MedSurg EXAM 1: Dysrhythmias, PERI-OP
Paralytic ileus: abdominal wall distended, no visible intestinal movement, decreased peristalsis (can delay nutrition & length hospital stay)
Assess for distended abdomen, discomfort, vomiting, no flatus/stool passage Passage of flatus or stool is THE ONLY INDICATOR of forward propulsion of intestinal contents for the entire GI tract which MAY indicate resolution of paralytic ileus Constipation- caused by anesthesia, opioids, decreased activity, decreased oral intake Assess abdomen (inspect, auscultate, palpate) IN THAT ORDER Document eliminate pattern and amount Encourage ambulation asap to promote peristalsis Increased dietary fiber, hydrations, mild laxatives, bulk-forming agents, or enemas may alleviate constipation CLEAR LIQUIDS= Easy to digest, no color to help determine vomit color reason, helps with hydration
Sinus Bradycardia (SB)
HR: <60 bpm Regular rhythm P Wave: before each QRS, identical PR Interval: 0.12-0.20 sec QRS: <0.12 sec Normal response to sleep, well conditioned athlete. Looks like NSR except slower rate CAUSES--> diminished blood flow to SA node, suctioning, gag reflex, valsava maneuver, hypothyroidism, hypoxia. ALSO taking beta blockers and calcium channel blockers (like digoxin) *give glucagon for beta blocker overdose during SB myocardial o2 demand is decreased TREATMENT: ATROPINE 0.5mg ever 3-5mins up to 3mg or 6 doses - if we use all doses and still need more consider using epinephrine - if pt has dypnea (o2 sat below 94%) give oxygen - pacemaker checks are done on ambulatory care basis
Sinus Tachycardia (ST)
HR: >100 Regular rhythm P Wave: before each QRS, identical PR interval: 0.12-0.20 sec QRS: <0.12 sec SNS stimulation or vagal (PS) inhibition results in increased rate of SA node discharge which increases the HR *palpitations, restlessness, anxiety, cool, pale skin assess for- SOB, low BP + high HR, low o2 sat MAY CAUSE T WAVE INVERSION, ST ELEVATION OR DEPRESSION causes: anxiety, stress, excercise, caffiene, atropine, epi, dehydration, hypoexemia, hyperthyroidism, alcohol increase in myocardial o2 demand TREATMENT: teach pt to avoid substances and stress management antiarrythmics meds: beta blockers: propanolol, sotalol, metoprolol calcium-channel blockers: cardizem, verapamil
Sinus Arrhythmias (SA)
HR: Usually 60-100 bpm Irregular rhythm P Wave: before each QSR, identical PR Interval: 0.12-0.20 sec QRS: <0.12 sec HR increased during inspiration and decreases during exhalation. Has all characteristics of NSR except for its irregularity. no noted treated "normal abnormal"
interprofessional collaborative care
Home meds, adls, support, financial services All refers that need to be made are done by nurse (we are responsible to initiate these referrals we are often the first to hear about it Important for nurses to teach!! HYGIENE, WOUND CARE, SYMPTOMS AND SIGNS, NUTRITION SURGEON WILL DECIDE WHEN PT CAN RESUME SEXUAL INTERCOURSE AND OTHER ACTIVITIES REHAB APPOINTMENTS WILL HELP DETERMINE THIS AS WELL SO PT NEEDS TO GO TO THESE APPTS
A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound?
