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?

Inserting IVs for fluid and medication delivery Signup and view all the answers

Which statement about surgical asepsis is accurate?

All surgical staff must engage in sterile technique to prevent infection. Signup and view all the answers

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

Every 15 minutes Signup and view all the answers

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

Maintaining and monitoring airway and circulation Signup and view all the answers

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

Wound drainage and gastrointestinal function Signup and view all the answers

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

Ensuring all safety measures are rigorously applied Signup and view all the answers

What is a key nursing intervention for managing postoperative pain?

Monitor and assess pain using an appropriate pain scale Signup and view all the answers

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

Voiding is expected but may take 6 to 8 hours Signup and view all the answers

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

Compression stockings and leg exercises every 2 hours Signup and view all the answers

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

Absence of bowel sounds in all quadrants after prolonged assessment Signup and view all the answers

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

To promote deep breathing and prevent respiratory complications Signup and view all the answers

Which factor primarily contributes to abdominal distention after surgery?

Surgical manipulation and gas introduction Signup and view all the answers

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

Implement noninvasive measures before considering catheterization 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?

Patient has stable vital signs and responds to stimuli. Signup and view all the answers

Which temperature indicates hypothermia post-surgery?

Oral temperature less than 96ºF Signup and view all the answers

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

Hypovolemic shock Signup and view all the answers

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

Stop the anesthetic agents and cool the body. Signup and view all the answers

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

Evisceration Signup and view all the answers

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

Place a pillow under the patient’s head. Signup and view all the answers

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

Notify the physician immediately. Signup and view all the answers

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

Encouraging deep breathing exercises. Signup and view all the answers

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

Observing nonverbal signs of discomfort Signup and view all the answers

Which statement reflects an important aspect of discharge instructions?

Documentation of discharge instructions is critical Signup and view all the answers

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

Patient must show signs of alertness and self-care ability Signup and view all the answers

Which goal should be prioritized during the postoperative phase?

Assist the patient in achieving effective pain management Signup and view all the answers

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

The nurse protects the patient's dignity and acts as an advocate Signup and view all the answers

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

False Signup and view all the answers

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.