21 Lec Surgical Pre-operative Nursing Notes

Surgical Patient Pre-operative Nursing Notes 10/08/2025

Learning Objectives

  • Explain preoperative nursing care responsibilities.

  • Discuss surgical risk factors & potential complications.

  • Describe components of the intraoperative surgical phase.

  • Explore the role of the nurse when caring for the postoperative client.

  • Discuss safety considerations when providing care for the surgical client.

Phases of Perioperative Nursing

  • Surgical Suite:

    • Houses the operating rooms (OR) where surgeries take place.

  • Phases of Perioperative Nursing:

    1. Pre-Op:

    • Starts when the client decides to have surgery (both physical & psychological preparations are made).

    • Ends once the client is transferred to the OR.

    1. Intra-Op:

    • Begins when the client is admitted to the OR.

    • Ends when the client is admitted to the recovery room (PACU).

    1. Post-Op:

    • Starts when the client is admitted to PACU and ends with the follow-up appointment (which can range from a few hours to includes rehabilitation & recuperation).

Categories of Surgical Procedures

  • Purposes of Surgeries:

    • Curative

    • Palliative

    • Cosmetic

    • Restorative

    • Diagnostic

    • Transplant

  • Acuity Categories of Surgical Procedures:

    • Emergent: Immediate intervention is necessary.

    • Urgent: Surgical intervention must occur within a reasonable time frame to prevent complications.

    • Elective: Scheduled surgeries that can be planned in advance. Common in outpatient or ambulatory settings like cataract removals and hernia repairs.

Pre-Op Nursing Care Responsibilities

  • Identification of Risk Factors: This is a major aspect of pre-Op care. Includes thorough data collection regarding the client’s physical, emotional, & psychosocial status prior to surgery.

Risk Factors for Surgical Complications

  • Obstructive Sleep Apnea:

    • Airway obstruction, oxygen desaturation.

  • Pregnancy:

    • Risks associated with anesthesia for the fetus.

  • Respiratory Disease:

    • Includes COPD, pneumonia, asthma.

  • Cardiovascular Disease:

    • Such as heart failure, myocardial infarction, dysrhythmias.

  • Diabetes Mellitus:

    • Issues with decreased intestinal motility, altered blood glucose levels, and delayed healing.

  • Liver Disease:

    • Affects medication metabolism and increases the risk for bleeding.

  • Kidney Disease:

    • Alters elimination and medication excretion.

  • Endocrine Disorders:

    • Issues include hypo/hyperthyroidism, Addison’s disease, and Cushing’s syndrome.

  • Immune System Disorders:

    • Being immunocompromised increases risk of complications.

  • Coagulation Defects:

    • Increase risk of bleeding.

  • Malnutrition:

    • Leads to delayed healing.

  • Obesity:

    • Can cause complications such as pulmonary issues due to hypoventilation, anesthesia, and wound healing difficulties.

  • Medications:

    • Certain medications (e.g., antihypertensives, anticoagulants, NSAIDs, tricyclic antidepressants, herbal medications, OTC medications) can complicate surgical outcomes.

  • Substance Use:

    • Tobacco and alcohol use should be addressed.

  • Family History:

    • Malignant hyperthermia may be a consideration.

  • Allergies:

    • Such as latex and anesthetic agents.

  • Psychological Factors:

    • Includes inability to cope and lack of a support system.

Medications with Special Implications for the Surgical Patient

  1. Anticoagulants:

    • Warfarin and aspirin should be stopped several days before surgery due to prolonged clotting times that may lead to hemorrhage.

  2. Antihypertensives:

    • May cause hypotension when combined with anesthesia and narcotics used for pain control.

  3. Antiseizure Drugs:

    • Long-term use can lead to interactions with anesthetic agents.

  4. Corticosteroids:

    • Can prolong bleeding and reduce the body's ability to handle surgical stress due to adrenal suppression.

  5. Diuretics:

    • May cause hypotension post-surgery.

  6. Herbal Therapies:

    • Some can affect bleeding times, such as ginseng which may increase hypoglycemia when taken with insulin.

  7. Insulin:

    • Blood glucose levels may require adjustment based on nutritional intake and stress response post-surgery.

  8. NSAIDs:

    • Inhibit platelet function and can prolong bleeding, leading to hemorrhage.

Risk Factors in Older Adult Clients

  • Age-Related Changes:

    • Decreased hepatic and renal function affecting anesthetic clearance, risks of adverse reactions, and less physiologic reserve compared to younger clients.

    • Challenges such as sensory decline, oral alterations (issues with dentures affecting intubation), and skin fragility.

    • Higher risk for dehydration due to less body water and decreased subcutaneous fat.

Pre-Preop Evaluation

  • Data Collection:

    • Medical & Surgical history, tolerance of anesthesia, and medication use.

    • Evaluation of psychosocial factors including cultural considerations and social support.

    • Allergies:

    • Medications (e.g., latex, propofol), food allergies (e.g., shellfish-related povidone-iodine allergies), and psychological status.

    • Baseline Data:

    • Head-to-toe physical assessment, vital signs, and oxygen saturations evaluated.

