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1

surgical classifications

diagnostic (eg. biopsy, exploratory laparotomy)
curative (eg. excision of a tumor or an inflamed appendix)
reparative (eg.multiple wound repair)
reconstructive or cosmetic (eg. mammoplasty or a facelift)
palliative (eg. to relieve pain or correct a problem-gastrostomy tube)

2

Emergent surgery

patient requires immediate attention; disorder may be life-threatening.
without delay.
Eg: severe bleeding
bladder or intestinal obstruction
fractured skull
gunshot or stab wounds
extensive burns.

3

Urgent surgery

within 24-30 hours
Eg:
acute gallbladder infection
kidney or ureteral stones

4

Required surgery

patient needs to have surgery
plan within a few weeks or months
Eg:
prostatic hyperplasia without bladder obstruction
thyroid disorders
cataracts

5

Elective surgery

patient should have surgery
failure to have surgery not catastrophic
Eg:
Repair of scars
simple hernia
vaginal repair

6

Optional surgery

decision rests with patient
Eg:
cosmetic surgery

7

surgical intervention should be tailored to?

patient's symptoms
overall functional
health status
predicted benefit of the intervention

8

Elderly people frequently do not report symptoms because?

fear of serious illness.
acceptance of symptoms as part of the aging process.

9

Protective measures for the elderly patients

adequate padding for tender areas.
moving patient slowly
protecting bony prominences

10

Surgical risk for the elderly patients

decrease ability to respond to stress.
increase vulnerability to changes in circulating volume and blood O2 levels.
pulmonary edema (excessive or rapid IV solutions).
increase susceptibility to hypothermia.
skin complications.
airway occlusion

11

surgical risk for the obese patient

dehiscence
wound infections.
shallow respirations when supine=hypoventilation and pulmonary complications.

12

nursing management for the obese patient before surgery.

careful assessment of the cardiopulmonary status.
thorough wound assessments.

13

when does the preoperative phase begins and ends?

begins when the decision to proceed with surgical intervention is made, and ends with the transfer of the patient onto the OR table.

14

Nursing activities during the preoperative phase

base line evaluation of..
H and P (history and physical)
emotional assessment
previous anesthetic
identification of allergies or genetic issues.
ensuring necessary labs have been done or will be performed.
arranging appropriate consultations
providing education about recovery from anesthesia and postoperative care.

15

what is the primary purpose of the informed consent process for surgical services?

To ensure patients, or their representative is provided information necessary to enable him or her to evaluate the proposed surgery before agreeing to it.

16

who obtains the informed consent?

it is the responsibility of the performing surgeon.

17

How should the nurse determined patient's nutritional needs?

measurement of body mass index (BMI) and waist circumference.

18

Normal BMI

18.5-24.9

19

BMI of less than 18.5

underweight

20

great than 25 BMI

overweight

21

BMI greater than 30

obese

22

A waist circumference measurement of greater than 40 inches for men and 35 inches in women is associated with?

increased cardiac risk.

23

Nutrients important for wound healing.

protein
Arginine (amino acid)
carbohydrates and fats
water
Vitamin C, E, A, K, B complex
magnesium
copper
zinc

24

Alcohol withdrawal syndrome or delirium tremens may be anticipated?

between 48 and 72 hours.

25

The patient with diabetes undergoing surgery is at risk for?

hypoglycemia = during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin.
hyperglycemia= stress of surgery because it triggers increased release of catecholamines .

26

surgical patients with type 1 diabetes are at risk for developing?

ketoacidosis : absence or inadequate amount of insulin.
SxS:
hyperglycemia
ketosis
dehydration
electrolyte loss
acidosis
polydipsia
polyuria
acetone breath (fruity odor similar to overripe apples)

27

signs of adrenal insufficiency

hyponatremia
hypoglycemia
hyperkalemia
weakness
fatigue

28

patients with uncontrolled thyroid disorders (hyperthyroid) are at risk for?

thyrotoxicosis

29

patients with hypothyroid disorders are at risk for?

respiratory failure

30

Foods to determine latex allergies

bananas
avocados
kiwi
chestnuts

31

An important outcomes of the psychosocial assessment.

determination of the extent and role of the patient's support network.
value and reliability of all available support systems.
level of functioning.
typical daily activities.

