PREOPERATIVE PHASE

OBJECTIVES
1. Define 3 phases of perioperative patient care
2. Describe comprehensive pre op assessment to identify risk factors
3. Identify health factors that affect pre op patients
4. Identify legal and ethical consideration rt obtaining informed consent for surgery
5. Describe pre op nursing measures that decrease risk for infection and other post op complications
6. Describe immediate pre op preparation of patient
7. Develop pre op teaching plan

DEFINITIONS
● Ambulatory surgery​ -​ includes ​OPD, same-day, or short-stay surgery​ ​that does not require an overnight hospital stay but may
entail admission to inpatient hospital setting ​less than 24 hrs
● Informed consent​ ​- ​patient's autonomous decision​ about whether to undergo a surgical procedure, based on the nature of the
condition, the treatment options, and risks/benefits involved
● Perioperative phase​ -​ period of time that ​constitutes the surgical experience​; include preoperative, intraoperative, and
postoperative phases of nursing care
● Preoperative phase​ ​- period of time from when the​ decision of surgical intervention is made to when the patient is transferred
to the OR table
● Intraoperative phase​ ​- period of time that begins with ​transfer of the patient to OR table​ and ​continues until patient is admitted
to postanesthesia care unit
● Postoperative phase​ ​- period of time that begins with the ​admission of the patient to postanesthesia care unit​ and ​ends after
follow-up evaluation​ in clinical setting or home
● Preadmission testing​ ​- ​diagnostic testing performed​ before admission to the hospital

SURGICAL CLASSIFICATIONS
● According to purpose:
 ○ Ablative/Curative ​- ​surgery to ​remove all malignant (cancerous) tissue​, which is​ ​meant to cure the disease.​ This
includes removing part or all of the cancerous organ or tissue and a small amount of healthy tissue around it; ​eg
excision of tumor or inflamed appendix, appendectomy, amputation
○ Diagnostic​ - to ​make or confirm a diagnosis​; eg biopsy, exploratory laparotomy
○ Exploratory - to estimate of the extent of the disease or confirmation of diagnosis. Examples: Exploratory laparotomy,
pelvic laparotomy.
○ Palliative​ - to ​relieve pain or correct a problem​ but ​does not actually cure disease​; eg gastrostomy
○ Reparative​ - to ​repair or to restore normal function of the organ​; eg multiple wound repair or total knee replacement
○ Reconstructive/cosmetic​ - ​the​ restoration of appearance and function​ following injury or disease, or the ​c​orrection of
congenital defects​, using the techniques of plastic surgery;​ ​eg mammoplasty/facelift
○ Transplant/Replacement​ - to ​replace organs or structures​ that are diseased or malfunctioning.
● According to urgency:
○ Emergent​ - patient requires immediate attention; ​disorder may be life-threatening​. ​Done immediately.
○ Urgent​ - patient requires prompt attention. Within ​24-30 hours.
○ Required​ - patient ​needs to have surgery.​ Within a ​few weeks or months.
○ Elective​ - patient should have surgery. ​Failure to have surgery is not catastrophic/life-threatening.
● According to risk:
○ Minor​ - ​any invasive operative procedure in which ​only skin or mucous membranes and connective tissue is resected
e.g. vascular cutdown for catheter placement, implanting pumps in subcutaneous tissue. Procedures in which the
surgical field cannot be effectively disinfected will generally be considered minor; eg ​biopsy, tooth extractions and
gingival grafts.
○ Major​ - ​any invasive operative procedure in which a ​more extensive resection is performed, e.g. a body cavity is
entered, organs are removed, or normal anatomy is altered.​ In general, if a ​mesenchymal barrier is opened​ (pleural
cavity, peritoneum, meninges), the surgery is considered major.

