Day in the life of a Perioperative Nurse in Private Hospitals

Meet Lauren Hudson, who gives you a really in-depth insight into what a day in the life of a perioperative nurse involves. You can check her out on Instagram.

Nineteen Surgeries by 23 years old

My name is Lauren, and I have been nursing for almost two years. I’m from Melbourne, Victoria and work in the operating theatres at one of the largest private hospitals in Melbourne. At this point in time, I am predominantly working in recovery, however, I am trained in anaesthetic nursing too.

In my short lifetime of twenty-three years, I have had nineteen surgeries (mostly on my hips, as I was born with hip dysplasia and had a late diagnosis at age three) and used to want to be an orthopaedic surgeon. As I grew up, my ambitions changed and I decided nursing sounded better suited to me. I’m so glad I followed my heart because I absolutely adore my job.

What is a perioperative nurse?

Perioperative nursing is an umbrella term that covers the huge variety of different areas within the theatre department, including roles such as pre-admission nurses, anaesthetic nurses, circulating nurses (a.k.a. scout nurses), instrument nurses (a.k.a. scrub nurses), PACU/recovery nurses and day surgery nurses. If I was to go into detail about the roles and responsibilities of every type of perioperative nurse, we could probably write a novel, but the ACORN (Australian College of Perioperative Nurses) website has a super detailed information page all about the different roles within the operating theatre – you can find it here.

It is important to note that you do not have to be a registered nurse to work in theatre. I think it is commonly misconstrued that enrolled nurses aren’t allowed to work in theatres, but this is not true at all. EN’s can work in almost any perioperative role.

What types of patients do you look after?

At my workplace, we care for almost every type of surgical patient except for neurosurgery, obstetrics and organ transplantation. We do offer cardiac, orthopaedic, vascular, plastic, oral/maxillofacial, ENT, colorectal, bariatric, general, gynaecological and urological surgery.

In my current role in recovery, I look after these patients as soon as they leave the theatre and are emerging from anaesthetic. We nurse patients until they are able to maintain their own airway, their post-anaesthetic conscious state and vital signs are stable and within satisfactory parameters, any pain they may have is manageable and they are otherwise fit for discharge to the ward or to day surgery.

Learning to be a perioperative nurse during COVID

The jump from having learnt anaesthetic nursing during COVID protocols to then learning what it was like when things went back to “normal”, was definitely not the only challenge. All the different airways, equipment and medications involved in peri-anaesthetic nursing presented a huge learning curve for me and I certainly have lots, lots more learning to do.

When working in recovery, I also had to get used to a whole different way of handing over than I was used to back on the ward, focused more on the surgical side of a patient’s journey rather than the patient as a whole. Perioperative nursing also gets you comfortable working alongside many different doctors, all with many different personalities, and have the confidence to escalate any patient concerns to them whenever needed.

As closely as we work with the medical staff, I do love the sense of autonomy that peri-anaesthetic nursing provides. They say that nurses are the backbone of the hospital, and this is definitely true in the perioperative area. Our role in making every patient’s surgical journey run as smoothly and comfortably as possible while ensuring their wishes and needs are always met, is certainly a unique one. I feel really privileged to be able to have such a huge part in a patient’s hospital experience and I think this is the biggest reason why I love and have stayed in perioperative nursing.

As a grad, and even still now, I often doubted myself and my skills and really suffered from imposter syndrome, as I felt I didn’t know enough/wasn’t competent enough to be looking after people. If I could give a new graduate nurse one piece of advice, it would be to trust in yourself and have faith in yourself. If you have made it to the point of being a new grad, you clearly have the knowledge and skills to be one.

Your graduate year is all about working on these skills, gaining confidence in your nursing in a safe and supportive environment, and learning as much as you can. You aren’t expected to know everything, nor will you ever be expected to know everything, as it would be impossible to do so. Believe in yourself, reach out to your loved/trusted ones if you ever need help or feel overwhelmed, and take it all one step at a time

Complications in recovery a perioperative nurse deals with?

In recovery, we often deal with complications such as airway obstruction and laryngospasm (where the vocal cords spasm, resulting in partial or complete loss of a patient’s airway). These issues are often treated by suctioning the airway and applying positive pressure ventilation using a bag valve mask to open the airway back up.

