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PREPARING PATIENTS
F O R S UR G E R Y ( 2 0 0 5 )
OBJECTIVES
1. Perform a preoperative physical assessment,
2. Identify the findings of the assessment that may require intervention,
3. Perform preoperative teaching,
4. Discuss the legal aspects of informed consent, and
5. Correctly prepare a patient for transfer to the operating room,
PRE TEST (TRUE OR FALSE)
1.
2.
3.
4.
5.
6.
Before surgery, physicians are responsible for preparing patients
for an operative and / or invasive procedures.
The preoperative phase of surgery ensures accurate identification
of the patient, using two identifiers, identification and marking
of the surgical site, adequacy of the patient preparation and
completeness of the documentation.
In physical assessment, the nurse will be focusing on subjective
data acquired after decision for surgery has been made.
In doing respiratory assessment it is important to note that the
patient should stop smoking 2 to 3 weeks prior to surgery.
Smoking is associated with the surgical complication of
atelectasis, and found it doubled the risk of postoperative
pneumonia.
In reviewing results of urinalysis, the following are to be
detected: albumin (which suggest kidney disease); glucose
( which suggest diabetes) and acetone and bacteria (which
suggest urinary tract infection).
7.
8.
9.
10.
Patients should be instructed to turn to sides, cough, and deep
breath at least 3 times an hour and to use the incetive spirometer
at least every 2 hours while awake.
Pre-anesthesia medication is usually given immediately before
surgery and is only done before all consents have been signed.
In an emergency, where the physician feels that delaying a
procedure would be an immediate threat to the patient’s life or
limb, and the patient cannot give consent, the physician may
proceed with the procedure without consent from anyone
An emancipate minor is usually recognized as one who is not
subject to parental control like in the case of a married minor, in
military service, college student under legal age but living away
from home, and a minor who has a child.
Perioperative nursing is a specialty that incorporates the care of the surgical
patient. It uses a multidisciplinary approach to care. In the hospital setting this
includes most disciplines in the hospital: nursing, pharmacy, dietary, materials,
environmental and plant operations. Perioperative nursing occurs in a variety of
settings. These include: Out Patient Centers, Surgical Services, Postanesthesia
Care Unit (PACU), physician offices, and any area in which surgery or invasive
procedures are performed. Perioperative nursing includes three phases of the
surgical experience: the preoperative, the intraoperative, and the postoperative
phases. This nursing specialty provides continuity of care through the perioperative phases. Registered Nurses are responsible for preparing patients for
an operative and/or invasive procedure.
By the year 2030, it is estimated that 20 percent of Americans will be older than
65, while one out of four elderly individuals will be older than 85 years of age.
Twenty-one percent of those over age 60 will undergo surgery and anesthesia as
compared with only 12 percent of those aged 45 to 60 years. Despite the higher
numbers of elderly patients having surgery, mortality and morbidity rates have
been declining. Old age appears to have assumed less influence as a
determinant of adverse outcomes as perioperative care has improved. A better
understanding of the associated risk factors leading to perioperative
complications may help healthcare providers to further lower the risk.
The preoperative phase begins when the decision for surgery is made and ends
when the patient is transferred to the operating room table. The preoperative
evaluation and teaching typically takes place several days before surgery in an
outpatient setting. Today, most perioperative patients are admitted to the
hospital the morning of their surgical procedure. However, there are times when
the preoperative phase will begin on the medical-surgical units or in the
emergency department. The first step of the preoperative phases begins with a
patient and chart assessment on all patients scheduled for an operative and/or
invasive procedure prior to transportation to the on all patients scheduled for an
operative and/or invasive procedure prior to transportation to the Surgical
Suites. This ensures accurate identification of the patient, using two identifiers,
identification and marking of the surgical site, adequacy of the preoperative
patient preparation, and completeness of the documentation. This assesses the
patient’s actual and potential health problems and facilitates implementation
and communication of the perioperative plan of care
Preoperative Assessment
A thorough nursing assessment and appropriate interventions can prevent or
minimize procedure related complications. The preoperative assessment is
essential to identify problems early, and to provide a comparison for
postoperative deviations from the norm. Sometimes, the initial nursing
assessment is done in a preadmission visit that may also include preoperative
teaching and outpatient testing. However, it is critical that the nursing
assessment be repeated the morning of surgery. This assessment should include
at a minimum, vital signs, respiratory status, an assessment of the level of
consciousness, and review of preoperative testing results.
