Preoperative Phase

Preoperative Phase

The patient who consents to have surgery, particularly surgery that requires a general anesthetic, renders himself dependent on the knowledge, skill, and integrity of the health care team. In accepting this trust, the healthcare team members have an obligation to make the patient’s welfare their first consideration during the surgical experience.

The scope of activities during the preoperative phase includes the establishment of the patient’s baseline assessment in the clinical setting or at home, carrying out preoperative interview and preparing the patient for the anesthetic to be given and the surgery.

Goals

Although the physician is responsible for explaining the surgical procedure to the patient, the patient may ask the nurse questions about the surgery. There may be specific learning needs about the surgery that the patient and support persons should know. A nursing care plan and a teaching plan should be carried out. During this phase, emphasis is placed on:

• Assessing and correcting physiological and psychological problems that may increase surgical risk.
• Giving the patient and significant others complete learning and teaching guidelines regarding the surgery.
• Instructing and demonstrating exercises that will benefit the patient postoperatively.
• Planning for discharge and any projected changes in lifestyle due to the surgery.

Physiologic Assessment

Before any treatment is initiated, a health history is obtained and a physical examination is performed during which vital signs are noted and a data base is establish for future comparisons.

The following are the physiologic assessments necessary during the preoperative phase:

• Age
• Obtain a health history and perform a physical examination to establish vital signs and a database for future comparisons.
• Assess patient’s usual level of functioning and typical daily activities to assist in patient’s care and recovery or rehabilitation plans.
• Assess mouth for dental caries, dentures, and partial plates. Decayed teeth or dental prostheses may become dislodged during intubation for anesthetic delivery and occlude the airway.
• Nutritional status and needs – determined by measuring the patient’s height and weight, triceps skinfold, upper arm circumference, serum protein levels and nitrogen balance. Obesity greatly increases the risk and severity of complications associated with surgery.
• Fluid and Electrolyte Imbalance – Dehydration, hypovolemia and electrolyte imbalances should be carefully assessed and documented.
• Infection
• Drug and alcohol use – the acutely intoxicated person is susceptible to injury.
• Respiratory status – patients with pre-existing pulmonary problems are evaluated by means pulmonary function studies and blood gas analysis to note the extent of respiratory insufficiency. The goal for potential surgical patient us to have an optimum respiratory function. Surgery is usually contraindicated for a patient who has a respiratory infection.
• Cardiovascular status – cardiovascular diseases increases the risk of complications. Depending on the severity of symptoms, surgery may be deferred until medical treatment can be instituted to improve the patient’s condition.
• Hepatic and renal function – surgery is contraindicated in patients with acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems. Any disorder of the liver on the other hand, can have an effect on how an anesthetic is metabolized.
• Presence of trauma
• Endocrine function – diabetes, corticosteroid intake, amount of insulin administered
• Immunologic function – existence of allergies, previous allergic reactions, sensitivities to certain medications, past adverse reactions to certain drugs, immunosuppression
• Previous medication therapy – It is essential that the patient’s medication history be assessed by the nurse and anesthesiologist. The following are the medications that cause particular concern during the upcoming surgery:
  • Adrenal corticosteroids – not to be discontinued abruptly before the surgery. Once discontinued suddenly, cardiovascular collapse may result for patients who are taking steroids for a long time. A bolus of steroid is then administered IV immediately before and after surgery.
  • Diuretics – thiazide diuretics may cause excessive respiratory depression during the anesthesia administration.
  • Phenothiazines – these medications may increase the hypotensive action of anesthetics.
  • Antidepressants – MAOIs increase the hypotensive effects of anesthetics.
  • Tranquilizers – medications such as barbiturates, diazepam and chlordiazepoxide may cause an increase anxiety, tension and even seizures if withdrawn suddenly.
  • Insulin – when a diabetic person is undergoing surgery, interaction between anesthetics and insulin must be considered.
  • Antibiotics – “Mycin” drugs such as neomycin, kanamycin, and less frequently streptomycin may present problems when combined with curariform muscle relaxant. As a result nerve transmission is interrupted and apnea due to respiratory paralysis develops.

Gerontologic Considerations

• Monitor older patients undergoing surgery for subtle clues that indicate underlying problems since elder patients have less physiologic reserve than younger patients.
• Monitor also elderly patients for dehydration, hypovolemia, and electrolyte imbalances.

