Perioperative & Classification
Has to do with purpose. Answer and provide an example.
With this type of surgery, the patient:
The intention is for the condition not to develop.
Preventative surgery
EX: Breast removal to prevent getting breast cancer
A tool that helps diagnose Obstructive Sleep Apnea:
"Stop bang questionnaire"
Dangers of Cardiac abnormalities with surgery and what to do:
Heart failure or A-fib:
Will not give them lots of fluids because they will not filter it out
Fluid could end up in the extremities or the lungs
Labs to consider preoperatively that screen for clotting?
CBC
Platelets - If High
PT-INR - If Low (increase Warfarin)
PTT-aPTT - If Low (increase Heparin)
What is another aspect of medical history to consider and is something the OR room would be highly prepped for? Something we always ask when we get oriented with the patient.
Allergies:
To meds
To topical agents
To latex: OR should be prepped for this in advance
Regarding urination and bowel movements, what is preferable before surgery and why?
Voiding or indwelling catheter (straight catheter).
Want the bowels clear prior to surgery to prevent infection - Allows the surgeon to see the bowels more clearly.
What are the steps to the Time Out Protocol and why is it used?
Prevents sentinel event - before surgery
Done at the start of the procedure and identifies:
Right patient with two identifiers - name/DOB
Correct procedure
The site marked - by the surgeon and patient
Implants identified - what patients are not born with - can affect the positioning of surgery
Imaging - MRI
Correct meds and allergies
The following are later signs of what condition?
Elevated temp - Up to 111.2 F – basically max temp
Myoglobinuria - High protein in the urine
Multiple organ failure
Malignant hyperthermia
What kind of GI activity is to be expected after surgery?
What can be done?
Decreased peristalsis 24 hours after - constipation
Ambulate
Listen for bowel sounds and flatus
Can give Stool softeners, laxatives, or fluids
What are interventions for someone with Post Op Delirium?
Reorient
Implement fall risks
Frequent rounds
Low doses of analgesics
Patient is 48 hours postoperatively following open reduction and internal fixation of a fractured tibia. Which of the following should the nurse report to provider?
A. Toes that are cold to the touch
B. Serous drainage from the pin sites
C. Blanching of the toenail beds with pressure
D. Pink tissue around the fixator insertion sites
A - Toes that are cold to the touch - manifestation of compartment syndrome following internal fixation.
B - Serous drainage expected first 2-3 days after procedure.
C - Blanching with pressure is expected
D - Pink to red tissue at the fixator insertion sites expected for the first 2 to 3 days following procedure
During surgery is called?
Name four priorities during surgery.
Intraoperative
Identifying rights, communication with the team (SBAR reporting), safety, preventing complications
The following are characteristics of which surgical risk factor:
Thermoregulation – temperature regulation not ideal
Hypothermia = issue
Altered fluid balance = requires more pushed
Special consideration with meds
Age - both old and young
Dangers of Postoperative nausea and vomiting (PONV) with surgery and what to do:
Aspiration
Dehydration
Arrhythmias - Low potassium
Electrolyte loss
Can give meds pre, intra and post (before, during, after)
PT-INR
Name something you'd want to collect preoperatively and then again postoperatively.
Hint: to compare
Vital signs
Want a good heart rhythm. Cardiac work up may be ordered otherwise.
Always assess
Patients can take up to 6 hours before the surgery.
Non-human milk
Light meal or toast
The following describes what role in the OR:
Suturing - Control bleeding - Expose the surgical area
Handling and cutting of tissue - Irrigating during the procedure
Registered nurse first assist
These are characteristics of what type of anesthesia:
Decreased sensation in a particular area of the body
Anesthetizing sensory pathways
Injecting an anesthetic along a nerve
Could be spinal, epidural, or "nerve block"
Regional anesthetic
What are the expected neurological outcomes post-surgery?
What can be affected as a result?
How do we accommodate patient decision-making?
Will have decreased level of consciousness and be drowsy
This may affect the airway
Explain things slowly – Encourage non-drastic decision making
What's the last courtesy that we show the patient before being discharged and it's as needed only?
Make referrals
PT, OT, Home health nurse
Follow-up wound care
Social services, Community Resources
Financial assistance, follow-up appointment
Preoperative teaching provided for patient who is scheduled for total knee arthroplasty. Which indicates an understanding of the teaching?
A. "I will wear a continues movement machine on my knee for 24 hours a day
B. "I should avoid taking NSAID meds for pain after surgery."
C. "I should wear elastic stockings on both my legs."
D. "I will begin exercising my legs the day after surgery."
C - "I should wear elastic stockings on both my legs."
