Perioperative Nursing Care
LAB ASSESSMENT (preoperative) PAT testing?
(Preadmission testing): 24 hour-28 days prior to establish baseline data before surgery
WOUND DEHISCENCE -Partial or complete separation of the outer layers of the wound--> __________________________. Treatment: -Apply sterile non-adherent / saline dressing. -Notify surgeon. -Supine position with _________________. Avoid coughing.
(i DIDN'T GET THIS INFO IN LECTURE)
POSITIONS (INTRAOPERATIVE) How to prevent Radial nerve complications (wrist drop) related to intraoperative positioning?
--support wrist with padding -be careful not to overtighten wrist straps
REGIONAL ANESTHESIA Field :
-A series of injections AROUND the operative field -Most commonly used for chest procedures,hernia repair,dental surgery,plastic surgery
SKIN CLOSURES Types of sutures:
-Absorbable vs. Nonabsorbable -Retention sutures
PREOPERATIVE ASSESSMENT: HISTORY Things the staff needs to know about a patient before surgery:
-Allergies -Medical and surgical history -Medications -CAM use (herbal therapies) -Drug and substance abuse
REGIONAL ANESTHESIA Complications of regional anesthesia:
-Anaphylaxis. -Incorrect delivery technique. -Systemic absorption & overdose.
REGIONAL ANESTHESIA Nurse's role:
-Assist anesthesia provider. -Observe for breaks in sterile technique. -Provide emotional support for patient. -Positioning of patient.
GENERAL ANESTHESIA (GA) Table 17-2: The four stages of General Anesthesia & related nursing interventions. Pg. 272. Stage 2: Excitement and Delirium Nursing Interventions:
-Assist anesthiologist with intubation. -Place patient into OR -Prep/scrub patient's skin over operative site as directed
GENERAL ANESTHESIA (GA) Table 17-2: The four stages of General Anesthesia & related nursing interventions. Pg. 272. Stage 2: Excitement and Delirium Nursing Interventions:
-Avoid autditory and physical stimuli -Protect the extremeties -Assist the anesthesiologist with suctioning as needed -Stay with the patient
GENERAL ANESTHESIA (GA) Table 17-2: The four stages of General Anesthesia & related nursing interventions. Pg. 272. Stage 2: Excitement and Delirium Description:
-Begins with LOC and ends with relaxation,regular breathing,loss of eyelid reflex -Patient may have irregular breathing,increased muscle tone,involuntary movements of extremeties. -Laryngospasm and vomiting may occur. -Patient is susceptible to external stimuli
GENERAL ANESTHESIA (GA) Table 17-2: The four stages of General Anesthesia & related nursing interventions. Pg. 272. Stage 4: Danger Description:
-Begins with depression of vital functions and ends with respiratory failure,cardiac arrest,possible death. -respiratory muscles are paralyzed, apnea occurs -pupils are fixed and dilated.
GENERAL ANESTHESIA (GA) Table 17-2: The four stages of General Anesthesia & related nursing interventions. Pg. 272. Stage 3: Operative anesthesia, Surgical Anesthesia Description:
-Begins with general muscle relaxaation and ends with loss of reflexes and depression of vital functions -Jaw is relaxed,breathing is quiet and regular -Patient can't hear -Sensations are lost (pain)
GENERAL ANESTHESIA (GA) Table 17-2: The four stages of General Anesthesia & related nursing interventions. Pg. 272. Stage 1: Description of Analgesia and Sedation, Relaxation?
-Begins with induction. Ends with LOC. -Patient feels drowsy,dizzy,reduced pain sensation, amnesia. -Hearing is exaggerated.
GENERAL ANESTHESIA (GA) Table 17-2: The four stages of General Anesthesia & related nursing interventions. Pg. 272. Stage 1: Analgesia and Sedation, Relaxation Nursing Interventions?
-Close operating room doors,dim lights,control traffic in OR -Postion patient with safelty belts -Keep discussion about patient to a minimum.
MALIGNANT HYPERTHERMIA Emergency Care for patient with malignant hyperthermia?
-Contact Malignant Hyperthermia Associationo of the Unites States hotline for more information regarding treatment -Transfer patient to ICU when stable.
MALIGNANT HYPERTHERMIA What is the DOC (drug of choice) to treat Malignant Hyperthermia? What is it's action?
-Dantrolene -Action: Skeletal muscle relaxant (helps decrease muscle rigidity)
GENERAL ANESTHESIA COMPLICATIONS: MALIGNANANT HYPERTHERMIA Malignant Hyperthermia can lead to ---->_____________
-Death from cardiac arrest -brain damage -internal hemorrhaging -failure of other body systems.
