Perioperative nursing

In short

Perioperative nursing is the care of a patient through three phases of surgery — preoperative (decision to operate until transfer to the operating table), intraoperative (on the table until transfer out of theatre) and postoperative (admission to PACU until recovery). The nurse's work spans consent verification, physical and psychological preparation, maintenance of surgical asepsis, patient safety and positioning, and detection of postoperative complications. It is a heavily weighted unit in Medical-Surgical Nursing under the INC B.Sc Nursing curriculum and recurs in NORCET/AIIMS, state nursing officer, RRB and ESIC recruitment papers. Interviews for OT, CSSD and PACU posts in AIIMS, PGIMER, Apollo, Fortis, Manipal and district hospitals test sterile technique, checklist steps and Aldrete scoring.

Explained

Phases, team and classification of surgery

• Perioperative = around surgery; three phases — pre, intra, post operative, each with its own nursing assessment, diagnoses, interventions and evaluation.
• Team roles: surgeon, assistant surgeon, anaesthesiologist, scrub nurse (sterile — handles instruments, maintains the sterile field, does counts), circulating nurse (unsterile — documents, counts with scrub nurse, fetches supplies, positions, manages specimens), OT technician, CSSD staff.
• By purpose: diagnostic (biopsy, laparoscopy), curative/ablative (appendicectomy), restorative/reconstructive (skin graft, joint replacement), palliative (colostomy for obstruction), cosmetic, transplant.
• By urgency: emergent (immediate — ruptured aneurysm), urgent (within 24–48 h — acute appendicitis), required (within weeks — cataract), elective (planned), optional (patient's choice).
• By magnitude: major (high risk, body cavity opened, long duration) vs minor; day-care/ambulatory surgery discharges the same day (cataract, hernia mesh repair, laparoscopic cholecystectomy in fit patients).
• Suffixes: -ectomy (removal), -ostomy (opening), -otomy (incision), -plasty (repair), -orrhaphy (suture), -oscopy (visual examination), -pexy (fixation).

Preoperative phase

• Assessment: history (previous surgery, anaesthetic reactions, bleeding tendency), allergies (latex, iodine, drugs), medications, comorbidities, substance use, pregnancy status, functional and nutritional status, airway and dentition.
• Investigations commonly ordered: Hb/CBC, blood grouping and cross-match, blood sugar, urea/creatinine, electrolytes, LFT, coagulation profile, urinalysis, ECG and chest X-ray (age or disease dependent), HIV/HBsAg as per policy, pulmonary function tests for thoracic surgery.
• Risk factors: age (very young, elderly), obesity, malnutrition and hypoalbuminaemia, diabetes, anaemia, smoking, COPD, cardiac disease, renal/hepatic impairment, immunosuppression, steroid use.
• ASA physical status classification (American Society of Anesthesiologists): I normal healthy; II mild systemic disease; III severe systemic disease; IV severe disease that is a constant threat to life; V moribund, not expected to survive without the operation; VI brain-dead organ donor; suffix E for emergency.
• Informed consent: the surgeon explains procedure, alternatives, risks and benefits; the nurse witnesses the signature, confirms it is voluntary and that the patient understands, and checks it is dated, timed and signed before sedation. Adults ≥18 years consent for themselves; for minors or the unconscious, a parent/guardian or next of kin signs; separate consent is required for anaesthesia, blood transfusion and, in many institutions, for sterilisation and MTP as per the respective Acts. Consent is a requirement of the Clinical Establishments Act framework, NABH standards and medical ethics; its absence makes the procedure legally assault.
• Physical preparation: bath/shower (chlorhexidine where ordered), hair removal by clipper or depilatory immediately before surgery — not by razor the night before (razors cause micro-abrasions and raise surgical site infection risk), bowel preparation if bowel surgery, removal of nail polish, jewellery, dentures, prosthesis, contact lenses and hairpins, hospital gown, identification band, voiding before premedication, antiembolism stockings if ordered.
• Fasting (ASA/consensus guidance, also followed in Indian practice): clear fluids up to 2 h, breast milk 4 h, infant formula/light meal 6 h, fatty or fried meal 8 h before anaesthesia. Local hospital policy prevails; the older "NPO from midnight" is no longer recommended for clear fluids.
• Preoperative teaching (reduces complications and anxiety): deep breathing and incentive spirometry, effective coughing with incision splinting, leg and ankle exercises, early ambulation, turning every 2 h, pain scale and analgesia plan, drains/catheters/tubes to expect, PACU environment.
• Premedication (anaesthetist's order): anxiolytic (midazolam), analgesic (fentanyl), anticholinergic to dry secretions (glycopyrrolate), antiemetic (ondansetron), H2 blocker/PPI and prokinetic to reduce aspiration risk; prophylactic antibiotic within 60 minutes before incision (within 120 min for vancomycin/fluoroquinolones).
• Preoperative checklist is completed before transfer: identity, site and side marked, consent, fasting time, allergies, vitals, investigations and blood availability, removal of prosthesis, premedication given, case sheet and X-rays accompanying the patient.

