Preparing the client on the day of surgery Before Leaving for the Operating Room Before the patient

goes to the OR suite, his or her physical and emotional status and vital signs should be assessed and recorded by the nurse on the surgical unit or in the same day admission unit. Any untoward signs and symptoms and extreme apprehension are reported to the surgeon, because they could affect the patient's intraoperative course. The following preparations are made: 1. The patient puts on a clean hospital gown. The surgeon permits some patients to wear underpants or pajama pants if the lower body segment is not part of the surgical site. This is helpful in adolescents and patients who are very embarrassed and uncomfortable. Any clothing removed in OR should be placed in a clear plastic bag and labeled with the patient's name, date, and surgeon's name. Menstruating patients should use a sanitary napkin if they will be under general anesthesia for more than 2 hours. Tampons can be used if they will not remain in place for more than a few a hours total. The presence of a tampon should be clearly noted in the chart so it is not forgotten if the surgery becomes more extensive and longer in duration. The circulating nurse should be informed verbally about the patient's menses so confusion does not arise if vaginal bleeding is noted. 2. Jewelry is removed for safekeeping. If a wedding ring cannot be removed, it is taped loosely or tied securely to prevent loss. The patient may be permitted to keep a religious symbol, but the patient should understand this may be removed during the surgical procedure. Document the personal items and their disposition in the chart before, during, and after the procedure. 3. Unless otherwise ordered, dentures and removable bridges are removed before the administration of the general anesthetic to safeguard them and to prevent them from obstructing respiration. Dentures are permitted during local anesthesia, especially if the patient can breathe more easily with them in place. Some anesthesia providers prefer that securely fitting dentures be left in place to facilitate the airway maintenance. Dentures are necessary to retain facial contours for some plastic surgery procedures. Dentures removed in the OR should be labeled and taken to PACU for placement in the patient's mouth during the post-procedure period. 4. All removable prostheses (e.g., eye, extremity, contact lenses, hearing aids, eyeglasses) are removed for safekeeping. In some instances the patient may be permitted to wear eyeglasses or a hearing aid to the OR. The circulating nurse safeguards them and sends them to the PACU with the patient. Contact lenses are removed before the administration of a general anesthetic because they may become dry and cause corneal abrasions. The patient's personal property is safeguarded to prevent loss or damage. Jewelry and valuables can be given to the family or sent to the hospital safe. The clothing of ambulatory surgery patients can be stored in a locker. The clothing of TCI patients can be sent to the room or unit where the patient will be admitted postoperatively. Be sure that all items are bagged and clearly marked with the patient's name and date. Document the disposition of all patient belongings. 5. Long hair may be braided. Wigs should be removed, or in special cases, covered with a surgical cap. Hairpins are removed to prevent scalp injury. 6. Antiembolic stockings or elastic bandages may be ordered for the lower extremities to prevent embolic phenomena. The stockings are applied before abdominal or pelvic procedures; for patients who have varicosities, are prone to thrombus formation, or have a history of emboli; and for some geriatric patients. They also are often applied for long procedures. 7. The patient voids to prevent overdistention of the bladder or incontinence during unconciousness. This is especially important for abdominal or pelvic procedures in which a large bladder may be traumatized or may interfere with adequate exposure of the abdominal

