Perioperative & Postoperative Care

Perioperative & Postoperative Care

Perioperative nursing spans three distinct phases of surgical care: preoperative, intraoperative, and postoperative. Registered nurses are responsible for preparing clients for surgery, monitoring recovery from anesthesia, and actively screening for and managing life-threatening postoperative complications.

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Preoperative Care and Safety

The preoperative phase begins when the decision to undergo surgery is made and ends when the client is transferred to the operating table. The nurse's primary focus is risk reduction, patient advocacy, and education.

The Preoperative Checklist

The preoperative checklist is a standardized tool completed prior to sedation or transfer to the operating room to verify that all necessary preparations are complete:

• Informed Consent: The surgeon is responsible for explaining the procedure, risks, benefits, and alternatives. The nurse witnesses the client's signature, confirming that the client is competent, signs voluntarily, and understands the explanation. If the client has questions about the surgery itself, the nurse must contact the surgeon to speak with the client before they are premedicated.
• NPO (Nil Per Os) Status: Verifying that the client has adhered to NPO guidelines (typically 6-8 hours for solid food, 2 hours for clear liquids) to prevent intraoperative aspiration.
• Patient Identification and Marking: Verifying the patient's identity using two identifiers (name and date of birth) and ensuring the surgical site is marked by the surgeon in participation with the client.
• Physical Preparation: Removal of jewelry, body piercings, prostheses, contact lenses, dentures, nail polish, and makeup. The client must wear a clean hospital gown, allergy bands, and a client identification band.
• Voiding: Instruct the client to void immediately before transfer to the operating room (after preoperative medications are administered or to prevent falls, the client should remain in bed with side rails up).

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Postoperative Recovery in the PACU

The immediate postoperative phase begins in the Post-Anesthesia Care Unit (PACU). The primary nursing priority is supporting the client's airway, ventilation, and cardiovascular stability during recovery from anesthesia.

PACU Priority Assessment (ABCs)

1. Airway Patency: Assess for obstruction (most commonly caused by the tongue falling backward in a semi-conscious client). Keep emergency airway equipment (suction, oral/nasal airways, bag-valve-mask) at the bedside.
2. Breathing and Ventilation: Monitor respiratory rate, depth, chest symmetry, and pulse oximetry.
3. Circulation: Assess blood pressure, heart rate, cardiac rhythm, peripheral pulses, capillary refill, and skin temperature. Monitor surgical dressings for bleeding.

Aldrete Scoring System

The Aldrete Score is a standardized assessment tool used to determine a client's readiness for discharge from the PACU to a medical-surgical unit. It evaluates five categories, with each category scored from 0 to 2:

• Activity: Ability to move limbs voluntarily or on command.
• Respiration: Ability to breathe deeply and cough.
• Circulation: Blood pressure within 20% of pre-anesthetic baseline.
• Consciousness: Full arousability and orientation.
• Oxygen Saturation: Maintenance of SpO2 > 92% on room air.

PACU Discharge Requirement: A minimum score of 8 to 10 is typically required for transfer.

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Management of Postoperative Complications

Once transferred to the clinical unit, the nurse must monitor for common postoperative complications, implement preventative care, and respond to emergencies.

1. Respiratory Complications: Atelectasis & Pneumonia

• Atelectasis (Alveolar Collapse): The most common cause of early postoperative fever (typically occurring within the first 24 to 48 hours). It is caused by shallow breathing due to residual anesthesia, pain, or immobility.
  • Assessment: Diminished breath sounds in lung bases, fine crackles, shallow respirations, and low-grade fever.
• Pneumonia: An infectious inflammation of lung tissue, typically developing 3 to 5 days postoperatively.
  • Assessment: High fever, productive cough with purulent sputum, coarse crackles/wheezes, dyspnea, and pleuritic chest pain.
• Nursing Interventions:
  • Incentive Spirometry: Instruct the client to exhale completely, seal their lips around the mouthpiece, inhale slowly and deeply to raise the cylinder, hold their breath for 3 to 5 seconds, and then exhale. Perform 10 times per hour while awake.
  • Coughing & Deep Breathing: Encourage deep, diaphragmatic breathing. Assist the client in performing splinted coughing by holding a pillow firmly against their abdominal or thoracic incision to support the muscles and minimize pain.
  • Early Mobilization: Assist the client out of bed as soon as prescribed to maximize lung expansion.

2. Cardiovascular Complications: DVT & Pulmonary Embolism

• Deep Vein Thrombosis (DVT): Thrombus formation in the deep veins of the lower extremities due to venous stasis, endothelial damage, and hypercoagulability (Virchow's Triad).
  • Assessment: Unilateral calf pain, swelling, warmth, redness, and edema.
  • Prevention: Apply Sequential Compression Devices (SCDs) or Intermittent Pneumatic Compression (IPC), fit anti-embolism stockings (TED hose), administer low-dose anticoagulants (e.g., Enoxaparin), and encourage leg exercises and early ambulation.
• Pulmonary Embolism (PE): A life-threatening emergency occurring when a DVT dislodges and travels to the pulmonary vasculature.
  • Assessment: Sudden onset of shortness of breath (dyspnea), sharp chest pain, tachypnea, tachycardia, and a drop in oxygen saturation.
  • Immediate Action: Raise the head of the bed, apply supplemental oxygen via nasal cannula or mask, obtain vital signs, notify the physician immediately, and prepare to administer anticoagulants (IV heparin). Do NOT apply SCDs or massage the legs if DVT is suspected.

3. Surgical Wound Complications: Dehiscence & Evisceration

• Wound Dehiscence: The partial or complete separation of outer wound layers.
• Wound Evisceration: The protrusion of internal organs (viscera) through the separated wound edges. This is a medical emergency.

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    A --> C["2. Stay with Client & Reassure Them"]
    A --> D["3. Cover Organs with Sterile Dressing Moistened with Normal Saline"]
    A --> E["4. Position Client in Low Fowler's with Knees Bent"]
    A --> F["5. Maintain NPO Status & Obtain Vital Signs"]
    
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• Immediate Nursing Protocol for Evisceration:
  1. Call for help and notify the surgeon immediately. Do not leave the client.
  2. Cover the protruding viscera with sterile dressings saturated with warm, sterile normal saline. This prevents the exposed bowel from drying, becoming ischemic, and necrosing.
  3. Position the client in a low Fowler's position (no higher than 15-20 degrees) with their hips and knees bent. This relaxes the abdominal muscles and reduces tension on the wound.
  4. Keep the client strictly NPO (Nil Per Os) in preparation for emergency surgical repair.
  5. Monitor vital signs frequently for signs of shock (tachycardia, hypotension).
  6. Instruct the client to remain still, avoid coughing, and breathe quietly.