3.) Minimally invasive surgery: Surgery performed in a body cavity or body area through one or more endoscopes, can correct problems, remove organs, take tissue for biopsy, re-route blood vessels and drainage systems, is a fast-growing and ever-changing type of surgery.
What are the different technologies that can be used for surgery?
Open procedures
Use of scopes and lasers
What are the 3 phases of Perioperative nursing?
Pre-operative: Decision to perform surgery --> transportation of patient to the OR
Intra-operative: OR --> transfer to Post-Anesthesia Care Unit (PACU)
Post-operative: Admission to PACU --> recovery time - anesthesia/stress of surgery
What are the major responsibilities in perioperative nursing?
1.) Safety!!
2.) Consistency of process
3.) Effectiveness
4.) Provide physical and emotional support to each person involved
What must the patient be informed of before they give informed consent?
REMEMBER 5 R's: "I would Rather Refuse the Required treatment, if the Risks out way the Results"!
1. Rathers:Options/alternative treatments; would you rather do this or that
2. Refuse: Right to refuse treatment, even if they signed the consent form.
3. Required:Why is the surgery necessary and what is involved?
4. Risks: Having surgery and NOT having surgery; Risks of anesthesia
5. Results:The benefits and expected results
Informed consent is our ___a__ and __b___ obligation.
a.) Legal
b.) Ethical
What is included in a consent form?
1.) Consent for the surgical procedure
2.) Consent for blood and blood products
3.) Signature of the patient
Supplemental: Forms that may refuse certain procedures or products. (i.e.: refuse blood products)
Who must explain the procedure to the patient?
The person performing the procedure!
What is the role of the nurse during the process of Informed Consent?
1.) Nurse supports and clarifies (PRN): Within reason
2.) Legally: nurse's signature on the consent means only that he/she witnessed the patient's signature and that they signed on their own free will
What are the National Patient Safety Guidelines that must be followed before a surgery?
1: Ensure the correct site is selected and the wrong site is avoided
2: Licensed independent practitioner marks the site, involving the patient, if possible
3: "Time out", before they begin, to ensure correct patient, correct site, correct limb, etc.
What are some of the surgical risk factors?
Age
Medical History
Use of tobacco
Medications
Cardiac History
Pulmonary History
Obesity
Who are at the highest risk for complications for surgery?
1.) Elderly
2.) Infants
Why are the elderly a high risk for complications of surgery?
The normal aging process decreases immune system functioning and delays wound healing. The frequency of chronic illness increases in older patients. Reductions of muscle mass and body water increase the risk for dehydration.
Why is it important to know about a patients past alcohol use?
They may have a higher tolerance to certain medications. (Anesthesia, pain meds, etc)
That's why it is important to know even if they only drink "a little"!!
Why is it important to know all of the medications that a patient is taking?
Interactions between drugs
Side effects
Prior narcotic use can indicate a higher tolerance to certain drugs
Why is it important to know a patient's nutritional status before surgery?
If they are emaciated, they will not heal well!
What electrolyte imbalance MUST be corrected prior to surgery.
ANY potassium imbalances:
1.) HypoKalemia
2.) HyperKalemia
What is included in the preoperative phase, in regard to emotions, that a patient may experience?
A patient may have:
1.) Perceptions of surgery
2.) Expectations/previous experience (either negative or positive)
3.) Fear / Anxiety
What is included in the socio-cultural portion of the assessment during the preoperative phase?
Support systems
Cultural implications
What labs are usually ordered before a surgery?
CBC
1: WBC (5,000-10,000)
2: RBC (Males 4.7-6.1; Females 4.2-5.4)
H&H
1: Hemoglobin (Males 14-18; Females 12-16)
2: Hematocrit (Male 42-52%; Female 47-57%)
Coagulation Studies
1: PT (11.0-12.5)
2: INR (0.8-1.1)
3: Platelets (150,000 - 400,000)
Electrolytes
1: K+ (3.5-5.0 mEq/L)
2: Na+ (135-145 mEq/L)
3: Mg+ (1.5-2.5 mEq/L)
4: Ca+ (4.5-5.5 or 8.5-10.5)
Urinalysis
1: Creatinine (Males 0.6-1.2; Female 0.5-1.1)
2: BUN (10-20 mg/dL)
3: Urine pH (4.6 - 8)
Type & Cross-match (if there is a risk for bleeding)
What screenings are usually included in imaging studies before surgery?
