Fundamentals Chapter 39 - Periopertive Care Flashcards


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1

Perioperative Nursing

Involves the care of the clients before, during, and after surgery and some other invasive procedures. Historically, perioperative nsg practice was called "operating room nursing" and was limited to transferring pts into and out of operating rooms and handing instruments to surgeons during surgical procedures. Now nurses in all phases of the operative experience actively provide and manage care, teach, and study the care of perioperative pts.

2
  1. Preoperative
  2. Intraoperative
  3. Postoperative
  1. Before surgery
  2. during surgery
  3. after surgery

3

AORN - The Association of Perioperative Registered Nurses

One of the most highly organized and influential specialty organizations within the nsg profession. AORN standards and recommended practices keep perioperative nurses up to date on current practice.

4

Perioperative Safety

An important aspect of the perioperative nsg role is to help prevent complications of surgery. Hand hygiene is an important component of prevention. Preventable periperative errors:

  • cause 10% of surgery related deaths
  • have an unfavorable financial impact on healthcare institutions
  • result in physical and emotional harm to pts

5

What are some recommended practices for hand hygiene?

  • Perform hand hygiene: immediately before and after each pt contact, after removing gloves, anytime you come in contact with blood or potentially infectious substances, before and after eating and using bathroom
  • remove rings, watches
  • keep fingernails short and clean
  • replace nail polish when chipped or q 4 days
  • don't wear fake nails
  • be sure there are no lesions or breaks in skin integrity on your hands

6

What are Never Events?

Name a few

Serious and costly errors resulting in severe consequences for the pt, and that are mostly preventable. They should never happen in a hospital and Medicare will no longer reimburse for care r/t such complications. Among the never events important to perioperative care are:

  • Surgery on the wrong body part
  • Surgery on the wrong patient
  • Wrong surgery on a patient
  • Deep vein thrombosis (DVT) or pulmonary embolism (PE) after total knee or hip replacement
  • Foreign body left in a patient after surgery
  • Surgical site infections after certain elective procedures.

7

Peropreative Phase - Before Surgery

Begins with the client's decision to have surgery and ends when he enters the operating room. Nsg care during this phase focuses on identifying existing health concerns, planning for intraoperative and postoperative needs, and providing preoperative teachin.

8

Classification of Surgeries:

By Body System

  • useful for determining the risk for postoperative infection
  • Example: Incisions that enter the gastrointestinal (GI), respiratory, or genitourinary tracts have a higher risk for infection than does surgery of other body systems.
  • However, if an organ ruptures or surgery is for repair a penetrating injury, the risk of infection is very high regardless of the body system involved.

9

Classification of Surgeries:

By purpose

  1. Ablative surgery
  2. Diagnostic (exploratory) surgery
  3. Palliative surgery
  4. Reconstructive surgery
  5. Cosmetic surgery
  6. Transplant surgery
  7. Procurement surgery
  1. Ablative Surgery involves removal of a diseased body part.
  2. Diagnostic (exploratory) surgery is done to confirm or rule out a diagnosis. Examples include a biopsy, fine-needle aspiration, or invasive testing such as a cardiac catheterization.
  3. Palliative surgery is performed to relieve discomfort or other disease symptoms without producing a cure. Examples include nerve root destruction for chronic pain.
  4. Reconstructive surgery is performed to restore function (rotator cuff repair)
  5. Cosmetic surgery is done to improve appearance
  6. Transplant surgery replaces a malfunctioning body part, tissue, or organ.
  7. Procurement surgery is r/t transplant surgery. An organ or tissue is harvested from someone pronounced brain dead for transplantation into another person

10

Classification of Surgeries:

By degree of urgency

  1. Emergency Surgery
  2. Urgent Surgery
  3. Elective Surgery
  1. Emergency surgery requires transport to the operating suite as soon as possible to preserve the patient’s life or function.
  2. Urgent surgery is scheduled within 24 to 48 hr to alleviate symptoms, repair a body part, or restore function. Removal of a cancerous breast and internal fixation of a fracture are examples.
  3. Elective surgery is performed when surgery is the recommended course of action, but the condition is not time sensitive. The client may delay surgery to gather information, consider options, or organize care for the family.

11

Classification of Surgeries:

By degree of Risk

  1. Major Surgery
  2. Minor Surgery
  • Major surgery is associated with a high degree of risk. For example, it may be associated with the potential for significant blood loss, involve vital organs, be a prolonged or complicated procedure, or have significant potential for postoperative complications. Examples include coronary artery bypass graft (CABG), organ transplantation.
  • Minor surgery, often performed on an outpatient basis, involves little risk and usually has few complications. Examples include arthroscopy, breast biopsy, and inguinal hernia repair.

12

An elderly woman fell at home and fractured her hip. After being admitted to the hospital, the nurse knows that the patient is to be “stabilized” prior to having surgery. This surgery would be classified as

a.Urgent

b.Elective

c.Emergency

d.Palliative

a. Urgent

13

Factors Contributing to Surgical Risk

Age/personal

The very young and very old are at greatest risk during surgical procedures. Infants have limited ability to regulate temp and have immature immune, cardio, liver and renal systems

Older adults are at increased risk because they have less physiological reserve and often have comorbid conditions. Physiological changes include: decreased kidney fx, diminished immune fx, decreased bone and lean body mass, increased peripheral vascular resistance, decreased cardiac output, decreased cough reflex, and increased time required for wound healing

14

Factors Contributing to Surgical Risk

Type of wound

Both preexisting wounds (e.g., from trauma) and the wounds (incisions) created by the surgical procedure can pose a risk for infection. Risk to the patient increases along with the risk for or presence of infection.

15

Factors Contributing to Surgical Risk

Preexisting conditions

Many surgical clients have underlying acute or chronic disorders that increase surgical risk.

Chronic Conditions:

  • Cardiovascular diseases
  • Coagulation disorders
  • Chronic respiratory disorders
  • Renal disease
  • Diabetes mellitus
  • Liver disease
  • Neurological disorders
  • Nutritional disorders

Acute Conditions:

  • Upper respiratory tract infection
  • Acute infections

16

Factors Contributing to Surgical Risk

Mental status

Patients with altered cognition, from either physical or mental illness, may be unable to comprehend preoperative instructions or give informed consent for surgical procedures. They may also require medications (e.g., antipsychotic agents) that interact with anesthetics and analgesics given in the perioperative period. Surgery and anesthesia may aggravate preexisting dementia, confusion, and disorientation.

17

Factors Contributing to Surgical Risk

Medications

Certain herbal and alternative medications can increase the risk for cardiac dysrhythmias secondary to potassium loss; interfere with metabolism of anesthetics because of their effects on the liver; increase the potential for excessive bleeding; decrease cerebral blood flow; cause hypertension; or increase the effects of opioids and sympathetic nervous system stimulants.

18

Factors Contributing to Surgical Risk

Personal Habits

Substance abuse can increase surgical risk. Smoking affects pulmonary fx; long term alcohol use contributes to liver disease, predisposing the pt to bleeding. Alcohol and drugs interact with anesthetic agents and meds to create adverse effects. Also, habitual substance abusers may have a cross tolerance to anesthetic and analgesic agents, causing them to need higher than normal doses.

19

Factors Contributing to Surgical Risk

Allergies

Patients may be allergic to meds, tape, latex, and solutions used in surgery. Reactions range from unpleasant to life threatening.

20

Preoperative Nursing Responsibilites

The nursing focus in the preoperative phase is to prepare the patient for surgery.

Focused Nursing History

Include the following topics in your preoperative assessment: health history, mental status, physical status, cultural and spiritual factors, allergies, access to social resources, coping strategies, alcohol and drug use, medications (including herbal products and over-the-counter medications), and knowledge and understanding of the surgery and anesthesia. It is also important to elicit patients’ values and expressed needs.

21

Preoperative Nursing Responsibilites

Focused Physical Assessment

If you identify risk factors from the nursing history, focus on these aspects during your brief head-to-toe physical assessment. For example, if the patient states she had a cough last week, perform a focused assessment of the ear, nose, throat, and lungs to determine how the cough may affect the patient’s risk.

For all pts, assess risk factors for thrombophlebitis, as venous thrombus is one of the never events that can lead to potentially life threatening pulmonary emboli.

22

Preoperative Nursing Responsibilites

Diagnostic Testing

Before surgery most institutions require:

  • CBC
  • urinalysis
  • electrocardiogram for patients over age 50

Age alone is NOT a risk factor for postoperative complications, but older adults with multiple comorbidities such as cardio or pulmonary disease, may be at risk for postop complications.

23

Preoperative Nursing Responsibilites

Informed Consent

Before a surgical procedure is performed, professional standards and the law require the surgeon to obtain the patient’s informed consent. The signed consent form verifies that the surgeon and patient have communicated adequately about the surgery. Once signed and witnessed, the consent form is part of the patient’s record and accompanies him or her to the operating room.

Informed Consent requires that the patient understood the communication and was not coerced to consent. The pt must be alert, rational, mentally competent, and not sedated when he signs; and the info must be given to him in a language and vocabulary that he can understand. Patients who are unconscious or have a mental disability; who have been judged insane; who cannot read, write, or hear; and those under the influence of sedative drugs or alcohol are generally not competent to give consent.

24

What is the surgeon and the nurses responsibility regarding informed consent?

The surgeon is responsible for (1) giving the patient the necessary information and (2) determining the patient's competence to make an informed decision about the surgery. The nurse is responsible for verifying that the surgical consent form is signed and witnessed.

The nurse should first verify that the physician has explained the procedure and answered all his questions. Then ask the patient to state what was told during the consent process. If the patient has questions or if the nurse has questions about the patients competence, notify the surgeon, and delay sending the pt to surgery. Document these conversations.

25

What is included in the surgical consent form?