32

The effect of corticosteroids-Prednisone (Deltasone) with Anesthetics.

cardiovascular collapse if discontinued suddenly.
Tx: bolus of corticosteroid may be administered intravenously immediately before or after surgery.

33

Diuretics
Hydrochlorothiazide (HydroDiuril) effect of interaction with Anesthetics.

may cause excessive respiratory depression resulting from associated electrolyte imbalance.

34

Phenothiazines
Chlorpromazine (Thorazine) effect of interaction with anesthetics.

may increase the hypotensive of anesthetics.

35

Tranquilizers
Diazepam (Valium) effect of interaction with anesthetics

may cause anxiety, tension, and seizures with withdrawn suddenly.

36

Insulin effect of interaction with anesthetics

IV insulin may need to be administered to keep the blood sugar within normal range.

37

Antibiotics
Erythromycin (Ery-Tab) effect of interaction with anesthetics.

when combined with a curariform muscle relaxant, never transmission is interrupted .
apnea from respiratory paralysis may result.

38

Anticoagulants
warfarin (Coumadin) effect of interaction with anesthetics.

increase the risk of bleeding.

39

Antiseizure medications
effect of interaction with anesthetics

IV administration may be needed to keep patient seizure free.

40

Monoamine Oxidase (MAO) Inhibitors
Phenelzine sulfate (Nardil) effect of interaction with anesthetics.

may increase the hypotensive action.

41

Thyroid Hormone
Levothyroxine sodium (Levothroid) effect of interaction with anesthetics.

IV administration may be needed during the postoperative period to maintain thyroid levels.

42

Central core disease (CCD)

genetic disorder presents in neonatal.
muscle weakness and hypotonia and mild facial weakness.
risk the risk of developing MH-malignant hyperthermia.

43

Duchenne muscular dystrophy and Becker dystrophy genetic disorders.

muscular dystrophies
risk for developing MH

44

Hyperkalemic periodic paralysis.

genetic disorder.
causes episodes of extreme muscle weakness.
associated with MH

45

King-Denborough syndrome

rare genetic disorder
musculoskeletal abnormalities.
associated with MH.

46

Preoperative Teaching

start in at the time of PAT
continues until patient arrives in OR
extends to discharge.

47

what is the goal of promoting coughing?

mobilize secretions, so they can be removed.

48

what may occur with infective coughing after surgery?

atelectasis (collapse of the alveoli)
pneumonia
lung complications

49

goal of promoting mobility postoperatively?

improve circulation
preventing venous stasis
promoting optimal respiratory function

50

what is the major purpose of withholding food and fluid before surgery (NPO)

To prevent aspiration.

51

goals of bowel preparation for patients undergoing abdominal or pelvic surgery? using cleansing enema or laxative

satisfactory visualization to prevent trauma.
contamination of the peritoneum by feces.

use the toilet or bedside commode to evacuate enema.

52

who is responsibly to relay the surgical findings and the prognosis?

The surgeon

53

when does the intraoperative phase begins and ends?

begins when patient is transferred onto the OR table and ends with admission to the PACU.

54

The surgical team

Circulating RN
scrub person
Registered nurse first assistant (RNFA)
Surgeon
Anesthesiologist and anesthetist (certified registered nurse anesthetists (CRNA)).

55

Responsibilities of the circulating nurse

checking and managing OR conditions
continually assessing the patient
verifying consent and ensuring documentation is correct
coordinating the team
monitoring aseptic practices
implementing fire safety precautions
accounting for all surgical counts in collaboration with scrub person.
specimen management
ensuring second verification of the surgical procedure.

56

Responsibilities of the scrub person

performing surgical hand scrub
setting up the sterile tables
preparing sutures, ligatures and special equipment
anticipating supplies and instruments required
counting all needles, sponges as the surgical incision is closed.

57

Responsibilities of the registered nurse first assistant (RNFA)

handling tissue
providing exposure at the operative field
suturing
maintaining hemostasis.

58

responsibilities of the surgeon

performing the surgical procedure
heading the surgical team

59

Responsibilities of Anesthesiologist, anesthetist (CRNA)

assessing the patient before surgery.
selecting the anesthesia and administering it
intubating the patient if necessary
managing any technical problems related to the administration of the anesthetic agent.
supervising the patient's condition throughout the surgical procedure.

