Exam 2 Flashcards
Universal Protocol
A three system principle to be used whenever an invasive surgical procedure is going to be performed.
These principles are:
1) That a preoperative verification of all required documents, results of lab tests, and diagnostic studies are available before the surgery and that the surgery is consistent with the patients expectation
2) Marking the operative site with indelible ink to mark left and right distinction, multiple structures, and levels of the spine
3) A time out before starting the procedure for final verification of the correct patient, procedure, site and any implants
Time-Out
in a surgical procedure it is used for final verification of the correct patient, procedure, site and any implants
Malignant Hyperthermia
Autosomal dominant trait characterized by often fatal hyperthermia in affected people exposed to certain anesthetic agents
Informed Consent
Process of obtaining permission from a patient to perform a specific test or procedure after describing all risks, side effects, and benefits
Emergent Surgery
Surgery for a condition which is immediately life-threatening. Surgery must be performed within a few hours
Urgent Surgery
Necessary for patients health; often prevents development of additional problems (tissues destruction or impaired organ function); not necessarily emergency
Required Surgery
A procedure that should be performed soon Examples Cataract, spinal fusion, sinus operation, repair of heart or valve defect, cholecystectomy for symptomatic stone, excision of oversized fibroid of uterus
Elective Surgery
Performed on basis of a patients choice; is not essential and is not always essential for health
Optional Surgery
An operation the patient chooses to have done, which may not be essential to the continuation or quality of life
-ectomy
Denoting surgical removal of a specified part of the body
-oscopy
Observation or a visual examination
-otomy
A cutting operation
What is the preoperative phase?
The preoperative phase is the time before the surgery where tests, assessments, and medical history checks are performed to determine possible risks or complications as well as educating the patient and having them sign an informed consent form.
What is the intraoperative phase?
The intraoperative phase is the time the actual surgery is being performed. Before the surgery begins the patient will confirm their identity, surgical site and procedure. During this a time-out will be performed to verify that this is the right patient, site, and procedure.
What is the postoperative phase?
The postoperative phase is the time after surgery that is focused on patient recovery. The recovery phase is divided into three parts; immediate after surgery recovery, intermediate time in which the patient is hospitalized, and a convalescent phase
What should you assess during the preoperative time?
Health history and physical exam Medications and allergies Nutritional, fluid status Dentition Drug or alcohol use Respiratory and cardiovascular status Hepatic, renal function Endocrine function Immune function Previous medication use Psychosocial factors Spiritual, cultural beliefs
What are some medications that could potentially effect the surgical experience?
Corticosteroids Diuretics Phenothiazines Tranquilizers Insulin Antibiotics Anticoagulants Anticonvulsant medications Thyroid hormone Opioids Over-the-counter and herbals
What are some gerontologic considerations?
Cardiac reserves are lower
Renal and hepatic functions are depressed
Gastrointestinal activity is likely to be reduced
Respiratory compromise
Decreased subcutaneous fat; more susceptible to temperature changes
May need more time and multiple explanations to understand and retain what is communicated restriction
What are some immediate preoperative nursing intervention?
Patient changes into gown, mouth inspected, jewelry removed, valuables stored in a secure place Administering preanesthetic medication Maintaining preoperative record Transporting patient to presurgical area Attending to family needs
What should the patient be educated in to promote healing and well being after surgery?
Deep breathing, coughing, incentive spirometry
Mobility, active body movement
Pain management
Cognitive coping strategies
Instruction for patients undergoing ambulatory surgery
What are the expected outcomes after educating the patient and assessing them before the surgery?
Relief of anxiety
Decreased fear
Understanding of the surgical intervention
No evidence of preoperative complications
Who are the members of the surgical team?
Patient
Anesthesiologist (physician) or certified registered nurse anesthetist (CRNA)
Surgeon
Nurses
Surgical technicians
Registered nurse first assistants (RNFAs) or certified surgical technologists (assistants)
What are the basic guidelines for surgical asepsis?
All materials in contact with the surgical wound or used within the sterile field must be sterile
Gowns considered sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff
Sterile drapes are used to create a sterile field. Only top of draped tables are considered sterile
Items dispensed by methods to preserve sterility
Movements of surgical team are from sterile to sterile, from unsterile to unsterile only
Movement at least 1-foot distance from sterile field must be maintained
When sterile barrier is breached, area is considered contaminated
Every sterile field is constantly maintained, monitored
Items of doubtful sterility considered unsterile
Sterile fields prepared as close to time of use
The routine administration of hyperoxia (high levels of oxygen) is not recommended to reduce surgical site infections
What intraoperative complications should we be aware of?
