Perioperative Care

In depth

The one-page summary above is what the PDF prints. These sections go further.

Consent and verification: who does what

Informed consent is a conversation, not a form. The provider obtaining consent explains the procedure and checks that the client understands, and the client signs after that talk and before any mind-altering medication; the client signs first, then the provider, then the witness, who attests to the client's identity and signature (AORN 2024). The nurse confirms that a valid, signed form is present and, if the client does not seem to understand, asks the provider to return and clarify rather than explaining the surgery in the provider's place (Open RN). Federal hospital rules require a properly executed consent form in the chart before surgery, except in emergencies, and a history and physical done no more than 30 days before or 24 hours after admission (42 CFR 482.51).

Capacity is a functional judgment about one decision; competence is a legal finding made by a court. Nurses cannot formally assess capacity but can start an evaluation and share what they see: inability to voice a choice, blanket acceptance or refusal, agitation, labile mood, hallucinations or intoxication (Open RN). A client who is drowsy from premedication is the classic exam case: hold the signature and call the provider.

The Joint Commission's procedure-safety goals (NPG.01.06.01 to .03, January 2026) keep the three Universal Protocol steps. Pre-procedure verification uses a standard list: history and physical, signed consent, nursing assessment, pre-anesthesia assessment, labeled and displayed results and images, and any blood products, implants, devices or special equipment. The site is marked when more than one location is possible, by the licensed practitioner accountable for the procedure who will be present (in limited cases a supervised resident, APRN or PA), with a mark that survives skin prep and draping; adhesive markers cannot be the only mark. The time-out happens immediately before the incision or start, is begun by a designated team member, includes everyone participating from the start, confirms at least the client, site and procedure, is repeated before each procedure when the person performing changes, and is documented.

Fasting and medications: the reasons

Fasting limits stomach contents at induction, when airway reflexes are lost and aspiration can occur. The ASA times apply to healthy clients of all ages having elective procedures with general or regional anesthesia or procedural sedation; they may not apply to pregnancy, obesity, diabetes, hiatal hernia, reflux, ileus or bowel obstruction, emergency surgery or enteral tube feeding, and they do not cover local anesthesia alone (ASA 2017).

Anticoagulants: in the BRIDGE trial (atrial fibrillation, warfarin stopped 5 days before), skipping LMWH bridging was as safe for arterial clots (0.4% vs 0.3%) and caused less major bleeding (1.3% vs 3.2%). In PAUSE, apixaban, rivaroxaban or dabigatran was omitted 1 day before a low-bleed procedure and 2 days before a high-bleed one, restarted 1 day or 2–3 days after, with no bridging or clotting tests; 30-day major bleeding was about 1–2% in each drug group overall and about 3% after high-bleed procedures. The nurse's job is to confirm the date of the last dose and report a drug that was not stopped.

Diabetes (ADA 2026): keep glucose 100–180 mg/dL before, during and after surgery and check at least every 2–4 hours while NPO; insulin is the only recommended glucose-lowering drug in this period. Hold metformin and other oral agents on the day of surgery. Cutting the evening basal dose by about 25% (long-acting analog to 75–80%, NPH to half) reaches goal with less hypoglycemia, though the cut may not suit some clients with type 1 diabetes. Hold SGLT2 inhibitors 3–4 days before elective surgery (FDA: at least 3) and watch for euglycemic DKA. GLP-1 agonists delay gastric emptying and carry an FDA warning about aspiration; the ASA first advised holding daily doses on the day and weekly doses for 7 days, but newer multisociety advice individualizes, sometimes with a 24-hour liquid diet, and ADA notes even a week off may not empty the stomach.

Beta-blockers: continuing a long-term beta-blocker through surgery was the one Class I recommendation of the 2014 ACC/AHA and ESC guidelines, and the 2014 ACC/AHA guideline advised against starting one on the day of surgery (Sherafati 2017). The reason is POISE: metoprolol begun just before surgery prevented some heart attacks but raised cardiovascular deaths and strokes.

PACU in detail

The ASA postanesthetic guideline lists what to assess during emergence and recovery: airway patency, respiratory rate and oxygen saturation; pulse and blood pressure with an ECG monitor at hand; neuromuscular function after nondepolarizing blockers; mental status; temperature; pain; nausea and vomiting; hydration; urine output in selected clients; and drainage and bleeding. Give oxygen to clients at risk of hypoxemia, aim for normothermia with forced-air warming, and treat shivering (often from hypothermia) by rewarming; meperidine is the listed drug for shivering. Reversal agents are not routine; after naloxone or flumazenil the client is observed long enough that respiratory depression does not recur, and abrupt opioid reversal can cause pain, hypertension, tachycardia or pulmonary edema.

