Module 1 Preoperative Care

Preoperative Phase

The phase beginning when the decision for surgery is made and ending when the patient is transferred to the OR bed

Intraoperative Phase

The phase beginning when the patient is placed on the OR bed and ending upon admission to the PACU

Postoperative Phase

The phase beginning when the patient is admitted to the PACU and ending with post-surgery recovery in a clinic or home

Emergent Surgery

Surgery classification requiring immediate intervention to save life or limb with no time for preparation

Urgent Surgery

Surgery classification that must be performed within hours to prevent further harm or damage

Required Surgery

Surgery classification that is necessary but can be planned within weeks to months

Elective Surgery

Surgery classification that is optional or scheduled based on patient preference, not immediately necessary

Pre-Admission Testing

The preoperative process of collecting admission data (health history, demographics), completing forms (consent), and performing diagnostic testing (labs)

Informed Consent

A process involving the surgeon, nurse, patient, and caregiver/family member; patient must be mentally capable and consent must be obtained prior to sedative medication

Surgical Risk Factors

Age, nutrition, fluid and electrolytes, cardiac conditions, coagulation disorders, upper respiratory infections, COPD, diabetes, liver or renal disease

Gerontologic Surgical Considerations - Cardiac/Respiratory

Elderly patients have low cardiac and respiratory reserves, increasing surgical risk

Gerontologic Surgical Considerations - GI

Elderly patients have decreased GI motility, increasing risk of postoperative complications

Gerontologic Surgical Considerations - Neurological

Elderly patients are at increased risk for post-op and ICU delirium

Gerontologic Surgical Considerations - Renal/Hepatic

Elderly patients have depressed organ function in the renal and hepatic systems

Gerontologic Surgical Considerations - Integumentary

Elderly patients have decreased subcutaneous fat, fragile skin, and greater susceptibility to temperature changes

Medications that Increase Surgical Risk

Anticoagulants, tranquilizers, heroin/opioids, alcohol, diuretics, steroids, OTC herbal preparations, Vitamin E

Preoperative Checklist Items

Identification bracelet, allergy bracelet, verify NPO and IV status, complete forms, past medical history, physical exam, remove jewelry/dentures/contacts, identify and mark surgical site, prepare surgical site, administer pre-op medications

Immediate Pre-Op Nursing Interventions

Patient changes into gown, hair covered, mouth inspected, jewelry removed, valuables secured; administer pre-anesthetic medications; complete pre-op checklist; transport to presurgical area with warming; attend to family needs

Pre-Op Antibiotic Timing

Prophylactic antibiotics must peak in the bloodstream before the surgical incision is made

Circulating Nurse Role

Acts as patient advocate; verifies consent, performs surgical pause, monitors aseptic practice, and travels through multiple OR rooms

Scrub Nurse Role

Monitors hand hygiene, maintains the sterilization field, follows surgical instructions, manages medications entering the sterile field, and performs counts

Surgical Asepsis - Gowns

Sterile from chest to the level of the sterile field in front; sleeves sterile from 2 inches above elbow to cuff

Surgical Asepsis - Sterile Field

Must maintain a 1-foot border around the sterile field; if breached, it is considered contaminated; prepared as close to time of use as possible

Surgical Safety Checklist - Sign In

Completed before induction of anesthesia; confirms patient identity, site, procedure, consent, site marking, anesthesia safety check, pulse oximeter, allergies, and airway/aspiration risk

Surgical Safety Checklist - Time Out

Completed before skin incision; all team members introduce themselves, confirm patient/site/procedure, review critical events, confirm antibiotic prophylaxis within last 60 minutes

Surgical Safety Checklist - Sign Out

Completed before patient leaves OR; nurse confirms procedure name, instrument/sponge/needle counts, specimen labeling, equipment problems, and key recovery concerns

General Anesthesia

Provides analgesia and amnesia; induces unconsciousness; patient should be in complete oblivion

