chapter 96 - ATI Testing

chapter 96
Unit 14
Nursing care of perioperative clients
Chapter 96 Preoperative Nursing Care
Overview
●●
Surgery can take on many forms, including curative, palliative, cosmetic, and functional.
●●
Inpatient surgical procedures are performed by three categories: emergent, urgent, or elective type surgery.
●●
●●
●●
Outpatient or ambulatory surgery generally is an elective surgery that is not considered acute (cataract
removal, hernia repair).
Preoperative care takes place from the time a client is scheduled for surgery until care is transferred to
the operating suite.
Assessment of risk factors is one of the major aspects of preoperative care. Preoperative care includes a
thorough assessment of the client’s physical, emotional, and psychosocial status prior to surgery.
Risk Factors
●●
Surgery
◯◯
Infection (risk of sepsis)
◯◯
Anemia (malnutrition, oxygenation, healing impact)
◯◯
Hypovolemia from dehydration or blood loss (circulatory compromise)
◯◯
Electrolyte imbalance through inadequate diet or disease process (dysrhythmias)
◯◯
Age (older adults are at greater risk because of decreased liver and kidney function due to age, and
the use of multiple prescribed medications)
◯◯
Pregnancy (fetal risk with anesthesia)
◯◯
Respiratory disease (COPD, pneumonia, asthma)
◯◯
Cardiovascular disease (cerebrovascular accident, heart failure, myocardial infarction,
hypertension, dysrhythmias)
◯◯
Diabetes mellitus (decreased intestinal motility, altered blood glucose levels, delayed healing)
◯◯
Liver disease (altered medication metabolism and increased risk for bleeding)
◯◯
Kidney disease (altered elimination and medication excretion)
◯◯
Endocrine disorders (hypo/hyperthyroidism, Addison’s disease, Cushing’s syndrome)
◯◯
Immune system disorders (allergies, immunocompromised)
◯◯
Coagulation defect (increased risk of bleeding)
◯◯
Malnutrition (delayed healing)
◯◯
◯◯
Obesity (pulmonary complications due to hypoventilation, impact on anesthesia, elimination, and
wound healing)
Certain medications (antihypertensives, anticoagulants, NSAIDs, tricyclic antidepressants, herbal
medications, over-the-counter medications)
◯◯
Substance use (tobacco, alcohol)
◯◯
Family history (malignant hyperthermia)
RN Adult Medical Surgical Nursing
1095
CHAPTER 96 Preoperative Nursing Care
◯◯
Allergies (latex, anesthetic agents)
◯◯
Cancer of the oral cavity
◯◯
Inability to cope, lack of support system
◯◯
Disease processes involving multiple body systems
◯◯
Older adult clients:
■■
■■
■■
■■
■■
■■
■■
Are at a greater risk of adverse reactions to preoperative medications.
Have less physiologic reserve than younger clients, which may cause decreased immune system
response and decreased wound healing.
Reduction of muscle mass and the amount of body water places the older adult client at risk
for dehydration.
Can have sensory limitations (poor eyesight, hearing loss), so the nurse must be alert to
maintaining a safe environment.
Can have oral alterations (dentures, bridges, loose teeth) that pose problems during intubation.
Perspire less, which leads to dry, itchy skin that becomes fragile and easily abraded. Precautions
need to be taken when moving and positioning these clients.
Have decreased subcutaneous fat, which makes them more susceptible to temperature changes.
Diagnostic Procedures
●●
Urinalysis – ruling out of infection
●●
Blood type and cross match – transfusion readiness
●●
CBC – infection/immune status
●●
Hgb and Hct – fluid status, anemia
●●
Pregnancy test – fetal risk of anesthesia
●●
Clotting studies (PT, INR, aPTT, platelet count)
●●
Electrolyte levels – electrolyte imbalances
●●
Serum creatinine and BUN – renal status
●●
ABGs – oxygenation status
●●
Chest x-ray – heart and lung status
●●
12-lead ECG – baseline heart rhythm, dysrhythmias, history of cardiac disease, performed on all
clients older than 40 years
Preoperative Assessment
●●
Preoperative nursing assessments
◯◯
◯◯
◯◯
Detailed history (including medical history, medication use, substance use, psychosocial history,
and cultural considerations)
Allergies to medications, latex related to a sensitivity to bananas and other fruits, betadine related
to an allergen to shellfish, propofol related to an allergy to eggs or soybean oil.
Anxiety level regarding the procedure, support systems, and coping mechanisms.
■■
1096
Older adult clients may be more fearful due to financial concerns and lack of social support.
◯◯
Laboratory results
◯◯
Head-to-toe assessment, vital signs, and oxygen saturations to obtain baseline data.
