Perioperative Nursing Chapter 37 Final Exam

Front 1

Perioperative Period

Back 1

Surgery is a unique experience of a planned physical alteration encompassing three phases; preoperative, intraoperative, and postoperative, These three phases are together referred to as the perioperative period.

Front 2

Preoperative Phase

Back 2

Begins when the decision to have surgery is make; it ends when the client is transferred to the operating table, The nursing activities associated with this phase include assessing the client, identifying potential or actual health problems, planning specific care based on the individual's needs, and providing preoperative teaching for the client, the family, and significant others.

Front 3

Intraoperative Phase

Back 3

Begins when the client is transferred to the operating table and ends when the client is admitted to the postanesthesia care unit [PACU[, also called the postanesthetic room or recovery room. The nursing activities related to this phase include a variety of specialized procedures designed to create and maintain a safe therapeutic enviromnent for the client and health care personnel. These activities include safety, maintaining an aseptic environment, ensuring proper functioning of equipment, and providing the surgical team with the instruments and supplies needed during the procedure.

Front 4

Postoperative Phase

Back 4

Begins with the admission of the client to the postanesthesia area and ends when healing is complete. During the postoperative phase, nursing activities include assessing the client's response to surgery, performing interventions to facilitate healing and provent complications, teaching and providing support to the client and support people, and planning for home care. The goal is to assist the client to achieve the most optimal health status possible.

Front 5

Types of Surgery

Back 5

Surgical procedures are commonly grouped according to [a]purpose [b] degree of urgency, and [c] degree of risk

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Purpose
DIAGNOSTIC

Back 6

Diagnostic--Confirms or establishes a diagnosis; for example, biopsy of a mass in a breast.

Front 7

Purpose
PALLIATIVE

Back 7

Relieves or reduces pain or symptoms of a disease; it does not cure; for example, resection of nerve roots.

Front 8

Purpose
ABLATIVE

Back 8

Removes a diseased body part; for example, removal of a gallbladder.

Front 9

Purpose
CONSTRUCTIVE

Back 9

Restores function or appearance that has been lost or reduced; for example, breast implant.

Front 10

Purpose
TRANSPLANT

Back 10

Replaces malfunctioning structures;for example, kidney transplant.

Front 11

Emergency Surgery

Back 11

Is performed immediately to preserve function or the life of the client.Surgeries to control internal hemorrhage or repair a fracture are examples of emergency surgeries.

Front 12

Elective Surgery

Back 12

Is performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening [but mayultimately threaten life or well-being] or to improve the client's life.
[hip replacement surgery, and plastic surgery procedures such as breast reduction surgery]

Front 13

Degree Of Risk
MAJOR SURGERY

Back 13

Involves a high degree of risk, for a variety of reasons; It may be complicated or prolonged, large losses of blood ma occur, vital organs may be involved, or postoperative complications may be likely. Examples are organ transplant, open heart surgery, removal of a kidney.

Front 14

Degree Of Risk
MINOR SURGERY

Back 14

Normally involves little risk, produces few complications, and is often performed in an outpatient setting. [breast biopsy, removal of tonsils, and knee surgery]

Front 15

Age

Back 15

Neonates/infants and elder clients are greater surgical risks than children and adults

Front 16

Neonates and Infants

Back 16

Blood volume in an infant is small, and fluid reserves are limited. This increases the risk of volume depletion during surgery resulting in inadequate oxygenation of body tissue.Because of the infant's relatively large body surface area and immature temperature regulatory mechanisms, the risk of hypothermia during surgery is significant. Other organ systems, such as the kidneys, liver, and immune system, also have not achieved maturity in infants, affecting their ability to metabolize and eliminate drugs and resist infection.

Front 17

Toddler and older children

Back 17

Are better able to withstand surgery physiologically, but they often fear separation from their parents, strangers, bodily injury/mutilation, and death. The parent-child relationship, the parents coping abilities, and the preoperative teaching and support will affect how well the child is able to deal with these surgical fears and the level of anxiety experienced.

