Peri OP care

What is the role of the PACU nurse?

"The transition from anesthesia to recovery carries risks for potentially life-threatening complications as well as discomforts such as nausea and vomiting, and pain."

Preop teaching prevents post op complications

-consider the individual's coping style -make sure information is at the patient's general level of comprehension, education and cultural background. -involve the family -pain management -post op activities such as restrictions, will they go home etc. -medications Anti-embolism stockings Sequential compression devices Teaching: C&DB'ing with splinting and IS Teaching: Leg Exercises Teaching: Moving in Bed Pain Management Possible tubes/drain postoperatively When family will be able to visit after surgery Letting family know where to wait and how they will be notified

Eviseration

-total separation of the layers and protrusion of internal organs or viscera through the open wound -causes: same as dehiscence Treatment -call for help -cover with sterile NS sealed gauze/towels -keep moist -do not reinsert organs -keep in supine position with knees/hips bent -assessment/VS q. 5 min until MD arrive -prepare for surgery

Phases of surgery

1. Preoperative: begins when the decision to have surgery is made and ends when the client is transferred to the OR table 2. Intraoperative: begins when the client is on the OR table and ends when the patient is admitted to the PACU 3. Postoperative: begins with admission to the PACU and ends when healing is complete

Selection of anesthesia

• Client health problems • Type and duration of surgery, • Area of body surgery • NPO status • Emergent vs. elective • Pain management after procedure • Airway management/client position

A nurse is caring for a client who is to receive a Level 2 dysphasia diet due to a recent stroke. Which of the following dietary selections is the most appropriate? A. Turkey sandwich B. Poached eggs C. Peanut butter crackers D. Granola

B

A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. Pacing B. Reflecting C. Paraphrasing D. Restating

B

A nurse is caring for a school age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the child's arm B. Sit at eye level with the child C. Stand facing the child D. Stand with a relaxed posture

B

A nurse is assisting an anesthesiologist in the delivery of nitrous oxide by face mask to a client during the induction of anesthesia. Which of the following is the priority nursing action? A. Assess oxygen saturation B. Measure blood pressure C. Palpate pulse rate D. Check temperature

A

A nurse is caring for a client who is experiencing mild acute pain after spraining an ankle. Which of the following analgesics should the nurse expect to administer? a. Ketorolac b. Ketamine c. Meperidine d. Methadone

A

A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client's temperature is 39°C (102.2°F) orally. Which of the following actions should the nurse take? A. Inform the surgeon of the elevated temperature. B. Transfer the client to the preoperative unit. C. Apply ice packs to the groin. D. Encourage the client to increase intake of clear liquids.

A

A nurse is providing teaching for a client who has a new diagnosis of hypertension and a prescription for a low-sodium diet. Which of the following client statements indicates a need for further teaching? A. "I should select organic canned vegetables." B. "I need to read food labels when grocery shopping." C. "I will stop eating frozen dinners for lunch at work." D. "I know that deli meats are usually high in sodium."

A

In monitoring a client for post-operative complications, which of the following is an indication of a potential complication that warrants notifying the MD? A. Patient complaint of pain and visible swelling in calf B. Clear yellow urine output of 30ml/h C. Heart rate of 92 and BP of 100/64. D. A rectal temp of 99.6F.

A

The perioperative nurse has a numberof major responsibilities when a patient is admitted to a surgical unit or center before surgery. Which of the following is the most important function? A. Completes the preoperative assessment. B. Develops a plan of care. C. Verifies that the operative consent is signed. D. Provides psychological support.

A

Which of the following activities would the nurse carry out in the preoperative period for a client scheduled for surgery? A. Identify potential or actual health problems. B. Perform specialized procedures to assure safety. C. Assess client's responses to interventions. D. Intervene to prevent complications.

A

Which of the following is the most important initial nursing activity in the postoperative recovery area?A. Maintain patient safety (airway & circulation) B. Administer medications and fluids C. Assess level of pain D. Inspect the surgical site

A

A nurse is caring for several clients in an extended care facility. Which of the following clients is the highest priority to observe during meals? A. A client who has decreased vision B. A client who has Parkinson's disease C. A client who has poor dentition D. A client who has anorexia

B

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? • A. Assess the patient's pain • B. Assess the patient's vital signs • C. Check the rate of the IV infusion • D. Check the physician's postoperative orders

B

Medical power of attorney

A legal document signed by a person who is giving another individual the power to make health care decisions for the first person if he or she becomes incompetent, unconscious, or unable to make decisions for himself or herself. DPOA

The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient? • A. Blood administration • B. Restoring circulating volume • C. An EKG to check circulatory status • D. Return to surgery to check for internal bleeding

B

Elective surgery

A surgical procedure that may be scheduled in advance, is not an emergency, and is discretionary on the part of the physician and patient, you want the surgery

A nurse is performing dietary needs assessments for a group of clients. A blenderized liquid diet is appropriate for which of the following clients? Select all that apply. A. A client who has a wired job due to a motor vehicle crash B. A client who is 24 hr postoperative following temporomandibular joint repair C. A client who has difficulty chewing due to oral surgery D. A client who has hypercholesterolemia due to a coronary artery disease E. A client who is scheduled for a colonoscopy the next morning

A, B, C

A nurse is caring for a client who manifests indications of hypovolemia while in the PACU. Which of the following findings requires action by the nurse? (select all that apply) a. urine output less that 25 mL/hr b. hematocrit 53% c. BUN 24 mg/dL d. tenting of the skin over the sternum e. apical pulse rate 62/min

A, B, C, D

A nurse is reviewing the medical records of several clients in the postanesthesia care unit (PACU) to identify risk factors that can lead to postoperative complications. Which of the following clients are at risk for complications? (select all that apply) a. a client who has a WBC of 22,500/uL b. a client who uses an insulin pump c. a client who takes warfarin daily d. a client who has heart failure e. a client who has BMI of 26

A, B, C, D

A nurse is caring for a client who develops malignant hyperthermia. Which of the following actions should the nurse take? A. Infuse iced IV fluids B. Provide 100% oxygen C. Place the client on a cooling blanket D. Treat the complication while continuing surgery E. Administer IV dantrolene

A, B, C, E

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (select all that apply) a. encourage use of the incentive spirometer every 2 hr b. instruct the client to splint the incision when coughing and deep breathing c. reposition the client every 2 hr d. administer antibiotic therapy e. assist with early ambulation

A, B, C, E

A nurse providing preoperative teachingto a client who is to have abdominal surgery. Which of the following statements should the nurse make? (Select all that apply) A. "Take your heart medication with a sip of water before surgery." B. "Splint the abdominal incision with a pillow when coughing and deep breathing." C. "Bed rest is recommended for the first 48 hrs." D. "Antiembolism stockings are applied before surgery." E. "You may not eat solid foods up to 4 hr before surgery."

A, B, D

A nurse knows that she must obtaina signed informed consent for which of the following procedures? Select all that apply. A. Surgery to repair a fracture B. Turning a patient on their side C. Cystoscopy D. Insertion of a peripheral intravenous line E. Insertion of a foley catheter

A, C

A nurse is planning care for an older adult client who is receiving treatment for malnutrition. The client is scheduled for discharge to his home where he lives alone. Which of the following actions are appropriate to include in the plan of care? (Select all that apply.) A. Consult social services to arrange home meal delivery. B. Encourage the client to purchase nonperishable boxed meals. C. Advise the client to purchase frozen fruits and vegetables. D. Recommend drinking a supplement between meals. E. Educate the client on how to read nutrition labels.

A, C, D, E

Which of the following actions should the nurse take when using the communication technique of active listening?(Select all that apply) A. Use an open posture B. Write down what the client says to avoid forgetting details C. Establish and maintain eye contact D. Nod in agreement with the client throughout the conversation E. Respond positively when giving feedback

A, C, E

Barriers to informed consent

Age Education Illness Language/Interpreter Content and readability of consent form Timing of the discussion Amount of time allotted to the discussion Family issues -blood products need consent -pts can change their mind

Which of the following strategies should a nurse use to establish a helping relationship with the client? A. Make sure the communication is equally reciprocal between the nurse and the client B. Encourage the client to communicate his thoughts and feelings C. Give the nurse-client communication no time limits D. Allow communication to occur spontaneously throughout the nurse-client relationship

B

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which id the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 feet away from client's bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of micro-organism into the surgical wound. D. Keep a box of facial tissues nearby for the client to use during the dressing change.

