Preparing for Surgery

Definition
Purpose
Description
Normal results

Definition

Preparing for a planned surgery (also called elective surgery ) includes selecting a surgery center and surgeon to perform the procedure, scheduling the surgery, undergoing presurgical testing, meeting with health-care professionals and the surgical team, receiving education about the procedure, receiving and following all of the appropriate preoperative instructions, and signing a consent form.

Purpose

Preparing for surgery helps the patient understand what to expect before surgery and ensures the patient is physically and psychologically ready for the surgery.

Description

Most patients go to the surgery center or hospital the same day as the scheduled surgery; thus, many of the steps involved in preparing for surgery will take place from one to four weeks before the scheduled surgery. Many surgeries are performed on an outpatient basis, which means that the patient goes home the same day as the surgery.

Selecting a surgeon and surgery center

SURGEON. A surgeon, along with a multi-disciplinary team of surgical specialists, will perform the surgery. The surgeon should be board certified by the American Board of Surgery, as well as certified by the medical specialty board or boards related to the type of surgery performed. Certification from a medical specialty board means that the surgeon has completed an approved educational training program (including three to seven years of full-time training in an accredited residency program). Certification also includes an evaluation, including an examination that assessed the surgeon’s knowledge, skills, and experience necessary to perform high-quality patient care in that specialty.

There are 24 certifying boards recognized by the American Board of Member Specialties (ABMS) and the American Medical Association (AMA). Most of the ABMS boards issue time-limited certificates, valid for six to 10 years. This requires physicians to become re-certified to maintain their board certification—a process that includes a credential review, continuing education in the specialty, and additional examinations. Even though board certification is not required for an individual physician to practice medicine, most hospitals require that a certain percentage of their staff be board certified.

The letters FACS (Fellow of the American College of Surgeons) after a surgeon’s name are a further indication of a surgeon’s qualifications. Those who become Fellows of the American College of Surgeons have passed a comprehensive evaluation of their surgical training and skills; they also have demonstrated their commitment to high standards of ethical conduct. This evaluation is conducted according to national standards that were established to ensure that patients receive the best possible surgical care.

A surgeon’s membership in professional societies is also an important consideration. Professional societies provide an independent forum for medical specialists to discuss issues of national interest and mutual concern. Examples of professional societies include the Society of Thoracic Surgeons (STS) and the American College of Physicians–American Society of Internal Medicine (ACP-ASIM).

To find information about a surgeon’s qualifications, the patient can call a state or county medical association for assistance. A reference book is also available: The Official ABMS Directory of Board Certified Medical Specialists that lists all surgeons who are certified by approved boards. This publication also contains brief information about each surgeon’s medical education and training, and it can be found in many libraries.

SURGERY CENTER. The surgeon will arrange for the procedure to be performed in a hospital where he or

KEY TERMS

Case manager— A health-care professional who can provide assistance with a patient’s needs beyond the hospital.

Discharge planner— A health-care professional who helps patients arrange for health and home care needs after they go home from the hospital.

Electrocardiogram (ECG, EKG)— A test that records the electrical activity of the heart using small electrode patches attached to the skin on the chest.

Infectious disease team— A team of physicians who help control the hospital environment to protect patients against harmful sources of infection.

Informed consent— An educational process between health-care providers and patients intended to instruct the patient about the nature and purpose of the procedure or treatment, the risks and benefits of the procedure, and alternatives, including the option of not proceeding with the test or treatment.

Inpatient surgery— Surgery that requires an overnight stay of one or more days in the hospital.

NPO— AA term that means nothing by mouth. NPO refers to the time after which the patient is not allowed to eat or drink prior to a procedure or treatment.

Outpatient surgery— Also called same-day or ambulatory surgery. The patient arrives for surgery and returns home on the same day.

she has staff privileges. The patient should make sure the hospital has been accredited by the Joint Commission on Accreditation of Healthcare Organizations, a professionally sponsored program that stimulates a high quality of patient care in health-care facilities. Joint Commission accreditation means the hospital voluntarily sought accreditation and met national health and safety standards. There is also an accreditation option that is available for ambulatory surgery centers.

