Data collection about the patient before surgery begins in various settings (e.g., the surgeon’s office, the preadmission or admission office, the inpatient unit, the telephone). Use privacy to increase the patient’s comfort with the interview process. Anesthesia and surgery are both physical and emotional stressors. Collect these data:

When taking a history, screen the patient for problems that increase the risk for complications during and after surgery. Some problems that increase the surgical risk or increase the risk for complications after surgery are listed in Table 16-3.

Older patients are at increased risk for complications (Doerflinger, 2009). The normal aging process decreases immune system functioning and delays wound healing. The frequency of chronic illness increases in older patients. In addition, reductions of muscle mass and body water increase the risk for dehydration. See Chart 16-1 for other changes in older adults that may alter the operative response or risk.

Drugs and substance use may affect patient responses to surgery. The use of tobacco increases the risk for pulmonary complications because of changes it causes to the lungs and chest cavity. Excessive alcohol and illicit substance use can alter the patient’s responses to anesthesia and pain medication. Withdrawal of alcohol before surgery may lead to delirium tremens. Prescription and over-the-counter drugs may also affect how the patient reacts to the operative experience. Adverse effects can occur with the use of some herbs, such as those listed in Table 16-4.

Medical history is important to obtain because many chronic illnesses increase surgical risks and need to be considered when planning care (Woolger, 2008). For example, a patient with systemic lupus erythematosus may need additional drugs to offset the stress of the surgery. A patient with diabetes may need a more extensive bowel preparation because of decreased intestinal motility. An infection may need to be treated before surgery.

Ask the patient specifically about cardiac disease because complications from anesthesia occur more often in patients with cardiac problems (Morse, 2009; Johnson, 2011). A patient with a history of rheumatic heart disease may be prescribed antibiotics before surgery. Cardiac problems that increase surgical risks include coronary artery disease, angina, myocardial infarction (MI) within 6 months before surgery, heart failure, hypertension, and dysrhythmias. These problems impair the patient’s ability to withstand hemodynamic changes and alter the response to anesthesia. The risk for an MI during surgery is higher in patients who have heart problems. Patients with cardiac disease may require perioperative therapy with beta-blocking drugs, as recommended by core measures for SCIP CARD-2 (see Table 16-1).

Pulmonary complications during or after surgery are more likely to occur in older patients, those with chronic respiratory problems, and smokers because of smoking- or age-related lung changes (Doerflinger, 2009). Increased chest rigidity and loss of lung elasticity reduce anesthetic excretion. Smoking increases the blood level of carboxyhemoglobin (carbon monoxide on oxygen-binding sites of the hemoglobin molecule), which decreases oxygen delivery to organs. Action of cilia in pulmonary mucous membranes decreases, which leads to retained secretions and predisposes the patient to infection (pneumonia) and atelectasis (collapse of alveoli). Atelectasis reduces gas exchange and causes intolerance of anesthesia. It is also a common problem after general anesthesia.

Chronic lung problems such as asthma, emphysema, and chronic bronchitis also reduce the elasticity of the lungs, which reduces gas exchange. As a result, patients with these problems have reduced tissue oxygenation.

Previous surgical procedures and anesthesia affect the patient’s readiness for surgery. Previous experiences, especially with complications, may increase anxiety about the scheduled surgery. Ask about the patient’s experience with anesthesia and all allergies. These data provide information about tolerance of and possible fears about the use of anesthesia. The family medical history and problems with anesthetics may indicate possible reactions to anesthesia, such as malignant hyperthermia (see Chapter 17).

A sensitivity or allergy to certain substances alerts you to a possible reaction to anesthetic agents or to substances that are used before or during surgery. For example, povidone-iodine (e.g., Betadine) used for skin cleansing contains the same allergens found in shellfish. Patients who are allergic to shellfish may have an adverse reaction to povidone-iodine. The patient with an allergy to bananas and other fruits may also have a latex sensitivity or allergy.

