Chapter 17: Surgical Care

preoperative checklist

Consent signed and on chart Allergies ID band(s) on patient Skin prep done Removal of dentures, glasses/contacts, jewelry, nail polish, hairpins, makeup TED stockings applied Preoperative vital signs Preoperative medications Physical disabilities and/or diseases History and physical and lab reports on chart -Blood type and screen are noted in chart -Valuables are given to family -Document last time patient ate or had something to drink

circulating nurse

-(Nonsterile member of team) -assists scrub nurses and surgeons -sterile scrubbing and gloving not necessary -account for used sponges, needles, and instruments during and after the case

scrub nurses

-(Sterile member of team) -assist surgeons -maintain sterile gowns, gloves, shoe covers -wear eye protection and caps -account for used sponges, needles, and instruments during and after the case

ambulation surgery

-Involves hospital stay which is less than 24 hrs. -These procedures are sometimes performed in hospitals -Sometimes pts go to ambulatory surgery centers where: • pt.is admitted • has surgery • recovers for a period of time • then is d/c home

anesthesia

-Local and regional anesthesia -General anesthesia -Moderate sedation

postspinal headache

-One complication of spinal anesthesia -more common in women, especially postpartum women, than in men. Keeping the patient flat for a specified period after spinal anesthesia may reduce the risk of headache.

preoperative pt teaching

-Patient teaching in physician's office, clinic, during preadmission workup, or after hospital admission -Teaching methods -• Direct teaching by the nurse used most often • Some hospitals have classes for all preoperative patients • Books, pamphlets, audiotapes, and videotapes

Surgery Classifications

-The seriousness of the patient's condition -The urgency of need for the procedure -The purpose for the procedure

general anesthesia

-acts on the CNS, causing loss of consciousness, sensation, reflexes, pain perception, and memory. -Combinations of drugs are used to achieve these effects without excessive CNS depression -Near the end of procedures performed under general anesthesia, the anesthetist or anesthesiologist administers drugs to reverse the effects of the anesthetic. -When the procedure is completed, a member of the surgical team escorts the patient to the postanesthesia care unit (PACU) and hand-off information is given. -Careful monitoring is maintained until the patient recovers from the anesthesia according to protocols.

preoperative phase

-begins when a decision is made to perform a surgical procedure and ends when the patient enters the operating room -During the preoperative phase, the goals of nursing care are for the patient to know what to expect in the surgical experience and to have minimal anxiety

Diagnostic surgery

-done to make an accurate diagnosis. -It often involves the removal and study of tissue, as with a biopsy of a skin lesion or the removal of a lump in breast tissue. -More extensive procedures require opening a body cavity to diagnose and to find out the extent of a disease process. A common example is an exploratory laparotomy, in which the abdomen is opened to find the cause of unexplained pain. -Some exploratory surgery can be performed using specialized scopes inserted into the body through small incisions

Epidural anesthesia and subarachnoid anesthesia

-examples of regional nerve blocks. This anesthesia is especially useful for surgical procedures on the lower abdomen and legs. -pose less risk for respiratory, cardiac, and gastrointestinal (GI) complications than does general anesthesia.

opioid analgesics

-meperidine hydrochloride (Demerol) -morphine sulfate (MS Contin, Duramorph)

sedatives/hypnotics

-pentobarbital (Nembutal) -secobarbital (Seconal) -chloral hydrate (Noctec)

tranquilizers

-promethazine hydrochloride (Phenergan) -hydroxyzine hydrochloride (Vistaril, Atarax) -diazepam (Valium) -chlorpromazine (Thorazine)

surgical team

-surgeon -assistant surgeon, a registered nurse first assistant (RNFA), or a physician assistant (PA) -RN -RNFA -LVN -anesthesia care provider (ACP) -Other technical personnel

local anesthetics administration

-topically, • by local infiltration, and • by nerve-blocking techniques.

chlorpromazine (Thorazine)

