AORN JOURNAL FEBRUARY 1987, VOL. 45, NO 2

Preoperative Care Unit AN ALTERNATIVE TO THE HOLDING ROOM

Carol Cramer, RN; Virginia R. Renz, RN

any holding rooms were established initially to increase efficiency because M immediate access to the patient lessens

the time required between surgical procedures. Recent trends toward reduced length of hospital stay have significantly affected the time available for the preparation of surgical patients and have altered the use of the modem holding room.

The practice of hospital admission the day of surgery has shortened the preoperative period. Preoperative nursing care that was traditionally initiated the evening before surgery must now be completed within a few hours. Under these conditions, effective use of the time immediately preceding surgery is a critical aspect of preop erative nursing care.

Maintaining quality presurgical care within a reduced time frame presents a challenge to health

care practitioners. Efficient mechanisms to provide emotional support of the patient and adequate processing of information are prime clinical considerations. In response to patient needs and hospital requirements, various hospital admission methods have been evaluated; among the alternatives is using the holding room as a preoperative care unit.

The new 11-bed surgery holding room at St Peter Hospital, Olympia, Wash, recently opened as the preoperative care unit. The change in the name of the unit stems from its dual function: a holding room and a preoperative care unit. Staff members coordinate the presurgical care of patients directly admitted to the preoperative care unit and those already admitted to the medical- surgical or ambulatory surgery units. Primary nursing responsibilities include completing the

preoperative care unit andpostan&h&a unit short stay unit, St Peter Hospilal Olympia, Wash She has an associue degree in nursing from St Petersburg (2%) Junior College, and both her bachelor of science &pee in nursing and master of nursing degree are from the University of Washington, Seattk

VVginia R. Re=, RN, BA, ir a charge nurse in the preoperathe care unit, St Peter Hospiral Olympia, Wash She has a diploma in nursing from Presentation Junior College School of Nursing Aberaken, SD, and a bachelor of an3 degree in liberal studies from Linfreld College,

Carol Gamer Viigiriia R. Renz

Carol Cramr, RN, MN, 13 the head nurse, McMinnviUe, Ore.

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preoperative teaching plan, performing nursing assessments, initiating physical preparation for surgery, maintaining an emotionally supportive environment for the patient and family, and reviewing the medical chart for pertinent data.

The name preoperative care unit dispels some of the negative connotations associated with “holding room.” Many patients have expressed the expectation of the holding room as a “corral” environment or as a waiting area without nursing staff. The preoperative care unit label emphasizes patient care.

Design and Staffing

he preoperative care unit is located adjacent to the operating room and postanesthesia T care units and includes a clean utility room,

soiled utility room, patient restroom and shower, and a nursing station. The nursing station contains a medication set-up area, a computer terminal, and an interdepartmental communication system. All patient care areas can be viewed from the nursing station without obstruction.

Patient care areas are arranged on both sides of the room, and each is separated by curtains. Each area is equipped with oxygen, suction, and a sphygmomanometer. Individual lighting for each area was a key point in planning because venipunctures and skin preparations are performed in the unit; gooseneck lights, as well as overhead fluorescent lighting, were selected.

Other equipment in the preoperative care unit includes:

a blanket warmer, drawers for each patient area, a portable electrocardiogram (ECG) monitor, a scale, one crash cart and defibrillator, two intravenous supply carts, one skin preparation supply cart, and a sound system for each patient.

The unit is carpeted and separated from other areas by automatic doors to eliminate as much noise as possible. To minimize stress from noise or from the anticipation of the surgical experience, each patient care area is equipped with headphones

and a threechannel selector (classical, country- western, and popular music). Once surgical preparation is complete, patients are offered the option of listening to music while they await surgery.

