Preoperative Nursing and Preoperative Care for the Patient
Before explaining in detail what preoperative nursing is, it is essential to explain what the perioperative procedure consists of. The perioperative procedure is a sequence of events which takes place before a surgical intervention is undertaken. It consists of three main phases: the preoperative phase, the intraoperative phase and the postoperative phase. A general preoperative phase begins when the patient is admitted to have a surgical procedure until he/she are transferred to the operating theater. Then comes the intraoperative phase where the patient is transferred to the operating room and goes on till he/she is admitted to the postanesthesia care unit (PACU). Finally the postoperative phase begins with the admission of the patient to the PACU and ends up with the follow-up evaluation in the clinical setting. In the perioperative phase a nurse has a duty to perform a number of vital tasks which are beneficial for the patient’s health like for example: preoperative fasting, obtaining informed consent, or immediate postoperative care (Christine Tea 2010).
Preoperative nursing involves a very important step which should never be overlooked. This refers to the preoperative fasting, which each individual must endure before entering the operating theater. Fasting is an essential step as it prevents the rise of gastric juices into the oesophagus when anaesthetic is administered, which could lead to aspiration (the inhalation of gastric contents). I decided to choose this topic because the subject is very debatable amongst nurses and anaesthetists. Even though I am just a first year student with very little experience, I have already seen some conflicting recommendations regarding this subject. While working in the ward, nurses encouraged preoperative fasting to start at midnight which contrasts with what we did in our lectures, in which a preoperative fast of 4-6hrs was recommended. Prolonged starvation can lead to other medical problems, including hypovolaemia, confusion, headache, hypoglycaemia and irritability. I shall therefore try and find recommendations based on research regarding the best timing of preoperative fasting because too much or too little time can be dangerous for the patient.
In order to verify what the main recommendations on preoperative fasting are, I consulted four nursing articles through the use of the CINAHL (the Cumulative Index to Nursing and Allied Health Literature) database which is a very reliable database regarding nursing and other allied health articles. It was noted that different results were obtained when using ‘preoperative fasting’ and ‘pre-operative fasting’ as search words. Both however gave reliabe results. The results aquired were also limited to full text and a published date from January 2006 up till April 2011 to get all the latest relevent articles.
The first article I came across goes by the name ‘Pre-operative fasting: a nationwide survey of German anaesthesia departments’ written by J.P. Breuer et al (2009). In the past, it was much more common to starve the patient from midnight before elective surgery. In October 2004, the German Society of Anaesthesiology and Intensive Care (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin, DGAI) and the Alliance of German Anaesthesiologists (Bund Deutscher Anästhesisten, BDA) set a number of guidelines, which recommended a fast of 6 hours from solid food and dairy products, and 2 hours from clear fluids before elective surgery takes place. It was recommended that there should be abstinence from nicotine at least 6hrs before surgery. J.P. Breuer et al (2009) suggested that the multidisciplinary team should constantly keep themselves up to date with the national recommendations regarding pre-operative fasting. A minority of respondents still follow a strict dogmatic NBM-after-midnight routine.
Another article, given the title ‘Preoperative Fasting Duration and Medication Instruction: Are We Improving?’, was written by Jeannehe T. Crenshaw and Elizabeth H. Winslow (2006). Crenshaw and Winslow made a literature review, on the guidelines created by the American Society of Anesthesiologists (ASA 1999) on preoperative fasting which have been summarised in the table below. This is called the ‘2-4-6-8’ guideline.
Length of Fast
Beverage or Food
Formula, milk, light meal
As cited by Pandit and Pandit (1997), Crenshaw and Winslow, stated that the focus of preoperative fasting should not be on how long we should keep a patient fasted, but to better identify patients at risk of aspiration so that stricter measures would be implemented on such patients. Studies made by ASA also show that taking clear liquids a few hours before surgery might actually reduce gastric contents due to stimulation of peristalsis. In its guidelines ASA stated that less importance should be given to the volume of liquid ingested before surgery than the type of liquid ingested. Fasting guidelines apply for both adults and children.
