Chapter 39: Perioperative

A 2-year-old child is scheduled for a tonsillectomy. When determining the plan of care, the nurse should: 1) Include the parents or caregivers in the plan of care. 2) Explain to the child that she will have a sore throat after surgery. 3) Tell the child that she can have her favorite foods for the first 24 hours after surgery. 4) Prepare the child for discharge from the hospital as soon as she is alert.

1) It is developmentally normal for toddlers to experience anxiety with separation from parents or caregivers. Be sure to include these people in the plan of care. Developmentally, a 2-year-old lives in the here and now and wouldnt grasp an intangible concept, such as pain in the future. The toddler would take liquids and soft foods within the first 24 hours when her throat is sore during swallowing. She should not eat foods that are rough and crunchy because they may scratch her throat and cause bleeding. After a tonsillectomy, the child will need to be monitored for bleeding and stable vital signs; therefore, she will not be discharged as soon as she is alert.

The nurse knows that the most important reason for controlling postoperative nausea/vomiting in the PACU is a. To prevent potential airway issues b. To prevent the patient from becoming dehydrated c. To prevent the surgical dressing from becoming soiled d. To prevent the patient from becoming upset

Correct answer: A The priority nursing intervention for the nurse in PACU is airway management. Controlling nausea and/or vomiting will prevent aspiration and ensure a patent airway.

The nurse is completing a preoperative patient assessment. Which finding indicates the greatest risk for the development of a postoperative complication? a.The patient has early stage Alzheimer's b.The patient is 60 years old c.The patient's blood pressure is 130/80mmHg d.The patient does not understand the surgery

Correct answer: A The surgical experience may exacerbate any type of dementia. Even in the early stages, a patient with Alzheimer's may not be able to comprehend written or oral directions related to care. In cases of major surgery, the patient with dementia may pull at dressing, drains, and IV lines and be at increased risk for falls.

An elderly woman fell at home and fractured her hip. After being admitted to the hospital, the nurse knows that the patient is to be "stabilized" prior to having surgery. This surgery would be classified as a.Urgent b.Elective c.Emergency d.Palliative

Correct answer: A This patient will most likely have her surgery within the next 48 hr. It must be done to restore joint function.

Which member of the intraoperative team sets up the sterile field, prepares the surgical instruments, assists with the sterile draping of the patient, anticipates and responds to the surgeon's needs, and maintains the integrity of the sterile field? 1) Scrub nurse 2) Registered nurse first assistant 3) Certified registered nurse anesthetist 4) Circulating nurse

1) Scrub nurse Rationale: The registered nurse first assistant (RNFA) is an RN who serves as an assistant to the surgeon. The RNFA works with the surgeon to perform the surgical procedure. A certified registered nurse anesthetist (CRNA) may administer anesthesia and is part of the clean team. The circulating nurse is also part of the clean team and is an RN who utilizes the nursing process to coordinate all activities in the operating room.

The nurse is performing irrigation of the nasograstric tube for a patient who had abdominal surgery and meets resistance when trying to instill the irrigant. The nurse should: 1) use extra force to push the obstruction through the tube. 2) remove the tape from the patient's nose and adjust the placement of the tube. 3) have the patient turn to the left side to change the position of the tube. 4) attempt to flush the tube via the air port.

3) have the patient turn to the left side to change the position of the tube. Rationale: Patients having abdominal surgery are at high risk of abdominal distention and will return from surgery with a nasogastric tube in place for gastric decompression. Management of nasograstric tubing includes irrigation with 30 mL to 50 mL of saline. The irrigant should be instilled slowly in the NG tube. If resistance is met when you irrigate, have the patient turn to the left side. Turning to one side changes the position of the distal tip of the NG tube. Do not force the solution. Do not instill fluid into the air vent. Manually adjusting the placement of the NG tube may cause accidental instillation of irrigant into the airway.