-use or action: Anticholinergic Sedative Antiemetic -side effects: Hypotension, dizziness, and fainting with parenteral administration Dry mouth, blurred vision, urinary retention, constipation Extrapyramidal symptoms: akathisia, parkinsonism, dystonias -nursing interventions: Keep patient in bed after parenteral administration Intramuscular (IM) dose: inject slowly, deeply; massage site Monitor blood pressure Take safety measures for drowsiness

hydroxyzine hydrochloride (Vistaril, Atarax)

-use or action: CNS depressant Anticholinergic -side effects: Tissue damage with IM route Drowsiness, dry mouth, pain at injection site, dizziness, ataxia -nursing interventions: IM dose should be given deep in large muscle mass using Ztrack method Maintain oral hygiene Take safety measures for drowsiness

diazepam (Valium)

-use or action: Central nervous system (CNS) depressant Skeletal muscle relaxant -side effects: Intravenous (IV) route: respiratory depression, dysrhythmias, thrombophlebitis Drowsiness, ataxia, orthostatic hypotension, headache, blurred vision, confusion -nursing interventions: Do not mix parenteral form with other drugs IM injection in deep deltoid site; IV route should use large vein Monitor pulse and respirations Contraindicated with acute narrow angle glaucoma or acute alcohol intoxication Keep in bed after parenteral administration

Opioid Analgesics meperidine hydrochloride (Demerol)

-use/action: Analgesic Decreases response to carbon dioxide (CO2) Decreases gastrointestinal (GI) secretions -side effects: Sedation, nausea, vomiting, lightheadedness, dizziness, sweating, constipation Respiratory depression with overdose Tolerance and physical dependence with repeated use -nursing interventions: Slow parenteral injection Monitor pulse, blood pressure, and respirations Withhold if respiratory rate less than 12 breaths per minute Take safety precautions for drowsiness Contraindicated with monoamine oxidase (MAO) inhibitors

morphine sulfate (MS Contin, Duramorph)

-use/action: Analgesic Decreases response to increased CO2 Decreases GI secretions -side effects: Circulatory collapse, cardiac arrest with rapid IV administration Dizziness, hypotension, nausea and vomiting Respiratory depression Occasional: sedation, vomiting, flushing, urinary retention -nursing interventions: Administer parenteral forms slowly; rotate sites Dose should be reduced in older adults Monitor respirations and blood pressure Take safety precautions if drowsy Contraindicated with surgical anastomosis, after biliary tract surgery

chloral hydrate (Noctec)

-use/action: CNS depression -side effects: Nausea, vomiting, flatulence, diarrhea, disorientation Somnolence, confusion, resp. depression, coma. -nursing interventions: Monitor pulse, blood pressure, and respirations

pentobarbital (Nembutal)

-use/action: Sedative -side effects: Drowsiness, sedation, Lethargy, irritability, nausea, anorexia, muscle aches and pain, gastric distress -nursing interventions: Deep IM injection in large muscle Monitor vital signs before and after IV administration

promethazine hydrochloride (Phenergan)

-use/action: Sedative Antihistamine Anticholinergic Antiemetic -side effects: Drowsiness, disorientation, hypotension, confusion Fainting in older adults Dry mouth, urinary retention, thickening of bronchial secretions Paradoxical reaction: excitation -nursing interventions: IM dose must be deep IV dose given through IV infusion tube Contraindicated with CNS depression, acute asthma attack Monitor pulse and blood pressure Maintain oral hygiene Take safety precautions for drowsiness

secobarbital (Seconal)

-use/action: Sedative-hypnotic -side effects: Severe CNS depression with overdose Tolerance and dependence with prolonged use -nursing interventions: Administer IV at prescribed rate Take safety precautions if drowsy Dose level should be reduced for older adults Monitor pulse, blood pressure, and respirations

The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery Principles

1. Conduct a preprocedure verification process: 2. Mark the procedure site, when possible, for the procedure.

32. A nurse discovers on the preoperative assessment that a patient has a condition that would require increased amounts of general anesthesia. The condition is _____.

