Perioperative Nursing Care Flashcards
(44 cards)
1
Q
Informed consent
A
- Surgeon is responsible for explaining the procedure and the nurse may be responsible for obtaining the client’s signature (be sure that client understands the procedure and may be a witness and must be documented).
- Minors may need a parent or legal guardian to sign, clients not alert or oriented may need a power of attorney or legal guardian, and psychiatric clients have a right to refuse treatment until a court has legally determined that they are unable to make decisions.
- No sedation should be adm before the client signs.
- Obtaining telephone consent from a legal guardian or power of attorney is a acceptable practice if client is unable to give consent. The nurse must engage another nurse to witness.
2
Q
Nutrition before surgery
A
-Review surgeon’s prescription regarding NPO and withhold food and liquids to avoid aspiration, usually for 6 to 8 hours before general anesthesia and 3 hours before local anesthesia.
3
Q
Elimination before surgery
A
If intestinal or abdominal surgery, and enema, laxative or both may be prescribed.
Client should void immediately before surgery.
Insert a urinary catheter if prescribed (should be emptied immediately before surgery and document the amount and characteristics).
4
Q
Surgical site before surgery
A
Should be cleaned with a mild antiseptic or antibacterial soap on the night before, as prescribed.
Shave the operative site as prescribed.
5
Q
Preoperative client teaching
A
- Inform the client what to expect post-op;
- Inform to notify nurse if experiences pain;
- Inform that requesting opioid will not make the client a drug addict.
- Demonstrate the use of PCA pump;
- Instruct how to use noninvasive pain relief techniques (relaxation, distraction, guided imagery);
- Instruct not to smoke (at least 24hs before surgery) and discuss cessation treatment.
- Instruct deep-breathing and coughing techniques, use of incentive spirometry to prevent atelectasis and pneumonia.
- Instruct leg and foot exercises and the purpose of sequential compression devices to prevent venous stasis of blood.
- Instruct how to splint an incision, turn and reposition.
- Inform of any invasive devices that may be needed.
- Instruct not to pull on any of the invasive devices.
6
Q
Preoperative checklist
A
- Identification bracelet
- Assess for allergies (specially latex)
- Informed consents signed
- Check lists, prescribed lab and radiological tests (agency policies)
- History and physical examination completed and documented
- Consultation requests completed and documented
- Lab results, ECG, chest RX, blood type, screen and cross match are documented
- Remove jewelry, makeup, dentures, hairpins, nail polish (depends), glasses, and prostheses.
- Document that valuables have been given to family or locked in the hospital’s safe.
- Document the last time the client ate or drank, that they voided before surgery, that the prescribed medications were given.
- Monitor and document the client’s vital signs.
7
Q
Medical problems that increase risk during surgery
A
Bleeding disorders, DM, chronic pain, heart disease, obstructive sleep apnea, upper respiratory infection, liver disease, fever, chronic respiratory disease, immunological disorders, abuse of street drugs.
8
Q
Substances that can affect the client in surgery:
Antibiotics
A
Potentiates the action of anesthetic agents.
9
Q
Substances that can affect the client in surgery:
Anticholinergics
A
Increase the potential for confusion, tachycardia, and intestinal hypotonicity and hypomotility.
10
Q
Substances that can affect the client in surgery:
Anticoagulants, Antiplatelets, and Thrombolytics
A
These medications alter normal clotting factors and increase risk of hemorrhaging.
Aspirin, clopidogrel, and nonsteroidal antiinflammatory drugs are commonly used medications that can alter platelet aggregation.
These meds should be discontinued at least 48 hours before surgery or as specified by the surgeon.
Clopidogrel usually has to be discontinued 5 days before surgery.
11
Q
Substances that can affect the client in surgery:
Anticonvulsants
A
Long-term use can alter the metabolism of anesthetic agents.
12
Q
Substances that can affect the client in surgery:
Antidepressants
A
May lower the blood pressure during anesthesia.
13
Q
Substances that can affect the client in surgery:
Antidysrhythmics
A
Reduce cardiac contractility and impair cardiac conduction during anesthesia.
14
Q
Substances that can affect the client in surgery:
Antihypertensives
A
Can interact with anesthetic agents and cause bradycardia, hypotension, and impaired circulation.
15
Q
Substances that can affect the client in surgery:
Corticosteroids
A
Cause adrenal atrophy and reduce the ability of the body to withstand stress.
Before and during surgery, dosages may be increased temporarily.
16
Q
Substances that can affect the client in surgery:
Diuretics
A
Potentiate electrolyte imbalances after surgery.
17
Q
Substances that can affect the client in surgery:
Herbal substances
A
Can interact with anesthesia and cause a variety of adverse effects.
May need to be stopped at a specific time before surgery.
18
Q
Substances that can affect the client in surgery:
Insulin
A
May be reduced because client’s intake is decreased or may need to be increased because of the stress response and IV adm of glucose solutions.
19
Q
Management of care on arrival in the operating room
A
- Surgeon meets the client and mark the operative site with surgical marking in the preoperative area.
- In the OR nurse and surgeon ensure and reconfirm the marking.
- Nurse verify the identification bracelet with client’s verbal response.
- Review the client’s record for consent forms, history, examination, and allergies.
- Surgeon’s prescriptions will be verified and implemented
- Time-out is conducted with all members.
- IV line may be initiated.
- The anesthesia team will adm the prescribed anesthesia.
20
Q
Postoperative Care
A
Care given during the immediate postoperative period as well as during the days after surgery.
The goal is to prevent complications, promote healing of the incision, and to return the client to a healthy state.
21
Q
Postoperative Care: Respiratory System
A
- Assess breath sounds (stridor, wheezing, or a crowing can indicate partial obstruction, bronchospasm, or laryngospasm. Crackles or rhonchi may indicate atelectasis, pneumonia, or pulmonary edema).
- Monitor vital signs and airway patency (ensure adequate ventilation) and oxygen adm if prescribed.
- Monitor for secretions and if the client is unable to cough, suction the secretions.
- Observe chest movement for symmetry and the use of accessory muscles.
- Monitor pulse oximetry and end tidal carbon dioxide as prescribed.
- Encourage deep-breathing and cough exercises.
- Note the rate, depth, and quality of respiration (10-30 rpm).
- Monitor for signs of respiratory distress, atelectasis, or other complications.
22
Q
Postoperative Care: Cardiovascular System
A
- Monitor circulatory status (skin color, peripheral pulse, capillary refill, absence of edema, numbness and tingling.
- Monitor for bleeding.
- Assess the pulse for rate, rhythm.
- Monitor for signs of hyper or hypotension.
- Monitor for dysrhythmias.
- Monitor for signs of thrombophlebitis.
- Encourage the use of antiembolism stockings or sequential compression devices (as prescribed).
23
Q
Postoperative Care: Musculoskeletal System
A
- Assess the client for movement of extremities.
- Encourage ambulation if prescribed.
- Position the client in semi-fowler after the surgery (unless contraindicated).
- Avoid supine position until pharyngeal reflexes have returned.
- If client is comatose or semicomatose, position on the side (an oral airway may be needed).
- If client is unable to get out of bed, turn every 1 to 2 hours, unless contraindicated.
24
Q
Postoperative Care: Neurological System
A
- Assess level of consciousness.
- Make frequent and periodic attempts to awaken the client.
- Orient to the environment.
- Speak in soft tone.
25
Postoperative Care: Temperature Control
- Monitor temperature and for signs of hypothermia.
| - Apply warm blankets, continue oxygen, and adm medications as prescribed.
26
Postoperative Care: Integumentary System
- Assess the surgical site, drains, and wound dressings (SEROUS drainage may occur).
- Mark time and date for any drainage on surgical dressings and monitor for excessive drainage.
- Assess the skin for redness, abrasions, or breakdown that may have resulted from surgical positioning.
- Monitor for signs of infection.
- Maintain a dry and intact dressing.
- Change dressings as prescribed.
- Wound drains should be patent and prepare to assist with the removal when the amount of drainage becomes insignificant. Always document the output and characteristics.
- An abdominal binder may be prescribed for obese and debilitated clients.
27
Postoperative Care: Fluid and Electrolyte Balance
- Monitor IV fluid intake adm as prescribed.
- Record intake and output.
- Monitor for signs of fluid or electrolyte imbalances.
28
Postoperative Care: Gastrointestinal System
- Monitor intake and output. Nausea and vomiting.
- Maintain patency of the nasogastric tube if present and monitor placement and drainage.
- Monitor for abdominal distension.
- Monitor for passage of flatus and return of bowel sounds.
- Adm frequent oral care, at least every 2 hours.
- Maintain the NPO status until the gag reflex and peristalsis return.
- When oral fluids are permitted, start with ice chips and water.
- Ensure that the client advances to clear liquids and then to a regular diet.
29
Postoperative Care: Renal System
- Assess the bladder for distension.
- Monitor urine output (should be at least 30ml/hr)
- If the client does not have a urinary catheter, the client is expected to void within 6 to 8 hours post-op depending on the type of anesthesia (ensure the amount is at least 200ml).
30
Postoperative Care: Pain management
- Assess for pain (type, location and degree).
- Monitor for objective data related to pain (facial expressions, body gestures, vital signs).
- Inquire the effectiveness of last pain med.
- Ensure client understand the use of PCA pump.
- Assess RR, BP, HR, Sat, and LOC.
- If opioid was adm, asses the client every 30 min for RR and pain relief.
- Use noninvasive measures.
- Document effectiveness of both.
31
Postoperative Complications: Pneumonia and Atelectasis (description, assessment, and intervention)
- Pneumonia: inflammation of the alveoli caused by a infectious process that may develop 3 to 5 day post-op
- Atelectasis: collapsed or airless state, may be the result of airway obstruction caused by accumulated secretions or failure of deep breathing or ambulate after surgery (1 to 2 days after).
- Dyspnea and increased RR, crackles, elevated temp, productive cough and chest pain.
- Assess lung sounds, reposition every 1-2hrs. Encourage deep breathe, cough and use o incentive spirometer, fluid intake and early ambulation. Provide chest physiotherapy and postural drainage. Use suction if necessary.
32
Postoperative Complications: Hypoxemia (description, assessment, and intervention)
- Inadequate concentration of oxygen in arterial blood, can be due to shallow breathing (effect of anesthesia).
- Restlessness, dyspnea, diaphoresis, tachycardia, hypertension, cyanosis, low pulse oximetry readings.
- Monitor for signs, lung sounds, pulse oximetry. Notify the surgeon and adm O2 as prescribed. Encourage deep breathing, coughing, and incentive spirometer. Turn and reposition frequently and encourage ambulation.
33
Postoperative Complications: Pulmonary Embolism (description, assessment, and intervention)
- Embolus blocking the pulmonary artery and disrupting blood flow to 1 or more lobes of the lung.
- Sudden dyspnea, sharp chest or abdominal pain, cyanosis, tachycardia, drop in BP.
- Notify the surgeon immediately, monitor vital signs and adm oxygen as prescribed.
34
Postoperative Complications: Hemorrhage (description, assessment, and intervention)
- Loss of large amount of blood (internally or externally).
- Restlessness, weak and rapid pulse, hypotension, tachypnea, cool, clammy skin, reduced urine output.
- Provide pressure to the site, notify the surgeon, adm O2 as prescribed, adm fluids and blood as prescribed, prepare the client for surgical procedure.
35
Postoperative Complications: Shock (description, assessment, and intervention)
- Loss of circulatory fluid volume (usually due to hemorrhage).
- Similar to assessment findings in hemorrhage.
- Notify the surgeon, elevate the legs, determine and treat the cause, adm O2 as prescribed, monitor LOC and vital signs, monitor intake and output, assess color, temp, turgor, and moisture. Adm IV fluids, blood and colloid solutions as prescribed.
36
Postoperative Complications: Thrombophlebitis (description, assessment, and intervention)
- An inflammation of a vein, often accompanied by clot formation.
- Vein inflammation, aching or cramping pain, vein feels hard and cord-like and is tender to touch. Elevated temperature.
- Monitor legs for swelling, inflammation, pain, tenderness, venous distension and cynosis. Elevate the extremity 30 degrees without allowing any pressure on the popliteal area. Encourage the use of stockings as prescribed, and remove twice a day to wash and inspect the legs. Use sequential compression device as prescribed. Perform passive range-of-motion exercises every two hours. Encourage early ambulation, do not allow to dangle the legs, and change position frequently. Adm anticoagulants as prescribed.
37
Postoperative Complications: Urinary retention (description, assessment, and intervention)
- Involuntary accumulation of urine in the bladder as a result of loss of muscle tone. Caused by the effects of anesthetics or opioid and appears 6 to 8 hours after surgery.
- Inability to void, restlessness, diaphoresis, lower abdominal pain, distended bladder, hypertension, on percussion the bladder sounds like a drum.
- Monitor for voiding, assess for a distended bladder, encourage ambulation AP, encourage fluid intake unless contraindicated, assist the client to void, provide privacy, help to stand, pour water over the perineum or allow client hear water running. Contact the surgeon and catheterize as prescribed.
38
Postoperative Complications: Constipation (description, assessment, and intervention)
- When the client resumes a solid diet, failure to pass stool within 48 hours may indicate constipation.
- Absence of bowel movements, abd distension, anorexia, headache, and nausea.
- Assess bowel sounds, encourage fluid intake, ambulation, consumption of fiber foods (as possible). Provide privacy and adequate time. Adm stool softeners and laxatives as prescribed.
39
Postoperative Complications: Paralytic Ileus (description, assessment, and intervention)
- Failure of appropriate forward movement of bowel contents, result of anesthesia or manipulation of bowel.
- Vomiting, abd distension, absence of bowel sounds, movement or flatus.
- Monitor intake and output. Maintain NPO status until bowel sounds return. Maintain patency of nasogastric tube if in place (for drainage). Encourage ambulation, adm IV fluids or parenteral nutrition as prescribed. Adm meds as prescribed to increase GI motility.
- If ileus occurs, it is treated first nonsurgically with bowel decompression by insertion of a nasogastric tube attached to intermittent or constant suction.
40
Postoperative Complications: Wound Infection (description, assessment, and intervention)
- May be caused by poor aseptic technique or a contaminated wound before surgery. DM or immunocompromise is a risk. Usually occurs 3 to 6 days after. Purulent material may exist.
- Fever, chills, warm, tender, painful and inflamed skin sutures. Edematous skin and tight sutures. Elevated white blood cell count.
- Monitor temp, incision site for approximation, edema, bleeding and sign of infection (REEDA). Notify the surgeon. Maintain patency of drains (assess amount, color and consistency), asepsis, change the dressing and perform wound irrigation as prescribed. Anticipate prescription for cultures. Adm antibiotics AP.
41
Postoperative Complications: Wound Dehiscence (description, assessment)
- Separation of the wound edges, usually 6 to 8 days after surgery. Most common among obese and abdominal surgery.
- Increased drainage, opened wound edges, and appearance of underlying tissue.
42
Postoperative Complications: Evisceration (description, assessment, and intervention)
- Protrusion of the internal organs through a incision, usually 6 to 8 days after surgery. Most common in obese and abdominal surgery. Is an emergency!
- Discharge of serosanguineous fluid from a previously dry wound. Appearance of loops of bowel or other abdominal contents. Client reports feeling a popping sensation after coughing or turning.
- Call for help, ask that the surgeon be notified and that needed supplies be brought to the room. Stay with the client, and while waiting, place the client on semi-fowler with the knees bent. Cover the wound with sterile normal saline dressing and keep it moist. Take the vital signs and monitor closely for signs of shock. Prepare for surgery as necessary and document the occurrence, actions taken and the client's response.
43
General criteria for client discharge
- Alert and oriented;
- vital signs at baseline;
- lab values within normal limits;
- has voided;
- no respiratory distress;
- able to ambulate, swallow and cough;
- minimal pain;
- not vomiting;
- minimal bleeding, if any, and absence of purulent drainage.
- responsible adult to take client home;
- Surgeon has signed the release form.
44
Discharge teaching
- should be performed before the date of surgery;
- provide written instructions;
- instruct about complications that can occur;
- provide appropriate resources for home care;
- instruct to seek evaluation if problems occur and keep follow up appointment.
- demonstrate care of the incision, and cover with plastic for shower;
- provide 48 hour supply of dressings;
- instruct that sutures are removed in 7 to 10 days and staples 7 to 14 days (skin becomes slightly red when staples are ready to be removed.
- Steri-strips may be applied after;
- instruct on the use of medications, diet, activity level (resume gradually).
- Client with abdominal incision should not lift more than 10 pounds and avoid pulling or pushing activities.
- can return to work in 6 to 8 weeks depending on procedure.
