6.2 Perioperative Nursing & Surgical Care

6.2 Perioperative Nursing & Surgical Care

Perioperative nursing encompasses the continuum of patient care delivered throughout three distinct clinical phases: preoperative (from the decision to undergo surgery until transfer to the operating room), intraoperative (from entrance into the operating room until transfer to the post-anesthesia care unit [PACU]), and postoperative (from admission to the PACU through clinical convalescence and discharge). To ensure patient safety, mitigate surgical complications, and adhere to Department of Health (DOH) clinical standards, registered nurses must master regulatory consent protocols, surgical asepsis, crisis management, and postoperative surveillance.

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The Preoperative Nursing Phase

The primary goals of the preoperative phase are comprehensive clinical evaluation, baseline physiological stabilization, risk stratification, and patient preparation.

Informed Surgical Consent: Legal and Professional Roles

Informed consent is an ethical doctrine and legal mandate establishing the patient's autonomous right to determine what is done to their body. The DOH Patient Consent Standard requires a clear informed discussion within the facility's approved process:

• Treating Physician: Explain the condition, proposed intervention, aftercare, expected benefits, material risks, alternatives and consequences of refusal in language the patient understands. Answer questions and respect the patient's decision.
• Registered Nurse: Verify identity, voluntariness, understanding and capacity concerns; witness the signature as required by policy. A witness signature does not replace the informed discussion. Provide explanations within nursing competence and refer unresolved surgical risks or alternatives to the responsible surgeon.

Special Consent Circumstances

• Incompetent or Incapacitated Adults: If an adult cannot consent, verify any legally designated alternative decision-maker or court-appointed guardian and follow the applicable DOH substitute-consent process. When consent is sought from relatives, use the prescribed priority rather than assuming that any available relative may decide.
• Minors: Patients under 18 normally require consent from a parent or legal guardian. If authorized consent cannot be obtained, escalate to the responsible physician and follow the DOH substitute-consent or emergency process.
• Emergency Doctrine: If a life-threatening or limb-threatening surgical emergency exists and neither the patient nor any authorized surrogate is reachable, the principle of implied consent allows surgeons to proceed with immediate, necessary operative intervention without a signed document, supported by clear medical record documentation.

Preoperative Fasting Guidelines (NPO Status)

Preoperative fasting mitigates the catastrophic risk of pulmonary aspiration of acidic gastric contents during the induction of general anesthesia (Mendelson's syndrome). The American Society of Anesthesiologists (ASA) guidelines establish evidence-based minimum fasting intervals:

Surgical Care Improvement Project (SCIP) Infection Prevention Bundles

Surgical Site Infections (SSIs) represent a major preventable category of healthcare-associated infections. Preoperative evidence-based prevention bundles mandate:

• Prophylactic Antibiotic Timing: Administer prescribed intravenous prophylactic antibiotics within 60 minutes prior to surgical skin incision (allowing antimicrobial tissue concentrations to peak during tissue incision). For infusions requiring prolonged delivery times—specifically vancomycin and fluoroquinolones (e.g., ciprofloxacin)—infusion must begin within 120 minutes prior to incision to avoid rapid infusion reactions (such as vancomycin flushing syndrome).
• Appropriate Hair Removal: Never use manual razors for preoperative hair removal; razor shaving produces microscopic skin abrasions and epidermal micro-nicks that harbor proliferating bacterial pathogens. If hair removal is clinically necessary, use electric surgical clippers with disposable single-use heads immediately prior to surgery in the preoperative holding area.
• Preoperative Antiseptic Bathing: Instruct or assist patients to bathe or shower with chlorhexidine gluconate (CHG) antiseptic soap on the evening before and the morning of the procedure.

