Ch 17 preoperative care Flashcards
is the art and science of treating diseases, injuries, and deformities by operation and instrumentation.
Surgery
total surgical episode is called the. This period includes the time before surgery (preoperative period), the time spent during the actual surgical procedure (intraoperative period), and the period after the surgery is over (postoperative period).
perioperative period
an interprofessional team, including the patient, surgeon, anesthesia care provider (ACP), nurse, and other health care team members
surgical experience involves
Determine the presence and extent of a pathologic condition (e.g., lymph node biopsy, bronchoscopy).
Diagnosis:
Alleviate symptoms without cure (e.g., cutting a nerve root [rhizotomy] to reduce pain, creating a colostomy to bypass an inoperable bowel obstruction).
Palliation
Surgery may be a carefully planned event
elective surgery
may arise with unexpected urgency
emergency surgery
, patients who are going to be admitted to the hospital are usually admitted on the day of surgery (same-day admission).
inpatient surgery
Most surgical procedures are performed as ambulatory surgery (also called same-day or outpatient surgery).
ambulatory surgery
endoscopy clinics, physicians’ offices, freestanding surgical clinics, and outpatient surgery units in hospitals
Ambulatory surgery often occurs in
Patients require less than a 24-hour stay after surgery. Many go home with a caregiver within hours of surgery.
Ambulatory surgery length
and any co-morbidities.
first know the reason the patient is undergoing surgery
identify the individual patient’s response to the stress of surgery.
Second, (prep pt for surgery)
know the results of preoperative diagnostic tests.
Third (prep pt for surgery)
identify potential risks and complications associated with the surgical procedure and any special considerations that should be addressed in the plan of care.
Last (prep pt for surgery)
operating room (OR), postanesthesia care unit (PACU), surgical intensive care unit (SICU), or surgical unit
nurse caring for the patient before surgery is likely to be different from the nurse in the
can occur in advance or on the day of surgery
preoperative interview
(1) obtain the patient’s health information, including drug and food allergies; (2) provide and clarify information about the planned surgery, including anesthesia; and (3) assess the patient’s emotional state and readiness for surgery, including his or her expectations about the surgical outcomes.
primary purposes of the patient interview are to
age, past experiences with illness and pain, current health, and socioeconomic status.
Many factors influence the patient’s reaction to stress, including
(1) continuing therapy, (2) withholding therapy for a time before and after surgery, or (3) withholding the therapy and starting subcutaneous or IV heparin therapy during the perioperative period.
Pt with long-term anticoagulation’s before surgery options
• Avoid astragalus and ginseng, since they can increase BP before and during surgery.
• Avoid garlic, vitamin E, ginkgo, and fish oils because they can increase bleeding.
• Avoid kava and valerian because they can cause excessive sedation.
• In general, stop taking all herbs 2 to 3 weeks before any surgical procedure. Consult your HCP for specific instructions.
• Take multivitamins until the day before surgery. Taking them on the day of surgery on an empty stomach may contribute to nausea and vomiting after surgery.
ALERTS BEFORE SURGERY
tobacco, alcohol, opioids, marijuana, cocaine, and amphetamines.
substances Use include
use can place the patient at risk because of lung, GI, or liver damage
Chronic alcohol affect during surgery
prolongs the metabolism of anesthetic agents, alters nutritional status, and increases the potential for postoperative complications
Decreased liver function cause
usually results in side effects that are unpleasant for the patient but are not life threatening.
Drug intolerance defined
include nausea, constipation, diarrhea, or idiosyncratic (opposite than expected) reactions.
