nursing care perioperative client – Flashcards
Unlock all answers in this set
Unlock answersquestion
Postoperative phase
answer
Begins with transfer of the client from the operating suite to the PACU or trsfr to ICU. sometimes patients with chronic conditions like heart problems will go directly to ICU
question
2 Primary Concerns of Post-op
answer
Trauma to body: disrupted homeostasis( abnorm. labs), and protective mechanisms(because of incision open to infections) Effects of anesthia & drugs- how people respond could cause death: pt less able to respond to stimuli and less able to help himself- not able to tell you they are hurting.
question
PACU Assessment "ABCDEFG"
answer
Airway management- endotrachial tube Breathing- asses rate, rhythm, and status Cardiovascular status Dressing/Drains/Discomfort Ego-LOC, Motor&Sensory, Protective reflexes(cough/gag) Fluid status- I & O Guard patient - SAFETY ALL THE TIME
question
Airway Assessment
answer
Presence of artificial airway O2 Sat (pulse ox)
question
Breathing Assessment
answer
Breath sounds Rate, rhythm & quality of respirations Use of accessory muscles
question
Circulation Assessment
answer
Rate, rhythm, & quality of heart rate. RR below 12 and above 20 is not good. Blood pressure, capillary refill Peripheral pulses Skin color #1 complications after surgery is Bleeding,
question
Dressing Assessment
answer
Location, drainage amount, type & color 1st surgical dressing changed by the doctor ABD dressing...... outline dressing date time and monitor drainage
question
Drainage Assessment
answer
Patency, drainage amount, type & color. outline dressing date time and monitor drainage. JP? Hemovac?
question
Discomfort Assessment
answer
Pain (do the PQRST) Any nausea and/or vomiting
question
Ego Assessment
answer
LOC, not responding->arousable with verbal stimulus->fully awake->oriented x3 Motor & sensory function- grips, dorsal plantar flexion. temp. Protective reflex - cough & gag
question
Fluid Status Assessment
answer
Intake & Output IV solution, speed & site Any signs of dehydration or fluid overload
question
Guard Patient Safety Assessment
answer
Side rails, brakes, call light ID band Introduce yourself as the nurse providing care Handwashing is VITAL!
question
PACU Respiratory Concerns
answer
Airway obstruction (leading to........ Hypoventilation (leading to...retaining co2 Hypoxemia (leading to..o2 in blood cells HYPOXIA! decreased tissure profusion after load.
question
PACU Cardiovascular Concerns
answer
Hypotension- decreased BP, possible bleeding Hypertension- Increase BP sympathic NS Arrhythmias- A-fib abnorm. conduction in heart #1 killer Hypovolemic Shock- hyper profusion increase fluid in blood PRE LOAD.
question
When can pt be d/c'd from PACU?
answer
Conscious & oriented- to person, place,time, event Clear airway and C&DB freely Vital signs stable(VSS) for at least 30 min Protective reflexes active-gag, cough Moves all extremeities I&O is adequate (at 30ml/hr) Afebrile or fever has been attended to- after 3 days something is wrong Dressings are clean/dry/intact(CDI); no overt drainage
question
Postop Unit Typical Assessment Pattern
answer
still very essential. HEAD TO TOE. upon arrival; then Q15min x4 Q 30 min x4 Q hour x4 Q 4 hours
question
Postop Unit Assessment
answer
Receive report from PACU nurse Prioritize ABCDEFG first most important! Diet allowed, IV&Meds (lactated ringers-electrolytes), Labs (H&H), Postioning & Activity. then Consult PACU record for postop dx, anesthetic & meds given, estimated blood loss
question
Continuing Concerns for Postop Assessment
answer
Absent or diminished breath sounds Abnormal or sudden change in VS ( KNOW BASELINE) Sudden chest pain (PE), SOB, diaphoresis Incisional pain more severe Decrease in neurovascualr checks(circ,motion,sensation)
question
Potential Postop Complications
answer
RESPIRATORY Aspiration Pneumonia Atelectasis- collapse of alveoli- incentive spirmontor Pneumonia-infection Pulmonary Embolus- sudden chest pain CARDIOVASCULAR Thrombophlebitis Hemorrhage- #1 after surgery Hypovolemia- electrolyte imbalance
question
Postop Nursing Interventions
answer
Deep breathing with IS 10 x q hr; cough while splinting(placinb pillow on operative side for support before coughing) Position changes q 1 to 2 hrs Adequate pain control Closely monitor I&O, VS, bleeding &/or drainage, early amb, SCDs while in bed & TED per order MONITOR FOR DECREASED URINE OUTPUT, could signal poor renal perfusion, red flag acute renal failure.
