Author
Patricia Hartley, RNC, MSN
is the Education/Employee Health
Coordinator at Lake
City Medical
Center. She received her
Masters Degree in Perinatal Nursing from Indiana University/Purdue University
at Indianapolis.
She has 5 years experience in Staff and Patient Education; 28 years clinical
experience that include almost 20 years of Neonatal Intensive Care. She is
certified in High Risk Neonatal Nursing and Fetal Monitoring.
Perioperative
nursing is a specialty that incorporates the care of the surgical patient. It uses
a multidisciplinary approach to care. In the hospital setting this includes most
disciplines in the hospital: nursing, pharmacy, dietary, materials,
environmental and plant operations. Perioperative nursing occurs in a variety
of settings. These include: Out
Patient Centers,
Surgical Services, Postanesthesia Care
Unit (PACU), physician offices, and any area in which surgery or
invasive procedures are performed. Perioperative nursing includes three phases
of the surgical experience: the preoperative, the intraoperative, and the
postoperative phases. This nursing specialty provides continuity of care
through the peri-operative phases. Registered Nurses are responsible for
preparing patients for an operative and/or invasive procedure.
By
the year 2030, it is estimated that 20 percent of Americans will be older than
65, while one out of four elderly individuals will be older than 85 years of
age. Twenty-one percent of those over age 60 will undergo surgery and
anesthesia as compared with only 12 percent of those aged 45 to 60 years.
Despite the higher numbers of elderly patients having surgery, mortality and
morbidity rates have been declining. Old age appears to have assumed less
influence as a determinant of adverse outcomes as perioperative care has improved.
A better understanding of the associated risk factors leading to perioperative
complications may help healthcare providers to further lower the risk.
The
preoperative phase begins when the decision for surgery is made and ends when
the patient is transferred to the operating room table. The preoperative
evaluation and teaching typically takes place several days before surgery in an
outpatient setting. Today, most perioperative patients are admitted to the
hospital the morning of their surgical procedure. However, there are times when
the preoperative phase will begin on the medical-surgical units or in the
emergency department. The first step of the preoperative phases begins with a
patient and chart assessment on all patients scheduled for an operative and/or
invasive procedure prior to transportation to the Surgical Suites. This ensures
accurate identification of the patient, using two identifiers, identification
and marking of the surgical site, adequacy of the preoperative patient
preparation, and completeness of the documentation. This assesses the patients
actual and potential health problems and facilitates implementation and
communication of the perioperative plan of care
Preoperative Assessment
A
thorough nursing assessment and appropriate interventions can prevent or
minimize procedure related complications. The preoperative assessment is
essential to identify problems early, and to provide a comparison for
postoperative deviations from the norm. Sometimes,
the initial nursing assessment is done in a preadmission visit that may also
include preoperative teaching and outpatient testing. However, it is critical
that the nursing assessment be repeated the morning of surgery. This assessment
should include at a minimum, vital signs, respiratory status, an assessment of
the level of consciousness, and review of preoperative testing results.
Psychosocial Assessment
The psychosocial assessment many times
will be different from the admission assessment; since surgery may not have
been a reality at the time of admission.
The
preoperative psychosocial assessment aims to identify potential or actual
sources of the patients anxiety, such as altered sleep patterns, increased
pulse and respiratory rates, increased perspiration, and frequent voiding. It includes
the patients understanding of the surgery, previous surgical experiences,
specific concerns or feelings about surgery, and religious feelings that affect
anxiety.
Fear can take different forms,
including fear of the unknown, loss of control, loss of love from significant
others, threat to sexuality from surgery, diagnosis of cancer, anesthesia,
dying, pain, disfigurement, permanent limitations, loss of lifestyle (as
evidenced by occupational and recreational changes), and current and future
financial problems.
Physical Assessment
The preoperative physical assessment
aims to make surgery safe and comfortable for the patient. Again, this will be
different than the admission assessment.
The nurse will be focusing on objective data acquired after the decision
for surgery has been made.
