CHAPTER 15. Preoperative Assessment
Kathleen P. Donohue and Susan M. Andrews
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. List three options available for conducting preoperative assessments and interviews.
2. Identify essential components of preadmission assessment.
3. Explain how the psychological and emotional assessment of a patient will help reduce anxiety on day of surgery.
4. Analyze the learning needs of ambulatory surgery patients.
I. TIMING OF PREOPERATIVE ASSESSMENT
A. Far enough in advance to ensure time for an appropriate evaluation
1. Obtain diagnostic testing and consultative services if needed.
2. Alter current medical regimen if necessary (e.g., anticoagulant therapy, glycemic control, hypertension).
3. Obtain equipment, supplies, and other items necessary for postoperative care.
4. Make arrangements in family schedule (home care, day care, transportation, etc.).
5. Prepare patient physically and emotionally for surgery.
B. Not too far in advance
1. Patient forgets preoperative instructions.
2. Diagnostic test results are outdated.
II. PURPOSE OF PREOPERATIVE ASSESSMENT AND PROGRAMS
A. Decrease potential delays and cancellations on day of surgery.
1. Provide for comprehensive assessments (nursing and anesthesia).
a. Potential problems identified and addressed before surgery
b. Nursing discharge plan
c. Complete systems review
d. Prior surgery, medical, and anesthesia history
e. American Society of Anesthesiologists (ASA) physical status identified
(1) ASA 1 or (P1): healthy patient
(2) ASA 2 or (P2): healthy patient with mild systemic disease
(a) Well-controlled chronic bronchitis
(b) Moderate obesity
(c) Diet-controlled diabetes mellitus
(d) Mild hypertension
(e) Old myocardial infarction (MI)
(3) ASA 3 or (P3): patients with severe systemic disease that limits activity but is not incapacitating
(a) Coronary artery disease with angina
(b) Type I diabetes mellitus
(c) Morbid obesity
(d) Moderate to severe pulmonary insufficiency
(4) ASA 4 or (P4): patients with severe systemic disease that is a constant threat to life
(a) Organic heart disease with marked cardiac insufficiency
(b) Persisting angina
(c) Intractable dysrhythmia
(d) Advanced pulmonary, renal, hepatic, or endocrine insufficiency
(5) ASA 5 or (P5): moribund patients who are not expected to survive without surgery
(a) Ruptured abdominal aortic aneurysm
(b) Major multi-system or cerebral trauma
(6) ASA 6 or (P6): patients declared brain dead whose organs are being harvested
(7) E: the E suffix denotes an emergency surgical procedure.
(8) Ambulatory surgery patients usually fall into the first three categories.
2. Provide for perioperative and perianesthesia teachings.
a. Physician and anesthesia providers are the chief source of information.
b. Preoperative nurse is the primary educator and teacher of the provided information.
c. Encourage patient and family to openly and honestly communicate their:
(1) Needs
(2) Emotions
(3) Concerns
d. Promote patient safety.
(1) Clear understanding of preoperative instructions
3. Provide patient and family opportunity for questions.
a. Clarify patient’s understanding of:
(1) Procedure
(2) Informed consent
(3) Anesthetic approach
(4) Goals/expected outcomes
(5) Personal responsibilities
(6) Comprehensive instructions
(a) Assist with understanding and compliance.
(b) Allow for preparation for transport and postoperative home needs.
(i) Caregiver
(ii) Practice techniques (e.g., emptying drains, dressing changes, crutch walking, injections, etc.)
(c) Physician follow-up care
4. Reduce patient anxiety.
a. Provide clear and concise explanations.
b. Inaccuracies or misinformation may cause fear.
(1) Induction of anesthesia smoother in calm persons
(2) Recovery enhanced when patient less stressed
c. Promote the wellness concept.
III. BENEFITS OF A PREOPERATIVE ASSESSMENT PROGRAM
A. Identify issues needing further work-up before admission to avoid costly delays and cancellations.
1. History and physical
a. Performed within 30 days of the scheduled surgery
b. Completed
c. Updated within 24 hours of surgery
2. Advance directive
a. Need to bring a copy on the day of surgery
b. Opportunity to convey patient’s decision about end of life care, if so desires
3. Identify needed laboratory, diagnostic testing, and/or additional work-ups.
4. Identify any postoperative care needs.
a. Supplies, prescriptions, medication teaching and demonstration (e.g., enoxaparin sodium [Lovenox])
b. Equipment for home use (crutches, walker, continuous passive motion, continuous positive airway pressure, etc.)
c. Arrange for home care services (visiting nurse, home care aide, etc.).
d. Transportation home if outpatient surgery
(1) Avoid unnecessary postoperative stays.
