PREP U Chapter 17

The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed?

"The nurse will explain the details of the surgery before I sign a consent."

Surgical complications risk factors

- hypovolemia -dehydration/ electrolyte imbalance -nutritional deficit -extremes of age -extremes of weight -infection & sepsis -toxic conditions -immunologic abnormalities -pulmonary disease (obstructive/restrictive disorder/ respiratory infection) -pregnancy -cardiovascular disease: a. coronary artery disease/ myocardial infection b. cardiac failure c. dysrhythmias d. hypertension e. prosthetic heart valve f. thromboembolism g. hemorrhagic disorder h. cerebrovascular diseases -endocrine dysfunction (diabetes, adrenal disorder, thyroid malfunction) -hepatic disease (cirrhosis, hepatitis) -pre-existing mental/physical disability

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.)

-Cardiovascular system -GI system -Pulmonary system

manifestations of latex allergy

-allergic to kiwi, avocado, banana -cannot blow up balloons

Genetic conditions that may cause complications with anesthesia

-malignant hyperthermia -central core disease -Duchenne muscular dystrophy -Hyperkalemic periodic paralysis -King-Denoborough syndrome

Categories of Surgery based on urgency:

1) Emergent: patient requires immediate attention; disorder may be life threatening -surgery without delay e.g. severe bleeding, bladder/intestinal obstruction, fractured skull, gunshot/ stab wounds, extensive burns 2) Urgent: requires prompt attention -surgery within 24-30 hours e.g. acute gallbladder infection, kidney/ureteral stones 3) Required: needs to have surgery -plan within a few weeks/months e.g. prostatic hyperplasia without bladder obstruction, thyroid disorders, cataracts 4) Elective: should have surgery -failure to have surgery not catastrophic e.g. repair of scars, simple hernia, vaginal repair 5) Optional: decision rests with patient -personal preference e.g. cosmetic surgery

Circumstances that informed consent is necessary

1) Invasive procedures e.g. surgical incision, biopsy, cystoscope, paracentesis 2) procedures requiring sedation/ anesthesia 3) nonsurgical procedure e.g. arteriography that carriers more than a slight risk to the patient 4) Procedures involving radiation

To prepare for surgery, all patients require a comprehensive

1) preoperative nursing assessment 2) Patient education 3) Nursing interventions to prepare for surgery

Valid informed consent

1. voluntary consent: must be without coercion, must be at least 18 years old -incompetent patient= not autonomous to withhold consent 2. informed subject: should be in writing a. explanation of procedure & risks b. benefits & alternatives c. offer to answer questions about procedure d. instructions that the patient may withdraw consent e. informing patient that protocol differs 3. patient able to comprehend

For the patient who is taking aspirin, it is important to stop taking this medication at least how many day(s) prior to surgery?

7

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

7 to 10 days

The on-call perioperative team is called for an urgent surgery to be performed as soon as they arrive. What surgical procedure is considered emergent?

A repair of multiple stab wounds

Patients who have received corticosteroids preoperatively are at risk for which type of insufficiency?

Adrenal

A patient refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?

Allow the ring to stay on the patient and cover it with tape.

The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following?

Cheeseburger, french fries, coleslaw, and ice cream

What action by the nurse best encompasses the preoperative phase?

Educating the patients on signs and symptoms of infection

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

Emergent

The nurse concludes that further teaching about diaphragmatic breathing is needed when the client:

Exhales forcefully with a short expiration

The nurse recognizes that written informed consent is required for insertion of a(n):

Peripherally-inserted central catheter.

You are physically preparing a client for surgery and instruct the person to remove any jewelry. The client refuses to remove a wedding band. What should you do in this situation with approval from your facility?

Place gauze under and over the ring and apply adhesive tape over it.

The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which of the following values would be of greatest concern to the nurse?

Potassium 6.2 mEq/L

When is the ideal time to discuss preoperative teaching

Pre-admission visit

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

Respiratory depression

A patient is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?

Splint the incision site using a pillow during deep breathing and coughing exercises.

When does the nurse understand the patient is knowledgeable about the impending surgical procedure?

The patient participates willingly in the preoperative preparation.

The nurse discovers that the client did not sign the operative consent before receiving the preoperative medication. The appropriate nursing action is:

To notify the surgeon

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

Up to 72 hours after alcohol withdrawal

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

Use diaphragmatic breathing.

At what point does the preoperative period end?

When the client is transferred onto the operating table

When assessing a postoperative client, the nurse is correct to relate which surgical risk factor that would decrease if the surgical client maintained a blood glucose level under 150 mg/dL?

Wound healing

Preoperative phase

begins when the decision to proceed with surgical intervention is made & ends with transfer of the patient onto the OR (operating room) bed 1) PAT - readmission testing 2) Admission to surgical center 3) In the holding area

Intraoperative phase

begins when the patient is transferred onto the OR bed & ends with admission to the PACU -nursing responsibilities: a. acting as scrub nurse b. circulating nurse c. registered nurse first assistant 1) maintenance of safety 2) physiologic monitoring 3) psychologic support

Postoperative phase

begins with the admission of the patient to the PACU & ends with a follow-up evaluation in the clinical setting/ home 1) transfer of patient to post-anesthesia care unit 2) postoperative assessment recovery area 3) surgical nursing unit 4) home/clinic

A 17-year-old client is having same-day surgery. During the intraoperative phase of perioperative care, the nurse:

continuously monitor sedated client

At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period?

during preoperative period

A client is undergoing preoperative assessment. During admission paperwork, the client reports having enjoyed a hearty breakfast this morning to be ready for the procedure. What is the nurse's next action?

notify the surgeon

if the surgical patient is currently using beta-blockers.

particular attention is given to ensure timely administration of the beta-blocker & appropriate monitoring of vital signs

Informed consent

patient's autonomous decision about whether to undergo a surgical procedure -voluntary & written informed consent from patient is necessary before non-emergent surgery -to protect patient from unsanctioned surgery & protect surgeon -legal mandate -helps the patient prepare psychologically (ensure & understand surgery) -surgeon's responsibility to provide a clear & simple explanation of what the surgery will entail prior to patient giving consent (must inform benefits, alternatives, possible risks, complications, disfigurement, disability, removal of body parts, what to expect postoperatively) --> nurse: clarifies information & notifies physician

Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery?

physician

Ambulatory surgeries

surgery that does not require an overnight hospital stay -PAT: readmission testing & preoperative preparation prior to admission (patient demographics, health history, consent forms, diagnostic & lab results) -increase the need for patient education, discharge planning, rehabilitation services -includes: a. outpatient b. same-day c. short stay surgery -does not require overnight hospital stay but observation in hospital setting for 23 hour/less

Emergency surgeries

unplanned & occur with little time for preparation of patient/ perioperative team

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

Perioperative nursing

-crucial: communication, teamwork, patient assessment -consists of 2 phases that being & end at particular points: a. Preoperative phase b. Intraoperative phase c. Postoperative phase -4 domains of nursing practice by the Perioperative Nursing Data Set: 1) safety 2) physiologic response 3) behavioral response 4) health care systems

before any surgical treatment, obtain

-health history, physical examination (vital signs), database for future comparisons -joint mobility= affect patient in surgery -genetic considerations = to prevent complications with anesthesia -ask patient about use of prescription & OTC & herbal supplements -activity level -known allergies -sign of abuse -blood test, x-rays, diagnostic tests

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply.

-health status -age -nutritional status -physical condition

Bariatrics

-patients who are obese -increases the risk & severity of complications associated with surgery -during surgery --> fatty tissues susceptible to infection -increases technical & mechanical problems (dehiscence; wound separation) -tend to have shallow respirations with supine= increasing the risk of hypoventilation & postoperative pulmonary complications -increased oxygen demand & decreased pulmonary reserves -frequently assess for obstructive sleep apnea & Tx: CPAP (continuous positive airway pressure)

A client is undergoing a surgical procedure to repair an ulcerated colon. Which client education topics will be discussed preoperatively? Select all that apply.

-postoperative pain control -cough & deep-breathing exercises -Intravenous fluids & other lines & tubes

Minimally invasive surgery

-surgical procedures that use specialized instruments inserted into the body -enables many surgeries to be performed on an outpatient basis