31.2 Preoperative Phase

Completing Preadmission and Preoperative Testing

Before being admitted for surgery, patients may need certain preadmission and preoperative tests. These assessments unveil vital information about the patient’s health, which may influence outcomes and can present challenges to a successful procedure. The preadmission testing (or preoperative testing) encompasses a range of examinations, laboratory or diagnostic tests, and procedures (e.g., electrocardiogram [ECG], bloodwork) to evaluate a patient’s health status. This testing is completed before a procedure or surgery.

The benefits of preadmission testing are multifaceted. Tests may reveal underlying medical conditions that could pose risks during surgery, allowing for adjustments to the surgical plan or even postponement if necessary. Information gleaned from preoperative tests helps the surgeon tailor the approach to the patient’s specific anatomy and health, leading to more precise and effective procedures. Testing that identifies potential issues beforehand can ultimately enhance patient safety (American College of Surgeons, n.d.). Some common tests include the following:

• Blood work:
  • Complete blood count can identify a low red blood cell count (e.g., anemia) and high white blood cell count (e.g., infection).
  • Serum electrolytes (e.g., sodium, potassium) help regulate heart rhythms and other body functions. Identifying serum electrolyte abnormalities in advance of surgery allows time to rectify the problem.
  • Serum glucose levels provide insights into the body’s ability to heal, among other things.
  • Coagulation studies (e.g., prothrombin time partial thromboplastin time) help prevent bleeding complications by measuring the activity of the clotting cascade.
• Imaging tests:
  • Chest x-rays help diagnose causes of shortness of breath, chest pain, cough, certain fevers, and abnormal heart and lung appearance.
  • Computed tomography (CT) and magnetic resonance imaging (MRI) scans offer detailed images of organs, bones, and tissues, assisting the surgeon in surgical planning and identifying potential anatomical variations.
• Electrocardiogram and echocardiogram (Echo): Assessing heart function is crucial for surgeries involving anesthesia with the goal of minimizing the risk of cardiac complications.
  • An ECG may identify abnormal rhythms (e.g., arrhythmias, dysrhythmias), heart muscle damage, and causes of chest pain, fluttering heartbeats (palpitations), and heart murmurs.
  • An Echo uses high-frequency sound waves to produce pictures of the heart. Among other things, an Echo can help diagnose heart attack, heart failure, valvular problems, and blood clots.
• Urinalysis is an important aspect of preadmission testing.
  • A urinalysis can help diagnose or rule out certain urological conditions (e.g., kidney and bladder infections). Urinalysis can also determine a patient’s hydration status and identify illegal drugs in the body.
  • Urine pregnancy tests are required for women of childbearing years who have not undergone a hysterectomy. This helps ensure patient safety and that of an unborn baby.

Confirming the Presence of Preoperative Documents

Before surgery, patients must complete a set of preoperative documents. These forms may seem daunting to patients; however, they play a vital role in ensuring a safe and successful procedure. Preoperative documents typically cover various aspects of the patient’s health and surgical plan. Some common forms include the following:

• Medical H&P: This form details past surgeries, medications, allergies, and any existing medical conditions. Family and social histories are also obtained, which helps in identifying potential risks and ensuring the patient is optimized for surgery. The professional completing the H&P also performs a physical examination.
• Informed consents: These are crucial legal documents that provide a detailed overview of the surgery, including its risks, benefits, and alternatives.
  • An informed consent (see 16.3 Legal Dimensions of Care) is a crucial legal process that goes beyond merely signing a form. It requires a thorough discussion between the healthcare provider and the patient (or their legal guardian) to ensure a complete understanding of the procedure and its risks, benefits, and alternatives. This crucial communication allows the patient to make an informed decision about their care. Although nurses may witness the signing of consent forms, the legal responsibility of obtaining informed consent and confirming the patient’s understanding lies with the professional who will perform the procedure (i.e., surgeon, anesthesia provider).
• Anesthesia assessment: This form gathers information about the patient’s tolerance for anesthesia and potential risks. The anesthesia provider completes this assessment.
• Advance directives: These documents specify the patient’s wishes regarding life-sustaining measures in case of complications.

Taking the time to carefully review and complete preoperative documents is essential for a smooth and successful surgical journey. By providing accurate information and fostering open communication, these forms pave the way for safer procedures, faster recoveries, and ultimately, improved patient outcomes.

