Ch 18 Intraoperative Nursing Management

The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system?

Cardiovascular system Depolarizing muscle relaxants can cause cardiac dysrhythmias.

An unconscious patient with normal pulse and respirations would be considered to be in what stage of general anesthesia?

Surgical anesthesia

Which of the following actions by the nurse is appropriate?

Discarding an object that comes in contact with the 1-inch border The 1-inch border of a sterile field is considered unsterile.

The circulating nurse is preparing a patient for a surgical procedure. What primary responsibility does the circulating nurse have in the perioperative experience?

Discussing the complications of the surgical procedure with the patient A foremost responsibility of the circulating nurse includes verifying consent; if not obtained, surgery may not commence. Verifying consent would include discussing the complications of the surgical procedure with the patient.

A medical student scheduled to observe surgery enters the unrestricted surgical zone wearing jeans, a t-shirt, and tennis shoes. What is the best action by the nurse?

Educate the medical student on required attire for each surgical zone.

Which would be included as a responsibility of the scrub nurse?

Handing instruments to the surgeon and assistants

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?

"I'll be sleepy but able to respond to your questions." With moderate sedation, the patient can maintain a patent airway (ie, doesn't need a tube to help breathing), retain protective airway reflexes, and respond to verbal and physical stimuli. The patient is not unconscious with moderate sedation. Local anesthesia involves anesthetizing or numbing the area of the surgery.

What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block?

"Remain supine for the time specified by the physician." The nurse should instruct the client to remain supine for the time specified by the physician. Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local anesthetics and food occur. Local anesthetics don't cause hematuria.

The nurse is working in the preoperative area with a client going to surgery for a cholecystectomy. The client has histamine2-receptor antagonists ordered preoperatively. The client asks the nurse why these medications are needed. What would be the nurse's best answer?

"These medications decrease gastric acidity and volume." The anesthesiologist frequently orders preoperative medications. Common preoperative medications include the following: anticholinergics, which decrease respiratory tract secretions, dry mucous membranes, and interrupt vagal stimulation; anti anxiety drugs, which reduce preoperative anxiety, slow motor activity, and promote induction of anesthesia; histamine2-receptor antagonists, which decrease gastric acidity and volume; narcotics, which decrease the amount of anesthesia needed, help reduce anxiety and pain, and promote sleep; sedatives, which promote sleep, decrease anxiety, and reduce the amount of anesthesia needed; and tranquilizers, which reduce nausea, prevent emesis, and enhance preoperative sedation.

Which of the following is the appropriate response to the statement, "I'm so nervous about my surgery"?

"You seem nervous about your surgery." Use of the communication technique of "restating" is recommended as a way to encourage the patient to expand his or her thoughts and feelings.

A client is undergoing a lumbar puncture. The nurse educates the client about surgical positioning. Which statement by the nurse is appropriate?

"You will be lying on your side with your knees to your chest."

Which intervention should the nurse plan to implement to decrease the client's risk for injury during the intraoperative period?

Assess the client for allergies. The nurse must be aware of the client's allergies to prevent exposure to the client.

Anesthesiologist and anesthetist

Anesthetizes pt-Provides appropriate levels of pain relief-Monitors pt'sphysiologic status-Provides the best operative conditions for the surgeons

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented?

Circulating nurse The circulating nurse is responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented. Each member of the surgical team verifies the patient's name, procedure, and surgical site using objective documentation and data before beginning the surgery.

Types of Anesthesia

Conscious, General, regional

The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered?

Denies sensation to perineum and lower abdomen

When integrating the principles for maintaining surgical asepsis during surgery, which of the following would be most appropriate?

Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff In the operating room, the sleeves of a gown are considered sterile from 2 inches above the elbow to the stockinette cuff. In addition, the gown is considered sterile in front from the chest to the level of the sterile field. When draping a table or patient, the sterile drape is held well above the surface to be covered and positioned from front to back. Circulating nurses and unsterile items contact only unsterile areas.

A patient is to receive general anesthesia. The nurse anticipates that which of the following would be used for induction?

