ch 12 ( nursing care of patients having surgery)

Preadmission surgical patient assessment

- interview with anesthesiologist - telephone or face to face with RN - needs health history, identification of risk factors, patient and family teaching, discharge planning, and referrals to social work, support group, and educational programs

Nurses expected outcome

- maintain oxygen therapy - encourage deep breathing - give analgesics - make sure suction is set up for secretions or emesis - check color and amount of drainage from dressing for fluid loss - maintain iv fluids and replace loss fluids but avoid fluid overload - monitor intake and output

Adjunct agent

- medication used ALONG with primary anesthetic agents - includes opiods to control pain, muscle relaxers , antiemetics to control nausea and vomiting, and sedative supplements

pain

- monitor - give IV opioid promptly for rapid onset of pain - begin PCA as ordered - re-position patient and provide warmth, and empty full bladder to help pain - play music and reduce noise - after pain meds are given then recheck pain levels 30 min later

phase 4 of healing

- months to 1 year - collagen deposited - flat, thin scar

Nursing assessment for preoperative patients

- name,age, occupation - condition for white surgery is scheduled - medical HX - surgical HX - alcohol and Tabacco use - family HX - for female patients last menses and OB info

curative

- removal of diseased or abnormal tissue inflamed appendix, tumor, or benign cyst, or hernia

Intraoperative nursing diagnosis and outcome

- risk for injury ( is free from injury) - Risk for impaired skin integrity ( skin integrity is maintained) - risk for deficient fluid volume ( maintains blood pressure, pulse, and urine output with in normal limits) - risk for infection ( is free of infection symptoms) - pain related to positioning, incision, and surgical procedure ( reports pain is relieved to satisfactory level)

Incentive spirometry

- sit upright at 45 degree angle - take 2 normal breaths and place mouth piece on mouth - inhale until target reached and hold breath for 3 to 5 seconds - exhale completely - perform 10 sets of breaths each hour ( coughing moves secretions to prevent pneumonia)

FACTORS INFLUENCING EMOTIONAL OUTCOME

- surgery causes anxious emotional reaction and anesthesia * age * nutrition * Smoking * alcohol * chronic disease

roles in the OR of the LPN

- the second assistant technician which assist the surgeon

diagnostic

- tissue sample, make incision or scope to make diagnosis - biopsy

physical assessment

- vitals - Height and Weight - emotional status - neurologic status - skin- warm, brusis, lesions, turgor, dryness - respiratory- breathe sounds, rate, pattern, effort - cardiovascular- everything - gastrointestinal - bowel sound, last bowel movment - muskuloskeletal- weakness, deformities, ROM,

14.During pre-admission, the data collection for a 24-year-old woman scheduled for a cholecystectomy includes a complete blood count and chest radiograph based on her age and medical history. What other test should the nurse anticipate being ordered? 1. Pregnancy test2. Electrolyte studies3. Liver enzyme studies4. Respiratory function tests

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16.A patient is prescribed a dose of ondansetron (Zofran) before surgery. What should the nurse explain to the patient about the purpose of this medication? 1. Reduces emesis2. Relieves anxiety3. Reduces acidic gastric secretions4. Enhances postoperative pain relief

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13.The nurse provides prescribed pain medication to a patient recovering from surgery. What additional actions should the nurse take to provide comfort for this patient? Select all that apply.1. Relieve a full bladder2. Reduce overhead lighting3. Reduce environmental noise4. Place in a comfortable position5. Set the room temperature to cool

1 ,2 ,3 , 4

10.The nurse wants to determine if a patient not fully awake from anesthesia for a surgical procedure is experiencing pain. What findings should the nurse use to make this determination? Select all that apply.1. Moaning2. Unarousable3. Restlessness4. Pulling at a body area5. Elevated blood pressure

1, 3 ,4 ,5

12.During a home visit, the nurse is collecting data from a patient recovering from spinal surgery conducted 3 weeks ago. Which wound finding should the nurse expect in the patient? 1. Raised scar2. Flat thin scar3. Pink wound bed4. Fever and malaise

#1

6.Fory-eight hours after surgery a patient continues to have no bowel sounds. What should the nurse do to promote the return of bowel function in this patient? Select all that apply.1. Assist to ambulate.2. Turn on the left side.3. Place the bed in the flat position.4. Provide the patient with chewing gum.5. Encourage movement of the lower extremities.

