Periop Lesson Plan

STATE COLLEGE OF NURSING, 107,CHANDER NAGAR,DEHRADUN

PRACTICE TEACHING Nursing Education on PRE-OPERATIVE PHASE Submitted to: Mrs. Asha Gangola Assistant propfessor SCON Dehradun, Uttarakhand

Submitted by: Rakhi Yadav M.Sc. Nursing [MSN] I year SCON Dehradun, Uttarakhand

Submitted on: / /2016

SUBJECT

:

NURSING EDUCATION

TOPIC

:

PRE-OPERATIVE PHASE

GROUP

:

B.Sc. NURSING 1stYear

PLACE

:

B.Sc. NURSING 1stYearCLASS ROOM

TIME

:

45 MIN

TEACHING METHOD

:

LECTURE CUM DISSCUSSION

INSTRUCTIONAL AIDS

:

DATE

:

BLACK BOARD, CHART, OVER HEAD PROJECTOR, POWER POINT PRESENTATION, VIDEOCLIP, LEAFLET

PREVIOUS KNOWLEDGE OF STUDENTS: THE STUDENT SHOULD KNOW ABOUT OERATION AND PRE OPERATION PREPARATION

GENERAL OBJECTIVE: At the end of the class student will acquire adequate knowledge regarding pre-operative phase, its principles, preparation done and nurses responsibility and apply this knowledge& skill in clinical practice and hospitals while handling any caring any patient who are going to have a surgery

SPECIFIC OBJECTIVE: At the end of the class student will be able to1. 2. 3. 4. 5.

Define preoperative phase List-out the goals of preoperative phase Describe purpose of preoperative phase Explain the various component of Pre-operative phase Discuss the nursing management of pre-operative phase

INTRODUCTION:

Surgery whether elective or emergent, is a stressful, complex event. The special field known as peri-operative and peri-anesthesia nursing includes a wide variety of nursing functions. It is the phase when the patient had decided for surgical intervention up to the time of transfer to the operating room.There is 3 phases of surgery that is pre-operative, intra-operative and postoperative. Preoperative care is the preparation and management of a patient prior to surgery. It includes both physical and psychological preparation. During the pre – operative phase, assessment is done in terms of age of the patient, by which young children and older adults are the most vulnerable to complications; the patient’s nutritional status, where in post op recovery usually relies; fluid and electrolyte status, because hydration is important to prevent hypovolemia during surgery; presence of infection and other health problems, since it can predispose the patient for sepsis and other unwanted conditions post operatively; the holistic bodily functions, clearance from cardio, respiratory, renal, neurologic, hematologic and other pertinent functions prior to procedure is really a routine to avoid life threatening situations during and after the surgical procedure; use of medications like anticoagulants, to prevent hemorrhagic complications; as well as health habits like smoking and sedentary lifestyle, in order to assess the possible needed health teachings suited for the patient. The preoperative phase can range from minutes to months. For a patient who has been diagnosed with a critical illness that must be corrected with surgery, the time from diagnosis to surgery may be measured in minutes. Those types of situations are usually caused by a traumatic injury or massive bleeding. For patients with a surgery planned in advance, the preoperative period may last for months. Some patients require extensive testing to determine whether they are able to tolerate the stresses of surgery and anesthesia Preoperative testing can range from having a few blood tests to having a full cardiac workup to determine if the heart is working properly.

S.NO

1.

Time

2 min

Specific objectives To define preoperative phase

Content



Teaching learning activity with AudioVisual Aids

Teacher activity: Preoperative care the psychologic and physiologic preparati Define preoperative on of a patient before an operation. The preoperative period phase with the help may be extremely short, as with an emergency operation, or of power point it may encompass several weeks during which diagnostics, presentation. specific medications and treatments, and measures to Learner activity: improve the patient's general wellbeing are employed in Students are preparation for surgery. listening and writing

DEFINITIONS:

Evaluation

Define preoperative phase?

