Nursing care applied to surgical patient in the pre-surgical period

Abstracts

Este trabalho é um estudo descritivo transversal, com abordagem quantitativa, realizado em unidades cirúrgicas de dois hospitais do município de Ponta Grossa, que objetivou caracterizar os cuidados de enfermagem prestados a pacientes em período pré-operatório de cirurgias eletivas. A população estudada, selecionada por meio de amostra de conveniência, constitui-se de 129 pacientes, na faixa etária de 18 a 70 anos. Para a coleta de dados, utilizou-se instrumento estruturado aplicado por meio de entrevista, no próprio hospital, após a cirurgia. Os resultados evidenciaram que os cuidados realizados estão voltados principalmente ao preparo físico do paciente, com poucas orientações em relação ao procedimento cirúrgico e aos cuidados de enfermagem efetuados. Percebe-se que alguns destes cuidados deixam os pacientes muito constrangidos: a colocação da camisola cirúrgica, a retirada de roupa íntima e da prótese dentária. Enfim, este estudo permitiu que se identificassem fragilidades no cuidado do paciente cirúrgico, no sentido de contribuir para a reflexão sobre a necessidade de mudança nas práticas da enfermagem no ambiente hospitalar.

Cuidados de enfermagem; Assistência perioperatória; Cirurgia

ORIGINAL ARTICLE

Berendina Elsina Bouwman Christóforo^I; Denise Siqueira Carvalho^II

^INurse. Master in Nursing. Professor at Centro de Ensino Superior dos Campos Gerais. Member of the Grupo de Estudo Multidisciplinar em Saúde do Adulto [Multidisciplinary Study Group on Adult Health] (GEMSA) at the Federal University of Paraná. Curitiba, PR, Brazil. [e-mail], [e-mail]

^IIPhD in Preventive Medicine. Master in Epidemiology. Adjunct Professor of the Community Health Department and the Nursing Graduate Program in the Heath Sciences Sector at Federal University of Paraná. Curitiba, PR, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

This is a descriptive, cross-sectional, qualitative study performed at the surgical units of two hospitals in the city of Ponta Grossa. The purpose was to characterize the nursing care provided to patients in the pre-surgical period of elective surgeries. The studied population, chosen as a convenience sample, consisted of 129 patients, aged 18 to 70 years. Data collection was performed through structured interviews carried out at the hospital after the surgery. The results show that the care provided is mainly focused on the physical preparation of the patient, in which few instructions are provided about the surgical procedure and the nursing care delivered. It was also observed that some types of nursing care embarrass the patients, such as wearing the surgical gown and removing their underwear and dental prosthetics. Eventually, this study allowed for the identification of weaknesses in the care provided to the surgical patients, so as to contribute for the reflection about the need to make changes in the nursing practices performed in the hospital.

Key words:Nursing care. Perioperative care. Surgery.

RESUMEN

Se trata de un estudio descriptivo y transversal, con un abordaje cuantitativo, realizado en unidades quirúrgicas de los hospitales del municipio de Ponta Grossa, que tuvo como objetivo caracterizar los cuidados de enfermería, realizados en pacientes, durante el período preoperatorio de cirugías electivas. La población estudiada, seleccionada por medio de muestra de conveniencia, se constituyó de 129 pacientes, que se encontraban dentro del intervalo de edad de 18 a 70 años. Para la recolección de datos, se utilizó un instrumento estructurado que fue aplicado por medio de una entrevista, en el propio hospital, después de la cirugía. Los resultados colocaron en evidencia que los cuidados realizados están dirigidos principalmente a la preparación física del paciente, con pocas orientaciones relacionadas con el procedimiento quirúrgico y con los cuidados de enfermería efectuados. Se percibe que algunos de estos cuidados incomodan a los pacientes, por ejemplo: la colocación de la camisa quirúrgica, la retirada de la ropa íntima y de la prótesis dentaria. En fin, este estudio permitió que se identificasen fragilidades en el cuidado del paciente quirúrgico, en el sentido de contribuir para la reflexión sobre la necesidad de introducir cambios en las prácticas de la enfermería en el ambiente hospitalario.

