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NCTC Med Surg
Case Studies Surgery- LVN surgical considerations
| Question | Answer |
|---|---|
| Glucose | 70 - 110 |
| Potassium | 3.5 - 5 |
| Sodium | 135 - 145 |
| Chloride | 100 - 108 |
| WBC | 4,500 - 11,000 |
| RBC | 4.5 - 5.3 Million |
| HGB (hemoglobin) | 13 - 18 |
| F (iron) | 12 - 16 |
| HCT | 35% - 49% |
| F | 36% - 46% |
| Pre Operative Teaching - Knee Replacement | * Cough and Deep breathe * Use of IS * Use of CPM machine * PT (exercises) |
| What preoperative assessment data do you collect? | Past medical hx * Current health hx * Medication hx * Family hx * VS * Height and Weight * Allergies |
| You explain to Mr. Jarvis that a safety strap will be placed across his right leg for his protection during surgery. You as the nurse know there is a specific place this strap should be. Where is this and why? | * 2” above the knees * Protects the popliteal nerve from continuous pressure which can lead to damage |
| You also know that it is imperative that you prevent nerve and muscle damage to limbs during surgery. How would you do this? | * Do not allow arms and legs to hang over the bed during surgery. |
| What is a CPM machine & what is it’s purpose? | * CPM stands for continuous passive motion * Used to prevent adhesions after surgery which causes the joint to “freeze” and be immobile |
| How many hours each day should the patient use the CPM machine? | * 24 hours-that’s why its called “continuous” * Can only be off to use bathroom or ambulate |
| What discharge instructions must you give prior to release from the hospital from knee replacement surgery? | * wound care * activity instructions * personal hygiene * call doctor for uncontrolled N/V/D or fever greater than 101 F * medications |
| IDDM, is in for a right below the knee amputation (RBKA). What complications might he expect due to his diabetes? | * poor wound healing * tissue edges may not stay closed due to poor circulation * increased risk of infection |
| What do patients with amputations experience that other patients do not? | * phantom limb pain * continue to experience pain in leg, toe, etc., after amputation even though they no longer have that limb or digit |
| From an ethical perspective, what is necessary for informed consent to be fully autonomous? | * the procedure must be fully explained * must be informed of the alternative treatments * must be informed of the risks and benefits * pt must agree to the procedure |
| What is the nurses role as far as the informed consent goes? | * witness to the signature only |
| Whose job is it to obtain an informed consent? | * the physician |
| May a consent be withdrawn after it is signed? | * absolutely |
| Who may sign an informed consent? | * pt or legal representative * must have Durable Power of Attorney in hand to sign for pt |
| What does a consent protect the patient from? | *the surgeon can NOT do any procedure that is not on the consent form |
| When must a patient sign consent? | * prior to the procedure * prior to sedation |
| How is consent obtained for those unable to consent for themselves and have no family members present? | * telephone consent with 2 witnesses |
| The nurse is responsible for discussing the events occurring pre & postoperatively. What would you tell Mrs. Murphy? | * Pt will go to the holding area prior to the OR, * will meet with anesthesiologist, * sign anesthesia consent, if required, * IV started * continues to be monitored closely while waking up |
| Meds OK to take prior to surgery: | * Cardiac/HTN meds * Anti-seizure meds |
| Meds to stop or avoid: | * Stop ASA 48 hours before surgery-increases bleeding * No ibuprofen or arthritis meds due to possibility of hemorrhage * No hypoglycemics, adjust insulin |
| Mrs. Murphy undergoes her liver biopsy. How is this procedure done? | * necessitates the removal of a small sample of tissue * can be done as an open procedure through an incision under general anesthesia * needle biopsy (most common) is done under CT using a special needle inserted into the liver to aspirate tissue |
| What does recovery from Liver biopsy entail? | * Assessment, including ABC’s * VS q 15 min x 4 then q 30 x 2 then q 1 if necessary * Assess site with each set of VS for bleeding, include assessment of back and side * Place pt on right side either on a sand bag or rolled up towel to hold pressur |
