Perioperative Assessment Combined

What does the preoperative phase encompass?

• It begins when the client decides to undergo surgery and ends when the client is transferred to the surgical suite.

To reduce the incidence of surgical errors, The Joint Commission has developed the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery.

What are some actions to prevent these errors from occurring?

According to the Universal Protocol for the surgical procedure includes:

✅ Signed consent form for the surgical procedure

✅ Completed preoperative assessments

✅ Laboratory results (e.g., blood work)

✅ Other diagnostic test results (e.g., imaging, ECG)

✅ Documentation for any special equipment required for the procedure

✅ Surgical site marked by the licensed provider performing the procedure

• 🔹 Note: Site marking may not be required if the provider remains physically present with the client from the time of verification through the procedure

What are the nurse's responsibilities during the preoperative phase?

• Complete Preoperative assessment

• Client teaching

• A signed informed consent form.

What is the main goal of the preoperative assessment?

• To ensure client safety by identifying risk factors for surgery and collecting baseline data.

• This is why is important to perform a Pre-op head-to-toe assessment to document what is baseline for that patient.

A nurse is interviewing a client during the preoperative phase. The client reports smoking 6 to 7 cigarettes per day for the past 4 years.

The nurse should identify that tobacco use prior to surgery can increase the client’s risk for which of the following complications?

• Blood clots

• Heart attacks (myocardial infarction)

• Infection

• Death

Rationale: tobacco use can lead to slower wound healing. Also, because oxygen is the main source of healing, the client’s risk for developing infections is greater when the client has engaged in recent use of tobacco.

What should a preoperative assessment include?

• A head-to-toe assessment

• Review of medical history

• Any laboratory or diagnostic tests ordered.

The time-out is being performed for a client scheduled for surgery.

The time-out occurs during which phase of the perioperative period? 

• Time-out occurs BEFORE starting the procedure

• BEFORE initiation of each procedure

• After surgical procedure is complete

Examples of Patients Who Can Give Informed Consent include:

• Legal age (typically 18+)

• Mentally competent (understands the situation, risks, benefits)

• Giving consent voluntarily (no coercion)

• A&O X4

❌ Examples of Patients Who Cannot Give Informed Consent:

❌ Examples:

1. A 4-year-old child – consent must be obtained from a parent or legal guardian.

2. A 30-year-old who is intoxicated – altered mental status prevents legal consent.

3. A 70-year-old with advanced dementia – lacks capacity to understand or decide.

4. A 22-year-old under general anesthesia or heavy sedation – not alert and oriented.

5. A developmentally delayed adult with documented legal incompetence – requires consent from a guardian.

6. A person with a head injury and fluctuating consciousness – not able to give informed consent reliably.

7. A 17-year-old minor without emancipated status – needs parental/guardian consent.

What is the importance of coughing and deep breathing after surgery.

This should include techniques for incision splinting and how to use an incentive spirometer.

✅ Why It Matters:

• Prevents atelectasis (collapse of alveoli)

• Reduces risk of pneumonia and other respiratory complications

• Helps clear mucus and secretions from the lungs

• Improves oxygenation and lung expansion

• Promotes circulation and prevents post-op complications
  

🛏 Technique: Incision Splinting

• Used to reduce pain and protect the surgical site during coughing or deep breathing

• Especially important after abdominal or thoracic surgery

How to Perform:

1. Place a pillow, folded blanket, or towel over the surgical incision.

2. Gently but firmly press the pillow against the incision.

3. Take a deep breath in through the nose.

4. Cough strongly while pressing to support the incision.

5. Repeat every 1–2 hours while awake.

Identify tasks and responsibilities that correspond to nursing staff from each of the following departments: Pre-ops, OR, & PACU (post-anesthesia care unit)

🏥 Preoperative Nurse

These nurses focus on preparing the client BEFORE surgery.

• ✅ Witness SIGNED consent

• ✅ Perform teaching on deep breathing and coughing

• ✅ Obtain history of allergies

• ✅ Collect the client's height and weight

🏨 Intraoperative (Circulating or Scrub) Nurse

These nurses are in the OR and handle sterile technique, surgical prep, and communication.

• ✅ Initiate time-out procedure

• ✅ Obtain supplies for the surgery team

• ✅ Document the count of surgical sponges and equipment

🛌 Postoperative (PACU/Recovery Room) Nurse

These nurses care for the client immediately after surgery, focusing on stabilization and pain control.

