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College of Nursing
Silliman University
Dumaguete City
RU on Preoperative Preparation
of the Patient
Submitted to: Mr. Eleno Mariano Melon IV
Submitted by: Jowillene Pearl O. Jatico
BSN IV D4
June 15, 2011
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VISION:
A leading Christian institution committed to total human development for the well- being for the w
of society and environment.
MISSION:
1.Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ; proan environment where Christian fellowship and relationship can be nurtured and promoted.
2.Provide opportunities for growth and excellence in every dimension of the University life in ordestrengthen character, competence and faith.
3.Instill in all members of the University community an enlightened social consciousness and a dsense of justice and compassion.
4.Promote unity among peoples and contribute to national development.College of Nursing
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SPECIFIC
OBJECTIVESCONTENT T/A T/L
ACTIVITI
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Appreci & 'e'
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)
portance
of
preoperati0
e
preparation
inthecareof
thepatient.
Correctl 1i
2
entifytheneededdata
to3
e
assessed
preoperati4
el
y.
I. Prayer
II. Introduction of Preoperative Preparation of the Patient2.1 O 5erviewThepreoperativeperiod
6
eginswhentheclient isscheduledforsurgeryandendsattheti7
eoftransfertothe
surgical suite.Asanurse, you7
ustactasaneducator, anadvocate, andapromoterofhealth. Thesurgical environment
demandstheuseofknowledge, judgment, andskills6
asedontheprinciplesofnursingscience.Care6
eforesurgery
focusesonclientreadiness. Thiscare includeseducationandany interventionneeded6
eforesurgerytoreduceanxiety
andcomplicationsandtopromotecooperation inproceduresaftersurgery.
2.2 GoalTheoverall goal ofpreoperativeperiod istoensurethattheclient ismentallyandphysicallypreparedforthesurgery.8urses have long
6
een recognizing the value of preoperative instructions, with this, they are teaching each patient
individuallyanduniquelywithconsiderations to theconcernsof the learningneedsof thepatient. Teaching strategies
suchasverbal, written, andreturndemonstrationareuseddependingonthepatientsneedsandabilities.9
reoperative
teaching is initiatedassoonaspossibleandshouldstartatthephysiciansofficeoratthetimeof9
AT continuedwhenthe
patientarrives inthe OR.
III. Nursing Process3.1PreoperativeAssessmentA. Physiological parametersy Age
Olderclientsareat increasedrisk forcomplications. Thenormal agingprocessdecreases immunesystem
functioninganddelayswoundhealing. Thefrequencyofchronic illness increases inolderclients.
y HealthAssessmenta. PastHealthHistory
5
mins.
1hour
Interacti
discussio
andgivi
of
handout
Socialize
lecture
withvisu
aid
presenta
n
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o Takebaselinebloodpressure inbotharms.o Identifyanydrugorherbal productthatmayaffectcoagulation.o Review laboratoryanddiagnostictestsforcardiovascularfunction.o Identifypatientswithpacemakersand/or implantabledefibrillators.
Respiratory System
o Identifyacuteorchronicproblems;notethepresenceofinfectionorchronicobstructivepulmonarydisease,asthma. Thepresenceofanupperairway infectionmayresult inthecancellationorpostponementofelective
surgerybecausetheexisting infectionwill placethepatientatan increasedrisk ofbronchospasm, laryngospasm,
decreasedoxygensaturation, andproblemswithrespiratorysecretions. Thenurseshouldalsoreportapatients
historyofdyspneaatrestorwithexertionandhemoptysis. Ifapatienthasahistoryofasthma, thenurseshould
inquireaboutthepatientsuseofinhaledororal corticosteroidsandbronchodilators, aswell asthefrequencyand
triggersofasthmaattacks. ThepatientwithahistoryofCOPD andasthmaareathighrisk ofpostoperative
pulmonarycomplications, which includehypoxemiaandatelectasis.
o Assesshistoryofsmoking, includingthetime interval sincethe lastcigaretteandthenumberofpack-years. Thepatientwhosmokesshouldbeencouragedtostopat least 6 weekspreoperativelytodecreasetherisk
intraoperativeandpostoperativereapiratorycomplications.
o Auscultate lungsfornormal andadventitiousbreathsounds.o Determinebaselinerespiratoryrateandrhythm, andregularityofpattern.o Observeforcough, dyspnea, anduseofaccessorymusclesofrespiration.