Medical Dictionary



The Preoperative phase is the time period between the decision to have surgery and the beginning of the surgical procedure

Teacher activity: List-out the goals of preoperative phase Although the physician is responsible for explaining the surgical procedure to the patient, the patient may ask the nurse with the help of questions about the surgery. There may be specific learning power point needs about the surgery that the patient and support persons presentation and should know. A nursing care plan and a teaching plan should be OHP carried out. During this phase, emphasis is placed on: Learner activity:  Assessing and correcting physiological and psychological Students are writing GOALS OF PREOPERATIVE PHASE

2.

4 min

To list-out the goals of preoperative phase

  

problems that may increase surgical risk. Giving the patient and significant others complete learning and teaching guidelines regarding the surgery. Instructing and demonstrating exercises that will benefit the patient postoperatively. Planning for discharge and any projected changes in lifestyle due to the surgery.

Tell any 2 goals of pre-operative phase?

PURPOSE 3

4

4 min

20 min

To describe purpose of preoperative phase

To explain the various component of Pre-operative phase

Patients who are physically and psychologically prepared for surgery tend to have better surgical outcomes. Preoperative teaching meets the patient's need for information regarding the surgical experience, which in turn may alleviate most of his or her fears. Patients who are more knowledgeable about what to expect after surgery, and who have an opportunity to express their goals and opinions, often cope better with postoperative pain and decreased mobility. Preoperative care is extremely important prior to any invasive procedure, regardless of whether the procedure is minimally invasive or a form of major surgery. Preoperative teaching must be individualized for each patient. Some people want as much information as possible, while others prefer only minimal information because too much knowledge may increase their anxiety.

COMPONENTS OF CARE IN PREOPERATIVE PHASE 1. PHYSICAL PREPARATION: - It consists of : Complete medical history and physical exam, including the patient's surgical and anesthesia background. The patient should inform the physician and hospital staff if he or she has ever had an adverse reaction to anesthesia (such as anaphylactic shock), or if there is a family history of malignant hyperthermia.  Laboratory tests may include complete blood count, electrolytes, prothrombin time, activated partial thromboplastin time, and urinalysis. The patient will most likely have an electrocardiogram (EKG) if he or she has a history of cardiac disease, or is over 50 years of age.  A chest x ray is done if the patient has a history of respiratory disease.  Part of the preparation includes assessment for risk factors that might impair healing, such as nutritional deficiencies, steroid use, radiation or chemotherapy, drug or

Teacher activity: Describe purpose of preoperative phase with the help of power point presentation Learner activity: Students are writing

Teacher activity: Explain the various component of Preoperative phase with the help of power point presentation, videoclip , flashcard and chart Learner activity: Students are writing

Why preoperative phase is important prior to surgery?

What do you understand by Latex allergy?









alcohol abuse, or metabolic diseases such as diabetes. The patient should also provide a list of all medications, vitamins, and herbal or food supplements that he or she uses. Supplements are often overlooked, but may cause adverse effects when used with general anesthetics (e.g., St. John's wort, valerian root). Some supplements can prolong bleeding time (e.g., garlic, gingko biloba). Latex Allergy has become a public health concern. Latex is found in most sterile surgical gloves, and is a common component in other medical supplies including general anesthesia masks, tubing, and multi-dose medication vials. It is estimated that 1–6% of the general population and 8– 17% of health care workers have this allergy. Children with disabilities are particularly susceptible. This includes children with Spina bifida, congenital urological abnormalities, cerebral palsy, and Dandy-Walker syndrome. At least 50% of children with spina bifida are latex-sensitive as a result of early, frequent surgical exposure. There is currently no cure available for latex allergy, and research has found that the allergy accounts for up to 19% of all anaphylactic reactions during surgery. Latex-free gloves and supplies must be used for anyone with a documented latex allergy. Bowel clearance may be ordered if the patient is having surgery of the lower gastrointestinal tract. The patient should start the bowel preparation early the evening before surgery to prevent interrupted sleep during the night. Some patients may benefit from a sleeping pill the night before surgery. The night before surgery, skin preparation is often ordered, which can take the form of scrubbing with a special soap (i.e., Hibiclens), or possibly hair removal from the surgical area. Shaving hair is no longer recommended because studies show that this practice may increase the chance of infection. Instead, adhesive barrier drapes can contain hair growth on the skin around the incision. The following are the physiologic assessments necessary during the preoperative phase:

  



  





  

Age and Obtain a health history and perform a physical examination to establish vital signs and a database for future comparisons. Assess patient’s usual level of functioning and typical daily activities to assist in patient’s care and recovery or rehabilitation plans. Assess mouth for dental caries, dentures, and partial plates. Decayed teeth or dental prostheses may become dislodged during intubation for anesthetic delivery and occlude the airway. Nutritional status and needs – determined by measuring the patient’s height and weight, triceps skinfold, upper arm circumference, serum protein levels and nitrogen balance. Obesity greatly increases the risk and severity of complications associated with surgery. Fluid and Electrolyte Imbalance – Dehydration, hypovolemia and electrolyte imbalances should be carefully assessed and documented. Drug and alcohol use – the acutely intoxicated person is susceptible to injury. Respiratory statuses – patients with pre-existing pulmonary problems are evaluated by means pulmonary function studies and blood gas analysis to note the extent of respiratory insufficiency. Cardiovascular status – cardiovascular diseases increases the risk of complications. Depending on the severity of symptoms, surgery may be deferred until medical treatment can be instituted to improve the patient’s condition. Hepatic and renal function – surgery is contraindicated in patients with acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems. Any disorder of the liver on the other hand, can have an effect on how an anesthetic is metabolized. Endocrine function – diabetes, corticosteroid intake, amount of insulin administered Immunologic function Previous medication therapy – It is essential that the

patient’s medication history be assessed by the nurse and anesthesiologist. 2. PSYCHOLOGICAL PREPARATION Patients are often fearful or anxious about having surgery. It is often helpful for them to express their concerns to health care workers. This can be especially beneficial for patients who are critically ill, or who are having a high-risk procedure. The family needs to be included in psychological preoperative care.. If the patient has a fear of dying during surgery, this concern should be expressed, and the surgeon notified. In some cases, the procedure may be postponed until the patient feels more secure. Children may be especially fearful. They should be allowed to have a parent with them as much as possible, as long as the parent is not demonstrably fearful and contributing to the child's apprehension..Patients and families who are prepared psychologically tend to cope better with the patient's postoperative course. Preparation leads to superior outcomes since the goals of recovery are known ahead of time, and the patient is able to manage postoperative pain more effectively. Psychological nursing assessment during the preoperative period:  Fear of the unknown  Fear of death  Fear of anesthesia  Concerns about loss of work, time, job and support from the family  Concerns on threat of permanent incapacity  Spiritual beliefs  Cultural values and beliefs  Fear of pain

3. INFORMED CONSENT The patient's or guardian's written consent for the surgery is a vital portion of preoperative care. By law, the physician who will perform the procedure must explain the risks and benefits of the surgery, along with other treatment options. However,

What is Patient psychological preparation ?

the nurse is often the person who actually witnesses the patient's signature on the consent form. It is important that the patient understands everything he or she has been told. Sometimes, patients are asked to explain what they were told so that the health care professional can determine how much is understood.Patients who are mentally impaired, heavily sedated, or critically ill are not considered legally able to give consent. In this situation, the next of kin (spouse, adult child, adult sibling, or person with medical power of attorney) may act as a surrogate and sign the consent form. Children under age 18 must have a parent or guardian sign. Criteria for a Valid Informed Consent  Consent voluntarily given. Valid consent must be freely given without coercion.  For incompetent subjects, those who are NOT autonomous and cannot give or withhold consent, permission is required from a responsible family member who could either be apparent or a legal guardian. Minors (below 18 years of age), unconscious, mentally retarded, psychologically incapacitated fall under the incompetent subjects.  The consent should be in writing and should contain the following:  Procedure explanation and the risks involved  Description of benefits and alternatives  An offer to answer questions about the procedure  Statement that emphasizes that the client may withdraw the consent  The information in the consent must be written and be delivered in language that a client can comprehend.  Should be obtained before sedation.

