The preoperative phase runs from the decision to operate until the client is transferred to the operating room. Its purpose is to identify and reduce risk, confirm that the client is informed and consenting, prepare the body for anesthesia and surgery, and teach the client how to recover.
Why preparation matters
- Anesthesia depresses protective airway reflexes → aspiration risk if the stomach is full
- Surgery triggers a stress response (↑cortisol, catecholamines, ADH) → hyperglycemia, fluid retention, impaired healing, clot formation
- Pain and anesthetic drugs reduce deep breathing → atelectasis and pneumonia afterward
- Immobility and tissue injury → venous thromboembolism (VTE)
Classification of surgery
| By urgency | Meaning |
|---|
| Emergency | Immediate, life-threatening (e.g., ruptured aneurysm) |
| Urgent | Within 24–48 hours (e.g., acute cholecystitis) |
| Elective / planned | Scheduled when the client is optimized |
By purpose: diagnostic (biopsy), curative (tumor removal), palliative (symptom relief), reconstructive, and cosmetic.
Factors that increase surgical risk: older age, smoking, obesity, obstructive sleep apnea, diabetes, cardiac and pulmonary disease, kidney or liver disease, malnutrition, alcohol or substance use, frailty, cognitive impairment, and medications (anticoagulants, corticosteroids, immunosuppressants).
ASA Physical Status (assigned by the anesthesia provider): I healthy; II mild systemic disease; III severe systemic disease; IV severe disease that is a constant threat to life; V moribund; VI brain-dead organ donor. "E" is added for emergency surgery.
Enhanced Recovery After Surgery (ERAS) pathways bundle evidence-based steps — shorter fasting with carbohydrate drinks, multimodal opioid-sparing analgesia, early eating, and early ambulation — to speed recovery.
Health history
- Current and past illnesses; previous surgeries and anesthesia problems; family history of problems with anesthesia (possible malignant hyperthermia susceptibility)
- Allergies: drugs, latex, iodine/contrast, adhesive tape, foods
- All medications, including over-the-counter drugs and herbal supplements (garlic, ginkgo, ginseng, fish oil, vitamin E increase bleeding; St. John's wort alters drug levels)
- Tobacco, alcohol (withdrawal risk after surgery), and substance use
- Obstructive sleep apnea screening (e.g., STOP-BANG); bring CPAP to hospital
- Pregnancy status
Physical and functional
- Baseline vital signs, SpO₂, height and weight, airway, heart and lung sounds, skin integrity, mobility, and nutritional status
- Cognitive function in older adults — a baseline is needed to detect postoperative delirium
- Sensory aids (glasses, hearing aids), dentures, prostheses
Psychosocial: anxiety and fears, coping, support system, cultural and religious preferences (e.g., about blood products), and advance directives.
Tests are chosen by the client's history and the type of surgery — not ordered routinely for everyone.
| Test | Why |
|---|
| CBC | Anemia, infection, platelet count |
| Electrolytes, glucose, BUN/creatinine | Potassium abnormalities increase dysrhythmia risk; kidney function affects drug dosing |
| PT/INR, aPTT | Anticoagulant use, liver disease, bleeding history |
| ECG | Known cardiac disease or significant risk factors |
| Chest X-ray | Only when heart or lung findings suggest a need |
| Pregnancy test | People who could be pregnant |
| Type and screen / crossmatch | Procedures with expected blood loss |
| A1C, glucose | Diabetes control |
A urine drug screen is not part of standard preoperative testing. Report abnormal results (e.g., potassium below 3.5 mEq/L, elevated INR, low platelets, very high glucose, positive pregnancy test) to the surgeon and anesthesia provider before surgery.
Informed consent
- The surgeon (the person performing the procedure) obtains consent by explaining the procedure, benefits, risks, alternatives, and the option to refuse
- The nurse's role is to confirm the client understands, that consent is voluntary, and to witness the signature. If the client has questions or does not understand, notify the surgeon before surgery
- The client must be an adult with decision-making capacity and not impaired by sedatives or opioids. Use a qualified interpreter when needed. A legally authorized representative signs when the client lacks capacity; emergency treatment may proceed without consent when delay would threaten life, per law and policy
- Consent is signed before preoperative sedation is given
Medication management (follow the specific surgeon and anesthesia instructions)
| Drug | Usual approach |
|---|
| Beta blockers | Continue, including the morning of surgery with a sip of water; do not start new on the day of surgery |
| Statins | Continue |
| ACE inhibitors, ARBs | Often held for 24 hours before surgery in hypertension to reduce intraoperative hypotension; continuation is reasonable in heart failure with reduced ejection fraction |
| Warfarin | Usually stopped about 5 days before; check INR; bridging with heparin only for high thrombotic risk |
| Direct oral anticoagulants | Stopped 1–3 days or more before, based on drug, kidney function, and bleeding risk; no bridging |
| Aspirin, P2Y12 inhibitors | Aspirin is often continued for secondary prevention (e.g., coronary stents) and stopped for primary prevention; stopping antiplatelets after recent stents requires cardiology input |
| Metformin | Usually held on the day of surgery |
| SGLT2 inhibitors | Hold 3 days before (4 days for ertugliflozin) — euglycemic ketoacidosis risk |
| Insulin | Basal dose usually reduced the night before or morning of surgery; monitor glucose |
| GLP-1 receptor agonists | Individualized: many continue; higher-risk clients (dose escalation, GI symptoms) may hold the drug or follow a liquid diet for 24 hours before. Report nausea, vomiting, bloating, or abdominal pain on the day of surgery — anesthesia may delay the case or treat it as a full stomach |
| Diuretics | Usually held the morning of surgery |
| Corticosteroids (long-term) | Continue; stress-dose coverage may be ordered |
| Herbal supplements | Usually stopped about 1–2 weeks before |
Fasting (healthy clients having elective procedures)
| Intake | Minimum fast before anesthesia |
|---|
| Clear liquids (water, clear juice without pulp, black coffee or tea) | 2 hours |
| Carbohydrate-containing clear drinks | 2 hours — allowed in healthy adults (ERAS protocols often use about 400 mL). Not for clients with diabetes, delayed gastric emptying, or other aspiration risk unless anesthesia approves |
| Breast milk | 4 hours |
| Nonhuman milk, infant formula | 6 hours |
| Light meal (toast and clear liquid) | 6 hours |
| Fried or fatty food, meat | 8 hours |
"Nothing after midnight" is outdated for most clients; prolonged fasting causes thirst, hunger, dehydration, and hypoglycemia. Stricter rules may apply for delayed gastric emptying, bowel obstruction, or emergency surgery.
