Name the 3 phases of perioperative care
Preoperative phase, Intraoperative phase, Postoperative phase
What is the preoperative phase?
Period of time from decision for surgery until patient is transferred into operating room
What is the intraoperative phase?
Period of time from when patient is transferred into operating room to admission to PACU
What is the postoperative phase?
Period of time from when patient is admitted to PACU to follow-up evaluation
What is physiologic reserve?
The ability of organs to return to normal after disturbances
Name the 3 categories of surgery by urgency
Emergent (Immediate), Urgent (Within 24-30 hrs), Elective (Scheduled, planned)
What are a few examples of emergent surgery
Ruptured appendix, traumatic injuries, ruptured aneurysm
What are a few examples of urgent surgery
Fracture that requires surgical repair, infected gall bladder
What are a few examples of elective surgery
Joint replacement, hernias, vasectomy
How does obesity affect surgery?
More dehiscence and infection risk, shallower respirations, difficulty intubating
The hazards of surgery to the elderly are proportional to what?
The number and severity of coexisting health problems
Name 6 purposes for surgery
Preventive, Diagnositc, Exploratory, Curative, Palliative, Reconstructive
Name 4 expected patient outcomes in the preoperative phase
Relief of anxiety, decreased fear, understanding of surgical intervention, no evidence of complications
How do anesthetics affect the elderly?
They need lower doses and the duration is longer
What else must be carefully considered in the elderly surgical patient?
Hypothermia, bone loss, strict observation of vitals
What nurse is an overall coordinator of the surgical procedure? What kind of nurses are they?
The circulating nurse. RN
Who is responsible for counting instruments in the surgical setting? What education must they have?
The scrub person. An RN, LPN, or Technician.
When and how often do you count sponges?
Once before surgery and twice after.
What are the 3 zones of the operating room called?
Restricted, semirestricted, un-restricted
What are the 4 stages of anesthesia?
Beginning, excitement, surgical, medullary depression
What is Malignant Hyperthermia, or MH?
A rare inherited muscle disorder that is chemically induced by anesthetic agents.
What are some s/s of MH?
Tachycardia (>150) is usually the first sign, dysrhythmias, hypotension, decreased cardiac output, oliguria, cardiac arrest
In the postop phase what systolic BP trends should be reported immediately?
Systolic BP of 90 or less, or a drop of 5 at subsequent BP readings.
What is the most common type of shock seen in the postop patient? What are the s/s?
Hypovolemic shock. Pallor, cool-moist skin, rapid breathing, cyanosis of the lips/gums/tongue, rapid/weak/thready pulse, narrowing pulse pressure, low BP, concentrated urine.
What aldrete score is usually required before a patient can be discharged from the PACU?
Name 2 types of hypoxemia that can affect postop patients
Subacute and episodic
What is subacute hypoxemia?
Constant low level of O2 saturation.
What is episodic hypoxemia?
Sudden drop in O2 saturation.
What is second intention healing?
When a gaping wound is allowed to granulate and heal without sutures or glue.
What is third intention healing?
When 2 granulated surfaces are sutured or glued.
What is the nurses (LPN/LVN) role in preoperative care?
Data collection, denture removal, VS, meds given, explanations/instructions, emotional/psychological support.
What kind of preoperative assessments will a nurse perform?
Nutrition, fluid, dentition, drug/alcohol, respiratory, cardio, hepatic/renal, endocrine, immune, meds, psychosocial, cultural/spiritual.
If you are asked to sign as a witness on a patients consent form, what does your signature signify?
That you witnessed the patient sign the document.
Who educates the patient about the risk factors involved with surgery?
What diagnostic tests must a patient usually have before a surgery can be done?
EKG and pregnancy test.
What do advanced directives contain and when is this done?
It contains directives on medical decisions only and is usually done upon admission.
When does discharge planning start?
What CAN'T a patient have before signing a consent form?
