Week 8 Flashcards

Question

Overall goal

Answer 1

The process involves establishing baseline data, confirming patient identification, assessing psychological readiness for surgery, identifying physiological risk factors, assessing medication use, identifying cultural or religious influences, and ensuring the patient understands the procedure and has received adequate information. This helps in predicting postoperative outcomes.

Answer 2

* patient (or carer if required) verbally confirms full name, date of birth and address * 3 points of identification match patient name band and all paperwork

Answer 3

* all previous medical diagnoses * current comorbidities * any previous surgeries - including dates, any associated problems, anaesthetic concerns * menstrual history * previous pregnancies - including dates, type of delivery, any associated problems * past hospitalisations * family history * any allergies e.g. seafood, latex, iodine, tapes

Answer 4

* smoker * alcohol intake * illicit drugs * history of falls * current place of employment / role * previous role if currently unemployed * does the patient live with anyone * who is the patient's next of kin in an emergency * who will be collecting the patient from hospital * who will be caring / staying with the patient after discharge

Answer 5

* known drug allergies * known adverse effects * all prescribed medications - including ones not currently being taken * over-the counter medications - including creams * herbal / supplementary / alternative * did the patient bring their medications with them to the hospital? * any medications ceased in the last month * has the patient taken any medications on the day of surgery? * 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

Answer 6

* 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.

Answer 7

* during the preoperative interview / assessment, it is the nurse's responsibility to ensure results of 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

Answer 8

○ confirm patient identity ○ patient have must have two ID bands on - usually wrist and ankle - white = no allergies - red = allergies

Answer 9

○ ask the patient if they have signed a consent ○ confirm consent has been signed by visualising the signed document ○ if consent has not been signed then the team performing the procedure need to be informed

Answer 10

○ list all known allergies, not just medication allergies - tapes - latex - iodine - medications

Answer 11

○ the patient must be nil by mouth - when was the last time the patient ate - when was the last time the patient drank ○ did the patient have a pre-medication ○ has the patient taken any regular medication on the day of surgery ○ is the patient pregnant - don't assume if a female patient is of child-bearing years, a pregnancy test must/may need to be completed

Answer 12

○ is the patient isolating - why? ○ do spinal precautions need to be followed ○ BP restrictions - previous mastectomy - regional lymph node dissection vs lymphadenectomy

Answer 13

○ does the patient have any metal / screws ○ does the patient have a permanent pacemaker ○ does the patient have an AV fistula ○ orthodontic bands

Answer 14

loose teeth, caps, crowns, dentures (full, upper, lower), partial plate

Answer 15

○ glasses / contact lenses ○ hearing aids ○ communication boards

Answer 16

○ jewellery - needs to be removed, sometimes it can be taped ○ where are the patients belongings ○ patient valuables - did the patient bring any valuables into the hospital - have any valuables been locked in patient cupboard / safe

Answer 17

○ adequate quantity of patient labels ○ all current documentation and charts ○ past history

Answer 18

○ results of all investigations

Answer 19

The patient's ward nurse is informed about the theatre/operating team's readiness for the procedure. An orderly is contacted for transport, and the registered nurse escorts the patient to the operating rooms. Documentation and XRs are transported, and bed rails are lifted for safety. A blanket is provided, and handover is given to the perioperative nurse.

Answer 20

* specialised waiting area adjacent to the operating rooms * often contains multiple bays for numerous patients * minor procedures can occur in this area ○ 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

Answer 21

The perioperative nurse receives handover from the ward nurse and follows a theatre checklist. They confirm patient identification, determine allergies, confirm planned procedure, sign consent, review patient assessment, perform vital signs, determine if pre-medications are administered, and determine the patient's fasting duration. They also verify patient's full name, date of birth, and current address.

Answer 22

The intraoperative phase extends from the time the patient is admitted to the theatre holding bay until the patient is transported to the postanaesthesia care unit (PACU) for recovery.

