Ch 30: Perioperative nursing

Question 1

Give the three phases of perioperative periods

Answer 1

Perioperative:
decision to have surgery
➡️
transferred to operating room

Intraoperative:
Transferred to OR bed
➡️
transferred to post anesthesia care unit (PACU)

Postoperative “recovery”:
From admission to PACU/recovery
➡️
Complete recovery last follow up

Question 2

 What is our ultimate surgical go

after surgery what is the pre-screening process

When should discharge planning begin perioperative



Answer 2

Ultimate surgical goal = shorter length of stay

Post surgery:
Pre-screening = intake
-Health history, meds, family nutrition, Elimination, rest, psychosocial, falls

Perioperative discharge planning begins when meeting the patient as you begin to anticipate needs after surgery




Question 3

When giving discharge instructions

• how should instructions be given
• what should instructions include

As you are discharging a patient what is the mode of transportation for discharge and what must you watch from discharge

 What do you want to tell patients not to bring to surgery

Answer 3

When giving discharge instructions:

• WRITTEN instructions given
• include wound care, activity level allowed

As are discharging a patient:

• discharge MUST BE BY WHEELCHAIR
• you must watch the patient get into the car

When having surgery do not bring valuables
- may be lost

Question 4

What does the AORN perioperative patient focused model study

Give the 4 AORN areas of focus

1. 
   - if you’re trying to manage physiologic responses what do you focus
2. 
   - what do you want to recognize an empathized with the patient and family

3.

• typical results of a PREOP needle biopsy
• name for normal biopsy

4.
-how are patients during surgery

Answer 4

The AORN perioperative patient focus model studies what can be improved Perioperatively for patient focus and safety

AORN 4 areas of focus:

1. physiologic➡️ response to anesthesia
   - if managing physiologic responses focus on meeting patients needs
2. behavioral (family and individual)
   - recognize an empathize with patient and family about the fear of unknown
3. Health system
   - PREOP needle biopsy is usually inconclusive
   - normal biopsy = lumpectomy
4. Safety
   - patients usually restrained during surgery

Question 5

1. Give physiological responses to surgery post op

Answer 5

1. 
•BP/hormone changes
• ⬆️ in total fluid volume
• blood shunted to vital organs
•⬇️ immune/inflammatory response
• ⬇️ insulin ⬆️ glucose

Question 6

Define types of surgical procedures And give examples

Urgency:

• elective + I.E
• urgent
• emergency

Risk

• give types
• done where/types of complications

Answer 6

Elective:
-planned by healthy people
•tonsillectomy

Urgent:
-done within 24 to 48 hours to PRESERVE PATIENTS HEALTH
•appendicitis


Emergency:
-IMMEDIATE to preserve life involves major Oregon
• Partial amputation/intracranial bleeds

Risk:

• minor or major
• done outpatient minimal complications

Question 7

Define types of surgical procedures And give examples

Purpose:
-diagnostic
- ablative
-palliative
-reconstructive
-transplant


Answer 7

Diagnostic:
-make or confirm diagnosis
• biopsy

Ablative:
-remove a diseased part
• amputation/appendicitis

Palliative:
-to relieve or reduce intensity of illness
• bowel blockage

Reconstructive:
-Restore function to tissue


Transplant:
-New Organ

Question 8

What is the ethical principles of anesthesia

What IS VITAL that you want to ensure EVERYTIME AFTER a procedure and how

Answer 8

No malfeasance
:Spare from harm and pain as much as possible

After procedure ensure patient can SWALLOW by assessing GAG REFLEX



Question 9

Describe general surgery

• highest what? what is the risk?
• how do you administer
• what happens to the patient and body
• common post op reactions 
• What age/procedures require general anesthesia

Answer 9

General surgery
-highest risk and 😵 rate

-administered: inhalation or IV

-physiologic response
• loss of consciousness
• Skeletal muscle relaxation (paralysis)

-Postop reactions:
• N/V
• bronchospasm
• children violently wake

-any age any procedure

Question 10

Describe moderate sedation/analgesia

• aka?
• when is it used
•  How do you administer
• what is reversal time
•  Give an example of moderate sedation/analgesia

Answer 10

moderate sedation/analgesia

• A.k.a. “ conscious sedation/analgesia”
• used for short term minimally invasive

-administered:
•intravenous
•sedatives
•analgesics

-PROMPTLY Reversed

-propofol


Question 11

Describe regional anesthesia
-Preferred for and why?
-how do you administer
-patients response to anesthesia (physiologic)
-Best for what type of surgery
-examples of the type of medication classifications


