Care of Surgical Patients (1)

The perioperative period includes all three surgical phases—preoperative, intraoperative, and postoperative—and nursing care during this time focuses on patient safety, collaboration, and quality outcomes.

Nurses play a central role in coordinating care, performing assessments, preventing complications, and serving as patient advocates throughout the surgical experience.

Nursing Goals in the Preoperative Area

1. Quality Improvement (QI) and Evidence-Based Practice (EBP): Nurses use research-based protocols to improve patient outcomes and minimize complications.
2. Patient Safety: Delivering high-quality, timely, and accurate care through monitoring, standardized procedures, and checklists.
3. Teamwork and Collaboration: Working closely with the surgical team—surgeons, anesthesiologists, and technicians—to coordinate safe interventions.
4. Effective Communication: Clear documentation and hand-off reports ensure continuity of care and prevent medical errors.
5. Nursing Process: Using systematic assessment, diagnosis, planning, implementation, and evaluation to guide surgical care.
6. Advocacy: Protecting the patient’s rights, dignity, and well-being before, during, and after surgery.
7. Cost Containment: Preventing complications and using resources efficiently to lower hospital costs without compromising safety.

Scientific Knowledge Base

Classification of Surgery

Surgical procedures are classified by seriousness, urgency, and purpose, allowing nurses and providers to anticipate risks and plan appropriate care.

• By Seriousness:
• Major surgery – involves high risk and significant blood loss or vital organ involvement (e.g., cardiac surgery, bowel resection).
• Minor surgery – low risk, often outpatient, minimal tissue involvement (e.g., mole removal).
• By Urgency:
• Elective – patient chooses when to have it; not essential to health (e.g., hernia repair).
• Urgent – necessary for health but not immediate; must be done soon (e.g., gallbladder removal for stones).
• Emergency – must be performed immediately to preserve life or function (e.g., ruptured appendix).
• By Purpose:
• Diagnostic – to determine origin or cause (e.g., biopsy).
• Ablative – removal of diseased tissue or organ (e.g., appendectomy).
• Palliative – relieves symptoms, not curative (e.g., tumor debulking).
• Reconstructive/Restorative – restores function or appearance (e.g., skin graft, knee replacement).
• Procurement – removal of organs/tissues for donation.
• Constructive – restores function lost due to congenital defect (e.g., cleft palate repair).
• Cosmetic – performed to improve appearance (e.g., rhinoplasty).

ASA Physical Status Classification (American Society of Anesthesiologists):

Rates a patient’s physiological risk regardless of surgery type:

• ASA I: Normal healthy patient.
• ASA II: Mild systemic disease (e.g., controlled hypertension).
• ASA III: Severe systemic disease (e.g., poorly controlled diabetes).
• ASA IV: Severe systemic disease that is a constant threat to life.
• ASA V: Moribund patient not expected to survive without surgery.
• ASA VI: Brain-dead organ donor.
• Add “E” if emergency.

This helps anesthesia providers anticipate intraoperative and postoperative complications.

Common Surgical Risk Factors:

• Smoking: Impairs oxygenation and wound healing.
• Age: Older adults and infants have decreased physiological reserve.
• Nutrition: Malnutrition delays healing; obesity adds stress to heart and lungs.
• Obesity: Increases wound stress and risk of infection or dehiscence.
• Obstructive Sleep Apnea (OSA): High risk of airway obstruction post-anesthesia.
• Immunosuppression: Increases infection risk and delays healing.
• Fluid/Electrolyte Imbalance: May occur from preoperative fasting or blood loss.
• PONV (Postoperative Nausea & Vomiting): Can cause aspiration and delayed recovery.
• VTE (Venous Thromboembolism): Risk rises with immobility, cancer, or obesity.

Nursing Knowledge Base

Perioperative Communication & Safety:

• Hand-off reports must include procedure, allergies, status, labs, and special precautions.
• Surgical Safety Checklist (WHO model): Used before anesthesia, before incision, and before leaving OR to prevent wrong-site or wrong-patient errors.

Glycemic Control & Infection Prevention:

• High blood glucose increases risk of surgical site infection (SSI) and mortality.
• Maintain target glucose range as per facility protocol; use insulin infusions as ordered.

Pressure Injury Prevention:

• Intrinsic factors: ↓mobility, ↓mental status, incontinence, aging, diabetes, comorbidities.
• Extrinsic factors: temperature extremes, friction, shear forces.
• OR-specific risks: long surgeries, improper positioning, poor padding, warming devices.

Preoperative Education & Critical Thinking

Preoperative Education:

Teaching the patient before surgery improves outcomes and confidence.

