Preoperative Nursing Management
Physiologic Assessment during the Preoperative Phase
Before any treatment is initiated, a health history is obtained and a physical examination is performed during which vital signs are noted and a data base is establish for future comparisons.
Diagnostic tests may be carried out during the preoperative phase such as:
- Blood analyses such as complete blood count, sedimentation rate, c-reactive protein, serum protein electrophoresis with immunofixation, calcium, alkaline phosphatase, and chemistry profile
- X-ray studies
- MRI and CT scans (with or without myelography)
- Electrodiagnostic studies
- Bone scan
- Tissue biopsies
- Stool studies
- Urine studies
Significant physical findings are also noted to further describe the patient’s overall health condition. When the patient has been determined to be an appropriate candidate for surgery, and has elected to proceed with surgical intervention, the pre-operative assessment phase begins. The purpose of pre-operative evaluation is to reduce the morbidity of surgery, increase quality of intra-operative care, reduce costs associated with surgery, and return the patient to optimal functioning as soon as possible.
The following are the physiologic assessments necessary during the preoperative phase:
- Nutritional status and needs – determined by measuring the patient’s height and weight, triceps skin fold, upper arm circumference, serum protein levels and nitrogen balance. Obesity greatly increases the risk and severity of complications associated with surgery.
- Fluid and Electrolyte Imbalance – Dehydration, hypovolemia and electrolyte imbalances should be carefully assessed and documented.
- Drug and alcohol use – the acutely intoxicated person is susceptible to injury.
- Respiratory status – patients with pre-existing pulmonary problems are evaluated by means pulmonary function studies and blood gas analysis to note the extent of respiratory insufficiency. The goal for potential surgical patient us to have an optimum respiratory function. Surgery is usually contraindicated for a patient who has a respiratory infection.
- Cardiovascular status – cardiovascular diseases increases the risk of complications. Depending on the severity of symptoms, surgery may be deferred until medical treatment can be instituted to improve the patient’s condition.
- Hepatic and renal function – surgery is contraindicated in patients with acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems. Any disorder of the liver on the other hand, can have an effect on how an anesthetic is metabolized.
- Endocrine function – diabetes, corticosteroid intake, amount of insulin administered
- Immunologic function – existence of allergies, previous allergic reactions, sensitivities to certain medications, past adverse reactions to certain drugs, immunosuppression
- Previous medication therapy – It is essential that the patient’s medication history be assessed by the nurse and anesthesiologist. The following are the medications that cause particular concern during the upcoming surgery:
- Adrenal corticosteroids – not to be discontinued abruptly before the surgery. Once discontinued suddenly, cardiovascular collapse may result for patients who are taking steroids for a long time. A bolus of steroid is then administered IV immediately before and after surgery.
- Diuretics – thiazide diuretics may cause excessive respiratory depression during the anesthesia administration.
- Phenothiazines – these medications may increase the hypotensive action of anesthetics.
- Antidepressants – MAOIs increase the hypotensive effects of anesthetics.
- Tranquilizers – medications such as barbiturates, diazepam and chlordiaxepoxide may cause an increase anxiety, tension and even seizures if withdrawn suddenly.
- Insulin – when a diabetic person is undergoing surgery, interaction between anesthetics and insulin must be considered.
- Antibiotics – “Mycin” drugs such as neomycin, kanamycin, and less frequently streptomycin may present problems when combined with curariform muscle relaxant. As a result nerve transmission is interrupted and apnea due to respiratory paralysis develops.
- Presence of trauma