Selecting a surgery center that has a multidisciplinary team of specialists is important. The surgery team should include surgeons, infectious disease specialists, pharmacologists, and advanced care registered nurses. Other surgical team members may include fellows and residents, clinical coordinators, physical therapists, respiratory therapists, registered dietitians, social workers, and financial counselors.

Choosing a surgery center with experience is important. Some questions to consider when choosing a surgery center or hospital include:

• How many surgeries are performed annually and what are the outcomes/survival rates of those surgeries?
• How do the surgery center’s outcomes compare with the national average?
• Does the surgery center offer treatment for a patient’s specific condition? How experienced is the staff in treating that condition?
• What is the center’s success record in providing the specific medical treatment or procedure?
• Does the surgery center have experience treating patients the same age as the inquiring patient?
• Does the surgery center explain the patient’s rights and responsibilities?
• Does the surgery center have a written description of its services and fees?
• How much does the patient’s type of treatment cost at this surgery center?
• Is financial help available?
• Who will be responsible for the patient’s specific care plan while he or she is in the hospital?
• If the center is far from the patient’s home, will accommodations be provided for caregivers?
• What type of services are available during the patient’s hospital stay?
• Will a discharge plan be developed before the patient goes home from the hospital?
• Does the hospital provide training to help the patient care for his or her condition at home?

Scheduling the surgery

Depending on the nature of the surgery, it may be scheduled within days or weeks after the surgery is determined to be the appropriate treatment option for the patient. The patient’s surgery time may not be determined until the business day before the scheduled surgery. The patient may be instructed to call the surgical center to find out the time of the scheduled surgery.

The time the patient is told to report to the surgery center (arrival time) is not the time when the surgery will take place. Patients are told to arrive at the surgery center far enough in advance (usually about two hours prior to the scheduled surgery time) so they can be properly prepared for surgery. In some cases, the patient’s surgery may need to be rescheduled if another patient requires emergency surgery at the patient’s scheduled time.

The patient should ask the health-care providers if the scheduled surgery will be performed on an outpatient or inpatient basis. Outpatient means the patient goes home the same day as the surgery; inpatient means a hospital stay is required.

Presurgical testing

Presurgical testing, also called preoperative testing or surgical consultation, includes a review of the patient’s medical history, a complete physical examination, a variety of tests, patient education, and meetings with the health-care team. The review of the patient’s medical history includes an evaluation of the patient’s previous and current medical conditions, surgeries and procedures, medications, and any other health conditions such as allergies that may impact the surgery. Presurgical testing is generally scheduled within one week before the surgery.

The patient may find it helpful to bring along a family member or friend to the presurgical testing appointments. This caregiver can help the patient remember important details to prepare for surgery.

After attending the surgical consultation, the patient may desire to seek a second opinion to confirm the first doctor’s treatment recommendations. The patient should check with his or her insurance provider to determine if the second opinion consultation is covered.

Meeting with the surgical team

During the surgical consultation, the patient meets with the surgeon or a member of the surgeon’s health-care team to discuss the surgery and other potential treatment options for the patient’s medical condition. At some time before the surgery, the patient will meet with other health-care providers, including the anesthesiologist, nurse clinicians, and sometimes a dietitian, social worker, or rehabilitation specialist.

Patient education

The surgical team will ensure that the patient understands the potential benefits and risks of the procedure as well as what to expect before the procedure and during the recovery. Patient education may include one-on-one instruction from a health-care provider, educational sessions in a group setting, or self-guided learning videos or modules. Informative and instructional handouts are usually provided to explain specific presurgical requirements.

Some surgery centers offer services such as guided imagery and relaxation tapes, massage therapy, aromatherapy, or other complementary techniques to reduce a patient’s level of stress and anxiety before a surgical procedure. Guided imagery is a form of focused relaxation that coaches the patient to visualize calm, peaceful images. Several research studies have proven that guided imagery can significantly reduce stress and anxiety before and after surgical and medical procedures and help the patient recover more rapidly. Guided imagery and relaxation tapes are available at many major bookstores and from some surgery centers. The patient may be able to listen to the tapes during the procedure, depending on the type of procedure being performed.

