Preoperative Nursing - summary notes PDF

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Preoperative Nursing The preoperative phase begins when the decision to proceed with surgical intervention is made, and ends with the transfer of the patient onto the OR table. The nursing roles during this phase focus on assessing the patient and developing a plan of care. This process is performed utilizing diverse modalities. Telephone interviews, face-to-face assessments and computer-aided tools are used to review the physical, psychological, sociocultural, and spiritual needs of the patient. Preadmission units work collaboratively with anesthesia providers to interview and assess the patient to identify potential or actual problems that may occur. The goals of preoperative assessment are to reduce the patient’s surgical and anesthetic perioperative morbidity or mortality. Medical history, laboratory values, and diagnostic tests help practitioners evaluate the patient. Preadmission nurses actively participate in pre-op education to prepare the patient and family to take an active role in their experience.

Informed Consent The surgical experience, except in extreme emergencies, begins after a patient has consented to a recommended surgical procedure. Voluntary and written informed consent from the patient is necessary before nonemergent surgery can be performed. The Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), believes that a patient or his or her representative (as allowed under state law) has the right to make informed decisions regarding the patient’s care. The guidelines further indicate that, for the surgical patient, a properly executed informed consent form for the operation must be in the patient’s chart prior to surgery, except in emergencies. The primary purpose of the informed consent process is to ensure that the patient, or the patient’s representative, is provided information necessary to enable him or her to evaluate the proposed surgery before agreeing to it (Centers for Medicare and Medicaid Services, 2017; Waisel, 2015). A written consent protects the patient from unsanctioned surgery and protects the surgeon from claims of an unauthorized operation (The Joint Commission, 2016b). It is normally the responsibility of the performing surgeon to obtain the informed surgical consent, which should consist of the following four basic elements: 1. The physician documents that the patient or surrogate has decision-making capacity, which is distinct from the legal concept of competency as determined by courts. Adults are presumed to be legally competent unless declared otherwise by a court (Waisel, 2015, p. 258). 2. The surgeon discloses to the patient details regarding the diagnosis and treatment options sufficiently for the patient to make an informed choice. 3. The patient demonstrates understanding of the disclosed information. 4. The patient freely authorizes a specific treatment plan without undue influence (Waisel, 2015). Informed consent is necessary in the following circumstances:  Invasive procedures, such as a surgical incision, a biopsy, a cystoscopy, or paracentesis  Procedures requiring sedation and/or anesthesia

A nonsurgical procedure, such as an arteriography, that carries more than slight risk to the patient  Procedures involving radiation If the patient has doubts and has not had the opportunity to investigate alternative treatments, a second opinion may be requested. No patient should be urged or coerced to give informed consent. Refusing to undergo a surgical procedure is a person’s legal right and privilege. The consent process can be improved by providing audiovisual materials to supplement discussion, by ensuring that the wording of the consent form is understandable, and by using other strategies and resources as needed to help the patient understand its content. It is required to have the consent available in multiple languages or have a trained medical interpreter available for non– English-speaking patients. In many cases, it is required to have alternative forms of communication (e.g., Braille, large print, sign interpreter) for the elderly and disabled. 

Preoperative Health Assessment Before any surgical treatment is initiated, a health history is obtained, a physical examination is performed during which vital signs are noted, and a database is established for future comparisons. Preoperative blood tests, x-rays, and other diagnostic tests are obtained as needed. The goal in the preoperative period is for the patient to have as many positive health factors as possible. Many risk factors may lead to complications (Box 5-2). Every attempt is made to stabilize those conditions that otherwise hinder recovery.

