Exam 1 Flashcards
1
Q
Identify the steps of the nursing process.
A
Assess Diagnose Plan Implementation Evaluation
2
Q
Describe critical thinking and clinical judgement.
A
- Clinical Thinking- a skill that is developed thru experience. You consider what is important, explore alternatives and then make an informed decision (includes all info)
- Clinical Judgement- using critical thinking skills and clinical reasoning to help us make decisions regarding patient care. (decision about patient)
•Observe and assess presenting situations
•Identify a prioritized client concern
•Generate the best possible evidence-based solutions in order to deliver safe client care.
3
Q
Discuss the relationship of the nursing process to critical thinking and clinical reasoning.
A
- select interventions based on client.
probably need more here???
4
Q
Describe the steps of the nursing process.
A
- Assessment- collection of subjective and objective data
- Diagnosis- analyze data to make a nursing judgement (nurses diagnosis, collaborative problem, or referral)
- Planning- determine outcome criteria and make a plan- how to correct problem (check history)
- Implementation- carry out plan (inform physicians or get prescription)
- Evaluation- come back to patient and assess if intervention worked (outcome criteria met), if not start all over and asses intervention (what worked and what didn’t)
5
Q
Assess the importance of client culture and ethnicity when planning care.
A
.
6
Q
Identify the processes fundamental to nursing practice
A
- caring
- communication
- documentation
- teaching & learning
7
Q
why is the nursing process called a blueprint for care?
A
it provides a framework
8
Q
advantages of using the nursing process to provide care
A
- individualizes client
- improves communication
- they can participate in their care
9
Q
ways to gather information about the client
A
- interview
- observe
- patient
- family
- health care provider
10
Q
culturally sensitive
A
knowledgable of other cultures
11
Q
culturally appropriate
A
apply knowledge to care
12
Q
culturally competent
A
address cultural context for each client
13
Q
culturally responsive
A
work with the patient to meet their specific needs and empower them
14
Q
cultural imposition
A
us being aware of our culture and avoiding bias (always accommodate with beliefs)
15
Q
three types of nursing diagnosis
A
- problem-focused
- risk factor
- health promotion
16
Q
three components of a nursing diagnosis
A
- label
- related factors
- as evidenced by
- ex. constipation related to use of opioid analgesics as evidenced by lack of passage of stool
17
Q
high priority
A
immediate threat to patients health/survival
18
Q
intermediate priority
A
non-emergency non-life-threatening needs of the patient
19
Q
low priority
A
potential problems not directly related to patients illness or disease
20
Q
Maslow’s Hierarchy of needs
A
- physiological (bottom)
- safety
- love and belonging
- esteem
- self-actualization (top)
21
Q
Medical Diagnosis
A
identification of a diseased condition based on specific evaluation (physical, signs, symptoms, history, diagnostic tests & procedures
22
Q
Nursing Diagnosis
A
- always done by a physician or advanced practice nurse
- clinical judgment concerning human response to health conditions, life processes, potential concerns that a nurse is licensed and competent to treat how patient responds to disease
23
Q
Nurse initiated interventions
A
actions based on identified problems in our scope of practice
24
Q
Provider initiated interventions
A
as a result of providers order or facilities protocol
25
collaborative interventions
nurses carry out with another health care provider
26
SMARTS
- Specific: addresses only one behavior
- Measurable: if goal can be observed
- Attainable: achieve goal with patient
- Realistic: agreed upon by patient
- Timed: short-term, long-term, if patient is making progress
- Singular: only 1 goal
27
Intervention
- act health care provider completes
| - offer, monitor, assess, discuss
28
nursing care plan
identify problem & set goal
29
essential components of a nursing care plan
1. identify problem
2. set goal/outcome
3. determine which intervention to use
4. evaluate
30
why is a nursing care plan important to the multidisciplinary health care team?
implements continuity in care
31
direct care
interventions with client
32
indirect care
interventions away from client on behalf of them
33
necessities for the nurse to pay attention to when preparing for implementation
1. time
2. equipment
3. personel/team members
4. environment is safe & conducive to intervention
5. client is ready
34
Pieces included in evaluation
1.
2.
3.
4.
5.
35
things nurse can do after evaluation
- terminate plan of care
- modify plan of care
- continue plan of care
36
critical thinking for a nurse
- consider what is important
- explore different alternatives
- solve problems & make informed decisions
37
why are creativity and reflection important to critical thinking?
problems need creative solutions, by reflecting you can look back and know how to evaluate client (growing Knowledge)
38
elements of critical thinking
1. knowledge
2. attitude
3. standards
4. experiences
39
standards that guide a nurse
- American nurses associated standards of professional nursing process
- evidence-based practice guidelines, policies, procedures
40
11 critical thinking attitudes
1. Confidence
2. thinking independently
3. fairness
4. responsibility & accountability
5. risk-taking
6. discipline
7. perseverance
8. creativity
9. curiosity
10. integrity
11. humility
41
CLOUD (helps us think)
```
Clear
Logical
Objective
Unbiased
Dispassionate
```
42
single most important way to prevent the spread of infection.
