NLE Perioperative & Pain Nursing — Preoperative and Intraoperative NursingRevision Notes

Exam Tips

• NLE loves classification questions. Memorize one example for each urgency category.
• If the question describes a 'ruptured ectopic pregnancy' or 'massive GI bleed' — think emergent.
• A 'bowel obstruction that has not yet perforated but is worsening' is typically urgent (24–48 hours).
• Any procedure described as patient-requested for appearance only = optional/cosmetic.

Key Points

• Surgery is classified by URGENCY, PURPOSE, and RISK — know all three dimensions for the NLE.
• By urgency: Emergent (immediate, life-threatening, e.g., ruptured abdominal aortic aneurysm), Urgent (within 24–48 hours, e.g., acute appendicitis), Elective (planned, non-life-threatening, e.g., cataract repair), and Optional (patient preference, e.g., cosmetic rhinoplasty).
• By purpose: Diagnostic (confirm or rule out a condition, e.g., biopsy), Curative/Ablative (remove the problem, e.g., appendectomy), Palliative (relieve symptoms without curing, e.g., colostomy for obstructing cancer), Reconstructive (restore function or appearance, e.g., cleft palate repair), and Cosmetic (improve appearance, e.g., rhytidectomy).
• By risk: Major (involves major body cavities or great vessels, longer duration, higher risk) vs. Minor (superficial, shorter, lower risk, e.g., excision of a skin lesion).
• Urgency classification drives how quickly NPO, consent, and preparation steps must be completed. In an emergent case, implied consent applies if the patient is unconscious and no guardian is available.

Definitions

Section Title

Classification of Surgery

Common Mistakes

• Confusing 'urgent' and 'emergent' — emergent is truly life-threatening and immediate; urgent allows 24–48 hours.
• Calling a cosmetic procedure 'elective' when NLE options differentiate elective from optional. Cosmetic surgery initiated purely by patient desire is 'optional,' not 'elective' in the strict classification.
• Forgetting that even in emergent cases, all feasible safety steps (identity check, site marking if possible) should still be performed.

Exam Tips

• The NLE frequently asks: 'Which herbal supplement increases bleeding risk?' Answer: Ginkgo biloba, garlic, ginseng, vitamin E — the '3 Gs + Vitamin E' mnemonic.
• Obesity is associated with risk of wound dehiscence and respiratory complications — know both.
• A patient with chronic renal failure going for surgery: expect electrolyte imbalances, drug accumulation (reduced excretion), and coagulation abnormalities.
• When the NLE asks about preoperative labs 'most important' for a diabetic patient = blood glucose level and HbA1c.
• Always link malnutrition → impaired wound healing → risk for surgical site infection (Maslow: physiological safety).

Key Points

• The nurse performs a comprehensive preoperative assessment to identify conditions that increase surgical and anesthesia risk and to implement strategies that reduce these risks before the patient goes to the OR.
• Key history to obtain: past surgical and anesthesia history (especially any adverse reactions), family history of malignant hyperthermia (MH), current medications including HERBALS and OTCs, allergies (include LATEX allergy and specific drug allergies), chronic diseases, and functional status.
• HIGH-RISK factors: extremes of age (very young and elderly), obesity (poor wound healing, respiratory and cardiovascular strain), malnutrition (protein and vitamin C deficiencies impair healing), uncontrolled diabetes (impairs wound healing and immune response), cardiovascular disease (risk of MI, arrhythmias), renal disease (drug accumulation, electrolyte imbalance), hepatic disease (impaired coagulation and drug metabolism), respiratory disease (risk of aspiration, hypoxia), smoking (impairs oxygenation and healing), and coagulation abnormalities.
• Medications that increase BLEEDING risk: anticoagulants (warfarin, heparin), antiplatelets (aspirin, clopidogrel), NSAIDs, and herbals — ginkgo biloba, garlic, ginseng, and vitamin E. These are typically held preoperatively.
• Medications that impair HEALING: corticosteroids (long-term use causes immunosuppression and poor wound healing); but corticosteroid-dependent patients need stress-dose steroids on the day of surgery to prevent adrenal crisis — do not simply hold these.
• Diabetes management: metformin and long-acting oral hypoglycemics are commonly held on the day of surgery; insulin is adjusted per anesthesia protocol (not simply held — glucose control is critical).
• Standard preoperative diagnostics: CBC, electrolytes, coagulation studies (PT, PTT, INR), blood typing and crossmatch, urinalysis, ECG (especially for patients over 40 or with cardiac history), chest X-ray, and pregnancy test for women of childbearing age.
• Nutritional assessment: serum albumin and prealbumin are markers of nutritional status that predict wound healing. A low albumin (<3.5 g/dL) signals malnutrition risk.

