Chapter 14 - Pre-Operative Nursing

📍 Learning Outcomes (What you should be able to do after this chapter)

1. Define the phases of perioperative patient care.

• Perioperative care = the entire surgical experience.

• It has 3 phases:

  • Preoperative phase: From the time the decision for surgery is made → until the patient is transferred to the OR table.

  • Intraoperative phase: From the patient entering the OR → until they are admitted to the PACU (Post Anesthesia Care Unit).

  • Postoperative phase: From PACU admission → until follow-up evaluation (either at home or clinical setting).

• In nursing practice: You must know which phase you’re in because assessment, interventions, and patient education differ depending on the phase.

2. Perform a comprehensive preoperative assessment to identify pertinent health and surgical risk factors.

• This means gathering all information that could affect surgical outcomes:

  • Medical history, medications, allergies, comorbidities.

  • Risk factors like age (older adults), obesity, smoking, cardiac/respiratory conditions.

  • Baseline labs and diagnostics (ex: CBC, coagulation studies, EKG).

• Why it matters: Complications can happen even in “simple” outpatient procedures, so risk screening is essential for safety.

3. Describe considerations related to preoperative nursing care of:

• Older adults: May have slower healing, more risk for confusion/delirium, and more chronic illnesses.

• Patients with obesity: Higher risk of wound infection, respiratory issues, positioning challenges.

• Patients with disability: May need extra support in communication, mobility, and consent.

• In nursing practice: anticipate special needs for these populations, plan individualized care, and coordinate with interdisciplinary teams.

4. Identify the regulatory documents required before surgery.

• Must have:

  • Informed consent: Patient understands procedure, risks, benefits, alternatives, and voluntarily agrees.

  • History & physical (H&P): Completed by surgeon before surgery, includes medical/surgical history, exam, and plan of care.

• Legal and safety requirement → surgery cannot start without these.

5. Initiate immediate preoperative preparation and patient education.

• Includes:

  • Patient teaching (what to expect before, during, after).

  • Clarifying NPO status, medications, skin prep.

  • Emotional support to decrease anxiety.

• This ensures the patient is physically and psychologically ready.

📍 Nursing Concepts in this Chapter

• Communication: Essential for informed consent, patient teaching, and coordinating with the surgical team. Example: explaining procedures in simple language to reduce anxiety.

• Managing Care: Nurses coordinate pre-op testing, ensure legal documents are in place, prep the patient, and manage care transitions (unit → OR → PACU).

• Mobility: Patients may have limited mobility post-op; nurses must plan for positioning, ambulation, and prevention of complications like DVT or pressure injuries.

📍 Glossary (Vocabulary You Must Know)

• Ambulatory surgery: Outpatient / same-day surgery → no overnight stay.

• Bariatrics: The field of medicine dealing with patients with obesity.

• History and physical (H&P): Surgeon’s mandatory comprehensive patient overview (history, current status, care plan).

• Informed consent: Patient’s voluntary decision after understanding procedure, risks, and benefits.

• Intraoperative phase: OR entry → PACU admission.

• Minimally invasive surgery (MIS): Uses small incisions/natural orifices + specialized instruments (example: laparoscopic cholecystectomy).

• Perioperative phase: Entire surgical experience (pre, intra, post).

• Postoperative phase: PACU admission → follow-up in clinic/home.

• Preadmission testing (PAT): Labs/diagnostics done before admission to prepare for surgery.

• Preoperative phase: From decision for surgery → transfer to OR table.

📍 Breakdown of Section You Sent

• Surgery today is less invasive and less debilitating due to minimally invasive surgery (MIS). These allow outpatient or same-day surgery, but stress and risks still exist.

• Even elective outpatient surgeries can have unexpected complications, which is why pre-op testing and assessment are critical.

• Some patients may only arrive 90 minutes before surgery, have quick assessments, surgery, recovery in PACU, then go home the same day.

• More complex cases or patients with comorbidities may require preadmission testing and post-op hospital stay.

• Traumatic/emergency surgeries usually mean longer hospital stays and require coordination of multiple disciplines.

• Regardless of the setting (ambulatory, outpatient, inpatient), all patients require:

  • Pre-op nursing assessment

  • Patient education

  • Nursing interventions to prepare for surgery

📍 Perioperative Nursing

🔹 Key Points:

• Communication, teamwork, and patient assessment = absolutely critical for safe outcomes.

• Nursing standards (from AORN & ASPAN) focus on:

  • Behavioral responses (patient’s anxiety, coping, stress)

  • Physiologic responses (vital signs, blood loss, airway, etc.)

  • Patient safety (sterility, prevention of complications)

• These standards guide nursing diagnoses, interventions, and care planning in the perioperative setting.

📍 Phases of Perioperative Nursing

These phases line up exactly with what you learned in the Learning Outcomes:

1. Preoperative phase

   • Starts: when the decision for surgery is made

   • Ends: when patient is transferred onto the OR bed

2. Intraoperative phase

   • Starts: once patient is on the OR bed

   • Ends: when patient is admitted to the PACU

   • Nurse’s roles: scrub nurse, circulating nurse, RN first assistant

3. Postoperative phase

   • Starts: admission to PACU

   • Ends: follow-up evaluation (clinic/home)

💡 Important NCLEX-style note:
If a question asks, “When does the preoperative phase end?” → Answer = when patient is placed on the OR bed, NOT when anesthesia begins.

📍 Nursing Standards & Model

• AORN developed a conceptual model of perioperative care with 4 domains:

  1. Safety

  2. Physiologic responses

  3. Behavioral responses

  4. Health care systems (processes, outcomes, and structural elements of care delivery)

These domains = foundation for nursing process → assessment → diagnosis → planning → implementation → evaluation.

📍 Advances in Surgical & Anesthesia Approaches

• Trend = less invasive procedures → faster recovery, shorter stays, lower morbidity.

• Minimally invasive surgery (MIS) and robotic surgery are replacing many traditional open surgeries.