ANESTHESIA Table 17-1: Advantages & disadvantages of various types of anesthesia. Pg. 272. Disadvantages of Regional or Local Anesthesia?
-Difficult to administer to an uncooperative or upset patient -No way to control agent after administration -Absorbs rapidly into the blood and causes cardiac depression (hypotension) or overdose
ANESTHESIA Table 17-1: Advantages & disadvantages of various types of anesthesia. Pg. 272. Disadvantages of General Anesthesia: Balanced (both IV and Inhalation route) ?
-Drug interactions can occur -pharmocologic effects on the body may be unpredictable
MALIGNANT HYPERTHERMIA What is important to increase the change of survival?
-Early diagnosis--> time is crucial!
PRE-OP: INTERVENTIONS Table 16-4: Preoperative teaching checklist. Pg. 252 Things to consider when planning individualized preop teaching for patients/families:
-Fears/anxieties -Surgical procedure -preop routines (NPO, blood samples,showering) -Invasive procedures (lines,catheters)
REGIONAL ANESTHESIA Types:
-Field block -Nerve block -Spinal epidural
ANESTHESIA Table 17-1: Advantages & disadvantages of various types of anesthesia. Pg. 272. Advantages of Regional or Local Anesthesia?
-Gag and cough reflexes stay intact -Allows participation and cooperation by the patient -Less disruption of physical and emotional body functions -Decreased chance of sensitivity to the agent -Decreased intraoperative stress
ANESTHESIA Table 17-1: Advantages & disadvantages of various types of anesthesia. Pg. 272. Types of Anesthesia?
-General -Regional or Local -Cryothermia -Hypnosis/Hypnoanesthesia
MALIGNANT HYPERTHERMIA Emergency Care for patient with malignant hyperthermia?
-Give IV fluids sufficient enough to maintain urine output above 2 ML/kg,hr. -Monitor urine for presence of blood or myoglobin. -If urine output falls below 2 mL/kg/hr, use osmotic or loop diuretics depending on patient's cardiac and kidney status.
MALIGNANT HYPERTHERMIA Emergency Care for patient with malignant hyperthermia: What cooling technique should the nurse use?
-Give iced saline (0.9% NaCl) IV at 15 mL/kg every 15 minutes. -Apply cooling blanket over torso. -Pack bags of ice around patient's axilla,groin,neck,head. -Lavage the stomach,bladder,rectum,and open body cavities with sterile iced normal saline.
CONSIOUS SEDATION Nursing Interventions: Pre-procedure:?
-History (allergies, meds,). -Full assessment: Baseline VS, heart rhythm, & LOC. -NPO 4 hours prior. -IV access. -Verify that client signed informed consent form.
POSITIONS (INTRAOPERATIVE) Purpose of skin closures?
-Hold wound edges in place until complete wound healing. -Occlude blood vessels, prevent bleeding & fluid loss. -Prevent wound contamination.
SKIN CLOSURES What's the purpose of them?
-Hold wound edges in place until complete wound healing. -Occlude blood vessels, prevent bleeding & fluid loss. -Prevent wound contamination.
PACU ASSESSMENT: CARDIOVASCULAR What to Monitor: Fluid & Electrolyte Balance?
-I/O: IV fluids, vomitus, urine, wound drainage, NGT. -Report: Urine output < 30 ml/hr. Urinary retention.
MALIGNANT HYPERTHERMIA Emergency Care for patient with malignant hyperthermia?
-If they have metabolic acidosis shown by ABG values, give sodium bicarbonate IV. -If hyperkalemia is present, give 10 units regular insulin in 50 mL of 50% dextrose IV.
ANESTHESIA Table 17-1: Advantages & disadvantages of various types of anesthesia. Pg. 272. Disadvantages of Regional or Local Anesthesia? (continued)
-Increased nervous system stimulation (overdose) -Not practical for extensive procedures because of the amount of dru that would be required to maintain anesthesia
REGIONAL ANESTHESIA Epidural anesthesia:
-Injection of an agent into the epidral space -most commonly used for anorectal,vaginal,perineal,hip, and lower extremity surgeries.
REGIONAL ANESTHESIA Spinal anesthesia:
-Injection of an anesthetic agent into the cerebrospinal fluid in the subarachnoid space -Most commonly used for lower abdominal,pelvic,hip, and knee surgery.
REGIONAL ANESTHESIA Nerve block:
-Injection of the local anesthetic agent INTO OR AROUND one nerve or group of nerves in the involved area. -Most commonly used for limb surgery or to relieve chronic pain.
MALIGNANT HYPERTHERMIA Emergency Care for patient with malignant hyperthermia?
-Insert Foley catheter to monitor urine output. -Treat any dysrhythmias that don't resolve on correction of hyperthermia and hyperkalemia with antidysrhythmic agents other than calcium channel blockers.