In the preoperative period
A female client is scheduled for a hysterectomy. While discussing the postoperative preparations the nurse determines that the client's understanding of the surgery is inadequate which nursing intervention would be performed
Notifying the surgeon that the client needs more information
NURSE ROLES WHEN PT IS GETTING EPIDURAL OR SPINAL INJECTION
Nurse stays with pt Nurse assists anesthesia provider Nurse helps position patient for injection and makes sure they're comfortable Nurses watches for any breaks in sterile technique Makes sure pt anxiety is reduced Observe for cns stimulation followed by cns and cardiac depression Protect airway Assess site for edema inflammation abscess Observe patient for behavioral or speech changes, or weird side effects
DURING EVISCERATION THE NURSE MUST
Position pt. Supine immediately, hips & knees bent, HOB 15°-20°( decreases pressure on that area and doesn't extend evisceration/opening) Create a sterile field with sterile towels Open & place items on sterile field Don sterile gloves Saturate abdominal dressings with warm saline solution Place moistened dressings over exposed viscera Place sterile, waterproof drape over dressings If NS (normal saline) not immediately available, cover wound with gauze & moisten with sterile NS as someone brings saline Do not attempt to reinsert the protruding organ or viscera Continue assessing pt., including VS, every 5-10 minutes until surgeon arrives Keep dressings continuously moist by adding warmed sterile saline to dressing as often as necessary Do not let the dressing become dry! Keep monitoring vital signs, stay with pt
Atrial Fibrillation (A-fib)
Problems: Lose the atrial kick = increase force generated by the atria which forces additional volumes of blood into ventricles (preload); Atria cannot properly pump blood to ventricles; Blood can pool and form clots; Ventricles cannot actively/forcefully push blood out or pump enough blood to the body, worry about decreased filling time and decreased CO Example: no discernible P's, F waves, Rate - 70, irregular rhythm, QRS - 0.06
Atrial Flutter (A-Flutter)
Problems: Ventricles will only beat when they fill up with enough blood; Blood can pool in the atria & form clots which can travel to the brain. AV nodes block contraction Example: atrial rate 250-350, ventricular variable depending on what is conducted. P waves look like flutter saw-tooth, QRS usually normal, may be wide CAUSES: surgery or underlying condition(hypertrophy, CHF, CM) PT MAY EXPERIENCE: palpitations, sob, fatigue, weakness TREATMENT: meds to stop flutter, slow HR, treat symptoms anticoagulants to prevent stroke
REVERSAL AGENT FOR midazolam/Versed: benzodiazepine
Romazicon (flumazenil)
during the peri-op experience was is most important?
SAFETY is #1 priority thought the period period for all personnel (and education/advocacy comes close second!!)
What are all important roles of the nurse?
SAFETY, EDUCATION, KNOWLEDGE, REDUCING PT ANXIETY- MAKING SURE PT IS READY TO HEAR THE INFORMATION!!!- MOST IMPORTANT THINGS! YOU MUST REDUCE PT ANXIETY BEFORE YOU EDUCATE THEM BECAUSE THEY WANT REMEMBER ANYTHING SO ASSESSING THEIR READINESS TO LEARN ABOUT THEIR SURGERY!!!! ALSO ASK WHAT THEY ALREADY KNOW SO YOU CAN SEE IF ITS ACCURATE
A client had an abdominal cholecystectomy. Postoperatively, the client refuses to deep breathe and cough, saying, "It's too painful." The nurse should:
Schedule coughing and deep-breathing exercises after analgesic has taken effect.
Three days after bariatric surgery, the client puts the call light on and states, "I felt a 'pop' in my belly after I had a coughing spell." The nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence?
Sharp increase in serosanguineous drainage
INFORMED CONSENT
Surgeon is responsible for providing complete explanations of surgical procedure & having consent form signed before sedation is given & before surgery is performed- THE SURGEON •The nurse is not responsible for providing detailed information about the surgical procedure
POST OP DRESSINGS
Surgeon usually performs first dressing change Go in there with the surgeon to see what is underneath so you know how to dress it If dressing unravels or leaks before first dressing change just try to reinforce it (put more pads already on the dressings) if THAT saturates then you wanna call somebody to let them know so they can look at it
WHEN MALIGNANT HYPERTHERMIA HAPPENS SURGERY MUST STOP IMMEDIATELY AND INHALATION AGENTS MUST BE STOPPED TO PROTECT AIRWAY
TREATMENT FOR MH: Dantrolene sodium (skeletal muscle relaxant) is approved drug of choice usually 2-3 nurses mixing it to bring pt temp down= active cooling by usage of iced saline, ice packs, sterile iced NS lavage COOLING THE PATIENT WILL DECREASE TEMPERATIVE, METABOLIC RATE AND PREVENT SEIZURES AND COMA
The nurse signs as a witness to informed consent provided by the client which does the signature of the nurse imply SATA -
That the client's signature is authentic That the client has given consent voluntarily That the client appears to be competent to give consent
Ventricular Fibrillation (V-fib)
There is no effective heart-beat at all. Life threatening; death usually results in 3-5 min unless resuscitation is begun and unfavorable results if perfusion is not restored
LOCAL ANESTHESIA
Topical: applied to skin or mucous membranes of area to be anesthetized •Local infiltration: injected directly into tissue around an incision, wound, or lesion •Briefly disrupts sensory nerve impulse transmission from specific body area or region •Reduces sensory perception in a limited area •Motor function may or may not be affected •Pt. remains conscious & can follow instructions •Gag & cough reflexes remain intact •Risk for aspiration is low •May be supplemented with sedatives, opioid analgesics, or hypnotics
A client is transferred to the postanesthesia care unit after abdominal surgery. The client begins vomiting. What nursing action is most important when caring for this client?
