Perioperative Nursing: Preoperative, Intraoperative, and Postoperative Care

Perioperative Nursing: Preoperative, Intraoperative, and Postoperative Care

Perioperative nursing spans three phases of the surgical experience: the preoperative phase (from the decision for surgery through transport to the operating room), the intraoperative phase (from arrival in the OR through transfer to the post-anesthesia care unit), and the postoperative phase (from PACU admission through recovery and discharge). As an LPN, your primary hands-on responsibilities fall in the preoperative and postoperative phases, always under the supervision of an RN or physician.

The Preoperative Phase: Preparing the Patient Safely

Your goal before surgery is to ensure the patient arrives in the OR as prepared and informed as possible. Use a standardized preoperative checklist to avoid omissions — missed steps can cause serious harm or legal liability.

Key preoperative checklist items include:

• Informed consent: Verify the surgical consent form is signed, dated, and witnessed before any sedating pre-op medication is given. Obtaining consent is the surgeon's responsibility; witnessing and verifying it is the nurse's. Never administer pre-op sedation if consent is missing.
• NPO status: Confirm the patient has been nothing by mouth (NPO) for the required period, typically nothing solid for at least 8 hours before general anesthesia (follow your facility's protocol and the anesthesia provider's orders). Aspiration of gastric contents during anesthesia can be fatal.
• Allergy identification: Document all allergies — medications, latex, tape, iodine, foods — and ensure the allergy band is on the patient's wrist and flagged in the chart.
• Vital signs: Obtain and document baseline vital signs. Abnormal findings must be reported to the RN or provider before the patient goes to surgery.
• Skin preparation: Document any ordered skin prep (bathing with antiseptic soap, hair removal per protocol). Hair removal, when ordered, is done with clippers — never a razor, which increases infection risk.
• IV access: Confirm a patent IV site with appropriate gauge catheter. Report infiltration or lack of access immediately.
• Jewelry, valuables, and prosthetics: Remove all jewelry (including body piercings), glasses, contact lenses, hearing aids, dentures, and prosthetic limbs per policy. Metal jewelry can cause burns with electrosurgical equipment.
• Pre-op medications: Administer and document ordered pre-op medications. Check the five rights before administration.
• Patient teaching: Teach and have the patient demonstrate deep-breathing exercises, coughing technique, and incentive spirometry. These prevent postoperative pneumonia and atelectasis.
• Identification verification: Confirm patient identity using two identifiers (name and date of birth or medical record number).

The Postoperative Phase: Systematic Assessment in the PACU

When a patient returns from surgery, perform a rapid, head-to-toe assessment prioritizing the ABCs — Airway, Breathing, Circulation — before anything else.

Systematic post-anesthesia assessment:

1. Airway patency: Is the airway open and clear? Listen and look for stridor, gurgling, or obstruction. Position the patient on the side or use a jaw-thrust if consciousness is altered.

2. Respiratory rate and breath sounds: Auscultate all lung fields. Note rate, depth, and equality. Absent or diminished breath sounds may indicate atelectasis or pneumothorax.

3. Oxygen saturation (SpO₂): Apply pulse oximeter. Values below 95% (or per provider order) require intervention — reposition, encourage deep breathing, increase supplemental oxygen, and notify the RN.

4. Blood pressure and heart rate: Compare to preoperative baseline. Hypotension may signal hemorrhage, dehydration, or anesthetic effects; hypertension may indicate pain or fluid overload.

5. Level of consciousness — ALDRETE score: The Aldrete scoring tool evaluates five parameters (activity, respiration, circulation, consciousness, oxygen saturation), each scored 0–2, for a maximum of 10. A score of 8 or higher is generally required for discharge from the PACU per standard practice.

6. Pain assessment: Use a numeric rating scale (0–10) or another validated tool. Document location, character, and severity, and intervene per orders.

7. Surgical site inspection: Assess dressing for bleeding, drainage type (sanguineous, serosanguineous, serous, purulent), and odor. Circle and time any spreading drainage on the dressing. Do not remove surgical dressings without a specific order.

8. IV site assessment: Check for patency, signs of infiltration, or phlebitis.

9. Urinary output: Monitor for adequate urine output. Urinary retention is common after anesthesia and spinal/epidural blocks.

Common Postoperative Complications and Nursing Interventions

| Complication | Key Signs | Nursing Intervention |

|---|---|---|

| Atelectasis/Pneumonia | Diminished breath sounds, fever, productive cough | Incentive spirometry q1–2h while awake, deep breathing and coughing, early ambulation |

| Deep Vein Thrombosis (DVT) | Unilateral leg swelling, warmth, pain | Apply SCDs, administer anticoagulants as ordered, encourage early ambulation |

| Surgical Site Infection (SSI) | Redness, warmth, purulent drainage, fever | Monitor wound, maintain sterile technique during dressing changes, report early signs |

| Urinary Retention | Distended bladder, inability to void, lower abdominal pain | Encourage voiding, catheterize per order, measure output |

| Paralytic Ileus | Absent bowel sounds, abdominal distension, nausea | NPO until bowel sounds return, early ambulation, report to provider |

| Hemorrhage | Dropping BP, rising pulse, increasing wound drainage | Apply direct pressure to wound, notify RN/provider immediately, monitor vitals |

Safety Priorities

• Never administer a pre-op sedative without a signed consent — a sedated patient cannot give legal informed consent.
• Always use two patient identifiers before any procedure or medication.
• When in doubt about a postoperative assessment finding, report immediately — early recognition saves lives.
• SCDs must be applied correctly and removed only for ambulation; they are ineffective if left off for long periods.

Incentive Spirometry: Correct Technique

Instruct the patient to: (1) sit upright or at 45 degrees or higher, (2) exhale normally, (3) seal lips around the mouthpiece, (4) inhale slowly and deeply to raise the indicator to the target level, (5) hold the breath 3–5 seconds, (6) exhale slowly, and (7) repeat 10 times every 1–2 hours while awake. Document teaching and patient's ability to demonstrate correct technique.