Learning Objectives
By the end of this section, you will be able to:
- Identify important aspects of preadmission care
- Discuss education and planning for patients scheduled for an operation
The first of the three phases included in perioperative nursing is the preoperative phase. The preoperative phase starts when the decision is made to proceed with a surgery or procedure and ends when the patient arrives in the operating room. Many hospitals or surgery centers have a presurgical services department to facilitate preadmission testing. The preadmission assessment and interview provide the nurse and anesthesia provider the opportunity to ensure the patient is safe to continue with the procedure or surgery. Based on the patient’s health history, the nurse may identify any potential risks, as well as any further testing that may be needed as outlined by the anesthesia provider or surgical protocol. Preadmission testing also identifies any risks or interventions that may need to be addressed prior to the procedure. At this time, the nurse will also need to obtain information pertinent to the procedure, such as consent forms (as appropriate).
The preoperative phase is a crucial phase to ensure patient safety throughout the surgical process. This phase requires the nurse to utilize clear and concise communication, strong teamwork, and flawless patient assessment skills to promote the patient’s best achievable outcomes and avoid errors or adverse events. The preoperative nurse should ensure the correct site and surgery are verbalized by the patient in their own words, as well as documented correctly both in the patient’s chart and the surgical consent. The surgeon is responsible for marking the correct limb or surgical site. The actual marking must be verified by both the preoperative and intraoperative nurse. Omitting these crucial steps could result in surgery being performed on the wrong site. Information that the preoperative nurse obtains will be communicated to the intraoperative nurse during patient handoff (see Chapter 26 Intraoperative Care).
Preadmission Care
Preadmission care the nurse provides will vary depending on the route the patient takes to the operating room (OR). In the case of a planned procedure, there will be a scheduled appointment 7-10 days, or even up to a month, beforehand. At this time, the nurse will gather information, which includes the patient’s demographics, health history, and any diagnostic and laboratory testing. This can be done via phone or in person depending on facility protocol. For example, a patient having a total joint replacement may need to come in person to the facility because the preadmission testing is extensive, as it includes several laboratory tests, an ECG, chest X-ray, and special preoperative instructions. Whereas a patient having a less invasive procedure, like a colonoscopy, is able to complete the preadmission screening over the phone.
When a patient is already in the facility (for example, admitted as an inpatient, in the ER, or in observation), the preoperative nurse is responsible for doing the interviewing and assessment at the patient’s bedside. The nurse will also need to ensure that any necessary diagnostic tests have been completed, and teaching is provided prior to the procedure.
Assessment and Testing
The timing of the nurse’s assessment and any preop testing may be days to weeks before a planned surgery, or day-of in the case of a more emergent surgery. The tasks are the same, whether it is happening far in advance or just hours before the procedure takes place.
The nurse should have the patient state in their own words the type of surgery they are having. This is the first safety check to see if the orders sent match the patient’s description of what needs to be completed, especially when it comes to ensuring the correct site for the surgery to be performed.
A nurse’s assessment needs to cover a great deal of information, including:
- Demographics (e.g., address, date of birth)
- Allergies
- Height, weight
- Current medications
- Health history
- Social history (including smoking, alcohol, and recreational drug use)
- Surgical history (including any potential problems with anesthesia—e.g., trouble waking up after surgery, nausea, vomiting, or malignant hyperthermia)
- Pertinent family history (such as diabetes, hypertension, or previous problems with anesthesia)
- History of falls
- Presence of any metal or implants in the body
- Use of corrective devices
- Advanced directive (if patient has one)
The nurse uses current, past, and family health histories obtained during the assessment to identify risks or the need for alternative medications due to an allergy. Height and weight are used to determine a person’s body mass index (BMI) to decide if a transfer device or specialty bed will be needed.
Special precautions may be implemented for patients who report previous complications with anesthesia. If a patient reports having a previous lumpectomy or mastectomy, or has an AV fistula or graft in place, the nurse should assess for any restrictions with blood pressure or IV placements in either limb. If there are contraindications, the nurse will need to create a limb alert per facility protocol. Examples of a limb alert include a colored band to communicate to other care team members that the identified extremity cannot be used for blood draws or IV placement.
By gathering this information, the nurse can help confirm preventive steps are taken to ensure the patient’s safety. Preadmission assessments can determine if anesthesia medications need to be adjusted from normal dosages, or if the patient may require longer monitoring in the post-anesthesia care unit (PACU) for potential reactions. The anesthesia provider may adjust the medications given during surgery for patients with a history of postoperative nausea and vomiting or trouble waking up from anesthesia, or for patients identified as those who use alcohol daily. The nurse will assess a baseline pain level acceptable to the patient, so the postoperative nurses can take that into consideration when planning a mutual, patient-centered care plan for pain management after surgery.
