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Define ablative surgery.
It removes a diseased body part (eg. cholecystectomy).
Define constructive surgery.
It restores a function or appearance that had been lost (eg. implant).
Define the purpose of the perioperative phase.
It assesses suitability for surgery, likely risk factors, patient education to avoid post-op problems, and creates a plan to meet patient safety/recovery needs.
Name 10 things on a pre-op checklist.
Patient ID on 2 limbs, fasting needs, consent, pre-op assessment findings, allergies, valuables, TEDS/compression stockings, BGL control, premedication, documentation needs, and elimination needs.
Name 10 aspects of a pre-op patient interview.
Current health status, family history, past hospitalisations, mental/emotional status (coping), current medications, removal of piercings, understanding of the procedure, social habits, cultural/spiritual considerations, consent, and discharge planning for community recovery.
Describe some legal considerations regarding consent.
Surgeons must obtain consent but nurses can witness, all forms must be fully filled out and signed, consent includes adequate disclosure and comprehension, it can be withdrawn at any time (emergencies override it).
What are some perioperative education points to reduce anxiety and complications?
Inform the patient about the surgery (things they want to know like the estimated length of stay, showering, eating and drinking restrictions)
Active listening, clarify misinterpretations
Describe staff roles and expectations
Create a pain relief plan and relevant management options
Consider support person/item for children (separation anxiety)
Define medication reconciliation.
Checking that prescribed medications match the medications that the patient should have to ensure continuity of care, prevent harm and reduce the risk of medication errors.
Define premedication.
Given for analgesia, N+V, sedation/amnesia, lowers anaesthetic needs, relieves anxiety, prevents autonomic reflex responses, lowers secretions (benzos, opioids, histamine H2 receptor antagonists). Ensure final questions are asked and consent is verified before giving premedications.
Describe surgical counts.
It includes absorbent items, sharps, instruments and items added during surgery. It’s chronological, signed by 2 nurses and the surgeon, and if interrupted you must restart. All items are radio-opaque so that imaging can pick it up if there are discrepancies in the count.
What are some post-op paediatric considerations?
A family centered approach, encourage parental contact when kid wakes up, fluid and electrolyte monitoring, temperature checks, hypoglycaemia from fasting, nourishment where possible, check BP after some procedures.
Describe the role of the anaesthetic nurse.
Collaborates with the anaesthetist, provides equipment, assists in maintaining airway, anticipates emergencies, helps transfer patients.
Describe the role of the circulating nurse.
Maintains sterility, anticipates needs before and during surgery, sends relevant pathology.
Describe the role of the scrub nurse.
Advocacy, prepares the instrument table, organises equipment, maintains sterile field, monitors for breaches, skin prep and draping, surgical count, correct handling of all items.
Define general anaesthesia.
Creates a loss of consciousness, airway reflexes, blocks awareness center in reticular activating system (RAS) so amnesia, analgesia, hypnosis, and relaxation occurs. It also suppresses physiological and emotional stress from surgery and pain. Close neuro, respiratory, and cardiac monitoring is needed.
Give an example of a general anaesthesia medication regime.
Induce with propofol with 30-40% O2 and nitrous oxide, amnesic drug (midazolam), analgesic (fentanyl/morphine sulphate), & relaxant (rocoronium).
Define regional anaesthesia.
A temporary interruption of nerve impulse transmissions to/from a body region causing loss of sensation/movement but not a loss of consciousness.
Local anaesthetic, peripheral nerve block, IV block, central nerve block.
Describe local anaesthetic (LA).
A drug that blocks conduction when applied to nerve tissue, interrupting impulse generation by altering sodium flow into nerve cells (eg. lidocaine).
Describe peripheral nerve blocks.
LA is injected into a nerve group that supplies sensation to a small or large region of the body.
Describe an IV block.
Used for arm/wrist/hand procedures, an occlusion tourniquet prevents infiltration or absorption beyond the extremity, time critical surgery.
Describe a central nerve block.
LA is injected into spinal roots coming from the spinal canal. Spinal blocks go into the subarachnoid space and an epidural goes into the epidural space.
What is the nursing management for a patient on a general or regional anaesthetic?
Get a history of anaesthetic use and outcomes, fasting status, vital signs, ANS blockage (hypotension, bradycardia, N+V), monitor for systemic absorption ad toxicity (block is too high), and supervise post-op ambulation.
What are some airway management considerations under anaesthesia?
