Nursing Process/Check In

Question 1

What are the steps of nursing process

Answer 1

Assessment 
Diagnosis 
Outcome identification & planning
Implementation 
Evaluation

Question 2

Assumptions with patient centered care?

Answer 2

Active partnership 
Patient autonomy 
Shared responsibility 
Respect privacy and decision making 
Sharing information
Culturally aware of beliefs / other factors that may influence patient 
Pt advocacy 
Respecting all cultural, racial, ethnic, gender and sexual orientation 
Aware of health literacy/language levels

Question 3

Why is patient engagement important?

Answer 3

Patient centered

Foundation for patient quality and safety

Question 4

What is covered in a complete assessment?

Answer 4

All systems including:
Cultural 
Emotional
Spiritual
Developmental 
Lifestyle aspects 
SDOH

Question 5

What is covered in a focused assessment?

Answer 5

Data collection required for specific health issue
Conducted when patient is unable to participate ex. Disorientated
Performed continually during nurse - patient contact

Question 6

Who was the first to incorporate nursing diagnosis into nursing process?

Answer 6

American Nurses Association

Question 7

Outcome part of nursing process?

Answer 7

Collaborate with patient to determine expected outcomes

Question 8

Planning part of nursing process?

Answer 8

Nurse establishes priorities of care

Chooses nursing intervention

Question 9

What is NANDA-I?

Answer 9

North American nursing diagnosis association

International

Question 10

TJC focused assessment. 5 W’s?

Answer 10

Who - correct patient
What - correct procedure, consent 
When - when is procedure? 2 at once?
Where - correct site, marked, consent 
Why - purpose of surgery

Question 11

What are you checking in patients chart in check in?

Answer 11

Consent 
H&P
Vital signs 
Allergies 
Diagnostic tests 
NPO status 
Doctors orders -abx 
Nurses notes
- info/concerns about pt
Confirming implants, prosthesis, deformities or disease processes that require special consideration for surgery

Question 12

Meeting a patient considerations?

Answer 12

2 identifiers
How would they like to be addressed
Never assume family relationships
Determine NPO status, last void, prep done
Confirm procedure, site, how it will be done
Consent - confirming signatures/blood consent

Question 13

What are patients concerns pre op?

Answer 13

Fear of unknown 
Giving control to others
Being awake during surgery 
Not waking up after anesthesia 
Surgery concerns
- pain, prognosis

Question 14

Affects of pre - op anxiety?

Answer 14

Affect surgical outcomes

• increase anesthetic doses
• HTN - increased bleeding, N/V
• increased risk for SSI’s

Question 15

Affects of anxiety on the body?

Answer 15

Brain - depression, irritability 
Immune system - decrease in function 
Skin - delayed healing 
Cardio - HTN
Gut - malabsorption 
Joints - pain, stiffness 
Reproductive- decreased libido

Question 16

Suicide mentioned in assessment?

Answer 16

Report immediately

Follow P&Ps

Question 17

Pain assessment?

Answer 17

Always use same pain scale

Question 18

Positioning considerations

Answer 18

Geriatric, obese, paediatric

• issues with shoulders, hips, knees
• extra precautions

Question 19

Pre procedure check in checklist?

Answer 19

Identify patient 
Allergies 
Procedure/site 
Consent 
Site marked 
H&P
Pre anesthesia assessment 
Diagnostic testing 
Blood products 
Special equipment/devices/implants 
Beta blocker meds 
VTE prophylaxis 
Normothermia measures

Question 20

Medications/ food/ supplemental therapies considerations for surgery?

Answer 20

Review all meds prescribed and OTC in pre op assessment

Can have impact on procedure and potentially cause adverse effects when combined with anesthesia

Question 21

Cannabis considerations?

Answer 21

Unknown affects to tolerance of anesthetic agents

Metabolized by liver and excreted through feces, bile and urine

Question 22

Cannabis affects on body?

Answer 22

CNS - sedative, anxiety, dizzy
Cardio - vasodilator, tachycardia
Pulmonary - airway edema, bronchodilation
GI - increased appetite, nausea

Question 23

Why is cannabis risk factor for surgery?

Answer 23

Hyperactive airway 
Anxiety 
Unknown tolerance to induction agents 
Unknown tolerance to pain meds 
Withdrawl

Question 24

ETOH risks with surgery?

Answer 24

Lowered immunity
Prolonged bleeding
Increased stress response
Cardiac complications

Question 25

Intra op hypothermia may cause?

Answer 25

Poor healing
Increased post op pain
Pressure injuries
Decreased drug metabolism

Question 26

Risk factors for hypothermia?

Answer 26

Low body weight 
Paediatric/ geriatric 
Thyroid disorders 
PVD
Diabetic neuropathy
Open cavity surgeries

Question 27

Active warming measures?

Answer 27

Forced air warming
Increased room temp
Warmed IV fluids

Question 28

Passive warming measures?

Answer 28

Thermal clothing
Warm cotton blankets
Reflective material

Question 29

VTE prophylaxis?

Answer 29

Mechanical / pharmaceutical

- SDCs, anticoagulant

Question 30

Patient risk factors for VTE?

Answer 30

> 40yrs old 
Obese 
Hx of VTE
Bedrest > 3 days 
Varicose veins 
CVC 
Smoking 
Dehydration 
OSA 
Pregnancy

Question 31

Procedure risk factors for VTE?

Answer 31

> 90min long 
Positioning 
Tourniquet use 
Transplant surgery 
Emergency surgery 
Concurrent surgeries 
Open surgery

Question 32

VTE meds?

Answer 32

Anticoagulant
Thrombolytic
Factor Xa inhibitors
Thrombin inhibitors

Question 33

How long should you stop VTE medications prior to surgery?

Answer 33

48hrs prior

Question 34

Patient sign in checks?

Answer 34

Correct patient 
Correct procedure 
Correct site & site marking 
Consent 
Allergies 
Pulse ox on 
Is patient aspiration risk or difficult airway - cart in room?
Risk of blood loss > 500mL - blood been ordered?

Question 35

Pre op assessment interview?

Answer 35

Physiological status 
Body size 
Mobility 
Pre existing health conditions 
Planned duration of procedure 
Type of anesthesia