Complications Flashcards
During a hysteroscopy procedure the patient’s capnograph and pulse oximeter readings fall dramatically, and the patient becomes hemodynamically unstable. Quickly the team places the patient in which position? And why?
Left lateral position; the patient is likely experiencing a venous air embolism
The patient is in a sitting position with a skull pin headrest when an air embolism occurs. The most important measure the perioperative nurse can take is to:
Ensure that the scrub nurse has saline for the surgeon to irrigate, detect, and occlude the vessel
What is the morbidly obese patient’s most immediate risk after a ventral hernia repair?
Deep vein thrombosis
Obese patients are at high risk for DVTs. Thromboembolism Prophylaxis is used in these patients especially if their lower
extremities will be bent or in a dependent
position.
Incisional infections are defined as surgical site infections when they occur within how many days of surgery?
30 days
During the laparoscopic cholecystectomy the perioperative nurse keeps the CO2 at less than 15 mmHg because increased CO2 pressures cause…
Respiratory compromise
Over pressurization can force CO2 to diffuse
into the blood resulting in Hypercarbia. End tidal CO2 monitoring is crucial. Excess pressure also increases diaphragmatic pressure and reduced intrathoracic space and thus tidal volume.
While preparing the patient for abdominal surgery the perioperative nurse notices an infected tattoo on a 15-year-old patient’s hip. They patients pleads with the nurse not to tell his parents about the tattoo…
Explain to the patient why you must let the
surgeon and parents know about the tattoo and its condition
Need to be informed so pt can receive the care they need
The 44-year-old man is admitted with second and third degree burns over his back, chest, head, neck, arms and hands. He’s come to the OR for debridement of dead tissue. The most effective way to maintain normothermia in this patient is to provide…
A blood fluid warmer
The preoperative patient received midazolam and subcutaneous lidocaine for a right subclavian central line and an arterial line. The patient begins to experience shortness of breath, back and chest pain, and decrease 02 saturation. What is the most likely cause?
Pneumothorax
Immediate complication
In the PACU the post thoracic outlet surgery patient has a BP 170/110, Pulse 115, Temp 37.2. The JP drain is full, and dressing is bloody. Pt complains nausea. What is the first action of the perioperative nurse?
Call the surgeon
Thoracic Outlet surgery releases a compressed brachial nerve usually between the first rib and the scalene muscles. Most commonly post op complications are weakness numbness and tingling in the affected arm. They commonly have a JP drain but drainage should be minimal.
The perioperative nurse is assisting the anesthesiologist during an interscalene block. What potential complication of this block should the perioperative nurse be aware?
Horner’s syndrome and a hoarse voice
used to block nerves to the upper arm and shoulder.
A hoarse voice may also result from block of the recurrent laryngeal nerve. Horner’s syndrome is also a complication of the interscalene block. With a temporary Horner’s syndrome, the eyelid droops and the pupil constricts on the affected side of the face. Both are self-limited and will resolve as the block resolves.
The pediatric patient is recovering in PACU after a Nissen Fundoplication procedure. The child has pulled out her nasogastric tube. The PACU nurse should…
Call anesthesia to see if the tube can remain out
Anesthesia places the tube and it is most
appropriate to ask them to discontinue it.
Anesthesia may consult with the surgeon before answering.
Mr. B is undergoing a transuretheral resection of the prostate. The resectoscope uses sterile water as an expansion medium. The perioperative nurse takes care to monitor the patient. Why is special care taken when using sterile water as an expansion medium?
This can cause hypervolemia and hyponatremia
Deep resection allows for increased venous
absorption of solution.
Hyponatremia can cause cerebral edema. Therefore, saline is used more often in the newer resectoscopes.
The older resectoscopes used Glycine, but once metabolized by the body it too becomes sterile
water.
Mr. K has come to the OR for a bowel resection. His preoperative lab work shows a potassium of 2.9. What manifestations would you expect to find?
Hypotension
S/s of hypokalemia include ectopic beats, dysrhythmias, hypotension, muscle weakness, gastric distension paralytic ileus and urinary retention.
