Perioperative Nursing
- Rois Narvaez
- 5 days ago
- 11 min read
Updated: 5 days ago
Perioperative nursing orchestrates safe, dignified, and efficient surgical care across pre-operative, intra-operative, and post-operative phases by aligning patient optimization, asepsis, physiologic stability, and precise handoffs into one continuous plan. These notes are clinical job aids for quick use in pre-op holding, the OR, and PACU.
Safety anchors: WHO Surgical Safety Checklist • AORN standards • QSEN • National Patient Safety Goals • Time-out/site marking
Clinical judgment: Collect cues → interpret significance → estimate risk → choose and sequence actions
Use this pack: Scan tables, practice Quick Checks, then test yourself with the NGN mini-item + answer keys.
Policy note: verify local NPO timings, antibiotic windows, and discharge criteria; always follow facility protocol.
1) Pre-operative Phase 📋
Prepare, optimize, and verify the patient to prevent complications and ensure informed, safe surgery.
1.1 Informed Consent ✍️
Secure lawful, autonomous agreement and document it fully before any sedation.
Item ✍️ | Surgeon 🧑⚕️ | Nurse 👩⚕️ | Notes 🗒️ |
Explain diagnosis, procedure, risks/benefits, alternatives, expected course | ✔️ | — | Use qualified interpreter; teach-back |
Confirm capacity & voluntariness | ✔️ | Screens/escalates | No coercion; address anxiety/health literacy |
Obtain signature & date/time | ✔️ | Witness per policy | Must be before premedication |
Mark site/side | ✔️ | Verifies visibility after prep/drape | Engage patient when able |
Special situations (minor, POA, emergency) | Directs plan | Verifies legal documents | Follow policy for exceptions |
Memory aid — C.O.N.S.E.N.T. (what valid consent requires)Components explained • Options discussed • No coercion/capacity present • Surrogate/POA if needed • Emergency exceptions per policy • Name/site/procedure match • Timing before sedation
Red flags ⚠️: patient already sedated • blanks on form • mismatched ID/site
1.2 Pre-op Screening & Optimization 🔍
Surface modifiable risks (airway, hemodynamics, glycemia, meds) and build a targeted plan.
Domain 🔍 | What to assess 📌 | Examples & actions ✅ |
Respiratory | OSA, COPD/asthma, recent infection | Teach IS; inhalers PRN; postpone if acute infection |
Cardiovascular | Hypertension, CAD/HF, rhythm, exercise tolerance (METs) | ECG per risk; optimize BP/volume; antiplatelet plan |
Endocrine | Diabetes, steroid use, thyroid disease | Glycemic targets per policy; stress-dose steroids if ordered |
Hepatic/Renal | LFTs/creatinine, dialysis schedule | Dose adjustments; fluid strategy |
Hematologic | Anticoagulants/antiplatelets, platelets | Hold/bridge per protocol; type & screen/crossmatch if needed |
Nutrition | Malnutrition/obesity | Dietitian consult; wound-healing risk |
Immunologic/Allergy | Immunosuppression, latex/iodine allergy | Antibiotic timing; allergy precautions |
Psychosocial | Anxiety, coping, supports | Early teaching; clarify expectations; address fears |
Memory aid — R-C-H-E-P (run this quick mental sweep)
Respiratory • Cardiovascular • Hepatic/Renal • Endocrine • Psychosocial
1.3 Pre-op Teaching: Breathing, Mobility & Pain 🫁
Give patients the skills that prevent pulmonary events, VTE, and delays in recovery.
Skill 🫁 | How to do it 🧾 | Frequency ⏱️ | Why 🎯 |
Incentive spirometer | Sit upright; seal lips; slow deep inhale to target; hold 3–5 s; exhale | ~10 breaths/hr while awake | Prevent atelectasis & pneumonia |
Splint & cough | Hug pillow; deep breath; cough effectively | Every 1–2 hours | Protect incision; clear secretions |
Mobility & leg exercises | Ankle pumps; quad/glute sets; early ambulation | Start day 0–1 | Reduce VTE; improve ventilation |
Pain plan | Pain scale; multimodal meds; PCA basics; non-pharm | Ongoing, reassess | Enables breathing/mobility/IS use |
Memory aid — B.R.E.A.T.H. (six habits that keep lungs open)Breathe with IS • Reposition often • Explain splint/cough • Activity early • Teach pain tools • Hourly reminders
1.4 Evening-Before Preparation 🧼
Reduce aspiration and surgical-site infection risk and set up a smooth induction.
