Nursing management of the preoperative and intraoperative client

Question 1

perioperative phase

Answer 1

period of time from decision for surgery until patient is transferred into operating room

Question 2

intraoperative phase

Answer 2

period of time from when patient transferred into operating room to admission to postanesthesia care unit (PACU)

Question 3

postoperative phase

Answer 3

: period of time from when patient is admitted to PACU to follow-up evaluation in clinical setting or at home

Question 4

different purposes of surgery

Answer 4

diagnostic 
curative 
palliative 
cosmetic 
functional

Question 5

example of diagnostic surgical purpose

Answer 5

tumor that is growing or a growth that the doctors need to remove to be tested in a lab

Question 6

example of curative surgical purpose

Answer 6

pt came in for an emergent type of surgery –> appendix rupture

Question 7

example of palliative surgical purpose

Answer 7

removing pain condition rt tumor or another ailment causing a lot of distress for a pt

Question 8

example of cosmetic surgical purpose

Answer 8

improve the looks of things – grfts or closures

Question 9

example of functional surgical purpose

Answer 9

orthopedic elective procedures

ex: hip or knee surgeries

Question 10

outpatient

Answer 10

Majority (est. 85%) of surgeries have moved to outpatient basis

Question 11

inpatient

Answer 11

Reserved for complex surgical procedures and/or resource intensive recovery: 
Total joint procedures
Neurological 
Major vascular/cardiac surgery
Trauma

Question 12

outpatient surgery

Answer 12

aka: same day, short stay, ambulatory, 23 hour
Can be performed in hospitals or surgi-centers

Set criteria must be met to qualify for this type of surgery
‘healthy’ patients

Question 13

what criteria must a person meet for discharge (from outpatient)

Answer 13

Patient must meet certain criteria for discharge
drink
void
walk
will be admitted for overnight stay if complications develop

Question 14

advantages of outpatient surgery

Answer 14

Decreased psychological stress
Decreased exposure to nosocomial infections
Economic benefit
Less separation anxiety, especially for kids

Question 15

disadvantages/challenges to outpatient surgery

Answer 15

Difficult if live alone & can’t drive self home
Increased patient teaching needs d/t short amount of time
No skilled observations for complications
Pain control – oral meds and pain pumps

Question 16

nursing activities during the preoperative period 5/6!!

Answer 16

Establish baseline assessment of patient via preop interview
** NEED TO KNOW IF THEY TOOK MEDS THAT DAY OR HELD THEM**
- need to know if any tests were done before sx (ex COVID test, needs to come back before procedure)
Includes physical and emotional assessment

Anesthesia history

Allergies or genetic problems

Latex allergy

Necessary testing ordered and performed

Preparatory education about recovery from anesthesia and post operative care

Question 17

preadmission testing

Answer 17

Initial preoperative assessment

Teaching appropriate to patient’s needs

Involve family in interview

Complete preoperative diagnostic tests (ex bloodwork, CXR, EKGs, etc)

Verify understanding of surgeon-specific preop orders

Discuss, review advanced-directive document

Begin discharge planning by assessing patient postoperative transportation, care

Question 18

preadmission testing for scheduled out-patients

Answer 18

Usually minimum amount of testing ordered (d/t ‘healthy’ patient status and type of surgery)

Most likely will be performed when patient arrives to hospital on day of surgery

Question 19

preadmission testing for scheduled in patients

Answer 19

Usually performed several days to weeks prior to date of surgery

Urinalysis, blood work (CBC, lytes, H&H), Chest Xray, EKG > 40 years old, any other MD ordered test

Due to patient health status or type of surgery, these test results may need to be reviewed prior to proceeding with surgery

Question 20

Nursing roles/responsibilities

Answer 20

Assessment
Patient support
Patient preparation and SAFETY (make sure everything is prepped and ready to go for surgeon)
Patient education
 TEACHING-TEACHNG-      TEACHING!
Patient advocate