Neurologic System
o Determineorientationtotime, place, andperson.o Identifypresenceofconfusion, disorderlythinking, or inabilitytofollowcommands.Alterations inthepatients
hearingandvisionmayaffectresponsesandabilitytofollowdirectionsthroughouttheperioperativeassessment
andevaluation. Thepatientsabilitytopayattention, concentrate, andrespondappropriately inthepreoperative
phasemustbedocumentedtoestablishanaccuratebaselineforpostoperativecomparison.
o Identifypasthistoryofstrokes, transient ischemicattacksornervoussystemdiseases.Urinary System
o Identifythepreexistingdisease. Thepresentdiseasestateandtreatmentusedtocontrol thediseaseshouldbenotedanddocumented.
o Determineabilitytovoid.Prostateenlargementmayaffectcatheterizationduringsurgeryandabilitytovoid
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preoperatively.
o Ifnecessary, notecolor, amount, andcharacteristicsofurine.o Review laboratoryanddiagnostictestsforrenal function.Adecrease inrenal functionmaycontributetoan
alteredresponsetodrugsandunpredictabledrugelimination. Renal functiontests, suchasserumcreatinineand
bloodureanitrogen, arecommonlyorderedpreoperatively, andresultsshouldbeavailableonthechartbefore
thepatientgoestosurgery.
Hepatic System
o Inspectskincolorandscleraofeyesforanysignsofjaundice.o Reviewpasthistoryofsubstanceabuse, especiallyalcohol and IV druguse.o Review laboratoryanddiagnostictestsfor liverfunction. Thepatientwithhepaticdysfunctionmayhavean
increasedperioperativerisk forclottingabnormalitiesandadverseresponsestomedications.
Integumentary System
o Assessmucousmembranesfordrynessand intactness. Thecurrentstatusoftheskinshouldbeassessedforboils,rashes, ulcers, orotherdermatologiccondition.
o Determineskinstatus;notedrying, bruising, orbreaks insurface. Skinproblemsmayaffectpostoperativehealing.o Inspectskinforrashes, boils, or infection, especiallyaroundtheplannedsurgical site.o Assessskinmoistureandtemperature.o Inspectthemucousmembranesandskinturgorfordehydration.
Musculoskeletal System
o Examineskin/bonepressurepoints.o Assessforpresenceofanypressureulcers.o Assessfor limitations in jointrangeofmotionandmuscleweakness.Mobilityrestrictionsmay influence
intraoperativeandpostoperativepositioningandambulation.
o Assessmobility, gait, andbalance.o Assessforpresenceofjointpain. Frequently, postoperativepain isduetochronicmusculoskeletal painand
positioningduringsurgery, ratherthantheacutepainofthesurgical procedure.
Gastrointestinal System
o Determinefoodandfluid intakepatternsandanyrecentweight loss. Thepatientshouldbe questionedabouttherecentpresenceofconditionsthat increasetherisk forfluidandelectrolyte imbalances, suchasvomiting,
diarrhea, ordifficultyswallowing.
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Electrolyte imbalancealso increaseoperativerisk.Preoperative laboratoryresultsshouldbecheckedtosee
whetherserumsodium, potassium, calcium, andmagnesiumconcentrationsarewithinthenormal range.
B. Psychosocial ParametersMostpatientshavesometypeofemotional reactionbeforeanysurgical procedure, be itobviousorhidden,
normal orabnormal. Fearsmayberelatedtofearoftheunknownorofdeath, anesthesia, pain, complications, or
cancer.Preoperativeanxietymaybeananticipatoryresponsetoanexperienceviewedbythepatientasathreatto
hisorhercustomaryrole in life, permanent incapacity, body integrity, increasedresponsibilitiesorburdenonfamily
members, or life itself. Lessobviousconcernsmayoccurbecauseofpreviousexperienceswiththehealthcaresystem
andpeoplethepatienthas knownwiththesamecondition.Psychological distressdirectly influencesbodyfunctioning. Therefore, it is imperativeto identifyanyanxietythepatient isexperiencing.Peopleexpressfear in
differentways. Forexample, somepatientsmayrepeatedlyask many questions, eventhoughanswersweregiven
previously. Othersmaywithdraw, deliberatelyavoidingcommunication, perhapsbyreading, watchingtelevision, or
talkingabouttrivialities.Consequently, thenursemustbeempathetic, listenwell, andprovide informationthathelps
alleviateconcerns.An importantoutcomeofthepsychosocial assessment isthedeterminationoftheextentandrole
ofthepatientssupportnetwork.