C

A nurse is caring for a client who develops a systemic toxic reaction following a regional block. Which of the following actions should the nurse take? A. Monitor serum creatinine levels B. Provide airway support C. Turn the client to the right side D. Administer 0.9% sodium chloride 500mL IV bolus

B

A nurse is caring for a client who has multiple sclerosis and requires liquids with honey-like thickness. Which of the following foods can the client consume without adding a thickening agent? A. Ice cream B. Yogurt C. Buttermilk D. Cream of chicken soup

B

A nurse is caring for a client who is at high risk for aspiration. Which of the following is an appropriate nursing intervention? A. Give the client thin liquids. B. Instruct the client to tuck her chin when swallowing. C. Have the client use a straw. D. Encourage the client to lie down and rest after meals.

B

A nurse has prepared a sterile field for assisting a provider with a chest tube injection. Which of the following events should the nurse recognize as contaminating the sterile field. (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hour because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field

B, C, D

A nurse is assisting a client who has a prescription for a mechanical soft diet with food selections. Which of the following are appropriate selections by the client? Select all that apply. A. Dried prunes B. Ground turkey C. Mashed carrots D. Fresh strawberries E. Cottage cheese

B, C, E

A nurse is reviewing hand hygiene technique with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing hand washing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing

B, D

A nurse is caring for a client following an appendectomy. The nurse verifies the postoperative prescription, which reads "discontinue NPO status; advanced diet as tolerated. "Which of the following are appropriate for the nurse to offer the client? Select all that apply. A. Applesauce B. Chicken broth C. Sherbet D. Wheat toast E. Cranberry juice

B, E

A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce the risk of thrombus development? (Select all that apply.) A. Instruct the client not to use the Valsalva maneuver. B. Apply elastic stockings. C. Review laboratory values for total protein level. D. Place pillows under the client's knees and lower extremities. E. Assist the client to change position often.

B, E

A nurse at a clinic is talking with a client who has cancer and takes extended-release opioids twice daily. The client reports an increase in localized, achy pain over the last few days. How should the nurse document this increase in pain? a. Phantom limb pain b. Mixed pain c. Breakthrough pain d. Neuropathic pain

C (usually in connection with cancer) severe pain that erupts while a patient is already medicated with a long-acting painkiller.

pulmonary embolism (PE)

Blocking of a pulmonary artery due to a blood clot -gets a CT to diagnos this

A nurse administered midazolam IV bolus to a client before a procedure. His blood pressure is 86/40mmHg, and his pulse is 134/min. Which of the following IV medications should the nurse administer? A. Naloxone B. Morphine C. Flumazenil D. Atropine

C

A nurse is caring for a client who has been sitting in a chair for 3 hr. Which of the following problems is the client at risk for developing?A. Stasis of secretions B. Muscle atrophy C. Pressure ulcer D. Fecal impaction

C

A nurse is caring for a client who is on a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup

C

A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following client statements indicates that the client understands how to use the device? a. "I'll wait to use the device until it's absolutely necessary." b. "I'll be careful about pushing the button so I don't get an overdose." c. "I should tell the nurse if the pain doesn't stop after I use this device." d. "I will ask my son to push the dose button while I am sleeping."

C

A nurse is caring for a client who is transitioning to an oral diet following a partial laryngectomy. Which of the following actions by the nurse is appropriate?\ A. Request to have the client's oral medications provided in liquid form. B. Instruct the client to follow each bite of food with a drink of water. C. Encourage the client to tuck the chin when swallowing. D. Consult the dietician about providing the client with a thin liquid diet.

C

A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following should the nurse take? A. Decrease the client's fluid intake B. Apply pressure to the puncture site. C. Place the head of the bed flat D. Instruct the client to lie prone

C

In the first 24 hours postop following bowel surgery, the nurse gives priority to: A. Assessment of urine output and encouraging oral intake. B. Assessment for infection and changing wound dressing. C. Assessment of bowel function and controlling nausea. D. Assessment of breath sounds and encouraging deep breathing.

