, hair is covered with a cap, and the mouth is inspected (for gum, dentures, etc.).

• Patient Property: All jewelry is removed, and valuables are stored in a secure location.

• Medication Administration: Preanesthetic medications (e.g., sedatives) are administered as ordered.

• Record Keeping: The preoperative record must be maintained and completed.

• Safety Measure (Voiding): The patient must void before receiving premedications to prevent falls and injury. Shifting away from "voiding on call to OR" toward voiding prior to sedation is a safety priority.

• Transport: The patient is moved safely to the presurgical or holding area.

• Family Care: Attending to the psychological and informational needs of the patient's family.

General Preoperative Nursing Interventions

• Psychosocial Interventions: Reducing patient anxiety and fear through therapeutic communication and respecting cultural, spiritual, and religious beliefs.

• Patient Safety: Ensuring the correct patient, correct site, and correct procedure.

• Nutrition and Fluid Management: Ensuring the patient adheres to "Nothing by Mouth" ($NPO$) status to prevent aspiration.

• Bowel Preparation: Administering enemas or laxatives if required for the specific surgical site.

• Skin Preparation: Preparing the surgical site (e.g., cleaning, hair clipping). Note: Clipping hair is evidence-based practice; shaving is no longer recommended due to the risk of micro-cuts and infection.

Questions & Discussion

Question 1: Which medication classification must be assessed during the preoperative period because it can cause an electrolyte imbalance during surgery?

• Options: Corticosteroids, Diuretics, Phenothiazines, Insulin.

• Answer: Diuretics.

• Rationale: Diuretics can cause electrolyte imbalances during anesthesia, which may lead to excessive respiratory depression. In contrast, corticosteroids carry the risk of cardiovascular collapse if stopped suddenly, and phenothiazines may exacerbate the hypotensive effects of anesthesia. Insulin management is critical for patients with diabetes due to potential interactions with anesthetic agents.

Question 2: Is it true or false that voluntary and written informed consent is necessary before nonemergent surgery solely to protect the surgeon from claims of battery?

• Answer: False.

• Rationale: Informed consent serves a dual purpose. While it does protect the surgeon from legal claims of unauthorized operation or battery, its primary purpose is to protect the patient from unsanctioned surgery and ensure they are psychologically prepared and fully understand the procedure to be performed.

Question 3: The nurse is preparing to administer a premedication. Which action should the nurse take first?

• Options: Have the family present, Ensure that the preoperative shave is completed, Have the patient void, Make sure the patient is covered with a warm blanket.

• Answer: Have the patient void.

• Rationale: Safety is the primary concern. Since many preoperative medications are sedative or amnesic, the patient's risk of falling is significantly increased after administration. Emptying the bladder first prevents injuries. Furthermore, "shaving" is no longer recommended; hair should be clipped according to evidence-based practice.

Expected Preoperative Outcomes

The goal of preoperative management is to achieve the following for the patient:

• Relief of anxiety.

• Decreased fear.

• A clear understanding of the surgical intervention.

• No evidence of preoperative complications.