New Nurse Notes
Perioperative nursing assessments
made simple
By Sheri L. Zastrow, RN, MSN
T
The nursing process is an integral part of patient care
in the perioperative setting and includes performing
a nursing assessment. For perioperative nurses, this
assessment differs from those performed on the
patient in a medical-surgical unit and requires some
alterations to the formal nursing process that can
challenge new perioperative nurses. One reason for
this difference is due to the brief time a periopera-
tive nurse has contact with a conscious patient. This
column will provide a synopsis of an efficient, effec-
tive perioperative assessment for nurses in the OR,
which can also be utilized for many specialties.
Nursing assessment 101
As a patient moves through the three phases of the
operative process (preoperative, intraoperative, and
postoperative), the perioperative nurse must adapt
the assessment to the setting. Assessment is the rele-
vant collection of data regarding the surgical patient.1
This information can be retrieved through various
avenues and doesn’t need to be repeated through all
the phases of the surgical patient’s operative process.
The concise assessment needs to be relevant to the
patient’s surgical procedure with adequate informa-
tion to provide individualized, safe care. With all
these concepts in mind, it’s apparent the periopera-
tive nurse could benefit from a succinct assessment
tool when navigating through the assessment.
Tools of the trade
Data collection is a progressive and orderly
process.1 Optimizing the most efficient assess-
ment begins with reviewing the patient’s history
using either a paper chart or an electronic version.
Previous surgical history, review of systems, cur-
rent medical diagnosis, indication for surgery, type
of surgery, allergies, as well as physiologic assess-
ment parameters such as diagnostic studies, labs,
and X-ray results, can all be obtained through
these resources.
16 OR Nurse 2009 July
Getting to know your patient
The perioperative nurse can perform the face-to-face
assessment in the preoperative designated area. This
should include an additional physical assessment as
well as a psychosocial assessment. During this time,
the perioperative nurse can assess the patient’s per-
ception of the surgical procedure, what knowledge
they have of the procedure including informed
consent, expectations of care, stress level, cultural
or religious beliefs, support from family or significant
others, or any nonverbal behavior.1 This is also a
time to build rapport with the patient. These psy-
chosocial parameters build confidence in the patient’s
perception of their care as well as aid the periopera-
tive nurse in developing the best plan of care for the
individual patient. This is not the time to repeat the
findings from previous data collection.
Documentation of the assessment is completed
according to the policy and procedures of the organi-
zation.2 The findings may be completed either in
a written or electronic document/flowsheet.
Patient assessments can be individualized and
should include the following:
• identification of patient; two identifiers are
needed, usually name and date of birth (this
may be individualized according to the specific
organization)
• operative procedure; side (if applicable), location
and site marking
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 • preoperative teaching, patient understanding, and
verbalization of procedure
• informed consent documented
• mental/physiological status
• pre-op orders; check history, electronic record
• range of motion/mobility
• internal/external prosthesis
• sensory impairments or language barrier
• cultural differences, religious/spiritual needs
• cardiovascular and respiratory status (vital signs
within +/-20% baseline, airway patent, maintain
oxygen saturation at 92% or +/- 2% of baseline)3
• nutritional status (N.P.O.)
• pain or discomfort (ongoing assessment of level
of pain or discomfort)
• surgical specialty assessment as appropriate:
cardiovascular, pulmonary, neurologic, orthope-
dic, gastrointestinal, gynecological, ophthalmic
• presence of prosthetics or corrective devices
• personal belongings and their location
• medications and allergies (obtain from patient’s
history)
• skin condition
• family/friends/significant others present.
A vital part of patient safety
Perioperative nursing assessments are succinct and
pertinent to the patient’s surgical procedure. Repetition
needs to be reduced as the patient’s history and data
can be retrieved from a variety of resources such as
the history, electronic record, patient’s interview, and
physical assessment. The assessment is critical for safe
patient-care delivery. OR
REFERENCES
1. Rothrock JC, McEwen DR. Alexander’s Care of the Patient in Surgery.
15th ed. St. Louis, MO: Mosby; 2007.
2. Association of periOperative Registered Nurses. Perioperative Standards,
Recommended Practices and Guidelines. AORN Inc.: Denver, Colo.; 2008.
3. Peterson C. AORN Perioperative Nursing Data Set, (2nd ed.). AORN
Inc.: Denver, CO; 2008.
Sheri L. Zastrow is a nursing education supervisor at the Mayo Clinic,
Rochester, Minn.

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