Preoperative Nursing

Surgery
is the art and science of treating diseases, injuries, and deformities by
Preoperative Nursing
operation and instrumentation implies the delivery of comprehensive patient care within the
preoperative, intraoperative, and postoperative periods of the patient's

Historical Perspective experience during operative and other invasive procedures by using the
framework of the nursing process.

1500's
Surgical advancements by Ambroise Pare of France
Surgery
Classification according to purpose:

Diagnostic Determination of the

pathologic condition
presence and extent of a

1800's
Ephraim McDowell pioneered abdominal surgeries Curative Elimination or repair of a pathologic condition
Palliative Alleviation of symptoms without cure
1865
Joseph Lister introduced the use of carbolic acid to prevent infection on
Preventive Removal of a body part before it becomes problematic
surgical wounds Cosmetic improvement
Surgical examination to determine the nature or extent
1898 Exploratoryof a disease
Surgical gloves were worn
Classification according to urgency:
patient requires immediate attention as the disorder
Emergent
1949 may be life/limb- threatening
Establishment of Association of Operating Room Nurses Urgent patient requires prompt attention (within 24-30 hours)
(AORN)
patient needs surgery but may be delayed up to few
1967 Required weeks or months
First open heart surgery was performed in Cape Town, SA patient should have surgery but failure to do so is not
Elective catastrophic

Minimally- Invasive Surgery (MIS) Optional decision rests with patient

Robot-Assisted High-Precision Surgery

 Major Types of Pathologic Processes Requiring Surgery

O Obstruction
p Perforation

E Erosion

T Tumors

Phases of Preoperative Care

Preoperative Phase
begins when the decision to proceed with surgical intervention is made
and ends with the transfer of the patient onto the operating room (OR)
bed.
Intraoperative Phase
begins when the patient is transferred onto the OR bed and ends with
admission to the PACU.
Postoperative Phase
begins with the admission of the patient to the PACU and ends with a
follow-up evaluation in the clinical setting or home

Preoperative Phase
Assessments Psychosocial Assessment
Informed consent
Emotional state influences stress response, and thus the surgical
Preoperative teachings
outcome
Special considerations
Fear of Death
Patient safety
Fear of pain
Skin preps
Fear of mutation Fear of the unknown
Bowel preps
Ask about allergies and comorbidities
Obtain baseline vital signs Informed Consent
Perform physical examination Informed consent is the patient’s autonomous decision about whether to
Skin assessment undergo a surgical procedure
Joint mobility Purposes:
Medication history (OTC, herbal, etc.) Protect patient from unsanctioned surgery
Psychosocial- spiritual assessments Protect surgeon from claims of an unauthorized operation or
batter

Elements of a Valid
Informed Consent
Element 1 Voluntary Consent
Consent must be freely given, without coercion
Patient must be at least 18 years old, unless emancipated minor
Patient is not incompetent
Legal incompetence: individual who is not autonomous and cannot
give or withhold consent
 Element 2 Informed Subject
Consent must be in writing and should contain:
Explanation of procedure and risks
Exercises
Diaphragmatic Breathing
Description of benefits and alternatives Coughing
An offer to answer questions about procedure Leg exercises
Instructions that the patient may withdraw consent Turning to sides
A statement informing the patient if the protocols differs from Getting out of bed
customary procedure
Element 3 Pt able to comprehend
Non - English speaking patients:
Cognitive Coping Strategies
Provide consent in a language that is understandable to patient
Consult with a trained medical interpreter ImageryThe patient concentrates on a pleasant experience or restful
scene
Patients with visual or hearing impairment:
Use alternative forms of communication (e.g., Braille, large print, Distraction The patient thinks of an enjoyable story or recites a
favourite poem or song
sign interpreter)
Nursing Responsibilities: Optimistic self-recitation The patient recites optimistic thoughts
The nurse may ask the patient to sign the form and witness the
signature Music The patient listens to soothing music
Clarify information provided by physician
If additional information is requested, notify physician Special Consideration Pt Safety
Ascertain that consent is signed before any psychoactive
premedication

Providing Pt Education
Characteristic of an Effective Health Teaching Plan:
Individualized
Integrates varied strategies Special consideration:
Begun as soon as possible
Allows time for patient to assimilate information NPO Status
Goes beyond description of procedure and includes explanations of Purpose: To prevent aspiration
the sensations the patient will experience
Contains enough details
Example:
Patient X, a 69-year-old male, came to the emergency department with
severe RUQ abdominal pain, and cholelcystitis was diagnosed. He is
scheduled for surgery in two days. Significant medical history includes
controlled hypertension and smoking for 50 years.