Topic 🧼 | Do ✅ | Don’t 🚫 |
Skin | Chlorhexidine wash if ordered | Shave hair (clip only if necessary) |
NPO | Follow fasting times per policy | Break NPO without order |
Substances | Stop alcohol/smoking; follow med holds | “Last drink” night before |
Valuables | Secure or send home | Bring to OR |
Rest | Promote sleep | Heavy late meals |
Memory aids — S.K.I.N. & N.P.O. (safer skin, safer airway)Scrub with CHG • Klip hair (no shave) • Identify/mark site • Nail/skin check • N.P.O. = nothing by mouth per policy times
1.5 Day-of-Surgery Checklist 🕘
Use a final standardized safety net before the patient leaves for the OR.
Check 🕘 | Details 📋 |
Consent and chart complete | Labs, imaging, H&P, orders present |
Handoff plan | SBAR to OR/PACU prepared |
ID and allergy bands | Cross-check with EMR and consent |
Medications | Antibiotics on time; held meds verified (e.g., anticoagulants) |
Site preparation & marking | Clip if needed; mark visible after prep/drape |
Safety set-up | Side rails up; stretcher low/locked; DVT prophylaxis ready |
Memory aid — C.H.A.M.P.S. (the last net before the OR door)Consent/chart • Handoff • Allergies/ID • Meds on-call/held • Prep+mark • Safety
1.6 Pre-anesthetic Medications 💊
Lower anxiety/secretions/aspiration risk and guard against oversedation.
Class 💊 | Purpose 🎯 | Nursing responsibilities 👩⚕️ |
Benzodiazepines | Anxiolysis | Verify consent before sedation; fall precautions; monitor response |
Anticholinergics | Reduce secretions; prevent bradycardia | Monitor heart rate; oral care |
H₂ blockers/PPIs | Lower aspiration risk | Administer at correct time |
Antiemetics | Prevent/treat nausea & vomiting | Evaluate effect; document |
Opioids | Analgesia | Monitor respiratory rate and sedation score |
Memory aid — R.A.I.L.S. (give it safe, keep it safe)
Raise side rails • Assess effects • Identify reactions • Low-stimulus setting • Safety checks documented
1.7 Immediate Pre-op & Transport 🚚
Lock down documents/equipment and hand off with precision to the OR team.
Step 🚚 | Actions ✅ |
Time-out readiness | All verification documents accessible |
Records | Results and consents attached to chart/EMR |
Allergies | Bands and EMR match; high-alert noted |
NPO | Time verified and documented |
Site/side mark | Surgeon initials visible after prep |
Family communication | Waiting plan and updates arranged |
Equipment/IV | Patency confirmed; rates correct; access secured |
Handoff | SBAR to holding/OR with key risks and priorities |
Memory aid — T.R.A.N.S.F.E.R. (nothing left behind)
Time-out • Records • Allergies • NPO • Site mark • Family informed • Equipment/IV • Report (SBAR)
2) Intra-operative Phase 🛠️
Maintain sterility and physiologic stability through coordinated roles, controlled environment, and rapid responses.
2.1 Roles & Scope 👥
Assign and execute tasks so airway, sterility, counts, positioning, and documentation are never missed.