Drug intolerance effects example
those with a history of previous thrombosis, blood-clotting disorders, cancer, varicosities, obesity, tobacco use, heart failure, or chronic obstructive pulmonary disease (COPD)
Patients at high risk for VTE include
bronchospasm, laryngospasm, decreased O2 saturation, and problems with respiratory secretions.
postpone surgery if Upper airway infections may increase the risk for
history of dyspnea at rest or with exertion, coughing (dry or productive), or hemoptysis (coughing blood)
Alert for pts with
6 weeks before surgery
patient to stop smoking at least
This is due to the added stressors of the surgical procedure, dehydration, hypothermia, and anesthesia and adjunctive drugs.
cognitive function before and after surgery sign esp for older adults bc
This is due to the added stressors of the surgical procedure, dehydration, hypothermia, and anesthesia and adjunctive drugs.
factors may contribute to the development of emergence delirium, a condition that may be falsely labeled as senility or dementia.
including fluid and electrolyte imbalances, coagulopathies, increased risk for infection, and impaired wound healing. Because the kidneys metabolize and excrete many drugs, a decrease in renal function can lead to an altered response to drugs and unpredictable drug elimination. Renal function tests (e.g., serum creatinine, blood urea nitrogen [BUN]) are often done before surgery.
Renal dysfunction is associated with several problems
during the first trimester.
Maternal and fetal exposure to anesthetics should be avoided
glucose homeostasis, fat metabolism, protein synthesis, drug and hormone metabolism, and bilirubin formation and excretion
liver is involved in
for clotting abnormalities and adverse responses to drugs.
hepatic dysfunction may have an increased perioperative risk
jaundice, hepatitis, alcohol abuse, or obesity.
Consider the presence of liver disease if there is a history of
injections, IV sites, and laboratory draws.
skin- When possible, select pigment-free areas for
intubation and airway management may be difficult.
If the neck is affected,
Hypoglycemia, hyperglycemia, delayed wound healing, and infection are common
complications of diabetes during the perioperative period.
because of changes in metabolic rate. If the patient takes a thyroid replacement drug, check with the ACP about administering the drug on the day of surgery. If the patient has a history of thyroid dysfunction, laboratory tests may be done to determine current levels of thyroid function.
Hyperthyroidism or hypothyroidism can place the patient at surgical risk
can occur if a patient abruptly stops taking replacement corticosteroids. The patient may need additional IV corticosteroid therapy from the stress of surgery
Addisonian crisis or shock
Impairment of the immune system can lead to delayed wound healing and increased risk for infections
Corticosteroids used in immunosuppressive doses may be tapered before surgery.
may have surgery if needed.
Patients with active chronic infections such as hepatitis B or C, acquired immunodeficiency syndrome, or tuberculosis
vomiting, diarrhea, or completing a bowel prep.
-ask bout diuretics
increase the risk for fluid and electrolyte imbalances, such as
, place more padding than usual on the OR table
if the patient is thin
to allow time to obtain special equipment needed for the patient’s care (e.g., longer instruments for abdominal surgery).
patient is severely obese (body mass index [BMI] greater than 40 kg/m2)
It predisposes the patient to wound dehiscence, wound infection, and incisional herniation after surgery. Adipose tissue is less vascular than other types of tissue. The patient may be slower to recover from anesthesia because adipose tissue absorbs and stores inhalation agents, so they leave the body more slowly.
Obesity stresses the heart and lung systems and makes access to the surgical site and anesthesia administration more difficult
are particularly important because these substances are essential for wound healing
A, C, and B complex deficiencies
history and physical examination (H&P) in their chart.12 This may be done in advance of surgery or on the day of surgery.
Joint Commission requires that all patients admitted to the OR have a documented
Findings from the H&P enable the ACP to assign the patient a physical status
rating for anesthesia administration
It uses a scale of P1 to P6. A rating of P6 is reserved for a brain-dead patient undergoing organ procurement. Patients undergoing surgery in ambulatory or outpatient settings generally have ratings of P1, P2, or P3. Other designations can be added to the ASA status (e.g., “E” to designate an “emergent” procedure).
Rating range for anesthesia administration
sensory, process, and procedural.
preoperative teaching includes 3 types of information:
patients find out what they will see, hear, smell, and feel during the surgery
-For example, you may tell them that the OR will be cold, but they can ask for a warm blanket; the lights in the OR are bright; or many unfamiliar sounds and specific smells will be present.
sensory information,(preoperative teaching)
may not want specific details but just the general flow of what is going to happen.
