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Purpose of Pre-Operative Assessment
To identify, quantify and mitigate surgical risk; optimise the patient's physiological condition; establish informed consent; and ensure readiness for anaesthesia and surgery. The nurse's role spans coordination, holistic assessment and patient education.
Pre-Admission Clinic (PAC)
Primary setting for pre-op nursing assessment
- Conducted 14–21 days before elective surgery
- Allows time to act on any findings (anaemia, uncontrolled DM)
- Multidisciplinary: nursing, anaesthetist, surgeon, pharmacist
- Reduces day-of-surgery cancellations by up to 40%
- Includes patient education on fasting, medications, site prep
- Documents allergies, previous anaesthetic history, medications
Core Assessment Aims
Risk stratification, optimisation, preparation
- Risk stratification — identify high-risk patients early
- Physiological optimisation — correct anaemia, glucose, BP
- Medication review — omit, continue or bridge as appropriate
- Consent & education — ensure informed, prepared patient
- VTE prophylaxis — risk-score and prescribe LMWH/TED stockings
- Safeguarding — screen frailty, cognition, social support
📋 ASA Physical Status Classification
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E Suffix — Emergency surgery modifier. Add “E” (e.g., ASA II-E) when surgery is emergency. This increases operative risk independent of ASA grade.
⚙ Surgical Risk Categories
Low Risk
<1% 30-day MACE
- Superficial/skin procedures
- Endoscopy
- Cataract surgery
- Day-case breast biopsy
- Minor orthopaedic (carpel tunnel)
Intermediate
1–5% 30-day MACE
- Intra-abdominal (lap chole)
- Orthopaedic (hip/knee replacement)
- Head & neck surgery
- Prostate surgery
- Peripheral vascular
High Risk
>5% 30-day MACE
- Aortic/major vascular
- Oesophagectomy / whipple
- Major hepatic resection
- Thoracotomy
- Emergency/trauma surgery
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Nursing vs Anaesthetic Assessment — Key Distinction
Nursing pre-op assessment covers holistic history, medication reconciliation, fasting guidance, VTE risk scoring, patient education and coordination of investigations. The anaesthetic pre-op assessment specifically evaluates airway, cardiorespiratory reserve, risk of anaesthetic complications and choice of anaesthetic technique. Both are complementary and documented separately.
📋 Systematic Pre-Operative History
❤ Cardiac History ⌄
- IHD / angina: CCS class, last episode, stent/CABG history
- Heart failure: NYHA class, recent echo, EF, diuretic use
- Arrhythmias: AF (anticoagulated?), pacemaker/ICD present
- Hypertension: BP control, medications, end-organ damage
- Valvular disease: aortic stenosis = major perioperative risk
- Recent MI: <30 days = delay all but emergency; 30–90 days = very high risk
- Syncope / palpitations: investigate before elective surgery
🥈 Respiratory History ⌄
- COPD / asthma: current control, steroid use, nebulisers
- OSA: STOP-BANG score, CPAP use — high risk for airway management
- Recent URTI: postpone elective surgery for 4–6 weeks (bronchospasm risk)
- Smoking: pack-year history; cessation ≥8 weeks improves outcomes
- Exercise tolerance: exertional dyspnoea grading (MRC scale)
- Spirometry: essential for thoracic and major abdominal surgery
🦓 Renal & Metabolic History ⌄
- CKD: stage, baseline creatinine/eGFR — risk of AKI perioperatively
- Dialysis: schedule dialysis around surgery; electrolyte management critical
- Diabetes: type, HbA1c, insulin vs oral agents, hypoglycaemia awareness
- Thyroid disease: elective surgery postponed if uncontrolled hypo/hyperthyroid
- Adrenal insufficiency: steroid cover required perioperatively
- Electrolyte abnormalities: K+ <3.0 or >5.5 mmol/L = correct before GA
🥩 Haematological & Hepatic ⌄
- Anaemia: cause determines management (iron, B12, EPO); Hb <80g/L = optimise first
