Perioperative Care Flashcards
(112 cards)
1
Q
What are the purposes for surgery?
A
Diagnosis Cure Palliation Prevetion Exploration Cosmetic improvemnt Transplant
2
Q
What are the four distinct phases of surgery?
A
Pre- operative
Intra- operative
Post- anesthesia
Post- operative
3
Q
What should be assess in pre- op?
A
Data collection Medication review (prescribed med, OTC, illegal, herbal, vitamins) Nutritional status Pain ROM limitations Pre- op labs and diagnostic tests Allergies Baseline VS
4
Q
What are some meds that would cause concern in pre- op assessment?
A
Anti- coagulant
- lovenox, heparin, warfarin, aspirin
Steroids
- prednisone
5
Q
Why is height and weight important?
A
To make sure they get the required anesthesia
6
Q
Why is ROM limitations important?
A
Positioning during surgery
7
Q
What is involved in health history for coping/adaption?
A
Psychological
Developmental
Socio-cultural
Spiritual
8
Q
Coping/adaption: Psychological
A
Stress and coping mechanisms
9
Q
Coping/adaption: Developmental
A
Age and gender
10
Q
Coping/adaption: Socio- cultural
A
Support system
Economics
Plans for convalescence
11
Q
Coping/adaption: Spiritual
A
Consider influence of religious/philosophical beliefs on surgical risk
Non- judgemental
Pastoral care referral
12
Q
What are some surgical risks?
A
Age Nutritional Smoking ETOH/Drug use Chronic steroid use Pre-existing conditions
13
Q
Why is age a surgical risk for the very young?
A
Poorly developed lungs: increases risk of pulmonary problems
Looses water quickly being dehydrated
14
Q
Why is being obese a surgical risk?
A
Excess adipose tissue and poor blood supply
- Prolonged surgery
- Prolonged excretion of anesthetic agent
- Reduced ventilatory function
- Slower healing process
15
Q
Why is being underweight a surgical risk?
A
May lack needed vitamins and proteins
- Risk for poor wound healing and infection
- May be at risk for skin impairment with significance of bony prominences
16
Q
Why is smoking a surgical risk?
A
Decreases ciliary action
Nicotine constricts blood vessels
Decreased amount of functional hemoglobin
17
Q
Why is excessive alcohol consumption a surgical risk?
A
Affects liver function
- Metabolism and detoxification of drugs may be delayed
- May have poor nutrition: delayed wound healing
At risk of alcohol withdrawal (DT)
18
Q
What are some pre- existing conditions?
A
Bleeding disorders Diabetes Heart disease Fever Upper resp. infection Chronic resp. disease Liver disease Immune disorders Renal insufficiency Chronic steroid use
19
Q
If steroids are being used chronically and abruptly stopped what can happen to the patient?
A
Adrenal crisis
- Hypertensive
20
Q
What does BUN assess?
A
Hydration
21
Q
What does creatinine assess?
A
Kidney function
22
Q
Guidelines and safe practice recommendations are published by who?
A
AORN (American operating room nurse association)
ASPAN (American society of perianesthesia nurses)
WHO (World health organization)
Joint Commission (SCIP)
23
Q
According to the WHO, what are the ten essential objectives to for safe surgery?
A
- Operate on correct Pt on correct site
- Use methods known to prevent harm from
administration of anesthetics while protecting
Pt from pain - Recognize & effectively prepare for life threatening
loss of airway or resp function - Recognize & effectively prepare for risk of
high blood loss - Avoid inducing an allergic or adverse drug
reaction - Use methods known to minimize risk for
surgical site infections - Prevent inadvertent retention of instruments
& sponges - Secure & identify all surgical specimens
- Effectively communicate & exchange critical
information - Establish routine surveillance of surgical
results
24
Q
When should the pre- op antibiotic be given?
A
Within 1 hr before incision
25
When should antibiotics be discontinued?
| With what exception?
Within 24hrs of anesthesia end time
48hrs for cardiac surgery
26
What antibiotics should they be given 2hrs before incision?
Vancomycin
| Levaquin
27
What should be remembered about blood glucose and cardiac surgery patients?
Controlled 6am post-op serum glucose (less than 200 mg/dl post-op day 1 and 2)
28
Why is maintaining a normal blood glucose important post-op?
Risk of infections higher if blood glucose levels are elevated
29
What should be used for hair removal?
Clippers (preferable)
30
Why shouldn't you shave with a razor?
