Practice nursing care to Preoperative Clients

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 ever before.

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 intervention needed before surgery to reduce anxiety and postoperative complications and to promote cooperation in postoperative 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.

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, intracranial surgery, or heart surgery).

The extent can be simple, modified, or radical.

Table 17-1 explains the categories and gives examples of surgical procedures.

SELECTED CATEGORIES OF SURGICAL PROCEDURES

Category Description

Condition or Surgical Procedure

REASONS FOR SURGERY

Diagnostic Performed to determine the origin and cause of a disorder or the cell type for cancer

Curative Performed to resolve a health problem by repairing or removing the cause

Restorative Performed to improve a client's functional ability

Palliative Performed to relieve symptoms of a disease process, but does not cure

Cosmetic Performed primarily to alter or enhance personal appearance

Breast biopsy

Exploratory laparotomy Arthroscopy

Laparoscopic cholecystectomy

Mastectomy

Hysterectomy

Total knee replacement

Finger reimplantation

Colostomy Nerve root resection

Tumor debulking lleostomy

Liposuction Revision of scars

Rhinoplasty Blepharoplasty

URGENCY OF SURGERY

Elective Planned for correction of a nonacute problem

Urgent Requires prompt intervention; may be life threatening if treatment is delayed more than 24-48 hr

Emergent Requires immediate intervention because of life-threatening consequences

Cataract removal Hernia repair Hemorrhoidectomy Total joint replacement

Intestinal obstruction

Bladder obstruction

Kidney or ureteral stones

Bone fracture

Eye injury

Acute cholecystitis

Gunshot or stab wound Severe bleeding Abdominal aortic aneurysm Compound fracture Appendectomy

DEGREE OF RISK OF SURGERY

Minor Procedure without significant risk; often done with local anesthesia

Major

Procedure of greater risk, usually longer and more extensive than a minor procedure

Incision and drainage (I&D) Implantation of a venous access device (VAD) Muscle biopsy

Mitral valve replacement Pancreas transplant Lymph node dissection

EXTENT OF SURGERY

Simple Only the most overtly affected areas involved in the surgery

Radical Extensive surgery beyond the area obviously involved; is directed atfinding a root cause

Simple/partial mastectomy

Radical prostatectomy

Radical hysterectomyten,

Surgical Settings

The term inpatient refers to a client who is admitted to a hospital. The client may be admitted the day before or, more of 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 preparation because of decreased gastrointestinal motility. An infection may need to be treated before surgery.

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)

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.

NURSING FOCUS on the OLDER ADULT

Changes of Aging as Surgical Risk Factors

CARDIOVASCULAR SYSTEM

Decreased cardiac output

Increased blood pressure

Decreased peripheral circulation

Nursing Interventions

Determine normal activity levels and note when the client tires.

Monitor vital signs, peripheral pulses, and capillary refill.

Rationale

Knowing limits helps prevent fatigue.

Having baseline data helps detect deviations.

RESPIRATORY SYSTEM

Reduced viral capacity

Loss of lung elasticity

Decreased oxygenation of blood

Nursing Interventions

Teach coughing and deep breathing exercises.

Monitor respirations and breathing effort.

Rationale

Pulmonary exercises help prevent pulmonary complications.

Having baseline data helps detect deviations

RENAL/URINARY SYSTEM

Decreased blood flow to kidneys

Reduced ability to excrete waste products

Decline in glomerular filtration rate

Nocturia common

Nursing Interventions

Monitor intake and output.

Assess overall hydration.

Monitor electrolyte status.

Assist frequently with toileting needs, especially at night.

Rationale

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

Frequent toileting helps prevent incontinence and falls.

NEUROLOGIC SYSTEM

Sensory deficits

Slower reaction time

Decreased ability to adjust to changes in the surroundings

Nursing Interventions

Orient the client to the surroundings.

Allow extra time for teaching the client.

Provide for the client's safety.

Rationale

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.

MUSCULOSKELETAL SYSTEM

Increased incidence of deformities related to osteoporosis or arthritis

Nursing Interventions

Assess the client's mobility.

Teach turning and positioning.

Encourage ambulation.

Place on fall precautions, if indicated.

Rationale

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.

ANTIARRHYTHMICS

Quinidine gluconate

(Quinate, Quinaglute Dura-Tabs)

Procainamide hydrochloride (Pronestyl, Procan SR)

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 opioid analgesics by inhibiting synthesis and storage of norepinephrine.

