Chapter 16: Perioperative Nursing Care

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Welcome to the Deep Dive.

Today, we're getting into a really fundamental part of nursing perioperative care.

That's right.

We're drawing from the Saunders Comprehensive Review for the NCLE -XPN Examination Seventh Edition.

Basically, we'll cover the whole journey.

From getting ready for surgery through recovery and even potential problems.

Think of it as everything you as the learner need to know, whether it's for your exams, your job, or just understanding the process better.

It's all about patient care during that surgical experience.

And the book highlights two big concepts right away.

Infection and safety.

Yeah, those are huge.

They really underpin everything we'll be talking about today.

You'll see them come up again and again.

The chapter even kicks off with a critical thinking bit about informed consent, which really puts the nurse's role front and center.

Exactly.

It's not just paperwork.

So let's dive in, starting with that crucial first phase, preoperative care.

Okay, so before anyone even gets near an OR,

there's a lot happening.

Informed consent seems like the place to start.

Absolutely.

It's foundational.

But it's important to know who does what.

Right.

The surgeon explains everything.

Yeah.

The risks, benefits, the procedure itself.

Precisely.

The surgeon has the responsibility for that explanation.

The nurse's role is a bit different.

So the nurse witnesses the signature?

Witnesses the signature, yes, but it's more than just watching them sign.

The nurse needs to verify that the patient actually seems to understand what the surgeon told them.

Ah, okay.

So if the patient seems confused after the surgeon leaves?

Then you absolutely need to get the surgeon back.

You can't just witness the signature if there's doubt about comprehension.

The surgeon needs to clarify things first.

That makes sense.

It has to be truly informed.

What about trickier situations like minors?

Right.

For minors under 18, you usually need consent from a parent or legal guardian.

And their ability to understand, a legal guardian might need to consent for them too.

It depends on their cognitive status.

What about psychiatric clients?

Do they lose their right to consent?

No, absolutely not.

They retain the right to refuse treatment, just like anyone else, unless a court has specifically determined they lack that capacity.

Patient autonomy is key.

Got it.

And a really crucial point, no sedation before signing, right?

Definitely not.

That would impair their ability to give informed consent.

They need to be fully aware.

The CHEPR also mentions telephone consent.

How does that work safely?

Yeah.

If the patient can't sign, but say a legal guardian is available by phone, that's possible.

But, and this is important, another nurse must listen in on that call as a witness to verify the consent was given.

Double verification.

Good safety measure.

Okay.

Let's shift to nutrition.

NPO status, nothing by mouth.

Why is that so critical?

Primarily, it's about preventing aspiration during anesthesia.

That's when stomach contents get into the lungs.

Very dangerous.

So you always follow the specific orders from the doctor?

Always.

But general guidelines are usually maybe six to eight hours without solid food before general anesthesia.

Maybe three hours for clear liquids before local.

But always check the specific order.

And IV lines, they usually get put in before surgery.

Often, yes.

It gives access for fluids, meds, and importantly, the CHEPR notes using a large catheter just in case blood products are needed quickly during the surgery.

Always be prepared.

Makes sense.

Okay.

Next up, elimination.

Bowel prep.

Is that always needed?

Not always, but often for intestinal or abdominal surgeries.

The surgeon might prescribe enemas or laxatives.

Why do that?

It cleans out the bowel, which can reduce infection risk and maybe give the surgeon a clear review.

And bladder -wise.

The patient needs to void urinate right before heading to the OR.

If they need a urinary catheter, it's either put in pre -op or sometimes after anesthesia starts.

Empty it just before surgery.

Document the output.

Got it.

What about preparing the actual surgical site, the skin itself?

Usually involves cleaning with a special antiseptic soap maybe the night before or morning of, if prescribed.

Reduces bacteria on the skin.

And hair removal?

Shaving?

The guidance is actually against using razors now.

They can cause tiny cuts, increasing infection risk.

So what's preferred?

Electric clippers or a special surgical shaver is better if hair removal is necessary at the site.

Good to know.

And hair on the head?

Or face?

Like eyebrows.

Only removed if it directly interferes with the surgery, and only if the surgeon orders it.

It's not routine.

Okay.

Let's talk about patient teaching before surgery.

This seems like a huge part of the nurse's role.

