Learning Objectives
By the end of this section, you will be able to:
- Describe the nursing care plan to ensure patient safety during the preoperative phase
- Describe the nursing care plan to initiate the prevention of complications during the preoperative phase
- Discuss the role of the nurse in providing education and psychosocial support to the patient and their family
The preoperative nursing care plan includes interventions aimed at preparing the patient both physically and psychologically for the procedure while prioritizing patient safety. The nurse must be familiar with the patient’s history, preadmission assessment and diagnostic results, surgeon orders and preferences, type of procedure, any special positioning required during the surgery, and type of anesthesia being used to adequately prepare the patient for surgery. The preoperative phase affects the entire surgical and recovery process, so it is crucial that the nurse effectively prepares the patient for surgery and documents nursing interventions.
Nursing Care Plan for the Preoperative Patient
The nursing care plan for the preoperative patient encompasses a variety of nursing interventions aimed at maintaining the safety of the patient and preventing complications. It’s important for the nurse to remember that every patient is at risk for becoming overwhelmed, confused, and anxious, or developing infections and complications like fluid and electrolyte imbalances and blood loss. While there will be patients who will be at a higher risk, the nurse should still take care to prepare all patients for their procedures.
Ensuring Patient Safety
Patients undergoing a procedure may experience anesthesia complications, physiological stress on the body, and the invasiveness of the procedure itself. To ensure patient safety in the preoperative phase, the nurse must ensure that the patient is stable enough to undergo the procedure by obtaining vital signs, obtaining any laboratory tests that were not done during the preoperative testing or need to be repeated, verifying medications taken or held for surgery, and taking steps to prevent a wrong-site surgery. The nurse must perform a proper preoperative assessment and surgical preparation, such as administering medications as ordered and hair clipping around the surgical site, if necessary. They will also monitor and manage the patient throughout the preoperative phase. Jewelry should not be worn into the operating room due to the risk of injury.
Interdisciplinary Plan of Care
Preoperative Team
Interdisciplinary care is vital to patient outcomes and patient safety. Each member of this team has their own role in the plan of care for a surgical patient. The following members play a vital role in the preoperative stage:
Surgeon: the provider who orders and performs the surgery, provides patient with vital information for informed consent, typically sees patient for a preoperative and postoperative appointment.
Anesthesia provider: the provider who provides anesthesia for the surgery, performs assessment prior to surgery, develops and explains anesthesia care plan to patient, oversees anesthesia care if a certified registered nurse anesthetist is present for surgery. A certified registered nurse anesthetist (CRNA) is an advanced practice RN who has received special training to administer anesthesia.
Preoperative nurse: the nurse who analyzes patient history, verifies surgery and informed consent, reviews medication, performs assessment, preps patient for surgery, reports any findings that may impact surgery or patient safety.
Other members may include:
- A social worker in the event the patient is in need of financial assistance
- A radiologist may be needed for any preoperative scans or X-rays
- A dietician to assist the patient with nutrition after surgery
- Medical interpreters may be needed when the patient does not read, speak, or understand English
Patient Identification
Patient identification is an important component of patient safety. The nurse must verify the patient’s name and date of birth and ensure that the patient has an ID wrist band. The nurse should also have the patient verify that the spelling of their name is correct. Any time the nurse is part of a patient handoff, the receiving nurse and transferring nurse should both verify patient name and date of birth comparing the wrist band to the patient chart and orders. This is especially important if the patient has received anesthetic agents and is not able to speak coherently.
Preventing Wrong-Site Surgery
Preventing wrong-site surgery is crucial to patient safety. Wrong-site surgeries are considered a sentinel event, or any unexpected event that causes serious harm to a patient or leads to death. Multiple steps are followed leading up to the surgery to prevent this from happening. As mentioned in 25.1 Preadmission Assessment and Education, the preoperative testing process is the first chance to ensure that the surgery the patient states they are having matches the surgical orders and consent. On the day of surgery, the preoperative nurse should ask the patient again to state in their own words the surgery they are having, including having them state the location of the surgery site without any coaching. For example, a patient having a joint replacement would be asked not only what surgery they are having, but also to identify the extremity and joint that is being replaced. The preoperative nurse should check the patient’s statements against the orders and consent. If they do not match, the nurse should contact the surgeon to correct the surgical orders and consent. The nurse should ensure any prep is being performed on the correct site and that the surgeon has marked the site correctly (Figure 25.2). Once the patient is ready to transfer to the operating room, a safety handoff is performed between the preoperative and intraoperative nurse to confirm the surgery and laterality with the patient and confirm with the orders, consent, and site the surgeon has marked.
