Learning Objectives
By the end of this section, you will be able to:
- Identify documentation priorities for the preoperative nurse
- Discuss aspects of the preoperative assessment
- Analyze the preoperative physical assessment
- Explain other preoperative patient care responsibilities
Preoperative nurses have several responsibilities and priorities. They are responsible for assessing not only the physical state of a patient but also the psychological and social states. The preoperative nurse prepares patients for surgery by educating the patient on any preparation to be done at home, educating on the surgical process, and prepping the patient on the day of surgery. The appropriate nursing interventions should be implemented per facility protocol or as ordered.
Documentation
In nursing, documentation is a crucial component of the nursing process. The preadmission assessments and testing performed in the preoperative phase prior to the surgery allow for a baseline to be recorded. This baseline allows members of the health-care team caring for a patient intraoperatively or postoperatively to determine the presence of any abnormalities or unexpected versus expected findings with the type of surgery performed or medications received from anesthesia. Any intervention or education provided is also documented to communicate that the patient has been provided with information they need to understand and make informed decisions about their care.
Verifying Consent
Informed consent is very important in the surgical setting, as the patient should not be coerced into a surgery, nor should they go into a procedure without all the information. The preoperative nurse verifies that the surgeon has given the patient all of the details regarding the procedure; that the patient understands its risks, complications, and benefits; and the patient consents to the procedure. An informed consent requires a witness signature. The preoperative nurse may witness the patient’s or guardian’s signature. It is the responsibility of the surgeon to provide the information needed for informed consent to the patient, as well as alternative therapies; the risk of disability or disfigurement; the removal of body parts (if necessary); what to expect postoperatively; and address any questions the patient may have. Consent must be signed prior to the patient receiving anesthesia or any medications that can alter the decision-making capacity of the patient. The nurse should also be aware of the standard requirements for what is listed on the surgical consents, which may vary by state. Obtaining consent also gives the nurse the opportunity to have the patient verbalize the surgery in their own words, which ensures patient safety and minimizes the risk of adverse events like wrong-site surgery.
Persons under age 18 may not sign their own consent unless they are an emancipated minor and have the appropriate documentation presented to the facility. Adults over age 18 who have certain neurological or cognitive impairment may be deemed incompetent and cannot sign their own consents because they lack the capacity to understand what they are signing. Instead, they will need someone with medical power of attorney to sign on their behalf. Individuals that do not understand or speak English as their native language will require a medically trained interpreter to aid with obtaining consent. The materials should be provided in their spoken language, if available. Interpreters cannot be family, friends, or other staff. To follow compliance guidelines, each medical facility has a trained medical interpreter available 24/7 via a hotline, or some facilities have one present on location. Alternative forms may be needed to ensure patient understanding, such as forms using large print if the patient has visual impairments, or a medically trained sign language interpreter for a deaf patient. The preoperative nurse must verify patient understanding in order to verify consent.
Link to Learning
The Joint Commission explains informed consent, barriers, and safety actions to consider. Informed consent is more than just getting the patient to sign a consent form; informed consent is the conversation a patient has with a provider that gives them enough information to decide about their care. Verifying informed consent ensures that the patient understands the risks, benefits, alternatives, and the surgery itself.
Nursing Documentation
Nursing documentation should include the patient’s neurological status, confirming whether the patient is cognitively capable of giving an informed consent, including if an interpreter was used. The interpreter’s ID and name should be documented on the consent form and in the chart. Documentation includes using the patient’s own words to describe the surgery to be performed. Other documentation includes components of the preoperative assessment. The following list displays examples.
- Recent fluid and nutrition intake
- Current medications and when the last doses were taken for each
- Current infections that could impact healing
- Recent drug or alcohol use
- Overall mental affect or psychological state
The physical assessment findings should also be documented as further discussed in the 25.3 Preoperative Nursing Care Plan. The presence of any immobilization devices, dressings, assistive devices, corrective devices, hardware, or implants should be documented. Any nursing interventions provided in the preoperative setting should be documented, along with the patient’s response to the interventions. For example, if iodine was used to prep the patient’s leg, the preoperative nurse will document if any reaction was noted.