60

A state of narcosis (severe CNS depression produced by pharmacologic agents), analgesia, relaxation, and reflex loss

Anesthesia

61

Patients under general anesthesia

not arousable
not even to painful stimuli
they lose the ability to maintain ventilatory function.
require assistance in maintaining a patent airway.
impaired cardiovascular function.

62

patients at greatest risk of anesthesia awareness

cardiac
obstetric
major trauma

63

Anesthetic agents used in general anesthesia

inhaled or administered by IV

64

what are the most reliable guides to patient's condition when general anesthesia is administered?

responses of the pupils
BP
respiration
cardiac rates

65

Type of anesthesia used to block nerves in the peripheral and CNS?

local anesthesia
blocks transmission of pain sensation along nerve fibers.
topical application
local infiltration.

66

A form off local anesthesia in which an anesthetic agent is injected around nerves, so that the area supplied by these nerves is anesthetized?

regional anesthesia
spinal, epidural
peripheral nerve blocks

patient is awake and aware

67

Spinal Anesthesia

nerve block
anesthetic into subarachnoid space lumbar level (L4 and L5)
anesthesia of the lower extremities, perineum, and lower abdomen.
side in knee to chest position for the lumbar puncture.
Position on back when injection has been made.

68

EBP shows that healthy patients are allowed clear fluids up to 2 to 3 hours prior to surgery. True or False

True

69

Benzodiazepines (versed, valium, Ativan) properties.

relieve anxiety
induce sleep
produces amnesia
no analgesic properties
metabolized by the liver
rapidly absorbed

when combined with opiates, increased the effect of the drug.
increase risk of respiratory depression.

70

Side effect of benzodiazepines (versed, valium, ativan)

CNS depression
respiratory depression
hypotension
bradycardia
drowsiness and ataxia
fatigue and confusion
weakness and dizziness

71

what is the reversal agent for benzodiazepines (versed, valium, Ativan)

Flumazenil (Romazicon)

72

Properties of Opioids (morphine, Demerol, Fentanyl)

analgesic and sedation

73

side effects of opioids (morphine, Demerol, Fentanyl)

respiratory depression
N/V
drowsiness
hypotension, orthostatic hypotension
bronchospasm in asthmatics
metabolized in the liver
excreted in the kidneys

74

what is the reversal agent for Opioids (morphine, Demerol, Fentanyl)

Naloxone (Narcan)

75

What are some properties of Histamine (H2) receptor antagonists (Tagamet, Pepcid, Zantac, Prilosec, Prevacid)

inhibit gastric acid secretion

Side effects: skin rash (hypersensitivity)
decreased RBC's, WBC's platelet synthesis

Nursing care: do not administer at same time as antacids
give oral preparation with meals.

76

Antiemetics (Reglan, Droperidol, Zofran, Phenergan)

Properties: Alleviate nausea and vomiting
Side Effects: drowsiness (CNS depression)
hypotension
dry mouth (anticholinergic effect)
blurred vision (dilation from anticholinergic)
in coordination

77

Anticholinergics (Atropine, Glycopyrolate, scopolamine)

Properties: decrease salivation, prevents bradycardia, inhibit smooth muscle contraction in GI tract.

Side Effects: decreased parasympathetic stimulation
decreased peristalsis, decreased salvation, urinary retention, CNS disturbances.

78

What will happen if a patient aspirates vomitus?

asthma-like attach
severe bronchial spasms
wheezing
pneumonitis
pulmonary edema
extreme hypoxia

79

what should the RN do if gagging occurs during surgery/

turn pt to the side
lower head of table or bed
provide a basin
might have to suction

80

what is given to increase gastric fluid PH?

Bicitra

81

what medications can be given to decrease gastric acid production?

histamine (h2) receptor antagonist- cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid).

82

what is the most common cause of anaphylaxis?

medications

RN must be aware of the type and method of anesthesia used as well as the specific agents.

83

Intervention for hypoxia and other respiratory complications

vigilant monitoring of O2 status.
peripheral perfusion
pulse oximetry values

84

Hypothermia

Indicated by a core body temperature that is lower than normal (36.6C (98.0F) or less).

85

what is the goal of intervention if hypothermia occurs?

minimize or reverse the physiologic process.

