Perioperative Nursing – Flashcards
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perioperative
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preoperative-before, intraoperative-during postoperative-after the surgery
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preoperative period
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begins when the patients is scheduled for surgery and ends at the time of transfer to the surgical suite.
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Intraoperative period
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begins when the patient enters the surgical suite and ends at the time of transfer to the postanesthesia recover area, same-day surgery unit, or the intensive care unit (ICU).
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postoperative period
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starts with completion of surgery and transfer of the patient to a specialized area for monitoring such as the postanesthesia care unit (PACU) and may continue after discharge from the hospital until all activity restrictions have been lifted.
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perioperative nursing
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Nursing care provided to surgery patients before and during the procedure and in the recovery room.
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preoperative teaching
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- Instruction regarding a patient's anticipated surgery and recovery given before surgery. - Instruction includes, but is not limited to, dietary and activity restrictions, anticipated assessment activities, postoperative procedures and pain relief measures.
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inpatient
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a patient who is admitted to a hospital
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outpatient/ambulatory
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a patient who goes to the surgical area the day of the surgery and returns home on the same day - often a case manager is needed to coordinate post-discharge care for the patient.
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ambulatory surgery
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procedures performed using general, regional, or local anesthetic, having an operating time of less than 2 hours, and requiring less than a 24-hour stay postoperatively
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never events
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Particularly shocking medical errors (such as wrong-site surgery) that should never occur. - The list of Never Events has expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.
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CRNA
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certified registered nurse anesthetist
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Circulating nurse
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- Assistant to the scrub nurse and surgeon whose role is to provide necessary supplies, dispose of soiled instruments and supplies, and keep an accurate count of instruments, needles, and sponges used. - are registered nurses who coordinate, oversee, and are involved in the client's nursing care in the operating room. - circulating nurse moves around the room and can see more of what is happening. - The circulating RN has the experience and background to write OR policy and has been employed in this hospital and is aware of hospital policy and procedures.
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Scrub nurse
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A registered nurse who assists surgeons during operations.
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Explain the interventions by the perioperative nurse that supports the use of the SCIP (Surgical Care Improvement Project) measures.
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- TJC (The Joint Commission) and other groups and agencies developed a plan for the reduction and eventual elimination of preventable surgical complications. - Implementation of these core measures is now mandatory for patient safety.
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The goal of SCIP
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- focuses on infection prevention, - prevention of serious cardiac events - prevention of VTE/DVT
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SCIP core measure overview-Infection
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1. Prophylactic antibiotic received within one hour prior to surgical incision 2. Prophylactic antibiotic selection for surgical patients 3. prophylactic antibiotics discontinued within 24 hours after surgery end time 4. cardiac surgery patients with controlled 6am postoperative blood glucose 6. appropriate hair removal 9. urinary catheter removed on postoperative day 1 or postoperative day 2 with day of surgery being day zero 10. perioperative temperature management
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SCIP core measure overview-CARD
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2. surgery patients on beta-blocker prior to arrival who received a beta-blocker during the perioperative period
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SCIP core measure overview-VTE
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1. surgery patients with recommended VTE prophylaxis 2. surgery patients who received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery
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List common nursing diagnosis for patients preparing for surgical procedure.
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- Knowledge deficit due to unfamiliar with procedure - Anxiety related to new or unknown experience - Fear - Risk for deficient fluid volume
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Identify key assessment information that is needed to ensure positive outcomes for perioperative or perianesthesia patient.
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- Medical/Surgical History --- Allergies, smoking --- obesity --- Herbs, OTC - Psycho social - Anesthesia assessment - assessing VS with temperature at least every 4 hours - assessing for increase in pain perception - assessing cognition - assessing the wound for pain, size, open areas, and drainage - assessing the skin immediately surrounding the wound for redness and swelling - assessing serial WBC with differential for changes.
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Describe the roles and responsibilities of the team in the perioperative environment that ensure patient safety and quality.
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- communication and collaboration with the surgical team are essential so that correct actions are taken to achieve the desired outcome
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Identify the priority nursing interventions for patients having a surgical/procedural intervention from the preoperative period.
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- Type of surgery - Preoperative Instruction --- NPO-often placed the status the night before the surgery in order to prevent aspiration pneumonia, Medications, Shower, Bowel Prep (if indicated) - Postoperative Instructions --- TCDB (turn cough, deep breath) --- ambulation (prevent blood clot) - Equipment --- Drains, IV's, urinary catheter
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Identify the priority nursing interventions for patients having a surgical/procedural intervention from the pre to the post-operative period.
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TCDB, ambulate, fluids, asepsis in caring for dressings, IV's
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atelectasis
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- An abnormal condition characterized by the collapse of alveoli, preventing the respiratory exchange of carbon dioxide and oxygen in a part of the lungs. Symptoms may include diminished breath sounds, or aspiratory crackles, a mediastinal shift toward the side of the collapse, fever, and increasing dyspnea. - atelectasis reduces gas exchange and causes intolerance of anesthesia. - a common problem after general anesthesia
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latex sensitivity/allergy
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patient with an allergy to avocados, bananas, strawberries
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providone-iodine (Betadine)
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shellfish
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propofol (Diprivan)
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- anesthetic agent - patient who have an egg, peanut, or soy allergy
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discharge planning
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- started before surgery - all patients, regardless of how minor the procedure or how often they have had surgery, should have discharge planning.
