Perioperative Nursing


Perioperative nursing describes the wide variety of nursing functions associated with the patient’s surgical management. It has three phases of the surgical experience namely:

  1. Preoperative phase. This phase begins when the decision for surgical intervention is made and ends when the patient is transferred from the operating room.
  2. Intraoperative phase. This phase begins when the patient is admitted or transferred to the surgery department and ends when he or she is admitted to the recovery area.
  3. Postoperative phase. This phase begins with the admission of the patient to the recovery area and ends with a follow-up evaluation in the clinical setting or at home.
Preoperative Phase

The patient who consents to have surgery, particularly surgery that requires a general anesthetic, renders himself dependent on the knowledge, skill, and integrity of the health care team. In accepting this trust, the health care team members have an obligation to make the patient’s welfare their first consideration during the surgical experience.

The scope of activities during the preoperative phase includes the establishment of the patient’s baseline assessment in the clinical setting or at home, carrying out preoperative interview and preparing the patient for the anesthetic to be given and the surgery.

Goals during the Preoperative Phase

Although the physician is responsible for explaining the surgical procedure to the patient, the patient may ask the nurse questions about the surgery. There may be specific learning needs about the surgery that the patient and support persons should know. A nursing care plan and a teaching plan should be carried out. During this phase, emphasis is placed on:

  • Assessing and correcting physiological and psychological problems that may increase surgical risk.
  • Giving the patient and significant others complete learning and teaching guidelines regarding the surgery.
  • Instructing and demonstrating exercises that will benefit the patient postoperatively.
  • Planning for discharge and any projected changes in lifestyle due to the surgery.
Physiologic Assessment during the Preoperative Phase

Before any treatment is initiated, a health history is obtained and a physical examination is performed during which vital signs are noted and a data base is establish for future comparisons.

Diagnostic tests may be carried out during the preoperative phase such as:

  • Blood analyses such as complete blood count, sedimentation rate, c-reactive protein, serum protein electrophoresis with immunofixation, calcium, alkaline phosphatase, and chemistry profile
  • X-ray studies
  • MRI and CT scans (with or without myelography)
  • Electrodiagnostic studies
  • Bone scan
  • Endoscopies
  • Tissue biopsies
  • Stool studies
  • Urine studies

Significant physical findings are also noted to further describe the patient’s overall health condition. When the patient has been determined to be an appropriate candidate for surgery, and has elected to proceed with surgical intervention, the pre-operative assessment phase begins. The purpose of pre-operative evaluation is to reduce the morbidity of surgery, increase quality of intra-operative care, reduce costs associated with surgery, and return the patient to optimal functioning as soon as possible.

The following are the physiologic assessments necessary during the preoperative phase:

  • Age
  • Nutritional status and needs – determined by measuring the patient’s height and weight, triceps skin fold, upper arm circumference, serum protein levels and nitrogen balance. Obesity greatly increases the risk and severity of complications associated with surgery.
  • Fluid and Electrolyte Imbalance – Dehydration, hypovolemia and electrolyte imbalances should be carefully assessed and documented.
  • Infection
  • Drug and alcohol use – the acutely intoxicated person is susceptible to injury.
  • Respiratory status – patients with pre-existing pulmonary problems are evaluated by means pulmonary function studies and blood gas analysis to note the extent of respiratory insufficiency. The goal for potential surgical patient us to have an optimum respiratory function. Surgery is usually contraindicated for a patient who has a respiratory infection.
  • Cardiovascular status – cardiovascular diseases increases the risk of complications. Depending on the severity of symptoms, surgery may be deferred until medical treatment can be instituted to improve the patient’s condition.
  • Hepatic and renal function – surgery is contraindicated in patients with acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems. Any disorder of the liver on the other hand, can have an effect on how an anesthetic is metabolized.
  • Endocrine function – diabetes, corticosteroid intake, amount of insulin administered
  • Immunologic function – existence of allergies, previous allergic reactions, sensitivities to certain medications, past adverse reactions to certain drugs, immunosuppression
  • Previous medication therapy – It is essential that the patient’s medication history be assessed by the nurse and anesthesiologist. The following are the medications that cause particular concern during the upcoming surgery:
    1. Adrenal corticosteroids – not to be discontinued abruptly before the surgery. Once discontinued suddenly, cardiovascular collapse may result for patients who are taking steroids for a long time. A bolus of steroid is then administered IV immediately before and after surgery.
    2. Diuretics – thiazide diuretics may cause excessive respiratory depression during the anesthesia administration.
    3. Phenothiazines – these medications may increase the hypotensive action of anesthetics.
    4. Antidepressants – MAOIs increase the hypotensive effects of anesthetics.
    5. Tranquilizers – medications such as barbiturates, diazepam and chlordiaxepoxide may cause an increase anxiety, tension and even seizures if withdrawn suddenly.
    6. Insulin – when a diabetic person is undergoing surgery, interaction between anesthetics and insulin must be considered.
    7. Antibiotics – “Mycin” drugs such as neomycin, kanamycin, and less frequently streptomycin may present problems when combined with curariform muscle relaxant. As a result nerve transmission is interrupted and apnea due to respiratory paralysis develops.
  • Presence of trauma
Psychological Nursing Assessment during the Preoperative Period
  • Fear of the unknown
  • Fear of death
  • Fear of anesthesia
  • Concerns about loss of work,  time, job and support from the family
  • Concerns on threat of permanent incapacity
  • Spiritual beliefs
  • Cultural values and beliefs
  • Fear of pain
Psychological Nursing Interventions:
  1. Explore the client’s fears, worries and concerns.
  2. Encourage patient verbalization of feelings.
  3. Provide information that helps to allay fears and concerns of the patient.
  4. Give empathetic support.
Informed consent

