Perioperative Nursing Flashcards by Glen McCormick

decisions are made here until wheeled back to the surgical suite. Can be days before when labs/xrays may be completed.

Preoperative

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beginning when the client is wheeled back to surgery and until the client is in post-op.

intraoperative

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–, after time person comes out of surgery until theyre discharged, could be anything after surgery
this phase continues until the client is discharged from care of the surgeon.

postoperative
after surgery

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– Determine the origin of the presenting symptoms and extent of a disease process

Diagnostic

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– Repair or removal of diseased organ or restore normal physiological functioning

Curative

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ie: Breast Biopsy

diagnostic

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ie: amputation of GREAT toe or removal of gallbladder

curative

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– Decrease the spread of the disease process to prolong life or to alleviate pain.

Palliative

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ie: partial tumor removal

palliative

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– Correct a disease process or improve cosmetic appearance after accident

Reconstructive

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ie: rhinoplasty (hit in nose)

Reconstructive

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– Improve cosmetic appearance ie: Face lifts, Breast Implants, Collagen Lips

Cosmetic

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– Improve cosmetic appearance

Cosmetic

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ie: Face lifts, Breast Implants, Collagen Lips

Cosmetic

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– Remove disease tissue or organ and replace with functioning tissue ie: a few are kidney, heart, eyes, large bone

Transplant

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– Remove disease tissue or organ and replace with functioning tissue

Transplant

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ie: a few are kidney, heart, eyes, large bone

Transplant

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Surgeries are categorized according to the degree of severity or _____

URGENCY

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surgery requiring immediate intervention to sustain life.

emergent

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Ie: gun shot, stabbing appendix

emergent

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surgery dictates the necessity to maintain health situations that are not life threatening.

urgent

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ie: bladder obstruction, intestinal obstruction

urgent

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– is usually performed at a convenient time with the client

elective

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ie: Carpal tunnel, breast biopsies.

elective

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Client that has been in hospital prior to surgery, and begins recovery as _______ after surgery.

inpatient

Client enters hospital or free standing outpatient center has surgery and is discharged home after recovering and stable from Anesthesia and the surgical procedure.

outpatient

is usually brief, carries a low risk and results in few complications. *

minor or low risk

_____ surgeries are mostly elective

Minor

teeth extraction ex.

minor or low risk

removal of _____ organs- requires hospitalization and may require specialized care.

major surgery

Hospitals (Large & Small) Ambulatory Care Free-standing Surgical Centers Doctors’ Offices

types of surgical centers

The primary goal of _____ nursing care is to place the client in the best possible condition for surgery through careful assessment and through preparation

preoperative

– provides pertinent information relative to factors that can increase the client’s risk or influence the expected surgical outcomes. ie: medical HX, medications, allergies, age-related factors, social, cultural, spiritual concerns and psychological status.

patient history

Nurse conducts the ______ in a quiet room, free of background noise. With the elderly – you may need to speak in a strong and clear voice.

interview

Pre-admission testing ____ before (tell about woman that was pregnant)

days

Usually clients come with another family member or friend – sometimes this is needed if the client having the surgery is having difficulty comprehending the surgical procedure. They may help interpret such

instructions

Why are you having surgery? When did this problem start? What do you think caused this problem? Has this problem prevented you from working? Are you able to take care of your own needs? Are you experiencing any discomfort or pain? What are you expecting from this surgery? Is there anything that you do not understand regarding this surgery? Are you worried about anything? Will someone be available to assist you when you return home?

questions you need to ask before surgery

Patient will be given specific instructions based on dr/facility protocols. May include using _____to shower day before and day of surgery to decrease bacteria.

chlorhexidine

Talk to them, how are they handling coming in for the surgery.

coping

– is usually vague, uneasy feeling often nonspecific their worried of the “unknown”

Anxiety

- usually they have a family member with them

Support system

– is a feeling of dread related to an identifiable source that the client validates. Grandparent died from Anesthesia

Common fears

If they are diabetic their blood sugar may ______ during or shortly after surgery. After surgery, the stress may cause an ______ in blood sugar which can delay healing of wounds or cause complications. Also malnutrition needs to be corrected as well as dehydration, and electrolyte imbalances.

drop, increase,

Alcohol/Drug use: patient may have ______ withdrawal ( a life threatening event that usually occurs 48 to 72 hours after alcohol withdrawal) They seize..

alcohol

Should encourage them to stop smoking 4 to 8 weeks prior if able to reduce ______ ___ ______ complications. Do be aware that most won’t and you will need to watch them more closely after.

pulmonary and wound healing

______ should not be taken for 7-10 days prior if possible. ______ meds should be d’cd 2-3 weeks before surgery.

Aspirin, Herbal

What are some special preexisting factors that you need to assess for?