Antihypertensives may cause a hypotensive crisis intra-operatively and postoperatively.

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)

Heparin sodium (Leo-Heparin, Нераlеаn)

Aspirin (acetylsalicylic acid, Ancasa,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, impaired vision, intense thirst

Boneset Liver toxicity, mental changes, respiratory problems

Coltsfoot Fever, liver toxicity

Dandelion Interactions with diuretics, increased concentration 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, potentiation of diabetes drugs

Ginseng Headache, anxiety, insomnia, hypertension, 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.

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.

NURSING FOCUS on the OLDER ADULT

Specific Considerations When Planning Care for the Older

Preoperative Client

Greater incidence of chronic illness Greater incidence of malnutrition More allergies

Increased incidence of impaired self-care abilities Inadequate support systems

Decreased ability to withstand the stress of surgery and anesthesia

Increased risk of postoperative cardiopulmonary complications

Risk of a change in mental status when admitted (related to unfamiliar surroundings, change in routine, medications administered, and so forth) Increased risk of a fall and resultant injury

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, hypoproteinemia slows postoperative recovery. Negative nitrogen balance may result from depleted protein stores. This situation increases the risk for perioperative morbidity and mortality from 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 socioeconomic 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.

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.

	LABORATORY PROFILE
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: 136-145 mEq/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: 90-110 mEq/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: 23-30 mEq/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: 70-105 mg/dL,	Hyperglycemia	Hypoglycemia
		or 4.1-5.9 mmol/L	Excess amounts of IV fluids	Excess insulin
		60-90 yr: 82-115 mg/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: 0.5-1.1 mg/dL,	struction of large number
		or 53-97 (j-mol/L	of nephrons
		60-90 yr: 0.6-1.2 mg/dL,	Renal insufficiency
		or 53-106 ixmol/L	Acute renal failure
		>90yr: 0.6-1.3 mg/dL, or	Chronic renal failure
		53-115 цтоІ/L	End-stage renal disease
		Males:	(ESRD)
		Up to 60 yr: 0.6-1.2 mg/dL,
		or 80-115 (jlitioI/L
		60-90 yr: 0.8-1.3 mg/dL,
		ог71-115цлтаІЛ.
		>90 yr: 1.0-1.7 mg/dL, or
		88-150 цлюІ/L
	Blood urea nitrogen	Up to 60 yr: 10-20 mg/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.

FOCUSED ASSESSMENT

of 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 Normalized Ratio (INR), or activated partial thromboplastintime (aPTT).

• Hypokalemia or hyperkalemia

• Client report of possible pregnancy or positive pregnancy 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 common nursing diagnoses for preoperative clients:

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

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

ADDITIONAL NURSING DIAGNOSES

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

• Disturbed Sleep Pattern related to internal sensory alterations (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 disorganization 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

INTERVENTION ACTIVITIES for The Preoperative Client

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 diagnostic 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.

NIC intervention activities selected from McCloskey, J.C., & Bulechek, G.M. (Eds.). (2000). Nursing interventions classification (NIC) (3rd ed.). St. Louis: Mosby. No part of this work is to be altered without prior written permission from the Publisher.

• 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.

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.

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 (Figure 17-1). Clients deserve, and rightly demand, to be informed and involved in decisions affecting their health care. Consent implies that one has been provided with information necessary to understand the following:

• The nature of and reason for surgery

All available options and the risks associated with each option

EVIDENCE BASED PRACTICE FOR NURSING

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.

Table 17-5 • PREOPERATIVE TEACHING CHECKLIST

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 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 8 hours 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 of 5% 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. Thus preparations for shaving are performed in the treatment room, the holding area of the operating suite, or the operating room (OR). 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.

Figure • Skin preparation of common surgical sites.

Shaded areas indicate areas of hair removal.

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.

Nasogastric tube

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

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.

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 and leg 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.

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.)

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

Postoperative Leg Exercises

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.

ANXIETY

PLANNING: EXPECTED OUTCOMES.

The preoperative client is expected to verbalize decreased or manageable preoperative anxiety and demonstrate evidence of relaxation when at rest.

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 Psychosocial Assessment. 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. 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 appropriately and 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 when necessary, 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 autologous 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 should be used with this client?

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.

. 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 that the 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. 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 CENTER PRE-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