Suffix	Meaning	Example
-ectomy	Excision or removal of	Appendectomy
-lysis	Destruction of	Electrolysis
-orrhaphy	Repair or suture of	Herniorrhaphy
-oscopy	Looking into	Endoscopy
-ostomy	Creation of opening into	Colostomy
-otomy	Cutting into or incision of	Tracheotomy
-plasty	Repair or reconstruction of	Mammoplasty

Surgical Settings

Surgery may be a carefully planned event (elective surgery) or may arise with unexpected urgency (emergency surgery). Both elective and emergency surgery may be performed in a variety of settings. The setting in which a surgical procedure may be safely and effectively performed is influenced by the type of surgery, potential complications, and the patient’s general health status.

For inpatient surgery, patients who are going to be admitted to the hospital are usually admitted on the day of surgery (same-day admission). Patients who are in the hospital before surgery are usually there because of acute or chronic medical conditions.

The majority of surgical procedures are performed as ambulatory surgery (also called same-day or outpatient surgery). Many of these surgeries use minimally invasive techniques (e.g., laparoscopic techniques). (The surgeries are described in chapters throughout the text in discussions of interventions for specific problems.) Ambulatory surgery may be conducted in endoscopy clinics, physicians’ offices, freestanding surgical clinics, and outpatient surgery units in hospitals. These procedures can be performed using general, regional, or local anesthetic; have an operating time of less than 2 hours; and require less than a 24-hour stay postoperatively. Many patients go home with a caregiver within hours of surgery.

Ambulatory surgery is often preferred by patients and physicians. Generally, it involves minimal laboratory tests, requires fewer preoperative and postoperative medications, and reduces the patient’s risk for health care–associated infections. Patients like the convenience of recovering at home, physicians prefer the flexibility in scheduling, and the cost is usually less for both the patient and the insurer.

Regardless of where the surgery is performed, you play an essential role in preparing the patient for surgery, caring for the patient during surgery, and facilitating the patient’s recovery after surgery. To perform these functions effectively, first know the nature of the disorder requiring surgery and any coexisting medical problems. Second, identify the individual patient’s response to the stress of surgery. Third, know the results of appropriate preoperative diagnostic tests. Finally, identify potential risks and complications associated with the surgical procedure and any coexisting medical problems that should be included in the plan of care. The nurse caring for the patient preoperatively is likely to be different from the nurse in the operating room (OR), postanesthesia care unit (PACU), surgical intensive care unit (SICU), or surgical unit. Thus communication and documentation of important preoperative assessment findings are essential for the continuity of care.

Patient Interview

One of the most important nursing actions is the preoperative interview. The nurse who works in the physician’s office, the ambulatory surgery center, or the hospital preoperative area may do the interview. The site of the interview and the time before surgery dictate the depth and completeness of the interview. Important findings must be documented and communicated to others to maintain continuity of care.

The preoperative interview can occur in advance or on the day of surgery. The primary purposes of the patient interview are to (1) obtain the patient’s health information; (2) provide and clarify information about the planned surgery, including anesthesia; and (3) assess the patient’s emotional state and readiness for surgery, including his or her expectations about the surgical outcomes. Ensure that the patient’s consent form for surgery has been signed and witnessed and that the appropriate laboratory and diagnostic tests have been ordered or completed.

The interview also provides the patient and the caregiver an opportunity to ask questions about surgery, anesthesia, and postoperative care. Often patients ask about taking their routine medications, such as insulin, anticoagulants, or cardiac medications, and if they will experience pain. By being aware of the patient’s and caregiver’s needs, you can provide the information and support needed during the perioperative period.

Nursing Assessment of Preoperative Patient

The overall goal of the preoperative assessment is to identify risk factors and plan care to ensure patient safety throughout the surgical experience. Goals of the assessment are to

• Determine the patient’s psychologic status in order to reinforce the use of coping strategies during the surgical experience.

• Determine physiologic factors directly or indirectly related to the surgical procedure that may contribute to operative risk factors.

• Establish baseline data for comparison in the intraoperative and postoperative period.

• Participate in the identification and documentation of the surgical site and/or side (of body) on which the surgical procedure will be performed.

