Care of Surgical Patient: Pre-operative and Post-operative Nursing

Care of Surgical Patient

Pre-operative & Post-operative Nursing Care

Pre-operative Care

1. Introduction
2. Pre-operative Assessment
3. Physical Preparation
4. Psychological Preparation
5. Consent & Documentation
6. Immediate Pre-operative Care

Introduction

Surgical patient care encompasses a comprehensive continuum of nursing interventions designed to optimize patient outcomes throughout the perioperative period. This continuum is divided into three distinct phases: pre-operative (before surgery), intra-operative (during surgery), and post-operative (after surgery). As nurses, our primary responsibility focuses on the pre-operative and post-operative phases, where we serve as patient advocates, educators, and care coordinators.

Key Learning Objectives

Demonstrate comprehensive pre-operative patient assessment and preparation
Implement evidence-based post-operative monitoring and intervention strategies
Identify and manage potential surgical complications
Apply therapeutic communication and patient education principles

PRE-OPERATIVE CARE

Pre-operative Assessment

Mnemonic: AMPLE History

Allergies – Drug, food, latex, environmental
Medications – Current prescriptions, OTC, herbal
Past medical history – Previous surgeries, hospitalizations

Last oral intake – NPO status verification
Events – Recent illness, trauma, stressors

Cardiovascular Assessment

• Baseline vital signs and orthostatic measurements
• Heart rhythm and murmurs assessment
• Peripheral pulse evaluation
• Capillary refill and skin color
• History of cardiac conditions, hypertension

Respiratory Assessment

• Respiratory rate, depth, and pattern
• Oxygen saturation levels
• Breath sounds and chest expansion
• History of respiratory conditions
• Smoking history and cessation status

High-Risk Factors Requiring Special Attention

• Age extremes (<2, >70 years)
• Obesity (BMI >30)
• Diabetes mellitus

• Renal insufficiency
• Liver disease
• Immunocompromised status

• Coagulation disorders
• Sleep apnea
• Substance abuse history

Physical Preparation

Pre-operative Preparation Timeline

24 Hours Before

NPO instructions, skin prep

2 Hours Before

Final preparations, medications

Immediate

Final checks, transport

NPO (Nothing Per Oral) Guidelines

Substance	NPO Duration
Clear liquids	2 hours
Breast milk	4 hours
Light meal	6 hours
Regular meal	8 hours

Skin Preparation Protocol

• Chlorhexidine gluconate shower night before and morning of surgery
• Hair removal only if necessary (clipping preferred over shaving)
• Remove all jewelry, piercings, and nail polish
• Oral care with antimicrobial mouthwash
• Bowel preparation if indicated by surgical site

Psychological Preparation

Mnemonic: FEARS Assessment

Fear of the unknown or death
Expectations about recovery
Anxiety about pain management

Role changes and body image concerns
Support system availability

Therapeutic Communication Strategies

Active Listening Techniques

• Maintain eye contact and open posture
• Use reflection and clarification
• Avoid interrupting or rushing responses
• Validate emotions and concerns

Patient Education Topics

• Surgical procedure explanation
• Expected timeline and recovery process
• Pain management options
• Post-operative activity restrictions

Immediate Pre-operative Care

Mnemonic: SAFETY First Checklist

Site marking and verification
Allergies double-checked and marked
Fasting status confirmed
Equipment and IV access secured

Time-out procedure completed
Yes to patient identification

Final Pre-operative Tasks (30 Minutes Before Surgery)

• Administer pre-operative medications
• Complete final vital signs
• Verify surgical site marking

• Ensure removal of all jewelry/prosthetics
• Complete pre-operative checklist
• Insert urinary catheter if ordered

• Apply sequential compression devices
• Transport patient to operating room
• Hand off report to OR team

POST-OPERATIVE CARE

Post-Anesthesia Care Unit (PACU) Management

Mnemonic: PACU Priority Assessment – ABCDE

Airway patency and protection
Breathing effectiveness and oxygenation
Circulation and hemodynamic stability

Disability and neurological function
Exposure and temperature regulation

Initial PACU Assessment (First 15 Minutes)