Intraoperative phase — asepsis, safety and anaesthesia

• OT zones: protective/outer (reception, changing rooms), clean (pre-anaesthesia, recovery), sterile/aseptic (operating room, scrub area), disposal zone. Air flows from sterile to less clean; positive pressure, HEPA-filtered air, controlled temperature (around 20–24 °C) and humidity (about 50–60%) — follow the current NABH/HICC and relevant Indian Standard for HVAC in operating theatres.
• Surgical asepsis principles: only sterile touches sterile; a sterile field is maintained in view at all times; the gown is sterile in front from chest to sterile-field level and on the sleeves; tables are sterile only at table level; a 2.5 cm (1 inch) border of a sterile drape is unsterile; moisture carries contamination (strike-through); reaching over a sterile field, turning one's back to it or any doubt about sterility = contaminated.
• Surgical hand scrub: nails short, no polish or artificial nails, no jewellery; antiseptic (4% chlorhexidine gluconate or povidone-iodine) scrub of hands and forearms to 5 cm above the elbows for the time specified by the manufacturer (commonly 2–5 min for the first scrub); hands held above elbows; dry with sterile towel; alcohol-based surgical rub is an accepted alternative. Then closed-gloving after gowning.
• Sterilisation and disinfection: autoclave (moist heat) 121 °C at 15 psi for 15–20 min or 134 °C at 30 psi for 3–4 min; dry heat (hot air oven) 160 °C for 2 h for glass and oils; ethylene oxide and low-temperature hydrogen peroxide plasma for heat-sensitive items; high-level disinfection (2% glutaraldehyde, ortho-phthalaldehyde) for endoscopes. Monitors: chemical indicators, Bowie-Dick test for pre-vacuum autoclaves, and biological indicator (*Geobacillus stearothermophilus* spores) as the definitive check.
• Spaulding classification: critical items (entering sterile tissue — instruments, implants) require sterilisation; semi-critical (contacting mucosa — endoscopes, laryngoscope blades) high-level disinfection; non-critical (intact skin — BP cuff) low-level disinfection.
• WHO Surgical Safety Checklist (3 steps, adopted by NABH and used widely in Indian hospitals):
  1. Sign In — before induction: identity, site, procedure and consent confirmed; site marked; anaesthesia safety check; pulse oximeter on; known allergy, difficult airway/aspiration risk, risk of >500 mL blood loss (7 mL/kg in children).
  2. Time Out — before skin incision: all team members introduce themselves by name and role; surgeon, anaesthetist and nurse confirm patient, site and procedure aloud; anticipated critical events, antibiotic prophylaxis within 60 min, imaging displayed.
  3. Sign Out — before the patient leaves theatre: nurse reads out the procedure recorded, instrument/sponge/needle counts correct, specimen labelling confirmed, equipment problems noted, key concerns for recovery.
• Counts: sponges, needles, blades and instruments are counted by scrub and circulating nurses — before the procedure, before closure of a cavity, at closure of the wound and at skin closure. An incorrect count requires a search and an X-ray before the patient leaves; a retained item is a sentinel event and a reportable patient-safety incident.
• Anaesthesia types:
  • General — reversible loss of consciousness; stages: I analgesia, II excitement/delirium, III surgical anaesthesia, IV medullary paralysis (overdose). Induction (propofol, thiopentone, ketamine), relaxant (succinylcholine, atracurium, vecuronium), maintenance (sevoflurane, isoflurane, N₂O, O₂), reversal (neostigmine with glycopyrrolate; sugammadex for rocuronium).
  • Regional — spinal (subarachnoid, single shot, below L2/L3), epidural (catheter, continuous), nerve/plexus block (brachial plexus), IV regional (Bier's block).
  • Local — infiltration/topical with lignocaine, bupivacaine; toxicity signs: circumoral tingling, metallic taste, tinnitus, slurred speech, convulsions, arrhythmia, cardiac arrest.
  • Conscious sedation / MAC — for endoscopy, cataract surgery.
• Intraoperative nursing responsibilities: patient identification and safety, correct positioning with padding of bony prominences and nerve protection, electrosurgical unit safety (dispersive pad on clean dry muscular area, check for burns), skin preparation from incision outwards in widening circles, counting, specimen handling and labelling, intake-output and blood-loss measurement, temperature maintenance (warming blanket, warmed fluids), documentation, and handover to PACU.
• Positions: supine (most), Trendelenburg (lower abdomen/pelvis — risk of respiratory compromise), reverse Trendelenburg (upper abdomen, thyroid), lithotomy (perineal, obstetric — raise and lower both legs together; peroneal nerve injury risk), lateral (kidney, thoracic), prone (spine), jackknife/Kraske (rectal), sitting/Fowler's (some neurosurgery, shoulder).
• Intraoperative complications: hypoxia, aspiration, hypotension, haemorrhage, arrhythmia, anaphylaxis, hypothermia, nerve/pressure injury from positioning, fluid and electrolyte imbalance, malignant hyperthermia (inherited, triggered by succinylcholine and volatile agents; rising ETCO₂, masseter spasm, tachycardia, rigidity, hyperthermia — stop the trigger, hyperventilate with 100% O₂, give dantrolene, cool actively, treat acidosis and hyperkalaemia).