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Consent
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- implies that the patient has sufficient information to understand - Needed for any invasive procedure, the patients deserve to be informed and involved in decisions affecting their health care. - Physician obtains informed consent (physician is required by law to inform the patient about informed consent) - Competent adults sign the operative permit - Language? - To be signed prior to medication RX given
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informed consent
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- Physician obtains informed consent - an active, shared decision-making process between the provider and the recipient of care that verifies the patient's consent for treatment
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universal precautions
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Precautions designed to prevent the transmission of blood-borne diseases such as HIV, hepatitis B, and other blood-borne pathogens when first aid or health care is provided. Under Universal Precautions, blood and certain body fluids of all patients are considered potentially infectious. The Precautions include specific recommendations for use of gloves, gowns, masks, and protective eyewear when contact with blood or body secretions containing blood is anticipated.
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anesthesia
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The absence of all sensation, especially sensitivity to pain, as induced by an anesthetic substance or by hypnosis or as occurs with traumatic or pathophysiologic damage to nerve tissue. Anesthesia induced for medical or surgical purposes may be topical, local, regional, or general and is named for the anesthetic technique or method. - with or without loss of consciousness
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General anesthesia
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The absence of sensation and consciousness as induced by various anesthetic medications, given by inhalation or IV injection.
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analgesia
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pain relief or pain suppression
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amnesia
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memory loss of the surgery
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moderate sedation/analgesia/conscious sedation
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Administration of central nervous system depressant drugs and/or analgesics to provide analgesia, relieve anxiety, and/or provide amnesia during surgical, diagnostic, or interventional procedures. Routinely used for diagnostic or therapeutic procedures that do not require complete anesthesia but simply a decreased level of consciousness.
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Balanced anesthesia
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-a combination of types of agents - used to provide hypnosis, amnesia, analgesia, muscle relaxation, and reduced reflexes with minimal disturbance of physiologic function.
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patient-controlled analgesia (PCA)
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A drug-delivery system that dispenses a preset intravascular dose of a narcotic analgesic when the patient pushes a switch on an electric cord. The device consists of a computerized pump with a chamber containing the drug. A lockout interval automatically inactivates the system if a patient tries to increase the amount of narcotic within a preset period.
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malignant hyperthermia
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- A rare genetic hypermetabolic condition characterized by severe hyperthermia and rigidity of the skeletal muscles, occurring in affected people exposed to inhalation anesthetics and succinylcholine, a nondepolarizing muscle relaxant. - an inherited muscle disorder, is an acute, life-threatening complication of certain drugs used for general anesthesia. - serum calcium and potassium levels are increased, as is the metabolic rate, leading to acidosis, cardiac dysrhythmias, and a high body temperature
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S/S of malignant hyperthermia
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increased body metabolism - tachycardia - dysrhythmias - muscle rigidity (es. jaw and upper chest) - hypotension - tachypnea - skin mottling - cyanosis - myoglobinuria (presence of muscle proteins in the urine) - unexpected rise in the end-tidal carbon dioxide level with a decrease in oxygen saturation and tachycardia - extremely elevated temperature, as high as 111.2 F (44 C)
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local anesthesia
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The infiltration of a local anesthetic medication to induce the absence of sensation into a small area of the body. The anesthetic may be applied topically to the surface of the skin or membrane or injected subcutaneously or intradermally. Advantages include low cost, ease of administration, low toxicity, and rapid recovery.
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regional anesthesia
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Anesthesia provided by injecting a local anesthetic to block a group of sensory nerve fibers. The tissues are anesthetized layer by layer, as the surgeon approaches the deeper structures of the body. Regional anesthesia has largely replaced local anesthesia for major procedures.
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moderate sedation
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- IV delivery of sedative, hypnotic, and opioid drugs to reduce sensory perception but allow the patient to maintain a patent airway. - the amnesia action is short, and the patient has a rapid return to ADLs.
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dehiscence
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The separation of a surgical incision or rupture of a wound closure.
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evisceration
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1. The removal of the viscera from the abdominal cavity; disembowelment. 2. The removal of the contents from an organ or an organ from its cavity. 3. The protrusion of an internal organ through a wound or surgical incision, especially in the abdominal wall.
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Explain the rationale for surgical asepsis in the operative environment.
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- All personnel wear scrubs provided by facility - Everyone wear hair cover, shoe covers, and mask --- No jewelry, artificial nails, if ill not to be in OR --- Scrub jackets worn to keep skin covered --- Airflow in OR to decease pathogen and dust-negative air - "Surgical scrub" - the surgeon, assistant, and the scrub nurse perform a surgical scrub after putting on a mask and before putting on a sterile gown and gloves. The scrub does not make the skin sterile. - Wash hands for 3-5 min, then apply alcohol solution - Low traffic in and out of OR
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Discuss the education that needs to be provided for the patient scheduled for perioperative procedure.
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- fears and anxieties - surgical procedures - preoperative routines (eg: NPO, blood samples, showering) - Invasive procedures (lines, catheters) - coughing, turning, deep breathing - Incentive spirometer --- how to use --- how to tell when used correctly - lower extremity exercises - stocking and pneumatic compression devices - early ambulation - splinting - pain management
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Identify key components to a plan of care (POC) for the perioperative patient.
