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47 Cards in this Set
- Front
- Back
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Intraoperative Nursing
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Room Preperation
Transferring Patient Scrubbing, Gowning, and Gloving *Sterile Positioning the Patient Preparing the surgical site Assisting the ACP |
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Safety - Risk for Injury
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Identification
Equipment Toxins Infection Positioning |
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Surgical Asepsis
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Infection control
*Physical Seperation of areas *Surgical team *Circulating nurse *Scrub nurse |
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Safety - Risk for injury: Positioning
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Surgical team access to patient
Clear view of surgical site Reduces bleeding by avoiding venous congestion Minimizes cardiac and respiratory problems Decreases risk of pressure-related damage to skin, nerves, joints, and muscles |
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Anesthesia
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General Anesthesia
*Airway support *MAC Regional Anesthesia (block) *Protection to region Local Anesthesia Lidacain w/ some epinephrone |
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Catastrophic Events in OR
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Anaphylactic Reactions
*Assessment - Masked by anesthesia *Vigilance and rapid intervention - Trending data *Malignant hyperthermia - High temp is not first sign; generally muscle rigidity is *Rare metabolic disease *Hyperthermia and muscle rigidity *Can result in death |
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Postoperative Period
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Begins immediately after surgery
Nursing Care *Protecting patient (safety) *Preventing complications |
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Postanesthesia Care Unit (PACU)
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Immediate postanesthesia period
*ECG and more intense monitoring *Goal: Prepare patient for transfer to Phase II or inpatient unit Phase II transfer to extend observation, home, or extended care facility |
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PACU Progression
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Rapid PACU progression
*Based on patient's achievement of discharge criteria Fast tracking, cuts costs and increases patient satisfaction without compromising safety |
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Phase I Initial Assessment
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Report from OR to PACU nurse
Priority Care *Monitoring and managing -Respiratory -Circulatory function - Pain - can affect resp & circulatory function - Temperature - Surgical site probably takes about 5 minutes for this process |
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Assessment - Post Op Care
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Airway patency
*Rate/Quality, breath sounds Pulse Ox *Noninvasive screening of O2 *ABGs ECG monitoring *BP and baseline data *Temp, skin color, and condition |
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Assessment - Neurologic
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Initial (Immediate post-op)
*Level of consciousness *Orientation *Sensory and motor status *Size, equality, and reactivity of pupils *Explain activities from admission *Sensory and motor blockade may be present in patients who have had regional anesthetic |
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Post Op Assessment
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Assessment of urinary system
*Input and Output - 30 ml/hr is minimal *Fluid balance Assess surgical site and condition of dressing *Note amount and type of drainage Expect patient to void after surgery |
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Potential Respiratory Problems
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Common causes of airway compromise
*Obstruction *Hypoxemia (PaO2 less than 60 mmHg) *Hypoventilation *Blockage of airway by tongue *Supine position - not good for extremely sleepy patient |
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Intervention - immediate Post-op Respiratory Complications
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Proper positioning to facilitate respirations and protect airway
*Lateral position unless contraindicated *Patient allowed in supine position with HOB elevated once conscious |
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Potential Respiratory Problems
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Pulmonary Edema
Aspiration Bronchospasm Hypoventilation |
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Common causes of Respiratory Problems
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Atelectasis
*Most common cause of postoperative hypoxemia *May result from bronchial obstruction from retained secretions or decreased respiratory excursion Pneumonia |
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Diagnosis - Respiratory
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Nursing diagnoses
*Ineffective airway clearance *Ineffective breathing pattern *Impaired gas exchange *Risk for aspiration *Potential complication -Atelectasis, Pneumonia, Hypoxemia |
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Interventions - Respiratory
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Supplemental oxygen therapy
Deep breathing Coughing techniques *TCDB - Turn, Cough, Deep breath Adequate and regular pain control |
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Potential Cardio Problems
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Most common complications
*Hypotension - Fluid loss *Hypertension - Pain, anxiety, bladder distension, respiratory compromise *Dysrhythmias |
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Potential Cardio Problems
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Clincal Unit
*Hypokalemia -potassium not replaced in IV fluids *Tissue perfusion or blood flow affects CV status - VTE -Pulmonary embolism *Syncope Potassium outside of normal range often indicates dysrhythmmias |
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Assessment - Cardio
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Frequently vital signs
*Compare with baseline Assess apical-radial pulse carefully and report irregularities Assess skin color, tem, and moisture |
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Diagnosis - Cardio
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Decreased cardiac output
Deficient fluid volume Excessive fluid volume Ineffective peripheral tissue perfusion Activity intolerance |
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Nursing Intervention - Cardio
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Accurate I/O records
IV management Early ambulation VTE Prevention Slow position change *Dangle |