Role 👥 | Core duties 🔧 |
Surgeon | Performs procedure; obtains consent; marks site; manages complications |
Anesthesia provider | Pre-anesthesia assessment; airway plan; anesthesia delivery; hemodynamic/ventilation management; emergence |
Scrub nurse/tech | Sets up sterile field; instrument handling; counts; specimen management |
Circulating RN | Patient advocacy; positioning; documentation; counts; traffic control; equipment; safety checks; time-out |
RN first assistant (RNFA) | Exposure; hemostasis; suturing; tissue handling |
Memory aids — S.C.R.U.B.S. / C.I.R.C.L.E. (quick role snapshots)
Scrub: sterile field • counts • instruments • asepsis • back-table • specimens
Circulator: charting • ID/time-out • room prep • circulation/safety • liaison • equipment
2.2 Surgical Environment & Zones 🚪
Control traffic and attire to limit bioburden and protect the sterile field.
Zone 🚪 | Attire 👕 | Traffic 🚦 |
Unrestricted | Street clothes | Open |
Semi-restricted | Scrubs and caps | Limited |
Restricted | Scrubs, caps, and masks | Minimal; sterile areas only |
Memory aid — U-S-R (who wears what, where) Unrestricted • Semi-restricted • Restricted
2.3 Asepsis & Sterile Technique 🧼
Apply consistent rules each case to prevent contamination and delays.
Principle 🧼 | What it means 🧠 |
Sterile touches sterile | Only sterile items contact the field |
2.5 cm (1-inch) border is unsterile | Treat edges as contaminated |
Waist level and above | Below waist is unsterile |
Moisture contaminates | Prevent strikethrough; keep items dry |
Minimize movement and airflow | Reduce dispersion of microbes |
When in doubt, discard | Replace questionable items immediately |
Memory aid — S.T.E.R.I.L.E. (never bend these rules)
Sterile-to-sterile • Table waist-up • Edge unsterile • Restrict reach/turns • Items dry & dated • Limit traffic • Eliminate doubt
2.4 Anesthesia Essentials 😴
Match anesthesia to the operation and anticipate physiologic shifts.
Type 😴 | Features 🧩 | Airway 🫁 | Notes 🗒️ |
General anesthesia | Amnesia, analgesia, immobility | LMA or ETT | Classic stages 1–4; depth monitored |
Epidural anesthesia | Segmental, titratable block | Natural airway | Slower onset; postoperative analgesia |
Spinal anesthesia | Dense, rapid block | Natural airway | Risk of post-dural puncture headache |
Moderate sedation/MAC | Responds to verbal/tactile stimuli | Natural airway (support PRN) | Continuous monitoring required |
Local anesthesia | Field/infiltration, topical | Natural airway | May include epinephrine for effect |
Epidural vs spinal — quick contrast
Feature 🔬 | Epidural 💉 | Spinal 🧪 |
Location | Epidural space | Subarachnoid space (CSF) |
Onset | Slower | Rapid |
Dose/level | Higher volume; segmental | Lower volume; dense |
Common risks | Hypotension; urinary retention | Hypotension; post-dural puncture headache |
Memory aid — S.T.A.G.E. (GA depth awareness)
Sedation begins • Twilight/excitement • Anesthesia surgical plane • Gone too deep (medullary depression) • Emerge
2.5 Intra-op Complications & Responses 🚨
Spot early cues and execute protocol—seconds matter.
Issue 🚨 | Key cues 👀 | First actions ⚡ |
Nausea/vomiting | Retching, gagging, pallor | Suction; antiemetic; protect airway; lateral head turn |
Hypoxia/airway problem | Low SpO₂; high airway pressures; absent breath sounds | Check tube/vent; 100% O₂; assess lungs; correct obstruction |
Hypothermia | Low core temp; shivering; cool skin | Forced-air warming; warm IV fluids; monitor temperature |
Malignant hyperthermia | Rising ETCO₂; rigidity; tachycardia; later rapid temperature rise; cola-colored urine | Stop triggers; dantrolene; 100% O₂ with hyperventilation; active cooling; treat hyperkalemia/acidosis; send labs; monitor urine |
Memory aids — REWARM / HOT-MALIGNANT / RESCUE
Treat hypothermia (REWARM) • Recognize MH cues (HOT→MALIGNANT) • Manage MH (RESCUE: remove triggers, 100% O₂ + hyperventilate, cool, give dantrolene, correct electrolytes, monitor urine)
2.6 Positioning 🛏️
Prevent nerve, pressure, and ocular injuries while preserving access and ventilation.
