Chapter 14: Preoperative Nursing Management

Overview of Perioperative Nursing Phases

• Preoperative Phase: This initial phase begins precisely when the decision to proceed with a surgical intervention is established. It concludes when the patient is successfully transferred onto the operating room (OR) bed.
• Intraoperative Phase: This phase commences at the moment the patient is transferred onto the OR bed. It encompasses the entirety of the surgical procedure and ends when the patient is admitted to the Postanesthesia Care Unit (PACU).
• Postoperative Phase: This final phase begins upon the patient’s admission to the PACU. It continues beyond the immediate recovery period, ending with a follow-up evaluation conducted in a clinical setting or at the patient's home.

Surgical Classification and Urgency

• Purposes of Surgical Intervention:
  • Facilitating a Diagnosis: Procedures intended to identify the cause of symptoms.
  • Cure or Repair: Interventions aimed at resolving a condition or fixing an anatomical defect.
  • Reconstructive and Cosmetic: Procedures to restore function or enhance appearance.
  • Palliative: Surgery intended to alleviate symptoms and improve quality of life without necessarily curing the underlying disease.
  • Rehabilitative: Procedures focused on restoring a patient to a higher level of function.
• Classification by Urgency:
  • Emergent: Requires immediate intervention without delay (e.g., life-threatening conditions).
  • Urgent: Requires prompt attention (within $24$ to $30$ hours).
  • Required: The patient needs to have surgery (within weeks or months).
  • Elective: The patient should have surgery but failure to do so is not catastrophic.
  • Optional: Decision rests solely with the patient (e.g., cosmetic preferences).

Preadmission Testing and Data Collection

• Initiation of the Nursing Process: Preadmission testing (PAT) serves as the starting point for the nursing assessment.
• Admission Data Requirements:
  • Comprehensive demographics.
  • Detailed health history.
  • Any other information pertinent to the specific surgical procedure.
• Verification of Diagnostics: The nurse ensures that all preoperative diagnostic testing necessitated by the patient's specific needs has been completed.
• Early Discharge Planning: Discharge planning begins at this stage by assessing the patient’s requirements for postoperative transportation and home care.

Comprehensive Preoperative Assessment Protocols

• Core Assessment Elements:
  • Health History and Physical Examination: Establishing a baseline for all physiological systems.
  • Medications and Allergies: Documenting all current drugs and known hypersensitivities.
  • Nutritional and Fluid Status: Assessing for malnutrition or dehydration which can impact healing.
  • Dentition: Identifying loose teeth or dental prosthetics to prevent airway complications during intubation.
  • Drug or Alcohol Use: Screening for substances that might lead to withdrawal or altered anesthetic metabolism.
  • Respiratory and Cardiovascular Status: Vital for assessing anesthetic risk and oxygenation capacity.
  • Hepatic and Renal Function: Crucial for determining the patient's ability to metabolize and excrete anesthetic agents.
• Extended Assessment Areas:
  • Endocrine Function: For example, managing glucose levels in diabetic patients.
  • Immune Function: Assessing for immunocompromise or autoimmune disorders.
  • Previous Medication Use: Historical drug use that may have long-term effects (e.g., chronic steroid use).
  • Psychosocial Factors: Evaluating anxiety, support systems, and coping mechanisms.
  • Spiritual and Cultural Beliefs: Ensuring the surgical plan respects the patient's worldview.

Pharmacological Management and Potential Surgical Interactions

• Specific Drug Classes and Their Risks:
  • Corticosteroids: Abrupt discontinuation can lead to cardiovascular collapse.
  • Diuretics: These can cause excessive respiratory depression during anesthesia due to associated electrolyte imbalances.
  • Phenothiazines: These may potentiate the hypotensive (low blood pressure) actions of anesthetic agents.
  • Insulin: Interactions between anesthetics and insulin must be carefully managed, especially for patients with diabetes mellitus.
  • Other Impactful Medications: include Tranquilizers, Antibiotics, Anticoagulants, Anticonvulsant medications, Thyroid hormone, and Opioids.
  • Non-Prescription Substances: Over-the-counter (OTC) medications and herbal supplements must be documented as they can affect bleeding and drug metabolism.