What preoperative education should the nurse discuss with Patient X

prior to his surgery?
 Special consideration: Intraoperative Phase
Bowel Preparation
Indication: Abdominal and pelvic surgeries
to allow satisfactory visualization of the surgical site and
Purpose: to prevent trauma to the intestine or contamination of Anesthesia Machine OR lights
the peritoneum by fecal material.
May be achieved through: Mayo Table
Cleansing enemas Pendulum
Laxatives
Back Table
Antibiotics OR bed
Special consideration: Surgical Team
Skin Preparation Surgical Environment
Principles of Asepsis
Purpose: To decrease bacteria without injuring skin Types of Anesthesia
Principles Intraoperative Positioning
Antiseptic skin cleansing protocols (if applicable)
Hair is generally not removed unless it is expected to interfere with
operation
Surgical Team
Use an electric clipper to remove hair before transferring to OR Pt
Mark surgical site prior to procedure (done by both patient and Surgeon
physician) Nurse
Anesthesiologist
Circulating Nurse
RN
Manages the OR
Protects patient’s safety and health by monitoring activities of
surgical team, checking OR condition, and monitoring patient for
signs of injury and implementing appropriate interventions
Coordinates the surgical team
Monitors strict observance of aseptic technique
Documents specific activities throughout the operation
Facilitates “Time Out”
Scrub Role
RN or LPN or Surgical technologist
Does surgical hand scrub
Sets up sterile field and equipment
Prepares sutures, ligatures, and special equipment
Assists the surgeon during procedure by ANTICIPATING the
instruments and supplies that will be required
Does counting of all needles, sponges, and instruments with the
circulating nurse
Labels tissue specimen obtained during surgery and sent to the lab
by CN
Surgical Safety Checklist Anesthisia
Anesthesia is a state of narcosis (severe CNS depression produced by
pharmacologic agents), analgesia, relaxation, and reflex loss
Anesthesia Experience
Receiving combination
anesthetics

Intubation (if required) Losing consciousness

Sedation

Induction

Starting an IV line

Types of Anesthesia
General Anesthesia
Regional Anesthesia
Moderate Sedation
Local Anesthesia
General Anesthesia (GA)
Characteristics of patients receiving GA:
Not arousable even to pain
Loss of spontaneous ventilation

Surgical Environment Possible impairment of CV function

Unrestricted Zone
Street clothes are allowed
Semi-restricted Zone
Scrub suit
Mask
Cap
OR shoes
Restricted Zone
Scrub suit
Mask
Cap
OR shoes
Shoe covers
OR gown (for sterile members)
Other PPEs
Methods of Induction
Inhalation
Intravenous

