Preoperative, Intraoperative & Postoperative Nursing Care

Perioperative nursing encompasses the entire surgical journey across three distinct phases: preoperative (from the decision to undergo surgery until transfer to the operating room bed), intraoperative (from transfer to the operating bed until admission to the Post-Anesthesia Care Unit [PACU]), and postoperative (from PACU admission to complete recovery and surgical discharge). Mastering the physiologic principles, patient safety mandates, and legal standards of each phase is essential for safe nursing practice and competitive examination success.

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1. Preoperative Nursing Care

The primary goals of the preoperative phase are to establish a comprehensive physiological baseline, identify surgical risk factors, alleviate anxiety, and prepare the patient physically and psychologically for anesthesia and intervention.

Comprehensive Baseline Assessment

• Cardiovascular & Respiratory Status: Obtain baseline vital signs, baseline 12-lead ECG (especially for patients > 40 years or with cardiovascular history), and chest radiography. Auscultate bilateral lung fields and heart sounds. Chronic smoking impairs mucociliary clearance and increases carboxyhemoglobin; elective surgery candidates are advised to cease smoking at least 4 to 8 weeks prior to reduce pulmonary complications.
• Renal & Hepatic Function: Serum creatinine, blood urea nitrogen (BUN), and liver enzyme panels (AST, ALT, bilirubin) evaluate the body's capacity to metabolize and excrete anesthetics, sedatives, and analgesics.
• Hematological & Coagulation Profile: Hemoglobin, hematocrit, platelet count, and coagulation metrics (Prothrombin Time [PT], International Normalized Ratio [INR], and activated Partial Thromboplastin Time [aPTT]) detect occult bleeding diatheses or anemia.
• Allergy Screening: Document drug allergies and specific reactions. Screen for latex allergy, which shares cross-reactivity with bananas, avocados, kiwis, chestnuts, and tomatoes. Inquire about povidone-iodine (Betadine) allergies, traditionally associated with shellfish or iodine sensitivities.
• Medication Reconciliation:
  • Anticoagulants / Antiplatelets: Warfarin is typically discontinued 5 days preoperatively (bridged with Low Molecular Weight Heparin [LMWH] if high thromboembolic risk); aspirin and clopidogrel are held 5 to 7 days prior; direct oral anticoagulants (DOACs like apixaban, rivaroxaban) are held 24 to 48 hours prior depending on renal clearance.
  • Hypoglycemics & Insulin: Oral hypoglycemics (metformin held 48 hours preoperatively due to lactic acidosis risk with IV contrast); long-acting insulin doses are modified (e.g., 50–75% of evening dose) on the day of surgery with frequent capillary blood glucose monitoring.
  • Antihypertensives: Beta-blockers are generally continued with a sip of water on the morning of surgery to prevent rebound tachycardia and myocardial ischemia; ACE inhibitors and ARBs are frequently withheld on the day of surgery to prevent refractory intraoperative hypotension.

Preoperative Patient Education

Effective preoperative teaching significantly reduces postoperative pulmonary complications, pain scores, and hospital length of stay:

1. Diaphragmatic Deep Breathing & Coughing: Teach the patient to take slow, deep breaths through the nose, hold for 3 seconds, and exhale completely through pursed lips, followed by two or three deep coughs to mobilize bronchial secretions.
2. Incisional Splinting: Instruct the patient to hug a folded towel or pillow firmly over abdominal or thoracic incisions while coughing or moving to minimize tension on the suture line and reduce incisional pain.
3. Incentive Spirometry: Instruct the patient to sit upright, seal lips tightly around the mouthpiece, inhale slowly and deeply (sustained maximal inspiration) to raise the piston/ball to the target volume, hold breath for 3 to 5 seconds, and exhale passively. Perform 10 breaths every hour while awake.
4. Leg & Ankle Exercises: Demonstrate active dorsiflexion, plantarflexion, ankle circles, and quadriceps-setting exercises (pressing knees flat against the mattress) every 1 to 2 hours while awake to stimulate the calf muscle pump and prevent venous thromboembolism.

