Chapter 18: Preoperative Nursing Care

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Have you ever stopped to think about just all the planning, all the checks and balances that go into preparing for something as big as surgery?

It's way more intense than preparing for, say, a big presentation, right?

So many moving parts.

Welcome to the deep dive.

This is where we take those really complex topics and, well, we break them down, make them clear and hopefully really useful for you.

Today we're diving deep into the critical world of preoperative care and we're using Chapter 18 of Lewis's Medical Surgical Nursing as our guide.

Exactly.

And our mission today, really, is to give you, our future nurses, a clear step -by -step understanding of everything involved when you're getting a patient ready for the OR.

We want to uncover the why behind every single assessment, every intervention.

It all comes down to patient safety and the nursing process from the very first time you talk to the patient right up until they actually go into the operating room.

Spot on.

So we'll cover why people have surgery in the first place, where it happens.

Then we'll really get into the weeds with the nursing assessment.

We're talking subjective data, the patient's story, and objective data, what you observe and measure,

plus crucial preoperative teaching, the legal stuff like informed consent, and of course those vital day of surgery preps.

And we won't forget special considerations either, like cultural competence and caring for older adults.

Those are huge.

Definitely.

It's quite a journey.

So let's start right at the beginning.

What is surgery?

I mean, fundamentally, it's defined as the art and science of treating diseases in injuries, deformities, using operations and instruments.

But the key thing, it's not just one moment, it's this whole period operative period.

There's preoperative before, intraoperative during, and postoperative after.

Right.

And this chapter focuses squarely on that crucial before part, setting the stage.

Precisely.

Getting it right here makes a massive difference downstream.

So why do patients actually undergo surgery?

It's not always just about fixing something obvious, is it?

Not at all.

And knowing the why really shapes how you approach them.

You've got surgery for diagnosis, maybe a biopsy to figure out what's wrong.

Okay.

Then there's cure, like taking out a ruptured appendix.

That's pretty straightforward.

But then you have palliation.

This is where we're not curing the disease, but we're alleviating symptoms, improving quality of life.

Think about creating a colostomy to bypass an obstruction you can't remove.

Okay.

The goals are different.

Vastly different.

And so are the patient's emotional needs.

Then there's prevention, like removing a mole before it becomes malignant.

Proactive.

Exactly.

And cosmetic improvement, which could be repairing a burn scar, often impacting function or confidence.

And you mentioned exploration used to be common.

Yeah.

Historically, opening someone up to just see what's going on was more frequent.

Thankfully, with advanced diagnostics now, CTs, MRIs.

We can often see without cutting.

Right.

Much less invasive, much safer generally.

So we know the why.

What about the where?

Surgery can be planned, elective, or boom, an emergency.

Correct.

And a huge shift we've seen is towards ambulatory surgery, also called same -day or outpatient.

Most surgeries now, right?

The majority, yes.

Often using minimally invasive techniques, maybe laparoscopy, done in clinics, outpatient units.

Patients typically go home within hours, needing a responsible adult with them.

And overnight stay is much less common now.

And that sounds like a win -win generally.

Fewer tests maybe, lower infection risk.

Definitely.

Plus, patients often prefer recovering at home.

It's more convenient, often less expensive.

Okay.

So let's shift gears to your role, the preoperative assessment.

This starts with that first connection, the interview.

Gathering the subjective data.

Yes.

And this is so much more than a checklist.

It's your chance to really listen.

Get crucial health info allergies are huge.

Drug and food allergies.

Clarify what they understand about the surgery, the anesthesia.

And critically, gauge their emotional state, their expectations.

What are they worried about?

And the number one goal through all of this assessment.

Patient safety.

Always.

You're looking for risk factors.

Anything that could cause a problem.

So you establish baseline data, what's normal for this patient.

You identify psychological factors, physiological ones,

pinpoint the exact surgical site.

And medications.

All of them.

All of them.

Prescription, over -the -counter, herbs.

We'll come back to that.

Check diagnostic results, consider cultural needs, and verify that informed consent is done.

It's thorough for a reason.

And that psychosocial piece?

Surgery is stressful.

Absolutely.

The body reacts physically, BP goes up, heart rate increases.

Your job is to figure out what's stressing them.

Anxiety seems almost universal.

Fear of the unknown,

past bad experiences.

All of the above.

