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NM3710: Pre-Operative Care
Introduction
This essay will consider the pre-operative nursing care I would give to Sophie Lawrence as a staff nurse
caring for her before a laparoscopy and left salpingectomy for a rupturing ectopic pregnancy
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1%, amounting to 12,000 every
year (CMACE, 2011)
...
Evidence shows that serious outcomes are typically a result
of delayed diagnosis which reinforces the need for health professionals to be familiar with the risk
factors, symptoms and treatment for women with ectopic pregnancies (Jurkovic and Wilkinson, 2011)
...
A fallopian tube is the tube along which an ovum travels to
the uterus (Kowalski and Yoder-Wise, 2007)
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A laparoscopy is a surgical procedure in which the inside of the
abdomen or pelvis can be accessed without making large cuts; it is often referred to as keyhole
surgery (Bupa, 2012)
...

Decision-making framework
When coming to assess a patient and make clinical decisions, it can be useful to use a framework in
order to help decide on an individualised plan of how to care for them
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The framework as applied to decisions made in this
scenario is outlined below:

What is it: care for a patient before an emergency laparoscopy and left salpingectomy
to treat a rupturing ectopic pregnancy to avoid haemorrhage and further blood loss
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
When: These decisions will need to be made from the moment of admission up until
Sophie goes to theatre
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
Why: To monitor Sophie’s pre-operative observations and to provide a systematic
assessment is important as it can identify early signs of deterioration (such as shock due to
blood loss) and help the nurse to prioritise care (Nicol et al, 2012)
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Pre-operative care involves both the physical and psychological care of a patient before a surgery
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Another important tool I would use is
a pre-operative checklist to ensure that the theatre staff and anaesthetist have a record of a
assessment of the patient’s preparation for surgery
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This framework
looks at Airway, Breathing, Circulation, Disability and Exposure, providing baseline observations to
compare with subsequent values (Resuscitation Council UK, 2010)
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It also leaves
room for integration of other tools within the assessment such as the Waterlow score (Waterlow,
2005), the Glasgow Coma Scale (Teasdale and Jennett, 1974) as well as recognition of the roles of
other healthcare professionals
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It is laid out below in relation to Sophie:
Airway
First, I would establish if Sophie is able to maintain her own airway (Resuscitation Council UK, 2010)
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This is easily established by asking Sophie specific questions: If she responds,
this indicates a patent airway (Nicol et al, 2012)
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If Sophie makes any noises other than talking, this could indicate a partial blockage which could
be attributed to swelling, spasms or the presence of a foreign body (Nicol et al, 2012)
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When completing this step, I would also consider potential hazards to the airway
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This
will warn the anaesthetist not to give her any drugs that she could react to which could potential
compromise her airway through an anaphylactic reaction (Nicol et al, 2012)
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I would also ascertain when the patient last ate and
drunk
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Breathing
If Sophie's airway is patent, the next step is to 'look, listen and report' on their breathing (Nicol et al,
2012)
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g
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I would also check her respiratory rate: 12-20 breaths per
minute is considered normal in adults
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I would expect the oxygen saturation (SpO2 ) to be
between 95-10% for Sophie as she is not a smoker and has no chronic respiratory disorders (Chen et
al, 2006)
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I
would then report any abnormalities from my breathing assessment to the theatre staff as the
anaesthetist may need to come and assess the patient before accepting her for surgery
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Circulation
A priority when completing this step is to assess the extent of Sophie's bleeding
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The signs of this can be hypotension, tachycardia and peripheral shut down which can cause
oliguria, confusion or unconsciousness (Tintinalli, 2010)
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This can help to give an
estimation of the amount of blood lost
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Sophie's pulse on admission was 120 beats per minute
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It is important to also
assess the amplitude and rhythm (Ingram and Lavery, 2010) which can be an indication of the volume
of circulating blood
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Blood pressure monitoring and the measurement of capillary refill time can also highlight possible
circulatory shock
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If these fall below expected values, I
would ask the doctors to assess her as she may need IV fluids or a blood transfusion
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I would ask her if that was
the case
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Sophie’s temperature is apyrexic at 36
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Capillary refill time is one measure of tissue perfusion; another test is to check if the hands and feet
are warm or cold
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Oliguria can occur for the same reason
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The next step would then be to ask a doctor or nurse with adequate training to insert a cannula
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This prevents dehydration
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I would then start a visual

