Foundations Test 1 Day 1
• Demonstrate postoperative exercises: diaphragmatic breathing, coughing, incentive spirometer use, turning, and leg exercises.
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• Describe the rationale for nursing interventions designed to prevent postoperative complications.
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• Explain the differences and similarities in caring for ambulatory versus inpatient surgical patients.
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• Prepare a patient for surgery.
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10 You have been given the following postoperative patients to care for on your shift. Based on the information provided, which patient should you see first? 1A 75-year-old following hip replacement surgery who is complaining of moderate pain in the surgical site, with a heart rate of 92 2 A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) with a history of OSA. The pulse oximeter has been alarming and reading 85% 3 A 36-year-old following bladder neck suspension who is 30 minutes late to receive her postoperative dose of antibiotic 4 A 48-year-old following total knee replacement who needs help repositioning in bed
10. Answer: 2. The patient with OSA has a risk of airway obstruction, which takes immediate precedence. She is symptomatic of oxygen desaturation.
11 Hand-off communications that occur between the postanesthesia care unit (PACU) nurse and the nurse on the postoperative nursing unit should be done when a patient returns to the nursing unit. Select appropriate components of a safe and effective hand-off. (Select all that apply.) 1Vital signs, the type of anesthesia provided, blood loss, and level of consciousness 2Uninterrupted time to review the recent pertinent events and ask questions 1293 1294 3Verification of the patient using one identifier and the type of surgery performed 4Review of pertinent events occurring in the operating room (OR) while at the nurses' station
11. Answer: 1, 2. A standardized approach or tool for hand-off communication helps providers provide accurate information about the care received in the OR and the PACU before coming to the postoperative nursing unit. Proper identification of the patient requires using a standard of two identifiers and explaining the surgery performed and information about the type of anesthesia provided, blood loss, and level of consciousness. Allowing appropriate time for questions and communication free of distraction improves the quality of the hand-off. It must occur at the patient's bedside.
12 A nurse is working in the preoperative holding area and is assigned to care for a patient who is having a prosthetic aortic valve placed. The nurse inserts an intravenous (IV) line and obtains vital signs. The patient has a temperature of 39° C (102° F), heart rate of 120, blood pressure (BP) of 84/50, and an elevated white blood cell (WBC) count. The nurse immediately notifies the surgeon of the patient's vital signs because: 1They need to get the patient into the operating room (OR) quickly to start the surgery because of the low blood pressure. 2The surgery may need to be delayed to check the patient's WBC count and investigate the source of fever before surgery. 3The nurse anticipates the need for a fluid bolus to increase the patient's BP. 4The nurse anticipates an order for a sedative to help calm the patient and decrease the heart rate.
12. Answer: 2. The patient has a fever, elevated WBC count, tachycardia, and hypotension, which are all signs of a potential infection. The surgery may need to be delayed until the source of the fever is treated.
13 A nurse is working in an ambulatory care setting and is ready to discharge a patient who is wheelchair dependent. The patient underwent dilation of an esophageal stricture. Her postanesthesia recovery score for ambulatory patients (PARSAP) score is 16. Her family is ready to go and eager to make the long road trip home. In determining if it is safe for the patient to be discharged at this time, the nurse should decide the following: 1The PARSAP score must be 18 or higher before being discharged. 2The patient's family is capable to care for her, and she understands her discharge instructions; thus the nurse proceeds with discharge. 3Since the patient hasn't been drinking much, the nurse is not concerned that she is unable to void and proceeds with discharge. 4Since the patient was admitted to the surgical center in a wheelchair, she can be discharged with a lower PARSAP score.
13. Answer: 4. The PARSAP is an important functional screen to assess the function of the ambulatory surgery patient. The total score must be at least 18 for a patient to be discharged to home, unless the patient is not walking or is unable to use extremities before surgery.
14 A patient is admitted through the emergency department for multisystem trauma following a motorcycle crash with multiple orthopedic injuries. He goes to surgery for repair of fractures. He is postoperative day 3 from an open reduction internal fixation of bilateral femur fractures and external fixator to his unstable pelvic fracture. Interventions that are necessary for prevention of venous thromboembolism in this high-risk postsurgical patient include: (Select all that apply.) 1Intermittent pneumatic compression stockings. 2Vitamin K therapy. 3Subcutaneous heparin or enoxaparin (Lovenox). 4Continuous heparin drip with a goal of an international normalized ratio (INR) 5 times higher than baseline.
14. Answer: 1, 3. Combination therapy with mechanical and pharmacological prophylaxis is recommended for high-risk patients. Vitamin K therapy creates a higher risk for clotting, and the goal INR should not be 5 times higher than baseline.
15 You are caring for a 65-year-old patient 2 days after surgery and helping him walk down the hallway. The surgeon has ordered exercise as tolerated. Your assessment indicates that the patient's heart rate at baseline is 88. After walking approximately 30 yards down the hallway, the heart rate is 110. What should be your next action? 1Stop exercise immediately and have him sit in a nearby chair. 2Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise. 3Tell him that he needs to walk further to reach a heart rate of 120. 4Have him walk slower; he has reached his maximum.
15. Answer: 2. The patient's maximum heart rate with exercise should be 220−65 = 155. He is still in a safe range. An assessment of how the patient feels is good practice. The patient can safely continue to walk.
