Exam 2 module 3 part 6 Flashcards
Ch 36: Caring for the Surgical Patient
1
Q
What does perioperative nursing involve?
A
Care of clients before, during, and after surgery and other invasive procedures.
2
Q
What was perioperative nursing historically called?
A
Operating room nursing.
3
Q
What are the current responsibilities of perioperative nurses?
A
Provide and manage care, teach, and study the care of perioperative patients.
4
Q
What is the AORN?
A
Association of periOperative Registered Nurses.
5
Q
What is a significant component of preventing complications in perioperative nursing?
A
Hand hygiene.
6
Q
What are the consequences of preventable perioperative errors?
A
Surgery-related deaths, unfavorable financial impact on healthcare institutions, physical and emotional harm to patients.
7
Q
What is one of the three domains under which AORN organizes its perioperative patient outcomes?
A
Perioperative safety.
8
Q
What specific safety outcomes does AORN focus on?
A
Prevention of injury and freedom from infection.
9
Q
What do the 2021 National Patient Safety Goals by The Joint Commission include?
A
Preventing infection, improving accuracy of patient identification, using medication safely, performing a time-out before procedures.
10
Q
What is the aim of the National Quality Partners (NQP) Leadership Consortium?
A
Achieving better care, improved health for people and communities, making quality care more affordable.
11
Q
What are some current national priorities and goals established by the NQP?
A
Improving medication safety, promoting high-quality home-based healthcare, preventing maternal mortality.
12
Q
What is the Institute for Healthcare Improvement (IHI)?
A
An independent, not-for-profit organization working to reduce morbidity and death in American healthcare.
13
Q
What was one goal of the IHI’s 100,000 Lives Campaign?
A
Reduce surgical complications, specifically surgical infections.
14
Q
When should hand hygiene be performed?
A
Immediately before and after each patient contact
* After removing gloves
* Any time you may have come in contact with blood or potentially infectious substances
* Before and after eating
* After using the restroom
These practices are essential to prevent the spread of infection.
15
Q
True or False: Wearing gloves substitutes for hand hygiene.
A
False
Gloves must be removed, and hand hygiene should still be performed.
16
Q
What should be removed before performing hand hygiene?
A
Rings, watches, and bracelets
Wearing rings has been associated with an increase in skin microorganism count.
17
Q
What is the recommended length for fingernails?
A
Short and clean
Fingernails should not extend beyond the fingertips.
18
Q
How often should chipped nail polish be replaced?
A
At least every 4 days
Regular replacement helps maintain proper hygiene.
19
Q
What is the recommendation regarding artificial nails?
A
Do not wear artificial nails
Fungal growth often occurs under artificial nails.
20
Q
What should be checked on hands before performing hand hygiene?
A
Lesions or breaks in skin integrity
Ensuring skin integrity is crucial for effective hand hygiene.
21
Q
What are ‘Never Events’?
A
‘Never Events’ are serious and costly errors resulting in severe consequences for the patient, and are mostly preventable.
Medicare no longer reimburses institutions for care related to such complications.
22
Q
Why are ‘Never Events’ significant in healthcare?
A
‘Never Events’ are significant because they are believed to be reasonably preventable and should never happen in a hospital.
These events lead to severe consequences for patients and increased healthcare costs.
23
Q
What organization does not reimburse for care related to ‘Never Events’?
A
Medicare
This policy is in place to encourage hospitals to prevent these events.
24
Q
List three examples of ‘Never Events’ relevant to perioperative care.
A
- Surgery on the wrong body part
- Wrong surgery on a patient
- Foreign body left in a patient after surgery
Other examples include surgery on the wrong patient and DVT or PE after total knee or hip replacement.
25
What is the preoperative phase?
The preoperative phase begins with the client’s decision to have surgery and ends when they enter the operating room.
## Footnote
The duration and patient teaching during this phase depend on the type of surgery and the patient's overall health status.
26
What factors influence the length of the preoperative period?
The type of surgery and the patient’s overall health status.
## Footnote
These factors determine the extent of patient teaching and preparation.
27
True or False: Surgical site infections after certain elective procedures are considered 'Never Events'.
True
## Footnote
Specifically referenced in the context of bariatric surgery for obesity.
28
Fill in the blank: The preoperative period ends when the patient _______.
enters the operating room.
29
Who extends the definition of 'Never Events' to include all infections?
AORN, The Joint Commission, National Priorities Partnership, and IHI.
## Footnote
These organizations focus on improving patient safety and quality of care.
30
What does CDC target in relation to 'Never Events'?
Certain antimicrobial-resistant bacterial infections.
## Footnote
This is part of efforts to prevent infections that could lead to 'Never Events'.
31
What is Perioperative Nursing?
A specialized area of nursing with specific, established standards of care
## Footnote
Focuses on integrating care standards into the nursing process for each patient.
32
What do caring nurses ensure regarding patients before surgery?
That a person is cognitively and psychologically prepared for surgery
## Footnote
This preparation is essential for patient safety and understanding.
33
What does it mean for a nurse to advocate for patients in a perioperative setting?
Stopping the line and placing a HOLD on surgery when an error or risk is identified
## Footnote
This action demonstrates accountability and commitment to patient safety.
34
What phrase can a nurse use to express concern about a surgical procedure?
I have a concern
## Footnote
Other phrases include: 'We need to stop and verify' or 'I cannot send the patient until the surgeon reviews the procedure.'
35
True or False: Preventing errors and 'never events' is solely the responsibility of the surgeon.
False
## Footnote
It is everyone’s responsibility in the surgical team.
36
What does 200% accountability in perioperative care refer to?
Taking full responsibility for one’s actions and ensuring patient safety by advocating for necessary changes
## Footnote
This includes speaking up about concerns.
37
Fill in the blank: A caring nurse strives to integrate _______ into the nursing process.
[established standards of care]
38
What is the focus of nursing care during the preoperative phase?
Identifying existing health concerns, planning for intraoperative and postoperative needs, and providing preoperative teaching.
39
In what settings is preoperative nursing care delivered?
Variety of settings, including outpatient settings like endoscopy suites, physicians’ offices, and ambulatory surgery centers.
40
What percentage of surgeries in the United States are performed in outpatient settings?
More than two-thirds.
41
How are surgeries classified?
By body system, purpose, level of urgency, and acuity.
42
What is the significance of body system classification in surgery?
It helps determine the postoperative risk of infection.
43
Which body systems have a higher risk for infection during surgery?
Gastrointestinal (GI), respiratory, and genitourinary tracts.
44
What is ablative surgery?
Removal of a diseased body part.
45
Provide an example of ablative surgery.
Cholecystectomy (removal of a diseased gallbladder).
46
What is diagnostic (exploratory) surgery?
Surgery done to confirm or rule out a diagnosis.
47
Give examples of diagnostic (exploratory) surgery.
Biopsy and invasive tests, such as cardiac catheterization.
48
What is palliative surgery?
Performed to relieve discomfort or disease symptoms without producing a cure.
49
Provide an example of palliative surgery.
Nerve root destruction for chronic pain.
50
What is reconstructive surgery?
Surgery performed to restore function.
51
Give an example of reconstructive surgery.
Rotator cuff repair.
52
What is cosmetic surgery?
Surgery done to improve appearance.
53
Provide an example of cosmetic surgery.
Face-lift.
54
What is transplant surgery?
Replaces a malfunctioning body part, tissue, or organ.
55
What types of procedures are included in transplant surgery?
Joint replacements and organ replacement procedures.
56
What is procurement surgery?
Related to transplant surgery, involving harvesting an organ or tissue from someone brain dead for transplantation.
57
What is the definition of emergency surgery?
Requires transport to the operating suite as soon as possible to preserve the patient’s life or function
## Footnote
Common causes include internal hemorrhage, rupture of an organ, and trauma.
58
What is the time frame for urgent surgery?
Scheduled within 24 to 48 hours
## Footnote
Aimed at alleviating symptoms, repairing a body part, or restoring function.
59
What characterizes elective surgery?
Performed when surgery is recommended but not time sensitive
## Footnote
Allows the client to delay surgery to gather information or consider options.
60
Provide examples of elective surgery.
* Repair of a torn ligament
* Removal of rectal polyps
61
What does the adage 'the only minor surgery is someone else’s surgery' imply?
Reflects the anxiety that often accompanies surgery
## Footnote
Suggests that all surgery carries some level of risk.
62
How is surgery categorized by degree of risk?
Defined as major or minor based on seriousness or risk associated with the procedure
## Footnote
The degree of risk varies with the client's condition and the type of surgery.
63
What is major surgery?
Associated with a high degree of risk
## Footnote
Involves significant blood loss, complicated procedures, or vital organs.
64
Give examples of major surgery.
* Coronary artery bypass graft
* Nephrectomy (removal of a kidney)
* Colon resection
65
What is minor surgery?
Involves little risk and usually has few complications
## Footnote
Often performed on an outpatient basis.
66
Provide examples of minor surgery.
* Breast biopsy
* Inguinal hernia repair
67
What are the main factors that affect surgical risk?
Patient's age, general health, personal habits.
68
Which age groups are at the greatest risk during surgical procedures?
Very young and very old.
69
What are some risk factors for infants during surgery?
* Limited ability to regulate temperature
* Immature immune, cardiovascular, liver, and renal systems
* Increased risk for infection
* Increased risk for excess fluid volume and deficient fluid volume
* Minor blood loss may represent a substantial portion of total blood
* Difficulty calming due to inability to understand the situation.
70
What are common concerns for toddlers undergoing surgery?
Anxiety about separation from parents or caregivers, fear of the dark.
71
What fears do preschoolers commonly have regarding surgery?
Fear of damage to body parts, fear of pain, fear of needles.
72
What concerns might teens have related to surgery?
Fear of disfigurement resulting from scars.
73
What are common anxieties for young adults facing surgery?
Anxiety about the cost associated with hospitalization or surgery.
74
Why are older adults at increased risk during surgical procedures?
Less physiological reserve, often have comorbid conditions, physiological changes of aging.
75
List some physiological changes in older adults that predispose them to surgical risk.
* Decreased kidney function
* Diminished immune function
* Decreased bone and lean body mass
* Increased peripheral vascular resistance
* Decreased cardiac output
* Decreased cough reflex
* Increased time required for wound healing.
76
What characterizes a clean wound?
Uninfected; minimal inflammation; little risk of infection
## Footnote
Clean wounds are typically associated with surgical procedures that do not involve the GI, respiratory, or genitourinary tract.
77
Which surgical procedures are considered clean surgeries?
* Face-lift
* Cataract surgery
* Joint replacement
* Breast biopsy
* Tonsillectomy
## Footnote
These procedures are performed in a controlled environment with minimal risk of infection.
78
True or False: Clean wounds have a high risk of infection.
False
## Footnote
Clean wounds are specifically defined by their low risk of infection.
79
Fill in the blank: A clean wound is _______.
[uninfected; minimal inflammation; little risk of infection]
80
What are clean-contaminated wounds?
Not infected, but carry increased risk for infection
## Footnote
These include surgical incisions that enter the GI, respiratory, or genitourinary tract.
81
What are contaminated wounds?
Not infected, but carry high risk for infection
## Footnote
Examples include surgery to repair trauma to open wounds, such as compound fractures, and surgery in which a major break in surgical asepsis occurred.
82
What defines infected wounds?
Evidence of infection, such as purulent drainage, necrotic tissue, or bacterial counts above 100,000 organisms per gram of tissue
## Footnote
This includes a postoperative surgical incision of any type that has evidence of infection.
83
What may patients with altered cognition be unable to do regarding surgical procedures?
Understand preoperative instructions or give informed consent for surgical procedures
## Footnote
Patients with altered cognition may also require medications that interact with anesthetics and analgesics.
84
What is a potential effect of surgery and anesthesia on patients with preexisting dementia?
Aggravate preexisting dementia, confusion, and disorientation
85
What do acute infections increase the risk of in surgical patients?
Various postoperative complications
## Footnote
Especially postoperative pneumonia in patients with upper respiratory tract infections receiving general anesthesia.
86
What chronic condition affects the heart's ability to function efficiently?
Cardiovascular diseases (e.g., hypertension, congestive heart failure, MI)
87
What can limit the surgical risk associated with chronic cardiovascular disorders?
Well-controlled disorders with BP medications or cardiotonic medications
88
Chronic respiratory disorders increase the risk of what postoperative complication?
Respiratory infection
## Footnote
Conditions such as emphysema, asthma, or bronchitis may be exacerbated by general anesthesia.
89
What do coagulation disorders increase the risk of during surgery?
Hemorrhage and hypovolemic shock
90
What risk is associated with a hypercoagulation state?
Stroke, embolism, or intravascular clotting
91
How does diabetes mellitus affect surgical outcomes?
Delays wound healing and increases the risk of infection and cardiovascular disorders
92
What does liver disease impair in surgical patients?
Ability to metabolize amino acids, carbohydrates, and fat; manufacture prothrombin; detoxify medications
93
What are the risks associated with neurological disorders in surgical patients?
Vasomotor instability and potential for wide swings in BP
## Footnote
Patients with seizure disorders are more likely to have seizures in the perioperative period.
94
How can nutritional disorders affect surgical outcomes?
Risk for delayed wound healing, infection, and fatigue
95
What additional risks do obese patients face during surgery?
Cardiovascular disorders and impaired pulmonary function
96
What does renal disease affect regarding medication in surgical patients?
Ability to excrete anesthetic agents and regulate fluid and electrolytes
97
What types of medications may increase surgical risk?
Both prescribed and over-the-counter (OTC) medications
## Footnote
Box 36-3 provides specific examples of medications that can increase surgical risk.
98
What is one example of a supplement that may increase surgical risk?
High doses of vitamin E
## Footnote
Self-prescribing high doses of vitamin E may lead to an increased risk for bleeding.
99
What effect can certain herbal medications have on cardiac health?
Increase the risk for cardiac dysrhythmias secondary to potassium loss
## Footnote
This is one of the potential risks associated with herbal and alternative medications.
100
How can herbal medications interfere with anesthesia?
Interfere with metabolism of anesthetics because of their effects on the liver
## Footnote
This can lead to complications during surgical procedures.
101
List three effects of herbal medications on surgical risk.