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- adequate capillary refill and peripheral pulses in all extremities - sensory perception and motor function after surgery at the same level as before surgery - absence of skin redness or open skin areas - absence of bruising
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Discuss the universal protocol and its impact on patient safety.
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- The universal protocol is a safety intervention/bundle developed by the Joint Commission to reduce the risks of wrong site surgery. - It ensures that all x-rays/implants/other instruments are in the department prior to initiating anesthesia and surgery, as well as that entire team is aware of what the planned procedure is. - Its focus is the intraoperative phase.
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State the components of the Universal Protocol
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- Conduct a pre-procedure verification process - Mark the procedure site - Perform a time-out
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the perioperative nurses' role/function
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- educators - advocates - promoters of health
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Discuss key components need to provide effective hand-offs to care providers between levels of care for the perioperative patient.
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- the handoff of the patient to the surgery staff provides to ensure patient safety. - The preoperative checklist, --- signed informed consent, ---pt.'s chart --- the patient ID card are components communicated during the handoff.
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Recognize processes that ensure optimal patient outcomes in the perioperative environment.
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- preventing pressure ulcer - preventing infection - preventing hypoventilation - maintain normal thermoregulation and body temperature - preventing injury r/t positioning, and other hazards, including unfamiliar experiences and uncertain outcomes - reducing anxiety
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List the interventions by the perioperative nurse that prevents perioperative complications.
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- positioning to prevent pressure ulcer - aseptic technique - good personal hygiene and frequent handwashing help prevent and control infection - maintain malignant hyperthermia cart - apply warming blanket to maintain normal body temperature - Padding bony prominences best minimizes skin breakdown. - Elastic stockings assist in increased venous return. Hypoxemia-airway maintenance; monitoring; positioning; oxygen therapy; breathing exercises; movement wound infection/delayed healing- nonsurgical management (dressing, drains, drug therapy); surgical management (management of dehiscence/evisceration); prevention managing pain- drug therapy; complimentary and alternative therapies.
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A post op client who had abdominal surgery is holding a pillow against his abdomen during deep breathing and coughing exercise. What term does the nurse use to describe this technique?
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Splinting
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The circulating nurse sees that a sponge is dropped onto the floor from the instrument table after the first surgical incision is opened. What is this nurse's best action? a. Obtain an additional sterile sponge to replace the contaminated one and place it on the instrument table. b. Place the sponge in the circulating area to include in the final count before incision closure. c. Pick up the sponge and throw it out so on one slips on it d. Hand the sponge back to the scrub nurse.
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b. Place the sponge in the circulating area to include in the final count before incision closure.
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The postanesthesia recovery unit nurse is receiving a handoff report from the nurse anesthetist and the circulating nurse for an 82-year-old client who had a 2-hour open reduction of a fractured elbow. For which reported information about the client or surgery does the receiving nurse ask the reporting team for more details? a. The client is Jewish b. The estimated blood loss is 150ml. c. The client reported an allergy to codeine d. The total intraoperative urine output is 25ml.
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d. The total intraoperative urine output is 25ml.
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The patient received lidocaine viscous before a gastroscopy was performed. Which of the following would be priority for the nurse to assess during the postprocedural period? a. Ability to stand b. Ability to urinate c. Leg pain d. Return of gag reflex
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d. Return of gag reflex
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The patient is admitted to PACU after surgery with general anesthesia. Which of the following assessment findings would the PACU nurse expect during recovery? a. Bradycardia b. Hypertension c. Respiratory depression d. Severe headache e. Urinary frequency
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a,c
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Because of an unexpected emergency case, a client is scheduled for colon surgery at 8 AM has been rescheduled for 11 AM. What is the nurse's best action related to the preoperative prophylactic antibiotic administration according to the Surgical Care Improvement Project (SCIP) guidelines? A. Administer the preoperative antibiotic at 7 AM as originally prescribed. B. Administer the antibiotic at the same time as the other prescribed preoperative drugs. C. Adjust the antibiotic administration time to be within 1 hour before the surgical incision. D. Hold the preoperative antibiotic until the client is actually in the operating room and has been anesthetized.
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C. Adjust the antibiotic administration time to be within 1 hour before the surgical incision. Rationale: A goal of prophylaxis is to establish bactericidal tissue and serum levels at the time of skin incision. The SCIP recommendations are that the antibiotic be administered 1 hour before the actual surgical incision. Giving the drug at 7 am seriously interferes with maintaining the blood (serum) level at the proper level when the surgery is actually taking place. Administering the antibiotic with the other preoperative drugs may or may not be within the recommended time frame. Waiting until the client is anesthetized is too late for best antibiotic action and peak serum levels.
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An 81-year-old client, scheduled for a long orthopedic procedure, appears to have a low body mass index. In addition to the body mass index value, which additional client information is most important for the nurse to report to the surgeon and perioperative team as indicating an increased risk for skin breakdown? A. Negative nitrogen balance. B. Previous abdominal surgery. C. Allergy to latex products. D. Change in mental status upon admission.