Gerontologic Considerations for the Surgical Patient

• Physiological Changes in Older Adults:
  • Cardiac Reserves: Reserves are lower, making the elderly more susceptible to heart failure or fluid overload.
  • Renal and Hepatic Function: Functions are depressed, slowing the clearance of medications.
  • Gastrointestinal (GI) Activity: Likely to be reduced.
  • Respiratory Compromise: Increased risk for pulmonary complications.
  • Thermoregulation: Decreased subcutaneous fat makes geriatric patients more susceptible to temperature changes and hypothermia.
• Educational Needs: Older patients may require additional time and multiple educational formats (visual, auditory, written) to fully understand and retain preoperative instructions.

Special Patient Population Considerations

• Patients with Obesity: Increased risk for infection, technical surgical difficulties, and respiratory issues.
• Patients with Disabilities: May require specific positioning, communication aids, or specialized equipment.
• Ambulatory Surgery Patients: Focused on rapid prep and ensuring the patient understands home-care instructions immediately.
• Emergency Surgery Patients: Focused on rapid assessment and life-saving stabilization simultaneously with preoperative preparation.

Legal and Ethical Mandates of Informed Consent

• Requirements for Consent:
  • Must be in writing prior to nonemergent surgery.
  • It is a legal mandate that protects both the patient and the surgeon.
• Roles and Responsibilities:
  • The Surgeon: Responsible for explaining the procedure, its benefits, risks, potential complications, and alternatives.
  • The Nurse: Responsible for clarifying the information provided by the surgeon and witnessing the patient's signature on the document.
• Validity and Timing: Consent is considered valid only when signed before the administration of any psychoactive premedication. The signed consent form must accompany the patient to the OR.
• Purpose: Protects the patient from unsanctioned surgery and protects the surgeon from claims of battery or unauthorized operation. It also aids the patient's psychological preparation.

Preoperative Patient Education Strategies

• Respiratory Intervention Education: Teaching deep breathing, coughing techniques, and the use of incentive spirometry to prevent postoperative pneumonia.
• Physical Activity: Instruction on mobility and active body movements to prevent venous thromboembolism.
• Symptom Management: Education on pain management expectations and strategies.
• Psychological Support: Teaching cognitive coping strategies to manage stress.
• Setting-Specific Education: Specialized instructions for those undergoing ambulatory (same-day) surgery.

Preoperative Nursing Interventions

• Immediate Nursing Interventions (Just Before Surgery):
  • Ensuring the patient changes into a surgical gown.
  • Covering the hair and inspecting the mouth (for dentures/piercings).
  • Removing jewelry and storing valuables in a secure, designated place.
  • Administering preanesthetic medications.
  • Maintaining the preoperative record.
  • Transporting the patient to the presurgical or holding area.
  • Attending to the needs of the family.
• General Nursing Interventions:
  • Psychosocial: Reducing anxiety and fear; respecting cultural, spiritual, and religious beliefs.
  • Patient Safety: Ensuring the correct patient, site, and procedure.
  • Physical Prep: Managing nutrition and fluid intake (NPO status), preparing the bowel (if required), and preparing the skin (cleansing).

Expected Outcomes of Preoperative Care

• Effective relief of patient anxiety.
• Significant decrease in patient fear.
• A comprehensive understanding of the surgical intervention by the patient.
• The absence of any evidence regarding preoperative complications.

Questions & Discussion

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

• Options: A. Corticosteroids; B. Diuretics; C. Phenothiazines; D. Insulin.
• Answer: B (Diuretics).
• Rationale: Diuretics may cause excessive respiratory depression resulting from electrolyte imbalances. Corticosteroids may lead to cardiovascular collapse if stopped suddenly; Phenothiazines increase hypotensive action; Insulin interactions must be monitored in diabetics.

Question 2: True or False: Voluntary and written informed consent from the patient is necessary before nonemergent surgery can be performed solely to protect the surgeon from claims of an unauthorized operation or battery.

• Answer: False.
• Rationale: Informed consent is intended to protect the patient from unsanctioned surgery as well as the surgeon from legal claims. It also facilitates psychological preparation by ensuring the patient understands the procedure.

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

• Options: A. Have the family present; B. Ensure that the preoperative shave is completed; C. Have the patient void; D. Make sure the patient is covered with a warm blanket.
• Answer: C (Have the patient void).
• Rationale: Safety is the priority. The risk of falls is significantly increased after sedative or amnesic premedications are administered, so the patient must void beforehand. Additionally, shaving is no longer recommended; evidence-based practice suggests clipping hair instead.