Preoperative Care

Patient Education
Patient Education is a vital component of the surgical experience.
Preoperative patient education may be offered through conversation, discussion,
the use of audiovisual aids, demonstrations, and return demonstrations. It is
designed to help the patient understand the surgical experience to minimize and
promote full recovery from surgery and anesthesia. The educational program may
be initiated before hospitalization by the physician, nurse practitioner or office
nurse, or other designated personnel. This is a particularly important for patients
who are admitted the day of surgery or undergo outpatient surgical procedures.
The perioperative nurse can assess the patients knowledge base and use this
information in developing a plan for an uneventful perioperative course.

Teaching Strategies obtain a database

1. Determine what the patient already knows or wants to know. This can be
accomplished by reading the patients chart, by interviewing the patient and
by communicating with the health care provider, family, and other
members of the health team.
2. As certain patients psychosocial adjustment to impending surgery.
3. Determine cultural or religious beliefs and practices that may have an
impact on the patient’s surgical experience, such as refusal of blood
transfusions, burial of amputated limbs within 24 hours, or special healing
rituals.

Plan and Implement teaching Program

1. Begin at the patient’s level of understanding and proceed from there.

2. Plan a presentation, or series of presentations, for this individual patient or
a group of patients.
3. Include family members and significant others in the teaching process.
4. Encourage active participation of patients in their care and recovery.
5. Demonstrate essential techniques; provide opportunity for patient practice
and return demonstration.
6. Provide time for and encourage patient to ask questions and express
concerns; make every effort to answer all questions truthfully and in basic
agreement with the overall therapeutic plan.
7. Provide general information and assess the patients level of interest in or
reaction to it.
a. explain details of preoperative preparation and provide tour of area and
view of equipment when possible.
b. Offer general information on the surgery
c. Tell when surgery is scheduled and approximately how long it will take;
explain that afterward the patient will go to recovery room.
d. Let patient know that family will be kept informed and that they will be
told where to wait and when they can see patient; note visiting hours.
e. Explain how a procedure or a test may feel during or after.
f. Describe the recovery room; what personnel and equipment the patient
may expect to see and hear.
g. Stress the importance of active participation in postoperative recovery.
8. Use other resource people; health care providers, therapists, chaplain,
interpreters.
9. Document what has been taught or discussed, as well as the patient’s
reaction and level of understanding.
10. Discuss with patient anticipated postoperative course.

General Instructions

Preoperatively, the patient will be instructed in the following postoperative

activities. This will allow a chance for practice and familiarity.
Diaphragmatic Breathing

This is a mode of breathing in which the dome of the diaphragm is flattened

during inspiration, resulting in enlargement of the upper abdomen as air
rushes into the chest. During expiration, abdominal muscles and the
diaphragm relax. It is an effective relaxation technique.

Instruct the patient to:

1. Assume bed position similar to that most likely to be used

postoperatively(semi-fowler’s)
2. Place both hands over lower rib cage; make a loose fist and rest the flat
surface of the fingernails against the chest(to feel chest movement).
3. Exhale slowly and fully; rib will sink downward and inward toward midline.
4. Inhale slowly and deeply through mouth and nose; permit abdomen to rise
as lungs fill with air.
5. Hold this breath through count of 5.
6. Exhale and let all air out through mouth and nose.
7. Repeat 15 times with a brief rest after each group of five.
8. Practice this twice each day preoperatively.

Incentive Spirometry

Preoperatively, the patient uses a spirometer to measure deep breaths

(inspired air) while exerting maximum effort. The preoperative measurement
becomes the goal to be achieved as soon as possible after the operation.

