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NUC0920 SOT160 > Surgical Information & Pre-Op > Flashcards

Surgical Information & Pre-Op Flashcards

1
Q

List 9 reasons why a patient would have surgery:

A
  1. Further explore the condition for the purpose of diagnosis.
  2. Take a biopsy of a suspicious lump
  3. Remove diseased tissues or organs
  4. Remove an obstruction
  5. Reposition structure to their normal position
  6. Redirect channels
  7. Transplant tissue or whole organs
  8. Implant mechanical or electronic devices
  9. Improve physical appearance
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2
Q

List the OR records to file Post-Op in the correct order:

A
  1. Consent to Surgical Procedure
  2. Nursing Unit Pre-Op Checklist
  3. Anesthesia Record Sheet
  4. Perioperative Nursing Record
  5. OR Count Sheet
  6. Physician’s OR Report
  7. Post Anesthetic Recovery Room Record

*6 and 7 could be interchangable depending on what is completed first.

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3
Q

Why would a consult be ordered?

A

The attending Physician may want to have the opinion of another doctor regarding the diagnosis and treatment of a patient.

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4
Q

What is a “Surgical Consent Form”?

A

The patient must sign a consent to surgical/investigative procedure authorizing the surgeon to carry out the surgical/investigative procedure.

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5
Q

What is the purpose of the “Preop checklist/OR check off list”?

A

The checklist is completed by the RN to insure all pre-operative tests and procedures have been done and the patient is prepared and ready for surgery.

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6
Q

What is the purpose of the “Aesthetic record”?

A

Is used by the Anesthetist to record in their observations and record all medications given to the patient during surgery.

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7
Q

What is the purpose of the “Surgical Count Sheet/or Count Sheet”?

A

To record all instruments used during a surgical procedure and account for all instruments following the surgery. The form is completed by the operating room nurse.

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8
Q

What is the purpose of the “Perioperative Nursing Record”?

A

Used by the OR nurse to record all information relevant to the surgical procedure, before, during and after the procedure is completed.

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9
Q

What is the the “Physicians Operation Record (followed by transcribe report)”?

A

Report detailing all aspects of the surgical procedure from start to finish, who was involved, findings, etc.

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10
Q

What is the purpose of the “Post Anaesthetic Recovery Room (PACU) Record”?

A

The PARR RN will record all observations, medications given and progress of the patient in the recovery room.

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11
Q

What is the purpose of the “Post-Surgical Ward Assessment”?

A

Completed by the RN when the patient returns to the nursing unit post op from the recovery room. They record all patient vitals and observations.

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12
Q

What is the purpose of the “Fluid Balance Record”?

A

Record used by the RN for monitoring all patient fluid intake and outputs during their surgical procedure and hospital stay.

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13
Q

What is the “Surgical Pathology Report”?

A

A report detailing specimen collected information that may have been removed from the patient during surgery and requires Pathological investigations.

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14
Q

What is a “Blood Transfusion Consent”?

A

Consent signed by the patient to allow transfusion of blood and/or blood products if it becomes necessary during the course of the patient’s treatment.

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15
Q

What is a “Refusal for Blood Transfusion” form?

A

Form signed by the patient refusing the administration of blood and/or blood products during the course of their treatment.

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16
Q

What is the “Blood Administration record”?

A

Record used to record all blood/blood product administered during the patient’s surgical procedure or hosptial visit.

17
Q

What is the OR Slate?

A

Schedule of surgeries usually received by the unit the day before the surgery.

18
Q

What information does the OR slate provide?

A
  • patient’s name
  • patient’s age
  • time of surgery
  • diagnosis
  • surgical procedure being performed
  • name of surgeon performing the procedure
  • anesthetist
  • family GP
  • allergies
  • any pertinent information/requests related to the procedure.
19
Q

What are Pre-Op Order?

A

Orders written by the doctor before surgery to prepare the patient for their sugical procedure.

