The preoperative exam— every patient having surgery needs to have a visit with a healthcare provider before their surgery in order to assess their health and verify that it is relatively safe to proceed with surgery. So nerve-wracking!
You're being asked to evaluate a patient before surgery—but what exactly are you responsible for? Are you supposed to “clear” the patient? How do you determine whether a patient needs additional testing or evaluation before surgery—and what should you document?
A preoperative evaluation isn't about declaring that surgery is completely safe. It's about identifying and assessing the patient's perioperative risk, looking for conditions that may need further evaluation or optimization before surgery, and communicating those findings to the surgical team.
In this updated episode of Real World NP, we're walking through a practical approach to preoperative evaluations for noncardiac surgery, including the updated perioperative cardiovascular guidelines, risk assessment tools, functional capacity, medication considerations, and how to communicate your findings to the surgical team.
Want a quick desk reference for this topic? Check out the Preoperative Evaluation Cheat Sheet in the Digital NP Binder.
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What I Cover in This Episode:
What your role is in the preoperative evaluation—and why we don't "clear" patients for surgery
How to assess surgical risk and identify reasons to pause before surgery
Tools to estimate perioperative cardiovascular risk + assess functional capacity
What to include in the preoperative history and physical exam
Evaluating chronic medical conditions and pulmonary risk
When preoperative labs, ECGs, and imaging are indicated
Perioperative medication considerations, including SGLT2 inhibitors
How to document your assessment and recommendations for the surgical team
Key Takeaways
A Preop visit isn't about “clearing” the patient. No surgery is risk-free. Your role is to assess the patient's current health and perioperative risk, identify conditions that may need further evaluation or optimization, and communicate your assessment and recommendations to the surgical team.
Start with the procedure + the patient. Clarify the planned procedure, its risk, and the patient's relevant medical history and current clinical status before deciding what additional evaluation or testing is needed.
Don't order routine preoperative testing just because surgery is planned. CBCs, metabolic testing, coagulation studies, ECGs, chest X-rays, and other tests should be ordered when indicated by the patient, procedure, medications, or clinical findings—not automatically for every preoperative patient.
Cardiovascular Assessment Is Stepwise. Assess for active or unstable cardiovascular conditions first, then consider surgical risk, estimated perioperative cardiovascular risk, functional capacity, and whether additional testing would change management.
Document risk—not “clearance.” Document your assessment of perioperative risk, relevant findings, conditions that have been optimized or still need attention, and recommendations for the surgical/anesthesia team.
Resources mentioned in this episode:
The Preoperative Evaluation Cheat Sheet walks you through surgical risk, cardiovascular risk, functional capacity, preop testing, and documentation—so you can quickly work through what your patient needs before surgery. Get the Cheat Sheet inside the Digital NP Binder.
Original Episode: Preoperative Evaluation
Want to hear more about the foundational approach to preoperative evaluations? In the original Real World NP episode from 2019, I walk through how to think about surgical risk, assess cardiovascular and pulmonary concerns, and approach preoperative visits as a newer nurse practitioner.
A note about this older episode: While many of the foundational concepts are still relevant, some recommendations have changed since it was recorded. For the most up-to-date guidance on cardiovascular risk assessment, preoperative testing, and documentation, refer to the updated episode above.
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Preoperative Evaluation — Episode Transcript
Welcome to the Real World NP podcast, where we share practical clinical education, real world practice insights, and honest conversations to help nurse practitioners feel more confident, capable, and supported in practice. Real World NP is an ANCC accredited continuing education company supporting nurse practitioners, schools, clinics, and fellowship programs in bridging the gap between graduate education and real world practice. Welcome to this week's episode.
Introduction
Today we're going to be talking about preoperative exams. So I'm going to be talking through the newest guidelines when it comes to non-cardiac surgeries and primary care, walking through a visit, how I think about it, what to document, what not to document, and things like that. If you've been around for a minute, you may know I've done an episode like this in the past, but I wanted to make an updated episode with the newest guidelines as well as how I think through them differently than I have in the past. Before I get too much further into the episode though, I want to let you know that there's a cheat sheet that goes along with this topic inside the digital NP binder.
So you can find that at realworldnp.com slash binder. And the reason I made this is just because there are some chief complaints or visit types that have a lot to remember that are just hard for me to memorize off the top of my head. So it's just nice to have a quick reference. So I didn't have time to make this as a new grad, and so I made it once I had more experience and more breathing room, and now I'm sharing it if that's helpful for you. And you can also get CE credit for it or not if you'd like.
