Perioperative Nursing

You care for the surgical patient at their most vulnerable, and your job spans the whole arc: before, during, and after the operation. Knowing why a surgery is being done, to cure, diagnose, prevent, improve, repair, or relieve, drives every decision you make and shapes the outcome.

What is Perioperative Nursing?

Surgery uses operative technique to investigate or treat disease and injury, and procedures run from minor and routine to complex and life-saving. Surgery is performed to cure illness by removing diseased tissue or organs, to visualize internal structures during diagnosis, to obtain tissue for examination by biopsy, to prevent disease or injury (prophylactic), to improve appearance (cosmetic), to repair or remove traumatized tissue and restore function, and to relieve symptoms or pain (palliative).

Perioperative nursing covers the care given before, during, and after surgery, and requires the RN to work as part of a tight surgical team. It runs in three phases.

Preoperative Phase

The preoperative phase starts when the decision for surgery is made and ends when the patient is transferred to the operating room. At pre-admission testing, do initial assessments, start patient education, verify tests and surgeon-specific orders, and assess postoperative care needs. On admission to the surgical center, complete preoperative assessments, check for complications, confirm signed consent, reinforce teaching, and develop the care plan. In the holding area, assess status, verify the surgical site, establish IV lines, give medications, ensure comfort, provide psychological support, and report the patient's emotional status to the team.

Intraoperative Phase

The intraoperative phase starts when the patient enters the surgery department and ends on admission to the recovery area. Maintain the aseptic environment and manage resources, position the patient, and keep correct counts of sponges, needles, and instruments. Complete intraoperative documentation and monitor fluid balance, cardiopulmonary data, and vital signs.

Postoperative Phase

The postoperative phase begins on admission to the recovery area and ends with a followup evaluation in clinic or at home. Communicate the intraoperative details, including surgery type, anesthetic used, and patient response. Monitor the immediate response, physiological status, and pain, ensure safety, and give prescribed treatments. On transfer to the unit, continue monitoring, educate, and assist with recovery and discharge planning. At home or clinic, give followup care, reinforce teaching, and assess the response to surgery and anesthesia.

Classifications of Surgical Procedures

Procedures are classified by purpose, urgency, and risk, which together set the degree of risk and how necessary the surgery is.

By purpose: diagnostic surgery finds the cause of an illness and confirms a diagnosis (biopsy, exploratory laparotomy); ablative/curative removes diseased parts or organs (gastrectomy, thyroidectomy, appendectomy); palliative relieves symptoms without curing (colostomy, debridement of necrotic tissue); reconstructive restores function to damaged tissue and improves self-concept (skin grafts, plastic surgery, scar revisions); transplant replaces diseased organs or structures; constructive restores function in congenital anomalies (cleft palate repair, closure of atrial-septal defect); exploratory estimates the extent of disease or confirms a diagnosis (exploratory and pelvic laparotomy); aesthetic improves physical features within the normal range (breast augmentation).

By urgency: elective surgery is pre-planned and can be delayed without harm (tonsillectomy, hernia repair, cataract extraction, mammoplasty, face lift, cesarean section); urgent surgery is necessary for health and is usually done within 24 to 48 hours (gallbladder removal, amputation, colon resection, coronary artery bypass, tumor removal); emergent surgery must be done immediately to preserve life, limb, or function (control of hemorrhage, repair of trauma, perforated ulcer, intestinal obstruction, tracheostomy).

Sterile Technique

Sterile technique is the set of practices that keeps the field free of all microorganisms: hand washing, sterilized instruments, sterile gloves and gowns, and a maintained sterile field. It is what prevents surgical infection.

Principles of Sterile Technique

All items used in surgery must be pre-sterilized. Sterile individuals touch only sterile items, and non-sterile individuals touch only non-sterile items. Sterile personnel keep at least a 12-inch distance from unsterile areas. If sterility is in any doubt, treat the item as unsterile. Gowns are sterile from the front waist to the shoulder and on the sleeves up to 2 inches above the elbows. Keep hands visible and above waist level and avoid touching the face. Do not fold arms, and discard any item dropped below the waist. Stay within sterile zones; when passing others, face sterile zones and have non-sterile individuals step aside. To sneeze or cough, step back and turn the head away. Sterile staff stay in the operating room rather than wandering, and limit contact with sterile zones, never leaning on tables, draped patients, or trays. Observers such as student nurses stay until the procedure ends, minimize chatter, and direct questions to the circulating nurse.