Answer 23

* 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 administered at this time to ensure the patient is relaxed prior to entering the operating room

Answer 24

* designed to minimise risk of infection, cross contamination and to ensure patient safety ○ clean equipment / stock is kept separate from dirty equipment / stock * smooth, one-way flow of patients, staff and equipment ○ clean → dirty ○ holding bay → anaesthetic bay → operating room → recovery → ward

Answer 25

* environmentally controlled room with restricted access to reduce the risk of infection ○ cold temperature to inhibit pathogen growth and to decrease risk of pathogen transfer ○ high-intensity lighting for precise view ○ may have ultraviolet lighting which also reduces the risk of airborne pathogen transfer ○ 50 - 60% humidity, again, to reduce growth of pathogens and to decrease static ○ dust filters ○ controlled airflow with high ventilation ○ easy to clean surfaces

Answer 26

* 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

Answer 27

* operating / procedural rooms, scrub bays, rooms / 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

Answer 28

A registered nurse plays a crucial role in the operating team, implementing patient care during the perioperative phase. They have advanced patient assessment skills, knowledge of airway management, cardiac monitoring, asepsis, surgical procedures, and anaesthetic methods.

Answer 29

* 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

Answer 30

A circulating nurse, also known as a non-sterile member of the operating team, coordinates all activities in the operating room, requires advanced critical thinking skills, adapts to changes, implements nursing plans, prepares the operating room, checks supplies, supports the instrument nurse, prepares skin prep, and serves as a patient advocate, documenting all patient care and procedure count.

Answer 31

A scrub nurse is a sterile member of the operating team, wearing surgical scrubs, gowns, gloves, and PPE. They set up and hand sterile supplies to the surgeon, maintain a close working relationship, perform surgical counts post procedure, monitor the intra-operative environment, and advocate for patient safety.

Answer 32

The nurse provides anaesthetic and post-anaesthetic nursing care, assists the anesthetist, prepares equipment for airway management, ensures medications are available, and directs patient care throughout anesthesia. They receive patients, check ID and consent, assist with airway management, monitor cardiac and hemodynamics, have advanced life support qualifications, understand surgery and complications, ensure patient comfort, and act as a patient advocate.

Answer 33

Individually chosen for each patient depending on: * type of surgical procedure * is muscle relaxation required * patient's past medical history and comorbidities * current patient wellness * equipment available at venue * skills of operating team

Answer 34

A pharmacologically induced lack of sensation. Involves the complex administration of a number of medications.

Answer 35

To manage the biological responses to surgery while minimising patient risks

Answer 36

* loss of sensation with loss of consciousness * combination of sedation, analgesia and muscle relaxants ○ can be combination of routes including IV, inhalation * with muscles relaxants, patient loses sympathetic nervous system reflexes ○ gag, cough, vomit * required advanced airway management ○ endotracheal intubation (ETT), laryngeal mask ○ please review this table for a review of the advantages and disadvantages of general anaesthetic

Answer 37

Nerve block is a procedure where a local anesthetic is administered into a nerve bundle, resulting in long-lasting loss of movement and sensation. It is used for invasive procedures like amputations and skin grafting, and can cause long-lasting loss of sensation. Examples include spinal, epidural, caudal, and peripheral blockages. Spinal block involves a one-shot injection into the spinal fluid, while epidural block involves continuous infusion and anesthetic for 4-5 days postoperatively.

Answer 38

must be regularly assessed until full sensation has returned * the area of skin that is supplied by a single spinal nerve is known as a dermatome * 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

Answer 39

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 received a score from 0 (full movement) to 3 (no movement) * 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

Answer 40

* 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 e.g., removal of a skin cancer, suturing, removal of a foreign body, insertion of IVC, collection of bloods

Answer 41

* similar to general * loss of sensation with loss of consciousness ○ sedative (e.g., 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 e.g., joint relocations, paediatric suturing, fracture reductions, eye surgery, colonoscopy

Answer 42

* from beginning of induction with propofol to unconsciousness * patient has a decreased awareness of pain, and has amnesia * respirations are regular * ends with loss of consciousness

Answer 43

* from loss of consciousness to beginning of regular respirations * patient has enhanced reflexes - they may try to talk, move around, may vomit * heart rate and BP may rise

Answer 44

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

Answer 45

* fixed and dilated pupils * cessation of breathing and circulatory collapse * death

Answer 46

Surgery is not without risk and a critical event can occur at any stage. This is why many safety checks are undertaken at every stage of the perioperative journey. Under anaesthesia and postoperatively, the patient is closely monitored. * cardiac arrhythmias * aspiration of stomach contents * hypoxaemia * hypovolaemia

Answer 47

The final phase of the surgical journey - 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.

Answer 48

Post anaesthetic care unit (PACU) is a critical area providing expert nursing care after surgery. It is located near operating rooms and is designed to help patients recover from anesthesia. Key to preventing adverse events include close observation, frequent vital sign assessments, regular reassessments, early recognition of deterioration, prompt intervention, and medication administration.

