My Nursing Mastery
My Nursing Mastery
Surgical Nursing-PreOp
***=might show up on the NCLEX
Cindi:Hi this is Cindi from NCLEX Mastery I'm one of the nurses here and today I'm going to talk about surgical nursing and focus on the pre operative period. You can check out additional podcasts in this series for advice on the intra operative and post-op nursing process. This podcast provides a solid foundation for surgical nursing. It is helpful to nursing students and also provides a good review for experienced nurses. Throughout the podcast, when you hear this sound***dinging sound*** it is followed by an essential NCLEXz concept important for entry level nursing practice. If you're studying for the NCLEX this may come up on the test. One of the most important nursing responsibilities is the pre operative assessment. We are going to cover this in detail facilities today have protocols in place that include checklists these checklists are used during the pre operative intra operative and post-operative periods. So the first step in any checklist, after verifying the identity of the client using two identifiers, is asking the client about the purpose of the procedure. You can ask what brought you here today or tell me in your own words what you're having done today. Knowing why the surgery is being done is important.***Making sure you have the right client at the right time for the right surgery ensures quality and safety. It not only contributes to safer care but it provides a starting point and guides conversations between the nurse and the client about the care plan. It also prompts the nurse to think about the type of surgery planned in relationship to precautions and care planning. For example, neck oral facial procedures. The nurse would be thinking of airway precautions chest or high abdominal procedures. The nurse may be thinking about pulmonary risk. Abdominal surgeries pose a risk for paralytic ileus or DDT. Believe it or not, providing emotional support and showing empathy requires some knowledge about what has been going on with the client recently, having a good sense of what the client knows, recent interactions with the healthcare provider, and any recent diagnostic procedures helps the nurse transition to the preoperative assessment. There are five general reasons for having surgery. The first is curative. If you're going to have a gallbladder out because it's diseased or you have an inflamed appendix removed that's curative surgery. The second kind is diagnostic. Some surgeries are required to remove tissue or obtain biopsies to make a diagnosis. The third type is restorative surgery. Applying grafts to restore the function of tissue would fall into this category. Palliative surgery involves removing a tumor that is compressing tissue and causing discomfort. For example the last kind is cosmetic surgery. This is surgery to change the appearance of tissue surgery can be classified. Also according to urgency elective surgeries are planned. An example would be a hernia repair or a cataract removal. Urgent surgeries are done in a timely way to avoid risk. An example might be an eye injury emergent surgeries are well an emergency. This includes examples like a ruptured aneurysm or an open fracture. There are other abbreviations or terms you may hear during handoffs in the preoperative periods such as SDA which stands for same day admission and SDS which stands for same day surgery. Just remember to clarify any abbreviations that are not crystal clear. Never assume. Now that you know you have the right client and they have confirmed the purpose of the surgery. The next priority is to perform an assessment. This step identifies any issues that could complicate care during the inter-op and post-op periods and also provides continuity of care. Continuity means that pertinent information about the client is effectively communicated to anyone caring for the client from start to finish and beyond. This is key for providing safe care and improved outcomes. Many errors occur because factors that impact care were not discovered or communicated during handoffs. There is no place where this matters more than in the OR. Most surgical facilities have a process in place where the nurse reviews the client's medical history and pre-op testing a few days ahead of time in addition to the preoperative assessment. The pre-op assessment is done when the client arrives for surgery and includes a client interview for medical history and the clinical assessment. Many times this is done by a different nurse than the nurse who performed the medical record review a few days earlier. Pre-op nurses must be meticulous about addressing every part of this assessment in a standardized way for each client. For the first part of the assessment, the nurse screens for conditions that may increase the risk for complications. Start with demographics. Any client over the age of 65 has an increased risk for complications. Next look at the home or routine medication list. At a glance, seeing what medications the client takes tells you a lot about chronic conditions that may impact the care plan. Let's consider a few drug classes that are super important.