Nursing Diagnosis

The following are possible nursing diagnosis during the preoperative phase:

• Anxiety related to the surgical experience (anesthesia, pain) and the outcome of surgery
• Risk for Ineffective Therapeutic Management Regiment related to deficient knowledge of preoperative procedures and protocols and postoperative expectations
• Fear related to perceived threat of the surgical procedure and separation from support system
• Deficient Knowledge related to the surgical process

Diagnostic Tests

These diagnostic tests may be carried out during the perioperative phase:

• Blood analyses such as complete blood count, sedimentation rate, c-reactive protein, serum protein electrophoresis with immunofixation, calcium, alkaline phosphatase, and chemistry profile
• X-ray studies
• MRI and CT scans (with or without myelography)
• Electrodiagnostic studies
• Bone scan
• Endoscopies
• Tissue biopsies
• Stool studies
• Urine studies

Significant physical findings are also noted to further describe the patient’s overall health condition. When the patient has been determined to be an appropriate candidate for surgery, and has elected to proceed with surgical intervention, the pre-operative assessment phase begins.

The purpose of pre-operative evaluation is to reduce the morbidity of surgery, increase quality of intraoperative care, reduce costs associated with surgery, and return the patient to optimal functioning as soon as possible.

Psychological Assessment

Psychological nursing assessment during the preoperative period: 

• Fear of the unknown
• Fear of death
• Fear of anesthesia
• Concerns about loss of work,  time, job and support from the family
• Concerns on threat of permanent incapacity
• Spiritual beliefs
• Cultural values and beliefs
• Fear of pain

Psychological Nursing Interventions

1. Explore the client’s fears, worries and concerns.
2. Encourage patient verbalization of feelings.
3. Provide information that helps to allay fears and concerns of the patient.
4. Give empathetic support.

Informed consent

• Reinforce information provided by surgeon.
• Notify physician if patient needs additional information to make his or her decision.
• Ascertain that the consent form has been signed before administering psychoactive premedication. Informed consent is required for invasive procedures, such as incisional, biopsy, cystoscopy, or paracentesis; procedures requiring sedation and/or anesthesia; nonsurgical procedures that pose more than slight risk to the patient (arteriography); and procedures involving radiation.
• Arrange for a responsible family member or legal guardian to be available to give consent when the patient is a minor or is unconscious or incompetent (an emancipated minor [married or independently earning own living] may sign his or her own surgical consent form).
• Place the signed consent form in a prominent place on the patient’s chart.

An informed consent is necessary to be signed by the patient before the surgery. The following are the purposes of an informed consent:

• Protects the patient against unsanctioned surgery.
• Protects the surgeon and hospital against legal action by a client who claims that an unauthorized procedure was performed.
• To ensure that the client understands the nature of his or her treatment including the possible complications and disfigurement.
• To indicate that the client’s decision was made without force or pressure.

Criteria for a Valid Informed Consent

• Consent voluntarily given. Valid consent must be freely given without coercion.
• For incompetent subjects, those who are NOT autonomous and cannot give or withhold consent, permission is required from a responsible family member who could either be apparent or a legal guardian. Minors (below 18 years of age), unconscious, mentally retarded, psychologically incapacitated fall under the incompetent subjects.
• The consent should be in writing and should contain the following:
  • Procedure explanation and the risks involved
  • Description of benefits and alternatives
  • An offer to answer questions about the procedure
  • Statement that emphasizes that the client may withdraw the consent
  • The information in the consent must be written and be delivered in language that a client can comprehend.
  • Should be obtained before sedation.

Nursing Interventions

Reducing Anxiety and Fear

• Provide psychosocial support.
• Be a good listener, be empathetic, and provide information that helps alleviate concerns.
• During preliminary contacts, give the patient opportunities to ask questions and to become acquainted with those who might be providing care during and after surgery.
• Acknowledge patient concerns or worries about impending surgery by listening and communicating therapeutically.
• Explore any fears with patient, and arrange for the assistance of other health professionals if required.
• Teach patient cognitive strategies that may be useful for relieving tension, overcoming anxiety, and achieving relaxation, including imagery, distraction, or optimistic affirmations.

