care of the surgical patient

pain assessments

- 0 to 10 - pain is whatever the patient says it is - administer even when patient is sleeping to promote comfort - wake up patient if its a PO med - don't wake up for IV

adverse reactions of Dantrolene (Dantrium)

- HR >130 - muscle rigidity - cardiac dysrhythmias - hepatotoxicity

moderate sedation anesthesia

- IV - opioid, sedation, or hypnotic drug - endoscopies

prevention of dehiscence and evisceration

- abdominal binder (prevents opening) - splints

prevention of DVT

- activity - move legs in bed - fluids - SCDs - elevation of lower extremities - passive ROM - tes hoes - put pillow under knee to prevent constriction

anesthesiologist role

- administers anesthesia - intubates patient - monitors vital signs

risk factors for dehiscence and evisceration

- age - weak muscle and tissues - obesity - diabetes - corticosteroids

intraoperative complication: anaphylaxis

- allergy to meds - have antidote ready

risk factors for paralytic ileus

- anesthesia - pain meds - sedation - decreased physical activity

intraoperative complication: hypoxia/ respiratory complication

- aspirations - have suction available - monitor o2 levels - monitor RR and signs of hypoxia

interventions for pneumonia

- assess lung sounds - activity - antibiotics

nursing priorities when a patient is on antiemetics

- assess nausea and vomiting - IV potency, redness, swelling - assess 30-60 minutes after - I&0 - document quantity of emesis

nursing priorities when a patient is on ketorolac (Toradol)

- assess pain - vitals - labs H/H

interventions for atelectasis

- assess pain level - deep breathing - incentive spirometer - assess respiratory rate - lung sounds - o2 saturation

nursing priorities when a patient is on acetametaphine (Tylenol)

- assess pain level - make sure not to exceed 4 grams daily - give with food

nurse priorities when a patent is on opiods

- assess pain level - monitor vitals - o2 sat - monitor sedation level - Bms - LOC - respiratory rate

nursing priorities when a patient is on opiod agonists (non opioids)

- assess pain level 30-60 minutes after administration - vitals - o2 sat - sedation/ LOC - respiratory sounds - mindful of acetametaphoine dosing - give with food - assess BMs

nurse priorities when a patient is on ibuprofen (motrin)

- assess pain levels - vitals - labs H/H

preventing urinary retention

- assess the bladder for dissension - assess I&Os

preventing a paralytic ileus

- assess the patients last BM - assess labs - excess stool softener? - laxatives

risk factors for pneumonia complication

- atelectasis - no activity - pooling of secretions in lungs that leads to infections bc of stasis

intraoperative complication: nausea/ vomitting

- bc of the anesthesia - have basin ready

intraoperative complication: hypothermia

- cold environment makes patient at risk for hypothermia - cold IV solution - goal is to gradually warm up the patient

post op complication: infection risk factors

- contaminating a sterile OR - corticosteroids (decrease immune response) - diabetes

how does the nurse know that the antiemetic meds are working

- decrease or absence of N/V - increased foods/ fluid intake

how does the nurse know that the corticosteroids are working

- decreases inflammation - decreases pain - no reports of diarrhea - stable WBC, temperature, and blood glucose

signs of circulatory overload

- diminished breath sounds - lung crackles - abdominal distention - high BP - swelling in lower extremities - SOB

preventing atelectasis

- encourage activity - OOB - pain meds - deep breathing exercises - TCDB q2h

adverse reactions of antiemetics

- excessive sedation - respiratory depression

interventions for DVT

- fluids and activity

intervention for nerve complication: urinary retention

- foley cath or straight cath - offer bed pain - monitor I&O - assess abdomen for dissension - bladder scanner

adverse reactions of ibuprofen (motrin)

- gastric ulcers - bleeding - ototoxicity (hearing loss)

scrub role

- handles equipment - drapes patient - counts utensils before and after surgery - labels specimen

acetametaphine (Tylenol) adverse reactions

- hepatotoxicity - elevated liver function tests - jaundice

risk factors for DVT

- immobility - anesthesia sedation

risk factors for atelectasis

- immobility - no deep breathing

intraoperative complication: anesthesia awareness

- its possible for patients to remember what happened during surgery - monitor what you say!

interventions for dehiscence and evisceration

- lower HOB (less pressure on abdomen) - sterile supplies - sterile water - hand hygiene

interventions for post op infections

- may show S/S of infection 5 days after surgery (usually at home) - encourage pt to take antibiotics as prescribed - notify HCP if you suspect an infection at the hospital

interventions for maintaining a patent airway

- monitor pulse ox and respiration - raise HOB - apply o2 - deep breathing exercises - incentive spirometer

preventing pneumonia

- monitor temperature - o2 sat - activity

circulating nurse role

- monitors the activity of the surgical scene - assures surgical aseptic techniques - documentation - verifies surgical site - brings any specimen to lab

what are the two opiods

- morphine - hydromorphone (dilaudid)

intraoperative complication: infection

- must be a sterile environment - increased risk for infection - discard things that have been contaminated

spinal anesthesia complications

- nerve damage - headache - nausea/vomiting

spinal anesthesia complication interventions

- neuro assessment - positioning - medication - 6-8 hours bed rest - quiet environment - fluids (3L)

IV pain meds

- opioids - patient education - assess for fear of addiction - only used for a short period of time to decrease pain

what are the opiod agonist (non opioids)

- oxycodone- acetometaphine (Percocet) - hydrocodone- acetometaphine (Lortab)

PCA pain control

- patient controlled anesthesia - patient controls breakthrough pain - educate patient on how to use the pump before surgery - pt administers pain when the pain gets worse

nurse roles in the PACU

- post op - monitors patient for any complications - assesses surgical site - neuro checks - cardio and lung sounds - vital signs - ABCs

what are the Antiemetics

- promethlezine (Phenergan) - metoclopramide (Reglan) - prochlorperazine (Compazine) - ondansetron (Zofran)

evisceration

- protruding of intestines - cover w wet gauze and sterile water - emergency!!!

regional anesthesia

- pt is conscious - epidurals - injections

local anesthesia

- pt is conscious - numbs area

general anesthesia does what?

- puts patient to sleep - depresses nervous system - respirator breathes for patient

nursing priorities when a patient is on Dantrolene (Dantrium)

- recognize s/s of malignant hyperthermia - assess HR, temp, and urinary output - liver function tests

causes of airway obstructions

- relaxation of tongue- falling back - secretions - stridor

how does the nurse know the acetametaphine (tylenol) is working

- reports of decreased pain

how will the nurse know when opiod agonists (non opioids) are working

- reports of decreased pain

how would the nurse know that that ibuprofen (motrin) is working

- reports of decreased pain

how will the nurse know that the opioids are working

- reports of decreased pain - fewer non verbal indicators

adverse reactions of opioid agonists (non opioid)

- respiratory depression - decreased o2 - bradycardia - brandypnea - change in LOC - urinary retention

adverse reactions of opioids

- respiratory depression - decreased o2 sat - bradycardia - change in LOC

bed safety in the PACU

- sedation - rails up - bed low position - bed brake - call light in reach - bed pan - bed side commode - nurse assit to the bathroom

why would a patient be receiving hydromorphone (dilaudid)

- severe pain (8-10) - IV

preventing infections during surgery

- sterile OR - hand hygiene - antibiotics 1 hour after surgery - change the dressing properly - WBC count - vital signs

intraoperative complication: malignant hyperthermia

- temperature increases (late sign) - HR increases over 150 (early sign) - dysrhythmias when under anesthesia

adverse reactions of corticosteroids

- thromboembolism - hyperglycemia - decreased wound healing - fluid retention

oxygen use in the PACU

- until the patient is conscious - can take deep breaths on their own - make sure o2 is between 92-100 -try to arouse patient first to make sure they're responding

interventions for urinary retention

- urine should be 30 mL/ hour - urine 240 mL for 8 hours - assess bladder for distention - straight cath if bladder is full - bedside commode - bed pan - assist patient to the bathroom

nursing priorities when a patient is on corticosteroids

- vitals - labs - I&Os - weights (fluid retention) - assess wound/ skin condition - assess blood glucose

nurse to patient ratio in the pacu

1:1

nurse/ patient ratio in the PACU

1:1

monitor patient during surgery to make sure that at least ____ mL of urine comes out every hour during and after surgery

30 mL

acetametophine dosing

4 grams total daily, even when mixing!!!

The nurse determines that a patient has post op abdominal distention. What does the nurse determine that the distention may be directly related to? A.) a temporary loss of peristalsis and gas accumulation in the intestines B.) beginning food intake in the immediate post op period C.) improper body positioning during the recovery period D.) the type of anesthetic administered

A

The patient asks the nurse why the food is withheld before surgery. What is the best response by the nurse? A.) "aspiration is a concern and can be a complication if food or fluid is taken close to surgery time" B.) "distention is a severe complication if food or fluid is taken close to the surgery time" C.) "infection may occur if food or fluid is taken prior to surgery" D.) "obstruction will occur if food or fluid is taken prior to surgery"

A

what medication should the nurse prepare to administer in the event a patient has malignant hyperthermia? A.) dantrolene sodium (Dantrium) B.) Fentanyl citrate (Sublimaze) C.) narcan D.) Thiopental sodium (Pentobarbital)

A

when does the nurse understand the patient is knowledgable about the impending surgical procedure? A.) the patient participates willingly in the pre-op preparation B.) the patient discusses stress factors causing the patient to feel depressed C.) the patient expresses concern bout post op pain D.) the patient verbalizes feats to family

A

The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? SELECT ALL THAT APPLY A.) assisting the patient with leg exercises B.) encouraging early ambulation C.) massaging the legs q4h D.) avoiding placement of pillows or blanket rolls under the patient's knees E.) applying compression stockings only at night