-This information would include the patient’s transfer to the holding area, visits by the nurse and the ACP before transfer to the OR, and waking up in the PACU.
process information (preoperative teaching)
, patients desire details that are more specific.
procedural information
pulmonary aspiration and nausea and vomiting.
Restricting fluids and food is designed to reduce the risk for
is an active, shared decision-making process between the HCP and recipient of care.
Informed consent
. First, there must be adequate disclosure of the (1) diagnosis; (2) nature and purpose of the proposed treatment; (3) risks and consequences of the proposed treatment; (4) probability of a successful outcome; (5) availability, benefits, and risks of alternative treatments; and (6) prognosis if treatment is not instituted.
Three conditions must be met for consent to be valid
, the patient must show a clear understanding of the information before receiving sedating preoperative drugs. If a patient is sedated prior to signing the consent, surgery may be cancelled or delayed
Second conditions must be met for consent to be valid
, the recipient of care must give consent voluntarily. The patient must not be persuaded or coerced in any way by anyone to undergo the procedure.
Third conditions must be met for consent to be valid
a legally appointed representative or responsible family member may give written permission.
If the patient is a minor, unconscious, or mentally incompetent to sign the permit,
is one who is younger than the legal age of consent but is recognized as having the legal capacity to provide consent.
emancipated minor
is to witness the signing of the document. This means that as a nurse, you attest to the fact that the patient’s signature was valid.
(consent) most states, the registered nurse’s legal role
next of kin may give consent when immediate medical treatment is necessary to preserve life or prevent serious impairment to life or limb and the patient is incapable of giving consent. If reaching the next of kin is not possible, the HCP may begin treatment
Emergency surgery rules about consent
note in the chart must document the medical necessity of the procedure. In the case of an emergency in which consent cannot be obtained, you will usually need to complete an event report because it is an occurrence that is inconsistent with routine agency practices.
emergency surgery without consent requirements
immediately before surgery include final preoperative teaching, assessment, and communication of pertinent findings. In addition, ensure that all preoperative orders are done and that the chart is complete and goes with the patient to the OR. It is especially important to verify the presence of a signed informed consent form, results of laboratory and diagnostic studies, an H&P, a record of any consultations, baseline vital signs, proper skin preparation, and completed nursing notes. The surgical site is identified and marked with an indelible marker by the surgeon and documented to show that the patient agrees
Nurses role on day of surgery
empty bladder prevents involuntary elimination under anesthesia and reduces the risk for urinary retention during the early postoperative recovery.
encourage pts to void before surgery
Benzodiazepines are used for their sedative and amnesic properties. Anticholinergics are sometimes given to reduce secretions. Opioids may be given to decrease pain and anesthetic requirements during surgery. Antiemetics can decrease nausea and vomiting.
medications given during preoperative
Other drugs that may be given before surgery include antibiotics, eyedrops, and routine prescription drugs. Antibiotics may be given throughout the perioperative period for patients with a history of prosthetic heart valve to prevent infective endocarditis and for patients with previous joint replacement. They also may be given when wound contamination is a potential risk (e.g., GI surgery).
other drugs given preoperative surgery
receive β-adrenergic blockers (β-blockers) to control BP or reduce the chances of MI and cardiac arrest.
People with known hypertension or coronary artery disease may
insulin in the preoperative period.1
diabetes are carefully monitored and may receive
Many times, the patient will need multiple sets of eyedrops given at 5-minute intervals
Eyedrops are often given prior for the patient undergoing cataract and other eye surgery.
a small sip of water 60 to 90 minutes before the patient goes to the OR unless otherwise ordered
Provide PO drugs with
and IV drugs are usually given to the patient after arrival in the preoperative holding area
Subcutaneous injections (e.g., insulin)
Older adults may have some sensory deficits. Bright lights may bother those with eye problems. They can have reduced vision and hearing. Thought processes and cognitive abilities may be slowed or impaired.
Older adults
one’s expression of pain, family expectations, and ability to verbally express needs
culture often determines
