Chapter 27 - Perioperative Care, Chapter 14-Perioperative Care, Chapter 11 pain management

During PRE-OPERATIVE ASSESSMENT nurse identifies potential RISK FACTORS for complications during surgery. What following surgical risk factors can increase likelihood of perioperative complications?

*Extremes of age *Dehydration *Malnutrition *Obesity *Smoking *Diabetes *Cardiopulmonary disease *Drug and alcohol abuse *Bleeding tendencies *Low hemoglobin and red cells *Pregnancy

Deep-breathing

*Form of controlled ventilation that opens and fills small passages in the lungs. *Especially advantageous for clients who receive general anesthesia or who breathe shallow after surgery due to pain. *Nurse practices deep breathing with client before they undergo surgery. *Incentive spirometers also are used to promote deep breathing.

Autologous Blood Donation Criteria

*Have physician's recommendation *Have hematocrit within safe range *Be free of infection at time of donation *Meet the blood collection's centers minimum weight requirement *Donate 40 to 3 days before the anticipated date of use *Donate no more frequently than every 3-5 days; once per week is preferred. *Assume responsibility for costs above the usual processing fees even if blood is not used *Be advised that his or her blood will be discarded if unused

DEEP-BREATHING involves:

*Inhaling deeply using abdominal muscles, holding breathe for several seconds, and exhaling slowly. *Pursing the lips may extend period of exhalation.

Important fact about Anti-embolism stockings:

*MUST FIT CLIENT PROPERLY AND BE APPLIED CORRECTLY. *When stockings are being washed, second pair is used. (Client should not go without.) *IF WASHED BY HAND, LAY FLAT TO DRY TO PREVENT LOSS OF ELASTICITY.

Pre-operative Nursing Assessment in non-emergency situation includes:

*Nurse preforms thorough history and physical examination. *Assesses client's understanding of surgical procedure, post-op expectations, and ability to participate in recovery. *Nurse also considers CULTURAL needs: as they relate to beliefs about surgery, personal privacy, and presence of family during pre-op and post-op care. *Nurse may question client in regards to feelings about DISPOSAL OF BODY PARTS and BLOOD PRODUCTS.

Reminding the nurse, in private, that the sensation of pain is whatever the patient says it is

A nurse overhears another nurse say, "That patient is asking for pain medication again. He is constantly on the call bell, always reporting how severe his pain is, and I think he is just drug-seeking. I am going to make him wait the full 4 hours before I give this medication again." Which action by the nurse is the most appropriate in this situation?

The nurse understands that which statement is true about tolerance and addiction?

Although clients may need increasing levels of opioids, they are not addicted.

A client being treated for rheumatoid arthritis has been prescribed a glucocorticosteroid. How should the nurse best ensure this client's safety during treatment?

Ensure the client knows to taper down the dose if it is discontinued by the care provider.

A preoperative client has called the nurse about an upcoming surgical procedure, 6 weeks from now. The client is concerned about receiving blood after surgery for fear of acquiring a blood-borne disease. What is the nurse's most appropriate response?

Explain to the client the practice of autologous blood donation.

During a client's preoperative assessment, which of the following would the nurse identify as risk factors for intra- or postoperative complications? Select all that apply.

Impaired nutritional status Advanced age Physical deconditioning Current tobacco use

The nurse has just received report on a client who is coming to the unit from the emergency department with a torn meniscus. The nurse reviews the PRN medications and sees that an NSAID (ibuprofen) is prescribed every 6 hours. How should the nurse best implement preventive pain measures?

Check for allergies, use a pain scale to assess the client's pain, and offer the ibuprofen every 6 hours until the client is discharged.

A patient is being seen in the health clinic for chronic headaches. He has been using pain medications on a regular basis. Which of the following would be part of the teaching plan for a patient?

Inform the primary health care provider about the use of salicylates before any procedure.

Which condition, approved by the U.S. Food and Drug Administration, is the only use for the lidocaine 5% patch?

