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MEDSURG PERIOP NOTES - Chapter 018

MEDSURG PERIOP NOTES - Chapter 018

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Published by Mae Flager

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Published by: Mae Flager on Aug 10, 2011
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07/31/2014

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Lewis: Medical-Surgical Nursing, 8
th
Edition
Chapter 18: Nursing Management: Preoperative CareKey Points – PrintableSURGICAL SETTINGS
Surgery is performed to diagnose, cure, palliate, prevent, explore, and/or providecosmetic improvement.
The total surgical episode is called the
 perioperative period 
.This period in the health care continuum includes the time before surgery (the preoperative period), the time spent duringthe actual surgical procedure (the intraoperative period), andthe period after the surgery is completed (the postoperative period).
Surgery may be a carefully planned event (elective surgery) or may arise withunexpected urgency (emergency surgery).
The setting in which a surgical procedure may be safely and effectively performedis influenced by the complexity of the surgery, potential complications, andgeneral health status of the patient.
The majority of surgical procedures are being performed as ambulatory surgery(also called
 same-day
or 
outpatient surgery
).
Regardless of where the surgery is performed, your role is to prepare the patientfor surgery, care for the patient during surgery, and facilitate the patient’srecovery following surgery.
PATIENT INTERVIEW
One of the most important nursing actions is the preoperative interview. It oftenoccurs in advance or on the day of surgery. The site of the interview and the time before surgery will dictate the depth and the completeness of the interview.
The primary purposes of the interview are to obtain the patient’s healthinformation, provide information regarding the surgical experience, and assess the patient’s readiness for surgery. It provides the patient and caregiver anopportunity to ask questions.
NURSING ASSESSMENT OF THE PREOPERATIVE PATIENT
The preoperative nursing assessment is performed to determine the patient’s psychologic status and physiologic factors that may contribute to operative risk factors; establish baseline detail; identify and document the surgical site and/or side (of body); identify prescription, over-the-counter drugs, and herbalsupplements taken by the patient; confirm laboratory and diagnostic test results;note cultural and ethnic factors that may affect the surgical experience; andvalidate that the informed consent form has been signed and witnessed.
Common fears associated with surgery include the potential for death or  permanent disability resulting from surgery, pain, change in body image, o
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
 
Key Points – Printableresults of a diagnostic procedure.
Your role in psychologically preparing the patient for surgery is to assess the patient for potential stressors that could negatively affect surgery and to providesupport during the preoperative period so that stress does not become distress.
In the nursing assessment, the nurse should perform a thorough body systemsreview. Ask specific questions to confirm the presence or absence of any diseases.Information should also be obtained about the patient’s family concerning anyhistory of adverse reactions to or problems with anesthesia. Patients should bescreened for possible latex allergies, as well as history of drug intolerance anddrug allergies.
All findings on the medication history should be documented and communicatedto the intraoperative and postoperative personnel.
The Joint Commission requires that all patients admitted to the operating room(OR) have a documented history and physical examination (H&P) in the chart prior to surgery.
 
Findings from the patient’s H&P will be used to assess the patient’s perioperative risk and may influence perioperative decisions.
The preoperative assessment of the older person’s baseline cognitive function isespecially crucial for intraoperative and postoperative evaluation.
The patient with diabetes is especially at risk for adverse effects of anesthesia andsurgery.
Obesity stresses both the cardiac and pulmonary system and makes access to thesurgical site and anesthesia administration more difficult.
NURSING MANAGEMENT: PREOPERATIVE PATIENT
Preoperative nursing interventions are derived from the nursing assessment andmust reflect each patient’s specific needs. Physical preparations will bedetermined by the pending surgery and the routines of the surgery setting.
Preoperative teaching involves the following:
o
Provision of sensory, process, and procedural information.
o
Instructions about deep breathing, coughing, and ambulating postoperatively.
o
Information about pain management, including the use of some type of  pain-rating scale.
o
An understanding that some patients, with varying cultures, backgrounds,and experiences, may need different types of information.
o
Inclusion of the patient’s caregiver in the teaching when appropriate.
o
Documentation of all teaching in the patient’s medical record.
 Legal Preparation for Surgery
Legal preparation for surgery consists of checking that all required forms have been correctly signed and are present on the chart, and that the patient andcaregiver clearly understand what is going to happen.
Anyone undergoing an invasive procedure must give informed consent for that procedure to be performed.Informed
 
consent is an active, shared decision-making
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
18-2
 
Key Points – Printable process between the provider and the recipient of care.
o
A true medical emergency may override the need to obtain informedconsent.
o
The physician is ultimately responsible for obtaining the patient’s consentfor surgical treatment. The nurse may be responsible for witnessing the patient’s signature on the consent form.
o
Adults sign their own operative permit. If the patient is a minor, isunconscious, or is mentally incompetent to sign the permit, the written permission may be given by a legally appointed representative or responsible family member.
 Day-of-Surgery Preparation
Day-of-surgery preparation will vary a great deal depending on whether the patient is an inpatient or an ambulatory surgical patient.
On the day of surgery, the nurse is responsible for the following:
o
Final preoperative teaching
o
Assessment and communication of pertinent findings
o
Ensuring that all preoperative preparation orders have been completed
o
Ensuring that records and reports are present and accompany the patient tothe OR 
o
Verifying the presence of a signed operative consent
o
Laboratory and diagnostic data
o
An H&P report
o
A record of any consultations
o
Baseline vital signs
o
Completed nurses’ notes and preoperative checklist
o
Final “handoff” of communication to the OR nurse receiving the patient toensure that all pertinent information regarding the patient has beenexchanged
A variety of preoperative medications may be used, either alone or incombination, depending on the patient and the type of surgery.
o
These include benzodiazepines for sedation and amnesia, anticholinergicsto reduce secretions, and opioids to decrease pain and intraoperativeanesthetic requirements.
o
Additional drugs include antiemetics, antibiotics, insulin, histamine-receptor antagonists, eye drops, and regular prescription drugs.
CULTURAL AND GERONTOLOGIC CONSIDERATIONS
The nurse should include cultural considerations when assessing andimplementing care for the preoperative needs of a patient.
Frequently performed procedures in the older adult are cataract extraction,coronary and vascular procedures, prostate surgery, herniorrhaphy,cholecystectomy, and joint repair/replacement.
Older adults may have sensory, motor, and cognitive deficits necessitating thatmore time may be needed to complete preoperative testing and understand
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.
18-3

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