Preoperative Phase

GOALS:

* assessing and correcting physiologic and psychologic problems that might increase surgical
risk.
* giving the person and significant others complete learning and teaching guidelines regarding
surgery.
* instructing and demonstrating exercises that will benefit the person during postop period.
* planning for discharge and any projected changes in lifestyle due to surgery.

PHYSIOLOGIC ASSESSMENT OF CLIENT

Assessment of health factors that affects patients preoperatively:

1.Nutritional status – optimal nutrition is an essential factor in promoting healing and resisting
infection and other
surgical complications.
Nutrients important for wound healing:
a. Protein – to restore blood volume and plasma CHON lost.
- for tissue repair and resistance to infection.
- for replacement of lean body mass.
b. Calories – to restore normal weight and spare protein.
- to replace losses related to lack of oral intake and hypermetabolism.
c. Water – to replace fluid lost through vomiting, hemorrhage, fever, exudates, drainage
& diuresis
d. Vitamin C – needed for antibody and capillary formation, tissue synthesis and wound
healing through collagen formation.
e. Thiamine, Niacin, Riboflavin, Folic Acid & B12 – for cell proliferation thus tissue
synthesis, important for RBC
maturation.
f. Vitamin A – for wound healing, tissue synthesis & increased Immune function.
g. Iron – to replace iron loss
h. Vitamin K – important for normal blood clotting.
 i. Zinc – needed for protein synthesis and wound healing, needed for normal phagocyte
and lymphocyte response
2. Drug or Alcohol use – person with a history of chronic alcoholism often suffers from
malnutrition and other systemic problems that increases the surgical risk.
3. Respiratory status – the goal for potential surgical patients is optimal respiratory function.
- surgery is usually postponed if patient has a respiratory infection.
- patient with COPD (emphysema, bronchiectasis etc.) are assessed carefully.
- patients who smoke are urge to stop 2 months before surgery.
4. Cardiovascular status – the goal in preparing any patient for surgery is to ensure a well
functioning cardiovascular system to meet the oxygen, fluid and nutritional needs of the
perioperative period.
5. Hepatic and Renal function – presurgical goal is optimal function of the liver and urinary
system to enhanceremoval of medications, anesthetics agents, body wastes and toxins
from the body.
6. Endocrine function – patient with diabetes who is undergoing surgery is at risk for
hypoglycemia and hyperglycemia.
7. Immune function – an important function of the preoperative assessment is to determine the
existence of allergies.
8. Previous Medication use – a medication history is obtained from each patient because of the
possibility of drug interactions.

Medications with are potential to affect the surgical experience:

a. Corticosteroids – can cause cardiovascular collapse if discontinued suddenly.
b. Diuretics – during anesthesia may cause respiratory depression resulting from an associated
electrolyte imbalance.
c. Phenothiazines – increases the hypotensive action of anesthetics.
d. Tranquilizers – may cause anxiety, tension & seizures if withdrawn suddenly.
e. Insulin – its interaction with anesthetics must be considered in a patient with diabetes.
f. Antibiotics (erythromycin) – when combine with curariform muscle relaxant, nerve
transmission is interrupted and apnea from respiratory paralysis.
g. Anticoagulants – increase the risk of bleeding during intraoperative and postoperative.
h. Antiseizure medications – should be administered intravenously to keep patient seizure-free.
i. Monoamine Oxidase (MAO) inhibitors – may increase hypotensive action of anesthesia.
PSYCHOSOCIAL ASSESSMENT AND CARE

• Causes of fears of the pre-operative clients:

 Fear of the unknown
 Fear of anesthesia, vulnerability while unconscious
 Fear of pain
 Fear of death
 Fear of disturbance in body image
 Worries – loss of finances, employment, social and family roles.