Muscle tone is lost when unconscious, consider OPAs, chin lift, jaw thrust, troubleshooting strategies, correct techniques to avoid complications.
Define a laryngeal mask airway (LMA).
It can be inserted without a muscle relaxant, minimises aspiration risk, for short procedures only, used if the surgical site is not in the head or neck. It’s positioned over the larynx and inflated (no need to visualise vocal cords).
Define laryngoscopes.
Used for ETT insertions, has different blade sizes with a light and handle. Adults have curved blades, babies have straight ones (different anatomy).
Define endo-trachial tubes (ETTs).
Aims to facilitate ventilation, prevent aspiration, different sizes, maintains an airway under difficult circumstances, for head/neck/throat surgeries, protects the trachea, and provides controlled ventilation.
Define rapid sequence intubation (RSI).
For emergent cases with an unknown fasting time, pregnancy, hiatus hernia, bowel obstruction, GI bleed, or aspiration event. Inserted with cricoid pressure of the larynx, oesophagus compressed by cricoid cartilage and C6 vertebra to stop aspiration, released when the ETT cuff is inflated.
Name the 4 airway obstructions and emergencies.
Obstructive sleep apnoea, aspiration, anaphylaxis and malignant hyperthermia.
Define aspiration during surgery.
Less throat reflexes under GA cause gastric contents to enter lungs. Residual effects impact lung function/gas exchange, causing oedema, alveoli collapse and hypoxia.
Define surgical anaphylaxis.
Mainly caused by latex or antibiotics, causing hypotension, tachycardia, bronchospasm and pulmonary oedema.
Define malignant hyperthermia.
Severe reaction in response to GA medications, causing muscle rigidity, tachycardia, tachypnoea, febrile pts, respiratory/metabolic acidosis, ventricular arrhythmias, and potentially a cardiac arrest or death.
Describe tracheostomy formation.
A surgically created stoma in the trachea to establish an airway that bypasses upper airway obstructions, helps remove secretions, for long term mechanical ventilation.
Describe the purpose of the PACU.
The Post Anaesthetic Care Unit (PACU) provides close monitoring to protect patients from environmental stimuli, involving 1:1 care for unconscious patients, an unobstructed view, side rails (deterioration risk). 2 handovers are required on admission (anaesthetist and the circulating nurse).
Describe a post anaesthetic airway assessment.
Check patency/adequacy. ETTS are removed in OT, LMAs can be removed in PACU. Provide adjunct support as needed, chin lift, jaw thrust, suction.
What are some potential post-op airway complications?
Laryngospasm (vocal cord closure), bronchospasm (smooth muscle contraction), tongue falling back, laryngeal oedema, or atelectasis.
Describe a post anaesthetic breathing assessment.
Check adequacy of ventilation/oxygenation (arterial O2 saturation, RR, rhythm, depth, accessory muscle use, air entry, breath sounds). Consider supplemental O2 (helps clear anaesthetic gases from system), encourage deep breathing, coughing, non-invasive ventilation, BVM.
What are some potential post-op breathing complications?
Hypoxia and CO2 retention (from obstruction, ongoing sedation, circulatory failure leading to respiratory arrest).
Describe a post anaesthetic circulation assessment.
Check adequacy of circulation (HR, rhythm, peripheral pulse amplitude and equality, BP, cap refill, skin warmth, intake, output, IVs, dehydration, fluid overload). Take BP 5-15 minutely immediately post-op, consider VTEp, fluid resus, inotropic support, and secondary surgeries.
What are some potential post-op circulation complications?
Pooling (stasis), haemodynamic instability, VTE, lack of perfusion, hypovolaemia (drains, wounds, haematoma, compartment syndrome), dehydration (monitor FBC).
Describe a post anaesthetic disability assessment.
Assess neurological function (ACVPU/GCS, protective reflexes like gag, cough, swallow, length of emergence from unconsciousness, limb power, BGL, pain), give pt a RASS sedation score (-5 to +5), reorient, reassure, reposition, check PCA chart, anaesthetic record, NIMC, give warm compress and oral care.
Describe a post anaesthetic exposure assessment.
Assess the operative site, dressing status, drainage type, amount, colour, patency, use of suction (on/off), body temperature.
What are some potential post-op exposure complications?
Risk of intra-operative hypothermia (impaired cardiac output/coagulation), irritation or infection of the surgical site, haemorrhage.
What are some post-op considerations for children?
