Preoperative Patient Care

8/12/2019 Preoperative Patient Care

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Preoperative patient care

Patients facing any surgical procedure tend to be fearful. They require emotional and physical support from the

time of admission through discharge. Surgery is often associated with anxiety, pain, and discomfort. Before

surgery, the patient is given medication to promote relaxation. During surgery, anesthetics are given to prevent

pain. After surgery, medications are given to reduce discomfort.

ANESTHESIA

Anesthesiais given to prevent pain, to relax muscles, and to induce forgetfulness. General anesthetics cause the

patient to become unconscious and block reception of pain in the brain. Local anesthetics induce loss of feeling

in a specific area of the body. Spinal anesthesiais used for some surgeries. The patient will be unable to feel or

move the legs after surgery. Special monitoring is required.


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SURGICAL CARE

Care of the surgical patient (perioperative) can be divided into three parts:

Preoperative(before surgery)

Operative(in the operating room)

Postoperative(after surgery)

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Physical Preparation

The nursing assistants responsibilities begin when the person is admitted. If the patient is in the facility the

evening before surgery, part of the surgical preparation may be done then. The patient will be placed on

NPO(nothing by mouth) orders after midnight. Remove the water pitcher from the room and post an NPO notice

over the bed, on the door, on the patients chart, and on the Kardex.

The surgical prep area- You may be assigned to prepare the patients skin before surgery. Hair removal was

routine for many years. The current trend is to avoid shaving whenever possible. In many facilities, preoperative

shaving requires a physicians order. Hair may be removed with clippers if it is especially thick. Studies have

shown that shaved patients develop more infections than unshaved patients. You may be instructed to wash and

prepare the operative area. This area will be larger than the surgical incision area

Immediate preoperative care- Approximately one hour before surgery, the nurse will give additional medication.

You will be instructed to elevate the side rails. Do not let the patient get up alone after the medication is given.
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Make sure the call signal is within reach. You may be asked to:

Take and record vital signs

Remove dentures and any other prosthesis(artificial part), such as a hearing aid contact lenses, or glasses.

Store these items appropriately.

Remove nail polish, makeup, hairpins, and jewelry. You may be permitted to tape a plain wedding band in

place. However, metal on the patients body interferes with an instrument used in some surgeries, and could

result in serious burns. Check with the nurse before taping a ring.

Dress the patient in a gown and cover the hair with a surgical cap.

Assist the patient to avoid and measure the urine, if ordered. Drain the catheter, if present, and record.

Keep the room quiet and comfortable.

Move furnishings to one side to make room for a stretcher.

Elevate the bed to stretcher height and assist in transferring the patient from the bed to the stretcher and, after

surgery, from the stretcher to the bed.

Complete the surgical checklist, if this is your responsibility.

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Caring for the Emotionally Stressed Patient

There are varying degrees and differing aspects of health. A person who is in poor physical health may be

mentally healthy. Because of good mental health, the person may be self-reliant, able to make decisions and to

live an effective, productive life.

In contrast, a person with good physical health may not be able to cope with and adapt to changes. This inability

limits the persons ability to participate successfully in society.
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MENTAL HEALTH

Mental health means exhibiting behaviors that reflect a persons adaptationor adjustment to the multiple stresses

of life. Stresses or stressors are situations, feelings, or conditions that cause a person to be anxious about his or

her physical or emotional well-being. Good mental health leads to positive adaptations. Poor mental health is

demonstrated by behaviors that harm the person or her adjustment. Physical and mental health are interrelated.

Physical illness is often preceded by stressful life situations. Ill health causes emotional stress. It is easy to

understand that each of these factors contributes to the total health pattern of each person. Ways of coping with

(handling) stressful situations are learned early in life. As people grow, they find the behaviors that work best for

them. They learn to use those behaviors to reduce stress and protect self-esteem. These coping patterns

become part of the individuals habitual responses, becoming more and more obvious as the person ages.

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ANXIETY DISORDERS
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Anxiety is fear, apprehension, or a sense of impending danger. It is often marked by vague physical symptoms,

such as tension, restlessness, and rapid heart rate. An anxiety disorder is one of a group of recognized mental

illnesses involving anxiety reactions in response to stress.

Assisting a Patient Who Is Upset, Anxious, or Agitated

Attempt to identify and eliminate str essors.

Do not argue with or confr ont the patient.

Make the environment safe.

Keep a recent photo of the patient in case he or she wanders of f

Monitor the patients activities. Such a patient is at risk of injury.

