Care of Preop, Intraop, and Postop Pats

Question 1

Preoperative(before surgery)
Postoperative (after surgery)
Together, these time periods are know as the perioperative period

Answer 1

Perioperative period

Question 2

begins when the patient is scheduled for surgery and ends at the time of transfer to the surgical suite

Answer 2

Preoperative(before surgery)

Question 3

starts with completion of surgery and transfer of the patient to a specialized area for monitoring such as the postanesthesia care unit (PACU) and may continue after discharge from the hospital until all activity restrictions have been lifted

Answer 3

Postoperative (after surgery)

Question 4

Because of an unexpected emergency case, a patient scheduled for colon surgery at 8 am has been rescheduled for 11 am. What is the nurse’s best action related to preoperative prophylactic antibiotic administration according to the Surgical Care Improvement Project (SCIP) guidelines?
1.Administer the preoperative antibiotic at 7 am as originally prescribed
2.Administer the antibiotic at the same time as the other prescribed preoperative drugs
3.Adjust the antibiotic administration time to be within 1 hour before the surgical incision
4.Hold the preoperative antibiotic until the patient is actually in the operating room and has been anesthetized

Answer 4

Answer: 3
Timing of that antibiotic directly related to the incision time
Trying to prevent any surgical infection - cutting in body and opening tissues gives opening for infection; why ORs so sterile so give prophylactic antibiotic; give antibiotic so not getting postop infection - very big deal

Question 5

Quality measures
Surgical Care Improvement Project (SCIP)
Communication and collaboration with the surgical team are essential - Every needs be on same page; ensure very good communication in all people OR, preop, PACU

Answer 5

Pat safety

Question 6

Centers for Medicare and Medicaid Services (CMS) collect this data for tracking patient outcomes and ensuring patient-centered care and accountability on the part of health care facilities; CMS collect this data and look at pat outcomes - making sure healthcare facilities doing jobs and having good patient outcomes
Every hospital has these and want make sure have these; want make sure look at this

Answer 6

Quality measures

Question 7

wrong-site surgery - Prevent Wrong site - mark and time out (what kind procedure, ask pat what having done and where having done)
patient falls - ensuring safety really big
hospital-acquired pressure ulcers - - esp for CABGs mepilex on bottom prophylactically because on back for awhile regardless if healthy or not because want prevent that - laying in one spot for long time, and
vascular catheter-associated infections - not want get central line infections

Answer 7

Centers for Medicare and Medicaid Services (CMS) collect this data for tracking patient outcomes and ensuring patient-centered care and accountability on the part of health care facilities; CMS collect this data and look at pat outcomes - making sure healthcare facilities doing jobs and having good patient outcomes

Question 8

Plan for the reduction and eventual elimination of preventable surgical complications
Reduce preventable surgical comps
Any time surgery - comps can arise and trying to prevent of those

Answer 8

Surgical Care Improvement Project (SCIP)

Question 9

infection prevention,
prevention of serious cardiac events
prevention of venous thromboembolism (VTE) - VTE: blood clot; SCDs, socks - measure prior to surgery to put on before/after surgery, not given before surgery normally low molecular weight blood thinners (heparin (often go home on lovenox injections postop)) to prevent blood clots - getting up and moving quickly

Answer 9

Plan for the reduction and eventual elimination of preventable surgical complications

Question 10

A 75-year old patient is having an exploratory laparotomy tomorrow. The wife tells the nurse that at night the patient gets up and walks around his room. What priority action does the nurse take after hearing this information?
1.Notifies the provider
2.Develops a plan to keep the patient safe
3.Obtains an order for sleep medication
4.Tells the patient not to get out of bed at night

Answer 10

Answer: 2
Know home gets up and walks around room
Postsurg - not anywhere knows and confused from anesthesia; want make sure safe and make sure putting in safety measures

Question 11

The nurse is preparing the patient for surgery. Which common laboratory tests does the nurse anticipate to be ordered? (Select all that apply)
1.Total cholesterol
2.Urinalysis
3.Electrolyte levels
4.Uric acid
5.Clotting studies
6.Serum creatinine