It helps reduce stress, clarify expectations, and decrease complications.

Benefits include:

• Reduced anxiety and postoperative pain.
• Shorter hospital stay and faster recovery.
• Increased satisfaction and adherence to treatment plans.
• Better collaboration and shared decision-making.

Critical Thinking in Surgical Nursing:

Successful perioperative judgment requires synthesis of knowledge, experience, environment, and standards.

Nurses integrate clinical judgment (data + experience) with professional standards to identify risks, prioritize actions, and plan care using the nursing process.

• ASA I: Normal healthy patient
• ASA II: Mild systemic disease (e.g., controlled HTN)
• ASA III: Severe systemic disease (e.g., uncontrolled diabetes)
• ASA IV: Severe disease, constant life threat
• ASA V: Moribund; unlikely to survive without surgery
• ASA VI: Brain-dead organ donor
• Add “E” → Emergency case

The preoperative phase is the period before surgery when the nurse gathers data, prepares the patient physically and psychologically, and identifies potential risks.

During this time, nurses assess not only the physical condition but also psychological readiness, support systems, and cultural or spiritual needs that could affect recovery and coping.

1. Support sources: Identify who will help the patient after surgery (family, friends, caregivers). This affects discharge planning and emotional stability.
2. Occupation: Work type can affect recovery expectations and restrictions (e.g., manual labor may delay return to work).
3. Preoperative pain assessment: Establishes a baseline and helps plan postoperative pain management.
4. Emotional health:
• Self-concept & body image: Patients may fear changes in appearance or function.
• Coping resources: Identify anxiety, fear, or depression and provide teaching or reassurance.
5. Cultural and spiritual factors: Beliefs may influence decisions about blood transfusions, surgery consent, or rituals for healing — nurses must respect and plan around these.

After assessment, the nurse formulates nursing diagnoses and develops a care plan to guide care through the surgical phases.

The implementation phase is when the nurse puts the preoperative plan into action. This includes ensuring legal and safety measures, teaching, infection prevention, and preparing the patient physically and emotionally for surgery.

1. Informed Consent
• Every surgical procedure requires documented, voluntary, and informed consent.
• The surgeon explains the procedure, risks, and alternatives.
• The nurse’s role is to witness the signature, verify understanding, and notify the surgeon if the patient seems confused or unsure.
2. Privacy and Confidentiality
• Protected under HIPAA. Nurses must never share patient information in public spaces or on social media.
• Even general details (like surgery time or diagnosis) must not be discussed without authorization.
3. Health Promotion & Preoperative Teaching
• Teach the patient what to expect before, during, and after surgery to reduce anxiety and promote cooperation.
• Key teaching includes:
• Time of surgery and what to bring
• Fasting or bowel prep instructions
• What postoperative monitoring (like IVs or drains) will occur
• Pain management methods and early ambulation benefits
• Breathing and coughing exercises to prevent complications
• Expected sensations (sights, smells, sounds) in the OR/recovery
4. Acute Care Before Surgery
• Infection prevention: Administer prophylactic antibiotics, perform antiseptic skin cleaning, and clip (not shave) hair to avoid micro-abrasions.
• Fluid and electrolyte balance: Ensure appropriate fasting, IV fluids, or nutrition if needed.
• Bowel preparation: Used to prevent contamination in abdominal procedures.
5. Day-of-Surgery Preparation
• Provide hygiene care (bath, mouth care, gown).
• Remove jewelry, dentures, contact lenses, nail polish, and cosmetics.
• Secure valuables.
• Obtain and record baseline vital signs.
• Apply anti-embolism stockings or SCDs for DVT prevention.
• Administer pre-op meds (antibiotics, sedatives) as ordered.
• Ensure accurate identification, documentation, and site verification before transfer.
6. Evaluation
• Evaluate if the patient’s anxiety decreased, and if teaching goals were understood (patient can repeat back instructions).
• Assess if all safety and preparation goals were completed before surgery.

Once the patient is prepared, the transport to the operating room (OR) and intraoperative phase begin.

The nurse’s role now focuses on safety, verification, monitoring, and coordination.

🚑 Transport to the Operating Room

• Before leaving the unit, the nurse notifies the OR team that the patient is ready.
• Verify patient identity using two identifiers (name & date of birth or ID band number).
• The family can visit briefly before transport and is directed to the waiting area once the patient leaves.
• Documentation must be complete (consent, allergies, site marked, valuables secured).

🩺 Pre-anesthesia (Holding Area / PCU or PSCU)

• A nurse in the preanesthesia care unit prepares the patient for anesthesia and final surgical checks.
• Tasks include:
• Inserting or verifying the IV line.
• Administering pre-op medications (sedatives, antibiotics).
• Monitoring vital signs and oxygen saturation.
• Inserting urinary catheter if ordered.
• Ensuring consent and surgical checklist are completed.