Hand Hygiene!
43
pyuria
puss in urine
44
Exudate types (drainage)
1st- serous- clear and gold- normal drainage every time you cut the body
2nd- serous sangranious- pink tinged- can be normal
3rd- sangranious- bloody drainage
4th- purulent or puss- yellow/green
45
Disinfectant
A chemical used on surfaces to kill pathogenic organisms, but not necessarily spore forms or viruses
46
Antiseptic
A chemical that is applied to living tissues to reduce the number or microorganisms present
47
Sterilization
- Destruction of ALL pathogenic organisms
| - Different methods are used to sterilize different materials
48
medical asepsis
- using antiseptics to disinfect
- reduces number of pathogens
- referred to as "clean techniques"
- used in administration of: medications, enemas, tube feedings, daily hygiene
- hand washing is #1
49
surgical asepsis
- sterilization to keep everything infection free
- eliminates all pathogens
- referred to as "sterile technique"
- used in: dressing changes, catheterizations, surgical procedures
50
Disinfecting Surfaces
- Equipment must be disinfected or sterilized between patients.
- Cleaning and disinfecting non-critical surfaces in patient-care areas are part of Standard Precautions.
- The cleaning and disinfection of all patient-care areas is important for frequently touched surfaces.
- The purple sani-cloths can be used on any hard, non-porous surfaces. 30 different microorganisms, works in 2 minutes
- Yellow- have bleach, need at least 4 minutes of surfacing, blood spills, cdiff (puts out spores), covid, 50 different microorganisms
51
Handling Linens
- never put it on the floor
- biohazard- if in isolation for infections
- do not fluff, gather it together to not aerosolize and send cells into air
- do not hold against self
52
standard precautions
- apply to blood, blood products, all body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes
53
airborne precautions
- Airborne respiratory particle: < 5 microns
- These tiny particles can travel a long way.
- Infection: measles, chickenpox, disseminated varicella zoster, pulmonary or laryngeal tuberculosis
- Protection: private room, negative-pressure airflow of at least 6 to 12 exchanges per hour via high-efficiency particulate air (HEPA) filtration; mask or respiratory protection device, N95 respirator (depending on condition), gown, gloves, dedicated equipment
54
droplet precautions
- Respiratory droplets come from coughs, sneezes, or talking. They can travel only a few feet through the air
- For disease that are transmitted by large droplets (> 5 microns) W/in 3 feet of the patient.
- Infection: Diphtheria (pharyngeal), rubella, streptococcal pharyngitis, pneumonia or scarlet fever in infants and young children, pertussis, mums, Mycoplasma pneumonia, meningococcal pneumonia or sepsis, pneumonic plague
- Protection: private room or cohort patients; mask or respirator required (depending on condition) Masks, gown and gloves, Dedicated equipment
55
contact precautions
- This can be direct skin-to-skin contact or indirect contact such as when an infection carrying person touches a surface and then someone else touches that same surface.
- Blood and bodily fluids can transmit disease if they contact a susceptible host’s broken skin or mucous membranes.
- infection: colonization or infection with multi drug-resistant organisms such as VRE and NRSA, Clostridium difficile, shigella, and other enteric pathogens; major wound infections; herpes simplex; scabies; varicella zoster (disseminated); respiratory syncytial virus in infants, young children, or immunocompromised
- Protection: private room or cohort patients, gloves, gowns (patients may leave their rooms for procedures or therapy if infectious material is contained or covered, placed in a clean gown, and if hands are clean)
56
protective environment
- Standard Precautions PLUS:
- PPE/dedicated equipment
- NO fresh flowers/plants/produce
- Strict hand washing
- Avoid contract with others who are sick
- infection: allogeneic hematopoietic stem cell transplants
- protection: private room; positive airflow with 12 or more air exchanges per hour, HEPA filtration for incoming air; mask to be worn by patient when out of room, during times of construction in area
57
Isolation carts
Patients in separate rooms now (all of them)
Identified infection that is communicable they will be put on isolation
Different facilities do it different
Right now, nurses are reusing masks because of covid (low supply)
Might see carts that are different colors
Code carts- red
Different procedure cart
Yellow- isolation
58
How do you know if you need to be put on isolation
- Nasal Swabs: Culture taken to detect Methicillin-Resistant Staphylococcus Aureus (MRSA)
- Sputum culture results
- Medical diagnosis
59
modified contact precautions
- will be reserved for “colonized” patients (e.g., MRSA nares), that do not have an active infection
- colonized: bacteria lives on skin and noses but is not causing an infection
- ex. MRSA in the nares- colonized but do not have infection- do not want them to spread them to others
60
transporting Isolation Patients
- When transport is necessary, using appropriate barriers on the patient (e.g., mask, gown, wrapping in sheets or use of impervious dressings to cover the affected area(s) when infectious skin lesions or drainage are present, consistent with the route and risk of transmission.