Postoperative phase

• Immediate (PACU) care — ABC first: patent airway (lateral or recovery position until the gag reflex returns, suction ready), oxygen, SpO₂, vitals every 15 min until stable then hourly, level of consciousness, wound and drain inspection, pain score, nausea, urine output, warming for hypothermia and shivering.
• Handover from anaesthetist includes: procedure done, anaesthesia and reversal, blood loss, fluids and blood given, drugs due, drains and catheters, complications, allergies.
• Discharge from PACU uses the Modified Aldrete score (0–2 each for activity, respiration, circulation, consciousness, oxygen saturation; ≥9 of 10 usually required); post-anaesthesia discharge scoring (PADSS) for day-care discharge adds vital signs, ambulation, nausea/vomiting, pain and surgical bleeding.
• Fluid, electrolyte and nutrition: IV fluids until oral intake resumes; oral fluids once bowel sounds/flatus return (ERAS protocols allow much earlier oral intake and ambulation); monitor for hyponatraemia from hypotonic fluids and for paralytic ileus.
• Pain management: multimodal — paracetamol, NSAIDs, opioids (tramadol, morphine), epidural infusion, patient-controlled analgesia, local wound infiltration; assess with a numeric or visual analogue scale; opioids require watch for respiratory depression, sedation and constipation. Narcotic analgesics are controlled under the NDPS Act, 1985 (as amended) with institutional custody and recording requirements.
• Postoperative complications by system and timing:
  • Respiratory: atelectasis (commonest cause of fever in the first 48 h), pneumonia, aspiration, pulmonary embolism — prevention: deep breathing, incentive spirometry, early ambulation, adequate analgesia.
  • Cardiovascular: hypotension, shock, haemorrhage (reactionary within 24 h, secondary at 7–10 days from infection), DVT and pulmonary embolism — prevention: early mobilisation, leg exercises, graduated compression stockings, intermittent pneumatic compression, low-molecular-weight heparin as prescribed.
  • Wound: infection (SSI — superficial incisional, deep incisional, organ/space; usually day 3–7), haematoma, dehiscence (partial separation, often day 5–10, "serosanguinous discharge" is an early sign), evisceration (protrusion of viscera — place the patient supine with knees flexed, cover with sterile saline-soaked gauze, nil by mouth, inform the surgeon immediately, prepare for emergency repair).
  • GI and urinary: nausea/vomiting, paralytic ileus, constipation, urinary retention (often first 6–8 h), UTI from catheterisation.
  • Others: hypothermia and shivering, hypoxia, pressure injury, delirium (especially elderly), nerve injury.
• Wound classification (determines infection risk): clean (about 1–3% SSI), clean-contaminated (up to ~10%), contaminated, dirty/infected (highest) — exact rates vary by procedure, surveillance method and institution.
