Procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [152], C).
2. 2.Show
   Discuss with the patient:

   • if they know what surgery they are having and why
   • if they can tell you about the wound, any intravenous infusions or drains, etc. that they may expect after the surgery
   • if they have been told about levels of pain and how it will be controlled
   • how they can be involved in ensuring they recover as quickly as possible.
   To ensure that the patient understands the nature and outcome of the surgery, to reduce anxiety and possible post‐operative complications (Turunen et al. [205], E).
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   Check that the patient has undergone relevant investigative procedures and that the results are included with the patient's notes. Examples include X‐ray, ECG, MRI, CT, ECHO, blood test and urinalysis.
   To ensure all relevant information is available to the nurses, anaesthetists and surgeons (AORN [17], C).
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   Confirm and document when the patient last had food or drink, ensuring that this complies with pre‐operative instructions. Record this in the pre‐operative documentation.
   To reduce the risk of regurgitation and inhalation of stomach contents on induction of anaesthesia. It can take 9 hours or more for a substantial meal to be emptied from the stomach (AAGBI [5], C; King [90], C; RCN [172], C).
5. 5.Show
   Confirm and document which medications the patient has taken and when. Ensure this complies with pre‐operative instructions and record in the pre‐operative documentation.
   To ensure the patient does not take and/or omit any medication that could adversely affect surgery (e.g. continuation of high‐dose warfarin). E
6. 6.Show
   If the patient is female and of child‐bearing age:
    
   1. Check her pregnancy status and record the result in the pre‐operative documentation. If a pregnancy test is required (e.g. if the patient expresses a concern that she may be pregnant or she is undergoing gynaecology surgery) (NICE [144]), the test results should be given to the patient and record in the pre‐operative documentation.
   To eliminate the possibility of unknown pregnancy prior to the planned surgical procedure (NPSA [156], E).

   b.	If appropriate, ask the patient whether she is menstruating and ensure that she has a sanitary towel in place and not a tampon.

   To prevent infection if the tampon is left in place for longer than 6 hours (www.tamponalert.org.uk, C).
7. 7.Show
   In the presence of the patient, check the consent form is correctly completed, signed and dated.
   To comply with legal requirements and hospital policy and to ensure that the patient has understood the surgical procedure (NMC [152], C).
8. 8.Show
   If applicable, check the operation site has been marked correctly with the patient and the consent form.
   To ensure the patient undergoes the correct surgery for which they have consented (AORN [17], C; Schäfli‐Thurnherr et al. [183], R).
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   Check that the patient has undergone pre‐anaesthetic assessment by the anaesthetist.
   To ensure that the patient can be given the most suitable anaesthetic and that any special requirements for anaesthetic have been highlighted (AORN [17], C).
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    Measure and record the patient's pulse, blood pressure, respirations, oxygen saturations, temperature, weight and blood sugar (if required) in the pre‐operative documentation.
    To provide baseline data for comparison intra‐ and post‐operatively. The weight is recorded so that the anaesthetist can calculate the correct dose of drugs to be administered (AORN [17], C).
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    Ask the patient to remove all jewellery, cosmetics and nail varnish. Wedding rings may be left on fingers but must be covered and secured with hypoallergenic tape. Patients requesting to wear other forms of metal jewellery (e.g. chains) for personal or religious reasons will need to discuss this with the operating team.
    Metal jewellery may be accidentally lost or may cause harm to the patient. Facial cosmetics make the patient's colour difficult to assess. Nail varnish makes the use of the pulse oximeter (which monitors the patient's pulse and oxygen saturation levels) impossible and masks peripheral cyanosis (Vedovato et al. [210], C).
12. 12.Show
    If the patient has valuables, these must be recorded and stored away securely according to hospital policy.
    To prevent loss of valuables. E
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    Ensure the patient has showered or bathed as close to the planned time of the operation as possible and before a pre‐medication is administered (if this has been prescribed). If the patient has long hair, this needs to be tied back with a non‐metallic tie.
    To minimize the risk of post‐operative wound infection (Loveday et al. [110], C).