MALIGNANT HYPERTHERMIA Emergency Care for patient with malignant hyperthermia?
-Insert NG tube and rectal tube. -Monitor core body temperature to assess effectiveness of interventions and to avoid hypothermia. -Montior cardiac rhythm by ECG to assess dysrhythmias.
MALIGNANT HYPERTHERMIA Emergency Care for patient with malignant hyperthermia?
-Instruct patient/family about testing for malignant hyperthermia risk -Refer patient and family to the Malignant Hyperthermia Association of the United Sttates -Report Incident to the North American Malignant Hyperthermia Registry at the University of Pittsburgh.
ANESTHESIA Table 17-1: Advantages & disadvantages of various types of anesthesia. Pg. 272. Advantages of General Anesthesia: Balanced (both IV and Inhalation route) ?
-Minimal disturbances to physiologic function -Minimal Side effects -Can be used with older and high risk patients
CONSIOUS SEDATION Used for what procedures?
-Minor surgical procedures. Diagnostic procedures. -Cardioversion. Wound care. -Reduction & immobilization of fractures. -Placement & removal of implanted devices, catheters, & tubes.
PACU ASSESSMENT: CARDIOVASCULAR (Response to Anesthesia & Cerebrovascular:) -Monitor:_____________. -Response to voice, touch, simple commands. -Nausea/vomiting:_________.
-Monitor: level of consiousness, movement/sensation in extremeties. -Nausea/vomiting: anti-emetic
ANESTHESIA Table 17-1: Advantages & disadvantages of various types of anesthesia. Pg. 272. Advantages of General Anesthesia: Inhalation route?
-Most controllable method -Induction and reversal accomplished with pulmonary ventilation -Few side effects
ANESTHESIA Table 17-1: Advantages & disadvantages of various types of anesthesia. Pg. 272. Disadvantages of General Anesthesia: Intravenous route?
-Must be metabolized and excreted from the bodyfor complete reversal -Contracindicated in presence of liver or kidney disease -Increased cardiac and respiratory distress -Retained by fat cells.
ANESTHESIA Table 17-1: Advantages & disadvantages of various types of anesthesia. Pg. 272. Disadvantages of General Anesthesia: Inhalation route?
-Must be used in combination with other agents for painful or prolonged procedure -Limited muscle relaxant effects -Postoperative nausea and shivering common.
PREOPERATIVE-PHYSICAL ASSESSMENT/MANIFESTATIONS Report any abnormal assessment findings to surgeon and anesthesia personnel:
-Neurologic Status -Musculoskeletal Status & Fall Risk -Nutrition Status -Psychosocial assessment
ANESTHESIA Table 17-1: Advantages & disadvantages of various types of anesthesia. Pg. 272. Disadvantages of Cryothermia?
-No way to control depth of anesthesia -Not used in long or extensive procedures -May not be appropriate for an anxious patient
WOUND EVISCERATION Treatment:
-Notiy surgeon. Remain with patient. Emotional support. -NG tube to decompress stomach (GA for sx). -retention sutures may be used
REGIONAL ANESTHESIA Explain the patient's state when receiving regional anesthesia?
-Patient is consious -Follows instructions -Intact gag and cough reflex-->decrease risk of aspiration
POSITIONS (INTRAOPERATIVE) How to prevent joint complications (stiffness, pain,inflammation,limited motion)related to intraoperative positioning?
-Place a pillow or foam padding under bony prominences -maintaiin the patient's extremeties in good anatomical alighnment -slightly flex joints and support with pillows,trochanter rolls, or pads.
GENERAL ANESTHESIA (GA) Table 17-2: The four stages of General Anesthesia & related nursing interventions. Pg. 272. Stage 4: Danger Nursing Interventions:
-Prepare for/assist in treatment of cardiac and/or pulmonary arrest. -Document occurrence in the patient's chart.
PACU: NURSING ASSESSMENT AND CARE (Airway & Respiratory Status:) The standard time intervals to check vital signs:
-Q15minX4-->Q30minX4-->Q2hourX4-->Q4hour24-24hours.
ANESTHESIA Table 17-1: Advantages & disadvantages of various types of anesthesia. Pg. 272. Advantages of General Anesthesia: Intravenous route?
-Rapid and pleasant induction -Low incidence of postoperative nausea and vomiting -Requires little equipment
For which client preadmission testing laboratory result does the nurse take immediate action? A.International Normalized Ratio 0.9 B.White Blood Cell Count 8500/mm3 ***C.Serum Potassium level 2.8 mEq/L D.Serum Sodium level 132 mEq/L
-Rationale: low K+-->causes ventricular arrythmias-->lethal. -Low or high K+ must be corrected before surgery
POST-ANESTHESIA CARE (PACU) What is the PACU?