Additional documentation includes any provided surgical preparation. This may include clipping hair from the skin or administration of a laxative regimen as a bowel preparation. The nurse will need to document whether the preparation was completed by the health-care provider or the patient, the type of prep that was used, when it was completed, and whether the patient experienced any reactions.
Education provided to the patient should also be documented. The type of education provided and how the education was performed (e.g., over the phone, in person, verbally, written, return demonstration) during preadmission should be documented in the patient chart, as well as any additional education provided in the preoperative setting. An evaluation of the patient’s understanding should be included in the documentation.
When the time comes for the intraoperative nurse (discussed in Chapter 26 Intraoperative Care) to take the patient to the operating room, the preoperative nurse should perform and document a patient handoff (see 1.2 Intercollaborative Care for more information on ISBAR during a handoff). The handoff report includes verifying the patient demographics, completed consent, surgery being performed, allergies, history and physical from the surgeon within 30 days, abnormal labs, and the marking from the surgeon verifying the surgical site. Handoff report should also be performed with the patient present as an additional safety check. Documentation should include the information discussed in handoff, the date and time, who was involved in the handoff, how the patient is being transported to the OR, and who is part of the transportation to the operating room.
Preoperative Assessment
The goals of a preoperative assessment are to:
- address the state of the patient prior to the procedure
- identify any risks that can contribute to postoperative complications or delay recovery
- establish a baseline for future comparisons to assess any unexpected or expected findings after the procedure is performed.
Any risks identified allow for a plan of action to be created in order to avoid potential complications. For example, if a patient states that they have a history of postoperative nausea and vomiting, then the anesthesia protocol may allow a scopolamine patch to be ordered unless otherwise contraindicated. If the patch is contraindicated, the anesthesia provider may adjust the type of medications given in order to decrease the likelihood of postoperative nausea and vomiting.
Unfolding Case Study
Care of the Surgical Patient: Part 1
The nurse is performing a preoperative assessment on a 45-year-old female who presents to the preoperative check at 06:00 for a 09:00 surgery for a left partial knee replacement. The patient is accompanied by her husband. The patient has left knee discomfort on admission and has been taking ibuprofen for her knee pain. She stopped taking the ibuprofen 7 days ago per her provider’s orders. The patient is slightly anxious but expresses, “I can’t believe I have done this to myself,” “I don’t have the stamina and mobility I used to have and miss running so much,” and “I am so depressed.” Patient is quiet and appears withdrawn at times.
| PMH | 3/12/24, 0600 Patient has a history of playing high school and college sports as a track and field athlete. Patient had a left knee meniscus tear with arthroscopic repair 15 years ago and a patellofemoral arthroscopy repair 5 years ago. Patient had one miscarriage 12 years ago. Patient works full time as a grade schoolteacher. They do not have children. Patient states that she experienced a severe adverse reaction of post-op nausea and vomiting (PONV). Family History Father is living, has a history of a heart attack and tobacco use. Mother alive with osteoarthritis. One brother, healthy Social History Patient lives at home with husband. Never smoked and states she drinks only drinks 1-2 drinks/week. Patient stays physically active with a recliner air bike and walks as tolerated 5 times/week. The patient went to counseling after her second surgery 5 years ago but does not currently see a counselor. Current Medication Ibuprofen 800 mg every 6 hours (max dose 3200 mg/24 hr) No known allergies |
| Nursing Notes | Triage Assessment, 3/12/24, 0600 The patient is alert and oriented. The patient’s skin is warm and dry, easy respirations, no dyspnea noted. She arrived via wheelchair but does not use an assistive device. 3/12/24, 0630 Physical Examination HEENT: Pupils equal and reactive to light, mucus membranes dry, no thyroid enlargement. Lymphatic: lymphatic nodes were not swollen or enlarged Respiratory: 16, easy, good depth, no SOB noted. Lungs clear all lung fields on auscultation. Cardiovascular: NSR noted on monitor Abdomen: soft, denies pain, abdomen distended, bowel sounds present all four quadrants Musculoskeletal: Moves all extremities well with the exception of existing pain limiting the full flexion and extension of the left leg related to knee injury. Skin: Warm and dry Mental assessment: Patient admits to increased anxiety and depression. The patient has been NPO as of 10 pm last night. Document full assessment in the patient’s EMR/chart. |