  • They type of surgery being performed
  • The name and qualifications of the person performing the surgery and the primary doctor for the patients care and treatment
  • A statement that the risks and benefits of surgery, as well as reasonable alternatives, have been explained to the pt
  • A statement of the relevant risks, benefits, and side effects of the alternatives
  • The likelihood of achieving goals
  • A statement that the patient has the right to refuse surgery or withdraw consent at any time
  • When indicated, any limitations on the confidentiality of info about the pt

26

The nurse is completing a preoperative patient assessment. Which finding indicates the greatest risk for the development of a postoperative complication?

a.The patient is 60 years old

b.The patient’s blood pressure is 130/88 mm Hg

c.The patient does not understand the surgery

d.The patient has early stage Alzheimer’s

b.The patient’s blood pressure is 130/88 mm Hg

27

Preoperative Nursing Responsibilites

Complete Preoperative Teaching

Preoperative teaching prepares the patient for the surgical experience, allays fears, and decreases the risks of postoperative complications. May include:

  • What will happen before, during, and after surgery
  • How patient or caregiver can participate in the care
  • Common feelings and concerns that pts have about surgery. This helps the pt feel supported and less anxious.
  • What pts and families can do to help prevent surgical site infection

28

What to teach patients to help prevent surgical site infection before and after surgery

BEFORE:

  • Stop smoking because those who smoke are more likely to get infections
  • Discuss health probs with surgeon because these can affect incision healing (ex: diabetes)
  • Ask your surgeon whether you should have antibiotics before surgery
  • Dont shave near where you will have surgery. Not all procedures require hair removal, but if they do, it should be done with electric clippers NOT a razor.

AFTER:

  • Be sure family and friends wash their hands or use alcohol based handrub before and after they visit
  • When anyone examines you or checks your incision ask them if they've washed their hands
  • Wash your hands before and after caring for your own incision
  • Don't allow family and friends to touch your incision or the dressing
  • Be sure you know how to care for your incision before you go home
  • If you have fever or redness, pain, or drainage at the surgery site, call you doc right away

29

Preoperative Nursing Responsibilites

How to teach

Use printed materials, videos, face to face discussion to provide preoperative teaching. Include family members in the teaching as much as possible and as much as desired by the patient, especially if the patient is a child or dependent adult

Older adults may have decreased hearing, vision, and sense of touch that may interfere with their ability to understand and remember. To increase understanding, allow for more time for the patient to process info, and provide written material that clearly conveys the essentials.

30

Preoperative Nursing Responsibilites

Preparing the Patient Physically for Surgery: Maintaining Normothermia

Maintaining a normal body temperature helps produce good surgical outcomes. You can provide passive thermal care measures, such as providing blankets, socks, and head coverings; and keeping the room temp at or above 75F.

31

Preoperative Nursing Responsibilites

Preparing the Patient Physically for Surgery: Nutritional Status

Anxiety and anesthesia reduce GI motility. To decrease the risk of nausea and vomiting, pts usually fast, taking no food or liquid (NPO) for 8 h before surgery. Stress the importance of fasting to avoid the danger of aspiration.

32

Preoperative Nursing Responsibilites

Preparing the Patient Physically for Surgery: Skin Preparation

Depending on the surgery and facility, patients may be asked to shower or scrub the surgical site with soap or an antibacterial solution (e.g., 4% chlorhexadine gluconate, Betadine) the evening before surgery and the morning of the surgery. Studies demonstrate that this reduces bacterial colonization on the skin but do not clearly prove that it reduces surgical infection.

33

Preoperative Nursing Responsibilites

Preparing the Patient Physically for Surgery:
Bowel Elimination

Enemas are used primarily for surgical procedures of the colon, not for all surgeries. To empty the colon of feces, patients are asked to consume a low-residue diet for several days before surgery and are given a regimen of medications and/or enemas to clear the bowel. Stress the importance of adhering to the regimen to limit the risk of contaminating the operative site with feces.

34

Preoperative Nursing Responsibilites

Preparing the Patient Physically for Surgery: Urinary Elimination

Indwelling catheters are not routinely inserted for surgery. Catheterization may be prescribed if it is important to keep the bladder empty during surgery, if fluid status is being carefully monitored, or if surgery is expected to last for a long period of time.

If a catheter is not prescribed, have the patient void before receiving preoperative meds. The pt could fall if he gets out of bed to use the bathroom after being sedated or given opioids for pain

35

Preoperative Nursing Responsibilites

Preparing the Patient Physically for Surgery: Preoperative Medications

The anesthesiologist may prescribe preoperative medications to relax the patient, reduce respiratory secretions, or reduce the risk of vomiting and aspiration. If the surgery time is known, the medication is prescribed at a prearranged time. If not, it may be prescribed to give “on call.” You will give the on-call medication when the surgical suite staff notifies you it is time to do so.

36

Preoperative Nursing Responsibilites

Preparing the Patient Physically for Surgery:
Routine Medications and Prostheses

Routine meds may or may not be given on the day of surgery. Patients on warfarin for anticoagulation may need to stop the med for 7 days before surgery.

Before being transported to the OR, the patient must remove all artificial body parts such as dentures, artificial limbs, or contact lenses. Wigs, glasses, makeup, and jewelry must also be removed

37

Preoperative Nursing Responsibilites

Preparing the Patient Physically for Surgery:
Antiembolism Stockings

These are elastic stockings that compress the veins of the legs and increase venous return to the heart. They may be applied preoperatively to prevent venous pooling during surgery and decrease the risk of thrombus formation. Along with prophylactic medications (antithrombotics) antiembolism stockings aid in the prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE).

38

What are some safety measures to prevent DVT in older adults?

