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Last (2) Lectures into Final > Perioperative Care > Flashcards

Perioperative Care Flashcards

1
Q

Perioperative Care

Care of clients before, during, and after surgery and some other invasive procedures

A

Perioperative Safety

* Goal of perioperative nursing - to help prevent complications of surgery

Hand hygiene - prevention

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2
Q

Preventable perioperative errors cause

  • 10% of surgery-related deaths
  • Negative financial impact on healthcare institutions
  • Result in physical and emotional harm to pt’s
  • “Never events”
A

Various government and private org’s stress the importance of pt safety:

  • The Association of periOperative Registered Nurses
  • The Joint Commission (2018)
  • National Quality Partners (NQP) Leadership Consortium (2017)
  • The Institute for Healthcare Improvement (IHI)
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3
Q

?

or serious reportable events = are serious and costly errors resulting in severe consequences for the pt, and that are mostly preventable

A

Never events

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4
Q

* Medicare no longer reimburses institutions for care r/t these “never event” complications

A

Examples of never events in perioperative care:

surgery on wrong part of body,
surgery on wrong pt,
DVT or PE after knee or hip replacement surgery, foreign body left in pt > surgery,
surgical site infections > elective surgeries like bariatric surgery for obesity

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5
Q

The Association of periOperative Registered Nurses

* To prevent injury & infection

A

The Joint Commission (2018)

* NPSG - preventing infection, improving the accuracy of pt identification, using rx safely, & performing a time-out immediately

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6
Q

National Quality Partners (NQP) Leadership Consortium (2017)

* Identify social determinants of health to provide health equity in the delivery of care

A

The Institute for Healthcare Improvement (IHI)

* Reduce surgical complications, more specifically surgical infections

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7
Q

Phases of Perioperative Nursing

A

Preoperative Phase
Intraoperative Phase
Postoperative Phase

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8
Q

?

Phase in which procedure is carried out

A

Intraoperative Phase

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9
Q

?

Phase of prevention of complications

A

Postoperative Phase

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10
Q

?

Phase in which person is prepared physically & emotionally

  • Preliminary studies, such as ECG and bloodwork, done
  • Informed consent obtained
A

Preoperative Phase

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11
Q

?

Begins with decision to have surgery & ends when client enters the operating room

  • Length of this & the extent of teaching depend on the type of surgery & overall health status
A

Preoperative phase

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12
Q

Classification of Surgeries

Body System

  • Used to determine post-op risk of infection
  • GI, respiratory, or GU tract - higher risk for infection

Purpose

  • Ablative
  • Diagnostic (exploratory)
  • Palliative
  • Reconstructive
  • Cosmetic
  • Transplant
  • Procurement
A

Classification of Surgeries

Level of urgency

  • Emergency
  • Urgent
  • Elective

Acuity
- Major or minor

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13
Q

___ surgery

Involves removal of a diseased body part

e.g. cholecystectomy removes a diseased gallbladder

A

Ablative

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14
Q

___ surgery

Is done to confirm or rule out a dx

e.g. includes a biopsy, fine-needle aspiration, or invasive testing, such as cardiac catheterization

A

Diagnostic (exploratory)

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15
Q

___ surgery

Is performed to relieve discomfort or other disease symptoms without producing a cure

e.g. nerve root destruction for chronic pain

A

Palliative

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16
Q

___ surgery

Is performed to restore function,

i.e. rotator cuff repair (repair of a torn ligament)

A

Reconstructive

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17
Q

___ surgery

Is done to improve appearance

i.e. a facelift

A

Cosmetic

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18
Q

___ surgery

Replaces a malfunctioning body part, tissue, or organ

i.e. joint replacements and organ replacement procedures are included in this category

A

Transplant

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19
Q

___ surgery

Is r/t transplant surgery

An organ or tissue is harvested from someone pronounced brain dead for transplantation into another person

A

Procurement

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20
Q

___ surgery

Requires transport to the operating suite as soon as possible to preserve patient’s life or function

Surgical team is summoned and preparations are made rapidly

Internal hemorrhage, rupture of an organ, and trauma are common causes of this type of surgery

A

Emergency

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21
Q

___ surgery

Is scheduled within 24 to 48 hours to alleviate symptoms, repair a body part, or restore function

Removal of a cancerous breast and internal fixation of a fracture are examples

A

Urgent

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22
Q

___ surgery

Is performed when surgery is the recommended course of action, but the condition is not time-sensitive

Client may delay surgery to gather information, consider options, or organize care for the family

Examples include repair of a torn ligament and removal of rectal polyps

A

Elective

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23
Q

There is an old adage concerning surgery: “The only minor surgery is someone else’s surgery.”

