What is the primary purpose of the nursing preoperative assessment in the perioperative environment?

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Introduction

Perioperative nursing is a specialty that incorporates the care of the surgical patient. It uses a multidisciplinary approach to care. In the hospital setting this includes most disciplines in the hospital: nursing, pharmacy, dietary, materials, environmental and plant operations. Perioperative nursing occurs in a variety of settings. These include: Out Patient Centers, Surgical Services, Postanesthesia Care Unit (PACU), physician offices, and any area in which surgery or invasive procedures are performed. Perioperative nursing includes three phases of the surgical experience: the preoperative, the intraoperative, and the postoperative phases. This nursing specialty provides continuity of care through the peri-operative phases. Registered Nurses are responsible for preparing patients for an operative and/or invasive procedure.

By the year 2030, it is estimated that 20 percent of Americans will be older than 65, while one out of four elderly individuals will be older than 85 years of age. Twenty-one percent of those over age 60 will undergo surgery and anesthesia as compared with only 12 percent of those aged 45 to 60 years. Despite the higher numbers of elderly patients having surgery, mortality and morbidity rates have been declining. Old age appears to have assumed less influence as a determinant of adverse outcomes as perioperative care has improved. A better understanding of the associated risk factors leading to perioperative complications may help healthcare providers to further lower the risk.

The preoperative phase begins when the decision for surgery is made and ends when the patient is transferred to the operating room table. The preoperative evaluation and teaching typically takes place several days before surgery in an outpatient setting. Today, most perioperative patients are admitted to the hospital the morning of their surgical procedure. However, there are times when the preoperative phase will begin on the medical-surgical units or in the emergency department. The first step of the preoperative phases begins with a patient and chart assessment on all patients scheduled for an operative and/or invasive procedure prior to transportation to the Surgical Suites. This ensures accurate identification of the patient, using two identifiers, identification and marking of the surgical site, adequacy of the preoperative patient preparation, and completeness of the documentation. This assesses the patient’s actual and potential health problems and facilitates implementation and communication of the perioperative plan of care

Preoperative Assessment

A thorough nursing assessment and appropriate interventions can prevent or minimize procedure related complications. The preoperative assessment is essential to identify problems early, and to provide a comparison for postoperative deviations from the norm.  Sometimes, the initial nursing assessment is done in a preadmission visit that may also include preoperative teaching and outpatient testing. However, it is critical that the nursing assessment be repeated the morning of surgery. This assessment should include at a minimum, vital signs, respiratory status, an assessment of the level of consciousness, and review of preoperative testing results.

Psychosocial Assessment

The psychosocial assessment many times will be different from the admission assessment; since surgery may not have been a reality at the time of admission. The preoperative psychosocial assessment aims to identify potential or actual sources of the patient’s anxiety, such as altered sleep patterns, increased pulse and respiratory rates, increased perspiration, and frequent voiding. It includes the patient’s understanding of the surgery, previous surgical experiences, specific concerns or feelings about surgery, and religious feelings that affect anxiety.

Fear can take different forms, including fear of the unknown, loss of control, loss of love from significant others, threat to sexuality from surgery, diagnosis of cancer, anesthesia, dying, pain, disfigurement, permanent limitations, loss of lifestyle (as evidenced by occupational and recreational changes), and current and future financial problems.

Physical Assessment

The preoperative physical assessment aims to make surgery safe and comfortable for the patient. Again, this will be different than the admission assessment.  The nurse will be focusing on objective data acquired after the decision for surgery has been made.

Respiratory Assessment

Question the patient about smoking. To prevent respiratory complications the patient should stop smoking 4 to 6 weeks prior to surgery.  Many studies have also shown a correlation between smoking and poor wound healing.  Optimally there should be no smoking the day of surgery. If they smoke, how many packs per day and for how long? Smoking increases post-op respiratory complication by decreasing the amount of functional hemoglobin available and impairs oxygen delivery to the tissues. Smoking is associated with the surgical complication of atelectasis, and one study found it doubled the risk of postoperative pneumonia (Tiernevu, 2000).