- Notify healthcare personnel in the receiving area of the impending arrival of the patient and of the precautions necessary to prevent transmission.
- For patients being transported outside the facility, inform the receiving facility and the medi-van or emergency vehicle personnel in advance about the type of Transmission-Based Precautions being used.
61
Donning isolation stuff
1. Gown (cover wrist and tie in back)
2. Mask
3. Goggles (if indicated)
4. Gloves (pull up over cuff)
62
removing isolation stuff
1. Gloves
2. Goggle or face shield (if used)
3. Gown - untie, let fall from shoulders, hold inside out at shoulders, and fold inside out, discard
4. Mask – untie lower string first (do not touch outer surface)
5. Perform hand hygiene
63
COVID PPE
- Gown
- Gloves
- Hair covering
- Mask
- Goggles
- Sometimes shoe coverings
64
Ebola PPE
- surgical cap
- goggles
- medical mask
- overalls
- scrubs
- apron
- double gloves
- boots
65
what to do if Exposed to an infection
- Prevention is best: get vaccines up to date and wear PPE
- If exposed: tell supervisor/instructor immediately
- Patient will be tested for diseases if not already known.
- Rinse and/or wash the area copiously
- Prophylactic medication therapy
- If a needle stick- patient will be tested for diseases
- If splashed with stool, wash it really well
66
Chain of infection
- Agent (germ)- bacteria, viruses, parasites
- Reservoir (where germs live)- people, animals, food, soil, water
- Portal of exit (how germs get out)- mouth, cuts in skin, during diapering and toiling
- Mode of Transmission (how germs get around)- contact, droplets
- Portal of entry (how germs get in)- mouth, cuts in skin, eyes
- Susceptible host (next sick person)- babies, children, elderly, people with weakened immune systems, unimmunized people, anyone
67
factors that affect hygiene
- Social Practices
- Personal Preference
- Body Image
- Socioeconomic status
- Health Beliefs and Motivation
- Cultural Variables
- Physical Condition
- Sometimes people think bathing certain body parts is detrimental to health
- Some patients may be in pain and be afraid of hurting during bathing (Premedicate, ask how they tolerated previous moves or baths)
- Some may be weak or short of breath and you may have to break up the bath into certain parts of the body
- Some patients do not want nurses of a certain sex giving them a bath
68
cultural aspects of care
- maintain privacy (especially with cultures who value feminine modesty)
- avoid uncovering and exposing the arms of middle eastern and East Asian women
- allow family members to participate in care if desired by adapting the schedule of hygiene activities
- provide gender-congruent caregivers as needed or requested.
- recognize that some cultures prohibit or restrict touching (some view it as magical or healing while others view it as evil or anxiety-producing)
- do not cut or shave hair without prior discussion with patient or family because of cultural or religious beliefs
- be aware that toiling practices vary by culture
- recognize that different cultures have preferences about hot and cold water and their effects on healing or diseases
69
What is bathing an opportunity for?
- A personal activity that shows caring and provides a good time for not only assessment but communication.
- Physical Exam-identify disease related conditions and new problems
- Feet and Nails
- Oral Cavity
- Hair and Scalp
- Sensory Aids- Clean hearing aids and apply them back before bath
- Examine skin and see if it is intact- skin is largest organ of the body & first best defense against infection
70
Equipment needed to bathe a patient
- 2 washcloths
- 2 bath towels
- Bath blanket
- Soap and soap dish
- Bath basins- Always wash bath basin with purple wipes, Let water run while drying (water is cold at first), Fill basin, Let patient test the water
- Toiletry items- Patients may have also brought their own toiletries from home
- Clean change of clothes
- Laundry bag
- Disposable gloves
71
Bathing the patients
- Check the room for supplies before you bring them in
- Prepare bath basin by cleaning with antiseptic wipes and fill 2/3 full with warm water
- Immerse washcloth in water and wring out and fold into mitt
- Start at head and work towards feet
- Remember to go from clean to dirty in all areas
- Use bath blanket to keep client covered while washing other areas
- Remove gown from the unaffected side first
- Watch them the whole time to see how they perform ADLs
72
Perineal care
- Last part of a complete bed bath
- Clean area from front to back
- Patients most in need of perineal care are those at greatest risk for acquiring in infection
- Risk factors-uncircumcised male, indwelling urinary catheters, rectal or genital surgery or childbirth
- Some patients may want to do parts themselves (perineal care) or other family members
- This needs to be done everyday even if you don’t do other parts
- wear gloves
73
Foot & nail care
- Diabetes or peripheral vascular disease increases risk of foot and nail problems
- If at risk you should inspect the feet daily
- Wash feet daily using lukewarm water, do not soak
- Pat feet dry and dry well between toes
- Do not cut corns or calluses or use any type of removers
- File nails straight across do not use scissors or clippers
- Report problems in charts
74
Oral Hygiene
- Thorough tooth brushing at least 4 times a day (after meals and before bed) or every 4 hours while awake
- Oral care in the unconscious patient is every 2 hours
- Instruct patients to buy new tooth brush every 3 months and to use fluoride toothpaste
- Flossing once a day
- Use an essential oil antiseptic mouthwash
- Never put your fingers between a patient’s teeth. Human bites are very dirty.
