Pre-operative
Aim
The main aim of preoperative counseling is to reduce patient anxiety, enhance understanding, and
improve surgical outcomes by preparing patients mentally, emotionally, and physically for their
procedure. It is a critical component of patient-centered care that helps align a patient’s
expectations with the clinical reality of their surgery. To ensure the consistent delivery of
benchmarked best practice standards to pre and post- operative patients it’s mandatory.
Key points
Key aims and objectives of preoperative counseling
◦ Informational and educational aims
• Provide accurate information: Counselors explain the details of the surgical
procedure, anesthesia, potential risks, and complications using clear, jargon-free language. This
directly addresses the fear of the unknown, a major source of anxiety.
• Educate on the perioperative process: The session informs patients and their
caregivers about the hospital protocols, the role of the surgical and anesthesia teams, and what to
expect before, during, and after the operation.
• Familiarize the patient with the environment: For some procedures, especially those
involving regional anesthesia, familiarizing a patient with the operating theater environment can
make the experience less intimidating.
• Set realistic expectations: By discussing expected outcomes, benefits, and
potential postsurgical issues like pain or disability, counseling helps manage expectations and
reduces the risk of disappointment with the results.
◦ Psychological and emotional aims
• Alleviate fears and anxiety: This is a primary goal, as high preoperative anxiety can
negatively impact physiological functions, increase pain sensitivity, and prolong hospital stays.
• Provide emotional support: The session offers an empathetic space for patients to
express concerns and receive reassurance. This strengthens trust between the patient and the
healthcare team.
• Improve coping abilities: Patients are given information and techniques to help
manage stress and cope with the surgical experience, especially when facing postsurgical
changes such as body disfigurement.
• Promote active participation: By encouraging questions and ensuring
comprehension, counseling empowers patients to become active participants in their own care
and recovery.
◦ Clinical and logistical aims
Obtain truly informed consent: Counseling ensures that consent is given based on a thorough
understanding of the procedure, not coercion or lack of information.
Facilitate faster recovery: Well-informed patients are more likely to follow postoperative
instructions and rehabilitation protocols, which can lead to faster mobilization and recovery times.
Reduce postoperative pain: By understanding pain management strategies beforehand, patients
can better cope with and communicate their pain, leading to better control and reduced need for
medication.
Enhance patient satisfaction: An overall improved surgical experience, better pain control, and
reduced anxiety contribute to higher patient satisfaction.
Shorten hospital stays: Multiple studies indicate that effective preoperative counseling can
contribute to a shorter length of hospital stay, reducing overall healthcare costs.
Prevent and identify complications: Educating patients and their caregivers on the early signs of
complications (like infection or thromboembolism) can lead to prompt intervention and reduce
severe issues.
Key PointsConsent:
1. Surgical procedures (other than in an emergency) performed under any kind of
anaesthesia and intravenous sedation, require the patient’s explicit consent sought and
documented.
2. The health practitioner ultimately responsible for providing treatment (e.g. lead
surgeon) must be satisfied that the consent process has been properly undertaken and the patient
has reached a decision to provide or withhold consent to the proposed treatment
3. The nurse / midwife shall check that a valid consent is present in the patients’
medical records prior to administering any pre medications. If there is a discrepancy, medical
team and perioperative coordinator shall be notified immediately.
4. For patients lacking capacity to consent: Check that a copy of Enduring Power of
Guardianship is present in the notes with the consent (where relevant).
5. Only when all aspects of consent are satisfied can the patient be given a
premedication or be transferred to theatre.
Enhanced recovery programmes
Offer an enhanced recovery programme to people having elective major or complex surgery.
Use an enhanced recovery programme that includes preoperative, intraoperative and
postoperative components.
Fasting :
is necessary prior to sedation or general anaesthesia to minimise the risk of regurgitation and
pulmonary aspiration. When emergency surgery is required, patients may sometimes undergo
general anaesthesia unfasted with appropriate precautions taken by the anaesthetic team.
Managing fluids
Oral fluids
Tell people having surgery,
• they may drink clear fluids until 2 hours before their operation
• drinking clear fluids before the operation can help reduce headaches, nausea and
vomiting afterwards
• clear fluids are water, fruit juice without pulp, coffee or tea without milk and ice
lollies.
• Consider carbohydrate drinks before surgery for people having abdominal major or
complex surgery.
Intravenous fluids
Consider using intravenous crystalloid for intraoperative fluid maintenance.
Identification:
Patients undergoing a surgical procedure must have patient identification bands in situ.
Special attention:
◦ All items of metal shall be removed (i.e. jewellery, body piercing, hairclips). Any
items that cannot be removed shall be covered with adhesive tape.
