Perioperative stages

Question 1

preoperative start and end

Answer 1

begin- agree to surgical intervention
end- transfer of pt onto OR bed
can include 2 wks before actual surgery
best time for education!!

Question 2

intraoperative start and end

Answer 2

start- transfer to OR
end- admission to PACU (post-anesthesia care unit)

focus on safety (positioning, med admin, infection control, vital signs (temp)

Question 3

postop start and end

Answer 3

start- admission to pacu
end- follow up eval in clinical setting or home

goals- pain management, airway

Question 4

preadmission testing

Answer 4

Initiates the nursing process
Admission data: demographics, health history, other information pertinent to the surgical procedure
Screening for complications (cardiac, pulmonary etc)
Verifies completion of preoperative diagnostic testing
Begins discharge planning by assessing patient’s need for postoperative care

Question 5

factors to monitor pre-op

Answer 5

oral intake 1h prior (aspiration risk)
allergy to latex (anaphylaxis, common allergies= banana, kiwi, avocado)
anticoag/herbals (inc bleeding risk)
bleeding episodes (risk hypoxia)
alcohol (withdrawl- delerium tremens, nutritonal state (dec healing, anemia, liver failure))
htn (inc risk cva/mi)
renal failure (drug accum, inc ammonia lvls)
smoking (delayed wound healing, inc risk pneumonia and respir failure)

Question 6

smoking recommendation for surgery

Answer 6

Will not perform surgery until cessation lasted at least month (optimize respir func and wound healing due to vasoconstriction)

Question 7

warfarin bridging

Answer 7

use low mol. Weight heparin (short 1/2 life) start right before surg and stop after to dec risk of stroke while not taking regular prescribed warfarin

Question 8

pre-op assessment

Answer 8

med use hx
immune function
endocrine (diab d/t impaired wound healing)
allergies
health hx
dentition (intubation)
drug/etoh use
respir/cardiovasc status- (detect hx Mi, shows irreg heart rhythms)
hepatic/renal function
fluid status
nutritional status

Question 9

anticoagulants and surgery

Answer 9

stop aspirin 7-10 days before surgery (bridging if needed)

Question 10

geriatric considerations

Answer 10

Cardiac reserves are lower
Renal and hepatic functions are depressed
Gastrointestinal activity is likely to be reduced
Respiratory compromise
Decreased subcutaneous fat; more susceptible to temperature changes
May need more time and multiple explanations to understand and retain what is communicated restrictions

Question 11

obesity consid

Answer 11

Risk of infection
Increased cardiac and oxygen demand w/ dec reserves
Poor wound healing incl dehiscence 
Hypoventilation
Inc tissue= inc pressure on lungs
Inc difficulty when intubating (girth)

Question 12

informed consent

Answer 12

Autonomous- voluntary decision
Incl blood product, radiation (anything w/ serious risks)
Should be in writing before nonemergent surgery
Legal mandate
Surgeon must explain the procedure, benefits, risks, complications, etc
Nurse clarifies information and witnesses signature
Consent is valid ONLY when signed before administering psychoactive premedication (sedation)
Consent accompanies patient to OR

Question 13

pre-op nursing intervention examples

Answer 13

Providing patient education
Deep breathing, coughing, and incentive spirometry
Mobility and active body movement
Pain management
Providing psychosocial interventions
Reducing anxiety and decreasing fear
Respecting cultural, spiritual, and religious beliefs
Maintaining patient safety
Managing nutrition, fluids
Preparing the bowel
Preparing the skin
Patient marks own surgical site, confirmed before operation (bilateral)

Question 14

surgical team roles

Answer 14

Circulating nurse
Not scrub in, monitor vs, gathering supplies
Scrub role
Surgeon
Registered nurse first assistant
Anesthesiologist, anesthetist 
Note: role of nurse as patient advocate
Proactive!

Question 15

prevention of infection

Answer 15

Surgical environment
Unrestricted zone: street clothes allowed
Semirestricted zone: scrub clothes and caps
Restricted zone: scrub clothes, shoe covers, caps, and masks
Surgical asepsis
Environmental controls
Air circulation 15/hr dec risk infection
Ortho surgeries highest risk- not want infection in joint cavity

Question 16

surgical asepsis guidelines

Answer 16

All materials in contact with the surgical wound or used within the sterile field must be sterile (BLUE)
Gowns considered sterile in front from chest to level of sterile field, sleeves from 2 inches above elbow to cuff
Sterile drapes are used to create a sterile field. Only top of draped tables are considered sterile
Items dispensed by methods to preserve sterility
Movements of surgical team are from sterile to sterile, from unsterile to unsterile only
Movement at least 1-foot distance from sterile field must be maintained
When sterile barrier is breached, area is considered contaminated
Every sterile field is constantly maintained, monitored
Items of doubtful sterility considered unsterile
Sterile fields prepared as close to time of use
The routine administration of hyperoxia (high levels of oxygen) is not recommended to reduce surgical site infections

