Preparation for Surgery
Voluntary and written informed consent from the patient is necessary before nonemergent surgery can be performed. Such written consent protects the patient from unsanctioned surgery and protects the surgeon from claims of an unauthorized oper-ation. In the best interests of all parties concerned, sound med-ical, ethical, and legal principles are followed. The nurse may ask the patient to sign the form and may witness the patient’s signature. It is the physician’s responsibility to provide appro-priate information. Chart 18-2 lists the criteria for a valid in-formed consent.
Many ethical principles are integral to informed consent. Before the patient signs the consent form, the surgeon must provide a clear and simple explanation of what the surgery will entail. The surgeon must also inform the patient of the ben-efits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. If the patient needs additional information to make his or her decision, the nurse notifies the physician about this. Also, the nurse ascertains that the consent form has been signed before administering psycho-active premedication, because the consent may not be valid if it was obtained while the patient was under the influence of medications that can affect judgment and decision-making capacity. Informed consent is necessary in the following circumstances:
• Invasive procedures, such as a surgical incision, a biopsy, a cystoscopy, or paracentesis
• Procedures requiring sedation and/or anesthesia
• A nonsurgical procedure, such as an arteriography, that car-ries more than slight risk to the patient
• Procedures involving radiation
The patient personally signs the consent if he or she is of legal age and is mentally capable. When the patient is a minor or un-conscious or incompetent, permission must be obtained from a responsible family member (preferably next of kin) or legal guardian. An emancipated minor (married or independently earning his or her own living) may sign his or her own consent form. State regulations and agency policy must be followed.
In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the patient’s informed consent. Every effort, however, must be made to contact the patient’s family. In such a situation, contact can be made by telephone, telegram, fax, or other electronic means.
When the patient has doubts and has not had the opportunity to investigate alternative treatments, a second opinion may be re-quested. No patient should be urged or coerced to sign an oper-ative permit. Refusing to undergo a surgical procedure is a person’s legal right and privilege. However, such information must be documented and relayed to the surgeon so that other arrangements can be made. For example, additional explanations may be provided to the patient and family, or the surgery may be rescheduled.
The consent process can be improved by providing audio-visual materials to supplement discussion, by ensuring that the wording of the consent form is understandable, and by using other strategies and resources as needed to help the patient understand its content.
The overall goal in the preoperative period is for the patient to have as many positive health factors as possible. Every attempt is made to stabilize those conditions that otherwise hinder a smooth recovery. When negative factors dominate, the risks of surgery and postoperative complications increase.
Before any surgical treatment is initiated, a health history is obtained, a physical examination is performed during which vital signs are noted, and a database is established for future compar-isons (Meeker & Rothrock, 1999). During the physical exami-nation, many factors are considered that have the potential to affect the patient undergoing surgery. Health care providers should be alert for signs of abuse that can occur at all ages and to men and women from all socioeconomic, ethnic, and cultural groups (Little, 2000; Marshall, Benton & Brazier, 2000). Findings need to be reported accordingly.
Blood tests, x-rays, and other diagnostic tests are prescribed when specifically indicated by information obtained from a thor-ough history and physical examination (King, 2000). These pre-liminary contacts with the health care team provide the patient with opportunities to ask questions and to become acquainted with those who may be providing care during and after surgery.
Optimal nutrition is an essential factor in promoting healing and resisting infection and other surgical complications (Braunschweig, Gomez & Sheean, 2000). Assessment of a patient’s nutritional sta-tus provides information on obesity, undernutrition, weight loss, malnutrition, deficiencies in specific nutrients, metabolic abnor-malities, the effects of medications on nutrition, and special prob-lems of the hospitalized patient (Quinn, 1999). Nutritional needs may be determined by measurement of body mass index and waist circumference (National Institutes of Health, 2000).
Any nutritional deficiency, such as malnutrition, should be corrected before surgery so that enough protein is available for tissue repair (King, 2000; Russell, Williams & Bulstrode, 2000). The nutrients needed for wound healing are summarized in Table 18-2.
Dehydration, hypovolemia, and electrolyte imbalances can lead to significant problems in patients with comorbid medical conditions or in elderly patients. The severity of fluid and electro-lyte imbalances is often difficult to determine. Mild volume de-ficits may be treated during surgery; however, additional time may be needed to correct pronounced fluid and electrolyte deficits to promote the best possible preoperative condition.
People who abuse drugs or alcohol frequently deny or attempt to hide it. In such situations, the nurse who is obtaining the patient’s health history needs to ask frank questions with patience, care, and a nonjudgmental attitude.
Because acutely intoxicated persons are susceptible to injury, surgery is postponed in these patients if possible. If emergency surgery is required, local, spinal, or regional block anesthesia is used for minor surgery. Otherwise, to prevent vomiting and po-tential aspiration, a nasogastric tube is inserted before adminis-tering general anesthesia.
