Preoperative care

Introduction

Preoperative care is the preparation and management of a patient before surgery.

Preoperative care begins when the practitioner plans the surgery and ends with the
administration of anesthesia. This phase of care includes a preoperative interview and
assessment to collect baseline subjective and objective data from the patient and family;
diagnostic tests, such as urinalysis, electrocardiography, and chest radiography; preoperative
teaching; informed consent from the patient; and physical preparation. 1 The main emphasis
of preoperative care is to identify risk factors that may increase surgical or postoperative
complications. Preoperative teaching should stress the importance of pain management and
prevention of postoperative complications. 1

If the patient is having same-day surgery, preoperative nursing interventions include providing
instructions before the day of surgery that cover arrival time to the facility, the need to leave
all jewelry and valuables at home, the need to have someone accompany and stay with the
patient after surgery, fasting guidelines, medication use, and any prescribed surgical
preparation, such as showering with an antimicrobial cleanser. 1

The nurse is responsible for performing a patient assessment and ensuring collection,
documentation, and communication of all data. 2

Equipment
Vital signs monitoring equipment
Stethoscope
Pulse oximeter and probe
Scale
Tape measure
Patient gown
Warm blanket
Facility-approved pain assessment scale
Facility-approved postoperative nausea and vomiting assessment tool
Preoperative checklist
Prescribed medications
Prescribed IV fluids
Patient education materials
Blood glucose monitoring supplies
Disinfectant pad
Optional: gloves, gown, mask with face shield or mask and goggles, IV catheter
insertion supplies, cardiac monitor with leads and electrodes, specimen collection
supplies, clippers, antiseptic mouthwash

Preparation of Equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has compromised
integrity, remove it from patient use, label it as expired or defective, and report the expiration
or defect as directed by your facility.
Implementation

Verify the practitioner's orders.

Gather and prepare the necessary equipment and supplies.
Review the patient's preadmission assessment findings, including X-rays, laboratory test
results, and other preoperative test findings, as indicated. 3 4
Perform hand hygiene. 5 6 7 8 9 10
Put on personal protective equipment, as needed, to comply with standard
precautions. 11 12 13
Confirm the patient's identity using at least two patient identifiers. 14
If the patient is having same-day surgery, ensure that arrangements are in place for
someone to accompany the patient home after surgery. 2 (See the "Preoperative patient
care, ambulatory surgery" procedure.)
Provide privacy. 15 16 17 18
Explain all procedures to the patient and family (if appropriate) according to their
individual communication and learning needs to increase their understanding, allay their
fears, and enhance cooperation. 19
Obtain a health history, including previous surgery, recent myocardial infarction (within
previous 60 days), 3 skin condition, immunization status, history of multiple drug-
resistant organisms, external or implanted medical devices, sensory limitations, and
home use of noninvasive positive-pressure ventilation or apnea monitors. 2 20 Use your
facility's preoperative surgical assessment database, if available, to gather this
information.
Assess the patient's knowledge, perceptions, and expectations about the planned
surgery. 3
Ask whether the patient has any known allergies to latex, medications, food, or other
substances to determine the risk of an allergic reaction. 2 20
Ask whether the patient has a personal or family history of a serious reaction to
anesthesia or intraoperative awareness (also known as anesthetic awareness). 2
Obtain a complete list of medications that the patient uses, including prescription drugs,
over-the-counter medications, herbal preparations and supplements, alcohol, tobacco,
and illicit drugs. 3 2 20 21 22 It may be necessary to adjust or continue medications
whose sudden cessation may provoke a withdrawal syndrome. 23 In addition, certain
herbs (nutraceuticals) have unknown interactions with anesthetic drugs and effects on
blood coagulation. Consult with the practitioner about discontinuation before surgery
and continuation after surgery for any medications that the patient is taking.
If the patient was taking a beta-adrenergic blocker, collaborate with the patient's
practitioner to make sure that the patient continues to receive it during the perioperative
period, as appropriate. 24
Ask whether the patient has an advance directive. 25 26 Provide information about
advance directives, as appropriate. (See the "Advance directives" procedure.)
Obtain the patient's height, weight (in kilograms), vital signs, and oxygen saturation
level using pulse oximetry. 2 20
Screen for and assess the patient’s pain using facility-defined criteria that are consistent
with the patient’s age, condition, and ability to understand. 23 27
Obtain a pain and analgesic history; ask about measures that have helped to effectively
relieve or control pain in the past. Also ask about expectations for controlling pain after
surgery. By obtaining a thorough pain history preoperatively, the health care team may
be able to better control pain postoperatively. 2 20
Perform educational, socioeconomic, cultural, and spiritual assessments to determine
the patient's level of understanding about the surgical procedure and to identify any
 special needs the patient might have while in the facility. 2 20
Assess for mobility limitations and disabilities, including mental and physical
impairments, that may require the use of additional equipment or supplies.
Assess and address the patient's safety needs, including the risk of falling, and
implement fall prevention interventions, as needed. 2 20 22 28
Assess the patient's risk of postoperative nausea and vomiting (PONV) to help determine
whether PONV prophylaxis should be administered to decrease postoperative
discomfort. Use a facility-approved PONV assessment tool, if available. Consider risk
factors, such as the patient's history of PONV and motion sickness, gender, and smoking
history; the duration and type of surgery and anesthesia; and the potential use of
postoperative opioids. 2 20 29 30
Assess the patient's cognitive and mental status, cardiopulmonary status, 22 31 skin
condition, functional and sensory limitations, and use of any hearing or visual aids and
assistive or prosthetic devices. Obtain other assessment data as pertinent to the surgical
procedure. 2 3 20
Perform a suicide risk assessment. 2
Identify risk factors that may interfere with a positive expected outcome. Be sure to
consider age, general health, medications, mobility, nutritional status, fluid and
electrolyte disturbances, and lifestyle. Also consider the location, nature, and extent of
the surgical procedure. 20

