Preoperative/Intraoperative Nursing (exam 1)

In this step, the patient's identification, surgical site marking, and procedure to be done are all verified

"Time out"

The STOP-Bang

(Snoring, Tired, Observed, Pressure, BMI, Age, Neck, Gender) to assess for the presence of OSA

Preoperative Nursing Duties

-History and Physical Assessment -Identify Risk Factors -Planning and Implementation -Baseline: health status, expectations -Clarify information/Provide education -Interventions

Intraoperative Phase Physiologic Monitoring

1.Communicates amount of fluid instillation and blood loss 2.Distinguishes normal from abnormal cardiovascular data 3.Reports changes in patient's vital signs 4.Institutes measures to promote normothermia

Postoperative Phase Transfer of Patient to Post anesthesia Care Unit

1.Communicates intraoperative information: a.Identifies patient by name b.States type of surgery performed c.Identifies type and amounts of anesthetic and analgesic agents used d.Reports patient's vital signs and response to surgical procedure and anesthesia e.Describes intraoperative factors (e.g., insertion of drains or catheters, administration of blood, medications during surgery, or occurrence of unexpected events) f.Describes physical limitations g.Reports patient's preoperative level of consciousness h.Communicates necessary equipment needs i.Communicates presence of family or significant others

Admission to Surgical Center

1.Completes preoperative assessment 2.Assesses for risks for postoperative complications 3.Reports unexpected findings or any deviations from normal 4.Verifies that operative consent has been signed 5.Coordinates patient education and plan of care with nursing staff and other health team members 6.Reinforces previous education 7.Explains phases in perioperative period and expectations 8.Answers patient's and family's questions

Surgical Nursing Unit

1.Continues close monitoring of patient's physical and psychological response to surgical intervention 2.Assesses patient's pain level and administers appropriate pain-relief measures 3.Provides education to patient during immediate recovery period 4.Assists patient in recovery and preparation for discharge home 5.Determines patient's psychological status 6.Assists with discharge planning

Postoperative Assessment Recovery Area

1.Determines patient's immediate response to surgical intervention 2.Monitors patient's vital signs and physiologic status 3.Assesses patient's pain level and administers appropriate pain-relief measures 4.Maintains patient's safety (airway, circulation, prevention of injury) 5.Administers medications, fluid, and blood component therapy, if prescribed 6.Provides oral fluids if prescribed for ambulatory surgery patient 7.Assesses patient's readiness for transfer to inhospital unit or for discharge home based on institutional policy (e.g., Aldrete score, see Chapter 16)

In the Preoperative Area

1.Identifies patient 2.Assesses patient's physical and emotional status, baseline pain, and nutritional status 3.Reviews medical record 4.Verifies surgical site and that it has been marked per institutional policy 5.Establishes IV line 6.Administers medications if prescribed 7.Takes measures to ensure patient's comfort 8.Provides psychological support 9.Communicates patient and family's needs to other appropriate members of the health care team

Intraoperative Phase Maintenance of Safety

1.Maintains aseptic, controlled environment 2.Effectively manages human resources, equipment, and supplies for individualized patient care 3.Transfers patient to operating room bed or table 4.Positions patient based on functional alignment and exposure of surgical site 5.Applies grounding device to patient 6.Ensures that the sponge, needle, and instrument counts are correct 7.Completes intraoperative documentation

Preadmission Testing

1.Performs initial preoperative assessment 2.Initiates education appropriate to patient's needs 3.Involves family in interview 4.Verifies completion of preoperative diagnostic testing according to patient's needs 5.Confirms understanding of surgeon-specific preoperative prescribed therapies (e.g., bowel preparation, preoperative shower) 6.Discusses and reviews advance directive document 7.Begins discharge planning by assessing patient's need for postoperative transportation and care

Intraoperative Phase Psychological Support (Before Induction and When Patient is Conscious)

1.Provides emotional support to patient 2.Stands near or touches patient during procedures and induction 3.Continues to assess patient's emotional status 4.Notifies the patient's family or significant others of updates throughout the procedure

Home or Clinic

1.Provides follow-up care during office or clinic visit or by telephone contact 2.Reinforces previous education and answers patient's and family's questions about surgery and follow-up care 3.Assesses patient's response to surgery and anesthesia and their effects on body image and function 4.Determines family's perception of surgery and its outcome

A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse: A. continuously monitors the sedated client. B. obtains a surgical consent from the client's mother. C. assesses how well the client is recovering from anesthesia. D. performs a complete assessment of the client.

