Question

Perioperative Care

1. The nurse is making a preoperative phone call to a 60-year-old woman who is scheduled for elective abdominal surgery under general anesthesia in 2 weeks. The woman has a history of chronic atrial fibrillation for which she takes amiodarone and warfarin, and rheumatoid arthritis for which she is currently taking prednisone because of a recent exacerbation. She also has a history of obesity and smokes one pack per day.

a.       In addition to the general surgical risks that exist for everyone, what additional risks exist for this woman because of her excess weight?

b.      What data from the history listed here should the nurse notify the provider about? Why is this data important to inform the provider about? Note the rationale for notification for each piece of data you list.

c.       The nurse asks the patient to go to the lab to have preoperative labs drawn prior to admission. What are the laboratory and diagnostic tests most frequently required preoperatively? Which tests are particularly important for this patient and why?

d.      The patient states that she has been advised to stop smoking before surgery. She says that her surgery has nothing to do with her smoking or her lungs. How should the nurse respond with information regarding smoking and surgical risks?

e.      The patient voices a concern about her wound opening after surgery. She asks when and how this could happen. Is she at risk? What information can the nurse provide for to answer her questions about when and how her wound could open and if she is at risk for this. What can the nurse teach her to care for herself at home postoperatively?

a.

b.

c.

d.

e.

2. The patient is admitted to the surgical floor at 7 am, three hours before her scheduled surgery.

a.       As the nurse is going over the pre-op check list at the beginning of his shift, what is the first priority to check for in the chart?

b.      List two priority questions for the nurse to ask the patient regarding her preparation for surgery at home that may affect whether the surgery will proceed today as planned. *Hint- consider the patient’s history as well as standard pre-op instructions given to patients who are about to undergo general anesthesia.

c.       How should the nurse prioritize and plan his work for the shift to prepare this patient for surgery without neglecting the needs of his other assigned patients?

d.      What classes of medications are frequently given as routine preoperative meds and why are they given?

e.      Considering the patient’s history and the surgical site, list at least two different areas in which pre-operative teaching should be done to prevent post-operative complications. Based on her history and surgical site, state the rationale for the importance of this education.

f.        The nurse teaches the patient about post op pain control using the PCA pump. The patient expresses fear that she might accidentally overdose herself on narcotics since she will be drowsy after surgery. What is the nurse’s best response?

3. How do TJC’s National Patient Safety Goals relate to the care of this patient?

4. What possible Hospital Acquired Events is this patient at risk for?

5. The surgeon visits and marks the patient’s abdomen with a permanent marker. After the surgeon leaves, the patient states,” That was odd- why is that necessary?” What is the nurse’s best response?

6. When the patient is in the operating room and prepped for surgery, the surgical staff should pause and observe at least one very important safety protocol. Explain what this is and why it is necessary.

7. The patient returns from surgery and is admitted to the PACU. She is not responding to verbal stimuli, and her vital signs are stable:   T 97.6 F, HR 88, RR 14, BP 130/70, SaO₂ 98% on 2 L oxygen per nasal cannula.

a.       What parameters will be used to determine her readiness for discharge from PACU? Discuss the standardized criteria used.

b.      When the PACU nurse takes the postoperative vital signs, she compares them with the preoperative values recorded in the chart. Why does she do this?

c.       What changes might the nurse see in the VS if the following situations occur? Be specific as to which parameter would change and how it would change (increase or decrease) and why.

·         Poor pain control

·         Internal Bleeding

·         Circulatory overload

·         Hypoxia

d.      The nurse observes that an abdominal dressing is in place with no visible drainage. Using a short concise statement, how would the nurse chart this finding?

8. The patient has returned to the surgical unit from the PACU. List at least 5 priority post-operative nursing assessments (each from a different body system/conceptual area), assessment parameters, what changes in these assessment parameters might indicate, and how frequently these assessments should be made over the first 24 hours after surgery. *Note- it might be useful to use a table to organize your answer to this question.

Area assessed

parameters

Changes in parameters

frequency

9. Considering the patient’s history and the type of surgery she had, list one priority nursing diagnosis that may apply to this patient during the immediate post-operative period in each of the following areas: oxygenation, comfort, tissue integrity, infection, and safety. List only the first two parts of the diagnosis.

10. Choose one of the diagnoses from the question above, develop an outcome statement, list three interventions with rationales, and determine the assessment parameters for how you will determine whether the outcome has been met. *Note- it might be useful to use a table to organize your answer to this question.

Answer 1

Answer(a) Additional risks exist for this woman because of her excess weight are:

• high blood pressure.
• high cholesterol and atherosclerosis (where fatty deposits narrow your arteries),
• coronary heart disease and stroke.
• asthma.
• metabolic syndrome (a combination of diabetes, high blood pressure and obesity)

Answer (b) From the history listed the nurse notify the provider about the woman that she has chronic atrial fibrillation for which she takes amiodarone and warfarin, and rheumatoid arthritis for which she is currently taking prednisone because of a recent exacerbation. She also has a history of obesity and smokes one pack per day. These data is necessary to notify the provider because she has to be operated and her surgery has to be done. So, its better to know about the medication she is taking earlier so that drug interaction may not take place.

Answer (c) The duty of the head nurse, who is the administrative officer of the hospital. The nursing care is needed during admissions and discharge of patients, doctor's rounds, drug administration and also during operation theatre administration. The nurse will manage the patients that are prioritizing and then she will handle this patient for surgery.

Answer(d) Medications are frequently given as routine preoperative are:

• Barbiturates. Amobarbital (trade name: Amytal) Methohexital (trade name: Brevital) Thiamylal (trade name: Surital)
• Benzodiazepines. Diazepam. Lorazepam. Midazolam.
• Etomidate.
• Ketamine.
• Propofol.

These medications are given so that the patient may not feel the pain during surgery.