This statement reflects the anxiety that often accompanies surgery

Nevertheless, surgery is defined as major or minor based on the degree of seriousness or risk associated with the procedure

Degree of risk varies with the condition of the client, as well as with the type of surgery and anesthesia

A
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24
Q

Major surgery is associated with a high degree of risk

i. e. the potential for significant blood loss, a prolonged or complicated procedure, surgery involving vital organs, or a high risk for post-op complications
i. e. CABG, nephrectomy, colon resection

A

Minor surgery, often performed on an outpt basis, involves little risk and usually has few complications

i.e. arthroscopy, breast biopsy, inguinal hernia repair

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25
Q

Factors that affect surgical RISK

Age

* Very young - very old = increased risk during surgery

* Older adults - less physiological reserve

  • kidney disease, reduced immune function, decreased bone and lean body mass, increased peripheral vascular resistance, decreased cardiac output, decreased cough reflex, and increased time required for wound healing
  • other comorbidities
A
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26
Q

Factors that affect surgical RISK

Type of wound

* Increases potential for INFECTION

A

Clean Wounds

Clean-Contaminated Wound

Contaminated Wounds

Infected Wounds

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27
Q
A
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28
Q

Clean Wounds

  • Face-lift, cataract surgery, joint replacement, breast biopsy, tonsillectomy

Clean-contaminated Wounds

  • Surgical incisions that enter the GI, respiratory, or GU tracts
A

Contaminated Wounds

  • Surgery to repair trauma to open wounds, such as compound fractures; surgery in which a major break in surgical asepsis occurred

Infected Wounds

  • A postoperative surgical incision of any type that has evidence of infection
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29
Q

Factors that affect surgical RISK

Pre-existing conditions

  • Underlying conditions that increase surgical RISK
  • Acute CONDITIONS (URI, infections)
  • Chronic CONDITIONS

> CVD, chronic respiratory illness, coagulation disorders, DM, liver disease, neurological disorders, nutritional disorders, renal disease

A

Acute infections tax the patient’s energy and physiological reserves, increasing the risk for various postoperative complications

Upper respiratory tract infections are associated with increased risk of postoperative pneumonia, especially if the patient receives a general anesthetic

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30
Q

Cardiovascular diseases (i.e. HTN, CHF, MI) affect the ability of the heart to work as an efficient pump. If these disorders are well controlled (e.g., w/BP rx’s or cardiotonic rx’s), risk is limited

A

Chronic respiratory disorders (i.e. emphysema, asthma, or bronchitis) decrease pulmonary function, increase the risk of respiratory infection, and may be exacerbated by general anesthesia

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31
Q

Coagulation disorders delay clotting and increase blood loss, placing the pt at risk for hemorrhage & hypovolemic shock. In contrast, a hypercoagulation state increases the risk of stroke, embolism, or intravascular clotting

A

Diabetes mellitus delays wound healing and increases the risk of infection and cardiovascular disorders associated w/diabetes

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32
Q

Liver disease affects the body’s ability to metabolize amino acids, carbohydrates, and fat; to manufacture prothrombin for clotting; and to detoxify rx’s.

Therefore, pt is at increased risk for poor wound healing, hemorrhage, and toxic reactions to anesthetics and rx’s

A

Neurological disorders (i.e. paralysis or spinal cord injury) increase the risk for vasomotor instability and thus create the potential for wide swings in BP.

In addition, pt’s w/seizure disorders are more likely to have a seizure in the perioperative period

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33
Q

Nutritional disorders can affect surgical outcomes. Pt’s who are malnourished or obese are at risk for delayed wound healing, infection, and fatigue.

Obese clients are also more prone to cardiovascular disorders and impaired pulmonary function

A

Renal disease affects the patient’s ability to excrete many rx’s, including anesthetic agents. Also affects the ability to regulate fluid and electrolytes

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34
Q

Factors that affect surgical RISK

Mental status

* Altered cognition

  • Unable to comprehend
  • Unable to give informed consent
  • May require medications that interact w/anesthetics & analgesics (i.e. anti-psychotics)
  • Surgery & anesthesia may aggravate dementia, confusion, & disorientation
A
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35
Q

Factors that affect surgical RISK

Medications

  • Herbal and alternative medications
  • Antibiotics
  • Anticoagulants
  • Anti-hypertensives
  • Aspirin / corticosteroids / diuretics / opioids / NSAIDs / tranquilizers
A

Certain herbal and alternative medications can have the following effects:

  • Increase risk for cardiac dysrhythmias 2º to potassium loss
  • Interfere w/metabolism of anesthetics b/c their effects on liver
  • Increase potential for excessive bleeding
  • Decrease cerebral blood flow
  • Cause HTN
  • Increase effects of opioids & SNS stimulants
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36
Q

___ increase the risk of respiratory depression

___ increase risk of respiratory depression

A

Tranquilizers

Opioids

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37
Q

___ alter fluid and electrolyte balance (especially potassium balance)

___ increases risk for bleeding

___ may impair cardiac function during anesthesia

A

Diuretics

Aspirin

Anti-dysrhythmics

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38
Q

___ may potentiate the action of anesthetic agents

___ increase risk for bleeding

___ delay wound healing and increase risk for infection

A

Antibiotics

Anticoagulants

Corticosteroids

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39
Q

___ inhibit platelet aggregation, increasing the risk for bleeding

___ increase the risk for hypotension during surgery; may interact w/anesthetic agents to cause bradycardia and impaired circulation

A

NSAIDs

Anti-hypertensives

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40
Q

Factors that affect surgical RISK

Personal habits

  • Substance abuse

> Smoking (affects pulmonary function)

> Long-term alcohol use (contributes to liver disease, inc risk for bleeding)