🔹 Robotic Surgery Advantages:

• Greater precision & accuracy for dissection/suturing

• Better instrument range of motion

• Access to deep structures

• 3D visual feedback for the surgeon

• Used in: cardiac, GI, urologic, gynecologic, ENT, thoracic, orthopedic

🔹 Anesthesia Advances:

• New methods for airway management

• Sophisticated monitoring devices

• Short-acting anesthetics → quicker recovery

• Antiemetics → reduced PONV (post-op nausea & vomiting)

• Improved pain control → safer and more comfortable recovery

💡 NCLEX tie-in: Expect questions about benefits of robotic surgery (precision, 3D visualization, less invasive, shorter recovery).

📍 Surgical Classifications

Purpose of Surgery:

• Diagnostic: biopsy, exploratory laparotomy, laparoscopy

• Curative: excision of tumor, appendectomy

• Repair: wound repair

• Reconstructive/cosmetic: breast reconstruction, facelift

• Palliative: relieve symptoms (tumor debulking, gallbladder removal for comfort)

• Rehabilitative: joint replacement to restore function

Urgency of Surgery (Table 14-1 categories):

• Emergent: life-threatening, immediate (ex: ruptured aneurysm, gunshot wound)

• Urgent: requires prompt attention (within 24–48 hrs, ex: kidney stones, bowel obstruction)

• Required: needs to be done but not immediately (ex: cataract removal)

• Elective: scheduled, not urgent (ex: hernia repair, plastic surgery)

• Optional: patient’s choice (ex: cosmetic procedures like liposuction)

📍 Preadmission Testing (PAT)

• Reason: Rising ambulatory/outpatient surgeries + cost reduction efforts.

• PAT = done BEFORE admission to:

  • Collect demographics & health history

  • Obtain diagnostic tests & labs

  • Verify consents

  • Provide teaching about what to expect

• Nurse’s role in PAT:

  • Begin assessment

  • Educate patient & family

  • Address anxiety, questions

  • Explain surgical procedure, anesthesia effects, functional recovery

  • Start discharge planning early

💡 Clinical application: If the NCLEX asks, “When does discharge planning begin for a surgical patient?” → Pre-op, during PAT.

📍 Chart 14-1 — Examples of Nursing Activities in the Perioperative Phases of Care

This is a must-know chart because it clearly divides nursing responsibilities by phase:

Preoperative Phase

• Preadmission testing: assessment, education, family involvement, verify tests, confirm therapy (bowel prep, shower), review advance directives, begin discharge planning

• Admission to surgical center: complete pre-op assessment, identify risks, report abnormal findings, verify consent, coordinate care, reinforce teaching, explain perioperative phases, answer questions

• In pre-op area: identify patient, assess baseline pain/nutrition/emotional status, review medical record, verify surgical site & marking, start IV, give ordered meds, provide comfort & support, communicate with team

Intraoperative Phase

• Safety: maintain sterility, manage equipment/staff, position patient, grounding device for cautery, sponge/needle/instrument counts, documentation

• Physiologic monitoring: fluid balance, monitor vitals, report abnormal signs, maintain normothermia

• Psychological support: stay near/touch patient, emotional reassurance, update family

Postoperative Phase

• Transfer to PACU: report includes patient ID, surgery performed, anesthetic/analgesics, vitals, complications, drains/catheters placed, events, consciousness, special equipment, family presence

• PACU assessment: check immediate surgical response, vitals, pain level, airway/circulation, safety, meds/fluids, oral fluids if ordered, readiness for transfer/discharge (e.g., Aldrete score)

• Surgical nursing unit: monitor patient, assess pain, continue teaching, assist with recovery/discharge, evaluate psychological status, reinforce discharge planning

• Home/clinic: provide follow-up, answer questions, assess surgical outcomes & body image, assess family’s perception

✅ This section showed you:

• The phases of perioperative nursing (with activities spelled out for each).

• How advances in surgery & anesthesia improve safety and recovery.

• The purposes and urgency classifications of surgery.

• How preadmission testing reduces costs and improves patient education.

📍 National Patient Safety Goals (Joint Commission & CMS)

• Created to reduce surgical complications.

• Focus areas:

  • VTE prevention (venous thromboembolism → DVT, PE)

  • SSI prevention (surgical site infection)

  • Wrong-site surgery prevention (positive patient ID, site marking)

💊 Medication review on day of surgery:

• Nurse verifies patient’s home medications:

  • Which meds were stopped? When?

  • Which meds were last taken?

• Example: Beta-blockers → if patient didn’t take their scheduled dose within 24 hrs, the anesthesiologist/CRNA must decide whether to give it before surgery.

• Nurses must check that orders are in place for:

  • VTE prophylaxis (anticoagulants, compression devices)

  • SSI prophylaxis (pre-op antibiotics, skin prep)

🚨 NCLEX tie-in:
If prophylactic antibiotics or VTE prevention orders are missing → nurse must notify provider immediately before surgery starts.

📍 Table 14-1: Categories of Surgery by Urgency

1. Emergent — Immediate, life-threatening, no delay.

   • Ex: severe bleeding, bowel obstruction, fractured skull, GSW/stab wounds, extensive burns

2. Urgent — Needs surgery within 24–30 hours.

   • Ex: closed fractures, infected wound exploration

3. Required — Must be done in weeks–months.

   • Ex: BPH, thyroid disorder, cataracts

4. Elective — Should be done, but not having it isn’t catastrophic.

   • Ex: scar repair, simple hernia, vaginal repair

5. Optional — Patient choice only.

   • Ex: cosmetic surgery

💡 Exam trick: “Elective” ≠ “optional.” → Elective means medically advisable but not urgent, optional means personal preference.

📍 Gerontologic Considerations (Older Adults)

• Risks ↑ with comorbidities + length/nature of surgery.

• Body system concerns:

  • ↓ cardiac reserve → arrhythmias, hypertension risk

  • ↓ renal/hepatic function → impaired drug clearance

  • ↓ GI activity → delayed healing

  • Fragile skin → assess carefully for bruises, abrasions

  • ↓ subcutaneous fat → poor temp regulation (prone to hypothermia)

• Cardiovascular = most critical system for anesthesia risk.