* Increase the potential for excessive bleeding
* Decrease cerebral blood flow
* Cause hypertension
102
What is a potential interaction between herbal medications and opioids?
Increase the effects of opioids and sympathetic nervous system stimulants
## Footnote
This can complicate pain management during and after surgery.
103
How does smoking affect surgical risk?
Affects pulmonary function
## Footnote
Impaired pulmonary function can lead to complications during surgery.
104
What long-term effect of alcohol use increases surgical risk?
Contributes to liver disease, increasing the risk for bleeding
## Footnote
Liver disease can affect the metabolism of anesthetics and other medications.
105
How can alcohol and drugs interact with anesthetic agents?
Create adverse effects
## Footnote
This interaction can complicate anesthesia and recovery.
106
What is cross-tolerance in habitual substance abusers?
A condition where habitual substance abusers may need higher than normal doses of anesthetic and analgesic agents
## Footnote
This can complicate pain management and anesthesia during surgery.
107
What type of medications may potentiate the action of anesthetic agents?
Antibiotics
## Footnote
Certain antibiotics can enhance the effects of anesthetics.
108
Which medications increase the risk for bleeding during surgery?
Anticoagulants, Aspirin, NSAIDs, Tranquilizers
## Footnote
These medications inhibit platelet aggregation and affect coagulation.
109
What effect do antidysrhythmics have during anesthesia?
May impair cardiac function
## Footnote
Antidysrhythmics can interfere with normal heart rhythms.
110
How do antihypertensives affect surgery?
Increase risk for hypotension
## Footnote
These medications may interact with anesthetics to cause bradycardia and impaired circulation.
111
What is a potential effect of corticosteroids on surgical outcomes?
Delay wound healing and increase risk for infection
## Footnote
Corticosteroids can suppress the immune response.
112
What impact do diuretics have on patients undergoing surgery?
Alter fluid and electrolyte balance
## Footnote
This is particularly true for potassium balance.
113
What risk is associated with opioid use during surgery?
Increase the risk of respiratory depression
## Footnote
Opioids can significantly affect respiratory function.
114
Which medications may impair respiratory function during anesthesia?
Opioids, Tranquilizers
## Footnote
Both classes of medications can lead to respiratory depression.
115
Fill in the blank: __________ may impair cardiac function during anesthesia.
Antidysrhythmics
## Footnote
These drugs can disrupt normal heart rhythms.
116
True or False: NSAIDs can increase the risk of bleeding.
True
## Footnote
NSAIDs inhibit platelet aggregation, contributing to bleeding risk.
117
What types of medications may patients be allergic to?
Patients may be allergic to medications such as antibiotics (e.g., penicillin) and analgesics (e.g., codeine)
## Footnote
Allergies can also extend to tape, latex, and solutions used in surgery.
118
What does the Perioperative Nursing Data Set (PNDS) describe?
The PNDS is a standardized vocabulary designed to describe the care of perioperative patients
## Footnote
It is recognized by the American Nurses Association.
119
What does the latest update of PNDS reflect?
The latest update reflects the nursing process, including nursing assessment, diagnoses, identified nursing-sensitive outcomes, nursing interventions, and implementation and evaluation.
120
What are the benefits of the PNDS?
* Promotes better communication among nurses and healthcare providers
* Increases visibility of nursing interventions
* Improves patient care
* Standardizes evaluation of nursing care outcomes
## Footnote
Source: Westra & Peterson, 2016.
121
What model is the PNDS derived from?
The PNDS is derived from the AORN’s Perioperative Patient-Focused model.
122
What is the focus of the Perioperative Patient-Focused model?
The patient is at the center of the model and is the focus of care.
123
What does the perioperative nurse do within the healthcare system?
The perioperative nurse intervenes to assist the patient throughout the perioperative experience.
124
What are the domains involved in the outcomes achieved by the perioperative nurse?
* Health System domain
* Patient-Centered domains (which include Safety, Physiological Responses to Surgery, and Behavioral Responses to Surgery)
125
What does the Health System domain refer to?
The Health System domain refers to the system in which perioperative care is given, involving administrative and structural elements necessary for successful surgical outcomes.
126
What elements are included in the Health System domain?
* Equipment
* Supplies
* Staff
* Policies
## Footnote
These elements are necessary for successful surgical outcomes.
127
What is the purpose of the Pre-Procedure Checklist?
To ensure all sections are completed prior to the start of the procedure or surgery.
128
What information is included in the Preparation section?
Height, Weight, Height/Weight Last Documented, CXR/KUB Date Completed, EKG Date Completed.
129
Fill in the blank: Last oral fluid intake is documented as _______.
[specific time or amount]
130
What are the possible levels of consciousness listed?
* Awake
* Arousable to Stimuli, Pain
* Arousable to Stimuli, Tactile
* Arousable to Stimuli, Verbal
* Obtunded
* Unresponsive
* Unable to Assess
* Other
131
What must be verified regarding the identification band?
It must be on and verified.
132
True or False: The allergy band must also be verified.
True
133
What must the physician be informed about before the procedure?
Consent must be verified.
134
What does 'N/A' stand for in the context of the checklist?
Not Applicable
135
What are the types of oxygen delivery methods listed?
* Room Air
* Aerosol Face Mask
* Ambu
* BIPAP
* CPAP
* Face Tent
* High Flow Nasal Cannula
* Home Ventilator
* Nasal Cannula
* Nonrebreather Mask
* Oxyhood
* Partial Rebreather Mask
* Passive
* Simple Mask
* T-piece
* Trach Collar
* Ventilator
* VentaMask
* Other
136
What is required for the Anesthesia Consent?
It must be completed and verified.
137
What does 'H&P' refer to in the context of the checklist?
History and Physical
138
Fill in the blank: Last dialysis is documented as _______.
[specific date or time]
139
What are the categories for the status of lab results?
* Yes
* N/A
* No
* Results Normal
140
What is the significance of the 'Pre Anesthesia Assessment'?
It must be completed prior to the procedure.
141
What must be documented regarding medications given?
* Beta Blocker Given
* Hypoglycemic Given
* Narcotic Given
* Antibiotic Given
* Anticoagulant Given
142
What must be completed prior to the start of a procedure or surgery?
All sections must be completed
## Footnote
This includes checking patient identification, allergies, consent, and special needs.
143
What should be verified regarding the identification band?
On and verified
## Footnote
This is crucial to ensure patient safety and correct procedure.
144
What should be checked regarding the allergy band?
Allergy band on and verified
## Footnote
Confirming allergies is essential to avoid adverse reactions.
145
What is required regarding the H&P or progress note?
Must be within 24 hours
## Footnote
Ensures that the patient's current health status is documented.
146
What should be confirmed if the patient has special needs?
Yes or No
## Footnote
This helps tailor the care and preparation needed for the patient.
147
What needs to be documented about a pacemaker?
Make/Model
## Footnote
Important for anesthesia and surgical planning.
148
What should be done regarding the procedure(s)/surgery?
Enter correct procedure(s)/surgery without abbreviations
## Footnote
This prevents any miscommunication regarding the planned operation.
149
What must be verified about the physician?
Physician informed consent verified
## Footnote
Ensures that the physician has obtained informed consent from the patient.
150
What should be noted about the patient's skin condition?
Skin breakdown
## Footnote
Important for preventing post-operative complications.
151
What is required if a patient has a history of obstructive sleep apnea?
CPAP or BIPAP settings (if known)
## Footnote
Necessary for managing the patient's respiratory needs during surgery.
152
What must all surgical patients have regarding scrubs?
2 scrubs except in emergent situations
## Footnote
Ensures sterile conditions are maintained.
153
What should be removed from the patient before surgery?
Contacts, eyeglasses, dental appliances, loose teeth, makeup, nail polish, prosthetic devices, hair accessories, undergarments, jewelry
## Footnote
These items can interfere with surgical procedures and anesthesia.
154
What is the protocol regarding urinary catheters?
Present or not
## Footnote
This is important for managing patient needs during surgery.
155
Fill in the blank: All surgical patients must void on call, yes or _______
No
## Footnote
Ensures that the bladder is empty before the procedure.
156
What is the SENC competence related to nursing and interdisciplinary teams?
Effective collaboration through open communication, mutual respect, and shared decision making
## Footnote
This ensures safe and effective patient care.
157
What impact do two-minute surgical briefings have?
Improve communication and reduce delays and wrong-site surgery
## Footnote
Referenced study by Lee, 2016.
158
Why are surgical briefings important for team dynamics?
Encourage team members to speak up when there are misgivings or problems
## Footnote
Supported by findings from Seifert et al., 2017.
159
What factors determine the safety of discharging a surgical client to home?
Type of surgery, client’s condition, and support system
## Footnote
Assessment focuses on the client's ability to care for themselves.
160
What is a key question to assess a client's ability to manage post-surgery care?
Is the client able to take care of themself?
## Footnote
If not, identification of available caregivers is crucial.
161
What should be assessed regarding the caregiver's ability?
Does the caregiver have the necessary skills to provide care?
## Footnote
If not, can these skills be taught before discharge?
162
What home environment features should be evaluated for a client after surgery?
Facilitators and inhibitors of the client's progress
## Footnote
Examples include bathroom accessibility and stair navigation.
163
What follow-up considerations are important after a client's discharge?
How soon should the patient visit the physician? Will there be home nursing care?
## Footnote
These are critical for ongoing recovery.
164
What elements should be included in the optimal preoperative assessment of older adults?
* Cognitive ability
* Capacity to understand the surgery
* Nutritional status
* Risk factors for postoperative delirium and pulmonary complications
* Patient’s treatment goals and expectations
* Family and social support system
* Depression
* Cardiac status
* Functional status
* History of falls
* Detailed medication history, including polypharmacy
* Baseline frailty score
* Diagnostic tests specific to older patients
## Footnote
Guidelines referenced from Mohanty et al., 2016.
165
What is the purpose of preoperative screening tests?
To assess a patient's health status before surgical procedures
## Footnote
The type of testing depends on the patient’s age, health history, and facility policies.
166
What are the standard tests required for patients older than age 50 years before surgery?
Complete blood count (CBC), urinalysis (UA), and electrocardiogram (ECG)
## Footnote
Most institutions require a CBC and UA, and an ECG for patients older than age 50 years.
167
Is a routine chest x-ray recommended for all patients prior to surgery?
No
## Footnote
Chest radiology incurs extra costs and exposes patients to small risks from radiation exposure.
168
What additional testing might patients with chronic health problems require?
Additional diagnostic tests as per their specific health conditions
## Footnote
Refer to the Diagnostic Testing box for Common Preoperative Screening Tests.
169
What is necessary for all preoperative patients besides diagnostic testing?
Preoperative teaching
## Footnote
It is not necessary to write a nursing diagnosis of Knowledge Deficit for every patient.
170
How should a nurse approach the diagnosis of anxiety in surgical patients?
There is no need to always include a diagnosis of Anxiety
## Footnote
Almost all surgical patients have at least mild anxiety, and routine actions can help relieve it.
171
What should be considered before adding a nursing diagnosis to a care plan?
It should be addressed with something other than routine preoperative interventions
## Footnote
KEY POINT: Do not put any nursing diagnosis on the care plan unless you plan to address it.
172
What is the purpose of a urinalysis in preoperative screening?
To detect urinary tract infections (UTIs) and the presence of glucose or protein in the urine, which may indicate poorly controlled diabetes or renal disease.
## Footnote
Urinalysis is a common test used to assess kidney function and overall health.
173
What does a CBC measure in preoperative screening?
It measures irregularities in hemoglobin (Hgb) and hematocrit (Hct), with low Hgb indicating anemia, which may place the client at risk if significant blood loss occurs.
## Footnote
CBC stands for Complete Blood Count.
174
What is the purpose of an Electrocardiogram (ECG) in preoperative testing?
To detect cardiac dysrhythmias and other cardiac pathology.
## Footnote
ECGs are crucial for assessing heart health before surgery.
175
What is detected through a chest x-ray examination in preoperative screening?
To detect underlying pulmonary disease and reveal heart size, as an indicator of heart function.
## Footnote
Chest x-rays help in evaluating respiratory and cardiac health.
176
What is the purpose of blood type and crossmatch testing?
To identify blood type in the event that blood transfusion becomes necessary.
## Footnote
This test is critical for preventing transfusion reactions.
177
What does the comprehensive metabolic panel include?
Electrolytes, blood glucose, liver function tests (ALT, AST), serum albumin and protein, and renal function tests (BUN and creatinine).
## Footnote
This panel is used to detect underlying health problems that may affect surgical risk or outcome.
178
Fill in the blank: A fasting blood sugar test is used to detect _______.
[diabetes or poorly controlled diabetes].
## Footnote
Fasting blood sugar levels are essential for diagnosing diabetes.
179
What do serum electrolytes tests measure?
Sodium, potassium, chloride, magnesium, calcium, and pH imbalances, which affect cardiac and other organ function and fluid balance.
## Footnote
Maintaining electrolyte balance is crucial for overall health.
180
What does platelet count in a CBC affect?
Clotting ability.
## Footnote
Platelet count is important for assessing bleeding risk during surgery.
181
True or False: A low hemoglobin level indicates a risk of anemia.
True.
## Footnote
Anemia can increase the risk of complications during surgery.
182
What is the significance of measuring WBC count in a CBC?
It serves as an indicator of immune function.
## Footnote
Abnormal WBC counts can indicate infection or other health issues.
183
What is the basis for individualized nursing diagnoses for preoperative patients?
They evolve from your assessment of the patient.
184
When should you identify an actual nursing diagnosis for a preoperative patient?
Only if the patient has the defining characteristics for it.
185
What is a key point regarding risk (potential) nursing diagnoses?
Identify them only if the patient has an underlying condition that places them at higher risk than the average surgical patient.
186
What are the levels of anxiety that may be observed in preoperative patients?
* Mild
* Moderate
* Severe
* Panic level
187
What symptoms might indicate anxiety in a preoperative patient?
* Restlessness
* Trembling
* Increased pulse
* Other defining characteristics
188
What common reactions to surgery may preoperative patients experience?
Fear related to unknown outcomes, learning diagnoses, and prospect of pain.
189
What nursing diagnosis is used for patients with a preexisting health problem affecting airway clearance?
Airway Clearance Impairment.
190
What can often result in a disturbed sleep pattern in preoperative patients?