An informed consent is necessary to be signed by the patient before the surgery. The following are the purposes of an informed consent:

  • Protects the patient against unsanctioned surgery.
  • Protects the surgeon and hospital against legal action by a client who claims that an unauthorized procedure was performed.
  • To ensure that the client understands the nature of his or her treatment including the possible complications and disfigurement.
  • To indicate that the client’s decision was made without force or pressure.

Criteria for a Valid Informed Consent

  • Consent voluntarily given. Valid consent must be freely given without coercion.
  • For incompetent subjects, those who are NOT autonomous and cannot give or withhold consent, permission is required from a responsible family member who could either be apparent or a legal guardian. Minors (below 18 years of age), unconscious, mentally retarded, psychologically incapacitated fall under the incompetent subjects.
  • The consent should be in writing and should contain the following:
  1. Procedure explanation and the risks involved
  2. Description of benefits and alternatives
  3. An offer to answer questions about the procedure
  4. Statement that emphasizes that the client may withdraw the consent
  5. The information in the consent must be written and be delivered in language that a client can comprehend.
  6. Should be obtained before sedation.
Intraoperative Phase

The intraoperative phase extends from the time the client is admitted to the operating room, to the time of anesthesia administration, performance of the surgical procedure and until the client is transported to the recovery room or postanethesia care unit (PACU). Throughout the surgical experience the nurse functions as the patient’s chief advocate. The nurse’s care and concern extend from the time the patient is prepared for and instructed about the forthcoming surgical procedure to the immediate preoperative period and into the operative phase and recovery from anesthesia. The patient needs the security of knowing that someone is providing protection during the procedure and while he is anesthetized because surgery is usually a stressful experience.

Goals during the Intraoperative Phase
  1. Promote the principle of asepsis asepsis.
  2. Homeostasis
  3. Safe administration of anesthesia
  4. Hemostasis
The Surgical Team

The intraoperative phase begins when the patient is received in the surgical area and lasts until the patient is transferred to the recovery area. Although the surgeon has the most important role in this phase, there are key members of the surgical team.

  1. Surgeon – leader of the surgical team. He or she is ultimately responsible for performing the surgery effectively and safely; however, he is dependent upon other members of the team for the patient’s emotional well being and physiologic monitoring.
  2. Anesthesiologist or anesthetist – provides smooth induction of the patient’s anesthesia in order to prevent pain. This member is also responsible for maintaining satisfactory degrees of relaxation of the patient for the duration of the surgical procedure. Aside from that, the anesthesiologist continually monitors the physiologic status of the patient for the duration of the surgical procedure and the physiologic status of the patient to include oxygen exchange, systemic circulation, neurologic status, and vital signs. He or she then informs and advises the surgeon of impending complications.
  3. Scrub Nurse or Assistant – a nurse or surgical technician who prepares the surgical set-up, maintains surgical asepsis while draping and handling instruments, and assists the surgeon by passing instruments, sutures, and supplies.
  4. Circulating Nurse – respond to request from the surgeon, anesthesiologist or anesthetist, obtain supplies, deliver supplies to the sterile field, and carry out the nursing care plan.
Intraoperative Nursing Functions

Circulating Nurse

The circulating nurse manages the operating room and protects the safety and health needs of the patient by monitoring activities of members of the surgical team and checking the conditions in the operating room. Responsibilities of a circulation nurse are the following:

  1. Assures cleanliness in the OR.
  2. Guarantees the proper room temperature, humidity and lighting in OR.
  3. Make certain that equipments are safely functioning.
  4. Ensure that supplies and materials are available for use during surgical procedures.
  5. Monitors aseptic technique while coordinating the movement of related personnel.
  6. Monitors the patient throughout the operative procedure to ensure the person’s safety and well being.

