Interventions for Preoperative Clients Care

1. Interventions for Preoperative Clients Care

2. Perioperative Care Three Phases • Preoperative • Intraoperative • Postoperative Preoperative

3. 3 Miss Iman Shaweesh

5. PREOPERATIVE NURSING CARE • CONDUCT A NURSING ASSESSMENT • PROVIDE PREOPERATIVE TEACHING • PERFORM METHODS OF PHYSICAL PREPARATION • ADMINISTER MEDICATIONS • ASSIST WITH PSYCHOSOCIAL PREPARATION • COMPLETE THE SURGICAL CHECKLIST

6. SURGERY CHECKLIST

7. Purposes of Surgery • Diagnostic • Curative • Restorative • Palliative surgery, which makes the client more comfortable • Cosmetic surgery, which reconstructs the skin and underlying structures

8. Collaborative Management Assessment • History and data collection • Age • Drugs and substance use • Medical history, including cardiac and pulmonary histories • Previous surgery and anesthesia • Blood donations • Discharge planning

9. Physical Assessment/Clinical Manifestations • Obtain baseline vital signs. • Focus on problem areas identified by the client’s history on all body systems affected by the surgical procedure. • Report any abnormal assessment findings to the surgeon and to anesthesiology personnel.

10. System Assessment • Cardiovascular system • Respiratory system • Renal/urinary system • Neurologic system • Musculoskeletal system • Nutritional status • Psychosocial assessment

11. Laboratory Assessment • Urinalysis • Blood type and crossmatch • Complete blood count or hemoglobin level and hematocrit • Clotting studies • Electrolyte levels • Serum creatinine level • Pregnancy test • Chest x-ray examination • Electrocardiogram

12. Preparing the Client(Continued) • Leg procedures and exercises, antiembolism stockings and elastic wraps, early ambulation, and range-of-motion exercises

13. DEEP BREATHING, COUGHING, LEG EXERCISES • Deep breathing is a form of controlled ventilation that opens and fills small air passages in the lungs to prevent atelectasis and pneumonia. • Coughing is a natural method of clearing secretions from the airways. • Leg exercises help promote circulation and reduce the risk of forming a thrombus in the veins. • Antiembolism stockings help prevent thrombi and emboli by compressing superficial veins and capillaries redirecting blood to larger and deeper veins, where it flows more effectively toward the heart.

14. DEEP BREATHING & COUGHING

16. Pre-Operative EducationDiaphragmatic Breathing Exercises

17. Pre-Operative EducationSplinting Abdomen while Coughing

18. Spirometry

20. Use of preoperative spirometry to predicted PPCs Jacob 1997 Bando 1997 Kocabas 1996 Kroenke 1993 Kispert 1992 Swensson 1991 Fogh 1987 Appleberg 1974 Stein 1970 Collin 1968 1 2 4 6 8 0 10 12 14 16 Adapt from Smetana GW,et al. New Engl J Med 1999;340:937-944.

22. Preoperative Care of Pulmonary Patients: Example • Male 60 yrs. • Dx: NSCLC stage Ib , RUL • Underlying COPD • Assessment • Not urgent surgery, high benefit • Risk ; elderly, COPD • History / Physical examination • Laboratory

23. Spirometry of the patient Irreversible airway obstruction

24. Further evaluation • PPO-FEV1 Rt=0.45(45%) Lt=0.55(55%) RUL = 24.7% LL = 55% RLL= 20.3% RUL : RLL= 0.55: 0.45 Acceptable, See Mx PPO-FEV1=1.04(39%)

25. Many factors related to PPCs Working as a team plays major roles Assessment of the risks ,do appropriated testing and modifying are the keys of preoperative caring Preoperative Care of Pulmonary Patients

26. Recommendation for preoperative CXR • Age > 50 years • Known pre-existing cardiopulmonary diseases • S/S like hoods of cardiopulmonary disease Smetana GW, et al Med Clin N Am 2003

27. PFTs and PPCs • Case-control study, elective abdominal surgery: • CXR highly associated with PPCs (OR 5.8) • Abnormal PE associated with PPCs • Whereas PFTs were not predictive Lawrence VA, et al. Chest 1996;110:744-50.

28. PFT Diagram in Preoperative Evaluation PFT(FEV1,MVV,DLCO) FEV1 >2 L MVV >50% DLCO >60% FEV1 > 2 L MVV<50% DLCO <60% FEV1 <2 L High risk consider exercise test Cleared for any resection Perfusion Scanning PPO-FEV1 PPO-FEV1 >1.3 PPO-FEV1 >0.8, <1.3 PPO-FEV1 <0.8 High risk consider exercise test Cleared for any resection Consider “Lesser” resection Non surgical therapy

29. Preoperative PFTs : Summary • Thoracic surgery • Upper abdominal surgery with respiratory symptoms remain unexplained after careful evaluation • Routine PFTs should not ordered solely without clinical assessment

30. Risk indices for preoperative assessment Arozullah AM,et al. Med Clin N Am 2003

31. Preoperative smoking cessation and PPCs % Complication Prospective study 200 patients, CABG Warner MA,et al. Mayo Clin Proc 1989

32. Preoperative smoking cessation and PPCs % Complication Retrospective study 288 patients, pulmonary surgery Nakagawa M, et al Chest 2001;120:705-10

33. Examples of external pneumatic compressiondevices used to promote venous return and prevent deepvein thrombosis (DVT)

34. Kendall SCD machine, sleeves, andTED stockings.

35. Venodyne pneumatic compression system

36. Flowtron DVT calf garments

37. Anxiety Interventions • Preoperative teaching • Encouraging communication • Promoting rest • Using distraction • Teaching family and significant others

38. Preoperative Chart Review • Ensure all documentation, preoperative procedures, and orders are complete. • Check the surgical consent form and others for completeness. • Document allergies • Document height and weight.