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CNOR > Intraoperative patient care and safety pt. 2 > Flashcards

Intraoperative patient care and safety pt. 2 Flashcards

1
Q

Who developed the universal protocol?

A

the joint commission

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2
Q

Who developed the universal protocol in 2007?

A

The Who or World Health Organization

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2
Q

Who also recognizes the importance of patient safety and endorses the sign-in portion of the checklist?

A

the American society of anesthesiologists

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3
Q

What does the ASA ensure?

A

the RN circulator and anesthesia professional the opportunity to ensure not only the right patient and procedure, but also the right anesthetic approach and prophylactic antibiotic needs.

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4
Q

When does the universal protocol begin?

A

before the patient enters the operating room

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5
Q

When is the universal protocol performed?

A

at the sign-in, time out, and sign-out

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6
Q

When should the briefing be completed?

A

before incision or procedure start

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7
Q

When should the debriefing be completed?

A

after the procedure prior to the surgeon leaving the room

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8
Q

What are the 13 things that should be included in the briefing?

A
  1. team member introductions
  2. patient identification - 2 unique identifiers
  3. verification of signed consent
  4. procedure specific - name, laterality, site marking, length, goals
  5. diagnostic tests and results
  6. patient position
  7. risk assessment for: pressure injury, fire, VTE, blood loss, difficult airway
  8. skin antisepsis used and dry time
  9. availability of: equipment/instruments, implants, blood products
  10. allergies
  11. special precautions
  12. antibiotics: administration time, redosing requirements
  13. anticipated needs for: glucose monitoring, imaging, pathology, postoperative plan of care
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9
Q

What are 10 universal protocol debriefing elements?

A
  1. procedure name
  2. surgical counts affirmed
  3. procedural issues with: equipment, supplies, preference card updates
  4. blood loss
  5. wound classification
  6. physiological: glycemic controls, pain management, VTE prophylaxis
  7. safety concerns
  8. specimen considerations: name and location, label, markings, disposition
  9. surgical complications
  10. postoperative expectations
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10
Q

What is the responsibility of health care organization leaders in patient and personnel safety?

A

creating a safe perioperative environment for patients and personnel

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11
Q

What is the responsibility of RN in patient and personnel safety?

A

following established policies and procedures created to protect personnel and patients

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12
Q

What is the responsibility of the team in patient and personnel safety?

A

protecting the patient

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13
Q

What is ESSENTIAL to the role of the RN in patient and personnel safety?

A

implenting interventions to prevent injury to personnel, patients, and visitors due to chemical hazards, fire, smoke plume, radiation, lasers, surgical positioning, and ergonomics

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14
Q

Safe handling and disposal of chemicals is guided by who?

A

local, state, and federal regulations

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15
Q

Who requires facility managers to ensure that safety data sheets are available to employees?

A

occupational safety and health administration (OSHA)

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16
Q

What kind of information is included on chemicals in safety data sheets?

A
  1. physical properties
  2. composition of ingredients and compound stability
  3. toxicology information
  4. specific hazard identification
  5. instructions for use
  6. proper handling, include storage
  7. required personal protective equipment
  8. fire extinguishing details
  9. recommendations for accidental spills
  10. first aid for exposure
  11. proper disposal
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17
Q

How far should eye wash stations be located?

A

no further than 10 seconds away from an area where chemicals are located

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18
Q

What should team members know in the event of a chemical spill emergency?

A
  1. locations of PPE
  2. where emergency spill kits are
  3. where respiratory protection is (respirators, exhaust hoods, or specific air exchange mandates).
  4. where eye wash stations
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19
Q

What does a fire risk assessment include? hint: 4 things

A
  1. identifying fuel sources
  2. ignition sources
  3. oxidizers
  4. whether the surgical site will be above the level of the xiphoid
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20
Q

What are 3 examples of fuel sources?

A
  1. alcohol based preparation solutions
  2. drapes
  3. endotracheal tubes
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21
Q

What are examples of ignition sources?

A
  1. ESU
  2. fiberoptic light cords
  3. lasers
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22
Q

What should you do during head, face, neck, and upper chest surgery to decrease fire risk?

