Focus on Preoperative Care

Focus on Preoperative Care
(Relates to Chapter 18, “Nursing Management: Preoperative Care,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Surgery Art and science of treating diseases, injuries, and deformities by operation and instrumentation The surgical experience involves an open and dynamic interaction among the patient, surgeon, anesthesia care provider (ACP), and nurse. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Surgery Performed for Diagnosis Cure Palliation Prevention Exploration Cosmetic improvement Diagnosis: Determination of the presence and/or extent of pathology (e.g., lymph node biopsy, bronchoscopy) Cure: Elimination or repair of pathology (e.g., removal of a ruptured appendix, benign ovarian cyst) Palliation: Alleviation of symptoms without cure (e.g., cutting a nerve root [rhizotomy] to remove symptoms of pain, creating a colostomy to bypass an inoperable bowel obstruction) Prevention: Examples include removal of a mole before it becomes malignant or removal of the colon in a patient with familial polyposis to prevent cancer Exploration: Surgical examination to determine the nature or extent of a disease (e.g., laparotomy) Cosmetic improvement: Examples include repairing a burn scar or breast reconstruction after a mastectomy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Surgical Settings Elective surgery vs. emergency surgery Inpatient Same-day admission Ambulatory (outpatient) Surgery may be a carefully planned event (elective surgery) or may arise with unexpected urgency (emergency surgery). Both elective and emergency surgery may be performed in a variety of settings. The setting in which a surgical procedure may be safely and effectively performed is influenced by the complexity of the surgery, potential complications, and the general health status of the patient. For inpatient surgery, patients who are going to be admitted to the hospital are usually admitted on the day of surgery (same-day admission). Patients who are in the hospital before surgery are usually there because of acute or chronic medical conditions. Most surgical procedures are being performed as ambulatory surgery (also called same-day or outpatient surgery). Many of these surgeries use minimally invasive techniques (e.g., laparoscopic techniques). Ambulatory surgery May be conducted in emergency departments, endoscopy clinics, physicians’ offices, free-standing surgical clinics, and outpatient surgery units in hospitals Can be performed using general, regional, or local anesthetic Have an operating time of less than 2 hours Require less than a 24-hour stay postoperatively Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Your Role Preop Have knowledge of the nature of the disorder requiring surgery. Identify the individual patient’s response to the stress of surgery. Assess the results of appropriate preoperative diagnostic tests. Provide a baseline by identifying potential risks and complications. The nurse caring for the patient preoperatively is likely to be different from the nurse in the operating room (OR), postanesthesia care unit (PACU), surgical intensive care unit (SICU), or surgical unit. Thus communication and documentation of important preoperative assessment findings are essential to the continuity of care. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Patient Interview Purpose Obtain health information. Determine expectations. Provide and clarify information on procedure. Assess emotional state and readiness. The interview also provides the patient and caregiver an opportunity to ask questions about surgery, anesthesia, and postoperative care. Often patients will ask about taking their routine medications, such as insulin, warfarin (Coumadin), or cardiac medications, and if they will experience pain. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Goals
Determine psychologic status to reinforce coping strategies. Determine psychologic factors of the procedure contributing to risks. Determine physiologic factors that may contribute to increased surgical risk. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Establish baseline data. Identify medications and herbs taken that may affect surgical outcome. Identify, document, and communicate results of laboratory/diagnostic tests. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Identify cultural and ethnic factors that may affect surgical experience. Determine receipt of adequate information from surgeon to sign informed consent. Determine informed consent and that informed consent form is signed and witnessed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Psychosocial assessment Excessive stress response can be magnified and affect recovery. Surgery is a stressful event, even when the procedure is considered relatively minor. Psychologic and physiologic reactions to the surgical procedure and anesthesia may elicit the stress response (e.g., elevated blood pressure [BP], heart rate). Because the patient may be admitted directly into the preoperative area from the community or home, you must be skilled in assessing vital psychologic factors in a very short time. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Use common language. Use translators if needed. Decreases level of anxiety Communicate all concerns to surgical team. Avoid medical jargon. Use words and language that are familiar to the patient to increase the patient’s understanding of surgical consent and the surgical experience. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Anxiety can impair cognition, decision making, and coping abilities. Anxiety can arise from Lack of knowledge Unrealistic expectations Information lessens anxiety. Most people are anxious when facing surgery because of the unknown. This is normal and is an inherent survival mechanism. However, if the anxiety level is high, cognition, decision making, and coping abilities are diminished. Anxiety may be a result of past experiences or the vicarious experiences provided by friends’ stories and the media. You can decrease some anxiety for the patient by providing information about what can be expected. (This is often done through classes or the use of educational CDs before the day of surgery). The surgeon should be informed if the patient requires any additional information or if anxiety seems excessive. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Anxiety may arise from conflict with interventions (i.e., blood transfusions) and religious/cultural beliefs. Identify beliefs and discuss with surgeon and operative staff. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Fears Death or disability May prompt postponement Influence outcome Pain Consult with ACP. Confirm drugs will be available. Patients fear surgery for many reasons. These are just examples. You should notify the physician if the patient has a strong fear of death, which may prompt postponement. For fear of pain, you should stress that the patient should ask for medications following surgery when pain is present, and that taking these medications will not contribute to an addiction. Instruct the patient on the use of some form of pain intensity scale (e.g., 0-10, FACES) and to request pain medication before the pain becomes severe. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Fears Mutilation/alteration in body image Assess concerns nonjudgmentally. Anesthesia ACP for consult Fear of anesthesia can result from a prior induction of anesthesia or information about hazards or complications (e.g., brain damage, paralysis). Many patients also fear losing control while under the influence of anesthesia. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Fears Disruption of life functioning Range from fear of permanent disability to temporary loss Include family and financial concerns Consultations PRN Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Hope May be strongest positive coping mechanism Never deny or minimize. Assess and support. Some surgeries are hopefully anticipated. These can be the surgeries that repair (e.g., plastic surgery for burn scars), rebuild (e.g., total joint replacement to minimize pain and improve function), or save and extend life (e.g., repair of aneurysm, organ transplant). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Health history Diagnosed medical conditions (previous and current) Previous surgeries and problems Menstrual/obstetric history You will need to determine if the patient understands the reason for surgery. For example, the patient scheduled for a total knee replacement may indicate that increasing pain and immobility are the reasons for the surgery. For menstrual history, you should ask the date of the last menstrual period and the number of pregnancies. Questions regarding reproductive function may be embarrassing for a teenager in the presence of parents or guardians. You may elect to ask these questions with parents or guardians out of the room. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Health history Familial diseases Conditions Reactions/problems to anesthesia (patient or family) With regard to reactions to anesthesia, the genetic predisposition for the condition known as malignant hyperthermia is now well documented, and measures can be taken to minimize complications associated with this condition. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Current medications Prescription and OTC Herbs Dietary supplements Recreational Drugs Alcohol Tobacco In many ambulatory surgery centers, patients are asked to bring their medications with them when reporting for surgery, to facilitate accurate assessment and documentation of both the name and dosage of current medications. In addition, assess and evaluate the patient’s compliance with the medication regimen to identify other concerns. Drugs and herbal supplements may interact with anesthetics. The interaction of the patient’s current medications and anesthetics can increase or decrease the desired physiologic effect. It is also important to consider the effects of opioids and prescribed medications for chronic health conditions (e.g., heart disease, hypertension, depression, epilepsy, diabetes mellitus). For example, tranquilizers may potentiate the effects of opioids and barbiturates, which are agents that can be used for anesthesia. You should ask specifically about the use of herbs and dietary supplements because their use is so prevalent. Many patients do not think to include herbal supplements in their list of medications. They believe that herbal supplements are “natural” and therefore do not pose a surgical risk. Under recreational drugs, the substances most likely to be abused include tobacco, alcohol, opioids, marijuana, cocaine, and amphetamines. Ask questions in a frank manner about the use of these substances. You should stress that recreational drug use may affect the type and amount of anesthesia that will be needed. When patients become aware of the potential interactions of these substances with anesthetics, most patients will respond honestly about their using them. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Allergies (drug and nondrug) Screen for latex allergy: Risk factors Contact urticaria or dermatitis Aerosol reactions History of reactions suggesting latex allergy You must also question the patient about drug intolerance and drug allergies. Drug intolerance usually results in side effects that are uncomfortable or unpleasant for the patient but not life threatening. These effects can include nausea, constipation, diarrhea, or idiosyncratic (opposite than expected) reactions. A true drug allergy produces hives and/or an anaphylactic reaction, causing cardiopulmonary compromise (e.g., hypotension, tachycardia, bronchospasm). You should inquire about nondrug allergies, specifically food and environmental (e.g., latex, pollen, animals) allergies. The patient with a history of any allergic reactions has a greater potential for demonstrating hypersensitivity reactions to drugs administered during anesthesia. Risk factors for latex allergy include long-term, multiple exposures to latex products, such as those experienced by health care and rubber industry workers. Additional risk factors include a history of hay fever, asthma, and allergies to certain foods. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Cardiovascular system Report Any cardiac problems so they can be monitored during the intraoperative period Use of cardiac drugs Presence of pacemaker/ICD The last component of the patient history is the body systems review. Ask specific questions to confirm the presence or absence of any diseases. Past medical problems can alert you to areas that should be more closely examined in the preoperative physical examination. In reviewing the CV system, you may find a history of cardiac problems, including hypertension, angina, dysrhythmias, heart failure, and/or myocardial infarction. You should inquire about the patient’s current treatment for the CV condition (e.g., medications) and the level of maintenance and functioning. Ask the patient if he/she is being followed by a cardiologist. If the patient has had a recent myocardial infarction, a pacemaker, or an implanted cardioverter-defibrillator, or if a cardiologist was consulted before surgery. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Cardiovascular system Vitals recorded preoperatively for baseline Bleeding/clotting times Laboratory reports Possible prophylactic antibiotics Postoperative venous thromboembolism (VTE), a condition that includes deep vein thrombosis and pulmonary embolism, is a concern for any surgical patient. Patients at high risk for VTE include those with a history of previous thrombosis, blood-clotting disorders, cancer, varicosities, obesity, smoking, heart failure, or chronic obstructive pulmonary disease (COPD). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Respiratory system Inquire about recent airway infections. Procedure could be cancelled because of increased risk of laryngo/bronchospasm or decreased SaO2. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Respiratory system History of dyspnea, coughing, or hemoptysis reported to operative team COPD or asthma High risk for atelectasis and hypoxemia Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Respiratory system Smokers should be encouraged to quit 6 weeks before procedure. Decreases risk of complications Greater years and number of packs = greater risk Conditions likely to influence or compromise respiratory function such as sleep apnea, obesity, and spinal, chest, and airway deformities should also be noted and reported. Depending on the patient’s history and physical examination, baseline pulmonary function tests and arterial blood gases (ABGs) may be ordered preoperatively. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Nervous system Evaluation of neurologic functioning Vision or hearing loss can influence results. Alterations in the patient’s hearing and vision may affect responses and ability to follow directions throughout the perioperative assessment and evaluation. The patient’s ability to pay attention, concentrate, and respond appropriately in the preoperative phase must be documented to establish an accurate baseline for postoperative comparison. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Genitourinary system History of urinary or renal diseases Renal dysfunction contributes to Fluid and electrolyte Increased risk of infection Impaired wound healing Altered response to drugs and their elimination Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Genitourinary system Renal function tests Note problems voiding, and inform operative team. Male patients may have physical alterations, such as an enlarged prostate, which can interfere with the insertion of a urinary catheter during surgery or can impair voiding in the postoperative period. For women of child-bearing age, you need to determine if they are pregnant or think they could be pregnant. The surgeon should be informed immediately if the patient states that she might be pregnant, because maternal and subsequent fetal exposure to anesthetics should be avoided during the first trimester. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Hepatic system Liver detoxifies many anesthesics and adjunctive drugs. Hepatic dysfunction may increase risk of postoperative complications. The patient with hepatic dysfunction may have increased perioperative risk for clotting abnormalities and adverse responses to medications. You should consider the presence of liver disease if the history includes jaundice, hepatitis, alcohol abuse, or obesity. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Integumentary system History of skin and musculoskeletal problems History of pressure ulcers Extra padding during procedure Affects postoperative healing Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Musculoskeletal system Identify joints affected with arthritis. Mobility restrictions may affect positioning and ambulation. Bring mobility aids to surgery. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Musculoskeletal system Report problems affecting neck or lumbar spine to ACP. Can affect airway management and anesthesia delivery Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Endocrine system Patients with diabetes mellitus especially at risk for: Hypo/hyperglycemia Ketosis Cardiovascular alterations Delayed wound healing Infection Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Endocrine system Patients with diabetes mellitus Serum or capillary glucose tests morning of surgery (baseline) Clarify with physician or ACP regarding insulin dose. ACP practitioners vary the usual insulin dose based on the patient’s current status and history of glucose control. Regardless of the preoperative insulin orders, the patient’s glucose levels will be assessed periodically and managed, if necessary, with regular (short-acting, rapid-onset) insulin. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Endocrine system Patients with thyroid dysfunction Hyper/hypothyroidism are surgical risks due to altered metabolic rate. Verify with ACP about giving thyroid medications. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Endocrine system Patients with Addison’s disease Abruptly stopping replacement corticosteroids could cause addisonian crisis. Stress of surgery may require increased dose of corticosteroids. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Immune system Patients with history of compromised immune system or use of immunosuppressive drugs can have Delayed wound healing Increased risk for infection Corticosteroids used in immunosuppressive doses may be tapered before surgery. If the patient has an acute infection (e.g., acute upper respiratory tract infection, acute sinusitis, influenza), elective surgery is frequently cancelled. Patients with active chronic infections such as hepatitis B or C, acquired immunodeficiency syndrome, and tuberculosis may have surgery if indicated. However, when preparing the patient for surgery, remember that infection control precautions are taken for the protection of the patient as well as the staff. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Fluid and electrolyte status Vomiting, diarrhea, or difficulty swallowing can cause imbalances. Identify drugs that alter F and E status. Diuretics Evaluate serum electrolyte levels. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Fluid and electrolyte status NPO status May require additional fluids and electrolytes before surgery if dehydration occurs Although a preoperative fluid balance history should be completed for all patients, it is especially critical for the older adult because reduced adaptive capacity leaves a narrow margin of safety between overhydration and underhydration. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Nutritional status Obesity Stresses cardiac and pulmonary systems Increased risk of wound dehiscence and infection Slower recovery from anesthesia Slower wound healing Notifying the team that a patient is morbidly obese (body mass index [BMI] > 40 kg/m2) allows time to obtain special equipment needed for the care of this patient (e.g., longer instruments for abdominal surgery). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment Nutritional status Provide extra padding to underweight patients to prevent pressure ulcers. Identify dietary habits that may affect recovery (e.g., caffeine). May be protein and vitamin deficient If the nutritional problem is severe, the surgery may be postponed. Nutritional deficiencies of protein and vitamins A, C, and B complex are particularly significant because these substances are essential for wound healing. Supplemental nutrition may be administered during the perioperative period to patients who are malnourished. The older adult is often at risk for malnutrition and fluid volume deficits. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment: Exam
Findings enable ACP to rate patient for anesthesia administration. Indicator of perioperative risk and overall outcome Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Assessment: Exam
Document relevant findings, and report to perioperative team. Obtain and evaluate results of laboratory tests. Monitor blood glucose for patients with diabetes. For example, if the patient is taking an antiplatelet medication (e.g., aspirin), a coagulation profile may be ordered; if a patient is on diuretic therapy, a potassium level may need to be assessed; if a patient is of child-bearing age, a pregnancy test should be ordered; or if a patient is taking medications for dysrhythmias, a preoperative electrocardiogram (ECG) will probably be performed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Preoperative teaching Patient has right to know what to expect and how to participate. Increases patient satisfaction Reduces fear, anxiety, stress, pain, and vomiting Teaching may also decrease the development of complications, the length of hospitalization, and the recovery time following discharge. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Preoperative teaching Limited time available Address needs of highest priority. Include information focused on safety. Provide written material. Preoperative teaching for these patients is generally done in the surgeon’s office or the preadmission surgical clinic and is reinforced on the day of surgery. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Preoperative teaching Several days before surgery Observe and listen to determine amount of teaching for each session. Anxiety and fear can hinder learning. Give priority to patient’s concerns. When providing preoperative teaching for a patient several days before surgery, you must provide a balance between telling so little that the patient is unprepared and explaining so much that the patient is overwhelmed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Preoperative teaching Three types Sensory Process Procedural With sensory information, patients want to know 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 very bright; or they will hear lots of sounds that are unfamiliar and may notice specific smells. Patients wanting process information may not want specific details but desire to know 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 ACP before transfer to the OR, and waking up in the PACU. With procedural information, desired details are more specific. For example, this information would include that an IV line will be started while the patient is in the holding area, and the surgeon will mark the operative area with an indelible marker to verify site and side. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Preoperative teaching Must be documented and reported to postoperative nurses Avoid duplication of information. Assess learning. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Preoperative teaching Teach deep breathing, coughing, and early ambulation as appropriate. Inform if tubes, drains, monitoring devices, or special equipment will be used postop. Provide surgery-specific information. The patient should also receive accurate surgery-specific information. For example, a patient having a total joint replacement may have an immobilizer following surgery, or a patient with extensive neurosurgery may need to be told about waking up in the intensive care unit. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Preoperative teaching Basic information before arrival Time and place Fluid and food restrictions Need for enema Need for shower Arrival time is usually 1 to 2 hours before the scheduled time of surgery to allow for completion of the preoperative assessment and paperwork. Information can also include the day-of-surgery events such as patient registration, parking, what to wear, what to bring, and the need to have a responsible adult present for transportation home after surgery. Restriction of fluids and food is designed to minimize the potential risk of pulmonary aspiration and to decrease the risk of postoperative nausea and vomiting. The patient who has not followed the NPO instructions may have surgery delayed or cancelled, so it is critical that the surgical patient understands and adheres to these restrictions. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Legal preparation All required forms are signed and in chart: Informed consent Blood transfusions Advance directives Power of attorney Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Consent for surgery Informed consent must include Adequate disclosure Understanding and comprehension Voluntarily given consent Three conditions must be met for consent to be valid. First, information must include adequate disclosure of the diagnosis; the nature and purpose of the proposed treatment; the risks and consequences of the proposed treatment; the probability of a successful outcome; the availability, benefits, and risks of alternative treatments; and the prognosis if treatment is not instituted. Second, the patient must demonstrate clear understanding and comprehension of the information being provided before receiving sedating preoperative medications. Third, 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Surgeon responsible for obtaining consent Nurse may obtain and witness signature. Verify patient has understanding. Permission may be withdrawn at any time. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Consent for surgery Medical emergency may override need for consent. When immediate medical treatment is needed to preserve life or to prevent serious impairment to life, and the individual patient is incapable of giving consent, the next of kin may give consent. If reaching the next of kin is not possible, the physician may institute treatment without written consent. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Day-of-surgery preparation Final preoperative teaching Assessment and report of pertinent findings Verify signed consent. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Day-of-surgery preparation Labs History and physical examination Baseline vitals Consultation records Nurse’s notes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Day-of-surgery preparation Patient should not wear any cosmetics. Observation of skin color is important. Remove nail polish for pulse oximeter. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Day-of-surgery preparation Valuables are returned to family member or locked up. Dentures, contacts, prostheses are removed. Identification and allergy bands on wrist Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Management Void before surgery Prevents involuntary elimination under anesthesia or during early postoperative recovery Before medication administration Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Question A 68-year-old scheduled for a herniorrhaphy at an ambulatory surgical center expresses concern that he will not have enough care at home and asks if he can stay in the hospital after the surgery. The best response by the nurse is: 1. “Who is available to help you at home after the surgery?” 2. “I’m sure you will be able to manage at home after surgery. It is a simple procedure.” 3. “We will teach you everything you need to know to be able to care for yourself after surgery.” 4. “Your health insurance will pay for inpatient care only if complications develop during surgery.” Answer: 1 Rationale: Ambulatory surgery patients are discharged on the day of surgery. The nurse should determine and anticipate what level of care is needed after the surgery. The nurse would be able to provide instructions to both the patient and the caregiver related to the patient’s needs after surgery. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Audience Response Question Preoperative instruction that is appropriate for all patients includes 1. Techniques of deep breathing and coughing. 2. Descriptions of the planned surgical procedure. 3. Physical procedures or preparation required before surgery. 4. Withholding of all oral fluids or food after midnight on the day of surgery. Answer: 3 Rationale: Not all patients will deep breathe and cough after surgery (such as after cranial surgery) or need to be NPO (nothing by mouth). Detailed instructions about the procedure may increase anxiety and are not usually helpful to the patient. Patients should have instruction on physical procedures or preparation required before surgery. Anticipatory guidance decreases anxiety and fear. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Case Study 45-year-old woman presents to holding area for presurgical workup for right breast lumpectomy. The nurse notes constant fidgeting. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Case Study She is unable to articulate details about what the surgeon will do or her disease process. She reacts angrily when asked if she would consent to transfusion, if needed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Discussion Questions What do you think is happening with her? What can you do to help her and prepare her for the procedure? She is extremely stressed over the impending surgery. She is not coping well with the stress. You can ask her how she is feeling and listen attentively. You can explain the procedure of the surgery and help her get a better understanding of outcomes. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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