C. Laboratoryand DiagnosticParametersThenurseshouldobtainandevaluatetheresultsoflaboratoryanddiagnostictestsorderedpreoperatively.
CommonPreoperative Diagnostic Testsare:
o Urinalysis-toscreenrenal functiono Chest X-ray-mayberequiredbyhospital policyormedically indicated.Apreoperativechestx-raystudy isnot
routinelyrequiredforall patients. Itmaybemedically indicatedasanadjuncttoclinical evaluationofpatients
withcardiacorpulmonarydiseaseandforsmokers, personsage 60 andolder, andcancerpatients.
o Bloodstudies: RBC, Hb, Hct, WBC-Thesemayberoutinelytestedforpersons 60 yearsofageorolder.Hematocritisusuallyorderedforwomenofall agesbeforetheadministrationofageneral anesthetic.
o Electrolyteso ABGs, oximetryo PT, PTT, plateletcount-to identify knownorsuspectedcoagulationdisorderso Bloodglucose
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o Creatinineo Bloodureanitrogeno Serumalbumino Electrocardiogram-Ifthepatienthas knownorsuspectedcardiacdisease, anelectrocardiogram ismandatory. It
mayberoutineforpatientsB
0 yearsofageorolderbypolicy.
o Pulmonaryfunctiontestso Liverfunctiontestso Typeandcrossmatch-Iftransfusion isanticipated, thepatientsblood istypedandcrossmatched.Manypatients
prefertohavetheirownblooddrawnandstoredforautotransfusion. Theystill shouldbetypedand
crossmatched, however, intheeventthatadditional transfusionsareneeded.o hCG
Preoperative laboratorytestsareorderedonthebasisofthe individual patienthistoryandphysical examination.
Thusthenursemustensurethatall laboratoryreportshavearrivedattherighttimeandareonthechart. Lack of
requireddiagnosticreportsmayresult inadelayorcancellationofthesurgery.
D. PreoperativeAnesthesia EvaluationTheanesthesiacareprovidervisitstheclientbeforesurgerytoperformacompleterespiratory, cardiovascular,
andneurologicexamination. Theclientsgeneral surgical risk isexpressedaccordingtothisgradingsystem:
P1Anormal healthyclient P2Aclientwithmildsystemicdisease P3Aclientwithseveresystemicdisease P4Aclientwithseveresystemicdiseasethat isaconstantthreatto life P5 Amoribundclientwho isnotexpectedtosurvivewithouttheoperation P6 Adeclaredbrain-deadclientwhoseorgansarebeingremovedfordonorpurposes
Generally, thetopicsdiscussedwiththeclientduringthisexamination includethetypeofanesthesiaplannedand
thesensationstheclientmayexperiencewhenundergoinganesthesia. Fearstheclienthasconcerninganesthesiaare
alsoaddressed. Theclientsrisk ofsideeffectsandcomplications isassessedatthistime.
Thepharmacologicpreparationoftheanesthesia isbasedonmanyvariables, includingtheclientsageand
physical andpsychological condition, thetypeofsurgery, andthetypeofanesthesiatobeused.
E. Preoperative Educational AssessmentTheclientsexperiencewithprevioussurgeryandthe level ofanxietyarenoted. Theclientseducation level,
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Enumerateatleast2
nursing
diagnoses in
preoperative
patient
preparation.
Formulate intheirown
understandin
gexpected
outcomes
basedonthe
nursing
diagnosesgiven.
sensory impairments, expectationsregardingtheoperation, andavailabilityofsupportsystemsshouldguideplansfor
teaching. Ingeneral, clientswhohaveundergonemultipleoperationsneed lesseducational preparation.However, do
notassumethatsuchclientsneednoreinforcementofpreoperativeandpostoperativeassessmentsand interventions.
