Perioperative nursing encompasses the comprehensive care provided to patients before, during, and after surgical procedures.

This specialized field is critical for ensuring patient safety, optimizing outcomes, and supporting individuals and their families throughout the surgical journey, which is inherently a significant life event requiring both physical and psychological adjustment.

Surgical interventions are broadly categorized based on the level of risk they pose to the patient. Minor surgery is typically a brief procedure associated with low risk and minimal complications.

It can be performed in various settings, including outpatient clinics, same-day surgery centers, or a hospital’s operating suite. In contrast, major surgery involves a higher degree of risk, is usually more extensive, and may involve vital organs or life-threatening conditions, often necessitating hospitalization and carrying a greater potential for postoperative complications.

Beyond the risk level, surgeries can also be classified by their urgency and purpose. Elective surgery is a planned procedure that is necessary but can be scheduled at a time convenient for both the patient and the healthcare provider. Regardless of whether a surgery is classified as major or minor, elective or emergent, it uniformly demands the patient and their family to adapt physically and psychologically.

Surgical procedures are also described by their objective:

• Ablative: Removal of a diseased or damaged body part (e.g., appendectomy).
• Diagnostic: Performed to obtain tissue or examine internal structures to establish a diagnosis (e.g., biopsy).
• Constructive: Aims to repair organs or tissues that are congenitally malformed (e.g., repair of a cleft lip or palate).
• Reconstructive: Involves the repair or restoration of damaged or diseased body structures, which may include cosmetic improvements (e.g., colostomy reversal, rhinoplasty).
• Palliative: Undertaken to alleviate pain or symptoms without curing the underlying disease (e.g., rhizotomy to interrupt nerve pathways).
• Transplant: Involves the transfer of an organ or tissue from one part of the body to another, or from one individual to another, to replace a compromised structure, restore function, or alter appearance (e.g., kidney transplant, skin graft).

It is common for a single surgical procedure to fit multiple classifications. For instance, a patient who has experienced trauma might undergo surgery classified as major, reconstructive, and emergency.

The impact of surgery on a patient extends beyond the physical realm. The extent of tissue injury and the invasiveness of the procedure contribute to physical stress. This is often significantly amplified by psychological stress. Anxiety and worry can deplete the energy reserves needed for the body’s healing process during recovery. The loss of consciousness and the lack of control or awareness during the procedure can also be sources of significant psychological distress.

Patients may experience psychological stress due to various factors, including:

• Experiencing pain.
• The potential loss of a body part or function.
• Fear of death or uncertain outcomes.
• Separation from their support network of family and friends.
• Concerns about how the surgery will affect their daily life, both personally and professionally.
• Vulnerability associated with body exposure to unfamiliar individuals.

It is important to recognize that from the patient’s perspective, any surgery, regardless of its classification, that induces physical and psychological stress is rarely perceived as truly “minor.”

The Preoperative Phase

The preoperative phase marks the beginning of the surgical experience, commencing with the decision to proceed with surgery and concluding when the patient is moved onto the operating room table. Patients arrive for surgery from diverse circumstances and with varying health statuses.

Nurses play a vital role during this phase, responsible for completing necessary documentation, executing physician’s orders for preoperative care, and meticulously recording all nursing interventions.

Key nursing responsibilities during the preoperative phase include:

• Preparing the patient’s chart: Ensuring the chart contains essential information such as patient identification, a checklist for relevant clinical records, space for current vital signs before administering preoperative medications, documentation of known allergies, a section for detailing all preoperative nursing actions, a space for noting any specific patient considerations (like the removal of prostheses or hearing impairments), and a signature line for the registered nurse to confirm completion of tasks.
• Facilitating Anesthesia Requests: Ensuring any necessary requests for anesthesia administration are completed.
• Verifying Surgical Consent: Confirming that the patient’s consent form for the surgical procedure is signed in the presence of a witness. The witness’s signature confirms the patient’s signature, not necessarily their understanding of the surgical risks. In cases where the adult patient is unconscious, semi-conscious, or not mentally competent, a family member or legal guardian may sign the consent form. For minors (typically under 18), a parent or legal guardian provides consent. An emancipated minor, who lives independently and is self-supporting, may sign their own consent. Nurses must be familiar with the legal age of consent in their state and the implications of consent signed by someone other than the patient. It is crucial that legal consent forms are signed before the administration of any preoperative or mind-altering medications, as these can invalidate the legal binding of the document.
• Implementing Physician’s Preoperative Orders: Executing specific preoperative care orders from the physician. This may include administering an enema to cleanse the colon and reduce the risk of wound contamination during surgery. If ordered, ensuring the surgical site is prepared, often involving cleaning and shaving a wide area around the planned incision site. This preparation helps to minimize the presence of hair and microorganisms on the skin surface, thereby decreasing the potential for wound contamination. This skin preparation may be performed on the nursing unit or in the operating room just before surgery.
• Managing Pre-Operative Diet: Adhering strictly to the physician’s instructions regarding withholding food and fluids before surgery. Typically, patients may have solid food until the evening before surgery but are required to be NPO (nothing by mouth) starting at midnight. The nurse is responsible for posting an NPO sign outside the patient’s room, explaining the importance of this restriction to the patient, removing water pitchers and glasses, and clearly marking the diet roster.
• Administering Sedatives: If prescribed, administering a sedative medication the evening before surgery to help the patient achieve restful sleep.
• Assisting with Patient Hygiene: Guiding the patient through personal hygiene routines before surgery. This often includes a bath or shower and hair wash the evening before surgery to cleanse the skin and promote relaxation. An antiseptic soap may be used in addition to or instead of plain soap and water.
• Managing Personal Effects: Instructing the patient to remove all makeup and nail polish, as these can obscure natural skin coloration, which is vital for assessing circulation and oxygenation (e.g., checking for cyanosis in the face, lips, oral mucosa, and nail beds). Wedding bands may be permitted but must be secured with tape and gauze, ensuring the wrapping is not too tight to impair circulation. All other jewelry and valuables should be removed and stored securely, ideally sent home with a family member if possible. Proper documentation of the disposition of valuables is essential.
• Providing Patient Information: Educating the patient about the planned surgery, including potential risks and benefits, the likely consequences of not having the surgery, and any alternative treatment options discussed by their doctor. The nurse also provides emotional support by actively listening to the patient and their concerned family members, answering questions, explaining each preoperative nursing step, providing opportunities for the patient to verbalize their feelings, and inquiring about their spiritual needs and desire to see a chaplain.
• Briefing Family Members: Providing information to the patient’s family about their role on the morning of surgery, including the location of the surgical waiting area and the estimated time they can visit the patient in the recovery room. Explaining the purpose of the recovery room and informing them about any medical equipment or tubes the patient may have after the procedure.
• Performing Pre-Operative Morning Care: Waking the patient early enough to complete necessary morning care. This includes providing a clean hospital gown and toiletries. A shower or bath with a topical antiseptic, such as povidone-iodine, may be required again on the morning of surgery to further reduce skin microorganisms. Assisting the patient with thorough mouth care to enhance comfort and prevent aspiration of any residual food particles. Instructing the patient not to chew gum.
• Removing Prostheses: Assisting the patient in removing any prostheses, including artificial limbs, eyes, contact lenses, eyeglasses, dentures, or removable oral appliances, while respecting their privacy. Small items should be placed in a labeled container, and dentures are often left at the bedside.
• Recording Vital Signs: Obtaining and documenting the patient’s temperature, pulse, respiration, and blood pressure before administering any preoperative medications.
• Allowing Time for Personal Measures: Providing the patient with time for last-minute personal preparations and visits with family before transfer to the operating room.
• Final Surgical Checklist and Medication Administration: Reviewing the surgical checklist to ensure all preparations are complete. Administering preoperative medications as ordered by the anesthesiologist, typically 30 to 60 minutes before the scheduled surgery time. These medications may be scheduled or given “on call” from the operating room. The medication regimen may include a narcotic or sedative for relaxation, a drug to reduce oral and respiratory secretions, and an antiemetic to prevent nausea. Before administering these medications, the patient should be encouraged to void. The nurse should explain the expected effects of the medications, such as drowsiness and dry mouth, and instruct the patient to remain in bed with the side rails raised and the call bell easily accessible. The nurse assists the operating room technician with transferring the patient to a wheeled litter or gurney, ensuring they are covered, comfortable, and securely restrained to prevent falls.
• Documenting Nursing Measures: Ensuring all essential information is documented in the patient’s chart before they leave the nursing unit. This includes verifying the patient’s identity band matches the chart, confirming the consent form is correctly signed and witnessed, and writing a “sign out” note in the nurse’s progress notes detailing the date, time, event of transfer, and the patient’s status at that time.