The nurse asks a preoperative patient to sign the operative permit as directed in the healthcare provider's orders. The patient says, "I do not really understand why I need surgery." The nurse should: 1) communicate the patient concerns to the circulating nurse upon arrival to the operating room. 2) explain what the planned surgical procedure is for and then have the patient sign the consent form. 3) have the patient sign the form anyway and then ask the healthcare provider to visit the patient. 4) notify the healthcare provider that the informed consent process is not complete and delay sending the patient to the operating suite

4) notify the healthcare provider that the informed consent process is not complete and delay sending the patient to the operating suite. Rationale: Professional standards and law require the surgeon to obtain the patient's informed consent. The signed informed consent verifies that the patient and the surgeon have discussed the surgery and the patient understood it and was not pressured into having the surgery. The surgeon is responsible for giving the patient necessary information. As a patient advocate, the nurse is responsible for assuring that the surgeon explained the procedure and that the patient understood the information. If you have any questions about the patient's understanding or ability to understand, notify the physician and delay sending the patient to surgery.

Which of the following potential complications is most likely related to the surgical procedure rather than to the general anesthetic? 1) Aspiration of gastric contents 2) Cardiovascular compromise 3) Fluid and electrolyte imbalance 4) Respiratory depression

3) Fluid and electrolyte imbalance Rationale: Most surgical patients are at risk for fluid and electrolyte imbalance. This may result from blood loss, compromised renal function, the overall health of the patient, or maintaining the NPO status. Aspiration of gastric contents, cardiovascular compromise, and respiratory depression are potential complications of anesthesia.

Which phase begins when the patient leaves the postanesthesia care unit (PACU) and ends when the patient has recovered from the surgery? 1) Postoperative 2) Intraoperative 3) Preoperative 4) Perioperative

1) Postoperative Rationale: The postoperative phase begins when the patient has recovered from anesthesia and ends when the patient has recovered from surgery. The preoperative phase begins with the client's decision to have surgery and ends when the client enters the operating room. The intraoperative phase begins when the client enters the surgical suite and ends with discharge to the postanesthesia care unit. The perioperative period includes the preoperative, intraoperative, and postoperative phases.

Which of the following is the most appropriate nursing goal for a 2-year-old who is to have a tonsillectomy? 1) Separation anxiety will be minimal. 2) The child will verbalize understanding of expected pain. 3) The child will tolerate a normal diet 24 hours after surgery. 4) The parent will indicate readiness to assume the childs care.

1) The only concrete information in this question is that the child is 2 years old. Therefore, the only problem the nurse can reasonably predict from this would be developmental in nature. It is developmentally normal for toddlers to experience anxiety with separation from parents or caregivers. Minimizing anxiety by involving the parents or caregivers would be the appropriate goal for separation anxiety. A 2-year-old child would not be expected to verbalize understanding of expected pain. The toddler would take liquids and soft foods within the first 24 hours when her throat is sore during swallowing. She should not eat foods that are rough and crunchy because they may scratch her throat and cause bleeding. Nurses should encourage parental involvement, but parents should not be expected to assume the childs care.

A patient is having surgery to remove an inflamed appendix. Which of the following describes this type of surgery by purpose? 1) Ablative 2) Diagnostic 3) Palliative 4) Reconstructive

1) Ablative Rationale: Ablative surgery involves removal of a diseased body part—in this case, the appendix. Diagnostic surgery is undertaken to confirm or negate a diagnosis (e.g., a biopsy or a fine-needle aspiration). In this situation, the diagnosis was already made and the surgery is being done to treat the condition. Palliative surgery is done to alleviate discomfort or other disease symptoms without producing a cure (e.g., nerve root destruction). In this situation, pain will be relieved, but a cure will also be effected. Reconstructive surgery is performed to restore function (e.g., repair of a torn ligament). This surgery removes the appendix rather than repairing it.

A patient arrives on the postoperative nursing unit following gastric bypass surgery. He is awake, alert, and oriented upon arrival. You are working with a NAP to assure timely and adequate patient care. Which of the following activities can you safely delegate to the NAP? Select all that apply. 1) Application of sequential compression device 2) Initial setup and irrigation of the nasogastric (NG) tube 3) Emptying and measuring urinary drainage 4) Reinforcing teaching about the pain scale

1) Application of sequential compression device 3) Emptying and measuring urinary drainage 4) Reinforcing teaching about the pain scale Rationale: When deciding to delegate, the nurse should think critically about the task, the ability of the assistive personnel, and the circumstances. Communication, supervision, and evaluation are essential steps in the delegation process. The nurse cannot delegate nursing care decisions. Application of sequential compression device can be delegated to the NAP who has training in that task. The nurse can also delegate emptying and recording drainage. Although the registered nurse should perform the initial teaching, the nurse can delegate to the NAP reinforcement of teaching. The registered nurse should perform the initial set-up and any subsequent irrigation of the gastric suctioning tube.

