Preoperative Patient Care Priorities

Chapter 15 Priorities for the Preoperative Patient \*\*\*\*\*\*\*\*INTRODUCTION There are many different purposes and types of surgical procedures. Common terms associated with the surgical process include the following: Emergency surgery---surgery that must be done immediately to save a patien...

Chapter 15 Priorities for the Preoperative Patient \*\*\*\*\*\*\*\*INTRODUCTION There are many different purposes and types of surgical procedures. Common terms associated with the surgical process include the following: Emergency surgery---surgery that must be done immediately to save a patient's life, limb, or ability to function Urgent surgery---surgery that must be done within 24 to 48 hours to prevent permanent injury to the patient or death Elective surgery---surgery that may be necessary but can be planned around the patient's and surgeon's schedule Ambulatory (outpatient) surgery---surgery usually performed in 1 day, with the patient being admitted to the ambulatory surgical center (ASC) in the morning and discharged after acceptable recovery criteria have been met Exploratory (diagnostic) surgery---surgery performed to obtain a diagnosis and possible resolution Ablative surgery---surgery to remove tissue from an organ or area of the body Palliative surgery---surgery performed to decrease pain or symptoms in patients suffering from incurable illnesses Reconstructive surgery---surgery to restore function or a defect in an area of the body Cosmetic surgery---surgery to change or revise an area or structure of the body Minimally invasive surgery---surgery performed through very small openings in the skin, using instruments through which the surgeon can visualize the area such as a laparoscope Telesurgery or robotic surgery---surgery performed from a location other than the surgical suite, by use of robotic equipment The operative experience is broken up into three phases: preoperative, intraoperative, and postoperative. Although each of these phases possesses unique nursing needs, the preoperative phase is a patient's first impression of the surgical setting. The preoperative phase commences when the decision for surgery is made and ends when the patient is transferred to the surgical suite. During this time, the preoperative nurse takes on a multitude of roles, including educator, advocator, and admittance nurse. It is crucial for the nurse to identify any potential needs the patient may have while in their care. The nurse's main priority is to complete a preoperative checklist (Fig. 15.1). Each facility's unique checklist ensures that the necessary documentation, admission assessment, physical preparation, and educational needs have been completed before the patient enters the surgical suite. This includes but is not limited to the following: A full medical history (including prescription, over-the-counter, herbal, and other alternative therapies) Assessment of the patient's health status Collection of information and paperwork necessary for intraoperative and postoperative care Completion of preoperative orders (IV antibiotics, thromboembolic-deterrent \[TED\] hose, etc.) Patient education regarding the entire surgical process Verifying that the patient and a witness signed the informed consent The initial time-out---"pause for cause"---when the patient verifies the following: All information on the identification band as correct The name of the surgeon The procedure that will be completed by the surgeon The correct side of the body on which the surgery will occur if this is a unilateral procedure These interventions not only identify potential issues before surgery but also ensure that all procedures are performed in a timely and safe manner. \*\*\*\*\*\*\*\*\*\*INFORMED CONSENT Informed consent is when a patient autonomously and cognitively grants permission to a provider to perform a surgical procedure after considering all alternatives, benefits, and risks of the procedure. Although obtaining consent is not the role of the nurse but that of the provider, it is the nurse's responsibility to ensure that the patient has all the information needed to make an informed decision about the procedure being offered. Working with the patient to identify and correct educational deficits not only makes the patient more comfortable about consenting to the surgical experience but also ensures the safest and most successful outcome. An informed patient is more likely to follow instructions preoperatively for preparation and postoperatively for recovery. It is important for the preoperative nurse to understand that every patient has the right to refuse a surgical intervention even when death is a risk of refusal of treatment. In the eyes of the law, treatment without consent is not allowed even at the risk of death. Components of an Informed Consent Surgical consent forms are similar in most institutions. Some may be preprinted; others must be completed to describe each procedure. Whichever form or forms are used, the required components are universal (Fig. 15.2). Components of consents include the following: Consent for the procedure itself, which should include the following information: Name of surgery, type of surgery, and reason for the surgery Name of the surgeon to perform the surgery Reason that intervention will benefit the patient All alternative options to surgery Potential outcomes if surgery is not performed Consent for anesthesia Consent to administer blood products Anesthesia Anesthesia consent is an additional consent the patient must sign. At this time, the anesthesiologist informs the patient of the