Anxiety about the upcoming surgery.
191
When is the nursing diagnosis of Ineffective Coping appropriate?
For a patient with extreme anxiety and concerns about surgery outcomes.
192
What nursing diagnosis applies to patients with a known allergy to latex?
Latex Allergy Reaction.
193
What factors contribute to the Risk for Latex Allergy Reaction diagnosis?
* Multiple surgeries
* Urinary catheterizations
* Daily latex exposure
* History of asthma
* Allergies to bananas, avocados, kiwi, chestnuts, or poinsettia plants
194
When is it appropriate to use a Knowledge Deficit diagnosis?
If the patient may not learn or the information is too complex to remember.
195
What is an example of a problem that could result from a Knowledge Deficit?
* Nonadherence to Therapeutic Regimen related to Knowledge Deficit of postoperative medications and office visits
* Risk for Infection related to Knowledge Deficit of wound care and asepsis
196
What is a key consideration for older adults over age 70 in nursing diagnoses?
They are likely to need individualized nursing diagnoses.
197
What unique risks do older adults present?
They often have other illnesses and physiological changes of aging.
198
How do older adults metabolize anesthetic agents compared to younger adults?
Differently.
199
What are two potential experiences older adults may have due to their metabolism of anesthetic agents?
* Confusion
* Gas Exchange Impairment
200
True or False: Physiological changes of aging do not impact the risks for older adults.
False
201
Fill in the blank: Older adults may experience _______ due to the different metabolism of anesthetic agents.
[Confusion or Gas Exchange Impairment]
202
What is a common condition among older adults related to heart health?
Coronary artery disease
## Footnote
Most older adults have at least some degree of coronary artery disease.
203
What potential complication can arise from orthostatic hypotension in older adults?
Risk for Falls
## Footnote
Hypotension can lead to falls in older adults.
204
What is one of the most common surgical complications in older adults?
Delirium
## Footnote
Delirium is common due to factors like age, functional disabilities, and coexisting conditions.
205
Name a factor that may increase the risk of delirium in older adults.
Poor vision and hearing
## Footnote
Other factors include male sex, depressive symptoms, and cognitive impairment.
206
What are some potential complications associated with age-related respiratory changes?
* Pneumonia
* Atelectasis
* Gas Exchange Impairment
* Ineffective Airway Clearance
## Footnote
Age-related changes include decreased chest wall compliance and diaphragmatic strength.
207
What are the age-related skin changes in older adults?
Dry, fragile skin; decreased turgor and elasticity
## Footnote
These changes can lead to risks for skin integrity impairment and pressure ulcers.
208
What musculoskeletal changes occur with aging?
Decreased bone mass and muscle fiber mass
## Footnote
These changes increase the risk for impaired physical mobility and falls.
209
Which central nervous system comorbidities are more common in older adults?
Dementia
## Footnote
Some CNS conditions may be aggravated by surgery and anesthesia.
210
What is a gastrointestinal change associated with aging?
Decreased gastrointestinal motility
## Footnote
This can lead to complications such as ileus and aspiration risk secondary to vomiting.
211
Fill in the blank: Delirium can lead to _______.
Acute Confusion
## Footnote
Delirium is characterized by acute confusion in older adults.
212
True or False: Age-related skin changes do not affect the risk for pressure ulcers.
False
## Footnote
Age-related skin changes increase the risk for pressure ulcers.
213
What is decreased bladder elasticity?
A reduction in the ability of the bladder to stretch and hold urine
## Footnote
This can lead to urinary incontinence and increased urgency.
214
What does decreased renal function refer to?
A decline in the kidneys' ability to filter blood and produce urine
## Footnote
This can result in fluid retention and electrolyte imbalances.
215
What are some side effects of medications that can affect genitourinary function?
Possible side effects include urinary retention, incontinence, and changes in renal function
## Footnote
Certain medications, especially diuretics and anticholinergics, may exacerbate these issues.
216
What are renal complications?
Issues related to impaired kidney function, including acute kidney injury and chronic kidney disease
## Footnote
These complications can arise from various factors, including medication side effects.
217
What is a urinary tract infection (UTI)?
An infection that affects any part of the urinary system, including the bladder and kidneys
## Footnote
UTIs are more common in individuals with urinary incontinence.
218
What is the risk for skin integrity related to urinary incontinence?
Increased risk of skin breakdown and pressure ulcers due to moisture from incontinence
## Footnote
Maintaining skin integrity is crucial in managing patients with urinary incontinence.
219
What does impairment related to urinary incontinence indicate?
A decrease in the ability to control urination, leading to involuntary leakage
## Footnote
This condition can significantly impact quality of life and may require interventions.
220
What is the purpose of the Perioperative Care domain in NIC?
To provide routine interventions for all preoperative patients
## Footnote
This domain includes interventions that are essential regardless of the patient's specific nursing diagnoses.
221
What is involved in Preoperative Coordination?
Facilitating preadmission diagnostic testing and preparation of the surgical patient
## Footnote
An example activity is notifying the physician of abnormal diagnostic test results.
222
What does Surgical Preparation entail?
Providing care immediately before surgery and verifying required procedures/tests and documentation
## Footnote
An example activity is completing the preoperative checklist.
223
What is the goal of Teaching: Preoperative?
Assisting a patient to understand and mentally prepare for surgery and postoperative recovery
## Footnote
An example activity is correcting unrealistic expectations of the surgery.
224
What must be confirmed before a surgical procedure?
That surgical consent has been obtained
## Footnote
This is a legal requirement and part of professional standards.
225
Who is responsible for obtaining the patient's informed consent?
The surgeon
## Footnote
The surgeon must provide necessary information and determine the patient's competence.
226
What does a signed consent form verify?
That the surgeon and patient have communicated adequately about the surgery
## Footnote
The signed form becomes part of the patient’s record and accompanies them to the operating room.
227
What is required of the nurse regarding the surgical consent form?
To verify that the surgical consent form is signed and witnessed
## Footnote
This is a critical responsibility of the nursing staff.
228
Fill in the blank: The surgeon is responsible for giving the patient the necessary information and determining the patient’s _______.
competence to make an informed decision about the surgery.
229
What is the purpose of administering antibiotics prophylactically?
To help prevent postoperative infection
## Footnote
This is particularly important before clean surgery involving the placement of a prosthesis or implant, clean-contaminated surgery, or contaminated surgery.
230
When should antibiotics be administered in relation to surgery?
Usually within 60 minutes preceding incision
## Footnote
This timing ensures that a bactericidal concentration of the drug will be present in serum and tissues.
231
How may antibiotics be administered if surgery lasts longer than the duration of the antibiotic?
Given at the start of anesthesia and repeated as needed
232
What routine medications are often held on the day of surgery?
Many routine medications, including insulin
## Footnote
For example, a patient with insulin-dependent diabetes may hold the morning injection or administer half of the normal dose.
233
How does NPO status affect insulin requirements?
It keeps the blood sugar lower than usual
234
Why might a patient receiving warfarin need to stop the medication before surgery?
To reduce the risk of bleeding during surgery
## Footnote
Patients may need to stop warfarin 7 days before surgery.
235
What must a patient do with artificial body parts before surgery?
Remove all artificial body parts, such as dentures, artificial limbs, or contact lenses
236
What are antiembolism stockings also known as?
Thromboembolic deterrent hose (TED hose)
237
What is the function of antiembolism stockings?
Compress the veins of the legs and increase venous return to the heart
238
What conditions do antiembolism stockings help prevent?
DVT and PE
## Footnote
They are used in conjunction with prophylactic medications (antithrombotics) to aid prevention.
239
What alternative methods are increasingly used instead of elastic stockings to prevent DVT?
SCDs and anticoagulation therapy
240
What is the primary purpose of antiembolism stockings?
To compress the veins of the legs and increase venous return to the heart.
241
Who is most in need of antiembolism stockings?
Older adults and those with risk factors for venous thromboembolism.
242
What are some risk factors for venous thromboembolism?
* Venous stasis (bedrest, lengthy surgery, varicose veins, heart failure)
* Vascular wall injury (surgery, IV catheter, irritating IV drugs, prior DVT, smoking)
* Hypercoagulability (estrogen therapy, oral contraceptive use, cancer, dehydration, pregnancy)
243
Why are older adults at higher risk for DVT?
They often have more than one risk factor for venous thromboembolism.
244
What safety measures can help prevent DVT in older adults?
* Range-of-motion exercises
* Applying antiembolism stockings
245
What types of antiembolism stockings are available?
* Foot to knee
* Foot to thigh
246
What does the Institute for Clinical Systems Improvement (ICSI) recommend regarding thigh-high stockings?
Thigh-high stockings should be avoided due to their tendency to roll and restrict circulation.
247
What feature do some antiembolism stockings have to assess circulation?
An opening at the toes.
248
Why is correct sizing and application of stockings important?
Stockings must be sized and applied correctly to be effective.
249
For which patients are antiembolism stockings contraindicated?
Patients with peripheral arterial disease.
250
What are the safety measures to prevent patient misidentification and wrong-site surgery?
Use a preoperative checklist, verify patient identity, mark the surgical site, take a time-out with all team members
## Footnote
According to The Joint Commission, these measures are essential for patient safety.
251
What should be used to mark the surgical site?
A permanent marker that will not be removed by the surgical skin prep
## Footnote
Involving the patient in the marking process is also recommended.
252
What is the purpose of a preoperative checklist?
To confirm that appropriate documents are available and activities have been performed
## Footnote
This step is crucial in ensuring patient safety before surgery.
253
What is a 'time-out' in the context of surgery?
A pause taken with all team members before starting the procedure
## Footnote
This practice is part of ensuring perioperative safety.
254
True or False: The patient's identity should be verified after they leave the preoperative area.
False
## Footnote
Verification should occur before the patient leaves the preoperative area.
255
What is the most common root cause of medical errors?
Communication failure
## Footnote
Referenced studies: Berger et al., 2015; D’Agostino et al., 2017
256
Why is good communication essential in perioperative care?
For patient safety
257
What must surgical team members receive to ensure successful communication?
A summary of the plan of care
258
What should surgical team members do if they have concerns about the procedure?
Speak up and be assertive
259
What is one way team members can clarify confusion during communication?
Ask questions
260
What must team members acknowledge to ensure effective communication?
That they have heard and understood
261
What type of feedback should be asked for and provided?
Critical information feedback (e.g., read back)
262
What is important to use during communication in the surgical team?
Standard terminology
263
What was associated with a reduction in morbidity, mortality, and length of in-hospital stay?
Implementation of the WHO Surgical Safety Checklist
## Footnote
Referenced study: Scott & Shafi, 2018
264
What type of briefings have been found to improve communication before surgery?
Two-minute briefings led by the attending surgeon
265
What do surgical briefings encourage team members to do?
Talk when there is no problem
266
True or False: Surgical briefings reduce delays and wrong-site surgery.
True
## Footnote
Referenced study: Lee, 2016
267
What must accompany the patient during transport to the operative area?
Preoperative checklist and patient’s chart
## Footnote
These documents are crucial for ensuring that all necessary information is available to the surgical team.
268
What should be done with the patient's valuables before transport?
Lock up according to agency policy or have the patient’s family keep them
## Footnote
This is to ensure the safety and security of the patient's personal items.
269
Can patients wear their glasses or hearing aids to the surgical suite?
Yes, if the patient has a significant sensory deficit
## Footnote
Arrangements should be made in advance with the surgical staff or anesthesia team.
270
What can children bring to the operating room for comfort?
A favorite toy
## Footnote
This helps to alleviate fears associated with surgery and separation from parents.
271
Why is it important to keep parents informed before a child's surgery?
To help them understand what to expect and to provide emotional support
## Footnote
This can reduce anxiety for both the child and the parents.
272
Fill in the blank: After preoperative care, the patient is ready for transport to the _______.
operative area
273
What should you do to prepare the postoperative room for a patient’s return after surgery?
Put clean linens on the bed and arrange the supplies and equipment needed
## Footnote
Ensure the bed is raised to stretcher height and the wheels are locked.
274
What is the intraoperative phase?
Begins when the patient enters the operating suite and ends when the patient is admitted to the postanesthesia care unit (PACU)
## Footnote
This phase involves all activities and care provided during surgery.
275
Fill in the blank: The intraoperative phase ends when the patient is admitted to the _______.
postanesthesia care unit (PACU)
276
What is the first action to take when transferring a patient to the surgical suite?
Prepare the postoperative room
## Footnote
This involves setting up clean linens and necessary supplies.
277
True or False: The wheels of the bed should be unlocked when preparing the postoperative room.
False
## Footnote
The wheels should be locked for safety.
278
What height should the bed be raised to when preparing for a patient's return from surgery?
Stretcher height
279
What chapter provides additional insights on preparing the room for a newly admitted patient?
Chapter 7
## Footnote
Refer to Clinical Insight 7-1 for detailed instructions.
280
List the key steps to prepare a postoperative room.
* Put clean linens on the bed
* Arrange supplies and equipment
* Raise the bed to stretcher height
* Lock the wheels
281
What is the term for the personnel who attend the client during the surgical procedure?
Intraoperative team
282
What are the two types of techniques used by the intraoperative team?
* Sterile technique
* Clean technique
283
What roles can a registered nurse (RN) fulfill during the intraoperative phase?
* Scrub nurse
* Circulating nurse
* RN first assistant (RNFA)
284
Who are the sterile team members of the intraoperative team?
* Surgeon
* Surgical assistant
* Scrub person
285
What is the first step the sterile team members perform before beginning surgery?
Surgical scrub of the hands and arms
286
What must sterile team members do after performing a surgical scrub?
* Dry with sterile towels
* Don sterile gowns and gloves
287
What professionals can serve as a scrub nurse?
* RN
* Licensed vocational nurse (LVN)/Licensed practical nurse (LPN)
* Surgical technician
288
What is one of the primary responsibilities of the scrub nurse?
Set up the sterile field
289
Fill in the blank: The scrub nurse prepares the surgical instruments and assists with the _______ of the patient.
Sterile draping
290
What does the scrub nurse maintain during the surgical procedure?
Integrity of the sterile field
291
True or False: The scrub nurse anticipates and responds to the surgeon’s needs.
True
292
What is an RNFA?
A registered nurse first assistant with additional education and training in surgical technique.
