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Module 3 (MedSurg 1) > PeriOperative/Clinical Judgement > Flashcards

PeriOperative/Clinical Judgement Flashcards

1
Q

When a patient goes to your floor, when must the nurse check VS? From hours 1 through 4

A

1st hour = every 15 mins
2nd hour = every 30 mins
3-4th hour = every hour

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2
Q

If a patient comes to your floor but his VS is not stable. Does the nurse have to accept the pt?

A

No (check pre-op baseline VS)

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3
Q

What is needed for legal preparation of surgery?

A

Informed Consent

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4
Q

What is needed for informed consent?

A

Understanding at the pt’s level
Adequate disclosure
Volutary

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5
Q

What is included in adequate disclosure?
Bolded are most important

A

Pt needs to understand the diagnosis
Other options besides surgery
Percentage of success
Type of surgery (Diagnostic/Palative/Curative)
Cost
Duration (approx)

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6
Q

_________ ______________ may override the need to obtain consent.

A

Medical Emergency

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7
Q

During a medical emergency, if the patient can not give consent, what is the order for people to obtain consent?

A

Next of kin
Need 2 surgeons to confirm an emergency
HCP may begin the tx

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8
Q

When does the surgical TIME-OUT occur? What happens during a TIME-OUT?

A

before making the incision
- the entire surgical team pauses as the surgical site listed on the consent is read aloud

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9
Q

SCIP protocols are best practices for

A

safety and quality implemented during pre-op and following up in post-op
prevention of infection, serious cardiac events, venous thromboembolism

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10
Q

What is Hand-off communication?

A

transfer of relevant patient information during peri-op
- standardized and includes an opportunity for questions

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11
Q

During pre-operative care, what does a surgeon do and why?

A

Marks the operation site required for r/l distinctions, multiple structures, and levels
- the client should be involved to avoid the wrong area

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12
Q

A legally appointed representative/responsible family member can give written permission for

A

minors
unconscious pt
mentally incompetent

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13
Q

What are the 3 phases of perioperative nursing?

A

Pre-op
Intra-op
Post-op

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14
Q

Pre-operative Nursing involves

A

NPO after midnight
Type and Cross
Medications needed

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15
Q

Why are surgical patients NPO after midnight?

A

risk of N/V
leads to aspiration

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16
Q

Nursing Management
Pre-procedure verification process

A

Results of diagnostic studies (X-rays, biopsy, MRI)
Any blood, devices, or special equipment available in the room
H&P on chart
Signed Consent

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17
Q

Members of the Surgical Team

A

Circulating nurse
scrub nurse
surgeon
surgeon assistant
registered nurse 1st assistant
anesthesiologist

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18
Q

Circulating Nurse

A

remains in the unsterile field
not scrubbed, gowned, or gloved
documents
-Prepares room with team
-Serves as pt advocate
-Maintain pt safety, privacy, dignity, and confidentiality

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19
Q

Safety considerations for nursing management in intraoperative phase

A

Fire
Smoke particles
Universal protocols
Surgical time-out

20
Q

Universal Protocol in OR includes

A

Surgical time-out
patient ID
procedure
surgical site - marked by surgeon w/ help of pt

21
Q

PACU Admission Report

A

Name, age, surgeon, procedure, type of anesthesia
Hx, MEDS, ALLERGIES, BASELINE

22
Q

Initial PACU Assessment
Airway

A

HOB up slightly to help breathing and prevent aspirations

23
Q

Initial PACU Assessment
Breathing

A

RR, O2 Sat, cyanosis of lips and mucosa, listen to breath sounds, Deep Breaths

24
Q

Initial PACU Assessment
Circulation

A

Assess for cap refill, pallor, wiggles, PULSE
SCDs

25
Q

Initial PACU Assessment
Neuro

A

LOC - listen, person, place, time, situation

26
Q

When you are put to sleep, the 1st thing that comes back is

A

hearing

27
Q

Initial PACU Assessment
Surgical Site/Pain

A

Pain focused assessment
priority choice

28
Q

Nursing Intervention in PACU

A

frequent VS monitoring
continous EKG monioring
adequate fluid replacement
assess surgical site for bleeding

29
Q

Phase 1 Nursing Management

A

initial recovery period in PACU
constant vigilance is required
vital to perform a frequent skilled assessment