A - Continuous movement machines are meant to be used for only a few hours at a time, several times a day. Not all patients prescribed this after surgery.
B - Pain initially addressed with analgesics and supplemented with additional meds, including NSAID's.
D - Instruct client to begin leg exercises while in bed during immediate post op period. Including heel pumps and quadricep setting exercises.
Has to do with purpose. Answer and provide an example.
With this type of surgery, the patient:
Confirms a diagnosis or surgery is exploratory.
Diagnostic surgery.
EX: Exploratory laparotomy
The following are characteristics of which surgical risk factor:
Daytime sleepiness
Poor concentration - Due to not sleeping well
Irritability
Obstructive Sleep Apnea (OSA)
Four things that hormones Aldosterone and Glucocorticoids are responsible for
Retain water and sodium
Deplete potassium
Cause shifts in electrolytes and fluids
Will be released by body under stress
First three main risk factors for VTE's:
Total anesthetic and surgery time more than 90 minutes
Surgery time of 60 minutes of surgery in pelvis or lower limb
Acute admission with inflammatory or intra-abdominal conditions
While taking the patient's medical history preoperatively, what are you screening for?
What are some red flag conditions?
Diabetes, Heart disease
History of Deep vein thrombosis (DVT) or Pulmonary Embolism (PE)
Pregnancy, Seizures, Malignant hypothermia
Any type of bleeding or clotting disorder
Name items that should be taken off of a patient before surgery.
Remove hair accessories, jewelry, and other metal items
Due to cautery procedures
Removal of: Dentures, hearing aids, contacts
What is one major thing that should be done to the operating limb? What is it considered if the wrong limb is operated on?
The limb/site should be signed by the patient and surgeon.
The wrong limb worked on = Sentinel event and malpractice
Important things to consider with the respiratory system.
Monitor lung sounds
Maintain airway - watch for obstructions
How much urinary elimination should a healthy patient display?
30ML an hour
Give fluids!
Blood in the urine is normal with urology patients
The following patients are at risk for what?
Dental issues
Esophagus disorders (heartburn, cancer)
Neurological disorders (Parkinson's, stroke)
Aspiration
Providing teaching to patient about surgical procedure scheduled for later in the day. Patient states no one has spoken to her about the procedure before. Which action should nurse make?
A. Continue the teaching, but check afterward with the surgeon about informed consent.
B. Stop the teaching and check with the surgeon about informed consent.
C. Stop the teaching and ask the client to sign an informed consent form
D. Continue the teaching and check the clients medical record afterward for a signed consent form
B. Stop the teaching and check with the surgeon about informed consent.
A - Informed consent not given
C - Not within the scope of practice to obtain informed consent
D - Informed consent not given
Has to do with purpose. Answer and provide an example.
With this type of surgery, the patient:
Needs to repair a body part or resolve a health problem.
Curative
EX: Gallbladder removal
The following are characteristics of which surgical risk factor:
Serious condition for clients with pre-existing neurocognitive disorders (Alzheimer’s, Hx stroke, Parkinson’s)
Considerable risk when anesthesia is involved
Age-related for older adults
Post Op Cognitive Dysfunction (POCD)
Dangers of GI disorders with surgery and what to do:
Hypervolemia
Could vomit out fluids or not absorbing it
Dehydration
Diarrhea/vomiting
Three additional tests are done preoperatively:
EKG: If prior heart disease
Pregnancy test: If less than 55 years old
Imaging: X-ray sometimes done the same morning if looking for kidney stones (determine positioning)
What is one thing you want to consider with Diabetes before surgery?
Check blood sugar before surgery
An instrument you will likely educate the patient on and how to use it:
Incentive Spirometer - Do 10x an hour
The following describes what role in the OR:
Set up sterile field
Set out instruments needed for the procedure - Lined up by a sterile drape
Will anticipate what the surgeon will need at a particular moment
Certified surgical technologist (scrub nurse)
These are characteristics of what type of anesthesia:
Depressed level of consciousness
For short procedures
Extremely drowsy
Common med = Versed
Moderate (conscious) sedation
An older adult stated that they've received pain meds for years and have a high tolerance. Demanding a higher dose but have not received the surgery yet and are in no pain. What do you do?
Older adults should get fewer pain meds
Address concerns therapeutically and move on.
What is a method that encourages and maintains a healthy respiratory tract?
