NLE Perioperative & Pain Nursing — Preoperative and Intraoperative NursingSummary

Surgery is categorized based on timing of intervention: Emergent surgery is immediate, life-threatening (e.g., ruptured aneurysm, acute massive bleeding) and proceeds without delay; Urgent surgery must be performed within 24–48 hours (e.g., acute appendicitis, acute intestinal obstruction); Elective surgery is planned for the patient's convenience and health optimization (e.g., cataract repair, hernia repair); Optional surgery is purely at the patient's discretion and may not have a clear health indication (e.g., cosmetic procedures). This classification affects the pace and depth of preoperative assessment and preparation. Emergent cases may require abbreviated assessment, while elective cases allow thorough workup.

Diagnostic surgery aims to identify disease (e.g., exploratory laparotomy, biopsy); Curative (ablative) surgery removes diseased tissue to cure disease (e.g., appendectomy, mastectomy); Palliative surgery relieves symptoms but does not cure (e.g., bypass surgery for advanced cancer pain, colostomy for inoperable bowel obstruction); Reconstructive surgery restores form and function after trauma or disease (e.g., skin grafting after burns, joint reconstruction); Cosmetic surgery improves appearance without health benefit (e.g., rhinoplasty, liposuction). The purpose influences patient education, expected outcomes, and psychological preparation.

Preoperative assessment identifies factors that increase surgical and anesthetic risk. Key risk factors include: Age (very young and older adults tolerate surgery less well due to physiologic reserve limitations); Obesity (increases wound complications, respiratory difficulty, cardiovascular strain); Malnutrition (impairs wound healing—protein and vitamin C are essential); Chronic diseases such as uncontrolled diabetes (impairs immune response and healing), cardiovascular disease (increases perioperative MI and arrhythmia risk), renal disease (affects drug metabolism and fluid balance), hepatic disease (affects coagulation and drug metabolism), respiratory disease (increases anesthetic risk); Smoking (impairs oxygenation, impairs healing, increases infection risk); Fluid, electrolyte, and coagulation abnormalities; and Medications (anticoagulants increase bleeding risk, corticosteroids delay healing, certain herbals like ginkgo, garlic, and ginseng increase bleeding). Baseline diagnostics may include CBC, electrolytes, coagulation studies, blood typing and crossmatch, ECG, chest X-ray, and pregnancy test where indicated.

Patients with chronic diseases require careful perioperative management. Diabetic patients need tight glucose control; long-acting oral hypoglycemics and metformin are typically held, and insulin dosing is adjusted on the day of surgery per protocol. Anticoagulant therapy (warfarin, DOACs) and antiplatelet agents (aspirin, clopidogrel) are usually discontinued 5–7 days before surgery to reduce bleeding risk, but high-risk patients may need bridging therapy. Corticosteroid-dependent patients require stress-dose steroids during surgery to prevent an adrenal crisis (the body cannot increase cortisol production under surgical stress). ACE inhibitors and ARBs are sometimes continued or held depending on protocol. Medication reconciliation is essential: clarify each hold or continue order with the surgical team.

Informed consent is a legal and ethical requirement protecting the patient's right to autonomy and self-determination. The process requires that the patient receives clear, understandable information about the procedure, its benefits, risks (including serious but rare complications), alternatives, and the consequences of refusing. The surgeon or physician performing the procedure is responsible for obtaining consent by providing this explanation. The nurse's role is NOT to explain the procedure but to: witness the patient's signature, verify the consent is signed voluntarily and in the patient's full understanding, confirm the form is complete and on the chart before sedation, and notify the surgeon if the patient shows misunderstanding or new questions. Critical requirements: The patient must be competent (mentally capable of understanding), NOT premedicated with sedatives when signing (consent signed after sedation is invalid), and signing must be voluntary without coercion. For minors and those who cannot consent, a legal guardian or authorized representative signs. In true life-threatening emergencies when consent cannot be obtained, treatment may proceed under 'implied consent' to save life. Documenting the date, time, and witness signatures is essential.

NPO status before surgery reduces the risk of aspiration of gastric contents and regurgitation under general anesthesia. Aspiration of gastric contents can cause aspiration pneumonia, which is a serious postoperative complication. Standard NPO guidelines are approximately 6–8 hours for solid foods and 2 hours for clear liquids (follow institutional and anesthesia protocols, as they vary). Clear liquids include water, black tea or coffee, apple juice, and broth; avoid milk products, alcohol, and fatty foods. The nurse verifies NPO compliance, explains the rationale to reduce anxiety, and reports any intake to the anesthesia provider. Clarify with the anesthesia team which routine medications should be taken with a small sip of water (often cardiac drugs, antihypertensives, thyroid medications) and which are held (anticoagulants, oral hypoglycemics, NSAIDs—depends on protocol and the specific medication).