A

stop supplemental oxygen at least 1 minute before and during electrocautery, electrosurgery, or laser use, if possible

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23
Q

What is one way to reduce exposure to the contaminants released by smoke plume?

A

use of evacuation systems with capture devices that use ultra-low particulate air or high-efficiency particulate air filters

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23
Q

What are contaminants in smoke plum?

A
  1. benzene
  2. bioaerosols
  3. formaldehyde
  4. hydrogen cyanide
  5. living cells
  6. toxic gases and vapors
  7. viruses
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24
Q

Use of what supports the risk reduction strategy of as low as reasonably achievable (ALARA)?

A

use of the principles of time, distance, and shielding supports the risk reduction strategy of ALARA

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25
Q

What should education and training on lasers for the perioperative team include?

A
  1. only properly trained and qualified personnel should operate lasers. a dedicated laser operator should have no other responsibilities when the laser is being operated
  2. the treatment area where lasers are used should be properly identified and access should be controlled
  3. patients and personnel should be protected from unintentional laser exposure (use of anodized instruments, protection of exposed skin or tissue with moist sponges, proper handling of laser fibers
  4. approved eyewear specific to each laser used should be worn by the perioperative team in the nominal hazard zone
    5.the patient’s eyes should be protected from the laser beam using laser safety goggles or moistened eye pads
  5. plume generated from the laser should be removed using a smoke vac system
  6. Considerations for basic electrical safety should be taken to prevent injury for personnel and patients. Manufacturer’s IFU should be followed. LIQUIDS SHOULD NOT BE PLACED ON TOP OF LASER UNITS
  7. Risk of fire should be minimized by preventing pooling of surgical prep solutions and allowing them to dry adequately. Drapes and sponges near where the laser is used should be kept moist. Sterile water should be on the field to assist with extinguishing a fire
  8. The patient’s airway should be protected when the laser is used in the oropharyngeal airway. A laser resistant endotracheal tube with the balloon inflated with saline should be used. Use of a dye such as ethylene blue with the saline can help with detection of a cuff puncture. The throat may be packed with moistened sponges
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26
Q

What is the nominal hazard zone?

A

the space in which the level of direct, reflected, or scattered radiation used during normal laser operation exceeds the applicable maximum persmissible exposure

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27
Q

What is the nominal hazard zone usually defined as?

A

usually defined as the space within the room where the laser procedure is performed

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28
Q

true or false: the RN is the only one responsible for safe patient positioning that incorporates patient-specific factors

A

false; all perioperative team members

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29
Q

Who are the 3 involved in patient positioning?

A
  1. anesthesia
  2. circulator
  3. surgeon
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30
Q

what are patient factors that require modifications to the typical patient positioning?

A
  1. age - pediatric, geriatric
  2. pregnancy
  3. weight(obesity)
  4. presence of comorbid conditions (cardiovascular or respiratory conditions, trauma, infection, limitations to RoM, neurologic deficits)
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31
Q

What special considerations for patient positioning should be made for neonates?

A

they do not have fully developed dermal and epidermal skin layers, which leaves them vulnerable to skin and pressure injuries

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32
Q

What are 2 things you can do to keep a neonate free of positioning injuries?

A
  1. wrinkle free bedding
  2. special focus on pressure points
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33
Q

What special considerations for patient positioning should be made for pediatric patients?

A

pediatric patients have a larger head proportionately compared to the body, to which they are susceptible to skin and pressure injuries around the occipital region

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34
Q

What is another very important consideration for pediatric patients?

A

the nutritional status of younger patients, as they may experience alterations in dietary intake and appetite, which in turn affects their risk of positioning injuries

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35
Q

What is there a decrease in-in geriatric patients?

A
  1. adipose tissue
  2. skin thickness
  3. elasticity
  4. mobility
  5. neurologic function
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36
Q

What can the decrease in those 5 things in geriatric patients cause?

A

it may alter patient’s ability to recognize painful stimuli

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37
Q

What is the RN responsible in surgical positioning?

A

implementing interventions to prevent skin and pressure injuries as a result of positioning

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38
Q

What 2 things should be implemented to prevent friction injuries?

