31.2: Preoperative Phase

Learning Objectives

By the end of this section, you will be able to:

• Describe the tasks involved in the preoperative stage of patient care
• Explain the role of the perioperative nurse

The preoperative stage is a critical component of the surgical road map, and it includes all the activities and preparations from the time surgery is decided on until the patient is transferred to the OR. This section covers the tasks involved in the preoperative stage of patient care that include, but are not limited to, conducting preoperative assessments, verifying surgical consents, performing risk assessments for anesthesia, educating the patient about the procedure, and preparing the patient physically and emotionally for surgery. This stage is essentially a touchstone for ensuring patient safety, optimizing surgical outcomes, and minimizing the risk of complications.

The preoperative nurse functions as the patient’s advocate and primary point of contact throughout the preoperative period, making sure that all preparations are completed accurately and that the patient is educated and emotionally supported in the time leading up to their surgery. Each task is necessary for identifying potential issues that could affect the surgery or recovery and ultimately ensuring that the patient is in the best possible condition to undergo the procedure. By understanding the tasks and responsibilities involved in preoperative care, nurses can effectively prepare patients for surgery, addressing both their physical and psychological needs.

Preoperative Care

The journey through surgery does not begin with the first incision; it starts long before, in the crucial stage of preoperative care. To ensure the safest possible surgical experience, preoperative care begins with a comprehensive assessment of the patient’s health. The preoperative nurse reviews the patient’s medical history, noting any preexisting conditions, allergies, and current medications. The nurse then performs a thorough physical examination or reviews the medical preoperative history and physical (H&P), which helps identify any potential issues that could affect the surgical procedure or influence recovery (American College of Surgeons, n.d.).

Preoperative care also goes beyond just physical preparation. Addressing psychological well-being and identifying the patient’s coping mechanisms and available emotional support can significantly contribute to a positive surgical experience. By meticulously laying the groundwork, preoperative care sets the stage for a smoother surgery and a faster, more successful recovery.

Based on the data collected, the nurse formulates a baseline understanding of the patient’s status and determines what appropriate preoperative testing is required. The nurse confirms that all required preoperative documents are present. The nurse also ensures the patient has undergone preoperative bowel preparation if required. Finally, the preoperative nurse performs surgical skin preparation and provides prehabilitation and postoperative instructions.

Completing Preadmission and Preoperative Testing

Before being admitted for surgery, patients may need certain preadmission and preoperative tests. These assessments unveil vital information about the patient’s health, which may influence outcomes and can present challenges to a successful procedure. The preadmission testing (or preoperative testing) encompasses a range of examinations, laboratory or diagnostic tests, and procedures (e.g., electrocardiogram [ECG], bloodwork) to evaluate a patient’s health status. This testing is completed before a procedure or surgery.

The benefits of preadmission testing are multifaceted. Tests may reveal underlying medical conditions that could pose risks during surgery, allowing for adjustments to the surgical plan or even postponement if necessary. Information gleaned from preoperative tests helps the surgeon tailor the approach to the patient’s specific anatomy and health, leading to more precise and effective procedures. Testing that identifies potential issues beforehand can ultimately enhance patient safety (American College of Surgeons, n.d.). Some common tests include the following:

• Blood work:
  • Complete blood count can identify a low red blood cell count (e.g., anemia) and high white blood cell count (e.g., infection).
  • Serum electrolytes (e.g., sodium, potassium) help regulate heart rhythms and other body functions. Identifying serum electrolyte abnormalities in advance of surgery allows time to rectify the problem.
  • Serum glucose levels provide insights into the body’s ability to heal, among other things.
  • Coagulation studies (e.g., prothrombin time partial thromboplastin time) help prevent bleeding complications by measuring the activity of the clotting cascade.
• Imaging tests:
  • Chest x-rays help diagnose causes of shortness of breath, chest pain, cough, certain fevers, and abnormal heart and lung appearance.
  • Computed tomography (CT) and magnetic resonance imaging (MRI) scans offer detailed images of organs, bones, and tissues, assisting the surgeon in surgical planning and identifying potential anatomical variations.
• Electrocardiogram and echocardiogram (Echo): Assessing heart function is crucial for surgeries involving anesthesia with the goal of minimizing the risk of cardiac complications.
  • An ECG may identify abnormal rhythms (e.g., arrhythmias, dysrhythmias), heart muscle damage, and causes of chest pain, fluttering heartbeats (palpitations), and heart murmurs.
  • An Echo uses high-frequency sound waves to produce pictures of the heart. Among other things, an Echo can help diagnose heart attack, heart failure, valvular problems, and blood clots.
• Urinalysis is an important aspect of preadmission testing.
  • A urinalysis can help diagnose or rule out certain urological conditions (e.g., kidney and bladder infections). Urinalysis can also determine a patient’s hydration status and identify illegal drugs in the body.
  • Urine pregnancy tests are required for women of childbearing years who have not undergone a hysterectomy. This helps ensure patient safety and that of an unborn baby.