• Cognition: stress + surgery can → confusion, poor concentration, disorganized thoughts.

• Teaching: older adults may need verbal + written education, extra time, reinforcement.

📍 Bariatric Patients (Obesity)

• Obesity prevalence: ~40% of U.S. adults.

• Risks:

  • Pulmonary: shallow respirations, hypoventilation, ↑ risk of postop pulmonary complications.

  • OSA: often undiagnosed, ↑ risk during intubation & postop.

  • Cardiovascular: higher strain on heart.

  • Integumentary: delayed wound healing, higher SSIs, joint replacement failures.

  • IV access = difficult due to excess adipose tissue.

• BMI > 45 = very high risk for joint replacement failure & postop infection.

💡 Exam tie-in:

• Obese patient + undiagnosed OSA = red flag → monitor airway very closely during and after surgery.

📍 Patients with Disability

• May need assistive devices: hearing aids, eyeglasses, braces, prostheses.

• Communication adaptations:

  • Hearing-impaired → interpreter or alternative method.

  • Lip readers → need visibility (not possible if masks on, or glasses removed).

• Mobility issues:

  • Difficulty transferring onto gurney.

  • May need special positioning to avoid pain/injury.

  • Risk: if unable to communicate → they may not sense/report malpositioning → ↑ risk for nerve or pressure injuries.

• Respiratory-related disabilities (MS, muscular dystrophy) → must alert anesthesia team to adjust plan.

💡 Nursing action: ID patient’s disability-related needs before surgery and ensure clear communication to surgical team.

📍 Patients Undergoing Ambulatory Surgery

• Same-day surgery (no overnight stay).

• Nurse must:

  • Do rapid but thorough pre-op assessment.

  • Educate: flow of surgery (pre-op area → OR → PACU → home).

  • Reinforce teaching.

  • Ensure discharge planning and follow-up care are in place.

💡 Exam tie-in: Ambulatory surgery = nurse must prioritize teaching and discharge planning early, since time is limited.

📍 Patients Undergoing Emergency Surgery

• Unplanned, urgent, little prep time.

• Nurse’s role: stay calm, efficient, clear in communication.

• Pre-op assessment may occur simultaneously with resuscitation.

• If trauma-related: quick visual survey to ID injuries.

• If unconscious: gather info (history, allergies) from family if available.

• Provide emotional support/explanation (patient & family).

✅ Summary of Key Nursing Priorities Across Special Populations:

• Older adults → cardiac, cognition, thermoregulation.

• Obesity → airway, wound healing, OSA, IV access.

• Disability → communication, positioning, assistive device security.

• Ambulatory → quick assessment, early discharge planning.

• Emergency → rapid response, gather essential info quickly, maintain calm.

📍 Informed Consent

• Definition: Patient’s autonomous, voluntary, written decision to undergo a procedure after being fully informed.

• Why important?

  • Protects the patient → from unauthorized surgery.

  • Protects the surgeon → from legal claims of assault/battery.

  • Helps patient psychologically prepare, since they know what to expect.

Who provides the explanation?

• Surgeon (and anesthesiologist for anesthesia):

  • Must explain: procedure details, benefits, risks, alternatives, complications, disfigurement/disability, removal of body parts, early & late postop expectations.

• Nurse:

  • Clarifies information.

  • Verifies patient (or designee) signature.

  • May sign as a witness.

  • If patient requests more info or shows lack of understanding → notify surgeon.

🚨 Key rule: Consent must be signed before giving psychoactive meds (e.g., sedatives, opioids). Once medicated, the patient’s judgment is impaired → consent = invalid.

🚨 Quality and Safety Nursing Alert

“Any signed form required for surgery is placed in a prominent place on the medical record and accompanies the patient to the OR.”

➡ This ensures:

• No delays once patient is in the OR.

• Legal protection is preserved.

• Every team member can confirm consent was obtained.

📍 When Informed Consent is Required

• Invasive procedures: incisions, biopsies, cystoscopies, paracentesis

• Procedures with anesthesia/sedation

• Risky nonsurgical procedures: arteriography

• Radiation procedures

• Blood product administration

💡 NCLEX note: Don’t assume consent is “just surgery.” → It also applies to things like blood transfusion, radiation, or diagnostic procedures with significant risk.

📍 Who Can Consent

• Patient personally: if legal age (≥18 unless emancipated minor) AND mentally capable.

• If incompetent (not autonomous): must come from a surrogate → usually next of kin or legal guardian.

• Emergency exception: Surgeon may proceed without consent if lifesaving, but must attempt to reach family (phone, fax, electronic consent if possible).

📍 Chart 14-2 – Valid Informed Consent

Voluntary Consent

• Must be freely given.

• Must be obtained by physician.

• Witness signature by professional staff.

Patient Who Is Incompetent

• Legally defined as unable to give or withhold consent (cognitive impairment, mental illness, neuro incapacity).

Informed Subject

• Consent form must include:

  • Explanation of procedure + risks

  • Benefits + alternatives

  • Offer to answer questions

  • Right to withdraw consent at any time

  • Disclosure if procedure differs from standard protocol

Patient Able to Comprehend

• Must be in a language the patient understands.

• Use medical interpreter (not family) for non-English speakers.

• Use alternative communication if disabled (Braille, large print, sign interpreter).

• Patient encouraged to restate understanding in their own words.

💡 If patient doubts or hasn’t explored alternatives: A second opinion may be requested.

Right to Refuse

• Patients have full legal right to refuse.

• Nurse must document refusal + inform surgeon.

📍 Additional Consent Situations

• Special consents: sterilization, abortion, disposal of body parts, organ donation, blood products.

• These provide extra protection for patient and provider.

• Regulations vary by state/region.

📍 History and Physical (H&P)

• Must be completed before OR entry.

• Valid for 30 days before surgery.