-Recovery Room -Circulating nurse & anesthesia provider bring patient to PACU. -"Hand-off" report: Circulating nurse-->PACU nurse.
ANESTHESIA Table 17-1: Advantages & disadvantages of various types of anesthesia. Pg. 272. Advantage of Hypnosis/Hypnoanesthesia?
-Reflexes remain intact
ANESTHESIA Table 17-1: Advantages & disadvantages of various types of anesthesia. Pg. 272. Advantages of Cryothermia?
-Reflexes remain intact -Decreases chane of adverse reactions -Decreased intraoperative stress
ANESTHESIA Table 17-1: Advantages & disadvantages of various types of anesthesia. Pg. 272. Disadvantages of Hypnosis/Hypnoanesthesia?
-Requires patient cooperation -Requires special training
REGIONAL ANESTHESIA Symptoms of systemic toxic reaction to regional anesthesia?
-Restlessness -excitement -incoherent speech -headache -blurred vision -metallic taste -Nausea and vomiting -tremors -seizures -increase in HR, respiratory rate, & BP.
PREOP INTERVENTIONS Other interventions: Pre-op drugs on-call to OR (sign informed consent before they're given):?
-Sedative,hypnotic,opioid,Reglan,Zantac/Tagamet
PREOP INTERVENTIONS Skin preparation:
-Shower with antiseptic solution (several times) -Hair removal with electrical clippers/depilatories(best closer to time of surgery).
NURSING INTERVENTIONS Intra-procedure:?
-Stay with client at all times. -Assist provider. -Maintain safe environment. -Monitor LOC,cardiac and respiratory status -CRASH CART. -Equipment: Oxygen. Suction. IV. EKG. Pulse ox.
MALIGNANT HYPERTHERMIA Emergency Care for patient with malignant hyperthermia?
-Stop anesthesia -Intubate -Ventilate with 100% oxygen & highest flow rate. -Give dantrolene sodium (Dantrium) IV at 2-3 mg/kg.
PACU ASSESSMENT Proper way to position patient:
-Supine with head flat. -Side-lying (unresponsive/unconscious). -When fully reactive-->rasise head of bed-->increases respiratory expansion. -Spinal anesthesia: Do not elevate legs higher than placement on a pillow.
PATIENT POSITIONS (INTRAOPERATIVE) Factors influencing repositioning:
-Surgical site. Surgeon's request. -Age, weight, & size of patient. -Anesthesia delivery technique. -Pain on movement (if conscious). -Limitations: arthritis, joint replacements, emphysema, implanted devices.
PRE-OP:INFORMED CONSENT What if family is not available in an emergency?
-Telephone/telegram authorization and followed up with written consent as soon as possible. -Written consultation with 2 other surgeons if family not available to give any kind of consent.
MALIGNANT HYPERTHERMIA Emergency Care for patient with malignant hyperthermia?
-Terminate surgery if possible or use anesthesia that don't cause malignant hyperthermia -Assess ABGs and serum chemistry for metablic acidosis and hyperkalemia.
WOUND EVISCERATION What is wound evisceration?
-Total separation of all wound layers & protrusion of internal organs through the open wound. .
ANESTHESIA Type of anesthesia depends many factors:
-Type & duration of procedure (sx). -Location of surgical site. -Whether emergency vs. scheduled sx. -Post-op pain management. -Duration of NPO. -Patient position during sx. -Patient awake during sx (follow instructions). -Previous response to anesthesia.
PREOPERATIVE-PHYSICAL ASSESSMENT/MANIFESTATIONS Report any abnormal assessment findings to surgeon and anesthesia personnel:
-Vital signs -CV Status -Respiratory Status -Renal Status
NURSING INTERVENTIONS: Nurse is assessing what during post-procedure:?
-Vital signs -Level of consiousness -Fully awake. -All assessment criteria return to pre-sedation levels
PACU: NURSING ASSESSMENT AND CARE (Airway & Respiratory Status:) Vital Signs: Compare to _______. Look for _______.