| What S/S would Mrs. Murphy experience with hemorrhage? | * Hemorrhage * bleeding at site * Pooling of blood on right side * severe pelvic, flank and low back pain * bruising in dependent areas |
| What S/S would Mrs. Murphy experience with pneumothorax? | * restlessness * tachypnea * hypoxia, decreasing spO2 diminished or absent breath sounds |
| Why are pts kept NPO before surgery? | Minimize the chances of vomiting and of aspirating emesis into the lungs during or immediately after surgery. |
| What might you do for Jim as far as elimination goes? What could happen during surgery that might be prevented by an indwelling catheter? | * Have pt void just prior to pre op medication * The OR will place Foley catheter after the patient is asleep * A distended bladder can complicate surgical procedures on the lower abdomen and increase the chances of bladder trauma during surgery. |
| What is GoLYTELY? Who normally drinks this and why? | * A laxative * Surgery on the lower abdomen may call for an empty colon. This is sometimes ordered in place of enemas, used to stimulate elimination the day before surgery * the pt drinks 1 cup every 15 minutes for 3 hours. |
| Nancy Nurse cares for Jim the night before his surgery. The physician orders Restoril 15 mg PO at HS. The nurse knows that the onset of this drug takes 2 hours. When would she administer this? | * 2 hours before his usual bedtime, usually around 2100 or 2200 |
| Jim survives the night without falls. Betty Bopp, LVN, obtains his vital signs before surgery. They are 99.6, 88, 20, 128/86. Which of these signs needs to be reported at once? | * The temperature. |
| What nursing considerations should you the nurse make when giving pre op meds? | * check allergies * inject very slowly in the IV per recommendations found in the drug book * safety precautions to prevent injury when sedated/dizzy i.e. side rails up, assistance to BR * check on pt frequently * reorient prn-pt may become confu |
| What might the physician order for an elderly pt. to assist her to sleep? | A sedative or hypnotic such as Ambien, which is gentle to the elderly |
| What must be removed before surgery? | * Remove dentures and bridges, Contact lens and any prostheses, hearing aids, glasses, wigs All makeup should be removed for observation of O2 at the tissue level. * Polish must be removed from one finger for the proper use of the pulse oximetry. |
| What is the purpose of the pre op medication? | * Reduces anxiety and provides a smoother induction. * Atropine, reduces secretions * Phenergan & Zofran reduce postop nausea |
| What else would you do before giving the preop medication? What is the purpose of emptying the bladder before surgery? | * Have the pt void A distended bladder can complicate surgery |
| You start Ima’s IV of D5RL at KVO rate. She asks you why she needs an IV. | * To provide anesthesia, meds, and fluids during surgery. * To provide access in case of an emergency during surgery. * To provide access for postop meds |
| What 2 cholinergic blockers are used routinely for preop pts? What is their expected outcome? | * Atropine and Robinul, used to decrease secretions before surgery, to calm delirium, and motion sickness. |
| What position is best for her to recover in when she is not fully awake? | * side lying to prevent aspiration * use pillow in between the legs to prevent adduction in hip replacement |
| Ima wakes up in pain; her vital signs are 95.0, 120, 24, 190/100, pain 9/10. The physician has ordered Demerol 50 mg with Phenergan 25 mg IM for severe pain, and Toradol 30 mg IM for moderate pain. | * Demerol based on her vital signs and pain scale * Check when she last received med |
| 30 minutes after you give the Demerol Ima vital signs are 95.6, 70, 8. 90/50. She is difficult to arouse. What should you do first? What medication might be prudent to give now and why? | * Maintain airway * give Narcan * notify surgeon |
| Ima is stable now and you check her dressing on her right hip. It is dry but you slide your hand under her hip. Why? | * To assess for dependent bleeding beneath her. |
| What kind of drains might you expect Ima to have after this type of surgery? | * Jackson Pratt, or Hemovac. * Not likely, but she could have a Penrose drain. |
| When do wound infections usually manifest themselves? | * By the fifth post op day * A postoperative wound infection is classified as a nosocomial infection if it manifests itself after 72 hours. A hosocomial is acquired at home and will show up within 72 hours |