Respiratory Assessment
Question the patient about smoking. To
prevent respiratory complications the patient should stop smoking 4 to 6 weeks
prior to surgery. Many studies have also
shown a correlation between smoking and poor wound healing. Optimally there should be no smoking the day
of surgery. If they smoke, how many
packs per day and for how long? Smoking increases post-op respiratory
complication by decreasing the amount of functional hemoglobin available and
impairs oxygen delivery to the tissues. Smoking
is associated with the surgical complication of atelectasis, and one study
found it doubled the risk of postoperative pneumonia (Tiernevu, 2000).
Evaluate patients with pulmonary
problems. Assess breath sounds and chest
expansion. Chest x-ray is ordered based
on history not on age. If ordered and
completed results need to be put on chart. Evaluation of the patient with
preexisting pulmonary problems may include PFT and ABG. A chest
x-ray should be done within 1 year prior to the procedure for older patients
(i.e. age 60 and older) and for patients with pulmonary conditions. Patient
specific factors that increase the risk of postoperative pulmonary complication
are chronic lung disease, morbid obesity and smoking (Tiernevu, 2000).
Does
the patient have respiratory allergic conditions, such as asthma or hay fever?
Has he had anesthesia-related problems with any previous surgeries? This may
affect the choice of anesthetic agents. Does the patient have chronic
obstructive pulmonary disease (COPD)? This disorder increases the risk of
complications and may require preoperative interventions to correct electrolyte
imbalances, prevent postoperative respiratory infection or remove excess
sputum. Does the patient have an upper or lower respiratory infection? Notify
the physician of such an infection, as it may be reason to delay the procedure.
Anesthesia produces increased bronchial secretions besides the congestion
already present in the case of a respiratory infection. This has a profound
effect on ventilation of the patient.
Cardiovascular Status
Assess heart sounds, rate, and rhythm.
Assess peripheral pulses. Obtain an EKG if ordered. EKG is ordered based on
history not age. Record peripheral pulses when surgery is to be performed on
major blood vessels or the extremities. Obtain CBC
and electrolytes (add type and cross-match if patient undergoing major surgery
that may involve considerable blood loss) REVIEW RESULTS FOR ABNORMAL
LEVELS! When labs are ordered please contact the physician with
abnormal results. Do not assume the lab has contacted them they only call
critical levels. The 2 test results that as a nurse it is especially important
to look at is blood glucose (link between wound healing) and bacteria which
suggest UTI. When ordering a
T&S or T&C for a preoperative patient please get a blood consent
also. Consents will be covered later in
this module.
Kidney and Liver Status
Does the patient have any complaints associated with
kidney or bladder infection? These include frequency, urgency, blood in the
urine, burning on urination, fever, or back, flank or suprapubic pain. Patients
with signs and symptoms of urinary or kidney infection need a more extensive
preoperative evaluation. If renal function is severely compromised by
infection, the stress of surgery can precipitate renal failure.
Liver
biotransforms anesthetics; liver disease impairs the ability to detoxify drugs
that may be given in the perioperative period. Review
results of liver function tests. Kidney excretes anesthetics and
metabolites; good renal function is necessary to maintain fluid and electrolyte
balance. Review results of urinalysis to detect:
albumin (which suggests kidney disease)
glucose (which suggests diabetes)
acetone (which suggests diabetes or
starvation)
bacteria (which suggests urinary tract
infection)
When implanting metallic objects
(TKA/THA), UTI can be very dangerous.
Many times procedures will be cancelled.
Immunologic Status
Assess for allergic reactions to any foods, medication, latex or
soaps. Report
history of bronchial asthma. Many patients with asthma will be given a
preoperative breathing treatment or given medication through a MDI. Some allergic
reactions can be fatal and some can be serious enough to permanently damage
vital organs. It is important that the surgery team know if the patient has
an allergy to iodine, seafood, hexachlorophene or latex prior to the procedure.
Latex
is becoming more of an issue in perioperative nursing. However; the public is not always aware of
latex allergies. Ask if they wear rubber
gloves at home, do they have irritation from their under garments, any problems
when they blow up a balloon? Check for
food allergies, which are linked to latex allergies bananas, kiwi, chestnuts,
papayas, mangos, potatoes. Inquire about unusual reaction to anesthesia by patient or
relatives. The concern is malignant hyperthermia which is
hereditary.