TCDB
Turn, Cough, Deep, Breath
Patient unstable, vitals measured every 15 min using machine. Nurse notices the machine is measuring BP at varied intervals, and readings are inconsistent. What should the nurse do?
A. Turn the machine on every 15 min to measure clients BP
B. Record only BP readings needed for 15-min intervals
C. Obtain manual and automatic readings and compare them
D. Disconnect the machine and measure BP manually every 15 min
D. Disconnect the machine and measure BP manually every 15 min - Use manual process and get rid of machine
A - Machine is questionable. Operating the machine differently cannot ensure accuracy. Tag machine and remove it
B - Machine is questionable. Operating the machine differently cannot ensure accuracy. Tag machine and remove it
C - Machine is questionable. Operating the machine differently cannot ensure accuracy. Tag machine and remove it
Has to do with purpose. Answer and provide an example.
With this type of surgery, the patient:
Requires an entirely new organ
Transplant surgery
EX: Lung transplant
Name surgical complications for Obstructive Sleep Apnea (OSA)
Pulmonary complications
Apnea during surgery, Post op apnea
Not getting good gas exchange
Poor ventilation
The following are characteristics of what?
Can travel to lungs and become pulmonary embolism
60% of clots happen in the hospital
Deep vein thrombosis (DVT)
Venous thromboembolism (VTE)
Deep vien thrombosis = type of VTE
Pulmonary embolism is a complication of DVT
Preventions for VTE's:
Exercises
Making circles with feet
Raising leg up
Squeezing of the thigh
Hydration
What is something you can do as a preventative measure for VTE's?
TED hoes
Sequential Compression Devices
IV fluid replacement. This IV flows out of the bloodstream into cells. It replaces cellular fluid - but should NOT BE USED for surgery - CAN LEAD TO DEHYDRATION.
Hypotonic
Ex: 0.45% Sodium chloride
What are the steps to SBAR reporting?
Specific
Background
Assessment
Recommendation/request
The following are symptoms of what condition?
Causes a hypermetabolic state in the body
Increased calcium levels
Triggered by anesthetic agents
Genetic condition
Malignant Hyperthermia - LIFE THREATENING – EMERGENCY
How long should a surgical dressing be left on before being changed?
24 hours
Then change PRN - so long as no infection
Provide patient education for discharge:
How to:
Change dressing, Splint, Take Meds, Eat well (protein), Exercise
Recognize:
Infection, Dehiscence, No tub bath, Too much bleeding, Too much pain, Unable to move
Receiving a client from the PACU who is postoperative following abdominal surgery. What should the nurse do to transfer client from stretcher to bed?
A - Lock the wheels on the bed and stretcher
B - instruct patient to raise arms above head
C - Elevate the stretcher 2.5 cm (1 in) above the height of the bed
D - log roll the patient
A - Lock the wheels on the bed and stretcher
B - Patient should cross arms to avoid injury
C - Stretcher should be no more than 1.3 cm (0.5 in) above the height of bed
D - Log rolling is for immobilization of neck, back, or spine - not abdominal surgery
Has to do with urgency. Answer and provide an example.
With this type of surgery, the patient:
Has a choice to have this specific procedure done, not always a necessary surgery
Elective surgery
EX: Nose job - cosmetic
The following are characteristics of which surgical risk factor:
Difficulty intubating, Lower O2, Increased time to process the anesthesia
Respiratory complications when given narcotic pain meds or others that cause sedation
Increased risk for DVT, Less ability to adapt in cardiovascular and respiratory
Cardiovascular, perfusion, and ventilation issues
Obesity
The following are symptoms of what condition during fluid imbalances?
Excess fluid in vascular space
Fluid overload
Renal or heart failure due to excess fluid
Hypervolemia
Additional considerations for VTE's:
Thicker blood = easier to clot
Blood cools = easier to clot
Exercise makes things better
Documentation that you must have before taking a patient to surgery?
The patient's Advanced Directive - Must go in the patient's chart.
Documentation of consent - the nurse can be a witness to the signing
Concerns need to be reported to the surgeon or anesthesiologist
Give antibiotics before surgery - 1 hour before surgery
Continue antibiotics postop - 24 hours
Check allergies before giving antibiotics
Skin antisepsis - Chlorohexidine wipes - Chlorohexidine shower night before - skin prep
Clip hair - don't shave - can also leave hair if the surgeon wants
Clean OR room with Beta thine
Who keeps the family informed during surgery?
Circulating nurse - only one unscrubbed
Nurse Liaison
The following are early signs of what condition?
