Preoperative care: A look at perioperative care

Focus Topic: Preoperative care

Many technological advances have made operations quicker, safer, and more effective. Even so, surgery remains one of the most stressful experiences a patient can undergo. Before the patient enters the operating room, you must fully address his psychological and physiologic needs. If prepared properly with careful teaching, a surgical patient will experience less pain, fewer postoperative complications, and shorter hospitalization.

Preoperative care

Careful, considerate preoperative care will help prevent future complications for the patient and ease anxiety felt by the patient and his family.

Preoperative care: Preoperative assessment

Focus Topic: Preoperative care

A thorough preoperative assessment helps systematically identify and correct problems before surgery and establishes a baseline for postoperative comparison. Begin by confirming the patient’s identity using two identifiers, according to your facility’s policy. Then verify the surgical procedure and surgical site with the patient. Next, focus on problem areas suggested by the patient’s history and on any body system that will be directly affected by the surgery. (See History lesson.) Consider your findings in relation to the specific age-group norms. Don’t forget to include the patient’s psychological status in your assessment because depression and anxiety can significantly interfere with recovery from surgery.

Preoperative care: Patient teaching

Focus Topic: Preoperative care

Your teaching can help the patient cope with the physical and psychological stress of surgery. Preadmission and preoperative teaching are more important than ever in these days of shorter hospital stays and same-day surgeries.

 

Evaluate, adapt, and consider

Focus Topic: Preoperative care

Evaluate the patient’s understanding and tell him what to expect before, during, and after the procedure. Adapt your teaching to fit the patient’s age, understanding, and cultural background. Also, consider the needs of the patient’s family or caregivers.

What to teach

Be sure to include these topics in your preoperative patient teaching:

  • diagnostic tests
  • the need to abstain from food and fluids for a period of time before surgery
  • what type of anesthesia is planned, such as general, regional, or balanced
  • airway management
  • placement of other tubes, such as nasogastric tubes or drains
  • operating room procedure
  • I.V. therapy
  • what to expect on the postanesthesia care unit (PACU)
  • pain control
  • postoperative care, including diet, mobility, and treatments.

Prepare for postop

Focus Topic: Preoperative care

Before surgery, teach the patient early postoperative mobility and ambulation techniques and leg exercises. In addition, teach coughing and deep-breathing exercises, including how to use an incentive spirometer. Make it clear that the patient will have to repeat these maneuvers several times after surgery. (See Teaching coughing and deep-breathing exercises.)

History lesson

Preoperative care

 

Tell the patient that postoperative exercises help prevent such complications as:

  • atelectasis
  • hypostatic pneumonia
  • thrombophlebitis
  • constipation
  • abdominal distention
  • venous pooling.

Have the patient perform postoperative exercises to assess whether further teaching is necessary and to support the teaching plan.

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Preoperative care: Getting ready

Focus Topic: Preoperative care

To prepare the patient for surgery, you may have to perform skin and bowel preparations and administer drugs.

Teaching coughing and deep-breathing exercises

Preoperative care

 

Skin preparation

In most facilities, skin preparation is carried out during the intraoperative phase. However, making sure the skin is as free from microorganisms as possible reduces the risk of infection at the incision site. The patient may be asked to bathe, shower, or scrub a local skin area with an antiseptic the evening before or the morning of surgery. The surgeon will usually specify the site for a local skin scrub if indicated.

Make it big, real big

Focus Topic: Preoperative care

To reduce the number of microorganisms in areas near the incision site, prepare a much larger area than the expected incision site. Doing so also helps prevent contamination during surgical draping. Document skin preparation, including the area prepared and any unexpected outcomes.

Bowel preparation

The extent of bowel preparation depends on the type and site of surgery. A patient scheduled for several days of postoperative bed rest who hasn’t had a recent bowel movement may receive a mild laxative or sodium phosphate enema. On the other hand, a patient scheduled for GI, pelvic, perianal, or rectal surgery will undergo more extensive intestinal preparation.

After three, make the call

Focus Topic: Preoperative care

If enemas are ordered until the bowel is clear and the third enema still hasn’t removed all stool, notify the practitioner because repeated enemas may cause fluid and electrolyte imbalances. Elderly patients, children, and patients who are allowed nothing by mouth and haven’t received I.V. fluids are at particularly high risk for these imbalances.

Preoperative drugs

The practitioner may order preoperative or preanesthesia drugs to:

  • ease anxiety
  • permit a smoother induction of anesthesia
  • decrease the amount of anesthesia needed
  • create amnesia for the events preceding surgery
  • minimize the flow of pharyngeal and respiratory secretions
  • minimize gastric secretions
  • reduce the risk of infection

Discussing drugs

Focus Topic: Preoperative care

Expect to administer ordered drugs 30 to 75 minutes before induction of anesthesia. Teach the patient about ordered drugs, their desired effects, and their possible adverse effects. These drugs include:

  • anticholinergics (vagolytic or drying agents)
  • sedatives
  • antianxiety drugs
  • opioid analgesics
  • neuroleptanalgesic agents
  • histamine-2 receptor antagonists
  • antibiotics

Final check

Before surgery, follow these important steps:

  • Make sure the patient has had no solid food for at least 6 hours and no water for at least 2 hours before surgery.
  • Make sure the chart contains all necessary information, such as signed surgical consent, diagnostic test results, health history, and physical examination. Patient allergies should be easily visible.
  • Tell the patient to remove jewelry (including body piercings), makeup, and nail polish. Ask the patient to shower with antimicrobial soap, if ordered, and to perform mouth care. Warn against swallowing water.
  • Instruct him to remove dentures or partial plates. Note on the chart if he has dental crowns, caps, or braces. Also have him remove contact lenses, glasses, or prostheses (such as an artificial eye). You may remove his hearing aid to make sure it doesn’t become lost. However, if the patient wishes to keep his hearing aid in place, inform operating room and PACU staff of this decision.
  • Have the patient void.
  • Put on a surgical cap and gown.
  • Take and record vital signs.
  • Make sure the informed consent form is signed by the patient or a responsible family member.
  • If the surgical site involves a right or left distinction, multiple structures (such as fingers or toes), or multiple levels (such as the spine), the site should be marked with a permanent marker by the person doing the procedure. The site should be marked before the patient is taken to the area where the procedure will be done, and the marking should be visible after the patient is prepped and draped.
  • Administer preoperative medication as ordered.
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