• ✅ Ensure a patent airway

• ✅ Provide updates to the client's family members

• ✅ Manage nausea

• ✅ Administer pain medications

• ✅ Control shivering

Roles of the Circulating nurse and Surgical Tech. in the surgical room include:

Role	Circulating Nurse (RN)	Certified Surgical Technologist (CST)
Sterility Role	Ensures sterile technique is maintained; does not scrub in	Sets up sterile field; scrubs in and works within sterile field
Tool Responsibility	Confirms counts with CST; provides needed supplies to the field	Prepares & maintains sterile instruments; passes tools to surgeon
Patient Interaction	Verifies identity, allergies, consent; provides emotional support	Limited patient interaction; assists with transfers
Documentation	Completes EMR, time-out, sponge/instrument count documentation	Documents intraoperative events (as assigned)
Positioning/Safety	Responsible for patient positioning & safety during procedure	Assists with physical positioning and draping (as needed)
Assisting with Procedure	Assists anesthesiologist, manages non-sterile tasks	Hands instruments, suctions, assists with suturing
Certification Needed?	Registered Nurse (RN) license	Certification via NBSTSA
Team Focus	Coordinates care before, during, and after surgery	Supports the surgeon during surgery

The certified surgical tech. or commonly referred to as a “scrub tech,” is responsible for ensuring which of the following procedures during surgery?

• Tools are sterile and ready for use.

• Hands over tools the surgeon.

• Moves or transfers patient in/out of surgical site safely and efficiently.

• Applies suction, assists w/ suturing.

• Documents during the procedure.

The surgical environment has very strict guidelines that must be maintained for each procedure such as:

🔬 Environmental Controls

• Antimicrobial agents are used to clean ceilings, floors, and walls.

• Temperature is maintained between 68°F and 75°F to limit pathogen growth.

• Relative humidity is kept between 20% and 60% to:

  • Control bacterial growth.

  • Prevent static electricity.

Before surgery, patients need to have their skin prepared for surgery which include:

🧼 Skin Preparation

• Client pre-surgery prep:

  • Must shower and use an antiseptic wash to reduce microbes on the skin.

• In the surgical environment:

  • Circulating nurse may:

    • Remove hair from surgical site.

    • Cleanse site using antiseptic (iodine, chlorohexidine, or alcohol).

    • Allow antiseptic to dry before proceeding.

• Scrubbing technique:

  • Start at the center of the site and move outward in a circular motion.

  • Outer edge of sponge = contaminated → must be discarded.

  • Use a new sponge for each pass.

• After skin prep:

  • Client is draped according to procedure and protocol.

  • Circulating nurse initiates the “time-out” (final verification step before surgery begins).

What are the three (3) types of anesthesia used during a surgical procedure?

💉 Anesthesia

• Three types:

  • Local – affects a small, specific area.

  • Regional – affects larger region (e.g., spinal, epidural).

  • General – results in total loss of sensation and consciousness.

• Effects:

  • May involve loss of feeling with or without loss of consciousness.

Assessment findings and interventions to decrease the risk of RESPIRATORY complications during the Post-op phase includes:

🫁 Respiratory System

Assessment Findings:

• Monitor airway patency and breath sounds

• Assess respiratory rate, rhythm, depth

• Monitor oxygen saturation (SpO₂)

• Watch for signs of atelectasis (diminished breath sounds, low SpO₂)

Interventions:

• Administer oxygen as needed

• Encourage use of incentive spirometer: 10x/hour, hold breath 3–5 sec

• Promote coughing and deep breathing every 2 hours (avoid with brain/eye surgeries)

• Encourage early ambulation

• Assist with clearing secretions if needed

Assessment findings and interventions to decrease the risk of CARDIOVASCULAR SYSTEM complications during the Post-op phase includes:

❤ Cardiovascular System

Assessment Findings:

• Monitor vital signs frequently (watch trends)

• Observe for signs of bleeding: ↓ BP, ↑ HR, ↓ SpO₂, changes in LOC

• Assess extremities for DVT signs: swelling, redness, pain, decreased pulses

• Monitor for fluid/electrolyte imbalances

Interventions:

• Encourage ankle pumps, early ambulation

• Use SCDs (sequential compression devices) and antiembolism stockings

• Reposition frequently

• Monitor for signs of hypovolemia/bleeding

Assessment findings and interventions to decrease the risk of NEUROLOGICAL complications during the Post-op phase includes:

🧠 Neurologic System

Assessment Findings:

• Assess level of consciousness (LOC) and orientation

• Monitor for over-sedation

• Watch for post-op delirium

• Use Aldrete Score to assess readiness post-anesthesia

Interventions:

• Reorient as needed

• Ensure a safe environment

• Stimulate gently if drowsy

• Monitor for return to neurologic baseline

Assessment findings and interventions to decrease the risk of PAIN MANAGEMENT complications during the Post-op phase includes:

😖 Pain Management

Assessment Findings:

• Use pain scale appropriate to the client

• Monitor effectiveness of medications

• Watch for signs of respiratory depression if on opioids

Interventions:

• Administer opioids or NSAIDs as prescribed

• Educate on and monitor use of PCA (patient-controlled analgesia) pump

• Use nonpharmacologic techniques: repositioning, music, breathing exercises, heat/cold

Assessment findings and interventions to decrease the risk of SKIN & WOUND complications during the Post-op phase includes:

🩹 Integumentary System (Skin & Wound)

Assessment Findings:

• Monitor surgical site for redness, swelling, pain, drainage

• Assess dressing and drains for amount/type of fluid

• Check for signs of infection

Interventions:

• Follow dressing change protocol (usually 24–48 hours post-op)

• Keep site clean, dry, and monitored

• Document appearance and drainage

• Remove dressings if infection suspected (per order)

What is the importance of monitoring hydration status on Post-op patients?

💧 Hydration Importance

Key Points:

• Promotes blood flow, prevents clots, and supports healing

• Replaces fluid loss from surgery

• Reduces risk of DVT and hypovolemia

Assessment:

• Check oral mucosa, skin turgor, and I&O

• Monitor for urine output ≥ 30 mL/hr

• Document all fluids in and out (IV, oral, drain, urine)

Proper way to use an incentive spirometer include:

📈 How to Use an Incentive Spirometer Purpose:

• Encourages slow, deep breathing to expand the lungs

• Prevents post-op pulmonary complications

Steps:

1. Sit upright in a chair or bed with back supported.

2. Hold the spirometer upright.

3. Exhale normally, then seal lips around the mouthpiece.

4. Inhale slowly and deeply through the mouthpiece to raise the piston/ball.

5. Try to hold the breath for at least 3–5 seconds.

6. Remove the mouthpiece and exhale slowly.

7. Repeat 10 times every hour while awake.

What is malignant hyperthermia?

• A severe reaction to certain medications given during anesthesia that can be life-threatening.

Why is it important to document a client's health history before surgery?

• It helps identify comorbidities and previous complications that could increase surgical risk.

What should be assessed regarding a client's allergies prior to surgery?

• All known allergies to medications and other substances must be identified and documented.

How can tobacco and alcohol use affect surgery risks?

• Recent tobacco use can increase risks for complications such as blood clots and myocardial infarction,

• While regular alcohol use can lead to bleeding and infections.

What aspects of a client's spiritual beliefs should a nurse consider?

• The nurse should record client requests based on spiritual beliefs and provide culturally competent care.

What is the importance of client teaching before surgery?

• It prepares the client for surgery, reduces anxiety, empowers self-care postoperatively, and supports the family.

What is informed consent in the context of surgery?

• Permission given by the client or their legal representative to provide care or perform a surgical procedure.

Who is responsible for explaining the procedure to the client before surgery?

• The provider is responsible for educating the client about the procedure.

Which tests may be prescribed prior to surgery?

• Tests may include complete blood count (CBC), metabolic panels, coagulation studies, and electrocardiograms.

What should be included in postoperative expectations during client teaching?

• Expectations include pain control methods, importance of coughing and deep breathing, and activity post-surgery.

What are some common laboratory tests done preoperatively?

• Complete blood count (CBC), comprehensive metabolic panel (CMP), basic metabolic panel (BMP), and coagulation studies.

What is the purpose of AORN’s Comprehensive Surgical Checklist?

• To enhance communication among the perioperative team and prevent errors and client harm.

A nurse is assessing a preoperative client with a history of obstructive sleep apnea (OSA). Which of the following should the nurse include in the plan of care?

A. Monitor for signs of hypoglycemia post-op

B. Place the client in a high Fowler’s position post-op

C. Administer supplemental oxygen via face mask continuously

D. Prepare to administer naloxone immediately post-op.

Correct Answer: B.
Rationale: OSA increases risk of airway obstruction; upright positioning supports airway patency post-op.

A client reports a family history of malignant hyperthermia. What is the nurse’s priority action?

A. Educate the client on post-op activity restrictions

B. Notify the anesthesia team immediately

C. Document the finding and proceed with standard prep D. Ask the client to sign the anesthesia consent again.

Correct Answer: B.
Rationale: Malignant hyperthermia is a life-threatening reaction to anesthesia. The intraoperative team must be informed to implement precautions.

A client reports an allergy to latex and bananas. What is the most appropriate nursing action?

