1
Q
What is the perioperative period?
A
Care of pt pre-op, intra-op, and post-op
2
Q
How are surgical procedures classified?
A
- Purpose
- Urgency
- Setting
- Risk
3
Q
What surgical procedures are classified under purpose?
7
A
- Diagnostic
- Ablative (removal of organ, tissue, extremity)
- Palliative (alleviate/not cure like bowel resection after cancer)
- Reconstructive (rebuild like skin graft)
- Constructive (build when absent like cleft palate)
- Transplant
- Incidental (done along with another surgery like adenoids with tonsil removal)
4
Q
What surgical procedure are classified under urgency? (3)
A
- Elective (done when convenient like bunions, cataracts)
- Emergency (ASAP like appy, ruptured aneurysm)
- Urgent (Necessary within 1-2 days like hip fx, heart bypass)
5
Q
What surgical procedures are classified under setting?
2
A
- Inpatient (@ hospital more than 23 hrs)
2. Outpatient
6
Q
What surgical procedures are classified under risk? (2)
A
- Minor (minimal risk like removal of skin lesions, ingrown toenails)
- Major (extensive assault and serious risk like TJR & Heart surgery)
7
Q
What is assessed in the preoperative assessment?
11
A
- Age
- Tobacco/ETOH use
- Med reconciliation
- Previous surgeries and hospitalizations
- Allergies
- Vital signs
- Respiratory/lung sounds
- Elimination
- Nutrition
- Coping/ Stress
- Obesity
8
Q
Why is age important to assess preoperatively?
A
Elderly are at increased risk. Decreased immunity with aging. Decreased wound healing r/t decreased nutrition. Increased risk of diabetes, heart disease. More chronic illnesses. Decreased cognition.
9
Q
Why is tobacco and ETOH use important to assess preoperatively?
A
Increased risk of pulm. complications. Nicotine constricts blood vessels. Excessive coughing leads to tearing of incisions. Alcohol is processed in the liver so pain meds may not work the same. May go thru withdraws.
10
Q
Why is med reconciliation important to assess preoperatively?
A
- Need to know current meds and let anesthesiologist know. (includes OTC, herbs, and supps) (STOP NSAIDs 1 wk prior. STOP Coumadin and switch to Heparin bc easier to reverse)
- Re-order post-op (pt can’t bring any of own meds unless Dr. okays it. Meds are assessed and re-ordered after surgery for safety)
- Prevent drugs to drugs interactions.
11
Q
Why is it important to assess previous surgeries and hospitalizations preoperatively?
A
To see what they are familiar with and if they had any complications. To show them how things work in the room if they don’t know how to work them. Decreases anxiety. To tell them about hospital routines. To tell them what is going to happen.
12
Q
Why is it important to assess allergies preoperatively?
A
Need to know any allergies to anesthesia, prep solution. Does it take a long time for them to recover for sedation? Nauseated. Iodine allergy? Beta-dine= shellfish. Latex, food, drug allergies, ect.
13
Q
Why is it important to assess vital signs preoperatively?
A
To know abnormalities and baselines. What is normal for the pt. Sometimes surgery will be canceled due to abnormalities. Have they had MI in last 6 mo? Hx of high BP, CHF, ect.
14
Q
Why is it important to assess resp/lung sounds preoperatively?
A
Decreased resp. status = harder to blow off anesthetic. Sick people can’t have surgery unless emergency, they may never be able to be extubated.
15
Q
Why is it important to assess elimination preoperatively?
A
To know pt baseline. To know last BM. Last void. Risk of urinary retention. Do they have kidney failure? Some anesthesia is eliminated thru kidneys.
16
Q
Why is nutrition important to assess preoperatively?
A
Malnutrition interferes with wound healing. Check complete metabolic panel preoperatively to get baseline (protein and albumin). Being aware of diet ( likes and dislikes)
17
Q
Why is coping/stress important to assess preoperatively?
A
To reduce anxiety. What is stressing them out? Are they having problems coping? Stress and anxiety both delay wound healing.
18
Q
Why is it important to assess obesity preoperatively?