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A. Negative nitrogen balance. Rationale: A negative nitrogen balance can be a sign of inadequate protein intake and malnutrition, resulting in a low BMI. These factors contribute to skin breakdown. Although the change in mental status can increase the risk for skin breakdown after surgery if the client is not aware of the need to change position, it is not the most critical risk factor at this time. The allergy to latex products is critical information to communicate to the perioperative team but does not contribute to skin breakdown.
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The preoperative admitting nurse notices that the client scheduled for total joint replacement surgery in 2 hours has a smell of alcohol on his breath even though he has just stated that he has fasted completely for the past 10 hours. What is the nurse's best first action? A. Accept the client's statement and continue the preoperative preparation. B. Report the discrepancy to the surgeon and anesthesiologist immediately. C. Tell the client the observation and provide the opportunity for him to explain. D. Remind the client that the alcohol consumption may require changes in anesthesia procedure.
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C. Tell the client the observation and provide the opportunity for him to explain. Rationale: Although alcohol consumption before a surgical procedure with anesthesia can cause serious problems, the nurse should not "jump to conclusions" with his or her observations. Before informing the surgeon and anesthesiologist, the nurse should provide the client with the opportunity to explain the alcohol smell on his breath. Some mouthwashes contain chemicals and alcohol that could leave a perceptible odor. Also, the nurse could be mistaken about the odor.
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The patient states the surgeon discussed the addition of a second procedure to the one indicated on the consent. The patient is visibly upset that the consent he is asked to sign with the surgical resident reflects only one procedure and cannot understand why the nurse and resident do not have the authority to "fix" the consent. In addition, he states he will not take his wedding ring off because it has never left his hand since his wife put it there 30 years ago. 1. How would you address the patient's immediate concern regarding the consent?
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Focus your answer on the safety aspect of the situation while acknowledging the patient's frustration. Inform the patient that you will contact the surgeon to clarify the consent in terms of accuracy and that neither you nor the surgical resident not have the authority to alter the consent without the surgeon's knowledge. Document it in the medical record.
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2. Under what conditions could the second procedure be performed?
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The second procedure could be performed if a new consent is developed with both procedures listed and signed by the patient. This new consent can only be used if the patient is not under the influence of preoperative drugs that could cloud his judgment and if the patient has received adequate information regarding both procedures to be able to make an informed choice.
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3. What remedy would you propose to prevent such occurrences in the future?
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Discuss the occurrence with the perioperative team, review existing policy, and make changes as needed. Propose a process for facilitating communication among departments and team members.
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4. How will you respond to the patient's unwillingness to remove his wedding ring?
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Explain to him that removal of the ring is not necessary if the finger is not the operative site. Tape the ring in place if agency policy permits. If the agency does not permit this action, explain why and have his wife keep the ring with her until she sees him after surgery.
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In going through the preoperative checklist, the nurse notices that the client's armband does not match the handwritten name on the informed consent, but it matches the stamped name. What does the nurse do first? a. Call admissions. b. Cancel the surgery. c. Contact the surgeon. d. Talk to the operating team.
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d. Talk to the operating team. Rational: The operating team should be called to see if any clients with similar names are having surgery done. The client should confirm the spelling of his or her last name. Also, confirm the procedure that is expected to be done and compare it with the informed consent form. Calling admissions is not the first step; the stamp is correct. Canceling surgery is not done by the floor nurse. This is an administrative issue, and not one for the surgeon.
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As the nurse obtains the informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response? a. Contact the anesthesiologist. b. Contact the surgeon. c. Explain the procedure. d. Have the client sign the form.
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b. Contact the surgeon. Rational: The nurse is not responsible for providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience. The anesthesiologist is responsible for the anesthesia, not the surgical details. Although the nurse is only witnessing the signature, it is the nurse's role to ensure that the facts are clarified before the consent form is signed.
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The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction? a. "I will wake up with a tube in my throat." b. "I will have a bandage on my chest." c. "My family will not be able to see me right away." d. "Pain medication will take away my pain."
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d. "Pain medication will take away my pain." Rational: Pain medication will minimize pain, but will not take it away completely. The client statement about waking up with a tube in the throat is accurate, because the client will be intubated. Following heart surgery, a dressing is placed on the chest. The client will not be able to see family immediately because he or she will go to recovery first.
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An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? a. Call the legal department to draft the paperwork. b. Document this in the chart. c. Thank the person and do nothing else. d. Talk to the client.
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d. Talk to the client. Rational: The nurse should determine the client's wishes and state of mind. The nurse should not call the legal department or document in the client's chart before speaking with the client. Doing nothing is not appropriate.
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A preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes? a. Instruct the client to quit smoking. b. Teach about the dangers of tobacco. c. Teach the importance of incentive spirometry. d. Tell the client where the smoking lounge is.
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c. Teach the importance of incentive spirometry. Rational: Incentive spirometry is good for lung hygiene; it encourages deep breathing. The nurse can suggest quitting or advise about the dangers of tobacco, but it is not therapeutic to instruct it at this time. Directing the client to the smoking lounge is not helpful or therapeutic.
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During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? a. "I am taking vitamins." b. "I drink a glass of wine a night." c. "I had a heart attack 4 months ago." d. "I don't like latex balloons."