Answer 11

Answer: 2, 3, 5, 6
Cholesterol - not right before surgery need to know; good to know overall
Urinalysis - also do with urine do pregnancy test unless had hysterectomy
Electrolyte levels - K, Mg - too high/low can affect and cause dysrhythmias and things like that
Clotting studies - how much are going to bleed; if numbers too high may not be able to go surgery or might need do something to lower them; not want go if very thin blood because could cause lots of bleeding
Serum creatinine - for kidneys

Question 12

Complete set of vital signs and report abnormal findings
Focus on problem areas identified from the patient’s history and on all body systems affected by the surgical procedure
Assess for and report any signs/symptoms of infection - No surgery if have an infection
Assess for and report factors that could contraindicate surgery, including:
Assess for and report clinical conditions that may need to be evaluated by a provider before proceeding with surgical plans
Psychosocial assessment
Laboratory assessment
Imaging assessment (CXR, CT, MRI) - type surgery and pat and what have going on
Other diagnostic assessments (ECG) - type surgery and pat and what have going on

Answer 12

Preop assessments

Question 13

report abnormal assessment findings to surgeon/anesthesiology personnel
Not say entire history - prob areas or things that might affect surgery

Answer 13

Focus on problem areas identified from the patient’s history and on all body systems affected by the surgical procedure

Question 14

Increased prothrombin time (PT), international normalized ratio (INR), or activated partial thromboplastin time (aPTT)
Abnormal electrolytes
Report of possible pregnancy or positive pregnancy test

Answer 14

Assess for and report factors that could contraindicate surgery, including:

Question 15

Change in mental status, vomiting, rash
Recent administration of an anticoagulant drug
Family or personal history of malignant hyperthermia with anesthesia
List of preop do and what not to do - sometimes things missed and give meds and do something not supposed to and might have to hold off on surgery; fam history MH: severe rxn to anesthesia drugs they can develop, knowing if fam history/personal; high fever and rigid muscles, high HR, need know ahead of time

Answer 15

Assess for and report clinical conditions that may need to be evaluated by a provider before proceeding with surgical plans

Question 16

level of anxiety, coping ability, support systems
Support sys - need postop; type surgery might need care some at home or fam drive home or to appointments and helps decide where go after discharge - need go to rehab facility for short period of time

Answer 16

Psychosocial assessment

Question 17

Diff depending on pats - most things look at prior to surgery
Can depend on the patient’s age, medical history, and type of anesthesia and surgery planned
UA, blood type and screen
CBC or H/H
clotting studies (PT, INR, aPTT, platelet count)
electrolyte levels
serum creatinine & BUN
pregnancy test
ABG’s may be assessed for patients with chronic pulmonary problems)

Answer 17

Laboratory assessment

Question 18

Age – older than 65
Certain Medications
Medical History
Prior surgical experiences
Family history - MH, high BP
Type of surgical procedure planned - open heart surgery (opening chest), spine related, brain related, neck/face area - anything to do with airway - surgical comps with breathing; big abdominal surgery - increased risk for more blood loss; if laproscopic/open surgery

Answer 18

Factors that increase the risk for surgical comps

Question 19

The nurse has given the ordered preoperative medications to the patient. What actions must the nurse take after administering these drugs? (Select all that apply)
1.Raise the side rails
2.Place the call light within the patient’s reach
3.Ask the patient to sign the consent form
4.Instruct the patient not to get out of bed
5.Place the bed in its lowest position

Answer 19

Answer: 1, 2, 4, 5
Consent - doc responsible explaining procedure, nurse when signing witness signature of pat; pats not ask sign; meds that might make drowsy, relaxed (benzodiazapene) - cannot say completely alert and oriented; not want them to do that; sign all consents before give any sort meds that alter mental state
Keeping them safe and got those drugs - had them and might change mental status

Question 20

Consent implies that the patient has sufficient information to understand:
The surgeon is responsible for having the consent form signed before sedation is given and before surgery is performed - Surgeon responsible for having form signed
Nurse’s responsibility is that the consent form is signed, and you serve as a witness to the signature, not to the fact that patient is informed - Nurse is witness (in preop checklist) and form been signed; questions is surgeons responsibility