ANS: alcoholism Individuals who use alcohol excessively usually require greater amounts of anesthesia. DIF: Cognitive Level: Comprehension REF: p. 257 OBJ: 6 TOP: Conditions That Affect Anesthesia KEY: Nursing Process Step: Assessment

8. A nurse is performing a postoperative assessment on a patient who has just returned from a hernia repair. The patient's blood pressure is 90/60 mm Hg, and the apical pulse is 108 beats/min. What should be the nurse's first action? a. Check the dressing for bleeding. b. Notify the registered nurse (RN). c. Document the vital signs. d. Increase the rate of infusion of intravenous fluids.

ANS: A A decrease in blood pressure and tachycardia could indicate postoperative bleeding. The first action of the nurse should be to check the dressing and then report to the RN. DIF: Cognitive Level: Application REF: p. 270 OBJ: 8 TOP: Postoperative Complications KEY: Nursing Process Step: Implementation

26. Why should a nurse assess a patient's limbs and position the limbs frequently after a regional anesthesia? a. Pain is not perceived, although motion is possible. b. Rashes and skin eruptions would indicate an allergy. c. Permanent paralysis is a concern. d. Contracture deformities may occur.

ANS: A After a regional anesthesia, movement is possible, but pain is not perceived immediately after surgery, which leaves the patient susceptible to injury. DIF: Cognitive Level: Comprehension REF: p. 267 OBJ: 6 TOP: Regional Anesthesia KEY: Nursing Process Step: Assessment

22. A patient scheduled for a liver biopsy has given a nurse a list of medications routinely taken at home. Which medication should the nurse question? a. Aspirin b. Multivitamin c. Furosemide d. Acetaminophen

ANS: A Aspirin is an anticoagulant, which can increase the risk of postoperative bleeding. Drugs that have been taken for a long time may require dose adjustments because of the effects of surgery or the effect of additional drugs, which may be held or modified. DIF: Cognitive Level: Application REF: p. 257 OBJ: 2 TOP: Preoperative Assessment KEY: Nursing Process Step: Assessment

15. A nurse is doing an assessment of a patient who has returned from a cardiac catheterization and had conscious sedation. Which finding should the nurse report? a. Difficulty arousing the patient b. Blood pressure of 124/72 mm Hg c. Oxygen saturation of 96% d. Patient complaints of the need to void

ANS: A Conscious sedation uses intravenous drugs to reduce pain intensity or awareness without a loss of reflexes. A complication may be excessive sedation approaching that of general anesthesia. The patient should be easily aroused. DIF: Cognitive Level: Application REF: p. 268 OBJ: 6 TOP: Anesthesia KEY: Nursing Process Step: Assessment

5. A nurse is caring for a postoperative patient who has had spinal anesthesia. Which assessment is a priority for this patient? a. Complaints of a headache b. Pulse rate of 78 beats/min c. Voided 300 mL d. Blood pressure of 126/78 mm Hg

ANS: A One complication of spinal anesthesia is postspinal headache, which is caused by the leaking of cerebrospinal fluid at the puncture site. DIF: Cognitive Level: Application REF: p. 267 OBJ: 7 TOP: Regional Anesthesia KEY: Nursing Process Step: Assessment

19. A nurse is assisting in the transfer of a postoperative patient from the postanesthesia care unit to the surgical nursing unit. What action should the nurse implement to ensure the safety of the patient? a. Put the side rails up after moving the patient from the stretcher to the bed. b. Ask the patient to move from the stretcher to the bed. c. Move the patient rapidly from the stretcher to the bed. d. Uncover the patient before transferring from the stretcher to the bed.

ANS: A The patient will probably still be experiencing residual effects of anesthesia; the side rails should be up to prevent the patient from falling out of bed. DIF: Cognitive Level: Application REF: p. 274 OBJ: 9 TOP: Postoperative Care KEY: Nursing Process Step: Implementation

29. A patient has an extensive bowel preparation of oral laxatives and enemas for a colon resection. What rationales should the nurse list when asked about the rigorous preparation? (Select all that apply.) a. Reduces possibility of fecal contamination of the operative site b. Flattens the colon c. Decreases postoperative distention d. Avoids postoperative constipation e. Decreases straining at stool

