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Flashcards in Chapter 50: Care of Surgical Patients Deck (131)
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1
Q

Perioperative Nursing includes

A
  • preoperative
  • intraoperative
  • postoperative
2
Q

Perioperative Nursing takes place in

A
  • hospitals
  • surgical centers
  • attached to hospitals
  • freestanding surgical centers
  • healthcare providers’ offices
3
Q

Important principles of perioperative nursing

A
  • High-quality and patient safety-focused care
  • EBP
  • Multidisciplinary teamwork
  • Effective therapeutic communication and collaboration with the patient, family, and surgical team
  • Effective and efficient assessment and intervention in all phases
  • Advocacy for the patient and family
  • Understanding of cost containment
4
Q

Preoperative Phase

A

involves all process that take place to prepare for surgery

5
Q

Processes of the Preoperative Phase include:

A
  • pre-op lab work
  • history and physical
  • consents
  • nursing assessment
  • cultural/spiritual concerns
  • education to patient and family
6
Q

Intraoperative Phase

A

primarily concerned with preventing injury and complications r/t anesthesia, surgery, positioning and equipment use.

7
Q

Postoperative Phase

A

focuses on immediate recovery and postoperative convalescence

8
Q

Processes for Immediate Recovery include

A
  • monitoring and maintaining airway
  • respiratory, circulatory and neurological status
  • fluid and electrolyte balance
  • pain management
9
Q

Processes for Postoperative Convalescence

A
  • pain management
  • bowel function
  • wound care
  • activity limitations
10
Q

Ambulatory Surgery

A
  • aka outpatient surgery, short-stay surgery or same-day surgery.
  • surgery that does not require an overnight hospital stay
11
Q

Ambulatory Surgery includes

A
  1. opthalmic
  2. gastroenterological
  3. gynecological
  4. EENT
  5. orthopedic
  6. cosmetic/restorative
  7. general
12
Q

Benefits of Ambulatory Surgery Centers

A
  • shorter operative times and faster recovery time. (choice of anesthetic drugs metabolize rapidly with few aftereffects, ex. propofol)
  • cost saving by eliminating the need for hospital stays
  • reduces possibility of acquiring HAIs
13
Q

Laparoscopic procedures are more advanced. Recovery

A

is as short as a few hours to 24 hours as opposed to larger abdominal incisions leading to a 1-3 day hospital stay and up to 4 weeks recovery.

14
Q

Classification of Surgery

A
  1. Seriousness
  2. Urgency
  3. Purpose
15
Q

Classification of Surgery: Seriousness

A

Major and Minor

16
Q

Major Surgery

A

extensive alteration

ex. coronary artery bypass and colon resection

17
Q

Minor Surgery

A

minimal alteration

ex. cataract procedure

18
Q

Classification of Surgery: Urgency

A
  1. Elective
  2. Urgent
  3. Emergency
19
Q

Elective Surgery

A

client choice, not essential

ex. breast reconstruction

20
Q

Urgent Surgery

A

necessary but not emergent

ex. cholecystectomy

21
Q

Emergency Surgery

A

threatens life or limb

ex. ruptured appendix

22
Q

Types of Surgery

A
  1. diagnostic
  2. ablative
  3. palliative
  4. reconstructive/restorative
  5. procurement for transplant
  6. constructive or cosmetic
23
Q

Diagnostic Surgery

A
  • to confirm diagnosis.

- usually involves removal of tissue for further diagnostic testing.

24
Q

Ablative Surgery

A

removal of a body party

25
Q

Palliative Surgery

A

relieves disease symptoms without producing a cure

26
Q

Reconstructive/Restorative Surgery

A

restoring function or appearance

27
Q

Procurement for Transplant Surgery

A

Taking tissues from one person and placing in another

28
Q

Constructive or Cosmetic Surgery

A

improves personal appearance

29
Q

Types of Anesthesia

A
  1. General
  2. Regional
  3. Local
  4. Conscious Sedation/Moderate Sedation
30
Q

General Anesthesia

A

loss of all sensations and consciousness

31
Q

Regional Anesthesia

A

loss of sensation in an area of the body (nerve block, spinal, epidural)

32
Q

Local Anesthesia

A

loss of sensation at a site (lidocaine)

33
Q

Conscious Sedation/Moderate Sedation

A

used for procedures that do not require complete anesthesia (propofol).

34
Q

Advantages of Conscious Sedation/Moderate Sedation

A

rapid recovery from anesthesia, stable VS, reduction of fear/anxiety, amnesia

35
Q

Physical Status Classification: P1

A

Normal Healthy Patient.

