Comprehensive Pre-operative Nursing Care and Surgical Nursing Study Guide

Classifications of Surgical Procedures and Impact on Nursing Care

Emergent Surgery
- Definition: A surgery that is not planned and must be performed immediately.
- Phase Duration: The pre-operative (pre-op) phase is significantly shorter because the procedure was not anticipated.
- Nursing Implications:
  - There is a higher risk of potential complications.
  - The nurse has less time to prepare the patient, collect data, or optimize the patient's condition.
Elective Surgery
- Definition: A planned surgery where there is plenty of time for preparation.
- Phase Duration: This involves one of the longest pre-operative periods.
- Risk Level: This is generally considered a lower-risk option compared to emergent surgeries due to the ability to plan and prepare.
Ambulatory Surgery
- Process: The patient arrives on the day of the surgery with the specific plan to be discharged and go home the same day.
- Nurse Perspective: This typically indicates a less complex, low-risk type of surgery. While traditionally performed at hospitals, the current trend is to move these procedures to standalone outpatient surgery centers.
Inpatient and Same-Day Admission
- Inpatient Surgery: The surgery occurs while the patient is already admitted to the hospital, and they return to a hospital bed post-operatively.
- Same-Day Admission: The surgery is planned, the patient arrives from home on the day of the procedure, but the surgery is complex enough that they must be admitted to the hospital for a stay afterward.

The Pre-operative Phase: Timeline and Nursing Roles

Timeline of the Pre-op Phase
- Beginning: The phase starts at the exact moment the patient decides to have surgery.
- Ending: The phase concludes when the pre-op nurse hands the patient off to the intra-operative (inter-op) nurse.
The Nurse's Primary Role
- Overall Goal: To help the surgical team assess the patient for the risk of complications.
- Core Tasks:
  - Conducting a thorough physical and history assessment.
  - Assessing laboratory results.
  - Ensuring all necessary documentation and results are present in the patient's chart.

System-Specific Pre-operative Risks and Nursing Judgment

Endocrine System (Diabetes/Insulin)
- The primary concern for diabetic patients is maintaining low risk through frequent monitoring.
- Nursing Action: The nurse must check blood sugar levels frequently before, during, and after the surgery.
Immune System Considerations
- Risk: Patients with a weakened immune system are at a significantly greater risk for post-operative infections.
- Precautions: Neutropenic precautions may be necessary.
- Causes of Weakness:
  - Autoimmune diseases.
  - Long-term use of corticosteroids (steroids).
  - Chemotherapy.
Renal System (Kidney Disease)
- Concerns: Fluid and electrolyte balance.
- Metabolism: Some medications used during surgery are metabolized by the kidneys, which the anesthesiologist must consider when planning sedation.
Reproductive and Respiratory Considerations
- Childbearing Age: Any woman of childbearing age must receive a pregnancy test prior to surgery ("when in doubt, take the test").
- Respiratory Disease: Higher risk for respiratory complications due to anesthesia and sedation.
- Sedation Impact: Sedatives suppress the patient's breathing effort.
- Ventilation: Patients with underlying lung disease face higher risks if they require a ventilator during general anesthesia.
- Inhaled Agents: Agents such as laughing gas (nitrous oxide) can negatively impact weak lungs, regardless of FDA approval.
Musculoskeletal and Hepatic Considerations
- Liver Disease: Similar to the kidneys, the liver is critical for the metabolism of medications; impairment is a significant concern for anesthesia.
- Arthritis and Mobility:
  - Positioning: Extra care must be taken when positioning the patient on the operating table to avoid worsening mobility problems.
  - Post-op Immobility: For patients with arthritis, it is vital to manage how long they remain immobile after surgery. Scheduling physical therapy and getting the patient up early is particularly important.

Medication Management and Implications

Prednisone (Corticosteroids)
- Side Effects (The Triple Whammy):
  1. Hyperglycemia (high blood sugar).
  2. Delayed wound healing.
  3. Weakened immune system.
- Critical Warning: Patients on long-term prednisone cannot stop taking it abruptly, even if they are NPO (nothing by mouth). Stopping cold turkey can be life-threatening; they must be weaned off the medication.
Other Key Medications
- Insulin: Requires frequent blood glucose checks.
- Aspirin: An antiplatelet medication. It is very often held for several days to a full week before a scheduled procedure to minimize bleeding risks.
- Cardizem (Diltiazem): Used for heart disease and hypertension. It serves as a "red flag" medication during assessment. If held the day of surgery, the nurse must warn the intra-op nurse that the patient's blood pressure might spike.

Laboratory Values and Pre-operative Teaching

Psychological Stress
- Nursing Note: Psychological stress can lead directly to physical complications. Surgeries are inherently stressful events for all patients.
Complete Blood Count (CBC) Analysis
- White Blood Cells (WBC): High counts indicate infection; low counts indicate neutropenia and a high risk for infection.
- Hemoglobin (Hgb): If low, the patient may be bleeding or anemic. Low levels cause fatigue, dizziness, and lightheadedness. For instance, an 86-year-old patient with a new hip who is anemic is at a severe risk for falls during post-op ambulation.
- Platelets: Too low leads to bleeding risks; too high leads to risks of over-clotting.
Coagulation Studies (PT/PTT)
- Used to determine the risk levels for clotting and bleeding during and after the procedure.
Pre-operative Teaching Topics
- Preparation for the day of surgery.
- Specific surgical preps and medications to take.
- Post-operative exercises: Coughing, deep breathing, and using an incentive spirometer.
- Waking up: What equipment will be present upon awakening and how pain will be managed.
- Logistics: Arrival time, procedure time, and expected discharge.

Informed Consent and Legal Standards

The Nurse's Role in Consent
- The nurse must ensure the consent form is signed and placed in the chart.
- The nurse answers or clarifies confusing points for the patient.
- Judgment Call: The nurse must decide if the patient's questions indicate that the surgeon needs to return to provide more information. The nurse should not be the sole source of education regarding the procedure details, as they are not the one performing it.
Inability to Give Consent
- Minors.
- Unconscious individuals.
- People deemed legally or medically incompetent.
- Gray Area: Patients with intermittent confusion represent a difficult area where consent depends on their status at the time of signing.

Intravenous (IV) Dosage Calculations

General Rules
- IV problems focus on volume (liquid) rather than the dosage (strength) of the medication.
- Determine if the infusion is "on the pump" or "off the pump" to choose the correct formula.
Off the Pump (Gravity/Drip Rate)
- Formula: $\frac{\text{Total Volume (mL)} \times \text{Drip Factor}}{\text{Time in Minutes}} = \text{Drops per Minute (gtt/min)}$
- Example Case: Volume of $200\,mL$ , drip factor of $15$ , time of $30\text{ minutes}$ .
- Calculation: $\frac{200 \times 15}{30} = 100\,gtt/min$
On the Pump (Electronic Infusion)
- Formula: $\frac{\text{Total Volume (mL)}}{\text{Time in Hours}} = \text{Milliliters per Hour (mL/hr)}$
- Note: Drip factor is irrelevant for pump problems.
- Example Case: Volume of $500\,mL$ over $2\text{ hours}$ .
- Calculation: $\frac{500}{2} = 250\,mL/hr$
- Conversions: If time is given in minutes, convert to hours (e.g., $90\text{ minutes} = 1.5\text{ hours}$ ; $30\text{ minutes} = 0.5\text{ hours}$ ; $15\text{ minutes} = 0.25\text{ hours}$ ).