Turning the client onto the side
emergent:
immediate intervention because of life threatening consequences (airway issues, traumatic accident, triple A, aneurysm, surgeries that need because patient will die fast without)
nurse must always do what before teaching the patient?
minimize any anxiety so patient is ready and competent to learn
a client receiving morphine by patient-controlled analgesia has a respiratory rate of 6 breaths/min. What intervention should the nurse anticipate?
naloxone(narcan) administration
WOUNDS- dehiscence
partial or complete separation of outer wound layers Apply sterile non adherent/telfa or saline dressing to wound Instruct pt to bend knees & avoid coughing Notify surgeon
On the third postoperative day after a subtotal gastrectomy, a client reports severe abdominal pain. The nurse palpates the client's abdomen and determines rigidity. Which action would the nurse perform?
patients vital signs
Elective
planned; correction of non-acute problem (no threat to life, first thing that was shut down during covid)
How would the nurse explain the purpose of early ambulation to a client who had surgery the previous day?
prevent blood pooling
Urgent
prompt intervention; may be life threatening if treatment is delayed > 24-48 hrs. (long bone surgeries, orthopedic issues like hip fractures because of possible bone shatters that can travel and cause thrombus/clots
POST OP DRAINS
provide exit route for air, blood, bile - help prevent deep infection/ abscess formation JP and hemovac- they don't work unless we create vacuum. Press down to create suction before we close it at the top
Outpatient /Ambulatory/Same-day Surgery:
pt. goes to surgical area day of surgery & returns home on same day (for some procedure they will numb a nerve for 6-8 hours for smaller surgeries-teach the patient you will NOT FEEL THE EXTREMITY) * May be cost-effective but also places more responsibility for post-op care on pt./family/caretaker
The nurse is providing the preoperative teaching to a client who is scheduled for abdominal surgery. The client is fidgeting, slightly diaphoretic, and asking simple questions, what is nurses priority
reduce patient anxiety
Which intervention is most important in preventing hospital-acquired catheter associated UTIs (CAUTISs)
removing the catheter
POST OP PERISTALSIS
surgery, opioid usage, F&E imbalances Assess peristalsis by auscultating bowel sounds in all 4 abdominal quadrants (if NG suction is on turn off before auscultation) remember to turn it back on! Abdominal cramping + distention= trapped, nonmoving gas Presence of active bowel sounds USUALLY indicates some peristalsis Absence of bowel sounds (hypomotility) does not confirm a lack of peristalsis Passage of flatus or stool is the best indicator of intestinal activity !!!!! MUST LISTEN TO BOWEL SOUNDS FOR CERTAIN AMT OF TIME (i think at least 5 minutes)
palliative
to increase the quality of life, reduce stressors on the body, relieve symptoms of a disease process
transplantation
to replace a malfunctioning structure ex: any organ transplant
Cosmetic
to reshape/alter/enhance normal body structures & personal appearance examples: RHINOPLASTY(CAN ALSO BE DEVIATED, OR RECONSTRUCTIVE), BREAST AUGMENTATION
curative
to resolve a health problem; repair or remove the cause example: laryngectomy (removal of cancerous tumor)
wounds- EVISCERATION
total separation of all wound layers with protrusion of internal organs Surgical emergency! CALL FOR HELP You stay with the pt Someone else should notify surgeon/rapid response team IMMEDIATELY Someone else bring needed supplies to pt room (sterile towels, irrigation set, abdominal dressings, steroid gloves)
Which issue related to antibiotic use is an increased risk for older adults
toxicity (also with anesthesia risk)
moderate sedation
used for dislocated joints Conscious sedation: IV delivery of sedative, opioid, to reduce sensory perception but allow pt to maintain a patent airways Commonly used for this: valium, versed, fentanyl, morphine Reduced LOC during short procedures Nurse monitors pt during and after procedure Ramsay sedation scale (LOC), airway, o2 sat, ECG status Vital signs monitoring every 15-30 mins until pt is awake and oriented
diagnostic baseline lab values
want to get a baseline on lab values before surgeries- can be done the day before, 24 hours in advance, etc, some common tests are HCG(pregnant), PTT(coagulation), BUN, CBC(wbc, rbc, hemoglobin, hematocrit, platelet) CREATININE, ALBUMIN, PROTEIN, GLUCOSE, HGBA1C, abg (OXYGENATION, PH, CARBON DIOXIDE)
The nurse is preparing to initiate antibiotic therapy for a client who developed an incisional infection. Which task would the nurse ensure has been completed before starting the first dose of intravenous antibiotics?
