Preoperative Phase - Perioperative Nursing

When a patient consents to surgery, especially under general anesthesia, they hand their safety to the team. The preoperative phase is where you make that safe: build a baseline, find and correct the problems that raise surgical risk, teach the patient what comes next, and get them physically and psychologically ready for anesthesia and the operating room.

Definition

The preoperative phase covers establishing the patient's baseline assessment in the clinical setting or at home, carrying out the preoperative interview, and preparing the patient for the anesthetic and the surgery.

Goals

The physician explains the procedure, but the patient often brings questions to the nurse, so carry out a nursing care plan and a teaching plan. Assess and correct physiologic and psychological problems that raise surgical risk, give the patient and support persons complete teaching about the surgery, instruct and demonstrate the exercises that will help postoperatively, and plan for discharge and any lifestyle changes the surgery will bring.

Physiologic Assessment

Before any treatment, obtain a health history and perform a physical examination, noting vital signs and building a database for future comparison. Assess the following:

Age, and the patient's usual level of functioning and typical daily activities, to guide care and recovery or rehabilitation planning. Inspect the mouth for dental caries, dentures, and partial plates, since decayed teeth or prostheses can dislodge during intubation and occlude the airway. Assess nutritional status and needs by height and weight, triceps skinfold, upper arm circumference, serum protein levels, and nitrogen balance; obesity greatly increases the risk and severity of surgical complications. Carefully assess and document dehydration, hypovolemia, and electrolyte imbalance, and check for infection. The acutely intoxicated person is susceptible to injury, so assess drug and alcohol use.

Evaluate respiratory status with pulmonary function studies and blood gas analysis in patients with pre-existing pulmonary problems; the goal is optimum respiratory function, and surgery is usually contraindicated with an active respiratory infection. Cardiovascular disease raises the risk of complications, and depending on severity, surgery may be deferred until medical treatment improves the patient's condition. Surgery is contraindicated in acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems, and any liver disorder can affect how an anesthetic is metabolized. Note the presence of trauma. Assess endocrine function (diabetes, corticosteroid intake, amount of insulin administered) and immunologic function (allergies, previous allergic reactions, drug sensitivities, past adverse drug reactions, immunosuppression).

The nurse and anesthesiologist must assess the patient's medication history. Medications of particular concern include:

• Adrenal corticosteroids: do not discontinue abruptly before surgery; sudden withdrawal in long-term users can cause cardiovascular collapse, so a bolus of steroid is given IV immediately before and after surgery.
• Diuretics: thiazide diuretics may cause excessive respiratory depression during anesthesia.
• Phenothiazines: may increase the hypotensive action of anesthetics.
• Antidepressants: MAOIs increase the hypotensive effects of anesthetics.
• Tranquilizers: barbiturates, diazepam, and chlordiazepoxide may cause increased anxiety, tension, and even seizures if withdrawn suddenly.
• Insulin: consider the interaction between anesthetics and insulin in the diabetic surgical patient.
• Antibiotics: "mycin" drugs such as neomycin, kanamycin, and less often streptomycin can interrupt nerve transmission when combined with curariform muscle relaxants, causing apnea from respiratory paralysis.

Gerontologic Considerations

Older patients have less physiologic reserve, so monitor for subtle clues of underlying problems, and watch for dehydration, hypovolemia, and electrolyte imbalances.

Nursing Diagnosis

Anxiety related to the surgical experience (anesthesia, pain) and the outcome of surgery. Risk for ineffective therapeutic management regimen related to deficient knowledge of preoperative procedures and postoperative expectations. Fear related to the perceived threat of surgery and separation from the support system. Deficient knowledge related to the surgical process.

Diagnostic Tests

Blood analyses such as complete blood count, sedimentation rate, c-reactive protein, serum protein electrophoresis with immunofixation, calcium, alkaline phosphatase, and chemistry profile; x-ray studies; MRI and CT scans (with or without myelography); electrodiagnostic studies; bone scan; endoscopies; tissue biopsies; stool studies; and urine studies.

Significant physical findings round out the picture of overall health. Once the patient is determined to be an appropriate candidate and elects to proceed, the preoperative assessment phase begins. Its purpose is to reduce the morbidity of surgery, improve the quality of intraoperative care, reduce costs, and return the patient to optimal functioning as soon as possible.

Psychological Assessment

Assess for fear of the unknown, fear of death, fear of anesthesia, fear of pain, concerns about loss of work, time, job, and family support, concern about permanent incapacity, and the patient's spiritual beliefs and cultural values.