4. PREOPERATIVE TEACHING Preoperative teaching includes instruction about the preoperative period, the surgery itself, and the postoperative period.  Instruction about the preoperative period deals primarily

Tell the criteria for taking informed consent?











with the arrival time, where the patient should go on the day of surgery, and how to prepare for surgery. For example, patients should be told how long they should be NPO (nothing by mouth), which medications to take prior to surgery, and the medications that should be brought with them (such as inhalers for patients with asthma). Instruction about the surgery itself includes informing the patient about what will be done during the surgery, and how long the procedure is expected to take. The patient should be told where the incision will be Knowledge about what to expect during the postoperative period is one of the best ways to improve the patient's outcome. Instruction about expected activities can also increase compliance and help prevent complications. This includes the opportunity for the patient to practice coughing and deep breathing exercises, use an incentive spirometer, and practice splinting the incision. Additionally, the patient should be informed about early ambulation (getting out of bed). The patient should also be taught that the respiratory interventions decrease the occurrence of pneumonia, and that early leg exercises and ambulation decrease the risk of blood clots. Patients hospitalized postoperatively should be informed about the tubes and equipment that they will have. These may include multiple intravenous lines, drainage tubes, dressings, and monitoring devices. In addition, they may have sequential compression stockings on their legs to prevent blood clots until they start ambulating. Pain management is the primary concern for many patients having surgery. Preoperative instruction should include information about the pain management method that they will utilize postoperatively. Patients should be encouraged to ask for or take pain medication before the pain becomes unbearable, and should be taught how to rate their discomfort on a pain scale. If they will be using a patient-controlled analgesia pump, instruction should take place during the preoperative period. Use of

Tell about respiratory exercise?

alternative methods of pain control (distraction, imagery, positioning, mindfulness meditation, music therapy) may also be presented.  Finally, the patient should understand long-term goals such as when he or she will be able to eat solid food, go home, drive a car, and return to work.

5. PREPARATION It is important to allow adequate time for preparation prior to surgery. The patient should understand that he or she has the right to add or strike out items on the generic consent form that do not pertain to the specific surgery. For example, a patient who is about to undergo a tonsillectomy might choose to strike out (and initial) an item that indicates sterility might be a complication of the operation.

6. GERONTOLOGIC CONSIDERATIONS  Monitor older patients undergoing surgery for subtle clues that indicate underlying problems since elder patients have less physiologic reserve than younger patients.  Monitor also elderly patients for dehydration, hypovolemia, and electrolyte imbalances.

5

15 min

To discuss the nursing management of pre-operative phase

NURSING MANAGEMENT Assessment : Assess for patient physical, psychological, spiritual, and social needs. Handle patient according to age group and take informconsent is important task of the preoperative phase for nurse. Thorough physical assessment and history collection is too important.

Teacher activity: Discuss the nursing management of preoperative phase with the help of power point presentation and leaflet Learner activity: Students are listening and writing

What is a nurse role in psychological preparation of patient?

Nursing interventions: 1. Reducing Anxiety and Fear:  

Provide psychosocial support. Be a good listener, be empathetic, and provide information that helps alleviate concerns.  During preliminary contacts, give the patient opportunities to ask questions and to become acquainted with those who might be providing care during and after surgery.  Acknowledge patient concerns or worries about impending surgery by listening and communicating therapeutically.  Explore any fears with patient, and arrange for the assistance of other health professionals if required. 2. Managing Nutrition and Fluids:  Provide nutritional support as ordered to correct any nutrient deficiency.  Instruct patient that oral intake of food or water should be withheld 8 to 10 hours before the operation (most common), unless physician allows clear fluids up to 3 to 4 hours before surgery.  Inform patient that a light meal may be permitted on the preceding evening when surgery is scheduled in the morning, or provide a soft breakfast, if prescribed, when surgery is scheduled to take place after noon and does not involve any part of the GI tract.  In dehydrated patients, and especially in older patients, encourage fluids by mouth, as ordered, before surgery, and administer fluids intravenously as ordered.  Monitor the patient with a history of chronic alcoholism for malnutrition and other systemic problems that increase the surgical risk as well as for alcohol withdrawal 3. Promoting Optimal Respiratory and Cardiovascular Status:  Urge patient to stop smoking 2 months before surgery (or at least 24 hours before).  Teach patient breathing exercises and how to use an





