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47 Cards in this Set

  • Front
  • Back
Intraoperative Nursing
Room Preperation

Transferring Patient

Scrubbing, Gowning, and Gloving

Positioning the Patient

Preparing the surgical site

Assisting the ACP
Safety - Risk for Injury




Surgical Asepsis
Infection control
*Physical Seperation of areas
*Surgical team
*Circulating nurse
*Scrub nurse
Safety - Risk for injury: Positioning
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
General Anesthesia
*Airway support

Regional Anesthesia (block)
*Protection to region

Local Anesthesia
Lidacain w/ some epinephrone
Catastrophic Events in OR
Anaphylactic Reactions
- 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
Postoperative Period
Begins immediately after surgery

Nursing Care
*Protecting patient (safety)
*Preventing complications
Postanesthesia Care Unit (PACU)
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
PACU Progression
Rapid PACU progression
*Based on patient's achievement of discharge criteria

Fast tracking, cuts costs and increases patient satisfaction without compromising safety
Phase I Initial Assessment
Report from OR to PACU nurse

Priority Care
*Monitoring and managing
-Circulatory function
- Pain - can affect resp & circulatory function
- Temperature
- Surgical site

probably takes about 5 minutes for this process
Assessment - Post Op Care
Airway patency
*Rate/Quality, breath sounds

Pulse Ox
*Noninvasive screening of O2

ECG monitoring
*BP and baseline data
*Temp, skin color, and condition
Assessment - Neurologic
Initial (Immediate post-op)
*Level of consciousness
*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
Post Op Assessment
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
Potential Respiratory Problems
Common causes of airway compromise
*Hypoxemia (PaO2 less than 60 mmHg)
*Blockage of airway by tongue
*Supine position - not good for extremely sleepy patient
Intervention - immediate Post-op Respiratory Complications
Proper positioning to facilitate respirations and protect airway
*Lateral position unless contraindicated
*Patient allowed in supine position with HOB elevated once conscious
Potential Respiratory Problems
Pulmonary Edema



Common causes of Respiratory Problems
*Most common cause of postoperative hypoxemia
*May result from bronchial obstruction from retained secretions or decreased respiratory excursion

Diagnosis - Respiratory
Nursing diagnoses
*Ineffective airway clearance
*Ineffective breathing pattern
*Impaired gas exchange
*Risk for aspiration
*Potential complication
-Atelectasis, Pneumonia, Hypoxemia
Interventions - Respiratory
Supplemental oxygen therapy

Deep breathing

Coughing techniques
*TCDB - Turn, Cough, Deep breath

Adequate and regular pain control
Potential Cardio Problems
Most common complications
- Fluid loss
- Pain, anxiety, bladder distension, respiratory compromise
Potential Cardio Problems
Clincal Unit
-potassium not replaced in IV fluids
*Tissue perfusion or blood flow affects CV status
-Pulmonary embolism

Potassium outside of normal range often indicates dysrhythmmias
Assessment - Cardio
Frequently vital signs
*Compare with baseline

Assess apical-radial pulse carefully and report irregularities

Assess skin color, tem, and moisture
Diagnosis - Cardio
Decreased cardiac output

Deficient fluid volume

Excessive fluid volume

Ineffective peripheral tissue perfusion

Activity intolerance
Nursing Intervention - Cardio
Accurate I/O records

IV management

Early ambulation

VTE Prevention

Slow position change
Intervention - Cardio
Notify provider
*Systolic < 90 mm Hg or > 160 mm Hg
*Pulse < 60 or > 120 bpm
*Pulse pressure narrows
"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
Potential Neurologic Problems
Postoperative cognitive dysfunction


Anxiety, depression

Alcohol withdrawal delirium
Assessment - Neurologic



Ability to follow commands

Size, reactivity, and equality of pupils

Sleep/wake cycle

Sensory and motor status
Diagnosis - Neurologic
Disturbed sensory perception

Risk for injury

Acute confusion

Impaired verbal communic.


Ineffective coping

Disturbed body image

Implementation - Neuro
Evaluate respiratory function
*hypoxemia causes post-op agitation

Sedation may be beneficial for controlling agitation and providing safety
Neuro Implementation
*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
Potential gastrointestinal problems
Most common - N & V
*Fluid and electrolyte imbalance
*Distention and flatus
*Paralytic ileus
Assessment - GI
Ask about nausea

Document characteristics of vomit

Assess the abdomen
*Auscultate all four quadrants
Diagnosis - GI

Risk for aspiration

Risk for deficient fluid volume

Imbalanced nutrition: less than body requirements
Nursing Implementation - GI Problems
*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
Potential Urinary Problems
Low urine output 24 hrs after surgery is normal

Acute urinary retention may occur as result of:
*Location of surgery
*Position and immobility
*Renal failure

Min output of 28-30 ml/hr
Assessment - Urinary Problems
Examine urine for quantity and quality
*note color, amount, consistency, and odor

Assess indwelling catheter

Most patients urinate 6 to 8 hrs after surgery
Diagnosis - Urinary Problems
Impaired urinary elimination

Potential complication: Acute urinary retention
Intervention - Urinary Problems
Facilitate voiding with positioning

Provide reassurance

Use helpful techniques

If ordered, catheterize 6 to 8 hrs after surgery if no void
Potential integumentary problems
Adequate nutrition is essential for wound healing

Factors affecting wound healing
*Chronic disease with nutritional deficiency
*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
Assessment - Surgical Wounds
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
Diagnosis - Surgical Wounds
Risk for infection

Potential complication: Impaired wound healing
Intervention - Surgical Wounds
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
Altered temperature
Nursing diagnoses
*Risk for imbalanced body temp
Hyperthermia - Fever
Wound infection

Respiratory tract infection

Urinary tract infection

Superficial thrombophlebitis

Clostridium difficile

Discharge Instructions - Same Day Surgery
Discharge (Transport)
-Availability of caregivers
-Access to pharmacy
-Access to phone
-Access to follow-up care

Follow-up phone call to evaluate status
Discharge Instructions
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