Preoperative Nursing

Management
CHAPTER 14

Dr. Yahia AL-Helih

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Page: 1188
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What do you think??

Communication, teamwork, and

patient assessment are essential
to ensure good patient outcomes
in the perioperative setting

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Perioperative Nursing
perioperative phase: period of time
that constitutes the surgical
experience; includes the preoperative,
intraoperative, and postoperative
phases of nursing care

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 The preoperative phase begins when the
decision to proceed with surgical intervention
is made and ends with the transfer of the
patient into the operating room (OR) bed.

The intraoperative phase begins when the

Perioperativ patient is transferred onto the OR bed and
e Nursing ends with admission to the post-anesthesia
care unit PACU.

The postoperative phase begins with the

admission of the patient to the PACU and ends
with a follow-up evaluation in the clinical
setting or home

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Advances in Surgical and Anesthesia Approaches

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Advances in Surgical and Anesthesia Approaches

Technologic advancements continue to lead health care industry

providers toward performing more complex procedures that are less
invasive, and therefore cause less morbidity during the recovery
phase of surgery.

Minimally invasive and robotic surgeries are continuing to replace

traditional surgical procedures. Advancements in surgical technology
allow for shorter hospital stays and promote patient comfort

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Advances in Surgical and Anesthesia Approaches

Advantages
 Modern methods of achieving airway patency, sophisticated
monitoring devices, and new pharmacologic agents, such as short-
acting anesthetics, have created a safer atmosphere in which to
operate.
 Effective antiemetic's have reduced postoperative nausea and
vomiting (PONV).
 Improved postoperative pain management and shortened
procedure and recovery times have improved the operative
experience for surgical patients.

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 Surgical Classifications
The decision to perform surgery may be based on
facilitating a diagnosis or its urgency:
Diagnostic procedure (e.g., biopsy, laparotomy, or
laparoscopy).
Cure (excision of a tumor or an inflamed appendix)
Repair (e.g., multiple wound repair).
Reconstructive or cosmetic (e.g., mammoplasty or a
facelift).
Palliative (e.g., to relieve pain or correct a problem—
such as debulking a tumor to achieve comfort).
Rehabilitative (e.g., total joint replacement) 9
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 Preoperative Phase
Preadmission Testing
1. Performs initial preoperative assessment.
2. Initiates education appropriate to patient’s
needs.
3. Involves family in interview.
4. Verifies completion of preoperative diagnostic
testing according to patient’s needs.
5. Confirms understanding of surgeon-specific
preoperative prescribed therapies (e.g., bowel
preparation, preoperative shower).
6. Discusses and reviews advance directive
document.
7. Begins discharge planning by assessing
patient’s need for postoperative
transportation and care 11
Preoperative Phase Preadmission Testing

1. Completes preoperative assessment

2. Assesses for risks for postoperative complications
3. Reports unexpected findings or any deviations from normal
4. Verifies that operative consent has been signed
5. Coordinates patient education and plan of care with nursing
staff and other health team members
6. Reinforces previous education
7. Explains phases in perioperative period and expectations
8. Answers patient’s and family’s questions

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Preoperative Phase (in the preoperative area)

1. Identifies patient
2. Assesses patient’s physical and emotional status, baseline pain, and
nutritional status
3. Reviews medical record
4. Verifies surgical site and that it has been marked per institutional
policy
5. Establishes IV line
6. Administers medications if prescribed
7. Takes measures to ensure patient’s comfort
8. Provides psychological support
9. Communicates patient and family’s needs to other appropriate
members of the health care team
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Special Considerations during the Perioperative Period
The Joint Commission and the Centers for Medicare and Medicaid
Services (CMS) developed National Patient Safety Goals. To reduce
surgical complications.

- The goals are updated yearly

- and identify performance measures aimed at preventing surgical

complications, including venous thromboembolism (VTE), surgical
site infections (SSIs), and wrong-site surgery related to positive
patient identification (Joint Commission, 2019).
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 Special Considerations during the
Perioperative Period

 On the day of surgery, the preoperative nurse should verify the list of
home medications or and the OTC with the patient and, if applicable:

 Confirm which medications the patient discontinued and when they were
last taken.

 This information assists providers in understanding the patient’s medical

conditions and helps to avoid medication interactions between what
patients take at home and what is administered to them during surgery

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Gerontology Considerations

Cardiac reserves are lower, renal and hepatic functions

are depressed, and gastrointestinal activity is likely to
be reduced. Therefore, a comprehensive assessment
that focuses on the cardiovascular, respiratory, and
renal systems may help improve immediate
perioperative outcomes

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Bariatric Patients
Bariatrics is a specialty that revolves around diagnosing,
treating, and managing patients with obesity.
Preoperative assessment of the patient with obesity should pay
careful attention to pulmonary, cardiovascular, psychological,
and integumentary systems.
Patients with obesity have more subcutaneous fat. The increase
in adipose tissue can result in difficult intravenous (IV) access
and delayed wound healing at the incision site
Obesity is also associated with increased SSIs and joint
replacement failure.
Those with (BMI) of greater than 45 are at a significantly
increased risk for total joint replacement failure and
postoperative infection 17
Patients Undergoing
Emergency Surgery

Emergency surgeries are unplanned and occur with

little time for preparation of the patient or the
perioperative team.
The unpredictable nature of trauma and emergency
surgery poses unique challenges throughout the
perioperative period.

