Midterm - 2016

• The midterm will consist of 70 multiple-choice questions.
• The time allotted for writing will be 2 hours.
• The midterm is worth 30% of the final grade.
• The time for the exam is from 0900 to 1100.
• The content covered is from weeks 1-6.

Signed Consent

• It is a legal requirement for surgical procedures.
• The patient/family must be aware and informed of the procedure.
• All required forms must be present and signed on the chart.
• Required forms include a consent form, consent to blood transfusion, consent for anesthesia interventions, and advance directives/power of attorney.

Informed Consent

• It is the physician's legal responsibility to obtain consent.
• Valid consent requires that it is voluntary and the patient has the mental capacity and is properly informed

RN's Role

• The RN verifies that consent is informed.
• The RN advocates for the patient if they are unclear about the procedure, options, risks, alternatives, or potential complications.
• The RN supports the patient's right to withdraw consent at any time, if indicated.
• The RN witnesses the patient's signature on the consent form, but only if the consent is informed.
• The RN verifies that the signed informed consent is on the chart in the immediate preoperative period.
• Surgeons may obtain consent in the OR holding area prior to medications. In that case, the consent will be unsigned and unverified until transport to the OR.

Near Miss/No Harm Incidents

• A patient safety incident (or adverse event) is an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient.
• Harmful incident is an incident that resulted in patient harm (previously known as a "preventable adverse event").
• Near miss is an incident that did not reach the patient (no harm resulted).
• No-harm incident is an incident that reached the patient, but no discernable harm resulted.

Medication Errors

• Contributing factors for medication errors include neglecting routine procedures, not checking dose calculations, administering unfamiliar meds, order neglect, failure to comply with the rights, and failure to perform required assessments e.g., BP, CBG.
• System factors for medication errors include distraction, illegible orders, transcription errors, and inappropriate abbreviations.
• Design of products, such as labeling, can also contribute to medication errors.

Incidence or Occurrence Report

• Any event that is inconsistent with the routine, expected care of a patient or the standard procedures in place.
• When an incident occurs, the nurse documents an objective description of what happened and the follow-up actions taken, including notifying the patient's health care provider in the medical record.
• It is important to evaluate and document the patient's response to the incident.
• Analysis of incident reports aids organizations in identifying trends that provide justification for changes in policies and procedures or for in-service programs.
• Any reference to an incident should not be included in the medical record because it enables a lawyer to argue that the reference makes the incident report part of the medical record and therefore subject to attorney review.

Chain of Prevention

• Education is the first step.
• Monitoring (patient assessment and vital signs) follows.
• Recognition comes third.
• Call for help is fourth.
• Response is last.
• It assists in preventing deterioration, cardiac arrests and deaths, admissions to ICU, and inappropriate resuscitation attempts.
• Patient assessment and measuring vital signs are the main components of "monitoring".
• Weakness of one or more of the components (rings) of the chain will inevitably result in failure of the whole system
• If the components of the chain are present and strong, this should be measurable as a reduction in the number of preventable cardiac arrests.
• Six physiological parameters to monitor: respiratory rate, oxygen saturation, temperature, systolic BP, pulse rate, level of consciousness.

Pre-op and Peri-op phases

• Includes preop, intraop, and postop.

Phases of Perioperative Care

• Preoperative begins with the decision to perform surgery and continues until the client reaches the operating area.
• Intraoperative includes the entire duration of the surgical procedure, until transfer of the client to the recovery area (PACU).
• Postoperative begins with admission to the recovery area and continues until the client receives follow-up evaluation at home or is discharged to a rehabilitation unit.

Classification of Surgeries

• Diagnosis, cure, palliation, prevention, cosmetic, and exploration are the purposes of surgery.
• Urgency is classified as emergent (immediate), urgent (24-30 hrs), required (within a few weeks or months), or elective (ambulatory, short stay or same-day surgery, or early hospital admission).

