Preparing the Patient for Surgery

1 Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. C H A P T E R. 2. Preparing the Patient for Surgery Learner Objectives 1. Identify desired Patient outcomes related to the preoperative phase. 2. Describe the critical factors included in a preoperative Patient assessment. 3. Recognize nursing diagnoses common to the surgical Patient in the preoperative phase. 4. Describe interventions in the preoperative phase to achieve desired Patient outcomes. 5. Identify at least eight factors that may contribute to wrong-site Surgery . 6. Describe the three components of the Joint Commission protocol to prevent wrong-site Surgery . 7. Discuss the content of preoperative Patient teaching. Lesson Outline Nursing Diagnoses I. Nursing Diagnoses 1. The perioperative nurse combines unique II. Desired Patient Outcomes knowledge of the surgical procedure with Patient assessment data and formulates nursing III.

2 Preoperative Preparation diagnoses that serve as the basis for the Patient 's IV. Preoperative Assessment and Interventions plan of care. A. Overview 2. The Perioperative Nursing Data Set (PNDS). B. Sources of Patient Information developed by the Association of periOpera- tive Registered Nurses (AORN) identifies 93. C. Assessment Parameters nursing diagnoses and 151 interventions rela- 1. Physiologic tive to the Patient undergoing a surgical or 2. Psychosocial invasive procedure and 40 nurse-sensitive Patient outcomes (AORN, 2011). V. Nursing Diagnoses and Interventions 3. More than 70 nursing diagnoses and hundreds A. Preoperative Period of nursing interventions have been identified B. Intraoperative Period through the North American Nursing Diag- VI. Prevention of Wrong-Site Surgery nosis Association (NANDA, 2012). These diagnoses and interventions are not mutually VII. Patient /Family Teaching exclusive, and any one or more might be appro- VIII.

3 Communication of Relevant Patient Data priate for an individual Patient . 13. Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 14 CHAPTER 2 Preparing the Patient for Surgery 4. The plan of care is developed as the periop- of the desired Patient outcomes begins with a erative nurse identifies nursing interventions Patient assessment. The Patient and family are based on the Patient 's nursing diagnoses. Some included in these activities as much as possible. nursing diagnoses will require interventions Assessing the Patient 's unique learning needs in all three phases of the surgical experience. ensures that Patient teaching will be relevant For other nursing diagnoses, the interventions and delivered in a manner appropriate for the will be confined to a single period or after the Patient . Patient has left the operating and recovery 12. Providing appropriate information and support rooms.

4 During the preoperative period addresses the 5. Each plan of care must be customized based on desired outcome that the Patient demonstrate specific individual Patient needs. Nevertheless, knowledge of expected responses to the opera- several nursing diagnoses, desired outcomes, tive or invasive procedure. and interventions are common to all surgical 13. Preoperative preparations focus on a variety patients . of nursing activities, including data collection through Patient assessment, Patient /family Desired Patient Outcomes teaching, emotional support, planning of care for the intraoperative and postoperative 6. A well-prepared Patient will have an under- periods, and communication of Patient infor- standing of the events that can be anticipated mation to healthcare team members. in the preoperative and immediate postopera- 14. The preoperative assessment provides infor- tive periods. For example, one AORN expected mation to address desired Patient outcomes: Patient outcome states, The Patient or desig- freedom from infection, freedom from injury, nated support person demonstrates knowledge skin integrity, electrolyte balance, and Patient of the expected responses to the operative inva- participation in the rehabilitation process.

5 For sive procedure (AORN, 2011, p. 114). This example, assessment data that reveal limited outcome includes knowledge of the procedure range of motion in a shoulder would be used to to be performed and an understanding of the plan positioning interventions to prevent further risks delineated on the consent form. shoulder injury. 7. The Patient should also be prepared for dis- 15. The body's defense against pathogens is directly charge and should demonstrate understanding related to tissue perfusion and oxygenation. of the expectations of his or her participation Obese patients have decreased levels of tissue in recovery and rehabilitation. oxygen, which increases their risk for surgical- 8. The Patient should feel supported in the pre- site infection (SSI) (Chopra et al., 2010). In operative period and should be encouraged to addition, obese patients have an increased fre- express his or her feelings about the surgical quency of comorbid conditions, such as dia- experience.