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c. "I had a heart attack 4 months ago." Rational: Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in clients who have heart problems. The type of vitamins the client takes should be assessed, but this is not the highest risk. Moderate alcohol consumption is not considered high-risk behavior. A dislike for latex is not the same as a latex allergy (however, it might be a good idea to ask why the client doesn't like latex balloons).
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The nurse completes the preoperative checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? a. Age 59 years b. General anesthesia complications experienced by the client's brother c. Diet-controlled diabetes mellitus d. Ten pounds over the client's ideal body weight
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c. Diet-controlled diabetes mellitus Rational: Diabetes contributes an increased risk for surgery or postsurgical complications. Older adults are at greater risk for surgical procedures, but this client is not classified as an older adult. Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but this is not the best answer. Obesity increases the risk for poor wound healing, but being 10 pounds overweight does not categorize this client as obese.
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Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? a. Creatinine, 1.9 mg/dL b. Fasting glucose, 80 mg/dL c. Potassium, 3.9 mEq/L d.Sodium, 140 mEq/L
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a. Creatinine, 1.9 mg/dL Rational: A creatinine of 1.9 mg/dL is outside the normal range and may indicate renal problems. A fasting glucose of 80 mg/dL, a potassium level of 3.9 mEq/L, and sodium level of 140 mEq/L are normal laboratory values.
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A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. Why is this preoperative procedure done? a. Decrease expected blood loss during surgery b. Eliminate any risk of infection c. Ensure that the bowel is sterile d. Reduce the number of intestinal bacteria
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d. Reduce the number of intestinal bacteria Rational: Bowel or intestinal preparations are performed to empty the bowel to minimize the leaking of bowel contents, prevent injury to the colon, and reduce the number of intestinal bacteria. Decreasing expected blood loss and sterilizing the bowel are not the goals of a bowel preparation. While the bowel prep may reduce the number of intestinal bacteria, it will not completely eliminate the risk of infection.
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The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? a. "I will take off my stockings one to three times a day for 30 minutes." b. "My stockings are too loose." c. "These stockings will prevent blood clots." d. "These stockings help promote blood flow."
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c. "These stockings will prevent blood clots." Rational: Antiembolism stockings alone will not prevent deep vein thrombosis (DVT). However, along with exercise, they will help promote venous return, which aids in preventing DVT. Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Stockings should be neither too loose (ineffective) nor too tight (inhibit blood flow). Antiembolism stockings may be used during and after surgery to promote venous return.
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Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area? a. Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter. b. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. c. Obtain the medical history from a client who is scheduled for a total hip replacement. Incorrect d. Assess the client who is being admitted for an elective laparoscopic cholecystectomy.
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b. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. Rational: Insertion of a catheter is within the scope of skills approved for the LPN/LVN. Preoperative teaching and physical assessment of a preoperative client are under the scope of the RN. History information would be completed by the RN on the unit.
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At 8:00 a.m., the registered nurse is admitting a client scheduled for sinus surgery to the outpatient surgery department. Which information given by the client is of most immediate concern to the nurse? a. An allergy to iodine and shellfish b. Being nauseated after a previous surgery c. Having a small glass of juice at 7:00 a.m. d. Expressing anxiety about the surgery
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c. Having a small glass of juice at 7:00 a.m. Rational: Clients need to be NPO for a sufficient length of time before surgery. Intake of food or fluids may delay the start time of the surgery, so the nurse must notify the surgeon and anesthesiologist for possible rescheduling. The nurse should confirm that all allergies are charted, and that the client has the correct allergy band identification. Many clients experience nausea after surgery; the nurse should document this in the client's information as well. The nurse should talk with the client and explore the anxiety; this is a normal feeling before surgery.
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A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish first? a. Use electric clippers to cut hair at the surgical site. b. Start an infusion of lactated Ringer's solution at 75 mL/hr. c. Administer one-half of the client's usual lispro insulin dose. d. Draw blood for glucose, electrolyte, and complete blood count values.
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d. Draw blood for glucose, electrolyte, and complete blood count values. Rational: If blood work is abnormal, the surgery may be rescheduled. The blood sample needs to be drawn and sent to the laboratory first to confirm that results are within normal limits. Removal of hair can be accomplished in the operating room directly before the start of surgery. The IV infusion can be accomplished after the laboratory orders have been completed. The nurse should check blood glucose with the laboratory orders before administration of lispro.
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An unidentified client from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse, who is verifying the informed consent, do? a. Ensure written consultation of two noninvolved physicians. b. Read the surgeon's consult to determine whether the client's condition is life-threatening. c. Sign the operative permit. d. Withhold surgery until the next of kin is notified.
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a. Ensure written consultation of two noninvolved physicians. Rational: In a life-threatening situation in which every effort has been made to contact the person with medical power of attorney, consent is desired but not essential. In place of written or oral consent, written consultation by at least two physicians who are not associated with the case may be requested by the health care provider. It is not within the nurse's role to make a judgment about the client based on the surgeon's consult. Signing documents on the client's behalf is not legal. Withholding surgery is not in this client's best interests.