They may not state pain levels (indicated through crying, fussiness, higher HR and BP, agitated), parents can go to the PACU when they wake up.
What are some post-op considerations for older adults?
They have less efficient reserves, more fatigue/weakness, increased confusion and agitation, requires follow up phone calls to check condition in community.
What are some post-op considerations for bariatric patients?
Airway obstruction (fat deposits in neck), atelectasis (diaphragm pressure), difficulty clearing anaesthetics from system, PI, thromboembolisms.
What are some general post-op considerations?
Diabetes (impairs healing), impaired vision/hearing, PVD, previous CVA, smoking, alcohol, drug use, developmental delays, cognitive impairments.
Describe the discharge protocol from PACU to the ward.
Must be rousable to voice, patent airway, breathing, good circulation, controlled pain, low N+V, neurologically stable, afebrile, specific surgical obs done, documentation completed, pt communication, wound care if needed.
Define pneumothorax.
Air enters the pleural cavity causing a partial or complete lung collapse. It can be spontaneous, iatrogenic (post procedure), traumatic (chest injury), tension (air, trachea deviates), haemothorax, or chylothorax (lymphatic fluid).
Define pleural effusion.
Abnormal fluid accumulation in the pleural space.
Why are chest tubes inserted?
Following cardiothoracic surgery (they decompress lungs on purpose), after chest trauma, spontaneous pneumothorax or any condition causing the accumulation of content in the pleural space.
What are the types of catheters used for chest drains?
Intercostal catheters (ICCs) - Upper anterior thorax
Small bore pleural catheters - Upper anterior thorax (pigtail/straight)
Subcostal catheters (SCCs) - Mediastinal space below the ribcage
What are the 3 chest drain components?
The collection chamber (single or multi chamber)
The water seal (1 way valve prevents air entry on inspiration)
Low suction source and/or vent to allow air to escape
What are underwater seal drains (UWSDs) monitored for?
Swinging/oscillation (fluid swings up/down the tube on breathing)
Drainage (drains into measurement chamber, kept below chest level)
Bubbling (air escapes out of the pleural space into the bottle)
What is the nursing management for chest drains?
Safety (bubbles, clamps at bedside, kept below pt, suction)
Observations (output, swing, respiratory assessment, auscultate, midline trachea, pain, water level, secured tubing, clear dressing)
Education (keep below chest level, positioning, call if mobilising)
What are some complications of chest drains?
Occlusion (kinks, squeeze tube to improve patency), air leaks (secure connections/dressing) disconnection (clamp, reconnect, unclamp), dislodgement (pinch skin together, redress, CXR, vitals), excessive drainage, infection, subcutaneous emphysema (air under skin, rice bubble feeling).
Define pneumonia.
Alveoli inflammation from infection, toxins, immobility, or impaired ventilation with pathogen growth, causing high temperature, cough, dyspnoea, and chest pain. Encourage breathing exercises and early ambulation.
Define atelectasis.
Alveoli collapse from mucous plugs, blocked bronchial airways, low lung expansion, or immobility, causing dyspnoea, tachypnoea, tachycardia, diaphoresis, and dull breath sounds. Encourage breathing exercises/ambulate.
Define pulmonary embolism.
Blood clot blocking a pulmonary artery, stops blood flow to part of the lung, caused by venous stasis/injury or coagulation issues. It causes sudden chest pain, SOB, cyanosis, and shock. Encourage repositioning, ambulation, TED stockings and other compression devices to promote venous blood flow.
Define non-invasive ventilation.
Positive pressure ventilation (forced into airway) via face mask or nasal cannula. It can occur through continuous positive airway pressure (CPAP) or high flow nasal cannula devices (HFNC).
Describe continuous positive airway pressure (CPAP).
Constant positively pressured gas given on inspiration and expiration, splints open airways. Used for post-op atelectasis, pulmonary oedema, T1 resp failure, COPD. Nurses can set the fraction of inspired oxygen (FiO2) between 21-100% O2, or the positive end expiratory pressure (PEEP) between 5-10 cmH2O.
Describe high flow nasal cannula (HFNC).
It is set to 20-60L/min, FiO2 is set between 21-100% O2. It generates PEEP in lower airways (PEEP can’t be controlled like with CPAPs), reduces respiratory effort, is better tolerated by pts, and becomes a bridge between CPAPs and low flow oxygen devices.
Define COPD.