> Alcohol & drugs interact w/anesthetic agents & rx’s to create adverse effects

> Habitual substance abusers may have a cross-tolerance to anesthetic & analgesic agents (causing them to need higher than normal doses)

A

Factors that affect surgical RISK

Allergies

  • Patients may be allergic to rx’s

> antibiotics (i.e. penicillin), analgesics (i.e. codeine), tape, latex, & solutions used in surgery

  • Reactions range from unpleasant to life-threatening
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41
Q

Assessment

Focused Nursing History

* Physiologically, cognitively, & psychologically prepared

A

* Data collection should include

  • Health hx / physical status / allergies / rx’s (including herbal products & OTC rx’s)
  • Mental status / knowledge & understanding of the surgery & anesthesia
  • Cultural/spiritual factors / access to social resources
  • Coping strategies / use of alcohol & drugs

It is important to elicit pt’s values & expressed needs

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42
Q

Assessment - Focused Physical Assessment

  • Focused assessment of the ear, nose, throat, & lungs
  • Assess risk factors for thrombophlebitis
A

Venous thrombosis is one of the never events that can lead to potentially life-threatening pulmonary emboli

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43
Q

Assessment of Older Adults

  • Cognitive ability / capacity to understand the surgery
  • Nutritional status
  • Risk factors for post-op delirium & pulmonary complications
  • Pt’s treatment goals & expectations
  • Family & social support system / depression / functional status
  • H/o falls / detailed rx history, including polypharmacy / baseline frailty score
  • Diagnostic tests specific to older pt’s
A
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44
Q

Preoperative Phase - Diagnostic Testing

* Preoperative screening tests - depends on the pt’s age, health history, & facility policies

  • Complete blood count (CBC), urinalysis (UA), & electrocardiogram (ECG)

> Most institutions require a CBC & UA as well as an ECG for pt’s older than age 50

  • Routine cxray is not recommended for all pt’s
  • Pt’s w/chronic health problems may require additional testing
A
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45
Q

Preoperative Phase - Nursing Diagnosis

* All preoperative pt’s need preoperative teaching

* Almost all surgical pt’s have @ least mild anxiety

A

Individualized Nursing Diagnoses

  • Anxiety
  • Fear
  • Airway Clearance Impairment
  • Disturbed Sleep Pattern
  • Ineffective Coping
  • Latex Allergy Reaction
  • Risk for Latex Allergy Reaction
  • Deficient Knowledge
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46
Q

Preoperative Phase: Nursing Diagnosis - Special Risks for Older Adults

Risk Factors / Potential Complications [within chart]

  • CAD
  • Delirium
  • Respiratory changes
  • Age-related skin & musculoskeletal changes
  • Comorbidities of the CNS
  • Decreased GI motility
  • Decreased GU function
A
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47
Q

Preoperative Phase: Planning Outcomes

Patient…

Is able to describe surgical procedure in a basic manner

Provides informed consent

States what can be expected in the post-op period

States very little anxiety

A
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48
Q

Preoperative Phase: Planning interventions

Routine interventions to be used for all preoperative pt’s

Three domains

* Preoperative Coordination

  • Activity example - notify the physician of abnormal diagnostic test results

* Surgical Preparation

  • Activity example - complete the preoperative checklist

* Teaching: Preoperative

  • Activity example - correct unrealistic expectations of the surgery, as appropriate
A
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49
Q

Preoperative Phase: Planning interventions

Confirm that the surgical consent has been obtained

* Surgeon is responsible

  • Provide necessary information
  • Determine competency to make informed decisions

* Nurse is responsible

  • Verify that consent form is signed & witnessed
  • Notify & delay
  • Document
A

Informed consent requires that the patient understood the communication and was not coerced (pressured) to consent

* 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 he can understand

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50
Q

Planning Interventions: Surgical Consent Form

  • Type of sx
  • Name & qualifications of person performing sx
  • Risks & benefits & side effects of alternative tx
  • Likelihood of achieving goals
  • Statement indicating right to refuse
  • Any limitations on confidentiality of information about client
  • Client signature implies consent - as a nurse you must certify INFORMED CONSENT
A

Client must be ALERT, RATIONAL, MENTALLY COMPETENT, and NOT SEDATED

Information must be in a LANGUAGE and VOCABULARY that client will understand

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51
Q

Planning Interventions: Provide Preoperative Teaching

  • Focus on explaining what will happen before, during, and after sx
  • Common feelings & concerns that pt’s have about surgery - less anxiety
  • Surgical site infection prevention
  • Type of sx influences the content of your teaching
  • Use written instructions, video presentations, phone contact, or face-to-face discussion
A

Planning Interventions: Provide Preoperative Teaching

  • Language

For elective surgery

Patients undergoing emergency surgery

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52
Q

Planning Interventions: PHYSICAL PREPARATION

* Maintain Normothermia

  • Core temp
  • Passive thermal care
  • Active pre-warming

* Nutritional status

  • NPO for 8 hrs prior to sx - AVOID ASPIRATION
A

* Skin prep

* Bowel prep

  • Enemas - colon sx

* Urinary elimination

* Preoperative rx’s - “ON CALL”

  • Prophylactic antibiotics
  • Routine rx’s - HOLD day of sx

> INSULIN / WARFARIN

* Prosthesis

* Anti-embolism stockings

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53
Q

Planning Interventions: PHYSICAL PREPARATION cont’d

* Common preoperative rx’s

Antibiotics / Anticholinergics / Anxiolytics / Antihistamines

Barbiturates / H2 receptor antagonists / hypnotics

Neuroleptics / opioid analgesics

A
54
Q

?