It causes skin abrasions which may lead to infections
31
When should a foley be removed and why?
Post op day 2
| Risk of UTI
32
What should be remembered about beta blockers and pre-op patients?
- Continue if patient on home beta blocker therapy
- Beta blocker may be given 24 hrs. prior to op or day of
procedure
33
What are the parameters to give a beta blocker?
Heart rate must be ≥ 50 and systolic blood pressure ≥ 100
34
Why is giving a beta blocker important with a pre-op patient?
- Perioperative myocardial ischemia has been identified as
the #1 risk factor for mortality after non-cardiac
surgery.
- Attributed to the exaggerated sympathetic response leading to persistently elevated heart rate.
- Has the potential to significantly reduce cardiac deaths for up to 2 years postoperatively
35
Why is timing of VTE prophylaxis important?
Reduces the risk of development of pulmonary embolism and DVT
36
What can happen to blood vessels if fluids are warmed up too much?
Burns to the blood vessels
37
What is temperature you want your patient to be at/above and within what time?
At least ≥ 96.8°F/36°C within 15 minutes of anesthesia end time or warmer used in OR
38
Why is temperature management important?
- 3 times greater incidence of surgical site infections with hypothermia
- Delayed wound closure which results in prolonged hospitalization
39
How can the nurse help in alleviating anxiety with a patient?
- Therapeutic communication
- Determine source of anxiety
- Knowledge of the surgery, anesthesia, and their role
- Educate & clear up misconceptions
40
What may be some of the causes for fear for a patient?
- Unknown: may be first surgery
- Pain and pain management
- Concern with body image/ change in image
- Death
- Anesthesia
- Disruption of life: having to be
dependent on others
41
What is the nurse's role with an informed consent for surgery?
- Verify that the healthcare provider has discussed
risks and benefits with patient and has obtained the persons signature
- Usually witnessed by the RN
42
What is involved in pre0op teaching?
- Cough & Deep Breathing
- Leg exercises
- ROM
- Patient movement (amblation, compression devices, splinting)
- Prevention of constipation
- Surgical incision care
43
What is the most beneficial mechanism to enhance breathing post-op?
Incentive spirometer
44
What are some ways to reduce the risk of infection?
- Chlorohexidine bath
- Use of clippers to shave hair from surgical area immediately prior to surgery
- Insertion and dressing of IV using aseptic technique
- Bowel prep if indicated
45
What is involved in pre-op diagnostic testing?
```
Labs (electrolytes, H/H, Cr, Type and cross, coagulation studies, blood sugar, ABG, total protein)
CXR/other XR
EKG
Pulmonary studies
Pregnancy test
```
46
What is the purpose of pre-op pharmacology?
- Facilitate effective anesthetics
- Minimize respiratory tract secretions
- Induce relaxation
- Reduce anxiety
47
Examples of opiates: narcotic analgesic?
Morphine Sulfate
Hydromorphone (x10)
Fentanyl (x100)
(increasing in level of strength)
48
What are opiates used for?
Control moderate to severe
| pain during intraoperative and postoperative phase and can also be used for patient sedation
49
What are the nursing considerations for opiates?
- Monitor for decreased LOC, eventually leads to respiratory depression
- Monitor for decreased B/P (tissue perfusion)
- Opiate overdose can be treated with Naloxone
50
What is the difference between Ondanestron and promethazine?
Ondanestron (Zofran) DOESN'T cause drowsiness
| Promethazine (Phenergan) DOES cause drowsiness
51
Examples of antiemetics?
Ondansetron Hydrochloride
(Zofran)
Promethazine (Phenergan)
52
What are antiemetics used for?
Decrease N/V when
| given during pre-op phase, from anesthesia during post-op phase
53
What are the nursing considerations of antiemetics?
- Monitor fluid and electrolytes
- Monitor for diarrhea
- Monitor for tachycardia and angina
54
Examples of H2 Receptor antagonists?
Cimetidine (Tagamet)
Famatidine (Pepcid)
Rantitidine (Zantac)
55
What can happen if promethazine is given to quickly through IV?
Necrosis of vein
56
Where should the IV be placed for a patient to receive promethazine IV?
Forearm and above
| Not hands
57
What are H2 receptor antagonists used for?
Decreases risk of stress ulcers
58
Why is acetaminophen usually given in pre-op?
Adjunct to narcotics to enhance effects
59
Examples of anti-anxiety meds?
