Three Phases in Perioperative Nursing

The term perioperative nursing refers to all the activities and responsibilities assumed by a nurse before, during, and after a surgical procedure. A systematic tool, known as the nursing process, guides the nurse in these procedures to ensure the quality of care that a surgical patient will receive.

Three Phases in Perioperative Nursing

1. Preoperative phase

It is the phase when the patient has decided to have the surgical intervention to transfer the patient to the procedure room. This phase can vary in time, from a few minutes to months. It depends on several factors including the urgency of the procedure, time for the patient to prepare, preoperative testing, the effectiveness of therapy, health status, staff and room availability, and insurance approval.

Nurses can utilize the preoperative phase to assess the patient’s risks and benefits of having the procedure. The nurse’s assessment considers many factors that include:

1. Age of the patient – young children and older adults are the most vulnerable to complications
2. Patient’s nutritional status – improving nutritional intake before surgery can increase strength and tissue recovery post-procedure.
3. Fluid and electrolyte status – hydration is important to prevent fluid and electrolyte imbalances, such as hypovolemia, during and after surgery.
4. Presence of infection and other health issues – these factors predispose the patient to sepsis and other conditions postoperatively.
5. Holistic bodily functions – clearance of cardio, respiratory, renal, neurologic, hematologic, and other pertinent functions prior to the procedure is imperative to avoid life-threatening situations during and after the surgical procedure.
6. Medication review – it is important to review medications that the patient is currently taking and have them hold medications that might cause hemorrhagic complications, such as anticoagulants.
7. Consider health habits – Lifestyle choices, like smoking and a sedentary lifestyle, may increase the chances of inter-operative complications and hinder the healing process. The nurse may consider health teachings best suited for the patient before the procedure in order to increase successful healing.
8. Informed consent preparations – during the preoperative phase include the process of obtaining informed consent. The care provider will discuss the risks and benefits of the procedure and answer questions. The patient has an opportunity to verbalize his or her fears. The provider and nurse can utilize therapeutic communication, a method of collaboration and building trust with the patient to encourage mental and physical wellness when discussing the procedure. The goal is for the patient to consent to the procedure willingly and with enough information to make an educated decision.
9. Health teaching – is an essential avenue to help lessen anxiety and stress for the upcoming surgical procedure. Teaching the patient about deep breathing, turning, splinting, and pursed-lip breathing exercises can be very helpful to prevent the patient from developing complications, like pneumonia and other respiratory problems, as well as circulatory conditions.
10. Handoff – The circulating nurse from the procedure room will come to get the patient from the pre-op holding area to take them to the procedure. They will ensure they have the correct patient by checking the patient’s name, date of birth, medical record number (MRN), and procedure to be performed with the pre-op nurse. They do this by one nurse reading the armband on the patient and the other reading the chart information and making sure it matches.

2. Intraoperative phase

It is from the time when the patient is received in the operating room to the time the patient is admitted to the Post Anesthesia Care Unit (PACU) or recovery room.

The surgical team is now responsible for the patient, composed of the surgeon, assistant surgeon, anesthesiologist, holding area nurse, circulating nurse, and scrub nurse. The team will perform a “time-out”, in which everyone in the room stops and a designated person reads off the patient’s name, date of birth, and medical record number (MRN) to ensure they have the right patient and the right procedure. The nurse’s responsibilities include the verification of the preoperative checklist, composing of the informed consent, various preparations, and if medications were given, as well as the availability of blood and intravenous access.

It is beneficial for the nurse to know the indicated surgical procedure well to know how to assist with positioning and skin preparation. The principles of surgical asepsis are strictly utilized during this phase and include preparations in terms of layout, the health of the surgical team, surgical attire, and surgical scrub.

Nurses in the operating room may have different roles. The circulating nurse will leave the operating room to collaborate with the family of the patient or other team members outside the operating room, such as the pre-op nurse. They will also “checkout” the patient in the pre-op holding area and with a pre-op nurse to hand over care to the procedure room.  The scrub nurse ensures a sterile environment and helps the health care provider during the procedure.