The preoperative care unit is staffed from 6 AM to 6 PM Monday through Friday. Three nursing shifts have been established, 6 AM to 2:30 PM, 6 AM to 1 PM, and 930 AM to 6 PM. These shifts were determined from peak census

The operating schedule begins at 7:30 AM and if all eight ORs are scheduled, all of those patients are in the preoperative unit at the same time. When some of the procedures are equal in length, a second volume peak occurs at 9:30 AM. The 9:30 AM to 6 PM shift provides adequate staffing for census peaks and rest periods for nursing personnel.

Registered nurw staff the preoperative care unit. The practice of initiating intravenous fluids and administering intravenous narcotics precludes use of licensed practical nurses or technicians. Venipuncture skills are essential, and previous experience as an intravenous therapist is an asset for the RN in this unit. Qualifications must also encompass knowledge of surgical procedures, anesthetic techniques, and principles of asepsis.

Preoperative nurses must possess skills in effective interpersonal communication. They must be able to anticipate sources of surgical stress, recognize patient anxiety and related behaviors, and offer support. Nursing interventions frequently include reviewing preoperative information and offering nonverbal support by sitting quietly with the patient and family.

periods.

Patient Population

atients admitted to the preoperative care unit consist of several groups: direct P admissions, preadmissions to the medical-

surgical or ambulatory surgery units, and transfers from the emergency department. Patients requiring isolation because of infection are not brought to the preoperative care unit; they are admitted to the medical-surgical unit and transferred directly to the operating room. Because of the unit staffig ratio, nursing skill requirements, and lack of

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hemodynamic monitoring equipment, critically ill patients are not cared for in the preoperative care unit.

The surgery department secretary coordinates the transfer of patients to the preoperative care unit. The anesthesia staff members and the circulating nurses notify the secretary of estimated case completion time. The medical-surgical unit staffs are notifed approximately one hour before the surgery will start so that they can transfer the patient to the preoperative care unit.

Direct admissions are negotiated between the admitting department and preoperative care unit sta&. Patients admitted to the hospital the same day of surgery are scheduled for admission two hours before surgery. After the admission process is completed, patients and families are escorted to the preoperative care unit by admitting personnel.

Completing Chart Requirements

ne of the primary functions of the nurses in the preoperative care unit is to ensure 0 that the patient chart contains all required

data. Mandatory chart requirements vary accord- ing to state regulations and hospital policies, but in general, key elements include laboratory data, x-ray and ECG results, operative consent, medical history and physical, and nursing assessment.

The efficient collection of data is a common problem in clinical settings, and in some situations, is hampered by communication between the physician’s office and hospital departments. The physician’s office staff initiates the hospital admission process by completing admitting orders and providing patient instructions, but problems emerge when orders are incomplete or the patient misinterprets verbal directions.

One solution is a preprinted admission order form that reinforces hospital requirements for surgery. This form outlines data necessary for surgery such as laboratory, radiology, respiratory therapy, intravenous therapy, and nursing care. An area of the order sheet designates the person accountable for collecting each data segment.

In the absence of written confirmation of laboratory or radiology appointments, the patient

may arrive at the hospital the same day of surgery without the required laboratory reports. Some hospitals have developed programs in which laboratory tests, anesthesia evaluations, preoper- ative teaching, and nursing assessments are completed several days in advance of surgery to alleviate this problem.

Streamlined interdepartmental communication methods can also facilitate hospital admission and collection of preoperative data. A preoperative care unit equipped with computer access to laboratory data reduces the time required to obtain information. Other equipment that aids in data collection includes a tube system, interdepartmen- tal intercom, and a computer Screen to identify physicians who are in the hospital.

Patient Care

he nursing care is dependent on the patient’s hospital admission status. Patients directly T admitted to the preoperative care unit

require a nursing assessment and history. The process and assessment forms are identical to those used for patients admitted to the medical-surgical units (Table 1).