Postherpetic neuralgia

Preoperative Meds-Sedative

Promote sleep, decrease anxiety and reduce the amount of anesthesia needed.

A nurse is caring for a client with a chest incision. Which action should the nurse ask the client to perform to induce forced coughing?

Pull the abdomen inward.

A preoperative assessment finds a client to be 75 pounds overweight. The client is to have abdominal surgery. What nursing diagnosis would be appropriate based on the client's weight?

Risk for Infection

Which condition is a heightened response that occurs after exposure to a noxious stimulus?

Sensitization

Voluntary Consent

Vlaid consent must be freeely given, without coercion.

The FACES rating scale

When caring for an older adult patient who does not speak English, which assessment tool is the most appropriate for the nurse to use to assess this patient's pain?

Asking the patient to take slow, full diaphragmatic/abdominal breaths

Which action by the nurse is the most appropriate when initiating guided imagery with a patient as a method to control pain?

Significant other's assessment of the pain

Which data collected by the nurse is nonessential when conducting a patient pain history?

Anti-inflammatory effects

Which is the reason for the nurse to administer ibuprofen, over acetaminophen, when providing patient pain management?

Pain tolerance

Which term should the nurse use to document the maximum amount of pain is able to tolerate?

Interstitial cystitis

Which type of pain syndrome should the nurse assess when providing care to a female patient?

Preoperative Meds-Histamine 2-Receptor Antagonists

decrease gastric acidity and volume.

Preoperative Meds-Anticholinergics

decrease respiratory tract secretions, dry mucous membranes, and interrupt vagal stimulation.l

Preoperative Meds-Opioids

decrease the amount of anesthesia needed, help reduce anxiety and pain, and promote sleep.

A nurse preparing an older adult client for hip replacement surgery is aware of the surgical risks related to the client's age. Which of the following accurately describes these risks? Select all that apply.

decreased peripheral circulation increased vascular rigidity decreased thermoregulation ability

The nurse is preparing a client for a surgical procedure that is scheduled for the next morning. What nursing action(s) is important to limit the risk of intraoperative and postoperative complications? Select all that apply.

educating client about postoperative care measuring baseline vital signs having the client void immediately before surgery checking that all diagnostic tests are completed

Which client will see the greatest permanent changes in lifestyle following surgery?

ileostomy

-Analgesic effects -Antipyretic effects -Anti-inflammatory effects

The nurse administers a nonsteroidal anti-inflammatory drug (NSAID) to a patient who is experiencing chronic pain. When teaching the patient about this medication, which effects will the nurse include in the session? Select all that apply.

Informing the patient that he looks uncomfortable and asking him to describe his pain

The nurse finds a postoperative patient perspiring with fist clenched upon entering the room. The nurse administers routine medication and provides care. The patient is pleasant and cooperative. Which action by the nurse is appropriate?

Vomiting

The nurse is caring for a patient who is experiencing acute pain. Which action by the patient, noted by the nurse during the assessment, is considered an associated symptom of pain?

-Administer a nonopioid analgesic first. -Administer analgesics upon patient request -Administer a combination nonopioid-opioid second

The nurse is creating a pain management plan using the three-step approach for a patient with intractable pain. Which interventions should the nurse include in this plan? Select all that apply.

"Tell me more about the pain and what you do for it when it hurts."

The nurse is obtaining a pain history. The patient reports pain in the right ear. Which response by the nurse is the most appropriate?

Administer the stronger analgesic ordered by the primary care provider

The nurse is providing care to a patient who had an abdominal nevus removed who is reporting intense pain. Which action by the nurse is appropriate?

"People who have real pain are unlikely to become addicted to analgesics provided to treat the pain."

The nurse is providing care to a postoperative patient who is getting out of bed for the first time since surgery. When conducting the pain assessment, the patient states, "It hurts, but I do not want to take any more drugs. I do not want to end up addicted." Which response by the nurse is most appropriate?