Tachypnea - Difficulty breathing
Tachycardia - High heart rate
Heart arrhythmias
Hyperkalemia - Increased potassium
Muscular rigidity - Mostly in the jaw or chest
Malignant hyperthermia
The following are signs of what condition?
Tachycardia
Decreased BP
Drowsiness
Decreased level of consciousness
Cool, clammy, pale in the face
Hypovolemic shock
Treat with fluids
A patient wishes to no longer receive surgery. Which of the following actions should the nurse take?
A - Tell the patient it's too late to change her mind because the surgery is already scheduled
B - Telephone the operating room and cancel the surgery
C - Inform the client's family
D - Notify the provider of the client's decision
D - Notify the provider
Nurse demonstrating postoperative deep breathing/coughing exercises to a client who is scheduled for emergency surgery for appendicitis. Which indicates a lack of readiness to learn?
A. Patient asks nurse to repeat the instructions before attempting.
B. Patient reports severe pain.
C. Patient asks nurse how often deep breathing should be done after surgery.
D. Patient tells nurse this exercise will probably be painful after surgery.
B. Patient reports severe pain. - Severe pain = not able to concentrate
A - Asking nurse to repeat instructions demonstrates readiness to learn.
C - Asking about the frequency demonstrates readiness to learn
D - Thinking about possible affects of exercise demonstrates readiness to learn
Has to do with urgency. Answer and provide an example.
With this type of surgery, the patient:
Necessary for help and done to prevent further complications.
Urgent surgery.
Colon tumor removal - Palliative
The following are characteristics of which surgical risk factor:
At risk for infection due to altered immune function
Immunosupression
Name four diseases that place a patient for greater risk of fluid imbalances.
Diabetes
Renal disease
GI disorders
Cardiac abnormalities
What condition are the following signs and symptoms of?
Chest pain - Especially when taking deep breaths
Difficulty breathing
Tachycardia
Hypoxia
Pulmonary embolism (PE)
Complication of DVT
Part of clot of DVT breaks off and travels to lungs – blocking it
List the type of medications you DO NOT take on the day of surgery:
Insulin
Ace inhibitor (-pril)
ARB
NSAID or other blood thinners: Ibuprofen, Aspirin
Patients can take up to 2 hours before the surgery.
Clear liquids
Ways to monitor the patients ongoing clinical status during surgery:
Vital signs
Capnography
I/O
If you listen for lung sounds and you hear crackles, what do you do?
Raise head of bed
Give diuretic
Give nebulizer Tx
Back down on fluids
How long do we expect pain to be present, how often do we check and what can occur due to pain meds?
First 24-48 hours
Pain assessment every 4 hours
Respiratory depression if too many pain meds - check O2 sat
Vital signs. Which one is outside of expected range?
A - Pulse rate 90/min
B - Rectal temp 38 C (100.4 F)
C - Pulse Oximetry 95%
D - BP 145/90 mmHG
D - blood pressure
Older adult patient becomes agitated when nurse requests dentures be removed prior to surgery. Which response is best?
A. "It's for your safety. Dentures can slip and block your airway during surgery."
B. "You wouldn't want your teeth to be lost or broken during surgery would you?"
C. "The anesthesiologist requires all clients to remove their dentures."
D. "What worries you about being without your teeth?"
D. "What worries you about being without your teeth?"
A. Nontherapeutic - ignores patients feelings
B. Nontherapeutic - disagreeing and offering advice
C. Nontherapeutic - focuses on inappropriate issues
Has to do with urgency. Answer and provide an example.
With this type of surgery, the patient:
Must get the surgery immediately to preserve life and/or body part.
Emergency surgery
Hemorrhaging - Curative
The following are characteristics of which surgical risk factor:
Deficiencies in vitamins + protein
Poor wound healing
Patients at risk:
Very thin, Obese
Nutrition
Dangers of Diabetes with surgery and what to do:
Glucose can get high or low
If above 200, insulin should be given
Typically tell patient not to take diabetes meds
Name some labs to consider preoperatively.
CBC, PT-INR
Hemoglobin - hematocrit
Platelets, White blood cell count
Electrolytes (CMP, Sodium, Potassium, Creatinine, BUN)
Pregnancy test, Urine culture
List the type of medications you DO take on the day of surgery:
Beta-blockers - Meds that end in (-lol)
Seizure meds, Anti-acids
Insulin if glucose is really high (over 200)
Acid reflux medications
Pain meds if under a lot of pain (non-blood thinning)
Patients can take up to 4 hours before the surgery.