Answer 20

Informed consent

Question 21

The nature of and reason for surgery
Who will be performing the surgery and whether others will be present during the procedure
All available options and the risks associated with each option
The risks associated with the surgical procedure and its potential outcomes
The risks associated with the use of anesthesia
Pats have all info side effects, surgery is and how affects them

Answer 21

Consent implies that the patient has sufficient information to understand:

Question 22

The nurse is monitoring a patient who is receiving moderation sedation. An expected outcome for conscious sedation is:
1.Blocked multiple peripheral nerves in a specific region
2.Decreased motor function in the targeted limb
3.Decreased level of consciousness, yet able to respond to verbal commands
4.CNS depression, resulting in analgesia and amnesia, with loss of muscle tone and reflexes

Answer 22

Answer: 3
Moderate/conscious sedation
Able to respond during surgery but not remember everything or feel those things; maintaining own airway
Gen anesthesia - intubated

Question 23

Which medical condition increases a patient’s risk for surgical wound infection?
1.Anxiety
2.Hiatal hernia
3.Diabetes mellitus
4.Amnesia

Answer 23

Answer: 3
DM - increase BG weakens immune sys, decrease blood flow, and more susceptible to infection - slowed wound healing

Question 24

The patient in the OR holding area tells the nurse that his surgery is for the right foot. The patient’s chart states that the surgery is for his left foot. What is the nurse’s best action?
1.Do nothing because the patient is confused after receiving premedications
2.Make a note about this in the nursing notes of the patient’s chart
3.Call the nurse anesthetist to check whether the chart or patient is correct
4.Notify the surgeon immediately before the patient goes into the OR about this discrepancy

Answer 24

Answer: 4
Not go into OR - get resolved before going back; need to clarify this and make sure everyone on same page because wrong site surgery not something want to happen

Question 25

Procedure completed in the OR suite prior to the start of any operation
Patient’s identity, correct site, correct patient position, and proposed procedure are verified = Making Correct patient, site, position, procedure
Involves the participation of all members of the surgical team - Involves everyone - everyone stops to make sure on same page

Answer 25

“Time-out” procedure

Question 26

The nurse is about to give the prescribed pain medication to a patient 30 minutes before a scheduled dressing change. The patient states that the drug makes him feel sick and he would rather “tough it out.” What is the nurse’s best first response?
1.“Tell me more about the sick feeling.”
2.“That’s fine. You have the right to refuse any drug.”
3.“Your surgeon would not have prescribed the drug if it wasn’t needed.”
4.“Remember that the pain of the dressing change would be worse than feeling sick.”

Answer 26

Answer: 1
Not want to tough it out esp when had surgery and having scheduled dressing change - bigger surgery and doing dressing change is painful and wound nurse/therapy will call before ask to give med before up there because want be able do all things need to do with therapy or change dressing to prevent postop comps and not want pat in so much pain that behind pain and want tell us more about it; can give something so less sick; switch med so can do something for pat

Question 27

Assess the patient’s comfort level and the effectiveness of therapies
Offer alternative therapies for relaxation, pain reduction, and distraction
Drug therapy

Answer 27

Managing pain

Question 28

Re-positioning, splinting, massage, relaxation techniques, and diversion

Answer 28

Offer alternative therapies for relaxation, pain reduction, and distraction

Question 29

Opioid analgesics are given during first 24 to 48 hours after surgery, maybe longer
Around-the-clock or patient-controlled analgesia (PCA) - PCA pump - pat has button and are pushing it and are terms to it and how often can it; better if it need it more around the clock
Assess the type, location, and intensity of the pain before and after giving medication
Commonly used medications: Morphine Sulfate, Hydromorphone (Dilaudid), Ketorolac (Toradol), Codiene, Butorphanol (Stadol), Oxycodone with aspirin (Percodan) or Oxycodone with acetaminophen (Tylox, Percocet)
Look at type pain and intensity of the pain - determines type drug given
Depends on type surgery pat had