***Anti hypertensives are common and may have been taken prior to arrival. Assess these clients for hypertension and always take an apical pulse. If a client takes insulin this will impact the care plan due to NPO's status. The client may require IV, normal saline, or a solution with dextrose depending on the facility policy. NP0 will affect insulin dosing and blood sugars. So anticipate orders from the provider. If the client takes oral anti hyperglycemics, expect blood sugars to run high as a result of NPO status. Glaucoma medications may contribute to changes in blood pressure. Tricyclic antidepressants or TCA's can cause cardiac problems in clients with heart disease and may cause orthostatic hypotension. All drugs in this class lower the seizure threshold. Anti-seizure medications alter how anesthesia is metabolized and may affect dosing for common drugs used in the OR. Anticoagulants and Zed's requires special attention by the nurse. Antiqua I glance are generally discontinued before surgery but not always. The nurse should have a good understanding of the plan from the provider and said such as ibuprofen or aspirin are avoided prior to surgery confirmed the last dose date and time corticosteroids can mask infection or delay wound healing anti arrhythmic. Slow heart impulse conduction but can interact with anesthesia and lead to bradycardia. Assess peripheral circulation for these clients and ask about the presence of an implantable cardioverter-defibrillator or ICD. Be sure to ask about the presence of a pacemaker and document this in the chart.***Opioids or antianxiety medications can impact sedation upon anesthesia and induction and during the recovery period. Okay, next review past medical history. Ask the patient about the following: a compromised immune system, diabetes, any pulmonary disease especially COPD, or a history of smoking. Smoking increases carboxyhaemoglobin which is carbon monoxide binding to oxygen sites on the hemoglobin molecule. This results in less oxygen for organs. Smoking also decreases the protective effects of mucus in the respiratory tract. It leads to increased secretions and an increased risk for atelectasis or collapsed alveoli. There are many cardiovascular disorders that increase risk during the operative period. For example, coronary artery disease, angina, an M-I within six months of surgery, congestive heart failure or uncontrolled hypertension. Ask the patient about hemo-dynamic instability any multi-system disease and especially any coagulation disorders like factor 5. Anemia is important to know because it decreases oxygenation, dehydration, infection or recent fever, and any other chronic disease is important to investigate. Next ask about health history including malnutrition or obesity, tobacco or alcohol, or substance use. Withdrawal from alcohol prior to surgery may cause delirium tremens. Withdrawal from benzodiazepines that are used chronically can lead to seizures. Ask about any risk for altered coping, any emotional responses to prior surgery experiences, and any post-operative complications from surgery in the past.***Ask about any allergies to medications, foods, or especially sensitivity or allergy to shellfish or iodine.*** Every client should be asked about personal and family history of malignant hyperthermia or extreme fever and muscle rigidity as a reaction to anesthesia. This is an inherited condition that can be triggered by certain anesthesia drugs and is life threatening. Ask the client,"Have you ever had a bad reaction or been told you have an allergy to anesthesia?" or,"Have you ever had a high fever during anesthesia or received the drug dantrolene to treat this condition during surgery.*** Dantrolene is the preferred drug used to treat or prevent malignant hyperthermia. The last portion of the client interview is to discuss any pre-surgery orders. It is especially important to discuss any plans for blood transfusion. There are a few ways that the client may receive blood during surgery. Autologous blood donation is donation that happens over the four to five weeks prior to surgery by the client themselves. If they have cardiovascular disease they may need special permission from their cardiologist to do this type of blood donation. The goal is to collect two to four units total. Blood should not be donated by the client within 72 hours of surgery. Directed blood donations come from family or friends with compatible blood types. It is important for the RN to know whether blood has arrived and where the donation was made. Bloodless surgery is also called auto transfusion. This transfuses the client's blood back into the client after being recycled. Clients with religious and cultural beliefs may not consent to transfusions. The nurse should be alert for this. Some other common things that the nurse may see during the preoperative assessment is that some facilities will limit the number of preoperative blood samples to be taken. In addition some clients may be given alpha to stimulate the client's own red blood cell production prior to surgery.***Remember that discharge planning always begins on admission. Now let's talk about the clinical assessment. This involves directly assessing the patient as well as looking at any pre op test results, morbidity and mortality increases in older adults, and chronically ill clients due to pre operative conditions. We talked earlier about the older client having higher risk. So the nurse needs to be on the lookout for signs of chronic conditions. Since 30 percent of peri operative deaths result from cardiac conditions, it's extremely important for the nurse to screen for uncontrolled hypertension prior to surgery. Other clinical indicators include anything that indicates a pulmonary condition. Here's some clinical assessment highlights that are commonly seen: alterations in cardiac, assess for hypertension preoperatively, clubbing finger tips indicate a chronic lack of oxygen. This is a deformity at the base of the nail bed. It is commonly found in clients with chronic pulmonary disease like COPD. Assess for cyanosis and osculate for adventitious breath sounds like crackles or wheezes. Assess for any urinary problems such as dysuria. Common medications