Surgical Part 3 & 4

The nurse is providing teaching about tissue repair and wound healing to a client who has a leg ulcer. Which of the following statements by the client indicates that teaching has been effective?

"I'll eat plenty of fruits and vegetables."

A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse?

"It assists in preventing infection." A wound drain assists in preventing infection by removing the medium in which bacteria could grow.

The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client?

"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis."

The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room?

7. The Aldrete score is usually between 7 and 10 before discharge from the PACU.

The nurse recognizes that which of the following clients is at the lowest risk for perioperative complications?

A client who has a history of arthritis. A history of arthritis does not increase the risk for complications during the perioperative period.

The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP?

Actions aimed at preventing surgical site infections. SCIP identifies performance measures aimed at preventing surgical complications, including venous thromboembolism (VTE) and surgical site infections (SSI).

The circulating nurse must be vigilant in monitoring the surgical environment. Which of the following actions by the nurse is inappropriate?

Allow unnecessary personnel to enter the OR environment.

A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate?

Apply a warm air blanket, gradually increasing body temperature.

When should the nurse encourage the postoperative patient to get out of bed?

As soon as it is indicated. Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery.

Postoperative return of consciousness

Assess Glasgow Coma Scale, Aldrete Scoring, AVPU.

A client has presented to the outpatient surgical center for a scheduled procedure. Which action should the nurse perform prior to the procedure?

Assess the client's allergy status.

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dL, and a blood pressure lying in bed of 110/70 mm Hg. The nurse suspects abnormal orthostatic changes when the client gets out of bed and reports vertigo. What vital sign value most supports the client's orthostatic changes?

Blood pressure of 90/50 mm Hg. The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis.

Scoliosis Treatment

Bracing or surgery may be needed if the spinal curve is moderate of severe. Maintain regular physical check ups.

Effects of Interaction with Anesthetics: Anticoagulants: Warfarin

Can increase the risk of bleeding during the intraoperative and postoperative periods; should be discontinued anticipation of elective surgery the patient should stop taking an anticoagulant, depending on the type of planned procedure and the medical condition of the patient.

Effect of Interaction with Anesthetics: Corticosteroids: Dexamethasone

Cardiovascular collapse can occur if discontinued suddenly. Therefore corticosteroids may be administered I.V. immediately before and after surgery.

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the:

Circulating nurse.

Traumatic Amputations

Complete vs. Incomplete Amputations. Causes: MVA, Construction Accidents, Firearms, Explosives, Defective Products (Grills, Appliances). Complications: Mobility, infection, phantom limb syndrome. Care: wrap amputated part in a dry, sterile gauze or clean cloth. Put wrapped part in a plastic bag or waterproof container. Place on ice. The goal is to keep cool but not cause more damage from cold ice.

What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities?

Coordinating surgical team. The person in the scrub role, either a nurse or a surgical technician, provides sterile instruments and supplies to the surgeon during the procedure by anticipating the surgical needs as the surgical case progresses.

A nursing measure for evisceration is to:

Cover protruding coils of intestines with sterile dressings moistened with sterile saline solution. If evisceration occurs, nurse aseptically covers abdominal contents with moist saline dressings to prevent drying of the bowel, notifies the surgical team immediately, and assesses patient's vital signs including oxygen saturation.

What medication should the nurse prepare to administer in the event the client has malignant hyperthermia?

Dantrolene sodium. Anesthesia & surgery should be postponed. However, if end-tidal carbon dioxide monitoring and dantrolene sodium are available and anesthesiologist is experienced in managing malignant hyperthermia, surgery may continue using a different anesthetic agent.

Immobilization Devices: Skin Traction

Distributing the force over a vast region of the skin and other soft tissues to impart traction to the bone.

Tonsillectomy: Post Op Teaching & Recovery

Drink plenty of fluids. Water, juices, and sports drinks. Soft foods such as ice cream, sherbet, yogurt, pudding, apple sauce, popsicles, and jello should also be encourages. Rest. Avoid hot or spicy foods, or foods that are hard and crunchy.

A fractured skull would be classified under which category of surgery based on urgency?

Emergent. Emergent surgery occurs when the client requires immediate attention.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

First intention. When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing.

The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of:

Hypoxemia and hypercapnia. The primary objective in the immediate postoperative period is to maintain pulmonary ventilation and thus prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced.

Effects of Interaction with Anesthetics: Insulins: Anticonvulsant Medications; Carbamazepine

I.V. administration of medication may be needed to keep the patient seizure-free in the intraoperative and postoperative periods.