A

After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements? A. "I'll be sleepy but able to respond to your questions." B. "I'm so glad that I will be unconscious during the surgery." C. "Only the surgical area will be numb." D. "I won't feel it, but I'll have a tube to help me breathe."

A

An example of a curative surgical procedure is A. tumor excision. B. placement of gastrostomy tube. C. a face-lift. D. a biopsy.

A

During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 40 C. The nurse should prepare to administer: A. dantrolene sodium (Dantrium) B. verapamil (Isoptin) C. an acetaminophen suppository D. potassium chloride

A

The nurse in the preoperative area has just medicated her client according to the anesthesiologist's orders. What is the nurse's priority action at this time? A. Place the side rails in the up position and make sure the call button is in reach. B. Take the client's vital signs. C. Have the family go to the waiting room. D. Take the client to the bathroom.

A

When a client is encouraged to concentrate on a pleasant experience or restful scene, the client is using the cognitive coping strategy called A. imagery. B. optimistic self-recitation. C. distraction. D. progressive muscular relaxation.

A

Splinting

Avoiding deep inspirations due to increased pain with breathing

A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications? A. Deep breathing and coughing exercises may be used as relaxation techniques. B. Splint the incision site using a pillow during deep breathing and coughing exercises. C. Pain medication should be taken before completing deep breathing and coughing exercises. D. Deep breathing and coughing exercises should be completed every 8 hours.

B

When does the nurse understand the patient is knowledgeable about the impending surgical procedure? A. The patient discusses stress factors causing the patient to feel depressed. B. The patient participates willingly in the preoperative preparation. C. The patient expresses concern about postoperative pain. D. The patient verbalizes fears to family.

B

These labs are monitored to assess kidney function

BUN/creatinine, GFR

A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia? A. Malignant hyperthermia occurs in the operating room only. B. The client will need to be discharged with special instructions. C. The client can develop malignant hyperthermia up to 24 hours after surgery. D. A client can develop malignant hyperthermia only with intravenous anesthesia after surgery.

C

A client is undergoing preoperative assessment. During admission paperwork, the client reports having enjoyed a hearty breakfast this morning to be ready for the procedure. What is the nurse's next action? A. Cancel the surgery. B. Give the client plenty of water to aid digestion. C. Notify the surgeon. D. Document what foods the client ate.

C

A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member? A. Circulating nurse B. Scrub nurse C.Surgeon D. Anesthetist

C

A registered nurse who is responsible for coordinating and documenting client care in the operating room is a A. anesthetist. B. scrub nurse. C. circulating nurse. D. anesthesiologist.

C

The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following? A. Turkey breast, baked sweet potato, asparagus, and an orange B. Baked chicken, mashed potatoes, broccoli, and strawberries C. Cheeseburger, french fries, coleslaw, and ice cream D. Grilled salmon, rice pilaf, green beans, and cantaloupe

C

This member of the surgical team helps to get the operating room ready for the procedure, among other duties, and is not scrubbed in

Circulating Nurse

A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery? A. 4 weeks B. 2 to 3 days C. 2 weeks D. 7 to 10 days

D

A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia? A. rocuronium B. alfentanil C. lidocaine D. oxygen

D

A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which post-surgical risk factor would decrease if the surgical client maintained strict blood glycemic control? A. respiratory complications B. liver dysfunction C. nutrient deficiencies D. wound healing

D

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? A. Exhale through an open mouth. B. Make inhalation longer than exhalation. C. Use chest breathing. D. Use diaphragmatic breathing.

D

A patient is scheduled for a surgical procedure. For which surgical procedure should the nurse prepare an informed consent form for the surgeon to sign? A. Urethral catheterization B. An insertion of an intravenous catheter C. Irrigation of the external ear canal D. An open reduction of a fracture

D

The nurse expects informed consent to be obtained for insertion of: A. An indwelling urinary catheter B. A nasogastric tube C. An intravenous catheter D. A gastrostomy tube

D

The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which laboratory value would be of greatest concern to the nurse? A. sodium 138 mEq/L B. white blood cell count 7.2 cells/mm C. calcium 9.8 mg/dL D. potassium 6.2 mEq/L