RN Adult Medical Surgical Nursing
CHAPTER 96 Preoperative Nursing Care
Nursing Actions
●●
Informed consent
◯◯
◯◯
◯◯
◯◯
Once surgery has been discussed as treatment with the client and significant other, family member, or
friend, it is the responsibility of the primary care provider to obtain consent after discussing the risks and
benefits of the procedure. The nurse is not to obtain the consent for the provider in any circumstance.
The nurse can clarify any information that remains unclear after the provider’s explanation of the
procedure. The nurse may not provide any new or additional information not previously given by
the provider.
The nurse’s role is to witness the client’s signing of the consent form after the client acknowledges
understanding of the procedure.
The nurse should determine if the client is:
■■
18 years of age.
■■
Mentally capable of understanding the risks, reason, and options for surgery and anesthesia.
■■
◯◯
◯◯
◯◯
Under the influence of medication that affects decision-making or judgment (opioids,
benzodiazepines, sedatives). Do not have the client sign the informed consent if medications
have been administered.
A legal guardian may need to sign the surgical consent form if the client is not capable of
providing consent or if there is no family.
Two witnesses are required if the client is able to only sign with an “X”, blind, deaf, or English is a
second language.
Informed consent is required for surgical procedures, invasive procedures (biopsy, paracentesis, scopes),
and any procedure requiring sedation or anesthesia, or involving radiation.
Responsibilities for Informed Consent
Provider:
Obtains
informed
consent
›› To obtain informed consent, the provider must give the client:
Client:
Gives
informed
consent
›› To give informed consent, the client must:
Nurse:
Witnesses
informed
consent
›› To witness informed consent, the nurse must:
»»A complete description of the
»»A description of the potential harm, pain,
treatment/procedure.
and/or discomfort that may occur.
»»A description of the professionals who will be »»Options for other treatments.
performing and participating in the treatment »»The right to refuse treatment.
»»Information on the risks of anesthesia.
»»Give it voluntarily (no coercion involved).
»»Receive enough information to make a
decision based on an understanding of
what is expected.
»»Be competent and of legal age or be
an emancipated minor. When the client
is unable to provide consent, another
authorized person must give consent.
»»Ensure that the provider gave the client
»»Have the client sign the informed
the necessary information.
consent document.
»»Ensure that the client understood the
»»The nurse documents questions the client
information and is competent to give
has and notifies the provider. The nurse also
informed consent.
documents any additional reinforcement
of teaching.
»»Notify the provider if the client has more
questions or appears to not understand any »»Provide a trained medical interpreter (not a
of the information provided. (The provider
family member or friend) and record the use
is then responsible for giving clarification.)
of an interpreter in the client’s medical record.
RN Adult Medical Surgical Nursing
1097
CHAPTER 96 Preoperative Nursing Care
●●
Preoperative teaching
◯◯
◯◯
◯◯
◯◯
Postoperative pain control techniques (medications, immobilization, patient-controlled analgesia
pumps, splinting)
Demonstration and importance of splinting, coughing, and deep breathing
Demonstration and importance of range-of-motion exercises and early ambulation for prevention
of thrombi and respiratory complications
Purpose of antiembolism stockings and pneumatic compression devices to prevent
deep‑vein thrombosis
◯◯
Invasive devices (drains, catheters, IV lines)
◯◯
Postoperative diet
◯◯
Use of the incentive spirometer
View Video: Incentive Spirometer
◯◯
Preoperative instructions (avoid cigarette smoking for 24 hr preoperatively, medications to hold,
bowel preparation)
■■
■■
■■
■■
◯◯
●●
Clients who take herbal medications (e.g., ginkgo biloba, ginseng, feverfew) should stop taking
them 2 to 3 weeks before surgery to prevent hemorrhage or adverse affects to the anesthetic.
Medications for cardiovascular disease, pulmonary disease, seizures, and diabetes mellitus,
certain antihypertensive medications, and eye drops for glaucoma may be taken prior to
surgery or a procedure.
Teach the client how to use a pain scale to rate pain level postoperative.
Care and restrictions relative to surgical procedure performed
Preoperative nursing actions
◯◯
◯◯
◯◯
◯◯
◯◯
◯◯
◯◯
Verify that the informed consent is accurately completed, signed, and witnessed.
Administer enemas and/or laxatives the night before and/or the morning of the surgery for clients
undergoing bowel surgery.
Regularly check the client’s scheduled medication prescriptions. Some medications
(antihypertensives, anticoagulants, antidepressants) may be held until after the procedure.
Ensure that the client remains NPO for at least 6 hr for solid foods and 2 hr for clear liquids before
surgery with general anesthesia, and 3 to 4 hr with local anesthesia to avoid aspiration. Note on
the chart the last time the client ate or drank.