question
Postop Complications-Bowel&UrinaryElimination
answer
N&V, Abd distention, constipation-elderly, Ileus, renal failure, urinary retention-bloated, pain bladder scan., UTI- after 3-4 days confusion starts.
question
Postop Nursing Interventions - GI System
answer
Pain mgmt; may cause constipation-morphine, assess bowel sounds at least q shift- right after surgery norm.not her hear bowel soungs., progress diet as tolerated- clear liquids, soft diet, NPO., turn & repostion q2h; early ambulation
question
Postop Nursing Interventions - NG tube
answer
Majority. Use; decompression suction, may need continous low or intermittent high suction, assess color, consistency & amount of drainage q shift, DO NOT irrigate NG for pt with abdomen surgery, use NS when irrigating- maintain electrolyte balance.
question
Postop Nursing Interventions - Urinary System
answer
I&O measurement, encourage oral intake, maintain asepsis with catheter care; when catheter dc'd pt may have difficulty voiding because of anistesia
question
Postop Complications-Wound/Incision
answer
Dehiscence- seperation of surgical cut Evisceration- protution of guts- cover sterile saline dressing & then call DR. Wound Infection- monitor and adminstor ordered meds.
question
Postop Wound Care
answer
Keep clean, dry & intact, check wound & drains for s/s of infection q shift, use asepsis when changing dressings, support incision with movement or cough, adequate nutrition/protien vitamin C & A essential for wound healing, teach pt to avoid straining & to watch for s/s of infection. Slight fever after surgery is normal.
question
Potential Postop Neuro Complications
answer
Delirium- possible dehydration, infection, CO2 build up on the brain. Postoperative depression- normal, expected if body parts were amputated.
question
Postop Nursing Interventions - Neuro
answer
Monitor for changes in LOC, increased lethargy, restlessness or irritabilty ( bad signs) motor, sensory & circulation deficits. Epidural or spinal assess movement of lower extremities; compare bilaterally MAINTAIN PATIENT SAFETY!
question
Postop Nursing Assessment of Labs
answer
Assess Complete blood count (CBC) check Hgb & Hct = hemmorrhage or overhydration check elevated WBC's = increased Neutrophils= acute infection. increased lymphocytes= chronic infection. Assess electrolytes - K+, Mg, Na+ Cl-, Ca++; Kidney - BUN, Creatinine; Clotting - PT/INR, PTT/APTT; Liver enzymes - GGT; ALT, AST, bilirubin, serum ALB and protein Type and Cross match- incase the patient needs a blood transfusion. Urinalysis Electrocardiogram (ECG) Radiology - Chest X-Ray
question
Assess for PAIN
answer
Pain is what the client says it is! Surgical wound, tissue/organ manipulation, drains Intraoperative positioning & prolonged intubation objective data - increased HR, RR, BP, diaphoresis, restlessness, confusion, wincing, moaning &/or crying. A Sympatheitc response. A law states for cancer patients, you need to take care of their pain NO MATTER WHAT!
question
Alternative Pain Relief Interventions
answer
Positioning Massage Relaxation & diversion use your own judgement. Pain threshold varies from person to person. American indians will not tell you when they are in pain.
