Preoperative Care
Chapter 17 (pgs. 299-312) (Hesi Book p.47)
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Learning Objectives for Pre, Intra, & Post-Operative:
At the conclusion of this lesson the student will be able to:
1. Differentiate the common settings of surgery, surgery departments, and attire.
2. Apply knowledge of the purpose and components of a preoperative nursing assessment.
3. Analyze the components and purpose of informed consent for surgery.
6. Differentiate the purposes and types of common preoperative, intraoperative, and postoperative medications.
7. Apply basic principles of aseptic technique & importance of safety used in the operating room.
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Pre-Operative – from the time the client makes the decision to have surgery until the operative suite.
Surgical Settings: elective surgery (carefully planned event) vs. emergency surgery (arise with unexpected urgency)
For inpatient surgery, patients who are going to be admitted to the hospital are usually admitted on the day of surgery
(Same-day admission) or Ambulatory (outpatient)
o May be conducted in endoscopy clinics, physicians’ offices, free-standing surgical clinics, and outpatient
surgery units in hospitals
o Can be performed using general, regional, or local anesthetic
o Have an operating time of less than 2 hours
o Require less than a 24-hour stay postoperatively
Your Role Preop - communication and documentation of important preoperative assessment findings are essential to
the continuity of care!!!!!
 Have knowledge of the nature of the disorder requiring surgery
 Identify the individual patient’s response to the stress of surgery
 Have knowledge of the results of preoperative diagnostic tests
 Identify potential risks and complications associated with surgery
Patient Interview - Occurs in advance of or on day of surgery
 Check documented information before interview to avoid repetition!
 The interview is one of the most important preoperative nursing actions.
 Important findings must be communicated to others for continuity of care.
 Obtain health information, including drug and food allergies
 Provide and clarify information about the surgery and anesthesia
 Assess emotional state and readiness
 Determine expectations
 An opportunity for them to ask questions about surgery, anesthesia, and postoperative care.
 Often patients will ask about: 1) taking their routine medications (such as insulin, warfarin (Coumadin), or
cardiac medications) and 2) experience pain
Nursing Assessment: Overall goals
1) Identify risk factors
2) Plan care to ensure patient safety
Nursing Assessment Goals
 Establish baseline data for comparison intraoperative and postoperative
 Determine psychologic status to reinforce coping strategies
 Determine physiologic factors of procedure contributing to risks
 Identify and document surgical site
 Identify drugs, OTC medications, and herbs taken that may affect surgical outcome
 Review results of preoperative diagnostic studies
 Identify cultural and ethnic factors that may affect surgical experience
 Determine receipt of adequate information from surgeon to sign informed consent
 Determine that consent form is signed and witnessed
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Nursing Assessment: Psychosocial assessment
 Excessive stress response can be magnified and affect recovery. Even for a procedure considered minor,
surgery is a stressful event. Psychologic and physiologic reactions to the surgical procedure and anesthesia
may elicit the stress response (e.g., elevated bp and heart rate).
 Use common language (not medical jargon; only lay terms)
 Use translators if needed to decrease level of anxiety
 Communicate all concerns to surgical team
 Anxiety can impair cognition, decision making, and coping abilities
 Anxiety can arise from:
1) Lack of knowledge
2) Unrealistic expectations
 Information lessens anxiety
 Identify beliefs and discuss with surgeon and operative staff (e.g., blood transfusions & Jehovah’s
Witnesses)
Nursing Assessment: Fears (Emotional state influences the stress response, and thus the surgical outcome.)
1. Death and disability
2. Pain

Consult with ACP (anesthesia care provider)

Confirm drugs will be available

For fear of pain, you should encourage the patient to ask for pain medications following surgery, and
that taking these medications will not contribute to an addiction. Instruct the patient how to use the
pain intensity scale (e.g., 0–10, FACES) and to request pain medication before the pain becomes
severe.
3. Mutilation and alteration of body image

