The preoperative surgical period represents a fundamental phase in client care, beginning when a surgical procedure is scheduled and concluding with the client’s transfer to the surgical suite. This critical window necessitates diligent preparation by healthcare professionals, with nurses assuming a pivotal role in ensuring clients are physically and emotionally ready for surgery.

Throughout this period, the nurse acts as a multifaceted caregiver: an educator, empowering clients with essential knowledge; an advocate, safeguarding their rights and safety; and a promoter of health and wellness, implementing best practices and fostering open communication within the healthcare team. This commitment to evidence-based care, adherence to protocols, and transparent communication establishes a robust culture of safety, crucial for optimal surgical outcomes.

A primary function of the preoperative nurse is education. They are responsible for reinforcing the information the surgeon has already shared with the client. This includes details about the planned surgical procedure, potential risks and benefits, necessary preoperative preparations, and what to anticipate during the postoperative recovery phase. By reiterating this information, the nurse ensures the client fully comprehends the rationale behind the surgery and has the opportunity to voice any concerns or ask clarifying questions.

This process is fundamental to empowering the client to actively participate in decisions regarding their healthcare and confirming that informed consent has been freely given. If the nurse observes any indication that the client’s consent is not adequately informed, they have a professional and ethical responsibility to notify the surgeon before the procedure commences. In situations where a power of attorney (POA) for health care has been activated, the nurse facilitates communication with the POA to obtain informed consent on the client’s behalf.

Beyond education, the nurse serves as a steadfast advocate for the client. This advocacy encompasses ensuring their rights, preferences, and overall safety are respected throughout the entire perioperative experience. Key advocacy actions include meticulously verifying proper client identification using at least two identifiers, confirming that the surgical site has been correctly marked according to established protocols, and ensuring that all necessary safety measures, such as those outlined by The Joint Commission, are in place before the client proceeds to the operating room. The nurse actively collaborates with the entire interdisciplinary team – including surgeons, anesthesiologists, technicians, and other specialists – to proactively identify and address any potential risks or complications, consistently advocating for the client’s best interests and well-being.

Effective communication and seamless collaboration are cornerstones of safe and efficient preoperative care, strongly emphasized by initiatives like The Joint Commission’s National Patient Safety Goals (NPSG). The preoperative nurse is an active participant in these vital processes, sharing relevant client information with the team, clarifying physician orders, and diligently addressing any potential gaps or discrepancies in the care plan or client information. This collaborative approach fosters strong teamwork, significantly enhances client safety by minimizing errors, and facilitates smooth transitions between the preoperative, intraoperative, and postoperative phases of care.

Applying the Nursing Process to Preoperative Care

The nursing process provides a structured, systematic approach to delivering high-quality preoperative care. The key nursing priorities during this period are centered around preparing the client comprehensively for the surgical experience:

1. Perform Preoperative Assessments: Conduct thorough assessments to evaluate the client’s current health status and identify any factors that could pose risks or contraindicate surgery.
2. Collaborate on the Perioperative Plan: Work with the healthcare team to develop a holistic plan encompassing preoperative preparation and anticipated postoperative care.
3. Provide Health Teaching: Educate the client about the surgical procedure, expected outcomes, and the recovery process.
4. Ensure Informed Consent: Verify that informed consent has been obtained and documented prior to the administration of preoperative medications and the surgical procedure itself.
5. Administer Preoperative Medications: Give prescribed medications as ordered, such as those for anxiety reduction or infection prophylaxis.

Assessment

A comprehensive preoperative assessment is foundational to identifying potential risks and optimizing client readiness for surgery. This assessment includes gathering a detailed health history and conducting a focused physical examination.