Answer 49

* 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

Answer 50

* DRABCD ○ danger ○ response - conscious state ○ airway - patient may require a jaw thrust to maintain airway patency, does the patient have an airway still in situ? ○ breathing - spontaneous, rate, depth, rhythm, quality, breath sounds, supplemental oxygen ○ circulation - colour and temperature of skin, HR (rhythm / rate), BP, SpO2, pulses, capillary refill, temperature ○ disability - conscious state/sedation score, orientation, BGL

Answer 51

* systems or head-to-toe assessment * localised pain, nausea * loss of function? * evidence of blood loss? * checking for any abnormalities, wounds, dressings etc.

Answer 52

* type of focussed assessment is specific to the surgery that was performed ○ surgical site assessment - dressings, drains, incisions, blood loss ○ neurological / neurovascular assessments

Answer 53

The patient's readiness for discharge from PACU depends on their stability and normal vital signs. The nurse assesses the patient using various scoring tools, performing primary, secondary, and focused assessments. The findings are then transferred to ward documentation for trending assessment purposes.

Answer 54

The receiving nurse receives a handover from the recovery nurse when the patient is 'ward ready'. If the receiving nurse is unsure about the patient's status or potential complications, they must clarify these concerns before taking responsibility for ongoing nursing care. The patient must meet discharge criteria to return to the ward. The receiving nurse must assess vital signs, ensure the patient has a patent airway, normal breathing, and no severe pain, review medication charts, and ensure all documentation is completed and the patient is comfortable.

Answer 55

Upon arrival, record return time and complete a full assessment, including DRABCD, vital signs, neurological, neurovascular, surgical wounds, pain, IV assessments, urine output, nausea/vomiting, and BGL. Compare findings with preoperative baseline values and document all findings. Monitor vital signs, neurological, surgical wounds, pain, IV, and urine output, and ensure emesis bag is within reach.

Answer 56

Considerations for nursing assessment following patients who have had intrathecal morphine (ITM) and transversus abdominis plane (TAP) blocks - commonly used with abdominal surgery

Answer 57

Intraoperative morphine administration improves pain management in abdominal surgery patients and chronic pain patients. Complications include respiratory depression, pruritus, and nausea. Monitoring post-administration includes sedation score, respiratory rate, and oxygen saturation. Naloxone can be prescribed for respiratory depression and sedation.

Answer 58

Transversus abdominis plane blocks are a pain management strategy for abdominal surgery patients, using local anesthetic Ropivacaine or Bupivacaine. However, local anesthetic systemic toxicity (LAST) is a concern, causing changes in the central nervous system and cardiovascular systems, necessitating immediate medical attention.

Answer 59

The nurse reviews all documentation, including fluid balance charts, medication charts, and postoperative orders. They ensure patient comfort, including pillows, blankets, bed positions, and a buzzer. They maintain an environment controlled with adequate lighting and minimal visitors. Fluid and food reintroduced as per surgeon's orders, depending on surgery type and postoperative complications. They also assess the patient's emotional state and provide support as needed.

Answer 60

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

Answer 61

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 <12 or >25 bpm * hypoxaemia - SpO2 <90% * hypotension - systolic BP <90 * bradycardia or tachycardia - heart rate <45 or >100 * sudden fall in conscious state - GCS drop of >2 points * serious concern about uncontrolled pain * haemorrhage - check site of surgery / dressing for bleeding

Answer 62

Postoperative nursing care involves regular assessments, postoperative movement, leg exercises, respiratory function promotion, elimination, GIT functioning, wound healing, rest and comfort, and emotional and spiritual support. These measures aim to prevent complications like DVT, pneumonia, and pain, and promote respiratory function, elimination, and wound healing. Regular position changes and early ambulation are encouraged, and leg exercises are recommended. Proper splinting and elimination techniques are also essential. Wound healing is promoted through a healthy diet and wound assessments. Emotional and spiritual support from Pastoral Care workers can also be provided to support the patient.

Answer 63

Nursing interventions for surgical wounds focus on preventing complications, performing assessments, adhering to surgeon's orders, using strict aseptic technique, keeping wound dry and dressing intact, and documenting progress.

Answer 64

Wound assessments should be performed every time vital signs are assessed, including checking for swelling, bruising, and pain. Patients should be educated about the importance of pain in recovery and the potential for complications. Symptoms of infection include fever, tachycardia, increased pain, purulent drainage, and erythematous tissue. Document dressings, drainage, swelling, bruising, and wound pain.

