Preoperative Nursing Management

Preoperative Nursing Management

Today’s trends in health care will be tomorrow’s exam­ples of how clients used to be treated. These constant changes reflect multiple advances and society’s needs. The technology explosion is responsible for the development of new diagnos­tic and interventional devices that provide opportunities for the use and refinement of new surgical techniques. Examples of such technical advances include the GAMMA knife for brain tumor resections, as well as other minimally invasive surgery. Advances in anesthetic agents and techniques also have developed. These changes improve the ways that a sur­gical client is treated and has made anesthesia safer than everbefore.

Cost reduction initiatives by third-party payers are also a driving force as to how the client is managed by the health care community. Shortened stays or outpatient treatment has become the expected. Ambulatory surgical services have rap­idly been expanded, with more clients being admitted as in-patients after a procedure, rather than before. Some clients may only be observed after surgery and not admitted as an in-patient. In response to the ongoing health care delivery changes and the use of multiple settings, nurses have modi­fied their interventions, remaining focused on client care be­fore (preoperative), during (intraoperative), and after (post­operative)surgery.

■ OVERVIEW

The preoperative period begins when the client is scheduled for surgery and ends at the time of transfer to the surgical suite. The nurse acts as an educator, an advocate, and a pro­moter of health. Perioperative nursing places special empha­sis on safety and client education.

Preoperative care consists of education and any interven­tioeeded before surgery to reduce anxiety and postopera­tive complications and to promote cooperation in postopera-tive procedures. In preoperative teaching, the nurse uses adult teaching and learning principles, validating and clarifying in­formation the physician has provided. In addition, during the preoperative assessment it is not uncommon for the nurse to identify situations that warrant further client assessment and/or intervention before surgery. In collaboration with the surgical team, appropriate action is taken to achieve the de­sired outcome.

I Categories and Purposes of Surgery

Surgical procedures are usually categorized according to the following:

•  The reason for the surgery

•  The urgency of the procedure

•  The degree of risk

•  The anatomic location

•  The extent of surgery required

The primary purposes, or reasons, for surgery can be di­vided into five general subcategories: diagnostic, curative, restorative, palliative, and cosmetic. Palliative surgery makes the client more comfortable, and cosmetic surgery recon­structs the skin and underlying structures. The urgency of the procedure can be divided into three subcategories: elective, ur­gent, and emergent. The degree of risk is classified as minor or major. Classification by location is based on the area of the body on which the surgery occurs (e.g., abdominal surgery, in-tracranial surgery, or heart surgery). The extent can be simple, modified, or radical. Table 17-1 explains the categories and gives examples of surgical procedures.

Simple/partial mastectomy

Radical prostatectomy Radical hysterectomyten, the day of surgery (often termed same-day admission [SDA]), or he or she may already be an inpatient when the need for surgical intervention is identified. In contrast, the terms outpatient and ambulatory refer to a client who goes to the surgical area the day of the surgery and returns home on the same day (i.e., same-day surgery [SDS]). Hospital-based ambulatory surgical centers, freestanding surgical centers, physicians’ offices, and ambulatory care centers are becoming increasingly more common. It is estimated that 70% to 90% of all surgical procedures in the United States are performed in ambulatory centers (Poole, 1999).

One of the many advantages of outpatient surgery is that clients are not separated from the comfort and security of their home and family. With continuous improvements in surgical techniques and anesthesia, more procedures are per­formed safely on an outpatient basis. Changes in the surgical experience, however, present particular challenges for the client who does not have an adequate or available support system. An older spouse may be unable to assist in preoper­ative and postoperative care. Clients who are primarily re­sponsible for others may be unable to perform their usual tasks within the family. They may try to continue their fam­ily role but jeopardize their own health by doing so. As a re­sult, their stress, fears, and anxieties about the surgical expe­rience and about returning home immediately after surgery may be increased.

Assessment

■ HISTORY

Collection of data about the client before surgery begins in various settings (e.g., the surgeon’s office, the preadmission or admission office, the inpatient unit, and over the tele­phone). The nurse provides privacy to increase the client’s comfort with the interview process. Anesthesia and surgery are both physical and emotional stressors. The nurse collects the following data:

•  Use of tobacco, alcohol, or illicit substances, including
marijuana

•  Current medications

•  Use of complementary or alternative medicines, such as
herbal therapies, folk remedies, or acupuncture

•  Medical history

•  Prior surgical procedures and experiences

•  Prior experience with anesthesia

– Autologous or directed blood donations

•  Allergies, including sensitivity to latex products

•  General health

•  Family history

•  Type of surgery planned

•  Knowledge about and understanding of events during
the perioperative period

• Adequacy and availability of the client’s support system
When taking a history, the nurse screens the preoperative

client for conditions that may increase the risk for compli­cations during the perioperative period.

AGE. Older clients are at increased risk for perioperative complications. The normal aging process decreases immune system functioning and delays wound healing. The frequency of chronic illness increases in older clients. See Chart 17-1 for other physiologic changes in older adults that may have an impact on the perioperative experience.

MEDICATION AND SUBSTANCE USE. The use of

tobacco products increases the risk of pulmonary complica­tions because of changes they cause to the lungs and thoracic cavity. Excessive alcohol and illicit substance use can alter the effects of anesthesia and response to pain medication. With­drawal of alcohol in preparation for surgery may precipitate delirium tremens. Prescription and over-the-counter medica­tions may also affect how the client reacts to the perioperative experience. The potential effects of specific medications are listed in Table 17-3. Another area of concern is the potential for reaction or serious adverse effects with some herbs, such as those listed in Table 17-4.

MEDICAL HISTORY. The nurse asks the client about his or her medical history. The presence of many chronic ill­nesses increases perioperative risks and is considered when planning care. For example, a client with systemic lupus ery-thematosus may need additional medication to offset the physical and emotional stress of the surgery. A client with di­abetes may need a more extensive preoperative bowel prepa-

AGE

• Older than 65 years

MEDICATIONS

•  Antihypertensives

•  Tricyclic antidepressants

•  Anticoagulants

•  Nonsteroidal anti-inflammatory drugs (NSAIDs)

MEDICAL HISTORY

•  Decreased immunity

•  Diabetes

•  Pulmonary disease

•  Cardiac disease

•  Hemodynamic instability

•  Multisystem disease

•  Coagulation defect or disorder

•  Anemia

•  Dehydration

•  Infection

•  Hypertension

•  Hypotension

•  Any chronic disease

PRIOR SURGICAL EXPERIENCES

•  Less-than-optimal emotional reaction

•  Anesthesia reactions or complications

•  Postoperative complications

HEALTH HISTORY

•  Malnutrition or obesity

•  Medication, tobacco, alcohol, or illicit substance use or
abuse

•  Altered coping ability

FAMILY HISTORY

•  Malignant hyperthermia

•  Cancer

•  Bleeding disorder

TYPE OF SURGICAL PROCEDURE PLANNED

•  Neck, oral, or facial procedures (airway complications)

•  Chest or high abdominal procedures (pulmonary
complications)

•  Abdominal surgery (paralytic ileus, deep vein thrombosis) ration because of decreased gastrointestinal motility. An in­fection may need to be treated before surgery.

PRIOR CARDiAC HISTORY. The nurse obtains a his­tory of cardiac disease because complications from anesthesia could occur in clients with cardiac problems. Cardiac disor­ders that increase risks associated with surgery include coro­nary artery disease, angina pectoris, myocardial infarction (MI) within 6 months before surgery, congestive heart failure, hypertension, and dysrhythmias. These disorders impair the ability to withstand and respond to both anesthesia and the he­modynamic changes associated with surgery. The risk of in-traoperative MI is also higher in clients with pre-existing heart problems.

PULMONARY HISTORY. Adults with chronic respira­tory problems, older persons, and smokers are at risk for pul­monary  complications  because  of smoking-induced pulmonary changes. Increased rigidity of the thoracic cavity and loss of lung elasticity reduce the efficiency of anesthesia ex­cretion. Smoking increases the level of circulating carboxy-hemoglobin (carbon monoxide in the oxygen-binding sites of the hemoglobin molecule), which in turn decreases oxygen delivery to organs. In addition, mucociliary transport de­creases, which leads to increased secretions and predisposes the client to infection (pneumonia) and atelectasis (collapse of alveoli). Atelectasis prevents the exchange of oxygen and carbon dioxide and causes intolerance of anesthesia.

Chronic conditions such as asthma, emphysema, and chronic bronchitis also reduce the elasticity of the lungs, which causes an ineffective exchange of carbon dioxide and oxygen. As a result, clients with these conditions have de­creased oxygen diffusion and decreased oxygenation of the tissues.

CARDIOVASCULAR SYSTEM

Decreased cardiac output Increased blood pressure Decreased peripheral circulation

RESPIRATORY SYSTEM

Reduced viral capacity Loss of lung elasticity Decreased oxygenation of blood

RENAL/URINARY SYSTEM

Decreased blood flow to kidneys Reduced ability to excrete

waste products

Decline in glomerular filtration rate Nocturia common

NEUROLOGIC SYSTEM

Sensory deficits Slower reaction time Decreased ability to adjust to changes in the surroundings

MUSCULOSKELETAL SYSTEM

Increased incidence of deformities related to osteoporosis or arthritis

Determine normal activity levels and

note when the client tires. Monitor vital signs, peripheral pulses,

and capillary refill.

