Perioperative Nursing for NCLEX-RN (1) Fundamentals

What paperwork needs to be signed and witnessed before a client leaves for surgery?

Informed consent: surgery is an invasive procedure and there are risks the client needs to be aware of.

How to handle the informed consent:

the HCP explains the risks
the client signs the form and the nurse can sign as a witness
if the client doesn’t understand the procedure or risks, the nurse informs the HCP

If it’s an emergency, the informed consent does NOT need to be signed.

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What are the general nursing interventions before a client goes to surgery?

all paperwork is completed
labs have been obtained
blood type and crossmatch in case of hemorrhage
basic assessment and vital signs are obtained
teaching on what to expect afterward has started

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What clinical paperwork should be completed pre-operatively?

history and physical: the HCP’s assessment of the client
labs: check for abnormalities and report them to HCP
diagnostic tests: specific to the problem

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What are the nursing interventions after a client returns from surgery?

assess for complications
implement safety precautions
teach about tubes, incisions, and preventing complications

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What diet is the client on before surgery?

The client is NPO for at least 8 hours before surgery.

If it’s an emergency, the client can go to surgery right away.
NPO = nothing by mouth.

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Which 2 bracelets should be applied to the client before surgery?

ID bracelet with name, birthday, and medical record number
medication allergy bracelet

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What should be removed before the client goes to surgery?

Jewelry, makeup, dentures, hairpins, nail polish, glasses, contacts, and prostheses.

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Where should the client’s valuables be placed in a healthcare facility?

Give valuables to family or lock in a safe.

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What should be documented about the client pre-operatively in regards to going to the bathroom and medications?

the last time the client ate, drank and urinated
what meds were taken that day

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What medication is commonly prescribed before surgery?

Antibiotics: to help decrease the risk of post-op infection

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Pre-operatively, how will a client’s urinary needs to taken care of?

The client will either urinate before surgery or get a foley catheter inserted before surgery.

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How will a surgical site be cleaned?

The site may be shaved and an antibacterial solution will be applied to prevent infection.

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What psychological problem should be assessed before a client goes to surgery?

Assess for anxiety before surgery.

Give anxiolytic meds to decrease anxiety if needed.

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If the client is having abdominal surgery, what treatment will the client get before the surgery?

The client may get an enema or laxative to clean out the bowels.

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Teaching:

Pain control after surgery

pain medicine options
possible pain pump and how to use (patient-controlled analgesia/PCA)
splinting the incision when coughing

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Teaching:

Preventing pneumonia and atelectasis after surgery

turn, cough and deep breath
use the incentive spirometer

Both of these interventions help open up the lungs and break up any mucus that may start to form.

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What are the 4 steps to teach the client about how to use an incentive spirometer?

place mouth tightly around the mouthpiece
inhale slowly and keep the floating indicator between 600 and 900 marks on the device (or higher marks depending on what the client can do)
hold the breath for 5 seconds
exhale through pursed lips

Repeat 10 times every hour!

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Teaching:

Preventing deep vein thrombosis (DVT) after surgery

ankle pumps/ foot exercises
sequential compression devices (SCD boots)
compression socks

These interventions increase blood circulation so the client doesn’t get a blood clot. If a blood clot forms it could break loose and travel to the lungs causing a pulmonary embolism that can kill the client.

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Why is a set of vital signs obtained right before the client gets wheeled off for surgery?

To make sure the client isn’t having any obvious complications such as dysrhythmias, difficulty breathing, infection or bleeding.

Teaching:

Tubes and surgery

Inform where the tubes will be coming from so the client is not alarmed when waking up from surgery.

What are the common types of tubes or lines post-op?

intravenous (IV) tubing
Foley catheter
wound drainage tubes (JP drain)
chest tubes
endotracheal tube (ET)
nasal cannula
nasogastric tube (NG)
pulse oximetry (O2 sat)
telemetry (EKG)
vacuum-assisted wound closure (wound vac)

What is this?