A
Increased risk (wound healing: dehiscence, evisceration) More at risk for pneumonia, VTE, arrhythmia, heart failure.
19
Q
What are common NUR DX and client goals?
A
Anxiety, risk for bleeding, KNOWLEDGE DEFICIT, ineffective coping, body image disturbance, risk for infection. Goals=understanding the procedure and preventative measures to reduce complications. Tell them how long to not drive, be off work, not take certain meds, ect. EDUCATE THEM.
20
Q
What is informed consent?
A
Signed operative permit, all the risks and complication have been explained. (LEGAL DOCUMENT)
21
Q
How does the informing for informed consent?
A
DR. OR SURGEON
22
Q
What is the role of the nurse for informed consent?
A
ADVOCATE and WITNESS
23
Q
What are common dx lab tests done preoperatively? (7)
A
- CBC ( r/o anemia, infection, platelet issues)
- Electrolytes (20 tests. K+ is important!)
- BS
- BUN (kidney function)
- Creatine
- PT and PTT (clotting factors and bleeding time)
- GFR (kidney function)
24
Q
What other dx test are done preoperatively?
A
X-rays, CXR, MRI, angiogram, ultrasound, PETscan, EKG (anyone over 40 yo or hx of hypertension r/t increased cardiac risk)
25
What preoperative interventions should be complete?
1. Make sure pt has medical clearance and all docs are in hand
2. Ordered labs and tests are done and available in chart or EMR
3. Make sure pt is NPO and doc last time they ate
4. Make sure pre-op meds are given and doc
5. If shower or scrub is ordered, make sure its done prior to surgery
6. No shaving to decrease risk of infection during surgery (less portals of entry)
7. Enemas may be order post-op. Make sure completed
8. If needed tubes inserted in OR (cath, NG). Also TEDS or SCDs applied preoperatively if ordered
9. Void before leaving for surgery to prevent bladder distention
26
What should the pt be taught before the IV is even inserted?
1. Poss of drains, tubes, IVs and what precautions to take. (show them how machines work, how to empty, ect.)
2. Cough and Deep breath and show them how
3. Anti-embolism devices and exercises and show how they work or do them
4. Importance of early ambulation post-op and that it will be within 1st day/evening to reduce risk of complications
5. Teach about PRN pain meds and how to ask for them and how to rate the pain
6. Stress to pt how important it is to NOT get up without nurses help. Educate family on this as well
27
What is the surgeons role intraoperatively?
Responsible for all judgements in the pts care.
28
What is the 1st assists role intraoperatively?
Can not function alone. Holds retractors, hand tools, help, ect. Can be surgical resident, med student, nurse, PA, tech.
29
What is the anesthesiologist or CRNA's role intraoperatively?
NEVER LEAVE THE PT. Administers anesthesia, records meds and vital signs. Cant see surgery...sits at pts head behind curtain. Tells surgeon what is going on with pt.
30
What is the holding nurse's role intraoperatively?
"Intake RN". Greets, reviews med record. Cant go in OR. Marks pt, assesses anxiety. Sometimes starts IV. Brings pt to holding area/anesthesiologist.
31
What is the role of the circulating nurse intraoperatively?
ADVOCATE for pt. Sets up non sterile part of OR. Charts about pt during surgery. Gets med supplies. Positions the pt. Checks safety of equipment. Cath pt if needed in OR. Sends specimens to lab.
32
What is the role of the scrub nurse (or tech) intraoperatively?
Sets up sterile field, hands supplies to surgeon, anticipates surgeons needs, counts instruments.
33
How keeps track/counts sponges, clothes, etc that go inside pt?
Circulating and scrub nurse.
34
What methods are in place to ensure pt safety during OR?
1. Traffic Flow (keeping people who shouldn't be in restricted areas out)
2. Attire (street clothes off, surgical scrubs on. No jewelry,. Surgical scrub by anyone touching anything sterile. Sterile drapes used)
3. Pt identification (wristband on. surgical sites marked/initaled by pt and surgeon)
4. Positioning with doc (by circulating nurse)
5. Universal protocol----"TIME OUT" (everyone stops and verifies location of operation, reviews paperwork before an incision is made).