Front 18

The older adult [65 years and older]

Back 18

Often has fewer physiologic reserves to meet the extra demands caused by surgery. Deficits of aging increase the surgical risk for the older adult. Because of a lower percentage of body water, decreased kidney function, and a decreased thirst response, elders are at greater risk for fluid and electrolyte imbalance. Some are malnurished and that inhibits healing, demonstrate changes in liver and kidney function, both of which can affect response to anesthesia and othr medications.

Front 19

General Health

Back 19

Of particular concern are upper respiratory tract infections, which together with a general anesthetic can adversely affect respiratory function. Where there are high risks of infection, antibiotics may be administered parenterally within l hour of surgery and continued for 24 to 72 hours after surgery. This practice allows time for drugs to reach therapeutic levels in the tissues but does not permit bacterial resistance to develop.

Front 20

Medications

Back 20

Anticoagulants--increase blood coagulation time
Tranquilizers--may interact with anesthetics, increasing the risk of respiratory depression
Corticosteroids--may interfere with wound healing and increase the risk of infection
Diuretics--may affect fluid and electrolyte balance,

Front 21

Preoperative Teaching

Back 21

Preoperative teaching is a vital part of nursing care. Studiess have shown that preoperative teaching reduces clients' anxiety and postoperative complications and increases their satisfaction with the surgical experience.

Front 22

Preoperative Teaching
Information, including what will happen to the client, when, and what the client will experience, such as expectged sensations and discomfort.

Back 22

The nurse needs to listen carefully and attentively to the client to identify specific concerns and fears.

Front 23

Psychosocial support to reduce anxiety

Back 23

The nurse prvides support to catively listening and providing accurate information. It is important to rectify any misperceptions the client may have.

Front 24

The roles of the client and support poeple in reoperative preparation, the surgical procedure, and during the postoperative phase.

Back 24

Understanding his or her role during the peripoerative experience increases the client's sense of control and reduces anxiety.

Front 25

Skills traingin

Back 25

This includes moving, deep breathing, coughing, splinting incisions with the hands or a pillow, and using an incentive spirometer.

Front 26

Preoperative regmen

Back 26

explain the need to reoperative test---Discuss bowel preparation---Discuss skin preparation---Preoperative medications---Explain individual therapies---Discuss the visit by anesthetist---Explain the need to restrict food and oral fluids---Provide information on time of surgery---Discuss the need to remove jewelry, makeup, eyeglasses, hearing aids, dentures, wig---Tell client about preoperative holding aTech deep breathing and coughing exercises, leg exercises and ways to turn and move---Complete the preoperative checklist.

Front 27

Postoperative Regimen

Back 27

Discuss the postanesthesia recovery room and emergency equipment---Rypes and frequency of assessment activities--Discuss pain management--Precautions related to getting up for the first time---Usual dietary alterations--Postoperative dressing changes--tour intensive care unit if client is to be transferred there

Front 28

Outpatient Surgical Clients

Back 28

Review all instructions--Discuss what to wear--Explain the need for a responsible adult ot drive them home--Discuss discharge, and how long they will be there--Discuss medications--Communicate by phone the evening before surgery to confirm--Communicat by phone within 48 hours postoperatively to evaluate surgical outcomes.

Front 29

Preoperatyive Preparation Include

Back 29

Nutrition and fluids, elimination, hygiene, medications, rest, care if valuables and prostheses, special orders, and surgical skin preparation. In many agencies a preoperative checklist is used on the day of surgery.

Front 30

Nutrition and Fluids

Back 30

Adequate hydration and nutrition promote healing. Nurses need to identify and record any signs of malnutrition or fluid imbalance. If the client is on intravenous fluids or on measured fluid intake, the nurses must encure that the fluid intake and output is accurately measured and recorded.

Front 31

"NPO" Order

Back 31

The order "NPO after midnight" has been a long-standing tradidtion because it was believed that anesthestics depress gastrointestinal functioning and there was a danger the client would vomit and aspirate during the administration or a general anesthetic, Reevaluation and research, however, do not support this tradition. As a result the [ASA] revised its practice guidelines for preoperative fasting in healthy clients undergoing elective procedures.