A young adult woman is scheduled for a bilateral breast reduction under general anesthesia. She is normally healthy and takes no daily medications. Identify the preoperative screening tests appropriate for this patient. Select all that apply. 1) Urinalysis 2) EKG 3) Chest x-ray 4) CBC

1) Urinalysis 4) CBC Rationale: Preoperative screening tests are ordered to determine whether the client has undetected underlying health concerns. Most institutions require a complete blood count (CBC) and urinalysis prior to all surgical procedures. Generally, an electrocardiograph (ECG) is ordered for clients over the age of 50 years or with known cardiac disease. A chest x-ray is not a routine presurgical screening test.

A patient had a hiatal hernia repair earlier today and is now in the postanesthesia care unit (PACU). The family asks the nurse why the patient is in the PACU rather than back in his room on the postsurgical unit. The nurse should inform the family that: 1) Patients who have had surgical complications are observed in the PACU until they are stable enough to return to the floor. 2) Patients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care. 3) The PACU is a holding area for patients awaiting a surgical unit bed or awaiting adequate staff to provide care on the postsurgical unit. 4) The nurse will ask the surgeon explain to them why the patient is not on the postsurgical unit, as is the usual procedure.

2) A client remains in the PACU until he has recovered from the effects of anesthesia. In the PACU, the client is assessed every 5 to 15 minutes in order to quickly identify surgical or anesthesia-related problems. Most surgical units routinely admit patients to the PACU for a period of observation. Admission to the PACU does not indicate surgical complications nor imply that a holding area is required. There is no reason the surgeon would need to explain this to the family, as the nurse could do it. It is not usual procedure for a patient to be transferred directly from surgery to the postsurgical unit.

The patient tells the nurse, Im so nervous. I want to be knocked out for the surgery so that I dont know what is going on. When the nurse communicates with the surgeon and anesthetist, she tells them that the patient desires which type of anesthesia? 1) Conscious sedation 2) General anesthesia 3) Local anesthesia 4) Regional anesthesia

2) General anesthesia produces rapid unconsciousness and loss of sensation. During conscious sedation, the client feels sleepy but is easily aroused by touch or speech. Regional anesthesia interrupts nerve impulses to and from the affected area, but the patient remains alert. Local anesthesia produces loss of pain sensation at the desired site and is typically used for minor procedures. The client remains alert during local anesthesia.

A patient is admitted from a local skilled nursing facility to the outpatient surgery center for surgical dbridement of a stage IV sacral pressure ulcer. The perioperative nurse discovers that the patient does not have a signed consent form for the surgery on the chart or in the surgery center. The patient says that she has not talked to the surgeon and that she has many questions regarding her surgery. When informed of this, the surgeon tells the nurse to have the patient sign the informed consent form, and he will review it prior to the surgery. What should the nurse do? 1) Follow the surgeons orders, and ask the patient to sign the surgical consent form. 2) Inform the surgeon that she will have the patient sign after he discusses the surgery with the patient. 3) Ensure that the signed surgical consent is witnessed by two nurses, because the surgeon is not available. 4) Cancel the surgery and transfer the patient back to the long-term care facility.

2) Informed surgical consent requires that the surgeon present information about the surgery to the patient, that the patient understands the information and agrees to the surgery, and that the patient has not been coerced to give consent. As a patient advocate, the nurse should verify with the patient that the surgeon has explained the procedure and answered all her questions. The surgeon is responsible for giving the patient the necessary information and determining the patients competence to make an informed decision about the surgery. If the patient has further questions, the nurse should notify the surgeon and delay sending the patient to surgery until an informed consent is obtained.

The focus of nursing activities in the preoperative phase is to: 1) Admit the patient to the surgical suite. 2) Prepare the patient mentally and physically for surgery. 3) Set up the sterile field in the operating room. 4) Perform the primary surgical scrub to the surgical site.