Amputations & mastectomies
4. Fear of anesthesia

Can result from a prior induction of anesthesia or information about the risks (e.g., brain damage,
paralysis). Many patients also fear losing control while under anesthesia.
Nursing Assessment: Past health history
Diagnosed medical conditions (previous and current)
Previous surgeries and problems
Familial diseases: Inherited traits & Conditions
Reactions/problems to anesthesia (patient or family)
Nursing Assessment: Current medications
Prescription and OTC
Herbs / Dietary supplements
Antiplatelets/NSAIDs (may contribute to postoperative bleeding)
Recreational (recreational drug use may affect the type and amount of anesthesia that will be needed. When patients
become aware of the potential interactions of these substances with anesthetics, most patients will respond honestly
about their using them.) Drugs, Alcohol, Tobacco
Nursing Assessment: Allergies (drug and nondrug)
Screen for drug intolerance vs. drug allergy
(Drug intolerance usually results in side effects that are unpleasant for the patient but not life threatening,
including nausea, constipation, diarrhea, or idiosyncratic (opposite than expected) reactions. A true drug allergy
produces hives and/or an anaphylactic reaction, causing cardiopulmonary compromise (e.g., hypotension,
tachycardia, bronchospasm).
Screen for latex allergy!!!!!!!!!!!!!!!!
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Risk factors for latex allergy include long-term, multiple exposures to latex products, such as those experienced
by health care and rubber industry workers. Additional risk factors include a history of hay fever, asthma, and
allergies to certain foods. (e.g., eggs, avocados, bananas, chestnuts, potatoes, peaches)
Nursing Assessment: Review of systems
(**Please read over these on your own pgs. 303-305**)
Nursing Assessment: Exam
 The Joint Commission (TJC) requires a history and physical to be in the chart on every client!!
 Complete your own physical examination
 Findings enable ACP to rate patient for anesthesia administration (indicator of perioperative risk and overall
outcome).
 Document relevant findings and share with the perioperative team
 Obtain and evaluate results of laboratory tests (For example, if the patient is taking an antiplatelet medication
(e.g., aspirin), a coagulation profile will be ordered. If a patient is on diuretic therapy, a potassium level is
assessed. If a patient is of child-bearing age, a pregnancy test should be ordered. If a patient is taking medications
for dysrhythmias, a preoperative electrocardiogram (ECG) is obtained.)
 Monitor blood glucose for patients with diabetes
Nursing Management: Preoperative teaching
 Regulations concerning jewelry, dentures, hearing aids, glasses/contacts, makeup, nail polish, etc.
 Patient has the right to know what to expect and how to participate
o Increases patient satisfaction
o Reduces fear, anxiety, stress, pain, and vomiting
 Teaching may also decrease the development of complications, the length of hospitalization, and the recovery
time following discharge.
o Address needs of highest priority (for patient and for RN)
o Include information focused on safety
o Provide written material
 Three types of information
o Sensory - see, hear, smell, and feel during the surgery. For example, you may tell them that the OR will
be cold, but they can ask for a warm blanket; the lights in the OR are very bright; or they will hear lots of
sounds that are unfamiliar and may notice specific smells.
o Process- Patients wanting process information may not want specific details but desire to know the
general flow of what is going to happen. This information would include the patient’s transfer to the
holding area, visits by the nurse and ACP before transfer to the OR and waking up in the PACU.
o Procedural - desired details are more specific. For example, this information would include that an IV
line will be started while the patient is in the holding area, and the surgeon will mark the operative area
with an indelible marker to verify surgical site.
 Must be documented and reported to postoperative nurses
 Teach deep breathing, coughing, and early ambulation as appropriate
 Inform if tubes, drains, monitoring devices, or special equipment will be used postoperatively
 Provide surgery-specific information and Post-Op procedures: ventilation, incentive spirometer, Range of motion
exercises, Pain control, dietary restrictions, ICU or PACU orientation
Nursing Management: Ambulatory surgery information
Basic information before arrival:
Time and place (arrival time is usually 1-2 hours before scheduled time of surgery)
What to wear and bring (paperwork, no jewelry)
Responsible adult needed (to drive home after anesthesia)
Fluid and food restrictions (Traditionally, patients having elective surgery are told to have nothing by mouth
(NPO) starting at midnight on the night before surgery to minimize risk of aspiration or post-op
nausea/vomiting. Depending on the MD, he may state anywhere from 4-8 hours NPO).
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Nursing Management: Legal preparation
Check that all required forms are signed and in chart
1) Informed consent
2) Blood transfusion form
3) Advanced directive
4) Power of attorney
Nursing Management: Consent for surgery
Informed consent must include: Adequate disclosure, Understanding and comprehension, voluntarily given consent
Surgeon responsible for obtaining consent: Nurse may witness signature, verify patient has understanding,
Permission may be withdrawn at any time even after consent is signed
Legally appointed representative of family may consent if patient is:

Minor

Unconscious

Mentally incompetent
Medical emergency may override need for consent
Immediate medical treatment needed to:
 Preserve life
 Prevent serious impairment to life or limb
Nursing Management: Day-of-surgery preparation
 Final preoperative teaching
 Assessment and report of pertinent findings
 Verification of signed consent
 Labs: H&H, electrolytes, glucose, type/crossmatch
 History and physical examination by HCP
 Baseline vitals
 Proper skin preparation & site marked by MD
 Hospital gown
 Patient should not wear any cosmetics
 Observation of skin color is important
 Remove nail polish for pulse oximeter
 Valuables are returned to family member or locked
up
 Dentures, contacts, glasses, prostheses are removed
 Identification and allergy bands on wrist
Nursing Management: Void before surgery & before med
administration
Prevents involuntary elimination under anesthesia
Reduces risk of urinary retention during early
postoperative recovery
Nursing Management: Preoperative medication – pg.308
Benzodiazepines – sedative and amnesic properties Ativan, valium, versed
Anticholinergics – reduces secretions atropine
Opioids – decrease pain and intraoperative anesthetic requirements morphine and fentanyl
Antiemetics – decrease nausea/vomiting Zofran and Phenergan
Antibiotics IV - decrease the risk of endocarditis in patients with a history of congenital or valvular heart disease,
and for patients with previous joint replacement. They may also be ordered for the patient undergoing surgery where
wound contamination is a potential risk (GI surgery) or where wound infection could have serious postoperative
consequences (cardiac or joint replacement surgery). vancomycin
β-Adrenergic blockers (β-blockers) – for known cases with HTN or CAD metoprolol, atenolol, propranolol
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Insulin – known DM
Eye drops – cataract or other eye surgeries
Nursing Management: Transportation to the OR
Via stretcher or wheelchair & Communication “handoff” – SBAR (refer to clinical syllabus for SBAR handout)
 Situation: patient name, age, surgical procedure, surgeon, surgical site, etc.
 Background: significant patient history, allergies, medications
 Assessment: baseline vital signs, findings relative to the surgical procedure, coping strategies
 Recommendation: preoperative care still needed, such as IV antibiotics, positioning concerns, etc.
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NCLEX QUESTION: A 68-year-old male scheduled for a hernia repair at an ambulatory surgical center expresses
concern that he will not have enough care at home and asks if he can stay in the hospital after the surgery. The best
response by the nurse is
a) “Who is available to help you at home after the surgery?”
b) “I’m sure you will be able to manage at home after surgery. It is a simple procedure.”
c) “We will teach you everything you need to know to be able to care for yourself after surgery.”
d) “Your health insurance will pay for inpatient care only if complications develop during surgery.”
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________ Intraoperative Care
Chapter 18 (pgs. 313-327) (Hesi Book p.48)
Intraoperative – from the time a client is received in the operative suite until admission to the PACU.
Historically, took place in OR, but now majority are ambulatory surgeries
• ↑ Minimally invasive surgery (MIS) - With minimally invasive surgeries (MIS), incisions are smaller, blood
loss is reduced, postoperative pain is decreased, recovery time is shorter, and patients are discharged sooner. (EX:
Endoscopes)
Physical Environment - The suite is divided into three distinct areas:
1. Unrestricted area
 People in street clothes interact with those in scrubs:
 Holding area – patient identification, one family is allowed, supplication of SCD’s, IV starts, drugs
administered
 Locker room
 Information areas (Nursing station & Control desk)
2. Semi-restrictive areas
 Peripheral support areas and corridors with only authorized staff
 Must wear surgical attire and cover all head and facial hair
3. Restricted area - the physical layout is designed to reduce cross-contamination.
 Operating rooms
 Scrub sink areas
 Sterile core
 Surgical attire, head covers, and masks required
SCIP: surgical care improvement project measures to implement here - a national quality partnership of organizations
focused on improving surgical care by significantly reducing the number of complications from surgery. Mandates
include:
 Prophylactic Antibiotic
 Postoperative Blood Glucose
 Appropriate Hair Removal
 Urinary catheter removed on Postoperative
 Temperature Management
 Beta Blocker Therapy
 Venous Thromboembolism Prophylaxis Ordered
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NPSG: national patient safety goals require a preprocedure verification process, including:

Verification of relevant documentation – H&P, signed consents, nursing and anesthesia assessment

