RU on Preop Prer

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College of Nursing

Silliman University

Dumaguete City

RU on Preoperative Preparation

of the Patient

Submitted to: Mr. Eleno Mariano Melon IV

Submitted by: Jowillene Pearl O. Jatico

BSN IV D4

June 15, 2011


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VISION:

A leading Christian institution committed to total human development for the well- being for the w

of society and environment.

MISSION:

1.Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ; proan environment where Christian fellowship and relationship can be nurtured and promoted.

2.Provide opportunities for growth and excellence in every dimension of the University life in ordestrengthen character, competence and faith.

3.Instill in all members of the University community an enlightened social consciousness and a dsense of justice and compassion.

4.Promote unity among peoples and contribute to national development.College of Nursing


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SPECIFIC

OBJECTIVESCONTENT T/A T/L

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entifytheneededdata

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I. Prayer

II. Introduction of Preoperative Preparation of the Patient2.1 O 5erviewThepreoperativeperiod

6

eginswhentheclient isscheduledforsurgeryandendsattheti7

eoftransfertothe

surgical suite.Asanurse, you7

ustactasaneducator, anadvocate, andapromoterofhealth. Thesurgical environment

demandstheuseofknowledge, judgment, andskills6

asedontheprinciplesofnursingscience.Care6

eforesurgery

focusesonclientreadiness. Thiscare includeseducationandany interventionneeded6

eforesurgerytoreduceanxiety

andcomplicationsandtopromotecooperation inproceduresaftersurgery.

2.2 GoalTheoverall goal ofpreoperativeperiod istoensurethattheclient ismentallyandphysicallypreparedforthesurgery.8urses have long

6

een recognizing the value of preoperative instructions, with this, they are teaching each patient

individuallyanduniquelywithconsiderations to theconcernsof the learningneedsof thepatient. Teaching strategies

suchasverbal, written, andreturndemonstrationareuseddependingonthepatientsneedsandabilities.9

reoperative

teaching is initiatedassoonaspossibleandshouldstartatthephysiciansofficeoratthetimeof9

AT continuedwhenthe

patientarrives inthe OR.

III. Nursing Process3.1PreoperativeAssessmentA. Physiological parametersy Age

Olderclientsareat increasedrisk forcomplications. Thenormal agingprocessdecreases immunesystem

functioninganddelayswoundhealing. Thefrequencyofchronic illness increases inolderclients.

y HealthAssessmenta. PastHealthHistory

5

mins.

1hour

Interacti

discussio

andgivi

of

handout

Socialize

lecture

withvisu

aid

presenta

n


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o Takebaselinebloodpressure inbotharms.o Identifyanydrugorherbal productthatmayaffectcoagulation.o Review laboratoryanddiagnostictestsforcardiovascularfunction.o Identifypatientswithpacemakersand/or implantabledefibrillators.

Respiratory System

o Identifyacuteorchronicproblems;notethepresenceofinfectionorchronicobstructivepulmonarydisease,asthma. Thepresenceofanupperairway infectionmayresult inthecancellationorpostponementofelective

surgerybecausetheexisting infectionwill placethepatientatan increasedrisk ofbronchospasm, laryngospasm,

decreasedoxygensaturation, andproblemswithrespiratorysecretions. Thenurseshouldalsoreportapatients

historyofdyspneaatrestorwithexertionandhemoptysis. Ifapatienthasahistoryofasthma, thenurseshould

inquireaboutthepatientsuseofinhaledororal corticosteroidsandbronchodilators, aswell asthefrequencyand

triggersofasthmaattacks. ThepatientwithahistoryofCOPD andasthmaareathighrisk ofpostoperative

pulmonarycomplications, which includehypoxemiaandatelectasis.

o Assesshistoryofsmoking, includingthetime interval sincethe lastcigaretteandthenumberofpack-years. Thepatientwhosmokesshouldbeencouragedtostopat least 6 weekspreoperativelytodecreasetherisk

intraoperativeandpostoperativereapiratorycomplications.

o Auscultate lungsfornormal andadventitiousbreathsounds.o Determinebaselinerespiratoryrateandrhythm, andregularityofpattern.o Observeforcough, dyspnea, anduseofaccessorymusclesofrespiration.

