Preoperative Nursing

1. Preoperative Nursing

2. PATIENT’S REACTION TO ILLNESS

3. Patients face surgical interaction in different ways • Fear – • -anticipation or awareness of danger -dependant on individual -intensity of stress • Cultural and Religious Influences Creates physiological changes

4. Other Reactions to Illness • Suspicion • Guilt, shame, punishment • Depression • Withdrawal • Regression • Denial • Anger, Hostility • Shock • Grieving, mourning

5. Preoperative Interview • Can discover: • pt. history of surgeries, infections, diseases • pt. allergies • Pt. use of chemicals, alcohol, recreational substances • Pt. history of smoking • Can help nsg. anticipate pt. needs, preoperatively, during surgery, and postoperatively

6. Preoperative Teaching • Lessening anxiety • Reduces the amount of anesthesia needed • Decreases post-surgical pain • Decreases post surgical complications • Reduces “sympathetic response” and cortico-steroid production • Wound healing occurs more rapidly

7. skeletal

8. Preoperative teaching • 1-2 days before surgery • decreases fear of the unknown and alleviating anxiety. • Prepare client/family for the expected events of the surgical day • What to expect post operatively • Ask client to discuss information known about upcoming surgery

9. Preoperative Teaching • Instruct about incision(s) • Size and location • Type of closure • Drains and dressings • Getting out of bed with abdominal incision • Instruct about possibility of tubes • Nasogastric tubes • Wound evacuation units • IV • Oxygen • When teaching, include family and significant other to promote support. • Discharge teaching and expectations

10. Leg Exercises Importance of Early Ambulation and TED hose Instruct in Assessment and Management of Pain Instruct in Splinting Activities with Cough and Deep Breathing (Exceptions, AHN, pg. 37, Box 2-6) Support groups may be available for pre-op visits - eg. Cancer, ostomy or amputation

11. Patient Special Needs • Patients of various ages and stages of development have different needs

12. Developmental Stages • Birth to 18 months • Dependent on caregivers • Startled easily • View hospital as abandonment • 18 to 30 months • Suffers separation anxiety • Fear immediate threats • 30 months to 5 year olds • Fears, real or imagined • Disfigurement • Fear death or nonexistence • May act out feelings • 6-12 Year olds • Loss of control • Prefers honesty and reassurance of safety • Not treated like a baby • 12-16 Year olds • Body image important • Prefers privacy/confidentiality • 17-Adult • May feel hostility towards authority • Torn between dependence and independence • Demands privacy and confidentially

13. Pediatric • May bring toy to O.R. depending on policy • Use vocabulary compatible with age • Don’t refer to general anesthesia as sleeping • Dress dolls as post op appearance • Be honest- • Never tell them something won’t hurt • Priority on schedule • Feeding routine • Guard against falls • Avoid adhesive tapes

14. Special Considerationsfor the Elderly • 80% of elderly -at least one chronic disease. • “Cascade effect” -failure in one system may lead to failure in another - • Late presentation • -low health expectations by the patient • -failure to recognize the problem • -low expectation, fear of treatment/hospitalization. • Presentation of a social problem • -obscures an underlying disease/complicate its • management. • Polypharmacy

15. Special Considerations for the Elderly • History-taking, diagnosis and management • Complicated by: • intellectual failure • inability to communicate • Depression, confusion and delirium • Short term memory loss • affects how well your client absorbs information during teaching.

16. Preoperative Preparation • Vital Signs • Laboratory tests • Urinalysis • Complete blood count • Blood chemistry profile • Endocrine, hepatic, renal, and cardiovascular function • Electrolytes • Diagnostic imaging • Chest x-ray • Electrocardiogram • Evaluation by Anesthesiology

17. Cardiovascular Risk • Surgical patients are given points to rate them for the possibility of not surviving the surgical procedure • A risk index of 26 or more points should undergo only life saving surgery • Scores of 13-25 probably exhibit sufficient cardiac risk to warrant routine preoperative cardiac evaluation.

18. Cardiovascular Considerations • Due to blood stasis, encourage LEG EXERCISES post operatively to assist venous flow. • With venous blood slowing  ↑ risk for thrombus  ↑ risk for embolus  ↑ risk for infarct. • Nursing measures: • Antiembolism stockings – TED hose; sequential compression device (SCDs) • Leg exercises • Ambulation as soon as MD approves

19. Informed consent • Patient’s Bill of Rights affirms Informed Consent • Information clear • Requires collaboration between • Patients • Physicians • Other health care professionals • Risks explained • Benefits identified • Consequences understood • Alternatives discussed • The surgeon is responsible for the informed consent. • Nurse may witness the client signing the informed consent but make sure the client has understood the surgeon’s explanations.