Preoperative Medication Management Protocols

Nurses must verify which chronic medications should be maintained, adjusted, or withheld prior to surgery:

• Anticoagulants and Antiplatelets: Follow the prescribed plan, balancing procedural bleeding and thrombotic risk. When interruption is required, warfarin is commonly stopped 5 days beforehand; apixaban/rivaroxaban usually 1–2 days, longer when renal impairment or procedure risk requires. Clopidogrel is generally held 5–7 days and ticagrelor 3–5 days. Manage aspirin with the surgical/prescribing team, especially after coronary stenting.
• Cardiovascular Agents: Continue beta-blockers (e.g., metoprolol, atenolol) on the morning of surgery with a small sip of water; sudden cessation causes rebound sympathetic surges, severe hypertension, tachycardia, and perioperative myocardial infarction. Verify the ACE-inhibitor/ARB plan: omission 24 hours before elevated-risk surgery may reduce hypotension in selected patients treated for controlled hypertension, while continuation for heart failure with reduced ejection fraction is reasonable. Follow the individualized anesthesia/prescriber order.
• Endocrine and Diabetes Medications: Hold SGLT2 inhibitors 3–4 days before elective surgery to reduce perioperative ketoacidosis risk; after emergency surgery, monitor for DKA even when glucose is not markedly elevated. Hold metformin and other oral glucose-lowering agents on the day of surgery. Give individualized prescribed basal insulin (commonly 75–80% of a long-acting dose or half-dose NPH); do not omit necessary basal insulin in type 1 diabetes. Check glucose every 2–4 hours while NPO. Follow the radiology protocol for any separate contrast-related metformin hold.

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The Intraoperative Nursing Phase

The intraoperative environment demands meticulous coordination, strict adherence to sterile technique, and vigilance against environmental and physiological hazards.

Multidisciplinary Surgical Team Roles

• Circulating Nurse: A licensed Registered Nurse who remains outside the sterile field. The circulating nurse manages all operations within the OR suite, maintains patient advocacy, coordinates equipment and supplies, monitors environmental temperature and sterility, connects electrical and suction apparatus, positions the patient safely, conducts surgical counts with the scrub nurse, labels and dispatches pathological specimens, documents the comprehensive intraoperative nursing record, and coordinates communication with family and PACU.
• Scrub Nurse / Surgical Technologist: A sterile team member who performs surgical hand antisepsis, dons sterile gown and gloves, arranges the sterile field and instrument tables, passes sterile instruments and supplies to the operating surgeon, anticipates surgical procedural needs, and performs counts with the circulating nurse.
• Anesthesia Provider: An anesthesiologist or certified registered nurse anesthetist who conducts pre-induction assessments, administers general, regional, or local anesthesia, secures and manages the airway, administers IV fluids and blood products, and continuously monitors vital physiological parameters.

Principles of Surgical Asepsis

Strict adherence to aseptic technique prevents microbial contamination:

• Sterile Field Boundaries: Surgical gowns are considered sterile on the anterior surface from the chest to the level of the sterile operative field, and the sleeves from two inches above the elbows to the stockinette cuffs. The back of the gown, neck, shoulders, axillae, and areas below the sterile field are always unsterile.
• Table Sterility: Only the horizontal top surface of a draped table is sterile. Any drape or suture hanging over the table edge is classified as unsterile.
• Movement Protocols: Sterile personnel touch only sterile items; non-sterile personnel touch only unsterile items. Sterile team members pass each other either back-to-back or face-to-face while keeping gloved hands clasped above waist level in front of the chest. Non-sterile personnel must maintain a minimum distance of 12 inches (30 cm) from any sterile surface.
• Contamination Rules: Any tear, pinhole puncture, or moisture contamination (strike-through) renders a sterile barrier contaminated. If any doubt exists regarding the sterility of an instrument or package, it must be considered unsterile and replaced immediately.

The WHO Surgical Safety Checklist

Endorsed by international surgical colleges and mandated by DOH Abu Dhabi, the World Health Organization (WHO) Surgical Safety Checklist establishes three critical pause points:

Surgical Counting Protocol

To eliminate Retained Foreign Objects (RFOs), the circulating nurse and scrub nurse must perform dual visual and audible counts across four standardized stages: (1) baseline count before incision; (2) before closure of any deep anatomical body cavity (peritoneum, pleura); (3) during closure of fascial layers; and (4) at final skin closure. If an item count is incorrect, the nurse must immediately alert the operating surgeon to halt closure, search the wound, sterile tables, floor, and waste receptacles, perform an immediate recount, and obtain a stat intraoperative wound radiograph (X-ray) before transferring the patient from the operating room.