Preoperative Health History: A thorough health history explores various factors influencing surgical risk:

• Age: Age significantly impacts physiological response to surgery. Older adults may have increased risks due to factors like a less robust immune response, slower wound healing, reduced renal function affecting drug excretion, decreased muscle mass, increased dehydration risk, and diminished physiological reserve. Assessing these factors helps in planning appropriate interventions to mitigate risks. Pediatric clients require specific considerations, including reduced anesthetic dosages, potentially specialized equipment due to size, and tailored communication techniques. Involving familiar support figures and utilizing child life specialists (when available) can significantly reduce anxiety by familiarizing children with the surgical environment.
• Drugs and Substance Use: A meticulous medication history is essential, covering all prescription drugs, over-the-counter medications, herbal supplements, and any substance use (tobacco, alcohol, marijuana). This is critical for identifying substances that could interact negatively with anesthetic agents, impair blood clotting, or increase the risk of respiratory or cardiovascular complications during and after surgery. Specific attention is given to substances known to have significant systemic effects.
• Medical History, Particularly Cardiac and Pulmonary Conditions: The client’s medical history, especially pre-existing cardiac and pulmonary conditions, must be rigorously evaluated. Clients with cardiac disease face a higher risk of complications related to anesthesia and may struggle to tolerate the hemodynamic shifts induced by anesthetic agents. For individuals at risk of cardiac events, specific preoperative measures, such as initiating or continuing beta-blocker therapy, may be implemented to lower the risk of myocardial infarction during surgery. Pulmonary status is assessed, particularly in clients with chronic obstructive pulmonary disease (COPD) or a history of smoking, as these conditions can lead to reduced lung function, impaired gas exchange, and increased susceptibility to anesthesia-related respiratory complications.
• History of Previous Surgical Procedures and Anesthesia: Reviewing the client’s past surgical experiences and previous encounters with anesthesia can reveal valuable information about their response to surgery and anesthetic agents. It’s also crucial to document any family history of malignant hyperthermia, a rare but potentially fatal inherited condition triggered by certain anesthetics.
• Allergies: A comprehensive allergy history is paramount to prevent adverse reactions during surgery. This includes allergies to medications (especially anesthetic agents like propofol) and materials commonly used in the surgical setting, such as latex. Identified allergies must be clearly communicated to the anesthesiologist and the entire surgical team to ensure appropriate precautions are taken and alternative options are considered.
• Previous Blood Donations: Information regarding previous autologous (self-donated) or directed (from a specific donor) blood donations is important for planning potential blood product transfusions during or after surgery. Additionally, documentation of any preoperative administration of erythropoietin (EPO) to stimulate red blood cell production is relevant, as it may reduce the need for transfusions.
• Discharge Planning: Although focused on the preoperative phase, early consideration of postoperative care and discharge planning is crucial. Assessing the client’s home environment for suitability for recovery, identifying available support systems, and evaluating their self-care abilities helps determine if additional assistance or resources will be required upon discharge. Factors such as anticipated postoperative needs, follow-up appointment scheduling, transportation arrangements, and the need for any medical equipment or supplies at home are all part of this proactive planning.

Preoperative Physical Assessment: While the primary healthcare provider conducts a comprehensive history and physical (H&P) to clear the client for surgery and orders necessary diagnostic tests and consults, the nurse performs a focused assessment just prior to the procedure as a final check. This assessment focuses on key body systems to identify any new concerns or changes in status that could impact surgical safety. If any significant findings are noted, the nurse immediately notifies the surgical team. Key focused assessments include:

• Cardiovascular System: Checking for new onset hypertension, which can significantly impact the hemodynamic response to surgery. Listening to heart sounds for rate, regularity, and any new abnormal sounds that might indicate underlying cardiac issues. Examining hands and feet for temperature, color, the presence and quality of peripheral pulses, capillary refill time, and edema, as abnormalities can signal poor circulation. Assessing for a history of venous thromboembolism (VTE), which increases the risk of developing blood clots during surgery.
• Respiratory System: Considering factors like age, smoking history, and chronic conditions such as COPD, which influence respiratory function and complication risk. Observing the respiratory rate, rhythm, depth, and overall breathing effort for any deviations. Documenting the presence of clubbing of the fingertips or cyanosis, which may suggest chronic respiratory compromise. Auscultating lung sounds to identify any abnormal sounds indicative of underlying pulmonary pathologies. Assessing for obesity, as it is a significant risk factor for obstructive sleep apnea (OSA) during and after surgery.
• Renal System: Inquiring about urinary symptoms like frequency, dysuria, nocturia, difficulty initiating urine flow, and oliguria, which could indicate underlying renal problems. Assessing the appearance and odor of urine and the degree of continence. Evaluating the client’s usual fluid intake, as it affects renal function. Evaluating kidney function is critical because decreased function can prolong the excretion of drugs and anesthetic agents, leading to extended effects.
• Neurological System: Assessing overall mental status, level of consciousness (LOC), orientation to person, place, and time, and the ability to follow commands to establish a baseline for postoperative comparison. Determining the client’s risk for falling, particularly in older adults, to implement necessary safety precautions.
• Musculoskeletal System: Inquiring about a history of arthritis or previous joint replacement surgeries, as these can impact client positioning and surgical approach. Assessing for any unique positioning requirements necessitated by existing conditions (e.g., neck or chest issues). Noting the presence of any prosthetic joints, tattoos, or scar tissue in the surgical area, as these can be affected by the use of electrocautery, requiring additional care during the procedure.
• Nutrition: Assessing the client’s nutritional status, specifically identifying malnutrition or obesity, as both can negatively impact wound healing and surgical outcomes. Observing for physical signs of malnutrition such as brittle nails, muscle wasting, or dry/flaky skin.

Preoperative Laboratory Assessment: Preoperative laboratory screening is a fundamental component of ensuring client safety. The primary healthcare provider typically orders a panel of tests as part of the H&P to assess overall health and screen for potential issues relevant to surgery and anesthesia. Common tests include a complete blood count (CBC) to assess for anemia, infection, or platelet abnormalities; a basic metabolic panel (BMP) to evaluate kidney function, electrolyte balance, and glucose levels; liver function tests (LFTs) to assess liver health; a coagulation profile (PT, PTT, INR) to evaluate blood clotting ability; a urinalysis (UA) to screen for urinary tract infections and assess kidney function; and a pregnancy test for females of childbearing age. The nurse ensures these results are readily available in the client’s chart as part of the preoperative checklist. These results provide crucial data for evaluating overall health, detecting potential issues, and informing decisions regarding surgical approach, anesthesia management, and postoperative care. Other specialized tests, such as serology, imaging (like a CT scan), or specific biomarkers, may be ordered depending on the client’s medical history and the nature of the surgical procedure.

Nursing Diagnoses

Based on the comprehensive preoperative history and assessment data, nurses formulate individualized nursing diagnoses. These diagnoses reflect the client’s specific needs and potential risks related to the upcoming surgery and guide the development of the care plan and nursing interventions. Common nursing diagnoses in the preoperative period include:

• Risk for Injury related to the surgical procedure and anesthetic administration.
• Risk for Bleeding related to the surgical incision or use of anticoagulant/antiplatelet medications.
• Risk for Delayed Surgical Recovery related to pre-existing health conditions or inadequate preoperative preparation.
• Anxiety related to the unknown outcome of surgery, potential pain, or disruption of life.
• Fear related to the surgical experience, anesthesia, or loss of control.
• Readiness for Enhanced Knowledge regarding the surgical procedure and postoperative care.

Outcome Identification

Outcome identification involves establishing realistic, client-centered goals and creating expected outcome statements that are measurable and have a specified time frame. These outcomes reflect the desired client responses to nursing interventions. Sample expected outcomes for preoperative nursing diagnoses include:

• The client will remain free from injury throughout the perioperative period.
• The client will verbalize at least three potential postoperative complications and describe actions to help prevent them before transferring to the surgical suite.
• The client will report a decrease in feelings of anxiety regarding the upcoming procedure or surgery by the time of transfer to the operating room.