| Flow Chart | Assessment, 3/12/24, 0600 Blood pressure: 110/70 Heart rate: 78 Respiratory Rate: 16 Temperature: 98.0 Oxygen Saturation: 99% room air Weight: 130 lbs Height: 5 ft 9 in Pain: 6/10 |
| Lab Results | Preop, 3/5/24 WBC, 8.0 × 103 cells/mm3 Platelet count, 200,000 Partial thromboplastin (PTT), 30 sec Prothrombin time (PT), 11 sec Hgb, 12 g/dl Hct, 41 % INR, 1.0 BUN, 14 mg/dl Creatinine, 0.09 mg/dl Fasting glucose, 84 mg/dl Na, 138 mEq/L K+, 3.8 mEq/L Cl, 100 mEq/L Liver function tests: ALT, 25 U/L AST, 19 U/L GGT, 20 U/L Total protein, 70 g/dL Total bilirubin, 11 mg/dL eGFR, 90 Rapid PCR-Covid test, negative Pulse oximetry, 99% RA Preop, 3/12/24 WBC, 8.0 × 103 cells/mm3 Platelet count, 200,000 per microliter Partial thromboplastin (PTT), 30 sec Prothrombin time (PT), 11 sec Hgb, 12 g/dl Hct, 41% INR, 1.0 BUN, 14 mg/dl Creatinine, .09 mg/dl Fasting BS, 84 mg/dl Na, 138 mEq/L K+, 3.8 mEq/L Cl, 100 mEq/L Liver function tests ALT, 25 U/L AST, 19 U/L GGT, 20 U/L Total protein, 70 g/dL Total bilirubin, 11 mg/dL eGFR, 90 Rapid PCR-Covid test, negative Pulse oximetry, 99% RA |
| Diagnostic Tests/Imaging Results | Preop Left knee X-ray: “repair of left knee meniscal tear with scar tissue formation, multipartite patellae as well as gross patella alta or baja,” post-surgical arthroscopy surgeries. CXR: normal ECG: normal, regular sinus rhythm |
| Provider’s Orders | Preop, 3/5/24 Left knee x-ray, anteroposterior, lateral and axial views CXR ECG CBC with differential Electrolytes Liver function studies Coagulation profile eGFR Covid test Hold ibuprofen for 7 days preoperative Consent obtained from provider for partial left knee replacement Preop, 3/12/24, 0600 Repeat electrolytes preop now Anesthesia provider to start IV Prep left knee for partial left knee replacement per standard preoperative orthopedic orders Confirm patient surgical consent has been obtained and patient understands what the surgeon will do during her surgery. The nurse will explain that once under anesthesia, the surgeon will inspect the left knee joint. The surgeon will make an incision at the front of the knee and explore the three compartments of the knee to verify that the cartilage damage is, in fact, limited to one compartment (unilateral), which is required for a partial knee replacement and that your ligaments are intact. If the surgeon feels that the knee is unsuitable for a partial knee replacement, the surgeon may instead perform a total knee replacement. Repeat labs in am if patient stays overnight: CBC with differential, Hgb, Hct, electrolytes, BS. |
Nutrition and Fluids
Adequate nutrition is key to aiding a body in the healing process and opposing infection or other complications. Assessing the nutritional status of a patient allows the preoperative nurse to identify any potential factors that can affect the patient’s surgery and recovery process, such as malnutrition, metabolic disorders, obesity, unexpected weight loss, nutrient deficiencies, and medication effects on nutrition. Any nutrient deficiencies noted need to be addressed prior to surgery, as optimal protein is needed to aid in tissue and wound healing. Height and weight should be taken again to confirm the body mass index (BMI) of the patient, as they may have gained or lost weight (or height for pediatric patients who are still growing). Weight is needed for accurate dosage calculation for anesthesia medications.
Monitoring the fluid status of a patient is also essential because hypovolemia, dehydration, and electrolyte imbalances (see Chapter 10 Fluid, Electrolyte, and Acid-Base Imbalances) can contribute to complications in older adults or those with other chronic health conditions or comorbidities. Patients undergoing bowel preparation are at risk for dehydration and chemical imbalances due to the depletion of fluids and electrolytes and fasting. Any identified fluid or electrolyte imbalances should be corrected prior to surgery. For example, a patient may need to have IV fluids administered prior to surgery, and some surgeons may allow a patient to continue to have water or Gatorade up to two hours prior to surgery. The nurse will need to follow the Enhanced Recovery After Surgery (ERSA) protocol per facility guidelines (Sung & Yuk, 2020).