Neurologic System

o Determineorientationtotime, place, andperson.o Identifypresenceofconfusion, disorderlythinking, or inabilitytofollowcommands.Alterations inthepatients

hearingandvisionmayaffectresponsesandabilitytofollowdirectionsthroughouttheperioperativeassessment

andevaluation. Thepatientsabilitytopayattention, concentrate, andrespondappropriately inthepreoperative

phasemustbedocumentedtoestablishanaccuratebaselineforpostoperativecomparison.

o Identifypasthistoryofstrokes, transient ischemicattacksornervoussystemdiseases.Urinary System

o Identifythepreexistingdisease. Thepresentdiseasestateandtreatmentusedtocontrol thediseaseshouldbenotedanddocumented.

o Determineabilitytovoid.Prostateenlargementmayaffectcatheterizationduringsurgeryandabilitytovoid


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preoperatively.

o Ifnecessary, notecolor, amount, andcharacteristicsofurine.o Review laboratoryanddiagnostictestsforrenal function.Adecrease inrenal functionmaycontributetoan

alteredresponsetodrugsandunpredictabledrugelimination. Renal functiontests, suchasserumcreatinineand

bloodureanitrogen, arecommonlyorderedpreoperatively, andresultsshouldbeavailableonthechartbefore

thepatientgoestosurgery.

Hepatic System

o Inspectskincolorandscleraofeyesforanysignsofjaundice.o Reviewpasthistoryofsubstanceabuse, especiallyalcohol and IV druguse.o Review laboratoryanddiagnostictestsfor liverfunction. Thepatientwithhepaticdysfunctionmayhavean

increasedperioperativerisk forclottingabnormalitiesandadverseresponsestomedications.

Integumentary System

o Assessmucousmembranesfordrynessand intactness. Thecurrentstatusoftheskinshouldbeassessedforboils,rashes, ulcers, orotherdermatologiccondition.

o Determineskinstatus;notedrying, bruising, orbreaks insurface. Skinproblemsmayaffectpostoperativehealing.o Inspectskinforrashes, boils, or infection, especiallyaroundtheplannedsurgical site.o Assessskinmoistureandtemperature.o Inspectthemucousmembranesandskinturgorfordehydration.

Musculoskeletal System

o Examineskin/bonepressurepoints.o Assessforpresenceofanypressureulcers.o Assessfor limitations in jointrangeofmotionandmuscleweakness.Mobilityrestrictionsmay influence

intraoperativeandpostoperativepositioningandambulation.

o Assessmobility, gait, andbalance.o Assessforpresenceofjointpain. Frequently, postoperativepain isduetochronicmusculoskeletal painand

positioningduringsurgery, ratherthantheacutepainofthesurgical procedure.

Gastrointestinal System

o Determinefoodandfluid intakepatternsandanyrecentweight loss. Thepatientshouldbe questionedabouttherecentpresenceofconditionsthat increasetherisk forfluidandelectrolyte imbalances, suchasvomiting,

diarrhea, ordifficultyswallowing.


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Electrolyte imbalancealso increaseoperativerisk.Preoperative laboratoryresultsshouldbecheckedtosee

whetherserumsodium, potassium, calcium, andmagnesiumconcentrationsarewithinthenormal range.

B. Psychosocial ParametersMostpatientshavesometypeofemotional reactionbeforeanysurgical procedure, be itobviousorhidden,

normal orabnormal. Fearsmayberelatedtofearoftheunknownorofdeath, anesthesia, pain, complications, or

cancer.Preoperativeanxietymaybeananticipatoryresponsetoanexperienceviewedbythepatientasathreatto

hisorhercustomaryrole in life, permanent incapacity, body integrity, increasedresponsibilitiesorburdenonfamily

members, or life itself. Lessobviousconcernsmayoccurbecauseofpreviousexperienceswiththehealthcaresystem

andpeoplethepatienthas knownwiththesamecondition.Psychological distressdirectly influencesbodyfunctioning. Therefore, it is imperativeto identifyanyanxietythepatient isexperiencing.Peopleexpressfear in

differentways. Forexample, somepatientsmayrepeatedlyask many questions, eventhoughanswersweregiven

previously. Othersmaywithdraw, deliberatelyavoidingcommunication, perhapsbyreading, watchingtelevision, or

talkingabouttrivialities.Consequently, thenursemustbeempathetic, listenwell, andprovide informationthathelps

alleviateconcerns.An importantoutcomeofthepsychosocial assessment isthedeterminationoftheextentandrole

ofthepatientssupportnetwork.