Moderate Sedation
Inhalation A form of anesthesia that involves the IV administration of
Uses volatile liquid agents and gases sedatives or analgesic medications to reduce patient anxiety and
Anesthesia is produced when patients inhale the vapor from these control pain during diagnostic or therapeutic procedures.
anesthetic agents Goal: reduce LOC to a moderate level to enable procedures to be
Given in combination with oxygen performed while ensuring comfort and cooperation
General Endotracheal Anesthesia (GETA) Characteristics of patients receiving moderate sedation:
Consists of introducing a soft rubber or plastic ETT into the trachea by Able to maintain patent airway
means of laryngoscope Retains protective airway reflexes
Responds to verbal and physical stimuli
Intranasal Intubation
An alternative means of anesthesia induction wherein the ETT is inserted Monitored Anesthesia Care (MAC)
A form of moderate sedation given by an anesthesiologist or CRNA
through the nose into the trachea
who must be prepared and qualified to convert to general
Laryngeal Mask Airway (LMA) anesthesia if necessary.
A flexible tube with an inflatable silicone ring and cuff that can be
Indications:
inserted into the larynx
Minor surgical procedures
Intravenous Critically ill patients who are unable to tolerate anesthesia without
May be used to induce and/or maintain anesthesia
invasive monitoring and pharmacological support
May be combined with inhalation anesthetics or used alone
Has a short duration of action and patient awakens with little n/v Local Anesthesia
Local anesthesia is the injection of a solution containing the anesthetic
Useful for short procedures
agent into the tissues at the planned incision site. Often used in
Regional Anesthesia (RA)
combination with epinephrine Epinephrine constricts blood vessels, which
Characteristics of patients receiving RA:
prevents rapid absorption of the anesthetic agent and thus prolongs its
Awake
local action and prevents seizures.
Aware of surroundings unless intentionally sedated
Mechanism of action:
An anesthetic agent is injected around nerves so that the region
supplied by these nerves is anesthetized.
Epidural Anesthesia
Intraoperative Complications
Achieved by injecting a local anesthetic agent into the epidural space Anesthesia awareness
that surrounds the dura mater of the spinal cord Nausea and vomiting
Spinal Anesthesia Anaphylaxis
An extensive conduction nerve block that is produced when a local Hypothermia
anesthetic agent is introduced into the subarachnoid space at the lumbar Malignant hyperthermia
level, usually between L4 and L5
 Anesthesia Awareness
Unintended intraoperative awareness refers to a patient becoming
cognizant of surgical interventions while under general anesthesia
and then recalling the incident.
Occurs on 0.1% to 0.2% of general anesthesia patients
Manifestations:
Increase in BP
Rapid HR
Presence of patient movements
Prevention:
Premedication with amnestic agent
Avoidance of muscle relaxants unless absolutely necessary Management
Nausea and Vomiting
Temporarily increase OR temp to 25C to 26.6C
Occurs as a side effect of anesthetic agents
Warm IV and irrigating fluids
Management:
Warm air blankets
Antiemetics
Minimize exposure
Turn patient to side
Malignant Hyperthermia
Lower head of bed Malignant hyperthermia is a rare inherited muscle disorder that is
Provide basin to collect vomitus chemically induced by anesthetic agents
Suction oral cavity Occurs in 1 in 50,000 to 100,000 adults
Anapnylaxis Mortality rate can be as high as 70% but can be lowered to 10%
Serious, life-threatening allergic reaction
with early detection and prompt treatment
Intraoperative Causes:
Risk Factors:
Medications
People with strong and bulky muscles
Latex
History of muscle cramps/weakness AND unexplained temperature
Manifestations:
elevation
Periorbital swelling
•History of unexplained death of a family member during surgery
Rash
that was accompanied by a febrile response
Flushing
Inhalation anesthetics and muscle relaxants (succinylcholine)
Laryngeal edema
Clinical Manifestations:
Cyanosis
Generalized muscle rigidity- EARLIEST SIGN
Management:
Tachycardia: HR > 150 bpm- early cardiac sign
Epinephrine SQ
Hypothermia Hypercapnia - early respiratory sign
A core temperature that is lower than 36.6C Hypotension
Intraoperative causes: Oliguria (UO <30cc/hr)
Low temperature in OR Rapid increase in body temperature (1C to 2C every 5 minutes) -
Infusion of cold fluids LATE SIGN
Inhalation of cold gases Management:
Open wounds/cavities Discontinue anesthesia
Decreased muscle activity Dantrolene sodium (Dantrium)- muscle relaxant
Advanced age Decrease body temperature
Medications Cooling blankets
Lower OR temperature
Cooled IVF
 Kidney Position
Intraoperative Positioning Patient lies on unaffected side for kidney surgery
The table is spread apart to provide space between the lower limbs
and pelvis
Principles of intraoperative positioning:
The upper leg is extended; the lower leg is flexed at the knee and
The patient should be in as comfortable a position as possible,
hip joints
whether conscious or unconscious.
A pillow is place between the legs
The operative field must be adequately exposed.
An awkward anatomical position, undue pressure on a body part, or
the use of stirrups or traction should not obstruct the vascular Postoperative Phase
supply.
Goals of Care
Respiration should not be impeded by pressure of arms on the Reestablishment of physiologic equilibrium
chest or by a gown that constricts the neck or chest. Alleviation of pain
Nerves must be protected from undue pressure. Improper Preventing complications
positioning of the arms, hands, legs, or feet can cause serious injury Education on self-care
or paralysis. Shoulder braces must be well padded to prevent
irreparable nerve injury, especially when the Trendelenburg position
is necessary. Post Anesthesia Care Unit
Supine
Flat on back (PACU)
Located adjacent to the theaters
Both arms positioned at side of table: one with the hand placed
palm down and the other carefully positioned on an armboard to Patients still under anesthesia or recovering from anesthesia are
facilitate infusion placed in this unit for easy access to experienced, highly skilled
Used for most abdominal surgeries, except for surgery of the gall nurses, anesthesia providers, surgeons, advanced hemodynamic and
bladder or pelvis pulmonary monitoring and support, special equipment, and
Principles of intraoperative positioning: medications.
Precautions for patient safety must be observed, particularly with Nursing care in the PACU
older adults, patients who are thin or obese, and those with a Provide supplemental oxygen, as ordered
physical deformity. Attach monitoring equipment
The patient may need light restraint before induction in case of Begin initial assessment:
excitement. Vital signs
Trendelenberg Position LOC
Head and body are lowered Surgical site for drainage or hemorrhage
The patient is supported in position by padded shoulder braces, bean Connection of drainage tubes and monitoring lines
bags, and foam paddings IV fluids and medications
Used for surgery on lower abdomen and a to obtain good exposure Monitor at least every 15 minutes
by displacing the intestines into the upper abdomen Administer post operative analgesics, as ordered
Reverse Trendelenberg Position
Head and body are elevated
Provides the space to operate on the upper abdomen by shifting
the intestines into the pelvis
Post Operative Drains
A padded footboard and other supportive cushioning preserve a safe
environment for the patient.
Hemovac
Lithotomy Position
Patient is positioned on the back with the legs and thighs flexed.
The position is maintained by placing the feet in stirrups
Used for nearly all perineal, rectal, and vaginal surgical procedures
 Management:
Jackson- Pratt (JP) drain If bleeding is evident:
Apply sterile gauze pad and pressure dressing
Elevate site of bleeding to heart level if possible
Place of modified Trendelenburg
If bleeding is suspected but cannot be visualized:
Patient is taken back to OR for emergency exploration of surgical
site
Hypovolemic Shock
Clinical Manifestations:
Pallor
Cool, moist skin
Rapid breathing
Cyanosis
Rapid, weak, thready pulse