The preoperative checklist ensures systematic preparation and prevents errors. Key elements: (1) Identify the patient using two identifiers (name and date of birth or hospital ID number) and verify the correct procedure and surgical site; (2) Mark the surgical site with an indelible marker to prevent wrong-site surgery; (3) Ensure the informed consent form is signed, dated, and on the chart; (4) Verify that all preoperative diagnostic results (lab work, imaging) are available in the chart; (5) Record baseline vital signs (BP, HR, RR, temperature) for comparison; (6) Instruct the patient to void to prevent bladder distension and reduce perioperative injury risk; (7) Remove all personal items: dentures, jewelry, contact lenses, hairpins, prostheses, nail polish, makeup, and wigs—nail beds must be visible to assess oxygenation by capillary refill and color; (8) Clip hair (do not shave) from the surgical site to reduce infection risk; (9) Dress the patient in a surgical gown and apply an identification band; (10) Administer preoperative medications (sedatives, antibiotic prophylaxis, antiemetics, proton pump inhibitors) as ordered; (11) Perform skin preparation as ordered—typically a surgical scrub or antiseptic shower the night before or morning of surgery.

Effective preoperative teaching, ideally conducted before the day of surgery when the patient is less anxious and more receptive, reduces postoperative anxiety and complications. Teaching should cover: (1) What to expect in the OR and recovery room (sensations, sounds, unfamiliar equipment, staff in masks and gowns); (2) Deep breathing and incentive spirometry exercises to prevent postoperative atelectasis and pneumonia—demonstrate, have the patient return-demonstrate, and explain that early, frequent practice improves postoperative ability; (3) Coughing technique and incision splinting (using a pillow to support the incision) to reduce postoperative pain and prevent wound dehiscence; (4) Leg exercises (ankle circles, quadriceps sets, gluteal sets) and early ambulation to prevent DVT and PE; (5) Pain management options (how to ask for pain medication, use of PCA if planned, expected pain levels); (6) Equipment that may be present postoperatively (drains, catheters, oxygen, IV lines, monitors) so the patient is not frightened; (7) NPO requirements and the importance of compliance; (8) When to report to the facility and what to bring; (9) Postoperative activity restrictions and wound care instructions; (10) Address individual fears, provide spiritual and emotional support, and involve the family. Teaching effectiveness is measured by the patient's ability to demonstrate the techniques and verbalize understanding.

General anesthesia produces loss of consciousness, analgesia (pain relief), amnesia (memory loss of the procedure), and muscle relaxation via intravenous and/or inhalation agents. An airway is secured using an endotracheal tube (a cuffed tube placed in the trachea) or a laryngeal mask airway (LMA). The anesthesia provider monitors depth of anesthesia, vital signs, oxygenation (SpO2), CO2 levels (ETCO2), and neuromuscular blockade. Risks include airway and respiratory complications (difficult intubation, aspiration, airway obstruction, hypoventilation), cardiovascular depression (hypotension, bradycardia), hypothermia, and emergence reactions (delirium, agitation as the patient wakes). Recovery involves gradual emergence from anesthesia in the post-anesthetic care unit (PACU), where airway, breathing, and circulation are monitored.

Malignant hyperthermia (MH) is a rare, inherited, life-threatening pharmacogenetic reaction to certain anesthetic agents—specifically volatile anesthetics (e.g., sevoflurane, isoflurane) and the depolarizing muscle relaxant succinylcholine. It results from a defect in calcium regulation in muscle cells, causing uncontrolled muscle contraction. Early signs include unexplained tachycardia (heart rate increases rapidly despite adequate anesthesia), rising end-tidal CO2 (ETCO2) on the capnograph (a critical, early sign), muscle rigidity, and jaw clenching. Late signs include very high, rapidly rising temperature (hyperthermic reaction is a late sign), rhabdomyolysis (muscle breakdown), myoglobinuria (dark, cola-colored urine), arrhythmias, and hyperkalemia (high potassium leading to cardiac arrest). MH is a medical emergency. Management: (1) Stop the offending anesthetic agents immediately and switch to safe agents (intravenous anesthesia without volatile agents); (2) Administer dantrolene sodium, a skeletal muscle relaxant that inhibits calcium release in muscle—the specific antidote; (3) Initiate active cooling measures (ice packs, cold saline irrigation, cold IV fluids); (4) Hyperventilate with 100% oxygen to remove CO2 and increase oxygenation; (5) Place a urinary catheter to monitor urine color and output (dark urine indicates rhabdomyolysis); (6) Monitor core temperature, serum potassium, creatinine kinase, and coagulation status; (7) Provide supportive care (fluid resuscitation, management of hyperkalemia with calcium gluconate, insulin with glucose, sodium bicarbonate, or dialysis). Survivors require follow-up muscle biopsy (caffeine halothane contracture test) and genetic counseling. A family history of unexplained perioperative death, muscle disease, or MH is a key screening question during preoperative assessment.