But anyway, let's talk about preoperative exams.
Your Role in the Preoperative Evaluation
So I'm going to talk about some background first, and then we'll talk about kind of walking through the visit. So your main thing that you're doing here is you're assessing them from a holistic perspective, whereas the surgeon and anesthesia team is really only looking at the problem at hand. I mean, of course, they're good clinicians and then they're looking at the full picture. But we have just better insight as their primary care provider to be able to look at all of those pieces. So what we're going to do is we're going to look at the patient and assess their status of their chronic conditions, cardiovascular as well as pulmonary risks, and decide does this patient need further evaluation and management before they proceed with this procedure or are they, you know, there's no reason to hold up the proceeding of this procedure.
So a couple of background pieces.
Understanding Surgical Risk
What you're going to need to know when it comes to a preop exam is that the surgeon is likely going to send them with some paperwork. Hopefully, they've brought it with them, but it will say things like they're having this surgery on this date with this doctor or this team. And here are the tests that we'd like to have done. And here's the information we need from you. How do we assess the risk of this surgery? Most of the time, what I've seen in primary care is things like cataract surgery, maybe a dental procedure, maybe a joint replacement, things like that. And so you're going to take a look at the surgery and look at the risk of major adverse cardiovascular events or MACE.
And low risk procedures are considered to be less than one percent of MACE. There are a bunch of these different risk estimators out there. There's not one universal one. I found one from UCLA that I use, which is also on the cheat sheet. If you want to use that as well. But that's the thing that we're kind of assessing and keeping in mind as we go forward.
Reasons to Pause Before Surgery
So what are some reasons to pause? One is active or unstable cardiovascular disease. And likely this is something really, yeah, I probably would assume that, but I just it's worth saying. So do they have, you know, chest pain, possible ACS, new or worsening dyspnea, decompensated heart failure, new or unstable or significant arrhythmias, syncope, murmurs, things like that. Right. So hopefully that would jump out to you being like, I don't know if we should proceed with the surgery, but those are just things to name that we're watching out for. We also want to look at those higher risk cardiovascular conditions, which may give us pause and want us to collaborate with the cardiovascular team as well as the surgery team.
So things like severe valvular disease, pulmonary hypertension, having a stent or a cabbage, recent stroke, having a pacemaker, frailty. So those are reasons to be like, maybe I need a little bit of input, especially if we're getting beyond that, like less than one percent of MACE low risk events.
Cardiovascular Risk Assessment
So after we think about those initial pieces, the thing we're going to do with our patients next is the kind of risk assessment estimators. You know, I love a good assessment tool, makes our jobs a little bit simpler and easier. So we're going to assess their cardiovascular risks. So the two the two tools that we that are recommended in the guidelines are RCRI, which is the Revised Cardiac Index, risk scoring, or you can use the ACS Nesquip risk calculator and SQIP. So for the RCRI is looking at a couple of things. So it's looking at how high risk is the surgery?
What is their history of heart disease or heart failure or cerebrovascular disease and other things like that to help estimate the RCRI score? And so if there's a low calculated risk, you can generally proceed without additional cardiac testing.
Functional Capacity
If there's an elevated risk, we also want to look at their functional capacity. And the way that we can look at that is another assessment tool called the DASI, and that's a Duke Activity Status Index. And that's just, again, just like a helpful tool for us to quickly assess what's going on with their functional status. And you're going to use your clinical judgment of the combination of do they have these more significant cardiovascular risk factors? We're going to look at their RCRI score. We're going to look at their DASI. And it's like, you know what, maybe we should think about consulting with the cardiovascular team before we continue and decide if they need any further support versus are they on the lower risk side?
Preoperative History
So when it comes to the actual visit with a patient, we're going to do a targeted history. And I have just like a I actually kind of like these visits. It's a little bit nerve racking to make that decision when they're in that borderline state of is this kind of safe to proceed? Or should we get some more management going forward? But it's a very kind of structured visit. So we're going to look at their past medical history, past surgical history, family history. We're going to do a med reconciliation. We're going to look at their alcohol, drug and tobacco use, because, again, that's going to be impacted post surgery, especially if they have to stay for a couple of days in the hospital.
They want to know what their baseline is. So what history, what surgeries have they had, again, in their past surgical history, but have they tolerated anesthesia or any adverse reactions? Do they have the personal or family history of malignant hypothermia in response to anesthesia? I always recap their chronic diseases and their current stability. So if they have type two diabetes, what's their A1C? What meds are they taking? It's kind of just some background for the surgeon in the hospital of like, what are they what are they kind of jumping into and what should they kind of expect going forward? Like, oh, this is, you know, at goal and it's managed by all these different specialists.