- Very important for patients health
75
Denture Care
- Dentures are expensive
- ALWAYS put in a denture cup (Label with name and room number)
- Remove at night to rest the gums
- Put in for patient to eat and talk well
- May not fit correctly and rub/hurt
- Rinse and then soak at night
- Always put washcloth in sink before you wash them (they can break or chip)
- Denture paste provided by hospital
- Ask if they have their own adhering agent
76
Hair & Scalp Care
- How well a person feels often depends on the way the hair looks
- Often overlooked by the health professional
- Keep hair combed and brushed
- If client has an itchy scalp find a way to do a wet shampoo and rinse
- Shampooing of hair can be done even if the client is confined to the bed with a shampoo board
- Most healthcare centers have portable hair driers
- Share with patient and family if you are washing hair for a special reason.
77
Shaving a Patient
- Soften the area with a warm, wet washcloth.
- Allow the patient to do what they can.
- Gently pull the skin taut and cut in the direction the hair grows.
- Use a patient’s own safety razor if there is a risk of bleeding.
- Never remove a patients beard or mustache unless it is an emergency or they ask
78
Back Massage
- May be used at end of the bath to relax the patient
- During the massage there is a release of endorphins
- May be used to relieve pain
- Avoid massaging reddened skin areas and report any changes in skin appearance.
- May be delegated to assistive personal after the nurse has assessed the patient.
79
Making a bed
- Bed can be made both occupied or unoccupied
- Never throw old linen on floor, hold line away from uniform and place directly in linen bags
- Use extra pads so you won’t have to be changing the bed frequently unless it’s a specialty bed-this can negate the pressure relief function
- Corners finished with triangular fold placed over side of mattress
- Closed bed- cover up, ready for new patient
- Open bed- when patient gets up, when coming back from a procedure or surgery
80
Describe how hygiene care may differ across the lifespan and in different cultures
?
81
Definition of pain
- An unpleasant subjective sensory and emotional experience associated with actual or potential tissue damage or describes in terms of such damage. Whatever the patient says it is.
82
What is included in understanding the nature of pain?
1. involves physical, emotional, and cognitive components
2. Pain is subjective and individualized
3. Reduces quality of life
4. Not measurable objectively
5. May lead to serious physical, psychological, social, and financial consequences
83
Vital Signs
- BP
- temperature
- respiration
- pulse
- oxygen saturation
- pain
84
Gate Control Theory
- Gating mechanisms located along the central nervous system regulate or block pain pulses, closing this gate is the basis for nonpharm pain relief interventions.
- Different things used to help block pain or distract the body from experiencing pain.
85
benefits of effective pain management
- Helps improve quality of life - reduce physical discomfort - promote earlier mobilization
- return to previous baseline functional activity levels
- can result in fewer hospital or clinic visits and reduce the length of stay
86
nurse’s role in managing the client’s pain
- Legally and ethically responsible for managing pain and helping to relieve the suffering
- Has to be patient centered, patient advocacy, patient empowerment, compassion and respect
- Measure the clients pain level on a continual basis
- provide individualized interventions
- assess for the effectiveness of intervention every 30-60 minutes depending on the medication given or method used
87
acute/transient pain
- Protective thing, warning body something is not right
- Identifiable cause
- Short duration
- Limited tissue damage
- Limited emotional response
- s/s: clinching teeth, facial grimacing, holding or guarding body part, bent over posture
- goal: provide pain relief that allows patient to participate in recovery, prevent complications, improve functional status
- pain goes away once injured area heals
- can threaten patients recovery because it can prevent them in being able to participate in being involved in their self-care
88
chronic/non persistant pain
- Not protective
- May or may not have an identifiable cause
- Can have dramatic affect on quality of life for patient, especially when don’t know what pain is coming from (Depression, disability)
- Must last longer than 6 months of what is expected or predicted
- s/s: physical and mental exhaustion, fatigue, insomnia, anger
- goal: improve functional status (ex. back pain, arthritis, peripheral neuropathy)
89
Chronic episodic pain
- Occurs sporadically over an extended period
- Can last Hours, days, weeks
- Comes and goes
90
Cancer Pain
- Can be acute or chronic
- Results from stimulus of pain nerves (Tumor progression, invasive procedures, chemo, infections, or physical limitations)
- Pain at actual site of tumor or distant (referred pain)
- Always report new pain
91
Breakthrough Pain
- Happens part of incident pain: predictable and elicited by specific behaviors
(Walking, treatments)
- Dosing pain: happens at the end of doing intervals
- Spontaneous: non-predictable and not associated with any event
92
different factors that influence pain control
1. Physiological factors:
- Anxiety- increases perception of pain
- Coping style- how well patient can cope or adjust to pain
- Age- cant assume they perceive pain different
- Fatigue
- genetics
2. Pain tolerance:
- Patient levels of pain varies
3. Social factors:
- Claim pain for social attention
- Previous experiences
- What kind of support they have
4. Spiritual factors
- Search for meanings- why is this happening
93
How do cultural aspects impact pain and pain control?