ROM exercises

Antiembolism stockings

39

Intraoperative Care

To provide intraoperative care you will need theoretical knowledge of the roles of the various members of the intraoperative team and the different types of anesthesia

40

Intraoperative Care

Sterile Team

It includes the surgeon, surgical assistant, and scrub nurse. Before beginning the surgery, they perform a surgical scrub of the hands and arms, dry with sterile towels, and don sterile gowns and gloves.

41

Intraoperative Care

Clean Team

Team members who abide by clean technique (medical asepsis) include the anesthesiologist or nurse anesthetist, the circulating RN, biomedical technicians, and radiology technicians. These personnel never enter the sterile field, but instead function around and beyond it.

42

The scrub nurse vs the circulating nurse

The scrub nurse can be an RN, LVN/LPN, or a surgical technician. They set up the sterile field, prepare the surgical instruments, assist with the sterile draping of the patient, anticipate and respond to the surgeon's needs, and maintains the integrity of the sterile field.

The circulating nurse is an RN who applies the nursing process to coordinate all activities in the OR. She's a strong client advocate who continuously monitors the client and the sterile field. She maintains a safe, comfortable environment, communicates with appropriate personnel outside the OR, manages care of the intraoperative client, and responds to emergencies. An important aspect of the circulating nurse's role is to attend to the patient during the induction of anesthesia

43

Registered Nurse First Assistant (RNFA)

An RN with additional education and training in surgical technique and is also part of the sterile team. The RNFA serves as an assistant to the surgeon, a role that has historically been filled by physicians. Rhe RNFA may be employed by the surgeon or the hospital

44

Anesthesiologist

An anesthesiologist or a nurse anesthetist (CRNA) induces amnesia, analgesia, and muscle relaxation or paralysis with anesthesia. The role is to continuously monitor and evaluate the patient’s responses to the anesthetic agent and the surgical procedure. CRNAs administer more than half of all anesthetics in the United States.

45

Intraoperative Care

Skin Prep and Positioning

  • Skin preparation: Depending on the surgery and facility, patients may be asked to shower or scrub the surgical site with soap or an antibacterial solution (e.g., 4% chlorhexadine gluconate, Betadine) the evening before surgery and the morning of the surgery. Studies demonstrate that this reduces bacterial colonization on the skin, but do not clearly prove that it reduces surgical infection.
  • Positioning: Five variables determine the position of the patient in the OR: the surgical site, access to the patient’s airway, the need to monitor vital signs, comfort, and safety. A position that is ideal for accessing the surgical site may not be used if any of the other factors are compromised. If the patient has preexisting injuries or discomfort, factor this information into the decision about how to position. For example, a patient with chronic cervical spine pain may be positioned using a neck-roll.

46

Intraoperative Care: Client Safety

Sponge, sharps, and instrument count

The circulating nurse and the scrub nurse count the material that is added to the sterile field. As the surgery comes to an end, a repeat count is performed to ensure that no instruments, sponges, or sharps are left inside the client. A retained sponge can lead to infection and additional surgeries.

47

Intraoperative Care: Client Safety

Documentation

Record the care provided and the client’s response to care on the surgical record. Usually you will use a graphic or a checklist form, perhaps with some space for narrative notes about anything the form does not address.

48

Intraoperative Care: Client Safety

Monitor I&O

Together with the anesthetist, the circulating nurse monitors the fluid infused, urine output, drainage, and blood loss.

49

Intraoperative Care: Client Safety

Assist the Scrub Nurse to Prepare and Maintain the Sterile Field

The circulating nurse gathers surgical supplies and equipment for use during surgery. She then works with the scrub nurse to transfer the supplies to the sterile field.

50

Intraoperative Care: Client Safety

Provide Supplies and Materials During Surgery

If additional supplies are needed during surgery, the circulating nurse obtains them and opens them on the sterile field. Supplies may include dressings, surgical equipment, meds, irrigating solutions, or sutures.

51

Intraoperative Care: Client Safety

Handle Specimens

The circulating nurse handles specimens and sends them to the lab or pathology for evaluation after the surgery is complete.

52

Postoperative Care: The PACU

Includes:

  • Recovery from anesthesia
  • Airway management
  • Vital signs/level of consciousness
  • Dressing assessment/drainage
  • Fluid therapy
  • Pain control
  • Recovery from anesthesia: The first postoperative phase is often known as the postanesthesia phase or the immediate postoperative phase. This phase begins when the client is transferred from the operating table to a bed (or gurney) for transport to the PACU. During this phase, the client is at high risk for respiratory and cardiovascular compromise. As a precaution, the anesthetist and the circulating nurse accompany the client and attend to his or her needs during transport to the PACU. They are also responsible for giving a comprehensive report to the PACU nurse.
  • Airway management: Incentive spirometry facilitates deep breathing, increases lung volume, and promotes coughing to clear mucus from the respiratory tree. The equipment varies in appearance, but all devices include a gauge to monitor the patient’s progress visibly.
  • Vital signs: Monitor vital signs according to facility policy and report abnormals to the physician and surgeon.

