MS Unit 3: Peri-Op
What are some pre-op considerations/risks for *The Bariatric Patient*?
*INFECTION*During surgery, fatty tissues are especially susceptible to infection. -Wound infections are more common in obese pts. -Obesity also ↑risk of technical/mechanical problems r/t surgery (ex. Dehiscence) *DIFFICULT CARE* Care may be more challenging to provide due to possible restrictions of movement r/t excessive weight *↑❤demand* (est. additional 25 miles of blood vessels needed for q30lbs of excess weight) *↓PULMONARY RESERVE* Tend to have shallow respirations when supine (↑risk for hypoventilation & postop pulmonary issues) -*Sleep apnea* or *physical characteristics that impede intubation* (short thick necks, large tongues, recessed chins, redundant pharyngeal tissue - ↑O2 demand
*Principles of Surgical Asepsis*: The CDC, AORN, and APIC all support the ban of surgical personnel having which of the following, and why? a. Hair extensions b. Visible Tattoos c. Body Piercings d. Artificial Nails e. Wedding bans
*d.* actually prohibited for HCW in general, as studies show that they harbor microorganisms and can cause nosocomial infections. Short, natural nails are encouraged, instead.
Adherence to AORN-recommended practices and TJC's National Patient Safety Goals are crucial to protect patients from injury. What is included on this list, and therefore, one of the major roles of the perioperative nurse?
-Identify pt's correctly -Improve staff communication -Use medicines safely -Use alarms safely -Prevent infection -Identify pt safety risks -Prevent mistakes in surgery (AORN: Association of preOperative Registered Nurses. TJC: The Joint Commission)
What are the dangers of having a high blood sugar for an operative patient?
-Increases infection and *⚠Delays wound healing* ↔ We should be worried about this!
What are some immediate *Preoperative Nursing Interventions*?
-Pt changes into gown, mouth inspected, jewelry removed, valuables stored in a secure place or given to family member -Preanesthetic medication is administered -Pt is transported to presurgical area -Family needs are attended to
*Categories of Surgery Based on Urgency*: a. Name, b. Classification, c. Indications, and d. 1 example of each: 1. Emergent 2. Urgent 3. Required 4. Elective 5. Optional
1. *Emergent* b.Pt requires immediate attention; disorder may be life-threatening. c. Without delay. d. Fx skull, extensive burns, bladder/intestinal obstruction 2. *Urgent* b. requires prompt attention. c. Within 24-30hrs. d. Acute gallbladder infection, kidney stones 3. *Required* b. Pt needs to have it. c. Plant w/in a few weeks/months. d. Thyroid disorders, cataracts 4. *Elective* b. pt should have it. c. Failure to have surgery not catastrophic. d. Repair of scars, simple hernia 5. *Optional* b. decision rests w/pt. c. Personal preference. d. Cosmetic surgery
*Informed Consent*: 1. How should it be obtained? 2. What information should be included in the form?
1. Autonomously, voluntary (noncoerced) and in writing. 2. Explanation of procedure & it's risks, benefits, alternatives, complications, disfigurements, disabilities, and removal of body parts, as well as what to expect in the early/late postop periods. Instructions that the pt may withdraw consent at any time. Offer to answer questions about procedure. Statement informing pt if the protocol differs from customary procedure.
List at least 5 circumstances in which it is legally mandated to obtain informed consent from a patient.
1. Invasive procedures (ex. surgical incisions, biopsy, cytoscopy, or paracentesis) 2. Procedures requiring sedation/anesthesia 3. Nonsurgical procedure that carries more than a slight risk to the pt (ex. arteriography) 4. Procedures involving radiation 5. Blood product administration
If the surgery is not performed as an emergency, how will a patient be instructed to prepare their skin prior to procedure? What about body hair?
1. SKIN: Most health care facilities/ambulatory surgical centers have implemented antiseptic skin cleansing protocols. 2. HAIR: Generally, hair is not removed preoperatively unless the hair at/around the incision site is likely to interfere w/operation. If hair must be removed, electric clippers are used before transferring pt to the OR.
List 5 typical preoperative medications given and why they might be given
1. Sedative/Tranquilizers 2. Anticholinergics (helps cause excess fluids to dry up) 3. Narcotic Analgesics (to reduce pain if it's present) 4. H2 Blockers/PPIs (to decrease gastric acids/decrease risk of stress ulcer) 5. Prophylactic antibiotics
1. What is the purpose of withholding food and fluid before surgery, (ex. fasting 8hrs night before surgery)? 2. Why are dentures or plates removed from the mouth immediately prior to surgery?
1. To prevent aspiration. 2. If left in mouth, these items could easily fall to the back of the throat during induction of anesthesia and cause respiratory obstruction.