Definitions

Section Title

Preoperative Assessment and Surgical Risk Factors

Common Mistakes

• Forgetting that HERBAL supplements (ginkgo, garlic, ginseng, vitamin E) increase bleeding — many patients do not report these unless specifically asked because they consider herbs 'not medicine.'
• Thinking that insulin is simply 'held' the night before surgery — insulin protocols are adjusted, not just stopped, and the anesthesia or surgical team specifies the exact dose and timing.
• Holding corticosteroids for a steroid-dependent patient — this can precipitate adrenal crisis. These patients need stress-dose coverage.
• Overlooking latex allergy when a patient reports allergy to bananas, avocados, kiwi, or chestnuts — these cross-react with latex (latex-fruit syndrome).

Exam Tips

• Classic NLE question: 'Who is responsible for obtaining informed consent?' Answer: The SURGEON (physician performing the procedure).
• Classic NLE question: 'What is the nurse's role in informed consent?' Answer: Witness the signature, verify understanding and competence, ensure the form is on the chart, and notify the surgeon if the patient has questions.
• If the NLE scenario says a patient was given a sedative and THEN asked to sign — the correct nurse action is to WITHHOLD the consent and notify the surgeon.
• Remember: a 16-year-old minor in the Philippines cannot legally consent to surgery alone — a parent or legal guardian must sign.

Key Points

• Informed consent is the patient's legal and ethical right to autonomy and self-determination — the right to decide what happens to their own body.
• WHO OBTAINS CONSENT: The SURGEON (or the physician who will perform the procedure) has the legal and ethical responsibility to explain the procedure, its purpose, expected benefits, material risks and complications, available alternatives, and the risks of refusing. This cannot be delegated to the nurse.
• THE NURSE'S ROLE IS TO: (1) WITNESS the patient's signature, confirming it was signed voluntarily; (2) verify the patient appears to understand what they are consenting to; (3) verify the patient is competent and NOT premedicated with sedatives; (4) ensure the completed, signed form is in the chart before the patient goes to the OR; and (5) notify the surgeon immediately if the patient expresses doubt, asks new questions, or appears not to understand.
• VALIDITY CONDITIONS: The patient must be (a) competent (mentally capable of understanding), (b) fully informed (has received adequate explanation), and (c) consenting voluntarily (free from coercion).
• SEDATION INVALIDATES CONSENT: Consent signed AFTER administration of sedatives or anxiolytics is legally invalid. The nurse must ensure consent is signed and complete BEFORE preoperative medications are given.
• SPECIAL SITUATIONS: Minors — parent or legal guardian signs. Unconscious or incompetent patients — legal guardian, spouse (in Filipino context, closest next-of-kin hierarchy), or legally designated representative signs. Life-threatening emergency with no one available to consent — IMPLIED CONSENT: the law presumes the patient would consent to life-saving treatment.
• In the Philippine context, RA 9173 mandates that nurses uphold patients' rights, including the right to informed consent. The nurse who witnesses consent must document it appropriately in the nursing record.
• If the patient tells the nurse 'I don't really understand what they said' or 'I don't want the surgery but I signed anyway' — the nurse has a DUTY to notify the surgeon and withhold the patient from the OR until the issue is resolved. This is a key patient advocacy role.