Diabetes Alcohol/Drugs Smoking Previous Medication use

Purpose Lab data Radiographic assessment Other diagnostic assessments Factors which influence risk

preop assessment continued

REMEMBER!!!! This is done a little differently depending where the surgery takes place.

preop assessment

Purpose is to determine the client’s present health status and ability to tolerate the surgical procedure and anesthesia. Generally the more involved the surgery; the more involved diagnostic testing.

preop assessment

Also, more involved testing with the client’s that are elderly or those that multiple pre-existing health problems Nursing advocacy to make sure the physician’s are aware of any significant abnormalities and follow-up is done.

preop assessment

client’s ability to tolerate blood loss involved with surgery,

- H&H

______ count assess the immune system and healing potential

White Blood

- normal range for proper heart an neuromuscular functioning

Fluid/Electrolytes Studies

– ability to clot normally post-surgery Prothrombin Time (PT) (evaluates the extrinsic system )& Partial Prothrombin Time (PTT) (assesses the intrinsic system )(which both id the clotting mechanism)

coagulation studies

cbc has?

H&H WBC

______, gives basic info regarding the heart and lungs, determine whether the client’s cardiac and respiratory systems are healthy for those scheduled for surgery and general Anesthesia.

X-ray & Electrocardiogram

____: Urinalysis general screening for diseases such as renal problems or diabetes

Lab

______: done if blood transfusion is anticipated

Blood type & cross match

______ blood transfusion this is where the clients donates their own blood ahead a time.

AUTOLOGOUS

gas exchange issues- may be affected more by anesthesia Kidney and liver issues possible- difficulty ridding body of anesthesia More likely to have issues with orientation after surgery

risk factors in the elderly

Kidney/liver: Increased risk with prolonged effects of anesthesia. Gas exchange: May have more trouble with keeping oxygen level up. Orientation: If patient has trouble with orientation, they are at a higher risk of falls- reorient. Also check to see if the patient was oriented prior to surgery to determine if it is a new problem

increased risk factors in the elderly

Increased risk of respiratory issues after surgery

increased risks with tobacco use

_____ possible withdrawal seizures Patient’s use of ______ may affect the way that a patient tolerates anesthesia and pain medication

alcohol drugs

______ are responsible for obtaining informed consent. However, the ______ should verify that the consent was obtained before treatment begins.

Surgeons nurse

The purpose of the consent – it states the extent of action documented. Ie: Amputation of right great toe The nurse can ______ the patient signing it and may ask the patient if they understand but if information about the surgery, risks, etc haven’t been given by the dr or if the patient has more questions the patient should notify the dr.

witness

Consent should be signed before any _____

preop meds (are given).

If the surgeon proceeds without appropriate consent, nursing administration should be notified immediately. The nurse should make notations ______ the chart, This practice protects the nurse should this case go to court.

outside

If the client reverses a decision and decides against the surgery, the _____ is OBLIGATED to inform the surgeon in order to prevent unwanted TXT.

NURSE

Client’s routine medications Specific Preparations ordered by Physician NPO Status Preoperative Medication

common orders

Instructions on taking ______ ( Diabetic Meds, antihypertensives, anticoagulants)

routine meds

The ______ needs to inform client, or Dr, office needs to inform Have client bring meds, or list of all meds.

Pre-admissions Nurse

Make sure you have a list of _____ including allergy to latex.

allergies

NPO STATUS – Nothing by mouth, decrease the likelihood of ____ and decrease the risk of ____

vomiting aspiration

Often 6-8 hours depending when surgery is scheduled. Keep in mind – client has an IV to keep fluid balanced , sometimes depending when the surgery is scheduled and the type of surgery

NPO status

Versed Fentanyl Tagamet Reglan Robinul Ancef

Preoperative Medications - specific time given 1 hr. before going back.