A
  1. the application of adequate padding with a special focus on bony prominences and the sacrum
  2. appropriate number of staff members to move the patient
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39
Q

What is a special consideration when positioning pregnant people? in regard to the vena cava

A

uterus can compress the vena cava against the spine, causing impaired venous return and decreased cardiac output.

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40
Q

What can compression of the aorta cause in pregnancy?

A

can impede placental and fetal perfusion

41
Q

What are 2 nursing interventions to prevent altered tissue perfusion during obstetric surgical procedures?

A
  1. placing a roll or bump under the pregnant patient’s right side or tilting the table to the left side
42
Q

What should be done for patients who are beyond 18 weeks gestation and having nonobstretric surgery?

A

the left tilt position should used, if at all possible

43
Q

What is class I obesity?

A

BMI 30 > 35 kg/m^2

44
Q

What is class II obesity?

A

BMI 35 > 40 kg/m^2

45
Q

What is class III obesity or extreme obesity?

A

BMI 40 > kg/m^2

46
Q

What are 2 huge considerations for obese individuals?

A

cardiac and pulmonary complications

47
Q

In obese individuals, what is the pulmonary function to increased cardiac output?

A

increased workload related to excess adipose

48
Q

In obese individuals, what is the pulmonary function to increased blood volume?

A

increase oxygen consumption leading to increased carbon dioxide production

49
Q

In obese individuals, what is the pulmonary function to left ventricular dilation and cardiac hypertrophy?

A

ineffective air exchange requiring increased effort to breathe

50
Q

In obese individuals, what is the pulmonary function to increased venous return?

A

elevated risk of aspiration from abdominal pressure and gastric reflux

51
Q

In obese individuals, what is the pulmonary function to right-sided heart failure from pulmonary vasoconstriction?

A

decreased lung capacity

52
Q

how should a patient weighing more than 157 pounds be transferred to the OR bed?

A

should be laterally transferred to the OR bed using a mechanical lifting device by 3 caregivers plus the anesthesia professional

53
Q

What are 11 factors influencing positioning?

A
  1. anticipated length of procedure
  2. availability of positioning devices
  3. required surgical position
  4. type of OR bed and mattress available
  5. presence of cold environment or exposure of a large area of body surface duringg the procedure, which may contribute to inadvertent surgical hypothermia
  6. moisture from pooling of prep solutions, which may lead to tissue maceration
  7. potential for shearing
  8. friction
  9. use of wound retractors for lengthy procedures
  10. placement and location of safety straps
  11. use of compression devices
54
Q

define shearing

A

sliding of skin and subcutaneous tissue over stationary muscle

55
Q

When is shearing more likely to occur

A

can occur in steep positions such as Trendelenburg

56
Q

define friction

A

the act of rubbing one tissue over another tissue or surface

57
Q

when is friction more likely to occur

A

if the patient is dragged from one surface to another without using a friction-reducing transfer device (i.e. using a draw sheet only with a heavy patient)

58
Q

What 4 things does the RN use to reduct the patient’s risk of positioning injury and to minimize the potential for complications?

A
  1. ergonomics
  2. body mechanics
  3. ongoing assessment
  4. coordination
59
Q

define ergonomics

A

the applied science of designing and arranging the environment to promote efficiency and safety

60
Q

When planning patient positioning the RN should do what 5 things…

A
  1. anticipate necessary equipment
  2. procure necessary equipment
  3. initiate interventions to prevent development of pressure injuries
  4. optimize exposure for the surgical procedure, support patient comfort, and support optimal physiologic responses related to the patient’s circulatory and respiratory functions
  5. work collaboratively with the perioperative team using any necessary assistive devices to reduce injury to the patient or team members
61
Q

true or false: the securing device should not be so tight as to restrict neuromuscular function in the tissue directly in contact with it

A

true

62
Q

What 2 things are super important when using a safety strap? 2 things the RN needs to ensure are happening

A

Rn should ensure…
1. there is a sheet or blanket between the patient’s skin and the leg strap
2. at least 2 fingers can be passed between the strap and the patient

63
Q

What are the 3 goals of excellent surgical positioning

A
  1. to place the patient in the best position for adequate surgical site exposure while respecting and maintaining the patient’s modesty and dignity
  2. preserving the patient’s best possible physical and anatomic functions
  3. preventing injury to skin, muscle, and neurovascular structures
64
Q

Is positioning a collaborative effort?