Answer 65

○ placed directly over or in the wound ○ a variety of primary dressing materials are available on the market ○ function is to absorb drainage and then wick it away from the wound edge - Cotton gauze or synthetic dressings may be used for this purpose ○ the layer of primary dressing directly contacting the wound should be non-adherent, unless debridement is desired.

Answer 66

○ placed directly over the primary dressing ○ function is to absorb excessive drainage, provide haemostasis by compression, and protect the wound from further trauma - usually accomplished with a bulky dressing, such as a combine (a pad that has a cotton filling and provides extra absorbency)

Answer 67

* cushioning and protection of the wound * protection from contamination * to absorb wound drainage * to provide support to the wound (splinting/immobilization of an area of the body part or incisional area) * physical comfort for the patient * to improve aesthetic appearance * to maintain a moist environment and prevent cell dehydration * application of medications

Answer 68

* Patients with infected wounds may require surgical wound debridement and sterile dressing changes performed under anaesthesia. * Patients also may also require wounds to be managed with a combination of surgical interventions and other treatment modalities, such as hyperbaric oxygenation (HBO), negative pressure therapy, hydrotherapy, use of engineered living skin substitutes, and the topical application of growth factors

Answer 69

- the act of removing dead and devitalized 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 procedures such as grafting, flaps, and other wound coverage

Answer 70

- increases the capacity of blood to carry oxygen to the tissues - the 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.

Answer 71

Negative-pressure wound therapy (VAC) is a clinical treatment used for complex wounds that don't respond to traditional methods. It uses a device to apply constant pressure to a wound filled with a drainage sponge and sealed with an occlusive dressing. The VAC system has three mechanisms: mechanical tension, macro-deformation, and micro-deformation. It's suitable for acute and traumatic wounds, pressure ulcers, chronic open wounds, meshed skin grafts, and skin flaps.

Answer 72

Surgical drains promote healing, prevent swelling, reduce the risk of infection and skin breakdown and reduce the need for dressing changes. * When surgeons anticipate large amounts of serosanguinous drainage, they insert a surgical drain ○ exit for air & fluids (serum, blood, lymph, intestinal secretions, bile, and pus) ○ inserted at the time of surgery through a separate small stab wound incision ○ drains may or may not be sutured to the skin

Answer 73

Penrose * penrose drains are a soft ribbon like tube that drains onto gauze or into a pouch * an open drainage system and therefore has a higher potential for infection Jackson Pratt (JP) * a closed drainage system where fluid is collected into a small soft bulb * risk of infection is reduced * commonly used for abdominal, breast and thoracic surgery * review the below patient discharge information video Redivac and Hemovac drains * closed drainage systems * a circular device connected to a tube that sits inside the body * removed fluid by creating low pressure suction in the tube - circular device is squeezed flat, as it slowly opens, creates suction * may have sutures holding the drain in place

Answer 74

The postoperative instructions for drain tube requirements should be checked, and drainage should change from sanguineous to serosanguineous to serous. Accurate documentation is required, and PPE must be used for removal. Assessments should include dressing condition, suction requirements, drain clamps, suture presence, potential infection signs, and drainage fluid type. Drainage should be documented on the fluid balance chart and emptied to maintain suction.

Answer 75

The process involves removing sutures or staples as per the surgeon's order, including education, pain explanation, wound care, and infection detection. The equipment needed includes a dressing trolley, dressing pack, saline/chlorhexidine, stitch cutter, staple remover, and steri strips. After removal, the suture line is cleaned, dried, and steri strips applied for new skin formation.

Answer 76

The patient's doctor records the drain tube's readiness for removal in their notes. Before the procedure, check the organization's policy on surgical drain tube removal. The necessary equipment includes dressing, gloves, and PPE. After removal, inspect the tubing for damage, notify the surgeon, and record the date and time. Record drainage on a fluid balance chart and reassess the dressing for excessive drainage.

Answer 77

* pain is whatever the person experiencing it says it is * adequate pain management is an ongoing challenge for nurses and remains a fundamental aspect of high-quality patient care. * failure to adequately manage a patient's postoperative pain can result in adverse psychological and physiological effects, both short and long term.