Breast milk
The following are aspects of what?
Prevents distraction, Clarifies which limb needs to be prepped and operated on
Education should be done at pre-op
Keeps communication clear, Verifies correct meds
Verifies allergies
Time out procedure
What should be assessed to prevent malignant hyperthermia?
Drop in O2 sat
Increase in entitle CO2
Heart rate, Temperature
Labs - monitor calcium levels
What kind of diet should be encouraged after surgery?
PROTEIN for wound healing - but overall good nutrition
Patient is postoperative and Hx of poor nutrition. Which one should be chosen to promote wound healing?
A - limit calories to 25 kcal/kg of weight
B - Provide 500 mg/day of Vitamin E
C - Limit fluids to 20 mL/Kg of body weight per day
D - Provide protein 1.5/kg of body weight per day
D - Protein 1.5/kg of body weight per day = maintains (+) nitrogen balance, which promotes wound healing
A - Need 35 - 40 kcal
B - Not essential for wound healing
C - Fluids should be encouraged and 30 - 35 mL/kg
Nurse communicating with a group about postoperative phase for surgery. Which is effective communication?
A. The motivation for communication is evident
B. Feedback is provided
C. A message is communicated to the group of clients
D. Multiple channels are used by the sender
B. Feedback is provided - Feedback indicates understanding
A - Not effective.
C - Message might be delivered but not necessarily effective.
D - Can improve communication but doesn't determine it effective.
Has to do with purpose. Answer and provide an example.
With this type of surgery, the patient:
Is trying to resolve issues with appearance.
Cosmetic surgery
EX: Nose job
Name contributing/risk factors for Obstructive sleep apnea (OSA)
Round/short neck
Obesity
Large Uvula
Enlarged tonsils
Smoking
Oropharyngeal edema
Dangers of Renal disease with surgery and what to do:
Hypervolemia: Excess fluid, Not getting rid of it regularly
Don’t want to give these patients many fluids
Labs to consider preoperatively that screen for bleeding (hemorrhage)
CBC
Platelets - If low
PT-INR - If High (decrease Warfarin)
PTT-aPTT - If High (decrease Heparin)
The provider will order meds to hold - must let the anesthesiologist know if the hold is violated (patient took meds mistakingly)
Considerations for pain relief measures.
Depends on the procedure and doctor
Want to stay on top of the pain. Don’t want the pain to get to a 10 to give pain meds.
Basic understanding of what will be done with pain.
Spinal anesthesia wears off a few hours after surgery, others can last much more.
The only role in the OR who remains unscrubbed.
Circulating nurse
What is something that may be compromised by anesthesia and what do you do if blood pressure is low?
If BP is high?
Circulation could be compromised
Give fluids/blood if blood pressure is low
Monitor/give meds if BP is high
Name interventions for fall risks:
Bright colored socks
Sign on the wall
Gait belts
Bed alarm
2 nurses needed first time gets up
A - "It'll be small enough that it won't show when wearing a bathing suit."
B - "Not our biggest concern right now. You'll be fine."
C - "You should be happy. No more pain."
D - "What's your favorite class in school?"
A - "Small enough that won't show in a bathing suit" - creepy, but best answer out of all available
B - Minimizes patient concerns
C - Minimizes patient concerns
D - Changes the subject
Patient immobile due to hip surgery. Which interventions should nurse take to prevent complications of immobility?
A. Move patient from supine to low fowlers position every 2-3 hours to prevent orthostatic hypotension
B. Limit fluid intake to 1 L (33.8 oz) in 24 hours to help prevent dependent edema.
C. Encourage the client to turn from side to side every 3-4 hours to help prevent respiratory complications
D. Instruct client to perform foot and leg exercises every 1-2 hours while awake to prevent thrombophlebitis
D. Instruct client to perform foot and leg exercises every 1-2 hours while awake to prevent thrombophlebitis
A - Not sufficient to prevent orthostatic hypotension, only moving them slowly helps
B - Immobile patients should ingest 1.1 - 1.4 L (37.2 - 47.3 oz) of fluid in 24 hours to help prevent bladder complications. Limiting fluid intake does not prevent dependent edema.
C - Patient should cough and breath deeply every 1-2 hours to prevent respiratory issues. This also helps prevent skin breakdown.
Has to do with the seriousness.
This type of surgery is when there are slight alterations to the body.
Give one example.