C

A nurse is assessing a client's laboratory values before surgery. Which of the following results should the nurse report to the provider? (Select all that apply) A. Potassium 3.9 mEq/L B. Sodium 145 mEq/L C. Creatinine 2.8 mg/dL D. Blood glucose 235 mg/dL E. WBC 17,850/mm3

C, D, E

A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make?(Select all that apply) A. You will do great! You just have to get used to it! B. Why are you worried about going home? C. Your daily routines will be different when you get home D. Tell me about you support system you'll have when you leave the hospital E. Let me tell you about a friend of mine with a colostomy who also enjoys swimming

C, D, E

A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? Select all that apply. a. Urinary inconinence b. Diarrhea c. Bradypnea d. Orthostatic hypotension e. Nausea

C, D, E

A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (Select all that apply.) A. Explain to the client the purpose of having the procedure. B. Inform the client of risks to having the procedure. C. Ensure the client understands information about the procedure. D. Witness the client signing the informed consent form. E. Determine if the client is capable of understanding the reason for the procedure.

C, D, E

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique. (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

C, D, E

A nurse is planning care for a client who has mechanical fixation of the jaw following a motorcyclecrash. Which of the following actions are appropriate to include in the plan of care? (Select all that apply.) A. Thicken the client's liquids to honey consistency. B. Educate the client about the use of a nasogastric tube. C. Assist the client to use a straw to drink liquids. D. Ensure that the client receives ground meats. E. Encourage the client's intake of fluids between meals.

C, E

Legal Aspects: Informed Consent

Communication between a patient and provider results in a patient authorizing a procedure Anesthesia, surgery, general admission Who is responsible for obtaining the signature? physician must speak to the pt then physician or nurse can have it signed

RISK FOR PERIOPERATIVE POSITIONING INJURY R/T SURGICAL PROCEDURE

• Comfortable position as possible • Operative field fully exposed • Vascular supply must not be obstructed • Respirations should not be impeded • Nerves must be protected from undue pressure. • Pay special attention to elderly, obese, with physical deformities • Failure to position correctly = impaired skin integrity, paresthesia, paralysis

Be aware of latex allergies

• Exposure can be percutaneously, mucosally, parenterally & via inhalation • Symptoms can vary from contact dermatitis to anaphylaxis • Symptoms in an anesthetized patient include flushing, facial swelling, urticaria, bronchospasm, hypotension & cardiac arrest • Be aware of equipment that contains latex, including tourniquets, catheters, surgical gowns, boots and drapes

A nurse has removed a sterile pack form its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closet to the body B. The right side flap C. The left side flap D. The flap farthest from the body

D

A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? a. compare and contrast the peripheral pulses b. apply a warm blanket c. assess dressings d. place the client in a lateral position

D

A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include? a. Most clients exaggerate their level of pain. b. Pain must have an identifiable source to justify the use of opioids. c. Objective data are essential in assessing pain. d. Pain is whatever the client says it is.

D

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following is the body's priority energy source? A. Fat B. Protein C. Glycogen D. Carbohydrates

D

A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take? A. Encourage the client to void after preoperative medication administration. B. Administer antibiotics 2 hr prior to surgical incision. C. Remove hair using a manual razor. D. Remove nail polish on fingers and toes.

D

All clients having surgery have a degree of risk associated with the surgery. The nurse would evaluate which of the following client-related factors as contributing to a high degree of risk associated with surgery? A. Institution reputation. B. Average nutritional status. C. Little likelihood of complications. D. History of cardiac and pulmonary disease.

D

The effectiveness of preoperative teaching will be most negatively influenced by: A. The presence of a significant other during the teaching session. B. Concern regarding the amount of insurance reimbursement. C. Prior experience with surgery in family members. D. Pain unrelieved by medication.

D

Ethical aspects of surgery

Does the benefit of the surgery outweigh the risk? Privacy Trainees/Students/Teaching hospitals The patient's wishes/family Medical teams opinions on family decisions

Review of safety measures

Ensure client is wearing proper identification, blood & allergy bands Always wash hands Ask client to explain in his/her own words what surgical procedure is being done and why - If explanation is not consistent with documentation, notify surgeon to speak with client Ensure client is not asked to sign consent form after preoperative drugs have been given Ensure surgical site is marked (W/A) Skin prep and colon prep completed (W/A) Ensure NPO status Medication reconciliation Ensure labs are drawn as needed

RISK FOR IMBALANCED BODY TEMPERATURE- HYPOTHERMIA R/T SURGERY

Factors that contribute: • Low temperature in the OR • Cold IV infusions • Inhalation of cold gases • Open body cavity • Decreased muscle activity • Advanced age • Medications such as vasodilators How to minimize: • Prevent exposure of nonsurgical body parts • Use head coverings and warm blankets • Warm IV fluids and anesthetic agents If hypothermic - warming must be accomplished gradually!!