Preoperative instructions

Preoperative instructions include information about reserving blood products for surgery, taking or discontinuing medications before the surgery, eating and drinking before surgery, quitting smoking, limiting activities before surgery, and preparing items to bring to the hospital the day of surgery.

BLOOD TRANSFUSIONS AND BLOOD DONATION. Blood transfusions may be necessary during surgery. A blood transfusion is the delivery of whole blood or blood components to replace blood lost through trauma, surgery, or disease. About one in three hospitalized patients will require a blood transfusion. The surgeon can provide an estimate of how much blood the patient’s procedure may require.

To decrease the risk of infection and immunologic complications, some surgery centers offer a preoperative blood donation program. Autologous blood (from the patient) is the safest blood available for transfusion, since there is no risk of disease transmission. Methods of autologous donation or collection include:

• Intraoperative blood collection: the blood lost during surgery is processed, and the red blood cells are re-infused during or immediately after surgery.
• Preoperative donation: the patient donates blood once a week for one to three weeks before surgery. The blood is separated and the blood components needed are re-infused during surgery.
• Immediate preoperative hemodilution: the patient donates blood immediately before surgery to decrease the loss of red blood cells during surgery. Immediately after donating, the patient receives fluids to compensate for the amount of blood removed. Since the blood is diluted, fewer red blood cells are lost from bleeding during surgery.
• Postoperative blood collection: blood lost from the surgical site right after surgery is collected and re-infused after the surgical site has been closed.

The surgeon determines what type of blood collection process, if any, is appropriate.

MEDICATION GUIDELINES. Depending on the type of surgery scheduled, certain medications may be prescribed or restricted before the surgery. The health-care team will provide specific guidelines. If certain medications need to be restricted before surgery, the patient will receive a complete list of the medications (including prescription, over-the-counter, and herbal medications) to avoid taking before the scheduled surgery.

If the physician advises the patient to take prescribed medication within 12 hours before surgery, it should be taken with small sips of water.

The patient should not bring any medications to the hospital; all necessary medications, as ordered by the doctor, will be provided in the hospital.

EATING AND DRINKING BEFORE SURGERY. Before most surgeries, the patient is advised not to eat or drink anything after midnight the evening before the surgery. This includes no smoking and no gum chewing. The patient should not drink any alcoholic beverages for at least 24 hours before surgery, unless instructed otherwise. If the patient has diabetes or if the surgery is to be performed on a child, the patient should ask the health-care team for specific guidelines about eating and drinking before surgery.

Smoking cessation

Patients who will undergo any surgical procedure are encouraged to quit smoking and stop using tobacco products at least two weeks before the procedure, and to make a commitment to be a nonsmoker after the procedure. Ideally, the patient should quit smoking at least eight weeks prior to surgery. Quitting smoking before surgery helps the patient recover more quickly from surgery. There are several smoking cessation programs available in the community. The patient should ask a health-care provider for more information if he or she needs help quitting smoking.

Activity before surgery

The patient should eat right, rest, and exercise as normal before surgery, unless given other instructions. The patient should try to get enough sleep to build up energy for the surgery. The health-care team may advise the patient to scrub the planned surgical site with a special disinfecting soap the evening before the surgery.

MAKING PLANS FOR HOME AND WORK. The patient should make arrangements ahead of time for someone to care for children and take care of any other necessary activities at home such as getting the mail or newspapers. The patient should inform family members about the scheduled surgery in advance, so they can provide help and support before, during, and after surgery.

The patient should ask the health-care team what supplies may be needed after surgery during recovery at home so these items can be purchased or rented ahead of time. Some supplies that may be needed include an adaptive chair for the toilet or bathtub, or supplies for changing the wound dressing at home. Ask the health care providers if home care assistance (in which a visiting nurse visits the home to provide medical care) will be needed after surgery.

Items to bring to the hospital

The patient should bring a list of current medications, allergies, and appropriate medical records upon admission to the surgery center. The patient should also bring a prepared list of questions to ask.

