PREOPERATIVE CARE - CH 18

SURGICAL SETTINGS
- Surgery
- Elective surgery: carefully planned
- Selective surgery (emergency) : unexpected urgency
- Inpatient → Same-day admission → require at least 1 night
- Ambulatory (same day or outpatient) MEOS
- Minimally invasive (laparoscopic/robotic surgery) → helps with wound dehiscence,
less infection rate, faster healing
- Endoscopy or surgical clinics
- Hospital outpatient surgery clinics
- Surgery center→ mostly healthy pts

YOUR ROLE PREOP

Why is the patient having surgery?

Comorbidities?

What's the patient’s response to the stress of surgery?

What are the results of preoperative diagnostic tests?

What's the potential risks and complications of the surgical procedure?

- Gatekeeper, paper work done, ANESTHESIA IN CHARGE (glucose, meds, fluids)

PATIENT INTERVIEW (pre procedure testing; PPTS)

- Avoid repetition: check documented information before interview
- Occurs in advance of or on day of surgery (scheduled cases)
- HCP’s office
- Ambulatory surgery center
- Hospital
- Purpose
- obtain health information, drug and food allergies
- Provide and clarify information about the surgery and anesthesia
- Assess emotional state and readiness
- Determined expectations

ASSESSMENT GOALS IDENTIFY RISK FACTORS & PLAN FOR SAFETY

- Establish baseline data for comparison intraoperative and postoperative
 - Determine psychological status to reinforce coping strategies
- Determine physiologic factors related to planned procedure contributing to risks
- Age
- Pre Existing conditions
- Meds → bleeding
- Wound infection
- Personal habit (smoking/drugs) (more anesthesia with alcohol use)
- Supplement use
- OTC meds → aspirin (in a lot of headache meds)
- Identify and document surgical site
- Identify prescription drugs, OTC medications, and herbs taken that may affect surgical
outcome
- Review results of preoperative diagnostic studies and share with HCPs
- Determine receipt of adequate information from surgeon to make informed decision for
surgery
- Verify that consent form is signed and witnessed
- Identify cultural and ethnic factors that may affect surgical experience
- Language barrier
- Surgical consent (NO FAMILY CAN TRANSLATE) (CALL LINE with BOTH
DOCS IN ROOM)

ASSESSMENT
Psychosocial assessment
- Excessive stress response can be magnified and affect recovery
- Influencing factors : Age, experiences with illness and pain, current health,
socioeconomic status
- can't afford rehabilitation
- insurance doesn't take it
- can they afford meds?
- Help at home?

ASSESSMENT
- Use common words and language
- Use translators if needed → Decreases level of anxiety
- Communicate all concerns to surgical team
- High anxiety level can impair cognition, decision making, and coping abilities
- Anxiety can arise from
- Lack of knowledge
- Uncertainty about outcome
- Past experiences and stories
- Fears

Information lessens anxiety (sometimes adds to anxiety → assess situation)

Address any fears the patient may have ( EX: Being exposed on the table)
ASSESSMENT

● Past health history

○ Health problems and surgeries
○ Understanding of reasons for surgery
○ Problems with previous surgeries
○ Menstrual, obstetric history
○ Reactions, problems to anesthesia: malignant hyperthermia (severe reaction to
certain drugs used for anesthesia) (PATIENT OR FAMILY)
○ MALIGNANT HYPERTHERMIA → anesthesia screens for
● Current medications
○ Prescriptions & OTC
○ Herbs → chart in book
■ Garlic
■ Vit E → cause bleeding
■ Fish oil
■ Ginseng
■ Latex allergy → kiwis, bananas, avocados, potatoes, peach
○ Diet supplements
○ Antiplatelets, NSAIDS
○ Recreational: drugs, alcohol, tobacco
○ Weed → more anesthesia
○ Alcohol → if says 3 beers, anesthesia will double it
○ Drug intolerances and allergies
Ask About a latex allergies: avocado, kiwi, banana can allergies can indicate latex allergy

● Cardiovascular system
○ Any history of hypertension, angina, dysrhythmias, HF, MI
○ Presence of pacemaker, ICD
○ 12 lead electrocardiogram (ECG)
○ Coagulation studies
○ Possible prophylactic antibiotic (antibiotic that prevent infection)
■ May receive before surgery to decrease the risk for infective endocarditis
for patients with prosthetic heart
○ Venous thromboembolism (VTE) prophylaxis → pharmacologic and
nonpharmacologic measures to diminish the risk of deep vein thrombosis (DVT)
and pulmonary embolism (PE)
Signs of DVT