Post Op Dietary Intake

• GI system needs to be "ready" • Dependent on type of surgery and anesthesia • How should a diet progress in the post-operative period? • NPO • Cl liq (anything you can see through) • Full liq • DAT (diet as tolerated) pt that gets meds such as narcotics for pain also get docusate bc they get constipated on these meds -6/8 hours they must pee after foley is removed

Nursing Management in the PACU • What is your First priority? • What is your Second Priority? • What is your Third Priority?.....in caring for Mrs. P • Immediately after receiving report and assessing your three major priorities, what other post-operative assessments should you be performing? • Discuss amongst yourselves specifically what you would assess for the top three priorities as well as other assessments.

First- airway!!!! second- breathing third- circulation -assess neurological status as well ABC -there is a score to move on from PACU

Ongoing nursing Interventions for Mrs. P.

• Teach-self care • Promote GI status • Abd. Assessment qs • Monitor NGT to LCS • Provide diet &fluids once BS • Clear liquids to full liquids to soft foods and then prescribed diet • Assess tolerance to diet • Encourage early ambulation • Provide wound care as ordered • Participate in D/C planning • Teaching • Diet, activity, medications, when to call MD • Schedule F-U care • Ensure home care / other support services are in place

Safety

Identify the patient! How??? Informed Consent (pt aware of what is being done once someone has talked to them) & Advanced Directives (pt says what will happen if something happened) OR checklist: Allergies Vital signs Last po intake Medications Anesthesia MD Visit Time Out

RISK FOR INFECTION R/T SURGERY

How do we prevent infection during surgery? • Maintain SURGICAL ASEPSIS ! Remember: • All objects on sterile field must be sterile • Sterile objects become unsterile when touched by unsterile objects or when exposed to airborne microorganisms for prolonged time • Objects below waist or table level or out of vision = Unsterile • Moisture passing through a sterile object draws microorganisms from unsterile surfaces rendering it unsterile • The 1-inch margin at each edge of a sterile field = unsterile • The skin cannot be sterilized and so is unsterile Maintaining surgical asepsis requires conscientiousness, alertness, and honesty!

RISK FOR IMPAIRED GAS EXCHANGE R/T ANESTHESIA & SMOKING HISTORY

INADEQUATE VENTILATION, AIRWAY OCCLUSION, INADVERTENT INTUBATION OF ESOPHAGUS • Factors that can compromise gas exchange: • Anesthesia = respiratory depression & loss of gag/cough reflexes • Neuromuscular agents = weak or paralyzed respiratory muscles • N/V = aspiration • Patient position = ineffective lung expansion All of these can lead to patient hypoxia! • Nursing interventions • Close monitoring of: - oxygenation status - Pulse oximetry - Capnography -Peripheral perfusion Often job of Often job of circulating RN

What interventions can the nurse implement to prevent cardio-vascular complications?

Increased risk for blood clots when you sit for a long time so walking can prevent this or you put the SCDs on (sequential compression device) or a pulmonary embolism can result from a dvt also can use thrombolytics so they dont have so much risk and thin blood out -ted stockings are suppose to b tight

Maintaining a sterile field

• Use sterile drapes/towels • Use sterile field to place sterile supplies • Drape equipment prior to use • Keep drapes dry and out of contact with non-sterile objects • Utilize sterile technique while adding or removing supplies from sterile fields

Malignant hyperthermia

Inherited disease that causes a rapid rise in body temperature and severe muscle contractions when the affected person receives general anesthesia (volatile anesthetics/succinylcholine) Related to altered mechanisms of calcium function in skeletal muscle cells Signs & Symptoms • Organ failure • Rhabdo • Hyperkalemia Treatment Complications • Hypermetabolism causing a build up of lactic acid in the body! Dantrolene (Ryanodex): Treats spasticity

Cultural aspects of surgery

Jehovah's Witnesses Do not stereotype a particular culture based on assumed cultural norms But........ Consider responses to pain, diet, & home remedies as well! Are there language barriers?