86

what are some possible cause of temperature changes 12 hr after surgery?

effects of anesthesia medication
low temp in OR
body heat loss during surgical exposure (open body wounds or cavities)
infusion of cold fluids
inhalation of cold gases
decrease muscle activity
age

87

what are some possible causes of temperature first 24-48 hr after surgery?

inflammatory responses to surgical stress
lung congestion
atelectasis

88

what are some possible cause of temperature elevation above 100 F (37.7) third/later after surgery?

wound infection
urinary infection
respiratory infection
phlebitis

89

On what post-op day would an RN expect to see an elevated temp related to a wound infection?

3 days

90

wound infection is often accompanied by?

fever spiking in afternoon and near-normal in the morning .

91

intermittent high temp with shaking chills and diaphoresis indicates?

Septicemia

92

Nursing assessment for pts with altered temperature

frequent temperature
observe for early signs of inflammation and infection

93

what are some nursing implementations for pts with altered temperature after surgery?

encourage airway clearance
chest X-ray
culture if infection is suspected
check order for antipyretics (temp 101.5)
body cooling of temp over 103

94

conscious sedation

drug induced depress of consciousness
patient maintains own airway but yet achieves pain control.
combination of anxiolytic (midazolam, versed) and Opioid (fentanyl).

provides analgesia relieves anxiety and or provides amnesia.

95

Patients at risk for malignant hyperthermia

strong and bulky muscles
family genetic mutations
first degree relatives of persons who have been diagnosed or suspected.
an unexplained death of a family member during surgery that was accompanied by febrile response.

96

A rare inherited muscle disorder that is chemically induced by anesthetic agents such as halothane, enflurane and muscle relaxants succinylcholine?

Malignant Hyperthermia (MH)

97

When does malignant hyperthermia occurs?

anytime from anesthesia induction to 24 hours post-op
it can result in death.

98

what is the earliest sign of malignant hyperthermia

Tachycardia (heart rate >150)

99

what can trigger malignant hyperthermia?

trauma
heat
stress
medications (epinephrine, atropine, digitalis)

100

what is the immediate response when pts experience malignant hypperthermia

discontinuation of the triggering agent and hyperventilation (100% O2).
Dantrolene sodium 2.5mg/kg=20 vials by 2 RNs via 2 IV lines.
Procainamide for arrhythmias.
IV glucose and insulin, calcium chloride for hyperkalemia
sodium bicarbonate for metabolic acidosis based upon ABGs.
Reduce temp (ice bags to armpits, groin).
hypothermia blanket
diuretics to clear filtered myoglobin in urine.
Increase fluid to maintain urinary output.

101

Treatment of MH on the floor

call for help
start icing patient
start second IV line
Administer O2 via non-rebreather mask
Expect patient to be transferred to ICU

102

S&S of malignant hyperthermia

rapid onset of a high temp (110 F and can rise 1-2 degrees q.5min
tetanus
muscle rigidity (jaw tightening)
elevated CO2
Tachycardia >150
Tachypnea
decreased cardiac output (CO)
Oliguria ( low urine output 300-500ml/day)
Dark brown urine
hypotension

103

what happens in malignant hyperthermia?

A biochemical chain reaction results in a sudden calcium rise in skeletal muscle cells.

104

Bloodless surgery

uses all available alternatives to decrease blood loss.
hemodilution
reduce temp (cold temp in OR causes increase platelet aggregation.
Re-use pt's blood (cell saver)
Maximize blood production (FeSO4, EPO, Vit K)
use other blood components
plasma proteins, fibrinogen

105

General anesthesia is used for?

procedures requiring ..
significant skeletal muscle relaxation, long periods
awkward positions
extremely anxious patients

106

Stage 1 of general anesthesia

Beginning anesthesia
pt feels warmth, dizziness and detachment
ringing, roaring, buzzing in the ears
inability to move extremities easily.

RN, unnecessary noise and motion should be avoided.

107

Stage 2 of general anesthesia

Excitement
struggling, shouting, talking, singing, laughing or crying
uncontrolled movement.

RN: pt should be touch only for restrained purposes.

108

stage 3 of general anesthesia

pt is unconscious
lies quietly on the table
with proper administration of anesthetic, may be maintained for hours.

109

Stage 4 of general anesthesia

medullary depression
too much anesthesia has been administered
cyanosis develops = rapid death.