• Drains: closed suction (Romovac/Jackson-Pratt), closed gravity (chest tube with underwater seal), open (corrugated); record amount, colour and consistency each shift; never raise a drain bag above the wound; remove as ordered when output falls.
• Suture removal: face 3–5 days, scalp/neck 5–7, trunk/abdomen 7–10, limbs 10–14, over joints and back 14 days — alternate sutures first if healing is doubtful.
• Discharge teaching: wound and drain care, activity and lifting limits, diet, medicines, suture/staple removal date, follow-up date, danger signs (fever, increasing pain, redness, discharge, bleeding, breathlessness, calf pain).
• Infection control and waste: hand hygiene (WHO 5 moments), standard precautions, PPE; segregate waste under the Bio-Medical Waste Management Rules, 2016 (as amended) — yellow (anatomical, soiled waste, for incineration), red (contaminated recyclable plastics — tubing, catheters, gloves), white translucent puncture-proof (sharps — needles, blades), blue (glass and metallic implants); needles are never recapped.

Key points

• Perioperative nursing — nursing care across pre, intra and postoperative phases of surgery.
• Scrub nurse vs circulating nurse — scrub is sterile and handles instruments; circulating is unsterile, documents, counts and supports from outside the field.
• Informed consent — surgeon explains, patient signs voluntarily before sedation, nurse witnesses; absence makes surgery legally indefensible.
• ASA grading — I to VI physical status before anaesthesia, E suffix for emergency.
• Fasting — clear fluids 2 h, breast milk 4 h, light meal 6 h, fatty meal 8 h; follow hospital policy.
• Hair removal — clippers immediately before surgery; shaving with a razor the night before raises SSI risk.
• Antibiotic prophylaxis — within 60 min before incision (120 min for vancomycin/fluoroquinolones).
• WHO checklist — Sign In (before induction), Time Out (before incision), Sign Out (before leaving theatre).
• Sterile field rules — sterile touches only sterile; 2.5 cm drape border and anything below table level is unsterile; doubt = contaminated.
• Autoclaving — 121 °C/15 psi/15–20 min or 134 °C/30 psi/3–4 min; spore test is the definitive check.
• Spaulding classification — critical sterilise, semi-critical high-level disinfect, non-critical low-level disinfect.
• Counts — sponges, needles, instruments counted at least four times; incorrect count = search plus X-ray before leaving theatre.
• Malignant hyperthermia — rising ETCO₂, rigidity, hyperthermia; stop trigger, 100% O₂, dantrolene, cool.
• Aldrete score — 5 parameters × 0–2; ≥9 for PACU discharge.
• Atelectasis — commonest cause of fever in the first 48 h; prevented by spirometry, coughing and ambulation.
• Dehiscence vs evisceration — separation of wound layers vs protrusion of viscera; cover with sterile saline gauze, supine with knees flexed, call the surgeon.
• DVT prophylaxis — early ambulation, leg exercises, compression stockings, LMWH as prescribed.
• BMW Rules, 2016 — yellow, red, white and blue segregation of operative waste.