Preparing the Bowel

The medical procedure of bowel preparation (bowel prep) is designed to clean the colon and rectum before certain medical or surgical procedures (e.g., colonoscopy, colorectal surgery). The goal of bowel prep is to remove stool and debris from the digestive tract, allowing for better visualization of the intestinal lining and reducing the risk of complications (e.g., infection) during the procedure. Bowel preparation typically involves a two-pronged approach:

• Dietary modifications: The day(s) leading up to surgery often require a low-fiber diet or clear liquid diet to minimize stool production. Clear liquids may include water, broth, clear juices, and gelatin. This reduces the volume of material that needs to be removed and lowers the risk of blockages during surgery.
• Medications: Laxatives or enemas may be prescribed to stimulate bowel movements and remove remaining stool.
  • Laxatives are medications that promote bowel movements and help clear the colon. They may be in the form of pills, powders, or liquids. Common laxatives include polyethylene glycol (PEG), magnesium citrate, sodium phosphate, or other prescribed medications.
  • Enemas involve introducing a liquid solution into the rectum to stimulate bowel movements and aid in cleaning the lower part of the colon. Types of enemas may include saline enemas or commercially available bowel prep solutions.

The specific timing of when to start the bowel prep and when to complete it depends on the type of preparation prescribed and the timing of the scheduled procedure. Healthcare providers give the patient clear instructions regarding when to start and complete each component of the bowel prep. It is crucial for patients to follow the provided instructions diligently to ensure effective bowel preparation. While bowel prep can be uncomfortable and may cause temporary diarrhea, its benefits in terms of improved visualization and safety during medical procedures outweigh the temporary inconvenience. Patients should communicate any concerns or difficulties with their healthcare providers, who can provide guidance and potentially adjust the bowel prep regimen based on individual needs.

Preparing the Skin

Preparing for surgery also involves prepping the skin on and around the incision site to minimize the risk of infection and ensure optimal healing. This meticulous process involves both preoperative and intraoperative measures.

Patients may be instructed on things they need to do at home before arriving at the surgical facility for surgery. For example, patients may be given specific instructions for cleansing the skin or showering before surgery and may be advised to avoid lotions and creams. The preoperative instructions often include using a special antiseptic solution to wash the skin. Common antiseptic solutions used for this purpose include alcohol-based chlorhexidine gluconate or iodine-based solutions. These antiseptics help reduce the number of microorganisms on the skin, decreasing the risk of a surgical site infection (SSI), an infection that occurs at or near surgical incisions within thirty days of the procedure or within one year in the case of organ or space infections with an implant. When choosing a product, the provider will take the requirements and location of the planned procedure as well as any patient allergies into account. Patients should be provided with clear instructions on how to use the product and know who to contact if they have questions about performing the preoperative routine.

Patients are instructed not to remove hair at the surgical site. Shaving the incision site and the area around it within twenty-four hours before surgery is no longer recommended. Instead, healthcare providers may trim or clip hair if necessary after the patient arrives at the facility, minimizing skin irritation and potential infection risk.

Just before surgery, a healthcare professional will meticulously clean on and around the incision area with specialized antiseptic solutions like chlorhexidine gluconate. This further reduces bacterial burden and prepares the skin for the sterile environment of the OR. Sterile drapes are then used to create a barrier between the surgical site and the surrounding nonsterile areas, minimizing the risk of contamination during the procedure.

Providing Preoperative Instructions

Preoperative instructions have several important roles:

• Enabling active patient participation: Patients become empowered partners in their care and are directly contributing to positive surgical outcomes by following the instructions.
• Empowering through knowledge: Patients are provided with the information they need to make informed decisions about their care and feel confident that they will be able to follow the instructions before and after surgery.
• Minimizing risk: Closely adhering to preoperative guidelines, such as fasting before surgery and stopping certain medications, reduces the risk of complications during and after surgery.
• Alleviating anxiety: Clear explanations about what to expect before, during, and after surgery help ease patients’ anxieties and give them more of a sense of control over the situation.
• Promoting optimal outcomes and patient health: Preoperative instructions may include guidance on lifestyle changes, medication adjustments, and hygiene practices that will help position patients to be in the best possible shape for their surgery and recovery.

