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preoperative nursing careSTUDENT NAME : EISSA HUSSAIN

COURSE COORDINATOR: DR. HASSAN OMRAN

CLINICAL INSTRUCTOR

: DR.SHADI ALSHADFAN

, DR.FIRAS ABU SNEINEH

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OBJECTIVES Surgical, medical

and anaesthetic aspects of assessment

optimise the patient's condition

take consent organise an

operating list

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OUTLINE INTRODUCTION PREOPERATIVE PLAN Assessment CONSENT INVESTIGATIONS postponing CONCLUSION

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2. PREOPERATIVE PREPARATION

Definition Preoperative care:

Preoperative care is the preparation and management of a patient prior to surgery. It includes both physical and psychological preparation.

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. INTRODUCTION

‘preoperative assessment’ clinic is essential to gather all information, optimise co morbidities, and then organise anaesthetic, surgical and postoperative care before surgery actually takes place. Patients with severe co morbidities should be referred to the relevant specialist to quantify the risks and to take appropriate measures to minimise operative morbidity.

• Surgery cannot be made risk free, but risks must be known so that the patient can make an informed decision.

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SURGICAL CLASSIFICATIONS Diagnostic- e.g., exploratory

lapratomy Curative- appendectomy Reconstructive or

cosmetic- face lift Palliative- gastrostomy tube

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.PREOPERATIVE PLAN

Preoperative plan for the best patient outcomes

• Gather and record all relevant information • Optimise patient condition • Choose surgery that offers minimal risk and

maximum benefit • Anticipate and plan for adverse events • Inform everyone concerned

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ASSESSMENT assessment differs from those performed on

the patient in a medical-surgical unit and requires some alterations to the formal nursing process that can challenge new perioperative nurses. One reason for this difference is due to the brief time a perioperative nurse has contact with a conscious patient.

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PSYCHOSOCIAL ASSESSMENT

Preoperative anxiety Outcome

anticipation Alleviate fear Avoid

misinformation Dispel false

conception Respect spiritual

and cultural beliefs

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PATIENT ASSESSMENT HISTORY TAKING • A standard history should be

taken. A set of fixed questions are needed to determine ‘fitness’ for surgery. Surgery-specific symptoms (including features not present), onset, duration and exacerbating and relieving factors should also be documented

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.PRINCIPLES OF HISTORY TAKING 9. PRINCIPLES OF HISTORY TAKING • Listen: What is the problem? (Open

questions) • Clarify: What does the patient expect?

(Closed questions) • Narrow: Differential diagnosis (Focused

questions) • Fitness: Co morbidities (Fixed questions)

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GENERAL PHYSICAL ASSESSMENT Assess nutritional status and

possibility for dehydration, hypovolemia, and electrolyte imbalance

Drug or alcohol use –alcohol withdrawal delirium

Respiratory status: any respiratory diseases and what medications are taken

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GENERAL PHYSICAL ASSESSMENT Cardiovascular

status: - Stabilize patient - Treat hypotension,

hypertension - Surgery can be

modified to meet cardiac tolerance

Hepatic and renal: kidney and liver function tests.

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.GENERAL PHYSICAL ASSESSMENT Endocrine Function: - Use of

corticosteroids - Insulin - Uncontrolled thyroid

: thyrotoxicosis and respiratory failure

Immunologic Function: - any existing allergies - Immunosupression

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GENERAL PHYSICAL ASSESSMENT Previous medication therapy: previous medications include: corticosteroids,

diuretics, antidepressants, tranquilizers, antibiotics, and insulin

Ambulatory patient assessment follow the same protocol

Elderely: Assess for coexisting health problems

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.PREOPERATIVE ASSESSMENT IN EMERGENCY SURGERY • In emergency surgery, the principles of

preoperative assessment is the same as in elective surgery, except that the opportunity to optimise the condition is limited by time constraints.

• Medical assessment and treatments should be started (e.g. according to the Advanced Trauma Life Support (ATLS) guidelines) even if there is no time to complete those before the surgical procedure is started.

• Some risks may be reduced, but some may persist and whenever possible these need to be explained to the patient

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CONSENT

• Valid consent implies that it is given voluntarily by a competent and informed person who is not under duress.

• In emergency situations or in an unconscious patient, consent may not be obtained and the procedure carried out ‘in the best interests of the patient’.