Answer 78

○ this assessment tool requires the patient to verbalise their responses to questions P = precipitating factors Q = quality R = radiation S = site and severity, pain score T = timing and treatment

Answer 79

○ 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 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

Answer 80

○ faces pain rating scale ○ used for assessing pain in paediatric patients or patients with intellectual dysfunction

Answer 81

A nurse assesses pain and initiates nursing interventions to manage it. They determine the source of pain, manage pharmacological management, check medication charts, escalate to a doctor if analgesics aren't adequate, and consider a multimodal approach. They must be aware of adverse effects of medications, and consider non-pharmacological management such as position changes, support, reassurance, and patient education.

Answer 82

Postoperative nausea and vomiting (PONV) is a distressing complication of surgery, affecting up to 30% of patients. It can lead to serious consequences like aspiration, fluid volume deficit, and electrolyte imbalance. Pharmacological management includes medication, while nonpharmacological management includes cool face flannel, reassurance, ice chips, and a vomit bag.

Answer 83

To ensure patient hygiene, wash face and hands, allow mouth rinse or brushing, offer water, monitor fluid intake, perform abdominal assessment, listen for bowel sounds, document volume on fluid balance chart, and document progress notes.

Answer 84

Post-surgery, temporary impairment of gastric and bowel motility can occur due to limited dietary intake, intestine handling, hypokalemia, and prolonged opioid analgesic administration. Small bowel motility usually resumes within 24 hours, while large bowel motility may be limited for 3-5 days.

Answer 85

The patient should remain NBM until peristalsis returns, perform abdominal assessment, monitor bowel sounds, encourage early ambulation, position patient on right side, pass flatus, check medication chart, and provide mouth care. Gradual reintroduction requires clear fluids, light diet, and full diet.

Answer 86

* assess patient for ○ severe headache ○ respiratory depression ○ hypotension ○ sensory response - dermatomes ○ motor response - bromage score * check infusion pump settings * check insertion site for ○ infection ○ swelling ○ catheter movement ○ leaking fluid

Answer 87

* respiratory complications ○ hypoxaemia ○ pneumonia - secondary to aspiration during surgery ○ atelectasis * cardiovascular complications ○ hypovolaemic shock * GIT complications ○ constipation ○ abdominal distention ○ intestinal obstruction * haematology / vascular complications ○ DVT / PE ○ haemorrhage * surgical site complications ○ wound infection - not evident in the first 48 hours postoperatively ○ wound dehiscence ○ compartments syndrome * neurological complications ○ postoperative delirium ○ headache * urinary complications ○ retention ○ oliguria - urine output < 0.5ml/kg/ hr

Answer 88

Discharge planning is an ongoing process that begins during the preoperative phase * an informed patient will be prepared for events * the patient will gradually assume more responsibility for self-care

Answer 89

Postoperative care involves following up with patients for symptoms such as fever, tachycardia, increased pain, and respiratory changes. It includes understanding medications, wound care, dressings, bathing requirements, and activities to avoid. Postoperative follow-up includes GP, specialist, and outpatient department. Dietary requirements, nursing support, and interprofessional team referrals are also essential. Patients seek help postoperatively for ongoing pain, wound infection, and medication advice. Written postoperative instructions and support details are provided.

Answer 90

Day surgery may include: * outpatients * same-day surgery * short-stay surgery Patients can be discharged when: * 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

Answer 91

There are many medications used during the surgical journey. Over the coming chapters, we will take a look at the medications used during the different phases of the peri-operative journey including: 1. H2-receptor antagonists 2. Benzodiazepines 3. Anaesthetic agents 4. Opioids including patient controlled analgesia (PCAs) 5. Antiemetics 6. Anticholinergics

Answer 92

Whilst not all patients require pre-operative medications (pre-meds), there are a number of reasons that these are given, including: * Provision of analgesia * Prevention of nausea and vomiting * Promote sedation and amnesia * Decrease anaesthetic requirements * Facilitate induction of anaesthesia * Relieve apprehension and anxiety * Prevent autonomic reflex response * Decrease respiratory and gastrointestinal secretions

Answer 93

Diazepam is a short-term medication used to manage anxiety, agitation, alcohol withdrawal, muscle spasm, and sedation. C- It can cause respiratory depression and myasthenia gravis. P-It should be reduced in people with renal or hepatic impairment, elderly, and children. Side effects include drowsiness, oversedation, and hypersalivation. Patients should have completed surgery consent before administering this medication.