TENS unit

The nurse is using a nonpharmacologic method to manage a patient's pain, and applies a unit that applies low-voltage electrical stimulation directly over the pain area. When documenting this intervention, which term is the most appropriate for the nurse to use?

-"Does anything other than your back hurt?" -"I'm sorry you're hurting. I want to make you feel better." -"People with back pain experience very different symptoms. Tell me more about your back pain."

The nurse is working on the orthopedic unit, and is caring for a patient who reports back pain. Which responses by the nurse would be appropriate when caring for this patient? Select all that apply.

Equianalgesia

The pain management team individualizes the analgesic regimen by guiding the adjustment of medication, dose, time intervals, and route of administration. When discussing this method of treating pain, which term is the most appropriate for the nurse to use?

Acute neuropathic pain

The patient has pain in the lower back that radiates down the leg as the result of a herniated disk compressing the sciatic nerve that began 4 months ago. When documenting this patient's pain, which term will the nurse use?

Massage

The patient reports difficulty sleeping related to anxiety. Which nonpharmacologic pain management intervention might the nurse consider performing in order to relax the patient?

Somatic pain

The patient with a sprained ankle is complaining of pain in the injured area. Which term will the nurse use when documenting this patient's pain?

Ambulatory Surgery

sometimes referred to as same-day or outpatient surgery. -Surgery that requires fewer than 24 hrs. of hospitalization. -brief: 1-2 hours or extend to overnight.

A client has been given a patient-controlled analgesia (PCA) device to control postoperative pain. The client expresses concern about administering too much of the analgesic and accidentally overdosing. What topic should the nurse teach the client about?

the limits on dose and frequency that are programmed into the PCA

A client who has undergone extensive fracture repair continues to request opioid pain medication with increasing frequency. The initial surgeries occurred more than 2 months ago, and the nurse is concerned about the repeated requests. What does the nurse suspect to be the cause of the client's frequent appeals for pain medication?

tolerance

Circulating Nurse

wears OR attire but NOT sterile gown. -obtains and opens wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, and coordinating activities of other personnel, like the pathologist and radiology techs.

While reviewing the medical record of a client who has had abdominal surgery, the nurse notes that the client has developed a paralytic ileus. The nurse interprets this information as indicative of what?

Bowel functioning is significantly decreased.

The nurse understands the definition of pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Which of the following comments by a client confirm the client's understanding of the fundamental concepts of pain? Select all that apply.

"I would love to go to church, but my back pain is too uncomfortable to make it through the service." Correct response: "I am tired of living with this nagging pain; I'm not sure how much longer I can go on." "I would love to go to church, but my back pain is too uncomfortable to make it through the service." "I used to walk every day for exercise; pain in my knee made me stop walking.

A client is prescribed morphine for a possible ankle fracture. When the nurse brings in a second dose of the medication, the client states, "This medicine made me sick." The nurse replies

"What do you mean by the word sick?"

Directed Blood Donation Criteria

(Blood donor chosen from among client's family or friends.) *Be at least 17 years of age *Meet all the criteria of a public donor *Have the same blood type as the potential recipient or one that is compatible *Not have received a blood transfusion within the last 6 months *Donate 20-30 days before anticipated use *Be free from blood-borne pathogens and high risk behaviors.

Two complications that DEEP-BREATHING can PREVENT post-operatively include:

*Atelectasis - airless, collapsed lung areas *Pneumonia - lung infection *Both can lead to hypoxemia

During PRE-OPERATIVE TEACHING the nurse also explains how to perform the following:

*Deep breathing *Coughing *Leg exercises

Informed Consent in Children under 18

*Parent or legal guardian MUST sign consent form *In EMERGENCY health care personnel make every effort to obtain consent by telephone, telegram, or fax.

On admission to Surgery during pre-operative stage what does the nursing review?

*Pre-op instructions: DIET AND FLUID RESTRICTIONS, BOWEL AND SKIN PREP, WITHHOLDING or SELF-ADMIN OF MEDS. *Nurse ensures client has followed them, if client has not carried out specific portion of instruction, nurse IMMEDIATELY NOTIFIES SURGEON.