Nutritional and Fluid Status Optimal nutrition is an essential factor in promoting healing and resisting infection and other surgical complications. Assessment of a patient’s nutritional status identifies factors that can affect the patient’s surgical course, such as obesity, under nutrition, weight loss, malnutrition, deficiencies in specific nutrients, metabolic abnormalities, and the effects of medications on nutrition. Nutritional needs may be determined by measurement of body mass index (BMI) and waist circumference (U.S. Department of Health and Human Services, 2015). A BMI of 18.5 to 24.9 is normal; less than 18.5 is underweight, greater than 25 is overweight, greater than 30 is obese, and 40 and greater is extreme obesity. A waist circumference measurement of greater than 40 in in men and 35 in in women is associated with increased cardiac risk. If possible, any nutritional deficiency, such as malnutrition, should be corrected before surgery to provide adequate protein for tissue repair. The nutrients needed for wound healing are summarized in Table 5-3. Dehydration, hypovolemia, and electrolyte imbalances can also lead to significant problems in patients with comorbid medical conditions or in patients who are elderly. The severity of fluid and electrolyte imbalances is often difficult to determine. Mild volume deficits may be treated during surgery; however, additional time may be needed to correct pronounced fluid and electrolyte deficits to promote the best possible preoperative condition.

Drug or Alcohol Use People who abuse drugs or alcohol frequently deny or attempt to hide it. In such situations, the nurse who is obtaining the patient’s health history needs to ask frank questions with patience, care, and a nonjudgmental attitude. Because acutely intoxicated people are at higher risk for potential injury, surgery is postponed if possible. If emergency surgery is required, local, spinal, or regional block anesthesia is used for minor surgery. Otherwise, to prevent vomiting and potential aspiration, a nasogastric tube is inserted before general anesthesia is administered. The person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase surgical risk. Alcohol withdrawal syndrome or delirium tremens (DTs) may be anticipated between 48 and 72 hours after alcohol withdrawal and is associated with a significant mortality rate when it occurs postoperatively.

Respiratory Status The goal for surgical patients is optimal respiratory function. Because adequate ventilation is potentially compromised during all phases of surgical treatment, surgery is usually postponed if the patient has a respiratory infection. Patients with underlying respiratory disease (e.g., asthma, chronic obstructive pulmonary disease [COPD]) are assessed carefully for current threats to their pulmonary status. Patients should be evaluated for conditions such as respiratory infection and neuromuscular diseases, such as Parkinson disease, which may affect respiratory function. The use of tobacco is an important risk factor but one that usually cannot be influenced. Even among smokers who have not developed chronic lung disease, smoking is associated with significant changes in lung function. While cessation for 2 days prior to surgery is recommended, a prospective study by Warner, Divertie, & Tinker (1984) revealed that smoking cessation for up to 8 weeks was necessary to reduce the rate of postoperative pulmonary complications. However, the ideal duration of cessation of smoking before surgery remains unclear. What it known is that, within 12 hours of quitting smoking, the patient would experience a decrease in carbon monoxide levels; improved oxygen delivery; lower nicotine levels, which improves vasodilatation; and a decrease in toxic substances that impair wound healing (Stoelting, Hines, & Marschall, 2012).

Cardiovascular Status The goal in preparing any patient for surgery is to ensure a well-functioning cardiovascular system to meet the oxygen, fluid, and nutritional needs of the perioperative period. If the patient has uncontrolled hypertension, surgery may be postponed until the blood pressure is stabilized. At times, surgical treatment can be modified to meet the cardiac tolerance of the patient. For example, in a patient with obstruction of the descending colon and coronary artery disease, a temporary simple colostomy may be performed rather than a more extensive colon resection that would require a prolonged period of anesthesia.

Hepatic and Kidney Function The presurgical goal is optimal function of the liver and urinary systems, so that medications, anesthetic agents, body wastes, and toxins are adequately processed and removed from the body. The liver is important in the biotransformation of anesthetic compounds. Therefore, any disorder of the liver has an effect on how anesthetic agents are metabolized. The limited ability of a failing liver increases the perioperative risks and presents significant challenges. Increased morbidity and mortality is associated with varying degrees of liver insufficiency; thus, it is important to quantify and grade preoperative liver dysfunction using various serum liver function tests (Kaufman & Roccaforte, 2013). Because the kidneys are involved in excreting anesthetic medications and their metabolites, and because acid–base status and metabolism are also important considerations in anesthesia administration, surgery is contraindicated if a patient has acute nephritis, acute kidney injury with oliguria or anuria, or other acute kidney problems. The exception is surgery that is performed as a life-saving measure or that is necessary to improve urinary function, as in the case of an obstructive uropathy.