Meaning of pain varies between cultures, different coping and reactions
94
tools for measuring pain
Readings, pictures, numerical pain scale
95
Characteristics of pain
- What does it feel like, quality
- Aggravating or precipitating factors
- What relief measures have worked
- Behavioral changes
- ADL changes
- Any other problems pain is causing (Nausea, headache, dizziness)
96
Immediate consequences of pain
- Decreased oxygen saturation
- Increased heart rate
- Diaphoresis
- Delayed wound healing
- Impaired GI function
- Restlessness
- Anxiety and stress
97
Long term consequences of pain
- Impaired inflammatory response
- Decreased immune system function
- Poor motor performance
- Temperament changes and psychosocial problems
- depression
98
Physiological Responses to Pain
1. Sympathetic:
- Dilation of bronchial tubes and increased respiratory rate
- Increased heart rate
- Peripheral vasoconstriction
- Increased blood glucose level
- Increased cortisol level
- Diaphoresis
- Increased muscular tension
- Dilation of pupils
- Decreased GI motility
2. Parasympathetic (severe or deep pain)
- Pallor
- Nausea and vomiting
- Decreased heart rate and blood pressure
- Rapid, irregular breathing
99
alphabet for pain nursing assessment
P – provocative or palliative factors (what makes pain worse? what makes it better?)
Q – quality or quantity (how do you describe your pain?)
R – region or radiation
R- relief measures
R- region (location)
S - severity (0-10)
T - timing (constant, intermittent, or both?)
U - (effect of pain on the patient, what can they not do, support system, how do they normally help with pain)
100
Superficial pain
- Short onset
- Localized
- Sharp sensation
- ex. (getting flu shot)
101
Deep or Visceral Pain
- Stimulation of external organs
- Radiates in several directions
- Last longer than superficial pain
- Can be dull or short
- ex. (crushing or burning pain from ulcer)
102
Referred Pain
- Pain in different part of body
| - ex. (myocardial infarction, pain to arm and jaw)
103
Radiating Pain
- Pain sensation that extends from initial site to another part of body
- Pain feels like its traveling down a body part
- ex. (low back pain that moves down back of leg)
104
Barriers to effective pain management
- Lack of knowledge by patient or nurse
- Misconceptions about management of pain
- Healthcare barriers
- Patient barriers
- Healthcare system barriers
105
Nonpharmacological pain relief interventions
1. Cognitive and behavioral approaches:
- Relaxation, guided imagery
2. Distraction:
- Music, tv
3. Cutaneous stimulation:
- Using Heat or cold
- Heat: increase blood flow, relaxes muscles, ease joint stiffness or pain, do not use over metal or over abdomen if pregnant, no active bleeding (24 hours)
- Cold: helps decrease inflammation or muscle spasms, prevents swelling, reduces bleeding, reduces fever, do not use over open wounds
- Considerations: make sure not using it on patients who are immobile or have impaired sensory problems, best for short term use, have to have an order for type, duration, location, and temperature, provide continued assessment of application site
4. Therapeutic touch:
- Massage
- Elevating extremities
106
Geriatric Pain control
- Understand that pain is not an inevitable part of aging (should not have pain)
- Perception does not decrease with age
- Greater likelihood of developing pathological conditions
- Age related changes and frailty can lead to having a less predictable response
107
Infant pain control
- Look at physical symptoms:
Crying, squeezing eyebrows together, squeezing eyes shut, mouth open, quivering chin, body tension, arching back, flailing
- FLACC 2 months to 7 years
108
Toddler pain control
- Tend to show signs of pain by grimacing, moving limbs, grabbing onto objects or caregivers, crying, moaning, groaning
109
Preschooler pain control
- Crying, whimpering, limb movement, facial movement
| - Wong baker face scale
110
school age pain control
- Able to verbalize pain
| - Crying, facial expressions, body movements, recoiling
111
adolescent pain control
- May try to hide pain
- Verbalize pain
- Facial expression, body posturing, become fearful
- Distraction or sensory stimulation, read, music, art, hypnosis, guided imagery, breathing techniques
112
pain evaluation
1. Client’s perspective- Patient is the one to tell us if interventions are working or not
2. Client outcomes
a- Looking to see if change in severity or quality of pain
- Make it more manageable
- If not met, have a conversation and reevaluate
- Describe limitations, if impacting sleep
- Documenting all interventions
-Pain evaluation includes measuring the changing character of pain, the patients response to interventions and their perceptions of the effectiveness of the therapy
113
surgery
- the performance of a procedure done to alter the human body using instruments by incision or manipulation (Body cut to remove, or rearrange body)
- Purposeful Controlled trauma to the body
- Both psychologically and physiologically stressful
