Chapter 50: Perioperative Nursing Care

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Okay, let's unpack this.

The journey a patient takes through surgery

is incredibly dynamic, and nurses are truly at the heart of it.

It's far more than just what happens in the operating room.

We're talking about a continuous, patient -centered endeavor that stands from the moment a patient even anticipates surgery right through to their full recovery.

And what's fascinating here is how seamless this entire process needs to be and how essential your clinical judgment is at every single step.

This is the world of perioperative nursing.

It's, well, it's a planned, patient -centered approach that expertly navigates three critical phases.

The preoperative, intraoperative, and postoperative.

And for you, our dedicated college -level nursing student, our mission with this deep dive is to extract the most important nuggets of knowledge from the fundamentals of nursing chapter on this topic.

Yeah, kind of boil it down.

Exactly.

We'll distill key concepts like patient care principles, clinical decision -making, and crucial safety protocols, making them accurate, accessible, and ready for real -world application.

Think of it as your essential shortcut to being really well -informed.

Packed with practical insights and maybe even some surprising facts.

OK, let's get into it.

Let's do it.

So let's start with how we classify surgery because it's more nuanced than just big surgery or small surgery, right?

Right.

Medically, we often classify by its seriousness major involving extensive reconstruction or high risks versus minor for minimal alteration.

But here's the crucial nursing insight, I think.

While a cataract extraction might be medically minor, for that patient, it's their sight, their independence on the line.

As a nurse, you quickly learn that minor on paper often translates to major anxiety for the person experiencing it.

Oh, absolutely.

You have to see it through their eyes.

And then there's urgency.

OK.

Elective surgeries are based on patient choice, like a bunionectomy not essential right now, you know?

Gotcha.

Urgent procedures are necessary to prevent further problems like removing a cancerous tumor.

Right.

Time -sensitive.

Exactly.

And emergency procedures must be done immediately to save a life or preserve function, such as repairing a ruptured appendix.

Understanding this really helps you triage and prioritize.

Makes sense.

We also classify by purpose, which gives you immediate clues about the patient's journey, doesn't it?

Yeah, it does.

For instance, a diagnostic surgery, like an exploratory biopsy, is all about confirming a diagnosis.

Figuring things out.

Right.

An ablative surgery removes diseased tissue, like an amputation.

Then you have palliative surgery, focused purely on relieving symptoms without curing the disease.

Think a colostomy to improve comfort.

Quality of life focus.

Precisely.

And reconstructive surgery, which aims to restore function or appearance.

Knowing the purpose helps you anticipate the patient's emotional state and their recovery expectations.

OK.

Beyond classifications, there's a vital risk assessment tool, the ASA classification.

Yes, the ASA physical status classification.

It's used by surgeons and anesthesia providers, and it gives the entire team a quick snapshot of a patient's overall health before surgery.

So what does that look like?

Well, ASAI is a normal, healthy patient.

ASA third would be a patient with severe systemic disease, like maybe poorly controlled diabetes.

OK.

And ASAV means a patient is moribund, basically, not expected to survive without the operation.

Wow.

So if you see an ASAFA patient on your assignment, you immediately know this isn't just about the surgery itself.

It's about meticulous, intensified monitoring for systemic instability before, during and after.

Right.

So here's where your clinical radar really comes into play.

Yeah.

Not every patient walks in perfectly healthy.

Not at all.

Your role is to be a clinical detective, sort of spotting those crucial risk factors.

Mm hmm.

And you have to remember, every patient experiences a surgical stress response.

Their body's physiological reaction to the trauma of surgery activates the endocrine system, increases blood pressure, heart rate.

So that baseline response happens to everyone.

Right.

Understanding this helps you anticipate and manage their needs, even in a healthy patient.

But then you layer on specific risks.

OK, like what?

Well, take smoking and vaping, for instance.

Patients who smoke face increased risks for pneumonia,

atelectasis, that's where parts of the lung collapse.

Right.

And delayed wound healing.

As a nurse, educating them on these risks beforehand is crucial.

Absolutely.

Then there's age.