Endocrine Function Diabetes is the most common endocrinopathy and has both acute and chronic disease manifestations. Because of this and other factors, patients with diabetes are more likely to require surgery. The majority of patients with diabetes develop disease in more than one body system, thus a thorough assessment of major organ disease (cardiac, renal, peripheral vascular) must be identified and managed carefully during the perioperative period. The patient with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin. Hyperglycemia, which can increase the risk for surgical wound infection, and fluid and electrolyte loss, may result from the stress of surgery because it triggers increased release of catecholamines. An increase in catecholamines contributes to an elevation in the blood glucose level. Previously, blood sugar was tightly controlled with intensive insulin therapy—this practice is no longer recommended routinely. Surgical patients with type 1 diabetes are also at risk for developing ketoacidosis. Refer to Chapter 30 for details on management of patients with diabetes. Patients who have received corticosteroids are at risk of adrenal insufficiency. Therefore, the use of corticosteroids for any purpose during the preceding year must be reported to the anesthesia provider and surgeon. The patient is monitored for signs of adrenal insufficiency, which frequently presents with hyponatremia, hypoglycemia, hyperkalemia, and complaints of weakness and fatigue. Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis (with hyperthyroid disorders) or respiratory failure (with hypothyroid disorders). Therefore, the patient is assessed for a history of these disorders. Refer to Chapter 31 for further discussion of endocrine disorders.

Immune Function The nurse determines the presence of allergies. It is especially important to identify and document any sensitivity to medications and past adverse reactions to these agents. The nurse asks the patient to identify any substances that precipitated previous allergic reactions, including medications, herbal supplements, blood transfusions, contrast agents, latex, and food products, and to describe the signs and symptoms produced by these substances. A sample latex allergy screening questionnaire is shown in Figure 5-1. Immunosuppression is common with corticosteroid therapy, kidney transplantation, radiation therapy, chemotherapy, and disorders affecting the immune system, such as AIDS and leukemia. The mildest symptoms or slightest temperature elevation must be investigated. Because patients who are immunosuppressed are highly susceptible to infection, the health care team should take great care to ensure strict asepsis.

Medication Use A medication history is obtained from each patient because of the possible effects of medications on the patient’s perioperative course, including the possibility of drug interactions. Any medication the patient is using or has used in the past is documented, including the frequency with which the medication is used. Potent medications have an effect on physiologic functions; interactions of such medications with anesthetic agents can cause serious problems, such as arterial hypotension and circulatory collapse. The potential effects of prior medication therapy are evaluated by the anesthesia provider, who considers the length of time the patient has used the medication, the physical condition of the patient, and the nature of the proposed surgery. Medications that cause particular concern are listed in Table 5-4. In addition, many patients take self-prescribed or over-the-counter (OTC) medications. Aspirin is a common OTC medication that inhibits platelet aggregation; therefore, it is prudent to stop aspirin at least 7 to 10 days before surgery if possible, especially for surgeries in which excess bleeding would cause significant complications, such as brain or spinal cord surgeries. Because of the effects of aspirin or other OTC medications and possible interactions with prescribed medications and anesthetic agents, it is important to ask a patient about their use. The information is noted in the patient’s chart and conveyed to the anesthesia provider and surgeon. The use of herbal medications is widespread among patients; because of their potential effects on coagulation and potentially lethal interactions with other medications, the nurse must ask surgical patients specifically about the use of these agents, document their use, and inform the surgical team and anesthesia provider. Decisions should be made by the surgical team about the discontinuation of herbal medications prior to surgery. Currently, there are no studies demonstrating specific adverse interactions between herbals and anesthetic drugs; however, some have been implicated to be related to pharmacokinetic and pharmacodynamic interactions (Wijeysundera & Sweitzer, 2015).

