Learning Objectives
By the end of this section, you will be able to:
- Identify measures to improve preoperative safety
- Discuss preoperative care changes of a patient requiring emergency surgery
- Identify how to adjust preoperative care to meet the needs of special populations
As with any specialty in nursing, the preoperative nurse must be aware of special considerations. Preoperative nursing requires special attention to promote safety. Many surgeries may be done on an elective or preplanned basis. However, there are instances where there may be an urgent or emergency surgery. There are also instances that require extra care or accommodation. The preoperative nurse must be aware of these special considerations to effectively care for various patient populations undergoing a variety of surgery types.
National Patient Safety Goals
The National Patient Safety Goals aim to promote patient safety. When it comes to surgery, these goals include (The Joint Commission, 2022):
- Identifying patients correctly
- Improving staff communication
- Using medicines safely
- Using alarms safely
- Preventing infection
- Identifying patient safety risks
- Preventing mistakes in surgery
Many interventions that support these goals have been discussed. The preoperative nurse plays a major role in performing or verifying that the proper steps are taken to promote patient safety. For example, the nurse verifies the medication record and implements interventions that promote the prevention of blood clots and surgical site infections.
Link to Learning
The Joint Commission’s Hospital National Patient Safety Goals aim to improve patient safety. This outlines safety goals for surgery and how to meet those goals.
Emergency Surgery Cases
Most surgeries are planned; however, there are instances where an emergency arises, leaving little time for surgical preparation. For example, a patient with a gunshot or stab wound requires immediate surgical intervention. When situations like this arise, there is generally not a preadmission testing appointment, and time is limited. Therefore, the patient does not receive presurgical instructions. These instances require the preoperative nurse to obtain as thorough a history as possible from either the patient or family member to verify medical history, medications, and allergies to try to prevent complications. The preoperative nurse must communicate these findings to other members of the surgical team. A quick assessment should also be performed to identify any possible signs of injury when trauma cases present. In emergent cases, skin preparation is often done in the OR to prevent delay of getting the patient into the OR.
Special Populations
Surgery is not a “one size fits all” procedure. Considerations are required for special populations like older adults, bariatric patients, and patients with disabilities. The preoperative nurse should remain knowledgeable of special populations to promote safety across each phase of surgery. The nurse should strive to be a lifelong learner and seek out opportunities for professional development related to their desired nursing specialty. The National League for Nurses (NLN), the American Nurses Association (ANA), and the Association of Operating Room Nurses (AORN) are a few examples of recognized organizations within the field of surgical nursing. Each hosts webinars, training, and workshops across the nation allowing OR nurses to remain up to date with best practice standards.
Older Adults
The older adult population is considered special because they have unique needs and require knowledge of the requirements to provide tailored care. People 65 and older not only have age-related changes that can impact the surgical process, but often they present multiple comorbidities that can impact surgical recovery outcomes. When a person reaches an advanced age, the organ systems tend to have lower reserves for recovery and may take longer to “bounce back” to the patient’s baseline after surgery. Cardiac and respiratory complications are common causes of postoperative morbidity and mortality in older adults. The prevalence or incidence of an illness within a population is called morbidity. The death of a population measured and expressed as a ratio is called its mortality. Changes in kidney function, body composition, and gastrointestinal physiology lead to variations correlated with pharmacokinetics and pharmacodynamics of most drugs (Maanen et al., 2020). This means that the older adult does not recover as quickly as the younger adult and metabolizes anesthetic agents and pain medications more slowly or are generally more sensitive to those drugs.
Advancing age is also associated with skin changes like dry, itchy skin that is more fragile. This requires careful precautions when moving older adults from one bed to another. Older adults are also more likely to experience temperature changes due to a reduction in adipose tissue. Maintaining as warm an environment as possible, applying a warming blanket or temperature monitoring system, if available, and asking if the patient feels warm enough are appropriate interventions. The patient’s subjective report of temperature may not reflect their actual body temperature; therefore, the nurse will also need to continue to monitor temperature to ensure not just comfort, but safety. Patients with decreased body temperatures are at risk for surgical site infections, blood loss, altered medication metabolism, increased pain, and cardiac arrythmias (Brooks & Bosserman, 2022).
Life-Stage Context
Older Adults and Surgical Procedures
Older adult patients are more at risk for surgical complications than younger adults. Therefore, the preoperative nurse must ensure they have performed a comprehensive preoperative exam. Postoperative and post-anesthesia care must also be thorough and skillful to promote optimal patient outcomes (Salzman et al., 2022). Postoperative care must also focus on effective communication to educate the patient about postsurgical care and pain management. Older adults may need more time to cover the education with multiple explanations to appropriately understand the information (Kumar et al., 2021).
