Perioperative Flashcards
2 types of local anesthetic that are commonly used because they are rapidly absorbed and rapid acting.
Lidocaine and benzocaine
2 ways to improve accuracy of pt identification
2 identifiers
make sure pt gets correct blood in transfusion
3 steps in obtaining signature on informed consent
Verify
Notify and delay if necessary
Document
4 Classifications of Surgery
By body system
by purpose
by degree of urgency
by degree of risk
A clot that occludes blood flow to a portion of the lungs; usually a result of clot formation in the lower extremities, which breaks loose and migrates to the lungs. May also be due to venous injuries, hypercoagulable state, use of high-dose estrogen, preexisting circulatory disorders.
Pulmonary Embolus
A decrease in the frequency of bowel movements, resulting in the passage of hard stool. Usually related to use of opioids, immobility, inadequate fluid intake, or low-fiber diet.
Constipation
a technique in which the anesthetist places a tourniquet on an arm or leg and then injects a local anesthetic agent intravenously below the level of the tourniquet. The tourniquet is maintained at a pressure that limits venous return but continues to allow arterial circulation. The patient feels no pain in the extremity as long as the tourniquet is in place.
Bier (intravenous) block
Accumulation of urine in the bladder. May result from poor muscle tone as a result of anesthesia and anticholinergic medications, handling of tissues during surgery, or inflammation in the pelvic region.
Urinary Retention
Advantages of conscious sedation
Pain and anxiety are adequately controlled without the risks of general anesthesia. Recovery is rapid.
Advantages of General Anesthesia
The patient is unconscious, so she experiences no anxiety that might affect cardiac and respiratory functioning.
The muscles are relaxed, so the patient remains completely motionless during the surgical procedure.
Anesthesia can be adjusted to accommodate age, physical condition, and the length of the procedure.
If surgical complications occur, the anesthesia can be continued for longer than originally planned.
advantages of Regional anesthesia
Low in cost, simple to administer, and requires a minimal recovery period. It is especially suitable for minor ambulatory procedures.
Airway inflammation caused by inhaling gastric secretions (especially hydrochloric acid from the stomach) because of absent gag reflex secondary to anesthesia
Aspiration Pneumonia
Anesthesia is classified as
general, conscious sedation, regional or local
are elastic stockings that compress the veins of the legs and increase venous return to the heart (Fig. 40-1). They may be applied preoperatively to prevent venous pooling during surgery and decrease the risk of thrombus formation. Along with prophylactic medications (antithrombotics), antiembolism stockings aid in the prevention of DVT and PE.
Antiembolism Stockings These are also referred to as thromboembolic disorder hose (or “T.E.D. hose”).
are serious and costly errors resulting in severe consequences for the patient, and that are mostly preventable.
Never events
begins when the client enters the postanesthesia care unit and ends when he has healed from the surgical procedure.
postoperative phase
begins when the patient enters the operating suite and ends when she is admitted to the postanesthesia care unit.
intraoperative phas
begins with the client’s decision to have surgery and ends when he enters the operating room.
preoperative phase
Benefits of adequate pain management are
arly mobilization, shorter hospital stay, reduced hospital costs, and increased patient satisfaction.
Bleeding may be internal or external. May be caused by slipped ligature, uncontrolled bleeder, or infection.
Hemorrhage
Blood clot and inflammation of a vein or artery, usually in the legs. Results from increased coagulability and venous stasis due to immobility during and after surgery.
Thrombophlebitis
Body System examples
GI
Respiratory
Cardiac
GU
By purpose surgery examples
Ablative - removal of diseased body part
Diagnostic/exploratory - confirm or rule out diagnosis
Palliative - to relie discomfort w/o cure
reconstructive - to restore function
cosmetic - improve appearance
transplant - replaces a part
procurement - act of harvesting from someone to transplant into another
can be used as a surgical anesthetic and to provide postoperative analgesia
Epidural Anesthesia
Collapse of alveoli due to hypoventilation, airways blocked by mucous plugs, opioid analgesics, immobility
Atelectasis
Decreased blood volume. May be due to blood loss during and after surgery; dehydration; or excess loss through vomiting, diarrhea, or drains.
Hypovolemia
Decreased or absent urine output due to hypovolemia, shock, or toxic reaction to medications
Renal Failure
Degree of Risk: associated with a high degree of risk, for example, the potential for significant blood loss, a prolonged or complicated procedure, surgery involving vital organs, or a high risk for postoperative complications.
Major surgery
Degree of Risk:often performed on an outpatient basis, involves little risk and usually has few complications.
Minor Surgery
Describe the typical physical preparation of a client undergoing surgery.