- Calf pain
- red/warm
- Swelling
- Homans sign → pt lying, push foot out, do have pain in back of leg?? (Only do if ordered) (do on
ICU and surg pts)
Prevents → Ted hose, compression socks

Worried about PE → dyspnea, chest pain

Treatment → STAY IN BED/limited activity, anticoagulants, s/s of PE

Risks→ obesity, gastric bypass, heart/lung bypass

- Length of surgery increased risk for DVT

Respiratory system
- The procedure could be canceled if patient have any recent respiratory infection
because of an increased risk of Laryngo/Bronchospasm or decrease SAO2
- History of dyspnea, coughing, or hemoptysis (cough up blood in the lung) reported to
the ACP and surgeon
- COPD and asthma are at high risk for atelectasis and hypoxemia
- everyone at risk, collapsed alveoli (USE SPIROMETER; 10x per hour while
awake)
- Sleep apnea, obesity, and airway deformities affect respiratory function
- Cannot operate on someone with a CURREN/recent INFECTION → post op infection risk!!
- Risks:
- Smokers (did you smoke today? How long have you smoked? How much?)
- Sleep apnea, obesity, airway deformities, COPD, Asthma

Neurologic system
- Patient’s ability to respond to questions, follow commands, maintain orderly thought
process (vision and hearing loss can affect responses)
- Cognitive deficits can affect informed consent and cause adverse outcome during and
after surgery
- Crucial to access in older adult (more prone to adverse outcomes during
before and after)
- Added stressors like dehydration, hypothermia, anesthesia and adjunctive drugs
may contribute to emergence delirium
- Anxiety can inhibit
- Neuro assessment

Genitourinary system
● Renal problems are associated with
○ Fluid and electrolyte imbalance
○ Coagulopathies
○ Increased risk of infection
○ Impaired wound healing
○ Altered response to drugs and their elimination
- BUN creatinine GFR
- A lot of drugs cleared through renal/liver system
- Older pts have harder time metabolizing
 - May not respond as quickly

Hepatic system
● Liver detoxifies many anesthetics and adjunctive drugs
● Hepatic dysfunction may increase risk of perioperative complications

Skin
● History of pressure injuries
○ Extra padding during surgery
○ Affects postoperative healing
● BODY ART SUCH AS TATTOOS, PIERCINGS → pts hesitant or don't do surgery
- Piercings conduct heat → lead to burns
- Extra padding/support
- Lies on IV tubing?

Musculoskeletal system
● Identify any joints affected by arthritis
● Mobility restrictions may affect positioning and ambulation
● Report problems affecting neck or lumbar spine to ACP
○ Spinal anesthesia may be difficult
○ Can affect intubation and airway management
- assess ROM
- Intubation affected if neck issue

Endocrine system
● Patient with diabetes at risk for
○ Hypo/hyperglycemia
○ Delayed wound healing
○ Infection
○ Serum or capillary glucose test the morning of the surgery
○ Clarify with surgeon or ACT about insulin does
○ Elevated glucose (with surgery as stressor too)→ infection
○ Put on sliding scale
○ Check glucose if diabetic morning of surgery and report to anesthesia
○ Hypoglycemia → jittery, diaphoretic, confused (NPO status)
● Patient with thyroid problems
○ hypo/hyperthyroidism poses surgical risk due to changes in metabolic rate → check lab
test
○ Verify with ACP about given thyroid medications
● Patient with addison’s disease (body doesn't make enough certain hormones)
○ Abruptly stopping replacement corticosteroids could cause addison crisis
 ○ STRESS OF SURGERY MAY REQUIRE INCREASED DOSE OF IV
CORTICOSTEROIDS

Immune system
● Patient with history of compromised immune system or use of immunosuppressive drugs
can have
○ Delayed wound healing
○ Increased risk for infection
● Elective surgery may be canceled for acute infection
- Cancer, autoimmune, acute infection (UTI)

Fluids and electrolytes status

● Vomiting, diarrhea, or preoperative bowel preps can cause imbalances (way behind on
fluid)
● Identify drugs that change f&e status → diuretics
● Evaluate serum electrolyte levels
● NPO status
○ Surgery delay → may lead to dehydration
○ Patient with or at risk for dehydration may have additional fluids and
electrolytes before surgery
- No order for orthostatic vitals
- DO THEM BEFORE FLUIDS TO GET ORDER FOR BOLUS

Nutritional status
● Customize care for patients with nutritional problems
○ May be protein or vitamin deficient
○ Provide extra padding for underweight patient
● Obesity
○ Stress cardiac and pulmonary system
○ Increase risk of wound dehiscence, infection, incisional hernia
○ Slower recovery from anesthesia and wound healing
- YOU NEED PROTEIN FOR WOUND TO HEAL
- Look at obesity sheet