You will also want to teach client about ____course. What will they expect when they wake up. Teach about pain relief, deep breathing, incentive spirometry, when they will get out of bed…

operative

Use the incentive spirometer in the ______

essential skills

Prescription anticoagulants Oral diabetics (insulin dose may be changed.. May be different depending on dr)

Routine Meds (Held):

Aspirin (in many versions) non-steroidal anti-inflammatory (NSAIDs) (in many versions) Vitamin E garlic ginger ginkgo biloba

Non prescription anticoagulants that are held

In general, blood pressure (heart) medications, anti-seizure medications

routine meds that are usually given

reduces anxiety, sedation, induces amnesic affect (push slowly) Monitor respiratory. depression, hypotension

Versed – Benzodiazepines

use to supplement general anesthesia, short-acting analgesic during perioperative periods. (ANALGESIC reduce pain) (push slowly)

Fentanyl – Narcotic/Opiate

Reduces gastric acid volume and concentration (hanging at a high port)

Tagamet – H2 recepter

Gastric empty

Reglan – Antiemetics

reduces respiratory secretions, decrease risk of aspiration, decreases vomiting ( used more in larger cases)

Robinul – Anticholinergics

used prophylaxis in clients having surgery assoc. with high risk for surgery.

Ancef - antiinfective, antibiotic

Client has ID band, and allergy bracelet Informed Consent is signed and witnessed Diagnostic tests results are at front of chart H & P with Hgt & Wgt Pre-Op intervention completed Pre-Op meds administered V/S taken right before exiting Pre-Op Client voided (can you get client up to void) Family members present say see you later. (try not to say good bye) ????? Check policy & procedure regarding dentures, glasses, hearing aids ( give to spouse, friend) Proper attire – jewelry off, nail polish, make-up (also according to policy & procedure)

preop checklist

Nurse signs off to the ______ Nurse places documentation on chart and includes

Anesthesia/Circulator

_____ prevention of wrong site, wrong procedure, wrong person surgery… These are ”never” events

Time out

A ______ is called by any member of the surgical team, but usually by a specifically designated person, e.g. the circulation nurse.

"time out"

Ideally, the patient should be ____ and participate in the verification process of patient identity, surgical site, and planned procedure (so-called "awake time out").

awake

The "time out" must be repeated intraoperatively for every additional ______ performed on the same patient.

procedure

Control risks for fire Control microbes Surgical Asepsis: Sterilized equipment Scrub Body covered with sterile drapes.

JCAHO's national patient safety goals

______ must be trained in reduction of risk for fires. Control heat sources, manage fuels, and minimize oxygen concentration under drapes.

Surgery staff

Microbes: _________ zone: scrubs and caps

semirestricted

______ zone: scrubs, shoe covers, caps, and masks. Artificial nails are banned on OR personnel .

Restricted

RN leadership role. Protects the patients’ safety and health. Monitors actions of the team. Verifies consent, coordinates team. Monitors aseptic practices.

circulating nurse

: rn, lpn, or scrub assistant. Sets up sterile tables and assists during the procedure by handing instruments, counts all needles, sponges and instruments at end of surgery.

Scrub nurse

Given inhalation and intravenous CNS depressed: Risk for Cardiac and respiratory problems

general anesthesia

What are the phases of general anesthesia?

induction maintenance emergence

______ – tracheal intubation for airway patency _______ – positioned, surgery performed ______ – anesthesia reversed; extubation

Induction, Maintenance, Emergence

is a type of local, it’s done with a topical, cream or spray applied to the skin that blocks the nerve impulse.

regional anesthesia

lidocaine is used to depresses the nerve sensation ( breast Biopsy, skin BX)

local anesthesia

injected to produce a lack of sensation over a certain area, ( wrist surgery)

nerve block

injected in the epidural space this can be used during abdomen or extremity surgeries ie: Maternity

epidural block

local anesthetic is injected in the subarachnoid space – lower abdomen, perineum, and lower extremities ie: Hip fractures elderly with poor health problem be aware of leakage of CSF Cerebrospinal Fld. Which will reduce CSF pressure and the client will have a post-op HA Intervention : Bed rest, hydrate

spinal block anesthesia

Epidural goes into the epidural space rather than the subarachnoid space that the _____ goes in. Epidural therefore requires more medication because it doesn’t have direct contact with spinal cord or nerve roots.

spinal

Spinal anesthesia goes into ______ at L4-L5. Both produce anesthesia of the lower extremities, perineum, and lower abdomen.

subarachnoid space

If it goes too high it will paralyze the respiratory muscles and will required mechanical ventilation until it wears off. Nausea, vomiting, and pain could occur in this surgery.

spinal anesthesia

Headache may be an after effect. ______common in the spinal than epidural due to leakage of CSF. If this occurs, then a blood patch may be performed.