The patient should not bring valuables such as jewelry, credit cards or other items. A small amount of cash (no more than $20) may be packed to purchase items such as newspapers or magazines.

Women should not wear nail polish or makeup the day of surgery.

If a hospital stay is expected after surgery, the patient should only pack what is needed. Some essential items include a toothbrush, toothpaste, comb or brush, deodorant, razor, eyeglasses (if applicable), slippers, robe, pajamas, and one change of comfortable clothes to wear when going home. The patient should also bring a list of family members’ names and phone numbers to contact in an emergency.

Transportation

The patient should arrange for transportation home, since the effects of anesthesia and other medications given before surgery make it unsafe to drive.

Preoperative preparation

Upon arriving at the hospital or surgery center, the patient will be required to complete paperwork and show an insurance identification card, if insured. An identification bracelet that includes the patient’s name and doctor’s name will be placed on the patient’s wrist.

INFORMED CONSENT. The health-care provider will review the informed consent form and ask the patient to sign it. Informed consent is an educational process between health-care providers and patients. Before any procedure is performed, the patient is asked to sign a consent form. Before signing the form, the patient should understand the nature and purpose of the procedure or treatment, the risks and benefits of the procedure, and alternatives, including the option of not proceeding with the procedure. Signing the informed consent form indicates that the patient permits the surgery or procedure to be performed. During the discussion about the procedure, the health-care providers are available to answer the patient’s questions about the consent form or procedure.

ADVANCED DIRECTIVES. The health-care provider will ask the patient if he or she has any advance directives to be included in the patient’s file. Advance directives are legal documents that increase a patient’s control over medical decisions. A patient may decide medical treatment in advance, in the event that he or she becomes physically or mentally unable to communicate his or her wishes. Advance directives either state what kind of treatment the patient wants to receive (living will ), or authorize another person to make medical decisions for the patient when he or she is unable to do so (durable power of attorney ). Advance directives are not required and may be changed or canceled at any time. Any change should be written, signed and dated in accordance with state law, and copies should be given to the physician and to others who received original copies. Advance directives can be revoked either in writing or by destroying the document. Advance directives are not do-not-resuscitate (DNR) orders. A DNR order indicates that a person— usually with a terminal illness or other serious medical condition—has decided not to have cardiopulmonary resuscitation (CPR) performed in the event that his or her heart or breathing stops.

TESTS AND PREOPERATIVE EVALUATION. Some routine tests will be performed, including blood pressure, temperature, pulse, and weight checks; blood tests; urinalysis; chest x ray; and electrocardiogram (ECG). A brief physical exam will be performed. In some cases, an enema may be required. The health-care team will ask several questions to evaluate the patient’s condition and to complete the final preparations for surgery. The patient should inform the health-care team if he or she drinks alcohol on a daily basis so precautions can be taken to avoid complications during and after surgery.

FINAL SURGICAL PREPARATION. Preoperative preparation generally includes these steps:

• The patient changes into a hospital gown.
• The patient removes (as applicable) contact lenses and glasses, dentures, hearing aids, nail polish, and jewelry.
• The patient empties his or her bladder.
• The health-care providers clean and possibly shave the area on the body where the surgery will be performed.
• The patient may receive medication to aid relaxation.
• An intravenous catheter will be placed in a vein in the patient’s arm to deliver fluids, medications, or blood during surgery.
• In some hospitals, the patient may wait in an area called a holding area until the operating room and surgical team are ready. Depending on the hospital’s policy, one or two of the patient’s family members may wait with the patient.
• The patient is taken to the operating room in a wheelchair or on a bed (also called a gurney) where monitors are placed to evaluate the patient’s condition during surgery.
• Anesthesia is administered; the type of anesthesia administered will depend upon the procedure, the patient’s general health, and medications.
• A catheter may be placed in the patient’s bladder to drain urine.
• The patient’s vital signs, including the blood oxygen level, electrical activity of the heart, blood pressure, pulse, temperature, breathing, mental status, and level of consciousness, are continuously monitored during and after the surgery.