• Identify prescription drugs, over-the-counter medications, and herbal supplements taken by the patient that may result in drug interactions affecting the surgical outcome.

• Document the results of all preoperative laboratory and diagnostic tests in the patient’s record, and communicate this information to appropriate health care providers.

• Identify cultural and ethnic factors that may affect the surgical experience.

• Determine if the patient has received adequate information from the surgeon to make an informed decision to have surgery and that the consent form is signed and witnessed.

Subjective Data

Psychosocial Assessment.

Surgery is a stressful event, even when the procedure is considered minor. The psychologic and physiologic reactions to surgery and anesthesia may elicit the stress response (e.g., elevated blood pressure [BP] and heart rate). The stress response enables the body to prepare to meet the demands in the perioperative period. If stressors or the responses to the stressors are excessive, the stress response can be magnified and may affect recovery. Many factors influence the patient’s susceptibility to stress, including age, past experiences with illness and pain, current health, and socioeconomic status. Identifying a patient’s perceived or actual stressors allows you to provide support during the preoperative period so that stress does not become distress.

The use of common language and avoidance of medical jargon are essential. Use words and language that are familiar to the patient to increase the patient’s understanding of surgical consent and the surgery. Familiar language also helps reduce preoperative anxiety.

Your role in psychologically preparing the patient for surgery is to assess the patient for potential stressors that could negatively affect surgery (Table 18-2). Communicate all concerns to the appropriate surgical team member, especially if the concern requires intervention later in the surgical experience. Because many patients are admitted directly into the preoperative area from their homes, you must be skilled in assessing important psychologic factors in a short time. The most common psychologic factors are anxiety, fear, and hope.

TABLE 18-2

PSYCHOSOCIAL ASSESSMENT OF PREOPERATIVE PATIENT

Situational Changes

• Identify support systems, including family, other caregivers, group and institutional structures, and religious and spiritual groups.

• Define current degree of personal control, decision making, and independence.

• Consider the impact of surgery and hospitalization and the possible effects on lifestyle.

• Determine the presence of hope and anticipation of positive results.

Concerns With the Unknown

• Identify specific areas and degree of anxiety and fears related to the surgery (e.g., pain).

• Identify expectations of surgery, changes in current health status, effects on daily living, and sexual activity (if appropriate).

Concerns With Body Image

• Identify current roles or relationships and view of self.

• Determine perceived or potential changes in roles or relationships and their impact on body image.

Past Experiences

• Review previous surgical experiences, hospitalizations, and treatments.

• Determine responses to those experiences (positive and negative).

• Identify current perceptions of surgical procedure in relation to the above and information from others (e.g., a friend’s view of a personal surgical experience).

Knowledge Deficit

• Identify the amount and type of preoperative information the patient wants.

• Assess understanding of the surgical procedure, including preparation, care, interventions, preoperative activities, restrictions, and expected outcomes.

• Identify the accuracy of information the patient has received from others, including health care team, family, friends, and the media.

Anxiety.

Most people are anxious when facing surgery because of the unknown. This is normal and is an inborn survival mechanism. However, if the anxiety level is high, cognition, decision making, and coping abilities are reduced.

Anxiety can arise from lack of knowledge, which may range from not knowing what to expect during surgery to uncertainty about the outcome. This may be a result of past experiences or stories heard through friends or the media. You can decrease some anxiety for the patient by providing information about what to expect. This is often done through classes, or web-based or audiovisual educational materials before surgery. Inform the surgeon if the patient requires any additional information or if anxiety is excessive.

The patient may experience anxiety when surgery is in conflict with his or her religious and cultural beliefs. In particular, identify, document, and communicate the patient’s religious and cultural beliefs about the possibility of blood transfusions. For example, Jehovah’s Witnesses may choose to refuse blood or blood products.¹

Common Fears.

Patients fear surgery for a number of reasons. The most common fear is the risk of death or permanent disability resulting from surgery. Sometimes the fear arises after hearing or reading about the risks during the informed consent process. Other fears are related to pain, change in body image, or results of diagnostic procedures.

