Preoperative care begins when surgery is planned and ends with the administration of anesthesia. This phase of care includes a preoperative interview and assessment to collect baseline subjective and objective data from the patient and his family; diagnostic tests such as urinalysis, electrocardiogram, and chest radiography; preoperative teaching; securing informed consent from the patient; and physical preparation.
Thermometer ▪ sphygmomanometer ▪ stethoscope ▪ watch with second hand ▪ weight scale ▪ tape measure.
Preparation of Equipment
Gather all equipment needed at the patient’s bedside or in the admission area.
Obtaining Informed Consent
Informed consent means that the patient is entitled to a full explanation of the procedure, its risks and complications, and the risk if the procedure isn’t performed at this time. Although obtaining informed consent is the doctor’s responsibility, the nurse is responsible for verifying that this step has been taken.
You may be asked to witness the patient’s signature. However, if you didn’t hear the doctor’s explanation to the patient, you must sign that you are witnessing the patient’s signature only.
Consent forms must be signed before the patient receives his preoperative medication because forms signed after sedatives are given are legally invalid. Adults and emancipated minors can sign their own consent forms. Children’s consent forms, or those of adults with impaired mental status, must be signed by a parent or guardian.
Review the patient’s preadmission findings.1
Make sure the patient has a signed informed consent form in his medical record (See Obtaining informed consent.)2,3
Confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.7
If the patient is having same-day surgery, make sure he knows ahead of time not to eat or drink anything for 8 hours before surgery. Confirm with him what time he’s scheduled to arrive at the facility, and tell him to leave all jewelry and valuables at home. Also make sure the patient has arranged for someone to accompany him home after surgery.
Obtain a health history and assess the patient’s knowledge, perceptions, and expectations about his surgery. Ask about previous medical and surgical interventions. Also determine the patient’s psychosocial needs; ask about occupational well-being, financial matters, support systems, mental status, and cultural beliefs. Use your facility’s preoperative surgical assessment database, if available, to gather this information.1
You may also need
Full access? Get Clinical Tree