The overall goal of the nurse is to ensure patient safety and promote stability. There is careful dispensing of supplies and instruments and there is strict maintenance of the aseptic environment. The circulating nurse oversees monitoring the patient’s well-being in collaboration with the anesthesiologist and the surgeon, obtaining fluids and medications, supplies and instruments, and documenting the progress of the surgery. The scrub nurse, on the other hand, assists the surgeon by handling instruments and supplies to the surgeon while maintaining surgical asepsis.

3. Postoperative phase

The postoperative phase is from the time of admission in the recovery room to the time of the follow-up evaluation.

This is the last phase of perioperative nursing, and it is just as critical as other phases. The patient needs to be closely monitored for complications from the procedure.  The anesthesiologist will give a handoff report to the nurse in the recovery room. The nurse’s notes from the intraoperative phase are verified prior to admission to the recovery room to make ensure that the recovery room nurse is receiving the patient anticipated.

The nursing process, which involves assessment, planning, implementation, and evaluation, is vital in the recovery period. The ABCs of the airway, breathing, and circulation, oxygen saturation, and ventilation, vital signs, and level of consciousness are being assessed and given priority, especially immediately after the procedure. Drainage, fluid status, and hydration are also assessed and documented in the Electronic Medical Record (EMR).

The patient’s ability to move, gag, and discomforts are later assessed when the patient is conscious. The nurse will use these assessments to plan any further care, such as giving morphine if the patient has an order for pain, and then evaluate if the intervention was effective. Once the patient meets the criteria for recovery room discharge, the patient can be transferred to either an outpatient room to receive teaching to go home or an inpatient room in the hospital.

Postoperative complications can include:

1. Wound infection – signs of infections can include swelling, pus, fever, redness, and pain
2. Reaction to anesthesia – patients can experience vomiting, chills, and/or nausea. Care providers may order antiemetics to be administered intraoperatively and postoperatively to prevent these symptoms.
3. Bleeding – Bleeding can occur internally or externally immediately after the procedure to several days postoperatively. Patients may experience swelling, bruising, tenderness, confusion, or agitation. Providers may have specific expectations of postoperative bleeding and further evaluation may be needed if bleeding is more than expected.
4. Lung issues – Patients may experience wheezing, chest pain, shortness of breath, and might even experience pneumonia.
5. Urinary retention – urinary retention is the inability to urinate after receiving anesthesia, even though there is urine in the bladder. Some physicians require patients to urinate before discharge home.
6. Pulmonary embolism – this is a very serious complication that is caused by a blood clot from one of the veins that travel to the lungs. It can be fatal without intervention.
7. Deep vein thrombosis – patients are at risk for deep vein thrombosis (DVT) even several weeks after the procedure. A DVT occurs when a blood clot or thrombus develops in a deep vein. Compression stockings or a Sequential Compression Device, SCD machine, may be ordered to prevent postoperative DVT’s.
8. Shock – shock can occur by infection or large amounts of blood loss after the procedure.

The nurse discharging the patient after the procedure will provide postoperative instructions prior to the patient going home. It is vital that the patient understands the instructions and has time to ask questions. One method is providing an opportunity for the patient to practice teach-back. This technique is important because it helps the nurse assess if the postoperative teaching was effective and can provide corrections as needed.

It is important that the nurse focuses on one topic at a time. The nurse can use several tools for teaching, such as written instructions, pictures, and videos, to further explain important points. The nurse can then ask the patient questions to prompt the patient to explain the lesson. For example, the nurse could ask if the patient could explain in their own words what they need to do at home for wound care. The nurse can then fill in the knowledge deficits if necessary.

Perioperative nursing is an exciting specialty. Nurses have the opportunity to utilize several nursing skills and critical thinking. They can work with a variety of team members and patients. There are opportunities to help prepare the patient prior to the procedure, work with the surgical team in the operating room, practice critical care nursing in the recovery room, and provide teaching postoperatively. There is a lot of variety and learning opportunities for nurses. It is an ideal specialty for the nurse wanting a challenge.