Often the drug of choice for induction of anesthesia or for conscious sedation Rapid induction, rapid return to consciousness, minimum residual effects Lack of memory of the surgical procedure Decreased nausea and vomiting postop For moderate (conscious) sedation- administer slowly over 2 min. ●● Monitor carefully during and after moderate sedation or anesthesia for respiratory arrest or hypotension. ●● Inject _______ into large vein to decrease pain at injection site. CLIENT EDUCATION: Arrange for a ride home following outpatient procedure.

propofol

Reduce anxiety preoperative ●Promote amnesia ●Produce mild sedation (unconsciousness) with little‑to ‑moderate respiratory depression with careful titration

midazolam [versed]

Lower doses of anesthetics are required in ______. Often experience an increase in duration of clinical effects of medications. Higher perioperative morbidity and mortality.

elderly

N/V Anaphylaxis Hypoxia Hypothermia Malignant hyperthermia Disseminated Intravascular Coagulation

Possible Intraop complications

- they will be turned on their side, suction used to remove saliva and gastric contents.

Gagging

: may be immediate or delayed reaction to meds given in OR.

Anaphylaxis

In general anesthesia this will be done by anesthetist or CRNA. In conscious sedation, the nurse is the one giving the medication and monitoring pulse ox, vital signs etc.

Monitor oxygenation status

glucose metabolism is reduced and temp may fall causing metabolic acidosis. This is a core body temp below 98 degrees. May occur as a result of infusion of cold fluids, inhalation of cold gases, open body wounds, advanced age, and meds. Interventions: warm IV fluids, dry . Should be done gradually not rapidly.

Hypothermia

Rare inherited muscle disorder chemically induced by anesthetics. ID of risk is imperative. Those at risk are those with strong bulky muscles, history of muscle cramps and weakness, unexplained temp elevations, and unexplained death of a family member during surgery that was accompanied by elevated temp. s/s of mal. Hyperthermia: tachycardia (over 150) is often the first sign. Hypotension, oliguria, and later cardiac arrest. Rising temp is usually a late sign that occurs rapidly.

Malignant hyperthermia:

Increased prothrombin and platelets Widespread formation of intravascular clots Clotting factor expended Severe generalized hemorrhaging Life Threatening Complication

DIC

s/s bleeding from puncture sites, gums… Treatment packed cells, fibrinogen, plasma, whole blood.

DIC

Gas exchange Pain Infection Tissue integrity

common priority problems post op

Respiratory paralysis elimination GI inform of procedure observe for hypotension no trauma to the extremities

thing you need to watch out for with anesthesia

after you want to monitor respirations frequently for residual effects of anesthesia and pain medication ( resp. rate and depth as well as pulse ox and skin color)

resp paralysis

both GI and GU may be affected. Often person may not be able to void right after surgery. You should encourage voiding if patient doesn’t have a catheter in. If unable to void within _______ (or when bladder palpable) you will have to get an order for catheterization.

7 or 8 hours

GI: patient GI system will “_____ during surgery. Therefore after surgery (general surgery) generally the client will not have anything to eat. They will move to clear liquids and advance diet.

stop”

Observe for ______ which could be a reaction to residual anesthesia or may be due to blood loss, position, or other medications.

hypotension

OR nurse and anesthesia give report to______ nurse she will monitor patency airway, vital signs, surgical site, coming off anesthesia, fluid status, pain control, other post operative orders ie: lab tests, IV fluids

PACU

When stable from _______ They go to 2nd stage PACU or to the floor to be monitored.

general Anesth.