Front 32

The revised guidelines allow for

Back 32

[1] The consumption of clear liquids up to 2 hours before elective surgery requiring general anesthesia, regional anesthesia, or sedation-analgesia
[2] A light breakfast [tea and toast] 6 hours before the procedure.
[3] A heavier meal 8 hours before surgery

Front 33

Elimination

Back 33

Enemas before surgery are no longer routine, but cleansing enemas may be ordered if bowel surgery is planned. The enemas help revent postoperative constipation and contamination of the surgical area. After surgery involving the intestines, peristalsis often doesn't return for 24 to 48 hours.

Front 34

Medications

Back 34

[1] Sedatives and tranquilizers [valium] to reduce anxiety and ease anesthetic induction
[2] Narcotic Analgesics [morphine, demerol] to provide client sedation and reduce the the required amount of anesthetic.
[3] Anticholinergics [atropine, scopolamine, and glycopyrrolate] to reduce oral and pulmonary secretions and prevent ;aryngospasm
[4] Histamine-receptor antihistamines such as [tagament, Zantac] to reduce gastric fluid volume and gastric acidity.
[5]Neuroleptaanalgesic agents such as [Innovar] to reduce general calmness and sleepiness

Front 35

Safety Protocols

First Step

Back 35

The first step requires preoperative verification, Client verification used to be a one-time procedure. The protocol requires client verification at the time surgery is scheduled, during admission, and when-ever the client is transferred to anotherf caregiver.

Front 36

Second Step

Back 36

Marking of the operative site in an unambiguous manner. An "X" is considered ambiguous and cannot be used. The same thing must be used all the time, The clients initials, the surgeons initials, the word YES.

Front 37

Third Step

Back 37

"time out" Before surgery begins the surgical team takes a time-out to conduct a final verification of the corredt client, procedure, and site, Any questions or concerns must be resolved before the procedure can begin.

Front 38

Antiemboli Stockings

Back 38

Ilastic stockings are firm elastic hose that compress the veins of the legs and thereby facilitate the return of venous blood to the heart. They also improve arterial circulation to the feet and prevent edema of the legs and feet. These stockings are frequently applied to surgical clients. Some go from the foot to the knee and some go to the foot to the midthigh, these stockings usually have a partial foot that exposes the heel or toes so that extremity circulation can be assessed.

Front 39

Sequential Compression Devices

Back 39

Clients who are undergoing surgery may benefit from a sequential compression device [SCDs] to promote venous return from the legs. SCDs inflate and deflate plastic sleeves wrapped around the legs to promote venous flow.

Front 40

Intraoperative Phase

Back 40

Nurse uses nursing process to design, coordinate, and deliver care to meet the identified needs of the clients whose protective reflexes or self-care abilities are potentially compromised because they are having operative or other invasive provedures

Front 41

Types of Anesthesia

GENERAL ANESTHESIA

Back 41

The loss of all sensation and consciousness. Protective reflexes such as cough and gag reflexes are lost. Blocks awareness centers in the brain so that amnesia [loss of memory], analgesia [insensibility to pain], hypnosis [artificial sleep], and relaxation [rendering a part of the body less tense] occurs.Its chief disadvantage is that it depresses the respiratory and circulatory systems.

Front 42

Regional Anesthesia

Back 42

Temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body. The client loses sensation in an area of the body but remains conscious. Several techniques are used.

Front 43

Topical [surface] Anesthesia

Back 43

Applied directly to the skin and mucous membranes, open dkin surfaces, wounds, and burns. The most commonly used topical agents are lidocaine [Xylocaine] and benzocaine. Topical anesthetics are readily absorbed and act rapidly.

Front 44

Local Anesthesia [infiltration]

Back 44

Injected into a specific area and is used for minor surgical procedures such as suturing a small wound or performing a biopsy. Lidocaine or tetracaine O.1% may be used.

Front 45

Nerve Block

Back 45

Technique in which the anesthetic agent is injected into and around a nerve or small nerve grou that supplies sensation to a small area of the body.Major blocks involve multiple nerve or a plexus grachial plexus anestherizes the arm.; Minor blosks involve a single nerve [facial nerve]

Front 46

Intravenous block [Bier Block]

Back 46

Used most often for procedures involving the arm, wrist, and hand. An occlusion tourniquet is applied to the extremity to prevent infiltration and absorption of the injected intravenous agent beyond the involved extremity.

