The Preoperative Period

The preoperative period, the time prior to surgery, is used to prepare the patient for
surgery both physically and psychologically. Ideally there is time to correct as many
abnormalities as possible prior to the surgical procedure. For patients having a
scheduled procedure with a significant anticipated blood loss, this is the time to
donate blood to be banked for use in their surgery and begin to take iron, folic acid,
vitamin B12, and vitamin C to aid in red blood cell production. Preoperative clear-
ance is given, informed consent is obtained, and preoperative teaching occurs dur-
ing this time.


PREOPERATIVE CLEARANCE
The patient’s primary care provider typically gives preoperative clearance for sur-
gery. This physician, nurse practitioner, or physician’s assistant is familiar with
the patient’s medical history and current medications and is able to adequately
assess the impending risk of the surgery to the patient. Things to consider when
providing clearance for the patient include the type of surgical intervention planned,
the potential for blood loss during surgery, the patient’s age, general health
and comorbidities, past medical and surgical history, current medications, use of
herbal remedies or supplements, alcohol use, smoking history, substance use,
allergies, family history including problems with surgery, and diagnostic testing
results. Diagnostic studies often include a CBC (to identify anemia or signs of
infection), a chemistry panel (to identify electrolyte imbalance, abnormal glu-
cose, liver or renal function), a urinalysis (to identify infection, protein, glucose),
PT/INR/PTT (to identify blood clotting disorders), an EKG (to identify abnormal
cardiac rhythms or damage to myocardium), chest x-ray (to identify pulmonary
pathology or enlargement of cardiac silhouette), or pulmonary function testing
(for patients with respiratory disorders such as asthma or emphysema). CT scans,
MRIs, PET scans, or stress testing may be ordered for individual patients depend-
ing on their medical history, type of surgical procedure planned, and results
of other diagnostic studies.

INFORMED CONSENT
An informed consent is obtained prior to any invasive or dangerous procedure.
The reason for the surgery, type and extent of surgery to be performed, the risks of
the procedure, the person to perform the procedure, alternative options and their
associated risks, and the risks associated with anesthesia are all explained to the
patient. It is the surgeon’s responsibility to make sure this information is explained
to the patient. The patient must be a competent adult in order for his or her signa-
ture to be valid. If the patient has been given medications that alter his or her abil-
ity to reason or to make judgments, the consent will not be valid. The nurse witnesses
the patient’s signature on the consent form.

PREOPERATIVE TEACHING
Explaining normal preoperative routines to the patient can be very helpful, so the
patient knows what to expect. The nurse needs to be familiar with the types of
surgical procedures and what the expected postoperative course will entail. The
extent of the procedure, type of incision, presence of any tubes or drains, and antic-
ipated pain level after the surgery will help guide the type of teaching necessary
for the patient.
Preoperatively the patient can expect to be NPO, or not allowed to eat or drink
anything for several hours prior to the procedure. The time frame will depend on
the extent and location of procedure, the type of anesthesia, and the scheduled time
of surgery. An exception to this nothing-by-mouth rule would be for patients who
need to take oral medications the morning of surgery. Cardiovascular, diabetic, and
certain other medications may need to be taken even though the patient is not to
eat or drink anything else.
An intravenous access site will be obtained prior to the surgery. Fluids can be
administered to the patient in this way. The access also allows for giving the patient
medications intravenously for rapid action. Fluids are routinely given in the oper-
ating room and in the immediate recovery period. The patient may have continued
intravenous fluids for more extensive procedures.
Skin preparation may only involve washing of the surgical site in the operating
room with an antimicrobial solution. Other patients may need to have removal of
hair from the surgical site. This may be with a razor or a depilatory agent. It is
important not to cut the skin if you are shaving a surgical site; small cuts or abra-
sions on the skin allow for potential sites of infection. Depilatory agents can be
caustic on the skin of some patients, causing irritation or a rash. A small spot test
away from the surgical area is a good idea in a patient with known skin sensitiv-
ity or history of allergies.

For patients having planned surgery involving the intestinal tract, a bowel
preparation will be completed prior to the surgery. This is done to decrease the bac-
terial count within the intestinal tract. Cleansing of the bowel is also completed to
empty the intestine of stool before the surgeon plans on cutting into either the small
or large intestine. Both of these preparations help to reduce the possibility of

infection in the postoperative period. For patients who will have tubes or drains in
place in the postoperative period, a simple explanation of what to expect can help
to alleviate some anxiety.
Availability of pain medication in the postoperative period should be explained
to the patient. In many instances the patient is able to manage his or her own pain
medication. For outpatient procedures, patients may be given a prescription for an
oral pain medication prior to the procedure. This way the medication is available
when the patient gets home from the surgery. For postoperative patients in the
hospital, many patients have an intravenous patient-controlled analgesia, known
as PCA, for pain management, where pain medication is delivered via a pump.
Typically a small basal dose of narcotic is delivered all the time. These patients
also have the ability to press a button whenever they are experiencing pain. The
pump will monitor the amount and timing of each dose of pain medication. If the
patient is due for medication, a dose will be administered; if the patient is not due
for medication, no dose will be administered.

TRANSFER OF THE PATIENT
Most facilities have a preoperative checklist to assist the nurse to make sure tha
all the needed components have been checked prior to sending the patient to the
operating room (OR). All pertinent documentation—the signed consent form
the patient’s chart, and current lab results—accompanies the patient to the OR.