Information for families

While the patient is in surgery, the family members wait in a designated waiting area. Some hospitals or surgery centers offer a pager to the patient’s family so they can be contacted for updates about the progress of the surgery. It may be helpful for the patient to select a spokesperson from the family to communicate with the health-care providers. This may improve communication with the health-care providers as well as to other family members. The patient should also communicate his or her wishes regarding the spokespersons telephone communications to other family members.

Educational classes may be available for family members to learn more about the patient’s surgery and what to expect during the recovery.

When the surgery is complete, the surgeon usually contacts the family members to provide information about the surgery. If a problem or complication occurs during surgery, the family members are notified immediately.

Normal results

Patients who receive proper preparation for surgery, including physical and psychological preparation, experience less anxiety and are more likely to make a quicker recovery at home, with fewer complications. Patients who perceive their surgical and

QUESTIONS TO ASK THE DOCTOR

• Will I have to have blood transfusions during the surgery?
• Do I take my medications the day of the surgery?
• Can I eat or drink the day of the surgery? If not, how long before the surgery should I stop eating and drinking?
• How long does my type of surgery typically last?
• How long will I have to stay in the hospital after surgery?
• What kind of pain or discomfort will I experience after the surgery and what can I take to I relieve it? What type of bruising, swelling, scarring, or pain should be expected after surgery?
• What types of resources are available to me during my hospital stay, and during my recovery at home?
• After I go home from the hospital, how long will it take me to recover?
• What are the signs of infection, and what types of symptoms should I report to my doctor?
• How should I care for my incision?
• What types of medications will I have to take after surgery? How long will I have to take them?
• When will I be able I resume my normal activities? When will I be able to drive? When will I be able to return to work?
• What lifestyle changes (including diet, weight management, exercise, and activity changes) are recommended after the surgery to improve my condition?
• How often do I need to see my doctor or surgeon for follow-up visits after surgery?
• Can I receive follow-up care from my primary physician, or do I need to have follow-up visits with the surgeon?

postoperative experiences as positive report that they had minimal pain and nausea, were relaxed, had confidence in the skills of their health-care team, felt they had some control over their care, and returned to their normal activities within the expected timeframe.

Resources

BOOKS

Huddleston, Peggy. Prepare for Surgery, Heal Faster. Cambridge, MA: Angel River Press, 2002.

Lichtenberg, Maggie. The Open Heart Companion: Preparation and Guidance for Open-Heart Surgery Recovery. Sante Fe, NM: Open Heart Pub., 2006.

PERIODICALS

Callery, Peter. “Preparing Children for Surgery.” Pediatric Nursing 17.3 (April 2005): 12–13.

Larson, Heather. “Pre-Op Jitters: Preparing for Surgery.” Whole Life Times (Jan 2002): 22–24.

Lucas, Brian. “Preparing Patients for Hip and Knee Replacement Surgery.” Nursing Standard 22.2 (Sept 19,2007): 50–58.

ORGANIZATIONS

Agency for Health Care Policy and Research (AHCPR), Publications Clearinghouse. P.O. Box 8547, Silver Spring, MD, 20907. (800) 358-9295. <http://www/ahcpr.gov>.

American Board of Surgery. 1617 John F. Kennedy Boulevard, Suite 860, Philadelphia, PA 19103. (215) 568-4000. http://www.absurgery.org/.

American Association of Nurse Anesthetists (AANA). 222 South Prospect Avenue, Park Ridge, IL 60068-4001. (847) 692-7050. http://www.aana.com/.

American College of Surgeons. 633 N. Saint Clair Street, Chicago, IL 60611-3211. (312) 202-5000. http://www.facs.org/.

American Society of Anesthesiologists (ASA). 520 North Northwest Highway, Park Ridge, IL 60068-2573. (847) 825-5586. <http://http://www.asahq.org/.

National Heart, Lung and Blood Institute. Information Center. P.O. Box 30105, Bethesda, MD 20824-0105. (301) 251-2222. http://www.nhlbi.nih.gov.

Angela M. Costello

Robert Bockstiegel

Pressure sores seeBedsores