Elder alert: Be aware that postoperative delirium is a common complication of surgery in

elderly patients. 22

Provide patient education using methods appropriate to the patient's and caregiver's
preference, reading level, and level of understanding, addressing any potential visual
impairments. 32 Include typical events that the patient can expect. Explain the incision,
dressings, and staples or sutures that the surgeon typically uses. Use the teach-back
method to assess comprehension and to guide additional teaching, if
needed. 2  Preoperative teaching can help reduce postoperative anxiety and pain,
increase patient adherence, hasten recovery, and decrease length of stay. 20
Teach the patient how to use a pain assessment scale that's appropriate for the patient's
age, condition, and ability to understand. Tell the patient how to rate and report pain,
and discuss relevant analgesic tools and methods such as patient-controlled
analgesia. 20 23 27 33
Provide patient and family education on behavioral pain control techniques, such as
biofeedback and progressive relaxation, to help the patient manage perioperative pain
and anxiety. 20 23
Discuss possible postoperative equipment, such as nasogastric tubes and IV
equipment. 2 20
Determine whether the patient will require home health care services; if so, help make
the necessary arrangements. 2 20
Teach the patient the importance of performing coughing and deep-breathing exercises
(while splinting the incision, if necessary) after surgery to minimize respiratory
complications.
Explain the importance of frequent repositioning, extremity exercises, and early
progressive ambulation after surgery to minimize complications associated with
immobility. 20 34