⚙️ Intraoperative Phase

This begins once the patient enters the OR and ends when transferred to the PACU (post-anesthesia care unit).

Three main nursing roles exist:

1. Circulating Nurse (RN)
• Coordinates the entire nursing process in the OR.
• Ensures sterility, safety, documentation, and communication with other departments.
• Not scrubbed in—acts as the “manager” of the environment.

2. Scrub Nurse (RN or Surgical Tech)
• Works directly within the sterile field.
• Passes instruments, maintains sterile technique, and counts sponges/instruments.

3. RN First Assistant (RNFA)
• Assists the surgeon during the operation with retraction, suturing, and controlling bleeding.

⚡ Key Intraoperative Care Tasks

• Physical preparation: Maintain sterility, ensure all equipment is functioning.
• Intraoperative warming: Prevents hypothermia, which can cause delayed healing and cardiac stress.
• Latex sensitivity: Use non-latex gloves and equipment for allergic patients.
• Anesthesia types:
• General: loss of consciousness.
• Regional: nerve block or spinal.
• Local: small, specific area.
• Moderate (conscious) sedation: patient remains responsive.
• Positioning: Prevents pressure injuries and facilitates surgical access.
• Documentation: Everything done during the procedure (meds, counts, events, vitals) must be accurately recorded.

🧾 Evaluation

• During surgery, evaluation focuses on the patient’s physiological stability and communication with family.
• Afterward, the nurse confirms all goals (safety, sterility, comfort) were maintained.

The postoperative phase starts immediately after surgery and continues until the patient has fully recovered.

It includes two main stages of recovery — immediate (PACU) and extended (inpatient or home recovery).

The nurse’s focus shifts from surgical preparation to monitoring, stabilization, comfort, and prevention of complications.

🩺 Phase I – Immediate Postoperative Recovery (PACU)

This is the critical monitoring phase after anesthesia. The patient is transferred here under continuous observation.

1. Hand-off Communication
• OR nurse reports to PACU nurse: type of surgery, anesthesia used, blood loss, drains/tubes, complications, and special orders.
2. Complete Systems Assessment
• The PACU nurse performs a full head-to-toe check: airway, breathing, circulation, consciousness, wound, and IV lines.
3. Airway Management
• Maintain patency; if conscious, encourage patient to expectorate secretions.
• Be alert for airway obstruction due to tongue relaxation, mucus, or swelling.
4. Vital Sign Stability
• Use Post-Anesthesia Recovery Score (PARS) or Aldrete Score to determine readiness for discharge (checks activity, respiration, circulation, consciousness, and O₂ saturation).
• Stable vitals = safe transfer from PACU.
5. Phase II – Ambulatory or Same-Day Recovery
• Focuses on patient independence, pain control, oral intake, and instructions for discharge home.

🏥 Inpatient Recovery & Convalescence

Once transferred to the surgical unit, the nurse performs a comprehensive assessment and focuses on restoring normal body functions.

1. Airway and Respiration: Monitor for obstruction, shallow breathing, or hypoxia; encourage coughing, deep breathing, and use of incentive spirometer.
2. Circulation: Assess blood pressure, heart rate, peripheral pulses, and signs of bleeding or DVT.
3. Temperature: Watch for malignant hyperthermia (genetic, life-threatening increase in body temperature after anesthesia).
4. Fluid & Electrolyte Balance: Monitor IV fluids, urine output (should be ≥30 mL/hr), and lab values.
5. Neurological Function: Check level of consciousness, orientation, and motor response.
6. Skin & Wound: Inspect dressings for bleeding, swelling, or infection.
7. Metabolism: Observe for altered glucose levels or poor nutrition.
8. Genitourinary & GI Function: Monitor voiding, bowel sounds, nausea, and return of peristalsis.
9. Mobility: Gradual ambulation to prevent DVT, improve lung expansion, and aid bowel function.
10. Comfort & Sleep: Promote rest, manage pain, and provide emotional reassurance.

The implementation phase of postoperative care focuses on acute recovery management — keeping the patient stable, preventing complications, and promoting healing.

The nurse plays a crucial role in maintaining body functions and encouraging gradual independence.

🫁 Maintaining Respiratory Function

• Encourage deep breathing, coughing, and use of incentive spirometer every 1–2 hours.
• Turn the patient every 2 hours and help them sit up early to promote lung expansion.
• Monitor for signs of atelectasis (collapsed alveoli) and pneumonia: decreased breath sounds, fever, crackles, or difficulty breathing.
• Provide oxygen as ordered.