Answer 94

Procedural sedation, induction of anaesthesia, sedation during ventilation, premedication This medication potentiates GABA inhibitory effects in the CNS, causing various effects like anxiolytic, sedative, hypnotic, muscle relaxant, and antiepileptic effects. C- It can cause respiratory depression and myasthenia gravis. P-It should be reduced in people with renal or hepatic impairment, elderly, and children. Common side effects include hypotension, hiccups, cough, pain, erythema, and arrhythmias. Monitor closely for respiratory depression risks.

Answer 95

N&V associated with cancer chemotherapy, postoperative and radiotherapy induced 5HT3 (serotonin) antagonist Blocks the transmission of 5HT3 in the GI tract thus reducing N&V. C-concomitant use with apomorphine. P-avoid use in patients with prolonged QT interval or ensure K+ and Mg2+ are corrected prior to administration Safe to use in pregnancy and breastfeeding Common – constipation, headache, dizziness Rare – hypersensitivity reactions, ECG changes Educate patients that wafers and dispersible tablets should be placed on top of the tongue to dissolve then swallowed.

Answer 96

Used for induction of anaesthesia and prevention of PONV OTHER: Short-term management of severe acute anxiety, agitation or disturbed behaviour, Bi-polar disorder NOTE: doses used for N&V are considerably lower (2.5-10mg) than those used for anti-psychosis (10-25mg). Dopamine antagonist – blocks dopamine receptors C-severe CNS depression, Parkinson’s disease, breast feeding, patients with prolonged QT interval. P-seek specialist advice during pregnancy Common – sedation Rare – prolonged QT interval At higher doses: Respiratory failure, hyperthyroidism, GI obstruction, extra-pyramidal side effects (EPSE) Medication generally only administered in the peri-operative period where patient can be closely monitored.

Answer 97

Nausea and vomiting associated with surgery, gastric stasis Dopamine antagonist – blocks dopamine receptors C-phaeochromocytoma, Parkinson’s disease, GI obstruction or perforation P-depression, people under 20, adjust dose in elderly Common – akathisia (restless limbs), drowsiness, dizziness, headache Infrequent – depression, EPSE, hypertension, hypotension, ^serum prolactin levels, galactorrhoea, diarrhoea, constipation Rare – agranulocytosis, arrhythmias. Educate patients regarding side effects and importance of seeking medical support if identified. Warn patient that risks of EPSE increase with prolonged use.

Answer 98

A synthetic glucocorticoid that has anti-inflammatory and immunosuppressant actions that is used for patients that are at high risk of PONV. Corticosteroid that is 25-30 times more potent than hydrocortisone.

Answer 99

Premedication to inhibit excessive salivary and bronchial secretions and diminish risk of vagal inhibition of the heart. Bradycardia with haemodynamic compromise Block the action of acetylcholine at the muscarinic receptors of the parasympathetic nervous system (PNS). C-known hypersensitivity to anticholinergic agents, obstructive diseases of the GI tract, reflux oesophagitis, prostatic enlargement, acute angle-closure glaucoma, unstable CVS status, tachycardia P-use with extreme caution in patients with heart disease, HTN, ulcerative colitis, ileus, hepatic and renal insufficiency. Considered to be safe to use in pregnancy and breastfeeding. Tachycardia, palpitations, dry mouth, tremor, fatigue, drowsiness, ataxia, mental confusion As atropine has a short half-life patients should have no ongoing issues related to its administration. Ensure patient has provided a complete medical history prior to surgery to ensure no contraindications are present.

Answer 100

Reduction of gastric pH prior to surgery Competitively blocks H2 receptors on parietal cells, reducing gastric acid secretion. C-known hypersensitivity These medications are generally well tolerated. Rare – confusion, rash, thrombocytopenia, agranulocytosis, leukopenia, hepatitis, hypersensitivity reactions. In the preoperative context, ensure patient swallows all of liquid – generally use effervescent formulation.

Answer 101

Prevention of acid aspiration Peptic ulcer disease (PUD) Gastro-oesophageal reflux disease (GORD) Dyspepsia Binds to the hydrogen/potassium ATPase enzyme system (proton pump), inhibiting acid secretion C-Allergy to medication P-monitor closely in patients with hepatic impairment. Safe for use in pregnancy and breast feeding. Common - headache, nausea, vomiting, diarrhoea, abdominal pain, constipation, flatulence. Infrequent - rash, itch, fatigue, drowsiness, insomnia, dry mouth Rare - gynaecomastia, myalgia/arthralgia, acute interstitial nephritis, peripheral oedema. Educate patient regarding need to swallow tablet whole, and potential side effects.

