Preparing the Patient for Surgery

Perioperative nursing is a specialty that incorporates the care of the surgical patient. It uses a multidisciplinary approach to care. In the hospital setting this includes most disciplines in the hospital: nursing, pharmacy, dietary, materials, environmental and plant operations. Perioperative nursing occurs in a variety of settings. These include: Out Patient Centers, Surgical Services, Postanesthesia Care Unit (PACU), physician offices, and any area in which surgery or invasive procedures are performed. Perioperative nursing includes three phases of the surgical experience: the preoperative, the intraoperative, and the postoperative phases. This nursing specialty provides continuity of care through the peri-operative phases. Registered Nurses are responsible for preparing patients for an operative and/or invasive procedure.

By the year 2030, it is estimated that 20 percent of Americans will be older than 65, while one out of four elderly individuals will be older than 85 years of age. Twenty-one percent of those over age 60 will undergo surgery and anesthesia as compared with only 12 percent of those aged 45 to 60 years. Despite the higher numbers of elderly patients having surgery, mortality and morbidity rates have been declining. Old age appears to have assumed less influence as a determinant of adverse outcomes as perioperative care has improved. A better understanding of the associated risk factors leading to perioperative complications may help healthcare providers to further lower the risk.

The preoperative phase begins when the decision for surgery is made and ends when the patient is transferred to the operating room table. The preoperative evaluation and teaching typically takes place several days before surgery in an outpatient setting. Today, most perioperative patients are admitted to the hospital the morning of their surgical procedure. However, there are times when the preoperative phase will begin on the medical-surgical units or in the emergency department. The first step of the preoperative phases begins with a patient and chart assessment on all patients scheduled for an operative and/or invasive procedure prior to transportation to the Surgical Suites. This ensures accurate identification of the patient, using two identifiers, identification and marking of the surgical site, adequacy of the preoperative patient preparation, and completeness of the documentation. This assesses the patient’s actual and potential health problems and facilitates implementation and communication of the perioperative plan of care

A thorough nursing assessment and appropriate interventions can prevent or minimize procedure related complications. The preoperative assessment is essential to identify problems early, and to provide a comparison for postoperative deviations from the norm.  Sometimes, the initial nursing assessment is done in a preadmission visit that may also include preoperative teaching and outpatient testing. However, it is critical that the nursing assessment be repeated the morning of surgery. This assessment should include at a minimum, vital signs, respiratory status, an assessment of the level of consciousness, and review of preoperative testing results.

Allergies – drugs, adhesive tape, latex or soap. Ask about preexisting illness, such as liver, respiratory, renal, cardiac, endocrine, and blood disease.

Inquire about use of medications that could interfere with anesthesia or contribute to postoperative complications, such as bleeding. Ask about herbal usage.  More and more people are using herbs and vitamins and will not always volunteer this information. Ask about difficulty with hearing or vision. Document the medications the patient takes regularly, including over the counter and herbal medications. St. John’s Wort, feverfew, ginkgo biloba, ticlid, plavix anticoagulants and non-steroidal anti-inflammatories effect coagulation and can increase the risk of hemorrhage.

Obtain nutritional history to evaluate dietary intake and nutritional status. Ask about elimination to detect constipation or diarrhea. Question the patient about motor problems, particularly difficulty with walking or with arm or leg movement due to arthritis or orthopedic surgery.  REMEMBER we want to promote early activity postoperatively.

Ask about the patient’s ability to sleep and relax, level of pain or discomfort, and expectations about postoperative pain relief; perform a baseline pain assessment.

The purpose of preoperative teaching is to decrease patient anxiety and prepare the patient for surgery. It will also decrease fear. Fear of the unknown increases anxiety. Preoperative teaching can alter unfavorable attitudes, influence postoperative recovery and promote satisfaction with care. Preoperative teaching may have been done and documented in a preadmission visit. If not, you must do the teaching. If it was done, you should reinforce the teaching. You can provide a description of and reason for preoperative tests, description of preoperative routines, time of surgery, probable length of surgery and estimated time in PACU. Explain the recovery process, including the place where the patient will awaken, nursing care provided, monitoring of vital signs and equipment used (O2 therapy, O2 saturation monitor, PCA). Cover the probable postoperative course – IV lines, need to increase activity as soon as possible, need to cough and deep breath despite discomfort, incentive spirometer (this is a good time to teach them on how to use an incentive spirometer and have them practice which will make it easier to use postoperatively) Stress that it is important to turn, cough and deep breathe to prevent atelectasis. Instruct him to turn cough and deep breath at least 3 times an hour and to use the incentive spirometer at least every 2 hours, while awake. Tell family members what time the patient is expected to go to surgery, where they can wait during surgery, when the physician will contact them with surgical results.

If you do the preoperative teaching during a preadmission visit, explain any instructions that require the patient to prepare himself at home, like bowel evacuation for a colonoscopy. The morning of the procedure, check to see if the patient was complied with the instructions. Failing to execute preoperative preparation may be a reason to postpone the procedure. Explain the meaning of NPO, emphasizing the importance of being compliant to avoiding aspiration. Sometimes, patients will be NPO except for their oral medications, which should be taken with clear water. This variation may be a policy at a specific facility, or the physician’s order will be written as NPO except for medications. Most patients will be NPO after midnight the day before the procedure. A physician may designate a later NPO status if the patient is scheduled late in the day. Instruct the patient to shower the morning of the procedure with an antimicrobial soap. The patient should wash the operative site for at least five minutes, scrubbing in a circular motion. Anesthetic will remain in the patient’s body for at least 24 hours post procedure, so caution the patient not to drive, operate dangerous equipment or make important decisions within 24 hours after the procedure. Some procedures have preoperative teaching needs that are specific to that procedure, like how to use a walker if you are going to have a hip replacement. These needs are determined in collaboration with the physician.

