QUIZ- preop and intraop Flashcards
preoperative=
from decision to have surgery up until transfer to the OR table
intraoperative=
from time patient is transferred to the OR table ends with admission to PACU
postoperative=
PACU admission to follow up evaluation in clinical setting or at home
emergent surgery…
without delay
urgent surgery…
within 24-30 hours
required surgery…
plan for a few weeks or months
elective surgery…
failure to have surgery is not catastrophic
risk factors for surgical complications?
- age (old and young)
- nutrition, dentition
- obesity
- immune function
- endocrine function
- fluid and electrolyte status
- pregnancy
- illicit drug use/alcohol
- smoking
- psychiatric/delirium history
common preoperative nursing diagnoses…
- risk of infection
- anxiety and fear
- risk of adverse physical response to anesthetics, medications
- risk of adverse outcomes related to risk factors
- improper consent process
preop planning
- patient will be physically and emotionally prepared for surgery
- risk factors will be identified and the surgical team will be made aware
- pre-op checks, paperwork and diagnostics will be complete and corrected
- risk for infection will be minimized
- patient will have knowlede related to surgery
preop interventions
- pt safety= primary concern
- provide preop teaching: expectations, post-op exercises
- complete paperwork, check consent
- re-confirm pt understands surgery
- attend to family needs
- bowel prep
- skin prep (chlorhexidine scrub)
immediate preop prep?
- complete checklist and chart
- hospital gown, voiding, removal of dentures, jewelry, contacts etc
- preop meds (lorazepam, antibiotics, anticoagulants
pre-op physicians orders include?
diagnostics, administer meds, initiate IV lines, complete pre-op skin care
pre-op evaluation?
- is pt physically and emotionally prepared for surgery
- any special risk factors accounted for?
- all preop paperwork and processes complete?
- skin prep and preop checklist complete?
- can pt explain surgery, expectations, exercises?
NPO guidleines?
depends on procedure and agency
- ex. peds: no solids after midnight, evening before surgery
aduls: no solids after midnight, clear fluids up to 3 hours prior to procedure
pre-op diagnostics?
- CBC
- electrolytes
- coagulation
- renal function
- glucose
- cross match if blood loss anticipated
- chest x ray
preop medications?
-IV started (sodium, potassium)
-anxiolytics, sedation (AFTER consent)
-antibiotics (1 hr pre or on call in OR)
gastric acid reduction (to prevent reflux/aspiration)
what are benzodiazepines used for?
- reduce anxiety
- induce sedation
- induce amnesia
- reduce anesthesia required
example of benzodiazepines?
- midazolam
- lorazepam
what are narcotics used for?
to relieve pain
examples of narcotics?
- morphine
- demerol
- fentanyl
what are gastric acid blockers and alkalinizers used for?
to increase pH
examples of gastric acid blockers/alkalinizers?
- pantoprazole
- sodium citrate
what are antiemetics used for?
decrease nausea and vomiting
examples of antiemetics?
ondansetron
dimenhydrinate
what are antibiotics used for?
prophylactic prevention of infection
example of antibiotic?
cefazolin
scrub nurse ROLE
scrub nurse prepares and maintains sterile tables with required equipment
- needs to anticipate what equipment and supplies will be required
- performs counts of supplies to ensure all accounted for
circulating nurse ROLE
manages OR and pt safety (positioning)
- verifies consent
- coordinates the team
- maintains environment
- documents throughout the procedure
- monitors pt
- second verification of surgical procedure
- performs counts of supplies to ensure all accounted for
RN first assistant?
more common in US, can assist the surgeon with the procedure (ex. cutting tissue, suturing, etc)
nurse anesthetist?
assesses patient
intubates patient
administers anesthetic meds and monitors pt throughout surgery
DEVELOPING in canada, more common in US
risk for longer surgeries for older patients risk?
prone for pressure injuries
surgeon role?
head of the surgical team! often a physician, performs the procedure dude!!
anesthesiologist role?
physician that has specialized
- assesses pt, intubates pt, monitors vitals
- adminsters anesthetics meds and monitors pt throughout surgery
what is the surgical safety checklist?
a checklist everyone has to follow to avoid error and mistakes in surgery, things can get left inside!!!
-hospitals may modify the tool
three parts of the surgical safety checklist?