53

The nurse knows that the most important reason for controlling postoperative nausea/vomiting in the
PACU is

a.To prevent the patient from becoming dehydrated

b.To prevent potential airway issues

c.To prevent the surgical dressing from
becoming soiled

d.To prevent the patient from becoming upset

b.To prevent potential airway issues

54

Which phase begins when the patient leaves the postanesthesia care unit (PACU) and ends when the patient has recovered from the surgery?

1) Postoperative

2) Intraoperative

3) Preoperative

4) Perioperative

Answer:

1) Postoperative

Rationale:

The postoperative phase begins when the patient has recovered from anesthesia and ends when the patient has recovered from surgery. The preoperative phase begins with the client's decision to have surgery and ends when the client enters the operating room. The intraoperative phase begins when the client enters the surgical suite and ends with discharge to the postanesthesia care unit. The perioperative period includes the preoperative, intraoperative, and postoperative phases.

55

The health record shows that a patient has been using long-acting oral opioids to manage severe, chronic back pain secondary to a tumor located along the lumbar spine. She has just had her appendix removed. Which outcome will assure the nurse that her pain interventions were effective?

1) The patient is discharged from the hospital on postoperative day five.

2) The patient ambulates from the bed to the bathroom on the day after surgery.

3) Pain is controlled and respirations are in patient's usual range.

4) Wound dressing remains dry and intact for 48 hours.

Answer:

3) Pain is controlled and respirations are in patient's usual range.

Rationale:

Pain management is a priority for this patient. However, opioids may cause respiratory depression and increase the risk of atelectasis and pneumonia. Well-managed pain and clear breath sounds indicate that the plan of care has been effective. The date of discharge from the hospital is dependent on many variables and is not an effective evaluative tool for pain—especially because this patient has chronic pain that is unrelated to her surgery. The distance ambulated depends on the patient's presurgical condition; although pain does affect ambulation, this is not the best criterion for determining the level of pain. The condition of the dressing does not reflect on the status of the patient's pain.

56

Which member of the intraoperative team sets up the sterile field, prepares the surgical instruments, assists with the sterile draping of the patient, anticipates and responds to the surgeon's needs, and maintains the integrity of the sterile field?

1) Scrub nurse

2) Registered nurse first assistant

3) Certified registered nurse anesthetist

4) Circulating nurse

Answer:

1) Scrub nurse

Rationale:

The registered nurse first assistant (RNFA) is an RN who serves as an assistant to the surgeon. The RNFA works with the surgeon to perform the surgical procedure. A certified registered nurse anesthetist (CRNA) may administer anesthesia and is part of the clean team. The circulating nurse is also part of the clean team and is an RN who utilizes the nursing process to coordinate all activities in the operating room.

57

Which of the following potential complications is most likely related to the surgical procedure rather than to the general anesthetic?

1) Aspiration of gastric contents

2) Cardiovascular compromise

3) Fluid and electrolyte imbalance

4) Respiratory depression

Answer:

3) Fluid and electrolyte imbalance

Rationale:

Most surgical patients are at risk for fluid and electrolyte imbalance. This may result from blood loss, compromised renal function, the overall health of the patient, or maintaining the NPO status. Aspiration of gastric contents, cardiovascular compromise, and respiratory depression are potential complications of anesthesia.

58

Which of the following nursing interventions would help prevent one of the "never events" identified by Medicare? Select all that apply.

1) Control unpleasant odors in the room.

2) Give analgesics before the pain becomes severe.

3) Count sponges in the operating room.

4) Carefully identify the patient on each contact.

Answer:

3) Count sponges in the operating room.4) Carefully identify the patient on each contact.

Rationale:

Controlling odors helps prevent and treat nausea, and timely administration of analgesics helps control pain. "Never events" are serious and costly errors resulting in severe consequences for the patient. "Never events" are generally preventable. Pain and nausea are not "never events" as identified by Medicare. Counting sponges in the OR helps prevent the "never event" of leaving a foreign body in the patient. Careful identification helps prevent wrong patient, wrong body part, wrong surgery in the perioperative period.

59

A patient is having surgery to remove an inflamed appendix. Which of the following describes this type of surgery by purpose?

1) Ablative

2) Diagnostic

3) Palliative

4) Reconstructive

Answer:

1) Ablative

Rationale:

Ablative surgery involves removal of a diseased body part—in this case, the appendix. Diagnostic surgery is undertaken to confirm or negate a diagnosis (e.g., a biopsy or a fine-needle aspiration). In this situation, the diagnosis was already made and the surgery is being done to treat the condition. Palliative surgery is done to alleviate discomfort or other disease symptoms without producing a cure (e.g., nerve root destruction). In this situation, pain will be relieved, but a cure will also be effected. Reconstructive surgery is performed to restore function (e.g., repair of a torn ligament). This surgery removes the appendix rather than repairing it.

60

The nurse is teaching a patient how to prevent surgical site infections in the postoperative period. She should focus her teaching on:

1) care for the surgical dressing

2) handwashing

3) medications used to control pain

4) the need to complete all ordered antibiotics after surgery

Answer:

2) handwashing

Rationale:

An important aspect of perioperative nursing it to prevent complications of surgery. Hand hygiene is an important component of prevention. Family and friends should wash their hands before and after they visit the patient. Anyone who examines the patient or checks their incision should wash their hands. Patients should be instructed to wash their hands before and after caring for their incision or surgical dressing.