Scrub Nurse

  1. Scrubbing for surgery.
  2. Setting up sterile tables.
  3. Preparing sutures and special equipments.
  4. Assists the surgeon and assistant during the surgical procedure by anticipating the required instruments, sponges, drains and other equipment.
  5. Keeps track of the time the patient is under anesthesia and the time the wound is open.
  6. Checks equipments and materials such as needles, sponges and instruments as the surgical incision is closed.
Classification of Physical status for Anesthesia before Surgery

The anesthesiologist should visit the patient before the surgery to provide information, answer questions and allay fears that may exist in the patient’s mind. The choice of anesthetic agent will be discussed and the patient has an opportunity to disclose and the patient has opportunity to disclose previous reactions and information about any medication currently being taken that may affect the choice of an agent. Aside from that, the patient’s general condition must also be assessed because it may affect the management of anesthesia. Thus, the anesthesiologist assesses the patient’s cardiovascular system and lungs. Inquiry about preexisting pulmonary infection sand the extent to which the patient smokes must also be determined. The classification of a client’s physical status for anesthesia before surgery is summarized below.

Classification of Physical Status for Anesthesia Before Surgery
GoodNo organic disease; no systemic disturbanceUncomplicated hernias, fracture
FairMild to moderate systemic disturbanceMild cardiac (I and II) disease, mild diabetes
PoorSevere systemic disturbancePoorly controlled diabetes, pulmonary complications, moderate cardiac (III) disease
SeriousSystemic disease threatening lifeSevere renal disease, severe cardiac disease (IV), decompensation
MoribundLittle chance of survival but submitting to operation in desperationMassive pulmonary embolus, ruptured abdominal aneurysm with profound shock
EmergencyAny of the abive when surgery is performed in an emergency situationAn uncomplicated hernia that is now strangulated and associated with nausea and vomiting.

Source: Brunner and Suddarth’s Medical-Surgical Nursing by Smeltzer and Bare


Anesthesia controls pain during surgery or other medical procedures. It includes using medicines, and sometimes close monitoring, to keep you comfortable. It can also help control breathing, blood pressure, blood flow, and heart rate and rhythm, when needed. Anesthetics are divided into two classes:

  1. Those that suspend sensation in the whole body – General anesthesia
  2. Those that suspend sensation in certain parts of the body – local, regional, epidural or spinal anesthesia

General Anesthesia

This type of anesthesia promotes total loss of consciousness and sensation. General anesthesia is commonly achieved when the anesthetic is inhaled or administered intravenously. It affects the brain as well as the entire body. Types of general anesthesia administration:

  • Volatile liquid anesthetics – this type of anesthetic produces anesthesia when their vapors are inhaled. Included in this group are the following:
    1. Halothane (Fluothane)
    2. Methoxyflurane (Penthrane)
    3. Enflurane (Ethrane)
    4. Isoflurane (Forane)
  • Gas Anesthetics – anesthetics administered by inhalation and are ALWAYS combined with oxygen. Included in this group are the following:
    1. Nitrous Oxide
    2. Cyclopropane

Stages of General Administration

Anesthesia consists of four stages, each of which presents a definite group of signs and symptoms.

Stage I: Onset or Induction or Beginning anesthesia. This stage extends from the administration of anesthesia to the time of loss of consciousness. The patient may have a ringing, roaring or buzzing in the ears and though still conscious, is aware of being unable to move the extremities easily. Low voices or minor sounds appear distressingly loud and unreal during this stage.

Stage II: Excitement or Delirium. Stage II extends from the time of loss of consciousness to the time of loss of lid reflex. This stage is characterized by struggling, shouting, talking, singing, laughing or even crying. However, these things may be avoided if the anesthetic is administered smoothly and quickly. The pupils become dilated but contract if exposed to light. Pulse rate is rapid and respirations are irregular.