contents. The time of voiding is recorded. Double check that a urine specimen is not needed before discarding the urine. When indicated, an indwelling Foley catheter is usually inserted in the OR after the patient has been anesthetized. Some urologic procedures require a full bladder, such as urodynamics (UD) with cystometrography (CMG) or electromyography (EMG); therefore, the patient should not void preoperatively. 8. If ordered, an antibiotic is given 1 hour preoperatively to establish and reach a therapeutic blood level of antibiotic prophylaxis intraoperatively. This may be a one time dose or may be continued into the postoperative period. If cultures or specimens are obtained during the surgical procedure, a notation should be made on the pathology specimen sheet to indicate antibiotic use. 9. Preanesthesia medications are given as ordered. Their purpose is to eliminate apprehension by making the patient calm, drowsy, and comfortable. Patients who receive a preanesthesia medication should be cautioned to remain in bed and not to smoke. Many of the drugs cause drowsiness, vertigo, or postural hypotension. Therefore the side rails on the bed should be raised and the call bell placed within the patient's reach. 10. The patient, bed, and chart are accurately identified and identifications are fastened securely in place. Allergies should be prominently noted on the chart and patients wristband. A preoperative checklist helps ensure that the patient has been properly prepared. If preparations is inadequate, the surgical procedure may be canceled. All essential records, including the plan of care or the clinical care map, must accompany the patient. EMOTIONAL PREPARATION by fulfilling spiritual and psychosocial needs, the caregiver helps to provide the preoperative patient with as much peace of mind as possible. Understandably, the patient's tension level rises as the time for the surgical procedure approaches. The better prepared the patient is emotionally, the smoother his or her post operative course will be. If the patient has not seen his or her cleric or the hospital chaplain and makes such a request, the nurse should make every effort to contact that person for the patient. Family members or significant others should be permitted to stay with the patient until he or she goes to the OR suite. Some hospitals permit parents to accompany infants and children into the OR suite. After leaving the patient, the family should be directed to the waiting area. TRANSPORTATION TO THE OPERATING ROOM SUITE patients may be taken to the OR suite approximately 30 to 45 minutes before the scheduled time of the procedure. For safety, they are commonly transported via a transport stretcher or wheelchair. If a stretcher is used, it should be pushed from the head end so the patient's feet go first. Rapid movements through corridors and around corners may cause dizziness and nausea, especially if the patient has been medicated. The attendant at the head end can observe for vomiting or respiratory distress. The patient may be more comfortable if the head end of the stretcher raised. If transporting by wheelchair, the patient should be instructed not to help with door opening and to keep hands on the lap. A blanket or sheet should be placed on the seat of the chair and cover over the lap for modesty. It is inappropriate for bare buttocks to be seated on the uncovered surface of the wheelchair. Take care with tubing such as Ivs or catheters so they do not get tangled in the wheels. Drainage bags should be maintained below the level of the bladder to prevent reflux infection. Some ambulatory patients may be permitted to walk to the OR. They are given foot protection such as slippers to prevent injury. The slippers should be skid-proof on the bottom. Papers slippers may be unsafe. They do not protect from injury or slippage. The slippers may need to be removed for the procedure but should be retained until the end of the procedure and returned to the patient for use

within the facility. Ideally, certain elevators are designated For Use Only which ensures privacy and minimizes microbial contamination. The patient should be comfortable, warm, and safe during transport. Side rails are raised, and restraint straps are applied. The patient should be instructed to keep his or her arms, hands, and fingers inside the side rails during transport to avoid injury when going through doorways. IV solutions bags hung on poles during transportation are attached securely and placed at the foot of the bed away from the patient's head; this minimizes the danger of injury to the patient if the container should fall. Gentle handling is indicated to prevent dislodging IV needles or indwelling catheters. parent(s) sometimes are permitted to accompany a child. If the patient has a language barrier or is profoundly deaf,an interpreter may accompany him or her to the OR and stay until the induction of anesthesia. ADMISSION TO THE PRESURGICAL HOLDING AREA. The holding nurse greets the patient by name and introduces himself or herself. The nurse stands next to the midsection of the stretcher so the patient can comfortably see him or her. The holding area nurse does the following: 1. Place a warm blanket on the patient, verifies patient identification and notifies the individual at the surgery control desk that the patient is in the holding area. 2. Verifies the surgical procedure, site, and surgeon verbally with the patient and/or family as appropriate. Some facilities require that the surgical site be physically marked with indelible ink or the surgeon's initials. Some facilities use a sticker applied to the spot. Take care that the sticker does not get rubbed off or moved. 3. Review the patient's chart for completeness a. Medical history and physical examination b. Laboratory reports c. Consent forms and documentation of consents 1. Informed consent data 2. General consent to treat 3. Anesthesia consent 4. Measures the vital signs and blood pressure. 5. Verifies allergies and medication history. 6. Checks skin tone and integrity. 7. Verifies allergies and medication history. 8. Note the patient's mental state. 9. Put a cap on the patient to protect his or her hair ( in case vomiting occurs), for purposes of asepsis, and to help prevent hypothermia. Patients who are bald are required to wear a head covering to prevent heat loss and dander shed. 10. Notifies the individual at the surgery control desk when the patient is ready for transport to the OR. The patient is under constant observation by the patient care staff until transported from the surgical department to another patient care unit or discharged The holding area nurse records pertinent findings in the perioperative patient care record. If a perioperative patient assessment has not been performed, the holding area nurse will assess the patient, formulate the nursing diagnoses and expected outcomes, and prepare an individualized plan of care or initialize the care map. TRANSFER TO THE OPERATING ROOM