Definitions

Section Title

Informed Consent: The Nurse's Legal and Ethical Role

Common Mistakes

• Thinking it is the nurse's job to explain the surgical procedure — it is NOT. The nurse witnesses, advocates, and notifies, but does not replace the surgeon's explanation.
• Allowing a patient to sign consent AFTER receiving preoperative sedation — this is legally invalid.
• Failing to escalate when a patient expresses doubt or misunderstanding — silence is not consent advocacy.
• Confusing 'witnessing consent' with 'obtaining consent' — these are fundamentally different legal acts.

Exam Tips

• NLE frequently asks: 'Why is nail polish removed preoperatively?' Answer: To assess nail beds for cyanosis and ensure accurate pulse oximetry readings.
• NLE frequently asks: 'Why is hair clipped rather than shaved?' Answer: Shaving causes microabrasions that increase SSI risk.
• The sequence for preoperative teaching: deep breathing → incentive spirometry → coughing with splinting → leg exercises → early ambulation → pain management.
• If a patient asks 'Can I take my amlodipine (antihypertensive) on the morning of surgery?' — the answer is generally yes, with a sip of water, but always clarify with the physician.
• DVT prevention = leg exercises + early ambulation + sequential compression devices (SCDs) + anticoagulation as ordered. Know all four interventions.

Key Points

• NPO STATUS — PURPOSE: To prevent aspiration of gastric contents into the lungs during anesthesia induction, which can cause aspiration pneumonia (Mendelson's syndrome) — a life-threatening complication.
• NPO GUIDELINES: Solids — NPO for approximately 6–8 hours before surgery. Clear liquids — NPO for approximately 2 hours before surgery (per anesthesia protocol and institutional policy). Verify and document that the patient has maintained NPO status. Report any inadvertent intake to the anesthesia team immediately.
• MEDICATIONS on the day of surgery: GIVE with a small sip of water — antihypertensives (most), cardiac medications (most), seizure medications. HOLD — anticoagulants, oral hypoglycemics (metformin), NSAIDs, herbals. ADJUST per protocol — insulin. Always clarify with the surgical/anesthesia team for individual patient orders.
• PREOPERATIVE CHECKLIST (key items): Two-patient identifiers confirmed; surgical consent signed and on chart; correct surgical site MARKED by the surgeon or designee; baseline vital signs documented; allergies confirmed and flagged (especially latex); lab and diagnostic results available and charted; patient voided or urinary catheter inserted as ordered; jewelry, dentures, contact lenses, hairpins, nail polish, and prostheses REMOVED; patient in hospital gown with identification band in place; preoperative medications administered and documented; skin preparation done (hair CLIPPED, not shaved).
• WHY REMOVE NAIL POLISH: So the nurse and anesthesia team can assess nail beds for CYANOSIS and oxygen saturation during and after surgery. Nail polish obscures color change and can interfere with pulse oximetry readings.
• SKIN PREP: Hair is CLIPPED (not shaved) at the surgical site immediately before surgery. Shaving with a razor causes microabrasions that increase the risk of surgical site infection (SSI). This is an evidence-based practice change from older protocols.
• PREOPERATIVE TEACHING — WHEN: Ideally done 1–2 days before surgery, not on the morning of surgery when anxiety is highest. The relaxed patient retains information better.
• WHAT TO TEACH: (1) Deep breathing exercises and use of the incentive spirometer (prevents atelectasis and pneumonia); (2) Splinting the incision when coughing — hug a pillow over the incision site to reduce pain and prevent dehiscence; (3) Leg exercises (ankle pumps, quadriceps sets) and early ambulation — prevent deep vein thrombosis (DVT) and pulmonary embolism; (4) Pain management — patient-controlled analgesia, pain scales, and when to ask for medication; (5) What to expect — when they will wake up, what tubes or drains they may have, what the recovery room looks like.
• Effective preoperative teaching is associated with reduced postoperative anxiety, shorter hospital stays, fewer complications, and better patient satisfaction — high-yield NLE rationale.