A. Document the allergy in the EHR

B. Notify dietary services

C. Apply an allergy ID band and notify the surgical team D. Give diphenhydramine preoperatively.

Correct Answer: C.

Rationale: Latex allergy often correlates with fruit allergies. The entire surgical team must be alerted to use non-latex equipment.

A client taking garlic, vitamin E, and warfarin daily is scheduled for surgery. Which is the priority concern?

A. Risk for post-op constipation

B. Risk for delayed wound healing

C. Risk for excessive bleeding

D. Risk for poor sedation response.

Correct Answer: C.

Rationale: Garlic and vitamin E can potentiate the anticoagulant effect of warfarin, increasing bleeding risk.

A nurse is interviewing a client who smokes daily. Which of the following complications should the nurse anticipate?

A. Hypothermia

B. Myocardial infarction

C. Nausea

D. Jaundice.

Correct Answer: B.

Rationale: Smoking increases the risk for post-op cardiovascular complications, including MI and blood clots.

A client who practices Christian Science expresses concern about receiving medical treatment. Which nursing action is appropriate?

A. Reassure the client and proceed with treatment

B. Document the client’s refusal and notify the provider

C. Educate the client about the benefits of surgery

D. Inform the OR staff that the client may cancel surgery.

Correct Answer: B.

Rationale: Client beliefs must be respected; refusal must be documented and communicated.

A nurse is planning multimodal pain management post-op. Which of the following is the primary advantage of this approach?

A. Promotes dependency on fewer medications

B. Reduces the need for postoperative monitoring

C. Minimizes opioid side effects while managing pain

D. Prevents infection and reduces hospital stay.

Correct Answer: C.

Rationale: Multimodal pain therapy enhances relief while reducing side effects of high-dose opioids.

Why is it important to assess a client’s orientation before surgery?

A. To ensure the client remembers discharge instructions B. To detect early signs of post-op infection

C. To establish a baseline for detecting post-op changes D. To verify understanding of pain rating scales.

Correct Answer: C.

Rationale: Baseline neurologic status helps detect early signs of decline post-op, such as delirium or hypoxia.

In which order should the nurse perform a GI assessment preoperatively?

A. Palpation, percussion, auscultation, inspection

B. Auscultation, palpation, percussion, inspection

C. Inspection, auscultation, percussion, palpation

D. Inspection, auscultation, palpation, percussion.

Correct Answer: D.

Rationale: This order prevents altering bowel sounds and ensures accurate findings.

A client with moderate developmental disability needs a surgical procedure. Who can legally provide informed consent?

A. The client's legal guardian

B. The nurse on duty

C. The client’s case manager

D. The client's sibling.

Correct Answer: A.

Rationale: A legal guardian is required to give consent when the client is not competent to do so.

Which preoperative test provides information about anemia and infection risk?

A. Electrocardiogram

B. Chest x-ray

C. Complete blood count (CBC)

D. Coagulation profile.

Correct Answer: C.

Rationale: A CBC evaluates hemoglobin levels and white blood cell count, indicating anemia or infection.

Which statement by a client indicates understanding of NPO instructions before surgery?

A. "I can eat toast until midnight and drink juice in the morning."

B. "I should stop eating and drinking after midnight before surgery."

C. "I can have coffee as long as there’s no cream."

D. "I’ll take my medications with a glass of milk."

Correct Answer: B.

Rationale: Clients are typically instructed to stop eating and drinking after midnight before surgery

What are the three phases of the perioperative experience?

• Pre-Op, Intra-Op, Post-Op.

What is the purpose of preoperative teaching?

• To increase patient satisfaction, reduce fear, anxiety, and stress, and may decrease complications.

What are common reasons patients have surgery?

• Diagnosis, Cure, Palliation, Prevention, Cosmetic improvement, Exploration.

What factors can influence a patient's stress response to surgery?

• Age, experiences with illness and pain, current health, socioeconomic status.

What is the standard NPO status for patients prior to surgery?

• NPO after midnight, though emergency situations may differ.

What should be included in a preoperative checklist?

• Final preoperative teaching, assessment communication of findings, verification of signed informed consent.

What are the different types of surgical settings?

• Elective surgery, emergency surgery, inpatient, same-day admission, ambulatory, minimally invasive.

What are the responsibilities of a circulating nurse during surgery?

• Remains in unsterile field, facilitates the progress of the procedure, keeps documentation.

What must be verified before a surgical procedure?

• Patient identification, surgical site, signed informed consent.

What are common fears patients may have regarding surgery?

• Death or disability, pain and discomfort, loss of control, and disruption of life functioning.