A 9-month-old infant is scheduled for heart surgery. When preparing this client for surgery, the nurse should consider which surgical risk associated with infants?

Impaired thermoregulation. Infants have difficulty maintaining stable body temperature during surgery because the shivering reflex is not well developed, making hypothermia or hyperthermia more likely.

A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client?

Implement leg exercises and turn the client in bed every 2 hours. Ambulation and leg exercises increase circulation, which prevents cardiovascular complications.

The nursing instructor is talking with her class about spinal anesthesia. What would be the nursing care intervention required when caring for a client recovering from spinal anesthesia?

Instruct the client to remain flat for 6 to 12 hours.

Effects of Interaction with Anesthetics: Insulins: Insulin

Interactions between anesthetics and insulin must be considered when a patient with diabetes is undergoing surgery. I.V. insulin may need to be given to keep the blood glucose within the normal range.

Controlling Nausea & Vomiting

Intervene at first indication of nausea. Medications. Assessment of postoperative nausea, vomiting risk, prophylactic treatment.

Bariatric Surgery (2)

Is done to help you lose excess weight and reduce your risk of potentially life threatening weight related health problems, including: heart disease, stroke, high blood pressure, non alcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH), sleep apnea, type 2 diabetes.

Effects of Interaction with Anesthetics: Opioids: Morphine Sulfate

Long-term use of opioids for chronic pain, > 6 months, in the preoperative period may alter the patient's response to analgesic agents.

A nurse is receiving a client to the postanesthesia unit. What initial nursing activity is most important in the postoperative recovery area?

Maintain patient safety. The most important postoperative nursing function is maintenance of patent safety, with airway and circulation as priorities.

PACU Nursing Interventions

Monitor vital signs, airway patentcy, neurological status, manage pain, assess surgery site, assess and maintain fluid and electrolyte balance. Provide a thorough report to the receiving nurse on the patient's status to the receiving nurse on the unit as well as the patient's family.

A postoperative client with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate?

Obtain the wound culture specimen. Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. The culture should be obtained even though the client is not demonstrating traditional signs and symptoms of infection.

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?

Ondansetron (Zofran) is used to treat nausea and vomiting.

Indicators of Hypovolemic Shock & Hemorrhage

Pallor. Cool, moist skin. Rapid respirations. Cyanosis. Rapid, weak, thread pulse. Decreasing pulse pressure. Low blood pressure. Concentrated urine.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

Pink to red and soft, bleeding easily. In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily.

A nurse is assessing a client who is experiencing pulmonary embolus. What would be the priority nursing intervention for this client?

Place client in semi-Fowler's position. Nursing interventions include notifying health care provider immediately, calling the medical intervention team, maintaining the client on bed rest in the semi-Fowler's position, assessing vital signs frequently, administering oxygen, administering medications, and instructing client to avoid Valsalva maneuver

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?

Pneumonia. Older clients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications.

Post Anesthesia Care (PACU): Phase 2

Preparing the patient for self-care or family care or for care in a phase 3 extended care environment.

Preventive

Prophylactic removal of tissue.

The nurse is teaching the client who recently experienced abdominal surgery to deep breathe and cough effectively. What observable action serves to best minimize pain that may result from the intervention?

Providing support to abdominal and accessory respiratory muscles. Coughing and deep breathing uses abdominal and accessory respiratory muscles, which may have been cut during surgery.

Post Operative Complications

Respiratory Complications: Atelectasis, Pneumonia, Pulmonary Embolism, Aspiration. Urinary Complications: Acute Urinary Retention, Urinary Tract Infection. GI Problems: Constipation, Paralytic Ileus, Bowel Obstruction.

Responsibilities of the PACU Nurse

Review pertinent information, baseline assessment upon admission to unit. Assess airway, level of consciousness, cardiac, respiratory, wound, and pain. Check drainage tubes, monitoring lines, I.V. fluids and medications. Assess vital signs at the time of arrival to PACU and repeated per institution protocol. Administration of postoperative analgesia. Transfer report to another unit or discharge patient to home, continuing or transitional care.

A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?

Scrub nurse. The scrub nurse is sterile and assists the surgical team by handing instruments to the surgeon, preparing sutures, receiving specimens to be sent to the lab, and counting sponges and needles.

Which of the following techniques least exhibits surgical asepsis?

