Nursing II Test 3 Client Care Surgical Experience

A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?

"I will support my incision with my hands when I cough and do my deep breathing exercises." Splinting of the incision provides support to the incision and helps to control pain, so this client statement is correct.

What to know about Dexamethasone

(Corticosteroids) Cardiovascular collapse can occur if discontinued suddenly. Therefore, a bolus of corticosteroids may be administered IV immediately before and after surgery.

Examples of non-invasive procedures that require informed consent:

- arteriogram - scans with dye - Radiation - Blood product administration

What does an informed consent include?

1. Clear explanation of surgery 2. Benefits and alternatives. 3. Possible risks/complications/disfigurement 4. What to expect post op.

What is a therapeutic range for apTT to be

1.5 - 2.5 times baseline values, or 60 - 80 seconds

How often should vitals and breath sounds be assessed upon arrival to nursing unit

15 minutes x 4 then every 30 minutes for two hours

what temp is an OR

68 - 73

How to treat surgically-induced hypothermia

78 - 80 degrees, warmed IV fluids, warm blankets, rewarm patients

What is an emancipated minor?

A minor who has proven to the court that they can legally sustain themselves without the help of their parents

clean-contaminated wound

A wound that occurs from the surgical entry of the reproductive, urinary, respiratory, or gastrointestinal system, oropharyngeal

Who is on the surgical team?

Anesthesiologist or CRNA Surgeon Circulating Nurse Scrub Nurse Surgical Technician Registered Nurse First Assist (RNFA's)

The purpose of withholding food before surgery is to prevent

Aspiration

Which blood chemistry is important for blood coagulability, neuromuscular activity, and automaticity of the nodal cells (sinus and atrioventricular nodes)

Calcium!

What is aPTT used to measure

Clotting status when the client is receiving HEPARIN

How do Anxiolytics (e.g., benzodiazepines) work with surgery

Control anxiety, calming pam/lam meds Alprazolam, clonazepam, diazepam, lorazepam, midazolam

Anxiolytics

Control anxiety, calming (pam and lam mediations like Diazepam)

Optional

Cosmetic surgery

Preoperative Phase

Decision for surgical intervention. Ends when transferred they're transferred to operating table.

Which implications can hypocalcaemia have for patients with cardiovascular disease?

Decreased calcium levels slow nodal function and impair myocardial contractility. The latter effect increases the risk for heart failure.

Diagnostic

Determines the cause of a particular health problem

What is Hydrochlorothiazide and what to know about it before surgery?

Diuretic, During anesthesia, may cause excessive respiratory depression resulting from an associated electrolyte imbalance.

A client with osteoarthritis receives a recommendation to have joint replacement surgery. For which type of surgery will the nurse plan teaching for this client?

Elective

__________ surgery means that the client should have the surgery even though failure to have the surgery is not catastrophic.

Elective

What type of surgery is intestinal obstruction/immediate therapy needed? gun shot wound

Emergent

Which INR is the target range for Warfarin

For most indications, the therapeutic range to achieve a target INR value of 2 to 3.

Which implications can hypercalcemia have for patients with cardiovascular disease?

Hypercalcemia potentiates digitalis toxicity, causes increased myocardial contractility, and increases the risk for varying degrees of heart block and sudden death from ventricular fibrillation.

A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for

Hypoglycemia The patient with diabetes who is undergoing surgery is at risk for both hypoglycemia and hyperglycemia. Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin. Hyperglycemia, which can increase the risk of surgical wound infection, may result from the stress of surgery, which can trigger increased levels of catecholamine. Other risks are acidosis and glucosuria, but hypoglycemia is a bigger risk. Dehydration is a lesser risk for a patient with diabetes than is hypoglycemia.

What is malignant hyperthermia?

INHERITED MUSCLE DISORDER!!! Chemically induced by anesthesia... muscle rigidity, damages nervous system and can lead to organ damage.

What to do if a person is on coriticosteriois

IV before and after surgery

What to do with medullary depression?

