1. Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Chapter 16
Care of Preoperative Patients

2. 2Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Preoperative Period
 Begins when patient is scheduled for surgery;
ends at time of transfer to surgical suite
 Nurse functions as educator, advocate,
promoter of health and safety

3. 3Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Patient & Family Teaching
 Tubes
 Drains
 Vascular access

4. 4Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Nasogastric Tube

5. 5Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Prevention of Respiratory
Complications
 Breathing exercises
 Incentive spirometry
 Coughing and splinting

6. 6Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Older Adults: Changes of Aging
as Surgical Risk Factors
 Decreased:
 Cardiac output, peripheral circulation
 Vital capacity, blood oxygenation
 Blood flow to kidneys, glomerular filtration rate
 Increased:
 Blood pressure
 Risk for skin damage, infection
 Sensory deficits
 Deformities related to osteoporosis/arthritis

7. 7Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Older Adults: Considerations for
Preoperative Care
 Chronic illness
 Malnutrition
 Impaired self-care ability
 Allergies
 Inadequate support systems

8. 8Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Older Adults: Considerations for
Preoperative Care (cont’d)
 Stress from surgery/anesthesia
 Cardiopulmonary complications after surgery
 Mental status changes
 Risk for falls

9. 9Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Reasons for Surgery
 Diagnostic – determines origin and cause of
disorder
 Curative – resolves health problem by
repairing or removing cause
 Restorative – improves patient’s functional
ability
 Palliative – relieves symptoms of disease
process, but does not cure
 Cosmetic – alters/enhances personal
appearance

10. 10Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Urgency and Degree of Risk of
Surgery
 Urgency:
 Elective
 Urgent
 Emergent
 Degree of Risk:
 Minor
 Major

11. 11Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Extent of Surgery
 Simple
 Radical
 Minimally invasive (MIS)

12. 12Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Anxiety Interventions
 Preoperative teaching
 Encourage communication
 Promote rest
 Use distraction
 Teach family members

13. 13Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Skin Preparation
 Break in the skin increases risk for infection
 Patient may be asked to shower using
antiseptic solution
 Hair removal by electric clippers, depilatories
 Shaving of hair creates risk for infection!

14. 14Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Preoperative Drugs
 Reduce anxiety
 Promote relaxation
 Reduce nasal and oral secretions

15. 15Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Preoperative Drugs (cont’d)
 Prevent laryngospasm
 Reduce vagal-induced bradycardia
 Inhibit gastric secretion
 Decrease amount of anesthetic needed for
induction and maintenance of anesthesia

16. 16Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Collaborative Management:
Assessment
 History and data collection:
 Age
 Drugs, substance use
 Medical history (including cardiac and pulmonary)
 Complementary/alternative practices
 Previous surgical procedures, anesthesia
 Blood donations
 Discharge planning

17. 17Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Physical Assessment/Clinical
Manifestations
 Obtain baseline vital signs
 Focus on problem areas identified in history;
all body systems affected by surgical
procedure
 Report abnormal assessment findings to
surgeon/anesthesiology personnel

18. 18Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
System Assessment
 Cardiovascular
 CAD, MI within 6 months before
surgery, angina, hypertension, dysrhythmias
 Respiratory
 Chronic respiratory problems
 Smoking increases carboxyhemoglobin blood
level, deceases oxygen delivery
 Renal/Urinary
 Kidney impairment inhibits drugs/anesthetic agent
excretion

19. 19Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
System Assessment (cont’d)
 Neurologic
 Determine baseline
 Assess LOC, ability to follow commands
 Musculoskeletal
 Nutritional status
 Malnutrition and obesity increase surgical risk
 Psychosocial

20. 20Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Prevention of Cardiovascular
Complications
 Be aware of patients at greater risk for DVT
 Antiembolism stockings
 Pneumatic compression devices
 Leg exercises
 Mobility

21. 21Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Laboratory Assessment
 Urinalysis
 Blood type and crossmatch
 CBC or hemoglobin level and hematocrit
 Clotting studies (PT, INR, aPTT)

22. 22Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Laboratory Assessment (cont’d)
 Electrolyte levels
 Serum creatinine level
 Pregnancy test
 Chest x-ray
 ECG

23. 23Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Insufficient Information Interventions
 Preoperative teaching
 Informed consent:
 Surgeon obtains signed consent before sedation
and/or surgery
 Nurse clarifies facts and dispels myths about
surgery
 Nurse not responsible for providing detailed
information about procedure!

24. 24Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Informed Consent
 Patients may sign with “X”
 In emergency, telephone authorization is
acceptable
 Special permits required for some procedures

25. 25Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
NPSGs and Informed Consent
 Ensure correct site is selected and wrong site
is avoided
 Licensed independent practitioner marks
site, involving patient if possible
 “Time out” procedure adopted by most
facilities

26. 26Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Implementing Dietary Restrictions
 NPO: Patient not to ingest anything by mouth
for 6 to 8 hours before surgery:
 Decreases risk for aspiration
 Give patients written/oral directions to stress
adherence
 Surgery can be canceled if instructions not
followed

27. 27Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Administering Regularly Scheduled
Medications
 Consult with physician and anesthesia
provider for instructions
 Drugs for certain conditions often allowed
with a sip of water:
 Cardiac disease
 Respiratory disease
 Seizures
 Hypertension

28. 28Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Intestinal Preparation
 Performed to prevent injury to colon; reduce
number of intestinal bacteria
 Enema or laxative

29. 29Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Patient Using Incentive Spirometer

30. 30Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Patients at Risk for VTE
 Obese patients
 Age 40 or older
 History of cancer
 Decreased mobility or immobile
 Spinal cord injury

31. 31Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Patients at Risk for VTE (cont’d)
 History of VTE, PE, varicose veins, edema
 Oral contraceptives
 Smoking
 History of decreased cardiac output
 Hip fracture, total hip/knee surgery

32. 32Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
External Pneumatic Compression
Devices

33. 33Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Preoperative Chart Review
 Ensure all documentation, preoperative
procedures, orders are complete
 Check surgical consent form and others for
completeness
 Inform patient that area will be marked before
procedure begins
 Document allergies, height, and weight

34. 34Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Preoperative Chart Review (cont’d)
 Ensure all laboratory and diagnostic test
results are in chart
 Document/report any abnormal results
 Report special needs and concerns

35. 35Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Preoperative Patient Preparation
 Remove most clothing; provide gown
 Leave valuables with family member or lock
up
 Tape rings in place if cannot be removed
 Ensure patient is wearing ID band

36. 36Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Preoperative Patient Preparation
(cont’d)
 Remove:
 Dentures
 Prosthetic devices
 Hearing aids
 Contact lenses
 Fingernail polish
 Artificial nails
 Pierced jewelry