D

Preoperative Assessment

Detailed history: Medical history, surgical history, tolerance of anesthesia, medication use, complementary or alternative therapies, substance use, psychosocial history, cultural history • Allergies: Medications, latex, contrast agents, and food products • Anxiety level: Regarding the procedure, support systems, and coping mechanisms • Baseline data: Head-to-toe assessment, vital signs, and oxygen saturations Nutrition and Fluid Status, Dentition, Drug and Alcohol Use, Respiratory Status, Cardiovascular Status, Hepatic and Renal Function, Endocrine Function, Immune Function, Previous Medication Use

Informed Consent- Nurse Responsibilities

Determine that informed consent is appropriate for client. • Client is 18 years of age or emancipated; mentally capable of understanding; not under the influence of medication that affects decision-making or judgment; client able to comprehend • Witness informed consent. To witness informed consent, the nurse must do the following 1• Ensure the provider gave the client the necessary information. Ensure that the client understood the information and is competent to give informed consent. 2• Notify the provider if the client has more questions or appears to not understand any of the information provided. Document questions that the client has and notification of the provider. 3• Have the client sign the informed consent document. Provide a trained medical interpreter if necessary

If a patient arrives for a scheduled surgery and says this, surgery will likely be cancelled (multiple options- give at least 2 options)

I don't have someone to drive me home, I had a smoothie this morning I started antibiotics for a sinus infection yesterday I'm having a panic attack because I know I'm going to die today

Risk Factors for Surgery

Infection • Anemia •Hypovolemia from dehydration or blood loss •Electrolyte imbalance through inadequate diet or disease process

Preoperative Nursing Interventions

Inform the client on what to expect •Provide patient education •Reduce client anxiety •Identify and decrease the risk of complications during and after surgery

The nurse may serve as a witness to the client's signature on this after the physician has explained the procedure, risks, benefits, & complications, before sedation is given and before surgery is performed.

Informed consent

Required Preoperative Documents

Informed consent is necessary in the following circumstances: • Invasive procedures, such as a surgical incision, a biopsy, a cystoscopy, or paracentesis • Procedures requiring sedation or anesthesia • A nonsurgical procedure, such as an arteriography, that carries more than a slight risk to the patient • Procedures involving radiation • Blood product administration

• Sedatives(benzodiazepines, barbiturates)

Monitor respiratory rate and oxygen saturation. Administer oxygen Administer a reversal agent, flumazenil

Opioids-

Monitor respiratory rate and oxygen saturation. Administer oxygen. Administer a reversal agent, naloxone. Perform prescribed intermittent catheterization

These medications should be discontinued prior to the day of surgery. (Identify 2 medication classes).

NSAIDS, Anticoagulants

If a patient states that she drinks a liter of wine a day and takes kava and melatonin to help her sleep at night, the nurse should do this

Notify the anesthesia care provider

Informed Consent-Provider Responsibilities

Obtain informed consent. To obtain informed consent, the provider must give the client the following. • Complete description of the treatment/procedure • Description of the professionals who will be performing and participating in the treatment • Information on the risks of anesthesia • Descriptions of the anticipated benefits of the treatment/procedure • Description of the potential harm, pain, and/or discomfort that may occur • Alternative treatment options • The right to refuse

emergent surgery

Patient requires immediate attention; disorder may be life-threatening - Without delay Severe bleeding Bladder or intestinal obstruction Fractured skull Gunshot or stab wounds Extensive burns

Informed Consent

Patient's autonomous decision about whether to undergo a surgical procedure. • Written in layman's terms • Information is correct and thorough • Demonstrates clear understanding of information • Voluntary • MUST BE SIGNED PRIOR TO PRE-OP MED • Filed in patient's medical record and accompanies patient to OR

Alterations in this electrolyte, both high and low, put a patient at risk for cardiac arrhythmias

Potassium

A woman of childbearing age who has not had a hysterectomy must have this done before any surgery

Pregnancy test

Nursing Interventions during intraoperative stage

Reducing anxiety • Reducing Latex Exposure • Preventing Perioperative positioning injury • Protecting client from injury • Patient advocate • Preventing retained surgical items • Monitoring and managing potential complications

Risk Factors for Surgical Complications

Respiratory disease Cardiovascular disease Diabetes mellitus Liver disease Kidney disease Endocrine disorders Immune system disorders Coagulation defect Malnutrition Obesity • Some medications: Antihypertensives, anticoagulants, NSAIDS, steroids, tricyclic antidepressants, herbal medications, over-the-counter • Substance use: Tobacco, alcohol • Family history: malignant hyperthermia • Allergies: latex, anesthetic agents • Dentition

This member of the surgical team remains in sterile gown and gloves and monitors sterile procedure throughout the surgery

