Preoperative care

Definition

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

Purpose

Patients who are physically and psychologically prepared for surgery tend to have better outcomes after surgery. Preoperative teaching meets the patient's need for information regarding the surgical experience, which in turn may alleviate most fears the patient has. Knowing what to expect after the surgery, and enlisting the patient's input about goals and expectations, often helps the patient cope better with postoperative pain and decreased mobility. Preoperative care is extremely important prior to any invasive procedure, regardless of whether the procedure is minimally invasive or major surgery.

Precautions

There are no contraindications to preoperative care. Even in an emergent situation, the patient must be physically prepared and should be prepared psychologically to the degree possible, as indicated by the patient's physical status. If the patient is unresponsive, emotional and psychological preparation should be focused on the family.

Preoperative teaching must be individualized for each patient, since some people want as much information as possible while others want only the minimum. For some patients, receiving too much information increases their anxiety . Patients have different capabilities in understanding medical procedures; if printed materials are used for teaching, the nurse must ascertain the patient's literacy level in order to provide appropriate material. The health care professional must maintain a balance between relaying essential information and meeting the patient's information needs.

Description

Preoperative care involves many components and may be done the day before surgery, in the hospital, or during the weeks before surgery on an outpatient basis. Many surgical procedures are now performed in a day-surgery setting and the patient is never admitted to the hospital.

Physical preparation

Physical preparation should include obtaining a complete history and physical, including the patient's surgical and anesthesia history. It should be determined if the patient has ever had an adverse reaction to anesthesia (such as anaphylactic shock ), or if there is a family history of malignant hyperthermia. Such laboratory tests as CBC, electrolytes, prothrombin time, activated partial thromboplastin time, or urinalysis may be done. An EKG should be done if the patient has a history of cardiac disease or is over 50 years of age. A chest X-ray should be taken if the patient has a history of respiratory disease. The patient should be assessed for risk factors that might impair healing, such as nutritional deficits, steroid use, radiation or chemotherapy , drug or alcohol abuse, or such metabolic diseases as diabetes. The patient should also provide a list of all medications, vitamins , and herbal or food supplements that they use. Supplements are often overlooked, but some can cause adverse effects when used with general anesthetics (e.g. St John's wort, valerian root) and others can prolong bleeding time (e.g. garlic, gingko biloba).

Latex allergy merits mention because it is becoming a public health concern. Latex is found in most sterile

KEY TERMS

Activated partial thromboplastin time (APTT) —A lab test that detects coagulation defects in the intrinsic clotting cascade. Used to regulate heparin dosing.

Complete blood count (CBC) —A lab test that determines the number of red and white blood cells per cubic millimeter of blood.

Electrocardiogram (EKG) —A graphic record showing the electrical activity of the heart.

Incentive spirometer —Device that is used postoperatively to prevent lung collapse and promote maximum inspiration. The patient inhales until a preset volume is reached, then sustains the volume by holding the breath for three to five seconds.

Prothrombin time (PT) —A lab test that detects coagulation defects in the extrinsic clotting cascade. Used to regulate coumadin dosing.

surgical gloves and is a common component in other medical supplies, including general anesthesia masks, tubing, and multi-dose medication vials. It is estimated that one percent to six percent of the general population and eight to seventeen percent of healthcare workers have this allergy. At least 50% of children with spina bifida are latex-sensitive as a result of early frequent surgical exposure. There is currently no cure available for latex allergy, and research has found that up to 19% of all anaphylactic reactions during surgery may be a result of latex allergy. The best treatment is prevention, but immediate symptomatic treatment is required if the allergic response occurs. Every patient should be assessed for a potential latex reaction. Patients with latex sensitivity should have their chart flagged with a caution label. Latex-free gloves and supplies must be used for anyone with a documented latex allergy.

Bowel clearance may be ordered if the patient is having surgery of the lower gastrointestinal (GI) tract. The patient should start the bowel preparation early in the evening to prevent interrupted sleep during the night. Some patients may benefit from a sleeping pill the night before surgery.

Often skin preparation is ordered for the night before surgery. Skin preparation can take the form of scrubbing with a special soap (i.e., Hibiclens), or hair removal from the surgical area. However, as of this printing (in 2001), shaving hair is no longer recommended because studies show that shaving the area may increase the chance of infection . Instead, adhesive barrier drapes can contain hair growth on the skin around the incision.

Psychological preparation

Patients are often fearful or anxious about having surgery. Health care workers can help decrease anxiety by listening to the patient's concerns, validating their legitimacy, and answering the patient's questions honestly. This responsiveness can be especially beneficial for patients who are critically ill or who are having a high-risk procedure. The family needs to be included in psychological preoperative care as much as the patient. In the hospital, pastoral care can be offered. If the patient expresses a fear of dying during surgery, this concern should not be discounted. The surgeon should be notified. In some cases, the procedure may be postponed until the patient feels more secure.

Children may be especially fearful. They should be allowed to have a parent with them as much as possible, as long as the parent is not demonstrably fearful and contributing to the child's apprehension. Children should also be encouraged to bring a favorite toy or blanket with them on the day of surgery.

Preparing the patient and family psychologically helps them to cope better with the patient's postoperative course. Preparation leads to superior outcomes, since the goals of recovery are known ahead of time and the patient is able to manage postoperative pain more effectively.

