Tissue Integrity/PeriOp Care Flashcards
Stage 1 Pressure ulcer
Red area that is not blanchable
Stage 2 Pressure ulcer
Shallow open wound w/o slough
Stage 3 Pressure ulcer
No bone or muscle present
Some slough but does not obscure
Full thickness loss
Stage 4 Pressure ulcer
Full thickness tissue loss
See bone or muscle
Slough and eschar may be present
Undermining and tunneling
Suspected deep tissue injury
Depth unknown
Purple discolored area of intact skin
Due to pressure or shear
Unstageable Pressure ulcer
Depth unknown
Full thickness tissue loss
Ulcer covered by slough and eschar in wound bed
Cannot stage until removed`
Priority screening before surgery
Screen for Malignant hyperthermia
What meds would the nurse check for a pt. before a surgery that puts them at a high risk during surgery
Aspirin
Antidepressants
Steroids
NSAIDs
What is best practice for marking a surgical site?
The physician should mark the site with the involvement of the pt.
Pt. has surgery in 3 hours but take her Beta-blocker every morning. True/False: The nurse should withhold the medication before surgery
False: This is a vital medication for heart function. The pt. should have the beta-blocker
Pt. has surgery in 3 hours but take her multivitamin every morning. True/False: The nurse should withhold the medication before surgery
True: this is not a vital medication
Surgical Time Out
ID right pt., right procedure, right site
Sponge and instrument count
Positioning
What is the last sense to go when a pt. is under anesthegia
Hearing
During the surgical procedure who is the advocate for the pt.?
Nurse circulator
Where should a ground device be placed?
Place over muscle
DO NOT place over bone or extremity with joint replacement
Pt. just under went an abdominal laparoscopic surgery 4 hours ago. The patient is complaining of pain in shoulders and upper chest. What should the nurse suspect?
Trapped gas from the surgery
Intervention: Ambulation
General anesthesia
Total loss of consciouness
Local anesthesia
topical or by local infiltration
Ex. skin cancer removal
Spinal anesthesia
Use for pt. that are not good candidates for general anesthesia
Ex. elderly, frailty, heart probs
Regional anesthesia
Nerve block
PACU phase 1 priority assessment
LOC
Can they maintain their own airway?
PACU Phase 1 handoff
anesthesia and circulating RN handoff to PACU RN
PACU Phase 2 and 3 handoff
PACU RN handoff to unit RN
What types of things are included in handoff report after surgery
Type of surgery Type of anesthesia VS Estimated blood loss (EBL) Dressings Drains Incisions Temp Health Hx IV fluids
Complication of surgery that the PACU RN should assess
Signs of shock
Hemorrhage
PACU RN’s pt. surgical site dressing is beginning to show blood through the dressing. True/False: The nurse should remove the soiled dressing and put a new dressing on to prevent infection and assess bleeding
False: the nurse should just “reinforce” the dressing. This means placing a new dressing OVER the old dressing. The first dressing change should be done by the HCP
What drains use negative pressure to drain fluids?
Jackson-Pratt
Hemovac
What should the nurse label a dressing with?
Date, time, intials
Penrose drains are primarily used for what type of surgery?
Abdominal surgeries
Gas exchange complication
atelectasis
pneumonia
Gas exchange interventions
Incentive spirometer
Turn, cough, deep breath
ambulation
Perfusion Complications
Venous stasis
DVT
PE
Hemorrhage
Perfusion Interventions
TED SCD Ambulation doriflexsion anticoagulants monitor blood loss (H and H) Dressings
Surgical site infection assessment
Drainage Pain redness Heat tenderness Odor Swelling
Prevention of surgical site infection
Admin antibiotics Sterile dressing and changes Know risk factors for infection Prevent hypothermia during surgery Effective preop skin prep
Wound Dehiscence
Serration of wound edges
Wound Evisceration
protrusion of intestinal contents through wound
Apply sterile gauze
Notify HC immediately
Fever 2 days after surgery can be in indicator of what respiratory complication?
Atelactesis
GI complications
Abd distension
Constipation
Postop ileus
GI interventions
Ambulation Bowel rest stool softeners chewing gum Help control N/V I and O
GU Complications
Urinary retention
Decreased urinary output
Incontinence
GU interventions
I and Os
Bladder scan
Remove foley as appropriate
Encourage fluids
Surgical Pt. being discharged. What signs should the nurse teach the pt. about when to call the HCP?
Excessive bleeding
yellow/foul smelling drainage
Temp greater than 100.8
What type of discharge teaching should the nurse provide to the pt.?