type of anesthesia, the medications to be used, and the risks associated with the type of anesthesia planned. The anesthesiologist or nurse anesthetist may also describe how the medication is administered, such as epidural anesthesia or regional block. The role of the preoperative nurse remains the same, one of patient advocate, ensuring that the patient understands the information being presented. Blood Products Consent to administer blood products may be a component of the general surgical consent or a separate form. The surgeon describes what situations will warrant the need for blood products and requests consent from the patient for their use. The nurse must be aware of cultural and religious obligations that prevent the patient from consenting to receive blood products. For example, because of religious beliefs, some patients will not consent to the use of blood products. In that case, the surgeon documents that the patient has refused blood products in the patient's chart. The preoperative nurse is responsible for identifying the patient as "no blood products" with a bracelet and sign on the patient's chart. Facilities have blood refusal forms that a patient is asked to sign if this situation presents. Providers can give blood without consent only in an emergency situation where the patient lacks the capacity to consent. Inability to Consent Special considerations occur when the patient is not able to consent for care. These situations include patients who are cognitively impaired or who are cognitively aware but unable to physically sign, a patient who is deaf or speaks another language, minors, or emergency situations. In situations where the patient is impaired, a medical power of attorney may be established for consent purposes. Patients who cannot physically sign but are able to make their own care decisions may sign with an "x." This consent needs to be witnessed by two people instead of just one as normally required. If the patient speaks another language or is deaf, a hospital interpreter may be used. For purposes of consent, this is desirable over a family member. The hospital interpreter is familiar with the medical terms being used. Also, the use of an anonymous interpreter avoids any bias that may occur with a family member during translation. Surgical consent for minors may be signed by the legal guardian of the child. However, if the child is old enough to understand the care, the procedure should still be explained. In emergency situations, a verbal consent is acceptable. Written consent should be obtained in a timely manner following the surgery. If the patient is incapable of giving consent, two providers document the need for surgery. This is acceptable only if the patient's medical power of attorney or next of kin is unreachable or the surgery is emergent and the patient has no support present. Other situations require special permits done well before the procedure. An example of this is sterilization procedures. The patient must sign a unique consent 6 weeks before the surgery. \*\*\*\*\*\*\*\*\*\*\*\*Advance Directives The Patient Self-Determination Act of 1991 grants all patients the right to determine and direct their care in times of medical emergency: the right to create an advance directive. An advance directive defines a patient's wishes should the patient be deemed incompetent to express their wishes in a medical emergency. Facilities are required by law to provide the means and guidance to complete an advance directive if desired before surgery. Within the advance directive, the patient may name a durable medical power of attorney, usually a spouse or adult child, who is designated to make all medical decisions should the patient become incompetent. The advance directive also allows the patient to express desires related to organ donation and end-of-life issues. As part of the advance directive, a living will defines care in the case of cardiac or respiratory failure or when the likelihood of recovery to a quality level of functioning is deemed unlikely. Patients may elect to have all necessary measures taken or may elect to stop life-sustaining procedures in the event of a cardiac arrest. The phrases "do not intubate," DNI, or "do not resuscitate," DNR, are recorded in the patient's chart. The patient also has the opportunity to express wishes in regard to feeding tubes or long-term ventilator-assisted breathing. The patient may select any combination of treatments they feel best matches their values and beliefs. It is imperative that if a patient has advance directives and/or a living will at the time of surgery, the nurse notes that on the chart and places a copy of these documents on the chart if the patient has brought them to the hospital. \*\*\*\*\*\*\*\*\*\*\*Obtaining Informed Consent Surgeon The surgeon is solely responsible for obtaining consent in the presence of the patient and one witness. Family members or support persons may be present at this time. Informed consent for a scheduled procedure must be obtained before the administration of pain medications and sedatives or the induction of anesthesia because these medications may alter the patient's ability to make an informed decision. In addition to obtaining informed consent, the surgeon uses this uninterrupted time to ensure that all of the patient's and family member's questions are answered. Preoperative Nurse Many patients admit to not reading the entire consent before signing (Box 15.1). The role of the preoperative nurse is to clarify information and ensure patient understanding. Nurses correct common misconceptions and ease concerns