Psychosocial Factors All patients have some type of emotional reaction before any surgical procedure, be it obvious or hidden, normal or abnormal. For example, preoperative anxiety may be an anticipatory response to an experience the patient views as a threat to his or her customary role in life, body integrity, or life itself. Psychological distress directly influences body functioning. In addition to providing anticipatory guidance about what the patient will experience during the operative procedure, the nurse provides opportunities for the patient to ask questions, so that concerns can be addressed. Most patients who are about to undergo surgery have fears, including fear of the unknown, of death, of anesthesia, of pain, or of cancer. Concerns about loss of work time, loss of job, increased responsibilities or burden on family members, and the threat of permanent incapacity further contribute to the emotional strain created by the prospect of surgery. Less obvious concerns may occur because of previous experiences with the health care system and people the patient has known with the same condition. People express fear in different ways. For example, some patients may repeatedly ask many questions, even though answers were given previously. Others may withdraw, deliberately avoiding communication, perhaps by reading, watching television, or talking about trivialities. Assessing the patient’s readiness to learn and determining the best approach to maximize comprehension provides the basis for preoperative patient education. Consequently, the nurse must be empathetic, listen well, and provide information that helps alleviate concerns. An important outcome of the psychosocial assessment is the determination of the extent and role of the patient’s support network. The value and reliability of all available support systems are assessed. Other information, such as usual level of functioning and typical daily activities, may assist in the patient’s care and rehabilitation plans.

Spiritual and Cultural Beliefs Spiritual beliefs play an important role in how people cope with fear and anxiety. Regardless of the patient’s religious affiliation, spiritual beliefs can be as therapeutic as medication. Every attempt must be made to help the patient obtain the spiritual support that he or she requests. Faith has great sustaining power. Therefore, the beliefs of each patient should be respected and supported. In addition, the nurse needs to communicate and document if the patient declines blood transfusions for religious reasons (Jehovah’s Witnesses), as this information needs to be clearly identified in the preoperative period. Some nurses avoid the subject of a clergy visit lest the suggestion alarm the patient. Asking whether the patient’s spiritual advisor knows about the impending surgery is a caring, nonthreatening approach. Showing respect for a patient’s cultural values and beliefs facilitates rapport and trust. Some areas of assessment include identifying the ethnic group to which the patient relates and the customs and beliefs the patient holds about illness and health care providers. For example, patients from some cultural groups are unaccustomed to expressing feelings openly. Nurses need to consider this pattern

of communication when assessing pain. Nurses should familiarize themselves with these cultural similarities and differences (see Box 1-3 in Chapter 1) and, recently, the Joint Commission has developed standards of cultural competency for health care workers (The Joint Commission, 2016a). Perhaps the most valuable skill at the nurse’s disposal is listening carefully to the patient, especially when obtaining the history. Invaluable information and insights may be gained through effective communication and interviewing skills. An unhurried, understanding, and caring nurse promotes confidence on the part of the patient.

Presence of Genetic Disorders In the preoperative period, attention needs to be paid to patients with various genetic disorders (listed below) since surgical outcomes may be altered related to complications with anesthesia.  Malignant hyperthermia (MH) (discussed on page 130)  Central core disease (CCD), is a genetic disorder that presents in the neonatal period or infancy with muscle weakness and hypotonia and mild facial weakness. This condition increases the risk of developing MH.  Duchenne muscular dystrophy and Becker dystrophy are two types of muscular dystrophies associated with risk of developing MH.  Hyperkalemic periodic paralysis is a genetic disorder that causes episodes of extreme muscle weakness and occasionally hyperkalemia. It is also associated with MH.  King–Denborough syndrome, a rare genet...