NURS 230 Quiz 2

perioperative nursing

o Covers before (pre), during (intra), and after (post)
o Use perioperative standards
o Teamwork and collaboration
o Advocacy for patient and family
o Cost containment
o Patient condition is always changing

when is a mistake most likely to happen?

during transfers

Although surgeries are classified as major or minor, any procedure can be considered?

major from the perspective of the patient and/or the family

major surgery

extensive reconstruction or great risk

minor surgery

Minimal alteration or risk

surgery urgency - elective

patient's choice, not essential

surgery urgency - urgent

necessary

surgery purpose

Diagnostic, ablative, palliative, reconstructive/restorative, procurement for transplant, constructive, cosmetic

a colon resection to remove a malignant tumor is?

major in seriousness, urgent in urgency, and ablative in purpose

(in many instances, the classifications intersect; urgent procedures are major in seriousness)

Frequently, the same procedure is performed for different reasons on different patients. For example, a gastrectomy may be performed as an ___________ procedure to resect a bleeding ulcer or as an _________ procedure to remove a malignant tumor. Knowing the classifications assists in planning appropriate perioperative care.

emergency, urgent

major surgery examples are -

coronary artery bypass, colon resection, resection of lung lobe.

minor surgery examples are -

cataract, tooth extraction, facial plastic surgery.

elective surgery examples are -

facial plastic surgery, breast reconstruction.

urgent surgery examples are -

excision of cancerous tumor, removal of gallstones

emergent surgery examples are -

repair of perforated appendix, traumatic amputation.

diagnostic surgery examples are -

surgical exploration; exploratory laparotomy, breast mass biopsy.

Ablative

excision or removal; amputation, removal of appendix.

palliative

relieves or reduces intensity of disease symptoms, does not produce cure; colostomy, debridement of necrotic tissue.

reconstructive/restorative

restores function or appearance; scar revision.

Procurement for transplant

removal of organs/tissues; kidney, heart, liver

constructive

restores function lost; repair of cleft palate

cosmetic

improve personal appearance; rhinoplasty. (normally non medically necessary)

effects of surgical outcomes are ?

o Smoking: greater difficulty clearing airway of mucus, more likely to develop pneumonia, slower wound healing, increased infection risk (delay in oxygen reaching cells)

o Age: very young or very old due to immature or declining physiological status, temperature control, dehydration, comorbidities

o Nutrition: protein or vitamin deficiency, fluid

o Obesity: ventilatory and cardiac function diminished, postop atelectasis, pneumonia, other comorbidities, poor wound healing, wound infection, dehiscence, evisceration

o Obstructive sleep apnea (OSA): oxygen desaturation, difficulty with sedatives, analgesics or anesthesia due to impaired airway

o Immunosuppression: increased risk for infection

o Risk for blood clotting

o Fluid or electrolyte imbalance

potential negative outcomes of surgery

o Fluid and electrolyte imbalance: delays healing, increases risk of infection

o Postoperative nausea and vomiting (PONV): pulmonary aspiration, dehydration, arrhythmias, dehiscence

o Venous thromboembolism (VTE): is a never event post knee or hip surgery

o Airway complications: pulmonary embolus; higher risk if long surgery, cancer patient, > 60, dehydration, known clotting disorder, obesity, horomone-replacement therapy or estrogen contraceptives.

o Most common post surgically: pneumonia (bc they are immobile, anesthesia, don't take deep breaths bc it hurts)

Perioperative Communication

hand-off

Poor ______________ control increases risk for wound infection and mortality

glucose

pressure injury prevention

Positioning, pressure-relieving surfaces
~easing fear of pain when trying to mobilize

Extrinsic pressure injury risks

temperature, friction, shearing, moisture.

OR pressure injury risks

length of surgery, position during surgery, devices used, anesthetic agents, intraoperative hemodynamics.

Intrinsic pressure injury risks

altered nutrition, decreased mobility, older age, decreased mental status, infection, incontinence, impaired sensory perception, diabetes, obesity.

when transitioning a patient to a different area of care the nurse wants to know what?

Patient identification

Type of anesthesia received

Name of the procedure performed

Location and number of drains and dressings

Estimated blood loss

Names and amounts of fluids received

Vital signs

Oxygen saturation

Urinary output

a bad hand-off leads to -

medical error

Postoperatively, the nurse instructs the patient to perform leg exercises every hour to:

A.maintain muscle tone.
B.assess range of motion.
C.exercise fatigued muscles.
D.increase venous return.