Front 47

Spinal Anesthesia [subarachnoid block [SBA]

Back 47

Lumbar puncture through one of the interspaces between lumbar dic 2 [L2] and the sacrum [S1] An anesthetic agent is injected into the subarachnoid space surrounding the spinal cord

Front 48

Epidural [peridural] Anesthesia

Back 48

Is an injection of an anesthetic aent into the epidural space, the area inside the spinal column but ouside the dura mater.

Front 49

Antiemboli Stockings

Back 49

Rmenove antiembolism stockings one to three times a day tor 30 minutes for skin care and inspection, note the appearance of the legs and skin integrity, any edema, peripheral pulses, and skin color and temperature. Compare to previous assessment data.

Front 50

Sequential Compression Devices [SCD]

Back 50

To promote venous return from the legs. SCD's inflate and deflate plasticd sleeves wrapped around the legs to promote venous flow.

Front 51

Types of Anesthesia
GENERAL, REGIONAL, OR LOCAL and are administered by an anesthesiologist or a certified registered nurse anesthetist [CRNA]

Back 51

GERERAL ANESTHESIA is the loss of all sensation and consciousness. Under gereral anesthesia, protective reflexes such as cough and gag reflexes are lost. It blocks the awareness center in the brain. Its chief disadvantage is that it depresses the respiratory and circulatory system

Front 52

Regional Anesthesia

Back 52

is the temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body. The client loses sensation in an area of the body but remains conscious. Several techniques are used.

Front 53

Topical [surface] Anesthesia

Back 53

is applied directly to the skin and mucous membranes, open skin surfaces, wounds, and burns. The most commonly used topical agents are lidocaine and benzocaine. Topical anesthetics are readily absorbed and act rapidly

Front 54

Local Anesthesia [infiltration]

Back 54

Is injected into a specific area and is used for minor surgical procedures such as suturing a small wound or performing a biopsy. Lidocaine or tetracaine 0.1% may be used.

Front 55

Nerve block

Back 55

Anesthetic agent is injected into and around a nerve or small nerve group that supplies sensation to a smao area of the body.

Front 56

Intravenous Block [Bier Block]

Back 56

Most often for procedures involving the arm, wrist, and hand. An occlusion tourniquet is applied to the extremity to provent infiltration and absorbtion of the injected intravenous agent beyond the involved extremity.

Front 57

Spinal Anesthesia referred to as Subarachnoid Block [SAB]

Back 57

Requires a lumbar puncture through one of the interspaces between lumbar disc 2[L2] and the sacrum [S1] An anesthetic agent is injected into the subarachnoid apace surrounding the spinal cord. Spinal anesthesia is often categorized as low,mid,or high spinal.Low Spinals are used fo perineal or rectal area. Mid spinals T10 for hernia repair or appendectomies, High spinals T4 used for cesarean sections

Front 58

Epidural [oerudyrak] Anesthesia

Back 58

Injection of an anesthetic agent into the epidural space, the area inside the spinal column but outside the dura mater.

Front 59

Conscious Sedation

Back 59

Minimal depression of the level of consciousness in which the client retains the ability to maintain a patent airway and respomd appropriately to commands. Conscious Sedation increases the clients pain threshold and induces a degree of amnesia but allows for prompt reversal of its effects and a rapid return to normal activities of daily living.

Front 60

Circulating Nurse

Back 60

Coordinates activities and manages client care by continually assessing client safety, aseptic practice, and the environment [temp, humidity, and lighting].

Front 61

Scrub person

Back 61

Is usually a UAP but can be an RN or LPN. Their role is to assist the surgeons. They wear sterile gowns, gloves, caps, and eye protection. This includes draping the client with sterile drapes and handling sterile instruments and supplies. The circulating nurse and the scrub person are responsible for accounting for all sponges, needles, and instruments at the close of surgery.

Front 62

Intraoperative Nurse

Back 62

Documents nurse documents the perioperative plan of care including assessment , diagnosis , outcome identification, planning, implementation, and evaluation

Front 63

Tissue Perfusion

Back 63

The color of the lips and nail beds

Front 64

Implementing

Back 64

Nursing interventions designed to promote client recovery and prevent complications include a] Pain management b]appropriate positioning, c]incentive spirometry and deep-breathing and coughing exercises, d] leg exercises e] early ambulation, f] adequate hydration, g] diet, h] promoting urinary and bowel elimination, i] suction maintenance, and j] wound care.