3 In the postanesthesia care unit (PACU) the nurse notes that the patient is having difficulty breathing and suspects an upper airway obstruction. The nurse would first: 1Suction the pharynx and bronchial tree. 2Give oxygen through a mask at 4 L/min. 3Ask the patient to use an incentive spirometer. 4Position the patient on one side with the face down and the neck slightly extended so the tongue falls forward.
3. Answer: 4. Weak pharyngeal/laryngeal muscle tone from anesthetics can occur. Positional change helps to move the tongue forward to open the airway. The immediate intervention should be to open the airway. Suctioning the bronchial tree or providing oxygen does not alleviate an upper airway obstruction.
time limit for original restraint order
4 hours for adults, 2 hours for ages 9 through 17, and 1 hour for children under age 9
5 You are caring for a patient after surgery who underwent a liver resection. His prothrombin time (PT) or an activated partial thromboplastin time (APTT) is greater than normal. He has low blood pressure; tachycardia; thready pulse; and cool, clammy, pale skin, and he is restless. You assess his surgical wound, and the dressing is saturated with blood. Which immediate interventions should you perform? (Select all that apply.) 1Notify the surgeon. 2Maintain intravenous (IV) fluid infusion and prepare to give volume replacement. 3Monitor the patient's vital signs every 15 minutes or more frequently until his condition stabilizes. 4Wean oxygen therapy. 5Provide comfort through bathing.
5. Answer: 1, 2, 3. A common early complication of surgery is bleeding. It is important to continue oxygen therapy and notify the surgeon. Signs of bleeding include hypotension; tachycardia; and cool, clammy, pale skin. Signs of bleeding may be visible, or the bleeding may be internal. Be prepared to administer fluid or blood as needed and frequently monitor vital signs to assess the patient's status.
6 You are a nurse in the postanesthesia care unit (PACU), and you note that your patient has a heart rate of 130 beats/min and a respiratory rate of 32 breaths/min; you also assess jaw muscle rigidity and rigidity of limbs, abdomen, and chest. What do you suspect, and which intervention is indicated? 1 Infection: Notify surgeon and anticipate administration of antibiotics. 2 Pneumonia: Listen to breath sounds, notify surgeon, and anticipate order for chest radiography. 3 Hypertension: Check blood pressure, notify surgeon, and anticipate administration of antihypertensives. 4 Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium), and monitor vital signs frequently.
6. Answer: 4. Malignant hyperthermia is a life-threatening complication of general anesthesia. It is a severe hypermetabolic condition that causes rigidity of skeletal muscles caused by an increase in intracellular calcium ion concentration and leads to hypercarbia, tachypnea, and tachycardia. Despite the name, an elevated temperature is a late sign, and an increase in the respiratory rate to eliminate carbon dioxide is one of the first signs. Dantrolene sodium (Dantrium) is a skeletal muscle relaxant that is used to treat this complication.
increased risk for falls
65 and older, reduced vision, orthostatic hypotension, gait and balance problems, urinary incontinence, use of walking aids, and the effects of various medications (e.g., . Common physical hazards that lead to falls include inadequate lighting, barriers along normal walking paths and stairways, and a lack of safety devices in the home
7 After a surgical patient has been given preoperative sedatives, which safety precaution should a nurse take? 1Reinforce to the patient to remain in bed or on the stretcher 2Raise the side rails and keep the bed or stretcher in the high position 3Determine if the patient has any allergies to latex 4Obtain informed consent immediately after sedative administration
7. Answer: 1. It is important for patient safety in patients who have been given sedatives to inform them of the importance of remaining in bed after preoperative sedatives are administered. It is inappropriate to have a bed or stretcher in the high position because of the increased fall risk and potential for injury. Informed consent should be obtained and allergy assessment done before sedative administration.
8 The operating room (OR) and postanesthesia care unit (PACU) are high-risk environments for patients with a latex allergy. Which safety measures to prevent a latex reaction should the nurse implement? (Select all that apply.) 1 Screening patients about food allergies known to have a cross-reactivity to latex such as kiwis and bananas 2 Having a latex allergy cart available at all times 3 Communicating with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a latex-sensitive patient is identified 4 Scheduling the latex-sensitive patient for the last operative case of the day
8. Answer: 1, 2, 3. Identifying patients with potential cross-reactivity is important since they may be unaware of their latex sensitivity. Having all necessary equipment easily accessible to staff is necessary to ensure that all items are available when needed. It is important for the operative team to be aware of the case so they can plan appropriate safeguards; scheduling the latex-sensitive patient for the first case means that latex dust from the previous day was removed overnight before the latex-sensitive patient's operation.
9 A nurse is recovering a patient who received conscious sedation for cosmetic surgery. Which of the following is an advantage that conscious sedation has over general anesthesia? 1Loss of sensation at the surgical site 2Reduction of fear and anxiety and need for assistance with airway patency and ventilation 3Amnesia and relief of pain 4Monitoring in phase I recovery
9. Answer: 3. Conscious sedation offers adequate sedation, reduction of fear and anxiety, amnesia, and relief of pain while maintaining airway patency and ventilation independently along with stable vital signs and rapid recovery. Loss of sensation at the surgical site is an effect of local anesthesia. These patients usually only go through phase II recovery.