Psychosocial Assessment
The psychosocial assessment many times will be different from the admission
assessment; since surgery may not have been a reality at the time of admission.
The preoperative psychosocial assessment aims to identify potential or actual
sources of the patient’s anxiety, such as altered sleep patterns, increased pulse
and respiratory rates, increased perspiration, and frequent voiding. It includes
the patient’s understanding of the surgery, previous surgical experiences,
specific concerns or feelings about surgery, and religious feelings that affect
anxiety.
Fear can take different forms, including fear of the unknown, loss of control, loss
of love from significant others, threat to sexuality from surgery, diagnosis of
cancer, anesthesia, dying, pain, disfigurement, permanent limitations, loss of
lifestyle (as evidenced by occupational and recreational changes), and current
and future financial problems.
Physical Assessment
The preoperative physical assessment aims to make surgery safe and
comfortable for the patient. Again, this will be different than the admission
assessment. The nurse will be focusing on objective data acquired after the
decision for surgery has been made.
Respiratory Assessment
Question the patient about smoking. To prevent respiratory complications the
patient should stop smoking 4 to 6 weeks prior to surgery. Many studies have
also shown a correlation between smoking and poor wound healing. Optimally
there should be no smoking the day of surgery. If they smoke, how many packs
per day and for how long? Smoking increases post-op respiratory complication
by decreasing the amount of functional hemoglobin available and impairs
oxygen delivery to the tissues. Smoking is associated with the surgical
complication of atelectasis, and one study found it doubled the risk of
postoperative pneumonia (Tiernevu, 2000).
Evaluate patients with pulmonary problems. Assess breath sounds and chest
expansion. Chest x-ray is ordered based on history not on age. If ordered and
completed results need to be put on chart. Evaluation of the patient with
preexisting pulmonary problems may include PFT and ABG. A chest x-ray
should be done within 1 year prior to the procedure for older patients (i.e. age 60
and older) and for patients with pulmonary conditions. Patient specific factors
that increase the risk of postoperative pulmonary complication are chronic lung
disease, morbid obesity and smoking (Tiernevu, 2000).
Does the patient have respiratory allergic conditions, such as asthma or hay
fever? Has he had anesthesia-related problems with any previous surgeries?
This may affect the choice of anesthetic agents. Does the patient have chronic
obstructive pulmonary disease (COPD)? This disorder increases the risk of
complications and may require preoperative interventions to correct disorder
increases the risk of complications and may require preoperative interventions
to correct electrolyte imbalances, prevent postoperative respiratory infection or
remove excess sputum. Does the patient have an upper or lower respiratory
infection? Notify the physician of such an infection, as it may be reason to delay
the procedure. Anesthesia produces increased bronchial secretions besides the
congestion already present in the case of a respiratory infection. This has a
profound effect on ventilation of the patient.
Cardiovascular Status
Assess heart sounds, rate, and rhythm. Assess peripheral pulses. Obtain an
EKG if ordered. EKG is ordered based on history not age. Record peripheral
pulses when surgery is to be performed on major blood vessels or the
extremities. Obtain CBC and electrolytes (add type and cross-match if patient
undergoing major surgery that may involve considerable blood loss) REVIEW
RESULTS FOR ABNORMAL LEVELS! When labs are ordered please contact
the physician with abnormal results. Do not assume the lab has contacted them
– they only call critical levels. The 2 test results that as a nurse it is especially
important to look at is blood glucose (link between wound healing) and bacteria
which suggest UTI. When ordering a T&S or T&C for a preoperative patient
please get a blood consent also. Consents will be covered later in this module.
