Preoperative Management and Nursing Care Using The Nursing Process

1. Pre-Operative Nursing Assessment

Preoperative assessment is essentially a clinical risk assessment where the health of a patient is appraised to ascertain that the person is fit to undergo the anaesthetic for a planned operation. The optimum time frame for this assessment to take place is three to four weeks before the surgery.

• Psychological assessment
• Social history
• Family health history
• Past health history

The management of the pre-operative drug regime falls into three categories; prescriptions to stop, prescriptions to alter, and prescriptions to start. In certain patients, bowel preparation and blood products may also need to be considered.

Good perioperative care should improve patient experience of care, including quality of care and satisfaction with care, improve health of populations, including returning to home/work and quality of life, and reduce the per capita cost of health care through improving value.

The goal of effective preoperative care is to 'ensure the individual is in the best physical and psychological condition possible before undergoing surgery.

2. The Principles of Preoperative Assessment

The principles of preoperative assessment are:

• To identify before surgery a patient’s medical, physical, psychological and spiritual needs;
• To liaise, where appropriate, with external agencies to implement discharge planning;
• To ensure a more effective use of hospital resources such as theatre time and bed occupancy by reducing the number of patients who do not attend scheduled surgery, the number of cancelled operations, and the length of time patients spend in hospital, thereby having a positive impact on waiting list

Medical history

The assessment is divided into three parts. The first involves taking a full medical history, with particular attention to any complications following previous operations/anaesthetics. When indicated, appropriate tests will be performed such as bloods, X-ray and electrocardiogram. Routine investigations are efficient, expensive and unnecessary (Association of Anaesthetists, 2001).

If any abnormalities are detected, these can be addressed before surgery, discussed with the anaesthetist and, if necessary, surgery can be deferred until the patient has reached optimum health.

The use of medications and herbal preparations before surgery

The pharmacist plays an important role in the first part of the assessment, by giving advice on changing treatments or stopping medications, such as the contraceptive pill, aspirin and warfarin, which need special consideration before a patient has scheduled surgery. Herbal preparations do not provoke drug interactions, although this will need to be checked in each individual case. It is important to consider carefully the continuing use of certain herbal remedies.

For example, garlic inhibits platelet aggregation, which may increase the risk of bleeding after surgery the patient needs to be told that any garlic supplements should be discontinued at least seven days before the date of the scheduled surgery.

If the patient is taking an echinacea preparation, which is used primarily as an immunostimulant, this must be discontinued as far in advance of surgery as possible. It may lead to an allergic reaction, the reduction of the effectiveness of immunosuppressant drugs, and subsequent poor wound healing, which could result in an increased risk of infection.

Information Exchange

The third part of the assessment is the information exchange that takes place preoperatively between the staff and the patient/carer. It offers an ideal opportunity to establish that the patient still wants the operation to go ahead and that he or she fully understands why they are having the procedure; the benefits and disadvantages of having the surgery; what will happen in hospital in terms of any drips, drains or pain control they may need; and details of the surgical procedure.

Written information about the operation/hospital stay is given to the patient and any carers. If patients require a blood transfusion as part of their surgery, autologous blood donation can be discussed if this service is available.

A systematic approach

Staff members must be able to disseminate accurate up-to-date information about the operation and the hospital stay and provide appropriate discharge advice.

A preoperative assessment service is a valuable and important part of the care of patients having elective surgery. The care is carefully planned and offers nurses the opportunity to ensure that patients will be as comfortable as possible. The effective introduction of a preoperative assessment service not only increases patient satisfaction.

3. Preoperative Health Teaching

Providing education to patients and their families is one of the most important aspects of nursing care. Preoperative education not only prepares the patient for surgery but also prepares them for what to expect following the surgery. Education can vary dramatically depending on individual need

The background of preoperative teaching for the outpatient surgical patient involves nursing staff providing education that includes expectations of the surgical procedure, medication and food restrictions before the procedure, as well as providing instructions for aftercare once a patient is discharged home, to provide information that will increase the patient's familiarity with the procedure, which will decrease anxiety.

PATIENT TEACHING before surgery can reduce your patient's anxiety, reduce her perception of postoperative pain, shorten the length of hospital stay, and improve her satisfaction with her health care.

4. Routine Preoperative Teaching for the Adult Patient

PURPOSE

To provide consistent teaching content for nursing personnel instructing the preoperative patient and provide standards for documentation in the medical record.

POLICY 

1. Inform outpatients during preoperative visit that they should:
• Avoid taking aspirin or aspirin-containing products for 2 weeks prior to surgery unless approved by physician
• Discontinue nonsteroidal anti-inflammatory medications 48 to 72 hours before surgery
• Bring a list or container of current medications
• Bring an adult escort who can drive if they are having an outpatient procedure with sedation or general anesthesia
• Wear loose clothing that can easily be removed (eg, avoid clothing that pulls on and off over the head)
2. Discuss the type of anesthesia planned (local or general). The anesthesiologist will evaluate all patients receiving general anesthesia preoperatively.
3. Instruct the patient to bathe/shower/shampoo the evening before or morning of surgery. Men should be cleanly shaved.
4. Instruct the patient on oral intake restrictions and medication schedule as ordered:
• NPO after midnight (including water)
• NPO after clear liquid or light breakfast if permitted
• AM meds with sip of water if ordered by physician/anesthesiologist
5. Instruct patient to perform oral hygiene (brush teeth and rinse mouth) the morning of surgery. Remind patient not to swallow the rinse.
6. Inform patient that before going to the operating room he/she will have to remove:
• Dentures/partial plates
• Glasses/contact lenses
• Appliances/prosthesis
• Makeup/nail polish
• Hairpins/hairpiece
• Undergarments
7. Inform the patient that valuables and jewelry should be given to a family member or friend or locked in the cashier's office or patient locker. Wedding rings may remain on fingers and will be secured with tape. (Exception: patients having major head and neck resection must remove all rings.)
8. Inform patient's family of the Day of Surgery Lounge and other designated waiting areas.
9. Inform patient of postoperative recovery destination.
10. Inform the patient of postoperative care:
• Vital signs monitored frequently
• Activity/diet restrictions
• Nursing personnel must assist with first ambulation
• Medications available for pain and nausea upon request
• Discharge criteria if anticipate same-day discharge
11. Document routine preoperative teaching completed and patient understanding in the medical record.

