radical-removal of tendons and muscle too (radical mastectomy)
what can severe preoperative anxiety lead to?
difficult postop care
what are two types of preop pediatric anxiety? how can we help them?
seperation anxiety (keep parents around as much as possible)
unfermilliar surroundings (take pt to rooms before operation, use "play activities")
what is the #1 anxiety intervention?
preop teaching to answer questions and decrease anxiety
what are the effects of stimulating the alpha, beta1, and beta2 adrenergic receptor sites?
alpha - vasoconstriction
beta1 - + Inotropic effects (increase force of heart contractions), and + Chronotropic effects (increase in heart rate)
beta2 - vasodilation and increased renin release from kidneys
what is the neuroendocrine response to surgery?
alpha and beta receptor cites are stimulated (sympathetic ns activated) causing vasocnstriction (helps maintain BP), and + Inotropic/Chronotropic effects on heart (maintains BP and helps perfuse vital organs)
what is the effect of surgery on the GI system?
decreased activity - can lead to constipation, gas pain, and anorexia
what is the effect of surgery on metabolism/blood glucose? what are two potential problems?
glucocorticoid secretion for the adrenal cortex is increased. this increases the breakdown of protein, CHO, and fats for healing and energy.
this can cause weight loss or high blood glucose (so watch in diabetics)
what effect can sergury have on the urinary system? what can they lead to?
increased ADH secretion can cause increased fluid volume/fluid overload
Na retention by kidneys (renin-angiotension system activation) can cause increased fluid volume and K loss (bad for muscle/heart function)
explain the renin-angiotensin system (RAS)
decrease in blood volume (ex: from surgery) causes kidneys to release renin
renin stimulates angiotensin production, constrict blood vessels, and increases adosterone secretion from the adrenal cortex
aldosterone causes Na resorption in tubules of the kidney which holds on to water and increases blood volume
what are some risk factors for surgery?
age- altered physiological respense, presence of chronic disease
duration of surgey
nutrition- malnutrition (decrease resources for healing), obesity (heavy chest = resp issues, wound seperation increase, DVT form decreased movement)
how can chronic diseases be a risk factor for surgery in older adults?
Chronic pulmonary disease - (COPD) don't respond well to anesthesia, prone to infection (pneumonia), C02 retention
Cardiovascular - meds must be adgustes, atherosclerosis inhibits blood vessel constriction
Renal - electrolyte imbalances, decreased kidney function (means they can't excrete anesthesia so doses must be lowered)
Diabetes - decreased wound healing
how is smoking a risk factor for surgery?
decreased ventilation/ability to remove secretions
what goes into the preop prep of a pt?
teaching (routines, where they will be, equipment, treatments-dressing change, pain managment, TCDB, how to pillow splint, IS, hob up 30-45 degrees)
NPO 6-8 hr before
checking labs/tests (CBC, UA, ECG, X-ray, coag)
what are some side effects to watch for from a preop bowel prep?
vasovagal response (decrease blood to brain can cause pt to pass out)
list functions of preop meds
reduce anxiety (valium)
reduce pharyngeal/gastic secretions (atropine-also inhibits GI motility)
decreases amount of anesthesia needed
what are the procedures for an informed consent
pt must be...
-mentally and physically competent (no opiats onboard)
-a legal adult
must be voluntary
pt must understand procedure, risks, benifits, and alternatives
pt must have had all their questions answered satisfactorily
interpreter must be used if necessary
what is the ONLY duty of the RN in regards to an informed consent?
to witness signature (can reinforce teaching)
what can happen if pt is not informed before signing an informed consent? what are osme exeptions?
charges of assault and battery or negligence
-physician invokes therapeutic privilege
-risk couldn't be predicted
what is used for a preop skin prep?
betadine or chlorhexidine body scrub/wipes 1-2 days before OR
what is pillow splinting?
bracing incision/abdomen by holding a pillow
what factors make a pt high risk for pulmonary complications?
thoracic/upper abdominal surgery (pt won't want to deep breathe due to pain)
chronic lung disease
tight abdominal binders/body casts
obesity (don't breathe deeply)
what are some leg exercises and why are they important postop?
ankle pumping and gluteal squeezes
they promote venous return (venous stasis can cause DVT formation whcih can lead to pulmonary emboli)
why is it important to ambulate a postop pt soon after surgey?
prevents decubitus ulcers
reduces risk of DVT
what is the final prep before sending a pt to the OR?
(see preop checklist)
check ID band
empty bladder (if not cathed)
advanced directives (DNR status)
give "en rout to OR" preop meds
RN to sign off
to OR by guerney
define concious sedation
reduction of LOC with IV drugs
what is the purpose of concious sedation?
to dull/decrease intensity or awareness of pain
reduce LOC while keeping defensive reflexes (gag reflex=no need to intubate)
who decided if a pt is a candidate for concious sedation?
in what cases is concious sedation used?
closed fracture reduction
PTCA (percutaneous transluminal coronary angiogram-like a cardiac cath)
electric convulsant therapy
other special but short procedures
what is the prep for concious sedation?