A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent?
A Give the child milk. B Give the child syrup of ipecac. C Call the poison control center. Correct D Take the child to the emergency department. Incorrect A poison control center is the best resource for patients and parents needing information about the treatment of an accidental poisoning.
At 3 am the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first?
A Prepare for an influx of patients Correct B Contact the American Red Cross Incorrect C Determine how to restore essential services D Evacuate patients per the disaster plan The emergency department nurse needs to prepare for the potential influx of patients first. Staff need to be aware of the disaster plan. Patients may need to be evaluated but not initially. The American Red Cross is not contacted initially. Determination of how to restore essential services is part of the disaster plan and is determined before an actual event.
The National Quality Forum List of Serious Reportable Events
A Surgery performed on the wrong body part B Surgery performed on the wrong patient C Wrong surgical procedure performed on a patient D Unintended retention of foreign object in a patient after surgery or procedure E Intraoperative or immediately postoperative death
Emmanuel is reminded by his preceptor to be diligent in preventing procedure-related accidents. Which of the following is an example of a procedure-related accident? (Select all that apply.)
A. Medication administration error B. Improper insertion of a urinary catheter C. Application of an incorrect bandage to a wound D. Incorrect transcription of a telephone order Answer: A, B, C Rationale: Procedure-related accidents are caused by health care providers and include medication and fluid administration errors, improper application of external devices, and accidents related to improper performance of procedures such as dressing changes and or urinary catheter insertion. The incorrect transcription of a telephone order is a documentation accident.
Postanesthesia recovery score for ambulatory patients (PARSAP), p. 1276
Activity Able to move four extremities voluntarily or on command Able to move two extremities voluntarily or on command Unable to move extremities voluntarily or on command Respiration Able to breathe deeply and cough freely Dyspnea, limited breathing, or tachypnea Apneic or on mechanical ventilator Circulation BP 20% of preanesthetic level BP 20%-49% of preanesthetic level BP 50% of preanesthetic level Consciousness Fully awake Arousable on calling Not responding O2 saturation Able to maintain O2 saturation >92% on room air Needs O2 inhalation to maintain O2 saturation >92% O2 saturation <90% even with O2 supplemen Dressing Dry and clean Wet but marked and not increasing Growing area of wetness Pain Pain free Mild pain handled by oral medication Severe pain requiring parenteral medication Ambulation Able to stand up and walk straight* Vertigo when erect Dizziness when supine Fasting-feeding Able to drink fluids Nauseated Nausea and vomiting Urine output Has voided Unable to void but comfortable Unable to void and uncomfortable TOTALS Possible score range 0-20
2. Mrs. Neuhausen's type 2 diabetes puts her at risk for impaired wound healing and increased susceptibility to infection. A. True B. False
Answer: A Rationale: Diabetes increases the patient's susceptibility to infection and impairs wound healing from altered glucose metabolism and associated circulatory impairment. Stress of surgery often results in hyperglycemia.
3. Brittany checks Mrs. Neuhausen's blood sugar, which is 210 mg/dL, using the fingerstick method. In addition to being concerned about her blood sugar level, for which other postsurgical condition that can decrease tissue healing should Brittany monitor Mrs. Neuhausen? A. Shock B. Myocardial infarction C. Fluid and electrolyte imbalance D. Sensory deficit
Answer: C Rationale: Hyperglycemia can cause an adrenocortical stress response in which the body retains sodium and water and loses potassium within the first 2 to 5 days following surgery. A patient who is hypovolemic or who has serious postoperative electrolyte alterations is at risk for decreased tissue healing and increased infection.
1. Mrs. Neuhausen's double mastectomy to remove cancerous breast tissue is considered an___________surgical procedure, and the surgical purpose of the breast reconstruction is considered ______________.
Answer: Urgent, cosmetic Rationale: Urgent surgical procedures are necessary for the patient's health to prevent additional problems such as the spread of cancer. Removal of cancerous tissue or tumors is considered urgent. Cosmetic procedures such as breast reconstruction are performed to improve personal appearance.
Aura
Before a convulsive episode a few patients report an aura, which serves as a warning or sense that a seizure is about to occur. An aura is often a bright light, smell, or taste
ablative surgery
Excision or removal of diseased body part Amputation, removal of appendix, cholecystectomy
• Design a preoperative teaching plan.
