ADH2 exam 1: Pre/Intra/Post Op phases

How would you classify Emergent, Urgent, and Elective categories of surgery?

1. Emergent: life-threatening—need to operate within minutes

   • bullet wound to chest/ lungs

2. Urgent: need to operate within few hours

   • save a limb

3. Elective: by choice

   • knee replacement

What are some risk factors to consider before surgery? (11)

1. Sleep apnea

   • airway obstx

   • O2 desaturation

2. Pregnant

   • risk to baby w/ anesthesia

3. CVD

   • HF, MI, HTN, dysrhythmias

4. Respiratory Disease

   • COPD, Pneumonia, asthma

5. DM

   • altered blood glucose

   • delayed healling

   • infx

6. Liver disease

   • altered medication metabolism

   • increasked risk for bleeding

7. Kidney disease

   • altered elimination + medication excretion

8. Immune system disorder

   • immunocompormised

9. Coagulation defect

   • high risk bleeding

10. Malnutrition

11. Obesity

What kind of things would you document as the nurse during pre-op phase? (3)

1. Informed consent

2. Nurse signs as witness

   • nurse can clarify but cant add additional info.

3. Nurse decides if client is capable

Who is considered a capable patient thats able to consent to a surgical procedure? (3)

1. 18+ yrs old; UNLESS and emancipated minor!!

2. Mentally capable of understanding risks and benefits/ alternative procedure

3. Free from medications that influence decision making (opiates: fentanyl)

Informed consent consists of: (7)

1. Consent for procedure itself

2. Name of surgeon to perform surgery

3. Benefits

4. risks

5. alternative

6. Consent for anesthesia

7. consent for blood administration

What to check for during Time out pre-op: (3)

1. Correct client

2. Correct procedure

3. Correct surgical site (mark it)

What does a nurse assess for during pre-operative phase? (6)

1. medical/ surgical hx

2. anesthesia tolerance

3. medication usage: complimentary/ alternative

   • aka prescribed meds vs OTC meds & herbs

4. Allergies

   • meds, latex, contrast agents (iodine), food (soybean oil/eggs = no propofol))

5. BASELINE!!!

   • full vitals and heat to toe assessment

6. VTE risk

   • wear stockings!

How would a nurse prepare the pt for surgery? (10)

1. Verify informed consent complete

2. NPO pre-procedure

3. Skin prep PRN

4. Bowel prep PRN

5. Remove jewelry

   • dentures

   • prosthetics

   • makeup, nail polish

   • glasses

6. Prevent hypothermia

   • give warm blanket

7. Establish IV PRN

8. Minimize anxiety

9. VTE prevention

10. Encourage provider to put med. orders in for post-op before hand

    • restraints

    • pain meds

    • O2 orders

Time frame for NPO pre-operation solid food vs liquid:

Solid: 6 hrs pre

Liquid: 2 hrs pre

Intraoperative phase—Time out again! : (7)

• to cover our own butts!

1. Correct pt

2. Correct procedure

3. Correct surgical site

4. Correct surgeon

5. Correct position

   • make sure to do b4 anesthesia bc body will be dead weight

6. Correct equipment

7. Correct imaging studies

   • ex: X-rays

Intra-op phase: 3 types of anesthesia:

1. General

2. Regional

3. Local

Whatas the difference between all the anesthesias? (3)

General knocks you completely unconscious

• ex: heart surgery

Regional blocks sensation in large area of body but ur usually awake for it

• ex: nerve block to numb a limb or epidural for birth

Local numbs a small specific area only

• ex: wisdom teeth/ stitches

How are general anesthesia administered? (2)

1. Volatile aka inhaled

   • ex: nitrous oxide (laughing gas)

2. IV

   a. opioids

   b. propofol/ ketamine

   c. Muscle relaxers—IV

   • ex: succinycholine

What is common during intra-operative phase when hooking pt up to anesthesia?

airway support!!

• intubation

Complications for GENERAL anesthesia? (4)

1. hypoxia

   • low O2 to tissues

2. hypotension

3. HTN

4. malignant hyperthermia!

   • core temp skyrockets

What are some examples of regional anesthesia? (4)

1. Spinal

   • injected into spinal fluid to numb waist down

2. Epidural

   • injected around spinal cord for birthing

3. Caudal

   • admin near tailbone in children for surgeries

4. Nerve blocks

   • numbs a limb/region

What should you do to head of bed after giving spinal anesthesia?

Keep HOB flat to avoid headaches

Complications of regional anesthesia: (2)

1. Hypotension

2. Respiratory paralysis

What would you use local anesthesia for? (3)

• dental procedures

• mole removal

• getting stitches

ex: lidocaine

What would moderate sedation be used for? (4)

1. colonoscopy

2. resetting fractured bone

3. dental surgeries

4. biopsies

WHY would someone use moderate sedation?

• for procedures that are less invasive and short and the pt is calm and pain free

  • also doesn’t need to be fully unconscious—meaning they can breathe for themselves still and doesn’t need to be intubated

Name the priority assessment in Post-Op phase: (5)

1. Airway/Breathing

2. Circulation

3. Vitals

4. Response to anesthesia

5. Monitor I/O

Stridor vs Snoring breath sounds:

• Stridor: physical obstx of airway (grape)

  • pt can die!

• Snoring: usually tongue is in the way

  • can reposition pt

means POOR air exchange!!

What to look for during assessment of airway/breathing in post-op phase: (5)

1. artificial airway left in place until pt can maintain their own airway

2. auscultate breath sounds—stridor/ snoring

3. O2 saturation is >95% compared to pre-op

4. suction secretions PRN

5. educate pt ASAP on:

   • cough

   • deep breathing

   • IS!!

Post op phase assess for circulation: (4)

1. look for bleeding

2. look for hyper/hypovolemia

3. report changes in BP to provider

4. give warm blanket after temp is obtained

Post op phase assess vital signs: (3)

1. obtain q15min until stable

2. report BP changes

3. give warm blanket after temp is secured

Post op phase response to anesthesia: (3)

1. monitor LOC

2. assess for mvmt/ sensation

3. admin antiemetic for N/V PRN

Monitoring I/O in post-op phase of assessments: (3)

1. give isotonic fluids (0.9% NS) to maintain adequate cardiac output and I/O balance

2. monitor output from drainage devices

   • catheter

   • NG tube

3. observe urine (color)

When discharging a pt from PACU, what would you make sure of? (7)

1. Aldrete score 8-10

   • Activity

   • Consciousness

   • Circulation

   • Respiration

   • O2 saturation

   • each is 0-2 points

2. VSS

   • “vital signs stable”

3. No bleeding

4. Reflex present

5. Minimal/ absent N/V

6. Wound drainage minimal

7. Urine output >30mL/hr