Progressive respiratory condition causing emphysema (alveolar destruction and elastic recoil) and chronic bronchitis, leading to dyspnoea and a worsened cough/sputum over 14 days. Managed with bronchodilators, infection reversal, glucocorticosteroids, and O2 therapy between 88-92% (NIV preferred).
What are some clinical manifestations of postoperative pain?
Pain stimulates the sympathetic nervous system causing tachycardia, shallow breathing, atelectasis, altered gas exchange, immobility and immunosuppression. It can be nociceptive or neuropathic pain.
Describe opioid analgesia regimes.
Continuous (via IV, epidural, PCA, PCEA)
Regular administration (IM/SC/SL options at standard intervals + PRN)
Transdermal - Standard application times
Describe a multimodal pharmacological approach to pain.
Involves non-opioid analgesia (paracetamol, NSAIDs, ketamine, Cox II inhibitors, pregabalin and gabapentin) as well as regional analgesia (nerve blocks).
Describe a non-pharmacological approach to pain.
Involves heat/cold massages, stretching, diversional therapies, reassurance, reorientation, repositioning, personal hygiene (reduces discomfort and promotes a ‘clean’ feeling).
Describe some severe complications of opioid therapy.
A respiratory rate under 8bpm, rousability score under 2, hypotension (under 90), bradycardia (under 50), severe itching/pruritus, hallucinations or dysphoria, confusion, agitation, and urinary retention.
Describe the nursing actions if a patient on opioid therapy has a RR under 8bpm or a rousability score under 2.
Stop the infusion, call for help (2222, MET), start BLS, administer O2 via a mask, attempt to wake pt verbally and physically, refer to BTF and PCA charts for response guidelines, stay with them, give meds as per MO.
Describe the nursing actions if a patient on opioid therapy has an SBP under 90mmHg or a HR under 50bpm.
Lay the pt flat, elevate lower limbs unless contraindicated, stop the infusion, remove bolus button, call a MET as per criteria.
Describe the nursing actions if a patient on opioid therapy has severe itching or pruritus.
Assess pruritus, give antihistamines as prescribed, monitor for increased signs of sedation from the antihistamines.
Describe the nursing actions if a patient on opioid therapy has hallucinations or dysphoria.
Reassure the pt, contact APS, reduce the therapy rate as instructed.
Describe the nursing actions if a patient on opioid therapy has confusion or agitation.
Assess the pt, have the MO review the pt (can be therapy induced delirium), stop the infusion, remove the bolus button and contact APS.
Describe the storage of S4D and S8 medications.
S4Ds are kept separate from other meds unless stored with S8s. The S8 cupboard must be lockable metal or hardwood and fixed to a wall or floor.
Describe how to access S4D or S8 medications.
There’s usually 1 key for each, word by the NUM or access nurse. It could be fingerprint, code, or swipe access as well but not given to agency or casual staff. It’s always accessed in the presence of 2 RNs.
Describe the protocol for S4D or S8 medication administration.
2 RNs must be present for the entire process, discarded meds must be countersigned and witnessed by 2 RNs, entries made in blue or black. Errors, daily checks, additional drugs added in red ink, errors are not crossed out. 2 RNs check the cupboard once daily at bare minimum.
Describe neuraxial CNS blocks.
Either spinal or epidural anaesthesia. Spinals are single CSF injections, epidurals are catheters placed in the epidural space for an infusion or PCEA. It allows for significantly less post-op complications compared to systemic analgesia as very little medication is absorbed into the bloodstream.
What are some safety issues regarding epidural anaesthesia?
Staff training, anesthetist is responsible for initial connection, pt must have emergency IV access, monitored by APS, notify ASAP if started on anticoagulants, specific lines and labels are used, check site regularly, occlusive window dressing used, ensure no kinks, remove after a few days.
What are some complications associated with epidural catheters?
Accidental disconnection (call APS, don’t reattach), epidurals may cause respiratory depression, assess hourly for 24 hours post insertion, hypotension, pruritus, motor blockade, urinary retention, if the block occurs at T3 or higher, the respiratory center could be impacted.
What are the 4 types of continuous local anaesthetics?
Paravertebral, fascial plane, perineural, and wound site infusions.
Describe patient controlled analgesia.
Allows self-administration of pain relief at a pre-set dose with a lock out time. It can be IV, subcut or epidural, with a dose and lock time that varies. 2 RNs check settings, changes and updates. Document ongoing pain levels, dosages, response, and usage. It’s locked with the red keys to stop abuse.
