01
Preoperative Care
Everything that happens before the patient goes to surgery.
Pre-Op Checklist
- Informed consent — signed by the patient BEFORE sedation. The surgeon explains risks, benefits, and alternatives. The nurse witnesses the signature and verifies understanding.
- NPO status — typically NPO after midnight (or 6–8 hours before surgery) to prevent aspiration
- Allergies — verify and apply allergy band. Document in chart.
- Labs and diagnostics — review CBC, BMP, PT/INR, type and screen, pregnancy test (women of childbearing age), chest X-ray, EKG
- Medications: Anticoagulants (hold warfarin 3–5 days, hold aspirin 7 days per surgeon). Metformin (hold day of surgery). Insulin (may give half dose). Herbal supplements (stop 2 weeks prior — some affect bleeding/anesthesia).
- Remove: jewelry, dentures, contacts, hearing aids, nail polish (need to see capillary refill), hairpins
- ID band check — verify name, DOB, MRN
- Surgical site marking — "time out" verification before incision
- Void before surgery — empty bladder
- Pre-op teaching: deep breathing, IS, leg exercises, splinting incision, pain scale
Exam Tip
If a question asks "the patient is anxious and wants to know about the risks of surgery" → that's the SURGEON'S responsibility to explain. The nurse's role is to clarify, answer questions, witness consent, and verify understanding.
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02
Intraoperative Care
The LPN's role is limited intra-op, but know these key concepts.
Types of Anesthesia
- General
- Complete loss of consciousness and sensation. Patient is intubated. Highest risk. Watch for malignant hyperthermia (rare but fatal — temp >104°F, muscle rigidity, tachycardia → give dantrolene).
- Regional
- Blocks sensation to a specific area (spinal, epidural, nerve block). Patient is awake. Spinal: monitor for spinal headache (keep flat after).
- Local
- Numbs a small area (lidocaine). Patient is awake. Lowest risk.
- Conscious sedation
- Patient is sedated but can respond. Monitor respiratory status closely. Have reversal agents ready (flumazenil for benzos, naloxone for opioids).
Surgical Time Out
Performed immediately before the first incision. The entire team verifies: correct patient, correct procedure, correct site, correct position, and that all relevant imaging/labs are available. This is a patient safety requirement.
Malignant Hyperthermia
A rare, life-threatening reaction to general anesthesia (especially halothane, succinylcholine). Signs: rapidly rising temperature (>104°F), muscle rigidity, tachycardia, dark urine (rhabdomyolysis). Treatment: STOP anesthesia, administer dantrolene IV, cooling measures, hydrate aggressively. This is a medical emergency.
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Postoperative Care
ABCs first — always.
PACU (Post-Anesthesia Care Unit) Priorities
1
Airway — #1 priority. Position on side (recovery position) or with head tilted to prevent aspiration. Suction PRN. Assess for stridor, snoring (tongue obstruction).
2
Breathing — monitor SpO₂, respiratory rate, depth. Administer O₂ as ordered. Assess breath sounds.
3
Circulation — vital signs q15 min, check surgical site for bleeding, monitor I&O, assess LOC.
Ongoing Post-Op Care
- Pain management — assess pain regularly, medicate before pain becomes severe, splint incision for coughing
- Deep breathing and coughing — IS every 1–2 hours while awake (prevents atelectasis and pneumonia)
- Early ambulation — prevents DVT, pneumonia, paralytic ileus, and pressure injuries. Usually within 24 hours.
- I&O monitoring — urine output ≥30 mL/hr (≥0.5 mL/kg/hr). Report if less.
- Surgical site assessment — check dressing for drainage (color, amount). Reinforce (do NOT remove original dressing — that's the surgeon's job for the first dressing change).
- Diet advancement — NPO → clear liquids → full liquids → soft → regular (only after bowel sounds return and patient passes flatus)
Exam Tip
If asked "what is the priority assessment for a patient arriving to the PACU?" → Airway. Always airway first. If asked about a patient who hasn't voided 6–8 hours post-op → assess for urinary retention (may need straight catheterization).
04
Post-Op Complications (By Timeframe)
Know when each complication typically occurs.
- Immediate (0–24 hrs)Hemorrhage
- ↑HR, ↓BP, restlessness, ↑ drainage, pallor. Check under patient (blood pools).
- ImmediateAirway obstruction
- Stridor, snoring, ↓SpO₂, restlessness. Jaw thrust, suction, reposition.