Immediately discontinue anesthesia, respiratory/cardiac support, narcotic antagonist if due to opioids

Diagnostic Surgery

Laparoscopy, biopsy, exploratory laparotomy

Which mineral is necessary for the absorption of calcium, maintenance of potassium stores, and metabolism of adenosine triphosphate, along with playing a role in protein and carb synthesis and muscle contraction?

Magnesium

Reconstructive/Cosmetic

Mamoplasty or a face lift.

What to watch for with regional anesthesia

Need to lay patient FLAT with spinal, hydrate because this can lower BP

Which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults

Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients.

Intraoperative Phase

Operating room to Post anesthetic or PACU

What to know about Morphine sulfate

Opioid, Long-term use of opioids for chronic pain (≥6 mo) in the preoperative period may alter the patient's response to analgesic agents.

Postoperative Phase

PACU to follow-up in clinical setting or home

Who does informed consent protect?

Patient and surgeon

When is palliative performed?

Performed to remove pain or symptoms of a disease process.

Which labs to check for liver function

Prothrombin time (PT) and bilirubin

Histamine Receptor Antagonists/antihistamines

Provide sedation and antiemetic effects (Hydroxyzine: diphenhydramine_

Who is the surgical team?

RN First Assist and PAs NPs

Histamine Receptor/H2 Receptor Antagonists

Reduce gastric acidity (Cimetidine, ranitidine)

A surgery like prosthetic hyperplasia, cataracts, thyroid disorders.. Few weeks to months surgery needed type:

Required

____________ surgery means that the client needs to have surgery within a few weeks or months.

Required

The nurse recognizes that the client who takes hydrochlorothiazide to manage hypertension is predisposed for which interaction with anesthesia?

Respiratory depression

Which stage of anesthesia should never occur and can lead to death?

STAGE 4

What does the scrub nurse do

Surgical Hand Scrub Setting Up the Sterile Equipment Tables & Sterile Field Preparing Sutures, Ligatures, & Special Equipment Assist Surgeon & Surgical Assistants Scrub & Circulator Count all Needles, Sponges, & Instruments Label all Tissue Specimens from Surgery Medication and Implant Labeling

When does thrombocytopenia occur?

The most common coagulation disorder is a deficiency of platelets, or thrombocytopenia , which occurs when platelet counts fall below 150,000 mm

What is there to know about MOA inhibitors and anesthesia?

They might increase the action of anesthesia

What to know about Levothyroxine sodium for surgery

Thyroid Hormone, IV administration may be needed during the postoperative period to maintain thyroid levels.

What is Diazepam and what is there to know about it with anethesesia

Tranquilizer - May cause anxiety, tension, and even seizures if withdrawn suddenly.

When a client with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the client may show signs of alcohol withdrawal delirium during which time period?

Up to 72 hours after alcohol withdrawal Alcohol withdrawal delirium is associated with a significant mortality rate when it occurs postoperatively. Onset of symptoms depends on when alcohol was last consumed. Twenty-four hours is too short a time frame to consider alcohol withdrawal delirium as no longer a threat to a chronic alcoholic.

The nurse would identify which vitamin deficiency to prevent hemorrhaging during surgery?

Vitamin K

Which nutrient plays an important role in normal blood clotting?

Vitamin K is important for normal blood clotting.

Which medication can increase the risk of bleeding during the intraoperative and postoperative periods; should be discontinued in anticipation of elective surgery.

Warfarin, anticoagulant

moderate or conscious sedation

a decreased level of consciousness in which the patient is not completely asleep. Patent airway.. Used in short term procedures.

A client is preparing for a surgical procedure is taking corticosteroids for Crohn's disease. What is most important for the nurse to monitor during the operative experience with the client?

adrenal insufficiency

Labs to check for kidney

albumin, creatnine, gfr

The nurse is reviewing information collected from a client during a preoperative assessment. Which condition(s) will the nurse highlight that increases the client's risk for a surgical complication?

asthma, arthritis, diabetes, and obesity (BMI 32)

What does decreased magnesium mean for the heart

atrial or ventricular tachycardias

What does decresased magnesium levle predispose patients to?

atrial or ventricular tachycardias

At what point are noises exaggerated during anesthesia

beginning

Gerontologic patients require less anethesia because

decreased tissue elasticity, reduced lean tissue mass, decreased plasma protein

Fatty tissue increases the risk for ____ with surgeries

dehiscence and wound infection

Rehabilitative

example: total knee replacement.

