CNOR

The preoperative assessment is the foundation of safe surgical care. The perioperative nurse gathers a complete health, surgical, medication, and allergy history, performs a focused physical and psychosocial assessment, confirms that indicated laboratory and diagnostic studies are available, applies standardized risk assessment tools, and communicates findings that call for optimization or a change in the plan. After surgery, a systematic postoperative assessment detects complications early and confirms readiness for discharge. Expect questions that ask which finding is most significant, which team member to notify, and what to do first.

Perioperative nurses conduct a systematic evaluation to identify patient-specific risks, optimize surgical outcomes, and develop an individualized plan of care. The comprehensive preoperative assessment includes the medical history, surgical and anesthesia history, medication history, allergy assessment, physical examination, psychosocial evaluation, and review of diagnostic studies.

Component	WhattoGatherandWhyItMatters
Medicalhistory	Chiefcomplaint historyofpresentillness pastmedicalconditions andreviewofsystems with , , , ,
	particularattentiontocardiovascularandpulmonarydisease diabetes renalandhepaticimpairment , , ,
	neurologicaldisorders bleedingdisorders andimmunocompromisedstates , ,
Surgicalandanesthesia	Previousoperations anesthesiaexperiences andcomplications includingdifficultintubation , , , ,
history	malignanthyperthermia(personalorfamily) prolongedneuromuscularblockade postoperative , ,
	nausea and vomiting and wound -healing problems ,
Medicationhistory	All prescription and over-the-counter drugs herbal supplements and recreational substances with , , ,
	thedoseandtimeofthelastdoseforanticoagulants antiplateletagents antihypertensives , , ,
	antidiabeticagents corticosteroids andimmunosuppressants , ,
Allergyhistory	Everydrug latex food adhesive andantisepticallergywiththespecificreaction severity timing , , , , , , ,
	andtreatmentrequired

True Allergy Versus Adverse Reaction

Allergy documentation must distinguish true allergies from adverse reactions, intolerances, and sensitivities. True allergies are immunoglobulin E (IgE)-mediated responses that produce urticaria, angioedema, bronchospasm, or anaphylaxis. Adverse reactions are predictable side effects, such as gastrointestinal upset, drowsiness, or itching with opioids. The distinction matters: a mislabeled penicillin "allergy" can lead the team to choose a less effective prophylactic antibiotic, while a missed true allergy can be fatal. Record the reaction the patient actually experienced, not just the drug name.

Latex Allergy Screening

Screen every patient for latex sensitivity. Higher-risk groups include health care workers, patients with spina bifida, patients with urogenital abnormalities who require repeated catheterization, people with multiple prior surgeries, and individuals with allergies to bananas, avocados, kiwis, or chestnuts, because latex proteins cross-react with these foods. A latex-allergic patient needs a latex-safe environment, ideally as the first case of the day, with all latex products removed from the room and the allergy communicated to every team member.

Communicate allergies through multiple channels: the patient's identification band, the electronic health record, the surgical schedule, and verbal handoff at every transition. The briefing and time-out are further opportunities to confirm allergies with the whole team.

The preoperative physical examination focuses on the airway, cardiopulmonary status, neurological baseline, skin integrity, and the planned surgical site. Findings establish the baseline against which postoperative changes are measured.

Airway Assessment and Mallampati Classification

Airway assessment predicts potential difficulty with mask ventilation and intubation. The Mallampati classification grades how much of the oropharynx is visible when the seated patient opens the mouth and protrudes the tongue. Higher classes correlate with more difficult intubation.

Class	StructuresVisible	Signifi cance
ClassI	Softpalate uvula fauces andtonsillarpillars , , ,	Easiestview
ClassII	Softpalate uvula andfauces , ,	Usuallyuncomplicated
ClassIII	Softpalateandbaseoftheuvula	Potentialdifficulty
ClassIV	Hardpalateonly	Highestpredicteddifficulty

Additional predictors of a difficult airway include a thyromental distance under 6 cm, limited neck extension, mouth opening under 3 cm, prominent upper incisors, a receding mandible, a short thick neck, obesity, and a history of obstructive sleep apnea. Report these findings to the anesthesia professional so that difficult airway equipment is in the room before induction.

Cardiopulmonary, Neurological, and Skin Assessment

Heart rate and rhythm, blood pressure, heart and lung sounds,

Level of consciousness, orientation, motor and sensory

respiratory rate, oxygen saturation, and exercise tolerance.

function, and existing deficits. The baseline makes new

Report new murmurs, gallops, rubs, wheezes, crackles, or

postoperative deficits recognizable.

diminished breath sounds.

Existing wounds, pressure injuries, rashes, bruising, and

Joint limitations, prostheses, and implants that will affect how

lesions, with location, size, and stage. Inspect skin over bony

the patient can be positioned safely, plus the ability to move

prominences and areas that will bear weight in the planned

independently onto the OR bed.

position.

Psychosocial and Cultural Assessment

Psychosocial evaluation addresses anxiety, coping mechanisms, social support, cultural considerations, spiritual needs, and the patient's understanding of the planned procedure. High preoperative anxiety correlates with increased postoperative pain, delayed recovery, and lower satisfaction, so identify patients who need additional support or pharmacologic anxiolysis. Cultural assessment identifies beliefs and preferences that affect surgical care, including religious observances, dietary restrictions, modesty concerns, family decision-making patterns, and attitudes toward blood transfusion or organ donation.

Advance directives must be reviewed before surgery. Confirm whether a living will, health care power of attorney, or do- not-resuscitate order exists and clarify how it applies during the procedure and the immediate postoperative period. A DNR order is not automatically suspended in the operating room; it must be discussed and reconsidered with the patient or surrogate, and the agreed plan documented and communicated to the team.