question
Postop Gerontologic Considerations
answer
Monitor for effective pulmonary hygiene- remind patient to us Incentive spirometer. drug toxicity- monitor vital signs altered mental status/delirium- infection, maybe pull out foley. change postion slowly (orthostatic chgs); know older adult may perceive pain differently
question
Postop Nursing Dx
answer
Impaired gas exchange R/T residual effects of anesthesia Ineffective airway clearance R/T poor cough effort Acute pain R/T abdominal incision Impaired skin integrity R/T surgical wound Risk for infection R/T presence of IV and Foley Self-care deficit R/T decreased mobility Anxiety R/T postoperative recovery
question
Postop Nursing Dx
answer
Disturbed body image R/T loss of left breast Disturbed sleep pattern R/T environmental stimuli Risk for falls R/T impaired balance Risk for imbalanced nutrition: less than body requirements R/T postoperative nausea
question
Postop Discharge Planning
answer
Provide client with written discharge instructions; when to call and/or visit physician restricted activities (showering, exercise, driving, sex) medications s/s that shoulb be reported promptly
question
Ablative
answer
amputation or removal of a diseased body part- ex- REMOVAL OF APPENDIX, GALLBLADDER
question
Diagnostic
answer
confirm or establish a diagnosis- explore to confirm diagnosis.- BIOPSY ONLY SOLE DEFINITE ANSWER OF CANCER
question
Palliative
answer
relieve or reduces intensity symptoms (or pain) of disease, but does not cure- ex. PACE MAKER, CUT NERVES ON CANCER PATIENTS.
question
Reconstructive
answer
restore function or appearance- ex. INTERNAL FIXATION OF FRACTURES, SCAR REVISION, TORN LIGAMENT, BROKEN HIP.
question
Cosmetic
answer
to improve personal appearance- RHINOPLASTY TO RESHAPE NOSE, FACE LIFT.
question
Transplant
answer
replace a malfuntioning body part, tissue, or organ. ex. KIDNEY, CORNEA, LIVER, HEART, LUNG.
question
Prevention
answer
removal of suspicious tissue-ex. SKIN CANCER, BREAST LUMP.
question
Exploration
answer
determine nature or extent of disease- ex. open-close surgery, go in and see and close right back up. Client admitted to hospital all tests are neg. but patient has symptoms, they open patient and close it, find out it's too late its cancer...
question
Degree of Urgency
answer
Emergency - life threatening Urgent - prompt intervention required Elective - correction of non-acuter problem
question
Degree of Surgical Risk
answer
Major - prolonged procedure, large loss of blood vital organs involved with risk of complicatins Minor - procedure with little risk and can be done with local anesthesia and in outpatient surgery center
question
Surgical Risk Factors
answer
Smoking- COPD Age-very old and very young Nutrition, Obesity, malnutrition Obstructive sleep apnea- effects o2 in body Immunocompetence Fluid & electrolyte balance Pregnancy
question
classification :seriousness of medical problem
answer
Major minor
question
Major
answer
involves extensive reconstruction or alteration in body parts; poses great risk to well being. Ex. CORONARY ARTERTY BYPASS, COLON RESECTION, REMOVEABLE OF LARYNX, hysterectomy, open heart, angio plasty not as invasive.
question
Minor
answer
involves minimal alterations in body parts, often desinged to correct disformities; involves minimal risks compared with major procedure. ex. CATARACT EXTRACTION, FACIAL PLASTIC SURGERY, TOOTH EXTRACTION, TONSILLECTOMY, LUMP ECTOMY.
question
classification: urgency of surgery
answer
Emergency, urgent, elective
question
Emergancy
answer
must be done immediately to save life or preserve function of body part ex. gallbladder, appendix, trauma, motor vehicle accident. control of internal hemorrhaging.
question
Urgent
answer
necessary for patients health, will possibly prevent additional problems from developing. ex- EXCISION OF CANCEROUS TUMOR, REMOVAL OF GALLBLADDER FOR STONES, SOMETIME OPEN HEART.
question
elective
answer
preformed on basis of patients choice, not essential and is not always necessary for health. ex- BREAST RECONSTRUCTION, FACIAL PLASTIC SURGERY, KNEE REPLACEMENT.
question
surgical risk with Major
answer
prolonged procedure, large loss of blood, vital organs involved with risk of complications
question
surgical risk with minor
answer
procedure with little risk and can be done with local anesthesia and in outpatient surgery center.