of the patient, family members, or support persons. In addition to reviewing the consent form and validating patient understanding, nurses often serve as the witness to the consent. The nurse is witnessing the physical signature, not the information provided. It is essential that the witness be with the patient as the consent is being signed. The nurse or other witness should never sign the consent form if they did not witness the patient signing the form. As part of preoperative procedures, the nurse is also responsible for documenting that a signed consent has been placed in the patient's chart. \*\*\*\*\*\*\*\*\*\*TIME-OUTS/PAUSE FOR CAUSE Surgical errors and wrong-site procedures are a documented occurrence and have been identified by hospital accreditation organizations as an area for improvement. A time-out is a formal process of identification performed by the patient and the healthcare team to identify the correct patient, correct procedure, and correct surgical site. The preoperative nurse is a part of the time-out process. The time-out, or "pause for cause," starts when the patient enters the surgical facility. On admission, the patient receives a wristband containing their identifying information. After reviewing the wristband, the patient confirms that all the information is correct; it is essential that the wristband note accurate information before the patient is moved into the surgical suite. The first responsibility of the preoperative nurse is to review the information on the wristband with the patient and have the patient name the procedure and site. This time-out is performed again by the circulating nurse on transfer to the surgical suite and once more immediately preceding incision by the entire team (Fig. 15.3). The surgeon marks the surgical site with their signature using a permanent marker. Some surgeons may require that, if possible, the patient marks the site themselves. Components of a Time-Out Although the process may vary in different facilities, the components of a time-out are consistent. The patient is asked to state their full name as printed on the identification bracelet and at least one other identifier, which is typically the patient's date of birth, although there are other acceptable identifiers (see Safety Alert). The patient is next asked to state the correct site and the procedure they are receiving. The surgeon then marks the correct site. As stated earlier, the process of identifying the patient, procedure, and site is completed again by the team immediately before incision. Performing a time-out immediately before incision makes an irreversible mistake less likely. \*\*\*\*\*\*\*\*\*\*\*\*PATIENT ASSESSMENT The surgical patient requires a detailed medical history and assessment to ensure a safe and successful surgery. The preoperative nurse is responsible for obtaining and documenting this history on admission. If a patient has already been admitted to an inpatient unit and has a history on record, the information should be reviewed and documented on the preoperative record. This allows the preoperative nurse and surgeon to identify any patient learning and medical needs that are unique to their surgical experience. \*\*\*\*\*\*\*\*\*\*\*\*\*Patient History Completed patient medical, social, and surgical histories are the key to a successful surgical experience. These questions may be asked during a preoperative workup or on admission to the surgical facility. As the nurse prepares the patient for surgery, they ask a series of detailed questions. Some of the questions may be very personal and, at times, uncomfortable for the patient to answer. The nurse should remind the patient that this information is important in providing a safe outcome. It is also important to assure the patient that no judgment will be made on their responses and that the information will be used only for medical purposes. Box 15.2 lists the components of a complete patient history. \*\*\*\*\*\*\*\*\*\*\*Medical History As the nurse asks questions pertaining to the patient's medical history, they should be taking special note of any conditions that will pose a risk during the surgical experience. For example, a patient with a history of DVT should be receiving coagulation studies before surgery. A patient with a cardiac condition may have an untoward response to anesthesia or may experience harmful hemodynamic changes during the surgical procedure and may require enhanced cardiac monitoring with a cardiologist's input before surgery. Chronic pulmonary conditions such as asthma, emphysema, and chronic bronchitis may complicate the removal of ventilatory support postoperatively and should be monitored with pulse oximetry and arterial blood gas (ABG) testing. These patients may require extended intubation, and admission to the intensive care unit (ICU) postoperatively should be anticipated. The presence of chronic illness such as diabetes or immune deficiencies places the patient at risk for poor wound healing postoperatively and indicates the need for increased blood glucose monitoring. Last, any implants, such as replacement joints and dental work, may interfere with positioning during surgery or intubation. If a patient has a pacemaker, because of possible electromagnetic interference from the use of an electrocautery device to control bleeding during the surgery, it may be necessary for the patient's pacemaker to be disabled during surgery. A representative of the pacemaker company may need to be present before and after surgery to manage the pacemaker. \*\*\*\*\*\*\*\*\*\*\*\*\*Surgical and Anesthesia History A patient's