## Footnote
The RNFA serves as an assistant to the surgeon, a role historically filled by physicians.
293
Who is allowed to enter the sterile field?
Sterile team members only.
## Footnote
The creation of the operative field is explained in Clinical Insight 36-3.
294
Who are the members of the Clean Team?
Anesthesiologist or nurse anesthetist, circulating RN, biomedical technicians, radiology technicians.
## Footnote
These personnel abide by clean technique (medical asepsis) and do not enter the sterile field.
295
What roles do anesthesiologists or CRNAs perform?
Induce amnesia, analgesia, and muscle relaxation or paralysis with anesthesia.
## Footnote
They continuously monitor and evaluate the patient’s responses to the anesthetic agent and the surgical procedure.
296
What percentage of anesthetics in the United States are administered by CRNAs?
More than half.
## Footnote
CRNAs play a significant role in anesthesia administration.
297
What is the primary role of the circulating nurse?
Coordinate all activities in the operating room and act as a client advocate.
## Footnote
The circulating nurse continuously monitors the client and the sterile field.
298
What responsibilities does the circulating nurse have?
* Maintains a safe, comfortable environment
* Communicates with personnel outside the operating room
* Responds to emergencies
* Attends to the patient during the induction of anesthesia.
299
True or False: The circulating nurse enters the sterile field.
False.
## Footnote
The circulating nurse operates around and beyond the sterile field.
300
What are the three classifications of anesthesia?
General, conscious sedation, regional
301
What is the primary effect of general anesthesia?
Rapid unconsciousness and loss of sensation
302
Who administers general anesthesia?
An anesthesiologist or nurse anesthetist
303
What types of medications are used in general anesthesia?
Inhaled and IV medications that depress the central nervous system and relax musculature
304
List some agents used during general anesthesia.
* Muscle relaxants
* Paralyzing agents
* Narcotics
* Barbiturates
* Inhaled gases
305
What is an advantage of general anesthesia related to patient anxiety?
The patient is unconscious, so they experience no anxiety that might affect cardiac and respiratory functioning
306
How does general anesthesia affect muscle movement during surgery?
The muscles are relaxed, so the patient remains completely motionless
307
How can anesthesia be adjusted during a procedure?
It can be adjusted to accommodate age, physical condition, and the length of the procedure
308
What happens if complications occur during general anesthesia?
The anesthesia can be continued for longer than originally planned
309
What is a significant disadvantage of general anesthesia?
Mechanical ventilation is needed due to depression of respiratory and circulatory muscles
310
What risks are associated with general anesthesia?
* Death
* Heart attack
* Stroke
* Malignant hyperthermia
311
What is malignant hyperthermia?
A rare, often fatal metabolic condition that can occur during the use of muscle relaxants and inhalation anesthesia
312
What happens to skeletal muscles during malignant hyperthermia?
Metabolism increases, they become rigid, and temperature rises rapidly
313
Is predisposition to malignant hyperthermia inherited?
Yes, it is inherited
314
What are common minor complaints after general anesthesia?
* Sore throat
* Nausea and vomiting
* Headache
* Uncontrollable shivering
* Confusion
315
What is conscious sedation?
Conscious sedation provides IV sedation and analgesia without producing unconsciousness.
316
During conscious sedation, how aware is the patient?
The patient may feel sleepy but is aware of their surroundings.
317
How can a patient in conscious sedation be aroused?
The patient can be easily aroused by touch or speech.
318
What vital signs are monitored during conscious sedation?
BP, heart rate, respiratory rate, and oxygen saturation.
319
What is commonly administered to the patient during conscious sedation?
The patient usually receives oxygen via nasal cannula.
320
What effect do many medications used in conscious sedation have on the patient?
The patient may not recall aspects of the procedure afterward.
321
List two procedures where conscious sedation is commonly used.
* Bronchoscopy
* Cosmetic surgery
322
What is an advantage of conscious sedation?
Pain and anxiety are adequately controlled without the risks of general anesthesia.
323
What is a disadvantage of conscious sedation?
Not practical for highly anxious patients.
324
What is regional anesthesia?
Regional anesthesia prevents pain by interrupting nerve impulses to and from the area of the procedure.
325
How does a patient feel during regional anesthesia?
The patient remains alert but is numb in the involved area.
326
How may regional anesthesia be administered?
By infiltration of the surgical site and surrounding tissue with local anesthetics.
327
Name two local anesthetics used in regional anesthesia.
* Lidocaine
* Bupivacaine
328
What is the purpose of injecting medications into and around specific nerves in regional anesthesia?
To depress the sensory, motor, and/or sympathetic impulses of a limited area of the body.
329
What is a key advantage of regional anesthesia?
Low in cost, simple to administer, and requires a minimal recovery period.
330
What are the disadvantages of regional anesthesia?
May not be practical if the patient is highly anxious or if adequate pain control cannot be achieved.
331
What is a common concern patients have regarding regional anesthesia?
Many patients are apprehensive about being able to see and hear the procedure.
332
What is a Peripheral Nerve Block?
The injection of an anesthetic into and around a nerve or group of nerves.
333
What is a Bier (IV) block?
A nerve block technique where a tourniquet is placed on an arm or leg, and a local anesthetic is injected intravenously below the tourniquet.
334
What is the purpose of the tourniquet in a Bier (IV) block?
To limit venous return while allowing arterial circulation.
335
True or False: Patients feel pain in the extremity during a Bier (IV) block as long as the tourniquet is in place.
False
336
Fill in the blank: A nerve block is the injection of an anesthetic into and around a _______.
[nerve or group of nerves]
337
What are the advantages of Bier block?
Onset and recovery time are both rapid. The tourniquet decreases bleeding during the surgical procedure and prevents systemic absorption of the local anesthetic.
338
What are the disadvantages of Bier block?
Potential for systemic absorption of the anesthetic after tourniquet deflation. The tourniquet must not be left in place for more than 2 hours to prevent tissue damage.
339
What is Spinal Anesthesia?
Injection of an anesthetic into the cerebrospinal fluid (CSF) in the subarachnoid space that blocks sensation and movement below the level of the injection.
340
What types of surgical procedures is spinal anesthesia often used for?
Procedures in the lower abdomen, pelvis, and lower extremities.
341
What is a key advantage of spinal anesthesia?
Allows the patient to remain conscious during the procedure and usually does not depress respirations.
342
What are some disadvantages and side effects of spinal anesthesia?
Medication may migrate upward, potentially depressing respirations and cardiac rate. Side effects include hypotension, nausea, vomiting, urinary retention, and headache from leakage of CSF.
343
What position may help prevent respiratory paralysis in spinal anesthesia?
Fowler position.
344
What must be closely monitored after spinal anesthesia, and why?
Headache from leakage of CSF; it may require additional treatment by the anesthesia staff.
345
What can cause a sudden decrease in blood pressure during spinal anesthesia?
Pervasive vasodilatation due to blocking of sympathetic vasomotor nerves.
346
What may patients with complications from spinal anesthesia require during surgery?
Ventilation and support of blood pressure; they must be carefully monitored.
347
What is the primary purpose of epidural anesthesia?
To produce loss of sensation through infusion of anesthetic agents into the epidural space
## Footnote
Epidural anesthesia can be used for surgical anesthesia and postoperative analgesia.
348
What is a key advantage of epidural anesthesia compared to spinal anesthesia?
It is safer because the anesthetic does not enter the subarachnoid space
## Footnote
The depth of anesthesia with epidural anesthesia is not as great as with spinal anesthesia.
349
What can occur if epidural medication is inadvertently injected too deeply?
Hypotension and respiratory paralysis
## Footnote
Temporary mechanical ventilation may be necessary in such cases.
350
Why is epidural anesthesia considered ideal for obstetric procedures?
It allows the mother to remain awake and bond with the newborn
## Footnote
Mobility is limited for only a short time during the procedure.
351
What is the primary effect of local anesthesia?
Produces loss of pain sensation at a specific site
## Footnote
It is commonly used for minor procedures.
352
How can local anesthetics be administered?
Topically or injected
## Footnote
Topical anesthetics are applied directly to skin and mucous membranes.
353
What are commonly used local anesthetics?
* Lidocaine
* Benzocaine
## Footnote
These are preferred for their rapid absorption and rapid action.
354
Fill in the blank: Epidural anesthesia requires insertion of a thin catheter into the _______.
epidural space
355
True or False: Local anesthesia is typically used for major surgeries.
False
## Footnote
Local anesthesia is generally used for minor procedures, though it can be used postoperatively.
356
What is a potential use of local anesthetics after major surgery?
To infiltrate the operative area for postoperative pain relief.
357
What is spinal anesthesia?
The injection of a local anesthetic into the subarachnoidy space to block sensation and movement.
## Footnote
Spinal anesthesia is commonly used for lower body surgeries.
358
What is continuous epidural anesthesia used for?
To provide postoperative analgesia.
## Footnote
It allows for pain relief after surgery while preserving motor function.
359
What is the first step a circulating nurse takes in the preoperative holding area?
Verify that the surgical consent has been signed and witnessed and that the preoperative checklist is complete.
## Footnote
This ensures that all necessary permissions and preparations are in place.
360
What are the key assessments a circulating nurse performs on a client?
Assess the client’s anxiety level and physical condition, measure vital signs, examine the surgical site, and inspect IV lines, drainage tubes, and catheters.
## Footnote
These assessments help ensure the client's readiness for surgery.
361
What action is often taken by the circulating nurse or anesthetist in the holding area?
Starts an IV line if one is not already present.
## Footnote
This is a critical step for administering medications and fluids during surgery.
362
What should be given in the holding area if prescribed?
Preoperative medication.
## Footnote
This medication may help reduce anxiety or pain before surgery.
363
How often should vital signs be monitored during the intraoperative period?
Often, or even continuously.
## Footnote
Continuous monitoring helps detect any changes in the patient's condition promptly.
364
What does the WHO Surgical Safety Checklist cover?
The three phases of a surgical procedure: 'sign in,' 'time out,' and 'sign out.'
## Footnote
This checklist aims to enhance communication, teamwork, and safety.
365
Who reviews the surgical safety checklist?
The checklist coordinator.
## Footnote
The coordinator verbally checks that each element was completed.
366
What is the goal of using a surgical checklist?
To enhance communication, teamwork, and safety by addressing key activities in the perioperative process.
## Footnote
This practice is based on recommendations from WHO in 2009.
367
What is a common nursing interview question regarding the patient's identity?
What is your name?
368
What type of surgery are you going to have today?
Type of surgery
369
What is an important question to ask about the patient's companions?
Is someone here with you?
370
What should a nurse inquire about in terms of allergies?
Are you allergic to any medications, latex, or tape?
371
When is the last time that you had anything to eat or drink?
Last intake time
372
What should be asked regarding dental or optical prostheses?
Do you have false teeth, contact lenses, or any other prostheses that need to be removed?
373
What medication-related question should a nurse ask?
Have you taken any medications today?
374
What is an important question regarding implants?
Do you have any implants, such as metal plates or a pacemaker?
375
What should a nurse check for on the patient's body?
Do you have any scratches, bruises, or other wounds on your body at this time?
376
What are the potential complications of surgery?
* Hypothermia
* Fluid and electrolyte imbalance
* Excessive bleeding or hemorrhage
* Musculoskeletal injury secondary to positioning
377
What is a potential complication of anesthesia?
Aspiration
378
Are there any parts of your body that are painful, such as a stiff shoulder or leg?
Pain assessment
379
What checklist is mentioned for surgical safety?
WHO Surgical Safety Checklist
380
Fill in the blank: Most intraoperative nursing care consists of standard activities to be used for all patients, as in the _______ phase.
preoperative
381
What is a potential complication of surgery related to temperature?
Hypothermia
## Footnote
Hypothermia can occur due to exposure in a cool environment and the administration of cool IV fluids.
382
List some potential complications of surgery.
* Fluid and electrolyte imbalance
* Excessive bleeding or hemorrhage
* Musculoskeletal injury secondary to positioning
383
What is a potential complication of anesthesia that affects breathing?
Respiratory depression
## Footnote
Respiratory depression can occur due to the effects of anesthesia on the respiratory system.
384
True or False: Aspiration is a potential complication of anesthesia.
True
385
What nursing diagnosis is related to exposure in a cool environment and administration of cool IV fluids?
Perioperative Hypothermia
386
Risk for Aspiration is related to what factors?
Depressed respirations and reflexes
## Footnote
This diagnosis is particularly relevant for patients with weak cough muscles or poor gag reflex.
387
What nursing diagnosis applies to patients at risk of changes in fluid volume due to NPO status?
Risk for Fluid Volume Alteration
388
Fill in the blank: Risk for _______ Injury is related to patient factors such as edema and obesity.
Perioperative Positioning
389
What should be considered before using the nursing diagnosis for Risk for Latex Allergy Response?
Defining characteristics or risk factors
## Footnote
These diagnoses should not be used routinely for all patients.
390
What is a potential complication of anesthesia that involves blood circulation?
Cardiovascular compromise
391
True or False: All patients undergoing major surgery require nursing diagnoses.
False
392
What is a complication of anesthesia that can result in low blood pressure?
Vasomotor instability
393
List the potential complications of anesthesia.
* Aspiration
* Vasomotor instability
* Respiratory depression
* Cardiovascular compromise
394
What nursing diagnosis is especially relevant for very young, very old, and very thin patients?
Perioperative Hypothermia
395
Fill in the blank: Risk for Latex Allergy Response is related to multiple exposures or _______.
history of related allergies
396
What are the overarching goals in the intraoperative phase for a patient?
Be free from injury, remain physiologically stable, experience optimal surgical outcomes
397
What are individualized goals/outcome statements based on?
Patient’s nursing diagnoses
398
Fill in the blank: Maintains body temperature within the _______.
normal range
399
What is the minimum urine output expected for a patient in the intraoperative phase?
At least 30 mL/hr
400
What should a patient experience regarding lung sounds and airway during surgery?
Clear lung sounds and patent airway
401
What is one of the goals concerning skin, tissue, or neuromuscular injury during positioning?
Will have no injury as a result of positioning
402
What is the aim concerning healthcare-related infection during the intraoperative period?
Will not acquire healthcare-related infection
403
What does NIC standardized interventions for the intraoperative period include?