Psychological interventions: explore the client's fears, worries, and concerns, encourage them to verbalize feelings, provide information that allays fears, and give empathetic support.

Informed Consent

Reinforce the information the surgeon provided, and notify the physician if the patient needs more information to decide. Make sure the consent form is signed before any psychoactive premedication. Informed consent is required for invasive procedures such as incision, biopsy, cystoscopy, or paracentesis; procedures requiring sedation or anesthesia; nonsurgical procedures that pose more than slight risk such as arteriography; and procedures involving radiation. Arrange for a responsible family member or legal guardian to give consent when the patient is a minor, unconscious, or incompetent (an emancipated minor, married or independently earning a living, may sign their own consent form). Place the signed form in a prominent place on the chart.

Informed consent protects the patient against unsanctioned surgery, protects the surgeon and hospital against legal action claiming an unauthorized procedure, ensures the client understands the nature of treatment including possible complications and disfigurement, and indicates the decision was made without force or pressure.

Criteria for valid informed consent: consent must be given voluntarily, without coercion. For incompetent subjects who cannot give or withhold consent, permission comes from a responsible family member or legal guardian; minors (below 18 years of age), the unconscious, the cognitively impaired, and the psychologically incapacitated fall under this category. The consent must be in writing and include an explanation of the procedure and its risks, a description of benefits and alternatives, an offer to answer questions, and a statement that the client may withdraw consent. It must be written in language the client can comprehend and obtained before sedation.

Nursing Interventions

Reducing Anxiety and Fear

Provide psychosocial support, listen, be empathetic, and give information that eases concerns. During early contacts, let the patient ask questions and meet the people who will care for them during and after surgery. Acknowledge worries by listening and communicating therapeutically, explore fears, and arrange other health professionals if needed. Teach cognitive strategies to relieve tension and achieve relaxation, including imagery, distraction, or optimistic affirmations.

Managing Nutrition and Fluids

Provide ordered nutritional support to correct deficiencies before surgery and supply protein for tissue repair. Withhold oral food and water 8 to 10 hours before the operation (most common), unless the physician allows clear fluids up to 3 to 4 hours before surgery. A light meal may be permitted the preceding evening for morning surgery, or a soft breakfast if prescribed when surgery is after noon and does not involve the GI tract. In dehydrated patients, especially older ones, encourage oral fluids as ordered before surgery and give IV fluids as ordered. Monitor the patient with chronic alcoholism for malnutrition and other systemic problems that raise surgical risk, and for alcohol withdrawal (delirium tremens up to 72 hours after withdrawal).

Promoting Optimal Respiratory and Cardiovascular Status

Urge the patient to stop smoking 2 months before surgery, or at least 24 hours before. Teach breathing exercises and use of an incentive spirometer if indicated. Assess the patient with underlying respiratory disease (asthma, COPD) for current threats to pulmonary status and for medications that may affect recovery. In cardiovascular disease, avoid sudden position changes, prolonged immobilization, hypotension, hypoxia, and circulatory overload with fluids or blood.

Supporting Hepatic and Renal Function

In liver disorders, carefully assess liver function tests and acid-base status. Monitor blood glucose frequently in the diabetic patient before, during, and after surgery. Report any steroid use during the preceding year to the anesthesiologist and surgeon, and monitor for signs of adrenal insufficiency. Assess patients with uncontrolled thyroid disorders for a history of thyrotoxicosis (hyperthyroid) or respiratory failure (hypothyroid).

Promoting Mobility and Active Body Movement

Explain why frequent position changes matter after surgery (improve circulation, prevent venous stasis, promote respiratory function), and show the patient how to turn side to side and assume the lateral position without pain or disrupting IV lines, drainage tubes, or other apparatus. Discuss any special position required after surgery (adduction or elevation of an extremity) and the value of staying as mobile as restrictions allow. Teach extremity exercises: extension and flexion of the knee and hip (like bicycling while lying on the side), foot rotation (tracing the largest circle with the great toe), and range of motion of the elbow and shoulder. Use proper body mechanics, instruct the patient to do the same, and keep the patient in proper alignment in any position.

Respecting Spiritual and Cultural Beliefs

Help the patient obtain spiritual help if requested, and respect and support each patient's beliefs. Ask whether the patient's spiritual adviser knows about the surgery. When assessing pain, remember that some cultural groups are unaccustomed to expressing feelings openly, and that lack of direct eye contact in some groups is a sign of respect, not avoidance or disinterest. Listen carefully, especially during the history; good communication and interviewing yields invaluable insight. Remain unhurried, understanding, and caring.