ANS: A, C, D, E Preoperative bowel prep reduces the risk for infection from bowel contents and decreases postoperative distention, constipation, and straining at stool. DIF: Cognitive Level: Comprehension REF: p. 260 OBJ: 4 TOP: Rationale for Bowel Preparation KEY: Nursing Process Step: Implementation

28. Patients with preoperative disorders put them at risk during recovery. What disorders should a nurse be aware may pose this hazard? (Select all that apply.) a. Diabetes b. Warfarin therapy c. Fungal skin infection d. Hepatitis C e. Chronic obstructive pulmonary disease (COPD)

ANS: A, D, E Diabetes, hepatitis C, and COPD all complicate recovery related to blood-clotting deficiencies, respiratory problems, or disturbance in the healing process. Warfarin therapy is not a disorder and should have been discontinued well before surgery, and fungal skin infections do not pose a threat. DIF: Cognitive Level: Comprehension REF: p. 257 OBJ: 2 TOP: Conditions That Complicate Recovery KEY: Nursing Process Step: Assessment

21. A patient has just returned to the surgical unit after varicose vein stripping and ligation. What is the best technique for a nurse to evaluate pain relief? a. Check the patient's record for the last dose of pain medication administered. b. Ask the patient to rate the severity of the pain on a scale of 1 to 10. c. Ask the family if they think that the patient is having pain. d. Tell the patient to ask for pain medicine when it is needed.

ANS: B Having the patient rate the pain provides a system for evaluating response to the pain medication. Pain is controlled better if treated before it becomes severe, and the patient may not ask for pain medicine soon enough. DIF: Cognitive Level: Application REF: p. 273 OBJ: 8 TOP: Postoperative Pain Relief KEY: Nursing Process Step: Assessment

9. A postoperative patient who has no previous medical conditions is difficult to arouse when transferred to the surgical unit from the postanesthesia care unit. A nurse monitors the pulse oximeter and gets a reading of 85%. What should be the nurse's next action? a. Assess the pulse oximeter reading again in 1 hour. b. Arouse the patient, have him cough, and encourage deep breathing. c. Administer a dose of pain medication. d. Suction fluid from the oral cavity.

ANS: B If the pulse oximeter reading is less than 90%, the patient should be aroused and encouraged to take deep breaths. The patient's respirations may not be adequate as a result of the effects of anesthesia. DIF: Cognitive Level: Application REF: p. 271 OBJ: 8 TOP: Hypoxia KEY: Nursing Process Step: Assessment

27. A patient who received Penthrane as an inhaled anesthesia complains of a sore throat and a raspy voice. What should the nurse explain as the probable cause of these discomforts? a. Drying effect of the anesthesia b. Insertion of an endotracheal tube c. Postsurgical dehydration d. Possible upper respiratory infection

ANS: B Inhalant anesthesia is administered via an endotracheal tube that is inserted after the patient is unconscious. DIF: Cognitive Level: Comprehension REF: p. 268 OBJ: 6 TOP: Inhalant Anesthesia KEY: Nursing Process Step: Implementation

16. What is the goal of palliative surgery? a. Remove and study tissue to make a diagnosis. b. Relieve symptoms or improve function without correcting the basic problem. c. Remove diseased tissue or correct defects. d. Correct serious defects that only affect appearance.

ANS: B Palliative surgery is performed only to relieve symptoms or to improve function. It is not curative. DIF: Cognitive Level: Comprehension REF: p. 256 OBJ: 1 TOP: Types of Surgery KEY: Nursing Process Step: Planning

3. A patient who had a hysterectomy yesterday has not been allowed food or drink by mouth (NPO). The physician has now ordered the patient's diet to be clear liquids. What should the nurse assess prior to providing this patient with clear liquids? a. Feelings of hunger b. Bowel sounds c. Positive Homans sign d. Gag reflex

ANS: B The absence of bowel sounds would contraindicate a diet of clear liquids. DIF: Cognitive Level: Application REF: p. 283 OBJ: 7 | 8 TOP: Postoperative Nursing Implementations KEY: Nursing Process Step: Assessment

4. Which technique should a nurse implement when changing a postoperative dressing? a. Enteric isolation b. Aseptic technique c. Clean technique d. Respiratory isolation

ANS: B The aseptic technique is important to reduce the risk of infection. DIF: Cognitive Level: Comprehension REF: p. 281 OBJ: 9 TOP: Postoperative Risk for Infection KEY: Nursing Process Step: Planning

24. What should a nurse suggest to a patient to prevent the effects of postoperative immobility on the gastrointestinal system? a. Avoid taking antibiotics. b. Increase her fluid intake. c. Avoid high-fiber foods. d. Limit her activity for the first 3 to 4 days.