Medications
Obtaining a patient’s medication history allows the preoperative nurse to identify any potential interactions or risks with any medications that may be administered during surgery. For example, patients taking blood thinners are at an increased bleeding risk associated with surgery, so these medications may need to be discontinued prior to surgery.
The patient’s medication history should include any prescribed medications, herbal supplements, vitamins, and over-the-counter medications. Some medications may be taken the day of surgery, while others may need to be discontinued for a recommended period of time to avoid risks of bleeding or interactions with anesthesia. Any medication that poses a risk should be outlined by the facility and anesthesia protocol, as well as instructions to provide to the patient with regards to stopping the medication. Some medications may require a clearance from the prescribing provider to stop. For example, a cardiac patient may be on aspirin or another blood thinner. The cardiologist (or prescribing physician) should clear the patient for surgery, giving approval for the patient to stop the medication and specifying how many days the patient should remain off the medication. Table 25.1 provides examples of common medications and treatments that are contraindicated before surgery because they increase the risk of bleeding (Sung & Yuk, 2020).
| Type of Medication | Examples |
|---|---|
| Anticoagulants | Warfarin, coumadin, heparin |
| Antiplatelet medications | Dipyridamole |
| Antibiotics | Flagyl, doxycycline |
| Antipsychotics | Thioridazine, thorazine |
| Corticosteroids | Hydrocortisone, prednisone |
| Herbal supplements | Gingko biloba, ginseng, St. John’s wort |
| Hormonal contraceptives or hormone replacement therapy | Oral birth control pills, estrogen creams/patches |
| Nonsteroidal anti-inflammatory medications | Aspirin, ibuprofen, naproxen |
| Tricyclic antidepressants | Anafranil, clomipramine, Elavil |
Many patients leave out the use of vitamins or herbal supplements during the medication assessment, so it is imperative the preoperative nurse specifically ask about their use. Common herbal supplements include garlic, ginger, St. John’s wort, echinacea, ginseng, ginkgo biloba, valerian root, and licorice extract. Many of these supplements can cause interactions with anesthesia or increase a patient’s risk of bleeding, so it is imperative that the preadmission testing nurse assess the patient’s use, as they may require discontinuation of one to two weeks prior to surgery.
Immune System
The function of the immune system is an important component to assess to determine if the patient has any allergies that may cause complications during or after surgery (e.g., medications, latex), as well as checking for the presence of an active infection. Infections may postpone a surgery and are usually detected by a urinalysis or obtaining a white blood cell count. Any allergies identified may alter the course of routine medications given during the surgical course. Allergies must be documented in the patient’s electronic medical record or paper chart, and a wrist band noting the allergy should be placed on the patient on a limb that does not interfere with the surgery. Allergies to medications, latex, foods, blood transfusions, and contrast should be assessed and identified, as well as the signs and symptoms associated with the reaction.
A special consideration with the immune system is if the patient is on or undergoing immunosuppressive drugs or therapies like corticosteroids, chemotherapy, radiation therapy, or if the patient has any immune system deficiencies. Examples of disorders that impact the immune system include HIV, AIDS, and leukemia. When the vital signs are obtained, any mild symptoms or temperature elevations must be reviewed in order to determine if surgery is a safe option for the patient at that time.
Alcohol and Drug Use
The use of alcohol and illicit drugs can greatly affect the anesthesia process. This can be a sensitive subject for patients to discuss, and they may not be honest. It is essential that the preoperative nurse ask direct questions about alcohol use in a nonjudgmental, caring, and patient manner. Those who consume larger amounts of alcohol respond differently to anesthesia and may require stronger medications or higher amounts of anesthesia. Any patient reporting daily drinking should be reported to anesthesia in order to determine if a change in the plan of care is warranted. Excessive alcohol use often leads to malnutrition and metabolic imbalances that can pose risks with surgery. Research has shown that patients who use substances, including alcohol and tobacco, have a higher risk of poor surgery outcomes, readmission, and reoperation. (Fernandez et al., 2022). Complications can include increased bleeding, cardiac events, vomiting, aspiration, sepsis, medication interactions, delayed recovery, stroke, and death.