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While at the scrub sink, the scrub person informs the circulating nurse that she now wears artificial nails because her own nails break frequently posing a risk for a glove puncture. What is the nurse's best response? A. Ask the scrub person to wear double-gloves to prevent puncture or contamination. B. Confirm with the scrub person that artificial nails are acceptable and do not affect hand hygiene. C. Support the scrub person's rationale that broken nails are a serious source of cross-contamination.??? D. Remind the scrub person that artificial nails alter skin flora, impede hand hygiene, and are not permitted.
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D. Remind the scrub person that artificial nails alter skin flora, impede hand hygiene, and are not permitted. Rationale: Although a punctured glove can cause contamination, artificial nails have been proven to harbor many pathogenic organisms even after the person has correctly performed an appropriate scrub. The World Health Organization's Guidelines on Hand Hygiene in Health Care warn against their presence in scrubbed operating room (OR) personnel.
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Which change in the anesthetized client alerts the nurse to the possibility of malignant hyperthermia? A. Widening pulse pressure B. Increasing output of dilute urine C. Increasing end-tidal carbon dioxide level D. Ascending flaccid paralysis of skeletal muscles
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C. Increasing end-tidal carbon dioxide level Rationale: The carbon dioxide level of expired (exhaled) air is an indication of acid-base balance. With malignant hyperthermia, the metabolism of skeletal muscles is greatly increased, generating extreme heat and causing an oxygen debt. This condition leads to lactic acidosis and increased production of carbon dioxide. A rise in end-tidal carbon dioxide level is the most sensitive indicator of the presence of malignant hyperthermia. A common mistake is to assume the best indication of malignant hyperthermia is a dramatic rise in body temperature. This is a very late sign, and if interventions are delayed until then, the risk for death or significant brain damage is increased.
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A patient scheduled for a palliative, pain-relieving procedure has a do-not-resuscitate (DNR) order confirmed in the medical record. However, after being premedicated, the patient requests the order be suspended during the procedure and that a family member be contacted. 1. Is the patient permitted to suspend the DNR order in light of the fact that he has already received premedication?
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This is a tricky situation. The hospital, surgeon, and other members of the health care team do not have the authority to suspend arbitrarily the DNR order during the perioperative period. However, the patient should be able to change his or her mind and request that the DNR order be suspended temporarily. Because the patient has already received premedication, his or her request needs to be evaluated on the basis of his or her ability to understand and make good decisions. It is possible that the preoperative drugs administered did not contain any drugs that alter cognition. It would be good to ask the patient what his or her concerns are about the DNR order during the perioperative period. Then any misinformation or unrealistic concerns could be clarified. Bringing in a family member at the patient's request is reasonable, especially if this person has medical power of attorney. All in all, the patient does have the right to suspend the DNR order.
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2. What principle of ethical behavior guides your response? (You may need to review the ethical principles in Chapter 1.)
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The important principles guiding the outcome are beneficence, nonmaleficence, and autonomy. Beneficence requires that the nurse do good for the patient. Thus, helping the patient emotionally by honoring his or her request to suspend the DNR would meet this principle. Nonmaleficence stresses the importance that the patient not be harmed. Suspending the DNR would not physically or emotionally harm this patient. Autonomy is the patient's right to self-determination. If it can be judged that the patient is cognitively aware sufficiently to know the consequences of suspending the DNR temporarily, the principle of autonomy would not be violated.
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3. How should the OR nurse proceed with the patient request?
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Clarify with the patient why he or she wants the suspension. Bring in the family member, the surgeon, and possibly the hospital ethicist and clergy.
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4. What steps could be taken to ensure that patient requests and revisions of requests can be handled appropriately in the future?
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Work with perioperative personnel to establish a policy regarding DNR status changes during the perioperative period. Some of the procedures could include: • Checking to determine which patients have a DNR on the chart before any medications are given • Asking the patient to explain in his or her own words what he or she believes a DNR order means for events that occur surgery • Asking the patient whether he or she wants to maintain or suspend the DNR during the perioperative period • Establishing who, in addition to the patient, should be involved in changing a DNR status • Have the patient voice any concerns or fears regarding the procedure and outcome
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A client is having an arthroscopy of the left knee and has just been moved to the surgical holding area. Which statement by the nurse properly identifies the client while the nurse checks the identification label? a. "Are you Mr. Smith?" b. "Good morning, Mr. Smith." c. "What is your name, and where were you born?" d. "What surgery are you having today?"
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c. "What is your name, and where were you born?" Rational: The nurse must verify the client's identity with two types of identifiers. This practice prevents errors by drowsy or confused clients. When asked to verify his or her name, or respond to a greeting, the client may respond inappropriately if he or she is anxious or sedated. Asking the client about his or her surgery does help with identification; however, it is really done to ascertain that the client's perception of the procedure, the operative permit, and the operative schedule are the same.
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As the nurse is about to give a preoperative medication to a client going into surgery, it is discovered that the surgical consent form is not signed. What does the nurse do? a. Calls the surgeon Incorrect b. Calls the anesthesiologist c. Gives the medication as ordered d. Asks the client to sign the consent form
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d. Asks the client to sign the consent form Rational: The nurse may ask the client to sign the consent form, after which the medication can be administered. Calling the surgeon or the anesthesiologist is not necessary. It is illegal for the client to sign the permit after being sedated.