114
surgery according to urgency
- Emergent: now (life threatening condition (burn, vehicle accident, gunshot wounds, excessive bleeding, fractured skull)
- Urgent: within 24-30 hours (wont die but needs to be done. ex. acute gallbladders, kidney or ureteral stones that need to be removed surgically for organ function)
- Required: within weeks-months (you really need to have this done but soon
Cancer diagnosis surgeries, catarax, thyroid)
- Elective: not catastrophe if don’t have (its not a catastrophe if you don’t repair but it can be uncomfortable
Repairs of hernia, bladder surgeries for incontinence)
- Optional: personal preference (a lot are cosmetic)
115
surgery according to purpose
- Curative or palliative: infectious or inflamed, affecting other things and live a comfortable life but wont cure disease
- Exploratory/diagnostic: wont know diagnosis is until open things up, look, and get a biopsy
- Aesthetic: cosmetic surgeries
116
three phases of surgery
- Preoperative: Assessing, evaluating, teaching and preparation (Assessing whether they have the knowledge and handle surgery, evaluating whether they can tolerate the surgery and have it done safely )
- Intraoperative: Safety, sterile environment, support (Supporting psychologically and physically )
- Postoperative: Recovery from surgery and adjustment to changes (Rehab or recovering from anesthesia)
117
Dr. Teodor Billroth
- Physician in 19th century
- advocated for choosing patients and doing surgery only if patient will survive and benefit from it
- Insisted on aseptic technique and advocated about keeping statistics to learn what worked and what didn’t and see what kinds of patients survive better than others
- First to safely performed and gastrectomy in 1881
- Invented billroth 1 and 2 surgeries
118
Increased surgical risk and special populations
- Pre-existing conditions
- Gerontological considerations
- Bariatric Patients
- Patients with Disabilities
- Patients undergoing ambulatory surgery
- Patients undergoing emergency surgery
119
Preoperative nursing
Assessment and testing:
- Is all the necessary information available for the surgical team?
- This is all the results of pre-operative testing. This may include x-ray and scan results, EKG results, laboratory results (This can include blood examinations or things like pulmonary testing), current weight and vital signs.
- Patient Identification and effective communication among caregivers.
- Patient education on pre-operative and post-operative expectations.
- Safety! Medications, infection prevention, and wrong site prevention using protocols and check lists.
120
preoperative activities
Preoperative teaching:
- Smoking cessation-
- Medications- Medications may need to be stopped before surgery, Aspirin or blood thinners need to be stopped weeks before,
Review all medications,
Beta blockers taken in the morning with a sip of water
- Diet Restrictions- not drinking anything after midnight, or diets that come with surgery
- Bowel/Skin Prep
Post op Expectations:
- Pain Management
- Mobility
- Cough/Deep Breath (Incentive Spirometer)
- Patient Safety after meds administered
- Family communication
121
preoperative area activities
- Is everything and everyone ready?
- Has the patient voided?
- Have they been NPO?
- Has all jewelry, belongings and prosthetics been removed?
- Is the CONSENT SIGNED!!!
- Are allergies, weight and recent vital signs noted?
- Medications taken, drug and alcohol use noted?
- Is IV access patent and the desired size of needle?
- Psychological, cultural and spiritual concerns have been addressed?
- Is the correct surgical site identified?
- Has patient been involved in marking surgical site?
122
informed consent
- No surgery can be performed without the consent of the patient or a legal guardian unless it is a life-threatening emergency
- Before consent is obtained the surgeon must inform the patient about the nature of the surgery, the expected benefits, risks and alternative treatments and the consequences of not having the surgery.
- The patient or guardian should have the opportunity to ask questions about the surgery until they are satisfied they have enough information about the surgery.
- A patient has a right to refuse to have surgery or to choose an alternative surgeon.
- Consider insurance coverage, work responsibilities, family issues, religious beliefs
- Surgery without consent can only be done in an emergency
- Needed for: Invasive procedures, procedures requiring sedation and those involving radiation.
- Surgeon responsibility to
Explain procedure, risks/benefits, post-op expectations
- Surgeon must be contacted if they feel they do not understand everything
- RN responsibility to ask patient to sign & witness signature
- RN may clarify, but if patient needs more info, surgeon must explain
- Place consent in prominent place on chart
123
signing the consent form
- The patient should NOT receive any psychoactive medications until consent is signed.
