Laboratory tests and diagnostic imaging

Testing before surgery depends on the institution’s policies, the physician’s directives, and the patient’s condition. Follow standing orders in completing this overall process. Laboratory tests commonly reviewed before surgery include a urinalysis; a complete blood count; and a blood chemistry profile to assess endocrine, hepatic, renal, and cardiovascular functions. Serum electrolytes are evaluated if extensive surgery is planned or the patient has associated problems. One essential electrolyte examined is potassium; if not enough potassium is available, dysrhythmias can occur during anesthesia and the patient’s recovery may be delayed by general muscle weakness. A chest x-ray evaluation and electrocardiogram are used to identify disease processes or existing respiratory or cardiac damage. Additional tests are conducted to assess the organ involved in surgery. Blood chemistry profile (lactate dehydrogenase, γ-glutamyltransferase, alkaline phosphatase, total bilirubin) and urine bilirubin levels are used to assess hepatic function.

Informed consent

The Patient’s Bill of Rights affirms that patients must give informed consent (permission to perform a specific test or procedure) before the beginning of any procedure. In signing the consent form, the patient must be competent and agrees to have the procedure that is stated on the form. Information must be clear, the risks explained, expected benefits identified, and consequences or alternatives for the presenting problem stated. Witnesses are required to meet the state’s legal requirements. A witness only verifies that this is the person who signed the consent and that it was a voluntary consent. The witness (often a nurse) does not verify that the patient understands the procedure. Ideally, the surgeon discusses the surgical procedure with the patient in advance. In some institutions, the surgical consent is completed in the physician’s office or in the admissions department before the patient is admitted to the unit. Informed consent should not be obtained if the patient is disoriented, unconscious, mentally incompetent, or, in some agencies, under the influence of sedatives. Know agency policy (see Chapter 2, Figure 2-1 in Foundations of Nursing).

If the patient does not see or hear well, allow additional time to explain the surgery. For patients who do not understand English or are deaf, an interpreter may be necessary. Never coerce a patient into signing a consent that he or she does not understand or that contains information different from that originally given. If necessary, contact the physician and indicate that the patient does not understand the procedure.

In an emergency, the patient may not be able to give consent for surgery. Every effort is made to locate family members to assume this responsibility. Occasionally telephone permission may be obtained. Hospitals have standard guidelines for obtaining verbal consent. If the patient’s life is in danger and family members cannot be located, the surgeon may legally perform surgery. If family members object to surgery that the physician believes is essential, a court order may be obtained for the procedure. This practice is used only in extreme circumstances, however (e.g., when a child’s life is in danger). Know agency policy.

Gastrointestinal preparation

At midnight before surgery, the patient is usually placed on nothing by mouth (NPO) status; this ensures the GI tract is empty when the patient is anesthetized, thereby decreasing the chance of vomiting or aspirating emesis after surgery. An NPO sign is posted over the patient’s bed, and all fluids are removed from the room. Reinforce with both the patient and the family the importance of not ingesting foods or fluids. If the patient fails to comply with the NPO order, notify the physician. An order for NPO after midnight should apply to solid foods for patients scheduled for surgery in the morning. An early light breakfast is allowed for afternoon procedures. Clear liquid may be taken up to 3 hours before surgery.

Patients can have oral care while NPO, but caution them not to swallow fluids used. A wet cloth on the lips helps relieve dryness. If patients need to be hydrated or require special IV medications, the physician may order parenteral fluids or medication. Depending on the surgery, many patients resume foods and fluids the same day after surgery.

Because anesthesia relaxes the bowel, a bowel cleanser may be ordered to evacuate fecal material and lessen postoperative GI problems (nausea and vomiting). A cleansing enema or a general laxative is frequently used. A GI lavage solution, GoLYTELY (an isosmotic solution), rapidly evacuates the bowel. GoLYTELY is contraindicated, however, in patients with GI obstruction, gastric retention, bowel perforation, toxic colitis, or megacolon. If a bowel preparation is used, chart the type of preparation used, the patient’s tolerance to the procedure, and results. Before bowel surgery, medication (neomycin, sulfonamides, erythromycin) may be given over a period of days to detoxify and sterilize the GI tract. This lessens the chance of fecal contamination during surgery.

Skin preparation

There is debate about the best method to remove hair. A lower rate of infection occurs with either no shave or use of electric clippers than with any other method. Use of a depilatory agent (a substance or procedure that removes hair) also has a low wound infection rate. In some cases, the patient showers after hair removal, unless contraindicated, using an antiseptic soap such as Hibiclens. If the surgical procedure involves the head, neck, or upper chest area, the patient also shampoos the hair.

If shaving is used, it should be performed close to the actual time of the surgical procedure to decrease the time for growth of bacteria and lower the potential for infection. Some surgical departments prepare the patient either in a surgical holding room or in the OR itself. Each agency or facility should have policies and protocols regarding the timing, the method, and the people responsible for the preoperative skin preparation of surgical patients.

Once the patient is in the OR, scrub the skin thoroughly with a detergent solution and then apply an antiseptic solution to kill more adherent and deeper-residing bacteria. The surgeon may place a transparent sterile drape directly over the skin before making an incision.

Latex allergy considerations

Focused assessment of risk factors helps identify patients with the nursing diagnosis of risk for latex allergy response. Assessing the patient’s experience helps identify those at risk for a systemic reaction; for example, patients may relate stories of complicated anesthesia events, hives from blowing up a balloon, or severe swelling of the labia with a urinary catheterization.

With the advent of Universal Precautions (now called Standard Precautions) in the late 1980s, the use of latex gloves dramatically increased, and latex allergies became much more common. Basically, every health care worker wears gloves. Most gloves are powdered to make them easier to put on. The powder absorbs protein allergens from the latex and deposits them on skin and into surgical wounds; it also aerosolizes the protein allergens. Aerosolized latex allergens are carried in ventilation systems, requiring further preventive measures.

Latex allergy is classified in three categories: irritant reaction and types IV and I allergic reactions. The irritant reaction, which is most commonly seen, is actually a nonallergic reaction. The type IV allergic reaction to latex is a cell-mediated response to the chemical irritants found in latex products. The true latex allergy is the type I allergic reaction, and it occurs shortly after exposure to the proteins in latex rubber. The type I reaction is an immunoglobulin E–mediated systemic reaction that occurs when latex proteins are touched, inhaled, or ingested.

To provide a latex-safe environment for susceptible patients, all surgical patients should be screened for the risk for latex allergy response before admission. Identification of patients at risk is the first step in preventing a reaction.

Respiratory preparation

If a general anesthetic is administered, it is essential to ventilate the lungs postoperatively to prevent or treat atelectasis, improve lung expansion, improve oxygenation, and prevent postoperative pneumonia. Because the lungs do not expand fully during surgery, mucus and gases remain in the lungs until expelled. Pulmonary exercises can assist in expanding the lungs and removing these by-products. Preoperative introduction to the use of the incentive spirometer is of great value to the patient.