Malignant Hyperthermia (MH) Crisis Protocol

Malignant Hyperthermia is a rare, life-threatening pharmacogenetic disorder of skeletal muscle inherited in an autosomal dominant pattern (primarily mutations in the ryanodine receptor gene, RYR1). Exposure to triggering agents provokes an uncontrolled surge of intracellular calcium release from the sarcoplasmic reticulum into the myoplasm, producing sustained muscle contractions, hypermetabolism, and cellular necrosis.

Triggering Agents and Safe Alternatives

• Volatile Inhalational Anesthetics: Sevoflurane, desflurane, isoflurane, and halothane.
• Depolarizing Neuromuscular Blockers: Succinylcholine.
• Safe Anesthetic Alternatives: Nitrous oxide, IV propofol, ketamine, etomidate, barbiturates, opioids, benzodiazepines, and non-depolarizing neuromuscular blockers (rocuronium, vecuronium).

Clinical Manifestations

• Earliest, Most Sensitive Indicator: An unexplained, dramatic, rapid rise in End-Tidal Carbon Dioxide (ETCO2) (often doubling or tripling, e.g., >60-80 mmHg) refractory to aggressive hyperventilation.
• Early Autonomic & Muscular Signs: Unexplained sinus tachycardia, tachypnea, labile blood pressure, mottling, cyanosis, and masseter muscle spasm / rigidity (trismus) following succinylcholine administration, preventing mouth opening for intubation.
• Late Signs: Generalized skeletal muscle rigidity ("board-like" rigidity), severe mixed respiratory and metabolic lactic acidosis, profound hyperkalemia, acute cardiac arrhythmias, myoglobinuria (dark amber or tea-colored urine resulting from extensive rhabdomyolysis), and hyperthermia (temperatures rising 1 to 2°C every 5 minutes, potentially exceeding 42°C [107.6°F]). Hyperthermia is a late sign; clinicians must never wait for fever to diagnose and treat MH.

Malignant Hyperthermia Emergency Protocol

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The Postoperative Nursing Phase

The postoperative phase begins upon transfer to the Post-Anesthesia Care Unit (PACU) and extends through surgical ward convalescence.

Phase I PACU Care and the Modified Aldrete Score

Upon PACU admission, the receiving nurse's immediate priority is evaluating airway patency and respiratory adequacy. The most common cause of early postoperative airway obstruction in unconscious or sedated patients is the tongue falling backward into the posterior pharynx; this is corrected immediately by performing a jaw-thrust or head-tilt chin-lift maneuver and inserting an oropharyngeal or nasopharyngeal airway.

Patients are evaluated for readiness for discharge from Phase I PACU to an inpatient surgical floor using the Modified Aldrete Scoring System. Five clinical parameters are graded from 0 to 2, yielding a maximum score of 10:

Common Postoperative Complications and Evidence-Based Interventions

1. Respiratory Complications: Atelectasis and Hypoxemia

Atelectasis (collapse of peripheral alveoli) is a common postoperative pulmonary complication caused by shallow breathing, pain-related splinting, and retained secretions. Findings include diminished basal breath sounds or fine crackles, tachypnea, and decreased SpO2. Fever in the first 24–48 hours frequently reflects the inflammatory response to surgery; assess for infection and other causes rather than attributing fever to lung collapse.

• Preventive Interventions: Instruct and encourage the patient to perform incentive spirometry (10 sustained deep breaths every hour while awake); teach diaphragmatic breathing and effective coughing while splinting the abdominal or thoracic incision with a pillow; ensure adequate multi-modal analgesia so pain does not inhibit respiratory excursion; and initiate early, progressive ambulation starting on postoperative day zero.

