Adult Health Chapter 17, 18, 19

Corticosteroids have which effect on wound healing? Reduce blood supply Mask the presence of infection Cause hemorrhage May cause protein-calorie depletion

Mask the presence of infection

Medications With the Potential to Affect the Surgical Experience Tranquilizers Diazepam (Valium)

May cause anxiety, tension, and even seizures if withdrawn suddenly.

optional surgery

Optional—Decision rests with patient Personal preference Cosmetic surgery

Phase 3 PACU

Patient is ready for discharge

urgent surgery

Patient requires prompt attention Within 24-30 h Acute gallbladder infection Kidney or ureteral stones

Required surgery

Required—Patient needs to have surgery Plan within a few weeks or months Prostatic hyperplasia without bladder obstruction Thyroid disorders Cataracts

Emergent surgery

Requires immediate intervention because of life-threatening consequences occurs without delay

A postanesthesia care unit (PACU) nurse is preparing to discharge a client home following ankle surgery. The client keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate? Ask the client, "Do you understand?" Continuously repeat the instructions until the client restates them. Give the written instructions to the client's 16-year-old child. Review the instructions with the client and an accompanying adult.

Review the instructions with the client and an accompanying adult.

general anesthesia

(inhalation, IV)

moderate sedation

(monitored anesthesia care [MAC])

Stage III:surgical anesthesia

. Surgical anesthesia is reached by administration of anesthetic vapor or gas and supported by IV agents as necessary. The patient is unconscious and lies quietly on the table. The pupils are small but constrict when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. With proper administration of the anesthetic agent, this stage may be maintained for hours in one of several planes, ranging from light (1) to deep (4), depending on the depth of anesthesia needed.

What measurement should the nurse report to the physician in the immediate postoperative period? A systolic blood pressure lower than 90 mm Hg A temperature reading between 97°F and 98°F Respirations between 20 and 25 breaths/min A hemoglobin of 13.6

A systolic blood pressure lower than 90 mm Hg

The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus? Abdominal tightness Abdominal distention Absence of peristalsis Increased abdominal girth

Absence of peristalsis

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O₂ saturation monitor despite the client's breathing appearing normal, what action should the nurse take first? Assess the client's heart rhythm and nail beds. Apply oxygen. Notify the physician. Document the findings.

Assess the client's heart rhythm and nail beds.

Medications With the Potential to Affect the Surgical Experience Diuretics Hydrochlorothiazide (Microxide)

During anesthesia, may cause excessive respiratory depression resulting from an associated electrolyte imbalance.

Medications With the Potential to Affect the Surgical Experience Thyroid Hormone Levothyroxine sodium (Synthroid)

IV administration may be needed during the postoperative period to maintain thyroid levels.

Medications With the Potential to Affect the Surgical Experience Insulins Insulin (Humalog)

Interaction between anesthetics and insulin must be considered when a patient with diabetes is undergoing surgery. IV insulin may need to be given to keep the blood glucose within the normal range.

Which of the following clinical manifestations increase the risk for evisceration in the postoperative client? Hypovolemia Edema Valsalva maneuver Hypoxia

Valsalva maneuver

Phase 1 PACU

area designated for care of surgical patients immediately after surgery and for patients whose condition warrants close monitoring

The nurse recognizes that a traumatic wound with fecal contamination would be classified as clean. clean contaminated. contaminated. dirty

dirty

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client? experiences pain within tolerable limits. exhibits wound healing without complications. resumes usual urinary elimination pattern. maintains adequate fluid status.

experiences pain within tolerable limits.

the goal of the preoperative assessment

for the patient to be as healthy as possible

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action? Re-attempt to auscultate bowel sounds. Prepare to insert a nasogastric tube. Call the health care provider. Prepare to administer a stool softener

Call the health care provider.

Medications With the Potential to Affect the Surgical Experience Corticosteroids Dexamethasone (Dexpak)

Cardiovascular collapse can occur if discontinued suddenly. Therefore, a bolus of corticosteroid may be administered IV immediately before and after surgery.

Medications With the Potential to Affect the Surgical Experience Opioids Morphine sulfate (MS Contin)

Long-term use of opioids for chronic pain (≥6 mo) in the preoperative period may alter the patient's response to analgesic agents.

A postanesthesia care unit (PACU) nurse is caring for a client with the following assessment data: pale, cool, moist skin; thready pulse of 122; blood pressure 78/60; urine output of 25 mL/h; temperature 99.2°F. What interventions by the nurse are appropriate? Select all that apply. Raise the head of the bed 30 degrees. Maintain a patent airway. Frequently monitor neurological status. Administer blood products per orders. Apply oxygen per orders. Apply a warming blanket.

Maintain a patent airway. Frequently monitor neurological status. Administer blood products per orders. Apply oxygen per orders.

Medications With the Potential to Affect the Surgical Experience Phenothiazines Chlorpromazine hydrochloride

May increase the hypotensive action of anesthetics.

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first? Place a dry, sterile dressing over the protruding organs. Place a pressure dressing over the opening and secure. Have the client lay quietly on back and call the physician. Moisten sterile gauze with normal saline and place on the protruding organ.