#1

4.A patient returning from the recovery room following abdominal surgery to drain an abscess has a nonsuction-type drain placed in the wound bed to allow drainage. Which drain should the nurse expect to see? 1. Penrose drain2. Hemovac drain3. Jackson-Pratt drain4. Mini-Snyder Hemovac drain

#1 A Penrose drain uses gravity to drain serosanguineous fluid from a surgical wound. All of the other drains listed work via suction.

2.A patient is having procedural sedation and analgesia for a short surgical procedure. How often should the nurse monitor the patient's vital signs? 1. Every 5 minutes2. Every 10 minutes3. Every 15 minutes4. Every 30 minutes

#1 The patient undergoing a procedure in which sedation and analgesia are used and IV medications and fluids are administered is to have vital signs, electrocardiogram, and oxygen saturation level monitored every 5 minutes. Any changes are reported to the physician.

3.A patient is having a regional block where a tourniquet is placed on an extremity to reduce the blood in the extremity and then have a local agent injected into the extremity. What type of block should the nurse document? 1. Bier block2. Field block3. Nerve block4. Epidural block

#1 There are several types of regional blocks. A Bier block is done by placing a tourniquet on an extremity to reduce blood in the extremity and then injecting the local agent into the extremity. Other types of regional blocks include a field block, in which a series of injections surrounding the surgical area are made; a nerve block, in which an anesthetic agent is inserted at a specific point; and a spinal or epidural block, in which a local agent is injected into an area around the spinal nerves.

1.A patient who received an epidural anesthetic for a surgical case is prescribed a blood patch for a spinal headache. What should the nurse explain about the purpose of this blood patch? 1. Stops hemorrhage2. Stops cerebrospinal fluid leakage3. Provides the patient with more blood4. Delivers drugs to the site of the local anesthesia

#2 If a post-epidural headache continues and is not relieved by a flat prone position, adequate fluid, and analgesics, or steroids, a blood patch is used to stop the leakage of cerebrospinal fluid. Approximately 10 mL of the patient's own blood is injected into the epidural space at the previous puncture site. The injected blood forms a clot that patches the hole in the dura to stop cerebrospinal fluid leakage. The blood patch is not used to stop a hemorrhage, provide the patient with more blood, or deliver drugs to

11.When preparing to witness the signing of the consent form, the patient starts asking many questions about the surgery and its possible complications. What action should the nurse take? 1. Try to answer all of the patient's questions.2. Ask the registered nurse (RN) to answer the patient's questions.3. Have the physician answer the patient's questions before consent signing.4. Tell the patient the physician has explained all of this before and to sign the consent form.

#3

7.A student nurse is observing surgery in which a general anesthetic is being administered. After the intravenous (IV) induction agent is given, what action should the nurse anticipate the anesthesia provider will take next? 1. Administer the primary anesthesia agent.2. Obtain an adjunct muscle relaxant to administer.3. Use an endotracheal tube to intubate the patient.4. Obtain an adjunct antiemetic for administration.

#3

5.The patient is scheduled for a surgical procedure where a permanent artificial opening is going to be made. Which suffix should the nurse use when documenting this patient's surgery? 1. -ectomy2. -oscopy3. -ostomy4. -otomy

#3 In some cases, the formation of a permanent artificial opening in or from an organ is necessary. The suffix -ostomy combined with the name of the organ describes the procedure. The suffix -ectomy refers to removal of all or part of an organ; -oscopy refers to looking at the organ for diagnostic purposes; and -otomy refers to an incision or cutting into a tissue or part of the body.