Question 21

preoperative nursing assessment includes

Answer 21

Nutritional & fluid balance assessment
Drug & alcohol usage
Respiratory status
Cardiovascular status
Hepatic, renal function
Endocrine status
Previous medication use
Psychosocial status 
Spiritual & cultural beliefs

Question 22

preoperative assessment… prior to teaching, you should know…

Answer 22

Prior to teaching, you should know:

History of patient’s illness
Rationale for surgery
Nature of surgery (curative, palliative, disfiguring, ostomies, etc)

Patient readiness to learn
age, mental status, pre-existing knowledge about condition, family reaction to surgery
should know the nature of sx, may be disfiguring to pt with body image - such as before having an ostomy

Question 23

preoperative teaching where does it start

Answer 23

Ideally starts in physician office and continues until patient arrives in operating room
Preoperative Teaching:
For planned inpatients - done during PAT visit.
For outpatients – via phone interviews or morning of surgery

Question 24

different teaching methods

Answer 24

verbal
written information
return demonstration
combination

Question 25

Preoperative teaching how does the nurse help

Answer 25

Nurse guides patient through experience & allows ample time for questions Patient concerns; fears about anesthesia Provide information to clear up misconceptions Reinforce explanation of procedure (MD obtains informed consent)

Question 26

how do nurses reinforce explanation of procedure

Answer 26

Explain preop procedures remove jewelry, nail polish Lab tests Skin preparation – cleansing, possible shaving (sometimes with prosthesis - they want the pt to scrub with a hibiclens, which helps reduce postop infections) Enemas or bowel preps before intestinal surgery (ostomy surgery - they need to be prepped before and make sure the bowel is cleaned out) Rationale for withholding food and fluids NPO status Use of OTC supplements; stop using 2-3 weeks prior to surgery

Question 27

what happens if a pt took their blood thinner the day of surgery

Answer 27

pt will not be having surgery that day

Question 28

preoperative teaching | about postoperative procedures

Answer 28

TCDB Incentive spirometer Leg exercises Moving in bed, splinting, getting out of bed Equipment to expect post op (NG, catheter, drains, NPWT, dressings) Importance of reporting pain/discomfort what will be done to relieve pain (change positions/medication)

Question 29

CRITERIA FOR INFORMED CONSENT

Answer 29

``` Voluntary Consent MUST include: Explanation of procedure and risks Description of benefits and alternatives An offer to answer questions Withdrawal statement Statement if protocol differs from usual ```

Question 30

Competent vs incompetent pt

Answer 30

any sx voluntary except for emergent sx in some cases - the pt or the pts proxy must consent to the procedure - save your life procedures must be done in some situations with or without consent - assume care

Question 31

emancipated minor

Answer 31

can give informed consent for him or herself

Question 32

Nurse responsibilities with informed consent

Answer 32

have consent signed before psychoactive meds are given can reinforce info supplied by physician WITNESS pts signature

Question 33

special surgical populations

Answer 33

``` Geriatric Pediatric Obese Patients with physical or mental disability Patients with co-morbid conditions Patients with limited support systems ```

Question 34

geri pop

Answer 34

psychosocial, cognititvely, do they need glasses? hearing aids? they have a lot of comorbidities

Question 35

peds pop

Answer 35

dealing w pt and fam | parental involvement? age of pt? stages of our growth

Question 36

obese pts

Answer 36

bias with society

Question 37

pts w physical/ mental disability

Answer 37

need to make sure the pt understands the procedure and they have support

Question 38

geriatric considerations

Answer 38

pain assessment may fail to report symptoms visual/hearing acuity changes less physical reserve for recovery (cardiac conditions, dehydration, arthritis, skin integrity, endurance) sensitivity to temp changes confusion clear communication elderly have greater risks (skillful preop assessment and tx, skillfull anesthesia and sx techniques, meticulous and competent post anesthesia management) pop is at greater risk for anesthesia problems if they have comorbid conditions they are most likely to have post op management problems as well

