NLE Perioperative & Pain Nursing — Preoperative and Intraoperative NursingCheat Sheet

Section Title

Classification of Surgery

Important Facts

• Classification by urgency determines timing and preoperative workup intensity.
• Classification by purpose guides nursing and patient education focus.
• Classification by risk (major vs. minor) informs anesthesia choice and recovery setting.

Key Definitions

Section Title

Preoperative Assessment and Surgical Risk Factors

Important Facts

• Age extremes (very young and older adults) = increased surgical risk; decreased physiologic reserve.
• Obesity increases risk of poor wound healing, dehiscence, respiratory compromise, DVT, PE.
• Malnutrition impairs wound healing; protein and vitamin C are essential preoperatively.
• Uncontrolled diabetes = poor infection control, delayed healing, hyperglycemia on operative day.
• Chronic disease (cardiovascular, renal, hepatic, respiratory) = increased anesthetic risk and delayed recovery.
• Smoking impairs oxygenation, increases infection risk, delays healing.
• Anticoagulants (warfarin, DOACs, heparin) = bleeding risk; usually held preoperatively per protocol.
• Herbal supplements (ginkgo, garlic, ginseng, vitamin E) = bleeding risk; discontinue ~2 weeks preoperatively.
• Corticosteroid-dependent patients = risk of adrenal crisis; may need stress-dose steroids perioperatively.
• Fluid/electrolyte imbalances = cardiac dysrhythmias, altered hemodynamics.
• Coagulation disorders (hemophilia, thrombocytopenia, liver disease) = excessive bleeding.
• Previous anesthesia reactions or family history of MH = CRITICAL to flag.

Key Definitions

Diagrams To Know

• Risk stratification flowchart (age → comorbidities → medications → lab results)
• Preoperative assessment checklist

Section Title

Baseline Preoperative Diagnostics

Important Facts

• CBC (Complete Blood Count): baseline hemoglobin/hematocrit, WBC for infection risk, platelets for coagulation.
• Electrolytes (Na, K, Cl, CO2): detect imbalances that affect cardiac function and anesthesia.
• Coagulation studies (PT/INR, aPTT, platelet count): assess bleeding risk.
• Blood typing and crossmatch: available for potential transfusion.
• ECG: baseline rhythm in older adults and cardiac patients; assess for dysrhythmias or ischemia.
• Chest X-ray: assess lung function in respiratory patients and older adults.
• Pregnancy test: mandatory in reproductive-age females; teratogenic drugs avoided.
• Renal function (BUN, creatinine): assess drug clearance and anesthetic risk.
• Liver function tests (AST, ALT, bilirubin): assess drug metabolism; coagulation synthesis.
• Glucose: baseline; critical in diabetics; target euglycemia perioperatively.

Section Title

Managing Chronic Conditions Preoperatively

Important Facts

• Diabetes: metformin held day of surgery (lactic acidosis risk); long-acting agents held; NPH reduced ~50%; regular insulin per protocol.
• Anticoagulants (warfarin, apixaban, dabigatran, rivaroxaban, heparin): hold per protocol (typically 3–7 days); timing depends on surgery type and risk.
• Antiplatelets (aspirin, clopidogrel, ticagrelor): hold ~5–7 days unless high thrombotic risk (e.g., recent stent); cardiology consulted.
• Corticosteroids: chronic users need stress-dose coverage; adrenal crisis risk if abruptly withdrawn.
• Hypertension: antihypertensives often continued with sip of water; avoid sudden withdrawal (rebound HTN).
• Beta-blockers: continue perioperatively to prevent tachycardia and ischemia.
• ACE inhibitors/ARBs: may be held day of surgery (intraoperative hypotension); resume postoperatively.
• Reconcile ALL medications with surgical team; clarify each hold or continue order.
• Document ALL medication adjustments in the chart and communicate to anesthesia.

Key Definitions

Section Title

Informed Consent — Critical Nursing Role

Important Facts

• SURGEON obtains consent; NURSE witnesses and verifies.
• Consent must be signed BEFORE sedation/premedication (sedated consent = INVALID).
• Patient must be COMPETENT (oriented, able to understand, not delirious).
• Consent must be VOLUNTARY (no coercion); patient has the RIGHT TO REFUSE.
• For minors: legal guardian or authorized representative signs (minor cannot give valid consent).
• For incompetent adults: legal guardian or healthcare proxy signs.
• Emergency implied consent: in life-threatening emergency when consent CANNOT be obtained, treatment may proceed to save life (e.g., unconscious trauma patient).
• If patient shows confusion or asks new questions, NOTIFY THE SURGEON; do not attempt to re-explain.
• Consent form must be COMPLETE, SIGNED, and IN THE CHART before patient is sedated.
• Document the time consent was witnessed and that patient appeared to understand.
• Verbal consent alone is NOT sufficient; written documentation is required.
• Advance directives and DNR orders must be reviewed and flagged.