Evaluate patients with pulmonary problems.  Assess breath sounds and chest expansion.  Chest x-ray is ordered based on history not on age.  If ordered and completed results need to be put on chart. Evaluation of the patient with preexisting pulmonary problems may include PFT and ABG. A chest x-ray should be done within 1 year prior to the procedure for older patients (i.e. age 60 and older) and for patients with pulmonary conditions. Patient specific factors that increase the risk of postoperative pulmonary complication are chronic lung disease, morbid obesity and smoking (Tiernevu, 2000).

Does the patient have respiratory allergic conditions, such as asthma or hay fever? Has he had anesthesia-related problems with any previous surgeries? This may affect the choice of anesthetic agents. Does the patient have chronic obstructive pulmonary disease (COPD)? This disorder increases the risk of complications and may require preoperative interventions to correct electrolyte imbalances, prevent postoperative respiratory infection or remove excess sputum. Does the patient have an upper or lower respiratory infection? Notify the physician of such an infection, as it may be reason to delay the procedure. Anesthesia produces increased bronchial secretions besides the congestion already present in the case of a respiratory infection. This has a profound effect on ventilation of the patient.

Cardiovascular Status

Assess heart sounds, rate, and rhythm. Assess peripheral pulses. Obtain an EKG if ordered. EKG is ordered based on history not age. Record peripheral pulses when surgery is to be performed on major blood vessels or the extremities. Obtain CBC and electrolytes (add type and cross-match if patient undergoing major surgery that may involve considerable blood loss) REVIEW RESULTS FOR ABNORMAL LEVELS! When labs are ordered please contact the physician with abnormal results. Do not assume the lab has contacted them – they only call critical levels. The 2 test results that as a nurse it is especially important to look at is blood glucose (link between wound healing) and bacteria which suggest UTI. When ordering a T&S or T&C for a preoperative patient please get a blood consent also.  Consents will be covered later in this module.

Kidney and Liver Status

Does the patient have any complaints associated with kidney or bladder infection? These include frequency, urgency, blood in the urine, burning on urination, fever, or back, flank or suprapubic pain. Patients with signs and symptoms of urinary or kidney infection need a more extensive preoperative evaluation. If renal function is severely compromised by infection, the stress of surgery can precipitate renal failure.

Liver biotransforms anesthetics; liver disease impairs the ability to detoxify drugs that may be given in the perioperative period.Review results of liver function tests. Kidney excretes anesthetics and metabolites; good renal function is necessary to maintain fluid and electrolyte balance. Review results of urinalysis to detect:

• albumin (which suggests kidney disease)
• glucose (which suggests diabetes)
• acetone (which suggests diabetes or starvation)
• bacteria (which suggests urinary tract infection)

When implanting metallic objects (TKA/THA), UTI can be very dangerous.  Many times procedures will be cancelled.

Immunologic Status

Assess for allergic reactions to any foods, medication, latex or soaps. Report history of bronchial asthma. Many patients with asthma will be given a preoperative breathing treatment or given medication through a MDI. Some allergic reactions can be fatal and some can be serious enough to permanently damage vital organs. It is important that the surgery team know if the patient has an allergy to iodine, seafood, hexachlorophene or latex prior to the procedure. Latex is becoming more of an issue in perioperative nursing.  However; the public is not always aware of latex allergies.  Ask if they wear rubber gloves at home, do they have irritation from their under garments, any problems when they blow up a balloon?  Check for food allergies, which are linked to latex allergies – bananas, kiwi, chestnuts, papayas, mangos, potatoes. Inquireabout unusual reaction to anesthesia by patient or relatives. The concern is malignant hyperthermia which is hereditary.