Blood donation for surgery can be made by the patient (autologous donations) a few weeks just before the scheduled surgery date. Then, if blood is needed during or after surgery, an autologous blood transfusion can be given. This practice eliminates transfusion reactions and reduces the risk for acquiring bloodborne disease.

Patients can donate their own blood up to 5 weeks before surgery if they are infection free, have a hemoglobin level greater than 11 g/dL (110 g/L), and have a physician’s prescription. Patients with cardiac disease may need additional clearance from their cardiologist before making an autologous donation. The physician may prescribe supplemental iron before the first donation. Autologous donations can be made as often as every 3 days if other criteria are met. Usually a total of 2 to 4 units are donated. The last donation cannot be made within 72 hours before surgery.

A special tag is placed on the blood bag when an autologous blood donation has been made. The blood donor center gives the patient a matching tag that he or she wears or brings to the surgical area before surgery, as required by The Joint Commission’s National Patient Safety Goals (NPSGs). This procedure helps ensure that patients receive only their own blood. If the blood is not used, some agencies discard it. In other agencies, the blood goes to the blood bank where it is processed into various blood components (e.g., plasma, packed cells, platelets) for infusion in other patients.

Patients may wish to have family and friends donate blood exclusively for their use, if needed. This practice (called directed blood donation) is possible only if the blood types are compatible and the donor’s blood is acceptable. Patients may fear disease transmission from unknown blood and feel more comfortable knowing who gave the blood. Many centers do not accept directed blood, stating that it gives a false sense of security. As with autologous blood donations, a special tag is attached to the blood bag. This tag notes the names of the patient and the donor and bears the patient’s signature.

Ask whether autologous or directed blood donations have been made, and document this information in the chart. It is important to know the specific blood collection center where the donation was made and whether the blood has arrived before the patient goes into surgery. The hospital receives and stores the blood units until they are used or are no longer needed. Unused blood is returned to the collection center.

Increased use of “bloodless surgery” and minimally invasive surgery provides alternatives for patients with religious or medical restrictions to blood transfusions. These programs reduce the need for transfusion during and after surgery. Some techniques used are limiting blood samples (the number of samples, as well as the volume of blood drawn per sample) before surgery and stimulating the patient’s own red blood cell production with epoetin alpha (e.g., Epogen, Procrit) before, during, and after surgery. Supplemental iron, folic acid, vitamin B₁₂, and vitamin C may be prescribed before surgery to help red blood cell formation. Newer equipment and surgical techniques cause less blood loss than older techniques. Such advances include recycling blood suctioned during surgery and immediately transfusing it back into the patient. Assess, monitor, teach, and support the patient during the bloodless surgery process.

Discharge planning is started before surgery. Assess the patient’s home environment, self-care capabilities, and support systems and anticipate postoperative needs before surgery. All patients, regardless of how minor the procedure or how often they have had surgery, should have discharge planning. Older patients and dependent adults may need transportation referrals to and from the physician’s office or the surgical setting. A home care nurse may be needed to monitor recovery and to provide instructions. All patients with few support systems may need follow-up care at home. Some patients need a planned direct admission to a rehabilitation hospital or center for physical therapy after surgery, especially joint replacement surgery (Lucas, 2008). Shortened hospital stays require adequate discharge planning to achieve the desired outcomes after surgery.

Throughout the physical assessment, focus on problem areas identified from the patient’s history and on all body systems affected by the surgical procedure. The older adult (Chart 16-2; see also Chapter 3) or chronically ill patient is at increased risk for complications during and after surgery. The number of serious problems (morbidity) and death (mortality) during or after surgery is higher in older and chronically ill patients (Morse, 2009).

