week 3 content Flashcards
types of surgery
- __________– comes in, has surgery, goes home on same day
- ____________– comes in for surgery, post op admission
- _________– admitted to hospital, has surgery, stays post op
same day admit , inpatient , ambulatory
types of surgery
- ambulatory – comes in, has surgery, goes home on same day
- same day admit – comes in for surgery, post op admission
- inpatient – admitted to hospital, has surgery, stays post op
SATA
Purpose of surgery
- diagnosis
- cure
- palliation
- prevention
- exploration
- cosmetic improvement
all
timing of surgery - elective surgery, semi elective surgery, urgent surgery, emergency surgery
o physical or psychological improvements to quality of life
o no urgent need for something to be done quickly, flexibility in scheduling
o ex – cataract removal, breast reduction
o general risks – bleeding, infection, anesthetic exposure
o low mortality/morbidity ris
elective surgery
timing of surgery - elective surgery, semi elective surgery, urgent surgery, emergency surgery
o more time sensitive that elective – priority compared to elective, not so urgent that it must be within 24 hours
o ex – cholecystectomy for gallstone removal, uterine artery ablation for postmenopausal bleeding from fibroids
o low mortality/morbidity risk
- semi-elective surgery
timing of surgery - elective surgery, semi elective surgery, urgent surgery, emergency surgery
o surgery required within 24 hours of diagnosis – to prevent unnecessary complications that can occur with waiting
o ex – hip fracture repair, appendectomy
- urgent surgery
timing of surgery - elective surgery, semi elective surgery, urgent surgery, emergency surgery
o cant be delayed and must occur within 24 hours, but ideally within 2 hours
o any delay may promote critical injury or systemic deterioration, required as a result of an urgent medical condition
o ex – GI bleed, subdural hematoma
- emergency surgery
subjective assessment of patient: patient interview/history
- check documented information
- occurs in advance or on day of surgery
- purpose:
- obtain health info
previous surgeries
previous anesthetics reactions to ___ and ___
family health history
current medication use – ___, ___, ___
allergies and intolerances – ___
illicit drug use and tobacco use – encourage quit smoking ___ weeks prior to surgery
current pregnancy and date of LMS - determine expectations
- provide and clarify information on procedure
explore pts understanding of the need for surgery to be performed - assess emotional state and readiness
is there anything else you would like to share with me or think I should know
previous surgeries
previous anesthetics reactions to self and family
family health history
current medication use – prescription, OTC, herbal
allergies and intolerances – latex
illicit drug use and tobacco use – encourage quit smoking 6 weeks prior to surgery
current pregnancy and date of LMS
SATA
latex allergy risk factors
- history of anaphylactic reaction during procedure
- first surgical procedure
- food allergies – kiwi
- food allergies – banana
- food allergies – avocado
- food allergies – peanuts
- allergy to poinsettia plant
- daily exposure to latex
- history of reaction to latex – balloons, condoms
- family history of latex
- history of anaphylactic reaction during procedure
X - multiple surgical procedures
X - food allergies – kiwi, banana, avocado, chestnuts - allergy to poinsettia plant
- daily exposure to latex
- history of reaction to latex – balloons, condoms
X - family history of latex (NOT A FACTOR)
it is for anasthesia!
subjective assessment of patient pre-op care includes
_________________
Inventory of body systems obtained through asking questions to identify s/s that confirm presence or absences of any disease
ROS - Review of systems
objective assessment of patient pre op includes
- physical exam (along with _________, required by joint commission)
- diagnostic study – results must be in __________
- physical exam (along with history, required by joint commission)
- diagnostic study – results in chart
teaching SATA
1. sensory information
o noise, lights, temp, etc.
2. procedural information
o getting ready for surgery
3. process information
o general flow of surgery
o preop area
o caregiver rules and waiting area
4. informed consent RN responsibility
- sensory information
o noise, lights, temp, etc. - procedural information
o getting ready for surgery - process information
o general flow of surgery
o preop area
o caregiver rules and waiting area
X 4. informed consent RN responsibility - surgeons obligation/responsibility
who explains
diagnosis
purpose of surgery
risks of surgery – common, uncommon, serious, unserious
alternative treatment and risk
risks of not treating
who will conduct surgery
short term costs – pain, length of stay, recovery time
long term costs – loss of function, restriction of activity, scarring
to the patient pre op?