Neurologic Status

The neurological exam provides you with a baseline to measure against through the postoperative process. Evaluate cognitive level, language barriers and behavior. Evaluate arm and leg muscle strength and coordination with ambulation. Assess orientation to person, place and time. Assessing orientation goes along ways in helping the Surgical Suite staff.  Is this patient competent to sign permits? Does the patient display any signs or symptoms suggesting significant neurological problems? Symptoms may include headache, numbness or tingling in an extremity, tremors or weakness in an extremity, unsteady gait, confusion or memory loss. It is important to document any neurological deficits preoperatively for comparison with the post-op assessment. Neurological and behavioral changes can result postoperatively from the effects of anesthetics, analgesic or sedatives. This is especially true in elderly patients.

Is the patient alcoholic? Chronic alcoholism suppresses the adrenocortical response to operative stress. If the patient does not admit to drinking heavily and you are concerned that he might be alcoholic, share these concerns with the physician. Alcoholic patients are at risk for delirium tremors with withdrawal.

Gastrointestinal (GI) Status

Does the patient complain GI symptoms? These include nausea & vomiting, diarrhea, constipation, spitting up blood or blood in the stool, gastric ulcer disease, inflammatory bowel disorder, or diverticular disease. Anesthesia and pain medications affect the GI function. So, a preoperative assessment is needed for comparison postoperatively to determine if any problems were caused by the medication or were preexisting.

Endocrine Status

Is the patient diabetic? Diabetics should not have insulin on the morning of surgery due to their NPO (nothing by mouth) status. Do a bedside blood glucose check and notify the physician of abnormal findings before the procedure. Diabetes puts the patient at risk for delayed wound healing, postoperative surgical infection, hypoglycemia or hyperglycemia.

Health History

Allergies – drugs, adhesive tape, latex or soap. Ask about preexisting illness, such as liver, respiratory, renal, cardiac, endocrine, and blood disease.

Inquire about use of medications that could interfere with anesthesia or contribute to postoperative complications, such as bleeding. Ask about herbal usage.  More and more people are using herbs and vitamins and will not always volunteer this information. Ask about difficulty with hearing or vision. Document the medications the patient takes regularly, including over the counter and herbal medications. St. John’s Wort, feverfew, ginkgo biloba, ticlid, plavix anticoagulants and non-steroidal anti-inflammatories effect coagulation and can increase the risk of hemorrhage.

Obtain nutritional history to evaluate dietary intake and nutritional status. Ask about elimination to detect constipation or diarrhea. Question the patient about motor problems, particularly difficulty with walking or with arm or leg movement due to arthritis or orthopedic surgery.  REMEMBER we want to promote early activity postoperatively.

Ask about the patient’s ability to sleep and relax, level of pain or discomfort, and expectations about postoperative pain relief; perform a baseline pain assessment.

Factors affecting patient response to surgery

Age

Elderly patients may be less able to tolerate the stress of surgery depending on their age-related physiological changes and the presence of chronic diseases.

Nutrition

Inadequate intake or an improper diet can impair the patient’s ability to tolerate the stress of surgery.  It may also have an impact on wound healing.  Excessive intake, reflected by obesity, also can complicate surgery and the patient’s postoperative period.

Chronic Disease States

Pulmonary Disease can affect the patient’s response to anesthesia and the ability to cope with respiratory problems postoperatively.

Cardiovascular disease can contribute to shock and fluid imbalances by impairing blood pumping and blood vessel constriction.  An inadequate supply of red or white blood cells may increase risks related to hemorrhage or inflammation.

Renal Insufficiency may impair electrolyte and waste product removal and increase the risk of fluid overload, if urine production is inadequate.

Endocrine Disease can delay wound healing because of an anti-inflammatory response.

Disabilities that limit patient activity increase the risk of postoperative atelectasis, pneumonia and thrombophlebitis.