wound culture
A CBC, urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse?
"They are done to identify other health risks."
POST-OP respiratory
*PT TALKING IS NOT RELIABLE INDICATION FOR GOOD GAS EXCHANGE Listen to lungs, measure o2 sat POST OP DAY 2- this is when the HIGHEST INCIDENCE OF IMPAIRED GAS EXCHANGE & HYPOXIA OCCUR AFTER SURGERY If o2 sat drops below 95% or below pts pre-op baseline NOTIFY RAPID RESPONSE &/OR SURGEON OR ANESTHESIA Pt may need reversal agent if overly sedated or exhibiting respiratory depression (<10 breaths/min) Benzodiazepines (versed, ativan)- reverse with flumazenil/romazicon Opioids (morphine, dilaudid)- reverse w naloxone/narcan IF YOU DON'T HAVE ORDERS FOR MEDS YOU CAN HELP BY: Thermoregulation: prevent shivering (increases oxygen demand) (keeping patient warm) Position to promote respiratory function: raise HOB, semi-fowlers unless contraindicated Help patient out of bed and ambulating asap TCDB- TURN COUGH DEEP BREATHE, splinting, IS (incentive spirometer)
EKG- standard speed of 25 mm/sec
1 small box = 0.04 seconds 5 small boxes = 1 large box= 0.20 seconds 5 large boxes = 1 second 30 large boxes = 6 seconds (typical strip looks at 6 seconds) vertical lines are 15 large blocks= 3 seconds
Surgical care improvement project (SCIP)
A plan for reducing & eliminating preventable surgical complications Core measures identified as actions required for prevention of these complications in patients identified as at risk Focus on infection prevention, prevention of serious cardiac events, prevention of VTE
EKG RHYTHM Dubin's method
300/# of large boxes. 300/3 would = 100 bpm R TO R interval MUST BE REGULAR. cannot use this method for irregular rhythm.
The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified?
A nosocomial infection is acquired in a health care setting.
PAIN post-op
Acute pain can be due to: tissue manipulation, surgical wound/incision, surgical positioning, drain placement, endo tube, pts pain experience Pain is subjective- the pt will report pain Pain management is important - prevent complications and promote rehab Assess both physical and behavioral signs of acute pain- crying, shaking, withdrawing Plan activities around analgesia to improve mobility ALWAYS reassess pain for effectiveness & side effects Monitor for respiratory depression
Malignant Hyperthermia
Acute, life-threatening, inherited muscle disorder (MH & genetic testing) Complication of anesthetic agents Most sensitive indication is unexpected rise in end-tidal CO2 (EtCO2 , usually 35-45 mmHg) with a decrease in oxygen saturation & tachycardia Other manifestations: tachycardia, dysrhythmias, muscle rigidity (esp. Jaw- can lead to difficulty getting oxygen if they have a tube & upper chest), hypotension, tachypnea, skin mottling, cyanosis, myoglobinuria- protein in urine, urine changes color
Which collaborative and nursing actions would help prevent venous thrombosis in a client during the perioperative period?Select all that apply. One, some, or all responses may be correct
Administer subcutaneous heparin injections. Assist the client to don antiembolism stockings. Apply pneumatic compression devices to the legs..
