Exam 2: The Perioperative Experience Flashcards
1
Q
In regards to Preoperative Fasting, Clear liquids can be taken up to _____hrs before elective surgery ?
A
2 hours
2
Q
In regards to Preoperative Fasting, you can have a light breakfast (tea & toast) up to _____hrs before surgery ?
A
6 hours
3
Q
In regards to Preoperative Fasting, a heavier meal can be consumed up to _____hrs before surgery ?
A
8 hours
- Always defer to written preoperative orders !
4
Q
On the day of surgery the patient must be alert & orientated to do what ?
A
Sign the consent
5
Q
On the day of surgery, why should nail polish be removed ?
A
To allow for the assessment of the pulse ox
6
Q
Why are cosmetics not allowed on the day of surgery ?
A
Having no cosmetics on, allows for skin color assessment
7
Q
On the day of surgery what do you want to make sure the patient has on ?
A
- I.D.
- Allergy band (if applicable)
8
Q
What should you make sure to remove on the day of surgery ?
A
Remove assistive devices, but keep handy to return to the pt. after surgery
9
Q
True or False: on the day of surgery you should make sure to do any remaining surgical scrubs if necessary ?
A
True
10
Q
What are some preoperative medications ?
A
- Benzodiazepines
- Narcotics
- H2-receptor antagonists
- Antacids
- Antiemetics
- Anticholinergics
11
Q
What are examples of Benzodiazepines ?
A
- Versed
- Valium
- Ativan
12
Q
What to Benzodiazepines do ?
A
- Decrease anxiety
- Induce sedation & amnesia
13
Q
What do Narcotics do ?
A
Relieve discomfort during pre-op procedures
14
Q
What are examples of Narcotics ?
A
- Morphine
- Demerol
- Fentanyl
15
Q
What do H2-receptor antagonists do ?
A
- Affects gastric PH
- Decreases gastric volume
16
Q
What are examples of H2-receptor antagonists ?
A
- Zantac
- Pepcid
- Tagament
17
Q
What do Antacids do ?
A
Affect gastric pH (don’t know how exactly)
18
Q
What is an example of an Antacid ?
A
Sodium citrate
19
Q
What do Antiemetics do/ are involved in ?
A
- Gastric emptying
- decrease N/V
20
Q
What are examples of Anticholinergics do ?
A
Reduce oral and respiratory secretions
21
Q
What is an example of an Anticholinergic ?
A
Atropine
22
Q
When/why are antibiotics used as preoperative medications ?
A
- Wound contamination risk
- Patients with valve disorders (Ex: Endocarditis)
- Serious post-op consequences of wound infection (cardiac joint)
23
Q
When administering antibiotics as a part of the Preoperative Medications, when do you want to give them ?
A
30 - 60 minutes before the surgical incision
24
Q
what age population is at greater risk for complications ?
A
Gerontologic population
25
The Gerontologic population is at risk for __________, especially after emergent surgery ?
delirium
26
In Preoperative nursing, what does the Circulating RN do ?
- Not scrubbed
- Gowned and gloved and remain in the unsterile field
(preps room, documents, counts equipment, measure blood and fluid loss, assessing patient)
27
What type of nurse preps the room, documents, counts equipment, measure blood and fluid loss, and assess the patient ?
The Circulating RN
28
What type of nurse follows the scrub procedure, is gowned and gloved in sterile attire, and remain in the sterile field (preps room, scrubs in, assists the surgeon, counts equipment, monitors aseptic technique)
Scrub Nurse
29
What is the goal of both the Circulating RN and the Scrub Nurse ?
To use critical thinking to provide safe patient care !
30
what are the possible team members in the OR ?
- Scrub Nurse
- Circulating Nurse
- Anesthesia care provider (MD or nurse anesthetist)
- Surgeon
- Surgeon Assistant
RN first assistant
PA
NP
Surgical tech
31
What needs to be done before a procedure is started ?