Opiate induced respiratory depression is a risk in patients with
OSA
24hr monitoring important
Unintentional hypothermia is core body temp less than
36°C (96.8°F)
Total spinal anesthesia (inadvertent)
Causes paralysis of respiratory muscles when spinal goes up
Need immediate intubation
Minor complication of anesthesia
Postop nausea and vomiting (PONV)
Major complication of anesthesia
Medication error
Dysrhythmias treatment- PVC
Lidocaine bolus
Followed by continuous drip
May need pacing
Dysrhythmias treatment– V-Tach
IV Lidocaine or procainamide
synchronized cardioversion
Dysrhythmias treatment– asystole
CPR
medications
Dysrhythmias treatment – V fib
Precordial thump
asynchronous defib
medications
Hypotension
20 to 30% lower from baseline
Hypertension
Persistently greater than 140/90
Acute MI patient risk factors
-Coronary artery disease
-diabetes
-significant dysrhythmias
Venous air embolism
-Occurs when air or gas is drawn into the circulation by the veins above the heart
-High risk in sitting/semi-sitting position
-neurosurgery or shoulder surgery
Venous air embolism treatment
Stop procedure
O2 100%
Control bleeding
Fill with fluid
Left lateral trendelenburg
CVP cath maybe placed to withdraw air of right atrium
IV fluids increased to move air
TEE to confirm diagnosis and insert catheter
CPR if needed
Iodism
Iodine poisoning
Pts most at risk: burns, current thyroid disorder, neonates, pregnant and lactating mothers
Can result in iodine induced hyperthyroidism
Preps on Neonates
CHG and alcohol can cause chemical burns and skin irritation
Central nervous system signs and symptoms of a local anesthetic systemic toxicity include
Numbness of the lips and tongue 
TUR syndrome
A rapid decrease in blood pressure and heart rate when being infused with 1.5% glycine as irrigation. 
Signs of a blood transfusion reaction
Hypotension
Hemoglobinuria
Hyperthermia 
Core body temperature that would indicate postoperative hypothermia
36°C (96.9°F)
Prolongs recovery time
Contributes to postoperative morbidity
Superficial surgical site infection
An infection with purulent incisional drainage involving only skin or incisional subcutaneous tissue that occurs within 30 days of the surgical procedure 
Ventricular fibrillation
A total disorganization of ventricular activity
Hypothermia complications
-Postop shivering increases O2 consumption by 400%
-myocardial ischemia
-cardiac arrhythmias below 90°F (32°C)
-Increased surgical site infections
-Acidosis
-Increase bleeding 99.9%
Medically induced hypothermia when
-Doing circulatory arrest in open heart, if working on root of aorta
-Slows their bleeding (0.1%)
possible question on exam
Avoiding complications - flap procedure
-vasoconstriction in graft areas, Biggest concern
-Monitor circulation with Doppler
-Protect site from shearing or pressure
-Keep warm
When should sequential compression devices be placed?
Before anesthesia, due to vasodilation and pooling (Venous stasis)
Signs of pulmonary emboli
-Painful
-Short of breath
-Sudden onset
-Pink frothy sputum
Fluid imbalances – burn patients
-Day 1&2: fluid shifts cause hypovolemia
Third spacing-fluid moving into tissue outside of vessels
-Day 3: fluid shifts back to vascular, causing hemodilution
Fluid imbalances – congestive heart failure patients
-Prone to fluid overload
-Tend to become vasodilated under anesthesia
Fluid imbalances – pediatrics
Small volumes= small margin of error
Fluid imbalances – Neuro patients
-fluid overload will increase ICP
-Dehydration decreases cerebral perfusion
-Autonomic dysfunction from cord injury causes loss of vasomotor tone (venous pooling d/t no vascular tone)
Fluid imbalances- liposuction
-Prone to hypovolemia
-Third spacing common
Fluid imbalances – diabetes insipidus
-trauma/surgery to pituitary gland or hypothalamus causes decrease in antidiuretic hormone
-Treat with vasopressin or DDAVP (desmopressin)
Fluid imbalances – renal patient
-prone to fluid overload
-When was the last time dialyzed?