NURSE ROLES IN PRE-OP PERIOD
Ensure safety Pt readiness for surgery Pt knowledge Educational needs Reduce anxiety reduce/prevent complications Promote adherence validate , clarify, reinforce info pt receives from surgical team ID problems that warrant further assessment or intervention before procedure Communicate & collaborate with surgical team Coordination of care
DURING POST-OP ASSESSMENT
Airway, breathing, circulation and mental status- initially focused on Then move on to FULL head to toe assessment within first few minutes with the pt Look at surgical incision site, pt temperature, IV fluids
The nurse is assigned to care for a client experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair?
Allow the client to dangle the legs in a sitting position on the bed before transferring to a chair.
BLOODLESS SURGERY
Alternatives for pts. with religious or medical restrictions to blood transfusions Reduce the need for transfusion during & after surgery
When obtaining an admission history of a preoperative client, the nurse learns that the client is taking several herbal supplements. Which is the priority nursing action?
Ask the client which herbs have been taken
Which action would the nurse take first when doing preoperative teaching for a client who is scheduled for a total laryngectomy?
Ask what questions the client has about the procedure
POST -OP URINARY
Assess bladder distention (inspect, palpate, percuss lower abdomen) POST-OP URINE RETENTION- pt is making urine but isn't able to void (anesthesia, drugs, surgery) Bladder scanner can be used Assess urine color, clarity, amount Report UOP <30 ml/hr (240mL per 8hr nursing shift) to provider/surgeon and any abnormal If <30ml/hr for 2 consecutive hours report to the surgeon. A temp higher than 100f or lower than 97f and a falling systolic BP <90 report immediately UA, urine electrolytes, serum creatine May need intermittent cath to empty bladder Order will indicate cath need (if you are getting more than >350 ml they might want you to leave cath in) If foley is placed during surgery, removal by post op day 2 (SCIP) (SURGICAL CARE IMPROVEMENT PROJECT) PT SHOULD GO TO BR BEFORE SURGERY PT SHOULD BE NPO 12 HRS BEFORE SURGERY DOC/SURGEON/PROVIDER DOES EVERYTHING RELATED TO PREOP PAPERWORK AND INFORMED CONSENT
A client is scheduled for head and neck surgery. Although the healthcare provider has explained the surgery, the client still has moderate to severe anxiety. Which action should the nurse take initially?
Attempt to discover what the client is concerned about.
the child is given midazolam preoperatively. for which purpose is the nurse administer this medication
induce sedation
A client is receiving patient-controlled analgesia (PCA) after surgery. Which benefit would this type of therapy provide? Select all that apply. One, some, or all responses may be correct.
Client is able to self-administer pain-relieving medications as necessary, Decreases client dependency, Increases client sense of autonomy
TIME-OUT
Conduct immediately before starting the invasive procedure or making the incision Designated team member starts time-out Conducted in OR suite, but also used for procedures done on the units/floors and other departments** Standardized Involved procedure team (anesthesia providers, circulating nurse, operating room tech, person performing procedure, etc) During time out team members agree on- correct pt identity, correct site, procedure to be done EVERYBODY HAS TO AGREE!!! Document the completion of the time-out
Which finding in a client who has just returned to the nursing unit after having the right upper lobectomy requires the most rapid action by the nurse?
Deviation of the client's trachea to the left side
Which action would the nurse take when observing that a postsurgical client has a urine output of 800 ml total in the first 24 hours after surgery?
Document the normal finding, 800-1500 mL is normal first 24 hours after surgery (you want AT LEAST 30 ML every hour)
what is important to do after surgery to aid in recovery?
Encourage the client to ambulate multiple times daily
da vinci surgical system approved in 2000
FIRST TOOL TO BE APPROVED TO DO MIS, shows how accurate this technology is (peeling skin off of a grape)
post-op NG TUBE
FOLLOW SURGEON ORDER IF YOU CAN MANIPULATE THE NG TUBE IN ANY WAY Usually low suction, either continuous or intermittent per order Assess secured to nose, skin irritation, patent, placement Document amount, consistency, color, odor
A postoperative client has 180 mL of urine in the urinary drainage bag from the past 8 hours. For which condition would the nurse monitor
renal failure
Nursing action after a client has had general anesthesia are directed at preventing postoperative respiratory complications
General anesthesia is a common cause of atelectasis.