2) The nursing focus in the preoperative phase is to prepare the patient mentally and physically for surgery. The patient is in the intraoperative phase when admitted to the surgical suite. The sterile field and the surgical scrub would be performed in the surgery suite during the intraoperative phase.

The nurse is teaching a patient how to prevent surgical site infections in the postoperative period. She should focus her teaching on: 1) care for the surgical dressing 2) handwashing 3) medications used to control pain 4) the need to complete all ordered antibiotics after surgery

2) handwashing Rationale: An important aspect of perioperative nursing it to prevent complications of surgery. Hand hygiene is an important component of prevention. Family and friends should wash their hands before and after they visit the patient. Anyone who examines the patient or checks their incision should wash their hands. Patients should be instructed to wash their hands before and after caring for their incision or surgical dressing.

Identify the type of surgery a terminally ill patient will undergo if the purpose is removal of tissue to relieve pain. 1) Procurement 2) Ablative 3) Palliative 4) Diagnostic

3) Palliative surgery alleviates discomfort or other disease symptoms without producing a cure. Procurement surgery occurs when an organ or tissue is harvested for transplantation into another. Ablative surgery involves removal of a body part. Diagnostic surgery confirms or negates a diagnosis.

The focus of nursing care in the intraoperative phase is to: 1) Prepare the patient for surgery. 2) Maintain the sterile field. 3) Ensure patient safety during the surgery. 4) Obtain a signed informed consent.

3) The intraoperative phase begins when the patient enters the operating suite and ends when the patient is admitted to the postanesthesia care unit. The nursing focus is to ensure patient safety during the surgical procedure by functioning as an advocate when clients cannot advocate for themselves and by monitoring the client and surgical environment throughout the procedure. Although the sterile field must be maintained in this phase, the focus of care is broader than the maintenance of sterility. Obtaining informed consent and preparing the patient for surgery are activities associated with the preoperative phase.

A patient is scheduled for abdominal surgery tomorrow. While gathering preoperative data, the nurse learns that the patient takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. The patient reports that he stopped taking the anticoagulant 4 days ago as instructed by the surgeon. He has continued to take the multivitamin and vitamin E. Based on the information given, the nurse telephones the surgeon because she: 1) Needs an order to restart the anticoagulant. 2) Is concerned about continued use of the multivitamin. 3) Is concerned about the vitamin E dosage. 4) Thinks the surgery should be delayed until further notice.

3) Both prescribed and over-the-counter medications may increase surgical risk. Many herbs can cause potassium loss and increase the risk for cardiac arrhythmias. High doses of vitamin E may increase the risk for bleeding. This patients use of 1,500 IU of vitamin E daily exceeds the recommended dosage, so the nurse should inform the surgeon of the vitamin E intake. Generally, the surgeon or anesthesiologist instructs patients to continue or discontinue taking their prescribed medicines. However, it is important to assess use of supplements and over-the-counter medicines. The surgeon would determine if the surgery should be delayed.

Which of the following nursing interventions would help prevent one of the "never events" identified by Medicare? Select all that apply. 1) Control unpleasant odors in the room. 2) Give analgesics before the pain becomes severe. 3) Count sponges in the operating room. 4) Carefully identify the patient on each contact.

3) Count sponges in the operating room. 4) Carefully identify the patient on each contact. Rationale: Controlling odors helps prevent and treat nausea, and timely administration of analgesics helps control pain. "Never events" are serious and costly errors resulting in severe consequences for the patient. "Never events" are generally preventable. Pain and nausea are not "never events" as identified by Medicare. Counting sponges in the OR helps prevent the "never event" of leaving a foreign body in the patient. Careful identification helps prevent wrong patient, wrong body part, wrong surgery in the perioperative period.

The health record shows that a patient has been using long-acting oral opioids to manage severe, chronic back pain secondary to a tumor located along the lumbar spine. She has just had her appendix removed. Which outcome will assure the nurse that her pain interventions were effective? 1) The patient is discharged from the hospital on postoperative day five. 2) The patient ambulates from the bed to the bathroom on the day after surgery. 3) Pain is controlled and respirations are in patient's usual range. 4) Wound dressing remains dry and intact for 48 hours.

