Exam 2 (W4 Operative nursing) Flashcards
Operative nursing
Preoperative
begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) bed.
Intraoperative
begins when the patient is transferred onto the OR bed and ends with admission to the PACU. Intraoperative nursing responsibilities involve acting as scrub nurse, circulating nurse, or registered nurse first assistant
Postoperative
begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home
Surgical classification: diagnostic
figuring out what is causing the problem (biopsy, large incision, laparoscopy)
Surgical classifications: Curative
– surgery to fix whatever is wrong (appendicitis appendectomy)
Surgical classifications: repair
fixing something broken (broken arm, perforated bowel)
Surgical classifications: reconstructive/cosmetic
child with cleft palate, breast reconstruction after breast cancer, face lift
Surgical classifications: Palliative
surgery done to relieve symptoms (someone that has really bad headaches from brain tumor cant get all of brain tumor but we can get as much as we can to relief the pressure in the brain to decrease symptoms)
Surgical classifications: rehabilitative
putting rods in back to help someone have back strength/fix scoliosis – get people back to functioning normal
emergent surgery
Patient requires immediate attention; disorder may be life-threatening - WITHOUT DELAY
Urgent surgery
Pt. requires prompt attention; needs to be taken care of wihin 24-30 hours
Require surgery
patient needs to have surgery - plan within a few weeks or months
elective surgery
patient should have surgey; can choose if they want to have it or not ; failure to have surgery is not catastrophic
optional surgery
personal preference - i.e. cosmostic surgery
Preaddmission testing: health history
Anyone with chronic health conditions = be aware the condition can strongly impact surgery
Must be current history and physical on chart before pt. goes to surgery (emergency – H&P is the extent this patient will go
Preadmission testing: consent
Obtained in preoperative time
The responsibility of PROVIDER and ONLY provider
When nurse signs it, its stating the the patient signed it and had no other questions
Ask what are you here for and do you have any questions
Preadmission testing: diagnostic
EKG, Xray, vascular studies, lung cancer resection (must be avail)
Preadmission testing: lab tess
electrolytes (especially K+ because it will make the heart irritable, and when anesthesia is introduced the heart will go crazy; notify HCP if high or low)
WBC (4,000-10,000)
Hgb (12-18)
Geriatric risk for surgery – cardiac
cardiac disease (decrease CO), many people have CAD and vascular disease as they age, anyone 50+ must have EKG before surgery
Geriatric risk for surgery – pulmonary
old people do not have reserve (interstitial) same with pulmonary reserve, big complication is pneumonia after surgery; diminished cough reflex
Geriatric risk for surgery – integumentary
skin is the largest organ and biggest protector; thin skin, tears easily, skin tear breaks protection
Geriatric risk for surgery – SQ fat
loss, increase risk for pressure areas, pressure areas need to be padded appropriately for surgery or will end up with pressure ulcer, skin breaks down quicker
Geriatric risk for surgery – hepatic and renal
decrease function in both, meds are not gong to be metabolized and excreted fast – might wake up crazy after surgery
Geriatric risk for surgery – GI
colon / peristalsis slows down
Bariatric risks for surgery
Fatty tissues increase infection risk
Wound dehiscence
– Splitting of subcutaneous
layers (they do not stick together the way muscle does)
– d/t excess tissue
shallow respirations when supine
- Pressure on diapragm, risk for pneumonia
- Someone on opioid or w pain – increase risk pneumonia
Preoperative considerations: glasses
Some people need to watch mouths, so remove glasses at last minute before surgery
Preoperative considerations: dentures
Should be removed b4 OR, some people want denture back in for self-esteem (respect it)
Preoperative considerations: hearing aid
Make sure they have them back in when done w surgery so they can hear instructions
Preoperative considerations: physical disability
Communicate disability to nurse and all staff involved / when giving report
Preoperative considerations: mental disability
Ppl with anxiety, learning disability, autism good to know when you wake them up after surgery so you know what to expect and how to approach
Informed consent
Nurse witness signature
Surgeon provide clear explanation of the procedure
Further information needed must come from surgeon
Obtain before pre op medications given
Accompany patient to OR in chart
All invasive procedures require consent
Blood & radiation require consent
Emergency – assumed consent by surgeion is there is no one there to consent for patient or if patient is unable to provide consent
Consent must be on chart
Preoperative assessment
Health history Physical examination VS Allergies Co morbid conditions Medications Genetics
What are important allergies to ask about during preoperative assessment
Banana related to latex allergy (same w kiwi and avocado)
Metal let OR know if their having metal impant
Iodine used to clean skin sometimes
Contrast dye
What are important medications to ask about during preoperative assessment?
