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Perioperative Nursing
Preoperative Nursing
Intraoperative Nursing
Postoperative Nursing
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Perioperative NursingPreoperative phase- the period of timefrom when the decision for surgicalintervention is made to when thepatient is transferred to the operatingroom table
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Perioperative Nursing
Intra-operative phase- period oftime from when the patient is
transferred to the operating tableto when he or she is admitted tothe post anesthesia care unit
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Perioperative Nursing
Postoperative phase- period of timethat begin with the admission of the
patient to the post anesthesia care unitand ends after a follow-up evaluation inthe clinic setting or home
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PREOPERATIVE NURSINGMANAGEMENT
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Examples of PerioperativeNursing Activities
Preoperative Phase
Preadmission Testing
a. Initiates initial preoperative assessmentb. Initiate teaching appropriate to patients
needs
c. Involves family in interviewd. Verifies completion of preoperative testinge. Assess patients need need for
postoperative transportation and care
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Admission to Surgical Unit
a. Completes preop assessment
b. Assesses for risk for post op complications
c. Reports unexpected findings or anydeviationsfrom normal
d. Verifies that operative consent has beensigned
e. Coordinates patient teaching with othernursing staff
f. Reinforce previous teaching
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g. Explain phases in perioperative period andexpectations
h. Answers patients and family questions
i. Develops a plan of care
Holding Areaa. Assess patient status
b. Review chart
c. Identifies patientd. Verifies surgical site
e. Establishes IV line
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f. Administers preop meds
g. Takes measures to assure patients
comfort
h. provides psychological support
i. Communicates patients emotional status toother appropriate member of health careteam
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Preoperative NursingManagement
Surgical Classifications/ Categories of SurgicalProcedures
1. Diagnostic- discovery or confirmation of a
diagnosis- biopsy2. Curative- removal of damaged or diseased
tissue or organs- excision of
tumor/appendectomy/ hysterectomy3. Constructive- repair of congenitally defective
body part- cleft palate/lip repair
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4. Reconstructive/cosmetics-partial/complete restoration of body
part- mammoplasty/facelift/ total hipreplacement
5. Aesthetic- improvement of physical
features that are within the normalrange- breast augmentation
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Classification of Surgery According toDegree of Urgency
1. Emergency- patient requires immediateattention; discomfort may be lifethreatening; without any delay eg.
Severe bleeding, bladder/intestinalobstruction, fractured skull, gunshot/stabwounds, extensive burns
2. Urgent- patient requires promptattention; within 24-30 hours, eg. Acutegallbladder infection, kidney and urethralstone
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3. Required- patient need to have surgery;plan within few weeks or months eg.
Prostatic hyperplasia without bladderobstruction, thyroid disorder and cataracts
4. Elective- patient should be operated on;
failure to have surgery not catastrophic eg.Repair of scar, simple hernia and vaginalrepair
5. Optional- decision rest to patient; personalpreference eg. Cosmetic surgery
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Preop assessment
1. Medical/ health history- history and
experience with anesthesia, serious illness,trauma-(a. allergy; b. bleeding tendencies;c.cortisone/ steriod; d. dm; e. emboli) alcohol,
chronic illness, advanced age, medicationhistory
2. Psychological examination- knowledge of
cultural beliefs/practices/ traditional healthcare, alternative and complementarypractices; lifestyle, ability to tolerate pain
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3. Physical examination- specific bodysystem assessment
4. Additional- age, pain nutritional status,F&E, infection and immunity, hematologicfunctions
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Medication History
Assess for possible drug to drug
interaction
a. adrenalcorticosteriods- should not be stopabruptly- CV collapse
b. Diuritics- excessive resp. depression
c. Phenobiazines- inc. hypotensive action ofanesthetics
d. Anti-depressants- MAO inhibitors;hypotensive action of anesthetics
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Informed Consent
Voluntary/ written/ signed before surgery