question
time out
answer
performed immediately before starting the surgery and includes correct patient identity, confirmation of marked site, accurate procedure consent, agreement by all on the procedure to be done, correct patient position, relevant images and results properly labeled and appropriately displayed, need to administer antibiotics or fluids for irrigation purposes, and safety precautions based on patient history or medication use.
question
pre-anesthesia care
answer
VERIFY CONSENTS Skin prep/hair removal Start IV Medications ADPIE Diagnosis- Knowledge Deficit? Anxiety? or Fear? Body Image Disturbance? Planning- Goal & Interventions Implementation- Pre-op Teaching, Pre-op Checklist Baseline Vitals Evaluation
question
SCIP
answer
Surgical Care Improvement Project National partnership of key surgical people, (doctors, nurses, pharmacists, administrators) Goal = reduce surgical complications by 25% (year 2010) 2 Measures Infection Venous Thromboembolism (VTE) EARKY AMBULATION , LOW DOSE HEPRIN, TED HOES.
question
preoperative consents
answer
are all required forms signed and in the chart. informed consent0 verfied by licensed person, no students. Doctor has to explain procedure to patient not the nurse. IF patient doesnt want to go call anesthetist to come explain to the patient. blood transfusion, advanced directive, medical power of attorney. IN CHART SIGNED VERY IMPORTANT.
question
two main medication orders for patients after surgery on bed rest.
answer
prevention of DVT prevention of Ulcers-when patient is admitted to the hospital stress goes up it increases acid in the stomach, meds given to reduce that.
question
informed consent
answer
An agreement by a client to accept a course of treatment or procedure after being provided complete information, including The diagnosis & purposes of the treatment What the client can expect to experience Benefits & risks Alternatives to the treatment Prognosis if not treated by a health care provider Obtaining written consent is the responsibility of the person who will perform the procedure. (Most nursing interventions rely on implied consent, e.g. the client's nonverbal behavior indicates agreement)
question
3 major elements of informed consent
answer
The consent must be given VOLUNTARILY. The consent must be given by a client or individual with the capacity and competence to UNDERSTAND. The client or individual must be given ENOUGH INFORMATION to be the ultimate decision maker.
question
data collection: nursing history
answer
Current health status Medications & Drugs Alcohol & drugs can affect responses OTC and Herbals can potentiate risks Allergies Previous surgeries Mental Status
question
data collection: physical assesment
answer
HEAD TO TOE ASSESMENT Cardiovascular system Respiratory system Nervous system Urinary system Musculoskeletal system Integumentary system Endocrine system Immune system Fluid & electrolyte status Nutritional status
question
data collection: psychological assessment
answer
ANXIETY Lack of knowledge; current changes; concerns FEAR- of Disfigurement; Death; Pain & discomfort; Anesthesia; Disruption of life HOPELESSNESS- Strongest "ingredient" of ineffective coping
question
the changes in older surgical patients
answer
Cardiovascular system- decrease cardiac output, increase BP, decrease peripheral circulation Respiratory system- decrease vital capacity, decrease lung elasticity, decrease oxygenation of blood Neurologic system- increase sensory deficits, decrease reaction time, decrease ability to adjust to change Renal/urinary system- Decrease glomerular filtration rate; difficulty voiding, urinary retention Musculoskeletal system- increase incidence of deformities, arthritis or osteoporosis Integumentary system- Skin more fragile and slower to heal
question
factors that increase surgical risk
answer
Smoking-COPD Nutrition- malnutrition. Helps with healing, coping and recovery. Need good nutrition. Obstructive sleep apnea- effects o2 in the body. Fluid and electrolyte balance- blood loss etc. Age- very old and very young. Obesity- risk for fluid electrolyte imbalance, heart problems, infection, and respiratory problems. Immunocompetence- increases risk for infection. Pregnancy, allergies, personal habits- recuational drug use etc.