Confirming the Presence of Preoperative Documents

Before surgery, patients must complete a set of preoperative documents. These forms may seem daunting to patients; however, they play a vital role in ensuring a safe and successful procedure. Preoperative documents typically cover various aspects of the patient’s health and surgical plan. Some common forms include the following:

• Medical H&P: This form details past surgeries, medications, allergies, and any existing medical conditions. Family and social histories are also obtained, which helps in identifying potential risks and ensuring the patient is optimized for surgery. The professional completing the H&P also performs a physical examination.
• Informed consents: These are crucial legal documents that provide a detailed overview of the surgery, including its risks, benefits, and alternatives.
  • An informed consent (see 16.3 Legal Dimensions of Care) is a crucial legal process that goes beyond merely signing a form. It requires a thorough discussion between the healthcare provider and the patient (or their legal guardian) to ensure a complete understanding of the procedure and its risks, benefits, and alternatives. This crucial communication allows the patient to make an informed decision about their care. Although nurses may witness the signing of consent forms, the legal responsibility of obtaining informed consent and confirming the patient’s understanding lies with the professional who will perform the procedure (i.e., surgeon, anesthesia provider).
• Anesthesia assessment: This form gathers information about the patient’s tolerance for anesthesia and potential risks. The anesthesia provider completes this assessment.
• Advance directives: These documents specify the patient’s wishes regarding life-sustaining measures in case of complications.

Taking the time to carefully review and complete preoperative documents is essential for a smooth and successful surgical journey. By providing accurate information and fostering open communication, these forms pave the way for safer procedures, faster recoveries, and ultimately, improved patient outcomes.

Preparing the Bowel

The medical procedure of bowel preparation (bowel prep) is designed to clean the colon and rectum before certain medical or surgical procedures (e.g., colonoscopy, colorectal surgery). The goal of bowel prep is to remove stool and debris from the digestive tract, allowing for better visualization of the intestinal lining and reducing the risk of complications (e.g., infection) during the procedure. Bowel preparation typically involves a two-pronged approach:

• Dietary modifications: The day(s) leading up to surgery often require a low-fiber diet or clear liquid diet to minimize stool production. Clear liquids may include water, broth, clear juices, and gelatin. This reduces the volume of material that needs to be removed and lowers the risk of blockages during surgery.
• Medications: Laxatives or enemas may be prescribed to stimulate bowel movements and remove remaining stool.
  • Laxatives are medications that promote bowel movements and help clear the colon. They may be in the form of pills, powders, or liquids. Common laxatives include polyethylene glycol (PEG), magnesium citrate, sodium phosphate, or other prescribed medications.
  • Enemas involve introducing a liquid solution into the rectum to stimulate bowel movements and aid in cleaning the lower part of the colon. Types of enemas may include saline enemas or commercially available bowel prep solutions.

The specific timing of when to start the bowel prep and when to complete it depends on the type of preparation prescribed and the timing of the scheduled procedure. Healthcare providers give the patient clear instructions regarding when to start and complete each component of the bowel prep. It is crucial for patients to follow the provided instructions diligently to ensure effective bowel preparation. While bowel prep can be uncomfortable and may cause temporary diarrhea, its benefits in terms of improved visualization and safety during medical procedures outweigh the temporary inconvenience. Patients should communicate any concerns or difficulties with their healthcare providers, who can provide guidance and potentially adjust the bowel prep regimen based on individual needs.

Preparing the Skin

Preparing for surgery also involves prepping the skin on and around the incision site to minimize the risk of infection and ensure optimal healing. This meticulous process involves both preoperative and intraoperative measures.

Patients may be instructed on things they need to do at home before arriving at the surgical facility for surgery. For example, patients may be given specific instructions for cleansing the skin or showering before surgery and may be advised to avoid lotions and creams. The preoperative instructions often include using a special antiseptic solution to wash the skin. Common antiseptic solutions used for this purpose include alcohol-based chlorhexidine gluconate or iodine-based solutions. These antiseptics help reduce the number of microorganisms on the skin, decreasing the risk of a surgical site infection (SSI), an infection that occurs at or near surgical incisions within thirty days of the procedure or within one year in the case of organ or space infections with an implant. When choosing a product, the provider will take the requirements and location of the planned procedure as well as any patient allergies into account. Patients should be provided with clear instructions on how to use the product and know who to contact if they have questions about performing the preoperative routine.

Patients are instructed not to remove hair at the surgical site. Shaving the incision site and the area around it within twenty-four hours before surgery is no longer recommended. Instead, healthcare providers may trim or clip hair if necessary after the patient arrives at the facility, minimizing skin irritation and potential infection risk.

Just before surgery, a healthcare professional will meticulously clean on and around the incision area with specialized antiseptic solutions like chlorhexidine gluconate. This further reduces bacterial burden and prepares the skin for the sterile environment of the OR. Sterile drapes are then used to create a barrier between the surgical site and the surrounding nonsterile areas, minimizing the risk of contamination during the procedure.