Hypothermia Malignant hyperthermia Infection Nausea Emesis Anaphylaxis Hypoxia/ respiratory compilations
What are some adverse effects or surgery and anesthesia?
Allergic reactions, drug toxicity or reactions
Cardiac dysrhythmias
CNS changes, over sedation, undersedation
Trauma: laryngeal, oral, nerve, skin, including burns
Hypotension
Thrombosis
What are the responsibilities of the PACU nurse?
Review pertinent information, baseline assessment upon admission to unit
Assess airway, respiratory function, cardiovascular function, skin color, level of consciousness, and ability to respond to commands
Reassess VS, patient status every 15 minutes or more frequently as needed
Administration of postoperative analgesia
Transfer report, to another unit or discharge patient to home
What are some indicators of hypovolemic shock/ hemorrhage?
Pallor Cool, moist skin Rapid respirations Cyanosis Rapid, weak, thready pulse Decreasing pulse pressure Low blood pressure Concentrated urine
Perioperative surgery-
Includes activities performed by a professional registered nurse before, during, and after surgery
American society of anesthesiologists-
Assigns classification on the basis of a patients physiological condition independent of the proposed surgical procedure
What is a moribund patient?
A moribund patient is a patient who is not expected to survive without the operation
Atelectasis-
Collapse of alveoli, preventing the normal respiratory exchange of oxygen and carbon dioxide
Co-morbid-
A chronic long term condition existing simultaneously with and usually independent of another medical condition
Bariatric-
Obese
Obstructive sleep apnea-
A disorder of sleep and wakefulness resulting from periodic, partial, or complete obstruction of the upper airway
Oxygen desaturation-
a decrees in oxygen concentration in the blood resulting from any condition that affects the exchange of carbon dioxide and oxygen
Association of perioperative registered nurses-
Developed the use of professional perioperative standards
American society of perianasthesia nurses-
Provides guidelines for perioperative management and evaluation of process and outcome
Ambulatory surgery-
Patients and/or family caregivers assume responsibility for postoperative care
Preoperative teaching plan-
Instruction regarding a patients anticipated surgery and recovery that is given before surgery
Informed consent -
Process of obtaining permission from a patient to perform a specific test or procedure after describing all the risks, side effects and benefits
Intermittent pneumatic compression stockings-
Stockings that inflate and deflate to mimic walking by alternating intermittent pressure sequentially from the ankle to the knee and alternating calves
Preanasthesia care unit-
Area outside the OR where preoperative preparations are completed
Circulating nurse-
Assistant to the scrub nurse and surgeon whos role is to provide necessary supplies; dispose of soiled instruments and supplies ; and keep an accurate count of instruments, needles, and sponges used
Scrub nurse-
Registered nurse or operating room technician who assists surgeons during operations
Latex sensitivity-
Sensitivity to latex or latex related products
General anesthesia-
Intravenous or inhaled medications that cause the patient to lose all sensation and consciousness
Regional anesthesia-
Loss of sensation in an area of the body supplied by sensory nerve pathways
Local anesthesia-
Loss of sensation at desired site of action
Conscious sedation-
Administration of central nervous system-depressant drugs and/or analgesics to provide analgesia, relieve anxiety, and/or provide amnesia during surgical, diagnostic, or interventional procedures
Postanasthesia recovery score-
Score that determines if a patient is ready to be discharged after anesthesia has worn off
Malignant hyperthermia-
Autosomal dominant trait characterized by often fatal hyperthermia in effected people exposed to analgesic agents
Paralytic ileus-
Usually temporary paralysis of intestinal wall that may occur after abdominal surgery or peritoneal injury and that causes cessation of peristalsis; leads to abdominal distention and symptoms of obstruction
Collagen-
Tough, fibrous protein
Pressure ulcer-
Inflammation, sore, or ulcer in the skin over a bony prominence
Tissue ischemia-
Point at which tissues receive insufficient oxygen and perfusion
Blanchable hyperemia-
Redness of the skin caused by dilation of the superficial capillaries. When pressure is applied to the skin, area blanches, or turns a lighter color
Nonblanchable erythmia-
Area does not blanch which may indicate possible deep tissue damage
Blanching-
When normal red tones of light skinned patients are absent
Induration-