Both the very young and older patients are at greater risk for temperature control issues, often leading to hypothermia.

Yeah, temperature regulation is a big one.

And for older adults, you're looking at potentially diminished reserve across all major systems, cardiac, pulmonary, renal, plus a higher risk for falls due to changes in blood pressure regulation and increased risk for aspiration because their cough reflex might be weaker.

Exactly.

Nutrition is also critical.

Patients who are either very thin or obese are at greater risk.

How so?

Malnutrition, for example, can lead to poor anesthesia tolerance and delayed recovery.

This is why enhanced recovery after surgery or ERS protocols are so important.

Now, right.

ERS, I've heard about that.

They often include things like carbohydrate based drinks before surgery and encourage early oral feeding post -op aiming for at least 1500 kilocalories per day for optimal healing.

That makes sense.

OK, speaking of obesity, what are the specific concerns there?

Well, it diminishes both ventilatory and cardiac function, increasing the risk for atelectasis and venous thromboembolism or VTE.

Plus, these patients have a higher risk for wound complications like infection, dehiscence, where the wound edge is separate and evisceration, where organs actually protrude through the incision.

That's often because fatty tissue has poor blood supply and pressure injuries, too, right on the table.

Definitely.

That's a major consideration during positioning.

Another big risk factor increasingly recognized is obstructive sleep apnea or OSA.

OK, tell me about that.

This is a chronic sleep disorder where the airway periodically narrows or collapses.

It leads to pauses in breathing and oxygen desaturation.

And anesthesia makes it worse.

Exactly.

Sedatives in general anesthesia can really worsen OSA, making careful screening essential.

There's a common tool called the stop P bang questionnaire.

Stop bang.

Yeah.

It quickly screens for snoring, tiredness, observed apnea, high blood pressure.

That's the SIP part.

OK.

And the bang is high BMI over 35, age over 50, large neck circumference over 40 centimeters and male gender.

It's a really useful screening tool.

Good to know.

What else?

Well, obviously, conditions like immunosuppression increase the risk for infection and delay wound healing.

Also, fluid and electrolyte imbalances are a big deal.

How does surgery affect those?

Certical stress can cause the body to retain sodium and water while losing potassium, which increases the risk for heart rhythm problems.

Dysrhythmias.

Got it.

What about common post -op issues like nausea?

Right.

Post -operative nausea and vomiting PONV is common and frankly, miserable for patients, affects about 30 percent of them.

And it can be serious.

It can lead to complications like pulmonary aspiration if they vomit and inhale it.

Key risk factors include being female, a history of PONV or motion sickness and being a nonsmoker, actually.

Interesting.

OK, another one.

Urinary retention.

Yes.

Post -operative urinary retention.

P .O .U .R.

It affects up to 70 percent of patients, believe it or not.

Wow, that high.

Yeah.

So if a patient can't void four hours post -op, a bladder scan is crucial.

And for ambulatory patients, if they haven't voided eight hours after discharge, they need to seek medical help.

You need to teach them that.

OK.

And the last big risk factor, a truly critical one considered a never event by CMS is venous thromboembolism or VTE.

That includes deep vein thrombosis or DBT.

Never event, meaning preventable and hospitals don't get paid if it happens.

Exactly.

Key risk factors include general anesthesia lasting over 90 minutes, immobility, active cancer, age over 55, prior VTE, obesity.

Lots of things we've already touched on.

OK, so let's bring this back to a patient.

Let's think about our case study, Mr.

Cooper.

Jeff, the nurse, is identifying his risk factors now.

He's 72, new cancer diagnosis, facing a bowel resection.

So his age, the cancer, the type of surgery that immediately flagged several risks.

Right.

Absolutely.

Potential physiological reserve issues due to age, the significant surgical stress response from a major cancer surgery.

So Jeff's thinking,

what specific questions do I need to ask to really dig into Mr.

Cooper's unique risks for surgical complications?

That's where your critical thinking really kicks in.

Precisely.

And that leads us right into the preoperative phase, where the nursing process assessment, diagnosis, planning, implementation, evaluation, combined with that critical thinking, forms the backbone of perioperative care.