- Coagulopathy: haemophilia, von Willebrand disease — haematology input
- Sickle cell disease/trait: high prevalence in GCC; avoid hypoxia/dehydration
- Liver disease: Child-Pugh score; coagulopathy, varices, ascites all affect risk
- Previous DVT/PE: anticoagulation management, IVC filter consideration
🧠 Neurological History ⌄
- Previous CVA/TIA: recent (<3m) = postpone elective; antiplatelet review
- Epilepsy: continue anti-epileptic drugs; note drug interactions with anaesthetic agents
- Dementia/cognitive impairment: post-operative delirium risk — document baseline
- Parkinson's disease: do NOT omit dopaminergic drugs perioperatively
- Myasthenia gravis: specialist input; sensitivity to neuromuscular blockers
💊 Medication Review ⌄
- Anticoagulants (warfarin): bridge with LMWH if high thromboembolic risk; check INR; omit 5 days pre-op
- DOACs (apixaban, rivaroxaban): omit 24–48hr (normal renal function); 48–96hr if CKD
- Antiplatelets (aspirin): continue for cardiac stents; discuss with surgeon for high bleed risk
- Clopidogrel: omit 5 days pre-op unless drug-eluting stent within 12m
- Insulin/oral hypoglycaemics: VRIII decision; omit metformin on day of surgery
- SGLT2 inhibitors: omit ≥72hr pre-op (DKA risk even in type 2 DM)
- ACE inhibitors/ARBs: omit morning of surgery (hypotension risk on induction)
- Beta-blockers & statins: CONTINUE — abrupt cessation causes rebound ischaemia
- Herbal supplements: garlic, ginkgo, ginseng, St John's Wort — stop 2 weeks before (bleeding/interaction risk)
- OCP/HRT: stop 4 weeks pre-major surgery (VTE risk)
⚡ Functional Capacity (METs)
Poor (<4 METs) — High Risk
- Unable to climb one flight of stairs
- Cannot walk on level ground at 4km/h
- Light housework only
Fair (4–7 METs) — Intermediate
- Climb one flight without stopping
- Walk on level at 4–6 km/h
- Heavy housework, golf
Good (7–10 METs) — Low Risk
- Climb hill or stairs briskly
- Jog/swim moderately
- Singles tennis
Excellent (>10 METs)
- Strenuous sport (football, squash)
- Heavy manual labour
- Running >10 km/h
Airway Assessment
Anticipate difficult intubation
- Mallampati class I–IV: Class III/IV indicates difficult airway
- Mouth opening: <3 fingers (<4 cm) = restricted
- Thyromental distance: <6.5 cm = difficult laryngoscopy
- Neck movements: limited extension (arthritis, cervical collar, obesity)
- Jaw protrusion test: inability = difficult mask ventilation
- OSA: document CPAP settings; ensure available post-op
- Previous difficult intubation: alert anaesthetic team — plan B essential
- LEMON assessment used in emergency scenarios
Allergy & Anaesthetic History
Document formally — patient safety critical
- True drug allergy vs intolerance: document reaction type clearly
- Latex allergy: schedule first on theatre list; latex-free kit required
- Suxamethonium apnoea: pseudocholinesterase deficiency — family history
- Malignant hyperthermia (MH): triggered by volatile anaesthetics; autosomal dominant; potentially fatal; requires MH-free anaesthetic (TIVA)
- Previous PONV: antiemetic prophylaxis plan required
- Previous awareness: document and communicate to anaesthetic team
- Contrast dye allergy: pre-medication (steroids + antihistamine) if imaging required
🔬 Routine Pre-Operative Investigations
Haematology & Biochemistry
- FBC: screen for anaemia (Hb), thrombocytopaenia, polycythaemia — indicated for intermediate/major surgery
- U&E / Creatinine / eGFR: baseline renal function; essential if on diuretics, ACEi, nephrotoxic drugs, or DM/HTN
- LFTs + Albumin: liver disease, nutritional status, drug metabolism; low albumin = poor healing risk
- Coagulation screen (PT/INR, APTT): patients on anticoagulants, liver disease, major surgery
- Group & Save (G&S): all intermediate/major surgery; crossmatch if >500ml blood loss anticipated
- HbA1c: all diabetic patients; target <8.5% (69 mmol/mol) for elective surgery
- Fasting glucose: day of surgery target 6–10 mmol/L