Not a day goes by that I don’t treat a patient for hyper-/hypotension or an irregular heart rhythm that may be pre-existing or triggered by anaesthetic drugs. We manage pain, both pharmacologically and non-pharmacologically. We treat postoperative nausea and vomiting, fluid volume deficits and bleeding. We manage patients who wake up delirious, aggressive or combative, and even hysterically upset. We also see patients who come out of their anaesthetic as if they’ve just had an afternoon nap, and are discharged from recovery within twenty minutes.

A typical day in theatre

It would be almost impossible to describe a “typical” day in theatre, as every day is vastly different from the rest, but I’ll give it a go. Usually, a shift in anaesthetics starts with finding out which theatre you’re in, and collecting your set-up basket/s from the anaesthetic storeroom. These usually contain copies of your theatre list, your anaesthetist’s FAD card (a card with their specific airway and equipment preferences on it) and a range of different masks, airways and IV equipment for each patient on your list, set up the previous day in accordance to the FAD card.

After collecting your box of muscle relaxant drugs from the fridge, you make your way to your theatre and start your anaesthetic machine checks. It takes roughly 5-10 minutes to fully check the machine to ensure you have power, gas and oxygen and that each component of the machine is functioning properly to make sure it is safe for your patients. If you would like to see each component of a machine check in a bit more detail, here is the link to the checklist from the Association of Anaesthetists.

During the machine check, I would usually set up a few fluids/lines for the first few patients on my list. This may include just a basic IV giving set, a manual pump set, or depending on the case, an arterial line or CVC. Eventually, one of the resource nurses would come in and count the S4/S8 drug cupboards with me, and usually, around this time, the anaesthetist would also arrive to the theatre and begin planning drugs and airways with me for each patient. I would then prepare the first airway ready with my machine, retrieve the drugs that the anaesthetist asked for, and go and check-in and bring the first patient to the theatre from the holding bay.

The check-in includes making sure your patient has a signed and valid consent form, and has actually understood and consented for the correct procedure. I would then go through their pre-op checklist, making sure any allergies have been documented, the patient’s ID bands are correct, they have fasted, etc. At this time, the theatre technician is usually getting the theatre and operating table ready, and the scrub team are usually scrubbing in and setting up the instruments for the procedure.

Once the checks are complete, the patient is brought around to the theatre, the anaesthetist puts their lines in, and then they are brought into the theatre, transferred to the operating table and hooked up to the monitoring. The scrub team receive a brief handover and when the surgeon and assistants are present, we all go through the Team Time Out. This is to make sure we have the correct patient, the correct procedure and procedure site, are aware of any allergies and have the patient’s full and valid consent.

We then begin the anaesthetic process, usually starting with pre-oxygenation, where we give the patient oxygen through a mask to increase their oxygen reserve. The idea of this is to prevent hypoxaemia during the period of apnoea that occurs once the patient is anaesthetised. The anaesthetist will then inject the anaesthetic agent, usually propofol, and turns on some volatile gas that the patient breathes in with the oxygen to help anaesthetise them (usually sevoflurane for induction, as desflurane, can cause adverse respiratory reactions e.g. coughing).

Once anaesthetised, we insert and secure their airway (either a laryngeal mask airway (LMA) or endotracheal tube (ETT), depending on the case), help the theatre tech position and prep the patient, and the procedure begins. Depending on the type of theatre you’re in, whether it be orthopaedic or minor plastics, for example, you may have some time in between each case to prepare for the next, or you may be running out the door as soon as the current patient is stable to check in and collect your next.

A typical day in PACU

In PACU (post-anaesthesia care unit), or recovery), the day usually starts with checking your allocated bays, ensuring you have working oxygen and suction, and plenty of supplies in your drawers. Our recovery room has a checklist of AM/PM tasks that need doing each day, such as checking the defibrillator, counting drugs and ensuring the blanket/fluid warmer is filled, amongst other things.

We print out the full theatre list for the day and check if there are any paediatric or ICU cases, as these both require 1:1 nursing and we need to make sure we will have adequate staff. Sometimes, there is a bit of a lull in the morning before the first case comes out of theatre.

Other times, it is non-stop early on, especially if there are dental/oral or endoscopic lists running where the cases are often extremely quick. Over the course of the day, we do a million drug checks for analgesia, antiemetics, vasopressors and antihypertensives. We make up PCAs and ketamine infusions, as well as the occasional epidural (usually for major abdominal surgeries).