Minor surgery
Cataracts
Name health risks that can be developed from Obstructive Sleep Apnea (OSA)
Hypertension, Stroke, Weight gain, Neurocognitive deficit, Diabetes, Pulmonary/cardiac disease
The following are symptoms of what condition during fluid imbalances?
Low plasma levels or volume depletion in vascular space
Fluid depletion
Hemorrhaging
Low BP due to lack of fluid in vascular space
Hypovolemia
Labs to consider preoperatively that affect drug concentration?
Any that indicate poor kidney function:
BUN - High value
Creatinine - High value
During a physical examination, what are three things we always look for?
Skin breakdown
Last bowel movement
Pedal pulses
Patients can take up to 8 hours before the surgery.
Meat or fried foods.
Identify the role of the Circulating nurse.
Patient care - positioning, skin prep, meds, implants
Placement/function - sequential compression devices, warming devices
Surgical count for instruments/sponges
Maintain sterile equipment and field
Specimens for lab
What does Some Hot Dude Better Give Iced Fluids Fast mean?
Stop-triggering agent
Hyperventilate/hundred percent oxygen
Dantrolene
Bicarbonate
Glucose
IV fluids/cooling blanket
Fluid output monitoring/Furosemide
Fast heart (tachycardia)
What kind of urinary elimination is to be expected after surgery?
What can be done?
Should urinate 8-12 hours after surgery
If not, can:
Do a bladder scan & call the provider
Patient states "I'm afraid coughing will hurt after surgery". Nurses response:
A - "After the surgeon removes the lung, you won't need to cough."
B - "I'll make sure you get a cough suppressant so you don't strain the incision when you cough."
C - "Don't worry. PCA gives pain meds PRN.
D - "I'll show you how to splint incision."
D - I'll show you how to splint the incision - Want them to cough to get build-up out and splinting helps pain
A & B - You want them to cough to clear secretions
C - Don't worry = bad communication and pain meds keep pain tolerable, doesn't make them pain free.
Has to do with the seriousness.
This type of surgery is when there are significant alterations to the body.
Give two examples.
Major surgery
Transplants and open heart surgery
The following are characteristics of which surgical risk factor:
The tongue or soft palate obstructs the airway during sleep
This causes them to stop breathing - 10 seconds or longer, 5x an hour
Obstructive Sleep Apnea (OSA)
Name the two hormones that regulate Fluid and Electrolyte Imbalances:
Aldosterone
Glucocorticoids
Medications for VTE's:
Blood thinners:
Enoxaparin (Lovenox) - LMWH
Factor Xa inhibitors:
Xarelto - Rivaroxaban
Eliquis - Apixaban
List foods that can cause allergy complications:
Food allergies can increase the risk of latex allergies
Strawberries, Bananas, Kiwi, Nectarines, Tomatoes, Avocadoes, Potatoes, Wheat, Chestnuts,
Berries in general
IV fluid replacement, this type of IV replaces blood volume and is the only one that should be used in surgery.
Crystalloids: Isotonic
Example: 0.9% sodium chloride (Normal Saline), lactated Ringers (L.R)
Important in hemorrhage, shock, or general fluid losses from surgery
Will stay where it needs to be (in vascular space)
What is something to keep in mind for patients with urology implants?
Cannot insert a urinary catheter
These are characteristics of what type of anesthesia:
Numbing in a particular area - sometimes topically
On the incision site - numbs a small area
Local anesthesia
Main issues with nausea & vomiting
Dehydration
Discomfort
Longer healing time
Dehiscence
Patient is postoperative, following hip replacement surgery. Patient feels apprehensive and restless. What should the nurse recognize as an indication of pulmonary embolism?
A. Sudden onset of dyspnea
B. Tracheal deviation
C. Bradycardia
D. Difficulty swallowing
A. Sudden onset of dyspnea - Pulmonary embolism has a rapid onset. Dyspnea occurs due to reduced fluid in the lungs
B - Happens due to pneumothorax
C - Would be Tachycardia for PE
D - Difficulty swallowing indicates many conditions, including oral cancer
Has to do with purpose. Answer and provide an example.
With this type of surgery, the patient:
Requires relief of the intensity of the disease and/or its symptoms. Does not necessarily cure the disease.
Palliative surgery.
EX: Ostomy for colon cancer
List how to take care of patients with Obstructive Sleep Apnea (OSA) during surgery
Pay close attention to O2 sat - Going down indicates a blockage
If blockage: Change their position, Jaw thrust to open jaw
Not give as many sedations
Lying them on back = negative effects for breathing
The anesthesiologist will make the patient open wide to determine if they will have issues maintaining an airway
This happens to 30% of patients who have surgery postoperative – common
Postoperative nausea and vomiting (PONV)
Labs to consider preoperatively that screen for fluid imbalances?