Required blood products and equipment such as implants, or devices needed

Diagnostic and radiology test results such as xrays, biopsy reports

Procedure site marked with patient involvement
Operating room within the Restricted Area:
Restricted inflow and outflow of personnel & Preferred location is next to PACU and surgical ICU
Filters & Controlled airflow (dust control) & No dust-collecting surfaces
Positive air pressure (prevents air from entering the operating room from halls/corridors)
UV lighting (reduces microorganisms in the air)
Materials resistant to corroding
Adjustable, easy-to-clean, and easy-to-move furniture is used
Equipment is checked for functioning and electrical safety
Lighting provides low to high intensity for precise view of surgical site
Communication system is used
Surgical Team –
Perioperative nurse
Surgeon’s assistant can be a physician, RN, or PA who
Is a registered nurse (RN)
functions in assisting role
Prepares room with the team
Holds retractors
Serves as patient advocate throughout surgical
Assists with homeostasis and suturing
experience
May perform portions of procedure under direct
Maintains patient safety, privacy, dignity,
supervision
confidentiality
Registered Nurse First Assistant (RNFA)
Communicates with the patient
Must have formal education & certification
Provides physical care
Works collaboratively with the surgeon, patient, and
surgical team
Scrub nurse
Follows designated surgical hand asepsis procedure
 Handles tissue
Gowned and gloved in sterile attire
 Uses instruments
Remains in sterile field
 Provides exposure to surgical site
Circulating nurse – (usually calls the surgical time-out)
 Assists with homeostasis
Not scrubbed, gowned, or gloved
 Performs suturing
Remains in unsterile field
Anesthesia care provider (ACP)
Documents (records all nursing care written or
Anesthesiologist, nurse anesthetist (CRNA), or
electronic)
anesthesiologist assistant (AA)
LPN or surgical technician (may fill the role of the
Maintenance of physiologic homeostasis throughout
circulating or scrub nurse)
intraoperative period
Performs scrubbed or circulating function
Provide care during recovery
Passes instruments and implements other technical
Prescribes preoperative and adjunctive medicines
functions
Monitors cardiac and respiratory status and vital
Supervised by RN and access to the RN at all times
signs throughout procedure
Surgeon
Physician who performs the procedure
Is responsible for
 Preoperative medical history
 Physical assessment
 Patient safety
 Postoperative management
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Communication (used every time patient care is transferred to another professional!!!!!!!!!!!)
 Situation
 Background
 Assessment
 Recommendations
Before Surgery Begins / Admitting the Patient: SAFETY!
 Proper Identification: right client, right procedure, right anatomic site.
 Ensure the sponge, needle, and instrument counts are accurate: done by 2 personnel before, during, before
closing the incision, and end of surgery.
 Final questioning re: valuables, dentures, prosthesis, contacts, food/fluid last intake
 Prophylactic antibiotics started 30-60 min. before incision & answering last minute questions
 Psychosocial assessment (answer questions to decrease anxiety) & offer alternative therapies: music,
aromatherapy, therapeutic touch, movies, etc. to decrease anxiety, reduce pain, and promote relaxation
 Cultural and spiritual assessment - For example, members of the Jehovah’s Witness community may refuse
blood transfusions. For Muslims, the left hand is considered unclean, so you should use the right hand to
administer forms, drugs, and treatments.
 History and physical assessment - vital signs, height, weight, and age; allergies to food, drugs, and latex;
integrity and cleanliness of skin; skeletal and muscle impairments; perceptual difficulties; level of
consciousness; nothing-by-mouth (NPO) status; and any sources of pain or discomfort.
 Chart review
 History and physical examination
 Urinalysis
 CBC
 Serum electrolytes
 Chest x-ray
 ECG
Room preparation
Surgical attire worn by all persons entering OR suite
Electrical and mechanical equipment checked for proper function (ceiling lifts, wall suction, etc.)
Aseptic technique practiced when placing instruments
 Counts - Sponges, needles, instruments, and small medical devices (e.g., surgical clip cartridges,
universal adapters). Any retained surgical supplies, devices, or instruments are sentinel event that can
result in negative outcomes for the patient.
 Functions of team members delineated
Transferring patient
Safety straps placed snugly across the patient’s thighs
Monitor telemetry leads, BP cuff, pulse oximetry, IV, and catheter
Scrubbing, gowning, and gloving
Cleanse hands and arms by scrubbing with detergent and brush
Fingers and hands
Progressing to elbows
Hands then held high - prevent contamination from clothing or detergent suds and water from draining from the