- Need history and physical on the chart
| - Need to complete a "Time-Out" (Surgeon and staff confirm the patient, correct site, correct procedure, etc)
32
In terms of Safety & Infection prevention; Everything in the OR must be what ?
Sterile
33
When prepping an incision site how should you clean it and the surrounding area ?
prep site from "clean" incision site to "dirty"
34
In regards to proper positioning of patients prior to surgery, what is a major thing that we want to prevent ?
Want to prevent pressure on nerves, skin, bony prominences, and eyes
35
What are important aspects to keep in mind in regards to proper positioning of patients preoperatively ?
- Accessibility of the operative site
- Administeration and monitoring of anesthetic agents
- Maintenance of airway
- Correct musculoskeletal alignment
- Prevent pressure on nerves, skin, eyes, and bony prominences
- Provide for adequate thoracic excursion
- Prevent occlusion of arteries and veins
- Provide modesty in exposure
- Secure extremities
- Provide adequate padding and support
- ** Above all, prevent injury ! **
36
What type of anesthesia is the technique of choice for surgeries with a significant duration or that require relaxation/uncomfortable position/control of respiration ?
General anesthesia
37
Most general anesthesia begins with what ?
IV agent
38
With General anesthesia, you have a loss of ______________ and _______________ ?
Consciousness and sensation
39
True or False ; General anesthesia is fast acting ?
True !
40
With General anesthesia, there is an elimination of what types of things ?
- cough
- gagging
- vomitting
- SNS responsiveness
41
What does "Adjuncts to General Anesthesia" mean ?
Added to achieve unconsciousness, analgesia, amnesia, muscle relaxation, or autonomic nervous system control
42
What are Adjuncts to General Anesthesia ?
- Opioids
- Benzodiazepines
- Neuromuscular blocking agents (help with intubation)
- Anti-emetics (prevent N/V associated with anesthesia)
(Anesthesia can be very hard on an empty stomach)
43
What does Local anesthesia cause ?
A Loss of sensation without a loss of consciousness !
44
How far in advance should Local anesthesia be given/applied before a procedure ?
30 to 60 minutes
45
What are different types of Local anesthesia ?
- Topical
- Ophthalmic
- Nebulized
- Injectable
46
What type of Anesthesia causes a loss of sensation in a body region without a loss of consciousness when specific nerves or group of nerves is blocked by the administration of a local anesthetic ?
Regional anesthesia
47
What is an Example of Regional anesthesia ?
Getting an Epidural during pregnancy
48
What type of regional anesthesia is, the injection of the agent into the CSF of the subarachnoid space ?
Spinal anesthesia
49
What type of Regional anesthesia is, an injection of an agent into the epidural space, and does not enter the CSF ?
Epidural block
50
What are the Risks of Spinal & Epidural Anesthesia ?
- Vasodilation
- Hypotension
- Bradycardia
- If anesthesia is placed "too high" it could result in inadequate respiration
- CSF leaks - causes spinal headaches
51
What should you monitor with Spinal & Epidural Anesthesia ?
The return of sensation and movement of the lower extremities
52
What are the advantages of Spinal & Epidural Anesthesia ?
- Pt. is awake
| - Risk of anesthesia effects (i.e. general) ???
53
With what age population should anesthetic drugs be more carefully titrated ?
Geriatric
54
What age group is at greater risk for skin injury from tape, electrodes, and warming/cooling blankets ?
Geriatric population
55
What age population is at greater risk for preoperative hypothermia ?
Geriatric population
56
what are examples of Catastrophic Events in the OR ?
- Anaphylactic reaction
| - Malignant hyperthermia
57
In the OR, manifestations of an Anaphylactic reaction may be masked by what ?
Anesthesia
- Vigilance and rapid intervention are essential
58
What is Malignant hyperthermia ?
A rare autosomal dominant, metabolic disease
59
How do individuals acquire Malignant hyperthermia ?
Born with it
60
What does Malignant hyperthermia cause ?