4.   

5. 

6. 

  

7. 

incentive spirometer if indicated. Assess patient with underlying respiratory disease (eg, asthma, chronic obstructive pulmonary disease [COPD]) carefully for current threats to pulmonary status; assess patient’s use of medications that may affect postoperative recovery. In the patient with cardiovascular disease, avoid sudden changes of position, prolonged immobilization, hypotension or hypoxia, and overloading of the circulatory system with fluids or blood. Supporting Hepatic and Renal Function If patient has a disorder of the liver, carefully assess various liver function tests and acid–base status. Frequently monitor blood glucose levels of the patient with diabetes before, during, and after surgery. Report the use of steroid medications for any purpose by the patient during the preceding year to the anesthesiologist and surgeon. Monitor patient for signs of adrenal insufficiency. Assess patients with uncontrolled thyroid disorders for a history of thyrotoxicosis (with hyperthyroid disorders) or respiratory failure (with hypothyroid disorders). Promoting Mobility and Active Body Movement Explain the rationale for frequent position changes after surgery (to improve circulation, prevent venous stasis, and promote optimal respiratory function) and show patient how to turn from side to side and assume the lateral position Discuss any special position patient will need to maintain after. Instruct patient in exercises of the extremities, including extension and flexion of the knee and hip joints and range of motion of the elbow and shoulder. Use proper body mechanics, and instruct patient to do the same. Maintain patient’s body in proper alignment when patient is placed in any position. Respecting Spiritual and Cultural Beliefs Help patient obtain spiritual help if he or she requests

it; respect and support the beliefs of each patient. Ask if the patient’s spiritual adviser knows about the impending surgery.  When assessing pain, remember that some cultural groups are unaccustomed to expressing feelings openly. Individuals from some cultural groups may not make direct eye contact with others; this lack of eye contact is not avoidance or a lack of interest but a sign of respect. 8. Providing Preoperative Patient Education  Teach each patient as an individual, with consideration for any unique concerns or learning needs.  Begin teaching as soon as possible, starting in the physician’s office and continuing during the pre admission visit, when diagnostic tests are being performed, through arrival in the operating room.  During the preadmission visit, arrange for the patient to meet and ask questions of the perianesthesia nurse, view audiovisuals, and review written materials. Provide a telephone number for patient to call if questions arise closer to the date of surgery. 9. Teaching the Ambulatory Surgical Patient  For the same day or ambulatory surgical patient, teach about discharge and follow-up home care. Education can be provided by a videotape, over the telephone, or during a group meeting, night classes, preadmission testing, or the preoperative interview.  Answer questions and describe what to expect. 10. Teaching Deep Breathing and Coughing Exercises  Teach the patient how to promote optimal lung expansion and consequent blood oxygenation after anesthesia by assuming a sitting position, taking deep and slow breaths (maximal sustained inspiration), and exhaling slowly.  Demonstrate how patient can splint the incision line to minimize pressure and control pain (if there will be a thoracic or abdominal incision).  Inform patient that medications are available to relieve pain and that they should be taken regularly for pain relief to 

