Week 1: Surgical nursing Flashcards
(114 cards)
1
Q
Define the preoperative phase
A
time period between the decision to have surgery and the beginning of the surgical procedure.
2
Q
Who completes the preoperative patient interview, what is its purpose and what is involved in it?
A
Completed by: nurse
Key points:
- to ensure continuity of care
- completed the day of or in advance
- can occur at hospital’s pre-admission clinic/ward or the surgeon’s rooms
Purpose:
- obtain patient information
- gain consent
- clarify information with the patient
- plan post-operative care
- assess patients’ readiness for surgery. (well supported, all questions answered?)
- implement support/targeted education
- ensure all blood work and pre diagnostic tests have been completed and are accessible during surgery
- to identify risk factors e.g. allergies, comorbidities
What is included:
- education
- preparation requirements e.g. bowel and fasting prep
3
Q
What are some supports/education points that may be included in the preoperative interview?
A
- what pain to expect post-op + how to manage this
- deep breathing and coughing exercises
- mobility and body movement
- pain management
- fasting requirements
- preparing the bowel
- preparing the skin
4
Q
What are some common comorbidities that cause
risk factors for someone undergoing surgery?
A
comorbidities
- endocrine dysfunction, cardiovascular, respiratory, renal, hepatic disease
- allergies
- smoking
- obesity
- nutritional status
- age
- genetic factors
- some current medications will need to be ceased and/or withheld either in the leadup to surgery or on the day of surgery. The Anaethetist and Surgeon, +/- other medical staff in the treating team, will decide which medications this will relate to.
5
Q
What medications should be stopped before surgery?
A
Combine oral contraceptives Stop 4 weeks prior Risk of venous thromboembolism Before any major surgery Before any leg surgery Before any surgery that has a prolonged period of immobilisation E.g. oestrogen and progesterone pill
Hormone replacement therapy
Stop 4-6 weeks prior
Risk of blood clots
Restart when fully mobile
Antidepressant 2 weeks prior Gradually withdraw Risk of arrhythmias and hypotension Inform anaesthetist if continued
Lithium (mood stabiliser)
Stop 24hrs prior
Stat constant fluids and electrolytes (avoid toxicity)
Potassium-sparing drug
ACE inhibitors/ARBs cause severe hypotension
Risk of hypokalemia as they act as diuretics and can impair renal perfusion cause tissue mage
Antiplatelet/oral anticoagulants
Consider and discuss stopping these medications
Use Heparin during surgery (a drug that prevents blood clots)
Risk of bleeding
Diabetes
Put patients on insulin for surgery
Give infusion of glucose w/ potassium and insulin on a sliding scale.
Once the patient begins to eat again, start SC insulin before breakfast and stop IV 30 mins after
6
Q
Why is stress detrimental in surgery?
A
The stress response impacts the boys ability to meet the demand of surgery, therefore complications and delayed recovery may occur.
7
Q
What is stress response influenced by?
A
Age
- youth: scared to leave family
- elderly: may see surgery as a sign of functional decline
Past experiences
- aesthetic recovery
- pain
Current health
- well/unwell
- pain
- comorbidities
- undetermined results of surgery
Socioeconomic factors
- employment
- income
- family/support
Emotional response to stress
8
Q
What are some common stress creating fears that people experience when due for surgery?
A
- dying
- pain
- waking up during surgery
- waking up with poor effects from anaesthesia e.g. vomiting
- length of hospital stay (income)
- recovery
- loss of previous function
- impacts on their quality of life
- body change issues
- not coping with self-care on discharge
9
Q
What is the impact of a nurse who acknowledges and treats a patients fears?
A
Nurse can alleviate some stressors and prevent the effects of the stress response e.g. delayed recovery and complications.
How is this achieved?
- education= restoring self esteem and empowering control
- appropriate language (avoid medical jargon, explain to the level of education and age, arrange interpreter)
- clear communication of patient concerns with their medical team
- provide targeted education e.g. run though the exact procedure- how the anesthetic will be given
10
Q
Describe preoperative education and how it should be delivered.
What three categories can it be divided into to?
A
Pre-op education should be provided in a targeted way. It may target areas such as;
- diagnosis
- procedure
- what to expect post-operatively
- expected time of admission
- what to do if any complications arise once discharged
- the role of patient’s carer
- how to manage pain
- sensory info
- procedural info
- process info
11
Q
Describe the sort of information that may be provided preoperatively that could be considered sensory information.
A
- expected noises
- expected odours
- expected temps
- lights that maybe on
12
Q
Describe the sort of information that may be provided preoperatively that could be considered procedural information.
A
- what to bring
- how to prepare your body
- expected time to arrive
- what to wear
- fasting instructions
- how/when to take any skin/bowel preps
- what meds should be avoided or not missed
- pain expectations (analgesic can be taken/will be provided)
- will IV line be inserted?
- deep breathing exercises
13
Q
Describe the sort of information that may be provided preoperatively that could be considered process information.
A
- patient registration area
- admission area
- waiting rooms
- paper work that needs to be provided
- preoperative holding bays
- PACU area (recovery)
- waiting room for family/carer
14
Q
What is the role of a GP pre operatively?
A
- make initial assessment + initial prelim diagnosis
- referral to specalist/surgeon
- involved in discharge (would review, additional prescriptions, further referrals)
15
Q
What is the role of a surgeon pre operatively?