Legalities of Informed Surgical Consent

Informed consent is an ethical and legal prerequisite for any invasive surgical procedure:

• Surgeon's Responsibility: The operating surgeon holds the sole legal responsibility to obtain informed consent. The surgeon must explain: (1) the exact nature of the procedure, (2) the medical indication, (3) anticipated benefits, (4) potential material risks and complications, (5) reasonable alternatives (including non-operative management), and (6) the prognosis if surgery is declined.
• Nurse's Responsibility: The nurse acts strictly as a witness to the consent process. The nurse verifies that:
  1. The patient is signing the document voluntarily without coercion.
  2. The signature is authentic and belongs to the patient (or legal guardian).
  3. The patient appears mentally competent, alert, oriented, and free from sedative or opioid medication influence at the time of signing.
  4. Critical Rule: If the patient expresses confusion, reveals misconceptions, or asks detailed questions about risks or alternative treatments, the nurse must not attempt to explain surgical details. The nurse must withhold sedation, withhold the consent form, and immediately notify the operating surgeon to return to the bedside for clarification.
• Special Circumstances:
  • Minors: Legal consent must be obtained from a parent or legal guardian, except in cases of legally emancipated minors, married minors, or specific statutory medical exemptions (e.g., emergency care, STI treatment, contraception, substance abuse treatment).
  • Emergency Exception Doctrine: When an unconscious, incapacitated, or incompetent patient requires immediate life- or limb-saving surgical intervention and no designated surrogate or next-of-kin is reachable, surgery may proceed under the emergency doctrine. The clinical necessity must be clearly documented by the attending surgeon (and preferably confirmed by a second independent physician).
  • Medical Incompetence: If an adult patient is legally declared incompetent or incapacitated by delirium, dementia, or severe intoxication, consent is obtained from the legal medical power of attorney (healthcare proxy) or next-of-kin.

Preoperative Fasting Guidelines (ASA Guidelines)

To prevent pulmonary aspiration of gastric contents during anesthesia induction, strict adherence to evidence-based fasting schedules is mandatory:

Physical Preparation & Pre-Anesthetic Medications

• Skin Preparation: Hair removal at the surgical site is performed only if hair directly interferes with the incision. Electric clipping immediately prior to surgery is the standard of care; razor shaving is strictly contraindicated because micro-abrasions dramatically elevate Surgical Site Infection (SSI) rates. Antiseptic bathing with chlorhexidine gluconate (CHG) reduces cutaneous bacterial bioburden.
• Gastrointestinal Preparation: Enemas or bowel cleansing solutions (e.g., polyethylene glycol) are indicated for colorectal procedures alongside oral non-absorbable antibiotics (neomycin, erythromycin base) to reduce intraluminal colonic bacterial loads.
• Pre-Anesthetic Pharmacotherapy:
  • Anticholinergics (Atropine, Glycopyrrolate): Reduce excessive oral, pharyngeal, and bronchial secretions; prevent reflex vagal-induced bradycardia during laryngoscopy and surgical manipulation.
  • Sedatives / Benzodiazepines (Midazolam): Administered for anxiolysis, sedation, and anterograde amnesia (bed rails raised; patient monitored for respiratory depression).
  • Gastrointestinal Agents: H2-receptor antagonists (Famotidine) and proton pump inhibitors (Pantoprazole) decrease gastric acid secretion; prokinetics (Metoclopramide) accelerate gastric emptying.
  • Prophylactic Antibiotics (e.g., IV Cefazolin): Administered within 60 minutes prior to surgical incision (within 120 minutes for vancomycin or fluoroquinolones) so that peak bactericidal tissue concentrations coincide with the skin incision.

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2. Intraoperative Nursing Care

The intraoperative phase begins when the patient is received into the surgical suite and continues until transfer to PACU. The operating room (OR) environment is strictly zoned to minimize airborne microorganisms and maintain surgical asepsis.

