Exam 1 Chapter 5 Flashcards
surgical classifications
diagnostic (eg. biopsy, exploratory laparotomy)
curative (eg. excision of a tumor or an inflamed appendix)
reparative (eg.multiple wound repair)
reconstructive or cosmetic (eg. mammoplasty or a facelift)
palliative (eg. to relieve pain or correct a problem-gastrostomy tube)
Emergent surgery
patient requires immediate attention; disorder may be life-threatening. without delay. Eg: severe bleeding bladder or intestinal obstruction fractured skull gunshot or stab wounds extensive burns.
Urgent surgery
within 24-30 hours
Eg:
acute gallbladder infection
kidney or ureteral stones
Required surgery
patient needs to have surgery plan within a few weeks or months Eg: prostatic hyperplasia without bladder obstruction thyroid disorders cataracts
Elective surgery
patient should have surgery failure to have surgery not catastrophic Eg: Repair of scars simple hernia vaginal repair
Optional surgery
decision rests with patient
Eg:
cosmetic surgery
surgical intervention should be tailored to?
patient’s symptoms
overall functional
health status
predicted benefit of the intervention
Elderly people frequently do not report symptoms because?
fear of serious illness.
acceptance of symptoms as part of the aging process.
Protective measures for the elderly patients
adequate padding for tender areas.
moving patient slowly
protecting bony prominences
Surgical risk for the elderly patients
decrease ability to respond to stress.
increase vulnerability to changes in circulating volume and blood O2 levels.
pulmonary edema (excessive or rapid IV solutions).
increase susceptibility to hypothermia.
skin complications.
airway occlusion
surgical risk for the obese patient
dehiscence
wound infections.
shallow respirations when supine=hypoventilation and pulmonary complications.
nursing management for the obese patient before surgery.
careful assessment of the cardiopulmonary status.
thorough wound assessments.
when does the preoperative phase begins and ends?
begins when the decision to proceed with surgical intervention is made, and ends with the transfer of the patient onto the OR table.
Nursing activities during the preoperative phase
base line evaluation of..
H and P (history and physical)
emotional assessment
previous anesthetic
identification of allergies or genetic issues.
ensuring necessary labs have been done or will be performed.
arranging appropriate consultations
providing education about recovery from anesthesia and postoperative care.
what is the primary purpose of the informed consent process for surgical services?
To ensure patients, or their representative is provided information necessary to enable him or her to evaluate the proposed surgery before agreeing to it.
who obtains the informed consent?
it is the responsibility of the performing surgeon.
How should the nurse determined patient’s nutritional needs?
measurement of body mass index (BMI) and waist circumference.
Normal BMI
18.5-24.9
BMI of less than 18.5
underweight
great than 25 BMI
overweight
BMI greater than 30
obese
A waist circumference measurement of greater than 40 inches for men and 35 inches in women is associated with?
increased cardiac risk.
Nutrients important for wound healing.
protein Arginine (amino acid) carbohydrates and fats water Vitamin C, E, A, K, B complex magnesium copper zinc
Alcohol withdrawal syndrome or delirium tremens may be anticipated?
between 48 and 72 hours.
The patient with diabetes undergoing surgery is at risk for?
hypoglycemia = during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin. hyperglycemia= stress of surgery because it triggers increased release of catecholamines .
surgical patients with type 1 diabetes are at risk for developing?
ketoacidosis : absence or inadequate amount of insulin. SxS: hyperglycemia ketosis dehydration electrolyte loss acidosis polydipsia polyuria acetone breath (fruity odor similar to overripe apples)
signs of adrenal insufficiency
hyponatremia hypoglycemia hyperkalemia weakness fatigue
patients with uncontrolled thyroid disorders (hyperthyroid) are at risk for?
thyrotoxicosis
patients with hypothyroid disorders are at risk for?
respiratory failure
Foods to determine latex allergies
bananas
avocados
kiwi
chestnuts
An important outcomes of the psychosocial assessment.
determination of the extent and role of the patient’s support network.
value and reliability of all available support systems.
level of functioning.
typical daily activities.
The effect of corticosteroids-Prednisone (Deltasone) with Anesthetics.
cardiovascular collapse if discontinued suddenly.