No disturbance.

36
Q

Physical Status Classification: P2

A

Patient with mild systemic disease.

CV disease w/ minimal restriction on activity.

37
Q

Physical Status Classification: P3

A

Patient with severe systemic disease.

HTN, obesity, DM

38
Q

Physical Status Classification: P4

A
  • Patient with severe systemic disease that is a constant threat to life.
  • CV or pulmonary disease that limits activity, MI, severe HTN, DM
39
Q

Physical Status Classification: P5

A
  • A moribund patient who is not expected to survive without the operation.
  • Severe system dysfunction
40
Q

Physical Status Classification: P6

A
  • Declared brain dead whose organs are being harvested for donor purposes.
  • Managed to optimize blood flow to organs.
41
Q

What are surgical risk factors?

A
  • smoking
  • age
  • nutrition
  • obesity
  • obstructive sleep apnea
  • immunosuppression
  • fluids and electrolyte imbalance
  • postoperative nausea and vomiting
  • venous thromboembolism
42
Q

Perioperative Communication

A
  • “hand off” between caregivers in the form of a standardized checklist.
  • accurate patient identification and communication.
43
Q

Glycemic Control and Infection Prevention

A

increase blood sugar levels and increase infection risk and mortality

44
Q

Pressure Ulcer Prevention

A

increased risk due to:

  • prolonged positioning
  • changes in hemodynamics
  • multiple layers of drapes
  • exposure of the skin to fluids to irrigate wounds during surgery
45
Q

The aim of assessment is to

A
  • identify the patient’s normal preoperative function
  • recognize any abnormality that may need to delay or cancel surgery.
  • recognize, prevent, and/or minimize postoperative complications.
  • form a caring relationship to effectively communicate
  • establish a plan of care that matches the patient’s needs and expectations
46
Q

What are some abnormalities that may indicate the need to delay or cancel surgery?

A
  • pt with a cough or low-grade fever

- abnormal lab results

47
Q

Assessment: Nursing History

A

rely on family if patient is a poor historian

48
Q

Assessment: Medical History

A
  • includes past illnesses, surgeries and chief c/o.

- screen for medical conditions that increase the risk for complications during or after surgery.

49
Q

Assessment: Perceptions and Knowledge Regarding Surgery

A
  • past experiences of surgery influence physical and psychological responses.
  • assess for motion sickness and N/V during previous surgeries (causes increased risk for aspiration).
50
Q

The nurse should confer with the surgeon if the patient has

A

an inaccurate perception or knowledge of the surgical procedure.

51
Q

Assessment: Medication History

A
  • assess for preexisting comorbid conditions
    ex. HTN, renal or heart disease, respiratory disorders, DM.
  • include assessment of OTC medications/vitamins/herbal supplements.
52
Q

For hospitalized patients, prescription medications taken before surgery are

A

automatically discontinued after surgery unless the LIP reorders them

53
Q

Assessment: Support Sources

A
  • in SDS, families assume responsibility for postoperative care.
  • encourage family presence during teaching because family may remember preoperative/postoperative teaching better than the patient.
  • Post discharge phone call.
54
Q

Assessment: Occupation

A

surgery may limit or delay ability to return to work

55
Q

Preoperative Pain Assessment

A

include pt/family expectations.

pain scale/scoring

56
Q

Assessment: Review of Emotional Health

A
  1. Self-concept
  2. Body image
  3. Coping resources
  4. Culture and religion
57
Q

Self-Concept RT Surgery

A

positive self-concept more likely to face experiences appropriately.

58
Q

Body Image RT Surgery

A
  • often leaves permanent disfigurement.
  • concern over mutilation (colostomy, amputation, breast tissue, hysterectomy, -prostatectomy-sexual fx)
  • assess body image alterations.
59
Q

Coping Resources RT Surgery

A

Activation of the endocrine system results in release of hormones/catecholamines which increase HR, BP, RR

60
Q

Culture and Religion RT Surgery

A

may affect the way each patient perceives and reacts to the surgical experience.