- informed consent = surgeons obligation/responsibility
informed consent SATA
- patient must agree that they have significant comprehension by providing signature on form
- voluntary process
- surgeon preforming surgery will explain/discuss this with patient
- if pt is minor, unconscious, or mentally incompetent – written permission may be given by a legally appointed rep or responsible family member
- emancipated minor – younger than legal age of consent but is not recognized as having legal capacity to provide consent
- a true medical emergency may override the need to obtain consent
X - patient must demonstrate significant comprehension
- voluntary process
- surgeon preforming surgery will explain/discuss this with patient
- if pt is minor, unconscious, or mentally incompetent – written permission may be given by a legally appointed rep or responsible family member
X - emancipated minor – younger than legal age of consent but is recognized as having legal capacity to provide consent
- a true medical emergency may override the need to obtain consent
preop informed consent
nurse’s role SATA
- witness patients’ signature
- be patient advocate
- answer appropriate questions
- give opinion about procedure when asked
if pt expresses concerns about procedure - SATA
find out concerns
convince patient to go through with procedure based on risk of not treating information
answer what nurse can
let provider/surgeon know that pt has concerns and/or 2nd thoughts
preop informed consent
nurse’s role SATA
- witness patients’ signature
- be patient advocate
- answer appropriate questions
X- give opinion about procedure when asked
if pt expresses concerns about procedure - SATA
find out concerns
X convince patient to go through with procedure based on risk of not treating information
answer what nurse can
let provider/surgeon know that pt has concerns and/or 2nd thoughts
intra op
Phase begins when the patient is wheeled into the ______ and ends when transferred to the _______
Phase begins when the patient is wheeled into the OR and ends when transferred to the immediate postoperative recovery area (PACU)
intra op nurse roles
- RNFA –
- CRNA –
- _________
o Remains in sterile field (follows sterile scrubs, gown, glove procedure) - ___________
o Remains in unsterile field (not scrubbed, gowned, gloved) – records all nursing care
Nurse roles
- RNFA – RN first assistant
- CRNA – certified RN anesthetist
- Scrub nurse
o Remains in sterile field (follows sterile scrubs, gown, glove procedure)
- Circulating nurse
o Remains in unsterile field (not scrubbed, gowned, gloved) – records all nursing care
intra op safety - SATA
- Time out – for safety, the entire surgical team will verify before incision is made
o Correct patient
o Correct surgical site
o Correct level, laterality, or structure, etc.
o Correct date
o Correct procedure
o Correct patient position
o Availability of correct implants and any special equipment or requirements
o Correct patient
o Correct surgical site
o Correct level, laterality, or structure, etc.
