PeriOperative/Clinical Judgement Flashcards
When a patient goes to your floor, when must the nurse check VS? From hours 1 through 4
1st hour = every 15 mins
2nd hour = every 30 mins
3-4th hour = every hour
If a patient comes to your floor but his VS is not stable. Does the nurse have to accept the pt?
No (check pre-op baseline VS)
What is needed for legal preparation of surgery?
Informed Consent
What is needed for informed consent?
Understanding at the pt’s level
Adequate disclosure
Volutary
What is included in adequate disclosure?
Bolded are most important
Pt needs to understand the diagnosis
Other options besides surgery
Percentage of success
Type of surgery (Diagnostic/Palative/Curative)
Cost
Duration (approx)
_________ ______________ may override the need to obtain consent.
Medical Emergency
During a medical emergency, if the patient can not give consent, what is the order for people to obtain consent?
Next of kin
Need 2 surgeons to confirm an emergency
HCP may begin the tx
When does the surgical TIME-OUT occur? What happens during a TIME-OUT?
before making the incision
- the entire surgical team pauses as the surgical site listed on the consent is read aloud
SCIP protocols are best practices for
safety and quality implemented during pre-op and following up in post-op
prevention of infection, serious cardiac events, venous thromboembolism
What is Hand-off communication?
transfer of relevant patient information during peri-op
- standardized and includes an opportunity for questions
During pre-operative care, what does a surgeon do and why?
Marks the operation site required for r/l distinctions, multiple structures, and levels
- the client should be involved to avoid the wrong area
A legally appointed representative/responsible family member can give written permission for
minors
unconscious pt
mentally incompetent
What are the 3 phases of perioperative nursing?
Pre-op
Intra-op
Post-op
Pre-operative Nursing involves
NPO after midnight
Type and Cross
Medications needed
Why are surgical patients NPO after midnight?
risk of N/V
leads to aspiration
Nursing Management
Pre-procedure verification process
Results of diagnostic studies (X-rays, biopsy, MRI)
Any blood, devices, or special equipment available in the room
H&P on chart
Signed Consent
Members of the Surgical Team
Circulating nurse
scrub nurse
surgeon
surgeon assistant
registered nurse 1st assistant
anesthesiologist
Circulating Nurse
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
Safety considerations for nursing management in intraoperative phase
Fire
Smoke particles
Universal protocols
Surgical time-out
Universal Protocol in OR includes
Surgical time-out
patient ID
procedure
surgical site - marked by surgeon w/ help of pt
PACU Admission Report
Name, age, surgeon, procedure, type of anesthesia
Hx, MEDS, ALLERGIES, BASELINE
Initial PACU Assessment
Airway
HOB up slightly to help breathing and prevent aspirations
Initial PACU Assessment
Breathing
RR, O2 Sat, cyanosis of lips and mucosa, listen to breath sounds, Deep Breaths
Initial PACU Assessment
Circulation
Assess for cap refill, pallor, wiggles, PULSE
SCDs
Initial PACU Assessment
Neuro
LOC - listen, person, place, time, situation
When you are put to sleep, the 1st thing that comes back is
hearing
Initial PACU Assessment
Surgical Site/Pain
Pain focused assessment
priority choice
Nursing Intervention in PACU
frequent VS monitoring
continous EKG monioring
adequate fluid replacement
assess surgical site for bleeding
Phase 1 Nursing Management
initial recovery period in PACU
constant vigilance is required
vital to perform a frequent skilled assessment
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
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
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
ADPIE
Assessment
Diagnosis/Priority
Plan/Outcome
Implement
Evaluation
NCJMM
Nursing Clinical Judgement Measurement Model
NCJMM is used to
recognize cues
analyze cues
prioritize hypotheses
generate solutions
take action
evaluate outcomes
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
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
Priortize Hypotheses by
ABC
Which are most/least likely?
Most serious?
Generate solutions questions
Desirable outcome?
Do interventions achieve the outcome?
Avoided?
Taking action is implementing solutions that address the
highest priority
- Most appropriate?
- How should it be provided?
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?
Critical Thinking concepts when used in the nursing process will result in
clinical judgement
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?
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
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
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