Hyperthermia with hypermetabolism and rigidity of skeletal muscles
- Increase temp in surgery & increase metabolism (Burning through energy fast !)
61
When does Malignant hyperthermia usually occur ?
Usually occurs during general anesthesia when exposed to certain types of anesthetic agents
62
What are signs of Malignant hyperthermia ?
- Tachycardia
- Tachypnea
- Ventricular dysrhythmias
- Late Sign = Rise in body temperature
* Can result in cardiac arrest and death*
63
What is the treatment for Malignant Hyperthermia ?
give DANTROLENE ! To slow metabolism and reduce muscle contraction
64
What does PACU stand for ?
Post
Anesthesia
Care
Unit
65
What type of information do you receive on the PACU Admission report ?
- General info (Pt. name, age, surgeon, procedure)
- Patient history
- Intraoperative management (type of anesthesia, meds, blood loss, fluid replacement, urine output)
- Intraoperative course (unexpected events, baseline & current VS, intro lab testing)
66
In the PACU the _________ outweigh pain ?
ABC's
- Airway
- Breathing
- Circulation
- safety
67
What is the priority care in the PACU ?
- Respiratory function (airway, RR, pulse ox)
- Circulatory function (HR, BP, Pulses, CRT, skin color)
- Neurological function (LOC, orientation, pupil run)
- Pain
- Intake & Output
- Surgical site (amount & type of drainage)
- Compare with pre-op baseline
68
In the PACU why is it important to explain everything your doing to the patient ?
Because he or she may be able to hear what is going on
69
True or False ; It is okay to transfer a pt. from the PACU to a med sure floor even if they are still lethargic, as long as their vitals & output is good ?
True !
70
What are some Respiratory Complications (Inadequate Oxygenation) Immediately Post-op ?
- Airway Obstruction
- Hypoxemia (PaO2 < 60mmHg)
- Hypoventilation (depression of resp. drive, decrease RR)
- Pulmonary edema
- Aspiration of gastric contents
- bronchospasm (wheezing, dyspnea)
71
What are Interventions for Respiratory Complications immediate Post-op ?
- Protect airway (pt. sleepy)
- Proper positioning
- Deep breathing
- O2
- Suction
- Bronchodilators
- Diuretics
- Reversal of Narcotics (Narcan)
- Mechanical Ventilation
72
What is Hypoxemia classified as (Lab value) ?
PaO2 less than 60mmHg
73
What does PaO2 stand for ?
Partial Pressure of Atrial Oxygen
< 60 = Abnormal
> 60 = Normal
74
Signs of Hypoxemia range from
____________ to ____________
____________ to ______________
____________ to _____________
- Agitation to Somnolence
- Hypertension to Hypotension
- Tachycardia to Bradycardia
75
What test is used to confirm if pulse oximetry is low ?
Arterial blood gas (ABG)
76
What is the most common cause of postoperative hypoxemia ?
Atelectasis
- Essentially air becomes trapped causing collapse (partial or full) of a lung(s)
77
Its important to use _________ _____________ to facilitate respirations and protect the airway postoperatively ?
Proper positioning
78
Post-op if a pt. is having difficulty getting rid of respiratory secretions, what position should you put them in ?
Lateral position (unless contraindicated)
79
Which position is allowed post-op once the patient is conscious ?
Supine with the HOB elevated
80
What are 3 Cardiovascular Complications Immediate Post-op ?
- Hypotension
- Arrhythmias
- Hypertension
81
Post-op, Hypotension can present as what ?
- Disorientation
- LOC
- Decreased urine output
82
What is Post-op hypotension most commonly attributed to ?
Unreplaced fluids & blood loss
83
How should you treat Post-op hypotension ?
Try a fluid bolus or blood transfusion
* if no results, think cardiac dysfunction
84
Post-op hypotension treatment should always begin with what ?
oxygen therapy to promote oxygenation of hypoperfused organs
85
Post-op arrhythmias are most commonly from ?