Fear of death can be extremely harmful. Notify the physician if the patient has a strong fear of death. A patient’s strong fear of impending death may prompt the physician to delay the surgery until the situation improves because the emotional state influences the stress response, and thus the surgical outcome.

Fear of pain and discomfort during and after surgery is common. If the fear is extreme, notify the ACP or the surgeon. Reassure the patient that drugs are available for both anesthesia and analgesia during surgery. For pain after surgery, tell patients to ask for pain medication before pain becomes severe. Instruct the patient on the use of a pain intensity scale (e.g., 0 to 10, FACES [see eFig. 9-3, available on the website for Chapter 9]). (Pain scales are explained in Chapter 9.)

Drugs may also be given that provide an amnesic effect so the patient will not remember what occurs during surgery. Tell the patient that this effect assists in decreasing anxiety after surgery.

Fear of mutilation or alteration in body image can occur whether the surgery is radical, such as amputation, or minor, such as a bunion repair. Even a small scar on the body can be upsetting to some, and others fear keloid development (overgrowth of a scar). Listen to and assess the patient’s concern about this fear with an accepting attitude.

Fear of anesthesia may arise from the unknown, personal experience, or tales of others’ bad experiences. These concerns can also result from information about the risks (e.g., brain damage, paralysis) of anesthesia. Many patients fear losing control while under anesthesia. If these fears are identified, inform the ACP immediately so that he or she can talk further with the patient. Reassure the patient that a nurse and the ACP will be present at all times during surgery.

Fear of disruption of life functioning may be present in varying degrees. It can range from fear of permanent disability to concern about not being able to engage in activities of daily living for a few weeks. Concerns about loss of role function, separation from family, and how the family will manage may be revealed. Financial concerns may be related to an anticipated loss of income or the costs of surgery.

If you identify any of these fears, a consult with the patient’s caregiver, a social worker, a spiritual or cultural advisor, or a psychologist may be appropriate. Financial advisors at the hospital may be able to provide information about financial support.

Hope.

Although many psychologic factors related to surgery seem to be negative, hope is a positive attribute.² Hope may be the patient’s strongest method of coping. To deny or minimize hope may negate the positive mental attitude necessary for a quick and full recovery. Some surgeries are hopefully anticipated. These can be the surgeries that repair (e.g., plastic surgery for burn scars), rebuild (e.g., total joint replacement to reduce pain and improve function), or save and extend life (e.g., repair of aneurysm, organ transplant). Assess and support the presence of hope and the patient’s anticipation of positive results.

Past Health History.

Ask the patient about any previous medical problems and surgeries. Determine if the patient understands the need for surgery. For example, the patient scheduled for a total knee replacement may indicate that increasing pain and immobility are the reasons for the surgery.

Document the reason for any past hospitalizations, including previous surgeries and the dates. Also identify any problems with previous surgeries. For example, the patient may have experienced a wound infection or a reaction to a medication.

Ask women about their menstrual and obstetric history. This includes the date of their last menstrual period, the number of pregnancies, and any history of cesarean section.

When obtaining a family health history, ask both patient and caregiver about any inherited traits, since they may contribute to the surgical outcome. Record any family history of cardiac and endocrine diseases. For example, if a patient reports a parent with hypertension, sudden cardiac death, or myocardial infarction, this should alert you to the possibility that the patient may have a similar predisposition or condition. Also obtain information about the patient’s family history of adverse reactions to or problems with anesthesia. For example, malignant hyperthermia has a genetic predisposition. Measures to decrease complications associated with this condition can be taken. (For further information on malignant hyperthermia, see Chapter 19.)

Medications.

Document all current routine and intermittent medication use, including over-the-counter drugs and herbal supplements. In many ambulatory surgery centers, patients are asked to bring their medications with them when reporting for surgery. This helps to accurately assess and document both the name and the dosage of medications.