Teach coughing and deep breathing

exercises. Monitor respirations and breathing

effort.

Monitor intake and output. Assess overall hydration. Monitor electrolyte status. Assist frequently with toileting needs, especially at night.

Orient the client to the surroundings. Allow extra time for teaching the client. Provide for the client’s safety.

Assess the client’s mobility. Teach turning and positioning. Encourage ambulation. Place on fall precautions, if indicated.

Knowing limits helps prevent fatigue. Having baseline data helps detect deviations.

Pulmonary exercises help prevent pul­monary complications.

Having baseline data helps detect deviations.

Ongoing assessment helps detect fluid and electrolyte imbalances and de­creased renal function.

Frequent toileting helps prevent inconti­nence and falls.

An individualized preoperative teaching plan is developed on the basis of the client’s orientation and any neurologic deficits.

Safety measures help prevent falls and injury.

Interventions help prevent complica­tions of immobility. Safety measures help prevent injury.

PREVIOUS   SURGERY  AND   ANESTHESIA. The

number and type of previous surgical procedures and previous surgical experiences affect the preoperative client’s readiness for surgery. Previous perioperative experiences, particularly those with complications, may contribute to fears and con­cerns about the scheduled surgery. The nurse asks about the client’s experience with anesthetic agents and all allergies. These data provide the nurse with information about tolerance of and possible fears about the use of anesthesia. A sensitiv­ity or allergy to certain substances alerts the nurse to a possi­ble reaction to anesthetic agents or to substances that are used for preoperative skin preparation. For example, povidone-iodine used for skin preparation contains some of the same components found in shellfish. Clients who are allergic to shellfish may have an adverse reaction to povidone-iodine. The family medical history and problems with anesthetics may indicate possible intraoperative needs and reactions to anesthesia, such as malignant hyperthermia.

AUTOLOGOUS OR DIRECTED BLOOD DONATIONS.

Clients may donate their own blood (autologous

donations) for a few weeks immediately before the scheduled surgery date. If they need blood during the perioperative pe­riod, an autologous blood transfusion can be given. This prac­tice eliminates the possibility of transfusion reactions and the transmission of bloodborne disease.

Clients may be candidates for autologous blood donations up to 5 weeks preoperatively if they are afebrile, have a he­moglobin level greater than 11 g/dL (110 g/L), and have a physician’s recommendation. Usually clients with a history of cardiovascular disease need additional clearance from their cardiologist. The physician may order supplemental iron be­ginning before the first donation. Autologous donations can be made as frequently as every 3 days if the other criteria are met. Usually a total of 2 to 4 units is donated. The last dona­tion cannot be made within 72 hours before surgery.

A special tag is affixed to the transfusion bag when an au­tologous blood donation has been made. The blood donor center gives the client a matching tag that he or she brings to the surgical area preoperatively. This procedure helps to en­sure that the client receives only his or her own blood. If the blood is not used, it goes to the blood bank to be used as would any other unit of donated blood.

Antiarrhythmic medications affect the client’s tolerance of anesthesia and potenti­ate anesthetics that are neuromuscular blockers.

Antiarrhythmics depress car­diac function by decreas­ing cardiac output and slowing the pulse rate.

Antiarrhythmics may cause peripheral vasodilation.

Communicate the use and type of antiarrhythmics to the anesthesia personnel.

Monitor vital signs.

Obtain a baseline electrocar­diogram, as ordered.

Assess the client’s peripheral circulation.

Cardiac complications during surgery can be life threatening.

Ongoing monitoring helps to detect deviations and po­tential complications.

ANTIHYPERTENSIVES

Methyldopa

(Aldomet, Novomedopa*) Captopril (Capoten) Clonidine hydrochloride

(Catapres)

Antihypertensive agents alter the client’s response to muscle relaxants and opi-oid analgesics by inhibiting synthesis and storage of norepinephrine.

Antihypertensives may cause a hypotensive crisis intra-operatively and postopera-tively.

Monitor blood pressure and

pulse frequently. Assess for hypotension during

transfer and turning.

Ongoing monitoring helps to detect deviations and po­tential complications.

Hypotensive crisis can occur and may be prevented through timely assessments.

CORTICOSTEROIDS

Dexamethasone

(Decadron, Dexasone) Hydrocortisone sodium

(Solu-Cortef) Prednisone

(Deltasone*, Winpred)

Surgery increases the de­mand for corticosteroids in the client with no adrenal function.

Steroids delay wound healing because of blockage of collagen formation.

Steroids increase the serum glucose level and block fi-broblast formation.

Steroids increase the risk of hemorrhage.

Steroids mask the signs and symptoms of infection.

Continue steroid therapy dur­ing surgery.

Monitor vital signs.

Assess for signs of hyper-glycemia.

Assess for subtle signs of in­fection and bleeding.

Monitor wound healing, sup­port the incision area with binders, and splint the wound when the client is turning, coughing, and deep breathing.

Continuation of steroid therapy avoids problems associated with abrupt withdrawal.

Ongoing monitoring helps to detect deviations and po­tential complications.

It is important to detect early signs and symptoms of in­fection.

Specific wound and incision care helps to prevent com­plications.

ANTICOAGULANTS

Wafarin sodium

(Coumadin, Warfilone

sodium*¹) Heparin sodium

(Leo-Heparin,

НераІеапФ) Aspirin

(acetylsalicylic

acid, AncasaW>,

Astrin*, Coryphen*)

Anticoagulant therapy in­creases the risk of hemor­rhage intraoperatively and postoperatively.

Monitor coagulation studies (aPTT, PT, INR).

Monitor for signs of bleeding.

Gradually discontinue antico­agulants 24-48 hr before surgery, as ordered.

Have an antidote (protamine sulfate for heparin and vita­min К [Mephyton] for war­farin sodium) available to re­verse the effects of the anticoagulant.

Coagulation studies help de­tect bleeding disorders.

Anticoagulant administration is discontinued to avoid hem­orrhage.

An antidote needs to be avail­able to prevent complica­tions of bleeding in an emer­gency situation.

ANTISEIZURE MEDICATIONS

Phenobarbital (Luminal, Gardena!*)

Seizure activity can cause in­jury to the surgical wound.

Antiseizure medications alter the metabolism of anes­thetic agents.

Maintain use of the drug.

Inform the anesthesiologist or anesthetist to allow for ad­justment of the dosage of the anesthetic.

Assess for seizure activity.

Pad the siderails of the bed.

Place suction equipment at the bedside.

Antiseizure medications pre­vent seizures. Safety measures prevent injury.

POTENTIAL EFFECTS OF HERBS Potential Effect

Black cohosh       Bradycardia, hypotension, joint pains

Bloodroot   Bradycardia, dysrhythmia, dizziness, im-

paired vision, intense thirst

Boneset        Liver toxicity, mental changes, respiratory

problems

Coltsfoot    Fever, liver toxicity

Dandelion     Interactions with diuretics, increased con-

centration of lithium or potassium

Ephedra       Headache, dizziness, insomnia, tachycardia,

hypertension, anxiety, irritability, dry mouth

Feverfew      Interference with blood-clotting mechanisms

Garlic          Hypotension, blood-clotting inhibition, po-

tentiation of diabetes drugs

Ginseng       Headache, anxiety, insomnia, hyperten-

sion, tachycardia, asthma attacks, post-menopausal bleeding

Goldenseal    Vasoconstriction

Hawthorn     Hypotension

Kava           Damage to the eyes, skin, liver, and spinal

cord from long-term use

Licorice      Hypokalemia, hypernatremia

Lobelia        Hearing and vision problems

Motherwort Increased anticoagulation

Nettle          Hypokalemia

Senna          Potentiation of digoxin

St. John’s Wort    Antidepressant, photosensitivity

Valerian root        Mild sedative or tranquilizer effect, hepato-toxicity

Clients may wish to have family and friends donate blood exclusively for their use, if needed. This practice of directed blood donation is possible only if the blood types are com­patible and the donor’s blood is acceptable. Clients may fear disease transmission from unknown blood and feel more comfortable knowing who gave the blood. Increasingly, blood collection centers and other health care personnel are dis­couraging this practice. Some centers do not accept directed blood, stating that it gives a false sense of security. As with autologous blood donations, a special tag is affixed to the blood. This tag notes the names of the client and the donor and bears the client’s signature.

The nurse asks whether autologous or directed blood do­nations have been made and documents this information in the chart. It may be important to know the specific blood col­lection center where the donation was made and whether the blood has arrived before the client goes into surgery.

PLANNING FOR BLOODLESS SURGERY. In­creased use of “bloodless surgery,” or minimally invasive sur­gery, programs is helping to provide another alternative for clients with religious or medical contraindications to blood transfusions. These programs reduce or eliminate the need for transfusion during and after surgery. Some techniques em­ployed include limiting preoperative blood samples (the num­ber of samples, as well as the volume of blood drawn per sam­ple) and stimulating the client’s own red blood cell production with epoetin alpha (Epogen, Procrit) before, during, and after surgery. The physician may prescribe supplemental iron, folic acid, vitamin B₁₂, and vitamin С preoperatively to further stimulate erythropoiesis. Special equipment and techniques used during the surgical procedure result in less blood loss than with older techniques. Such technologic advances include autotransfusion of suctioned blood during surgery to be recy­cled and immediately transfused back into the client. The nurse assesses, monitors, teaches, and supports the client dur­ing the bloodless surgery process (Vernon & Pfeifer,1997).