SPECIAL CONSIDERATIONS
● Gerontologic considerations
 ○ Post op care of elderly patients have ​less ​physiological reserve​, meaning the​ ability of an organ to return to normal
after a disturbance in its equilibrium
○ Respiratory and cardiac complications​ are ​leading causes​ of post op morbidity and mortality
○ Cardiac reserves are lower, renal and hepatic functions are depressed, GI activity is likely to be reduced
○ Dehydration, constipation, and malnutrition​ may occur
○ Nurse must be alert to ​maintaining a safe environment​ due to ​sensory limitation ​which cause falls
○ Arthritis​ is common in older people and may affect mobility = ​positions changes and ambulation may cause discomfort
○ ↑ age = ↓ perspiration = ​dry, itchy skin​ that become fragile and easily abraded = ​precautions must be taken when
moving ​an elderly person
○ ↓ subcutaneous fat​ makes older people ​more susceptible to temperature changes
○ Protective measures:
■ Adequate padding for tender areas ■ Providing gentle massage to promote
■ Moving patient slowly circulation
■ Protecting bony prominences from
prolonged pressure
○ Critical risk factors:
■ Skillful pre op assessment and treatment
■ Skillful anesthesia and surgery
■ Meticulous and competent post op and post anesthesia management
● Patients who are ​obese
○ Fatty tissues​ are ​more susceptible​ to infection
○ Can increase technical and mechanical problems during surgery = ​dehiscence​ ​(or wound separation) and wound
infections​ are ​more common
○ Have shallow respirations when ​supine​ = ​increased risk of ​hypoventilation​ and post op pulmonary complications
○ Increased demand for oxygen and decreased reserves​ can make ​intubation difficult
○ Must also ​assess for ​obstructive sleep apnea​, often diagnosed and treated with ​positive continuous airway pressure
(PCAP) pre op
■ Use should continue throughout periop period​, esp when sleep is likely (ie in the recovery room or at night)
● Patients with ​disabilities
○ Special considerations include:
■ Need for appropriate assistive devices
■ Modifications in preop teaching
■ Additional assistance with and attention to positioning/transferring
○ Any needs of the patient must be identified in pre op evaluation and clearly communicate to personnel
■ Ex: patient who relies on sign language or speech (lip) reading must be given an alternative method of
communication
■ Specific strategies for accommodating patient’s needs must be identified in advance
■ Patients with respiratory problems rt disability may experience difficulties and should be clearly identified and
communicated to appropriate personnel
○ Patient with disability that affect body position (eg neuromuscular disorders) may need special positioning during
surgery to prevent pain and injury
■ These patients may be unable to sense if extremities are positioned incorrectly
● Patients undergoing ambulatory surgery
○ Ambulatory surgery ​- ​see above for definition
○ Nurse must quickly and comprehensively assess and anticipate patient’s needs as well as begin to discharge planning
and follow-up home care
○ Patient will first go to preop holding area before going to OR and then spend some time in PACU before being
discharged
● Patients undergoing emergency surgery
○ The ​only opportunity for preop assessment​ may take place at the ​same time as resuscitation in the ER
○ For unconscious patient, informed consent and essential information (eg past medical history and allergies) need to be
obtained from family member if available
■ Quick visual survey of patient is essential to identify all sites of injury if emergency surgery is due
■ Extra support and explanation of surgery may be needed
INFORMED CONSENT
● Patient's autonomous decision about whether to undergo surgical procedure
● Patient must be of legal age and mentally capable to sign informed consent
○ Otherwise, permission is obtained from surrogate (ie family member or legal guardian)
● Voluntary and written informed consent from patient is necessary before surgery to protect patient from unsanctioned surgery
and protect surgeon from claims of an unauthorized operation
● Consent​ - ​legal mandate​; also​ helps patient prepare psychologically​ as it helps to ensure patient understands surgery to be
performed
○ Surgeon’s responsibility to provide clear and simple explanation of what the surgery will entail prior to patient giving
consent
○ Surgeon must also inform patient of benefits, alternatives, possible risks, complications, disfigurement, disability, and
removal of body parts as well ass what to expect early and late post op periods
○ Nurse ascertain that consent form has been signed before administering psychoactive premed bc ​consent is not valid if
obtained while patient is under the influence of meds​ which can affect judgment and decision-making capacity
● Necessary in the following circumstances:
○ Invasive procedures (eg surgical incision, biopsy, cystoscopy, paracentesis)
○ Procedures requiring sedation and/or anesthesia
○ Nonsurgical procedure that carries slight risk to patient (eg arteriography)
○ Procedures involving radiation
● In an emergency, may be necessary for the surgeon to operate as life saving measure without the patient's informed consent
○ Every effort must be made to contact the patient's family
○ Contact can be made by​ ​telephone, fax, or other electronic means
○ No patient should be urged or coerced to give informed consent
■ Refusing to undergo surgical procedure is a person’s legal right and privilege
■ Information must be documented and relayed to surgeon
■ Consent for specific procedures provide additional protection for patient
● Sterilization ● Disposal of severed body parts
● Therapeutic abortion ● Organ donation
 ● Blood product administration