Provide pain relief and sedation; induce anesthesia

e.g. Fentanyl, meperidine, morphine

A

Opioid analgesics

55
Q

?

Provide sedation and increase the duration of sleep

e.g. Temazepam

A

Hypnotics

56
Q

?

Reduce gastric acidity

e.g. cimetidine, ranitidine

A

H2 receptor antagonists

57
Q

?

Provide sedative, anti-emetic, and anti-convulsant effects

e.g. Droperidol, fentanyl

A

Neuroleptics

58
Q

?

Provide sedation and anti-emetic effects

e.g. hydroxyzine, diphenhydramine

A

Anti-histamines

59
Q

?

Provide sedation without significant cardiopulmonary depression

e.g. secobarbital, pentobarbital

A

Barbiturates

60
Q

?

Reduce oral and pulmonary secretions; prevent laryngospasms; prevent bradycardia

e.g. atropine, chlorpromazine, scopolamine, glycopyrrolate

A

Anticholinergics (e.g. phenothiazines)

61
Q

?

Control anxiety, calming

e.g. alprazolam, clonazepam, diazepam, lorazepam, midazolam

A

Anxiolytics (e.g. benzodiazepines)

62
Q

?

Reduce the microbial burden of intraoperative contamination to a level that cannot overwhelm host defenses

e.g. cephalosporins (cefazolin, cefoxitin), clindamycin, vancomycin

A

Antibiotics

63
Q

A Tale of Two Pre-Op Medications… Vistaril & Ativan

A
64
Q

?

Can be given PO, IM, or IV push

You will feel calmer and then become more sedated

A

Lorazepam (Ativan)

65
Q

?

Can be given IM or PO

You will feel relaxed and then sleepy

A

Hydroxyzine (Vistaril)

66
Q

Preoperative Phase

* Take measures to prevent wrong patient, wrong site, wrong surgery

  • Use a preoperative checklist
  • Verify the pt’s identity before the pt leaves the preoperative area
  • Take a time-out with all team members before starting the procedure
A
67
Q

Intraoperative Phase

* Begins when client enters the operating suite and ends when admitted to the postanesthesia care unit

A

* Operative personnel or INTRAOPERATIVE TEAM

Sterile team

> Scrub nurse

> RN 1st assistant (RNFA)

CLEAN TEAM

> NEVER ENTER STERILE FIELD

> Anesthesiologist or nurse anesthesiologist

> Circulating RN

* These personnel never enter the sterile field but instead function around and beyond it

68
Q

Intraoperative Phase - Anesthesia

Used to:

Obtain analgesia (control pain)

Muscle relaxation (paralysis)

Amnesia (memory loss)

A

Types of Anesthesia

GENERAL

CONSCIOUS SEDATION

REGIONAL

LOCAL

69
Q

?

Produces rapid unconsciousness and loss of sensation

Anesthesiologist or nurse anesthetist administers inhaled & IV rx’s that depress the pt’s CNS & relax the musculature

Muscle relaxants, paralyzing agents, narcotics, barbiturates, & inhaled gases are some of the agents used during here

A

General anesthesia

70
Q

Advantages of General Anesthesia

* Pt is unconscious, so she experiences no anxiety that might affect cardiac & resp functioning

* Muscles are relaxed, so pt remains completely motionless during surgical procedure

* Anesthesia can be adjusted to accomodate length of procedure & the pt’s age & physical condition; e.g., an older adult may require less anesthetic than anticipated; if so, the anesthetist can decrease the dosage w/o interrupting the procedure

* If complications occur, the anesthesia can be continued for longer than originally planned

A

Disdvantages of General Anesthesia

* Resp & circulatory muscles are depressed, so mechanical ventilation is needed while pt is under effects of anesthetic agent(s); these effects predispose pt to pneumonia & thrombophlebitis in post-op period

* General anesthesia creates a risk for death, heart attack, stroke, & malignant hyperthermia

* Frequent minor complaints after general anesthesia include sore throat (from intubation), N/V (from relaxation of GI smooth muscle), HA, uncontrollable shivering, & confusion

71
Q

?

___ is a rare, often fatal, metabolic condition that can occur during the use of muscle relaxants & inhalation anesthesia

Metabolism increases in the skeletal muscles & they become rigid

Temp rises rapidly; predisposition to this condition is inherited

A

Malignant hyperthermia

72
Q

?

Is an alternative form of anesthesia that provides IV sedation & analgesia w/o producing unconsciousness

During, the pt may feel sleepy but is aware of her surroundings, can be easily aroused by touch or speech, & can talk w/the surgical team

BP, heart rate, RR, and O2 sat are monitored, & pt usually receives O2 via nasal cannula during procedure

B/c of the amnesiac effect of many of the rx’s, pt may not recall aspects of procedure after

Used for procedures like bronchoscopy & cosmetic surgery

A

Conscious sedation

73
Q

Conscious Sedation - Advantages

* Pain & anxiety are adequately controlled w/o risks of general anesthesia

* Recovery rapid

A

Conscious Sedation - Disadvantages

* Not practical for highly anxious pt’s

74
Q

?

