clinical nursing concepts/perioperative care/john hale 2

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Upon arrival in the Preoperative Holding Area, Mr. Hale's identity is confirmed. This is best done by: Hint asking his name When confirming a patient's identity, asking the patient to state his name is not foolproof. Patients can have similar names. asking him what surgery he is scheduled for Asking a patient what surgery he is scheduled for is not a foolproof way of confirming his identity. Patients can be scheduled for similar surgeries. checking his identification bracelet and asking his name and birth date Correct To insure accuracy of patient identification, at least two patient identifiers should be used. Checking a patient's identification bracelet and asking his name and birth date are acceptable safe ways to confirm identity. The patient's identification bracelet should contain his full name (correctly spelled), birth date, and an assigned identification number. The name, birth date, and identification number on the patient's identification bracelet should match the patient identity information contained in the patient's medical record and on the surgery schedule.
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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.
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Versed (midazolam hydrochloride) is often used as preanesthesia medication prior to general anesthesia. You expect that the Versed (midazolam hydrochloride) will: Select all that apply (there are 3 correct answers). Hint promote systemic muscle relaxation Correct Versed (midazolam hydrochloride) causes central nervous system depression that should promote muscle relaxation in Mr. Hale. induce local analgesia Versed (midazolam hydrochloride) does not cause local analgesia. induce systemic analgesia Versed (midazolam hydrochloride) does not cause systemic analgesia. decrease Mr. Hale's anxiety Correct Versed (midazolam hydrochloride), a short-acting benzodiazepine, should have an anti-anxiety effect on Mr. Hale. It is a potent short-acting sedative agent that should also make him drowsy. provide for amnesia of perioperative events Correct Versed (midazolam hydrochloride) should effectively provide for anterograde amnesia of perioperative events.
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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.
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You assess Mr. Hale. The most critical, high-priority assessment to be done is: Hint operative site Assessment of the operative site is important. However, another assessment is more critical when a surgical patient is received from the Post Anesthesia Care Unit (PACU). skin integrity Assessment of skin integrity is important. However, another assessment should be done first. pulse Pulse assessment is important. However, another assessment is more critical when a surgical patient is received from the Post Anesthesia Care Unit (PACU). airway Correct The nurse's initial priority when admitting a patient to the Surgical Unit is to determine and insure the adequacy of the patient's airway and breathing. The patient's airway should be assessed for patency. Respiratory rate, rhythm, and quality should be determined. Breath sounds should be auscultated as soon as possible. Mr. Hale is breathing on his own at 16 regular, deep breaths per minute. You know that to meet criteria for discharge from the Post Anesthesia Care Unit (PACU), Mr. Hale had a SpO2 of 94-100% on room air for a minimum of five minutes. SpO2 measures O2 saturation noninvasively by means of pulse oximetry. blood pressure BP assessment is important. However, another assessment is more critical when a surgical patient is received from the Post Anesthesia Care Unit (PACU).
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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.
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You also check Mr. Hale's temperature. Which body temperature variation do you expect? Hint High body temperature Fever is not expected immediately after surgery. In the immediate postoperative period, fever could indicate a complication of anesthesia or surgery, such as malignant hyperthermia or sepsis. Low body temperature Correct Postoperative patients often have a low body temperature that persists even after they are discharged from PACU. The cool room temperature in the OR (generally 68-75 degrees F) contributes to a low body temperature. This cool temperature discourages bacterial growth, minimizes risk for surgical wound infection, and provides a relatively comfortable environment for the surgical team. Anesthetics also contribute to low body temperature. Central nervous system depression associated with general anesthesia interferes with physiological mechanisms that maintain body temperature within normal limits. Peripheral vasodilation associated with spinal anesthesia causes heat loss. In the OR, measures to prevent heat loss include warming of infusions and irrigation fluids, and limiting patient exposure as much as possible (including covering of the patient's head).
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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.