Providing Preoperative Instructions

Preoperative instructions have several important roles:

• Enabling active patient participation: Patients become empowered partners in their care and are directly contributing to positive surgical outcomes by following the instructions.
• Empowering through knowledge: Patients are provided with the information they need to make informed decisions about their care and feel confident that they will be able to follow the instructions before and after surgery.
• Minimizing risk: Closely adhering to preoperative guidelines, such as fasting before surgery and stopping certain medications, reduces the risk of complications during and after surgery.
• Alleviating anxiety: Clear explanations about what to expect before, during, and after surgery help ease patients’ anxieties and give them more of a sense of control over the situation.
• Promoting optimal outcomes and patient health: Preoperative instructions may include guidance on lifestyle changes, medication adjustments, and hygiene practices that will help position patients to be in the best possible shape for their surgery and recovery.

Preoperative instructions cover many topics. These include fasting guidelines, medication management, hygiene practices, clothing and personal items, transportation arrangements, and arrival time:

• Fasting guidelines: Clear instructions on when to stop eating and drinking before surgery help minimize the risk of aspiration during anesthesia and decrease the severity of pulmonary complications if aspiration occurs. Historically, patients were instructed to fast after midnight the night before surgery. However, many patients experience problems (e.g., dehydration) with extended fasting, especially if surgery is scheduled for the afternoon (Chon et al., 2017). These guidelines have been updated (Apfelbaum et al., 2017). A common instruction for the timing of preoperative fasting includes the following:
  • Two hours: Simple or complex carbohydrate–containing clear liquids are encouraged up to two hours before surgeries requiring general anesthesia, regional anesthesia, or procedural sedation.
  • Four hours: Infants may consume breast milk up to four hours before surgery.
  • Six hours:
    • A light meal (e.g., toast and clear liquids) may be eaten six hours before surgery.
    • Nonhuman milk and formula should be stopped six hours before surgery.
  • Eight hours: Fried or fatty foods and milk may require additional fasting time.
• Medication management: The nurse performing the preoperative phone call should use facility guidelines and physician-specific orders to determine whether to continue or discontinue certain prescription and over-the-counter medications in the days leading up to surgery. The goal is to help lower risks associated with bleeding or interactions with anesthetic medications. While each facility and surgeon may have specific protocols, here are a few common examples:
  • Anticoagulants (blood thinners) (e.g., aspirin, warfarin, clopidogrel, nonsteroidal anti-inflammatory medications such as ibuprofen) and all vitamins, supplements (fish oil), and herbals should be discontinued for a specified period of time before surgery (e.g., five to ten days before surgery).
  • Antihypertensive medications: Certain antihypertensive medications as listed should be held before surgery. If the patient takes the medication at night, instruct the patient to hold the evening dose the night before surgery. Also, have the patient hold the medication the day of surgery (Wagner et al., 2019). The following should be held before surgery:
    • angiotensin converting enzyme inhibitors (ACE-I): benazepril (Lotensin), lisinopril (Prinivil), enalapril (Vasotec)
    • angiotensin II receptor blockers: losartan (Cozaar), valsartan (Diovan), irbesartan (Avapro)
  • Patients with diabetes:
    • Insulin: Nurses should refer to facility protocol for perioperative management of patients with diabetes. A finger-stick blood sugar should be performed on arrival at the facility on the day of surgery if the patient has diabetes. The nurse should notify the anesthesia provider if surgery start time is delayed for guidance on blood sugar monitoring and IV placement (Khan et al., 2024).
    • Oral antidiabetics: Patients should hold on the day of surgery.
  • Weight-loss/central nervous system (CNS) (e.g., phentermine) stimulant medications: Patients should stop taking seven days before surgery (Adams, 2023).
  • Anti–attention deficit hyperactivity disorder agents: Agents such as dextroamphetamine (e.g., Adderall) should not be taken the day of surgery (Engelman & Cramer, 2023).
• Hygiene practices: The nurse should instruct the patient on preoperative bathing and skin preparation with antimicrobial soap to help reduce the microbial load on the skin, which can help prevent SSIs.
• Clothing and personal items: The nurse should instruct the patient on what clothing to wear on the day of surgery and to leave valuables at home to prevent the loss or contamination of these items. The patient should be told not to wear cosmetics or use lotions before surgery. The nurse should instruct the patient to remove all jewelry and accessories. This includes removing rings and all body piercings to prevent patient injury from burns, pressure-related tissue injury, and SSIs. Nurses should understand that simply placing tape over the jewelry does not eliminate the risks of wearing them in surgery.
  • When electrosurgery is used during a procedure, body jewelry may conduct the electrical current and cause electrical burns to the surrounding tissue.
  • Metal body jewelry may interfere with ultrasound, CT, and MRI and cause injury to the patient during the procedure.
  • Nursing personnel should learn techniques for safe jewelry removal and to maintain patent piercing tracts. Facilities should ensure the availability of tools needed to safely remove body-piercing jewelry. Nose, tongue, or lip jewelry make airway management and visualization of the airway during intubation difficult and dangerous to the patient. Genital piercing can pose problems during urinary catheter insertion and may result in urethral tears that could require cystostomy or surgical closure.
• Transportation arrangements: To give patients time to plan, the nurse making the preoperative call should gather information about transportation to and from the surgical facility, including any restrictions on driving after certain types of anesthesia. If the patient is having same-day surgery and is undergoing general or regional anesthesia or conscious sedation, a driver is required to take the patient home. Patients may ask if they can take a rideshare (e.g., Lyft, Uber, taxi). However, the rideshare driver cannot be held responsible for transporting the patient into and out of the vehicle. Therefore, rideshares are prohibited unless an adult accompanies the patient and assumes responsibility for the patient.
• Arrival time: Specific instructions on when to arrive at the surgical facility or hospital for preoperative assessments and preparations are needed to guide patients through the schedule for the day. Adequate time ensures steps are completed without rushing.
• Documentation: The nurse should remind the patient to bring essential documents, including photo identification, insurance information, and any preoperative paperwork and consent forms. This helps make the process go more smoothly on the day of the surgery and decreases the likelihood that something important will be forgotten or incomplete.
• Contact information: Emergency contact information should be obtained from the patient as well as instructions on whom to contact if the patient has questions or concerns before the surgery.