Interrupts nerve impulses to & from procedure areas

ALERT but NUMB

Advantages - low cost, easy recovery - minor ambulatory procedures

Disadvantages - not practical in high anxiety pt’s

A

Regional anesthesia

75
Q

SPINAL anesthesia

Blocks sensation & movement below lvl of injection

Sx of lower abdomen, pelvis, & lower extremities

A

EPIDURAL anesthesia

Administered into epidural space

Obstetrical procedures

76
Q

A ___ is the injection of an anesthetic into and around a nerve or group of nerves (e.g., the facial nerve)

A

nerve block

77
Q

A __ (___) block is a nerve block technique in which the anesthetist places a tourniquet on an arm or leg, and then injects a local anesthetic agent into the vein below the lvl of the tourniquet

Tourniquet is maintained @ a pressure that limits venous return but continues to allow arterial circulation

Pt feels no pain in the extremity as long as tourniquet is in place

A

Bier (intravenous)

78
Q

Advantages of the Bier block

* Onset & recovery time are both rapid

* Tourniquet decreases bleeding during surgical procedure & prevents systemic absorption of local anesthetic

A

Disadvantages of the Bier block

* When procedure is finished, tourniquet is deflated, & there is potential for systemic absorption of the anesthetic

* To prevent tissue damage, tourniquet must not be left in place for more than 2 hrs

79
Q

?

Is the injection of an anesthetic into the CSF in the subarachnoid space

Injection blocks sensation & movement below the lvl of the injection

Often used for surgical procedures in lower abdomen, pelvis, & lower extremities

A

Spinal anesthesia

80
Q

Spinal anesthesia - Advantages

* Allows pt to remain conscious during procedure

* Usually does not depress respirations

A

Spinal anesthesia - Disadvantages

* Rx may migrate upward in the spinal fluid, depressing respirations & cardiac rate. Placing pt in Fowler’s position may prevent respiratory paralysis

* Side effects include hypotension, N/V, urinary retention, or an HA from leakage of CSF. HA must be closely monitored & may require addl treatment by anesthesia staff

* BP may also decrease suddenly d/t pervasive vasodilation - the anesthesia blocks the sympathetic vasomotor nerves, which normally maintain muscle tone in peripheral blood vessels

* Pt’s w/these complications often require ventilation & support of BP during surgery, so they must be carefully monitored during surgery & in the recovery period

81
Q

?

Requires insertion of a thin catheter into the epidural space

Anesthetic agents are infused through the catheter to produce loss of sensation

Can be used as a surgical anesthetic & to provide post-op analgesia

A

Epidural anesthesia

82
Q

Epidural anesthesia - Advantages/Disadvantages

* Similar to spinal anesthesia. Is safer than spinal b/c the anesthetic does not enter the subarachnoid space & the depth of anesthesia is not as great

* Drugs used for epidural admin. are of a higher conc than those for spinal admin; so if the rx is inadvertently injected too deeply (into the subarachnoid space), hypotension & resp paralysis occur, & temporary mechanical ventilation is necessary

A

* Is ideal for obstetrics procedures (e.g., cesarean birth or pain control w/vaginal birth) b/c the mother is awake to bond w/the newborn, & her mobility is limited only for a short time

83
Q

?

Produces loss of pain sensation at the desired site (e.g., a wound to be sutured, a skin growth to be removed)

Used for minor procedures

Applied topically or injected

> Topical anesthetic - applied directly to the skin & mucous membranes

> Lidocaine & benzocaine - common - rapidly absorbed & rapid-acting

A

Local anesthesia

84
Q

Intraoperative Phase - Assessment

* Assess anxiety level & physical condition

* Measure the VS; examine the surgical site, & inspect IV lines, drainage tubes, & catheters

* Give preoperative rx in holding area, if prescribed

* Monitor VS often, or even continuously, during the intraoperative period

A

WHO Surgical Safety Checklist covers the 3 phases of a surgical procedure, commonly referred to as “sign in,” “time-out”, and “sign out”

3 phases of the checklist are reviewed by the checklist coordinator, who verbally checks that each element was done

Goal of using a surgical checklist is to enhance communication, teamwork, & safety by addressing key activities that occur as part of the perioperative process

85
Q

Intraoperative Phase - Nursing Diagnosis

* Perioperative hypothermia

* Risk for aspiration

* Risk for fluid volume alteration

* Risk for perioperative positioning injury

* Risk for latex allergy reaction

A

Potential Complications (collaborative problems)

Of surgery

  • hypothermia, fluid & electrolyte imbalance, excessive bleeding or hemorrhage, MSK injury 2º positioning

Of anesthetic

  • aspiration, vasomotor instability (& resultant hypotension & diminished peripheral perfusion), resp depression & cardiovascular compromise
86
Q