Descriptores: Atención de enfermería. Atención perioperativa. Cirugía.

INTRODUCTION

Specific terminology is used for the period that involves the surgery. When the patient needs a surgery and it is scheduled, it is said that the patient is in the perioperative period, comprehending the mediate and immediate preoperatorive, transoperatorive, anesthetic recovery and postoperative stages⁽¹⁾. This study emphasizes the nursing care provided in the first two stages, i.e. during the mediate and immediate preoperative periods, extending from the moment when the surgery is decided for - either an elective, urgency or emergency surgery - until the moment preceding the surgical act, when the patient is taken to the surgery center.

The patient's well-being should be the main objective of the professionals who assist the surgery patient because, in the preoperative period, they may present high levels of stress, as well as develop feelings that can act negatively on their mood, making them vulnerable and dependent. It is often observed that the levels of stress do not depend on the surgery's degree of complexity, but are related to misinformation about the surgery procedures, anesthesia and care procedures to be performed.

When providing care to the pre-surgery patient, the nursing team is responsible for preparing, establishing and developing several nursing care actions according with the specifics of the surgery. These care procedures, in turn, are performed in accordance with specialized knowledge, in order to meet the needs originating in the surgical treatment. This kind of care also includes orientation, physical and emotional preparation, assessment and transportation to the surgery center, with a view to reducing the surgery risk, promoting recovery and avoiding postoperative complications, since these are usually associated to inadequate preoperative preparations^(1-2).

Considering the specific characteristics of the surgery patient, several studies appoint and note the importance of efforts to improve nursing care quality. This kind of quality can be achieved by using the nursing process applied to the surgery patient, denominated Perioperative Nursing Care System - Sistema de Assistência de Enfermagem Perioperatório (SAEP). This starts in the preoperative period, when the patient arrives at the hospital, and ends 24 or 48 hours after the anesthesia-surgery act. The main goal of this healthcare model is planning and putting in practice patient care^(3-5).

For this reason, the importance of nurses' work in the preoperative period is highlighted. The nurse is responsible for planning the nursing care provided to surgery patients, regarding their physical and emotional needs, and also for orientations about the surgery itself and the physical preparation necessary for the surgical intervention⁽⁴⁾.

There are still deficiencies regarding the physical, psychological and spiritual preparation of the patient in the preoperative period⁽⁵⁾, which have not been sufficiently investigated in the academia. Thus, it is believed that better quality and adequacy should be sought in care delivery, assessing patients' real necessities with a view to individualized care, with the participation of the patient and well-supported on theoretical bases.

This is the context in which nursing is challenged to offer quality healthcare in the preoperative period. This care would then involve the physical and psychological preparation of the patient for the surgery, attempting to help the patient understand the nursing care to be provided and any possible discomfort that could result from the care provided, clarifying doubts and seeking to answer questions.

In this perspective, literature in this field presents evidence-based discussions about nursing practice, which lead us to believe that nurses strive towards the conscious, explicit and informed usage of the information derived from theories and research. These would be used to support both healthcare planning and decision making about the care provided⁽⁶⁾.

For most patients submitted to elective surgeries, preparation in the preoperative stage starts upon admission, since hospitalization occurs in the immediate preoperative period, i.e. a few hours before the procedure. Since this period is short, there is the need to reconsider the effectiveness of the care provided in the preoperative period and assess its execution, in order to verify whether these care procedures are performed adequately or in a mechanical, routinely way, distant from the direct and integral care that should be provided⁽⁷⁾.

Therefore, care provided to the patient during the preoperative period should be planned according to the individuality of each patient, based on scientific evidence and determined by patients' health status, type of surgery, routine established at the institution, time available from admission to surgery and the particular needs present.

OBJECTIVE

To characterize nursing care provided in the preparation of patients to elective surgeries in the immediate preoperative period, at two hospitals in the city of Ponta Grossa, Brazil.