What do patients need to know?

A lot.

It's about managing expectations and empowering them for recovery.

They need to know what to expect after surgery, waking up in the PPCU, the monitors, the general timeline.

And pain management is obviously a big concern.

Huge.

You need to tell them to ask for pain relief.

That medication will be available based on the doctor's orders.

And teach them the pain scale, 0 to 10.

So they can communicate effectively.

Exactly.

The goal isn't zero pain necessarily, but managing it to a tolerable level so they can

move, breathe deeply.

The chapter mentions reassuring patients about addiction fears with post -operative opioids.

Yes, that's important.

Short -term use for acute surgical pain is very unlikely to cause addiction.

Addressing that fear is key.

And if they'll have a PCA pump, patient -controlled analgesia.

Right.

They need clear instructions on how to use it safely before surgery.

Are non -drug methods for pain also taught?

Definitely.

Things like relaxation, guided imagery, deep breathing.

Encourage them to use these before the pain gets bad.

Smoking is another big one for pre -op teaching.

Absolutely.

Smokers need to stop at least 24 hours before, but ideally much longer.

It impacts breathing and healing.

You should also discuss resources to help them quit for good.

And their regular medications.

Crucial conversation.

They need to tell the surgeon everything they take prescriptions.

Over -the -counter, aspirin, vitamins, herbs.

Some need to be stopped days or weeks before surgery.

Because of interactions or bleeding risk.

Exactly.

The surgeon gives specific instructions on what to stop and when.

Then there are those post -operative exercises they need to learn beforehand.

Yes.

Deep breathing and coughing exercises are vital.

Using that incentive spirometer helps prevent lung complications like pneumonia and ateleftasis.

Atelectasis.

That's collapsed alveoli, right?

Correct.

Very common after surgery if patients don't expand their lungs well.

Box 16 -1 in the chapter gives detailed instructions.

And leg exercises.

Also key.

Simple things like ankle pumps, leg raises.

They help prevent blood clots, venous stasis.

The chapter shows figures and refers to the box again.

Plus, using those SCDs.

Sequential compression devices.

The inflatable leg sleeves.

Yep.

Figure 16 -2 shows those.

They squeeze the legs gently to keep blood moving.

What about splinting an incision?

Important for abdominal or chest surgery.

You teach them to hold a pillow firmly against the incision when they cough or deep breathe.

Why?

Reduces pain?

Reduces pain, provides support, and helps prevent the wound edges from separating that's called dehiscence.

Figure 16 -3 and box 16 -1 illustrate this.

Patients also need preparing for, well, tubes and drains.

Yeah, let them know if they might wake up with an NG tube, drains, a catheter, IV lines.

Tell them not to pull on anything and reassure them they'll come out as soon as possible.

Okay.

Beyond the physical, what about the psychological side?

Anxiety.

Huge factor.

Nurses need to be tuned into the patient's anxiety level.

Encourage them to talk about their fears.

Says listen.

Listen.

Answer questions honestly.

Address concerns.

Provide privacy for them to kind of process things.

Offer support.

And be aware of cultural aspects too.

Box 16 -2 touches on that.

Makes sense.

Now, right before they go to the OR, there's the preoperative checklist.

Sounds critical.

It absolutely is.

It's like the final safety check.

Ensures everything's done, signed, documented.

Like what specifically?

ID band.

Ah.

Allergies.

Yes.

Check the ID band.

Check for all allergies, including latex.

Review the whole list to make sure nothing's missed.

Follow agency policy.

And consent forms.

All of them.

All of them.

Procedure, anesthesia, blood transfusion consent if needed.

Limb disposal if relevant.

Sterilization consent.

All signed and in the chart.

Wow, it's detailed.

What else?

History and physical.

Confirmed H &P is documented.

The chapter has box 16 -3 on medical conditions that increase surgical risk that's reviewed.

Any necessary clearances like cardiology noted, lab results, ECG reports, chest x -ray.

All verified.

All verified and documented.

Consultation reports in the chart.

Blood type and screen or cross -match confirmed and within the valid time frame.

What about personal items?

Jewelry.

Dentures.

Generally removed per policy.

Jewelry, makeup, dentures, hairpins, nail polish, prostheses.

Valuables secured or given to family.

