Exam 1 Flashcards
labs and diagnostic testing preoperative
complete 1-2 weeks before surgery
- CBC
- electrolyes, glucose, LTF’s, albumin, BUN, and creatinine
- PT and PTT
- blood type and cross
- UA
-CXR and EKG
Pre-op orders to review with the patient
food and fluid restrictions
meds t take and meds to hold
smoking cessation
no alc before surgery
anticoags- when to hold
no shaving surgical site
bowel prep if appropriate
pre op assessment
provide baseline data
usually performed 1-2 weeks prior with another assessment 1-2 hrs before the actual procedure
DELEGATION: the skill of preoperative assessment cannot be delegated to assistive personnel ( weight, vitals, and measurements)
review unexpected outcomes and patient understanding of procedure
check pt allergies
pre op teaching
select best learning method for pt
involve family members and care givers where possible
plan to have the patient demonstrate expected post operative skills
described
DELEGATION: teaching cannot be delegated
unexpected outcomes and related interventions
check pt understand of post op exercises
Patient prep for surgery
confirming key assessment findings, providing ordered pre op procedures, verifying patient understanding, verifying required tests and procedures have been performed
DELEGATION: only get vital signs in stable patients, apply anti-embolism socks, help remove jewelry clothes and prostheses
- if patient cannot consent obtain from next of kin and document
- make sure form is signed and pt remained NPO
Post of exercises
coughing and deep breathing
incentive spirometer
early ambulation
turning and positioning
splinting
post op care phase 1
Takes place during the immediate recovery period
The first 1 to 2 hours are the most critical for assessing the aftereffects of anesthesia.
A patient’s condition can change rapidly; assessments must be timely, knowledgeable, and accurate.
A patient is usually ready for discharge home or to a general patient care unit in a hospital when specific standardized criteria are met.
Aldrete score
Postanesthetic Discharge Scoring System (PADSS)
post op delegation
The skill of initiating immediate anesthesia recovery of a patient cannot be delegated to AP. The AP may provide basic comfort and hygiene measures. The nurse instructs the AP by:
Explaining any restrictions for how to provide comfort measures.
Offering instruction in providing needed supplies.
Note: AP may be allowed to do more in ambulatory surgery recovery such as provide initial PO liquids.
post op unexpected outcomes
Patient exhibits respiratory depression
Promptly report assessment findings to surgeon.
Administer oxygen as ordered by nasal cannula. Give patients with chronic obstructive pulmonary disease (COPD) 2 L/min or less of oxygen (as ordered) to prevent hypercapnia.
Encourage deep breathing every 5 to 15 minutes.
Position to promote chest expansion (on side or semi-Fowler).
Administer prescribed medications
atient exhibits signs of hypovolemia.
Elevate patient’s legs. Do not lower head past flat position.
Promptly report patient’s present status to surgeon.
Administer oxygen at 6 to 10 L/min by mask per order.
Increase rate of IV fluid or administer blood products as ordered.
Monitor BP and pulse every 5 to 15 minutes.
Apply pressure dressings per order
Patient remains NPO because it is often necessary to return to surgery for control of bleeding.
Patient complains of severe incisional pain.
Administer analgesics; reassess and provide analgesia before pain is severe.
Pain sometimes lowers BP; analgesia may restore vital signs to normal.
Monitor vital signs carefully.
For patients with patient-controlled analgesia (PCA), be sure that patient is using device correctly. Teach family caregiver not to manipulate PCA.
Orthopedic surgery: Earliest symptom of compartment syndrome in extremity is pain unrelieved by analgesics.
early post op and convalescent stage
Early postoperative (Phase II) anesthesia recovery
Prepares a patient for self-care, care by family members, or care in an extended care environment
Convalescent (Phase III) anesthesia recovery
Provides ongoing care for patients who require extended observation or intervention after transfer from Phase I or Phase II.
post op delegation
The skill of providing early postoperative and convalescent phase recovery cannot be delegated to AP. AP may obtain vital signs (if patient is stable), apply nasal cannula or oxygen mask (but not adjust oxygen flow), and provide hygiene or repositioning for comfort. The nurse instructs the AP by:
Explaining how often to take vital signs.
