Special Considerations - Preoperative Nursing Management

Special Considerations

In 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.

THE AMBULATORY SURGERY PATIENT

The 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.

The 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 (Quinn, 1999).

ELDERLY PATIENTS

The 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.

Health 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 circulation.

The 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.

An 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).

As 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.

Most 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.

Preoperative 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).

Because 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.

OBESE PATIENTS

Like 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 heart.

PATIENTS WITH DISABILITIES

Special 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).

Assistive 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.

Most 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.

Patients 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.

PATIENTS UNDERGOING EMERGENCY SURGERY

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.

All 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.