Preoperative and Intraoperative Nursing - Cheat Sheet
Your last-minute revision companion for exam-critical preoperative and intraoperative nursing concepts, surgical risk assessment, informed consent, NPO management, anesthesia types, and intraoperative safety protocols. Focus on patient safety, the nursing process, and PRC NLE high-yield content.
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
Emergent Surgery
Example
Ruptured appendix with sepsis requiring immediate surgery.
Immediate intervention required; life-threatening condition (e.g., ruptured aneurysm, acute hemorrhage); no time for extensive preoperative preparation.
Urgent Surgery
Example
Acute appendicitis diagnosed in the evening; scheduled for surgery next morning.
Required within 24–48 hours; serious condition but not immediately life-threatening (e.g., acute appendicitis, fracture).
Elective Surgery
Example
Cataract repair, hernia repair, joint replacement.
Planned, non-emergency procedure scheduled in advance; patient and team prepare thoroughly.
Optional Surgery
Example
Cosmetic rhinoplasty, hair transplant.
Performed at patient's preference; not medically necessary; mainly cosmetic or quality-of-life improvements.
Diagnostic Surgery
Example
Breast biopsy to confirm or rule out malignancy.
Performed to identify or confirm a condition (e.g., biopsy, laparoscopy).
Curative/Ablative Surgery
Example
Mastectomy for breast cancer, appendectomy for appendicitis.
Removes diseased tissue or organ to treat the condition.
Palliative Surgery
Example
Pain management procedure in terminal cancer patient.
Relieves symptoms or discomfort but does not cure the underlying disease.
Reconstructive Surgery
Example
Skin grafting after burns, breast reconstruction after mastectomy.
Restores form and function after injury, disease, or surgical removal.
Major Surgery
Example
Coronary artery bypass, total abdominal hysterectomy, open-heart surgery.
Involves large incision, significant blood loss risk, major organ involvement, extended operative time, or high physiologic stress.
Minor Surgery
Example
Cyst removal, laceration repair, minor biopsy under local anesthesia.
Limited incision, minimal blood loss, short operative time, minimal physiologic stress; often outpatient.
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
Surgical Risk
Example
An 75-year-old diabetic with untreated hypertension has HIGH surgical risk.
Probability of adverse perioperative outcome based on patient factors, procedure complexity, and anesthesia choice; identified through preoperative assessment.
Malignant Hyperthermia (MH)
Example
Family history of unexpected anesthetic death or muscle rigidity during surgery.
Rare, inherited, life-threatening pharmacogenetic reaction to certain anesthetic agents; characterized by uncontrolled muscle metabolism and dangerous hyperthermia.
Diagrams to know
- Risk stratification flowchart (age → comorbidities → medications → lab results)
- Preoperative assessment checklist
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.
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
Perioperative Glucose Control
Example
Metformin and long-acting sulfonylureas held; NPH insulin often reduced 50%; regular insulin given per sliding scale.
Strict glucose regulation (target 100–180 mg/dL) to optimize wound healing and reduce infection; insulin adjusted per protocol; oral hypoglycemics usually held.
Stress-Dose Steroids
Example
Patient on prednisone 10 mg daily may receive hydrocortisone 50–100 mg IV perioperatively.
Supplemental corticosteroids given perioperatively to prevent adrenal insufficiency in chronic steroid-dependent patients.
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
Informed Consent
Example
Patient signs surgical consent form after surgeon explains the procedure, possible complications, and alternatives.
Voluntary agreement by a competent patient to undergo a procedure after the surgeon has explained the procedure, benefits, risks, and alternatives; protects autonomy and is a legal requirement.
Surgeon's Role in Consent
Example
Surgeon describes the mastectomy procedure, risks of bleeding/infection, and alternatives (radiation, lumpectomy).
The physician performing the procedure obtains consent by explaining the procedure, its benefits, risks, and alternatives in understandable terms.
Nurse's Role in Consent
Example
Nurse checks consent form is signed, asks 'Do you have any questions?' and documents the patient appeared to understand.
Witnesses the signature, verifies the patient is competent and NOT sedated, confirms understanding, and alerts the surgeon to any patient questions or confusion; does NOT explain the procedure.