2. Cardiovascular Complications: Hemorrhage, Shock, and VTE

• Hemorrhage and Hypovolemic Shock: Manifests as progressive tachycardia (early), hypotension, narrowing pulse pressure, cold clammy skin, pallor, oliguria (< 30 mL/h), and copious bright red sanguineous drainage saturating surgical dressings or filling closed-suction drains (e.g., Jackson-Pratt, Hemovac). Nursing actions: reinforce external dressings (never remove initial surgical dressings placed in OR without surgeon order), elevate the patient's legs (modified Trendelenburg), open IV crystalloid infusions (0.9% Normal Saline or Lactated Ringer's), notify the surgical team stat, and prepare blood products for transfusion.
• Venous Thromboembolism (DVT and Pulmonary Embolism): Driven by Virchow's triad (venous stasis, endothelial vascular trauma, and hypercoagulability). DVT manifests as unilateral calf swelling, warmth, erythema, and localized tenderness. Pulmonary Embolism (PE) presents abruptly with dyspnea, pleuritic chest pain, tachypnea, tachycardia, and acute oxygen desaturation.
  • Prophylaxis: Apply bilateral sequential compression devices (SCDs) or graduated compression stockings before surgery; ensure SCDs remain operational whenever the patient is in bed; initiate subcutaneous low-molecular-weight heparin (enoxaparin 40 mg daily) once post-op bleeding risk subsides; and ambulate early.

3. Gastrointestinal Complications: Postoperative Ileus and PONV

• Postoperative Nausea and Vomiting (PONV): Triggered by volatile agents, abdominal manipulation, and opioid analgesics. Treat proactively with multimodal antiemetics (ondansetron 4 mg IV, dexamethasone 4 mg IV, or metoclopramide). Turn nauseated or vomiting patients onto their side to prevent aspiration.
• Paralytic Ileus: Temporary impairment of gastrointestinal motility resulting from bowel handling, peritoneal inflammation, and opioid administration. Signs: absent bowel sounds, abdominal distension, absence of flatus or stool, nausea, and vomiting. Interventions: keep patient NPO, insert or maintain nasogastric (NG) tube decompression to low intermittent suction if ordered, minimize intravenous opioids by utilizing non-opioid multimodal analgesics (acetaminophen, NSAIDs if renal function permits), and encourage ambulation.

4. Surgical Wound Complications: Dehiscence and Evisceration

• Wound Dehiscence: Partial or complete separation of the outer fascial or cutaneous margins of an operative incision without visceral extrusion. Risk factors include obesity, malnutrition, advanced age, diabetes, severe coughing, straining, and wound infection. It is classically heralded by a sudden gush of serosanguinous fluid from the dressing, accompanied by the patient reporting that "something popped or gave way."
• Wound Evisceration: A catastrophic, life-threatening surgical emergency characterized by the total separation of all wound layers and the actual protrusion of internal abdominal viscera (bowel loops) through the incisional defect.

Emergency Protocol for Abdominal Wound Evisceration

When wound evisceration occurs, the nurse must execute the following sequential emergency actions:

1. Remain with the Patient and Call for Help: Never leave the patient unattended. Press the emergency call bell to summon nursing colleagues and instruct them to notify the operating surgeon and surgical resident immediately.
2. Position the Patient Appropriately: Place the patient in a low-Fowler's position (15 to 30 degrees) with the knees and hips flexed (or semi-Fowler's with knees bent). This anatomical positioning relieves tension on the abdominal wall musculature and prevents further visceral extrusion.
3. Apply Sterile, Saline-Soaked Dressings: Immediately cover the protruding viscera with sterile surgical gauze, laparotomy pads, or towels thoroughly moistened with warm, sterile 0.9% normal saline. This protects delicate, exposed peritoneal membranes from atmospheric drying, airborne bacterial contamination, and vascular necrosis. Re-moisten dressings periodically with warm sterile saline; never allow the exposed tissue to dry out.
4. DO NOT Attempt to Reinsert Organs: Under no circumstances should the nurse attempt to push protruding loops of bowel or internal organs back into the peritoneal cavity. Doing so introduces lethal bacterial contaminants, causes bowel perforation, and induces mesenteric vascular strangulation.
5. Maintain Strict NPO Status: Place the patient on immediate, absolute NPO status in preparation for emergent exploratory laparotomy and surgical repair under general anesthesia.
6. Monitor Hemodynamics and Resuscitate: Assess vital signs every 5 to 10 minutes, monitoring for manifestations of hypovolemic shock. Ensure patent large-bore intravenous access, maintain IV fluid hydration as prescribed, and verify that blood type and screen or crossmatch is current.
7. Provide Calm Reassurance: Evisceration is a profoundly terrifying event. Reassure the patient, instruct them to avoid coughing or straining, and prepare them for rapid transport to the surgical operating suite.