7. The nurse understands that which of the following is the reason that long-term steroid therapy cannot be abruptly stopped? 1. Higher steroid levels are needed during stress. 2. Malignant hyperthermia will result. 3. Malignant hypertension will occur. 4. Respiratory failure will result.

(1) Higher steroid levels are needed during stress to the body, which surgery produces. (2, 3, 4) are not complications of steroid withdrawal; circulatory collapse is.

4. Which of the following is a discharge criterion from the PACU for a patient after surgery? 1. Oxygen saturation above 90% 2. Oxygen saturation below 90% 3. Intravenous (IV) narcotics given less than 15 minutes earlier 4. IV narcotics given less than 30 minutes earlier

(1) Oxygen saturation must be above 90%. (2) is incorrect. (3) Patients do not have to void before perianesthesia care unit (PACU) discharge. (4) IV narcotics cannot have been given less than 30 minutes ago.

14. After surgery, the nurse notes that the patient's urine is dark amber and concentrated. Which of the following does the nurse understand may be the reason for this? 1. The sympathetic nervous system saves fluid in re sponse to stress of surgery. 2. The sympathetic nervous system diureses fluid in response to stress of surgery. 3. The parasympathetic nervous system saves fluid in response to stress of surgery. 4. The parasympathetic nervous system diureses fluid in response to stress of surgery.

(1) The sympathetic nervous system saves fluid in response to stress of surgery, which reduces urine output initially. (2, 3, 4) are incorrect.

Which of the following is an intraoperative outcome for a patient undergoing an inguinal hernia repair? 1. Verbalizes fears. 2. Maintains skin integrity. 3. Demonstrates leg exercises. 4. Explains deep-breathing exercises.

(2) Skin integrity is maintained during surgery with proper positioning and avoidance of pressure points. (1, 3, 4) are preoperative goals.

6. The LPN/LVN is caring for a patient in the preoperative period who, even after verbalizing concerns and having questions answered, states, "I know I am not going to wake up after surgery." Which of the following actions should the LPN/LVN take? 1. Reassure patient everything will be all right. 2. Inform the registered nurse. 3. Explain national surgery death rate. 4. Ask family to comfort the patient.

(2) The registered nurse must be informed so the surgeon can be notified. (1, 3, 4) are not appropriate interventions, and if the patient is extremely scared, the surgeon must be told because surgery may need to be canceled.

10. Which of the following actions should the nurse take to maintain patient safety when ambulating a patient for the first time postoperatively? 1. Use one person to assist patient. 2. Use two people to assist patient. 3. Encourage patient to "dangle" self 1 hour before ambulation. 4. Give narcotic 15 minutes before ambulation.

(2) Use two people to assist patient for first time in case patient is lightheaded. (1) One person may not be enough to support patient if fainting occurs. (3) For safety reasons, patient should not self-dangle. (4) Narcotics should be given about 1 hour before ambulation so patient is comfortable but hypotension is less likely.

preoperative consent

- give legal permission for surgery and has 2 purposes - valid for 30 days after signing - surgeon must explain in terms to patient understands about the diagnosis - consent must be signed before analgesics or sedatives are given - consent must be given voluntarily - nurses only witness persons signature of consent

Phase 1 of healting

- incision to 2nd postoperative day - inflammatory response - fever, malaise

15. The patient develops a low-grade fever 18 hours post operatively and has diminished breath sounds. Which of the following actions is most appropriate for the nurse to take to prevent complications? Select all that apply. 1. Administer antibiotics. 2. Encourage coughing and deep breathing. 3. Administer acetaminophen (Tylenol). 4. Decrease fluid intake. 5. Ambulate patient as ordered. 6. Monitor intake and output.

(2, 5) New-onset fever occurring shortly after surgery is often due to atelectasis because a new infection related to surgery would take longer to develop, so encouraging coughing and deep breathing and ambulating to expand lungs can help prevent pneumonia. (1) An infection is not usually the cause of a fever in this time frame.

12. The patient is dangling at the bedside and states, "Oh, my stomach is tearing open." Which of the following actions should the nurse immediately take when dehiscence occurs? 1. Have patient sit upright in a chair. 2. Slow IV fluids. 3. Have patient lie down.4. Obtain a sterile suture set.