◦ Hearing aids may be left in situ.
◦ Dentures may remain in situ unless specified by the anaesthetist.
◦ Glasses or contact lenses shall be removed prior to transfer to operating theatre.
◦ All patients under 50 years of age who are scheduled for intrauterine surgery or a
hysterectomy shall have a pregnancy test prior to going to theatre. Exceptions to this are women
with pregnancy failure.
Procedure
1. Fully complete the surgical safety checklist.
2. Ensure any results from pathology or X-ray are available.
• Ensure the consent form has been completed and signed by the patient and
medical officer. Check the consent with the patient against the consent form to confirm that theconsent fulfils the following criteria: Verification that patient details (name, date of birth, UMRN)
are the same on the consent form and the patient identification band
• Specific to the proposed procedure
• Valid: Consent is considered valid until the patient withdraws consent or the
proposed treatment is no longer appropriate due to a change in the patient’s circumstances.
• Ensure the patient has correct identification bands secured. These bands shall not
interfere with the IV access site and must be placed on top of graduated compression stockings.
• Ensure the patient has fasted as per Anesthetic Clinical Guidelines.
• Assess: Pressure injury risk
• Complete Falls Risk Assessment and Management Plan
• Caesarean patients- complete the risk assessments within the Postnatal Pathway.
• Ensure assessment of the patient’s risk for venous thromboembolism (VTE).
According to medical staff instructions, commence VTE prophylaxis.
• Record the patient’s baseline vital signs; temperature, weight and height on the
Preoperative Perioperative Checklist
• Request / assist the patient to remove eye make-up and nail varnish. If the patient
has acrylic nails, they may be left on.
• Complete the pre-operative hair clip. Shaving hair is strongly discouraged- the use
of razor blades has been shown to lead to an increase in the incidence of surgical site infection.
Hair removal with clippers was found to be safer and resulted in a lower incidence of surgical site
infections than shaving with a razor blade regardless of the timing of hair removal
• Avoid routine hair removal- if circumstances necessitate, clip on the day of surgery
or as close as possible to the time of operation. Hair removal should occur outside of the
operating theatre.
• Provide an explanation to the patient and obtain verbal consent.
• Assess the operation site. Document the presence of lesions such as moles, warts
or other skin conditions in the medical notes. When preparing the operative site, give
consideration to the length of the incision, potential drains etc.
• A single-use disposable clipper blade shall be used for each patient and disposed
of after use in a sharps container.
Area to be clipped General gynaecology
Laparoscopy / minor surgery Clip 2.5cm of pubic hair proximal to umbilicus – include any long
hair in area of incision
Vaginal surgery Clip vulval/perineal area only (not abdominal pubic hair)
Major abdominal surgery Remove all visible pubic hair with patient supine and legs closed
Minimal invasive sling Remove all visible abdominal, pubic and perineal hair
Major oncology
Vaginal surgery Remove all vulval/perineal hair and through to mid-thigh and excessive hair
on inner thigh. Clip long pubic hair.
Plus Gracillus graft Remove all hair to mid-thigh
Abdominal surgery Remove all visible pubic hair with patient supine and all hair from
anticipated area of incision
Possible Gracillus graft surgery Remove all hair to mid-thigh
Obstetrics
Caesarean See Caesarean Birth guideline. Remove excess pubic hair only as required for the
incision just prior to surgery.
• Procedure
• Ensure the patient has showered and not applied creams, deodorants or perfumes
prior to admission.
• For patients undergoing a caesarean section, a 2% chlorhexidine wash cloth
should be used.
• Wipe the operative area in a back and forth motion to thoroughly cleanse the skin
• The area closest to pubis to be left last
• Pay careful attention to skin folds and in abdominal creases
• Let air dry
• Do not rinse
• Do not use on patients with a chlorhexidine allergy
• Request / assist the patient into perioperative attire.
• Ensure the patient is warm and supply blankets as required.• Request the patient to empty their bladder prior to surgery. Record the last void on
the Preoperative Perioperative Checklist
• Administer premedication as charted. Once given, advise the patient to remain in
bed, raise the bedrails and ensure that the nurse call bell is within reach.
• Collect the patient admission pack and escort them to theatre.
Post-operative
Aim: The aim of postoperative counseling is to facilitate a complete and smooth recovery by
addressing the patient’s physical, emotional, and psychological needs after a surgical procedure.
It provides patients and their families with the necessary information and support to manage the
recovery process, minimize complications, and improve overall well-being.
• Key objectives of postoperative counseling
• Prevent and manage complications: Patients are educated on the signs of potential
complications, such as infection or blood clots, and what steps to take if they occur. The goal is
to detect and address issues early to prevent them from becoming more serious.
