348 Week 3: Caring for the Surgical Patient

When does the preoperative phase begin and end?

Begins when the decision for surgery is made and ends when the patient is transferred to the OR.

Primary goal of the preoperative assessment

Identify patient risks that could affect surgical outcomes.

Two patient identifiers used before surgery

Name and date of birth.

What physical assessments are important preoperatively?

Cardiovascular, respiratory, renal status, skin condition, nutritional status/NPO duration, mobility/ROM, and pain.

What aspects of the patient's medical history are especially important before surgery?

Previous surgeries, anesthesia experiences, and substance use including tobacco, alcohol, and illicit drugs.

Which allergies are important when considering propofol?

Egg and soybean oil allergies.

What food allergies can indicate increased risk for latex sensitivity?

Banana and kiwi allergies.

Does a shellfish allergy automatically mean the patient cannot receive contrast media?

No. It may indicate iodine sensitivity, but further assessment is required.

Why is obstructive sleep apnea (OSA) a major perioperative concern?

Increased risk for airway obstruction and hypoxemia after anesthesia.

What postoperative complications are associated with diabetes?

Delayed wound healing, infection, and gastroparesis.

Why are older adults more susceptible to anesthetic agents?

Decreased hepatic/renal function and physiologic reserve, along with fragile skin

What should the nurse do if a patient has a genetic history of malignant hyperthermia?

Immediately communicate it to the surgical team.

Who is responsible for explaining the surgery, risks, benefits, consequences, and alternatives?

The provider/surgeon.

What is the nurse's primary role regarding the consent signature?

Witness the patient's signature after acknowledging that the patient understands the procedure.

Verify: The patient is legally capable, mentally competent, and not under the influence of sedatives.

What should the nurse do if the patient says, "I don't understand what the surgeon explained"?

Notify the provider/surgeon so the procedure can be explained further.

What should be used when a patient has a language barrier?

A trained medical interpreter—not a family member

What does the Joint Commission's Universal Protocol prevent?

Wrong-person, wrong-procedure, and wrong-site surgery.

3 major components of the Universal Protocol

Verification, site marking, and timeout.

Who marks the surgical site?

The surgeon, involving the patient when possible.

When does the surgical timeout occur?

Immediately before the incision.

Surgical timeout: a short, mandatory pause taken by the entire operating room team immediately before an incision or invasive procedure begins to verify critical patient and safety details

What should the nurse do if a patient is experiencing severe anxiety or panic before surgery?

Use nonpharmacological interventions such as distraction or imagery and notify the provider because sedative premedication may be indicated.

General anesthesia causes

CNS depression, loss of responsiveness, and muscle relaxation.

What major nursing intervention is associated with general anesthesia?

Airway management, including intubation.

Spinal anesthesia

Injection of anesthetic into the cerebrospinal fluid/subarachnoid space.

Monitor for spinal headache caused by CSF leakage. (Have pt lay flat)

Epidural anesthesia injection site

Into the epidural space, usually in the thoracic or lumbar region.

What serious complication can occur with epidural anesthesia if the dura is punctured?

High spinal anesthesia, which can cause respiratory arrest and hypotension.

What is a nerve/field block used for?

Specific operative sites or extremities, such as hernia or dental procedures.

Nerve/Field block: An injection of local anesthetic placed directly next to a specific major nerve or cluster of nerves

Signs of local anesthetic toxicity

Metallic taste, tremors, seizures, and tachycardia.

What is moderate sedation/MAC?

The patient is relaxed but arousable to verbal stimuli and maintains their own airway

RN monitoring: 1:1 monitoring by an ACLS-certified RN.

Reversal agent for fentanyl and morphine

Naloxone (Narcan)

What are midazolam and diazepam used for?

Amnesia and anxiety.

What reverses benzodiazepines such as midazolam and diazepam?

Flumazenil

What does succinylcholine cause?

Total flaccid paralysis.

Requires mechanical ventiltion

What is atropine used for during anesthesia?

Decreases secretions and reduces the risk of bradycardia.

DONT use if pt has glaucoma

What are ondansetron and metoclopramide used for?

Preventing nausea/vomiting; metoclopramide also enhances gastric emptying.

What is the priority during Phase I PACU recovery?

Airway patency, ventilation, and circulation.

1:1 level of care is required during Phase I

Phase II recovery PACU

Consciousness returns to baseline and pulmonary, cardiac, and renal function stabilize.

Phase III recovery PACU

Ongoing care in an extended observation or inpatient unit.

Aldrete Score

Determines readiness for discharge from the PACU. Ranges from 0-10

Required for PACU discharge→ score of 7–10.

Aldrete score letters

“A" - Activity.

"R"- Respiration.

"C" - Circulation. (BP within 20% of baseline.)

"C" - Consciousness.

"O"- Oxygen saturation. (Greater than 92% on room air.)

What triggers malignant hyperthermia?

Certain inhaled anesthetic gases or succinylcholine.

First sign→ increased CO2

Other early signs occur with malignant hyperthermia

Tachycardia, muscle rigidity, and tachypnea.

Late sign of malignant hyperthermia

Extremely high temperature, potentially up to 107°F/41.7°C.

What medication is the priority treatment for malignant hyperthermia

IV dantrolene.

What oxygen treatment is used during malignant hyperthermia?

100% oxygen.

What cooling interventions are used for malignant hyperthermia

Iced 0.9% NaCl, cooling blankets, and ice to the axillae and groin.

What does stridor/sternal retraction indicate?

Laryngospasm or airway obstruction.

Nursing Intervention: Perform head-tilt/chin-lift and immediately notify the anesthesiologist.

2 major postoperative respiratory complications

Atelectasis and pneumonia.

How often should an incentive spirometer be used

Every 1–2 hours.

What additional interventions help prevent postoperative respiratory complications?

Coughing/deep breathing and splinting the incision with a pillow.

What are major postoperative cardiovascular complications?

VTE/DVT and hypovolemic shock.

What interventions help prevent postoperative VTE/DVT?

Early ambulation, SCDs, leg exercises, and prescribed anticoagulants.

What is a major postoperative GI complication?

Paralytic ileus.

Nurse should monitor bowel sounds and passage of flatus.

When should the patient remain NPO according to the study guide?

Until the gag reflex returns.

Dehiscence & Evisceration

Dehiscence: Separation of a surgical wound.

Evisceration: Protrusion of internal organs through a surgical incision.

What is the FIRST thing the nurse should do when evisceration occurs?

Stay with the patient and call for help.

Place a sterile dressing moistened with sterile saline

DONT PUSH ORGAN BACK IN ABDOMEN

What position should a patient with evisceration be placed in?

Low-Fowler's with hips and knees bent.

What should the nurse do after treating the eviscerated wound?

Notify the provider immediately.

PRIORITY intervention for a patient experiencing postoperative nausea and vomiting

Turn the patient to a lateral position to prevent aspiration. →

THEN assess bowel sounds and administer prescribed antiemetics.

Why are older adults at increased risk for hypothermia

Decreased subcutaneous fat.

Complications: contribute to coagulopathy and dysrhythmias.

What mental-status change should the nurse monitor for in older postoperative patients?

Acute confusion or delirium.

Contributions: Anesthesia, hypoxia, and electrolyte imbalances.

Why should special care be taken with an older adult's skin?

Their skin is fragile and easily abraded.

Use paper tape to help prevent