Study topic
Perioperative care
NCLEX perioperative chapter: PACU airway priorities, atelectasis and clot prevention, hemorrhage and evisceration, malignant hyperthermia, and procedure-specific aftercare.
Perioperative nursing is pattern recognition across three windows: keep the airway and lungs open after anesthesia, catch the complications that kill in the first hours to days, and match each diagnostic procedure to its own position and watch-for list.
PACU and early recovery: airway first
While the client is still drowsy from general anesthesia, oxygenation and airway patency outrank comfort and teaching. Snoring respirations with a falling saturation usually mean soft-tissue obstruction. Reposition and open the airway before you assume the problem is only the nasal cannula.
- Confirm return of protective reflexes before oral intake, especially after bronchoscopy or topical throat anesthesia.
- Pain control matters because a client who will not expand the chest will atelectasize. Treat pain so incentive spirometry is possible.
- If the client ate a full breakfast after NPO instructions, stop the morning-of flow and notify anesthesia and the surgeon.
Prevent the usual postoperative traps
| Risk | What you do | Why it shows up on the exam |
|---|---|---|
| Atelectasis / pneumonia | Incentive spirometer, turn-cough-deep breathe, early ambulation, sitting up for lung expansion | IS purpose is alveolar expansion, not “exercise the arms” |
| DVT / PE | Early ambulation, sequential compression, anticoagulation when ordered, leg exercises in bed | Immobility plus surgery is the classic clot setup |
| Ileus / delayed diet | Confirm appropriate bowel/gastric readiness before advancing diet per order | First PO after abdominal surgery is not automatic with wakefulness alone |
Hemorrhage and shock after surgery
In the first hours, bright red saturation of a dressing plus restlessness, tachycardia, and falling blood pressure is hemorrhage until proven otherwise. Support the site (direct pressure when appropriate), keep IV access open, prepare for fluid/blood orders, and notify the surgeon. A firm, distending abdomen with the same vital-sign slide can mean internal bleeding even when the outer dressing looks quieter.
Wound failure: dehiscence vs evisceration
| Finding | Action |
|---|---|
| Incision edges separate (dehiscence) | Stay with client, cover with sterile dressing (often saline-moist), low Fowler's, notify surgeon, keep NPO |
| Organ/bowel protrudes (evisceration) | Sterile saline-moistened dressings over the bowel, low Fowler's with knees bent if ordered/protocol allows, **do not replace bowel**, call surgeon now |
Named postoperative emergencies
Malignant hyperthermia
Soon after volatile anesthetics or succinylcholine: rapidly rising temperature, jaw/muscle rigidity, tachycardia, rising end-tidal CO2. This is a crisis protocol, not a cooling blanket alone. Stop triggering agents, give dantrolene as ordered, support ventilation, cool, and call for help.
Compartment syndrome
After cast or crush/fracture care: pain out of proportion, pain with passive stretch, tightness, pallor or delayed refill, paresthesias. Report immediately. Do not assume another opioid dose will fix a mechanical pressure emergency.
Fat embolism
Hours to a day or two after long-bone repair: sudden confusion, hypoxemia, and a petechial rash (often chest/axilla). Oxygen and escalate. Do not chalk it up to “waking up weird from anesthesia” when the triad appears late.
Post-thyroidectomy airway and calcium
Neck hematoma, stridor, or progressive dyspnea is an airway emergency. Perioral tingling and neuromuscular irritability flag hypocalcemia from parathyroid disturbance. Both need prompt recognition; the noisy neck comes first.
Safety
If findings point to hemorrhage, evisceration, malignant hyperthermia, compartment syndrome, or airway compromise after neck surgery, escalate now. Comfort measures alone are not the priority action.