*Informed Consent*: 3. Who's responsibility is it to provide a clear and simple explanation of what the surgery will entail, prior to the pt giving consent? 4. Which technique can promote the nurses' understanding of the patients' comprehension of the surgery they are about to have? 5. The nurse ascertains that the consent form has been signed before ___________, because consent is not valid if it's obtained afterwards. Why?
3. The surgeon must explain first. The nurse can clarify, after. If pt has additional questions, the nurse notifies surgeon. 4. Asking pt to describe the surgery they are about to have in their own words. 5. Before administering psychoactive premedication, because otherwise, pt is under the influence of meds that can affect judgement and decision-making capacity.
*Preoperative Care*: Patient education to prevent respiratory issues?
"Turn, Cough, Deep breaths": and how to use incentive spirometer q2h.
Explain the following statement: "The underlying principle that guides post-op care for older adult patients, is that geriatric patients have less physiologic reserve than younger patients"
The capability of an organ to carry out its activity under stress, or return to normal functioning after a disturbance in its equilibrium, decreases as we age.
The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk? a. Anemia b. Atelectasis c. Peripheral edema d. Dehydration
b. Atelectasis occurs when the postoperative client fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the client loses a significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the client is most at risk for atelectasis
*1.* Identify: Includes outpatient, same-day, or short-stay surgery that does not require an overnight hospital stay. 2. What does an increase in type *1.* surgeries mean for patients?
Ambulatory surgery. The increasing use of ambulatory outpatient, or short-stay surgery means that patients leave the hospital sooner and recuperate quicker.
Before nonemergent surgery can be performed, confirmation of which decision is legally necessary? Why?
Informed Consent- pt's autonomous decision about whether to undergo a surgical procedure. Voluntary & written consent from pt is necessary to protect the pt from unsanctioned surgery, and to protect surgeon from claims of unauthorized operation or battery.
*Name! That! Medication!* Could interfere with wound healing and inflammatory process after surgery
Corticosteroids
The goal of the *Preoperative Period* for the patient is to be as healthy as possible. What efforts are made to achieve this goal?
Every attempt is made to assess for and address risk factors that may contribute to postop complications & delay recovery. A plan of action is designed so that potential complications are averted. Before any Tx is initiated, a health Hx is obtained, physical exam is performed (VS, baseline is established for future comparison). RN asks abt allergies, comorbidities, genetic considerations, prescription, OTC & herbal suppls., activity & functional level is determined.
*Name! That! Medication!* (or herbal supplement) Interaction w/anesthetics could increase pt's risk of bleeding during intra- and post-op periods; should be discontinued in anticipation of elective surgery. (Duration of discontinuation will be determined by surgeon)
Meds: Anticoagulants [ex. Warfarin (Coumadin)] OTC: Platelet Aggregation Inhibitor (Aspirin) Herbs: Gingko biloba, Garlic, Ginseng.
When/why are enemas prescribed preoperatively for patients undergoing surgery? What else might be prescribed in addition, and why?
Not commonly prescribed unless pt is undergoing abdominal or pelvic surgery. A cleansing enema or laxative may be prescribed the evening before surgery & may be repeated morning of, to allow satisfactory visualization of the surgical site, and to prevent trauma to the intestine or contamination of the peritoneum by fecal material. -In addition, antibiotics may be prescribed to reduce intestinal flora.
Explain the principles of *surgical asepsis* of the OR in regards to the following:* a. Surgical items/tools b. Floors/surfaces of OR? c. Gowns worn by surgical personnel
a. *All* surgical supplies, instruments, needles, sutures, dressings, gloves, covers, solutions that may come into contact with surgical wound/exposed tissues MUST be sterilized before use b. Cleaned between cases w/detergent, soap, water or germicide. c. Considered sterile in the front, from chest to the level of sterile field. Sleeves are sterile from 2in above the elbow to the stockinette cuff
*Identify the Members of the Surgical Team that are NURSES❤*: a. Trained to deliver anesthesia & to monitor the pt's condition during surgery b. Coordinates & documents pt care in OR. Plans/Assists w/pt positioning, preps site of surgery, manages surgical specimens, anticipates needs of surgical team. c. Plays a hands-on role in surgical procedures: may help control bleeding, handle tissue, suture, & take action to maintain homeostasis. d. Scrubs & dons sterile surgical attire, preps instruments/supplies, hands instruments to surgeon during procedure
a. Certified Registered Nurse Anesthetist (CRNA) b. Circulating Nurse (Super important role! Does not scrub in) c. Registered Nurse First Assistant (RFNA) (Super lucrative role! Additional education/certification after BSN) d. Scrub Nurse (LPN or RN in scrub role) (Nowadays, often filled by a Surg Tech - certified from trade school in 12mo & trained on job)
a. What is totally or partially relinquished by the patient when entering the operating room? b. To prevent complications, promote high-quality pt outcomes, and control iatrogenic & individual risks, collaborative effects from staff of *which departments* are implemented in the professional standards of care? c. Which member of the surgical team acts as the pt's advocate?
a. Consciousness or full awareness, mobility, protective biological functions, personal control. b. Staff from depts. of anesthesia, nursing, and surgery. c. The OR nurse is the patient's advocate while surgery proceeds.
