Preoperative Care in Adults

Introduction

Preoperative care in adults is a critical phase in the surgical journey that ensures patients are physically, emotionally, and medically prepared for surgery. It’s not just about checking boxes it’s about optimizing outcomes, minimizing risks, and empowering patients.

Definitions

Perioperative nursing is the specialized care of a patient before, during, and after surgery in which the registered nurse works as a team member in collaboration with other surgical health professionals.

Perioperative care includes three phases: preoperative phase, intraoperative phase, and postoperative phase.

Preoperative nursing care refers to the physical and psychosocial nursing care that prepares a patient to undergo surgery safely and extends throughout the preoperative period which begins when the patient is booked for surgery and ends with the transfer of the patient to the theater or surgical suite.

Purposes

• To assess whether the patient’s preoperative condition is optimized to achieve the best outcome from surgery.
• To identify and control reversible factors that may increase the perioperative risk for the patient.
• To establish baseline data for comparison in the intraoperative and postoperative phases.
• To alleviate the patient’s fear and anxiety regarding surgery.
• To impart adequate knowledge to the patient and family members regarding the surgical procedure, preparation, aftercare, and projected lifestyle changes that may be necessary due to the surgery.
• To identify cultural and ethnic factors that may affect the surgical experience.
• To determine whether the patient has received adequate and accurate information from the surgeon to make an informed decision to undergo surgery and that the informed consent form is signed and witnessed.

Indications

• All patients undergoing any type of surgical procedure regardless of the extent, purpose, nature of surgery, or the setting.

Articles

Examine the following:

• Functional ability and daily routine along with mobility impairment to plan rehabilitation activities.
• Nutritional status and needs (measure the patient’s height, weight, triceps skin fold thickness, upper arm circumference, serum protein levels, and nitrogen balance).
• Fluid and electrolyte imbalance (dehydration, hypovolemia, and electrolyte imbalance).
• Infection.
• Smoking, drugs, and alcohol use (intoxication can cause surgical complications).
• Skin condition (skin color, rashes, lesions).
• Mouth for dental caries, dentures, and braces to prepare for intubation.
• Respiratory status (poor lung function, infection, obstructive airway disorders, etc., may affect oxygenation especially in case of general anesthesia/ intubation).
• Cardiovascular status (to identify abnormalities requiring supportive management prior to surgery).
• Hepatic and renal function (insufficiency or failure may be a contraindication for surgery).
• Presence of trauma.
• Endocrine function (diabetes, corticosteroid intake, insulin dosage).
• Immunological function [any known allergies (latex), previous sensitivity/reaction to drugs/anesthetics, immunosuppression].
• Previous and current medication therapy (use of medications such as adrenal corticosteroids, diuretics, phenothiazines, antidepressants, tranquilizers, insulin, and antibiotics must be noted and tapered or temporarily discontinued as medically advised).
• Presence of prosthetic devices (orthopedic implants, pacemaker, vascular prosthesis, etc.).
• Weight/height/BMI (extremely underweight/overweight, surgical risk due to obesity, height greater than the length of the operating room table, implications for medication dosage).

Diagnostic Tests

The following tests are generally performed prior to surgery:

• Blood tests: Complete blood count, erythrocyte sedimentation rate, C-reactive protein, serum protein electrophoresis with immunofixation, calcium, alkaline phosphatase, and blood chemistry profile; blood grouping and cross-matching; hemoglobin and hematocrit levels, coagulation profile.
• Electrocardiogram.
• Chest X-ray.
• Other tests such as ECHO/CT/MRI/PET/bone scan, ultrasound, endoscopy, tissue biopsies, and stool and urine tests based on the type of surgery.

Psychological Assessment

Assess the patient for the following:

• Fear of the unknown, death, anesthesia, or pain.
• Understanding and perception of the surgical procedure.
• Concerns about loss of work, job, time, and support from the family.
• Concerns about the threat of permanent disability.
• Spiritual and cultural values and beliefs.
• Coping and comprehensive ability.
• Readiness to learn.

Informed Consent

• Informed consent is a process in which the healthcare provider gives the patient important information, including possible risks and benefits, about a medical procedure or treatment, genetic testing, or a clinical trial to obtain his or her formal willingness to undergo it.
  Informed consent form is the document containing these details which has to be signed by the patient, physician/surgeon, and a witness, usually the nurse.