Notify the nurse pr omptly if the patient wanders away fr om the unit, facility, or home.

Assign the patient brief tasks, or engage the patient in activities that enhance self-esteem.

Use bean-bag seats and r ocking chairs in the long-term care facility or the patients home.

Watch for injuries.

Prevent the patient fr om becoming exhausted.

AFFECTIVE DISORDERS

Affective disordersare a group of mental disorders characterized by a disturbance in mood. They may also be

called mood disorders, and are usually marked by a profound and persistent sadness.

AFFECTIVE DISORDERS


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Assisting the Patient Who Is Depressed

Be honest, supportive, and caring.

Be a good listener. Encourage the patient to express feelings. Avoid passing judgment or criticizing what the

patient feels. Avoid interrupting or changing the subject.

Give positive feedback on the patients strengths and successes.

Acknowledge the patients feelings.

Avoid comments like, Cheer up. Things could be worse.

Encourage physical activity to the extent possible. Exercise reduces stress.

Encourage the patient to laugh r egularly. Laughter is therapeutic and reduces stress. Turn on a funny

television program or tell a joke.

Monitor the patients appetite and report overeating or undereating to the nurse.

Reinforce the patients self-concept by emphasizing the patients value to society and helping the patient to use

his or her support systems.

Encourage and allow the patient to make decisions about daily routines and activities. Give him or her as much


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control as possible.

Do not act sympathetic. This validates the patient s poor self-image and depressed feelings.

Report complaints so that pr oblems may be identified and corrected rather than being attributed to the

depression.

Provide the patient with activities within his or her limitations.

Use simple language and speak slowly when giving instructions.

Monitor elimination carefully; constipation is common.

Provide fluids frequently; the patient may be too preoccupied to drink.

Be alert to the potential for suicide(the taking of ones own life).

Watch for and report:

Change in mood or behavior, such as deepening depression or suddenly seeming happy and calm

Withdrawal or secretiveness

Repeated, prolonged, or sporadic refusal of food, care, medications, or fluids

Hoarding of medications

Sudden decision to donate body parts to a medical school

Sudden interest or disinterest in religion

Purchase of a gun, razor blades, or other harmful items and hiding them

Statements such as: I just want out, or I want to end it all

Increased use of alcohol and drugs

Deep preoccupation with something that cannot be explained

Nursing Care of a Patient with the Potential for Suicide

Never assume that a suicide attempt is a means of getting the attention of staff or family. At least 15% of people

who try to commit suicide do it again. The suicide rate is higher in acute medical units than it is on psychiatric

units. Most suicides occur while the person is being supervised by a health provider, who either misses or

ignores the clues.

Suicide Precautions

When a person is suicidal, the care plan will list certain suicide precautions. These are checks and practices a

facility follows if a patient is a suicide risk. The pr ecautions are continued until the patient is believed to be out of

danger. When a patient is on suicide precautions, you should:

Monitor for and report clues to suicide attempts; never ignore a patients statements or threats about suicide.

Be consistent in approaches and care.

Emphasize positive aspects of the patients life, and give the patient hope while being r ealistic

Work to restore the patients self-esteem, self-worth, and self-respect.

Make the patient feel accepted and valued as a unique individual.

EATING DISORDERS

Eating disorders are a group of conditions in which the person has disturbances of appetite or food intake. The

two most common are anorexia nervosa and bulimia nervosa. These conditions can occur in both males and


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females. Eating disorders are common in persons with borderline personality disorder. The conditions often

overlap and are difficult to identify. People with eating disorders are usually very secretive, so family and close

friends may not become aware of the condition until weight loss is profound. The electrolyte imbalance and

starvation caused by these conditions can lead to death.

COMMON EATING DISORDERS

Anorexia nervosa- Condition in which the person views his or her body as fat and limits food intake through diet,

exercise, purging, and taking laxatives and diuretics.

Bulimia nervosa- Condition in which the person binge-eats huge amounts, then vomits (purges), or takes

laxatives and diuretics to undo the binge.