Cardiovascular status is critical to assess because cardiac problems may cause as many as 30% of surgery-related deaths. Check the patient for hypertension, which is common, is often undiagnosed, and can affect the response to surgery. Cardiac assessment includes listening to heart sounds for rate, regularity, and abnormalities. Ask whether the patient has ever had a venous thromboembolism (VTE). Examine the patient’s hands and feet for temperature, color, peripheral pulses, capillary refill, and edema. Report any problems (e.g., absent peripheral pulses, pitting edema, cardiac symptoms, chest pain, shortness of breath, and dyspnea) to the physician for further assessment and evaluation. (Cardiac assessment is discussed further in Chapter 35.)

Respiratory status considers age, smoking history (including exposure to secondhand smoke), and any chronic illness (Doerflinger, 2009). Observe the patient’s posture; respiratory rate, rhythm, and depth; overall respiratory effort; and lung expansion. Document any clubbing of the fingertips (swelling at the base of the nail beds caused by a chronic lack of oxygen) or cyanosis. Auscultate the lungs to assess for any abnormal breath sounds (crackles, wheezes, rubs). (More information on respiratory assessment is found in Chapter 29.)

Kidney function affects the excretion of drugs and waste products, including anesthetic and analgesic agents. If kidney function is reduced, fluid and electrolyte balance can be altered, especially in older patients. Ask about problems such as urinary frequency, dysuria (painful urination), nocturia (awakening during nighttime sleep because of a need to void), difficulty starting urine flow, and oliguria (scant amount of urine). Ask the patient about the appearance and odor of the urine. Equally important is an assessment of usual fluid intake and degree of continence. If the patient has kidney or urinary problems, consult with the physician about further workup. (Kidney/urinary assessment is discussed further in Chapter 68.)

Kidney impairment decreases the excretion of drugs and anesthetic agents. As a result, drug effectiveness may be altered. Scopolamine (Buscopan ), morphine, other opioids, and barbiturates often cause confusion, disorientation, apprehension, and restlessness when given to patients with decreased kidney function.

Neurologic status includes the patient’s overall mental status, level of consciousness, orientation, and ability to follow commands. This information is needed before planning preoperative teaching and care after surgery. A problem in any of these areas affects the type of care needed during the surgical experience. Determine the patient’s baseline neurologic status to be able to identify changes that may occur later. Also assess for any motor or sensory deficits. (See Chapter 43 for complete nervous system assessment.)

The usual neurologic status of a mentally impaired patient may be difficult to assess (Doerflinger, 2009; Grebe, 2007). The patient who has been independent and oriented at home may become disoriented in the hospital setting. Family members can often provide information about what the patient was like at home.

The Joint Commission’s NPSGs require that you ensure patient safety by assessing the patient’s risk for falling, especially older patients. Evaluate factors such as mental status, muscle strength, steadiness of gait, and sense of independence to determine the patient’s risk. Document the patient’s ability to ambulate and the steadiness of gait as baseline data.

Musculoskeletal status problems may interfere with positioning during and after surgery. For example, patients with arthritis may be able to assume surgical positions but have discomfort after surgery from prolonged joint immobilization. Other anatomic features, such as the shape and length of the neck and the shape of the chest cavity, may interfere with respiratory and cardiac function or require special positioning during surgery.

Ask about a history of joint replacement, and document the exact location of any prostheses. During surgery, ensure that electrocautery pads, which could cause an electrical burn, are not placed on or near the area of the prosthesis.

Nutritional status, especially malnutrition and obesity, can increase surgical risk (Woolger, 2008). Surgery increases metabolic rate and depletes potassium, vitamin C, and B vitamins, all of which are needed for wound healing and blood clotting. In malnourished patients, decreased serum protein levels slow recovery. Negative nitrogen balance may result from depleted protein stores. This problem increases the risk for skin breakdown, delayed wound healing, possible dehiscence or evisceration (see Chapter 18), dehydration, and sepsis.

Some older patients may have poor nutrition because of chronic illness, diuretic or laxative use, poor dietary planning or habits, anorexia, and lack of motivation or financial limitations (Touhy & Jett, 2010). Indications of poor fluid or nutritional status include:

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