We give heat packs, ice packs, warm blankets and cold compresses. Remove laryngeal mask airways and sometimes insert nasopharyngeal or oropharyngeal airways. We check dressings, drains, dermatomes, flap and neurovascular obs. Then we take patients through to day surgery or up to their rooms on the ward, wishing them luck with the rest of their recovery, and return to PACU to do it all over again with the next patient who is wheeled into our bay. No two days are the same, and no two patients are the same.

Autonomy as a perioperative nurse

As I mentioned before, I love the sense of autonomy that perioperative nursing provides. This is especially true working in recovery, where we are given a patient, some post-op orders from their surgeon, a list of drugs from the anaesthetist, and the rest is up to us and our own clinical judgement. Sometimes, patients are super easy to manage in recovery and don’t stay with us for too long.

Other times, they will have complications such as uncontrolled nausea and vomiting, or extreme hypertension or bradycardia (systolic BPs of >200 and HRs of <40 are not that uncommon in PACU) that we need to treat before they are even close to fitting our discharge criteria.

A big challenge of perioperative nursing is the risk of compassion fatigue, something I have recently experienced myself. There are a few studies around that have found that perioperative nurses, specifically PACU nurses, can experience secondary traumatic stress from looking after patients in the post-op period.

Every patient that comes into recovery has been through a surgical trauma, and this can be extremely emotionally, physically and psychologically distressing for them. In order to comfort, support and educate patients through this stress, it takes a huge amount of care and empathy – doing this all day, every day, it can easily become exhausting without you realising it.

Cool piece of equipment

A cool piece of equipment we use in anaesthetics and recovery is the video laryngoscope. At my hospital, we use both the Glidescope and C-MAC, but I have personally used the Glidescope a lot more often. The Glidescope is a device that has a laryngoscope with a tiny HD camera and light, connected to a screen, allowing anaesthetists a better visualisation of the patient’s larynx compared to a normal laryngoscope, and therefore making intubation significantly safer and easier.

This is especially helpful in patients who have difficult airways, such as very small children or morbidly obese patients, as well as those who may have their C-spine immobilised or those who have a lot of oral secretions. If you aren’t familiar with intubation, or video laryngoscopes, here is a great video showing intubation using a Glidescope (https://www.youtube.com/watch?v=XY5g08gT-5Y).

Misconceptions about being a perioperative nurse

A common misconception about perioperative nursing is that we don’t have much patient contact, but this is entirely untrue. We care for patients both directly and indirectly and every part of our care is done so on behalf of the patient to ensure that all their needs and wishes are met before, during and after surgery.

We interact with patients, their families and carers, as well as the entire multidisciplinary team caring for the patient during their time in hospital. Every patient and their individual acuity may require a slightly different level of contact and support, but we are definitely involved in every step of every patient’s surgical journey.

If you are someone that enjoys a challenging, stimulating career, perioperative nursing may be for you. If you enjoy a fast-paced environment that requires a high level of organisation, assessment and communication skills, you might like to consider working as a pre-admission/holding bay or day surgery nurse.

If you’re interested in anaesthesia and enjoy the challenge of airway management and problem-solving, you might make an awesome anaesthetic nurse. If you want to be more involved inside the operating theatre, enjoy anatomy and physiology, working in a team and can think on your feet (and also plan ahead), scrub/scout nursing might be for you. If you love critical thinking, excellent assessment and communication skills and love the thrill of a deteriorating patient, you might enjoy recovery.

There are always endless opportunities to learn and develop professionally in perioperative nursing – you will never get bored. You can even go into education or management roles in any of these areas, teaching your colleagues about the latest equipment or leading your nursing team to success.

What do you wish you knew before becoming a perioperative nurse?

Something I wish I had known before starting in perioperative nursing, and one of the greatest lessons I have learnt so far is that, as I mentioned before, compassion fatigue is real and it is so important to know how to recognise it. The Cambridge Dictionary defines compassion as a strong feeling of sympathy for the suffering of others, and a wish to help them.

As nurses, we invest so much emotion into caring for patients, and sometimes we can overextend ourselves. This is a really serious issue and can have a huge impact on our own health, both physically and mentally. I recently experienced this myself, feeling constantly exhausted no matter how much sleep I had and feeling emotional for no apparent reason.

I couldn’t concentrate properly, couldn’t work to the best of my ability and my anxiety went through the roof, especially at work. Thankfully, I am surrounded by amazing, supportive colleagues and managers and I was able to take a break from work to rest and recuperate. My experience with compassion fatigue has made me really passionate about it, and the biggest thing I want to encourage other nurses and student nurses to do is take time and look after yourself.