Chest X-Ray (CXR)
Other X-Rays
Scans, as indicated
EKG
Why is it important for someone to have an EKG (ECG) before surgery?
To find out how the heart is working, if the heart can tolerate the surgery!
NOTE: Anyone over 25 years should have one done.
What is included in pre-op teaching?
What to expect in general
Pre-op teaching checklist
Pre-op holding
Post-op routine/assessment
What is the nurses role during pre-op teaching?
To reduce stress and provide a positive influence on the patient's experience
During pre-op teaching, what are the main points that should be taught to the patient?
ORT's/surgical technologist may be used in addition to nursing staff
What are the responsibilities of the Surgeon?
A physician who assumes responsibility for the surgical procedure and and any surgical judgments about the patient.
What are the responsibilities of the surgical assistant?
Can be another surgeon (or physician, such as a resident or intern) or an advanced practice nurse, physician assistant, certified registered nurse first assistant (CRNFA), or surgical technologist. Under the direction of the surgeon and within the legal scope of practice for each state, the assistant may hold retractors, surgeon the wound (to improve viewing of the operative site), cut tissue, suture, and dress wounds.
What are the responsibilities of the Anesthesiologist?
The anesthesiologist: A physician who specializes in giving anesthetic agents.
A certified registered nurse anesthetist (CRNA): A registered nurse with additional education and credentials who delivers anesthetic agents under supervision (Anesthesiologist, surgeon, dentist or podiatrist = a doctor).
• The anesthesia provider induces and maintains anesthesia, delivers other drugs as needed, and monitors cardiopulmonary function, capnography, vital signs, and intake and output.
What are the responsibilities of the "holding area" nurse?
Holding area nurses work in pre-surgical holding areas coordinating care, reviewing the medical record and preoperative checklist, verifying that the operative consent forms are signed, and documenting the risk assessment.
What are the responsibilities of the Circulating Nurse?
Circulating nurses or “circulators” are registered nurses who coordinate patient’s nursing care in the OR, setting up the OR, and ensuring that supplies are available as needed. The circulator may assume the responsibilities of the holding area role.
1) The circulator also assists the OR team in the patient transfer to the bed, positioning the patient and protecting bony areas, providing comfort and reassurance, inserting a Foley catheter if needed, and scrubbing the surgical site.
2) Documentation is handled by this nurse as well. Documenting presence of drains or catheters, the length of the surgery, and a count of all sponges, "sharps" (needles, blades), and instruments, he or she notifies the post-anesthesia care unit (PACU) of the patient's estimated time of arrival and any special needs.
What are the responsibilities of the scrub nurse?
Scrub nurses set up the sterile field, drape the patient, and hand sterile supplies, sterile equipment, and instruments to the surgeon and the assistant.
What are the responsibilities of the OR or Surgical technologist?
A specially trained person who is not a nurse may perform the scrub role; these include operating room technicians or surgical technologists.
What are the responsibilities of the Specialty nurse?
May be in charge of a particular type of surgery (orthopedic, cardiac, ophthalmologic). They assess, maintains, and recommends equipment, instruments, and supplies used in that specialty.
State the scrubbing, gowning, and gloving process.
1) The surgical scrub.
2) Rinsing. Note the water falling off the hands and arms. Also note the foot-operated handle that controls the water flow. (After scrubbing and rinsing, the scrub nurse dries his hands and arms with a sterile towel inside the operating room and then is assisted into a sterile gown.)
3) The scrub nurse prepares sterile gloves. Note that the scrub nurse's hands are inside the sleeve of the gown and that he is touching the sterile gloves only with the sterile sleeve.
4) The scrub nurse puts on his first sterile glove while the sterile gown is being tied in the back. Note again that his hand never emerges from under the sterile sleeve.
5) The scrub nurse puts on his second sterile glove.
Modern anesthetic agents are better in what ways for the patient?
They are easier to reverse and they allow the patient to recover with fewer unpleasent effects
What are the 3 types of anesthesia?
General: "Like a suspended code"
Regional: Spinal block, epidural
Conscious Sedation or Moderate sedation: Usually includes amnesiacs.
What are the different ways to administer general anesthesia?