A
- determines what, why and how surgery needs to be performed
- interview patient prior to surgery
- obtain consent
Ensure adequate disclosure of;
- diagnosis
- purpose of surgery
- potential complications/risks - consequences of procedure
- probability of outcomes
- prognosis if procedure is not completed
16
Q
What is the role of an anesthetist pre operatively?
A
- determine PMHx
- determine PSHx and GA history (including complications)
- assess patients airway/resp system
- assess patients weight
- determine and plan the provision of aesthetic drugs
17
Q
What factors determine the preparation for surgery?
e.g. the patient interview performance
A
- the facility
- types of surgery performed
- inpatient/outpatient
outpatients - the pre-admissions nurse would have called 1-2 days prior to surgery to confirm day / time of arrival, where to present, expected routine, what to bring to hospital, what to wear, who will be the patient’s responsible person for discharge purposes.
18
Q
What is the nurse’s role on the day of the procedure?
A
- prepare patient
- hand over any information that must be provided to the surgical team (e.g. pt wearing a ring)
- ensure correct patient ID (2 bands- red band if has an allergy)
- ensure patient interview has been completed
- patient education is sufficient
- complete nursing assessment
- communicate findings with surgical team + document
- complete pre op prep
e. g. ensure patient remains nil by mouth, restrict food/fluid= reduces risk of pulmonary aspiration + post op nausea/vomiting
e. g. removal of all jewellery
e. g. correct clothing
19
Q
Explain why a patient needs to be restricted from fluid and food pre op and what can occur if it is not completed.
A
aka Nil by mouth
- reduces the risk of pulmonary aspiration and postoperative nausea / vomiting
Failure to be NBM can result in cancelling/postponing surgery
20
Q
What are the current fsting guidelines?
A
Light breakfast (tea+ toast) 6hrs prior to surgery
Max 200mls clear, unsweetened fluids up to 2 hrs prior to surgery= postoperative dehydration can contribute to postop complications such as nausea and vomiting
Other guides;
Morning procedure= from midnight
Arvo procedure= have a light breakfast before 0600 then NBM
21
Q
Explain why metal (including a prosthetic) can not be worn during surgery?
A
Diathermy machine used in surgery for electrocautery.
- generates electricity to heal seal blood vessels.
Patient requires a grounding plate to be attached to their skin
If the grounding plate is placed near metal (jewellery or prosthesis) - it can cause an electrical arc, resulting in burns to the patient. If near oxygen, this arc can also cause a fire in the theatre.
All jewellery and prosthesis must be removed- if unable they mist be taped and surgical team informed!
22
Q
What is the correct surgical attire?
A
Different for every surgery and venue.
Peads= may be able to wear button down pjs for example. Adults= hospital gowns, caps
Outpatients sometimes allows for patients to wear their own underwear-
Bras must not be worn as wire is an issue and chest must be fully and easily accessable.
23
Q
Describe the use of the premedication= H2-receptor antagonist
A
prescribed for patients at an increased risk of gastric regurgitation
examples - dispersible ranitidine
24
Q
Describe the use of the premedication= Benzodiazepines
A
- reduces anxiety
- induces sedation
e. g. midazolam, diazepam, lorazepam
25
Describe the use of the premedication= opioids
- reduce anxiety
- provide analgesia
e.g. morphine, fentanyl
26
Describe the use of the premedication= Antiemetics
- increase gastric emptying and therefore reduce risk of nausea and vomiting
- e.g. metoclopramide, droperidol
27
Describe the use of the premedication= Anticholinergics
- decrease oral/resp secretions and prevent bradycardia
e. g. atropine, hyoscine
other- antibiotics, eye drops, routine meds, insulin
28
What are some extra, uncategorised requirements of surgery?
- all cosmetics to be removed (including nail polish as unable to visualise cyanosis if hypoxemia and inaccurate pulse oximetry readings)
- patient can not wear perfume (alcohol is flammable)
- ensure aids such as (glasses/ hearing aids) stay with vulnerable patients as long as they need to ensure reliable communication
- ensure patient uses toilet before going to theatre (urine specimen if necessary)
- some patients require anti-thrombotic stockings (TED stockings) to be applied on the day of surgery
29
What is the goal of the preoperative nursing assessment?
- establish baseline data to compare intraoperatively and postoperatively.
- confirm patient ID
- confirm procedure type + location
- determine patients psychological readiness and ability to cope post op
- determine any physiological factors that may result in intraoperative or post-op risk factors
- identify if the patient is taking any over the counter medications, herbal or naturopathic remedies or prescribed medications that may result in drug interactions and affect outcome
- identify any cultural or religious factors that may affect the patient's surgical experience
- determine if the patient understands what procedure will be performed and if they have received adequate information
30
What 6 components make up a pre-op nursing assessment?
- correct patient ID
- Past history
- social history
- Medications
- Physical assessment/examination
- diagnostics
31
Explain how you can ensure you have the correct patient in a pre op nursing ssessment.
Check;
- name band
- check paper work
- get them to verbally say it
Check name, DOB and address or UR
32
What would you be asking for in a past history pre operative assessment?
- past surgeries (any anaesthetic concerns?)