surgical and anesthesia history is a very important part of the patient's history. Previous surgery may have left scar tissue, internal adhesions, or medical implants that need to be considered. The nurse should inquire about types of surgery, the year the surgery was performed, the indication for surgery, any poor incision healing, and what type of anesthesia was used for each procedure. Any negative responses to anesthesia or wound healing must be taken into consideration while planning the patient's care. \*\*\*\*\*\*\*\*\*\*Allergies All patient allergies must be documented to ensure patient safety. Allergies to medications, food, medical dyes, latex, medical adhesive, and environmental conditions must be documented along with the patient's physical response to exposure to these products. An alert bracelet is placed on the patient, and the surgical team is made aware. Allergies to antibiotics determine what preoperative and postoperative prophylaxis medications are used. If a patient is allergic to antiseptic solutions such as Betadine or chlorhexidine, an alternative skin preparation must be selected. Latex allergies are a serious concern. Each facility must have adequate latex-free equipment available for these cases. In some outpatient settings, patients with latex allergies are scheduled as first cases of the day to ensure that the surgical suite is free of latex contamination. Many hospitals are choosing to create latex-free environments for all surgical suites for this reason. \*\*\*\*\*\*\*\*\*Medications Current medications are an extremely important part of the preoperative history (Table 15.1). The use of antihypertensives, anticoagulants, and antiarrhythmics, to name a few, can have a tremendous impact on the care provided in the operating room (OR). Herbal remedies and over-the-counter medications also may have potential interactions with medications used during the procedure and postoperatively or may increase the risk of bleeding. \*\*\*\*\*\*\*\*\*\*Last Oral Intake Last oral intake is an essential assessment parameter before anesthesia. The guidelines may be modified for different populations, but typically, all patients requiring surgical intervention should have had nothing to eat or drink (NPO) for at least 8 hours before the procedure. A patient who has eaten within 8 hours is at risk of aspiration, the introduction of food particles into the lungs through emesis. The preoperative nurse is responsible for documenting the last oral intake. Patients who have special needs, such as those with diabetes mellitus, may have altered NPO orders before surgery. Exceptions are sometimes made that allow patients to take essential medications with sips of water before the procedure. According to recent guidelines for elective procedures, the patient may be advised to be NPO 6 to 8 hours for solid foods and 2 hours for clear fluids. There are different preoperative NPO parameters for children and infants: No solid food is allowed for 8 hours before surgery. Infant formula can be given up to 6 hours before surgery. Breast milk can be given up to 4 hours before surgery. Clear liquids can be given up to 2 hours before surgery. \*\*\*\*\*\*\*\*\*\*\*\*Alcohol, Smoking, and Drug Use Alcohol, smoking, and drug use are sometimes uncomfortable but important questions to ask of all patients. Smoking puts patients at risk for respiratory depression during the procedure and DVT during postoperative care. Because of changes in the pulmonary system, intubation and ventilation may also be compromised. Smoking may also increase the healing time for surgical wounds. Alcohol and drug use may compromise the patient's response to anesthesia. Additionally, postoperative pain management is complicated with recreational drug use, and such use must be taken into consideration when making discharge plans. \*\*\*\*\*\*\*\*\*\*\*\*\*\*Special Considerations When a patient history is obtained, some questions require privacy because of their sensitive nature. All psychosocial questions, such as questions about abuse at home and gynecological and mental illness, must be asked with no other family or support persons present. Any conflicting medical information from the patient's chart and the patient's responses should also be addressed at this time. Physical Assessment The physical assessment of the surgical patient is another component of the preoperative admission workup. Assessment parameters include height and weight, vital signs, and systems assessment. \*\*\*\*\*\*\*\*\*\*\*\*Height and Weight Height and weight help the anesthesia provider determine fluid needs and medication dosages for anesthesia or antibiotics during the procedure. A patient with a high body mass index (BMI) may also require a larger operating table and recovery bed. Most operating tables have extensions that can meet increased weight requirements. In addition, the OR team may adjust diligence equipment used to transfer the patient. Vital Signs Vital signs are obtained by the nurse during the initial assessment. This includes blood pressure, respirations, pulse, temperature, and pulse oximetry. If available, the nurse should compare the admission vital signs with any previously recorded vital signs to note trends or major changes. If the initial set varies significantly from the patient's normal, a second set of vital signs may be taken 10 to 15 minutes later because many patients may be nervous, which may alter their vital signs. The presence of fever may be an indication of infection. That may necessitate a postponement of the surgical procedure. If the patient is held in the preoperative