*Types/Classifications of Surgery*: Each of the following describes *purpose* of which type of surgery? Give an example of each surgery. a. Explorative b. Ablation (removal of body tissue) c. Restore function and correct deformities d. Improving physical appearance e. Increased comfort f. Replacement of diseased organ g. Replacement/Correction
a. Diagnostic Surgery (ex. biopsy, laparoscopy) b. Curative Surgery (ex. removal of malignant tumor or inflamed appendix) c. Reconstructive Surgery (ex. Mamoplasty) d. Cosmetic Surgery (ex. facelift) e. Palliative Surgery (not curative, but ↑ quality of life) (ex. debulking a tumor or removing dysfunctional gallbladder) f. Transplant Surgery (ex. heart transplant) g. Rehabilitative Surgery (ex. join replacement)
Explain *Preadmission Testing (PAT)*: a. What is it? b. When does it occur? c. What is involved? d. How is post-op care involved?
a. Diagnostic testing b. Performed before admission to the hospital c. Initiates the nursing process and focuses on admission data: demographics, drug/alcohol use, health Hx, medications, allergies, nutritional status, psychosocial/spiritual beliefs/needs, other pertinent info for surgery (consent forms, Dx/Lab tests) d. Discharge planning begins by assessing pt's need for postoperative care
Optimal nutrition is an essential factor in avoiding surgical complications, so it is included during Preoperative Assessment. If a pt has a deficiency in the following nutrients, what is a possible outcome? a. Protein b. Water c. Vitamin C d. Zinc e. Vitamin K
a. Impaired/delayed wound healing, ↓skin & wound strength, ↑ wound infection b. S&S/complications of dehydration (poor skin turgor, ↑pulse, weight loss) c. Impaired/delayed wound healing, increased risk of infection d. Impaired immune response e. Prolonged prothrombin time. Hematomas contributing to impaired healing & predisposition to wound infections.
*Identify the Members of the Surgical Team*: a. The individual undergoing the surgery b. Physician trained to deliver anesthesia and to monitor the pt's condition during surgery c. Physician qualified to perform surgery d. Scrubs & dons sterile surgical attire, preps instruments/supplies, hands instruments to surgeon during procedure
a. Patient b. Anesthesiologist (Physician) or CRNA c. Surgeon d. Surgical Technician (or LPN/RN in scrub role)
*Informed Consent*: Explain regulations/policy for the following situations: a. Patient is under 18 years old or mentally incapable. b. Emergency situation requiring lifesaving measures c. Patient is non-English speaking d. Patient is hearing-impaired, blind, or has a disability that affects vision/hearing
a. Permission is otherwise obtained from a surrogate, who most often is a responsible family member (preferably next of kin) or legal guardian. b. May be necessary for surgeon to operate as a lifesaving measure w/o pt consent, *However,* every effort must be made to contact the pt's family (phone, fax, any means possible) c. Necessary to provide consent (written & verbal) in a language that is understandable to pt. A trained medical interpreter may be consulted. d. Alternative forms of communication (Braille, large print, sign interpreter) is necessary.
a. Why is it important for the nurse to consider *Psychosocial Factors* of the patient prior to surgery? b. What could contribute to pt's fear, prior to surgery? c. How might fear look in pt's, prior to surgery?
a. Psychological distress directly influences body functioning so it's important to identify the anxiety and help ease it b. Fear of the unknown, lack of control, death, anesthesia, pain, complications, cancer, prior surgical experience that didn't go well c. obvious or veiled, normal/abnormal... different in everyone: pt may ask repeated questions, regardless of info already shared w/them. Others may withdraw, deliberately avoiding communication by reading, watching TV, talking about trivialities.