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Intervention - Cardio
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Notify provider
*Systolic < 90 mm Hg or > 160 mm Hg *Pulse < 60 or > 120 bpm *Pulse pressure narrows |
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SBAR
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"How you carry out notifying physician when something goes wrong"
Situation - Why you are concerned Background - Pertinent background information related to situation Assessment - What has changed/ What is problem Recommendation - What is you recommendation |
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Potential Neurologic Problems
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Postoperative cognitive dysfunction
Delirium Anxiety, depression Alcohol withdrawal delirium |
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Assessment - Neurologic
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LOC
Orientation Memory Ability to follow commands Size, reactivity, and equality of pupils Sleep/wake cycle Sensory and motor status |
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Diagnosis - Neurologic
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Disturbed sensory perception
Risk for injury Acute confusion Impaired verbal communic. Anxiety Ineffective coping Disturbed body image Fear |
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Implementation - Neuro
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Evaluate respiratory function
*hypoxemia causes post-op agitation Sedation may be beneficial for controlling agitation and providing safety |
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Neuro Implementation
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Safety
*Side rails up *Secure IV lines and artficial airways *Verify ID and allergy bands Physiological status monitoring Maintain normal physiologic function Concrete Objective info *Orient patient *limit psychologic problems *discuss expectations |
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Potential gastrointestinal problems
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Most common - N & V
*Fluid and electrolyte imbalance *Distention and flatus *Paralytic ileus *Hiccups |
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Assessment - GI
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Ask about nausea
Document characteristics of vomit Assess the abdomen *Auscultate all four quadrants |
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Diagnosis - GI
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Nausea
Risk for aspiration Risk for deficient fluid volume Imbalanced nutrition: less than body requirements |
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Nursing Implementation - GI Problems
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Nausea/Vomiting
*Antiemetic drugs *Oral fluids as tolerated *Suction at bedside *Begin oral intake when gag reflex returns *If NPO, IV infusions to maintain F/E balance Abdominal distention *Early and frequent ambulation *Encourage patient to expel flatus *Position patient on right side *Bisacodyl (Dulcolax) may be ordered |
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Potential Urinary Problems
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Low urine output 24 hrs after surgery is normal
Acute urinary retention may occur as result of: *Anesthesia *Location of surgery *Position and immobility *Renal failure Min output of 28-30 ml/hr |
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Assessment - Urinary Problems
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Examine urine for quantity and quality
*note color, amount, consistency, and odor Assess indwelling catheter Most patients urinate 6 to 8 hrs after surgery |
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Diagnosis - Urinary Problems
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Impaired urinary elimination
Potential complication: Acute urinary retention |
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Intervention - Urinary Problems
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Facilitate voiding with positioning
Provide reassurance Use helpful techniques If ordered, catheterize 6 to 8 hrs after surgery if no void |
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Potential integumentary problems
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Adequate nutrition is essential for wound healing
Factors affecting wound healing *Chronic disease with nutritional deficiency *Obesity *Older adults Wound infection may result from a number of sites Incidence is higher with certain types of patients Evidence of infection is not apparent for 3 to 5 days Surgeon may place drain in incision |
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Assessment - Surgical Wounds
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Serous draining is common from any wound
*More drainage when drain present Drainage should change from sanguineous, serosanguineous, serous (red to pink to clear yellow) Wound dehiscence may be preceded by a sudden discharge of drainage Serous- yellow fluid Sang- blood- bright blood Serosang- combo of two |
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Diagnosis - Surgical Wounds
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Risk for infection
Potential complication: Impaired wound healing |
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Intervention - Surgical Wounds
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Document drainage
*type, amount, color, consistency, odor Home care: dressing may be removed if no drainage for 24 to 48 hrs Avoid dislodging drains Observe for signs of infection |
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Altered temperature
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Nursing diagnoses
*Hypothermia *Hyperthermia *Risk for imbalanced body temp |
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Hyperthermia - Fever
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Wound infection
Respiratory tract infection Urinary tract infection Superficial thrombophlebitis Clostridium difficile Septicemia |
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Discharge Instructions - Same Day Surgery
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Discharge (Transport)
*Determine -Availability of caregivers -Access to pharmacy -Access to phone -Access to follow-up care Follow-up phone call to evaluate status |
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Discharge Instructions
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Reasons to seek help after discharge
*Unrelieved pain *Need advice on medications *Wound oozing and/or bleeding Written and verbal instructions Patient and caregivers must have information regarding *Care of incisions and dressings *Actions/side effects of any meds *Activities allowed and prohibited *Dietary restrictions and modifications Patient and caregivers must have information regarding *Symptoms to be reported *Where and when to return for follow-up care *Answers to individual's questions or concerns |