Key Definitions

Diagrams To Know

• Informed consent decision tree (competent? signed? before sedation?)

Common Values

Section Title

NPO (Nothing by Mouth) Status

Important Facts

• Standard NPO guidelines: ~6–8 hours for solids, ~2 hours for clear liquids (FOLLOW INSTITUTIONAL/ANESTHESIA PROTOCOL).
• Purpose: reduce gastric volume and aspiration risk.
• Verify NPO status is maintained and report ANY INTAKE immediately.
• Clear liquids typically allowed up to 2 hours preoperatively (water, black coffee, apple juice WITHOUT PULP).
• Milk, formula, and non-clear liquids = treat as solids; require ~6 hours NPO.
• Gum, candy, and sips beyond protocol = BREAK NPO; report.
• Clarify with anesthesia which routine medications should be taken with a SIP of water (e.g., cardiac, antihypertensive drugs).
• Insulin, oral hypoglycemics: held or adjusted per protocol; confirm with surgical team.
• Anticoagulants: typically held; clarify with surgeon.
• Post-NPO: patient allowed fluids/solids per postoperative protocol once alert and gag reflex returns.

Key Definitions

Diagrams To Know

• NPO timeline and guidelines flowchart

Section Title

Preoperative Checklist and Physical Preparation

Important Facts

• VERIFY PATIENT IDENTITY with TWO IDENTIFIERS (name + DOB, name + MRN) — NOT room number.
• VERIFY CORRECT PROCEDURE by reading the operative permit and comparing to the surgeon's order.
• MARK THE SURGICAL SITE (by surgeon or designee) with permanent marker on the correct side/site.
• CONFIRM SIGNED CONSENT FORM is on the chart and complete.
• CONFIRM LAB AND DIAGNOSTIC RESULTS are available (CBC, electrolytes, type & cross, ECG, CXR, imaging).
• RECORD BASELINE VITAL SIGNS (BP, HR, RR, temp, O2 sat, pain level).
• HAVE PATIENT VOID or catheterize to empty bladder (reduces injury risk, improves surgical exposure).
• REMOVE ALL FOREIGN OBJECTS:
• – Dentures, partial plates, bridges (aspiration/airway obstruction risk)
• – Jewelry, body piercings (fire/burn risk in OR with electrocautery)
• – Contact lenses, glasses, hearing aids (loss/damage risk; verify patient given to family or stored safely)
• – Hairpins, clips, wigs (fire/aspiration risk)
• – Prosthetics, orthotic devices (stored safely; verify location)
• – Nail polish, artificial nails (prevents accurate pulse oximetry and nail bed assessment for oxygenation)
• – Makeup, powder, lotion (interferes with skin prep and monitoring electrode adhesion)
• REMOVE MAKEUP so skin can be assessed; particularly nail beds for perfusion/oxygenation.
• CLIP (NOT SHAVE) HAIR at surgical site per protocol (clipping reduces infection risk; shaving causes microtrauma and nicks).
• DRESS PATIENT in hospital gown (easy access for surgery and monitoring).
• APPLY IDENTIFICATION BAND with name, DOB, MRN, allergies.
• ADMINISTER PREOPERATIVE MEDICATIONS as ordered:
• – Sedatives/anxiolytics (reduce anxiety; impair judgment for consent)
• – Prophylactic antibiotics (prevent surgical site infection)
• – Antiemetics (reduce nausea/vomiting)
• – Proton pump inhibitors/H2 blockers (reduce gastric acid; reduce aspiration risk)
• PERFORM SKIN ANTISEPSIS/SHOWER as ordered (some protocols require chlorhexidine or iodine shower night before).
• DOCUMENT COMPLETION of entire checklist on the preoperative record.
• COMMUNICATE FINDINGS to OR staff; ensure chart accompanies patient to OR.