Question 39

peds considerations

Answer 39

provide age specific teaching family oriented teaching, parents can reinforce teaching sensitivity to temp changes (warm blankets, warm room, warming devices) safety size of equipment. instruments be congizant of the age of the child as well as safety (make sure child has equipment and instruments)

Question 40

bariatric pt

Answer 40

increased risk of sx complications (infection (dr anatomical folds), wound dehiscense, pulmonary) size of equipment/instruments need to have larger support surface underneath them, as well as larger commode safety supports - walkers that are larger for them so they can move adequately

Question 41

diabilities

Answer 41

modifications in preop teaching assistive devices (hearing aids, glasses, braces, prostheses) use of interpreters for signing mobility issues (may need extra personnel) positioning devices

Question 42

emergency surgery

Answer 42

``` Unplanned, little time to prepare Trauma, ruptured aneurysm, subdural hematoma, acute abdomen, complicated fracture, cardiothoracic, vascular Preop assessment – not much time! Unconscious patient Medical history; allergies What about informed consent? Family members ```

Question 43

what to do if pt is unconscious (emergency)

Answer 43

if no fam member is present that can consent then assume care

Question 44

spiritual and cultural beliefs

Answer 44

Assess primary language spoken Feelings/attitudes regarding surgery/pain Patient expectations Patient support system Use of professional interpreters Use of picture cards with various languages Provide printed teaching materials in variety of languages

Question 45

IMMEDIATE preop nursing interventions

Answer 45

Patient changes into hospital gown No hairpins, wigs, may braid long hair – surgical cap usually placed on patient in OR holding area Dentures, partials, hearing aides may be left in until patient gets to OR (individual hospital policy) Jewelry should be removed and left with family members; piercings should be removed for safety reasons Have patient void just before going to OR Medications – may or may not have antibiotic or sedative ordered Blood glucose Documentation – complete OR checklist Provide information for family members

Question 46

surgical site infection (SSI) prevention

Answer 46

(Surgical Complications Improvement Project = SCIP) Hair removal: no shaving or minimum shaving of surgical site (and done just prior to surgery); use clippers only, NO RAZORS Prophylactic preop antibiotics for appropriate surgeries: Bowel, vascular, any surgery involving implants Given 30-60 minutes prior to incision BG well controlled prior to surgery (BG = <200) Beta blockers Venous thromboembolism prevention (DVT & PE)

Question 47

preop anesthesia | COMPLETE INTERVIEW

Answer 47

``` May be done at PAT or day of surgery Includes pre-op assessment medical dx; allergies smoking/ETOH history past experience with anesthesia family hx of problems with anesthesia malignant hyperthermia History used to determine anesthesia to be administered. ```

Question 48

preoperative medications PURPOSE!

Answer 48

Are not given often, sometimes due to morning admissions. May be given on inpatient units. Purpose: Decrease anxiety and relax patient. Facilitate smooth induction of anesthesia. Decrease amt of anesthetic needed. Provide amnesia for periop period. Relieve pre and post-op pain. Minimize side effects of some anesthetic agents: salivation, bradycardia, post-op vomiting.

Question 49

Five major types of drugs used (preoperative meds)

Answer 49

``` sedatives tranquilziers narcotics vagolytic agents (anticholinergic) H2 receptor antagonists ```

Question 50

sedatives used preop

Answer 50

promote sleep before surgery | pentobarbital, dalmane, chloral hydrate

Question 51

tranquilizers used preop

Answer 51

decrease anxiety | valium

Question 52

narcotic analgesics used preop

Answer 52

preop analgesia | dilaudid

Question 53

vagolytic agents preop

Answer 53

decrease oral secretions, interrupt impulse that slow heart | atrophine

Question 54

h2 receptor antagonists preop

Answer 54

decrease amount of gastric secretion & increase pH of secretions pepcid (c-section pts especially)

Question 55

who are the people in the OR

Answer 55