Preoperative Teaching

The purpose of preoperative teaching is to decrease patient anxiety and prepare the patient for surgery. It will also decrease fear. Fear of the unknown increases anxiety. Preoperative teaching can alter unfavorable attitudes, influence postoperative recovery and promote satisfaction with care. Preoperative teaching may have been done and documented in a preadmission visit. If not, you must do the teaching. If it was done, you should reinforce the teaching. You can provide a description of and reason for preoperative tests, description of preoperative routines, time of surgery, probable length of surgery and estimated time in PACU. Explain the recovery process, including the place where the patient will awaken, nursing care provided, monitoring of vital signs and equipment used (O2 therapy, O2 saturation monitor, PCA). Cover the probable postoperative course – IV lines, need to increase activity as soon as possible, need to cough and deep breath despite discomfort, incentive spirometer (this is a good time to teach them on how to use an incentive spirometer and have them practice which will make it easier to use postoperatively) Stress that it is important to turn, cough and deep breathe to prevent atelectasis. Instruct him to turn cough and deep breath at least 3 times an hour and to use the incentive spirometer at least every 2 hours, while awake. Tell family members what time the patient is expected to go to surgery, where they can wait during surgery, when the physician will contact them with surgical results.

If you do the preoperative teaching during a preadmission visit, explain any instructions that require the patient to prepare himself at home, like bowel evacuation for a colonoscopy. The morning of the procedure, check to see if the patient was complied with the instructions. Failing to execute preoperative preparation may be a reason to postpone the procedure. Explain the meaning of NPO, emphasizing the importance of being compliant to avoiding aspiration. Sometimes, patients will be NPO except for their oral medications, which should be taken with clear water. This variation may be a policy at a specific facility, or the physician’s order will be written as NPO except for medications. Most patients will be NPO after midnight the day before the procedure. A physician may designate a later NPO status if the patient is scheduled late in the day. Instruct the patient to shower the morning of the procedure with an antimicrobial soap. The patient should wash the operative site for at least five minutes, scrubbing in a circular motion. Anesthetic will remain in the patient’s body for at least 24 hours post procedure, so caution the patient not to drive, operate dangerous equipment or make important decisions within 24 hours after the procedure. Some procedures have preoperative teaching needs that are specific to that procedure, like how to use a walker if you are going to have a hip replacement. These needs are determined in collaboration with the physician.

Pre-anesthesia Medication

Pre-anesthesia medication varies from facility to facility. It is usually given immediately before surgery to:

• Decrease anxiety
• Provide sedation
• Induce amnesia
• Decrease pharyngeal secretions
• Slow hydrochloric acid production
• Prevent allergic reaction to anesthetics

If they are given, they will normally be given by the anesthesia provider just prior to patient going into the OR.  This is only done AFTER all consents have been signed and are verified complete. This is not to be confused with the administration of preoperative medications – antibiotics, inhaler, breathing treatment, antacid or h2 blockers (Zantac - which inhibits gastric acid secretion), antiemetic (Reglan – given for gastro esophageal reflux and/or delayed gastric emptying). May hear term sour stomach.

Informed Consent

Requiring permission to operate protects the patient from unsanctioned surgery and protects the surgeon from claims of unauthorized operation. The informed consent document indicates the specific procedure to be performed and includes a list of possible complications. The consent should be written as stated in physician orders. It is clearly worded in simple terms without abbreviations. All blanks must be filled in. If you have questions about the correct layman’s terms, the OR staff, the physician or nursing supervisor should be called for verification. If there is question about diagnosis/reason for procedure consult physician performing the procedure. The consent contains the patient’s signature, if the patient is of age and competent, date and time signed. There is should also be a clause for photographs and blood transfusion.  If the patient is having conscious sedation this should be included on the consent. Conscious sedation may be given to patient having colonoscopy/EDG/painful procedures. If the operative permit is not signed, have the patient sign and date it. Witness the signature. A nurse’s signature of witness is verifying that the patient signed the form. It does not hold any other legal responsibility. It does not mean that you participated in informed consent. Informed consent is done between the physician and the patient in a discussion. The operative permit has the patient signature to verify that consent. If the patient is unable to write, an “X” to indicate his agreement is acceptable. You should have a second witness to the “X”. The information that the patient must understand is a definition of the procedure, possible complications and risks of the procedure. If the patient expresses that he has unanswered questions about the procedure, or does not want the procedure, you have the responsibility to contact the physician and let him know.