Interventions for all intraoperative patients, regardless of their individual nursing diagnoses
404
Who must perform Anesthesia Administration?
An anesthesiologist or nurse anesthetist
405
What role does the nurse play in anesthesia administration?
Assists in implementing a number of interventions
406
List three NIC standardized interventions for the intraoperative period.
* Anesthesia Administration
* Infection Control
* Surgical Assistance
Standard is for every patient
407
Fill in the blank: Sterile _______ is an important focus in the intraoperative period.
asepsis
408
What should healthcare providers always be mindful of during the intraoperative period?
Using hand hygiene
409
Name one intervention related to temperature regulation during the perioperative phase.
Temperature Regulation: Perioperative
410
What chapter should you review for more information on sterile asepsis?
Chapter 20
411
What does 'routine' mean in the context of nursing interventions?
Activities are planned and performed for all patients
## Footnote
Nursing interventions must always be performed with thought and skill.
412
What is the purpose of surgical skin preparation?
Reduces the risk of postoperative wound infection by reducing the microbial count at the operative site
413
When does skin preparation begin?
In the preoperative phase, when the client cleanses the skin with an antimicrobial solution the evening before and the morning of surgery
414
What should the intraoperative nurse assess during skin preparation?
Assess the skin for signs of infection, rash, or other skin irritation
415
What should be documented on the intraoperative record?
The condition of the skin
416
When is hair removal from the surgical site necessary?
Only if there is a large amount of hair or if the surgeon specifies a preference
417
What risks are associated with hair removal?
Increases the risk of abrasions or nicks in the skin, providing a portal of entry for bacteria
418
When should hair removal be performed?
In the preoperative holding area immediately before surgery
419
What methods should be used for hair removal to minimize skin irritation?
Clippers or depilatory cream
420
True or False: Hair removal should always be performed for all surgical patients.
False
## Footnote
Hair removal is only necessary if specified or if there is a large amount of hair.
421
What is the first step in preparing a surgical site?
Cleanse the surgical site and surrounding area with an anti-infective solution
## Footnote
Povidone-iodine (Betadine) is commonly used for this purpose.
422
What should be done if a client is allergic to iodine?
Use an alternative preparation solution
## Footnote
Alternatives to povidone-iodine should be readily available.
423
What factors determine the positioning of a patient in the operating room?
Factors include:
* Surgical site
* Access to airway
* Monitoring vital signs
* Comfort
* Safety
## Footnote
The ideal position for the surgical site may need to be adjusted based on these factors.
424
When is the patient usually positioned in the operating room?
After anesthesia has begun
## Footnote
This ensures the patient is comfortable and stable during positioning.
425
What tools can be used to maintain a patient's position during surgery?
Tools include:
* Straps
* Wedges
* Pillows
* Surgical table attachments
## Footnote
These help secure the patient safely and comfortably.
426
What is the responsibility of the circulating nurse regarding patient positioning?
Preventing positioning injuries
## Footnote
The circulating nurse monitors the patient to avoid complications.
427
Why are surgical patients at risk for pressure ulcers?
They often spend multiple hours in the same position
## Footnote
The risk is compounded by anesthetic agents that decrease tissue perfusion.
428
What is one measure to protect a patient from positioning injuries during surgery?
Padding bony prominences
## Footnote
This helps to distribute pressure and minimize skin breakdown.
429
True or False: The surgical team does not assist with patient positioning.
False
## Footnote
The surgical team often assists with positioning to ensure patient safety.
430
Fill in the blank: To prevent shearing, ______ the patient into position.
lift
## Footnote
Sliding the patient can increase the risk of skin injury.
431
What should be factored into the decision about how to position a patient with preexisting injuries?
Information about their injuries or discomfort
## Footnote
This ensures that the positioning does not exacerbate the patient's condition.
432
What is the primary responsibility of the circulating nurse before a surgical procedure?
Conduct a final verification process to confirm the correct patient, procedure, and site
## Footnote
This is in accordance with The Joint Commission guidelines from 2020.
433
What is one of the key responsibilities of the circulating nurse during surgery?
Assist the scrub nurse to prepare and maintain the sterile field
434
What does the circulating nurse gather for use during surgery?
Surgical supplies and equipment
435
How does the circulating nurse assist with additional supplies needed during surgery?
Obtains and opens them onto the sterile field
436
What types of supplies might the circulating nurse provide during surgery?
* Dressings
* Surgical equipment
* Medications
* Irrigating solutions
* Sutures
437
What does I&O stand for in the context of intraoperative monitoring?
Intake and output
438
Who monitors the fluid infused, urine output, drainage, and blood loss during surgery?
The circulating nurse, together with the anesthetist
439
What is the role of the circulating nurse regarding specimens during surgery?
Handles specimens and sends them to the laboratory or pathology for evaluation
440
What may the surgeon obtain that requires analysis during the operative procedure?
A tissue sample
441
What does the circulator do with the specimen after it is received?
Coordinates with the pathologist to review the sample and reports the pathology findings to the surgeon
442
What is the purpose of performing sponge, sharps, and instrument counts during surgery?
To ensure that no instruments, sponges, or sharps are left inside the client
## Footnote
A retained sponge can lead to infection and additional surgeries.
443
Who is responsible for counting the supplies added to the sterile field?
The circulating nurse and the scrub nurse
## Footnote
They perform a repeat count at the end of the surgery.
444
What can make sponges difficult to see in the body cavity during surgery?
Once soaked in blood, sponges can blend in with the body cavity
## Footnote
This is particularly concerning during major surgeries, such as heart surgery.
445
What technology is being used to prevent retained sponges?
Barcode scanning and radiofrequency identification technology
## Footnote
These systems alert the surgical team if a sponge is left behind.
446
What should be documented on the surgical record?
The care provided and the client’s response to care
## Footnote
This is usually done on a graphic or checklist form.
447
Fill in the blank: A retained sponge can lead to _______.
infection and additional surgeries
448
True or False: The surgical team relies solely on manual counting of sponges and instruments.
False
## Footnote
Agencies are now using advanced technologies such as barcode scanning and RFID.
449
What is the significance of performing a repeat count at the end of surgery?
To ensure no instruments, sponges, or sharps are left inside the client
450
What marks the beginning and end of the postoperative phase?
Begins when the client enters the PACU and ends when the client has healed from the surgical procedure
451
What are the two parts of the postoperative phase?
* Recovery from anesthesia
* Recovery from surgery
452
What is the first postoperative phase commonly known as?
Postanesthesia phase or immediate postoperative phase
453
When does the immediate postoperative phase begin?
When the patient is transferred from the operating table to a bed or gurney for transport to the PACU
454
What risks are patients at during the immediate postoperative phase?
High risk for respiratory and cardiovascular compromise
455
Who accompanies the patient during transport to the PACU?
The anesthetist and the circulating nurse
456
What is the role of the anesthetist and circulating nurse during transport?
Attend to any needs during transport and give a comprehensive report to the PACU nurse
457
What is the PACU and its typical characteristics?
Located near the operating room, typically an open unit allowing easy observation of patients
458
What type of education and experience do PACU nurses have?
Specialized education and experience in caring for postoperative clients, commonly with critical care experience
459
What does the PACU nurse receive from the anesthesia provider and circulating nurse?
A comprehensive report
460
What information is included in the report from the surgical suite? (List at least 5 items)
* Procedure performed
* Type of anesthesia
* Medications administered in the surgical suite
* Duration of the procedure and anesthesia
* Postoperative vital signs
461
Fill in the blank: The PACU nurse monitors _______ values.
Pulse oximetry
462
What types of complications may be noted in the report from the surgical suite?
Surgical complications
463
What information regarding fluid balance is included in the report?
Fluid I&O, including urine, stool, gastric losses
464
What preoperative status details are included in the report? (List at least 3)
* Mobility status
* Skin integrity
* Sensory perception abilities
465
What existing medical devices might be noted in the report?
* Presence of tubes
* Drains
* Catheters
* Existing IV lines
466
What is included in the report concerning postoperative care?
Postoperative prescriptions
467
What is the goal of the second phase of postoperative care?
To facilitate healing and prevent postoperative complications
## Footnote
This phase begins when the patient is discharged from the PACU.
468
When is a patient transported to the surgical unit after surgery?
After recovery from anesthesia is evident and the patient is stable
## Footnote
This ensures the patient's safety and readiness for further care.
469
What does the PACU nurse perform upon initial assessment of the surgical patient?
A quick, focused initial assessment in the presence of the anesthesia provider and circulating nurse
## Footnote
This assessment is crucial for determining the patient's immediate postoperative status.
470
How often does the PACU nurse assess the patient after the initial assessment?
Every 5 to 15 minutes
## Footnote
This regular assessment helps monitor the patient's recovery progress.
471
What is the only postoperative intervention from NIC’s Perioperative Care category?
Postanesthesia Care
## Footnote
This encompasses assessments and measures for patient safety.
472
What essential element must be determined by the PACU nurse regarding the patient's recovery?
That the patient has recovered from the effects of anesthesia
## Footnote
This includes the ability to maintain their airway.
473
Fill in the blank: The PACU nurse assesses the patient every _______ minutes.
5 to 15
474
True or False: The PACU nurse can transfer the patient to the surgical unit without confirming recovery from anesthesia.
False
## Footnote
The nurse must confirm the patient's recovery before transfer.
475
What is a common airway management tool used in the PACU?
Artificial airway or endotracheal tube
## Footnote
These tools help maintain the patient's airway until they recover from anesthesia.
476
What does the NIC intervention 'Postanesthesia Care' include?
Assessments and measures such as providing for safety and administering oxygen
## Footnote
This intervention is crucial for patient recovery in the PACU.
477
What is the recommended position for an unconscious client to maintain an open airway?
On their side
## Footnote
This positioning helps decrease the likelihood of aspirating mucus or saliva.
478
What is one benefit of elevating the superior arm on a pillow for an unconscious client?
Good chest expansion
## Footnote
This allows the patient to breathe deeply and expand the lungs.
479
What organization identified the essential elements of assessment in the PACU?
AORN
## Footnote
AORN stands for the Association of periOperative Registered Nurses.
480
List three vital signs to assess in the PACU.
* Blood Pressure
* Respiratory Rate
* Temperature
481
What type of blood pressure measurement can be used in the PACU?
Cuff or arterial
## Footnote
Both methods provide important information about the patient's hemodynamic status.
482
What should be assessed regarding respiratory adequacy in the PACU?
* Respiratory competence
* Breath sounds
* Skin color and condition
483
What is the significance of recording temperature measurement type in the PACU?
It provides context for the patient's temperature status
## Footnote
Examples include skin, tympanic, or oral measurements.
484
What is considered when assessing oxygen saturation in the PACU?
Pulse oximeter reading
## Footnote
This assessment helps determine the patient's respiratory function.
485
What aspects of peripheral circulation should be evaluated postoperatively?
* Peripheral pulses
* Sensation at extremities
486
What neurological status indicators should be assessed in the PACU?
* Pupil response
* Intracranial pressure (if indicated)
487
What components are included in assessing mental status in the PACU?
* Level of consciousness
* Alertness
* Lucidity
* Orientation
488
What should be checked regarding IV therapy in the PACU?
* Patency
* Location of sites
* Rates of solution(s) and/or blood products infusing
489
What should be assessed in terms of allergies and sensitivities in the PACU?
Document any known allergies or sensitivities
## Footnote
This information is crucial for safe patient care.
490
What aspects of pain should be assessed in the PACU?
Pain level and management needs
## Footnote
Pain assessment is critical for postoperative care.
491
What motor abilities should be evaluated in the PACU?
Return of sensory and motor control in affected areas
## Footnote
This is particularly relevant for areas affected by local or regional anesthetics.
492
What should be assessed regarding skin integrity in the PACU?
Condition of the skin and any surgical incisions
## Footnote
This is important for preventing infection and promoting healing.
493
What is included in the assessment of temperature regulation in the PACU?
Monitoring for hypothermia or hyperthermia
## Footnote
Temperature regulation is critical in postoperative patients.
494
What should be inspected at the surgical incision site in the PACU?
Condition of suture line(s) if visible
## Footnote
This helps assess healing and detect any complications.
495
What should be monitored for nausea and vomiting in the PACU?
Presence and severity of symptoms
## Footnote
This is important for patient comfort and safety.
496
What components are included in assessing fluid and electrolyte balance in the PACU?
* Input and output
* Electrolyte levels
497
What safety needs should be addressed in the PACU?
Ensure siderails are raised
## Footnote
This is to prevent falls and ensure patient safety.
498
What two pressures might be monitored in the PACU?
* Central venous pressure
* Pulmonary wedge pressure
499
What should be assessed regarding the airway in the PACU?
* Patency
* Presence of artificial airway
* Mechanical ventilator settings
500
What should be assessed about dressings in the PACU?
Condition of dressing(s)
## Footnote
This includes checking for signs of infection or bleeding.
501
What drainage aspects should be monitored in the PACU?
* Type
* Patency
* Amount and type of drainage from dressings, tubes, and catheters
502
What is the first evidence of recovery from anesthesia related to airway?
The patient is able to maintain a patent airway independently and to deep-breathe, cough, and expectorate secretions.
503
What level of consciousness indicates recovery from anesthesia?
The patient is conscious and easily reoriented, often drifting off to sleep between arousals.
504
What are the vital signs criteria for recovery from anesthesia?
Vital signs are stable and within an acceptable range, though BP may differ from preoperative measures.
505
What factors may affect blood pressure readings post-anesthesia?
Anxiety, pain, and not administering routine BP medications due to NPO status.
506
What mobility and sensation indicators suggest recovery from anesthesia?
The patient is able to move all extremities that they could move preoperatively.
507
What does fluid balance (I&O) indicate in recovery from anesthesia?
The patient is urinating at least 30 mL/hr and is in relative fluid balance.
508
What should be considered when calculating fluid balance?
* Blood loss
* Urine output
* Gastric drainage
* Emesis
509
What are the criteria for dressings and drains during recovery from anesthesia?
Dressings are dry and intact, or wound drainage is appropriate for the procedure.
510
What signs indicate a patient is ready to be transferred to the surgical unit?
The patient should have no overt signs of excessive blood or fluid loss.
511
What is the initial postoperative assessment compared to?
Identical to the assessment performed by the PACU nurse
512
What changes occur in the frequency of assessment after surgery?