Protects the patient from unsanctioned surgeryand protects the surgeon from claims of anauthorized surgery
Physician provide simple clear explanation ofwhat the surgery entail
Inform the patient of alternative, possible risks,
complications, disfigurement, disability,removal of body parts
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Not valid if patient signed is under theinfluence of substances/ medications
that affect judgment and decisionmaking capability
Consent necessary:
a. Procedure is invasiveb. Anesthesia is used
c. Non-surgical procedure with risk-
anteriogramd. Procedures with radiations
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Patient signs the consent in legalage/mentally capable
Life saving measures may perform operationwithout consent
No patient should be urged or coerced to
sign a consent; valid consent must be freelygiven without coercion, threat, force, urge
Refusing to undergo a surgical procedure isa persons legal right and privilege
Cant sign patient who are mentallyretarded, ill and comatose
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The consent should be written andcontain:
a. Explanation of procedure/risk
b. Description of benefits/ alternatives
c. Offer Q&A about procedure
d. Instruction to withdraw from consent
e. Other changes from routine procedure
Written in language understandable to thepatient Q&A open communication forconfusion
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Immediate Preop Care
PHYSICAL CARE
a. Prepare the skin- shower/bathing
b. GIT- dec. vomiting/aspiration/ dec. possiblebowel obstruction; 8-10h food/fluidrestricted
c. Nutritional care-inc. CHO, CHON, vit. C, Kand minerals
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d. Preoperative teaching
1. Sensory information
2. Psychosocial information- copingabilities, worries about family,concerns
3. Procedural information- before, duringand after surgery; before surgery pxshould be taught with deep breathing,
coughing, turning, ambulating,paincontrol and equipments
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Immediate Preop Activities1. Allergies recorded2. VS3. Correct identification4. Consent form signed
5. Skin prep6. Check special orders7. NPO
8.Client voided/cath. Recorded
9. Oral hygiene/ other physical care completed10. Check for presence of dentures or prosthesis
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11. Valuables should be endorsed/ kept anddocumented
12. Jewelry removed- wedding band allowed-secured; remove wigs, hair pins
13. Hearing aide- for communication
14. Hospital gown with cap on
15. Colored nail polish removed
16. Make-up removed for for skin color to beobserved
C l d
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Commonly Used PreopMedications
1. Tranquilizers- Diazepam (valium)- dec.anxiety; se. dizziness, clumsiness or
confusion; Properidol (inapsine)- dec. anxietyse. anxiety, hypotension
2. Sedatives- midazola HCl- induces sleep, dec.anxiety se. dec BP, resp. depression
Phenergan (promethazines HCl) - dec.anxiety/ antiemetic se. dec. BP
3. Secobarbital Na/ pentobarbital Na- dec.
anxiety/ sedation se. disorientation
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4. Anlgesics- morphine sulfate- relieves pain, anddec. anxiety/sedation se. resp/ circulatory
depression, dec. BP, GI motility, vomiting5. Anticholenergics- atropine SO4 se. dry mouth,
tachycardia
6. Histamine H2- receptor antagonistcimetidine(Tagamet)- dec. gastric acid production se.mild dizziness, diarrhea somnolence and rash
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Focus of planning/ goal/implementation is to decrease preop
anxiety and increase knowledge ofpreop preparations and post opexpectations
Transport patient to or room safely andsecurely medical record, smoothtransfer to avoid nausea and dizziness
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Preop Nursing Diagnosis
Anxiety related to the surgical experience(anesthesia and pain) and the outcome of
the surgeryRisk for ineffective management oftherapeutic regimen r/t knowledge deficit
regarding preoperative procedures andprotocols and postoperative expectations
Anticipatory grieving process related to loss
of limb
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evaluationExpected outcomes:
a. Anxiety is relieved- discusses concerns,verbalized understanding on preanesthesiameds and gen anesthesia; relaxes quietly
b. Prepares for surgical intervention- participatesin preop preparations; demostrate anddescribes exercises to be performed postop,
accepts preop meds, remains in bed, relaxesduring transportation, states rationale for siderails
c. Participates in discharge planning
INTRAOPERATIVE NURSING
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INTRAOPERATIVE NURSINGMANAGEMENT
I t ti N i
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Intraoperative NursingManagement