Moderate (Conscious) Sedation

Blocks patient pain and reduces anxiety; used for diagnostic or therapeutic procedures; patient remains responsive

Spinal Anesthesia

Regional anesthetic delivered as a one-time dose into the cerebrospinal fluid (CSF)

Epidural Anesthesia

Regional anesthetic delivered as a continuous infusion through a catheter placed in the epidural space

Peripheral Nerve Block

Regional anesthetic technique that blocks sensation to a specific area by targeting peripheral nerves

Anesthesia Awareness

Unintended consciousness during general anesthesia; monitored via EEG brain waves; signs include increased BP, HR, and movement (patient cannot communicate due to neuromuscular blockade)

Malignant Hyperthermia

A severe, genetically linked adverse reaction to anesthetic agents; presents with markedly elevated temperature, muscle rigidity/spasms, tachycardia, and rapid shallow breathing; treated immediately with dantrolene; can cause rhabdomyolysis, hyperkalemia, and organ failure if untreated

Intraoperative Hypothermia Risk Factors

Cardiovascular events, SSIs, bleeding, delayed arousal from anesthesia, advanced age

Intraoperative Hypothermia Interventions

Temporarily increase OR temperature, infuse/irrigate with warmed fluids, replace wet gowns/drapes with dry material, apply warm air/thermal blankets to non-operative areas

PONV Risk Factors

Female gender, age less than 50, opioid administration

PONV Management

Turn patient to side, use suction, administer antiemetics; important to avoid aspiration of vomit

Top Cause of Perioperative Anaphylaxis

Muscle relaxants (69.2% incidence); most commonly succinylcholine, rocuronium, atracurium

Intraoperative Respiratory Complications

Inadequate ventilation, airway occlusion, inadvertent esophageal intubation, hypoxia; monitored via pulse oximetry, peripheral perfusion assessment, and capnography

Postoperative Assessment (PACU)

Vital signs (HR, BP, RR, O2, temp), level of consciousness, skin color and condition, dressing location and condition, IV fluids, drainage tubes, and position

PACU Phase I

Immediate recovery from anesthesia; intensive nursing care; patient requires stable airway and must be extubated; may transfer to inpatient unit or Phase II

PACU Phase II

Focus on preparing for hospital discharge; patient may transfer to inpatient unit, extended care setting, or be discharged home

OR Report to PACU

Includes patient name/gender/age, language barriers, allergies, comorbidities, procedure performed, OR time, anesthesia used/reversal agents, fluid/blood loss, last vitals, complications, immediate post-op plan, and family location

Postoperative Respiratory Complications - Hypoxemia

Inadequate arterial oxygen due to shallow breathing; signs include restlessness, dyspnea, diaphoresis, tachycardia, HTN, cyanosis, low pulse ox; treat with O2, deep breathing, coughing, IS, repositioning

Atelectasis

Collapsed alveoli occurring 1-2 days post-op due to insufficient deep breathing, coughing, or immobility

Postoperative Pneumonia

Develops 3-5 days post-op due to infection, aspiration, or immobility; signs include dyspnea, increased RR, crackles, fever, cough, chest pain; treated with turning, deep breathing, coughing, IS, chest physiotherapy

Postoperative Cardiovascular Assessment

Monitor circulation, vital signs, bleeding, cardiac dysrhythmias, thrombophlebitis; encourage SCD use and early ambulation; watch for hemorrhage and shock

Thrombophlebitis

Vein inflammation with clot formation most commonly in the legs; signs include aching, cord-like vein, tenderness, elevated temp; prevent with anti-embolism stockings, SCDs, passive ROM, early ambulation, no dangling legs, anticoagulants as prescribed

Wound Dehiscence

Separation of wound edges at the suture line, typically 6-8 days post-op; signs include drainage, opened edges, and visible underlying tissue