6 Betes mellitus, that may increase their risk for 9. The Patient 's level of anxiety or fear should be SSIs. reduced to a minimum. 16. The perioperative nurse may be responsible for administering antibiotics prior to Surgery . Administration of antibiotics prior to the inci- Preoperative Preparation sion in certain types of Surgery has been shown to significantly reduce the rate of surgical infec- 10. The Patient is prepared psychologically and tion and has been incorporated into the Surgical physiologically for Surgery during the pre- Care Improvement Project (SCIP) sponsored by operative period. Interventions are directed the Centers for Medicare & Medicaid Services toward treating or minimizing preexisting (CMS) in collaboration with a number of other medical conditions, and providing informa- national partners, including the American Hos- tion and support for the Patient through the pital Association (AHA), Centers for Disease surgical experience.

7 Control and Prevention (CDC), Institute for 11. Nursing activities are planned to achieve positive Healthcare Improvement (IHI), and The Joint Patient outcomes. Planning for the achievement Commission (TJC). Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. Preoperative Assessment and Interventions 15. 17. Prophylactic antibiotics should be given far thorough assessment of the Patient a day or enough in advance of the start of Surgery so more prior to Surgery . More commonly, preop- that the level of antibiotic in the Patient 's serum erative testing is accomplished at another site, and tissue is sufficient to destroy microorgan- and the initial assessment is made by someone isms that might be encountered during Surgery . other than the nurse who will actually provide The ideal time frame is usually within 1 hour the intraoperative care. prior to incision (Alexander et al., 2011). 18.

8 Until recently, prophylactic antibiotics were Sources of Patient Information given just prior to the Patient 's transport to the 23. The perioperative nurse most often encoun- operating room. However, delays in transport ters the Patient for the first time in the holding and preparations for Surgery often result in delay area immediately prior to Surgery . During this of the surgical incision by more than 1 hour, in encounter, there is usually not enough time to which case the antibiotics are not effective. carry out a comprehensive history and assess- 19. Most healthcare facilities have preoperative ment. The perioperative nurse must, therefore, prophylactic antibiotic protocols that identify rely on the information gathered by others. the type of Surgery , the type of antibiotic, and 24. The nurse gathers assessment data from a the time frame in which the antibiotic should combination of chart review, Patient /family be given.

9 Many facilities have determined questionnaire and interview, Patient observa- that compliance with the 60-minute time tion, and communication with other health- frame is best achieved when the periopera- care providers. The Patient 's chart may include tive nurse assumes responsibility for antibiotic an assessment and preoperative checklist that administration. was completed prior to transport to the holding 20. Body mass index (BMI), or percent body fat, area (Figures 2-1 and 2-2). has emerged as a major risk factor for postop- 25. Transfer of care is an essential component of erative SSIs on virtually all surgical services. Patient safety. Standardization in hand-off Obese patients (BMI > 30 g/m2) require a larger protocols is another effective way to promote loading dose of antibiotic to provide consis- Patient safety (AORN, 2012, p. 467). tent tissue concentrations over the duration of the surgical procedure.

10 Prophylactic antibiotic 26. Several transfer protocols have been used suc- protocols for morbidly obese patients often cessfully to share information comprehensively recommend twice the normal dose (Edmiston and concisely: et al., 2011). The SBAR (Situation, Background, Assess- ment, and Recommendation) technique is an example of a process that can be used Preoperative Assessment and Interventions for prompt and appropriate communica- tion throughout the perioperative period, including during preoperative assessment, Overview intraoperatively among caregivers, and 21. The perioperative nurse is the Patient 's advo- during hand-off to the PACU. SBAR is mod- cate during Surgery . The Patient , whose protec- eled on naval military protocol and was tive reflexes are compromised, is dependent on adapted for use in health care by Kaiser Per- members of the healthcare team to advocate manente (Figure 2-3).