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 Required Preoperative Documents
Informed consent

It is the patient’s autonomous decision about whether

to undergo a surgical procedure.

Voluntary and written informed consent from the

patient is necessary before nonemergent surgery can
be performed to protect the patient from unsanctioned
surgery and protect the surgeon from claims of an
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 inform the patient of the benefits,
alternatives, possible risks,
Role of complications, disability, and removal
of body parts as well as what to
Surgeons expect in the early and late
postoperative periods.
and The nurse:
clarifies the information provided,
nurses in verifies the presence of the patient’s
or designee’s signature, and may be
Informed asked to sign as a witness. If at any
point the patient requests additional
Consent information, or if the nurse feels that
the patient may not understand, the
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 Valid consent must be freely given,
without coercion. Patient must be at least

Informed 18 years of age (unless an emancipated

consent minor), a physician must obtain consent,
and a professional staff member must
witness patient’s signature.

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 Informed consent is necessary
in the following
circumstances:
1. Invasive procedures, such as a
surgical incision, a biopsy, a
cystoscopy, or paracentesis
Informed
consent 2. Procedures requiring sedation
or anaesthesia
3. A nonsurgical procedure, such
as arteriography
4. Procedures involving radiation
5. Blood product administration
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 Preoperative Assessment

 Nutritional and  Hepatic and

Fluid Status Renal Function
 Dentition  Endocrine
 Drug or Alcohol Function
Use  Immune Function
 Respiratory  Previous
Status Medication Use
 Cardiovascular  Psychosocial
Status factors
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 Nutritional and Fluid Status
Optimal nutrition is an essential factor in promoting healing and resisting infection and other
surgical complications.

Assessment of a patient’s nutritional status identifies factors that can affect the patient’s
surgical course, such as obesity, weight loss, malnutrition, deficiencies in specific nutrients,
metabolic abnormalities, and the effects of medications on nutrition

Nutritional needs may be determined by measurement of BMI and waist circumference.

Any Nutritional deficiency should be corrected before surgery to provide adequate protein for
tissue repair.

Refer to TABLE 14-2 Nutrients Important for Wound Healing chapter 14, page 1211.

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 Nutritional and Fluid Status
 Hydration status is also essential.

 The patient’s NPO (Nothing by Mouth or nil per os) status

should be confirmed preoperatively.

 Preoperative fasting helps prevent the risk of aspiration.

 Preoperative fasting may lead to dehydration and fluid

electrolyte imbalances.

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 Dentition
The condition of the mouth is an important health factor to asses.

Dental caries, dentures, and partial plates are particularly

significant to the anesthesiologist.

Because the displaced and moved during intubation and

occluded the airway.

The condition of the mouth is also important because any bodily

infection, even in the mouth, can be a source of postoperative infection

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 Drug or Alcohol Use
Excessive alcohol consumption can cause arrhythmias,
infections, and withdrawal. These factors can lead to
extended hospital stays and increased complications.

Identifying excessive alcohol use pre-surgically and

implementing interventions can reduce the incidence
of complications by about 50%.

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 Respiratory Status
 The patient is educated about breathing exercises and
the use of an incentive spirometer, if indicated, to
achieve optimal respiratory function prior to surgery. In
case of chest infection, the elective surgery may
cancelled.
 Preoperative smoking cessation interventions can be
effective in changing smoking behavior and reducing
the incidence of postoperative complications.
 Patients who smoke are more likely to experience poor
wound healing, a higher incidence of SSI, and
complications that include Venous thromboembolism
(VTE) and pneumonia.
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 Cardiovascular Status
 Ensure that the cardiovascular system can support
the oxygen, fluid, and nutritional needs of the
perioperative period.
 Perform a chest x-ray and electrocardiogram
(ECG) to rule out any undiagnosed cardiac condition.
 Before surgery, the patient’s baseline vital signs and
blood pressure are taken.
 In elective situations, surgery may be postponed if
there is evidence of cardiac decomposition or
unexplained elevated blood pressure.
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 Hepatic and Renal Function
 The liver and kidneys are the routes for the elimination of medications and

toxins.

 Acute liver disease is associated with high surgical mortality.

 The kidneys are involved in excreting medications and their metabolites

(surgery is contraindicated if a patient has acute nephritis, acute renal

insufficiency, or other acute renal problems).

 Exceptions include surgeries performed as lifesaving measures, surgery to

enable easier access for dialysis, or those necessary to improve urinary function

(e.g., obstructive uropathy or hydronephrosis).