Patient education is an important aspect of the patient's surgical experience (see Chapter 25). Provided in a systematic and structured format with teaching and learning principles, preoperative teaching regarding a patient's expected postoperative course has a positive influence on the patient's recovery (Kruzik, 2009). Preadmission nurses call patients up to 1 week before surgery to clarify questions and reinforce explanations. Preoperative information and instructions are delivered by telephone calls, mailings from the health care provider's office or hospital, printed preoperative teaching guidelines and checklists, or the use of videotapes or websites. The American College of Surgeons developed a patient education website titled Partners in Surgical Care, which provides a supplement to the surgeon's teaching (American College of Surgeons, 2006). Education throughout the perioperative period is essential. The Joanna Briggs Institute (2000) highlights the importance of preoperative teaching for knowledge acquisition and skill performance. It is ideal to attempt perioperative education before admission, during the hospital stay, and after discharge. Including family members in perioperative preparation is advisable. Often a family member is the coach for postoperative exercises when the patient returns from surgery. The family often has better retention of preoperative teaching and will be with the patient and able to help them in their recovery. If anxious relatives do not understand routine postoperative events, it is likely that their anxiety heightens the patient's fears and concerns. Perioperative preparation of family members before surgery lessens anxiety and misunderstanding. Provide patients with information about sensations typically experienced after surgery. Preparatory information helps them anticipate the steps of a procedure and thus form realistic images of the surgical experience. For example, in the OR the anesthesia provider applies ointment to patients' eyes to prevent corneal 1267 1268 damage. Warning patients about sensations of blurred vision reduces their anxiety on awakening from surgery. Other sensations to describe include the expected pain at the surgical site, the tightness of dressings, dryness of the mouth, and the sensation of a sore throat resulting from an endotracheal tube. Anxiety and fear are barriers to learning, and both emotions heighten as surgery approaches. If the patient is capable of and receptive to learning, present information in a logical sequence, beginning with preoperative events and advancing to intraoperative and postoperative routines. The AORN (2011) has the following standards to demonstrate patient understanding of the surgical experience.
Status epilepticus
Prolonged or repeated seizures indicate status epilepticus. This condition is a medical emergency and requires intensive monitoring and treatment
palliative surgery
Relieves or reduces intensity of disease symptoms; does not produce cure Colostomy, debridement of necrotic tissue, resection of nerve roots
examples of safety nursing diagnoses
Risk for falls • Impaired home maintenance • Risk for injury • Deficient knowledge • Risk for poisoning • Risk for suffocation • Risk for trauma
You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.) 1Smokes a pack a day 2Used a cane to walk at home 3Takes antihypertensive and diuretics 4History of recent fall 5Neglect, spatial and perceptual abilities, impulsive 6Requires assistance with activity, unsteady gait 7IV line, urinary catheter
Smoking is not a risk factor for falls. Because the patient used the cane at home, it is not a current risk factor for falls. Risk is determined by his current status
6 The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) 1Contact the nursing supervisor. 2Restrict the family's visiting privileges. 3Ask the family to stay with the patient if possible. 4Inform the family of the risks associated with side-rail use. 5Thank the family for being conscientious and put the four rails up. 6Discuss alternatives with the family that are appropriate for this patient.
The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concerns, the risk of using restraints related to using four side rails, and safer alternatives such as the presences of a family member. If the family still insists on use of four side rails, you could contact the nursing supervisor to further discuss the situation with them. This is not a reason to restrict visitation; but, although you should appreciate their concern, the use of four side rails should be avoided
What are the leading causes of unintentional injuries?
Unintentional injuries are the fifth leading cause of death for Americans of all ages (National Center for Injury Prevention, 2010a). Motor vehicle accidents are the leading cause, followed by poisonings and falls. Additional hazards consist of fire and disasters
• A routine preoperative safety checklist is...
a guide for final preparation of the patient before surgery.
Pollutant
a harmful chemical or waste material discharged into the water, soil, or air. People commonly think of pollution only in terms of air, land, or water pollution; but excessive noise is also a form of pollution that presents health risks. Air pollution is the contamination of the atmosphere with a harmful chemical. Prolonged exposure to it increases the risk of pulmonary disease
Malignant hyperthermia, p. 1278
a life-threatening complication of anesthesia, develops. Malignant hyperthermia causes hypercarbia (elevated carbon dioxide), tachypnea, tachycardia, premature ventricular contractions (PVCs), unstable blood pressure, cyanosis, skin mottling, and muscular rigidity. Despite the name, an elevated temperature occurs late. The increased expired carbon dioxide is one of the first signs. Although it often occurs during the induction phase of anesthesia, symptoms can occur after surgery or with repeated exposures to anesthesia (Rothrock, 2007). Without prompt detection and treatment, it is potentially fatal.
• Structured preoperative teaching positively influences.....
a patient's postoperative recovery.
Obstructive sleep apnea (OSA), p. 1260
a syndrome of periodic, partial, or complete obstruction of the upper airway during sleep. Patients with diagnosed OSA have an increased incidence of postoperative complications, the most frequent being oxygen desaturation
Preoperative teaching plan, p. 1265
for the diagnosis of deficient knowledge. Critical thinking ensures that the patient's plan of care integrates knowledge, previous experiences, critical thinking attitudes, and established standards of practice. Previous experience in caring for surgical patients helps you anticipate how to approach patient care (e.g., complications to prevent and anticipate and methods to reduce anxiety). Professional standards are especially important to consider when selecting interventions for the plan of care. These standards often establish scientifically proven guidelines for preferred nursing interventions.
Seizure
hyperexcitation and disorderly discharge of neurons in the brain leading to a sudden, violent, involuntary series of muscle contractions that is paroxysmal and episodic, causing loss of consciousness, falling, tonicity (rigidity of muscles), and clonicity (jerking of muscles) During the seizure activity the patient often experiences shallow breathing, cyanosis, and loss of bladder and bowel control
Adolescents are at risk for...
injury from automobile accidents, suicide, and substance abuse. Risks to the safety of adolescents involve many factors outside the home because much of their time is spent away from home and with their peer group. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs.
