exam 1 (periop plus) Flashcards
consent needed for
Invasive procedures-biopsy Procedures requiring sedation Nonsurgical-arteriography Radiation Blood administration*
- Physician documents patient’s capacity to make medical decisions (if can’t, POA signs)
- Surgeon discusses treatment options and diagnosis
- Patient demonstrates understanding of disclosed information (write in own words)
- Patient signs consent
4 basic elements of preop informed consent
Nutritional status: BMI (18.5-24.9), Obese = cardiac risk Malnutrition = poor wound healing; correct fluid/electrolyte imbalance
Drugs/Alcohol: alcoholic=nutritional deficiencies; withdrawl 48-72 hrs
Respiratory status: ventilator, acute resp. infection (postpone), smokers
Cardiovascular status: controlled BP, ensure electrolytes are optimized
Hepatic/Renal function: optimal function so meds can be cleared
Blood status: cross match
preop health ass.
Endocrine function: diabeteic?–> wound healing/BS; corticosteroid use=risk for adrenal insufficiency (weakness, hyperkalemia, low BS, fatigue)
Immune function: allergies/sensitivity to meds
Medication use
Including preop medications: Blood thinners (aspirin), OTC
Psychosocial: anxiety, distress
Spiritual/Cultural Beliefs
Genetic disorders: *malignant hyperthermia,
preop health ass. continued
Begins when patient is transported to OR table and ends with PACU Patient safety Aseptic environment Proper function of equipment Provide surgeon with instruments Documentation Emotional support Positioning
Intraoperative nursing
Manages OR conditions (check temp, cleanliness of OR, safe, supplies)
Assess for signs of injury (implement interventions)
Verifies consent
Coordinates team
Monitors for aseptic technique
Fire safety precautions
Surgical counts (2nd verification, documentation)
intraoperative
Circulating nurse
Performs surgical hand scrub
Sets up sterile tables
Prepares special equipment
Anticipates the instruments and supplies that will be required (sponges)
Counts all needles, sponges and instruments along with the nurse
Intraop scrub person
Most people call it “First Assist” or “Assisting”
Handles tissue
Suturing
Maintains hemostasis
Can be a scrub person, RN, NP, PA, student, or even another surgeon
intraop
registered nurse first assistant
Exposure to blood/body fluids-double gloving, goggles, face shield
Latex-must identify pts. with these allergies, need a latex allergy cart and maintenance of precautions. There are latex free products
Laser risks-When the laser is in use, there must be a sign posted to alert personnel.
Foreign objects-left in people during surgery. Risk increases when surgery is emergent, when there is a complication and when the patient has a high BMI.
intraop care safety
top priority: risk for injury and infection
General
-Not arouseable
-*Can’t maintain airway
-Inhaled or IV-cross the blood-brain barrier
Inhaled
-Common
-Good for easy access/loss of peripheral access
-shut off/wake up & cough/deep breath
Intravenous
-alone or with inhaled sedation
-Works fast, wears off fast
general anesthesia
Opioids
-Morphine-premedication
-Fentanyl-epidural infusions, post-operative pain
Muscle Relaxants
-Vecuronium-intubation
-body fights back and makes surgery worse without this
IV anesthesia
-Etomidate-induction (cardio version: shock <3 off/on)
-Propofol-Induction & maintenance
-Midazolam-hypnotic-used as adjunct or induction
general anesthesia IV
-Blocks nerves in peripheral and central nervous system
-Can be used alone or with other types of anesthesia
-Administered by surgeon provider to specific areas-monitored by nurse (toxicity)
Blocks transmission of pain
Nurse needs to keep environment quiet for therapeutic reasons
regional anesthesia
Local
Extensive conduction nerve block-when local anesthesia is introduced into the subarachnoid space at lumbar level
Affects lower extremities, perineum, lower abdomen
Rapid onset
If reaches respiratory muscles-respiratory paralysis
Nausea, vomiting, pain, headache
*Headache-quiet environment, lay flat increase hydration
spinal
Conduction block-local anesthesia into epidural space
Differs from spinal due to site of injection and the higher anesthetic used
Epidural doses are higher than spinal
Less hypotension, less hemodynamic changes
*Headache-worse than spinal headache
If punctures the dura-anesthesia will flow upward and can have hypotension and negative respiratory affects.. need to
-Support airway
-IV fluids
-Vasopressors for blood pressure support
doses are higher: anesthetic doesn’t make direct contact with spinal cord/nerve roots
regional anesthesia - epidural
no spinal or epidermal if..
scoliosis, osteoporosis, osteoarthritis, obese
Cause:
leakage ofspinalfluid through a puncture hole in the tough membrane (dura mater) that surrounds thespinalcord. This leakage decreases the pressure exerted by thespinalfluid on the brain andspinalcord, which leads to aheadache.