ASSESSMENT
● Nutritional and fluid status
○ Optimal nutrition​ ​- essential factor in promoting healing and resisting infection and other surgical complications
○ Assessment of patient’s nutritional status identifies factors that can affect patient’s surgical course
■ Obesity/weight loss
■ Malnutrition
■ Deficiencies in specific nutrients
■ Metabolic abnormalities
■ Effects of medications on nutrition
○ Any ​nutritional deficiency should be corrected before surgery​ to provide adequate protein for tissue repair
○ Dehydration, hypovolemia, and electrolyte imbalances can lead to significant problems in patients with comorbid
medical conditions or in patient's who are elderly
● Dentition
○ Dental caries, dentures​, and ​partial plates​ are particularly significant to anesthesiologist/anesthetist bc decayed teeth or
dental prostheses ​may become dislodged​ during intubation and occlude the airway, esp important for elderly patients,
underserved communities, or who are uninsured or do not have regular dental care
● Drug or alcohol use
○ People who abuse drugs or alcohol frequently deny or attempt to hide it
○ Acutely intoxicated people are susceptible to injury, surgery is postponed if possible
○ Required emergency surgery = local, spinal, or regional block anesthesia is used for minor surgery
■ Prevent vomiting and potential aspiration = nasogastric tube is inserted before general anesthesia is
administered
○ Person with history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase
surgical risk
■ Alcohol withdrawal syndrome​ (ie ​delirium tremens​) may be anticipated between ​48-72 hours after alcohol
withdrawal
 ● Associated with significant mortality rate when it occurs post op
● Can contribute to cardiac dysrhythmias, cardiomyopathy, and bleeding tendencies seen in long-term
alcohol abuse
● Respiratory status
○ Primary goal: optimal respiratory function
○ Patient is taught breathing exercise and use of incentive spirometer if indicated
■ If ventilation is potentially compromised, surgery is usually postponed if patient has respiratory infection
■ Patients with underlying respiratory disease are assessed carefully for current threats to pulmonary status
■ Patient also needs to be assessed for comorbid conditions which may affect respiratory function
○ Patients who smoke are ​urged to stop 4-8 weeks before surgery​ to significantly reduce pulmonary and wound healing
complications
■ Preop smoking cessation interventions can effective in changing smoking behavior and reducing incidence of
postop complications
● CV status
○ Primary goal: to ensure a well-functioning CV system to meet the oxygen, fluid, and nutritional needs of the periop
period
○ If patient has ​uncontrolled HPN​, ​surgery may be ​postponed​ until BP is under control
■ Surgical treatment can be modified to meet cardiac tolerance of patient
■ Ex: patient with obstruction of descending colon and coronary artery disease, temporary simple colostomy may
