exam 1 (periop plus) Flashcards by Callie Wanek

consent needed for

Invasive procedures-biopsy
Procedures requiring sedation
Nonsurgical-arteriography
Radiation
Blood administration*

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Physician documents patient’s capacity to make medical decisions (if can’t, POA signs)
Surgeon discusses treatment options and diagnosis
Patient demonstrates understanding of disclosed information (write in own words)
Patient signs consent

4 basic elements of preop informed consent

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Nutritional status: BMI (18.5-24.9), Obese = cardiac risk Malnutrition = poor wound healing; correct fluid/electrolyte imbalance

Drugs/Alcohol: alcoholic=nutritional deficiencies; withdrawl 48-72 hrs

Respiratory status: ventilator, acute resp. infection (postpone), smokers

Cardiovascular status: controlled BP, ensure electrolytes are optimized

Hepatic/Renal function: optimal function so meds can be cleared

Blood status: cross match

preop health ass.

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Endocrine function: diabeteic?–> wound healing/BS; corticosteroid use=risk for adrenal insufficiency (weakness, hyperkalemia, low BS, fatigue)

Immune function: allergies/sensitivity to meds

Medication use
Including preop medications: Blood thinners (aspirin), OTC

Psychosocial: anxiety, distress

Spiritual/Cultural Beliefs

Genetic disorders: *malignant hyperthermia,

preop health ass. continued

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Begins when patient is transported to OR table and ends with PACU
Patient safety
Aseptic environment
Proper function of equipment
Provide surgeon with instruments
Documentation
Emotional support
Positioning

Intraoperative nursing

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Manages OR conditions (check temp, cleanliness of OR, safe, supplies)
Assess for signs of injury (implement interventions)
Verifies consent
Coordinates team
Monitors for aseptic technique
Fire safety precautions
Surgical counts (2nd verification, documentation)

intraoperative

Circulating nurse

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Performs surgical hand scrub
Sets up sterile tables
Prepares special equipment
Anticipates the instruments and supplies that will be required (sponges)
Counts all needles, sponges and instruments along with the nurse

Intraop scrub person

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Most people call it “First Assist” or “Assisting”
Handles tissue
Suturing
Maintains hemostasis

Can be a scrub person, RN, NP, PA, student, or even another surgeon

intraop

registered nurse first assistant

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Exposure to blood/body fluids-double gloving, goggles, face shield
Latex-must identify pts. with these allergies, need a latex allergy cart and maintenance of precautions. There are latex free products
Laser risks-When the laser is in use, there must be a sign posted to alert personnel.
Foreign objects-left in people during surgery. Risk increases when surgery is emergent, when there is a complication and when the patient has a high BMI.

intraop care safety

top priority: risk for injury and infection

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General
-Not arouseable
-*Can’t maintain airway
-Inhaled or IV-cross the blood-brain barrier
Inhaled
-Common
-Good for easy access/loss of peripheral access
-shut off/wake up & cough/deep breath
Intravenous
-alone or with inhaled sedation
-Works fast, wears off fast

general anesthesia

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Opioids
-Morphine-premedication
-Fentanyl-epidural infusions, post-operative pain
Muscle Relaxants
-Vecuronium-intubation
-body fights back and makes surgery worse without this
IV anesthesia
-Etomidate-induction (cardio version: shock <3 off/on)
-Propofol-Induction & maintenance
-Midazolam-hypnotic-used as adjunct or induction

general anesthesia IV

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-Blocks nerves in peripheral and central nervous system
-Can be used alone or with other types of anesthesia
-Administered by surgeon provider to specific areas-monitored by nurse (toxicity)
Blocks transmission of pain
Nurse needs to keep environment quiet for therapeutic reasons

regional anesthesia

Local

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Extensive conduction nerve block-when local anesthesia is introduced into the subarachnoid space at lumbar level

Affects lower extremities, perineum, lower abdomen
Rapid onset
If reaches respiratory muscles-respiratory paralysis
Nausea, vomiting, pain, headache
*Headache-quiet environment, lay flat increase hydration

spinal

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Conduction block-local anesthesia into epidural space
Differs from spinal due to site of injection and the higher anesthetic used
Epidural doses are higher than spinal
Less hypotension, less hemodynamic changes
*Headache-worse than spinal headache
If punctures the dura-anesthesia will flow upward and can have hypotension and negative respiratory affects.. need to
-Support airway
-IV fluids
-Vasopressors for blood pressure support
doses are higher: anesthetic doesn’t make direct contact with spinal cord/nerve roots

regional anesthesia - epidural

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no spinal or epidermal if..

