care of the surgical patient
pain assessments
- 0 to 10 - pain is whatever the patient says it is - administer even when patient is sleeping to promote comfort - wake up patient if its a PO med - don't wake up for IV
adverse reactions of Dantrolene (Dantrium)
- HR >130 - muscle rigidity - cardiac dysrhythmias - hepatotoxicity
moderate sedation anesthesia
- IV - opioid, sedation, or hypnotic drug - endoscopies
prevention of dehiscence and evisceration
- abdominal binder (prevents opening) - splints
prevention of DVT
- activity - move legs in bed - fluids - SCDs - elevation of lower extremities - passive ROM - tes hoes - put pillow under knee to prevent constriction
anesthesiologist role
- administers anesthesia - intubates patient - monitors vital signs
risk factors for dehiscence and evisceration
- age - weak muscle and tissues - obesity - diabetes - corticosteroids
intraoperative complication: anaphylaxis
- allergy to meds - have antidote ready
risk factors for paralytic ileus
- anesthesia - pain meds - sedation - decreased physical activity
intraoperative complication: hypoxia/ respiratory complication
- aspirations - have suction available - monitor o2 levels - monitor RR and signs of hypoxia
interventions for pneumonia
- assess lung sounds - activity - antibiotics
nursing priorities when a patient is on antiemetics
- assess nausea and vomiting - IV potency, redness, swelling - assess 30-60 minutes after - I&0 - document quantity of emesis
nursing priorities when a patient is on ketorolac (Toradol)
- assess pain - vitals - labs H/H
interventions for atelectasis
- assess pain level - deep breathing - incentive spirometer - assess respiratory rate - lung sounds - o2 saturation
nursing priorities when a patient is on acetametaphine (Tylenol)
- assess pain level - make sure not to exceed 4 grams daily - give with food
nurse priorities when a patent is on opiods
- assess pain level - monitor vitals - o2 sat - monitor sedation level - Bms - LOC - respiratory rate
nursing priorities when a patient is on opiod agonists (non opioids)
- assess pain level 30-60 minutes after administration - vitals - o2 sat - sedation/ LOC - respiratory sounds - mindful of acetametaphoine dosing - give with food - assess BMs
nurse priorities when a patient is on ibuprofen (motrin)
- assess pain levels - vitals - labs H/H
preventing urinary retention
- assess the bladder for dissension - assess I&Os
preventing a paralytic ileus
- assess the patients last BM - assess labs - excess stool softener? - laxatives
risk factors for pneumonia complication
- atelectasis - no activity - pooling of secretions in lungs that leads to infections bc of stasis
intraoperative complication: nausea/ vomitting
- bc of the anesthesia - have basin ready
intraoperative complication: hypothermia
- cold environment makes patient at risk for hypothermia - cold IV solution - goal is to gradually warm up the patient
post op complication: infection risk factors
- contaminating a sterile OR - corticosteroids (decrease immune response) - diabetes
how does the nurse know that the antiemetic meds are working
- decrease or absence of N/V - increased foods/ fluid intake
how does the nurse know that the corticosteroids are working
- decreases inflammation - decreases pain - no reports of diarrhea - stable WBC, temperature, and blood glucose
signs of circulatory overload
- diminished breath sounds - lung crackles - abdominal distention - high BP - swelling in lower extremities - SOB
preventing atelectasis
- encourage activity - OOB - pain meds - deep breathing exercises - TCDB q2h
adverse reactions of antiemetics
- excessive sedation - respiratory depression
interventions for DVT
- fluids and activity
intervention for nerve complication: urinary retention
- foley cath or straight cath - offer bed pain - monitor I&O - assess abdomen for dissension - bladder scanner
adverse reactions of ibuprofen (motrin)
- gastric ulcers - bleeding - ototoxicity (hearing loss)
scrub role
- handles equipment - drapes patient - counts utensils before and after surgery - labels specimen
acetametaphine (Tylenol) adverse reactions
- hepatotoxicity - elevated liver function tests - jaundice
risk factors for DVT
- immobility - anesthesia sedation
risk factors for atelectasis
- immobility - no deep breathing
intraoperative complication: anesthesia awareness
- its possible for patients to remember what happened during surgery - monitor what you say!