ANS: B The intake of oral fluids and ingestion of a normal diet help stimulate peristalsis. DIF: Cognitive Level: Application REF: p. 283 OBJ: 9 TOP: Postoperative Complications KEY: Nursing Process Step: Implementation

31. What are the responsibilities of a circulating nurse? (Select all that apply.) a. Assisting the surgeon with the procedure b. Setting up the surgical room c. Scrubbing in to handle instruments d. Maintaining patient safety e. Documenting nursing care

ANS: B, D, E The circulating nurse is in charge of the operating room, monitors asepsis, provides supplies, and documents patient care. The first assistant helps the surgeon with the procedure and the scrub nurse handles the instruments. DIF: Cognitive Level: Knowledge REF: p. 266 OBJ: 5 TOP: Circulating Nurse KEY: Nursing Process Step: N/A

30. A nurse carefully monitors an obese patient after a hysterectomy for the peculiar postoperative complications. Which postoperative complications are associated with obesity? (Select all that apply.) a. Nausea b. Wound infection c. Hypertension d. Hemorrhage e. Respiratory difficulties

ANS: B, E Obese patients are especially prone to postoperative respiratory complications of pneumonia and atelectasis. Obese patients are at increased risk for infection because of the amount of adipose tissue. DIF: Cognitive Level: Comprehension REF: p. 271 OBJ: 8 TOP: Postoperative Complications in the Obese Patient KEY: Nursing Process Step: Assessment

17. What information should a nurse ask a patient during the preoperative assessment? a. Current address and telephone number b. Food preferences c. Allergies, medications, and past medical conditions d. Bathing and sleep patterns

ANS: C If an emergency should arise, any allergies can be promptly managed. Knowledge of the patient's medications can enable the nurse to anticipate possible drug interactions. Past medical conditions may increase surgical risks or require special attention during the perioperative period. DIF: Cognitive Level: Comprehension REF: p. 257-258 OBJ: 2 TOP: Preoperative Assessment KEY: Nursing Process Step: Assessment

2. A nurse is caring for a postoperative patient. What should the nurse ask when assessing for the complication of malignant hyperthermia? a. "Do you think you might have a fever?" b. "Do you currently have an infection?" c. "Has anyone in your family ever had problems with general anesthesia?" d. "Have you ever had any type of malignancy?"

ANS: C Malignant hyperthermia is a life-threatening complication that occurs in response to certain drugs. Susceptibility to this response is inherited. DIF: Cognitive Level: Application REF: p. 268 OBJ: 7 TOP: General Anesthesia KEY: Nursing Process Step: Assessment

23. A patient scheduled for a bronchoscopy is placed on an NPO status after midnight before the procedure. The patient is complaining of being thirsty and requests some water on the morning of the procedure. What action should the nurse implement? a. Deny any oral fluid per order. b. Allow 8 oz of tap water. c. Offer limited ice chips. d. Administer only carbonated drinks.

ANS: C Patients are given nothing by mouth from midnight before the scheduled procedure to reduce the risk of vomiting and aspiration during or after the procedure. Recent practice allows small amounts of fluid or ice chips during the day of surgery. DIF: Cognitive Level: Application REF: p. 262 OBJ: 3 TOP: Preparation for Surgery KEY: Nursing Process Step: Implementation

14. When obtaining a patient's signature on the surgical consent form, the patient seems confused about the procedure to be performed. What is the most appropriate response by the nurse? a. Tell the patient to talk to the physician after he or she gets to the surgical department. b. Ask the patient to go ahead and sign the consent. c. Ask the patient what the physician told him and then call the physician if necessary. d. Encourage the patient to ask his family what the physician told them.