Intraoperative Phase - Nursing Outcomes

* Maintains body temp within the normal range

* Has clear lung sounds & patent airway

* Has urine output of at least 30 mL/hr

* Will have no skin, tissue, or neuromuscular injury as a result of positioning

* Will not acquire healthcare-related infection

A
87
Q

Intraoperative Phase - Nursing Interventions

Skin preparation

  • Assessment
  • Remove hair for site
  • Cleanse surgical site

Positioning

  • Determined by surgical site, access to airway, monitor VS, comfort, & safety
  • Usually positioned >anesthesia has begun
  • Prevent positioning injuries
A

Intraoperative safety measures

  • Prepare & maintain sterile field
  • Provide supplies
  • Monitor I&O
  • Handle specimens
  • Perform sponge, sharps, & instrument counts
  • Document care & response
88
Q

Postoperative Phase

* Begins when the pt enters the postanesthesia care unit & ends when healed from the surgical procedure

* Recovery from anesthesia

> Postanesthesia phase - from OR table to PACU

* Recovery from surgery

> Second phase of postoperative care - from PACU to surgical unit - STABILE CONDITION ONLY

A

* Hand-off reports should include information from surgical report

89
Q

Information From Surgical Report

* Procedure performed / type of anesthesia

* Rx’s given in the surgical suite / duration of procedure & anesthesia

* Post-op VS / Pulse oximetry values

* Allergies / lab values

* Estimated blood loss / fluid I&O, including urine, stool, gastric losses

A

* Pre-op mobility status, skin integrity, & sensory perception abilities

* Surgical complications / presence of tubes, drains, catheters

* Existing IV lines / Post-op rx’s

90
Q

Postanesthesia Care Unit (PACU)

Initial assessment - focused initial assessment

Continuing assessment - assessment every 5-15 min

Positioning - unconscious - side to maintain airway

Determining recovery from anesthesia - removal of artificial airway or endotracheal tube

A

Evidence of recovery from anesthesia

Airway - able to maintain a patent airway independently and to deep-breathe, cough, & expectorate secretions

LOC - conscious and easily reoriented

VS - stable & within an acceptable range

Mobility & sensation - move all extremities

Fluid balance (I&O) - urinating at least 30 mL/hr

Dressings & drains - dressings are dry & intact

91
Q

Postoperative Nursing Care on the Surgical Unit

* Perform assessment & listen to a summary report from the PACU nurse

ASSESSMENT

  • On arrival to the nursing unit

* every 15 min for the 1st hr

* every 30 min for the next 2 hrs

* Every hr for the next 4 hrs

* Then every 4 hrs

A

Nursing Diagnosis

* Acute pain

* Activity intolerance

* Anxiety

* Nausea

* Constipation

* Urinary retention

92
Q

Write potential nursing diagnoses (instead of collaborative problems) only if a patient has a higher risk for the problem than the average surgical patient

Of course, you will use a nursing diagnosis whenever a problem becomes actual instead of merely potential

A

Examples of 2 common post-op nursing diagnoses are Surgical Recovery Delay and Acute Pain

93
Q

Postoperative Phase

* Focus on prevention & early detection of complications

Some are done during the preoperative phase

Others are routine for all postoperative clients

A

“4W’s”

Wind (pulmonary)

Wound

Water (UTI)

Walk (thrombophlebitis)

94
Q

Potential Complications and Interventions

A
95
Q

RESPIRATORY SYSTEM

Aspiration Pneumonia

Clinical Signs

* Cough, fever, elevated WBC, decreased or absent breath sounds, decreased oxygen saturation (SaO2), tachypnea, dyspnea, blood-tinged sputum

A

Interventions for Prevention and Early Detection

* Preoperative - NPO (nothing by mouth) for at least 8 hrs before surgery

* Postoperative - continue NPO until intestinal motility returns; carefully monitor sedated pt & place in side-lying position

96
Q

?

Airway inflammation caused by inhaling gastric secretions (especially HCl acid from the stomach) b/c of absent gag reflex 2º anesthesia

A

Aspiration pneumonia

97
Q

RESPIRATORY SYSTEM

Atelectasis

Clinical Signs

  • Decreased or absent breath sounds, noisy respirations, decreased O2 saturation, chest asymmetry, sternal retractions, accessory muscle use, trachea deviated from midline, fever, tachypnea, dyspnea, tachycardia, diaphoresis, pleural pain, increased restlessness, anxiety
A

Interventions for Prevention and Early Detection

  • Monitor for clinical signs
  • Monitor rate, rhythm, depth, & effort of respirations
  • Monitor ability to cough effectively
  • Determine need for suctioning by listening for crackles & 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
98
Q

?

Collapse of alveoli d/t hypoventilation, airways blocked by mucous plugs, opioid analgesics, immobility

A

Atelectasis

99
Q

RESPIRATORY SYSTEM - Pneumonia

Clinical Signs

  • Productive cough w/blood-tinged or purulent sputum, fever, elevated WBC, decreased or absent breath sounds, decreased SaO2, chest pain, tachypnea, dyspnea

Interventions for Prevention and Early Detection

  • Monitor for clinical signs
  • Encourage & assist w/deep breathing, coughing, moving in bed, ambulation, use of incentive spirometry
A
100
Q

?

