2. Overview
● Preoperative care takes place from the time a
client is scheduled for surgery until care is
transferred to the operating suite.
● Assessment of risk factors is one of the major
aspects of preoperative care. Preoperative care
includes a thorough assessment of the client’s
physical, emotional, and psychosocial status
prior to surgery.
3. Risk Factors
● Surgery
• Infection (risk of sepsis)
• Anemia (malnutrition, oxygenation, healing impact)
• Hypovolemia from dehydration or blood loss (circulatory
compromise)
• Electrolyte imbalance through inadequate diet or disease
process (dysrhythmias)
• Age (older adults are at greater risk because of decreased
liver and kidney function due to age, and the use of
multiple prescribed medications)
• Pregnancy (fetal risk with anesthesia)
• Respiratory disease (COPD, pneumonia, asthma)
5. cont
- Coagulation defect (increased risk of bleeding)
- Malnutrition (delayed healing)
- Obesity (pulmonary complications due to
hypoventilation, impact on anesthesia, elimination, and
wound healing)
-Certain medications (antihypertensives, anticoagulants,
NSAIDs, tricyclic antidepressants, herbal
medications, over-the-counter medications)
- Substance use (tobacco, alcohol)
- Family history (malignant hyperthermia)
6. cont
- Allergies (latex, anesthetic agents)
- Cancer of the oral cavity
- Inability to cope, lack of support system
- Disease processes involving multiple body
systems
7. cont
Older adult clients:
■ Are at a greater risk of adverse reactions to
preoperative medications.
■ Have less physiologic reserve than younger
clients, which may cause decreased immune
system response and decreased wound healing.
■ Reduction of muscle mass and the amount of
body water places the older adult client at risk
for dehydration.
8. cont
■ Can have sensory limitations (poor eyesight, hearing
loss), so the nurse must be alert to
maintaining a safe environment.
■ Can have oral alterations (dentures, bridges, loose
teeth) that pose problems during intubation.
■ Perspire less, which leads to dry, itchy skin that
becomes fragile and easily abraded. Precautions
need to be taken when moving and positioning these
clients.
■ Have decreased subcutaneous fat, which makes them
more susceptible to temperature changes.
9. Diagnostic Procedures
● Urinalysis – ruling out of
infection
● Blood type and cross match
– transfusion readiness
● CBC – infection/immune
status
● Hgb and Hct – fluid status,
anemia
● Pregnancy test – fetal risk of
anesthesia
● Clotting studies (PT, INR,
aPTT, platelet count)
● Electrolyte levels –
electrolyte imbalances
● Serum creatinine and BUN
– renal status
● ABGs – oxygenation status
● Chest x-ray – heart and
lung status
● 12-lead ECG – baseline
heart rhythm, dysrhythmias,
history of cardiac disease,
performed on all clients
older than 40 years
10. Preoperative Assessment
● Preoperative nursing assessments
- Detailed history (including medical history, medication
use, substance use, psychosocial history,
and cultural considerations)
- Allergies to medications, latex related to a sensitivity to
bananas and other fruits, betadine related to an allergen
to shellfish, propofol related to an allergy to eggs or
soybean oil.
- Anxiety level regarding the procedure, support systems,
and coping mechanisms.
■ Older adult clients may be more fearful due to financial
concerns and lack of social support.
11. cont
- Allergies to medications, betadine related to an
allergen to shellfish, propofol related to an allergy to
eggs or soybean oil.
- Anxiety level regarding the procedure, support
systems, and coping mechanisms.
■ Older adult clients may be more fearful due to
financial concerns and lack of social support.
- Laboratory results
- Head-to-toe assessment, vital signs, and oxygen
saturations to obtain baseline data.
12. Nursing Actions
● Informed consent
- Once surgery has been discussed as treatment with the
client and significant other, family member, or
friend, it is the responsibility of the primary care provider to
obtain consent after discussing the risks and
benefits of the procedure. The nurse is not to obtain the
consent for the provider in any circumstance.
- The nurse can clarify any information that remains unclear
after the provider’s explanation of the procedure. The nurse
may not provide any new or additional information not
previously given by
the provider.
13. cont
- The nurse’s role is to witness the client’s signing of the
consent form after the client acknowledges
understanding of the procedure.
- The nurse should determine if the client is:
■ 18 years of age.
■ Mentally capable of understanding the risks, reason, and
options for surgery and anesthesia.
■ Under the influence of medication that affects decision-
making or judgment (opioids, benzodiazepines, sedatives). Do
not have the client sign the informed consent if medications
have been administered.
14. cont
- A legal guardian may need to sign the surgical
consent form if the client is not capable of
providing consent or if there is no family.
- Two witnesses are required if the client is able to
only sign with an “X”, blind, deaf, or English is a
second language.
- nformed consent is required for surgical
procedures, invasive procedures (biopsy,
paracentesis, scopes),
and any procedure requiring sedation or
anesthesia, or involving radiation.