6. Sponge and sometimes instrument counts by scrub and circulating nurses.
35
Why are OR protocols important?
PT SAFTEY
36
What is anesthesia?
artificially induced state of of partial or total loss of sensation. with or without loss of consciousness.
37
What are determining factors of anesthesia?
UP TO ANESTHESIOLOGIST! Type, duration, emergency vs non emergency, area of body operated on, client positioning for surgery, age, post-op pain management.
38
What is general anesthesia?
- Reversible, UNCONSCIOUS state characterized by amnesia, analgesia, depression of reflexes, muscle relaxation, and homeostasis (maintain BP, profusion, etc)
- Drug induced loss of consciousness during which pt is not arousable.
- Can be done with IV and inhalation drugs. Started with IV then switched to inhalation after "OUT" and intubated. And used in combo with IV meds= balanced anesthesia.
- 30 Secs for pt to fall asleep once administered.
39
What is regional anesthesia?
- Reversible loss of sensation in a SPECIFIC area or region of the body when a local anesthetic is injected purposefully to block or anesthetize nerve fibers and around operative site.
- Examples: Spinals, epidurals, caudal, peripheral nerve blocks. Used in OB procedures, dental procedures if multiple areas of the mouth.
40
What is an epidural?
Anesthetic injection into epidural space. Often left in for pain relief (PCA-pump). Less complications, no cardiac/resp depression.
41
What is conscious sedation/analgesia?
- Drug induced depression of consciousness during which pt. responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation.
- Meds commonly used: versed, valium, fentanyl.
- Reversal= Narcan
- Nurse can administer by anesthesiologist must be in the building somewhere.
- Monitor VS.
- PT maintains airway.
- If MAC (level up from conscious sedation) pt can not maintain their own airway.
42
What is local anesthesia?
- Administration of anesthetic to one part of the body (smaller area)
- Local infiltration or topical application.
- Ex. Skin biopsy
- No anesthesiologist because no sedation occurs.
- LEAST AMOUNT OF ANESTHESIA
43
Adjunct meds used before surgery are;
Preanesthetic meds: given for sedation, to reduce anxiety (versed), increase comfort, reduce gastric acidity, decrease N/V, pain relief, cough suppression, decrease infection.
1. Anxiety/Increase Amnesia= benzos (VERSED, valium, ativan)
2. Pain relief/cough suppression= opioid (morphine, dilaudid, fentanyl)
3. Anticholinergics used to decrease secretions (atropine, robinul)
44
Adjunct meds used after surgery are;
Post anesthesia:
1. Analgesics: opioid if severe, by can delay PACU time.
2. Antiemetics: Decreases/stops N/V (Zofran)
3. Cardiac: if bradycardic
45
NUR DX for intra-op are...
-Impaired gas exchange, high risk of injury, impaired skin integrity, fluid vol deficit, high risk for infection, fear and powerlessness (pre and post-op)
46
What is important info to give to PACU?
1. Type/Length of procedure
2. Level of anxiety pre-op
3. Immobility
4. Complications
5. Resp. functions
6. Visual/Hearing probe
7. Past reactions to Anesthesia
47
NUR assessment/ interventions in PACU are;
1. VS- making sure stable. Watching resp. status, pulse ox, temp. Q15 min.
2. Dressing, drains, bleeding- watch for overt bleeding (ASAP), location of incisions. Should NOT have to do dressing change in PACU. If so, there is a problem!
3. Gag reflex- making sure it is returning. Pt can't drink until it is.
4. Airway patency- SX and O2 equipment must remain at bedside in PACU. Make sure pt. blows off drugs and breaths okay on own.
5. Adequate respirations- NC/Mask. Rarely intubated. Keep mask and pulse ox on pt at all times.
6. Peripheral circulation- joint/limb mobility. Are you allowed to move it?
7. Fluid Volume- Do they have IVs? How much fluid did they receive in surgery?
8. Level of consciousness- What is their baseline? Compare. Need to be able to breath on own before leaving the PACU.
9. Pain meds- to give or not to give? Can interact with anesthetic in pts system. Can cause resp arrest, deepening of LOC, respiratory depression ( LARGE CONCERN), and so is urinary retention.