Preoperative tests ordered may vary, depending on the provider’s orders and the nurse’s assessment. Some surgeons request their own testing or simply ask the facility to follow their anesthesia protocol. Anesthesia protocols typically include:
- ECG for patients that have a cardiac history or above a certain age
- Pregnancy test for women of childbearing age
- Basic metabolic panel for those with diabetes and those with hypertension
- Fasting blood glucose for patients with diabetes the morning of surgery
- Chest X-rays for those who complain of chest pain or shortness of breath that is new or worsening
- Cardiologist clearance may be required for patients with a history of cardiac conditions or any identified dysrhythmia
Again, it’s important to note that the timeline for testing may depend on the path the patient takes to the OR. If the procedure is planned, some testing may be performed prior to the date either at the patient’s primary care provider or at an outpatient facility. While the patient may have some flexibility, the testing needs to be done in time for the anesthesia team or surgeon to view the results before surgery. In emergent cases or when the patient is are already admitted to a facility, testing will be done in hospital on the day of the procedure.
Education and Planning
Preoperative education includes what to expect on the day of surgery, like arrival time versus surgical start time, explaining the need for necessary tasks prior to the surgical start time. The nurse may start by helping the patient visualize what they can expect the day of their procedure. The nurse might explain that once the patient checks in at the designated area on the day of surgery, the preoperative nurse will escort them back to a preoperative room to change clothes, sign consents, place an IV, administer medications, and perform any preparation to the surgical site, such as a surgical scrub or wipe down with antimicrobial solutions.
The patient should be educated to remain NPO, which means to take nothing by mouth, after midnight the night before surgery. The nurse will teach that this includes not smoking, not swallowing water or toothpaste, and not using gum or hard candies the morning of surgery. Anything eliciting extra saliva or gastric juice production will need to be avoided. The patient will need to know which medications should not be taken, and which medications can be taken. For example, a patient with diabetes may be instructed to take only half a dose of insulin the night before surgery and to take diabetic medications or insulin the morning of surgery as normally prescribed. If there are any medications the patient should take the morning of surgery, the nurse will instruct the patient to take medications with a very small sip of water. The nurse must make sure that the patient understands that it’s not only prescribed medications that may need to be stopped or changed—over-the-counter medications and supplements should also be discussed. Some common over-the-counter medications like aspirin and certain herbal remedies can thin the blood, while others may interact with medications given during or after surgery. For example, a surgeon may request that a patient stop using aspirin for up to 10 days prior to the procedure to reduce the risk of bleeding, though it will depend on the reason for aspirin therapy. (Plümer et al., 2017) If the patient reports having sleep apnea, the preoperative nurse will advise the patient to bring their sleep apnea machine with them, as it will be incorporated into their plan of care.
The nurse will also need to assess the patient’s psychological state, as this can impact their readiness to learn and receive preoperative education. For example, a patient who has never had a medical procedure before may be anxious and scared. Or a patient who is in a great deal of pain will likely be distracted and unable to focus. Until the patient’s pain is controlled and they are in a more relaxed state, they will not be able to fully understand the information that the nurse is providing to them about their care. The nurse should determine the readiness of the patient and provide appropriate nursing interventions to each patient scenario. Patients who are cognitively or developmentally impaired will need a guardian present for education.
Other instructions include showering with either an antibacterial soap or surgical soap per facility protocol. The patient is educated on what clothes to wear the day of surgery to accommodate the type of surgery performed. For example, loose fitting pants that will fit around a cast, boot, or immobilizer. The patient should also be instructed not to wear contact lenses, nail polish, makeup, or jewelry. The patient should be instructed to bring their own bag for personal items on the day of surgery. Also, they should be provided with information on visitor policies, and if they will need to have someone drive them home after surgery. Some facilities may require the person driving the patient home to be on campus prior to the surgery starting, as well as remaining there until the patient is ready to discharge.
At this point, advance directives are also discussed. An advance directive is a document that allows a patient to convey, in writing, their wishes for care if they are unable to advocate for themselves due to a medical condition. If a patient does not have an advance directive, they may be given information about the documents to help them decide if this planning is something they would like to complete before surgery. The nurse may advise patients about talking to the health information department or checking the facility’s website for forms or templates that help patients create their advance directives. Patients who have an advance directive may be asked to bring it with them to their surgery so that the facility can have it on file in the event the patient is not able to make decisions for themselves.
The general recovery process for the facility can be explained prior to surgery, but most of the time, postoperative instructions are not available until after the surgeon has performed the procedure. For example, patients undergoing foot surgery may be told in the office that they will be weight-bearing as tolerated after surgery. However, if the surgery was more extensive than the surgeon originally thought, the surgeon may decide that the patient will need to be non-weight bearing. For this reason, postoperative instructions are generally given after the surgery to ensure consistency and avoid confusion. Postoperative instructions are printed and verbalized with family or a responsible adult present.
Patients who will stay overnight after surgery should be informed of this, as well as what things they may need to bring with them. Some facilities request medications either be left at home or brought into the facility in their original bottles. Patients should also be educated on approximately when they will be discharged, and that the provider will come to assess them to determine if the patient is ready to discharge.