Suctioning the nasopharyngeal cavity of a client

The nurse is caring for a client who had abdominal surgery yesterday and is reluctant to cough and perform deep breathing. Which strategy will most likely increase the client's willingness to cough and perform deep breathing?

Teach the client how to splint the abdomen while coughing. Splinting the abdomen decreases discomfort while coughing.

The nurse is reviewing a list of surgical clients. Which clients would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period?

The 27-year-old client with non-insulin dependent diabetes. The 70-year-old client who takes no routine medications.

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client?

The client can be discharged from the PACU. Aldrete score is usually 8 to 10 before discharge from the PACU. Clients with score of less than 7 remain in the PACU until their condition improves or they are transferred to intensive care area, depending on their preoperative baseline score.

A nurse is teaching a client about diaphragmatic breathing. What client action indicates that further teaching is needed?

The client exhales forcefully with a short expiration. Diaphragmatic breathing should be performed gently and fully.

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition?

The client is displaying early signs of shock. The early stage of shock manifests with feelings of apprehension and decreased cardiac output.

A client recovering from surgery reports pain as 9 on a scale from 0 to 10. Which goal for pain control will the nurse identify as realistic for this client?

The client will be able to tolerate pain experienced.

The nurse is teaching a client about postoperative pain management. The client states, "I would like to use as little medication as possible after surgery. Will anything else help to relieve my pain?" Which response is appropriate?

There are several nonpharmacologic methods to reduce pain and anxiety. Let me teach you about some of them."

Immobilization: Skeletal Traction

This method involves applying force directly to the bone using metal pins that have been surgically implanted through the bone. Invasive.

Ablative

To remove a diseased body part

Curative

To remove diseased tissue specific to one area.

Transplantation

To replace organs or structures.

The nurse is taking a history on Kumar, who informs her that he has an allergy to adhesive tape. When the nurse asks Kumar to describe his reaction to the tape, he describes it as "blotchy and reddened." What type of allergic reaction is this?

Type IV. A type IV reaction is characterized by local inflammation, pruritus and erythema.

Following diagnostic testing, a patient requires a cholecystectomy. This surgical procedure would be categorized as which of the following?

Urgent. Acute gallbladder infection would be categorized as an urgent surgery.

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

Vitamin K is important for normal blood clotting.

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing?

Wound infection. Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.

When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of:

a partial airway obstruction. Loud, irregular respirations may indicate obstruction of the airway, possibly from emesis, accumulated secretions, or client positioning that allows the tongue to fall to the back of the throat.

A nurse explains the effects of conscious sedation to a client undergoing a colonoscopy. Which of the following occurs with conscious sedation?

altered mood. Conscious sedation is a type of anesthesia used for short procedures; the intravenous administration of sedatives and analgesics raises the pain threshold and produces an altered mood and some degree of amnesia, but the client maintains cardiopulmonary function and can respond to verbal commands.

Peripheral Nerve Blocks (PNB'S)

are used in conjunction with general or MAC anestesia, or as a stand-alone method. Instead of a single nerve being targeted, a bundle of nerves is located via ultrasound and injected with an anesthetic, opioid, or steroid.

The nurse knows the term perioperative phase refers to care given to the client:

before, during, and after the operative phase.

When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as

clean contaminated. Clean contaminated cases are those with a potential, limited source for infection, the exposure to which can largely be controlled.

The nurse recognizes that the older adult is at risk for surgical complications due to:

decreased renal function. Renal function declines with age, resulting in slowed excretion of waste products and anesthetic agents.

Gastroparesis

delayed gastric emptying as a result of injury to the vagus nerve due to surgery on your stomach, small intestine esophagus as well as diabetes, some autoimmune and CNS disorders or viral infections.

Spinal Anesthesia

involved injection through the dura mater into the subarachnoid space surrounding the spinal cord at the lumbar level, usually L4 and L5. It produces anesthesia of the lower extremities, perineum, and lower abdomen. For the lumbar puncture procedure, the patient usually lies on the side in a knee-chest position. Side Effect: Severe Headache.

Epidural Anesthesia

is achieved by injecting a local anesthetic agent into the epidural space that surrounds the dura mater of the spinal cord. The given medication diffuses across the layers of the spinal cord to provide anesthesia and pain relief.

Regional Anesthesia

is injected around nerves so that the region supplied by these nerves is anesthetized. The effect depends on the type of nerve involved. The patient receiving regional anesthesia is awake and awake of their surroundings unless medications are given to produce mild sedation or to relieve anxiety.