Etomidate Anesthesia induction begins with IV anesthesia, such as etomidate, and then is maintained at the desired stage by inhalation methods, such as isoflurane or nitrous oxide. Tetracaine is used for local or regional anesthesia.

A client has been administered ketamine for moderate sedation. What is the priority nursing intervention?

Frequently monitoring vital signs Vital signs must be monitored frequently to assess for respiratory depression and to enable quick intervention. Oxygen may need to be administered if respiratory depression occurs; therefore, monitoring vital signs is a higher priority nursing intervention. Providing a dark quiet room is appropriate after the procedure is completed and the client is recovering. Hallucinations may occur as a side effect of the medication.

The nurse recognizes the client has reached stage III of general anesthesia when the client:

Has small pupils that react to light Stage III of general anesthesia is characterized by dilation and reaction of pupils. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed.

The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching?

Headache Headache is a common effect following spinal anesthesia.

A client is receiving general anesthesia. The nurse anesthetist starts to administer the anesthesia. The client begins giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings?

II

Which stage of surgical anesthesia is also known as excitement?

II

Which stage of anesthesia is referred to as surgical anesthesia?

III-Stage III may be maintained for hours with proper administration of the anesthetic. Stage I is beginning anesthesia, where the client breathes in the anesthetic mixture and experiences warmth, dizziness, and a feeling of detachment. Stage II is the excitement stage, which may be characterized by struggling, singing, laughing, or crying. Stage IV is a state of medullary depression and is reached when too much anesthesia has been administered.

An obese client is undergoing abdominal surgery. During the procedure a surgical resident states, "The amount of fat we have to cut through is disgusting." What is the best response by the nurse?

Inform the resident that all communication needs to remain professional.

Which position is used for perineal surgical procedures?

Lithotomy

A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention?

Mask is placed over nose and extends to bottom lip. The mask should fit tightly, covering the nose and mouth. The mask should extend down past the chin. The mask may not effectively cover the mouth if extended only to the bottom lip. The hair, scrub top, drawstring, and shoe covering are all appropriate and do not require intervention.

Which is the most common cause of anaphylaxis?

Medications Because medications are the most common cause of anaphylaxis, intraoperative nurses must be aware of the type and method of anesthesia used as well as the specific agents. Latex, fibrin sealants, and plastic are not the most common causes of anaphylaxis.

A client is administered succinylcholine and propofol for induction of anesthesia. One hour after administration, the client demonstrates muscle rigidity with a heart rate of 180. What should the nurse do first?

Notify the surgical team. Tachycardia and muscle rigidity are often the earliest signs of malignant hyperthermia. Early recognition of malignant hyperthermia increases survival. The nurse would document the findings, and administer dantrolene sodium, obtain cooling blankets as part of the treatment for malignant hyperthermia, but the nurse would need to ensure the surgical team is aware of the findings first.

A 55-year-old patient arrives at the operating room. The nurse is reviewing the medical record and notes that the patient has a history of osteoporosis in her lower back and hips. The patient is scheduled to receive epidural anesthesia. Which of the following nursing diagnoses would be a priority for this patient?

Risk for perioperative positioning injury related to operative position

A client receiving moderate sedation for a minor surgical procedure begins to vomit. What should the nurse do first?

Roll the client onto his or her side.

Scrub nurse (RN or Scrub tech)

Scrub nurse (RN or Scrub tech) Remains sterile and assists the surgical team

Anesthesia-Factors influencing dosage and types

Type and duration of the procedure-Area of the body being operated on-Whether the procedure is an emergency-Options of management of postop pain-How long since ptate, had liquids, or medications-Pt position for the surgical procedures

The anesthesiologist or CRNA administers the

anesthetic agent.

During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer:

dantrolene sodium (Dantrium) The client is exhibiting clinical manifestations of malignant hyperthermia. Dantrolene sodium, a skeletal muscle relaxant, is administered.

Monitored anesthesia care differs from moderate sedation in that monitored anesthesia care:

may result in the administration of general anesthesia. Monitored anesthesia care may require the anesthsiologist to convert to general anesthesia.