Normal Sinus Rhythm (NSR)
HR: 60-100 bpm Regular Rhythm P Wave: Before each QRS, identical PR Interval: 0.12-0.20 sec (3-5 small boxes) QRS: <0.12 sec (usually 0.06-0.10 1.5-2.5 small boxes) originating from the SA node equal spacing between R's and identical p waves
Premature Atrial Contraction (PAC)
HR: N/A Irregular rhythm P Wave: premature and abnormal or hidden PR Interval: <0.20 sec QRS: <0.12 sec May lead to more serious dysrhythmias. P wave shape differs and they may be hidden PAC usually followed by pause. causes--> stress, fatigue, anxiety, caffiene, electrolyte imbalance, infection, ischemia TREATMENT-> stress management and avoiding substances that cause atrial irritation. Usually asymptomatic feels like heart is skipping beat bigeminy, trigeminy, quadrigeminy
Which statement given by the client indicated the need for further teaching about the postsurgical care that needs to be taken after eye surgery
I will wait for more obvious signs of infection before reporting to my primary health care provider
liver or kidney impairment can
INCREASES ANESTHESIA EFFECTS this is a risk for TOXICITY (look for this in older adults)
Periop- Safety Initiatives National Patient Safety Goals (NPSGs)
Identify pts. correctly (i.e., 2 identifiers) Improve staff communication (i.e., timely report of important results) Use medicines safely (i.e., labeled, blood thinners, med reconciliation) Use alarms safely (audible, alarm response) Prevent infection (i.e., hand hygiene) Identify pt. safety risks (i.e., suicide) Prevent mistakes in surgery (TJC Universal Protocol) Correct procedure, correct pt., correct body location, Mark correct place on pts. body where surgery is to be done, Pause before surgery to make sure mistakes are not being made
Which is the first sign that would help the nurse in diagnosing malignant hyperthermia in a client
Increased expired carbon dioxide
Artifact
Interference seen on monitor or rhythm strip. Can be caused by pt movement, loose or defective electrodes, improper grounding, or faculty equipment
Regional anesthesia (type of local anesthesia that covers a larger area)
MAY BLOCK MULTIPLE PERIPHERAL NERVES Good for pain management after surgery Field block: injections around operative field Nerve block: injection into 1 nerve or group of nerves in area Spinal: injection into CSF in subarachnoid space Epidural: injection in epidural space
REVERSAL AGENT FOR morphine; hydromorphone/Dilaudid: opioid analgesics
NALOXENE/NARCAN
what is the nurses role with diagnostics?
NURSE MUST MAKE SURE ANY PRE OP DIAGNOSTICS THAT ARE ORDERED ARE ACTUALLY PLACED AND COMPLETED AND MUST REPORT ANY ABNORMALITIES TO ANESTHESIA AND sSURGERY TEAM
The preop period- assessment history
NURSE MUST VALIDATE INFO Every pt must have a history that should be looked over before surgery Exs that would be on it: allergies, medications, family history with anesthesia, medical history, surgical history, and Any system disease or disorder that may affect CO, perfusion, oxygenation, gas exchange, pharmacokinetics, F&E balance, the pt's. ability to sense, communicate, or follow commands
Agonal Rhythm and Asystole
Need to confirm unresponsiveness, call 911 or emergency response team, gather AED or defibrillator, CAB- compressions (100/min), airway, breathing (30 to 2 ratio)
Which statement needs correction regarding obtaining informed consent from clients?
Obtaining informed consent is an important part of the nurse-client relationship; it is vital to nursing duty- FALSE informed consent is the providers duty
PAIN MANAGEMENT
Opioids, non-opioids analgesics, nsaids, anxiolytics (anxiety),relaxation technique, positioning hydroMorphone/dilaudid is 10x more potent than morphine Common: morphine, dilaudid, oxycodone/percocet/percodan/aspirin/acetaminophen, ketorolac/toradol, ibuprofen Also common: drug therapy, diverso=ion, meditation, massage, breathing exercises, music, rest, ice, etc As soon as we can change pt to iv to oral that is priority Important to make sure pain dosage doesnt mask symptoms (pain can be a sign that there is a surgery complication) important to always assess pain
The nurse is providing post operative care to a client after an abdominal surgery. Which assessment finding would be reported to the surgeon immediately?