Nursing care focuses on the clientsemotional well-being and physical
factors such as safety, positioning,maintaining asepsis and controlling thesurgical environment
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Example activities during Intraoperative Phase
Maintenance of Safety
1. Positions the patienta. Functional alignmentb. Exposure of surgical site
c. Maintenance of position throughout theprocedure
2. Applies grounding device to patient
3. Provide physical support4. Ensures that sponges, needles and
instrument counts are correct
5. Maintains aseptic technique
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6. Effectively manages human resources
Physiologic Monitoring
1. Calculates effects on patient ofexcessive fluid loss or gain
2. Distinguishes normal from abnormalCP data; reports any changes in pulse,resp, temp, and BP
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Psychological Support before Induction
while Conscious1. Provides emotional support
2. Stands near or touches patient during
the induction of anesthetics3. Continues to assess patients
emotional status
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Members of the Surgical Team
a. Surgeon- head of surgical team; makesdecision on surgical procedures; secondsurgeon or specially trained nurse may serve
as assistantb. Anesthesiologist- alleviates pain; promote
relaxation with meds; provides/ maintains
airway, monitor circulation, resp, estimatesblood and fluid loss, infuses blood and fluids,alerts surgeon if any complication occurs
c Nurse anesthetist- trained to induct
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c. Nurse anesthetist- trained to inductanesthesia; 2 yrs additional edu. BSN + Iyear ICU experience; work under
anesthesiologist
d. Circulating nurse- core member of thesurgical team; maintains the coordination of
team members; client advocate, RN, dontwear sterile clothing can go in and out in or;ensuring all equipments working properly;
maintains sterility of instruments/supplies;assisting with positioning; performing skinprep; monitoring the room and teammembers for break on sterile technique
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Assisting anesthesia personnel; handlingspecimen; coordinate with other department;
documenting care rendered and minimizingconversation and traffic with in operating suite
e. Scrub nurse- RN or surgical technician;
scrubbing for surgery; setting up sterile table;preparing sutures, ligatures, special equipment;assisting surgeon; anticipating needs; keeping
tract of the time/ time wound opened; countsall needles, sponges and instruments beforeclosing the incision
Labels specimen/ send to lab;should be
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Labels specimen/ send to lab;should be
RN or PN or surgical technician
f. Registered nurse first assistant- providingexposure of the surgical area; usinginstrument to hold and cut; retracting andhandling tissue; providing hemostasis;
suturing; and must work with a surgeon;not an independent practitioner
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Anesthesia
Artificial induction state of partial orcomplete loss of sensation with or
without loss of consciousness it canproduce muscle relaxation, block nervepain impulses transmission, suppressesreflexes and temp. dec. in memoryretrieval and recall
Types
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Types1. General- block pain stimulus at cerebral
cortex and induces depression of CNS/effects: analgesia, amnesia, unconsciousness,loss of reflexes and muscle tone- resp; cv;neuro; suited for surgery of head, neck ,
upper torso, back, prolonged surgicalprocedures or cant lie for long period of time
2. Regional-blocks the pain stimulus at its
origin, along afferent neurons, or along thespinal cord; does not result tounconsciousness of patient + sedative-
drowsiness
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Four Stages of Anesthesia
I. Onset- loss of consciousness; pt.Drowsy;dizzy; auditory and visualhallucination; nurse must close the door,quiet, stay in the side of the client
II. Excitement- loss of consciousness; loss ofeyelid reflexes; inc. autonomic activity,irregular breathing; struggle- remain quieton side ; assist anesthetist
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III. Surgical anesthesia- loss of eyelid reflexes;dec. vital functions; pt. Unconscious,
muscles relax, no blink or gag reflexesIV. Danger (death)- vital functions depressed;
client not breathing; no heart beat- est.
airway, prep cardiac arrest tray, drugs,syringes, close/ open cardiac massage
Administration of General
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Administration of GeneralAnesthesia
Most common method is neuroleptic orbalanced anesthesia combination ofinhalation agent; O2, narcotic,and neuro
blocking agentTypes:
a. IV- rapid transition stages 1-3 eg.
