7.1 Preoperative, Intraoperative & Postoperative Nursing Care

Preoperative, Intraoperative & Postoperative Nursing Care

Clinical Core: Perioperative nursing encompasses three contiguous, distinct phases: preoperative, intraoperative, and postoperative. Safe perioperative care demands vigilant patient advocacy, rigorous adherence to sterile boundaries, structured surgical team communication, and rapid clinical intervention to prevent life-threatening complications such as malignant hyperthermia, hypoxemia, deep vein thrombosis, and wound evisceration.

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Preoperative Assessment, Fasting & Preparation

The preoperative phase begins when the decision for surgical intervention is established and concludes upon physical transfer of the client onto the operating room (OR) table. Nursing actions center on physiological optimization, psychosocial support, and procedural verification.

Fasting Guidelines (NPO Status)

Preoperative fasting reduces gastric volume and acidity, preventing aspiration of gastric contents during anesthesia induction. The American Society of Anesthesiologists (ASA) guidelines establish minimum fasting intervals before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation:

Informed Consent and Medication Reconciliation

• Informed Consent Verification: The operating surgeon holds primary legal and ethical accountability for explaining the surgical diagnosis, proposed procedure, alternatives, risks, benefits, and consequences of non-treatment. The registered nurse acts as an autonomous patient advocate whose signature witnesses that the client (or designated surrogate) is competent, voluntarily signs the consent form without coercion, and understands what was explained. If the client expresses confusion or raises fundamental questions regarding the surgical procedure, the nurse must withhold sedation, notify the surgeon, and ensure the surgeon returns to clarify before the client enters the OR.
• Medication Reconciliation: Preoperative medication evaluation prevents catastrophic drug-anesthesia interactions. Anticoagulants (warfarin, direct oral anticoagulants) and antiplatelet agents (clopidogrel, aspirin) are withheld prior to surgery (typically 5 to 7 days for warfarin/clopidogrel, adjusted for surgical bleeding risk) to prevent uncontrolled hemorrhage. Nonsteroidal anti-inflammatory drugs (NSAIDs) are stopped 48 to 72 hours preoperatively. Conversely, chronic beta-blocker therapy is generally continued on the morning of surgery with a sip of water to avoid rebound sympathetic hypertension and ischemia. Antidiabetic agents require structured adjustments: oral hypoglycemics (such as metformin) are held on the morning of surgery, and basal insulin doses are typically reduced according to anesthesiology protocols, with capillary blood glucose monitored closely.

The Preoperative Checklist and Site Marking

Prior to sedation, the nurse completes the comprehensive preoperative checklist:

• Confirm removal of jewelry, piercings, dentures, contact lenses, nail polish, and metal prostheses.
• Ensure the client has voided immediately prior to premedication to prevent intraoperative bladder distention.
• Administer pre-procedural skin antisepsis (chlorhexidine gluconate showers or surgical skin wipes) to reduce skin surface bioburden and surgical site infection (SSI) incidence.
• Surgical Site Marking: The operating surgeon marks the precise surgical site and laterality (e.g., "Right" vs. "Left") using a surgical skin marker while the client is fully awake, alert, and participatory. The nurse verifies that the mark is visible at the incision site prior to transferring the client to the operating suite.

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Intraoperative Nursing Care: Roles, Safety & The WHO Checklist

The intraoperative phase spans the client's entry into the OR through transfer into the Post-Anesthesia Care Unit (PACU).