Illicit or illegal drugs may increase the sedative effects of anesthesia and can lead to respiratory failure. Some drugs may also be associated with cardiac risks or other interactions when mixed with anesthesia. If a person presents for surgery under the influence or suspected under the influence of illicit or illegal drugs, the surgery will be cancelled to avoid complications or injury. In the event of emergency surgery, special precautions are implemented for those under the influence, such as using a local, regional, or spinal block. A nasogastric tube is inserted before general anesthesia in emergency cases to prevent vomiting and aspiration.
The use of alcohol and drugs can weaken a person’s immune system, which can deter healing, as well as increase the chances of postoperative complications. If the patient is admitted to the facility (inpatient) after surgery, they could experience symptoms of withdrawal from a substance, or detoxification. This situation will require special monitoring in the postsurgical unit. Signs of withdrawal from suddenly stopping alcohol include seizures, delirium, or death. A Clinical Institute Withdrawal Assessment (CIWA) scale should be used for patients experiencing detoxification (Canver et al., 2024).
Link to Learning
Review the Clinical Institute Withdrawal Assessment of Alcohol Scale – Revised from the British Journal of Addiction, which is used for assessing a patient’s withdrawal status.
Psychosocial Status
Surgery may trigger many emotions for some patients. Some people may experience fear or anxiety due to the unknown. Some may be anxious over the lack of control they have over the situation. Other people may be expecting the worst outcome, and the anticipation of pain is too much to handle. The nurse can relieve these symptoms by providing education related to each step of the procedure.
The preoperative nurse should assess the patient’s psychosocial state prior to surgery by asking questions and observing the patient’s behavior. Some patients may cry, be withdrawn, bite fingernails, talk excessively, avoid eye contact, or exhibit other types of behavior typical of someone experiencing anxiety. The nurse should remain empathetic, address concerns the patient may have, or ensure the patient has a support person nearby, when allowed. Some patients may be more relaxed when their loved one waits with them in their room before their surgery; some might prefer not to have family or a friend with them.
Cultural Context
Spiritual Surgical Care
Patient-centered care is culturally competent and spiritually aware care. The preoperative nurse should inquire about and honor any spiritual or cultural beliefs the patient has. If these beliefs are unable to be honored due to possible harm, the nurse should provide an explanation and offer an alternative, if possible. For example, a patient may request that a clergy come visit the patient before surgery.
A nurse who is culturally competent understands that in some cultures, it is more polite to avoid eye contact. When the nurse understands the cultural practice, they knowe that not making eye contact is not a sign of anxiety or fear in the patient but a sign of respect. Another example of cultural competence is in some Thai cultures, the top of the head is considered sacred. In this case, the nurse would allow the patient to put their own surgical cap on to avoid offending the patient by touching their head.
Preoperative Physical Assessment
An adequate preoperative physical assessment includes the assessing of all the systems of the body for optimal functioning. The baseline assessment data that are collected ensures the patient is stable for surgery and allows the postoperative nurse to compare their data to the baseline. Any abnormalities or unexpected findings in the preoperative physical assessment should be investigated further prior to surgery. If those findings are found postoperatively, the postoperative nurse will have a protocol to follow to investigate further.
Respiratory
The respiratory system is assessed prior to surgery and includes breathing pattern, respiratory rate, breath sounds, work of breathing, and oxygen saturation. Elective surgeries may be postponed for patients who have poor or weak vitals, or present with a respiratory infection. Patient history is also obtained to identify patients with respiratory disorders as well as those with any recent changes in their respiratory status. A chest X-ray may be ordered prior to surgery depending on the type of surgery or if the patient has had new or worsening respiratory symptoms.
Patients who smoke should be educated to stop smoking 30 days prior to surgery to aid wound healing and reduce pulmonary complications. Those who smoke are at higher risk for delayed wound healing, surgical site infection, pneumonia, and venous thromboembolism (Fernandez et al., 2022). Smoking cessation education and materials should be provided to the patient.
When needed, patients will be educated about the use of an incentive spirometer or tool used for breathing exercises to promote lung function postsurgery. This education is important to be performed prior to the administration of any anesthesia medications, so that the patient is able to fully inhale and exhale in order to set the appropriate goals. This is important to the patient’s ability to fully inflate the lungs when breathing after surgery to prevent pneumonia or atelectasis.
