1. Pre-Operative Care - Lecture notes 1 PDF

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Perioperative: the span of surgery, including before, during, and after the surgery. Patient safety is primary goal of nursing. Pre-Operative: begins with schedule of procedure and ends at transfer to the OR. Nurse role: Educate, advocate, and prep patient for surgery. Intra-Operative: begins transfer to the OR and ends with transfer to the PACU. Nurse priority: pt safety and advocacy. Post-Operative: begins when the patient arrives in the recovery area and after the procedure ends with full recovery from the procedure. Inpatient Surgery: admitted to the hospital and stays overnight. Outpatient/Ambulatory Surgery: leaves the same day of procedure or has a doctor’s office procedure. Surgical Procedure Classifications: Reason: Diagnostic: determine cause of disorder or cell type differentiation. Eg: breast biopsy. Curative: resolve issue by repairing or removing causative agent. Eg: Hernia repair, bladder suspension. Restorative: improve a patient’s fx ability. Eg: total knee arthroplasty, ligament repair. Palliative: only to relieve symptoms of disease, do not necessarily cure disease. Eg: tumor removal. Cosmetic: alter or enhance a person’s appearance. Eg: rhinoplasty nose surgery. Urgency: Elective: planned and not acute in nature. Eg: knee arthroplasty. Urgent: require prompt intervention, may be life threatening if delayed more than 24-48 hours. Eg: infected knee. Emergent: require immediate prevention d/t life threatening consequences. Eg: protruding broken knee cap pressing on major blood vessels. Degree: Minor: a procedure without significant risk. Eg: removal of mole, carpal tunnel surgery, removal of toe. Major: a procedure with greater risk. Eg: open heart surgery, bowel resection. Extent: Simple: involve the obvious affected area. Eg: simple mastectomy, which only removes breast tissue. Radical: extensive, go beyond the obvious affected area. Eg: radical mastectomy, removes also muscle, etc. MIS: minimally invasive surgery. Performed within body cavity with minimal opening surgical areas with the use of endoscopies. Eg: The use of robotics in hysterectomies, or doing wrist/knee repair under arthroscopy. Informed Consent: Definition of IC: A person’s agreement to allow something to happen based on full disclosure of risks, benefits, alternatives and consequences of procedure. It emerged as a matter of state law with the mindset that an adult who is competent has the right to self-determination. Nurses legal obligation is to ask the patient if they have been explained the procedure and if they have any questions or need further information. If so, the physician must be notified. Implies Patient Understands: The nature and reason for surgery. Who will be doing the procedure? Available options and risks associated with the other available options. Risks associated with anesthesia. Indications for Consent: Invasive procedures. Anesthesia, Radiation, Surgical Procedures, Blood Products Nurse Responsibility: If it is clarification of facts provided by physician and not new medical information, an RN may clarify. The RN must verify it is an authentic patient signature by witnessing the signing of the document. Patient is competent to give consent and that they signed. Physician Responsibility: Ensure that it is obtained and signed prior to anesthesia and procedure. Do Not Resuscitate Order: Definition of DNR: A DNR order should not be upheld or suspended routinely during anesthesia or surgery. This should be