C. Laboratoryand DiagnosticParametersThenurseshouldobtainandevaluatetheresultsoflaboratoryanddiagnostictestsorderedpreoperatively.

CommonPreoperative Diagnostic Testsare:

o Urinalysis-toscreenrenal functiono Chest X-ray-mayberequiredbyhospital policyormedically indicated.Apreoperativechestx-raystudy isnot

routinelyrequiredforall patients. Itmaybemedically indicatedasanadjuncttoclinical evaluationofpatients

withcardiacorpulmonarydiseaseandforsmokers, personsage 60 andolder, andcancerpatients.

o Bloodstudies: RBC, Hb, Hct, WBC-Thesemayberoutinelytestedforpersons 60 yearsofageorolder.Hematocritisusuallyorderedforwomenofall agesbeforetheadministrationofageneral anesthetic.

o Electrolyteso ABGs, oximetryo PT, PTT, plateletcount-to identify knownorsuspectedcoagulationdisorderso Bloodglucose


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o Creatinineo Bloodureanitrogeno Serumalbumino Electrocardiogram-Ifthepatienthas knownorsuspectedcardiacdisease, anelectrocardiogram ismandatory. It

mayberoutineforpatientsB

0 yearsofageorolderbypolicy.

o Pulmonaryfunctiontestso Liverfunctiontestso Typeandcrossmatch-Iftransfusion isanticipated, thepatientsblood istypedandcrossmatched.Manypatients

prefertohavetheirownblooddrawnandstoredforautotransfusion. Theystill shouldbetypedand

crossmatched, however, intheeventthatadditional transfusionsareneeded.o hCG

Preoperative laboratorytestsareorderedonthebasisofthe individual patienthistoryandphysical examination.

Thusthenursemustensurethatall laboratoryreportshavearrivedattherighttimeandareonthechart. Lack of

requireddiagnosticreportsmayresult inadelayorcancellationofthesurgery.

D. PreoperativeAnesthesia EvaluationTheanesthesiacareprovidervisitstheclientbeforesurgerytoperformacompleterespiratory, cardiovascular,

andneurologicexamination. Theclientsgeneral surgical risk isexpressedaccordingtothisgradingsystem:

P1Anormal healthyclient P2Aclientwithmildsystemicdisease P3Aclientwithseveresystemicdisease P4Aclientwithseveresystemicdiseasethat isaconstantthreatto life P5 Amoribundclientwho isnotexpectedtosurvivewithouttheoperation P6 Adeclaredbrain-deadclientwhoseorgansarebeingremovedfordonorpurposes

Generally, thetopicsdiscussedwiththeclientduringthisexamination includethetypeofanesthesiaplannedand

thesensationstheclientmayexperiencewhenundergoinganesthesia. Fearstheclienthasconcerninganesthesiaare

alsoaddressed. Theclientsrisk ofsideeffectsandcomplications isassessedatthistime.

Thepharmacologicpreparationoftheanesthesia isbasedonmanyvariables, includingtheclientsageand

physical andpsychological condition, thetypeofsurgery, andthetypeofanesthesiatobeused.

E. Preoperative Educational AssessmentTheclientsexperiencewithprevioussurgeryandthe level ofanxietyarenoted. Theclientseducation level,


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Enumerateatleast2

nursing

diagnoses in

preoperative

patient

preparation.

Formulate intheirown

understandin

gexpected

outcomes

basedonthe

nursing

diagnosesgiven.

sensory impairments, expectationsregardingtheoperation, andavailabilityofsupportsystemsshouldguideplansfor

teaching. Ingeneral, clientswhohaveundergonemultipleoperationsneed lesseducational preparation.However, do

notassumethatsuchclientsneednoreinforcementofpreoperativeandpostoperativeassessmentsand interventions.