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Which of the following apply to Mr. Hale in this postoperative period? Select all that apply (there are 4 correct answers). Hint Acute Pain Correct Acute pain is expected after major abdominal surgery. Even though Mr. Hale is now comfortable, because he recently received pain medication, it is expected that pain will return if medication is not continued. When pain is severe, it is more difficult to control. Acute Pain is a collaborative problem. To minimize and control pain, medical and nursing interventions are indicated. Morphine has been ordered by the physician. Nursing interventions to promote comfort will also be used with Mr. Hale. These include proper positioning, and providing for hygiene and back care. Self-Care Deficit: Bathing/Hygiene Correct Because of imposed immobility, difficulty moving, depressant effects of medications, and fatigue from the trauma of surgery, Mr. Hale temporarily needs assistance with activities of daily living. The nursing diagnosis Self-Care Deficit: Bathing/Hygiene applies to his care. Impaired Verbal Communication There is no data to support Impaired Verbal Communication as a nursing diagnosis. Mr. Hale is able to communicate his needs. Impaired Oral Mucous Membrane Correct Mr. Hale's mouth and lips are dry and cracked. The nursing diagnosis Impaired Oral Mucous Membrane applies to his care. Lack of oral fluid intake contributes to dry mouth and lips. Dry mouth and lips can also be associated with fluid volume deficit and dehydration. Mouth care is indicated to alleviate the discomfort of dry mouth and lips. Mouth care may include brushing teeth, mouth rinsing, chewing gum, sucking of ice chips (if permitted), and use of a water-soluble lubricant on the lips. Risk for Impaired Skin Integrity Correct Because of imposed immobility and difficulty moving, Mr. Hale is at risk for the development of pressure ulcers. Repositioning Mr. Hale at least every two hours, avoiding pressure on bony prominences, and insuring that his skin is clean and dry, should help prevent pressure ulcers. Deficient Fluid Volume There is no evidence that Mr. Hale is fluid deprived. Although his mouth and lips are dry, his pulse (strong, with a rate of 72) and BP (110/72) are normal, indicating an adequate circulating fluid volume. With fluid volume deficit (hypovolemia), tachycardia and hypotension would generally be present. Disturbed Self-Concept There is no data that validates Disturbed Self-Concept as a nursing diagnosis for Mr. Hale at this time.
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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.
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If a postoperative patient is not catheterized and has not yet voided, other indicators of volume depletion are important. Besides a decreased urine output, other indicators of volume depletion can include: Select all that apply (there are 3 correct answers). Hint decreasing blood pressure Correct When fluid volume is depleted, physiological compensation occurs. Peripheral vasoconstriction helps to maintain blood pressure and the perfusion of major organs. Postural hypotension may be present. Over time, if fluid volume remains depleted, compensation mechanisms fail and blood pressure decreases. Postural hypotension and/or decreasing blood pressure should be reported. tachycardia Correct When fluid volume is depleted, physiological compensation occurs. Heart rate increases to perfuse tissues and organs at a faster rate. Increasing heart rate should be reported. flushed skin When fluid volume is depleted, physiological compensation occurs. Peripheral vasoconstriction occurs. Skin becomes pale, not flushed. Skin will also be cool to touch. dry mouth Correct When fluid volume is depleted, physiological compensation occurs. Peripheral tissues and mucous membranes are poorly perfused, as blood is directed at perfusion of major organs. Oral mucous membranes will be dry.
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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.