• Must be updated within 24 hours before surgery for non-inpatients.

• Includes:

  • History of present illness

  • Surgical, medical, social, family history

  • Allergies

  • Medications

  • Plan of care

• Other required documentation:

  • Medication reconciliation

  • Power of Attorney form (if applicable)

• Surgical team is responsible for ensuring all documents are accurate and present in the pre-op area.

✅ NCLEX-Level Must-Knows From This Section:

• Consent is invalid if obtained after sedatives given.

• Nurse witnesses, but surgeon explains.

• Consent needed for blood products and radiation too.

• Emergency = may proceed without consent, but must attempt to contact family.

• Interpreter must be used (not family) for non-English speakers.

• H&P must be current (≤30 days old) and updated within 24 hours pre-surgery.

📍 Goal of Preoperative Assessment

• Main goal: Ensure patient is as healthy as possible before surgery.

• Nurses must identify and address risk factors → to prevent complications and promote faster recovery.

• The assessment considers:

  • Medical history

  • Physical exam (ex: joint mobility)

  • Genetic factors → can affect anesthesia safety (see Chart 14-4, which deals with genetic considerations).

📍 Chart 14-3 — Select Risk Factors for Surgical Complications

These are conditions you must watch for, because they can alter response to surgery or anesthesia:

🔹 Musculoskeletal

• Arthritis → affects mobility, positioning, airway management if cervical spine involved.

🔹 Cardiovascular

• CAD or previous MI → high risk for cardiac ischemia.

• Heart failure → impaired perfusion during stress.

• Cerebrovascular disease → risk for stroke.

• Arrhythmias → risk for unstable rhythms with anesthesia.

• Hemorrhagic disorders → risk of bleeding.

• Hypertension → risk of poor perfusion, stroke, heart strain.

• Prosthetic heart valve → usually requires anticoagulation management.

• VTE (venous thromboembolism) → must prevent DVT/PE.

🔹 Fluid/Electrolytes

• Dehydration or imbalance → arrhythmias, poor perfusion.

• Hypovolemia → increased anesthesia risk.

🔹 Endocrine

• Adrenal disorders → risk of Addisonian crisis if steroids withdrawn.

• Diabetes → poor wound healing, infection, glucose instability.

• Thyroid disorders → sensitivity to anesthesia, cardiac instability.

🔹 Age & Weight

• Extremes of age → neonates/older adults less resilient.

• Underweight/obese → both complicate wound healing, thermoregulation, and recovery.

🔹 Hepatic

• Cirrhosis, hepatitis → poor drug metabolism, bleeding risks.

🔹 Immunologic

• Immunodeficiency or abnormalities → higher infection risk.

🔹 Infectious

• Infection or sepsis → worsens outcomes, may delay elective surgery.

🔹 Other

• Low socioeconomic status → less access to follow-up care/nutrition.

• Medications → prescription, OTC, herbal must be reviewed (can interact with anesthesia).

• Nicotine use → poor oxygenation, delayed wound healing.

• Nutritional deficits → poor tissue healing.

• Pregnancy → maternal reserve limited, fetal risk.

• Preexisting cognitive/physical/sensory disability → complicates consent, positioning, teaching.

🔹 Pulmonary

• Obstructive disease (asthma, COPD)

• Restrictive disorder (pulmonary fibrosis, scoliosis affecting lungs)

• Respiratory infection → can cause severe post-op complications.

🔹 Renal/Urinary

• Decreased kidney function → delayed drug clearance.

• UTI → risk of infection spreading.

• Obstruction/toxic conditions → complicates anesthesia and recovery.

💡 Exam tie-in: Any condition that affects the heart, lungs, liver, or kidneys greatly increases surgical risk.

📍 Medications, Allergies, Functional Status

• Ask about ALL meds: prescription, OTC, herbs, supplements. (Example: garlic, ginkgo, and ginseng increase bleeding risk).

• Functional activity levels → helps predict how well patient will recover.

• Allergies: drugs, foods, adhesives, latex.

  • Latex allergy associations: kiwi, avocado, banana, balloons.

🚨 Quality and Safety Nursing Alert

Latex allergy can cause: rash, asthma, or anaphylaxis.

• Nurses must assess for latex sensitivity (foods, balloons, past reactions).

• OR precautions:

  • Use latex-free supplies.

  • Remove powdered gloves.

  • Thoroughly clean surgical area.

  • Team awareness → critical to prevent life-threatening reaction.

📍 Obstructive Sleep Apnea (OSA) Risk

• Many patients have undiagnosed OSA.

• Pre-op screening tool = STOP-Bang:

  • Snoring

  • Tired (daytime sleepiness)

  • Observed apneas

  • Pressure (hypertension)

  • BMI (>35)

  • Age (>50)

  • Neck circumference (>40 cm)

  • Gender (male)

• Positive screening = higher risk for airway obstruction post-op → needs monitoring.

📍 Other Pre-op Considerations

• Interpersonal violence (IPV): nurses must assess for and report suspected abuse (can occur in any group, regardless of age, sex, socioeconomic status).

• Lab/diagnostics: ordered based on history & physical findings.

• Autologous blood donation: patients may donate their own blood in advance for use during surgery (discussed further in Chapter 28).

✅ NCLEX Key Takeaways:

• Always check cardiac, pulmonary, renal, and hepatic function → top surgical risk factors.

• Assess for latex allergy via cross-reactions (banana, kiwi, avocado).

• Latex allergy can be fatal → rash, asthma, anaphylaxis.

• STOP-Bang tool screens for OSA.

• Medication and herbal history = essential.

• Assess for signs of abuse during pre-op.

• Consent, H&P, and risk-factor management are all part of pre-op readiness.

📍 Nutritional and Fluid Status

• Nutrition = essential for wound healing and infection resistance.

• Nurse must assess for:

  • Obesity, weight loss, malnutrition

  • Deficiencies in specific nutrients

  • Medication effects on nutrition

• Tools: BMI, waist circumference.