Medications with Potential to Affect Surgical Experience

• Corticosteroids, if discontinued suddenly, may cause cardiovascular collapse and may require IV boluses before/after surgery.
• Diazepam (Valium) may cause anxiety, tension, and even seizure if withdrawn suddenly.
• IV insulin (short acting-clear) may be required to keep BG in normal range.
• Surgeons must decide how long to stop anticoagulants before elective surgery to prevent bleeding; in emergency, Vitamin K may be needed for warfarin, and protamine for heparin.
• Anticonvulsants may require IV administration to keep the patient seizure-free.
• Thyroid hormone medication may be given with a sip of water the morning of surgery or via IV to maintain levels.
• Opioid Use require an acute pain service assessment to prevent withdrawal and to manage perioperative pain effectively.

Effects of Herbs and Supplements During the Preoperative Period

• Echinacea is an immunosuppressant with long-term use, so discontinue use as far in advance of OR as possible.

• Ginkgo biloba may increase bleeding, especially if on anticoagulants, so discontinue use at least 36 hrs preop.

• Ginseng may falsely elevate digoxin levels and potentiate MAOIs, is contraindicated for cardiac disorders, HTN, and hypoglycemia, so discontinue use at least 7 days preop.

• Saw palmetto may have additive effects with other hormone replacement therapies.

• St. John's Wort may prolong effects of anaesthetics, potentiate opioids, and cause peripheral neuropathy.

• Valerian potentiates sedatives-hypnotics and may prolong anaesthetic recovery time, so taper the dose 1-2 weeks preop.

• Vitamin E may increase bleeding.

• A client scheduled for a surgical procedure in 2 days and reports use of ginkgo daily, so the priority intervention is to notify the anesthesia care provider.

• The herb interferes with anesthetics.

• A client tells the nurse in the preoperative setting that she has noticed she has a reaction when wearing rubber gloves, so ask additional questions to assess for a possible latex allergy. (screening)

• A client is scheduled for surgery requiring general anesthesia at an ambulatory surgical center & says they ate a light breakfast a couple of hours before, so you notify the anesthesia care provider of when and what the client last ate.

• The nurse's role when assisting with informed consent is to ask the client to explain what surgical procedure they are having and ensures that the client understands what is going to be performed.

Preoperative Fasting Recommendations

• After drinking clear liquids (e.g., water, clear tea, black coffee, carbonated beverages, and fruit juice without pulp), the minimum fasting period is 2 hours.
• After ingesting breast milk, the minimum fasting period is 4 hours.
• After a light meal (e.g., toast and clear liquids) or after drinking infant formula or nonhuman milk, the minimum fasting period is 6 hours.
• After a meal including meat, fried or fatty food, the minimum fasting period is 8 hours.

Signs and Symptoms of Opioid Abuse and Opioid Withdrawal

• Signs of Opioid Abuse include vomiting, pruritis, sweating, twitching, miosis, loss of appetite, drowsiness, respiratory depression, coma, needle marks.
• Signs of Opioid Withdrawal include dysphoric mood, nausea/vomiting, lacrimation, rhinorrhea, muscle aches, pupillary dilation, piloerection, sweating, diarrhea, yawning, fever, insomnia.
• The RN is prepared to recognize signs and symptoms of opioid abuse and acute opioid withdrawal.
• Morphine and heroine withdrawal begins in 6-18 hours, while methadone withdrawal begins in 24-48 hours.

Summary of Preoperative Teaching

• NPO guidelines help keep the stomach empty, reducing the potential for aspiration during anaesthesia induction.

• Diet is increased slowly to prevent gastric overfilling and prevent nausea.

• Early ambulation increases circulation, ventilation, muscle tone, and vital capacity; improves gastrointestinal and urinary function; reduces pain; and supports healing.

• Antiembolic stockings reduce the incidence of postoperative formation of deep vein thrombosis.

• To perform deep breathing and coughing exercises, splinting, and use an incentive spirometer.