Scrub nurse

postoperative instructions

Teach the client how to use a pain scale to rate pain level postoperative. Teach the client postoperative pain control techniques (medications, immobilization, patient-controlled analgesia pumps, splinting) • Demonstrate and teach the importance of splinting, coughing, and deep breathing. Teach the client use of the incentive spirometer . • Demonstrate and teach the importance of range-of-motion exercises and early ambulation for prevention of thrombi and respiratory complications. • Instruct the client about the purpose of antiembolism stockings and pneumatic compression devices to prevent deep-vein thrombosis. • Reinforce care and restrictions relative to the surgical procedure performed. • Instruct the client about invasive devices (drains, catheters, IV lines). • Teach the client about the postoperative diet.

Guided Imagery

The patient concentrates on a pleasant experience or restful scene.

Aromatherapy

The patient inhales aromatic oils to trigger emotional and physical relaxation responses through the olfactory system and brain.

Optimistic Self-Recitation

The patient recites optimistic thoughts ("I know all will go well").

Distraction

The patient thinks of an enjoyable story or recites a favorite poem or song.

Reiki

The practitioner places hands over the patient to (theoretically) transfer energy to promote healing and relaxation.

True or False: Latex can be found in bananas or kiwi

True

This would be required if surgical consent was being obtained via the telephone.

Two RN verification/signatures.

Voluntary Consent

Valid consent must be freely given, without coercion. Patient must be at least 18 years of age (unless an emancipated minor), a physician must obtain consent, and a professional staff member must witness patient's signature.

Nursing Care: Preoperative

Verify that the informed consent is accurately completed, signed, witnessed. • Administer enemas and/or laxatives the night before and /or morning of the surgery for clients undergoing bowel surgery • Regularly check scheduled medication orders • Ensure that the client is NPO per orders before surgery with general anesthesia to avoid aspiration • Perform skin preparation as ordered, which can include cleansing with antimicrobial soap • Ensure that jewelry, denture, prosthetics, makeup, mail polish, and glasses are removed. • Cover the client with a lightweight cotton blanket heated in a warmer to prevent hypothermia.

registered nurse first assistant

a member of the operating room team whose responsibilities may include handling tissue, providing exposure at the operative field, suturing, and maintaining hemostasis

A patient with this type of problem will need extra precautions in positioning for surgery

a musculoskeletal problem

circulating nurse (or circulator)

a qualified registered nurse, works in collaboration with surgeons, anesthesia providers, and other health care providers to plan the best course of action for each patient In this leadership role, the circulating nurse manages the OR and protects the patient's safety and health by monitoring the activities of the surgical team, checking the OR conditions, and continually assessing the patient for signs of injury and implementing appropriate interventions.

malignant hyperthermia

a rare life-threatening condition triggered by exposure to most anesthetic agents inducing a drastic and uncontrolled increase in skeletal muscle oxidative metabolism that can overwhelm the body's capacity to supply oxygen, remove carbon dioxide, and regulate body temperature, eventually leading to circulatory collapse and death if untreated; often inherited as an autosomal dominant disorder

anesthesia

a state of narcosis or severe central nervous system depression produced by pharmacologic agents

laparoscope

a thin endoscope inserted through a small incision into a cavity or joint using fiber-optic technology to project live images of structures onto a video monitor; other small incisions allow additional instruments to be inserted to facilitate laparoscopic surgery

surgical asepsis

absence of microorganisms in the surgical environment to reduce the risk of infection

certified registered nurse anesthetist (CRNA):

advanced practice registered nurse who delivers anesthesia care under the direction of an anesthesiologist

This person is in charge of monitoring the patient throughout the surgery

anesthesia care provider

unrestricted zone

area in the operating room that interfaces with other departments; includes patient reception area and holding area

restricted zone

area in the operating room where scrub attire and surgical masks are required; includes operating room and sterile core areas

semirestricted zone

area in the operating room where scrub attire is required; may include areas where surgical instruments are processed

This classification of medication is often given pre-operatively for its anti-anxiety and sedative effects

benzodiazepine

What can a sudden or prolonged decline in blood pressure may lead to?

cerebral ischemia, thrombosis, embolism, infarction, and anoxia. Reduced gas exchange can result in cerebral hypoxia.

