Goal: The patient will be prepared physically and psychologically to proceed to surgery.
1. Check the patient’s chart for the type of surgery and review the medical orders. Review the nursing database, history, and physical examination. Check that the baseline data are recorded; report those that are abnormal.
2. Gather the necessary supplies and bring to the bedside stand or overbed table.
3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient.
6. Check that preoperative consent forms are signed, witnessed, and correct; that advance directives are in the medical record (as applicable); and that the patient’s chart is in order.
7. Check vital signs. Notify primary care provider and surgeon of any pertinent changes (e.g., rise or drop in blood pressure, elevated temperature, cough, symptoms
of infection).
8. Provide hygiene and oral care. Assess for loose teeth and caps. Remind patient of food and fluid restrictions before surgery.
9. Instruct the patient to remove all personal clothing, including underwear, and put on a hospital gown.
10. Ask patient to remove cosmetics, jewelry including bodypiercing, nail polish, and prostheses (e.g., contact lenses, false eyelashes, dentures, and so forth). Some facilities allow a wedding band to be left in place depending on the type of surgery, provided it is secured to the finger with tape.
11. If possible, give valuables to family member or place valuables in appropriate area, such as the hospital safe, if this is not possible. They should not be placed in narcotics drawer.
12. Have patient empty bladder and bowel before surgery.
13. Attend to any special preoperative orders, such as starting an IV line.
14. Complete preoperative checklist and record of patient’s preoperative preparation.
15. Question patient regarding the location of the operative site. Document the location in the medical record according to facility policy. The actual site will be marked on the patient when the patient arrives in the preoperative holding area by the licensed independent practitioner who will be directly involved in the procedure (The Joint Commission, 2008).
16. Administer preoperative medication as prescribed by physician/anesthesia provider.
17. Raise side rails of bed; place bed in lowest position. Instruct patient to remain in bed or on stretcher. If necessary, use a safety belt.
18. Help move the patient from the bed to the transport stretcher, if necessary. Reconfirm patient identification and ensure that all preoperative events and measures are documented.
19. Tell the patient’s family where the patient will be taken after surgery and the location of the waiting area where the surgeon will come to explain the outcome of the surgery. If possible, take the family to the waiting area.
20. After the patient leaves for the operating room, prepare the room and make a postoperative bed for the patient. Anticipate any necessary equipment based on the type of surgery and the patient’s history.
21. Remove PPE, if used. Perform hand hygiene.
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