SURGICAL CLIENT & ERAS Flashcards
1
Q
Name the components of the ABCSDEF prioritization framework
A
Airway
Breathing
Circulation
Safety
Discomfort
Education
Feelings
2
Q
Name the 5 levels of Maslow’s hierarchy of needs
A
- Physiological
- Safety
- Love, belonging
- Self esteem
- Self actualization
3
Q
What are 4 examples of pieces of information to ensure to get during report to determine the patient’s acuity level?
A
- Preoperative health status
- Comorbidities
- Emerg vs elective surgery
- Length and type of surgery
4
Q
What are 5 examples of ways surgery could affect the patient’s airway?
A
- Intubation/extubation
- Anaphylaxis
- Inflammation
- Sedation
- Surgery of the neck/face
5
Q
What are 4 examples of ways surgery could affect the patient’s breathing?
A
- Aspiration
- Medication (esp. opioids)
- Pain or decreased LOC
- Fluid overload > pulmonary edema
6
Q
What are 3 examples of ways surgery could affect the patient’s circulation?
A
- Blood loss
- Fluid overload > hypertension
- Thrombosis
7
Q
When should hyperthermia postoperatively be a concern?
A
After 48 hours postop, especially if >38 deg
8
Q
What are 2 causes of postop ileus?
A
Anesthesia
Manipulation
9
Q
What are 2 signs of postop ileus?
A
Firm abdomen
Vomiting bile
10
Q
What are 2 interventions for postop ileus?
A
NG insertion and encourage mobilization until pt passes gas
(Bowel protocol may be contraindicated until pt passes gas, depends on policy)
11
Q
What rate of urine output is desireable postop?
A
~30 ml/h
12
Q
What are 4 main components of clinical pathways?
A
- Timeline
- Categories of care
- Outcome criteria
- Variance record
13
Q
What are 5 advantages of clinical pathways?
A
- Collaborative practice
- Tracking
- Reduce unecessary variations
- Decision support
- Evidence-informed best practice
14
Q
What are 6 core principles of ERAS (enhanced recovery after surgery)?
A
- Patient and family engagement
- Nutrition management
- Fluid/hydration management
- Multi-modal opioid sparing analgesia
- Perioperative best practices (e.g. SSI, HAP, CAUTI, VTE)
- Mobilization
15
Q
The stress response causes changes in which 6 physiological areas?
A
- Oxygen consumption
- Metabolic
- Fluid shifting/retention
- Immunity
- Coagulability
- GI motility
16
Q
What are 3 guidelines for preoperative fasting under ERAS?
A
- Clear liquids up to 2 hrs before surgery
- Light meal/milk up to 6 hrs before surgery
- Additional fasting time after eating fried/fatty foods or meat
17
Q
Under ERAS, how soon preop should carbohydrate rich drinks be ingested?
A
Up to 2 hours
18
Q
What are 3 advantages of preoperative carbo loading?
A
- Avoids catabolic state
- Increases insulin sensitivity
- Decreases risk of post-op hyperglycemia
19
Q
What are 3 advantages to early oral intake postoperatively?
A
- Sooner discontinuation of IV fluids
- Stimulates GI motility
- Lower incidence of SSI
20
Q
What are 2 guidelines to progressing the patient’s diet postoperatively?
A
- Sips of clear fluid 2 hrs post-op
- Offer regular diet POD1
21
Q
What is the general CBG target for all postoperative patients?
A
<10 mmol/l
22
Q
What are 3 reasons hypervolemia be avoided postoperatively?
A
- Cardiopulmonary complications
- Bowel complications (e.g. anastomotic leak, impaired GI motility)
- Tissue hypoperfusion (poor wound healing, SSI)
23
Q
Which IV fluid should be avoided in postoperative patients?
A
Normal saline
24
Q
Which assessment value should not be the sole basis for ordering an IV bolus?
A
Urine output
25
Name the components of the I-COUGH acronym
I: Incentive spirometry (10x/hr)
C: Cough and deep breathe
O: Oral care (2x/day)
U: Understanding (patient education)
G: Get out of bed
H: Head of bed elevated
26
Foley catheters should generally be removed when postoperatively?
POD1 in am
27
If the nurse decides not to remove the Foley in the first 24 hrs, what needs to be provided?
Rationale
28
What is the guideline for mobilization preoperatively?
Dangle at the bedside or get up to the chair for 2 hrs
29
What are 2 guidelines for mobilization postoperatively?
1. Up in chair for all meals
2. Ambulate/get out of bed for at least 6 hr/day
30
What are 2 principles to prevent surgical site infection?
1. Early removal of drains/tubes
2. Follow physician's orders for dressing changes
31
According to WHO, what are 5 precautions to take pre and post-op to prevent infection?
1. Bathe/shower
2. Do not shave
3. Use antibiotics sparingly
4. Use chlorhexidine skin prep
5. Wound care/monitoring
32
What are 4 reasons postoperative nausea/vomiting should be prevented?