Planning Preoperative Interventions

Planning preoperative care involves meticulous attention to detail to ensure a safe and smooth surgical experience for the client. Several key elements are considered:

• Informed Consent: While the surgeon is ultimately responsible for obtaining the client’s signed informed consent for the procedure, nurses play a vital supportive role. This includes witnessing the client’s signature to confirm it is authentic and voluntary. Furthermore, nurses are often instrumental in clarifying information the physician has presented and dispelling any myths or misconceptions the client or their family may have about the surgery. It is crucial to remember that clients retain the right to withdraw their consent at any point before the surgery begins, and healthcare providers must honor this decision. The process of consent should be viewed as ongoing, allowing clients to make informed choices about their care at each stage.
• NPO (Nothing by Mouth): Adhering to NPO status is critically important before surgery. This means the client must refrain from eating, drinking, and smoking for a specified period. The primary reason for NPO status is to minimize the volume of gastric secretions, thereby reducing the significant risk of pulmonary aspiration (inhaling stomach contents into the lungs) during the administration of anesthesia. Generally, clients are advised to avoid solid food for at least six to eight hours before surgery and clear liquids for at least two hours. The importance of strict adherence to NPO guidelines is strongly emphasized to clients, as failure to comply is a common reason for surgical procedures to be delayed or canceled to prevent potentially life-threatening complications during anesthesia.
• Intestinal Preparation (Bowel Prep): For certain surgical procedures, particularly those involving the colon or rectum, intestinal preparation, commonly referred to as “bowel prep,” may be necessary. This preparation typically involves administering laxatives or enemas to thoroughly cleanse the intestines. The purpose is twofold: to reduce the bacterial count within the bowel, thereby lowering the risk of infection if the bowel is inadvertently entered during surgery, and to ensure the intestines are empty, which can facilitate the surgical approach and reduce the risk of injury to the bowel during manipulation.
• Administration of Regularly Scheduled Medications: Clients who take prescription or over-the-counter medications on a regular basis require careful evaluation before surgery. They must consult with their medical physician and the anesthesia provider to determine which medications should be continued, adjusted in dosage, or temporarily withheld in the period leading up to surgery. These decisions are made on an individual basis, considering the specific medication, the reason the client is taking it, and the type of surgery being performed. The goal is to minimize potential complications related to medication interactions with anesthetic agents, increased bleeding risk, or altered physiological responses during and after the procedure. Medications commonly withheld or adjusted dosages prior to surgical procedures include ACE Inhibitors and Angiotensin Receptor Blockers (ARBs) due to the increased risk of hypotension under anesthesia; certain non-soluble Antacids which can increase aspiration risk; Anticoagulants and Antiplatelets due to increased bleeding risk (with the decision to hold often based on weighing the risk of bleeding against the risk of thromboembolism); non-statin Antihyperlipidemic Agents which can increase the risk of bowel obstruction and rhabdomyolysis; Diuretics due to the risk of hypokalemia and hypotension (though sometimes continued for heart failure); Herbal Supplements which can affect coagulation or interact with anesthesia; Intermediate and Long-Acting Insulin (typically dose decreased) and Rapid and Short-Acting Insulin and Oral Antidiabetics due to the risk of hypoglycemia; NSAIDs due to increased bleeding risk; and Triptans due to the potential for serotonin syndrome when combined with certain preoperative medications like ondansetron.

Interventions

Nurses perform a wide array of interventions during the preoperative period, all aimed at preparing the client for a safe and successful surgical experience.