Clinical responsibilities common to all patient populations include the following:

Intravenous fluid therapy: Intravenous oper- ative fluids are prescribed by the anesthesiol- ogist and initiated in the preoperative care unit by nursing staff. Preoperative medications: Registered nurses administer preoperative (usually IV) medica- tions and monitor the efficacy of drugs. Physical assessment: A systems assessment and patient history are completed for patients admitted directly to the unit. The preoperative checklist is used to assess patients previously admitted to the hospital. Vital signs are obtained on admission to the unit and after administration of preoperative medications. The surgical site is assessed before shaving the area. Skin preparation: Generally, the surgical site is shaved with a razor. Physician speclfcations are maintained in the policy and procedure manual.

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Table 1 Preoperative Care Unit Phn of Nursing Care

Nursing Diagnosis

Knowledge deficit related to ineffective preoperative teach- ing, anxiety, or unfa- miliarity with surgi- cal procedures or experiences

Anxiety related to surgical procedure, unfamiliar environ- ment, ineffective individual or family coping mechanisms

Self-concept distur- bance related to dependency on nurs- ing staff, anticipated loss of body part or function, loss of social role

Expected Outcome

Patient relates realis- tic surgical prognosis Demonstrates behav- iors or identifies strategies to facilitate recovery: postopera- tive turning, deep breathing, coughing Identifies sequence of surgical events: preoperative care unit, operating room, postanesthesia care unit, transfer to medical-surgical unit

Vital signs consistent with medical-surgical unit measurement Interacts in a calm manner and relates realistic surgical outcomes Appropriately seeks out family or nursing staff and relates concerns

Identifies own strengths in influenc- ing surgical recovery and related realistic surgical prognosis and activities

Nursing Intervention

Explain preoperative procedures and time frame Individualize patient teaching by related present experiences with past surgical experience. Com- mon areas of patient concern include

type of anesthesia SurgicaVanesthetic risks recovery period and pain, and participation of family members in immediate

Evaluate family’s ability to reinforce realistic sur- gical outcome and patient paticipation in postop erative course Consult OR, PACU, medical-surgical unit staff for identified need to follow up on preoperative

recovery period

teaching

Evaluate degree of anxiety by observing anxiety- related behaviors: decreased eye contact, patient withdrawn or hostile, pressured speech or exces- sive talking, agitation. Initiate intervention to minimize anxiety, including

offering reassurance and remain with patient considering distractive strategies from anxiety- producing focus: slow deep breathing, music therapy (offer headphones) offering clear and brief explanations considering family support while patient is awaiting surgery and after physical prepara- tion is complete considering pharmacological therapy

Reinforce availability of nursing staff Consult OR and PACU staff for follow-up in assisting patient in developing effective coping strategies

Maintain privacy by using curtains to perform procedures Evaluate perceptions of physiological function after surgery and reinforce realistic outcome. Involve family in reinforcing realistic prognosis Offer support and focus on patient strengths

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Nursing Diagnosis

Impaired gas exchange related to administration of preoperative narcot- icdanalgesics

Cardiac output decreased related to effects of preopera- tive medication

Tissue perfusion impaired related to IV fluid administration

Sensory perceptual alteration related to preoperative medication

Skin integrity impair- ment of surgical site related to pre-existing medical condition or allergy to cleansing agents used for surgi- cal skin preparation

Injury potential related to physiologi- cal or environmental factors

Expected Outcome

Vital signs consistent with medical-surgical unit measurements Skin color pink

Respiratory rate 12 to 20 breaths per minute or consistent with medical status

IV site without red- ness, edema Patent IV

Arousable and able to respond to ques- tions and follow directions

Surgical site without signs of irritation, bruising, cuts

Nursing Intervention

Obtain vital signs on admission and after medi- cations are administered and compare with values obtained by medical-surgical unit staff

Observe skin color and color of mucous mem- branes and consider tissue perfusion status Administer oxygen (5 L to 8 L) by mask for res- piratory rate less than 12 breaths per minute. Consult anesthesia staff Acute respiratory depression: Assist ventilation with Ambu bag/100% oxygen and immediately consult anesthesia staff.