Transfer

Last final checks: Consents History & Assessment Teaching Preparations Medications Documentation!!!

Nursing assessment

Medical History and RISKS!! Surgical History (including problems with anesthesia) Allergies & Current medications (make sure allergy band is on) Last PO intake -want empty stomach so you don't throw up then aspirate Height & Weight Vitals Signs -know all baselines in case there is a difference in the OR Smoking, alcohol and drug use Possibility of pregnancy Systems assessment including emotional response Testing results

Post-op pneumonia

Lung sounds q. 4 -get them out of bed

MOLST

Medical document that specifies which treatments will be allowed during end of life care

Medications- anesthesia

• What is anesthesia?• "lack of or no sensation" Goals? • Amnesia (don't remember) • Analgesia (no pain) • Reflexes (not moving) • Relaxation • Manipulation • General (Anesthesia that affects the whole body and induces a loss of consciousness.) • Regional (Regional anesthesia blocks feeling (usually deeper like childbirth) • Monitored (Conscious sedation) • Local (Local anesthesia is used to numb a specific part of the body and lasts for a short time (like a cavity)

Mrs. p labs Na= 135 K+= 3.2- low Cl+108 Gluc= 226 WBC= 9 Hgb= 9.8 12-18 Hct= 29.4 30-40 Low Plt= 174 PT 14.1 INR 1.4

Most IV potassium in an hour is 10

Postoperative nursing care

• You are working in the PACU when Mrs. P. is brought out of the OR following a colon resection with anastomosis of the descending & sigmoid colon. What are your responsibilities for Mrs. P. while in the PACU?

Administering blood products

Must be sure of signed consent to receive blood/blood products! • Obtain sample for typing • Sample is "cross-matched" (run it in the lab and match it to another blood that is the same • "Type & Cross Match" -nurses can't get consent from pts to get blood products H&H -low when a lot of drainage is coming out

What interventions can the nurse implement to prevent gastro-intestinal complications?

NPO or NGtube

Toradol (ketorolac)

NSAID (non-steroidal anti inflammatory)

Jehovah's Witness

No blood products should be used -can reinfuse what came out of them bc it never stopped but not everyone accepts that

Preoperative assessment

Nutrition Blood sugar -careful bc they shouldn't take this because they are not eating, rather have a 200bs than 80 Smoking Medications -drugs that could cause extra bleeding and cardiac risks

Breathing

PAIN prevents deep breathing! Teach splinting Coughing and deep breathing exercises! What interventions can you as the nurse implement to prevent the respiratory complications of atelectasis and pneumonia? Tell them to use the incentive spirometer Aerobika you breathe out

Malignant hyperthermia management

•Have a MH Cart stocked and readily available •Recognize the symptoms EARLY •Administer Dantrolene Sodium ASAP as ordered •Discontinue the anesthetic immediately •100% oxygen •Cooling blankets •Ice Packs; bags and buckets of ice •Cold NS IVF's to lavage stomach, rectum, bladder and open cavities •Follow the Malignant Hyperthermia Association of the US treatment protocol Circulating nurse -watching over everything and making sure it is right

Pre-operative checklist

Patient clothing Cosmetics / Nail Polish Patient jewelry -Wedding Ring Remove dentures May keep in hearing aides (see hospital policy) Glasses may stay on if per hospital protocol but may need to be removed Secure valuables

Ongoing nursing Interventions for Mrs. P. • Safety: • Call light, emesis basin, tissues, ice chips etc... within reach • Bed in low position and locked with 3 side rails up • Monitor VS and Oxygen saturation as ordered • Monitor Cardiovascular status as per unit protocol • Encourage IS, C&DB'ing q 1-2 hours WA • Ensure splinting is done • Encourage activity as tolerated • Teach & encourage leg exercises • Use support stockings or SCDs • Communicate with family /SO's if patient allows • Monitor for infection • Administer antibiotics on time

Provide for adequate PAIN management!! • Assess at least every 4 hours • Reassess within one hour after pain intervention • Document rating, location, quality & other characteristics• Consider both pharmacological & non-pharmacological measures • PCA • Opioids • Music • Distraction • Massage • Heat / Ice • Monitor UO closely • Assess I&O status • Mobilization of fluids