Preoperative instructions cover many topics. These include fasting guidelines, medication management, hygiene practices, clothing and personal items, transportation arrangements, and arrival time:

• Fasting guidelines: Clear instructions on when to stop eating and drinking before surgery help minimize the risk of aspiration during anesthesia and decrease the severity of pulmonary complications if aspiration occurs. Historically, patients were instructed to fast after midnight the night before surgery. However, many patients experience problems (e.g., dehydration) with extended fasting, especially if surgery is scheduled for the afternoon (Chon et al., 2017). These guidelines have been updated (Apfelbaum et al., 2017). A common instruction for the timing of preoperative fasting includes the following:
  • Two hours: Simple or complex carbohydrate–containing clear liquids are encouraged up to two hours before surgeries requiring general anesthesia, regional anesthesia, or procedural sedation.
  • Four hours: Infants may consume breast milk up to four hours before surgery.
  • Six hours:
    • A light meal (e.g., toast and clear liquids) may be eaten six hours before surgery.
    • Nonhuman milk and formula should be stopped six hours before surgery.
  • Eight hours: Fried or fatty foods and milk may require additional fasting time.
• Medication management: The nurse performing the preoperative phone call should use facility guidelines and physician-specific orders to determine whether to continue or discontinue certain prescription and over-the-counter medications in the days leading up to surgery. The goal is to help lower risks associated with bleeding or interactions with anesthetic medications. While each facility and surgeon may have specific protocols, here are a few common examples:
  • Anticoagulants (blood thinners) (e.g., aspirin, warfarin, clopidogrel, nonsteroidal anti-inflammatory medications such as ibuprofen) and all vitamins, supplements (fish oil), and herbals should be discontinued for a specified period of time before surgery (e.g., five to ten days before surgery).
  • Antihypertensive medications: Certain antihypertensive medications as listed should be held before surgery. If the patient takes the medication at night, instruct the patient to hold the evening dose the night before surgery. Also, have the patient hold the medication the day of surgery (Wagner et al., 2019). The following should be held before surgery:
    • angiotensin converting enzyme inhibitors (ACE-I): benazepril (Lotensin), lisinopril (Prinivil), enalapril (Vasotec)
    • angiotensin II receptor blockers: losartan (Cozaar), valsartan (Diovan), irbesartan (Avapro)
  • Patients with diabetes:
    • Insulin: Nurses should refer to facility protocol for perioperative management of patients with diabetes. A finger-stick blood sugar should be performed on arrival at the facility on the day of surgery if the patient has diabetes. The nurse should notify the anesthesia provider if surgery start time is delayed for guidance on blood sugar monitoring and IV placement (Khan et al., 2024).
    • Oral antidiabetics: Patients should hold on the day of surgery.
  • Weight-loss/central nervous system (CNS) (e.g., phentermine) stimulant medications: Patients should stop taking seven days before surgery (Adams, 2023).
  • Anti–attention deficit hyperactivity disorder agents: Agents such as dextroamphetamine (e.g., Adderall) should not be taken the day of surgery (Engelman & Cramer, 2023).
• Hygiene practices: The nurse should instruct the patient on preoperative bathing and skin preparation with antimicrobial soap to help reduce the microbial load on the skin, which can help prevent SSIs.
• Clothing and personal items: The nurse should instruct the patient on what clothing to wear on the day of surgery and to leave valuables at home to prevent the loss or contamination of these items. The patient should be told not to wear cosmetics or use lotions before surgery. The nurse should instruct the patient to remove all jewelry and accessories. This includes removing rings and all body piercings to prevent patient injury from burns, pressure-related tissue injury, and SSIs. Nurses should understand that simply placing tape over the jewelry does not eliminate the risks of wearing them in surgery.
  • When electrosurgery is used during a procedure, body jewelry may conduct the electrical current and cause electrical burns to the surrounding tissue.
  • Metal body jewelry may interfere with ultrasound, CT, and MRI and cause injury to the patient during the procedure.
  • Nursing personnel should learn techniques for safe jewelry removal and to maintain patent piercing tracts. Facilities should ensure the availability of tools needed to safely remove body-piercing jewelry. Nose, tongue, or lip jewelry make airway management and visualization of the airway during intubation difficult and dangerous to the patient. Genital piercing can pose problems during urinary catheter insertion and may result in urethral tears that could require cystostomy or surgical closure.
• Transportation arrangements: To give patients time to plan, the nurse making the preoperative call should gather information about transportation to and from the surgical facility, including any restrictions on driving after certain types of anesthesia. If the patient is having same-day surgery and is undergoing general or regional anesthesia or conscious sedation, a driver is required to take the patient home. Patients may ask if they can take a rideshare (e.g., Lyft, Uber, taxi). However, the rideshare driver cannot be held responsible for transporting the patient into and out of the vehicle. Therefore, rideshares are prohibited unless an adult accompanies the patient and assumes responsibility for the patient.
• Arrival time: Specific instructions on when to arrive at the surgical facility or hospital for preoperative assessments and preparations are needed to guide patients through the schedule for the day. Adequate time ensures steps are completed without rushing.
• Documentation: The nurse should remind the patient to bring essential documents, including photo identification, insurance information, and any preoperative paperwork and consent forms. This helps make the process go more smoothly on the day of the surgery and decreases the likelihood that something important will be forgotten or incomplete.
• Contact information: Emergency contact information should be obtained from the patient as well as instructions on whom to contact if the patient has questions or concerns before the surgery.