Diagnostic

to make or confirm a diagnosis.

The nurse is teaching leg exercises to the client preoperatively. The client asks why the exercises are important. The best response by the nurse is:

"Leg exercises help prevent blood clots in your legs." Leg exercises improve circulation of the lower extremities by preventing venous stasis, which can lead to deep vein thrombosis in the postoperative client.

Moderate Sedation

A form of anesthesia that involves the I.V. administration of sedatives or analgesic medications to reduce patient anxiety and control pain during diagnostic or therapeutic procedures.

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported.

Bucks Traction

A type of physical therapy practice commonly used for the management of femoral fractures (thigh bone fractures). The goals to maintain buck's traction position are to restore normal bone alignment and length, lessen or eliminate muscular spasms and reduce pressure on nerves.

Adverse Effects of Surgery & Anesthesia

Allergic reactions, drug toxicity, reactions, cardiac dysrhythmias (stress), CNS changes, over sedation, and under sedation. Trauma such as laryngeal, oral, nerve, skin, including burns. Also, hypotension and thrombosis.

Relieving Pain & Anxiety

Assess patient comfort. Control of environment such as quietness, low lights, noise level. Administer analgesics as indicated; usually short acting opioids I.V. Family visit, dealing with family anxiety. Non pharmacologic, emotional, and psychological support.

A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?

Assessing WBC count, temperature, and wound appearance. The client has an increased risk for infection related to the surgical wound, which is classified as dirty. Assessing the WBC count, temperature, and wound appearance allows the nurse to intervene at the earliest sign of infection.

Gerontologic Considerations

Decreased Physiologic Reserve. Monitor Carefully, Frequently. Increased Confusion. Dosage. Hydration. Thermoregulation. Increased likelihood of postoperative confusion, delirium. Hypoxia, Hypotension, Hypoglycemia. Reorient as needed. Pain.

A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following?

Decreased lean tissue mass. Elderly patients require lower doses of anesthetic agents because of decreased tissue elasticity and reduced lean tissue mass.

A term used to describe a partial or complete separation of wound edges is

Dehiscence is the partial or complete separation of wound edges.

A nurse asks a client who had abdominal surgery 1 day ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?

Encourage the client to ambulate as soon as possible after surgery. Ambulating stimulates peristalsis, which helps the bowels to move.

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

Evisceration

Immobilization: Halo Traction

For cervical fractures. You must move patient as a unit. Never pull on rods. Keep wrench at bedside for removal in emergency situations.

Bariatric Surgery

Gastric bypass and other weight-loss surgeries; known collectively as bariatric surgery. Involve making changes to your digestive system to help you lose weight. Bariatric surgery is done when diet and exercise haven't worked or when you have serious health problems because of your weight. Some procedures limit how much you can eat. Other procedures work by reducing the body's ability to absorb nutrients. Some procedures do both.

Anesthesia Types

General Anesthesia; Inhalation, I.V.; Stages 1 to 4. Regional Anesthesia; Epidural, Spinal, and Local Conduction Blocks. Moderate Sedation; Monitored Anesthesia Care aka MAC. Local Anesthesia.

Immediate Postoperative Interventions

Maintaining a patient airway, maintaining cardiovascular stability, hypotension and shock, hemorrhage, hypertension, arrhythmia's, relieving pain and anxiety, controlling nausea and vomiting.

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication?

Malignant hyperthermia is an inherited disorder that occurs when body temperature, muscle metabolism, and heat production increase rapidly, progressively, and uncontrollably in response to stress and some anesthetic agents.

Effects of Interaction with Anesthetics:Tranquilizers: Diazepam

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

Effects of Interaction with Anesthetics: Phenothiazines: Chlorpromazine; Hydrochloride

May increase the hypotensive action of anesthetics.

Maintaining Cardiovascular Stability

Monitor all indications of cardiovascular status. Assess all I.V. lines. Potential for hypotension or shock. Potential for Hemorrhage. Potential for hypertension or arrhythmias.

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?

Pink to red and soft, noting that it bleeds easily. Second-intention healing or granulation occurs in infected wounds or in wounds in which the edges have not been approximated. The necrotic material disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily.

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse?

Position the client in the side-lying position. The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits.

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

Position the client to maintain a patent airway.

Maintaining a Patent Airway

Primary consideration: necessary to maintain ventilation oxygenation. Provide supplemental oxygen as indicated. Assess breathing by placing hand near face to feel movement of air. May require suctioning. If vomiting occurs, turn patient to side.