• Correction of deficiencies pre-op ensures:

  • Enough protein for collagen synthesis and tissue repair

  • Stronger immune system

🔹 NPO Status

• Must be confirmed before surgery.

• Purpose: ↓ risk of aspiration during anesthesia.

• BUT → fasting causes stress on the body:

  • Loss of glycogen → body breaks down lean muscle for energy

  • Can cause dehydration → signs include low BP, electrolyte imbalance, abnormal labs

• Bowel prep + prolonged fasting → increases dehydration risk.

📍 Table 14-2 — Nutrients Important for Wound Healing

Critical for NCLEX and patient care.

💡 Remember: Protein + Vitamin C + Zinc are the “big three” in wound healing questions.

📍 Chart 14-4 — Genetics in Perioperative Nursing

🔹 Genetic Disorders Impacting Anesthesia

• Autosomal Dominant:

  • Central core disease

  • Hyperkalemic periodic paralysis

  • Malignant hyperthermia (MH)

• Other disorders with surgical risk:

  • Cystic fibrosis (AR)

  • Duchenne muscular dystrophy (X-linked)

  • Ehlers-Danlos syndrome

  • Factor V Leiden (AD)

  • Hemophilia (X-linked)

  • Scleroderma

🔹 Nursing Assessments (Family Hx – 3 generations)

• Any prior complications with surgery/anesthesia (fever, rigidity, dark urine).

• History of muscle problems, heat intolerance, drug reactions.

• Family history of sudden unexplained death, esp. during athletics.

• Known family syndromes (King–Denborough → high MH risk).

🔹 Patient Assessment

• Look for inherited disorders affecting connective tissue, metabolism, bleeding, or neuro system.

• Subclinical muscle weakness.

• Physical features (contractures, kyphoscoliosis, abnormal skeletal development).

🔹 Management Issues

• Check if family genetic testing was done.

• Refer to genetic counseling when needed.

• Provide family support (esp. with MH diagnosis).

💡 Genetic Red Flag for NCLEX: Malignant hyperthermia = life-threatening anesthesia complication → rapid ↑ temp, muscle rigidity, dark urine.

📍 Dentition

• Assess teeth, dentures, partial plates.

• Risks:

  • Broken or loose teeth/dentures may dislodge during intubation → airway obstruction.

  • Poor oral health = source of infection → may seed into surgical wounds.

• Especially important in older adults who may have poor dental care.

📍 Drug and Alcohol Use

• Excessive alcohol:

  • ↑ arrhythmias, infections, withdrawal complications.

  • Withdrawal → can extend hospital stay and increase morbidity.

• Illicit drugs + alcohol: may alter effectiveness of anesthesia/medications.

• If acutely intoxicated: surgery usually postponed, unless emergency.

  • If urgent → local/spinal/regional preferred over general anesthesia.

  • If general anesthesia is required → insert NG tube to prevent aspiration.

• History of alcohol abuse:

  • Often linked with malnutrition, metabolic imbalances.

  • Patients may deny use → nurse must ask frank, nonjudgmental questions.

  • Screening question: “Have you had ≥2 drinks/day regularly in the past 2 weeks?”

💡 Teaching point: Alcohol withdrawal after surgery can be severe. Pre-op identification reduces complications by ~50%.

📍 Respiratory Status

• Patients taught breathing exercises + incentive spirometry before surgery.

• Elective surgery is postponed if active respiratory infection present.

• Pre-op smoking cessation is key:

  • Smokers = poor wound healing, ↑ SSI, ↑ risk of VTE & pneumonia.

  • Highest risk: surgeries involving implants (joint replacements, grafts, breast enhancements).

• At PAT visit → encourage cessation & document tobacco history.

📍 Cardiovascular Status

• Must ensure CV system can handle surgery stress.

• Assess for: CHF, SOB, arrhythmias.

• Pre-op testing: chest x-ray, ECG.

• Baseline vitals and BP required.

• Elective surgery may be postponed if:

  • Cardiac decompensation present.

  • Unexplained high BP.

📍 Hepatic and Renal Function

• Goal: optimal function for safe metabolism and elimination of anesthetics.

• Liver: metabolizes anesthetics.

  • Acute liver disease = high surgical mortality.

  • Pre-op improvement in function is necessary.

• Kidneys: excrete anesthetics/metabolites.

  • Surgery contraindicated if acute nephritis, renal insufficiency with oliguria/anuria, or acute renal disease.

  • Exceptions: lifesaving surgery, access for dialysis, or surgery to improve urinary function (ex: relieve obstruction).

✅ NCLEX Key Takeaways From This Section:

• Nutrition: Protein, Vit C, Zinc most critical for wound healing.

• Fluid/NPO: Fasting = aspiration prevention but ↑ dehydration/stress.

• Genetics: Malignant hyperthermia = autosomal dominant, anesthesia crisis.

• Dentition: Loose teeth/dentures = airway obstruction risk.

• Substance use: Alcohol withdrawal = major risk; NG tube if emergency + intoxicated.

• Respiratory: Surgery delayed with infection; smoking ↑ SSI, pneumonia, VTE risk.

• Cardiac: Surgery delayed if unstable or uncontrolled BP.

• Hepatic/renal: Dysfunction impairs metabolism/elimination of anesthetics.

📍 Endocrine Function

🔹 Corticosteroid Use

• Patients who’ve taken corticosteroids in the past year are at risk for adrenal insufficiency.

• Why? → Steroids suppress the adrenal gland; sudden withdrawal → adrenal crisis (low BP, shock, collapse).

• Nursing action: Report corticosteroid use to anesthesiologist/surgeon.

• Patient may receive IV steroid bolus before & after surgery.

🔹 Thyroid Disorders

• Uncontrolled hyperthyroidism → risk of thyrotoxicosis (thyroid storm).

• Uncontrolled hypothyroidism → risk of respiratory failure.

• Nursing action: Assess for thyroid history; optimize before surgery.

🔹 Diabetes

• Surgical risks:

  • Hypoglycemia → can happen during anesthesia or postop if insulin given without enough carbs.