unclean area above the elbows to the clean and previously scrubbed areas of the hands and fingers.
Waterless, alcohol-based agents may replace traditional soap and water in some facilities
Sterile gown
Two pair of gloves
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Nursing Management - Basic aseptic technique
Center of sterile field is site of surgical incision
Only sterilized items in sterile field
Protective equipment worn: face shield, caps, gloves,
aprons, eye wear
Safety considerations
 Fire – from electrosurgical equipment (smoke evacuators
used to minimize exposure)
 Electrosurgery plume – toxic gas and vapors from
equipment
 Universal protocol – National Patient Safety Goals (NPSGs)
prevent wrong site, wrong procedure, wrong surgery
 Surgical time-out - All members of the surgical team stop
what they are doing during a surgical time-out just before
the procedure starts to verify patient identification, surgical
procedure, and surgical site. Before the induction of
anesthesia, ask the patient to confirm name, birth date,
surgical procedure and site, and consent. Wrong surgical
procedure and surgery performed on the wrong body part or wrong patient are defined as sentinel events.
 RN responsibility for correct labeling and handling of all samples. If excessive blood loss occurs, calculate effect on
client and report any changes in BP, HR, temp., and RR.
Positioning of patient - critical part of every procedure and usually follows administration of anesthesia.
Accessibility of operative site
Maintenance of airway
Correct musculoskeletal alignment
Prevent pressure on nerves, skin over bony prominences, earlobes, eyes
Prevent occlusion of arteries and veins
Provide modesty in exposure
Prevent injury such as muscle strain, joint damage, pressure ulcers, nerve damage, etc.
 Patient will not feel pain impulses because of anesthesia
 Secure extremities
 Provide adequate padding and support
Preventing hypothermia - correlation between unintended hypothermia and impaired wound healing, adverse
cardiac events, altered drug metabolism, and coagulopathies.
 Closely monitor temperature
 Apply warming blankets
 Warm IV fluids
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Catastrophic Events in the OR –
Anaphylactic reaction (caused by anesthetics, antibiotics, blood products, latex)
Manifestation may be masked by anesthesia
Symptoms include hypotension, tachycardia, bronchospasm, pulmonary edema
Vigilance and rapid intervention are essential
Malignant hyperthermia
Rare metabolic disorder of Hyperthermia with rigidity of skeletal muscles
Often occurs with exposure to succinylcholine (Anectine), especially in conjunction with inhalation agents
Usually occurs under general anesthesia but may also occur in recovery
Other triggers: Trauma / Heat / Stress
Autosomal dominant trait
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S/S: Tachycardia, Tachypnea, Hypercarbia (elevated carbon dioxide (CO2) levels in the blood), Ventricular
dysrhythmias, Rise in body temperature (HOWEVER, NOT an early sign)
Can result in cardiac arrest and death
Definitive Treatment: Dantrolene (Dantrium) – type of muscle relaxant that prevents spasms and hyperthermia
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NCLEX Question: During admission of the patient to the holding area or operating room before surgery, the
perioperative nurse must:
a) Verify the patient’s understanding of the risks of surgery.
b) Ensure the patient’s identity with a formal identification process.
c) Prepare the skin by scrubbing the surgical site with an antimicrobial agent.
d) Perform a preoperative assessment with a patient history and physical examination.
NCLEX QUESTION: During the administration of any regional anesthetic, it is most important that the nurse:
a) Monitor for ascending neurologic depression and unconsciousness
b) Ensure that airway equipment, emergency drugs, and monitors are immediately available
c) Monitor the patient’s response to the anesthesia, assessing the extent of loss of sensation
d) Have reversal drugs such as anticholinesterase agents (e.g., neostigmine [Prostigmin]) available in case of
respiratory arrest
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Postoperative Care
Chapter 19 (pgs. 328-347) (Hesi Book p.48-49)
Postoperative Period - Begins immediately after surgery until client has recovered.
PACU is located adjacent to OR - Limits transportation & Provides ready access to anesthesia and OR personnel
Nursing Care Focus
The primary goal of nursing care in the PACU is to monitor the patient for complications of anesthesia and/or the
surgical procedure!!!!!!!!
PACU Progression Postanesthesia care is divided into three phases: phase 1, phase 2, and extended observation
PACU Progression: Phase I
The initial recovery period.
Basic life-sustaining needs are of the highest priority
Patient is most prone to complications!!!!!!!
The patient assessment may include:

Management of an artificial airway

Pulse oximetry to assess oxygenation

Transcutaneous carbon dioxide (PtcCO2) and end-tidal CO2 PetCO2) (capnography) monitoring to detect
respiratory depression

Continuous ECG monitoring- for changes in HR that may indicate pain, anxiety, bleeding, hypovolemia,
abnormal electrolytes

Frequent BP monitoring (may have invasive arterial monitoring that provides continuous BP readings) for
complications of hypo- or hypertension

Frequent assessment of circulation, including body temperature, capillary refill, skin color, and moisture

Frequent assessment of neurologic system- LOC, orientation, sensory and motor status, pupils

Frequent assessment of intake and output, and fluid balance

Management of IV fluids and medications (this may include some reversal agents for neuromuscular blocking
agents given in the OR)

Management of catheters/drains

Goal is to prepare the patient for Phase II or an inpatient unit
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Phase I - Equipment Required
Various types and sizes of artificial airways
Ventilator
Various means of oxygen delivery
Pulse oximeter
Suction equipment
Means to measure BP and vital signs
ECG monitor/defibrillator
Pulmonary artery catheters, arterial/central lines supplies
IV supplies and fluids
Stock medications (opioids/antiemetics) & stock supplies
(e.g. foley kits, dressing kits, NG tubes, etc.)
Means to address hypo- or hyperthermia
PACU Progression: Phase II
Phase II care again is an inpatient setting.
 Nursing care focuses on preparing the patient for managing care at home or in an extended care environment
(rehab).
 Consider nursing care required during this time frame. Consider equipment required to care for the patient.
 Equipment required is not for intense monitoring.
 Equipment would include the equipment required to care for the surgical procedure/condition of the patient.
 May include surgical incision assessment/dressing change material.
 May include braces or splint or ambulatory assist devices if a joint was replaced, etc.
Phase II - Equipment Required
Oxygen delivery
ECG monitor/code cart
Bag valve mask
Stock supplies
Means to measure vital signs
Bladder scanner/means to assess urinary output
Urinary straight catheter kits
PACU Progression: Extended Observation
Occurs in area for patient to receive continued observation and care
Follows discharge from Phase I or Phase II
Nursing care focus: Preparing patient for self-care at home
Extended Observation - Equipment Required
Depends on
Type of surgery
Patient population
Institutional guidelines
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







Postoperative Assessment per Body System
Airway
Patency
Artificial airway
Breathing
RR and quality
Breath sounds
Supplemental oxygen
Pulse oximetry and capnography
Circulation
ECG monitoring
Vital signs
Peripheral pulses
Capillary refill
Skin color and temperature
Neurologic
LOC/ Glasgow Coma Scale
Orientation
Sensory and motor status
Pupil size and reaction
Genitourinary
Intake (IV fluids)
Output (urine and NG)
Estimated blood loss (EBL)
Gastrointestinal
Bowel sounds
NG—Verify placement to suction or clamped
Nausea
Surgical site - Dressing
Pain - Incisional
Laboratory and diagnostic tests - Review results of ordered exams
POTENTIAL COMPLICATIONS: (table 3.22 Hesi Book p.49)
Potential Postoperative Complications - Respiratory
 Airway obstruction - Airway obstruction is commonly caused by the patient’s tongue and is most pronounced
when supine and extremely sleepy.
 Hypoxemia: Atelectasis / Pulmonary edema - symptoms including agitation to somnolence, hypertension to
hypotension, and tachycardia to bradycardia. Pulse oximetry will be <90%. Atelectasis (alveolar collapse) or
pulmonary edema (fluid accumulation in the alveoli) may cause hypoxemia.
 Atelectasis, the most common cause of hypoxemia, is caused by retained secretions, decreased respiratory
excursion, or general anesthesia, and occurs when mucus blocks bronchioles or when the amount of alveolar
surfactant is reduced.
 Pulmonary edema is caused by an accumulation of fluid in the alveoli, and may be the result of fluid overload,
heart failure, prolonged airway obstruction, sepsis, or aspiration.
 Aspiration - gastric contents into the lungs may cause laryngospasm, infection, and pulmonary edema.
 Bronchospasm - increased bronchial smooth muscle tone, resulting in closure of small airways. This results in
wheezing, dyspnea, use of accessory muscles, hypoxemia, and tachycardia.
 Hypoventilation - decreased respiratory rate or effort and increased arterial carbon dioxide level (PaCO2). This
may occur as a result of depression of the central respiratory drive secondary to anesthesia and/or use of opioids.
 Pneumonia & Pulmonary Embolism – 1-2 days postop occurrence
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Nursing Interventions to Prevent Respiratory Complications
Proper patient positioning
 Lateral “recovery” position
 Once conscious – supine position
Oxygen therapy
 Coughing and deep breathing / Incentive spirometer
 Sustained maximal inspiration
Change patient position every 1 to 2 hours
Early mobilization & Pain management
Adequate hydration: Parenteral or oral
Chest physical therapy
Splinting with a Pillow or Blanket
Postoperative Complications - Cardiovascular
 Hypotension - seen in hypoperfusion to vital organs,
including the brain, heart, and kidneys.
 Hypertension - the result of sympathetic nervous system
stimulation caused by pain, anxiety, bladder distention,
respiratory distress, hypothermia, or preexisting
hypertension.
 Dysrhythmias - caused by hypoxemia, hypercapnia,
electrolyte and acid-base imbalances, circulatory instability,
and preexisting heart disease
 Syncope - (fainting) is caused by decreased cardiac output,
fluid deficits, or defects in cerebral perfusion.
 Thrombophlebitis/VTE (venous thromboembolism)– 6-14
days postop; may form in the leg veins as a result of
inactivity, body position, and pressure
Splinting with Pillow
Postoperative Complications - Fluid and Electrolytes
 Fluid overload: IV fluid
 Fluid deficit: dehydration status due to NPO
 Electrolyte imbalances: hypokalemia
 Acid-base imbalances: respiratory depression associated with anesthesia
Nursing Interventions to Prevent Cardiovascular & Fluid/Electrolyte Complications