Diagrams to know
- Informed consent decision tree (competent? signed? before sedation?)
NPO (Nothing by Mouth) Status
Common values
Value
6–8 hours
Symbol
NPO solids
Quantity
NPO for solids
Value
2 hours
Symbol
NPO liquids
Quantity
NPO for clear liquids
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
NPO Status
Example
NPO from midnight (or 6 hours preoperatively) to reduce gastric contents during general anesthesia.
Patient refrains from oral intake (solids, liquids, medications) before surgery to reduce gastric volume and aspiration risk under anesthesia.
Aspiration
Example
Anesthetized patient with full stomach vomits; stomach acid and food particles enter lungs causing chemical pneumonitis.
Inhalation of gastric contents (food, liquid, secretions) into the airway during anesthesia; can cause hypoxemia, pneumonitis, and death if untreated.
Diagrams to know
- NPO timeline and guidelines flowchart
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
Two-Identifier Verification
Example
Ask patient to state name and birthdate; verify against ID band and chart.
Confirming patient identity using TWO independent identifiers (e.g., name and medical record number, NOT room number) to prevent wrong-patient surgery.
Surgical Site Marking
Example
Surgeon marks 'left knee' with permanent marker before patient enters OR.
Marking the correct surgical site with a permanent marker by the surgeon or designee preoperatively to prevent wrong-site surgery.
Diagrams to know
- Preoperative checklist flowchart (verification → preparation → documentation)
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
Preoperative Teaching
Example
Teach deep breathing, coughing, leg exercises, pain management, and expected sensations (tubes, drains, monitors).
Patient education delivered BEFORE surgery to reduce anxiety, improve compliance, and prevent postoperative complications; most effective 1–2 days before when anxiety is lower.
Incentive Spirometry
Example
Patient inhales deeply through spirometer mouthpiece, holds breath ~3 sec, exhales; goal is to reach target volume.
Device and technique to encourage deep breathing postoperatively; prevents atelectasis and hypoxemia by expanding alveoli.
Splinting the Incision
Example
After abdominal surgery, patient holds a pillow against the abdomen while coughing to reduce pain.
Supporting the surgical incision with hands, pillow, or abdominal binder during coughing and movement to reduce pain and protect the incision.
Diagrams to know
- Preoperative teaching content checklist
Anesthesia Types and Nursing Considerations
Common values
Value
2.5 mg/kg IV; repeat q5min up to 10 mg/kg
Symbol
MH treatment
Quantity
Dantrolene dose for MH
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
General Anesthesia
Example
Propofol IV induction + sevoflurane inhalation + succinylcholine for intubation; patient is completely unconscious.
Reversible loss of consciousness, analgesia, amnesia, and muscle relaxation; achieved with IV and/or inhalational agents; airway is intubated with endotracheal tube (ETT) or laryngeal mask airway (LMA).
Malignant Hyperthermia (MH)
Example
Unexplained tachycardia and rising end-tidal CO2 intraoperatively signal MH; treat immediately with dantrolene and cooling.
Rare, inherited, life-threatening pharmacogenetic reaction triggered by exposure to volatile anesthetics (sevoflurane, desflurane, isoflurane) or succinylcholine; uncontrolled muscle metabolism produces extreme heat and metabolic crisis.
Spinal Anesthesia
Example
Injection of bupivacaine at L3–L4 for cesarean section; patient has no sensation below waist but is awake.
Local anesthetic injected into the subarachnoid (CSF) space; produces rapid, dense sensory and motor block below injection level; patient remains conscious.
Epidural Anesthesia
Example
Epidural catheter placed for labor analgesia or postoperative pain management; medication infused continuously or as needed.
Local anesthetic injected into the epidural space (outside dura); blocks sensation and motor function in the area supplied; allows repeated dosing via catheter.
Nerve Block
Example
Brachial plexus block for shoulder surgery; interscalene approach anesthetizes the arm.
Local anesthetic injected around a specific nerve or nerve plexus to anesthetize a region; used for limb surgery or postoperative analgesia.
Local Anesthesia
Example
Lidocaine 1% infiltrated around a laceration for suturing in the ED.