Oxygen saturation drops to 90%
The nurse would primarily focus on which concept when providing preoperative teaching
Providing general information to reduce client and family anxiety.
Premature Ventricular Contraction (PVC)
QRS is wide and bizarre. No P wave preceding. May be felt as a skipped beat. Become problematic when they occur more than once/frequently, in a patten
Ventricular Tachycardia (V-tach)
Rapid ventricular rate - 150, no P's or QRS, cardiac output will decrease. This rhythm will decompensate to another dysrhythmia
Atrial Tachycardia
Rate: 150-250 beats per minute Regularity: regular P-waves: may be upright or inverted will appear different from underlying rhythm QRS-complex: Normal PR interval- may be normal, shortened, or prolonged
Minimally invasive surgery (MIS)
Reduced surgery time for some surgeries Decrease chance for infections Smaller incisions Reduced blood loss Faster recovery time Less pain after surgery insufflation - Does not totally guarantee the procedure will not need to become an open surgical procedure
SBAR hand-off
Situation Background Assessment recommendation/request SHOULD BE ABLE TO SAY ALL THE INFORMATION IN 3 MINUTES OR LESS
ERYTHROPOIETIN
Stimulating pt's. own RBC production with epoetin alfa (erythropoietin) - naturally occurs in our body, helps stimulate rbc production, can give it in synthetic form (in IV, in meds) to help stimulate patient own RBC production
POST OP WOUNDS
THE CDC DEFINES SURGICAL SITE INFECTIONS AS OCCURRING 30 DAYS POST OP Pts at risk for wound infection may receive antibiotic therapy before & during surgery (SCIP) NEED FOR ANTIBIOTIC RE-EVALUATED AT 24 HOURS POST-OP No indication of infection= discontinued antibiotics Prosthetic (ex:hip replacement)= bathed in liquid antibiotic and irrigate it with antibiotics during implantation Asses for healing and infection- redness, warmth, edema, tenderness, pain, drainage •Risk factors for delayed wound healing: age, health status, malnutrition, obesity, diabetes, smoker, immunocompromised, infection, size & location of wound, stress on wound, blood flow to wound area
NURSES ROLE WITH INFORMED CONSENT
The nurse is not responsible for providing detailed information about the surgical procedure nurse roles: Clarify facts that have been presented by the surgeon Dispel myths the pt./family/caregiver may have about surgical experience Verify consent form is signed, dated, timed May serve as witness to signature, not to adequacy of pt. understanding (NURSE DOES NOT DECLARE COMPETENCE) Contacting surgeon & requesting he/she see pt. for further clarification if you believe pt. has not been adequately informed or any discrepancy→ Document this action in the medical record
Supraventricular Tachycardia (SVT) (AT), (PSVT), (PAT)
There is no T-wave, meaning there is no time for the heart to repolarize and fill with blood rapid stimulus of atrial tissue can start suddenly, can be intermittent, can stop suddenly HR- 100-280 bpm or greater p wave may or may not be visible, they are not coming from SA node pt will experience: palpitations, fluttering, dizziness, SOB, anxiety, CP, fatigue, hypotension, weakness TREATMENT: vagal maneuvers: bearing down, ice on face 1ST DRUG OF CHOICE: adenosine 6mg-12mg-12mg (can cause asystole) stop the heart with electric and allow atria to reboot catheter ablation long term beta blockers or calcium channel blockers
Which finding by the nurse is the best indicator that ,measures to prevent postoperative atelectasis after abdominal surgery have been effective
Vesicular breath sounds heard over both lungs
Which non pharmacological nursing intervention is effective in helping relieve postoperative pain?
repositioning
A client is extubated in the post anesthesia care unit after surgery for which common response would be alert when monitoring the client for acute respiratory distress?
restlessness
IMPORTANT LAB VALUES TO KNOW
abnormal lab values assist the nurse in assessing if there is a contraindication to surgery or anything that should be reported as a potential complication White blood cell count (WBC) = 5,000-10,000/mm3, sodium (Na+) = 135-145 mEq/L, potassium (K+) = 3.5-5.0 mEq/L, and what should not be found in a urinalysis.