Inhalation
IV Injection
Balanced anesthesia
Adjuncts to general anesthetic agents
Hypnotics
Opiod analgesics
Nueromuscular blocking agents
What is the name of the space that a spinal block / epidural placed?
Subaracnoid space
What is the purpose of a nerve block?
To block the pain signals lower than the spot that it is placed.
Stop the transmission!!
What are the different positions a patient can be placed in for surgery?
Which surgeries included in the "preferred technique" for robotic surgery?
Cholecystectomy
Joint surgery
Cardiac surgery
Splenectomy
Spinal surgery
What are the potential injuries associated with Minimally Invasive Surgery (MIS)?
Mechanical trauma - (If you don't insert enough gas, than the space is very tight and you can hit something!!)
Thermal injury - Lasers
Wound closure: Staples
Often used in long lacerations
Special tool for removal
No increase in inflammatory response vs. sutures
Wound closure: Sutures
Self dissolving
Manual removal
Wound closure: Steri-Strips
Used on the dermis for superficial wounds
To close laparoscopic wounds
Wound closure: Secondary Intention
Let the wound heal from the inside out!!
Common skin closures
With large wounds, what is normally prescribed to help it heal by secondary intention?
Wound Vac
T or F:
Nurses are allowed to give pain meds during surgery.
False! Nurses do not medicate during surgery.
What does PACU stand for?
Postanesthesia Care Unit
What is included in the immediate postoperative phase?
ABC's
Vital Signs
Fluids - intake and output
Incisions, tubes
Pain management
LOC and response to stimuli
Why is it so important to check blood pressure after surgery?
Can indicate fluid loss, blood loss, and after effects of medications.
In the PACU unit, where are the postoperative orders for pain management from?
Anethesia
What does ACLS mean?
Advanced Cardiac Life Support
What does EBL mean?
Estimated blood loss
Explain the purpose for a drain in a wound site.
Removes the puddles of fluid that can collect in a surgical area. If the puddles are allowed to stay there, there is the possibility infection and abscess.
Why is it so important to medicate pain before it becomes intense for the patient?
Once its out of control, its hard to get back under control!!
What are the some of the parameters for transfer to the floor from the PACU?
Adequate score on recovery scale, i.e Aldren score
Vital Signs stable
No overt bleeding
Return of gag, cough, and swallow reflexes
What are some points included in the "aldren score" (Or any test the hospital uses for discharge from the floor)?
Awake
Breathing
BP within normal range
How long must a patient stay in the PACU?
At least 1 hour, or until the criteria to transfer has been met.
What preparations should be made for a patient to be transferred to the floor?
Bed ready
VS equipment in room
IV pole
Receiving nurse gets report from PACU nurse
What are the major aspects included in the post op assessment of the floor nurse?
Focused assessment
O2, IVs, Dressing, tubes, drains
Vitals
Respiratory
Cardiac/Circulation
Neurological
Fluid and Electrolytes
Renal and Urinary System
What is the typical timeline or frequency for assessing vital signs when you have post-op patient?
Q 15 min x 4
Q 30 min x 2
Q 1 hr x 4
Why is it so important to assess vital signs post op?
1: It compares these vitals to baseline.
Good assessment to help keep pain under control.
NOTE: Often first sign of complications.
What is included in the respiratory aspect of post op care?
1.) Assessing breath sounds and rate.
2.) Monitoring the for the effects of anesthesia and pain meds
What is included in the cardiac/circulation portion of post op care and why are they important?
1: Pulses - to make sure the heart is beating adequatly
2: Color - can indicate blood loss, infection, etc.
3: Temperature - can be a sign of infection
What does tachycardia in a post op patient indicate?
Sign of bleeding, infection, etc.
NOTE: Always indicates a change!
What is included in the neurological portion of the post op assessment?
1: Cerebral assessment (ALOC)
2: Sensory/motor assessment (i.e. sensation in lower limbs after epidural or spinal block)
What is included in the fluid and electrolyte balance portion of the post op physical assessment?
1: Hydration assessment
2: Intake and output (IVs, tubes, drains) broken down in the chart!
What is included in the post op renal/urinary system portion of the post op assessment?
Special attention should be paid to the first void!
REMEMBER: DC the foley ASAP (minimizes infection rates)
When assessing the GI system post op, what is the best indication that normal bowel patterns have returned?