D

(postoperative exercises help to prevent pulmonary and vascular complications. encourage patients to perform leg exercises at least every hour while awake. exercise may be contraindicated in an extremity with a vascular repair or realignment of fractured bones and torn cartilage)

Pre-Surgery General Assessment:

o What are the patient's expectations? Perceptions? Knowledge?
o Advance directive (lets us know what the patient wants when they no longer can make decisions)
o Any previous complications from surgery
o Medications
o Allergies (medications, latex, bananas, chestnuts, kiwifruit, avocados, potatoes, strawberries, nectarines, tomatoes, wheat)
o Pregnancy (a pregnant patient has surgery only on an emergent or urgent basis)

Pre-Surgery Assessment Questions

Have you had surgery in the past? If so, when and what was the surgery for?

Did you have trouble with the anesthetic, such as nausea or vomiting, when awakening from the anesthetic?

Are you allergic to any pain medications?

Did you receive pain medication after your last surgery, and did you have a reaction to the medication?

Did you have problems with bleeding or wound healing after your last surgery? What were those problems?

What might surgeons do with medications before surgery?

temporarily discontinue them before surgery or adjust doses

For inpatients, all prescription medications taken before surgery are?

automatically discontinued after surgery unless reordered

For outpatients, instruct patients to ask their surgeons whether they should take their usual medications? (when)

the night before and the morning of surgery

what is the risk for bleeding disorders?

hemorrhage pre- or postoperative

what is the risk for DM?

infection, wound healing, hyperglycemia

what is the risk for heart disease?

increased demand on cardiac output

what is the risk for HTN?

cardiovascular complications (CVA)

what is the risk for respiratory infection?

further respiratory complications

what is the risk for renal disease?

alteration of excretion of medications, acid-base imbalance

what is the risk for liver disease?

alteration of metabolism and excretion of medications

what is the risk for fever?

fluid and electrolyte imbalance

what is the risk for COPD?

acid-base imbalance, hypoventilation

what is the risk for immunological disorder?

infection, delayed wound healing

what is the risk for abuse of alcohol or opioids?

interferences with anesthesia, wound healing

what is the risk for chronic pain?

difficulty controlling postoperative pain

assessment acronym for obstructive sleep apnea (OSA)

Snoring

Tired

Observed

Pressure (blood)

BMI

Age

Neck circumference

Gender (sex)

Overall Assessment

o Support sources
o Occupation
o Preoperative pain assessment
o Emotional health
o Cultural and spiritual factors
o Physical assessment

Machine Assessments

o CBC: detect hemorrhage, dietary deficiencies, anemia, hydration status, coagulation ability, and infection

o Electrolytes: assess electrolyte balance and guide the administration of fluid and electrolyte therapy

o Blood type and cross match: determine blood type before donating or receiving blood

o BUN, creatinine, GFR: measure renal function

o Pulmonary function test: assess lungs and pulmonary reserve before anesthesia, assess response to bronchodilator therapy, and detect pulmonary deficiencies

o Chest Xray: obtain information about the heart and lungs and the bone structure and large blood vessels in the chest

o Blood glucose: directly measure blood glucose and evaluate diabetic patients

o ALT, AST: to identify alterations in liver function

o Coagulation: evaluate clotting mechanisms

o EKG: evaluate dysrhythmias, conduction defects, myocardial injuries and damage, and pericardial disease

o Urinalysis: detect urinary tract disease and gain basic information about kidney function and other metabolic processes

o hCG: detect pregnancy

Prioritize Hypothesis

o Ineffective Coping
o Impaired skin integrity
o Risk for perioperative positioning injury
o Deficient knowledge (specify)
o Impaired physical mobility
o Ineffective thermoregulation
o Nausea
o Acute pain
o Delayed surgical recovery

generate solutions

establish priorities (high, intermediate, low; depends on urgency of surgery)
determine goals and outcomes (remain patient centered)
identify interventions (nursing driven)

Preoperative implementation

o Informed consent (the patient must sign the informed consent form before administration of any anesthetic or sedative drug, the patient must be deemed mentally sound and of legal age to give consent)
o Report concerns about patient understanding to surgeon or anesthesia provider
o Privacy
o Education (the more someone understands why something is being done the more likely they are to participate and be compliant.)

Risk for infection
~antibiotics
~skin antisepsis
~clipping vs shaving

Maintaining normal fluid and electrolyte balance
~fasting prior to surgery
~IV fluid replacement
~parenteral nutrition
~bowel preparations

o Hygiene, no cosmetics, jewelry, etc.
o Remove prostheses
o Safeguard valuables
o Vital signs
o Antiembolism device
o Preoperative medications
o Transportation and handoff
o Documentation

Who is responsible for obtaining the actual informed consent for surgery?

the surgeon

(the nurse is the person who witnesses the patient’s signature and affirms that the consent is given voluntarily)

In emergencies, there may not be time to obtain informed consent, and/or the patient may not have the ability to provide consent based on the severity of the condition. If family members or a POA are not available, informed consent is?