Sometimes it's rooted in cultural or religious beliefs like Jehovah's Witnesses and blood transfusions.

Your best tool.

Information.

Telling them what to expect.

What are the common fears you hear?

Oh, fear of death.

Definitely.

Permanent disability.

Pain is a big one.

And you can reassure them about pain management.

Teach them the pain scale before surgery.

Fear of mutilation or altered body image.

Fear of the anesthesia itself losing control, waking up during...

Scary thoughts.

Very.

And that's where getting the anesthesia care provider, the ACP, to talk with them directly is key.

They might also worry about disruption to their life finances.

Family separation.

Amidst all that fear, though, you mentioned hope.

Yes.

Hope is incredibly powerful.

If they have a positive outlook, you support that.

Focus on the good results they're anticipating.

Okay.

Let's dig into the health history.

Past medical conditions, previous surgeries.

Any problems back then, like infections?

Documented all.

Family history, too.

Any inherited conditions.

Hypertension.

Malignant hyperthermia.

That's a critical one for anesthesia.

And medications.

You said we'd come back to this.

This sounds crucial.

It is absolutely critical.

Document everything.

Prescription, OTC, and especially herbs and supplements.

Why the special emphasis on herbs?

Because patients often don't think of them as drugs.

But things like garlic, ginger, ginkgo, they can increase bleeding risk, especially with anticoagulants.

St.

John's wort can mess with drug metabolism.

Cava and valerian can increase sedation.

You have to ask specifically.

Wow.

And what about regular meds?

Table 18 .3 in Lewis's talks about adjustments.

Right.

Antidepressants can interact with opioids.

Antihypertensives might cause hypotension during surgery.

Insulin and oral hypoglycemics almost always need careful adjustment.

And anticoagulants like warfarin.

Huge deal.

They might be stopped, continued, or maybe bridged with short -acting heparin.

Needs a clear plan.

And substance use.

Got to ask directly.

You have to be frank.

Tobacco, alcohol, opioids, marijuana, it all affects anesthesia.

Chronic alcohol use.

Think liver damage, altered drug metabolism, potential withdrawal, post -op.

Serious stuff.

Allergies, too.

You mentioned distinguishing intolerance from a true allergy.

Yes.

Intolerance is unpleasant, like nausea from codeine.

A true allergy is an immune response hives, itching, maybe anaphylaxis, life -threatening.

Screen for non -drug allergies, too.

Food, environmental, and latex.

Ask if they react to gloves, balloons.

Certain food allergies, like bananas or avocados, increase latex risk.

And a specific safety alert you mentioned?

Yes.

Bisulfites.

They're preservatives in some local anesthetics.

So always ask about allergies to sulfur -containing drugs.

Crucial safety point.

Okay, that covers this objective data pretty well.

Now the objective data, starting with the review of systems, ROS, your head -to -toe scan, where do you start?

I usually start with cardiovascular.

Check BP baseline, any history of angina, dysrhythmias, heart failure, past heart attacks, cardiology consult might be needed.

And you mentioned something often missed here.

Yes.

The risk for VTE venous thromboembolism, DVT and PE.

You need to assess risk factors,

immobility, history of clots, cancer, obesity, smoking.

Even in patients who seem lower risk, you need to be thinking about it.

We might even put on those intermittent pneumatic compression devices, the IPCs, in the holding area.

Proactive prevention.

Good point.

What about the respiratory system?

Look for any active infections that might postpone elective surgery.

History of asthma, COPD.

They're at higher risk for low oxygen levels, collapsed lung sections, adlectasis,

and smoking cessation.

Ideally six weeks before, but any reduction helps.

Neurologic.

Especially thinking about older adults.

Absolutely.

Assess their baseline cognitive function.

Are they oriented?

Can they follow commands?

Older adults are more prone to post -op confusion, that emergence delirium, knowing their normal is vital.

Got it.

Quick hits on other systems.

Genitourinary.

Real disease history, UTIs.

And for women of childbearing age, always a pregnancy test.

Anesthesia exposure in the first trimester is generally avoided.

Liver function.

Liver disease means higher risk for clotting problems and trouble metabolizing drugs.

Again.

Check for rashes, breakdown, pressure injuries.

You might need extra padding in the OR, no tattoos, piercings, And the musculoskeletal.

Arthritis, mobility issues.

This affects positioning during surgery, ambulation after, even placing spinal anesthesia.

