The pre-operative nursing stage is a relatively long period, starting from the moment the patient is informed about the need for a surgical intervention up until they reach the operating theatre. The goal during this period is to prepare the patient in a way that reduces the risk of complications both during and after surgery. And the pre-operative nursing assessment helps us in identifying such risks.
In these notes, we’ll discuss the assessment that nurses need to carry out during the pre-operative phase. But before we get into it, make sure to read the Pre-Operative Documentation, as these form a big chunk of the pre-op nursing care.
Introduction to Pre-Operative Nursing Assessment
As we mentioned above, the goal in the pre-operative phase is to identify any risk factors that might complicate the surgery or the recovery and then implement strategies to reduce them. There are five main tasks that you need to perform during the pre-operative nursing assessment, these include:
Obtaining the patient’s medical history
Performing a physical examination
Evaluating the patient’s psychosocial factors
Get all the required medical tests
Ensure all pre-operative documentation is in order
Pre-Operative Nursing Assessment Part 1: Medical History
This is typically done alongside the surgeon or their doctors, as it holds a lot of valuable information and can sometimes reveal undiagnosed conditions. The patient will be asked about their
Past and current medical conditions
Past surgeries
Medical and surgical family history
Social aspects (ie. tobacco use, recreational drugs or alcohol)
Past and current allergies or unusual reactions to drugs
Any knowledge of complications with anaesthesia (both the patient and family)
Current medications or herbal supplements
History of falls and incontinence
If the patient is a child, then you will also need to obtain a birth history including:
Prematurity at birth
Perinatal complications
Congenital chromosomal or anatomic malformations
Recent infections
While interviewing the patient, you should pay attention to their level of cognition and sensory function as this is an important factor to consider before obtaining consent.
Pre-Operative Nursing Assessment Part 2: Physical Assessment
Once you’ve obtained a good understanding of the patient’s medical history, you will move onto the physical assessment. The surgical team will investigate the patient’s physiology including their:
Nutritional Status
Dentition
Respiratory Status
Cardiovascular Status
Hepatic and Renal Function
Endocrine Function
Immune Function
If any imbalances, conditions or complications are identified the surgical team would create a plan to control them. In addition to the medical examination, you will need to perform a nursing physical assessment which investigates the patient’s:
Fall Risk: by checking their gait, coordination and need for assistive walking devices
Toileting needs: whether the patient is continent or not, and if they require assistance to the bathroom
Presence of external devices: such as catheters, drains or stomas
Baseline parameters: including oxygen saturation levels, respiratory rate, blood pressure, pulse and their pain score.
Skin assessment: look out for any areas of dryness, lesions, bruising or sores.
Pre-Operative Nursing Assessment Part 3: Psychosocial Assessment
As we should all know by now, holistic care is the foundation of nursing, and so assessing the patient from a medical point of view is not enough. It is also crucial for you to assess the patient’s psychosocial factors that will affect their surgical journey. Ask your patient about their understanding of the surgery and identify their level of knowledge about the upcoming surgery.
You should also ask your patient for their next of kin and whether they have anyone in their family or friend circle that could support them throughout their journey. As this will help you determine the need for assistive services that might be required upon discharge, such as community medical care. Lastly, ask your patient about their spiritual and cultural beliefs, and note how these come into play in their daily lives.
Pre-Operative Nursing Assessment Part 4: Medical Tests
Having completed all assessments, the patient will most likely require a series of medical tests to have a baseline value of their physiology and identify any unnoticed complications. Typically these include the following blood tests:
Complete Blood Count
Blood Typing and Cross Match
INR & APTT
Electrolytes & Creatinine
Fasting Glucose if the patient is diabetic
ECG
In addition, certain surgeries might require the patient to attend to radiography scans prior to the surgery. In that case, you need to coordinate the appointments and provide assistance as necessary.
Pre-Operative Nursing Assessment Part 5: Documentation
Lastly, you need to assess which pre-operative documents have been complete, and which documents still need to be done. These include:
Informed Consent
Pre-operative Nursing Checklist (in ward)
All above mentioned assessments have been documented and are available in the patient’s file.
After you complete the assessment, you can now move on to determining the diagnoses and implementing interventions as required.