Frequency can be less than in the PACU
513
What is the standard assessment frequency upon arrival to the nursing unit?
On arrival to the nursing unit
514
What is the assessment frequency for the first hour postoperatively?
Every 15 minutes for the first hour
515
What is the assessment frequency for the next 2 hours after the first hour?
Every 30 minutes for the next 2 hours
516
What is the assessment frequency for the next 4 hours after the first 2 hours?
Every hour for the next 4 hours
517
What is the assessment frequency after the initial 4 hours?
Then every 4 hours
518
Fill in the blank: The PACU nurse assesses the patient every _______ minutes.
5 to 15
519
True or False: Agency protocols for postoperative assessments are uniform and do not vary.
False
520
What should be done if the patient's condition changes?
Increase the frequency of assessment
521
What is Aspiration Pneumonia?
Airway inflammation caused by inhaling gastric secretions (especially hydrochloric acid from the stomach) due to absent gag reflex secondary to anesthesia
## Footnote
Aspiration pneumonia is a serious postoperative complication that can arise from inadequate airway protection during anesthesia.
522
What are the clinical signs of Aspiration Pneumonia?
* Cough
* Fever
* Elevated white blood cell (WBC) count
* Decreased or absent breath sounds
* Decreased oxygen saturation (SaO2)
* Tachypnea
* Dyspnea
* Blood-tinged sputum
## Footnote
These signs indicate the presence of inflammation and infection in the lungs.
523
What is the preoperative intervention for preventing Aspiration Pneumonia?
Institute NPO (nothing by mouth) as ordered prior to surgery
## Footnote
This intervention helps reduce the risk of gastric contents being present in the stomach during anesthesia.
524
What should be done postoperatively to prevent Aspiration Pneumonia?
Continue NPO until intestinal motility returns; carefully monitor sedated patient and place in side-lying position
## Footnote
Monitoring and positioning are critical to prevent aspiration of secretions.
525
What is atelectasis?
Collapse of alveoli due to hypoventilation, airways blocked by mucous plugs, opioid analgesics, immobility
## Footnote
Atelectasis can lead to decreased gas exchange and respiratory complications.
526
List three clinical signs of atelectasis.
* Decreased or absent breath sounds
* Noisy respirations
* Decreased O2 saturation (SaO2)
## Footnote
Other signs may include chest asymmetry and sternal retractions.
527
True or False: Fever is a clinical sign of atelectasis.
True
## Footnote
Fever can indicate infection or inflammation associated with atelectasis.
528
What should be monitored to prevent and detect atelectasis early?
* Clinical signs
* Rate, rhythm, depth, and effort of respirations
* Ability to cough effectively
## Footnote
Monitoring these factors helps identify potential respiratory issues.
529
Fill in the blank: The use of _______ can help encourage deep breathing and prevent atelectasis.
[incentive spirometry]
## Footnote
Incentive spirometry encourages patients to take deep breaths, which can help expand collapsed alveoli.
530
What interventions should be taken if crackles and rhonchi are heard?
Suction, as needed
## Footnote
Suctioning can clear secretions that may be contributing to airway blockage.
531
What are some signs of respiratory distress in a patient with atelectasis?
* Increased restlessness
* Anxiety
* Tachypnea
* Dyspnea
* Tachycardia
* Diaphoresis
* Pleural pain
## Footnote
These signs indicate that the patient may be struggling to breathe and requires immediate attention.
532
What action should be taken after suctioning the patient?
Auscultate lung sounds to determine effectiveness
## Footnote
This helps ensure that the airway is clear and that normal breath sounds are restored.
533
True or False: Encouraging ambulation is an intervention for preventing atelectasis.
True
## Footnote
Mobility helps promote lung expansion and clear secretions.
534
What is pneumonia?
Inflammation of the alveoli due to infection with bacteria or viruses, toxins, or irritants.
535
What are common causes of pneumonia?
Hypoventilation secondary to anesthesia and opioid analgesics, poor cough effort due to aging, pain, or weakness.
536
List the clinical signs of pneumonia.
* Productive cough with blood-tinged or purulent sputum
* Fever
* Elevated WBC
* Decreased or absent breath sounds
* Decreased SaO2
* Chest pain
* Tachypnea
* Dyspnea
537
What interventions can be taken for the prevention and early detection of pneumonia?
* Monitor for clinical signs
* Encourage deep breathing
* Assist with coughing
* Promote moving in bed
* Encourage ambulation
* Use of incentive spirometry
538
True or False: Pneumonia can be caused by irritants.
True
539
Fill in the blank: Pneumonia is caused by _______ secondary to anesthesia and opioid analgesics.
[hypoventilation]
540
What is a common symptom of pneumonia related to breathing?
Decreased or absent breath sounds
541
What is the significance of elevated WBC in pneumonia?
It indicates an infection or inflammatory response.
542
What role does incentive spirometry play in pneumonia management?
It helps encourage deep breathing to improve lung function.
543
What is a Pulmonary Embolus?
A clot that occludes blood flow to a portion of the lungs
## Footnote
Usually results from clot formation in the lower extremities, which breaks loose and migrates to the lungs.
544
What are the potential causes of a Pulmonary Embolus?
Clot formation in lower extremities, venous injuries, hypercoagulable state, preexisting circulatory disorders
## Footnote
These factors contribute to the risk of developing a pulmonary embolus.
545
What are the clinical signs of a Pulmonary Embolus?
Sudden onset of dyspnea, shortness of breath, chest pain, hypotension, tachycardia, decreased SaO2, cyanosis
## Footnote
These symptoms can vary in severity and may require immediate medical attention.
546
Fill in the blank: The sudden onset of _______ is a clinical sign of a Pulmonary Embolus.
dyspnea
547
What interventions can be taken for the prevention of Pulmonary Embolus?
Encourage leg exercises, ambulation, antiembolism stockings, sequential compression devices, hydration
## Footnote
These interventions aim to prevent thrombophlebitis and improve circulation.
548
What should be done if thrombophlebitis occurs?
Position and immobilize the limb; do not massage calves
## Footnote
Proper management is crucial to avoid further complications.
549
True or False: Massaging the calves is recommended if thrombophlebitis occurs.
False
550
What is Thrombophlebitis?
Blood clot and inflammation of a vein or artery, usually in the legs
## Footnote
Results from increased coagulability and venous stasis due to immobility during and after surgery.
551
What are the clinical signs of Superficial Thrombophlebitis?
Vein is red, hard, and hot to touch
## Footnote
Indicates localized inflammation.
552
What are the clinical signs of Deep Thrombophlebitis?
Limb is pale and edematous; aching, cramping in limb; Homans sign (pain in calf when foot is dorsiflexed)
## Footnote
Homans sign is a classic indicator of deep vein thrombosis.
553
What does an Embolus refer to?
Movement of a thrombus or foreign body from its original location
## Footnote
Can lead to serious complications based on its location.
554
What are potential outcomes of embolus movement in the arterial system?
Cerebrovascular accident (CVA), myocardial infarction (MI), or loss of circulation to an area
## Footnote
These outcomes are critical and require immediate medical attention.
555
What is a common result of embolus movement in the venous system?
Pulmonary embolus
## Footnote
This condition can be life-threatening.
556
What should be monitored for in the prevention and early detection of emboli?
Clinical signs
## Footnote
Early detection is crucial for effective intervention.
557
What are interventions for preventing thrombophlebitis?
Monitor for clinical signs; position and immobilize the limb; do not massage calves
## Footnote
Massaging calves can dislodge a thrombus and lead to embolism.
558
True or False: Thrombophlebitis can occur due to immobility during and after surgery.
True
## Footnote
Immobility increases the risk of venous stasis and coagulability.
559
What is hemorrhage?
Bleeding that may be internal or external
## Footnote
Caused by slipped ligature, uncontrolled bleeder, or infection.
560
What are clinical signs of external hemorrhage?
Dressings saturated with bright red blood; increased output in drains or chest tubes.
561
What are clinical signs of internal hemorrhage?
Increased pain, increasing abdominal girth, ecchymosis or swelling around incision, tachycardia, hypotension.
562
What interventions can be taken for prevention and early detection of hemorrhage?
Frequently monitor vital signs, dressings, and wound drainage.
563
What is hypovolemia?
Decreased blood volume
## Footnote
May be due to blood loss during and after surgery; dehydration; or excess loss through vomiting, diarrhea, or drains.
564
What are clinical signs of hypovolemia?
Hypotension, tachycardia, decreased urine output, fatigue, thirst, dehydration.
565
What interventions can be taken for prevention and early detection of hypovolemia?
Monitor vital signs and I&O; insert urinary catheter if appropriate; monitor skin color, temperature, and moistness; identify possible causes of changes in vital signs.
566
What should be administered as prescribed for hypovolemia?
IV therapy, blood, or blood products.
567
Fill in the blank: Hypovolemia may be caused by _______.
[blood loss during and after surgery; dehydration; excess loss through vomiting, diarrhea, or drains]
568
What is nausea and vomiting related to?
Pain, anxiety, anesthesia, medications, or oral intake before peristalsis returns
569
What are the clinical signs of nausea and vomiting?
Vomiting, retching, stated nausea
570
What is the first intervention for preventing nausea and vomiting?
Maintain NPO until return of bowel sounds
571
How should the diet be advanced after nausea and vomiting?
Advance diet slowly
572
What is abdominal distention also known as?
Tympanites
573
What causes abdominal distention?
Excess gas within the intestines; slow return of peristalsis or handling of intestines during surgery
574
What are the clinical signs of abdominal distention?
Abdominal discomfort, bloating, hypoactive or absent bowel sounds
575
What intervention can help prevent abdominal distention?
Encourage and assist to move in bed and ambulate
576
What should be maintained until the return of bowel sounds in abdominal distention?
NPO
577
What should be avoided when drinking to prevent abdominal distention?
Drinking with a straw
578
What temperature should fluids be provided at for abdominal distention?
Room temperature
579
What is constipation?
A decrease in the frequency of bowel movements, resulting in the passage of hard stool
## Footnote
Usually related to use of opioids, immobility, inadequate fluid intake, or low-fiber diet.
580
What are clinical signs of constipation?
Abdominal discomfort, bloating, hypoactive or absent bowel sounds
## Footnote
These signs indicate potential issues with bowel function.
581
What interventions can prevent and detect constipation?
Encourage and assist the patient to:
* Move in bed
* Ambulate
* Increase fluid intake
* Increase fiber intake after bowel sounds return
## Footnote
These actions help support bowel function and reduce risks.
582
What is ileus?
Loss of the forward flow of intestinal contents due to decreased peristalsis
## Footnote
Causes include anesthesia, handling of the intestines during surgery, electrolyte imbalances, infection, or ischemic bowel.
583
What are clinical signs of ileus?
Abdominal pain, distention, absent bowel sounds, vomiting
## Footnote
These signs suggest a disruption in normal intestinal activity.
584
What interventions can prevent and detect ileus?
Observe for symptoms; notify the surgeon
## Footnote
There are few independent preventive measures for ileus.
585
What is renal failure?
Decreased or absent urine output due to hypovolemia, shock, or toxic reaction to medications
## Footnote
Renal failure can lead to serious complications and requires prompt medical intervention.
586
What are the clinical signs of renal failure?
Urine output less than 30 mL/hr; rising blood urea nitrogen (BUN) and creatinine levels
## Footnote
These signs indicate a decline in kidney function and may necessitate further evaluation.
587
What are the interventions for prevention and early detection of renal failure?
Carefully monitor I&O and laboratory values
## Footnote
Monitoring is crucial for identifying changes in renal function early.
588
What is urinary retention?
Accumulation of urine in the bladder
## Footnote
This condition can lead to discomfort and complications if not addressed.
589
What may cause urinary retention?
Poor muscle tone due to anesthesia, anticholinergic medications, handling of tissues during surgery, or inflammation in the pelvic region
## Footnote
Understanding the causes can help in prevention and management.
590
What are the clinical signs of urinary retention?
Bladder distention, suprapubic pain, diminished urine output or output less than fluid intake, inability to void or small, frequent voidings, hypertension, restlessness
## Footnote
These signs can help healthcare providers identify urinary retention early.
591
What are the interventions for prevention and early detection of urinary retention?
Monitor for clinical signs, provide privacy and adequate time to urinate, catheterize if needed
## Footnote
Prompt intervention can alleviate discomfort and prevent complications.
592
What is a urinary tract infection (UTI)?
Infection in the urinary tract related to catheterization, stagnant urine in the bladder, or instrumentation of the urinary tract
## Footnote
UTIs are common and can lead to more serious infections if untreated.
593
What are the clinical signs of a urinary tract infection?
Urinary frequency, suprapubic discomfort, burning on urination, cloudy urine
## Footnote
Recognizing these signs early can lead to prompt treatment.
594
What are the interventions for prevention and early detection of urinary tract infections?
Monitor for clinical signs, monitor I&O, use aseptic technique with catheterization and perineal care, provide adequate IV and oral fluids
## Footnote
These practices help minimize the risk of infection.
595
What is dehiscence in surgical terms?
Separation of one or more layers of the wound due to poor nutritional status, obesity, strain on suture line, inadequate closure of muscles, or wound infection
## Footnote
Dehiscence can lead to complications if not addressed promptly.
596
What are the clinical signs of dehiscence?
A pop or tearing sensation, especially with sudden straining, and an immediate increase in serosanguinous drainage
## Footnote
Sudden straining can occur from coughing, vomiting, or changing positions in bed.
597
List the interventions for prevention and early detection of dehiscence.
* Provide adequate nutrition
* Use binders to support the incision
* Have client avoid strain
* Monitor for infection
## Footnote
These interventions are crucial to minimize the risk of complications.
598
What is evisceration in surgical terms?
Protrusion of organs or tissues through the separated incision
## Footnote
Evisceration is often a result of dehiscence.
599
What are the clinical signs of evisceration?
Visible protrusion of organs through the incision
## Footnote
This is a serious condition that requires immediate medical attention.
600
True or False: The interventions for prevention and early detection of evisceration are different from those for dehiscence.
False
## Footnote
The interventions for evisceration are the same as those for dehiscence.
601
What is wound infection?
Inflammation or drainage from a wound due to growth of microorganisms secondary to inadequate aseptic technique or pathogens already present in surgical area.