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.RISK ASSESSMENT AND CONSENT RISK ASSESSMENT AND CONSENT • Risks: Related to the co-

morbidities, anaesthesia and surgery

• Explain: Advantages, side effects, prognosis

• Language: Simple, use daily life comparisons to explain risks

• Consents: Valid consent is necessary except in life-saving circumstances

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.INVESTIGATIONS • Full blood count • Serum creatinine • Electrocardiography • Chest radiography • Urinalysis • Blood glucose and HbA1C • Others ( Clotting

screening, β-Human chorionic gonadotrophin, Arterial blood gases, Liver function tests, Relevant investigations to assess capacity of specific organ system and risk associated)

Routine investigation : urine analysis & CBC

Medically fit pt less than 40 yr old ( Hb & sugar in urine )

Medically fit pt more than 50 yr old ( Hb & sugar in urine + chest X-ray & ECG )

More investigation, if the pt has any medical diseases.

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THE OPERATIVE TEAM • Ward, theatre and specialist

nursing staff (circulating, scrub)

• Anaesthetic and surgical teams

• Radiology, pathology involvement

• Rehabilitation and social care workers

• Specific personnel in individual cases

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DUTIES OF NURSES THE PREOPERATIVE HOLDING AREA NURSE'S PRIMARY RESPONSIBILITY IS:

• To provide information and emotional support for patients and their family members.

• To ensure that all preoperative data have been accumulated

• To maintain patients' baseline hemodynamic statuses.

• Instructing and demonstrating exercises that will benefit the patient postoperatively.

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MEDICATIONS

• Continue medication over the perioperative period, especially drugs for hypertension, ischaemic heart disease and bronchodilators.

• Give patients on oral steroid therapy intravenous hydrocortisone.

• Stop oral warfarin anticoagulation 3-4 days preoperatively and check the prothrombin time prior to surgery. If the prothrombin time remains unacceptably high, the patient may require an infusion of fresh frozen plasma.

• Those on warfarin who have had a life-threatening thrombotic episode (e.g. pulmonary embolus) within the previous 3 months should be switched to heparin intravenously until 6h before surgery; the heparin can usually be recommenced 4h after surgery.

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COMMON CAUSES FOR POSTPONING SURGERY Acute upper respiratory tract

infection. Untreated medical diseases. Inadequate resuscitates pt in

emergency( 1/3 of fluid lost ) in dehydrated pt & 100 BP in shock pt.

Recent ingestion of food. Failure to obtain informed consent. MI : wait 6 months

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TRANSPORTING THE PT TO THE PRESURGICAL SUITE

On a bed or stretcher 30 minutes before surgery

Pillow and blanket Communicate with and

reassure Pt. Attend for family needs

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CONCLUSION

• The anticipated outcome of preoperative preparation is a patient who is informed about the surgical course, and copes with it successfully. The goal is to decrease complications and promote recovery.

• When patients are adequately prepared psychologically and physically, and policies and guidelines have been followed, the risk of postoperative complications should be low, leading to a quick recovery

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REFERENCES www.medicinenet.com BOOKS Beauchamp, Daniel R., M.D., Mark B. Evers, M.D.,

Kenneth L. Mattox, M.D., Courtney M. Townsend, and David C. Sabiston, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 16th ed. London: W. B. Saunders Co., 2001.

Lawrence, Peter F., Richard M. Bell, and Merril T. Dayton, eds. Essentials of General Surgery, 3rd ed. Philadelphia, PA: Lippincott, Williams & Wilkins, 2000.

Lubin, Michael F., H. Kenneth Walker, and Robert B. Smith, eds. Medical Management of the Surgical Patient, 4th ed. Cambridge, UK: Cambridge University Press, 2003.

Ponsky, Jeffrey, Michael Rosen, Jason Brodsky, M.D., Frederick Brody, M.D., and Jeffrey L. Ponsky. The Cleveland Clinic Guide to Surgical Patient Management, 1st ed. Philadelphia, PA: Mosby, 2002.

Switzer, Bobbiejean, M.D., ed. Handbook of Preoperative Assessment and Management. Philadelphia, PA: Lippincott Williams & Wilkins, 2000.

1. Rothrock JC, McEwen DR. Alexander's Care of the Patient in Surgery. 15th ed. St. Louis, MO: Mosby; 2007. [Context Link]

2. Association of periOperative Registered Nurses. Perioperative Standards, Recommended Practices and Guidelines. AORN Inc.: Denver, Colo.; 2008. [Context Link]

3. Peterson C. AORN Perioperative Nursing Data Set, (2nd ed.). AORN Inc.: Denver, CO; 2008. [Context Link]

http://www.healthline.com

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