DISCHARGE   PLANNING. The  nurse  assesses  the

client’s home environment, self-care capabilities, and support systems and anticipates postoperative needs during the preoperative period. All clients, regardless of how minor the proce­dure, should have discharge planning. Older persons and de­pendent adults may need referrals for transportation to and from the physician’s office or the surgical setting. A home care nurse may be needed to monitor postoperative recovery and to provide instruction on wound care. All clients with in­adequate support systems may need follow-up care at home. Some require a planned direct admission to a rehabilitation hospital or center for extensive physical therapy following surgery, as in the case of total hip arthroplasty. Shortened hos­pital stays necessitate adequate discharge planning to achieve the desired outcomes after surgery.

PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS

The preoperative client may be of any age, with a health status that varies from well to debilitated. The nurse performs a com­plete preoperative physical assessment to obtain baseline data. During physical assessment the nurse also identifies current health problems, potential complications related to the adminis­tration of anesthesia, and potential postoperative complications.

When beginning the assessment, the nurse obtains a com­plete set of vital signs. The nurse may need to obtain vital signs several times for accurate baseline values. Abnormal vi­tal signs may cause the postponement of surgery until the un­derlying problem is treated and the client’s condition is stable. The nurse also assesses for anxiety, which could increase blood pressure, pulse, and respiratory rate. These findings are documented in the chart as part of the overall assessment.

Throughout the physical assessment, the nurse focuses on problem areas identified from the client’s history and on all body systems affected directly or indirectly by the surgical procedure. The older adult (Chart 17-2; see also Chapter 5) or chronically ill client is at increased risk for intraoperative and postoperative complications. Perioperative morbidity and mortality are higher in older and chronically ill clients be­cause of their preoperative physical condition.

The nurse reports any abnormalities found on physical as­sessment to the physician and anesthesiology personnel. In this manner, the nurse functions as a proactive client advocate and is exercising professional legal responsibility. Often, es­tablished protocols or care maps identify what interventions are to be performed in the preoperative period.

CARDIOVASCULAR SYSTEM. Alterations in cardiac status are responsible for as many as 30% of perioperative deaths. The nurse evaluates the client for hypertension, which is common, is often undiagnosed, and can affect the response to surgery. Cardiovascular assessment also includes ausculta­tion of heart sounds for rate, regularity, and abnormalities. The nurse evaluates the client’s extremities for temperature, color, peripheral pulses, capillary refill, and edema. Any physical alterations, such as absent peripheral pulses, pitting edema, or cardiac symptoms, such as chest pain, shortness of breath, and dyspnea, are reported to the physician for further assessment and evaluation. (Cardiovascular assessment is dis­cussed further in Chapter 33.)

RESPIRATORY SYSTEM. In assessing the client’s respiratory status, the nurse considers the client’s age, smok­ing history, and the presence of any chronic illness. The nurse observes the client’s posture; respiratory rate, rhythm, and depth; overall respiratory effort; and lung expansion. Club­bing of the fingertips (swelling at the base of the nail beds caused by a chronic lack of oxygen) or any cyanosis is noted. The nurse auscultates the lungs to determine the quality and presence of any adventitious (crackles, wheezes, rubs) or ab­normal breath sounds.

RENAL/URINARY SYSTEM. Renal and urinary func­tion affects the filtration and eventual excretion of waste prod­ucts, including anesthetic and analgesic agents. If renal and urinary function is less than optimal, fluid and electrolyte bal­ance can be altered, especially in the older client. The nurse asks about the presence or absence of symptoms such as uri­nary frequency, dysuria (painful urination), nocturia (awak­ening during nighttime sleep because of a need to void), dif­ficulty starting urine flow, and oliguria (scant amount of urine). The client is asked about the appearance and odor of the urine. Equally important is an assessment of usual fluid intake and degree of continence. If the client is suspected of having underlying renal or urinary problems, the nurse con­sults with the physician about further workup. (Renal/urinary assessment is discussed further in Chapter 69.)

Abnormal renal function can decrease the excretion rate of preoperative medications and anesthetic agents. As a result, the drug’s effectiveness may be altered. Scopolamine (ВшсорапФ), morphine, meperidine (Demerol), and barbiturates frequently cause confusion, disorientation, apprehension, and restlessness when administered to clients with decreased renal function.

NEUROLOGIC   SYSTEM.   The  nurse  assesses   the client’s overall mental status, including level of consciousness, orientation, and ability to follow commands, before planning preoperative teaching and postoperative care. A deficit in any of these areas affects the type of care required during the periop­erative experience. The nurse determines the client’s baseline neurologic status to be able to identify changes that may occur later. The nurse also assesses for any motor or sensory deficits. (See Chapter 41 for complete nervous system assessment.)

The usual neurologic status of a mentally impaired or older client may be difficult to assess. The client who has been in­dependent and oriented while in the home environment may become disoriented in an unfamiliar hospital setting. Family members and significant others can often provide information about what the client was like at home.Often, as part of the neurologic assessment, the nurse as­sesses the client’s risk for falling, especially in older clients. Factors such as mental status, muscle strength, steadiness of gait, and sense of independence are evaluated to determine the client’s risk. The client’s ability to ambulate and his or her steadiness of gait are noted preoperatively as baseline data.

MUSCULOSKELETAL SYSTEM. Deformities of the musculoskeletal system may interfere with intraoperative and postoperative positioning. For example, clients with arthritis may be able to assume conventional intraoperative positions but have unnecessary discomfort postoperatively from pro­longed immobilization of joints. Other anatomic characteris­tics, such as the shape and length of the neck and the shape of the thoracic cavity, may interfere with respiratory and cardiac function or require special positioning during surgery.

The nurse asks about a history of joint replacements and notes the exact location of any prostheses. During surgery the nurse ensures that electrocautery pads, which could cause an electrical burn, are not placed near the area of the prosthesis.

NUTRITIONAL STATUS. Malnutrition and obesity can increase surgical risk. Surgery usually increases the body’s metabolic rate and consequently depletes potassium, ascorbic acid, and В vitamins, all of which are needed for wound heal­ing and fibrin formation. In malnourished clients, hypopro-teinemia slows postoperative recovery. Negative nitrogen bal­ance may result from depleted protein stores. This situation increases the risk for perioperative morbidity and mortalityfrom delayed wound healing, possible dehiscence or eviscer­ation (see Chapter 19), fluid volume deficit, and sepsis.

Some older clients may have nutritional imbalances be­cause of chronic illness, diuretic or laxative use, poor dietary planning or habits, anorexia, lack of motivation, or financial limitations. Clinical indications of poor fluid or nutritional status include brittle nails, muscle wasting, dry or flaky skin, hair alterations (e.g., dull, sparse, dry), decreased skin turgor, orthostatic (postural) hypotension, decreased serum albumin levels, and abnormal serum electrolyte values.

The obese client is often malnourished because of poor eating habits and an imbalanced diet. Obesity increases the risk for poor or incomplete wound healing because of exces­sive adipose tissue. Fatty tissue has poor vasculature, little collagen, and decreased nutrients, all of which are important for wound healing. Obesity causes increased stress on the heart and reduces the available lung volumes, which can af­fect the intraoperative experience and postoperative recovery. In addition, obese clients may require larger doses of medica­tion and retain them longer in their systems postoperatively.

■ PSYCHOSOCIAL ASSESSMENT

The nurse performs a psychosocial assessment and prepara­tion to determine the client’s level of anxiety, coping ability, and support systems; provide information; and offer support. Most clients scheduled for surgery experience some pre­operative anxiety and fear. The extent and type of these reac­tions vary according to the type of surgery, the perceived ef­fects of the surgery and its potential outcome, and the client’s basic personality. Surgery may be seen as a threat to biologic integrity, body image, self-esteem, self-concept, or lifestyle. Clients may fear death, pain, helplessness, decreased socioe-

conomic status, a diagnosis of life-threatening conditions, possible disabling or crippling effects, or the unknown.

The client’s anxiety and fear affect his or her ability to learn, cope, and cooperate with preoperative teaching and pe­rioperative procedures. Anxiety and fear may also influence the amount and type of anesthesia needed and may retard postoperative recovery. The nurse is aware of potential fears and anxieties when interviewing the client and planning pre­operative teaching.

The nurse assesses coping mechanisms used by the client under similar situations or in the past when confronted with a stressful situation. The nurse asks open-ended questions per­taining to the client’s feelings about the entire perioperative experience. Factors to be assessed that influence coping in­clude age; previous surgical or sick-role experiences; and emo­tional and physical signs of fear, anxiety, or discomfort. Signs of fear and anxiety include anger, crying, restlessness, di­aphoresis (sweating, usually profusely), increased pulse rate, palpitations, sleeplessness, diarrhea, and urinary frequency.