| What is the most common wound infection culprits? | Staphylococcus aureus and Escherichia coli, plus Pseudomonas |
| What is the most important thing to remember when changing a wound dressing? | * maintain sterile technique * failure to do so can result in infection |
| What position must the pt’s right leg be kept in at all times with a hip replacement and how is this achieved? | * abduction * use an abductor pillow, regular pillows use a trocanter roll on outside of legs to prevent over abduction |
| Lance Flatus had an orthopedic surgery yesterday Today is his first postop day and he wants to have something to eat. He is currently NPO with ice chips with an order to advance diet as tolerated when can his diet be advanced | •When bowel sounds are heard |
| As long as Lance does not have bowel sounds, can the nurse advance his diet? | No |
| What complication can occur if Lance eats before bowel sounds are heard? | He can get a bowel obstruction |
| Lance begins to experience severe gas pains as it begins to build up in his bowels. What common interventions would help Lance? | • walking • rectal tube • simethicone • laxative or enema |
| Often times, physicians will order clear liquids for patients in the immediate post op period rather than keeping them NPO. Before allowing the patient to drink, what should you assess for or do? | • make sure patient is fully awake • check for gag reflex • have suction equipment available to help prevent aspiration |
| What other potential complications should you be aware of for an orthopedic patient? | • Infection • Pneumonia • Pulmonary embolus |
| What can cause a pulmonary embolus? | • thrombus or blood clot • forms when not active or on CBR |
| What is the difference between a thrombus and emboli? | • thrombus is a blood clot • embolus is a clot that breaks loose and travels in the blood stream until it lodges in a small vessel |
| What are the S/S of a pulmonary embolus? | • increased restlessness • anxiety • hypoxia • tachypnea • SOB • increased heart rate |
| What can be done to prevent a polumonary embolus from happening? | • ankle circles • leg raises • ROM |
| Mary Miller, age 48, is admitted to your outpatient surgery center this morning for a laparoscopic assisted vaginal hysterectomy. (LAVH) What items would need to be checked before surgery? | • NPO after MN or at least 12 hours • Take appropriate meds • No lotion or make up • Removal of all jewelry (can tape rings if unable to remove), dentures, prosthetics (except eyes), nail polish • Void • Labs on chart • H & P on chart • Consents o |
| What is the purpose of Atropine? | • Atropine is a cholinergic blocker used to reduce secretions before surgery, to calm delirium, and for motion sickness. |
| What is the purpose of Versed? | • Versed is a general anesthetic used for preoperative sedation, general anesthesia induction, and other sedation indications |
| If Mary was to have laparoscopy how would it be performed? | • A scope is used to visualize internal structures and perform various surgeries • The insertion site is the navel, right and left upper quads, and below navel • Some use a fifth site |
| The surgeon, Dr. Gatt, uses surgical asepsis. What does this mean and why is this so important? | • Surgical asepsis is a condition in which there is a complete absence of germs. It is absolute. There is no compromise or modification. |
| When is Aseptic technique used? | • catheterization or surgical dressing changes. • when ever the skin or mucous membranes are perforated or incised. |
| What are other terms for aseptic technique? | • Other terms for surgical asepsis are sterile technique and aseptic technique. |
| What 4 ways is sterilization accomplished? | • Boiling for 10-20 minutes kills most vegetative forms of bacteria • Steam under pressure or autoclaving. Moist heat. • Dry heat sterilization. Electric oven sterilizer. • Ethylene Oxide-chemical found as both a liquid and as vapor. |
| Who are the sterile members of a surgical team? | • Sterile: Scrub nurse or Scrub Tech • anticipate the needs of the surgeon and assist at the operative site. • They prepare the instruments and materials used by the surgeon. |
| Who are the non sterile members of a surgical team? | Circulating nurse • has an overall picture of the needs of the pt and of the other team members. • Their duties include maintaining a safe environment for the pt by observing breaks in sterile technique. • Anticipating the need for supplies for the |
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