Guide — Perioperative Nursing
Surgical Complications
Postoperative complications are preventable in many cases — but require early recognition and prompt intervention when they occur. Nurses are often the first to identify deteriorating clinical trends. This guide covers the major surgical complications: hemorrhage, infection, thromboembolic events, pulmonary complications, and wound integrity failures.
12 min read · Perioperative Nursing
Educational use only. This content is intended for nursing students and exam preparation. Postoperative complication management requires provider notification and individualized clinical judgment. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Hemorrhage
Most immediately life-threatening surgical complication
Postoperative hemorrhage occurs when bleeding at the surgical site is not adequately controlled. Early recognition requires tracking trends, not just single values — a rising heart rate and falling blood pressure together are more significant than either alone.
| Types | Primary: bleeding at time of surgery (vessel laceration). Reactionary: occurs within 24 hours — clot dislodgement from vasodilatation as BP rises post-anesthesia. Secondary: occurs days later — typically from infection eroding a vessel. |
| Clinical signs | Tachycardia (first sign), hypotension (late sign), increased respiratory rate, restlessness and anxiety (early — often mistaken for pain or emergence agitation), pallor, cool/clammy skin, decreased urine output, confusion, increasing drain output, bright red bleeding from incision or drain |
| Risk factors | Anticoagulant use, coagulopathy, hypertension, vascular surgery, inadequate intraoperative hemostasis, blood thinning medications not held |
| Nursing actions | STAT notify provider. Apply direct pressure to wound if accessible. Increase IV fluids per order. Prepare for possible return to OR. Type and crossmatch blood products. Monitor vital signs continuously. Prepare for blood transfusion per order. Do NOT leave the patient alone. |
| Prevention | Verify anticoagulants held preoperatively; confirm INR within acceptable range; accurate intraoperative sponge and instrument count; report unexpected increases in drain output promptly |
Surgical Site Infection (SSI)
| SSI Type | Depth | Signs & Symptoms | Timing |
|---|---|---|---|
| Superficial incisional | Skin and subcutaneous tissue only | Redness (erythema), warmth, edema, purulent drainage at incision, fever, pain/tenderness | Within 30 days of surgery |
| Deep incisional | Fascia and muscle layers | Fever, wound dehiscence, deep pain/tenderness, purulent drainage from deep tissue | Within 30–90 days |
| Organ/space SSI | Any organ or space opened during surgery | Fever, abdominal pain, abnormal lab values, positive cultures from organ/space | Within 30 or 90 days (per NHSN procedure category) |
SSI Prevention (SCIP Bundle)
Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)
Virchow's Triad explains the mechanism: (1) Venous stasis — immobility during and after surgery; (2) Endothelial injury — surgical trauma to vessel walls; (3) Hypercoagulability — surgical stress response activates clotting cascade.
DVT — Signs & Management
- ✦Unilateral calf/leg pain, warmth, and swelling
- ✦Erythema along the vein distribution
- ✦Low-grade fever
- ✦Positive Homans sign (calf pain with dorsiflexion — unreliable, use with caution)
- ✦Diagnosis: Doppler ultrasound
- ✦Treatment: anticoagulation (heparin → warfarin or DOAC); IVC filter if anticoagulation contraindicated
PE — Signs & Emergency Management
- !Sudden dyspnea (most common presenting sign)
- !Pleuritic chest pain (worsens with inspiration)
- !Tachycardia, tachypnea, hypoxia
- !Hemoptysis (blood-tinged sputum)
- !Massive PE: hemodynamic instability, cardiac arrest
- !Emergency: call provider STAT, high-flow O2, IV access, prepare for anticoagulation or thrombolytics
DVT/PE Prevention
Atelectasis and Pneumonia
| Atelectasis | Collapse of alveoli — most common pulmonary complication. Caused by shallow breathing (pain), mucus plug, prolonged supine position. | Low-grade fever (most common cause of fever in first 24–48 hours postoperatively), decreased or absent breath sounds at bases, decreased SpO2, tachypnea | Incentive spirometer every hour while awake; deep breathing and coughing (C&DB); ambulation; pain control to enable deep breathing; positioning — HOB 30–45° |
| Pneumonia | Bacterial infection of the lung parenchyma — often develops from untreated atelectasis or aspiration during surgery. | High fever, productive cough, purulent sputum, pleuritic chest pain, decreased breath sounds with crackles/consolidation, elevated WBC | Antibiotic therapy per culture; continued pulmonary toilet; hydration; early mobilization; aspiration precautions if altered swallow |
Key NCLEX fact: Atelectasis is the most common cause of fever in the first 24–48 hours after surgery. The incentive spirometer and early ambulation are the primary prevention and treatment interventions.
Wound Dehiscence and Evisceration
Wound Dehiscence
Definition: Partial or complete separation of wound layers (skin and/or deeper tissue) without organ protrusion.
Signs:
- •Patient reports feeling a 'giving way' or 'popping' sensation
- •Wound edges separate or gap visible
- •Serosanguineous drainage from wound suddenly increases
- •Typically occurs days 5–10 postoperatively
Nursing actions:
- ✦Cover wound with sterile saline-soaked dressing
- ✦Notify provider immediately
- ✦Keep patient supine with knees slightly flexed (reduces tension on incision)
- ✦Prepare patient for possible wound closure procedure
Evisceration — SURGICAL EMERGENCY
Definition: Protrusion of abdominal organs (usually bowel) through the wound opening. Always accompanies dehiscence. Requires emergency surgical intervention.
Immediate nursing actions:
- 1.CALL FOR HELP — this is a surgical emergency
- 2.Cover organs with large sterile saline-soaked dressings — keep moist at all times
- 3.Do NOT attempt to push organs back in
- 4.Keep patient calm and supine with knees slightly flexed
- 5.NPO immediately
- 6.Notify surgeon and OR team
- 7.Monitor for shock — IV access, vital signs
Risk factors for dehiscence/evisceration
Other Common Postoperative Complications
Paralytic Ileus
Signs: Absent bowel sounds, abdominal distension, nausea, no flatus or stool after 3–4 days postoperatively
Interventions: Early ambulation; NG decompression if severe; NPO until bowel sounds return; avoid opioids when possible; neostigmine per order for prolonged ileus
Urinary Retention
Signs: Bladder distension, inability to void within 6–8 hours of surgery, suprapubic discomfort, restlessness
Interventions: Bladder scan to confirm retention (>400 mL concerning). Bladder stimulation techniques (warm water, running water). Straight catheterization or Foley if unable to void. Monitor for urinary tract infection after catheterization.
Hypothermia
Signs: Core temperature <36°C, shivering, pale/cool skin, vasoconstriction, impaired wound healing, dysrhythmias if severe
Interventions: Forced-air warming blankets, warm IV fluids, warm blankets, increase room temperature; shivering increases O2 demand — treat aggressively
Post-op Nausea/Vomiting (PONV)
Signs: Nausea, retching, vomiting — very common, especially with opioids and certain inhalational anesthetics
Interventions: Antiemetics (ondansetron, metoclopramide, scopolamine patch) as ordered; avoid sudden position changes; small sips of clear liquid before solids; position HOB elevated
NCLEX Pearls — Surgical Complications
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with AORN Guidelines for Perioperative Practice · American Society of Anesthesiologists (ASA). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →