Week 5: Perioperative Care

Question 1

Pre-op Very low risk

Answer 1

no known medical problems

Question 2

pre-op low risk

Answer 2

Hypertension, hyperlipidemia, asthma, chronic stable medical
conditions

Question 3

pre-op intermediate risk

Answer 3

age 70+, non-insulin dependent diabetes, history of
treated stable CAD, morbid obesity, anemia, mild renal insufficiency

Question 4

pre-op high risk

Answer 4

recent coronary stent, chronic CHF, insulin-dependent diabetes,
renal insufficiency, moderate COPD, obstructive sleep apnea, history of
stroke, dementia, chronic pain syndrome

Question 5

pre-op very high risk

Answer 5

unstable/severe cardiac disease, severe COPD, use of home
O2, pulmonary hypertension, severe liver disease, physical incapacitation

Question 6

pre-op patient risk factors

Answer 6

Less physiologic reserve – old/young age, pregnancy, many comorbid health conditions

Comorbidities – cardiac, respiratory, diabetes, renal/hepatic disorders, pain disorders

Health status – poor nutrition, high BMI, mobility

Past surgical experiences – past experience with anesthesia

Allergies – medication, latex, anesthetics

Question 7

pre-op high risk medications

Answer 7

blood thinners & diuretics

Question 8

Pre-op lab values

Answer 8

CBC:
RBCs (Hb, Hct)
Hb is connected to oxygen and carries that oxygen to help perfuse our body. Hb value reflects the number of red blood cells in someone’s blood. Low hb could postpone surgery or result in blood transfusion.
Hct measures the percentage of our total blood volume. A low value indicates diluted or potentially well-hydrated. A high value indicates the client Is not well hydrated.

WBCs (high or low without explanation warrant further investigation)

PLTs (platelets; low – risk of bleeding)

Electrolytes:
Na, K, Cl, HCO3

Creatinine:
eGFR
Cr - make sure the kidneys can excrete the anesthetic meds

Electrocardiogram (ECG)

Question 9

consent

Answer 9

Informed consent is a legal mandate

Surgeon is responsible for providing information for informed consent

No minimum age for consent (must use professional judgement)

Question 10

pre-op prepping

Answer 10

Nutrition, fluids, elimination, and skin prep

Holding food and fluids

Insert IV

Complete orders (catheter, bowel prep, skin cleansing, shaving, etc.)

Question 11

Scrub nurse role

Answer 11

Set up sterile field, prepare instruments and equipment

Pass instruments and supplies to surgical team

Monitors aseptic technique

Performs sponge, needle and instrument count with circulating nurse

Sends specimens to lab

Question 12

Circulating nurse (typically RN) roles

Answer 12

Monitors patient

Coordinates team

Monitors aseptic practice

Verifies consent

Performs second surgical safety checklist

Counts with scrub nurse

Transfers patient to PACU

Question 13

RN-First Assist (RNFA) role

Answer 13

Provides care under direction and supervision of surgeon

Intraoperative performance of surgical first assistance techniques; using
instruments and medical devices, providing surgical site exposure,
handling/cutting tissue, providing hemostasis suturing, wound management

Question 14

RN-Anesthesia Assistant (RNAA) role

Answer 14

Can provide anesthesia care under the direct supervision of anesthesiologist and under medical directives

Question 15

PACU priorities:

Answer 15

Assess immediate response to surgery

Health status (ABCs, VSs, fluids)

Pain

Readiness of transfer from PACU to next destination

Question 16

Post-op Pain

Answer 16

Expected: Pain tolerable as per client

Complications:
Pain not adequately managed by interventions to support healing, as defined by client

Interventions:
IV Pain Medications (IV Push, Patient-Controlled, Regional Block, Intrathecal, Continuous Infusion)
Oral Pain Medications
Non-Pharmacological Interventions

Question 17

Post-op LOC

Answer 17

Expected:
As appropriate for time from surgery
Moving towards alert and oriented
Expected drowsiness within 24 hours of surgery
Return to baseline*

Complications:
Failure to return to baseline
Delirium
Findings: changes to LOC, low Glasgow coma scale

Question 18

Post-op ABCs: Airway/breathing

Answer 18

Expected:
Patent airway
Normal rate, rhythm and depth (low normal*)
Deep breathing/coughing, +/- incentive spirometry

Complications:
Hypoxia (findings: dyspnea, bradypnea, low SpO2, cyanosis) - lack of oxygen

Atelectasis (findings: dyspnea, tachypnea, low SpO2, cyanosis, increased HR) - partial or complete collapse of lung

Opiate pain meds can cause respiratory depression

Question 19

Post-op ABCs Circulation

Answer 19

Expected:
Normal HR/BP
Temperature, colour
Bleeding as expected based on surgery
Heart rhythm expected

Complications:
Hypotension
Hypothermia (findings: low temp, shivering, piloerection)
Hemorrhage/Hypovolemic Shock (findings: increased bleeding-wound, drainage, internal; S/S shock)
Dysrhythmias (findings: changes in BP/HR, rhythm abnormal)

DVT (findings: pain in lower extremities, cramping, leg swelling, red, pain)
PE (findings: SOB, chest pain)

Question 20

Post-op circulation DVT

Answer 20

DVT (findings: pain in lower extremities, cramping, leg swelling, red, pain)
PE (findings: SOB, chest pain)

Prophylaxis (prevention):
Low Molecular Weight Heparins (Deltaparin, Enoxaparin)
Decreased risk of bleeding compared to heparin
S/C injections : Give 2-inches from umbilicus, Never rub site or aspirate, Note: mild bruising is normal)

Question 21

Post-op mobility

Answer 21

Expected:
Return to baseline

Complications:
DVT->PE

Interventions:
Pain management
Compression stockings
Sequential Compression Devices
Elevate legs
Interprofessional team*

Question 22

post-op surgical site

Answer 22

Expected:
Appropriate drainage as per surgery
Edges approximated
Healthy wound healing
Dressing dry and intact

Complications:
Infection (findings: s/s infection)
Dehiscence (findings: edges of wound unintentionally not-approximated)
Evisceration (findings: edges of wound unintentionally not-approximated, fascia +/- organs visible or protrude)

Question 23

dehiscence vs evisceration

Answer 23

Dehiscence occurs when an incisional wound separates after surgery; evisceration occurs when an internal bodily organ protrudes through the incision.

Question 24

post-op lines, tubes, drains

Answer 24

Expected:
Patency
Appropriate rate
Insertion site healthy
Appropriate drainage

Complications:
Insertion site infection or other complications (phlebitis, interstitial)
Failure to drain (findings: dry tubing/container)

Question 25

post-op GI & GU

Answer 25

Expected:
N/V controlled
Return of GI motility
GU within expected range

Complications:
N/V: administering mediations, non-pharm interventions *concern for dehiscence!
Aspiration: NPO until recovered from sedation, bowel sounds return
Paralytic ileus: findings; abdo distension, absence of BS
Oliguria: findings; urine output < 30ml/hr, bladder distension)

Question 26

ambulatory

Answer 26

transfer to surgical day care unit (SDCU), then discharged

Readiness of discharge

Health teaching

Question 27

admission

Answer 27

transfer to surgical inpatient unit, then discharged following
recovery

Monitor health status & pain
Risk for complications
Health teaching
Discharge planning