Managing Nutrition and Fluids

• Provide nutritional support as ordered to correct any nutrient deficiency before surgery to provide enough protein for tissue repair.
• Instruct patient that oral intake of food or water should be withheld 8 to 10 hours before the operation (most common), unless physician allows clear fluids up to 3 to 4 hours before surgery.
• Inform patient that a light meal may be permitted on the preceding evening when surgery is scheduled in the morning, or provide a soft breakfast, if prescribed, when surgery is scheduled to take place after noon and does not involve any part of the GI tract.
• In dehydrated patients, and especially in older patients, encourage fluids by mouth, as ordered, before surgery, and administer fluids intravenously as ordered.
• Monitor the patient with a history of chronic alcoholism for malnutrition and other systemic problems that increase the surgical risk as well as for alcohol withdrawal (delirium tremens up to 72 hours after alcohol withdrawal).

Promoting Optimal Respiratory and Cardiovascular Status

• Urge patient to stop smoking 2 months before surgery (or at least 24 hours before).
• Teach patient breathing exercises and how to use an incentive spirometer if indicated.
• Assess patient with underlying respiratory disease (eg, asthma, chronic obstructive pulmonary disease [COPD]) carefully for current threats to pulmonary status; assess patient’s use of medications that may affect postoperative recovery.
• In the patient with cardiovascular disease, avoid sudden changes of position, prolonged immobilization, hypotension or hypoxia, and overloading of the circulatory system with fluids or blood.

Supporting Hepatic and Renal Function

• If patient has a disorder of the liver, carefully assess various liver function tests and acid–base status.
• Frequently monitor blood glucose levels of the patient with diabetes before, during, and after surgery.
• Report the use of steroid medications for any purpose by the patient during the preceding year to the anesthesiologist and surgeon.

Monitor patient for signs of adrenal insufficiency.

• Assess patients with uncontrolled thyroid disorders for a history of thyrotoxicosis (with hyperthyroid disorders) or respiratory failure (with hypothyroid disorders).

Promoting Mobility and Active Body Movement

• Explain the rationale for frequent position changes after surgery (to improve circulation, prevent venous stasis, and promote optimal respiratory function) and show patient how to turn from side to side and assume the lateral position without causing pain or disrupting IV lines, drainage tubes, or other apparatus.
• Discuss any special position patient will need to maintain after surgery (eg, adduction or elevation of an extremity) and the importance of maintaining as much mobility as possible despite restrictions.
• Instruct patient in exercises of the extremities, including extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side); foot rotation (tracing the largest possible circle with the great toe); and range of motion of the elbow and shoulder.
• Use proper body mechanics, and instruct patient to do the same. Maintain patient’s body in proper alignment when patient is placed in any position.

Respecting Spiritual and Cultural Beliefs

• Help patient obtain spiritual help if he or she requests it; respect and support the beliefs of each patient.
• Ask if the patient’s spiritual adviser knows about the impending surgery.
• When assessing pain, remember that some cultural groups are unaccustomed to expressing feelings openly. Individuals from some cultural groups may not make direct eye contact with others; this lack of eye contact is not avoidance or a lack of interest but a sign of respect.
• Listen carefully to patient, especially when obtaining the history. Correct use of communication and interviewing skills can help the nurse acquire invaluable information and insight. Remain unhurried, understanding, and caring.

Providing Preoperative Patient Education

• Teach each patient as an individual, with consideration for any unique concerns or learning needs.
• Begin teaching as soon as possible, starting in the physician’s office and continuing during the pre admission visit, when diagnostic tests are being performed, through arrival in the operating room.
• Space instruction over a period of time to allow patient to assimilate information and ask questions.
• Combine teaching sessions with various preparation proce-dures to allow for an easy flow of information. Include descriptions of the procedures and explanations of the sensations the patient will experience.
• During the preadmission visit, arrange for the patient to meet and ask questions of the perianesthesia nurse, view audiovisuals, and review written materials. Provide a telephone number for patient to call if questions arise closer to the date of surgery.
• Reinforce information about the possible need for a ventilator and the presence of drainage tubes or other types of equipment to help the patient adjust during thepostoperative period.
• Inform the patient when family and friends will be able to visit after surgery and that a spiritual advisor will be available if desired.

Teaching the Ambulatory Surgical Patient

• For the same day or ambulatory surgical patient, teach about discharge and follow-up home care. Education can be provided by a videotape, over the telephone, or during a group meeting, night classes, preadmission testing, or the preoperative interview.
• Answer questions and describe what to expect.
• Tell the patient when and where to report, what to bring (insurance card, list of medications and allergies), what to leave at home (jewelry, watch, medications, contact lenses), and what to wear (loose-fitting, comfortable clothes; flat shoes).
• During the last preoperative phone call, remind the patient not to eat or drink as directed; brushing teeth is permitted, but no fluids should be swallowed.