Hemoglobin: Oxygenated blood imbalances
Hematocrit: Blood volume, low = overload, high = dehydration
Sodium: low = fluid overload, high = dehydration
BUN: low = bad liver, overload, high = bad kidney's/renal, dehydration
Creatinine: low = Malnutrition, high = bad kindey's/renal
Chloride = follows sodium
When providing therapeutic communication, what are some main things you never want to do?
Never:
Ask "why" ;)
Falsely reassure (not a fortune teller)
Ignore/not address the concern and move on
The right answer is usually to rephrase the question
The first time a patient gets out of bed, what are you worried about?
Two people are needed the first time a patient gets out of bed
Fall risk
Considerations for keeping the patient comfortable, name them:
Can give antiemetics for nausea - Haldol
Pain meds if a lot of pain
Anti-anxiety if a lot of anxiety
Anti-acid reflux - Pepcid, Versed
What do you do if a patient is bleeding too much?
Give blood
Give fluids
Apply pressure to the sight
How much fluid/food should be given to a new surgical patient right away? What types?
Gradual increases
Jello and juice - monitor and advance from there
What goes in should come out - monitor I & O
Postoperative following a hip arthroplasty. In Hx, history of Chronic Obstructive Pulmonary disease (COPD). Which oxygen delivery methods should be used?
A. Simple face mask
B. Nonrebreather mask
C. Bag-valve-mask device
D. Nasal cannula
D. Nasal canula - delivers precise concentration of O2 which is necessary for COPD
A - Simple face mask provides O2 flow rate that is harmful for COPD
B - Nonrebreather mask provides O2 at flow rates that is harmful for COPD
C - A bag-valve-mask (Manuel resuscitation bag) is a handheld device that provides ventilation to a client who is not breathing or who is breathing inadequately
After surgery is called?
Name three priorities after surgery.
Postoperative
Communication with the team (SBAR reporting), safety, preventing complications
List factors that help patients with Obstructive Sleep Apnea:
Changing positions
Weight loss
Bi-Pap or C-Pap machine
Two conditions that occur due to fluid imbalances:
Hypovolemia
Hypervolemia
Additional risk factors of VTE's:
Very reduced mobility after surgery
Active cancer
60 +
Dehydration, Critical care admission, Obese
Known clotting disorder, Pregnant women
If a patient is feeling stressed over the surgery, what are some things we could do for them preoperatively?
Meet their spiritual and cultural requests: give quiet time to pray if requested
Provide anti-anxiety medications
IV fluid replacement. This IV shifts fluid into the blood vessel - but should NOT BE USED for surgery - CAN LEAD TO FLUID OVERLOAD.
Hypertonic
Ex: 3% Sodium Chloride
Identify physical preparations during surgery.
Strap patient down to OR table - position
Hook up vitals - HR, Heart rhythm, Pulse ox, Capnography for CO2
Sequential compression devices and forced air warmer
How do you treat malignant hyperthermia?
Get on O2 – intubate
Give insulin/glucose to lower potassium - gets it out of the bloodstream and back into cells
Keep on heart monitor - Vital signs
Foley
Ice for the temperature - Cooling blanket - Cool IV fluids
Bicarbonate IV fluid to regulate PH of blood
What are interventions for Nausea and vomiting?
Splint abdominal wounds
Give:
Antiemetic's
Advance diet slowly
Alcohol swab to nose
Nurse providing discharge teaching for a client who had a left total hip arthroplasty. Which statement indicates effective teaching?
A - "I should expect swelling of the affected leg for several weeks."
B - "I should not cross my legs at the ankles or knees."
C - "I will inspect my hip incision every other day for redness."
D - "I can bend over at the hip to pick up objects."
B - "I should not cross my legs at the ankles or knees." - This could result in dislocation of femoral head
A - Patient needs to call provider for swelling that is present for that long. could be indication of DVT
C - Patient needs to inspect the incision site daily for redness and warmth. Indicates infection.
D - Patient needs to avoid bending at the hip. This can cause dislocation of the hip following surgery.
Has to do with purpose. Answer and provide an example.
With this type of surgery, the patient:
Requires improvement in the structure or function of a damaged body part.
Reconstructive surgery
EX: Hip replacement surgery
The following are characteristics of which surgical risk factor:
Confusion/disorientation
Temporary – may come and go days to weeks after surgery
Age-related for older adults
Post-Op Delirium
What is an adverse drug effect from opiate analgesics?
Postoperative nausea and vomiting (PONV)
Labs to consider preoperatively that screen for infection or heart arrhythmias:
White blood cell: High = infection, Low = Poor immunity
Potassium: High or low = heart arrhythmias
What are some aspects of anesthesia use to consider when noting medical history preoperatively?
Check for complications or issues in the past:
Hard time waking up from anesthesia
Nausea and vomiting
High blood pressure
Additional things you will educate the patient on.
Sensory preparation - Explain what people may feel post op
Activity resumption/rest - Basic understanding of what activity will be like after surgery
During surgical verification, what are two key aspects of overall communication?
Hand-off communication - SBAR reporting
Time out protocol
With DVT prevention, what are we looking for and how do we prevent it?
Looking for clotting
Encourage activity, leg exercises, and blood thinners if needed
Compression devices as well
At what point after surgery could you see signs of infection?
3-6 days
Will not see infection on the first day after surgery
Patient with pelvic fracture. Client reports sudden SOB, stabbing chest pain, and feelings of doom. What is this complication?
A. Pneumonia
B. Pulmonary embolism
C. Tension pneumothorax
D. Tuberculosis
B - Pulmonary embolism - immobility increases the risk. Patient could also have Tachycardia, chest petechiae, decreased SaO2.
A - Productive cough and pleural pain as findings of pneumonia, which is a complication of immobility following pelvic Fx. Expected
C - Tracheal deviation and absent breath sounds of affected side for tension pneumothorax expected with chest trauma or mechanical ventilation
D - Anorexia, fatigue and night sweats is expected with tuberculosis. Also causes hemoptysis and chest tightness
Before surgery is called?
Name four priorities before surgery.
Additional things to look out for.
Preoperative
Client education, communication with team (SBAR reporting), safety, preventing complications
Pressure injuries, burns, falls
The following are characteristics of which surgical risk factor:
Increased complications before and after surgery, secretions are thicker - can cause pneumonia or atelectasis, poor wound healing.
Increased risk: clotting, bleeding, myocardial infarction, infection, death
Smoking
The anesthesiologist may have a difficult time due to having to regulate breathing
The following are characteristics of which surgical risk factor:
Regulated by hormones
Released by body under stress
Fluid and electrolyte imbalance
What condition are the following signs and symptoms of?
Redness, Pain
Swelling – sometimes unilateral, one swells more than other
Tenderness, Warmth
Deep Vein Thrombosis (DVT)
Blood clot originates deep in vein - often extremities
What is something you want the patient to be able to recite to you, before surgery?
If unable to, what do you do?
If they cannot explain the procedure, call the provider. Your job is to provide limited info and clarification.
What are some things you will educate the patient on mainly?
Estimated surgery time
Anticipated monitoring and therapy - quick understanding - Before, during, and after
PT
Heat/ice therapy - Pain regiment - PCA pump
Postoperative unit and waiting area
Where the patient is going afterwards and where relatives should wait
What is something to consider when intubating the patient?
Ask about caps or crowns
So that when intubating, doesn’t break off and obstruct the airway
These are characteristics of what type of anesthesia:
Unconscious, Lose all sensation, Lose refluxes
Muscle relaxation, Amnesia, Memory loss
Given IV or inhalation, CRNA will give
Effects don’t stick around very long
Will stop giving towards the end of the procedure
General anesthesia
How should a patient be positioned after surgery?
Keep in normal alignment
Elevate the extremity - Helps with swelling, pain, and circulation
Patient had a below knee amputation for gangrene of the right foot. Patient reports burning & crushing pain in the toes of the absent foot. Which statement should the nurse make?
A. "This type of pain usually decreases over time as the limb becomes less sensitive."
B. "Try to look at the surgical wound as a reminder the limb is gone."
C. "Use a cold compress intermittently to decrease these pain sensations."
D. "Grief over the lost limb can sometimes cause denial that the limb is really gone."
A - "This type of pain usually decreases over time as the limb becomes less sensitive." - Phantom limb pain. Instruct that it goes away over time. Recognize the pain, provide Tx, and handle the limb gently to decrease risk of triggering pain.
B - This statement does not address patient concerns
C - Patient should use heat and massage, along with meds, to manage this type of pain
D - Patients report of pain should be validated and treat it accordingly. Patient is not exhibiting denial.