• Vital signs every 5 minutes initially
• Oxygen saturation continuous monitoring
• Level of consciousness using Aldrete Score
• Pain assessment using appropriate scale
• Surgical site and dressing assessment
• Drain output measurement and patency

Aldrete Scoring System

Activity (2 points max):

• 2: Moves all extremities voluntarily
• 1: Moves 2 extremities voluntarily
• 0: Unable to move extremities

Respiration (2 points max):

• 2: Breathes deeply, coughs freely
• 1: Dyspnea or limited breathing
• 0: Apneic

Score ≥9/10 required for discharge

Airway Management & Respiratory Care

Respiratory Assessment Flow

O2 Sat

Check SpO2

Target >95%

Listen

Breath Sounds

Bilateral equality

Rate

RR & Pattern

12-20/min

ABG

If Indicated

pH, CO2, O2

Respiratory Complications

Airway Obstruction: Stridor, accessory muscle use
Hypoventilation: Shallow breathing, CO2 retention
Aspiration: Wet cough, crackles, fever
Pneumothorax: Sudden chest pain, unequal breath sounds
Pulmonary Embolism: Sudden dyspnea, chest pain, tachycardia

Respiratory Interventions

• Position for optimal ventilation (semi-Fowler’s)
• Encourage deep breathing and coughing
• Incentive spirometry education and use
• Early ambulation to prevent atelectasis
• Oxygen therapy as prescribed
• Chest physiotherapy if indicated

Circulation & Hemodynamic Monitoring

Mnemonic: PULSE Check for Circulation

Pulse rate, rhythm, and quality
Urinary output monitoring
Level of consciousness changes

Skin color, temperature, moisture
Edema and capillary refill

Vital Signs Monitoring

Frequency:
• Q15min x 4 (first hour)
• Q30min x 2 (second hour)
• Q1h x 4 (next 4 hours)
• Q4h thereafter (stable)

Fluid Balance

• Strict I&O measurement
• Daily weights
• IV fluid rate monitoring
• Drain output assessment
• Signs of fluid overload/deficit

Laboratory Monitoring

• Hemoglobin/Hematocrit
• Electrolyte panel
• Coagulation studies
• Arterial blood gases
• Glucose levels

Early Warning Signs of Shock

Hypovolemic Shock Signs:

• Tachycardia (early sign)
• Hypotension (late sign)
• Decreased urine output (<0.5 mL/kg/hr)
• Cool, clammy skin
• Altered mental status

Immediate Interventions:

• Position supine with legs elevated
• Establish large-bore IV access
• Administer fluid bolus as ordered
• Notify physician immediately
• Prepare for blood transfusion

Post-operative Pain Management

Mnemonic: PQRST Pain Assessment

Provocation/Palliation – What makes it better/worse?
Quality – Sharp, dull, burning, aching?
Region/Radiation – Where is it? Does it spread?

Severity – Rate 0-10 pain scale
Timing – When did it start? Constant/intermittent?

Pharmacological Pain Management

Multimodal Approach:

• Opioids (morphine, fentanyl, oxycodone)
• NSAIDs (ibuprofen, ketorolac)
• Acetaminophen (around-the-clock dosing)
• Regional blocks (nerve blocks, epidural)
• Adjuvants (gabapentin, clonidine)

Non-pharmacological Interventions

• Ice/heat therapy application
• Positioning and support devices
• Deep breathing and relaxation techniques
• Distraction therapy (music, imagery)
• Massage and gentle mobilization
• TENS units for chronic pain

Opioid Side Effects Monitoring

Respiratory:

• Respiratory depression (<8/min)
• Decreased oxygen saturation
• Shallow breathing pattern

Neurological:

• Sedation level assessment
• Confusion or delirium
• Dizziness and falls risk

Gastrointestinal:

• Constipation prevention
• Nausea and vomiting
• Decreased appetite

Surgical Wound Care & Assessment

Mnemonic: WOUND Assessment

Warmth and skin temperature
Odor from drainage or wound
Unusual drainage color/amount

New pain or tenderness
Dehiscence or separation of edges

Normal Wound Healing Phases

Inflammatory Phase (0-4 days):

Vasoconstriction, clot formation, mild swelling and redness

Proliferative Phase (4-21 days):