(3) Have patient lie down to reduce pressure on the incisional area to help prevent evisceration. (1) Having patient sit upright promotes evisceration. (2) Intravenous (IV) fluids should be maintained at ordered rate and increased fluid needs anticipated because of large fluid loss occurring with dehiscence and evisceration. (4) This would not be the nurse's first action, and the patient would likely be prepared for surgery.

5. Which of the following is one of the discharge criteria from ambulatory surgery for patients following surgery? 1. Able to drive self home. 2. Has home telephone. 3. Understands discharge instructions. 4. IV narcotics given less than 30 minutes before discharge.

(3) Patients and a responsible adult must understand discharge instructions before discharge. (1) Patients cannot drive home. (2) Patient does not have to have home telephone but must be able to be contacted in some way for follow-up. (4) IV narcotics cannot have been given less than 30 minutes ago.

9. The nurse is caring for a patient with a bowel resection. Which of the following would indicate that the patient's gastrointestinal tract is resuming normal function? 1. Firm abdomen 2. Excessive thirst 3. Presence of flatus 4. Absent bowel sounds

(3) Pneumonia can be prevented with lung expansion promoted by ambulation. (1, 2, 4) are not prevented with ambulation.

11. The nurse is caring for a patient with a bowel resection. Which of the following would indicate that the patient's gastrointestinal tract is resuming normal function? 1. Firm abdomen 2. Excessive thirst 3. Presence of flatus 4. Absent bowel sounds

(3) Presence of flatus occurs with normal bowel function. (1, 4) indicate the bowel is not functioning normally. (2) is not related to bowel function.

1. Which of the following is an LPN/LVN patient care role in the preoperative phase? 1. Obtaining preoperative orders 2. Explaining the surgical procedure 3. Offering emotional support 4. Providing informed consent

(3) The LPN/LVN can offer emotional support as needed to patients. (1) is the role of the registered nurse (RN). (2, 4) are roles of the health care provider

8. The nurse is to provide preoperative teaching for a 74-year old patient. Which of the following actions should the nurse take to improve learning? 1. Sit in front of window in bright sunlight. 2. Use small, white-on-black printed materials. 3. Speak in a high tone. 4. Eliminate background noise.

(4) Eliminate background noise as the older adult is not able to filter out noise. (1) This increases glare, which will interfere with vision. (2) Large blackon- white print should be used. (3) A low tone should be used.

13. When the nurse is assisting the patient to use an incen tive spirometer, which of the following actions by the patient indicates that the patient needs further teaching on how to use the spirometer? 1. Taking two normal breaths before use 2. Inhaling deeply to reach target 3. Sitting upright before use 4. Exhaling deeply to reach target

(4) Exhaling deeply to reach target is incorrect and would indicate need for teaching. (1, 2, 3) are incorrect because they are appropriate ways to use the spirometer.

When the patient's signature is witnessed by the nurse on the surgical consent, which of the following does the nurse's signature indicate? 1. The nurse obtained informed consent. 2. The nurse provided informed consent. 3. The nurse answered all surgical procedure questions. 4. The nurse verified that the patient signed the consent.

(4) The nurse's signature verifies that it was the patient who signed the consent after informed consent was provided by the surgeon. (1, 2, 3) are not the role of the nurse and are not indicated by the witnessing of the consent.

Anesthesia

- 2 types ( general and local) - general causes patient to lose sensation and consciousness and reflexes and acts directly on the central nervous system - local blocks nerve impulses along the nerve where it is infected without loss of consciousness

phase 2 of healing

- 3rd to 14th postoperative day - granulatioin tissue forms - feeling better

phase 3 of healing

- 3rd to 6th postoperative week - collagen deposited - raised scar formed

Medications

- Coumadin or NSAIDS need to be stopped several days before surgery to avoid bleeding problems - Herbal meds need to stop 1-2 weeks before surgery because some can increase bleeding times

perioperative

- all 3 phases surrounding and during surgery

pallliative

- alleviation of symptoms when disease cannot be cured - cuts nerve root to remove pain - gastronomy tube to provide tube feedings for swallowing problems or colostomy for incurable bowel obstruction

