Preoperative Nursing Care in Plastic Surgery

By Stine Thestrup Hansen, RN, PhD, Postdoc in Nursing

Assessment of the Plastic Surgical Patient

The interdiciplinary health assessment is patient-centered and is an extremely valuable tool for the plastic surgery team, including the plastic surgery nurse. A comprehensive and skilled assessment yields significant information that will aid in the identification of differential diagnoses. Assessment uses subjective data that is the personal medical history provided by the patient. Assessment also involves objective data gathered through the physical exam and includes that which is observable and measurable by the nurse. (2,4)

In addition to a physical assessment, the health assessment includes an evaluation of the patient’s nutritional status, cultural needs, individual coping strengths, limitations, and strategies. A psychosocial assessment also determines the patient’s level of anxiety. The health assessment period can be utilized to establish and strengthen the nurse-patient relationship and forge a bond with the patient’s relatives. The purpose of a health assessment is to (2):

1. Collect data.

2. Build knowledge of presenting signs and symptoms.

3. Determine the significance of a current condition or alteration in health status.

4. Anticipate potential problems.

5. Identify coping mechanisms and support systems.

6. Develop a plan of treatment and care.

7. Plan patient information using the patient’s support system/relatives

8. Identify and minimize risk factors.

The assessment for the plastic surgical patient requires that the nurse have knowledge in more than one specialty area. The plastic surgical patient’s care might be coordinated with other specialty areas such as orthopedics, pediatrics, oncology, gynecology, dermatology, oral surgery, neurology, general surgery, and otolaryngology. The plastic surgery team must be aware of the impact of comorbid conditions on the patient and the recovery process. The plastic surgical nurse functions as an educator, advocate, and promoter of health, and is often expected to navigate the entire perioperative experience for the patient. The person-centred health assessment includes data collection (obtaining a health history, performing a physical examination, receiving diagnostic test results), data analysis (interpreting and correlating the data) and a data synthesis (integrating the collected and analyzed data to develop a patient treatment and care plan). (1,2)+

Quit Smoking

The leading concern about nicotine with plastic surgery is tissue necrosis, an irreversible premature death of living body tissue that occurs when blood does not flow to the area. Cigarette smoking affects wound healing through numerous pathways and mediators, including nicotine, carbon monoxide, hydrogen cyanide, and nitric oxide (see Figure 1). Smoking increases the risk of wound healing complications in common plastic surgery procedures by 2- to 3-fold (5).

During plastic surgery procedures, the surgeon often makes lateral incisions to allow for more effective and accurate repositioning of the tissue, allowing implants to be placed or tissue to be removed. This method severs the end of blood vessels something that is not in other surgeries like an appendectomy or knee surgery. While this is generally safe, it is only safe when the blood vessels are healthy. This is where nicotine comes in. Nicotine causes blood vessels to constrict, limiting blood flow and cutting off circulation to tissue. Couple this with already limited vessels, and the area around the incision can be left without proper blood flow to the area, leading to tissue necrosis. When tissue necrosis takes place, it must be removed, meaning patients might could lose a portion of skin and other tissues around the incision site, and if implants were placed, they will need to be removed, too.

While tissue necrosis is bad enough, smoking, vaping, and nicotine products can lead to other complications following plastic surgery, including (6):

1. Blood clots as nicotine affects circulation
2. Infection
3. Delayed or prolonged healing
4. Fat necrosis which causes hard lumps under the skin
5. Permanent blood vessel damage
6. Increased risk of stroke or heart attack

Figure 1: The effects of smoking on wound healing involves multiple pathways and mediators with a common downstream effect. (Adapted as original from the publication by Rinker (5))

It is recommended that patient attending plastic surgical procedures quit smoking, vaping, and using all nicotine products between three and six weeks (or as early as possible) before the procedure, and you patients are recommended to continue to abstain for up to six weeks after the procedure (though preferably permanently). This means no cigarettes, nicotine gum, patches, and even vaping or e-cigarettes are off the table as they do contain nicotine.

It is well known that it is hard to quit vaping and smoking or using nicotine as this is a highly addictive substance. Here are some tips that might support your patient to stop:

• Put a picture of your inspiration for wanting to have plastic surgery done. Look at it anytime you feel a craving to smoke or vape.
• Avoid triggers. For example, if you usually smoke while drinking alcohol, abstain from drinking. If you crave a cigarette while you drive, keep gum or candy in the car.
• Stay busy with hobbies or activities that keep your mind off smoking.
• Spend time in vape and smoke-free zones, like going window shopping, seeing a movie, or spending time with non-smoking friends or loved ones.
• Download a stop-smoking App to your phone to help monitor your progress, manage cravings, get tips, and other tools to help.
• Discuss non-nicotine prescription medications with your doctor to help you quit.

Alcohol

Alcohol consumption increases the risks of postoperative complications, admission to intensive care units, and death (7).

If a patient consume alcohol in accordance with health authority’s guidelines (maximum 4 units per day or 10 units per week), the patient do not need to stop drinking alcohol before surgery. If, on the other hand, the patient has a larger consumption, it is recommended to stop drinking alcohol completely at least 4 weeks before planned surgery.

Alcohol interferes with blood’s ability to clot, which could make incisions and controlling blood loss during surgery particularly difficult. Bleeding out is a serious surgical complication that can result from thinned blood after consuming alcohol. Alcohol is also an anesthesiologist’s nightmare! Because of that, patients should be informed not to have any alcohol before and after surgery for the same reason: thin blood may make it difficult for the body to heal, which prolongs the recovery stage.