METHOD

The research adopted a descriptive, quantitative, cross-sectional approach and was developed at two hospitals with surgery centers in the city of Ponta Grossa, Paraná. According to the guidelines of the National Health Council Resolution 196/96⁽⁸⁾, the project was submitted to the Ethics Committee of Universidade Federal do Paraná (UFPR) and approved on November 9^th, 2005 (CAAE #0045.0.091.000-05), using the consent form for patients who agreed to take part in the study.

The study population consisted of 129 patients, selected according to a convenience sample. All inclusion criteria were: patients hospitalized in one of the two study hospitals for a period longer than 12 hours and submitted to elective surgeries, aged 18 or older, of both genders. Patients with psychiatric disorders or whose critical conditions in the mediate postoperative period would not allow for interviews were excluded from the study.

After being informed of the study objectives, the patients were consulted about their willingness to take part in the research, and those who agreed were asked to sign the term of consent. This process resulted in 129 patients.

Regarding the research period, the study was performed from May 8^th to June 2^nd, 2006 at institution "A" and between June 5^th and June 30^th, 2006 at institution "B", totaling four weeks of data collection at each institution.

Structured interviews were used as data collection instruments, by filling out a specific instrument elaborated by the researchers. This instrument contained issues related to physical and psychological care provided to the patients in the preoperative period, the characterization of the care provided, the identification of those responsible for care delivery, the verification of the existence of orientations and how the caregivers felt when performing them. Before starting data collection, the instrument was tested with a pilot study. After evaluating the comprehension of the questions and coherence of the answers in the instrument, this study showed that it was adequate for application. During the interview, the answers were recorded by the researcher by means of the instrument. Data were processed using Epi-info software, version 6.04.

RESULTS

During the data collection period, 362 procedures were performed at institution A and 151 at institution B. Of this total, 129 patients were interviewed, 82 (23%) in the first institution and 47 (31%) in the second. The other patients were not part of the sample because they did not meet the prerequisites established for this study.

Patient characteristics are presented in the table below. It can be observed that the predominant characteristics were: female gender, age range from 18 to 39 years, education above primary school level, married and with a health insurance plan.

It should be noted that 61% of the patients were admitted on the same day as the surgery was performed, and 31% one day before the intervention. The greatest number of surgeries occurred in the morning, with 64% of those occurring between 7 and 9 AM and 19% between 9 AM and 12 AM. The others were performed in the afternoon, up to 6 PM.

The most frequent types of nursing care (Table 2) were assisted transportation to the surgery center, utilization of clothes provided by the institution, fasting assessment, verification of vital signs and underwear removal. Those performed least frequently were gastrointestinal preparation and nail polish removal.

Preoperative orientations were given by the surgeons (91%) and nurses (5.6%). The specific orientations most often emphasized were related to the surgery, the surgical risk and the type of anesthesia to be used.

Regarding some nursing care routines, it was observed that 34% of the patients at institution A were shaved, compared to 28% at Institution B. Among those who were shaved, 32% reported doing it at home. Among the 58% who did it at the hospital, 10% performed the procedure at the surgery center. The nursing auxiliaries (49%) and nurses (20%) were usually responsible for this care routine, although it was also performed by doctors and the patients themselves. The instruments used in this procedure were blades (59%), razors (39%) and scissors (2%). In 46% of the cases, this procedure occurred up to 2 hours before the surgery.

It was observed that 41% of the patients were not bathed. Among those who were, 53% did it at home and the others were oriented to do it at the hospital. Thirty-seven percent of the patients in this study used dentures, and were asked to remove them in 73% of the cases. Regarding other types of prosthetics, eyeglasses were among the most common (9%), whose removal was requested before the surgery. Regarding the clothes used on the way to the surgery center, 64% wore surgical gowns; 30% wore pajamas, and 6% wore common gowns. Almost all patients were required to remove their underwear. Among the surgeries, 31% required underwear removal due to the place where the surgical incision would be performed.

Table 3 presents a synthesis of the feelings manifested by the patients when receiving care. It was observed that, among all care procedures, wearing the scrubs, underwear removal and denture removal caused some embarrassment and were the care procedures with the highest levels of discomfort. Shaving also caused embarrassment and discomfort in some of the patients. Bathing, fasting, nail polisher and jewelry removal were mostly faced with indifference, according to the patients.

