Module 3

Question 1

What does surgery cause

Answer 1

Interrupts the natural physiological processes of the body. Causes stress & risks for complications.

Question 2

What variables affect surgery

Answer 2

Procedure, age, coexisting medical conditions, and nutritional status.

Question 3

What age is most at risk for surgery complications? Why?

Answer 3

70+. They respond different to anesthesia/drugs and take longer to awaken from anesthesia.

Question 4

What risk does an underweight patient have after surgery?

Answer 4

Increased problems with wound healing/infections.

Question 5

What risk does an overweight patient have after surgery?

Answer 5

Increased problems with wound complications and respiratory complications.

Question 6

What why is adipose tissue important to keep in mind after surgery?

Answer 6

Adipose tissue has poor perfusion meaning it heals slower. “Holds on” to anesthesia longer.

Question 7

Diagnostic surgery.

Answer 7

Completed to make an accurate diagnosis through removal and study of tissue or opening of a body cavity to determine the extent of a disease process or may be performed through use of a scope.

Question 8

Exploratory surgery

Answer 8

More extensive surgery to diagnose an issue.

Question 9

Curative surgery

Answer 9

Removal of diseased tissue, replacement of defective tissue to restore function, or to repair wounds.

Question 10

Palliative surgery

Answer 10

Performed to relieve symptoms or improve function without correcting the problem.

Question 11

Cosmetic surgery

Answer 11

Improves a person’s appearance.

Question 12

Preventative surgery

Answer 12

Removes noncancerous tissue that has a high probably to become cancerous.

Question 13

Reconstructive surgery

Answer 13

Done to restore structure.

Question 14

Procurement surgery

Answer 14

Refers to the removal of organs for transplant.

Question 15

Nursing goals during surgery

Answer 15

Minimize clients’ anxiety
Prepare for surgery
Monitor for complications during surgery
Assist in uncomplicated recovery

Question 16

How many phases of surgery are there?

Answer 16

3; preoperative, intraoperative, postoperative

Question 17

Preoperative phase

Answer 17

Begins when the decision to perform surgery is made and continues until the client arrives at the operating room

Question 18

Intraoperative phase

Answer 18

Starts when the client reaches the operating room and ends when the client is moved to the recovery room

Question 19

Postoperative phase

Answer 19

Begins when the client is admitted to the recovery room until the client has a follow-up evaluation with the surgeon

Question 20

Assessments for surgery

Answer 20

Completion of preoperative labs and diagnostic studies
Review of preoperative instructions; diet, skin prep
Identifies risks related to age, nutritional status, alcohol or tobacco use, physical condition
Performs history and physical examination
Assess clients’ understanding of surgery
Consider cultural needs; beliefs, disposal of body parts, blood transfusions

Question 21

What is an informed consent?

Answer 21

Indicates the client consents to a procedure and understands the risks and benefits of the procedure.
Required for invasive procedures that require anesthesia and has risks of complications

Question 22

Criteria for valid informed consent

Answer 22

Voluntary and over 18 years of age, prior to mind-altering medications
If an incompetent client (cognitively impaired, mentally ill, or neurologically incapacitated, signed by a family member or guardian
Minor clients, unless emancipated must be signed by parent or guardian. Signature requires an adult witness
Nurse is responsible to have signed consent on client’s chart

Question 23

When is patient teaching best accomplished?

Answer 23

Preoperative period

Question 24

What is included in patient teaching?

Answer 24

Preoperative and postoperative medications and pain control
Description of postanesthesia area and routines (recovery room)
Discuss frequency of vital signs/monitoring equipment
Explains and demonstrates deep-breathing and coughing, incentive spirometry, splints, leg and feet exercises, and encourage return demonstrations
Inform of IV fluids and anticipated drainage tubes
Allow the client to express anxieties and fears
Include family members in preoperative explanations
In emergency situations, provide as much teaching as possible in the time allotted or as able depending on the client’s alertness or cognitive status

Question 25

Gerontological considerations during patient teaching

Answer 25

Diminished abilities to hear, see, and understand may interfere with preoperative/postoperative teaching.
May need to repeat explanations and demonstrations.
Include family members
Be aware of cognitive changes due to pain, medications, or change in environment
Use the teach-back technique to help understand needs that need to be clarified

Question 26

Skin preparation for surgery

Answer 26

Several days prior to surgery, client may be required to bathe with a germicide soap
Hair removal is not done unless it may interfere with the incision due to potential microabrasions
If necessary, hair is removed with electric clippers

Question 27

Elimination preparation for surgery

Answer 27

The client may require insertion of an indwelling catheter or the client voids immediately prior to surgery or administration of preoperative medications
Enemas or laxatives may be required to clean out the bowel for some abdominal surgeries to prevent potential fecal contamination

Question 28

Foods and fluids preparation for surgery

Answer 28

NPO at least 8-10 hours prior to surgery
Some surgical procedures may allow for clear liquids up to 2 hours prior to surgery
An adequate intake of protein and ascorbic acid is necessary for appropriate wound healing

Question 29

Care of valuables for surgery

Answer 29

The client’s valuables should be left at home, if possible, given to a family member/significant other, or placed in an envelope to be locked in a secure area
If a ring is unable to be removed or the client is reluctant to remove, wrap gauze around the ring or cover with adhesive tape
Glasses or contact lenses should be removed

Question 30

Attire/grooming preparations for surgery

Answer 30

The client generally wears a hospital gown, and a cap to cover the hair
All makeup and nail polish should be removed
If an ambulatory surgery, only portions of the clothing, makeup or polish may need to be removed
Antiembolism stockings or elastic wraps may be required preoperatively

Question 31

Preoperative medications

Answer 31

Antianxiety medications, histamine-2 receptor antagonists, anticholinergics, opioids, sedatives, and/or antibiotics

Question 32

Safety preoperative instructions

Answer 32

Follow the patient rights for medications administration, check for drug allergies, vital signs, ask client to void, surgical consent is signed

Question 33

Instructions for sedative medication administration

Answer 33

The client should remain in bed, side rails should be placed up for safety, call button is within reach

Question 34

Ambulatory surgery

Answer 34

Surgery that requires less than 24H of hospitalization

Question 35

Elective surgery

Answer 35

Surgery which the client will not be harmed if the surgery is not performed but will benefit if it is performed

Question 36

Psychosocial preparations for surgery

Answer 36

Preoperative teaching and listening
Assess coping methods
Preoperative checklist

Question 37

When does intraoperative care start?

Answer 37

When patient is transferred to operative table

Question 38

What are anesthetic agents used for?

Answer 38

Completely or partially alter sensation with our without the loss of consciousness so that surgical procedures can be done painless & safely

Question 39

General anesthesia

Answer 39

Loss of sensation, reflexes, and consciousness. Endotracheal tube may be required for respirations during anesthesia; requires close monitoring of client status; anesthesia is withdrawn at the end of the procedure

Question 40

What are the 4 stages of general anesthesia

Answer 40

Induction - administered with IV or inhalation & produces unconsciousness
Excitement - uninhibited movements or vocalizations
Surgical anesthesia - appropriate level of anesthesia for the procedure
Medullary depression - too much anesthesia

Question 41

Regional anesthesia

Answer 41

Loss of sensation and decreased mobility to specific anesthetized area with use of local anesthetics; risk for injury and burns due to lack of sensation; may require sedative to promote relaxation; includes spinal and epidural anesthesia; complications can include spinal headache

Question 42

Procedural sedation

Answer 42

conscious sedation in which client is free of pain, fear, and anxiety and able to tolerate the procedure; nurses must be aware of side effects and that sedatives can cause respiratory depression; antagonists can be administered to reverse the effects – Naloxone for opioids and flumazenil for barbiturates; requires close monitoring of client status
Clients should not be allowed to drive to make important decisions for at least 24-48 hours

Question 43

Gerontological considerations

Answer 43

Anesthesia, narcotics, and barbiturates can cause confusion, disorientation, or other physiological alterations in the older population

Question 44

Anesthesiologist

Answer 44

Physician specializing in anesthesia

Question 45

Anesthetist

Answer 45

Physician without an anesthesia specialty or a registered nurse who is certified in anesthesia and works under the supervision of a physician

Question 46

Anesthesiologist & anesthetist role in surgery

Answer 46

Assess the client prior to surgery, orders preoperative medications; explains anesthesia, risks and potential complications to the client; administers the anesthesia and monitors the client during and after surgery
Not a sterile member of the team

Question 47

Suregon role in surgery

Answer 47

Heads the surgical team
Determines procedure to be performed, obtains client’s consent, performs the procedure, and follows the client after the procedure

Question 48

Surgical assistants role in surgery

Answer 48

First assistant assists in procedure and may assist with pre- and postoperative care
May be physician, resident or certified RN
Second assistant and third assistants assist surgeon and first assistant
May be RNs or LPNs or surgical technologists
All assistants are sterile members of the team

Question 49

Scrub nurses role in surgery

Answer 49

Hands instruments to the surgeon, prepares sutures, receives specimens, counts sponges, instruments, and needles. Sterile team member.

Question 50

Circulating nurse role in surgery

Answer 50

Oversees health and safety of the client by monitoring all the surgical team’s activities
Assesses client for injury with interventions as necessary; obtains and opens wrapped sterile equipment and supplies before and during surgery; keeps records; assists in sponge, instrument, and needle counts; adjusts lighting; receives specimens; and coordinates activities of other personnel
Not a sterile team member

Question 51

Operating room environment

Answer 51

The operating room is physically isolated from other areas
Only authorized OR personnel or surgical clients are allowed
The air is filtered and positive pressure is maintained to reduce infection
The temperature is below 70° F to decrease bacterial growth and provide comfort to the surgical team
Surgical attire decreases microbial growth
All symptoms of infection in the surgical team must be reported
Furniture is stainless steel for easy cleaning and disinfecting

Question 52

What are the 3 designated zones in the OR?

Answer 52

Unrestricted zone – Street clothes are allowed; where clients, personnel, and supplies arrive
Semirestricted zone – Does require surgical attire, but not masks; Includes sterile and clean storage areas; work areas for cleaning instruments; and corridors leading to the restricted areas
Restricted zone – Includes OR and procedure room and scrub sink areas; requires full surgical attire

Question 53

What is included in the intraoperative assessment prior to anesthesia?

Answer 53

BP and pulse and respiratory rates
Level of consciousness
General physical condition
Presence of catheters and tubes
Review of client’s medical record

Question 54

Complications in the intraoperative room

Answer 54

Infection prevention includes monitoring for breaks in the sterile technique or field and counting of sharps, sponges, and instruments
Fluid volume excess or deficit – The anesthesiologist administers IV fluids, but the circulating nurse tracks IV fluids administered and measures urine output during surgery when appropriate
Injury due to positioning can occur in as little as 2 hours due to interruption of blood flow to an area resulting in pressure injuries, nerve injury, postoperative hypotension, dependent edema, and joint injury
Hypothermia is a possibility due to the low temperature in the OR; cold IV fluids; inhalation of cool gases; exposure of body surfaces for the procedure; open wounds; and prolonged activity or intentional body temperature lowering for some surgical procedures
Malignant hyperthermia is an inherited disorder
Body temperature, muscle metabolism, and heat production increase rapidly in response to stress and some anesthetic agents
Symptoms include jaw muscle rigidity, rapidly elevating temperature, elevated CO2 levels, elevated potassium, metabolic acidosis, hypotension, irregular heart rhythm, and kidney failure and cardiac arrest if left untreated
Gerontological considerations include increased risk for injury with prolonged surgical positioning; chronic conditions increase risk of complications

Question 55

When does the postoperative period begin?

Answer 55

When client is admitted to the postanesthesia care unit (PACU) or recovery room

Question 56

Who takes patient to PACU?

Answer 56

Anesthesia personnel/circulating nurse

Question 57

What is included in the immediate post OP nursing management?

Answer 57

Maintaining an intact surgical site
Observing for vascular changes
Keeping client warm
Positioning of client; protect incision and drains
Assessing for orthostatic hypotension

Question 58

Initial postoperative nursing management

Answer 58

Refer to the Aldrete scale
Airway patency, effective respirations, artificial airways, mechanical ventilation, oxygen
Circulatory status; wound condition, dressing, and drains
Fluid balance: IV fluids, catheter and drain output
Level of consciousness and pain
Monitors for potential complications

Question 59

What is the Aldrete scale

Answer 59

Aldrete scale is a tool used to assess how well a client is recovering from anesthesia, rating the client’s mobility, respirations, blood pressure, level of consciousness, and pulse oximetry

Question 60

Post op complications

Answer 60

Hemorrhage: Inspects the dressings, continues or initiates blood transfusions, reinforces dressings, monitors wound drains
Shock: Fluid and electrolyte loss, trauma, anesthetics, medications all contribute to shock; treat with blood, plasma expanders, IV fluids, oxygen, and medications if present
Hypoxia: Residual drug effects, pain, positioning, pooling of secretions, or obstructed airway can cause hypoxia; oxygen and suction equipment should be available; assess for signs of cyanosis and dyspnea
Aspiration: Aspiration from saliva, mucus, vomitus, or blood can occur until client is awake and able to swallow without difficulty; have suction equipment at bedside; assess for difficulty swallowing, side-lying position may be helpful
Wound dehiscence is separation of wound edges without protrusion of organs
Likely to occur within 7-10 days postoperatively; risks include poor nutrition; chronic disease; older adult; increased abdominal tension; obesity; infection
Decrease strain on incision and notify surgeon
Evisceration is separation of wound edges with protrusion of organs
Cover with sterile dressings moistened with normal saline and notify surgeon
Paralytic ileus are paralyzed intestines and no parastaltic activity
May require nasogastric tube and NPO status until bowel sounds return
Pneumonia and atelectasis, or the collapse of alveoli, are possible due to drug effects, failure to take deep breaths, and immobility
The older adult is most at risk for these complications, in addition to the obese, clients with COPD, or clients having had chest or abdominal surgery
Infection is indicated by increased wound pain or drainage, erythema, increased warmth, edema, and purulent exudate; increased body temperature; may require antibiotics
Infection risk is increased with traumatic wounds, wounds that were not treated promptly, or wounds that were infected preoperatively, in addition to clients who are obese, immunosuppressed or with diabetes mellitus
Thrombophlebitis is the inflammation of veins with the formation of blood clots usually caused by long periods of immobility
These clients are at increased risk for pulmonary emboli
Antiembolism stockings or sequential compression devices may be used to reduce the risk of blood clot formation in the legs

Question 61

When does the later postoperative period begin

Answer 61

Begins when the client arrives to the hospital room or postsurgical care unit

Question 62

Assessment of later postoperative period

Answer 62

Respiratory status, circulation, pain management, fluids and nutrition, skin integrity, wound healing, activity, bowel elimination, urinary elimination and psychosocial status
The nurse should assess respiratory and cardiac function, general condition, vital signs, fluid status, pain level, elimination and flatus, dressings, drains, and IV lines
Respiratory status – Encourage deep breathing exercises, use of incentive spirometer and splinting of incision; provide supplement oxygen as needed; encourage frequent position changes and early mobilization
Circulatory status requires assessment of blood pressure and potential orthostatic hypotension; assessment for bleeding; and venous circulation impairment in the form of deep vein thrombosis, which could break off and become pulmonary emboli
Postoperative pain is at its greatest 12-36 hours post procedure; pain should be treated before it becomes uncontrollable; pain unrelieved by medication can indicate complications
Opioids
Indications: Relieve moderate to severe pain; May be used in conjunction with anesthetics; Suppress cough center (codeine)
Adverse effects: Constipation; strong abuse potential; flushing and orthostatic hypotension; sedation; N/V; urinary depression; respiratory depression; confusion
Contraindications: Drug allergy; severe asthma; respiratory insufficiency; elevated ICP; morbid obesity; sleep apnea myasthenia gravis; paralytic ileus; pregnancy
Interactions: CNS depressants; alcohol
Treatment of overdose: naloxone and naltrexone
Opioid agonists
Bind to an opioid pain receptor in the brain causing an analgesic effect
Examples:
Codeine – Antitussive; ceiling effect (higher doses do not improve pain relief)
Fentanyl – Injectable – operative; Transdermal for chronic pain – breakthrough pain may include administration of an immediate-release opioid
Hydromorphone
Meperidine – High risk of toxicity
Methadone – Detoxification of opioid addicts
Morphine
Oxycodone
Agonists-antagonists opioids
AKA partial agonist or mixed agonist
Bind to a pain receptor and causes a weaker pain response than a full agonist
Avoids oversedation – useful in obstetrical clients; useful in opioid addiction; decreased risk for addiction or dependency
Examples: Butorphanol, nalbuphine, pentazocine
Opioid antagonists
Bind to a pain receptor but does not reduce pain signals
Examples: Naloxone
Fluids and nutrition: IV fluids, dietary progression is dependent on type of surgery, client’s progress, and physician order; assess for nausea and vomiting, nasogastric tube may be placed in abdominal surgery clients
Nursing guidelines for resuming oral fluids
NPO/assess bowel sounds; GI activity may not resume for 24 to 48 hours
Assess swallowing/introduce sips of water/ice chips slowly - usually within 4-24 hours postoperatively unless GI surgery
Administer antiemetic medications if client nauseous or vomits
When able, promote protein, calories, vitamins A, C, and zinc for wound healing and immune system function
Skin integrity/wound healing: wound assessment
Wound devices:
Drains remove fluids from wounds
Drains may remove fluid passively or actively with suction
A penrose drain is a flat, silicone-type drain that is placed deep into the wound and lies flat on the skin outside the wound
There is often a sterile safety placed in the portion of the drain that lies on the skin to prevent it sliding into the wound
A Jackson-Pratt or Reliavac drain is a hollow silicone bulb with a cap to drain and measure the exudate, and is attached to a tube that is placed near the wound through a stab site
The cap is open and the bulb is compressed – while holding the compression, the cap is replaced
The drain is often secured to the client with a suture
The bulb is often secured to a dressing or the client’s clothing with a safety pin through the tab on the bulb to prevent dislodgement
A circular, drum-shaped, spring-loaded drain, often referred to as a Hemovac is another option, and is often used with orthopedic surgeries
While the cap is open, the drain is compressed, and the cap is replaced
This drain may also be secured to the client with a suture
This is one of the drains that may have the option of reinfusing sanguinous exudate
This drain usually has a clip, similar to those on Foley catheter tubing, to secure it to the bed or client’s clothing
Clients may have a nasogastric tube inserted through one the nares and is attached to low, intermittent suction
These tubes are secured to the client’s nose with adhesive
The tube is often secured to the client’s gown to help prevent dislodgement
Wound assessment includes assessing approximation of wound edges, intactness of staples/sutures; signs of infection, and reactions to the adhesive or dressing
Phases of wound healing include the inflammatory stage, proliferative phase, and maturation/remodeling phase
Three modes of wound healing
Primary intention is healing of a wound with edges that are well-approximated with sutures/staples
Secondary intention is healing of a wound from the bottom up and edges are not approximated
Tertiary intention is the leaving of a wound open initially and going back to suture the edges at a later time
Factors affecting healing: impaired circulation, malnutrition; hyperglycemia, infection, foreign bodies, age, immobility
Signs of wound infection: increased incisional pain, redness, swelling, heat around incision, purulent drainage, fever, headache, anorexia
Complications: dehiscence, evisceration
Activity: Advance activity as tolerated as soon as possible, administer pain medication
Regional anesthesia—initially restricted until feeling returns
Spinal headache: remain lying flat for longer period of time
Bowel elimination
Abdominal distention: May be caused by narcotics, diet, and inactivity; encourage to ambulate, frequent position changes, diet advancement
Paralytic ileus is paralyzed intestines, acute gastric dilatation is a stomach dilated with fluids
Urinary elimination may be difficult after surgery
If unable to void within 8 hours postoperatively, encourage voiding, may require straight catheterization
Psychosocial status may be altered due to changes in body image or lifestyle
Assess for issues
Referrals for counseling, support groups
Gerontological considerations
The older adult can develop confusion and disorientation with narcotic and barbiturate use
Respiratory depression risk is also greater in the older adult with narcotics
May have a delay in healing due to thinner skin and loss of subcutaneous tissue
Are at an increased risk for infection due to a diminished immune response