Xo Correct date
o Correct procedure
o Correct patient position
o Availability of correct implants and any special equipment or requirements
intra op safety
- At least ___ pt identifiers
- Site identification
o Surgeries involving extremities, laterality (right vs left), multiple structures (fingers, toes) or levels (spine) of the body must have surgical site markings (surgeon initials) by the surgeon, on __________, and must be visible after the pt has been________
- At least 2 identifiers
- Site identification
o Surgeries involving extremities, laterality (right vs left), multiple structures (fingers, toes) or levels (spine) of the body must have surgical site markings (surgeon initials) by the surgeon, on incision site, and must be visible after the pt has been draped
- Improper pt positioning during intraop could cause SATA
o n/v
o Muscle strain
o Joint damage
o Pressure ulcers
o Nerve damage
Xo n/v
o Muscle strain
o Joint damage
o Pressure ulcers
o Nerve damage
Types of anesthesia - Regional, General, Monitored anesthesia care (conscious sedation), Local
___________ anesthesia
- Inhalation or injection (or both) of anesthetic drug, resulting in loss of all sensation and consciousness with amnesia
__________ anesthesia
- Medication is instilled into or around nerves to block transmission of nerve impulses in a particular region
- Loss of sensation without loss of consciousness
- Ex – nerve block, bier block, spinal, epidural
_______ anesthesia
- Temporary loss of feeling as result of inhibition of nerve endings in part of body
- Loss of sensation without loss of consciousness
____________ anesthesia
- Similar to general anesthesia, but does not involve inhaled agents
- loss of all sensation without loss of consciousness, amnesia, but pt stays responsive
General anesthesia
- Inhalation or injection (or both) of anesthetic drug, resulting in loss of all sensation and consciousness with amnesia
Regional anesthesia
- Medication is instilled into or around nerves to block transmission of nerve impulses in a particular region
- Loss of sensation without loss of consciousness
- Ex – nerve block, bier block, spinal, epidural
Local anesthesia
- Temporary loss of feeling as result of inhibition of nerve endings in part of body
- Loss of sensation without loss of consciousness
Monitored anesthesia care (conscious sedation)
- Similar to general anesthesia, but does not involve inhaled agents
- loss of all sensation without loss of consciousness, amnesia, but pt stays responsive
___________________
inherited muscle disorder triggered by certain types of anesthesia that may cause fast acting life-threatening crisis
SATA
- triggering agents result in unregulated calcium accumulation
- 90% have no family history
- 50% have had uneventful anesthesia history
- No way to predict it = be aware it can happen and act quickly!!
malignant hyperthermia
inherited muscle disorder triggered by certain types of anesthesia that may cause fast acting life-threatening crisis
- triggering agents result in unregulated calcium accumulation
- 90% have no family history
- 50% have had uneventful anesthesia history
- No way to predict it = be aware it can happen and act quickly!!
post op patient is
showing signs of malignant hyperthermia SATA
- hypercarbia
- sinus bradycardia
- general muscle rigidity
- hyperthermia (is the presenting sign)
- sustained muscle contraction
- muscle breakdown – rhabdomyolysis
- anaerobic metabolism
- metabolic acidosis
antidote = dantrolene IV or calcium carbonate IV?
early presentation
- hypercarbia
X- sinus tachycardia
- general muscle rigidity
X- hyperthermia is not the presenting sign
- sustained muscle contraction
- muscle breakdown – rhabdomyolysis
- anaerobic metabolism
- metabolic acidosis
antidote = dantrolene IV
Perioperative nursing: postoperative care
starts in ________ and goes beyond (ongoing care in ICU, step-down or med-surg units)
PACU nursing care focus: SATA
- Recovery from general anesthesia
- Airways management
- Pain management
- Close observation of physiologic indicators
- monitoring for GI return
T/F - All preop orders are continued in postop in addition to some new orders from surgeon
starts in PACU and goes beyond (ongoing care in ICU, step-down or med-surg units)
PACU nursing care focus:
- Recovery from general anesthesia
- Airways management
- Pain management
- Close observation of physiologic indicators
X- monitoring for GI return
F - All preop orders are d/c and surgeon gives new orders postop
post op Respiratory problems SATA
- Hypoxia due to
o Shallow breaths
o Anesthesia
o anorexia
o Obstruction of airway
o Respiratory depression
o Laryngospasm - Atelectasis
- PNA
- Hypoxia due to
o Shallow breaths