15. Responsibilities for Informed Consent
Provider:
Obtains
informed
consent
›› To obtain informed consent, the provider
must give the client:
-A complete description of the
treatment/procedure.
-A description of the professionals who will be
performing and participating in the treatment
-Information on the risks of anesthesia.
-A description of the potential harm, pain,
and/or discomfort that may occur.
-Options for other treatments.
-he right to refuse treatment.
16. cont
Client:
Gives
informed
consent
›› To give informed consent, the client
must:
- Give it voluntarily (no coercion
involved).
- Receive enough information to make a
decision based on an understanding of
what is expected.
- Be competent and of legal age or be
an emancipated minor. When the client
is unable to provide consent, another
authorized person must give consent.
17. cont
Nurse:
Witnesses
informed
consent
›› To witness informed consent, the nurse must:
- Ensure that the provider gave the client
the necessary information.
- Ensure that the client understood the
information and is competent to give
informed consent.
- Notify the provider if the client has more
questions or appears to not understand any
of the information provided. (The provider
is then responsible for giving clarification.)
- Have the client sign the informed
consent document.
- The nurse documents questions the client
has and notifies the provider. The nurse also
documents any additional reinforcement
of teaching.
- Provide a trained medical interpreter (not a
family member or friend) and record the use
of an interpreter in the client’s medical record.
18. Preoperative teaching
• Postoperative pain control techniques
(medications, immobilization, patient-controlled
analgesia pumps, splinting)
- Demonstration and importance of splinting,
coughing, and deep breathing
- Demonstration and importance of range-of-
motion exercises and early ambulation for
prevention of thrombi and respiratory
complications
- Purpose of antiembolism stockings to prevent
deep-vein thrombosis
19. cont
• Invasive devices (drains, catheters, IV lines)
• Postoperative diet
• Use of the incentive spirometer
20. cont
- Preoperative instructions (avoid cigarette smoking for 24 hr
preoperatively, medications to hold, bowel preparation)
■ Clients who are taking acetylsalicylic acid (Aspirin) should stop taking
it for 1 week before an elective surgery to decrease the risk of
bleeding.
■ Clients who take herbal medications (e.g. ginseng) should stop taking
them 2 to 3 weeks before surgery to prevent hemorrhage or adverse
affects to the anesthetic.
■ Medications for cardiovascular disease, pulmonary disease, seizures,
and diabetes mellitus, certain antihypertensive medications, and eye
drops for glaucoma may be taken prior to surgery or a procedure.
■ Teach the client how to use a pain scale to rate pain level
postoperative.
21. Preoperative nursing actions
◯ Verify that the informed consent is accurately completed,
signed, and witnessed.
◯ Administer enemas and/or laxatives the night before and/or
the morning of the surgery for clients undergoing bowel surgery.
◯ Regularly check the client’s scheduled medication
prescriptions. Some medications (antihypertensives,
anticoagulants, antidepressants) may be held until after the
procedure.
◯ Ensure that the client remains NPO for at least 6 hr for solid
foods and 2 hr for clear liquids before surgery with general
anesthesia, and 3 to 4 hr with local anesthesia to avoid
aspiration. Note on the chart the last time the client ate or
drank.
22. cont
- Perform skin preparation, which may include
cleansing with antimicrobial soap. If absolutely
necessary, use electric clippers or chemical
depilatories to remove hair in areas that will be
involved in the surgery.
- Ensure that jewelry, dentures, prosthetics,
makeup, nail polish, and glasses are removed.
These items can either be given to the family or
stored safely.
- Cover the client with lightweight cotton blanket
heated in a warmer to prevent hypothermia.
23. cont
- Establish IV access using a large-bore (18-gauge) catheter for
easier infusing of IV fluids or blood products.
- Administer preoperative medications (prophylactic
antimicrobials, antiemetics, sedatives) as prescribed.
■ Prophylactic antibiotics are administered 1 hr prior to
surgical incision.
■ If the client previously took a beta-blocker, administer a
beta-blocker prior to surgery to prevent a cardiac event and
mortality.
■ Have the client void prior to administration.
■ Monitor the client’s response to the medications.
■ Raise side rails following administration to prevent injury.
24. cont
- Ensure that the preoperative checklist is
complete.
- Confirm and verify the correct surgical site with
the client and all health care team members
before clearly marking the surgical site.
25. Complications
● Complications during the postoperative period
usually are related to the medications given
preoperatively. These medications and their
possible complications are as follows:
27. cont
● For clients encountering severe anxiety and panic,
reassurance will be necessary and sedation medications
may be given.
Nonpharmacological interventions, such as distraction,
imagery, and music therapy, can be initiated.
● Ensure that measures are taken to prevent deep-vein
thromboembolism postoperative by continuing
anticoagulation therapy and/or antiembolism stockings,
pneumatic compression device, and range-of-motion
exercises.
● Be alert for any allergic reactions the client has to
medications.