Answer 11

Regional anesthesia

-preferred for OLDER as it
• ⬇️ hospital staying
• carries LOWER risk

-administered
• injected near nerve//Nerve pathway
• around operative site

-physiological effects:
• loss of sensation
• ⬇️ reflex

-Best for lower abdominal surgery

• nerve blocks/epidurals
• spinal blocks

Question 12

Describe topical and local anesthesia

• used on
• physiologic response to anesthesia
•  What kind of tissues targeted

Answer 12

Topical and local anesthesia

-used on:
•mucous membranes
•open skin 
•wounds
• burns

-physiologic response to topical/local
• prolonged relief
• two underlying tissues

-Target specific tissues



Question 13

Give 2 reversal medications

Give a few medications for your “oscopy”


Answer 13

Reversal medication’s
-Narcan
-Romazicon (Flumazenil)
• V. conscious sedation

Drugs for”oscopy”
-Versed
-fentanyl
-morphine
-valium


Question 14

Give the 3 phases of general anesthesia

What do you want to watch for with general anesthesia

Answer 14

1. induction
   -from administration
   ➡️
   Ready for incision
2. Maintenance
   Incision
   ➡️
   Near completion of procedure

3.
emerges from anesthesia
➡️
Ready to leave operating room

• with general anesthesia watch for bronco/laryngospasm
  

Question 15

Give the 5 p’s of surgery
(part of the 7 p’s)

 wanna patient loses consciousness what do they lose

What may relaxed skeletal muscles lead to

What kind of reflexes get depressed during surgery

Answer 15

-Pain
- pallor
• poikilothermia
-paresthesia
- paralysis
-pulse

When patients lose consciousness: lose control

Relaxed skeletal muscles may lead to respiratory depression

 depressed reflexes: gag and cough reflex

Question 16

Types of regional anesthesia

1. Nerve blocks
   -  for what purpose
2. Spinal anesthesia
   - injected to where
   - for what locations
   - what do you want to ensure and why
3.  epidural anesthesia
   - injected to where
   - risk for
4. Caudal anesthesia
   - to where
   - for what body locations

Answer 16

Nerve blocks:
- jaw, extremities, LABOR

 spinal anesthesia:
-injected into subarachnoid space by lumbar puncture
• for for lower abdomen/legs
• ensure patient can urinate as it may cause urinary retention and hypotension + headache

Epidural anesthesia:
-anesthesia to intravertebral spaces
• risk of G.I. complications

Caudal anesthesia:
-to epidural space via sacrum
• for lower extremities/perineum

Question 17

What is a Nurses responsibility relating to informed consent

Who’s responsibility is it to give the details of the surgery

What is the ethical principle within informed consent

Answer 17

Nurses must ensure:
-patient have signed the permission for surgery
-be a witness to signature
+ Advocate and support patients decision

It is the surgeons/doctors responsibility to give the details of the surgery

 ethical principle of informed consent:
-AUTONONY: patient’s ability to make personal decisions even if not in best interest

Question 18

What does the informed consent form have

• description of/alternative
• underlying/natural course
• what about the person performing procedure
• what is explained (#’s)
• what rights do patients have
• expected (4)

Answer 18

Description of procedure an alternative therapies

Underlying disease process and its natural course

Name and qualification of person performing procedure

Explanation of risks and how often they occur

Explanation of right to refusal and withdrawal consent at ANYYYYY time

Explanation of expected outcome, recovered, rehab plan, course of treatment



Question 19

When should you get the signature for informed consent (before what)

If there’s an emergency and facility cannot contact family how is consent given

Answer 19

Patient must sign before narcotic given

If emergency and faculty cannot contact family
-2 doctors sign the document

Question 20

How many times do you ask for an advance directive

Define an advanced directive

Define a living will

Define a durable power of attorney

Answer 20

Ask three times if patient has an advanced directive

Advanced directive:
-specific instructions for health care treatment if unable

living wills:
-end of life care instructions

durable power of attorney:
-person who makes healthcare decisions on behalf of patient if pt not competent

Question 21

What does the self-determination act Allow patient to do

Answer 21

self-determination act allows the right of a patient to make healthcare decisions (accepting and denying care) + The right to make an advance directive

Question 22

Advantage:

• what kind of risk do outpatient/same day surgeries carry
• what is reduced for the patient

Answer 22

advantage: same day/outpatient surgery
-  very low risk
- decrease hospital state length and anxiety

Disadvantage:
-May require additional teaching and home care service
WE MUST KNOW AHEAD OF TIME 

Question 23

What are a few outcomes for surgical patients

Answer 23

• Receive respectful culturally age-appropriate care
• be free from injury/ADR
• be free from infection/DVT

-maintain fluid and electrolyte balance,
skin integrity, normal temperature
• especially an elderly : Deep breathing to prevent increase in temperature

• have pain managed
• have understanding of physiologic/psychological responses to surgery
• participate in rehab