Clinical alert: Be aware that a patient who's undergoing ophthalmic or neurologic surgery
should avoid coughing because coughing increases intracranial pressure.
 Talk the patient through the sequence of events from the operating room (OR), to the
postanesthesia care unit, and back to the patient's room, an intensive care unit, or a
surgical care unit, as appropriate, to allay the patient's anxiety: 20
When discussing transfer procedures and techniques, describe sensations that the
patient will experience.
Tell the patient that the use of a stretcher is necessary for travel to the OR and
explain the procedure for transfer from the stretcher to an OR table. Explain that,
for safety reasons, the patient will be held securely to the table with soft straps.
Tell the patient that the OR might feel cool.
Explain that the OR nurses will frequently check the patient's vital signs and may
put electrodes on the patient's chest to monitor the heart rate during surgery.
Describe the drowsy floating sensation that the patient will feel as the anesthetic
takes effect. Explain the importance of relaxing at this time.
Tell the patient about the need to fast before the procedure according to the
practitioner's order to reduce the risk of vomiting and aspiration. Minimum fasting
recommendations include 2 hours for clear liquids, 6 or more hours for a light meal or
nonhuman milk, and 8 or more hours for fried foods, fatty foods, and meat. 35
If the patient is undergoing colorectal surgery, administer a combination of parenteral
and oral antimicrobial agents, if ordered by the practitioner, following safe medication
administration practices to reduce the risk of surgical site infection. 36 37 38 39 If
ordered, administer a mechanical bowel preparation in combination with oral
antimicrobial agents. Research supports the use of oral antimicrobials in combination
with a mechanical bowel preparation to reduce the risk of surgical site infection. 40 Be
aware that routine use of vancomycin isn't recommended for antimicrobial prophylaxis;
instead, it should be reserved for special clinical situations. 40
Advise the patient not to shave or remove hair at or near the surgical site before surgery
to reduce the risk of surgical site infection. 41 Also tell the patient to clean the skin the
night before or the morning of surgery. Some studies support the use of 2%
chlorhexidine cloths wiped on the surgical site the night before and the morning of
surgery for specific procedures, such as cardiothoracic and total joint procedures. 3 40
If ordered, administer an antiseptic mouthwash and have the patient gargle with it;
research supports gargling with bactericidal mouthwash to reduce bioburden in the
oropharynx. 42
Obtain IV access, as needed and ordered, and begin IV fluid administration to provide a
route for medication administration and to prevent dehydration caused by the required
nothing-by-mouth status. (See the "IV catheter insertion" procedure.)
Remove and discard your personal protective equipment, if worn. 13
Perform hand hygiene. 5 6 7 8 9 10
Clean and disinfect your stethoscope with a disinfectant pad. 43 44
Perform hand hygiene. 5 6 7 8 9 10
Document the procedure. 45 46 47 48

On the day of surgery

Verify the practitioner's orders.

Confirm that informed consent has been obtained and that the signed consent form is in
the patient's medical record. 49 50 51 52 (See the "Informed consent" procedure.)
Conduct a preprocedure verification to make sure that all documentation, related
information, and equipment are available and correctly identified with the patient's
identifiers. 4 53
Verify that ordered laboratory and imaging studies have been completed and that the
results are in the patient's medical record. Notify the practitioner of any unexpected
 results.
If ordered, confirm completion of blood typing and crossmatching and verify that
appropriate blood is available and ready for possible transfusion. 1
Perform hand hygiene. 5 6 7 8 9 10
Confirm the patient's identity using at least two patient identifiers. 14
Assess the patient's vital signs to serve as baselines for comparison during and after the
procedure.
Collect additional laboratory specimens and perform other tests, such as an
electrocardiogram, as indicated and ordered. 2
Ensure patent IV access.
Implement measures to prevent surgical site infection:
Don't remove hair at the operative site unless the presence of hair would interfere
with the operative procedure. If hair removal is necessary, remove the hair using
clippers; don't use a razor. 3 40 41
Administer a prophylactic antibiotic within 1 hour before incision (2 hours for
fluoroquinolones and vancomycin), as prescribed, following safe medication
administration practices, to maximize tissue concentration. 36 37 38 39 40 41
Obtain the patient's blood glucose level, as ordered, to identify hyperglycemia;
initiate treatment as needed and ordered. 41

Hospital-acquired condition alert: Keep in mind that the Centers for Medicare and
Medicaid Services considers surgical site infection after certain cardiac surgeries, bariatric
surgeries, and orthopedic procedures a hospital-acquired condition because it can be
reasonably prevented using a variety of best practices. Make sure to follow evidence-based
infection-prevention techniques, such as using clippers for hair removal, administering
prophylactic antibiotics before incision, maintaining normothermia, and monitoring for
hyperglycemia, to reduce the risk of surgical site infection. 41 54 55

Administer ordered preoperative medications, including analgesics as part of a

multimodal analgesic pain management program, following safe medication
administration practices. 23 36 37 38 39
Complete a preoperative checklist, such as the World Health Organization's Surgical
Safety Checklist.