Position 🛏️ | Major risks ⚠️ | Protection checklist ✅ |
Supine (dorsal) | Brachial/ulnar nerve pressure; skin breakdown | Pad arms; neutral neck; protect bony prominences |
Trendelenburg | Airway edema; ↑ICP; sliding | Secure airway and patient; limit time |
Lithotomy | Peroneal/saphenous nerve injury; compartment syndrome | Even leg support; avoid extreme flexion; limit time/height |
Lateral (Sims) | Dependent nerve/eye/ear pressure | Axillary roll; protect eyes/ears; pad knees/ankles |
Memory aid — P.A.D. P.O.S.E. (position safely, reassess regularly)
Pad bony points • Align spine • Don’t overstretch • Pressure map • Ocular/nerve protect • Strap safely • Evaluate q15–30 min
3) Post-operative Phase 🌅
Guide safe emergence, stabilize ABCs, relieve pain, mobilize early, and meet objective discharge criteria.
3.1 PACU Phases 🏁
Follow staged recovery from immediate stabilization to education and discharge.
Phase 🏁 | Focus 🎯 | Typical goals ✅ |
Phase I | Airway, ventilation, hemodynamics, neuro, temperature, pain, N/V, site/drains, urine | Stabilize ABCs; treat immediate problems |
Phase II | Education, comfort, mobility, discharge preparation | Meet criteria; complete teaching & equipment needs |
Phase III | Extended observation (if criteria unmet) | Continue monitoring and interventions |
Memory aid — P.A.C.U. (priorities on arrival)
Protect airway • Assess ABCs • Connect monitors/lines • Understand and carry out orders
'3.2 Priority Assessment (initial) 🔎
Work ABCs first, then targeted system checks and device/drain safety.
Airway 🫁: patency, positioning, oral/nasal airway as ordered
Breathing 🌬️: rate, depth, sounds, SpO₂, ETCO₂ if available
Circulation ❤️: HR, BP, skin color/temp, cap refill; IVs, drains, dressings
Neurologic 🧠: LOC/orientation, response to commands, pupils if indicated
Pain & nausea 🤕🤢: scale, effect of medications
Lines/tubes/drains 🧪: placement, patency, securement, outputs
Safety 🛟: side rails up, alarms on, fall risk addressed
Memory aids — A-B-C-N-C-R-L / S.A.F.E.T.Y. Airway • Breathing • Circulation • Neuro • Color/Cap refill • Response/Pain • Lines/DrainsSide rails • Alarms • Fall risk • Equipment checks • Tubes secure • “Yes” ID
3.3 Hemodynamic Stability & Complications ❤️
Detect shock/bleeding early and correct causes before organ injury.
Problem ❤️ | Cues 👀 | First steps ⚡ |
Hypotension/shock | Low BP, tachycardia, cool/clammy skin, delayed cap refill | High-flow O₂; elevate legs if appropriate; rapid IV fluids/blood per orders; call surgeon; continuous monitoring |
Hemorrhage | Expanding dressing, increased drain output, tachycardia, hypotension | Reinforce/mark dressing; check source; send labs including type & cross; prepare for return to OR if uncontrolled |
Hypertension/dysrhythmias | Elevated BP/HR, irregular rhythm; often pain, hypoxia, bladder distention | Treat cause first (analgesia, oxygen, empty bladder); notify provider for medication adjustments |
Memory aids — S.H.O.C.K. / B.L.E.E.D. / H.Y.P.E.R.First moves for hypotension • Signs/actions for bleeding • Why BP/HR spike post-op
3.4 Immediate Post-op Orders & Nursing Care 📄
Deliver standard bundles that accelerate recovery while preventing pulmonary and thrombotic events.