What complications can diuretics cause with surgery?

excessive respiratory depression associated with an electrolytes

Curative/repair

excision, removal of tumors, multiple wound repair.

What if BUN is elevated but creatnine is normal?

fluid volume deficit

Patient not arousable, client on a ventilator

general anesthesia

What could too much potassium do to the heart

heart block, asystole, ventricular arrythmias

What increased magnesium can mean for the heart

heart block, depressed contractility "broke ma heart slowly"

What type of shock is the most common from surgery?

hypovolemic

What is an I & D and what type of surgery is it?

incision and drainage URGENT surgery

how do antirrsrthmics increase surgical risk

may impair cardiac function during anesthesia

how do antibiotics increase surgical risk

may potentiiate the action of anesthetic agents

What type of med is naloxone

opioid

Signs of hypovolemic shock

pale, clammy, weak, rapid pulse, light-headed, hypotensive

Urgent

prompt attention: within 24 - 30 hours. Close fractures, infected wounds. Incision, Exploration, irrigation. I&D Incision and drainage...

What does an elevated BUN indicate

reduced renal perfusion or intravascular fluid volume deficit from diuretic therapy/dehydration

Which type of anesthesia is client awake and alert and includes epidural, spinal, and peripheral nerve block

regional anesthesia

What to watch for with general anesthesia?

respiratory depression and level of consciouness, turn head to side to drain secretions.

Which assessments are necessary for Preoperative

respiratory, cardiovascular, hepatic & renal, endocrine, immune

What to watch for local conduction blocks

sensation return

What to know about Carbamazepine

the Anticonvulsant Medication IV administration of medication may be needed to keep the patient seizure-free in the intraoperative and postoperative periods.

Second intention healing

the wound edges are widely separated, leading to a more time-consuming and complex reparative process

Palliative

to relieve pain

What could hypokalemia do to the heart

ventricular tachycardia or ventricular fibrillation

nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which post-surgical risk factor would decrease if the surgical client maintained strict blood glycemic control?

wound healing In caring for a postoperative client, the nurse is correct to correlate hyperglycemia with an increased risk of surgical incision infections and delayed wound healing. Strict control of glycemic blood levels at the therapeutic range of 80-110 mg/dL would reduce this risk factor.

A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery?

7 to 10 days

What types of food do you have to fast with and how long before surgery

8 hours after eating fatty foods and 6 hours after eating milk products

What is the blood glucose level goal for a diabetic client who will be having a surgical procedure?

80 to 110 mg/dL

Which of the following medications may increases the hypotensive action of anesthesia?

Chlorpromazine Chlorpromazine (Thorazine) may increase the hypotensive action of anesthetics. Prednisone (Deltasone) may cause cardiovascular collapse and should be discontinued immediately. Warfarin (Coumadin) can increase the risk of bleeding during the intraoperative and postoperative periods. Hydrochlorothiazide (HydroDIURIL) may cause respiratory depression resulting from an associated electrolyte imbalance during anesthesia.

Which drug classification may cause respiratory depression from an associated electrolyte imbalance during anesthesia?

Diuretics during anesthesia may cause excessive respiratory depression

What to do if a patient is refusing to sign the informed consent?

Document in EMR and inform the surgeon.

contaminated wounds

New trauma wound... open, traumatic wounds or surgical incisions in which a major break in asepsis occurred

circulating nurse

Not scrubbed, gowned, or gloved Remains in unsterile field Documents - monitors acitivitis of surg team - check OR conditions - continually assess patient for signs of injury - fire safety precautions Pretty much does everything that isn't sterile and makes sure everyone is sterile

The nurse is conducting a preoperative assessment on a client scheduled for gallbladder surgery. The client reports a frequent cough producing green sputum for 3 days and denies fever. Upon auscultation, the nurse notes rhonchi throughout the right lung, with an occasional expiratory wheeze. Respiratory rate is 20, temperature is 99.8 (taken orally), heart rate is 87, and blood pressure is 124/70. What is the best action by the nurse?