5. Planning and Goals

Planning and Goals

The major goals for the preoperative surgical patient may include:

• relief of preoperative anxiety
• decreased fear
• increased knowledge of perioperative expectations
• absence of preoperative complications

6. What is consent according to the law?

'Consent' defined. —Two or more persons are said to consent when they agree upon the same thing in the same sense.

Define Consent

For consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to make the decision.

The meaning of these terms is:

• voluntary – the decision to either consent or not to consent to treatment must be made by the person, and must not be influenced by pressure from medical staff, friends or family
• informed – the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead
• capacity – the person must be capable of giving consent, which means they understand the information given to them and can use it to make an informed decision

6.1. Types of Consent

Types of consent include implied consent, express consent, informed consent and unanimous consent.

Informed consent: A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment, genetic testing, or a clinical trial. This is to help them decide if they want to be treated, tested, or take part in the trial.

Consent to treatment means a person must give permission before they receive any type of medical treatment, test or examination. This must be done on the basis of an explanation by a clinician. Consent from a patient is needed regardless of the procedure, whether it's a physical examination or something else.

The principle of consent is an important part of medical ethics and international human rights law.

Informed consent information

• Explanation of risks and how often they occur.
• Explanation that patient has the right to refuse treatment or withdraw consent.
• Patient must be 18 years old to sign own consent or be an emancipated minor.
• Parent signs for dependent children as legally responsible.

Informed Consent for Surgery & Blood Transfusion

3 requirements:

• Adequate disclosure of diagnosis-purpose, risks, and consequences of treatment, probability of success, prognosis if not instituted
• Understanding & comprehension -patient must be drug free prior to signing consent
• Consent given voluntarily -patient must not be persuaded or coerced to undergo the procedure

Informed consent

• Patient signs consent if of legal age (18 above)
• Family member signs permit if patient a minor
• Family sign permit if patient incapacitated
• Signed permit is a part of chart (mentally disabled will be consented by guardian)

7. What is pre anesthesia care?

A pre-anesthesia evaluation is conducted to assess the risks and develop the plan for anesthesia. This evaluation specifically identifies the risks of the anesthesia encounter and is the sole purview of an anesthesia professional.

The preanesthetic assessment involves the consideration of information from various sources that include the past medical records, interview, physical examination, as well as results from medical and laboratory test.

8. Preparing Yourself Emotionally and Physically for Surgery

1. Practice relaxation exercises.
2. Perform deep-breathing exercises.
3. Think positively.
4. Use visualization and imaging techniques.
5. Learn about managing pain after surgery.
6. Share questions and concerns with your doctor.
7. Review last minute instruction.

9. What is pre-operative checklist?

The Preoperative Checklist is completed by clinicians working within their scope of clinical practice and is designed to aid patient preparation prior to their transfer to theatre and support effective clinical handover when there is a transfer of professional responsibility and accountability

Preoperative care of surgical patient

Preoperative care refers to the physical and psychosocial care that prepares a patient to undergo surgery safely. The preoperative period begins when the patient is booked for surgery and ends with their transfer to the theatre or surgical suite.

Providing patient information

• Nutritional support.
• Smoking cessation.
• Alcohol intake.
• Risk of surgery.
• Potential complications.
• Fasting preoperatively.
• Bowel preparation.
• Management of medicines.

10. Classification of anesthesia

General anesthesia: Patient is unconscious and feels nothing. Patient receives medicine by breathing it or through an IV.

Local anesthesia: Patient is wide awake during surgery. Medicine is injected to numb a small area.
Local anesthesia is an aesthetic agent given to temporarily stop the sense of pain in a particular area of the body.

Regional anesthesia: Patient is awake, and parts of the body are asleep. Medicine is injected.
Regional anesthesia is used to numb only the portion of the body that will undergo the surgery

General anesthesia
Provides loss of consciousness and loss of sensation.

Regional anesthesia
Involves the injection of a local anesthetic to provide numbness, loss of pain or loss of sensation to a large region of the body. Regional anesthetic techniques include spinal blocks, epidural blocks and arm and leg blocks. Medications can be given that will make the patient comfortable.

11. Pre –anesthetic Care

• Standards for Preanesthetic Care.
• Reviewing the available medical record. Interviewing and performing a focused examination of the patient to: Discuss the medical history, including previous anesthetic experiences and medical therapy.
• Assess those aspects of the patient’s physical condition that might affect decisions regarding perioperative risk and management.
• Ordering and reviewing pertinent available tests and consultations as necessary for the delivery of anesthesia care.
• Ordering appropriate preoperative medications.
• Ensuring that consent has been obtained for the anesthesia care.
• Documenting in the chart that the above has been performed.

12. Discharge Criteria

• Post anesthetic discharge scoring (PADS) system is a simple cumulative index that measures the patient's home readiness.
• Five major criteria: (1) vital signs, including blood pressure, heart rate, respiratory rate, and temperature; (2) ambulation and mental status; (3) pain and PONV; (4) surgical bleeding; and (5) fluid intake/output.
• Patients who achieve a score of 9 or greater and have an adult escort are considered fit for discharge (or home ready).