Front 65

Pain Management

Back 65

Pain is usually greatest 12 to 36 hours after surgery, decreasing the second and third day after surgery.

Front 66

Positioning

Back 66

Clients who have had spinal anesthetics usually lie flat for 8 to 12 hours. An unconscious or semi-conscious client is placed on one side with the head slightly elevated, if possible, or in a position that allows fluids to drain from the mouth. unless contraindicated, elevation of affected extremities [following foot surgery] with the distal extremity higher than the heart promotes venous drainage and reduces swelling

Front 67

Deep Breathing and Coughing Exercises

Back 67

Help remove mucus, which can form and remain in the lungs due to the effects of heneral anesthetic and analgesics. These drugs depress the action of both the cilia of the mucous membranes lining the respiratory tract and the respiratory center in the brain. By increasing lung expansion and preventing rhe accumulation of secretions, deep breathing helps prevent pneumonia and ATELECTASIS [collapse of the alveoli] which may result from stagnation of fluid in the lungs. Encourage client to use the incentive spiromenter every hour while awake the first few days.

Front 68

Leg Exercises

Back 68

Encourage the client to do leg exercises taught in the preoperative period every l to 2 hours during waking hours. Muscle contractions compress the veins, preventing the stasis of blood in the veins, a cause of THROMBUS [stationary clot adhered to the wall of a vessel] formation and subsequent THROMBOPHLEBITIS [ inflammation of a vein followed by formation of a blood clot] and EMBOLI [a blood clot that has moved]. Contractions also promote arterial blood flow.

Front 69

Moving and Ambulation

Back 69

Encourage the client to turn from side to side at least every 2 hours. Turning alternates which lung can achieve maximum expansion because it is uppermost. Avoid placing pillows or rolls under the clients knees because pressure on the popliteal blood vessesl can interfere with blood circulation to and from the lower extremities. Generally clients begin ambulating the evening of the day of surgery or the first day after surgery .

Front 70

Hydration

Back 70

Measure the client's fluid intake and output for at least 2 days or until fluid balance is stable without an intravenous infusion. Ensuring adequate fluid balance is important. Sufficient fluids deep the respiratory mucous membranes and secretions moist, thus facilitating the expectoration of mucus during coughing. Also an adequate fluid balance is important to maintain renal and cardiovascular function.

Front 71

Diet

Back 71

Depending on the extent of surgery and the organs involved, the client may be allowed nothing by mouth for several days or may be able to resume oral intake when nausea is no longer proesent. When diet is tolerated only give clear liquids at first. If the client tolerates these with no nausea, the diet can often progress to full liquids and then to a regular diet. Assess the return of peristalsis by auscultating the abdomen. Gurgling and rumbling sounds indicate peristalsis. Oral fluids and food are usually started after the return of peristalsis. Therefore bowel sounds should be carefully assessed everfy 4 to 6 hours after surgery.

Front 72

Urinary Elimination

Back 72

Report to the surgeon if a client does not viod within 8 hours following surgery. Anesthetic agents temporarily depress urinary bladder tone, which usually returns within 6 to 8 hours after surgery, if promoting voiding fails a cathereter may be ordered. Keep I & O records for at least 2 days or until the client reestablishes fluid balance.

Front 73

Suction

Back 73

The suction ordered can be continuous or intermittent. Intermittent suction is applied when a single-lumen tube is used to reduce the risk of damage to mucous membrane near the distal port if the tube, Continuous suction may be applied if a double lumen tube is in place.

Front 74

Sutures

Back 74

Skin sutures can be broadly categorized as either interrupted [each stitch is tied and knotted separately] or continuous[one thread runs in a series of stitches and is tied only at the beginning and at the end of the run.]
Retention are sutures that are very large sutures used in addition to dkin sutures for som incisions.[used to support incisions in obese individuals or when healing may be prolonged.] They are are frequently left in place longer than skin sutures.