Local anesthetic agent injected or applied topically to numb a small, specific area; patient remains fully conscious.
Moderate (Conscious) Sedation
Example
Midazolam + fentanyl for colonoscopy; patient is drowsy but arousable and can respond to commands.
Depressed level of consciousness in which patient maintains airway patency and responds to stimuli; not true anesthesia; used for minor procedures.
Post-Dural Puncture Headache (PDPH)
Example
Patient develops severe headache 24–48 hours after spinal anesthesia; managed with bed rest, hydration, analgesics, or epidural blood patch.
Complication of spinal anesthesia caused by CSF leakage through the dura puncture; presents as headache worsened by sitting/standing and relieved by lying flat.
Diagrams to know
- Anesthesia types by level of consciousness (general vs. regional vs. local)
- Malignant hyperthermia signs and management flowchart
Intraoperative Nursing and Safety
Common values
Value
2.5 cm
Symbol
Sterile border
Quantity
Sterile field contaminated margin
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
Scrub Nurse
Example
Scrub nurse hands instruments to surgeon during surgery and performs sponge counts before closure.
Sterile team member who maintains the sterile field, passes instruments and supplies to the surgeon, and counts sponges, instruments, and sharps.
Circulating Nurse
Example
Circulating nurse verifies consent, performs time-out, documents fluid intake/output, and alerts surgeon to count discrepancies.
Non-sterile team member who manages the OR, documents findings, coordinates with outside staff, maintains sterile field integrity, and advocates for the anesthetized patient.
Surgical Time-Out
Example
Surgeon says 'Time-out: This is John Smith, correct patient? Yes. Left knee arthroscopy, correct procedure? Yes. Left knee marked, correct site? Yes.'
Brief pause before incision where the entire OR team (surgeon, anesthesia, nurses) verifies the CORRECT PATIENT, CORRECT PROCEDURE, and CORRECT SITE (WHO Surgical Safety Checklist); prevents wrong-site, wrong-procedure, wrong-patient surgery.
Surgical Counts
Example
Scrub nurse counts 10 sponges before starting; before closing abdomen, count is 10 again; if count is 9, surgeon is notified and incision is searched or X-ray taken.
Verification that the number of sponges, instruments, and needles (sharps) before the procedure, before closing a cavity, and before skin closure matches the number used; prevents retained foreign objects.
Retained Foreign Object (RFO)
Example
Sponge left in abdomen after cesarean section causes infection and abscess 2 weeks postoperatively.
Surgical sponge, instrument, or needle left inside the surgical wound; serious complication causing infection, abscess, obstruction, sepsis, or death.
Surgical Asepsis
Example
Scrub nurse uses sterile gloves, sterile instruments are placed on a sterile field, and only sterile items touch sterile items.
Strict adherence to sterile technique to prevent microbial contamination of the surgical field and wound; includes hand hygiene, sterile gloves/gowns, sterile instruments, and sterile field maintenance.
Diagrams to know
- Surgical counting and verification flowchart
- Sterile field zones and contamination rules diagram
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
Intraoperative Positioning
Example
Supine position for abdominal surgery; lithotomy for gynecologic surgery; prone for spinal surgery.
Strategic placement of the anesthetized patient to allow surgical access while protecting the body, maintaining alignment, and preventing injury (pressure ulcers, nerve damage, joint strain).
Pressure Injury
Example
Pressure ulcer develops on sacrum after 4-hour abdominal surgery without proper padding and repositioning.
Localized tissue damage (erythema, necrosis) caused by sustained pressure, friction, or shear on bony prominences; OR patients at risk due to anesthesia and prolonged immobility.
Nerve Damage (Intraoperative)
Example
Improper positioning compresses the peroneal nerve; patient wakes with foot drop and inability to dorsiflex.
Injury to nerves from prolonged pressure, stretching, or positioning; results in postoperative numbness, weakness, or pain in the supplied region.
Diagrams to know
- Common surgical positions and pressure points diagram
- Safe positioning and padding checklist
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
Unrestricted Zone
Example
Family waiting area, OR reception desk.