Link to Learning
Watch this video to learn how a patient can use an incentive spirometer to fully inflate the lungs, taking slow, deep breaths.
Cardiovascular
Assessment of the cardiovascular system prior to surgery includes obtaining baseline blood pressure and heart rate; assessing capillary refill time; obtaining peripheral or radial pulses (as appropriate); and obtaining the patient’s history and verifying medications. An ECG may also be performed prior to surgery. Surgery may be postponed for patients with uncontrolled dysrhythmias or uncontrolled heart rate until the condition is resolved or the patient has been cleared by a cardiologist.
Renal and Hepatic
The kidneys and liver metabolize and filter out wastes, toxins, and medications. It is essential to ensure that the renal and hepatic systems function optimally before, during, and after surgery, as these systems are integral to the clearance of medication (including anesthesia) and waste from the body. The following blood tests may be ordered to assess their functionality: liver function tests (ALT, AST, GGT, total protein, bilirubin, LDH), CMP, PT/INR, eGFR, BUN, and creatinine. A urinalysis may also be performed to check for color, cloudiness, odor, the presence of acid, albumin, bacteria, glucose, or specific gravity for urine concentration.
Patients with poor liver function are at higher risk for surgical mortality due to the inability to effectively metabolize anesthesia medications. Elective or non-emergent surgeries may be postponed, allowing time for interventions that will increase liver function. Surgery may be contraindicated in those with acute renal insufficiency, oliguria, anuria, or acute nephritis. However, exceptions include life-saving surgeries, procedures aimed at improving renal function, or surgeries to provide dialysis access.
Endocrine
Endocrine disorders that impact surgery include diabetes, thyroid disorders, and Addison’s disease. Poorly controlled diabetes and hyperglycemia increase the risk of slowed surgical site healing and infection. The patient’s blood glucose should be monitored preoperatively, intraoperatively, and postoperatively. Facility protocols should be implemented if the fasting blood glucose is too high or low. Patients with hyperthyroidism are at risk for thyrotoxicosis, while patients with hypothyroidism are at risk for respiratory failure. Patients should be educated on the importance of continuing with their thyroid medications prior to surgery to ensure their thyroid levels remain controlled. Patients taking corticosteroids are at risk for surgical complications. Corticosteroids can have a negative impact on adrenal function. The use of corticosteroids within the last year should be reported to the anesthesia provider or surgeon as soon as possible. The patient will need to be monitored for signs of adrenal insufficiency. Close monitoring is also paramount for patients with Addison’s disease, in which an adrenal crisis may be triggered by fasting, the stress of surgery, or medications.
Preoperative Patient Care
Patient care in the preoperative setting may include skin preparation, bowel preparation, and education. Some preparation may be performed at home by the patient or by the preoperative or intraoperative nurse on the day of surgery. Skin preparation and bowel preparation should be followed per surgeon order or per facility protocol if there is no surgeon specification.
Skin Preparation
Skin preparation is essential to prevent infection. Some surgeons may request the patient’s hair be clipped if the hair interferes with the procedure or the surgeon’s field of vision. For example, if the surgeon is using a microscope, hair can interfere with the surgeon’s ability to see. Patients should be educated to not shave at home to reduce risk of skin injury or infection. If hair removal is necessary, the nurse will perform it prior to the procedure. Other skin care may include the patient’s use of a surgical or antibacterial soap prior to coming to the facility. The preoperative nurse may also use a type of skin preparation such as iodine or chlorhexidine gluconate the day of surgery.
An important component of skin preparation is for the surgeon to mark the site where surgery is to be performed prior to surgery. The surgery site should be verified by the preoperative and intraoperative team as part of a safety handoff prior to the patient transferring to the operating room.
Bowel Preparation
Bowel preparation is only warranted for procedures where the patient is undergoing an abdominal or pelvic procedure. Laxatives or enemas may be prescribed for the patient to perform at home or by the preoperative nurse if the patient is admitted prior to surgery. Complete bowel elimination allows the surgeon to see inside the intestines clearly and reduces the potential for infection from fecal matter, if an accidental perforation happens during surgery.