Flatus!
What do you look for when assessing the GI system post op?
1: Nausea / vomiting
2: Return of bowel sounds (will determine oral fluids and food)
3: Flatus
During the post op assessment what is included in the skin assessment?
Assess for:
- Normal wound healing - record drainage!
- Complications of wound healing
What are the important aspects to remember about post op pain?
1: Worst within the first 48 hours!
2: Always assess for the type of pain:
- Appropriate to situation?
3: Medicate before pain severe or before it starts
4: Be aware of the effects of narcotics
5: Use diversionary interventions between doses of medication (positioning, massage, relaxation/diversion)
What is one of the most important aspects to remember when choosing a pain med for a patient?
1: Different pain meds work differently for each patient. (i.e Morphine wont work for some, but another one may work great!)
2: Don't be afraid to call the doctor!
How can we help a patient, who is dealing with pain?
1: Reposition
2: Ice pack
3: Turn onto side
4: Put knees up
What position can help take the pressure off a belly incision?
On side, with knees up
Diversionary interventions are very important for patients who are experiencing fear of...?
Pain: They are concerned that once their medicines wear off that they will hurt Therefore they clock watch and want their meds now!!
What is included in post op care related to helping to prevent nausea and vomiting?
1: Oral care
2: Elevate the head of the bed - this will help them breath better and less risk of aspiration!
3: Anti-emetics, prn
4: Start out with ice chips, then progress to small, frequent amounts of water
What are the environmental concerns in post op care?
Noise: Don't disturb unless necessary
monitor visitors (tell the family to let grandma sleep!!!)
Why is it important to ambulate as soon as possible after surgery?
1: To help prevent DVTs
2: Help prevent complications from surgery
What is the usual progression of nutrition for a post op patient?
Clear liquids then decadence per orders
Why is it important to begin patient teaching as soon as possible?
The more the patient hears it, the more they are going to retain from the teaching.
The post-op complication of Hypoxia is related to what?
1: Decreased respiratory action
2: Increased secretions
3: Obstructed Airway - chin lift to improve airway
4: Drug effects
- Morphine? Give narcan as ordered
5: Pain
What are the signs of Hypoxia as a post op complication?
1: Restlessness
2: Pallor - shows circulation and bleeding
3: Dyspnea - shortness of breath
4: Diaphoresis - can show infection
5: Bounding pulse - shows possible compensation for low BP and lack of O2
What interventions can you use to help a patient with the post op complication of hypoxia?
1: Raise the head of the bed
2: Put on O2
3: Suction secretions
4: Pain management
5: Chin tilt to open airway better
What would you do if you thought a patient was bleeding abnormally post-op?
1: Ask for an H&H, stat. It will tell you if there is bleeding.
2: Call the doctor with the results
If there is . . . back to surgery
What factors can cause aspiration, and how can we prevent it?
- r/t lack of reflexes
Check for reflex action: gag reflex
Care: Slowly advance diet - start w/clear liquids, positioning for ease of swallowing, then progress to soft foods, and finally harder foods.
Make sure you aren't feeding someone who isn't able to eat yet!!
What factors can cause pneumonia, as a post op complication?
What can we do to help prevent it?
Related to stasis of secretions, incomplete lung expansion
TCDB: Turn, cough, deep breathe
IS: Incentive spirometer (can help help stimulate a cough)
Mobility: Keep moving!!
What factors can cause Atelectasis?
What can we do to help prevent it?
Lack of expansion of part of the lung R/T obstruction, usually a mucous plug (or snot) sticks in the bronchial tubes.
TCDB: Turn, cough, deep breathe
IS: Incentive spirometer
SVN: Small volume nebulizer
Mobility: Keep moving!
In post-op _________ will help more than anything else!
Moving
What are the interventions for post-op hemmorage?
1: Assess wound and under the patient (Always look and see!!)
2: Don't remove the dressing - reinforce!
Sometimes putting on a compression dressing for a little while can help to stop the bleeding!
REMEMBER: Bright red blood is fresh
What are the signs of hypovolemic shock?
1: Apprehension
2: Rapid, weak pulse
3: Decreasing BP
4: Cold/clammy skin
5: Deep rapid respirations
What are the interventions for a post op patient in hypovolemic shock?
1: Lay flat with extremities elevated - causes BP to rise!
