Chapter 2

Preoperative Case Study Answers

1.  What information do you need to know or gather about this patient before surgery occurs? Why?

• Last time aspirin or Tylenol was taken (bleeding consideration)
• Consent needed to be explained again, by the surgeon, whether surgery is vaginal or abdominal (Patient isn’t clear about approach for surgery)
• Prior problems with surgery or anesthesia for patient or family members (Assesses malignant hyperthermia risk)
• Support system of a friend or family members who can help during recovery and whether they are present (Second person to listen to postoperative instructions to later coach patient/monitor and assist patient in the first 24 hours after surgery)
• Full medication reconciliation to identify if any medications would interact with the anesthesia and if they were taken within a time frame of the surgery
• Thorough health assessment to consider risk factors (Hypoventilation, renal excretion of medications, etc.)
• Patient’s normal blood pressure/pulse range (Monitor hemodynamic changes related to surgery)
• Height/weight (Anesthesia dosing)
• Allergies (Drug interactions)
• Preexisting infections, medical conditions, and H&P to identify any potential for increased surgical risk 
• Support system at home when discharged
• Electrocardiogram for patient over 40 years old (Identify cardiac risk) and preoperative labs such as CBC and BMP to examine bleeding risk, renal function, etc.

2.  Describe the patient teaching needed. How would you prioritize teaching needs?

• Priority consideration is clarifying the procedure for the patient to ensure informed consent.
  • Need for surgeon to explain to the patient the procedure; at this point the nurse has determined the consent hasn’t been obtained as the patient has questions and doesn’t understand the type of surgery being performed. 
  • To assess understanding, have the patient reiterate the procedure to determine understanding using no leading language, “Ms. Smith, can you tell me why you are at the hospital today?” 

Additional teaching related to the procedure may include the following:

• • Teaching about pain management, expected blood loss, infection signs/risk, etc.
  • Teaching the importance of cough and deep breathing after surgery, as well as early ambulation and leg exercises 

• Patient also demonstrates sign of psychological discomfort related to the procedure. As a result, the preoperative nurse should take the following actions:
  • Anesthesiologist can provide additional teaching/reassurance regarding fear of “going under” 
  • Anesthesiologist may order preoperative anxiety medication 
  • Nurse and members of surgical team should continue to reinforce what to expect before, during, and after the surgery (incisions, dressings, wound care, etc.)

3. What lab tests and other diagnostic tests should be completed? Why?

• RBC, Hgb, Hct, and platelet levels due to prior heavy bleeding 
• WBC to determine if WBCs are elevated, which may indicate underlying infection and potentially delayed surgery 
• Blood glucose (if diabetic) to know if patient will need medications during or before surgery to keep blood sugar stable  
• Blood type needed (in case the patient needs blood transfusion with expected blood loss)

4. Is there any information that should be shared with the surgeon or anesthesiologist?

• Patient has never had surgery (risk for malignant hyperthermia) and no known reaction to anesthesia.
• The patient is unclear about aspects of her surgery and needs further explanation. She is anxious and afraid.

5. What interventions can be used to reduce the patient’s anxiety?

•  Answer any questions
•  Relaxation techniques 
•  Distraction 
•  Family present 
•  Medications (i.e., Midazolam [Versed], Lorazepam [Ativan])
•  Explain what will happen after surgery 
•  Explain what she will likely be feeling 
•  Explain what she can do to decrease pain

6. Based upon the information provided, what type of surgery is being described?

• The surgery would be classified as curative to resolve health problems. It would be considered a major surgery with general anesthesia.
• Hysterectomy is a surgical operation to remove all or part of the uterus. The surgery can be identified as abdominal, vaginal, or laparoscopic.

7. What medications might be given preoperatively to this patient and why?

• The medications that might be given preoperatively include Midazolam to assist with relaxation, Atropine (if anesthesiologist prefers) to help dry secretions), Famotidine to help with controlling potential acid reflux with surgery, and Ondansetron if patient experiences nausea.

8. What if this patient were 88 years old. How should preoperative care be modified to meet the needs of an older adult?

• Making sure a family member is with the patient 
• Identify patient’s decision-making capacity, identified/activated power of attorney for health care
• Different reactions to anesthesia and medications
• The elderly are at a higher risk for fluid imbalance, leading to confusion, postural hypotension  
• Weakened respiratory muscles can lead to collapsed lungs and impaired respiratory pattern.

9. What risks are more likely with an older adult?

• Delayed/ impaired healing 
• Increased risk of infection 
• Risk for falls 
• Less able to adjust to the stress of surgery 
• More prone to postural hypotension 
• Potential complications with the lungs 
• Difficulty maintaining blood pressure 
• Need for more help with after-surgery medications 
• Increased risk for aspiration  
• Diminished hearing 
• Forgetfulness -> impaired ability to retain information  
• Decreased liver/kidney function -> may need reduced dosage of narcotics/sedatives  
• Adverse drug responses -> fat soluble drugs have longer duration of action  
• Hypoventilation due to decreased lung expansion and weakened respiratory muscles 
• Skin breakdown due to decreased mobility  

All of the answers to the interactive element are found within the element.