NOP for several hours
informed consent signed
special procedure room/PAC Unit (post anesthesia care unit)
how is concious sedation usually administered?
direct IV push
concious sedation is a combination of what types of drugs? give examples
what are the nursing responsibilities during surgery? who supervises?
the MD supervises and the RN must...
have advanced training in IV med administration
manage airway and ACLS (advanced cardiac life support)
monitor airway, LOC, ECG, 02sat, VS q 15min (until fully awake and responsive)
what is given to reverse concious sedation meds?
Narcan for Opioids
Romazicon for benzodiazepines (both have "Zs" in them)
what are the 5 perioperative staff/team members?
scrub nurse/surgical tech
surgeon and surgical assistant
anesthesiologist or CRNA (certified RN anesthesiologist)
what is a "time out"?
when the entire team stops to varify that it is the correct patient, procedure, and site
what are some risks related to body positioning of pt perioperatively?
burning from improper grounding during electrocautery (electric cauterization)
pressure ulcer formation
obstruction of circulation/respiration/nerve conduction
what is laproscopic surgery?
surgery using toold inserted through small incisions instead of one large one.
what can cause shoulder pain after laproscopic abdominal surgery? how can if be fixed?
C02 is used to inflate the abdomen and, if it isn't all removed before incisions are sutured, when the pt sits up it can travel up to the shoulders and cause pain. have pt lay down until C02 can be absorbed by the body
define steril, clean, and contamination
steril - free from living microorganisms
clean - free from dirt
contaminated - the introduction of dirt of microorganisms onto something formerly clean or steril
how far should a non-steril person be from anything steril?
what areas of a gown are considered steril?
the waist to the shoulders
the sleeves to 2 inches above the elbows
define general anesthesia
reversable loss of conciousness by inhibiting CNS
define regional anesthesia
temporary disruption to spacific are of sensation (epidural, spinal, nerve block)
define local anesthesia
directly applies anesthesic agent (topical)
what is malignant hyperthermia?
an inherited disease where pt experiences a drastic rise in temperature when given anesthesia
what are some complications from general anesthesia?
overdose of anesthesia (pt won't wake up)
unrecognised hypoventilation (lungs don't fully fill when ventilated)
complications with spacific anesthesia agents (can cause kidney, heart, GI paralysis)
how is general anesthesia administered?
inhalation: intake and excretion of anesthesia by lungs via a mask
IV injection: barbiturates, katamine, and propofol through the blood
what are some adjuncts to general anesthetic agents?
neuromuscular blocking agents
what can cause postop shock?
moving pt from table to bed
jarring guerney during transport
reactions to drugs/anesthesia
loss of blood/body fluids (check EBL)
cardia arrhythmias/heart failure
decreased sympathetic response
what is the purpose of the PACU recovery room?
provide ongoing evaluation and stabalization of patients to anticipate, prevent, and treat complications after surgery
why should a postop pt be turned on thir side?
to prevent tongue from closing off their airway
how much drainage is too much postop?
what is the #1 nursing diagnosis postop?
pain can be either the diagnosis or etiologic factor)
who should you not give demerol and why?
children, because it produces toxic metabolites
what are some advantages to a PCA?
increased satisfaction with pain control so pt uses less
decreased pulmonary complications
shorter hospital stay
who should always be in control of the PCA?
the patient! no PCA by proxy
what are three tips for monitoring a PCA?
consistantly use a pain/sedation rating scale
follow standard policy for monitoring over-sedation and adverse reactions
assess sedation using minimal spoken and tactile stimulation
what are some common GI reactions following surgery?
decreased or absent paristalsis (due to anesthesia time, bowel handling, and opioid use), can last up to 24 hours
describe the 4 phases of wound healing (give time frames for each)
Phase I - (1 to 3 days) inflammatory response, blood flow reestablished
Phase II - (3 to 14 days) collagen fills in (epithielization)
Phase III - (2-6 weeks) more collagen and compression of blood flow
Phase IV - (several months) shrinking and contraction of scar
when can ineffective wound healing most often be seen?
between the 5th and 10th days after surgery
what is dehiscence?
partial or complete seperation of the outer wound layers (splitting open)
what is evisceration?
total seperation of all wound layers and protrusion of internal organs
when and how often should dressings and drains be assessed for drainage postop?
on admission to the PACU and hourly thereafter
what function do drains serve?
they provide an exit for air, blood, and bile to prevent deel infections and abscess formation during healing