Ш LABORATORY ASSESSMENT

Preoperative laboratory tests provide baseline data about the client’s health and help predict potential complications. The client scheduled for surgery in an ambulatory surgical center or admitted to the hospital on the morning of or day before surgery may have preadmission testing performed from 48 hours to 28 days before the scheduled surgery, depending on the facility’s policy. The results of prior tests are usually valid unless there has been a change in the client’s condition that warrants repeated testing or the client is taking medications that can alter laboratory values (such as warfarin [Coumadin], aspirin, or diuretics).

The choice of routine preoperative laboratory tests varies among facilities and depends on the client’s age and medical history and the type of anesthesia planned. The most common tests are urinalysis, blood type and crossmatch, complete blood count or hemoglobin level and hematocrit, coagulation studies (prothrombin time [PT], International Normalized Ratio [INR], activated partial thromboplastin time [aPTT], and platelet count), electrolyte levels, and serum creatinine level. Depending on a female client’s age and the nature of the planned procedure, a pregnancy test may also be ordered.

A preoperative urinalysis is performed to assess for the presence of protein, glucose, blood, and bacteria, all of which are abnormal constituents of the urine. If renal disease is sus­pected or the client is older, the physician may order other tests to determine the type and degree of disease present.

The nurse reports electrolyte imbalances or other abnormal results to the anesthesia team and the surgeon before surgery. Hypokalemia (decreased serum potassium level) increases the risk of digoxin toxicity (if the client is taking digoxin), slows recovery from anesthesia, and increases cardiac irri­tability. Hyperkalemia (increased serum potassium level) in­creases the risk for cardiac dysrhythmias, especially with the use of anesthesia. Both hypokalemia and hyperkalemia should be corrected before the surgery.

The physician may order other studies, depending on the client’s medical history. For example, baseline arterial blood gas (ABG) values are assessed before surgery for clients with chronic pulmonary problems. Chart 17-3 presents abnormal laboratory findings and their possible causes.

Perioperative Assessment
			Significance of	Abnormal Findings
	Test	Normal Range for Adults	Increased in	Decreased in
	Potassium (K+) level	3.5-5.0 mEq/L, or 3.5-5.0	Dehydration	NPO status when potas-
		mmol/L	Renal failure	sium replacement is
			Acidosis	inadequate
			Cellular/tissue damage	Excessive use of
			Hemolysis of the specimen	non-potassium-sparing
				diuretics
				Vomiting
				Malnutrition
				Diarrhea
				Alkalosis
	Sodium (Na+)	Up to 90 yr: 136-145mEq/L,	Cardiac or renal failure	Nasogastric drainage
		or 136-145 mmol/L	Hypertension	Vomiting or diarrhea
		>90yr: 132-146 mEq/L, or	Excessive amounts of IV	Excessive use of laxatives
		132-146 mmol/L	fluids containing normal	or diuretics
			saline	Excessive amounts of IV
			Edema	fluids containing water
			Dehydration (hemoconcen-	Syndrome of inappropri-
			tration)	ate antidiuretic hor-
				mone (SIADH)
	Chloride (Сґ)	Up to 90 yr: 90-110mEq/L,	Respiratory alkalosis	Excessive nasogastric
		or 98-106 mmol/L	Dehydration	drainage
		>90 yr: 98-111 mEq/L, or	Renal failure	Vomiting
		98-111 mmol/L	Excessive amounts of IV	Excessive use of diuretics
			fluids containing sodium	Diarrhea
			chloride (NaCI)
	Carbon dioxide (CO2)	Up to 60 yr: 23-30mEq/L, or	Chronic pulmonary disease	Hyperventilation
		23-30 mmol/L	Intestinal obstruction	Diabetic ketoacidosis
		60-90 yr: 23-31 mEq/L, or	Vomiting or nasogastric	Diarrhea
		23-31 mmol/L	suctioning	Lactic acidosis
		>90 yr: 20-29 mEq/L, or	Metabolic alkalosis	Renal failure
		20-29 mmol/L		Salicylate toxicity
	Glucose (fasting)	Up to 60 yr: 70-105mg/dL,	Hyperglycemia	Hypoglycemia
		or 4.1-5.9 mmol/L	Excess amounts of IV fluids	Excess insulin
		60-90 yr: 82-115mg/dL, or	containing glucose
		4.6-6.4 mmol/L	Stress
		>90 yr: 75-121 mg/dL, or	Steroid use
		4.2-6.7 mmol/L	Pancreatic or hepatic
			disease
	Creatinine	Females:	Renal damage with de-	Atrophy of muscle tissue
		Up to 60 yr: 0.5-1.1mg/dL,	struction of large number
		or 53-97 (j-mol/L	of nephrons
		60-90 yr: 0.6-1.2mg/dL,	Renal insufficiency
		or 53-106 ixmol/L	Acute renal failure
		>90yr: 0.6-1.3mg/dL, or	Chronic renal failure
		53-115 цтоІ/L	End-stage renal disease
		Males:	(ESRD)
		Up to 60 yr: 0.6-1.2mg/dL,
		or 80-115(JLITIOI/L
		60-90 yr: 0.8-1.3mg/dL,
		ог71-115цлтаІЛ.
		>90 yr: 1.0-1.7mg/dL, or
		88-150 цлюІ/L
	Blood urea nitrogen	Up to 60 yr: 10-20mg/dL, or	Dehydration	Overhydration
	(BUN)	2.1-7.1 mmol/L	Renal failure	Malnutrition
		60-90 yr: 8-23 mg/dL, or	Excessive protein in diet
		2.9-8.2 mmol/L	Liver failure
		>90 yr: 10-31 mg/dL, or 3.6-
		11.1 mmol/L

 

■ RADIOGRAPHIC ASSESSMENT

A chest x-ray film, ordered by the physician or anesthesiol­ogist, is commonly obtained to determine the size and con­tour of the heart, lungs, and major vessels and to determine the presence of any infiltrates that could indicate pneumo­nia or tuberculosis. A chest x-ray study also provides base­line data in the event of postoperative complications. Ab­normal x-ray findings alert the physician to potential cardiac or pulmonary complications. The presence of con­gestive heart failure, cardiomyopathy, pneumonia, or infil­trates may cause cancellation or delay of elective surgery. For emergency surgery, x-ray results assist the anesthesiol­ogist in the selection of anesthesia. In many facilities, chest x-ray results are valid when done within 6 months before surgery, provided that there has not been a change in the client’s condition.

Other radiographic studies are based on individual need, the medical history, and the nature of the surgical procedure. For example, a client with back pain may have computed to­mography (CT) or magnetic resonance imaging (MRI) done

before a laminectomy (spinal surgery) to identify the exact location of the abnormality.

■  OTHER DIAGNOSTIC ASSESSMENT

An electrocardiogram (ECG) may routinely be required for all clients older than a specific age who are to have general anesthesia. The age varies among facilities but is often 40 to 45 years. An ECG may also be ordered for clients with a his­tory of cardiac disease or those at risk for cardiovascular complications. An ECG provides baseline information on new or pre-existing cardiac conditions, such as an old ante­rior wall myocardial infarction (MI). A client with a known cardiac condition may require a preoperative consultation with a cardiologist. Prophylactic medication, such as nitro-glycerin and antibiotics, may be needed during the perioper­ative period to reduce or prevent stress on the cardiovascular system. Abnormal or potentially life-threatening ECG results may cause the cancellation of surgery until the client’s car­diac status is stable.

INTERVENTION ACTIVITIES/or The Preoperative Client

As part of the cardiopulmonary assessment, take and record vital signs; report the following:

•  Hypotension or hypertension

•  Heart rate of less than 60 or more than 120 beats/min

•  Irregular heart rate

•  Chest pain

•  Shortness of breath or dyspnea

•  Tachypnea

•  Pulse oximetry reading of <94%

Assess for and report any signs or symptoms of infection, including the following:

•  Fever

•  Purulent sputum

•  Dysuria or cloudy, foul-smelling urine

•  Any red, swollen, draining IV or wound site

•  Increased white blood cell count

Assess for and report signs or symptoms that could con-traindicate surgery, including the following:

•  Increased prothrombin time (PT), International Normal­
ized Ratio (INR), or activated partial thromboplastin
time (aPTT).

•  Hypokalemia or hyperkalemia

•  Client report of possible pregnancy or positive preg­
nancy test

Assess for and report other clinical conditions that may need to be evaluated by a physician or advanced nurse practitioner before proceeding with the surgical plans, in­cluding the following:

•  Change in mental status

•  Vomiting

•  Rash

•  Recent administration of an anticoagulant medication

Analysis

• COMMON NURSING DIAGNOSES

The following are commoursing diagnoses for preopera­tive clients:

1.    Deficient Knowledge related to a lack of education
and lack of exposure to the specific perioperative ex­
perience

2. Anxiety related to the threat of a change in health status
or fear of the unknown

 ADDITIONAL NURSING DIAGNOSES

In addition to the commoursing diagnoses, preoperative clients may have one or more of the following:

•  Disturbed Sleep Pattern related to internal sensory alter­
ations (e.g., illness and anxiety)

•  Ineffective Coping related to the impending surgery

•  Anticipatory Grieving related to the effects of surgery

■ Disturbed Body Image related to anticipated changes in the body’s appearance or function

•  Disabled Family Coping related to temporary family dis­
organization and role changes

•  Powerlessness related to the health care environment,
loss of independence, and loss of control of one’s body

•  Interrupted Family Processes related to situational crisis

Preoperative Coordination: Facilitating preadmission diag­nostic testing and preparation of the surgical client

•  Review planned surgery.