Regional anesthesia blocks sensation in a region while the patient remains conscious and can maintain their own airway. Types include: (1) Spinal anesthesia—local anesthetic injected directly into the subarachnoid space containing cerebrospinal fluid, producing rapid, dense sensory and motor blockade below the injection level; commonly used for lower abdominal, pelvic, and lower extremity surgery. Nursing implications include monitoring for hypotension and bradycardia (from sympathetic nervous system blockade), keeping the patient supine or with head-of-bed elevated slightly to prevent further spread of local anesthetic, and observing for respiratory depression if the block ascends high. A post-dural puncture headache (spinal headache) can occur 24–48 hours after spinal anesthesia due to leakage of CSF through the dural puncture; it is worse when upright and better when lying down. Management includes keeping the patient flat, encouraging hydration and caffeine intake, analgesia, and, if severe and refractory, an epidural blood patch (injection of the patient's own blood into the epidural space to seal the leak). (2) Epidural anesthesia—local anesthetic injected into the epidural space (outside the dura mater), producing a slower onset and less dense blockade; commonly used for labor analgesia, postoperative analgesia, and surgical anesthesia. An epidural catheter allows continuous infusion. Risks include hypotension, post-dural puncture headache (if the dura is accidentally punctured), and nerve damage (rare). (3) Nerve blocks—anesthetic injected around a specific peripheral nerve or plexus (e.g., brachial plexus, femoral nerve) to numb that region; used for upper and lower extremity surgery and pain management. Advantages of regional anesthesia include reduced systemic drug exposure, maintained airway reflexes, and excellent postoperative analgesia.

Local anesthesia numbs a specific small area of tissue by infiltrating the site with a local anesthetic agent (e.g., lidocaine, bupivacaine), used for minor procedures (e.g., incision and drainage of an abscess, suturing a laceration, tooth extraction). The patient remains awake and aware. Moderate (conscious) sedation, also called procedural sedation, depresses the level of consciousness such that the patient can respond to stimulation but may not be fully alert; the patient maintains their own airway and cardiovascular reflexes. Moderate sedation is commonly used for minor procedures (e.g., endoscopy, cardiac catheterization, laceration repair) and is administered by a qualified anesthesia provider or sedation-trained physician. Nursing responsibilities during moderate sedation include: continuous monitoring of airway patency, respiratory rate (watch for hypoventilation), oxygen saturation (maintain SpO2 ≥92%), heart rate and rhythm, blood pressure, and level of consciousness; maintaining IV access for medication and reversal agent administration; keeping emergency equipment and reversal agents immediately available (naloxone for opioid reversal, flumazenil for benzodiazepine reversal); avoiding stimulation that might startle the patient; and providing reassurance. Risks include respiratory depression, airway obstruction, aspiration, hypoxemia, and cardiovascular depression. The patient must fast (NPO) beforehand.

The operating room team includes the surgeon (performs the procedure), anesthesia provider (manages airway, breathing, and anesthesia), scrub nurse (maintains the sterile field, passes instruments and supplies to the surgeon, counts sponges and instruments), and circulating nurse (coordinates care outside the sterile field, documents care, communicates with other departments, manages patient safety, and ensures supplies). The intraoperative nurse—whether scrub or circulating—advocates for the anesthetized, vulnerable patient who cannot protect themselves. Under RA 9173, registered nurses function as perioperative nurses and are accountable for patient safety, asepsis, and accurate documentation. The circulating nurse conducts the time-out, verifies counts, and ensures adherence to safety protocols.

The surgical time-out is a brief, structured team pause performed immediately before the incision. The entire surgical team (surgeon, anesthesia provider, scrub nurse, circulating nurse, and any others present) participates. The circulating nurse (or designated person) confirms verbally and checks the chart to verify: (1) Correct patient identity (name and date of birth), (2) Correct procedure to be performed, (3) Correct surgical site and side (if applicable), and (4) Presence of informed consent. This is part of the WHO Surgical Safety Checklist and is mandated in Philippine healthcare facilities accredited to international standards. Any discrepancy stops the procedure until resolved. Marking the surgical site with an indelible marker (done preoperatively by the surgeon or per institutional protocol) is a critical additional safeguard against wrong-site surgery.