Diagnostic procedures: aftercare that matches the hole you made
Each invasive test has one or two aftercare rules the exam loves. Memorize the position and the “call now” finding.
| Procedure | Immediate care / teaching | Watch for |
|---|---|---|
| Percutaneous liver biopsy | Right side-lying to compress the site; limited activity per order | Bleeding, peritonitis signs, rising pain |
| Bronchoscopy (topical airway anesthesia) | NPO until gag returns | Aspiration if fed too early; respiratory distress |
| Large-volume paracentesis | Monitor BP and volume status closely in first hours | Hypotension / hypovolemia after fluid shift |
| Thoracentesis | Respiratory assessment after the procedure | Sudden severe dyspnea and falling SpO2 → possible pneumothorax |
| Renal biopsy | Pressure/rest per protocol; monitor vitals and urine | Hypotension, tachycardia, expanding flank pain/bruising → bleeding |
| Lumbar puncture | Flat rest as ordered; fluids if allowed | Post-dural headache worse upright, better flat (afebrile, soft neck) |
| Bone marrow biopsy (iliac crest) | Firm pressure on the puncture site | Ongoing bleeding at the site |
| EGD / colonoscopy / ERCP | NPO until safe to swallow; ERCP teaching includes pancreatitis watch | Colonoscopy: rigid abdomen / severe pain after polypectomy → perforation; ERCP: severe epigastric pain radiating to back |
| MRI | Screen metal implants, aneurysm clips, some pacemakers/ICDs, metal fragments, incompatible pumps | Cancel or clarify before the magnet, not after |
Priority map
- Noisy or obstructed airway / falling SpO2 → open airway and oxygenate.
- Saturating bright-red dressing with shock vitals → hemorrhage pathway.
- Bowel outside the incision → saline-moist sterile cover; do not reduce.
- Rigidity + soaring temperature under anesthesia → malignant hyperthermia protocol.
- Named procedure + classic complication cue → treat that complication, not a generic “rest and reassess.”
Must know
- 1PACU first: airway and oxygenation. Snoring with falling SpO2 → open the airway (jaw thrust / reposition) before chasing other causes.
- 2Prevent atelectasis: incentive spirometry, turn-cough-deep breathe, early ambulation, pain control that lets the client expand the chest.
- 3Before first oral intake after anesthesia or throat topical anesthesia: confirm return of the gag reflex.
- 4NPO broken on the morning of surgery: hold, notify anesthesia/surgeon. Do not quietly proceed.
- 5Hemorrhage picture: saturating dressing, restlessness, tachycardia, falling BP → pressure/support per wound type, IV access, notify surgeon now.
- 6Evisceration: cover protruding bowel with sterile saline-moistened dressings, low Fowler's, do not push bowel back, call the surgeon.
- 7Malignant hyperthermia: rising temperature, muscle rigidity, tachycardia, rising ETCO2 → stop triggering agents, give dantrolene, cool, support ABCs.
- 8Compartment syndrome: pain out of proportion, worse with passive stretch, tight/swollen limb → report immediately; do not elevate past heart level as the only “fix.”
- 9Fat embolism after long-bone repair: sudden confusion, hypoxia, petechial rash on chest/axilla → oxygen and escalate.
- 10Thyroidectomy airway: neck swelling, stridor, or progressive dyspnea is an emergency. Perioral tingling flags hypocalcemia risk.
- 11Procedure positions/watchouts: liver biopsy → right side; bronchoscopy → gag before PO; thoracentesis sudden dyspnea → pneumothorax; post-LP headache worse upright → flat rest.
Memory hooks
Airway before tray
Snoring, obstructed breathing, or no gag reflex beats offering water, getting a full set of labs, or teaching IS in that minute.
Cover, don't stuff
Eviscerated bowel gets a sterile saline-moist cover and a surgeon call. Never push the loop back into the wound.
Right side after liver poke
After percutaneous liver biopsy, place the client on the right side to compress the puncture site and reduce bleeding risk.
How it's tested
Stems stack PACU vitals with snoring, a soaking dressing with shock cues, an open incision with bowel visible, or a named procedure with one wrong aftercare action. Distractors offer food before gag returns, elevate a compartment limb as the whole plan, push bowel back in, or treat malignant hyperthermia like a simple fever.