Perform skin preparation, which may include cleansing with antimicrobial soap. If absolutely necessary,
use electric clippers or chemical depilatories to remove hair in areas that will be involved in the surgery.
Ensure that jewelry, dentures, prosthetics, makeup, nail polish, and glasses are removed. These
items can either be given to the family or stored safely.
Cover the client with lightweight cotton blanket heated in a warmer to prevent hypothermia.
■■
1098
Clients who are taking acetylsalicylic acid (Aspirin) should stop taking it for 1 week before an
elective surgery to decrease the risk of bleeding.
Hypothermia increases the chance for surgical wound infections, alters metabolism of
medication, and causes coagulation problems and cardiac dysrhythmias.
RN Adult Medical Surgical Nursing
CHAPTER 96 Preoperative Nursing Care
◯◯
◯◯
Establish IV access using a large-bore (18-gauge) catheter for easier infusing of IV fluids or
blood products.
Administer preoperative medications (prophylactic antimicrobials, antiemetics, sedatives)
as prescribed.
■■
■■
◯◯
Prophylactic antibiotics are administered 1 hr prior to surgical incision.
If the client previously took a beta-blocker, administer a beta-blocker prior to surgery to prevent
a cardiac event and mortality.
■■
Have the client void prior to administration.
■■
Monitor the client’s response to the medications.
■■
Raise side rails following administration to prevent injury.
Ensure that the preoperative checklist is complete.
View Image: Preoperative Checklist
◯◯
Confirm and verify the correct surgical site with the client and all health care team members
before clearly marking the surgical site.
Complications
●●
Complications during the postoperative period usually are related to the medications given
preoperatively. These medications and their possible complications are as follows:
Medication Class
Possible Complications
›› Sedatives (benzodiazepines, barbiturates)
›› Respiratory depression, drowsiness, dizziness
›› Opioids
›› Respiratory depression, drowsiness, dizziness,
constipation, urinary retention
›› IV infusions (0.9% NaCl, lactated Ringer’s)
›› Fluid overload, hypernatremia
›› Gastrointestinal medications (antiemetics,
antacids, H2 receptor blockers)
›› Alkalosis, cardiac abnormalities (certain H2 receptor
blockers), drowsiness
●●
For clients encountering severe anxiety and panic, reassurance will be necessary and sedation
medications may be given.
◯◯
●●
●●
Nonpharmacological interventions, such as distraction, imagery, and music therapy, can
be initiated.
Ensure that measures are taken to prevent deep-vein thromboembolism postoperative by continuing
anticoagulation therapy and/or antiembolism stockings, pneumatic compression device, and
range‑of-motion exercises.
Be alert for any allergic reactions the client has to medications.
RN Adult Medical Surgical Nursing
1099
CHAPTER 96 Preoperative Nursing Care
Application Exercises
1. A nurse in the preoperative unit is assessing a client’s laboratory values before surgery. Which of the
following should the nurse report to the provider? (Select all that apply.)
A. Potassium 3.9 mEq/L
B. Sodium chloride 145 mEq/L
C. Creatinine 2.8 mg/dL
D. Blood glucose 235 mg/dL
E. WBC 17,850/uL
2. A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client’s temperature is
39° C (102.2° F) orally. Which of the following is an appropriate action by the nurse?
A. Inform the surgeon of the elevated temperature.
B. Transfer the client to the preoperative unit.
C. Apply ice packs to the client’s groin.
D. Encourage the client to increase intake of clear liquids.
3. A nurse is obtaining informed consent for a client who is having a paracentesis. Which of the following
are appropriate nursing actions? (Select all that apply.)
A. Explain to the client the purpose of having the procedure.
B. Inform the client of risks to having the procedure.
C. Ensure the client understood the information about the procedure.
D. Witness the client signing the informed consent form.
E. Determine if the client is mentally capable of understanding the reason for the procedure.
4. A nurse is preoperative teaching a client scheduled for abdominal surgery. Which of the following
statements by the nurse are appropriate? (Select all that apply.)
A. “Take your blood pressure medication with a sip of water before surgery.”
B. “Splint the abdominal incision with a pillow when coughing and deep breathing.”
C. “Bedrest is recommended for the first 48 hr.”
D. “Antiembolism stocking are applied before surgery.”
E. “You may eat solid foods up to 4 hr before surgery.”
1100
RN Adult Medical Surgical Nursing
CHAPTER 96 Preoperative Nursing Care
5. A preoperative nurse is caring for a client who is having a colon resection. Which of the following is an
appropriate nursing action?