• Postoperative patients are at risk for pulmonary complications (e.g., pneumonia) because of increased respiratory secretions, decreased lung expansion, and depression of the respiratory center that occurs during general anaesthesia.

• Surgical attire and a head cover are appropriate for the semi-restricted area of the surgery department.

• The activities a scrub nurse might perform during surgery is to prepare the instrument table, coordinate activities occurring in the operating room & maintaining accurate counts of sponges, needles, and instruments.

Interprofessional Responsibilities

• The circulating nurse remains in an unsterile field and documents all OR personnel involved in pt. care, event times, interventions, positioning, skin prep, monitoring devices, the type(s) anaesthesia, and serial numbers.
• The circulating nurse also documents identifying information (prosthesis, drains, catheters), specimens taken, estimated blood loss (EBL), and the surgical count, completing it in collaboration with the scrub nurse.
• They ensure all people entering the OR are wearing surgical attire (scrubs, mask, eyewear, cap or hood, all hair covered, and wearing no jewelry or false nails.
• Supports anaesthetist, surgical team, monitors aseptic practices, provides ongoing supplies and communication & documenting of care.
• Scrub Nurse practices surgical hand asepsis, is gowned and gloved in sterile attire, and remains in the sterile field.
• Scrub nurses set priorities and ensure an efficient aseptic setup for a given procedure.
• They set up and handle instruments and monitors aseptic technique throughout the procedure
• They perform surgical counts (sponges, sharps, instruments) and documented it according to ORNAC guidelines and hospital policy.

Hand Hygiene comparison: Medical vs. Surgical Asepsis

• Medical asepsis: Hand hygiene, 10-15 seconds, hands are most contaminated, keep hands and forearms lower than elbows, dry with paper towel from fingers to wrists to forearms.
• Surgical asepsis: Surgical scrub, 2-6 min, hands become cleanest, wet hands and arms to ~5 cm above elbows, keep hands above elbows at all times, dry with sterile towel.

Classification of Anesthesia

-General -Regional (epidural, spinal) -Moderate (conscious sedation) -Local

Classification of Anaesthesia: Regional: Epidural vs Spinal

• Epidural: Local anaesthetic and/or opioids injected into epidural space (lumbar or thoracic); binds to nerve roots as they exit subarachnoid space, providing anaesthesia and pain relief, blocks sensory, motor, and autonomic function.
• Dose is high (10-20 mL); Onset gradual (25-30 min); multiple or continuous dosing possible. Does not cause significant neuromuscular block; Absence of headache; effective analgesia with lower doses opioids; improved pulmonary function; lower risk ileus; reduced sedation and nausea, supports early mobilization
• *Potential complications: epidural hematoma, epidural abscess, local anaesthetic toxicity
• Spinal: Injection usually between L4-L5 through t (intrathecal) space; usually between L4-L5, producing anaesthesia of lower extremities, perineum, lower abdomen, requiring low dose
• Spinal con if paralysis of respiratory muscles requires mechanical ventilation (i.e. if med migrates too high). -Order of Recovery (2-4 hrs):1) Motor 2) Sensory 3) Autonomic (BP). -spinal Con: Risk of post dural puncture headache; prevention-quiet environment, supine/flat positioning, hydration

Potential Intraoperative Complications

• Malignant hyperthermia (MH): a rare multifactorial genetically inherited autosomal dominant disorder characterized by life-threatening hyperthermia with rigidity of skeletal muscles death
• Treatment of MH, stop triggering agent; Maintain O2 access; administer Dantrolene (muscle relaxant) measure cooling, pH, and urine

Nursing considerations in Postoperative phase

• Obtain report from PACU nurse, Initial assessment of all incision site, Perform dressing changes,Check IV site

Postoperative Complications

• Cardiovascular: hypotension, hypertension, and dysrhythmias Nervous system: can include delirium-delayed emergence from anesthesia
• Gastrointestinal: nausea, vomiting, i Includes - urinary: retention +tract infections i Includes -SBAR-R
• I-identification S-situation Background -recommendation