room for longer than 2 hours, a second set of vital signs may be required before transfer to the surgical suite. Assessment of vital signs must include the fifth vital sign, pain. The patient is asked to rate pain in one of several ways. Examples of pain scales include the following: A scale of 0 to 10, with 10 being the worst pain the patient has ever experienced A series of faces ranging from a smile to a frown for pediatric patients Another required admission question is the documentation of the patient's acceptable pain score. Each patient handles pain differently, and therefore a subjective pain scale is interpreted differently. This score is used by the postanesthesia nurse and surgeon as a guide for adequate pain management. \*\*\*\*\*\*\*\*\*\*\*\*Systems Assessment During the initial assessment, the nurse performs a head-to-toe physical assessment of the preoperative patient. Key elements for the preoperative assessment are presented in the following subsections. Cardiovascular Assessment In addition to pulse and blood pressure, the nurse further assesses the patient's cardiovascular health. Peripheral pulses, color, skin turgor, capillary refill, temperature, and edema are important parameters to assess. The nurse also auscultates the heart for rhythm, rate, and murmurs. Respiratory Assessment The nurse assesses the patient's breathing for rate, depth, rhythm, and adventitious breath sounds such as crackles, rhonchi, or wheezing. Pulse oximetry is used to assess the patient's oxygen saturation on room air. In addition, the nurse should report any clubbing in the fingers, which could indicate long-term oxygen deprivation. The nurse must also ensure that the patient has a clear airway. The patient is asked to stick out their tongue, breathe with the head tilted up and with the chin down, and swallow. This ensures that an airway and any intubation may be safely maintained during the procedure. The anesthesiologist assesses the patient as well during their consultation. Neurological Assessment Before the induction of anesthesia, it is important for the nurse to obtain a baseline neurological evaluation. Assessment of general cognition and the ability to understand commands is important before the induction of general anesthesia. The nurse also assesses the movement, strength, and sensation of the extremities. This is especially important in a patient who will receive some type of regional block for the procedure. The presence of preoperative delirium or confusion may delay or postpone the procedure or necessitate admission to the hospital postoperatively. Liver/Renal Assessment It is important to note potential renal or liver disease in the surgical patient. The effects of anesthesia and other medications used before, during, and after an operation may be altered if the patient has decreased hepatic or renal clearance. A complete metabolic panel helps the team to identify any signs of dysfunction. Integumentary Assessment A general assessment of the patient includes assessing appearance, such as skin integrity and hygiene. Patients with poor skin turgor or fragile skin may heal more slowly than a healthy individual. Also, the team may want to be careful as to the type of dressings that are used to protect the skin from further damage beyond the incision. For example, in an older patient or a patient with fragile skin, the nurse may want to use a leg strap instead of an adhesive to secure a urinary catheter. If hygiene is an issue, the nurse may need to give extra instruction on wound care in an effort to decrease the risk for infection. Gastrointestinal Assessment It is important for the nurse to note typical bowel habits of the patient, especially if the patient will be admitted to the hospital after surgery. The nurse should also document the presence of normal bowel sounds and any areas of tenderness on the abdomen. Genitourinary Assessment The nurse should document any devices noted for urinary elimination, such as an indwelling urinary catheter. The nurse should have the patient void before entering the operating suite and note any unusual odor or color of the urine. The patient may wish to discuss any concerns about urination postoperatively; some patients worry about being able to get into the bathroom without assistance. The nurse should also document any perineal abnormalities on the chart. \*\*\*\*\*\*\*\*\*\*\*PATIENT PREPARATION FOR THE SURGICAL EXPERIENCE Laboratory Assessment Preoperative laboratory work is essential in determining the patient's readiness for surgery. This can be done at an appointment before surgery or the morning of surgery. If done on the day of surgery, labs will be drawn as the nurse places an IV line to be used for venous access during surgery. A type and screen to determine blood type and the presence of antibodies is drawn. This sample is used to crossmatch blood in the event the patient needs blood during the surgical procedure. Often, facilities have the patient wear a blood identification bracelet with unique numbers that match the drawn sample for the purpose of easy and safe identification. A complete metabolic panel provides baseline information on renal and liver functions, including liver enzymes, albumin, electrolytes, blood urea nitrogen, and creatinine. This information helps in the selection of medications and dosages for the surgical procedure. Coagulation studies show how quickly the patient's blood clots after injury, determining any bleeding abnormalities. The complete blood count (CBC) measures hemoglobin/hematocrit (blood volume and oxygen-carrying capability) and the white blood