scoliosis, osteoporosis, osteoarthritis, obese

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Cause:
leakage ofspinalfluid through a puncture hole in the tough membrane (dura mater) that surrounds thespinalcord. This leakage decreases the pressure exerted by thespinalfluid on the brain andspinalcord, which leads to aheadache.
Symptoms:
lowerbackpain,nausea,vomiting,vertigoand tinnitus
Treatment:
May resolve on their own (within a few days)
Blood patch
Keep flat and hydrate

spinal headaches

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Blocks the brachial plexus, lumbar plexus and specific peripheral nerves
Advantages
-reduced physiological stress
-avoidance of airway manipulation
-avoidance of complications of endotracheal intubation and all side effects from general anesthesia

regional anesthesia

peripheral nerve block

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Moderate sedation-sedation by non anesthesiologists

Administered by anesthesiologist or CRNA

IV administration of sedatives/analgesics to reduce anxiety and control pain

Goal-depress LOC to a moderate level to enable procedures to be complete

Patient maintains airway, respond to verbal stimuli

moderate sedation/monitored anesthesia care (MAC)

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Can be administered by specially trained nurse-differs in each state

Never leave patient alone*

Short 1/2 life; take deep breaths until OK

Monitor EKG, oxygen status, vital signs, LOC

moderate sedation

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Begins when admitted to post anesthesia care unit and ends with follow up evaluation at home

Nursing responsibilities
-Maintain patient’s airway (breathing on own, can lift legs)
-Monitor vital signs (increase due to pain)
-Assess effects of anesthetic agents
-Assess patient for complications
-Provide comfort (splint, reposition, talk)
Watch for malignant hyperthermia

postop phase

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Phase 1-immediately after surgery
Phase 2- prepared for discharge or admission to hospital
PACU nurse provides care until 
-Baseline cognition
-Stable vital signs
-No evidence of complications

post anesthesia care unit PACU

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Assess CSM-circulation, sensory, mobility
Know pt history
Patent airway-maintain pulmonary ventilation and prevent hypoxemia and hypercapnia….nurse checks oxygen and assesse resp. rate and depth, ease of respirations, O2 sats, breath sounds

Hypotension/shock-hypotension usually from blood loss and fluid loss. Pt’s 3rd space their fluids-intravascularly dry. Shock from hypovolemia and decreased intravascular volume.
Hemorrhage- Can be immediate or post op. Pt becomes restless, skin cold, pale, tachycardia, RR rapid and deep. CO decreases.
Hypertension/arrhythmias-sympathetic nervous system stimulation from pain, hypoxia or bladder distention. Arrhythmias-electrolyte imbalance, altered resp function, pain, hypothermia

PACU nursing responsibilities

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Relieve pain & anxiety-IV opioids-watch for resp depression
Controlling n/v-very common. Administer anti-emetics
Prepare for discharge-remain in the pacu until fully recovered from anesthesia.

Aldrete score-scoring system to determine the pt’s readiness for transfer from the pacu. Assess pt q15 min and total score is calculated and recorded.

PACU nursing responsibilities

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Hypothermia-anesthesia makes pt susceptible to hypothermia. SS reported to MD. Keep room warm as possible, warm blankets, oxygen, hydration, nutrition. Risk is greater in elderly.
N/V-very common after anesthesia due to accumulation of fluid in stomach, inflation of stomach, ingestion of fluids too soon. May need NG tube and anti-emetics are common. The sooner they can eat and drink the sooner peristalsis will occur. If no bowel sounds, can’t give anything by mouth—ileus and intestinal obstruction may occur. Watch for flatus.
Urinary retention-pt can’t feel their bladder as full due to anesthesia-if patient hasn’t voided in 8 hrs. need to bladder scan and may need to straight cath. Watch I&O-even if they have voided.

A/E of surgery anesthesia

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Cardiac complications-mortality rate for surgical pts. who experience a MI after non-cardiac surgery is 15-25%. May present with dyspnea, hypotension, atypical pain. DVT/PE-due to blood hypercoagulability after surgery, dehydration, decreased CO and bed rest. Pain in calf sign of dvt. Pulmonary embolism from a DVT, sudden shortness of breath, tachypnea, tachycardia, chest pain, apprehension

potential complications

Infection  surgical wounds classified (see pg. 144 Pellico) Prophylactic care pre-op Teaching-most will go home prior to diagnosis of wound infection May need surgical intervention (incision and drainage) Hematoma-concealed bleeding under skin of surgical site. Usually stops spontaneously but can cause clot formation within the wound and will delay healing. Surgical site infections-increase length of stay, cost and complications. See pg. 144 in Pellico for different classifications of wound. Wound dehiscence-disruption of surgical incision or wound-evisceration-protrusion of wound contents-usually due to sutures weakening, infection, distention or coughing.