Answer 29

Drug therapy

Question 30

The nurse is assessing a postoperative patient’s gastrointestinal system. What is the best indicator that peristaltic activity has resumed?
1.Presence of bowel sounds
2.Patient states he is hungry
3.Passing of flatus or stool
4.Presence of abdominal cramping

Answer 30

Answer: 3
Presence BS good but not as good as passing flatus/stool - tell us for sure has returned and things are moving; presence of BS do want listen for but not tell us as well as flatus/stool

Question 31

Postoperative nausea and vomiting (PONV) - Diff drugs given for PONV
Decreased or no peristalsis for up to 24 hours
Paralytic ileus - Decrease in bowel activity and need monitor for it and esp if had abd surgery - need monitory for that; any surgery need prevent ileus and think about constipation; often drugs given that cause constipation - help that along with stool softeners (Miralax) help pass stool - not want constipation along with ileus
Constipation

Answer 31

Common rxns after surgery

Question 32

Treatment: Ondansetron (Zofran), Dimenhydrinate (Dramamine), Scopolamine

Answer 32

Postoperative nausea and vomiting (PONV) - Diff drugs given for PONV

Question 33

Monitor bowel sounds, passage of flatus or stool

Answer 33

Decreased or no peristalsis for up to 24 hours

Question 34

What is the priority nursing assessment when a patient is admitted to the PACU?
1.Level of consciousness
2.Airway and gas exchange
3.Dressing and incision status
4.Vital signs and body temperature

Answer 34

Answer: 2
All are imp; what priority and number 1 thing look at: ABCs

Question 35

A patient who is 2 days postoperative for abdominal surgery states, “I coughed and heard something pop.” The nurse’s immediate assessment reveals an opened incision with a portion of large intestine protruding. Which statements apply to this clinical situation? (Select all that apply)
1.Dehiscence has occurred
2.This is an emergency situation
3.The wound must be kept moist with normal saline-soaked sterile dressings
4.This is an urgent situation
5.Evisceration has occurred

Answer 35

Answer: 2, 3, 5

Question 36

Dehiscence –
Evisceration –

Answer 36

Wound comps

Question 37

partial or complete separation of the outer wound layers, sometimes described as a “splitting open of the wound”
Apply a sterile nonadherent (e.g., Telfa) or saline dressing to the wound
Notify the surgeon
Instruct patient to lie supine, bend the knees, avoid coughing
Notify surgeon because need to fix; avoid getting to point of evisceration and opening more

Answer 37

Dehiscence –

Question 38

total separation of all wound layers and protrusion of internal organs through the open wound
Surgical emergency-prepare for surgery
Notify the surgeon
Apply sterile saline soaked gauze
Instruct patient to lie supine, bend knees, avoid coughing
Review Emergency Care of the Patient with Surgical Wound Evisceration
Stay with pat - not let move and get more of the wound out

Answer 38

Evisceration –

Question 39

Dressing change
Assess wound for infection
Assess drains
Drug therapy (antibiotics) - antibiotics - prophylactically

Answer 39

Preventing wound infection and delayed healing

Question 40

Surgeon will change first dressing

Answer 40

Dressing change

Question 41

reinforce the dressing if needed -Might need to reinforce it but they will usually be ones to come up; nursing notes of how to do it/wound care

Answer 41

Surgeon will change first dressing

Question 42

warmth, swelling, tenderness or pain
type and amount of drainage
See what looks like and how much; little bit mark it and see how much growing; norm some drainage but not want copious amounts drainage

Answer 42

Assess wound for infection

Question 43

Patency
amount, color, and type of drainage
If drain assess patency - what looks like and amount, type

Answer 43

Assess drains

Question 44

Which are interventions for the medical-surgical nurse to use in preventing hypoxemia for the postoperative patient? (Select all that apply)
1.Monitor the patient’s oxygen saturation
2.Position the patient supine
3.Encourage the patient to cough and breathe deeply
4.Get the patient up ambulating as soon as possible
5.Instruct the patient to rest as much as possible