    For safety, to prevent hair getting caught in equipment and to reduce the risk of infection. E
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    Apply antiembolic stockings according to local trust procedure (see Procedure guideline 16.1: Measuring and applying antiembolic stockings)
    To reduce the risk of post‐operative deep vein thrombosis or pulmonary emboli (NICE [148], C).
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    Ensure the patient is wearing two electronic/barcoded name bands containing their full name, date of birth and NHS number. One should be placed on the patient's wrist and the other on the ankle. Prior to placing the name bands on the patient, the details should be verbally checked and confirmed as accurate by the patient and against the patient's medical notes. The name bands should be white unless local trust policy stipulates that colour coding is necessary to alert healthcare professionals to a risk (e.g. allergy), in which case the wristbands should be red (NPSA [155]).
    To ensure correct identification and prevent possible patient misidentification (AORN [17], C).

    To reduce allergic reactions to known causative agents and to alert all involved in the care of the patient in the operating theatre (AORN [19], C).
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    Record whether the patient has dental caps, crowns, bridge work or loose teeth in the pre‐operative checklist.
    The anaesthetist needs to be informed to prevent accidental damage. Loose teeth or a dental prosthesis could be inhaled by the patient when an endotracheal tube is inserted. E
17. 17.Show
    Document any patient prostheses in the pre‐operative checklist and whether they are removable (e.g. artificial limb, dentures or hearing aid) or irremovable (e.g. pacemaker or knee replacement). Removable prostheses may be retained until the patient is in the anaesthetic room. Spectacles and hearing aids may be retained until the patient has been anaesthetized (these may be left in position if a local anaesthetic is used). Any prosthesis that is removed should be labelled clearly (ideally with a patient identifier) and retained in the recovery room.
    To promote patient safety during surgery. For example, dentures may obstruct the airway and contact lenses can cause corneal abrasions. Internal non‐removable prostheses may be affected by the electric current used in diathermy. C

    To enable the patient to communicate fully, thus reducing anxiety and enabling the patient to understand any procedures carried out. E

    To enable patients with prosthetic limbs to mobilize independently to theatre. C
18. 18.Show
    Check whether the patient passed urine before pre‐medication or anaesthetic.
    For patient comfort and because a full bladder may impede the surgeon's view during abdominal surgery. To prevent catheterization. To prevent urinary incontinence when sedated and/or unconscious and possible contamination of sterile area. E
19. 19.Show
    Once the pre‐operative checklist has been fully completed, administer any pre‐medication, if prescribed, in accordance with the anaesthetist's instructions. Patients who receive a sedative pre‐medication should be advised to remain in bed and to use the nurse call system if assistance is needed.
    Specific drugs may be prescribed to complement the anaesthetic to be given (e.g. temazepam to reduce patient anxiety by inducing sleep and relaxation). E

    Questioning premedicated patients is not a reliable source of checking information as the patient may be drowsy and/or disorientated (AfPP [9], C).

    To reduce the risk of accidental patient injury as the pre‐medication may make the patient drowsy and disorientated. E
20. 20.Show
    Accompany the patient to theatre, taking with you their notes, medication chart, X‐rays/scans, blood results, completed consent form and pre‐operative checklist. The patient should be accompanied to the theatre by a qualified nurse. Mobile patients who have not received a sedative pre‐medication will be able to walk to theatre wearing appropriately fitting footwear. Immobile patients or patients who have received a sedative pre‐medication will need to be taken to theatre on a theatre trolley.
    To prevent delays, which can increase the patient's anxiety, and to ensure that the anaesthetist and surgeon have all the information they require for safe treatment of the patient. E

    To reduce patient anxiety and ensure a safe environment during anaesthetic induction. E

    To reduce the risk of accidental patient injury as pre‐medication may make a patient drowsy and disorientated. E
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    Give a full handover to the anaesthetic nurse or operating department practitioner on arrival in the anaesthetic room, using the patient's records and the pre‐operative checklist. Stay with the patient until they have been fully checked in by the anaesthetic assistant or nurse.
    To ensure the patient has the correct operation. To ensure continuity of care and to maintain the safety of the patient by exchanging all relevant information (AfPP [9], C).