Thiopental, ketalar, fentanyl citrate- dec.motor activity; resp; allergy; dont mix withatropine /contra- CVA, HPN, inc. ICP,
alcoholics, COPD, renal dysfunctions
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b. Inhalations- mixture of volatile liquidsor gas + oxygen ; maintains the client
in stage 3; given thru mask or ET eg.halothane; forane; nitrous oxide ;enflurane- dont give with seizure
history, check for BP and pulse, dontgive patient in labor
Administration of Regional
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Administration of RegionalAnesthesia
Types:
1. Spinal- subarachnoid space; comp-
hypotension; trendelenburg ; increaseIV; NV;Headache- flat on bed 6-8hpostop, binder, analgesic; resp.
paralysis- artificial resp; neurologiccomplications- muscle weakness,paraplegia
2 Epidural- epidural block- injected in epidural
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2. Epidural epidural block injected in epiduralspace; hypotension, resp. paralysis,dysfunctions
3. Caudal-used with OB clients commonly
4. Topical
5 . Local infiltration-skin and SQ
6. Field block-the area of incision; avoid bloodvessel for systemic effect
7. Peripheral nerve block- individual nerves8. Bier block(IV regional extremity block
anesthesia) lidocaine injected to veintourniquet is applied to control distribution
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Intraoperative Nursing Care
Maintain safety and prevent injury
Position the patient:
a. supine/ dorsal recumbent- bypass,mastectomy, bowel resectionb. Trendelenburg- intestinal; lower abd,
pelvis
c. Lithotomy- perineal and rectal, vaginalrepairs
d. Lateral- kidney chest/ hip injury
Provide equipment safely- counting surgical
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Provide equipment safely counting surgicalsuppliessuch as needles, sponges, andinstrument with 2 persons when?
a. Before initial incision
b. During surgery
c. Before wound is close
All plugs, wires and equipment should bechecked for their proper functioning and avoidelectrical burn
Maintain surgical asepsis- surgeon, assistantsand scrub personnel
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Assisting with wound closure- sutures,staples, skin strips tapes, drain is place-
promote healing prevent infection,characteristic of drainage
Monitoring body temperature- 60-70 degrees
F- comfort, inhibit bacterial growth, coolingbody dec. metabolic rate; patient should becovered heat loss is great; infant/burn warm
the environment; weakness, fainting andnausea leave the room
a. Malignant hyperthermia- occur when succinyl
choline and inhalation agent esp. halothane
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Monitoring for emergency
a. Malignant hyperthermia-genetic-uncontrollable skeletal muscle contraction;occur when succinyl choline and inhalationagent esp. halothane; 30 min after induction
or several hours; inc. CO2, muscle rigiditycardiac dysrhythmias, hypermetabolic rate,fever of 43 degrees C; treatment:
datholene- skeletal muscle relaxant- dec.muscle rigidity
b. Allergic reaction- latex, solutions and
materials
c N and V full stomach turn px to side with
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c. N and V- full stomach, turn px to side withbasin, suction saliva and vomitus
d. Cardiac and resp. arrest- crash cart available;death- surgeon resp. to communicate withfolks
d.Hypoxia/ pulmonary complications- inadequate
ventilation, pulse oximeter- monitoring, canocclude salive, blood or vomitus
e. hypothermia- anesthesia; temp in or; cold
infusion IV; cold gases inhalation, openwound and cavities; dec muscle activitiy;advance age, drugs- vasodilation likephenothiazine and gen. anesthesia
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Intraop Nursing Diagnosis
AnxietyRisk for injury related to anesthesia andsurgery
Risk for perioperative positioning injuryrelated to required position and loss ofprotective responses secondary to anesthesia
Sensory/ perceptual alteration r/t to generalanesthesia or conscious sedation
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evaluation
Exhibits low level of anxiety
No threat to security
Free from surgical positioning injuriesMaintain environmental safety
Dignity preserved
Free from complications or experiencesuccessful management of adverseeffects of surgery and anesthesia
Moving and Transporting the
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Moving and Transporting theClient
Wipes excess blood and debris; put onnew gown
Avoid rapid movementIV patent
Avoid rough handling
Side rails upstrapped;with warmblanket
Maintain patients modesty
Major causes of death during
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Major causes of death duringor after surgery
Pneumonia
Renal failure
Cardiac arrestStroke
Pulmonary emboli
Sepsis
Peritonitis
hypovolemic shock
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The classic sign of shock:
Pallor
Cool, moist skin
Rapid breathingCyanosis of lips, gums, and tongue
Reapi, weak, thready pulse
Decreasing pulse
Low blood pressure and concentrated urine
POSTOPERATIVE NURSING
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POSTOPERATIVE NURSINGMANAGEMENT
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Postoperative Nursing
Example of activities post op phase:Transfer of patient to postanesthesia care unit
1. Communicates intraoperative information
a. Identify patient by name
b. States surgery performed
c. Identifies type of anesthesia used
d. Reports patients response to surgicalprocedure