Maintain NPO for 8 hours before surgery.
• Shower or scrub the surgical site with an antibacterial solution the evening before surgery and the morning of the surgery.
Have the client void before receiving preoperative medications, including prophylactic antibiotics.
• Administer any prescribed preoperative medications.
• Review daily medications with the anesthesia team.
• Remove all artificial body parts, such as dentures, limbs, or contact lenses; wigs, eyeglasses, makeup, and jewelry must also be removed.
• Apply antiembolism stockings, if prescribed.
Disadvantages of conscious sedation
Not practical for highly anxious patients.
Disadvantages of General Anesthesia
The respiratory and circulatory muscles are depressed, so mechanical ventilation is needed while the patient is under the effects of the anesthetic agent(s). These effects predispose the patient to pneumonia and thrombophlebitis in the postoperative period.
General anesthesia creates a risk for death, heart attack, stroke, and malignant hyperthermia. Malignant hyperthermia is a rare, often fatal, metabolic condition that can occur during the use of muscle relaxants and inhalation anesthesia. Metabolism increases in the skeletal muscles and they become rigid. The temperature rises rapidly. Predisposition to this condition is inherited.
Frequent minor complaints after general anesthesia include sore throat (from intubation), nausea and vomiting (from relaxation of gastrointestinal smooth muscle), headache, uncontrollable shivering, and confusion.
disadvantages of Regional anesthesia
May not be practical if the patient is highly anxious or if adequate pain control cannot be achieved. Many patients are apprehensive about being able to see and hear the procedure.
Drugs used for __________are of a higher concentration than those for ___________
Epidural Anesthesia
Spinal Anesthesia
Duties of circulating nurse
client advocate
continuously monitors the client and the sterile field.
maintains a safe, comfortable environment;
communicates with appropriate personnel outside the operating room; and responds to emergencies.
attend to the patient during the induction of anesthesia.
Embolus in this system -results in symptoms in the area affected (e.g., cerebrovascular accident, myocardial infarction, or loss of circulation to an area).
arterial
embolus in venous system often results in
PE - pulmonary embolus
Examples of never events
Surgery on the wrong body part
Surgery on the wrong patient
Wrong surgery on a patient
Deep vein thrombosis (DVT) or pulmonary embolism (PE) after total knee or hip replacement
Foreign body left in a patient after surgery (e.g., sponge, clip for draping)
Surgical site infections after certain elective procedures (e.g., after bariatric surgery for obesity). AORN, The Joint Commission, National Priorities Partnership, and IHI extend that to include all infections that occur after surgery
Excess gas within the intestines; may be due to a slow return of peristalsis or from handling of the intestines during surgery.
Abdominal Distention (Tympanites)
hospitals are increasingly using ____ ____ ____ and anticoagulation therapy, instead of elastic stockings, to prevent DVT
sequential compression devices
How often is a patient typically assessed after surgery -In the postanesthesia care unit (PACU)
every 5 to 15 minutes
How often is a patient typically assessed after surgery -In the surgical unit:
- Upon arrival
- Every 15 minutes for the first hour
- Every 30 minutes for the next 2 hours • Every hour for the next 4 hours
- Then every 4 hours
Identify topics that should be discussed in preopera- tive teaching.
focused on explaining what will happen before, during, and after surgery and how the client can participate in the care. Part of the teaching plan is also to discuss common feelings and concerns that clients have about surgery.
induces amnesia, analgesia, and muscle relaxation or paralysis with anesthesia. His role is to continuously monitor and evaluate the patient’s responses to the anesthetic agent and the surgical procedure.
anesthesiologist or a nurse anesthetist (CRNA)
Inflammation of the alveoli due to infection with bacteria or viruses, toxins, or irritants. Caused by hypoventilation secondary to anesthesia and opioid analgesics, and by poor cough effort as a result of aging or weakness.
Pneumonia
information you should gather in the preoperative nursing history.
Health history. • Physical status. • Allergies. . • Medications. • Mental status. • Knowledge and understanding of the surgery and anesthesia. • Cultural and spiritual factors. • Access to social resources. I • Coping strategies. • Use of alcohol and drugs.
Informed consent requires that the patient understood the communication and was not coerced (pressured) to consent. There are two important requirements:
The patient must be alert, rational, mentally competent, and not sedated when he signs.
The information must be given to him in a language and vocabulary that he can understand.
interventions for Abdominal Distention (Tympanites)
Encourage and assist to move in bed and ambulate.
Maintain NPO until return of bowel sounds; avoid drinking with a straw.
Provide fluids at room temperature.
interventions for Aspiration Pneumonia
Pre Op?
Post Op?
Institute NPO for at least 8 hours prior to surgery.