question
pre-op teaching includes
answer
Preoperative instructions Deep breathing & coughing/ splinting/ incentive spirometry (IS) Methods of moving & repositioning Leg exercises Determine client's readiness to learn Include family in teaching
question
post-op expectations: preop teaching
answer
Post-op expectations Pain & discomfort Progressive movement-early ambulation. Diet- radually, clear liquid to solids. Restrictions Equipment Continuous Passive Movement (CPM) for knee replacement surgery Sequential Compression Devices (SCD's)/ Anti-embolism (TED) stockings Foley catheter IV with Patient Controlled Analgesia (PCA) Oxygen
question
pre-op nursing check list includes?
answer
Assess NPO status Restrict food & fluids as required Prepare skin: surgical scrub Remove jewelry, makeup, nail polish, & prostheses (glasses, hearing aids, etc.) Bowel preparation, if required Apply anti-embolism stockings, if ordered Diagnostic results in place Vital signs Have client empty the bladder Administer preoperative medications Safety precautions
question
pre-op medications that are given
answer
Anti-anxiety/Benzodiazepines-reduce anxiety. Opioid analgesics- reduce pain H2-receptor blockers- heart meds. Anticholinergics Prophylactic antibiotics- prevent infections
question
intraoperative phase
answer
BEGINS when the client is moved INTO the operating room ENDS when the client is moved OUT of the operating room
question
intraoperative surgical team
answer
Surgeon & Surgical Assistant (RNFA) Scrub nurse or surgical technician Anesthesiologist or Nurse anesthetist (CRNA) Circulating nurse
question
types of anesthesia
answer
GENERAL- Loss of consciousness, senses, reflexes REGIONAL- Loss of sensation in a specific area by anesthetizing a sensory pathway. group of nerve blocks. - Topical (surface) - Local - Nerve block - Intravenous block (Bier block) - Spinal - Epidural LOCAL- Loss of sensation in a specific site by inhibiting peripheral nerve conduction. MODERATE SEDATION-Also known as conscious sedation, used for diagnostic or therapeutic procedures. patient maintains own airway; responds appropriately to verbal commands or physical stimulation
question
anaphylactic reaction
answer
primary emergencies from anesthesia May be "masked" by anesthesia
question
malignant hyperthermia
answer
Rare, genetic Hypermetabolism of skeletal muscle Often due to exposure to succinylcholine, esp. with inhalation Mostly during general anesthesia or its recovery
question
A-S-E-P-S-I-S
answer
A All objects used in a sterile field must be sterile and must be handled by sterile gloves. S Sterile objects become unsterile when touched by unsterile objects. Remain at least 1 foot away from a sterile field if you are "unsterile" and vice versa. E Exposure to airborne "bugs" may contaminate the sterile field. Avoid reaching over a sterile field. Close doors and limit foot traffic. Wear a protective mask when necessary. P Placing a sterile item out of vision or below the waist or table makes it unsterile. S Surgically wash hands higher than the elbows (to prevent contamination), (as fluids flow in the direction of gravity). Likewise: hold forceps with the tips up. Also: fluids can act as wicks and contaminate a field; use sterile containers & caution over the sterile field. I Inside the 1 inch border of the sterile drape is required, (as the border of the drape is in contact with the contaminated table surface). S Skin cannot be sterilized.
question
Continual Postoperative care: planning & implementation
answer
PCA- patient controlled Anaglesia for IV- monitor every hour for resp. rate epidural analgesia- every 30 mins. monitor Resp. rate. other routes- oral, sc, im, topical antagonist- Narcan- antedote for morphine
question
post op nursing goal
answer
NO POST OP COMPLICATIONS
question
discharge planning- going home
answer
The client may not be going home but to a transitional care or skilled nursing facility. explain to the patient so they understand where they will be going next. Begin preoperatively & on admission Based on admission data, determine availability of caregivers Identify home safety issues Provide discharge teaching throughout hospitalization (exercises, medications, dressing changes, drainage devices, complications) Dietary restrictions Provide client with written discharge instructions when to call and/or visit physician restricted activities after discharge (showering, exercise, driving, sex) Medications Signs and symptoms that should be reported promptly