Providing Postoperative Instructions

Providing postoperative instructions is crucial to help prepare the patient in advance for self-care on discharge. Instructions may include the following:

• General information about what to expect after surgery (e.g., postoperative pain management, activity restrictions and recommendations, potential side effects) helps the patient feel more prepared.
• Instructions for wound care are also important, and patients need to be aware of their responsibility for taking care of their wound after the procedure. This may involve changing bandages regularly or leaving them undisturbed until the follow-up appointment. Patients should also be instructed on how to recognize a potential wound infection as well as what signs and symptoms would warrant calling their provider.
• Additional instructions may include general advice for maintaining good personal hygiene (e.g., hand hygiene before and after touching the wound), adhering to dietary and nutritional instructions, and staying adequately hydrated and well rested. Instructions should be provided for the safe application of ice or heat after surgery if ordered.
• The nurse should provide personalized guidelines to help the patient manage pain and ensure that the patient is knowledgeable about the prescribed pain medications ordered for home use.

Formats Used for Preoperative Instructions

Using a combination of communication methods helps address the needs of diverse patient learning styles and preferences.

• Written instructions: Printed or electronic documents are often given to patients from the surgeon’s office during preoperative visits or via online patient portals.
  • Whenever possible, the nurse should ensure that instructions are written at no greater than a sixth-grade reading level. Stress and fear greatly inhibit learning. Even people with advanced education may have difficulty understanding and remembering surgical information.
  • Visual aids: Infographics, videos, or visual aids can enhance patient understanding and are useful for offering clarification or answering questions.
  • Foreign language: Facilities should be prepared to provide written instructions in the patient’s primary language.
• Verbal communication: Healthcare providers, including nurses and surgeons, will verbally reinforce instructions during preoperative assessments or consultations. Patients are encouraged to ask questions, clarifying any concerns and ensuring full comprehension.
  • Facilities should be prepared to provide interpreters in the patient’s primary language.
  • As an alternative to in-person translators, nurses should be aware of and prepared to use one of the many online, real-time interpretation services that are now available.

The Role of the Perioperative Nurse

Nurses are the patient’s primary advocate serving as a trusted resource and ensuring patient safety throughout the surgical journey. They explain procedures, address concerns, provide emotional support, ease anxieties, and foster a sense of security. The perioperative nurse may work in any of the three areas of perioperative services:

• Preoperative preparation: A few of the steps of care provided by the preoperative nurse are assessing patients, managing anxieties, and ensuring informed consent has been completed by the surgeon.
• Intraoperative care: The scrub person (nurse, surgical technologist) sets up the sterile field and assists the surgeon by passing instruments. The RN circulator manages the overall environment to ensure safety, prepares the patient, and provides necessary supplies. A perioperative first assistant (e.g., registered nurse first assistant [RNFA], certified surgical first assistant [CSFA], surgical physician’s assistant [PA], perioperative nurse practitioner [NP]) with advanced education and training helps the surgeon with tasks such as holding retractors and suturing.
• Postoperative recovery: Perioperative nurses assess and care for patients in the postanesthesia care unit (PACU) (formerly referred to as the recovery room), manage pain, monitor vital signs, anticipate and treat postoperative complications (e.g., airway management, cardiovascular interventions), and provide essential early postoperative care.

The perioperative nurse’s role is not merely technical; it is deeply human. The nurse navigates the emotional tides of patients and families, offering reassurance and compassion during a vulnerable time. Their expertise, adaptability, and unwavering dedication are the bedrock of safe and successful surgery.