Pre-anesthesia medication varies from facility to facility. It is usually given immediately before surgery to:

• Decrease anxiety
• Provide sedation
• Induce amnesia
• Decrease pharyngeal secretions
• Slow hydrochloric acid production
• Prevent allergic reaction to anesthetics

If they are given, they will normally be given by the anesthesia provider just prior to patient going into the OR.  This is only done AFTER all consents have been signed and are verified complete. This is not to be confused with the administration of preoperative medications – antibiotics, inhaler, breathing treatment, antacid or h2 blockers (Zantac - which inhibits gastric acid secretion), antiemetic (Reglan – given for gastro esophageal reflux and/or delayed gastric emptying). May hear term sour stomach.

Requiring permission to operate protects the patient from unsanctioned surgery and protects the surgeon from claims of unauthorized operation. The informed consent document indicates the specific procedure to be performed and includes a list of possible complications. The consent should be written as stated in physician orders. It is clearly worded in simple terms without abbreviations. All blanks must be filled in. If you have questions about the correct layman’s terms, the OR staff, the physician or nursing supervisor should be called for verification. If there is question about diagnosis/reason for procedure consult physician performing the procedure. The consent contains the patient’s signature, if the patient is of age and competent, date and time signed. There is should also be a clause for photographs and blood transfusion.  If the patient is having conscious sedation this should be included on the consent. Conscious sedation may be given to patient having colonoscopy/EDG/painful procedures. If the operative permit is not signed, have the patient sign and date it. Witness the signature. A nurse’s signature of witness is verifying that the patient signed the form. It does not hold any other legal responsibility. It does not mean that you participated in informed consent. Informed consent is done between the physician and the patient in a discussion. The operative permit has the patient signature to verify that consent. If the patient is unable to write, an “X” to indicate his agreement is acceptable. You should have a second witness to the “X”. The information that the patient must understand is a definition of the procedure, possible complications and risks of the procedure. If the patient expresses that he has unanswered questions about the procedure, or does not want the procedure, you have the responsibility to contact the physician and let him know.

If the patient is awake and oriented x 3, 1 witness is needed. If the patient is a minor, the legal guardian must sign the consent and 1 witness is needed. Most states have statues regarding the treatment of minors. An emancipate minor is usually recognized as one who is not subject to parental control, as in the following situations:

• Married minor
• In military service
• College student under legal age but living away from home
• Minor who has a child.

If the patient is incompetent or incapacitated, permission can be sought from a patient representative. Laws vary from state to state and policy varies from facility to facility. An incompetent patient is any patient who is mentally or physically incapacitated, as determined by physicians, such that the patient cannot communicate treatment preferences. Facility policy usually dictates the process and how many physicians must be involved in the decision. The patient does not have to be adjudicated incompetent by a court of law for the purposes of consenting for a procedure. If the family or Power of Attorney signs the consent 2 witnesses are needed.  

In an emergency, where the physician feels that delaying a procedure would be an immediate threat to the patient’s life or limb, and the patient cannot give consent, the physician may proceed with the procedure without consent. This process requires extensive documentation and often a consultation with other physicians. Check facility policy. The informed consent document should be placed on the patient’s chart and accompany the patient to the Surgical Suite.

Informed Consent:

• Must be obtained BEFORE patient receives pre-op meds that induce sedation or amnesia or reduces anxiety
• Ensure that the patient has actually been informed
• Physician performing the surgery must sign the consent
• Ensure that the consent has date and time
• 2 witnesses are required for incompetent patients and telephone consents

In final preparation before the patient is transported to surgery the pre-operative checklist should be reviewed for documentation of nursing actions which include:

• Removal of jewelry and other objects (remember to check for “unique” body jewelry)
• Checking patient identification using 2 identifiers ensures surgical site is identified and marked with an “X”
• Asking the patient to void
• Check for necessary documents – patient history, physical assessment, consent form, test results
• Administering pre-op meds
• MAR on chart
• Recent vital signs (should not be greater than 1 hour)

Depending on the facility policy, dentures may or may not be removed prior to a procedure.

On the preoperative checklist the nurse documents actions, such as patient identification; allergies; removing jewelry or other objects; asking patient to void; ensuring all needed documentation (H&P, consent, test results) are available. Mark the site of surgery, however; not immediate over the site. What IV Fluid is hanging? Incomplete chart work can delay the surgical procedure. The nurse may be required to go to the OR to identify the patient and to complete documentation.

Nursing’s preoperative teaching and assessment contribute heavily to the success of a procedure. No surgery is without risk but complications can be decreased with proper preoperative assessment and documentation of coexisting disease. Medical optimization, adequate planning preoperatively, including scheduling surgery electively as opposed to emergently, and improving nutrition status may be helpful. Opportunity to improve perioperative outcomes will be possible when risk factors for adverse events can be modified.

Nettina, S, (2001). The Lippincott Manual of Nursing Practice, 7th edition. Philadelphia, PA: Lippincott Williams & Wilkins. pp107-136.

Gruber, E. & Tschernko, E. (2003). Anaesthesia and postoperative analgesia in older patients with chronic obstructive pulmonary disease: Special considerations. Drugs & Aging 20(5), 347-361.

Walker, J., (2002). Emotional and psychological preoperative preparation in adults. British Journal of Nursing. 11(8), 567-576.