The third article I reviewed was titled ‘Pre-operative fasting for elective surgical patients’ written by Alan Woodhouse (2006). Woodhouse recommended an improvement in the patient’s assessment to avoid the patient having to wait for unecessary amounts of time without food or liquid. Liasing with the operating theater staff could avoid confusions in the timetable and further prolonged fasting. Furthermore the author also stated that nursing schools should train their students to analyse and critique clinical procedures and not only learn clinical skills as some schools tend to do. According to the study there seemed to be confusion regarding the best timing for fasting. Keeping a constant update with recent research articles can enhance education within the multidisciplinary team, resulting in less confusion.
The last article analysed in the literature review was titled ‘Preoperative fasting for preventing perioperative complications in children’ with authors Robertson-Malt S, Winters A, Ewing S, Jackson D and Kiame G (2008) in which special focus was placed on children cases. Robertson et al asserted that clear liquids can be administered up to two hours before surgery although more studies have to be done for other cases. Furthermore they concluded that there is no increased risk in aspiration during surgery and may provide the patient with a better preoperative experience. The American Academy of Padeatrics (as cited by Robertson et al) noted that milk or solids can be ingested four hours in neonates, six hours in infants and eight hours for children.
J.P. Breuer et al (2009) made a survey consisting of direct questions to confirm wether the anaesthesiologists are in touch with the new set of guidelines established. The writers were also capable of providing evidence regarding the best method of preoperative fasting by making a study on the number of aspirations which occured. It was concluded that the least amount of aspirations occured when following the new guidelines.
Studies in various hospitals show that there was a decrease in the number of aspirations. In 1996, Mandelson concluded that 0.15% of the patients in the study suffered pulmonary aspirations. Due to today’s change in focus regarding preoperative fasting, as stated by Pandit and Pandit (1997), only 0.04% suffered aspirations as recorded by Olsson et al (1986). Furthermore when gastric contents were suctioned after administration of anaesthesia, same volumes were obtained for bot patients fasted overnight and patients fasted from the morning of surgery.
On the other hand, this article takes a different approach. In this article a grounded theory approach was taken by being qulitative instead of quantitative. The writer decided to ask individual nurses about their attitudes on preoperative nursing, a method which was used by Strauss and Corbin's (1998). From this an empirical-based conclusion can be created by: interviews, analysing observations, and categorising findings.
When reviewing the evidence from a total of 1,274 children, evidence shows that a fast of two hours from clear liquids does not put children at risk of aspiration. Regarding the intake of milk preoperatively, there is insufficient evidence currently available even though van der Walt (1989 - cows' milk) and Cook-Sather (2003 - formula milk) addressed the issue. The evidence provided proved to be insufficient on the basis of these two small trials.
c. In general, all arguments agreed with each other and sought to prove that a shorter duration of preoperative fasting was enough for patients with elective surgery. In the first article, J.P. Breuer et al (2009), as cited by the DGAI and BDA, went into less detail, by stating that a preoperative fast of six hours for solids and two hours for clear liquids should be made. In another article Crenshaw and Winslow (2006), as cited by ASA, went into greater detail by noting certain exceptions such as milk which is considered as a solid in the stomach. Furthermore, Crenshaw and Winslow (2006) stated that guidelines set up by ASA are the same for both adults and children. On the other hand the American Academy of Paediatrics, as cited by Robertson et al (2008) gave specific fasting times for neonates, infants and children i.e. depending on age.
d. Personally I think that ASA, as cited by Crenshaw and Winslow (2006), used a better technique when explaining the time at which certain types of food can be ingested before surgery. A clearer message is delivered to the readers. As regards the conflicting recommendation when Crenshaw and Winslow (2006) and Robertson (2008) discussed preoperative fasting in children, I tend to agree with the latter more. This is because an adult stomach cannot be considered to be as large as that of a newborn hence different preoperative fasting times need to be established.