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e. Describe intraop factors eg. Insertionof drains, catheter, adm of blood,
analgesic agentsf. Describe physical limitations
g. Reports patients preop level of
consciousnessh. Communicates accessory equipments
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Postoperative Assessment Recovery Area
1. Determine patients immediate
response to surgical intervention2. Monitor patients physiologic state
3. Maintains patients safety- airway,
breathing, safety4. Adm medication , fluids and blood
5. Assess patients readiness to transfer to
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pinhospital unit or for discharge
Surgical Unit:
1. Continues close monitoring of patientsphysical and psychological response tosurgical intervention
2. Provides teaching during immediaterecovery period
3. Assist patient in recovery and preparationfor discharge home
4. Identifies patient psychological status
5. assisting with discharge planning
Cl
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Home or Clinic:
1. Provides follow-up care during office or
clinic visit or by telephone contact2. Reinforce previous teaching; answer
their questions about surgery and
follow-up care3. Assess pts response to surgery and
anesthesia and their effects on body
image and function4. Determine familys perception of sugery
and its outcome
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Postop Period
3 Phases:
1. Initial period of time for recovery from
anesthesia2. Discharge from PACU to the first day
after surgery; pt recovering from
effects of surgery; beginning to eat andambulate
3. Time of healing, last for weeks, months
or even years
P t th i i d iti l ti th t
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Post anesthesia period- critical time thatneeds close and constant observation,
positioning, patent airway, suctionmachine available in bedside
Immediate Assessment: airway; breathing-
abnormalities, stay in bedside until gagrefrex return; circulation- bp, pulse, color,wound status, dressing, pulse oximeter,electrolyte imbalances, pain, hypovolemia
Others- level of consciousness, musclestrength, drains, temp
Assessment of the postop
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Assessment of the postopclient:
Assess resp status
Assess circulation
Assess neurologic status- level ofconsciousness
Monitor wound- appearance, drainage,
discomforts; infn- 3-4 days post op,redness beyond incision line, edema,drainage, fever, malaise, anorexia, inc
WBC
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Dehiscence- opening of incision
Evisceration- incision site opened withinternal organ- cover organ with steriledressings moisten with NSS, VS, calmthe pt. Notify the physician
Monitor intravenous lines- patency,type, rate , I/O
Monitor drainage tube- NGT, suction,characteristic, document
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Promote comfort- pain, prn meds, descriptionof pain, effects of pain common N and V
Reduce N and V- morphine, meperidine,cardiac glycosides, and amphetamines tocontrol: anticholinergics; antidopaminergics
and GI antispasmodicsDischarge instructions and care- informationand skills needed to continue care, meds
instructions, wound care, appointments, opencommunicatin for questions, collaborate withhealth care workes in community andrehabilitation services
Home Care Teaching Check
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Home Care Teaching CheckList
State procedure performed
Describe post op medication and
treatmentDescribe procedure for changingdressing and providing wound care
State activities to avoid- driving,operating machinery
State allowed activities
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State dietary restrictions
Describe signs and symptoms of
complicationsState time and date follow-upappointments
State how to reach health provider withquestions or complications
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Postop Nursing Diagnosis
Risk for injuryHypothermia
Risk for infection
Pain r/t surgical incisionRisk for ineffective airway clearance r/t decresp function
Self care deficit r/t post op fatigue andpain
Impaired skin integrity r/t surgical incision
and drainage
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Body image disrurbance
Risk for altered nutrition: less than r/t
dec intake and inc need for nutrientsecondary to surgery
Risk for altered elimination: constipation
r/t effects of meds, diet change,immobility
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Potential Complications:
a. Atelectasis and pneumonia
b. Deep vein thrombosisc. Wound infection
d. Dehiscence/ evisceration
e. Paralytic ileus
f. Hemorrhage/ hypovolemic shock
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SAMPLE QUESTION
Keeping tract of the time patient under
anesthesia and time of incision is
made are functions primarily by a:a. anesthesiologist
b. scrub nurse
c. circulating nursed. surgical assistant
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Ans.B
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SAMPLE QUESTION
Handling specimen and documenting carerendered to patient during intra-operative period are tasks to
accomplish by a:a. Registered Nurse First Assistant
b. scrub nurse
c. OR managerd. circulating nurse
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ANS. D
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ANS. B
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SAMPLE QUESTION
1. During the initial interview, the nurse hasassessed for history of seafood allergy withMrs. L. Which nursing action is appropriate?