ANS: C The patient may not understand some of the medical terms used by the physician, and the nurse may be able to explain them. If the patient needs further information, notify the physician. The physician is responsible for explaining the procedure and the risks to the patient. DIF: Cognitive Level: Application REF: p. 260 OBJ: 3 TOP: Consent Form KEY: Nursing Process Step: Implementation

12. The suprapubic area of a postoperative patient is distended. The patient states that he has not voided since surgery approximately 9 hours ago. What should be the nurse's first action? a. Notify the head nurse or physician. b. Insert a catheter and document insertion. c. Seat the patient on the side of the bed to try to void. d. Prepare the patient to return to surgery.

ANS: C The patient should be encouraged to try to void in a natural position before other measures are taken. Seated on the bedside or on a bedside commode may make urination easier. DIF: Cognitive Level: Application REF: p. 283 OBJ: 9 TOP: Postoperative Urinary Retention KEY: Nursing Process Step: Implementation

25. A postanesthesia care nurse is evaluating a patient for possible transfer to the surgical unit. Which assessment should prevent the patient's transfer? a. Blood pressure of 126/78 mm Hg b. Pulse rate of 82 beats/min c. Pulse oximeter reading of 85% d. Respirations of 22 breaths/min

ANS: C The pulse oximeter reading should be 95% to 100%. The patient should not be transferred from the recovery room until the vital signs are stable, respiratory and circulatory functions are adequate, pain is minimal, the patient is easily awakened, no complications have been experienced, and the gag reflex is present. DIF: Cognitive Level: Analysis REF: p. 281 OBJ: 8 TOP: Postoperative Assessment KEY: Nursing Process Step: Assessment

13. Which modification should the nurse implement when caring for a postoperative patient after cataract surgery? a. Early ambulation is not necessary. b. Remove the dressing immediately. c. Omit instructions relative to coughing. d. Omit use of an incentive spirometer for deep breathing.

ANS: C There are only a few instances in which coughing is contraindicated. They include surgeries for hernias, cataracts, and brain surgery. DIF: Cognitive Level: Application REF: p. 282 OBJ: 7 TOP: Postoperative Complications KEY: Nursing Process Step: Planning

7. During a nurse's preoperative assessment, the nurse notices that a patient is extremely anxious. The patient's blood pressure is 142/92 mm Hg, the heart rate is 104 beats/min, and respirations are 32 breaths/min. What nursing action should be implemented? a. Give the preoperative medicine early to help calm the patient. b. Call the surgical department and cancel the surgery. c. Notify the anesthesiologist or surgeon. d. Instruct the patient on possible postoperative complications.

ANS: C When significant fear is associated with surgical complications, sometimes surgery is postponed until the anxiety level is reduced. DIF: Cognitive Level: Analysis REF: p. 259 OBJ: 3 TOP: Preoperative Anxiety KEY: Nursing Process Step: Planning

11. A nurse should include the proper use of an incentive spirometer in teaching a preoperative patient. What postoperative assessment of this patient would reveal that the incentive spirometry teaching has been effective? a. Adventitious breath sounds b. Expiratory wheezing c. Thick, green respiratory secretions d. Clear breath sounds

ANS: D An incentive spirometer is used to promote lung expansion, which opens airways, reduces atelectasis, and stimulates coughing to clear secretions. DIF: Cognitive Level: Comprehension REF: p. 281 OBJ: 8 TOP: Impaired Gas Exchange KEY: Nursing Process Step: Evaluation

6. What should a nurse ensure that a postoperative patient implement to best prevent deep vein thrombosis (DVT)? a. Splint the incision. b. Cough and deep breathe every 2 hours. c. Regularly remove antiembolism stockings. d. Ambulate frequently.