4. Having gathered all of the above information I can now summarise and finalise the above recommendations into guidelines:
Improve the preoperative assessment of the patient as it may very well lead to improved conditioning of the patient’s health status in the postoperative phase and a decrease in the risk of pulmonary aspiration during surgery. Its aim is to explore the knowledge, past experience, perceptions and opinions of nurses working in surgical units at a local hospital with regard to preoperative fasting times, using a grounded theory approach.
For all patients, except in certain exceptions such as patients with GI problems, a fasting of 2-4 hours from clear liquids is generally enough to prevent pulmonary aspiration of gastric contents. Examples of clear liquids include: water, black coffee and pulp free orange juice.
Infants and newborn children who are still on breast milk, have a fasting period of around 4 hours in total.
For most patients, a light meal consisting of low fat and fried foods can be taken 6 hours before surgery begins. All types of solid food and non-human milk can be consumed 6 hours before.
Smoking should be avoided at all times, however one should not smoke at least 6 hours before the procedure.
Patients who have a tendency to aspirate more than others, such as obese individuals and patients who suffer from GI problems should be fasted for longer times, around 8 hours, to avoid complication during surgery.
Communicate with the operating theater staff to know exactly the time when patients are called for surgery. This should prevent the patient’s prolonged starvation .
Preoperative Hair Removal
Another role of the nurse in preoperative care is hair removal at the planned surgical site. Hair removal using a razor blade, is a widely practised technique in many hospitals before the patient gets ready for elective surgery. I decided to choose this topic because lately individual studies have shown opposition to this technique by stating that hair removal in the surgical site could create nicks in the skin, which can be easily colonised by microorganisms. During my placement in the orthopaedic ward I have seen numerous surgical site infections (SSIs). Extending my knowledge further to what may be the possible causes of an SSI would help me when faced with such situations. Therefore I shall do my best to search for evidence based recommendations on wether hair removal should be considered and if so, how should it be carried out.
Once again, I decided to make use of the CINAHL database to obtain recommendations from articles and systematic reviews. By using evidence based research one can back his/her arguments with reliable information. The search words used in this case were combinations of the following: preoperative, pre-operative, hair, removal, SSI and prevention. Articles were just limited to full text and a published date range was set starting from the 1990’s up to the present day i.e. May 2011. There sere limited search results when trying to find articles relating to the recent past.
The first article I found reliable was titled, ‘Preoperative hair removal: a systematic review’ and was written by authors Professor Judith Tanner, Kate Moncaster and Dianne Woodings (2007). As cited by Tanner et al, the British Hospital Infection Society (HIS) Working Party guidelines of 2003, suggested that hair removal should be avoided with the exception when interferance with the surgical site is made. To the contrary of HIS recommendations, the Norwegian Centre for Health Technology Assessment (SMM 2000) suggested that hair removal shouldn’t be strongly disregarded as there is no concrete evidence that opposes its use. Also the three organisations recommend different methods of hair removal when needed. The CDC suggests that hair should be removed immediately before surgery by using clippers (Mangram 1999). The Norwegian centre for Health Technology Assessment (SMM 2000) agrees slightly on these terms however it also recommends the use of depilatory cream instead because clippers tend to have a greater tendency to form nicks and scratches in the area being shaved, which can all increase the chance of an SSI. HIS (2003) suggested that hair removal should be done by using a depilatory cream instead.
Another article with the title ‘The Impact of Preoperative hair removal on Surgical Site Infection’, written by corporate authors of the Joanna Briggs Institute (2003), held a number of recommendations which could prove essential when working in a clinical setting. The authors suggested that hair removal should be avoided when possible before surgery, especially with a razor, as evidence proves that the risk of SSIs increases if this is done. When comparing the best method to remove hair i.e. by shaving or clipping, two randomised studies concluded that the differnce in the patients who sustained an SSI for both techniques was statistically significant to say that clipping is much safer. However in patients who are going to have abdominal surgery the application of depilatory cream is preffered over the latter two. The writer also suggested that the process of hair removal should take place at least 2 hours before surgery.