Providing Preoperative Patient Education

Teach each patient as an individual, accounting for their concerns and learning needs. Begin as early as possible, in the physician's office and continuing through the preadmission visit, diagnostic testing, and arrival in the operating room. Space instruction over time so the patient can absorb information and ask questions, and combine teaching with preparation procedures for an easy flow, including descriptions of the procedures and the sensations the patient will feel. During the preadmission visit, arrange for the patient to meet and question the perianesthesia nurse, view audiovisuals, and review written materials, and provide a phone number to call with later questions. Reinforce the possible need for a ventilator and the presence of drainage tubes or other equipment so the patient can adjust postoperatively, and tell the patient when family and friends can visit and that a spiritual adviser is available.

Teaching the Ambulatory Surgical Patient

For same-day or ambulatory surgery, teach about discharge and followup home care by videotape, telephone, group meeting, night class, preadmission testing, or the preoperative interview. Answer questions and describe what to expect. Tell the patient when and where to report, what to bring (insurance card, list of medications and allergies), what to leave at home (jewelry, watch, medications, contact lenses), and what to wear (loose-fitting comfortable clothes, flat shoes). During the last preoperative phone call, remind the patient not to eat or drink as directed; brushing teeth is permitted but no fluids should be swallowed.

Teaching Deep Breathing and Coughing Exercises

Teach the patient to promote lung expansion and blood oxygenation after anesthesia by sitting up, taking deep slow breaths (maximal sustained inspiration), and exhaling slowly. Demonstrate how to splint the incision line to minimize pressure and control pain for a thoracic or abdominal incision. Tell the patient that pain medications are available and should be taken regularly so deep breathing and coughing exercises stay effective.

Explaining Pain Management

Instruct the patient to take medications as frequently as prescribed during the initial postoperative period. Discuss oral analgesics before surgery and assess the patient's interest and willingness to participate in pain relief. Teach the use of a pain rating scale to support postoperative pain management.

Preparing the Bowel for Surgery

If ordered, give or instruct the patient to take the antibiotic and a cleansing enema or laxative the evening before surgery, repeated the morning of surgery. Have the patient use the toilet or bedside commode rather than the bedpan for the enema, unless contraindicated.

Preparing the Patient for Surgery

If the surgery is not an emergency, have the patient use a detergent-germicide for several days at home. If hair is to be removed, remove it immediately before the operation with electric clippers. Dress the patient in a hospital gown left untied and open in the back. Cover the hair completely with a disposable paper cap; long hair may be braided and hairpins removed. Inspect the mouth and remove dentures or plates.

Remove jewelry, including wedding rings; if the patient objects, securely fasten the ring with tape. Give all valuables, dentures, and prosthetic devices to family, or label them clearly with the patient's name and store them safely per agency policy. Assist patients (except those with urologic disorders) to void immediately before going to the operating room. Give preanesthetic medication as ordered, keep the patient in bed with side rails raised, observe for untoward reactions, and keep the surroundings quiet to promote relaxation.

Transporting the Patient to the Operating Room

Send the completed chart with the patient, attaching the surgical consent form, all laboratory reports, and nurses' records, and note any unusual last-minute observations bearing on anesthesia or surgery at the front of the chart. Take the patient to the preoperative holding area and keep it quiet, avoiding unpleasant sounds or conversation.

Attending to the Special Needs of Older Patients

Assess the older patient for dehydration, constipation, and malnutrition, and report if present. Maintain a safe environment for sensory limitations such as impaired vision or hearing and reduced tactile sensitivity. For arthritis affecting mobility and comfort, use adequate padding for tender areas, move the patient slowly, protect bony prominences from prolonged pressure, and use gentle massage to promote circulation. Take added care when moving an elderly patient, since decreased perspiration leaves dry, itchy, fragile skin that abrades easily. Apply a lightweight cotton blanket during transport, since decreased subcutaneous fat makes older people more susceptible to temperature changes. Give the patient a chance to express fears, which brings some peace of mind and a sense of being understood.

Attending to the Family's Needs

Assist the family to the surgical waiting room, where the surgeon may meet them after surgery. Reassure them not to judge the seriousness of the operation by how long the patient is in the operating room. Tell those waiting that the patient may return with equipment in place (IV lines, indwelling urinary catheter, nasogastric tube, suction bottles, oxygen lines, monitoring equipment, blood transfusion lines). When the patient returns to the room, explain the frequent postoperative observations.