Formulas and examples

Example 1 — Aldrete scoring. A 45-year-old man 40 min after laparoscopic cholecystectomy: moves all four limbs on command (activity 2), breathes deeply and coughs freely (respiration 2), BP 132/84 against a preoperative 126/80, i.e. a change under 20% (circulation 2), fully awake (consciousness 2), SpO₂ 92% on room air (saturation 1 — a 2 requires SpO₂ above 92% on room air, while 1 is the level that needs supplemental O₂ to maintain SpO₂ above 90%). Total = 2+2+2+2+1 = 9 → meets the usual ≥9 criterion, but oxygen supplementation and continued pulse oximetry are documented at shift to the ward.

Example 2 — Maintenance fluid by the 4-2-1 rule. Child weighing 26 kg: 4 × 10 = 40, 2 × 10 = 20, 1 × 6 = 6 → 66 mL/h. Over 8 h of postoperative nil-by-mouth = 66 × 8 = 528 mL. Running this with a 60 drops/mL micro set: (66 × 60)/60 = 66 drops/min; with a 20 drops/mL macro set: (66 × 20)/60 = 22 drops/min.

Example 3 — Allowable blood loss. A 60 kg woman for open myomectomy, starting haematocrit 36%, lowest acceptable 27%. EBV = 60 × 70 = 4,200 mL. ABL = 4,200 × (36 − 27)/36 = 4,200 × 0.25 = 1,050 mL. Suction canister holds 600 mL and six fully soaked large sponges are weighed: dry 20 g each, wet 70 g each → blood in sponges = 6 × (70 − 20) = 300 g ≈ 300 mL (1 g ≈ 1 mL). Total loss ≈ 900 mL — below the 1,050 mL limit but above the 500 mL checklist threshold, so cross-matched blood is kept ready and Hb is rechecked.

Example 4 — Antibiotic timing. Incision is scheduled for 09:20. A single dose of cefazolin must go in within 60 min before incision, i.e. not before 08:20 — the nurse gives it at 08:55. If surgery runs beyond two half-lives (for cefazolin about 3–4 h) or blood loss exceeds roughly 1,500 mL, an intraoperative redose is given on the surgeon's order.

Example 5 — Fasting times. An elective hernia repair is listed for 08:00. Working backwards: fatty breakfast must stop by 00:00, a light meal (toast and tea) by 02:00, and clear water is permitted until 06:00. A patient who drank sweet black tea without milk at 06:30 has had clear fluid 90 min before induction — report to the anaesthetist, who may delay the list by 30 min rather than cancel.

Where it is used

• Operation theatre and CSSD nursing: scrub and circulating roles, instrument sets, sterilisation cycle monitoring and records in AIIMS, PGIMER, JIPMER, CMC Vellore, Apollo, Fortis, Max and district hospitals.
• PACU, ICU and surgical wards: Aldrete scoring, handover, early warning scores, pain and drain management; day-care surgery units for cataract, hernia and laparoscopic procedures.
• Quality and infection control: HICC/infection-control nurse roles auditing WHO checklist compliance, SSI surveillance, hand-hygiene audits and NABH accreditation documentation; bio-medical waste records for the State Pollution Control Board.
• Government recruitment and practice: NORCET (AIIMS), ESIC, RRB, state nursing officer and military nursing service exams; practice registration under state nursing councils and the National Nursing and Midwifery Commission Act, 2023 framework replacing the Indian Nursing Council Act, 1947.
• Programme-linked surgery: cataract and sterilisation camps under NPCB and family-welfare programmes, Ayushman Bharat PM-JAY surgical packages, and NHM-funded district surgical services where checklist and asepsis standards apply.
• Education and industry: clinical instructor roles in B.Sc/GNM colleges; product and application roles with surgical instrument, suture, implant and sterilisation-equipment companies.

