Section 8.1: Perioperative Care & Surgical Nursing

Preoperative Nursing Care

The preoperative phase begins when the decision for surgical intervention is made and ends with the patient's transfer to the operating room bed. The primary focus is on conducting a thorough baseline assessment, ensuring patient safety, providing education, and verifying legal documents such as the informed consent.

Informed Consent Under standard nursing jurisprudence and healthcare mandates, the informed consent is a legal document that protects the patient's right to self-determination. The physician or surgeon is exclusively responsible for explaining the medical procedure, alternatives, risks, and benefits. The registered nurse's role is strictly to witness the signature, confirm that the patient comprehends the information, and ensure the consent is signed voluntarily before any psychoactive medications (e.g., sedatives, narcotics, anxiolytics) are administered. If the patient has specific medical questions regarding the surgery itself, the nurse must notify the physician to clarify before the patient signs the document.

Patient Preparation and Assessment A comprehensive health history, including allergies (especially latex, iodine, or specific food allergies like bananas which may cross-react with latex), current medications, and previous surgical experiences, is vital. Certain medications must be managed specifically:

• Anticoagulants (e.g., Warfarin, Aspirin) are typically discontinued 5-7 days before surgery to prevent severe hemorrhage.
• Insulin dosages may be adjusted depending on NPO (nil per os) status to prevent intraoperative hypoglycemia or hyperglycemia.
• Herbal Supplements (e.g., garlic, ginkgo biloba, ginseng) can dramatically increase bleeding risk and should generally be stopped 2 weeks prior to surgery.

Preoperative teaching focuses on what the patient will experience and what is expected of them postoperatively. Essential teaching points include:

• Deep Breathing and Coughing Exercises: Taught to prevent alveolar collapse (atelectasis) and pneumonia.
• Incentive Spirometry: Encourages sustained maximal inspiration and opens collapsed alveoli.
• Leg Exercises and Early Ambulation: Crucial for preventing deep vein thrombosis (DVT).
• Pain Management: Explaining the pain scale and how to use patient-controlled analgesia (PCA) if ordered.

Intraoperative Nursing Care

The intraoperative phase extends from the patient's transfer to the operating room until admission to the Post-Anesthesia Care Unit (PACU). The primary goals are maintaining asepsis, ensuring patient safety, and supporting the patient's physiological status during anesthesia.

Roles of the Nursing Team

• Scrub Nurse: Performs surgical hand scrub, sets up the sterile field, assists the surgeon with instruments, and maintains accurate counts of sponges, sharps, and instruments.
• Circulating Nurse: Manages the overall nursing care in the OR, coordinates the surgical team, monitors the sterile field from the outside, positions the patient, preps the skin, and documents the procedure. The circulating nurse is primarily responsible for patient safety and advocating for the patient while they are under anesthesia.

Surgical Safety and Timeout To prevent wrong-site, wrong-procedure, and wrong-person surgeries, the Universal Protocol is implemented. The Surgical Timeout occurs immediately before the initial incision. The entire surgical team must pause and verbally confirm the patient's identity, the correct procedure, and the correct surgical site. Additionally, rigorous surgical counts of all instruments, sponges, and sharps are performed before, during, and at the end of the procedure to prevent retained foreign bodies.

Positioning and Equipment Improper positioning can lead to nerve damage (e.g., brachial plexus injury), pressure ulcers, and compromised ventilation. Padding bony prominences and ensuring anatomical alignment are critical nursing responsibilities. Additionally, grounding pads must be correctly placed to prevent burns from electrosurgical units.

Postoperative Nursing Care

This phase begins with admission to the PACU and continues until follow-up evaluation. Immediate postoperative care focuses on assessing the ABCs (Airway, Breathing, Circulation).

Immediate Assessments in the PACU

1. Airway: Check for patency. The most common cause of airway obstruction postoperatively is the tongue falling back against the pharynx due to lingering general anesthesia.
2. Breathing: Monitor respiratory rate, depth, and oxygen saturation. Note signs of hypoventilation, which can occur from narcotic administration.
3. Circulation: Assess vital signs frequently. Tachycardia and hypotension may indicate internal hemorrhage or hypovolemic shock. Monitor surgical dressings for excessive drainage.
4. Neurological Status: Evaluate the level of consciousness and return of sensory/motor function, especially following spinal anesthesia.

Managing Postoperative Complications

Postoperative pain management is essential not only for comfort but to facilitate mobility and deep breathing. Multimodal pain therapy, combining opioids, NSAIDs, and non-pharmacologic interventions, is typically employed. Careful monitoring for opioid-induced respiratory depression is a high priority.