-baseline -trends
LAB ASSESSMENT (preoperative) Chart 16-3 Laboratory Profile: Perioperative assessment. Pg. 249 - 250. Other conditions that may need to be evaluated by doctor before surgery occurs:
-change in mental status -vomiting -rash -recent administration of anticoagulant drug
PRE-OP: INTERVENTIONS Table 16-4: Preoperative teaching checklist. Pg. 252 Things to consider when planning individualized preop teaching for patients/families:
-coughing,turning,deep breathing -incentive spirometer (how to use,how to tell when to use correctly) -lower extremity exercises
LAB ASSESSMENT (preoperative) Chart 16-3 Laboratory Profile: Perioperative assessment. Pg. 249 - 250. Assess for and report s/s of infection:
-fever -purulent sputum -dysuria or cloudy,foul-smelling urine -any red, swollen,draining IV or wound site -increased white blood count
LAB ASSESSMENT (preoperative) Lab values that need to be reported:_________
-high or low K+ -high PT,INR,PTT -high WBC count
LAB ASSESSMENT (preoperative) Chart 16-3 Laboratory Profile: Perioperative assessment. Pg. 249 - 250. As part of the cardiopulmonary assessment, vital signs to report:
-hypotension/hypertension -heart rate less than 60 or more than 120 beats/min -irregular heart rate -chest pain -shortness of breath or dyspnea -tachypnea -pulse oximetry reading of less than 94%
GENERAL ANESTHESIA COMPLICATIONS: MALIGNANANT HYPERTHERMIA What are the symptoms?
-increase in metabolic rate (increase HR,Blood pressure) -muscle rigidity -high fever
GENERAL ANESTHESIA COMPLICATIONS: MALIGNANANT HYPERTHERMIA Problems that result from malignant hyperthermia:
-increased HR -dysrhythmias -muscle rigidity (jaw & upper chest) -decreased BP -increased respiratory rate -skin mottling -cyanosis -myoglobinuria.
POSITIONS (INTRAOPERATIVE) How to prevent Peroneal nerve complications (foot drop)related to intraoperative positioning?
-pad knees and ankles -maintain minimal external rotation of the hips -support the lower extremeties -be careful not to overtighten leg straps
POSITIONS (INTRAOPERATIVE) How to prevent Brachial plexus complications related to intraoperative positioning?
-pad the elbow if tucked at the side -avoid excessive abduction -secure the arm firmly on a padded armboard,positioned at shoulder level, and extended less than 90 degrees.
REGIONAL ANESTHESIA Treatment of complications (toxic reaction) from regional anesthesia?
-patent airway -oxygen -fast acting Barbiturates.
CONSIOUS SEDATION qualities of the patient during consious sedation?
-patient can respond to verbal stimulation -retains gag reflex -easily arrousable -maintains patent airway
POSITIONS (INTRAOPERATIVE) How to prevent Medial or ulnar nerve complications (hand weakness,claw hand) related to intraoperative positioning?
-place the safety strap above or below the nerve locations.
POSITIONS (INTRAOPERATIVE) How to prevent Tibial nerve complications (loss of sensation on the plantar surface of the foot) related to intraoperative positioning?
-place the safety strap above the ankle -do not place equipment on lower extremeties -urge OR personnel to avoid leaning on the patient's lower extremeties.
PACU: NURSING ASSESSMENT AND CARE (Airway & Respiratory Status:) Respiratory Rate less than________ and _____respiratory patterns--->the nurse should be alarmed.
-respiratory rate <10/minute -Shallow
PACU: NURSING ASSESSMENT AND CARE (Airway & Respiratory Status:) Check vital signs until _______ (Q15 min) or per______.
-stable -agency protocol
PRE-OP: INTERVENTIONS Table 16-4: Preoperative teaching checklist. Pg. 252 Things to consider when planning individualized preop teaching for patients/families:
-stockings and pneumatic compression devices -early ambulation -splinting -pain management
MALIGNANT HYPERTHERMIA Emergency Care for patient with malignant hyperthermia: What does the nurse monitor unitl the patient remains normal for 24 hours?
-temperature -ECG -ABGs -electrolytes -creatine kinase -coagulation studies -serium/urine myoglobin levels
SKIN CLOSURES What are retention sutures?
-used in addition to standard sutures-->patients at high risk for impaired wound healing. Obese, diabetics, and patient's on steroids.
A client brought to the holding area tells the nurse he has never had surgery before & is afraid of anything "medical." Which nursing action is most likely to reduce this client's anxiety? A.Administer the preoperative medication as soon as possible. B.Assure the client that his scheduled surgery is routine & that nothing will go wrong. ***C.Determine whether the client wants family members to be with him in the holding area. D.Explain to the client that this hospital's surgical area is the most technologically advanced in the city.
...
CONSIOUS SEDATION *LOOK AT ATI BOOK: PG. 1205*
...
Chart 16-3: Laboratory Profile: Perioperative assessment. Pg. 249 - 250.
...
MEMBERS OF THE SURGICAL TEAM Depends on the type of surgery: -Surgeon: Performs the procedure. -Surgical assistants. -Anesthesia provider: -OR Nursing Staff: Holding area nurses Circulating nurses Scrub nurses
...
NURSING INTERVENTIONS (Post-procedure:Discharge Criteria) -Patient can cough and deep breath. -Patient is able to tolerate oral fluids.
...