Informed consent

Obtaining the patient's or guardian's written consent for the surgery is a vital portion of preoperative care. By law, the physician who will perform the procedure must explain the risks and benefits of the surgery, along with other treatment options. However, the nurse is often the person who actually witnesses the patient's signature on the consent form. The nurse should verify that the patient understands everything the physician told them by asking the patient to explain what they have been told.

Patients who are mentally impaired, heavily sedated, or critically ill are not considered legally able to give consent. In this situation, the next of kin (spouse, adult child, adult sibling, or person with medical power of attorney) may act as a surrogate and sign the consent form. Children under age 18 must have a parent or guardian sign.

Preoperative teaching

Preoperative teaching includes teaching about the preoperative period, the surgery itself, and the postoperative period.

Instruction about the preoperative period deals primarily with where the patient should go on the day of surgery, the time they should arrive, and how they should prepare for surgery. For example, they should be told how long they should be NPO (nothing by mouth); which medications to take prior to surgery; and the medications that should be brought with them (such as inhalers for patients with asthma ).

Instruction about the surgery itself includes informing the patient about what will be done during the surgery and how long it is expected to take. The patient should be told where the incision would be. Children having surgery should be allowed to "practice" on a doll or stuffed animal. It may be helpful to demonstrate procedures on the doll prior to doing them on the child. It is also important to tell the family (or other concerned parties) where they can wait during the surgery; when they can expect progress information (and from whom); and how long it will be before they can see the patient.

Informing the patient about what to expect during the postoperative period is one of the best ways to improve the patient's outcome. Instruction about expected activities can also increase compliance and help prevent complications. This includes the opportunity for the patient to practice coughing and deep breathing exercises, use an incentive spirometer, and practice splinting the incision. Additionally, the patient should be informed about early ambulation, The patient should also be taught that the respiratory interventions decrease the occurrence of pneumonia and that early leg exercises and ambulation decrease the risk of blood clots.

Patients hospitalized postoperatively should be informed about the tubes and equipment that they will have. These may include multiple IV lines, drainage tubes, dressings, and monitoring devices. In addition, they may have sequential compression stockings on their legs to prevent blood clots until they start ambulating.

Pain management is the primary concern for many patients having surgery. Preoperative instruction should include information about the pain management method that they will utilize postoperatively. Patients should be encouraged to ask for or take pain medication before the pain becomes unbearable, and should be taught how to rate their pain on a pain scale. This instruction allows the patients, and others who may be assessing them, to evaluate the pain consistently. If they will be using a patient-controlled analgesia (PCA) pump, they should be taught how to use it during the preoperative period. Use of alternative methods of pain control (distraction, imagery, positioning, mindfulness meditation, music therapy) may also be presented.

Finally, long-term goals should be discussed, such as when the patient will be able to eat solid food, when they will be discharged if they are hospitalized, and when they will be able to drive a car or return to work.

Preparation

Preparation for preoperative care involves ensuring that all supplies for physical preparation are accessible. To prepare for teaching, any applicable patient handouts or videos should be gathered and offered to the patient. The consent form should be ready for the patient to sign, with the name of the physician and the procedure filled in. A sufficient amount of time should be scheduled so that the patient does not feel rushed, and the patient should understand that they have the right to add or strike out items on the generic consent form that they do not wish to agree to. For example, a patient who is about to undergo a tonsillectomy might choose to strike out (and initial) an item that indicates sterility might be a complication of the operation.

Aftercare

The only aftercare required is to ensure that the patient understands the surgery and that all of their questions are answered.

Complications

Complications can result from improper preoperative care. For example, surgery may be done on the wrong side of the body if the incorrect body part is marked during physical preparation. Hospitalized patients may be given the wrong preoperative medications; or sedatives may be inadvertently given before informed consent is obtained.

Results

The anticipated outcome of preoperative care is a patient who is informed about their surgical course and able to cope with it successfully. The goal is to decrease complications and promote recovery.

Health care team roles

As mentioned above, the physician is legally responsible for discussing the risks and benefits of the procedure and for obtaining the patient's informed consent. However, the nurse is often the one who witnesses the patient's signature. If the nurses were not present for the physicians' discussions with the patients, the nurses must ensure that the patients understand the risks and benefits of the surgery by having the patients relate what they were told by their physician. The nurse is usually responsible for preoperative instruction, although a respiratory therapist often teaches about the postoperative respiratory exercises, especially in a hospital setting. Laboratory personnel may draw blood samples and perform laboratory tests. Radiology personnel perform the chest x-ray if one is ordered.

Resources

BOOKS

Brozenec, Sally, and Sally Russell, eds. Core Curriculum for Medical-Surgical Nursing, 2nd ed. Pitman, NJ: Academy of Medical-Surgical Nurses, 1999.

Carpenito, Lynda. Nursing Care Plans and Documentation, 3rd ed. Philadelphia, PA: Lippincott, 1999.

PERIODICALS

Barnes, S. "Preparing for Surgery: Providing the Details."Journal of Perianesthesia Nursing 16 no. 1 (2001): 31-32.

Flanagan, K. "Preoperative Assessment: Safety Considerations for Patients Taking Herbal Products." Journal of Perianesthesia Nursing 16 no. 1 (2001): 19-26.

Olsen-Chavarriaga, D. "Informed Consent: Do You Know Your Role?" Nursing 2000 30 no. 5 (2000): 60-61.

Abby Wojahn RN, BSN, CCRN