Nursing Interventions
How do SCD - Sequential Compression Devices work? What are we trying to prevent?
What is alternating compression (inflation) and deflation of leg stockings...to prevent venous stasis and DVT's
The _______ explains the procedure, available alternatives, and risks of procedure and anesthesia.
The _____ makes sure consent forms list correct surgical procedure and is signed by the patient and physician.
What is the physician and nurse
_____ _____ is called when the patient enters the OR to prevent the risk of the wrong patient, wrong site, and wrong surgery.
What is a time-out.
Which action is most important in PACU?
ABC's, Always check airway first looking for obstruction, stridor, or decreased oxygen saturation. If a patient is unconscious position them on their side to prevent aspiration or if they have difficulty breathing position in semifolwer/fowlers position.
Absolute #1 priority post op care.
What is PATIENT SAFETY (Infection control, positioning, continuous monitoring, aspiration prevention...) Post op surgical nursing uses strict hand hygiene, aseptic wound care (sterile technique for dressings especially for first 48 hours and then as per HCP orders, assessing site for signs of infection (REEDA: redness, edema, ecchymosis, drainage and note any purulent or malorderous drainage), ensure drains e.g. JP, hemovac is compressed and emptied aseptically, position in semifowlers with head turned to side to prevent aspiration, and administer antiemetics, proper positioning promotes lung expansion, continuous monitoring for temp spike, or changes in blood pressure or heart rate to prevent shock, leg exercises and ankle pumps, scds to prevent dvt
Interventions to prevent DVT
What is ambulate, compression stockings, SCD, ankle/foot exercises
What is the minimum laboratory test for all preoperative patients?
What is CBC (hgb, hct, wbc, plt) , UA and EKG
A type of anesthesia where the patient is asleep but not totally unconscious and can breathe on his/her own.
What is conscious sedation.
Type of anesthesia where the patient is totally unconscious and must be intubated
What is general anesthesia.
If a patient does not have a foley, the patient must void within ____ hours, if not an order may need to be obtained to either perform a straight catheter or insert an indwelling catheter.
What is 8 hours.
Interventions to prevent Ineffective breathing or ineffective airway clearance
What is side lying position to protect airway, Turn cough and deep breathe, Incentive spirometry, splint incision, control pain, encourage fluids as tolerated, ensure gag reflex and bowel sounds before offering liquids
How do you perform turning and coughing and deep breathing exercises & how often?
What is splint incision, offer pain medication, deep breath in through nose, hold and cough, use incentive spirometry 10x/hour while awake or turn and position every 2 hours
What is malignant hyperthermia?
A life-threatening reaction to anesthesia marked by high fever, muscle rigidity, and tachycardia. The immediate treatment is stopping anesthesia, cooling measures and giving Dantrolene.
What are the suffixes for the words describing the surgical procedures:
_____: to remove
_____: to create an opening
What is ectomy and ostomy
Patient on 40 % venturi mask post-op and needs to eat. What action is needed?
The venturi mask provides the most precise amount of oxygen to the patient. It cannot be just discontinued. The nurse must get an order from HCP to switch to nasal cannula during meal times. This frees the mouth for eating while providing continuous oxygen support.
Intervention if surgical dressing presents with drainage during first 24 hours.
What is use an ink pen, draw circle around drainage noting date and time.
If dressing is saturated with blood, reinforce with sterile gauze 4x4s or large Abd dressing and notify the surgeon.
DO NOT remove the initial surgical dressing without a physicians order!
Top 3 concerns in PACU following surgery?
Airway/breathing hypoventilation leading to atelectasis a precursor to pneumonia, hemmorhage and hypovolemic shock leading to rapid blood loss or hypovolemia (nurses constantly monitor vitals especially low bp and tachycardia and surgical site drainage. DVT and risk blood clots forming in legs which can travel to lungs (PE).
Serves as the primary patient advocate and is responsible for ensuring that everything is done in the OR is in the best interest of the patient. Responsible for coordination of the surgical team. Maintaining a safe environment and will also take sponge and needle count during, and after surgery.
What is the Circulating Nurse
Repairs anatomical or congenital defect.
What is Corrective Surgery or Reconstructive Surgery. These procedures are aimed at curing the defect and restoring the body part to its normal function and appearance.
This would complicaion is the partial separation of a surgical incision, often preceded by a patient stating they felt a "pop."
Dehisence is the partial or complete separation of the outer wound layers. The nursing actions are focused on protecting the wound and preventing infection by covering the wound with a moistened saline sterile gauze, monitor vital signs, notifying the surgeon and prepare for intervention. Note if the complication proceeds to evisceration or protrusion of organs, the steps are the same but the urgency is higher.
Interventions taken if dehiscence occurs.
What is cover the wound with a large sterile dressing or sterile surgical towel moistened with sterile normal saline. Notify the surgeon immediately. Keep NPO anticipating surgery.
If you are going to administer preop sedatation and notice the consent has not been signed. What should nurse do?
Withhold the medication and notify the surgeon. Once sedated the patient cannot sign the consent.
Sets up the sterile field with all the appropriate sterile instruments and supplies and ensures that the sterility of the field is maintained while actively assisting
What is the Scrub Nurse
Alleviates symptoms and provides comfort, but does not necessarily cure the disease or heal the injury.
Ex: removing as much of a tumor as possible, known as debulking tumor, which can decrease pain an relieve pressure , though it will not cure cancer.
What is Palliative Surgery
What is the first priority postop if patient complains of severe chest pain, dyspnea and becomes hypotensive and tachycardic?
Ensure Airway patency and high flow oxygen. Immediately apply non-rebreather mask to deliver 100 % oxygen to correct hypoxia, place the patient in modified trendelenburg position to promote venous return (unless contraindicated e.g. head injury). Call rapid response and HCP.