Discharge: the modified Aldrete score rates activity, respiration, circulation, consciousness and oxygen saturation 0–2 each, and 9 or more signals readiness to leave phase I (OpenAnesthesia; SPA writes 'above 9'). It does not score pain, nausea or bleeding, which home-readiness tools such as PADSS add. ASA says routine voiding or drinking before discharge should not be required (only for selected clients), there should be no fixed minimum stay, and every client going home must have a responsible adult.

Malignant hyperthermia

Malignant hyperthermia is an inherited muscle disorder (autosomal dominant; each child or sibling usually has a 50% chance) triggered by volatile anesthetics such as sevoflurane, desflurane and isoflurane and by succinylcholine. Metabolism surges, and the result is a rising heart rate, rigidity, acidosis, very high fever, muscle breakdown with hyperkalemia (ventricular arrhythmias) and myoglobin that injures the kidneys (MHAUS). In adults the earliest and most common sign is a rise in end-tidal CO2 that persists despite more ventilation; jaw (masseter) spasm after succinylcholine is a warning in children; fever often comes late, though infants can heat early (NORD). A previous uneventful anesthetic does not rule it out, relatives of an affected person are treated as susceptible, and the hour after surgery, including the PACU, is still a danger period (MHAUS).

• Stop the triggers; the surgeon halts or finishes with non-triggering drugs.
• Call for help and the dantrolene cart; MHAUS hotline 1-800-644-9737.
• Hyperventilate with 100% oxygen at 10 L/min.
• Dantrolene 2.5 mg/kg rapid IV, repeated until EtCO2, rigidity and heart rate improve; more than 10 mg/kg may be needed. Dantrium or Revonto 20 mg vial in 60 mL sterile water; Ryanodex 250 mg vial in 5 mL.
• Cool if core temperature is above 39 °C or rising fast; stop below 38 °C.
• Treat hyperkalemia (calcium, bicarbonate, insulin with dextrose) and arrhythmias, but no calcium channel blockers.
• Keep urine output above 1 mL/kg/h; bladder catheter and core temperature monitoring.
• Monitor in PACU or ICU for at least 24 hours: K+, CK, blood gases, urine myoglobin, clotting.

Complications: what the evidence says

Lungs: atelectasis is common after surgery; anesthesia and shallow breathing from pain or weakness are the usual causes, and mild collapse may cause no symptoms. Prevention is deep breathing after anesthesia and getting the client moving (MedlinePlus). The incentive spirometer is the bedside tool exams expect alongside deep breathing and early walking.

Gut: some slowing after surgery is normal and self-limited; prolonged ileus is often defined as no bowel movement and no oral intake beyond postoperative day 4, and it affects about 10–27% after abdominal surgery. Treatment is supportive (NG decompression for persistent vomiting, IV fluids and potassium); prevention works better: opioid-sparing analgesia, minimally invasive surgery, and chewing gum, which reduced ileus after colorectal surgery (Sommer 2021).

Wound: a superficial incisional infection by the CDC NHSN definition appears within 30 days, involves skin and subcutaneous tissue, and has purulent drainage, a positive culture from the incision, an incision the surgeon deliberately opens (with local pain, swelling, redness or heat and antibiotics started), or a physician diagnosis. Superficial infections are tracked for 30 days after every procedure; deep and organ-space infections after some implant procedures, such as knee replacement, for 90 days. A stitch abscess alone does not count. Abdominal wound dehiscence occurred at a mean of day 9 (range 0–32), 90% by day 15, with in-hospital mortality of 22% (van Ramshorst 2010); risk rises with age, male sex, chronic lung disease, ascites, jaundice, anemia, emergency surgery, coughing and wound infection. Warning signs are pain, bruising, a heavy serosanguineous discharge and no healing ridge by days 5–9 (Downey 2020).

Clots: DVT shows as swelling, pain, warmth and redness of one limb; PE as sudden dyspnea, a fast or irregular heartbeat, chest pain that worsens with a deep breath or cough, coughing up blood, and low blood pressure or fainting. Prevention after surgery is moving as soon as possible, with compression stockings or an anticoagulant for those at risk (CDC).

Exam pearls

• The surgeon obtains consent; the nurse verifies and witnesses. Questions or sedation: stop and call.
• NPO: 2 h clear, 4 h breast milk, 6 h formula, milk or light meal, 8 h fatty food.
• Hold metformin the day of surgery and SGLT2 inhibitors 3–4 days; reduce, do not stop, basal insulin.
• Warfarin off about 5 days; DOACs 1–2 days; continue a long-term beta-blocker.
• Surgeon marks the site; time-out right before the incision with the whole team.
• PACU: airway first. Aldrete 9 or more to leave phase I.
• MH: rising EtCO2 first, fever late; dantrolene 2.5 mg/kg.
• Ileus: no flatus, distension; NG if vomiting, IV fluids and potassium.
• Dehiscence or evisceration: stay, low Fowler with knees bent, moist sterile saline dressing, call the surgeon, NPO.
• Prevent clots and atelectasis the same way: get the client moving early.