7.5 Perioperative & Complications Management

The Perioperative Continuum

Perioperative care spans three phases - pre-operative (before surgery), intra-operative (in the operating room), and post-operative (recovery through discharge). On the CPNRE and REx-PN, most surgical items sit within Reduction of Risk Potential, testing whether you can prevent predictable complications and recognize the earliest sign of one. The practical nurse's guiding question is always: what am I doing to lower this client's risk, and what deterioration must I catch first?

Pre-Operative Assessment, Consent, and Teaching

Pre-operative work establishes a baseline (vital signs, allergies, medications, mobility) so post-operative changes are meaningful. Allergy screening is safety-critical: a reported previous severe reaction to iodinated contrast must be reported before any contrast CT scan, because re-exposure can trigger anaphylaxis. Confirm the client is NPO as ordered to reduce aspiration risk under anesthesia. Informed consent must be signed before sedation and is procedure-specific - if the surgical approach changes significantly, the original consent is void and a new one is required. The nurse witnesses the signature and confirms understanding but does not obtain consent for the surgeon's procedure.

Structured pre-operative teaching directly reduces complications. Teaching deep breathing, coughing, and use of an incentive spirometer promotes lung expansion and prevents post-operative atelectasis and pneumonia. Teach leg exercises and early ambulation to prevent venous stasis, and review pain management and splinting of the incision so the client cooperates after surgery.

Intra-Operative Safety and the Time-Out

In the operating room, safety hinges on the surgical safety checklist and the time-out - a deliberate pause before incision when the whole team confirms the correct client, correct procedure, and correct site (site marking), plus allergies, antibiotic prophylaxis, and equipment. This prevents wrong-site and wrong-person surgery, classic never events. Maintaining sterile technique, accurate sponge and instrument counts, and safe client positioning to protect skin and nerves are core intra-operative risk-reduction measures the practical nurse supports within scope.

Post-Operative Care and the PACU

Recovery begins in the post-anesthesia care unit (PACU), where priorities follow the ABCs: a patent airway and adequate breathing first (anesthesia and opioids depress respiration), then circulation - vital signs, the surgical site, and drains. Monitor level of consciousness, pain, temperature, and urine output; a urine output below about 30 mL per hour signals hypovolemia or renal hypoperfusion and must be reported. Keep the client's airway protected in a side-lying or head-turned position until fully awake, watch for a respiratory rate under 12 breaths per minute, and reassess frequently because the early hours carry the highest risk of bleeding and respiratory depression. Discharge from the PACU follows objective criteria (stable vitals, protected airway, controlled pain, and return of protective reflexes) rather than a fixed clock.

Recognizing and Preventing Complications

Hemorrhage is often internal: after a liver biopsy, increasing abdominal pain with a rising heart rate and falling blood pressure signals internal bleeding and demands immediate action. After femoral cardiac catheterization, watch the puncture site for bleeding or hematoma and check distal pulses, colour, temperature, and sensation, keeping the leg straight. Phlebitis at a peripheral IV (redness, warmth, and a palpable cord along the vein) means stop the infusion, remove the IV, and restart at a new site.

Venous thromboembolism is largely preventable: early and progressive mobilization, leg exercises, hydration, and prescribed anticoagulation or sequential compression devices reduce DVT and its feared sequel, pulmonary embolism. If PE is suspected, the priority is to stay with the client, raise the head of the bed, apply oxygen, and notify the prescriber urgently. Wound dehiscence and evisceration are surgical emergencies - cover protruding bowel with sterile normal saline-moistened gauze, position the client supine with knees flexed to reduce tension, keep them NPO, and call the surgeon. In the postpartum client, a boggy uterus with increasing bleeding indicates uterine atony, and the first action is to massage the fundus until firm before escalating.

Reduction-of-Risk Priorities and a Common Trap

The unifying skill across these emergencies is recognizing a deteriorating trend early. Vital signs of blood pressure 88/54 mmHg with a heart rate of 122 bpm, pallor, and diaphoresis are classic early shock, and the correct answer is to recognize the trend and act promptly rather than wait for a single dramatic sign. A frequent exam trap is choosing to document, reassess later, or call the family when the client needs an immediate physiological intervention; documentation always follows the intervention. Another trap is applying comfort measures (a warm blanket, an oral analgesic) to a client who actually needs oxygen, positioning, and urgent notification. Prevention is equally weighted: early mobilization is the single most powerful post-operative intervention, simultaneously reducing DVT and PE, atelectasis and pneumonia, ileus, and pressure injury. Across every scenario, the reduction-of-risk priority is the same - anticipate the predictable complication, intervene early, and escalate the moment a warning trend appears.