Moisten sterile gauze with normal saline and place on the protruding organ.

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what? Requirement of intermittent catheterization Calculus formation Urine retention Urinary infection

Urine retention

preoperative phase begins when

begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) bed

intraoperative phase begins when

begins when the patient is transferred onto the OR bed and ends with admission to the PACU

the postoperative phase begins when

begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home

The goal of preoperative skin preparation is to

decrease bacteria without injuring the skin.

Elective surgery

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

Surgical Care Improvement Project (SCIP)

In an effort to reduce surgical complications, instituted as a national partnership of the Joint Commission and the Center for Medicare and Medicaid Services

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis? Acute incisional pain Ineffective thermoregulation Decreased cardiac output Ineffective airway clearance

Ineffective thermoregulation

Stage I: beginning anesthesia.

Dizziness and a feeling of detachment may be experienced during induction. The patient may have a ringing, roaring, or buzzing in the ears and, although still conscious, may sense an inability to move the extremities easily. These sensations can result in agitation. During this stage, noises are exaggerated; even low voices or minor sounds seem loud and unreal. For these reasons, unnecessary noises and motions are avoided when anesthesia begins.

Medications With the Potential to Affect the Surgical Experience Anticonvulsant Medications Carbamazepine (Tegretol)

IV administration of medication may be needed to keep the patient seizure free in the intraoperative and postoperative periods.

Which is a classic sign of hypovolemic shock? Dilute urine Pallor High blood pressure Bradypnea

Pallor

Corticosteroids and surgery

Patients who have received corticosteroids are at risk for adrenal insufficiency. The use of corticosteroids for any purpose during the preceding year must be reported to the anesthesiologist or CRNA and surgeon. The patient is monitored for signs of adrenal insufficiency

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem? Pink color Copious red blood in the sputum Foul smell Pieces of vomitus

Pink color

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? Necrotic and hard Pale yet able to blanch with digital pressure Pink to red and soft, noting that it bleeds easily White with long, thin areas of scar tissue

Pink to red and soft, noting that it bleeds easily

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. Which of the following actions by the nurse would be inappropriate? Administer oxygen. Restrict oral fluids. Provide a blanket. Monitor for cardiac dysrhythmias.

Restrict oral fluids. The client exhibits clinical manifestations of hypothermia. The nurse should maintain adequate hydration of the client rather than restrict fluids.

Which findings would be indicative of a nursing diagnosis of decreased cardiac output? urinary output > 60 ml; BP 90/60; tachypnea bradycardia; urinary output < 30 ml; confusion tachycardia; hemoglobin 10.9 gm/dL; BP 88/56 confusion; tachypnea; hemoglobin 14.2 gm/dL

tachycardia; hemoglobin 10.9 gm/dL; BP 88/56

restricted zone

where scrub clothes, shoe covers, caps, and masks are worn.

Which term refers to the protrusion of abdominal organs through the surgical incision? Hernia Evisceration Dehiscence Erythema

evisceration

The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room? 4 5 6 7

7

Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply. Ambulate the length of the client's house Get out of bed without assistance Be able to self-toilet Be able to drive to the grocery Pass a stress test

Ambulate the length of the client's house Get out of bed without assistance Be able to self-toilet

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: Assisting with incentive spirometry every 6 hours Ambulating the client as soon as possible Positioning the client in a supine position Assessing breath sounds at least every 2 hours

Ambulating the client as soon as possible

Anesthesia

Anesthesia is a state of narcosis (severe central nervous system depression produced by pharmacologic agents), analgesia, relaxation, and reflex loss. Patients under general anesthesia are not arousable, not even to painful stimuli. They lose the ability to maintain ventilatory function and require assistance in maintaining a patent airway. Cardiovascular function may be impaired as well.

On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing? Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing Covering the well-approximated wound edges with a dry dressing Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive Cleaning the wound with soap and water, then leaving it open to the air

Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order. Lubricate the sterile suction catheter. Position the client in Fowlers position. Apply intermittent suction while withdrawing the catheter. Insert suction catheter into the lumen of the tube. Apply intermittent suction while withdrawing the catheter. Don sterile gloves.

Position the client in Fowlers position. Don sterile gloves. Lubricate the sterile suction catheter. Insert suction catheter into the lumen of the tube. Apply intermittent suction while withdrawing the catheter.

ambulatory surgery

surgery that does not require an overnight hospital stay

Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis? Acute pain Ineffective airway clearance Decreased cardiac output Urinary retention

Decreased cardiac output

A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention? Assessing WBC count, temperature, and wound appearance Obtaining dietary consultation for improved wound healing Educating the client on safe bed-to-chair transfer procedures Administering pain medications within 1 hour of the client's request

Assessing WBC count, temperature, and wound appearance

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dL, and a blood pressure lying in bed of 110/70 mm Hg. The nurse suspects abnormal orthostatic changes when the client gets out of bed and reports vertigo. What vital sign value most supports the client's orthostatic changes? Blood pressure of 150/100 mm Hg Blood pressure of 120/90 mm Hg Blood pressure of 110/80 mm Hg Blood pressure of 90/50 mm Hg

Blood pressure of 90/50 mm Hg

Medications With the Potential to Affect the Surgical Experience Anticoagulants Warfarin (Coumadin)

Can increase the risk of bleeding during the intraoperative and postoperative periods; should be discontinued in anticipation of elective surgery. The surgeon will determine how long before the elective surgery the patient should stop taking an anticoagulant, depending on the type of planned procedure and the medical condition of the patient.