1. Postoperatively, the patient is encouraged to use the incentive spirometer

about 10-12 times a hour.
2. Deep inhalations expand alveoli, which, in turn, prevents atelectasis and
other pulmonary complications.
3. There is less pain with inspiratory concentration than with expiratory
concentration, such as with coughing.
 Coughing

Coughing promotes the removal of chest secretions. Instruct the patient to:

1. Interlace the fingers and place the hands over the proposed incision site;
this will act as a splint during coughing and not harm the incision.
2. Lean forward slightly while sitting in bed.
3. Breathe, using the diaphragm as described under diaphragmatic breathing.
4. Inhale fully with the mouth slightly open.
5. Let out 3 or 4 sharp “hacks”.
6. Then, with mouth open, take in a deep breath and quickly give 1 or 2 strong
coughs.
7. Secretions should be readily cleared from the chest to prevent respiratory
complications (pneumonia, obstruction).
Note: certain position changes may be contraindicated after some surgeries
(e.g craniotomy)

Turning

Changing positions from back to side-lying(and vice versa)stimulates circulation,

encourages deeper breathing ,and relieves pressure areas.

1. Assist the patient to move onto side if assistance is needed.

2. Place the uppermost leg in a more flexed position than that of the lower leg
and place a pillow comfortably between the legs.
3. Ensure that the patient is turned from one side to back and onto the other
side every 2 hours.

Foot and Leg Exercises

Moving the legs improves circulation and muscle tone.

1. Have the patient lie on back; instruct patient to bend the knee and raise the
foot hold it a few seconds, extend the leg , and lower it to the bed.
2. Repeat above about five times with one leg and then with the other.
Repeat the set five times every 3 to 5 hours.
3. Then have the patient lie on side; exercise the legs by pretending to pedal a
bicycle.
4. Suggest the following foot exercise: Trace a complete circle with the great
toe.

Evaluation of Teaching Program

1. Observe patient for correct demonstration of expected postoperative
behaviors, such as foot and leg exercises and special breathing techniques.
2. Ask pertinent questions to determine patient’s level of understanding.
3. Reinforce information when necessary.

Preparation of the Operative Area

Skin
1. Human skin normally harbors transient and resident bacterial flora, some
of which are pathogenic.
2. Skin cannot be sterilized without destroying skin cells.
3. Friction enhances the action of detergent antiseptics; however, friction
should not be applied over a superficial malignancy (causes plaque
dislodgement and emboli).
4. It is ideal for the patient to bathe or shower , using a bacteriostatic soap
(eg, Hibiclens ), on the day of surgery. The surgical schedule may require
that the shower be taken the night before.
5. The Centers for Disease Control and Prevention recommend that hair not
be removed near the operative site unless it will interfere with surgery.
Skin is easily injured during shaving and often results in higher rate of
postoperative wound infection.
6. If requested, shaving should be performed as close to the operative time
possible. The longer the interval between the shave and operation, the
higher the incidence of postoperative wound infection.
a. Use of electric clippers is preferable. Hair should be removed within 1 to
2 mm of the skin to avoid skin abrasion. Thorough cleaning of the
clippers, after use is essential.
 A sharp disposable razor, with a recessed blade, may be used as long as
“wet shave” is done. It is important that the shave be done in the
direction of hair growth.
b. Depilatory creams (hair-removing chemicals) offer the advantage of
eliminating possible abrasions and cuts and producing clean, smooth,
intact skin. Many patients even find this form of skin preparation
relaxing. The depilatory creams may cause transient skin reactions in
some patients, especially when use near the rectal and scrotal areas.
c. Scissors may be used to remove hair greater than 3 mm in length.
7. For head surgery , obtain specific instructions from the surgeon concerning
the extent of shaving.

Gastrointestinal Tract
1. Preparation of the bowel is imperative for intestinal surgery because
escaping bacteria can invade adjacent tissues and cause sepsis.
a. Cathartics and enemas remove gross collections of stool.
b. Oral antimicrobial agents(eg. Neomycin, erythromycin) suppress the
colon’s potent microflora.
c. Enemas “until clear” are prescribed the evening of elective surgery. No
more than 3 enemas should be given because of negative effects on
fluid and electrolytes balance.
2. Solid food is withheld from the patient for 6 hours before surgery. Patient
having morning surgery are kept NPO overnight. Clear fluids(water) may be
given up to 4 hours before surgery if ordered, to help the patient swallow
medications.

