NR 463 Pre, Intra, Post Op
An operating room nurse is positioning a client on the operating room table to prevent the client's extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to prevent which of the following? -An increase in pulse rate -A drop in blood pressure -Nerve and muscle damage -Muscle fatigue in the extremities
-Nerve and muscle damage
what is the preparation of day of surgery?
-No cosmetics -No nail polish (pulse ox) -Valuables w/family members or in safe -Dentures, contacts, prostheses removed & given to family -identification and allergy bands on wrist -void before surgery **before med administration
what nursing implementations could you do to help with respiratory complications?
-O2 therapy -Monitor pulse ox & respiratory rate/depth -Encourage deep breathing to facilitate gas exchange & promote waking up -Pain control -TCDB/IS -Ambulation
what will you check with fluid balance in the PACU?
Input Urinary output Estimated blood loss (EBL)
what labs are concerns before going into surgery?
K+ (cardiac dysrhythmias) -BP/P with fluid deficit
what will you assess with the GI in the PACU?
Nausea & Vomiting Bowel Sounds? Flatus? Hiccups
what is the role of the preoperative nurse
Patient advocate throughout surgical experience
A postoperative client asks a nurse why it is so important to deep breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to: Pneumonia Fluid imbalance Pulmonary embolism Carbon dioxide retention
Pneumonia -begins with atelectasis which is due to the lack of breathing of the patient -first sign of atelectasis is a low grade fever
what are the conditions that make you at higher risk for surgery regarding respiratory system?
Receive general anesthesia Are older Smoke tobacco Have lung disease Are obese Undergo thoracic, airway, or abdominal surgery
why is hypoventilation a a concern post op?
Signs and symptoms of ↓ rate of effort, hypoxemia, and ↑ PaCO2
what is the unrestricted area of surgery?
Street clothes & scrubs Changing /Locker room Pre-Op Holding Nurses' station
What is exploratory surgery?
Surgical examination to determine the nature or extent of a disease (e.g., laparotomy)
what is included in the patient prep education?
TCDB/IS - Why so important? Frequent vital signs Early ambulation Anticipated tubes, drains, monitoring devices, SCDs/Ted hose; other special equipment I & O, U/O Pain Management Surgery specific info -CABG, Hip replacement
what is the intraoperative care for general anesthesia?
-IV (TIVA) -Inhalation -Adjuncts *Opioids *Benzodiazepines *Neuromuscular blocking agents *Antiemetics -Endotracheal tube vs. LMA (laryngeal mask airway)
why is atelectasis a concern post op?
-Most common cause of postoperative hypoxemia -Bronchial obstruction from retained secretions or decreased respiratory excursion
what is the restricted area of surgery?
Controlled environment - 3 areas Designed to minimize spread of infection Allows smooth flow of patients, personnel, instruments & equipment
A preoperative client expresses anxiety to a nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? -"If it's any help, everyone is nervous before surgery." -"I will be happy to explain the entire surgical procedure to you." -"Can you share with me what you've been told about the surgery?" -"Let me tell you about the care you'll receive after surgery and the amount of pain to anticipate."
"Can you share with me what you've been told about the surgery?"
A nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse determines that the client needs additional teaching if the client states: -"Aspirin can cause bleeding after surgery." -"Aspirin can cause my ability to clot to be abnormal." -"I need to continue to take the aspirin until the day of surgery." -"I need to check with my physician about the need to stop aspirin before the scheduled surgery."
"I need to continue to take the aspirin until the day of surgery." -aspirin should generally be stopped within 1 week of surgery but it is determined by the physician
why is pulmonary edema a concern post op?
-Accumulation of fluids in alveoli -Fluid overload or left ventricular failure -Crackles, decreased compliance, or infiltrates on x-ray
Elderly patient considerations with anesthesia
-Anesthetic drugs should be carefully titrated. -Communication issues (Vision/Hearing) -Risk from tape, electrodes, and warming/cooling blankets -Positioning (Osteoporosis, Arthritis) -Perioperative hypothermia
A nurse receives a telephone call from the postanesthesia care unit stating that the client is being transferred to the surgical unit. The nurse plans to do which of the following first on arrival of the client? -Assess the patency of the airway. -Check tubes or drains for patency. -Check the dressing to assess for bleeding. -Assess the vital signs to compare with preoperative measurements.
-Assess the patency of the airway.
what are you concerned with for pre op in regards to their nervous system?
-Cognitive function -ability to answer questions -follow commands, weakness -speech or sensory issues -vision or hearing loss -hx of stroke, SCI.
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. -Contact the surgeon -Instruct the client to remain quiet. -Prepare the client for wound closure. -Document the findings and actions taken. -Place a sterile dressing and ice packs over the wound. -Place the client in a supine position without a pillow under the head.