- If taking chronic pain it the med does not alter them then it is not considered psychoactive
- Verify that it is the correct person signing the consent.
- No abbreviations are allowed on the form. The name of the surgery and any acceptations must be explicitly written.
- Refusing to undergo procedure is patient’s legal right.
- If underage or mentally incompetent then the legal guardian or DPOA signs the consent.
124
surgical never events
- surgery performed on the wrong body part
- surgery performed on the wrong patient
- wrong surgical procedure performed on a patient
- unintended retention of a foreign object in a patient after surgery or other procedure
- intra-operative or immediate postoperative death in an ASA grade 1 patient
125
Human factors for error
- 40% information transmitted in an inaccurate fashion
- 50% never transmitted at all
- written orders and checklists should support inter-individual verbal communication including the count of sponges and surgical instruments and in order to reduce the incidence of adverse events
- Make sure to slow down and let them know what they need to know while getting feedback to make sure they heard what you said
- Nurses and surgeons tend to downplay the effect that stress of fatigue has on them so the nurses must speak up if there is an error
126
"Time Out"
- Part of the Universal Protocols from the Joint Commission for patient safety.
- It is the final review and assurance of the correct patient, planned procedure, procedure location/surgical site and any special patient needs.
- When patient arrives in OR and everyone stops and verifies they are doing the right thing to the right person
- Sometimes they are awake and will get introduced- helps see them as a real person
- Surgical sites should be marked with permanent marker and not stickers or anything else removable
- If possible, involve patient in marking to verify placing
- Procedure should not be started until all questions have been answered
127
Intraoperative considerations
- Asepsis & Sterile Field- reducing risk of infections
- Safety: “Time Out”
- Positioning/padding- atient in specific position which can put a lot of pressure in different body parts- this can end up causing damage in the long run
- Accurate count instruments/supplies- done by surgical or circulating nurse,
Sterile supplies and instruments must be opened and and an initial sponge, sharp, and instrument count must be done by the rn circulator and scrub person before the patient enters room
- Fire safety: fire- oxygen, nitrous oxide, room air sources (lasers, fiberoptics, etc.)
128
Sterile fields
1. Sterile objects remain sterile only when touched by another sterile object.
2. ONLY sterile objects may be placed on a sterile field.
3. A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated.
4. A sterile object or field becomes contaminated by prolonged exposure to air.
5. The edges of a sterile filed or container are considered to be contaminated.
6. When a sterile surface comes in contact with a wet, contaminated surface the sterile object or field is considered contaminated.
- Do not reach over field
- Flap away, sides, flap closest
- Anything touching clean is contaminated
- Always pour some liquid out of sterile container to clear the lip
- Discard all open fluids within 24 hours
129
Positioning goal
- position area to be operated on to be easy to operate on while causing the least injury
- Padding and positioning patient protects against pressuring and misalignment injuries
- Hyperextension of the joint- wrist is elevated and elbow bent to prevent ulnar nerve damage- gel pads used
130
Fire safety in the surgical environment
- In OR are rare but they do happen
- Normally in upper body and face
- Communication of what chemicals are used
- Electrical surgical equipment, lasers, defibrillators
- Oxygen and nitrous oxide can lower temperature at which fluid will ignite
- Vital to know where fire fighting equipment is along with the gas shutoff valves
131
who is in the OR?
- Scrub nurse (or surgical technician)- prepare room for next procedure
- RN circulator- controls who comes in and out and phone calls, assists anesthesia professional with the induction of anesthesia (quiet time), will open all items, receive and label on samples, completes intraoperative charting, alerts post anesthesia care unit nurse that it is being completed, circulating and anesthesia professional transfer and give directions to PACU nurse
- First assist- surgeon, resident, RN first assistant or surgical assistant
- Anesthesia professional
- Surgeon- leads atmosphere in OR (chief and assistant)
- They all may have an assistant or student with them
132
the "Count"
- Keeping track of instruments, sharps and sponges (towels and gauze)
- Everything must be accounted for.
