clinical nursing concepts/perioperative care/john hale 2

Of the following, which are also appropriate at this time? Select all that apply (there are 3 correct answers). Contact lenses should be removed Correct Contact lenses should be removed before surgery. Any dentures should also be removed, to avoid the possibility of airway obstruction or interference with intubation. Preferably, a family member can hold or secure personal items, including any jewelry or eyeglasses, until they are needed. Mr. Hale should be asked to void Correct Mr. Hale should urinate before surgery, before any preanesthesia medications are given. The bladder should be emptied to prevent urinary incontinence during surgery and avoid urinary retention after surgery. Also, a full bladder could obstruct surgical view and possibly be injured during surgery. Vital signs should be taken and recorded Correct Vital signs should be taken before surgery, and recorded. Preoperative vital signs establish a baseline for postoperative comparison. Baseline vital signs should be determined before the depressant effects of any preanesthesia medications have taken effect. Mr. Hale's baseline vital signs are BP 124/80, apical pulse rate 86, respiratory rate 20. His temperature, taken with a tympanic thermometer, is 36.6 degrees C (97.9 degrees F). Preoperative blood pressure and pulse rate may be higher than usual, because of the emotional stress associated with surgery. Mrs. Hale should be asked to leave The presence of a family member or other support person can be comforting and alleviate anxiety. Usually, family members are permitted to stay until the patient is taken to the Surgical Suite. Mrs. Hale need not be asked to leave at this time.

Surgical site marking is required for some procedures. For which of the following procedures would site marking be required? Select all that apply (there are 3 correct answers). Hint Left leg above the knee amputation Correct Surgical site marking is designed to prevent wrong procedure and wrong site surgery. Site marking directs the surgical team to the correct location for the surgical procedure. Surgical site marking is required for all procedures that involve right/left distinction, multiple structures (e.g., finger, toes etc.), or levels (e.g., spinal surgery). For a left leg above the knee amputation, the left leg would be marked at the level of the amputation. Right inguinal hernia repair Correct Surgical site marking is designed to prevent wrong procedure and wrong site surgery. Site marking directs the surgical team to the correct location for the surgical procedure. Surgical site marking is required for all procedures that involve right/left distinction, multiple structures (e.g., finger, toes etc.), or levels (e.g., spinal surgery). For a right inguinal hernia repair, the right side of the lower abdomen would be marked. Cesarean section Surgical site marking is designed to prevent wrong procedure and wrong site surgery. Site marking directs the surgical team to the correct location for the surgical procedure. Surgical site marking is required for all procedures that involve right/left distinction, multiple structures (e.g., finger, toes etc.), or levels (e.g., spinal surgery). Generally, site marking is not required for Cesarean section. Protocols for site marking may vary. Cataract removal left eye Correct Surgical site marking is designed to prevent wrong procedure and wrong site surgery. Site marking directs the surgical team to the correct location for the surgical procedure. Surgical site marking is required for all procedures that involve right/left distinction, multiple structures (e.g., finger, toes etc.), or levels (e.g., spinal surgery). For left eye cataract removal, the skin area adjacent to the left eye would be marked. Exploratory laparotomy Surgical site marking is designed to prevent wrong procedure and wrong site surgery. Site marking directs the surgical team to the correct location for the surgical procedure. Surgical site marking is required for all procedures that involve right/left distinction, multiple structures (e.g., finger, toes etc.), or levels (e.g., spinal surgery). Generally, site marking is not required for exploratory laparotomy. Protocols for site marking may vary.