Operating Room Zoning & Microclimate

• Unrestricted Zone: Street clothes permitted; includes the holding reception area, locker rooms, and nursing stations.
• Semi-Restricted Zone: Scrub attire and hair covering (surgical cap) required; masks optional unless sterile supplies are exposed; includes storage corridors, instrument processing areas, and surgical scrub sink hallways.
• Restricted Zone: Full surgical attire required (scrub suit, hair covering, surgical mask, and eye protection; sterile gowns and gloves for sterile personnel); includes the active operating room suites.
• OR Microclimate:
  • Ventilation: Positive pressure laminar airflow (minimum 15 to 20 air changes per hour, including ≥ 3 outdoor air changes) ensures air flows outwards when doors open, preventing contaminated corridor air from entering.
  • Temperature: Maintained between 20°C and 24°C (68°F to 75°F) to inhibit bacterial growth while balancing patient hypothermia risks.
  • Relative Humidity: Maintained between 30% and 60%; levels < 30% increase electrostatic discharge hazards, while levels > 60% foster bacterial and fungal proliferation.

Surgical Team Roles: Sterile vs. Non-Sterile Members

• Sterile Team Members (perform surgical hand scrub, wear sterile gown and gloves, work directly within the sterile field):
  • Surgeon: Leads the surgical team and performs the procedure.
  • Surgical Assistant / First Assistant (MD, PA, or RNFA): Retracts tissues, assists with hemostasis, suctions, and sutures under the surgeon's direction.
  • Scrub Nurse / Surgical Technologist: Prepares and maintains the sterile instrument field, passes instruments and supplies to the surgeon, anticipates surgical needs, and participates in surgical counts.
• Non-Sterile Team Members (function outside the sterile field, wear scrub suits, caps, and masks):
  • Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA): Administers anesthesia, manages airway and ventilation, infuses IV fluids and blood products, and monitors hemodynamic stability.
  • Circulating Nurse (Registered Nurse): Coordinates the entire OR environment, manages patient positioning, performs skin antiseptic prep, ensures aseptic technique across the room, acts as patient advocate, documents intraoperative care, and conducts surgical counts with the scrub nurse.

Surgical Counts Protocol

To prevent Retained Surgical Items (RSI), standardized counting of sponges, sharps (needles, blades), and instruments is mandatory at four distinct intervals:

1. Initial baseline count prior to skin incision.
2. Before closure of any deep cavity or hollow organ within a cavity.
3. At the initiation of wound closure (fascia / subcutaneous tissue).
4. At final skin closure. Count Discrepancy Protocol: If a count is incorrect, the circulating nurse immediately informs the surgeon, the surgical field and room are thoroughly searched, the count is repeated, and if unresolved, an intraoperative radiograph (X-ray) of the surgical site is performed before the patient leaves the operating suite.

The WHO Surgical Safety Checklist

Developed to dramatically reduce avoidable perioperative morbidity and mortality, the World Health Organization (WHO) Surgical Safety Checklist identifies three mandatory checkpoints:

Surgical Positioning Complications

Improper patient positioning during anesthesia creates severe nerve compression, ischemic tissue injury, and hemodynamic compromise:

• Supine (Dorsal Decubitus): Pressure points at occiput, scapulae, sacrum, and calcaneus; arms abducted < 90 degrees to avoid brachial plexus stretch injury.
• Trendelenburg (Head tilted down): Increases venous return to the heart, but elevates intracranial and intraocular pressures; restricts lung expansion by displacing abdominal viscera against the diaphragm.
• Reverse Trendelenburg (Head tilted up): Facilitates upper abdominal visualization; risk of hypotension due to peripheral venous pooling in the lower extremities.
• Lithotomy (Legs in stirrups): Essential for perineal, gynecological, and urological procedures. Major Risk: Compression of the lateral aspect of the knee against stirrups damages the common peroneal nerve, resulting in foot drop and loss of foot dorsiflexion. Extreme hip flexion can compress the femoral nerve or obturator nerve. Prolonged lithotomy (> 2 hours) dramatically raises the risk of lower extremity compartment syndrome. Legs must be raised and lowered simultaneously to avoid pelvic torsion and sudden hemodynamic shifts.
• Prone (Face down): Demands cervical spine alignment; eyes and ears must be meticulously padded to prevent corneal abrasion and retinal artery thrombosis; pressure on breasts in females and genitalia in males must be relieved.
• Lateral Decubitus: Requires an axillary roll placed inferior to the dependent axilla (never directly in the axilla) to prevent brachial plexus compression and preserve vascular perfusion to the dependent arm.