Preoperative Laboratory Tests
While many tests can be performed during preadmission testing, some laboratory tests are not performed until the day of surgery for accuracy. For example, a pregnancy test performed the day of the surgery is more current than days prior to the surgery to confirm whether a patient is pregnant. A blood test may be done the day of the surgery for accuracy (Wechter, 2024). Fasting blood glucose should be assessed the day of the surgery to ensure that the patient has a stable blood glucose before undergoing the procedure.
Blood type screening for AB antibodies, in case of an emergency and blood transfusions are needed, can be done prior to the surgery date as well. However, most facilities have a policy that a blood identification wrist band is good for a certain period of time. The nurse will need to follow facility protocol on the timing of blood typing. The preoperative nurse should review the results prior to the patient going into surgery to ensure any lab or diagnostics are within range to not cause harm to the patient. Any critical or abnormal values should be reported to the surgeon and anesthesia provider.
Medication Safety
Another way to ensure patient safety is to verify the patient’s medication list and when the last dose of each medication was taken. Some medications can interact with anesthetic agents and have major complications or risks, and some medications can pose a risk of heavy bleeding. The preoperative nurse should be familiar with the medications that pose risks and make sure that the surgeon is aware of any medications that were taken that could cause harm to the patient during the procedure. The nurse should also verify allergies, ensure that the patient has an allergy band if they do have an allergy, and ensure that the allergy is documented in the patient’s chart. The nurse should also confirm with the patient the symptoms associated with the allergy and ensure that the intraoperative and anesthesia teams are aware.
Prevention of Complications
The preoperative nurse is typically the first health-care professional to meet the patient the day of surgery. They are in the position to assess for risks, verify patient information, obtain a baseline of vital signs, confirm that surgery site and laterality are correct, and get the patient’s consent. The nurse will also ask the patient questions, such as:
- When they last ate or drank
- Medication history and last doses
- Last shower
- Wounds or rashes
- Metal or implants in the body
- Use of corrective devices
- Previous problems with anesthesia
- Allergies and associated symptoms
- Who will take them home after the procedure
While the preoperative nurse is not in the operating room with the patient, there are interventions they can implement to help prevent complications during surgery. Patients having surgery are at risk for a variety of complications, including anesthesia complications, aspiration, injury, blood clots, and infection. Diligent care by the preoperative nurse helps minimize these risks. Ensuring a thorough and accurate assessment and history of the patient is crucial for their safety. The preoperative nurse should review the patient’s chart and be familiar with the patient’s history and ask any questions that need clarification. For example, a patient’s medications must be reviewed in case they have started any new medications between their preoperative appointment and the surgery, and any that could pose a risk must be reported to the surgeon in case the procedure needs to be delayed to avoid harm.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Safety
Definition: “Minimize risk of harm to patients and providers through both system effectiveness and individual performances” (Quality and Safety Education for Nurses, 2020, Table 5).
Knowledge: The nurse will analyze basic safety principles, understand evidence-based practice standards, be familiar with facility and anesthesia protocols as well as state regulations, and reflect on unsafe nursing practices (for instance, stating the surgery rather than the patient stating the surgery and laterality in their own words).
Skill: Demonstrate effective use of strategies to reduce risk of harm to self or others, the nurse will:
- Describe factors that facilitate a culture of safety in surgery, such as time outs (see 26.3 Intraoperative Nursing Management), obtaining health history, performing assessments, medication reconciliation
- Value personal role in error prevention (verifying surgical sites, medications)
- Value the contribution of reliability for safety (preventing patient harm or near-miss events)
- Use national patient safety resources for own professional development (National Patient Safety Goals from The Joint Commission)
- Communicate observations or concerns related to hazards and errors to patients, health-care team members, and families (for example, if the patient states a different laterality than the surgeon, then the nurse should clarify and correct to ensure the correct site surgery is performed)
- Examine human factors and other basic safety design principles
- Examine commonly used unsafe practices (not verifying laterality, not reading over patient health history, not verifying medications)
- Value continuous improvement of own conflict resolution and communication skills
Attitude: Nurses caring for those undergoing surgery must prioritize patient safety and exhibit the practices listed precedingly. Surgery is a special instance where patients are not always able to advocate for themselves due to anesthetic agents, pain medications, mental state, health status, or the type of injury. The nurse must be aware of the vulnerability of the patient, be prepared to intervene when necessary, stopping immediately if something that threatens patient safety is suspected or apparent. The nurse possesses the knowledge and skills needed to promote optimal patient outcomes and uses clinical judgment to maintain patient safety.
(QSEN Institute, n.d.)