602
List the clinical signs of wound infection.
* Localized swelling
* Redness
* Heat
* Pain
* Fever greater than 38°C (100.4°F)
* Foul-smelling drainage
* Change in the color of the drainage
603
What is an effective intervention for preventing wound infection in the preoperative period?
Effective skin prep
604
What should be done according to guidelines in the intraoperative period to prevent infection?
Surgical scrub
605
What should be monitored for early detection of wound infection?
Systemic and localized signs and symptoms of infection
606
What specific areas should be inspected to check for signs of infection?
* Incision and drain areas for redness and extreme warmth
* Surgical dressings for drainage and odor
607
Which vital sign is especially important to monitor for signs of infection?
Temperature
608
What technique should be maintained during surgical dressing changes?
Aseptic nontouch technique
609
What is recommended for wound cleansing up to 48 hours post-operation?
Sterile saline
610
What should be limited to help prevent wound infection?
The number of visitors, as appropriate
611
What action should be taken as needed for wound infection?
Obtain cultures
612
What should be encouraged to support recovery from wound infection?
Sufficient nutritional and fluid intake
613
What should clients be taught regarding wound infection?
Signs of infection
614
What is the key point regarding potential nursing diagnoses?
Write potential nursing diagnoses only if a patient has a higher risk for the problem than the average surgical patient.
615
What nursing diagnosis might be used for patients with a history of peripheral arterial disease?
Peripheral Tissue Perfusion Alteration Risk.
616
What nursing diagnosis is appropriate for patients who have lost a large amount of blood in surgery?
Fluid Volume Deficit Risk.
617
Identify a nursing diagnosis for patients with weak accessory muscles for breathing.
Breathing Pattern Impairment Risk.
618
What nursing diagnosis applies to patients with compromised immune status?
Infection Risk.
619
When should an actual nursing diagnosis be used?
Whenever a problem becomes actual instead of merely potential.
620
What is a common postoperative nursing diagnosis related to recovery time?
Surgical Recovery Delay.
621
What is a common postoperative nursing diagnosis that nearly every surgical patient experiences?
Acute Pain.
622
What are independent nursing interventions to relieve pain postoperatively?
Teaching the patient to splint the incision.
623
What usually needs to be administered for adequate pain relief in the early post-op period?
Analgesics, which require a medical prescription.
624
What nursing diagnosis is typically unnecessary for postoperative patients?
Knowledge Deficit diagnosis.
625
What is the nursing diagnosis related to postoperative patients experiencing pain and stressors of surgery?
Activity Intolerance
## Footnote
This diagnosis is associated with limitations in physical activity due to pain and the effects of surgery.
626
List three NOC outcomes for postoperative patients with activity intolerance.
* Activity Tolerance
* Energy Conservation
* Psychomotor Energy
## Footnote
These outcomes aim to assess the patient's ability to engage in activities without undue fatigue.
627
What are the goals related to vital signs in postoperative patients with activity intolerance?
* O2 saturation not compromised with activity
* Heart rate not compromised with activity
* Respiratory rate not compromised with activity
* Systolic and diastolic BP not compromised with activity
## Footnote
These goals are essential to ensure the patient's safety during physical activity.
628
What should be ensured regarding the ease of breathing for postoperative patients during activity?
Ease of breathing with activity not compromised
## Footnote
This goal is critical to monitor the patient's respiratory status during physical exertion.
629
What is one goal related to the patient's ability to perform daily activities?
Ease of performing activities of daily living not compromised
## Footnote
This goal focuses on maintaining the patient's independence and functional abilities.
630
Fill in the blank: The patient should be able to __________ with physical activity not compromised.
speak
## Footnote
This indicates that the patient's respiratory function and energy levels are adequate.
631
What is an indicator that energy restoration is successful after rest?
Energy restored after rest, not compromised
## Footnote
This indicates effective recovery and readiness for activity.
632
What are two nursing interventions related to activity for postoperative patients?
* Activity Therapy
* Energy Management
## Footnote
These interventions aim to enhance the patient's physical activity levels while managing energy expenditure.
633
What should nurses assist patients with to promote activity?
* Choosing appropriate activities
* Focusing on strengths
* Identifying activity preferences
## Footnote
This approach encourages patient engagement and motivation in their recovery process.
634
What is a recommended technique to reduce competition for oxygen supply during activities?
Arrange physical activities to avoid activity immediately after meals
## Footnote
This helps ensure that the body has adequate oxygen for both digestion and physical exertion.
635
What should be avoided during scheduled rest periods for postoperative patients?
Care activities
## Footnote
This is to ensure that patients have uninterrupted time to recover and rest.
636
What is one way to assist patients who are unable to transfer or walk?
Assist to sit on side of bed ('dangle')
## Footnote
This technique can help improve circulation and prepare the patient for standing or walking.
637
What should nurses monitor during activity for postoperative patients?
Location and nature of pain
## Footnote
Monitoring pain helps assess the patient's tolerance to activity and guide further interventions.
638
What teaching should be provided to prevent fatigue in postoperative patients?
Activity organization and time management techniques
## Footnote
This empowers patients to manage their energy levels effectively.
639
What is the nursing diagnosis related to postoperative patients experiencing pain and stressors of surgery?
Activity Intolerance
## Footnote
This diagnosis is associated with limitations in physical activity due to pain and the effects of surgery.
640
List three NOC outcomes for postoperative patients with activity intolerance.
* Activity Tolerance
* Energy Conservation
* Psychomotor Energy
## Footnote
These outcomes aim to assess the patient's ability to engage in activities without undue fatigue.
641
What are the goals related to vital signs in postoperative patients with activity intolerance?
* O2 saturation not compromised with activity
* Heart rate not compromised with activity
* Respiratory rate not compromised with activity
* Systolic and diastolic BP not compromised with activity
## Footnote
These goals are essential to ensure the patient's safety during physical activity.
642
What should be ensured regarding the ease of breathing for postoperative patients during activity?
Ease of breathing with activity not compromised
## Footnote
This goal is critical to monitor the patient's respiratory status during physical exertion.
643
What is one goal related to the patient's ability to perform daily activities?
Ease of performing activities of daily living not compromised
## Footnote
This goal focuses on maintaining the patient's independence and functional abilities.
644
Fill in the blank: The patient should be able to __________ with physical activity not compromised.
speak
## Footnote
This indicates that the patient's respiratory function and energy levels are adequate.
645
What is an indicator that energy restoration is successful after rest?
Energy restored after rest, not compromised
## Footnote
This indicates effective recovery and readiness for activity.
646
What are two nursing interventions related to activity for postoperative patients?
* Activity Therapy
* Energy Management
## Footnote
These interventions aim to enhance the patient's physical activity levels while managing energy expenditure.
647
What should nurses assist patients with to promote activity?
* Choosing appropriate activities
* Focusing on strengths
* Identifying activity preferences
## Footnote
This approach encourages patient engagement and motivation in their recovery process.
648
What is a recommended technique to reduce competition for oxygen supply during activities?
Arrange physical activities to avoid activity immediately after meals
## Footnote
This helps ensure that the body has adequate oxygen for both digestion and physical exertion.
649
What should be avoided during scheduled rest periods for postoperative patients?
Care activities
## Footnote
This is to ensure that patients have uninterrupted time to recover and rest.
650
What is one way to assist patients who are unable to transfer or walk?
Assist to sit on side of bed ('dangle')
## Footnote
This technique can help improve circulation and prepare the patient for standing or walking.
651
What should nurses monitor during activity for postoperative patients?
Location and nature of pain
## Footnote
Monitoring pain helps assess the patient's tolerance to activity and guide further interventions.
652
What teaching should be provided to prevent fatigue in postoperative patients?
Activity organization and time management techniques
## Footnote
This empowers patients to manage their energy levels effectively.
653
What are the causes of pain that should be provided to clients?
Causes of the pain, duration of pain, anticipated discomforts from procedures
## Footnote
Example: Teach the client to splint incision when ambulating.
654
What is the optimal method for pain relief?
Provide optimal pain relief with analgesics as appropriate.
655
What does PCA stand for in pain management?
Patient-Controlled Analgesia
656
When should interventions be implemented to manage pain?
Before pain becomes severe.
657
What should be done before a client engages in activity to manage pain?
Medicate before activity to increase participation.
658
What are some nonpharmacological pain relief measures?
Visualization, progressive muscle relaxation.
659
What approach should be utilized for effective pain management?
Multidisciplinary approach.
660
What is the nursing diagnosis related to anxiety?
Anxiety r/t change in health status, hospital environment.
661
What are the NOC outcomes for anxiety?
Anxiety Level, Anxiety Self-Control.
662
What are the NOC goals for managing anxiety?
* Consistently uses effective coping strategies
* Often seeks information to reduce anxiety
* Consistently uses relaxation techniques to reduce anxiety
* Often maintains concentration
* Verbalizes that anxiety is mild
* Minimal restlessness, hand wringing, muscle tension, facial tension, difficulty concentrating.
663
What is a key NIC intervention for anxiety reduction?
Anxiety Reduction.
664
What nursing activities can help reduce anxiety?
* Use calm, reassuring approach
* Observe for verbal and nonverbal signs of anxiety
* Explain all procedures and activities
* Provide information concerning diagnosis, treatment, prognosis
* Administer back rub or neck rub as appropriate
* Listen attentively
* Create trusting atmosphere
* Assist the client to identify stressful situations.
665
What are signs of minimal anxiety response?
Minimal changes in vital signs; no dilated pupils, sweating, or dizziness.
666
What should be encouraged to help clients recognize anxiety?
Assist the client to recognize that they are anxious.
667
What should clients be encouraged to verbalize regarding their surgical procedure?
Feelings, perceptions, and fears related to the surgical procedure.
668
What role do family visits play in anxiety management?
Encourage family visits if these ease the client’s stress.
669
What should clients be instructed in to help manage anxiety?
Use of relaxation techniques.
670
What is the nursing diagnosis related to nausea?
Nausea r/t manipulation of gastrointestinal tract, decreased peristalsis secondary to anesthesia
## Footnote
'r/t' stands for 'related to'.
671
What are the NOC outcomes for nausea management?
* Nausea & Vomiting Control
* Nausea & Vomiting: Disruptive Effects
* Nausea & Vomiting Severity
* Nutritional Status: Food & Fluid Intake
## Footnote
NOC stands for Nursing Outcomes Classification.
672
What is one goal for NOC related to nausea?
No nausea, or intensity only mild
## Footnote
This goal aims to minimize the impact of nausea on the patient's quality of life.
673
What should patients recognize as part of nausea management goals?
* Recognizes onset of nausea
* Recognizes precipitating stimuli
## Footnote
Understanding triggers can help patients avoid or mitigate nausea.
674
What are the NIC interventions for nausea management?
* Nausea Management
* Medication Management
## Footnote
NIC stands for Nursing Interventions Classification.
675
What information should be provided to patients regarding nausea and vomiting?
* Cause of nausea and vomiting
* Expected duration of symptoms
## Footnote
Providing information helps patients understand their condition better.
676
What should be explained about antiemetic treatment?
* Goals
* Effects
* Possible side effects
## Footnote
Understanding antiemetics helps in managing expectations and adherence to treatment.
677
What is the limited role of administering parenteral fluids?
To prevent dehydration and to administer supplemental electrolytes (e.g., potassium)
## Footnote
Parenteral fluids are used when oral intake is not possible.
678
Fill in the blank: Clients should be encouraged to monitor their own nausea experience using a _______.
symptom diary
## Footnote
A symptom diary helps track patterns and triggers related to nausea.
679
What strategies should clients learn for nausea management?
Strategies for managing own nausea
## Footnote
Empowering clients with self-management strategies is crucial for effective care.
680
What should be included in a complete assessment for nausea?
* Frequency
* Duration
* Severity
* Precipitating factors
## Footnote
A thorough assessment helps in understanding the patient's condition and planning care.
681
What is a common observation related to food and fluid intake in patients experiencing nausea?
Only mild decrease in food and fluid intake
## Footnote
Indicates that while the patient may not be consuming as much, they are not severely affected.
682
What weight change is typically reported in patients experiencing nausea?
No weight loss
## Footnote
Suggests that the patient is maintaining their weight despite nausea.
683
What bothersome issues may patients report concerning antiemetic treatment?
Reports bothersome side effects from antiemetics
## Footnote
Side effects can impact compliance and effectiveness.
684
What is a common report regarding the effectiveness of antiemetic treatment?
Reports failure of antiemetic treatment
## Footnote
Indicates that the medications are not providing the desired relief.
685
What should be observed for in patients experiencing nausea?
Nonverbal cues of discomfort
## Footnote
Important for understanding the patient's experience beyond verbal communication.
686
What past experiences should be evaluated in patients with nausea?
Past experiences with nausea
## Footnote
Helps in tailoring treatment strategies based on individual history.
687
What types of techniques should be discussed if anxiety is suspected in patients with nausea?
Relaxation and distraction techniques
## Footnote
Techniques like guided imagery, self-hypnosis, biofeedback, and music therapy may be beneficial.
688
What should be encouraged for oral hygiene in patients experiencing nausea?
Frequent oral hygiene unless it stimulates nausea
## Footnote
Maintaining oral health can be important, but care must be taken to avoid triggering nausea.
689
What types of food are recommended for patients experiencing nausea?
Cold, clear, odorless foods
## Footnote
These are often more tolerable for patients with nausea.
690
What dietary advice is given regarding the composition of meals for those with nausea?
High-carbohydrate and low-fat foods; small, frequent meals
## Footnote
This helps reduce the likelihood of nausea and promotes easier digestion.
691
What beverage is suggested for patients experiencing nausea, and how should it be consumed?
Drink cola, but not too cold; suck on an ice cube, sorbet, or a piece of frozen fruit
## Footnote
These can be soothing and may help with nausea.
692
How long should a patient sit in an upright position after eating?
30 to 45 minutes
## Footnote
This position can aid in digestion and reduce the risk of nausea.
693
What environmental factors should be controlled in the room of a patient experiencing nausea?
Odors and unpleasant visual stimuli
## Footnote
Minimizing these factors can help create a more comfortable environment.
694
What type of medications should be administered for nausea?
Antiemetic medications
## Footnote
These are specifically designed to alleviate nausea and vomiting.
695
When should a referral to a dietician be considered for a patient experiencing nausea?