Local anesthesia, p. 1273
involves loss of sensation at the desired site (e.g., a skin growth or the cornea of the eye). The anesthetic agent (e.g., lidocaine [Xylocaine]) inhibits nerve conduction until the drug diffuses into the circulation. It is injected locally or applied topically. The patient experiences a loss in pain and touch sensation and motor and autonomic activities (e.g., bladder emptying). Local anesthesia is common for minor procedures performed in ambulatory surgery.
Laparoscopic, p. 1255
involves the use of minimally invasive techniques with small incisions and cameras or scopes for performance of the surgery as opposed to a large incision required for an open surgery. Because of the small incision, a laparoscopic cholecystectomy involves only a few hours to a 24-hour hospital stay and a recovery period of a week
Scrub nurse, p. 1271
is an RN, a licensed practical nurse, or a surgical technologist. This individual maintains a sterile field during the surgical procedure, assists with applying sterile drapes, hands instruments and other sterile supplies to surgeons, and counts the sponges and instruments.
• Surgery is classified by....
level of severity, urgency, and purpose.
Threats to an adult's safety are frequently associated with...
lifestyle habits. like smoking and alcohol use
Reduce the transmission of pathogens through...
medical and surgical asepsis, immunization, adequate food sanitation, insect and rodent control, and appropriate disposal of human waste, controlling pollution
General anesthesia, p. 1272
medically induced coma and loss of protective reflexes resulting from the administration of one or more agents
Circulating nurse, p. 1271
must be an RN. His or her responsibilities include reviewing the preoperative assessment, establishing and implementing the intraoperative plan of care, evaluating the care, and providing for continuity of care after surgery. The circulating nurse assists with procedures such as endotracheal intubation and blood administration as needed. In addition, this nurse positions the patient, monitors sterile technique and a safe OR environment, assists the surgeon and surgical team by operating nonsterile equipment, provides additional supplies, verifies sponge and instrument counts, and maintains accurate and complete written records.
Ambulatory surgery, p. 1255
outpatient surgery, short-stay surgery, or same-day surgery, changed the perioperative process. Centers providing these services are hospital-based or freestanding surgical centers. Starting in 1982 Medicare began paying for surgeries performed in ASCs, and now over half of all elective surgical procedures occur on an outpatient basis. This increase is the result of payer changes and advances in medical technology. These procedures include ophthalmic, gastroenterological, gynecological, eye-ear-nose-throat, orthopedic, cosmetic/restorative, and general
Moribund, p. 1256
patient who is not expected to survive without the operation Severe cardiac, pulmonary, renal, hepatic, or endocrine dysfunction
A safe health care environment is one that...
reduces the risk of injury, including minimizing falls, patient-inherent accidents, procedure-inherent accidents, and equipment-related accidents.
Conscious sedation, p. 1273
routinely used for procedures that do not require complete anesthesia but rather a depressed level of consciousness. A patient under conscious sedation must independently maintain a patent airway and adequate ventilation and be able to respond appropriately to verbal stimuli or light tactile stimulation (Rothrock, 2007). Short-acting IV sedatives such as midazolam (Versed) are given. Advantages of conscious sedation include adequate sedation, reduction of fear and anxiety, amnesia, relief of pain and noxious stimuli, mood alteration, elevation of pain threshold, enhanced patient cooperation, stable vital signs, and rapid recovery. A variety of therapeutic procedures is appropriate for conscious sedation. Nurses assisting with the administration of local anesthesia and conscious sedation need to demonstrate competency in the care of these patients. Knowledge of anatomy, physiology, cardiac dysrhythmias, procedural complications, and pharmacological principles related to the administration of individual agents is essential. You also need to assess, diagnose, and intervene in the event of untoward reactions and demonstrate skill in airway management and oxygen delivery. Resuscitation equipment must be readily available when using local anesthesia or conscious sedation
Postanesthesia recovery score (PARS), p. 1275
the most widely used scoring tool (Table 50-7). The criteria are assessed on admission; at 5, 15, 30, 45, and 60 minutes; and on discharge from the PACU. The patient must receive a composite score of 8 to 10 before discharge from the PACU (Aldrete, 1998). If the patient's condition is still poor after 2 to 3 hours, the stay lengthens, or the surgeon transfers the patient to an intensive care unit (ICU). vital sign stability compared with the preoperative data. Other outcomes for discharge include body temperature control, good ventilatory function and oxygenation status, orientation to surroundings, absence of complications, minimal pain and nausea, controlled wound drainage, adequate urine output, and fluid and electrolyte balance Activity Able to move four extremities voluntarily or on command Able to move two extremities voluntarily or on command Unable to move extremities voluntarily or on command Respiratory Able to breathe deeply and cough freely Dyspnea or limited breathing Apneic Circulation BP 20% of preanesthetic level BP 20%-49% of preanesthetic level BP 50% of preanesthetic level Consciousness Fully awake Arousable on calling Not responding Oxygen (O2) Saturation Able to maintain O2 saturation >92% on room air Needs O2 inhalation to maintain O2 saturation >92% O2 saturation <90% even with O2 supplement
Continually evaluate....
the patient's safety risk and update the nursing care plan appropriately.
• Primary responsibility for informed consent rests with.....
the patient's surgeon.
what are the 5 P's of nursing care?
these are the things that check during hourly rounding pain, potty, position, possessions, and plan of care.