Inflammation of the alveoli d/t infection w/bacteria or viruses, toxins, or irritants

Caused by hypoventilation 2° to anesthesia & opioid analgesics, & by poor cough effort as a result of aging or weakness

A

Pneumonia

101
Q

RESPIRATORY SYSTEM - Pulmonary Embolus

Clinical Signs

  • Sudden onset of dyspnea, SOB, chest pain, hypotension, tachycardia, decreased SaO2, cyanosis
A

Interventions for Prevention and Early Detection

  • Prevent thrombophlebitis: Encourage and assist w/leg exercises, ambulation, antiembolism stockings, sequential compression devices, hydration. See Procedures 39-2 and 39-3
  • If thrombophlebitis occurs, position & immobilize the limb; do not massage calves
102
Q

?

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, pre-existing circulatory disorders

A

Pulmonary embolus

103
Q

CARDIOVASCULAR SYSTEM - Thrombophlebitis

Clinical Signs

___ - vein is red, hard, and hot to touch

___ - limb is pale & edematous; aching, cramping in limb; Homans’ sign (pain in calf when foot is dorsiflexed)

A

Superficial

Deep

104
Q

Embolus

Movement in the arterial system, results in symptoms in the area affected (e.g., CVA, MI, or loss of circulation to an area)

In the venous system, often results in pulmonary embolus

Clinical signs - depends on locations

A

Interventions for Prevention and Early Detection

  • Monitor for clinical signs
  • Prevent thrombophlebitis. If thrombophlebitis occurs, position and immobilize the limb
  • Do not massage calves
105
Q

?

Movement of a thrombus or foreign body from its original location

A

embolus

106
Q

?

Blood clot and inflammation of a vein or artery, usually in the legs. Results from increased coagulability and venous stasis d/t immobility during & after surgery

A

thrombophlebitis

107
Q

?

Bleeding that may be internal or external. May be caused by slipped ligature, uncontrolled bleeder, or infection

A

Hemorrhage

108
Q

CARDIOVASCULAR SYSTEM - Hemorrhage

Clinical Signs

If ___ : increased pain, increasing abdominal girth, ecchymosis or swelling around incision, tachycardia, hypotension

If ___ : dressings saturated w/bright red blood; increased output in drains or chest tubes

> Frequently monitor VS, dressings, & wound drainage

A

internal

external

109
Q

CARDIOVASCULAR SYSTEM - Hypovolemia

Decreased blood volume. Blood loss during & after surgery; dehydration; or excess loss through vomiting, diarrhea, or drains

Clinical Signs

  • Hypotension, tachycardia, decreased urine output, fatigue, thirst, dehydration
A

Interventions for Prevention and Early Detection

  • Monitor VS and I&O
  • Insert urinary catheter, if appropriate
  • Monitor skin color, temperature, and moistness; central & peripheral cyanosis
  • ID possible causes of changes in VS
  • Admin IV therapy as prescribed
  • Promote oral intake when tolerated
  • Prepare to administer blood or blood products, as prescribed
110
Q

GASTROINTESTINAL SYSTEM

Nausea & Vomiting - stomach upset or vomiting r/t pain, anxiety, anesthesia, rx’s, or oral intake before peristalsis returns

Clinical Signs

  • Vomiting, retching, stated nausea
A

Interventions for Prevention and Early Detection

  • Have pt remain NPO until return of bowel sounds
  • Advance diet slowly
  • Treat pain
111
Q

GASTROINTESTINAL SYSTEM

Abdominal Distention (___) - excess gas within the intestines

Clinical Signs

  • Abdominal discomfort, bloating, hypoactive or absent bowel sounds
A

Tympanites

112
Q

Interventions for Prevention and Early Detection

  • Encourage and assist to move in bed and ambulate
  • Maintain NPO until return of bowel sounds; avoid drinking w/a straw
  • Provide fluids at room temp
A
113
Q

?

Excess gas within the intestines; may be due to a slow return of peristalsis or from handling of the intestines during surgery

A

Tympanites

114
Q

GASTROINTESTINAL SYSTEM - Constipation

Clinical Signs

  • Abdominal discomfort, bloating, hypoactive or absent bowel sounds

Interventions for Prevention and Early Detection

  • Encourage & assist the pt to move in bed, ambulate, & increase fluid & fiber intake >bowel sounds return
A

GASTROINTESTINAL SYSTEM - Ileus

Clinical Signs

  • Abdominal pain, distention, absent bowel sounds, vomiting

Interventions for Prevention and Early Detection

  • Observe for symptoms; notify the surgeon
115
Q

?

Loss of the forward flow of intestinal contents d/t decreased peristalsis 2° anesthesia, handling of the intestines during surgery, electrolyte imbalances, infection, or ischemic bowel

A

Ileus

116
Q

?

A decrease in the frequency of bowel movements; resulting in the passage of hard stool

Usually r/t use of opioids, immobility, inadequate fluid intake, or low-fiber diet

A

Constipation

117
Q

GENITOURINARY SYSTEM - Renal Failure

Decreased or absent urine output d/t hypovolemia, shock, or toxic reaction to rx’s

Clinical Signs

Urine output <30 mL/hr; rising BUN and creatinine lvls

A

Interventions for Prevention and Early Detection

Carefully monitor I&O and lab values

118
Q

GENITOURINARY SYSTEM - Urinary Retention

Clinical Signs

  • Bladder distention, suprapubic pain, diminished urine output or output less than fluid intake, inability to void or small, frequent voidings; HTN, restlessness
A

Interventions for Prevention and Early Detection

  • Monitor for clinical signs
  • Provide privacy and adequate time to urinate
  • Catheterize if needed
119
Q

?