- all previous medical diagnoses
- current comorbidities
- any previous pregnancies (date, delivery type)
- past hospitalisations
- family history
- any allergies e.g. latex, tapes, medications, iodine?
33
What would you be asking for in a social history pre operative assessment?
- who do u live with?
- are you married?
- are you employed
- smoker?
- alcohol?
- who is your next of kin?
34
What would you be asking for in a medications pre operative assessment?
- what are you currently taking? dose? time?
- what have you previously stopped?
- have you had them the day of surgery?
- any allergies
- any known adverse effects?
- any over the counter (including creams)
- any herbal/supplements/alternative meds?
- did u bring them to the hospital?
The nurse should be particularly concerned about anticoagulants, immunosuppressants, anticonvusants, narcotics, antihypertensives, sedatives, endocrine replacement medications - missed / taken doses can result in complications such seizures, haemorrhage, withdrawal
35
What would you be asking for in a physical assessment/examination pre operative assessment?
- baseline vital signs - HR, RR, BP, SpO2, temperature
- weight
- height
- BGL
When assessing systems (if required), target specific questions to determine if the patient has any potential disorders i.e. hypertension, asthma, GORD, history of falls, altered sensation to limbs, incontinence, vision / hearing loss etc.
36
What would you be asking for in a diagnostics pre operative assessment?
During the preoperative interview / assessment-> nurse's responsibility to ensure all imaging / investigations ordered preoperatively are available either in the patient's chart or online.
Any abnormal results should be conveyed to the medical team prior to surgery:
- urinalysis
- BGL
- ECG
- CXR, USS, MRI
- bloods - electrolytes, full blood count, coagulation profile, drug levels, blood type and cross match
- BHCG (pregnancy test)
- swabs
37
What is included in a theatre checklist?
- Patient ID (2x ID bands, white= no allergies, red= allergies)
- Consent (ask if patient has given written consent, confirm consent have been signed and visualised)
- allergies
- patient preparation (NBM? pre meds? pregnant- tested?
- Patient alerts (are they isolating? why?, so spinal precautions need to be followed?)
- Protheses (any metal screws?, pacemaker? AV fistula? orthodontic bands?)
- Dental (lose teeth, caps, crowns, dentures, partial plate)
- Communication aids (glasses, hearing aids)
- Belongings (jewellery needs to be removed, valuables in safe?)
- Charts (all up to date)
- Diagnostics (results of all investigations)
38
Describe transportation to theatre
- call will be made to ward nurse that is caring for patient that theatre team is ready
- an orderly/patient transporting in the hospital will be contacted and they will transport patient.
- Rn that completed the check list will escort patient to theatre
- ensure all documentation is handed over
- handover given to the perioperative nurse
- all checks need to be performed prior to the ward nurse leaving
- correct patient
- theatre checklist completed and checked
- all paperwork, including consent, with the patient
39
Define the intraoperative phase
phase that extends from the time the patient is admitted to the theatre holding bay until the patient is transported to post anaesthesia care unit (PACU) for recovery
40
What does PACU stand for?
post anaesthesia care unit
41
Describe the intraoperative journey and all the places.
- peri operative holding bay
- Handover
- Medical review
- Operating room
42
What occurs in the peri-operative holding bay of the intraoperative journey?
- specialised waiting area adjacent to the operating rooms
- often contains multiple bays for numerous patients
- minor procedures can occur in this area
e. g. IVC / ART line insertion, removal of casts, dressings
- patient's family/carer can occasionally accompany the patient into the holding bay for support and to reduce anxiety
- young children / elderly / confused
43
What occurs in the handover of the intraoperative journey?
- Perioperative nurse receives handover from the ward nurse in the holding bay
- follows the theatre checklist already completed by the ward nurse
- confirms patient identification in front of ward nurse
- patient verbalises full name, date of birth and current address
confirmed as positive match with patient labels on documentation
- correct patient ID bands x two
- determines if the patient has any allergies
- patient verbalises known allergies and reactions
- if allergies confirmed - red hair cap and red ID bands
- confirms planned procedure
patient verbalises procedure and location of procedure
confirms consent has been signed
- patient to verbalise that they have signed a consent
- reviews patient assessment
- performs another set of vital signs
- Determines if pre- medications administered if ordered
- Determines how long the patient has been fasting for
44
What occurs in the medical review of the intraoperative journey?
surgeon= consultant or registrar will check in with the patient and provide an update on progress
anaesthetist=
- airway / respiratory assessment performed if not completed on ward / pre-admission clinic
- some organisations will transport the patient to an anaesthetic holding bay
- IVC inserted
- IV fluids commenced
- occasionally a sedative will be admisistered at this time to ensure the patient is relaxed prior to entering the operating room
45
What occurs in the operating room of the intraoperative journey?
- Environmentally controlled room with restricted access to reduce the risk of infection
often located with easy access to ICU
- provides proximity to medical / nursing assistance if needed urgently due to a complication
- the patient will be transferred into the operating room on a trolley
- transferred off trolley and onto operating room bed
monitors and other operating equipment attached e.g. BP cuff, pulse oximetry, electrodes for ECG monitoring, armboards for arm stabilisation of arm with IVC inserted to prevent dislodgement
- diathermy grounding plate
patient receives anaesthesia
procedure performed
46
Explain some infection control measures in the intraoperative environment
- strict hand washing and PPE restrictions
- sterile felid established
- clear clean and dirty items in storage
- smooth, one way floe of patients, staff and equipment
e. g. clean-> dirty
e. g. holding bay-> anaesthetic bay -> OR -> recovery-> ward
47
What are the three distinct zones of an OR?