Which situation does the nurse consider to be the most appropriate method of obtaining informed consent?
after the primary healthcare provider has given a detailed explanation of the risks, benefits, and alternatives to the procedure.
Which items would the nurse include in assessment of the integumentary system for a preoperative client? Select all that apply. One, some, or all responses may be correct
assess, examine, question
general anesthesia
reversible loss of consciousness Single or multiple agents Analgesia and amnesia Muscle relaxation and reduced reflexes
diagnostics help us determine:
baseline information for that pt, anesthesia type and amount , any risks
intraoperative
begins when pt enters surgical suite and ends at time of transfer to PACU, ICU, etc (PRE OP HOLDING, ACTUAL SURGERY, EVERYTHING UP UNTIL TRANSFER TO UNIT AFTER SURGERY ENDS)
preoperative
begins when pt is scheduled for surgery and ends at time of transfer to surgical suite (EVEN IF SURGERY IS SCHEDULED 3 MONTHS AHEAD OF TIME)
postoperative
begins with completion of surgery and transfer of pt to a specialized area for monitoring *may continue after discharge from hospital until all activity restrictions have been lifted (ends once they have been released and free from ALL activity restrictions)
autologous blood donation
blood donation made by the pt. before their surgery date Eliminates transfusion reactions & reduces risk for acquiring bloodborne diseases Special tag placed on the blood bag & blood donor center gives pt. matching tag to wear or bring to surgical area before surgery (required by the American Association of Blood Banks)
EVIDENCE-BASED PRACTICE (EBP
comprised of three things RESEARCH, CLINICAL PRACTITIONERS EXPERIENCE, PREFERENCE OF THE PATIENT
Categories of Surgical Procedures - Purpose
cosmetic curative diagnostic palliative preventative reconstructive transplantation
EKG RHYTHM 6-SECOND STRIP
count # of QRS complexes in a 6 second strip and multiply that by 10 to determine HR - can use for irregular rhythm
A client is scheduled for gastrointestinal surgery. What is the most important nursing action that should be implemented the evening before surgery?
ensuring the bowel preparation is initiated
preventable "never events"
errors in medical care that are clearly identifiable, preventable; result in serious consequences for pts. - can result in death (ex; wrong patient, wrong body part, wrong surgery, wrong blood) indicate that there is a problem with the credibility of the place
with anesthesia we are worried about
gas exchange
Insufflation
injecting gas or air into the cavity before surgery to separate organs and improve visualization- MIS or laparoscopic surgery (in order for the surgeon to see they have to puff up the stomach/distend it to help improve visualization because of all the intestines. Patients might complain of right shoulder pain after this because of the gas)
commonly ordered pre-op drugs
midazolam/Versed: benzodiazepine for sedation, sleep, amnesia morphine; hydromorphone/Dilaudid: opioid analgesics
diagnostic
to determine the origin & cause of a disorder or cell type (CA); to diagnose or stage a condition example: biopsy
reconstructive/restorative
to improve functional ability on an abnormal or damaged body structure example: cleft lip/palate repair
POSTOP- CARDIOVASCULAR
•Monitor BP, HR, pulse quality (esp. apical with radial), heart sounds, rhythm •Peripheral vascular assessment to evaluate peripheral circulation 6 P's: Pallor (color), Poikilothermia (temperature), Pulselessness, Paresthesia (sensation), Paralysis (movement), Pain •VTE risk & appropriate prophylaxis for at least first 24 hrs. post-op (SCIP) anti-embolism stocking, pneumatic compression device - important to get right size, - Remove 2-3 times/day for 30 minutes for skin inspection & skin care Compression device: check pressures (usually 35-55 mm Hg) PATIENT SHOULD NEVER BE ON LEVAQUIN AND HEPARIN AT THE SAME TIME- question provided if both ordered
POST OP NAUSEA AND VOMITING
•Risks r/t general anesthesia, hx motion sickness, obesity, abdominal surgery, opioid analgesics, elevating HOB too fast/too soon •Complications: stress & irritate abdominal & GI wounds increase intracranial pressure with head & neck surgery elevate intraocular pressure with eye surgery increase risk for aspiration •Meds can be prescribed prophylactically in preop phase & also postop ondansetron/Zofran- TO HELP NAUSEA AND VOMITING