cell count for indications of infection. Any deviation from the facility's defined ranges should be reported to the surgeon or anesthesiologist, as appropriate, to be corrected to avoid complications. For example, a low platelet count or hemoglobin/hematocrit will be further decreased by surgery. The surgeon may ask for blood to be typed and crossmatched before the procedure, or the provider may ask for platelet administration before surgery. Clotting abnormalities may also require the administration of fresh frozen plasma before the procedure can begin. Last, urine is measured for the presence of glucose, blood, protein, and specific gravity and the presence of ketones. These measures help determine the presence of infection or the hydration status of the patient. Immediately before surgery, patients may be tested for pregnancy. Radiological Assessment Radiological imaging is sometimes required before surgery. Common preoperative images are magnetic resonance imaging (MRI), computerized axial tomography (CAT scans; more commonly referred to as computed tomography \[CT\]), ultrasonography, or x-ray imaging. Imaging studies may also be required immediately before and during the surgery to monitor progress. An electrocardiogram (ECG) may also be performed before or on admission to the surgical facility, and cardiac monitoring may be ongoing. \*\*\*\*\*\*\*\*\*\*\*\*\*Patient Teaching It is important at this time to complete any necessary patient teaching. Patient teaching helps decrease anxiety, which has been shown to improve patient outcomes (see Evidence-Based Practice). Anxiety has been shown to increase postoperative pain medication requirements, necessitating more pain medication. This can affect the postoperative recovery by decreasing activity and mobility, which puts the patient at risk for complications such as DVT, pneumonia, and constipation. Anxiety also plays a role in increasing the risk of infection by decreasing the immune system response. Most facilities have a patient teaching record where teaching is documented. The patient's family should be included in the preoperative teaching. At this time, the nurse should take the opportunity to have a discussion with the patient and their family support regarding what to expect during the patient's surgical and postoperative experience. For example, the nurse should discuss how long the procedure will be, how long the patient will be in the postanesthesia care unit (PACU), and how soon the family will receive an update on the patient's status and be able to see the patient. Discharge care may be covered at this time because the patient may be fatigued or drowsy after the procedure. The nurse can address any family concerns at that time as well. Last, the nurse should ensure that the family is guided to the appropriate waiting area where the staff will be able to locate them for updates. See Box 15.3 for a checklist of preoperative learning needs. \*\*\*\*\*\*\*\*\*\*\*\*\*Physical Preparations Intravenous Line (IV Line) An IV line is inserted during the preoperative admission, typically for the purpose of the administration of anesthesia and fluids during the surgery. An 18-gauge catheter is preferred because this size is required for the administration of all blood products. Factors to consider when placing the IV line include the location of the procedure and whether multiple sites are required. The IV should be labeled with gauge, time and date of placement, and the nurse's initials. The nurse may also administer any preoperative antibiotics at this time. Bowel and Bladder Preparation Patients receiving abdominal, intestinal, gynecological, or rectal surgery may be asked to perform a bowel preparation. This may be done by use of an enema or gentle laxatives that the patient self-administers at home the night before the procedure. The nurse should confirm and document that this preparation has been performed. Skin Preparation Before surgery, skin preparation is done to help prevent infection at the surgical site. Patients may be instructed to shower and wash with Betadine or hexachlorophene soap before admission. A surgical shave may be necessary depending on the patient's skin type and the location of the incision. If a shave is appropriate, the nurse uses a sterile electric clipper. A razor is not recommended because of the risk of infection caused by small nicks in the skin that may occur with a razor. Shaving may be done in the OR after the induction of anesthesia. In addition, the nurse should confirm that all body piercings have been removed and that nails are clear of polish. Medications Preoperative medications may be required. Patients with preoperative anxiety may be prescribed a benzodiazepine such as midazolam HCl, diazepam, or lorazepam. Antiemetics such as metoclopramide HCl or ondansetron HCl may be used preoperatively if a patient has a history of nausea and vomiting due to anesthesia. \*\*\*\*\*\*\*\*\*\*\*\*\*\*Transfer Preparing the patient for transfer to the OR suite is the final responsibility of the preoperative nurse. Before transport, the nurse should make sure that all consents have been signed; the history and assessment have been completed and documented, including vital signs; learning needs have been met; skin and bowel preparation are complete; and preoperative medication has been administered. The intraoperative nurse may accompany the patient to the surgical suite, or the anesthesia team may be responsible for this transport depending on the surgical suite's policies. Once transferred, the patient is now considered to be receiving intraoperative care.