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Module 3 (MedSurg 1) > PeriOperative/Clinical Judgement > Flashcards

PeriOperative/Clinical Judgement Flashcards

1
Q

When a patient goes to your floor, when must the nurse check VS? From hours 1 through 4

A

1st hour = every 15 mins
2nd hour = every 30 mins
3-4th hour = every hour

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2
Q

If a patient comes to your floor but his VS is not stable. Does the nurse have to accept the pt?

A

No (check pre-op baseline VS)

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3
Q

What is needed for legal preparation of surgery?

A

Informed Consent

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4
Q

What is needed for informed consent?

A

Understanding at the pt’s level
Adequate disclosure
Volutary

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5
Q

What is included in adequate disclosure?
Bolded are most important

A

Pt needs to understand the diagnosis
Other options besides surgery
Percentage of success
Type of surgery (Diagnostic/Palative/Curative)
Cost
Duration (approx)

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6
Q

_________ ______________ may override the need to obtain consent.

A

Medical Emergency

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7
Q

During a medical emergency, if the patient can not give consent, what is the order for people to obtain consent?

A

Next of kin
Need 2 surgeons to confirm an emergency
HCP may begin the tx

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8
Q

When does the surgical TIME-OUT occur? What happens during a TIME-OUT?

A

before making the incision
- the entire surgical team pauses as the surgical site listed on the consent is read aloud

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9
Q

SCIP protocols are best practices for

A

safety and quality implemented during pre-op and following up in post-op
prevention of infection, serious cardiac events, venous thromboembolism

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10
Q

What is Hand-off communication?

A

transfer of relevant patient information during peri-op
- standardized and includes an opportunity for questions

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11
Q

During pre-operative care, what does a surgeon do and why?

A

Marks the operation site required for r/l distinctions, multiple structures, and levels
- the client should be involved to avoid the wrong area

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12
Q

A legally appointed representative/responsible family member can give written permission for

A

minors
unconscious pt
mentally incompetent

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13
Q

What are the 3 phases of perioperative nursing?

A

Pre-op
Intra-op
Post-op

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14
Q

Pre-operative Nursing involves

A

NPO after midnight
Type and Cross
Medications needed

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15
Q

Why are surgical patients NPO after midnight?

A

risk of N/V
leads to aspiration

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16
Q

Nursing Management
Pre-procedure verification process

A

Results of diagnostic studies (X-rays, biopsy, MRI)
Any blood, devices, or special equipment available in the room
H&P on chart
Signed Consent

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17
Q

Members of the Surgical Team

A

Circulating nurse
scrub nurse
surgeon
surgeon assistant
registered nurse 1st assistant
anesthesiologist

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18
Q

Circulating Nurse

A

remains in the unsterile field
not scrubbed, gowned, or gloved
documents
-Prepares room with team
-Serves as pt advocate
-Maintain pt safety, privacy, dignity, and confidentiality

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19
Q

Safety considerations for nursing management in intraoperative phase

A

Fire
Smoke particles
Universal protocols
Surgical time-out

20
Q

Universal Protocol in OR includes

A

Surgical time-out
patient ID
procedure
surgical site - marked by surgeon w/ help of pt