(2) Potential unsafe transportation plans
e. Responsible adult (18 years or older), especially for first 24 hours
B. Allows for preoperative diagnostic screening
1. Based on specific individualized clinical indicators or risk factors (Figure 15-1)
a. Age
b. Preexisting disease or illness
c. Surgical procedure being performed
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| FIGURE 15-1 ▪ Preadmission testing algorithm. |
C. Allows for identification of potential safety issues
1. Patient and family history
a. Malignant hyperthermia
b. Pseudocholinesterase deficiency
c. Allergies including latex allergy/sensitivity
(1) Notify operating room (OR) before of day of surgery.
d. Use of narcotics for chronic pain
e. Use of street drugs/herbals
f. History of postoperative/postdischarge nausea and vomiting (PONV/PDNV)
2. Mobility issues
3. Ability to care for self if lives alone
4. Quality and amount of caregiver assistance
5. Ability and willingness to comply with preoperative instructions
a. Fasting and nothing by mouth (NPO) requirements
b. Smoking cessation
c. Necessary preoperative preparations
D. Allows for medication review and education
1. Current medications reviewed
a. Medication reconciliation starts preoperatively.
b. Name, dose, frequency
c. Herbals, supplements and over-the-counter medications
(1) Ask about specific supplements used. Patients often do not consider these “medications.”
2. Preoperative medication instructions
a. Some medications may be stopped before surgery as determined by surgeon and/or anesthesia provider.
(1) Anticoagulant therapy and nonsteroidal anti-inflammatory drugs, aspirin
(a) How handled may be procedure or physician specific
(2) Aspirin can affect platelet adhesiveness for up to 7 days.
(3) Coumadin often discontinued 48 hours before surgery.
(a) Clotting studies done immediately before surgery
(b) Closely monitor patients receiving long-term therapy for signs of bleeding.
(4) Dipyridamole (Persantine) usually stopped 2 days before surgery
(5) Indomethacin, tricyclic antidepressants, phenothiazines, furosemide, and steroids can interfere with platelet function.
(6) Herbals and supplements
(a) Feverfew, garlic, ginger, ginkgo, ginseng, and vitamin E may increase bleeding, particularly in patients already taking anticoagulants.
(b) Ginseng may cause an increase in heart rate and blood pressure.
(c) Licorice, some mixture types may increase blood pressure.
(d) Goldenseal and vitamin E may exacerbate high blood pressure in people who already have hypertension.
3. Some medications may be held the day of surgery as determined by surgeon and/or anesthesia provider.
a. Diuretics, insulin, oral hypoglycemic medications, etc.
b. Monoamine oxidase inhibitor (MAOI) antidepressants
(1) Usually discontinued before anesthesia
(2) Interaction with anesthetic drugs can result in a release of epinephrine and dopamine.
4. Medications that may be taken the day of surgery as determined by surgeon and/or anesthesia provider
a. Cardiac, antihypertensive (may be held if contain diuretics)
b. Beta-blockers
c. Calcium channel blockers
d. Anticonvulsants
e. Chronic pain medications
E. Provide preoperative teaching.
1. Procedure-specific instructions in nonmedical jargon
a. Provide information in easy-to-understand language at the level of the patient’s understanding.
b. Reinforce verbal instructions with written handouts whenever possible.
c. Video aids for patients to take home are an excellent teaching reinforcement tool.
2. Need for compliance with preoperative instructions
a. Arrival time
b. Leave valuables at home.
c. Bring needed documents (medication list, advance directive, any paperwork from surgeon, picture identification, etc.).
d. Need for responsible adult, at least first 24 hours postoperative
e. Transportation
f. Diet, NPO, and smoking restrictions
(1) No gum or hard candy
(a) Increases stomach acid secretions
(2) Small amounts of clear liquids morning of surgery can reduce stomach acid secretions.
(3) Refrain from smoking for at least 8 hours or per facility policy.
(a) Reduces amount of carbon monoxide in blood
(b) Promotes better oxygenation during anesthesia
(c) Reduces upper airway irritation
(d) Reduces bronchospastic tendency
(e) Reduces gastric volumes
3. What type of clothing to wear
a. Front button-down shirt for eye cases, skirt or loose fitting pants for leg surgery, etc.
b. Refrain from wearing makeup, nail polish.
4. Need for surgical preoperative preparations (e.g., bowel prep, antiseptic shower, no shaving of operative site, etc.)
5. Review of preoperative and postoperative expectations
6. Importance of caregiver support
7. Postoperative pain management
F. Patient/family satisfaction
1. Convenient for patient
2. Informative
3. Allows patient and family to ask questions and express concerns
IV. TYPES OF PREOPERATIVE ASSESSMENTS AND PROGRAMS
A. Hospital or freestanding ambulatory surgery center in-person interview
1. Advantages
a. Formal program
b. May have nursing, anesthesia, other health care team and diagnostic testing at same time and place
c. Decreases delays and cancellations day of surgery
(1) Able to take corrective actions on recognized complications or problems
d. Allows patient and families the opportunity to see facility, meet staff, ask questions
e. Allows interviewer to assess patient’s level of understanding, apprehension, etc.
f. Able to identify potential issues (e.g., language, other communication barriers, physical disabilities that may affect preparation time day of surgery)
2. Disadvantages
a. Some patients precluded
(1) Time constraints
(2) Transportation issues
(3) Travel distance
(4) Physical limitations
(5) Emergent or add-on cases
b. Cost
(1) Staff
(2) Physical space
B. Surgeon or primary care provider (PCP) office in-person interview
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1. Advantages
a. Saves patient’s time
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