Sterile Members

The surgeon leads the team and specializes in specific procedures. The certified surgical technologist prepares and manages sterile supplies and assists the surgeon, from handing instruments to acting as a primary assistant.

Non-Sterile Members

The anesthesiologist gives pain-relief drugs and continuously monitors the patient's response. The registered nurse circulator manages patient care during surgery, assists the anesthesiologist, maintains records, and supplies the sterile team as needed.

Gowning and Gloving Procedure

1. After the hand scrub, enter the operating room with hands raised to avoid contamination.
2. Dry your hands and arms with a sterile towel, then drop the towel.
3. Pick up the gown, let it unfold, find the arm holes, and insert your hands into the sleeves while a non-scrubbed person assists.
4. Retrieve a gown from the sterile pack for the surgeon; after they insert their arms, release the gown without non-sterile contact, then present gloves without touching their skin.

Assessment

Assess the surgical patient based on the duration and severity of the underlying problem and the involvement of other body systems, since this drives the care plan, the diagnostic studies, and additional nursing diagnoses. For circulation, note any cardiac disease, heart failure, pulmonary edema, peripheral vascular disease, and changes in heart rate. For ego integrity, note anxiety, fear, anger, or apathy, restlessness, and changes in heart and respiratory rates. For elimination, note kidney or bladder conditions and use of diuretics or laxatives. For food and fluid, note pancreatic insufficiency or diabetes, malnutrition, and dry mucous membranes. For respiration, note infections, chronic respiratory conditions, persistent cough, or smoking, and changes in respiratory rate. For safety, note allergies, immune deficiencies, cancer history, family history of malignant hyperthermia, autoimmune disease, hepatic disease, prior transfusions, and signs of infection such as fever. For teaching and learning, note all medications, OTC drugs, and substances, since these carry risks of liver damage, coagulation problems, anesthesia complications, and postoperative withdrawal.

Diagnostic Studies

Preoperative studies evaluate health status and surface conditions that must be addressed before anesthesia. Which tests are needed depends on the procedure, underlying conditions, current medications, age, and weight.

The general workup centers on three studies. On the CBC, an elevated WBC count points to an inflammatory process such as appendicitis, while a decreased WBC suggests a viral process or a dysfunctional immune system; low hemoglobin suggests anemia or blood loss that impairs tissue oxygenation and reduces the hemoglobin available to bind inhalation anesthetics, possibly requiring a crossmatch or transfusion; an elevated hematocrit suggests dehydration, and a decreased hematocrit suggests fluid overload. PT and aPTT assess coagulation, since prolonged times threaten intraoperative and postoperative hemostasis while hypercoagulation raises thrombosis risk, especially with the dehydration and reduced mobility of surgery. A chest x-ray should be clear of infiltrates and pneumonia and is used to find masses and COPD.

Additional tests depend on the patient. BUN and creatinine evaluate kidney function. Glucose monitoring matters especially in diabetes. ABGs assess respiratory status, particularly in smokers and chronic lung disease. Electrolyte imbalances impair organ function; for example, decreased potassium reduces cardiac muscle contractility and lowers cardiac output. Liver function tests gauge the organ that metabolizes drugs and maintains hemostasis. Thyroid and nutritional studies assess metabolism and recovery capacity. An ECG must be reviewed, since abnormal findings need attention before anesthesia to avoid complications and to catch arrhythmias. Urinalysis showing WBCs or bacteria indicates infection, and elevated specific gravity reflects dehydration. A positive pregnancy test affects the timing of the procedure and the choice of agents.

Nursing Priorities

1. Reduce anxiety and emotional trauma with support and reassurance.
2. Provide for physical safety through positioning, monitoring, and sterile technique.
3. Prevent complications such as infection, thromboembolism, and respiratory problems.
4. Alleviate pain with medication and non-pharmacological methods.
5. Facilitate recovery with appropriate interventions and monitoring.
6. Provide information on the disease process, procedure, prognosis, and treatment needs.

Discharge Goals

The patient deals realistically with the current situation, sustains no new injury, and has complications prevented or minimized. Pain is relieved or controlled, the wound heals and organ function progresses toward normal, and the patient and caregivers understand the disease process, the procedure performed, the prognosis, and the therapeutic regimen. A plan is in place to meet needs after discharge, covering followup appointments, home care, medications, and lifestyle changes.