Answer 102

Whilst most of you will not be involved in administering intra-operative medications, you need to be aware of the different types of medications used and their side-effects. These guide many of the assessment requirements that we undertake post-operatively. Medications used during the continuum of general anaesthesia are broken down into the following: * Pre-induction - premedication which was covered in the previous chapter * Induction * Maintenance * Emergence

Answer 103

Ultra short-acting CNS depressant inducing hypnosis and anaesthesia. Works within 30-40 seconds Duration of action < 5 minutes Adverse cardiac effects (myocardial depression), hypotension, respiratory depression Usually have minimal postoperative effects because of short duration of action. ^incidence of nausea in patients with barbiturate sensitivity, histamine-triggered nausea and vomiting.

Answer 104

Induces hypnosis, amnesia and skeletal muscle relaxation Abolition of skeletal muscle reflexes Respiratory depression, hypotension, myocardial depression. Increase risks of PONV Limited analgesia Assess and treat pain during early anaesthesia and recovery Assess for adverse reactions – cardiopulmonary depression with hypotension and prolonged respiratory depression. Monitor for nausea and vomiting

Answer 105

General anaesthetic producing profound analgesia. Potent analgesic and amnesic Useful for brief procedures May cause hallucinations and nightmares, increased intracranial and intraocular pressure, increased HR and BP Some patients have ketamine infusions post operatively. Anticipate administration of a benzodiazepine if hallucinations and agitation occur.

Answer 106

Mimics acetylcholine depolarising the motor end plate resulting in skeletal muscle relaxation (paralysation) Facilitates endotracheal intubation and promotes skeletal muscle relaxation to enhance access to surgical sites Apnoea related to paralysis of respiratory muscles. Hyperkalaemia occurs with the action of sux., so must not be used in patients with burn or crush injuries due to risk of cardiac arrhythmias and death. Patients with myasthenia gravis should not be given sux., as they may have an ongoing block. As these patients are unable to breathe whilst these medications are in use, full respiratory support and monitoring of haemodynamic status must be in place. Post operatively, monitoring of temperature and levels of muscle strength with temperature changes must occur. Patients may suffer from muscle pains for 24 hours post op so inform patient of this.

Answer 107

Analgesia means loss of sensation of pain (Brown et. al., 2023). Whilst this is not always completely possible, it should be our aim to provide effective pain management for individuals. In the postoperative phase, pain may be directly related to the surgical manipulation of tissue, reflex muscle spasm, positioning during the surgical procedure or the presence of catheters and tubes. Some patients may also have persistent pain from other comorbidities that needs to be considered.

Answer 108

Opioid analgesics are used for both acute and persistent pain with nociceptive (pain originating in the tissues), acute pain being more responsive to them than persistent or neuropathic (pain originating from nerve damage) pain. Each person is individual in their pain experience and this also holds true to their response to opioid analgesics. What works for one person may not work as well, or at all, for another. This individuality requires us to use different forms of opioid medications in combination with other forms of pain control, including both pharmacological and non-pharmacological until something that works is identified.

Answer 109

Tablets – 10mg, 20mg, 30mg Oral liquid – 1- 10mg/ml Injection – 5-30mg/ml Injection intrathecal – 200-500microgs/ml Controlled release – 5-200mg tablets, 10-120mg capsules P-adjust dose in patients with renal impairment as risks of respiratory depression and delirium increase. Dose adjustment also required for elderly population and those with hepatic impairment. Monitor for side effects. Ensure controlled release medications are swallowed whole and not chewed, dissolved or crushed. Ensure that patient has antiemetic and stool softeners orders to counteract side effects.

Answer 110

Tablets – 100-800 microgs s/l; 100-800 microgs oral disintegrating Lozenge – 200-800 microgs Injection 50microgs/ml in 2, 5, 10ml. Patch – 12 – 100 microgs/hour C-patches must not be used for postoperative or other acute pain. Concomitant use with MAOI anti-depressant. P-dose adjustment required for elderly population and children. Warn patient of potential side effects and monitor for same post administration. Ensure that patient has antiemetic and stool softeners orders to counteract side effects.