Answer 44

Answer: 1, 3, 4
Supine - better with elevated; raise head of bed to open up lungs
Rest - want to rest but cannot have lay there; need them up and moving to prevent surgical comps; not want atlecetasis or postop pneumonia; want rest but want up and moving

Question 45

Airway maintenance
Monitor oxygen saturation, pulse oximetry
Positioning
therapy, if indicated
Breathing exercises
Movement/Mobility

Answer 45

Preventing hypoxemia

Question 46

Splint incision, cough, deep breathe, use incentive spirometer
Pain control - want be able to breathe deeply - too much pain start shallow breathing - start issues; splint the incision - pillow and brace up against wound and help with pain

Answer 46

Breathing exercises

Question 47

Encourage early ambulation
If the patient is on bed rest, reposition every 2 hours, perform breathing and leg exercises
Antiembolism stockings
Pneumatic compression devices
Moving around - on bed rest that reposition

Answer 47

Movement/Mobility

Question 48

Atelectasis/Pneumonia
VTE (Deep vein thrombosis/Pulmonary embolus)
Hypertension/Hypotension
Dysrhythmias
Infection
Impaired wound healing
Bleeding
Ileus
Urinary retention
Can develop that we are trying to avoid that we are doing preventive measures

Answer 48

Postop comps

Question 49

Charlie Glenisky, a 73-year-old male, has severe pain and limited mobility in his left hip due to osteoarthritis. He has been scheduled for a hip replacement in 2 weeks. Mr. Glenisky is independent and lives at home with his wife. He is unable to work or pursue his hobbies due to the limited mobility and pain. Mr. Glenisky is excited about the surgery outcomes yet is anxious about the procedure. He is at the surgeon’s office and the nurse is providing preoperative teaching for Mr. Glenisky and his wife.
What information should the nurse include when teaching Mr. Glenisky and his wife?

Answer 49

dietary restrictions before the surgery
medications to take or to hold
the tests needing to be done 24 hours before the surgery
the surgery process (preoperative, perioperative, and postoperative information)
pain control after the surgery
Rationale: Preoperative patient and family education decreases anxiety and the fear of the unknown allowing the patient to focus on recovery. Education prepares the patient for the procedure, allowing the procedure to be completed in a timely manner (for example, the patient completes the preoperative testing on time for results to be analyzed by the surgeon).

Question 50

Mr. Glenisky and his wife arrive at the hospital for his surgical procedure. He is admitted and taken to his hospital room in which he will return to after the surgery. The nurse shows Mr. and Mrs. Glenisky the IV and pain pumps, pneumatic compression devices, wound drain, and an indwelling catheter.
What is the purpose of taking Mr. Glenisky and his wife to his room and showing them the postoperative equipment before the surgical procedure?

Answer 50

Answer: The purpose is to reduce stress and anxiety by familiarizing Mr. Glenisky with his surroundings and the equipment that will be attached to him after the surgery.
Rationale: A familiar environment and knowledge of the equipment that will be used will reduce patient stress and anxiety.

Question 51

Mr. Glenisky is in bed waiting to be taken to the surgical suite. The nurse has administered preoperative medications, including antianxiety and opioid medications.
What safety precautions should the nurse take to ensure that Mr. Glenisky remains safe?

Answer 51

call light within patient reach
siderails up
may be family member at the bedside
take Mr. Glenisky to the bathroom before administering his medications
door open or ajar
Rationale: The preoperative medications may decrease the patient’s level of consciousness and increases the risk for falls. All of these actions decrease the chance of falls and other injuries.

Question 52

Mrs. Sims is preparing to undergo a colonoscopy and is to receive IV moderate (conscious) sedation.
What should be the expected outcome for Mrs. Sims as she undergoes moderate (conscious) sedation?

Answer 52

A decreased level of consciousness
Ability to respond to verbal commands
Ability to maintain airway
Ability to breathe independently
Ability to maintain adequate perfusion (HR, BP, body temp)
Rationale: The purposes of IV moderate (conscious) sedation is to relax the patient so that the procedure will be more comfortable and less stressful, yet allow the patient to be responsive to commands.