61

The nurse asks a preoperative patient to sign the operative permit as directed in the healthcare provider's orders. The patient says, "I do not really understand why I need surgery." The nurse should:

1) communicate the patient concerns to the circulating nurse upon arrival to the operating room.

2) explain what the planned surgical procedure is for and then have the patient sign the consent form.

3) have the patient sign the form anyway and then ask the healthcare provider to visit the patient.

4) notify the healthcare provider that the informed consent process is not complete and delay sending the patient to the operating suite

Answer:

4) notify the healthcare provider that the informed consent process is not complete and delay sending the patient to the operating suite.

Rationale:

Professional standards and law require the surgeon to obtain the patient's informed consent. The signed informed consent verifies that the patient and the surgeon have discussed the surgery and the patient understood it and was not pressured into having the surgery. The surgeon is responsible for giving the patient necessary information. As a patient advocate, the nurse is responsible for assuring that the surgeon explained the procedure and that the patient understood the information. If you have any questions about the patient's understanding or ability to understand, notify the physician and delay sending the patient to surgery.

62

An 83-year-old patient had surgery to repair a hip fracture and has not yet ambulated postoperatively. Based on this information, the nurse identifies the priority collaborative problem for the patient as:

1) fluid and electrolyte imbalance.

2) impaired surgical wound healing.

3) thromboembolism.

4) hypovolemia.

Answer:

3) thromboembolism.

Rationale:

Older adults are at greatest risk for complications during surgical procedures because they have less physiological reserve and often have comorbid conditions. Thromboembolism results from incresased coagulability and venous stasis due to immobility during and after surgery, and puts patients at risk for life-threatening pulmonary embolus. Nursing care should focus on preventing thrombophlebitis by encouraging and assisting with leg exercises and ambulation, applying antiembolism stockings or sequential compression devices, and maintaining adequate hydration.

63

The nurse is performing irrigation of the nasograstric tube for a patient who had abdominal surgery and meets resistance when trying to instill the irrigant. The nurse should:

1) use extra force to push the obstruction through the tube.

2) remove the tape from the patient's nose and adjust the placement of the tube.

3) have the patient turn to the left side to change the position of the tube.

4) attempt to flush the tube via the air port.

Answer:

3) have the patient turn to the left side to change the position of the tube.

Rationale:

Patients having abdominal surgery are at high risk of abdominal distention and will return from surgery with a nasogastric tube in place for gastric decompression. Management of nasograstric tubing includes irrigation with 30 mL to 50 mL of saline. The irrigant should be instilled slowly in the NG tube. If resistance is met when you irrigate, have the patient turn to the left side. Turning to one side changes the position of the distal tip of the NG tube. Do not force the solution. Do not instill fluid into the air vent. Manually adjusting the placement of the NG tube may cause accidental instillation of irrigant into the airway.

64

A young adult woman is scheduled for a bilateral breast reduction under general anesthesia. She is normally healthy and takes no daily medications. Identify the preoperative screening tests appropriate for this patient. Select all that apply.

1) Urinalysis

2) EKG

3) Chest x-ray

4) CBC

Answer:

1) Urinalysis4) CBC

Rationale:

Preoperative screening tests are ordered to determine whether the client has undetected underlying health concerns. Most institutions require a complete blood count (CBC) and urinalysis prior to all surgical procedures. Generally, an electrocardiograph (ECG) is ordered for clients over the age of 50 years or with known cardiac disease. A chest x-ray is not a routine presurgical screening test.

65

A patient arrives on the postoperative nursing unit following gastric bypass surgery. He is awake, alert, and oriented upon arrival. You are working with a NAP to assure timely and adequate patient care. Which of the following activities can you safely delegate to the NAP? Select all that apply.

1) Application of sequential compression device

2) Initial setup and irrigation of the nasogastric (NG) tube

3) Emptying and measuring urinary drainage

4) Reinforcing teaching about the pain scale

Answer:

1) Application of sequential compression device3) Emptying and measuring urinary drainage4) Reinforcing teaching about the pain scale

Rationale:

When deciding to delegate, the nurse should think critically about the task, the ability of the assistive personnel, and the circumstances. Communication, supervision, and evaluation are essential steps in the delegation process. The nurse cannot delegate nursing care decisions. Application of sequential compression device can be delegated to the NAP who has training in that task. The nurse can also delegate emptying and recording drainage. Although the registered nurse should perform the initial teaching, the nurse can delegate to the NAP reinforcement of teaching. The registered nurse should perform the initial set-up and any subsequent irrigation of the gastric suctioning tube.

66

The nurse has a prescription to give a series of medications on an "on call" basis. The nurse realizes that these medications will be given:

1) in the postanesthesia recovery unit.

2) at the time specified in the order.

3) on the patient's arrival in the surgery suite.

4) when the OR staff notify the nurse to do so.

Answer:

4) When the OR staff notify the nurse to do so.

Rationale:

The anesthesia team may order medications to be given "on call" if the surgery time is likely to vary. The nurse will give "on call" medications when he is notified to do so by the OR staff.

67

You are preparing a client for surgery. The client is currently taking warfarin, an anticoagulant. You are aware that this medication increases the risk for which of the following during or immediately after surgery?