- before induction of anaesthesia SIGN IN
- before skin incision TIME OUT
- before patient leaves operating room SIGN OUT
wht occurs in the sign in ???
right pt, site masked, anesthesia safety check, allergies
what occurs in the time out ???
confirm all team members introduce self, anticipated critical events, confirm the PT, SITE, PROCEDURE
what occurs in the sign out???
nurse verbally confirms w team: name of procedure, instruments, needle, sponge count are correct, specimen labeled
nursing diagnosis’s in surgery?
- risk for tissue injury
- risk for anaphylaxis
- risk for hypothermia
- risk for joint injury
- risk for hemorrhage
- risk for n&v
- risk for infection
- risk for malignant hyperthermia
- anxiety r/t surgery
INTRAOPERATIVE complications
- nausea and vomiting
- anaphylaxis
- hypoxia and resp complications
- hypothermia
- malignant hyperthermia
nursing goals during INTRAOP period?
reduce anxiety
- prevent positioning injuries
- maintain pt safety
- serve as pt advocate
- avoid complications: PRIMARY goal
protecting the pt from injury (things u do)?
- pt identification
- correct informed consent
- verification of records of health history and examination
- results of diagnostic test
- allergies (include latex)
- monitoring and modifying physical environment
- safety measures (grounding of equip, restraints, not leaving a sedated pt)
- verification and accessibility of blood
what is an anesthetic
med that incudes anesthesia
what is anesthesia?
CNS depression, loss of consciousness, loss of sensation
—-> can be general, regional, local
what is general anesthesia?
CNS nerve impulses altered leading to reduced pain, sensation, loss of consciousness and resp depression
general anesthesia meds can be:
inhaled (ex. nitrous oxide, isoflurane)
or
parenteral (ex. propofol)
balanced anesthesia?
it is common to combine drugs to allow for lower doses of each drug to be administered and better control of the anesthetised state
larger amounts of anesthesis are given…
at initiation, lesser during maintenance
general anesthesias SUMMARY
major or long surgeries
- UNCONSCIOUS
- potential cardiac, resp, renal, liver effects
- benefit: NO awareness of surgery
epidural SUMMARY
surgeries to lower body, c-section
- into epidural space surrounding dura mater of spinal cord
- conscious
- risks: hypotension, resp depression, infection risk, pruiritis
- benefits: no headache, safer for pt with cardiac and resp comorbidities, flexible-prolonged pain relief
spinal SUMMARY
surgeries to lower body short surgeries, C-section
- conscious
- pt lies on side in a knee to chest position
- risks: hypotension, spinal headache, resp complications, increased infection risk
benefits: safer for pt with cardiac and resp comorbidities, profound block
moderate (conscious) sedation SUMMARY
endoscopy, pediatric procedures
- SEMI conscious
- risk: resp depression
- benefit: patient compliance, amnesia
local SUMMARY
small surgeries like cyst removal, mole removal
-conscious
-limited risks
safe
what are adjunct anaesthetics
- “helper drugs” complement the use of other drugs
- used w general anaesthetics for induction . of anaesthesia or to counteract adverse effects
types of adjunct meds?
- neuromuscular blocking drugs
- benzodiazepines
- opioids
- anticholinergics
- antiemetics
- alpha2 adrenergic agonists
procedural/moderate sedation… tell me more
anesthesia that does not cause complete LOC
used mostly in office or out-pt settings
-pts maintain airway, can respond to verbal commands
-most common used drugs: midazolam w or w/out fentanyl
-rapid recovery time
-in peds: oral
regional/local anesthesia… tell me more
- types: central (spinal and epidural) or peripheral (infiltration, nerve block, topical)
- specific parts of body made insensitive to pain w/o major effects on CNS
- awake and aware
- may use lidocaine, bupivacaine etc
spinal anesthesia.. tell me more
often injected once, can be continuous infusion
- less med needed than epidural because it goes into CSF right around spinal cord
- L4/5 to ensure it is below spinal cord
- rapid acting (minutes)
- block sensory, motor, and autonomic functions
tell me more about epidural anesthesia!
can be performed anywhere along the vertebral colun and catheter often left in for continuous infusion
- larger amounts of med
- onset slower (has to diffuse through
- can block sensory, motor and autonomic functions
what is infiltration (as a local anesthesia)
small amounts injection to tissue (ex dental surgery)
nerve block (as a local anesthesia)
larger amount injected when a nerve innervates a specific area
topical (as a local anesthesia)
applied to skin/mucous membranes
pantaprazole is a…
GASTRIC acid blocker….
