the preoperative period, attention needs to be paid to patients with special
considerations. These may include the patient who is undergoing ambulatory
surgery, the geriatric patient, the patient who is obese, the patient with a
disability, and the patient under-going emergency surgery.
brief time the patient and family spend in the ambulatory setting is an
important factor in the preoperative period. The nurse must quickly and
comprehensively assess and anticipate the patient’s needs and at the same time
begin planning for discharge and follow-up home care.
nurse needs to be sure that the patient and family under-stand that the patient
will go first to the preoperative holding area before going to the operating
room for the surgical procedure and then will spend some time in the PACU
before being discharged home with the family later that day. Other preoperative
teaching content should also be verified and reinforced as needed. The nurse
should ensure that any plans for follow-up home care are in place if needed
older person undergoing surgery may have a combination of chronic illnesses and
health problems in addition to the specific one for which surgery is indicated.
Elderly people frequently do not report symptoms, perhaps because they fear a
serious illness may be diagnosed or because they accept such symptoms as part
of the aging process. Subtle clues alert the nurse to underlying problems.
care staff must remember that the hazards of surgery for the aged are
proportional to the number and severity of co-existing health problems and the
nature and duration of the operative procedure. The underlying principle that
guides the preoperative assessment, surgical care, and postoperative care is
that the aged patient has less physiologic reserve (the ability of an organ to
return to normal after a disturbance in its equilibrium) than the younger
patient. Cardiac reserves are lower; renal and he-patic functions are
depressed; and gastrointestinal activity is likely to be reduced. Dehydration,
constipation, and malnutrition may be evident. Sensory limitations, such as
impaired vision or hear-ing and reduced tactile sensitivity, are often the
reasons for falls and burns. Therefore, the nurse must be alert to maintaining
a safe environment. Arthritis is common in older people and may affect
mobility, making it difficult for the patient to turn from one side to the
other or ambulate without discomfort. Protective measures include adequate
padding for tender areas, moving the patient slowly, protecting bony
prominences from prolonged pressure, and providing gentle massage to promote
condition of the mouth is important to assess. Dental caries, dentures, and
partial plates are particularly significant to the anesthesiologist or
anesthetist because decayed teeth or dental prostheses may become dislodged
during intubation and occlude the airway.
additional area to assess in elderly patients is the pre-operative level of
activity. Research suggests that elderly patients who had hip replacement
surgery and who reported performing greater physical activities (including
heavy chores) preopera-tively can walk greater distances postoperatively than
elderly pa-tients who are less physically active prior to surgery (Whitney
& Parkman, 2002).
the body ages, its ability to perspire decreases. Because de-creased
perspiration leads to dry, itchy skin, which becomes frag-ile and is easily
abraded, precautions are taken when moving an elderly person. Decreased
subcutaneous fat makes older people more susceptible to temperature changes. A
lightweight cotton blanket is an appropriate cover when an elderly patient is
moved to and from the operating room.
elderly people have experienced personal illnesses and possibly
life-threatening illnesses of friends and family. Such ex-periences may result
in fears about the surgery and about the fu-ture. Providing the patient with an
opportunity to express these fears enables the patient to gain some peace of
mind and a sense of being understood.
pain assessment and teaching are important with elderly patients. It is
important for nurses to incorporate pain man-agement information and pain
communication skills when teach-ing elderly persons how to obtain greater
postoperative pain relief (McDonald, Freeland, Thomas & Moore, 2001).
the elderly patient may have greater risks during the perioperative period, the
following are critical: (1) skillful pre-operative assessment and treatment,
(2) skillful anesthesia and surgery, and (3) meticulous and competent
postoperative and postanesthesia management.
age, obesity increases the risk and severity of complications associated with
surgery (National Institutes of Health, 2000). During surgery, fatty tissues
are especially susceptible to infec-tion. Additionally, obesity increases
technical and mechanical problems related to surgery. Therefore, dehiscence
(wound sepa-ration) and wound infections are more common. Moreover, the obese
patient may be more difficult to care for because of the added weight; the
patient tends to breathe poorly when supine, which increases the risk of
hypoventilation and postoperative pul-monary complications. In addition,
abdominal distention, phle-bitis, and cardiovascular, endocrine, hepatic, and
biliary diseases occur more readily in obese patients (Dudek, 2001). It has
been estimated that for each 30 pounds of excess weight, about 25 ad-ditional
miles of blood vessels are needed, and this places in-creased demands on the
considerations for patients with a mental or physical dis-ability include the
need for assistive devices, modifications in pre-operative teaching, additional
assistance with and attention to positioning or transferring, and the effects
of the disability on surgery and anesthesia (Quinn, 1999).
devices include hearing aids, eyeglasses, braces, pros-theses, and other
devices. Individuals who are hearing-impaired may need a translator or some
alternative communication system perioperatively. If they rely on signing or
speech (lip) reading, and if their eyeglasses or contact lenses are removed or
if health care staff wear surgical masks, these patients will need an
alternative method of communication. These needs must be identified as a factor
in the preoperative evaluation and clearly communicated to personnel. Specific
strategies for accommodating the patient’s needs must be identified ahead of
time. Ensuring the safety of as-sistive devices is important; these devices are
expensive and likely to be lost.
patients are directed to move from the stretcher to the operating room table
and back again. In addition to being unable to see or hear instructions,
patients with a disability may be un-able to move without special devices or a
great deal of assistance. The patient with a disability that affects body
position (eg, cerebral palsy, post-polio syndrome, and other neuromuscular
disorders) may need special positioning during surgery to prevent pain and
injury. Moreover, these patients may be unable to sense whether their
extremities are positioned incorrectly.
with respiratory problems related to a disability (eg, multiple sclerosis,
muscular dystrophy) may experience difficul-ties unless the problems are made
known to the anesthesiologist or anesthetist and adjustments are made. These
factors need to be clearly identified in the preoperative period and
communicated to the appropriate personnel.
Emergency surgeries are unplanned
and occur with little time for preparation (Meeker & Rothrock, 1999). The
unpredictable na-ture of trauma and emergency surgery poses unique challenges
to the nurse throughout the perioperative period.
of the previously discussed factors that affect patients preparing to undergo
surgery apply to these patients, usually in a very condensed time frame. The preoperative
assessment may ac-tually coincide with resuscitation efforts in the emergency
depart-ment (Meeker & Rothrock, 1999). For the unconscious patient,
informed consent and essential information, such as pertinent past medical
history and allergies, need to be obtained from a fam-ily member, if one is
available. A quick visual survey of the patient is essential to identify all
sites of injury when the emergency surgery is due to trauma.
The psychological status of the
patient undergoing emergency surgery should be assessed quickly if the patient
is awake (Meeker & Rothrock, 1999). The patient may have undergone a very
frightening experience and may need extra support and explana-tion
of the surgery.