The third article, named ‘Preoperative hair removal: a case report with implications for nursing’ by Sandra P. Small (1995), in my opinion, was the most accurate out of all three. This report strongly recommended that hair removal should not be encouraged only if the surgical site is densely covered with hair. If the hair follicles need to be removed from this area, clippers, or better, depilatory cream should be applied. It also supports the previous two articles reviewed which states that hair removal should be done as close as possible to the time of surgery. The author encouraged all nurses to apply the theoratical findings in such reports to be applied in the clinical setting.
The final article reviewed carried the title ‘Razors versus clippers’ and was written by authors Tracy Taylor and Judith Tanner (2005). A study was done on razors and clippers to try and determine which is the best method of hair removal. The final recommendation of this article was to use clippers if hair removal is absolutely necessary even though the difference in surgical site infection is not statistically significant. Taylor and Tanner found that the chance of causing abrasions is greater when using a razor blade therefore it is more traumatic. This makes it easier for microorganisms to colonise the wound. As cited by Taylor and Tanner, the Cochrane review found insufficient evidence to conclude that depilatory cream has an advantage over clippers and razors.
The literature written by Tanner et al (2007) is a systematic review which essentially is a study on a particular subject which is later evaluated depending on the type of information gathered. A series of randomised control trials were prepared and different methods of hair removal were compared and tested against each other. By using this method Tanner et al sought to discover: if hair removal is necessary or not, the best method of hair removal and the ideal timing of hair removal.
The article written by the Joanna Briggs Institute (2003) also had the same format of a systematic review. In addition to this the systematic review also contained levels of evidence so that the reader would have a good idea on the qaulity of research which has been performed. The main research was held in the following: shaving vs no hair removal, shaving vs clipping, shaving vs depilation, timing of hair removal and wet vs dry shaving.
Small (1995) made use of different research material based on evidence proposed by other writers to try and find the best recommendations regarding preoperative care. The writer discussed a variety of research methods carried out by others before stating which is the best recommendation based on the results of these articles.
Taylor and Tanner’s (2005) article was also based on a systematic review in which they decided to create two sets of randomised controlled trials in order to determine which is the more efficient from razors and clippers. Postoperatively the patients were asked direct questions to determine the results of preoperative hair removal.
c. Although not much conflicting recommendations were found in the articles mentioned, still there are some institutes/authors that do not agree with each other’s suggestion. In the above recommendations, HIS (2003) and the Joanna Briggs Institute (2003) all agreed that preoperative hair removal should be avoided if the incision site is not completely obstructed by hair. To the contrary of this the Norwegian Centre for Health Technology Assessment stated that there is no concrete evidence to go against preoperative hair removal. Taylor and Tanner (2005) also found that there is no evidence to suggest that depilatory cream is more efficient than clipping and using razors. On the other hand the Norwegian Centre for Health Technology Assessment (2000) recommends the use of depilatory cream to remove hair as there are less chances of nicks being formed in the skin, causing an SSI.
d. In accordance with HIS (2003) and the Joanna Briggs Institute (2003) I suggest that preoperative hair removal should be avoided if possible because this creates a greater chance for bacteria to colonise the area. This would eventually leads to a SSI. Furthermore I also encourage the use of the recommendation set by the Norwegian Centre for Health Technology Assessment (2000) because unlike razors or clipper, depilatory cream works by dissolving the hair itself while avoiding skin irritation with sharp objects.
Having gathered all of the above information I can now summarise and finalise the above recommendations into guidelines:
Assess the surgical site and determine if hair removal can be avoided or not. If hair is thick and clustered in the area, than hair should be removed.
Explain to the patient why hair removal is to take place
Remove hair by using either clippers or depilatory cream. Try to avoid razors as these could increase the chance of suffering an SSI.
The process of hair removal should take place as close as possible to surgery, ideally 2 hours before surgery.
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