The Intraoperative Phase

The intraoperative phase spans the period during which the patient is undergoing surgery within the operating room, concluding upon their transfer to the post-anesthesia recovery unit.

Surgical procedures can be classified based on the reason for the intervention, using descriptors such as ablative, diagnostic, constructive, reconstructive, palliative, and transplant, as previously described.

The primary reasons for performing surgical interventions include:

• To cure or treat an illness by removing diseased tissue or organs.
• To visualize internal structures for diagnostic purposes.
• To obtain tissue specimens for laboratory examination.
• To prevent the onset or progression of disease or injury.
• To improve physical appearance.
• To repair or remove tissue and structures damaged by trauma.
• To alleviate symptoms or provide pain relief.

The Surgical Team

The intraoperative phase begins when the patient arrives in the surgical area and ends with their transfer to the recovery area. While the surgeon is the primary leader, the surgical team is a collaborative unit comprising several key members:

• The Surgeon: The lead physician responsible for performing the surgical procedure. They are ultimately accountable for the surgery’s effectiveness and safety, relying on other team members for patient monitoring and support.
• The Anesthesiologist/Anesthetist: A physician (anesthesiologist) or a highly trained registered nurse (anesthetist) specializing in administering anesthetic agents. Their responsibilities include ensuring a smooth induction and maintenance of anesthesia, providing adequate muscle relaxation, continuously monitoring the patient’s physiological status (including oxygenation, circulation, neurological status, and vital signs), advising the surgeon of potential complications, and intervening as needed.
• The Scrub Nurse/Assistant: A nurse or surgical technician who prepares the sterile surgical field, maintains aseptic technique throughout the procedure by handling instruments and supplies, and assists the surgeon directly by passing instruments, sutures, and other necessary items. The scrub nurse must possess in-depth knowledge of all surgical instruments and their uses and wears sterile attire (gown, cap, mask, and gloves).
• The Circulating Nurse: A registered nurse who oversees the overall nursing care within the operating room and acts as a link between the sterile surgical field and the non-sterile areas. The circulating nurse is not scrubbed and does not wear sterile attire. Their duties include the initial assessment of the patient upon arrival in the operating room, assisting with monitoring, helping the sterile team members don their gowns and gloves, anticipating the need for equipment, instruments, medications, and blood products, opening sterile packages for the scrub nurse, preparing and arranging for the transfer of specimens to the laboratory, and accurately counting all sponges, instruments, and needles used during the procedure to prevent items from being inadvertently left in the wound.

Major Classifications of Anesthetic Agents

Anesthetic agents, used to block sensation and awareness during surgery, are typically categorized into three main types:

• General Anesthesia: Induces a state of unconsciousness, affecting the entire body. This is achieved by administering drugs that depress the central nervous system.

  • Characteristics of an ideal general anesthetic include the ability to produce pain relief (analgesia), complete loss of consciousness, muscle relaxation, and suppression of reflexes, while being safe with minimal side effects.
  • General anesthesia is commonly used for major surgical procedures involving the head, neck, chest, upper abdomen, and extremities.
  • General anesthesia involves three phases: Induction (rendering the patient unconscious), Maintenance (sustaining the surgical level of anesthesia), and Emergence (when the patient begins to regain consciousness).
  • Achieving optimal general anesthesia often involves using a combination of agents. Intravenous drugs are frequently used for rapid induction, supplemented by other agents. Inhalation anesthetics offer rapid excretion and reversal but carry risks of respiratory and circulatory depression.
  • Routes of administration for general anesthetic agents include intravenous infusion and inhalation. Rectal administration is less common in modern practice. No single anesthetic agent fulfills all the criteria of an ideal general anesthetic.