Cardiac & Imaging Investigations
- ECG indications: age >40 (NICE), known cardiac disease, HTN, DM, high-risk surgery
- Echocardiogram: unexplained dyspnoea, known HF, significant murmur, valve disease, poor functional capacity pre-major surgery
- CXR indications: not routine; indicated for known cardiac/respiratory disease, recent URTI requiring imaging, abnormal clinical findings — NOT age alone
- Stress testing/cardiopulmonary exercise testing (CPET): poor functional capacity (<4 METs) pre-major surgery to quantify risk
- Lung function (spirometry): thoracic surgery (all), major abdominal surgery with respiratory symptoms, smoking history with dyspnoea
🌍 GCC-Specific Investigations
🏭 Sickle Cell Screening — GCC Relevance
- Sickle cell trait (HbAS) prevalence 2–25% in Gulf Arab, Omani & East African populations
- Sickle cell disease (HbSS) less common but present in GCC national populations
- Screening: HPLC or Hb electrophoresis for all Gulf national patients prior to GA if not previously screened
- Perioperative risk: avoid hypoxia (SpO2 <95%), hypothermia, dehydration, acidosis — all precipitate sickling
- Trait (HbAS): generally low risk; disease (HbSS): may need exchange transfusion pre-major surgery to reduce HbS <30%
- Many GCC institutions mandate sickle cell screen on pre-op form for nationals
🔔 Pregnancy Testing — GCC Policy
- Beta-hCG (urine or serum) mandatory for all women of reproductive age (12–55 years) prior to elective GA in most GCC hospitals
- JCI and CBAHI standards require documentation of pregnancy status
- Positive result: postpone all elective surgery; obstetric review; consent complexities
- Emergency surgery: multidisciplinary decision with obstetric input; fetal monitoring
- Document patient's knowledge of result and consent; cultural sensitivity required in GCC context
- Testing repeated if >2 weeks since last test at time of surgery
📋 Investigation Selection by ASA & Surgery Risk
✅ Fasting Guidelines (ERAS Protocol)
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ERAS (Enhanced Recovery After Surgery) — Standard GCC Hospitals Outdated “nil by mouth from midnight” practice is replaced by evidence-based fasting that maintains patient comfort, reduces insulin resistance and improves outcomes.
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High Aspiration Risk Exceptions — Maintain Standard NPO (8hr solids / 2hr fluids): Morbid obesity, known GORD, hiatus hernia, diabetes with gastroparesis, opioid use, recent trauma, acute abdominal pathology. Anaesthetist to assess individually.
💉 VTE Risk Assessment & Prophylaxis
Caprini / NICE VTE Risk Scoring
Complete for every surgical admission
- Age 41–60 = 1pt; 61–74 = 2pt; ≥75 = 3pt
- Surgery >45 min = 2pt; elective arthroplasty = 5pt
- Active malignancy = 3pt; previous VTE = 3pt
- BMI >25 = 1pt; immobility (<72hr ambulation) = 1pt
- Oral contraceptive/HRT = 1pt; pregnancy/post-partum = 1pt
- Inherited thrombophilia = 3pt; stroke/TIA = 5pt
- Score 0–1 = low; 2 = moderate; 3–4 = high; ≥5 = very high
VTE Prophylaxis Recommendations
- Low risk: early mobilisation only; encourage hydration
- Moderate risk: TED stockings (knee-length, fitted) + LMWH post-op
- High risk: TED + LMWH + pneumatic compression devices (IPCDs)
- LMWH (Enoxaparin 40mg SC OD) — commence 6–12hr post-op if haemostasis achieved
- Spinal/epidural: LMWH minimum 12hr before needle insertion; 4hr after catheter removal
- Duration: abdominal cancer surgery = 28 days LMWH; hip/knee = 14–35 days
- Contraindications to LMWH: active bleeding, heparin-induced thrombocytopaenia (HIT), severe thrombocytopaenia
👴 Pre-Operative Nursing Checklist Tasks
1Consent verification
2Site marking
3CHX wash
4Fasting confirmed
5Allergy wristband
6IV access
7VTE score documented
8Medications reviewed
9Investigations filed
10WHO briefing ready
Site Marking Protocol
- Mark by the operating surgeon (not nurse alone — unless delegated by policy)