Definitions

Section Title

Preoperative Preparation: NPO, Checklist, and Patient Teaching

Common Mistakes

• Saying the patient is NPO from 'midnight' as a blanket rule — current evidence-based guidelines differentiate solids (6–8 hrs) from clear liquids (2 hrs). Follow institutional and anesthesia protocol.
• Forgetting to ask which medications to hold vs. continue — this requires a specific order, not a blanket 'hold all meds' decision by the nurse.
• Teaching postoperative exercises for the first time in the PACU — by then, the patient is in pain and drowsy. Preoperative teaching is more effective.
• Shaving the surgical site with a razor — always clip. Shaving increases SSI risk.
• Forgetting that nail polish must be removed BEFORE the patient goes to the OR — not just removing it from one finger.

Exam Tips

• Malignant hyperthermia mnemonic: 'RISE' — Rigidity (muscle rigidity), Increased temperature (late sign), SpO2 drop, Early tachycardia. Antidote = DANTROLENE.
• Spinal headache = positional (worse sitting/upright, better lying flat). First nursing action: position patient FLAT and increase oral fluids.
• The NLE often asks: 'Which reversal agent is used for benzodiazepine overdose during conscious sedation?' Answer: FLUMAZENIL.
• Moderate sedation nursing monitoring: airway, SpO2, respiratory rate, HR, BP, and LOC — monitor ALL of these continuously.
• Know the difference between general, regional, and local anesthesia — the NLE may ask which type is 'most appropriate' for a given surgical scenario or patient condition.

Key Points

• GENERAL ANESTHESIA produces loss of consciousness (LOC), analgesia (no pain), amnesia (no memory), and muscle relaxation — the four components are often remembered as the '4 As': Analgesia, Amnesia, Areflexia (muscle relaxation/absence of reflexes), and Akinesia (loss of movement).
• General anesthesia is given by INHALATION agents (e.g., sevoflurane, isoflurane, nitrous oxide) and IV agents (e.g., propofol, ketamine, thiopental). The airway is secured with an ENDOTRACHEAL TUBE (ETT) or laryngeal mask airway (LMA).
• MALIGNANT HYPERTHERMIA (MH): A rare, inherited (autosomal dominant) hypermetabolic crisis triggered by succinylcholine and volatile inhalation agents. Pathophysiology: uncontrolled calcium release from sarcoplasmic reticulum → sustained muscle contraction → heat production + metabolic acidosis. EARLY signs: unexplained tachycardia, rising end-tidal CO2, muscle rigidity. LATE sign: very rapidly rising, extreme temperature (may exceed 40–41°C). Treatment: STOP the triggering agent immediately, administer DANTROLENE SODIUM (the specific antidote), apply active cooling, treat acidosis and hyperkalemia, and monitor in ICU. Dantrolene works by blocking calcium release from the sarcoplasmic reticulum.
• SPINAL ANESTHESIA: Local anesthetic injected into the SUBARACHNOID SPACE (cerebrospinal fluid). Produces rapid, dense sensory and motor block BELOW the level of injection. Used for lower abdominal, pelvic, perineal, and lower extremity surgery. Key risk: HYPOTENSION and BRADYCARDIA from sympathetic blockade (preload vessels dilate, reducing venous return). Nursing: prehydrate the patient, monitor BP closely, have vasopressors (ephedrine) and atropine ready. Postoperative complication: SPINAL HEADACHE (post-dural puncture headache, PDPH) — a positional, bifrontal headache that worsens upright and improves lying flat. Occurs because of CSF leak through the dural puncture. Management: FLAT POSITION, increased oral fluid intake, caffeine, and if persistent — a blood patch.
• EPIDURAL ANESTHESIA: Local anesthetic injected into the EPIDURAL SPACE (outside the dura). Slower onset than spinal; can be maintained via epidural catheter for prolonged anesthesia or postoperative analgesia. Used in labor and delivery and for postoperative pain control. Risks similar to spinal but slower onset; accidental dural puncture causes a PDPH.
• LOCAL ANESTHESIA: Numbs a small, specific area for minor procedures (e.g., suturing, excision of a skin lesion). Patient remains fully conscious. Risk: systemic toxicity from absorption (seizures, cardiovascular collapse) if injected intravascularly. Nurse monitors for CNS symptoms (ringing in ears, metallic taste, dizziness, seizures).
• MODERATE (CONSCIOUS) SEDATION: Sedation and analgesia that depresses consciousness while the patient maintains their own airway, responds to verbal stimuli, and breathes independently. Used for endoscopy, minor procedures, cardiac catheterization. Nurse's role: continuous monitoring of airway, SpO2, respiratory rate, LOC, BP, and HR. Have REVERSAL AGENTS available: NALOXONE (Narcan) reverses opioids; FLUMAZENIL (Anexate) reverses benzodiazepines. Nurse must be trained in monitoring and in managing complications.

