Tissue Integrity/PeriOp Care Flashcards by Madison Harding

Stage 1 Pressure ulcer

Red area that is not blanchable

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Stage 2 Pressure ulcer

Shallow open wound w/o slough

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Stage 3 Pressure ulcer

No bone or muscle present
Some slough but does not obscure
Full thickness loss

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Stage 4 Pressure ulcer

Full thickness tissue loss
See bone or muscle
Slough and eschar may be present
Undermining and tunneling

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Suspected deep tissue injury

Depth unknown
Purple discolored area of intact skin
Due to pressure or shear

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Unstageable Pressure ulcer

Depth unknown
Full thickness tissue loss
Ulcer covered by slough and eschar in wound bed
Cannot stage until removed`

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Priority screening before surgery

Screen for Malignant hyperthermia

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What meds would the nurse check for a pt. before a surgery that puts them at a high risk during surgery

Aspirin
Antidepressants
Steroids
NSAIDs

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What is best practice for marking a surgical site?

The physician should mark the site with the involvement of the pt.

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Pt. has surgery in 3 hours but take her Beta-blocker every morning. True/False: The nurse should withhold the medication before surgery

False: This is a vital medication for heart function. The pt. should have the beta-blocker

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Pt. has surgery in 3 hours but take her multivitamin every morning. True/False: The nurse should withhold the medication before surgery

True: this is not a vital medication

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Surgical Time Out

ID right pt., right procedure, right site
Sponge and instrument count
Positioning

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What is the last sense to go when a pt. is under anesthegia

Hearing

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During the surgical procedure who is the advocate for the pt.?

Nurse circulator

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Where should a ground device be placed?

Place over muscle

DO NOT place over bone or extremity with joint replacement

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Pt. just under went an abdominal laparoscopic surgery 4 hours ago. The patient is complaining of pain in shoulders and upper chest. What should the nurse suspect?

Trapped gas from the surgery

Intervention: Ambulation

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General anesthesia

Total loss of consciouness

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Local anesthesia

topical or by local infiltration

Ex. skin cancer removal

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Spinal anesthesia

Use for pt. that are not good candidates for general anesthesia
Ex. elderly, frailty, heart probs

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Regional anesthesia

Nerve block

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PACU phase 1 priority assessment

LOC

Can they maintain their own airway?

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PACU Phase 1 handoff

anesthesia and circulating RN handoff to PACU RN

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PACU Phase 2 and 3 handoff

PACU RN handoff to unit RN

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What types of things are included in handoff report after surgery

Type of surgery
Type of anesthesia
VS
Estimated blood loss (EBL)
Dressings
Drains
Incisions
Temp
Health Hx
IV fluids

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Complication of surgery that the PACU RN should assess

Signs of shock | Hemorrhage

PACU RN's pt. surgical site dressing is beginning to show blood through the dressing. True/False: The nurse should remove the soiled dressing and put a new dressing on to prevent infection and assess bleeding

False: the nurse should just "reinforce" the dressing. This means placing a new dressing OVER the old dressing. The first dressing change should be done by the HCP

What drains use negative pressure to drain fluids?

Jackson-Pratt | Hemovac

What should the nurse label a dressing with?

Date, time, intials

Penrose drains are primarily used for what type of surgery?

Abdominal surgeries

Gas exchange complication

atelectasis | pneumonia

Gas exchange interventions

Incentive spirometer Turn, cough, deep breath ambulation

Perfusion Complications

Venous stasis DVT PE Hemorrhage

Perfusion Interventions

``` TED SCD Ambulation doriflexsion anticoagulants monitor blood loss (H and H) Dressings ```

Surgical site infection assessment

``` Drainage Pain redness Heat tenderness Odor Swelling ```

Prevention of surgical site infection

``` Admin antibiotics Sterile dressing and changes Know risk factors for infection Prevent hypothermia during surgery Effective preop skin prep ```

Wound Dehiscence

Serration of wound edges

Wound Evisceration

protrusion of intestinal contents through wound Apply sterile gauze Notify HC immediately

Fever 2 days after surgery can be in indicator of what respiratory complication?

Atelactesis

GI complications

Abd distension Constipation Postop ileus

GI interventions

``` Ambulation Bowel rest stool softeners chewing gum Help control N/V I and O ```

GU Complications

Urinary retention Decreased urinary output Incontinence

GU interventions

I and Os Bladder scan Remove foley as appropriate Encourage fluids

Surgical Pt. being discharged. What signs should the nurse teach the pt. about when to call the HCP?

Excessive bleeding yellow/foul smelling drainage Temp greater than 100.8

What type of discharge teaching should the nurse provide to the pt.?

