NLE Perioperative & Pain Nursing — Preoperative and Intraoperative NursingDetailed Explanation

Classification of Surgery

Surgery is classified in three ways: by urgency, by purpose, and by risk level. Understanding these classifications helps the nurse prioritize care, prepare the patient appropriately, and anticipate complications. **By Urgency:** - **Emergent (Emergency):** Must be done immediately to save the patient's life or limb. There is no time for full preoperative preparation. Example: ruptured abdominal aortic aneurysm, severe internal hemorrhage, or bowel perforation. In this case, implied consent may apply if the patient is unconscious and no family is available. - **Urgent:** Must be done within 24–48 hours. The condition is serious but allows for some preparation. Example: acute appendicitis, hip fracture in an elderly patient. - **Elective:** Planned ahead of time; surgery is needed but can be scheduled. Example: cataract repair, herniorrhaphy, cholecystectomy for chronic gallstones. - **Optional (Cosmetic/Elective Preference):** Based on the patient's desire rather than medical necessity. Example: rhinoplasty, breast augmentation. **By Purpose:** - **Diagnostic:** To confirm or establish a diagnosis. Example: exploratory laparotomy, biopsy. - **Curative (Ablative):** Removes or repairs the diseased tissue. Example: appendectomy, mastectomy. - **Palliative:** Relieves symptoms but does not cure. Example: colostomy for inoperable colon cancer. - **Reconstructive:** Restores function or appearance. Example: skin grafting after burns, cleft palate repair. - **Cosmetic:** Improves appearance. Example: facelift, liposuction. **By Risk Level:** - **Major surgery:** Involves significant risk, large body cavities, or vital organs. Longer anesthesia time. Example: open-heart surgery, total gastrectomy. - **Minor surgery:** Lower risk, shorter duration, often done under local anesthesia. Example: mole removal, circumcision.

Preoperative Assessment and Surgical Risk

The goal of preoperative assessment is to identify factors that increase surgical risk and take steps to reduce them before the patient goes to the operating room. This is a comprehensive process involving history-taking, physical examination, and diagnostic testing. **Key Areas of Preoperative Assessment:** 1. **Complete Health History:** Past surgeries, chronic illnesses, current medications (prescribed, over-the-counter, and herbal supplements), allergies (especially to **latex** and medications), and previous anesthesia reactions. A crucial question is whether the patient or any family member has ever had a reaction to anesthesia — this screens for **malignant hyperthermia**, a potentially fatal inherited condition. 2. **Factors That Increase Surgical Risk:** - **Age extremes:** The very young (immature systems) and the elderly (decreased organ reserve, polypharmacy, slower healing) are at higher risk. - **Obesity:** Increases risk of poor wound healing, wound dehiscence, respiratory complications (decreased lung expansion), and cardiovascular stress. Obese patients are also harder to intubate. - **Malnutrition:** Protein and Vitamin C are essential for wound healing; malnourished patients heal poorly and are more prone to infection. - **Chronic diseases:** Uncontrolled diabetes mellitus impairs healing and immune response. Cardiovascular disease increases risk of intraoperative MI or arrhythmia. Renal and hepatic disease affect drug metabolism and coagulation. Respiratory disease impairs oxygenation. - **Smoking:** Impairs oxygenation and mucociliary function; increases risk of respiratory complications. - **Fluid and electrolyte imbalances:** Must be corrected before surgery. - **Coagulation abnormalities:** Risk of intraoperative bleeding or postoperative DVT. - **Medications:** Anticoagulants (warfarin, heparin) increase bleeding risk. Corticosteroids impair wound healing and immune response. **Herbal supplements that increase bleeding risk: Ginkgo biloba, Garlic, Ginseng, and Vitamin E** — the 'three Gs and a V' — must be stopped before surgery. 3. **Baseline Diagnostics:** - Complete Blood Count (CBC): detects anemia, infection - Electrolytes and BUN/Creatinine: assess fluid balance and renal function - Coagulation studies (PT, PTT, INR): bleeding risk - Blood typing and crossmatch: if transfusion is anticipated - ECG: for patients over 40 or with cardiac history - Chest X-ray: pulmonary baseline - Pregnancy test: for women of childbearing age - Fasting blood glucose/HbA1c: for diabetic patients 4. **Managing Chronic Conditions Before Surgery:** - **Diabetes:** Careful glucose control is essential. Long-acting oral hypoglycemics (especially **metformin**) are commonly held the day of surgery (risk of lactic acidosis with contrast or renal stress). Insulin doses are adjusted per protocol. - **Anticoagulants/Antiplatelets:** Warfarin, aspirin, clopidogrel are usually held several days before surgery to reduce bleeding risk. - **Corticosteroids:** Patients on long-term steroids may need **stress-dose steroids** before surgery to prevent adrenal crisis (the adrenal glands may be suppressed and unable to respond to surgical stress). - Reconcile ALL medications with the surgical team: clarify what to hold, what to continue (often cardiac meds and antihypertensives are continued with a sip of water).