If the patient is awake and oriented x 3, 1 witness is needed. If the patient is a minor, the legal guardian must sign the consent and 1 witness is needed. Most states have statues regarding the treatment of minors. An emancipate minor is usually recognized as one who is not subject to parental control, as in the following situations:

• Married minor
• In military service
• College student under legal age but living away from home
• Minor who has a child.

If the patient is incompetent or incapacitated, permission can be sought from a patient representative. Laws vary from state to state and policy varies from facility to facility. An incompetent patient is any patient who is mentally or physically incapacitated, as determined by physicians, such that the patient cannot communicate treatment preferences. Facility policy usually dictates the process and how many physicians must be involved in the decision. The patient does not have to be adjudicated incompetent by a court of law for the purposes of consenting for a procedure. If the family or Power of Attorney signs the consent 2 witnesses are needed.  

In an emergency, where the physician feels that delaying a procedure would be an immediate threat to the patient’s life or limb, and the patient cannot give consent, the physician may proceed with the procedure without consent. This process requires extensive documentation and often a consultation with other physicians. Check facility policy. The informed consent document should be placed on the patient’s chart and accompany the patient to the Surgical Suite.

Informed Consent:

• Must be obtained BEFORE patient receives pre-op meds that induce sedation or amnesia or reduces anxiety
• Ensure that the patient has actually been informed
• Physician performing the surgery must sign the consent
• Ensure that the consent has date and time
• 2 witnesses are required for incompetent patients and telephone consents

Preoperative Checklist

In final preparation before the patient is transported to surgery the pre-operative checklist should be reviewed for documentation of nursing actions which include:

• Removal of jewelry and other objects (remember to check for “unique” body jewelry)
• Checking patient identification using 2 identifiers ensures surgical site is identified and marked with an “X”
• Asking the patient to void
• Check for necessary documents – patient history, physical assessment, consent form, test results
• Administering pre-op meds
• MAR on chart
• Recent vital signs (should not be greater than 1 hour)

Depending on the facility policy, dentures may or may not be removed prior to a procedure.

On the preoperative checklist the nurse documents actions, such as patient identification; allergies; removing jewelry or other objects; asking patient to void; ensuring all needed documentation (H&P, consent, test results) are available. Mark the site of surgery, however; not immediate over the site. What IV Fluid is hanging? Incomplete chart work can delay the surgical procedure. The nurse may be required to go to the OR to identify the patient and to complete documentation.

Summary

Nursing’s preoperative teaching and assessment contribute heavily to the success of a procedure. No surgery is without risk but complications can be decreased with proper preoperative assessment and documentation of coexisting disease. Medical optimization, adequate planning preoperatively, including scheduling surgery electively as opposed to emergently, and improving nutrition status may be helpful. Opportunity to improve perioperative outcomes will be possible when risk factors for adverse events can be modified.

References:

Nettina, S, (2001). The Lippincott Manual of Nursing Practice, 7th edition. Philadelphia, PA: Lippincott Williams & Wilkins. pp107-136.

Gruber, E. & Tschernko, E. (2003). Anaesthesia and postoperative analgesia in older patients with chronic obstructive pulmonary disease: Special considerations. Drugs & Aging 20(5), 347-361.

Walker, J., (2002). Emotional and psychological preoperative preparation in adults. British Journal of Nursing. 11(8), 567-576.

What is the primary purpose of the preoperative assessment?

What is the primary focus of perioperative nursing?

What are the nursing responsibilities during preoperative phase?