``` Surgeon: May have an assistant or resident. Anesthesia personnel: Anesthesiologist or CRNA Circulating RN Surgical Technician Radiology Technician Cardiovascular Technician Students Pathologist Representatives of supply companies ```

Question 56

prevention of infections surgical environment zones

Answer 56

unrestricted zone semi-restricted zone restricted zone surgical asepsis environmental controls

Question 57

unresticted zone

Answer 57

street clothes permitted; locker rooms

Question 58

semi-restricted zone

Answer 58

hallways, corridors, offices, equipment rooms, staff break rooms - scrub attire and hair covering required

Question 59

restricted zone

Answer 59

sterile storage rooms and inside ORs - scrub attire, hair covering, and mask all times

Question 60

role of the circulating nurse

Answer 60

Patient advocate, protect from harm, emotional support Nurse reviews chart for completeness: patient identity and procedure, consent, allergies, emotional support SAFETY IS NUMBER 1 Assist anesthesia staff with induction Patient identification Operative site verification Maintain aseptic environment Proper function of equipment, ground pads, safety straps Necessary supplies and instruments Positioning to protect nerves, circulation, respiration, and skin integrity Correct surgical counts – no retained items after surgery Appropriate documentation Promote normothermia Distinguish normal from abnormal cardiopulmonary data Monitor blood, fluid, and drainage output. Maintain sterile technique of all present.

Question 61

Intraoperative complications

Answer 61

``` Anesthesia awareness Nausea, vomiting Anaphylaxis Hypoxia, respiratory complications Hypothermia Malignant hyperthermia Disseminated intravascular coagulation (DIC) Infection ```

Question 62

types of anesthesia

Answer 62

General Complete amnesia and paralysis Regional Decreases all painful sensation and motion to a body part or region without inducing unconsciousness Produced by blocking sensory impulses to the brain

Question 63

general anesthesia

Answer 63

Depression of CNS with total loss of sensation Complete loss of consciousness Goal: keep patient under for shortest time possible No one ideal agent so variety of agents are often used to create “Balanced Anesthesia”

Question 64

advantages of general anesthesia

Answer 64

``` flexibility used for any type of surgery adequate for lengthy procedures better monitoring and control of respiratory and circulatory functions when patient is unconscious (not awake and fearful). ` ```

Question 65

balanced anesthesia

Answer 65

anesthesia (unconsciousness), analgesia, amnesia, muscle relaxation, elimination of certain reflexes. Methods: inhalation, IV, rectal, Oral

Question 66

general anesthesia and disadvantages

Answer 66

respiratory and circulatory depression which can cause death nausea and vomiting aspiration during induction hepatic toxicity

Question 67

nursing interventions with general anesthesia

Answer 67

must know agents used & expected outcomes (length of action, recovery, amt of pain expected); maintain airway, protect, orient client, monitor VS, prevent aspiration postop by elevating HOB Be ready to assist with cardiac or respiratory arrest.

Question 68

methods: regional anesthesia

Answer 68

Topical Local: disrupt nerve endings (Never use local anesthetic with epinephrine on fingers!) Nerve Block: anesthesia in an area of distribution Spinal: inject anesthetic into CSF that surrounds lower spinal cord/nerve roots. For lower extremity, perineum, lower abdomen Epidural: into epidural space Caudal: through sacral canal (Hint: any med ending in ‘caine’ is a type of regional anesthetic)

Question 69

advantages of regional anesthesia

Answer 69

Better airway control, patient can control secretions Fewer respiratory complications because pt can C+DB normally to decrease pooling of mucous in bronchi Safer for patients with cardiorespiratory conditions Good for surgery of lower limbs, lower abdomen, or perineum

Question 70

disadvantages of regional anesthesia

Answer 70

Fear of paralysis Anxiety & fear r/t patients being able to see & hear during procedure; sedatives may be used to decrease anxiety Lack of flexibility may be difficult to use with small children, elderly (dementia), uncooperative patients, or for lengthy procedures