Informed Consent: The Nurse's Critical Role

Informed consent is one of the most heavily tested topics in the NLE perioperative section. It is both a **legal requirement** and an **ethical obligation** that protects the patient's right to autonomy and self-determination — the right to decide what happens to their own body. **What Informed Consent Requires:** For consent to be valid, three conditions must be met: 1. **Disclosure:** The patient must receive adequate information about the procedure — what it is, why it is needed, its benefits, its risks, its alternatives, and the consequences of refusing. 2. **Competence:** The patient must be mentally competent (able to understand and process the information and make a rational decision). 3. **Voluntariness:** The consent must be given freely, without coercion or pressure. **Who Obtains Informed Consent?** This is the most commonly tested aspect. The responsibility for explaining the procedure and obtaining the patient's consent belongs to the **SURGEON (or the physician performing the procedure)** — NOT the nurse. The surgeon must explain: - The nature and purpose of the procedure - Risks and benefits - Available alternatives - The right to refuse **The Nurse's Role in Informed Consent:** - The nurse's primary role is to **witness the patient's signature** on the consent form. - The nurse verifies that the patient **appears to understand** what they are consenting to, is signing **voluntarily**, and is **competent** (oriented, not sedated). - If the patient expresses **new concerns, misunderstanding, or new questions** about the procedure after the surgeon has explained it, the nurse does **NOT** independently re-explain the procedure. Instead, the nurse **notifies and calls back the surgeon** to address the patient's questions. - The nurse also ensures the signed consent form is placed in the patient's chart before surgery proceeds. **Critical Rule: Consent Must Be Signed BEFORE Sedation** - If the patient has already received preoperative sedation (e.g., midazolam, diazepam), they are no longer considered competent to give voluntary informed consent. Any consent signed after sedation is **legally invalid**. - If you discover the consent is not signed and the patient has already been medicated, surgery must be **delayed** until the issue is resolved. **Special Situations:** - **Minors:** A parent or legal guardian must sign. In the Philippines, a patient is considered a minor if under 18 years of age. Emancipated minors (married or self-supporting) may consent for themselves. - **Unconscious or mentally incompetent patients:** A legal guardian, spouse, or next of kin (following the legal hierarchy) provides consent. - **Emergency (life-threatening) when consent cannot be obtained:** **Implied consent** applies — the law presumes a reasonable person would consent to life-saving treatment. Two physician signatures documenting the emergency are typically required. - **Jehovah's Witnesses and blood transfusions:** Competent adult patients have the right to refuse blood transfusions, even if refusal may result in death. Document the informed refusal. For minor children of Jehovah's Witnesses, the courts may authorize transfusion against parental wishes to save the child.

