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1

As part of his preoperative care, the surgeon has requested that Joseph shower using an antimicrobial pre-op wash solution. How would you explain the rationale behind these aspects of preoperative care to Joseph? Try to keep the explanation in lay-person terms.

>It reduces the bacterial count on the skin therefore less risk of infection postoperative.
>Before surgery, you can play an important role in your own health. Because skin is not sterile, we need to be sure that your skin is as clean as possible. Your skin will be prepared with antiseptic before your surgery, but the antiseptic can work better if your skin is clean.

2

Whilst checking Joseph’s paperwork for theatre, you see that his consent still needs to be signed.
What action do you take? How do you know if this is a valid consent? What are the different ways that
consent is given?

Ensure valid consent
Ask the client what they understand to be involved
Recognise the patients may be overwhelmed with information and provide brochures, diagrams, videos
Provide time for questions
Restate or repeat information
Valid Consent Consent given:
–freely & voluntarily given
–properly informed
–person giving the consent has the legal capacity to give such a consent
–relates only to the specific procedure consented
Informed consent
–Nature
–What is the operation
–How will it be performed
–Expectation of pre, intra and post-operative progress
–Consequences
–Outcomes? Success?
–Risks –in broad terms to meet consent requirements
–Alternatives to surgery
Ways consent can be given
Implies
Verbally
In writing

3

You also notice that Joseph’s admission paperwork is incomplete. In particular, the discharge planning section is yet to be filled in and discussed with the patient, i.e. his transition of care processes have not been completely processed. What is your responsibility as his nurse in planning for his discharge?

Communication
Co-ordinating discharge planning (transition of care)
Anticipation & prevention of complications - monitoring physiological state (observations)
Nutrition & hydration
Personal hygiene & dressing needs
Elimination
Pressure area care
Positioning & movement
Medication

4

What are the main areas of breakdown that can cause an adverse event related to transitions of care?

It is about care co-ordination.
Planning from admission to transfer of care in NSW public hospitals includes a number of steps and is now mandatory:
> Pre-admission/admission ( information gathered can include answers to the following questions:
does the patient live alone or/and have caring responsibilities for someone else, has the patient used community services, is the patient at risk of falls and have their medications changed recently? )
>MDT review
>Estimated date of discharge
>Referrals & liaison for patient transfer of care
> Transfer of care out of hospital (checklist)
>Transfer to home/community / GP

5

What are the main areas of breakdown that can cause an adverse event related to transitions of care?

> Communication – handovers are not timely or effective, reliance on secondary sources of information
> Patient education – patients and families/carers are given different or conflicting recommendations with confusing medication regimes.
> Accountability – different expections of senders and receivers of information.

6

Joseph has medications to be administered at 0800hrs. When examining his medication order, how do you know that it is indeed a valid order, prior to dispensing the medications and doing your three checks? What are ‘the 5 rights’ of medication administration, and when do you perform the 3 checks?

Valid Order -Prior to administering a medication you must check if the medication order meets the
legal requirements:
o Written or printed in ink
o Signed by prescriber
o Full name of recipient (medical record number), medication, dosage, route and frequency
o Instructions for adequate use
o Detail the number of times the drug may be dispensed or the time between repeated
administrations
Accountability and responsibility
Check allergies
Ensure documentation
Safe medication administration
-1. Right medication
-2. Right dose
-3. Right patient
-4. Right route
-5. Right time/frequency
Prior to administering any medication, it is essential that you follow the 5 rights of medication
administration before the medication is given to the patient
The 5 rights are checked 3 times
-1st time: prior to dispensing the medication
-2nd time: after dispensing the medication
-3rd time: immediately prior to administering medication to patient

7

What does the term ‘Time Out’ mean in the intraoperative environment

> suspension of activity immediately before commencing a procedure to undertake final verification

8

What types of oral medications cannot be crushed prior to administration?

> Modified release medicines -Frequently identifiable by two letters such as m/r, LA, SA, CR, XL or SR at the end of the name. Words such as "Retard" or "Slow" in the title sometimes used instead. For medicine designed to be released over prolonged period, the mechanism for slowing absorption may be damaged if the medication is manipulated. Disruption of a modified release coating may result in the patient experiencing a period where the systemic drug concentration is too high, causing toxicity or an overdose, followed by period where the drug concentration is too low to be therapeutically active.

> Enteric coated medicines
Usually identifiable by the two letters EN or EC at the end of the name. Medicine designed not to be released in the stomach. Disruption of the enteric coating may increase the likelihood of stomach irritation or damage, reduced potency of the drug due to acid degradation of the active ingredient, or release of the drug at the wrong site of action.