Kidney and Liver Status
Does the patient have any complaints associated with kidney or bladder
infection? These include frequency, urgency, blood in the urine, burning on
urination, fever, or back, flank or suprapubic pain. Patients with signs and
symptoms of urinary or kidney infection need a more extensive preoperative
evaluation. If renal function is severely compromised by infection, the stress of
surgery can precipitate renal failure.
Liver biotransforms anesthetics; liver disease impairs the ability to detoxify
drugs that may be given in the perioperative period. Review results of liver
function tests. Kidney excretes anesthetics and metabolites; good renal function
is necessary to maintain fluid and electrolyte balance. Review results of
urinalysis to detect:
• albumin (which suggests kidney disease)
• glucose (which suggests diabetes)
• acetone (which suggests diabetes or starvation)
• bacteria (which suggests urinary tract infection)
• When implanting metallic objects (TKA/THA), UTI can be very dangerous.
Many times procedures will be cancelled.
Immunologic Status
Assess for allergic reactions to any foods, medication, latex or soaps. Report
history of bronchial asthma. Many patients with asthma will be given a
preoperative breathing treatment or given medication through a MDI. Some
allergic reactions can be fatal and some can be serious enough to permanently
damage vital organs. It is important that the surgery team know if the patient
has an allergy to iodine, seafood, hexachlorophene or latex prior to the
procedure. Latex is becoming more of an issue in perioperative nursing.
However; the public is not always aware of latex allergies. Ask if they wear
rubber gloves at home, do they have irritation from their under garments, any
problems when they blow up a balloon? Check for food allergies, which are
linked to latex allergies – bananas, kiwi, chestnuts, papayas, mangos, potatoes.
Inquire about unusual reaction to anesthesia by patient or relatives. The
concern is malignant hyperthermia which is hereditary.
Neurologic Status
The neurological exam provides you with a baseline to measure against through
the postoperative process. Evaluate cognitive level, language barriers and
behavior. Evaluate arm and leg muscle strength and coordination with
ambulation. Assess orientation to person, place and time. Assessing orientation
goes along ways in helping the Surgical Suite staff. Is this patient competent to
sign permits? Does the patient display any signs or symptoms suggesting
significant neurological problems? Symptoms may include headache, numbness
or tingling in an extremity, tremors or weakness in an extremity, unsteady gait,
confusion or memory loss. It is important to document any neurological deficits
preoperatively for comparison with the post-op assessment. Neurological and
behavioral changes can result postoperatively from the effects of anesthetics,
analgesic or sedatives. This is especially true in elderly patients.
Is the patient alcoholic? Chronic alcoholism suppresses the adrenocortical
response to operative stress. If the patient does not admit to drinking heavily
and you are concerned that he might be alcoholic, share these concerns with the
physician. Alcoholic patients are at risk for delirium tremors with withdrawal.
Gastrointestinal (GI) Status
Does the patient complain GI symptoms? These include nausea & vomiting,
diarrhea, constipation, spitting up blood or blood in the stool, gastric ulcer
disease, inflammatory bowel disorder, or diverticular disease. Anesthesia and
pain medications affect the GI function. So, a preoperative assessment is needed
for comparison postoperatively to determine if any problems were caused by the
medication or were preexisting.
Endocrine Status
Is the patient diabetic? Diabetics should not have insulin on the morning of
surgery due to their NPO (nothing by mouth) status. Do a bedside blood glucose
check and notify the physician of abnormal findings before the procedure.
Diabetes puts the patient at risk for delayed wound healing, postoperative
surgical infection, hypoglycemia or hyperglycemia.