Constructive surgery

Restores function lost or reduced as result of congenital anomalies

Risk for aspiration related to N/V

• How to prevent: (no single way to prevent) • -NPO status preoperatively • -Use new anesthetics which have reduced incidence of N/V • -Administer antiemetic pre- or intraoperative • -Administer antacids to neutralize stomach acids • -Administer a histamine-2 receptor antagonist such as -cimetidine, ranitidine, famotidine to decrease gastric acid production. • -Administer PPI postoperatively (pantoprazole) • If it does occur: Work as a team! • Turn patient to side • Raise HOB if not able to turn to side • Utilize suction to remove vomitus • Support oxygenation PATENT PATENT AIRWAY AIRWAY NEEDED!!

General principles of preoperative sterility

• Keep sterile supplies dry and unopened • "Lip" solutions after initial use • Maintain cleanliness of surgical suite • Check package expiration dates to verify sterility • Don't use solutions that were already opened or wet

Prevention of malignant hyperthermia

• MH risk assessment during preop interview • Caffeine intolerance • H/O MH (family history) • Prior complications r/t anesthesia • Ensure during surgery continuous monitoring of: • ECG • ET CO2 • Pulse Oximeter • Temperature

Preoperative phase

Safety Nursing Assessment Medications Teaching Advocacy Complications

Complications of general anesthesia

• Malignant Hyperthermia • Overdose • Unrecognized hypoventilation • Post intubation complications -sore throat, laryngeal edema, hoarseness, vocal cord issues, - Nausea/vomiting, corneal abrasions, chipped teeth, mouth trauma

Emergency surgery

Surgery done at once to save life or function

Administering blood products cont.

• Need order to administer!!! (Even if "type & cross match" is already ordered) • TWO RN'S MUST SIGN TOGETHER TO CONFIRM: • Right patient (blood band ID) • Right blood type • Right unit # • Right donor # • Expiration date of blood product Check with faculty policy -start slow to see first then speed it up Run blood fast if H&H is low -if a pt is having a blood reaction stop it and call the doctor

Common Complications in the PACU:

• Neurological • Respiratory (feel like you can't breathe and anxiety can occur) • Cardiovascular • Thermoregulation (usually hypothermic bc the OR is cold but when you warm them up their vessels dilate so BP may drop) • Gastrointestinal (no bowel sounds for pt that had surgery in the abdomen and you slow the new diet, wait for bowel sounds to come back) • Genitourinary (may need to b straight cath cause you can retain urine) • Skin Integrity • Pain

Surgical errors

The Joint Commission The American Medical Association The Perioperative Nursing Association The World Health Organization -failure to get informed consent -wrong side operation -puncture things -leaving surgical instruments in body

Drain types

• Passive (rely on gravity to drain): • Penrose • T-tube • Uresil • Active (relies on external force): • Open - Salem sump (NGT) • Closed - JP drain, Hemovac

Safety

• Preoperative checklist • Time out • Surgical Scrub • Surgical Attire • Patient mobility & positioning • Be sure to review hand washing, surgical asepsis, and sterile fields. • Resistant organisms

Mrs. P 76 y.o. H/O Type 2 DM, CAD, HTN & PVD 50 pack yr. smoker 2 weeks ago underwent a colonoscopy from which a biopsy was done. It came back positive for Stage 2 colon cancer. She is scheduled for a colon resection tomorrow at 10:00am. Medications: Glucophage XR 1000mg/evening, ASA EC 325mg/day, Plavix 75mg/day, Toprol XL 100mg/day. She has advanced directives (LW & DPOA for healthcare) NKDA Risk factors?

Think airway bc she is a smoker and may have trouble coming off oxygen -glucophage, stop aspirin ahead of time, placid is also a blood thinner -ask if she took meds, when she ate last, family -she has a durable power of attorney so we would want that in the hospital

PCA

patient controlled analgesia -can get oversedated When would a patient transition to oral pain medication? -when they have bowel sounds back bc during surgery ur stomach slows down also make sure they dont have N/V

PCEA

patient controlled epidural analgesia

Mrs. P gets the go ahead to return to nursing unit! Mrs. P. 's vital signs are stable and she is breathing on her own without difficulty. She has a positive gag reflex and is sitting up in bed! She is alert and oriented times three. Her husband is currently in visiting. You have called report to the nurse who will be receiving Mrs. P. You let Mrs. P. and her husband know that she will be moving to the nursing unit , call transport, and await help for the transfer of your patient.