Foley catheter

What is this?

Wound drainage tube (Jackson-Pratt drain)

What is this?

Chest tube container

What kind of tube is this?

Endotracheal tube (ET)

What kind of tubing is this?

Nasal cannula for oxygen

What kind of tube is this?

Nasogastric tube (NG)

What is this?

Telemetry monitoring (EKG)

What is this?

Vacuum-assisted wound closure (wound vac) to help with healing.

How will the **surgeon** know where on the body to operate on?

The surgeon will **mark the operative site with a marker.** ## Footnote The team in the OR will do a **"time-out"** to make sure they have the: * right client * the right procedure * the right operative area OR = operating room

What are the **basic nursing assessments** when a client comes back from surgery?

* assure correct post-op position * assess respirations/breathing * check vital signs and LOC * assess pain and nausea * assess operative site or dressing * check any drains/tubes * quick full-body assessment

After the post-op assessment, what are the **basic nursing interventions**?

* give pain meds and anti-nausea meds if needed * get client comfortable in bed * put bed in lowest position * put side rails up * give client call light * check back on client in 30 minutes

What is **most important** to assess for post-surgery?

Complications

What are **6 immediate** post-op complications? | (Immediate Complication)

1. hypoxia 2. pulmonary embolism 3. pulmonary edema 4. hemorrhage/shock/fluid volume deficit 5. wound dehiscence and evisceration 6. paralytic ileus

What are the **signs and symptoms** of hypoxia? | (Immediate Complication)

* restlessness * low oxygen saturation * decreased LOC ## Footnote The immediate treatment is to give oxygen.

What are the **signs and symptoms** of pulmonary embolism? | (Immediate Complication)

* difficulty breathing * blood-tinged sputum ## Footnote Immediate intervention is to place in high Fowler's position and give oxygen.

What are the signs and symptoms of **pulmonary edema?** | (Immediate Complication)

* difficulty breathing * pink frothy sputum * low O₂ reading ## Footnote Immediate interventions are to STOP fluids, high-Fowler's and give O₂.

What are the signs and symptoms of **hemorrhage?** | (Immediate Complication)

* bright red blood from the surgical site * low BP, high HR ## Footnote Immediate interventions are to put pressure on site and call surgeon for possible admission back to surgery.

What is **wound dehiscence** and **evisceration**? | (Immediate Complication)

* _Dehiscence_ is when the **surgical incision opens** * _Evisceration_ is when the **abdominal organ comes out of the incision** ## Footnote Immediate intervention is to put a sterile, saline-soaked dressing over site and place supine with knees bent.

What is a **paralytic ileus**?

When the **bowels have shut down** due to anesthesia or manipulation of bowels. ## Footnote Immediate interventions are place an NG tube on suction and give IV fluids.

What are the **signs and symptoms of a paralytic ileus**?

* vomiting * absent bowel sounds and flatus * abdominal distention

Why is **urinary retention** a common postoperative complication?

Urinary retention is caused by **side effects of anesthesia** and **pain.**

What are the post-operative interventions for **urinary retention**?

* pour warm water on perineum * stand up and walk * straight cath client as a last resort

Why is **constipation** a common postoperative complication?

Because it can be caused by side effects of **opioid pain meds** and **inactivity**.

What are the post-operative interventions for **constipation**?

* encourage **fluids, food with fiber, and walking** * **stool softeners** and **laxatives** as a last resort

What is included in **discharge teaching** post-op?

* report signs of infection and bleeding * no heavy lifting * sutures are removed in about a week

When can a client be **discharged post-op**?

* A&Ox3 * has voided and can walk * vital signs stable * pain and nausea is controlled by PO meds * minimal bleeding from operative site * HCP has signed the discharge paperwork * follow-up appointments are made * discharge teaching is done * has someone to drive them home

Perioperative Nursing Flashcards

Review the nursing care before and after a surgery.