Post Operative Complications Hypotension

Narrowing pulse pressure
Concentrated and low urine output
Hypopharyngeal Obstruction Nursing Responsibilities:
Occurs when the patient lies on their back, the lower jaw and the Position in modified Trendelenburg- The patient is placed flat with
tongue fall backward and the air passages become obstructed the legs elevated, usually with a pillow.
Manifestations: Fluid replacement, as ordered
Choking Administer supplemental oxygen, as ordered
Noisy and irregular respirations Administer vasopressors, as ordered if unresponsive to fluid
Desaturation replacement
Cyanosis
Management: Head tilt- Chin lift Maneuver Pain
Tilt the head back and push forward on the angle of the lower jaw, Determine pain score using appropriate pain assessment tool
as if to push the lower teeth in front of the upper teeth Give postoperative analgesics before pain gets severe
IV opioids are commonly used in PACU as they provide immediate
Hypotension pain relief and are short- acting
Causes:
Blood loss – Most common Nausea and Vomiting
Hypoventilation
Position changes
Pooling of blood in extremities
Side effect of medications and anesthetics
Nursing Responsibilities:
Fluid replacement, as ordered Management:
Blood transfusion if blood loss > 500 mL, as ordered Reposition to side
Hemorrhage Administer antiemetics, as ordered
Hemorrhage is an uncommon yet serious complication of surgery that Encourage DBE
can result in hypovolemic shock and death. Aromatherapy
Clinical Manifestations
Hypotension
Rapid, thready pulse
Disorientation
Restlessness
Oliguria
Discharging Pt’s from PACU
Aldrete Score
Used to determine the patient’s general condition and readiness for
transfer from the PACU
Allows an objective assessment of the
patient’s condition in the PACU
Interpretation:
Score of 7-10: Discharge
Score < 7: remain in PACU until condition improves