Preoperative Preparation: NPO Status, Checklist, and Patient Teaching

Proper preoperative preparation is a core nursing function that directly impacts surgical safety and outcomes. It covers three interconnected areas: NPO status, the preoperative physical checklist, and patient teaching. --- **NPO STATUS (Nothing by Mouth)** The patient is kept NPO before surgery to **prevent aspiration** of gastric contents into the lungs during anesthesia (when protective airway reflexes are lost). Aspiration can cause **aspiration pneumonia** or **aspiration pneumonitis (Mendelson's syndrome)** — potentially fatal. General NPO Guidelines (verify with institutional/anesthesia protocol): - **Solids, milk, and milk products:** NPO for at least **6–8 hours** before surgery - **Clear liquids** (water, apple juice, black coffee, clear broth): NPO for at least **2 hours** before surgery - **Breast milk:** NPO for at least **4 hours** before surgery - **Infant formula:** NPO for at least **6 hours** before surgery Nursing Actions for NPO: - Confirm the patient has been NPO as ordered - Place an NPO sign at the head of the bed and remove food and water from the bedside - Clarify which medications should still be taken with a **small sip of water**: typically cardiac medications, antihypertensives, and seizure medications - Medications typically HELD: anticoagulants, oral hypoglycemics (especially metformin), and insulin (dose adjusted per protocol) --- **PREOPERATIVE PHYSICAL CHECKLIST** The preoperative checklist is a safety document that the nurse completes before transferring the patient to the OR. Key components: 1. **Identify the patient with TWO identifiers** (name + birthdate, or name + hospital ID number) — standard patient safety practice 2. **Verify the surgical consent form** is signed and on the chart 3. **Verify the surgical site is marked** — the surgeon marks the site with a permanent marker to prevent wrong-site surgery (a sentinel event) 4. **Record baseline vital signs** — serve as a reference during and after surgery 5. **Void or insert urinary catheter** as ordered — an empty bladder prevents accidental injury to the bladder during surgery 6. **Remove and secure:** - Dentures and dental appliances (can be aspirated, obstruct airway) - Jewelry including rings (can cause burns during electrocautery; restrict circulation with swelling) - Contact lenses and eyeglasses - Hairpins and wigs - Prosthetics (artificial limbs, eyes) - **Nail polish and makeup** — this is a commonly tested NLE point. Nail polish and makeup are removed so that **nail beds and skin color can be assessed for oxygenation** (cyanosis detection) during surgery 7. **Dress patient** in a hospital gown and apply an **identification band** if not already in place 8. **Ensure lab results and diagnostic reports** are on the chart (CBC, ECG, etc.) 9. **Administer preoperative medications** as ordered: sedatives/anxiolytics (e.g., midazolam), prophylactic antibiotics (given within 1 hour before incision), antiemetics, proton pump inhibitors 10. **Skin preparation:** Hair is **clipped** (not shaved) at the surgical site when needed. Shaving creates microabrasions that increase infection risk. Use electric clippers. --- **PREOPERATIVE PATIENT TEACHING** Preoperative teaching is most effective when done **before the day of surgery** (ideally during a preadmission visit) when the patient is less anxious and more receptive. Effective preoperative teaching reduces postoperative complications, anxiety, pain, and hospital length of stay. Teach the patient: 1. **Deep breathing exercises and incentive spirometry** — expands the lungs, prevents atelectasis and pneumonia postoperatively 2. **Coughing with splinting** — teach the patient to hold a pillow firmly over the incision while coughing to reduce pain and protect the wound 3. **Leg exercises and early ambulation** — ankle circles, knee flexion, and walking as early as the night of or the day after surgery prevent **Deep Vein Thrombosis (DVT)** and pulmonary embolism 4. **Pain management** — explain the pain scale, available pain relief options (PCA pump, epidural, oral medications), and that asking for pain control is appropriate and important 5. **What to expect** — preoperative procedures, what the OR looks like, waking up in the PACU, expected tubes or drains, timeline for recovery 6. **Emotional and psychological support** — address fears, provide clear information, involve the family, and offer spiritual support as culturally appropriate (Filipino patients often find comfort in prayer and family presence)