Unrestricted
- central point designed for monitoring / control the flow within the theatre
- entry / exit of staff, patients, equipment, stores / stock
- includes holding bay, staff pick-up points, reception area, PACU
- staff can enter this area in their everyday clothes / uniform
Semi restricted
- support areas and corridors within the perioperative space
- includes store rooms, medication room, PACU corridors that lead to restricted areas
- staff can enter this area while wearing theatre scrubs or hospital gowns over everyday clothes / uniform and with shoe coverings
Restricted
- operating / procedural rooms, scrub bays, roms / areas for preparing sterile stock / equipment, sterile stock store room
- can only be accessed through semi-restricted zones
- full PPE, theatre scrubs and shoe coverings can only be worn in this area
48
What is the role of the perioperative nurse in the intraoperative space?
To work closely with surgeons, theatre technicians, anaesthetists
- a registered nurse who implements patient care during the perioperative phase
- specialised, critical care role with high-level skills
- advanced patient assessment skills
- airway management, cardiac monitoring, haemodynamic monitoring, fluid balance
- asepsis
- surgical procedures (surgical methods / equipment / instruments)
- including an in-depth understanding / management of surgical complications
- good understanding of anaesthetic methods, agents and equipment
- scrubbing / gowning / gloving, PPE
- specific roles include scout nurse, instrument nurse, anaesthetic nurse, recovery nurse
49
What is a PCA? and what are its features
Patient controlled analgesia (PCA)
- can have a bolus or continued dose plus an amount that a patient can push button initiate when they want more.
- commonly used post-op
50
What are the advantages of a PCA
- helps avoid analgesic peaks and troughs
- enables patients to receive pain relief without delay
- increases the patient's sense of control- empowerment/autonomy
- opioid blood concentrations are maintained within therapeutic ranges
- prompt management of pain caused by activity
- patients are able to anticipate when they ay have increased pain in movements such as coughing or showering and provide themselves a bolus dose in advance.
- enables increased patient mobility
51
What are the three modes of a PCA?
PCA mode only → demand dose, the patient will only receive a dose of analgesia when they press the PCA button, there is a lock-out period after each bolus dose self-administered by the patient as a safety measure
Continuous infusion → a background infusion where the patient will receive a continuous dose of analgesia, cannot be altered by the patient
Continuous infusion with additional demand analgesia → the PCA is set for a continuous background infusion as per orders but the patient can self-administer an additional bolus of analgesia as required
52
What are key points of nursing management for a PCA?
1. Always review the medical order, including the section on reportable observations
2. RN must have a thorough understanding of the medication being administered, including common adverse effects
3. When caring for a patient on a PCA, the following reviews / assessments should be performed hourly, unless indicated by the medical orders or organisational clinical practice guidelines:
- vital signs
- assess your patient for CNS effects of opioid overdose → respiratory depression, drowsiness, confusion
- pain assessment
- device review to ensure there are no problems such as leaking around connections / kinked tubing
- IVC assessment
- documentation
53
What should be continually measured and managed with a PCA?
- the number of PCA demands versus dose deliveries are documented to evaluate its effectiveness
- if the demands are high compared to the doses delivered, the patient needs reassessment → notify your buddy nurse
- PCAs are only suitable for patients that have a clear understanding of the use → patient's with a cognitive impairment will not understand the concepts of self-administering analgesia and they will not be able to comply with the instructions on how to use the device
54
What is the role of a scout nurse in the intraoperative space?
aka circulating nurse
- a non-sterile member of the OR team
Broad role
- coordinates all activities in the OR
- must have advanced critical thinging skills
- must always be aware of what going on in the room.
- implements nursing plan of care
- prepares OR
- checks stocks, supplies and instruments
- supports instrumental nurse
- supplies sterile team with instruments
- preps skin
- acts as a patient advocate who meets family
- documents all cares that patient receives - documents the sound at the end of the procedure with the instrumental nurse
55
What is the role of a instrumental nurse in the intraoperative space?
aka scrub nurse
- sterile member
Wear additional sterile gown and gloves
Broad role
- setting up and handing sterile supplies / instruments to the surgeon
- close working relationship with the surgeon
- performs surgical count post procedure with the scout nurse
- needs to maintain an accurate count of all accountable items used throughout the procedure
- closely monitors the intra-operative environment and the aseptic status of the surgical team
- patient advocate ensures patient wishes, dignity and safety is maintained while the patient is under anaesthetic
- surgical safety checklist
- maintaining asepsis
- documentation
56
What is the role of an anaesthetic nurse in the intraoperative space?
- includes both anaesthetic and post-anaesthetic nursing care
- will meet with the patient in the holding bay prior to surgery
- assistant to the anaesthetist
- specialty role includes
- prepares all equipment required for airway management
- ensures all medications are available to maintain anaesthetic event
- direct patient care during the continuum of anaesthesia
- pre-anaesthesia
- intra-operatively
- post-operatively
- receives the patient into the operating room
- checks patient ID and consent
- assists with airway management
- assists with patient monitoring during anaesthesia
- cardiac
- haemodynamic
- will have advanced life support qualifications
- in-depth understanding of the surgery and possible complications
- in-depth understanding of anaesthetic drugs and all possible complications
- ensures patient comfort during procedure
- warmth
- pressure areas
- assists with patient care as the patient emerges from anaesthetic
- patient advocate
57
Define anaesthesia
A pharmacologically induced lack of sensation. Involves the complex administration of a number of medications.