The Joint Commission (TJC) tells surgeon → requires a history and physical (surgeon does)

Findings enable ACP to rate patients for anesthesia administration

- Evaluate and determine risk for surgery

 - Indicator of perioperative risk and overall outcome

Pg 341 table 18-4 Scoring** → Book has P1-P6

ASA1 = healthy pt no meds

Emergency ASA1E → came from ER

ASA2 → one thing, one med

ASA3 → severe systemic disease (comorbidities)

ASA4 → severe with constant threat to life

ASA5 → TRAUMA , Caos

ASA6 → Brain dead (organ donation)

Nursing management
● Preoperative teaching
○ Patient have the right to know what to expect and how to participate (reduce fear,
anxiety, stress)
○ Teach deep breathing, coughing and early ambulation as appropriate
○ Inform if tubes, drains, monitoring devices, special equipment will be use
postoperative
○ Provide surgery specific information
● Ambulatory surgery information
○ Basic information before arrival
■ Arrival time and place
■ Registration and parking
■ What to wear and bring
■ Responsible adult needed
■ Fluid and food restrictions
■ WHEN YOU CAN EAT (clear ensure → has protein can drink NPO) (also can
drink gatorade → not red ones) (if surg later in day)
■ WHAT MEDS CAN/CANT TAKE

LOOK AT ERAS (enhanced recovery after surgery) SHEET WEEK 2

● Legal preparation
○ Check that all required forms are signed and in chart
■ Informed consent
■ Blood transfusion
 ■ Advance directives
■ Power of attorney
● Consent for surgery
● Informed consent must include
○ Adequate disclosure
○ Clear understanding
○ Voluntarily consent
● Surgeon ultimately responsible for obtaining consent
○ Nurse may witness signature
○ Verify patient understanding
○ Permission may be withdrawn anytime
● Legally appointed representative of family may consent if patient is
○ Minor
○ Unconscious
○ Mentally incompetent
● Emancipated minor is younger than legal age but able to provide legal consent
● Medical emergency may override the need for consent if immediate medical treatment
is needed to
○ Preserve life
○ Prevent serious impairment to life or limb
○ Patient incapable of giving consent
○ HAS TO BE CLEARLY WRITTEN BY DR
○ UNCONSCIOUS PTS ARE SEEN PRIORITY
● Day of surgery preparation
■ Final preoperative teaching
■ Verification of signed informed consent
■ Laboratory and diagnostic study results
■ History and physical examination, baseline vitals
■ Proper skin preparation , functioning IV
■ Surgical identification
■ Hospital gown
■ No cosmetic, remove nail polish
■ Identification and allergy band on wrist
■ Valuables are returned to caregiver or locked up
■ Denture, contacts glasses, prosthesis are removed
■ Jewelry removed if electrocautery devices is used
■ Leave hearing aids in place to allow patient to hear instructions

● Void before surgery

○ Before preoperative drugs
○ Prevents involuntary elimination under anesthesia
○ Reduces risk of urinary retention during early postoperative recovery
○ Worried about CAUTI (catheter UTI)
 ● Preoperative medications
○ Benzodiazepines, midazolam (versed)
■ Reduce anxiety
■ induce sedations amnesic effect (makes you forget)
■ Have reversal on deck
■ Watch RR
○ Anticholinergics, glycopyrrolate (robinul)
■ Decrease oral and respiratory secretion
■ Increases HR gently
○ Opioids, sublimaze (fentanyl)
■ Relieve pain
■ Hydromorphone given too (dilaudid → less N/V)
■ Watch RR
○ Antiemetics
■ Ondansetron (zofran)
● Prevent nausea and vomiting
● Especially people who get motion sickness
● Not a great rescue drug if already experiencing N/V → good
preventative
■ metoclopramide (reglan)
● Increase gastric emptying (pts on ozempic especially)
○ Antibiotic → Give within 30 mins of surgery start time
■ Anesthesia team starts it (needs to chart it)
■ Vancommyoicin → 1 hr
■ Antibiotic prophylactic → before and after surgery up to 24 hours to ward off
infection
○ B-adrenergic blockers (B-blockers)
■ Manage hypertension
■ Can LOWER HR
■ If bleeding → HR increases (to NORMAL RANGE!!!) watch carefully
HR 60-100

