Pre-operative care | CHAPTER-3 | Medical and Surgical Nursing

Pre-operative care – This course is designed to understand the concept of community health nursing: nurses’ roles and interventions in family health, school health, occupational health, environmental health, elderly health care, gender issues, disaster management and principles and terminology of epidemiology. The aim of the course is to acquire knowledge and skills in community health nursing.

Pre-operative care

Definition of Preoperative Care:

Preoperative care is the preparation and management of a patient prior to surgery. It includes both physical and psychological preparation.

Or,

Preoperative care refers to health care provided before a surgical operation. The aim of preoperative care is to do whatever is right to increase the success of the surgery.

Or,

Care given before surgery when physical and psychological preparations are made for the operation, according to the individual needs of the patient is known as preoperative care.

Pre-Operative Investigation of a Patient:

1. Hematological Investigation:

• CBC (Complete blood count)
• ESR, Hb%
• Serum creatinine.
• Serum electrolytes
• Blood urea

2. Blood grouping and cross matching

3. Random blood sugar and fasting blood sugar.

4. Liver function test

5. Clotting screening

6. Chest X-ray, ECG

7. Routine examination

8. Pregnancy test (B-HCG).

9. HIV (In all high risk case. patient must give consent and receive counseling)

10. Urinalysis

The Examination Can Be Divided Into Three Areas:

A. General medical examination:

a) General: Anemia, Jaundice, cyanosis, nutritional status, teeth, feet, leg ulcers (sources of infection).

b) CVS: Pulse, BP, heart sound, peripheral pulses, peripheral edema.

c) Respiratory: Respiratory rate and effort, Chest expansion and percussion note, breath sounds, oxygen saturation.

d) GIT: Abdominal masses, ascites, bowel sound, bruits, hernia, genitalia.

e) Neurological: Consciousness level, any pre-existing cognitive impairment or confusion, deafness, neurological status of limbs.

B. Specific surgical examination:

a) Confirm previous findings and therefore the diagnosis

b) Determine severity – how much is this now affecting the patient?

e) Gauge extent are other structures involved that will affect surgical planning.

C. Specific medical examination:

a) Hematological Investigation:

• CBC (Complete blood count)
• ESR, Hb%
• Serum creatinine.
• Serum electrolytes
• Blood urea

b) Blood grouping and cross matching

e) Random blood sugar and fasting blood sugar.

d) Liver function test

e) Clotting screening

1) Chest X-ray, ECG

g) Routine examination

b) Pregnancy test (B-HCG).

1) HIV (In all high risk case. patient must give consent and receive counseling)

j) Urinalysis

Important history taken from a surgical patient.

a) Particulars of patient.

b) History of presenting complaint:

• Symptoms including features not present.
• Onset
• Relieving factors
• Exacerbating factors
• Pain, nature of the pain, any radiation etc.
• Other therapies.
• Planned surgery
• Expectations

c) Past medical history:

CVS:

1. Ischemic heart disease: Angina, MI
2. Hypertension,
3. Heart failure
4. Peripheral vascular disease.
5. Deep vein thrombosis and pulmonary embolism.
6. Anaemia

Respiratory:

1. Chronic obstructive pulmonary disease
2. Asthma
3. Respiratory infections
4. Malignancy

GIT:

1. Peptic ulcer disease and gastro esophageal reflux. Bowel habit-bleeding per rectum, obstruction.
2. Malignancy
3. Liver disease: Jaundice, alcohol, coagulopathy.

Genitourinary tract:

1. Urinary tract infection
2. Prostatism
3. Renal dysfunction

Endocrine:

1. Diabetes
2. Thyroid dysfunction
3. Phaechromocytoma
4. Porphyria

Infectious disease:

1. HIV
2. Hepatitis
3. TB

Locomotor system:

1. Osteoarthritis
2. Inflammatory arthropathy, eg. Rheumatoid arthritis.

Previous surgery

preoperative problems of a patient before surgery

a) Diabetes:

• Diabetic patients are high risk cases.
• Hyper-glycaemia carries a high risk of sepsis.
• Patients with diabetes also have a risk of CVA and MI.

b) Obesity:

• Difficulty intubation.
• Risk of myocardial infarction and stroke.
• Deep vein thrombosis and pulmonary embolism.
• Respiratory compromise.
• Pressure sores.
• Poor wound healing, leading to infection.

c) Jaundice:

• Obstruction and sepsis.
• Impaired clotting
• Risk of renal failure resulting from dehydration
• Impaired resistance to infection.

d) Hypertension:

• Patients with a blood pressure greater than 160 mm Hg systolic or 95 mm Hg diastolic are considered as high risk.