Question 71

spinal anesthesia

Answer 71

“False security”: drugs that can cause systemic depression with respiratory or circulatory problems Respiratory depression if spinal goes too high & paralyzes diaphragm in intercostal muscles then patient can’t breathe on own Amount of local anesthetic may be toxic Spinal headache

Question 72

nursing interventions for spinal anesthesia

Answer 72

Patient advocate secondary to lack of sensation Monitor for proper position, pressure points, distended bladder Monitor VS: look for block of sympathetic nerves leads to vasodilation and venous pooling which cause dec BP & P, could be severe bradycardia. Keep patient flat approximately 8-12 hours after spinal to prevent HA. Monitor CMS for return of function. Recovered when VS within normal limits and sensation has returned. Encourage oral fluids

Question 73

spinal anesthesia complications

Answer 73

Headaches from Spinal Anesthesia Cause: leakage of CSF, occurs 24-72 hours after anesthesia May have stiff neck Decreased incidence with small bore needle

Question 74

nursing interventions for complications w spinal anesthesia

Answer 74

Analgesics as ordered Lie Flat 24-48 hours Force fluids, unless contraindicated; caffeine (unless known to cause HA) because increase vascular pressure at leak site to seal hole Keep surroundings dark & quiet. Teach patient to avoid straining with moving in bed or having bowel movement leading to increased ICP causing increase in headache Last resort: blood patch or saline injection

Question 75

epidural (regional anesthesia)

Answer 75

Pain management by infusing analgesic &/or local anesthesia | Administered via infusion pump into epidural space at a rate & quantity specified by an anesthesiologist

Question 76

nursing interventions for epidural anesthesia

Answer 76

``` Elevate HOB >30 degrees if opioid infusion Pulse ox O2 per protocol Pain & sedation scale Bladder distention Epidural catheter site & dressing assessment I&O Monitor function & sensory block PRN meds? ```

Question 77

complications for epidural anesthesia

Answer 77

Respiratory depression – most serious side effect Relatively rare Increases with pt age & combination of other opioids Assess frequently for change in respiratory status Generally peaks 6-12 hours after epidural started Urinary retention Pruritus Nausea, vomiting, and dizziness

Question 78

inhaled anesthetics

Answer 78

Administered by inhalation of gases & vaporous fluids into the respiratory tract Dose controlled by anesthetist, can stop STAT Gaseous anesthetic (nitrous oxide): produces narcosis, analgesia, amnesia, dep CNS, greatest use as an induction agent Vaporous (Halothane, Fluothane): slower onset in induction.

Question 79

inhaled anesthetics SEs

Answer 79

hypotension | postop NV

Question 80

NI for inhalation anesthetics

Answer 80

monitor VS | ADEQUATE O2

Question 81

advantages for intravenous anesthetics

Answer 81

rapid pleasant induction | low incidence of post-op N/V

Question 82

disadvantages for inhalation anesthetics

Answer 82

``` Disadvantage laryngospasm bronchospasm decreased BP respiratory arrest irritating to skin and subcu tissue ``` Used to induce and maintain general anesthesia and amnesia

Question 83

NI for inhalation anesthetics

Answer 83

NIs monitor VS, esp airway, breathing safety straps for patient

Question 84

examples of intravenous anesthetics

Answer 84

``` Examples Barbituates short duration with very rapid onset induction smooth, easy, pleasant Narcotics / Neuraleptanalgesics Fentanyl, Sublimaze Used for anesthetic & analgesia Fast onset and short duration Decreases arterial BP d/t vasodilation effects ```

Question 85

moderate sedation - fetanyl

Answer 85

Fentanyl Causes analgesia, quietude and detachment from environment without loss of consciousness Patient is aware and able to cooperate, but feels no pain Need to decrease use of post-op narcotics for about 12 hrs since respiratory depression last longer than analgesia

Question 86

SE of moderate sedation

Answer 86

respiratory depression apea hypotension bradycardia

Question 87

NIs for moderate sedation

Answer 87

``` Never leave patient alone Constantly monitor airway Level of consciousness, pulse ox, ECG VS q 15-30 minutes Assess patient ability to maintain airway and respond to verbal commands ```

Question 88

complications of surgery following general anesthesia

Answer 88

Nausea and/or vomiting (first 24-48hrs). Caused by: pain meds, gastric distention, surgical manipulation, electrolyte abnormalities, pain, shock, psychological.