Signs of fluid overload
-Edema
-Dyspnea
-rales
-weight gain
-Neck vein distention
-Increased CVP and BP
Sign of fluid overload in babies
Bulging fontanelle
Signs of hypovolemia
-postural hypotension
-Decreased BP
-Increased pulse
-Dry mucous membranes
-Decreased urine output
-Dizziness or fainting
Sign of hypovolemia in babies
Sunken fontanelle
Sodium normal value
135–145
Hyponatremia causes
-Irrigation fluid absorbed into venous sinuses
-Results from fluid overload
-hysteroscopies and TUR procedures
-Glycine and sorbitol leave behind free water after metabolism
Hyponatremia signs and symptoms
-N/V, irritability
-slowed breathing
-Headache, blurred vision
-Edema
-Muscle twitching, cramping
Hyponatremia treatment
-restrict fluids
-Diuretics
-hypertonic saline solution
If electrolyte does not start with the letter P
Electrolyte and muscle symptoms are opposite
Ex: hyponatremia, hyper muscles
Hypernatremia causes
Hypovolemia from:
-Dialysis
-dehydration
-burns
-Diuretics
-Diabetes insipidus
Hypernatremia signs and symptoms
-thirst
-Concentrated urine
-Muscle weakness
-Seizures
-Coma
Treat with fluid
Potassium normal value
3.5-5
Hypokalemia causes
-Lost by diuretics (Lasix, hydrochlorothiazide)
-Bowel prep
-Vomiting or diarrhea
-Laxative abuse
-Alkalosis
Hypokalemia signs and symptoms
-Abdominal distention
-loss of bowel sounds
-Weakness or paralysis
-Hypotension
Treat with potassium replacement
Hyperkalemia causes
-too much in IV fluid
-Intracellular potassium
-ex: MH, succinylcholine to pt w/ degenerative muscle disease (cerebral palsy, muscular dystrophy, quadriplegic, paraplegic)
Potassium, hydrogen ion, and glucose are pals
Hyperkalemia signs and symptoms
-intestinal cramping
-Elevated T-wave
-Hypertension
-Spastic paralysis
-Cardiac standstill
Hyperkalemia treatment
-Kayexalate (takes several hours)
-D50 followed by insulin (potassium follows glucose)
-Correction of acidosis
Calcium normal value
8.5-10.5
Serum calcium bound to albumin
Normal ionized calcium value
4.5-5.6
Hypocalcemia causes
-Multiple banked blood transfusions (have citrate-keeps blood from clotting)
-Hypoparathyroidism
-parathyroid regulates calcium and phosphate levels (inverse relationship)
-Diuretics
Hypocalcemia signs and symptoms
-Twitching
-Laryngospasm
-cramping
-Arrhythmias
-Positive Chvostek’s sign (facial muscles twitch when cheek is tapped)
-Positive trousseau’s sign (inflated tourniquet or BP cuff, arm goes up or thumb twitches)
Treat with replacement
Hypercalcemia causes
-Medically from TPN
-Hyperparathyroidism
-Bone cancer/multiple myeloma (released from bone)
-Sarcoidosis (autoimmune disorder, increases GI absorption of dietary calcium)
Hypercalcemia signs and symptoms
-Neuromuscular depression
-Arrhythmias
Treat with
-Mirhramycin for bony tumors
-Phosphate replacement
Phosphate normal value
1-2 mEq/L
Hypophosphatemia causes
-Hypercalcemia
-Hyperparathyroidism
-Bone cancer/multiple myeloma
-Sarcoidosis (increases GI absorption of dietary calcium)
Hypophosphatemia signs and symptoms
-Neuromuscular depression
-Arrhythmia
Treat with
-mithramycin
-Phosphate replacement
Hyperphosphatemia causes
-hypocalcemia
-hypoparathyroidism
-parathyroid regulates calcium and phos levels
-Diuretics
Hyperphosphatemia signs and symptoms
-Twitching
-Laryngospasm
-cramping
-Arrhythmias
-Positive Chvostek’s sign
-Positive trousseau’s sign
Treat with replacement
Magnesium normal value
1.5.-2.5
Magnesium deficiency (hypomagnesemia) causes
-Poor nutrition
-Alcoholism
-pancreatitis
-Diuretics (potassium wasting diuretics also waste calcium and lastly magnesium)
Hypomagnesemia signs and symptoms
-Muscle spasms
-Twitching
Treat with replacement
Magnesium excess (hypermagnesemia)
-Sedative effect on the CNS
-Used for premature labor, preeclampsia
-Mag level 6-8
-Monitor mom and baby
-Treatment for V fib and torsade’s de pointes
RBCs normal range for women
3.5-5.5
RBCs normal range for men
4.3-5.9
Hematocrit normal range for men
42-52
Hematocrit normal range for women
37-47
Ideally, how should low H&H be treated?
With iron preoperatively
Normal range for platelets
150-450 uL
Not a problem for most surgeries if above 50 uL
Normal range white blood cells
5000-10,000 cells/mm3
Causes of increase in white blood cells
-Infection
-Autoimmune disease
-Leukemia
Causes of decrease in white blood cells
-prolonged infection
-bone marrow suppression
-Chemotherapy
-Radiation
Prothrombin time (PT)
11-12.5 sec
Evaluates the coagulation factors
-Extrinsic: VII
-Common: X, V, II and I (bills less than $20)
What does it mean if prothrombin time is out of normal range?
-Bleeding or clotting disorder
-Liver disease
-Warfarin (Coumadin) therapy*
-May cancel case if unsuspected
Partial thromboplastin time (PTT) normal value
30-40 seconds
Evaluates coagulation factors
-Intrinsic: XII, XI, IX, VIII
-common: X, V, II and I
What does it mean if PTT is out of normal range?
-bleeding or clotting disorder
-Heparin therapy*
-Hemophilia
-Shortened in early stage DIC
-May cancel case if unsuspected
During the preoperative assessment for a patient scheduled for an emergency C-section, the perioperative nurse notes that the patient’s magnesium level is 6mg/L. This places the patient at risk for
Hypotensive episode
Normal is 1.5-2.5