The person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase the surgical risk. Additionally, alcohol withdrawal delirium (delirium tremens) may be anticipated up to 72 hours after alcohol with-drawal. Delirium tremens is associated with a significant mortal-ity rate when it occurs postoperatively.
Chart 18-3 gives more information about risk factors that may lead to complications.
The goal for potential surgical patients is optimal respiratory function. Patients are taught breathing exercises and use of an incentive spirometer if indicated. Because adequate ventilation is potentially compromised during all phases of surgical treat-ment, surgery is usually postponed when the patient has a respi-ratory infection. Patients with underlying respiratory disease (eg, asthma, chronic obstructive pulmonary disease) are assessed carefully for current threats to their pulmonary status. Patients’ use of medications that may affect recovery is also assessed (King, 2000; Smetana, 1999).
Patients who smoke are urged to stop 2 months before sur-gery (King, 2000), although many do not do so. These patients should be counseled to stop smoking at least 24 hours prior to surgery. Research suggests that counseling has a positive effect on the patient’s smoking behavior 24 hours preceding surgery, helping reduce the potential for adverse effects associated with smoking such as increased airway reactivity, decreased muco-ciliary clearance, as well as physiologic changes in the cardio-vascular and immune systems (Shannon-Cain, Webster & Cain, 2002).
The goal in preparing any patient for surgery is to ensure a well-functioning cardiovascular system to meet the oxygen, fluid, and nutritional needs of the perioperative period. If the patient has uncontrolled hypertension, surgery may be postponed until the blood pressure is under control.
Because cardiovascular disease increases the risk for complica-tions, patients with these conditions require greater-than-usual diligence during all phases of nursing management and care (King, 2000). Depending on the severity of the symptoms, surgery may be deferred until medical treatment can be instituted to improve the patient’s condition. At times, surgical treatment can be mod-ified to meet the cardiac tolerance of the patient. For example, in a patient with obstruction of the descending colon and coronary artery disease, a temporary simple colostomy may be performed rather than a more extensive colon resection that would require a prolonged period of anesthesia.
The presurgical goal is optimal function of the liver and urinary systems so that medications, anesthetic agents, body wastes, and toxins are adequately processed and removed from the body.
The liver is important in the biotransformation of anesthetic compounds. Therefore, any disorder of the liver has an effect on how anesthetic agents are metabolized. Because acute liver disease is associated with high surgical mortality, preoperative improve-ment in liver function is a goal. Careful assessment is made with the help of various liver function tests.
Because the kidneys are involved in excreting anesthetic drugs and their metabolites and because acid–base status and metabolism are also important considerations in anesthesia administration, surgery is contraindicated when a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems. The exception is surgery that is performed as a lifesav-ing measure or that is necessary to improve urinary function, as in the case of an obstructive uropathy.
The patient with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohy-drates or from excessive administration of insulin. Hyperglycemia, which may increase the risk for surgical wound infection, may re-sult from the stress of surgery, which may trigger increased levels of catecholamine. Other risks are acidosis and glucosuria. Although the surgical risk in the patient with controlled diabetes is no greater than in the nondiabetic patient, the goal is to maintain the blood glucose level at less than 200 mg/dL. Frequent monitoring of blood glucose levels is important before, during, and after surgery.
Patients who have received corticosteroids are at risk for adre-nal insufficiency. Therefore, the use of corticosteroids for any purpose during the preceding year must be reported to the anes-thesiologist or anesthetist and surgeon. Additionally, the patient is monitored for signs of adrenal insufficiency.
Patients with uncontrolled thyroid disorders are at risk for thy-rotoxicosis (with hyperthyroid disorders) and respiratory failure (with hypothyroid disorders). Therefore, the patient is assessed for a history of these disorders.
An important function of the preoperative assessment is to de-termine the existence of allergies, including the nature of previous allergic reactions. It is especially important to identify and docu-ment any sensitivity to medications and past adverse reactions to these agents. The patient is asked to identify any substances that precipitated previous allergic reactions, including medications, blood transfusions, contrast agents, latex, and food products, and to describe the signs and symptoms produced by these substan-ces. A sample latex allergy screening questionnaire is shown in Figure 18-2.
Immunosuppression is common with corticosteroid therapy, renal transplantation, radiation therapy, chemotherapy, and dis-orders affecting the immune system, such as acquired immuno-deficiency syndrome (AIDS) and leukemia. The mildest symptoms or slightest temperature elevation must be investigated. Because pa-tients who are immunosuppressed are highly susceptible to infec-tion, great care is taken to ensure strict asepsis.