2: Call physician - orders may include increased IV rate, blood, meds
1: What are the r/t factors?
2: How can we prevent thrombophlebitis/DVT?
1: Related to factors are - Immobility, venous stasis, surgeries of the lower extremities
2: Prevention - Mobility, leg exercises, TED hose, SCD's
NOTE: Homan Sign is a test that can be done to assess DVT's. Hurts when the patient dorsal flexes.
What is an important fact to remember about the timing of DVTs?
That DVTs are delayed
Get moving, moving, moving!!!
1: What is a pulmonary embolism?
2: How do we assess for it?
3: What interventions can we do to help a patient with one?
1:Blood clot or other foreign body lodges in pulmonary vessel.
2: Assessment
- Dyspnea
- CP
- Cough
- Hemopytsis - bloody sputum
- Cyanosis
- Increased RR and HR
- Anxiety
3: Interventions
- O2
- Raise HOB
- Notify physician immediately
NOTE: This is an immediate problem!!
What orders would you expect to hear after informing a physician you suspect a possible pulmonary embolism.
1: Get a CT and chest x-ray
2: VQ scan - ventilation profusion scan
only a probability of it being there, not
yes or no!! (given when you cant get a
CT)
What are the possible complications of the GI system post op?
Inference with peristalsis: Anesthesia, manipulation internal organs, inactivity, altered fluids/nutrition, tendency to swallow air when anxious or in pain.
Distension: R/T decreased peristalsis and the inability to pass flatus
Constipation: Due to medications
Paralytic ileus: Portion of the bowel does not want to "wake up"
What is paralytic ileus?
Absence of peristalsis in portion of bowel
- May cause nausea and emesis
- A section of the bowel doesn't want to wake up!
NOTE: Be careful... bowel obstruction!
What is included in the assessment of post op GI complications?
1: Bowel sounds
2: Passing flatus
3: Distention
4: Pain
What interventions are indicated to help prevent post op GI complications?
1: Ambulation, fluids and foods when appropriate
2: Privacy when using the bedpan or commode (only to the level where they are still safe!)
3: NG tube for decompression
1: What is urinary retention relating to post-op complications?
2: How do you assess for it?
3: What interventions can you use to help?
1: The inability to void - common with surgery especially with spinal anesthesia, back, or abdominal surgeries
What are some of the neurological complications after surgery?
1: Disorientation - Especially in elderly after anesthesia (Interferes with their normal schedule)
2: Post operative psychosis and delirium (The patient screaming after surgery!)
3: Intractable Pain - never goes away, very uncontrollable (Amputations)
- I.E prior serious pain issue compounded by bowel obstruction.
What are some of the signs of infection?
1: Reddened wound margins
2: Purulent drainage
3: Foul order
4: Fever
5: Increased WBC's
What is partial or complete separation of wound layers called?
Dehiscence
What interventions should be used for dehiscence?
Apply sterile, non adherent or saline dressing to wound and notify the surgeon
What is the total separation of all wound layers and protrusion of internal organs through open wound?
Evisceration
What interventions should be used for evisceration?
Its a surgical emergency! Cover site, same as with dehiscence and page surgeon!
What are common reasons for staples to pull out?
Obese patient
Infection starting
What is included in the discharge planning for a post-op patient?
1: Care of wound and dressing changes
2: Medications - when, how, and side effects (if you take this pain med, you may have constipation)
3: Activities allowed (no driving, sports, sex, etc. So they know their limits!!)
4: Dietary restriction or modifications
5: Symptoms to report - what and when to report!!
6: Follow-up care
7: Questions and Answers about home care
When do we start planning for a patients discharge?
Before they even have surgery!
What are some considerations we must look at when providing individualized care?
1: Physical factors
- Obesity
- Age
- Nutritional status
2: Psychosocial factors
- Family support
- Coping mechanisms
- Thought processes
- Culture
3: Health History
- CV status
- Respiratory status
- Metabolic status
- Alcoholic/tobacco usage ("Are you going to go home and start drinking?? Very important not to mix the pain meds and liquor")
Name this drain:
Penrose drain
Name this drain:
Jackson-pratt drain
What is important to remember about the Jackson-Pratt drain?
1: The drain is under bulb suction
2: I & O's are very important
May be labeled: Drain 1, Drain 2
NOTE:Separate section on the chart for each!