Neurologic Status
The neurological exam provides you with
a baseline to measure against through the postoperative process. Evaluate
cognitive level, language barriers and behavior. Evaluate arm and leg muscle
strength and coordination with ambulation. Assess orientation to person, place
and time. Assessing orientation goes along ways
in helping the Surgical Suite staff. Is this patient competent to sign permits? Does the patient display any signs or symptoms
suggesting significant neurological problems? Symptoms may include headache, numbness
or tingling in an extremity, tremors or weakness in an extremity, unsteady gait,
confusion or memory loss. It is important to document any neurological
deficits preoperatively for comparison with the post-op assessment.
Neurological and behavioral changes can result postoperatively from the effects
of anesthetics, analgesic or sedatives. This is especially true in elderly
patients.
Is
the patient alcoholic? Chronic alcoholism suppresses the adrenocortical
response to operative stress. If the patient does not admit to drinking heavily
and you are concerned that he might be alcoholic, share these concerns with the
physician. Alcoholic patients are at risk for delirium tremors with withdrawal.
Gastrointestinal (GI) Status
Does
the patient complain GI symptoms? These include nausea & vomiting, diarrhea,
constipation, spitting up blood or blood in the stool, gastric ulcer disease, inflammatory
bowel disorder, or diverticular disease. Anesthesia and pain medications affect
the GI function. So, a preoperative assessment is needed for comparison
postoperatively to determine if any problems were caused by the medication or
were preexisting.
Endocrine Status
Is
the patient diabetic? Diabetics should not have insulin on the morning of
surgery due to their NPO (nothing by mouth) status. Do a bedside blood glucose
check and notify the physician of abnormal findings before the procedure. Diabetes
puts the patient at risk for delayed wound healing, postoperative surgical
infection, hypoglycemia or hyperglycemia.
Health History
Allergies drugs, adhesive tape, latex
or soap. Ask about preexisting illness, such as liver, respiratory, renal,
cardiac, endocrine, and blood disease.
Inquire about use of medications that
could interfere with anesthesia or contribute to postoperative complications,
such as bleeding. Ask about herbal usage.
More and more people are using herbs and vitamins and will not always
volunteer this information. Ask about difficulty with hearing or vision. Document
the medications the patient takes regularly, including over the counter and
herbal medications. St.
Johns Wort, feverfew,
ginkgo biloba, ticlid, plavix anticoagulants and non-steroidal
anti-inflammatories effect coagulation and can increase the risk of hemorrhage.
Obtain nutritional history to evaluate
dietary intake and nutritional status. Ask about elimination to detect
constipation or diarrhea. Question the patient about motor problems,
particularly difficulty with walking or with arm or leg movement due to
arthritis or orthopedic surgery.
REMEMBER we want to promote early activity postoperatively.
Ask about the patients ability to
sleep and relax, level of pain or discomfort, and expectations about
postoperative pain relief; perform a baseline pain assessment.
Factors affecting patient response to surgery
Age
Elderly patients may be less able to
tolerate the stress of surgery depending on their age-related physiological
changes and the presence of chronic diseases.
Nutrition
Inadequate intake or an improper diet
can impair the patients ability to tolerate the stress of surgery. It may also have an impact on wound
healing. Excessive intake, reflected by
obesity, also can complicate surgery and the patients postoperative period.
Chronic Disease States
Pulmonary
Disease
can affect the patients response to anesthesia and the ability to cope with
respiratory problems postoperatively.
Cardiovascular
disease
can contribute to shock and fluid imbalances by impairing blood pumping and
blood vessel constriction. An inadequate
supply of red or white blood cells may increase risks related to hemorrhage or
inflammation.
Renal
Insufficiency
may impair electrolyte and waste product removal and increase the risk of fluid
overload, if urine production is inadequate.
Endocrine
Disease can
delay wound healing because of an anti-inflammatory response.
