1. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. (Relates to Chapter 18, “Nursing Management: Preoperative Care,” in the textbook)

2. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Art and science of treating diseases, injuries, and deformities by operation and instrumentation

3. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Performed for ◦ Diagnosis ◦ Cure ◦ Palliation ◦ Prevention ◦ Exploration ◦ Cosmetic improvement

4. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Inpatient ◦ Same day admission  Ambulatory (outpatient) ◦ Usually less than 3 to 4 hours in PACU

5. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Check documented information prior to interview ◦ Avoids repetition  Occurs in advance or on day of surgery

6. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Purpose ◦ Obtain health information ◦ Determine expectations ◦ Provide and clarify information on procedure ◦ Assess emotional state and readiness

7. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Overall goal ◦ Identify risk factors ◦ Plan care to ensure patient safety

8. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Determine psychologic status to reinforce coping strategies  Determine psychologic factors of procedure contributing to risks

9. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Establish baseline data  Identify medications and herbs taken that may affect surgical outcome  Identify, document, and communicate results of laboratory/diagnostic tests

10. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Identify cultural and ethnic factors that may affect surgical experience  Determine receipt of adequate information from surgeon in order to sign informed consent

11. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Psychosocial assessment ◦ Excessive stress response can be magnified and recovery affected

12. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Influencing factors ◦ Age ◦ Past experience ◦ Current health ◦ Socioeconomic status

13. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Use common language  Use translators if needed ◦ Decreases level of anxiety  Communicate all concerns to surgical team

14. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Anxiety can impair cognition, decision making, and coping abilities ◦ Lack of knowledge ◦ Unrealistic expectations ◦ Information lessens anxiety

15. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Anxiety may arise from conflict with interventions (e.g., blood transfusions) and religious/cultural beliefs ◦ Identify beliefs and discuss with surgeon and operative staff

16. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Fears ◦ Death or disability  May prompt postponement  Influence outcome ◦ Pain  Consult with ACP  Reassure that drugs will be available

17. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Fears ◦ Mutilation/alteration in body image  Assess concerns nonjudgmentally ◦ Anesthesia  ACP for consult  Assess malignant hyperthermia risk

18. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Fears ◦ Disruption of life functioning  Range from fear of permanent disability to temporary loss  Include family and financial concerns  Consultations PRN

19. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Hope ◦ May be strongest positive coping mechanism  Never deny or minimize ◦ Assess and support

20. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Health history ◦ Diagnosed medical conditions ◦ Previous surgeries and problems ◦ Menstrual/obstetric history

21. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Health history ◦ Familial diseases  Conditions ◦ Reactions/problems to anesthesia (patient or family)

22. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Current medications ◦ Prescription and OTC ◦ Herbs ◦ Vitamins ◦ Recreational  Drugs  Alcohol  Tobacco

23. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Allergies (drug and nondrug)  Screen areas: ◦ Risk factors ◦ Contact urticaria ◦ Aerosol reactions ◦ History of reactions suggesting latex allergy

24. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Cardiovascular system ◦ Report  Problems for effective monitoring  Use of cardiac drugs  Presence of pacemaker/MI

25. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Cardiovascular system ◦ Vitals recorded preoperatively for baseline ◦ Bleeding/clotting times ◦ Laboratory reports ◦ Possible prophylactic antibiotics

26. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Respiratory system ◦ Inquire about recent airway infections  Procedure could be cancelled because of increased risk of laryngo/bronchospasm or decreased SaO 2

27. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Respiratory system ◦ History of dyspnea, coughing, or hemoptysis reported to operative team ◦ COPD or asthma  High risk for atelectasis and hypoxemia

28. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Respiratory system ◦ Smokers should be encouraged to quit 6 weeks before procedure  Decreases risk of complications  Greater years and number of packs = greater risk

29. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Nervous system ◦ Evaluation of neurologic functioning  Vision or hearing loss can influence results

30. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Nervous system ◦ Cognitive function  Assess or correct any deficits before surgery  Durable power of attorney for health care should be obtained if deficits cannot be corrected

31. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Nervous system ◦ Cognitive function  Postoperative delirium (falsely labeled senility or dementia) can occur with dehydration, hypothermia, and adjunctive medications

32. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Urinary system ◦ History of urinary or renal diseases ◦ Renal dysfunction contributes to  Fluid and electrolyte imbalances  Increased risk of infection  Impaired wound healing  Altered response to drugs and their elimination

33. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Urinary system ◦ Renal function tests ◦ Note problems voiding and inform operative team

34. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Integumentary system ◦ History of skin and musculoskeletal problems ◦ History of pressure ulcers  Extra padding during procedure  Affect postoperative healing

35. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Musculoskeletal system ◦ Identify joints affected with arthritis ◦ Mobility restrictions may affect positioning and ambulation ◦ Bring mobility aids to surgery

36. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Musculoskeletal system ◦ Report problems affecting neck or lumbar spine to ACP  Can affect airway management and anesthesia delivery

37. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Endocrine system ◦ Patients with diabetes mellitus especially at risk for:  Hypo/hyperglycemia  Ketosis  Cardiovascular alterations  Delayed wound healing  Infection

38. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Endocrine system ◦ Patients with diabetes mellitus  Serum glucose tests morning of surgery (baseline)  Clarify with physician or ACP if usual dose of insulin is taken

39. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Endocrine system ◦ Patients with thyroid dysfunction  Hyper/hypothyroidism are surgical risks due to altered metabolic rate  Verify with ACP about giving medications

40. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Endocrine system ◦ Patients with Addison’s disease  Abruptly stopping replacement corticosteroids could cause addisonian crisis  Stress of surgery may require increased dose of corticosteroids

41. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Immune system ◦ Patients with history of compromised immune system or use of immunosuppressive drugs can have  Delayed wound healing  Increased risk for infection

42. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Fluid and electrolyte status ◦ Vomiting, diarrhea, or difficulty swallowing can cause imbalance ◦ Identify drugs that alter status  Diuretics ◦ Evaluate serum electrolyte levels

43. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Fluid and electrolyte status ◦ NPO status  May require additional fluids and electrolytes before surgery if dehydration occurs

44. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Nutritional status ◦ Obesity  Stresses cardiac and pulmonary systems  Increased risk of wound dehiscence and infection  Slower recovery from anesthesia  Slower wound healing

45. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Nutritional status ◦ Provide extra padding to underweight patients to prevent pressure ulcers ◦ Identify dietary habits that may affect recovery (e.g., caffeine)

46. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Findings enable ACP to rate patient for anesthesia administration ◦ Indicator of perioperative risk and overall outcome

47. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Document relevant findings and report to perioperative team  Obtain and evaluate results of laboratory tests  Monitor blood glucose for diabetics

48. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Preoperative teaching ◦ Patient has right to know what to expect and how to participate  Increases patient satisfaction  Reduces fear, anxiety, stress, pain, and vomiting

49. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Preoperative teaching ◦ Limited time available  Address needs of highest priority  Include information focused on safety  Provide written material

50. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  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

51. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Preoperative teaching ◦ Must be documented and reported to postoperative nurses  Avoid duplication of information  Assess learning

52. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Preoperative teaching ◦ Teach deep breathing, coughing, and moving for postop ◦ Inform if tubes, drains, monitoring devices, or special equipment will be used postop

53. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Preoperative teaching ◦ Basic information before arrival  Time and place  Fluid and food restrictions  Need for enema  Need for shower

54. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Legal preparation ◦ All required forms are signed and in chart  Informed consent  Blood transfusions  Advance directives  Power of attorney

55. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Consent for surgery ◦ Informed consent must include  Adequate disclosure  Understanding and comprehension  Voluntarily given consent

56. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Surgeon responsible for obtaining consent ◦ Nurse may obtain and witness signature ◦ Verify patient has understanding ◦ Permission may be withdrawn at any time

57. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Consent for surgery ◦ Medical emergency may override need for consent

58. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Legally appointed representative of family may consent if patient is ◦ Child ◦ Unconscious ◦ Mentally incompetent

59. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Day-of-surgery preparation ◦ Final preoperative teaching ◦ Assessment and report of pertinent findings ◦ Verify signed consent

60. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Day-of-surgery preparation ◦ Labs ◦ History and physical examination ◦ Baseline vitals ◦ Consultation records ◦ Nurse’s notes

61. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Day-of-surgery preparation ◦ Patient should not wear any cosmetics  Observation of skin color is important  Remove nail polish for pulse oximeter

62. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Day-of-surgery preparation ◦ Valuables returned to family member or locked up ◦ Dentures, contacts, prostheses are removed ◦ Identification and allergy bands on wrist

63. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Void before surgery ◦ Prevents involuntary elimination under anesthesia or early postoperative recovery ◦ Before medication administration

64. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

65.  45-year-old woman presents to holding area for presurgical workup for lumpectomy  The nurse notes consistent fidgeting

66. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  She is unable to articulate details about what surgeon will do or her disease process  She reacts angrily when asked if she would consent to transfusion, if needed

67. Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 1. What do you think is happening with her? 2. What can you do to help her and prepare her for the procedure? 3. What should you not ask the patient to do?