Documented.

Exception.

Hearing aids and glasses often stay until the last minute for communication.

And ensure translator access, if needed, right up until anesthesia.

Okay, last minute checks on the list.

Final vital signs documented.

Record the last time they ate or drank anything.

Document that they voided.

And note any preoperative medications given box 16 -4 lists substances that can affect surgery.

Speaking of those preop meds, what's the nurse's role there?

Either administer them as prescribed or make sure they're ready for the OR staff.

And importantly, tell the patient why they're getting them like for anxiety or to dry up secretions.

And safety after giving them if they cause drowsiness.

Huge priority.

Keep them in red.

Side rails up per policy.

Call bell within reach.

Tell them explicitly not to get up without help.

Fall risk is high.

Okay, so after all that, the patient arrives in the OR.

Safety is still paramount, right?

Especially preventing wrong site surgery.

Absolutely critical.

The surgeon should have already marked the site with indelible ink in the preop area.

And that mark gets checked again.

Yes.

The OR nurse and surgeon reconfirm the mark in the OR itself.

Then, before the first cut, there's the timeout.

The timeout.

Tell me about that.

Everyone stops.

The entire team, surgeon, anesthesia, nurses, they verbally confirm correct patient, correct procedure, correct site.

It's a vital pause to prevent errors.

Sounds incredibly important.

What else happens when they arrive?

OR nurse verifies the ID band again, asks the patient their name and birth date.

They do a final chart check consent, H &P, allergies, verify the doctor's orders, start an IV if not already done, then anesthesia steps in.

Constant vigilance.

Always.

Especially patient ID and surgical site verification.

You can't be too careful.

Okay.

Surgery's done.

Now we're into post -operative care.

Big transition.

Big transition.

Now the focus shifts to recovery, preventing complications, getting the patient back to health.

The chapter mentions stages.

Immediate, intermediate.

Yeah.

Immediate is roughly the first one to four hours, usually in the PACU.

Intermediate is maybe four, 24 hours.

Extended is the next few days.

Needs and risks change through these stages.

Let's focus on the immediate stage.

Respiratory system first seems top priority.

Absolutely.

You're listening closely to breath sounds.

Stridor, wheezing, crowing could mean airway obstruction.

Crackles or raunchy might mean fluid like pulmonary edema.

Vital signs.

Airway.

Monitor vitals constantly compared to their baseline.

Ensure the airway is patent open.

Check ventilation.

Remember, anesthesia can affect breathing for a while.

Even if they're awake.

If they're still groggy, they might struggle to keep their airway clear.

Monitor closely.

Suction secretions if they can't cough effectively.

Watch chest movement.

Is it symmetrical?

Are they using extra muscles to breathe?

Oxygen monitoring.

Monitor any oxygen admin.

Definitely watch the pulse oximetry.

SpO2.

Sometimes end -tidal CO2 is monitored too.

And those exercises they learned before.

Deep breathing, coughing.

Encourage them.

ASA.

Use that incendiosperometer.

Figure 16 of 4 shows it.

Monitor their respiratory rate.

Depth.

Quality.

Normal adult rate is maybe 1030 breaths minute post -op.

Watch for any signs of distress or atelectasis.

Okay.

Cardiovascular next.

What are we looking for?

Circulatory status.

Skin color.

Peripheral pulses.

Cap refill.

Any edema.

Numbness.

Tingling.

And crucially monitor for bleeding.

Check dressings.

Drains.

Heart rate and rhythm.

Check the pulse rate and rhythm.

A bounding pulse could mean high blood pressure or fluid overload.

Watch for any dysrhythmias.

And be aware of thrombophlebitis risk, especially after certain positions like lithotomy.

Use anti -embolism stockings if ordered.

Mustula skeletal system.

How soon do they move?

Assess their ability to move extremities.

Always check the surgeon's orders for positioning or restrictions.

Encourage ambulation, if prescribed, but carefully.

Sit them on the edge of the bed first.

Let them dangle their feet.

Check for dizziness.

Positioning in bed?

Low Fowler's position usually helps lung expansion and less contraindicated.

Avoid lying flat until their gag reflexes back.

Side lying is often good if they're still groggy.

And turn immobile patients every 1 -2 hours.

Prevents skin breakdown.