Providing Postoperative Instructions

Providing postoperative instructions is crucial to help prepare the patient in advance for self-care on discharge. Instructions may include the following:

• General information about what to expect after surgery (e.g., postoperative pain management, activity restrictions and recommendations, potential side effects) helps the patient feel more prepared.
• Instructions for wound care are also important, and patients need to be aware of their responsibility for taking care of their wound after the procedure. This may involve changing bandages regularly or leaving them undisturbed until the follow-up appointment. Patients should also be instructed on how to recognize a potential wound infection as well as what signs and symptoms would warrant calling their provider.
• Additional instructions may include general advice for maintaining good personal hygiene (e.g., hand hygiene before and after touching the wound), adhering to dietary and nutritional instructions, and staying adequately hydrated and well rested. Instructions should be provided for the safe application of ice or heat after surgery if ordered.
• The nurse should provide personalized guidelines to help the patient manage pain and ensure that the patient is knowledgeable about the prescribed pain medications ordered for home use.

Formats Used for Preoperative Instructions

Using a combination of communication methods helps address the needs of diverse patient learning styles and preferences.

• Written instructions: Printed or electronic documents are often given to patients from the surgeon’s office during preoperative visits or via online patient portals.
  • Whenever possible, the nurse should ensure that instructions are written at no greater than a sixth-grade reading level. Stress and fear greatly inhibit learning. Even people with advanced education may have difficulty understanding and remembering surgical information.
  • Visual aids: Infographics, videos, or visual aids can enhance patient understanding and are useful for offering clarification or answering questions.
  • Foreign language: Facilities should be prepared to provide written instructions in the patient’s primary language.
• Verbal communication: Healthcare providers, including nurses and surgeons, will verbally reinforce instructions during preoperative assessments or consultations. Patients are encouraged to ask questions, clarifying any concerns and ensuring full comprehension.
  • Facilities should be prepared to provide interpreters in the patient’s primary language.
  • As an alternative to in-person translators, nurses should be aware of and prepared to use one of the many online, real-time interpretation services that are now available.

Performing the Preoperative Assessment

The nurse’s role in preoperative assessment includes conducting a comprehensive physical and psychosocial evaluation. The nurse is responsible for reviewing past surgeries, medications, allergies, and any preexisting conditions and identifying potential risks. The nurse then tailors a patient-specific nursing care plan.

The nurse assesses the patient’s overall health, pain levels, and potential anatomical variations that might affect the procedure. It is also the responsibility of all surgical team members at every step of the process to confirm the patient’s identity and the type and site of the surgery to be performed to ensure that the correct location is established before the patient goes to the OR. The nurse should also recognize the emotional weight of surgery. Addressing anxieties, providing emotional support, and ensuring informed consent are crucial aspects of a holistic assessment.

The nurse’s keen observation skills and ability to build rapport with patients are invaluable assets. They can detect subtle cues of discomfort, unearth hidden concerns, and ensure the patient feels heard and understood. The preoperative nurse then communicates this information to the surgeon, anesthesia provider, and RN circulator to ensure a collaborative approach to care.

Implementing Preoperative Nursing Interventions

Although the facility and surgical team will have specific requirements for the nurse to follow to prepare patients for surgery, there are some items that are expected components of the preoperative nursing assessment checklist (Table 31.2) (Stony Brook Medicine, n.d.).