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The surgical client Flashcards

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1
Q

What assessment should the nurse complete for preoperative patients?

A

*Head to toe assessment
*Reviews health history
*Reviews labs & diagnostics
*Identifies risk factors
*Older adult considerations

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2
Q

What are the steps for the head to toe assessment for a surgical client?

A

Vital signs
General appearance
Pain
Neurological system
Head & neck
Integumentary
Lungs & thorax
Cardiovascular
Gastrointestinal
Nutritional
Psycho/social
Cultural considerations
Religious/spiritual
Expectations

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3
Q

What information should the nurse gather from the patients health history records prior to surgery?

A

Medical & surgical history
*Cardiac and pulmonary diseases
*Surgical complications
*Family complications during surgery
*Malignant hyperthermia
*Health habits
*Allergies
*Current medications
*Social history
-Spiritual and cultural beliefs

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4
Q

Malignant hyperthermia

A

-SEVERE reaction to medications from anesthesia agents
-Causes a hypermetabolic state
-Life threatening emergency

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5
Q

What are the signs and symptoms of Malignant hyperthermia?

A

-tachycardia
-hyperthermia
-muscle rigidity
-acidosis
-hypercarbia
- glycolysis
-hypoxemia

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6
Q

What treatment for Malignant hyperthermia

A

dantrolene

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7
Q

What potential interactions do NSAIDs and anticoagullants have during surgery ?

A

Both Increases risk for bleeding

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8
Q

What potential interactions do anticonvulsants (seizure med) have during surgery ?

A

-Can alter the metabolism of anesthesia

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9
Q

What potential interactions do diuretics have during surgery ?

A

-risk for electrolyte imbalances
-nurse must monitor electrolytes pre and post surgery

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10
Q

What potential interactions do antihypertensive have during surgery ?

A

-Monitor BP and inform medical staff

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11
Q

What potential interactions do insulin have during surgery ?

A

-Glucose levels can rise during surgery
-Insulin may needed post op

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12
Q

Labs and diagnostic test potentially needed for surgery include..

A

-Complete blood count (CBC)
-Complete metabolic panel (CMP)/Basic metabolic panel (BMP)
-Fasting blood glucose/hemoglobin A1C
-Coagulation studies
-Blood type and screen/type and cross
-Urinalysis
-Electrocardiogram (ECG)
-Stress testing
-Chest X-ray
-Pulmonary function tests
-Sleep study

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13
Q

What are complications & risk factors that can interfere with surgery?

A

Cardiac & pulmonary diseases
-Chronic obstructive pulmonary disease (COPD)
-Obstructive sleep apnea (OSA)
-Asthma
-Coronary artery disease (CAD)
-Congestive heart failure (CHF)

-Pregnancy
-Diabetes
-Liver disease
-Kidney disease
-Obesity and malnutrition
-Age
-Older adults
-Tobacco and alcohol

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14
Q

Informed consent (signed)

A

permission given by the client (or their legal representative) to provide care or perform a surgical procedure

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15
Q

What is the nurses responsibility during a informed consent?

A

-Verify and witness that the appropriate person signed the consent
-Ensure they have enough information to make the decision

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16
Q

Elements of informed consent include…

A

Full disclosure
-Explanation of procedure
-Who will be performing the procedure
-Risks vs benefits
-Consequences of refusal & alternative treatments
-Rights to refuse treatment and withdraw consent

Terms the client can understand
-The client needs to understand need for procedure and risks
-Use lay person terms

Voluntary
-No coercion (do not pursude client to do anything)
-Mentally competent
-Not sedated
-Not a minor

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17
Q

Emergency consent only happens when…

A

-When client cannot give permission and family/guardian is not available
-Two providers must document the necessity for the surgery beforehand
-Post operation consent is later obtained

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18
Q

What are the goal for client teaching?

A

-Prepare for surgery and recovery
-Reduce anxiety
Encourage client to provide self-care post operatively
-Provide support to client’s family
-Promote active participation from the client
-Teaching begins when decision to have surgery begins

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19
Q

What general information should you teach the client prior to surgery?

A

-When to arrive
-Where to go
-What to bring
-Visitor policy
-How long they are expected to stay
-NPO status
-Skin preparation
-Medications
-Tobacco & alcohol use

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20
Q

What are post op expectations that should be met for the client after surgery?

A

-What to expect immediately following surgery
-Pain management plan
-Pulmonary hygiene post op
-Post op activity/exercises

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21
Q

Prehabilitation goal is to provide ..

Study These Flashcards
A

surgery interventions to improve the client’s health and fitness to reduce post op complications, decrease length of stay, and enhance recovery

Involves:
-Medication optimization
-Physical activity
-Nutrition plan
-Strategies to reduce anxiety
-General health promotion

22
Q

Fasting prior to surgery for specific diets

Study These Flashcards
A

Clears: 2 hours or more
Light meals: 6 hours
Meat and fried food: 8 hours

Most agencies: NPO midnight

23
Q

Preoperative checklist includes…

Study These Flashcards
A

-Ensure all informed consents are completed
-Documentation
-Vital signs
-Hygiene
-Removal of jewelry, prosthetics, dentures, partials, hearing aids, valuables, etc
-Urinary prep
-Anti embolism devices
-Pre-op meds
-Educational needs
-IV in place

24
Q

Intraoperative nursing

Study These Flashcards
A

-Involves the nurses care from the moment the surgical procedure takes places until the completion of surgery

25
Nursing responsibilities intraoperative
-Make sure pre operative check list is complete -Make sure informed consent is signed -Promote safety and privacy for the client -Ensure that the Time Out is performed and participate in it -Position the client -Ensure the count is accurately completed
26
Time out (Joint commission standard)
-Entire operating room team does a final verification of the right client, procedure, and site -If possible include the client in the time out -Introduce all team members to promote active communication
27
Anesthesia: Local & adverse effects
-Used to numb a small area in the body -Prevents conduction of pain impulses -No central effects Adverse Effects: -Hives -Itching -Rash -Acute or severe anaphylactic EX: breast biopsy, sutures, broken bone
28
Anesthesia: regional & adverse effects
-Loss of sensory and/or motor function of a specific portion of the body -No central effects Adverse Effects: -Spinal and epidural= rapid hypotension and respiratory paralysis -Spinal=spinal headache - hematoma - Abscess (puss filled pimple)
29
Anesthesia: General & adverse effects
-Loss of all sensations, consciousness, and reflexes -Given by : IV, inhaled gases, and muscle relaxants Adverse effects : -Hypoxia -Respiratory and/or cardiac dysfunction, - Hypotension and hypertension -F&E imbalances -Residual muscle paralysis - Neurological problems, -Malignant hyperthermia
30
Anesthesia: moderate sedation and Adverse effects
-Decreased/impaired level of consciousness Adverse effects: -Depends on the medication given -Drowsiness -Hypotension -Headache -Nausea -Vomiting -Respiratory depression -Bradycardia -Pruritus (itching)
31
Common client positioning include ..
*Postition goal = client safety* -Supine -Trendelenburg -Reverse Trendelenburg -Fowler's -Prone -Jackknife -Lateral -Lithotomy
32
PACU care for post operative clients
-Continue to assess and monitor the responses to surgery and anesthesia -Resolve any problems that arise quickly when noticed -Evaluate outcomes of interventions -Ongoing assessments -Evaluation of meeting criteria to be discharged -Make sure patients is being discharge to appropriate location or unit
33
inpatient unit : Post operative care
-Complete full assessment -Complete assessment with PACU nurse still there -Encourage the use of IS nurse still there -Frequent TCDB -Reposition q2h -Ambulate early -Follow diet order -Pain management -Collect I&O -SCDs -Mark drainage, assess drains and incision
34
What are some home discharge requirements that must be fulfilled?
-Client awake and alert -VS at baseline -Tolerating PO liquids -Pain relief with PO medications and/or nonpharmacological methods -Client is stable and can walk steadily -Client able to void  -No s/s of bleeding -Skin is intact and surgical dressing -No complications present from surgery -No further inpatient testing required -Client understands the education provided and plan of care
35
Computerized pump with a syringe of pain medication connected to an IV line that the client can self-administer based on their level of pain is called ______________________
Patient controlled Anesthesia Pump (PCA)
36
What assessments should you do for respiratory post op?
-Lung sounds -Respiratory rate -Breathing pattern -Oxygen level
37
What assessments should you do for Cardiovascular post op?
-S/S of electrolyte imbalance, - VS -Pulses -S/S of DVT and bleeding
38
What assessments should you do for Neurological post op?
-LOC -Mental status -S/S of oversedation -S/S of post op delirium
39
What assessments should you do for Pain management post op?
-Pain assessment using appropriate scale
40
What assessments should you do for Integumentary post op?
-Dressing, -incision -S/S surgical Infection -Drainage -Drains in place
41
What assessments and interventions should you do for Gastrointestinal post op?
Assess: -Presence of nausea and vomiting -Bowel sounds and bowel movement Intervention: -Ambulate, bowel meds PRN
42
What assessments should you do for Renal post op?
Assess: -Urine I&O's -Mucous membranes -Tenting -Edema -Distended bladder -Catheter -Catheter care
43
Post op assessment: Epidural
-Respiratory -VS -Pain -Degree of motor and sensory block -N&V -Urine output -Presence of headache -Epidural site
44
Post op assessment: Spinal
-Assess for presence of headache -Ensure client lays flat initially to avoid HA -VS -Respiratory -Movement and sensation
45
Post op assessment: Regional
-Location specific -Pain -Movement and sensation -VS
46
Wound care and diet for healing
-Assess wound and document every shift -Provider changes first one 24 hours after surgery -When changing dressing teach the client how to do it as well -Use proper hand hygiene -Mark drainage to keep track -May reinforce Diet: -Rich in protein, vitamins A, C, and Zinc
47
What are potential post operative complications?
-Deep vein thrombosis (DVT) -Pulmonary embolism (PE) -Atelectasis -Delirium -Evisceration -ileus -Falls -Aspiration -Surgical site infection -Dehiscence -Post operative nausea nad vomiting (Fluid imbalances) -Hypovolemia -Hypervolemia
48
What is aspiration and ways to prevent it ?
-When food/liquid is inhaled into lungs -Very high-risk during surgery -Dysphagia increases this risk -Ensure they fast pre-op Post op: - sitting up for meals -stay up for at least an hour after -small bites -eat/drink slow - avoid talking/watching TV while eating
49
Fall risk preventions
-Many occur at home -Move slowly -Yellow wristband -Assess home for risks -Install handrails in bathroom -Nonskid shoes -Education regarding medications
50
what are causes of impaired cognition after post op and interventions?
-Post op delirium -Prolong hospital stay -Increased risk of death - Administration of anticholinergics -Often occurs when clients feel disoriented for a brief period of time after surgery  Interventions: -Monitor mental status -Oxygenation status -Mobilize early -Monitor F&E balance

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