Frequent vital signs monitoring - every 15 minutes in Phase I

Call surgeon if any of the following occur:
 Systolic BP <90mm Hg or >160mm Hg
 Pulse rate <60 or >120beats/min
 Pulse pressure (difference between systolic and diastolic blood pressure) narrows
 BP trends gradually decrease or increase over several consecutive readings
 Change in heart rhythm
 Significant deviation from preoperative readings

Continuous ECG monitoring

Adequate fluid replacement

Assess surgical site for bleeding

Intake and output

Monitor laboratory results: Potassium, BUN/creatinine, Magnesium, Hgb/Hct

Early ambulation & leg exercises every 8 hours while in bed

VTE prophylaxis: low molecular weight heparin (LMWH) & sequential compression devices (SCDs) &
thromboembolic deterrent hose (TED hose)
12


Monitor for orthostatic BP with increase in mobility
Slow changes in body position
Postoperative Complications - Neurologic/Psychologic

Emergence delirium: post-surgical phenomenon when arousing from anesthesia

Delayed emergence: delayed arousing from prolonged action of opioids / sedatives

Anxiety: unfamiliar location

Postoperative cognitive dysfunction (POCD): memory loss, inability to concentrate

Alcohol withdrawal delirium
Nursing Interventions to Prevent Neuropsychologic Complications

Monitor oxygen levels with pulse oximetry & Oxygen therapy!

Pain management

Reversal agents (Phase I)

Assess for anxiety and depression

Alcohol protocols

Fluid and electrolyte balance

Adequate nutrition & proper sleep

Proper bowel and bladder functioning
Postoperative Complications – Pain and Discomfort

Physiologic factors: include irritation of skin and underlying tissues by incision and retraction during surgery.
Reflex muscle spasms, positioning during surgery, and placement of various tubes may also contribute to pain
and discomfort.

Psychologic factors: fear and anxiety

Other sources: nausea, vomiting, environmental noises, noxious odors, shivering
Nursing Interventions to Prevent Pain and Discomfort

Patient teaching regarding how to report pain

Single modalities: e.g., opioid drugs

Multimodal analgesia: e.g., opioid and nonsteroidal anti-inflammatory drug [NSAID]) recommended when
possible to achieve better pain relief and decreased inflammation with fewer or less severe side effects.

Patient-controlled analgesia (PCA): involves self-administration of predetermined doses of analgesia via IV
Postoperative Complications - Alterations in Temperature

Hypothermia/ shivering: core body temperature of less than 96.8 (36oC); Shivering can increase resting energy
expenditure and oxygen consumption, carbon dioxide production, contribute to increased heart rate, BP, and
intracranial pressure, contribute to increased heart rate, BP, and intracranial pressure

Hyperthermia - Fever: 100 or greater

Malignant hyperthermia: rapid rise in core body temperature to 105(40.5°C) or higher and severe muscle
contractions
Nursing Interventions to Prevent Hypothermia and Fever

Passive warming: warmed cotton blankets, socks, reflective blankets, and limiting skin exposure.

Active warming: application of external warming devices, including forced air warmers, radiant warmers, and
heated, humidified oxygen and warmed IV fluids.

