Perioperative Nursing - Advanced

Perioperative safety also lives in the “edges”: medication strategy, fire/laser/radiation protection, blood stewardship, ERAS pathways, implants/specimens, and human factors like delirium and counts. This add-on pack expands your toolkit with high-yield concepts not covered in the core perioperative notes.

Safety anchors: OR Fire Risk Assessment • Surgical counts & RSI prevention • Precise antibiotic timing/redose • Device/implant ID & tracking • Closed-loop communication & debriefsClinical judgment: Map the risk (patient • procedure • environment) → apply the right bundle → verify effect → document & hand off

Use this pack: Scan tables • practice Quick Checks • try the NGN mini-item + answer key.

Policy note: follow local protocols for ERAS, antithrombotics, transfusion thresholds, laser/radiation safety, tourniquet times/pressures, and specimen/implant workflows.

1) ERAS Pathways 🛤️

Coordinated steps that shorten stays, cut complications, and reduce opioids.

Phase	Key elements	Nursing actions
Pre-op	Prehab, carb drink per protocol, smoking cessation, PONV risk, anemia screen	Verify fasting per ERAS; carb drink timing; teach early ambulation & IS
Intra-op	Opioid-sparing multimodal analgesia, normothermia, goal-directed fluids	Warm early; balanced crystalloids; document multimodal meds
Post-op	Early feed/mobilize, scheduled non-opioids, catheter/tube minimization	Advance diet per protocol; walk day 0–1; remove devices asap

Memory aid — E.R.A.S.E.: Early feed • Reduced opioids • Active warming • Stepwise fluids • Early walk.

2) Medication & Antithrombotic Management 💊

What to continue/hold/bridge (always confirm with anesthesia/surgeon & policy).

Med class	Typical approach	Pearls
Beta-blockers	Continue	Prevent rebound tachy/ischemia
ACE-I/ARB	Hold AM of surgery (varies by service)	Reduces refractory hypotension risk
Antiplatelets	ASA often continue for cardiac/vascular; P2Y12 depends on stent/timing	Get cardiology input if recent stent
Warfarin	Stop ~5 days; bridge if high thrombotic risk	Target INR per procedure
DOACs	Hold 1–4 days (renal/procedure risk)	Longer for neuraxial; check creatinine
SGLT2 inhibitors	Stop 3–4 days pre-op	Prevent euglycemic DKA
Insulin	Basal reduced dose; hold prandials NPO	Follow glucose protocol

Memory aid — H.O.L.D.S.: High-risk antithrombotics • OR hypotension (ACE/ARB) • Low sugar meds (SGLT2) • Dose basal • Stop prandials.

3) Antibiotic Prophylaxis & Redosing 🧫

Right drug, right clock, right dose.

Step	Target	Notes
Timing	Infuse within 60 min of cut (vanco/fluoro: 120 min)	Document start/stop times
Dose	Weight-based (e.g., cefazolin 2–3 g)	Obesity may need higher dose
Redose	Per half-life or EBL >1500 mL or long case	Put redose time on the room board
Stop	Usually ≤24 h post-op	Stewardship matters

Memory aid — T.I.M.E.D.: Timing • Indication • Milligrams • EBL/Redose • Duration.

4) Patient Blood Management (PBM) 🩸

Reduce avoidable transfusion; treat anemia; keep patients warm and euvolemic.

Domain	Actions	Why it matters
Detect & treat anemia	Iron ± ESA per protocol	↑Reserve; fewer transfusions
Antifibrinolytic	TXA when indicated	↓Blood loss
Cell salvage	For high-EBL surgeries	Autologous return
Restrictive thresholds	Transfuse per Hgb/clinical status	Avoids harm/overuse
Warmth & BP	Normothermia; controlled BP	Less bleeding; fewer SSI

Memory aid — S.A.V.E. B.L.O.O.D.: Screen anemia • Antifibrinolytic • Volume strategy • Equipment warmers • Blood Loss plan • Output track • Optimize O₂ delivery • Document decisions.

5) Fire, Laser & Radiation Safety 🔥💡☢️

Keep the team safe by controlling the environment.

OR Fire (triangle = oxidizer • fuel • heat)

• Prevention: minimize open O₂, moist drapes, allow prep to dry, manage ESU tips.

• If airway fire: stop gases, pull tube, saline to extinguish, bag with air, re-intubate per algorithm.

Laser

• Door signage, correct eyewear by wavelength, wet sponges, plume evacuation on.

Radiation (fluoro)

• Time • Distance • Shielding; dosimeters; lead for patient areas as indicated.

Memory aids: F.I.R.E. (FiO₂ down • Ignition off • Ready saline • Evacuate plume), R.A.D. (Reduce time • Add distance • Don lead), L.A.S.E.R. (Label wavelength • Appropriate goggles • Smoke evacuate • Eye/skin cover • Record exposure).

6) Electrosurgery & Tourniquet Safety ⚡🦵

Topic	Do ✅	Don’t/Watch ⚠️
Return electrode (ground pad)	Place on well-perfused muscle, close to site; avoid bony prominences & scars	Over hair, implants, or compromised skin
Pacers/ICDs	Use bipolar when possible; magnet/rep protocol	Monopolar near generator without plan
Tourniquet	Correct size, padding, limb exsanguination, set pressure/time, document checks	Exceed time limits; ignore pain/paresthesia
Documentation	Start/stop times, pressure, skin condition	Missing relief checks

7) Surgical Smoke/Plume 🌫️

• Contains particulates, toxic gases, possible bioaerosols.

• Action: Use smoke evacuators within 2 in of source, high-filtration masks, change filters per schedule.