o Anesthesia
X o obesity
o Obstruction of airway
o Respiratory depression
o Laryngospasm - Atelectasis
- PNA
Prevention
post op Respiratory problems SATA
- Raise HOB
- VS
- oxygen
- suction
- Effective coughing – splint PRN
- ISO
- Turn Q2
- Early ambulation
- Pain management when pt reports pain higher than 4/10
- Raise HOB
- VS, O2, oxygen, suction
- Effective coughing – splint PRN
- ISO
- Turn Q2
- Early ambulation
X- Pain management – ATC dosing
post op Cardiovascular problems
1. Decreased CO
o Indirect measures = ______, ________, ______, _____
2. DVT
o Esp ____, _____, ______
3. Pulmonary embolus
o Indirect measures = BP, HR, pulses, skin temp/color
o Esp OA, obese, immobilized
post op Cardiovascular problems Prevention
- Monitor VS – compare trends to baseline
- Leg and ankle exercises – mimic walking to promote venous return and reduce risk of clot
- SCDs
- Ambulation
- Phlebitis assessment
- Monitor/protect wound
- raise HOB
- Monitor VS – compare trends to baseline
- Leg and ankle exercises – mimic walking to promote venous return and reduce risk of clot
- SCDs
- Ambulation
- Phlebitis assessment
- Monitor/protect wound
X - raise HOB- respiratory
post op Cardiovascular problems Prevention
should nurse Notify HCP if -
- SBP <90 or >160 and symptomatic (Rapid or weak pulse and Cold clammy skin)
- SBP <90 or >160 and normal pulse and warm/pink skin
- Pulse pressure narrows
- BP trends increase over several readings
- BP trends decrease over several readings
- Change in heart rhythm
- Pulse <60 or >120 and first dose of pain meds was given 5 minutes ago
- Pulse <60 or >120 with no obvious reason for cause of BP
- SBP <90 or >160 and symptomatic (Rapid or weak pulse and Cold clammy skin) = needs immediate intervention, could be impending hypovolemic shock
X 2. SBP <90 or >160 and normal pulse and warm/pink skin = keep monitoring, usually vasodilation from anesthesia
- Pulse pressure narrows = difference between SBP and DBP
- BP trends increase over several readings
- BP trends decrease over several readings
- Change in heart rhythm
X 7. Pulse <60 or >120 and first dose of pain meds was given 5 minutes ago = obvious reason, monitor
- Pulse <60 or >120 with no obvious reason for cause of BP
Neurological and psychological problems post op - SATA
restlessness
disorientation
thrashing
shouting
depression
delirium
all
***restlessness = think hypoxia!!
But it can be caused by other things like anesthesia, pain, ET tubes, etc.
Pain problems post op - SATA
- Post op pain = intermittent
- ATC dosing required
- Watch for s/e like respiratory depression esp if opioid naïve
- Pain increases as anesthesia wears off
- Pharmacologic pain interventions = supplemental
- Nonpharmacologic pain interventions = focus
Pain problems
X - Post op pain = continuous, ongoing pain
- ATC dosing
- Watch for s/e (respiratory depression, esp if opioid naïve)
- Pain increases as anesthesia wears off
X - Pharmacologic pain interventions = focus
X - Nonpharmacologic pain interventions = supplemental
Body temp problems post op
hypothermic
- During surgery pt may become hypothermic bc of ___________ during procedure
Hyperthermic
- First 48 hours = suspect infection of no?
o First 48 hours Mild fever (<100.4) =
- inflammatory response to surgical stress = expected finding, monitor it
- lung congestion, dehydration = pulmonary toilet, increase fluids
- infection – wound, urinary, respiratory = look where infection could be, WBC with diff
o First 48 hours Moderate fever (>100.4)
- inflammatory response to surgical stress = expected finding, monitor it
- lung congestion, dehydration = pulmonary toilet, increase fluids
- infection – wound, urinary, respiratory = look where infection could be, WBC with diff
- After 48 hours Elevation of fever (>100)
- inflammatory response to surgical stress = expected finding, monitor it
- lung congestion, dehydration = pulmonary toilet, increase fluids
- infection – wound, urinary, respiratory = look where infection could be, WBC with diff
Body temp problems
hypothermic
- During surgery pt may become hypothermic bc of body heat loss during procedure
Hyperthermic
- First 48 hours (too soon to have a fever from infection)
o Mild fever (<100.4) = inflammatory response to surgical stress = expected finding, monitor it
o Moderate fever (>100.4) = lung congestion, dehydration = pulmonary toilet, increase fluids
- After 48 hours
o Elevation of fever (>100) = infection – wound, urinary, respiratory = look where infection could be, WBC with diff
24 hours post op
temp 99.9
suspicion =
action =
- First 48 hours (too soon to have a fever from infection)
o Mild fever (<100.4) = inflammatory response to surgical stress = expected finding, monitor it