OR entrance/holding area; street clothes and minimal protective attire permitted; minimal environmental controls; highest contamination potential.
Semi-Restricted Zone
Example
Sterile processing, equipment storage, PACU.
Storage, instrument cleaning, recovery areas; scrub attire (scrubs, cap) required; moderate environmental controls.
Restricted Zone
Example
Inside the OR during surgery; all staff wear scrubs, caps, masks, and eye protection.
The OR itself; maximum sterility required; scrub attire, cap, AND mask mandatory; strict environmental controls (filtered air, positive pressure, temperature/humidity).
Surgical Field (Sterile Field)
Example
Prepped and draped surgical site; sterile instruments, sponges, and gloved surgeon work within this field.
Prepared area on the patient and draped surfaces where the surgery occurs; maintained under strict asepsis; only sterile items/personnel (gloved/gowned) contact it.
Diagrams to know
- OR zone classification and attire requirements diagram
- Sterile field contamination prevention flowchart
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.
Must remember
- 1. NPO: 6–8 hours solids, 2 hours clear liquids PREVENTS ASPIRATION — the #1 preoperative nursing priority. Verify and report ANY oral intake.
- 2. Informed Consent: SURGEON obtains by explaining procedure/risks/alternatives; NURSE witnesses signature BEFORE sedation and verifies patient is competent. If patient confused, NOTIFY SURGEON — do not re-explain.
- 3. Two-Identifier Verification: name + DOB (NOT room number); CORRECT PROCEDURE verified on operative permit; SURGICAL SITE marked by surgeon with permanent marker. PREVENTS WRONG-SITE SURGERY.
- 4. Remove Nail Polish (and makeup): ALLOWS NAIL BED ASSESSMENT for oxygenation and SpO2 monitoring — must be visible for accurate pulse oximetry.
- 5. CLIP Hair (Not Shave): Clipping reduces infection risk; shaving causes microtrauma and nicks. Document clipping per protocol.
- 6. Preoperative Teaching: Deep breathing, incentive spirometry, coughing with splinting, leg exercises, early ambulation PREVENT POSTOPERATIVE COMPLICATIONS (atelectasis, DVT, pneumonia). Teach 1–2 days before surgery when anxiety is lower.
- 7. Malignant Hyperthermia: EARLY sign is unexplained TACHYCARDIA + rising end-tidal CO2 (NOT high temp as first sign); TREAT IMMEDIATELY with dantrolene 2.5 mg/kg IV + cooling measures. ASK ABOUT FAMILY HISTORY preoperatively.
- 8. Surgical Time-Out: BEFORE INCISION, whole OR team pauses and verifies CORRECT PATIENT, CORRECT PROCEDURE, CORRECT SITE — WHO Surgical Safety Checklist. PREVENTS WRONG-SITE/WRONG-PROCEDURE/WRONG-PATIENT SURGERY.
- 9. Surgical Counts: Sponges, instruments, sharps counted BEFORE procedure, BEFORE closing cavity, at SKIN CLOSURE. INCORRECT COUNT = notify surgeon IMMEDIATELY; wound NOT closed until reconciled. PREVENTS RETAINED FOREIGN OBJECTS.
- 10. Intraoperative Positioning: PAD bony prominences (sacrum, heels, elbows, occiput, knees); maintain alignment; avoid nerve compression; monitor circulation/respiration. Anesthetized patient CANNOT feel pain or reposition — TEAM RESPONSIBILITY to prevent pressure injuries and nerve damage.
Last minute tips
- 1. Consent TIMING is exam-critical: Consent MUST be signed BEFORE any sedatives/premedication. Consent signed after sedation = INVALID and is a major legal/ethical violation. If patient is already sedated when you discover consent unsigned, notify surgeon immediately — do NOT sedate further.
- 2. NPO status is the MOST COMMONLY TESTED preoperative concept on NLE. Remember: solids 6–8 hours, clear liquids 2 hours. If a patient has eaten 2 hours before scheduled general anesthesia with 2-hour fasting, anesthesia MUST be DELAYED or CANCELLED due to aspiration risk. Always ask and report.