Tx: D/C immediately, initiate respiratory and circulatory support

110

what are the phases of general anesthesia

induction
maintenance
Emersion

111

what are the purpose of general anesthesia

Loss of sensation
absence of pain
amnesia
LOC
muscle relaxation

112

Implications for general anesthesia recovery

ABCs
airway
breathing
circulation

113

What are some ways local anesthesia can be administer

Topically
intracutaneously
subcutaneously

114

Local Anesthesia

autonomic nervous system blockade
anesthesia in area affected
skeletal muscle paralysis in area of affected nerve
little systemic absorption
rapid recovery
little residual "hangover"

115

what are some possible discomfort for local anesthesia?

hypotension
seizures

116

purpose for regional anesthesia

Loss of sensation
absence of pain (in body region)
pt remains awake

117

spinal regional anesthesia

sensation loss and paralysis from umbilicus to toes
into subarachnoid space (CSF) below L2

Precautions: have HOB flat

118

Epidural regional anesthesia

sensation loss = waist to thighs
injection into epidural space
does not enter CSF
No LOC

119

identify some factors that influence pain tolerance

energy level
stress level
culture background
meaning of pain to patient

120

Nursing management to prevent fluid volume excess in patient with existing cardiovascular or renal disease, advance age and stress from surgery.

assessing the patency of the IV lines
ensuring the correct fluids are administered at the prescribed rate
recording I&Os.
reporting urinary catheter rate of less than 30mL/hour
if output of patient voiding is less than 240 mL/8hr
Monitor electrolyte and H&H levels

121

decrease H&H levels after surgery can indicate?

blood loss
dilution of circulating volume by IV fluids

122

"third space" associated with surgery fluid usually returns to the intravascular space by?

postop day(POD) 2 or 3

123

what can the RN do to stimulate circulation thereby preventing DVT?

leg exercises
frequent position changes to stimulate circulation

124

Patient teaching to prevent DVT

avoid positions that compromise venous return
raising the bed's knee gatch
placing a pillow under the knees
sitting for long periods
dangling the legs with pressure at the back of the knees

125

what should the RN be concerned about when a patient gets out of bed for the first time after surgery?

orthostatic hypotension
when patient change from supine to a standing position.
changes in circulating blood volume and bed rest
S&S: increase in HR with 15 mm Hg in decrease in systolic pressure or 10 mm Hg in diastolic pressure.
weakness, dizziness, leg buckling, visual blurring.

126

what are the healing phases of surgical wound healing?

inflammatory
proliferative
maturation

127

why is nausea and vomiting after anesthesia common in obese people

fat cells at as reservoirs for the anesthetic.

128

nausea and vomiting after anesthesia are most common in

obese patient
women
patients who have undergone lengthy surgical procedures

129

what are some potential postoperative complications that occur in patients undergoing intestinal or abdominal surgery

paralytic ileus
intestinal obstruction

130

if the abdomen is not distended and bowel sounds are normal and patient does not have a bowel movement postop day 2 or 3 what should the nurse do?

notify the Dr. for laxative to be given that evening

131

interventions to promote bowel elimination after surgery

early ambulation
dietary intake
hydration
stool softener (if prescribed)

132

when are patients expected to void after surgery

8 hours

133

what types of surgeries place a patient at risk for urinal retention

hip
abdominal
pelvic

134

why are straight intermittent catheterization preferred over indwelling?

risk of infection is higher with indwelling catheter

135

what should be done when a patient is unable to void 8 hours postop and bladder scan verifies distention

straight catheterization which is removed after the bladder is emptied.

136

how many mL of urine in residual volume is consider diagnostic urinary retention

100 mL

137

what other tools can the RN use to assess residual urine when a bladder scan is not available.

palpating the suprapubic area for distention or tenderness after the patient urinates

138

what are some S&S of postop myocardial ischemia/infarction (MI)

dyspnea
hypotension
atypical pain ( fatigue, sweating, lightheadedness, difficult breathing

139

signs of angina (heart attack)

pressure
squeezing pain in left section of the chest
radiates to left shoulder, arm, jaw and back.

140

Nursing assessment for urinary retention

examined for quantity and quality
note color, amount, consistency and order
assess indwelling catheters for patency
urine output should be at least 0.5 ml/kg/hr

141

what are some expected outcomes for urinary retention

voids at least 180 ml within 6 hr (depending of Dr order and policy)
clear yellow urine
normal urine odor
no urgency, frequency, dysuria
no S&S of distention
no fever, chills
no WBCs, bacteria in urine