Question 24



Question 25

When we look at a patient holistically what are three factors were looking at What kind of stressor is surgery, define the specific fear, What does this fear do What are a few social cultural needs

Answer 25

Holistically: body mind and spirit Surgery is a psychological stressor (fear of unknown) leads to increased risk of surgery because of the physical stress already happening Socio cultural needs: - food preferences (so they will eat) - language difference - cultural beliefs (stoic) - family interaction

Question 26

Give developmental differences perioperatively -infant • Lower volume ,drug metabolism, liver -adolescent •need for what -Older • tolerance, CO/wound healing, kidneys,liver What medications are vital to know if patient is going into surgery

Answer 26

Infant: - ⬇️ total blood volume - ⬇️ drug metabolism + immature liver Adolescent: -⬆️ need for control and privacy Older: - ⬇️ tolerance to amnesia - ⬇️ cardiac output/wound healing - ⬇️ renal blood flow + hepatic function ``` Vital medications to ask for: -diuretics -anticoagulant -Tranquilizers -steroids -aspirin  ```

Question 27

What two medications do you never want to abruptly withdraw before surgery What nutritional supplement is needed for healing What kind of blood supply and healing does fatty tissue have

Answer 27

Do not abruptly withdraw: - antibiotics - relaxants Protein is needed for healing Fatty tissue has low blood supply with delayed wound healing 

Question 28

If your patient is an alcoholic what will their analgesic dose look like -Rx for DT What complications will smokers have - secretions - postop risk

Answer 28

If alcoholic, there is an increased need for larger doses of analgesic -use Librium for alcoholic Delirium Tremens Smoker will have surgical resp complications - ⬆️secretions - post op ⬆️ risk for pneumonia

Question 29

What surgical risk will anticoagulants cause? Surgical risk tranquilizers -increase what risk for anesthetics Surgical risk for adrenal steroids -what will abrupt withdrawal cause What will “mycin” antibiotic cause?

Answer 29

Anticoags will cause hemmorage Tranquilizers ⬆️ hypotension effects of anesthetic Abrupt withdraw of Adrenal steroids can cause cardiovascular collapse “Mycin” antibiotics may cause: -resp paralysis When + with muscle relaxers

Question 30

Presurgical screening tests What will chest x rays show ECG show? Complete WBC COUNT Electroytes When do you do glucose testing?

Answer 30

Chest x show - Pn - chronic bronchitis ECG: dysrhythmias WBC count: H&h:12-18 Electrolytes: Urinalysis Glucose testing done PREOP and surgery day

Question 31

What is a nurses role in pre surgical testing

Answer 31

Ensure tests are explained to the patient Collects specimens Ensure results recoded in chart pre op Update abnormal results

Question 32

Nursing interventions: -when teaching post op what do you want establish with a patient and what will it allow - what do you want to use to identify anxiety and fear - how do you demonstrate genuine empathy and caring - be prepared to respond to common patient questions If you do not know the answer to a patient question what do you do (2 things) 

Answer 32

* Postop establish therapeutic relationship with patients that will allow patients to verbalize fears and concerns * Use active listening to identify anxiety and fear * use touch to demonstrate genuine empathy and caring If you do not know the answer - find out - refer the question to a doctor or surg

Question 33

What do you wanna do if patient says “ I think I’m going to die during surgery” Give to nursing diagnosis for peri operative

Answer 33

Notify Dr immediately  Nursing diagnosis: - anxiety - risk for infection

Question 34

Give the construction techniques for deep breathing Frequency of physical activity

Answer 34

``` Position: semi Fowler‘s hands over ribs Technique: -exhale gently and completely -inhale through nose - Hold 3-5 seconds - exhale pursed lips -repeat three times ``` Q 1 – 2 hours for the first 24 hours postop

Question 35

Give the technique for effective coughing

Answer 35

Position: semi Fowlers leaning forward splinting abdomen with pillow technique: - inhale exhale through nose slowly 3 times - inhale hold 3 seconds - hack out 3 short breaths - with mouth open take quick breath - cough deeply one or two times - take another breath repeat q2h !!!

Question 36

Describe leg exercises

Answer 36

Position: semi Fowler’s Technique: - Bend knee and raise foot - Extend lower leg lower to bed five times each leg - Point toes - dorsiflex - circular motion repeat 3 times

Question 37

What are physical activities you can do to prepare a patient

Answer 37

``` Deep breathing coughing Incentive spirometer leg exercises :⬆️ Venus return turning patient in bed early ambulation ```

Question 38

 When does planning for the perioperative period Happen

Answer 38

Planning for ENTIRE perioperative period done preop

Question 39

How should pt bath and shower Why do you not use razors what do you use instead Regarding elimination: - when does peristalsis usually return after surgery - what kind of sign is flatus - !!!What do you want to ask a patient to do before receiving preoperative Mets

Answer 39

Patients should be in the shower in a 3 to 4 step process -apply lather rinse Use clippers instead of razors because of Knicks Elimination: -Peristalsis returns 24 to 48 hours post bowel surgery -flatus (gas) = good sign  -ask patients to use the restroom before giving preop meds!!!  