10. N/V- Zofran. It comes on very quick!
48
Common NUR DX post-op:
IMPAIRED GAS EXCHANGE, risk for injury, pain, constipation, fluid volume deficit, ineffective airway clearance, high risk for urinary retention, knowledge deficit.
49
What is "D before E"?
Dehiscense- splitting/separating of incision.
| Evisceration- extrusion of viscera or intestine through surgical wound.
50
NUR assessment/interventions to prevent complications once pt has returned to unit:
1. Resp exercises ( C and DB) Splint incision if necessary
2. Maintaining suction/ other drainage tubing ( SX available and working. Assess drain and vans)
3. Dressing and incisional care- changing dressings, know the MD order and when to change.
4. Drainage- describe, measure, volume, recognizing changes.
5. Analgesia- assess and provide relief, and doc.
6. Pt and family teaching- infection prevention, wound prevention, restrictions, diets, meds, how to manage drains, D/C planning.
7. Progressive activity and restrictions- prevent VTE and pneumonia. As much as able to. Ambulate.
8. Discharge planning- starts at admission. Will they need help when they go home?
51
NUR implications for meds prescribed for surgical pt;
1. Stool softeners and laxative (colase, senna, miralax, peri-colase, milk of mag, fleets enema, ducalax supp, metamucil) due to immobility and pain meds. Post-op GI assessments is important! Pt teaching includes fruit, prune juice fiber.
2. Vitamins, Calcium, Iron to aid in healing (depending on type of surgery)
3. Anticoagulants for pt on bedrest to reduce risk of VTE. (TED hose, SCDs, Heparin, Aspirin)
4. Antibiotics (most bowel surgeries)
5. Other meds specific to type of surgery- Antispasmodic to reduce urinary retention. Hormones for hysterectomy. Muscle relaxants for oath/neuro surgeries.
52
PRN Pain Meds:
1. Types
2. Advantage
3. Disadvantage
1. Morphine, Norco, Acetaminophen, Valium, ect. Ask for med when they are in pain. (Injection, IV, PO)
2. Advantages: Pt. doesn't get overmedicated. Doesn't get meds if they do not want or need them.
3. Disadvantages: Wait for them. Don't get immediate relief and pain can build to intolerant level.
* ***TELL PT THAT MED IS PRN****
53
PCA PUMP:
1. Def
2. Advantage
3. Disadvantage
1. Narcotic at bedside. Pt controls when he is dosed. IV pump. Device that gives med when pt pushed button. Has a lockout. Time limit is set by MD.
2. Advantages: Pt has control. Delivery is immediate.
3. Disadvantages: Pt has to be physically and mentally able to push button. Family can not! IV dosage is limited to frequency/amount. More record keeping for RN. Have to replace at bedside and need another nurse with you to verify when changing to new bag.
54
Epidural, pain pumps, other-meds:
1. Def
2. Advantage
3. Disadvantage
1. Meds automatically injected at a controlled rate or is repeated before effects wear off. Can also set so pt can give themselves a bolus as well as constant med admin.
2. Advantage: excellent pain control
3. Disadvantage: Invasive procedure to place cath. High risk of infections. Limits pt from moving about freely. Certain amount of time before pt can have blood thinners. (faculty protocol...usually about 6 hours)
55
Define Anemia:
Abnormally low number of circulating RBCs, hemoglobin concentration or both. Lack of O2 to the cells and consequences that follow.
***Anemia is a symptom of an underlying disorder***
56
Causes of anemia: (4)
1. Blood loss (RBC being lost too quickly)
2. Inadequate production (not making enough RBC)
3. Increased RBC destruction (meds, nutrition, depressed bone marrow)
4. Insufficient or defective Hgb contributes to anemia.
57
Anemia is categorized by cause: (4)
1. Blood loss (Acute or Chronic. Losing volume)
2. Nutritional (Intake and absorbtion. RBC formation)
3. Hemolytic (Destruction of RBC)
4. Bone marrow failure/suppression (Aplastic)
58
Acute Blood Loss Anemia:
Due to hemorrhage such as GI bled. Losing RBC quickly. Can be unseen, not always due to trauma. Causes peripheral edema. RBC are normal size (normocytic), normal shape, normal color (normochromic).