  • Hyperglycemia → stress of surgery releases catecholamines → ↑ glucose → ↑ SSI risk.

  • Other risks: acidosis, glucosuria.

• Best outcomes = strict glycemic control.

• Frequent glucose monitoring: pre-op, intra-op, and postop.

💡 NCLEX note: For diabetics, both hypo- and hyperglycemia are dangerous perioperatively. Always expect glucose monitoring orders.

📍 Immune Function

• Assess for infection: WBC, urinalysis.

• Elective surgery postponed if infection or fever is present.

• Document allergies/sensitivities: meds, adhesives, blood products, contrast agents, latex, food.

• Ask about specific past allergic reactions (signs/symptoms).

• Immunosuppressed patients (chemo, radiation, steroids, organ transplant, HIV, leukemia) = at higher risk → even a small temp elevation is significant.

📍 Medications That Affect Surgery (Table 14-3)

🚨 Quality & Safety Nursing Alert
Nurse must:

• Assess and document all prescription, OTC, and herbal use.

• Report to intra-op team.

• Failure to communicate = ↑ risk of dangerous drug interactions.

📍 Herbal & Dietary Supplements (Table 14-4)

Many patients don’t report herbal use → nurse must ask specifically.
ASA recommends stopping ≥2 weeks before surgery.

💡 Exam tip: The most testable herbs = Garlic, Ginkgo, Ginseng (all ↑ bleeding risk).

✅ NCLEX Key Takeaways from this Section:

• Corticosteroids → risk of adrenal crisis → must supplement with IV peri-op.

• Uncontrolled thyroid disease → ↑ surgical risk (thyroid storm or resp failure).

• Diabetes → risk for both hypo- & hyperglycemia → monitor closely.

• Surgery postponed if infection present.

• Warfarin/anticoagulants must be stopped prior to elective surgery.

• Herbal meds (esp. garlic, ginkgo, ginseng) → ↑ bleeding. Stop ≥2 weeks pre-op.

• ASA warning: patients often don’t disclose herbal use → always ask directly.

📍 Psychosocial Factors

• Emotional reactions before surgery are normal → can be overt (asking questions, crying) or subtle (withdrawal, avoidance).

• Common fears:

  • Unknown, loss of control, death

  • Anesthesia (not waking up, awareness)

  • Pain, complications, cancer recurrence

  • Prior surgical experiences

  • Family burden, loss of role, disability, disfigurement

🔹 Anxiety

• Triggers epinephrine & norepinephrine release → ↑ BP, ↑ HR, ↑ cardiac output, ↑ glucose.

• These physiologic effects:

  • Impaired healing

  • Higher infection risk

  • Increased pain sensitivity

🔹 Nurse’s Role

• Identify anxiety early → use empathetic listening, supportive guidance, and clear info.

• Assess support network (family, caregivers).

• Assess readiness to learn + best teaching strategies.

• For patients with developmental/cognitive impairment → education and consent may involve legal guardian.

📍 Spiritual and Cultural Beliefs

• Respecting culture, ethnicity, spirituality builds trust and rapport.

• Consider:

  • Some groups don’t express pain openly.

  • Some avoid eye contact → not disrespect, just cultural.

  • In some cultures, the head is sacred → don’t place surgical cap, allow patient to do it.

• Holistic care: nurse looks beyond diagnosis → considers psychosocial, cultural, spiritual, and educational needs.

• Advocacy: respect patient’s values and goals, treat all equally.

📍 Preoperative Nursing Interventions

🔹 Initial Assessment

• History, physical, medication list, allergies, surgical/anesthesia history.

• Establish baseline health + patient understanding.

📍 Patient Education

• Individualized, multiple methods (verbal, written, demonstration).

• Start as early as possible (physician office, clinic, PAT).

• Provide resources (written instructions, videos, phone numbers).

• Spread out education → so patient can ask questions.

• Combine teaching with prep procedures for efficiency.

• Go beyond describing the surgery: explain what sensations to expect (lightheadedness, drowsiness).

• Adjust detail → too much info may ↑ anxiety.

📍 Deep Breathing, Coughing, Incentive Spirometry

• Goal: expand lungs, improve oxygenation, prevent atelectasis/pneumonia.

• Teach in sitting/semi-Fowler’s position.

• Deep slow breaths, hold for 5 sec, exhale slowly.

• Incentive spirometer = feedback and measurement of lung expansion.

• Splinting incisions: place hands/fingers interlaced across incision → ↓ pain, support when coughing.

• Coughing mobilizes secretions → prevents complications.

• Without it → risk for atelectasis, pneumonia, hypoxemia.

📍 Mobility and Active Body Movement

• Goals: improve circulation, prevent venous stasis (DVT), promote lung function.

• Teach before surgery (patient may be too drowsy or uncomfortable post-op).

• Education includes:

  • Turning: side-to-side, lateral position, without disrupting tubes/lines.

  • Ambulation: frequent, early walking = best prevention for complications.

  • Exercises:

    • Knee/hip flexion-extension (bicycle motion)

    • Toe circles

    • Arm/elbow ROM

  • Reinforce proper body mechanics.

• Maintains muscle tone → easier ambulation postop.

📍 Chart 14-5 – Patient Education to Prevent Post-op Complications

• Diaphragmatic breathing: semi-Fowler’s, hand on ribs, slow inspiration, abdomen rises, hold 5 sec, exhale fully. Repeat 15× twice daily pre-op.

• Coughing: splint incision, diaphragmatic breath, hack 3 short breaths, then deep cough. Clears secretions.

• Leg exercises: semi-Fowler’s, flex knee/raise foot, extend/lower, repeat 5× each leg. Foot circles. Improves venous return.

• Turning: flex upper leg, use rail, practice breathing/coughing on side.

• Getting out of bed: turn on side, push up with one hand, swing legs out.

📍 Pain Management

• Assess pain preoperatively: use scales, differentiate acute vs. chronic pain.

• Patients should know that acute post-op pain is expected, different from chronic conditions.

