Abnormal findings may necessitate postponement of elective surgery.
- H&P exam determines readiness for surgery and establishes a pre-op baseline for comparison in OR and postoperatively.
- Pt may already have an H&P on record—This information should be reviewed and documented on pre-op record. Note: if H&P >30 days old, a new H&P should be completed by surgeon.
- Pre-op baseline exam includes age, height, weight, pain level, allergies, VS, ECG, systems assessment, lab, and diagnostic studies.
- Record baseline dermatome level, distal CSM, and neurological status for neurological surgeries and if receiving spinal anesthesia.
Components of a Complete Preoperative History
- Age of Pt: See Geriatric and Gerontological Considerations below.
- Last Oral Intake: See Fasting (NPO) Guidelines below.
- Allergies/Sensitivities: Drugs, skin preps, adhesives, latex, food.
- Current Medications: Rx, OTC, vitamins, herbs (see table below).
- Current Health Status: Recent cough, cold, illness, or injury.
- History: Medical and surgical history and treatment plans; prior anesthesia and response to anesthesia; family medical and surgical history (inquire about adverse reaction to anesthesia); recent weight loss or gains; mental illness; abuse; Hx of PTSD.
- Social History: Alcohol habits, drug use, smoking, vaping/e-cig; support system and living conditions; AD including code status.
- Implants and Piercings: Medical implants or devices (e.g., pacemaker, insulin pump, stimulators); dental implants (permanent or removable); jewelry or body piercings.
- Assistive Devices: Dentures, glasses/contacts, hearing aids, CPAP, walkers/canes/wheelchairs.
Geriatric and Gerontological Considerations
Older adult Pts (65 or older) must be assessed carefully for:
- Polypharmacy: Using multiple medications, from multiple providers, purchased at multiple pharmacies can lead to medication interactions, which can affect medication given perioperatively.
- Cardiac Status: Verify presence of a pre-op ECG; establish a baseline cardiac rhythm prior to surgery.
- Respiratory Status: Determine if Pt is having breathing difficulties, assess lung sounds, and establish baseline SpO2. Note if Pt on room air, on home oxygen, and if oxygen required to maintain SpO2 >92%.
- Cognitive and Sensory Status: Determine if Pt is capable of giving consent for surgery, if Pt understands risks and outcomes of surgery, and if Pt can demonstrate understanding of post-op teaching.
- Muscular Status: Determine Pt at risk for falls, especially after anesthesia and pain medication.
- Skin Status: Older adult Pts very often have decreased adipose tissue, which can lead to increased risk of hypothermia during surgery. They very often also have changes in epidermis, which can lead to risk of shearing injury to skin and delayed healing.
- Nutritional Status: D/t NPO status, Pt must be assessed carefully for dehydration before surgery.
- Laboratory Studies: Determine if decreased renal/hepatic function is noted in pre-op lab studies. Report all abnormal lab findings. Older adult Pts typically have decreased number of kidney nephrons and a decreased liver size; both affect how medications are metabolized.
- Chronic Conditions: Document all chronic conditions.
- Caregiver/Support: Pt may require post-op hospitalization if they have no caregivers or are unable to care for themselves after surgery. Ensure Pt has strong support system, and identify caregiver responsible for helping Pt with any care needs when returning home.