Disabilities that limit
patient activity increase the risk of postoperative atelectasis, pneumonia and
thrombophlebitis.
Preoperative Teaching
The purpose of preoperative teaching is
to decrease patient anxiety and prepare the patient for surgery. It will also
decrease fear. Fear of the unknown increases anxiety. Preoperative teaching can alter unfavorable attitudes,
influence postoperative recovery and promote satisfaction with care. Preoperative teaching may have been done and documented in
a preadmission visit. If not, you must do the teaching. If it was done, you should reinforce the teaching. You can provide a description of and reason for preoperative
tests, description of preoperative routines, time of surgery, probable length
of surgery and estimated time in PACU.
Explain
the recovery process, including the place where the patient will awaken,
nursing care provided, monitoring of vital signs and equipment used (O2
therapy, O2 saturation monitor, PCA).
Cover
the probable postoperative course IV lines, need to increase activity as soon
as possible, need to cough and deep breath despite discomfort, incentive
spirometer (this is a good time to teach them on how to use an incentive
spirometer and have them practice which will make it easier to use
postoperatively) Stress that it is
important to turn, cough and deep breathe to prevent atelectasis. Instruct
him to turn cough and deep breath at least 3 times an hour and to use the
incentive spirometer at least every 2 hours, while awake. Tell family
members what time the patient is expected to go to surgery, where they can wait
during surgery, when the physician will contact them with surgical results.
If
you do the preoperative teaching during a preadmission visit, explain any
instructions that require the patient to prepare himself at home, like bowel
evacuation for a colonoscopy. The morning of the procedure, check to see if the
patient was complied with the instructions. Failing to execute preoperative
preparation may be a reason to postpone the procedure. Explain the meaning of
NPO, emphasizing the importance of being compliant to avoiding aspiration.
Sometimes, patients will be NPO except for their oral medications, which should
be taken with clear water. This variation may be a policy at a specific
facility, or the physicians order will be written as NPO except for
medications. Most patients will be NPO after midnight the day before the procedure. A physician may
designate a later NPO status if the patient is scheduled late in the day.
Instruct the patient to shower the morning of the procedure with an
antimicrobial soap. The patient should wash the operative site for at least
five minutes, scrubbing in a circular motion. Anesthetic will remain in the
patients body for at least 24 hours post procedure, so caution the patient not
to drive, operate dangerous equipment or make important decisions within 24
hours after the procedure. Some procedures have preoperative teaching needs
that are specific to that procedure, like how to use a walker if you are going
to have a hip replacement. These needs are determined in collaboration with the
physician.
Pre-anesthesia Medication
Pre-anesthesia medication varies from
facility to facility. It is usually given immediately before surgery to:
Decrease anxiety
Provide sedation
Induce amnesia
Decrease pharyngeal secretions
Slow hydrochloric acid production
Prevent allergic reaction to anesthetics
If
they are given, they will normally be given by the anesthesia provider just
prior to patient going into the OR. This
is only done AFTER all consents have been signed and are verified complete.
This is not to be confused with the administration of preoperative medications
antibiotics, inhaler, breathing treatment, antacid or h2 blockers (Zantac -
which inhibits gastric acid secretion), antiemetic (Reglan given for gastro
esophageal reflux and/or delayed gastric emptying). May hear term sour stomach.
Informed
Consent
Requiring permission to operate
protects the patient from unsanctioned surgery and protects the surgeon from
claims of unauthorized operation. The informed consent document indicates the
specific procedure to be performed and includes a list of possible
complications. The consent should be written as stated in physician orders. It
is clearly worded in simple terms without abbreviations. All blanks must be
filled in. If you have questions about the correct laymans terms, the OR
staff, the physician or nursing supervisor should be called for verification.