• Older adults: need careful assessment, may underreport.

• Chart 14-6 highlights older adult pain and pre-op education.

🔹 Post-op Pain Control Options

• Inpatients:

  • PCA (Patient-controlled analgesia)

  • Epidural bolus or infusion

  • PCEA (Patient-controlled epidural analgesia)

• Outpatients:

  • Oral analgesics.

• Education includes what method will be used, and reassurance that meds are available for pain relief.

💡 Key NCLEX Note: Encourage patients to take meds on schedule, not wait until pain is severe → prevents poor deep breathing, coughing, mobility.

📍 Older Adult Pre-op Assessment & Education (Chart 14-6)

🔹 Assessment

• Allergies, comorbidities.

• Cognitive & sensory function before consent process.

• Fall risk assessment:

  • Prior falls, meds (sedatives), LOC, cognitive/language barriers, sensory deficits, coordination, toileting needs, external devices.

• Determine need for support person/POA for consent.

• Review polypharmacy risks (multiple meds, prescribers, OTC use).

• Baseline vitals, cardiac rhythm, O₂ sat.

• Skin assessment (dryness, bruises, lesions).

• Nutrition/hydration status.

• Psychosocial: fears, anxiety, loneliness.

• Assess support for ADLs at home.

🔹 Education

• Discuss advanced directives/code status.

• Teach importance of pain control.

• Use extra time, therapeutic touch, and family support to ↓ anxiety.

✅ NCLEX Key Takeaways From This Section

• Anxiety pre-op → ↑ catecholamines → worsens outcomes (pain, infection, healing).

• Holistic assessment includes psychosocial, cultural, spiritual.

• Early individualized patient education = ↓ anxiety, better outcomes.

• Teach deep breathing, coughing, incentive spirometry, mobility, leg exercises before surgery.

• Splinting incision is critical for safe, comfortable coughing.

• Pain control education = patient must take meds regularly, not just PRN.

• Older adults: assess cognition, sensory, fall risk, polypharmacy, and home support.

📍 Cognitive Coping Strategies

Untreated pre-op anxiety = complications (tachycardia, arrhythmias, hypertension, ↑ pain).
Cognitive strategies help relieve tension and promote relaxation:

• Guided imagery → focus on pleasant experience/scene.

• Distraction → recite a poem, song, story.

• Optimistic self-recitation → “I know all will go well.”

• Music therapy → inexpensive, noninvasive calming intervention.

• Aromatherapy → relaxation through olfactory response.

• Reiki / therapeutic touch → energy healing concepts.

• Other options: acupuncture, yoga, muscle relaxation.

💡 Exam tie-in: Nonpharmacologic strategies are encouraged pre-op to reduce anxiety and improve outcomes.

📍 Ambulatory Surgery – Patient Education

Ambulatory = same-day/outpatient surgery.

• Includes all basic pre-op teaching + discharge planning for home care.

• Education may occur via group classes, media, PAT, or phone calls.

• Nurse reviews:

  • When/where to report.

  • What to bring: insurance card, med/allergy list.

  • What to leave home: jewelry, contacts, meds, watches.

  • What to wear: loose clothing, flat shoes.

• Final phone call → reinforce fasting, skin cleansing, last-minute instructions.

📍 Providing Psychosocial Interventions

• Nurses must establish trust quickly (limited pre-op time).

• Introduce yourself with title, role, and thank the patient for choosing facility.

• Provide clear expectations: surgery length, what will happen, equipment (ventilator, drains).

• Help patient identify personal coping strategies they’ve used before.

• Reassure about support → family visits, spiritual advisor if desired.

• Pay attention to delays in surgery → can ↑ fear & anxiety.

📍 Respecting Cultural, Spiritual, Religious Beliefs

• Respect normal pain expressions → some stoic, some expressive.

• Some groups avoid eye contact → cultural respect, not disinterest.

• Some view head as sacred → let patient place own surgical cap.

• Jehovah’s Witnesses → decline blood transfusion. Must be clearly documented and communicated.

• Nurse advocates to preserve patient’s values + equality in care.

📍 Maintaining Patient Safety

Nurse’s major perioperative role = injury prevention.
Must follow:

• AORN standards

• The Joint Commission’s 2019 National Patient Safety Goals (Chart 14-7):

  • Identify patients correctly.

  • Improve staff communication.

  • Use medicines safely.

  • Use alarms safely.

  • Prevent infection.

  • Identify patient safety risks.

  • Prevent mistakes in surgery (correct site, patient, procedure).

📍 Managing Nutrition & Fluids

• Purpose of NPO = prevent aspiration.

• Typical fasting guidelines:

  • Fatty foods → 8 hrs.

  • Milk products → 6 hrs.

  • Clear liquids → allowed up to 2 hrs before elective surgery (for healthy patients).

• Carbohydrate loading (newer ERAS protocols):

  • Carbohydrate-rich drink before surgery = safe (not aspiration risk if controlled).

  • Benefits: ↓ insulin resistance, ↓ LOS, ↓ PONV, ↓ pain.

📍 Preparing the Bowel

• Not routine, only for abdominal/pelvic surgery.

• If prescribed → enema/laxative evening before and maybe morning of surgery.

• Goals:

  • Improve visualization of surgical site.

  • Prevent contamination/trauma from fecal material.

• Antibiotics may also be given to ↓ intestinal flora.

• Encourage use of toilet/commode instead of bedpan if possible.

📍 Preparing the Skin

• Goal: ↓ bacteria, prevent SSI.

• Most facilities: antiseptic full-body wash with antimicrobial soap night before surgery.

• Chlorhexidine wipes may also be used.

• Hair removal: only if necessary → use electric clippers (NOT razors) to avoid microabrasions/infection.

• Special attention: gynecologic, urologic, cranial surgeries.

• Correct site marking: surgeon + patient mark site before surgery → safety measure against wrong-site surgery.

✅ NCLEX-Level Must-Knows From This Section:

• Cognitive coping strategies = music therapy, guided imagery, self-talk.

