Gloria Alexander, 63, has just been admitted to your medical-surgical unit by her primary healthcare provider after complaints of right upper abdominal pain, diarrhea, and nausea following meals for the past week. Further workup reveals acute cholecystitis. A laparoscopic cholecystectomy is indicated after consultation with the general surgeon. The surgery is scheduled for tomorrow morning at 7:30 a.m.
The surgeon has written pre-op orders for preparation of your patient that include:
* N.P.O. after midnight
* I.V. 0.45% sodium chloride solution—keep the vein open
* chest X-ray
* complete blood cell count, chemistry
* thigh-high graduated compression stockings (GCSs) with sequential compression devices (SCDs)
* shower with 4% chlorhexidine gluconate (CHG) in a.m. twice—no shave prep
* instruct on deep breathing/coughing and use of incentive spirometry
* discontinue all anticoagulants.
Gloria's medical history includes hypertension, type 2 diabetes (meal plan controlled), and coronary artery disease. Current medications include aspirin and an antihypertensive daily, and she has no known allergies. Gloria works part time as a cashier after retiring 2 years ago. She's accompanied by her husband of 41 years, who will be taking care of her after her surgery. Gloria has expressed that she's nervous because she has never had surgery before.
In this article, I'll walk you through the basics of preparing your patient preoperatively.
First things first
Your patient is relying on you for information, comfort, pain control, and performance of interventions to ensure her safety throughout her hospital stay. Surgery is psychologically stressful; your patient may be anxious about the procedure, as well as the recovery period. Education and explanation is the best way to help ease her anxiety. Keep explanations simple and easy—if you can explain things in their simplest form, your patient should have a good understanding of what to expect (see Expected pre-op patient outcomes).
Are there nuts in that?
One of the most important questions to ask your patient is about her allergy status. Allergies are now classified into three categories: medications, food, and contact/environmental. Medication allergies are the most commonly questioned; however, it's important for the anesthesia department and the surgical team to be aware of food and contact allergies as well. Food allergies that may be important include nuts and eggs. The anesthetist may use propofol, which may be contraindicated in the presence of an egg allergy. Contact allergies important for the surgical team to be aware of include latex and adhesives used in tape or bandages.
Although most ORs have made considerable effort to become latex free, there are certain measures that must be taken if a patient has a true latex allergy. In the event of a topical allergy to iodine, it may also be necessary for the surgical team to use an alternative prepping solution that doesn't contain iodine. Update your patient's allergy ID band and chart if there are any changes during her stay. If you're aware of a latex or topical allergy to iodine, contact the OR to give them a heads-up.
Making a list, checking it twice
Obtaining or verifying a current and accurate list of all prescribed medications, as well as over-the-counter and herbal preparations, is necessary. The surgeon or anesthesia provider may order the discontinuation or alteration of some medications. Generally, anticoagulants are stopped 3 to 4 days before surgery to reduce the risk of bleeding, unless contraindicated due to disease processes or medical history. If your patient is to receive medications by mouth, these should only be given with a small amount of water (enough to adequately swallow safely) to maintain her N.P.O. status.
Pain, pain go away
You'll need to explain to your patient that she'll experience some discomfort after the procedure and pain medication will be ordered by her surgeon. As you know, pain is subjective—everyone has a different pain threshold and reacts to pain in an individual way. The most common way to assess for pain is to have your patient rate it using a pain scale. Provide your patient with the following explanation so she'll know what to expect post-op when you assess her pain: The pain scale is a rating of 0 to 10, with 0 being no pain at all and 10 being the most excruciating pain you've ever felt. Let her know you'll be asking the following questions: How would you rate your pain? Where's your pain located? What does the pain feel like? Pain control is important because a patient with controlled pain will be more likely to get out of bed and ambulate quicker than a patient with poorly controlled pain.