Midazolam (Versed)
| Diazepam (Valium)
60
What special effect does Midazolam (Versed) have?
Amnesia
61
Examples of anticholinergics?
```
Atropine sulfate (Atropine)
Hyoscine hydrobromide (Scopolamine) (patch behind ear)
Glycopyrrolate bromide (Robinul)
```
62
What do anticholinergic increase?
HR (use cautiously in pts with cardiac issues)
63
Examples of antibiotics?
```
Cefazolin (Ancef)
Cefoxitin (Mefoxin)
Ampicillin/sulbactram (Unasyn)
Vancomycin
Clindamycin
Levofloxacin
```
64
What is the role of the circulating nurse?
- Plans & coordinates care in OR
- Assists in setting up OR room
- Gathers supplies & equipment
- Opens instruments & supplies
- Brings the patient to & from the pre-op area
- Collects and verifies patient information
- Verifies consent
- Supports the patient & acts as the patient advocate
- Anticipates & meets the needs of the surgeon, anesthesia & scrub nurse
- Monitors & controls the OR environment
- Monitors blood loss with anesthesia
- Documents nursing care and all equipment counts
65
When is equipment counted?
Before (once)
After (Twice)
Anytime circulating nurse feels the need equipment needs to be counted (During)
66
What is electrosurgery and how is it used?
Electrical current to cut & coagulate fat, fascia, muscle, internal organs & small blood
vessels
Decreases the amount of diffuse bleeding
67
What is the biggest hazard of electrosurgery?
Electrical burns through the patient’s skin
68
How is the patient grounded?
With a pad
69
What are some ways of maintaining safety and decreasing risk of infection?
- Hand washing (5-10 hand &
arm scrub)
- Laminar air flow to reduce air currents
- HEPA filters in air ducts
- Sterile field is created & maintained throughout surgical procedure
70
What are the types of anesthesia?
Local
Regional
General
71
What is local anesthesia?
```
- Numbs a small area on the
body
- Patient is awake and conscious
- The surgical site is injected
with a anesthetic, such as
lidocaine, into the SQ tissue in
order to depress the superficial
peripheral nerves
```
72
What is regional anesthesia?
- Blocks the feeling to a large part of the body
- Includes epidural and nerve blocks
- Regional- reversible loss of sensation &/or movement when a local anesthetic is injected to block or anesthetize nerve fibers (Spinals, Epidurals, Caudals or Major peripheral blocks such as a brachial nerve block)
73
What is general anesthesia?
```
Reversible, unconscious state
◦ Amnesia
◦ Analgesia
◦ Depression/loss of reflexes
◦ Muscle relaxation
◦ Homeostasis or manipulation of physiological functions
```
74
What is conscious sedation?
- State of reduced consciousness which allows performance of unpleasant
procedures while preserving protective airway, reflexes, & the ability to respond to verbal commands`
75
What type of meds are given for conscious sedation?
Amnesic
Analgesic
Sedative
Morphine & Midazolam (Versed)
76
What is balanced anesthesia?
Use of combining IV anesthetics, analgesics, amnesics & inhalation drugs to
achieve unconsciousness, skeletal muscle relaxation, pain relief & physiological homeostasis
77
What are some complications of anesthesia?
- N/V
- Anaphylactic reaction
- Malignant hyperthermia
- Hypotension
- Fluid imbalance
- Electrolyte imbalance
- Hypothermia
- Hypoventilation
- Airway obstruction
- Loss of sensation &/or movement from regional
- Hematoma, infection, tissue trauma from regional/local
- Inability to void from regional
- Drug toxicity
78
What does the PACU focus on?
- Respiratory status
- CV status
- Pain level
- Type of anesthesia given
- Temperature
- Control of N/V
- Operative site assessment
79
What is a sign for low temperature?
Bradycardia
80
What are some S/S of ineffective airway clearance?
- Snoring
- Nasal flaring
- Accessory muscle use
- Intercostal retractions
81
What are some S/S of ineffective breathing pattern?
- CO2>45 mmHg
- Extreme sedation
- Decreased RR
- Shallow respirations
- HR & BP ↑ or ↓
82
Cause of ineffective airway clearance?
Tongue occlusion
83
Treatment for ineffective airway clearance?
- Chin lift / jaw thrust
- Stimulate the patient
- Insert oral airway
- Intubation
84
Causes of ineffective breathing pattern?