Hemorrhage, Hypovolemic Shock Deep Venous Thrombosis (DVT) Pulmonary Embolism

cardiovascular complications

Client becomes restless or less responsive Monitor postoperative H&H (?) Hypotension, tachycardia Pressure for obvious bleeding Notify surgeon

cardiovascular complications

_______ may result from blood loss, hypoventilation, position changes, pooling of blood in extremities, or side effects of medication and anesthetics. Most common cause is blood loss.

Hypotension and shock

______ pallor, cool moist skin, rapid breathing, cyanosis, rapid weak thready pulse, narrowing pulse pressure, low blood pressure, concentrated urine.

Shock:

Client has pain, edema usually in one leg Bed rest Contact Physician immediately After DXN; Placed on an Anticoagulant Prevention: Ted hose use intermittent devices ie: external pneumatic compression machine (SCDS or SCUDS) Early ambulation Adequate hydration

DVT) Thrombus in deep vein of leg

DVT _____, moves, and lodges in pulmonary circulation Client has chest pain, dyspnea, tachycardia bed rest, contact physician immediately, Prevention includes adequately treating DVT

dislodges

what are these?

scuds

Atelectasis Prevention Aspiration

respiratory complications from surgery

_______ is the closure or collapse of alveoli. Occurs frequently postop due to a shallow breathing pattern caused by anesthetic, pain medications and not taking deep breaths due to fear of pain.

Atelectasis

cough sputum production and low grade fever May be sever e and cause dyspnea, tachycardia, tachypnea, pleural pain and central cyanosis. Prevention - cough and deep breathe, instruct client to use incentive spirometry splinted cough

s/s atelectasis

what lung condition is associated with pneumonia?

atelectasis

Early in postop period PACU at risk for hypoxia due to hypoventilation and airway obstruction related to continued anesthetic effects. Their muscles are relaxed and the muscles of the pharynx are included. When the patient is on back the lower jaw and tongue may fall backward and the air passages become obstructed. Tile the head vback and push forward on the angle of the lower jaw. This pulls the tongue forward and opns air passage. They may come back with a plastic airway. Resp. difficulty may be caused by excessive mucous or aspiration of vomit. Turn to side. Elevate HOB if not contraindicated..

hypoventilation

Prevention - Aspiration how do we tell client to lay if they are not rid of heavy secretions

left side laying

The collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression. Causes include bronchial obstruction by secretions due to impaired cough mechanism or conditions that restrict normal lung expansion on inspiration. Postoperative patients are at high risk for ________

atelectasis

Symptoms are insidious and include cough, sputum production, and a low-grade fever. Respiratory distress, anxiety, and symptoms of hypoxia occur if large areas of the lung are affected.

s/s of atelectasis

What are nursing interventions associated with problems with anesthesia?

Urine Elimination might need a one time cath Bowel Elimination encourage them to move around

Discharge from PACU Based on:

Respirations Energy Alertness Circulation Temperature will discharge when theyre awake and alert, vitals are stable, and breathing alright.

when they get to med surge: check _________

breathing, check vitals, PULSE OX Airway (patent?) Breathing- Quality, pattern, rate, depth Using accessory muscles? Pulse ox? 0xygen? Rate and device? CV status: BP, pulse within patient’s baseline? Peripheral pulses? Heart rate/rhythm Mental status: How does it compare to prior to surgery? Respond to verbal stimuli? Temperature- Near preop range? IV fluids- What is infusing? How much is remaining? What is rate needed? What rate is it set on? Any tubes- If there are they draining appropriately and what does the draining look like? Surgical incision site- How is it dressed? How much drainage on dressing? Check under patient for further bleeding or drainage Drains present? If so are they set properly? look under the patient to make sure theyre not bleeding out

Airway (patent?) Breathing- Quality, pattern, rate, depth Using accessory muscles? Pulse ox? 0xygen? Rate and device? CV status: BP, pulse within patient’s baseline? Peripheral pulses? Heart rate/rhythm Mental status: How does it compare to prior to surgery? Respond to verbal stimuli? Temperature- Near preop range? IV fluids- What is infusing? How much is remaining? What is rate needed? What rate is it set on? Any tubes- If there are they draining appropriately and what does the draining look like? Surgical incision site- How is it dressed? How much drainage on dressing? Check under patient for further bleeding or drainage Drains present? If so are they set properly? look under the patient to make sure theyre not bleeding out