Question 53

Mrs. Sims is ready for the procedure and begins to receive the IV drugs that will place her in moderate (conscious) sedation.
Discuss the role and responsibilities of the nurse who is monitoring Mrs. Sims as she is undergoing moderate (conscious) sedation.

Answer 53

It is important to monitor
the patient’s airway,
level of consciousness,
oxygen saturation,
carbon dioxide level,
ECG status,
vital signs every 5 to 10 minutes
Rationale: These must be monitored to ensure the patient is receiving appropriate dosages of the medications.

Question 54

The procedure is completed successfully and Mrs. Sims is transferred to the recovery area.
What actions should be taken by the nurse to ensure patient safety?

Answer 54

The nurse should monitor
the patient’s airway,
level of consciousness,
oxygen saturation,
carbon dioxide level,
vital signs every 15 to 30 minutes
return of gag reflex
Rationale: After successful moderate (conscious) sedation, the patient is calm, able to follow commands, and is oriented. If the carbon dioxide and oxygen saturation levels are normal, the patient has effective gas exchange.

Question 55

Ms. Kay, a 23-year-old female, is being transferred to the medical-surgical unit after an appendectomy 3 hours ago. She has an IV and an indwelling catheter.
What information should the PACU nurse provide to the unit nurse upon transfer of Ms. Kay?

Answer 55

Answer: Information may include response to surgery/medications, any unexpected events, vital signs, estimated blood loss, urinary output, and amount of IV fluids given.
Rationale: General anesthesia depresses brain function and has potential risks. The unit nurse needs to be informed of information that impacts the patient’s postoperative care. Knowing the physiological baseline of the patient’s status will help the nurse to trend data and identify any deterioration or improvement in condition. The report of information from one nurse to another nurse enhances continuity of care.

Question 56

Post anesthesia care unit (PACU)/Recovery Room purpose is:
Hand-off report (two-way verbal interaction)
Review Best Practice for Patient Safety and Quality Care

Answer 56

Overview of PACU and Hand-off report

Question 57

ongoing evaluation and stabilization of patients
anticipate, prevent, and manage complications after surgery

Answer 57

Post anesthesia care unit (PACU)/Recovery Room purpose is:

Question 58

Report between two health care professionals is required to communicate the patient’s condition and needs

Answer 58

Hand-off report (two-way verbal interaction)

Question 59

Postoperative Hand-off Report

Answer 59

Review Best Practice for Patient Safety and Quality Care

Question 60

Ms. Kay is transferred to the unit bed. Her family is in the waiting room and anxious to see her.
What priority assessments should the nurse make first?

Answer 60

Answer: Assessments should include focused assessment, the dressing, IV fluids, indwelling secured catheter, and respiratory and cognitive statuses.
Rationale: The nurse should establish a baseline of data with the initial assessment when the patient arrives on the unit. The priority assessments listed above are the elements of the focused assessment. Knowing the physiological baseline of the patient’s status, will help the nurse to trend data and identify any deterioration or improvement in condition.

Question 61

Airway (patent?)
Breathing (quality, pattern, rate, depth, accessory muscle use, oxygen, pulse oximetry, lung sounds)
Mental status (level of consciousness or awareness)
Surgical incision site (dressing, amount of drainage, bleeding, drains)
T, P, BP (baseline, different from PACU?)
IV fluids (type, how much infused, rate, monitor intake)
Other tubes (foley, NG, monitor output)
Pain assessment and management

Answer 61

Focused assessment on a med-surg unit after discharge from PACU

Question 62

Ms. Kay is to be discharged on the second postoperative day.
What information is important for the nurse to provide to Ms. Kay? How can the nurse measure Ms. Kay’s understanding of wound care instructions?

Answer 62

wound care, including S&S of infection
physical or activity limitations (if any)
medications
follow-up care
A return demonstration can measure the patient’s understanding of wound care.
Rationale: The patient must know how to take care of the surgical wound to prevent postoperative complications, be cognizant of any physical limitations that help with recovery, and when notification of the primary health care provider is required to ensure safe care and recovery. Return demonstration of wound care would best indicate the patient’s understanding.