Anesthesia: Types, Risks, and Nursing Implications

Anesthesia is the pharmacologic management of pain, consciousness, and muscle relaxation during surgery. The nurse must understand each type of anesthesia, its risks, and how to monitor for and respond to complications. --- **GENERAL ANESTHESIA** General anesthesia produces four effects: **Loss of Consciousness, Analgesia, Amnesia, and Muscle Relaxation** (remember: 'CALM' — Consciousness suppressed, Analgesia, Loss of memory/amnesia, Muscle relaxation). Administered via: - **Inhalation agents:** Isoflurane, sevoflurane, desflurane, nitrous oxide - **Intravenous agents:** Propofol (induction), ketamine, etomidate - **Neuromuscular blocking agents (paralytics):** Succinylcholine (depolarizing), vecuronium, rocuronium (non-depolarizing) Airway management: Endotracheal tube (ETT) or Laryngeal Mask Airway (LMA) is inserted to maintain the airway. Risks: Airway and respiratory complications, cardiovascular depression, prolonged emergence, malignant hyperthermia. **MALIGNANT HYPERTHERMIA (MH) — HIGH-PRIORITY NLE TOPIC** Malignant hyperthermia is a rare, life-threatening, **inherited (autosomal dominant)** hypermetabolic reaction to certain triggering agents. It is not an allergy — it is a pharmacogenetic disorder. Triggers: **Succinylcholine** (a depolarizing neuromuscular blocker) and **volatile inhalation agents** (halothane, isoflurane, sevoflurane) Pathophysiology: Uncontrolled release of calcium from skeletal muscle sarcoplasmic reticulum → continuous muscle contraction → hypermetabolism → rapidly rising temperature, CO2 production, metabolic acidosis Signs and Symptoms (in order of appearance): - EARLY: Unexplained **tachycardia**, rising **end-tidal CO2**, muscle rigidity (masseter muscle spasm after succinylcholine) - LATE: **Rapidly rising, very high fever** (can exceed 40–41°C or higher), cyanosis, mottled skin, metabolic acidosis, arrhythmias - KEY NLE POINT: **Hyperthermia is a LATE sign** of malignant hyperthermia. **Tachycardia and rising CO2 are EARLY signs.** Treatment: 1. **Stop the triggering agent immediately** 2. Call for help and activate the MH protocol 3. Administer **DANTROLENE** (the antidote — a skeletal muscle relaxant that inhibits calcium release) — give immediately, IV, in large doses 4. Institute **cooling measures**: ice packs to axillae and groin, cold IV fluids, cooling blankets 5. Supportive care: bicarbonate for acidosis, treat arrhythmias, maintain urine output 6. Monitor in ICU postoperatively Prevention: Preoperative screening with family history questions. Use a **non-triggering anesthetic technique** for susceptible patients. --- **REGIONAL ANESTHESIA** 1. **Spinal Anesthesia (Subarachnoid Block)** - Local anesthetic is injected into the **subarachnoid space** (into the CSF), below the level of the spinal cord (usually at L3-L4 or L4-L5) - Produces a rapid, dense sensory and motor block below the level of injection - Common uses: lower abdominal, perineal, and lower extremity surgeries; cesarean section - COMPLICATIONS: - **Hypotension and bradycardia:** Due to sympathetic blockade (vasodilation). Treat with IV fluids, positioning (left lateral tilt in pregnancy), vasopressors (ephedrine), atropine for bradycardia - **Post-dural puncture headache (spinal headache):** Caused by leakage of CSF through the dural puncture hole. Presents as a severe headache that worsens when the patient sits up and improves when lying flat. Management: **keep the patient flat**, encourage oral fluids, analgesics, and caffeine. Definitive treatment: **epidural blood patch** - Total spinal: too high a level of block → respiratory arrest - Urinary retention 2. **Epidural Anesthesia** - Local anesthetic injected into the **epidural space** (outside the dura mater) - Slower onset than spinal; catheter can be left in place for continuous postoperative analgesia - Common uses: labor analgesia, postoperative pain management, thoracic and abdominal surgery - Risks: similar to spinal but risk of dural puncture headache is lower; risk of epidural hematoma (especially with anticoagulants) 3. **Nerve Blocks** - Local anesthetic injected near a specific nerve or nerve plexus to block a region - Examples: brachial plexus block for arm surgery, femoral nerve block for knee surgery - Advantages: excellent postoperative analgesia without systemic opioid side effects --- **LOCAL ANESTHESIA AND MODERATE (CONSCIOUS) SEDATION** - **Local anesthesia:** Numbs only a small, localized area. Used for minor procedures (suturing, skin biopsy, dental work). Examples: lidocaine, bupivacaine. - **Moderate Sedation (Conscious Sedation):** - The patient's consciousness is depressed but they can still respond to verbal commands and maintain their own airway - Used for minor invasive procedures (endoscopy, cardiac catheterization, minor orthopedic procedures) - Nursing role during moderate sedation: - **Continuous monitoring** of airway, oxygen saturation (SpO2), blood pressure, heart rate, respiratory rate, and **level of consciousness** - Have **reversal agents** immediately available: - **Naloxone (Narcan)** — reverses opioids - **Flumazenil (Anexate)** — reverses benzodiazepines - Maintain IV access - Resuscitation equipment must be at bedside