Upon arrival to med surg

________: the single most significant measure to prevent complications

AMBULATION

When caring for post op patient think of the 4 Ws

Wind: prevent respiratory complications Wound: prevent infection Water: monitor I & O Walk: prevent thrombophlebitis [i think she meant thrombosis or thromboembolism]

Effects of increased ADH & increased Aldosterone after Surgery

water and sodium retention(first 24 hours) After 24 hours, post-op diuresis can be sweaty and will urinate more and putting off a lot of fluid

Effects of increased ADH & increased Aldosterone after Surgery

unable to void 8-10 hour post op palpable bladder frequent small amount of voiding pain in suprapubic area

urinary retention which is a possible post op complication

What systems are usually affected if a post op complication occurs?

Urinary system Respiratory system GI system Wound -skin/musculoskeletal system circulatory system

s/s of pneumonia

s/s of atelectasis

What are respiratory complications that can occur post op?

pneumonia atelectasis

What are GI complications that can occur post op?

gastric dilation paralytic ileus

nausea & vomiting abdomen distention

s/s gastric dilation

decreased bowel sounds no stool or flatus nausea vomiting abdomen distention/tenderness

s/s paralytic ileus

What are complications that can occur with the wound/skin/musculoskeletal systems?

Infection Dehiscence evisceration

evidence of bowel through incision increased pain

s/s of evisceration

separation of incision

dehiscence

redness purulent drainage fever tachycardia leukocytosis

s/s of infection

what are possible post op complications associated with the circulatory system?

pulmonary emolism hypovolemic shock

decreased urine decreased bp weak pulse cool clammy restless increased bleeding increased thirst decreased CVP

s/s of hypovolemic shock

chest pain dyspnea increased resp rate tachycardia increased anxiety diaphoresis decreased orientation decreased bp blood gas changes

s/s of pulmonary embolism

What are post op complications associated with the urinary system?

urinary retention

unable to void 8-10 hours post op palpable bladder frequent, small amount of voiding pain in the suprapubic area

s/s of urinary retention

Home care preparation Health teaching Psychosocial preparation Health care resources

factors associated with discharge

is inserted to maintain patency of the duct and to promote bile passage, this is after a cholecystectomy

T-tube

______________________________________immediately after surgery nurses may have to empty every 15-60 minutes, with time every 2-4 hrs.

Jackson-Pratt (small Oval ) & Hemo-vac (accordion)

Document amount, color, consistency, and odor from the drain. If there is large amount notify the ______

physician

JP drain. Works by vacuum. Need to drain and then re-collapse before closing. Need to pin to gown so that they don’t pull.

hemovac

surgical wound pulled shut with sutures incision edges are well-approximated

Primary Intention:

- wound is gaping, irregular granulation tissue fills in , some scaring. DO we need to worry about infection?

Secondary Intention

– not sutured, tissue heals by granulation process usually a large scar.

Tertiary Intention

– clear or slightly yellow (serum plasma of blood) drainage

Serous

– thick reddish, contains red blood cells and serum drainage

Sanguineous

drainage – result of infection, contains white blood cell, tissue debris, bacteria, thick, color varies with causative organisms

Purulent

thin pink or light red drainage

Serosainguinous:

– separation of layers of incision wound

Dehiscence

– protrusion of body organs through area where incision cam apart( with the abdomen the intestines may protrude)

Evisceration

what is the protocol for wound evisceration?

An intervention would be to cover with sterile dressing soaked in sterile saline then call Dr. for surgical closure.

dehiscence

Evisceration This of course is emergent. An intervention would be to cover with sterile dressing soaked in sterile saline then call Dr. for surgical closure.

Adequate pain control Allows the client to participate in recovery and avoid ______

complications

Use a pain scale administer and evaluate med effectiveness Obtain alternate meds or routes if pain is ineffective Teach client how to splint incision with movement Ways to changing position that lessen pull on incision

pain control measures

Discharge Instructions Follow-up plans Home Care Wound Care Prescriptions Contact Person Follow-up Appointment

promotion of recovery post op

Also look at chart 20- 4 in your text about patient education on wound care Look at Chart 19 2 Homecare checklist for discharge and 19 3 for interventions immediately post surgery