Tx: bolus of corticosteroid may be administered intravenously immediately before or after surgery.
Diuretics Hydrochlorothiazide (HydroDiuril) effect of interaction with Anesthetics.
may cause excessive respiratory depression resulting from associated electrolyte imbalance.
Phenothiazines Chlorpromazine (Thorazine) effect of interaction with anesthetics.
may increase the hypotensive of anesthetics.
Tranquilizers Diazepam (Valium) effect of interaction with anesthetics
may cause anxiety, tension, and seizures with withdrawn suddenly.
Insulin effect of interaction with anesthetics
IV insulin may need to be administered to keep the blood sugar within normal range.
Antibiotics Erythromycin (Ery-Tab) effect of interaction with anesthetics.
when combined with a curariform muscle relaxant, never transmission is interrupted .
apnea from respiratory paralysis may result.
Anticoagulants warfarin (Coumadin) effect of interaction with anesthetics.
increase the risk of bleeding.
Antiseizure medications
effect of interaction with anesthetics
IV administration may be needed to keep patient seizure free.
Monoamine Oxidase (MAO) Inhibitors Phenelzine sulfate (Nardil) effect of interaction with anesthetics.
may increase the hypotensive action.
Thyroid Hormone Levothyroxine sodium (Levothroid) effect of interaction with anesthetics.
IV administration may be needed during the postoperative period to maintain thyroid levels.
Central core disease (CCD)
genetic disorder presents in neonatal.
muscle weakness and hypotonia and mild facial weakness.
risk the risk of developing MH-malignant hyperthermia.
Duchenne muscular dystrophy and Becker dystrophy genetic disorders.
muscular dystrophies
risk for developing MH
Hyperkalemic periodic paralysis.
genetic disorder.
causes episodes of extreme muscle weakness.
associated with MH
King-Denborough syndrome
rare genetic disorder
musculoskeletal abnormalities.
associated with MH.
Preoperative Teaching
start in at the time of PAT
continues until patient arrives in OR
extends to discharge.
what is the goal of promoting coughing?
mobilize secretions, so they can be removed.
what may occur with infective coughing after surgery?
atelectasis (collapse of the alveoli)
pneumonia
lung complications
goal of promoting mobility postoperatively?
improve circulation
preventing venous stasis
promoting optimal respiratory function
what is the major purpose of withholding food and fluid before surgery (NPO)
To prevent aspiration.
goals of bowel preparation for patients undergoing abdominal or pelvic surgery? using cleansing enema or laxative
satisfactory visualization to prevent trauma.
contamination of the peritoneum by feces.
use the toilet or bedside commode to evacuate enema.
who is responsibly to relay the surgical findings and the prognosis?
The surgeon
when does the intraoperative phase begins and ends?
begins when patient is transferred onto the OR table and ends with admission to the PACU.
The surgical team
Circulating RN scrub person Registered nurse first assistant (RNFA) Surgeon Anesthesiologist and anesthetist (certified registered nurse anesthetists (CRNA)).
Responsibilities of the circulating nurse
checking and managing OR conditions
continually assessing the patient
verifying consent and ensuring documentation is correct
coordinating the team
monitoring aseptic practices
implementing fire safety precautions
accounting for all surgical counts in collaboration with scrub person.
specimen management
ensuring second verification of the surgical procedure.
Responsibilities of the scrub person
performing surgical hand scrub
setting up the sterile tables
preparing sutures, ligatures and special equipment
anticipating supplies and instruments required
counting all needles, sponges as the surgical incision is closed.
Responsibilities of the registered nurse first assistant (RNFA)
handling tissue
providing exposure at the operative field
suturing
maintaining hemostasis.
responsibilities of the surgeon
performing the surgical procedure
heading the surgical team
Responsibilities of Anesthesiologist, anesthetist (CRNA)
assessing the patient before surgery.
selecting the anesthesia and administering it
intubating the patient if necessary
managing any technical problems related to the administration of the anesthetic agent.
supervising the patient’s condition throughout the surgical procedure.