Wound Evisceration

Protrusion of internal organs through the wound, 6-8 days post-op; signs include serosanguinous fluid, visible bowel loops, and patient reporting a popping sensation; this is a SURGICAL EMERGENCY

Evisceration Nursing Interventions

Call for help, stay with patient, position in low-Fowler's with knees bent, cover wound with sterile dressing moistened with normal saline, monitor VS, and assess for shock

Risk Factors for Poor Wound Healing

Older age, hemorrhage, hypovolemia, edema, poor dressing technique, nutritional deficit, oxygen deficiency, corticosteroids, anticoagulants, shock, acidosis, hypoxia, kidney injury, immunosuppression, wound stressors (vomiting, Valsalva, heavy coughing), poorly controlled diabetes, tobacco use

REEDA Scale

Assessment tool for wound infection: Redness, Erythema, Ecchymosis, Drainage, and Approximation (closure of wound edges)

Wound Infection Signs

Fever, chills, warm/tender/painful/inflamed site, edematous skin, tight sutures, elevated WBC, positive REEDA findings

Wound Infection Interventions

Monitor temperature and suture line, assess drainage, maintain asepsis, obtain wound/blood cultures and sensitivity, administer antibiotics

Postoperative GI Assessment

Monitor for nausea/vomiting with patient in side-lying position, check NG tube patency and drainage, assess for abdominal distention, monitor bowel sounds and flatus, provide oral care q2h, maintain NPO until gag reflex and peristalsis return

Post-Op Diet Progression

NPO → ice chips and water → clear liquid → regular diet as tolerated

Constipation (Post-Op)

Defined as failure to pass stool within 48 hours after resuming solid diet; treat with increased fluids up to 3000 mL/day, early ambulation, fiber, privacy, stool softeners, and laxatives

Paralytic Ileus

Failure of appropriate forward bowel movement post-op due to anesthetics or bowel manipulation; treat with NPO status, NG tube, ambulation, IV fluids/parenteral nutrition, motility-increasing medications

Urinary Retention (Post-Op)

Involuntary urine accumulation in bladder 6-8 hours post-op due to anesthetic or opioid effects; signs include inability to void, restlessness, diaphoresis, lower abdominal pain, distended bladder, hypertension, drum-like percussion sound

Urinary Retention Interventions

Monitor voiding, palpate/bladder scan for distention, encourage ambulation and fluids, assist with positioning and privacy, run warm water; if noninvasive measures fail, notify HCP and consider straight catheter or Foley insertion

Post-Op Pain Management

Review anesthetic type used; assess pain via patient report and physical exam; check analgesic effectiveness 30-60 minutes after administration; monitor RR, BP, HR, O2 sat, LOC; use multi-modal approach including non-pharmacological interventions

PCA (Patient-Controlled Analgesia)

A pain management device that allows patients to self-administer doses of analgesia within prescribed limits; patient education is required

Discharge Planning for Outpatient Surgery

Confirm caregiver availability, ensure patient cannot drive, provide pharmacy and prescription info, review follow-up care, explain signs/symptoms to report, instruct on incision care and medication side effects

Incentive Spirometry (IS)

A breathing device used post-op to encourage deep breathing, prevent atelectasis, and improve lung expansion

Sequential Compression Devices (SCDs)

Pneumatic devices placed on the legs to promote venous return and prevent thrombophlebitis and DVT formation in post-op patients

Musculoskeletal Post-Op Assessment

Assess extremity movement, follow positioning restrictions, perform q2 turning, progress ambulation by dangling first, use low-Fowler's position to increase thoracic size; avoid supine until gag reflex returns

Neurological Post-Op Assessment

Assess level of consciousness with frequent attempts to wake patient, orient to environment, speak softly, filter noise, maintain body temperature with warm blankets, monitor for hypothermia

Integumentary Post-Op Assessment

Assess surgical site, drains, wound dressings, and any areas affected by surgical positioning; monitor for signs of infection including fever and wound changes