Graded compression stockings, p. 1272
tight elastic stockings that keep blood from pooling in feet
• Describe the assessment data to collect for a surgical patient.
...
• Explain the nurse's role in the operating room.
...
Bariatric, p. 1260
obese
Nursing interventions for promoting safety are individualized for.....
patients' developmental stage, lifestyle, and environment.
Paralytic ileus, p. 1279
nonmechanical obstruction caused by lack of intestinal peristalsis
2 The primary reason that family members should be included when the nurse teaches the patient preoperative exercises is so they can: 1Coach and encourage the patient after surgery. 2Demonstrate to the patient at home. 3Relieve the nurse by getting the patient to do the exercises every 2 hours. 4Practice with the patient while he or she is waiting to be taken to the operating room.
2. Answer: 1. Patients may need support from family to be motivated to return to their previous state of health. The family may also have better retention of preoperative teaching and will be with the patient and able to help them in their recovery.
4 Because an older adult is at increased risk for respiratory complications after surgery, the nurse should: 1Withhold pain medications and ambulate the patient every 2 hours. 2Monitor fluid and electrolyte status every shift and vital signs with temperature every 4 hours. 3 Orient the patient to the surrounding environment frequently and ambulate the patient every 2 hours. 4 Encourage the patient to turn, deep breathe, and cough frequently and ensure adequate pain control.
4. Answer: 4. Adequate pain control is important to allow participation in postoperative exercises such as turning, deep coughing, and deep breathing to prevent respiratory complications.
Emmanuel completes the 2-day classroom orientation and is assigned to a preceptor to follow in the ambulatory surgery center for 2 weeks. This constitutes his "hands on" orientation, during which he will be able to care for patients under the guidance of his preceptor.
A. Tag it and report the malfunction B. Put it in the soiled linen room C. Discontinue the patient's IV infusion D. Bang on the pump until function is restored Answer: A Rationale: Defective equipment should be tagged and reported per institution policies and procedures.
The intravenous (IV) pump that Emmanuel is using on a patient malfunctions. The screen on the pump goes blank and cannot be reset. What should Emmanuel do with the pump?
A. Tag it and report the malfunction B. Put it in the soiled linen room C. Discontinue the patient's IV infusion D. Bang on the pump until function is restored Answer: A Rationale: Defective equipment should be tagged and reported per institution policies and procedures.
• Nurses' responsibilities within the operating room focus on.....
protecting the patient from potential harm.
Immunization
reduces, and in some cases prevents, the transmission of disease from person to person. Individuals acquire active immunity by an injection of a small amount of attenuated (weakened) or dead organisms or modified toxins from the organism (toxoids) into the body
Regional anesthesia, p. 1273
results in loss of sensation in an area of the body. The method of induction such as spinal, epidural, or a peripheral nerve block influences the portion of sensory pathways that are anesthetized. No loss of consciousness occurs with regional anesthesia, but the patient is often sedated. The anesthesia provider gives regional anesthetics by infiltration and local application.
Emmanuel is caring for Mr. Natik, a 61-year-old Caucasian male who has just undergone cataract surgery in his right eye. Emmanuel teaches Mr. Natik safety precautions, including preventing the risk of burns while cooking. A self-inflicted burn is referred to as a ________-____________ accident.
Answer: Patient-inherent Rationale: Patient-inherent accidents are accidents (other than falls) for which the patient is the primary cause. Examples include self-inflicted cuts and burns.
Case study to use for following sections
Emmanuel is a new nurse graduate who has been hired by the local hospital to work in the ambulatory surgery center. Emmanuel is required to attend the hospital orientation to learn about facility policies and procedures. Of particular importance are the protocols that surround patient safety.
Perioperative nursing, p. 1254
nursing care given before (preoperative), during (intraoperative), and after (postoperative) surgery. It takes place in hospitals, surgical centers attached to hospitals, freestanding surgical centers, or health care providers' offices. Perioperative nursing is a fast-paced, changing, and challenging field. It is based on the nurse's understanding of several important principles, including: • High-quality and patient safety-focused care. • Multidisciplinary teamwork. • Effective therapeutic communication and collaboration with the patient, the patient's family, and the surgical team. • Effective and efficient assessment and intervention in all phases of surgery. • Advocacy for the patient and the patient's family. • Understanding of cost containment.
• Nursing diagnoses for a surgical patient apply to nursing care during....
one or all phases of surgery.
When should you use physical restraints?
only as a last resort, when patients' behavior places them or others at risk for injury.
Risks for injury for older patients are directly related to the...
physiological changes of the aging process.
Procedure-related incidents
Procedure-related accidents are caused by health care providers and include medication and fluid administration errors, improper application of external devices, and accidents related to improper performance of procedures such as dressing changes or urinary catheter insertion. Nurses are able to prevent many procedure-related accidents by adhering to organizational policy and procedures and standards of nursing practice. For example, proper preparation and administration of medications, use of patient and medication bar coding, and "Smart" intravenous (IV) pumps reduce medication errors (see Chapters 31 and 41). All staff need to be aware that distractions and interruptions contribute to procedure-related accidents and need to be limited, especially during high-risk procedures such as medication administration. The potential for infection is reduced when surgical asepsis is used for sterile dressing changes or any invasive procedure such as insertion of a urinary catheter. Finally, correct use of safe patient handling techniques and equipment reduces the risk of injuries when moving and lifting patients
Medical errors are the...