• Empower patients for self-care: Counseling provides clear, detailed instructions on
how to manage wound care, medication schedules, and dietary recommendations after
discharge. This equips patients to take an active role in their own recovery, which leads to better
outcomes and increased satisfaction.
• Manage pain and discomfort: Counselors work with patients to create an effective
pain management plan, which can include medication, relaxation techniques, and physical
therapy. Effective pain control is crucial for promoting comfort, mobility, and healing.
• Provide emotional and psychological support: It is common for patients to
experience anxiety, frustration, or depression during recovery. Counseling addresses these
emotional challenges, helping patients and their families cope with the stress of surgery and its
aftermath.
• Set realistic expectations: Patients are guided to understand what to expect during
recovery, including typical timelines for regaining strength and mobility. This helps manage
frustration and promotes a positive mindset by celebrating small victories.
• Guide long-term rehabilitation: For surgeries that require it, counseling helps
patients understand and commit to their rehabilitation plan. This may involve setting goals for
physical therapy, mobility, strength building, and a gradual return to normal activities.
• Improve long-term outcomes and quality of life: By addressing the full spectrum of
physical and mental health issues, postoperative counseling improves the chances of a
successful long-term recovery and enhances the patient’s overall quality of life.
Key Points:
Day surgery patients
Acceptance to the Day Surgery Unit (DSU) is subject to the patient having met the requirements
for discharge from the Post-Anaesthetic Care Unit (PACU).
• Confirm the patient’s identity .Also check the baby’s ID labels prior to leaving
PACU.
• Review the Operation Report. Review postoperative orders
• Review the ongoing orders for analgesia, intravenous hydration, indwelling catheter
(IDC) etc.
• Check the epidural/opiate infusion pump program as ordered and check the rate
infusing and the rate prescribed are correct.
• Check all dressings, drains, IV therapy and observations. Check all IV/arterial/
epidural/naso-gastric lines are labelled appropriately.
• Clarify any concerns before leaving the area.
• Following iSoBAR clinical handover the PACU nurse / midwife and the ward nurse /
midwife must sign the handover section of Handover to Recovery/Ward
• The patient is transported to the ward area on their bed. Bedrails should be
engaged during transportation. Ensure any prosthetic items are with the patient e.g. glasses, false
teeth, hearing aid.
Ward patientsOn the ward – prepare the room
1. Check the oxygen and suction is working correctly and that all equipment is
present before collecting the patient.
2. Ensure an IV stand is available.
3. Place the additional following equipment in the patient’s room: Continence sheet;
Perineal pads
4. Emesis container
5. Water jug, glass
6. Jug to empty IDC
On return to the ward
• Return the patient to the room, position appropriately, ensure brakes are on
• Hang the IV, IDC and drains as required
• Remove any under sheets and check vaginal loss
• Check the epidural site and all dependent pressure areas
• Complete the Falls Risk Management .
• Perform baseline observations
1. Initial checks:
• Ensure all documentation is complete. Complete relevant care plan
• Check the: Medication chart for analgesia.
• Post op Nausea and Vomiting
• Ensure dentures and medical records are returned to the ward with the patient.
• Position the patient according to the surgical procedure performed. Recheck and
document all sites/dressings/drains.
• Ensure water, emesis container and the patient’s bell are accessible to the patient.
• Empty IDC/SPC and observe drainage on drainage bottles. Mark drainage at 2400
hours.
Care following surgery: Gynaecology, oncology or urogynaecology
1. Respiratory system – atelectasis, pneumonia, hypoxia, pulmonary embolism.
2. Cardiovascular system – haemorrhage, hypovolaemic shock, thrombophlebitis,
embolism, myocardial infarction
3. Gastrointestinal system – abdominal distension from paralytic ileus, constipation,
nausea and vomiting, intra operative injury
4. Genitourinary system – urinary retention, fluid imbalance, renal failure,
intraoperative injury/ haemorrhage
5. Integumentary system – wound infection, dehiscence or evisceration, pressure
areas, surgical emphysema / haemorrhage
6. Nervous system – intractable pain, delirium, cerebral vascular accident (CVA)
Key points
1. Routine management will be subject to an accurate assessment of each individual
patient and may vary according to the patient’s pre-operative history, surgical events and
necessary supportive therapies.
2. Patient acceptance to the gynaecology ward is subject to the woman having met
the criteria for discharge to the ward from PACU.
3. Standard Infection Control principles shall be consistently applied throughout a
woman’s episode of care.
4. Patient self-care shall be encouraged as early as possible and is dependent on the
patient’s age, mobility, surgery performed and self-caring ability prior to admission.
