Exam 16 - Intraoperative and Postoperative Nursing Care
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Questions and Answers

What are the primary concerns for nursing interventions during the intraoperative phase?

  • Patient’s nutritional needs and hydration levels
  • Patient’s psychological preparation for surgery
  • Postoperative pain management and medication administration
  • Patient positioning and promotion of asepsis (correct)
  • Which of the following describes the role of the scrub nurse while they are in operating room?

  • Reviews the patient’s medical history
  • Maintains the sterile field and assists the surgeon (correct)
  • Assists with anesthesia administration
  • Prepares the patient for discharge post-surgery
  • What is an essential action for ensuring patient safety regarding surgical tools?

  • Keep syringes and needles within reach for quick access
  • Disregard safety straps if the patient appears calm
  • Use transparent containers for all used surgical tools
  • Secure needles and syringes away from the patient (correct)
  • In the holding area, what should nurses focus on?

    <p>Inserting IVs for fluid and medication delivery (B)</p> Signup and view all the answers

    Which statement about surgical asepsis is accurate?

    <p>All surgical staff must engage in sterile technique to prevent infection. (C)</p> Signup and view all the answers

    How frequently should vital signs be assessed in the immediate postoperative phase?

    <p>Every 15 minutes (A)</p> Signup and view all the answers

    What is the main goal of interventions during the immediate postoperative phase?

    <p>Maintaining and monitoring airway and circulation (C)</p> Signup and view all the answers

    What should be monitored in the recovery period post-surgery?

    <p>Wound drainage and gastrointestinal function (A)</p> Signup and view all the answers

    Which aspect of patient safety is critical if a patient is delirious or disoriented?

    <p>Ensuring all safety measures are rigorously applied (C)</p> Signup and view all the answers

    What is a key nursing intervention for managing postoperative pain?

    <p>Monitor and assess pain using an appropriate pain scale (A)</p> Signup and view all the answers

    What is the expected outcome for a patient regarding urinary function after surgery?

    <p>Voiding is expected but may take 6 to 8 hours (D)</p> Signup and view all the answers

    Which of the following is a preventative measure for venous stasis?

    <p>Compression stockings and leg exercises every 2 hours (A)</p> Signup and view all the answers

    What could indicate a potential paralytic ileus in a postoperative patient?

    <p>Absence of bowel sounds in all quadrants after prolonged assessment (D)</p> Signup and view all the answers

    What is the purpose of using an incentive spirometer post-surgery?

    <p>To promote deep breathing and prevent respiratory complications (A)</p> Signup and view all the answers

    Which factor primarily contributes to abdominal distention after surgery?

    <p>Surgical manipulation and gas introduction (B)</p> Signup and view all the answers

    What should a nurse do if a patient has not voided within 8 hours postoperatively?

    <p>Implement noninvasive measures before considering catheterization (B)</p> Signup and view all the answers

    What is the primary indicator for a patient being ready for transfer from the PACU to the nursing unit?

    <p>Patient has stable vital signs and responds to stimuli. (C)</p> Signup and view all the answers

    Which temperature indicates hypothermia post-surgery?

    <p>Oral temperature less than 96ºF (C)</p> Signup and view all the answers

    What complication can occur suddenly and is critical to assess for during postoperative monitoring?

    <p>Hypovolemic shock (D)</p> Signup and view all the answers

    What should a nurse do if a patient exhibits signs of malignant hyperthermia?

    <p>Stop the anesthetic agents and cool the body. (B)</p> Signup and view all the answers

    What post-operative complication involves the protrusion of an internal organ through a surgical incision?

    <p>Evisceration (A)</p> Signup and view all the answers

    Which of the following actions should NOT be performed if the patient is at risk for aspiration?

    <p>Place a pillow under the patient’s head. (D)</p> Signup and view all the answers

    What should be done immediately if a nurse observes coffee-ground emesis from the patient?

    <p>Notify the physician immediately. (A)</p> Signup and view all the answers

    During postoperative recovery, what is commonly the most effective method for preventing hypoventilation?

    <p>Encouraging deep breathing exercises. (D)</p> Signup and view all the answers

    During the evaluation phase, which of the following is an example of an evaluative measure?

    <p>Observing nonverbal signs of discomfort (D)</p> Signup and view all the answers

    Which statement reflects an important aspect of discharge instructions?

    <p>Documentation of discharge instructions is critical (D)</p> Signup and view all the answers

    What is a required criterion for a patient before leaving an ambulatory surgery setting?

    <p>Patient must show signs of alertness and self-care ability (A)</p> Signup and view all the answers

    Which goal should be prioritized during the postoperative phase?

    <p>Assist the patient in achieving effective pain management (C)</p> Signup and view all the answers

    Which of the following reflects the nurse's role during the surgical process?