Preoperative diagnostic tests

- chest xray - oxygen saturation - serum test such as arterial blood gases, bleeding time, blood urea nitrogen, creatinine, CBC, Electrolytes, fasting blood glucose, pregnancy, urinalysis, INR, type and cross match

reconstructive

- correction of defect body parts - scare repair, knee replacement, face lift, mammoplasty

Postoperative phase

- final phase in the PACU - to watch airway - vital signs - monitor carbon dioxide levels - level of consciousness and responsivness - surgical site - pain level

spinal and epidural blocks

- injection into the epidural space in the lower extremities, and lower abdominal surgery - a complication is postdural puncture headache from leakage of CSF which can be severe - LA to S1 - higher up the epidural the more it can effect your breathing

1. The nurse is contributing to the plan of care for a preoperative patient. Which of the following nursing actions should the nurse implement to reduce surgical risk factors for the preoperative patient? Select all that apply. 1. Playing music of patient's choice 2. Avoiding discussion of fears 3. Reinforcing pain control methods 4. Showing use of incentive spirometer 5. Monitoring blood glucose for a patient with diabetes 6. Teaching to perform leg exercises hourly while awake

1, 3, 4, 5, 6. All except 2, which can contribute to increasing anxiety and fear, will calm the patient, place the patient in a healthier state, or teach the patient ways to promote recovery.

5. The nurse is contributing to the plan of care for a patient undergoing a cholecystectomy. Which of the following interventions would help prevent atelectasis for this patient? Select all that apply. 1. Coughing and deep breathing 2. Holding breath while moving 3. Restricting fluids 4. Leg exercises 5. Pain control 6. Ambulation

1, 5, 6. Controlling pain allows the patient to cough and deep breathe more comfortably, which expands the lungs, as does ambulation.

2. The LPN/LVN is caring for a preoperative patient. Which of the following roles can the LPN/LVN provide for the patient's care in the preoperative phase? 1. Assisting in data collection 2. Explaining the surgical procedure 3. Obtaining preoperative orders 4. Conducting the preoperative anesthesia interview

1. Assisting in data collection is an LPN function; selections 2 and 4 are the physician's role, and selection 3 is the RN's role.

7. The nurse is caring for a patient who returned from surgery 3 hours ago. Which of these findings would the nurse recognize as being the most urgent to report to the surgeon? 1. Tachycardia 2. Polyuria 3. Nausea 4. Fever

1. Tachycardia is a compensatory sign to maintain cardiac output for fluid volume loss, as in hemorrhage.

15.In the perianesthesia care unit, the nurse monitors the patient's temperature, pulse rate, respiration rate, blood pressure, and pain level. What additional bodily function should the nurse monitor in this patient? 1. Bilirubin2. Oxygen saturation3. Blood urea nitrogen4. Erythrocyte sedimentation rate

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17.The dressing on a patient's abdominal wound is saturated with blood and drainage 16 hours after surgery. What should the nurse do for this patient? 1. Change the dressing.2. Reinforce the dressing.3. Call the surgeon to change the dressing.4. Remove the dressing and keep the wound open to air.

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8.Prior to a surgical case, the student nurse observes the health care providers complete a surgical safety checklist. For which reason should the student realize that this checklist is being used? 1. Decreases the need for duplicate forms2. Reduces errors and patient complications3. Improves patient satisfaction survey results4. Increases staff compliance with The Joint Commission's standards

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4. The nurse is contributing to the teaching plan for an older adult. Which of the following is a teaching strategy that improves learning for the older adult? 1. Sit near a window with bright sunlight. 2. Use large black-on-white printed materials. 3. Sit beside patient. 4. Use blue and green colors for brochures.