20. Consent for Surgery • Voluntary and informed act • Mentally able to understand • Should not be under the influence of pain medications • Agrees to the procedure • Granting party must have authority • Competent adult • Parent or legal guardian of a minor • Legal Guardian (permanent, temp.) • Courts

21. Written Informed Consent • Patient’s legal name • Surgeon’s name • Procedure to be performed • Patient’s legal signature • Signature of witness(es) • Date and time of signatures

22. Latex Allergy Considerations • Nsg. - focused assessment of risk factors: • Hx. anaphylactic reaction of unknown etiology during a medical or surgical procedure • Hx. reaction to latex (blowing up/handling balloons, gloves, condoms/condom catheters) • Multiple surgical procedures • Food allergies – esp. kiwi, bananas, avocado, chestnuts • Allergy to poinsettia plant • Hx. of allergies and/or asthma

23. Latex Allergy Considerations • Pt. with suspected or known latex allergy: • All latex is avoided • Admitted directly to the OR • 1st case of the day • Some are returned to a converted isolation room (with reverse flow ventilation) that is latex-safe • Medic-Alert bracelet • Prep meds with latex-free measures • Latex-free supplies on the Crash Cart

24. Latex Allergy Considerations • Preeoperative Prophylaxis • Treat with glucocorticosteroids and antihistamines • Reference: AHN p. 28 Box 2-5

25. Sleep Promotion the Night before Surgery Sleep gives neurons a chance to shut down and repair themselves. Without sleep, neurons may become so depleted in energy or so polluted with byproducts of normal cellular activities that they begin to malfunction.

26. Preoperative medication • Reduces anxiety • Valium, Versed, Ativan • Facilitate induction of anesthesia • Morphine, Fentanyl (Sublimaze) and sufentanil (sulenta) • Minimize some of the undesirable after effects of anesthetics such as excessive salivation, laryngospasm, bradycardia and vomiting • Anticholinergics—atropine • Side effect: skin flush and fever, urinary retention • If given on nursing unit, use safety measures • Bed in low position and side rails up • Monitor every 15-30 minutes

27. Preoperative checklist • Permits signed and on chart • Allergies (don’t forget Latex) • ID band(s) on patient (remember, once patient is sedated, they don’t talk) • Skin prep done • Removal of dentures, glasses/contacts, jewelry, nail polish, hairpins, makeup • TED stockings applied • Preoperative vital signs • Preoperative medications • Physical disabilities and/or diseases • History and physical and lab reports on chart

28. Skin Preparation • Skin preparation • Check Policy and Procedure book • Shower and wash hair the night before • All nail polish and make up should be removed • Removal of body hair in general wide zone of surgery • Clipping only • Assess for skin impairment • Infection • Irritation • Bruises • Lesions • All rings, bracelets and necklaces need to be removed • Intravenous Therapy initiated

29. Skin Prep

30. Gastrointestinal preparation • NPO after midnight (6-8 hrsfor general surg., 2-3 hours for local anesthesia) • Sign on door and over bed • May have oral care • Moist cloth to lips • Void immediately or empty Foley bag before surgery • Bowel cleanser night before, if GI procedure • Enema • Laxative • GI lavage (GoLYTELY) • Medication to detoxify and sterilize bowel

31. Respiratory Considerations • SMOKERS • May have impaired alveoli and reduced lung capacity, what is the ciliary “elevator?” • Mucous and anesthesia by-products may get trapped in the lungs  atelectasis and pneumonia • Post operative breathing exercise and treatment is aimed at increasing lung expansion

32. Respiratory Considerations • Incentive Spirometer- what is the goal? • Keep at the bedside • Increase, maintain tidal capacity • See AHN p. 28-29 Skill 2-2 • Turn, Cough, Deep Breathing Exercises • Staff to turn q 2 hours (unless MD restricts movement) • Coughing: contraindicated after brain, neck, spinal, and eye surgery • Teach the pt. how to ‘splint’ the operative site during DB and coughing. What is splinting for thoracic procedures? • Perform respiratory exercises q2 hrs and prn

33. GU Considerations • After general anesthesia - ↓ urinary bladder tone • Preoperatively, assess the pt. nrml. bladder habits and identify when pt. experiences fullness and distention of bladder • Inform the pt. of frequent lower abdominal palpation by nurse post operatively • Inform pt. of possible catheter placement • I and O • Most common complications: urinary retention and bladder infection

34. Holding area • Pre-anesthesia care unit • Compare patient’s ID bracelet to the medical record • Preoperative preparations • IV • Preoperative medications • Skin prep (hair removal) • Transport to the operating room • Direct family to appropriate waiting area

35. Transportation Methods • Standard stretcher • Gurney

36. Crib • Stryker Frame • Ward bed