•  Obtain client history, as appropriate.

•  Complete a physical assessment, as appropriate.

•  Describe and explain preadmission treatments and diag­
nostic tests.

•  Interpret diagnostic tests, as appropriate.

•  Determine the client’s expectations about the surgery.

•  Provide time for the client and significant other to ask
questions and voice concerns.

•  Discuss postoperative discharge plans.

•  Determine ability of caretakers.

• Planning and Implementation

■ DEFICIENT KNOWLEDGE

PLANNING: EXPECTED OUTCOMES. The preop­erative client is expected to verbalize and comply with preop­erative procedures and demonstrate techniques to prevent postoperative complications.

INTERVENTIONS. Interventions to increase the client’s knowledge level are listed in Chart 17-5. Because the periop­erative experience is foreign to many people, the nurse focuses on preoperative education of the client and family members. Preoperative teaching usually begins in the surgeon’s office for planned or elective surgery. Pamphlets, written instructions, and videotapes may be given and sent to the client as well. More teaching may occur when the client has preadmission testing. Some facilities conduct preoperative classes for groups of clients or have videos for those who are having the same or similar surgical procedures. A tour of the operating suite and the postanesthesia care unit (PACU) may be included.

Information about informed consent, dietary restrictions, preoperative preparation (bowel and skin preparations), postop­erative exercises, and plans for pain management promote clients’ participation and help achieve the desired outcome in their health care (see the Evidence-Based Practice for Nursing box on p. 248). A sample preoperative educational checklist is shown in Table 17-5. Because education occurs in a variety of settings, coordination of client teaching efforts is particularly challenging. The nurse who cares for the client immediately be­fore surgery (same-day, ambulatory surgery [outpatient] unit or inpatient hospital unit) assesses the client’s and family mem­ber’s knowledge and provides additional information as needed.

ENSURING INFORMED CONSENT. Surgery of any type involves invasion of the body and requires informed consent from the client or legal guardian (Figure17-1). Clients deserve, and rightly demand, to be informed and involved in decisions af­fecting their health care. Consent implies that one has been pro­vided with informatioecessary to understand the following:

• The nature of and reason for surgery

*  All available options and the risks associated with each
option

The primary purpose of this prospective experimental nursing study was to determine if preoperative teaching about the cor­rect use of a patient-controlled analgesia (PCA) pump system increased postoperative use of the system and increased clients’ pain control. A total of 76 adult surgical clients were enrolled in this study and randomly assigned to an interven­tion group or a control group. All clients completed a preoper­ative questionnaire regarding PCAs and pain control strate­gies. Intervention group clients received an intervention in the form of an 11 -minute instructional video and practice using a pump control button. The intervention took place in an ambu­latory surgery unit waiting area before preoperative medica­tions or surgical procedures were initiated. Clients in the con­trol group received no structured preoperative information regarding PCA equipment or function. The two groups were homogeneous with regard to age, gender, ethnicity, and the types of surgical procedures.

After surgery, data were collected from both groups using a post-test with the PCA questionnaire and an 11 -point scale to measure pain intensity. Pain intensity scores were obtained postoperatively at 4 hours, at 8 hours, and at the end of PCA therapy.

The pretest scores were not different between the two groups. The post-test scores were significantly different be­tween the two groups, with the intervention group showing greater understanding of pain management strategies. How­ever, clients in both groups scored poorly on the test item re­garding the use of pain medication before pain becomes se­vere. The intervention group had lower mean and median pain scores at all points after surgery than did the control group, al­though the differences did not reach statistical significance.

Critique. The study was well designed and well controlled. The finding that even the clients who received the intervention were unsure about using medication before the pain becomes severe indicates the need for clarifying this issue in the video­tape.

Implications for Nursing. Clients may be unfamiliar with the proper use of technical equipment designed to relieve postoperative pain. Timing the teaching about the equipment and providing time to practice using it before the client’s focus is interrupted by pain or anesthesia increase the likelihood that the teaching will be effective.

The physician is responsible for having the consent form signed before preoperative sedation is given and before sur­gery is performed. The nurse is not responsible for providing detailed information about the surgical procedure. Rather, the nurse clarifies facts that have been presented by the physician and dispels myths that the client or family may have about the perioperative experience. The nurse ensures that the consent form is signed and serves as a witness to the signature, not to

Consider the following items when planning individualized preoperative teaching for clients and families:

•  Fears and anxieties

•  Surgical procedure

•  Preoperative routines (e.g., NPO, enemas, blood samples,
showering)

•  Invasive procedures (e.g., lines, catheters)

•  Coughing, turning, deep breathing

•  Incentive spirometer

How to use

How to tell when used correctly

•  Lower extremity exercises

•  Stockings and pneumatic compression devices

•  Early ambulation

•  Splinting

•  Pain management

the fact that the client is informed. The surgeon is contacted and requested to see the client for clarification of information if the nurse believes that the client has not been adequately in­formed. The nurse documents this action in the chart.

Clients who cannot write may sign with an X, which must be witnessed by two persons. In an emergency, telephone or telegram authorization is acceptable and should be followed with written consent as soon as possible. The number of wit­nesses (usually two) and the type of documentation vary ac­cording to the facility’s policy. In a life-threatening situation in which every effort has been made to contact the person with medical power of attorney, consent is desired but not es­sential. In place of written or oral consent, written consulta­tion by at least two physicians who are not associated with the case may be requested by the physician. This formal consul­tation legally supports the decision for surgery until the ap­propriate person can sign a consent form. If the client is not capable of giving consent and has no family, the court can ap­point a legal guardian to represent the client’s best interests.

A blind client is capable of signing his or her own consent form, which usually needs to be witnessed by two persons. Clients who speak a language other than the general language of the agency require a translator and a second witness. Some fa­cilities have consent forms written in more than one language.

Some surgical procedures require a special permit in addi­tion to the standard consent. National and local governing bod­ies and the individual surgical facility determine which proce­dures require a separate permit. Intraocular lens implants, sterilization, and experimental procedures are examples of procedures for which the extra form is usually required. Sepa­rate consents for anesthesia and the administration of blood products may be required as well.

CLIENT SELF-DETERMINATION ACT. All individuals receiving medical care have the right to have or initiate ad­vance directives, such as living wills and durable power of at­torney, as mandated by the Patient Self-Determination Act. Advance directives provide legal instructions to the health care providers about the client’s wishes and are to be fol­lowed. Surgery does not provide an exception to a client’s ad­vance directives or living will tricted to nothing by mouth (NPO) for 6 to 8hours before surgery. NPO means no eating, drinking (including water), or smoking (nicotine stimulates gastric secretions). It is common practice to begin NPO status for all preoperative clients at mid­night on the night before surgery. This extra precaution en­sures that the stomach contains a limited volume of gastric se­cretions, which helps decrease the possibility of aspiration. Outpatients and clients who are scheduled for admission to the hospital on the same day that surgery is performed must re­ceive written and oral instructions about remaining NPO after midnight. The nurse emphasizes the importance of compli­ance; failure to comply can result in cancellation of surgery or an increased risk of intraoperative or postoperative aspiration.

ADMINISTERING REGULARLY SCHEDULED MED­ICATIONS. On the day of surgery, the client’s usual medica­tion schedule may need to be altered. The nurse consults the medical physician and the anesthesiologist for instructions about administration of medications, such as those taken for diabetes mellitus, cardiac disease, or glaucoma, as well as regularly scheduled anticonvulsants, antihypertensives, anti­coagulants, antidepressants, or corticosteroids. The physician may order some medications, including over-the-counter medications, such as aspirin, to be stopped until after surgery. The physician may order other medications to be adminis­tered by the intravenous (IV) route to maintain the level of the medication in the blood. Medications for cardiac disease and hypertension are commonly allowed with a sip of water if taken at least 2 hours before surgery. Some antihypertensive or antidepressant medications may be withheld on the day of surgery because of a possible adverse effect on the blood pressure intraoperatively.

The client with diabetes who is taking insulin may be given a reduced dose of intermediate- or long-acting insulin on the basis of the serum glucose level, or he or she may be given regular (fast-acting) insulin subcutaneously in divided doses on the day of surgery. An alternative method of diabetes management is an IV infusion of5% dextrose in water given with the insulin to prevent hypoglycemia intraoperatively. Because of numerous treatment approaches to diabetes, the

nurse clarifies medication and IV orders with the physician. (More information about the client with diabetes is found in Chapter 65.)

GASTROINTESTINAL PREPARATION. Bowel or gas­trointestinal (GI) preparation procedures are performed to prevent injury to the colon and to reduce the number of intes­tinal bacteria. Evacuation of the GI tract is done when a client is having major abdominal, pelvic, perineal, or perianal sur­gery. The surgeon’s preference and the type of surgical proce­dure determine the type of bowel preparation. Table 17-6 shows typical GI preparation regimens for common surgical procedures and complications of the regimens. An enema or­dered to be given until return flow is clear is a physically stressful procedure for anyone, but especially for the older client. Repeated enemas can cause electrolyte imbalance (es­pecially potassium depletion), fluid volume deficit, vagal stimulation, and postural (orthostatic) hypotension. Enemas also cause severe anorectal discomfort in clients with hemor­rhoids. To prevent complications, some physicians prescribe potent laxatives (e.g., polyethylene glycol electrolyte solution [GoLYTELY]) instead of enemas, especially for older clients. Bowel preparation procedures can be exhausting, and the nurse takes safety precautions to prevent falls.