Notify the surgeon to possibly delay the surgery. A respiratory infection can delay a nonemergent surgical procedure because the infection can increase the risk for respiratory complications. Therefore, the nurse should notify the surgeon about delaying the surgery. The primary physician may be called to provide care based on the assessment findings, but that should be done only after the surgeon has been notified. Continuing through the preoperative phase without notifying the surgeon and waiting 1 hour then repeating the assessment are not appropriate.

Anticholinergic

Reduce oral and pulmonary secretions, prevent laryngospasms, prevent bradycardia (Atropines: chlopromazine)

Antibiotics

Reduce the microbial burden of intraoperative contamination to a level that cannot overwhelm host defenses Cephalosporins (e.g., cefazolin, cefoxitin), clindamycin, vancomycin

Elective

Repair of scars, vaginal repairs, hernia repairs

Which type of surgery needs prompt attention? Infected wound 24 - 30 hours.. Closed fractures

Urgent

________ surgery means that prompt attention is required within 24 to 30 hours.

Urgent

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Use diaphragmatic breathing. In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.

Which question is most important for the nurse to ask the client when obtaining the preoperative admission history?

When is the last time you ate or drank?" Consumption of food and fluids near to the time of surgery places the client at increased risk for aspiration.

How do diuretics increase surgical risk

alter fluid and electrolyte balance, esp potassium

dirty wound

an infected wound

What is significant to know about hypothermia related to intra operative complications?

anesthesia can cause body temp to drop, glucose metabolism reduced, metabolic acidosis develops. Bleeding, delayed wound healing, increased PACU stay, cardiac dysfunction

Who intubates the patient if necessary during surgery

anesthesiologist/crna

Required

cataracts...

What does an informed consent need to include?

clear & simple explanation, benefits, risks, what to expect postop.

Common adverse effects of opioids

constipation, nausea, orthostatic hypotension, respiratory depression, sedation, urinary retention

How do corticosteroids increase surgical risk

delay wound healing and increase risk for infection

How does aspirin increase surgical risk

increase risk for bleeding

how do anticoagulants increase surgical risk

increase risk for bleeding

how do antihypertensives increase surgical risk

increase the risk for hypotension and may interact with anesthetic agents to cause bradycardia and impaired circulation

how do opioids increase surgical risk

increase the risk of respiratory depression

how do tranquilizers increase surgical risk

increase the risk of respiratory depression

What indicates renal impairment

increased BUN and creatnine

how do NSAIDS increase surgical risk

inhibit platelet aggregation, increasing the risk for bleeding

apTT what to do for heparin if when

less than 50 seconds increase dose, greater than 100 seconds, decrease dose... normal range is usually 21 - 35

Which vitamin deficiency would delay wound healing?

magnesium

Which stage of anesthesia do we want to avoid because too much anesthesia was administered: respirations can become shallow, pulse weak, pupils dilated... cyanosis may occur, death follows?

medullary depression

First intention healing

method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation

Elective surgery examples:

non-catastrophic, repair of scars, hernia repairs, vaginal repairs

what is a normal aptt and what is therapeutic?

normal values ranging from 25 to 40 seconds therapeutic values: 60 - 80

Which type of diuretic can cause hypercalcemia

thiazides

When is PT Prothrombin time used and what is an effective therapeutic range for it?

to monitor level of anticoagulation with warfarin. 2 - 3

__________ surgery means that the client requires immediate attention for a life-threatening disorder without delay.

Emergent

Which complications can tranquilizers cause if withdrawn

anxiety

Food and fluid is held before surgery to prevent

aspiration

Which type of medication can cause cardiovascular collapse if discontinued abruptly?

corticosteroids

What to do in case of vomiting during excitement stage of anesthesia?

cricoid pressure

Exision, multiple wound repair, removal of tumor mass or inflamed appendix

curative/repair

what temp is reportable post op

less than 97 or more than 100 is reportable

Emergent

life threatening

Which diagnostics are used for hypertension:

lipid, CBC, urinalysis