Written and verbal

Celluitis

diffuse infection of the dermis and SQ tissue | Tx: vary depending on causative agent

MRSA

Decrease risk by giving CHG baths prior to surgery

Risk Factors for surgical complications

``` Pre-existing conditions (COPD, asthma, sleep apnea, smoking) Kidney issues - excreting anesthesia Malignant hyperthermia Age Obesity Immunocompromised Urinary issues - inability to excrete urine Cardiac Hx ```

Post surgery Issues

``` Hypovolemic shock Hemorrhage Wound infection DVT, PE Urinary retention anesthesia reaction ```

Which lab result is concerning for a pt. going to orthopedic surgery? a. ) Ca 9.2 b. ) INR 2.6 c. ) Hemoglobin 10.5 d. ) K+ 3.5

INR 2.6

Pt. going for surgery smokes 2 packs of cigarettes a day. What is this client at greatest risk for? a. ) Wound infection b. ) Hemorrhage c. ) Atelectasis d. ) Postoperative ileus

C Atelectasis: because bad lungs, more at risk for lung probs

What is the minimum age a person can consent to surgery in Alabama

14 years old can consent to their own surgeries

What assessment is most important for the client who has delayed surgical wound healing? a. ) Family Hx b. ) Serum albumin and prealbumin c. ) Hx of Kidney stones d. ) K+ levels

B - Albumin and prealbumin, measure of nutrition | Nutrition effects wound healing

What type of anesthesia is used for a pt. undergoing an EGD? a. ) general b. ) regional c. ) local d. ) Moderate sedation

D- moderate sedation

What is NOT a risk factor for respiratory depression with PCA? a. ) obesity b. ) middle age c. ) advanced age d. ) Low body weight

B - middle age

Moderate Sedation

Able to breath on their own

Which meds can NOT be used with PCA a. ) nerve meds b. ) acetaminophen c. ) NSAIDS d. ) Fentanyl

D- Fentanyl

Which med is NOT acceptable for a NPO patient? a. ) Aspirin oral b. ) labetalol c. ) Digoxin d. ) pantoprazole

D - Pantoprazole

Which of these tests is used to r/o pneumonia? a. ) CT scan b. ) Chest x ray c. ) MRI

B - Chest X ray

RN is talking o client about cellulitis. What description is NOT correct? a. ) can occur in many different settings, typical unilateral b. ) Caused by gram positive bacteria such as Staph A or Strep P c. ) Infection of dermis and SubQ tissues d. ) Collection of pus within the dermis and subQ tissue

D- Collection of pus within the dermis and subQ tissue

Client is recieving PO pain med for pain 9/10 at 1100. When is the follow up? a. ) 1115 b. ) 1215 c. ) 1200 d. ) 1230

C - 1200

Which population is most likely at risk for inadequate pain control a. ) AOC X 3 b. ) Current Hx of cocaine use c. ) Proficient bilingual client

b - Current Hx of cocaine use

The nurse is assessing the pt. surgical dressing. What is not considered an emergency situation? a. ) Sx dressing is saturate through multiple reinforcements b. ) Organ tissue is protruding out of the exposed wound c. ) Wound bed edges are slightly separated with scarce drainage

Which is NOT a Tx option for malignant hyperthermia? a. ) meds b. ) Ice c. ) fluids d. ) K+

D- K+

Client is ready to have a PICC line placed. What is most important task performed in the intra-op phase? a. ) Assessment of drain tubes placed b. ) Understanding of surgical procedure c. ) Surgical time out d. ) Reviewing previous surgery Hx

C- Surgical time out

Client is concerned about robotic procedure. What is NOT an advantage of robotic procedures? a. ) Less dexterity b. ) Shorter recovery time c. ) Less puncture wounds d. ) Less pain

A - Less dexterity

Pt. jsut came back from oral procedure. What is the priority assessment while in PACU? a. ) O2 sat b. ) Pain c. ) LOC d. ) RR

C - LOC

RN assessing surgical site of a pt. from Sx. What is NOT indicative of risk for surgical site infection? a. ) WBC of 100 b. ) Taking steroids for asthma c. ) Moderate serosangious output from drain d. ) Being 100 years old

C - Moderate serosangious output form drain

Client receiving IV Dilaudid PCA pump. What makes you concerned about pt. potential RASS score? a. ) Wife hitting button for pt. b. ) pt moans with deep breaths c. ) Pt. is easy to arouse

A - wife hitting button for pt

Client is ready for discharge. What action BEST tells the RN the client can empty the drain properly? a. ) Reading discharge instructions b. ) Return demostration c. ) Have significant other empty the drain

B - return demostration

RN is assessing arm of pt. What is a major complication of celluitis? a. ) Overuse and misuse of systemic antibiotics b. ) Bleeding from biopsy site c. ) blood culture inaccuracies

A - Overuse and misuse of antibiotics

Tissue Integrity/PeriOp Care Flashcards

(70 cards)