The verbal report you receive from the Post Anesthesia Care Unit (PACU) nurse should include: Select all that apply (there are 6 correct answers). Hint the name of the surgical procedure Mr. Hale had Correct Knowing the procedure the patient had is critical. Your surgical care plan should include standards of care relevant to the surgical procedure, individualized for Mr. Hale. Mr. Hale's relevant health history Correct Comprehensive medical information is collected on every patient prior to surgery. Relevant data in a concise format should be communicated to nurses in all areas. Relevant information from the patient's history includes the patient's age, allergies, medication use, and major health problems (including substance abuse history). Any identified latex sensitivity should also be communicated. Latex-sensitive patients require use of latex-safe equipment, and use of nonlatex gloves by caregivers. The PACU nurse tells you about Mr. Hale and his history of diabetes. A recent fingerstick glucose reading was 142 mg/dl. Mr. Hale's fluid status and IV therapy Correct Fluid balance is a critical assessment postoperatively. Fluids are generally restricted preoperatively and fluid loss is common during surgery. Fluids are generally administered during and after surgery to correct deficits and maintain fluid balance. Knowledge of efforts to maintain fluid balance during and after surgery is critical. Urine output also provides information about fluid status and should be reported. The PACU nurse reports that Mr. Hale received one unit of packed red cells during surgery. In PACU, Lactated Ringer's infused at 125 mL per hour, and continues to infuse. Mr. Hale does not have a Foley catheter and has not voided. information about any tubes or drains Correct Tubes and drains need ongoing assessment and care. Tubes present should be determined when a patient is received from PACU. The PACU nurse reports that Mr. Hale has a vented nasogastric (NG) tube to be connected to suction. NG tube drainage has been bloody, and 75 mL has drained since surgery. Mr. Hale does not have a Foley catheter and he has not voided. information about anesthesia and drugs that were administered Correct Knowing about anesthetics and medications that were administered will enable you to determine drug-specific assessments and interventions, and also to plan for Mr. Hale's pain control. The PACU nurse reports that Mr. Hale had general anesthesia. In PACU, morphine sulfate 2 mg IV was given just prior to bringing Mr. Hale to the Surgical Unit. At that time, Mr. Hale complained of incisional pain, rated as 7 on a scale of 1-10. Morphine provided relief of pain. In PACU, because the depressant effects of anesthetics are generally still in effect, a small dose of a narcotic analgesic usually achieves analgesia. the condition of Mr. Hale's surgical incision Correct The condition of the surgical incision should be reported, including type of wound closure and any dressing. Any bleeding or other drainage at the incision should also be reported. The PACU nurse tells you that Mr. Hale has a midline incision with staples. A gauze dressing applied over the wound is intact, with a quarter-size area of bloody drainage circled. Mr. Hale's religious preference Ordinarily, a patient's religious preference is not included in a verbal report when a patient is admitted from PACU. This information should be accessible, however, in the patient's medical record.

When checking for evidence of cyanosis, which of the following body areas should be observed? Select all that apply (there are 4 correct answers). Hint Axillae Cyanosis is most evident in specific body areas. Areas other than the axillae would more readily show evidence of cyanosis. Nailbeds Correct Cyanosis is most evident in specific body areas, such as the nailbeds. Lips Correct Cyanosis is most evident in specific body areas, such as the lips. Palms of the hands Correct Cyanosis is most evident in specific body areas, such as the palms of the hands. Sternum Cyanosis is most evident in specific body areas. Areas other than the sternum would more readily show evidence of cyanosis. Earlobes Correct Cyanosis is most evident in specific body areas, such as the earlobes.

When a postoperative patient is not responsive, or when an alert postoperative patient is vomiting, which position is preferred? Hint Semi-Fowler's (30 degrees) When a postoperative patient is not responsive, or when an alert postoperative patient is vomiting, the semi-Fowler's (30 degrees) position is not the preferred position. Another position is better for preventing aspiration. Fowler's (90 degrees) When a postoperative patient is not responsive, or when an alert postoperative patient is vomiting, the Fowler's (90 degrees) position is not the preferred position. Another position is better for preventing aspiration. Supine When a postoperative patient is not responsive, or when an alert postoperative patient is vomiting, the supine position is not the preferred position. Another position is better for preventing aspiration. Side-lying Correct When a postoperative patient is not responsive, or when an alert postoperative patient is vomiting, the side-lying position is preferred, to prevent aspiration or obstruction of air passages with mucous or vomit. The depressant effects of general anesthetics can suppress the gag reflex. The patient may not be able to swallow and manage secretions or vomit. The side-lying position facilitates discharge of mucous or vomit from the patient's mouth.

In general, when urine output is measurable, urine output less than 30 mL per hour can reflect volume depletion with poor renal perfusion, and should be reported.

Which actions on your part are indicated in response to Mr. Hale's reluctance to use the incentive spirometer? Select all that apply (there are 2 correct answers). Hint Continue to encourage Mr. Hale to use his incentive spirometer and cough Correct It is important that you continue to encourage Mr. Hale to deep breathe and cough, with use of the incentive spirometer. Suggest that Mr. Hale self-administer morphine before using the incentive spirometer Correct Advising Mr. Hale to self-administer morphine before deep breathing and coughing should help to control any associated discomfort. Use of pain medication before an uncomfortable procedure usually increases cooperation during the procedure. The action of IV morphine peaks at 20 minutes. Mr. Hale can administer a dose 20 minutes before deep breathing and coughing to see if this helps. Ask the respiratory therapist to work with Mr. Hale You can help Mr. Hale without calling the respiratory therapist at this time. These breathing exercises are within the scope of your nursing expertise. Call the physician It is not necessary to call the physician. You can help Mr. Hale independently. These breathing exercises are within the scope of your nursing expertise.