ANS: D DVT is best prevented by early and frequent ambulation of the patient. DIF: Cognitive Level: Application REF: p. 272 OBJ: 7 TOP: Postoperative Complications KEY: Nursing Process Step: Planning

18. Which member of the surgical team administers anesthetics and monitors the patient's status throughout the procedure? a. Surgeon b. Circulating nurse c. Perfusionist d. Anesthesiologist

ANS: D The anesthesiologist and nurse anesthetist have special training and are the members of the surgical team that administer anesthesia and are responsible for closely monitoring the patient during surgery. DIF: Cognitive Level: Knowledge REF: p. 267 OBJ: 5 TOP: Surgical Team KEY: Nursing Process Step: N/A

20. A patient who has just undergone a colon resection complains to a nurse that he felt something pop under his dressing while trying to get out of bed. The nurse removes the dressing and finds that dehiscence of the wound has occurred. What nursing action should be implemented first? a. Replace the dressing; dehiscence is normal. b. Call the physician. c. Pull the wound edges together and replace the dressing. d. Cover the wound with sterile dressings saturated with normal saline.

ANS: D The first action of the nurse should be to cover the wound with saline-saturated dressings to prevent damage of the exposed organs from drying and then to call the physician. DIF: Cognitive Level: Application REF: p. 271 OBJ: 9 TOP: Wound Dehiscence KEY: Nursing Process Step: Implementation

10. A nurse has completed giving discharge instructions to a patient after a hernia repair. What verbalization by the patient should lead the nurse to determine that the patient understands the instructions? a. Go back to work tomorrow. b. Do not change the dressing until he sees his physician in 2 weeks. c. Ignore changes in the size of his abdomen. d. Report fever, redness, swelling, or increased pain at the incision site.

ANS: D The patient should report any signs and symptoms of infection (e.g., fever, redness, swelling, pain). DIF: Cognitive Level: Comprehension REF: p. 284 OBJ: 10 TOP: Discharge Planning KEY: Nursing Process Step: Evaluation

1. A postoperative patient is complaining of incisional pain. An order has been given for morphine every 4 to 6 hours as needed (PRN). What should the nurse assess first? a. Assess for the presence of bowel sounds. b. Assess pupillary reaction. c. Ask the patient's family if she is having pain. d. Determine when the patient last received pain medication.

ANS: D Verifying the time of the last dose decreases the risk of a dose of medication being given too soon. DIF: Cognitive Level: Application REF: p. 277 OBJ: 9 TOP: Acute Pain KEY: Nursing Process Step: Assessment

Past Medical History

Acute and chronic conditions, previous hospitalizations and surgeries, allergies, recent and current medications (to include recreational and herbal medications)

Variables Affecting Surgical Outcomes

Age Nutritional status Fluid and electrolyte balance Medical diagnoses Drugs Habits

Garlic

Can cause blood pressure changes and risk of prolonged bleeding

Black cohosh

Can cause blood pressure decrease and may increase bleeding

Hoodia

Can cause changes in blood sugar and possible arrhythmia

Echinacea

Can cause immune suppression and liver inflammation

Valerian

Can cause increased sedative effects

St. John's wort

Can cause sedation, blood pressure changes, and has risk of interaction with other medications that prolong effects of anesthesia

physical examination: extremities

Color, hair distribution, lesions, deformities, range of motion, crepitus, pain, weakness

physical examination: skin

Color, lesions, bruises, warmth, turgor, moisture

informed consent by surgeon

Competent • Mentally able to understand • Should not be under the influence of pain medications Agrees to the procedure Information clear Risks explained Benefits identified Consequences understood Alternatives discussed Ability to understand (language, disabilities) -consent must be witnessed

physical examination: abdomen

Distention, scars, bowel sounds

physical examination: general survery

Emotional state, ability to communicate, response to directions

Kava

Has potential liver toxicity and increases risk of additive effect to medications

Ginseng

Has risk of cardiac effects

Ginger

Has sedative effects and can cause risk of bleeding especially if taken with aspirin and ginkgo

physical examination: prostheses

Hearing aids, eyeglasses, contact lenses, dentures, artificial limbs, other devices

health history

Identifying Data • Age, marital status History of Present Illness • Problem being treated surgically

Ginkgo

May increase bleeding

physical examination: thorax

Respiratory pattern and effort, breath sounds, apical pulse

minor surgery

Surgery which presents little risk to life

fear of the unknown

The primary stressor prior to surgery

perioperative period

The time before, during, and after surgery

anesthesiologist

a physician who specializes in anesthesia.