Definitions

Section Title

Anesthesia: Types, Risks, and Nursing Implications

Common Mistakes

• Confusing the EARLY and LATE signs of malignant hyperthermia — tachycardia and rising CO2 are EARLY; hyperthermia (very high temperature) is a LATE sign. Students often think the temperature spike is the first thing that happens.
• Confusing spinal (subarachnoid space) with epidural (epidural space) — remember: spinal = CSF = faster onset, denser block; epidural = outside dura = slower onset, controllable via catheter.
• Thinking that a spinal headache should be treated by sitting the patient up — the opposite is correct. Lay the patient FLAT.
• Forgetting that flumazenil has a shorter half-life than most benzodiazepines, meaning re-sedation can occur after flumazenil wears off.
• Forgetting that reversing opioids with naloxone also reverses all analgesia — sudden severe pain and possibly withdrawal reactions.

Exam Tips

• NLE classic: 'What does the nurse do if a sponge count is incorrect at closure?' Answer: Notify the surgeon IMMEDIATELY and do NOT close the wound; take an X-ray to locate the missing item.
• NLE classic: 'When is the surgical time-out performed?' Answer: Immediately BEFORE the first incision, with the entire team present.
• Peroneal nerve injury in lithotomy position: numbness/weakness of dorsiflexion of the foot (foot drop) due to pressure at the fibular head by stirrups.
• Sterile field rule: When in DOUBT = CONTAMINATED. This is the inviolable rule of surgical asepsis.
• For a latex-allergic patient: schedule as the FIRST CASE of the day and ensure all latex items are removed from the room.
• Intraoperative hypothermia prevention: warming blanket + warmed IV fluids + forced-air warming device. Know all three interventions.