1. Airway compromise
2. Aspiration pneumonia
3. Fluid/electrolyte imbalance
4. Stress on incision
33
Besides pain, infection, or drug side effects, what are 6 possible underlying causes for postoperative nausea/vomiting?
1. Hypovolemia
2. Hypotension
3. Hypoxia
4. Hyper or hypothermia
5. Hunger
6. Oral hygiene
34
What are 5 characteristics of concerning pain?
1. Increasing
2. New onset
3. Change in character
4. Change in location
5. Not getting batter
35
Surgical trauma may cause what state in the patient, which may be the root cause for chronic pain syndrome?
Neuroplasticity/spinal sensitization
36
What are 3 advantages to using multi-modal opioid sparing analgesia?
1. Max analgesia
2. Lower doses
3. Lower risk of side effects
37
Which route is not recommended for postoperative pain management?
Intramuscular
38
What are 2 contraindications to using NSAIDs?
1. Certain comorbidities
2. GI anastomosis
39
What are 2 examples of weak opioids, and what kind of pain are they used to treat?
Codeine and tramadol; mild to moderate pain
40
What are 7 criteria for discharge?
1. Mobilizing well
2. Adequate oral intake
3. Normal urinary function
4. Pain control
5. Afebrile
6. Patient comfortable with discharge
7. Patient teaching complete
41
What is the term for local anesthetic injected into the CSF in the subarachnoid space below L2?
Spinal anesthesia
42
What level of blockade is achieved with spinal anesthesia?
Autonomic, sensory, and motor
43
Autonomic blockade results in what outcome in the patient?
Vasodilation, hypotension
44
What kind of procedures typically use spinal anesthesia?
Abdominal, lower extremities, back
45
What is the term for local anesthesia injected into the epidural space that binds to the nerve roots?
Epidural anesthesia
46
What level of blockade is achieved with epidural anesthesia?
Sensory and motor (amount controlled by anesthesiologist)
47
What kind of procedures typically use epidural anesthesia?
Maternity, knee/hip replacements
48
Between spinal and epidural anesthesia, which mode has a faster onset of action?
Spinal anesthesia
49
Between spinal and epidural anesthesia, which mode has a higher risk of post-anesthesia headache?
Spinal anesthesia
50
What is the term for sedatives administered intravenously with or without analgesia, resulting in the client being conscious but with reduced anxiety?
Procedural sedation
51
For patients who have received procedural sedation, what must be assessed immediately upon arrival back to the unit?
ABCs and LOC
52
What are 5 examples of procedures that may use procedural sedation?
1. IR
2. Endo
3. Wound debridement
4. CVC or chest tube insertion
5. Dental
53
What is the mechanism of action of ondansetron?
5-HT3 receptor antagonist
54
How is ondansetron administered?
IV intermittent or push
55
What are 2 adverse effects of ondansetron?
Drowsiness, heart dysrhythmias
56
What is the mechanism of action of ibuprofen?
Prevents synthesis of prostaglandins by inhibiting COX-1 and COX-2
57
How does acetaminophen work as an antipyretic?
Works on hypothalamus
58
What is the mechanism of action of gabapentin when used to treat pain?
Binds to gabapentin receptors in the brain
59
How is gabapentin usually administered?
Oral
60
What is another example of a gabapentinoid?
Pregabalin
61
Why is pulse oximetry not a first line indicator of opioid induced respiratory depression?
1. Resp depression may be masked by O2 administration
2. SpO2 readings may remain normal for minutes after patient stops breathing
62
What should be avoided when assessing a client's LOC?
Patient stimulation
63
What are 3 ways opioids cause respiratory depression?
1. Depress respiratory effort/rate
2. Relax pharyngeal tone
3. Depress response to hypoxia/hypercarbia
64
What is the mechanism of action of hydromorphone?
Mu-receptor agonist; blocks ascending pain pathways
65
How is hydromorphone administered?
All routes; however IM not recommended
66
What patient comorbidity should be considered when administering hydromorphone?
Renal dysfunction
67
What is the mechanism of action of morphine?
Agonist-analgesic of opiate receptors; blocks ascending pain pathways
68
How is morphine administered?
All routes except IM
69
Which 2 adjuvant drugs act as non-competitive NMDA receptor antagonists?
Ketamine, magnesium
70
Which adjuvant drug is an alpha-2 adrenergic agonist?
Clonidine
71
Which non-pharmacological treatment is used to treat postoperative nausea and vomiting?
P6 acupoint (below wrist in between 2 tendons)
72
What airway complication is a concern for patients who were intubated in the OR?
Laryngospasm/laryngeal edema
73
What is generally the desired systolic BP for postoperative patients?
90-160
74
What is generally the desired heartrate for postoperative patients?
60-120
75
When considering pulse pressure (difference between systolic and diastolic BP readings) what finding would be a cause for concern?
Narrow pulse pressure
76
During the first 48hrs post-op, what is an expected temperature finding?
Mild elevation (<38)
77
What temperature reading would be concerning more than 48 hrs post-op?
>37.7
78
When is postoperative ileus considered as paralytic ileus?
2-3 days post-op