Reviewing specific safety concerns and what to observe and report back to the nurse.
Explaining any precautions that affect how to provide basic hygiene and comfort measures.
early and convalescent stage unexpected outcomes
Unexpected outcomes and related interventions
Vital signs are above or below patient’s baseline or expected range.
Identify contributing factors.
Notify surgeon.
Patient complains of severe incisional pain.
Report to surgeon; discuss alternative analgesic option.
Try nonpharmacological pain control measures.
post op assessment
Receive patient and report
Anesthesia and circulating nurse
Reconnect any attachments
Airway – check breathing
Turn on side if possible
Head to side
Circulation
Color
Pulses
Cap refill < 3 sec
VS Q 5-15 minutes
Check Gag reflex
Call by name / attempt to arouse
Orient to location
Encourage coughing when awake
Monitor the wound
Dressing
Mark drainage
Drains: JP, Hemovoc, Penrose
Monitor output devices
Urinary catheter
NGT
Check IV
Site
Redness, swelling, edema, leakage, pain, warmth
Fluids
Rate
Pain / nausea control
Oral care
recording and reporting post op
Arrival time at PACU
VS and other physical parameters
LOC
Pain level
Dressings, tubes, character of drainage
I & O
Abnormal assessment findings and signs of complications to surgeon
transfer to floor
Room prep on surgical unit
Raise bed height / lock / call light
Supplies
Emesis basin, waterproof pads
Transfer with 3 or slide board
Check any tubes, IV’s, O2
post op assessment and documentation
VS and other physical parameters
On unit: Q 15 min X4; Q 30 min X2, Q hour X4
LOC
IV lines
Pain level
Dressings, tubes, character of drainage
I & O
Cardiorespiratory
Bowel sounds
Skin
Fall risk
Oral care
Abnormal assessment findings and signs of complications to surgeon
post op complications
spiration/Pneumonia
Atelectesis
Can be prevented by incentive spirometer
DVT/PE/renal failure
Hypovolemia
N/V/Constipation
Eviseration
Hemorrhage
Paralytic ileus
Infection
oxygen delivery
nasal cannula (1-6L 24-44%)
high flow nasal cannula ( up to 10L)
oxygen masks:
-simple face mask: 5-1L 40%-60% o2
-venturi mask: 4-12L, 24-60% o2 ( determined according to inserted disks or arrow reading on tube)
- patial rebreather: 10-15L 60-90% o2 (Inflate bad before applying)
- non rebreather: 15L 60-100% o2 ( one way valave, highest amount of o2 device, inflate before applying)
airway management
ambu-bag or bag valve mask
- face tent and nebulizer
administering oxygen therapy to a aptient with an artificial airway
- humidification is required
- parts: t tube, tracheostomy collar
types of suctioning
oropharyngeal, nasopharyngeal, tracheostomy
suctioning
indicated when a patient cannot clear secretions
S/S: irritability, fatigue, lethargy, change in mental status, syncope, dizziness, elevated RR, dysrhythmia, lower o2 sat and sob
Perform nasotracheal before oropharyngeal
Adult – insert catheter 6.5 in
Older children – insert 3-5in
Infants and Young Child – insert 1.5-3 in
oropharyngeal suctioning
Yankauer suction catheter
Rigid, minimally flexible plastic
Multiple openings
Used when secretions are copious and thick
nasopharyngeal suctioning
Small flexible sterile catheter, use sterile technique
Duration of procedure
10-15 seconds
Wait 1 min between each pass with supplemental O2
No more than 2 passes
Catheter sizes
Infant →5-6 fr
Small child →6-8 fr
Child →8-10 fr
Adults →10-16 fr
Suction pressures (mm/Hg):
Adult: 80-120
closed suctioning
Involves the use of multi-use suction catheter that is housed within a plastic sleeve and is attached to the patient’s airway
trach suctioning
Hyperoxygenate
Insert the catheter until patient coughs – pull back 0.4 in before applying suction
Suction should not be applied for more than fifteen seconds for adults
Reoxygenate and hyperventilate the patient prior to performing another suction maneuver – no more than 2 passes
Do not lubricate catheter
Trachostomies
Tracheostomy tube (TT)
Long term airway management
Often used for patients requiring prolonged mechanical ventilation
Complete healing of the stoma typically takes approximately 1 week
Tracheostomy cuff
TTs may be cuffed or un-cuffed
The purpose of the cuff is to provide a closed system
under inflation of the cuff promotes leakage
over inflation of the cuff can cause tracheal ulcerations
Trach care
Care includes securing tube, inflating cuff to appropriate pressure, maintaining patency by suctioning, and providing oral hygiene
Dressing changes
It is possible to administer oxygen with a trach mask or via nasal cannula if the TT is small.