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Because Mr. Hale is receiving morphine, it is important to know its possible effects. These include which of the following? Select all that apply (there are 4 correct answers). Hint Increase in heart rate Morphine is a central nervous system depressant. It can be expected to decrease, not increase, heart rate. Increase in gastrointestinal peristalsis Morphine is a central nervous system depressant. It can be expected to decrease, not increase, gastrointestinal peristalsis. Because of this effect, nausea and vomiting may occur, although it is less likely since Mr. Hale has nasogastric suctioning. The return of peristalsis after surgery may be delayed. Constipation may occur with long-term use of morphine. Decrease in blood pressure Correct Morphine is a central nervous system depressant. It can be expected to cause a decrease in blood pressure. Severe hypotension would be an adverse effect. Decrease in respiratory rate Correct Morphine is a central nervous system depressant. It can be expected to decrease respiratory rate. Severe respiratory depression (slow, shallow respirations) would be a major adverse effect of morphine. Respirations should be closely monitored when a patient is receiving morphine. Opioids are generally withheld if respiratory rate decreases below 8-10 breaths per minute. Since sedation generally occurs before respiratory depression, a patient who is using a patient controlled analgesia device is less likely to experience respiratory depression. The narcotic antagonist Narcan (naloxone) is kept available on the nursing unit in case it is needed to treat opioid-induced respiratory depression. Pupillary constriction Correct Morphine is expected to cause constriction of the pupils (miosis). This would be a normal observation in a person receiving morphine. Urinary retention Correct Morphine is a central nervous system depressant. It can contribute to postoperative urinary retention. Mr. Hale has not yet voided after surgery.
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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.
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What nursing actions are indicated to facilitate voiding? Select all that apply (there are 2 correct answers). Increase Mr. Hale's IV flow rate It would not be appropriate to increase Mr. Hale's IV flow rate without a physician's order. Suggest to the physician that Mr. Hale be permitted to stand to attempt to void Correct It would be appropriate to ask the physician that Mr. Hale be allowed to stand to void. For men, standing facilitates voiding. You obtain an order for Mr. Hale to stand for voiding. Allow Mr. Hale to drink some sips of water Drinking oral fluids can be a stimulus for voiding in a person who is not voiding. However, Mr. Hale is NPO. He is not allowed to have sips of water by mouth, although he could rinse his mouth with water. Mouth rinsing might be a stimulus for voiding. Run the water in the Mr. Hale's room Correct Hearing running water can be a stimulus for voiding in a person who is not voiding. Letting Mr. Hale hear running water is appropriate. You run the water in his room.
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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.
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You assess Mr. Hale specifically for any signs of deep vein thrombosis (DVT) in his legs. Signs of DVT secondary to surgery generally become evident after 24 hours. With DVT, the area of thrombosis may be: Select all that apply (there are 4 correct answers). Hint painful Correct Inflammation associated with deep vein thrombosis (DVT) generally causes tenderness at the affected area. swollen Correct With deep vein thrombosis (DVT) in a lower leg vein, inflammation causes swelling that can increase calf circumference (girth). reddened Correct Inflammation associated with deep vein thrombosis (DVT) in a lower leg vein can cause localized redness at the affected area. necrotic With deep vein thrombosis (DVT), the area of thrombosis is not necrotic. Necrotic tissue is dead tissue. pruritic With deep vein thrombosis (DVT), the area of thrombosis is not usually itchy. warm to touch Correct Inflammation associated with deep vein thrombosis (DVT) in a lower leg vein can cause localized warmth at the affected area.
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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.
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Mr. Hale will remain NPO and have a nasogastric (NG) tube until gastrointestinal (GI) function has returned. To check for return of GI function you: Select all that apply (there are 2 correct answers). Hint ask Mr. Hale to move his bowels Asking Mr. Hale to move his bowels would not be an appropriate way to determine if gastrointestinal (GI) function is present. insert a rectal tube Inserting a rectal tube would not be an appropriate way to determine if gastrointestinal (GI) function is present. inspect for bowel sounds Bowel sounds are auscultated, not inspected. However, Mr. Hale's abdomen can be inspected for abdominal distention, which could occur with paralytic ileus. ask Mr. Hale if he has passed gas Correct Passing of gas or having a bowel movement would indicate the presence of peristalsis and return of gastrointestinal (GI) function. auscultate for bowel sounds Correct The presence of bowel sounds, determined with auscultation, would indicate the presence of peristalsis and return of gastrointestinal (GI) function.
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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.
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