• Collaborate With the Interprofessional Team: As previously highlighted, nurses are integral members of the interprofessional team. They are responsible for conducting initial and ongoing preoperative assessments, gathering essential client history, and performing physical examinations to identify any potential risks or complications that could impact the surgery. Based on these findings, nurses collaborate closely with surgeons, anesthesiologists, and other team members to ensure the client is in the optimal physiological and psychological state for the procedure. This effective collaboration and communication are vital for ensuring a smooth and safe transition from the preoperative holding area to the operating room.
• Provide Emotional Support: The preoperative period can be a time of significant anxiety and fear for clients and their families. Nurses play a crucial role in providing emotional support and reassurance. This involves actively listening to their concerns, demonstrating empathy, and utilizing therapeutic communication techniques to help alleviate anxiety, build trust, and improve the client’s overall perception of the surgical experience. Creating a calm and supportive environment is paramount.
• Perform Preoperative Preparations: Nurses ensure that all necessary preoperative preparations are meticulously completed. This includes confirming that all required diagnostic tests have been performed and the results are available, preparing the surgical site according to sterile protocols (often involving specific cleansing procedures), administering all ordered preoperative medications within the correct timeframe, and ensuring the client is physically ready for transportation to the operating room. Nurses must pay close attention to detail and strictly adhere to infection control practices throughout all preparations to maintain client safety. Proper skin preparation is a critical intervention for preventing surgical wound infections; this typically involves cleansing the entire body with antiseptic wipes (such as chlorhexidine wipes) or requiring the client to shower with an antiseptic soap before surgery. After skin cleansing, bed linens are changed, and the client is dressed in a clean surgical gown.
• Document and Implement Other Safety Measures: Accurate and thorough documentation is a core responsibility of the preoperative nurse. All assessments, interventions performed, and client responses are meticulously documented according to established protocols and guidelines. Beyond documentation, nurses are directly involved in implementing crucial safety measures designed to prevent errors. These include rigorously verifying client identification using at least two identifiers, confirming that the correct surgical site has been clearly marked, and actively participating in the “time-out” procedure conducted by the surgical team just before the incision is made. The time-out is a universal protocol where the team pauses to verbally confirm the correct client, correct procedure, and correct surgical site, serving as a final critical check to prevent wrong-site, wrong-procedure, or wrong-person surgery.
• Provide Health Teaching About Postoperative Procedures: Educating clients about the surgical process extends to preparing them for the postoperative period. Nurses provide detailed teaching about what the client can expect immediately after surgery and during their recovery. This includes explaining the purpose and expected duration of any tubes, drains (like nasogastric tubes or surgical drains), or vascular access devices (like IVs) that may be in place. Providing this information can significantly reduce client anxiety and improve their understanding and cooperation with postoperative care. Comprehensive health teaching about anticipated postoperative care is vital for promoting optimal recovery and minimizing complications. Key topics for postoperative teaching include:
  
  • Prevention of Respiratory Complications: Teaching deep breathing exercises and the correct use of an incentive spirometer (IS) to promote lung expansion, improve oxygenation, and prevent atelectasis (collapse of alveoli). Demonstrating effective coughing techniques and how to splint the surgical incision to support the area and reduce pain while coughing to clear airway secretions.
  • Prevention of Cardiovascular Complications: Explaining the rationale for using anti-embolism stockings (TED hose) and sequential compression devices (SCDs) to prevent venous stasis and reduce the risk of deep vein thrombosis (DVT). Teaching clients the signs and symptoms of DVT to report to their healthcare provider (e.g., calf pain, unilateral swelling, redness). Encouraging leg exercises and early ambulation as tolerated to enhance blood flow and further reduce the risk of cardiovascular complications, including DVT.
  • Infection Prevention: Providing clear instructions on how to care for the surgical incision upon discharge, emphasizing the importance of keeping it clean and dry. Teaching clients the signs of surgical site infection, wound dehiscence (wound splitting open), or poor wound healing to report promptly. Reinforcing the critical importance of frequent hand hygiene using soap and water or hand sanitizer. Educating clients on the importance of completing the full course of any prescribed postoperative antibiotics. Providing guidance on avoiding unnecessary touching of the incision site and protecting it from potential contamination. Discussing the importance of staying up-to-date with recommended vaccinations as part of overall infection prevention.
  • Pain Control: Providing detailed instructions on the prescribed pain medication regimen, including the name of the medication, dosage, frequency, and potential side effects to anticipate. Explaining and demonstrating nonpharmacological pain relief strategies (e.g., positioning, relaxation techniques). Reinforcing any postoperative activity restrictions and providing guidance on safe mobility, including the correct use of assistive devices if needed. Emphasizing the importance of balancing rest with gradually increasing activity levels as tolerated. Teaching proper positioning techniques to enhance comfort and reduce pain. Educating clients on how to use pain scales (e.g., 0-10 scale) to accurately communicate their pain levels to the healthcare team, enabling effective pain management.
  • Prevention of Gastrointestinal and Genitourinary Complications: Explaining that it is common for bowel function to slow or cease temporarily after surgery due to anesthesia and manipulation. Informing clients that their diet will typically advance gradually from clear liquids as bowel sounds return and they pass flatus. Teaching strategies to prevent and treat constipation, a common postoperative issue, including the benefits of early ambulation, increasing fluid intake, incorporating high-fiber foods as their diet advances, and the use of prescribed stool softeners. Instructing clients to notify the healthcare provider if they have not had a bowel movement within two or three days after surgery. To prevent urinary complications, encouraging adequate fluid intake and monitoring urine output and color. Instructing clients to report low urine output or symptoms suggestive of a urinary tract infection, such as increased frequency, burning sensation during urination, or foul-smelling urine.
• Administer Preoperative Medications: Administering prescribed preoperative medications is a key nursing intervention. The selection of these medications is highly individualized based on the client’s age, physical and psychological condition, medication history, height, weight, other medications being taken, and the specific surgical procedure. The primary goals of preoperative medication administration are to optimize client comfort, safety, and the effectiveness of the anesthetic. It is absolutely essential to ensure that informed consent for the surgical procedure has been signed and documented before administering any medications that could alter the client’s level of consciousness or cognitive ability to make decisions. Common classes of preoperative medications and their rationales include:
  