Keep em' circulating
To help prevent blood clots in the lower extremities during and after surgery, the surgeon may order knee- or thigh-high GCSs, which may be used in conjunction with SCDs. The purpose of SCDs is to minimize the incidence of deep vein thrombosis and peripheral edema in the post-op patient. The SCDs are comprised of a sleeve that's wrapped around each leg. The sleeves are then alternately inflated with air, creating pressure around the calves and improving venous return. SCDs and/or GCSs are normally used until your patient starts to ambulate.
Take a deep breath
Pneumonia is the second most common hospital-acquired infection in the United States and is associated with substantial morbidity and mortality, according to the CDC. To help prevent pneumonia, pre-op teaching of the following will be beneficial to your patient:
* deep breathing—these exercises reduce atelectasis and improve pulmonary function; deep breaths expand the lungs fully so that air can get behind mucus and facilitate the effects of coughing
* coughing—consecutive coughs help remove mucus more effectively and completely than one forceful cough; provide a pillow and teach your patient how to splint because she may be reluctant to cough due to pain from the surgery
* use of incentive spirometry—this helps maintain maximum inspiration and reduces the risk of progressive collapse of individual alveoli; incentive spirometry should be done 10 times/hour while your patient is awake.
Skin prep and shaving
Before surgery, the surgeon may have ordered your patient to bathe with a medicated scrub. Staphylococcus aureus is the most common organism causing surgical site infections. Showering with 4% CHG before surgery to reduce the number of microorganisms on the skin will reduce the risk of subsequent contamination of the surgical wound. You should also educate your patient on the importance of not shaving or using a depilatory on the surgical site because studies have shown a higher risk of surgical site infection with shaving. If a shave prep is needed, it's performed with a mechanical shaver by a member of the surgical team in either the pre-op holding area or OR.
What to expect
After the OR has sent for your patient, you should inform her. Commonly, the patient's family isn't present and this way she can call them and let them know she'll be heading into surgery. You'll want to make sure that your patient is wearing a fresh, clean gown and all jewelry is removed, including hairpins and combs. If your patient has dentures, have her remove them at this time and stow them away in a safe place.
If her family is present, now is a good time to explain what to expect. After the surgery, the surgeon will be out to see them in the surgical waiting area, so it's best if they stay nearby. Gloria will be in the postanesthesia care unit for about 1 hour or so and then will be transferred back to her room.
Explain to your patient that she'll arrive in the holding area, where she'll meet the OR staff and anesthetist if she hasn't already. A review of her chart, including all required documents, will be performed and an I.V. will be inserted or an existing one evaluated. Stress to your patient that several people will be asking the same questions to maintain her safety. Some of the questions she may be asked by each individual include her name, birth date, allergies, what procedure she's having, which side if laterality is applicable, who's the surgeon, and if she has any questions before they proceed. Explaining this ahead of time will alleviate any anxiety as she's asked these questions.
Pre-op preparation is important for the smooth transition from the pre-op to the post-op stage and on through your patient's discharge.
Expected pre-op patient outcomes
Relief of anxiety, evidenced when the patient:
* discusses concerns related to types of anesthesia and induction
* verbalizes an understanding of the preanesthetic medication and general anesthesia
* discusses last-minute concerns
* discusses financial concerns, when appropriate
* requests a visit with a spiritual advisor, when appropriate
* relaxes quietly after being visited by healthcare team members.
Decreased fear, evidenced when the patient:
* discusses fears with healthcare professionals or a spiritual advisor, or both
* verbalizes an understanding of any expected bodily changes, including the expected duration of bodily changes.
Understanding of the surgical intervention, evidenced when the patient:
* participates in pre-op preparation
* demonstrates and describes exercises she's expected to perform postoperatively
* reviews information about post-op care
* accepts preanesthetic medication, if prescribed
* remains in bed once premedicated
* relaxes during transportation to the OR or unit
* discusses post-op expectations.
No evidence of pre-op complications
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