Tissue rebuilding, granulation tissue formation

Maturation Phase (21 days-2 years):

Scar tissue remodeling and strengthening

Signs of Wound Complications

Infection: Purulent drainage, erythema >2cm from incision
Dehiscence: Partial/complete separation of wound edges
Evisceration: Protrusion of organs through wound
Hematoma: Collection of blood under skin
Seroma: Collection of clear fluid

Dressing Change Protocol

Hand Hygiene

Wash hands, don gloves

Remove Old

Gentle removal, assess

Clean Wound

Normal saline, pat dry

Apply New

Sterile technique

Post-operative Complications Management

Pulmonary Complications

Atelectasis:

• Decreased breath sounds, fever
• Incentive spirometry, early mobilization

Pneumonia:

• Productive cough, crackles, fever
• Antibiotics, respiratory therapy

Cardiovascular Complications

Deep Vein Thrombosis:

• Calf pain, swelling, warmth
• Anticoagulation, compression stockings

Pulmonary Embolism:

• Sudden dyspnea, chest pain, tachycardia
• Emergency anticoagulation, oxygen

Mnemonic: COMPLICATIONS Prevention

Cough and deep breathe every 2 hours
Out of bed early and often
Move legs frequently when in bed
Pain control to enable mobility
Liquids and nutrition optimization
Infection prevention measures

Compression devices for DVT prevention
Antiemetics for nausea control
Temperature monitoring
IV site care and monitoring
Oxygen therapy as needed
Neurological assessments
Surgical site protection

NURSING IMPLEMENTATION IN PRACTICE

Evidence-Based Practice Integration

Implement Enhanced Recovery After Surgery (ERAS) protocols for improved patient outcomes and reduced length of stay
Use validated assessment tools (Braden Scale, Morse Fall Scale) for comprehensive risk assessment
Apply bundled care approaches for infection prevention and VTE prophylaxis
Utilize technology-assisted monitoring systems for early detection of clinical deterioration

Interprofessional Collaboration

Coordinate with surgical team for optimal timing of interventions and discharge planning
Collaborate with pharmacy for medication reconciliation and pain management optimization
Work with physical/occupational therapy for early mobilization and functional recovery
Engage social work and case management for discharge planning and resource coordination

24-Hour Post-operative Care Timeline

0-2h

Immediate Recovery

• Frequent vital signs
• Airway assessment
• Pain management
• Surgical site check

2-8h

Stabilization

• Progressive monitoring
• Begin oral intake
• Early mobilization
• Catheter management

8-16h

Active Recovery

• Ambulation progression
• Diet advancement
• Bowel function return
• Patient education

16-24h

Preparation

• Discharge planning
• Home care teaching
• Follow-up scheduling
• Final assessments

Patient and Family Education Priorities

Pre-operative Education:

• Surgical procedure explanation in lay terms
• Pre-operative preparation requirements
• Expected post-operative course and timeline
• Pain management options and expectations
• When to seek immediate medical attention
• Role of family members in care process

Discharge Education:

• Wound care techniques and supplies needed
• Activity restrictions and progression guidelines
• Medication management and side effects
• Signs and symptoms requiring immediate care
• Follow-up appointment scheduling and importance
• Community resources and support services

Quality Improvement and Safety Measures

Safety Initiatives:

• Surgical site infection reduction bundles
• Falls prevention programs
• Medication error reduction strategies
• Pressure injury prevention protocols

Quality Metrics:

• Length of stay optimization
• Patient satisfaction scores
• Readmission rate monitoring
• Complication rate tracking

Documentation Standards:

• Accurate and timely charting
• Complete assessment documentation
• Incident reporting and follow-up
• Handoff communication protocols

Key Takeaways for Nursing Practice

Holistic patient care requires attention to physical, psychological, and social needs throughout the surgical continuum
Early identification and intervention for complications significantly improves patient outcomes
Patient and family education is essential for successful recovery and adherence to treatment plans

Interprofessional collaboration enhances care coordination and patient safety
Evidence-based practice guidelines should inform all nursing interventions and decisions
Continuous monitoring and assessment are fundamental to detecting changes in patient condition