Conducting a General Preoperative Assessment and Checklist

A preoperative assessment is a structured evaluation conducted before surgery to ensure the patient is medically optimized, informed, and safe to undergo anesthesia and the planned procedure. It’s a cornerstone of perioperative care that helps reduce complications, cancellations, and hospital stays.

Definition

Preoperative assessment is the clinical investigation that precedes anesthesia for surgical or nonsurgical procedures and includes collecting relevant data pertaining to the preoperative status of surgical

Purpose

 To Reduce the risks associated with anesthesia and surgery and to restore the patient to desired level of function.

Preoperative assessment and checklist

Identification Data

Name                    :

Age                       :

Sex                        :

IP No                     :

Wand                    :

Bed No                          :

Diagnosis                      :

Surgery proposed        :

Dare of surgery            :

Type of anesthesia      :

Day prior to surgery     :

Type of anesthesia        :

1. Day prior to surgery;

1. Weight                    :
2. Height                      :
3. Known allergy            :
4. Medications consumed (specify)                                           :

( Place tick mark (+) for items carried out)                                        

1. Consent for surgery is obtained in specified format             :
2. Teaching about postoperative exercise given                        :
3. Explanation about anesthesia and surgery given                   :
4. Local skin preparation done                                                     :
5. Nails cut and bath given                                                          :
6. Enema/bowel wash given                                                        :
7. Recording done about any cough/alteration in vital signs/loose teeth/skin            :

Infection/menstruation/any others

• X-rays, scan, ECG, laboratory reports, etc, collected and attached to the patient :
• Instructions given about fasting                                             :
• Nail polish and make-up removed                                         :
• Old chart requested and obtained                                        :
• Type and cross-match for blood done                                 :
• Consent for receiving blood transfusion obtained :
• Notified surgeon for any abnormal laboratory report :

Signatures

1. Nursing student                                                     :
2. Staff nurse                                                                                :
3. Ward sister/supervisor                                                            ;

B, Day of surgery

1. Confirm NPO status                                                                :
2. Enema/bowel wash given (if indicated)                              :         
3. Bath given                                                                                :
4. Final skin preparation done                                                   :
5. Ryle’s tube passed (if indicated)                                          :
6. Intravenous line in place                                                        :
7. Clean gown given, hair groomed
8. Jewelry, dentures, glasses, contact lenses, hairpins, nail polish, and hearing aids removed                                                :
9. Vital signs checked and recorded                                       :
10. Bladder emptied (catheterization if indicated)                  :

1. Premedication given                                                              :
2. Identification band and blood band checked for accuracy            :
3. Side rails put up and bed brought down to lowest level                  :
4. Patient instructed not to get out of bed without nursing assistance      :
5. Laboratory reports, X-rays, scan reports, ECG reports, blank prescription form, fresh doctor’s order sheet, and operation record attached to patient’s chart          ;
6. Specify materials, such as drugs, articles to be sent with patient (Ryle’s tube, Foley catheter, urosac, medications, and Asepto syringe) :
7.  Time when patient left the ward                                                                 :

Signatures

1. Nursing student                         :
2. Staff nurse                                  :
3. Ward sister/supervisor              :              

Special Considerations

• Elderly: Assess for cognitive impairment, frailty, and polypharmacy
• Diabetics: Adjust insulin/oral hypoglycemics; monitor glucose perioperatively
• Cardiac patients: May need stress testing or cardiology clearance
• Anticoagulated patients: Plan for bridging or temporary cessation
• Pregnancy: Avoid teratogenic drugs; fetal monitoring if needed

Nurses Role in Preoperative Assessment

• Collect history and vitals
• Ensure labs and investigations are complete
• Provide pre-op instructions (NPO, medication adjustments)
• Offer emotional support and clarify doubts
• Document findings and escalate concerns

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884

Stories are the threads that bind us; through them, we understand each other, grow, and heal.

JOHN NOORD

Connect with “Nurses Lab Editorial Team”

I hope you found this information helpful. Do you have any questions or comments? Kindly write in comments section. Subscribe the Blog with your email so you can stay updated on upcoming events and the latest articles.