You may be teaching the patient how to drain the bulbs (if they are going home with them). Make sure to communicate what to expect!!
Name this drain:
T tube
What is a T-tube usually used for and why?
1: To drain bile
2: They don't want too much to accumulate
3: Placed in the common bile duct
The hemovac is like the _____ only bigger!
Jackson-pratt drain
Remember: It is like an accordion.
When assessing the laboratory work of a 65-year-old patient who is scheduled for surgery this morning, which laboratory value may result in cancellation of the surgery?
A.Serum sodium level 149 mEq/L
B.Fasting blood glucose 120 mg/dL
C.Hemoglobin 10.5 g/dL
Serum potassium 2.9 mEq/L
Answer:
D
Rationale:
Although all the laboratory results listed are not within normal ranges, the presence of hypokalemia (normal serum potassium levels should be between 3.0 and 5.5 mEq/L) increases the risk for toxicity if the patient is taking digoxin, slows recovery from anesthesia, and increases cardiac irritability. Potassium problems must be corrected before the surgery.
During a surgical procedure, the nurse notices the sponge count is incorrect. One sponge is missing. What should the nurse do?
A.Write a report to the nurse
manager concerning the error in sponge count .
B.Anticipate that the surgeon will
order an x-ray to look for the sponge postoperatively.
C.Examine the environmental
distractions, refocus, and count the sponges again.
D.Communicate the discrepancy to
the surgical team immediately.
Answer:
D
Rationale:
There are many risk factors that can contribute to a retained foreign body. The process by which counts are performed is not standardized from operating room to operating room across the country, or even within the same institution. The most significant factor in retained foreign objects in the body is failure to effectively communicate with the surgical team when a discrepancy is discovered. Other factors include environmental stimuli that create distraction related errors. Current national guidelines suggest a systematic process for counting and communicating are needed in the operating room to prevent retained foreign body errors in surgery.
A patient having surgery is at risk for infection if which additional factor is present?
A.Impaired liver function
B.Diabetes mellitus
C.Insertion of a surgical drain
D.Age greater than 65
Answer:
B
Rationale:
The risk for infection is higher in patients with pre-existing health problems such as diabetes mellitus, immune deficiency, obesity, and kidney failure. A surgical drain allows for removal of secretions and fluids from within the tissues around the surgical area. If these secretions are not drained, slowed healing and bacterial growth could result in wound infection. Age increases risk-related skin injury from positioning and prolonged immobility during the surgical procedure.
A patient has had bowel surgery. The nurse is assessing the patient’s abdomen and knows that the best indicator of intestinal activity is:
A.Passage of flatus or stool
B.Abdominal cramping with
distention
C.Detection of bowel sounds upon
auscultation
D.Patient’s report of hunger
Answer:
A
Rationale: The presence of active bowel sounds usually indicates return of peristalsis. However, the absence of bowel sounds does not confirm a lack of peristalsis. The best indicator of intestinal activity is the passage of flatus or stool. Abdominal cramping along with distention denotes trapped, nonmoving gas, not peristalsis.
When a patient is admitted to the PACU, the nurse should first assess the patient’s:
A.Level of consciousness
B.Airway and gas exchange
C.Dressing and incision status
D.Vital signs and body temperature
Answer:
B
Rationale:
When the patient is admitted to the PACU, the nurse must immediately assess for a patent airway and adequate gas exchange. The other choices are secondary to a patent airway.
When using positioning to decrease pain in the postoperative patient, which intervention is most appropriate?
A.Reposition the patient at least
every 2 hours.
B.Raise the knees of the bed.
C.Place pillows under the patient’s
knees.
D.Allow the patient to get out of
bed as soon as possible.
Answer:
A
Rationale:
In positioning the patient, consider the position during surgery, the location of the surgical incision and drains, and problems such as arthritis and chronic lung disease. Assist the patient to a position of comfort. Support the extremities with pillows. Turn or help the patient turn at least every 2 hours while he or she is bedridden to prevent complications caused by immobility. Do not raise the knee gatch, because this position could restrict circulation and increase the risk for thrombophlebitis. During the PACU recovery, the patient may not yet be able to get out of bed.
Author
sisterbarley
ID
196783
Card Set
Block II, Test 2; Periop, Iggy chapters 16, 17, and 18