Anesthesia Modalities

• General Anesthesia: Reversible loss of consciousness, sensation, analgesia, amnesia, and skeletal muscle relaxation via IV induction agents (Propofol, Ketamine, Etomidate) and volatile inhalational agents (Sevoflurane, Isoflurane, Desflurane) alongside neuromuscular blockers (Vecuronium, Rocuronium, Succinylcholine).
• Regional Anesthesia: Blockade of nerve conduction to a specific anatomical region without loss of consciousness:
  • Spinal Anesthesia: Local anesthetic injected into the subarachnoid space (cerebrospinal fluid [CSF]) below L2 (typically L3–L4 or L4–L5, below the termination of the conus medullaris). Results in sensory, motor, and autonomic blockade.
  • Epidural Anesthesia: Local anesthetic injected into the epidural space (outside the dura mater); catheter can be placed for continuous infusion.
  • Spinal Complications: (1) Hypotension: Sympathetic nervous blockade produces systemic vasodilation and arterial/venous pooling; managed with pre-procedure IV crystalloid hydration (500–1,000 mL) and vasopressors (Ephedrine, Phenylephrine). (2) Post-Dural Puncture Headache (PDPH): Occurs due to CSF leakage through the dural puncture hole, lowering intracranial pressure; headache is characteristically frontal-occipital, throbbing, worsens dramatically when sitting or standing, and resolves when lying flat. Management includes bed rest, aggressive oral/IV hydration, caffeine sodium benzoate, and if refractory, an epidural blood patch (injecting 10 to 20 mL of autologous blood into the epidural space to form a fibrin plug over the dural leak).
• Moderate Sedation / Conscious Sedation: Drug-induced depression of consciousness (e.g., Midazolam + Fentanyl) where the patient maintains patent airway reflexes independently and responds purposefully to verbal commands.

Malignant Hyperthermia (MH): Intraoperative Emergency

• Pathophysiology: Rare, autosomal dominant pharmacogenetic disorder of skeletal muscle. A genetic defect in the ryanodine receptor gene (RYR1) on chromosome 19 causes an uncontrollable, massive release of intracellular calcium from the sarcoplasmic reticulum into the myoplasm. This triggers sustained muscle contractions, an overwhelming hypermetabolic state, hypercarbia, metabolic acidosis, rhabdomyolysis, and severe hyperthermia.
• Triggering Agents:
  1. Volatile halogenated inhalational anesthetics (Sevoflurane, Isoflurane, Desflurane, Halothane).
  2. Depolarizing neuromuscular blocker: Succinylcholine.
• Clinical Presentation:
  • Earliest Signs: Unexplained, sudden sinus tachycardia, tachypnea, and a rapid, profound rise in end-tidal carbon dioxide ($EtCO_2$) that fails to respond to increased mechanical ventilation.
  • Muscular Signs: Masseter muscle spasm / trismus (jaw rigidity following succinylcholine administration) and generalized skeletal muscle rigidity.
  • Hemodynamic & Metabolic Signs: Cyanosis, cardiac dysrhythmias, severe metabolic and respiratory acidosis, hyperkalemia (from muscle breakdown), elevated serum creatine kinase (CK), and myoglobinuria (tea-colored urine).
  • Late Sign: Dramatic, rapid hyperthermia—body temperature rises 1°C to 2°C every 5 minutes, reaching temperatures up to 43°C (109.4°F).
• Emergency Management Protocol (MHAUS Guidelines):
  1. Immediately halt triggering agents: Discontinue all volatile anesthetics and succinylcholine; inform the surgeon to stop or conclude surgery immediately.
  2. Hyperventilate: Ventilate with 100% oxygen at maximum flow rates (≥ 10 L/min) using a clean, non-contaminated breathing circuit to wash out anesthetics and eliminate excessive carbon dioxide.
  3. Administer Dantrolene Sodium: The only specific antidote. Administer an initial IV bolus of 2.5 mg/kg rapidly through a large-bore IV line. Repeat boluses of 1 to 2.5 mg/kg every 5 to 10 minutes until tachycardia, muscle rigidity, and hypercarbia resolve (up to a cumulative maximum dose of 10 mg/kg). Dantrolene mechanism: Binds directly to the RYR1 ryanodine receptor, blocking sarcoplasmic calcium release.
  4. Active Cooling Measures: Infuse cold normal saline (4°C) IV; perform chilled irrigation of open body cavities, bladder, and stomach; apply surface ice packs to axillae, groin, and neck. Cease active cooling when core body temperature reaches 38°C (100.4°F) to prevent hypothermic overshoot.
  5. Correct Acidosis & Hyperkalemia: Administer IV sodium bicarbonate (1–2 mEq/kg) for severe metabolic acidosis. Treat hyperkalemia with regular insulin (10 units IV) plus 50% dextrose (50 mL), alongside calcium chloride/gluconate to stabilize the cardiac membrane.
  6. Maintain Diuresis: Administer IV fluids, mannitol, or furosemide to maintain urine output ≥ 1 to 2 mL/kg/hour to flush myoglobin and protect against acute tubular necrosis.

