09 Perioperative and Wound Care

Perioperative safety and preoperative checks

Perioperative nursing care spans the preoperative, intraoperative, and postoperative periods. Across all three, priorities are patient identification, prevention of harm, timely recognition of complications, and clear communication. Follow the patient’s orders, facility procedures, and the scope of practice set by applicable law; promptly report unexpected findings to the supervising nurse or provider.

Before surgery, establish a baseline and confirm that required preparations are complete. Review the patient’s health history, allergies and reactions, current medications, relevant test results, and prescribed preoperative instructions. Report important risks, including anticoagulant use, diabetes, sleep apnea, prior anesthesia reactions, or a change in health status. Verify the ordered fasting instructions rather than assuming they are the same for every patient.

Identity, consent, and the preoperative checklist

Confirm identity using the required identifiers and check that the planned procedure and site agree with the consent and records. The provider performing the procedure is responsible for explaining the procedure and obtaining informed consent. The nurse may witness the signature according to policy, but should not explain risks beyond their role or treat a signed form as proof of understanding. If the patient has unanswered questions, appears unsure, or has received sedating medication before consent is complete, pause and notify the appropriate clinician.

Use the preoperative checklist and speak up about mismatches or missing information. Checklist topics include allergies, patient and procedure identification, site marking, anesthesia and airway risks, equipment, and prevention of venous thromboembolism (VTE). A team time-out immediately before incision rechecks the patient, procedure, and site; voice concerns before proceeding.

Intraoperative safety and recovery assessment

In the operating room, safety depends on coordinated teamwork, sterile practice, correct positioning, accurate counts, and clear labeling of medications and specimens. The surgical team conducts a final count and discusses recovery concerns before the patient leaves the room.

On arrival in the recovery area, assess airway, breathing, and circulation first. Then assess level of consciousness, vital signs, oxygenation, pain, temperature, incision or dressing, drains, IV fluids, and urine output as indicated. Compare findings with baseline and the expected response to the procedure and anesthesia. An obstructed airway, difficult breathing, rapidly changing vital signs, heavy bleeding, or reduced responsiveness requires immediate action and escalation according to emergency procedures.

Postoperative monitoring and prevention

Postoperative care includes respiratory support, prevention of VTE, monitoring of gastrointestinal and urinary function, and attention to safety and comfort.

• Respiratory support: Position as appropriate; encourage prescribed deep breathing, coughing, and incentive-spirometer use. Splint an abdominal incision with a pillow when coughing. Mobilize as ordered.

• VTE prevention: Encourage prescribed mobility and use ordered compression devices or medications. Report new unilateral leg swelling or pain. Sudden shortness of breath, chest pain, faintness, or coughing blood may signal pulmonary embolism and requires emergency response.

• GI and urinary monitoring: Track intake and output as ordered. Assess for nausea, vomiting, abdominal distention, bowel function, and ability to void. Report concerning changes rather than assuming they are routine effects of anesthesia.

• Safety and comfort: Reorient as needed, assist with transfers until safe, and reassess after interventions or changes in condition.

Wound healing, assessment, and dressing care

Wounds may heal by primary intention, in which edges are brought together; secondary intention, in which a wound fills in from its base; or tertiary intention, in which closure is delayed. Healing is affected by factors such as infection, circulation, nutrition, diabetes, and smoking.

Assess wounds systematically and compare findings with prior assessments. Record location and size, including length, width, and depth when appropriate; wound-bed and surrounding-skin appearance; edge approximation; drainage amount and character; odor; swelling; and pain. Note drains and their output.

Follow the ordered dressing plan and local procedure for clean or sterile technique. Do not remove or change a dressing earlier than instructed unless assessment or an urgent concern requires it. For a dressing change, prepare supplies and a clean work area, perform hand hygiene, and use the prescribed technique and protective equipment. Remove the old dressing gently; if it adheres, follow the order or wound-care instructions rather than pulling forcefully. Clean or irrigate only as directed, and apply the ordered dressing. Do not add ointments, antiseptics, or other products unless prescribed or specifically instructed. Document wound findings, care, drainage, pain, and the patient’s response.

Recognizing wound complications and emergencies

Report increasing redness, warmth, swelling, pain, wound separation, new or increasing bleeding, or thick, discolored, or foul-smelling drainage. Fever may also be a warning sign; use the patient’s instructions and facility escalation criteria.

Dehiscence is separation of a wound’s edges. Evisceration is protrusion of internal tissue or organs through an opened abdominal incision and is an emergency. Stay with the patient, call for immediate help, reduce strain on the incision—for example, position with knees slightly flexed if appropriate—and cover exposed tissue with sterile gauze moistened with sterile saline. Keep the patient from eating or drinking, do not push tissue back into the wound, and prepare for urgent treatment.

Suspect hemorrhage with rapidly increasing drainage or a saturated dressing, active bleeding, pallor, cool clammy skin, weakness, confusion, or falling blood pressure with a rising pulse. Stay with the patient, summon urgent assistance, and follow emergency orders and facility procedure. Do not delay escalation to complete routine wound care.

Pain control and medication safety

Pain is subjective. Ask the patient to describe its location, quality, severity, timing, and effect on movement, breathing, sleep, or other goals. Use an age- and communication-appropriate scale and reassess after treatment. A useful goal is pain controlled enough for the patient’s desired function—not necessarily zero pain.

Use prescribed multimodal care when appropriate. Nonopioid medicines, opioids, regional techniques, positioning, splinting, relaxation, and other comfort measures may be combined. Check allergies, relevant conditions, medication timing, and orders. Before and after opioid administration, assess sedation and respiratory status as well as pain. If the patient is unusually drowsy, difficult to arouse, or breathing inadequately, do not give another opioid dose; get help and follow emergency and naloxone protocols. Reassess relief and adverse effects within the time appropriate to the route and facility procedure.

For patient-controlled analgesia (PCA), teach that only the patient should press the button unless the care plan and policy specifically authorize otherwise. A family member pressing it for a sleeping or sedated patient can increase the risk of oversedation and respiratory depression.

Responding to changing clinical findings

If a postoperative patient’s dressing becomes increasingly saturated, the pulse rises, and the patient looks pale and dizzy, treat this as possible bleeding—not simply a dressing-change task. Stay with the patient, assess airway, breathing, circulation, and vital signs, call for urgent assistance, and follow emergency directions. Report objective changes and the trend, then document actions and the response. Prioritize immediate threats to life before routine comfort or teaching needs.