Question 89

complications following general anesthesia

Answer 89

Singulitis (hiccoughs) Causes: surgery near phrenic nerve, peritonitis, gastric distention, intestinal obstruction, acid/base or electrolyte imbalances. If short lived- no problem If continuous - painful with abdominal incision leading to vomiting which could lead to dehiscence, exhaustion.

Question 90

cause of a sore throat from general anesthesia

Answer 90

usually d/t ET tube placement during surgery

Question 91

nursing intervention for sore throat from general anesthesia

Answer 91

treat w ice | treat w lozenges (cepacol)

Question 92

headache complication from general anesthesia NI

Answer 92

usually sinus type treat w ice analgesics as ordered

Question 93

causes of muscle aches/paresthesia from general anesthesia

Answer 93

Position during surgery. Muscle spasms due to certain medications Usually resolves spontaneously

Question 94

NI for muscle aches/paresthesia from general anesthesia

Answer 94

Assess for pain other than surgical site. Assess for numbness in pressure areas from position during surgery, if numbness lasts, call anesthesia Analgesics as ordered Heat to lower back, back rubs, change position, OOB

Question 95

hypothermia from general anesthesia causes

Answer 95

cold OR & PACU rooms, exposed “guts”, decreased metabolism, cold IV’s, blood & gases

Question 96

hypothermia NI from general anesthesia

Answer 96

``` Warm blankets Frequent VS with continuous monitoring of temp Warming devices Bair hugger Keep dry ```

Question 97

malignant hyperthermia

Answer 97

Medical emergency! Most common cause of anesthetic induced deaths An adverse reaction to anesthetic drugs during induction Usually presents in first 10-20 mins, but can occur in 1st 24 hours. 60-70% mortality if not treated Inherited disorder of abnormal increase in muscle catabolism & heat production in response to stress or certain anesthetic. If family hx, will have muscle biopsy prior to sched surgery Wear medic alert bracelet / necklace.

Question 98

S/S of malignant hyperthermia

Answer 98

‘Rigid’ jaw upon intubation; ‘tetany’ Tachycardia: HR>150 Tachypnea Increased temp: as much as 1 degree every 5 mins (can go to 106 degrees) Increased metabolism with sustained muscle contractions

Question 99

treatment and nursing interventions for malignant hyperthermia

Answer 99

d/c anesthesia meds STAT Emergency treatment = Dantrium(Dantrolene) (skeletal muscle relaxant) Hyperventilate with 100% oxygen. Iced IV solutions Draw labs – ABG, CK, electrolytes Cooling blanket Mannitol & Lasix to maintain urinary output Foley catheter – strict I & O Monitor patient closely for next 36 hours

Question 100

reason for post anesthesia hypertension

Answer 100

Pt with controlled hypertension pre-op may have increased or decreased BP related to: Pain Decreased temp in OR leading to vasoconstriction which causes increased BP Hypervolemia

Question 101

NI for post anesthesia hypertension

Answer 101

Pt with controlled hypertension pre-op may have increased or decreased BP related to: Pain Decreased temp in OR leading to vasoconstriction which causes increased BP Hypervolemia

Question 102

other causes of pain from things other than incision

Answer 102

full bladder tight dressing cast position

Question 103

pain medication interaction

Answer 103

Narcotics usually needed first 24-48 hours, use noninvasive pain-relieving measures to increase effectiveness or allow use of lower dose DON’T be afraid to use narcotics the first few days- little risk of addiction & patient can do post-op exercises which decreases complications Patient Controlled Analgesia (PCA)

Question 104

perioperative nursing organizations

Answer 104

AORN | ASPAN