A patient who is having abdominal surgery should always receive teaching on this in the pre-op stage

coughing and deep breathing, splinting

Diagnosis surgery

determination of the presence and or extent of pathology Ex: biopsy

preadmission testing

diagnostic testing performed before admission to the hospital •Incentives to reduce hospital stays and contain cost • Preoperative preparation prior to admission •Patient learns what to expect on the day of surgery and receive answers to questions •Nurses responsible for communicating information related to the surgical procedure

curative surgery

elimination or repair of pathology; ex: removal of a ruptured appendix

bariatrics

having to do with patients with obesity

hyperglycemia

high blood sugar which can increase the risk of SSI, may result from the stress of surgery, which can trigger increased levels of catecholamine.

This assessment is often done by the surgeon and should always be in a surgical patient's chart

history & physical

The patient with diabetes who is undergoing surgery is at risk for what?

hypoglycemia and hyperglycemia

time out in surgery

identification of patient, procedure, and surgical site and fire risk assessment before operation continues

ambulatory surgery

includes outpatient, same-day, or short-stay surgery that does not require an overnight hospital stay

The nurse would consider it a priority to report what type of allergies to the surgical team? (Identify at least 2)

latex, PCN/Antibiotics, iodine

Hypoglycemia

low blood sugar may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin.

history and physical

mandatory form completed by the surgeon that gives a comprehensive overview of the patient's history, current physical status, and plan of care

sterile technique

measures taken to maintain an area free from living microorganisms, including all spores

monitored anesthesia care

moderate sedation given by an anesthesiologist or CRNA

OSA

obstructive sleep apnea

This type of surgery alleviates symptoms but does not cure the patient's condition

palliative surgery

preoperative phase

period of time from when the decision for surgical intervention is made to when the patient is transferred to the operating room table

postoperative phase

period of time that begins with the admission of the patient to the postanesthesia care unit and ends after follow-up evaluation in the clinical setting or home

intraoperative phase

period of time that begins with transfer of the patient to the operating room area and continues until the patient is admitted to the postanesthesia care unit

perioperative phase

period of time that constitutes the surgical experience; includes the preoperative, intraoperative, and postoperative phases of nursing care

anesthesiologist

physician trained to deliver anesthesia and to monitor the patient's condition during surgery

Thrombocytopenia is when this type of cell is below this number

platelets below 150,000

moderate sedation

previously referred to as conscious sedation, involves the use of sedation to depress the level of consciousness without altering the patient's ability to maintain a patent airway and to respond to physical stimuli and verbal commands

These factors would be a part of the Pre-Operative checklist (Name at least 4).

proper patient identification, allergy/blood product identification, skin preparation, bowel/bladder preparation, NPO, dentures/jewelry removed.

circulating nurse

registered nurse who coordinates and documents patient care in the operating room (synonym: circulator)

scrub role

registered nurse, licensed practical nurse, or surgical technologist who scrubs and dons sterile surgical attire, prepares instruments and supplies, and hands instruments to the surgeon during the procedure

The four domains of the conceptual model of patient care, published by AORN

safety physiologic responses behavioral responses health care systems

palliative surgery

surgery that is performed to relieve pain or other symptoms but not to cure the cancer or prolong a patient's life

minimally invasive surgery

surgical procedures that use specialized instruments inserted into the body either through natural orifices or through small incisions

multimodal anesthesia

the intentional practice of using a combination of nonopioid pharmaceuticals and regional anesthesia techniques

informed consent

the patient's autonomous decision about whether to undergo a surgical procedure, based on the nature of the condition, the treatment options, and the risks and benefits involved

anesthetic agent:

the substance, such as a chemical or gas, used to induce anesthesia

The goal of preoperative skin preparation

to decrease bacteria without injuring the skin.

Why must clients who are taking acetylsalicylic acid/NSAIDS/anticoagulants stop taking it for several days before an elective surgery

to decrease the risk of bleeding.

Why do clients who take herbal medications (e.g., ginkgo biloba, ginseng, feverfew) stop taking them 2 weeks before surgery

to prevent hemorrhage or adverse effect to the anesthetic.

Optional surgery

—Decision rests with patient Personal preference Cosmetic surgery

Required surgery

—Patient needs to have surgery Plan within a few weeks or months Prostatic hyperplasia Thyroid disorders Cataracts

Urgent surgery

—Patient requires prompt attention Within 24-30 h Closed fractures Infected wound exploration/irrigation

Elective surgery

—Patient should have surgery Failure to have surgery not catastrophic Repair of scars Simple hernia Vaginal repair

Holding Area

• Confirmation of identity, procedure, etc • Paperwork completed • Anesthesia interview if not already completed •Meds