- Use indelible marker; site must survive antiseptic skin prep
- Patient actively involved and confirms correct side/site
- Required for: laterality (left/right), level (spine), digit, organ (kidney)
- NOT required for: midline structures, single-organ cases with no laterality ambiguity
- Document in pre-op checklist and WHO Surgical Safety Checklist
Pre-Op Shower / Antiseptic Wash
- Chlorhexidine gluconate (CHX) 2–4% wash recommended night before AND morning of surgery
- Reduces SSI (surgical site infection) rates — NICE NG125 recommendation
- Provide patient with impregnated wipes or shower gel with instructions
- Hair removal: electric clipper only (NOT razor — micro-abrasions increase SSI risk)
- Remove nail polish (oximetry accuracy) and jewellery (diathermy burns)
- Dentures: remove before theatre unless general/regional anaesthesia policy varies
Nursing Role in Consent Process
Facilitator, witness and advocate — NOT the consenting clinician
- Nurse confirms consent form signed before premedication
- Witness to signature only — does NOT consent on behalf of surgeon
- Provide patient information leaflets in appropriate language (Arabic/Urdu/English)
- Verify patient understands procedure, risks and alternatives
- For patients lacking capacity: ensure Power of Attorney or next of kin involvement documented per local jurisdiction (UAE/KSA/Qatar law differs from UK)
- Children: parental/guardian consent; Gillick competence not applicable in most GCC jurisdictions
- Emergency: document best-interests decision with senior clinician co-signature
⚙ Diabetes Perioperative Optimisation
Glucose Management Goals
Perioperative target: 6–10 mmol/L (JBDS Guidelines)
VRIII (Variable Rate Insulin Infusion) Decision
- VRIII indicated if: fasting >1 meal; poorly controlled DM (HbA1c >8.5%); T1DM undergoing any surgery; T2DM on insulin undergoing major surgery
- Not required for T2DM on diet/oral agents having minor surgery if glucose controlled
- Glucose monitoring: 1–2 hourly perioperatively
- Hypoglycaemia (<4mmol/L): follow hypoglycaemia protocol; 150ml 10% glucose IV
Medication Guidance
- Metformin: omit on day of surgery (lactic acidosis risk + AKI); restart when eating and renal function confirmed normal
- SGLT2 inhibitors: STOP ≥72hr pre-op — risk of euglycaemic DKA perioperatively even in T2DM
- Sulphonylureas: omit morning of surgery (hypoglycaemia risk)
- Long-acting insulin: reduce by 20% the night before — do not omit entirely in T1DM
- HbA1c >10% (>86 mmol/mol): refer for glycaemic optimisation before elective surgery
Cardiac Optimisation
- Beta-blockers: CONTINUE perioperatively — abrupt withdrawal causes rebound tachycardia and ischaemia; titrate to HR 60–80
- Statins: CONTINUE — pleiotropic cardioprotective effect; withdrawal increases peri-op MI risk
- Revascularisation: if severe coronary disease found pre-op, consider PCI/CABG before major elective surgery; discuss with cardiology
- Heart failure: optimise with diuretics; target dry weight; liaise with cardiology for BNP/Echo
- Pacemakers/ICDs: device check required; reprogram before surgery; magnet available in theatre
- Aspirin: continue for secondary prevention in most; discuss with surgeon for high-bleed surgery
Anaemia Optimisation
- Pre-op anaemia target: Hb >100g/L for elective surgery; >80g/L minimum for urgent cases
- Iron deficiency anaemia: IV iron preferred when <6 weeks to surgery; oral iron if >6 weeks
- IV iron timing: ferric carboxymaltose at least 14 days before surgery for response; response seen in 3–4 weeks
- B12/folate deficiency: replace; response slower than iron
- Erythropoietin (EPO): used in renal anaemia or Jehovah's Witness cases
- Cell salvage: intra-operative option for major surgery to reduce allogenic transfusion
Paediatric Pre-Op Nursing
- Fasting: clear fluids 1hr (<1yr) / 2hr (>1yr); breast milk 4hr; formula/solids 6hr