discussed with the patient or family before surgery to determine if it should be maintained during surgery. If the patient has opted to alter their DNR during the procedure, there must be clear documentation in the medical record by the physician on whether or not it should be reinstated. Pre-Operative Assessment: Establish A Rapport: during initial contact to allow effective communication. Decrease patient/family anxiety. What Nurses Do: perform pre-op assessments, develop nursing dx, identify expected patient outcomes. Equipment Needed: oxygen, suction, hemodynamic monitoring (EKG, Pulse Ox, BP). Emergency med cart/defib. Risk Factors for Complications: Age: age >65 increases risk: Cardiovascular: ↓ cardiac output, ↑ SBP, ↓ peripheral circulation. Intervention: Monitor VS, peri pulses, cap refill, activity levels. Respiratory: ↓ vital capacity, loss of lung elasticity, ↓ oxygenation of blood. Intervention: teach coughing and deep breathing exercises. Monitor respirations. Renal: ↓ blood flow to kidneys, reduced ability to excrete waste, ↓ glomerular filtration rate, ↑ nocturia. Intervention: monitor I/O, access hydration, monitor electrolytes, assist with toileting. Neurological: sensory deficit, ↓ reaction time, ↓ ability to adjust to changes in environment. Intervention: orient pt to surroundings, allow extra time for teaching, provide pt safety. Musculoskeletal: ↑ incidence of deformities r/t osteoporosis or arthritis. Intervention: assess pt mobility, teach turn & reposition, encourage ambulation, fall precaution. Skin: delays in wound healing and ^ risk infection, dry with less subQ fat increases risk for damage. Intervention: Skin assess before sx, pad bony prominences, avoid skin tape, q2 turns. Meds: antihypertensives, tricyclic antidepressants, anticoagulants, NSAIDs. Med Hx: ↓ immunity, diabetes, cardio-pulmonary disease, multi-system disease, hemodynamic instability, coagulation defect or disorder, anemia, dehydration, infection, hypertension, hypotension, any chronic disease. Prior Sx Experience: less-than-optimal emotional rx, anesthesia rx or complications, post op complications. Health Hx: Malnutrition or obesity, drug/tobacco/alcohol/illicit substance use or abuse, altered coping ability. Family Hx: Malignant hyperthermia, cancer, bleeding disorder. Procedure: Airway Complications: Neck, oral, or facial procedure. Pulmonary Complications: Chest or high abdominal procedures. Paralytic Ileus/VTE: Abdominal procedures. Cardiopulmonary and vital signs: Hypotension or hypertension. HR ↓ 60 or ↑ 120. Irregular HR. Chest Pain. SOB or dyspnea. Tachypnea. Pulse Ox ↓ 94%. Fever. Purulent Sputum. Dysuria or cloudy, foul-smelling urine. Any red, swollen, draining IV or wound site. ↑ WBC. Signs or symptoms that contraindicate surgery: ↑ PT, ↑ INR, ↑ PTT. Hypokalemia or hyperkalemia. Patient report of possible pregnancy.

Signs or symptoms that need physician or APRN evaluation: AMS, vomiting, rash, recent administration of anticoagulant drug. Age Related Changes in Fluid Balance: Skin: ↓ elasticity, turgor, oil production. Result: Skin becomes unreliable indicator of fluid status. Dry and easily damaged. Kidney: ↓ glomerular filtration (GFR), concentrating capacity. Result: Poor excretion of waste, ↑ water loss and risk for dehydration. Muscular: ↓ muscle loss. Result: ↓ total body water, ↑ risk for dehydration. Neurologic: ↓ thirst reflex. Result: ↓ fluid intake, ↑ risk for dehydration. Endocrine: Adrenal atrophy. Result: Poor regulation of sodium and potassium, ↑ risk hyponatremia & hyperkalemia. Pre-Op Lab Values Most common include: Urinalysis, clotting studies, electrolyte levels, serum creatine, BUN levels. Pregnancy test for all women of childbearing age. HTC: 35-52% ↑ indications: Dehydration, polycythemia, high altitude. ↓ indications: Blood loss, anemia, kidney failure. HGB: 11.7-18 g/dL ↑ indications: Dehydration, polycythemia, chronic pulmonary disease, congestive heart failure. ↓ indications: Blood loss, anemia, renal failure. WBC: 5000-10000/mm3 ↑ indications: Infection, inflammation, stress, tissue necrosis. ↓ indications: Immune disorder, immunosuppressive therapy. aPTT: 30-40 sec ↑ indications: Coagulation defect (bleeding disorder). Anticoagulation therapy (heparin). Liver disease. ↓ indications: Coagulation (clotting) disorder, such as thrombophlebitis or pulmonary embolism. INR: 0.7-1.8 ↑ indications: Anticoagulant therapy (aspirin, warfarin). ↓ indications: Extensive cancer. PT: 11-12.5 sec, 85-100% ↑ indications: Coagulation defect (bleeding disorder), Vitamin K deficiency. ↓ indications: Coagulation (clotting) disorder, such as thrombophlebitis or pulmonary embolism. BUN: 8-23 mg/dL ↑ indications: Dehydration, kidney impairment, excessive protein in diet, liver failure. ↓ indications: Overhydration, malnutrition. CRE: 0.5-1.3 mg/dL, 53-106 µmol/L ↑ indications: Kidney damage w/ destruction with large number of nephrons, renal insufficiency, AKI, CKD, ESRD. ↓ indications: Atrophy of muscle tissue. GLU: 70-115 mg/dL ↑ indications: Hyperglycemia: excess amounts of IV fluids w/ glucose, stress, steroid use, pancreatic & hepatic disease. ↓ indications: Hypoglycemia: excess insulin. CO2 (Serum): 23-30 mEq/L