- Residual effects of anesthesia
- Pain
- Obesity
- Supine positioning
85
Treatment for ineffective breathing pattern?
- Stimulate the patient to take deep breathes
- Supplemental O2
- Elevate HOB
- Place in lateral position
- Provide pain relief
86
What is atelectasis?
Partial or complete collapse of the lung
87
Causes of atelectasis?
```
- Hypoventilation/mechanical
ventilation
- Mucous plugs
- Decreased surfactant production
- Constant recumbent position
- Ineffective coughing
- History of smoking
- Can lead to the development of Pneumonia
```
88
What are some interventions to prevent atelectasis?
- HOB elevated 30 degrees
- O2 therapy as ordered
- Coughing & Deep breathing Q1hr
- Incentive spirometer Q1hr
- Incisional splinting
- Changing position Q1-2hr
- Early ambulation
- Adequate hydration
89
What can cause altered tissue perfusion?
Hypotension ( 160/90)
90
Causes of hypotension?
Hemorrhage
Hypovolemia
MI
Embolism or drugs
91
Causes of hypertension?
```
Pain
Anxiety,
Full bladder
Pulmonary emboli Hypervolemia
Hypothermia
Hypoxemia
```
92
Treatment for hypotension?
Fluid replacement
Vasoconstriction meds
Elevate the pts legs
Monitor VS & I&O
93
Treatment for hypertension?
Treat the cause & give quick
| acting antihypertensives
94
What are post-op patients most at risk for?
VTE
95
What are some interventions for
- Prophylaxis for VTE (Heparin or LMWH, SCD's)
- Accurate I&O
- Monitoring of electrolyte levels
- Close monitoring of IV therapy
replacement
- Promote early, progressive ambulation
96
Risk factors for pulmonary emboli?
- Childbirth
- Pregnancy
- Birth control pills
- Older adults with hx of A-fib or heart valve disease
- Trauma/Surgery
- Cancer
- Sedentary lifestyle
- Overweight
- Smoking
- Drug abuse
- Dehydration
- Hypertension
97
S/S of pulmonary emboli
- Sudden onset of dyspnea
- Increase in HR & RR
- Chest pain
- Hemoptysis
- Crackles
- Fever
- Accentuation of pulmonic heart sounds
- Sudden change in mental status
98
Diagnosis of pulmonary emboli
- Pulse Oximetry
- ABGs
- Blood Coagulation studies
- EKG
- CT (spiral) Scan
- Pulmonary angiogram
- V/Q scan
99
Treatment for pulmonary emboli?
- Stay with patient
- Thorough assessment
- Call Doctor
- Provide pain relief measures
- Prepare patient for diagnostic tests as ordered
- Bedrest
100
What should be done for decreased CO and altered tissue perfusion?
- Assess for S/S right sided heart failure (Cor Pulmonale)
- Digoxin
- Diuretics
- Vasopressors if in shock
101
How should heparin be administered?
Given continuous IV infusion after initial bolus dose, given for up to 7 days until Coumadin PO has been given for a few days & the PT is 1 1/2 to 2 times the control
102
Heparin Drip Protocol:
| less than 35
↑ drip by 4u/kg/h, give 80u/kg bolus
103
Heparin Drip Protocol:
| 35 - 49
↑ drip by 2u/kg/h, give 40u/kg bolus
104
Heparin Drip Protocol:
| 50 - 80
No change
105
Heparin Drip Protocol:
| 81 - 100
↓ infusion by 2u/kg/h
106
Heparin Drip Protocol:
| 100 - 120
↓ infusion by 3u/kg/h
107
Heparin Drip Protocol:
| >120
Stop infusion, call doctor immediately
108
Heparin Drip Protocol:
| After any change in drip, what should you do?
Repeat PPT in 6hrs
109
Heparin Drip Protocol:
| Heparin antidote?
Protamine sulfate
110
What should be avoided while taking anticoagulants?
Trauma
| Green leafy veggies
111
What interventions are used for pain?
- IV opioids provide most rapid pain relief
- Sustained relief (Epidurals, PCA pumps, Regional anesthesia blockade)
- First 48 hours (Opioids)
- Thereafter: Non-opioids (NSAID’s)
- Times prior to activity
112
What significant findings should be reported?
- Prolonged unresponsiveness
- Changes in LOC
- O2 saturation 120 BPM
- Hyper or hypotension
- Absence of peripheral pulses
- UO