Infection prevention
- Shower or bathe with soap or an antiseptic agent (such as chlorhexidine) the night before or morning of surgery as ordered
- Hair removal only if necessary, with clippers immediately before surgery — never razors, which cause micro-cuts
- Prophylactic antibiotic within 60 minutes before incision (120 minutes for vancomycin and fluoroquinolones)
- Glucose control; smoking cessation (benefits increase with longer abstinence, ideally at least 4 weeks)
Other preparation: VTE risk assessment and prophylaxis; bowel preparation only for selected bowel surgery; stress ulcer and aspiration prophylaxis when ordered.
Universal Protocol (wrong-site surgery prevention)
- Preprocedure verification of client, procedure, site, and documents
- Site marking by the person performing the procedure, with the client involved when possible
- Time-out immediately before the incision
Listed in priority order.
- Identify and report safety risks — abnormal vital signs, labs, new symptoms (chest pain, fever, respiratory infection), recent intake despite fasting instructions, and allergies (latex allergy → latex-free room and supplies)
- Verify client identity, procedure, and site marking; confirm the consent is signed and the client understands
- Medication administration — give only the medications ordered for the morning of surgery; give prophylactic antibiotics on time; administer preoperative sedatives after consent and voiding
- Physical preparation
- Ask the client to void before sedation
- Remove jewelry, piercings, makeup, and prostheses; dentures are removed per policy (hearing aids and glasses may stay until the operating room to help communication)
- Apply compression devices as ordered; insert IV
- Safety after sedation — bed in low position, side rails per policy, call light, no ambulation without help
- Complete the preoperative checklist and give a structured handoff (e.g., SBAR) to the operating room team
- Reduce anxiety — use open-ended questions to explore specific worries ("What concerns you most about the surgery?"); avoid false reassurance; include family
Teach before surgery, with return demonstration:
- Deep breathing and incentive spirometry — 10–15 breaths every 1–2 hours while awake, or as ordered — to prevent atelectasis and pneumonia
- Coughing with incision splinting (pillow over the incision) when secretions are present
- Leg exercises (ankle pumps, quadriceps setting) and early ambulation to prevent VTE and promote bowel function
- Pain plan: how to use the pain scale, report pain early, and use patient-controlled analgesia if ordered
- What to expect: IV lines, drains, catheters, oxygen, recovery unit, and visiting
- Fasting and medication instructions in writing; arrange an adult to drive and stay with outpatient clients after anesthesia
- Stop smoking and alcohol; control glucose
| Finding before surgery | Why it matters |
|---|
| Client does not understand the procedure or was sedated when signing | Consent is not valid — notify the surgeon |
| Recent food intake | Aspiration risk — notify anesthesia |
| Potassium abnormality, elevated INR, low platelets | Dysrhythmias, bleeding |
| Fever, cough, new infection | Surgery may be postponed |
| Chest pain, new dysrhythmia | Cardiac evaluation needed |
| Personal or family history of malignant hyperthermia | Trigger-free anesthesia plan |
| Positive pregnancy test | Anesthesia and surgical plan change |
| SGLT2 inhibitor not held | Euglycemic ketoacidosis risk |
- Surgeon obtains consent; the nurse confirms understanding and witnesses; unclear understanding → notify surgeon
- Sedated or impaired clients cannot give valid consent
- Fasting: clear liquids until 2 hours, light meal 6 hours, fatty meal 8 hours before anesthesia
- Continue beta blockers on the day of surgery; hold SGLT2 inhibitors 3–4 days
- Anticoagulants, antiplatelets, and herbal supplements (garlic, ginkgo, ginseng) → bleeding risk; follow specific hold instructions
- Clippers, not razors, for hair removal
- Antibiotic prophylaxis within 60 minutes before incision
- Universal Protocol: verification, site marking, time-out
- Preoperative teaching: deep breathing, incentive spirometry, coughing with splinting, leg exercises, early ambulation
- Older adults: assess cognition and medications — delirium risk
- Anxiety → open-ended questions, not false reassurance
Country Notes
United States
- The Joint Commission Universal Protocol (verification, site marking, time-out) is required in accredited hospitals and ambulatory surgery centers.
Philippines
- Hospitals commonly use the WHO Surgical Safety Checklist (sign in, time-out, sign out).
- Families are often closely involved in surgical decisions; include them in teaching, but consent must still come from the competent adult client, in a language the client understands.