Nurse’s responsibility related to obtaining consent is as follows:

• Reinforce the information given by the surgeon.
• Notify the physician if the patient needs more information.
• Ensure that consent has been taken before initiating major/advanced procedures related to surgery.
• Arrange for a responsible family member or legal guardian to be available for giving consent if the patient is minor/unconscious/incompetent.
• Place the signed consent form in a prominent place in the patient’s chart.

Preoperative Nursing Intervention

Reducing fear and anxiety

• Explore the patient’s fears, worries, and concerns.
• Encourage the patient to verbalize feelings.
• Provide information that helps to allay fears and concerns of the patient.
• Be a good listener and give empathetic support.
• Teach the patient cognitive strategies such as imagery distraction, and meditation that may be useful the relieving tension, overcoming anxiety, and achieving relaxation.

Managing nutrition and fluids

• Provide nutritional support to correct deficiencies before surgery.
• Instruct the patient not to take food or water orally 8-10 hours (or as required based on the procedure) prior to the procedure. Clear fluids may be permitted up to 3-4 hours before surgery.
• Inform the patient that a light meal may be permitted on the previous evening when surgery is scheduled for the next morning, or a soft breakfast if surgery is to be done in the evening.
• Encourage oral fluid intake and substitute with IV fluids for dehydrated patients.
• Monitor chronic alcoholic patients for malnutrition or other systemic problems which may pose a surgical risk.

Promoting optimal cardiac and respiratory function

• Urge the patient to stop smoking 2 months prior to surgery (or at least 24 hours before).
• Teach the patient breathing exercises and use of spirometer, if indicated.
• Monitor any known surgical risk to pulmonary status due to existing respiratory disorder.
• In patients with cardiac problems, avoid sudden position change, prolonged immobilization, hypotension or hypoxia, and fluid overload.

Supporting hepatic and renal function

• Monitor liver function tests in patients with known liver disorders and blood glucose levels in patients with diabetes before, during, and after surgery.
• Inform the surgeon and anesthesiologist regarding any steroid medication being used by the patient.

Monitoring endocrine function

• Check for any adrenal insufficiency.
• Assess patients with uncontrolled thyroid disorders for a history of thyrotoxicosis (with hyperthyroid disorders) or respiratory failure (with hypothyroid disorders).

Promoting mobility and functional ability

• Explain the need for frequent position changes after surgery (to improve circulation, prevent venous stasis, and promote optimal respiratory function).
• Demonstrate how to turn from side to side and assume the lateral position without causing pain or disrupting IV lines, drainage tubes, or other apparatus.
• Discuss any special position that the patient would need to maintain after surgery (e.g., adduction or elevation of an extremity) and the importance of continued mobility as much as possible despite restrictions.
• Instruct patients to exercise the extremities. This includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side), foot rotation (tracing the largest possible circle with the great toe), and rotation along the range of motion of the elbow and shoulder.
• Instruct the patient regarding the use of proper body mechanics and ensure that the patient lies in proper alignment in all positions.

Respecting spiritual and cultural beliefs

• Help the patient obtain spiritual help if he or she requests; respect and support the beliefs of each patient.
• Ask whether the patient’s spiritual adviser knows about the impending surgery.
• When assessing pain, remember that some cultural groups are unaccustomed to expressing feelings openly. Individuals from some cultural groups may not make direct eye contact with others; this lack of eye contact is not avoidance or a lack of interest but a sign of respect.
• Listen carefully to the patient, especially when obtaining the history. Correct use of communication and interviewing skills can help the nurse acquire invaluable information and insight. Remain unhurried, understanding, and caring.

Providing preoperative patient education

• Patient education should start as soon as possible, starting in the physician’s office and continuing during the preadmission visit, when diagnostic tests are being performed, through arrival in the operating room.
• Space instructions over a period of time to allow the patient to assimilate information and ask questions.
• The concerns of each patient are individually addressed with consideration for any unique concern or learning need.
• Combine teaching sessions with various preparation procedures to allow for an easy flow of information. Include description of the procedures and explanation of the sensations that the patient will experience.
• During the preadmission visit, arrange for the patient to meet and ask questions about anesthesia, view audio-visuals, and review written materials. Provide a telephone number for the patient to call if questions arise closer to the date of surgery.
• Reinforce information about the possible need for a ventilator and the presence of drainage tubes or other types of equipment to help the patient adjust during the postoperative period.
• Inform the patient when family and friends will be able to visit after surgery and that a spiritual advisor will be available if desired.