Bundle 📄 | Elements 🧩 |
Fluids & I&O | Hourly urine output; IV rates; fluid balance; lab trends |
Pulmonary hygiene | Turn-cough-deep-breathe; incentive spirometer schedule; oxygen as ordered |
Analgesia & antiemetics | Multimodal approach; sedation scale; rescue plans |
Mobility & DVT prevention | Early ambulation; leg exercises; prophylaxis per orders |
Wound & dressing | Assess/mark drainage; reinforce as needed; keep clean and dry |
Glycemic & temperature control | Monitor blood glucose; maintain normothermia |
Diet | Advance as tolerated per procedure and orders |
Memory aid — I.C.E. P.A.C.K. (early recovery bundle)Intake/Output • C&DB/IS • Early ambulation • Pain plan • Antiemetic plan • Catheter PRN • Keep dressing clean/dry
3.5 Discharge Readiness (Aldrete) & Teaching 🧮🏠
Use objective scoring and clear instructions to ensure safe discharge and continuity.
Aldrete domain 🧮 | Target 🎯 | Notes 🗒️ |
Activity | Moves extremities on command | Compare with baseline |
Respiration | Adequate ventilation without distress | Minimal oxygen support |
Circulation | BP near baseline | Monitor trends rather than single values |
Consciousness | Awake and oriented or at baseline | No new neurologic deficit |
Oxygen saturation | Meets target on room air or low-flow O₂ | Stable without frequent desaturation |
Home instructions 🏠: meds; wound care; diet/fluids; activity limits; IS use; red-flag symptoms (fever, bleeding, shortness of breath, uncontrolled pain); no driving/alcohol/major decisions for 24 h after sedation/GA; follow-ups; emergency contacts.
Memory aid — H.O.M.E. (what to teach for safe discharge) How to care • Out-of-bounds signs • Meds & meals • Events (follow-ups)
3.6 Receiving the Patient on the Unit 🛎️
Prepare the room and verify monitoring so the handoff lands safely.
Item 🛎️ | Details 📋 |
Respiratory equipment | Oxygen source working; suction set-up; pulse oximeter ready |
Monitoring | ECG, BP, SpO₂ connected; alarms set appropriately |
Analgesia | Pumps available; orders reviewed; rescue meds stocked |
Dressings & drains | Extra gauze/tape; labels; measuring devices |
Identification & labels | Wristbands correct; specimen/line labels match EMR |
Bed & environment | Bed low/locked; side rails up; call bell within reach |
Power/IV access | Pumps/poles present; outlets available; IV patency confirmed |
Baseline documentation | Initial vital signs; focused assessment; intake/output started |
Memory aid — R.E.A.D.Y. R.O.O.M. (room ready, patient safe)Respiratory gear • ECG/BP/SpO₂ • Analgesia equipment • Drain/dressing supplies • Yes-ID & labels • Raise bed/rails • Oxygen on • Outlets/IV access • Monitor alarms set
Quick Checks (Retrieval) 🧠✅
List three verifications required before giving pre-anesthetic medications.
Name two early signs of malignant hyperthermia and state your first action.
PACU: BP 86/54, HR 124, cool clammy skin, drain filling rapidly—name your top three priorities.
Incentive spirometer: give two key steps and a typical frequency.
List the five Aldrete domains.
NGN-Style Mini Item 🧩
Scenario: Post-op day 0 after abdominal surgery. Select all cues that require immediate follow-up.
Cue 🧩 | Follow-up now? ✅ |
SpO₂ 88% on 2 L nasal cannula with new restlessness | ☐ Yes ☐ No |
Urine output 20 mL in the last hour (70-kg patient) | ☐ Yes ☐ No |
Temperature 37.8 °C with shivering | ☐ Yes ☐ No |
Dressing with a 1-cm serosanguineous spot | ☐ Yes ☐ No |
Pain score 8/10, BP 148/86 | ☐ Yes ☐ No |
Rigid, tender abdomen with tachycardia | ☐ Yes ☐ No |
Closing Practice Pearls ✨
A crisp handoff prevents harm. Deliver SBAR like a therapy: right content, right timing, right receiver.
Trends beat snapshots. A drifting SpO₂ or MAP warns you earlier than a single abnormal.