SKIN PREPARATION. The skin preparation may be em­barrassing or uncomfortable for the client, especially if the surgical site is in a sensitive or generally private body area. The nurse provides a warm, comfortable, and private environ­ment during the procedure.

The skin is the body’s first line of defense against infec­tion. A break in this protective mechanism increases the risk of infection, especially for older clients. Preoperative skin preparation is the initial step in the prevention of wound in­fection. One or two days before the scheduled surgery, the surgeon may require the client to shower using an antiseptic solution such as povidone-iodine (Betadine) or hexa-chlorophene. The physician may want the client to be espe­cially attentive to cleaning around the proposed surgical site. If the client is hospitalized before surgery, the showering and cleaning is often repeated the night before surgery or in the morning before transfer to the surgical suite. This cleaning re­duces contamination of the surgical field, as well as the num­ber of microorganisms on the surgical field. After the final cleaning procedure, especially for an orthopedic surgical pro­cedure, the area may be covered with sterile towels or drapes to prevent contamination.

A controversial step in preoperative skin preparation after the cleaning or showering is the shave. Many health care prac­titioners believe that the shaving procedure itself is a possible source of contamination of the surgical area and traumatizes the skin around the area where the incision will be made. Those factors believed to predispose the client to wound con­tamination include bacteria found in hair follicles, disruption of the normal protective mechanisms of the skin, and nicks in the skin (e.g., from shaving). Shaving of hair creates the po­tential for infection. Clipping of the hair with electrical surgi­cal clippers is becoming increasingly popular to decrease the complications associated with traditional razors. In the United States the Centers for Disease Control and Prevention (CDC) recommend that if shaving is necessary, the hair should be re­moved using disposable sterile supplies and aseptic principles immediately before the start of the surgical procedure. Thuspreparations for shaving are performed in the treatment room, the holding area of the operating suite, or the operating room (OR). Figure 17-2 shows areas shaved for various surgical procedures. Shaving of hair, especially from the head or gen­ital area, can be emotionally upsetting to the client, and re-growth of this hair can be uncomfortable.

PREPARING THE CLIENT FOR TUBES, DRAINS, AND INTRAVENOUS ACCESS. The nurse prepares the client for possible insertion of tubes, drains, and IV access devices. Preparation reduces the client’s postoperative anxiety and fear, and the family’s negative reaction. The nurse is careful not to scare the client while providing information about the purpose of each tube.

TUBES. The client may require an indwelling urinary (Foley) catheter before, during, or after surgery to keep the bladder empty and to enable monitoring of renal function. The client having major abdominal or genitourinary surgery usually has a Foley catheter.

A nasogastric tube may be inserted before emergency sur­gery or major abdominal surgery for decompressing or emp­tying the stomach and the upper bowel. More often, however, the tube is inserted after the induction of anesthesia, when in­sertion is less disturbing to the client and is easier to perform.

DRAINS. Drains are frequently inserted during surgery to promote the evacuation of fluid from the surgical site. Some drains are under the dressing, whereas others are visible and require emptying. Drains come in various shapes and sizes (see Chapter 19). The nurse informs the client that drains are often used routinely and that generally they are not painful but may cause some discomfort. The nurse further discusses the reasons why they should not kink or pull on the drain.

INTRAVENOUS ACCESS. An IV access (line) is placed by the nurse or anesthesia personnel for all clients receiving general anesthesia and most clients receiving other types of anesthesia. An access is needed to administer medication and

fluids before, during, and after surgery. Clients who are dehy­drated or who are at risk for dehydration, such as older clients, may receive fluids before surgery.

 CONSIDERATIONS FOR OLDER ADULTS

WB Older clients are more susceptible to dehydration be­cause their fluid reserves are lower than those of young or middle-aged adults. Careful monitoring is required for older clients and for clients with cardiac disease who are receiving IV fluids. (See Chapter 14 for more information on IV therapy.)

The IV access is usually placed in the arm or the posterior aspect of the hand using a large, short catheter (e.g., 18-gauge, 1-inch catheter). This type of catheter provides the least resistance to fluid or blood infusion, especially in an emergency when rapid infusions may be necessary. Depend­ing on the individual client’s needs and the facility’s policies and practices, the IV access can be placed before surgery when the client is in the hospital room, in the holding or ad­mission area of the surgical suite, or in the OR.

 

Forearm, elbow, or hand surgery

Thoracoabdominal surgery

Head surgery

Unilateral chest surgery

 

 

 

 

Gynecologic surgery

Genitourinary surgery

Thigh and legsurgery

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 TEACHING ABOUT POSTOPERATIVE PROCEDURES AND EXERCISES. The nurse instructs the client and family members about postoperative exercises and procedures (e.g., checking dressings and obtaining vital signs frequently). Pre­operative teaching reduces apprehension and fear, increases cooperation and participation in postoperative care, and de­creases the incidence and severity of postoperative complica­tions. When the fear or anxiety level is high, however, the nurse explores the client’s attitudes and feelings before dis­cussing procedures (Cipperley, Butcher,& Hayes, 1995). Dis­cussion, demonstration, and return demonstration and practice by the client aid in the ability to perform various breathing (Chart 17-6) and leg (Chart 17-7) exercises during postopera­tive recovery. The nurse emphasizes the need to begin exer­cises early in the recovery phase and to continue them, with five to ten repetitions each, every 1 to 2 hours after surgery for at least the first 48 hours. The nurse also explains that the client may need to be awakened for these activities.

BREATHING EXERCISES. In deep, or diaphragmatic, breathing, the diaphragm flattens during inspiration, enlarg­ing the upper abdominal cavity. During expiration the ab­dominal muscles and diaphragm contract, which completely expands the lungs. After the nurse demonstrates and explains the technique, the client is encouraged to practice the five steps of deep breathing.

For clients with chronic pulmonary disease or limited up­per chest expansion, as seen in older clients because of the ag­ing process, expansion breathing exercises are useful. For the client having thoracic surgery, expansion breathing exercises strengthen accessory muscles and should be initiated preoper-atively. Expansion breathing may be used postoperatively during chest physiotherapy (percussion, vibration, and pos­tural drainage) to assist with loosening secretions and main­taining an adequate air exchange.

INCENTIVE SPIROMETRY. Incentive spirometry is an­other way to encourage the client to take deep breaths. Its pur­pose is to promote complete lung expansion and to prevent respiratory complications. Various types of incentive spirom-eters are available; some examples are shown in Figure 17-3.

With all types, the client must be able to seal his or her lips tightly around the mouthpiece, inhale spontaneously, and hold his or her breath for 3 to 5 seconds to achieve effective lung expansion. Goals (e.g., attaining specific volumes) can be set according to the client’s ability and the type of incentive spirometer. Visualization through seeing a light move up a column or a bellows expanding often reinforces and motivates the client to continue performance.

COUGHING AND SPLINTING. Coughing may be per­formed in conjunction with deep breathing every 1 to 2 hours postoperatively. The purposes of coughing are to promote ex­pectoration of secretions, keep the lungs clear, allow full aer­ation, and prevent pneumonia and atelectasis. Coughing may be uncomfortable for the client, but when performed cor­rectly, it should not harm the surgical area. Splinting (e.g., holding) the incision area provides support, promotes a feel­ing of security, and reduces pain during coughing. The proper technique for splinting the incision site and coughing is de­scribed in Chart 17-6. A folded bath blanket is helpful to use as a splint.

Some practitioners think that coughing exercises should no longer be encouraged routinely. Their belief is that coughing has the potential to harm the surgical wound and that it would be better to emphasize other, safer measures for pulmonary hygiene, such as deep breathing and incentive spirometer exercises. When routine coughing exercises are contraindicated for a client, such as after a hernia repair, the physician usually writes a “do not cough” order.

LEG PROCEDURES AND EXERCISES. Antiembolism stockings (TED or Jobst stockings), elastic (Ace) wraps, or pneumatic compression devices (e.g., “sequentials” or “boots”) may be used perioperatively in combination with leg exercises and early ambulation to promote venous return. Ve­nous stasis can lead to deep vein thrombosis (DVT) or a pul­monary embolus (PE) if the blood clot breaks off and travels to the lungs. Interventions depend on the client’s risk factors.Clients at greater risk for DVT:

•  Are obese

•  Are older than 40 years of age

•  Have a concurrent diagnosis of cancer

•  Have decreased mobility or immobility

•  Have a fracture or leg trauma

•  Have a history of DVT, PE, varicose veins, or edema

•  Are taking estrogen or oral contraceptives

•  Smoke

•  Have decreased cardiac output

•  Are undergoing pelvic surgery

Antiembolism Stockings and Elastic Wraps. Stock­ings and elastic wraps provide graduated compression of the lower extremities, starting distally at the foot and ankle. The nurse measures the client’s leg length and circumference and orders the appropriate stocking size. Elastic wraps are used when the legs are too large or too small for the stockings. The nurse assists the client in applying the devices and ensures that they are neither too loose (are ineffective) nor too tight (inhibit blood flow). They also need to be worn as ordered to be effective and should be removed one to three times per day for 30 minutes for skin care and inspection.