Answer 111

Tablets – 5mg immediate release Tablets – 5-80mg controlled release Capsules – 5-20mg Oral liquid – 1mg/ml Suppository – 30mg Injection – 10-50mg/ml in 1 or 2 ml. P-avoid OxyContin tablets in patients with swallowing disorders as they may swell and occlude the oesophagus. Adjust dose in renal and hepatic impairment. Avoid if hepatic impairment severe. Warn patient of potential side effects and monitor for same post administration. Ensure that patient has antiemetic and stool softeners orders to counteract side effects.

Answer 112

Tablets – 30mg Oral liquid – 5mg/ml C-children <12 years, renal impairment, during breastfeeding, P-dose adjustment required in hepatic impairment, elderly and those with respiratory depression including COPD. Educate patients regarding combination medications to avoid overdose.

Answer 113

Tablets – 50mg-200mg controlled release Capsules – 50mg Oral liquid – 100mg/ml Injection – 50mg/ml in 2ml C- Concomitant use with MAOI anti-depressant. P-reduce dose in those with renal and hepatic impairment. Warn patient of potential side effects and monitor for same post administration. Ensure that patient has antiemetic and stool softeners orders to counteract side effects.

Answer 114

Tablets – 50mg immediate release Tablets – 50-250mg controlled release C-Concomitant use with MAOI ant-depressant P-reduce dose in those with renal and hepatic impairment. Warn patient of potential side effects and monitor for same post administration. Ensure that patient has antiemetic and stool softeners orders to counteract side effects.

Answer 115

Nausea is an uneasy stomach sensation often resulting in vomiting. It is a complex process involving multiple nerve pathways and neurotransmitters. It is a protective mechanism to rid the body of toxic substances. In severe cases, it can cause fluid and electrolyte disturbances. Nausea and vomiting can be distressing for patients, especially during the postoperative phase. Various causes and medications are available to manage these symptoms.

Answer 116

PCA is commonly used in the postoperative period to provide immediate analgesia * an effective method of pain management because it delivers a constant level of an analgesic agent * will contain schedule 8 analgesic medications (opioids) → morphine, fentanyl, tramadol are common examples

Answer 117

* enables the patient to receive pain relief without delay ○ increases the patient's sense of control → empowerment * opioid blood concentrations are maintained within therapeutic ranges * prompt management of pain caused by activity ○ patients are able to anticipate activities such as coughing or movement associated with increased pain and provide themselves with an opioid bolus in advance ○ enables increased patient mobility

Answer 118

1. 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 2. Continuous infusion → a background infusion where the patient will receive a continuous dose of analgesia, cannot be altered by the patient 3. 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

Answer 119

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 4. Good patient education is essential for effective management. Patient must be educated in: ○ Use of the PCA ○ When to use. Patient should not wait for severe pain ○ Explain lockout process ○ Patient must inform nurse if pain not relieved or multiple doses needed

Answer 120

Some patients will be prescribed a loading dose after the set-up of the PCA. This ensures therapeutic action of the medication is reached immediately after set-up. This is not always ordered so it is essential you check the order carefully for a loading dose.

Answer 121

This is the amount of opioid (or other medication) that the PCA pump will deliver when the demand button is pressed.

Answer 122

The time from the end of the delivery of one dose until the PCA pump will respond to another demand is called the “lockout” interval. This is to allow the effect of one dose to be felt before another can be given and is one of the safety features of the PCA pump.

Answer 123

Some PCA's will have a background continuous infusion rate ordered along-side the bolus dose. The purpose of a continuous infusion is to help maintain a stable analgesic level. This may enable the patient to make less demands on the PCA. This is not always ordered so it is essential you check the order carefully to determine if a continuous infusion is also required.

Answer 124

This is the period of time between demands that a patient cannot exceed and is documented on the PCA order in minute increments (i.e. 5 minutes). For example, if your patient has a successful PCA demand at 1025hrs, if their lock out is 5 minutes, they will be unable to have another dose delivered until 1030hrs regardless of how many times they press the button.

Answer 125

In addition to the lock out another safety feature of the PCA is the hourly limit. This is the maximum does that the PCA will deliver in any one hour.

Answer 126

This the number of times the patient has pressed the button. It is not the same as the amount/dose that has been delivered to the patient. When reading the PCA on the hour, a patient may have had 12 attempts but only 4 doses delivered in this time. This can indicate if education and/or dose increases/ other forms of analgesia are required.

Answer 127

* 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 or are under the age of 5 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 * If a patient normally uses a CPAP machine, this MUST be in place during sleep periods.

Week 8 Flashcards

(152 cards)