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Which statement by a student nurse indicates a need for further teaching about operating room (OR) surgical attire? a. "I must cover my facial hair." b. "I don't need a sterile gown to be in the OR." c. "If I go into the OR, I must wear a protective mask." d. "My scrubs are sterile."
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d. "My scrubs are sterile." Rational: Scrub attire is provided by the hospital and is clean, not sterile. All members of the surgical team must cover their hair, including any facial hair. Team members who are not scrubbed (e.g., anesthesia provider, student nurse) are not required to be sterile; they may wear cover scrub jackets that are snapped or buttoned closed to prevent shedding of organisms from bare arms. Everyone who enters an OR in which a sterile field is present must wear a mask.
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A client has undergone an 8-hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding? a. Decreased sensation in the lower extremities b. Diminished peripheral pulses in the lower extremities c. Pale, cool extremities d. Reddened areas over bony prominences
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b. Diminished peripheral pulses in the lower extremities Rational: Diminished peripheral pulses in the lower extremities indicate diminished blood flow. Decreased sensation; pale, cool extremities; and reddened areas over bony prominences can be normal occurrences in clients who have undergone a long surgical procedure.
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The charge nurse for a hospital operating room is making client assignments for the day. Which client is most appropriate to assign to the least-experienced circulating nurse? a. The 20-year-old client who has a ruptured appendix and is having an emergency appendectomy b. The 28-year-old client with a fractured femur who is having an open reduction and internal fixation c. The 45-year-old client with coronary artery disease who is having coronary artery bypass grafting d. The 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed
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d. The 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed Rational: The client with stage I breast cancer is the most stable client among all scheduled procedures. This assignment would be appropriate for the beginning nurse or one with less experience. The client who has a ruptured appendix is less stable and at high risk for infection/sepsis; a more experienced nurse is required. The client with a fractured femur is at high risk for clotting, infection, and aspiration owing to the surgery; a more experienced nurse would be better. The client with coronary artery disease is having high-risk surgery with risk for multiple complications and requires an experienced operating room nurse.
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Which assessment parameter is most important for the nurse to employ for the client admitted to the postanesthesia care unit (PACU) for recovery after surgery under epidural anesthesia? A. Determining the client's level of consciousness B. Checking for pain on dorsi and plantar flexion of the foot. C. Assessing the response to pin prick stimulation from feet to mid chest level D. Comparing blood pressure taken in the right arm to blood pressure taken in the left arm
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C. Assessing the response to pin prick stimulation from feet to mid chest level Rationale: Epidural anesthesia blocks both motor and sensory function of spinal nerves from at least the level of injection down. The agent can climb higher in the epidural space and affect function above the level of injection. The motor and sensory responses must be assessed for return of function. Moving the extremities is an indication of return of motor function. Sensory function is assessed by the ability of the patient to feel. The most common method of sensory assessment is to lightly prick the client's skin with a needle or pin and have the client indicate when the sensation feels sharp rather than dull or just pressure. Blood pressure can fall as a result of the vasodilation from epidural anesthesia, but the anesthesia does not cause a difference in blood pressure from one arm to the other. The level of consciousness is not affected by epidural anesthesia.
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The assessment findings for the nasogastric tube drainage of a client recently transferred from the PACU include the presence of 140 mL of greenish-yellow drainage. What is the nurse's best action? A. Instruct the client to drink water until the drainage is clear. B. Reposition the tube to increase the drainage. C. Call and report this finding to the surgeon. D. Document the finding as the only action.
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D. Document the finding as the only action. Rationale: Both the amount and color of the fluid draining from the NG tube are normal and expected for this point in the postoperative period. It is not necessary to notify the surgeon, nor should the tube be repositioned. The client remains NPO (nothing by mouth) while the NG tube is in place. Moreover, the fluid would not be expected to ever be clear.
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The nurse is about to give the prescribed pain medication to a client 30 minutes before a scheduled dressing change. The client states that the drug makes him feel sick and he would rather "tough it out." What is the nurse's best first response? A. "Tell me more about the sick feeling." B. "That's fine. You have the right to refuse any drug." C. "Your surgeon would not have prescribed the drug if it wasn't needed." D. "Remember that the pain of the dressing change would be worse than feeling sick."
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A. "Tell me more about the sick feeling." Rationale: Although the client does have the right to refuse any medication, the "sick feeling" is a vague description. He may mean nausea, but he could also mean some other response that could indicate a possible adverse reaction to the drug. It is important to gather more information. Also, by acknowledging the client's feelings, the nurse is using therapeutic communication before implementing the next step.
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The patient is a 71-year-old woman who came from the operating room to the postanesthesia recovery unit about an hour ago after a short procedure (dilation and curettage) under general anesthesia for dysfunctional uterine bleeding. She awakens when her name is called, but she does not know where she is or why. In addition, she has pulled off her oxygen cannula and keeps trying to pull out her IV. Her last vital signs, taken 15 minutes ago, were BP, 140/92; pulse, 88; respirations, 18. When you check her vital signs now, they are BP, 128/102; pulse 110; respirations 24. She is saying she is thirsty and wants some water. 1. Are any of the changes in vital signs a cause for concern? If so which ones?
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All her vital sign changes (elevated pulse, elevated respiration, narrowed pulse pressure, decreasing systolic pressure, rising diastolic pressure) are cause for concern because they are indicators of progressing shock. In addition, the increased sensation of thirst should be considered manifestations of shock until proven otherwise.