Any type of sedation.
What should be included in the informed consent documents?
Explanation of procedure, description of benefits, alternatives, offer to answer questions, instructions that patient may withdraw consent at any time, statement if protocol is different from the norm.
Name 6 preoperative instructions
NPO, meds, bowel prep, pain control, mobility/body movements, coping strategies.
Name 3 postoperative exercises
Incentive spirometry, leg exercises, turn/deep breath/cough
What is the device called that you blow into that measures positive pressure in the lungs and keeps alveoli open?
PEP = Positive End Pressure
What is the "Twighlight" drug and how does it affect the patient?
Versed (midazolam). It makes the patient forget what happended to them.
How should a patient use an incentive spirometer? What does it prevent?
HOB at 45 degrees, inhale, hold for 5 seconds, slowly exhale, 10x per hr when awake. Atelectasis (the collapse of part of or (less commonly) all of a lung)
When are pre-op meds usually given?
1 hr before surgery.
What do H2 agonists do?
Reduce gastric juices.
Where is an epidural injection given?
Into the epidural space that surrounds the dura mater of the spinal cord.
Where is a spinal block injected?
Into the subarachnoid space of the spinal column, usually between L4 and L5.
What are the advantages/disadvantages of epidurals vs. spinal blocks?
An epidural doesn't produce the headaches that are associated with spinal blocks, but is more difficult to do.
What are pre-surgery anticholinergic drugs used for?
Muscle relaxation and decreases secretions.
What is Succinylcholine?
Anticholinergic muscle relaxer. (look for -ium, -ron, or -ine suffixes)
What client would not be a good candidate for anesthesia?
The hypovolemic client.
What types of nerves do general anesthetics block?
When taking a patient to surgery, when do you put the side rails up on the gurney?
After pre-op is completed.
When should vitals be taken on a surgery patient?
Within 4 hrs of surgery or 30 min after pre-op.
In what surgery area would the IV be inserted and any necessary IV antibiotics given?
In the holding area.
When and where is intubation done?
In the operating room, after anesthesia is given.
Who actually assists the physician?
The scrub person. (hands instruments, maintains sterile field)
What is a circulating nurse, or RNFA?
They monitor VS, equipment, environment, sponge count, preps the patient, documents procedure.
Which part of the surgical gown is considered to be sterile?
From the middle of the chest down to the sterile field and from the cuff to 2 inches above the elbow.
How far from the sterile field must unsterile equipment be kept?
1 foot or more.
Name some antiemetics often used for surgery?
Phenergan, Droperidol, Zofran.
Name 2 muscle relaxants used for surgery.
Flexeril and Valium.
Name 2 narcotics used for surgery.
Demerol and Morphine.
Name 3 sedatives used for surgery.
Pentobarbitol, Valium, and Xanax.
Name 2 local anesthetics.
Marcaine and Lidocaine.
What type of sedation is used for dental procedures and colonoscopy? What types of drugs are used?
Moderate (conscious) sedation. Narcotics, sedatives, and hypnotics.
What is in the epidural space?
Blood, fat, and nerves.
What type of anesthesia would be through the intrathecal route?
What are some side effects of epidurals and spinal blocks?
Respiratory depression, N/V, itching, urinary retention.
What is done for respiratory depression?
Give Narcan and O2.
What is done for N/V?
Give Zofran or Droperidol.
What is done for itching?
What is done for urinary retention?
Monitor I&O and have an anchored catheter in place for 24 hrs after meds are started.
What do you do for a spinal HA?
Lie patient flat, increase fluids and blood patch (Pt's blood injected into epidural space at the puncture site to create a clot)
Where would you put a strap if a patient were in the laparotomy or trendelenburg positions?
Above the knees.
How long is a patient usually in the PACU?
At least 30 mins to 3 hrs.
What is the nurse's main role in the PACU?
Frequent skilled assessments at least every 15 minutes.