enable effective deepbreathing and coughing exercises. 11. Explaining Pain Management  Instruct patient to take medications as frequently as prescribed during the initial postoperative period for pain relief 12. Preparing the Bowel for Surgery  If ordered preoperatively, administer or instruct the patient to take the antibiotic and a cleansing enema or laxative the evening before surgery and repeat it the morning of surgery. 13. Preparing Patient for Surgery  If hair is to be removed, remove it immediately before the operation using electric clippers.  Dress patient in a hospital gown that is left untied and open in the back.  Cover patient’s hair completely with a disposable paper cap; if patient has long hair, it may be braided; hairpins are removed. 14. Remove jewelry, including wedding rings 15. Transporting Patient to Operating Room  Send the completed chart with patient to operating room; attach surgical consent form and all laboratory reports and nurses’ records, noting any unusual last minute observations that may have a bearing on the anesthesia or surgery at the front of the chart in a prominent place.  Take the patient to the preoperative holding area, and keep the area quiet, avoiding unpleasant sounds or conversation. 16. Attending to Special Needs of Older Patients 17. Attending to the Family’s Needs 18. Spiritual Considerations

SUMMARY : The pre-op phase is an important phase of peri-operative nursing. The preoperative phase is used to perform tests, attempt to limit preoperational anxiety and may include the fasting. The patient who consents to have surgery, particularly surgery that requires a general anesthetic, renders himself dependent on the knowledge, skill, and integrity of the health care team. In accepting this trust, the health care team members have an obligation to make the patient's welfare their first consideration during the surgical experience. The scope of activities during the preoperative phase includes the establishment of the patient’s baseline assessment in the clinical setting or at home, carrying out preoperative interview and preparing the patient for the anesthetic to be given and the surgery. Nurses have to assess and fulfill the physical, psychological, spiritual, social, needs. Nurses has a responsibility to take informed consent, patient education , part preparation, bowel preparation ,assess for any special needs, nutritional status, pre-op medication and vital , pre-op general healthy and tell patient how to cope with surgery postoperatively like post-op exercise, breathing exercise, special diet, family support and early ambulation with good ROM.

ASSIGNMENT : Q- Write down the “NURSES RESPONSIBILITIES IN PREOPERATIVE PHASE”?

EVALUATION: Q1:- Which of the following is not a phase of peri-operative nursing? a) Pre-operative b) Post-operative c) Intra-operative d) peri-operative Q2:- What is the goal of the preoperative phase? a) To assess patient need during surgery b) to assess patient need after surgery c) To assess need of patient who is undergoing a surgery d) all of above Q3:- Importance of pre-operative phase is? a) To assess patient recovery b) to rule out special need c) to evaluate pre surgery status d) all of above Q4:- What of the following drug discontinue prior to surgery? a) Prednisolone b) Warfarin c) Propanolol d) Aspirin Q5: Informed consent is? a) Taken prior to Surgery b) Taken after telling patient all aspects of surgery c) taken from guardian for one who is under18 d) All of above

REFERENCES: BOOK : Joecy M. Black, “Medical-Surgical Nursing”, edition 6, published by Saunders, page no. 184-199  Lewis’s “ Medical Surgical Nursing, Assessment and Management of Clinical Problem” , 2nd south Asia edition, volume- I, Elsevier Publication, pg. no.- 233-245  Linda , “Priorities in Crirtical Care Nursing”, Fourth Edition, Mosby Publication,  Phipp’s “Medical Surgical Nursing, Health and Illness Prespectives, 8th Edition, Mosby Publication, Pg.no.- 237-260  Suddarth’s and brunner, “ Textbook of medical –surgical nursing”, 11th Edition, Wolters kluwer Publication, pg no.-198-205

ONLINE:   

http://nurseslabs.com/preoperative-phase/ https://en.wikipedia.org/wiki/Perioperative http://www.brooksidepress.org/Products/Nursing_Care_of_the_Surgical_Patient/lesson_1_Section_1.htm http://www.dictionary.com/browse/preoperative

ARTICLE : http://www.surgeryencyclopedia.com/Pa-St/Preoperative-Care.html  http://www.surgeryencyclopedia.com/Pa-St/Preoperative-Care.html#ixzz4JMAOPtMU