A state of narcosis (severe CNS depression produced by pharmacologic agents), analgesia, relaxation, and reflex loss
Anesthesia
Patients under general anesthesia
not arousable
not even to painful stimuli
they lose the ability to maintain ventilatory function.
require assistance in maintaining a patent airway.
impaired cardiovascular function.
patients at greatest risk of anesthesia awareness
cardiac
obstetric
major trauma
Anesthetic agents used in general anesthesia
inhaled or administered by IV
what are the most reliable guides to patient’s condition when general anesthesia is administered?
responses of the pupils
BP
respiration
cardiac rates
Type of anesthesia used to block nerves in the peripheral and CNS?
local anesthesia
blocks transmission of pain sensation along nerve fibers.
topical application
local infiltration.
A form off local anesthesia in which an anesthetic agent is injected around nerves, so that the area supplied by these nerves is anesthetized?
regional anesthesia
spinal, epidural
peripheral nerve blocks
patient is awake and aware
Spinal Anesthesia
nerve block
anesthetic into subarachnoid space lumbar level (L4 and L5)
anesthesia of the lower extremities, perineum, and lower abdomen.
side in knee to chest position for the lumbar puncture.
Position on back when injection has been made.
EBP shows that healthy patients are allowed clear fluids up to 2 to 3 hours prior to surgery. True or False
True
Benzodiazepines (versed, valium, Ativan) properties.
relieve anxiety induce sleep produces amnesia no analgesic properties metabolized by the liver rapidly absorbed
when combined with opiates, increased the effect of the drug.
increase risk of respiratory depression.
Side effect of benzodiazepines (versed, valium, ativan)
CNS depression respiratory depression hypotension bradycardia drowsiness and ataxia fatigue and confusion weakness and dizziness
what is the reversal agent for benzodiazepines (versed, valium, Ativan)
Flumazenil (Romazicon)
Properties of Opioids (morphine, Demerol, Fentanyl)
analgesic and sedation
side effects of opioids (morphine, Demerol, Fentanyl)
respiratory depression N/V drowsiness hypotension, orthostatic hypotension bronchospasm in asthmatics metabolized in the liver excreted in the kidneys
what is the reversal agent for Opioids (morphine, Demerol, Fentanyl)
Naloxone (Narcan)
What are some properties of Histamine (H2) receptor antagonists (Tagamet, Pepcid, Zantac, Prilosec, Prevacid)
inhibit gastric acid secretion
Side effects: skin rash (hypersensitivity)
decreased RBC’s, WBC’s platelet synthesis
Nursing care: do not administer at same time as antacids
give oral preparation with meals.
Antiemetics (Reglan, Droperidol, Zofran, Phenergan)
Properties: Alleviate nausea and vomiting
Side Effects: drowsiness (CNS depression)
hypotension
dry mouth (anticholinergic effect)
blurred vision (dilation from anticholinergic)
in coordination
Anticholinergics (Atropine, Glycopyrolate, scopolamine)
Properties: decrease salivation, prevents bradycardia, inhibit smooth muscle contraction in GI tract.
Side Effects: decreased parasympathetic stimulation
decreased peristalsis, decreased salvation, urinary retention, CNS disturbances.
What will happen if a patient aspirates vomitus?
asthma-like attach severe bronchial spasms wheezing pneumonitis pulmonary edema extreme hypoxia
what should the RN do if gagging occurs during surgery/
turn pt to the side
lower head of table or bed
provide a basin
might have to suction
what is given to increase gastric fluid PH?
Bicitra
what medications can be given to decrease gastric acid production?
histamine (h2) receptor antagonist- cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid).
what is the most common cause of anaphylaxis?
medications
RN must be aware of the type and method of anesthesia used as well as the specific agents.
Intervention for hypoxia and other respiratory complications
vigilant monitoring of O2 status.
peripheral perfusion
pulse oximetry values
Hypothermia
Indicated by a core body temperature that is lower than normal (36.6C (98.0F) or less).
what is the goal of intervention if hypothermia occurs?
minimize or reverse the physiologic process.
what are some possible cause of temperature changes 12 hr after surgery?
effects of anesthesia medication low temp in OR body heat loss during surgical exposure (open body wounds or cavities) infusion of cold fluids inhalation of cold gases decrease muscle activity age
what are some possible causes of temperature first 24-48 hr after surgery?
inflammatory responses to surgical stress
lung congestion
atelectasis
what are some possible cause of temperature elevation above 100 F (37.7) third/later after surgery?
wound infection
urinary infection
respiratory infection
phlebitis
On what post-op day would an RN expect to see an elevated temp related to a wound infection?