On admission to the preoperative area, the client scheduled for hip replacement tells the nurse that 3 autologous blood donations for surgery have been made in the past 3 weeks. What is the nurse's best action? A.Check the client's international normalized ratio (INR). ***B.Call laboratory to ensure that blood is physically at the operating facility. C.Ensure that the client has given consent to receive blood if a transfusion is necessary. D.Inform client that an autologous transfusion does not eliminate risk for development of bloodborne diseases.
...
PACU ASSESSMENT: CARDIOVASCULAR Monitoring urine output: needs to be minimum of 240 mL/8 hour shift or 720 mL/24 hours.
...
POST-ANESTHESIA CARE (PACU) Chart 18-1: Postoperative hand-off report. Pg. 285.
...
PREOP INTERVENTIONS Chart 16-6: Postoperative leg exercises. Pg. 257.
...
PREOP INTERVENTIONS It is the patient's right to refuse treatment. Advance Directives---> are followed in the OR!
...
PREOPERATIVE INTERVENTIONS PICTURES: Figure 16-2: Skin preparation of common surgical sites. Pg. 255.
...
Post-Op Med-Surg Unit Chart 18-2: The patient on arrival at the medical-surgical unit after discharge form the PACU. Pg. 288. Chart 18-3: Emergency care of the patient experiencing a Benzodiazepine overdose. Pg. 293. Chart 18-6: Management of postoperative pain. Pg. 298. Chart 18-7: Emergency care of the patient experiencing an Opioid overdose. Pg. 299.
...
The circulating nurse sees that a sponge is dropped onto the floor from the instrument table after the first surgical incision is opened. What is this nurse's best action? A.Obtain an additional sterile sponge to replace the contaminated one & place it on the instrument table. ***B.Place the sponge in the circulating area to include in the final count before incision closure. C.Pick up the sponge & throw it out so no one slips on it. D.Hand the sponge back to the scrub nurse.
...
WOUNDS.. Chart 18-5: Emergency care of the patient with surgical wound evisceration. Pg. 296.
...
PREOP INTERVENTIONS Vital signs taken __-___ hours before surgery.
1-2 hours before surgery
PRE-OP INTERVENTIONS Chart 16-5: Perioperative respiratory care. Pg. 256 Instructions for Expansion Breathing:
1. Sit upright with knees slightly bent 2.Place hands on each side of lower rib cage, just above the waist. 3.Take a deep breath through your nose,using shoulder muscles to expand your lower rib cage outward during inhalation 4.exhale, concentrating first on moving your chest, then on moving lower ribs inward, while gently squeezing the rib cage and forcing air out of the base of lungs.
PRE-OP INTERVENTIONS Chart 16-5: Perioperative respiratory care. Pg. 256 Instructions on Splinting of the surgical incision:
1. place pillow, towel, over surgical incision and hold firmly in place. 2.take 3 slow, deep breaths to stimulate cough reflex. 3.inhale through nose, exhale through mouth. 4.on the 3rd deep breath,cough to clear secretions from lungs while holding pillow against incsision.
PRE-OP INTERVENTIONS Chart 16-5: Perioperative respiratory care. Pg. 256 Instructions for Deep (diaphragmatic) Breathing:
1. sit upright (after surgery:fowler's or semi-fowler's) 2. Take gentle breath through your mouth 3.Breathe out gently and completely 4.Take deep breath through your nose and mouth, and hold breath to the count of five. 5.exhale through your nose and mouth.
PACU ASSESSMENT: CARDIOVASCULAR Monitoring Urine output: ______ml/hour is a red flag, and urine output should be monitored very closely.
50 mL/hour
PRE-OP: INTERVENTIONS NPO for easily digested solids?______ NPO for clear liquids?________
>6 hours for easily digested solids 2 hours for clear liquids
WOUND EVISCERATION What causes it?
After forceful coughing, vomiting, straining, & whether patient used splinting when moving.
GENERAL ANESTHESIA (GA) Table 17-2: The four stages of General Anesthesia & related nursing interventions. Pg. 272. Stage 1:
Analgesia and Sedation, Relaxation
SURGICAL SUITE When are the counts done for instruments, sharps, and sponges?
Before and during closure of a surgical wound Before complete closure
REGIONAL ANESTHESIA Action?
Briefly disrupts sensory nerve impulse transmission from specific body area/region
REGIONAL ANESTHESIA Signs of systemic toxic reaction?
CNS stimulation followed by CNS depression & cardiac depression
PACU: NURSING ASSESSMENT AND CARE (Airway & Respiratory Status:) Humidified O2.: use a pulse ox to measure o2 saturation and what does it need to be compared to?