Think....As the nurse admitting Mrs. P. to yourmedical-surgical unit, what immediate nursing interventions do you think will need to be done? -Check for pain right away -vitals -neuro status -if she had bowel surgery make sure the incision site is good and if it was saturated with drainage and put a new one on -head to toe assessment

Time out

The surgical time out is the last part of the protocol and is performed in the operating room, immediately before the planned procedure is initiated. (Also with bedside procedures.)

Preoperative phase responsibilities

Verify completion of paperwork: Informed consent(s) -make sure they sign before giving them medication so they are fully aware Anesthesia, procedure, blood Pre-operative checklist Ensure correct surgical site -Mark when applicable as per hospital policy If outpatient procedure- ensure ride home Complete pre-operative teaching for postop care to prevent complications Provide emotional support Physical Preparation of patient -Skin preparation Cleansing Hair removal Preparing GI Tract Ensure NPO status Colon Cleansing Antiembolism Stockings Have patient void / Catheterization Start an intravenous infusion Administer premedication if applicable (on call to OR)

Palliative surgery

To relieve or reduce intensity of illness; is not curative.. may still be dying

Ablative surgery

To remove a diseased body part

Urgent surgery

surgery that is not an emergency, but must be done within a reasonably short time frame to preserve health

BE AWARE OF BLOOD & BODY FLUIDS EXPOSURE

Use: • Goggles • Fluid-protectant shields • Waterproof apron • Sleeve protectors • Double Glove & change periodically as they can leak • Extreme caution with sharps

• What routes do we use for pain management? • How do we decide what to give the patient? • What assessment tools can we use? • If pain is not well controlled what happens?

Usually IV or SQ right after bc bowel sounds aren't present yet Pain scale but if they don't talk you could use a chart If pain isnt controlled they won't take deep breathes and get up

Nursing diagnoses for intraoperative patient

• Risk for aspiration • Impaired skin integrity: Actual or risk?? • Risk for perioperative positioning injury • Risk for imbalanced body temperature • Ineffective tissue perfusion • Risk for Deficient fluid volume • Risk for infection • Risk for hypoventilation

Intraoperative phase

• Safety • Medications • Teaching • Advocacy • Complications Surgical team • Surgeon • Anesthesiologist • Scrub Nurse • Circulating Nurse • Surgical tech • Nurse Anesthetist

Post-op Report on Mrs. P. • General anesthesia w/o any signs of MH. • Surgery was tolerated well-no complications • Questionable allergy to tape/bandaids • Received 2 liters of LR & one unit of PRBCs in the OR • EBL - 500ml (estimated blood loss) • Currently positive 860mL • She has a JP drain at abd. incision site with minimal serosanguinous drainage, a large bulky dressing on surgical site is D/I, an NG tube to LCS with 180 mL bilious drainage, & a urinary catheter which was just emptied for 480 mL -clear yellow urine. • Two PIVs - 18g in left AC and 20g in left forearm. Left AC has D5.45NS infusing at 125 mL/hour.

Vitals: HR 96 & regular, BP 110/68, Temp. 97.4 RR 10 & shallow, O2 Sat. 90% on 4l of oxygen via NC. Lungs are diminished throughout Pain is 4/10...she was medicated with 2mg morphine 20 minutes ago. She states this pain level is tolerable. Still a bit groggy but arousable to verbal stimuli. Oriented X3 and able to follow commands. Abd. Tender to touch, soft/nondistended; no BS

Teaching

What to expect in the OR What to expect in recovery How to prevent post-operative complications

A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following hysterectomy. Which of the following actions should the nurse perform first? a. assess bowel sounds b. administer antiemetic medication c. restart prescribed IV fluids d. insert a prescribed nasogastric tube

a

A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? SATA A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Hypertension

a, b, d, e

Atelectasis

collapsed lung; incomplete expansion of alveoli which leads to pneumonia

DNR/DNI

do not resuscitate/do not intubate

Diagnostic surgery

done to provide data for a diagnosis of the problem

Hypovalemia

low blood volume