MANIFESTATIONS OF FEARS:
 Anxiousness
 Bewilderment
 Anger
 Tendency to exaggerate
 Inability to concentrate
 Short attention span

Preoperative Nursing Problems:
1. Anxiety related to the surgical experience (anesthesia & pain) & outcome of surgery
2. Fear related to perceived threat of the surgical procedure and separation from support system
3. Knowledge deficit of preoperative procedures and protocols and postoperative expectation

NURSING INTERVENTIONS TO MINIMIZE ANXIETY:

> explore client’s feelings
> allow client/s to speak openly about fears / concerns
> give accurate information regarding surgery
> give empathetic support
> consider the persons religious preferences and arrange for visit by priest as desired

Preoperative Nursing Management:

1. Teach deep-Breathing, Coughing and Incentive Spirometer
2. Encourage mobility and active body movement
3. Pain management – patient-controlled analgesia (PCA), epidural catheter bolus or infusion &
patient controlled epidural analgesia (PCEA)
4. Teach cognitive coping strategies
a. Imagery – patient concentrates on a pleasant experience or restful scene.
b. Distraction – patient thinks of an enjoyable story or recites a favorite poem or song.
c. Optimistic self-recitation – patient recites optimistic thoughts (“I know all will go well”)
5. Instruction for Ambulatory Surgical patients:
a. Inform the patient the scheduled date and time of the surgery and where to report.
b. Instruct what to bring (insurance card, list of meds & allergies)
c. Instruct what to leave at home (jewelry, watch, medications & contact lenses)
d. Instruct what to wear (loose-fitting, comfortable clothes & flat shoes)
e. Remind the patient not to eat or drink as directed (fasting period of 8 hours or more is
recommended)

PHYSICAL PREPARATIONS

A. BEFORE SURGERY:
- correct any dietary deficiencies
- reduce an obese person’s weight
- correct fluid and electrolyte imbalances.
- restore adequate blood volume with blood transfusion
- treat chronic diseases – DM , HEART DISEASE, RENAL
- halt or treat any infectious process
- treat an alcoholic person with vitamin supplementation
B. TEACHING PREOP EXERCISES
- deep breathing exercises – diaphragmatic
- incentive spirometry
- coughing exercises
- turning exercises
- foot and leg exercises

PREPARING THE PERSON THE EVENING BEFORE THE SURGERY:

- Preparing the skin:
> have full bath to reduce microorganisms in the skin
> shaving if possible
. Preparing the GI tract:
> NPO ; cleansing enema is required
. Preparing for anesthesia:
> avoid alcohol and cigarette smoking for at least 24hrs before surgery
. Promoting rest and sleep:
> administer sedatives as ordered.

PREPARING THE CLIENT ON THE DAY OF SURGERY

Early AM care:
- awaken 1hr before preop medication
- morning bath; mouth wash/ oral care
- provide clean gown
- remove hairpins, dentures, foreign materials, colored nail polish, hearing aid, contact
lens..( wedding ring – tie with gauze and fasten around the wrist)
- take baseline VS BEFORE PREOP
- check ID band, skin prep
- check for special orders- enema, GI tube insertion, IV line
- have client void before preop medication
- continue to support emotionally
- accomplish preop checklist

What to Remove
Prostheses
Dentures
Glasses
Nail polish
Make up
Jewelries

PREOPERATIVE MEDICATIONS/PREANESTHETIC DRUGS

Goals: - to facilitate the administration of any anesthetic
- to minimize respiratory tract secretions and changes in heart rate
- to relax the client and reduce anxiety.

Commonly Used Preop Meds

1. Sedatives/ Hypnotics/ Tranquilizers
 Decrease anxiety
 Provide sedation
 Nembutal (pentobarbital Sodium)
 Vistaril (hydroxyzine)
 Valium (diazepam)
 Phenergan (promethazine)
 Versed (midazolam)
2. Narcotics
 Relieve pain/ discomfort
 Demerol
 Fentanyl
 Check respiratory depression

3. Anticholinergics
 Decreases
Decreases secretions of saliva and gastric juices; prevents
bradycardia
 Atropine Sulfate
> Scopalamine
> check
check BP and HR
> Dry mouth, drowsiness, urinary hesitancy
4. Antiulcer (Histamine H2 Antagonist)
 prevent aspiration pneumonitis
> Ranitidine (Zantac)
>Cimetidine (Tagamet)
 >Famotidine ( Pepcid)
5. Antiemetics
 Decrease nausea and vomiting
>Metoclopramide (Reglan)
>Zofran
>Zofran

Patient’s family:
> direct proper visiting room
> doctor informs family after surgery
> explain reason for long interval of waiting
> explain what to expect postop

Pre-op Nursing Evaluation

1. Reports relief of anxiety
2. Reports that fear is decreased
3. Voices understanding of surgical intervention
4. Shows no evidence of preoperative complications