OK, so in the preoperative assessment, your role is to really dig deep.

It's so important to ask patients, tell me the type of surgery you are having in your own words.

Yeah, you need to gauge their understanding.

Right.

It helps you understand their knowledge and expectations of recovery, which might be very different from the medical teams.

For Mr.

Cooper, understanding his perspective on his upcoming colostomy is absolutely crucial for addressing his anxiety.

Beyond that, a thorough medical history review is vital.

You're looking for conditions that increase surgical risk, bleeding disorders, diabetes, heart disease, things that could complicate surgery or anesthesia.

Exactly.

For example, a patient with a history of heart failure might need slower IV fluid rates to prevent fluid overload.

You'll also ask about family history, especially for anesthetic complications like malignant hyperthomia.

Oh, right.

The genetic component.

Yes.

Yeah.

And a comprehensive medication and allergy review is non -negotiable.

And not just prescriptions, right?

Definitely not.

It includes over -the -counter medications, herbal supplements, things patients might not think are important, but can interact with anesthesia or affect bleeding like anticoagulants or even NSAIDs.

They had allergies?

Critically important, especially latex allergies.

You need to know about cross sensitivities, too, like to foods such as bananas or kiwi to ensure a latex -free environment if needed.

Good point.

Then we need to consider the person as a whole, emotional and cultural factors.

Absolutely.

You need to assess anxiety levels, self -concept, body image, again, for Mr.

Cooper, his colostomy will impact this significantly.

And they're coping resources.

And culture.

Cultural sensitivity is key.

Understanding their primary language, feelings about pain or religious convictions, like maybe an opposition to blood products.

You have to adapt your care.

OK.

What about the physical examination in this phase?

What's the focus?

It's focused.

You'll check hydration status, look at their oral mucus membranes, inspect the skin for pressure injury risk, particularly over bony prominences.

Thinking ahead to the OR table.

Exactly.

Think about positioning like the lithotomy position, legs up in stirrups.

That puts pressure on the sacrum and heels.

You'll listen to lung and heart sounds to get baselines and assess neurological status before anesthesia hits.

And diagnostic screening, labs and stuff.

Essential.

You need to understand why common lab tests are ordered.

Why check hemoglobin?

To look for anemia, glucose for diabetes or just the stress response,

INR.

To assess bleeding risk.

These results directly guide your plan of care.

OK.

So all this assessment information leads directly to nursing diagnoses and collaborative planning.

Right.

For instance, Jeff assessing Mr.

Cooper might lead to a diagnosis like anxiety related to insufficient information about surgery based on his concerns about the colostomy.

So it's about identifying the patient's problems.

Yes.

And then setting patient centered goals involving the patient and family to set realistic outcomes like Mr.

Cooper's goal to understand his colostomy better and manage his anxiety.

And remember, those ERS protocols help standardize care and improve outcomes based on evidence.

OK.

Now, a huge part of the preoperative nurse's role.

Preoperative education.

Oh, definitely.

This is where you become the patient's most important coach.

It's not just checking boxes, is it?

Not at all.

Preoperative teaching truly empowers the patient and profoundly impacts their recovery.

Research shows it can lead to reduced anxiety, improve lung function, faster recovery, better pain management.

It's huge.

What's the key content?

It starts with informed consent.

Now, remember, it's the surgeon's responsibility to explain the procedure risks benefits.

But the nurse's role.

Your role is to verify that the patient understands all of this before any sedation is given and that the consent form is signed correctly.

You're the final check, the patient advocate.

Got it.

Then you'll review preoperative routines like NPO.

Exactly.

Strict NPO guidelines.

Nothing by mouth.

That might mean no clear liquids two hours before surgery, no solid food for six to eight hours, depending on the policy.

And you explain why it's critical to prevent aspiration during anesthesia.

Makes sense.

What else?

Skin preparation, using antiseptic washes like chlorhexidine, gluconate or CHG, and emphasizing clipping hair, not shaving, because shaving causes micro nicks that can increase infection risk.

Good tip.

What about preparing them for the OR itself?