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? Complete blood count Central venous pressure Upper endoscopy Chest x-ray

Central venous pressure

The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by: Granulation First intention Second intention Third intention

First intention

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? First intention Second intention Third intention Fourth intention

First intention

Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis? Prolonged dangling of the legs over the edge of the bed Hourly leg exercises Use of blanket rolls to elevate the lower extremities Fluid restriction

Hourly leg exercises

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? Pleurisy Pneumonia Hypoxemia Pulmonary edema

Pneumonia

What complication is the nurse aware of that is associated with deep venous thrombosis? Pulmonary embolism Immobility because of calf pain Marked tenderness over the anteromedial surface of the thigh Swelling of the entire leg owing to edema

Pulmonary embolism

The nurse is attempting to ambulate a client who underwent shoulder surgery earlier in the day, but the client is refusing to do so. What action by the nurse is most appropriate? Document the client's refusal. Delegate the task to the unlicensed assistive personnel. Reinforce the importance of early mobility in preventing complications. Use multiple staff members to remove the client from the bed.

Reinforce the importance of early mobility in preventing complications.

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? Primary-intention healing First-intention healing Second-intention healing Third-intention healing

Second-intention healing

A recently extubated postoperative client starts to gag and make vomiting sounds. What action should the nurse perform first? Provide an emesis basin. Turn the client onto their side. Administer an antiemetic. Obtain suction equipment.

Turn the client onto their side.

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client? The client can be discharged from the PACU. The client must remain in the PACU. The client should be transferred to an intensive care area. The client must be put on immediate life support.

The client can be discharged from the PACU.

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition? The client is displaying early signs of shock. The client is showing signs of a medication reaction. The client is displaying late signs of shock. The client is showing signs of an anesthesia reaction.

The client is displaying early signs of shock.

Stage II: excitement

The excitement stage, characterized variously by struggling, shouting, talking, singing, laughing, or crying, is often avoided if IV anesthetic agents are given smoothly and quickly. The pupils dilate, but they constrict if exposed to light; the pulse rate is rapid, and respirations may be irregular. Because of the possibility of uncontrolled movements of the patient during this stage, the anesthesiologist or CRNA must always be assisted by someone ready to help restrain the patient or to apply cricoid pressure in the case of vomiting to prevent aspiration. Manipulation increases circulation to the operative site and thereby increases the potential for bleeding.

The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan? The client can self-administer oral pain medication as needed with patient-controlled analgesia. Family members can be involved in the administration of pain medications with patient-controlled analgesia. Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. There are no advantages of patient-controlled analgesia over a PRN dosing schedule.

Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.

third intention healing

Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two opposing granulation surfaces.

Stage IV: medullary depression.

This stage is reached if too much anesthesia has been given. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer constrict when exposed to light. Cyanosis develops and, without prompt intervention, death rapidly follows. If this stage develops, the anesthetic agent is discontinued immediately and respiratory and circulatory support is initiated to prevent death. Stimulants, although rarely used, may be given; narcotic antagonists can be used if the overdose is due to opioids. It is not a planned stage of surgical anesthesia.

You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult? Respiratory depressive effects Tolerance Convalescent period Detailed medication history

Tolerance

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: auscultate bowel sounds. palpate the abdomen. change the client's position. insert a rectal tube.

auscultate bowel sounds.

CLABSI

central line associated blood stream infection

The client is experiencing intractable hiccups following surgery. What would the nurse expect the surgeon to order? chlorpromazine metoclopramide omeprazole ranitidine

chlorpromazine Chlorpromazine (Thorazine) is used to treat intractable hiccups.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: first intention. second intention. third intention. fourth intention.

first intention.

The primary objective in the immediate postoperative period is controlling nausea and vomiting. relieving pain. maintaining pulmonary ventilation. monitoring for hypotension.

maintaining pulmonary ventilation.

Second intention healing

method of healing in which wound edges are not surgically approximated and integumentary continuity is restored by the process known as granulation

First intention healing

method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? chlorpromazine omeprazole ondansetron ranitidine

ondansetron Ondansetron (Zofran) is used to treat nausea and vomiting.

purpose of withholding food and fluid before surgery

prevent aspiration

Reasons older adults dont respond to anesthesia as well as young people..

progressive loss of skeletal muscle mass in conjunction with an increase in adipose tissue Comorbidities advanced systemic disease,increased susceptibility to illness, Age alone

regional anesthesia

regional anesthesia (epidural, spinal, and local conduction blocks)

Phase 2 PACU

the patient is prepared for self-care or an extended care setting.