Practice questions Flashcards
- As part of his preoperative care, the surgeon has requested that Joseph shower using an
antimicrobial pre-op wash solution. How would you explain the rationale behind these aspects of
preoperative care to Joseph? Try to keep the explanation in lay-person terms.
Reduces the bacterial count on the skin therefore less risk of infection postoperative. Before surgery, you can play an important role in your own health. Because skin is not sterile, we need to be
sure that your skin is as clean as possible. Your skin will be prepared with antiseptic
before your surgery, but the antiseptic can work better if your skin is clean.
- Whilst checking Joseph’s paperwork for theatre, you see that his consent still needs to be signed.
What action do you take? How do you know if this is a valid consent? What are the different ways that consent is given?
Ensure valid consent
Ask the client what they understand to be involved
Recognise the patients may be overwhelmed with information and provide brochures, diagrams,
videos
Provide time for questions
Restate or repeat information
Valid Consent Consent given:
–freely & voluntarily given
–properly informed
–person giving the consent has the legal capacity to give such a consent
–relates only to the specific procedure consented
Informed consent –Nature –What is the operation –How will it be performed –Expectation of pre, intra and post-operative progress –Consequences –Outcomes? Success? –Risks –in broad terms to meet consent requirements –Alternatives to surgery
Ways consent can be given
- Implies
- Verbally
- In writing
- You also notice that Joseph’s admission paperwork is incomplete. In particular, the discharge
planning section is yet to be filled in and discussed with the patient, i.e. his transition of care
processes have not been completely processed. What is your responsibility as his nurse in planning
for his discharge?
Communication Co-ordinating discharge planning (transition of care) Anticipation & prevention of complications - monitoring physiological state (observations) Nutrition & hydration Personal hygiene & dressing needs Elimination Pressure area care Positioning & movement Medication
- Outline the strategies for best practice in the transition of care, as set out by the Clinical Excellence
Commissionc
It is about care co-ordination.
Planning from admission to transfer of care in NSW public hospitals includes a number of steps and
is now mandatory:
Pre-admission/admission ( information gathered can include answers to the following
questions: does the patient live alone or/and have caring responsibilities for someone
else, has the patient used community services, is the patient at risk of falls and have
their medications changed recently? )
MDT review
Estimated date of discharge
Referrals & liaison for patient transfer of care
Transfer of care out of hospital (checklist)
Transfer to home/community / GP
- What are the main areas of breakdown that can cause an adverse event related to transitions of
care?
Communication – handovers are not timely or effective, reliance on secondary sources of
information
Patient education – patients and families/carers are given different or conflicting
recommendations with confusing medication regimes.
Accountability – different expections of senders and receivers of information.
- Joseph has medications to be administered at 0800hrs. When examining his medication order, how
do you know that it is indeed a valid order, prior to dispensing the medications and doing your
three checks? What are ‘the 5 rights’ of medication administration, and when do you perform the
3 checks?
Valid Order -Prior to administering a medication you must check if the medication order meets the
legal requirements:
o Written or printed in ink
o Signed by prescriber
o Full name of recipient (medical record number), medication, dosage, route and frequency
o Instructions for adequate use
o Detail the number of times the drug may be dispensed or the time between repeated
administrations
Accountability and responsibility Check allergies Ensure documentation Safe medication administration -1. Right medication -2. Right dose -3. Right patient -4. Right route -5. Right time/frequency Prior to administering any medication, it is essential that you follow the 5 rights of medication administration before the medication is given to the patient
The 5 rights are checked 3 times
- 1st time: prior to dispensing the medication
- 2nd time: after dispensing the medication
- 3rd time: immediately prior to administering medication to patient
- What does the term ‘Time Out’ mean in the intraoperative environment?
= “an immediate pause by the entire surgical team to confirm the correct patient, procedure, and site,”
- confirm team members have introduced themselves and role
- Surgeon, anaesthesia and nurse verbally confirm patient, site and procedure
- Surgeon reviews what critical steps are
- anaesthesia team reviews any patient concerns
- nursing team reviews sterile and equipement issues
- Has antibiotic prophylaxis been given in last 60 mins
- What types of oral medications cannot be crushed prior to administration?