Document IV site observations and equipment used to establish IV access Evaluate patency and condition of IV site before and after medication administration

Document level of consciousness on admission and after administration of preoperative medication Consider noise level in the unit and relationship to patient perceptions

Assess surgical site and report alterations to surgeon Perform surgical skin preparation/wet shave of surgical site and monitor skin reactions to antimi- crobial agents Establish patient allergies to antimicrobial agents

Complete preoperative checklist to include: removal of dentures, prostheses, contact lenses, eye glasses, makeup, hairpins documented drug sensitivities secured patient identification and blood bands accurate and complete surgical consent complete and documented laboratory data and history and physical dietary restriction consistent with anesthesia instructions jewelry removed or secured fluid status documented; urinary output before surgery

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The primary goal of preoperative nursing care is to reduce patient and family stress associated with the surgical experience. Family members are encouraged to accompany the patient to the preoperative care unit and remain in the unit during the admission interview. This initial contact includes introduction of the primary nurse, completion of the questions contained in the preoperative checklist, reinforcement of preoper- ative teaching, and explanation of procedures. Common questions elicited during the admission interview include:

Is my surgery going to be on time? Will the procedure hurt? Are my test results normal? Will I see my physician before surgery? How much time will the surgery take? What type of anesthesia will be used?

After the initial interview, family members are directed to the surgery waiting area. This area is staffed by hospital volunteers who provide support by assisting families, preoperative care unit staff, postanesthesia care unit and surgery department personnel, and physicians. During the waiting period, preoperative care unit nurses are available to provide additional clinical information or support.

The patient’s physical preparation for surgery is completed after family members leave the unit. Intravenous fluid therapy is initiated, medications are administered, and the surgical site is shaved. In addition, anesthesia staff members may perform axillary blocks or insert invasive hemodynamic monitoring lines. Privacy for the patient is maintained by drawing the curtains which encircle each bed.

Summary

ealth care reimbursement practices are contributing to a decreased length of H hospital stay. Subsequently, the time

frame for surgical preparation has been reduced, and the hospital admission process has been considerably accelerated.

The patient admitted the same day of surgery can experience a hurried sequence of events. Within hours the patient is interviewed by

admitting department personnel, assessed by medical-surgical unit nursing staff, evaluated by “holding room”,nurses, assessed by anesthesia staff, and introduced to the operating room personnel. This rushed environment may lend to a negative surgical experience and increased surgery-related stress.

In contrast, establishing a preoperative care unit can increase surgical preparation time alotted to the patient by minimizing the number of personnel involved in the admitting process and decreasing

0 physical transfer of the patient.

Suggested reading Carpenito, L J. Nursing Diagnosis: Application to

Clinical Practice. Philadelphia: J B Lippincott Co, 1983.

Chansky, E R. “Reducing patients’ anxiety: Techniques for dealing with crisis.” AORN Journal 40 (September 1984) 375-377.

Connaway, C A; Blackledge, D. “Preoperative testing center: Central location to evaluate and educate patients.” AORN Journal 43 (March 1986) 666- 670.

Herth, K. “The therapeutic use of music.’’ Supervisor Nurse 9 (October 1978) 22-23.

Long, L; Johnson, J. “Using music to aid relaxation and relieve pain.” Dentul Survey 54 (August 1978)

MacClelland, D C. “Music in the operating room.” AORN Journal 29 (February 1979) 252-260.

McNeal, P Duncan, M L. “Assessing patients in the holding area.” Today’s OR Nurse 7 (March 1985) 16-19.

Silva, M C et al. “Caring for those who wait.” Today’s OR Nurse 6 (June 1984) 26-30.

Yoder, M E. “Nursing diagnosis Applications in perioperative practice.” AORN Journal 40 (August

35-38.

1984) 183-188.

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