Pneumatic Compression Devices. Pneumatic com­pression devices enhance venous blood flow by providing in­termittent periods of compression on the lower extremities. The nurse measures the client’s legs and orders the appropri­ate size. The nurse places the boots on the client’s legs and sets and checks the prescribed or recommended compression pressures (often 35 to 55 mm Hg). Figure 17-4 shows various types of sequential devices. Antiembolism stockings may be worn in addition to the boots and may alleviate some of the uncomfortable sensations associated with the boots (e.g., itch­ing, sweating, heat).

Leg Exercises. Leg exercises also promote venous re­turn. The nurse teaches the postoperative leg exercises out­lined in Chart 17-7 and then encourages the client to practice these exercises preoperatively. The exercises are important, even when the other devices are being used.

EARLY AMBULATION. Mobility soon after surgery (early ambulation) stimulates gastrointestinal motility, enhances lung expansion, mobilizes secretions, promotes venous return, pre­vents rigidity of joints, and relieves pressure. In general, the nurse instructs the client that he or she should turn at least every 2 hours after surgery while confined to bed. To aid clients, the nurse teaches them how to use the bed siderails safely for turning and how to protect the surgical wound (splinting) when turning. The nurse assures clients that assis­tance and pain medication will be given as needed to alleviate any anxiety and pain they may have in relation to this activity.

CLIENT EDUCATION GUIDE vPostoperative Leg Exercises

 

Exercise No. 1

1. Lie in bed with the head of your bed elevated to about
45 degrees. [Using semi-Fowler’s position during post­
operative leg exercises improves peripheral circulation,
prevents thrombus formation, and strengthens muscles.]

2. Beginning with your right leg, bend your knee, raise your
foot off the bed, and hold this position for a few sec­
onds.

3. Extend your leg by unbending your knee, and lower the
leg to the bed.

4. Repeat this sequence four more times with your right
leg, then perform this same exercise five times with your
left leg.

Exercise No. 2

1.Beginning with your right leg, point your toes toward the
bottom of the bed.

2.With the same leg, point your toes up toward your face.

3.Repeat this exercise several times with your right leg,
then perform this same exercise with your left leg.

Exercise No. 3

1.Beginning with your right leg, make circles with your an­
kles, first to the left, then to the right.

2.Repeat this exercise several times with your right leg,
then perform this same exercise with your left leg.

Exercise No. 4

1.Beginning with your right leg, bend your knee and push
the ball of your foot into the bed or floor until you feel
your calf and thigh muscles contracting.

2.Repeat this exercise several times with your right leg,
then perform this same exercise with your left leg.

For certain surgical procedures, such as some brain, spinal, and orthopedic procedures, the physician may order turning restrictions. The nurse discusses with the physician other in­terventions to prevent complications associated with immo­bility in clients with turning restrictions. The nurse informs the client of anticipated turning restrictions during preopera­tive teaching.

Many clients are allowed and encouraged to get out of bed the day of or the day after surgery. The nurse assists the client into a chair or with ambulation after the surgery or the next day, depending on the type and time of surgery and the physician’s preference. If a client must remain in bed, he or she must turn, deep breathe, and perform leg exercises at least every 2 hours to prevent the complications of postoperative immobility.

RANGE-OF-MOTION EXERCISES. Passive or active range-of-motion (ROM) exercises help prevent joint rigidity and muscle contracture. The client should do these exercises three to five times each, three to four times a day while bedridden. The nurse instructs the client in these procedures and informs the client that he or she will receive assistance as needed postoperatively.

PLANNING: EXPECTED OUTCOMES. The preop­erative client is expected to verbalize decreased or manage­able preoperative anxiety and demonstrate evidence of relax­ation when at rest.as restlessness and sleepless­ness. The surgical client perceives the perioperative experience

Figure 17-3 • Examples of volume incentive spirometers for lung expansion. A, A volume dis­placement incentive spirometer. B, A volumetric incentive spirometer. (Courtesy DHD Healthcare, Canastota, NY.)

 

Figure 17Examples of external peumatic compres­sion devices used to promote venous return and prevent deep vein thrombosis (DVT). A, Kendall SCD machine, sleeves, and TED stockings. B, Venodyne pneumatic compression system. C, Flowtron DVT calf garments. (A courtesy Kendall Healthcare Company; В courtesy Venodyne, Inc.; С courtesy Huntleigh Healthcare.)

INTERVENTIONS. Preoperative anxiety frequently causes physical symptoms such as a threat to biopsychosocial integrity. The nurse first assesses the client’s level of anxiety, as discussed earlier under Psy-chosocial Assessment, p. 244. Interventions such as teaching and communicating with the client preoperatively, enabling the client to use previously successful coping mechanisms, and administering antianxiety agents help to reduce the anxi­ety and subsequent complications. The nurse incorporates ap­propriate and available support systems into the plan of care.

PREOPERATIVE TEACHING. The nurse assesses the client’s knowledge about the perioperative experience that he or she has acquired from prior surgical experiences and pro­cedures and from other sources (see earlier discussion under Deficient Knowledge, p. 247). Factual information about the surgery and the perioperative experience is provided to pro­mote the client’s understanding. Ample time is allowed for questions. The nurse responds to the questions appropriatelyand accurately and refers unanswered questions to the proper person. During the discussion, the nurse continually assesses the client’s responses and anxiety level. The nurse must be careful not to provide information that might increase anxiety. Clients have ranked psychosocial support as the most impor­tant component during preoperative teaching. The informed, educated client is better able to anticipate events and maintain self-control and is thus less anxious.

ENCOURAGING COMMUNICATION. Stating feelings, fears, and concerns is an appropriate way to reduce anxiety. The nurse develops a trusting relationship with the client so that he or she can express feelings freely without fear of ridicule or judgment. The nurse keeps the client informed, clarifies information, answers questions, and allays some ap­prehensions about the surgery.

PROMOTING REST. The stress and anxiety of impending surgery frequently interfere with the client’s ability to sleep and rest the night before surgery. The preoperative experience is physically and emotionally stressful. To assist the client in relaxing, the nurse determines what the client usually does to relax and fall asleep. If permitted and able, the client is en­couraged to continue these methods of relaxation. A back rub is a relaxing and therapeutic measure and can be performed by a nurse or family member. The physician may prescribe a sedative or short-acting hypnotic to ensure that the client is well rested for surgery.

USING DISTRACTION. The nurse may plan distraction as an intervention for anxiety. Especially in the 24 hours imme­diately before surgery, listening to music or audiotapes may decrease anxiety, as may watching television, reading, or vis­iting with family members.

TEACHING FAMILY AND SIGNIFICANT OTHERS. The

nurse assesses the readiness and desire of the family or sig­nificant others to take an active part in the client’s care. The involved family provides support and helps reduce anxiety. A positive sign of family interest is members’ initiation of ques­tions about the perioperative experience. After family readi­ness is determined, the nurse keeps family members informed and encourages their involvement in all aspects of preopera­tive education. The nurse emphasizes the important role of the family preoperatively but guides discussions and practice sessions so that family members do not dominate the sessions. Family members can encourage and help the client practice postoperative exercises.

The nurse informs the family of the time for surgery, if known, and of any schedule changes. If the client is an outpa­tient, he or she and the family need clear directions regarding any specific night-before procedures, what time and where to report, and what to bring with them. The family is encouraged to stay with the client preoperatively for support.

Most families are anxious about the surgery planned for their loved one. To reduce their anxiety, the nurse explains the intraoperative and postoperative routine to them. The nurse explains that after the client leaves the hospital room or ad­mission area, there is usually a 30- to 60-minute preparation period in the operating area (holding room, treatment area, and so on) before the surgery actually begins. After surgery, the client is taken to the postanesthesia care unit (PACU) for 1 to 2 hours before returning to the hospital room or discharge area. The nurse instructs the family about the best place to wait for the client or surgeon according to the facility’s policy and the physician’s preference. Many hospitals and surgical centers have designated surgical waiting areas so that families can wait in comfortable surroundings and be easily located when the procedure is completed.

 CRITICAL THINKING CHALLENGE  The client, a 49-year-old single retired military nurse, has been waiting for 45 minutes to go into surgery for an emergency open reduction with internal fixation of her left an­kle. While visiting her friends out of town, she slipped on ice and fractured her ankle in multiple locations. The client is anx­ious about having surgery and her ability to get back home to her dog as scheduled before her fall. Her constant focus is on who will take care of her dog until she gets there. The medical record review documented that she minimized her preopera­tive teaching, since “I am a nurse” and appeared disinterested in the coughing and deep breathing exercises. During her pre­operative assessment, she almost forgets to tell you about her sensitivity to latex but remembers as she is being measured for antiembolism stockings.

•  As the preoperative nurse, how do you decrease this client’s
anxiety and assess her readiness for surgery?

•  What nursing diagnoses should be anticipated  in this
client’s care?