Helps lungs.

Neurological status.

Level of consciousness.

Monitor that closely.

Keep trying to orient them as they wake up.

Where are you?

What happened?

Use a calm voice.

Keep noise down.

Keep them warm.

Two warm blankets.

Adjust room temp.

Temperature affects neurological recovery.

So temperature control is its own point.

Hypothermia risk.

Yes.

Anesthesia.

Cool ORs.

Body exposure.

All can lower temperature.

Monitor their temp.

If they're cold or shivering, apply warm blankets.

Keep oxygen on.

Maybe give meds for shivering if ordered.

Integumentary system.

The skin.

The wound.

What's the focus?

Check the surgical site.

Drains.

Dressings.

A little serious drainage is normal, but report excessive bleeding immediately.

Check their skin generally for redness or breakdown from positioning during surgery.

Wound infection signs.

Monitor for warmth, redness, swelling, pain, purulent drainage, fever.

Keep dressings dry and intact.

Change them as ordered.

Noting drainage amount, color, odor.

Check suture staple integrity.

What about drains?

Ensure they're patent.

Working.

Measure and document drainage.

Report sudden changes, big increases, or sudden stops.

Assist with removal when drainage lessens, as ordered.

Abdominal binders might be used for support, especially in obese patients, to prevent

Fluid and electrolyte balance is ongoing.

Continuous monitoring.

Track voivy fluids.

Record all intake and output meticulously.

Watch for signs of imbalance.

Monitor lab results.

Replace electrolytes as ordered per protocol.

Gastrointestinal system.

Nausea, vomiting, common.

Can be.

Monitor intake output.

Assess for nausea.

If there's an NG tube, maintain patency, check placement,

monitor suction, and drainage.

Assess for abdominal distension.

Listen for bowel sounds.

Ask about flattest signs that the gut is waking up.

Oral care.

When can they eat?

Frequent oral care is important, especially while NPO.

Stay NPO until the gag reflex returns and you hear bowel sounds.

Then start slow ice chips, clear liquids, advances tolerated per orders.

If they vomit, turn them on their side, have suction ready to prevent aspiration.

Renal system, making sure they can urinate.

Assess for bladder distension, especially if retention is likely.

Use palpation or a bladder scan.

Monitor urine output.

Need at least 30 millimelods per hour.

If no catheter, they should void within about 6 -8 hours post -op, at least 200 millimellor.

Okay, last big area of post -op assessment.

Pain management.

Critical.

Absolutely critical for comfort and recovery.

Assess the pain thoroughly.

Type, location, intensity using that 0 -10 scale.

Or a descriptor scale, if needed.

Look for objective signs, too.

Yes, facial expressions guarding vital sign changes can indicate pain, especially if the patient can't verbalize well.

Ask how well the last dose worked.

Medication administration.

Give meds as prescribed.

If using a PCA pump, reinforce instructions, make sure they understand.

Monitor respiratory rate and CO2 if ordered, especially with opioids.

Monitoring after opioid doses.

Crucial.

Check vitals before giving the first dose.

Then reassess respiratory rate and pain relief about 30 minutes after, especially with initial doses.

Don't forget non -drug methods.

Never!

Use distraction, comfort measures, positioning,

back rubs, keep the environment quiet, document the effectiveness of everything meds and non -invasive measures, and consider cultural factors in pain expression and management.

Okay, that covers routine post -op care.

But things can go wrong?

Let's talk complications.

Box 16 -5 is key here.

Pneumonia and atelectasis first.

Right.

Pneumonia inflammation infection, maybe from aspiration or immobility, shows up 3 -5 days post -op,

usually.

Atelectasis collapsed alveoli from mucous plugging much sooner, 1 -2 days post -op, it's the most common one.

Figure 16 -5 shows atelectasis.

Signs to watch for.

Shortness of breath, dyspnea, increased respiratory rate.

Pneumonia might add fever, productive cough, chest pain, crackles.

Interventions.

Monitor lungs, temp.

Encourage fluids, ambulation.

Reposition every 1 -2 hours.

Keep pushing deep breathing, coughing, incentive spirometer, suction if needed.

Chest physiotherapy might be ordered.

Hypoxemia.

Low oxygen in the blood.