implied

(the surgeon must document the nature of the emergency and any attempts to obtain consent)

Preoperative Implementation: Education

o Reasons for preoperative instructions and exercises
o Preoperative routines
o Postoperative unit
o Anticipated postoperative monitoring
o Surgical procedure
o Postoperative expectations
o Length of stay
o Anxiety about pain management

pre anesthesia implementation

o Paranesthesia/presurgical care unit
o Initiate or check IV
o Administer any additional preoperative medications
o Monitor vital signs
o Anesthesia provider performs assessment

intraoperative implementation

o Family/visitors
o Prepare for patient return

Surgical nurse roles
o Circulating
o Scrub
o RN first assistant

RN tasks
o Temperature
o Positioning
o Documentation

Surgeon (and any assistant surgeons)

Treats malformations, injuries, and diseases by manipulation or surgery

Scrub nurse

Prepares the sterile field, sets up surgical equipment
Maintains surgical asepsis while draping
Assists the surgeon by passing instruments, sutures, and supplies

Circulating nurse (brings belongings to people)

Acts as the patient's advocate and a liaison between scrubbed personnel and the surgical team
Initiates the "time-out" validation process
Communicates with anesthesiologist/CRNA about patient physiologic status
Coordinates the needs of the surgical team by obtaining supplies and carrying out the nursing care plan
Assesses patient safety and aseptic practice

Documents in the electronic health record (EHR)

Anesthesiologist or CRNA

Administers anesthesia (the CRNA collaborates with the anesthesiologist as needed)
Monitors the patient and the patient's vital signs during surgery

Registered Nurse First Assistant (RNFA) (have to have special accreditation)

Collaborates with the surgeon and health care team members during the procedure

postoperative implementation phase I and II

Phase I: immediate recovery
o Removal of airway device
o ABCs
o Close monitoring
o Different scoring systems available to determine ability to be discharged from PACU
o Handoff from PACU to acute care

Phase II: recovery
o Continued monitoring of vitals and responsiveness
o Temperature control
o Fluid and electrolyte balance
o Education reinforced

postoperative implementation phase III

Phase III: discharge to home or to another unit

respiratory function: diaphragmatic breathing, incentive spirometry, turn, cough, deep breathe, splint

circulatory complications: leg exercises, IPCs, medications, compression hose, bleeding precautions.

promote early mobility: addresses so many things, fall risk, mobility limitations

achieve rest and comfort: therapeutic coping strategies, distraction, meditation, medication.

temperature regulation: hypothermia, malignant hyperthermia (life-threatening complication of anesthesia)

neurological function: assess orientation, pupil and gag reflexes, movement, hand grips, safety.

fluid and electrolyte imbalance: monitor lab values, maintain patency of IV, document I&O, weight

gastro and urinary: gag reflex and bowel sounds, encourage when appropriate, ambulate.

skin and wound care: wound care, activity restrictions, diet, assess skin, drainage, dressings.

self-concept: scars, changes, incisions, drains, fear, include patient and caregivers.

discharge preparation: referrals, rehabilitation, in home care, follow up appointments.

education: promote healing and wellness.

Signs of VTE:

pain, tenderness, redness, warmth, or swelling in an extremity

Postoperative mobility is necessary to promote?

respiratory, circulatory, and gastrointestinal function.

(immobility may result in deconditioning and increase the patient’s risk for hospital-acquired conditions; pressure injury’s and falls)

Early and Later signs of Malignant Hyperthermia:

Early: tachypnea, tachycardia, heart arrhythmias, hyperkalemia, hypercarbia, and muscular rigidity

Later: elevated temperature, myoglobinuria, and multiple organ failure

nurses role and safety

o Coughing and deep breathing may be contraindicated after brain, spinal, head, neck, or eye surgery
o Bariatric patients may have improved lung capacity in reverse Trendelenburg or side-lying
o Purposeful rounding
o Fall precautions: low bed, call bell, side rails

(purposeful rounding improves patient safety by decreasing the occurrence of patient preventable events and proactively addresses problems before they occur)

When conducting preoperative patient and family teaching, you demonstrate proper use of the incentive spirometer. You know that the patient understands the need for this intervention when the patient states, "I use this device to:

A.help my cough reflex."
B.expand my lungs after surgery."
C.increase my lung capacity."
D.drain excess fluid from my lungs."

B

(use of an incentive spirometer promotes expansion of the lungs. the patient should try to reach the inspiratory target volume achieved before surgery on the spirometer)

evaluation

criteria (identify and define evaluation standards)
collection (gather data)
interpretation (determine if standards were met)
document
next steps (goals are different postoperatively and may continue into home setting)

(this evolves throughout the care of the perioperative patient)