Teaching Deep Breathing and Coughing Exercises

• Teach the patient how to promote optimal lung expansion and consequent blood oxygenation after anesthesia by assuming a sitting position, taking deep and slow breaths (maximal sustained inspiration), and exhaling slowly.
• Demonstrate how patient can splint the incision line to minimize pressure and control pain (if there will be a thoracic or abdominal incision).
• Inform patient that medications are available to relieve pain and that they should be taken regularly for pain relief to enable effective deepbreathing and coughing exercises.

Explaining Pain Management

• Instruct patient to take medications as frequently as prescribed during the initial postoperative period for pain relief.
• Discuss the use of oral analgesic agents with patient before surgery, and assess patient’s interest and willingness to participate in pain relief methods.
• Instruct patient in the use of a pain rating scale to promote postoperative pain management.

Preparing the Bowel for Surgery

• If ordered preoperatively, administer or instruct the patient to take the antibiotic and a cleansing enema or laxative the evening before surgery and repeat it the morning of surgery.
• Have the patient use the toilet or bedside commode rather than the bedpan for evacuation of the enema, unless the patient’s condition presents some contraindication.

Preparing Patient for Surgery

• Instruct patient to use detergent–germicide for several days at home (if the surgery is not an emergency).
• If hair is to be removed, remove it immediately before the operation using electric clippers.
• Dress patient in a hospital gown that is left untied and open in the back.
• Cover patient’s hair completely with a disposable paper cap; if patient has long hair, it may be braided; hairpins are removed.
• Inspect patient’s mouth and remove dentures or plates.

Remove jewelry, including wedding rings

• If patient objects, securely fasten the ring with tape.
• Give all articles of value, including dentures and prosthetic devices, to family members, or if needed label articles clearly with patient’s name and store in a safe place according to agency policy.
• Assist patients (except those with urologic disorders) to void immediately before going to the operating room.
• Administer preanesthetic medication as ordered, and keep the patient in bed with the side rails raised. Observe patient for any untoward reaction to the medications. Keep the immediate surroundings quiet to promote relaxation.

Transporting Patient to Operating Room

• Send the completed chart with patient to operating room; attach surgical consent form and all laboratory reports and nurses’ records, noting any unusual last minute observations that may have a bearing on the anesthesia or surgery at the front of the chart in a prominent place.
• Take the patient to the preoperative holding area, and keep the area quiet, avoiding unpleasant sounds or conversation.

Attending to Special Needs of Older Patients

• Assess the older patient for dehydration, constipation, and malnutrition; report if present.
• Maintain a safe environment for the older patient with sensory limitations such as impaired vision or hearing and reduced tactile sensitivity.
• Initiate protective measures for the older patient with arthritis, which may affect mobility and comfort. Use adequate padding for tender areas. Move patient slowly and protect bony prominences from prolonged pressure. Provide gentle massage to promote circulation.
• Take added precautions when moving an elderly patient because decreased perspiration leads to dry, itchy, fragile skin that is easily abraded.
• Apply a lightweight cotton blanket as a cover when the elderly patient is moved to and from the operating room, because decreased subcutaneous fat makes older people more susceptible to temperature changes.
• Provide the elderly patient with an opportunity to express fears; this enables patient to gain some peace of mind and a sense of being understood

Attending to the Family’s Needs

• Assist the family to the surgical waiting room, where the surgeon may meet the family after surgery.
• Reassure the family they should not judge the seriousness of an operation by the length of time the patient is in the operating room.
• Inform those waiting to see the patient after surgery that the patient may have certain equipment or devices in place (ie, IV lines, indwelling urinary catheter, nasogastric tube, suction bottles, oxygen lines, monitoring equipment, and blood transfusion lines).
• When the patient returns to the room, provide explanations regarding the frequent postoperative observations.

Spiritual Considerations

• Help patient obtain spiritual help if he or she requests it; respect and support the beliefs of each patient.
• Ask if the patient’s spiritual adviser knows about the impending surgery.
• When assessing pain, remember that some cultural groups are unaccustomed to expressing feelings openly. Individuals from some cultural groups may not make direct eye contact with others; this lack of eye contact is not avoidance or a lack of interest but a sign of respect.
• Listen carefully to patient, especially when obtaining the history. Correct use of communication and interviewing skills can help the nurse acquire invaluable information and insight. Remain unhurried, understanding, and caring.