- Hypoxemia
- Electrolyte imbalances
- hypothermia
- pain
- stress
- or pre-existing disease
* Try to identify and treat the cause*
86
Post-op Hypertension is most frequently the result of what ?
SNS stimulation (pain, anxiety, full bladder, etc)
* Try to treat the cause*
- Meds if pre-existing HTN
87
What is the most common cause of Post-op Delerium ?
Hypoxemia
88
what is Emergence Delirium ?
Waking up wild !
89
When dealing with Post-op delirium, What are some possible causes that should be addressed ?
- Hypoxemia
- Anesthetic agent
- Bladder distention
- pain
- or ET tube
90
What is Hypothermia confirmed as ?
Core temperature < 95.0 degrees F
91
What is post-op hypothermia due to ?
- Use of cold irrigants
- unwarmed inhaled gases
- loss of body heat
92
What should you do post-op to counter act hypothermia ?
Monitor & Warm (passive vs. active)
93
To help manage pain post-op what is the route of choice ?
IV
94
How should you deal with pain post-op ?
- Assess the pt.
| - IV Narcotics
95
How much urine output is expected for the first 24 hours post-op ?
200 - 1500mL
96
To prevent aspiration post-op, what position should you put the patient in ?
Lateral position
97
What Discharge Criteria must be met to leave the PACU ?
- Awake or at baseline (Lethargy/sleepy is okay as long as the person is arousable)
- Vital signs stable
- No excess bleeding or drainage
- No respiratory depression
- O2 stat > 90%
- Report given (SBAR)
98
What are Discharge Criteria for Ambulatory Surgery ?
- ALL PACU d/c criteria met
- No IV narcotics for 30min
- Minimal N/V
- Voided
- Able to ambulate if appropriate/ not contraindicated
* Responsible adult to accompany home*
- D/C instructions given & understood
99
After PACU discharge, what admission & assessment information will you obtain on the Clinical Unit ?
- Time (of arrival on unit)
- Airway
- Breathing, oxygen
- Mental status - LOC, orientation
- Surgical incision site
- Vitals (until order to cut back on post-op vitals)
- IV fluids
- Other tubes
100
Atelectasis can lead to what ?
Pneumonia (PNA) !
101
What are interventions that can be done to prevent Atelectasis ?
- Turn every 1-2 hours (helps to drain fluid from the lungs)
- Incentive spirometry or C&DB 10 times/hr
- AMBULATE ! & do it early
- Monitor temperature
- Medicate prior to C&DB or IS
102
If a pt. has a mild temperature (ex: 100.8 which is too mild to call the doc), what should you have them do ?
Ambulate !
* want to promote good lung hygiene *
103
What does ADH stand for ?
Anti-diuretic hormone
104
What does ACTH stand for ?
Adrenocorticotropic hormone
105
What is the normal potassium range ?
3.5 - 5
106
What are S/S of fluid & electrolyte imbalances ?
- Fluid retention
- Fluid overload
- Fluid deficit
- Hypokalemia
107
What is the best indicator of fluid status ?
Daily weights !
108
What are interventions for fluid & electrolyte imbalances ?
- Daily weight
- I & O
- Fluid replacement
- Fluid restriction
- K+ replacement
- Monitor labs
- Monitor urine output
109
what describes the distribution of body water ?
Fluid Spacing
110
What is First spacing ?
Normal distribution of fluid in the ICF and ECF compartments
111
What is Second spacing ?
Abnormal accumulation of interstitial fluid (fluid around the cells). ------- Edema
112
What is Third Spacing ?
Fluid trapped and unavailable for functional use.
- Not easily exchanged with the rest of the ECF
113
What are examples of Third Spacing ?
- Ascites
| - Edema associated with burns, trauma, & sepsis
114
What are S/S of Pulmonary Embolisms ?
- Sudden onset
- Anxious (sense of "doom")
- Tachypnea
- Dyspnea
- Tachycardia
- Chest pain
- Arrhythmias
115
What are symptoms of DVT's ?