Prepare patients for anticipated sensations.

Describe the OR environment, bright, cool, the sounds of monitors.

It helps reduce anxiety if they know what to expect.

And pain?

You need to talk about pain relief measures.

Let them know pain is expected, but it is manageable.

Explain multimodal analgesia using different types of pain relievers together, like opioids with non -opioids.

And PCA pumps.

Yes.

Explain how patient controlled analgesia or PCA works and stress the importance of using it proactively.

Don't wait for pain to get severe before pushing the button.

Stay ahead of it.

OK.

And then there are the crucial postoperative exercises you teach beforehand.

Absolutely vital.

You need to teach and have them demonstrate these, like how to turn in bed safely and, crucially, how to splint the incision with a pillow when they move or cough.

Describe exactly how to hold it firmly against the incision.

Reduces pain.

Significantly.

Then you guide them through deep breathing and coughing exercises.

Maybe sitting up in high foulers, placing hands on the abdomen to feel the diaphragm move.

Inhale slowly through the nose, hold for a few seconds.

And then the cough?

A productive huff, cough, not just clearing the throat.

Explain the rationale.

Preventing adellectasis and pneumonia.

What about the incentive spirometer?

Explain its purpose.

It's a visual aid for deep breathing.

Show them how.

Exhale completely.

Seal lips around the mouthpiece.

Inhale slowly to raise the piston or ball to the target volume.

Hold for two, three seconds.

Then exhale slowly.

Helps expand the lungs.

OK.

And leg exercises.

Yes.

Guide them through specific movements.

Ankle rotations, pointing and flexing the feet.

Dorsiflexion plantar flexion.

Tightening thigh muscles.

Quadriceps setting.

Lifting hips and legs slightly.

Explain how these promote venous return and prevent DVT.

And finally, early ambulation.

Stress how vital it is for preventing complications and speeding up recovery.

You'll assess their tolerance later, but teach the importance now.

You can even give them a simple way to estimate a safe target heart rate for activity later on.

Wow, that's a lot of teaching.

It is, but it's so important.

An evaluation in the preoperative phase is ongoing.

You're checking if your teaching is sticking, like watching Mr.

Cooper use the incentive spirometer correctly and confirming that signed consent is truly informed.

OK, let's move into the OR,

the intraoperative nurse.

What's their primary role?

Patient advocate.

Absolutely.

You'll see two key nursing roles typically.

The circulating nurse is an RN who manages the whole OR suite.

They're constantly monitoring the patient, ensuring safety, documenting, coordinating the team, kind of the conductor of the orchestra.

Got it.

And the other role, the scrub nurse.

This can be an RN or a surgical technologist.

They work directly with the surgeon within the sterile field, handing instruments, anticipating needs very hands on.

And sometimes an RN first assistant.

Yes, that's an expanded role, an RN with advanced training who assists the surgeon directly with the procedure itself.

So safety in the OR is paramount.

What does that involve?

It starts with meticulous patient positioning.

Nurses protect anesthetized patients from injury, pressure injuries, nerve damage by carefully positioning them on the OR table using padding specialized devices.

Remember, the patient can't tell you if something hurts or is putting pressure on a nerve.

So you have to anticipate that.

You absolutely do.

And intraoperative warming is essential.

Active warming measures like force air warming blankets are used to prevent hypothermia.

Why is hypothermia so bad?

It can lead to serious complications.

Shivering, which increases oxygen demand, cardiac issues like arrhythmias or even a rest.

And it increases the risk of surgical site infections.

OK, another critical safety point, latex sensitivity or allergy.

You must identify this preoperatively and create a completely latex free environment if needed.

Latex is in so many things, gloves, tubing,

catheters.

And reactions can be severe.

They can range from a skin rash to a life threatening anaphylaxis.

You have to be vigilant.

Makes sense.

Yeah.

We also need to understand the different types of anesthesia and the nursing care involved, right?

Yes.

With general anesthesia, the patient has a complete loss of sensation and consciousness.

They're intubated.

So you're carefully monitoring respiratory status, vital signs for any depression or instability.

OK.

What about regional?