- 3. Malignant Hyperthermia early warning signs: TACHYCARDIA + rising ETCO2 on the capnograph are the FIRST detectable signs (before temperature rises). If you see this pattern intraoperatively, suspect MH and alert anesthesia IMMEDIATELY. High temperature is a LATE sign and indicates severe metabolic derangement.
- 4. Surgical counts: Exams often test what happens if a count is INCORRECT. Answer: NOTIFY SURGEON IMMEDIATELY; wound is NOT CLOSED; X-ray may be taken; incision may be explored. It is NEVER acceptable to close without reconciling a discrepant count.
- 5. Patient positioning for common surgeries: Supine (abdominal), prone (spine), lithotomy (gynecologic), lateral (flank). Exams test which nerves/pressure points are at risk for EACH position. Example: lithotomy position = risk of DVT, rhabdomyolysis, foot drop (peroneal nerve); Trendelenburg = respiratory compromise, facial edema. Study position + complication pairs.
Comparison tables
Types of Anesthesia Comparison
| Type | Consciousness | Airway Control | Best Use | Key Risks | Nursing Considerations |
|---|---|---|---|---|---|
| General | Loss of consciousness | Intubated (ETT/LMA) | Major surgery (abdominal, thoracic, cardiac) | Aspiration, hypoxemia, malignant hyperthermia, cardiovascular depression | Continuous monitoring (SpO2, ETCO2, BP, HR); watch for MH signs; extubate when awake |
| Spinal | Conscious | Patent airway | Lower extremity, pelvic, cesarean surgery | Hypotension, bradycardia, PDPH, high block (respiratory paralysis) | Monitor BP/HR closely; fluid bolus ready; position flat for PDPH; educate about headache risk |
| Epidural | Conscious | Patent airway | Labor analgesia, postoperative pain, lower extremity surgery | Hypotension, epidural hematoma, infection, toxicity from local anesthetic | Monitor BP; assess sensory block level; watch for signs of hematoma/infection |
| Nerve Block | Conscious | Patent airway | Limb surgery, postoperative analgesia | Local anesthetic toxicity, block failure, nerve injury | Verify block level before surgery; monitor for toxicity; educate about expected duration |
| Local | Conscious | Patent airway | Minor procedures (laceration repair, small biopsy) | Local anesthetic toxicity (high concentrations), allergic reaction | Monitor vitals; educate about expected sensations; have reversal drugs ready |
| Moderate Sedation | Depressed consciousness | Maintained (monitor carefully) | Diagnostic procedures (colonoscopy, endoscopy) | Airway obstruction, hypoxemia, oversedation | Continuous SpO2/ETCO2 monitoring; have reversal agents (naloxone, flumazenil) at bedside; do NOT perform on patients requiring airway control |
Surgical Risk Factors and Nursing Interventions
| Risk Factor | Impact on Surgery | Preoperative Management |
|---|---|---|
| Extreme Age | Decreased physiologic reserve; slower recovery | Detailed history/physical; baseline assessment; optimize chronic disease control |
| Obesity | Poor wound healing, dehiscence, respiratory compromise, DVT/PE | Screen for sleep apnea; encourage smoking cessation; optimize medications |
| Malnutrition | Delayed wound healing; impaired immunity | Nutritional assessment; supplement with protein/vitamin C; encourage oral intake preoperatively |
| Uncontrolled Diabetes | Hyperglycemia, poor infection control, delayed healing | Achieve euglycemia (target 100–180 mg/dL); adjust insulin/oral agents per protocol; monitor glucose day of surgery |
| Cardiovascular Disease | MI, dysrhythmias, hypotension, heart failure | ECG baseline; optimize cardiac medications; cardiology consult if high risk; continue beta-blockers/ACE inhibitors per protocol |
| Respiratory Disease | Hypoxemia, respiratory failure, atelectasis, pneumonia | Chest X-ray, spirometry; optimize inhaler therapy; teach deep breathing/incentive spirometry; smoking cessation |
| Renal Disease | Delayed drug clearance, fluid/electrolyte imbalance, bleeding risk (uremia) | Check creatinine/BUN; adjust drug doses; monitor fluid balance; assess coagulation |
| Hepatic Disease | Impaired drug metabolism, coagulopathy, bleeding, delayed recovery | Check liver function tests, INR, albumin; avoid hepatotoxic drugs; assess coagulation; monitor for encephalopathy postoperatively |