Yeah, often from shallow breathing due to anesthesia or pain meds.

Signs include restlessness, dyspnea, sweating, fast heart rate, high BP initially, then maybe cyanosis and low spio 2.

What do you do?

Monitor for signs, notify our insurgent stat, try to fix the cause.

Keep monitoring lungs, PO2.

Give oxygen as ordered.

Encourage cough, deep breathing, repositioning, ambulation.

Re -checks PO2 after intervening.

Pulmonary embolism.

PE sounds serious.

Very serious.

A clot usually from the leg travels and blocks a lung artery.

Life -threatening.

Sudden shortness of breath, sharp chest or upper abdominal pain.

Cyanosis, tachycardia, drop in blood pressure.

Notify our insurgent immediately.

Monitor vitals.

Give oxygen.

Meds as ordered.

Prepare for potential urgent interventions.

Hemorrhage.

Significant bleeding.

Yes, internal or external happening quickly.

Look for restlessness, weak rapid pulse, low BP, fast breathing, cool clammy skin, reduced urine output.

What's the immediate response?

Apply pressure if it's external bleeding.

Notify our insurgent stat.

Give oxygen, IV fluids, maybe blood as ordered.

Prepare for possible return to surgery.

Shock often follows hemorrhage.

Usually hypovolemic shock from the fluid loss.

Same signs, basically poor perfusion.

Interventions for shock.

Notify our insurgent stat, oxygen.

Treat the cause, the bleeding.

Monitor level of consciousness, vitals closely, HR up, BP down.

Intake output, skin signs.

Assist with rapid fluid blood colloid administration.

Thrombophlebitis, vein inflammation with a clot, usually legs.

Correct.

Signs are aching, cramping pain.

The vein might feel hard, cord -like, tender, maybe low fever, swelling in one leg.

Prevention and care.

Monitor legs closely for swelling, pain, etc.

Report stat if found.

Elevate leg 30 degrees.

Avoid pressure behind the knee.

Use anti -embolism stockings, SCDs if ordered.

Passive ROM if on bed rest.

Early ambulation is key once allowed.

No leg dangling, don't sit too long.

Anticoagulants might be prescribed.

Urinary retention, inability to void.

Yeah, from anesthesia or opioids affecting bladder tone.

Usually six, eight hours post -op.

Signs, can't void, restless, sweaty, lower abdominal pain.

Distended bladder on palpation or scan, maybe high BP.

What else?

Monitor voiding, check for distension.

Encourage ambulation, fluids if allowed.

Help them stand or use commode.

Privacy, try running water sound, warm water over perineum.

If nothing works, catheterization might be ordered.

Constipation common after surgery.

Very.

Due to inactivity, diet changes, anesthesia, opioids.

No bowel movement within 48 hours of eating solids might mean constipation.

Look for abdominal distension, poor appetite, headache, nausea.

Check bowel sounds, push fluids.

Three all day, okay, ambulation.

Encourage fiber if diet allows.

Privacy for toileting.

Stool softeners or laxatives, often prescribed, especially with opioids.

Paralytic alias, more serious like a bowel movement.

Yes, the bowel just stops moving temporarily.

It causes anesthesia, bowel handling and surgery, low potassium, opioids.

Signs, nausea, vomiting, distension, absent bowel sounds, no gas or stool.

NPO, until bowel sounds return.

NG tube, often used for decompression.

Keep it patent, maybe on suction.

Encourage ambulation.

5E fluids or parenteral nutrition.

Maybe meds to stimulate motility.

Usually non -surgical first.

Wound infection signs again.

Usually three, six days post -op.

Fever, chills.

Incision looks warm, tender, painful, red, swollen, maybe tight skin.

Purulent drainage.

Elevated white blood cell count.

Interventions.

Monitor temp.

Assess incision using redness, edema, ecomosis, drainage approximation.

Report infection signs.

Maintain drain patency.

Use aseptic technique for dressing changes.

Give antibiotics as ordered.

Lastly, wound adhescence and evisceration.

Scary ones.

Adhescence is wound edges separating.

Evisceration is organs protruding, both usually six to eight days post -op.

Evisceration is an emergency, more common in obese patients or after abdominal surgery.

Figure 16 -6 shows this.

Signs of adhescence.