Performing the Preoperative Assessment

The nurse’s role in preoperative assessment includes conducting a comprehensive physical and psychosocial evaluation. The nurse is responsible for reviewing past surgeries, medications, allergies, and any preexisting conditions and identifying potential risks. The nurse then tailors a patient-specific nursing care plan.

The nurse assesses the patient’s overall health, pain levels, and potential anatomical variations that might affect the procedure. It is also the responsibility of all surgical team members at every step of the process to confirm the patient’s identity and the type and site of the surgery to be performed to ensure that the correct location is established before the patient goes to the OR. The nurse should also recognize the emotional weight of surgery. Addressing anxieties, providing emotional support, and ensuring informed consent are crucial aspects of a holistic assessment.

Cultural Context

Cultural Considerations During the Preoperative Assessment

The nurse should be aware of the unique individual needs of each patient and pay particularly close attention to how a patient’s culture may influence their beliefs and practices about surgery and recovery. Providing culturally aware care during the preoperative stage helps build trust, establishes therapeutic rapport, improves understanding, and contributes to better patient outcomes. Here are a few ways that nurses can incorporate a patient’s cultural considerations into their assessment.

Language and communication:

• Identify the patient’s primary/preferred language: Ask, “What language do you prefer to speak?” Never make assumptions about a patient’s language based on appearance or name.
• Provide interpreters: When possible, use certified medical interpreters for patients with limited proficiency in the primary language of the healthcare setting. Translating medical and legal language requires specific skills. Therefore, do not have patient family members translate because this can lead to misunderstandings. If a medical interpreter is not available, assistive technology that helps translate in these situations may be useful.
• Translate materials: Give instructions and documents in the patient’s preferred language, if possible. Check with your facility to see if they have a trusted translation service for medical documents or if documents can be printed in multiple languages.

Health beliefs and practices:

• Be open to learning from patients: Ask, “Are there any cultural or religious beliefs I should be aware of regarding your health or upcoming surgery?” For example, a patient might request a moment of prayer or a ritual cleansing before surgery.
• Respect traditions: Some patients may use traditional remedies or have specific beliefs about illness and healing. For example, a patient from a culture that uses traditional medicine might be apprehensive about conventional surgical procedures or anesthesia. Acknowledge these beliefs with respect, and find ways to incorporate them into the care plan.

Decision-making and family:

• Identify decision-makers: In some cultures, decisions are made collectively with their family or specific people within the family. Ask the patient who should be involved in discussions.
• Support family involvement: Facilitate family participation in the preoperative process, if desired by the patient. If not, make sure you have a clear understanding of who should not be involved in the patient’s care.

Religious practices:

• Spiritual needs: Ask about any religious practices or rituals that the patient would like to be accommodated before, during, or after surgery. For example, some patients may refuse blood transfusions because of their religious beliefs, and this must be considered in surgical planning. Nurses should be prepared to discuss alternatives to blood transfusion that may be available, for instance, implementing options for preoperative optimization of hemoglobin levels, employing cell salvage (a procedure whereby blood lost during or after surgery is collected and then transfused back to the patient) intraoperatively and postoperatively, and supporting hematopoiesis (the process by which blood cells are produced to maintain the levels of circulating blood cells in the body) throughout perioperative care.
• Dietary restrictions: Be knowledgeable of any fasting practices (e.g., Ramadan) or dietary restrictions (e.g., kosher, halal) that may need to be factored into preoperative and postoperative instructions.

Modesty and privacy:

• Respectful draping: Provide options for gowns or draping that align with cultural preferences and norms around modesty.
• Gender considerations: Some patients may have a clear preference to be treated by healthcare providers of the same gender identity, if possible. Nursing managers should make every effort to facilitate these interactions in accordance with patient preferences.

Nonverbal communication:

• Observe cues: Be aware that nonverbal cues (e.g., eye contact, body language) may have different meanings across cultures. Do not assume that your perception based on your cultural background is the same for your patient. For example, in American culture, avoiding eye contact may be seen as shyness or even evasiveness. However, for Muslim patients, it may be a sign of deference and respect.
• Avoid assumptions: Do not assume that a patient’s silence implies agreement or understanding. It is critical that you create a safe space for questions and clarification.

Complementary and alternative medicine (CAM):

• Ask about CAM use: Ask patients if they use herbs, supplements, or traditional healing practices. Do this not only so you can include them in care, when possible, but also so you can be alert for how they might interact or affect traditional treatments or medications used during surgery.
• Prioritize collaboration, not judgment: Work with patients, families, and other healthcare providers to integrate any safe and beneficial CAM practices into the patient’s care plan.
• Cultural sensitivity: When providing care, cultural sensitivity requires open communication, respect, and a willingness to learn. What is considered acceptable in some cultures may be considered abhorrent in others. Nurses cannot look at the norms of one culture through the lens of their own culture.