- Painful
- Erythema
- Edema
- Warmth
116
DVT's can occur in any extremity, but what is the most common location ?
The Calf(s)
117
patients are more at risk for what Post-surgery ?
Pulmonary Emboli
118
What populations / groups are more at risk for a PE to DVT post-op ?
- Older adults
- Smokers
- Obese pt's.
- Those who have had previous PE or DVT
119
If a Pt. has a confirmed clot, what should NOT be done ?
DO NOT put SCD's on the affected area !
- Don't want to massage the clot out of place
120
What are nursing interventions to prevent PE's and DVT's ?
- Leg exercises
- Ambulate
- Elastic stockings (TEDS)/SCD's
- Prophylactic heparin/lovenox
- Avoid pressure to popliteal fossa (i.e., no crossed legs)
121
If a pt. has a foley present post-op, what do we want to do ?
Try to discontinue in the first 24 hours to prevent a CAUTI
122
If a pt. is post-op, what should you do if they haven't voided in 6-8 hours ?
Cath them (Need MD order)
123
What is the most common GI complication post-op ?
Nausea & Vomiting
124
Aside from N/V, what are other post-op GI complications ?
- Abdominal distention
| - Hiccups (short term)
125
What are some post-op GI interventions ?
- Abdominal assessment
- Ambulation !!
- Encourage pt. to expel flatus (means things are working)
- Oral hygiene
- Antiemetic drugs
- Suction at bedside
- Begin intake with return of bowel sounds, as tolerated
- If NPO, give IV infusions to maintain fluid and electrolyte balance
126
In the first 24-47 hours post-op what type of temperature changes would you expect ?
- Mild elevations up to 100.4 F, due to inflammatory response
127
A temperature > 100.4 F may be signs of what ?
- Lung congestion
- Atelectasis
- dehydration
* Encourage: IS, C&DB, & ambulation
128
After 48 hours post-op, a fever > 100 F may hint at what ?
Possible...
- Wound infection
- Urinary infection
- Respiratory infection
- Phlebitis
129
What is Sanguineous fluid ?
Blood
130
What is zero-sanguineous fluid ?
A mix of blood & serous (clear) fluid
131
What is serous fluid ?
Clear
132
Evidence of an Infection of a surgical wound is usually not apparent for _________________ ?
3 to 5 days
133
What are S/S of a wound infection ?
- Purulent drainage
- Increased pain
- Increased erythema
- Induration (hardening)
- Dehiscence (seperation)
- Evisceration (internal organs start to protrude out)
(Cover w/ sterile NS dressings & CALL MD !)
134
Postoperatively, when is pain typically at its most severe ?
1st 24-48 hours
135
When trying to control pain postoperatively, the first 24-48 hours may require what type of medication ?
Narcotic analgesics (MS)
136
Post-op what should you do prior to activities to optimize the patients participations with things such as IS, C&DB, ambulation, etc., ?
Medicate prior !
137
What is the most significant general nursing measure to prevent postoperative complications ?
Ambulation !
| And IS and C&DB
138
What are the benefits of ambulation postoperatively ?
- Increases muscle tone
- Improves GI and GU function
- Stimulates circulation to prevent DVT and PE & speed wound healing
- Increases vital capacity and maintains normal respiratory function
139
What age population may experience a longer and more difficult recovery ?
Geriatric population
140
With the Geriatric population, what is the most common post-op "problem" ?
Delirium (15-35%) ----> Check Pox first !
141
With what population may post-op pain be underrated ?
Geriatric population
142
With Geriatrics, ______________ (respiratory condition) is a common post-op complication ?
Pneumonia
143
With the Geriatric population What do we want to monitor for post-op (in terms of medication administration) ?
Drug toxicity
- Due to a possible decrease in renal and liver function
144
True or False ; with discharge teaching we want to give both verbal and written discharge instructions ?
True