- Never leave item unattended
- Cannot leave cotton in body or will spike temperature
Sponges separated out to count
- 2 people doing count, RN circulator
- Surgeon must be told if missing number before surgery is closed up
- Gauze and cotton have a radiopaque strip
- Soft item will show up on X-rays
133
Anesthesia
- state of narcosis, analgesia, reflex loss
- RN Responsibility: Prevent injury, Patient advocate (Provide emotional support
Be mindful of conversations)
- Assist with complications (N/V,
Allergic reactions, Hypo/hyperthermia)
134
General anesthesia
- Causes severe CNS depression, required intubation
Stages of Induction:
I: Beginning-Noises exaggerated
watch your conversations
II: Excitement-possible uncontrolled movements
III. Surgical anesthesia- patient unconscious
Normal surgery
Maintained for hours on several planes
Light – deep
IV: Medullary depression- too much anesthesia
Not normal- this is an overdose
- make sure they recover before they get up and walk
135
Epidural anesthesia
- Administered by anesthetist
- local anesthetic in spinal cord epidural space
- Blocks sensory, motor, autonomic functions
- Epidural advantage: no HA
- Epidural Disadvantage: more challenging to administer
136
Spinal anesthesia
- Administered by anesthetist
- local anesthetic in spinal cord sub-arachnoid space (L4-L5)
- Anesthesia lower extremities, perineum, lower abdomen
Paralysis toes, perineum, legs, abdomen
- Complications: N/V, post-HA
- Lumbar puncture
137
Regional anesthesia
- anesthetic injected around nerves; area innervated anesthetized
- Administered by anesthetist or other physician
- Patient aware unless psychoactive meds given
- AVOID: careless conversation, un-necessary noise, unpleasant odors
- DO NOT state diagnosis out loud if patient is not
aware of it before procedure
- Example: ingrown toenail, amputation of a toe
138
Conscious sedation
- Moderately depress LOC
- Patient able to hear, respond, maintain own airway
- Administered by anesthetist or specially trained/credentialed personnel
- Uncomfortable procedures- colonoscopies and cardiac catheterization
- Nursing Considerations:
Do not leave patient alone
Monitor LOC, VS, ECG
Be prepared with emergency equipment
Be mindful of conversations
139
Local anesthesia
- Medication is injected to numb an area for a procedure.
- Often used for closing lacerations, obtaining skin biopsies, removing skin cancers and minor cosmetic surgeries.
- It may cause bruising and/or nerve damage if injected incorrectly.
- Done by nurses (with special education), doctors, or PA
- Done in outpatient settings, patients room, ER
- Injecting local along incision line to help with pain relief during recovery or a pump that can release small amount along incision for the first few days
140
Intraoperative complications
1. Nausea/vomiting: controlled with medications, nasogastric tube, suction
2. Allergic reactions/anaphylaxis: this can be due to medication or equipment such as latex.
3. Hypo or hyperthermia: continuously monitor core temperature
141
Postoperative management first few hours after surgery
- PACU
- Recovery from anesthesia
- Airway maintenance-maintain ventilator or extubation: removal of endotracheal tube and restore independent respiration
- VS and I&O’s
- Prevent cardiovascular instability- watch for signs of hemorrhage and assess need for emergent return to surgery
- Stabilize patient so they can go to the unit
- For in-depth surgeries they may go straight to ICU
- Can go back into surgery if something bad happens in recovery room
- If become critical but don’t need to go back to surgery they go to ICU
- Tell family where they go
142
Postoperative management first few hours back on the unit
- Hospital Floor
- PACU calls floor
- Get report from PACU nurse- medications, oxygen, IV, output
- Usually need several people to transfer back in bed
- Ask family to stay outside while patient gets “settled”
- Remove any bloody sheets that are under them
- Respiratory function: can be first sign they are having issues
- VS: start with every 15 min., then 30 minutes x2, then 1 hour x4, then 4 hours
- Pain control
- Incisional bleeding: Mark bleeding, or reinforce dressing do not remove and replac, If a hemorrhage call doctor
- I & O’s – urinary output, retention (30mL of urine/hour)
- Activity: walk, stand (slowly), Swallowing may be painful- note activity
- GI function- assess swallowing/treat nausea
- Catheter removed after 24 hours, if removed too soon they may have urinary retention (drug given in surgery)
143
decreasing risk of complications
Postoperative:
- Assessment
- Activity
- DVT prevention
- Pain Management
- Pneumonia/aletectasis
- Prevention with IS
144
diet progression after surgery
- Can they eat?
- First day- surgeon will leave food orders, ice chips or sips of water
- Things might not taste right
- Clear liquids
- "Advanced diet is tolerated"- full liquids, whatever diet they were on before
145
adverse effects and complications from surgery
- Allergic reaction
- Injury:Falls
- Side effects from anesthesia
- Infections
- Hemorrhage
- Wound dehiscence (comes apart) or evisceration (things coming out)
- Respiratory complications
- CV complications
- VTE/PE
- Disseminated Intravascular Coagulation (DIC)
146
Preventing Atelectasis and Pneumonia
- Incentive Spirometer
- Tell the patient this instrument should not be shared with others.
- Inspire, breath in, do not “blow” into device.
- Deep breath and cough
- May help decrease incisional pain if the patient hugs a pillow to stabilize the incision.
- May not be appropriate in cases where we do not want to increase the intracranial pressure.
147
DVT prevention
- TED hose: May be knee high or thigh high
- Must be properly fitted and removed once a shift for skin assessment!
- Sequential compression devices
- Chemical prophylaxis or ted hose or use both together
- If up and walking they do not have to have hose on
148
Malignant hyperthermia
a rare inherited reaction to anesthesia-HR>150, Temp up to 107 F, muscle rigidity, ↓ BP