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 Endocrine Function
Dysfunction of the endocrine system is associated with overproduction
or underproduction of a hormone

Assess dysfunction of the endocrine system and the use of hormonal

replacement (e.g., adrenal insufficiency, using corticosteroids).
Assess patients with uncontrolled thyroid disorders
 Risk for thyrotoxicosis (with hyperthyroid disorders) or respiratory failure
(with hypothyroid disorders).
The patient with diabetes is at risk for both hypoglycemia and hyperglycemia.
Frequent monitoring of blood glucose levels is important before, during, and after
surgery.
Hyperglycemia, which can increase the risk of SSI, may result from the
stress of surgery

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Immune Function

An important function of Routine laboratory tests

the preoperative used to detect infection
assessment is to determine include the white blood
the presence of infection or cell (WBC) and the
allergies. urinalysis.

Assess any sensitivity or

Surgery may be
allergy to medications,
postponed in the
solutions, adhesives,
presence of infection or
and past adverse
elevated temperature.
reactions

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 Previous Medication Use
A medication history is obtained because of the
possible interactions with medications that might
be given during surgery and the effects of any of
these medications on the patient’s perioperative
course. Any medications the patient is using or
has used in the past are documented.
 Aspirin and other medications that inhibit
platelet aggregation should be prudently
discontinued 7 to 10 days before surgery;
otherwise, the patient may be at increased
risk for bleeding.

Assess dietary and herbal supplements that may

increase surgical risks
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 Psychosocial factors
 The nurse anticipates that most patients have emotional
reactions prior to surgery.

 Fear may be related to the unknown, lack of control, or of death

and may be influenced by anesthesia, pain, complications,
cancer, or prior surgical experience

 Preoperative anxiety can be a preemptive response to a threat

to the patient’s role in life, a permanent incapacity or body
integrity, increased responsibilities or burden on family
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 Showing respect for a patient’s cultural values and beliefs
facilitates rapport and trust.

Spiritual and Assessment includes identifying the ethnic group to which

Cultural the patient relates and the customs and beliefs the patient
Beliefs holds about illness and health care providers.

Knowledge of the patient’s physiologic, psychosocial,

cultural, spiritual, and educational needs allows the
perioperative nurse to provide a holistic approach to care

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 Preoperative Nursing Interventions
Nursing Intervention
1. Providing Patient Education
 Nurses have long recognized the value of preoperative
education
 Each patient’s education is individualized, with consideration
for any unique concerns or learning needs. Multiple education
strategies should be used (e.g., verbal, written, return
demonstration), depending on the patient’s needs and
abilities
 Preoperative education is initiated as soon as possible

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 Preoperative Nursing Interventions
Providing Patient Education
 Deep Breathing, Coughing, and Incentive Spirometry
 Mobility and Active Body Movement (see Chart 14-5 page
1223-1225).
 pain management (acute Vs. Chronic , pain intensity
scale)
 cognitive Coping Strategies: Cognitive strategies may be
useful for relieving tension, overcoming anxiety, decreasing
fear, and achieving relaxation. Examples of general strategies
include:
 Guided Imagery, Distraction, Music Therapy,, Yoga therapy,
Muscle relaxation, and therapeutic touch….
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 Preoperative Nursing Interventions
Providing Psychosocial Interventions:

The nurse assesses for and provides interventions to

enhance coping mechanisms to deal effectively with
anxiety and fears, and thus provide emotional comfort

Reducing Anxiety and Decreasing Fear

Respecting Cultural, Spiritual, and Religious

Beliefs
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Preoperative Nursing Interventions
Maintaining Patient Safety

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 Managing Nutrition and Fluids
The purpose of withholding food and
fluid before surgery is to prevent
Preoperati aspiration.
ve Nursing Specific recommendations for
Interventio restrictions depend on the age of the
ns patient and the type of food eaten.
For example, adults may be advised
to fast for 8 hours after eating fatty
food and 6 hours after ingesting milk
products.
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 Preoperative Nursing Interventions
Preparing the Bowel:
 Enemas are not commonly prescribed preoperatively
unless the patient is undergoing abdominal or pelvic
surgery. In this case, a cleansing enema or laxative
may be prescribed the evening before surgery and may
be repeated the morning of surgery
 The goals of this preparation are to allow satisfactory
visualization of the surgical site and to prevent trauma
to the intestine or contamination of the peritoneum by
fecal material.
 Unless the condition of the patient presents some
contraindication 41
 Preoperative Nursing Interventions
Preparing the Skin
 The goal of preoperative skin preparation is to decrease
bacteria without injuring the skin.
 If the surgery is not performed as an emergency, most
healthcare facilities and ambulatory surgical centers
have implemented preoperative antiseptic skin
cleansing protocols.
 At a minimum, preoperative bathing should consist of a
full-body wash using antimicrobial soap the night before
the planned surgery

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 Preoperative Nursing Interventions
Immediate intervention prior operation :
 Patient ID
 Ensure that patient is wearing the hospital gown
 Inspect mouth (dentures)
 Check nails, jewelleries
 Administrating medication: antibiotics to reduce the risk
of SSI
 Maintaining the Preoperative Record
 Preoperative Patient Warming
 Attending to Family Needs
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Reference
Hinkle, J. L., Cheever, K. H., & Overbaugh, K. J. (2022). Brunner
& Suddarth's textbook of medical-surgical nursing. 15th edition.
Philadelphia, Wolters Kluwer Health.

Chapter 14

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Thank you

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