Regional anesthesia

achieved by using local anesthetics that block the conduction of nerve impulses in a specific area.

surgeon

actually performs the procedure

nerve block

administered by injecting an anesthetic agent around a nerve to block the transmission of impulses.

Optional

based on client preference, such as gastric stapling

anesthesia care provider (ACP)

can be a certified registered nurse anesthetist (CRNA) or anesthesiologist

Other technical personnel

have specialized jobs. For example, a perfusionist operates the heart bypass machine during open heart surgery.

registered nurse

in the circulating role.

general anesthetics are given

inhalation or intravenous infusion.

Ablative surgery

is performed to remove diseased tissue such as an inflamed gallbladder.

Required

necessary for client's well-being, usually within weeks to months, such as cholecystectomy, if not acute

Emergent

performed immediately to save a person's life, limb, or organ, such as testicular torsion

Cosmetic surgery

performed to improve a person's appearance. Common cosmetic procedures are performed to change the shape of facial features, remove wrinkles, flatten the abdomen, and change the size or shape of the breasts.

Procurement for transplant

refers to the removal of organs (e.g., heart, lungs, liver) from a living donor or a deceased person for transplantation into another person.

surgery

refers to the treatment of injury, through invasive operating methods

Palliative surgery

relieves symptoms or improves function without correcting the basic problem.

Urgent

requires prompt attention, usually within 24 hours, such as reduction of a broken bone

Constructive surgery

restores function lost because of congenital defects such as a cleft palate.

Reconstructive or restorative surgery

restores function or structure to damaged or malfunctioning tissue.

Elective

surgery is necessary but condition is not imminently life-threatening; surgery will improve the client's life, such as plastic surgery

balanced anesthesia

use of multiple drugs

assistant surgeon

who assists the surgeon in the procedure.

LVN

who scrubs and handles instruments within the sterile field and monitors the sterility of the surgical field.

RNFA

works collaboratively with the surgeon and has advanced training for specific duties such as suturing and handling tissue with instruments.

review of systems

• Disabilities and limitations: • hearing or vision loss, • paralysis, • stiffness, • weakness, • cognitive impairment; • any current health deviations

physical examination

• General Survey: • Height and Weight • Vital Signs • Skin -thorax -abdomen

preparation for surgery

• Informed consent • Preparation of digestive tract • Food and fluid restriction • Skin preparation • Dress and grooming • Prostheses • Circulation • Preoperative medications • Preoperative checklist

functional assessment

• Occupation, • roles, • responsibilities, • diet and fluid intake, • exercise, • tobacco and alcohol use, • sources of stress and support, • coping strategies, • expectations of surgery

Mark the procedure site, when possible, for the procedure.

• Perform a "time-out" in the operating room. • The procedure is not started until all questions or concerns are resolved. • It must be done before an incision is made, involve active members of the procedure team, confirm the patient identity, site, and procedure; and be documented

major surgery

• Surgery which presents a possible risk to life or a potential hazard to and disruption of physiological function

Conduct a preprocedure verification process:

• confirm procedure, patient, site, availability of all items and documents needed for the procedure. • Involve the patient if possible. • Address missing information or discrepancies before starting the procedure.

inhalation agents

• isoflurane (Forane), • sevoflurane (Ultane), • enflurane (Ethrane), • desflurane (Suprane), and • nitrous oxide.

local anesthetics examples

• lidocaine hydrochloride (Xylocaine), • bupivacaine hydrochloride (Marcaine HCl), • tetracaine (Pontocaine), and • ropivacaine (Naropin).

local anesthesia complications

• toxic effects caused by overdose, • local tissue damage, and • allergic responses. -Local tissue effects may be inflammation and edema -Abscesses and necrosis sometimes develop at the injection site. This circumstance is thought to be caused by poor technique rather than by the anesthetic agent