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Adult 2 Test 1 > Surgical Patient > Flashcards

Surgical Patient Flashcards

1
Q

Preoperative care of a surgical patient:

A
  1. is delivered before or during hospital stay
  2. History
  3. Labs and other diagnostic tests
  4. Consent
  5. Preoperative teaching
  6. Medications
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2
Q

Patient History includes

A

pre-existing health problems, meds, past surgical experiences, ROS-Review of Systems, allergies

Looking for Malignant Hyperthermia

(1) Prior Surgeries
(2) Problems with prior surgeries
(3) Family history of prior surgeries

Physical exam to include system specific focus plus cardiopulmonary exam. Check Vital signs

(1) Elevated temperature
(2) Changes in heart rate/rhythm
(3) Changes in blood pressure

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3
Q

Blood labs

A

WBC
CBC
Platelets

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4
Q

WBC

A

3.5 – 9.5

Elevation may mean infection – Check differential

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5
Q

CBC

A

complete blood count 4500-11000

What to look for:

(a) Check for bleeding (Look for changes)
(b) Check for anemia
(c) Check for sickling
(d) Anesthetics are carried by RBCs in respiratory inhalation

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6
Q

Platelets

A

150-400
Checks bleeding tendencies-what medications can effect Platelets? What subcutaneous medications are commonly given? (Coumadin/Warfarin)

< 100,000 = thrombocytopenia
< 50,000 = risk for bleeding once bleeding starts
< 20,000 = risk for spontaneous bleeding
< 10,000 = poor prognosis

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7
Q

Na (Sodium)

A

135-145
Indicates fluid status
High = dehydration
Low = risk for cerebral edema

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8
Q

K (Potassium)

A

3.5-5
Cardiac

Low = risk for tachy arrhythmias
PVC’s, premature ventricular contractions
Note: if creatinine high, K may be low

High = risk for brady arrhythmias, cardiac arrest, secondary tachy-arrhythmias

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9
Q

BUN (Blood Urea Nitrogen)

A

10-20
protein waste product, Renal function
Not specific: Hydration status, liver failure, protein intake, etc can effect BUN levels

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10
Q

Creatinine

A

0.8-1.2
waste product from muscles-Renal function
Specific of how well the kidneys are working.

Increased-lead to impaired kidney function

Many medications excreted by kidneys.

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11
Q

LFTs (Liver Function Tests)

A

ALT and AST

High = Impaired liver function

Almost all medications cleared by liver including anesthetics

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12
Q

BNP

A

electrolytes and renal function

Complete BNP = electrolytes, renal function, and LFTs

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13
Q

Consent

A

The responsibility of the person providing the service

(1) Surgeon
(2) Anesthetist
(3) NOT nurse; nurse is witness

3 conditions for consent

(1) Adequate disclosure – diagnosis, treatment plan, risks, outcome probability, alternatives, prognosis if tx not instituted
(2) Clear understanding (before sedation)
(3) Voluntary

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14
Q

Preoperative Teaching

A

Also the responsibility of the person providing the service

(1) Surgeon: Surgical procedure and follow-up care (Often delegated)
(2) Anesthetist: Anesthesia protocols.

Nursing: Pre and post-op expectations/procedures.

(a) preparation (clothing, jewelry, shaving, bathing, glasses, dentures, etc),
(b) environment of the OR,
(c) transferring from area to area (preop, OR, pacu, floor/discharge),
(d) IV initiation,
(e) procedure,
(f) pain,
(g) surgical site,
(h) understanding/questions about the procedure.

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15
Q

Insulin precautions during surgery are:

A

Dextrose IV running

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16
Q

Preoperative check and time out are to check for what 4 things?

A

right person, right procedure, right side, consent**

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17
Q

anesthesia delivery methods

A

IV, intubation, inhalation

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18
Q

What is the reasons for positioning of the patient during surgery?

A

access to operating site and preventing nerve damage/skin breakdown/muscle strain.

(1) pad bony prominences
(2) straps to keep from falling

19
Q

Nursing roles during surgery

A

Intraop nurse-vital signs, retrieving instruments, etc.

Sterile vs non-sterile

20
Q

Anaphylactic reaction

A

Severe allergic reaction

(1) May be masked by anesthesia, Blood products, antibiotics, anesthetics, plasma expanders, latex
(2) Anything administered via IV can cause an allergic reaction

Clinical manifestations:

(1) pulmonary edema,
(2) bronchospasms,
(3) tachycardia,
(4) hypotension.

