10.1 Preoperative & Intraoperative Care

Surgical Classifications

Surgery is classified by urgency and by severity. Urgency determines how much preparation time exists; severity predicts the physiologic stress and risk.

By severity: minor surgery carries minimal risk and is often performed with local anesthesia or moderate sedation (cataract extraction, skin lesion excision). Major surgery involves significant risk, prolonged anesthesia, and potential for major blood loss (thoracotomy, open abdominal aortic aneurysm repair, organ transplantation).

Preoperative Assessment

A thorough preoperative history includes prior surgeries and any personal or family history of anesthesia problems — always ask about malignant hyperthermia. Document comorbidities (diabetes, cardiovascular disease, chronic obstructive pulmonary disease, obstructive sleep apnea), smoking and alcohol use, latex allergy, functional status, and baseline vital signs, which become the comparison point for postoperative changes. Common preoperative testing includes a complete blood count, basic metabolic panel, coagulation studies (prothrombin time/international normalized ratio, activated partial thromboplastin time), type and screen for major procedures, a pregnancy test for women of childbearing potential, and an electrocardiogram based on age and history.

Medications: Hold or Continue

This is one of the most frequently tested areas of preoperative judgment.

Safety pearl: a patient with a coronary stent must never have antiplatelet therapy stopped without cardiology input — abrupt discontinuation risks stent thrombosis.

NPO Guidelines

Standard aspiration-prevention fasting guidelines: 8 hours for solid food (especially fried or fatty meals), 6 hours for a light meal, and 2 hours for clear liquids (water, black coffee, clear juice without pulp). Confirm NPO status as a last-minute verification item — always ask directly rather than assume. If the patient has eaten, notify the anesthesia provider and surgeon immediately; the case may be delayed or canceled.

Informed Consent: The Nurse's Role

Obtaining informed consent is the surgeon's legal responsibility — the surgeon explains the procedure, risks, benefits, and alternatives. The nurse's role is to witness the patient's signature and verify that consent was given voluntarily and that the patient understands what was explained. The nurse does NOT explain the procedure or its risks. If the patient is confused or has unanswered questions, the nurse notifies the surgeon to return and clarify before the consent is signed. A patient who has already received sedating preoperative medication cannot give valid consent, and consent must be verified on the preoperative checklist before any sedation is administered.

Preoperative Checklist and Verification

Before transport to the operating room, the nurse completes and documents a preoperative checklist:

• Signed informed consent, history and physical, and advance directives on the chart
• Baseline vital signs and required laboratory/diagnostic results reviewed
• Allergy band applied, including latex allergy verification
• NPO status confirmed with the time of last intake documented
• Hair removal with clippers, never a razor — razors cause micro-abrasions and increase surgical site infection risk
• Jewelry, dentures, glasses, contacts, hearing aids, nail polish, and prosthetics removed and secured
• Patient voids before transport (unless an indwelling catheter is present)
• Identity confirmed using two identifiers
• Surgical site marked by the surgeon with the patient awake and participating, when applicable
• Preoperative antibiotics administered within 60 minutes of incision

Preoperative Teaching

Teaching done preoperatively dramatically improves outcomes, because anxious, sedated postoperative patients retain little new information. Core elements:

• Incentive spirometer: inhale slowly and deeply through the device, hold 3-5 seconds, and repeat 10 times per hour while awake. This is the primary defense against atelectasis, the most common postoperative pulmonary complication. Emphasize sustained inhalation — the patient breathes in, not out, through the device.
• Coughing and deep breathing with splinting: hug a pillow firmly over the incision while coughing to reduce pain and the fear of opening the wound.
• Leg exercises: ankle circles, dorsiflexion/plantar flexion, and quadriceps sets promote venous return and reduce deep vein thrombosis risk.
• Early ambulation: explain that the patient will be out of bed the evening of surgery or on postoperative day 1; early mobility improves ventilation, circulation, bowel function, and muscle tone.
• Turning every 1-2 hours postoperatively, and how to use patient-controlled analgesia — only the patient presses the button.
• What to expect: tubes, drains, catheters, and a pain-control goal of manageable pain, not zero pain.

Anesthesia Types

Intraoperative Safety

The circulating nurse is the patient's advocate, managing positioning, counts, documentation, and traffic, while the scrub nurse/technologist maintains the sterile field and handles instruments.

• Positioning injuries: anesthetized patients cannot report pain or pressure. Pad bony prominences, maintain neutral alignment, and avoid hyperextension. Classic injuries include brachial plexus injury from arms extended beyond 90 degrees on arm boards, peroneal nerve compression in lithotomy position causing foot drop, and ulnar nerve compression at the elbow. Pressure injuries can begin within 2 hours.
• Surgical counts: sponges, sharps, and instruments are counted before the procedure, before wound closure, and at skin closure, by the scrub and circulating nurse together. A discrepancy halts closure until the item is found or imaging rules out a retained object.
• Time-out (Universal Protocol): immediately before incision, the entire team pauses to verbally verify the correct patient, procedure, site and side, implants, and antibiotic administration. Site marking and pre-procedure verification precede the time-out.
• Normothermia: forced-air warming prevents hypothermia, which increases bleeding, infection, and cardiac events.
• Malignant hyperthermia basics: a rare, inherited hypermetabolic crisis triggered by volatile inhalational anesthetics (such as sevoflurane) and succinylcholine. The earliest signs are unexplained tachycardia and rising end-tidal CO2, along with masseter (jaw) muscle rigidity; high fever is a late sign. Treatment centers on dantrolene sodium and active cooling (details in Section 10.3).