1
Q
What are common signs and symptoms of acute abdominal pain?
A
- Pain
- Nausea
- Vomiting
- Diarrhoea
- Constipation
- Flatulence
- Fever
- Bloating
2
Q
What is in the Right Upper Quadrant (RUQ)?
A
- Liver
- Gallbladder
- Duodenum
- Head of pancreas
- Right kidney and adrenal
- Hepatic flexure of colon
- Part of ascending and transverse colon
3
Q
What is in the Left Upper Quadrant (LUQ)?
A
- Stomach
- Spleen
- Left lobe of liver
- Body of pancreas
- Left kidney and adrenal
- Splenic flexure of colon
- Part of transverse and descending colon
4
Q
What is in the Right Lower Quadrant (RLQ)?
A
- Cecum
- Appendix
- Right ovary and tube
- Right ureter
- Right spermatic cord
5
Q
What is in the Left Lower Quadrant (LLQ)
A
- Part of descending colon
- Sigmoid colon
- Left ovary and tube
- Left ureter
- Left spermatic cord
6
Q
What is in the Midline?
A
- Aorta
- Uterus (if enlarged)
- Bladder (if distended
7
Q
How do you assess abdominal pain?
A
Old Carts:
- Onset
- Location
- Duration
- Characteristics
- Aggravating factors
- Relieving factors
- Timing
- Severity
8
Q
What is the aetiology of inflammation?
A
- Gastroenteritis
- Appendicitis
- Pancreatitis
- Diverticulitis
- Cholecystitis
9
Q
What are life threatening effects of inflammation?
A
- Risk of perforation and peritonitis
- Fluid shifts to area of inflammation
- Unable to ingest fluid
10
Q
What can the life threatening effects of inflammation cause?
A
- Septic shock
- Hypovolaemic shock
11
Q
What is the aetiology of peritonitis?
A
- Perforated peptic ulcers
- Ruptured diverticula
- Ruptured appendix
- Intestinal perforation
12
Q
What are life threatening effects of peritonitis?
A
- Overwhelming infection
- Fluid shifts to area of inflammation
- Unable to ingest fluid
13
Q
What can the life threatening effects of peritonitis cause?
A
- Septic shock
- Hypovolaemic shock
14
Q
What is the aetiology of obstruction?
A
- Bowel obstruction
- Biliary obstruction
- Mesenteric vascular occlusion
15
Q
What are life threatening effects of obstruction?
A
- Strangulation risk
- Fluid trapped in bowel
- Fluid shifts to interstitial space
- Unable to ingest fluid
16
Q
What can the life threatening effects of obstruction cause?
A
- Septic shock
- Hypovolaemic shock
17
Q
What is the aetiology of internal bleeding?
A
- Trauma
- Ruptured abdominal aneurysm
- GI bleed
18
Q
What are life threatening effects of internal bleeding?
A
- Blood lost from vascular space
- Unable to ingest fluid
19
Q
What can the life threatening effects of internal bleeding cause?
A
Hypovolaemic shock
20
Q
Types of pain?
A
Nociceptive:
- Somatic
- Visceral
Neuropathic
21
Q
What is the nursing assessment you would undertake of a patient who presents to the ED complaining of acute abdominal pain?
A
- Pain assessment
- Patient history
- Family history
- Diet
- Medications
- Constipation
- ABCD
- Vital signs
- Intake and output
- LOC
- Skin colour/temp
- Abdominal assessment
- Pregnancy test
- STI
- Amylase and lipase
22
Q
What are diagnostic studies and MDT care?
A
- Complete history and physical examination
- FBC and Lytes
- ? X-match
- Urinalysis
- ? stool spec
- ECG
- AXR
- USS
- CT scan (+/- contrast)
- Pregnancy test
23
Q
What is appendicitis?
A
- Inflammation of the appendix
- Most common cause is obstruction of the lumen by faeces, foreign body or tumour
24
Q
What are signs and symptoms of appendicitis?
A
- Periumbilical pain
- Anorexia
- Nausea and vomiting
- Persistent pain , eventually shifting right lower quadrant and localising at McBurney’s point
- Localised tenderness, rebound tenderness and muscle guarding
- Patient may lie still often with the right leg flexed
25
What is peritonitis?
- Localised or generalised inflammatory process of peritoneum
- Results in massive fluid shifts and adhesions as body attempts to wall off infection
26
What are signs and symptoms of peritonitis?