- Parental presence at induction: encouraged in most GCC hospitals; reduces child anxiety significantly
- Premedication: midazolam oral 0.5mg/kg (max 10mg) for anxious children if policy allows
- EMLA/Ametop cream applied to cannula sites 45–60min pre-procedure
- Weight-based medication calculations — use Broselow tape or WETFLAG aide
- Parental consent essential; child assent encouraged from age ~7 in GCC practice
- Post-op: parental presence in recovery per unit policy; pain assessment tools (FLACC <3yr; Faces >3yr)
Frailty Assessment
Clinical Frailty Scale (CFS) — Rockwood 1–9
- CFS 1–2: Very fit / well — routine perioperative management
- CFS 3–4: Managing well / vulnerable — enhanced recovery, early physio
- CFS 5–6: Mildly/moderately frail — proactive delirium prevention, occupational therapy input, nutritional assessment
- CFS 7–9: Severely frail / terminally ill — goals of care discussion; consider DNACPR; enhanced post-op monitoring
- CFS ≥5 = increased risk of post-op delirium, prolonged LOS, functional decline, 30-day mortality
- Screen all patients ≥65yr; document CFS in pre-op notes
Obese Patient Considerations (BMI >35)
High-risk category requiring structured pre-op planning
- BMI >40 = High anaesthetic risk (difficult airway, OSA, LV dysfunction)
- STOP-BANG score for OSA; if positive ≥5, overnight oximetry or sleep study
- Specialist bariatric team referral if BMI >50 for major elective surgery
- VTE risk significantly elevated — LMWH dose adjustment (weight-based)
- Positioning challenges: specialist theatre table weight rating >250kg; pressure care
- Blood pressure cuffs: use large-size or thigh cuff for accuracy
- Gastric emptying delayed: high aspiration risk — RSI technique often preferred
- Post-op HDU/ICU monitoring likely for BMI >50 post-general/major surgery
Smoking Cessation
Evidence-based timing for pre-op benefit
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4–8 hours CO normalises; carboxyhaemoglobin falls — tissue oxygenation improves slightly
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4–6 weeks Wound healing and immune function begin improving; sputum volume decreases
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8 weeks+ Optimal: pulmonary function improved; SSI and respiratory complication risk significantly reduced
Referral to smoking cessation services should occur at pre-admission clinic. NRT/varenicline options documented. Do not withhold surgery purely due to smoking but document risk and counsel appropriately.
Anticoagulation Bridging Protocols
High Thromboembolic Risk — Bridge required
- AF with CHADS2-VASc ≥5; mechanical heart valve (mitral); VTE within 3m
- Stop warfarin 5 days pre-op; bridge with therapeutic LMWH from day 3; last dose 24hr pre-op
- Restart warfarin post-op when haemostasis achieved; therapeutic LMWH until INR therapeutic
Low Thromboembolic Risk — No bridge needed
- AF with CHADS2-VASc <4; bioprosthetic valve; VTE >12m ago
- Stop warfarin 5 days pre-op; no bridging; restart post-op when safe
- DOACs: simply omit 24–48hr (or 48–96hr if CKD); no bridging required
🌍 GCC-Specific Clinical Considerations
🧠 High Diabetes Prevalence
- GCC region has among the highest DM prevalence globally (KSA ~18%, UAE ~16%, Kuwait ~21%)
- Pre-op HbA1c >8.5% is common; structured optimisation pathways essential in all GCC hospitals
- T2DM on insulin more common than in Western populations — VRIII protocols widely applied
- Complications: nephropathy, retinopathy, neuropathy, gastroparesis — all affect peri-op management
- DM-related cardiac risk: GCC patients often present with CAD at younger age (4th decade)
- Mandatory HbA1c on all pre-op forms in JCI-accredited GCC hospitals
⚖ High Obesity Rates
- GCC countries have some of the world's highest obesity prevalence; BMI >35 routinely encountered in PAC
- Bariatric surgery is the most common elective procedure in many GCC private hospitals