Orientations provided to the patients by the healthcare professionals before providing care are presented in Table 4. Fasting was recommended for half the patients who received this type of care, shaving for 39% and denture removal for 31.4%. The necessary care procedures for which the patients received the smallest amount of recommendations were bathing, transportation, utilization of the clothes provided by the hospital, underwear removal and jewelry removal.

DISCUSSION

According to the research results, it is verified that aided transportation to the surgery center, fasting assessment, wearing the clothes established by the institution, underwear removal and verification of vital signs are the care procedures most often performed. Regarding these, although almost all care procedures had been performed, more than half (70.5%) were not provided with orientation. This suggests the involvement of the professionals in their daily routine. Hushed to prepare the patients, forget about the importance attributed to orientations about the care delivered, providing care mechanically.

The daily practice of nursing professionals, involved with their tasks, shows that a deeper reflection of their professional activity is not common. The evaluation of their practices should be a part of this reflection and involve questions about their support on scientific knowledge, i.e. one should reflect about the healthcare plan designed in order to observe whether it is specific for that patient, as well as the surgery the patient will be submitted to, avoiding the practice of simply following rules imposed by the institution or prescribed by physicians.

The care procedures about which the patients received the least orientations were the verification of vital signs, transportation to the surgery center, underwear removal, wearing the clothes determined by the institution and denture removal. The care procedures with the highest incidence of patient orientation were fasting and shaving.

It should be noted that the period before hospitalization is often a period of little information for the patients. They know little about their situation and about what will occur to them. For many, lay people, friends and relatives who underwent similar situations are an important source of information. However, in some situations, the information they receive from these sources is flawed, which often increases their fear of the surgery that they will undergo^(9-11).

The orientation is a way to clarify the doubts caused by the surgical intervention and the nurse is the professional who, in addition to being prepared to perform it, is legally and morally obliged to prepare the patient for the surgery and the pre- and postoperative procedures, the risks and benefits, using language that is easy to understand⁽¹²⁾. In a healthcare practice performed with patients in the preoperative period⁽¹³⁾, it was observed that the preoperative orientation provided for a calmer surgical moment, which reflected in the patient's good recovery. This shows how important the nurse's role is in preventing and minimizing the stressful aspects of the surgical process.

Regarding the feelings manifested by the patients when faced with the many care routines performed, bathing, nail polish removal, jewelry removal, removing other prosthetics, transportation and gastrointestinal preparation were the procedures most patients accepted with indifference. The procedures that embarrassed the patients were: wearing the clothes established by the institution (27.9%), underwear removal (36.4%) and denture removal (17.1%).

It was observed that there were few patients expressing a negative view of the care procedures they were submitted to. However, regarding the feelings manifested, it should be considered that many had no knowledge of the preoperative routine, feeling indifferent to the care received. Consequently, the patients, due to necessity or lack of knowledge, accept these procedures as performed by the professionals.

In this study, it was observed that the pre-anesthetic medication prescribed by the physician was not often used in the preoperative period. However, among those patients who received it, less than half knew about its utilization. Pre-anesthetic drugs should be administered between 30 and 90 minutes before the surgery. Although they are commonly used to relieve anxiety and concerns of the patients, in addition to aiding in the administration of the anesthetic, minimizing respiratory secretions and heart rhythm alterations, the visits of the anesthetist physician and the nurse in the preoperative period are usually the most important procedures to relieve such feelings⁽¹⁴⁾.

The verification of vital signs was performed in nearly all patients (96.1%). This procedure is justified because it is extremely necessary to assess the physiological conditions of the patient. It should be performed in all patients immediately after hospitalization for the surgery.

During the preoperative period, the surgery team should know whether the patient who will be submitted to surgery has already had some type of allergy, in order to avoid complications in the transoperative period. Regarding this type of care, less than half (31.8%) of the patients reported being asked this question, and less than half (31.75%) of the patients were asked this question by the nursing team. According to some authors⁽¹⁴⁾, the incidence of anaphylactic reactions during the anesthetic act has increased. Therefore, the surgery team should know patients' history of allergic reactions.