potential complications

Hemoglbin

female: 12-16 g/dL male: 13-18 g/dL

Hematocrit

female: 40-48% male: 42-50%

sodium level

135-145 mEq/L

postassium

3.5-5 mEq/L

magnesium

1.32-2.1 mEq/L

calcium

8.5-10.5 mEq/L

WBC

5,000-10,000

total cholesterol

<200 mg/dL

HDL

>40 mg/dL

LDL

<160 mg/dL

``` neutrophins lymphocytes monocytes eosinophils basophils ```

2400-8000

glucose

70-120 fasting

hgbA1C

4-6%

urine specific gravity

1.015-1.025

``` Edema Ecchymosis Tenderness Abnormal joint movement Pain ```

manifestation of sprain, strain or contusion

Circulation- color (appropriate to race), temp (warm to touch, not hot), pulses (feel blood supply), cap refil (<2 secs) Sensation- pain (nerve damage first and you get sensation of numbness and tingling), paresthesia, pain, absence of feeling Motion- weakness, paralysis Is there nerve, blood supply damage, or injury to bone? Can tell through CSM

CSM | Circulation, Sensation, Motion

Bones forming joint are no longer aligned Biggest risk are ball and socket joints -Shoulder Hip -Degree of ROM will help you decide degree of injury --Have them abduct, adduct, swirl Literally out of the joint Effusion: fluid in joint sack Subluxation: incomplete joint dislocation (slippage of joint) Avascular necrosis: bad complication; lost blood supply to bone Ischemia, pain, death of tissue in bone

Joint dislocation

Immobilization Reduction: reduce injury Analgesics Muscle relaxants: muscle tension can make more difficult Anesthesia Monitor neuro status: sensation, numbness/tingling, or any type of nerve damage you may have Gentle ROM: keep moving so you don’t have disuse

treatment of joint dislocation

Complete: all the way through bone Incomplete: ½ way through bone Oblique: splintered more diagonally Comminuted: nasty; splintered into bunch of pieces; may have bone pieces everywhere Closed: no puncture through skin Open: bone sticks out of skin Colle’s: wrist facture; usually in old women Stress: weight bearing load; continually put pressure on and overtime the bone breaks down Compression: similar ^; bone grinds into self; usually in vertabre or spin; press into themselves and factures it; occurs in osteoporosis

fracture types

Pain Loss of function: can you move it? Deformity: bending one way it’s not supposed to Shortening: limb looks shorter than other Crepitus: bone rubbing on bone; grinding/clicking sound Swelling/edema 20 mins after Discoloration

S/S of fracture | diagnose with symptoms, physical signs and xray

Immobilize: splints, sling, traction

treatment of fractures

1. Pain 2. Poikilothermia (cold limb) 3. Pallor 4. Paresthesia 5. Pulselessness

monitor for 5 P's of neurovascular impairment in fractures

Education regarding treatment -What to expect, normal/not normal/ S/S of infection Pain management Improved mobility ``` Monitor s/s of shock: Thirst Anxiety ^ HR Weak pulse Decrease Blood pressure Cool/clammy skin due to blood not getting to Decrease Urine output due to lack of vascular space Rapid/shallow respirations ```

nursing care for fractures

Immobilized-assess q 4 hours -Trapeze: shift/move and still keep immobilized -Abduction bar: bar inside of legs and you have to keep legs that way -Spica cast: pelvic fractures: cast over thighs over waste; could be entire body -DVT risk: no movement = higher risk for clots, especially in calves Assess for 5 P’s Assess circulation/edema Assess nerve function

How to maintain neuro function in fractures

Fat may be released from bone when fractured Hypoxia, tachypnea, tachycardia, pyrexia, resp. distress, dyspnea, crackles, and wheezes, mottle of skin Can lead to death ``` Treatment X Ray for DX Respiratory support -Suppress immune system with steroids -Vent -PEEP -Continuous O2 monitoring IV corticosteroids ```

potential complications of fractures

Delayed union, malunion (doesn’t heal correctly), & Nonunion (hasn’t fused at all) ``` Causes: Smoking Steroid use: inhibits immune system and you need that to heal bone Infection Poor reduction Cancer ``` Treatment of nonunion Internal fixation Bone graft Electrical bone stimulation: stirs up cells to make them fuse