> Film or sugar-coated medicines
Disruption of the film or sugar coating on drugs may result in rapid degradation of the active ingredient, poor tasting medicines which may be more difficult to swallow. They may also cause skin irritation in patients or carers.

> Hormonal cytoxic or steroidal medicines
If there are swallowing difficulties like dysphagia, a risk assessment form requires completion if drug is to be crushed prior to administration. If the tablet is crushed, the drug may go into the air and the dose inadvertently received by the administrating nurse
or carer.

9

Joseph has an on-call pre-medication charted before going to theatre. The Anaesthetist calls the ward and you are to administer his Temazepam 10mg PO STAT. The nurse in charge informs you that this is an ‘S4 appendix D medication’. What does this mean? What implications will this have for safe medication administration?

Schedule 4 Appendix D and Schedule 8 are defined as ‘accountable medications’
Schedule 4 Appendix D (S4D) drugs are those Schedule 4 drugs that are liable to abuse and include benzodiazepines, ephedrine and anabolic steroids.
S4D drugs must be stored apart from all other drugs (except Schedule 8 drugs) in a separate sturdy cupboard, preferably a metal safe, which is securely attached to a wall or to the floor, and kept locked when not in immediate use

10

You have transferred Joseph to the pre-op area and handed over to the nurse there. Regarding intraoperative safety, discuss the stages of the WHO surgical safety checklist

The checklist identifies three phases of an operation, each corresponding to a specific period in the normal flow of work: Before the induction of anaesthesia (“sign in”), before the incision of the skin (“time out”) and before the patient leaves the operating room (“sign out”).- see question 7 on the exam answers document

11

What are the systemic considerations in relation to respiratory, cardiac and musculoskeletal systems that the operating room nurse needs to be aware of throughout Joseph’s operation?

Respiratory
a. Positioning may impede
b. Hindered diaphragmatic movements
c. Pre-existing resp conditions
d. Smokers, obese, pregnancy
Cardiovascular
e. Anaesthetic agents
f. Pooling of blood
g. Pregnancy risk
h. Occlusion or pressure
i. VTE
Musculoskeletal
j. Lack of protective mechanisms
k. Overstretched, twisted, strained or hyperextension of limbs
l. Osteoporotic or previous joint surgery pts
m. Maintenance of body alignment

12

Joseph returns to the ward from recovery at 1600hrs. What assessments will you need to perform in this postoperative period, both generally for any post-operative patient, and specifically for Joseph and the type of surgery he has just had?

- Airway: Patent/compromised
- Breathing: rate, depth, SpO2
blood gas analysis, auscultation of chest
– Circulation: HR, BP, capillary refill, pallor, urination, any signs of bleeding,
– Disability: neurological signs, Glasgow Coma Scale, AVPU
– Exposure: check patient head to toe
– Fluids: fluid regime/balance
– Glucose
Check cardiac monitor, chest drain, wound intact

13

As part of your initial A-G assessment, you observe that Joseph has oxygen therapy in progress at 2L/min via nasal prongs. Why does he require oxygen therapy? What are the advantages and disadvantages of administering oxygen therapy via nasal prongs?

(a) Nasal cannula:
It is ideal for long term oxygen therapy. It does not increase dead space and there is no rebreathing.
Flow rate of 2-4 L/min is recommended as higher flow rate (>5L/min) can result in discomfort of the patient.
Advantages
1. Easy to use
2. Low-flow oxygen administration
3. Less restrictive than face mask
4. No increase in dead space
5. More tolerable than oxygen mask
6. Allow speech and eating/drinking
Disadvantages
1. Drying and irritation of nasal mucosa
2. Chance of nasal bleeding
3. Sores around the external nares in long term use

14

What is an advantage of using the venturi mask for oxygen therapy?

Venturimasks are colour coded and it states the flow of oxygen in litres per minute required to deliver a specific inspired oxygen concentration. Holes on the Venturi device allow entrainment of room air by the Venturi principle. These holes also flush expired gas.
Advantages of using Ventimask include very precise measurement of delivered oxygen and no rebreathing. However, the mask is hot and may irritate the skin. Oxygen concentration may lower by kinking the tubing.

15

Joseph returns to the ward with a morphine PCA in progress. Joseph complains that he is in “a lot of pain in my right knee”. He falls asleep intermittently whilst you are still performing your postoperative assessment. How would you educate Joseph about his PCA and how it works? What specific assessments must you perform when a patient has a PCA in progress? How do you assess sedation?