- 24–48 hrsAtelectasis
- Most common post-op complication causing fever. ↓Breath sounds, crackles. IS, deep breathing.
- 24–72 hrsParalytic ileus
- Absent bowel sounds, distension, N/V, no flatus. NPO, NG tube decompression.
- 3–5 daysWound infection
- Fever, redness, warmth, purulent drainage, ↑WBC. Culture wound, antibiotics.
- 7–10 daysDehiscence/Evisceration
- Wound opens, organs may protrude. Cover with sterile saline gauze, NPO, call surgeon.
- AnytimeDVT/PE
- Unilateral leg swelling (DVT). Sudden dyspnea, chest pain (PE). SCDs, anticoagulants, early ambulation.
Post-Op Fever Timeline
Atelectasis is the #1 cause of fever in the first 24–48 hours post-op (NOT infection). Intervention: incentive spirometry, deep breathing, early ambulation. Wound infection fever typically occurs around day 3–5.
? A patient 36 hours post-op develops a fever of 38.8°C and has decreased breath sounds at the bases. What is the most likely cause?
Atelectasis — the most common cause of post-op fever in the first 24–48 hours. The collapsed alveoli create decreased breath sounds and crackles. The intervention is incentive spirometry, deep breathing exercises, and early ambulation — not antibiotics, which would be for a wound infection that typically develops at day 3–5.
05
Wound Healing
Three types of wound closure and the phases of healing.
Types of Wound Closure
- Primary intention: Clean edges brought together (surgical incision, sutured wound). Least scarring, fastest healing.
- Secondary intention: Wound left open to heal from the inside out (pressure injury, abscess). More scarring, longer healing. Requires packing.
- Tertiary intention (delayed primary): Wound left open initially (to clear infection), then closed later with sutures.
Phases of Wound Healing
1
Hemostasis (immediate) — blood clotting, scab formation
2
Inflammatory (1–4 days) — redness, swelling, warmth, pain. WBCs clean debris. This is NORMAL.
3
Proliferative (4–21 days) — granulation tissue forms (red, beefy, moist = healthy), collagen is laid down, wound contracts
4
Remodeling/Maturation (21 days to 2 years) — scar tissue strengthens but never reaches full original strength (~80%)
Factors That Impair Healing
- Poor nutrition (protein and vitamin C are essential for healing)
- Diabetes (impaired circulation and immune response)
- Obesity, smoking, advanced age
- Infection, immunosuppression, corticosteroid use
- Poor blood supply to the area
06
Pressure Injuries (Pressure Ulcers)
Know the staging system and the Braden Scale — both are heavily tested.
- Stage 1
- Intact skin with non-blanchable redness. Skin is not broken.
- Stage 2
- Partial-thickness skin loss with exposed dermis. May look like a blister or shallow open wound.
- Stage 3
- Full-thickness skin loss. Fat may be visible. Bone, tendon, and muscle are NOT visible.
- Stage 4
- Full-thickness loss with exposed bone, tendon, or muscle. High risk for osteomyelitis.
- Unstageable
- Wound bed covered by slough (yellow) or eschar (black). Cannot determine depth until removed.
- Deep Tissue Injury (DTI)
- Intact skin with deep purple or maroon discoloration. Indicates damage to underlying tissue.
Braden Scale
Assesses risk for pressure injury. Score range: 6–23. Lower score = higher risk. Score ≤18 = at risk. Evaluates: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Prevention Interventions
- Reposition every 2 hours — use a turning schedule
- Use pressure-redistributing surfaces (specialty mattress)
- Keep skin clean and dry (manage incontinence)
- Adequate nutrition (protein, calories, vitamin C, zinc)
- Avoid friction and shear (lift, don't drag patients)
- Assess skin at least every shift, especially bony prominences (sacrum, heels, elbows, occiput, scapulae)
- Do NOT massage reddened areas (causes further tissue damage)
Do NOT Massage Reddened Skin
Massaging over bony prominences or reddened areas was once thought to improve circulation, but it actually causes further tissue damage. If a question asks about care for a reddened sacrum → reposition, offload pressure, do NOT massage.
07
Drains & Dressings
Know the common drains and when to notify the provider.
Common Surgical Drains
- Jackson-Pratt (JP)
- Bulb-shaped, closed suction. Compress bulb to create suction. Empty when half full. Record output. Drainage should decrease over time.