3.2PreoperativeNursing DiagnosesThefollowingareprioritynursingdiagnosesforpreoperativeclients:

o Deficient Knowledge (specificexperiencesbefore, during, andaftersurgery)relatedtoa lack ofexposureo Anxietyrelatedtothethreatofachange inhealthstatusorfearoftheunknown

Othercommonnursingdiagnosesforpreoperativeclients:

o Disturbed Sleeppatternrelatedto internal sensoryalterationso IneffectiveCopingrelatedtothe impendingsurgeryo Anticipatory Grievingrelatedtotheeffectsofthesurgeryo DisturbedBody Imagerelatedtoanticipatdchanges inthebodysappearanceorfunctiono Disabled FamilyCopingrelatedtotemporaryfamilydisorganizationandrolechangeso Powerlessnessrelatedtothehealthcareenvironment, lossofindependence, and lossofcontrol ofonesbody3.3Expected Outcomes

Gained knowledge, asevidencedwhenthepatient

Explainsthepurposeandexpectedresultsoftheplannedsurgery Asks questionswhenatermorprocedure isunknown AdherestotheNPO requirements Statesanunderstandingofpreoperativepreparations (e.g.skinpreparation, bowel preparation) Demonstratescorrectuseofexercisesandtechniquestobeusedaftersurgeryforthepreventionof

complications (splintingthe incision, coughing/deepbreathing, performing legexercises, ambulatingasearlyas

permitted)

Reliefofanxiety, evidencedwhenthepatient

Discusseswiththeanesthesiologistandanesthetistconcernsrelatedtotypesofanesthesiaand induction Verbalizesanunderstandingofthepreanestheticmedicationandgeneral anesthesia Discusses last-minuteconcernswiththenurseorphysician Discussesfinancial concernswiththesocial worker, whenappropriate


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Statecorrectlyat

least3

appropriate

preoperative

instructions.

Requestsvisitwithspiritual advisorwhenappropriate Appearsrelaxedwhenvisitedbyhealthcareteammembers

Decreasedfear, evidencedwhenthepatient Discussesfearswithhealthcareprofessionalsoraspiritual advisor, orboth Verbalizesanunderstandingofanyexpectedbodilychanges, includingexpecteddurationofbodilychanges.

Understandingofthesurgical intervention, evidencedwhenthepatient

Participates inpreoperativepreparation Demonstartesanddescribesexercisesheorshe isexpectedtoperformpostoperatively Reviews informationaboutpostoperativecare Acceptspreanestheticmedication, ifprescribed Remains inbedoncepremedicated Relaxesduringtransportationtothe OR orunit Statesrationaleforuseofsiderails Discussespostoperativeexpectations

Noevidenceofpreoperativecomplications

3.4PreoperativeNursing Interventions3.4.1Day-of-surgeryProceduresA. FacilitatingPreoperative InstructionsNurseshave longrecognizedthevalueofpreoperative instruction. Eachpatient istaughtasan individual,

withconsiderationforanyuniqueconcernsorneeds;theprogramofinstructionshouldbebasedonthe individual's

learningneeds.Multipleteamingstrategiesshouldbeused (e.g.verbal, written, returndemonstration), dependingon

thepatient'sneedsandabilities.Preoperativeteaching is initiatedassoonaspossible. Itshouldstart inthephysician's

officeandcontinueuntil thepatientarrives intheoperatingroom.

WhenandWhatto Teach?

Ideally, instruction isspacedoveraperiodoftimetoallowthepatienttoassimilate informationandask

questionsastheyarise. Frequently, teachingsessionsarecombinedwithvariouspreparationprocedurestoallowfor

aneasyandtimelyflowofinformation. Thenurseshouldguidethepatientthroughtheexperienceandallowample

timefor questions. Somepatientsmayfeel toomanydescriptivedetailswill increasetheiranxiety level, andthenurse

shouldrespecttheirwishfor lessdetail.

Teachingshouldgobeyonddescriptionsoftheprocedureandshould includeexplanationsofthesensations


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y Hospitalsmayrequirethatapatientwearahospital gownwithnounderclothes, whereassurgerycentersmayallowthepatienttowearunderwear, dependingonthesurgical proceduretobeperformed.

y Thepatientshouldnotwearcosmeticsbecauseobservationofskincolorwill be important.y Nail polishandartificial nailsshouldberemovedsothatcapillaryrefill andpulseoximetrycanbeassessed.y An identificationband isputonthepatientand, ifapplicable, anallergyband.y All patientvaluablesarereturnedtoafamilymemberorsecuredaccordingto institutional protocol. Ifthe

patientprefersnottoremoveaweddingring, theringcanbetapedsecurelytothefingertoprevent loss.