The nurse’s keen observation skills and ability to build rapport with patients are invaluable assets. They can detect subtle cues of discomfort, unearth hidden concerns, and ensure the patient feels heard and understood. The preoperative nurse then communicates this information to the surgeon, anesthesia provider, and RN circulator to ensure a collaborative approach to care.

Implementing Preoperative Nursing Interventions

Although the facility and surgical team will have specific requirements for the nurse to follow to prepare patients for surgery, there are some items that are expected components of the preoperative nursing assessment checklist (Table 31.2) (Stony Brook Medicine, n.d.).

Stage	Nurse’s Role	Things to Consider
General information	Confirm patient identification, reason for surgery, allergies, medications, and advance directives.	Direct patient to appropriate resource if insurance questions arise.
Medical and surgical history	Document chronic and acute medical conditions, past surgeries, anesthesia history, and family history.	Determine which, if any, conditions may affect the perioperative course.
Physical assessment	Assist with gowning, confirm surgical site, establish IV access, obtain baseline vitals, and perform relevant system assessments (cardiovascular, respiratory, neurological, skin, musculoskeletal). Encourage voiding.	Ensure patient’s personal belongings are secure.
Psychosocial assessment	Assess anxiety levels, support systems, coping mechanisms, and understanding of the procedure.	Consider cultural, spiritual, and religious beliefs/practices that may be relevant to surgery and postoperative care.
Preoperative preparation	Verify NPO (nothing passed orally) status (no eating or drinking for a set period of time before surgery), review laboratory/diagnostic tests, perform skin preparation if needed, document prostheses/devices, and confirm removal if necessary.	Ensure hair removal from linen and surgical garments if applicable.
Education and discharge planning	Reinforce preoperative instructions, demonstrate postoperative exercises, discuss postoperative expectations (pain management, recovery, wound care, activity restrictions, follow-up), and identify patient’s support system.	Preoperative exercises (e.g., have the patient demonstrate correct use of the incentive spirometer) can improve postoperative compliance and recovery.

Table 31.2 Components of the Preoperative Nursing Assessment Checklist

Link to Learning

This document provides an example of a task checklist that preoperative nurses may encounter.

Providing Pain Management

While pain medication plays a crucial role in preoperative care, the nurse’s involvement in pain management extends far beyond simply administering medications. They take a patient-centered approach, employing various interventions to minimize discomfort and promote a calmer, more positive surgical experience.

When possible, nurses may recommend medications or nerve blocks before the onset of significant pain. As the patient’s advocate, the nurse may be called on to collaborate with providers to determine if this proactive approach is appropriate for the patient and would help reduce postoperative discomfort and improve recovery time. It is important for nurses to recognize that anxiety and fear can exacerbate pain perception. Nurses should provide emotional support, address concerns, and employ relaxation techniques like guided imagery or deep breathing to manage anxiety and reduce pain (Stanford Medicine, n.d.).

Nurses should educate patients about nonpharmacological pain management techniques that can be used both before and after surgery. These strategies can reduce pain, decrease how much pain medication is needed, and alleviate stress. While pain management must be tailored to the patient, there are some general nonpharmacological pain management strategies the nurse should be aware of and able to suggest to patients:

• Deep breathing and relaxation techniques: Practicing deep breathing exercises, mindfulness techniques, or guided meditation may help manage anxiety and may even decrease sensitivity to pain.
• Distraction methods: Distraction techniques such as listening to music, watching a favorite show, or engaging in light conversation may help divert attention from pain or discomfort.
• Cold and heat therapy: The safe use of cold packs or heating pads can help reduce inflammation and pain, depending on the specific procedure and surgeon’s recommendations.
• Proper positioning: Positioning that supports the body, reduces pressure on surgical sites, and promotes comfort can go a long way to helping patients be more at ease physically and mentally. Provide pillows or other positioning aids for comfort as well as to help prevent pressure sores.

What works for one patient may not work for another, so it is up to the nurse to work with the patient and advocate on their behalf to ensure their pain is managed and to adapt to changing needs for pain management throughout the surgical journey and on to recovery.

Teaching Coping Strategies

A key aspect of preoperative interventions involves teaching patients coping strategies to navigate the anxiety and stress associated with the upcoming procedure (Stanford Medicine, n.d.; Tsegaye et al., 2023). Nurses should take a personalized approach, tailoring guidance to each patient’s individual needs and preferences. They may do the following:

• Identify coping mechanisms: Encourage patients to explore their existing coping skills, whether it is deep breathing, mindfulness techniques, spending time with loved ones, or engaging in hobbies.
• Introduce new strategies: Introduce relaxation techniques like guided imagery, progressive muscle relaxation, or visualization exercises if a patient lacks coping mechanisms.
• Promote positive self-talk: Encourage the patient to challenge their own negative thoughts and replace them with affirmations; this can significantly reduce anxiety and pain levels and improve preoperative well-being.
• Provide resources: Connect patients with additional resources, such as support groups, educational materials, or online resources to enhance their coping toolbox.