*Pre-Op Gerontologic Considerations*: a. Which body system complications are the leading causes of postop morbidity and mortality in older adults? Why? b. Why are precautions taken when moving an older adult (ex. to/from OR)? c. Is a lightweight cotton blanket an appropriate cover when moving an older patient to/from OR? Why/why not? d. Education/Communication considerations for this population?
a. Respiratory & Cardiac complications (↓Cardiac reserves & compromised Respiratory function) b. Fragile, thin skin that is easily abraded. c. Yes, but ↓subQ fat makes older adults more susceptible to temp. △, so we must still ask them if they feel warm enough, never assume. d. Include caregiver/family whenever possible. May need more time/multiple explanations to understand & retain info/restrictions/expectations
To help decrease microbes, the surgical area is divided into three zones. Describe them: a. Unrestricted Zone b. Semirestricted Zone c. Restricted Zone
a. Street clothes are allowed b. Attire consists of scrub clothes & caps c. Scrub clothes, shoe covers, caps, and masks are worn. (The surgeons & other surgical team members wear additional sterile clothing & protective devices during surgery)
*The Surgical Environment....*: a. ..is know for its ____ appearance and ____ temperature. b. ..is located behind double doors, situated in a location that is central to........, and access is limited to .......... personnel? c. ..typically requires warming of the patient, because...? it begins during...? d. ..has special air filtration devices to......?
a. stark & cool/cold b. suite is central to all supporting services (pathology, x-ray, lab)....only authorized, appropriately clad personnel have access c. normothermia has been linked to improved pt outcomes (enhanced healing, ↓infection rates, ↓malaise). May begin in preop phase & continue d. Screens out contaminating particles, dust, and pollutants.
a. What is latex? b. What can cause some people to develop an allergy to latex? c. A latex allergy can manifest as a....? d. How do most hospital products avoid latex allergy reactions?
a. the milky fluid from the rubber tree, is found in many products. b. Repeated exposure can cause an immune response to the protein c. rash, asthma, or anaphylactic shock. d. Most products today are latex-free. *However*, even the rubber stopper on a med vial can trigger a 💀reaction following injection from that vial.
*Members of the Surgical Team* Whose responsibility is it to...: a. Protect the pt's safety & health by monitoring the activities of surgical team, aseptic technique, and implementing fire safety precautions b. Leads a team debriefing session following completion of surgery, to identify potential problems w/postop care of pt/areas for improvement c. Practices directly under the surgeon. Must have thorough understanding of A&P and must be able to handle any emergency situation in the OR
a., b. = Circulating Registered Nurse (aka Circulator) c. Registered Nurse First Assistant (RNFA) (scope of practice depends on each state's NPA)
A 76-year-old client had surgery for an abdominal hernia. The PACU nurse observes that the client is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply. a. Reorient the client. b. Assess for hypoxia. c. Assess urine output. d. Administer opioid pain medication per orders. e. Ambulate the client. f. Apply wrist restraints.
a., b., c. Rationale: The nurse should provide reassurance and reorient the client as needed. Hypoxia and urinary retention may cause acute confusion in the older adults postoperatively, so it would be appropriate for the nurse to assess for hypoxia and urine output. Opioid pain medications may cause further confusion; the physician should be consulted about the type and dosage of the pain medication. Ambulating the client may present safety concerns, especially if the client is bleeding or hypoxic.
There may be an association with an allergy to latex, if the patient states that they are allergic to which of the following (SATA): a. banana b. avocado c. peanuts d. soy e. kiwi f. milk products g. balloons
a., b., e., g. (these products contain proteins similar to latex) *pt's may have early manifestations of latex allergy and be unaware of this.* If they are allergic to the above, there may be an association w/an allergy to latex
The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply. a. Tachypnea b. Wheezes c. Crackles d. Afebrile e. Chills
a., c.,e. Pneumonia is characterized by fever, chills, tachycardia, tachypnea, and crackles. Cough may or may not be present. Wheezing is not an expected finding of pneumonia.
The nurse is caring for a client in the postanesthesia care unit (PACU). The client has the following vital signs: pulse 115, respirations 20, oral temperature 97.2°F, blood pressure 84/50. What should the nurse do first? a. Notify the physician. b. Increase rate of IV fluids. c. Assess for bleeding. d. Review the client's preoperative vital signs.
c. The client is tachycardic with low blood pressure; thus assessing for hemorrhage is the priority action. While the physician may need to be notified, the nurse needs to be able to communicate a complete picture of the client, which would include bleeding, when calling the physician. The rate of IV fluid administration should be adjusted according to a physician order. The nurse should review prior vital signs but only after the immediate threat of hemorrhage is assessed.
Explain the principles of *surgical asepsis* of the OR in regards to the following:* a. Surgical items/tools b. Floors/surfaces of OR? c. Gowns worn by surgical personnel d. The movement of the surgical team to diff. areas e. Tear or puncture of the drape f. Area of the pt's skin larger than requiring exposure during surgery, and remainder of pt's body
d. *Always from sterile to sterile areas* (or from unsterile to unsterile). Scrubbed ppl & sterile items contact only sterile areas, Circulating nurses/unsterile items contact only unsterile areas. e. If the tear/puncture permits access to an unsterile surface underneath the drape, it renders the area unsterile. Such a drape must be replaced. f. Area is meticulously cleaned and an antiseptic solution is applied. The remainder of pt's body is covered w/sterile drapes.
