2.3 Preoperative Nursing Care

The preoperative surgical period refers to the phase of client care that occurs before a surgical procedure. It is a critical time when health care professionals, including nurses, play a crucial role in preparing clients physically and emotionally for surgery. The preoperative period begins when the client is scheduled for surgery and ends at the time of transfer to the surgical suite. During this time, the nurse plays a crucial role as an educator, advocate, and promoter of health and safety. The nurse ensures a culture of safety by implementing evidence-based practices, adhering to protocols, and maintaining open communication with the client and the health care team.^[1],[2],[3]

As an educator, the nurse reinforces information already provided to the client by the surgeon regarding the surgical procedure, potential risks and benefits, preoperative preparations, and postoperative expectations. By reinforcing this information, the nurse ensures the client understands the reason for the surgery and addresses any concerns or questions they may have. By empowering the client with knowledge, the nurse promotes active participation in decision-making and ensures informed consent. If the nurse does not believe the client has provided adequate informed consent, the surgeon should be notified before the procedure occurs. If a power of attorney (POA) for health care has been activated, the POA should be contacted for informed consent.^[4],[5],[6]

The nurse also acts as an advocate for the client, ensuring their rights, preferences, and safety are respected throughout the perioperative period. This involves advocating for proper client identification, verifying surgical site marking, and ensuring that all necessary safety measures are in place. The nurse collaborates with the interdisciplinary team to address any potential risks or complications and advocates for the client’s best interests.^[7],[8],[9]

Communication and collaboration are essential within the health care team, as emphasized by The Joint Commission’s National Patient Safety Goals (NPSG). The nurse actively participates in effective communication and collaboration by sharing relevant client information, clarifying orders, and addressing any potential gaps or discrepancies. This promotes teamwork, enhances client safety, and facilitates seamless transitions between different phases of care.^{[10],[11],[12]}

Applying the Nursing Process to Preoperative Care

The following are the nursing priorities during the preoperative surgical period^[13]:

• Perform preoperative assessments to evaluate the client’s overall health status and identify potential risks or contraindications for surgery.
• Collaborate with the health care team to develop a comprehensive perioperative plan for the client, including preoperative preparation and postoperative care.
• Provide health teaching about the surgery/procedure, expected outcomes, and postoperative recovery process.
• Ensure informed consent is obtained prior to administration of preoperative medication administration and the surgical procedure.
• Administer preoperative medications as prescribed, such as premedication for anxiety or prophylactic antibiotics.

Assessment

Preoperative Health History

The nurse assesses many factors as the client is prepared for surgery to ensure safety and optimize their surgical outcomes. A preoperative health history includes the following components^{[14],[15][16]}:

• Age: The client’s age is an important factor to consider, as it can impact their physiological response to surgery. Older adults have increased risk of surgical complications due to factors such as delayed immune system response, delayed wound healing, delayed renal excretion, decreased muscle mass, increased risk of dehydration, and decreased physiological reserve. It is important to assess these factors and take appropriate measures to mitigate the associated risks.  Pediatric patients will require reduced dosages of anesthetic agents, may require specialized equipment due to reduced size, and will require different communication techniques and familiar support when transitioning into the surgical environment.  Utilizing child life specialists (when available) to familiarize pediatric patients to the sights and sounds associated with the operating room can be very beneficial in reducing anxiety. Child life specialists are members of the health care team who work with children and their families to provide education and preparation during hospitalization.
• Drugs and substance use: A comprehensive medication history should be obtained, including prescription and over-the-counter (OTC) medications, supplements, and substance use. It is crucial to identify medications or substances that may interfere with anesthesia and clotting or increase the risk of complications during and after surgery. Special attention should be given to substances such as tobacco, alcohol, and marijuana, as they can have significant effects on the client’s respiratory and cardiovascular systems.
• Medical history, particularly cardiac and pulmonary conditions: The client’s medical history, particularly cardiac and pulmonary conditions, should be thoroughly evaluated. Clients with cardiac disease are at a higher risk of anesthesia-related complications and may have difficulty tolerating hemodynamic changes induced by anesthesia. For individuals at risk of cardiac complications, specific measures, such as administration of preoperative beta-blockers, may be necessary to reduce the risk of myocardial infarction (MI) during surgery. Pulmonary complications should be assessed, especially in clients with chronic obstructive pulmonary disease (COPD) or a history of smoking. Clients who smoke or have COPD may have reduced lung function, decreased gas exchange, and increased risk of anesthesia-related complications.
• History of previous surgical procedures and anesthesia: The client’s history of previous surgeries and experiences with anesthesia should be reviewed. Previous surgical procedures and anesthesia may have an impact on the client’s readiness for the current surgery. Additionally, a family history of malignant hyperthermia, a rare but life-threatening reaction to certain anesthetics, should be documented.
• Allergies: Allergies, particularly those related to anesthesia and surgical supplies, must be identified to prevent adverse effects. Common allergies include latex (found in gloves and other medical supplies) and medications related to anesthesia (such as propofol). Allergies must be communicated to the anesthesiologist and surgical team so that precautions and alternative options are considered.
• Previous blood donations: If the client has donated blood, either autologous (donating one’s own blood for later use) or directed (other donor donating blood specifically for the client’s use), this must be documented. This information is important for planning potential blood product transfusions during or after surgery. Additionally, in some cases, the client may have received erythropoietin (EPO) to stimulate red blood cell production before surgery, which can reduce the need for blood transfusions.
• Discharge planning: Preparation for surgery also involves considering the client’s postoperative care and discharge planning. The client’s home environment should be evaluated to ensure it is conducive to recovery and necessary support systems are in place. Self-care abilities should be assessed to determine if additional assistance or resources will be required after surgery. Factors such as postoperative needs, follow-up appointments, transportation, and any necessary medical equipment or supplies should also be taken into account during discharge planning.^{[17],[18],[19]}