You palpate Mr. Hale's lower abdomen and note suprapubic distention. This is most likely a result of: bleeding It is unlikely that Mr. Hale's suprapubic distention is a result of bleeding. Although internal bleeding might be palpable, it would more likely be reflected in changes in vital signs and skin color (elevated pulse and respiratory rates, gradually decreasing blood pressure, pallor). a distended urinary bladder Correct Mr. Hale's suprapubic distention is probably a result of a distended bladder. Urinary retention is not uncommon after surgery with general anesthesia and Mr. Hale has not yet voided. Urinary retention can impair bladder and kidney function, places stress on the surgical site, and is uncomfortable. It should be alleviated. Mr. Hale states he feels the need to pass urine but knows he can't do so until he stands up. tension in abdominal muscles Mr. Hale's abdominal muscles may be tense, especially when he is in pain. However, suprapubic distention does not reflect abdominal muscle tension. inflammation secondary to surgical manipulation Inflammation will occur at the surgical site, both superficially and in deeper structures as a result of surgery. However, inflammatory effects would not be reflected in suprapubic distention.

You assist Mr. Hale to sitting position on the side of the bed and allow him to dangle for a few minutes. This will help to prevent _________ when Mr. Hale stands. Hint orthostatic hypotension Correct Orthostatic hypotension, accompanied by dizziness, can occur with standing. Under normal circumstances, in response to a position change from horizontal to vertical, sympathetic vasoconstriction prevents pooling of blood in the lower extremities and helps to maintain adequate blood pressure and perfusion of vital organs. Residual effects of the anesthetics and analgesics Mr. Hale received, along with the fact that Mr. Hale has been recumbent and immobile (although for a short time), may make this autonomic response sluggish, and increase the possibility of orthostatic hypotension. Gradual position changes from supine to sitting to standing allow time for the autonomic nervous system to adapt and should help to prevent dizziness and possible injury in Mr. Hale. Mr. Hale's blood pressure drops slightly with sitting and he complains of some dizziness that quickly subsides. orthostatic hypertension Allowing Mr. Hale to sit on the side of the bed for a few minutes before getting off the bed to stand is not done to prevent orthostatic hypertension. orthostatic paresis Allowing Mr. Hale to sit on the side of the bed for a few minutes before getting off the bed to stand is not done to prevent orthostatic paresis. orthostatic paralysis Allowing Mr. Hale to sit on the side of the bed for a few minutes before getting off the bed to stand is not done to prevent orthostatic paralysis.

You assess a postoperative patient and find calf tenderness and swelling. What should you do in response to these findings? Hint Massage the calf to relieve venous congestion Calf tenderness and swelling could indicate that deep vein thrombosis (DVT) is present. NEVER massage the calf area if a thrombus is suspected. Massage could cause a piece of a clot to break off and travel to another part of the body. When a clot travels from one part of the body to another it is called an embolus. A pulmonary embolism (PE) may occur as a consequence of deep vein thrombosis (DVT). Raise the knee gatch of the bed to alleviate venous stasis Calf tenderness and swelling could indicate that deep vein thrombosis (DVT) is present. The knee gatch should not be used if a thrombus is suspected. A raised knee gatch impedes venous outflow from the lower legs and increases risk for thrombus formation. A raised knee gatch applies pressure at the popliteal area, and may increase risk for thrombus formation in the popliteal vein. Encourage the patient to walk to increase peripheral blood flow Calf tenderness and swelling could indicate that deep vein thrombosis (DVT) is present. When deep vein thrombosis (DVT) is suspected, bed rest is indicated to avoid pulmonary embolism (PE). In the early stage of deep vein thrombosis (DVT), thrombi adhere poorly to vessel walls. Bed rest can prevent thrombi migration and PE. Bed rest is generally continued until leg symptoms subside. Elevate the patient's legs to promote venous return to the heart Correct Calf tenderness and swelling could indicate that deep vein thrombosis (DVT) is present. The physician should be notified so the patient can be evaluated. Whether or not DVT is present, leg elevation will be useful in alleviating swelling and discomfort, by promoting venous return to the heart.