3 days
wound infection is often accompanied by?
fever spiking in afternoon and near-normal in the morning .
intermittent high temp with shaking chills and diaphoresis indicates?
Septicemia
Nursing assessment for pts with altered temperature
frequent temperature
observe for early signs of inflammation and infection
what are some nursing implementations for pts with altered temperature after surgery?
encourage airway clearance chest X-ray culture if infection is suspected check order for antipyretics (temp 101.5) body cooling of temp over 103
conscious sedation
drug induced depress of consciousness
patient maintains own airway but yet achieves pain control.
combination of anxiolytic (midazolam, versed) and Opioid (fentanyl).
provides analgesia relieves anxiety and or provides amnesia.
Patients at risk for malignant hyperthermia
strong and bulky muscles
family genetic mutations
first degree relatives of persons who have been diagnosed or suspected.
an unexplained death of a family member during surgery that was accompanied by febrile response.
A rare inherited muscle disorder that is chemically induced by anesthetic agents such as halothane, enflurane and muscle relaxants succinylcholine?
Malignant Hyperthermia (MH)
When does malignant hyperthermia occurs?
anytime from anesthesia induction to 24 hours post-op
it can result in death.
what is the earliest sign of malignant hyperthermia
Tachycardia (heart rate >150)
what can trigger malignant hyperthermia?
trauma
heat
stress
medications (epinephrine, atropine, digitalis)
what is the immediate response when pts experience malignant hypperthermia
discontinuation of the triggering agent and hyperventilation (100% O2).
Dantrolene sodium 2.5mg/kg=20 vials by 2 RNs via 2 IV lines.
Procainamide for arrhythmias.
IV glucose and insulin, calcium chloride for hyperkalemia
sodium bicarbonate for metabolic acidosis based upon ABGs.
Reduce temp (ice bags to armpits, groin).
hypothermia blanket
diuretics to clear filtered myoglobin in urine.
Increase fluid to maintain urinary output.
Treatment of MH on the floor
call for help start icing patient start second IV line Administer O2 via non-rebreather mask Expect patient to be transferred to ICU
S&S of malignant hyperthermia
rapid onset of a high temp (110 F and can rise 1-2 degrees q.5min tetanus muscle rigidity (jaw tightening) elevated CO2 Tachycardia >150 Tachypnea decreased cardiac output (CO) Oliguria ( low urine output 300-500ml/day) Dark brown urine hypotension
what happens in malignant hyperthermia?
A biochemical chain reaction results in a sudden calcium rise in skeletal muscle cells.
Bloodless surgery
uses all available alternatives to decrease blood loss.
hemodilution
reduce temp (cold temp in OR causes increase platelet aggregation.
Re-use pt’s blood (cell saver)
Maximize blood production (FeSO4, EPO, Vit K)
use other blood components
plasma proteins, fibrinogen
General anesthesia is used for?
procedures requiring ..
significant skeletal muscle relaxation, long periods
awkward positions
extremely anxious patients
Stage 1 of general anesthesia
Beginning anesthesia
pt feels warmth, dizziness and detachment
ringing, roaring, buzzing in the ears
inability to move extremities easily.
RN, unnecessary noise and motion should be avoided.
Stage 2 of general anesthesia
Excitement
struggling, shouting, talking, singing, laughing or crying
uncontrolled movement.
RN: pt should be touch only for restrained purposes.
stage 3 of general anesthesia
pt is unconscious
lies quietly on the table
with proper administration of anesthetic, may be maintained for hours.
Stage 4 of general anesthesia
medullary depression
too much anesthesia has been administered
cyanosis develops = rapid death.