Monitor O2sat
Monitor for:
Tube dislodgment
Tube obstruction
Dislodgement during the first postoperative week is a medical emergency
The most common cause of obstruction is a build-up of respiratory secretions in the tube
Suction via the tube can immediately remedy this
Suction as needed
Site should be inspected for indications of inflammation and infection
Dressing changes as per policy or as needed
Assess communication needs
recording and reporting for trachs
Record respiratory assessments before and after care; type and size of tracheostomy tube; frequency and extent of care; type, color, and amount of secretions; patient tolerance and understanding of procedure; and special care
to be provided in the event of unexpected outcomes
Record condition of stoma and skin around stoma site and under dressing
Record any interventions that were performed to address patient complications
Report accidental decannulation or respiratory distress
Types of catheterizations
Intermittent: removed when urine flow stops
Relieves bladder distention
Provides a sterile urine specimen
Assesses residual urine
Manages patients with spinal cord injuries, neuromuscular degeneration, and incompetent bladder
May be preceded by a bladder scan
Gender specific
Indwelling catheter
Long term: 3 weeks to 6 months
Severe retention with recurring UTI’s
Obstruction
Rashes, ulcers, wounds irritated by urine
Terminal illness incontinence and bed changes are painful
Indwelling: remains in bladder for a longer period of time (hours, days, weeks, etc.)
Reasons:
For an obstruction
During and after surgery
Assessment of output
Irrigations of the bladder
suprapubic catheter
Suprapubic: surgical insertion through the abdominal wall just above the pubic bone and into the bladder.
When a long term catheter is needed
Enlarged prostate
Stricture
Catheter facts
Catheter-associated urinary tract infection (CAUTI) prevention
Use aseptic catheter insertion using sterile equipment
Patients in need of long-term catheterization should be managed with intermittent catheterization
Use only trained dedicated personnel to insert urinary catheters
Use smallest catheter possible
Remove catheter as soon as possible
Secure indwelling catheters
Catheter-associated urinary tract infection (CAUTI) prevention
Maintain a sterile, closed urinary drainage system
Maintain an unobstructed flow of urine
Keep urinary drainage bag below bladder
When emptying the urinary drainage bag, use a separate measuring receptacle for each patient
Perform perineal hygiene daily and after soiling
Quality improvement/surveillance programs should be in place to alert providers that a catheter is in place and should include regular educational programming about catheter care
inserting indwelling catheter
Urinary catheterization (straight and indwelling)
Placement of a hollow flexible tube into the bladder to remove urine
An invasive procedure that needs a health care provider’s order
Requires strict sterile technique
Use is associated with numerous complications
Catheter-associated urinary tract infection (CAUTI)
Urinary catheters
Single-lumen catheters
Intermittent catheterization
Lumen is for urinary drainage
Double-lumen catheters
Indwelling catheters
Second lumen is for balloon inflation to keep catheter in place
Triple-lumen catheters
Third lumen delivers fluid from an irrigation bag into the bladder