Key Points

• THE OR TEAM: Surgeon (operator), Anesthesia provider (anesthesiologist or CRNA), SCRUB NURSE/TECH (maintains the sterile field, handles instruments, counts sponges/instruments/sharps — inside the sterile field), CIRCULATING NURSE (manages the room, documentation, coordinates outside the sterile field, advocates for the patient, counts with the scrub nurse). The circulating nurse is the patient's primary advocate in the OR.
• SURGICAL TIME-OUT (Universal Protocol): Performed BEFORE incision with the ENTIRE TEAM PRESENT. Verifies: (1) Correct PATIENT (two identifiers), (2) Correct PROCEDURE, (3) Correct SITE (confirmed with marked site). Based on the WHO Surgical Safety Checklist. Purpose: prevent wrong patient, wrong procedure, wrong site surgery — a 'never event.'
• SURGICAL COUNTS: Sponges, instruments (including needles/sharps) are counted THREE times: (1) Before the procedure begins (baseline), (2) Before closing a body cavity, and (3) At skin closure. If counts are INCORRECT: notify the surgeon immediately; do NOT close the wound until the discrepancy is reconciled. An X-ray may be taken to locate a retained foreign object (RFO). RFOs (especially retained surgical sponges = gossypiboma) are preventable 'never events' and serious patient safety incidents.
• PATIENT POSITIONING: The anesthetized patient CANNOT feel pain, reposition themselves, or report discomfort — making the OR team entirely responsible for preventing positioning injuries. Principles: (1) Maintain correct body ALIGNMENT; (2) PAD all bony prominences and pressure points (heels, sacrum, occiput, elbows) to prevent pressure injuries and compartment syndrome; (3) Secure with safety straps across the thighs; (4) Avoid hyperextension or hyperflexion of joints to prevent nerve damage (brachial plexus, ulnar nerve, radial nerve, peroneal nerve); (5) Ensure adequate respiratory excursion and venous return. Trendelenburg and lithotomy positions carry specific physiological risks (see below).
• POSITION-SPECIFIC RISKS: Trendelenburg (head-down) — respiratory compromise (abdominal organs push on diaphragm), increased ICP, facial/airway edema. Lithotomy — peroneal nerve injury (nerve compressed at fibular head by stirrups), compartment syndrome of the legs, hypotension when legs are lowered after surgery. Lateral (side-lying) — brachial plexus injury, peroneal nerve injury. Prone (face-down) — airway issues, pressure on eyes (corneal injury, blindness), brachial plexus injury.
• HYPOTHERMIA PREVENTION: The operating room is cold by design (18–24°C). Anesthesia impairs thermoregulation. Intraoperative hypothermia increases risk of SSI, coagulopathy, cardiac arrhythmias, and prolonged drug effects. Preventive measures: warming blankets, warmed IV fluids, forced-air warming devices.
• SURGICAL ASEPSIS AND OR ZONES: Unrestricted zone (hallways, outside OR) — street clothes permitted. Semi-restricted zone (corridors adjacent to OR, scrub sink area) — scrub attire and caps required. Restricted zone (inside the OR) — scrub attire, caps, AND masks required.
• STERILE FIELD PRINCIPLES: Only sterile items touch sterile items. The sterile gown: front from chest to table level and sleeves from 2 inches above elbow to cuff are sterile. Back of gown = NOT sterile. Anything BELOW the waist or table level = NOT sterile. Anything outside the visual field of the scrub person = NOT sterile. Edges of sterile packages (approximately 2.5 cm border) = NOT sterile. If sterility is in DOUBT — it is considered CONTAMINATED. A sterile field should never be left unattended and must be prepared as close to the time of use as possible.
• LATEX ALLERGY in the OR: Must be identified preoperatively and flagged. The OR team prepares a LATEX-FREE environment. Latex-allergic patients should be scheduled as the FIRST CASE of the day when latex particles in room air are at their lowest. Cross-reactivity foods: banana, avocado, kiwi, chestnuts.

Definitions

Section Title

Intraoperative Nursing: Safety, Counts, Positioning, and Asepsis

Common Mistakes

• Confusing the scrub nurse (inside sterile field) with the circulating nurse (outside sterile field) — they have completely different roles and responsibilities.
• Thinking the time-out can be performed by just one person — it requires the ENTIRE team to pause, speak up, and confirm together.
• Forgetting the three times counts are done: baseline, before cavity closure, and at skin closure. Answering 'twice' or 'once' is incorrect.
• Thinking the back of the sterile gown is sterile — it is NOT. Only the front from chest to waist and the sleeves.
• Forgetting that anything below the draped table level is not sterile — this is a classic NLE trick question about the sterile field.
• Positioning the patient in lithotomy and forgetting to lower the legs slowly to prevent hypotension — a practical NLE safety question.