be performed
● Hepatic and renal function
○ Presurgical goal: optimal function of liver and urinary system so that medications, anesthetic agents, body wastes, and
toxins are adequately metabolized and removed from the body
● Endocrine function
○ Diabetic patients​ - at risk for ​hypo/hyperglycemia
○ Clients receiving steroids​ - at risk of ​adrenal insufficiency
○ Clients with ​uncontrolled thyroid disorders​ - at risk for ​thyrotoxicosis​ (hyperthyroid) or ​respiratory failure
(hypothyroid)
 ■ Assess clients for history of above disorders
● Immune function
○ Determine presence of allergies (esp. shellfish due to iodine in reagents)
○ Immunosuppression​ - common with ​corticosteroid therapy​, renal transplantation, radiotherapy, chemotherapy,
disorders affecting immune system (ie AIDS and leukemia)
○ Ensure strict asepsis
● Previous medication use
■ Obtain medication history
■ Medications affecting surgery:
● Anticoagulants - ​DC 48 H before ● Corticosteroid - ​decrease ability
surgery​, ​alters clotting to withstand stress
● Diuretics - electrolyte imbalance ● Insulin
(loss of K+) ● Antidysrhythmics​ - ​reduces
● Anti HPN - hypotension cardiac contractility
● Antidepressants - hypotension ● Herbal supplements - interact
● Antibiotics - potentiates action of with anesthetics
anesthetics
■ Herbal preparations
● Most commonly used
○ Ephedra ○ Kava kava
○ Echinacea ○ St John's wort
○ Garlic ○ Licorice extract
○ Ginkgo biloba ○ Valerian
○ Ginseng
■ Effects of some herbal medications: should be ​DC 2-3 weeks before surgery
● Ginkgo biloba, garlic, ginger, ginseng - ​prevent clot formation
● Ginkgo biloba - ​CI​ to those taking ​meds for seizure
● St John's wort (anti depressant) and kava kava (relaxant) - ​prolonged sedative effects​ of anesthesia
 ● Chamomile - sedative effect
● Feverfew​ - ​impairs clotting​, used for ​migraine headaches
● Saw palmetto​ - used for ​enlarged prostate gland​, ​diuretic and urinary antiseptic​, ​reduces sexual drive
(​affects testosterone​), ​CI​: ​hormonal therapies
● Black cohosh​ - menopausal symptoms
● Psychosocial/psychological factors
○ Causes of fears of the preop client
■ Fear of the unknown ■ Fear of pain
■ Fear of anesthesia, vulnerability while ■ Fear of death
unconscious ■ Fear of disturbance of body image
○ Worries - loss of finances, employment, social and family roles
○ Preop anxiety - interventions to minimize anxiety
■ Explore client’s feelings
■ Allow clients to speak openly about fears/concerns
■ Give accurate information regarding surgery
■ Give empathetic support
■ Consider the person’s religious preferences and arrange for visit by priest/minister as desired
○ Important outcome​ = ​determine extent​ and ​role of the client’s support network
● Spiritual and cultural beliefs
○ Spiritual beliefs play an important role in how people cope with fear and anxiety
○ Showing respect for a client’s cultural values and beliefs facilitates rapport and trust