    <p>The nurse protects the patient's dignity and acts as an advocate (C)</p> Signup and view all the answers

    During the intraoperative phase, the patient's identification requires only one form of identification.

    <p>False (B)</p> Signup and view all the answers

    Flashcards

    Intraoperative Nursing

    Nursing care provided during surgery.

    Surgical Asepsis

    Sterile technique to prevent infection during surgery.

    Patient Identification

    Verifying patient's identity in the OR.

    Holding Area (Pre-anesthesia Unit)

    Area outside operating room for pre-op preparations.

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    Postoperative Phase

    Nursing care after surgery.

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    PACU

    Post-Anesthesia Care Unit (recovery room).

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    Vital Signs Monitoring

    Regularly checking patient's vital signs (heart rate, BP).

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    Scrub Nurse

    OR nurse responsible for maintaining sterile field.

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    Circulating Nurse

    OR nurse who manages the surgical environment.

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    Postoperative Assessment

    Evaluating a patient's condition after surgery.

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    PACU Patient Discharge Criteria

    Factors assessed before a patient leaves the PACU: pain levels, nausea/vomiting, vital signs, cognitive function, and bleeding from the surgical site.

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    Hypothermia (PACU)

    Low body temperature (below 96°F rectal or 95°F oral) in the Post-Anesthesia Care Unit (PACU).

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    Malignant Hyperthermia

    Rare, genetic disorder causing uncontrolled muscle contractions and potentially fatal hyperthermia, triggered by certain anesthetic agents.

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    Post-Op Assessment (PACU)

    Comprehensive checks of vital signs, IV access, incision sites, tubes (if present), orders and body systems, performed when a patient returns to the nursing unit post-surgery.

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    Patient Positioning (Post-Op)

    Positioning patient while awake after surgery on their side, head elevated at 45 degrees—to reduce risk of aspiration.

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    Post-Op Nausea/Vomiting

    Nausea and vomiting are common after surgery in the first 12-24 hours, and an emesis basin should be kept bedside.

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    Hypovolemic Shock

    Life-threatening condition caused by internal bleeding or fluid loss during surgery—resulting in increased pulse, decreased blood pressure, cool skin and reduced urine output .

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    Wound Dehiscence

    Separation or rupture of a surgical incision, commonly during the first few post-operating days, sometimes indicating further complications.

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    Wound Evisceration

    Internal organs protruding through a surgical incision.

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    Postoperative Ventilation

    Monitoring and supporting breathing after surgery, as some drugs or factors can cause a patient to hypoventilate.

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    Incentive Spirometer

    A device that helps patients take deep breaths to prevent lung complications after surgery.

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    Bronchodilators

    Medications that widen the airways in the lungs, making it easier to breathe.

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    Postoperative Pain - Acute

    Intense pain that usually subsides within 24 to 48 hours after surgery.

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    Postoperative Pain - Objective Signs

    Observable signs of pain like changes in vital signs, restlessness, sweating, and facial expressions.

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    Urinary Retention

    Inability to urinate even though the bladder is full.

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    Venous Stasis

    Slowed or stopped blood flow in a vein.

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    Venous Stasis Prevention

    Measures to prevent blood clots from forming due to slowed blood flow.

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    Early Ambulation

    Getting out of bed and walking soon after surgery, which helps with recovery.

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    Paralytic Ileus

    A serious condition where the intestines stop working, often after surgery.

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    Fluid and Electrolyte Balance

    Maintaining the right balance of fluids and electrolytes in the body, especially important after surgery.

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    Postoperative Pain Management

    Managing pain after surgery with medications, interventions, and strategies tailored to the patient.

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    Discharge Instructions

    Providing information about diet, activity limitations, wound care, and medication after surgery.

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    Patient Advocacy in Surgery

    The nurse's role in protecting and representing the patient's rights and interests during the surgical process.

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    Preoperative Teaching

    Educating the patient about the surgical procedure, risks, and recovery expectations.

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    Ambulatory Surgery Recovery

    Managing postoperative pain and nausea, assessing mobility, and providing discharge instructions for patients who go home the same day.

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    Postoperative Complications

    Potential problems a patient may experience after surgery, such as infection, blood clots, or delayed wound healing.

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    Postoperative Evaluation

    Assessing the patient's progress after surgery, monitoring vital signs, assessing pain levels, and evaluating the effectiveness of interventions.

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    Deep Breathing and Coughing

    A technique used to improve lung function and prevent lung complications after surgery.

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    Discharge Planning

    Preparing the patient for a safe and smooth transition home after surgery, including providing instructions and support.

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    Two Identifiers

    A safety measure in the OR where a patient's identity is confirmed using two separate sources like a wristband and verbal confirmation.