-Contact the surgeon -Instruct the client to remain quiet. -Prepare the client for wound closure. -Document the findings and actions taken.
A nurse in the preoperative holding unit administers a dose of scopolamine to a client scheduled for surgery. The nurse tells the client to expect which side effect of the medication? -Excessive urination -Diaphoresis -Dry mouth -Pupillary constriction
-Diaphoresis -pupillary dilation
The nurse is preparing a preoperative client for transfer to the operating room. The nurse should take which of the following actions in the care of this client at this time? -Ensure that the client has voided. -Administer all the daily medications. -Have the client practice postoperative breathing exercises. -Verify that the client has not eaten for the last 24 hours.
-Ensure that the client has voided.
what is the role of the scrub nurse/ tech- sterile?
-Follows designated scrub procedure -Gowned and gloved in sterile attire -Prepares instrument table -Passes instruments to surgeon
what are you concerned with for pre op in regards to their cardiac system?
-History of cardiac problems -cardiac meds -pacemaker/ICD -cardiac surgery -problems clotting or bleeding
what are the post op cardiovascular problems?
-Hypotension -Hypertension -Heart failure -Dysrhythmias -VTE/PE
A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which appropriate action in the care of this client? -Obtain a court order for the surgery -Send the client to surgery without the consent form being signed -Have the hospital chaplain sign the informed consent immediately -Obtain a telephone consent from a family member, following agency protocol
-Obtain a telephone consent from a family member, following agency protocol
what are the pre operative tasks a nurse must perform?
-Obtain health information. -Determine expectations. -Provide and clarify information on procedure. -Assess emotional state and readiness
what are the different regional local anesthesia types?
-Peripheral nerve block -IV regional nerve block (Bier block) -Spinal anesthesia -Epidural anesthesia -Pain ball (On-Q pump)
what is the semi restricted area of surgery?
-Peripheral support areas and corridors w/authorized personnel -Surgical attire & covers for head & facial hair
what is the role of the circulating nurse- unsterile?
-Prepares room with the team -Not scrubbed, gowned, or gloved -Remains in unsterile field -Documents, gathers supplies
what needs to happen during the transfer from PACU to other floor
-Provide verbal report to receiving nurse. -During transport, take care of IV lines, drains, dressings, and traction devices. -Receiving nurse obtains vital signs and compares with PACU report.
what is the patient preparation for surgery?
-Transfer patient to operating table *Patient transfer or staff transfer -Safety precautions *Straps across patient *Wheels locked- Watch all the lines! *Application of monitoring devices ***EKG ***BP cuff ***Pulse ox ***Perioperative nerve monitoring (spine patient, leg surgery etc) ***BIS (prevent anesthesia awareness)
A nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which of the following parameters most carefully during the next hour? -Urinary output of 20mL/hr -Temperature of 37.6 C (99.6 F) -Blood pressure of 100/70 mmHg -Serous drainage on the surgical dressing
-Urinary output of 20mL/hr
what other problems can occur in the OR?
-cardiac -hemorrhage -malignant hyperthermia -anesthesia awareness
what are the interventions that you can do for abdominal distention?
-check for renal failure -bladder scan -palpate -bed pan -fluid increase to help stimulate
what are you concerned about with obese or malnourished patients?
-check their albumin levels -need to consider their healing abilities *deficient in vitamin A,C, and B complex which are necessary in healing
what are the neurologic problems after surgery?
-emergency delirium -waking up restlessness, agitation, disorientation, thrashing and shouting -delayed emergence -commonly caused by prolonged drug action
what medical conditions are we concerned about with surgical procedures?
-heart failure -Liver failure -kidney problems -autoimmune disorders *steroid usage -muscular *mobility, arthritis, pain -menstrual *pregnancy test, when their last period was
what are you concerned with for pre op in regards to their integumentary system?
-history of pressure ulcer -carefully assess and document any skin break down **if you don't have it documented, it is assumed to be our fault
what care steps do we need to take when the patient is in pre op holding?
-review charts -meet and assess patient -education- any last questions? -patient has proper ID band? -consent -reassure/meds if anxious
What is included in the time out during surgery?
-right patient -right procedure -right location -right equipment -right diagnostic data -antibiotics
What medication would you give the patient to help with hiccups?
-thorazine -baclofen
what are you concerned with for pre op in regards to their renal system?
-voiding problems after surgery UTI
How long does a sterile scrub take?
5 minute scrub
how many weeks is recommended to quit smoking before surgery?
6 weeks before procedure is ideal
what is the best intervention top help with the patients GI system?
Ambulation!
what are the nursing diagnosis with respiratory complications?
Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Risk for aspiration...PREVENTION? Potential complication: Hypoxemia Potential complication: Pneumonia Potential complication: Atelectasis AIRWAY, AIRWAY AIRWAY !!!