Key Definitions

Diagrams To Know

• Preoperative checklist flowchart (verification → preparation → documentation)

Section Title

Preoperative Teaching

Important Facts

• Teach BEFORE the day of surgery (preoperative anxiety is lower; better retention).
• Address patient FEARS and MISCONCEPTIONS; provide emotional and spiritual support.
• Cover WHAT TO EXPECT: OR environment, monitors, endotracheal tube (if general anesthesia), positioning, potential sounds/sensations.
• TEACH DEEP BREATHING: slow, deep breaths to oxygenate and prevent atelectasis.
• TEACH INCENTIVE SPIROMETRY: use before and after surgery; goal is personal best volume.
• TEACH COUGHING AND SPLINTING: splint incision with pillow/hands; cough to clear secretions (prevents pneumonia).
• TEACH LEG EXERCISES: dorsiflexion, plantarflexion, leg lifts postoperatively to promote circulation and prevent DVT.
• TEACH EARLY AMBULATION: get out of bed as soon as safe to prevent DVT, PE, atelectasis.
• TEACH PAIN MANAGEMENT: patient-controlled analgesia (PCA), epidural, regional blocks, oral analgesics; encourage use before pain is severe.
• TEACH ABOUT EQUIPMENT: explain drains, tubes (NGT, foley, chest tube), monitors, oxygen mask, IV lines.
• TEACH RANGE OF MOTION and positioning to prevent contractures and pressure injuries.
• PROVIDE WRITTEN MATERIALS to reinforce teaching; use teach-back method (ask patient to demonstrate or repeat-back).
• EFFECTIVE PREOPERATIVE TEACHING = reduced anxiety, reduced postoperative complications, faster recovery, improved pain control.

Key Definitions

Diagrams To Know

• Preoperative teaching content checklist

Common Values

Section Title

Anesthesia Types and Nursing Considerations

Important Facts

• GENERAL ANESTHESIA: loss of consciousness, analgesia, amnesia, muscle relaxation; airway intubated; induction agents (propofol, thiopental), inhalational agents (sevoflurane, desflurane), muscle relaxants (succinylcholine, rocuronium).
• GA RISKS: airway obstruction, aspiration, hypoxemia, hypotension, dysrhythmias, malignant hyperthermia.
• MALIGNANT HYPERTHERMIA: EARLY SIGNS = unexplained TACHYCARDIA, rising end-tidal CO2, muscle rigidity, hyperthermia (LATE sign); TREATMENT = STOP anesthetic agents, GIVE DANTROLENE (2.5 mg/kg IV, repeat q5min up to 10 mg/kg), cool patient (IV cold saline, ice packs, cold lavage), monitor for rhabdomyolysis/acute kidney injury, treat dysrhythmias, hyperkalemia.
• MH PREVENTION: screen for family history (MH relative, unexplained anesthetic death, perioperative death from heat); use MH-safe anesthetics (propofol, etomidate, opioids, benzodiazepines, local anesthetics, non-depolarizing relaxants).
• SPINAL ANESTHESIA: intrathecal local anesthetic; rapid onset, dense block; WATCH FOR hypotension (sympathetic blockade) and bradycardia → fluid bolus, vasopressor (ephedrine, phenylephrine); PDPH managed with bed rest, hydration, analgesics, epidural blood patch if severe.
• EPIDURAL ANESTHESIA: injected into epidural space; slower onset than spinal; allows catheter for repeated dosing; used for labor, postoperative analgesia; monitor for hypotension, epidural hematoma, infection.
• NERVE BLOCKS: specific peripheral nerve anesthetized; used for limb surgery and postoperative analgesia; requires landmark technique or ultrasound guidance.
• LOCAL ANESTHESIA: agent infiltrated into tissue; patient conscious; suitable for minor procedures (laceration repair, small biopsies); lowest systemic toxicity.
• MODERATE SEDATION: depressed consciousness but airway protected and patient arousable; used for diagnostic procedures (colonoscopy, endoscopy); CONTINUOUS MONITORING required (SpO2, ETCO2, cardiac rhythm); reversal agents available (naloxone for opioids, flumazenil for benzodiazepines).
• ALWAYS ASK about family history of MH, anesthetic reactions, difficult intubation, postoperative nausea/vomiting.