Diagnostic Procedures

  • Common Tests:

    1. Urinalysis: Evaluates renal function and rules out infection.

    2. Blood type & cross-match: Prepares for potential transfusion.

    3. Complete Blood Count (CBC): Assesses fluid status, anemia, and immune status.

    4. Pregnancy Tests: Evaluates fetal risk associated with anesthesia.

    5. Clotting Studies: Measures PT, INR, aPTT, and platelet count.

    6. Blood Electrolyte Levels: Evaluates imbalances prior to surgery.

    7. Creatinine and BUN Levels: Assesses renal status.

    8. ABGs: Important for determining oxygen status.

    9. Chest X-ray: Assesses overall heart and lung status; particularly for clients over 40.

    10. 12-lead ECG: Evaluates baseline heart rhythm and history of dysrhythmias.

Patient Preparation

  • Informed Consent:

    • Must be signed, witnessed, and properly filled out.

  • Pre-Op Measures:

    • Administer enemas/laxatives for bowel surgeries, check scheduled medications, and prepare autologous blood donations if necessary.

    • NPO Guidelines:

    • No solid food for at least 6 hours and clear liquids for 2 hours before surgery.

  • Skin Preparation:

    • Cleanse with antimicrobial soap when applicable; hair removal using clippers or depilatories may be necessary.

  • Safety Measures:

    • Remove jewelry, dentures, and other items as necessary; cover the client to prevent hypothermia with a heated blanket if needed.

  • IV Access:

    • Establish large-bore IV access (at least 18-gauge) for fluid and blood product administration.

Pre-Op Checklist

  • Check Completion:

    • The preoperative checklist includes items such as:

    • Informed consent completion and signing.

    • NPO status checked.

    • Skin prep done.

    • Patient voided prior to pre-op meds.

    • Documentation including vital signs and allergy information recorded.

  • Transfer Readiness:

    • Ensure bed in low position and side rails up post-medication.

Medications for Pre-Op

  • Medications and Their Purposes:

    1. Benzodiazepines: Provides sedation (e.g., midazolam).

    2. Opioids: Reduces the required amount of anesthesia (e.g., morphine).

    3. Antibiotics: Minimizes the risk of infection (e.g., cefazolin).

    4. Antiemetics: Prevents post-op nausea/vomiting (e.g., metoclopramide).

    5. Anticholinergics: Decreases oral/respiratory secretions (e.g., atropine).

    6. Corticosteroids: Reduces inflammation (e.g., methylprednisolone).

    7. NSAIDs: Provides mild pain relief (e.g., ketorolac).

    8. Anticoagulants: Helps prevent clots (e.g., enoxaparin; heparin).

Informed Consent

  • Responsibility:

    • The provider is responsible for obtaining informed consent post-discussion of surgery risks and benefits.

  • Nurse’s Role:

    • Witness the signing of the consent form. Ensure the client understands the information provided.

    • Determine the client’s capacity to consent (age, mental capability, not influenced by medication).

  • Alternative Signatory:

    • A guardian or surrogate can sign if the client cannot. Two witnesses may be required if there is an 'X' signature, impairment, or language barrier.

  • Required Situations for Consent:

    • Surgical and invasive procedures requiring anesthesia.

Client Education on Surgery Day

  • General Info:

    • Timing and location for check-in, what to bring, and visitor policies.

  • Pre-Op Preparation:

    • Advising on NPO status and potential medication adjustments.

  • Post-Op Expectations:

    • Understanding methods for pain control and postoperative restrictions (e.g., ambulation, DVT prevention).

    • Importance of ROM exercises and the use of antiembolism stockings.

Complications Related to Preoperative Medications

  • Common Complications:

    • Inadequate wound healing, infection/sepsis, anemia, hypovolemia, electrolyte imbalances, allergic reactions.

Medications and Their Complications

Medication Class

Complications

Nursing Actions

Sedatives

Respiratory depression, dizziness

Monitor RR & O2 saturation; administer O2; flumazenil.

Opioids

Respiratory depression, dizziness, constipation

Monitor RR & O2 saturation; administer O2; naloxone.

IV Infusions

Fluid overload, hypernatremia

Monitor I&O, adjust fluid rate, and diuretics if needed.

GI Medications

Alkalosis, cardiac abnormalities, drowsiness

Obtain pre-Op cardiac history; monitor electrolytes.

Categories of Anesthesia

  1. General Anesthesia:

    • Produces amnesia, analgesia, muscle paralysis, and sedation; used for major surgery that requires extensive tissue manipulation.

    • Common Agents: Propofol, nitrous oxide.

    • Common Adverse Effects: Cardiovascular depression, respiratory depression, organ damage.

  2. Regional Anesthesia:

    • Causes loss of sensation in a body area without loss of consciousness; can be administered via infiltration or local applications (epidural, nerve block, or spinal).

  3. Local Anesthesia:

    • Provides localized loss of sensation; commonly used for minor procedures (e.g., biopsies).

  4. Conscious Sedation (Moderate Sedation):

    • Reduces anxiety and discomfort; patients must maintain patent airways and respond to stimuli; often used in dental/dressing procedures.

Test Yourself Questions

  1. Pre-surgery laboratory value reviews - identify levels that require provider notification.

  2. Statements for post-operative teaching - review best practices for patient education post-surgery.

  3. Informed consent verification steps - ensure compliance with nurse's role in the consent process.

  4. Handling elevated temperatures in surgical patients - appropriate nursing interventions.

  5. Assessments after pre-op medication administration.

  6. Consent authority - identify who can legally give consent in different situations.

The End

  • Thank you for reviewing.