Examples of information to include in PRE-OPERATIVE TEACHING

*Pre-operative meds - when they are given and their effects *Post-operative pain control *Explanation and description of the post-anesthesia recovery room or post-surgical protocol *Discussion of the frequency of assessing vital signs and the use of monitoring equipment.

How does Pre-operative Nursing Assessment vary depending on type of surgery?

*Share with physician responsibility for assessing pre-op clients. *Assessment varies depending on urgency of the surgery, and if client is admitted same day or earlier. *Pre-op assessment is ALWAYS necessary, but particular circumstances dictate extent of process because there may not be time for detailed assessment.

Problems that can cause surgery to be postponed or cancelled include:

*Unexplained elevation in temperature *Abnormal Lab data *current infectious disease *Significant deviations in vital signs

PRE-OPERATIVE Teaching

*Varies with type of surgery and length of hospitalization *Pre-operatively, clients are alert and free from pain or In less pain at this time, which facilitates participation. (If instructions were given after surgery client could have difficulties remembering, because of anesthesia or other factors from surgery such as pain and discomfort.) *KNOWLEDGE OF WHAT TO EXPECT ON THE PART OF CLIENTS AND FAMILY CAN ENHANCE RECOVERY FROM SURGERY. *Explaining to client what will happen can also help to reduce anxiety. If they know what to expect they will be less likely to be alarmed by regular activities that must be done throughout and after surgery.

Unique safety precaution for laser surgery

*eye, fire, heat and vapor *volatile substances such as alcohol and acetone are not used because of flammability. *Surgical instruments are coated black to avoid heating up by absorbing scattered light. *Teeth covered to guard metal fillings *NO JEWELRY

Scrub Nurse

-wears a sterile gown and gloves and assists the surgical team by handing instruments to the surgeon an assistants, preparing sutures, receiving specimens for lab, and counting sponges and needles.

When can client be discharged from outpatient surgery?

1 - Client is awake and alert 2 - vital signs are stable 3 - pain and nausea are controlled 4 - oral fluids are retained 5 - client voids a sufficient quantity of urine 6 - client has received discharged instructions

Preoperative Assessment-Assess Physical Needs

1. Ability to communicate 2. Vital Signs 3. LOC 4. wt. & ht. 5. Skin integrity 6. ROM 7.Level of exercise 8. Circulatory status

Preoperative Laboratory and Diagnostic Studies For Preoperative Assessment

1. CBC 2. BLood type and crossmatch 3. Serum electrolytes 4. Urinalysis 5. CXR 6. Electrocardiogram Other tests related to procedure or pts. medical condition.

Criteria for Pt. Admission for Ambulatory Surgery

1. Client is not critically ill 2. surgical procedure is not extensive and does not require many hrs. of general anesthesia 3. pt. has hardly any coexisting and disiabling illnesses 4. Recovery is expected to be quick, minimal specialized care after surgery 5. pt. or family can provide adequate postoperative care.

Preoperative Assessment-Pts. HX & preparation for Surgery

1. HX of present illness and reason for surgery -Past medical history medical conditions acute and chronic -previous hospitalizations and surgeries -ALLERGIES!!!! -Present Medications -Substance use 2. Review of Systems.

A client has been prescribed a fentanyl patch for pain control. The nurse understands that this patch should be replaced every

48-72 hours.

-Codeine -Hydrocodone with ibuprofen -Oxycodone with acetaminophen

According to the World Health Organization Three-Step Approach, if the nurse is caring for a patient reporting mild pain that persists after using full doses of step 1 medications, which medications can the nurse administer? Select all that apply.

Containing informed consent may be DELAYED IF

Adult client is under influence of mind altering drug such as narcotic or alcohol intoxication.

A home health nurse is visiting a client who has been taking the same dose of acetaminophen/hydrocodone for 2 months. To monitor for the presence of expected side effects of this medication, what should the nurse include in the assessment of the client?