  
  

8) Specimens & Implants — Right ID, Right Pathway 🧪🔩

Item	Best practice	Pitfalls
Specimen labeling	Two identifiers, site/side, time, preservative type, requisition completed before leaving room	Verbal shorthand; unlabeled containers
Chain of custody	Hand-to-hand handoff; log time	“Leave on counter”
Implant tracking	Scan UDI/lot/serial, doc model/size/site	Sticker without site/side/date
Recalled items	Know retrieval process	Missing implant card info

Memory aid — L.A.B.E.L.S.: Label now • Accurate site/side • Bag/preservative right • Escorted to path • Log time/receiver • Scan UDI.

9) Counts & RSI Prevention 🧮

Enhanced practices for sponges, sharps, instruments.

Moment	What to do
Initial	Count all items in; baseline documented
Cavity close	Count before closing any cavity; pause if discrepancy
Skin close	Final count; surgeon/LIP verifies field clear
Relief/Shift change	Dual handoff count with both teams
Discrepancy	Stop; search; notify; intra-op imaging per policy; incident report

Memory aid — C.O.U.N.T.S.: Communicate • Open items tracked • Unused accounted • No relief without count • Take imaging if mismatch • Sign off together.

10) Glycemic & Temperature Control 🌡️🧪

Element	Target/Action	Why
Glucose	Often 80–180 mg/dL (unit policy)	↓SSI & delirium risk
Warming	Forced-air warming + warmed fluids	Normothermia lowers blood loss & infection
Checks	Q1–2 h in long cases or insulin infusions	Prevent hypo/hyperglycemia

11) Fluids & Goal-Directed Therapy (GDT) 💧📈

Goal	Tools	Nursing role
Avoid over/under	SVV/PPV, echo, urine output trends	Track I&O, lactate if ordered, escalate if hypotension unresponsive
Balanced crystalloids	Prefer over high-chloride loads unless indicated	Watch acid–base & electrolytes
Vasopressors per order	If fluid-refractory	Document MAP goals & responses

12) PONV Risk & Prophylaxis 🤢

Risk (Apfel)	Points
Female	1
Nonsmoker	1
Hx motion sickness/PONV	1
Post-op opioid use	1

Score 0–1: 0–1 antiemetic • 2: 2 agents different classes • 3–4: 3 agents + non-opioid analgesia.Rescue: use a different class than prophylaxis; avoid repeats too soon.

13) Delirium Prevention & Geriatric Bundle 🧠

Risk	Prevention
Age, dementia, sensory loss, anticholinergics, sleep loss	Reorient, glasses/hearing aids, day–night cues, pain control, avoid deliriogenic meds, mobilize early

Screen: 4AT/CAM per policy. Engage family early.

14) Robotic & Long-Duration Positioning 🤖

• Steep Trendelenburg/lithotomy: eye protection, tongue/lip checks, shoulder braces per policy, reassess q30–60 min for pressure/nerve risk.

• Secure lines; pad carefully; consider periodic micro-reposition if safe.

15) Team Brief–Time-out–Debrief 🗣️📋

• Brief: roles, case plan, antibiotics, fire risk, equipment.

• Time-out: full pause; site/side/implant; imaging displayed.

• Debrief: counts, specimens, equipment issues, learning points, update preference cards.

16) Environmental Sustainability (Green OR) 🌿

Waste segregation, reprocessable devices per policy, minimize volatile agents, energy-saving between cases, smart linen use—safety first, sustainability second.

Quick Checks (Retrieval) 🧠✅

1. List the four T.I.M.E.D. elements for antibiotic prophylaxis.

2. What are the three parts of the OR fire triangle, and your first three actions for an airway fire?

3. Two must-document items for tourniquet use.

4. Apfel score 3—how many prophylactic antiemetic classes? Name two options.

5. Give two steps to prevent RSI when a count is off.

Answer Key (peek):

1. Timing • Indication • Milligrams • EBL/Redose • Duration.

2. Oxidizer/fuel/ignition; stop gases → remove tube → saline to extinguish → re-oxygenate with air, then reassess airway.

3. Pressure & total time (with skin checks).

4. Three classes; e.g., ondansetron + dexamethasone + droperidol/scopolamine.

5. Stop & search; notify; intra-op imaging per policy; document & incident follow-up.

NGN-Style Mini-Item 🧩

Scenario: Electrocautery to the face with open O₂ via nasal cannula and alcohol-based prep used 2 minutes ago. Drapes in place; surgeon asks to “turn up the oxygen.”

Select all immediate priority actions:

• ☐ Increase O₂ to improve saturation

• ☐ Reduce FiO₂ to the lowest effective level and allow prep to dry fully

• ☐ Place moist towels around the field; verify smoke evacuation is on

• ☐ Confirm fire risk score and verbalize mitigation steps before activation

• ☐ Proceed; no change needed if SpO₂ is ≥96%

Correct: ✅ Reduce FiO₂ & ensure prep is dry • ✅ Moist towels + smoke evac • ✅ Confirm fire risk & mitigationWhy: High oxygen + recent alcohol prep + cautery = fire-ready field. Control oxidizer and fuel, then proceed with documented mitigations.

Closing Practice Pearls ✨

• Bundles beat one-offs. Pair antibiotic timing with warming, glucose control, and counts.

• Label & log before leaving. Specimen/implant mistakes are preventable.

• Lower FiO₂ when you can. Fire risk shrinks and hyperoxia harm drops.

• Count like a mantra. Relief counts and cavity checks save lives.

• Debrief to improve. Every case is a chance to tune the next one.