Question 40

If a patient is going to receive a colonoscopy what are teaching instructions you want to give them the night before When going in for surgery what must you remove

Answer 40

If colonoscopy: - NPO at midnight of surgery + sign on door - take away fluids When going for surgery:remove : - jewelry - dentures - nail polish - contacts - void

Question 41

When are preop meds usually given (timeframe) Give examples of sedative and what are used for Give examples of anti-cholinergics what are used for Give examples of narcotic analgesics Give examples of neuroleptic analgesic agents and what are used for Give examples of H2 antihistamines and what are used for

Answer 41

Preop meds given 45 to 75 minutes before surgery Sedatives: ⬇️ anxiety - valium - Versed Anti-cholinergics: ⬇️ salvation -Robinul/atropine Narcotic - morphine - Demerol Neuroleptic analgesic agents: V psych behaviors -fentanyl H 2 antihistamines:⬇️ stress ulcers -Tagamet

Question 42

How does the joint commission prevent wrong person, site, procedure

Answer 42

1 Perioperative patient ID process 2. Marking the operative site 3. “Time out” Final verification just before procedure -done by nurse checking all 3 criteria and documents 

Question 43

How often do you do post op assessments until when How often do you do child postop assessments What is the priority Prevention. post op

Answer 43

Assess adult clients postop q10-15 minutes Assess children postop q5min post op priority is to prevent anesthesia complications

Question 44

When do you remove an artificial airway!!! What is the # 1 problem post ANESTHESIA what is the intervention you want to do  what temperature do you want to keep a patient postop  if a patient first  Wound dressing is leaking what do you do

Answer 44

Do not move artificial airway until patient has gag reflex!!! 1 problem post ANESTHESIA is a respiratory obstruction suction Keep patient warm post op If first one dressing out of surgery is leaking reinforce and wait for surgeon

Question 45

 If pt is awake but not oriented what do you do if patient is awake and oriented what do you do How many children wake up from anesthesia

Answer 45

Awake but not oriented: continue to monitor Awake and oriented: report to nurse receiving patient Children may wake up violent (thrashing) from anesthesia

Question 46

Cardiovascular complications Signs and symptoms of hemorrhage ``` Interventions to do if hemorrhage #1 #2 ```

Answer 46

Hemorrhage S & S: - restless - ⬇️ BP⬆️ HR ⬆️resp rate -  Cold and clammy skin ``` Interventions: #1 stop bleeding with pressure #2 call Doc ```

Question 47

Cardiovascular complications: shock Issues Look for Intervention

Answer 47

Shock: Issues: -circulatory failure due to volume loss (hypovolemic shock) Look for: - hemorrhage - poor tissue refusion - poor capillary refill Interventions: - elevate legs 30 to 45° - airway/02/ABG/warmth

Question 48

# Define thrombophlebitis Thrombophlebitis signs and symptoms to call Doc Pulmonary embolism signs and symptoms

Answer 48

Thrombophlebitis: inflammation of vein Thrombophlebitis S&S -CB + SOB = CALL DOC NOW‼️‼️ Pulmonary embolism S&S -CP + SOB = CALL DOC NOW‼️‼️ possible PE

Question 49

DVT signs and symptoms

Answer 49

DVT S and S: •Calf, thigh , cramp pain • swollen legs • increase temperature ``` DVT interventions #1 put compression socks ``` Patients at risk for DVT -obese comorbidities

Question 50

Signs and symptoms of atelectasis  intervention for atelectasis 

Answer 50

Atelectasis S & S: - dyspnea - decrease breath sounds - crackles - cyanosis Atelectasis = incentive spirometer

Question 51

Signs of symptoms of hydrostatic bacteria

Answer 51

- aspiration ammonia - fever/chills - chest pain - ⬆️ heart rate/resp

Question 52

What is the acronym ICOUGH stand for And why is used

Answer 52

 ICOUGH used as interventions to prevent respiratory complications I-incentive spirometer (q1-2hr) C-coughing/ deep breathing (splint pillow O-oral care U-understand exercise important G-get out of bed minimum three times daily H-Head of bed elevated 30 to 45°

Question 53

As a patient postop how long are you NPO For When Does a patient urinary and bowel retention resolve postop

Answer 53

NPO Until gag reflex V aspiration pneumonia Patient urinary and bowel retention resolves four hours postop