Ask about the client's bowel pattern.

A preventative approach to pain relief with non-steroidal anti-inflammatory drugs (NSAIDs) means that the medication is given:

Before pain is experienced.

Informed consent if adult client is CONFUSED, UNCONCIOUS, or MENTALLY INCOMPENTANT

Client's spouse, nearest blood relative, or someone with durable power of attorney can provide informed consent.

Identify four MAJOR activities that nurses perform for all clients IMMEDIATELY before surgery

Conducting nursing assessment, providing pre-operative teaching, performing methods of physical preparation, administering medications, assisting with psychological preparation, and completing the surgical checklist.

Choose the most likely reason why a nurse should question the use of Demerol for pain management in an elderly patient? There is (are):

Decreased binding of meperidine by plasma protein.

Preoperative Assessment-Psychological Needs

Emotional state Level of understanding the surgical procedure, preoperative and postoperative instructions. Coping Strategies Support system Roles and responsibilities.

The advance nurse practitioner, who is treating a client diagnosed with neuropathic pain, decides to start adjuvant analgesic agent therapy. Which medication is appropriate for the nurse practitioner to prescribe?

Gabapentin

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

Handing instruments to the surgeon and assistants

The nurse is caring for a 4-month-old client on the pediatric unit following repair of an umbilical hernia repair. The infant just woke up from anesthesia and is crying. What would be appropriate initial interventions? Select all that apply.

Have the parent hold the infant in a rocking chair. Offer a pacifier. Use distraction with a stuffed toy

Which stage of anesthesia is referred to as surgical anesthesia?

III

When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose an example of chronic pain.

Intervertebral disk herniation

Preoperative Assessment-Cultural Needs

Language Particular customs related to surgery, privacy, disposal of body parts, and BLOOD TRANSFUSIONS.

A nurse is giving preoperative information to a client scheduled for outpatient surgery. What are recommended education guidelines? Select all that apply.

Notify the surgeon's office if a cold or infection develops before surgery. List allergies and be sure the operating staff is aware of these. Have someone available for transportation home after recovery from anesthesia.

Informed consent

Nurse can assist with any questions or concerns, but physician is responsible for getting informed consent (permission a client gives after an explanation of risks, benefits, and alternatives. *SIGNED form witnessed by nurse. (NURSES DUTY to make sure client understands, and that they witness ACTUAL patients signature and understanding in case of complications or future law suits arising since NURSES signature will also be on consent form.) *NURSES RESPONSIBILTY to make sure client has signed form, and that is in clients chart before the client goes to operating room.

A 60-year-old client who has diabetes had a below-knee amputation 1 week ago. The client asks, "Why does it still feel like my leg is attached, and why does it still hurt?" The nurse explains neuropathic pain in terms that are accessible to the client. The nurse should describe what pathophysiologic process?

The abnormal reorganization of the nervous system

The nurse is checking the informed consent for an older adult client who requires surgery and who has recently been diagnosed with Alzheimer disease. When obtaining informed consent, who is legally responsible for signing?

The client

"Let's talk about the medication you're giving and warning signs to be concerned about."

The hospice nurse is making a home visit to a patient with terminal cancer. The patient reports poor pain control when the spouse says, "I am giving such big doses of medication, I am afraid she is going to overdose if I give her more." Which response by the nurse is the most appropriate?

Slow rhythmic breathing

The nurse administered an oral analgesic to a patient complaining of a mild-to-moderate headache. Which activity would the nurse consider to help relieve the patient's discomfort until the analgesic takes effect?

Surgical Consent

pt. MUST sign a surgical consent form or operative permit. -form indicates that the client consents to the procedure-understands its risks and benefits as explained by the surgeon. NOTE-if pt. confused, unconscious, not mentally competent, or younger than 18 yrs. of age a guardian or parent must sign.

A nurse is caring for an infant who is postoperative following cardiac surgery. What is the most common postoperative complication found in this age group?

respiratory complications