- Hemovac
- Larger closed suction drain. Compress to create suction. Similar care to JP.
- Penrose
- Open drain — drainage collects on dressings (not a suction drain). Expect drainage on dressings. Safety pin prevents retraction into wound.
- T-tube
- Placed after gallbladder surgery (cholecystectomy). Drains bile. Keep bag below insertion site. Expect 500 mL bile in first 24 hrs. Clamp before meals per order (to aid digestion).
Wound Drainage Types
- Serous — clear, watery, straw-colored. Normal.
- Sanguineous — bright red, bloody. Expected immediately post-op, but report if excessive.
- Serosanguineous — pink-tinged. Mix of serous and blood. Normal during healing.
- Purulent — thick, yellow/green, foul-smelling. Indicates INFECTION — notify provider.
08
Dehiscence & Evisceration
One is bad. The other is a surgical emergency.
- Dehiscenceserious
- Wound edges separate (partial or complete). Typically 7–10 days post-op. Risk factors: obesity, coughing/straining, poor nutrition, infection, diabetes, steroids.
- Eviscerationsurgical emergency
- Internal organs protrude through the open wound. Same timing — often follows dehiscence. Same risk factors. Requires emergency return to surgery.
Nursing Actions for Evisceration
1
Do NOT push organs back in
2
Cover with sterile saline-soaked gauze (keep moist)
3
Position supine with knees flexed (reduces abdominal tension)
4
NPO
5
Notify the surgeon IMMEDIATELY
6
Monitor vital signs (risk for shock)
7
Prepare for emergency return to surgery
Evisceration = Cover, Don't Push
If a question describes organs protruding from a surgical wound → NEVER reinsert them. Cover with sterile saline-soaked gauze, position with knees bent, NPO, call the surgeon. This is one of the most commonly tested perioperative questions.
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Frequently Asked Questions
Common student questions on this topic.
What are the phases of wound healing?
Wound healing has three (sometimes four) phases. Hemostasis (immediate): clotting and platelet plug. Inflammatory (1–4 days): redness, warmth, swelling, neutrophil cleanup. Proliferative (4–21 days): granulation tissue, collagen formation, epithelialization. Remodeling/maturation (21 days to 2 years): collagen reorganization, scar maturation. Each phase can be impaired by infection, poor nutrition, diabetes, smoking, or steroids.
What is the difference between dehiscence and evisceration?
Dehiscence is the separation of wound edges or surgical layers — sometimes the patient describes feeling something "pop." Evisceration is the protrusion of internal organs through the open wound — a medical emergency. For evisceration: place the patient supine with knees flexed, cover the wound with sterile saline-soaked gauze, NPO, notify the provider STAT, and prepare for surgical repair.
What are signs of a wound infection?
Watch for the classic signs of inflammation that persist or worsen after the first 3–5 days: increased redness, warmth, swelling, pain, purulent drainage, foul odor, fever, and delayed healing. Mild inflammation in the first 1–2 days is normal. New or increasing pain after pain had been improving is a key warning sign. Notify the provider for wound culture and likely antibiotic therapy.
What is the purpose of incentive spirometry post-op?
Incentive spirometry helps prevent atelectasis and pneumonia by encouraging deep breathing and full lung expansion. Have the patient sit upright, inhale slowly and deeply through the mouthpiece to raise the ball/piston, hold for 3–5 seconds, then exhale. Recommend 10 breaths per hour while awake for the first few days post-op. Combine with coughing, splinting, and early ambulation.
What are the priority assessments in the post-anesthesia care unit (PACU)?
Priorities follow ABCs. Assess in this order: Airway and breathing (patency, rate, SpO₂), Circulation (BP, HR, perfusion, bleeding), Level of consciousness, Pain, Surgical site (dressing, drainage, drains), Temperature, and Output (urinary, NG). Vital signs are checked every 15 minutes initially, then less frequently as the patient stabilizes.
How do I describe wound drainage correctly?
Use the standard terms: Serous = clear, watery (normal early healing). Sanguineous = bloody. Serosanguineous = pink/light red, mix of serous and bloody (most common). Purulent = thick, yellow/green/brown — indicates infection. Also document amount (scant, small, moderate, large), odor, and how much saturates the dressing. Precise documentation supports continuity of care and legal protection.
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Perioperative & Wound Care Cheatsheet
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