• Ambulatory surgery = focus on discharge planning & home instructions.

• Respect cultural/religious differences (e.g., JW & blood transfusion refusal).

• NPO guidelines: clear liquids allowed up to 2 hrs pre-op in healthy adults.

• Carbohydrate loading = evidence-based ERAS protocol benefit.

• Bowel prep only for specific abdominal/pelvic procedures.

• Skin prep = antimicrobial wash + clippers for hair removal.

• Site marking = essential for wrong-site surgery prevention.

📍 Immediate Preoperative Nursing Interventions

🔹 Patient Identification & Safety

• Confirm patient identity (two identifiers: name + DOB).

• Apply “alert” bracelets for:

  • Allergies

  • Fall risk

  • Extremity precautions (no BP/IV in that limb)

  • Code status

• Remove nail polish → can interfere with oxygen saturation/hemodynamic monitoring.

• Remove dentures/plates → prevent airway obstruction during induction.

• Remove jewelry/piercings → prevent burns, injuries. If patient refuses → inform of risks.

• Valuables (glasses, dentures, prosthetics, hearing aids, etc.) → given to family or secured safely.

💡 NCLEX tie-in: If patient refuses to remove jewelry, nurse documents refusal, explains risks, and notifies surgical team.

🔹 Voiding

• Patient should void immediately before OR transfer.

• Especially important for low abdominal surgery (better visibility, comfort).

• Urinary catheterization → done in OR only if necessary.

🔹 Medications

• Preanesthetic meds: used sparingly in ambulatory surgery, but may help with anxiety.

  • After administration → patient stays in bed with side rails raised (risk: dizziness, drowsiness).

  • Nurse monitors for adverse reactions.

• Antibiotics: given pre-op to ↓ SSI risk.

  • Must be timed so drug is at peak effect at time of incision.

• Other meds (e.g., insulin, steroids) given per individualized protocol.

🔹 Preoperative Record

• Complete pre-op checklist → includes consents, labs, allergies, safety alerts.

• All forms must accompany patient to OR:

  • Consent form

  • H&P

  • Lab reports

  • Nurse’s notes

  • Pre-op verification form

• Electronic records must be accessible and verified.

📍 Preoperative Patient Warming

🔹 Why Important

• Unintended perioperative hypothermia (UPH) = temp < 36°C (96.8°F).

• Risks: ↑ wound infections, pain, coagulation issues, cardiac complications, longer LOS.

🔹 Nursing Research Profile (Chart 14-8)

• Study: Prewarming with self-warming blankets in joint replacement patients.

• Findings:

  • Hypothermia in 13% of prewarmed group vs 43% in controls.

  • Prewarming kept temps above 36°C.

• Nursing implication: Prewarming ↓ risk of UPH, should be part of protocols.

🔹 Interventions

• Warm blankets

• Forced-air warming devices

• Warmed IV fluids

• Educate patients about warming’s purpose.

• Monitor for sweating, abnormal temps, discomfort.

📍 Attending to Family Needs

• Family waits in designated area → equipped with comfort items, updates.

• Volunteers may provide coffee, info, emotional support.

• Important: Surgery length ≠ seriousness of procedure. Delays may be due to:

  • Transport to OR

  • Anesthesia prep (30–60 min)

  • Longer preceding case

• After surgery → patient goes to PACU first (not straight to room).

• Nurse explains postop equipment (IVs, catheters, NG tube, O₂, monitors).

• Surgeon (not nurse) discusses surgical findings/prognosis with family.

📍 Expected Patient Outcomes (Chart 14-9)

Relief of Anxiety

• Talks with anesthesiologist about concerns.

• Verbalizes understanding of anesthesia/meds.

• Expresses last-minute fears/questions.

• Meets with social worker/spiritual advisor if desired.

• Appears relaxed with team.

Decreased Fear

• Discusses fears with team/spiritual advisor.

• States understanding of expected bodily changes (duration, impact).

Understanding of Surgery

• Participates in prep (bowel prep, shower).

• Demonstrates postop exercises (breathing, mobility).

• Reviews postop care instructions.

• Accepts preanesthetic meds, remains in bed afterward.

• Verbalizes purpose of side rails.

• Relaxes during transport to OR.

• States postop expectations.

📍 Critical Thinking Exercises

1. 55-year-old man, prostatectomy, anxiety/fear/insomnia

• Priorities:

  • Assess anxiety source, sleep history, support system.

  • Identify cardiac risks (since stress response ↑ HR/BP).

• Interventions:

  • Emotional support, relaxation strategies (guided imagery, music).

  • Pre-op teaching about procedure, sensations, pain management.

  • Possibly involve spiritual advisor/family for support.

2. 60-year-old woman, obesity + severe OSA, for hysterectomy

• Resources: Evidence-based guidelines (AORN, ASPAN, ASA).

• Evidence-based practices:

  • Careful airway management, anesthesia planning.

  • Use of CPAP post-op if needed.

  • Enhanced respiratory monitoring (pulse ox, capnography).

• Evaluation criteria: Decreased post-op hypoventilation, O₂ desaturation, and airway obstruction.

3. 38-year-old man, knee surgery, family history of anesthesia problems

• Immediate pre-op assessments:

  • Ask about symptoms during family anesthesia events (fever, rigidity, dark urine).

  • Assess for genetic disorders like malignant hyperthermia.

• Handoff to surgical team:

  • Family history of anesthesia reaction (possible MH).

  • Stress importance of availability of dantrolene (MH treatment).

  • Monitor for early signs of MH intra-op.

✅ NCLEX Key Takeaways from this Section

• Confirm ID + safety alerts, remove dentures/jewelry, secure valuables.

• Patient must void before OR transfer.

• Pre-op antibiotics timed for incision.

• Prewarming prevents hypothermia and complications.

• Surgeon, not nurse, gives prognosis to family.

• Anxiety/fear outcomes measured by patient relaxation, understanding, and participation.

• MH family history = critical handoff to surgical team.