8th leading cause of death "Speak up" campaign The Joint Commission and Centers for Medicaid and Medicare Services
RACE acronym
R—Rescue and remove all patients in immediate danger. A—Activate the alarm. Always do this before attempting to extinguish even a minor fire. C—Confine the fire by closing doors and windows and turning off oxygen and electrical equipment. E—Extinguish the fire using an appropriate extinguisher
• Preoperative assessment of vital signs and physical findings provides......
an important baseline with which to compare postoperative assessment data.
In the community a safe environment means that...
basic needs are achievable, physical hazards are reduced, transmission of pathogens and parasites is reduced, pollution is controlled, and sanitation is maintained
• The preoperative period may be....
several days or only a few hours long, with some patients assessed in the health care provider's office, preadmission clinic, or anesthesia clinic or by telephone.
1 Obesity places patients at an increased surgical risk because of which of the following factors? (Select all that apply.) 1Risk for bleeding is increased. 2Ventilatory capacity is reduced. 3Fatty tissue has a poor blood supply. 4Metabolic demands are increased.
1. Answer: 2, 3. A decreased blood supply in adipose tissue slows the delivery of essential nutrients, antibodies, and enzymes needed for wound healing. A decreased ventilatory capacity allows for alveolar collapse, which can lead to pneumonia.
alternatives to restraints
• Orient patients and families to environment; explain all procedures and treatments. • Provide companionship and supervision; use trained sitters; adjust staffing and involve family. • Offer diversionary activities such as music or something to hold; enlist support and input from family. • Assign confused or disoriented patients to rooms near nurses' station and observe them frequently. • Use calm, simple statements and physical cues as needed. • Use de-escalation, time-out, and other verbal intervention techniques when managing aggressive behaviors. • Provide appropriate visual and auditory stimuli (e.g., family pictures, clock, radio). • Remove cues that promote leaving (e.g., elevators, stairs, or street clothes). • Promote relaxation techniques and normal sleep patterns. • Institute exercise and ambulation schedules as allowed by patient's condition; consult physical therapist for mobility and exercise programs. • Attend frequently to needs for toileting, food, and liquid. • Camouflage intravenous lines with clothing, stockinette, or Kling dressing. • Evaluate all medications patient is receiving and ensure effective pain management. • Reassess physical status and review laboratory findings.
steps for accidental poisoning
1 Assess for signs or symptoms of ingestion of harmful substance such as nausea, vomiting, foaming at the mouth, drooling, difficulty breathing, sweating, and lethargy. 2 Terminate exposure to the poison by having the person empty his or her mouth of pills, plant parts, or other material. 3 If poisoning is caused by skin or eye contact, irrigate the skin or eye with copious amounts of cool tap water for 15 to 20 minutes. In the case of an inhalation exposure, safely remove the victim from the potentially dangerous environment. 4 Identify the type and amount of substance ingested to help determine the correct type and amount of antidote needed. 5 If the victim is conscious and alert, call the local poison control center or the national toll-free poison control center number (1-800-222-1222) before attempting any intervention. Poison control centers have information needed to treat poisoned patients or offer referral to treat. The administration of ipecac syrup is no longer recommended for routine home treatment of poisoning. 6 If the victim has collapsed or stopped breathing, call 911 for emergency transportation to the hospital. Initiate CPR if indicated until emergency personnel arrive. Ambulance personnel can provide emergency measures if needed. In addition, a parent or guardian is sometimes too upset to drive safely. 7 Position the victim with head turned to side to reduce risk for aspiration. 8 Never induce vomiting if the victim has ingested the following poisonous substances: lye, household cleaners, hair care products, grease or petroleum products, furniture polish, paint thinner, or kerosene. 9 Never induce vomiting in an unconscious or convulsing victim because vomiting increases risk for aspiration.
Association of periOperative Registered Nurses (AORN), p. 1255
AORN is the driving force for the practice of perioperative nursing and has developed standards of nursing practice that outline the scope of responsibility of the perioperative nurse. It was the first nursing organization to develop structure, process, and outcome standards as defined by the American Nurses Association (ANA). Current standards of perioperative professional practice include a patient-centered model of care with focus on (1) clinical practice, (2) professional practice, (3) administrative practice, (4) patient outcomes, and (5) quality improvement
equipment related accidents
Accidents that are equipment related result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard. To avoid rapid infusion of IV fluids, all general-use and patient-controlled analgesic pumps need to have free-flow protection devices. To avoid accidents, do not operate monitoring or therapy equipment without adequate instruction. If faulty equipment is discovered, place a tag on it to prevent it from being used on another patient and promptly report any malfunctions. Assess potential electrical hazards to reduce the risk of electrical fires, electrocution, or injury from faulty equipment. In health care settings the clinical engineering staff make regular safety checks of equipment. Facilities must report all suspected medical device—related deaths to both the FDA and the manufacturer of the product if known (FDA, 2009). This is usually done in conjunction with the risk management department after tagging and removing the piece of equipment.