Intraoperative Nursing: Roles, Surgical Safety, and Patient Protection

The intraoperative phase begins when the patient is transferred to the OR table and ends when the patient is admitted to the PACU (Post-Anesthesia Care Unit). The nurse's role in the OR is to advocate for the anesthetized, unconscious patient who cannot speak for or protect themselves. --- **THE OPERATING ROOM TEAM** - **Surgeon:** Performs the surgery; is responsible for informed consent and surgical site marking - **Anesthesia Provider:** Anesthesiologist (physician) or Certified Registered Nurse Anesthetist (CRNA) — manages anesthesia - **Scrub Nurse (Scrub Tech/Instrument Nurse):** - Works WITHIN the sterile field - Prepares and organizes sterile instruments and supplies - Hands instruments to the surgeon during the procedure - Performs and participates in counts (sponge, sharps, instrument) - Must maintain sterility at all times - **Circulating Nurse:** - Works OUTSIDE the sterile field - Manages the OR environment: room setup, lighting, positioning, temperature - Documents all activities and counts - Coordinates communication between the sterile team and the outside world - Retrieves supplies, sends specimens to laboratory - Monitors the patient's overall condition - Advocates for patient safety - The circulating nurse is typically a REGISTERED NURSE (under RA 9173, this role requires a licensed nurse) --- **SURGICAL SAFETY: TIME-OUT AND THE WHO SURGICAL SAFETY CHECKLIST** The **Surgical Time-Out** is a mandatory pause performed by the ENTIRE surgical team IMMEDIATELY BEFORE the first incision. The purpose is to confirm: 1. **Correct PATIENT** — verify with two identifiers 2. **Correct PROCEDURE** — everyone agrees on what surgery is being done 3. **Correct SITE** — the marked site is confirmed (and the surgeon-marked mark is visible) 4. **Anticipated critical events** — anesthesia concerns, equipment needs, antibiotic timing 5. **Confirmation that sponge/instrument/needle counts have been completed** The WHO Surgical Safety Checklist has three phases: - **Sign In:** Before anesthesia induction - **Time Out:** Before skin incision - **Sign Out:** Before the patient leaves the OR The time-out is a **Joint Commission National Patient Safety Goal** and is practiced in accredited Philippine hospitals. Wrong-site surgery is a **sentinel event** — a preventable, serious error. --- **SURGICAL COUNTS: SPONGE, INSTRUMENT, AND SHARPS** Surgical counts are performed to prevent **Retained Foreign Objects (RFO)** — one of the most serious preventable surgical complications and a sentinel event. COUNTS ARE PERFORMED AT THREE POINTS: 1. **Before the procedure begins** (baseline count) 2. **Before closing a body cavity** (inner count) 3. **At skin closure** (final count) ADDITIONAL counts are done when: - New packages of supplies are opened during surgery - There is a change in scrub nurse/tech during the procedure - The surgeon requests it What is counted: **Sponges (laparotomy sponges, gauze), Instruments (clamps, scissors, retractors), Sharps/Needles** If a count is INCORRECT: 1. Notify the surgeon IMMEDIATELY 2. The wound is NOT closed until the missing item is found or accounted for 3. If the item cannot be located, an **intraoperative X-ray** is taken to detect the retained item 4. Document the event as a safety incident --- **PATIENT POSITIONING** The anesthetized patient cannot feel pain or discomfort and cannot reposition to relieve pressure — making the nurse responsible for protecting them from positioning-related injuries. Principles of Intraoperative Positioning: 1. **Maintain correct body alignment** — prevent joint dislocation and nerve stretch 2. **Pad all bony prominences and pressure points** — occiput, shoulder blades, elbows, sacrum, heels. Prevents pressure injuries and nerve damage (e.g., brachial plexus injury from arm over-abduction) 3. **Secure the patient with safety straps** — prevent falls, but do not apply too tightly 4. **Avoid overextension of joints** — especially in elderly patients with arthritis 5. **Consider respiratory and circulatory effects:** Extreme Trendelenburg position limits diaphragmatic excursion; lithotomy position can impair venous return. Monitor for these effects. 6. **Protect extremities** — do not let arms dangle off the table; use padded arm boards Common surgical positions and risks: - **Supine:** Most common; risk: pressure to heels, sacrum, occiput - **Trendelenburg** (head down): Risk: respiratory compromise, increased ICP - **Reverse Trendelenburg** (head up): Risk: hypotension from venous pooling in legs - **Lithotomy** (legs in stirrups): Risk: DVT, peroneal nerve damage from stirrups pressing on knees, compartment syndrome - **Lateral (side-lying):** Risk: pressure on ear, shoulder, hip, knee - **Prone (face-down):** Risk: pressure on face, eyes (especially corneal abrasion), breasts, genitalia --- **SURGICAL ASEPSIS AND OR ZONES** The OR is divided into three zones: 1. **Unrestricted Zone:** Entrance area; street clothes permitted, hair covering required 2. **Semi-restricted Zone:** Corridors and peripheral support areas; scrub attire and surgical cap required 3. **Restricted Zone:** The OR itself; scrub attire, cap, AND surgical mask required; OR shoes Key rules of the Sterile Field: - Only sterile items contact sterile items - The sterile gown: front (chest to waist level) and gloved hands to elbows = sterile. Back, under arms, below waist = NOT sterile - The edges of any sterile package (2.5 cm or 1 inch) = NOT sterile (considered contaminated) - Anything below the table level or out of sight = NOT sterile - **When in doubt about sterility = contaminated. Treat it as non-sterile.** - Moisture carries microorganisms through barriers (strike-through contamination): wet sterile drape is contaminated **Latex Allergy:** Must be identified preoperatively and flagged. Severe intraoperative anaphylaxis can occur. Prepare a latex-free environment (latex-free gloves, tubing, catheters). Signs of intraoperative anaphylaxis: hypotension, bronchospasm, rash, tachycardia. Treat with epinephrine. **Preventing Hypothermia:** The OR is kept cold; anesthesia impairs thermoregulation. Use warming blankets, warm IV fluids, and warm irrigation fluids to prevent intraoperative hypothermia, which impairs coagulation and wound healing.