Preoperative Physical Assessment

The primary health care provider completes a history and physical (H&P) and orders diagnostic testing and/or consults that are needed for the patient to be cleared for surgery. The nurse ensures the H&P is in the chart as part of a preoperative checklist.

A nurse may also perform a final assessment just prior to surgery. Table 2.3a provides an overview of focused nursing assessments by body system. The preoperative assessments focus on various physiological and psychosocial factors that can impact surgical outcomes.^[20] If any new concerns are found, the nurse notifies the surgical team to minimize potential risks.

Table 2.3a. Key Focused Preoperative Assessments^[21]

Preoperative Laboratory Assessment

Preoperative screening plays a crucial role in ensuring client safety and optimal surgical outcomes. A comprehensive evaluation of a client’s health status before undergoing surgery is essential to identify any underlying conditions or abnormalities that may impact the surgical procedure or pose risks during the operation. Prior to planned surgeries, the client’s primary health care provider completes a History and Physical (H&P). Its purpose is to assess overall health and screen for potential issues in regard to surgery and anesthesia.

Laboratory tests, including the complete blood count (CBC), basic metabolic panel (BMP), liver function tests (LFTs), and coagulation profile (PT, PTT, and INR) are commonly performed as part of the preoperative H&P.^[22] These tests provide valuable information about the client’s blood cell counts, organ function, electrolyte balance, liver health, and clotting ability.

The nurse ensures the H&P and related preoperative lab work results are included in the patient’s chart as part of the preoperative checklist. By analyzing these parameters, health care professionals evaluate a client’s overall health, detect any potential issues, and make informed decisions regarding the surgical approach, anesthesia management, and postoperative care. For this reason, preoperative labs serve as an important tool to optimize client care, enhance surgical safety, and minimize potential complications. Table 2.3b summarizes common preoperative lab work and its purpose. Refer to Appendix A for a summary of common laboratory tests and their normal reference ranges.

Table 2.3b. Preoperative Lab Work^[23]

Nursing Diagnoses

Nursing priorities for clients undergoing surgery are formulated based on the client’s preoperative history and assessment data and their specific needs related to the surgery. These nursing diagnoses guide the development of individualized care plans and nursing interventions.

Common nursing diagnoses related to preoperative care include the following:

• Risk for Injury
• Risk for Bleeding
• Risk for Delayed Surgical Recovery
• Anxiety
• Fear
• Readiness for Enhanced Knowledge

Outcome Identification

Outcome identification includes setting short- and long-term goals and creating expected outcome statements customized for the client’s specific needs. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions.

Sample expected outcomes for common nursing diagnoses related to preoperative care are as follows:

• The client will remain free from injury during the perioperative period.
• The client will verbalize three potential postoperative complications and related actions to prevent them from occurring.
• The client will report decreased feelings of anxiety regarding the upcoming procedure or surgery.