If there is question about diagnosis/reason for procedure consult physician
performing the procedure. The consent contains the patients signature, if the
patient is of age and competent, date and time signed. There is should also be a
clause for photographs and blood transfusion. If the patient is having conscious sedation
this should be included on the consent. Conscious sedation may be given to
patient having colonoscopy/EDG/painful
procedures. If the operative permit is
not signed, have the patient sign and date it. Witness the signature. A
nurses signature of witness is verifying that the patient signed the form. It
does not hold any other legal responsibility. It does not mean that you
participated in informed consent. Informed consent is done between the
physician and the patient in a discussion. The operative permit has the patient
signature to verify that consent. If the patient is unable to write, an X to
indicate his agreement is acceptable. You should have a second witness to the
X. The information that the patient must understand is a definition of the
procedure, possible complications and risks of the procedure. If the patient
expresses that he has unanswered questions about the procedure, or does not
want the procedure, you have the responsibility to contact the physician and
let him know.
If the patient is awake and oriented x
3, 1 witness is needed. If the patient is a minor, the legal guardian must sign
the consent and 1 witness is needed. Most states have statues regarding the
treatment of minors. An emancipate minor is usually recognized as one who is
not subject to parental control, as in the following situations:
- Married
minor
- In
military service
- College
student under legal age but living away from home
- Minor who
has a child.
If the patient is incompetent or
incapacitated, permission can be sought from a patient representative. Laws
vary from state to state and policy varies from facility to facility. An
incompetent patient is any patient who is mentally or physically incapacitated,
as determined by physicians, such that the patient cannot communicate treatment
preferences. Facility policy usually dictates the process and how many
physicians must be involved in the decision. The patient does not have to be
adjudicated incompetent by a court of law for the purposes of consenting for a
procedure. If the family or Power of Attorney signs the consent 2 witnesses are
needed.
In an emergency, where the physician
feels that delaying a procedure would be an immediate threat to the patients
life or limb, and the patient cannot give consent, the physician may proceed
with the procedure without consent. This process requires extensive
documentation and often a consultation with other physicians. Check facility
policy. The informed consent document should be placed on the patients chart
and accompany the patient to the Surgical Suite.
Informed
Consent:
Must be obtained BEFORE patient receives
pre-op meds that induce sedation or amnesia or reduces anxiety
Ensure that the patient has actually been informed
Physician performing the surgery must sign the consent
Ensure that the consent has date and time
2 witnesses are required for incompetent patients and
telephone consents
Preoperative Checklist
In final preparation before the patient
is transported to surgery the pre-operative checklist should be reviewed for
documentation of nursing actions which include:
Removal of
jewelry and other objects (remember to check for unique body jewelry)
Checking
patient identification using 2 identifiers ensures surgical site is identified
and marked with an X
Asking the
patient to void
Check for
necessary documents patient history, physical assessment, consent form, test
results
Administering
pre-op meds
MAR on chart
Recent vital
signs (should not be greater than 1 hour)
Depending
on the facility policy, dentures may or may not be removed prior to a
procedure.
On
the preoperative checklist the nurse documents actions, such as patient identification;
allergies; removing jewelry or other objects; asking patient to void; ensuring
all needed documentation (H&P, consent, test results) are available. Mark
the site of surgery, however; not immediate over the site. What IV Fluid is hanging? Incomplete
chart work can delay the surgical procedure. The nurse may be required to go to
the OR to identify the patient and to complete documentation.
Nursings
preoperative teaching and assessment contribute heavily to the success of a
procedure. No surgery is without risk but complications can be decreased with
proper preoperative assessment and documentation of coexisting disease. Medical
optimization, adequate planning preoperatively, including scheduling surgery
electively as opposed to emergently, and improving nutrition status may be
helpful. Opportunity to improve perioperative
outcomes will be possible when risk factors for adverse events can be modified.
References:
Nettina, S, (2001). The Lippincott Manual of Nursing Practice,
7th edition. Philadelphia, PA: Lippincott
Williams & Wilkins. pp107-136.
Gruber, E. & Tschernko, E. (2003).
Anaesthesia and postoperative analgesia in older patients with chronic
obstructive pulmonary disease: Special considerations. Drugs & Aging 20(5), 347-361.
Walker, J., (2002). Emotional and
psychological preoperative preparation in adults. British Journal of Nursing. 11(8), 567-576.