59
Chronic Blood Loss Anemia:
Slow blood loss. Such as colon cancer, other cancers, menstruation (over time). Can be iron def. anemia as well. RBC are microcytic (small) and hypochromic (pale) due to decreases hemoglobin and iron.
60
Causes of Iron Def. Anemia:
- Most common in elderly.
- Causes; inadequate intake, malabsorption (Crohne's. Not absorbing correctly), increased needs (preg), chronic bleeding, GI inflammation, hemorrhoids, cancers.
61
What are the RBC like in Iron Def. Anemia?
Microcytic, hypochromic, malformed.
62
What are symptoms of Iron Def. Anemia?
- Brittle, spoon shaped nails
- Cheilosis
- Smooth, sore tongue
- Pica
63
TX of Iron Def. Anemia?
- TX is iron supp PO, for what can't be replaced by diet.
| - Foods high in iron= Popeye, spinach, red meat (beef), iron fortified foods.
64
What increases absorption of Iron? What decreases it?
Increases: Vitamin C
Decreases: Antacids
65
What are the two blood loss anemias we are studying?
Chronic and Acute
66
What are the three nutritional anemias we are studying?
Iron Def, Vit B12 Def, and Folic Acid Def.
67
What is the one hemolytic anemia we are studying?
Sickle Cell
68
What is pancytopenia?
When all blood cells are low.
69
What is the #1 cause post-op?
Resp. Status
70
Decrease BP & increased heart rate is a sign of what?
Shock
71
What is the number one preventable cause of death in the hospital?
Pulm. Embolism
72
What is Vit B 12 Def Anemia?
RBCs have impaired cell division and maturation of cell nucleus.
73
What do they RBCs look like in Vit B 12 Def Anemia?
Macrocytic, misshaped, fragile, short lift span.
74
What are the causes of Vit B 12 Def Anemia?
1. Fail to absorb dietary Vit B 12 due to lack of (GENETIC) intrinsic factor (Pernicious Anemia) Giving PO B12 is not helpful because pt is unable to absorb.
2. Occurs in pt who have had gastrectomy or ileal resection, loss of pancreatic secretions, chronic gastritis (may be because of alcoholism), and strict vegetarians.
75
S/S of Vit B 12 Def Anemia?
- Glossitis ( Smooth, red, beefy, sore tongue)
- Cheilosis
- Gradual onset NEURO probe such as parenthesis in extremities, proprioception, impaired balance.
76
Are the neuro probs in Vit B 12 Anemia reversible?
Up to 6 months
77
What is tx for Vit B 12 Anemia?
Early intervention...IM B12 shot because pt can't absorb B12 in stomach. Earlier the better to avoid neuro probs.
*For veg, increase oral intake of meats, eggs, dairy, or supplements.
78
What are the two megaloblastic anemia?
Vit B 12 Def and Folic Acid Def anemias
79
How does folic acid def anemia occur?
Inhibition of DNA synthesis in RBC...so they are not properly developed.
80
What do they RBCs in foilc acid anemia look like?
Dark red, large, immature
81
What are the causes of folic acid anemia?
1. Inadequate intake, chronically malnourished (IE: elderly, drug addicts, ETOH d/t chronic gastric inflammation, pts on chemo)
2. Increased need (IE infants and teens in growth spurts and pregnancy)
82
S/S of folic acid def anemia?
- Pallor
- Progressive weakness and fatigue
- SOB
- Palpitations
- Glossitis
- Cheilosis
- Diarrhea
83
What is tx for folic acid def anemia?
-Increases diet intake (green leafy veg, fruit, fortified cereals, meats, whole grains.
-Supplements as last resort
(ALWAYS DIET BEFORE SUPPS FOR ANYTHING)
84
What is hemolytic anemia in general?
