SECTION 4 Perioperative and Emergency Care
18
Preoperative Care
Janice A. Neil
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Anxiety Safety
Patient Education
LEARNING OUTCOMES
1. Distinguish the common purposes and settings of surgery. 5. Examine the nursing role in the preparation of the surgical
2. Describe the purpose and components of a preoperative patient.
nursing assessment. 6. Prioritize the nursing responsibilities related to day-of-
3. Interpret the significance of data related to the preoperative surgery preparation for the surgical patient.
patient’s health status and operative risk. 7. Discern the purposes and types of common preoperative
4. Analyze the components and purpose of the patient’s drugs.
informed consent for surgery. 8. Plan care to include special considerations of preoperative
preparation for the older adult surgical patient.
KEY TERMS
ambulatory surgery perioperative
elective surgery same-day admission
emergency surgery surgery
informed consent
Surgery is the art and science of treating diseases, injuries, and • C ure: Eliminate or repair a pathologic condition (e.g., remove
deformities by operation and instrumentation. The periop- a ruptured appendix or benign ovarian cyst).
erative period includes the time before surgery (preoperative • Palliation: Alleviate symptoms without cure (e.g., cutting a
period), the time spent during the actual surgical procedure nerve root to reduce pain, creating a colostomy to bypass an
(intraoperative period), and the period after the surgery is over inoperable bowel obstruction).
(postoperative period). • Prevention: Reduce the risk of developing a condition (e.g.,
The surgical experience involves an interprofessional team, removal of a mole before it becomes malignant, removal of
including the patient, surgeon, anesthesia care provider (ACP), the colon in a patient with familial polyposis to prevent can-
nurse, and other health care team members. Preparing patients cer).
for surgery is an important nursing role. This chapter discusses • Cosmetic improvement: Alter physical appearance (e.g.,
preoperative care that applies to all surgical patients. Preparation repairing a burn scar, breast reconstruction after a mastec-
measures for specific surgeries (abdominal, thoracic, orthopedic tomy).
surgery) are discussed in the appropriate chapters of this book. • Exploration: Determine the nature or extent of a disease
Patients have surgery for many reasons. These include: (e.g., laparotomy). With the use of advanced diagnostic tests,
• Diagnosis: Determine the presence and extent of a pathologic exploration is less common because we can identify many
condition (e.g., lymph node biopsy, bronchoscopy). problems noninvasively.
335
, 336 SECTION 4 Perioperative and Emergency Care
TABLE 18.1 Suffixes Describing Surgical surgery center, or hospital may do the interview. It can occur in
Procedures advance or on the day of surgery.
The primary purposes of the patient interview are to (1)
Suffix Meaning Example
obtain the patient’s health information, including drug and
-ectomy Excision or removal of Appendectomy
food allergies; (2) provide and clarify information about the
-lysis Destruction of Electrolysis
planned surgery, including anesthesia; and (3) assess the
-orrhaphy Repair or suture of Herniorrhaphy
-oscopy Looking into Endoscopy
patient’s emotional state and readiness for surgery, including
-ostomy Creation of opening into Colostomy their expectations about the surgical outcomes. The interview
-otomy Cutting into or incision of Tracheotomy gives the patient and caregiver an opportunity to ask questions
-plasty Repair or reconstruction of Mammoplasty about the surgery, anesthesia, and postoperative care. Often
patients ask about taking their routine drugs, such as insulin,
anticoagulants, or heart medications, and if they will have
Surgical procedures are usually described by combining spe- pain. By being aware of the patient’s and caregiver’s needs, you
cific suffixes with a body part or organ (Table 18.1). can provide the information and support needed during the
perioperative period.
SURGICAL SETTINGS
Surgery may be a carefully planned event (elective surgery) or may
ASSESSMENT OF PREOPERATIVE PATIENT
arise with unexpected urgency (emergency surgery). Both elective The overall goal of the preoperative assessment is to identify risk
and emergency surgeries are done in a variety of settings. The type factors and plan care to ensure patient safety. To achieve this,
of surgery, potential complications, and the patient’s health status you will need to do the following:
influence the setting where a patient can safely have surgery. • Establish baseline data for comparison in the intraoperative
For inpatient surgery, patients are usually admitted to the and postoperative period.
hospital on the day of surgery (same-day admission). Patients • Determine the patient’s psychologic status to reinforce the
who are in the hospital before surgery are usually there because use of coping strategies.
of acute or chronic medical conditions. • Determine physiologic factors related to the planned proce-
Most surgeries are performed as ambulatory surgery (also dure that may contribute to operative risk factors.
called same-day or outpatient surgery). Many of these use mini- • Participate in the identification and documentation of the
mally invasive techniques such as laparoscopy. Ambulatory sur- surgical site according to agency protocol.
gery often occurs in endoscopy clinics, health care providers’ • Identify prescription drugs, over-the-counter (OTC) drugs,
(HCP) offices, surgical clinics, and hospital outpatient surgery and herbs taken by the patient that may result in drug inter-
units. These procedures can involve the use of general, regional, actions affecting the surgical outcome.
or local anesthetic. Patients require less than a 24-hour stay after • Review the results of all preoperative diagnostic studies
surgery. Many go home with a caregiver within hours of surgery. in the patient’s record and share this information with the
Patients and HCPs often prefer ambulatory surgery. appropriate HCPs.