The interaction of the patient’s current medications and anesthetics can increase or decrease the desired physiologic effect of anesthetics. Consider the effects of opioids and prescribed medications for chronic health conditions (e.g., heart disease, hypertension, depression, epilepsy, diabetes mellitus). For example, certain antidepressants can potentiate the effect of opioids, agents that can be used for anesthesia. Antihypertensive drugs may predispose the patient to shock from the combined effect of the drug and the vasodilator effect of some anesthetic agents. Insulin or oral hypoglycemic agents may require dose or agent adjustments during the perioperative period because of increased body metabolism, decreased oral intake, stress, and anesthesia. Antiplatelet drugs (e.g., aspirin, clopidogrel [Plavix]) and nonsteroidal antiinflammatory drugs (NSAIDs) inhibit platelet aggregation and may contribute to postoperative bleeding. Surgeons may instruct patients to withhold these medications before surgery. Specific timeframes for withholding drugs depend on the drug and the patient. Patients on long-term anticoagulation therapy (e.g., warfarin [Coumadin]) present a unique challenge. The options for these patients include (1) continuing therapy, (2) withholding therapy for a time before and after surgery, or (3) withholding the therapy and starting subcutaneous or IV heparin therapy during the perioperative period. The management strategy selected is determined by patient characteristics and the nature of the surgery.³

Ask about the use of herbs and dietary supplements because their use is so common. Many patients do not think to include supplements in their list of medications. They believe that herbal and dietary supplements are “natural” and do not pose a surgical risk.⁴ (See the Complementary & Alternative Therapies box in Chapter 3 on p. 39 on how to assess for the use of herbal supplements.) Excessive use of vitamins and herbs can cause harmful effects in patients undergoing surgery. In patients taking anticoagulants or antiplatelets, herbal supplements can produce excessive postoperative bleeding that may require a return to the OR.⁵ The effects of specific herbs that are of concern during the perioperative period are listed below in the Complementary & Alternative Therapies box.

Complementary & Alternative Therapies

Herbal Products and Surgery

The following can be used as a guide for patient teaching:

• Notify your health care provider of all vitamins, herbal products, and dietary supplements that you are or have been taking.

• Avoid astragalus and ginseng, since they can increase blood pressure before and during surgery.

• Avoid garlic, vitamin E, ginkgo, and fish oils because they can increase bleeding.

• Avoid kava and valerian because they can cause excess sedation.

• In general, discontinue all herbal supplements 2 to 3 weeks before any surgical procedure. Consult your health care provider for specific instructions.

Helpful Herbs and Vitamins

• Ginger can be useful for preventing nausea associated with anesthesia. Consider ginger ale, crystallized ginger, or ginger tea.

• Arnica is a homeopathic remedy useful in soft tissue healing.

• Multivitamins can be taken until the day before surgery. Taking them on the day of surgery, on an empty stomach, may contribute to nausea and vomiting after surgery.

Also ask the patient about possible recreational drug use, abuse, and addiction. The substances most likely to be abused include tobacco, alcohol, opioids, marijuana, cocaine, and amphetamines. Ask questions about the use of these substances in a frank manner. Stress that recreational drug use may affect the type and amount of anesthesia that will be needed. When patients become aware of the potential interactions of these substances with anesthetics, most patients respond honestly about using them. Chronic alcohol use can place the patient at risk because of lung, gastrointestinal, or liver damage. When liver function is decreased, metabolism of anesthetic agents is prolonged, nutritional status is altered, and the potential for postoperative complications is increased. Alcohol withdrawal can also occur during lengthy surgery or in the postoperative period. Although this can be a life-threatening event, it can be avoided with appropriate planning and management (see Chapter 11).

Document and communicate all findings of the medication history to the perioperative health care team. The ACP will determine the appropriate schedule and dose of the patient’s routine medications before and after surgery. Ensure that all of the patient’s medications are identified, implement any changes in the medication plan, and monitor the patient for potential interactions and complications.

Preoperative assessment of the older person’s baseline cognitive function is especially crucial for intraoperative and postoperative evaluation.⁸ The older adult may have intact mental abilities preoperatively, but is more prone to adverse outcomes during and after surgery than the younger adult. This is due to the additional stressors of the surgical procedure, dehydration, hypothermia, and anesthesia and adjunctive medications. These factors may contribute to the development of emergence delirium (“waking up wild”), a condition that may be falsely labeled as senility or dementia. Thus preoperative findings are critical for postoperative comparison.