And there's nothing else that we need to do before they have surgery. The main kind of it's not that we have to go through every single disease that they have, but the main chronic conditions we're looking out for are, again, cardiovascular, pulmonary, cerebral vascular, kidney and liver, diseases, as well as diabetes. We also want to touch on any bleeding or clotting disorder history. Do they have sleep apnea or CPAP use and how are they using it? And do they have any pregnancy possibility if that is applicable to that patient?
Pulmonary Assessment
When it comes to pulmonary assessment, there aren't necessarily the risk calculators that there are for cardiovascular assessment. But we do want to jump in and say, hey, how are we doing with their asthma, COPD? Do they have a new respiratory infection? Do they again, do they have sleep apnea? How are they using CPAP if they use it? And if we think that they might need a screening for sleep apnea, hopefully we're doing that all the time in every visit with patients or when it's applicable. But you can consider using a screening tool, something like Stop Bang to help us understand do they need a workout for sleep apnea?
Physical Exam and Testing
There's no there's no hard and fast physical exam that we need to do for preoperative visits. We really want to think about what is the surgery? What do we need to assess? But typically speaking, I'm doing an HGENT exam, cardiovascular, pulmonary, GI, as well as extremity exam to look for any signs of fluid overload. And then the testing is really selective. It's really based on that guiding principle of what chronic conditions do they have? What would change management in terms of making us not want to proceed with the surgery? If their A1C was 15 or something like that, maybe that would be a reason to not proceed with a knee replacement right away.
I'm using again, I'm not saying that's a hard and fast rule. I'm just giving that as an example of maybe that's a reason to consider pausing and having a conversation with the surgeon as well as using your clinical judgment, as well as discussing with your supervisor, especially if you're a newer grad. But to especially note, no routine ECG for an asymptomatic patient undergoing a low risk surgery is recommended. We don't need to get a chest x-ray in an asymptomatic patient routinely before a surgery.
Perioperative Medication Plans
And lastly, I want to talk about medication plans. So we've already done the medication reconciliation, but we also want to specifically make note and communicate with the surgical or anesthesia team about things like anticoagulants or antiplatelets, diabetes medications and insulin, SGLT2 inhibitors, GLP1 medications, antihypertensives, NSAIDs and supplements, if that's applicable. And they likely have a plan set up already for those patients, but just making considerations about those things, collaborating with your supervisor if you're not sure. And then just a pearl about SGLT2 inhibitors, we do want to hold that three to four days before a planned surgery to reduce the perioperative metabolic acidosis risk or euglycemic DKA risk.
And basically, if you're not familiar, those have a med class side effect that with volume depletion, you can have normal glucose, but you can actually develop ketoacidosis when you're in those volume depleted states. And so typically that's the recommendation is holding around that time. So just checking in with your supervisor, checking in with the surgical and anesthesia team and coordinating how to manage medications around the surgery. So again, if you want to have all these written out for quick reference, you can check that out inside the digital NP binder at realworldnp.com slash binder.
Documentation
And the very last thing I almost forgot is what do we want to document? And so it isn't necessarily prescriptive of what we need to document, but effectively, this is a communication tool for the team that you're working with. What is the surgery? What's the date? What's the provider? What is the surgical risk estimated? What is your RCRI score? What is your DESI or DASI score if that's the one that you're using? You're documenting things like there's no active or unstable cardiopulmonary conditions, their relevant chronic conditions are reviewed, they're stable or optimized or etc. We're going to document their functional capacity if that's relevant, and we're going to document any pulmonary risks or concerns, any perioperative testing that we're doing or any medication plans that we've discussed.
And basically you're saying that based on this today's evaluation, there's no further evaluation as indicated before this planned procedure or that you recommend X, Y, and Z before the procedure. So yeah, so again, that's not legal advice. That's just like the general gist of what you are documenting to make sure that you're communicating with the team, both what you've done and where they can kind of pick up the patient's care when they're in the hospital setting or in that outpatient surgical setting. And yeah, if you want to have this all on a cheat sheet to keep at your desk, check out the digital NP binder at realworldnp.com slash binder.
Closing
And thanks so much for listening. Thanks for spending this time with us on Real World NP podcast. We're so glad you're here. If you haven't grabbed your copy of the ultimate resource guide for the new NP, head over to realworldnp.com slash guide to explore courses, resources, and more. You can also find that all at realworldnp.com until next time. Take care.
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