Hardening of the tissue, particularly of the skin, because of edema or inflammation
Friction-
Effects of rubbing or the resistance that a moving body meets from the surface on which it moves; a force that occurs in a direction to oppose movement
Fluctuance-
Soft, boggy felling when tissue is palpated; usually a sign of tissue infection
Granulation tissue-
Soft, pink, fleshy projections of tissues that form during the healing process in a wound not healing by primary intention
Slough-
Stingy substance attached to the wound bed
Eschar-
Thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn. It may be allowed to be sloughed off naturally, or it may need to be surgically removed
Exudate-
Fluid, cells, or other substances that have been discharged from cells or blood vessels slowly through small pores or breaks in cell membranes
Wound-
A disruption of the integrity and function of tissues in the body
Primary intention-
Primary union of the edges of a wound, progressing to complete scar formation without formation of granulation tissue
Approximated-
To come together, as in the edges of a wound
Secondary intention-
Wound closure in which the edges are separated; granulation tissues are developed to fill in the gap; and finally, epithelium grows in over the granulation, producing a larger scar than results with primary intention
Hemostasis-
Termination of bleeding by mechanical or chemical means or the coagulation process of the body
Fibrin-
Provides a framework for cellular repair
Epithelialization-
Process where a wound get covered with epithelial tissue
Hemorrhage-
Bleeding from a wound site
Hematoma-
Localized collection of blood under the tissues
Purulent-
Yellow, green, or brown drainage from a wound
Dehiscence-
Partial or total separation of wound layers
Evisceration-
Protrusion of visceral organs through a wound opening
Abrasion-
Superficial wound with little bleeding and is considered a partial thickness wound
Laceration-
Torn jagged wound
Puncture-
Deep piercing wound that bleeds in relation to its depth
Serous-
Clear, watery plasma drainage
Serosanguinous-
Pale, pink, watery; mixture of clear and red fluid
Sanguineous-
Bright red drainage; indicates active bleeding
Shearing force-
Forces that cause the skin to shear
Reactive hyperemia-
Hyperemia following the arrest and subsequent restoration of the blood supply to a part
Debridement-
Removal of nonviable, necrotic tissue
Vacuum-assisted closure (V.A.C.)-
A device that helps in wound closure by applying localized negative pressure to draw the edges of a wound together
Sutures-
Threads or metal used to sew body tissues together
Drainage evacuators-
Portable units that connect to tubular drains lying within a wound bed and excerpt a safe, constant, low pressure vacuum to remove and collect drainage
What are 5 signs and symptoms of inflammation?
Pain Swelling Redness Heat Impaired function of body part (if severe injury)
What are the three stages of inflammation?
Vascular & Cellular Responses
Exudate Production
Reparative Phase
What are the three stages of inflammation?
Vascular & Cellular Responses
Exudate Production
Reparative Phase
Cholecystitis-
Acute inflammation of the gallbladder
Cholelithiasis-
Formation or presence of stones in the gallbladder
What are some signs and symptoms of appendicitis?
Initially, Mild, continuous, generalized or upper abdominal pain
Pain becomes severe and localizes in right lower quadrant of the abdomen
Moving, walking, or coughing increases pain
Rebound tenderness at McBurney point
Extension or internal rotation of the right hip increases pain
Low-grade fever
Anorexia
Nausea & vomiting
What are some ways that appendicitis is diagnosed?
CBC* Urinalysis Abdominal ultrasound* Abdominal x-rays Intravenous pyelogram (IVP)
What are some signs and symptoms of gallbladder disease?
Pain
Abrupt onset
Severe, steady
Epigastrium and RUQ of abdomen
May radiate to back, right scapula, and shoulder
Anorexia
Nausea & vomiting
RUQ tenderness and guarding
Chills and feverWhat are some ways to diagnose gallbladder disease?`
Serum bilirubin CBC Serum amylase and lipase Abdominal x-ray Ultrasound of the gallbladder Oral cholecystogram Gallbladder scan (HIDA scan)
Ulcerative colitis-
Diarrhea with blood and mucus LLQ pain Fever rare Affects mucosa and submucosa continuous from rectum Granular, dull, hyperemic, friable Complications Toxic megacolon, perforation, massive hemorrhage Colorectal cancer
Crohn disease-
Diarrhea no blood or mucus RLQ or periumbilical pain w/ mass Fever Patchy, skip lesions throughout entire bowel wall Cobblestone appearance Complications Obstruction, fistulization, abscess formation, malabsorption Colon cancer
What is the point called where the appendix is found?