Genitourinary Tract
A medicated douche may be prescribed preoperatively if the patient is to
have a gynecologic or neurologic operation.
 Preoperative Medication
With the increase of ambulatory surgery and same-day admissions,
preanesthetic medications, skin preps, and douches are seldom ordered.
However, medication may be prescribed preoperatively to facilitate the following
goals:

1. To facilitate the administration of any anesthetic.

2. To minimize respiratory tract secretions and changes in heart rate.
3. To relax the patient and reduce anxiety.

Types:

1. Opiates-such as morphine (roxanol)and meperidine(Demerol) are given to

relax the patient and potentiate anesthesia.
2. Anticholinergics-such as atrophine, scopolamine, and
gycopyrrolate(Robinul) are given primarily to reduce respiratory tract
secretions and to prevent severe reflex slowing of the heart during
anesthesia. Typically given in conjunction with an opiate less than an hour
before the patient’s trip to the operating room.
3. Barbiturates/tranquilizers-such as pentobarbital(Nembutal) and other
hypnotic agents are given the night before the surgery to help ensure a
restful night’s sleep. It is important to note that reassurance from the
nurse, anesthesiologist, and health care provider can do much to alleviate
the patient’s anxiety and insomnia.
4. Prophylactic antibiotics-are administered just before or during surgery
when bacterial contamination is expected; ideally before skin incision is
made.

Administering “On Call” Medications

1. Have medication ready and administer as soon as call is received from the
operating room.
2. Proceed with remaining preparations activities.
 3. Indicate on the chart or preoperative checklist the time when medication
was administered and by whom.

Admitting the Patient to surgery

Final checklist

The preoperative checklist is the last procedure before taking the patient to
the operating room. Most facilities have a standard form for this check.

Identification and Verification

This includes verbal identification by the perioperative nurse while checking

the identification band on the patient’s wrist and written
documentation(eg. Chart) of the patients identity, the procedure to be
performed, the specific surgical site (includes right or left), the surgeon, and
the type of anesthesia.

Review of Patient Record

Check for inclusion of the face sheet; allergies; history and physical;
completed preoperative checklist; laboratory values, including most recent
ones; ECG and chest X-rays, if necessary; preoperative medications; and
other preoperative orders by either the surgeon or anesthesiologist.

Consent Form

All nurses involved with patient care in the preoperative settings should be
aware of the individual state laws regarding informed consent and the
specific hospital policy. Obtaining informed consent is the responsibility of
the surgeon performing the specific procedure. Consent forms should
contain the stated procedure, the various risks, and alternatives to surgery,
if any. It is a nursing responsibility to make sure consent form has been
obtained and is in chart.
Patient Preparedness

1. NPO status
2. Proper attire(gown)
3. Skin preparation, if ordered
4. IV started with correct gauge needle
5. Dentures or plates removed
6. Jewelry, contact lenses, glasses removed and secured in locked area
given to family member.
7. Allow patient to void.

Transporting Patient to the Operating room

1. Adhere to the principle of maintaining the comfort and safety of the

patient.
2. Accompany operating room attendants to patient’s bedside for
introduction and proper identification.
3. Assist in transferring the patient from bed to strectcher (unless bed goes
to operating floor).
4. Complete chart and preoperative checklist; include laboratory reports
and X-rays as required by hospital policy or health care provider’s
directive.
5. Recognize importance of coordinating team effort to ensure arrival of
the patient in the operating room at the proper time.

The Patient’s Family

1. Direct the patient’s family to the proper waiting room where magazines,
TV, and coffee may be available.
2. Tell the family that the surgeon will probably contact them there
immediately after surgery to inform them about the operation.
3. Acquaint the family with the fact that a long interval of waiting does not
mean the patient is in the operating room all the while; anesthesia
preparation and induction take time, after surgery the patient is taken
to the recovery room.
4. Tell the family what to expect postoperatively when they see the
patient-tubes; monitoring equipment; and blood transfusion, suctioning,
and oxygen equipment.

Virgen Milagrosa University Foundation

 College of Nursing

Martin Posadas Ave. San Carlos City, Pangasinan

Submitted by:

IV-C

1. Madrideo, Raquel
2. Nava, Melody
3. Olaco, Raymund
4. Paningbatan, Maroger
5. Polintan, Joe Laurence
6. Quinto, Vanessa
Submitted to:
Mrs. Gladiola Salih, RN
Clinical Instructor