Provide support to the patient and family.

Notify the surgeon and anesthesia care provider about any abnormal assessment
findings and document responding orders. 2
Assess the patient's retention of preoperative teaching and reinforce education, as
indicated. 2 20
Make sure that the patient is accompanied by a responsible adult who can provide
transportation home and assume the patient's care after discharge. Instruct the patient
not to drive to maintain patient safety. 2
Allow loved ones time to be with the patient before surgery so that the patient feels
comforted and supported preoperatively by the physical and emotional presence of the
family. 56

Just before moving the patient to the surgical area

Make sure that the patient's vital signs are documented in the patient's medical record.
Make sure that the patient is wearing a hospital gown and identification band.
Provide a warm blanket to reduce the risk of hypothermia. 57
Verify that no hearing aid(s), glasses, hair accessories, nail polish, body piercing
accessories, or jewelry remains on the patient. 58
 Note whether the patient removed dentures, contact lenses, or prosthetic devices or left
them in place.
Verify with the patient that the surgeon has marked the correct surgical site as directed
by your facility. 53 59 (See the "Surgical site verification, preoperative" procedure.)
Provide handoff communication for the person who will assume responsibility for the
patient's care. Allow time for questions, as necessary, to avoid miscommunications that
may cause patient care errors during transitions of care. As part of the handoff process,
allow time for the receiving staff member to trace each tubing and catheter from the
patient to its point of origin; a standardized line reconciliation process should be
used. 35 61 62 63
Perform hand hygiene. 5 6 7 8 9 10
Clean and disinfect your stethoscope using a disinfectant pad. 43 44
Perform hand hygiene. 5 6 7 8 9 10
Document the procedure. 45 46 47 48

Special Considerations

Be aware that the patient may benefit from receiving a tour of the areas in which
perioperative events will occur. Arrange such a tour as time allows and as permitted by
the facility.
If the patient smokes, as appropriate, emphasize the benefits of smoking cessation
before surgery, including improved blood flow and oxygen delivery to tissues.
Recommend that the patient quit smoking 8 weeks before surgery, if possible. 64
The Joint Commission issued a sentinel event alert related to managing risk during
transition to new International Organization for Standardization tubing standards that
were designed to prevent dangerous tubing misconnections, which can lead to serious
patient injury and death. During the transition, make sure to trace the tubing and
catheter from the patient to the point of origin before connecting or reconnecting any
device or infusion, at any care transition (such as a new setting or service), and as part
of the handoff process; route tubes and catheters having different purposes in different
standardized directions; when there are different access sites or several bags hanging,
label the tubing at both the distal and proximal ends; use tubing and equipment only as
intended; and store medications for different delivery routes in separate locations. 62
The Joint Commission issued a sentinel event alert concerning inadequate handoff
communication because of the potential for patient harm that can result when a receiver
receives inaccurate, incomplete, untimely, misinterpreted, or otherwise inadequate
information. To improve handoff communication, standardize the critical information
communicated by the sender. At a minimum, include the sender contact information;
illness assessment; patient summary, including events leading up to the illness or
admission, hospital course, ongoing assessment, and plan of care; to-do action list;
contingency plans; allergy list; code status; medication list; and dated laboratory test
results and vital signs. Whenever possible, provide face-to-face communication using
facility-approved, standardized tools and methods (for example, forms, templates,
checklists, protocols, and mnemonics) in an interruption-free location. Provide ample
time and opportunity for questions. Include the multidisciplinary team members and the
patient and family when appropriate.
If the patient's family or friends are present, direct them to the appropriate waiting area
and offer support, as needed. 56

Complications
Incomplete or inadequate preoperative patient assessment and care can result in cancellation
of the surgical procedure, patient injury, and postoperative complications. 1

Documentation
Complete the preoperative checklist used by your facility. Record all nursing care measures
that you performed, preoperative medications that you administered, results of diagnostic
tests, and the time that the patient was transferred to the surgical area. Record teaching
provided to the patient and family (if applicable), their understanding of that teaching, and
any need for follow-up teaching. Make sure that the patient's medical record and the surgical
checklist accompany the patient to surgery.

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