y All prostheses, includingdentures, contact lenses, andglasses, aregenerallyremovedtoprevent lossordamagetothem.

y Hearingaidsmaybe left inplacetoallowthepatienttobetterfollow instructions.y Glassesandhearingaidsmustbereturnedtothepatientassoonaspossiblefollowingsurgery.y Thepatientshouldbeencouragedtovoidbeforepreoperativemedicationsareadministered ifthe

medicationswill interferewithmaintainingbalanceand increasetherisk forafall whenambulatingtothe

bathroom.

y Thepatientshouldalsohaveanemptybladderontransfertothe OR toprevent involuntaryeliminationunderanesthesiaandreducethepossibilityofurinaryretentionduringearlypostoperativerecovery.

y Theuseofapreoperativechecklistensuresthatall preoperativehavebeencompletedbeforethepatient isgivenanysedatingmedications.

a. PreoperativeMedicationsPreoperativemedicationsareusedforavarietyofreasons.Apatientmayreceiveasingledrugoracombination

ofdrugs.

y Benzodiazepinesandbarbituratesareusedfortheirsedativeandamnesicproperties.y Anticholinergicsaregiventoreducesecretions.y Opioidsmaybegiventodecrease intraoperativeanestheticrequirementsandtodecreasepain.y Antiemeticsmaybegiventodecreasenauseaandvomiting.

Othermedicationsthatmaybeadministeredpreoperatively includeantibiotics, eyedrops, androutineprescription

drugs.

y Antibioticsmaybeadministeredthroughoutthepreoperativeperiodforapatientwithahistoryofcongenital or


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Activelyparticipate in

theopen

forumby

askingand

answering

questions

correctly.

hospitalsprovidepagerstowaitingfamilymemberssothattheymayeatordoerrandsduringthesurgery.

Whilethepatient is insurgerythe inpatientnurseshouldhavethepatientsroompreparedforthe

postoperativearrival.Anyadditional necessaryequipment, including IV poles, oxygen, suction, andadditional pillowsforpositioning, shouldalsobeplaced intheroom. Theroomalso isorganizedtofacilitateentryofthetransportcart.

3.4.4 Caringforthe SignificantOthersAdesignatedwaitingarea isusuallyprovidedforfamilymembersduringsurgery. Whendiscussingthesurgical

procedurewiththeclientssignificantothers, besurethatyouare located inaprivateareaandprovideanswers

congruentwiththe informationthatthesurgeonhasalreadyprovided. Familymembersshouldalsobepreparedfor

anyequipmentthatmayaccompanytheclientpostoperatively.Apreoperativeexplanationwill assistthefamily inunderstandingwhatequipment isattachedtotheir lovedone, andwhy. Significantothersneedtobe informedwhen

surgery iscompletedor ifthereareanydelays. Thesurgeonshouldspeak withfamilymembersassoonaspossible

aftercompletionoftheprocedure.

3.5Evaluation: OutcomesEvaluatethecareofthepreoperativeclientonthebasisofthe identifiednursingdiagnoses. Theexpected

outcomes includesthattheclient:

Statesunderstandingofthe informedconsentandpreoperativeprocedures Demonstratespostoperativeexercisesandtechniquesforpreventionofcomplications Hasreducedanxiety

IV. Open Forum 20mins.


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Resources:

Atkinson, I. J., Fortunato, N.H. (1996). Berry & Kohns Operating Room Techniques. 8th

ed. Missouri: Mosby Elsevier.

Black, J.M. & Hawks, J.H. (2009). Clinical management for positive outcomes. 8th

ed. Missouri: Saunders Elsevier, Inc.

Ignatavicius, D.D. & Workman, M.L. (2006). Medical surgical nursing: critical thinking for collaborative care. 5th

ed. Singapore: Elsevier Pte Ltd.

Lewis, S.M., et.al. (2004).Medical surgical nursing: assessmentandmanagementofclinical problems. 6th

ed. Philadelphia: Mosby, Inc.

Smeltzer, S. , Bare, B. , et.al (2008). Textbook ofMedical-SurgicalN

ursing.11

th

ed. Lippincott,U

SA.

V. Evaluation 5mins.


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