infusion phlebitis score, a risk assessment found in most trusts which monitors the cannula site for any
signs of infection, inflammation or blood clots
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These include doing a ‘group and save’ to
determine Sophie’s blood type in case she needs a transfusion, a full blood count to investigate if
there are any concerns over anaemia, urea and electrolytes which could affect anaesthetic drugs
given
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Disability/Diabetes/Drugs
At this point I would assess Sophie’s pain level as this can have an effect on physiological processes
such as pulse, respiration rate and blood pressure
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Some would consider it important to treat
right at the start of the process in order to relieve physiological and emotional stress which can affect
the rest of the assessment
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There is usually a pain assessment
system on the early warning scores which could help me evaluate Sophie's level of pain
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A commonly
used simple tool is the AVPU scale which assesses if the patient is alert, responds to verbal commands,
localises to pain or is unconscious; this scale is found on modified early warning scores which are
integrated into most hospital observation charts (RCP, 2012)
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Sophie has no previous history of diabetes
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This is especially
important if she has any unexplained drowsiness
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Some factors that would also be considered here are whether Sophie wears any glasses, contact
lenses or hearing aids
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Some theatres allow the
patient to take their glasses or hearing aids with them in the anaesthetic room to be given to the
nurse to take back to the ward when the time comes for them to induced
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At this stage, I would also weigh Sophie and ask her if she has lost any weight over the last 3 months
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If there is any concern over this, I would ask the dietician to review her in case she
needs any eating plan after the surgery
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When considering drugs, I would check that Sophie has a drug chart that is complete and that
appropriate PRN analgesia and anti-emetics are prescribed in anticipation for her return to the ward
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Exposure
The final category is Exposure, which is a head to toe examination
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This can include things such as
consent
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The patient must have
capacity and understanding of the benefits, risks and consequences of the procedure
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It is
important that consent form is signed usually; the surgeon is the ultimately responsible for obtaining
the patient consent (Wheeler, 2006)
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At this point, I would gain Sophie's consent for a physical examination and check her for any other
issues that may be of concern
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This is an important consideration as risk factors of thrombosis
include immobility due to surgery; a blood clot is dangerous as it can break off and block a major
blood vessel such as in the case of a pulmonary embolism (Hughes et al, 2010)
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These work by promoting venous
return through compression
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However, these are not used for
patients who are actively bleeding or going for surgery as it can increase the blood loss
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I would check Sophie's skin integrity and state and calculate a Waterlow score using the
framework laid out by Judy Waterlow (2005)
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If the score determines her to be at risk, I would let
the theatre know so that they can take appropriate steps to reduce that risk while in surgery with
appropriate pressure-relieving supports and repositioning if possible
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This will include asking Sophie to wear a gown
and disposable underwear in order to make it easier for the surgeon to access the surgical site and
also avoid damaging her own clothes with any blood or surgical scrub
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If not, they would be a standard white name band
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Next, I would ensure that Sophie’s partner and next of kin are informed that she will be going into
surgery, as long as she is happy for me to share that information
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If the test came back positive, I would let the theatre know so that they can
take the appropriate precautions
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They would have to cleanse the
theatre thoroughly after her operation to prevent contamination of any other patients
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Further considerations
Although it can be useful to use the systematic approach laid out by the ABCDE assessment, one
criticism may be that fact that one does not have the flexibility of being able to change the order of
categories
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Some of these aren’t considered until the final stage
(Exposure)
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Once I had taken Sophie’s observations, I would use the MEWS to assess how often observations
would need to be taken
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According to the recommendations of the framework, I would
also let the ward doctor know about this and report any increase in the score which could indicate
deterioration
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The NHS advocates an enhanced recovery pathway for many surgeries which encourages mobilisation
and return to 'normalcy' as soon as possible post-surgery (NHS, 2013)
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I will explain the aims behind
this to her and benefits of early mobilisation, catheter removal and resuming oral intake
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She may or may
not have been trying for a baby in which case the degree of psychological impact may vary
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There is also an increased risk of
future ectopic pregnancies
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It is vital to give Sophie the relevant information before surgery to allow her to be
prepared for what will happen to her and the recovery time from this type of surgery
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She may have fears or concerns which may be triggered by several different factors
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Maslow (1970) distinguishes ‘safety’ as a
fundamental human need, second only to physiological needs
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I would discuss the operation with
her, describe what she can expect in recovery such as I
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fluids, regular observations and what kind
of pain relief she will be offered
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PCAs are used in patients with
severe pain, for example in end of life care and more extensive operations (Kowalski and Yoder-Wise,

2007)
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In addition to this,
there are associated risks with having a cannula in situ such as phlebitis and infection (Nicol et al,
2012)
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Title: Pre-operative care
Description: An 4500 word essay looking at providing pre-operative care using the ABCDE approach. Critical appraisal of relevant sources completed at a Class I level, Adult Nursing BSc.

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