Perioperative Nursing

Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current drug references.

1. Overview and Pathophysiology

Perioperative care spans preoperative, intraoperative, and postoperative phases. Nursing goals: safety, informed participation, physiologic stability, and complication prevention.

Surgical stress triggers sympathetic and endocrine responses (tachycardia, fluid shifts, hyperglycemia, hypercoagulability). Anesthesia blunts airway reflexes and thermoregulation—hence PACU priorities of airway, breathing, circulation, then pain and nausea.

Malignant hyperthermia (MH) is a rare inherited hypermetabolic reaction to certain anesthetics (succinylcholine, volatile agents). Rising end-tidal CO₂, rigidity, tachycardia, then fever—treat with dantrolene and stopping triggers.

2. Causes and Risk Factors (complications)

• Atelectasis/pneumonia: shallow breathing, immobility, smoking, obesity
• VTE: surgery type, cancer, prior VTE, immobility
• Hemorrhage/shock: vessel injury, coagulopathy
• Wound dehiscence/evisceration: obesity, diabetes, steroids, infection, coughing without splinting
• Delirium: older age, ICU, infection, meds
• MH: genetic susceptibility + triggering agents
• Aspiration: full stomach, GERD, emergency surgery

3. Signs and Symptoms to Watch

• Pre-op red flags: uncontrolled glucose, K⁺ extremes, active infection, anticoagulation not held per plan, unsettled consent questions
• PACU: hypoventilation, desaturation, hypotension/hypertension, arrhythmias, emergence delirium, uncontrolled pain/PONV
• Hemorrhage: restlessness, tachycardia, falling BP, saturated dressings, drain surge
• PE: sudden dyspnea, chest pain, tachycardia
• Evisceration: “something gave way,” visible organs
• MH: unexplained ↑ETCO₂, masseter rigidity, mixed acidosis, hyperthermia (late)

4. Diagnostics and Labs

Lab reference ranges vary by laboratory. Always use your facility’s ranges.

5. Priority Nursing Assessments

1. Identity, procedure, site marked; allergies (latex, anesthesia, drugs)
2. NPO status; last dose of anticoagulants/herbal agents
3. Baseline VS, neuro, skin, mobility, fall risk
4. Consent signed before sedation; client understanding
5. PACU: airway/RR/SpO₂ first, then BP/ECG, LOC, pain, temperature, dressing/drains, urine output (≥ ~30 mL/hr or 0.5 mL/kg/hr commonly taught)
6. Aldrete or facility discharge scoring

6. Priority Nursing Interventions

Pre-op: teaching (IS, SCDs, pain plan), skin prep as ordered, remove jewelry/dentures per policy, verify checklist, warm patient, give pre-op antibiotics on time when ordered (SCIP timing).

Intra-op (circulator concepts): Universal Protocol time-out, sterile field integrity, positioning safety, counts, MH cart awareness, specimen handling.

Post-op:

• Airway positioning, O₂, cough/deep breathe, IS ~10×/hr while awake
• Early ambulation; SCDs on when in bed; anticoagulants as ordered
• Pain control balanced with sedation/RR monitoring; reverse with naloxone/flumazenil only as ordered
• Wound: reinforce dressings initially; mark drainage; surgical team changes first OR dressing often
• Evisceration: stay with client, sterile saline-moistened dressing, low Fowler’s knees flexed, NPO, call surgeon STAT—never push organs back
• MH: call MH emergency, stop triggers, 100% O₂ high flow, dantrolene, cool, treat hyperkalemia/acidosis per protocol

7. Medications

8. Patient Education

• NPO instructions and which BP meds to take sip of water (per anesthesia)
• Stop herbal agents (ginkgo, garlic, ginseng, etc.) as instructed—bleeding risk
• Incentive spirometer demo with teach-back
• Splint incision when coughing; call for help before first ambulation
• Report calf pain, sudden SOB, fever after 48–72 h, wound opening, urinary retention
• Home opioid safety and disposal

9. Complications Timeline Pearls

• First 24–48 h fever: often atelectasis → IS and mobilization
• Later fever: wound infection, UTI, pneumonia, VTE
• POD 1–3: urinary retention, ileus, delirium risk
• Any time: bleed, PE, MH (intra-op/early PACU)

10. Memory Aids

• “Airway first in PACU”
• “Consent before sedation”
• “Time-out: right patient, site, procedure”
• “Cover, don’t shove” for evisceration
• “Rising CO₂ + rigidity → think MH → dantrolene”

11. NCLEX-Style Practice Questions

1. Client coughs and bowel protrudes from the incision. First action?

A. Push the bowel back in
B. Cover with sterile saline-moistened dressings, position low Fowler’s with knees bent, notify surgeon
C. Have the client walk to reduce pressure
D. Apply a dry tight binder and leave

Answer: B. Protect organs and escalate—never reinsert.

2. POD 2 sudden dyspnea, sharp chest pain, HR 122. Priority?

A. Ambulate farther to “work through it”
B. Raise HOB, apply O₂, call rapid response—possible PE
C. Give a PRN laxative only
D. Wait an hour to reassess without intervening

Answer: B. Support ABCs and escalate.

3. Nurse’s role in informed consent?

A. Explain all surgical risks in place of the surgeon
B. Witness signature after verifying the client is informed and not sedated; notify provider if questions remain
C. Sign for the client if family is unavailable always
D. Obtain consent after premedication for convenience

Answer: B. Provider discloses; nurse advocates and witnesses appropriately.

4. Early PACU finding needing immediate action?

A. RR 8/min, SpO₂ 86%, difficult to arouse after opioid
B. Pain 4/10 stating preference for ice chips later
C. Small amount serous drainage on dressing
D. Asking what time family visits

Answer: A. Hypoventilation/sedation threatens airway—support ventilation and follow opioid-reversal orders as indicated.

5. Suspected malignant hyperthermia—medication to anticipate?

A. Protamine only
B. Dantrolene
C. High-dose succinylcholine booster
D. Oral ibuprofen alone

Answer: B. Dantrolene is the specific MH antidote alongside stopping triggers and supportive care.

References

The Joint Commission. (n.d.). Universal Protocol / National Patient Safety Goals. https://www.jointcommission.org/

AORN. (n.d.). Guidelines for perioperative practice (overview resources). https://www.aorn.org/

MedlinePlus. (n.d.). After surgery. National Library of Medicine. Retrieved October 15, 2026, from https://medlineplus.gov/aftersurgery.html

National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page

Rosenbaum, H. K., & Rosenberg, H. (related MH reviews). Malignant hyperthermia. In StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK430828/