1) Impairing cardiac functioning during anesthesia

2) Delaying wound healing

3) Bleeding

4) Developing respiratory depression

3

Correct!

Anticoagulants increase the risk for bleeding.

68

You are a circulating nurse working in and around a hospital's operating rooms. Which of the following are some of your key responsibilities?

SELECT ALL THAT APPLY.

1) Set up the sterile field.

2) Communicate with personnel outside the operating room.

3) Manage the care of the intraoperative client.

4) Prepare the surgical instruments.

5) Attend the patient during induction of anesthesia.

6) Anticipate and respond to the surgeon's needs.

2 3 5

Correct!

Feedback 1: The scrub nurse, not the circulating nurse, sets up the sterile field.

Feedback 2: The circulating nurse communicates with appropriate personnel outside the operating room.

Feedback 3: The circulating nurse manages the care of the intraoperative client.

Feedback 4: The scrub nurse, not the circulating nurse, prepares the surgical instruments.

Feedback 5: The circulating nurse attends the patient during induction of anesthesia.

Feedback 6: The scrub nurse, not the circulating nurse, anticipates and responds to the surgeon's needs.

69

What percentage of surgery-related deaths are caused by preventable perioperative errors?

1) 1%

2) 5%

3) 10%

4) 20%

3

Correct!

Preventable perioperative errors cause 10% of surgery-related deaths, have an unfavorable financial impact on healthcare institutions, and result in physical and emotional harm to patients.

70

Below are the steps for applying antiembolism stockings to a client. Put them in the correct order.

  • Insert your hand and turn the stocking inside out to the level of the heel.
  • Gradually pull the stocking up and over the leg.
  • Inspect the legs and feet for edema, abrasions, lesions, open areas, and circulatory changes.
  • Make sure the stocking is free of wrinkles and is not rolled at the top or bunched.
  • Elevate the patient's legs for at least 15 minutes.
  • Insert the patient's foot into the stocking.
  • Measure the patient's leg.

Correct!

The steps for applying antiembolism stockings to a client are as follows: 1. Measure the patient's leg. 2. Inspect the legs and feet for edema, abrasions, lesions, open areas, and circulatory changes. 3. Elevate the patient's legs for at least 15 minutes. 4. Insert your hand and turn the stocking inside out to the level of the heel. 5. Insert the patient's foot into the stocking. 6. Gradually pull the stocking up and over the leg. 7. Make sure the stocking is free of wrinkles and is not rolled at the top or bunched.

71

You are assisting in a biopsy surgery for a client with a brain tumor. Which of the following types of surgery is this?

1) Ablative

2) Diagnostic

3) Palliative

4) Reconstructive

2

Correct!

Diagnostic (exploratory) surgery is done to confirm or rule out a diagnosis. Examples include a biopsy, a fine-needle aspiration, or invasive testing, such as a cardiac catheterization.

72

You are preparing a client for surgery. Which of the following actions should you take in the preoperative phase of the perioperative period?

1) Set up the sterile field.

2) Assess risk factors for thrombophlebitis.

3) Shave the surgical site, as needed.

4) Assist the client in performing incentive spirometry.

2

Correct!

The preoperative phase begins with the client's decision to have surgery and ends when he enters the operating room. For all patients, during the preoperative phase, assess risk factors for thrombophlebitis, as venous thrombus is one of the never events that can lead to potentially life-threatening pulmonary emboli.

73

You are about to have the client sign a surgical consent form. Which of the following items should this form contain?

SELECT ALL THAT APPLY.

1) Type of surgery being performed

2) A statement that the patient has the right to refuse surgery up to 24 hours before it begins

3) Name and qualifications of person performing surgery

4) A statement of the relative risks, benefits, and side effects of the alternatives

5) A brief history of all the prior surgeries of this type the surgeon has performed

6) A guarantee that the patient will not experience any complications related to the surgery

1 3 4

Correct!

Feedback 1: The surgical consent form should contain the type of surgery being performed.

Feedback 2: The surgical consent form should contain a statement that the patient has the right to refuse surgery or withdraw consent at any time, not just up to 24 hours before it begins.

Feedback 3: The surgical consent form should contain the name and qualifications of the person performing the surgery (e.g., Jason Esmar, MD) and the primary practitioner for the patient's care and treatment.

Feedback 4: The surgical consent form should contain a statement of the relevant risks, benefits, and side effects of the alternatives.

Feedback 5: A brief history of all the prior surgeries of this type that the surgeon has performed is not required on the surgical consent form.

Feedback 6: A guarantee that the patient will not experience any complications related to the surgery should not be included on the surgical consent form. Even with the greatest care, there is no guarantee that complications will not occur.

74

You observe that a client who will be undergoing surgery later in the day is restless and trembling and has dark circles under her eyes. When you ask her what is wrong, she says she is just nervous about the outcome of her surgery. She hasn't slept well the past few nights because of it. Which of the following would be the most accurate nursing diagnosis for this client?

1) Disturbed Sleep Pattern related to upcoming surgery as evidenced by anxiety

2) Fear related to disturbed sleep pattern as evidenced by ineffective coping

3) Anxiety related to upcoming surgery as evidenced by restlessness and disturbed sleep pattern

4) Ineffective coping related to disturbed sleep pattern as evidenced by restlessness

3

Correct!