61
Q

Risk Factors RT Surgery

A
  1. Age
  2. Nutrition
  3. Obesity
  4. Obstructive Sleep Apnea
  5. Smoking Habits
  6. Alcohol/Substance Use/Abuse
  7. Allergies
  8. Immunocompromised
  9. Fluid & Electrolyte Imbalance
  10. Pregnancy
62
Q

Risks of Surgery in the Very Young

A
  • Body temperature: anesthetics often cause vasodilation and heat loss.
  • Smaller Blood Volume: small amount of loss can be serious.
  • Dehydration vs over-hydration.
  • Airway management
  • *check book for more info
63
Q

Risks of Surgery in the Very Old

A
  • Less adaptable to stress-physiological
  • Cognitive/psychological
  • Sociological Changes
  • *check book for more info
64
Q

Risks for Surgery: Nutrition

A
  • tissue repair and resistance to infection depend on adequate nutrients.
  • Vit A, C and zinc facilitate wound healing.
65
Q

How does poor nutrition affect a patient’s risk for surgery?

A

makes patient more prone to:

  • poor tolerance to anesthesia
  • negative nitrogen balance (lack of protein)
  • delayed blood clotting mechanisms
  • infection
  • poor wound healing
66
Q

Risks for Surgery: Obesity

A

-has an increased risk for obstructive sleep apnea, HTN, CAD, DM, heart failure, embolism, atelectasis, pneumonia, poor wound healing, wound infection, dehiscence and evisceration.

67
Q

Risks for Surgery: Obstructive Sleep Apnea

A

syndrome of periodic, partial or complete obstruction of the upper airway during sleep

68
Q

CPAP

A

Continuous positive airway pressure.

Treatment for Sleep Apnea

69
Q

NIPPV

A

Non-invasive {nasal} positive pressure ventilation.

Treatment for Sleep Apnea

70
Q

Risks for Surgery: Smoking Habits

A
  • Risk for pulmonary complications
  • Increased amount/thickness of mucus secretions in lung, decreased ciliary activity
  • Gen anesthesia increases airway irritation, stimulates pulmonary secretions.
  • C &DB exercises essential
71
Q

Risks for Surgery: Alcohol/Substance Use/Abuse

A
  • Possible cross-tolerance to anesthetic agents (may need higher than normal doses)
  • May need increased postoperative analgesics.
  • Often malnourished, delays healing
  • Risk for liver disease, portal hypertension, esophageal varices (hemorrhage)
  • Acute alcohol withdrawal/delirium tremens (DT’s).
72
Q

Risks for Surgery: Latex Allergy

A
  • genetic predisposition, children with spina bifida, patients with urogenital abnormalities or spinal cord injury (long hx of urinary catheter use), hx of multiple surgeries, those who manufacture rubber products
  • also patients with allergies to certain foods such as bananas, chestnuts, kiwi fruit, avocadoes, and tomatoes have shown a cross-sensitivity to latex.
73
Q

Risks for Surgery: Immunocompromised

A
  • At risk for developing infection.

- include patients: cancer(chemotherapy), bone marrow alterations, radiation therapy, steroids (COPD).

74
Q

Risks for Surgery: Fluid and Electrolyte Imbalance

A
  • Negative nitrogen balance & hyperglycemia causes increased risk for infection.
  • Adrenocortical stress response: body retains Na+ and loses K+ within the first 2-5 days after surgery.
  • If CV, GI, or renal abnormalities, risk of F&E alterations is greater.
75
Q

Risks for Surgery: Pregnancy

A
  • Two patients involved: mother and fetus.
  • Anesthesia increases risk for fetal death and preterm labor.
  • Psychological assessment of mother and family is essential.
  • Increased fibrinogen (blood clots); decreased GI motility and H & H (increased circulating volume).
76
Q

Assessment: Physical Exam

A
  1. General Survey
  2. Head/Neck
  3. Integument
  4. Thorax/Lungs
  5. Heart/Vascular System
  6. Abdomen
  7. Neurological Status
77
Q

Physical Exam: General Survey

A

Pre-op VS: Important baseline data

*elevated temp cause for concern-notify the surgeon

78
Q

Physical Exam: Head/Neck

A
  • Mucous membranes, level of hydration.
  • Sinus drainage may indicate respiratory or sinus infection.
  • Identify loose or capped teeth, piercings and dentures.
79
Q

Physical Exam: Integument

A
  • full skin assessment
  • bony prominences
  • chronic use of steroids increase risk of skin tears.
  • hydration
80
Q

Physical Exam: Thorax/Lungs

A
  • breathing pattern
  • ventilatory capacity
  • auscultate breath sounds.
  • if wheezing auscultated, notify LIP.
81
Q

Physical Exam: Heart/Vascular System

A
  • apical pulse/heart sounds/capillary refill
  • color temp of extremities
  • peripheral pulses
82
Q

Physical Exam: Abdomen

A

symmetry/presence of distention

83
Q

Physical Exam: Neurological Status

A

LOC, orientation, mood, ease of speech.