This question integrates medication reconciliation, laboratory interpretation, and surgical risk factor identification — all common NLE competency areas. The nurse uses clinical judgment to prioritize physiologic safety (Maslow's first level) before proceeding. The nurse does not independently manage these issues but documents findings, notifies the surgeon and anesthesiologist, and facilitates orders. Atenolol (antihypertensive/cardiac) is typically CONTINUED through the perioperative period.

This tests rapid emergency response and knowledge of MH management. The circulating nurse is the coordinator in the OR — calling for help, retrieving the MH cart and dantrolene, and documenting. The key priorities are stopping the trigger and giving dantrolene. Antipyretics (e.g., paracetamol) are NOT used for MH — they do not address the underlying calcium dysregulation causing the hypermetabolic crisis.

This question tests priority-setting using Maslow's hierarchy of physiologic safety. Latex allergy and NPO violation are both immediate life-safety threats and are tied for highest priority — in practice, you would address both simultaneously by alerting the team. The consent and site marking are also critical safety issues but are the next priorities. This type of multi-problem checklist scenario is very common on the NLE.

The positional nature of the headache — worsening upright, better supine — is the classic hallmark of PDPH and distinguishes it from other types of postoperative headache. The NLE will describe this scenario and ask you to identify the condition and the nursing interventions. Always start with the non-pharmacological and positioning intervention before medications.