Bariatric Patients
This special patient population requires meticulous care as there are a number of complications that may arise with surgery as shown in Table 25.2 (Rakhlin, n.d.).
| Possible Complication | Reasoning |
|---|---|
| Surgical site infections or delayed wound healing | Reduced blood flow to the area; diabetes or uncontrolled blood glucose; malnutrition |
| Blood clots | Higher amounts of estrogen in the body; more difficult to ambulate after surgery |
| Hypoventilation, atelectasis, pneumonia, or other pulmonary complications | Shallow breathing in supine position; sleep apnea |
| Wound dehiscence or hernia | Increased tissue weight exerting forced on dependent tissue |
| Increased cardiac demand | 1 mile of capillaries must be created to perfuse 1 pound of excess weight; risk for poor oxygenation |
| Anesthesia complications | High blood pressure may affect perfusion; airway obstruction from excess fat; high cholesterol and lipid metabolism may alter anesthesia effects (Ramírez-Reyes-Reyes et al., 2021; Seyni-Boureima et al., 2022) |
If a patient with obesity also smokes, they are at an increased risk of wound infections due to the reduction of oxygen available to the tissues. Excess adipose tissue can lead to impaired circulation. Decreased oxygenation and reduced circulation are directly related to impaired healing. Reduced oxygenation can cause impaired immune function (de Frel et al., 2020). Due to the potential complications associated with surgery, the preoperative nurse will want to ensure a thorough and accurate assessment has been obtained.
Pregnant Patients
Pregnant patients may need surgery that is related or unrelated to their pregnancy. In either case, the health and safety of both the patient and the fetus are addressed during preoperative care. Even if the patient is having a non-obstetric procedure, their pregnancy care provider will be an important collaborator during planning.
While a pregnant patient will receive much of the same preoperative care, counseling, and education as a non-pregnant patient, they will likely have some specific concerns about the well-being of the fetus that the nurse will need to address. For example, a patient may worry that the anesthesia during the surgery could harm the fetus, or that the procedure itself could be harmful. The nurse will want to address the patient’s concerns fully and make sure they understand the risks and benefits of having the procedure.
While an elective procedure can often be postponed until after delivery, surgery cannot always be delayed. In the case when a procedure is medically necessary for a pregnant patient, coordination between care team members is key to ensuring the health and safety of both the patient and the fetus. This involves close monitoring of both the mother and baby and taking proactive steps to prevent complications like preterm labor and thrombosis. Ideally, the procedure would be done at a facility with a neonatologist or pediatric specialist who can be present during the procedure (ACOG, 2022).
Patients with Disability
The preoperative nurse will care for patients with both physical and mental disabilities. The nurse may need to make accommodations for the use of any needed assistive devices, modify patient education, or ensure additional assistance is available to aid with transferring or positioning. The preoperative nurse should verify the needs of the patient, as well as document what type of assistive devices the patient brought with them to the facility and where those items were placed prior to surgery. This allows the postoperative personnel to ensure the patient receives their belongings after surgery.
Patients with mental disabilities may be accompanied by a caretaker or advocate who can help facilitate clear communication. While the person overseeing their care does need to be made aware of the details, that does not mean a patient with a mental disability can simply be “talked over” or ignored during the preoperative assessment. A patient’s capacity to fully understand the reasons for the procedure and what will happen during it will depend on their intellectual function, so the nurse will need to meet the patient where they are in terms of understanding. The education should be aligned with the patient’s level of comprehension, and other forms of media (such as graphics or videos) may also be helpful.
Generally, patients are asked to move from the stretcher to the operating room bed at the start of the surgery and back after the surgery. Patients that are either unable to hear or understand instructions or unable to move independently will require assistance in the operating room. Therefore, it is important that the preoperative nurse communicate those needs to the intraoperative nurse when transferring care.
Cultural Considerations
Cultural considerations the preoperative nurse must consider include but are not limited to language, eye contact, gender, touch, and spirituality. Patients who speak and understand another language require a medically trained interpreter for consent and education. Materials should be provided in the language that the patient reads and understands. The medical protocols seen as common to some are not allowed in certain cultures or communities. For example, the administration of blood products is not allowed in the Jehovah’s Witnesses community (Cummins & Nicoli, 2018).
Other cultures may have preferences when it comes to gender. For example, some Chinese cultures view the husband’s role as protector of his wife. The husband may answer questions on behalf of his wife, or act as a buffer to provide protection (Badanta et al., 2022). Another example is touch. Touching a person can be a sign of comfort or compassion to some people, while others may consider touch to be greatly offensive or inappropriate. Providing culturally competent care means the nurse should ask the patient and their family what their preferences are regarding care.