- Abdominal pain
- Rebound tenderness
- Muscular rigidity
- Spasm
- Patient has shallow respirations
- Abdominal distension
- Fever
- Tachycardia, tachypnoea
- Nausea and vomiting
27
What is intestinal obstruction?
- Intestinal obstruction (partial or complete) occurs when intestinal contents cannot pass through the GI tract
- Requires urgent treatment
28
What are types of intestinal obstruction?
- Mechanical (90% of admissions)
| - Non- mechanical
29
What are symptoms of a small intestinal obstruction?
- Onset - Rapid
- Vomiting - Frequent and copious
- Pain - Colicky, cramp like, intermittent pain
- Bowel movement - Faeces for a short time
- Abdominal distension - Greatly increased
30
What are symptoms of a large intestinal obstruction?
- Onset - Gradual
- Vomiting - Rare
- Pain - Low-grade, cramping abdominal pain
- Bowel movement - Absolute constipation
- Abdominal distension - Increased
31
What is the nursing assessment for intestinal obstruction?
- Early recognition of deterioration
- Patient history and physical examination
- Assessment of vomitus
- Hydration status
- Pain
- Nutritional status
- Need for surgery
- Anxiety
32
What is cholelithiasis?
Stones in gallbladder
33
What is cholecystitis
Inflammation of the gall bladder
34
What is choledocholithiasis?
One or more gallstones in the CBD
35
What is assessment and care of cholelithiasis and acute cholecystitis?
- Pain control
- Antiemetic
- Antibiotics
- Maintain fluid and electrolytes
- Potentially NBM
36
What are symptoms of total obstruction?
- Jaundice
- Dark amber urine
- Clay-colored stools
- Pruritus
- Intolerance of fatty foods
- Bleeding tendencies
- Steatorrhoea
37
What are signs and symptoms of cholelithiasis and acute cholecystitis?
- Pain
- Indigestion
- Fever
- Jaundice
- Nausea and Vomiting
- Restlessness
- Diaphoresis
- Inflammation
38
What are etiological factors of acute pancreatitis?
- Alcohol
- Biliary tract disease
- Trauma
- Infection
- Drugs
- Postoperative GI Surgery
- Unknown
39
What can etiological factors in acute pancreatitis lead to?
- Activation of pancreatic enzymes
| - Injury to pancreatic cells
40
What is nursing care for peritonitis?
- Analgesics
- NBM
- Respiratory assessment
- Oxygen therapy
- Antibiotic therapy
- Fluids and electrolytes
41
What are signs and symptoms of acute pancreatitis?
- Abdominal pain – LUQ radiating to the back
- Aggravated by eating, relieved by vomiting
- Abdominal tenderness with muscle guarding
- Paralytic ileus
- Greys Turners spots
- Cullen’s sign
- Signs of shock
- Watch for respiratory distress – ARF to ARDS
- D.I.C.
- Clots
- Tetany
42
What is treatment of pancreatitis?
- Relief and control of pain
- Prevention of or treating shock
- Fluid and electrolyte imbalances corrected
- Nasogastric tube to decompress the stomach
- NBM w/ NG
- Antacids, PPI’s to neutralise gastric secretions and decrease hydrochloric acid stimulation
- Antibiotics and antispasmodics
- Removal of precipitating cause if possible
- Nutritional therapy
- When food allowed small frequent high carbohydrates
43
What is management of pancreatitis?
- Pain management
- Watch electrolytes and blood glucose
- Manage fluid imbalance
- Manage nutritional imbalances: maintain caloric needs while NBM
- Assessment: TPR, weight
- Surgery: pre and post operative care
44
What surgery can a patient receive if they have gallstones?
- ERCP with or without sphincterotomy/stenting (opens sphincter allowing stones to pass)
- ESWL (breaks up stones)
45
What does the activation of pancreatic enzymes cause?
Pancreatic enzymes (e.g. Trypsin) begin to digest within the pancreas (e.g. forming trypsinogen)
46
What is a non-acute surgical patient?
- Usually made by a General Practitioner (GP) or specialist
- Patient is evaluated for eligibility of accessing treatments by using Clinical Priority Access Criteria, and in some areas, a Clinical Priority System is used in the outpatient clinic by the specialist
- The patient is put on the elective waiting list
47
What is an acute surgical patient?