Tx: D/C immediately, initiate respiratory and circulatory support
what are the phases of general anesthesia
induction
maintenance
Emersion
what are the purpose of general anesthesia
Loss of sensation absence of pain amnesia LOC muscle relaxation
Implications for general anesthesia recovery
ABCs
airway
breathing
circulation
What are some ways local anesthesia can be administer
Topically
intracutaneously
subcutaneously
Local Anesthesia
autonomic nervous system blockade anesthesia in area affected skeletal muscle paralysis in area of affected nerve little systemic absorption rapid recovery little residual "hangover"
what are some possible discomfort for local anesthesia?
hypotension
seizures
purpose for regional anesthesia
Loss of sensation
absence of pain (in body region)
pt remains awake
spinal regional anesthesia
sensation loss and paralysis from umbilicus to toes
into subarachnoid space (CSF) below L2
Precautions: have HOB flat
Epidural regional anesthesia
sensation loss = waist to thighs
injection into epidural space
does not enter CSF
No LOC
identify some factors that influence pain tolerance
energy level
stress level
culture background
meaning of pain to patient
Nursing management to prevent fluid volume excess in patient with existing cardiovascular or renal disease, advance age and stress from surgery.
assessing the patency of the IV lines
ensuring the correct fluids are administered at the prescribed rate
recording I&Os.
reporting urinary catheter rate of less than 30mL/hour
if output of patient voiding is less than 240 mL/8hr
Monitor electrolyte and H&H levels
decrease H&H levels after surgery can indicate?
blood loss
dilution of circulating volume by IV fluids
“third space” associated with surgery fluid usually returns to the intravascular space by?
postop day(POD) 2 or 3
what can the RN do to stimulate circulation thereby preventing DVT?
leg exercises
frequent position changes to stimulate circulation
Patient teaching to prevent DVT
avoid positions that compromise venous return
raising the bed’s knee gatch
placing a pillow under the knees
sitting for long periods
dangling the legs with pressure at the back of the knees
what should the RN be concerned about when a patient gets out of bed for the first time after surgery?
orthostatic hypotension
when patient change from supine to a standing position.
changes in circulating blood volume and bed rest
S&S: increase in HR with 15 mm Hg in decrease in systolic pressure or 10 mm Hg in diastolic pressure.
weakness, dizziness, leg buckling, visual blurring.
what are the healing phases of surgical wound healing?
inflammatory
proliferative
maturation
why is nausea and vomiting after anesthesia common in obese people
fat cells at as reservoirs for the anesthetic.
nausea and vomiting after anesthesia are most common in
obese patient
women
patients who have undergone lengthy surgical procedures
what are some potential postoperative complications that occur in patients undergoing intestinal or abdominal surgery
paralytic ileus
intestinal obstruction
if the abdomen is not distended and bowel sounds are normal and patient does not have a bowel movement postop day 2 or 3 what should the nurse do?
notify the Dr. for laxative to be given that evening
interventions to promote bowel elimination after surgery
early ambulation
dietary intake
hydration
stool softener (if prescribed)
when are patients expected to void after surgery
8 hours
what types of surgeries place a patient at risk for urinal retention
hip
abdominal
pelvic
why are straight intermittent catheterization preferred over indwelling?
risk of infection is higher with indwelling catheter
what should be done when a patient is unable to void 8 hours postop and bladder scan verifies distention
straight catheterization which is removed after the bladder is emptied.
how many mL of urine in residual volume is consider diagnostic urinary retention
100 mL
what other tools can the RN use to assess residual urine when a bladder scan is not available.
palpating the suprapubic area for distention or tenderness after the patient urinates
what are some S&S of postop myocardial ischemia/infarction (MI)
dyspnea
hypotension
atypical pain ( fatigue, sweating, lightheadedness, difficult breathing
signs of angina (heart attack)
pressure
squeezing pain in left section of the chest
radiates to left shoulder, arm, jaw and back.
Nursing assessment for urinary retention
examined for quantity and quality
note color, amount, consistency and order
assess indwelling catheters for patency
urine output should be at least 0.5 ml/kg/hr
what are some expected outcomes for urinary retention
voids at least 180 ml within 6 hr (depending of Dr order and policy) clear yellow urine normal urine odor no urgency, frequency, dysuria no S&S of distention no fever, chills no WBCs, bacteria in urine