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    PACU Transfer

    The process of transferring a patient from the operating room to the recovery room (PACU) after surgery, with thorough communication between nurses.

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    Study Notes

    Intraoperative Nursing Care

    • Patient Safety: Two identifiers are used to verify patient identity upon entering the OR. Nurses monitor for potential harm, recognizing vulnerable body areas. Safety measures like side rails, straps, and positioning are essential. Nurses must also be aware of patient status (delirious, semi-comatose, disoriented) to ensure safety.
    • Holding Area: The preanesthesia unit outside the OR. Nurses complete preoperative preparations, typically inserting large-bore IVs for fluid replacement and medications. Important to note the cool OR temperature and offering blankets.
    • Surgical Asepsis: All personnel in the OR must maintain sterile technique to prevent infections. This includes using sterile technique and preventing contamination of the surgical site (equipment, catheters, drains, surgical wounds).

    Postoperative Nursing Care

    • Immediate Postoperative Phase: OR nurses transfer patients to the PACU, recovery, or intensive care. A vital review of patient status (meds, fluids, blood products, dressing, complications) is conducted to plan care. Airway, breathing, consciousness, circulation, and systems are monitored every 15 minutes. Continuous assessment focuses on wound drainage, pain, and vital signs. Discharge occurs once stable and conscious, based on facility criteria.
    • PACU Nurse Responsibilities: Monitoring body temperature is critical, especially preventing hypothermia (rectal/oral temp below 96°F/95°F). Warmed blankets/convective warming are used. Vital signs are monitored every 15 minutes until discharge (often 1 hour or longer). Discharge criteria assess pain, nausea/vomiting, vital signs, cognitive level, and bleeding. Recognizing and managing malignant hyperthermia.
    • Post-PACU Assessment: Following OR review from the surgical suite and PACU, patients are assessed for vital signs, IVs, incision sites, tubes, orders, and body systems. Safety first - appropriate positioning (side rails, call light, head-elevated). Assess and document emesis, noting coffee-ground emesis immediately.
    • Postoperative Complications: Thorough monitoring for signs of life-threatening complications, such as hypovolemic shock (internal hemorrhage/fluid/blood loss). Monitor for increased pulse, declining blood pressure, cool/clammy skin, reduced output, and narrowing pulse pressure.
    • Wound Complications: Monitoring incision sites for bleeding or drainage. Dehiscence (wound separation) and evisceration (protrusion of organs) are critical post-surgical events. Record assessment times and drainage measurements. Knowing the potential timeline for separation (technical, post-op complications (distention, vomiting, coughing, dehydration, infection), and metabolic factors (cachexia, hypoproteinemia, age, malignancy, radiation) is key.
    • Ventilation: Hypoventilation (related to drugs or surgical factors) impacting ability to adequately breathe. Assessment for adequate ventilation via ABG or pulse oximetry. Interventions: cough, deep breathing exercises, supporting pillows to incision.
    • Pain management: Pain assessment and management (using a pain scale). Immediate relief to reduce complications, especially regarding mobility and rest. Evaluate objective and subjective data. Implement non-pharmacological measures (repositioning, diversion).
    • Urinary Function: Assessment of bladder and renal function, especially looking at post-op voiding to detect retention. Monitoring intake and output, urine, and IV fluids. Identifying and treating fluid deficits.
    • Venous Stasis: Preventing and managing venous stasis to prevent thrombus formation. Implement prevention methods (exercises, compression devices, stockings).
    • Postoperative Activity: Importance of early ambulation to prevent complications. Assess for contraindications (infection, thrombophlebitis).
    • GI Status: Assess for abdominal distention/paralytic ileus. Document flatus, bowel sounds, and abdominal girth. Treat paralytic ileus (if indicated, with NG tubes).
    • Fluid and Electrolytes: Monitor fluid tolerance/electrolytes. Maintain IV therapy, monitor IV site.
    • Postoperative Interventions: Nursing process and overall care: assessment, diagnosis, planning, implementation, and evaluation. This includes understanding pre-op history (surgery, allergies, meds, alcohol/drug use).

    Discharge and Ambulatory Surgery

    • Discharge Instructions: Comprehensive discharge instructions for patients and families are integral. This includes reinforcing verbal information with written instructions and documenting the teaching.
    • Ambulatory Surgery Discharge: Discharge criteria for ambulatory patients include self-care ability and mobility. Key focus is controlling pain, nausea, and vomiting. Specific and general instructions are crucial, emphasizing the need for accompaniment.

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    Description

    This quiz covers essential aspects of intraoperative and postoperative nursing care, including patient safety protocols, preoperative preparations, and maintaining surgical asepsis. It is designed for nursing students and professionals looking to enhance their knowledge in these critical areas of patient care during surgery.

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