Accumulation of urine in the bladder

May result from poor muscle tone as a result of anesthesia and anticholinergic rx’s, handling of tissues during surgery, or inflammation in the pelvic region

A

Urinary retention

120
Q

GENITOURINARY SYSTEM - Urinary Tract Infection

Clinical Signs

  • Urinary frequency, suprapubic discomfort, burning on urination, cloudy urine
A

Interventions for Prevention and Early Detection

  • Monitor for clinical signs
  • Monitor I&O
  • Use aseptic technique w/catheterization and perineal care
  • Provide adequate IV and oral fluids
121
Q

?

Infection in the urinary tract r/t catheterization, stagnant urine in the bladder 2° to immobility or anticholinergic rx’s, or instrumentation of the urinary tract

A

Urinary Tract Infection

122
Q

SURGICAL INCISION

___ - separation of one or more layers of the wound d/t poor nutritional status, obesity, or other strain on suture line, inadequate closure of the muscles, or wound infection

A

Dehiscence

123
Q

Clinical Signs

  • A pop or tearing sensation, especially w/sudden straining from coughing, vomiting, or changing positions in bed
  • Usually an immediate increase in serosanguineous drainage occurs
A

Interventions for Prevention and Early Detection

  • Provide adequate nutrition
  • Use binders to support the incision
  • Have client avoid strain
  • Monitor for infection
124
Q

SURGICAL INCISION

___ - protrusion of organs or tissues through the separated incision

Clinical Signs

  • Visible protrusion of organs through incision

Interventions for Prevention and Early Detection

  • Provide adequate nutrition / use binders to support incision
  • Have client avoid strain / Monitor for infection
A

Evisceration

125
Q

Know the difference between these 2 complications

A

A = dehiscence

B = evisceration

126
Q

SURGICAL INCISION - Wound Infection

Clinical Signs

  • Localized swelling, redness, heat, pain, fever >100.4°F, foul-smelling drainage, or a change in the color of the drainage
A

Interventions for Prevention and Early Detection

* Effective skin prep & surgical scrub

* Monitor for systemic & localized s/s of infection

* Inspect incision & drain areas for redness & extreme warmth

* Inspect surgical dressings for drainage & odor

* Monitor VS

* Maintain aseptic technique - dressing changes

127
Q

Interventions for Prevention and Early Detection cont’d

* Use & teach good hand hygiene

* Use sterile saline for wound cleansing up to 48 hrs post-op

* Limit the # of visitors

* Obtain cultures as needed

* Encourage sufficient nutritional & fluid intake

* Teach client about signs of infection

A
128
Q

Postoperative Period - Nursing Interventions - Pain Management

* The primary goal - to minimize the dose of medications (to lessen side effects) while still providing adequate pain management

  • Pain control individualized
  • Interprofessional team approach
  • Benefits of adequate pain management
A

Analgesics - more than one route

* Oral opioids should be given preference to IV opioids when possible. IM injections can cause additional pain. Plus, absorption is unreliable postoperatively.

ADMINISTER round-the-clock NSAIDs

Sufficient pain control for older adults - undermedicated

Monitor side effects of analgesics - respiratory depression, hypotension, allergic reaction

129
Q

Postoperative Teaching

* Reinforcement of preoperative teaching

* Efficient timing

* Comfortable and alert

* Do not teach when pt is in pain, needs to void, or is drowsy

A

Self-Care

  • Treatment regimen (dressing changes, exercises)
  • Diet & food selection
  • Activity
  • s/s complications
  • Return office visits
  • Lifestyle changes / community resources
130
Q

Incentive Spirometry

* High risk for atelectasis & pneumonia

* Facilitates deep breathing, increases lung volume, & promotes coughing to clear mucus from the resp tract

* Explain use during pre-op or post-op

A
131
Q

Antiembolism Stockings and Sequential Compression Devices

* Surgical pt’s high risk for venous thromboembolism - preventive measures include anticoagulant rx’s, post-op exercises, & antiembolism stockings

Antiembolism Stockings

  • Encourage post-op pt’s to ambulate as soon and as much as possible
A

Sequential Compression Devices (SCDs)

  • SCDs apply brief pressure to each segment of the leg. This compresses the veins & promotes venous return to the heart
132
Q

Gastrointestinal Suction

* Used in laparatomy to close a bowel perforation or surgery to relieve a bowel obstruction - high risk for abdominal distention

* Distention can increase post-op resp problems, place a strain on suture lines, & interfere w/wound closure

* Nasogastric (NG) or nasointestinal tube in place for gastric or intestinal decompression

A

* Decompression tubes - connected to intermittent or continuous suction

  • Suction is continued until peristalsis resumes, bowel sounds are audible, and the pt is passing flatus
  • While suction is in place, the pt remains NPO

Last (2) Lectures into Final (2 decks)

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