50s with people on beta blockers or extensive exercise

HR in 30s = BP DOWN

TRANSPORTATION TO THE OR

- VIA STRETCHER, WHEELCHAIR, OR BED

- HAND-OFF COMMUNICATION SBAR
○ SITUATION
○ BACKGROUND
 ○ ASSESSMENT
○ RECOMMENDATION
- CAREGIVERS DIRECTED TO WAITING ROOM

Special concerns
● Culturally competent
○ Patient’s expression of pain
○ Family expectations
○ Ability to verbally express needs
● Geriatric consideration
○ Surgical may be overwhelming
○ Increase risk with anesthesia and surgery
○ May have sensory deficits or decrease in cognitive function
-

AUDIENCE RESPONSE QUESTION

A 68-YEAR-OLD MALE SCHEDULED FOR HERNIA REPAIR AT AN AMBULATORY
SURGICAL CENTER EXPRESSES CONCERN THAT HE WILL NOT HAVE ENOUGH CARE
AT HOME AND ASKS IF HE CAN STAY IN THE HOSPITAL AFTER THE SURGERY. WHICH
RESPONSE WOULD THE NURSE PROVIDE?

1. “WHO IS AVAILABLE TO HELP YOU AT HOME AFTER THE SURGERY?”

2. M SURE YOU WILL BE ABLE TO MANAGE AT HOME AFTER SURGERY. IT IS A
SIMPLE PROCEDURE.”
3. WILL TEACH YOU EVERYTHING YOU NEED TO KNOW TO BE ABLE TO CARE FOR
YOURSELF AFTER SURGERY.”
4. “YOUR HEALTH INSURANCE WILL PAY FOR INPATIENT CARE ONLY IF
COMPLICATIONS DEVELOP DURING SURGERY.”

WHICH PREOPERATIVE INSTRUCTION IS APPROPRIATE FOR ALL PATIENTS?

1. TECHNIQUES OF DEEP BREATHING AND COUGHING. (not for children!)

2. DESCRIPTIONS OF THE PLANNED SURGICAL PROCEDURE.
3. PHYSICAL PROCEDURES OR PREPARATION REQUIRED BEFORE SURGERY.
4. WITHHOLDING OF ALL ORAL FLUIDS OR FOOD AFTER MIDNIGHT ON THE DAY
OF SURGERY.

https://www.youtube.com/watch?v=oo4eIbi1vmA&ab_channel=NexusNursing

https://www.youtube.com/watch?v=9aNKPZfyJzE&ab_channel=LevelUpRN
https://www.youtube.com/watch?v=87FBupeZw3s&ab_channel=Thatnursingprof

Pre OP notes
Quiz → pre op and anesthesia, labs

Looking for →
- Baseline vitals
- Meds →
- Anticoagulants: Aspirin, coumadin (stopped 4-5 days before) , eliquis ,
diabetic (insulin) ANYTHING CAUSING BLEEDING
- Cardiac meds
- Steroids → need more of
- ONLY GIVE CRUCIAL MEDS TO PRE OP PTS WHEN NPO
- Opioids → may have tolerance (Narcan/naloxone reverse)
- Benzos → anxiety (tend to double if needs surgery and takes regularly) (anxiety
assessment) (reverse is flumazenil - romazicon)
- Glucose level goes UP in surgery (NPO; take half insulin before)
- Anesthesia provider → does meds!! Answers all questions on that too
- Higher risks for hemorrhage → HYPERTENSION
- DON'T WAIT FOR LABS TO DROP FOR BLEEDING (18-24 hrs)
- BP down, HR up
- Touch patient (roll fingers around incision → feeling for hard spot)
- Hematoma → hard feeling → collection of blood
- Do focused assessment → cardiac, respiratory, surgical area assessment
- BASELINES
- 0-10 scales for ALL
- Labs
- CBC → platelets (bleeding), H/H, WBCs (infection)
- Basic/comprehensive fluid and electrolytes
- Basic → glucose, creatinine (kidney) , Na+, K+, BUN (kidney) GFR (renal function;
less than 60 hang normal saline)
- Comprehensive (don't always need) → pt that takes coumadin/warfarin → Coags (PT
→ INR coumadin/warfarin) (PTT → Heparin)
FORMS
- Consent
- Over 18 unless emancipated or pregnant
- Proxy or power of attorney → mentally ill pts
- Someone else can consent if you're heavily sedated (spouse/friend)
- History and Physical → surgeon writes
- Anesthesia assessment → anesthesia docs
- Asthmatic/COPD → respiratory consult
- Insulin → endocrine consult
- Cardiac problems → cardiac consult
IF UNCONSCIOUS → PRIORITY PT
First exam → meds