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3. Postoperative Nursing Care

The postoperative phase begins with PACU admission. The primary focus is maintaining airway patency, monitoring cardiovascular stability, relieving pain, and detecting early surgical complications.

PACU Airway & Respiratory Management

Upon arrival, the nurse immediately assesses the patient's airway, breathing, and circulation (ABCs):

• Hypopharyngeal Airway Obstruction: The most common cause of early postoperative airway obstruction in the unconscious patient is the tongue falling backward against the posterior pharynx due to residual neuromuscular blockade and sedation. Signs include snoring respirations, stridor, retraction of intercostal muscles, and cyanosis.
• Immediate Interventions: Perform the head-tilt chin-lift maneuver (or jaw-thrust maneuver if cervical injury is suspected); insert an oral or nasopharyngeal airway; position the patient in the lateral recovery position (unless contraindicated by surgical positioning) to permit forward displacement of the tongue and drainage of oral secretions.
• Respiratory Depression: Monitor for bradypnea (respiratory rate < 10 breaths/min), shallow hypopnea, or dropping pulse oximetry ($SpO_2 < 92\%$), frequently caused by residual opioids or neuromuscular blockers. Administer supplemental oxygen; be prepared to administer Naloxone for opioid overdose or Neostigmine / Sugammadex for residual neuromuscular block.

Modified Aldrete Scoring System

The Modified Aldrete Score is the internationally accepted tool used to determine a patient's readiness for discharge from the PACU to the surgical floor. A cumulative score of ≥ 9 out of 10 is required for safe transfer:

Common Postoperative Complications & Nursing Care

1. Atelectasis & Pneumonia:
   • Atelectasis (Alveolar Collapse): The most frequent cause of low-grade fever within the first 24 to 48 hours postoperatively. Auscultation reveals decreased breath sounds and crackles at the lung bases.
   • Interventions: Early ambulation, incentive spirometry (10 breaths/hr), hourly deep breathing and coughing with incisional splinting, and adequate analgesia to facilitate thoracic expansion.
   • Hypostatic Pneumonia: Develops 48 to 72 hours postoperatively if atelectasis remains untreated; characterized by high fever, productive purulent cough, tachypnea, and leukocytosis.
2. Deep Vein Thrombosis (DVT) & Pulmonary Embolism (PE):
   • Pathophysiology: Driven by Virchow's Triad: venous stasis (anesthesia, bed rest), endothelial injury (surgical trauma), and hypercoagulability (surgical acute-phase response).
   • DVT Assessment: Unilateral calf pain, tenderness, warmth, erythema, and localized edema. Caution: Assessing for Homan's sign (calf pain upon forced dorsiflexion of the foot) is unreliable and clinically discouraged because manipulation risks dislodging the thrombus into the pulmonary circulation.
   • DVT Prevention: Application of Sequential Compression Devices (SCDs) or graduated compression stockings, early postoperative ambulation, active ankle pumping exercises, and pharmacological prophylaxis with subcutaneous enoxaparin or low-dose unfractionated heparin.
   • Pulmonary Embolism (PE): Occurs when a detached venous thrombus occludes the pulmonary arterial bed. Manifests as sudden dyspnea, pleuritic chest pain, tachypnea, tachycardia, cyanosis, and acute hypoxemia. Immediate actions: Place patient in high Fowler's position, administer high-flow oxygen, monitor vitals continuously, obtain stat arterial blood gases and CT pulmonary angiography, and initiate anticoagulant therapy.
3. Paralytic Ileus:
   • Temporary paralysis of intestinal peristalsis resulting from anesthetic agents, opioid analgesia, and surgical manipulation of bowel loops.
   • Manifestations: Absence of bowel sounds after 48 to 72 hours, abdominal distension, absence of flatus or stool passage, nausea, and vomiting.
   • Interventions: Maintain NPO status, insert a nasogastric (NG) tube connected to low intermittent suction to decompress the stomach, infuse IV fluids to maintain electrolyte balance, encourage early ambulation, and minimize opioid dosages (multimodal analgesia).
4. Urinary Retention:
   • Common following spinal anesthesia, pelvic surgery, or anticholinergic/opioid administration, which suppress detrusor muscle contractility.
   • Standard Rule: The patient must void spontaneously within 6 to 8 hours following surgery or catheter removal.
   • Assessment & Care: Percuss and palpate the suprapubic area for bladder fullness or perform an ultrasonic bladder scan. If volume > 400 to 500 mL and patient is unable to void after conservative measures (running tap water, warm water over perineum, upright voiding posture), perform straight in-and-out catheterization under strict aseptic technique.
5. Surgical Site Infection (SSI):
   • Typically manifests 3 to 5 days postoperatively with localized erythema, warmth, induration, purulent wound drainage, worsening incisional pain, systemic fever, and elevated WBC count.
   • Interventions: Obtain wound cultures before starting empiric antibiotics, perform prescribed sterile dressing changes, and maintain surgical drains (Jackson-Pratt, Hemovac) to prevent fluid accumulation.

Wound Dehiscence vs. Wound Evisceration

• Wound Dehiscence: Partial or complete separation of the surgical incision edges without protrusion of internal organs. Often preceded by a sudden, copious discharge of serosanguinous ("pink-tinted") fluid from the wound on postoperative days 5 to 8.
• Wound Evisceration: Total disruption of surgical wound layers with the protrusion of internal visceral organs (such as loops of small intestine) through the open incision. This represents a critical, life-threatening surgical emergency. Precipitating factors include vigorous coughing, vomiting, sneezing, severe abdominal distension, obesity, malnutrition, infection, and steroid use.
• Immediate Step-by-Step Emergency Nursing Protocol for Wound Evisceration:
  1. Stay with the patient: Never leave the patient unattended. Call aloud for help and instruct a colleague to immediately notify the attending surgeon and the operating room team.
  2. Position the patient correctly: Immediately place the patient in low Fowler's position (15 to 30 degrees) with the knees flexed (or hips bent). This position relaxes the abdominal wall muscles and dramatically reduces tension on the disrupted surgical incision.
  3. Cover the extruded organs: Immediately cover the protruding viscera with sterile surgical gauze, towels, or dressings soaked in warm sterile 0.9% normal saline. The sterile saline dressing prevents drying, desiccation, ischemia, and necrosis of the exposed bowel tissue.
  4. Strict Warning — Never manipulate viscera: DO NOT attempt to push, reinsert, or manipulate the protruding organs back into the abdominal cavity, as this causes severe vascular tearing, perforation, and peritoneal contamination.
  5. Maintain strict NPO status: The patient will require immediate emergency exploratory laparotomy; withhold all oral fluids and food.
  6. Monitor vitals & provide supportive care: Monitor vital signs every 5 to 10 minutes for signs of hypovolemic or neurogenic shock (tachycardia, hypotension). Ensure large-bore patent IV access, administer supplemental oxygen, maintain calm reassurance, and prepare the patient for urgent transport to the operating room.