Division of Intraoperative Nursing Roles

Intraoperative care relies on a coordinated partnership between the scrub nurse and the circulating nurse:

The WHO Surgical Safety Checklist

The World Health Organization (WHO) Surgical Safety Checklist establishes three mandatory verbal pauses:

1. Sign In (Before Induction of Anesthesia): With at least the nurse and anesthesia provider present, verify client identity, surgical site and laterality, consent, pulse oximeter placement, known allergies, difficult airway/aspiration risk, and expected blood loss (>500 mL in adults requires dual large-bore IV access and crossmatched units).
2. Time-Out (Before Skin Incision): All team members (surgeon, anesthesia provider, scrub nurse, circulating nurse) halt all other activities. They verbally verify correct client identity, exact procedure, correct anatomical site and side, visibility of site marking, prophylactic antibiotic administration within 60 minutes prior to incision, and essential radiologic imaging displays.
3. Sign Out (Before the Client Leaves the OR): The team verbally confirms the recorded name of the completed surgical procedure, completes formal instrument/sponge/needle counts, confirms diagnostic specimen labeling with client name and anatomical source, and reviews key postoperative PACU recovery concerns.

Patient Positioning and Surgical Counts

• Positioning Safety: Proper positioning prevents peripheral nerve injuries (e.g., brachial plexus stretch, common peroneal nerve compression at the fibular head) and pressure ulcers. The circulating nurse pads all bony prominences, ensures the grounding pad for the monopolar electrosurgical unit is securely placed over a vascular, muscular area free of scar tissue or metal implants, and avoids excessive hyperextension of extremities.
• Surgical Count Protocols: Sponges, sharps (needles, blades), and instruments are counted at four standardized intervals: (1) baseline count prior to procedure start, (2) before closing a cavity within a cavity, (3) before closure of the fascia or peritoneum, and (4) at final skin closure. If a count discrepancy occurs, the scrub and circulating nurses recount immediately; if still unresolved, the surgeon searches the wound, the circulator searches trash and linen receptacles, and an immediate intraoperative X-ray is obtained before the client departs the OR.

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Postoperative PACU Care & Complication Management

Post-Anesthesia Care Unit (PACU) Assessment and The Aldrete Score

Upon arrival in the PACU, the nurse establishes airway patency, verifies ventilation, connects continuous pulse oximetry and cardiac telemetry, and measures baseline vital signs. PACU discharge readiness is determined by validated scoring systems, most commonly the Modified Aldrete Score, which evaluates five physiological domains:

• Activity: Ability to move 4 extremities (2 points), 2 extremities (1 point), 0 extremities (0 points).
• Respiration: Able to breathe deeply and cough freely (2 points), dyspneic or limited breathing (1 point), apneic (0 points).
• Circulation (Blood Pressure): BP within $\pm 20\%$ of pre-anesthesia baseline (2 points), $\pm 20\%$ to $50\%$ of baseline (1 point), $\pm 50\%$ of baseline (0 points).
• Consciousness: Fully awake and oriented (2 points), arousable on calling (1 point), unresponsive (0 points).
• Oxygen Saturation: SpO2 $>92\%$ on room air (2 points), requires supplemental O2 to maintain SpO2 $>90\%$ (1 point), SpO2 $<90\%$ despite oxygen (0 points).
• Discharge Threshold: A cumulative score of 8 to 10 is required for discharge from the PACU to an inpatient surgical ward.

Airway Patency & Hypopharyngeal Obstruction

The most frequent cause of immediate postoperative airway obstruction in the unconscious client is the tongue falling backward against the posterior pharynx (hypopharyngeal obstruction). Clinical indicators include stridor, snoring respirations, retractions of intercostal muscles, and declining oxygen saturation. The nurse immediately performs a head-tilt chin-lift maneuver (or jaw thrust if cervical spine injury is suspected) and inserts an oral or nasopharyngeal airway. Once airway protective reflexes return (gagging), the oral airway is promptly removed to avoid stimulating laryngospasm or emesis.

Malignant Hyperthermia: Emergency Recognition & Protocol

Malignant hyperthermia (MH) is a life-threatening, pharmacogenetic disorder of skeletal muscle calcium regulation transmitted as an autosomal dominant trait, primarily involving mutations in the RYR1 (ryanodine receptor) gene.