❤️ Preventing Circulatory Complications

• Encourage leg exercises, early ambulation, and use antiembolism stockings or sequential compression devices (SCDs).
• Assess pulses, skin color, and warmth in extremities.
• Watch for DVT (pain, swelling, redness) and pulmonary embolism (sudden dyspnea, chest pain, low O₂ sat).
• Administer anticoagulants (e.g., heparin, enoxaparin) if prescribed.

🦵 Promoting Early Mobility

• Early movement improves circulation, lung function, and bowel activity.
• Begin with dangling legs at bedside, then walking short distances as tolerated.
• Prevent orthostatic hypotension by helping patient stand slowly.

😴 Achieving Rest and Comfort

• Provide adequate pain management — combine pharmacologic (opioids, NSAIDs) and non-pharmacologic (positioning, relaxation, distraction) methods.
• Manage environmental factors (noise, light) to promote sleep and recovery.

🌡️ Temperature Regulation

• Mild fever (<100.4°F) in the first 48 hours is normal due to inflammation; persistent or high fever may indicate infection.
• Use warming blankets for hypothermia; monitor for malignant hyperthermia if anesthesia-related symptoms reappear.

🧠 Maintaining Neurological Function

• Assess level of consciousness, orientation, pupil response, and movement.
• Watch for delayed awakening due to anesthesia or hypoxia.
• Maintain safety: call light within reach, side rails up, assist with ambulation.

💧 Maintaining Fluid and Electrolyte Balance

• Monitor IV fluids, urine output, and lab values (Na⁺, K⁺, BUN, creatinine).
• Urine output <30 mL/hr → report possible hypovolemia or renal dysfunction.
• Record input/output every shift.
• Encourage oral fluids when bowel sounds return.

🍎 Promoting GI Function & Nutrition

• Listen for bowel sounds and monitor for nausea, distension, or absence of flatus (signs of ileus).
• Start with clear liquids, advance diet gradually.
• Encourage ambulation to stimulate peristalsis.
• Administer stool softeners or antiemetics as needed.

🚽 Promoting Urinary Elimination

• Assess for bladder distension; assist to bathroom or use commode.
• Catheterize only if ordered and necessary.

• Report inability to void within 6–8 hours after surgery.

🩹 Skin & Wound Care

• Inspect dressings for drainage:
• Serous or serosanguinous = normal
• Purulent or foul odor = infection
• Keep area clean and dry; use aseptic technique when changing dressings.
• Note dehiscence (wound separation) or evisceration (organ protrusion) → cover with sterile saline dressing and notify surgeon immediately.

💬 Maintaining/Enhancing Self-Concept

• Encourage self-care activities and positive reinforcement.
• Explain wound changes, scars, or physical limitations compassionately.
• Involve family and provide privacy and emotional support.

Once the patient is medically stable, the nurse’s focus shifts from acute recovery to restoration, independence, and discharge planning.

This includes education, emotional support, and coordination of care for home or rehabilitation.

🏡 Restorative and Continuing Care

1. Prepare for Discharge

• Begin discharge planning early—ideally during the preoperative phase.
• Ensure that the patient and family understand medication schedules, wound care, activity restrictions, diet, and follow-up appointments.
• Review warning signs that must be reported (fever, increased drainage, shortness of breath, pain not relieved by meds).

2. Provide Patient Education

• Teach self-care measures like:
• How to change a dressing safely.
• When to remove compression stockings.
• How to perform breathing or leg exercises at home.
• Pain management and use of prescribed medications.
• Reinforce the importance of rest and gradual activity.

3. Help Patients Adhere to Exercise Programs

• Instruct patients to resume physical activity gradually to avoid fatigue or wound strain.
• Demonstrate or refer to physical therapy for safe movement patterns.
• Emphasize consistency over intensity — daily short walks are better than one long session.

4. Make Referrals to Home Care as Needed

• If the patient has limited mobility, cognitive impairment, or complex wound care needs, the nurse arranges home health, physical therapy, or wound nurse visits.
• Social workers can assist with equipment (walker, commode) and transportation support.

🧾 Evaluation

1. Through the Patient’s Eyes
• Ask if the patient’s expectations and comfort goals have been met.
• Encourage honest feedback about pain, mobility, and emotional adaptation.
2. Patient Outcomes
• Pain relief: Evaluate using a pain scale and note if interventions are effective.
• Self-care measures: Assess if the patient or caregiver can perform wound care, medication administration, and exercise safely.
• Functional independence: Determine if the patient can manage ADLs or needs continued assistance.