30
Q

Phase 1: PACU Discharge Criteria

A

pt awake
vs stable
no excess bleeding/drainage
no respiratory depression (O2 greater than 90)
pain controlled or acceptable
minimal N/V
report given

31
Q

Phase 2/3: Ambulatory Surgery Discharge Criteria

A

All Phase 1 complete
No IV opioid drugs for the last 30 mins
voided
able to ambulate if not contraindicated
responsible adult present
written discharge given and understood

32
Q

Nursing process

A

the systematic, problem-solving approach used to identify, prevent and treat health problems and promote healing
- care for individuals, families, groups, and communities

33
Q

ADPIE

A

Assessment
Diagnosis/Priority
Plan/Outcome
Implement
Evaluation

34
Q

NCJMM

A

Nursing Clinical Judgement Measurement Model

35
Q

NCJMM is used to

A

recognize cues
analyze cues
prioritize hypotheses
generate solutions
take action
evaluate outcomes

36
Q

What questions do you ask when RECOGNIZING CUES?

A
  • identify relevance from different sources from hx, VS
    What is relevant?
    What is MOST important?
    What is a priority?
    Do not connect with hypothesis
37
Q

Analyze Cues questions

A

What pt conditions are consistent with the cues?
Are cues contraindicating or supporting the pt’s condition?
Why are particular cues concerning?
What other information help establish the significance of a cue?
Multiple things could happen

38
Q

Priortize Hypotheses by

A

ABC
Which are most/least likely?
Most serious?

39
Q

Generate solutions questions

A

Desirable outcome?
Do interventions achieve the outcome?
Avoided?

40
Q

Taking action is implementing solutions that address the

A

highest priority
- Most appropriate?
- How should it be provided?

41
Q

When evaluating outcomes what questions do you ask?

A

Were the interventions effective?
Would other interventions have been more effective?
What signs point to improving, or changing, and status?

42
Q

Critical Thinking concepts when used in the nursing process will result in

A

clinical judgement

43
Q

Questions used in clinical judgement/decision-making?

A

WHO does it involve?
WHAT is the problem?
WHERE does it occur?
WHEN does it occur?
WHY make a decision?
HOW to make a decision?

44
Q

80-YEAR-OLD FEMALE
POST OP DAY 1 FROM HIP REPLACEMENT
- Patient returned from surgery yesterday afternoon. Reports pain of 8/10 and has physical therapy scheduled in 1 hour.
- Hx: diabetes type II, MI, degenerative joint disease
- BP: 110/60
- HR: 82
- O2 sat: 95% on room air
- Hgb: 10.6 g/dL
- Hct: 39%
- Creatanine: 1.6 mg/dL

ORDER: Ketorolac 30 mg IVP dose now

A
  • Effect bleeding and kidney excretion
    Stomach or intestinal bleeding without warning in older adults

No, because creatinine is high

45
Q

6-YEAR-OLD MALE
PRESENTS TO ER WITH ASTHMA ATTACK
- Patient developed wheezing while playing outside. Used a rescue inhaler and had some relief but difficulty breathing has continued.
- Hx: asthma
- BP: 100/60
- HR: 110
- RR: 32
- O2 sat: 82% on room air
Lung sounds: wheezing throughout
Able to speak a few sentences
ORDER: ALBUTEROL/IPRATROPIUM 3ML VIA NEBULIZER

A

Yes because prevents exercise bronchospasms

46
Q

77-YEAR-OLD MALE
CHF EXACERBATION
- Patient noted a weight gain of 10 pounds last week as well as swelling in the lower extremities.
- Hx: CHF, CAD, HTN, GI bleed, skull fracture
- BP: 90/50
- HR: 60
- RR: 16
- O2 sat: 93% on 2L O2
Sodium - 132 meQ/L
- Potassium - 3.3 mEq/L
Magnesium - 1.6 mEq/L
Lung sounds - crackles throughout, SOB with activity
ORDER: FUROSEMIDE 60MG IV PUSH TWICE DAILY

A

Fluid excess/retention
Potassium is too low so no for diuretics (risk of arrhythmia and confused)
No, I would not give.
- Ask maybe of 30 not 60

Module 3 (MedSurg 1) (12 decks)

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