3.2PreoperativeNursing DiagnosesThefollowingareprioritynursingdiagnosesforpreoperativeclients:
o Deficient Knowledge (specificexperiencesbefore, during, andaftersurgery)relatedtoa lack ofexposureo Anxietyrelatedtothethreatofachange inhealthstatusorfearoftheunknown
Othercommonnursingdiagnosesforpreoperativeclients:
o Disturbed Sleeppatternrelatedto internal sensoryalterationso IneffectiveCopingrelatedtothe impendingsurgeryo Anticipatory Grievingrelatedtotheeffectsofthesurgeryo DisturbedBody Imagerelatedtoanticipatdchanges inthebodysappearanceorfunctiono Disabled FamilyCopingrelatedtotemporaryfamilydisorganizationandrolechangeso Powerlessnessrelatedtothehealthcareenvironment, lossofindependence, and lossofcontrol ofonesbody3.3Expected Outcomes
Gained knowledge, asevidencedwhenthepatient
Explainsthepurposeandexpectedresultsoftheplannedsurgery Asks questionswhenatermorprocedure isunknown AdherestotheNPO requirements Statesanunderstandingofpreoperativepreparations (e.g.skinpreparation, bowel preparation) Demonstratescorrectuseofexercisesandtechniquestobeusedaftersurgeryforthepreventionof
complications (splintingthe incision, coughing/deepbreathing, performing legexercises, ambulatingasearlyas
permitted)
Reliefofanxiety, evidencedwhenthepatient
Discusseswiththeanesthesiologistandanesthetistconcernsrelatedtotypesofanesthesiaand induction Verbalizesanunderstandingofthepreanestheticmedicationandgeneral anesthesia Discusses last-minuteconcernswiththenurseorphysician Discussesfinancial concernswiththesocial worker, whenappropriate
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Statecorrectlyat
least3
appropriate
preoperative
instructions.
Requestsvisitwithspiritual advisorwhenappropriate Appearsrelaxedwhenvisitedbyhealthcareteammembers
Decreasedfear, evidencedwhenthepatient Discussesfearswithhealthcareprofessionalsoraspiritual advisor, orboth Verbalizesanunderstandingofanyexpectedbodilychanges, includingexpecteddurationofbodilychanges.
Understandingofthesurgical intervention, evidencedwhenthepatient
Participates inpreoperativepreparation Demonstartesanddescribesexercisesheorshe isexpectedtoperformpostoperatively Reviews informationaboutpostoperativecare Acceptspreanestheticmedication, ifprescribed Remains inbedoncepremedicated Relaxesduringtransportationtothe OR orunit Statesrationaleforuseofsiderails Discussespostoperativeexpectations
Noevidenceofpreoperativecomplications
3.4PreoperativeNursing Interventions3.4.1Day-of-surgeryProceduresA. FacilitatingPreoperative InstructionsNurseshave longrecognizedthevalueofpreoperative instruction. Eachpatient istaughtasan individual,
withconsiderationforanyuniqueconcernsorneeds;theprogramofinstructionshouldbebasedonthe individual's
learningneeds.Multipleteamingstrategiesshouldbeused (e.g.verbal, written, returndemonstration), dependingon
thepatient'sneedsandabilities.Preoperativeteaching is initiatedassoonaspossible. Itshouldstart inthephysician's
officeandcontinueuntil thepatientarrives intheoperatingroom.
WhenandWhatto Teach?
Ideally, instruction isspacedoveraperiodoftimetoallowthepatienttoassimilate informationandask
questionsastheyarise. Frequently, teachingsessionsarecombinedwithvariouspreparationprocedurestoallowfor
aneasyandtimelyflowofinformation. Thenurseshouldguidethepatientthroughtheexperienceandallowample
timefor questions. Somepatientsmayfeel toomanydescriptivedetailswill increasetheiranxiety level, andthenurse
shouldrespecttheirwishfor lessdetail.
Teachingshouldgobeyonddescriptionsoftheprocedureandshould includeexplanationsofthesensations
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y Hospitalsmayrequirethatapatientwearahospital gownwithnounderclothes, whereassurgerycentersmayallowthepatienttowearunderwear, dependingonthesurgical proceduretobeperformed.
y Thepatientshouldnotwearcosmeticsbecauseobservationofskincolorwill be important.y Nail polishandartificial nailsshouldberemovedsothatcapillaryrefill andpulseoximetrycanbeassessed.y An identificationband isputonthepatientand, ifapplicable, anallergyband.y All patientvaluablesarereturnedtoafamilymemberorsecuredaccordingto institutional protocol. Ifthe
patientprefersnottoremoveaweddingring, theringcanbetapedsecurelytothefingertoprevent loss.