How high is the HOB usually set in PACU?
When is the trach tube removed?
When the patient's gag reflex returns.
What is the #1 concern in the PACU?
Who changes the 1st post-op dressing?
Members of the surgical team.
How often are VS taken during post-op?
Initially every 15 min, or per protocol, then at least every 4 hrs through the first 24 hrs.
Name 3 non-invasive pain relief methods.
Cutaneous stimulation, distraction, and relaxation.
What does PQRST mean in a post-op pain assessment?
Provoking, Quality, Region, Severity, Timing.
How often should you turn a post-op patient?
Every 2 hrs.
What are the s/s of hypovolemic shock?
Decreased urine output, decreased BP, weak pulse, cool/clammy skin, restless, increased bleeding, and increased thirst.
What are the s/s of pulmonary embolism?
Chest pain, dyspnea, increased respirations, increased anxiety, diaphoresis, ABG changes, decreased orientation, decreased BP.
What are the s/s of urinary retention?
Unable to void 8-10 hrs post-op, palpable bladder, frequent small voids, pain in the suprapubic area.
What are the s/s of pneumonia?
Rapid/shallow respirations, fever, wet breath sounds, asymmetrical chest movements, productive cough, hypoxia, tachycardia, leukocytosis.
What are the s/s of atelectasis?
Dyspnea, tachypnea, decreased breath sounds, asymmetrical chest movements, tachycardia, increased restlessness.
What are the s/s of paralytic ileus?
Decreased bowel sounds, no stool or flatus, N/V, abdominal distension/tenderness.
What needs to be monitored for a patient that has suffered from a dehiscence or an evisceration?
Monitor for shock and cover the wound with warm, saline soaked towels.
How can you prevent dehiscence or evisceration?
Splint wound when coughing or use a binder.
What types of drugs put a surgical patient at risk?
Aspirin, NSAIDs, steroids, and antidepressants.
Name a few sterile procedures.
Surgeries, catheters, biopsies, injections, infusions, and dressing changes.
What happens to a cell when its ECF osmolarity increases?
The cells shrivel.
What happens to a cell when its ECF osmolarity decreases?
The cells swell.
What is osmolarity?
Concentration of substances in body fluids.
What does water do when osmolarity is different?
Continue to move until equalized.
What is an isotonic solution?
Solution that has the same osmolarity as blood plasma.
What is a hypertonic solution?
Solution that has a greater osmolarity than blood plasma.
What is a hypotonic solution?
Solution that has a lower osmolarity than blood plasma.
Name some isotonic solutions?
Normal Saline (0.9% NS) and Lactated Ringer's (LR).
Name some hypotonic solutions?
1/2 Normal Saline (0.45% NS).
Name some hypertonic solutions?
Dextrose 5% in Normal Saline (D5NS), Dextrose 5% in 1/2 Normal Saline (D51/2NS), and Dextrose 5% in Lactated Ringer's (D5LR).
What is the difference between sensible and insensible fluid losses?
Sensible fluid losses are from voiding, vomiting, and drains. Insensible losses are from sweating, breathing, etc.
What is one of the quickest ways to raise a patient's BP?
Elevate their legs.
What is the most reliable indicator of FVE?
Weight gain of 2-3 lbs in 24 hrs.
What position should FVE patients be placed in?
How can you assess FVD through postural changes?
When moving from lying position to a sitting position their BP changes by 20 mmHg or their pulse changes by 10 BPM.
What does the S3 heart sound indicate?
If the patient's capillary refill takes longer than 3-5 secs, could it be caused by FVE or FVD?
What generally causes dysrhythmias?
K, Ca, & Mg abnormalities.
What can cause changes in LOC?
Changes in serum osmolality or serum Na
What Neuro s/s are seen with FVD or acid-base imbalance?
What is the normal range for sodium?
What is the role of sodium?
Sodium plays a vital role in maintaining concentration and volume of ECF.
