Question

This will be the patient's first surgical experience and the patient states, "I am nervous about this." The vital signs show BP 158/88, HR 96, RR 24. In the assessment, the nurse finds that the lungs are clear, bowel tones are evident, peripheral pulses are strong, and the patient is fidgeting nervously. The patient took alprazolam (Xanax) at bedtime last night and takes acetaminophen (Tylenol) for tension headaches. Related to this assessment information, what should the nurse do before the patient goes to surgery?

1. Review the surgery with the patient.
2. Notify the anesthesia care provider (ACP).
3. Administer another dose of alprazolam (Xanax).
4. Tell the patient that everything will be okay with the surgery.

Answer 1

The nurse should confirm the patient's identity, procedure details, and consent; discuss the patient's current medications with the anesthesiologist; and provide reassurance. A pre-operative "time out" is necessary to ensure surgical safety and proper anesthesia management.

Step-by-step explanation:

Before the patient goes into surgery, the nurse should engage in practices aimed at ensuring surgical safety and reducing the patient's anxiety. This includes reconfirming the patient's identity, surgical site, and procedure; ensuring that the proper consent has been obtained; and marking the surgical site if necessary. The nurse should review the patient's medications, including the recent use of alprazolam and acetaminophen, discussing this with the anesthesia staff to ensure safe anesthesia management.

As the patient is displaying signs of nervousness and has elevated vital signs, the nurse should provide reassurance and, as needed, consult with the anesthesia professional regarding potential pre-operative anxiolytic medication to help the patient relax before the surgery. It is also important that the team conducts a "time out" just before the surgery to confirm all final checks and readiness of the patient for the procedure. Patient safety protocols, such as double-checking allergies and verifying the functionality of essential equipment like the pulse oximeter, are crucial at this stage.