Health History
Allergies – drugs, adhesive tape, latex or soap. Ask about preexisting illness,
such as liver, respiratory, renal, cardiac, endocrine, and blood disease. Inquire
about use of medications that could interfere with anesthesia or contribute to
postoperative complications, such as bleeding. Ask about herbal usage. More
and more people are using herbs and vitamins and will not always volunteer
this information. Ask about difficulty with hearing or vision. Document the
medications the patient takes regularly, including over the counter and herbal
medications. St. John’s Wort, feverfew, ginkgo biloba, ticlid, plavix
anticoagulants and non-steroidal anti-inflammatories effect coagulation and can
increase the risk of hemorrhage.
Obtain nutritional history to evaluate dietary intake and nutritional status. Ask
about elimination to detect constipation or diarrhea. Question the patient about
motor problems, particularly difficulty with walking or with arm or leg
movement due to arthritis or orthopedic surgery. REMEMBER we want to
promote early activity postoperatively. Ask about the patient’s ability to sleep
and relax, level of pain or discomfort, and expectations about postoperative pain
relief; perform a baseline pain assessment.
Factors affecting patient response to surgery
Age
Elderly patients may be less able to tolerate the stress of surgery depending on
their agerelated physiological changes and the presence of chronic diseases.
Nutrition
Inadequate intake or an improper diet can impair the patient’s ability to
tolerate the stress of surgery. It may also have an impact on wound healing.
Excessive intake, reflected by obesity, also can complicate surgery and the
patient’s postoperative period.
Chronic Disease States
Pulmonary Disease can affect the patient’s response to anesthesia and the
ability to cope with respiratory problems postoperatively.
Cardiovascular disease can contribute to shock and fluid imbalances by
impairing blood pumping and blood vessel constriction. An inadequate supply of
red or white blood cells may increase risks related to hemorrhage or
inflammation.
Renal Insufficiency may impair electrolyte and waste product removal and
increase the risk of fluid overload, if urine production is inadequate.
Endocrine Disease can delay wound healing because of an anti-inflammatory
response.
Disabilities that limit patient activity increase the risk of postoperative
atelectasis, pneumonia and thrombophlebitis.
Preoperative Teaching
The purpose of preoperative teaching is to decrease patient anxiety and prepare
the patient for surgery. It will also decrease fear. Fear of the unknown increases
anxiety. Preoperative teaching can alter unfavorable attitudes, influence
postoperative recovery and promote satisfaction with care. Preoperative
teaching may have been done and documented in a preadmission visit. If not,
you must do the teaching. If it was done, you should reinforce the teaching. You
can provide a description of and reason for preoperative tests, description of
preoperative routines, time of surgery, probable length of surgery and estimated
time in PACU. Explain the recovery process, including the place where the
patient will awaken, nursing care provided, monitoring of vital signs and
equipment used (O2 therapy, O2 saturation monitor, PCA). Cover the probable
postoperative course – IV lines, need to increase activity as soon as possible,
need to cough and deep breath despite discomfort, incentive spirometer (this is a
good time to teach them on how to use an incentive spirometer and have them
practice which will make it easier to use postoperatively) Stress that it is
important to turn, cough and deep breathe to prevent atelectasis. Instruct him
to turn cough and deep breath at least 3 times an hour and to use the incentive
spirometer at least every 2 hours, while awake. Tell family members what time
the patient is expected to go to surgery, where they can wait during surgery,
when the physician will contact them with surgical results.
If you do the preoperative teaching during a preadmission visit, explain any
instructions that require the patient to prepare himself at home, like bowel
evacuation for a colonoscopy. The morning of the procedure, check to see if the
patient was complied with the instructions. Failing to execute preoperative
preparation may be a reason to postpone the procedure. Explain the meaning of
NPO, emphasizing the importance of being compliant to avoiding aspiration.
Sometimes, patients will be NPO except for their oral medications, which should
be taken with clear water. This variation may be a policy at a specific facility, or
the physician’s order will be written as NPO except for medications. Most
patients will be NPO after midnight the day before the procedure. A physician
may designate a later NPO status if the patient is scheduled late in the day.
