Chapter 18

Preoperative Care

KEY POINTS

SURGICAL SETTINGS

• Surgery is performed to diagnose, cure, palliate, prevent, explore, and/or provide cosmetic

improvement.

• The total surgical episode is called the perioperative period. This period in the health care

continuum includes the time before surgery (preoperative period), the time spent during the

actual surgical procedure (intraoperative period), and the period after the surgery is completed

(postoperative period).

• Surgery may be a carefully planned event (elective surgery) or may arise with unexpected

urgency (emergency surgery).

• The surgical setting is influenced by the complexity of the surgery, potential complications, and

general health status of the patient.

• Most surgical procedures are being performed as ambulatory surgery (also called same-day or

outpatient surgery).

• Regardless of where the patient has surgery, your role is to prepare the patient for surgery, care

for the patient during surgery, and aid the patient’s recovery after surgery.

PATIENT INTERVIEW

• One of the most important nursing actions is the preoperative interview. It often occurs in

advance or on the day of surgery.

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• The primary purposes of the interview are to obtain the patient’s health information, provide

information about the surgical experience, and assess the patient’s readiness for surgery. The

patient and caregiver have an opportunity to ask questions.

NURSING ASSESSMENT OF THE PREOPERATIVE PATIENT

• The preoperative nursing assessment is performed to determine the patient’s psychologic status

and physiologic factors that may contribute to operative risk factors; establish baseline detail;

identify and document the surgical site; identify prescription, over-the-counter drugs, and herbs

taken by the patient; confirm laboratory and diagnostic study results; note cultural and ethnic

factors that may affect the surgical experience; and validate that the informed consent form has

been signed and witnessed.

• Common fears associated with surgery include the potential for death or permanent disability

resulting from surgery, pain, change in body image, or results of a diagnostic procedure.

• Your role in psychologically preparing the patient for surgery is to assess the patient for

potential stressors that could negatively affect surgery and to provide support during the

preoperative period.

• In the nursing assessment, you should perform a thorough body systems review. Ask specific

questions to confirm the presence or absence of any diseases. Obtain information about any

family history of adverse reactions to or problems with anesthesia. Screen patients for possible

latex allergies, drug intolerances and drug allergies.

• Record and share all findings on the medication history, including allergies, with the

intraoperative and postoperative personnel.

• Findings from the patient’s preoperative assessment are used to assess the patient’s

perioperative risk and may influence perioperative decisions.

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• The preoperative assessment of the older person’s baseline cognitive function is essential for

intraoperative and postoperative evaluation as well as for choice of type of anesthesia.

• The patient with diabetes is at higher risk for adverse effects of anesthesia and surgery.

• Obesity stresses the heart and lung system and makes access to the surgical site and anesthesia

administration more difficult.

NURSING MANAGEMENT: PREOPERATIVE PATIENT

• The Association of periOperative Registered Nurses (AORN) provides perioperative standards

and recommended practices to guide nursing practice in the perioperative setting.

• Derive preoperative nursing interventions from the nursing assessment, based on each patient’s

specific needs. Physical preparations depend on the type of surgery and routines of the surgery

setting.

• Preoperative teaching involves the following:

o Provision of sensory, process, and procedural information

o Instructions about deep breathing, coughing, and ambulating postoperatively

o Information about pain management, including the use of a pain-rating scale

o An understanding that some patients, with varying cultures, backgrounds, and

experiences, may need different types of information

o Inclusion of the patient’s caregiver in the teaching when appropriate

o Documentation of all teaching in the patient’s chart

LEGAL PREPARATION

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• Legal preparation for surgery consists of checking that all required forms have been correctly

signed and are present on the chart and that the patient and caregiver clearly understand what is

going to happen.

• Anyone undergoing an invasive procedure must give informed consent for the procedure to be

performed. Informed consent is an active, shared decision-making process between the provider

and the recipient of care.

• A true medical emergency may override the need to obtain informed consent.

• The surgeon is ultimately responsible for obtaining the patient’s consent for surgical treatment.

• As a nurse, you may witness the patient’s signature on the consent form.

• Adults and emancipated minors sign their own operative permit.

• If the patient is a minor, is unconscious, or is mentally incompetent to sign the permit, a legally

appointed representative or responsible family member gives permission.

DAY-OF-SURGERY PREPARATION

• Day-of-surgery preparation will vary a great deal depending on whether the patient is an

inpatient or an ambulatory surgical patient.

• On the day of surgery, you are responsible for the following:

o Final preoperative teaching

o Assessment and communication of pertinent findings

o Ensuring that all preoperative orders have been completed

o Ensuring that records and reports are present and go with the patient to the OR

o Verifying the presence of a signed operative consent

o Laboratory and diagnostic data

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 o A history and physical report

o A record of any consultations

o Baseline vital signs

o Completed nurses’ notes and preoperative checklist

o Final “hand-off” communication to the OR nurse receiving the patient to ensure that

all pertinent information about the patient has been exchanged

• A variety of preoperative drugs may be used, including benzodiazepines for sedation and

amnesia, anticholinergics to reduce secretions, and opioids to decrease pain and anesthetic

requirements.

• Other drugs include antiemetics, antibiotics, insulin, histamine-receptor antagonists, eyedrops,

and regular prescription drugs.

CULTURAL AND GERONTOLOGIC CONSIDERATIONS

• Frequently performed procedures in the older adult are cataract extraction, coronary and

vascular procedures, prostate surgery, herniorrhaphy, cholecystectomy, and joint

repair/replacement.

• Include cultural considerations when assessing and implementing care for the preoperative

patient.

• Older adults may have sensory, motor, and cognitive deficits. They may need more time to

complete preoperative testing and understand preoperative instructions. These changes need

attention to promote patient safety and prevent injury.

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