The client's primary problem is anxiety about the upcoming surgery, as evidenced by restlessness, trembling, and a disturbed sleep pattern.

75

You are working as the nurse in the postanesthesia care unit (PACU). You must confirm that the patient you are caring for has recovered sufficiently from anesthesia to be transferred to the surgical unit. Which of the following findings are necessary to indicate that the patient is ready to be transferred?

SELECT ALL THAT APPLY.

1) The patient is able to maintain his own airway, breathe deeply, cough, and expectorate secretions.

2) The patient is able to ambulate unassisted.

3) The patient is conscious and easily reoriented.

4) The patient's vital signs are stable and within an acceptable range.

5) The patient is urinating at least 10 mL/hr.

6) The patient's dressings are dry and intact.

1 3 4 6

Correct!

Feedback 1: The patient should be able to maintain a patent airway independently and to deep-breathe, cough, and expectorate secretions.

Feedback 2: The patient should be able to move all extremities that he could move preoperatively; however, he need not be able to ambulate unassisted.

Feedback 3: The patient should be conscious and easily reoriented. Often, patients will drift off to sleep between arousals; however, they should be easy to reorient and generally aware of circumstances and surroundings.

Feedback 4: The vital signs should be stable and within an acceptable range.

Feedback 5: The patient should be urinating at least 30 mL/hr, not 10 mL/hr, and in relative fluid balance.

Feedback 6: The patient's dressings should be dry and intact, or wound drainage considered appropriate for the procedure.

76

As the circulating nurse, you are assisting the scrub nurse during an operation. Which of the following interventions should you perform to prevent foreign objects from being left in the patient's body cavity after surgery?

1) Prepare and maintain the sterile field.

2) Obtain additional supplies and materials needed during surgery and open them on to the sterile field.

3) Monitor the intake and output of the patient.

4) Perform sponge, sharps, and instrument counts.

4

Correct!

The circulating nurse and the scrub nurse count the material that is added to the sterile field. As the surgery comes to an end, a repeat count is performed to ensure that no instruments, sponges, or sharps are left inside the client. A retained sponge can lead to infection and additional surgeries.

77

You are preparing a patient for a bronchoscopy procedure. The patient requires anesthesia that will control pain and anxiety. Which of the following types of anesthesia would be most appropriate in this situation?

1) General anesthesia

2) Conscious sedation

3) Regional anesthesia

4) Local anesthesia

2

Correct!

Conscious sedation is an alternative form of anesthesia that provides intravenous sedation and analgesia without producing unconsciousness. Advantages are that (1) pain and anxiety are adequately controlled without the risks of general anesthesia, and (2) recovery is rapid. Conscious sedation is used for procedures such as bronchoscopy and cosmetic surgery, but it is not practical for highly anxious patients.

78

You are preparing a client for surgery. The client is currently taking a corticosteroid. You are aware that this medication increases the risk for which of the following during or immediately after surgery?

1) Impairing cardiac functioning during anesthesia

2) Delaying wound healing

3) Bleeding

4) Developing respiratory depression

2

Correct!

Corticosteroids delay wound healing and increase the risk for infection.

79

You are caring for a client who recently came out of surgery. Which of the following actions should you take in the postoperative phase of the perioperative period?

1) Set up the sterile field.

2) Assess risk factors for thrombophlebitis.

3) Shave the surgical site, as needed.

4) Assist the client in performing incentive spirometry.

4

Correct!

The postoperative phase begins when the client enters the postanesthesia care unit and ends when he has healed from the surgical procedure. Incentive spirometry may be prescribed postoperatively for patients who are at high risk for atelectasis and pneumonia. It facilitates deep breathing, increases lung volume, and promotes coughing to clear mucus from the respiratory tree. If incentive spirometry is prescribed postoperatively, explain its use to the patient.

80

You are preparing a client for a mastectomy (surgical removal of a breast) for treatment of breast cancer. Which of the following types of surgery is this?

1) Ablative

2) Diagnostic

3) Palliative

4) Reconstructive

1

Correct!

Ablative surgery involves removal of a diseased body part. For example, a cholecystectomy removes a diseased gallbladder.

81

Which of the following are Joint Commission 2012 patient safety goals that are applicable to surgery?

SELECT ALL THAT APPLY.

1) Increasing lighting in operating rooms

2) Restricting access to the operating room to designated personnel

3) Preventing infection

4) Improving accuracy of patient identification

5) Using medication safely

6) Performing a time-out immediately before starting procedures

3 4 5 6

Correct!

Feedback 1: Increasing lighting in operating rooms is not a 2012 patient safety goal of The Joint Commission.

Feedback 2: Restricting access to the operating room to designated personnel is not a 2012 patient safety goal of The Joint Commission.

Feedback 3: Preventing infection is a 2012 patient safety goal of The Joint Commission.

Feedback 4: Improving accuracy of patient identification is a 2012 patient safety goal of The Joint Commission.

Feedback 5: Using medication safely is a 2012 patient safety goal of The Joint Commission.

Feedback 6: Performing a time-out immediately before starting procedures is a 2012 patient safety goal of The Joint Commission.