Postoperative: Continue NPO until intestinal motility returns; carefully monitor sedated patient and place in side-lying position.
Interventions for Atelectasis
Monitor for clinical signs.
Monitor rate, rhythm, depth, and effort of respirations.
Monitor ability to cough effectively.
Determine need for suctioning by listening for crackles and rhonchi over major airways.
Suction, as needed. Auscultate lung sounds after suctioning and other respiratory treatments to determine effectiveness.
Encourage deep breathing, coughing, moving in bed, ambulation, use of incentive spirometry.
interventions for hypovolemia
Monitor vital signs and I&O.
Insert urinary catheter, if appropriate.
Monitor skin color, temperature, and moistness; central and peripheral cyanosis.
Identify possible causes of changes in vital signs.
Administer IV therapy as prescribed.
Promote oral intake when tolerated.
Prepare to administer blood or blood products, as prescribed.
Interventions for pneumonia
Monitor for clinical signs.
Encourage and assist with deep breathing, coughing, moving in bed, ambulation, use of incentive spirometry.
Interventions for pulmonary embolus
Prevent thrombophlebitis: Encourage and assist with leg exercises, ambulation, antiembolism stockings, sequential compression devices, hydration.
If thrombophlebitis occurs, position and immobilize the limb; do not massage calves.
Interventions for Thrombophlebitis
Encourage and assist with leg exercises, ambulation, antiembolism stockings, sequential compression devices, hydration.
If thrombophlebitis occurs, position and immobilize the limb; do not massage calves.
Interventions fr nausea and vomiting
Have patient remain NPO until return of bowel sounds.
Advance diet slowly.
Treat pain.
involves the care of clients before, during, and after surgery and some other invasive procedures
Perioperative nursing
is an RN who applies the nursing process to coordinate all activities in the operating room
circulating nurse
is an RN with additional education and training in surgical technique. serves as an assistant to the surgeon, a role that has historically been filled by physicians. may be employed by the surgeon or the hospital.
registered nurse first assistant (RNFA)
is often used for surgical procedures in the lower abdomen, pelvis, and lower extremities. This technique allows the patient to remain conscious during the procedure and usually does not depress respirations.
Spinal Anesthesia
is responsible for (1) giving the patient the necessary information and (2) determining the patient’s competence to make an informed decision about the surgery
The surgeon
is safer than spinal anesthesia because the anesthetic does not enter the subarachnoid space and the depth of anesthesia is not as great.
Epidural Anesthesia
is the injection of an anesthetic into and around a nerve or group of nerves (e.g., the facial nerve).
nerve block
is the injection of an anesthetic into the cerebrospinal fluid (CSF) in the subarachnoid space . This injection blocks sensation and movement below the level of the injection.
Spinal Anesthesia
may be applied topically or injected
Local anesthetic
may be prescribed in addition to antiembolism stockings for patients at high risk for thrombophlebitis. is a plastic sleeve with chambers. The sleeve is wrapped around the patient’s legs and connected to an air pump that provides sequential pressure to the chambers of the plastic sleeve.
Sequential Compression Devices (SCDs)
Medication safety tips
label medicines not labeled in syringes, cups and basin
Movement of a thrombus or foreign body from its original location.
Embolus
NPSG goals
prevent infection - hand hygiene
improve accuracy of pt identification
using medication safely
performing time out immediately before procedure
NPSG is
National Patient Safety Goals
Occasionally a higher level of spinal anesthesia is achieved than intended—that is, the medication may migrate upward in the spinal fluid.
Which may(1)_________ then what can you do(2)____________
Also this can decrease suddenly(3) ______ due to(4) _________. These patients often require ventilation and careful(5) _________
1 depress respirations and cardiac rate
2 Placing the patient in Fowler’s position may prevent respiratory paralysis
3 Blood pressure
4 vasodilation
5 monitoring
Patients who are unconscious or have a mental disability; who have been judged insane; who cannot read, write, or hear; and those under the influence of sedative drugs or alcohol are generally not competent to give ___________
In most states, who can give consent for the procedure?
consent
family member, conservator, or legal guardian
postoperative consists of two parts:
recovery from anesthesia and recovery from surgery.
prevents pain by interrupting nerve impulses to and from the area of the procedure. The patient remains alert but is numb in the involved area
Regional anesthesia
produces loss of pain sensation at the desired site (e.g., a wound to be sutured, a skin growth to be removed). It is typically used for minor procedures
Local anesthesia
produces rapid unconsciousness and loss of sensation.