Treatment:

(1) Discontinue what is running,
(2) oxygen,
(3) epinephrine IM,
(4) benadryl (diphenhydramine),
(5) corticosteroids,
(6) albuterol,
(7) fluids

21
Q

Postoperative Care - Getting report includes:

A

Name, age, surgeon, anesthesiologist, procedure

Relevant patient history

Intraoperative meds, blood loss, fluid replacements, urine output

Intraoperative course

(1) VS and trends,
(2) labs or tests done with results,
(3) unexpected or adverse outcomes

Last dose of medications: pain, anti-anxiety

Drains, tubes, lines, dressings, drainage

Position

22
Q

Postoperative Nursing Assessments:

A

Airway - Is the airway clear? maintained? airway noises?air movement? (Try stimulation, O2)

Breathing - respiratory rate? SpO2? respiratory pattern?chest symmetry? accessory muscles? patient color?

Circulation - manual pulse? bp? color? cap refill?

Neurologic - AAx4? (Can use stimulation)

Genitourinary

Surgical Site

(1) Don’t take off 1st dressing
(a) Surgeon does this
(b) Nurse can reinforce dressing

Pain

Fluid and electrolyte status

23
Q

postoperative period is ___.

A

30 days

24
Q

postoperative complications can affect any system and may be related to (4).

A

anesthesia, position, procedure, or pre-surgical conditions.

25
Q

malignant hyperthermia

A

rapid rise in temperature, 105 F degrees, or 40.5 C

Usually happens intra-operatively but CAN HAPPEN IN POST-OP

Susceptibility

(a) rare
(b) Genetic components
(c) Stress, trauma, heat

S&S

(a) Hyperthermia (NOT the 1st sign)
(b) Muscle rigidity

Causes
(a) Altered control of Ca++  increased metabolism of skeletal muscle (contractures)  elevated temperature  hypoxemia  lactic acidosis  hemodynamic/cardiac alterations  death

Trigger

(a) Succinylcholine
(b) Inhalation Agents

Treatment

(a) Early detection is critical
(b) ICE!
(c) IV dantrolene (Dantrium) - Slows metabolism and reduces muscle contractions

Prevention - Obtain family history

26
Q

Malignant Hyperthermia treatment medication is:

A

IV dantrolene (Dantrium)

Slows metabolism and reduces muscle contractions

27
Q

respiratory complications include:

A

Airway obstruction – Especially if intubated

Hypoxemia

(i) Atelectasis
(ii) Pulmonary edema
(iii) Aspiration
(iv) Bronchospasm
(v) Pulmonary embolus

Hypoventilation due to decreased drive, decreased effort, restriction, pain

Pneumonia

28
Q

An elevated temperature in the PACU is usually a sign of what?

A

atelectasis, not infection.

What can we instruct the patient on to prevent atelectasis? Cough and Deep Breathe

29
Q

Temperature indicator points in PACU?

A

First 48 hours,
less than 100.4 F=inflammatory response, surgical stress.
Greater than 100.4 F=atelectasis, dehydration

Greater than 48 hours,
greater than 100.4 F=infection (wound, respiratory, urinary).

30
Q

Nursing Prevention and Treatment of Respiratory Complications

A

(a) Know pre-op respiratory function, frequent assessment
(b) Position appropriately – prevents stasis of lung secretions
(c) Stimulation – helps clear anesthetic effect
(d) Anesthetic reversal
(e) Hydration – prevents mucus plugging
(f) Cough, deep breathe, turn, IS – the key to preventing complications
(g) Intraoperative SCDs,
(h) prophylactic anticoagulation (Heparin)
(i) Suction and emergency airway equipment readily available
(j) Pain management
(k) Monitoring

31
Q

Cardiac complications Post-op include:

A

Hypotension, Hypertension, Dysrhythmias, and Myocardial Infarction

key is monitoring pt and know the pre-op status!

32
Q

Hypotension post-op

A

Abrupt hypotension indicates hemorrhage or cardiac dysfunction (consider pain meds)

The most common cause is third spacing

Treatment

  1. Lower head of bed to a neutral position
  2. NS given as IV bolus
    a. Replace fluid (preload) that has shifted from the vascular space into the void left by surgical excision.
    b. Maintain perfusion of tissues and organs – especially the kidneys.
  3. Notify provider

Treatment

  1. Vasoconstrictors (afterload): Dopamine, Neo-synephrine, Norepinephrine
  2. NS – increases volume
33
Q

Hypertension post-op

A

Check body systems first – pain, anxiety levels, full bladder

Pharmacologic therapy

a. Vasodilators – Decrease afterload
b. Beta blockers-effect HR too
c. Calcium channel blockers- can effect HR
d. ACE inhibitors
e. Nitrates

34
Q

Dysrhythmias post-op

A

Maintain electrolytes WNL

Atrial

a. Bradycardia: Atropine, Epinephrine
b. Tachycardia: Beta blockers, Calcium channel blockers, Digitalis, Adenosine
c. Atrial flutter/fibrillation:
i. If new, cardioversion.
ii. If of questionable duration, control heart rate with Beta blockers, calcium channel blocker, or digitalis until the presence of atrial clots confirmed or denied, then either anti-coagulation or cardioversion.