Define postoperative cognitive dysfunction.
Cognitive deficits that appear immediately post-op from a suspected inflammatory process. It arises more commonly after extensive surgery under GA, secondary surgeries or if post-op complications occur.
Define delayed emergence/awakening.
Lack of consciousness 20-30 minutes after the last anaesthetic medication was given. It can be from hepatic/renal insufficiency, age, weight, body temperature or the medication’s half life.
Describe the anatomy of the urethra and bladder.
The urethra is 3-4cm long in women, 20cm long in males. There are stretch receptors at the 2nd-4th sacral vertebrae (issues for pts with spinal injuries or cerebral haemorrhage above this point). The average bladder volume is 400mL.
What are some urinary considerations for infants and children?
UTIs are common, needs MO review if frequent. Teach perineal hygiene (cotton underwear, wipe front to back, go when sensation is felt).
What are some urinary considerations for older adults?
Low PO intake, low urination needs, high dehydration risk, UTIs cause incontinence, confusion and falls. Low perineal tone occurs with age, bladder support, stress incontinence, leakage on exertion.
What are some general urinary considerations?
Sex reassignment surgery, urethra changes cause incontinence, overactive bladder, low blood flow, genital mutilation or obstetric fistulas, or functional incontinence from impaired mobility, joint/bone pain, and dementia.
Define pre-renal failure.
Influenced by haemorrhage, dehydration, burns, shock, and low intravascular volume.
Define intra-renal failure.
Nephrotoxic agents like gentamicin, transfusion reactions, glomeruli diseases, renal neoplasms, systemic diseases like diabetes, infections, hereditary conditions like polycystic kidneys.
Define post-renal failure.
Obstructions from calculi causing stones, clots or tumours.
Name some post-op assessment questions regarding urination.
Ask about voiding patterns, description (colour, changes), problems (force, frequency, pain), consider medications, fluid intake, environment (mobility, daily function), stress, disease, disability, and recent surgery/procedures.
What are the typical results of bladder scanning?
Normal scan post void should show 50-100mL, escalate if more than 500mL drains post IDC insertion, or if more than 150mL shows up on bladder scan post IDC removal or TOV.
What are some considerations for altered urine production/retention?
Normal output is around 1500mL daily. Oliguria, anuria, polyuria, nocturia, urgency or enuresis is abnormal. Patients must void 8 hours post-op, anaesthetic depresses bladder, strict FBC, consider IDC if strategies fail.
What is the red and yellow zone criteria for urine output?
Yellow - Low output for 4 hours (under 100mL in 4 hours or under 0.5mL/kg/hr via an IDC).
Red - Low output for 8 hours (under 200mL in 8 hours or under 0.5mL/kg/hr via an IDC).
Define a suprapubic catheter.
Surgically inserted catheter through the abdominal wall into the bladder with LA, closed drainage system, temporary or long-term, maintain the tube (blocks easily), care for the dressing at the insertion site.
Describe the period of use of different urinary catheters.
Silicone/rubber catheters are used for 6 weeks. Latex or plastic catheters are in for 1 week max.
What are the 5 indications for an IDC insertion?
Urine output monitoring
Retention (acute/chronic and/or renal compromise)
Intra-operative procedure (eg. bladder washout)
Neurological conditions (eg. spinal cord injury)
End of life (to minimise pain, incontinence)
What are some IDC insertion complications and contraindications?
Insertion - Tract damage, bleeding, discomfort, retention post removal, UTI
Contraindications - Blood at urethral meatus, suspected trauma (pelvic fracture), urinary surgery, risk of disrupting anastomosis (vessel connection)
Describe bladder irrigation and continuous irrigation fluid balance principles.
It can be continuous or intermittent, closed or open irrigation to prevent clots and mucous occluding the catheter (eg. from post genitourinary surgery). Aim 3L intake/day unless advised against, irrigation volume is deducted from overall output to determine accurate output, assess drainage every 30 minutes, bladder scan pre-post installation.
Define acute kidney injury (AKI).
From slight deterioration to severe impairment, rapid onset and loss of kidney function along with high creatinine and/or urine output reduction. Can be reversed, high mortality, usually following severe prolonged hypotension or hypovolaemia/exposure to neurotoxic agents.
Define chronic kidney disease (CKD).
Progressive, irreversible, kidney function loss, up to 80% of GFR is lost without much functional change, leftover nephrons hypertrophy to compensate, involves every organ, main cause DM or HTN.
