Preoperative Assessment
History: medical/surgical, medications (especially anticoagulants, antihypertensives, insulin, steroids), allergies, anesthesia history (malignant hyperthermia), family history, smoking/alcohol/drug use. Physical: airway assessment (Mallampati score), cardiovascular, respiratory, baseline vitals. Labs: based on age, procedure, comorbidities — not routine for healthy patients. ECG: men >35, women >40, cardiac history. Pregnancy test: all women of childbearing age.
ASA Physical Status
American Society of Anesthesiologists classification: ASA I: healthy patient. ASA II: mild systemic disease. ASA III: severe systemic disease (functional limitation). ASA IV: severe systemic disease that is a constant threat to life. ASA V: moribund, not expected to survive without surgery. ASA VI: organ donor. E: emergency. Higher ASA = higher perioperative risk. ASA III–IV require careful optimization.
NPO Guidelines
Enhanced Recovery After Surgery (ERAS) guidelines: Clear liquids until 2 hours before anesthesia (water, clear juice, black coffee). Light meal (toast, cereal) until 6 hours. Fatty/fried food, meat: 8 hours. Medications: take on morning of surgery with sip of water (especially antihypertensives, cardiac meds). Hold: oral hypoglycemics morning of surgery, warfarin 5 days, antiplatelets per surgeon. Insulin: reduce morning dose.
Informed Consent
Components: procedure explained, risks/benefits/alternatives, expected outcomes, consent for anesthesia/blood. Nurse WITNESSES consent — physician OBTAINS consent. Verify: correct patient, correct procedure, correct site (site marking), signed form. If patient cannot consent (unconscious, minor): surrogate decision-maker. If no consent obtained: SURGEON must be called — nurse does not obtain consent.
Preoperative Checklist
Verify: identity (2 identifiers), surgical consent signed, site marked, NPO status, allergies, medications taken/held, pregnancy status, baseline vitals, labs/EKG done, IV access, surgical site prep (hair removal if needed — use clippers not razor), removal of jewelry/nail polish/dentures/hearing aids. Teach: incentive spirometry, splinting incision for coughing, early ambulation, DVT prophylaxis. Address anxiety.
Important Notes
- Nurse WITNESSES consent — does NOT obtain it. If consent is missing or incomplete, surgeon must be contacted before proceeding.
- Mallampati Class IV airway = difficult intubation risk — anesthesia team should be alerted.
Clinical Tips
- ERAS NPO: clear liquids 2 hours before — improves patient comfort, reduces dehydration, no increase in aspiration risk. Old "NPO after midnight" is outdated.
Summary
Preoperative assessment includes history, physical exam, risk stratification (ASA), NPO verification, consent confirmation, and patient preparation. Meticulous checklist completion prevents wrong-site surgery and complications.