• Regional Anesthesia: Causes a loss of sensation in a specific, large area of the body while the patient typically remains awake. This is achieved by injecting an anesthetic agent near a nerve or nerve pathway, blocking nerve impulses to that region. Reflexes in the affected area may also be lost.

  • Types of regional anesthesia include nerve blocks, where anesthetic is injected around a nerve trunk supplying the surgical area (e.g., for procedures on the jaw, face, or limbs).
  • Subdural blocks (spinal anesthesia) involve injecting anesthetic into the cerebrospinal fluid in the subarachnoid space via a lumbar puncture, resulting in sensory, motor, and autonomic blockade of the lower body, used for surgery on the lower abdomen, perineum, and lower extremities. Potential side effects include headache, low blood pressure, and difficulty urinating.
  • Epidural blocks involve injecting anesthetic into the epidural space outside the spinal canal, typically in the lumbar region, also providing numbness in the lower body.

• Local Anesthesia: Involves administering an anesthetic agent directly into the tissue of a small, localized area, resulting in loss of sensation only in that specific spot. It can be applied topically to skin or mucous membranes or injected intradermally.

The effects of anesthesia vary depending on the type. General anesthesia produces unconsciousness, pain relief, reflex loss, and muscle relaxation. Regional anesthesia provides pain relief and reflex loss but not unconsciousness. Local anesthesia causes loss of sensation in a limited area.

The choice of anesthetic agent and administration route is primarily determined by the anesthesiologist or anesthetist in consultation with the patient. Several factors influence this decision:

• The specific type and location of the surgical procedure.
• The anticipated duration of the surgery.
• The patient’s overall health status and age.
• The patient’s history with previous anesthesia.
• The availability of necessary equipment.
• The preferences of both the anesthesia provider and the patient.
• The skill and experience of the anesthesiologist or anesthetist.

Additional factors considered during anesthetic selection include:

• The patient’s smoking and alcohol consumption habits.
• Current medications the patient is taking.
• Presence of any pre-existing diseases.

Pre-existing medical conditions, particularly those affecting pulmonary, hepatic, renal, or cardiovascular function, are significant concerns when selecting anesthesia. Respiratory infections and chronic lung diseases can be exacerbated by general anesthesia and increase the risk of postoperative lung complications. Liver disease can impair the metabolism and detoxification of anesthetic drugs, affect blood clotting, and hinder nutrient metabolism essential for healing. Kidney insufficiency can alter drug excretion and fluid/electrolyte balance, influencing the patient’s response to anesthesia. While well-managed cardiac conditions pose minimal risk, severe hypertension, heart failure, or recent myocardial infarction significantly increase surgical risks.

Certain medications can interact adversely with anesthetic agents and increase surgical risk:

• Adrenal steroids: Abrupt withdrawal can lead to cardiovascular collapse.
• Antibiotics (specifically the mycin group): May cause respiratory paralysis when combined with certain muscle relaxants used in surgery.
• Anticoagulants: Increase the risk of hemorrhage.
• Diuretics: Can cause electrolyte imbalances, potentially leading to respiratory depression under anesthesia.
• Tranquilizers: May increase the hypotensive effect of anesthetic agents, contributing to shock.

A thorough medication history, including prescribed and over-the-counter drugs, is crucial during the preoperative assessment to identify potential interactions and risks. While some medications are typically withheld before surgery, others, like those for cardiovascular problems or diabetes, may be continued.

The Recovery Room (Post-Anesthesia Care Unit – PACU)

The recovery room, or PACU, is a specialized unit where patients are closely monitored immediately following surgery. After the procedure, the patient is carefully transferred from the operating table to a stretcher or bed and moved to the PACU. Patients typically remain in the PACU until they begin to regain consciousness and their physiological status stabilizes. The postoperative phase officially begins upon the patient’s admission to the recovery room and continues until their full recovery from the surgical procedure.