used in the inter-operative periods such as scopolamine, morphine, and barbiturates can cause confusion, disorientation and other mental status changes when administered to clients with decreased renal function. For the mentally impaired or older client, they may become disoriented in unfamiliar settings. Talk with the family about what they're like at home. Assess the client's ability to ambulate; what their normal gait is. You want this for baseline data preoperatively. Assess for a history of joint replacements and prosthesis. Assess nutritional status. Fatty tissue has poor vasculature with very little collagen; this decreases nutrients and effects wound healing. Most clients pre-surgically have some level of anxiety or fear including anger, crying, restlessness, even diaphoresis, increased heart rate, palpitations or insomnia. Diarrhea and urinary frequency can also be symptoms of anxiety. Assess for all of these. Problems with potassium levels can be particularly problematic during surgery. Check for hypokalemia which increases the risk for digoxin toxicity. This should be corrected before surgery.***Also assess for hyperkalemia, high potassium which increases the risk for dysrhythmia's especially with anesthesia. Again, this should be corrected before surgery. Look for a chest X-ray results within the last six months. This can alert the provider to cardiac or pulmonary complications. Check for history of laminectomy or any spinal surgery or any other conditions that might contribute to problems with positioning during surgery. An ECG may be routinely required for most clients over the age of 45. So find out what your facility policy is. Now for planning and care management. Two legal and ethical concerns regarding the principles of honesty and autonomy need special mention here. The first is advanced directives. Advanced directives provide instructions to health care providers about the client's wishes. They allow the client to make decisions autonomously, without influence. This is an important principle in nursing practice. There are many different kinds of advanced directives and laws vary from state to state. So I won't cover them in detail here.***Nurses should know that the patient self-determination act of 1990 required by law that clients have the right to accept or refuse treatment even if the treatment is required to prevent death. Clients can write their wishes down in a legal document called an advance directive. Nurses are obligated to ask about advance directives and integrate them into the care plan. Facilities often have protocols for offering assistance to clients who wish to make advanced directives which is offered before surgery or treatment. The second ethical issue is informed consent. Understanding legal informed consent is required to enter nursing practice. If you are studying for the NCLEX this is something you will need to know.***Competent adults can refuse treatment. According to the U.S. Department of Health and Human Services, the definition of informed consent is a process not a piece of paper. Forms are used to document that informed consent has been obtained by the provider, not the nurse. For surgery, it includes disclosure of information by the provider making sure the client understands the information and promoting voluntary participation. Client choice: healthcare providers are required to discuss with the client the nature of the surgery, all available options and risks, the expected outcome, and risk associated with anesthesia. They are required to provide an opportunity for questions. In most cases the surgeon will review this information as well as the anesthesiologist. Here's a practice tip: there are separate consents for anesthesia, blood transfusions, implants, sterilization, and experimental procedures.***Nurses are not responsible for providing detailed information about a surgical procedure or any of the risks and benefits, although they may clarify what the provider has discussed. The nurse is responsible for ensuring that consent is signed and may serve as a witness to the client's signature, not that the client is informed. That responsibility falls to the provider.***Important: if the nurse suspects that the client is not adequately informed the nurse should contact the provider immediately and then document this in the chart. In special situations the client may place an X indicating they are informed. But this must be witnessed by two persons depending on policies and may require a translator. This includes a client who cannot write their name or is blind or cannot speak English. In emergencies, verbal informed consent over the phone may occur. When this is not possible the surgeon may seek signatures from additional consulting providers. Now I'm going to talk about specific interventions. Remember the thorough assessment we performed initially. It provides information to identify what needs to be included on the pre-op, intervention, and teaching checklist. Care maps are very common and identify what interventions are to be performed preoperatively. This is something that you'll see frequently. Here is a summary of the most important areas for nursing interventions. These are things that the nurse or the client does to prepare for surgery in addition to teaching required during the recovery period. The nurse needs to address fears and anxiety. Take care not to scare the client when you're providing information. The nurse should be able to describe what the client can expect during surgery. Pre-op routines may be reviewed or confirmed including NPO status, enemas, and lab work. The nurse would document the last meal and drink according to facility policy. Invasive procedures