20
Q

List 7 types of pre-operative orders:

A
  1. Lab orders
  2. Diagnostic orders
  3. Dietary prep orders
  4. Skin prep orders
  5. Bowel prep orders
  6. Pre-op medication orders
  7. Consult orders - such as Anaesthetist/Internal
21
Q

What are the most common ordered pre-op lab tests? What else is commonly ordered?

A

CBC, Lytes, Urea, Creatinine, INR and PTT.

Also Urinalysis and Group & Screen and Crossmatch.

22
Q

How long are pre-op lab results valid for?

A

30days prior to the day of surgery for patients who have no prior medical issues.

23
Q

How long are pre-op ECG results valid for?

A

90days prior to day of surgery for patients who have no prior medical/cardiac issues.

24
Q

Which section is Parenteral Therapy recorded under on the Kardex?

A

IV section of Kardex

25
Q

Why are IV’s started prior to surgery?

A
  • to ensure patient does not become depleted
  • to ensure IV site access is obtained prior for administration of pre-op medications
  • for any IV medications that may be administered during surgery
26
Q

What is the purpose of skin prep orders prior to surgery?

A

Patients skin must be cleaned prior to surgery to help prevent post-op infections. All patients require a shower or bath proir to their surgical procedure.

27
Q

Where are the skin prep orders recorded on the Kardex?

A

under the personal hygiene or treatment section

28
Q

Why are patients limited to food/fluid intake prior to surgery?

A

To ensure there is no danger of regurgitation and possible aspiration during the procedure.

29
Q

How long must a patient consume clear fluids only if they are scheduled for bowel surgery?

A

48hrs

30
Q

Where are bowel prep orders recorded on the Kardex?

A

elimination section or treatment section

31
Q

Why would the surgeon consult the Anesthetist, Internal Medicine or Cardiologist Specialists prior to surgery?

A

To ensure the patient is stable for surgery.

32
Q

What types of diagnostic tests would be ordered pre-op?

A

CXR

US

ECG

33
Q

List 3 guidelines for anesthesia for most surgical procedures:

A
  1. all patients with diabetes who are over 40 years old
  2. all patients with signs or symptoms of cardiovascular disease
  3. all patients over 40 who smoke or have a significant family history of cardiovascular disease
  4. patients with any significant medical condition
  5. patients on medications with cardiac toxicity
  6. all patients coming for intrathoracic, intraperitoneal or major orthapaedic surgery and over 40 years old
  7. all patients over 60 years old for general anesthesia
34
Q

Name 3 miscellaneous pre-op orders and where they are recorded:

A
  1. Old chart - recorded on Kardex in miscellaenous section
  2. Glucometer - recorded on Kardex in Glucometer section
  3. Insert foley - recorded on Kardex under elimiation section
  4. IV start - recorded on Kardex under IV section
35
Q

What must the NUC ensure is done before surgery?

A
  1. The Surgical Chart Pack is addressographed and cliped to inside of the chart.
  2. The consent form is completed and clipped to the chart.
  3. That all pre-op orders have been processed.
  4. That the surgery with date and time has been recorded on the Kardex and the whiteboard.
  5. That the OR date and time is written on any requisitions prn
  6. That the old chart has been received from Health Records prn
36
Q

What must the unit clerk ensure is done the morning of the surgery?

A
  1. That all diagnostic reports are filed in the patients chart
  2. That the consent form is signed
  3. That the addressograph/patient labels are attached to the chart
  4. That the current, old and thinned charts are collected and sent to the OR with the patient
  5. That all pre-op orders have been processed
  6. That the current MAR is attached to the patients chart
  7. That a line is drawn after the pre-op Physicians order and write “TO OR” with diagnonal lines
  8. That there are several blank POs in the patients chart.
37
Q

What must the NUC do when the OR calls for the patient?

A

Advise the RN

NUC0920 SOT160 (10 decks)

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