Endocrine is a big one, especially diabetes.

Huge.

Diabetics risk hypo and hyperglycemia, poor wound healing, infection.

Blood sugar control is key.

Thyroid issues.

Addison's disease also need careful medication management.

Immune system.

Immunosuppression.

Delayed healing.

Infection risk.

Acute infections might delay surgery.

Chronic ones need specific precautions.

Fluid and electrolytes.

Vomiting.

Diarrhea.

Diuretic use can cause imbalances.

Older adults have less reserve here, a narrower margin of safety.

And nutrition.

You mentioned obesity, but also malnutrition.

Yes.

Obesity.

BMI over 40.

Stresses the heart and lungs, makes surgery harder.

Impacts healing and anesthesia recovery.

But being malnourished, even if obese or very thin, also impairs healing significantly.

And that caffeine point again asks about intake.

Withdrawal headaches can mimic serious post -op issues like spinal headaches.

That's a really practical tip.

So after the ROS, we have the physical examination.

The findings lead to that ASA rating.

The Joint Commission requires a documented history and physical.

The findings help the ACP assign the ASA physical status rating P1 being healthy up to P6 for brain dead organ donor.

It directly reflects perioperative risk.

And finally, diagnostic studies labs.

ECG.

Get and check results for things like blood glucose, ECG, maybe a pregnancy test, HCG, coagulation studies, PTPT -TINR, kidney function, BUN creatinine.

Table 18 .6 lists common ones.

MRSA screening might be done too.

The absolute key.

Make sure all reports are in the chart before the patient goes to the OR.

Missing results cause delays.

Okay.

Assessment complete.

Let's move to nursing interventions.

Preoperative teaching seems paramount.

It really is.

Good teaching boosts satisfaction, reduces fear and stress, and can actually lower complication rates, shorten hospital stays.

It's powerful.

You mentioned three types of information.

Sensory, process, procedural.

That's right.

Sensory is what they'll see, hear, smell, feel.

The OR might feel cold.

You'll hear beeping sounds.

Process is the general flow.

First, you'll go to the holding area, then the OR, then recovery.

And procedural is specific stuff.

We'll start in the IV line here.

The surgeon will mark the spot.

And general instructions, like deep breathing.

Yes.

Unless there's a reason not to, teach deep breathing, coughing, and early ambulation before surgery.

Let them practice.

Explain any tubes or drains they might have afterwards.

Talk about pain management expectations.

For ambulatory surgery patients.

Clear instructions are vital.

When to arrive, what to wear, what not to bring.

And stress the absolute need for a responsible adult to drive them home and ideally stay with them.

And those NPO guidelines.

Non -negotiable you said.

Absolutely non -negotiable.

For SACI, preventing aspiration.

Remember the general times.

Two hours for clear liquids.

Four for breast milk.

Six for non -human milk or a light meal.

Eight or more for a regular meal.

Check your hospital policy, but stick to it strictly.

Legal prep next.

Informed consent.

This protects everyone, right?

It does.

And three things make it valid.

One,

adequate disclosure by the surgeon diagnosis.

Purpose, risks, alternatives, prognosis.

Two, the patient have to understand it all before any sedating meds are given.

Crucial timing.

Critical.

And three, it must be voluntary, no pressure, no coercion.

And the nurse's role.

You witnessed the signature, but it's more than that.

Much more.

You act as a patient advocate.

You verify they seem to understand.

If they have questions, if they seem confused, you must contact the surgeon before they sign or proceed.

And remember, they can withdraw consent anytime.

Special rules apply for minors, emergencies, or if the patient can't consent themselves.

Okay.

Fast forward.

Day of surgery.

Final checks.

What's on your list?

Final teaching.

Quick assessment.

Communicate any last -minute issues.

Ensure the chart is perfect.

Sign consent.

H &P.

All labs and diagnostics present.

Verify the surgical site marking with the patient.

Have them remove cosmetics, nail polish, jewelry, most prosthetic, dentures, contacts.

Hearing aids stay in.

Usually, yes, so they can hear.

ID and allergy bans on.

Secure any valuables according to policy.

And that simple but vital step before meds.

Have the patient void.

Empty the bladder.

Prevents accidents under anesthesia and helps reduce post -op urinary retention.

And come the preoperative medications.

Specific drugs for specific reasons.