McBurney’s point
What is the cause of acute cholecystitis? What follows after?
Obstruction of the cystic duct by a stone which creates ischemia of the gallbladder wall & mucosa. Chemical & bacterial inflammation follows. Ischemia can lead to necrosis & perforation of the gallbladder wall.
What is the cause of chronic cholecystitis? What can be present in the bile due to cholecystitis?
Repeated cases of acute cholecystitis or by irritation by stones. Bacteria can be present in the bile.
Who is most at risk of gallbladder disease?
Greater in women who are overweight and who are multiparous
What groups have a higher risk of developing gallstones?
Native Americans have higher incidence of gallstones than Caucasians. Thought due to a genetic predisposition to secrete higher levels of cholesterol in bile.
Mexican American men & women of all ages also have elevated rates of gallstones
What is a non-surgical procedure that can be done to remove gallstones?
Endoscopic retrograde cholangiopancreatography (ERCP)- Scope passes into gallbladder & crushes stones & left to pass on their own. These patients are more prone to pancreatitis. Need to be alert for signs & symptoms of pancreatitis.
Extracorporeal shock wave lithotripsy
What are some surgical procedures that can be done to remove gallstones?
1) Laparoscopic cholecystectomy is the treatment of choice- minimally invasive, requires hospitalization of 24 hours or less
2) Laparotomy only if there is a reason not to perform a Lap chole
3) If a stone is lodged in a duct, then a cholecystectomy with common duct exploration may be performed resulting in a possible T-Tube is insertion to maintain patency of the duct.
4) Cholecystotomy- Gallbladder is drained & is performed for those who are a poor surgical candidate.
5) Choledochostomy-Removes stones in the duct with T-Tube placement in common duct until healing takes place. Again, for patients who are not good surgical candidates.
6) Percutaneous cholecystectomy-US guided drainage of GB for surgical high risk patients.
What can cause acute pancreatitis?
Alcoholism & gallstones are primary factors
What can cause chronic pancreatitis?
Alcohol abuse, autoimmune disorders, cystic fibrosis, hypertriglyceridemia, hyperparathyroidism, medications such as estrogens, corticosteroids, & thiazide diuretics
When does acute pancreatitis occur?
Occurs when there is digestion of the pancreas by its own enzymes, primarily trypsin
What is chronic pancreatitis?
A progressive, destructive disease that causes permanent dysfunction
What is the average lab value of magnesium?
1.5-2.5 mg/dL
What is the average lab value of phosphate?
2.5-4.5 mg/dL
What is the average lab value of potassium?
3.5=5 mEq/L
What is the average lab value of calcium?
8.5-10.5 mg/dL
What is the average lab value of chloride?
95-105 mEq/L
What is the average lab value of sodium?
135-145 mEq/L
How is crohns disease diagnosed?
H & H –Decreased WBC- Increased Erythrocyte Sedimentation Rate (ESR)-Increased C-Reactive Protein (CRP)- Increased Serum Albumin- Decreased Stool for Occult Blood- Can be positive K+, Mg, and Ca-Decreased VCE (Video Capsule Endoscopy) Folic Acid and B12 Anti-glycan antibodies-Increased Urinalysis
How is ulcerative colitis diagnosed?
H & H –Decreased WBC- Increased Erythrocyte Sedimentation Rate (ESR)-Increased C-Reactive Protein (CRP)- Increased Serum Albumin- Decreased Stool for Occult Blood- Can be positive K+, Mg, and Ca-Decreased
What is characteristic of a Stage 1 pressure ulcer?
Skin will be intact with erythema
What is characteristic of a Stage 2 pressure ulcer?
Partial thickness skin loss will be present with erythema around the site
What is characteristic of a Stage 3 pressure ulcer?
Skin will have full thickness loss but will not involve the underlying fascia
What is characteristic of a Stage 4 pressure ulcer?
Full thickness skin loss will be present with extensive destruction of the tissues
What would make a pressure ulcer be unstageable?
The base of the ulcer being covered with slough and/or eschar would be present in the wound bed