interventions for dehiscence and evisceration
- lower HOB (less pressure on abdomen) - sterile supplies - sterile water - hand hygiene
interventions for post op infections
- may show S/S of infection 5 days after surgery (usually at home) - encourage pt to take antibiotics as prescribed - notify HCP if you suspect an infection at the hospital
interventions for maintaining a patent airway
- monitor pulse ox and respiration - raise HOB - apply o2 - deep breathing exercises - incentive spirometer
preventing pneumonia
- monitor temperature - o2 sat - activity
circulating nurse role
- monitors the activity of the surgical scene - assures surgical aseptic techniques - documentation - verifies surgical site - brings any specimen to lab
what are the two opiods
- morphine - hydromorphone (dilaudid)
intraoperative complication: infection
- must be a sterile environment - increased risk for infection - discard things that have been contaminated
spinal anesthesia complications
- nerve damage - headache - nausea/vomiting
spinal anesthesia complication interventions
- neuro assessment - positioning - medication - 6-8 hours bed rest - quiet environment - fluids (3L)
IV pain meds
- opioids - patient education - assess for fear of addiction - only used for a short period of time to decrease pain
what are the opiod agonist (non opioids)
- oxycodone- acetometaphine (Percocet) - hydrocodone- acetometaphine (Lortab)
PCA pain control
- patient controlled anesthesia - patient controls breakthrough pain - educate patient on how to use the pump before surgery - pt administers pain when the pain gets worse
nurse roles in the PACU
- post op - monitors patient for any complications - assesses surgical site - neuro checks - cardio and lung sounds - vital signs - ABCs
what are the Antiemetics
- promethlezine (Phenergan) - metoclopramide (Reglan) - prochlorperazine (Compazine) - ondansetron (Zofran)
evisceration
- protruding of intestines - cover w wet gauze and sterile water - emergency!!!
regional anesthesia
- pt is conscious - epidurals - injections
local anesthesia
- pt is conscious - numbs area
general anesthesia does what?
- puts patient to sleep - depresses nervous system - respirator breathes for patient
nursing priorities when a patient is on Dantrolene (Dantrium)
- recognize s/s of malignant hyperthermia - assess HR, temp, and urinary output - liver function tests
causes of airway obstructions
- relaxation of tongue- falling back - secretions - stridor
how does the nurse know the acetametaphine (tylenol) is working
- reports of decreased pain
how will the nurse know when opiod agonists (non opioids) are working
- reports of decreased pain
how would the nurse know that that ibuprofen (motrin) is working
- reports of decreased pain
how will the nurse know that the opioids are working
- reports of decreased pain - fewer non verbal indicators
adverse reactions of opioid agonists (non opioid)
- respiratory depression - decreased o2 - bradycardia - brandypnea - change in LOC - urinary retention
adverse reactions of opioids
- respiratory depression - decreased o2 sat - bradycardia - change in LOC
bed safety in the PACU
- sedation - rails up - bed low position - bed brake - call light in reach - bed pan - bed side commode - nurse assit to the bathroom
why would a patient be receiving hydromorphone (dilaudid)
- severe pain (8-10) - IV
preventing infections during surgery
- sterile OR - hand hygiene - antibiotics 1 hour after surgery - change the dressing properly - WBC count - vital signs
intraoperative complication: malignant hyperthermia
- temperature increases (late sign) - HR increases over 150 (early sign) - dysrhythmias when under anesthesia
adverse reactions of corticosteroids
- thromboembolism - hyperglycemia - decreased wound healing - fluid retention
oxygen use in the PACU
- until the patient is conscious - can take deep breaths on their own - make sure o2 is between 92-100 -try to arouse patient first to make sure they're responding
interventions for urinary retention
- urine should be 30 mL/ hour - urine 240 mL for 8 hours - assess bladder for distention - straight cath if bladder is full - bedside commode - bed pan - assist patient to the bathroom
nursing priorities when a patient is on corticosteroids
- vitals - labs - I&Os - weights (fluid retention) - assess wound/ skin condition - assess blood glucose
nurse to patient ratio in the pacu
1:1
nurse/ patient ratio in the PACU
1:1
monitor patient during surgery to make sure that at least ____ mL of urine comes out every hour during and after surgery
30 mL
acetametophine dosing
4 grams total daily, even when mixing!!!