58
How is the type of aesthetic chosen for a patient?
- type of surgery
- muscle relaxation required?
- patients's PMHx and comorbidities
- current patient wellness
- equipment available at venue
- allergies
- skills of operating team
59
What is the goal of anesthesia?
to manage the biological responses to surgery while minimising patient risks
60
What are the classifications of anesthetic?
- general
- regional
- local
- procedural
61
Describe GA
- loss of sensation and loss of consciousness
- combination of sedation, analgesia and muscle relaxants (can be combined routes of admission e.g. IV and inhalation)
- Muscle relaxants= patient losses sympathetic nervous system reflexes e.g gag, cough, vomit
- requires advanced airway management (e.g. endotracheal intubation- ET, laryngeal mask)
62
What are some advantages VS disadvantages of a GA?
Advantages
- allows for adequate muscle relaxation for prolonged periods of time
- is easily adaptable in a procedure that may have an unpredicted extent and duration
- can usually be administered rapidly
- facilitates complete control of the airway, breathing and circulation by the anesthesiology
- allows for multiple surgeries to occur over multiple parts of the body
- can be administered a patient in a supine position
Disadvantages
- requires multi-disciplines and a variety of health care professionals
- requires complex and expensive equipment
- carries major risks of complications including resp distress, death, MCI and cerebrovascular accidents
- requires continued intervention
- associated with less serious complications such as nausea or vomiting, sore throat, headache, shivering and sedation
63
Describe regional anaesthetic
= a loss of sensation to a region of the body without loss of consciousness
Mode of action= nerve block achieved with administration of a local anaesthetic into a nerve bundle
- used for procedures that can be invasive but the risks for general are too great eg amputations, caesarean section, skin grafting
- will result in long lasting loss of movement and / or sensation to a region
eg leg after knee surgery = patient will be unable to weight bear due to no sensation to leg / foot
64
Explain the regional anaesthesia- spinal
- ‘one-shot’ injection of anesthetic into the CSF (which bathes the spinal cord)
- spinal block can be used for surgeries on lower limbs, e.g. a knee replacement, or a caesarean birth
- a spinal anaesthetic will block muscle movement and sensation for a few hours
- managing a spinal block postoperatively is an advanced nursing skill with hypotension as a common side effect
65
Explain the regional anaesthesia- epidural
- anaesthetic is injected into the epidural space
| - patients often have a continuous infusion and anaesthetic for 4-5 days postoperatively
66
Explain the regional anaesthesia- caudal
- ‘numbs’ the perineal area
| - useful for post operative analgesia, e.g., a haemorrhoidectomy
67
Explain dermatome levels and how they are measured
Dermatome= the area of skin that is supplied by a single spinal nerve.
- our sensory fibres respond to pain, temperature, touch and pressure and are similarly affected by local anaesthetic drugs
- nurses need to assess the patient to determine the level of where the patient is ‘blocked’ to
- the ice test is used to check for sensation
- both left and right sides must be assessed and compared
- https://c8.alamy.com/comp/ADTWMF/the-dermatomes-ADTWMF.jpg
68
Explain bromage scores and how they are measured
=used to assess movement ability of the lower extremities after regional anaesthesia administered
- rates the patient’s ability to move their feet and legs
- patient's recieved a score from 0 (full movement) to 3 (no movement)
- please see this image of the bromage assessment for further information
Motor block assessment should be conducted as per the following and until full sensation / movement has returned:
- in the recovery room
- on return to the ward / unit from the operating suite
- at the start of each shift
- prior to ambulation
69
Describe local anaesthetic
- loss of sensation without loss of consciousness
- induced subcutaneously via infiltration (needle through the skin)
- can be administered topically - nebulised, ointment / cream (EMLA, ANGEL cream), aerosolised
- used for minimally invasive procedures eg removal of a skin cancer, suturing, removal of a foriegn body, insertion of IVC, collection of bloods
- please see the linked table on common types of local anaesthesia
70
Describe procedural sedation
- similar to general
- loss of sensation with loss of consciousness
- sedative (eg propofol), analgesic, and / or anxiolytic (medication to reduce anxiety eg midazolam)
- patient can usually maintain their own airway
- patients may require airway management if deep sedation required to complete procedure
- used for short, minor procedures eg joint relocations, paediatric suturing, fracture reductions, eye surgery, colonoscopy
71
What are the stages someone follows when they for though anaesthesia?