may need to be performed such as an I.V. catheter or inserting a urinary catheter. Stockings and pneumatic compression devices are generally part of the intervention. The nurse may review teaching for post-op exercises or coughing, turning, deep breathing, and splinting, depending on the surgery. Incentive spirometry and lower extremity exercises may be reviewed. The nurse may talk about early ambulation and its benefits and pain management. Here's some practice tips: outpatients must receive written and oral instructions about NPO status after midnight in most facilities. NP0 means no eating or drinking, even water. Some cardiac and hypertension meds are commonly allowed with a sip of water two hours prior to surgery. Diabetes medications, including insulin, may have special instructions and may be given in divided doses the day of the surgery. The nurse usually discourages smoking six to eight hours prior to surgery because this increases gastric secretions. Bowel prep requires special teaching. This can be exhausting for the client. It can lead to electrolyte imbalances, fluid volume deficit, vagal stimulation, orthostatic hypotension or severe discomfort if the client has hemorrhoids. Skin preparation on the surgical site is usually very specific. It may include a shower using an antiseptic.***Shaving hair increases the risk for infection. Electrical razors are commonly used. This is often done in asepsis immediately prior to surgery in the intra operative period. If the client is having major abdominal or genital urinary surgery they will usually have a foley catheter inserted and they may have a nasal gastric tube for decompressing the stomach. These may be inserted prior to surgery, but are usually done after anesthesia is induced. The nurse explains reasons why not to kink or pull on drains that may be used for evacuation of fluid from the surgical site. An I.V. is usually inserted and is large bore in the hand or arm.***Nurses should pay special attention to measures that prevent deep vein thrombosis and clots post operatively. This is an evidence based practice pearl. Clients at increased risk include obesity, those older than 40 years, any cancer diagnosis, decreased mobility or immobility, fracture or leg trauma, anyone having pelvic surgery, anyone taking estrogen or oral contraceptive pills, and smoking as well as anyone with a history of deep vein thrombosis, pulmonary embolism, varicose veins or lower extremity edema. Measures to reduce the risk of this complication include anti-embolism stockings or elastic wraps. These are also called Teds or job stockings. The nurse measures the circumference and leg length and orders the correct size prior to surgery. These should be removed one to three times per day for 30 minutes to allow for skin care. Pneumatic compression devices are also called sequential or boots. Recommended pressures are from 35 to 55 millimeters mercury. For teaching post top exercises. The nurse should explore attitudes and feelings before discussing any procedures. They should discuss, demonstrate, and have the client return demonstrate and practice. These include incentives spirometry and leg exercises as well as deep diaphragmatic breathing for some procedures. Leg exercises and wraps promote venous return and lower the risk for thrombosis. There are several exercises the client can perform while in bed including knee lifts and extentions, foot flexion, ankle circumspection and bent knee calf presses if they are allowed. The nurse discusses the benefits of early ambulation instructing the client to turn at least every two hours after surgery while in bed, again, depending on the procedure. The nurse informs the client of turning restrictions.***if the client must remain in bed, they are taught to perform deep breathing and leg exercises every two hours. Anxiety in the preoperative period often causes physical symptoms. The nurse provides pre-op teaching and encourages communication, promotes rest, and uses distraction. OK before we conclude the pre-operative period let's do a chart review. These are some final things that the nurse will do before the client goes to the OR. A chart review includes the nurse confirming the scheduled procedure and left versus right for the surgical site on the consent form. The nurse obtains an accurate height and weight to calculate medication doses. Record baseline vital signs within 1 to 2 hours prior to surgery. Underwear is usually permitted for surgery above the waist and socks except for foot surgery. Tape rings that cannot be removed according to facility policy. All pierced jewelry is generally removed. Dentures and partials are also removed. Document any capped teeth. All prosthetics are usually removed, including eyes, limbs, and wigs. Hair clips must be removed because electricity from cautery can cause scalp burns. Glasses and hearing aids may be permitted to a certain point or may be removed. Polish and artificial nails are generally removed. This is to allow for an accurate pulse oxygen saturation measurement. Have the client empty their bladder before surgery and record the output in the medical record. Remind the client that they may become drowsy and have dry mouth due to medications used to induce anesthesia. Typical medications include a sedative, tranquilizer, and opioid and an anticholinergic. I.V. is preferred for administering medications versus intra muscular or oral due to the differing absorption rates by those methods. We've concluded the review of the pre-operative period for surgical nursing. For more podcasts and tips to pass the NCLEX. Go to nclexmastery.com or go to flo.buzzsprout.com. Or check us out on Facebook at Nursing and NCLEX Mastery.