A medication history is obtained from each patient because of the possible effects of medications on the patient’s perioperative and perianesthesia course and the possibility of drug interactions (Quinn, 1999). Any medication the patient is using or has used in the past is documented, including over-the-counter (OTC) preparations and herbal agents and the frequency with which they are used. Potent medications have an effect on physiologic functions; interactions of such medications with anesthetic agents can cause serious problems, such as arterial hypotension and cir-culatory collapse.
The potential effects of prior medication therapy are evaluated by the anesthesiologist or anesthetist, who considers the length of time the patient has used the medications, the physical condition of the patient, and the nature of the proposed surgery. Medica-tions that cause particular concern are listed in Table 18-3.
Many patients take self-prescribed or OTC medications in ad-dition to those listed in Table 18-3. Aspirin is a common OTC medication prescribed by physicians or taken independently by patients to prevent myocardial infarction, stroke, and other dis-orders (Karch, 2002). Because of the effects of aspirin or other OTC medications and possible interactions with other medica-tions and anesthetic agents, it is important to ask a patient about their use. The information is noted in the patient’s chart and con-veyed to the anesthesiologist or anesthetist and surgeon.
The use of herbal medications is widespread among patients. Approximately 15 million Americans report their use (Ang-Lee, Moss & Yuan, 2001; Karch, 2002; Lyons, 2002). Patients with chronic illnesses may be using herbal medications to supplement their prescribed medications or in place of them.
Certain herbal medications, such as echinacea, ephedra, garlic (Allium sativum), ginkgo, ginseng, kava kava (Piper methysticum), St. John’s wort (Hypericum perforatum), licorice (Glycyhiza glabra), and valerian (Valeriana officinalis) have been identified as the most commonly used herbal medications that may cause concern during the peri-operative period (Ang-Lee, Moss & Yuan, 2001; Kuhn, 1999; Lyons, 2002). Because of the potential effects of herbal medica-tions on coagulation and potential interactions with other med-ications, the nurse must ask surgical patients explicitly about the use of these agents, document their use, and inform the surgical team and anesthesiologist or anesthetist (Brumly, 2000).
All patients have some type of emotional reaction before any sur-gical procedure, be it obvious or hidden, normal or abnormal. For example, preoperative anxiety may be an anticipatory response to an experience the patient views as a threat to his or her custom-ary role in life, body integrity, or life itself. Psychological distress directly influences body functioning. Therefore, it is imperative to identify any anxiety the patient is experiencing.
By taking a careful health history, the nurse elicits patient con-cerns that can have a bearing on the course of the surgical expe-rience (Quinn, 1999). Undoubtedly, a patient about to undergo surgery is faced with various fears, including fears of the unknown, of death, of anesthesia, pain, or cancer.
Concerns about loss of work time, loss of job, increased responsibilities or burden on family members, and the threat of permanent incapacity further contribute to the emotional strain created by the prospect of surgery. Less obvious concerns may occur because of previous ex-periences with the health care system and people the patient has known with the same condition.
People express fear in different ways. For example, one patient may repeatedly ask a lot of questions, even though answers were given previously. Another person may withdraw, deliberately avoiding communication, perhaps by reading or watching televi-sion. Still others may talk about trivialities. Consequently, the nurse must be empathetic, listen well, and provide information that helps alleviate concerns.
An important outcome of the psychosocial assessment is the determination of the extent and role of the patient’s support net-work. The value and reliability of all available support systems are assessed. Other information, such as usual level of functioning and typical daily activities, may assist in the patient’s care and re-habilitation plans. Assessing the patient’s readiness to learn and determining the best approach to maximize comprehension will provide the basis for preoperative patient education.
Spiritual beliefs play an important role in how people cope with fear and anxiety. Regardless of the patient’s religious affiliation, spiritual beliefs can be as therapeutic as medication. Every at-tempt must be made to help the patient obtain the spiritual help that he or she requests. Faith has great sustaining power. Thus, the beliefs of each patient should be respected and supported. Somenurses avoid the subject of a clergy visit lest the suggestion alarm the patient. Asking if the patient’s spiritual advisor knows about the impending surgery is a caring, nonthreatening approach.
Showing respect for a patient’s cultural values and beliefs fa-cilitates rapport and trust. Some areas of assessment include iden-tifying the ethnic group to which the patient relates and the customs and beliefs the patient holds about illness and health care providers. For example, patients from some cultural groups are unaccustomed to expressing feelings openly. Nurses need to consider this pattern of communication when assessing pain. As a sign of respect, people from other cultural groups may not make direct eye contact with others. The nurse needs to know that this lack of eye contact is not avoidance or a lack of interest.
Perhaps the most valuable skill at the nurse’s disposal is listen-ing carefully to the patient, especially when obtaining the history. Invaluable information and insights may be gained by engaging in conversation and using communication and interviewing skills. An unhurried, understanding, and caring nurse invites confidence on the part of the patient.