y All prostheses, includingdentures, contact lenses, andglasses, aregenerallyremovedtoprevent lossordamagetothem.
y Hearingaidsmaybe left inplacetoallowthepatienttobetterfollow instructions.y Glassesandhearingaidsmustbereturnedtothepatientassoonaspossiblefollowingsurgery.y Thepatientshouldbeencouragedtovoidbeforepreoperativemedicationsareadministered ifthe
medicationswill interferewithmaintainingbalanceand increasetherisk forafall whenambulatingtothe
bathroom.
y Thepatientshouldalsohaveanemptybladderontransfertothe OR toprevent involuntaryeliminationunderanesthesiaandreducethepossibilityofurinaryretentionduringearlypostoperativerecovery.
y Theuseofapreoperativechecklistensuresthatall preoperativehavebeencompletedbeforethepatient isgivenanysedatingmedications.
a. PreoperativeMedicationsPreoperativemedicationsareusedforavarietyofreasons.Apatientmayreceiveasingledrugoracombination
ofdrugs.
y Benzodiazepinesandbarbituratesareusedfortheirsedativeandamnesicproperties.y Anticholinergicsaregiventoreducesecretions.y Opioidsmaybegiventodecrease intraoperativeanestheticrequirementsandtodecreasepain.y Antiemeticsmaybegiventodecreasenauseaandvomiting.
Othermedicationsthatmaybeadministeredpreoperatively includeantibiotics, eyedrops, androutineprescription
drugs.
y Antibioticsmaybeadministeredthroughoutthepreoperativeperiodforapatientwithahistoryofcongenital or
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Activelyparticipate in
theopen
forumby
askingand
answering
questions
correctly.
hospitalsprovidepagerstowaitingfamilymemberssothattheymayeatordoerrandsduringthesurgery.
Whilethepatient is insurgerythe inpatientnurseshouldhavethepatientsroompreparedforthe
postoperativearrival.Anyadditional necessaryequipment, including IV poles, oxygen, suction, andadditional pillowsforpositioning, shouldalsobeplaced intheroom. Theroomalso isorganizedtofacilitateentryofthetransportcart.
3.4.4 Caringforthe SignificantOthersAdesignatedwaitingarea isusuallyprovidedforfamilymembersduringsurgery. Whendiscussingthesurgical
procedurewiththeclientssignificantothers, besurethatyouare located inaprivateareaandprovideanswers
congruentwiththe informationthatthesurgeonhasalreadyprovided. Familymembersshouldalsobepreparedfor
anyequipmentthatmayaccompanytheclientpostoperatively.Apreoperativeexplanationwill assistthefamily inunderstandingwhatequipment isattachedtotheir lovedone, andwhy. Significantothersneedtobe informedwhen
surgery iscompletedor ifthereareanydelays. Thesurgeonshouldspeak withfamilymembersassoonaspossible
aftercompletionoftheprocedure.
3.5Evaluation: OutcomesEvaluatethecareofthepreoperativeclientonthebasisofthe identifiednursingdiagnoses. Theexpected
outcomes includesthattheclient:
Statesunderstandingofthe informedconsentandpreoperativeprocedures Demonstratespostoperativeexercisesandtechniquesforpreventionofcomplications Hasreducedanxiety
IV. Open Forum 20mins.
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Resources:
Atkinson, I. J., Fortunato, N.H. (1996). Berry & Kohns Operating Room Techniques. 8th
ed. Missouri: Mosby Elsevier.
Black, J.M. & Hawks, J.H. (2009). Clinical management for positive outcomes. 8th
ed. Missouri: Saunders Elsevier, Inc.
Ignatavicius, D.D. & Workman, M.L. (2006). Medical surgical nursing: critical thinking for collaborative care. 5th
ed. Singapore: Elsevier Pte Ltd.
Lewis, S.M., et.al. (2004).Medical surgical nursing: assessmentandmanagementofclinical problems. 6th
ed. Philadelphia: Mosby, Inc.
Smeltzer, S. , Bare, B. , et.al (2008). Textbook ofMedical-SurgicalN
ursing.11
th
ed. Lippincott,U
SA.
V. Evaluation 5mins.
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