A

yes!

65
Q

What are the most frequent triggers of back and shoulder problems in nurses?

A

transferring and handling patients

66
Q

What are 7 high risk tasks specific to perioperative nurses?

A
  1. transferring patients on and off OR beds
  2. repositioning patients in OR beds
  3. lifting and holding patients’ extremities
  4. standing for long periods
  5. holding retractors for long periods
  6. lifting and moving equipment
  7. sustaining awkward positions
67
Q

What are potential complications associated with supine (with or without armboards)

A

pressure points - occiput, scapulae, olecranon, thoracic vertebrae, sacrum and coccyx, calcaneus

68
Q

What are 6 interventions for supine with or without armboards?

A
  1. provide adequate padding of all bony prominences
  2. ensure that the hands are not touching any metal, especially if the arms are tucked
  3. pad adequately under the arms and elbows to prevent ulnar nerve pressure
  4. consider using a pressure-reducing viscoelastic mattress, especially if the patient is obese or underweight
  5. Position the arms on armboards no greater than 90 degree extension with the patient’s palms up to prevent hyperextension and brachial nerve stretching
  6. maintain the head in midline positioning to prevent or minimize stretching of the patient’s neck musculature
69
Q

What are 5 potential complications with Trendelenburg?

A
  1. supine pressure considerations
  2. potential for increased intraocular and intracranial pressure
  3. increased blood pressure and cardiac output
  4. risk for tissue compromise as a result of shearing
70
Q

what are 2 nursing interventions for trendelenburg?

A
  1. monitor the needs of the anesthesia professional during long procedures
  2. apply compression stockings and devices as ordered by the surgeon
71
Q

What are 4 potential complications with reverse trendelenburg?

A
  1. similar to erect positioning
  2. supine pressure considerations
  3. venous circulation may be compromised in long procedures
  4. head and neck procedures may require a rolled towel or pillow to produce hyperextension of the neck
72
Q

What are 3 nursing interventions for reverse Trendelenburg?

A
  1. monitor the needs of the anesthesia professional during long procedures
  2. use a padded footboard to help secure the patient in position
73
Q

What are 6 potential complications for lithotomy (low, standard, high, exaggerated)

A
  1. risk of crushing the patient’s digits
  2. potential for acute changes in vasculature volume and cardiac exertion when positioning the legs
  3. risk for hyperabduction of the hips
74
Q

What 2 risks are associated with high or exaggerated positions of lithotomy?

A
  1. risk for decreased respiratory function and tidal volume because of increasing intra-abdominal pressure
  2. potential for compartment syndrome, which is more likely in high or exaggerated positions
75
Q

What are 7 nursing interventions for lithotomy?

A
  1. prevent crushing the patient’s digits in the table break
  2. ensure proper alignment of the lower extremities
  3. raise the legs simultaneously
  4. lower the legs simultaneously
  5. consult with the surgeon and anesthesiaa professional to decrease the effect of cardiovascular and respiratory compromise in high and exaggerated positions
  6. do not allow flexion of the knees > 90 degrees
  7. apply compression stockings and devices if surgery is anticipated to be longer than 2 hours
76
Q

What are 5 potential complications with semi-fowler/beach chair?

A
  1. neuromuscular bundle strain
  2. slipping down on OR bed
  3. Potential for decreased vascular return volume
  4. pressure points similar to supine positioning
  5. air embolism
77
Q

What are 10 nursing considerations for semi-fowler/beach chair?

A
  1. maintain the had in proper alignment
  2. place a pillow under the knees to ease lumbar strain and relieve heel pressure
  3. maintain the nonoperative side arm in anatomic positioning without strain on neuromuscular bundle
  4. be prepared to obtain special armboards and positioning to maintain the nonoperative side arm for the orthopedic procedure
  5. use a padded footboard to prevent the patient from slipping down in the OR bed
  6. apply compression devices per physician preference, particularly for procedures lasting longer than 30 minutes
  7. prevent neck muscle strain
  8. prevent undue strain on the hips and knees
  9. Pad bony prominences
  10. consider using a pressure-reducing viscoelastic mattress for obese patients
78
Q

What are 2 potential complications with sitting?

A
  1. same considerations as in semi-fowler positions
  2. reduced intracranial pressure
79
Q

What are 2 nursing interventions for sitting?

A
  1. ensure availability of a doppler should the anesthesia professional require its use during neurologic procedures
  2. ensure availability of a bulb syringe for the scrub person to prevent air embolus
80
Q

What are 2 potential complications for prone?

A
  1. pressure points include the cheeks, eyes, ears, female breasts, male genitlia, knees, and toes
  2. respiratory volume is compromised because of limited anterolateral movement and potential limitation of diaphragmatic movement
81
Q

What can occur with prolonged pressure on the eyes in prone position?

A

blindness

82
Q

What are 7 nursing interventions for prone position?

A
  1. Assist the anesthesia professional in the placement of proper pressure-reducing devices for the patient head
  2. provide positioning devices or special OR bed and padding according to the surgeon preference
  3. assess ROM of the arms and cervical neck before induction of anesthesia and assess for any pain during ROM testing
  4. Communicate any deficit ROM or pain before surgery to the anesthesia professional
  5. document any preprocedure deficits
  6. ensure that the patient’s abdomen is hanging freely between the pelvis, hip, and chest supports
  7. monitor for any kinking dislodgment of endotracheal tubing when positioning the patient for surgery and postoperatively
83
Q

Who established guidelines that facilities must incorporate into their radiation safety programs?

A

National council on radiation protection and measurements AND US nuclear regulatory commission

84
Q

What are lead options for both patients and personnel in the OR?

A
  1. lead aprons
  2. wraparound skirts and vests
  3. thyroid shield
  4. gloves
  5. leaded safety glasses with side shields
85
Q

What is another shielding option that is not worn?

A

mobile rigid shields

86
Q

What is shielding to protect patients?

A

flexible gowns covering the areas not being x-rayed, with attention to the ovaries and testes

87
Q

What is the manager’s responsibility when it comes to PPE?

A

to provide health care team members with appropriate PPE and to educate them on the proper use of the products

88
Q

Who dictates the use of PPE?

A

OSHA

89
Q

What are 5 different types of PPE?

A
  1. gloves
  2. fluid-resistant attire
  3. approved eye protection
  4. surgical masks approved for the perioperative setting
  5. approved N-95 masks or respirators for specific isolation needs
90
Q

What PPE is required when there is a risk of splashing?

A

safety goggles with side shields

91
Q

When are safety goggles with side shields required for the RN?

A
  1. when bagging sponges
  2. when within close proximity to the sterile field
  3. when there is any risk of exposure to contaminants
92
Q

According to the American National Standard for Safe Use of Lasers, what is required when lasers are used?

A

specific laser-approved goggles or eyewear that is based on the wavelength of a specific laser

93
Q

What is the role of the health care manager in safety goggles?

A

managers are required to provide the eye protection for surgical team members involved with the procedures involving lasers

94
Q

According to OSHA, what are the 2 primary methods that should be implemented to either eliminate or reduce the risk of sharps injuries?

A
  1. engineering controls
  2. work practice controls
95
Q

What do engineering controls do for sharps injuries?

A

isolate or eliminate the hazard from the workplace

96
Q

What are examples of engineering controls?

A

self-sheathing needles, needless IV systems

97
Q

What do work practice controls do for sharps injuries?

A

reduce the likelihood of exposure by modifying the way a task is performed

98
Q

What are examples of work practice controls?

A
  1. neutral zone
  2. no recapping of needles
99
Q

What are 6 strategies to reduce the incidence of needle sticks?

A
  1. double gloving
  2. no-touch technique
  3. use of a neutral zone
  4. use of a sharps/needle counter
  5. situational awareness and communication related to the location of sharps
100
Q

What is the RN’s responsibility for manufacturer’s IFU?

A

the RN creates a safe environment for a patient undergoing a surgical procedure that may involve the use of many types of equipment in accordance with the manufacturer’s IFU.

101
Q

What is manager’s responsibility for manufacturer’s IFU?

A

required to provide the necessary training for all surgical team members when equipment is purchased.

102
Q
A

CNOR (12 decks)

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