Definition of Informed Consent:

Informed consent is the process by which a patient learns about and understands the purpose, benefits, and potential risks of a medical or surgical intervention, including clinical trials, and then agrees to receive the treatment or participate in the trial. Informed consent generally requires the patient or responsible party to sign a statement confirming that they understand the risks and benefits of the procedure or treatment.

Or,

Informed consent is a process for getting permission before conducting a healthcare intervention on a person, or for disclosing personal information.

a) Preparation:

• Introduction: Give your own name. Check patient name. Explain what you are doing and by what authority.
• Background: check what the patient already known’ s. Explore how much he or she actually wants to know.

b) Explanation:

• What is wrong: Explain diagnosis in simple English or mother language.
• Action: What is the proposed action? Does it differ from national or other guidelines? If so justify.
• Outcome: Describe the likely short and long term outcomes.
• Choices: Describe all viable choices, including doing nothing.
• Complications:

1. Explain in clear English all serious complication and those with a risk>1%.
2. Describe the actions that will be taken to prevent each.
3. Explain how complications will be managed if they do occur.

• Right of refusal:

1. Make it clear that the final decision is the patients alone.
2. Give the patient time to think about the decision.

c) Check competence:

• Competence to give consent: Check the ability of patient to take in, retain and consider the information provided and articulate the decision. This can be achieved by recording the d patients answer to the question “Tell me what you have understood”.

d) Closer:

• Open question: Use open questions, for example “Is there anything else you would like to discuss?”
• Record: Record what was discussed and what was agreed.

The pre-operative investigation you done before general anesthesia with justification?

A) Pre-anesthetic assessment: It includes proper history taking, physical examination and investigation.

B) History:

a) Any concurrent medical disease with special attention to respiratory, CVS, hepatic and renal disorder like-

• Asthma
• Emphysema
• Hypertension (HTN)
• Myocardial infarction (MI)
• Diabetes mellitus (DM)
• Chronic renal failure (CRF)
• Haemophilia
• CLD

b) Personal history: smoking, alcohol, drug abuse, use of OCP

c) Drug history: Drug allergy, use of steroid, anti-hypertensive, antibiotics, anticoagulant.

d) About previous operation or anesthesia – any problem like jaundice or of hepatic function after operation.

C) Physical exam:

a) General: General metabolic state:

• Nutrition
• Height
• Weight
• Pulse
• Blood pressure (BP)
• Temperature
• Respiration
• Anemia
• Jaundice
• Dehydration

b) Systemic- Due to attention to heart and lungs

c) Dentures-Present or not

D) Investigation:

a) Routine

• Blood-

✔TC, DC, Hb%, ESR

✔ Groping and cross matching

✔ Fasting blood sugar

✔ Blood urea

✔ Serum creatinine

✔ Serum electrolytes

• Urine for RME for protein, sugar, casts, pus cell.
• Chest X-ray
• ECG

b) Special test-

• LFT, HBsAg, HCV
• Coagulation screening-BT, CT, PT, platelet count
• Degree of airway constriction-FEV1/FVC ration in COPD (Chronic obstructive
• pulmonary disease)
• Sputum C/S
• Written consent of the patient for G/A

Importance/Purpose of Preoperative Care:

• Patients who are physically and psychologically prepared for surgery tend to have better
• outcomes after surgery.
• Preoperative teaching meets the patient’s need for information regarding the surgical experience.
• Evaluate patient’s current medical status
• Provide clinical risk profile
• Provide recommendations for management in the perioperative period
• Not to give-cardiac clearance
• Alter or cancel the planned procedure
• Recommend re-vascularization if outcome would be altered
• Preoperative care is extremely important prior to any invasive procedure, regardless of whether the procedure is minimally invasive or major surgery.

Pre-Operative Care of a Hospitalized Patient/ Duties & Responsibilities before Sending a Patient to the Operation Theatre:

• Reassure the patient physically & psychologically about operation.
• Provide correct information about operation/surgery.
• Take history & collect all investigations report & prepared a preoperative file
• Check vital sign with height, weight & record all information on chart
• Patient should be kept on nothing by mouth (NPO) usually 6-8 hours before surgery
• Sedative as well as laxative should be given at night according to physician order.
• Enema given early in the morning if necessary
• All jewelries & false teeth, hearing aids etc. should be removed
• Shave & clean respective area for operation
• Check vital sign time & noted on chart
• Written consent/ informed consent must be collected from patient
• Ask the patient to empty the bladder before going to the operation table
• IV infusion should be given
• Catheter should be introduced
• Helps the patient to maintain personal hygiene
• If the patient female twisting hair 1/2 braids for long
• Administer pre anesthetic medication as per as doctors order
• Provide support to the patient & their relatives.
• Explain the surgical procedure to the patient
• Reduce fear about the upcoming surgery & recovery
• Send the patient to the OT with patient file

Read more:

• Medical and Surgical Nursing | Diploma in Nursing Science and Midwifery