- Patient is usually admitted through the ED
- The patient maybe referred by the GP
- The patient is urgently referred due to an urgent or emergency surgical condition
- The patients may further classified as:
Either an acute elective case
Or an emergency case that can be life threatening and needs immediate treatment
48
Why does a person need surgery?
- Diagnostic
- Curative
- Restoration
- Ablative
- Palliative
- Cosmetic
49
How is surgery done?
- Laser surgery
- Cryosurgery
- High frequency sound waves – ultrasound
- Endoscope
- Transplantation surgery
- Skin/tissue graft
50
What is the risk level presenting in the surgery?
- Minor
| - Major
51
What occurs in the pre-admission clinic?
- Admitted one month prior to the preoperative clinic for assessment and preparation for pending surgery
- Scheduled to have a specific surgery with a specialist due to health problem
- Discuss the nurses role during this appointment
52
What are routes of admission for elective patients?
- Day surgery patient: day-of-surgery admission (DOSA)
- Other elective patients: via Operating Room Direct Admission service (ORDA) then transferred to the ward post-operatively
- Private patients reviewed in the surgeon’s room/clinic
53
What are routes of admission for acute/emergency patients?
- Acute admission to the ward
| - Acute admission to the operating theatre
54
What assessment is done with the patient pre-operatively?
- Past medical history and allergies
- Physical examination
- Blood tests, blood grouping and antibody screen, biochemical tests indicated, ECG, x-ray, etc
- Radiology
- Medications
- Psychosocial concerns
- Language and cultural needs
- Discharge planning
55
What are factors that may affect the patient’s surgical experience?
- Older adult patients
- General health status
- Reason for admission
- Habit/lifestyle
56
Why do pre-operative preparation?
- To ensure the patient participates in the goal setting of treatment plan
(patient-centred care)
- To establish trust and rapport (therapeutic communication)
- To ensure the process of signing the informed consent is valid (legal and ethical aspect)
- To identify and manage any physiological and psychosocial issues (physical and psychological preparation)
- To take proactive steps in managing adverse factors that may increase risk of post-op complications
- To determine if patient is safe and understands the scheduled surgery in order to achieve the best outcome
57
What are physiological effects of surgery?
```
Surgery is a stressor
All systems are affected:
- Respiratory
- Cardiovascular
- Urinary/hepatic
- Neurological/Musculoskeletal
- Endocrine system
- Immune system
- Gastrointestinal/Nutritional status
- Integumentary
```
58
What is physical preparation for surgery?
- Bowel preparation
- Food and fluid restriction (NBM)
- Preparation of the skin
- Dress the patient with the theatre gown (no undies)
- DVT prophylaxis: compression stockings and low-molecular weight heparin administration
- Prostheses
- Medications: pre-operative medications
59
What are examples of pre-operative patient education?
- Anti-embolism stockings
- Anticoagulant agents administration
- Education of bed exercises and deep breathing and coughing exercises
- Pain management
- Information on the procedure and equipment
- Dietary restrictions
60
What is the psychosocial nursing care help to determine?
- Perception of the surgery
- Expected outcome
- Coping mechanisms
- Knowledge level
61
What are psychosocial questions you could ask the patient?
- Why you are having surgery?
- How much you know about the surgery?
- What you expect from the surgery?
- How will the surgery impact upon your life?
- What are your cultural and spiritual beliefs that may impact on your surgical experience?
- What concerns do you have regarding your role at home or elsewhere?
- Who do you get help from in case of need?
- Where you will go post discharge?
62
What are examples of psychosocial nursing diagnoses?
```
Fear specifically related to:
- Anaesthesia
- Pain and discomfort
Anxiety generally related to:
- Unknown
- Loss of control
```
63
What should surgical informed consent include?
```
Always:
- Consent for procedure
- Consent for anaesthesia
Most likely:
- Consent for blood and blood products
```
64
What is a nurse’s role in the informed consent process?
- A legal and ethical document
- A voluntary and written consent signed by the
individual patient (or other legal person)
- Surgeon and anaesthetist’s responsibility
- Special considerations
65
What do you document for surgery?
- Pre-operative checklist
- Observation charts
- Medication charts: FBC, drug chart
- Nursing notes: initiating the care plan and progress notes
66
For surgery what is the nurse responsible for?