Surgical counts are performed to prevent a retained foreign object (a serious postoperative complication that can lead to infection, abscess, reoperation, and patient harm). Three counts are mandatory: (1) Before the procedure begins (initial count—all sponges, instruments, and sharps are counted and recorded); (2) Before closing a body cavity (if a cavity such as the abdomen or chest is opened) to catch any object before closure; (3) At skin closure (final count). If the count is incorrect at any point, the surgeon is notified immediately, and the operative field and surrounding area are searched. If an item cannot be located, an intraoperative X-ray is obtained to verify retention. The wound is NOT closed until the count is reconciled or the missing item is located (by imaging or exploration). Documentation includes the count items, times, and who performed the count. Sponges used in the operative field are typically large, marked with radiopaque material so they can be seen on X-ray, and are segregated from those outside the field. Instruments are counted individually. Sharps (needles, blade pieces) must be accounted for scrupulously.

Proper positioning during surgery is essential for surgical access while protecting the anesthetized patient from injury and complications. The anesthetized patient cannot feel pain, pressure, or discomfort and cannot reposition themselves, making them entirely dependent on the surgical team. Positioning principles: (1) Maintain correct body alignment to prevent musculoskeletal strain and complications (e.g., brachial plexus injury from excessive shoulder abduction); (2) Pad bony prominences (heels, sacrum, elbows, occipital bone, knees) and pressure points with foam, gel pads, or pillows to prevent pressure injury (decubitus ulcer) and nerve compression injury; (3) Secure the patient with safety straps or tape to prevent falls or rolling, especially on a tilting table; (4) Avoid overextension of joints (hip, knee, ankle, shoulder) to prevent joint damage and rhabdomyolysis; (5) Protect skin integrity from prep solutions (which can cause irritant dermatitis), electrocautery burns, and pressure. Position-specific considerations: Trendelenburg (head-down) and reverse Trendelenburg increase intracranial pressure and affect venous return; lithotomy (legs elevated in stirrups for pelvic procedures) strains the hips, knees, and lower back and may impair respiratory excursion if extreme; prone positioning increases the risk of corneal abrasion and facial and airway compression; lateral positions require careful padding and support. Prevent hypothermia (a common intraoperative complication) with blankets, warm IV fluids, and room temperature control. Reposition the patient slowly postoperatively to prevent orthostatic hypotension.

Surgical asepsis (sterile technique) is the highest level of asepsis and is mandatory in the operating room to prevent surgical site infections (SSI). The OR is organized into three zones with progressively stricter requirements: (1) Unrestricted zone—areas where street clothes and regular attire are permitted (e.g., locker rooms, administrative areas); (2) Semi-restricted zone—areas where surgical attire (scrubs, caps, shoe covers) are required but masks may be optional (e.g., hallways leading to the OR, equipment storage); (3) Restricted zone—the OR itself, where full surgical attire is mandatory (scrubs, cap, mask covering nose and mouth, shoe covers, gloves for sterile personnel). A sterile field is created using sterile drapes and maintained under strict rules: (1) Only sterile items touch sterile items (a non-sterile item contaminates the field); (2) Hands, the gloved hands to the elbows, and the front of a sterile gown from chest to waist level are considered sterile; (3) Areas below the waist, behind the back, or outside the visual field of the sterile person are not sterile; (4) The edges of any sterile package (approximately 1 inch or 2.5 cm border) are considered contaminated; (5) If sterility is in doubt, the item or field is considered contaminated and must be replaced. The scrub nurse and surgeon maintain the sterile field throughout the procedure. Any breach of asepsis (e.g., sterile person touching non-sterile item, non-sterile person reaching over the field) requires immediate correction.

Latex allergy affects a significant portion of the population and can range from mild contact dermatitis to severe anaphylaxis. Individuals at higher risk include healthcare workers (due to frequent glove use), patients with spina bifida, and those with a history of multiple surgeries (sensitization occurs with repeated exposure). Latex is found in surgical gloves, tourniquets, balloons on urinary catheters, and other OR equipment. A patient with a known or suspected latex allergy requires a latex-free environment, meaning all latex-containing items must be removed or replaced with latex-free alternatives before the patient enters the OR. The circulating nurse should ask about latex allergy during preoperative assessment, clearly document any allergy in the chart and on the surgical schedule, ensure the OR is prepared with latex-free gloves and equipment before the patient arrives, and communicate the allergy to all OR personnel. During the procedure, latex-free gloves are worn by the entire OR team. An intraoperative anaphylactic reaction to latex presents with urticaria (hives), bronchoconstriction (wheezing, shortness of breath), hypotension, and cardiovascular collapse. Management includes immediate removal of the latex item, administration of epinephrine IM, IV access, antihistamines, corticosteroids, oxygen, and supportive care.