1. Analgesia
- from beginning of induction with propofol to unconscious
- patient has decreased awareness of pain and has amnesia
- resps are normal
- ends with loss of consciousness
2. excitement
- from loss of consciousness to beginning of regular respiration
- patient has enhanced reflexes- they may try to talk, move around, may vomit
- HR and BP may rise
3. surgical anaesthesia
Four planes of anaesthesia;
Plane 1 – light anaesthesia
Plane 2 – loss of blink reflex, no longer responsive to non-painful stimuli, reflex-like responses to pain
Plane 3 – deep anaesthesia; no movement. Airway and breathing assistance needed
Plane 4 – diaphragmatic respiration only, cardiovascular and respiratory support needed
4. Medullary dilated pupils
- fixed and dilated pupils
- cessation of breathing and circulation
- death
72
List some complications in the intra-operative complication
- cardiac arrhythmias
- aspiration of stomach contents
- hypoxaemia
- hypovolaemia
- laryngeal trauma / - laryngospasm
- broken teeth (from difficult intubation)
- hypothermia (from the
- lower temperature in theatre and having internal organs exposed)
- infection
- thrombosis
- haemorrhage
- nerve and tissue damage (from poor body alignment intraoperatively)
- electrical shock or burns (from the diathermy)
- wrong side / site of operation
- medication error including anaesthetic toxicity
- unknown allergy to anaesthetic drugs
- retained surgical items
- stroke
- cardiac arrest
73
Define the postoperative
the postoperative period begins immediately following surgery when the patient is transferred to recovery and continues until the patient is discharged from the venue. Depending on the type of surgery that was performed, this phase can be brief, only lasting a few hours, or it can be prolonged and involve many months of rehabilitation.
74
Where does recovery take place?
aka PACU
- located in close proximity to the OR
- area designed to provide expert, focused nursing care immediately following surgery, while the patient is vulnerable and recovers from the effects of anaesthetic
On arrival to PACU, patients are usually:
- in a compromised state eg no / slow reflexes, abnormal vital signs, sedated / unconscious
- at risk of losing their airway patency
75
What are some keys to preventing adverse events post surgery and anaesthetic?
Close observation / monitoring
- frequent vital sign assessment - eg every 5-15 minutes, depending on the state of the patient
Regular reassessments
- airway, respiratory function, wounds, drains
Early recognition of deterioration
Prompt escalation and intervention
Administration of medications
- antiemetics, analgesia - usually by IV route
76
Explain key points in the ISBAR from the OR to PACU
- patient escorted by Anaesthetist and perioperative nurse
- usually requires 100% O2 being delivered via hudson mask
- detailed clinical handover provided using ISBAR tool
- vital sign trends
- volume loss - blood, urine, fluid
- temperature throughout
- wounds / dressings / drains
- medications administered
- current infusions
- any intraoperative event
- plans
77
Briefly outline what would be involved in a primary , secondary and focused post operative assessment.
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Primary
DRSABCD
- Danger
- response (conscious state)
- airways
- breathing
- circulation
- disability (BGL, conscious state/sedation score)
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Secondary assessment
- systematic head to toe assessment
- Do they look well
- pain assessment
- check for abnormalities
Focused assessment
- type of focussed assessment is specific to the surgery that was performed
surgical site assessment - dressings, drains, incisions, blood loss
neurological / neurovascular assessments
For example:
- a patient who has had a spinal anaesthetic will require dermatome levels checked
- a patient who has had a caesarian section will have the wound, blood loss, PV loss and the height of the uterus assessed
- a patient who has had an appendectomy will have the surgical wound and bowel sounds assessed
- a patient who has had a colonoscopy will have bowel sounds assessed.
The recovery nurse must also re-orientate the patient, and provide general nursing care such as reassurance, provision of a warm blanket for comfort, etc.
78
Who assesses the patient to determine if they are ready for discharge?
PACU nurse
79
What factors determine where the patient may be discharged too.
- depends on the type of ward the patient is being transferred to e.g. ward vs ICU
- the patient must be stable and their vital signs must be within normal limits and not close to or within MET call criteria
- airway, breathing, circulation
- there are numerous scoring tools available to determine the patient's readiness for discharge from PACU
80
What is a discharge criteria?
Discharge criteria will differ according to the ward the patient is being transferred to e.g. HDU, ICU, day surgery, ward.
There are numerous scoring tools that can be used to determine if the patient is ward ready. These tools will vary between healthcare organisations. Please see the previous point on various scoring tools.
Essentially, the receiving RN must:
assess DRABCD, vital signs, conscious state and wounds – must be an independent assessment, compare findings with the last assessment completed by the PACU nurse
- review the medication chart
- ensure orders are available for analgesia, antiemetics, ongoing fluids if required
- for a Day Surgery patient, check if a ‘take home’ script is required
- review additional documentation i.e. the fluid balance chart
- ensure the medical orders are clear and understandable
- ensure all documentation is completed and with the patient for transfer
- ensure the patient is comfortable.
81
What should be completed in the first 4hrs post op?
A full assessment and compared them to the findings with pre-op baseline values
DRABCD - airway, breathing, circulation
secondary and focussed assessments
vital signs - HR, RR, BP, SpO2, temperature
neurological assessment - level of consciousness, sedation score = AVPU tool, GCS
neurovascular assessment - ability to move all limbs
surgical wounds - type / number of dressings, drains, evidence of bleeding / exudate on dressings
pain assessment - FLACC, PQRST, pain score
IV assessments - IVCs, patency, type of fluid, rate, how much fluid has already been administered, additional orders
urine output - IDC assessment if insitu, time of last void
assess all drains / tubes - NGT, IDC
assess for nausea / vomiting - ensure emesis bag is within reach
BGL - as per orders
document all findings
82
What should be the frequency lf assessments in the first 4 hrs post op?