Regional anesthesia, like a spinal or epidural block, causes loss of sensation in a specific body area.

The patient might be awake or sedated.

Key monitoring includes watching for respiratory paralysis if the block goes too high or a sudden drop in blood pressure.

And local.

Local anesthesia is just site specific numbness, like for stitching up a cut.

And then there's moderate or conscious sedation.

Where they're relaxed, but awake.

Exactly.

They can respond to commands, maintain their own airway.

But you still need to monitor closely for respiratory depression because they are sedated.

OK.

Now, a huge safety protocol.

The universal protocol.

Absolutely crucial.

Designed to prevent those never events like wrong site, wrong procedure, wrong patient surgery.

What are the parts?

Three key components.

First, preoperative verification, making sure all the documents, consent, history, physical labs are present and consistent.

Marking the operative site.

The surgeon marks the correct site with indelible ink, ideally with the patient involved while they're awake.

And third, the timeout.

This is a mandatory pause just before the incision.

The entire surgical team stops and confirms allowed.

Correct patient, correct procedure, correct site, any necessary implants available.

Everyone has to agree.

Non -negotiable safety step.

Totally.

And to ensure smooth information flow between phases, the SBR handoff communication tool is used.

Situation, background, assessment, recommendation.

It provides a standardized structure for clear, concise, critical information transfer, say from the preoperative nurse to the OR nurse.

Really reduces errors.

OK.

And evaluation during the intraoperative phase.

That's largely the circulating nurse's role.

Ongoing monitoring, patient's temperature, skin integrity under the drapes and positioning devices, fluid balance, estimated blood loss and crucially, keeping the family informed with periodic updates during long procedures.

Right.

OK, surgery is done.

Now we move to the postoperative nurse and guiding the recovery.

Exactly.

And recovery happens in phases.

Phase one is the immediate,

intense monitoring, usually in the post anesthesia care unit.

TCU, guys.

Phase two is early, less intense recovery, often for ambulatory or same day surgery patients.

Focus is on preparing for discharge home.

And phase three.

That's convalescent care.

Ongoing observation and care for hospitalized patients, preparing them for self care or maybe transfer to a rehab unit.

So let's focus on immediate postoperative recovery.

PCU phase one.

What's the absolute top priority?

Airway patency.

Always, always, always.

It's the most critical concern right after anesthesia.

Right.

The tongue is a common obstruction when muscles are relaxed from anesthesia.

That's why placing the patient in a side lying position until they're more awake is key, helps keep the airway open.

Makes sense.

What does the initial PCU assessment involve?

It's rapid, thorough head to toe.

You're checking vital signs constantly, respiratory status, oxygen saturation,

breath sounds, effort level of consciousness, pain level, the condition of dressings, drains, IV fluids,

comparing everything to the baseline report you got from the OR team.

And managing common complications.

Yes.

Like PONV having anti -medics ready.

POUR doing bladder scans if they haven't voided.

And of course, ongoing monitoring for bleeding or VTE signs.

How do they decide when a patient can leave PCU?

Based on specific discharge criteria.

Stable vital signs.

Patient is awake and alert or back to their baseline.

Pain and nausea are controlled.

Often scoring systems like the post anesthetic discharge scoring system or PADSS are used to make it objective.

OK.

What about recovery in ambulatory surgery?

Phase two, preparing for home.

The focus shifts more to patient comfort and getting them ready for self care.

Patient teaching for home care is absolutely paramount here.

What needs to be included?

Clear, written instructions.

Contact info for questions or problems.

Medication details.

What, when, how much.

Activity and diet restrictions.

Wound care instructions.

And warning signs.

Critically important.

Signs of complications to report immediately.

Fever, increased pain, redness or drainage from the wound.

Trouble breathing.

And you must use the teach back method.

Explain that.

You ask the patient and their family member to restate the instructions back to you in their own words.

It confirms they actually understood, not just nodded along.

This is vital for safe discharge and preventing readmissions.

Great point.

Now, for recovery of inpatients, phase three, those staying in the hospital.

It's about continuous detailed assessment, but maybe less frequent than PSU.