Purpose of Post Operative Dressings

Provide healing environment. Absorb Drainage. Spint or Immobilize. Protect. Promote Homeostasis. Promote Patient's Physical & Mental Comfort.

Post Anesthesia Care (PACU): Phase 3

Providing ongoing care for patients requiring extended observation or intervention after transfer or discharge from phase 1 or phase 2.

Post Anesthesia Care (PACU): Phase 1

Providing patient care from a totally anesthetized state to one requiring less acute nursing interventions.

What complication is the nurse aware of that is associated with deep venous thrombosis?

Pulmonary embolism. Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing dressings or applying pressure if bleeding is frank

The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure?

Risk for perioperative positioning injury related to positioning in OR. Pressure ulcers, nerve & blood vessel damage, impeded respiration, hyperextended joints, & discomfort are risks associated with prolonged, awkward positioning required for some surgical procedures.

Reasons to Have a Tonsillectomy

Sleep apnea related to enlarged tonsils. Recurrent strep throat. Frequent chronic infections. Anesthesia Complications. Bleeding after Surgery. Infection.

Scoliosis: Surgical Options

Spinal Fusion. Expanding Rod. Vertebral Body Tethering.

Which stage of anesthesia is referred to as surgical anesthesia?

Stage III may be maintained for hours with proper administration of the anesthetic.

The nurse is caring for a client during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?

Temperature of 102.5°F (39°C). Intraoperative hyperthermia can indicate a life-threatening condition called malignant hyperthermia. The circulating nurse closely monitors the client for signs of hyperthermia.

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented?

The circulating nurse is responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented.

A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia?

The client can develop malignant hyperthermia up to 24 hours after surgery. Malignant hyperthermia usually manifests about 10 to 20 minutes after induction of anesthesia, can also occur during first 24 hours after surgery. Malignant hyperthermia can be triggered by inhalant anesthesia with muscle relaxants.

Bryant Traction

The majority of patients who receive this treatment are infants and young children who suffer hip fracture pathophysiology or congenital deformities of the hip. Both of the patient's legs are bent slightly at the knees and hips as they are held in a vertical position in the air at an angle of ninety degrees. A pulley system is used to slowly and progressively move the hips further away from the body over several days. The patient's own body acts as the counter-traction in this situation.

A client is at postoperative hour 8 after an appendectomy and is anxious, stating "Something is not right. My pain is worse than ever and my stomach is swollen." Blood pressure is 88/50, pulse is 115, and respirations are 24 and labored. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate?

The physician should be notified of the findings. The client may be hemorrhaging internally and may need to return to surgery.

Post Operative Complications (2)

Wound Complications: Infection, Dehiscence, Evisceration, Delayed Healing, Hemorrhage, Hematoma. Neurologic: Delirium & Stroke. Skin: Breakdown. Cardiovascular: Shock, Thrombophlebitis. Functional: Weakness, Fatigue, Functional Decline.

Scoliosis

abnormal lateral curve in the spine; shoulders that are not level; an asymmetric waistline; and a prominent scapula, which is accentuated by bending forward. May be congenital, idiopathic (without an identifiable cause), or the result of damage to the para spinal muscles.

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client?

experiences pain within tolerable limits. Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

first intention. Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention.

Moderate Anesthesia Care (MAC)

is moderate sedation given by an anesthesiologist or CRNA who must be prepared and qualified to convert to general anesthesia if necessary.

The nurse understands that the purpose of the "time out" is to:

maintain the safety of the client. Verification of the identification of the client, procedure, and operative site are essential to maintain the safety of the client.

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation. The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia.

Immobilization Devices: Manual Traction

meaning that the pull is applied physically using the hands.

A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia?

oxygen. Sevoflurane is an inhalation anesthetic always combined with oxygen to decrease the risk of coughing and laryngospasm.

Tonsillectomy

surgery to remove the tonsils. Tonsils are lumps of tissue on both sides of the back of the throat that help the immune system protect the body from infections. Most common childhood surgery.

Which findings would be indicative of a nursing diagnosis of decreased cardiac output?

tachycardia; hemoglobin 10.9 gm/dL; BP 88/56. Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.

Immobilization Devices: Traction

the process of slowly and gently pulling on a body part that has been fractured or dislocated. Ropes, pulleys, and weights are common tools used in the process.

Palliative

to relive or reduce intensity.

Reconstructive

to restore function

Constructive

to restore function in congenital anomalies