Key Definitions

Diagrams To Know

• Anesthesia types by level of consciousness (general vs. regional vs. local)
• Malignant hyperthermia signs and management flowchart

Common Values

Section Title

Intraoperative Nursing and Safety

Important Facts

• OR TEAM: surgeon, anesthesia provider, scrub nurse (sterile), circulating nurse (non-sterile), others as needed.
• CIRCULATING NURSE ROLE: manage OR, document, coordinate, maintain sterile field integrity, ADVOCATE for anesthetized patient.
• SCRUB NURSE ROLE: maintain sterile field, pass instruments, count sponges/instruments/sharps.
• TIME-OUT performed BEFORE INCISION; whole team participates; verifies CORRECT PATIENT, CORRECT PROCEDURE, CORRECT SITE.
• SURGICAL COUNTS: performed BEFORE procedure, BEFORE closing a cavity (abdomen, chest, pelvis), and at SKIN CLOSURE; sponges, instruments, and sharps counted.
• INCORRECT COUNT: notify surgeon IMMEDIATELY; wound NOT CLOSED until count is reconciled (may require X-ray, exploration, or repeat count).
• RETAINED FOREIGN OBJECTS: serious complication; prevent by strict counting and verification.
• STERILE FIELD MAINTENANCE: only sterile items touch sterile items; edges of sterile packages (~2.5 cm) considered contaminated; anything below waist/table level or out of sight is NOT sterile.
• STERILE GOWN/GLOVES: front of gown chest to waist is sterile; sleeves to elbow are sterile; back of gown is NOT sterile.
• IF STERILITY IS DOUBTED: item is CONTAMINATED; discard and replace.
• LATEX ALLERGY: major concern in OR; latex-free environment required; latex gloves, blood pressure cuffs, catheters, anesthesia equipment all latex-free.
• ANAPHYLAXIS in OR: present with hypotension, flushed skin, wheezing, angioedema; TREAT with epinephrine 0.3–0.5 mg IM immediately.
• SURGICAL SITE INFECTIONS (SSI): prevent with prophylactic antibiotics, skin prep, aseptic technique, environmental controls.

Key Definitions

Diagrams To Know

• Surgical counting and verification flowchart
• Sterile field zones and contamination rules diagram

Section Title

Intraoperative Patient Positioning and Safety

Important Facts

• ANESTHETIZED PATIENTS CANNOT FEEL PAIN or reposition themselves; they depend on the team for protection.
• MAINTAIN CORRECT BODY ALIGNMENT: straight spine, neutral joints, no extreme flexion/extension.
• PAD BONY PROMINENCES: heels, sacrum, elbows, occiput, shoulders, knees, hips (prevent pressure ulcers).
• PAD PRESSURE POINTS: areas under equipment, drapes, retractors.
• SECURE PATIENT with safety straps (but NOT too tight; avoid nerve compression).
• AVOID OVEREXTENSION of joints: keep joints in neutral or slight flexion.
• PREVENT FALLS: ensure proper positioning, secure straps, side rails if patient is elevated.
• MONITOR CIRCULATION: check color, warmth, pulses distal to pressure points; repositioning improves venous return.
• WATCH RESPIRATORY COMPROMISE: extreme positions (reverse Trendelenburg, lithotomy) may impair ventilation; monitor chest rise and SpO2.
• COMMON POSITIONS:
• – Supine: routine abdominal/thoracic/extremity surgery; good alignment
• – Prone: spinal surgery; watch respiratory compromise, facial pressure
• – Lithotomy: gynecologic/urologic surgery; high pressure on sacrum/knees; monitor for DVT risk, rhabdomyolysis if prolonged
• – Lateral: flank surgery; axilla padding critical (axillary nerve); chest may compress lung
• – Trendelenburg (head down): pelvic surgery; increases intracranial pressure, impairs ventilation; risk of facial/airway edema
• – Reverse Trendelenburg (head up): upper abdominal surgery; facilitates breathing but risk of hypotension
• PREVENT HYPOTHERMIA: use warming blankets, warm IV fluids, reduce heat loss; monitor core temperature.
• SKIN PROTECTION: protect from prep solutions (iodine, alcohol burn risk; cover eyes), electrocautery pad placement (avoid bony prominences), drapes.
• DOCUMENT positioning, padding, pressure points protected, and any positioning concerns.
• COMMUNICATE positioning changes to anesthesia (may affect circulation, ventilation).