potential complication of fracture

Symptom of DVT and PE | Also potential complication of fracture

``` Sudden SOB Restlessness Increase respiration tachycardia chest pain low grade fever ```

Treatment: 1st. Stabalize pelvic 2. Compress bleeding vessels Monitor for injuries to bladder/intestinal bleeding, bone shards (can puncture bladder, pneumnothorax, organs)

pelvic fracture

Pain: med, traction, elevation, positioning Neurovascular complications -Assessment q 2-4 hours for pules, color, cap refill, temp, sensation, & movement to check circulation DVT- teds, lovenox/heparin, SCD’s -Monitor for calf tenderness, swelling, warmth, fever, & malaise -Give lovenax or heparin Pulmonary complications-lung sounds, cough deep breathing, IS -Immediently SOB, tachycardia, restless

Common post op complications of hip fracture

Heart failure -Monitor for signs and symptom -S/S: edema due to fluid back up, lung failure or crack, jugular vein distention Reduced GI motility -Monitor I/O, bowel sounds -Anesthesia can effect it: *the muscle relaxant puts GI muscle asleep* -If it’s not woken up: S/S absent bowel sounds -No GI motility: S/S distended abdomen, pain, nausea, post op ileus (obstruction – treat bowl obstruction with NG tube to suck everything out) Loss of bladder control -Incontinence or retention -Can put bladder asleep; slow to wake up -Functional incontinence -Retention: so much fluid in surgery and can be hard to clear out; -Check residual: palpate and bladder scan Infection -Monitor for signs and symptoms

Common post op complications of hip fracture 2

Acute sudden and severe decrease in blood flow to the tissue distal to an area w/ injury Can result in ischemic necrosis that compresses nerve and blood vessels Occurs when swelling occurs in extremality Swelling gets bigger, there’s no where for skin to stretch so compresses vessels and cuts off blood supply You will see pallor, discoloration, cold limb, pain from eschemia to tissue

Acute compartment syndrome | those in cast are higher risk

Chronic pain, aching, and tightness in muscle after stress or exercise Increased by 20% with stretching of the fascia and inflammation Crush caused by massive compression or crushing results in rhabdomyolysis (muscle breaks down/apart)and can lead to acute renal failure and MODS

Acute compartment syndrome

``` Paleness of limb Cool skin temp Delayed cap refill Weak pulsations Paresthesia Decreased sensation cast/tight and bandages decreased mobility ```

S/S compartment syndrome

MD removes cast if this is the cause Nurse holds extremity align Incompartmental pressure monitor Fasciotomy-surgical opening in skin and fascia

treatment compartment syndrome

Skin traction to lower leg | Immobilizes fracture of the proximal femur before surgery

Bucks extension

Goal is to maintain alignment of injured limb and counteract the shortening of the limb Applied directly to bone Used to treat fracture of femur, tibia, and cervical spine ``` maintain it: Check apparatus q hour -Weights hanging freely and knots tied securely Make sure patients body aligned Check skin Provide pin care -Avoid infections of bone and skin ```

Skeletal Traction

Changes in cartilage->soft tissue changes->hypertrophy of the bone->osteophyte formation Degenerative joint disease progressive deterioration in joint and vertebrae See if weight bearing joints (knee, hip, finger) Primary: idiopathic Secondary: trauma/disease

Osteoarthritis

``` Pain Stiffness Loss of movement and function Crepitus Joint enlargement/effusion (do joint enlargement/effusion) Worsen by activates, better with rest ``` ``` Diagnosis Clinical impression Labs: ESR or C-reactive protein Radiographic findings Arthroscopy: take fluid, fill knee, use camera to find problem ``` ``` Manage Heat/ice Rest joint protection weight reduction exercise CAM therapies Tylenol > NSAIDS > Cox2 > inhibitors >opioids ```

OA S/S diagnosis

Synovectomy: Excision of synovial membrane Arthrodesis: Fusion of joint Tenorrhaphy: Suturing of tendon Osteotomy: Remove bone or spurs to alter the weight distribution Arthroplasty: Joint replacement Lavage: Wash out knee, fill with fluid; Can provide pain relief for up to 6 months

Surgical Management of OA

``` Arthroplasty: joint replacement Arthrodesis: fusion of bone Joint wont function; we fused it together Arthroscopy: look with camera Osteotomy: clipping/removing bone ```

terms

``` Pre-op -Assess risk factors for complications -Neuro status of extremity -Teaching about abduction Postop -Avoid hip flexion of < 90 degrees -Avoid adduction, rotation, and excessive weight bearing -Avoid crossing legs -Monitor for s/s of dislocation of prosthesis -Call MD if dislocated ```

Post op total hip

``` Pain Dislocation Infection Skin integrity DVT’s Weight bearing ```

nursing assessment priorities for hip

``` Compression bandage Ice Neuro assessments Active flexion of foot Drain care CPM machine Knee immobilizer w/ activity Monitor for complications ```

post of nursing for total knee

exam 1 (periop plus) Flashcards

(69 cards)