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SUBSTANCE ABUSE

Substance abuse is characterized by the use of one or more substances (such as alcohol or drugs) to alter

mood or behavior, resulting in impairment and poor judgment. Over time, the behavior strains finances, causes

irresponsibility, and interferes with the persons ability to function normally. Drug abuse can be by use of illegal

(street) drugs, such as marijuana, cocaine, or heroin; or misuse of prescription drugs, such as narcotic pain

medications, without proper physician knowledge or oversight. Drugs may be swallowed, chewed, inhaled,

injected, or smoked

Alcoholism

Alcohol is a drug and alcoholismis a disease. Some people use alcohol as a means of coping with stress. It

slows brain activity and alters alertness, judgment, coordination, and reaction time. It mixes unfavorably with

many other drugs. Persons who are quitting the use of alcohol may have delirium tremens (DTs). DTs are

serious withdrawal symptoms seen in persons who stop drinking suddenly following continuous and heavy

consumption. These symptoms usually begin 48 to 96 hours after the person takes the last drink. They can

become lifethreatening and require immediate treatment. Common signs and symptoms of DTs are confusion,tremors, and hallucinations.

DEFENSE MECHANISMS

The inability to cope with stress threatens self-esteem, causing the person to act in protective ways. These

actions are called defense mechanisms. The defense mechanisms temporarily reduce the stress, but do not

resolve it.

Everyone uses defense mechanisms from time to time. Most people use a combination of defenses. People are

usually unaware that they are behaving defensively. This behavior becomes harmful only when it is the major or

sole means of coping with stress and the person avoids using problem-solving to respond to reality.

ASSISTING PATIENTS TO COPE
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The nursing assistant can help patients become better able to cope and adapt by:

Being a good listener.

Trying to identify the source of stress so it can be removed.

Being sensitive to body language that may give clues to the source of stress.

Recognizing the patient as a unique individual and treating him or her with respect.

Trying to understand the patients point of view without passing judgment.

Showing that you are dependable and respect the patients privacy and feelings.

Being supportive.

THE DEMANDING PATIENT

In every nursing care situation, you will meet patients who are very demanding. This can be a difficult experience

for everyone if it is not handled correctly. Being demanding is a coping behavior that some patients use when

they are frustrated. Persons who are very demanding are usually feeling as if they have lost control. To be

successful in caring for these patients, the nursing assistant can use several tactics:

Reassure the patient that you understand the complaint or problem and will report it to the appropriate person.

If the complaints are about care given by others, remain neutral and do not criticize other workers. If complaints

are about your care, listen, but do not argue or become defensive.

Attempt to determine the cause of unjustified complaints and correct it, if possible.

Try to identify the triggers of the demanding behavior.

Show that you care, but control your emotions.

Support the patient; be a good listener and be sensitive to the patients body language.

Provide opportunities for the patient to regain some control.

Encourage and allow the patient to make decisions about things that affect him or her.


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Disorientation is a condition in which a person shows a lack of reality awareness with regard to time, person, or

place. It may be mild or severe, temporary or prolonged. The person has impaired judgment, memory, and

understanding.

Delirium is an acute confusional state caused by reversible medical problems. It is often hard to tell whether a

person is disoriented, has delirium, or both. Delirium is common in elderly persons as a result of medical

problems such as infection and dehydration. Anesthesia, some medications, and uncorrected vision or hearing

may cause the patient to misinterpret the environment. Delirium goes away when the physical and mental

triggers of the problem are identified and eliminated. This can be confusing, because delirium often has multiple

causes. All must be treated before the mental status returns to baseline.

Nursing Assistant Responsibilities

People with disorientation and delirium are not responsible for their actions, and cannot protect themselves.

Thepatients sensory problems (delusions or hallucinations) may put others at risk. Protecting the patients is the

most important nursing responsibility.

Assist disoriented patients with reality orientation activities. Reality orientation involves making the patient aware

of person, place, and time by visual reminders, activities, and verbal cues. This approach reduces agitation in

some patients, but increases agitation in others. Follow the care plan and the nurses instructions.


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Reminiscing is an approach you may see listed on the care plans of some patients. Reminiscing(remembering

past experiences) is a natural activity for people of all ages. We reminisce when we see old friends or get

together with families.

Validation therapy is a technique that maintains dignity by acknowledging the patients memories and feelings. It

involves encouraging patients to express their feelings, and reassuring the patient that their feelings are

worthwhile. When the patient describes an emotion, assure him or her that it is okay. Your facility will teach you

how to provide reality orientation, reminiscing, and validation therapy if you will be using these techniques in

patient care. You may also wish to review the information on managing behavior problems, sleeping problems,


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dementia, aggression, yelling and calling out, sexual behavior problems, wandering, reality orientation,

reminiscence and validation therapy.