Premature breakdown of RBCs in circulation. (INCREASED DESTRUCTION)
85
What do the RBCs look like in MOST types of hemolytic anemias?
Normocytic and normochromic. Look normal but do not last long.
86
What are the causes of hemolytic anemias?
- Intrinsic factor (inside RBC)
- Extrinsic factor (outside RBC)
* *Radiation, burns, drugs, bacteria, infection, trauma
87
How are hemolytic anemias txed?
Tx what is causing the issue
88
What is sickle cell anemia?
- Hereditary, chronic hemolytic anemia
- Episodes of sickling (present shaped RBC from abnormal form of hgb)
- Normal RBC with sickle cells mixed in
- Most common in African Americans
89
How is sickle cell anemia dx?
Thru hemoglobin electrophoresis to look for HbS gene from BOTH parents. Both parents need to have in order for child to have.
90
What are S/S for sickle cell anemia?
- Fever and intense pain
- Priapism
- Pallor
- Jaundice (RBC are broken down in the liver)
- Irritability
- Decreased circulation
- Occlusion
- Ischemia (Lack of blood flow)
- Infarction
91
What happens in a SC crisis?
RBCs get stuck, clot, decrease O2 to the area, severe pain!
92
What contributes to SC crisis?
* ***Anything that interferes with O2 demand! Because it brings blood to the area and things get blocked up!
- Hypoxia
- Low environmental temp or body temp
- Excessive exercise
- Anesthesia
- Dehydration
- Infection
- Acidosis
- Swelling
93
What are tx for sickle cell anemia?
- Transplant to remove sickle cells and replace with normal cells
- Blood transfusion
- Pain management
- Hydroxyurea: makes RBC more flexible and increases production of fetal hgb in RBC. Prevents sickling from rigid RBCs
94
What are the two other hemolytic anemias?
- Thalassemia
| - G6PD
95
What is aplastic anemia?
* *Rare anemia!
| - Bone marrow failure results in pancytopenia. Bone marrow is replaced by fat.
96
What are the causes of aplastic anemia?
- Viral infection
- Radiation
- Chemo
- Benzene
- Arsenic
- Nitrogen Mustard
- Chloramphenicol
97
How is aplastic anemia dx?
Thru bone marrow examination. A sample must be tested.
98
What are the S/S of aplastic anemia?
(Vary with severity)
- Pallor
- Fatigue
- HA
- DOE
- Tachycardia
- Heart failure
99
What is the tx for aplastic anemia?
* *Remove the causative agent!
- Bone marrow transplant (may or may not be successful)
- Blood transfusion
100
What is a CBC to dx anemia?
CBC is complete blood count. Looks for RBCs, WBCs, platelets, hgb, hematocrit
101
What is MCV to dx anemia?
Mean Corpuscular (or cell) Volume.
Measures RBC size on bell graph.
Can either be microcytic, normocytic, or macrocytic.
(Helps to classify RBC to a certain type of anemia)
102
What is RDW to dx anemia?
Red Cell Distribution Width.
RDW is elevated in accordance with variation in red cell size. ( When RDW is elevated, increases variation in red cell size is expected)
103
What does iron levels and TIBC show to dx anemia?
TIBC is the total iron binding capacity.
| These tests show the ability of the body to transport iron. (If decrease...its iron def. anemia)
104
What is serum ferritin test used to dx anemia?
Its another iron test. Looks at malnutrition.
105
What are common S/S when on iron supp?
- Tarry stools
- Heart burn
- Nausea
- Epigastric pain
- Constipation
* ***Should take on EMPTY stomach and with Vitamin C. DO NOT mix with antacids (milk).
* ****Be aware of iron overdose in young children.
* ****MVI (multivitamin) has iron in it! Be aware!
106
NUR DX for anemias:
- Impaired gas exchange
- Activity intolerance
- Pain
- IMPAIRED TISSUE PROFUSION (r/t peripheral tissue is compromised bc body is working so hard to get blood to vital organs)
- Coping
- Knowledge Deficit
NUR 103
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