While in the PACU, the patient's blood pressure drops from an admission pressure of 126/82 to 106/78 with a pulse change of 70 to 94. The nurse administers oxygen and then: A. Increases the rate of the IV fluids. B. Notifies the anesthesia care provider. C. Performs neurovascular checks on the lower extremities. D. Uses a cardiac monitor to assess the patient's heart rhythm.
A. Increases the rate of the IV fluids.
what is the most important nursing care concern in the PACU?
ABC's -airway -breathing: pulse ox, RR, WOB -Circulation: cap refill, pulses, vital signs, color, temp, LOC, Urine output
During admission of the patient to the holding area or operating room before surgery, the perioperative nurse must: A. Verify the patient's understanding of the risks of surgery. B. Ensure the patient's identity with a formal identification process. C. Prepare the skin by scrubbing the surgical site with an antimicrobial agent. D. Perform a preoperative assessment with a patient history and physical examination.
B. Ensure the patient's identity with a formal identification process.
A patient becomes restless and agitated in the postanesthesia care unit (PACU) as he begins to regain consciousness. The first action the nurse should take is: A. Turn the patient to a lateral position. B. Orient the patient and tell him that the surgery is over. C. Administer the ordered postoperative pain medication. D. Check the patient's oxygen saturation with pulse oximetry.
D. Check the patient's oxygen saturation with pulse oximetry.
what is the treatment for malignant hyperthermia?
Dantrolene -A very large amount
what are the cardiac nursing diagnosis?
Decreased CO FVD FVE Ineffective peripheral tissue perfusion Activity intolerance Potential complication: Hypovolemic shock Potential complication: VTE
A nurse in a surgical unit receives a postoperative client from the postanesthesia care unit. After the initial assessment of the client, the nurse should plan to continue with postoperative assessment activities: -Every hour for 2 hours, and then every 4 hours as needed -Every 30 minutes for the first hour, every hour for 2 hours, and then every 4 hours as needed -Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed -Every 5 minutes for the first half-hour, every 15 minutes for 2 hours, every 30 minutes for 4 hours, and then every hour as needed
Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed
what nursing implementation should you perform for cardiac problems after surgery?
Treatment of hypotension.....How? -Hypertension -Address and eliminate cause of SNS stimulation. -Analgesics, voiding, correction of respiratory problems -Antihypertensives -Heart Failure *Diuretics -Dysrhythmia *Treat identifiable causes
what are the different types of anesthesia?
Types of anesthesia General anesthesia Induction routine Anesthesia Induction video Local anesthesia Regional anesthesia Monitored Anesthesia Care (conscious sedation)
what is it called when the incision is no longer connected?
Wound dehiscence
what is it called when the incision has intestines coming through the wound?
Wound evisceration
if a patient is unconscious, is consent assumed?
YES
will you assess pain in the PACU?
YES -P,Q,R,S,T -onset -location -quality -intensity -duration -instigating and alleviating factors
How would you like the incision to look?
approximated clean edges pink
what is the nurses role with the informed consent?
as the nurse you can witness the signature
Discharge from PACU should look like what?
assess their -muscle activity -breathing -consciousness -circulation (AP) -SpO2
respiratory complications
atelectasis pneumonia -prevention: cough, incentive spirometer -decrease RR
why are they at increased risk for infection with diabetes?
bacteria thrives in a sugar environment
what age groups are you concerned about with surgery?
children elderly
do you administer insulin before surgery?
generally injectables are given but not oral -ask the physician to clarify
what question should you ask a patient before surgery about malignant hyperthermia?
has anyone in your family died during surgery?
what is the risk of a patient with addison's disease?
if you stop their steroids, they could go into shock
what is malignant hyperthermia?
inherited hyper metabolism of skeletal muscle resulting in alter control of intracellular Ca -increased influx of calcium is the cause** -causes a contraction of all the skeletal muscles
what is a grouping pad used for?
it is used when cauterizing the patient to prevent damage from burning
what is a anaphylactic reaction?
most severe form of an allergic reaction. Can lead to life-threatening pulmonary and circulatory complications. -Etiology: anesthetics, antibiotics, blood products, plasma expanders -S/sx: masked by general anesthesia
what does PACU stand for?
post anesthesia care unit
what devices should you be using after surgery?
pulse ox EKG BP CO2 monitoring-- RR
who obtains the informed consent?
the physician will need to explain the procedure, the risks and benefit, and consented voluntarily
what is used to prepare the surgical site?
they use betadine to prep the patient -they would use chlorhexidine if the patient has an allergy
what is the nursing responsibility during surgery?
to be the advocate to the patient -the needs of the patient determine the type of care that you provide
what is the five W of a fever?
wind(1-3d) - respiratory distress syndroe water(3-5d)- UTI walking(4-8d)- thrombophlebitis, DVT, PE wound infection(5-7d)- infected incision wonder drugs (anytime)