Stage III: Surgical Anesthesia. This stage extends from the loss of lid reflex to the loss of most reflexes. It is reached by continued administration of the vapor or gas. The patient now is unconscious and is lying quietly on the table. Respirations are regular and the pulse rate is normal.

Stage IV: Overdosage or Medullary or Stage of Danger. This stage is reached when too much anesthesia has been administered. It is characterized by respiratory or cardiac depression or arrest. Respirations become shallow, the pulse is weak and thread and the pupils are widely dilated and no longer contract when exposed to light. Cyanosis develops afterwards and death follows rapidly unless prompt action is taken. To prevent death, immediate discontinuation of anesthetic should be done and respiratory and circulatory support is necessary.

Local Anesthesia

Local anesthetics can be topical, or isolated just to the surface. These are usually in the form of gels, creams or sprays. They may be applied to the skin before the injection of a local anesthetic that works to numb the area more deeply, in order to avoid the pain of the needle or the drug itself (penicillin, for example, causes pain upon injection).

Regional anesthesia

Regional anesthesia blocks pain to a larger part of the body. Anesthetic is injected around major nerves or the spinal cord. Medications may be administered to help the patient relax or sleep. Major types of regional anesthesia include:

  1. Peripheral nerve blocks. A nerve block is a shot of anesthetic near a specific nerve or group of nerves. It blocks pain in the part of the body supplied by the nerve. Nerve blocks are most often used for procedures on the hands, arms, feet, legs, or face.
  2. Epidural and spinal anesthesia. This is a shot of anesthetic near the spinal cord and the nerves that connect to it. It blocks pain from an entire region of the body, such as the belly, hips, or legs.

With regional anesthesia, an anesthetic agent is injected around the nerved so that the area supplied by these nerves is anesthetized. The effect depends on the type of nerve involved. The patient under a spinal or local anesthesia is awake and aware of his or her surroundings.

Regional anesthesia carries more risks than local anesthesia, such as seizures and heart attacks, because of the increased involvement of the central nervous system. Sometimes regional anesthesia fails to provide enough pain relief or paralysis, and switching to general anesthesia is necessary.

Spinal Anesthesia

This is a type of conduction nerve block that occurs by introducing a local anesthetic into the subarachnoid space at the lumbar level which is usually between L4 and L5. Sterile technique is used as the spinal puncture is made and medication is injected through the needle. The spread of the anesthetic agent and the level of anesthesia depend on:

  1. the amount of fluid injected
  2. the speed with which it is injected
  3. positioning of the patient after injection
  4. specific gravity of the agent

Nursing Assessment after Spinal Anesthesia

  1. Monitoring vital signs.
  2. Observe patient and record the time when motion and sensation of the legs and the toes return.

Side Effects of Anesthesia

  1. Some numbness or reduced feeling in part of your body (local anesthesia)
  2. Nausea and vomiting.
  3. A mild drop in body temperature.

How do anesthesiologists determine the type of anesthesia to be used?

The type of anesthesia the anesthesiologist chooses depends on many factors. These include the procedure the client is having and his or her current health.

Position a Patient on the Operating Table

The nurse should have an idea which patient position is required for a certain surgical procedure to be performed. There are lots of factors to consider in positioning the patient which includes the following:

  1. Patient should be in a comfortable position as possible whether he or she is awake or asleep.
  2. The operative area must be adequately exposed.
  3. The vascular supply should not be obstructed by an awkward position or undue pressure on a part.
  4. There should be no interference with the patient’s respiration as a result of pressure of the arms on the chest or constriction of the neck or chest caused by a gown.
  5. The nerves of the client must be protected from undue pressure. Serious injury or paralysis may result from improper positioning of the arms, hands, legs or feet.
  6. Shoulder braces must be well padded to prevent irreparable nerve injury.
  7. Patient safety must be observed at all times.
  8. In case of excitement, the patient needs gentle restraint before induction.
Reason of Performing a Surgical Procedure
  1. To cure an illness or disease by removing the diseased tissue or organs.
  2. To visualize internal structures during diagnosis.
  3. To obtain tissue for examination.
  4. To prevent disease or injury.
  5. To improve appearance.
  6. To repair or remove traumatized tissue and structures.
  7. To relieve symptoms or pain.
Nursing Responsibility during the Intraoperative Phase
  1. Safety. Is the Highest Priority of nurses.
  2. Simultaneous placement of feet. This is to prevent dislocation of hip.
  3. Always apply knee strap.
  4. Arms should not be more than 90°
  5. Prepare and apply cautery pad. Cautery is used to stop bleeding.