Symptoms:
lowerbackpain,nausea,vomiting,vertigoand tinnitus
Treatment:
May resolve on their own (within a few days)
Blood patch
Keep flat and hydrate
spinal headaches
Blocks the brachial plexus, lumbar plexus and specific peripheral nerves
Advantages
-reduced physiological stress
-avoidance of airway manipulation
-avoidance of complications of endotracheal intubation and all side effects from general anesthesia
regional anesthesia
peripheral nerve block
Moderate sedation-sedation by non anesthesiologists
Administered by anesthesiologist or CRNA
IV administration of sedatives/analgesics to reduce anxiety and control pain
Goal-depress LOC to a moderate level to enable procedures to be complete
Patient maintains airway, respond to verbal stimuli
moderate sedation/monitored anesthesia care (MAC)
Can be administered by specially trained nurse-differs in each state
Never leave patient alone*
Short 1/2 life; take deep breaths until OK
Monitor EKG, oxygen status, vital signs, LOC
moderate sedation
Begins when admitted to post anesthesia care unit and ends with follow up evaluation at home
Nursing responsibilities
-Maintain patient’s airway (breathing on own, can lift legs)
-Monitor vital signs (increase due to pain)
-Assess effects of anesthetic agents
-Assess patient for complications
-Provide comfort (splint, reposition, talk)
Watch for malignant hyperthermia
postop phase
Phase 1-immediately after surgery Phase 2- prepared for discharge or admission to hospital PACU nurse provides care until -Baseline cognition -Stable vital signs -No evidence of complications
post anesthesia care unit PACU
Assess CSM-circulation, sensory, mobility
Know pt history
Patent airway-maintain pulmonary ventilation and prevent hypoxemia and hypercapnia….nurse checks oxygen and assesse resp. rate and depth, ease of respirations, O2 sats, breath sounds
Hypotension/shock-hypotension usually from blood loss and fluid loss. Pt’s 3rd space their fluids-intravascularly dry. Shock from hypovolemia and decreased intravascular volume.
Hemorrhage- Can be immediate or post op. Pt becomes restless, skin cold, pale, tachycardia, RR rapid and deep. CO decreases.
Hypertension/arrhythmias-sympathetic nervous system stimulation from pain, hypoxia or bladder distention. Arrhythmias-electrolyte imbalance, altered resp function, pain, hypothermia
PACU nursing responsibilities
Relieve pain & anxiety-IV opioids-watch for resp depression
Controlling n/v-very common. Administer anti-emetics
Prepare for discharge-remain in the pacu until fully recovered from anesthesia.
Aldrete score-scoring system to determine the pt’s readiness for transfer from the pacu. Assess pt q15 min and total score is calculated and recorded.
PACU nursing responsibilities
Hypothermia-anesthesia makes pt susceptible to hypothermia. SS reported to MD. Keep room warm as possible, warm blankets, oxygen, hydration, nutrition. Risk is greater in elderly.
N/V-very common after anesthesia due to accumulation of fluid in stomach, inflation of stomach, ingestion of fluids too soon. May need NG tube and anti-emetics are common. The sooner they can eat and drink the sooner peristalsis will occur. If no bowel sounds, can’t give anything by mouth—ileus and intestinal obstruction may occur. Watch for flatus.
Urinary retention-pt can’t feel their bladder as full due to anesthesia-if patient hasn’t voided in 8 hrs. need to bladder scan and may need to straight cath. Watch I&O-even if they have voided.
A/E of surgery anesthesia
Cardiac complications-mortality rate for surgical pts. who experience a MI after non-cardiac surgery is 15-25%. May present with dyspnea, hypotension, atypical pain.
DVT/PE-due to blood hypercoagulability after surgery, dehydration, decreased CO and bed rest. Pain in calf sign of dvt.
Pulmonary embolism from a DVT, sudden shortness of breath, tachypnea, tachycardia, chest pain, apprehension
potential complications
Infection surgical wounds classified (see pg. 144 Pellico)
Prophylactic care pre-op
Teaching-most will go home prior to diagnosis of wound infection
May need surgical intervention (incision and drainage)
Hematoma-concealed bleeding under skin of surgical site. Usually stops spontaneously but can cause clot formation within the wound and will delay healing.
Surgical site infections-increase length of stay, cost and complications. See pg. 144 in Pellico for different classifications of wound.
Wound dehiscence-disruption of surgical incision or wound-evisceration-protrusion of wound contents-usually due to sutures weakening, infection, distention or coughing.
potential complications
Hemoglbin
female: 12-16 g/dL
male: 13-18 g/dL