Instruct the patient to shower the morning of the procedure with an
antimicrobial soap. The patient should wash the operative site for at least five
minutes, scrubbing in a circular motion. Anesthetic will remain in the patient’s
body for at least 24 hours post procedure, so caution the patient not to drive,
operate dangerous equipment or make important decisions within 24 hours
after the procedure. Some procedures have preoperative teaching needs that are
specific to that procedure, like how to use a walker if you are going to have a hip
replacement. These needs are determined in collaboration with the physician.
Pre-anesthesia Medication
Pre-anesthesia medication varies from facility to facility. It is usually given
immediately before surgery to:
•
•
•
•
•
•
Decrease anxiety
Provide sedation
Induce amnesia
Decrease pharyngeal secretions
Slow hydrochloric acid production
Prevent allergic reaction to anesthetics
If they are given, they will normally be given by the anesthesia provider just
prior to patient going into the OR. This is only done AFTER all consents have
been signed and are verified complete. This is not to be confused with the
administration of preoperative medications – antibiotics, inhaler, breathing
treatment, antacid or h2 blockers (Zantac - which inhibits gastric acid
secretion), antiemetic (Reglan – given for gastro esophageal reflux and/or
delayed gastric emptying). May hear term sour stomach.
Informed Consent
Requiring permission to operate protects the patient from unsanctioned surgery
and protects the surgeon from claims of unauthorized operation. The informed
consent document indicates the specific procedure to be performed and includes
a list of possible complications. The consent should be written as stated in
physician orders. It is clearly worded in simple terms without abbreviations. All
blanks must be filled in. If you have questions about the correct layman’s terms,
the OR staff, the physician or nursing supervisor should be called for
verification. If there is question about diagnosis/reason for procedure consult
physician performing the procedure. The consent contains the patient’s
signature, if the patient is of age and competent, date and time signed. There is
should also be a clause for photographs and blood transfusion. If the patient is
having conscious sedation this should be included on the consent. Conscious
sedation may be given to patient having colonoscopy/EDG/painful procedures. If
the operative permit is not signed, have the patient sign and date it. Witness
the signature. A nurse’s signature of witness is verifying that the patient signed
the form. It does not hold any other legal responsibility. It does not mean that
you participated in informed consent. Informed consent is done between the
physician and the patient in a discussion. The operative permit has the patient
signature to verify that consent. If the patient is unable to write, an “X” to
indicate his agreement is acceptable. You should have a second witness to the
“X”. The information that the patient must understand is a definition of the
procedure, possible complications and risks of the procedure. If the patient
expresses that he has unanswered questions about the procedure, or does not
want the procedure, you have the responsibility to contact the physician and let
him know.
If the patient is awake and oriented x 3, 1 witness is needed. If the patient is a
minor, the legal guardian must sign the consent and 1 witness is needed. Most
states have statues regarding the treatment of minors. An emancipate minor is
usually recognized as one who is not subject to parental control, as in the
following situations:
• Married minor
• In military service
• College student under legal age but living away from home
• Minor who has a child.
If the patient is incompetent or incapacitated, permission can be sought from a
patient representative. Laws vary from state to state and policy varies from
facility to facility. An incompetent patient is any patient who is mentally or
physically incapacitated, as determined by incompetent patient is any patient
who is mentally or physically incapacitated, as determined by physicians, such
that the patient cannot communicate treatment preferences. Facility policy
usually dictates the process and how many physicians must be involved in the
decision. The patient does not have to be adjudicated incompetent by a court of
law for the purposes of consenting for a procedure. If the family or Power of
Attorney signs the consent 2 witnesses are needed.
In an emergency, where the physician feels that delaying a procedure would be
an immediate threat to the patient’s life or limb, and the patient cannot give
consent, the physician may proceed with the procedure without consent. This
process requires extensive documentation and often a consultation with other
physicians. Check facility policy. The informed consent document should be
placed on the patient’s chart and accompany the patient to the Surgical Suite.