Written and verbal
Celluitis
diffuse infection of the dermis and SQ tissue
Tx: vary depending on causative agent
MRSA
Decrease risk by giving CHG baths prior to surgery
Risk Factors for surgical complications
Pre-existing conditions (COPD, asthma, sleep apnea, smoking) Kidney issues - excreting anesthesia Malignant hyperthermia Age Obesity Immunocompromised Urinary issues - inability to excrete urine Cardiac Hx
Post surgery Issues
Hypovolemic shock Hemorrhage Wound infection DVT, PE Urinary retention anesthesia reaction
Which lab result is concerning for a pt. going to orthopedic surgery?
a. ) Ca 9.2
b. ) INR 2.6
c. ) Hemoglobin 10.5
d. ) K+ 3.5
INR 2.6
Pt. going for surgery smokes 2 packs of cigarettes a day. What is this client at greatest risk for?
a. ) Wound infection
b. ) Hemorrhage
c. ) Atelectasis
d. ) Postoperative ileus
C Atelectasis: because bad lungs, more at risk for lung probs
What is the minimum age a person can consent to surgery in Alabama
14 years old can consent to their own surgeries
What assessment is most important for the client who has delayed surgical wound healing?
a. ) Family Hx
b. ) Serum albumin and prealbumin
c. ) Hx of Kidney stones
d. ) K+ levels
B - Albumin and prealbumin, measure of nutrition
Nutrition effects wound healing
What type of anesthesia is used for a pt. undergoing an EGD?
a. ) general
b. ) regional
c. ) local
d. ) Moderate sedation
D- moderate sedation
What is NOT a risk factor for respiratory depression with PCA?
a. ) obesity
b. ) middle age
c. ) advanced age
d. ) Low body weight
B - middle age
Moderate Sedation
Able to breath on their own
Which meds can NOT be used with PCA
a. ) nerve meds
b. ) acetaminophen
c. ) NSAIDS
d. ) Fentanyl
D- Fentanyl
Which med is NOT acceptable for a NPO patient?
a. ) Aspirin oral
b. ) labetalol
c. ) Digoxin
d. ) pantoprazole
D - Pantoprazole
Which of these tests is used to r/o pneumonia?
a. ) CT scan
b. ) Chest x ray
c. ) MRI
B - Chest X ray
RN is talking o client about cellulitis. What description is NOT correct?
a. ) can occur in many different settings, typical unilateral
b. ) Caused by gram positive bacteria such as Staph A or Strep P
c. ) Infection of dermis and SubQ tissues
d. ) Collection of pus within the dermis and subQ tissue
D- Collection of pus within the dermis and subQ tissue
Client is recieving PO pain med for pain 9/10 at 1100. When is the follow up?
a. ) 1115
b. ) 1215
c. ) 1200
d. ) 1230
C - 1200
Which population is most likely at risk for inadequate pain control
a. ) AOC X 3
b. ) Current Hx of cocaine use
c. ) Proficient bilingual client
b - Current Hx of cocaine use
The nurse is assessing the pt. surgical dressing. What is not considered an emergency situation?
a. ) Sx dressing is saturate through multiple reinforcements
b. ) Organ tissue is protruding out of the exposed wound
c. ) Wound bed edges are slightly separated with scarce drainage
C
Which is NOT a Tx option for malignant hyperthermia?
a. ) meds
b. ) Ice
c. ) fluids
d. ) K+
D- K+
Client is ready to have a PICC line placed. What is most important task performed in the intra-op phase?
a. ) Assessment of drain tubes placed
b. ) Understanding of surgical procedure
c. ) Surgical time out
d. ) Reviewing previous surgery Hx
C- Surgical time out
Client is concerned about robotic procedure. What is NOT an advantage of robotic procedures?
a. ) Less dexterity
b. ) Shorter recovery time
c. ) Less puncture wounds
d. ) Less pain
A - Less dexterity
Pt. jsut came back from oral procedure. What is the priority assessment while in PACU?
a. ) O2 sat
b. ) Pain
c. ) LOC
d. ) RR
C - LOC
RN assessing surgical site of a pt. from Sx. What is NOT indicative of risk for surgical site infection?
a. ) WBC of 100
b. ) Taking steroids for asthma
c. ) Moderate serosangious output from drain
d. ) Being 100 years old
C - Moderate serosangious output form drain
Client receiving IV Dilaudid PCA pump. What makes you concerned about pt. potential RASS score?
a. ) Wife hitting button for pt.
b. ) pt moans with deep breaths
c. ) Pt. is easy to arouse
A - wife hitting button for pt
Client is ready for discharge. What action BEST tells the RN the client can empty the drain properly?
a. ) Reading discharge instructions
b. ) Return demostration
c. ) Have significant other empty the drain
B - return demostration
RN is assessing arm of pt. What is a major complication of celluitis?
a. ) Overuse and misuse of systemic antibiotics
b. ) Bleeding from biopsy site
c. ) blood culture inaccuracies
A - Overuse and misuse of antibiotics