• Triggers: Volatile inhalational anesthetics (isoflurane, sevoflurane, desflurane) and depolarizing neuromuscular blocking agents (succinylcholine).
• Clinical Manifestations:
  • Earliest, Most Sensitive Indicator: Unexplained sinus tachycardia, tachypnea, and rapidly climbing end-tidal carbon dioxide ($EtCO_2$) that remains elevated despite hyperventilation.
  • Muscular Signs: Masseter muscle spasm / trismus (jaw clenching preventing endotracheal intubation) followed by generalized skeletal muscle rigidity.
  • Late Signs: Marked hyperpyrexia (core body temperature rising up to $1^{\circ}\text{C}$ to $2^{\circ}\text{C}$ every 5 minutes, exceeding $43^{\circ}\text{C}$ [$109.4^{\circ}\text{F}$]), severe mixed metabolic and respiratory acidosis, hyperkalemia, cardiac dysrhythmias, rhabdomyolysis, and dark cola-colored urine (myoglobinuria) progressing to acute renal failure.
• Emergency Treatment Protocol:
  1. Immediately discontinue all volatile anesthetics and succinylcholine; conclude surgery as rapidly as possible.
  2. Hyperventilate the client with 100% oxygen at high flow rates (10 L/min or higher) using clean, non-contaminated tubing.
  3. Administer Dantrolene sodium immediately: initial dose is 2.5 mg/kg IV rapid bolus, repeated every 5 to 10 minutes until muscle rigidity, tachycardia, and hyperthermia resolve (maximum cumulative dose can exceed 10 mg/kg).
  4. Initiate active cooling measures: cold intravenous 0.9% normal saline infusions, ice packs applied to axillae, groin, and neck, and cold-water nasogastric/bladder lavages; halt cooling when core temperature reaches $38^{\circ}\text{C}$ ($100.4^{\circ}\text{F}$) to avoid rebound hypothermia.
  5. Correct severe metabolic acidosis with intravenous sodium bicarbonate; treat hyperkalemia with regular insulin and dextrose infusions.

Prevention and Management of Postoperative Complications

• Atelectasis and Pneumonia: Hypoventilation and pain cause alveolar collapse. The nurse teaches the client to perform incentive spirometry 10 times per waking hour, execute coughing and deep-breathing exercises while splinting the abdominal incision with a pillow, and supports early out-of-bed ambulation within 24 hours postoperatively.
• Deep Vein Thrombosis (DVT) & Pulmonary Embolism (PE): Surgical immobility and tissue trauma activate Virchow's Triad (venous stasis, endothelial injury, and hypercoagulability). Interventions include sequential compression devices (SCDs), graduated compression stockings, low-dose subcutaneous enoxaparin or unfractionated heparin, and active ankle-pumping exercises. If a client develops sudden dyspnea, pleuritic chest pain, tachypnea, and oxygen desaturation, the nurse suspects PE, elevates the head of the bed, applies high-flow oxygen, obtains vital signs, and alerts the rapid response team immediately.
• Wound Dehiscence and Evisceration:
  • Dehiscence: Partial or total separation of superficial surgical wound layers without organ protrusion.
  • Evisceration: Total disruption of all fascial wound layers with direct protrusion of internal abdominal viscera (usually small bowel loops) through the surgical opening. Preceded often by the client reporting "a sudden popping or giving-way sensation" following coughing or straining, accompanied by serosanguineous wound discharge.
  • Emergency Nursing Protocol for Evisceration:
    1. Stay with the client; call for urgent help.
    2. Immediately place the client in low Fowler's position (15 to 30 degrees) with the hips and knees slightly flexed to minimize abdominal wall tension.
    3. Cover the protruding abdominal viscera with sterile dressings saturated with warm sterile 0.9% normal saline. Never attempt to reinsert protruding organs; never apply dry gauze (dry dressings adhere to and tear the delicate intestinal serosa).
    4. Maintain strict NPO status in anticipation of emergency re-exploration in the operating room.
    5. Assess vital signs for neurogenic or hypovolemic shock; notify the attending surgeon immediately.