DIAGNOSTIC TESTS AND NURSING PROCESS

● Diagnostic tests
○ Urinalysis
○ Creatinine level
○ ABG - arterial blood gas; oxygen levels of patient
○ BUN
 ○ Albumin
○ ECG - routinely for 40+ yrs old or have CV disease
○ Complete blood count
○ Electrolyte studies = K+, Na+, Cl-
○ Coagulation studies = prothrombin time (PT), partial thromboplastin time (PTT)
○ Chest x-ray = esp in elderly with risk factors rt heart and lung function
● Nursing diagnosis
○ Common:
■ Knowledge deficit rt perioperative ■ Anxiety
experience ■ Fear
○ Additional diagnosis
■ Sleep pattern disturbance rt fear of impending surgery
■ Ineffective individual coping
■ Anticipatory grieving
■ Body image disturbance
● Planning - ​expected outcomes
○ Knowledge deficit - client will ​verbalize understanding of the preparation​ for perioperative experience
○ Anxiety - client will ​appear relaxed​ and will report that​ anxiety is​ reduced to ​manageable​ level
● Interventions
○ Providing patient teaching
■ Sensory info - sights, sounds and feel of the OR
■ Psychosocial info - coping abilities and worries about family
■ Deep breathing, coughing and incentive spirometry
● Deep breathing exercises - nurse emphasizes the need to begin exercises early in the recovery phase
5-10 times every 1-2 hrs for 2 days
● Coughing exercise​ - ​removes retained secretions​ from bronchi and airways
○ Purpose​: to ​prevent upper respiratory infection
○ Performed in conjunction with deep breathing every 1-2 hrs postoperatively
 ● Splinting
● Incentive spirometry​ - ​promote expansion of alveoli​ by guiding the client to reach a predetermined level
of lung inflation strengthens respiratory muscles
■ Mobility and active body movement
● Purpose: improve circulation, prevent venous stasis, promote optimal respiratory function
● Position changes
● Exercise of extremities
● Ambulation
● Use of TED hose
■ Pain management
● Cognitive coping strategies - useful for relieving tension, overcoming anxiety, decreasing fear,
achieving relaxation
○ Imagery ○ Optimistic self-recitation
○ Distraction ○ Music therapy
● Preparing client for tubes, drains and vascular access
■ Clients undergoing ambulatory surgery
● Verbal and written instructions be provided
● Outcomes and complications
● Limiting activities
● Referral for homecare
● Follow up care
■ Providing psychosocial interventions
● Reducing anxiety and decreasing fear
○ Assist client identify coping strategies
○ Discuss regarding post-op routines, tubes, and equipment
● Respecting cultural, spiritual, and religious beliefs
■ Maintain patient safety - protect clients from injury
■ Managing nutrition and fluids
 ● Purpose: patient must be nutritionally prepared before surgery occurs to prevent effects that delay
healing process
● On ​NPO status​ - ​3-4 hrs before minor ​surgery;​ 8-12 hrs before major​ surgery
● Some alterations in the client’s usual medication schedule

IMMEDIATE PRE OP NURSING INTERVENTIONS

○ Awaken early for preparation ○ All prosthetic devices are removed
○ Nurse makes assessments ○ Hearing aids
○ Client to remove all clothing, hair covered ○ Hairpins and clips, wigs, and toupees are
○ Antiembolism stockings or ace bandages are removed
applied ○ Remove nail polish
○ Remove all jewelry - tight wedding bands ○ Nurse asks client to empty his/her bladder
○ Religious emblems may be pinned or securely ○ Measurement of VS​ ​before​ administration of
fastened to client’s gown preop meds​ and transfer of client to surgical
○ Client wears an ID band suite
○ Dentures, including partial dental plates
● Administering preanesthetic medications
○ Goals:
■ To facilitate the administration of any anesthetic
■ To ​minimize respiratory tract secretions
■ To relax the client and reduce anxiety
○ Commonly used
■ Tranquilizers​ - ​decreases anxiety and ● Hydroxyzine (vistaril; atarax)
apprehension ■ Hypnotics
● Diazepam​ (valium) ■ Opioid analgesics
● Droperidol​ (inapsine) - ■ Anticholinergics​ - ​control secretions
antiemetic ● Atropine sulfate
■ Sedatives ● Glycopyrrolate (robinul)
 ■ H2 receptor antagonist ■ For ​rapid emptying of stomach
● Cimetidine (tagamet) ● Metoclopramide​ (reglan)
● Ranitidine (zantac)
○ “On call to OR” - ​prepare patient and give pre op medications​ before surgery
○ Nursing care after administering meds
● Expected patient outcomes
○ Nurse evaluate the case of preop client according to identified nursing diagnosis:
■ Client will….
● Verbalize understanding of informed consent as it applies to surgery
● States understanding of pre op dietary restrictions
● Verbalize understanding of and reason for bowel preparation
● Demonstrates use of incentive spirometer
● Demonstrates post op exercises and techniques for prevention of complications
● States understanding of pre op procedures
● States reduced anxiety