The nurse determines that a patient has post op abdominal distention. What does the nurse determine that the distention may be directly related to? A.) a temporary loss of peristalsis and gas accumulation in the intestines B.) beginning food intake in the immediate post op period C.) improper body positioning during the recovery period D.) the type of anesthetic administered
A
The patient asks the nurse why the food is withheld before surgery. What is the best response by the nurse? A.) "aspiration is a concern and can be a complication if food or fluid is taken close to surgery time" B.) "distention is a severe complication if food or fluid is taken close to the surgery time" C.) "infection may occur if food or fluid is taken prior to surgery" D.) "obstruction will occur if food or fluid is taken prior to surgery"
A
what medication should the nurse prepare to administer in the event a patient has malignant hyperthermia? A.) dantrolene sodium (Dantrium) B.) Fentanyl citrate (Sublimaze) C.) narcan D.) Thiopental sodium (Pentobarbital)
A
when does the nurse understand the patient is knowledgable about the impending surgical procedure? A.) the patient participates willingly in the pre-op preparation B.) the patient discusses stress factors causing the patient to feel depressed C.) the patient expresses concern bout post op pain D.) the patient verbalizes feats to family
A
The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? SELECT ALL THAT APPLY A.) assisting the patient with leg exercises B.) encouraging early ambulation C.) massaging the legs q4h D.) avoiding placement of pillows or blanket rolls under the patient's knees E.) applying compression stockings only at night
ABD
what does the nurse recognize as one of the most common post op respiratory complications in elderly patients? A.) pleurisy B.) pneumonia C.) hypoxemia D.) pulmonary edema
B
A patient is complaining of a headache after receiving a spinal anesthesia. What does the nurse understand may be the cause of headache? SELECT ALL THAT APPLY A.) the patient lying in a supine position B.) leakage of fluid from the subarachnoid space C.) size of spinal needle used D.) degree of patient hydration E.) an allergic reaction to the medicine used
BCD
The nurse is concerned that a post op patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus? A.) abdominal tightness B.) abdominal distention C.) absence of peristalsis D.) increased abdominal girth
C
when should the nurse encourage the patient to get out of bed? A.) within 6-8 hours after surgery B.) between 10 and 12 hours after surgery C.) as soon as indicated D.) on the second post op day
C
why is assessment of dentition important in the patient preparing to have a surgical procedure with general anesthesia? A.) the patient may require referral to the dentist B.) oral hygiene is important for all patients C.) decayed teeth or dental prosthesis can become dislodged during intubation D.) the patient can sue if a tooth falls out during surgery
C
The nurse is assessing a post op patient's wound and observes a portion of the intestines protruding through the wound. What is the priority intervention for the nurse to provide? A.) apply an abdominal binder snugly so that the intestines can be slowly pushed back into the abdominal cavity B.) approximate the wound edges with adhesive tape so that the intestines can be gently pushed back into the abdominal cavity C.) carefully push the intestines back in D.) cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution
D
The nurse is caring for a patient who is at risk for malignant hyperthermia from general anesthesia. What is the most common early sign that the nurse should assess for? A.) hypertension B.) muscle rigidity C.) oliguria D.) tachycardia
D
what is the best response by the nurse when the patient states, " I'm so nervous about my surgery"? A.) "relax. your recover period will be shorter fi you're less nervous" B.) "stop worrying. it only makes you more nervous" C.) "you don't need to worry. your doctor has done this surgery many times before" D.) "would you like to discuss the concerns that you have?"
D
ON-Q pump
HCP controls pain medication on continuous rate - nurse does not control
CDC guidlines for antibiotics
OR nurse must give surgical patient antibiotics 1 hour before surgery so that the meds are at the peak during surgery to help prevent infection
what are the corticosteriods
Prednisone (Sterapred) Methylprednisone (Solumedrol)
The nurse assesses an older adult patient who complains of dimmed vision. What does this alert the nurse to plan for? A.) a safe environment B.) restrictions of the patient's unassisted mobility activities C.) probable cataract extractions D.) referral to an ophthalmologist
a
The nurse is caring for a patient who is obese prior to a surgical procedure. What surgical complications positively correlated with obesity should the nurse monitor for? SELECT ALL THAT APPLY A.) cardiovascular system B.) GI system C.) pulmonary systen D.) renal system E.) nervous system
abc
what are the non opioid drugs
acetometiphen (tylenol) ibuprofen (Motrin)
what are some intraoperative complications
anesthesia awareness nausea, vomitting anaphylaxis hypoxia hypothermia malignant hyperthermia infection
RN first assistant role
assists with suturing and helping surgeon
time out procedure
before surgery takes place - verifies right patient, location, and procedure
adverse reactions of ketorolac (Toradol)
bleeding
how often should the nurse check on the patient in the PACU
every 15 minutes
how does a nurse know that ketorolac (Toradol) is working
fewer reports of pain
post op complication: atelectasis
from immobility - pooling of lung secretions - collapsed alveoli
what is the NSAID
ketorolac (Toradol)
why would a patient receive Dantrolene (Dantrium)
malignant hyperthermia
why would a patient be receiving ibuprofen (motrin)
mild to moderate pain
when is tylenol used
mild to moderate pain (0-5)
why would a patient be receiving ketorolac (Toradol)
moderate to severe pain (6-10)
why would a patient be receiving morphine
moderate to severe pain (6-10)
why would a patient be receiving percocet or lortab
moderate to severe pain (6-10)
why would a patient be on antiemetics
nausea and vomiting
dehiscence
opening of surgical incision - risk for infection
sedation can cause...
respiratory sedation - monitor RR
how would the nurse know that Dantrolene (Dantrium) is working
s/s eliminated
risk factors for urinary retention complication
sedation from anesthesia
post op complication- paralytic ileus
slowing down of the bowels, stops moving
nerve complication: urinary retention
sometimes patient doesn't get the feeling that they need to go if theres no foley cath
interventions for nausea and vomiting
suctioning, anti emetics, basins
where would you assess for hemorrhaging
their back
why would a patient be on corticosteroids
to decrease any inflammation
Explain why the postoperative complications of atelectasis and hypostatic pneumonia are reduced as a result of early ambulation
ventilation is increased and the stasis of bronchial secretions in lungs is reduced
explain patient controlled anesthesia (PCA)
when the patient is feeling breakthrough pain their push the button on their pump to self administer their dose of pain meds
opioid agonists (non opioid) should be given when?
with food to decrease GI upset