↑ indications: Chronic pulmonary disease, intestinal obstruction, vomiting or nasogastric suctioning, metabolic alkalosis. ↓ indications: Hyperventilation, diabetic ketoacidosis, diarrhea, lactic acidosis, renal failure, salicylate toxicity. Na+ (Serum): 136-145 mEq/L ↑ indications: Hypernatremia: dehydration, kidney disease, hypercortisolism. ↓ indications: Hyponatremia: fluid overload, liver disease, adrenal insufficiency. K+ (Serum): 3.5-50 mEq/L ↑ indications: Hyperkalemia: dehydration, kidney disease, acidosis, adrenal insufficiency, crush injuries. ↓ indications: Hypokalemia: fluid overload, diuretic therapy, alkalosis, insulin administration, hyperaldosteronism. Ca2 (Serum): 9.0-10.5 mEq/L ↑ indications: Hypercalcemia: hyperthyroidism, hyperparathyroidism. ↓ indications: Hypocalcemia: Vit. D deficiency, hypothyroidism, hypoparathyroidism, kidney disease, excessive intake of phosphorus-containing foods and drinks. Cl- (Serum): 98-106 mEq/L ↑ indications: Hyperchloremia: metabolic acidosis, respiratory alkalosis, hypercortisolism. ↓ indications: Hypochloremia: fluid overload, excessive vomiting or diarrhea, adrenal insufficiency, diuretic therapy. Mg2+ (Serum): 1.3-2.1 mEq/L ↑ indications: Hypermagnesemia: kidney disease, hypothyroidism, adrenal insufficiency. ↓ indications: Hypomagnesemia: malnutrition, alcoholism, ketoacidosis. P/PO4 (Serum): 3.0-4.5 mg/dL ↑ indications: Hyperphosphatemia: kidney disease, hypoparathyroidism, acidosis, hypocalcemia. ↓ indications: Hypophosphatemia: chronic antacid use, hyperparathyroidism, hypercalcemia, Vit. D. deficiency, alcoholism, malnutrition.

Specific Considerations When Planning Care of Older Pre-Op Patient: ↑ incidence of chronic illness, malnutrition, allergies, impaired self-care, inadequate support systems, risk for change in mental status (r/t unfamiliar surroundings, change in routine, drugs), risk for falls and resultant injury. ↓ability to withstand stress of surgery and anesthesia. Specific Considerations When Planning Pre-Op Teaching of Patient and Families:

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Fears and anxieties: Surgical procedure: Preoperative routines: the who, what, where, when and why. Explains process from the time that patient enters facility until procedure. Helps reduce anxiety. Invasive procedures: Coughing, turning, deep breathing: reduces post-op complications. Mobile secretions. Deep (Diaphragmatic) Breathing: Sit upright on edge of bed or chair and make sure feet are firmly on the floor. After Sx, fowler or semi-fowler positions. Take a gentle breath through mouth. Breathe out gently and completely. Take a deep breath through nose and mouth, and hold this breath to the count of five. Exhale through your nose and mouth. Expansion Breathing: Find a comfortable, upright position with your knees slightly bent (decreases tension on abdominal muscles as well as decreases respiratory resistance and discomfort). Place your hands on each side of your lower rib cage, just above your waste. Take a deep breath through your nose, using your shoulder muscles to expand your rib cage outward during inhalation. Exhale, concentrating first on moving your chest, then on moving your lower ribs inward, while gently squeezing the rib cage and forcing air out of the base of your lungs. Splinting of Surgical Incision: help reduce pain, encourage deep breathing. Incentive spirometer: how to use and how to tell when it is used correctly. Aids in lung expansion. Lower extremity exercises: Aids in prevention of DVT. Exercise 1: Exercise 2: Exercise 3: Exercise 4: Stockings and pneumatic compression devices: venous stasis may result in thromboembolism. May break off and travel to lung as a pulmonary embolism. Prevention is key. Also SUBQ heparin and lovenox. Aids in prevention of VTE. Early ambulation: Aids in prevention of VTE. Pain management: Physical Prep of Patient Pre-Op: Diet: adequate understanding and insurance from patient to prevent delays, cancellations, patient dissatisfaction. May be up to 8 hours. Includes food, water, gum, hard candy, smoking and smokeless tobacco. If light meal is allowed, nurse must describe what a light meal details: soup, salad, toast, butter, juice, coffee, fruit. NPO may leave patients at risk for dehydration if start time is delayed. Skin: antiseptic skin performed pre-procedure; first step in reducing risk of post-op infection. May take 2. Do not shave on operative site prior to procedure. Enhances microbial growth. No oil or hairspray, but shampoo is fine. Bowel: only required if having major abdominal, pelvic, perineal, or perianal surgery. Oral laxative/enema. NG Tube may be required. Stomach may be suctioned/aspirated. Bladder: performed if urinary retention is anticipated or need for hourly monitoring of urinary output before, during or after the procedure. Medications: procedures with marked blood loss may have 14 or 16 gauge IV cath for rapid infusion of blood, fluid, or IV Medications. Also for maintaining adequate fluid and electrolyte balances. Transfusions: begins with physician decision or anticipation to use blood products during or after. Must have consent separate of surgical consent. Must have type and cross. Patient may donate blood to themselves in electives (like orthopedic procedures).

Personal Items: nurse should advise patient to wear comfortable and loose fitting clothes. Bring phone numbers, dentures, eye glasses, CPAP, list of medications, list of all allergies, insurance cards, photo IDs, and any other documents that the surgeon’s office instructed them to bring. Pre-Op Medications: Anticholinergics: Use: Block acetylcholine receptors. Control pre-op secretions. Prevent bronchospasms by airway dilation. Reduce GI contractions. Side Effects: Dry mouth, throat and nasal cavity, constipation, increased intraocular pressure, urinary retention, dry skin. Also: can increase the effects of digoxin. Examples: Atropine, Glycopyrrolate (Robinul), Scopolamine Antiemetic / H2 Receptors: Use: Prevent nausea and vomiting. Decrease gastric secretions. Side Effects: drowsiness, dry mouth, restlessness, confusion (Zantac) Also: Antiemetic Examples: Metoclopramide (Reglan), Droperidol (Inaspine), Ondansetron (Zofran). H2 Receptor Examples: Rantidine (Zantac) and Cimetidine (Tagamet). Anxiolytic: Benzodiazepines Use: Control anxiety and provide pre-op sedation, induce amnesia. Side Effects: sedation, dizziness, weakness, unsteadiness. Also: Monitor BP, Pulse, orthostatic hypotension, no grapefruit. Anxiolytic Examples: Diazepam, Lorazepam, Alprazolam. Antidote: Flumazenil (Romazicon) Sedatives: Use: Depresses CNS functions. Very high doses have sedative and hypnotic effects for anesthesia. Side Effects: Hangover, dependency, tolerance, excessive depression, respiratory depression, hypersensitivity. Also: Sedatives Examples: Barbiturates, Phenobarbital, Xanax, Restoril, Ambien, Sodium Pentothal....