med surg peri op

Living Will

- different than DNR; decides what you want ex. No tube feeding

Malignant Hyperthermia

- life-threatening condition that is triggered by exposure to certain drugs -Inherited disease that causes a rapid rise in body temperature and severe muscle contractions when the affected person receives general anesthesia

DNR Status

- no compressions, no intubation - is a order a doctor writes

Durable power of attorney for healthcare

- unable to make healthcare decisions

Incentive spirometer

- used to open alveoli and prevent atelectasis

Four Stages of General Anesthesia:

1. Drowsy & dizzy; depressed pain 2. Irreg. breathing; involuntary movements -Avoid stimulation 3. Appropriate level of anesthesia for procedure Muscle relaxation Constricted pupils Absent eyelid reflex 4. Medullary depression; Near death -pupils fixed and dilated, respirations weak, pulse rapid and thready.

Three required elements of IC

1. Given voluntarily 2. Given by individual with capacity & competence to understand 3. Sufficient information must be given to allow for an informed decision *Patient needs to understand what is being said (literacy level) *Interpreter PRN

Priority Assessments that should be performed in PACU - Easy as ABC!!!

1. Maintaining a patent AIRWAY!! -assess for reflexes - gag, swallow, cough -listen for crackles or rhonchi -assess for wheezing or stridor 2. Ensure patient is BREATHING (ventilation) !! -RR should be 10-26 -equal/unequal 3. Ensure adequate Cardiovascular Status - CIRCULATION!! -cardiac monitor -VS q15 min until stable -VS q30min when stable -Fluid status -Skin color -Pneumatic boots/antiembolism stockings -Assess for hypotension/shock -Assess for hemorrage: -dressing drains -urine output -distention of body tissue -Check 5 P's

A nurse knows that she must obtain a signed informed consent for which of the following procedures? Select all that apply. A. Arteriography B. Open reduction of a fracture C. Insertion of a urethral catheter D. Cystoscopy E. Insertion of a peripheral intravenous line F. Paracentesis

A. Arteriography B. Open reduction of a fracture D. Cystoscopy F. Paracentesis

Which of the following activities would the nurse carry out in the preoperative period for a client scheduled for surgery? A. Identify potential or actual health problems. B. Perform specialized procedures to assure safety. C. Assess client's responses to interventions. D. Intervene to prevent complications.

A. Identify potential or actual health problems.

Which of the following is the most important initial nursing activity in the postoperative recovery area? A. Maintain patient safety (airway & circulation) B. Administer medications and fluids C. Assess level of pain D. Inspect the surgical site

A. Maintain patient safety (airway & circulation)

colon resection for Stage 2 colon cancer What is the urgency of Mrs. P.'s surgery? A. Elective B. Urgent C. Emergent D. Required

B. Urgent

The perioperative nurse has a number of major responsibilities when a patient is admitted to a surgical unit or center. Which of the following is the most important function? A. Completes the preoperative assessment. B. Develops a plan of care. C. Verifies that the operative consent is signed. D. Provides psychological support.

C. Verifies that the operative consent is signed.

Risk for perioperative positioning injury r/t surgical procedure

Comfortable position as possible Operative field fully exposed Vascular supply must not be obstructed Respirations should not be impeded Nerves must be protected from undue pressure. *Pay special attention to elderly, obese, with physical deformities *Failure to position correctly = impaired skin integrity, paresthesia, paralysis

colon resection for Stage 2 colon cancer What is the purpose/surgical classification of Mrs. P's procedure? Diagnostic Curative Reparative Reconstructive / Cosmetic Palliative

Curative

All clients having surgery have a degree of risk associated with the surgery. The nurse would evaluate which of the following client-related factors as contributing to a high degree of risk associated with surgery? A. Institution reputation. B. Average nutritional status. C. Little likelihood of complications. D. History of cardiac and pulmonary disease.

D. History of cardiac and pulmonary disease.

The effectiveness of preoperative teaching will be most negatively influenced by: A. The presence of a significant other during the teaching session. B. Concern regarding the amount of insurance reimbursement. C. Prior experience with surgery in family members. D. Pain unrelieved by medication.

D. Pain unrelieved by medication.

Minor

Few postoperative complications One-Day surgery / Outpatient Surgery

Risk for Infection r/t surgery

How do we prevent infection during surgery? Maintain SURGICAL ASEPSIS ! Maintaining surgical asepsis requires conscientiousness, alertness, and honesty!

Risk for imbalanced body temperature- hypothermia r/t surgery

How to minimize: Prevent exposure of nonsurgical body parts Use head coverings and warm blankets Warm IV fluids and anesthetic agents *warm pt gradually

Risk for Aspiration r/t nausea and vomiting

How to prevent: (no single way to prevent) NPO status preoperatively Use new anesthetics which have reduced incidence of N/V Administer antiemetic & antacids

Nurses Role with IC

IC is NOT a nursing responsibility Physician must obtain consent Nurse, however, can reinforce MD explanations Nurses role is to serve as witness

important "Safety" measures in the OR?