ABD

what does the nurse recognize as one of the most common post op respiratory complications in elderly patients? A.) pleurisy B.) pneumonia C.) hypoxemia D.) pulmonary edema

B

A patient is complaining of a headache after receiving a spinal anesthesia. What does the nurse understand may be the cause of headache? SELECT ALL THAT APPLY A.) the patient lying in a supine position B.) leakage of fluid from the subarachnoid space C.) size of spinal needle used D.) degree of patient hydration E.) an allergic reaction to the medicine used

BCD

The nurse is concerned that a post op patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus? A.) abdominal tightness B.) abdominal distention C.) absence of peristalsis D.) increased abdominal girth

C

when should the nurse encourage the patient to get out of bed? A.) within 6-8 hours after surgery B.) between 10 and 12 hours after surgery C.) as soon as indicated D.) on the second post op day

C

why is assessment of dentition important in the patient preparing to have a surgical procedure with general anesthesia? A.) the patient may require referral to the dentist B.) oral hygiene is important for all patients C.) decayed teeth or dental prosthesis can become dislodged during intubation D.) the patient can sue if a tooth falls out during surgery

C

The nurse is assessing a post op patient's wound and observes a portion of the intestines protruding through the wound. What is the priority intervention for the nurse to provide? A.) apply an abdominal binder snugly so that the intestines can be slowly pushed back into the abdominal cavity B.) approximate the wound edges with adhesive tape so that the intestines can be gently pushed back into the abdominal cavity C.) carefully push the intestines back in D.) cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution

D

The nurse is caring for a patient who is at risk for malignant hyperthermia from general anesthesia. What is the most common early sign that the nurse should assess for? A.) hypertension B.) muscle rigidity C.) oliguria D.) tachycardia

D

what is the best response by the nurse when the patient states, " I'm so nervous about my surgery"? A.) "relax. your recover period will be shorter fi you're less nervous" B.) "stop worrying. it only makes you more nervous" C.) "you don't need to worry. your doctor has done this surgery many times before" D.) "would you like to discuss the concerns that you have?"

D

ON-Q pump

HCP controls pain medication on continuous rate - nurse does not control

CDC guidlines for antibiotics

OR nurse must give surgical patient antibiotics 1 hour before surgery so that the meds are at the peak during surgery to help prevent infection

what are the corticosteriods

Prednisone (Sterapred) Methylprednisone (Solumedrol)

The nurse assesses an older adult patient who complains of dimmed vision. What does this alert the nurse to plan for? A.) a safe environment B.) restrictions of the patient's unassisted mobility activities C.) probable cataract extractions D.) referral to an ophthalmologist

a

The nurse is caring for a patient who is obese prior to a surgical procedure. What surgical complications positively correlated with obesity should the nurse monitor for? SELECT ALL THAT APPLY A.) cardiovascular system B.) GI system C.) pulmonary systen D.) renal system E.) nervous system

abc

what are the non opioid drugs

acetometiphen (tylenol) ibuprofen (Motrin)

what are some intraoperative complications

anesthesia awareness nausea, vomitting anaphylaxis hypoxia hypothermia malignant hyperthermia infection

RN first assistant role

assists with suturing and helping surgeon

time out procedure

before surgery takes place - verifies right patient, location, and procedure

adverse reactions of ketorolac (Toradol)

bleeding

how often should the nurse check on the patient in the PACU

every 15 minutes

how does a nurse know that ketorolac (Toradol) is working

fewer reports of pain

post op complication: atelectasis

from immobility - pooling of lung secretions - collapsed alveoli

what is the NSAID

ketorolac (Toradol)

why would a patient receive Dantrolene (Dantrium)

malignant hyperthermia

why would a patient be receiving ibuprofen (motrin)

mild to moderate pain

when is tylenol used

mild to moderate pain (0-5)

why would a patient be receiving ketorolac (Toradol)

moderate to severe pain (6-10)

why would a patient be receiving morphine

moderate to severe pain (6-10)

why would a patient be receiving percocet or lortab

moderate to severe pain (6-10)

why would a patient be on antiemetics

nausea and vomiting

dehiscence

opening of surgical incision - risk for infection

sedation can cause...

respiratory sedation - monitor RR

how would the nurse know that Dantrolene (Dantrium) is working

s/s eliminated

risk factors for urinary retention complication

sedation from anesthesia

post op complication- paralytic ileus

slowing down of the bowels, stops moving

nerve complication: urinary retention

sometimes patient doesn't get the feeling that they need to go if theres no foley cath

interventions for nausea and vomiting

suctioning, anti emetics, basins

where would you assess for hemorrhaging

their back

why would a patient be on corticosteroids

to decrease any inflammation

Explain why the postoperative complications of atelectasis and hypostatic pneumonia are reduced as a result of early ambulation

ventilation is increased and the stasis of bronchial secretions in lungs is reduced

explain patient controlled anesthesia (PCA)

when the patient is feeling breakthrough pain their push the button on their pump to self administer their dose of pain meds

opioid agonists (non opioid) should be given when?

with food to decrease GI upset