Exactly.

Targeted approach.

Enzodiazepines like mitazolam or diazepam for anxiety, sedation, amnesia.

Anticholinergics like atropine or glycopyrrolate to dry up secretions.

Prevent nausea.

Opioids for pain relief.

Antiemetics like ondanskron for nausea vomiting.

Others too.

Antibiotics.

Yes.

Antibiotics are common.

Given within 30 -60 minutes before incision to prevent infection.

They be beta blockers for BP control, insulin adjustments for diabetics, specific eye drops for eye surgery.

And the big safety check before giving these.

Use that preoperative checklist.

Every single time.

Ensure all preparations are done before giving any sedating medication.

Once they have that benzo, they can't sign consent for instance.

Safety first.

Got it.

Now those special considerations.

Cultural competence.

Huge.

Yeah.

Culture impacts everything.

Pain expression.

Family roles and decisions.

You mentioned the example of older Hispanic women potentially deferring to family.

Be aware.

Be respectful.

And always use qualified medical interpreters if there's a language barrier.

Never rely on family for complex medical translation.

Makes sense.

And gerontologic considerations.

Older adults are more vulnerable.

Definitely.

Surgery and hospitalization can be overwhelming.

Feel like a loss of independence.

Their bodies have less reserve due to normal aging.

Chronic illnesses are common.

They have a decreased ability to cope with the stress of surgery.

So we assess their physiologic age, not just the number.

How well are their systems functioning?

And cognitive or sensory issues.

Need careful assessment.

Reduced vision.

Hearing.

Slower processing.

Balance problems.

Assess their baseline thoroughly.

Give clear, simple instructions.

Maybe broken down.

Allow more time.

Prioritize safety fall risk is higher.

And caregiver support.

Essential.

Especially for discharge planning after ambulatory surgery.

Who's going to help them at home?

Okay, let's tie it all together with that clinical scenario.

NT, 66 years old, for a hysteroscopy DNC.

Obese, type 2 diabetes, hypertension, AFib, NPO since midnight, but it's now noon.

BP, 1 -909 -4 -K -plus -3 .4, takes aspirin daily, uses herbs for sleep, anxious.

Lives alone.

Wow.

Where do you even start?

Okay, deep breath.

First thing screaming at me is NPO for 12 hours with diabetes.

Right.

Risk for hypoglycemia.

Big time.

Priority 1.

Check blood glucose.

Stat.

And notify the ACP immediately.

Her insulin or meds likely need adjustment now, delaying surgery might even be necessary depending on the glucose.

Makes sense.

Beyond the glucose, what else jumps out as immediate risks or things influencing her care?

Well, the hypertension 80 -0 -94 is high.

The atrial fibrillation increases stroke risk.

Obesity impacts anesthesia, positioning, wound healing.

The low potassium, 3 .4, needs attention.

Affects cardiac function.

Daily aspirin plus unknown herbs.

Bleeding risk is high.

Her anxiety needs addressing.

Living alone impacts discharge planning.

It's a lot.

So after checking glucose, what are your next priority assessments and actions?

Okay.

Recheck that BP.

Confirm that low potassium with labs.

Notify provider.

Get details on the specific herbs she takes and when she last took aspirin and herbs.

Assess her anxiety, what's driving it.

Interventions.

Strict NPO confirmation.

Collaborate closely with the ACP and surgeon about managing her BP, AFib, diabetes, potential bleeding risk.

Implement fall precautions now, especially if any sedatives are planned.

Address her anxiety, provide reassurance and clear information.

That really highlights the complexity and the critical thinking needed.

It absolutely does.

Every patient is unique and your assessment guides everything.

So, wrapping up.

We've journeyed through preoperative care today.

We've seen how vital the nurse's role is in assessment, teaching, advocating.

From understanding why the surgery is happening to meticulously preparing the patient physically and mentally.

It's all geared towards safety and the best possible outcome.

It really is.

And here's something for you, our listeners, to think about as you move forward in your careers.

How can a truly patient -centered approach during this preoperative phase change the entire surgical experience for someone?

Not just physically, but emotionally too.

What's maybe one small thing you could do differently next time to empower your patient before they head into the OR?

We really hope this deep dive has helped solidify your understanding of preoperative care, made it feel a bit more manageable.

From all of us here at the Deep Dive team, thank you so much for joining us today.