When everything is ready, the circulating nurse comes to the holding area for the patient. It is advantageous if this person is the perioperative nurse who made the preoperative visit, because the patient will appreciate seeing a familiar face. Before transporting the patient into the OR, the circulating nurse has several important duties to fulfill: 1. Greet the patient, and validate his or her identity. a. the nurse should introduce himself or herself if he or she has not previously met the patient. The patient should be addressed as Mr. and Mrs. or Ms. - not by the first name. The patient should be asked his or her full name and date of birth. b. when the patient arrives at the facility, an identifying wristband is put on in the admitting office. The perianesthesia nurse checks the band before the patient leaves for the OR. The circulating nurse compares the information on the wristband, including the identification number, with the information on the surgical schedule: name, anticipated surgical procedure, time, and surgeon. An allergy band and other notification band (e.g., Do Not Resuscitate[DNR]) should be checked at the same time. c. identification on the stretcher or bed ensures the patient's return to the same stretcher or bed after surgery, if this is the procedure. If the patient is an infant or child, the identification tag on the crib should be out of his or her reach. Always validate the identity of a child with a parent. Ask what procedure is being performed. d. verification of the surgical procedure, site, and surgeon with the patient provides reassurance that this is the correct patient. The patient's own words should be documented on the chart. The circulating nurse should note the presence of the surgeon's identifying mark on the surgical site. If the patient is heavily sedated, the surgeon may be asked to help identify the patient. 2. Check the side rails, restraining straps, IV infusions, and indwelling catheters. 3. Observe the patient for any reaction to the medication. 4. Observe the patient's anxiety level. 5. Check the history and physical examination data, laboratory tests, radiograph reports, and consent form(s) or documentation in the patient's chart. 6. Review the plan of care or care map. a. Pay particular attention to allergies and any previous unfavorable reactions to anesthesia or blood transfusions. b. Become familiar with this parent's unique and individual needs. The patient is taken into the OR after the surgeon sees him or her and the anesthesia provider is ready to receive the patient. The main preparations for the procedure should be complete so the circulating nurse can devote undivided attention to the patient. BEFORE THE INDUCTION OF ANESTHESIA The anesthesia provider also has immediate preanesthesia duties, such as the following: 1. Checking and assembling equipment before the patient enters the room. Airways, endotracheal tubes, laryngoscopes, suction catheters, labeled prefilled medication syringers, and other items are arranged on a cart or table. 2. Reviewing the preoperative physical examination, history, and laboratory reports in the chart. 3. Making certain that the patient is comfortable and secure on the operating bed. 4. Checking for denture removal or any loose teeth. The latter may be slucred with a 2-0

silk tie and taped to the patient's cheek to prevent possible apiration. 5. Checking to be certain that contact lenses have been removed. 6. Asking the patient when he or she last took anything by mouth, including medications. 7. Checking the patient's pulse, respiration, and blood pressure to obtain a baseline for the subsequent assessment of vital signs while the patient is anesthetized. 8. Listening to the heart and lungs, and then connecting ECG monitor leads and attaching the pulse oximeter and other monitoring devices. 9. Starting the IV access. This may be done in the holding area or in an induction room. Some patients arrive with an IV line in place. 10. Preparing for and explaining the induction procedure to the patient. If properly premedicated, the patient should be able to respond to simple instructions.