The effectiveness of these strategies is backed by research. Studies have shown that educational conversations between the patient and healthcare providers can help prepare surgical patients and significantly reduce anxiety (Aust et al., 2016). By facilitating or providing teaching, nurses not only lessen the emotional burden of surgery but also play a crucial role in optimizing the overall surgical experience.

Patient Conversations

Coping with Pain

Nurse: Hi, I’m Maria. I will be your preoperative nurse this morning. Can you tell me your name, birthday, and the surgery you are having today?

Patient: Yes, I’m Veronica LaBate and my birthday is July 6, 1972. I am having a right knee replacement.

Nurse: Thank you. How are you feeling? Do you have a few minutes to talk with me about your surgery?

Patient: Sure. Honestly, I’m a little bit nervous. Well, maybe a lot nervous. I’ve heard the recovery can be . . . pretty rough.

Nurse: Feeling nervous is normal. That’s why having a chat now is helpful. We want to make sure that any concerns or questions you have get answered. By “rough,” are you worried about how long it will take to heal? Or that you’ll be in pain?

Patient: Oh, I’m scared of the pain. I know it’s going to hurt some, but what if I wake up and it hurts a lot?

Nurse: Managing pain is a very important part of what the team will do for you, and it starts before we even get to the OR. We can talk about it now, actually. Let’s start by talking about how to measure your pain. We use a pain scale to help you tell us about your pain. It goes from zero, which is no pain at all, to ten, which is the worst possible pain you could ever imagine. When I had surgery last year, I reminded myself that ten pain is like standing on a sidewalk and a car runs over you. That helped me be objective about my pain so I could compare the pain number I gave my pain before surgery with the pain number I gave the pain after surgery. Does that make sense?

Patient: Yes, I think I understand.

Nurse: So, how would you rate your pain or discomfort right now?

Patient: My knee just aches right now. I guess I would say it’s a two out of ten.

Nurse: OK. When you wake from surgery, your recovery nurse will ask you to rate your pain. Remember what it felt like now and what ten might be like compared to your postoperative pain. So, let’s get back to your fear of pain after surgery.

Patient: Well, I know you’ll give me medicine, but I don’t even like taking a Tylenol for a headache. I’m pretty nervous about those painkillers people get addicted to, and I think I’ll try to tough it out without them.

Nurse: Medicine is part of pain management, and it has an important role in helping keep your pain controlled during the surgery and afterward. It’s important that you’re not in so much pain that you can’t rest and heal properly, but we want to balance that with the side effects and risks that come with medicine. Luckily, you don’t just have to rely on pain medicine alone to cope. Can you think of any nonmedical ways you deal with pain?

Patient: Well, when my knee aches a heating pad usually helps.

Nurse: Heat therapy is what we call a nonpharmacological pain management technique. There will be some techniques that you can use after your surgery to help you cope with the pain, and sometimes they work well enough that you don’t need as much pain medicine. For example, deep breathing exercises and relaxation techniques can significantly help with pain and anxiety.

Patient: Really? How?

Nurse: Well, deep breathing gets more oxygen flowing through your body and brain and can help you relax and loosen your muscles, which can naturally ease pain. Mindfulness or guided imagery can help distract your mind from the pain, which can sometimes make it more manageable. Some people find that listening to music or watching movies also helps distract them.

Patient: Will I be able to use my heating pad?

Nurse: Cold or heat therapy can be very effective. Cold therapy is great for reducing swelling and inflammation, while heat therapy can relax muscle tension and improve blood flow, helping with pain relief. We’ll find out for sure from your surgeon whether these will be appropriate options for you, depending on your surgery.

Patient: That all sounds fine, but what if I do all those things and I’m still in a lot of pain?

Nurse: Well, if at any point the pain is worse or not something you feel you can manage, we want you to let us know right away. It’s important for your recovery that we manage your pain. At that point, we may want to adjust the amount or type of your medicine so that it helps more. It can also help to change positions and move around to avoid putting extra pressure on your wound, which can hurt and delay healing.

Patient: How will I remember all this after I get home?

Nurse: Before you’re discharged, we’ll give you detailed instructions on managing your pain at home, including how to take your medicine safely and a list of these other techniques we talked about that you might want to try. Plus, we will make sure it’s clear how and when you should contact your surgeon if you have any concerns about your pain levels.

Patient: That makes me feel a bit better, actually. Not just knowing I have options but that I can call someone if I get home and am hurting and don’t know what to do.

Nurse: We definitely want you to feel informed and empowered, but don’t worry—you won’t be going through this alone.

Attending to Family Needs

The preoperative stage is often a whirlwind of emotions for not only the patient but also their family members. Navigating anxieties, managing logistics, and providing support all fall within the scope of the preoperative nurse’s role, ensuring a positive experience for both the patient and their loved ones.