As needed
## Footnote
A dietician can provide specialized dietary advice to manage nausea effectively.
696
What is the nursing diagnosis related to constipation?
Constipation r/t decreased activity, decreased food or fluid intake, decreased peristalsis secondary to anesthesia, pain medication
697
What is the NOC outcome for a patient with constipation?
Bowel Elimination
698
What are the NOC goals for bowel elimination?
* Elimination pattern not compromised
* Reports ease of stool passage not compromised
* Bowel sounds not compromised
* Muscle tone to evacuate stool not compromised
* Passes soft, formed stool in amount appropriate for diet
* No pain with passage of stool
699
What is one non-goal related to constipation management?
Bloating not present
700
What are the NIC interventions for constipation?
* Bowel Management
* Constipation/Impaction Management
701
What nursing activities should be performed for a patient with constipation?
* Monitor for signs and symptoms of constipation
* Note date of last bowel movement
* Monitor bowel sounds
* Monitor frequency, consistency, shape, volume, and color of bowel movements
* Teach the client about specific foods that assist promotion of bowel regularity
* Insert a rectal suppository, enema, or irrigation, as needed
* Evaluate medication profile for GI side effects (e.g., narcotic analgesics)
* Give warm liquids after meals
* Instruct the client in foods high in fiber
702
What is the nursing diagnosis discussed in the text?
Urinary Retention
## Footnote
Related to anesthesia, preoperative medications (anticholinergics), pain, fear, unfamiliar surroundings, and client’s position.
703
What is the NOC outcome related to Urinary Retention?
Urinary Elimination
704
List the NOC goals for managing Urinary Retention.
* Empties bladder completely
* Fluid intake not compromised
* No hesitancy with urination
705
What are the NIC interventions for Urinary Retention?
* Urinary Retention Care
* Urinary Catheterization
706
What nursing activities are involved in managing Urinary Retention?
Perform comprehensive urinary assessment
## Footnote
This includes fluid intake, urinary output, voiding pattern, cognitive function, and preexisting urinary problems.
707
What is the subjective feeling of an empty bladder referred to?
Reports subjective feeling of empty bladder
## Footnote
This refers to the patient's perception, which may not always correlate with actual bladder volume.
708
What should be provided to ensure privacy during elimination?
Provide privacy for elimination
## Footnote
This is essential for patient comfort and dignity during the process.
709
How long should a client be allowed to empty their bladder?
At least 10 minutes
## Footnote
This allows sufficient time for the client to relax and void.
710
What technique can be used to estimate the degree of bladder distention?
Use percussion and palpation
## Footnote
These techniques help assess bladder fullness non-invasively.
711
What nursing diagnosis is appropriate when a patient requires more days to recover than the anticipated length of stay for surgery?
Delayed Surgical Recovery
## Footnote
This diagnosis encompasses various postoperative issues and does not require separate diagnoses for related symptoms unless indicated.
712
Name one NOC outcome related to post-procedure recovery.
Wound Healing: Primary Intention
## Footnote
This indicates the expected healing process following surgical intervention.
713
What are some NIC interventions for managing postoperative patients?
Embolus Precautions, Exercise Therapy: Ambulation, Incision Site Care
## Footnote
These interventions are crucial for preventing complications and promoting recovery.
714
What nursing activity involves monitoring for postoperative complications?
Monitor for postoperative complications
## Footnote
This includes assessing for signs of infection, bleeding, or delayed healing.
715
What is a potential nursing diagnosis related to pain following surgery?
Activity Intolerance r/t pain
## Footnote
This diagnosis indicates the patient may struggle with usual activities due to pain levels.
716
What is an appropriate dietary recommendation to support recovery?
Encourage increased intake of protein, iron, and vitamin C
## Footnote
These nutrients are vital for healing and recovery post-surgery.
717
What should be monitored to ensure postoperative readiness for discharge?
No postoperative complications
## Footnote
This includes assessing for bleeding, infection, or delayed wound healing.
718
Fill in the blank: The nursing diagnosis 'Anxiety' may relate to a change in _______.
health status
## Footnote
This reflects the patient's emotional response to their surgical experience.
719
True or False: Nausea can occur due to manipulation of the gastrointestinal tract during surgery.
True
## Footnote
This is a common postoperative symptom due to anesthesia and surgical intervention.
720
What should be taught to clients regarding incision care?
Teach the client and family how to care for the incision
## Footnote
Proper education on incision care is essential for preventing infection and promoting healing.
721
What is one goal of pain management postoperatively?
Facilitate pain relief
## Footnote
This can be achieved through various pharmacological and non-pharmacological measures.
722
What is a sign of adequate postoperative recovery related to blood pressure?
Systolic BP within 20 mm Hg of baseline
## Footnote
Monitoring blood pressure is crucial to assess the patient's stability post-surgery.
723
What is one expected outcome for ambulation post-surgery?
Ambulation tolerance in normal range
## Footnote
This indicates the patient is recovering physically and can resume movement comfortably.
724
What is a common cause of constipation postoperatively?
Decreased activity, decreased food or fluid intake, decreased peristalsis secondary to anesthesia, pain medication
## Footnote
Constipation can develop due to a combination of factors that affect gastrointestinal function.
725
What are some factors contributing to urinary retention after surgery?
Anesthesia, preoperative medications (anticholinergics), pain, fear, unfamiliar surroundings, client’s position
## Footnote
Urinary retention can be influenced by both physical and psychological factors surrounding the surgical experience.
726
What is the significance of planning outcomes in postoperative care?
A comprehensive plan of care includes NOC standardized outcomes and individualized goals
## Footnote
Effective planning helps ensure that patients receive tailored care that addresses their specific recovery needs.
727
How has the postoperative period changed due to shortened hospital stays?
The postoperative period now extends well past the patient’s discharge from the hospital
## Footnote
This change emphasizes the need for ongoing care and monitoring after leaving the hospital.
728
Who often continues to follow the patient at home after surgery?
A home health nurse
## Footnote
Home health nurses provide support to facilitate a smoother transition through the postoperative process.
729
What are some examples of NOC standardized outcomes for the postoperative period?
* Activity Tolerance
* Ambulation
* Anxiety Level
* Blood Loss Severity
* Bowel Elimination
* Circulation Status
* Energy Conservation
* Hydration
* Nausea and Vomiting Severity
* Pain Control; Pain Level
* Post-Procedure Recovery
* Urinary Elimination
* Wound Healing: Primary Intention
## Footnote
These outcomes help in assessing patient recovery and setting specific goals.
730
Fill in the blank: A comprehensive plan of care for postoperative patients includes _______ standardized outcomes.
[NOC]
## Footnote
NOC stands for Nursing Outcomes Classification, which provides a framework for measuring patient outcomes.
731
True or False: The postoperative period is only relevant while the patient is in the hospital.
False
## Footnote
The postoperative period is an ongoing process that extends beyond hospital discharge.
732
What is the primary focus of most postoperative interventions?
Prevention and early detection of potential complications
## Footnote
Collaborative problems are addressed through these interventions.
733
What should specific nursing activities be designed to address?
Identified nursing diagnoses
## Footnote
This includes pain management and routine postoperative teaching.
734
What is the primary goal of postoperative pain management?
Minimize the dose of medications while providing adequate pain management
## Footnote
This approach helps to lessen side effects.
735
Why is it important to consider individual factors in pain control?
Because no one drug is likely to work for every person with pain
## Footnote
Factors include medical condition, age, fear, surgical procedure, and response to care.
736
What approach should be used to formulate a pain relief plan for complicated patients?
An interprofessional team approach
## Footnote
This is essential for patients with medical comorbidities.
737
What are some benefits of adequate pain management?
Early mobilization, shorter hospital stay, reduced hospital costs, increased patient satisfaction
## Footnote
These benefits highlight the importance of effective pain control.
738
What routes of analgesics are usually administered postoperatively?
IV, epidural medications, oral opioids, nonopioid analgesics
## Footnote
This progression typically occurs in the immediate postoperative period.
739
What is the preferred method of administering opioids postoperatively?
Oral opioids should be given preference to IV opioids
## Footnote
Intramuscular injections can cause additional pain and have unreliable absorption.
740
What should be administered around-the-clock in addition to pain control measures?
NSAIDs if not contraindicated
## Footnote
This helps to maintain effective pain control.
741
What challenges exist in providing pain control for older adults?
Concerns about impaired cognition, medical comorbidities, drug interactions, and appropriate dosing
## Footnote
These factors often lead to older adults being undermedicated.
742
What side effects of analgesics should be monitored?
Respiratory depression, hypotension, allergic reaction
## Footnote
Monitoring is crucial to prevent complications.
743
What symptoms did women report improved after receiving acupuncture post-surgery?
Pain, nausea, anxiety, and increased ability to cope with symptoms
## Footnote
Acupuncture may serve as a nonpharmacologic intervention for symptom management in women undergoing breast cancer surgery.
744
What is the purpose of a single-use pain relief pump?
Administers a continuous, regulated flow of local anesthetic through a catheter directly into the surgical site
## Footnote
It reduces the need for opioids and associated complications.
745
How long can a single-use pain relief pump remain in place?
Up to 5 days, depending on the amount of anesthetic included
## Footnote
The pump is filled with 65 to 750 mL of medication.
746
Why is postoperative teaching important?
Most patients must perform quite a bit of self-care
## Footnote
Teaching reinforces preoperative content and aids in patient recovery.
747
What should be considered before attempting to teach a postoperative patient?
Ensure the patient is comfortable but alert
## Footnote
Avoid teaching when the patient is in pain, needs to void, or is drowsy from opioids.
748
What is the purpose of incentive spirometry?
Facilitates deep breathing, increases lung volume, and promotes coughing to clear mucus
## Footnote
It is prescribed for patients at high risk for atelectasis and pneumonia.
749
What should be included in preoperative teaching if a patient will use an incentive spirometer postoperatively?
Explain its use to the patient
## Footnote
This helps prepare the patient for postoperative care.
750
Fill in the blank: A single-use pain relief pump can be carried in a _______.
small bag
751
True or False: Acupuncture is a pharmacologic intervention for symptom management.
False
## Footnote
Acupuncture is a nonpharmacologic intervention.
752
What should be monitored when using incentive spirometry?
The patient's progress using a gauge
## Footnote
All incentive spirometer devices include a gauge for this purpose.
753
What are the key postoperative treatment regimen topics?
Dressing changes, exercises, self-management, expected results, prescribed diet, prescribed activity, signs of complications, return visits, lifestyle changes, community resources
## Footnote
Each of these topics is crucial for patient recovery and understanding after surgery.
754
Why are antiembolism stockings used in postoperative care?
To promote peripheral circulation and prevent thrombophlebitis
## Footnote
They are particularly important as more than half of hospitalized patients are at risk for venous thromboembolism.
755
What should patients do to manage their postoperative treatment regimen?
Follow prescribed activities, dietary recommendations, and self-management strategies
## Footnote
This includes understanding how to recognize signs of complications.
756
What are the signs and symptoms of complications that require notification to a healthcare provider?
Signs of complications vary; patients should be educated on specific symptoms relevant to their surgery
## Footnote
Examples might include excessive bleeding, signs of infection, or severe pain.
757
What lifestyle changes may be needed after surgery?
Changes based on surgical type and personal health needs
## Footnote
This could include diet modifications, activity level adjustments, or smoking cessation.
758
True or False: Antiembolism stockings can replace the need for physical activity in postoperative patients.
False
## Footnote
Antiembolism stockings are an adjunct to, not a substitute for, patient activity.
759
What community resource was mentioned for postoperative patients?
Reach for Recovery
## Footnote
This resource may provide additional support and information for recovery.
760
Fill in the blank: More than half of hospitalized patients are at risk for _______.
venous thromboembolism
## Footnote
Surgical patients are at higher risk than medical patients.
761
What are the components of the prescribed diet for postoperative patients?
Nutritional guidelines tailored to individual needs
## Footnote
Patients should learn how to select foods appropriate for their recovery.
762
What is the rationale for postoperative exercises?
To promote recovery and prevent complications
## Footnote
Exercises help improve circulation and reduce the risk of thromboembolism.
763
What is the role of anticoagulant medications in postoperative care?
To prevent venous thromboembolism
## Footnote
These medications are often prescribed to surgical patients to minimize the risk of blood clots.
764
What is the purpose of an incentive spirometer?
To enable patients to monitor the depth of their breathing
## Footnote
Patients with abdominal or chest incisions may require pain medication to use the incentive spirometer.
765
What position should a patient be in when using an incentive spirometer?
Upright position in the bed or chair
766
What are the steps a patient should follow to use an incentive spirometer?
1. Breathe out normally
2. Place the mouthpiece in the mouth and create a seal with the lips
3. Breathe in slowly and deeply through the mouthpiece
4. Hold the breath for a slow count of three
5. Remove the mouthpiece and exhale
6. Rest for a few seconds
7. Repeat 10 times every hour while awake
8. Cough after each set of 10 deep breaths
767
How should a patient support an incision while coughing?
By holding a pillow firmly against it
768
What are Sequential Compression Devices (SCDs) used for?
To prevent thrombophlebitis in high-risk patients
769
Describe the function of Sequential Compression Devices (SCDs).
They apply sequential pressure to the chambers of a plastic sleeve wrapped around the legs, promoting venous return to the heart
770
What is the process of pressure application in SCDs?
Starting at the ankle, chambers inflate and deflate sequentially
771
What type of patients are at high risk for abdominal distention?
Patients having certain surgeries, such as those for bowel obstruction
772
What complications can abdominal distention cause?
Pain, increased postoperative respiratory problems, strain on suture lines, and interference with wound closure
773
What type of tube may be placed for gastric or intestinal decompression?
Nasogastric (NG) or nasointestinal tube
774
What may be performed if prolonged intestinal decompression is anticipated?
Gastrostomy
775
What is the purpose of decompression tubes?
To collect excess fluid and gas from the stomach or intestines
776
What are the conditions for suction to be continued with decompression tubes?
Until peristalsis resumes, bowel sounds are audible, and the patient is passing flatus
777
What does NPO stand for in a medical context?
Nothing by mouth
778
What is the connection between NG tubes and gastrointestinal suction?
NG tubes are used for gastric decompression and are typically connected to intermittent or continuous suction