What are other non-vital roles does sodium play?
Main cation of ECF and major determinant of ECF osmolality. Maintains irritability and conduction of nerve and muscle tissue. Assists with regulation of acid-base balance. Important in maintenance of BP.
What are some s/s of Hyponatremia?
Sodium < 135 mEq/L, tachycardia, hypotension, HA, tremor, mental status changes (neurons don't work right in the brain), weakness, seizures, coma, N/V.
What are some causes of Hyponatremia?
Excessive oral water intake (dilutes urine), tap water enemas, NG suctioning, burns, peripheral edema, ascites, wound drainage, excessive hypotonic solutions, inadequate sodium intake (NPO status - need to ck electrolytes often), diuretic meds, SIADH (too much ADH).
What 2 types of drugs can affect fluid balance, thereby adjusting sodium balance?
Diuretics (lose water) and steroids (retain water).
What are some s/s of Hypernatremia?
Sodium > 145 mEq/L, thirst, mental status changes, flushed skin, disorientation, irritability (very common).
What are some causes of Hypernatremia?
Water deprivation (NPO status, inadequate fluid intake - causes concentration of sodium in the blood to increase), excessive sodium intake (hypertonic solution dietary sodium), sodium retention (Cushing's, renal failure, glucocorticosteroids), fluid losses (fever, burns, diarrhea), elderly (altered thirst mechanism).
What is the normal range for potassium?
What type of IV solution would you give to a patient with hypernatremia?
What are the roles of potassium?
Primary intracelluar cation. Vital role in cell metabolism. Balances Na in ECF. Promotes transmission & conduction of nerve impulses & contraction of skeletal, cardiac & smooth muscles.
What are s/s of Hypokalemia?
K+ < 3.5 mEq/L, weak/irregular pulse, muscle weakness, cramps, hypoactive reflexes, decreased GI/skeletal/cardiac muscle fxn (big one), shallow respirations, mental status changes, cardiac dysrhythmias/arrest (biggest problems).
What are the 2 main causes of hypokalemia in the elderly?
Diuretic and corticosteroid use.
Name a few K+ rich foods.
Bananas, potatoes, yogurt, and soybeans.
How do you NEVER give a K+ replacement?
IVP. Must be diluted!!! (can cause cardiac arrest).
What are some s/s of Hyperkalemia?
K+ > 5 mEq/L, muscle twitching and cramps (later muscle weakness), increased GI motility (abd cramps & diarrhea), low BP, weak pulse, cardiac dysrhythmia/arrest, peaked T wave..
What are causes of Hyperkalemia?
IV potassium, salt substitutes, hypertonic states such as uncontrolled diabetes, decreased secretion of K+.
What are some causes of decreased secretion of K+?
Renal failure, severe dehydration, Potassium sparing diuretics, adrenal insufficiency.
Name 2 K+ losing diuretics.
Lasix and HCTZ
What is Kayexelate?
A drug that binds to K+ and removes it via the GI tract.
What can giving K+ via IVP cause?
What is the normal range for Magnesium?
What is the roles of Magnesium in the body?
Major intracellular ion. Involved in metabolism of carbohydrates, protein, and triggers the Na-K pump. Neural transmission within CNS. Neuromuscular activity. Contracts myocardium. Influences calcium levels.
What are some s/s of hypomagnesemia?
Mg++ < 1.5 mEq/L, dizziness, confusion, positive Trousseau's sign, positive Chvostek's sign, cardiac dysrhythmia and arrest.
What is the normal pH range for blood?
7.35-7.45 is normal.
What pH levels must we have to maintain life?
Anything below 7.29 or above 7.52 is incompatible with life.
How do cellular buffers correct acid-base imbalances?
They are the body's first attempt to return pH to normal.
How do the lungs control acid-base balances?
Rapid compensation, second line of defense.
How do the kidneys control acid-base balances?
Slow to compensate, last defense.