  • Anxiolytics: Such as diazepam (Valium), administered to reduce preoperative anxiety and promote a state of relaxation and calmness.
  • Sedatives/Hypnotics: Such as midazolam (Versed), used to induce relaxation, alleviate preoperative stress, and create a more comfortable and less apprehensive state for the client before transferring to the operating room.
  • Anticholinergics: Such as atropine or glycopyrrolate, administered to reduce nasal and oral secretions, helping to maintain a clear airway during anesthesia. Glycopyrrolate specifically helps prevent laryngospasm by blocking parasympathetic effects.
  • Vagal Blockers: Such as atropine, used to decrease the risk of vagal-induced bradycardia (slowing of the heart rate) which can occur due to stimulation of the vagus nerve during surgical procedures.
  • Antiemetics: Such as ondansetron, administered to prevent postoperative nausea and vomiting (PONV), a common and often distressing complication after anesthesia and surgery.
  • Induction Agents: While often administered in the surgical suite, some medications might be given preoperatively or are relevant to the preoperative plan, such as discussing how agents like propofol are used to facilitate the induction and maintenance of anesthesia, potentially reducing the overall amount of anesthetic required and contributing to more stable anesthesia and improved outcomes.
  • Antibiotics: Prophylactic antibiotics, such as cefazolin (Ancef), are typically administered within approximately 60 minutes before the surgical incision is made. The timing is crucial to ensure adequate tissue levels of the antibiotic are present at the time of incision to effectively combat any potential bacteria introduced during the procedure and reduce the risk of surgical site infections.

The careful selection, accurate dosage calculation, and timely administration of preoperative medications are critical nursing responsibilities aimed at enhancing client safety, comfort, and contributing to positive surgical outcomes.

Evaluation and Perform Final Checks Prior to Surgery

The final phase of the nursing process, evaluation, in the preoperative period focuses on assessing the effectiveness of the nursing interventions performed and determining if the client’s individualized expected outcomes have been met within the established time frames. Nurses utilize critical thinking skills to analyze reassessment data collected throughout the preoperative phase. If the expected outcomes have not been met, or have only been partially met, by the specified time, the nursing care plan must be revised to incorporate alternative or additional interventions. Reassessment is an ongoing process that occurs every time the nurse interacts with the client, reviews updated laboratory or diagnostic test results, or receives new information. Just before the client is transferred to the surgical suite, the nurse performs crucial final checks, including verifying the client’s identity once more, confirming the surgical site marking, reviewing the preoperative checklist to ensure all preparations are complete, confirming NPO status, and addressing any last-minute client questions or concerns. This final evaluation and series of checks are the last line of defense in ensuring client safety and readiness for surgery.

This comprehensive approach to preoperative nursing care, guided by the nursing process, is essential for preparing clients physically, emotionally, and psychologically for surgery, contributing significantly to positive surgical outcomes and a smoother recovery.