| Smoking | Impaired oxygenation, reduced healing, increased infection | Encourage smoking cessation at least 4 weeks before (improved oxygenation); brief perioperative cessation still helps |
| Anticoagulation | Excessive bleeding perioperatively | Clarify hold/continue orders with surgeon; timing varies by drug and surgery type; bridging therapy may be needed |
| Corticosteroid Dependence | Adrenal insufficiency (hypotension, shock) if abruptly stopped | Give stress-dose steroids perioperatively; do NOT abruptly stop |
| Herbal Supplements (ginkgo, garlic, ginseng, vitamin E) | Increased bleeding risk | Discontinue ~2 weeks before surgery; educate patient about bleeding risk |
Preoperative Checklist — Critical Items
| Item | Why Important | Nurse Action |
|---|---|---|
| Two-Identifier Verification | Prevents wrong-patient surgery | Ask patient name and DOB; compare to ID band and chart; document verification |
| Consent Form Signed and Complete | Legal/ethical requirement; informed decision | Verify signature, date, legibility; confirm BEFORE sedation; alert surgeon to questions |
| Surgical Site Marked | Prevents wrong-site surgery | Verify surgeon has marked correct site with permanent marker; patient agrees with mark |
| NPO Status Verified | Prevents aspiration | Confirm last solid/liquid intake; ask about gum, candy, sips; report any intake |
| Lab/Diagnostic Results Available | Allows anesthesia risk assessment; identifies abnormalities | Verify CBC, electrolytes, type & cross, coagulation studies, ECG, CXR, imaging available and reviewed |
| Baseline Vitals Recorded | Provides baseline for intraoperative/postoperative comparison | Record BP, HR, RR, temperature, SpO2, pain level, neuro status |
| Foreign Objects Removed | Prevents aspiration, fire, injury, loss, and monitoring interference | Remove dentures, jewelry, contacts, hairpins, prosthetics, nail polish, makeup; document location of items given to family/stored |
| Hair Clipped (Not Shaved) | Clipping reduces infection risk; shaving causes microtrauma | Clip hair at surgical site per protocol; do NOT shave; document clipping |
| Patient in Hospital Gown, ID Band Applied | Ensures correct identification, easy access for surgery/monitoring | Dress in gown; apply armband with name, DOB, MRN, allergy alerts |
| Preoperative Medications Given | Reduces anxiety, prevents infection, reduces nausea, manages gastric acid | Give sedatives, antibiotics, antiemetics, PPIs per anesthesia orders; document time and route |
| Allergy Status Confirmed | Prevents allergic reactions (medication, latex, iodine) | Ask about all allergies; flag latex allergy prominently; communicate to OR team |
| Void or Catheterize | Empty bladder reduces injury risk and improves surgical exposure | Assist to bathroom or insert foley per order; document output |
Diagrams
Preoperative Assessment and Preparation Flowchart
This flowchart shows the sequential steps of preoperative assessment and preparation, emphasizing critical decision points (consent timing, NPO status, verification) that directly prevent wrong-site surgery and aspiration.
Malignant Hyperthermia Recognition and Emergency Management
Emergency flowchart for recognizing and managing malignant hyperthermia, emphasizing that unexplained tachycardia + rising ETCO2 (NOT high temperature as a first sign) trigger immediate discontinuation of triggering agents, dantrolene administration, and cooling measures.
Preoperative and Intraoperative Nursing Concepts
Comprehensive mind map organizing all preoperative and intraoperative nursing concepts into major categories (assessment, preparation, medications) and intraoperative priorities (safety, counts, positioning, asepsis, anesthesia management). Useful for quick topic review and identifying knowledge gaps.
Surgical Count Verification and Discrepancy Resolution
Detailed flowchart showing the surgical count process at three critical points (before procedure, before cavity closure, at skin closure) and the mandatory steps when a count is discrepant: immediate surgeon notification, wound search, X-ray if needed, and prevention of closure until reconciliation.