Key Definitions

Diagrams To Know

• Common surgical positions and pressure points diagram
• Safe positioning and padding checklist

Section Title

Operating Room Environment and Asepsis Zones

Important Facts

• OR ZONING prevents contamination by controlling access and attire.
• UNRESTRICTED ZONE: street clothes OK; no special precautions; public access area.
• SEMI-RESTRICTED ZONE: scrubs and cap required; minimal street clothes exposure.
• RESTRICTED ZONE (OR): scrubs, cap, AND MASK required at all times; eye protection recommended; NO street clothes.
• MASK PURPOSE: source control; filters particles from wearer's respiratory tract; do NOT protect wearer from infection.
• HAND HYGIENE: perform before entering semi-restricted and restricted zones; surgical scrub for OR personnel.
• SURGICAL ASEPSIS RULES:
• – Only STERILE items touch the sterile field.
• – Only STERILE personnel (gloved/gowned) contact the sterile field.
• – Edges of sterile packages are CONTAMINATED (~2.5 cm border).
• – Anything BELOW WAIST LEVEL or OUT OF SIGHT is NOT sterile.
• – Back of a gown/sleeves above elbow are NOT sterile.
• – If sterility is DOUBTED, it IS contaminated.
• LATEX-FREE ENVIRONMENT: CRITICAL for latex-allergic patients; latex-free gloves, catheters, blood pressure cuffs, anesthesia equipment, tape, drapes; risk of intraoperative anaphylaxis.
• ENVIRONMENTAL CONTROLS: laminar flow, HEPA filtration, positive pressure, temperature (20–23°C), humidity (30–60%), air exchanges (15–25/hour).
• TRAFFIC CONTROL: minimize OR door openings; only essential personnel present.
• SHARPS SAFETY: needle-stick prevention; use safety-engineered devices; careful passing of sharps.
• CHEMICAL SAFETY: housekeeping agents, sterilants (ethylene oxide), disinfectants; ensure ventilation.
• FIRE SAFETY: three-part fire triangle (ignition source, fuel, oxygen); fire extinguishers available; know escape routes.

Key Definitions

Diagrams To Know

• OR zone classification and attire requirements diagram
• Sterile field contamination prevention flowchart

Section Title

High-Yield NLE Exam Focus Points

Important Facts

• NPO STATUS: ~6–8 hrs solids, ~2 hrs clear liquids; PREVENTS ASPIRATION (most commonly tested).
• TWO-IDENTIFIER VERIFICATION: name + DOB or MRN (NOT room number); prevents wrong-patient surgery.
• SURGICAL SITE MARKING: permanent marker by surgeon; prevents wrong-site surgery.
• INFORMED CONSENT: SURGEON explains and obtains; NURSE witnesses and verifies BEFORE sedation; patient must be COMPETENT and VOLUNTARY.
• NAIL POLISH REMOVAL: allows NAIL BED ASSESSMENT for oxygenation (SpO2 monitoring).
• HAIR CLIPPING (NOT SHAVING): reduces infection risk; shaving causes microtrauma.
• PREOPERATIVE TEACHING: deep breathing, incentive spirometry, coughing with splinting, leg exercises, early ambulation; REDUCES POSTOPERATIVE COMPLICATIONS.
• MALIGNANT HYPERTHERMIA: EARLY SIGN = TACHYCARDIA + rising CO2; TREATMENT = dantrolene + cooling; ASK ABOUT FAMILY HISTORY.
• SPINAL ANESTHESIA COMPLICATION: hypotension/bradycardia (sympathetic blockade); POST-DURAL PUNCTURE HEADACHE (flat positioning, fluids).
• SURGICAL TIME-OUT: before INCISION; whole team verifies CORRECT PATIENT, CORRECT PROCEDURE, CORRECT SITE.
• SURGICAL COUNTS: BEFORE procedure, BEFORE closing cavity, at SKIN CLOSURE; sponges, instruments, sharps; prevents RETAINED FOREIGN OBJECTS.
• INTRAOPERATIVE POSITIONING: PAD bony prominences; maintain alignment; avoid nerve compression; monitor circulation and respiration.
• LATEX ALLERGY: flag early; latex-free environment; risk of anaphylaxis in OR.

Rows

Columns

• Type
• Consciousness
• Airway Control
• Best Use
• Key Risks
• Nursing Considerations

Table Title

Types of Anesthesia Comparison

Rows

Columns

• Risk Factor
• Impact on Surgery
• Preoperative Management

Table Title

Surgical Risk Factors and Nursing Interventions

Rows

Columns

• Item
• Why Important
• Nurse Action

Table Title

Preoperative Checklist — Critical Items