Interview questions

• Q: What are the three phases of perioperative nursing and when does each begin and end? A: Preoperative, from the decision for surgery until transfer to the operating table; intraoperative, from the table until transfer to PACU; postoperative, from PACU admission until recovery or discharge.
• Q: Who is responsible for obtaining informed consent, and what is the nurse's role? A: The surgeon obtains it by explaining the procedure, risks, benefits and alternatives; the nurse witnesses the signature, confirms voluntariness and understanding, and ensures it is signed before any sedation.
• Q: Why is hair not removed with a razor the night before surgery? A: Razor shaving causes micro-abrasions that let bacteria colonise and multiply overnight, raising surgical site infection risk; clippers or depilatory immediately before surgery are preferred, or no removal at all.
• Q: State the three steps of the WHO Surgical Safety Checklist. A: Sign In before induction, Time Out before skin incision, and Sign Out before the patient leaves theatre.
• Q: When are sponge and instrument counts done and what if a count is incorrect? A: Before the procedure, before cavity closure, at wound closure and at skin closure; an incorrect count means stopping to search the field, drapes and floor, taking an X-ray and informing the surgeon before the patient leaves theatre.
• Q: A patient's wound shows pinkish serosanguinous discharge on day 6 and she says something "gave way" when she coughed. What is happening and what do you do? A: Impending wound dehiscence — place her supine with knees flexed, keep her nil by mouth, avoid coughing or straining, cover any protruding tissue with sterile saline-soaked gauze and inform the surgeon urgently.
• Q: What is the commonest cause of fever in the first 48 hours after abdominal surgery? A: Atelectasis from shallow breathing and retained secretions; it is managed with deep breathing, incentive spirometry, adequate analgesia, early ambulation and chest physiotherapy.
• Q: How do you decide a patient can leave the PACU? A: By a Modified Aldrete score, usually 9 or more out of 10 across activity, respiration, circulation, consciousness and oxygen saturation, with stable vitals, controlled pain, no active bleeding and a protected airway.
• Q: What are the early signs of malignant hyperthermia and the immediate action? A: Rising end-tidal CO₂, masseter spasm, rigidity, tachycardia and hyperthermia; stop the triggering agent, hyperventilate with 100% oxygen, give IV dantrolene, cool actively and treat hyperkalaemia and acidosis.
• Q: Why must a spinal anaesthesia patient be watched for hypotension and urinary retention? A: Sympathetic blockade causes vasodilatation and a fall in blood pressure and heart rate, and sacral block interferes with bladder emptying until the block wears off.
• Q: How is operation theatre waste segregated in India? A: Under the Bio-Medical Waste Management Rules, 2016 — yellow for anatomical and soiled waste, red for contaminated recyclable plastics, white puncture-proof containers for sharps and blue for glass and metallic implants.
• Q: What is the difference between surgical asepsis and medical asepsis? A: Surgical asepsis keeps an area completely free of all micro-organisms and spores (sterile technique in theatre); medical asepsis reduces the number and spread of organisms (hand hygiene, clean technique on the ward).

Common mistakes

• Writing "NPO from midnight" for all patients instead of the graded fasting intervals, and forgetting that clear fluids are allowed up to 2 hours.
• Confusing the scrub nurse's and circulating nurse's duties — saying the scrub nurse documents or fetches supplies, or that the circulating nurse handles instruments.
• Giving prophylactic antibiotics after incision, or hours earlier, instead of within 60 minutes before.
• Mixing up dehiscence and evisceration, or recommending that protruding viscera be pushed back in rather than covered with sterile moist gauze.
• Listing infection as the cause of first-day postoperative fever when atelectasis is the usual cause, and ignoring the day-wise fever pattern.
• Scoring the Aldrete parameters loosely — giving 2 for oxygen saturation when the patient needs supplemental oxygen, or omitting a parameter and still reporting a score out of 10.
• Breaking sterile technique in the exam viva: reaching across the sterile field, holding hands below elbow level after scrubbing, or calling the lower 2.5 cm border of a drape sterile.

Related topics

Wound care and pressure injuries · Critical care nursing · Infection control and biomedical waste management · Anaesthesia and pain management · Fluid, electrolyte and blood transfusion therapy · Nursing management of the patient undergoing laparotomy