Generally, it requires fewer laboratory tests and medications. • Identify cultural and ethnic factors that may affect the surgi-
There is a lower risk for health care–associated infections. cal experience.
Patients like the convenience of recovering at home. HCPs pre- • Determine if the patient received adequate information from
fer the flexibility in scheduling. The costs are usually less for the the surgeon to make an informed decision to have surgery.
patient and the insurer. Verify that the consent form is signed and witnessed.
You play an essential role in preparing the patient for sur-
gery. To perform this function effectively, first identify the rea- Subjective Data
son the patient is undergoing surgery and any comorbidities. Psychosocial Assessment
Second, assess the patient’s response to the stress of surgery. Surgery is a stressful event, even for a minor procedure. The
Third, review the results of preoperative diagnostic tests. Last, psychologic and physiologic reactions to surgery may elicit the
identify potential risks and complications of the surgical pro- stress response (e.g., increased BP and heart rate). The stress
cedure and any special considerations for planning care. The response enables the body to meet the perioperative demands,
patient is likely to receive care from several different nurses in but excessive stressors or responses may affect recovery. Many
the preoperative area, operating room (OR), postanesthesia factors influence the patient’s reaction to stress, including age,
care unit (PACU), surgical intensive care unit (SICU), and/or their experiences with illness and pain, current health, and
surgical unit. Document and directly communicate important socioeconomic status. Avoid medical jargon. Use common
assessment findings to health team members. words and language familiar to the patient. This promotes
understanding and reduces anxiety.
Your role in psychologically preparing the patient for surgery
PATIENT INTERVIEW is to assess the patient for potential or actual stressors that could
The preoperative interview is an important nursing respon- negatively affect outcomes (Table 18.2). Communicate all con-
sibility. The nurse who works in the HCP’s office, ambulatory cerns to the appropriate surgical team member, especially if the
18
Preoperative Care
Janice A. Neil
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Anxiety Safety
Patient Education
LEARNING OUTCOMES
1. Distinguish the common purposes and settings of surgery. 5. Examine the nursing role in the preparation of the surgical
2. Describe the purpose and components of a preoperative patient.
nursing assessment. 6. Prioritize the nursing responsibilities related to day-of-
3. Interpret the significance of data related to the preoperative surgery preparation for the surgical patient.
patient’s health status and operative risk. 7. Discern the purposes and types of common preoperative
4. Analyze the components and purpose of the patient’s drugs.
informed consent for surgery. 8. Plan care to include special considerations of preoperative
preparation for the older adult surgical patient.
KEY TERMS
ambulatory surgery perioperative
elective surgery same-day admission
emergency surgery surgery
informed consent
Surgery is the art and science of treating diseases, injuries, and • C ure: Eliminate or repair a pathologic condition (e.g., remove
deformities by operation and instrumentation. The periop- a ruptured appendix or benign ovarian cyst).
erative period includes the time before surgery (preoperative • Palliation: Alleviate symptoms without cure (e.g., cutting a
period), the time spent during the actual surgical procedure nerve root to reduce pain, creating a colostomy to bypass an
(intraoperative period), and the period after the surgery is over inoperable bowel obstruction).
(postoperative period). • Prevention: Reduce the risk of developing a condition (e.g.,
The surgical experience involves an interprofessional team, removal of a mole before it becomes malignant, removal of
including the patient, surgeon, anesthesia care provider (ACP), the colon in a patient with familial polyposis to prevent can-
nurse, and other health care team members. Preparing patients cer).
for surgery is an important nursing role. This chapter discusses • Cosmetic improvement: Alter physical appearance (e.g.,
preoperative care that applies to all surgical patients. Preparation repairing a burn scar, breast reconstruction after a mastec-
measures for specific surgeries (abdominal, thoracic, orthopedic tomy).
surgery) are discussed in the appropriate chapters of this book. • Exploration: Determine the nature or extent of a disease
Patients have surgery for many reasons. These include: (e.g., laparotomy). With the use of advanced diagnostic tests,
• Diagnosis: Determine the presence and extent of a pathologic exploration is less common because we can identify many
condition (e.g., lymph node biopsy, bronchoscopy). problems noninvasively.