Planning Preoperative Interventions

Preoperative client planning involves careful consideration of various elements to ensure a smooth and safe surgical experience.^{[24],[25],[26]}

• Informed Consent: While the responsibility of obtaining signed consent lies with the surgeon, nurses play a crucial role in the process by assisting in obtaining and witnessing the client’s signature as valid consent. Nurses can also contribute to client understanding by clarifying facts presented by the physician and dispelling any myths or misconceptions that the client or family may have about the surgery. Clients have the right to withdraw their consent before undergoing surgery, and health care providers must respect their decision in such cases. Consent should be an ongoing process, allowing clients to make informed choices about their health care.^[27],[28] Review additional information about informed consent in the “Basic Concepts Related to Surgery” section.
• NPO (Nothing by Mouth): NPO status, which includes refraining from eating, drinking, and smoking, is crucial before surgery. It helps reduce the risk of aspiration during anesthesia by minimizing gastric secretions. Typically, clients are advised to avoid food for at least 6 to 8 hours and clear liquids for 2 hours before the procedure. Adherence to NPO guidelines is stressed, as failure to comply can result in surgery cancellation to prevent complications during anesthesia.
• Intestinal Preparation (Bowel Prep): In some surgical procedures, such as those involving the colon, intestinal preparation may be necessary. This is often referred to as “bowel prep.” Preparation involves the use of laxatives or enemas to cleanse the intestines, reducing the number of bacteria and preventing injury to the colon during surgery.
• Administration of Regularly Scheduled Medications: Clients who regularly take prescription and over-the-counter medications should consult with their medical physician and anesthesia provider to determine whether they should continue taking their medications before surgery. Depending on the medication, the indication for the use of the medication, and the surgery being performed, dosing may be adjusted or temporarily withheld to minimize potential complications. See Table 2.3c for a list of medications that are commonly withheld (or have adjusted dosages) prior to surgical procedures.

Table 2.3c. Medications Commonly Withheld or Have Dosage Adjustment Prior to Surgery^[29],[30]

Interventions

Nurses perform many interventions during the perioperative period. Common interventions are described in the following subsections.

Collaborate With the Interprofessional Team to Prepare the Client for Surgery

As previously discussed, nurses are responsible for conducting preoperative assessments, gathering client history, and performing physical examinations to identify any potential risks or complications. Based on the assessment findings, nurses collaborate with the health care team to ensure the client is in optimal condition for the procedure. They collaborate and communicate effectively to ensure a smooth transition from the preoperative period to the operating room.

Provide Emotional Support

Nurses provide emotional support and reassurance to clients and their families during the preoperative period. They address client fears, anxiety, and concerns by actively listening, showing empathy, and utilizing therapeutic communication techniques. Nurses create a supportive environment to alleviate anxiety, promote trust, and improve the overall surgical experience.

Perform Preoperative Preparations

Nurses ensure that all necessary preoperative preparations are completed. This involves arranging for diagnostic tests, preparing the surgical site, administering preoperative medications as ordered, and ensuring that the client is ready for transportation to the operating room. Nurses pay close attention to detail and adhere to infection control practices to maintain client safety.^[31],[32]

Proper skin preparation is vital in preventing surgical wound infections by eliminating or reducing the number of microorganisms on the skin. This generally entails cleansing the entire body with antiseptic wipes (i.e., chlorhexidine wipes) prior to surgery. Some providers may also require patients to shower with antiseptic soap preoperatively. After the skin is cleansed, bed linens are to be changed, and the patient is placed in a clean gown.

Nurses typically complete standardized documentation referred to as a “Preoperative Checklist” when preparing a client for surgery. See an example of a preoperative checklist in the following box.

Document and Implement Other Safety Measures

Nurses are responsible for accurate documentation in the preoperative period. They document all assessments, interventions, and client responses according to established protocols and guidelines. Nurses also implement safety measures, such as verifying patient identification, confirming surgical site markings, and conducting time-outs to prevent wrong-site surgeries.^{[33],[34],[35]}

Provide Health Teaching About Postoperative Procedures

Nurses teach clients about the surgical process and what to expect. They explain the procedure, address any concerns or questions, and provide instructions on preoperative preparations such as fasting, medication restrictions, and hygiene practices. Nurses ensure that clients understand the importance of following these instructions for a safe and successful surgery.

Clients may have various tubes, drains, or vascular access devices inserted before, during, and after surgery. Examples include nasogastric (NG) tubes for gastric decompression, intravenous (IV) access for administering fluids and medications, and surgical drains to remove excess fluids. Providing education about the purpose of these devices, their expected duration, and any necessary care or monitoring can help alleviate client anxiety and improve understanding.