a. administer anti-histamine
b. prepare resuscitative equipment andemergency medication postoperatively
c. prominently note allergies of patient on chart
d. do not give pre-op medication an hour beforethe schedule of surgery
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ANS. C
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SAMPLE QUESTION
One of the patients in surgical ward scheduledfor amputation in the next two daysverbalized, Im going to miss my leg.
Which of the following nursing diagnosis isappropriate in the statement presented:
a. Fear and anxiety related to surgery
b. Potential for injury related to hemorrhage
c. Anticipatory grieving process related to lossof limb
d. Immobility related to loss of limb functioning
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ANS. C
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SAMPLE QUESTION
Which of the following is not included in
the physical preparation of patient
undergoing surgery?a. assessing level fear and concerns
b. sedation for sleep
c. cleansing of the colond. informed consent
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ANS. A
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SAMPLE QUESTION
The following must be observed by the ward
nurse on the day of surgery, EXCEPT:
a. patient must wear hospital gown
b. jewelry must be removed includingprosthesis
c. pre-op medication given 30 min in
anticipated time scheduled. long hair braided
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ANS. D
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SAMPLE QUESTION
Atropine sulfate is given to operative patient to
counteract the effects of vagal stimulation.
This medication is classified as:
a. sedative
b. narcotic
c. anticholenergic
d. neuro-blocking agent
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ANS. C
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SAMPLE QUESTION
Mrs. had undergone surgical laparotomy 2days post op, because of fear of pain,patient refuses to do coughing exercise.
Which nursing action appropriate tominimize pain during coughing exercises?
a. Splint the area of incision with hands andapply pressure
b. splint abdominal area with elastic bandagec. give sedative to lessen post-op pain
d. turn patient side
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ANS. A
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SAMPLE QUESTION
Healing of surgical wound is most apt to
be retarded by inadequate intake of:
a. carbohydrateb. fat
c. minerals and vitamins
d. protein
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ANS. D
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SAMPLE QUESTION
Which of the following nursing interventions should beconsidered by the nurse if evisceration will exist to apost op patient?
a. keep patient calm and place a sterile gauze with
D5LR solutionb. cover the incision site with sterile gauze or towel
moisten with isotonic solution
c. cover with gauze only since moisture could attractmicroorganism and can cause contamination
d. look for the surgeon and never perform any nursingintervention with the wound since this incident needsdoctors order to avoid malpractice
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ANS. B
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SAMPLE QUESTION
Early ambulation should be initiated
primarily to:
a. prevent thrombophlebitisb. fast relief o post-op pain
c. early healing of wound
d. prevent pneumonia
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ANS. A
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SAMPLE QUESTION
Patient Mr. G. complains of postop pain aftergaining consciousness, your nextappropriate nursing action:
a. give morphine sulfate after checking therespiratory rate
b. check bowel sounds
c. encourage deep breathing and coughingexercises
d. frequent change of position as desired
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ANS. A
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SAMPLE QUESTION
The fourth stage of anesthesia is
characterized by:
a. uncontrolled movementb. flushed skin
c. elevated BP
d. non-reactive pupil
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ANS. D
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SAMPLE QUESTION
The stage of anesthesia induction where
the patient may perceive things and
sounds heard differently?
a. danger stage
b. excitement stage
c. onset staged. surgical anesthesia stage
S Q S O
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SAMPLE QUESTION
The scrub nurse together with circulating nursecounts the instruments and sponges:
a. prior to the removal of oxygen and before
closure of surgical incisionb. before the start of the abdominal incision
and before the closure of the fascia
c. prior the abdominal incision and after the
closure of perineumd. before the start of abdominal incision and
prior to closure of peritoneum
ANS D
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ANS. D
SAMPLE QUESTION
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SAMPLE QUESTION
Which of the following activities improvesbowel and bladder a day aftersurgery?
a. deep breathingb. leg exercises
c. coughing
d. walking
d
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end
Thank you!!!