335
, 336 SECTION 4 Perioperative and Emergency Care
TABLE 18.1 Suffixes Describing Surgical surgery center, or hospital may do the interview. It can occur in
Procedures advance or on the day of surgery.
The primary purposes of the patient interview are to (1)
Suffix Meaning Example
obtain the patient’s health information, including drug and
-ectomy Excision or removal of Appendectomy
food allergies; (2) provide and clarify information about the
-lysis Destruction of Electrolysis
planned surgery, including anesthesia; and (3) assess the
-orrhaphy Repair or suture of Herniorrhaphy
-oscopy Looking into Endoscopy
patient’s emotional state and readiness for surgery, including
-ostomy Creation of opening into Colostomy their expectations about the surgical outcomes. The interview
-otomy Cutting into or incision of Tracheotomy gives the patient and caregiver an opportunity to ask questions
-plasty Repair or reconstruction of Mammoplasty about the surgery, anesthesia, and postoperative care. Often
patients ask about taking their routine drugs, such as insulin,
anticoagulants, or heart medications, and if they will have
Surgical procedures are usually described by combining spe- pain. By being aware of the patient’s and caregiver’s needs, you
cific suffixes with a body part or organ (Table 18.1). can provide the information and support needed during the
perioperative period.
SURGICAL SETTINGS
Surgery may be a carefully planned event (elective surgery) or may
ASSESSMENT OF PREOPERATIVE PATIENT
arise with unexpected urgency (emergency surgery). Both elective The overall goal of the preoperative assessment is to identify risk
and emergency surgeries are done in a variety of settings. The type factors and plan care to ensure patient safety. To achieve this,
of surgery, potential complications, and the patient’s health status you will need to do the following:
influence the setting where a patient can safely have surgery. • Establish baseline data for comparison in the intraoperative
For inpatient surgery, patients are usually admitted to the and postoperative period.
hospital on the day of surgery (same-day admission). Patients • Determine the patient’s psychologic status to reinforce the
who are in the hospital before surgery are usually there because use of coping strategies.
of acute or chronic medical conditions. • Determine physiologic factors related to the planned proce-
Most surgeries are performed as ambulatory surgery (also dure that may contribute to operative risk factors.
called same-day or outpatient surgery). Many of these use mini- • Participate in the identification and documentation of the
mally invasive techniques such as laparoscopy. Ambulatory sur- surgical site according to agency protocol.
gery often occurs in endoscopy clinics, health care providers’ • Identify prescription drugs, over-the-counter (OTC) drugs,
(HCP) offices, surgical clinics, and hospital outpatient surgery and herbs taken by the patient that may result in drug inter-
units. These procedures can involve the use of general, regional, actions affecting the surgical outcome.
or local anesthetic. Patients require less than a 24-hour stay after • Review the results of all preoperative diagnostic studies
surgery. Many go home with a caregiver within hours of surgery. in the patient’s record and share this information with the
Patients and HCPs often prefer ambulatory surgery. appropriate HCPs.
Generally, it requires fewer laboratory tests and medications. • Identify cultural and ethnic factors that may affect the surgi-
There is a lower risk for health care–associated infections. cal experience.
Patients like the convenience of recovering at home. HCPs pre- • Determine if the patient received adequate information from
fer the flexibility in scheduling. The costs are usually less for the the surgeon to make an informed decision to have surgery.
patient and the insurer. Verify that the consent form is signed and witnessed.
You play an essential role in preparing the patient for sur-
gery. To perform this function effectively, first identify the rea- Subjective Data
son the patient is undergoing surgery and any comorbidities. Psychosocial Assessment
Second, assess the patient’s response to the stress of surgery. Surgery is a stressful event, even for a minor procedure. The
Third, review the results of preoperative diagnostic tests. Last, psychologic and physiologic reactions to surgery may elicit the
identify potential risks and complications of the surgical pro- stress response (e.g., increased BP and heart rate). The stress
cedure and any special considerations for planning care. The response enables the body to meet the perioperative demands,
patient is likely to receive care from several different nurses in but excessive stressors or responses may affect recovery. Many
the preoperative area, operating room (OR), postanesthesia factors influence the patient’s reaction to stress, including age,
care unit (PACU), surgical intensive care unit (SICU), and/or their experiences with illness and pain, current health, and
surgical unit. Document and directly communicate important socioeconomic status. Avoid medical jargon. Use common
assessment findings to health team members. words and language familiar to the patient. This promotes
understanding and reduces anxiety.
Your role in psychologically preparing the patient for surgery
PATIENT INTERVIEW is to assess the patient for potential or actual stressors that could
The preoperative interview is an important nursing respon- negatively affect outcomes (Table 18.2). Communicate all con-
sibility. The nurse who works in the HCP’s office, ambulatory cerns to the appropriate surgical team member, especially if the