Meticulous asepsis

Coughing/deep breathing

Dantrolene (Dantrium) medication of choice for Malignant Hyperthermia!
Postoperative Complications – Gastrointestinal

Post-operative nausea and vomiting (PONV): most common complication

Constipation: due to paralysis of intestines

Postoperative ileus: due to use of opioids and immobility

Delayed gastric emptying
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
Hiccups: Irritation of the phrenic nerve may contribute to hiccups. May be caused by the presence of an NG tube
or drinking hot or cold fluids.
Nursing Interventions to Prevent GI Complications
PONV
 NPO, IV fluids, clear liquids
 Antiemetics (decreases nausea)/prokinetics (increase GI motility)
 Alternative therapy: guided imagery
Adequate hydration
Assess bowel sounds/flatulence
 Chewing gum mimics the act of eating and may stimulate gastric and bowel motility.
 Clear liquids may be ordered after return of bowel sounds.
 Constipation may be prevented with the use of stool softeners and laxatives.
Early mobilization
Postoperative Complications - Urinary
1. Retention
2. Oliguria (decreased urine output)
3. Catheter associated urinary tract infection (CAUTI)
Nursing Interventions to Prevent Urinary Complications

Monitor urine output

Adequate hydration

Remove urinary catheter when no longer indicated

Normal positioning for elimination

Bladder scan/straight catheter per orders
Postoperative Complications - Surgical Site Infection

Surgical site infection (SSI)

Contamination of the wound

Accumulation of fluid in the wound

Dehiscence / Evisceration (dehisce = detaches; evisceration = protrude)
Nursing Interventions to Prevent Wound Infections/SSI
 Assess the wound:
 Note drainage color, consistency, and amount
 Assess effect of position changes on wound/drain tube drainage
 Signs/symptoms of infection
 Ordered prophylactic antibiotics
 Maintain glycemic control
Modified Aldrete Scoring System
Used to assess transition from Phase I to Phase II
A score of 9-10_ indicates readiness for transfer or discharge to the next phase of recovery
DISCHARGE CRITERIA
Score
Consciousness

Fully awake
2

Arousable to voice
1

Unresponsive
0
14
Activity: Able to move voluntarily or on command

Four extremities
2

Two extremities
1

No extremities
0
Respiration

Able to take deep breath and cough
2

Dypsnea/shallow breathing
1

Apnea
0
Oxygen Saturation



2
2
Saturation maintains > 92% on room air
Needs oxygen to maintain saturation > 92%
Saturation > 90% even with supplemental oxygen
1
1
0
0
Circulation



BP within + 20 mm Hg of preoperative level
2

1

BP within + 20-50 mm Hg of preoperative level
0

BP within + 50 mm Hg of preoperative level
______________________________________________________________________________________________
NCLEX QUESTION: A patient becomes restless and agitated in the postanesthesia care unit (PACU) as he begins to
regain consciousness. The first action the nurse should take is to
a) Turn the patient to a lateral position.
b) Orient the patient and tell him that the surgery is over.
c) Administer the ordered postoperative pain medication.
d) Check the patient’s oxygen saturation with pulse oximetry.
NCLEX QUESTION: While in the PACU, the patient’s blood pressure drops from an admission pressure of 126/82 to
106/78 with a pulse change of 70 to 94. The nurse administers oxygen and then
a) Increases the rate of the IV fluids
b) Notifies the anesthesia care provider
c) Performs neurovascular checks on the lower extremities
d) Uses a cardiac monitor to assess the patient’s heart rhythm
NCLEX QUESTION: The nurse is preparing to discharge a patient from the ambulatory surgery center following an
inguinal hernia repair. The nurse delays the release of the patient upon discovering that the patient
a) Had IV morphine 45 minutes ago
b) Has an oxygen saturation of 92%
c) Has not voided since before surgery
d) Had one episode of vomiting 30 minutes ago
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




Surgical Risk Factors (table 3.21 Hesi Book p.47)
Age: very old or very young
Nutrition: obesity or malnourished
Fluid & Electrolyte Imbalances: dehydration, hypovolemia, calcium, magnesium, potassium, and phosphorus
General Health:
 previous cardiac conditions (angina, MI, HTN, CHF),
 coagulation disorders (bleeding, hemorrhage, shock),
 respiratory infection or COPD
 renal disease effects fluid/electrolyte regulations
 uncontrolled diabetes mellitus predisposes clients to infection and delayed wound healing
 liver disease impairs ability to detoxify medications
 obesity
Prescribed Medications:
 Anticoagulants, Tranquilizers, Heroin, Antibiotics, Diuretics, Steroids, Herbal medications, Vitamin E
(bleeding)
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