Reassessments will need to occur as per organisational guidelines, but is usually:
- every 30 minutes until stable
- then hourly for the next 4 hours
- then every 4 hours for the next 24 hours
83
What are the potential post op complications?
Most postoperative complications generally occur in PACU. However, complications can still occur within the first 4 hours. Prompt escalation of concerns / abnormal findings is vital when caring for a patient in the postoperative period. MET call criteria usually includes:
- threatened airway
- bradypnoea or tachypnoea - respiratory rate <6 or >36 bpm
- hypoxaemia - SpO2 <90%
- hypotension - systolic BP <90
- bradycardia or tachycardia - heart rate <40 or >140
- sudden fall in conscious state - GCS drop of >2 points
- serious concern about uncontrolled pain
- haemorrhage - check site of surgery / dressing for bleeding
84
What are some ongoing nursing managements for someone post operativley?
- vital signs
- neurological assessments
- pain assessments
- bowel assessments
- wound assessments
- focused assessments
85
Discuss post operative movement
- aimed to prevent postop complications such as DTV, pneumonia and pain
- reduce atrophy
- encourage regular position changes
86
What are some preventatives measures agains VTE?
Prophylactic measures include
- leg exercises
- TED stockings
- pneumatic calf compressors
87
What are key practice point of wound management?
- start a wound chart
- document in progress notes
- document when wound needs to be changed
- wound assessments
88
How frequently should wound assessment be performed on surgical wound?
Assess every time you do vital signs
The postoperative period the skin around the incision should be normal colour, or it may be a slight red colour
inspect skin around the dressing for swelling, bruising → lightly palpate the skin to assess for pain / tenderness → if the patient cannot tolerate light palpation, it may indicate an emerging problem (infection) or the patient may require analgesia → explain to the patient why pain can prolong patient recovery time and increase their potential to develop complications
patient / staff should monitor for signs and symptoms of infection fever, tachycardia, increased pain, purulent drainage from the wound, tissue surrounding incision becomes erythematous (red), swollen and warm to touch infection unlikely to show in first 48 hours
- assess and document dressings / drainage → dry and intact or increasing exudate, amount, consistency and type of ooze, offensive odour
- presence of swelling / bruising around surgical site
- wound pain
89
Surgical wound dressing can be grouped into two main categories;
Primary= placed directly over wound.
- absorb drainage
- cotton gauze or synthetic dressings may be used for this purpose
Secondary dressings
- placed over primary dressing
- absorb excess drainage
- provide compression
- protect from further trauma
90
What are some other wound interventions that can be used to increase healing?
- hyperbaric oxygenation (HBO)
- negative pressure therapy
- hydrotherapy
- use of engineered living skin substitutes
- the topical application of growth factors
91
How would you manage debis in a wound?
- remove dead + devitalised tissue from a wound
- debridement of wounds may be necessary because dead tissue in the wound provides a focus for wound infection
- patients with chronic, non-healing wounds may require produces such as grafting, flaps and other wound coverage
92
What is HBO and what are its benefits?
- increases the capacity of blood to carry oxygen to the tissues
- increased oxygenation assists in cellular restoration, and improves leukocyte migration and phagocytosis, as well as fibroblast function
- HBO therapy is administered in a pressurized chamber with the patient breathing 100% oxygen at elevated atmospheric pressures.
- benefits for chronic wounds may include reduction in inflammation, oedema, and inhibition of infection.
93
What is negative pressure wound therapy and what are its benefits?
AKA vacuum-assisted closure (VAC)
NPWT= negative-pressure wound therapy
- used on patients who have complex wounds, that do not respond to traditional wound care methods
- works by using a device to apply constant controlled negative pressure to a wound that is filled with a drainage sponge and sealed with an occlusive dressing
VAC system has three mechanisms of action that interact to promote wound healing.
- 1st - negative pressure results in mechanical tension on the tissues, causing a reduction in oedema and increasing fluid removal, which provides an optimal wound environment. The fluid removal also serves to decrease the bacteria load.
- 2nd - macro-deformation and wound contraction
- 3rd - micro-deformation and mechanical stretch perfusion.
VAC therapy may be used for acute and traumatic wounds, pressure ulcers, chronic open wounds, meshed skin grafts, and skin flaps.
Potential complications when using NPWT are significant pain, particularly during dressing changes, and problems obtaining an adequate seal in irregularly shaped wounds
NPWT may accelerate granulation tissue formation and promote closure in a number of wound types, while reducing the number of painful dressing changes.
94
What are the benefits of surgical drains?
When are they implemented?
- healing
- prevent swelling
- reduce the risk of infection and skin breakdown
- reduce the need for dressing changes
- inserted at the time of surgery through a separate small stab wound incision
- drains may or may not be sutured to the skin
Implemented when;
- when surgeon anticipates large amounts of serosanguinous drainage
- release air and fluid (serum, blood, lymph, intestinal secretions, bile, and pus)
95
Describe a jackson prat drain
a tube from wound attached to bulb. Bulb squeezed, then attached to tube providing low pressure suction to drain fluid.
96
Describe a hemovac drain
low pressure closed drainage system (like JP rain); suction is maintained by compressing a spring like device in the collection unit. Larger capacity for holding draining blood/fluid than JP drain.