Compare patient's o2 with their baseline
The client who had neck surgery to remove the entire thyroid gland is transferred to the medical-surgical unit after 4 hours in the PACU. The client reports difficulty swallowing. What is the nurse's priority action? A.Assess the client's respiratory status. ***B.Inspect the client's throat with a penlight. C.Adjust the position of the drain in the incision. D.Reassure the client that this is a normal & common problem after anesthesia.
Crust: from serum thats oozing
GENERAL ANESTHESIA (GA) Table 17-2: The four stages of General Anesthesia & related nursing interventions. Pg. 272. Stage 4:
Danger
PACU ASSESSMENT (Surgical Wound, Incision Site, &/Or Dressing:) Assess Drainage tubes_________ Dressings: ___________
Drainage tubes: patency and proper functioning Dressings: excessive drainage
GENERAL ANESTHESIA (GA) Table 17-2: The four stages of General Anesthesia & related nursing interventions. Pg. 272. Stage 2:
Excitement, Delirium
SURGICAL SUITE How is electrical safety implemented?
Grounding pad is properly placed.
GENERAL ANESTHESIA (GA) Administered via:
IV injection or inhalation.
GENERAL ANESTHESIA COMPLICATIONS: MALIGNANANT HYPERTHERMIA The pathophysiology of malignant hyperthermia?______
Increased calcium levels in muscle cells & increased muscle metabolism--> increase serum calcium & potassium levels--> increase metabolic rate-->acidosis, cardiac dysrhythmias, high body temperature
ANESTHESIA Anesthesia?
Induced state of partial or total loss of sensation, with/without LOC.
PREOPERATIVE ASSESSMENT: HISTORY (Allergies:) Shellfish--->_______________ Banana and other fruits--->________________
Iodine,Betadine latex
WOUNDS.... What should be done first when a wound evisceration is discovered by the nurse?
Lay down the patient.
NURSING INTERVENTIONS (Post-procedure:Discharge Criteria) Level of consiousness:? Vital signs:?
Level of consiousness: as on admission Vital signs: stable fro 30-90 minutes
Modified Aldrete Scoring Maximum total score:________ Score required for discharge:_______
Max score: 10 Score for discharge:9
CONSIOUS SEDATION Medications used: Dosage:
Medications: Opoids,anesthetics,benzodiazapines Dosage: Individualized and tirated.
MALIGNANT HYPERTHERMIA When does it occur?
Occurs: Immediately after induction, several hours into sx, or after anesthetic is removed.
GENERAL ANESTHESIA (GA) Table 17-2: The four stages of General Anesthesia & related nursing interventions. Pg. 272. Stage 3:
Operative Anesthesia,Surgical Anesthesia
MARK THE SPOT Who is supposed to mark the spot for surgery?
PATIENT/SURGEON TO MARK THE SITE WITH MARKER TO ENSURE CORRECT SITE.
POSITIONS (INTRAOPERATIVE) What complications need to be prevented related to intraoperative positioning?
Prevention of: -Brachial plexus complications -Radial nerve complications -Medial or ulnar nerve complications -Peroneal nerve complications -Tibial nerve complications -Joint complications
PACU ASSESSMENT Purpose of positioning the patient side-lying when they're unresponsive and unconscious?
Prevents hypotension and aspiration.
The PACU nurse is receiving a hand-off report from the nurse anesthetist & the circulating nurse for an 82-y/o client who had a 2-hour open reduction of a fractured elbow. For which reported information about the client or surgery does the receiving nurse ask the reporting team for more details? A.The client is Jewish. B.The estimated blood loss is 150 mL. C.The client reported an allergy to codeine. ***D.The total intraoperative urine output is 25 mL.
Ratioale: If there's adequate blood supply to kidney-->minimum urine output will be atleast 30 mL/hour.
A client is NPO for Sx scheduled to occur in 4 hours. It is now 9 am, & the client's regularly prescribed oral drugs (digoxin 0.125 mg, docusate [Colace] (stool softener)300 mg, & ferrous fumarate [Feostat] (iron)325 mg) are due. The physician will not be available until time of surgery. What is the nurse's best action? ***A.Administer digoxin with minimal water & hold the other drugs. B.Administer all medications parenterally. C.Administer all medications orally. D.Hold all medications
Rationale: Answer B and C: The nurse needs a Dr. order for different routes Answer A: Digoxin is a positive inotropic agent. It decreases contractility and HR--->better for cardiac functioning.
The client undergoing induction of anesthesia with succinylcholine (depolarizing blocker agent), begins to experience generalized muscle twitching. What the circulating nurse's best response? A.Call the anesthesia provider's attention to this response. B Ensure the client is secured to the table. C. Cover the client with a warm blanket. ***D. Document this expected response.
Rationale: Since it's the early stage (undergoing induction), and muscle twitching occur in the early stage-->just document the response.