3) Pain is controlled and respirations are in patient's usual range. Rationale: Pain management is a priority for this patient. However, opioids may cause respiratory depression and increase the risk of atelectasis and pneumonia. Well-managed pain and clear breath sounds indicate that the plan of care has been effective. The date of discharge from the hospital is dependent on many variables and is not an effective evaluative tool for pain—especially because this patient has chronic pain that is unrelated to her surgery. The distance ambulated depends on the patient's presurgical condition; although pain does affect ambulation, this is not the best criterion for determining the level of pain. The condition of the dressing does not reflect on the status of the patient's pain.

An 83-year-old patient had surgery to repair a hip fracture and has not yet ambulated postoperatively. Based on this information, the nurse identifies the priority collaborative problem for the patient as: 1) fluid and electrolyte imbalance. 2) impaired surgical wound healing. 3) thromboembolism. 4) hypovolemia.

3) thromboembolism. Rationale: Older adults are at greatest risk for complications during surgical procedures because they have less physiological reserve and often have comorbid conditions. Thromboembolism results from increased coagulability and venous stasis due to immobility during and after surgery, and puts patients at risk for life-threatening pulmonary embolus. Nursing care should focus on preventing thrombophlebitis by encouraging and assisting with leg exercises and ambulation, applying antiembolism stockings or sequential compression devices, and maintaining adequate hydration.

The nurse has a prescription to give a series of medications on an "on call" basis. The nurse realizes that these medications will be given: 1) in the postanesthesia recovery unit. 2) at the time specified in the order. 3) on the patient's arrival in the surgery suite. 4) when the OR staff notify the nurse to do so.

4) When the OR staff notify the nurse to do so. Rationale: The anesthesia team may order medications to be given "on call" if the surgery time is likely to vary. The nurse will give "on call" medications when he is notified to do so by the OR staff.

A patient has chronic confusion secondary to dementia. As a result, he is unable to sign an informed consent for surgery. In this situation: 1) An informed consent is not needed. 2) Two nurses may sign the informed consent for the patient. 3) The surgeon must sign the informed consent. 4) A family member will be asked to sign the informed consent.

4) In most states, a family member, conservator, or legal guardian may give consent for a procedure if a patient is not capable of giving an informed consent or if the patient is a minor.

A patient is admitted for hip surgery. The patient usually takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. He stopped taking his anticoagulant 4 days ago as instructed by his surgeon, but has continued to take the multivitamin and vitamin E. An important collaborative problem or nursing diagnosis for this patient is which of the following? 1) Potential complication: anemia 2) Risk for infection related to inadequate anticoagulant dosage 3) Risk for noncompliance related to inability to follow instructions 4) Potential complication: increased bleeding

4) The patient is at an increased risk for bleeding due to his intake of vitamin E. He may be at risk for anemia if he experiences a large blood loss in surgery; however, this problem is not appropriate before he experiences the blood loss. This patient does not have a higher-than-average risk for infection because he is not having surgery involving a contaminated system (e.g., the gastrointestinal system). There is no evidence to suggest that this is noncompliant simply he because he stopped taking his anticoagulant as ordered.

The preoperative phase encompasses which period of time? 1) Entry to the operating suite until admission to postanesthesia care 2) Entry into the operating suite until discharge from the hospital 3) The decision to have surgery until admission to postanesthesia care 4) The decision to have surgery until entry to the operating suite

4) The preoperative phase begins with the decision to have surgery and ends when the patient enters the operating room. The intraoperative phase begins when the patient enters the operating suite and ends when the patient is admitted to the postanesthesia care unit.

A patient is to have a sequential compression device (SCD) applied on the postoperative unit. The patient is wearing knee-high elastic (antiembolism) stockings. When applying the SCD, what should the nurse do? 1) Remove the antiembolism stockings and not replace them. 2) Replace the knee-high stockings with thigh-high stockings. 3) Notify the surgeon that the patient is wearing antiembolism stockings. 4) Apply the SCD over the knee-high antiembolism stockings.

4) If elastic stockings have been ordered with the sequential compression device, leave them in place; if the patient is not yet wearing them, obtain them and put them on the patient. Knee-high stockings do not need to be replaced with thigh-high stockings. Some research has shown knee-high stockings to be equally effective. There is no need to notify the surgeon, as patients commonly return from surgery wearing antiembolism stockings, as prescribed.