97
Describe a penrose drain
passive drain (no suction); flexible plastic tube placed in surgical site/wound to allow fluid to drain out
98
Describe a Pigtail/catheter
placed using radiologic (xray) guidance into organ or cavity to drain unwanted fluid.
99
Explain some nursing management of surgical drains
- check instructions for drain management
- drainage is expected to change from sanguineous (red) to serosanguineous (pink) to serous (clear drainage)
- accurate documentation
- use PPE for removal (goggles, gloves and gown)
100
What is involved in a wound assessment?
condition of the dressing→ is it dry and intact, is there ooze from the wound
suction requirements → is the drain tube patent and draining, is it on free drainage?
are the drain clamps closed or open
presence of suture/s holding the drain in place
potential signs of infection (inflammation, localised discharge, increased pain at site)
description of the type of drainage fluid in their nursing note, e.g: serous ooze, haemoserous ooze, bright blood
drainage should be documented on the fluid balance chart
- emptying drains also helps to maintain drain tube suction
101
List some equipment for removing a surgical drain
- dressing pack
- normal saline (sachet)
- stitch cutter (for stitch removal)
- sterile gloves
- non-sterile gloves
- non-adherent dressing e.g. melolin adhesive tape, hyperfix
- PPE - protective eyewear, gown or plastic apron
- rubbish bag
- procedure trolley
102
What should be done once tubing is removed?
- inspect the tip to ensure there are no tears or jagged edges of tubing
- notify the surgeon if the drain tube is not intact
- do not throw any damaged tubing out until after the surgeon has inspected it
- record the date and time the drain tube was removed in the patient notes
- record the drainage on the fluid balance chart
- reassess the the dressing for any signs of excessive drainage
103
Explain the pain assessment tool FLACC
Useful when the patient is non-verbal or has an altered level of consciousness
F = face - no particular expression / smile, occasional grimace / frown, frequent frowning, clenched jaw
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L = legs - normal relaxed position, uneasy, restless, tense, kicking or legs drawn up
A = activity - lying quietly, moving easily, squirming, shifting back and forth, tense, arched, rigid, jerking
C = cry - no crying, awake / asleep, moaning, whimpers, occasional complaint, crying steadily, screams, sobs
C = consolability - content, relaxed, reassured by occasional touching / hugging / being talked to, difficult to console
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104
Explain the pain assessment tool PQRSTU
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P = precipitating factors
Q = quality
R = radiation
S = site and severity, pain score
T = timing and treatment
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105
Explain Wong baker scale
- face pain rating scale
| - used for assessing pain in paediatric patients or patients with intellectual dysfunction
106
Explain what a multi modal pain relief pain?
It is when two forms of pain relief are used that target different components of the pain pathway in order to best treat pain.
e.g. prevent transmission and then treat perception
107
List some non pharmacological managements for pain
- heat pack
- ice pack
- position change
- help the surgical sit/injury e.g. wet perineum when urinating or splint the abdomen when coughing
- support with pillows
- patient education
108
Who is more at risk of nausea/vomiting after surgery?
- female gender
- non-smoking
- history of postoperative
- nausea and vomiting
- history of motion sickness
- age >50
Those who have had
- opioid drugs
- general anaesthetic
- inhaled anaesthetic gasses e.g. nitrous oxide
- dehydration
- prolongued surgery
- particular ttype of surgery e.g. gynaecological surgery in particular
109
Describe paralytic ileus.
and why they may occur?
The temporary impairment of gastric and bowel motility which can occur after surgery
occurs due to:
- limited dietary intake prior to surgery
- handling of intestines during surgery - more common after major abdominal surgery
- hypokalaemia
- prolonged opioid analgesic administration
110
How long does a paralytic ileus take to recover and resume function?
- small bowel motility will usually resume within 24 hours of surgery
- large bowel motility may be limited for 3-5 days postoperatively
results in abdominal distention and increased pain from flatus (accumulation of GI secretions), hiccups (irritation of the phrenic nerve)
111
List some nursing management of a ileus
- perform abdominal assessment
- bowel sounds
- encourage early ambulation and frequent repositioning - stimulates motility
- position patient on their right side - relieves gas pain as gas will rise along the transverse colon which facilitates release
- encourage patient to pass flatus rather than holding it in
- check medication chart for antiemetic orders
- mouth care if the patient remains NBM
- when bowel sounds return and the patient can recommence oral intake, gradual reintroduction is required - clear fluids, light diet, full diet
112
What should be done prior to dischrage?
Discuss
- medications
- wound care
- activities that should be avoided
- dietary requirements
- interprofessional team referrals (physio, social support, dietician)
113
What must be completed for a patient to be discharged from hospital?
- alert
- mobile
- vital signs must be within 20% of preoperative baseline values and stable for > 1hour
- have voided
- tolerating oral intake - food and fluids
- minimal pain, nausea and vomiting - can be pharmacologically controlled
- absent / minimal surgical site bleeding - no dressing changes required
- can self-care once at home
114
What are the 7 principles of pain management?
1. use a wholistic approach
- pain affects life!
2. use a combination of pharmacological and non-pharmacological interventions
3. Use a multimodal approach
4. Use an interprofessional approach
5. Evaluate effectiveness of interventions
6. Manage / prevent adverse effects
7. Educate the patient / carer