2. Large black-on-white printed materials are most easily seen by the older adult.

9.A 2-day postoperative patient is receiving 1000 mL normal saline over 10 hours. The patient has an intake of 4 ounces of orange juice, one 8-ounce cup of coffee, 3 cups of water, and 1 cup of tea. This patient has a total intake of _________ mL over the 12-hour period. Note: Enter Numeric Input

2520 Convert cups to ounces (1 cup = 8 ounces) and then ounces to milliliters (1 oz = 30 mL). Thus, the patient had an intake of 120 mL orange juice, 240 mL coffee, 720 mL water, and 240 mL tea for a total oral intake of 1320 mL. Add to this the amount of the IV given over 12 hours (1000 ÷ 10 hours = 100 mL per hour × 12 hours = 1200 mL). So, 1320 + 1200 = 2520 mL.

6. The nurse is caring for a patient after thoracic surgery. Which of the following would the nurse evaluate as indicating that interventions to prevent respiratory complications have been effective? 1. Pain level "2" 2. No abdominal distention 3. Clear lung sounds 4. Good appetite

3. Clear lung sounds indicate that the lungs are functioning normally.

3. The LPN/LVN is caring for a patient preoperatively who is to sign consent for surgery. Which of the following is within the LPN/LVN's scope of practice related to the patient providing consent for surgery? Select all that apply. 1. Witnessing minor patient's signature on the consent 2. Providing informed consent 3. Answering surgical procedure questions 4. Requesting patient questions be referred to surgeon 5. Witnessing the patient's signature on the consent 6. Reading the consent to a patient before he or she signs it

4, 5, 6. The LPN may refer questions to the surgeon, read the consent to a patient, and witness the signature of a patient who is informed.

8. The nurse is assisting with data collection on an ambulatory postoperative patient. Which of the following criterion would the nurse evaluate as indicating patient readiness for discharge after ambulatory? 1. Ability to drive an automobile 2. Ability to ambulate 50 feet 3. Being pain free 4. Absence of nausea or vomiting

4. Nausea and vomiting must be controlled before discharge. Pain at a tolerable level is expected in the immediate postoperative period

Malignant hypothermia

A rare hereditary muscular disease that can be triggered by general anesthetics - produces a very high fever, muscle rigidity, tachycardia, hypertension, dysrhythmias, metabolic and respiratory acidosis and cynosis - dantrolene is a medication used to help

surgery levels

Emergency level- immediate needed to save life or limb without delay ex: ruptured aneurysm or appendix, limp amputation, loss of extremity pulse from emboli

9. What is the role of the home health nurse in caring for postoperative patients? Fill in the blank.

The home health nurse's role is to assist the patient's recovery

purposes of surgery

aesthetic- requested by patient for improvement like breast augmentation

phase 3 postoperative

begins with admission to pacu and continues until recovery is complete

Phase 1 preoperative

begins with decision for surgery and ends with transfer to operating room - develop patients plan of care - reinforce explanations and instructions given to patient by surgeon and RN - provide emotional and psychological support for patients and their families

Phase 2 intraoperative

begins with transfer to operating room and ends with admission to PACU

exploratory

confirmation or measurement of extent of condition - exploratory laparotomy

A-V pump or SCD

for postoperative patients to prevent deep venous thrombosis and to reduce pain and edema

general anesthesia

given IV or inhalation with an Endotracheal tube with can irritate the respiratory tract

types of surgery

minimally invasive surgery(scope, laser, robotic) - laser is used instead of scapel to cut tissue often for eye surgery - endoscope is also called a keyhole surgery for abdominal or pelvic cavity - robotic is the Da Vinci is a surgical robotic with 3 or 4 arms that acts as the surgeons arms

surgeons

physicians who perform surgery

elective level

planned/scheduled with no time requirements ex: joint replacement, hernia repair, skin lesion removal

preventive

removal of tissue before it causes a problem - mole or polyp to prevent cancer

Urgent level

surgery needed with in 24-30 hours ex: fracture repair, infected gallbladder

optional level

surgery requested by the patient ex: cosmetic surgery

Wound healing phases

wounds heal from the inside to out