Decreasing Complications with Anesthesia
Some complications that may arise with anesthesia include:
- Anaphylaxis or allergic reaction
- Malignant hyperthermia
- Tooth damage
- Nausea and vomiting
- Aspiration
- Nerve injury
- Stroke
- Respiratory depression
- Cardiac events
- Awareness under anesthesia
- Embolisms
The anesthesia provider or CRNA will be monitoring the patient throughout the procedure to prevent complications and be able to intervene quickly if necessary. The preoperative nurse should ensure an adequate history of allergies and anesthesia and report any previous problems with anesthesia that the patient or a blood-related family member has experienced. The patient’s teeth should be examined prior to surgery to identify any loose teeth or potential for damage due to intubation. Patients with a history of nausea and vomiting are at risk for aspiration. The anesthesia provider may request the preoperative nurse apply a scopolamine patch to the patient, or they may opt to adjust the anesthesia medications through the IV to aid with preventing nausea and vomiting. Special precautions are implemented for patients with a personal or family history of malignant hyperthermia, a serious genetic condition that causes a life-threatening elevation of body temperature and muscle spasms, among other severe symptoms. The preoperative nurse must follow the facility and anesthesia protocol.
Decreasing Aspiration Risk
To prevent aspiration, the preoperative nurse must assess when the patient last had anything to eat or drink. If the patient ate breakfast or had a large amount of something to drink prior to coming into a procedure, they are at risk for vomiting during surgery. If the patient vomits, they are at risk for aspiration. If the nurse suspects the patient is not being truthful, they should educate the patient about the risks of aspiration. A patient who experienced nausea and vomiting with a past surgery is also at risk for aspiration.
Decreasing Injury Risk
The preoperative nurse can aid in decreasing injury risk by assessing the patient and ensuring a thorough history has been obtained. The preoperative nurse should be aware of the patient’s position during the surgery, as this aids in the decision of where to place an IV line that is not in the way or poses a risk of injury to the patient. Swelling could also occur due to positioning and pose injury risk or impaired circulation. The preoperative nurse assesses for any metal or jewelry on the patient, which can pose a burn risk in the operating room. Metal such as jewelry can cause sparks and is a fire hazard. Patients may be able to leave on various clothing items as long as there is no metal present. To avoid pressure injuries, the intraoperative nurse is generally the one to implement those interventions, as the patient will transfer to an operating room bed in the operating room.
Decreasing Clot Risk
Depending on the surgery, the surgeon may order compression stockings or thromboembolic deterrent (TED) hose for the patient to be worn on either both legs or a specific leg. These garments help stimulate blood flow to help reduce the risk of clots after surgery, particularly in patients who will be spending time immobile or in bed. While the preoperative nurse is applying the TED hose, they should explain to the patient how to appropriately put them on and to ensure they are not up walking without socks or shoes that provide traction to avoid slipping. The surgeon may also order sequential compression devices to be used on a patient during a surgery, or the facility may have protocols in place for surgeries over a certain length of time. The patient should be educated on how to prevent blood clots postoperatively. Interventions include frequent position changes, walking as soon as possible (unless contraindicated), and the use of compression stockings or hose.
Decreasing Infection Risk
One of the main goals of a preoperative nurse is to prevent infection. Surgical site prevention is crucial, as the number of identified infections continues to increase. The burden of surgical site infections (SSIs) has been shown to be increasing over the last 10 years (Utzolino et al., 2021). This is due to the increasing number of comorbidities patients are presenting with and the number of surgical procedures being performed continuing to rise. According to the CDC, over half of SSIs are deemed preventable using evidence-based strategies (Utzolino et al., 2021).
The patient’s vital signs and bloodwork should be analyzed for potential signs of infection, and any abnormalities should be reported to the provider. The patient’s skin is assessed for any wounds or rashes. The preoperative nurse must take special care in performing skin preparation to the surgical site per facility or surgeon order and explain to the patient that the intraoperative nurse will repeat the skin preparation in the operating room as well.
Link to Learning
The CDC defines surgical site infections as well as provides guidelines on how to prevent the infections. Many of these guidelines are tools that have been adapted by facility protocols and surgeon orders to aid in preventing surgical site infections. However, the patient must understand their role at home in preventing infection as well.
Patient and Family-Centered Care
Patient and family-centered care can have a positive impact on the surgical experience, as fear or anxiety is common among people undergoing surgery and their families. Preoperative nurses provide patient and family-centered care by focusing on education, reducing anxiety and fear, and providing emotional support.
Education
Some fear and anxiety associated with surgery can be due to the patient or family being unaware of what to expect. The preoperative nurse should explain what to expect on the day of surgery. For example, the patient should be informed of all the steps that will be taken in preop, what transferring to the operating room looks like, where the patient will recover, and about how long the patient will be in recovery as long as there are no complications. The nurse should educate the family about where they will wait while their loved one is in surgery and that they will be reunited with the patient once the surgery is completed and the patient is stable in the recovery room.