- Performs physical, psychological and social assessment and preparation
- Communicates pre-operative concerns with the multidisciplinary teams
- Ensure the patient’s consent is “informed”
- Acts as an advocate for the patient
- Completes relevant documentations
67
What occurs in the preoperative phase?
- Starts with the patients decision to have surgery and ends with her transferred to OR
- Care focuses on preparing and teaching the patient
68
What occurs in the intra-operative phase?
- Starts when the patient is placed on the OR table and ends when transferred to the PACU
- Care focuses on providing safe environment during surgery
69
What occurs in the postoperative phase?
- Starts when the patient is admitted to the PACU and ends when no longer needs surgery-related nursing care
- The focus is on preventing complications and relieving pain
70
What forms of teaching can occur pre-op?
- Medications
- Diagnostic tests
- Dietary and fasting guidelines
- Surgical preparation
- Anaesthesia concerns
- Surgical procedures
- PACU experience
- Pain control
- Deep breathing and coughing exercises
- Incentive spirometer use
- Postoperative exercises
- Use of assistive devices, such as crutches or a walker
- Postoperative tubes and drains
- Postoperative expectations
71
What are the different key areas of operating suites?
- Unrestricted (waiting room)
- Semi-restricted (pre op area)
- Restricted (operating suites)
72
What are the staff during surgery?
- Surgeon
- Surgeon assistant
- Scrub nurse
- RN First Surgical Assistant
- Anaesthetist
- Anaesthetic assistant
- Circulating nurse
- Observers
73
What is the OT/OR experience?
- Scrubbing (5 min scrub)
- Gowning
- Gloving
- Aseptic technique in theatre and the sterile field
- Observing potential for syncopal episodes, breach of sterility
74
What are the classifications of anaesthesia?
- Conscious sedation
- Procedural sedation
- General anaesthesia and adjuncts
- Regional anaesthesia
- Local anaesthesia
75
What are catastrophic events in the OT?
- Sudden death
- Anaphylactic reactions
- Malignant Hyperthermia
76
After transferring to PACU what is the responsibility of PACU nurses?
```
Initial assessment includes:
- ABC (airway, breathing and circulation)
- Oxygen therapy
- Electrocardiographic (ECG) monitoring
- Neurological assessment
- Urinary system
- Surgical site
Ongoing assessment
```
77
What are potential alterations in respiratory function?
Airway compromise causes:
- Airway obstruction
- Hypoxaemia
- Atelectasis, pulmonary oedema, aspiration of gastric contents, bronchospasm
- Hypoventilation
78
What are potential alterations in cardiovascular function?
- Hypotension
- Hypertension
- Cardiac arrhythmias
79
What are potential alterations in neurological function?
- Emergence delirium
- Delayed awakening
- Normally is transient and reversible
80
What are negative effects of pain due to surgery?
- Common reason for a prolonged stay
| - May contribute to complications
81
Who has an increased risk of hypothermia in surgery?
- Older adult patients
- Debilitated patients
- Intoxicated patients
82
What is the ward nurse responsible for before go picking up post-op patient?
- Clear the bed space, make your surgical bed
- Get the equipment or devices: e.g. IV pole; BP cuff, stethoscope, pulse oximeter
- Check O2 and suction patency
- Anticipate if your patient needs heel pads (extra pillows), vomit cartons, tissues, extra blankets; due to the type of surgery
83
What is the ward nurse responsible for when arriving at PACU?
- Take the handover and then
- Determine if your patient is ready to be discharged from the PACU
- Remember do not take patient back to the ward if you do not think they are stable
84
What occurs in a PACU handover?
```
General information:
- Demographic data, anaesthetist, surgeon and surgical procedure
Patient history:
- Medical history, meds and allergies
Intra-operative management:
- Anaesthetic types and medications
- Other meds given pre/intra-op
- Blood loss
- Fluid replacement
- Urine output
- Unexpected intra-operative events
PACU management:
- Potential and expected problems in PACU
- Interventions
- Medications given or charted; PCA/Epidural
Documentation:
- Vital signs, FBC, and monitoring trends
- Medication charts for pain and nausea
- Results of intra-op lab tests
- Postoperative orders from surgeon and anaesthetist
Family notification
```
85
How to determine your patient’s readiness for discharge to the ward?