increases gastric ph, decreases gastric acid secretion
sodium citrate is a…
antacid, increases gastric pH
anticholinergics …
atropine, scopolamine
- decrease oral and resp secretions
- PREVENT BRADYCARDIA
mini med card on pantoprazole…
proton pump inhibitor
- give preop to pt at risk of aspiration
- inhibits gastric acid production and decreases gastric volume
- slower onset
- NURSING: assess epigastric, abdominal pain, frank/occult blood in stool/emesis, risk of C-diff infection
mini med card on sodium citrate
- alkalinizing agent (increase gastric pH)
- given preop to pt at risk of aspiration
- faster acting and preferred for emergency surgery
- NURSING: minimal as only getting one dose preop, if given ongoing could cause metabolic acidosis
mini med card on lorazepam (ativan)
type: benzodiazepine
use: adjunct anesthetic, reduce anxiety prior to surgery, produce amnesia
advantages: increases effects of anesthetics so less is required
NURSING: can cause dizziness, drowsy
mini med card on lidocaine
type: anesthetic
use: can be used as regional/local anesthetic (topical, epidural, spinal, nerve block)
NURSING: as epidural/spinal: can cause resp depression, bradycardia, CNS depression. as a topical: numbing, minimal side effects
mini med card on succinylcholine
type: neuromuscular blocking agent (muscle relaxant)
use: adjunct, relax skeletal muscles for surgery, for intubation
advantages: short duration, rapid onset
disadvantages: no effect on consciousness, pain. causes paralysis
NURSING: high alert med, can trigger malignant hyperthermia!!
mini med card on nitrous oxide
INHALED
-for short procedures (often dental)
often used with other agents
advantage: rapid onset and recovery
disadvantage: weak anesthetic, can cause hypoxia, poor relaxant
NURSING: use w other meds that are longeracting
-monitor for hypotension, bradycardia, decreased CO, NV
-watch for chest pain and STROKE
mini med card on isoflurane
INHALED
induction and maintenance of anesthesia
-rapid onset and recovery
-can increase effects of muscle relaxants!
DISadvantage: profound resp depression!!
NURSING: closely mintor reps, hypotension, transient tacycardia, malignant hyperthermia, n/v
most widely used IV anesthetic?
propofol
- indicated for general anesthesia
- causes CNS depression
- can cause death from resp arrest so monitor resp depress, hypotension, NARROW therapeutic range
preferred anesthesia in any surgery?
local anesthesia, but mya increase pt anxiety
what is malignant hyperthermia?
- rare inherited muscle disorder
- triggered by myopathies, emotional stress, heatstroke
- susceptible to those with strong bulky muscles and history of muscle cramps
- unexplained temp elevation!
hypothermia:
pt temp drop, glucose metabolism is reduced, metabolic acidosis may develop
- may occur bc of cold temp in OR
- core body temp of 36.6 or less
what is medullary depression
if too much anesthesia is given,
resps shallow, cyanosis, pupils will not contract, without prompt intervention—> death
beginning anesthesia:
pt breathes in mixture, may be conscious, noises are exaggerated
hazards of the surgery environment?
-faulty equipment or improper use, toxic substances, infectious wastes, cuts, needles, laser beams, unintentional retention of an object, exposure to blood and body fluids
key points about the surgical environment?
- strict aspesis
- central location to all supporting services
- special air filtration
- risk of fire always present
- unrestricted zones, restricted zone, and semi-restricted
- do not hang masks around neck
- room temp of 20-23 degrees, positive pressure reltive to adjacent areas
acute liver disease is associated with
high surgery mortality bc liver is significant in metabolizing anesthesia
aspirin and surgery>
stop it 7-10 days before
stop taking natural health products 2-3 weeks before as well
pt who smoke and surgery?
urged to stop 4-8 weeks before to reduce pulmonary and wound healing complications
elder considerations?
- physiologic reserve
- resp and cardiac complications are leading cause of post op morbidity
- reserves lower, renal and hepatic functions depressed, GI reduced
- dehydration, malnutrition, decreaased ability to perspire
obese pt considerations?
increases risk
- dehiscence of wound more popular
- more demand on heart
- shallow resps when supine
- increased risk of hypoventilation
- sleep apnea
ambulatory surgery?
same day surgery outpatient, no overnight stay
optional surgery?
patient can decide whether or not to have it, cosmetic surgery
examples of emergent surgery
severe bleeding, bladder or intestinal obstruction, stab or wound, fractured skull
urgent surgery example
acute gallbladder infection, urethral or kidney stones