case study to use with the following questions
Mrs. Charlene Neuhausen is a 59-year-old Caucasian woman who underwent a double mastectomy and breast reconstruction for breast cancer. During the surgery the surgeon also removed several malignant lymph nodes. Diagnostics indicate that Mrs. Neuhausen has no other metastasis at this time. She has been transferred to the medical-surgical unit for recovery where she is resting comfortably. Brittany is the nursing student assigned to Mrs. Neuhausen. She performs an admission history and notes Mrs. Neuhausen's history of type 2 diabetes and asthma. Brittany takes Mrs. Neuhausen's vital signs: temperature 98.9° F, blood pressure 152/74 mm Hg, pulse 68 beats/min and regular, and respirations 20 breaths/min on room air. Mrs. Neuhausen rates her pain as 3 out of 10 on a scale of 0 to 10.
5 The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.)
Older adults in an unfamiliar environment may become confused. A night light may be beneficial for safety and orientation. Toileting is a common reason for a patient attempting to get out of bed. Placing the patient on a routine toileting schedule should help decrease this risk factor. Hospital environments can quickly become cluttered with equipment, personal items, and other things that create a hazard for falling. Keep pathways clear. All alternatives should be tried and considered before using a restraint. Restraint should not be an initial response. The bed should be kept in a low position. Upper side rails may be used; however, the addition of lower side rails can increase the risk of injury. The use of side rails alone for a disoriented patient may cause more confusion and further injury. A confused patient who is determined to get out of bed attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt usually results in a fall or injury
things to remember when a person is having a seizure
Once a seizure begins, you need to monitor the patient and provide a safe environment. A seizure is not an indication for cardiopulmonary resuscitation. A person having a seizure should not be restrained, but the environment should be made safe. Objects should not be forced into the mouth. See the Skills in the chapter for more information.
What does PASS stand for?
Helps you remember how to use a fire extinguisher. Pull the pin to unlock handle, Aim low at the base of the fire, Squeeze the handles, and Sweep the unit from side to side
Informed consent, p. 1267
It is the surgeon's responsibility to explain the procedure and obtain the informed consent. After the patient completes the consent form, place it in the medical record. The record goes to the OR with the patient.
Food and Drug Administration (FDA
The FDA is a federal agency responsible for the enforcement of federal regulations regarding the manufacture, processing, and distribution of foods, drugs, and cosmetics to protect consumers against the sale of impure or dangerous substances
American Society of Anesthesiologists (ASA), p. 1255
an educational, research and scientific association of physicians organized to raise the standards of the medical practice of anesthesiology and to improve patient care
What medications increase an elderly persons risk for for falls
anticholinergics, diuretics, anxiolytic and hypnotic agents, antidepressants, antihypertensives, vasodilators, analgesics, and laxatives
Restraint
any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely
Pathogen
any microorganism capable of producing an illness. The most common means of transmission of pathogens is by the hands. Hand hygiene is the number one way to decrease risk of transmitting of pathogens
Poison
any substance that impairs health or destroys life when ingested, inhaled, or absorbed by the body. Poison control center is the best resource when you know someone has ingested a poison
• Family members are important in.....
assisting patients with any physical limitations and providing emotional support during postoperative recovery.
The school-age child is at risk for injury...
at home, at school, and while traveling to and from school.
• All medications taken before surgery are.....
automatically discontinued after surgery unless a health care provider reorders the drugs.
• The explanation of all preoperative and postoperative routines and demonstration of postoperative exercises are....
basic to preoperative teaching.
Atelectasis, p. 1260
collapse or closure of a lung resulting in reduced or absent gas exchange
kyphosis
curvature of the spine (abnormal) associated with osteoporosis or arthritis (Hunchback)
• In ambulatory surgery nurses use the limited time available to
educate patients, assess their health status, and prepare them for surgery.
common among bariatric population
embolus, atelectasis, would dehisce, pneumonia because fatty tissue contains poor blood supply
Seizure precautions
encompass all nursing interventions to protect the patient from traumatic injury, position for adequate ventilation and drainage of oral secretions, and provide privacy and support following the seizure
how often should you remove a restraint
every two hours
• Identify risks to patient/client safety related to the healthcare environment.
falls, patient-inherent accidents, procedure-related accidents, and equipment-related accidents. The nurse assesses for these four potential problem areas and, considering the developmental level of the patient, takes steps to prevent or minimize accidents.
Cholecystectomy, p. 1255
gallbladder removal
• Accurate pain assessment and intervention are necessary for....
healing.
Children younger than 5 years of age are at greatest risk for...
home accidents that result in severe injury and death.
When oxygen is in use, precautions need to be taken to prevent fire and protect the patient. Patients need to be taught precautions, which include
posting Oxygen in Use signage, not using oxygen around electrical equipment or flammable products, properly handling oxygen cylinders/containers, ensuring that tubing is unobstructed, not adjusting liter flow without a physician’s order, and taking precautions when traveling with oxygen
Reduction of physical hazards in the environment includes...
providing adequate lighting, decreasing clutter, and securing the home.
standardized wristband colors
red for patient allergies, yellow for fall risk, and purple for do-not-resuscitate preference
• Care of the postoperative patient centers on....
the body systems that anesthesia, immobilization, and surgical trauma most likely affect.