- Specialist bariatric pre-op pathways mandatory for BMI >50
- OSA prevalence very high — CPAP provision post-op, HDU monitoring protocols in place
- VTE risk compounded by sedentary lifestyle and high temperatures (dehydration)
- Weight-based LMWH dosing (0.5mg/kg enoxaparin BD for BMI >40) more common than standard 40mg dose
🏭 Sickle Cell Disease in Gulf Populations
- Trait prevalence in Omani, Saudi, Bahraini and Eastern Province populations up to 25%
- Many patients unaware of trait status — pre-op screening critical
- Perioperative sickling triggered by: hypoxia, hypothermia, acidosis, dehydration, tourniquet use
- HbSS disease: exchange transfusion may be required pre-major surgery; haematology co-management
- Intraoperative: maintain warm theatre, generous IV fluids, SpO2 >95% at all times
- Post-op: supplemental oxygen, early mobilisation, adequate analgesia to prevent splinting
☁ Ramadan — Surgical Scheduling
- Muslim patients may refuse surgery during Ramadan even if medically indicated — respect and document decision
- ERAS fasting guidelines adapt: Suhoor (pre-dawn meal) = equivalent to “last solid food”; schedule surgery for early morning list
- Patient able to take essential medications with <30ml water — does not break fast in most scholarly interpretations
- IV fluids and medications given during fasting hours are generally permissible per Islamic jurisprudence (fatwa) for medical necessity
- Chaplaincy/imam consultation available in many GCC hospitals for individual rulings
- Elective cases: offer Ramadan-friendly scheduling; fasting timing confirmed the day before surgery
💊 GCC Cardiac Risk Profile
- MI presentation common in patients under 45 years in GCC (young MI syndrome — often related to DM/smoking/FH)
- High prevalence of premature CAD means ASA II–III common in younger patients than in Western pre-op populations
- ECG and functional assessment should not be guided by age alone in GCC — DM/HTN/smoking thresholds lower
- Cardiac biomarkers (troponin) should be requested if clinical suspicion of recent ACS pre-op
- Lipid profiles: high triglycerides and low HDL pattern common in Gulf Arab population
📢 JCI / CBAHI Regulatory Standards
- JCI (Joint Commission International) — most private and tertiary GCC hospitals are accredited
- CBAHI (Saudi Arabia), JCI-MENA, HAAD (Abu Dhabi), DHA (Dubai) — regulatory variations per emirate/country
- Mandatory pre-op elements: history & physical within 30 days (updated <24hr if >30d); signed consent; fasting status documentation; site marking; WHO checklist completion
- Arabic interpreter service must be documented as available for all non-Arabic-speaking staff managing Arabic-speaking patients (and vice versa)
- Pre-op nursing assessment must be documented separately from medical assessment per JCI FMS standards
- Beta-hCG documentation: results must be in notes before GA induction per JCI standards
🏠 Day-Case Surgery Expansion in GCC
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GCC Private Sector Trend: Day-case surgery as a proportion of elective procedures is rapidly increasing across UAE, Qatar and KSA private hospitals, driven by payer (insurance) pressures and ERAS adoption. Nurses must apply day-case selection criteria rigorously.
Day-Case Suitable Criteria
- ASA I–III (stable); BMI <40 (hospital policy varies)
- Responsible adult escort and home carer for 24hr
- Within 1hr drive of hospital (emergency return)
- Telephone contact available post-op
- Compliant, understanding patient with adequate home conditions
- Procedure <2hr; minimal blood loss anticipated
Exclude from Day-Case
- Uncontrolled DM (HbA1c >10%), severe OSA without CPAP
- Unstable cardiac disease, recent MI (<6m)
- Lives alone; no responsible carer
- Language barrier with no interpreter at home
- Opioid-dependent (PONV and respiratory monitoring needed)
- Complex wound/drain requiring in-patient nursing care