21
Q

PACU Admission Report

A

Name, age, surgeon, procedure, type of anesthesia
Hx, MEDS, ALLERGIES, BASELINE

22
Q

Initial PACU Assessment
Airway

A

HOB up slightly to help breathing and prevent aspirations

23
Q

Initial PACU Assessment
Breathing

A

RR, O2 Sat, cyanosis of lips and mucosa, listen to breath sounds, Deep Breaths

24
Q

Initial PACU Assessment
Circulation

A

Assess for cap refill, pallor, wiggles, PULSE
SCDs

25
Initial PACU Assessment Neuro
LOC - listen, person, place, time, situation
26
When you are put to sleep, the 1st thing that comes back is
hearing
27
Initial PACU Assessment Surgical Site/Pain
Pain focused assessment priority choice
28
Nursing Intervention in PACU
frequent VS monitoring continous EKG monioring adequate fluid replacement assess surgical site for bleeding
29
Phase 1 Nursing Management
initial recovery period in PACU **constant vigilance** is required vital to perform a **frequent skilled assessment**
30
Phase 1: PACU Discharge Criteria
pt awake vs stable no excess bleeding/drainage no respiratory depression (O2 greater than 90) pain controlled or acceptable minimal N/V report given
31
Phase 2/3: Ambulatory Surgery Discharge Criteria
All Phase 1 complete **No IV opioid drugs for the last 30 mins voided able to ambulate if not contraindicated responsible adult present written discharge given and understood**
32
Nursing process
the systematic, problem-solving approach used to identify, prevent and treat health problems and promote healing - care for individuals, families, groups, and communities
33
ADPIE
Assessment Diagnosis/Priority Plan/Outcome Implement Evaluation
34
NCJMM
Nursing Clinical Judgement Measurement Model
35
NCJMM is used to
recognize cues analyze cues prioritize hypotheses generate solutions take action evaluate outcomes
36
What questions do you ask when RECOGNIZING CUES?
- identify relevance from different sources from hx, VS What is relevant? What is MOST important? What is a **priority?** **Do not connect with hypothesis**
37
Analyze Cues questions
What pt conditions are **consistent** with the cues? Are cues **contraindicating or supporting** the pt's condition? Why are **particular cues concerning?** What other information help **establish the significance of a cue?** **Multiple things could happen**
38
Priortize Hypotheses by
ABC Which are most/least likely? Most serious?
39
Generate solutions questions
Desirable outcome? Do interventions achieve the outcome? Avoided?
40
Taking action is implementing solutions that address the
highest priority - Most appropriate? - How should it be provided?
41
When evaluating outcomes what questions do you ask?
Were the interventions effective? Would other interventions have been more effective? What signs point to improving, or changing, and status?
42
Critical Thinking concepts when used in the nursing process will result in
clinical judgement
43
Questions used in clinical judgement/decision-making?
WHO does it involve? WHAT is the problem? WHERE does it occur? WHEN does it occur? WHY make a decision? HOW to make a decision?
44
80-YEAR-OLD FEMALE POST OP DAY 1 FROM HIP REPLACEMENT - Patient returned from surgery yesterday afternoon. Reports pain of 8/10 and has physical therapy scheduled in 1 hour. - Hx: diabetes type II, MI, degenerative joint disease - BP: 110/60 - HR: 82 - O2 sat: 95% on room air - Hgb: 10.6 g/dL - Hct: 39% - Creatanine: 1.6 mg/dL ORDER: Ketorolac 30 mg IVP dose now
- Effect bleeding and kidney excretion Stomach or intestinal bleeding without warning in older adults No, because creatinine is high
45
6-YEAR-OLD MALE PRESENTS TO ER WITH ASTHMA ATTACK - Patient developed wheezing while playing outside. Used a rescue inhaler and had some relief but difficulty breathing has continued. - Hx: asthma - BP: 100/60 - HR: 110 - RR: 32 - O2 sat: 82% on room air Lung sounds: wheezing throughout Able to speak a few sentences ORDER: ALBUTEROL/IPRATROPIUM 3ML VIA NEBULIZER
Yes because prevents exercise bronchospasms
46
77-YEAR-OLD MALE CHF EXACERBATION - Patient noted a weight gain of 10 pounds last week as well as swelling in the lower extremities. - Hx: CHF, CAD, HTN, GI bleed, skull fracture - BP: 90/50 - HR: 60 - RR: 16 - O2 sat: 93% on 2L O2 Sodium - 132 meQ/L - Potassium - 3.3 mEq/L Magnesium - 1.6 mEq/L Lung sounds - crackles throughout, SOB with activity ORDER: FUROSEMIDE 60MG IV PUSH TWICE DAILY
Fluid excess/retention Potassium is too low so no for diuretics (risk of arrhythmia and confused) No, I would not give. - Ask maybe of 30 not 60

Module 3 (MedSurg 1) (12 decks)

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