Informed Consent:
• Must be obtained BEFORE patient receives pre-op meds that induce
sedation or amnesia or reduces anxiety
• Ensure that the patient has actually been informed
• Physician performing the surgery must sign the consent
• Ensure that the consent has date and time
• 2 witnesses are required for incompetent patients and telephone consents
Preoperative Checklist
In final preparation before the patient is transported to surgery the preoperative checklist should be reviewed for documentation of nursing actions
which include:
• Removal of jewelry and other objects (remember to check for “unique” body
jewelry)
• Checking patient identification using 2 identifiers ensures surgical site is
identified and marked with an “X”
• Asking the patient to void
• Check for necessary documents – patient history, physical assessment,
consent form, test results
• Administering pre-op meds
• MAR on chart
• Recent vital signs (should not be greater than 1 hour)
Depending on the facility policy, dentures may or may not be removed prior to a
procedure.
On the preoperative checklist the nurse documents actions, such as patient
identification; allergies; removing jewelry or other objects; asking patient to
void; ensuring all needed documentation (H&P, consent, test results) are
available. Mark the site of surgery, however; not immediate over the site. What
IV Fluid is hanging? Incomplete chart work can delay the surgical procedure.
The nurse may be required to go to the OR to identify the patient and to
complete documentation.
Summary
Nursing’s preoperative teaching and assessment contribute heavily to the
success of a procedure. No surgery is without risk but complications can be
decreased with proper preoperative assessment and documentation of coexisting
disease. Medical optimization, adequate planning preoperatively, including
scheduling surgery electively as opposed to emergently, and improving nutrition
status may be helpful. Opportunity to improve perioperative outcomes will be
possible when risk factors for adverse events can be modified.
PRE TEST (TRUE OR FALSE)
1.
F
2.
T
3.
F
4.
F
5.
T
6.
F
Before surgery, physicians are responsible for preparing patients
for an operative and / or invasive procedures.
The preoperative phase of surgery ensures accurate identification
of the patient, using two identifiers, identification and marking
of the surgical site, adequacy of the patient preparation and
completeness of the documentation.
In physical assessment, the nurse will be focusing on subjective
data acquired after decision for surgery has been made.
In doing respiratory assessment it is important to note that the
patient should stop smoking 2 to 3 weeks prior to surgery.
Smoking is associated with the surgical complication of
atelectasis, and found it doubled the risk of postoperative
pneumonia.
In reviewing results of urinalysis, the following are to be
detected: albumin (which suggest kidney disease); glucose
( which suggest diabetes) and acetone and bacteria (which
suggest urinary tract infection).
7.
T
8.
F
9.
T
10.
T
Patients should be instructed to turn to sides, cough, and deep
breath at least 3 times an hour and to use the incetive spirometer
at least every 2 hours while awake.
Pre-anesthesia medication is usually given immediately before
surgery and is only done before all consents have been signed.
In an emergency, where the physician feels that delaying a
procedure would be an immediate threat to the patient’s life or
limb, and the patient cannot give consent, the physician may
proceed with the procedure without consent from anyone
An emancipate minor is usually recognized as one who is not
subject to parental control like in the case of a married minor, in
military service, college student under legal age but living away
from home, and a minor who has a child.
REFERENCES:
• Nettina, S, (2001). The Lippincott Manual of Nursing Practice, 7th edition.
Philadelphia, PA: Lippincott Williams &Wilkins. pp107-136.
• Gruber, E. & Tschernko, E. (2003). Anaesthesia and postoperative
analgesia in older patients with chronic obstructive pulmonary disease:
Special considerations. Drugs & Aging 20(5), 347-361.
• Walker, J., (2002). Emotional and psychological preoperative preparation
in adults. British Journal of Nursing. 11(8), 567-576.