The nurse recognizes older adults require lower doses of anesthetic agents due to:

decreased lean tissue mass. Lower doses of anesthetic agents are required in older adults, as they have decreased lean tissue mass, decreased tissue elasticity, and decreased liver mass. Bone mass is unrelated to doses of anesthesia.

The nurse recognizes that the older adult is at risk for surgical complications due to:

decreased renal function Renal function declines with age, resulting in slowed excretion of waste products and anesthetic agents.

A nurse is administering moderate sedation to a client with chronic obstructive pulmonary disease (COPD). The nurse bases her next action on the principle that:

it may be necessary to raise the head of this client's bed.

The nurse understands that the purpose of the "time out" is to:

maintain the safety of the client. Verification of the identification of the client, procedure, and operative site are essential to maintain the safety of the client.

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication?

malignant hyperthermia Malignant hyperthermia is an inherited disorder that occurs when body temperature, muscle metabolism, and heat production increase rapidly, progressively, and uncontrollably in response to stress and some anesthetic agents. If the client's temperature begins to rise rapidly, anesthesia is discontinued, and the OR team implements measures to correct physiologic problems, such as fever or dysrhythmias. Hypothermia is a lower than expected body temperature. Signs of infection would not present during the procedure. Increased body temperature would not indicate fluid volume excess.

What medication should the nurse prepare to administer in the event the patient has malignant hyperthermia?

Dantrolene sodium (Dantrium)

Which nursing diagnosis should the nurse plan to address first in the client upon arrival in the intraoperative setting?

Anxiety related to ineffective coping with surgical concerns Putting the client at ease helps the client prepare for the surgical experience by promoting psychological comfort of the client and giving the client a sense of control.

A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate?

Apply a warm air blanket, gradually increasing body temperature.

What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities?

Coordinating the surgical team The person in the scrub role, either a nurse or a surgical technician, provides sterile instruments and supplies to the surgeon during the procedure by anticipating the surgical needs as the surgical case progresses. The circulating nurse coordinates the care of the patient in the OR. Care provided by the circulating nurse includes planning for and assisting with patient positioning, preparing the patient's skin for surgery, managing surgical specimens, anticipating the needs of the surgical team, and documenting intraoperative events.

What is the priority action by the scrub nurse when the surgeon begins to close the surgical wound?

Count the sponges. Standards call for the scrub nurse and the circulating nurse to count the sponges at the beginning of the surgery, when the surgical wound is being sutured, and when the skin is being sutured. Tissue specimens should be labeled when obtained. The sutures should be ready before the surgeon needs them. Although the scrub nurse does hand equipment to the surgeon, the sponge count is a higher priority action.

Surgeon (Physician)

Determines preoperative diagnosis, the choice and execution of the surgical procedure-Explains risks and benefits-Obtains informed consent -Manages postoperative care

Nursing students are reviewing information about agents used for anesthesia. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic?

Halothane Halothane is an example of an inhalation anesthetic. Fentanyl, succinylcholine, and propofol are commonly used intravenous agents for anesthesia.

Fentanyl is categorized as which type of intravenous anesthetic agent?

Opioid Fentanyl is 75 to 100 times more potent than morphine and has about 25% of the duration of morphine (IV). Examples of tranquilizers include midazolam and diazepam. Ketamine is a dissociative agent.

A patient is to receive general anesthesia with sevoflurane. The nurse anticipates the need for which of the following?

Oxygen Sevoflurane is an inhalation anesthetic always combined with oxygen. It would not be combined with alfentanil, rocuronium, or lidocaine. Alfentanil and rocuronium are intravenous anesthetics. Lidocaine is a local anesthetic.

The nurse positions the client in the lithotomy position in preparation for

Perineal surgery

The surgical client is at risk for injury related to positioning. Which of the following clinical manifestations exhibited by the client would indicate the goal was met of avoiding injury?

Peripheral pulses palpable Surgical clients are at risk for pressure ulcers and damage to nerves and blood vessels as a result of awkward positioning required for surgical procedures. Palpable peripheral pulses indicate integrity of the blood vessels.