In PCA, a computerized pump called the patient-controlled analgesia pump, which contains a syringe of pain medication as prescribed by a doctor, is connected directly to a patient's intravenous (IV) line. In some cases, the pump is set to deliver a small, constant flow of pain medication.
> OBS recorded hourly for 6 hours
> PCA pump settings checked each shift
> no other sedatives to be adminstered
> Assessments include: pain score, sedation (0-3), RR, Nausea, PCA delivery (total dose, total attempts, total successful attempts)

16

. What are the potential complications that may occur in a postoperative patient? What can you do to prevent these from happening to Joseph?

General Complications
Atelectasis & pneumonia see below
DVT
Syncope
Low UO
Decreased peristalsis
Surgical wounds and pain.
(prevention on the document)

17

What is atelectasis and explain how it can occur in a post-op patient.

Ateles and ektasis: "incomplete" "expansion or extension"
Diminished volume affect part or all of the lung
Common post-operative pulmonary complication
especially upper abdominal and thoracic surgery
Usually bibasal and segmental
Pathophysiology:
a. decreased diaphragmatic expansion
b. diminished surfactant activity
Clinical manifestations:
can be minor to severe symptoms, dependent on magnitude of lung collapse
cough and dyspnoea common but can also cause hypoxaemia, tachycardia, hypotension or pneumonia
Diagnosis:
Chest X-ray, lung sounds, ABG, symptoms
› Treatment:
- Primary treatment option – early mobilisation and incentive spirometry
- Chest physiotherapy: postural drainage, chest wall percussion and vibration
- Coughing, nebulised bronchodilators
- Positive pressure ventilation
- Oxygen and antibiotics

18

Regarding wound healing, what are the four elements of wound management?

The four stages of wound management are
1. Define the aetiology
2. Identify and control factors affecting wound healing
3. Select the appropriate wound dressing
4. Maintain wound healing
> Aetiology
o Vascular – chronic venous insufficiency, arterial, mixed, vasculitis
o Mechanical – pressure, friction, shear, trauma, neuropathic, surgical and infection
> Identify and control factors affecting wound healing
o Intrinsic
> Health status, age, body build/obesity, immune function, port nutritional status,
PVD, diabetes
o Extrinsic
> Drying/ maceration, wound temperature, mechanical stress, friction and
shearing force, chemical stress, foreign bodies and infection
> Select the appropriate wound dressing
> Maintain wound healing
Examination / Assessment
History

19

State 2 types of wound healing

1. Primary Intention – primary healing – wound edges are primarily and anatomically accurately opposed and closed by sutures, and healing proceeds without complications - uncomplicated
surgical wound
2. Secondary intention – usually wounds involving loss of tissue, heal more slowly because of the volume of connective tissue to fill the defect – e.g. pressure ulcer, vascular ulcers.

20

What are the characteristics of a clean surgical wound?

Clean – elective, not emergency, non-traumatic, primarily closed. No acute inflammation, no breakin technique – respiratory, gastrointestinal, biliary and genitourinary tracts not entered.

21

It is Day 2 post-op, and after the surgical team has reviewed Joseph, there is a written order in the progress notes for his dressing to be changed today. You will perform this simple, non-complex dressing using an aseptic non-touch technique. Describe the term ANTT and asepsis

Aseptic Technique: the infection control method and precautions taken during invasive clinical procedures to prevent the transfer of microorganisms from the health care worker, procedure equipment or the immediate environment to the patient. The term aseptic means free from pathogenic microorganisms (Merriam-Webster, 2010) NonTouch technique: not touching key parts directly or indirectly Sterile technique: free from all living microrganisms (APIC,2009)

22

Why is the education to be provided to Joseph and his family an essential component of his care?

> it enables family to actively participate in their healthcare and any treatment they may be receiving
> to provide timely and effective patient education requires health professionals to be prepared and knowledgable about the patient education process
> effective education: increases use of self management strategies, improved health related quality of life, improved patient outcomes, increase satisfaction

23

What general content or under what circumstances might patient education be given?

> Providing information about ...
> Giving guidance / instruction on ...
> Demonstration of a skill ... When:
> Before, during,following a procedure
> At admission, discharge,transfer
> Planned or opportunistic
> Initiated by you or the patient

24

What general content or under what circumstances might patient education

> Providing information about ...
> Giving guidance / instruction on ...
> Demonstration of a skill ... When:
> Before, during, following a procedure
> At admission, discharge, transfer
> Planned or opportunistic
> Initiated by you or the patient