Teaching the ambulatory surgical patient

• Answer questions and describe what to expect.
• Tell the patient when and where to report, what to bring (insurance card, list of medications and allergies), what to leave at home (jewelry, watch, medications, contact lenses), and what to wear (loose-fitting, comfortable clothes; flat shoes).
• During the last preoperative phone call, remind the patient not to eat or drink as directed; brushing teeth is permitted, but no fluids should be swallowed.
• For an ambulatory surgical patient or a patient in day care, teach about discharge and follow-up home care. Education can be provided by a videotape, over the telephone, or during a group meeting, night classes, preadmission testing, or the preoperative interview.

Teaching deep breathing and coughing exercises

• Teach the patient how to promote optimal lung expansion and consequent blood oxygenation after anesthesia by assuming a sitting position, taking deep and slow breaths (maximal sustained inspiration), and exhaling slowly.
• Demonstrate how the patient can splint the incision line to minimize pressure and control pain (for thoracic and abdominal incisions).
• Inform the patient that medications are available to relieve pain and that they should be taken regularly for pain relief to enable effective deep breathing and coughing exercises.

Explaining pain management

• Instruct the patient to take medications as frequently as prescribed during the initial postoperative period for pain relief.
• Discuss the use of oral analgesic agents with the patient before surgery, and assess the patient’s interest and willingness to participate in pain relief methods.
• Instruct the patient in the use of a pain rating scale to promote postoperative pain management.

Preparing the bowel for surgery

• If ordered preoperatively, administer or instruct the patient to take the antibiotic and a cleansing enema or laxative the evening before surgery and to repeat it the morning of surgery.
• Have the patient use the toilet or bedside commode rather than the bedpan for evacuation of the enema, unless contraindicated.

Preparing patient for surgery

• Instruct the patient to use detergent-germicide for several days at home (if the surgery is not an emergency).
• Dress the patient in a hospital gown that is left untied and open at the back.
• Cover the patient’s hair completely with a disposable paper cap; if the patient has long hair, it may be braided; hairpins are removed.
• If hair is to be removed, remove it immediately before the operation using electric clippers.
• Inspect the patient’s mouth and remove dentures or plates.

Removing jewelry, including wedding rings

• If the patient objects, securely fasten the ring with tape.
• Give all articles of value, including dentures and prosthetic devices, to family members, or if needed label articles clearly with the patient’s name and store in a safe place according to the agency policy.
• Assist patients (except those with urological disorders) to void immediately before going to the operating room.
• Administer preanesthetic medication as ordered, and keep the patient in bed with the side rails raised. Observe the patient for any untoward reaction to the medications. Keep the immediate surroundings quiet to promote relaxation.

Transporting patient to operating room

• Send the completed chart with the patient to the operating room; attach the surgical consent form and all laboratory reports and nurses’ records, noting any unusual last-minute observations that may have a bearing on the anesthesia or surgery in the front of the chart at a prominent place.
• Take the patient to the preoperative holding area, and keep the area quiet, avoiding unpleasant sounds or conversation.

Attending to special needs of elderly patients

• Assess the elderly patients for dehydration, constipation, and malnutrition; report if present.
• Maintain a safe environment for the elderly patients with sensory limitations such as impaired vision or hearing and reduced tactile sensitivity.
• Initiate protective measures for the elderly patients with arthritis, which may affect mobility and comfort. Use adequate padding for tender areas. Move the patient slowly and protect bony prominences from prolonged pressure. Provide gentle massage to promote circulation.
• Take added precautions when moving an elderly patient because decreased perspiration leads to dry, itchy, fragile skin that is easily abraded.
• Apply a lightweight cotton blanket as a cover when the elderly patient is moved to and from the operating room, because decreased subcutaneous fat makes older people more susceptible to temperature changes.
• Provide the elderly patient with an opportunity to express fears; this enables the patient to gain some peace of mind and a sense of being understood.

Attending to the family’s needs

• Assist the family to the surgical waiting room, where the surgeon may meet the family after surgery.
• Reassure the family that they should not judge the seriousness of an operation by the length of time the patient is in the operating room.
• Inform those waiting to see the patient after surgery that the patient may have certain equipment or devices in place (i.e., IV lines, indwelling urinary catheter, nasogastric tube, suction bottles, oxygen lines, monitoring equipment, and blood transfusion lines).
• When the patient returns to the room, provide explanations regarding the frequent postoperative observations.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884

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