Health teaching about anticipated postoperative care plays a vital role in promoting optimal recovery and preventing complications following surgical procedures. By providing comprehensive and tailored education, health care professionals empower clients to actively participate in their own care, minimize complications, and support a smooth recovery process. See Table 2.3d for information regarding common topics for health teaching related to surgery.^{[36],[37],[38],[39]}

Table 2.3d. Health Teaching About Postoperative Procedures^{[40],[41],[42],[43]}

Administer Preoperative Medications

Preoperative medication administration is carefully tailored to the individual client based on various factors such as age, physical and psychological condition, medication history, height and weight, other medications being taken, and the specific surgical procedure. The selection of preoperative medications aims to address different aspects of the client's needs and optimize their surgical experience.^[45] Be sure that informed consent has been signed before administering any medications that may alter thinking processes. Table 2.3e summarizes common preoperative medications.

Table 2.3e. Common Preoperative Medications^{[46],[47],[48]}

To reduce anxiety, anxiolytics may be administered to help calm and relax the client.^[49] Sedatives or hypnotics may also be used to promote relaxation and alleviate any preoperative stress or apprehension. These medications help create a more comfortable environment for the client and facilitate a smoother transition into the operating room.

Anticholinergics may be given to reduce nasal and oral secretions, which can help maintain a clear airway during surgery. Additionally, anticholinergics can help prevent laryngospasm, a condition where the vocal cords spasm and cause difficulty in breathing. By blocking the effects of the parasympathetic nervous system, anticholinergics minimize secretions and help maintain a patent airway.^[50],[51]

Another important consideration is the use of medications to address specific physiological responses. These medications can reduce vagal-induced bradycardia, which is a slowing of the heart rate caused by stimulation of the vagus nerve. Additionally, H2 blockers may be administered to inhibit gastric secretion, reducing the risk of aspiration and other gastrointestinal complications during surgery.^[52],[53]

In some cases, preoperative medications can help decrease the amount of anesthetic needed for the induction and maintenance of anesthesia. This can lead to more stable anesthesia and improved client outcomes.^[54],[55]

Lastly, administration of antibiotics is a crucial step in preventing surgical site infections. Antibiotics are typically given approximately 60 minutes prior to the incision to ensure adequate levels are present in the client's system to combat any potential bacteria introduced during the surgical procedure.^[56],[57]

Overall, the selection and administration of preoperative medications are carefully determined based on individual client needs, aiming to optimize client comfort, safety, and surgical outcomes. It is important for health care professionals to closely assess each client and consider their unique circumstances when determining the appropriate preoperative medication regimen.^[58],[59]

Evaluation and Perform Final Checks Prior to Surgery

Evaluation focuses on the effectiveness of the nursing interventions by reviewing the client’s expected outcomes to determine if they were met by the time frames indicated. During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a client’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time frame indicated, the care plan should be revised. Reassessment should occur every time the nurse interacts with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with others on the interprofessional team.

The nurse plays a crucial role in ensuring that the client's chart preparation is finalized before surgery to facilitate a smooth and safe surgical experience. It is the nurse's responsibility to meticulously review the client's chart, ensuring that all documentation, preoperative procedures, and orders are complete and up-to-date. This includes verifying that the surgical consent form and other relevant documents are properly filled out and signed by the client. Additionally, the nurse should carefully document and promptly report any abnormal test results or findings that may impact the client's surgical course. By effectively communicating special needs and concerns to the surgical team, the nurse contributes to a comprehensive understanding of the client's condition and ensures that appropriate interventions and accommodations are in place. Through their attention to detail and proactive approach, nurses play a crucial role in ensuring that the client's chart is thoroughly prepared, minimizing potential risks and maximizing the overall quality of care during the surgical process.

Prior to surgery, it is essential to finalize the preparation of the client to ensure a safe and efficient surgical experience. The nurse plays a key role in this process by ensuring that the client is appropriately dressed in a hospital gown, which allows for easy access to the surgical site while maintaining their privacy. To prevent loss or damage, the nurse ensures that no valuables are on the client and advises them to tape their rings in place if they cannot be removed. All pierced jewelry is removed to minimize the risk of injury during surgery. The nurse confirms that the client's identification (ID) and allergy bands are securely fastened to ensure accurate client identification and prevent adverse reactions. Dentures are removed, as well as glasses/contacts and hearing aids. Additionally, the nurse instructs the client to empty their bladder before the surgery to promote comfort and prevent potential complications during the procedure.