It was also verified that shaving is still performed by the nursing team in the healthcare institutions, in spite of the short time of hospitalization before the surgery. It is noted that shaving is performed about two hours prior, and also 10 hours prior to the surgery.

The CDC (Center for Disease Control) Guide for preventing SCI (Surgical site infection) recommends that shaving should be performed only when strictly necessary. In these cases, it should be done immediately before the surgery, with electric devices and the adequate technique^(15-16). In the past years, there has been a consensus among professionals regarding the indication of avoiding shaving, but there is still no consensus on whether hair removal results in lower SCI incidence when compared to non-removal⁽¹⁷⁾.

Regarding hygiene care, bathing was provided to slightly more than half the patients before the surgery. Some authors highlight that bathing in the preoperative period is considered one of the stages of surgical preparation of the skin, a recommendation that has been maintained in the past years. However, its efficacy has not been scientifically proven, although it is based on logical practices of hygiene and contamination control⁽¹⁷⁾.

It is verified that nearly half the patients (45.7%) wore jewelry when they were hospitalized, and nearly all of them were oriented by the nursing team to have them removed in the room before the surgery. There are several justifications for that, such as the risk of finger garroting in the case of rings, possibility of losing the jewels and electrical risks. However, when the patient refuses to remove a given piece of jewelry, such as a wedding ring for example, a careful hand washing procedure is usually enough as a measure of infection control⁽¹⁷⁾.

Less than half (37.2%) of the patients used full dentures. Most of them (72.9%) were asked to remove the prosthetic by the nursing team, regardless of the type of anesthesia to be used. Denture removal may cause some discomfort, but about half (54.3%) of the patients did not report this feeling, being indifferent to the procedure.

Dentures should be removed to avoid having them slide towards the lower airways during the anesthetic induction, as well as the possibility of being lost during the surgery. Thus, when they are removed, they should be identified and stored safely.

Removing eyeglasses was a care procedure provided to all patients who wore them, before being taken to the surgery center. It is noted that, when the patients go to the surgery center⁽¹⁸⁾, some devices are removed, such as eyeglasses, hearing aids, dentures, among others. The need to remove these devices is a matter of discussion, since their absence may limit the interaction with the surgery team, which may in turn interpret that the patient is not interacting well with the team and the environment for other reasons, in addition to embarrassing the patient.

The gown patients wear when they are taken to the surgery center is a sleeveless gown, with an opening in the back. In certain situations, for some patients, it ends up being rather short. The model of the gown is always the same, regardless of the patient's age or gender. The gown was used by most of the patients who took part in the study when they were taken to the surgery center. It should be noted, however, that some were taken to the surgery center wearing pajamas, which is justified by an insufficient number of gowns to meet the demands of the institution.

Several patients were embarrassed by having to wear the surgical gown with an opening in the back. In addition, most of them stated that they were not oriented about the reason why the gowns should be worn. As such, it is observed that there is a need for studies that evaluate its real purpose, even to the point of proposing the elaboration of new models that grant more privacy to the patient, exposing less of their bodies. The gown could be longer and have a smaller opening in the back, or the patients could be allowed to wear pajamas, which already occurs in some situations. It should be noted that, in spite of great advances in surgery technologies in the past years, there have been few advances in the gown models used in surgery.

Underwear removal is a care procedure provided to nearly all patients before they were taken to the surgery center. There are authors who mention that underwear interferes with the electric cauterizer used in surgeries. However, the issue is a matter of discussion⁽¹⁸⁾ since there are no studies specifying these risks.

The care procedures that most embarrassed the patients were wearing the gown and underwear removal. These procedures were mostly performed without any orientation about their need. Nursing often exposes patients without previous orientation, adopting an authoritarian attitude. The patients, in turn, do not question this attitude because, although the procedure makes them feel embarrassed and ashamed⁽¹⁸⁾, they understand that it is necessary. However, these feelings could be relieved if they received explanations about why they are necessary.