■    PREOPERATIVE CHART REVIEW

The nurse reviews the client’s chart to ensure that all docu­mentation, preoperative procedures, and orders are com­pleted. The nurse checks the surgical informed consent form and, if indicated, any other special consent forms to see that they are signed and dated, and that they contain the witnesses’ signatures. The nurse confirms that the scheduled procedure, including the identification of left versus right wheeces­sary, is what is listed on the consent form. Allergies must be noted according to facility policy. Accurate documentation of height and weight is important for proper dosage calculation of the anesthetic agents. The results of all laboratory, radio-graphic, and diagnostic tests should be on the chart; any ab­normal results are documented and reported to the physician and the anesthesiologist or anesthetist. If the client is an auChapter 17   Interventions for Preoperative Clients tologous blood donor or has had directed blood donations made, those special slips must be included in the chart. The nurse records a current set of vital signs (within 1 to 2 hours of the scheduled surgery time) and documents any significant physical or psychosocial observations. The nurse reports spe­cial needs, concerns, and instructions (advance directives) to the surgical team. For example, the nurse advises the surgical team whether the client is a member of Jehovah’s Witnesses and does not accept blood products or whether the client is hard of hearing and does not have his or her hearing aid. This information assists the surgical team in providing continuity of care while the client is in the surgical area.

The removal of fingernail polish or artificial nails is con­troversial. Polish is flammable, and artificial nails may affect the accuracy of pulse oximetry readings. In some facilities at least one artificial nail must be removed for this reason.

After the client is prepared for surgery and the operating suite is ready to receive him or her, the nurse asks the client to empty his or her bladder to prevent incontinence or overdistention and to provide a starting point for intake and output measurement. An overly full bladder may hinder ac­cess to the surgical site. The nurse answers any final ques­tions, offers reassurance as needed, and administers any or­dered preoperative medication.

 CRITICAL THINKING CHALLENGE

You are about to send the client, described in the ear­lier Critical Thinking Challenge (p. 256) to the surgical suite.

•  How should you communicate this client’s allergies?

•  What interventions to prevent deep vein thrombosis {DVT}
should be used with this client?

. http://www.wbsaunders.com/SIMON/lggy/.

Ш PREOPERATIVE CLIENT PREPARATION

Facilities generally require that the client remove most cloth­ing and wear a hospital gown into the operating room (OR). Underwear may be permitted for surgery above the waist; socks may be worn, except for foot or leg surgery. If ordered by the surgeon, antiembolism stockings are applied preopera-tively. In some ambulatory settings, such as for cataract sur­gery, minimal clothes are removed.

Clients are often advised to leave all valuables at home. If the client has valuables, including jewelry, money, and clothes, they are typically given to a family member or locked in a safe place, according to the facility’s policy. The nurse tapes in place rings that cannot be removed. All pierced jew­elry is removed. Religious emblems may be pinned or fas­tened securely to the client’s gown; in some facilities, paper emblems are available from a religious leader.

The client wears an identification band that clearly gives his or her first and last name and hospital number. An optional bracelet, usually red, identifies any allergies. A bracelet des­ignating that a blood sample for type and crossmatch has been drawn may be worn, depending on the facility’s policy.

Dentures, including partial dental plates, are removed and placed in a labeled denture cup. The removal of dentures is a safety measure to prevent aspiration and obstruction of the airway. If a client has any capped teeth, the nurse documents this finding on the preoperative checklist.

All prosthetic devices, such as artificial eyes and limbs, are removed and given to a family member or safely stored, as are contact lenses, wigs, and toupees. The nurse checks for hair­pins and clips, which, if not removed, can conduct electrical current used during surgery and cause scalp burns.

Some facilities allow hearing aids in the surgical suite to facilitate communication before and after surgery. If the client is sent to surgery with a hearing aid, the nurse communicates this to the surgical nurse to prevent accidental loss of or dam­age to the device. Some facilities allow items such as den­tures, wigs, and glasses to be worn into the operating suite to prevent embarrassment to the client. These items can then be removed when absolutely necessary.

Ш. PREOPERATIVE MEDICATIONS

Preoperative medication may be ordered regardless of the type of planned anesthesia. Various preoperative medications reduce anxiety, promote relaxation, reduce pharyngeal secre­tions, prevent laryngospasm, inhibit gastric secretions, and decrease the amount of anesthetic required for the induction and maintenance of anesthesia. The selection of medication is based on the client’s age, physical and psychologic condition, medical history, and height and weight; the medications thatthe client takes routinely; the results of preoperative tests; and the type and extensiveness of the surgical procedure. If more than one pharmacologic response is required, combination therapy may be ordered. A typical combination consists of a sedative or tranquilizer, an opioid analgesic, and an anti-cholinergic agent.

The preoperative medication is often ordered when the client is “on call” to the surgical suite. After the nurse posi­tively identifies the client (using the arm band) and makes sure the operative permit is signed, the correct medication is ad­ministered. Then the nurse raises the siderails, places the call system within easy reach of the client while reminding him or her not to try to get out of bed, and places the bed in a low po­sition. The nurse tells the client that he or she may become drowsy and have a dry mouth as a result of the medication.

An increasingly common practice is for the premedication to be given after the client is transferred to the operating area. This practice permits the surgical team and anesthesia per­sonnel to make more accurate assessments and have last-minute discussions with a client not yet affected by medica­tion. In addition, after the client is in the operating area, medications can be given via the IV route. The oral or intra­muscular (IM) route is less desirable because of unpredictable absorption rates.

CLIENT TRANSFER TO THE SURGICAL SUITE

In the immediate preoperative preparation, the nurse reviews and updates the client’s chart, reinforces preoperative teach­ing, ensures that the client is appropriately dressed for sur­gery, and administers preoperative medication if ordered. The nurse uses a preoperative checklist to assist in a smooth, effi­cient transfer to the surgical suite (Figure 17-5). The client, along with the signed consent form, the completed preopera­tive checklist, the chart, and the Addressograph plate, is trans­ported to the surgical suite.

Most clients in the hospital setting are transferred to the surgical suite on a stretcher with the siderails up. In special circumstances (e.g., clients requiring traction, those having

NORTHWEST HOSPITAL CENTERPRE-OPERATIVE CHECKLIST Date of Surgery	Addressograph Plate
ALLERGIES
CLINICAL DATA:	YES	NO	COMMENTS
Authorization for Surqical Treatment Completed
Height & Weiqht Charted
History and Physical
Chest X-Rav
EKG Report
Urine Report
Blood Suqar Within Ranqe of (75-250mq%)
Hematocrit Within Ranqe of (27-55%)
Potassium Within Ranqe of (3.2-5.5mEq/L)
Results Out of Ranqe Reported to Dept. of Anesthesia
Anesthesioloqist                                                                Time:                                              By:
PATIENT PREPARATION:	YES	NO	COMMENTS
Jewelry Removed
Hair Piece, Wiq, Hairpin, Barrettes, Beads, Rubberbands Removed
Loose Teeth or Caps Noted
Dentures Removed
Artificial Eve, Contact Lenses, Glasses Removed
Any Prosthetic Appliance Removed
Voided or Catheterized – I&O Sheet on Chart
Identification Bracelet in Place
Parenteral Fluids Patent & Infusinq at          cc/hr
B/P, T.P.R. Charted
Premedication Given As Ordered
Side Rails Up-R. Care Data & Care Plan on Chart
Is Patient on Isolation – If Yes, What Type
COMMUNICATION ASSESSMENT:	Normal	Abnormal	COMMENTS
Vision
Hearing
Mental
Speech
Other
Patient’s Preferred Name:
Limb For Burial         П Yes     П No           Funeral Home:
R.N. Completing Checklist
702/1091-3-R-4/95  (40-1471)                                                                                                                                                                                                                                 pl/3133N

Figure 17-5    •    A preoperative checklist. (Courtesy Northwest Hospital Center, Randallstown, MD.)

orthopedic surgery, and those who should be moved as little as possible immediately after surgery) the client is transferred in his or her hospital bed. Other factors that influence the nurse’s decision to transfer in a bed are the client’s age, size, and physical condition. In ambulatory settings clients either walk or are transferred to the surgical suite on a stretcher or in a wheelchair.

‘Evaluation: Outcomes

The nurse evaluates the care of the preoperative client on the basis of the identified nursing diagnoses. The expected outcomes include that the client:

•  States that he or she understands informed consent as it
applies to surgery

•  Complies with the nothing-by-mouth (NPO) require­
ment before surgery

•  Verbalizes an understanding of and the reason for a
bowel preparation, if applicable

•  States the purpose of the skin preparation

•  Verbalizes an understanding of how tubes, drains, and IV lines and catheters may be used during and after surgery

•  Demonstrates  postoperative  exercises:   turning,  deep breathing, splinting, coughing, and performing specific leg exercises

•  Demonstrates the use of an incentive spirometer

•  States that preoperative anxiety is lessened after preoperative teaching

 

ONLINE RESOURCES:

1                         http://intranet.tdmu.edu.ua/data/kafedra/video/ims/ADN/second%20course/Adult%20Health%20I/index.php?name_film=Preoperative%20nursing%20care%20-%2012

2                         http://intranet.tdmu.edu.ua/data/kafedra/video/ims/ADN/second%20course/Adult%20Health%20I/index.php?name_film=Asepsis%20-%2011