Ventricular

a. Slow/escape rhythms: Atropine
b. Dysrhythmias (PVCs, VT): Amiodarone, Lidocaine, Procainamide
c. Ventricular fibrillation and VT (unconscious): Defibrillation followed by Amiodarone, Lidocaine, or Procainamide as needed. Epinephrine as needed

35
Q

Myocardial Infarction post-op

A

Monitor urine output
low perfusion to the kidney due to the MI = low urinary output

Monitor vital signs and treat as needed

Postoperative cardiac evaluation including enzymes

Evaluate EKG-ST changes

Complaining of chest pain, pressure, radiates to jaw/arm

36
Q

post-op neurologic complications include:

A

Delayed emergence
Check liver and kidney function

Delirium
causes include anesthesia, medications, respiratory

Hypothermia
how can we warm the patient? Warm blankets or Bear hugger

Prevention and Treatment
(a) Know at risk groups – Elderly – lower immune system, comorbidities
(b) Create safe environment
(c) Careful patient and family history
Was the pt previously confused? – GET a baseline!
(d) Ongoing observation
(e) Reversal agents
(i) Narcan – opioids
(ii) Romazicon – versed (antianxiety)
(iii) Fresh frozen plasma - warfin
(f) Careful use of pain medication-sedation, confusion
(g) Medications to manage withdrawal symptoms - Adivan
(h) Think about electrolytes – Low Na+  cerebral edema
(i) Keep patient warm

37
Q

Gi postoperative complications include:

A

N/V, paralytic ileum, hiccups

38
Q

Nausea/Vomiting

A

Common after anesthesia

GI rest until BS resume, nausea subsides

Treatment

(i) Zofran to prevent N/V
(ii) Promethazine (Phenergan), chlorpromazine (Thorazine), Prochlorperazine (Compazine), hydroxyzine (Vistaril) to treat
- Watch sedation levels, watch bp

What if they start vomiting, how do you protect their airway?

  1. Turn on side
  2. suction
39
Q

Paralytic ileum

A

Monitor bowel sounds

  1. if they have an NG-turn off LIWS (low intermittent with suction) temporarily to auscultate bowel sounds
  2. have Suction equipment at bedside

Consider alternative pain meds (Tylenol)

Fluids when gag reflex is present if low risk

AMBULATE!

Right sided position - Helps follow GI track and gets it moving!

40
Q

Hiccups

A

Causes include: Gastric distension, intestinal obstruction, intraabdominal bleeding, subphrenic abscess, acid-base imbalance, electrolyte imbalance, hot or cold liquids.

Give Hiccup meds - anticholinergics

Usually lasts a short time

41
Q

Post-op urinary complications:

A

Infection, Retention, Low urinary output

Prevention and Treatment

(a) Monitor I & O
(b) Cautious use of pain meds in high risk
(c) Avoid catheter if possible
(d) Males- stand to void
(e) Fluid challenge

42
Q

Low Urinary Output

A
  • minimal accept urinary output 0.5 ml/kg/hr or 30 mL
  • First 24 hours, 800 ml to 1500 ml of urinary output is expected.
  • Most void 6 to 8 hours after surgery.

What do you do if there is a low urinary output?
Bladder scanner
1. Yes to bladder full -> straight catheter
2. No to bladder full -> fluid bolus, check creatinine

Common causes of low uop is third spacing (edema), low volume, sepsis, heart failure, obstruction, and medication harm.

Treatment:

  1. NS fluid bolus X 2-if low on volume/fluid-usually the first intervention
  2. Diuretic-will pull fluid from third spacing/edema and back into the vascular space
  3. Dialysis
43
Q

Surgical wound complications include:

A

Hemorrhage, Infection, Dehiscence, Evisceration

Care

(a) Check drains, adjacent tissue, dressings
(b) Watch BP, trend H&H-bleeding
(c) Clean technique with dressing change-infection control!
(d) Wound support in stress areas such as Pillow for cough and deep breathing
(e) Prophylactic antibiotics

Discharge Instructions

(a) Activities
(i) What can pt do/not do? (like heavy lifting)
(b) Diet (high protein for wound healing)
(c) Wound/Incisional Care
(d) Meds- new, old, when to resume
(e) When to call, and when not to
(i) What to worry about (S/S infection)
(ii) What not to worry about
(f) Who to call
(g) When, where to return for follow up
(h) Other information as needed

44
Q

Dehiscence vs Evisceration

A

Dehiscence – splitting/bursting of a wound

Evisceration – protrusion of the internal organs (usually abdominal) through an incision

Evisceration tx – sterile gauze w/NS or sterile water over organ & notify HCP; check vitals

Adult 2 Test 1 (6 decks)

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