Vital is every 15, 30 minutes initially, then maybe hourly, then every four hours.

Always comparing to baseline to detect complications early.

And reinforcing those preoperative teachings.

Absolutely.

Maintaining respiratory function is key.

Keep reinforcing early ambulation, deep breathing, coughing, incentive spirometry.

Don't let them forget.

And preventing circulatory complications.

Same deal.

Stressing leg exercises, applying compression devices like IPC stockings.

Those sleeves that inflate and deflate around the calves to mimic walking and push blood back up.

Oh, yeah, the sequential compression devices.

Right.

And encouraging early ambulation to prevent DVT.

Plus, you're vigilantly monitoring for any signs of hemorrhage, checking dressings, drains, vital signs.

You mentioned malignant hypothermia, MH earlier.

Can that show up post -op too?

Yes.

Although it usually starts interoperatively, it can manifest or recur in the PICU.

Remember, it's that rare genetic disorder causing a hypermetabolic state.

Signs again.

Rapid breathing, tachypnea, fast heart rate, tachycardia, muscle rigidity, and especially a rapidly rising temperature.

It's an emergency.

And the treatment.

Gantuline sodium.

You need to know where it is and how to administer it fast.

OK.

What else is key in phase three?

Fluid and electrolyte balance.

Maintaining IV patency, meticulously tracking intake and output, urine, drains, NG tube output, and often daily weights to monitor fluid status.

And getting the gut working again.

Gastrointestinal function.

Yes.

General anesthesia slows GI motility.

So early ambulation is key here, too.

You listen for bowel sounds, ask about passing gas, flattice, and progress the diet slowly as tolerated, usually starting with clear liquids.

And urinary function.

Managing P .O .U .R.

if it occurs, but also aiming to get indwelling catheters out as soon as possible to prevent C .I .U .T .I.'s catheter associated urinary tract infections.

That's a major hospital acquired infection focus.

OK.

Skin and wound care.

Ongoing assessment.

Keep checking for pressure injuries.

They can sometimes take 48 hours or more to show up after prolonged or a time.

Inspect the wound regularly for drainage type and amount.

Signs of infection usually appear four to five days post -op redness, warmth, pus and watch closely for separation, dehiscence or the worst case scenario, evisceration.

Protect the wound and comfort.

Ensuring rest and comfort involves aggressive pain management.

Use those multimodal approaches we talked about.

Non -pharmacological methods to positioning, distraction, relaxation.

Encourage patients to take their scheduled pain meds.

Don't let your pain get ahead of you.

Good advice.

What about the psychological side?

Maintaining self -concept is crucial, especially after surgeries that change body image like Mr.

Cooper's colostomy.

Provide privacy during wound care.

Help maintain hygiene.

Support their independence as much as possible.

Be sensitive.

And finally, looking towards discharge for inpatients.

Restorative and continuing care emphasizes an interprofessional team approach.

Physical therapy, occupational therapy, social work, home care nursing, all collaborating for robust discharge planning and rehabilitation, especially for complex cases or frail older adults.

So as we wrap up this deep dive, it's really clear, isn't it?

Your role as a nurse in the perioperative journey is incredibly dynamic and

truly comprehensive.

Absolutely.

From that meticulous preoperative assessment and teaching through vigilant intraoperative advocacy and then guiding the patient safely through recovery.

Your impact is felt at every single step.

It really is a unique blend of skills.

It is.

If we connect this to the bigger picture,

your ability to synthesize all this diverse information, anticipate patient needs before they happen and act decisively with sound clinical judgment.

That's what elevates good care to truly exceptional care in the perioperative setting.

It's that mix of science, observation, critical thinking and compassionate, patient centered care.

You can't forget that piece.

So as you prepare for your clinical practice, maybe consider this.

How will you use these principles of meticulous assessment and tailored education not just to, you know, perform the care tasks, but to truly partner with each patient?

How will you make their journey through surgery as safe, as comfortable and as empowering as possible?

That's the goal, right?

Thank you for joining us on this deep dive.

We're really honored to have you as part of our learning community here at the deep dive.