- Stable vital signs
- Orientated to person, place, time (and events)
- Uncompromised pulmonary function (no airway support)
- Adequate pulse oximetry readings
- Urine output at least 30-35 mL/h (≥0.5mL/kg/hr)
- Nausea and vomiting absent or under control
- Minimal pain (aim for <2-3/10)
86
What do you assess postoperatively?
- Record time of arrival back on ward
- Assessment of ABC's
- Assessment of neurological status
- Baseline vital signs
- Assess wound (do not take dressing off), dressing intactness and drainage tubes (attached to? – measure and mark on FBC)
- Assess colour and appearance of skin, check PP, peripheries
- Assess urine output (IDC – note on FBC) (2L bag or urometer?)
- Assess pain and nausea (sore throat) – PCA? Epidural? (know policies)
- Positioning for airway maintenance, safety, SR, bed low, call bell in place
- Check intravenous therapy (check from OT records and current Rx) –FBC
- Check drainage tubes/drains/bottles – mark levels
- Emesis basin and tissues
- Emotional status
- Orient patient to environment / family; orientate family to processes
- Check and carry out postoperative orders
87
What are cues for post-operative assessment?
A, B, C, 4Ds (drips drains, drugs, and disabilities), and E (extras)
88
What are levels of consciousness (LOC)?
- Drowsiness
- Alertness
- Disorientation
- Confusion
89
What to check for airway?
- Check patency of airway
- Head and neck position
- Evidence of obstruction
90
What to check for breathing?
- Rate > 12
- Rhythm
- Depth and quality
- O2 requirements, O2 Sats >95%,
- Presence of stridor, wheeze, use of accessory
muscles
91
What are common concerns for airway?
Ineffective airway clearance
92
What are common concerns for breathing?
- Ineffective breathing
pattern
- Ineffective gas exchange
- Presence of atelectasis
93
What to check for circulation?
- BP compare to baseline
- Pulse, rhythm, rate
- Temperature
- Skin colour and moistness
- Capillary refill
94
What are common concerns for circulation?
- Decreased cardiac output
- Fluid deficit
- Fluid overloading
- Ineffective tissue perfusion
- Potential of thrombosis
95
What are clinical manifestations of inadequate oxygenation?
- Restless
- Tachycardia, bradycardia and arrhythmias
- Cyanosis
- Prolonged capillary refill
- Flushed and moist skin
- Increased or absent respiratory effort
- Abnormal breath sounds
- Abnormal arterial gases
96
What are types of drips post surgery?
- IV therapy: IV fluids; blood transfusion
- Infusions - GIK infusion in patients with diabetes
- PCA and Epidural infusion
- Order for post-operative diet (POD)
97
What are types of drains post surgery?
- Surgical drains
- Wound discharge
- Nasogastric (NG) tube
- Any vomiting
- Urinary catheter: indwelling catheter (IDC), suprapubic catheter (SPC)
- Any packing: vaginal packing, nasal packing
98
What are types of drugs post surgery?
```
PRN and regular medications prescribed:
- Analgesics
- Antiemetics
- Anti-inflammatory
- Anti-coagulant
- Antibiotics
- Adjuvant drugs: antidepressant
Patient’s self-medications clarified and prescribed
```
99
What are types of disabilities to be aware of for surgery?
- LOC-GCS
- Diabetes
- Heart disease
- Arthritis
- Any long term health conditions and treatment
100
What are extras to be aware of for surgery?
- Family notification
- Patient comfort care: post-op wash, mouth care
- Pressure area care
- Procedure specific care: neurovascular assessment, bowel sounds
- Special requirement: sedative request, post-op exercise, nutrition
101
What kind of complications affect post-op patients?
- Pneumonia
- Hypovolemia
- Paralytic ileus
- Pressure ulcers
- Pulmonary embolism
- Infection/ septicaemia
- Urine retention
- Wound infection
- PONV (post-op nausea and vomiting)
Also:
- Atelectasis
- Compartment syndrome
- Fat embolism
- Thrombophlebitis
- Wound dehiscence and evisceration
102
What are post-op exercises for every post-op patient?
- DB and C q1-2h
- Incentive spirometry q2h while awake
- Leg exercises
- Splinting incision with pillow
- Changing position q1-2h
- Chest physio if patient has atelectasis
103
What are drugs for nausea and vomiting?
- Cyclozine
- Phenergan
- Stemetil
- Ondansetron
- Dexamethasone
168.362
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