Identify correct pt, surgery and side Ask if anyone has concern Make sure all equipment is present Give antibiotics 60 minutes before operating Everyone introduces their role

when is IC needed?

Invasive procedures Procedures requiring sedation/anesthesia A non-surgical procedure that carries a higher risk Procedures requiring radiation

General Anesthesia

Loss of all sensation & consciousness Administered by IV or inhalation of gases Used for major surgeries, exploratory laparotomies

Regional Anesthesia

Loss of sensation to one part of body ex; Local Nerve Block Epidural Block Spinal Anesthesia Subarachnoid space

What information needs to be included when giving IC?

Nature & purpose of treatment/procedure Expected outcomes & probability of success Risks, benefits & consequences Alternatives Prognosis if not done

"Preadmission Testing" (PAT)

Nursing assessment Diagnostic & lab tests Consent & Advanced Directive forms Teaching Surgeon preop. orders (bowel prep., skin cleansing, meds) Post-op happenings Discharge planning Referrals for home care/rehabilitation services

pt risk category - assigned by anestesiologist

P1 - normal, healthy pt P2- mild systemic disease P3- severe systemic disease P4-severe systemic disease, that is a constant threat to life P5-pt isn't expected to survive w/o surgery P6- declared brain dead pt that organs are being removed E- added to end of P category if an emergency surgery

Risk for Impaired Gas Exchange r/t Anesthesia & smoking history

Prevention - Close monitoring of: -oxygenation status -Pulse oximetry -Capnography (CO2) -Peripheral perfusion by anesthesiologist/anesthetist/circulating RN

Major

Prolonged OR time Large loss of blood Involvement a vital organ(s) Associated with postoperative complications

Discharge Criteria from PACU

Pt needs score of 8-10 before leaving PACU

Nursing Diagnoses for Intraoperative Patient (during surgery)

Risk for aspiration Impaired skin integrity Risk for perioperative positioning injury Risk for imbalanced body temperature Ineffective tissue perfusion Risk for Deficient fluid volume Risk for infection Risk for hypoventilation

prevention of malignant hyperthermia

Role of Periop RN!!!! MH risk assessment during preop interview -Caffeine intolerance -H/O MH -Prior complications r/t anesthesia Ensure during surgery continuous monitoring of: ECG ET CO2 Pulse Oximeter Temperature

There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements. Stage I: Beginning anesthesia Stage II: Excitement Stage III: Surgical anesthesia Stage IV: Medullary depression

Stage II: Excitement

Risk for imbalanced body temperature- malignant hyperthermia r/t anesthesia

Symptoms associated with are: Rise in ETCO2 (normal is 35-40%) and decrease in O2 sat. Tachycardia (>150bpm)- Generalized muscle rigidity- jaw & chest especially 3 EARLY signs High CO2 Low O2 Jaw and muscle rigidity

if pt aspirates during surgery

Turn patient to side Lower HOB Utilize suction to remove vomitus Support oxygenation

OR zones

Unrestrictive (ex. Locker room) Semi-restrictive: everyone needs OR scrubs and hair caps Restrictive: everyone must have scrubs, caps, masks and shoe covers

postoperative phase

begins at admission to PAUC ends at final follow up appointment *maintain airway - SAFETY *keep good watch on VS

intraoperative phase

begins at transfer to OR ends at transfer to PACU *maintain safety!! (position is important) *assist doctor

The Preoperative Phase

begins when it is determined pt needs surgery ends when nurse reports off to OR nurse

optional surgery

client preference ex; plastic surgery

reconstructive/cosmetic surgery

ex; mauled by dog, fix shape of face benefits from before & after

reparative surgery

multiple wound repairs ex; in motor vehicle accident

elective surgery

needed but not life threatening; will improve pt life ex; scar removal

required surgery

needed for clients well being weeks-months ex; cataracts

5 P's for extremities

pain pallor -coloring pulse - do they have one? paresthesia - numbness/tingling? paralysis- can't move?

Malignant Hyperthermia signs

rapid rise in temp tachycardia high BP muscle contractions Reversal agent - Dantrolene

curative surgery

removal of pathological cause ex; tumor removal

urgent surgery

requires prompt attention within 24-30hr ex; kidney stones

emergent surgery

surgery has to be preformed immediately to save life, limb or organ unplanned so there is little time to prepare might not have informed consent, but do it anyway to save life ex; gunshot

diagnostic/exploratory surgery

to get diagnosis ex. breast biopsy for cancer

palliative surgery

to relieve pain

number one indicator of Fluid volume deficit

urine output

reversal for coumadin

vitamin K