General anesthesia
provides intravenous sedation and analgesia without producing unconsciousness., the patient may feel sleepy but is aware of his surroundings, can be easily aroused by touch or speech, and can talk with the surgical team.
conscious sedation
pump that administers a continuous, regulated flow of local anesthetic through a thin catheter directly into the patient’s surgical site.
Single-Use, Continuous-Flow Pump/ ON Q
requires insertion of a thin catheter into the epidural space . Anesthetic agents are infused through the catheter to produce loss of sensation.
Epidural Anesthesia
responsible for verifying that the surgical consent form is signed and witnessed.
nurse
s/s of Pneumonia
Productive cough with blood-tinged or purulent sputum, fever, elevated WBC, decreased or absent breath sounds, decreased SaO2, chest pain, tachypnea, dyspnea
s/s of Abdominal Distention (Tympanites)
Abdominal discomfort, bloating, hypoactive or absent bowel sounds
s/s of Aspiration Pneumonia
Cough, fever, elevated WBC, decreased or absent breath sounds, decreased oxygen saturation (SaO2), tachypnea, dyspnea, blood-tinged sputum.
s/s of Atelectasis
Decreased or absent breath sounds, noisy respirations, decreased O2 saturation (SaO2), chest asymmetry, sternal retractions, accessory muscle use, trachea deviated from midline, fever, tachypnea, dyspnea, tachycardia, diaphoresis, pleural pain, increased restlessness, anxiety
s/s of hemorrhage
If external: Dressings saturated with bright red blood; increased output in drains or chest tubes
If internal: Increased pain, increasing abdominal girth, ecchymosis or swelling around incision, tachycardia, hypotension
s/s of hypovolemia
Hypotension, tachycardia, decreased urine output, fatigue, thirst, dehydration
s/s of pulmonary embolus
Sudden onset of dyspnea, shortness of breath, chest pain, hypotension, tachycardia, decreased SaO2, cyanosis
s/s of Thrombophlebitis
Superficial: Vein is red, hard, and hot to touch.
Deep: Limb is pale and edematous; aching, cramping in limb; Homans’ sign (pain in calf when foot is dorsiflexed).
sets up the sterile field, prepares the surgical instruments, assists with the sterile draping of the patient, anticipates and responds to the surgeon’s needs, and maintains the integrity of the sterile field.
scrub nurse
Side effects of spinal anesthesia include
hypotension, nausea, vomiting, urinary retention, and headache from leakage of CSF. A headache after spinal anesthesia must be closely monitored and may require additional treatment by the anesthesia staff.
sign of renal failure
Urine output < 30 mL/hr; rising BUN and creatinine levels
signs of urinary retention
Bladder distention, suprapubic pain, diminished urine output or output less than fluid intake, inability to void or small, frequent voidings, hypertension, restlessness
The primary goal of _____ ______ ______ is to minimize the dose of medications (to lessen side effects) while still providing adequate pain management.
postoperative pain management
Time out is_____, why
an immediate pause prior to procedure by the entire surgical team to assure correct pt, procedure, site and side
Types of Degree of Urgency
Emergency - ASAP to preserve life or function
Urgent - scheduled within 24-48 hours
Elective - condition is not time sensitive
Types of Regional Anesthesia
Peripheral Nerve Block
Spinal Anesthesia
Epidural Anesthesia
Under what type(s) of anesthesia does the client remain conscious?
The client remains conscious in all types of anesthesia except general anesthesia.
What does it mean to notify and delay if necessary?
If the patient has questions or if you have any questions about the patient’s competence, notify the surgeon and delay sending the patient to surgery.
What does it mean to verify signature/consent?
verify with the patient that the physician has explained the procedure and answered all his questions: Ask the patient to state what he was told during the consent process.
What factors affect surgical risk?
Seven factors affect surgical risk: • Age • Type of wound (potential for infection) • Preexisting conditions • Mental status • Medications • Personal habits • Allergies
What laboratory tests are most commonly prescribed before surgery?
- A complete blood count, urinalysis, and serum electrolytes (chemistry panel)
- An ECG (electrocardiogram) is often required for clients older than 50 years or with a history of cardiac problems
What should you document about informed surgical consent?
conversations, questions the patient had and that the surgeon was notified of any additional questions or co ferns
What type of physical assessment is performed as part of the preoperative assessment?
Part of the preoperative assessment is a brief head-to- toe assessment. For concerns that have been identified in the nursing history, perform a focused assessment.
Who is responsible for obtaining informed consent for the surgical procedure?
Before a surgical procedure can be performed, the surgeon is required by law to provide the necessary information and obtain the client’s consent.
Why are sequential compression devices used?
Sequential compression devices are used for clients at high risk for thrombophlebitis. They compress the veins, thereby promoting venous return to the heart and decreasing venous stasis.