Modified release medicines
Enteric coated medicines
film or sugar coated medicines
Hormonal cytoxic or steroidal medicines
- Joseph has an on-call pre-medication charted before going to theatre. The Anaesthetist calls the
ward and you are to administer his Temazepam 10mg PO STAT. The nurse in charge informs you
that this is an ‘S4 appendix D medication’. What does this mean? What implications will this have
for safe medication administration?
Schedule 4 Appendix D and Schedule 8 are defined as ‘accountable medications’
Schedule 4 Appendix D (S4D) drugs are those Schedule 4 drugs that are liable to abuse and include
benzodiazepines, ephedrine and anabolic steroids.
S4D drugs must be stored apart from all other drugs (except
Schedule 8 drugs) in a separate sturdy
cupboard, preferably a metal safe, which is securely attached to a wall or to the floor, and kept
locked when not in immediate use.
- You have transferred Joseph to the pre-op area and handed over to the nurse there. Regarding
intraoperative safety, discuss the stages of the WHO surgical safety checklist.
The checklist identifies three phases of an operation, each corresponding to a specific period in the
normal flow of work: Before the induction of anaesthesia (“sign in”), before the incision of the skin
(“time out”) and before the patient leaves the operating room (“sign out”).- see question 7
- What are the systemic considerations in relation to respiratory, cardiac and musculoskeletal
systems that the operating room nurse needs to be aware of throughout Joseph’s operation?
Respiratory a. Positioning may impede b. Hindered diaphragmatic movements c. Pre-existing resp conditions d. Smokers, obese, pregnancy Cardiovascular e. Anaesthetic agents f. Pooling of blood g. Pregnancy risk h. Occlusion or pressure i. VTE Musculoskeletal j. Lack of protective mechanisms k. Overstretched, twisted, strained or hyperextension of limbs l. Osteoporotic or previous joint surgery pts m. Maintenance of body alignment
- Joseph returns to the ward from recovery at 1600hrs. What assessments will you need to perform
in this postoperative period, both generally for any post-operative patient, and specifically for
Joseph and the type of surgery he has just had?
Airway: Patent/compromised
Breathing: rate, depth, SpO2
blood gas analysis, auscultation of chest
– Circulation: HR, BP, capillary refill, pallor, urination, any signs of bleeding,
– Disability: neurological signs, Glasgow Coma Scale, AVPU
– Exposure: check patient head to toe
– Fluids: fluid regime/balance
– Glucose
Check cardiac monitor, chest drain, wound intact
- As part of your initial A-G assessment, you observe that Joseph has oxygen therapy in progress at
2L/min via nasal prongs. Why does he require oxygen therapy? What are the advantages and
disadvantages of administering oxygen therapy via nasal prongs?
(a) Nasal cannula:
It is ideal for long term oxygen therapy. It does not increase dead space and there is no rebreathing.
Flow rate of 2-4
L/min is recommended as higher flow rate (>5L/min) can result in discomfort of the patient.
Advantages
- Easy to use
- Low-flow oxygen administration
- Less restrictive than face mask
- No increase in dead space
- More tolerable than oxygen mask
- Allow speech and eating/drinking
Disadvantages
- Drying and irritation of nasal mucosa
- Chance of nasal bleeding
- Sores around the external nares in long term use
- What is an advantage of using the venturi mask for oxygen therapy?
Venturimasks are colour coded and it states the flow of oxygen in litres per minute required to deliver
a specific inspired oxygen concentration. Holes on the Venturi device allow entrainment of room air
by the Venturi principle. These holes also flush expired gas. Advantages of using Ventimask include
very precise measurement of delivered oxygen and no rebreathing. However, the mask is hot and
may irritate the skin. Oxygen concentration may lower by kinking the tubing.
- Joseph returns to the ward with a morphine PCA in progress. Joseph complains that he is in “a lot
of pain in my right knee”. He falls asleep intermittently whilst you are still performing your postoperative assessment. How would you educate Joseph about his PCA and how it works? What
specific assessments must you perform when a patient has a PCA in progress? How do you assess
sedation?
PCA adult observations chart
- pain
- sedation
- RR
- Oxygen therapy
- PCA delivery : good tries, bad tries, total, background infusion
- N and V