The scrub nurse is responsible for:

Preparing the sterile instruments for the surgical procedure The scrub nurse is responsible for preparing the sterile instruments for the surgical procedure.

The circulating nurse is unsure whether proper technique was followed when an object was placed in the sterile field during a surgical procedure. What is the best action by the nurse?

Remove the entire sterile field from use. If any doubt exists about the maintenance of sterility, the field should be considered not sterile. Because the object in question was placed in the sterile field, the sterile field must be removed from use. Removing the individual item is not appropriate, as the entire field was potentially contaminated. Reviewing the client's chart at a later date does not decrease the chance of infection. Although another nurse could observe the technique used to put objects in a sterile field, it does not resolve the immediate concern.

A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role?

Scrub role The scrub role includes performing a surgical hand scrub, setting up the sterile tables, and preparing sutures, ligatures, and special equipment. The circulating nurse manages the operating room and protects patient safety. The registered nurse first assistant functions under the direct supervision of the surgeon. Responsibilities may include handling tissue, providing exposure of the operative field, suturing, and maintaining hemostasis. The anesthetist administers the anesthetic medications.

Which of the following positions would the nurse expect the client to be positioned on the operating table for renal surgery?

Sims position

The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia?

Stage IV

The client vomits during the surgical procedure. The best action by the nurse is:

Suction the client to remove saliva and gastric secretions. The nurse immediately suctions the client to prevent aspiration of vomitus.

Which of the following techniques least exhibits surgical asepsis?

Suctioning the nasopharyngeal cavity of a clienTo maintain surgical asepsis, only sterile items should touch sterile items.

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?

Surgeon The registered nurse first assistant practices under the direct supervision of the surgeon. The circulating nurse works in collaboration with other members of the health care team to plan the best course of action for each patient. The scrub nurse assists the surgeon during the procedure as well as setting up sterile tables and preparing equipment. The anesthetist administers the anesthetic medications.

The nurse is caring for a patient who is at risk for malignant hyperthermia subsequent to general anesthesia. What is the most common early sign that the nurse should assess for?

Tachycardia

The nurse caring for a patient who is at risk for malignant hyperthermia subsequent to general anesthesia would assess for the most common early sign of:

Tachycardia (HR >150 bpm). The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. In addition to the tachycardia (often the earliest sign), sympathetic nervous stimulation leads to ventricular arrhythmia, hypotension, decreased cardiac output, oliguria, and, eventually, cardiac arrest.

The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?

Temperature of 102.5°F (39°C)

A patient is to undergo surgery on his kidney. The patient would be placed in which position for the surgery?

The Sims' or lateral position as shown in Option D would be used for renal surgery. The dorsal recumbent position (Option A) is used for most abdominal surgeries, except those for the gallbladder or pelvis. The Trendelenburg position (Option B) is used for surgery on the lower abdomen and pelvis. The lithotomy position (Option C) is used for nearly all perineal, rectal, and vaginal surgical procedures.

A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize?

The edges of a sterile package, once opened, are considered unsterile.

The physician requests lidocaine 2% with epinephrine for use in local infiltration anesthesia. What does the nurse understand is the purpose of adding epinephrine to the lidocaine? (Select all that apply.)

The epinephrine causes vasoconstriction. The epinephrine prevents rapid absorption of the anesthetic drug. The epinephrine prolongs the local action of the anesthetic agent.

The nurse should know that, postoperatively, a general anesthetic is primarily eliminated via what organ(s)?

The lungs

A patient is having a surgical procedure that requires the patient to be in the prone position. What is an expected patient outcome?

The patient remains free of perioperative positioning injury. The potential for transient discomfort or permanent injury is present because many surgical positions are awkward. Hyperextending joints, compressing arteries, or pressing on nerves and bony prominences usually results in discomfort simply because the position must be sustained for a long period of time (Rothrock, 2010).

A client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse?

Verify consent.

Circulating nurse

manages activities outside the sterile field & documentation