The client scheduled for knee replacement surgery today performed all of the following actions yesterday. Which action is most important for the nurse to report to the surgeon? A.Took 50 mg of diphenhydramine (Benadryl) at bedtime. B.Smoked one pack of cigarettes instead of two C.Drank two 12-ounce glasses of beer. ***D.Took two aspirins three times.
Rationale: prevents platelets from sticking
NURSING INTERVENTIONS (Post-procedure:) When all assessment criteria return to pre-sedation levels--->
Remove monitors & emergency equipment from bedside.
SURGICAL SUITE Things that are done to increase patient safety:
Safety straps. Prevent hypothermia. Prevent skin breakdown. Counts: Instruments, sharps, sponges. Electrical safety:
PRE-OP:INFORMED CONSENT Surgeons Role: Nurse's Role:
Surgeon's Role: their responsibility (before sedation or surgery). Nurse's Role: -Clarify facts presented by surgeon. -Verify that consent form is signed (witness) -Contact surgeon if patient is inadequately informed-->document.
PRE-OP:INFORMED CONSENT What if the patient cannot write?
They sign an "X", which must be witnessed by 2 people.
SURGICAL SUITE The layout depeds on : .
Type of surgery. Equipment
MARK THE SPOT What is the "Time-Out" Procedure?
Verifying: Patient ID, correct side & site, correct patient position, correct procedure, correct implants or equipment
NURSING INTERVENTIONS (Post-procedure:Discharge Criteria) Voids: No:
Voids:able to pass urine before discharge. No: nausea vomiting, shortness of breath,dizziness
GENERAL ANESTHESIA COMPLICATIONS: MALIGNANANT HYPERTHERMIA What is it?
What is it? Chain reaction of symptoms (syndrome) triggered by certain drugs for general anesthesia
GENERAL ANESTHESIA (GA) Reversible LOC, induces--->
analgesia & amnesia, unconsciousness, loss of muscle tone & reflexes.
LAB ASSESSMENT (preoperative) Scheduled surgery is postponed until UTI is treated first with __________.
antibiotics.
PACU: NURSING ASSESSMENT AND CARE (Airway & Respiratory Status:) The nurse is looking for ______chest movement.
bilateral
LAB ASSESSMENT (preoperative) Chart 16-3 Laboratory Profile: Perioperative assessment. Pg. 249 - 250. Possible pregnancy and/or positive pregancy test--->
contraindication for surgery
PATIENT POSITIONS (INTRAOPERATIVE) Preserve patient's_________!
dignity
PRE-OP: INTERVENTIONS Patient teaching--->________
document!
PREOPERATIVE ASSESSMENT: HISTORY (Medications) Drugs that are allowed before surgery with a sip of water:
drugs for cardiac and respiratory disease,seizures,and hypertension
LAB ASSESSMENT (preoperative) Qualities of urine that need to be reported:________
dysuria or cloudy, foul-smelling urine-->sign of UTI
LAB ASSESSMENT (preoperative) UTI in surgical patient---->________
increase risk for post-surgery pneumonia because organisms travel to cause more infection.
PREOP INTERVENTIONS Items to be removed before surgery:
jewelry,dentures,prosthesis,contact lenses,wigs,glasses,etc.
WOUND EVISCERATION High risk patients:
obese,diabetics,immune deficiency, malnutrition,steroids
PREOPERATIVE ASSESSMENT: HISTORY (Drug and Substance Abuse) -Tobacco--->____________
pulmonary complications
PREOPERATIVE ASSESSMENT: HISTORY (Medications) Diabetics on insulin--->________________
reduced does of intermediate or long-acting insulin based on blood glucose level or regular insulin in divided doses.
CONSIOUS SEDATION Administer sedatives &/or hypnotics to a point where the patient is _______--> perform minor procedures without discomfort.
relaxed
PREOPERATIVE ASSESSMENT: HISTORY (Drug and Substance Abuse) -Alcohol/Substance use---->___________
response to anesthesia and pain medication,withdrawal s/s (delirium tremens)
PREOP INTERVENTIONS Procedures that require a special permit in addition to the standard consent?___________
sterilization,experimental procedures,intraocular lens implants
PRE-OP: INTERVENTIONS If recommended NPO time isn't followed by patient----->_____
surgery may be cancelled because it could result in aspiration---->pneumonia.
PACU: NURSING ASSESSMENT AND CARE (Airway & Respiratory Status:) Endotracheal tube: How long to use on patient? RR (< 10/min); pattern (shallow); breath sounds (air movement?); & bilateral chest movement. Vital Signs: Compare to baseline. Look for ______________. Per agency protocol. Until stable (Q 15 min).
use (suction secretions) until patient can maintain own airway.
