Chapter 14: Preoperative Nursing Management

Overview of Perioperative Nursing

Perioperative nursing encompasses the care provided before, during, and after surgery. It is essential for ensuring patient safety, optimal outcomes, and effective communication among the healthcare team. The perioperative period is divided into three main phases:

• Preoperative: From the decision to proceed with surgery until transfer to the operating room (OR) bed.

• Intraoperative: From transfer to the OR bed until admission to the postanesthesia care unit (PACU).

• Postoperative: From admission to the PACU until follow-up evaluation.

Nursing activities are guided by standards from the Association of periOperative Registered Nurses (AORN) and the American Society of PeriAnesthesia Nurses (ASPAN).

Conceptual Model of Patient Care (AORN)

The AORN model outlines the relationship between nursing practice and patient outcomes, focusing on four domains:

• Safety

• Physiologic responses

• Behavioral responses

• Health care systems (structural data elements)

This model emphasizes the importance of nursing diagnoses, interventions, and outcomes in achieving optimal patient results.

Preoperative Phase

Preadmission Testing and Assessment

Preadmission testing (PAT) is conducted to ensure the patient is prepared for surgery. It includes:

• Initial preoperative assessment and education

• Verification of diagnostic testing and preoperative therapies

• Review of advance directives and initiation of discharge planning

During admission to the surgical center, nurses complete assessments, verify consent, and reinforce education. In the preoperative area, they confirm patient identity, assess status, review records, and ensure comfort and psychological support.

Intraoperative and Postoperative Phases

During surgery, nurses maintain safety, monitor physiologic status, and provide emotional support. Postoperatively, they communicate intraoperative information, monitor recovery, manage pain, and assist with discharge planning and follow-up care.

Advances in Surgery and Anesthesia

Technological and Methodological Advances

• Minimally invasive and robotic surgeries reduce morbidity and recovery time.

• Modern anesthesia methods improve safety and patient experience.

• Short-acting anesthetics and effective antiemetics reduce complications.

Robotic surgery offers enhanced precision, range of motion, and visualization, with applications in cardiac, gastrointestinal, urologic, gynecologic, ENT, thoracic, and orthopedic procedures.

Surgical Classifications

Types and Urgency of Surgery

• Diagnostic: Biopsy, exploratory laparotomy

• Curative: Tumor excision, appendectomy

• Repair: Multiple wound repair

• Reconstructive/Cosmetic: Mammoplasty, facelift

• Palliative: Tumor debulking

• Rehabilitative: Joint replacement

Classified by urgency as emergent, urgent, required, elective, or optional.

Categories of Surgery Based on Urgency

• Emergent: Immediate, life-threatening (e.g., severe bleeding)

• Urgent: Within 24–30 hours (e.g., closed fractures)

• Required: Within weeks or months (e.g., prostatic hyperplasia)

• Elective: Not catastrophic if delayed (e.g., scar repair)

• Optional: Personal preference (e.g., cosmetic surgery)

Preadmission Testing and Ambulatory Surgery

Ambulatory (outpatient) surgery does not require an overnight stay. PAT reduces hospital stays and costs, and involves education, assessment, and planning for discharge and follow-up care.

Preoperative Risk Factors for Surgical Complications

Identifying risk factors is essential for minimizing complications. Common risk factors include:

• Cardiovascular disease

• Respiratory disorders

• Renal or hepatic dysfunction

• Diabetes

• Obesity or malnutrition

• Advanced age or very young age

• Immunosuppression

• Substance use (alcohol, tobacco, drugs)

• Medication use (anticoagulants, corticosteroids, etc.)

• Psychological or cognitive impairment

Special Patient Populations

Older Adults

• Increased risk due to comorbidities and altered physiology

• Comprehensive assessment of cardiovascular, respiratory, and renal systems

• Monitor for temperature sensitivity and skin integrity

Bariatric Patients

• Obesity increases surgical risk and complicates care

• Assess for obstructive sleep apnea and cardiovascular issues

• Monitor for delayed wound healing and increased infection risk

Patients With Disabilities

• Ensure assistive devices are available and secure

• Address communication needs and special positioning

• Optimize respiratory status and develop a comprehensive care plan

Ambulatory and Emergency Surgery Patients

• Quick, comprehensive assessment and education for ambulatory patients

• Calm, effective communication and rapid assessment for emergency cases

• Obtain essential information from family if patient is unconscious

Preoperative Documentation and Consent

• Informed consent is a legal and ethical requirement

• Surgeon explains procedure, risks, and benefits; nurse verifies understanding and signature

• Consent must be obtained before administering psychoactive medications

Comprehensive Preoperative Assessment

• Health history, allergies, previous anesthesia complications

• Physical examination and laboratory/diagnostic tests as indicated

• Assessment of nutritional, respiratory, cardiovascular, hepatic, renal, endocrine, and immune function

• Medication history and management of current medications

Psychosocial, Spiritual, and Cultural Considerations

• Assess emotional reactions, anxiety, and coping strategies

• Respect cultural, spiritual, and religious beliefs

• Use effective communication and provide individualized education

Preoperative Nursing Interventions

• Provide patient education using multiple strategies

• Teach deep breathing, coughing, and incentive spirometry

• Promote mobility and active body movement

• Educate on pain management and anxiety reduction techniques

• Maintain patient safety and manage nutrition, fluids, bowel, and skin preparation

• Administer preoperative medications and maintain accurate records

• Prevent hypothermia and attend to family needs

Expected Patient Outcomes

• Reduced anxiety and fear

• Increased knowledge and understanding of the surgical process

• Active participation in preoperative preparation and postoperative exercises

• Safe and effective transition to the intraoperative phase