*note weakness/impaired mobility

84
Q

Diagnostic Screening

A
  • blood usually drawn several days before surgery
  • testing the day of surgery is limited to blood glucose monitoring (DM)
  • may include a type and cross match
  • over age of 40 may include CXR, ECG
  • pulmonary hx may include pulmonary function testing, ABG analysis
  • patient may donate blood if done well in advance.
85
Q

Nursing Process: Diagnosis RT Surgery

A
  • Ineffective Airway
  • Clearance
  • Anxiety
  • Ineffective Coping
  • Impaired Skin Integrity
  • Risk for Aspiration
  • Risk for Infection
  • Deficient Knowledge
  • Impaired Physical Mobility
  • Nausea
  • Acute Pain
86
Q

Patient Teaching RT Surgery

A
  • relieves anxiety/address pain control issues
  • better compliance post-op
  • family can act as coach
  • increases return to normal activity post-op
87
Q

Informed Consent

A

a process of communication between a patient and physician that results in the patient’s authorization or agreement to undergo a specific medical intervention

88
Q

When filling out the informed consent

A

ensure it is filled out correctly and signed by the patient.
no abbreviations!

89
Q

If a lack of understanding by the patient regarding their surgical procedure is assessed

A

notify the surgeon

90
Q

RN’s assess the patient’s knowledge

A

regarding their understanding of the procedure

91
Q

Informed consent includes

A
  • the nature and purpose of the procedure
  • the risks and benefits of the treatment or procedure
  • alternatives
  • the risks and benefits of the alternatives
  • the risks and benefits of not receiving or undergoing a treatment or procedure.
92
Q

Pre-operative teaching include

A
  • Purpose & use of pneumatic stockings
  • Incentive spirometer, deep breathing
  • Turning/Coughing (splinting)/Deep Breathing exercises
  • Leg exercises
  • Pain relief measures
  • Early activity
  • Preoperative Routines
  • Identifying feelings regarding surgery
93
Q

Coughing may be contraindicated after

A

brain, spinal, or eye surgery because it increases intracranial pressure (ICP)

94
Q

Leg exercises include

A

foot circles, dorsiflexion, plantar flexion, quadriceps setting, hip & knee movements

95
Q

Preparation: Day of Surgery

A
  1. Hygiene: oral care, may require pre-op scrube
  2. Hair/Cosmetics: Remove wigs/hair pins
  3. Removal of Prostheses: Remove and safeguard
  4. Safeguarding Valuables: Secure and Document
  5. Preparing the Bowel/Bladder: void before pre-op med. May get catheter while under anesthesia. Bowel preps
  6. Vital Signs: all data documented and accounted for
  7. Prevention of DVT: antiembolism devices
  8. Administering Preoperative Medications: Sign consent first.
96
Q

Surgical Time-Out

A
  • used for preventing wrong site, wrong procedure, wrong person surgery
  • occurs with the participation of the entire OR team immediately preceding the procedure.
97
Q

Verification of the correct person, procedure and site should occur when

A

the patient is awake and aware if possible

98
Q

Site marking should occur by

A

the LIP involved in the procedure with the patient’s participation if possible.

99
Q

Circulating Nurse

A

must be an RN

100
Q

What are the responsibilities of the circulating nurse?

A
  • Review of preoperative assessment
  • Establishes and implements the plan of care
  • Manages patient positioning
  • Monitors sterile technique and safe OR environment
  • Verifies sponge and instrument counts
  • Maintains accurate records
  • Assists with procedures-endotracheal intubation, blood administration prn.
101
Q

Scrub Nurse

A

May be an RN, LPN, or surgical technician

102
Q

What are the responsibilities of the scrub nurse?

A
  • Maintains sterile field
  • Assists with sterile drapes
  • Hands instruments and other sterile supplies to surgeons
  • Counts sponges and instruments
103
Q

Intraoperative assessment

A

t. 50-7 pg 1284

104
Q

Intraoperative Nursing Diagnosis

A
  • Ineffective Airway Clearance
  • Risk for Perioperative Positioning Injury
  • Impaired skin Integrity
  • Risk for Thermal Injury
  • Risk for Injury
105
Q

Intraoperative Nursing Implementation

A

physical preparation

106
Q

Postoperative Surgical Phase I

A
  • Patient may be aware of his/her surroundings

- OR nurse provides hand-off communication to PACU nurse.