Behavior change leads equipment. Restlessness often flags oxygen debt before numbers crash.
Guard nerves and eyes. Positioning injuries can outlast incisions—pad, align, reassess.
If sterility is uncertain, it isn’t sterile. Replace first, debate later.
Pain control unlocks progress. Breathing, coughing, and walking depend on it.
Warm early, bleed less. Normothermia is therapy, not just comfort.
Write for the next nurse. Clear notes power safe continuity.
Kindness changes outcomes. Calm voice + plain language build trust.
Your presence is a safety device. Verify often; speak up every time
References
Parameters. Anesthesiology, 126(3), 376–393. https://doi.org/10.1097/ALN.0000000000001452
Association of periOperative Registered Nurses. (2023). Guidelines for perioperative practice. AORN. https://www.aorn.org/guidelines
Centers for Disease Control and Prevention. (2017). Guideline for the prevention of surgical site infection. JAMA Surgery, 152(8), 784–791. https://doi.org/10.1001/jamasurg.2017.0904
Centers for Disease Control and Prevention. (2023). Infection control in healthcare personnel. U.S. Department of Health & Human Services. https://www.cdc.gov/infectioncontrol
Miller, R. D., & Pardo, M. C. (2018). Basics of anesthesia (7th ed.). Elsevier.
National Institute for Health and Care Excellence. (2020). Perioperative care in adults. NICE guideline [NG180]. https://www.nice.org.uk/guidance/ng180
Nagelhout, J. J., & Elisha, S. (2022). Nurse anesthesia (7th ed.). Elsevier.
QSEN Institute. (n.d.). Competencies. Retrieved August 11, 2025, from https://www.qsen.org/competencies
The Joint Commission. (2025). National Patient Safety Goals®. https://www.jointcommission.org/standards/national-patient-safety-goals/
World Health Organization. (2009). WHO surgical safety checklist and implementation manual. https://www.who.int/publications/i/item/9789241598590
Quick Checks — Answer Key & Rationales 🧠✅
(1) Consent complete/valid; NPO status/time verified; ID & allergy bands match the chart. (Credit: IV patent; baseline VS; site marked; pregnancy test PRN.)
(2) Rising end-tidal CO₂ and generalized muscle rigidity (often with tachycardia); first action: stop triggers, 100% O₂ with hyperventilation, activate MH protocol, prepare dantrolene, and start active cooling.
(3) High-flow oxygen; rapid bleeding assessment and control; fluid resuscitation/blood as ordered; notify surgeon/rapid response.
(4) Sit upright; seal lips; slow deep inhale to target; hold 3–5 s; exhale; ~10 breaths/hour while awake; cough after sets.
(5) Activity • Respiration • Circulation (BP) • Consciousness • Oxygen saturation.
NGN Answer Key & Rationales 🧩✅
Cue 🧩 | Answer ✅ | Why 🧠 | First actions ⚡ |
SpO₂ 88% on 2 L NC with new restlessness | Yes | Hypoxemia; behavior change is early; airway/oxygenation priority | Elevate head; airway maneuvers; ↑O₂ per protocol; assess lungs; encourage expansion; escalate if unresolved |
Urine output 20 mL/h (70-kg) | Yes | Oliguria (<0.5 mL/kg/h) → hypovolemia/retention/renal hypoperfusion | Check bladder; assess bleeding; fluids per orders; labs; notify |
Temperature 37.8 °C, shivering | No (monitor) | Mild early elevation common; shivering ↑O₂ demand but not emergent | Warm actively; reassess; antipyretic if ordered |
Dressing 1-cm spot | No (monitor) | Small expected ooze early | Circle/time mark; reassess; check drains/VS |
Pain 8/10, BP 148/86 | No (address promptly) | Likely pain/stress response; not immediate ABC threat | Treat pain; reassess for hypoxia/urinary retention if disproportionate |
Rigid, tender abdomen with tachycardia | Yes | Possible internal bleeding/peritonitis | Call surgeon; high-flow O₂; large-bore IVs; fluids/blood per orders; NPO; frequent VS; labs; prep for possible return to OR |