- anti-coagulants
- Diuretics – K+ issues
- insulin for diabetics – will not take insulin until they get to surgery center – nurse takes BG and anesthesia / surgeon give direction for how much insulin they get – they wont be hypoglycemic because the stress of surgery releases cortisol and increases BG – they keep BG 100 or lower, higher BG leads to longer healing times
- Aspirin
- Herbal G’s – can all cause bleeding
- St. johns wort (depression) = will delay ppl from waking up after surgery
Beta blockers – never stop taking abruptly
Never stop taking steroids abruptly – someone who takes a steroid everyday their adrenal glands go on “vacation” (adrenal insufficiency) they are under stress so they don’t have adrenal-cortisol response so we need to give them more steroids with their daily dose while they’re in hospital, clean mouth, reduced immune system, slower healing
Nutrition and fluid status
Bowel prep
–> If we are NPO and have bowel prep, IV needs to be started to get fluid replacement and pay attention to electrolytes (k+)
Dehydration and electrolytes
Nutrition for healing
Teeth - clean (source of infection), careful with broken / decayed teeth
Albumin levels should be adequate so they’re ready to heal – If not high in vitamin C and protein
Explain how drugs and alcohol impact anesthesia
Alcoholic – more anesthetic
Drugs can have adverse fx w anesthesia
Pneumonia is a huge problem during surgery, explain how we can prevent this?
Coughing and deep breathing
Splint incisions during pre-op (education)
Get up and moving decreases risk of pneumonia
Incentive spirometer
How does smoking impact the respiratory system in times of surgery?
Higher incidence of DVT, infections, poor wound healing, pneumonia
Smokers cough and hack when they wake up – increases risk of making wounds split open
Explain how the cardiovascular system is impacted during surgery
Ensure the CV system can support oxygen, fluid & nutritional needs
Hypertension risk during surgery
May alter the intended surgery for less anesthesia time
Make sure CO is what we need intra-op and post op
If someone does not have adequate cardiac or pulmonary status, on O2, or bad CHF – we may alter how procedure is done – might want to use local anesthetic
Explain how the hepatic and renal functions play a role into surgery
Medications
– Don’t metabolize anesthesia as quick –> continued effects
Acute infections contraindicate surgery unless life saving (i.e., bladder infection) especially if youre giving foreign material inside body
Explain how endocrine functions impact surgery
DM risk for hypo/hyperglycemia
Hyper increase risk for infection when diabetic
Maintain blood glucose 80-110 & tight control
Corticosteroids risk adrenal insufficiency
How does the use of Synthroid impact someones surgery
For thyroid
- if someone is taking this, they need to maintain thyroid function, so they WILL take the medication before surgery despite NPO orders
WBC count
4,000-10,000
How do we care differently postoperatively for those who are immunosuppressed?
take special care during and after surgery (incision care, get up and moving to aid in healing)
How might Dexamethasone (Dekpak) interest with anesthesia?
Cardiovascular collapse can occur if discontinued suddenly. Therefore, a bolus of corticosteroid may be administered IV immediately before and after surgery.
How might hydochlorothiaside (Microxide) interfere with anesthesia?
During anesthesia, may cause excessive respiratory depression resulting from an associated electrolyte imbalance.
How might Chlorpromazine hydrochloride interfere with anesthesia?
May increase the hypotensive action of anesthetics.
How might Diazepam (Valium) interfere with anesthesia?
May cause anxiety, tension, and even seizures if withdrawn suddenly.
How might insulin (humalog) interfere with surgery?
Interaction between anesthetics and insulin must be considered when a patient with diabetes is undergoing surgery. IV insulin may need to be given to keep the blood glucose within the normal range.
How might Warfarin (Coumadin) interfere with anesthesia?
Can increase the risk of bleeding during the intraoperative and postoperative periods; should be discontinued in anticipation of elective surgery. The surgeon will determine how long before the elective surgery the patient should stop taking an anticoagulant, depending on the type of planned procedure and the medical condition of the patient.
How might Carbamazepine (Tegretol) interfere with anesthesia?
IV administration of medication may be needed to keep the patient seizure free in the intraoperative and postoperative periods.
How might Levothyroxine sodium (Synthroid) interfere with anesthesia?
IV administration may be needed during the postoperative period to maintain thyroid levels.
How might Morphine sulfate (MS Contin) interfere with anethesia?
Long-term use of opioids for chronic pain (≥6 mo) in the preoperative period may alter the patient’s response to analgesic agents.
Preoperative: nursing interventions
a. Patient education (pain management, deep breathing/coughing/incentive spirometer/mobility)
b. Psychosocial interventions (benzo)
c. patient safety
d. Nutrition and fluids (NPO)
e. Preparing bowel
f. Preparing skin (Antiseptic to reduce risk of bacteria ; wipes or special soaps for so many days before surgery (common for ortho surgery)
What does the nurse do in pre-op following informed consent and patient education?
Administer pre anesthetic medication
Maintain the pre op record
–> Check list of what to do and what to have on chart b4 surgery
Transport to surgical suite
Family
–>If we have child; family will go to OR suite to decrease anxiety; adult alone
Who is considered the surgical team during intraoperative phase is surgery?