BEHAVIOR OBSERVATIONS -TO MAKE AND REPORT

Always report abnormal behavior to the nurse, even if you believe that the behavior is normal for the patient.

Who? Does the behavior involve another person or specific types of people? How ar e these individuals alike?

What? Describe the behavior. What were the circumstances in which the behavior occurred?

Where? Did the behavior occur in one specific location?

When? What is the time of day? Does the behavior occur at predictable times or in predictable situations, such

as during bathing? When the patient is tired, when the patient awakens, etc.?

What were the environmental conditions? Was it light, dark, hot, cold, noisy, quiet?

How do others respond to the patients behavior? Is there anyone who is never approached by the patient? If

so, how does this person manage or prevent the behavior?

Is there a pattern to the behavior? Can you identify clues or signals that the behavior is about to begin?

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PROFESSIONAL BOUNDARIES

As a nursing assistant, you must stay within certain professional boundariesin the care of each patient.

Boundaries are unspoken limits on your physical and emotional relationship with patients. It takes good

judgment and experience to identify boundaries and keep from crossing them. Boundaries are like traveling from

town to town on a one-way street. You cannot see a line marking when you leave one town and enter another.

Once you have crossed the line, though, turning around on the one-way street is impossible. Learn how to

identify boundaries and avoid crossing them.

Ethical Behavior with Patients and Families

As a nursing assistant, patients expect you to act in their best interests and treat them with dignity. You do this

by not taking advantage of a patients situation and by avoiding inappropriate involvement in the patientspersonal and family relationships. Some relationships with patients and families are not healthy. It is not always

easy to recognize unhealthy relationships until it is too late. Strive to keep your relationships professional.

Actively work to find a balance in your relationships with patients and families. If any of the following occur, you

are probably crossing professional boundaries and may be in a relationship danger zone:

Discussing your personal problems with the patient or his or her family members

Being flirtatious with a patient, including using sexual innuendoes, telling jokes that are sexual in nature, or

using offensive language

Discussing your feelings of sexual attraction with a patient

Feeling that you may become involved in a sexual relationship with the patient

Keeping secrets with a patient and becoming defensive when someone questions your relationship or
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involvement in the patients personal life

Thinking that you are immune from having an unhealthy relationship with a patient

Believing that you are the only nursing assistant who can meet the patients needs

Spending an inappropriate amount of time with the patient, including off-duty visits or trading assignments with

others to be with the patient

Reporting only partial information about the patient to the nurse, because you fear disclosing unfavorable

information or secrets the patient has told you

Feeling that you must protect the patient from other workers and always siding with the patients position. If you

have trouble staying objective, or think you may cross a boundary, seek help from the nurse, your clergyperson,

or another professional person whom you trust.

Consequences of Boundary Violations

Boundary violations lead to inappropriate relationships. These cloud your clinical judgment, and often carry over

into your personal life. The improper relationship may cause you to do things that you would not ordinarily do(such as stealing from your employer). There are many serious personal, legal, and professional consequences

to inappropriate relationships. For your own well-being, be aware that professional boundaries exist, and actively

take steps to keep from crossing them.

Enabling

Enabling behavior is a method of shielding a patient from the consequences of his or her behavior. Enabling

differs from helping because it allows the patient to be irresponsible. By respecting professional boundaries, you

will avoid helping others inappropriately. Enabling behavior causes dependency rather than moving the patient

toward independence and good mental health.

Strive to keep your behavior in the zone of helpfulness to avoid crossing professional boundaries and enabling

patients.

Assisting Patients Who Have Behavior Problems

Follow the care plan.

Control your own responses and reactions.

Be a good communicator.

Practice empathy.

Avoid lying to the patient.

Avoid making promises you cannot keep.

Do not give a patient false hope.

Avoid making a patient feel as if her problems, feelings, or hopes are unimportant.

Avoid discussing facility or staf f problems with the patient.

Protect the safety of the patient and others.

Follow the car e plan when the tar get behavior starts.

Attempt to learn the cause (trigger) of the behavior ,and remove it if known.

Inform others know if you discover an approach that works.

Modify your own behavior in r esponse to the patients behavior.


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Watch the patients response to your approaches. Adjust your approach, if necessary.

Meet the patients physical needs. Anticipate needs for patients who cannot communicate.

Give patients as much contr ol as possible. Offer choices in care and routines. Encourage patients to direct

their own care.

Be patient. Make sure your body language does not send the wr ong message.

Be happy. Smile. Positive behavior is contagious.

Preoperative Patient Care

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