Nail polish removal was performed in half (50%) of the patients who wore it. It could be stated that the nail polish was not removed when the color used by the patient was light, which is allowed in certain institutions. Nowadays⁽¹⁹⁾, nail polish removal is not justified by the utilization of the oxymeter, because this device reads the levels of oxygen saturation through several colors of polish accurately. Continuing nail polish removal in practice may suggest reserves regarding the technological evolution and the perpetuation of practices that lack critical evaluation.

Gastrointestinal preparation was not performed often, which is justified, since this is recommended for surgeries involving the gastrointestinal system, and only a small share of the interventions covered by this study presented that characteristic. The preparation has the purpose of avoiding accidental trauma of intestinal loops in abdominal and pelvic surgeries, in addition to facilitating the view of the operative field and avoiding the risk of releasing intestinal content, or accidental contamination of the peritoneum with feces⁽²⁰⁾.

Fasting was performed by most patients. More than half (50.8%) were oriented about fasting by the physician. Considering that hospitalization predominantly occurs on the same day of the surgery, the patients usually come to the hospital while fasting, being therefore previously oriented by the physician.

Most of them fasted for over 10 hours. This fact may be associated to the number of surgeries performed in the morning. Therefore, the patients fasted during the night and the morning, until it was time for the surgery. The main purpose of preoperative fasting is to reduce the risk and the degree of gastric regurgitation⁽²⁰⁾. The author refers to several studies about preoperative fasting to replace old orientations, such as ingesting nothing after midnight for shorter preoperative fasting periods, especially allowing for the ingestion of liquids, which brings more comfort to the patient. Some of these orientations are liquids without residues, suspension of food two hours before surgery for all ages, light diet, 6-hour fasting and solids, 8-hour fasting.

Adult patients traditionally should fast for at least four to six hours before elective surgeries. However, it is noted that a shorted period of liquid fasting may be acceptable, according to published research⁽¹⁴⁾.

It was verified that all patients were taken to the surgery center on stretchers, at both institutions. This procedure may be justified, since transportation on stretchers should be comfortable, with lateral protection, covered with bedsheets and with the stretcher header in a raised position. The patient should be accompanied until the entry door of the surgery center to feel safe and confident.

CONCLUSION

Some authors^(4,7,17) state that some nursing care procedures are being performed due to empirical knowledge, with no scientific studies that justify all the procedures that are performed. Hence, one important issue in nursing activity would be to retrieve scientific support for the care provided in the preoperative stage, so that it is not based on myths, rituals and the opinions of authors. However, it should be noted that, in the same way, patient needs and care adequacy should not be forgotten.

This study observed that some care procedures are provided more frequently and others less, which shows that there are differences in patient preparation routines, since some were not performed and other were performed needlessly. Among those performed, several were done without previous orientation, leaving the patient without knowledge of why that procedure was performed, which could result in negative feelings towards the surgery. Several feelings were manifested during preoperative care delivery. This makes it necessary to evaluate whether all care procedures are really valid for the proposed surgery, and whether they are performed adequately.

Regarding the surgery patient, maybe nursing should seek means to perform appointments in the mediate preoperative period, before the hospitalization, where the patients could be assessed and oriented about all steps of the hospitalization regarding the care procedures, clarifying their doubts so that they know about pre-, trans- and postoperative care procedures, which would result in a quieter surgery. The results of this research show that several patients did not receive this type of orientation.

This study intends to instigate reflections, awaken or influence the nurses' ideas, habits, ways of acting and thinking, regarding the need to rebuild new healthcare practices towards surgery patients in the preoperative period, as well as their institution, so that improvements can be made to benefit the patients, preserving their right to receive care according to their needs as well as quality nursing care.

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Nursing care applied to surgical patient in the pre-surgical period

Cuidados de enfermería realizados en el paciente quirúrgico en el período preoperatorio

Publication Dates

• Publication in this collection
  09 Apr 2009
• Date of issue
  Mar 2009

History

• Accepted
  31 July 2008
• Received
  15 Aug 2007