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2. Given her surgery, where should you look for bleeding?
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The dilatation and curettage is performed vaginally and involves using a sharp instrument to scrape and remove the innermost lining of the uterus. Damage to the uterus could cause vaginal bleeding. A more rare complication of the procedure is a puncture by the curette through the uterine wall and into the pelvic and abdominal cavity with possible tearing of a blood vessel. This would result in internal bleeding rather than vaginal bleeding. Pelvic and abdominal bleeding is harder to detect and manifests as increasing abdominal size and pain. Vital sign changes would occur first.
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3. Should you apply oxygen? Why or why not?
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Yes, oxygen should be reapplied. Her confusion could be more related to shock manifestations and hypoxemia than to the general anesthesia. The fact that she is confused may make oxygen delivery a problem, especially with a mask or nasal cannula. A partial mask or tube could be placed near her nose and mouth to increase the oxygen content of inspired air.
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4. Should you give her sips of water? Why or why not?
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Do not give her sips of water until her vital signs have stabilized and no manifestations of shock are present. Depending on the cause of shock, she may need further surgery.
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5. Should you notify the surgeon or anesthesia provider. Why or why not?
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Yes, the surgeon would be the best first choice. She has many indicators of impending shock. Bleeding from this procedure is not always obvious.
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The nurse reviews with a client a routine discharge teaching plan concerning postoperative care. Which statement by the client indicates that teaching was effective? a. "I may need to restrict my activities for several months." ??? b. "The dressing should stay in place unless it gets wet." ??? c. "The incision needs to be cleaned every 4 hours with hydrogen peroxide." d. "The wound will completely heal in about 2 months."
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a. "I may need to restrict my activities for several months." Rational: To protect the integrity of the wound, activities may need to be restricted. The wound will need to be open to air for healing. Using hydrogen peroxide can cause wound irritation, unless specifically ordered. The length of time it takes for a wound to heal varies; a wound can take up to 2 years to heal.
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Which assessment finding in a postoperative client after general anesthesia requires immediate intervention? a. Heart rate of 58 beats/min b. Pale, cool extremities c. Respiratory rate of 6 breaths/min d. Suppressed gag reflex ???
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c. Respiratory rate of 6 breaths/min Rational: The most important postoperative assessment is respiratory assessment, and a rate of 6 breaths/min is too low. A heart rate of 58 beats/min, pale and cool extremities, and a suppressed gag reflex are all normal postoperative findings.
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In conducting a postoperative assessment of a client, what is important for the nurse to examine first? a. Breathing pattern b. Level of consciousness c. Oxygen saturation d. Surgical site
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a. Breathing pattern Rational: Respiratory assessment is the most important. Assessing level of consciousness, oxygen saturation, and the surgical site are important, but not the priority.
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A client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement is true about this client? a. Supplemental pain reduction is needed. b. One dose is needed. c. This is an acute emergency. Incorrect d. The client will be hostile.
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a. Supplemental pain reduction is needed. Rational: The client has breakthrough pain after the opioid antagonist is given, so other interventions to promote comfort are needed. Several doses of naloxone may be needed because the drug has a short half-life. Opioid depression is a manageable situation, not an acute emergency. The client with opioid depression usually is not fully conscious.
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The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse the greatest concern? a. Crusting along the incision line b. Redness and swelling around the incision c. Sanguineous drainage at the suture site d. Serosanguineous drainage on the dressing
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b. Redness and swelling around the incision Rational: Redness and swelling around the incision indicate an infection. Crusting along the incision line, sanguineous drainage, and serosanguineous drainage are normal.
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Five RNs have been floated to the postanesthesia care unit for the day. A 16-year-old diabetic client has also just arrived from the operating room (OR) after having laparoscopic abdominal surgery. The charge nurse assigns the floating RN with which kind of experience to care for this new client? a. RN who usually works on the inpatient pediatric unit b. RN who provides education to diabetic clients in a clinic c. RN who has 5 years of experience in the delivery room d. RN who ordinarily works as a scrub nurse in the OR
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c. RN who has 5 years of experience in the delivery room Rational: The RN with delivery room experience would have experience with abdominal surgery and with postoperative care of clients with diabetes, and would be aware of possible postoperative complications for this client. The RN who usually works on the pediatric unit would not be aware of potential complications and routine assessments for this client. The RN who provides education to diabetic clients in a clinic would be able to provide required care for the client's diabetes but not the postoperative aspect of care. The RN who works as a scrub nurse would not have the knowledge and understanding of routine postoperative care that is needed for this client.
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The RN has just received reports about all of these clients on the inpatient surgical unit. Which client does the nurse care for first? a. A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing b. A 46-year-old who had a thoracotomy 5 days ago and needs discharge teaching before going home c. A 48-year-old who had bladder surgery earlier in the day and is reporting pain when coughing d. A 49-year-old who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4° F (38° C)
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a. A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing Rational: New drainage on the seventh postoperative day is unusual and suggests a complication that would require further assessment and possible immediate action. A temperature of 100.4° F and pain upon coughing following bladder surgery are normal on the first postsurgical day. The client awaiting discharge teaching is not a priority.