107
Q

PACU RN focus is

A
  • Maintaining airway
  • Pain Management
  • Respiratory, circulatory, and neurological status
  • Keep normothermic
  • Evaluate patients readiness for discharge from PACU
108
Q

Whose responsibility is it to describe the patient’s status, results of surgery and any complications that occurred to the family?

A

it is the surgeon’s responsibility.

109
Q

Malignant Hyperthermia

A
  • rare reaction to anesthesia (genetic)

- lethal if untreated/unrecognized

110
Q

Clinical Signs and Symptoms of Malignant Hyperthermia

A
  • Tachycardia
  • jaw/muscle rigidity
  • increased respiratory rate
  • hypercarbia
  • tachypnea
  • PVC’s
  • unstable BP
  • cyanosis
  • skin mottling
111
Q

What is a late sign of Malignant Hyperthermia?

A

hyperthermia

112
Q

Postoperative Recovery II - Ambulatory Surgery

A

-Discharge from the PACU based on Aldret Score (most widely used scoring tool)

113
Q

What Aldret Score must a patient receive before discharge from PACU?

A

score of 8-10

*patient may be admitted to ICU if condition remains poor.

114
Q

Alderet Score

A

-every 5 minutes x 3 or every 15 minutes x 1 hour or up to 3 hours (depending on hospital protocol) until stable

115
Q

Postoperative Nursing Assessment: Recovery and Convalescence

A
  • Pain/Comfort
  • Airway/Respiration
  • Circulation
  • Temperature Control
  • Fluid/Electrolyte Balance
  • Neurological functions
  • Skin Integrity/Wound Condition
  • Metabolism
  • Genitourinary Function
  • Gastrointestinal Function: Paralytic ileus (lack peristalsis)
116
Q

Postoperative Nursing Assessment: Neurological Functions

A

LOC, gag and pupil reflexes

117
Q

Postoperative Nursing Assessment: Genitourinary

A
  • Urinary function returns in 6 to 8 hours
  • Remove Foley catheter per SCIP protocol and MD orders
  • Patient may have trouble voiding r/t anesthesia.
118
Q

Postoperative Nursing Assessment: Gastrointestinal

A
  • Anesthesia slows motility
  • Check bowel sounds/is patient passing gas?
  • Advance diet as ordered/tolerated
119
Q

Postoperative Nursing Assessment: Maintain Normoglycemia

A
  • Decreased wound infections
  • Decreased bloodstream infections
  • Decreased mortality
120
Q

Postoperative Nursing Assessment: Skin integrity and condition of wound

A
  • Check skin for rashes, petechiae, abrasions or burns.
  • Check wound for drainage/document
  • Look underneath patient for drainage
  • Note amount and color of drainage
  • Venous thromboembolism (VTE) prevention
  • MD may want to be present for 1st dressing change
121
Q

Dehiscence

A

opening of the suture line

122
Q

Evisceration

A

abdominal contents protrude through incision

123
Q

Fatty tissue which also contains poor oxygen supply can be a challenge in wound closure due to

A

extra pressure on the incision

124
Q

Unexpected Outcomes

A

slide 56

125
Q

Post Op Diagnosis

A
Ineffective Airway Clearance
Anxiety
Fear
Risk for Infection
Deficient Knowledge
Impaired Physical Mobility
Impaired Skin Integrity
Nausea
Acute Pain
126
Q

Implementation: Promoting Expansion of the Lungs

A
Diaphragmatic Breathing Exercises q1 hour w/a.
CPAP or NIPPV
Incentive Spirometer 
C&DB exercises
Early ambulation/leg exercises
Turning q2h w/a; sit when possible
Pain Control: will participate in C&DB exercises
Splinting incisions
Suction as needed
Oral care
O2 as needed
127
Q

Promote Wound Healing

A

Critical period for healing 24-72 hours after surgery.

If a wound becomes infected, it usually occurs 3-6 days after surgery.

A clean surgical wound usually does not regain strength against normal stress for 15-20 days after surgery.

Good nutrition: at least 1500cal/day.

Hydration

Movement/Ambulation/Exercise

128
Q

Risk of Infection is determined by

A
  • The amount and type of microorganisms contaminating a wound.
  • Susceptibility of the host.
  • The condition of the surgical wound itself.
129
Q

Emphasize preventing the occurrence of

A

surgical site infections

130
Q

Surgical Care Improvement Project (S.C.I.P)

A
-A national quality partnership of 
organizations interested in improving 
surgical care by significantly reducing
surgical complications. 
-Involves all peri-operative procedures
131
Q

slide

A

64