A. Encourage the client to void after medication administration.
B. Administer antibiotics 30 min prior to surgical incision.
C. Remove hair using a manual razor.
D. Remove nail polish on fingers and toes.
6. A preoperative nurse is planning preventative care for a client who is having a surgical procedure.
What potential complications should the nurse include in the preventive plan of care? Use the ATI Active
Learning Template: Basic Concept to complete this item to include the following:
A. Related Content: List three preventions for potential complications.
●●
Underlying Principles: Explain the related cause of each potential complication.
●●
Nursing Interventions: Include one intervention for each potential complication.
RN Adult Medical Surgical Nursing
1101
CHAPTER 96 Preoperative Nursing Care
Application Exercises Key
1.A.
INCORRECT: The potassium level is within the expected reference range.
B.
INCORRECT: The sodium chloride is within the expected reference range.
C.
CORRECT: The nurse should report an elevated creatinine level, which may indicate kidney failure,
to the provider before surgery.
D.
CORRECT: The nurse should report an elevated blood glucose, which needs treatment prior to surgery.
E.
CORRECT: The nurse should report an elevated WBC count, which indicates a need for antibiotic
therapy before surgery.
NCLEX® Connection: Reduction of Risk Potential, Laboratory Values
2.A.
CORRECT: An appropriate action by the nurse is immediately notifying the surgeon of the elevated
temperature to determine if cancelling the surgery is necessary due to an underlying infection.
B.
INCORRECT: Transferring the client to the preoperative unit is not an appropriate nursing action
when there is a possible underlying infection.
C.
INCORRECT: Applying ice packs to the client’s groin is not an appropriate action by the nurse for a
temperature of 39° C (102.2° F). Instead, administer acetaminophen (Tylenol).
D.
INCORRECT: Increasing intake of clear liquids is not an appropriate action by the nurse because the
client should be NPO for at least 2 hr before surgery.
NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures
3.A.
INCORRECT: The provider should explain the purpose of the procedure.
B.
INCORRECT: The provider should inform the client of risks to having the procedure.
C.
CORRECT: Ensuring the client understood the information about the procedure is an appropriate
nursing action.
D.
CORRECT: Witnessing the client signing the informed consent is an appropriate nursing action.
E.
CORRECT: Determining if the client is mentally capable to sign the informed consent is an
appropriate nursing action.
NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures
1102
RN Adult Medical Surgical Nursing
CHAPTER 96 Preoperative Nursing Care
4.A.
CORRECT: The nurse should teach the client to take certain antihypertensive and other
medications as prescribed with a sip of water before surgery.
B.
CORRECT: The nurse should teach the client how to splint with a pillow to support the incision
when coughing and deep breathing postoperatively.
C.
INCORRECT: The nurse should teach the client the importance of early ambulation following
abdominal surgery to prevent complications.
D.
CORRECT: The nurse should inform the client of the application of antiembolism stockings to
prevent deep-vein thrombosis.
E.
INCORRECT: The nurse should inform the client to stop eating solid food for 6 hr or more
before surgery.
NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures
5.A.
INCORRECT: The client should void before administration of medication for relaxation or sedation
to prevent the risk for falls.
B.
INCORRECT: The nurse should administer antibiotics 1 hr prior the surgical incision as a
prophylactic measure to prevent infection.
C.
INCORRECT: The nurse should remove the client’s hair at the surgical site with electric clippers or
use a chemical depilatory to prevent traumatizing the skin and increasing the risk for infection.
D.
CORRECT: The nurse should ensure the nail beds are visible for color and circulation by removing
nail polish before surgery.
NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures
6.
Using the ATI Active Learning Template: Basic Concept
A. Related Content
●●
Prevent respiratory depression
◯◯
◯◯
●●
●●
Caused by overmedication with
benzodiazepines, barbiturates,
or opioids.
Prevent deep-vein thrombosis
◯◯
Administer a reversal agent, and
monitor closely.
◯◯
Prevent fluid overload
◯◯
◯◯
Caused by too much IV fluids and
inability to readily excrete the fluids.
Obtain a preoperative cardiac and
pulmonary history, monitor I&O closely,
slow the rate of IV fluids, and administer
a prescribed diuretic.
●●
Caused by blood stasis in
lower extremities due to absent
muscle contractility.
Apply antiembolism stocking and
pneumatic compression device,
administer prescribed anticoagulants,
and teach range-of-motion exercises.
Prevent infection
◯◯
◯◯
Caused by microorganisms
contaminating the surgical wound.
Administer a prophylactic antibiotic
1 hr before the surgical incision is made.
NCLEX® Connection: Reduction of Risk Potential, Potential for Complications from Surgical
Procedures and Health Alterations
RN Adult Medical Surgical Nursing
1103

Download Report