Education should also include any preparation performed in preop. If compression devices such as TED hose are required, the patient and family should be instructed on how to put them on, the need to smooth out wrinkles, and not to walk around without assistance or nonslip socks to avoid falling. Any skin preparation should also be explained, as well as any signs of intolerance or allergies. For example, if iodine was used, the patient should be educated to contact the surgeon’s office if any rashes, hives, itching, or other symptoms appear. The preoperative nurse should also educate on any medications given in preop, side effects, and why they are being given.
The preoperative nurse should ask if the patient or family has any questions. If it is anything related to the surgery, its risks and benefits, or alternatives, the nurse should direct those questions to the surgeon to ensure the patient has informed consent of the procedure. Most postoperative education is given in the PACU by the postoperative nurse unless the physician has already outlined their instructions. If the surgeon has prepared postoperative instructions, the preoperative nurse can provide those as well.
Reducing Anxiety and Fear
If the patient or family is still experiencing anxiety or fear after the nurse has provided education, the preoperative nurse should ask if there is anything specific that they are nervous about. The nurse can address those concerns if it is something that the nurse knows the answer to. If the nurse is unsure of the answer, they should inform the patient they will find out and come back with an answer. Some resources may be available if it is a financial concern, such as contacting a social worker. If a patient requests prayer or a visit from a spiritual advisor, the nurse should make accommodations.
Most facilities have a way for the family to monitor the patient while they are in surgery. The preoperative nurse should ensure that the family is aware of how to track their loved one throughout surgery. Some patients and families may be concerned about the length of the surgery or how long the patient has been in the operating room. The nurse should assure them that the length of time has no bearing on the severity of an operation. The length of time is determined by preparation that needs to be performed by anesthesia and the intraoperative team prior to the surgeon starting the case. In addition, some patients are taken to the preop holding area in advance of the surgery starting, and the surgeon could still be in a previous surgery, causing a delay in the surgical start time of their family member.
Providing Emotional Support
Preoperative nurses can provide emotional support by active listening and remaining empathetic. The nurse should encourage the patient to be a part of the care plan in order to provide person-centered care. There is usually a waiting area with amenities (drinks, snacks, television) for the family while their loved one is undergoing surgery. Some facilities even have resources available to visitors, such as notary services, in the case legal documents like advance directives need to be signed. A staff member should also provide frequent updates on the progress throughout the procedure.
Clinical Judgment Measurement Model
Applying the CJMM to the Preoperative Patient
Recognize and Analyze Cues
Before recognizing cues, nurses must make sure they have enough information about a patient’s situation before interpreting the information and developing a plan of care. For example, the preadmission testing nurse completes a health history prior to the patient’s arrival at surgery. On the day of surgery, the preoperative nurse reviews the patient’s health history, performs an assessment, and verifies the patient’s medication list is up to date and accurate.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
When the nurse considers the patient’s history and assessment, they can then move on to the next step of the CJMM to prioritize a hypothesis and take action. During this step in the preoperative phase, the nurse will need to use their knowledge and skill to determine the patient’s safety. For example, any unexpected wounds or rashes that could interfere with the surgery or pose risk of infection or any medications taken that were not supposed to be taken day of surgery need to be addressed with the surgeon and anesthesia provider to ensure the patient is safe to undergo the procedure. If the patent is safe to undergo the procedure, the nurse can continue with any surgeon orders or preferences per facility protocol like skin preparation, starting an IV, administering fluids, administering medications, drawing labs for diagnostic testing, and notifying respiratory therapy to come in for any incentive spirometer education or ECG testing. The nurse will also assess and care for the patient’s psychosocial status as well.
Evaluation of Nursing Care/Evaluating Outcomes
After the surgical preparation has been performed, the nurse should verify the patient’s tolerance. For example, the nurse should verify that the patient did not have any signs of allergic reaction with any medications or skin preparation. The nurse should also verify the results of any testing performed. Any abnormal or critical values should be reported to the surgeon. Some values may warrant the surgery to be postponed or warrant intervention, like a medication to be administered prior to surgery. Any education given to the patient in preop should be assessed for patient understanding. The nurse should document any interventions performed, patient tolerance, education given, and patient understanding (return demonstration, verbalized). In the event of any undesirable outcome, the nurse may have to start over with the Clinical Judgment Measurement Model in order to reach an optimal outcome. However, with surgery, if the patient is unable to have surgery on that day, the Clinical Judgment Measurement Model will start over when the patient comes back in for surgery.
(National Council of State Boards of Nursing, n.d.)