Increased drainage, maybe serosanguineous.

Wound edges visibly opening.

Underlying tissue might be seen.

And evisceration.

Sudden gush of serosanguineous fluid from a previously dry wound.

Visible bowel loops or organs.

Patient might say they felt something pop.

Priority actions for evisceration.

This is critical.

Stay calm.

Call for help immediately.

Are in contact, surgeon.

Get supplies.

Stay with the patient.

Position them low foulers, knees bent.

Cover the protruding organs with sterile saline soaked gauze.

Keep it moist.

Monitor vitals for shock.

Prepare for immediate surgery.

Document everything.

Wow, okay, quick actions needed there.

Shifting gears, slightly ambulatory surgery.

When can patients go home?

They need to be alert, oriented, have voided.

No respiratory distress.

Stable vitals and O2 set.

Able to walk, swallow, cough.

Pain minimal.

No significant bleeding.

No vomiting.

And crucially, a responsible adult to drive them.

Plus, the surgeon's okay.

Discharge instructions or P here too.

Box 16 -6.

Absolutely vital.

Give written instructions to patient and family.

Cover potential complications.

Home care resources.

No driving for 24 -8 years after general anesthesia.

Who to call for problems.

Follow -up appointments.

Specifics on wound care.

Meds.

Activity.

Yes.

How to care for the incision.

Change dressings.

Shower cover incision.

Supply dressings for 48 years.

When suture staples come out, usually 7 -10 days.

Steri strips fall off on their own.

Detailed med instructions.

Purpose, dose, side effects.

Diet fluids.

Six take.

Glasses day.

Activity limits resume gradually.

No heavy lifting for maybe six weeks after major surgery.

When to return to work.

Surgeon advises, often six to eight weeks.

And clear sign symptoms of complications and exactly when to call a surgeon.

Very thorough.

Okay, let's quickly run through those practice questions to submit some key points.

Question 131.

Essential pre -op activities.

Making sure the client voids right before surgery and verifying that signed consent form is in the chart.

Both crucial.

132.

Client worried about surgery.

First step.

Ask them what they know.

You need to understand their specific concerns before you can address them.

133.

What pre -op data must be reported.

Things like penicillin allergy, recently quitting smoking, worries about incontinence post -op, and a history of DVT.

All impact care.

134 post -op vitals.

BP, 13060, P90, RR20.

Actions.

Assess how the client feels.

Dizzy.

Check when they last had pain meds and compare these vitals to their PCU baseline to see the trend.

135.

Initial action on PCU admission.

Airway.

Always assess airway patency first, ABCs.

136 bays.

Which finding most likely indicates a complication.

Urinary output of only 20 mH that's too low suggests potential kidney issues or retention.

Needs follow -up.

137 post -op fever, cough, crackles .2.

Pneumonia.

Classic signs.

138.

Caring for a Jackson -Pratt drain.

Basically all the listed actions are correct.

Check patency, keep it decompressed for suction, monitor drainage, use sterile technique when emptying, empty regularly.

139 signs suggesting wound infection.

Purulent drainage and tender firmness around the incision.

Strong indicators.

And 140.

Increased drainage, wound separation, tissue visible.

Apply a sterile saline dressing immediately and notify the RN provider.

Those are signs of dehiscence.

Okay, that covers the questions.

So wrapping up this deep dive, we've really gone through the entire period operative journey based on that Saunders chapter.

Yeah, from pre -op prep, touching on those crucial intra -op checks like the timeout, through detailed post -op management, potential complications, and discharge planning.

And those themes of infection and safety kept coming up.

Constantly.

They are absolutely central to everything a nurse does in the period operative setting.

It's all about keeping the patient safe and preventing problems.

Understanding all this detail is just so vital for providing that safe, effective nursing care we aim for.

Absolutely.

Which leads to maybe a final thought for you, the listener, to ponder.

Given everything we've discussed, the complexity, the risks, the different phases, what single aspect of period operative nursing care do you think ultimately makes the biggest difference in achieving a positive outcome for the patient?

That's a great question to reflect on.

Something that requires balancing technical skill with communication and vigilance.

Thank you for joining us on this comprehensive exploration of period operative nursing.

We hope this deep dive has been helpful and clarified this really essential area of practice for you.