Post-operative observations
1. Monitor and record a full set of observations as per relevant observation and
response chart (ORC). In addition, document: Wound sites / drains – measure and record as a
baseline
2. Urinary output – measure and record as a baseline
3. Intravenous therapy rate and IV site(s)
4. Vaginal loss
5. Nasogastric tube drainage (if applicable)6. Opioid infusion- PCIA / PCEA, inspect the insertion site and record the
dermatomes
7. The following observations shall be performed and recorded on the Adult ORC
◦ ½ hourly for the first 2 hours, then
◦ 1 hourly for 2 hours, then
◦ 2 hourly for 2 hours, then
◦ 4 hourly for 24 hours, providing the patient’s condition remains stable.
8. For minor procedures, the following observations shall be performed and recorded
on the Adult ORC (MR 285.02):
◦ ½ hourly for 1 hour, then
◦ 1 hourly for 2 hours, then
◦ 4 hourly, providing the patient’s condition remains stable.
9.Observations shall be recorded as often as dictated by patient condition.
Urinary output: This is to be performed with all observations
• Assess urinary output/ patients urge to void or bladder distension
• Record the urine output- amount and colour. Notify the medical officer if the
volume is less than 30mL / hour.
• Ensure the drainage bag is securely attached and draining
Wound sites / drains
• Note dressing type and integrity/document
• Monitor output- record on fluid balance chart
• Mark drainage bottles at 2400 hour
Fluid balance / hydration
• Manage intravenous therapy as ordered and monitoring IV site for complications
• Monitor and record fluid intake / output from all sources (IV therapy, oral fluids / ice,
urinary catheter, nasogastric drainage if in situ, drainage tubing, emesis, any fistula or stoma)
Medication
• Pain management: Assess pain score and offer analgesia as prescribed
• Post-operative nausea and vomiting-
• VTE prophylaxis: Administer anticoagulants as prescribed
• Antibiotics: Check medication chart and administer antibiotics if prescribed
Non-pharmacological VTE prophylaxis
• Examples include: Graduated compression stockings; encourage deep breathing,
coughing and a range of motion exercises (if required, refer the patient to the Physiotherapy
Department); Encourage hydration and early mobilisation
Hygiene and comfort
• Position the patient for maximum airway ventilation and comfort.
• When the patient’s condition is satisfactory, attend to hygiene needs, mouth care
and if appropriate change the patient into their own clothes
Pressure areas and falls screening and risk reduction
First post-operative day until discharge
• Continue to provide care as above
• Assess for postural hypotension and motor / sensory loss prior to mobilising.
• Assess the need for continuing intravenous therapy. Diet and fluids to commenced
as per the post op orders.
• Remove IV cannula once no longer needed
• Administer an aperient in the evening of the third post-operative day, unless
ordered otherwise. Bowel management for oncology patients must be discussed with the
oncology team prior to initiation.• Remove the IDC as per post-operative orders.
• Administer antibiotics and other medications as prescribed.
• Wound dressing
• Assess the wound for signs of healing or infection. If complications are identified
refer to the medical team.
• Re-apply a wound dressing if appropriate.
• Sutures / staples shall be removed as per post-operative orders.
• Discharge planning shall be commenced at the time of admission. Review available
home support and determine whether additional support is required. Liaise with the relevant staff /
departments and confirm arrangements.
References and resources
1. Department of Health Western Australia. WA Health consent to treatment procedure. Perth:
Department of Health WA; 2023.
2. National Health and Medical Research Council [NHMRC] and the Australian Commission on
Safety and Quality in Healthcare [ACSQHS]. Australian guidelines for the prevention and control of
infection in healthcare: NHMRC, ACSQHC; 2019. Available from: https://www.nhmrc.gov.au/
about-us/publications/astralian-guidelines-prevention-and-control-infection-healthcare-2019
3. Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection.
Cochrane Database of Systematic Reviews. 2011 (11). Available from: http://
onlinelibrary.wiley.com/doi/10.1002/14651858.CD004122.pub4/pdf
4. Paull T. Preoperative skin preparation: hair removal. JBI Evidence Summary JBI197. 2018.
Adelaide (South Australia): Joanna Briggs Institute, [cited 2018 Feb 28].
5. NICE guidance of perioperative care of adults
Compiled By
Dr. Rafaa Islam
Contributors
1. Prof Dr Fawzia Hossain
2. Dr Maniza Khan
3. Dr Taslima Akhter
4. Dr Amena Fardous
5. Dr Aklima Zakaria
6. Dr Seeham Saif
7. Dr Georgia Hoque
8. Dr Tasrina Akhter