Question 17

intraop complications

Answer 17

Anesthesia awareness
Seems sedated but has sensory abilities (hearing)
Nausea, vomiting
Risk aspiration
Turn head to side, suction, antiemetics
Anaphylaxis
Med interactions, latex
Epinephrine, antihistamine, H2 blockers
Hypoxia, respiratory complications
d/t anesthesia
Supp O2, prevent aspiration (positioning)
Hypothermia
Esp w/ elderly
<98 degrees
Warm blankets, warm IV fluid
Infection
Prevent surgical asepsis, prophylactic antib, dec #ppl in room
malignant hyperthermia

Question 18

malignant hyperthemia

Answer 18

Rare- autosomal dominant disorder
Anesthesia induced
Hypermetab state, core body temp inc > 107 degrees, altered mech Ca in skel musc, inc musc contractions, tetany, rigidity
First signs- tachycardia 
risk- genetics, bulky muscles

Question 19

ae surgery

Answer 19

Allergic reactions, drug toxicity or reactions
Cardiac dysrhythmias
CNS changes, oversedation, undersedation
Trauma: laryngeal, oral, nerve, skin (pressure injuries), including burns
Hypotension
Thrombosis

Question 20

gerontologic complication considerations

Answer 20

Older adult patients are at higher risk for complications from anesthesia and surgery compared to younger adult patients due to several factors:
Age-related cardiovascular and pulmonary changes
Decreased tissue elasticity (lung and cardiovascular systems) and reduced lean tissue mass
Decreases the rate at which the liver can inactivate many anesthetic agents
Decreased kidney function slows the elimination of waste products and anesthetic agents
Impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms

Question 21

general anesthesia v regional

Answer 21

general- inhalation and intravenous (cns depression- need airway assistance)

regional- nerve blocks, specific to area
inc. epidural and spinal

Question 22

patient safety intraoperatively

Answer 22

Monitoring, modifying physical environment
Safety measures (grounding of equipment, restraints, not leaving a sedated patient)
Verification, accessibility of blood
Patient identification
Correct informed consent
Verification of records of health history, exam
Results of diagnostic tests
Allergies (include latex allergy)

Question 23

intraop interventions

Answer 23

Reducing anxiety
Reducing latex exposure
Preventing perioperative positioning injury, refer to Figure 18-5
Protecting patient from injury
Ex. Pressure ulcers, peripheral nerve injuries (compression), vascular compression
Inc risk- low weight and obese
Serving as patient advocate
Monitoring, managing potential complications

Question 24

positioning factors- intraop

Answer 24

Patient should be as comfortable as possible
Operative field must be adequately exposed
Position must not obstruct/compress respirations, vascular supply, or nerves
Extra safety precautions for older adults, patients who are thin or obese, and anyone with a physical deformity
Light restraint before induction in case of excitement

Question 25

PACU care management

Answer 25

Provide care for patient until patient has recovered from effects of anesthesia
Resumption of motor and sensory function
Oriented
Stable VS
Shows no evidence of hemorrhage or other complications of surgery
Vital to perform frequent skilled assessment of patient
Assess airway, respiratory function, cardiovascular function, skin color, level of consciousness, and ability to respond to commands
Reassess VS, patient status every 15 minutes or more frequently as needed

Question 26

post op pt assessment in pacu

Answer 26

Respiratory 
Cns depression, airway obstruction
Pain
Mental status/LOC
General discomfort

Question 27

maintaining patent airway

Answer 27

Primary consideration: necessary to maintain ventilation, oxygenation
Provide supplemental oxygen as indicated
Assess breathing by placing hand near face to feel movement of air
Keep head of bed elevated 15 to 30 degrees unless contraindicated
May require suctioning
If vomiting occurs, turn patient to side

Question 28

maintaining cardiovasc stability

Answer 28

Monitor all indicators of cardiovascular status
Bp (systolic <90), hct/hgb, cardiac rhythm, skin color, urinary output, LOC
Assess all IV lines, dressings
Potential for hypotension, shock
Potential for hemorrhage
Potential for hypertension, dysrhythmias
Refer to Table 19-4
Report if Bp drop 5mmHg every 15min

Question 29

s/s hypovolemic shock + hemorrhage

Answer 29

Pallor
Cool, moist skin
Rapid respirations
Cyanosis
Rapid, weak, thread pulse
Decreasing pulse pressure
Low blood pressure
Concentrated urine

Question 30

controlling n/v

Answer 30

Prevent aspiration, tolerate food, have adeq nutrition for good wound healing
Intervene at first indication of nausea (better prevent than play catch up)
Medications
Assessment of postoperative nausea, vomiting risk, prophylactic treatment

Question 31

post op complications

Answer 31

Pulmonary infection/hypoxia
IS, coughing and deep breathing
Symptomatic of atelectasis, diminished b sounds– fine crackles that clear w/ coughing or deep b
Deep vein thrombosis/PE
Early ambulation, leg exercises, SCD’s, LMWH
Hematoma/hemorrhage
If bandage soaked through, apply pressure and secure dressing- call surgeon
Infection
Wash hands, aspectic wound care
Wound dehiscence or evisceration
Evisceration- wet sterile dressing, secure site, notify surgeon, change position (15-30 degrees)= dec pressure on abdomen