The primary nursing goals in the recovery room include:

• Maintaining Airway Patency and Respiratory Function: Surgery and anesthesia can suppress the cough reflex and lead to mucus accumulation. Anesthesia and pain medication can also depress respiration, and incisional pain may discourage deep breathing. These factors increase the risk of respiratory complications like atelectasis and infection. An artificial airway is often kept in place until the patient’s protective reflexes (gagging and swallowing) return. The nurse monitors respiratory status closely.
• Monitoring Physiological Status: Continuously assessing vital signs (heart rate, blood pressure, respiration, oxygen saturation), level of consciousness, and the surgical site for bleeding or drainage.
• Managing Pain: Pain is often most severe in the initial 12 to 36 hours post-surgery. Analgesics are typically administered regularly, and their effectiveness is enhanced if given before pain becomes severe. Patient-controlled analgesia (PCA) may be used.
• Promoting Circulation: Venous return from the legs can be reduced during surgery, increasing the risk of blood clots (thrombophlebitis and emboli). Nurses encourage leg exercises to promote circulation.
• Preventing Complications: Vigilantly monitoring for and preventing potential complications such as respiratory distress and hypovolemic shock. Early detection is key to managing complications effectively.

The recovery room provides short-term, intensive monitoring until the patient recovers from the immediate effects of anesthesia. Surgical intensive care units, in contrast, provide prolonged, critical care for patients requiring more extensive support over a longer period.

Postoperative Patient Care by Body System

Postoperative nursing care involves addressing the specific needs of each body system to facilitate recovery and prevent complications.

Respiratory System:

• The nurse encourages and reinforces deep breathing exercises, taught preoperatively, to help expand the lungs, clear anesthetic gases and secretions, and improve oxygenation. This involves slow, deep inhalations and exhalations, often with a breath hold. These exercises should be performed regularly while the patient is awake.
• Coughing, in conjunction with deep breathing, helps remove mucus. The nurse instructs the patient on effective coughing techniques, often involving supporting the incision with a pillow or blanket to reduce pain.
• Incentive spirometry may be used to encourage deep inspiration, improve lung volume, and aid venous return. The nurse guides the patient on proper use and encourages regular use while awake.
• Positioning the patient in a semi-Fowler’s position, if permitted, can aid lung expansion. Turning and ambulating the patient as ordered also promote respiratory function.

Cardiovascular System:

• To prevent thrombophlebitis and emboli, the nurse encourages regular leg exercises to promote venous return. These may include flexing and extending the knees, pointing and circling the toes, and raising and lowering the legs while keeping them straight.
• Early ambulation is strongly encouraged as ordered to improve circulation and prevent complications. The nurse provides physical support during initial attempts at walking.
• Before ambulating, the patient may be asked to dangle their legs at the bedside. The nurse monitors blood pressure during dangling and defers ambulation if the patient is hypotensive or dizzy, reporting this to the supervisor.

Urinary System:

• Patients, particularly after abdominal or pelvic surgery, may experience difficulty urinating due to operative trauma near the bladder or fear of pain. The nurse monitors for signs of bladder distention if the patient does not have a urinary catheter and has not voided within eight hours post-surgery, reporting this to the supervisor.
• The nurse assists the patient with voiding by providing privacy, positioning comfortably, and offering a bedpan or urinal. Urine output is measured and recorded. A urinary output less than 30 cc in the first void after surgery should be reported. Any blood or abnormal content in the urine or pain during voiding also warrants reporting.
• If the patient has a Foley catheter, the nurse follows infection control protocols according to standing operating procedures.

Gastrointestinal System:

• Inactivity and changes in diet during the perioperative period can affect gastrointestinal function. Nausea and vomiting may occur due to accumulated stomach contents or organ manipulation during abdominal surgery. The nurse monitors for abdominal distention and reports this to the supervisor.