Nurses should employ active listening and open communication, addressing specific fears and questions to create a foundation of trust and understanding. It is also important to explain the procedure, potential complications, and recovery process, which empowers families to be active participants in their loved one’s care. Clear communication reduces anxiety and facilitates informed decision-making. Family members often grapple with their own anxieties. Nurses can offer emotional support, provide resources like support groups, and connect them with other families facing similar experiences.

By attending to both the emotional and practical needs of families, nurses play a crucial role in creating a supportive environment for patients during preoperative interventions. This holistic approach not only fosters a positive experience for the entire family but also contributes to a smoother and more successful surgical journey for the patient.

Initiating the Perioperative Records

Perioperative nurses, acting as guardians of information, play a critical role in initiating and maintaining accurate and comprehensive patient records. These records are not mere paperwork; they are the vital narratives of a patient’s surgical journey, informing future care, ensuring safety, and contributing to medical advancements. From the moment the patient arrives at the facility to when they go to the OR, preoperative nurses meticulously record every step of the process, including vital signs, medications administered, procedures performed, and unexpected events. This detailed record serves as a real-time account of the preoperative stage, allowing for immediate adjustments and ensuring accurate communication between the different perioperative stages.

The RN circulator continues to maintain the patient’s record by documenting intraoperative activities (e.g., time-outs performed, position and positioning aids used, hypothermia interventions, counts, medications on the sterile field, wound irrigation, electrosurgical dispersive pad placement) and patient outcomes (e.g., surgical procedures performed, skin integrity, wound status, final count status). As the patient recovers, PACU nurses continue to document vital signs, pain levels, interventions provided, and any complications.

This ongoing record tracks the patient’s progress, identifies potential issues early, and helps tailor recovery plans for optimal outcomes. Maintaining consistent formats and adhering to established documentation protocols ensures clarity, completeness, and legibility of records. This allows for efficient information sharing between healthcare providers and facilitates accurate data analysis for research and quality improvement initiatives. By meticulously documenting every aspect of the perioperative journey, nurses play a crucial role in safeguarding patient safety, informing future care, and advancing the field of medicine. Their dedication to accurate and comprehensive records ensures that every scalpel stroke, every suture, and every heartbeat is not just witnessed but also remembered for the benefit of patients now and in the future.

Administering Preanesthetic Medication

Preoperative nurses, acting as medication safety champions, ensure the safe and effective delivery of preanesthetic medications. These critical medications promote a safe, comfortable surgical experience. Nurses conduct thorough patient reviews, considering factors like allergies, medical history, and medication interactions. This comprehensive analysis ensures the selection of the most appropriate preanesthetic medication for each individual patient, minimizing risks and optimizing outcomes. Preanesthetic medications serve several purposes, including the following (Aegis Anesthesia, 2023):

• Anxiolysis: An anxiolytic, like benzodiazepines (e.g., midazolam), reduces anxiety and promotes a calming effect. This can help alleviate preoperative fears and create a more relaxed state.
• Sedation: Certain medications (e.g., benzodiazepines, opioids) induce a state of relaxation and sedation. This helps minimize distress and discomfort during the induction of anesthesia.
• Amnesia: Some preanesthetic medications, particularly benzodiazepines because of their rapid onset and short duration of action, are used to promote temporary memory loss or amnesia. This helps patients forget the events surrounding the induction of anesthesia and the procedure itself.
• Analgesia: Opioid analgesics like fentanyl may be administered preoperatively to provide pain relief and reduce the perception of pain during the preoperative process, surgery, and postoperative recovery period.
• Antisialagogue and anticholinergics: Medications called antisialagogues and anticholinergics, like glycopyrrolate, reduce salivation, minimizing the risk of aspiration during the procedure and preventing bradycardia.
• H2 blockers or proton pump inhibitors: These medications (e.g., omeprazole [Prilosec]) are given to reduce gastric acid secretion and minimize the risk of aspiration in patients at risk.
• Antiemetic: Medications can be administered intravenously (ondansetron [Zofran]) and transdermally (scopolamine patches) for their antiemetic properties to prevent postoperative nausea and vomiting.

It is essential to administer preanesthetic medications according to the appropriate schedule to ensure the medication has sufficient time to take effect before the induction of anesthesia. Continuously monitoring the patient’s vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is crucial during and after the administration of preanesthetic medications to make sure they remain a safe and effective treatment. Prior to the administration of preanesthetic medications, it is also important for the patient to sign the necessary consent forms and to urinate, ensuring they are physically and legally prepared for the procedure.

Nurses follow strict protocols and guidelines for medication administration, adhering to the eight rights of medication administration: right patient, right medication, right dose/concentration, right route, right time, right documentation, right reason, and right patient response (Comerford & Durkin, 2021). Meticulous adherence to the eight rights helps to prevent errors and helps ensure the intended effects of the medication are realized. Nurses proactively address any emerging issues, adjusting medication regimens or notifying the surgical and anesthesia team, if necessary.