Patient, circulating nurse, scrub role, surgeon, RNFA, anesthesiologist/CRNA
Intraoperative - Time out
Everyone stops and review what they’re doing, what side, and is the site marked by surgeon, checking with consent and chart
Review if there is risk for signif. Blood loss, if so, is it on chart and is blood avail
Intraoperative - surgical count
Keep track of items used during surgery (circulatory nurse job)
If count is wrong, XRAY needed
Important things to ensure in the surgical environment
Maintaining sterile technique
Sterile is waist to shoulders any thing above and below is not sterile
No one gets needle stick if they have HIV
General anesthesia
a. Inhalation
b. IV
keep pt. unaware, out of pain and paralyzed. Given medication (neuromuscular blocker) so they can’t move. Takes a while to fully metabolize
- confused upon waking, people get scared (aggressive behaviors); keep patient and safe (drains, IV, etc.)
Regional anesthesia
a. Epidural (both extremities)
b. Spinal (Both extremities)
c. Nerve blockers (Radia, femoral, etc. - only 1 extremity)
epidural and spinal given in back (according in NCLEC, everyone who needs these kinds must sit up on edge of bed; opens up vertebral space)
- epidural and spinal difference – less than mm space
- monitor that epidural aren’t getting hypofecal dose (?)
- all 3 of these no control
- keep body aligned because patient has no orientation of where body is
Moderate sedation
Monitored anesthesia care (MAC)
Sedation (no paralyzing), no airway assistance
No anesthesia provider needed, nurse or surgeon can administer
Monitor for breathing, ensure tongue out of away
Local (-cain) anesthesia
Tetracaine, lidocaine, cocaine –
Can use quickly is someone has not been NPO
Titrated around incision so numb around incision
Intraoperative Complications
Nausea & Vomiting (turn to side, vomit out side of mouth)
Skin care (caution of pressure sores)
Anaphylaxis for allergic reactions
Hypoxia (have controlled airway unless not controlling airway (local) so monitor)
Hypothermia (keep warm)
Malignant hyperthermia
Malignant hyperthermia
Development of high temp because certain medication
- first indication of this – stiff muscles (when someone is under anesthesia, you’ll know their muscles are stiff if they’re difficult to ventilate as chest wall becomes stiff; going to see increase in CO2) – everyone under general anesthesia. Will have o2 monitored
- can happen intra or post op
s/s malignant hyperthermia
muscle stiffness, tachycardia, sleepy, high CO2, still muscles and hyperthermia (late sign)
How can we treat malignant hyperthermia
Muscle relaxant (dantroline)
How do we monitor maligniant hyperthermia in post-operative care
co2 rising and we are not monitoring the o2, rising co2 –> sleep and die (hard to pick up because everyone is tired in post-op)
What genetic factor puts someone at risk for malignant hyperthermia
muscular dystrophy
Postoperative nursing: post anesthesia care unit (PACU)
Patient leaves OR until last follow up visit with surgeon
a. phase I
b. phase II
c. phase III
Postoperative nursing: Report
Procedure Fluids Allergies Complications Pre op assessment
Postoperative nursing: position
Protect incision
IVs
Drains
Protect incision, IV and drains. (b4 patient wakes)
Safe, airway (patent), vitals (order of operation in this setting)
PACU: what do we assess when patient arrives here?
safety, VS, incision
PACU: patient airway
Tongue (hypopharyngeal obstruction)
Push jaw forward to wake and move tongue
PACU: CV stability
Cardiac rhythm
Hypotension & shock
Hemorrhage
Hypertension & Dysrhythmias
What needs to be checked in preparation for the patient being d/c?
Discharge to home Inpatient unit Report VSS N/V controlled Pain controlled
Care of the inpatient surgical patient - things to obtain
If you’re receiving patient from OR, get report, assess, vitals before you care about orders – make sure patient is stable
Postoperative nursing interventions
a. Prevent respiratory complications
b. Pain relief (pain can prevent adequate breathing)
c. Promoting cardiac output with fluid and mobility
d. Encourage activity
e. Caring for wounds (surgeon usually takes off 1st surgical dressing)
f. Maintaining normal body temperature
g. GI function returned (b/b function, UOP within 8 hours of surgery - if not, interventions)
Bowel function, bladder function, safe environment, emotional support
Post operative complication: DVT
occurs when a blood clot forms in a deep vein.
Post operative complications
Large blood collection around incision (not normal, bruise is)
post operative complications: infection
purulent drainage
post operative complications: wound dehiscence and evisceration
dehiscence: incision split open
evisceration: intestines coming out
Sterile saline soaked gauze on wound is 1st thing you do, then get back to bed
What should the nurse do if evisceration occurs?
Sterile saline soaked gauze on wound is 1st thing you do, then get back to bed
NPO, vitals, call surgeon immediately back to surgery
What should the nurse do if dehiscence occurs?
Sterile saline soaked gauze on wound is 1st thing you do, then get back to bed
vitals, call doc. Can mostly occur through secondary intention
