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preoperative(Pre-op) begins with patient decides to have surgery; consents; needs clearance before surgery--> includes labs, MR, etc.
intraoperative OR--> PACU
postoperative(post-op) PACU; goes up to unit or goes to recovery room and then home; this phase lasts until pt is healed; depends on type of surgery(inpt or outpt)
reasons for surgery diagnostic; curative; restorative; palliative; cosmetic
diagnostic reason for surgery biopsy, laparotomy
curative reason for surgery appendectomy
restorative reason for surgery total knee repair
palliative reason for surgery relieve symptoms
cosmetic reason for surgery rhinoplasty; usually done on outpt basis
causes of surgery-related stress fears- death; scared; pain; problem going under; being able to do anything on own; being disabled; how getting around; embarassment
surgical risk factors infection; rxn to anesthesia; death; wrong site surgery; do everything we can to reduce these
patient assessment before surgery/history and physical establish baseline
general early preop car: therapeutic communication client and fam teaching; pre-op, post-op(tubes, tubes, tubes); pre-op prep; make sure they understand the enviro of coming out of surgery
health teaching before surgery deep breathing and coughing; incentive spirometer; lower extremity exercises; positioning; pain meds; PCA pump/pain rating scales
lower extremity exercises surgery movement to prevent venous stasis/blood clots
positioning surgery understanding the position during surgery to understand soreness may occur after surgery
pain meds and surgery available afterwards; important to understand may not be given on regu basis; pain assessments will be done/evaluated; given PRN; pts need to be their own advocate
PCA(patient controlled analgesia) pump IV fluids; provide another level of control over pain; understand that it is individualized; family needs to know they should not be taking control only pt; not used with elderly, causes a lot of elderly pts to be confused
pre-op chart review ensure all documentation, preop procedures and orders are complete; pre-surg check list; check consent forms & others for complete; doc allergies, height and weight; ensure all labs/tests are on chart; doc/report abnormal results, special needs & concerns
pre surgical check list allergies; iso precaut; side/site ID; labs/tests; vitals; NPO since; wt/ht; last period; pts belongings secured/removed; blood type and cross match; antimicrobial prophylaxis guideline checked & faxed to pharm; IV am prior; site prep; equipment to OR w pt
pre op pt prep surgical checklist NPO after midnight(MN); verify consent; ID, allergy, blood bands; ht/wt/allergies
pre op informed consent surgeons role responsible for obtaining signed consent before sedation and/or surgery; if nurse feels pt is not adequately informed--> contact and request to see the pt for further clarification
pre op informed consent nurses role clarify facts presented by physician and address questions and concerns that the pt or family may have about surgery; not responsible for providing details about surgical procedure; can serve as witness to signature but not that the pt is informed;
informed consent implies that person has sufficient info to understand nature and reason for surgery; who will perform surgery and who will be present; options and risks assoc with each option; risks with procedure; potential outcomes and risk assoc with anesthesia
holding area prior to surgery never leave pt alone; greets pt; preop checklist; verify consent forms; ask pt what surg procedure is being done; assess emo status, gives support, answers ?; start IV/epidural; ID pt(2); fam ok here; if specific site, pt and nurse initial site
preop pt prep skin, prep, IVs, fluids; remove contacts, dentures, hearing aids, makeup, nail polish, jewlery(wedding band)
incentive spirometer purpose encourages pt to take deep breaths; promote complete lung expansion and to prevent pulm problems i.e. atelectasis; pneumo; uses visual feedback to encourage pt
incentive spirometer steps Seal lips tightly around mouthpiece; Inhale spontaneously; Hold breath for 3- 5 sec for effective lung expansion; AARC recs 5 to 10 breaths per session every hr while awake; Pain meds before helps pt achieve deep breathing by reducing pain, splinting
incentive spirometer goals can be set according to pts ability and type; Post-op capacity ½ to ¾ of pre op volume is acceptable due to post op pain
sequential compressions devices(SCDs) to promote venous return and prevent DVTs
preop labs CBC, PT, PTT, U/A,BMP; CXR, void; pre-op meds/VS; document
preop pt prep drugs(if ordered) antibiotics(on call); sedatives, histamine H2-receptor; antagonists; analgesics
the older surgical pt sensory impairments hypotension; hypothermia; hypoxemia r/t anasthesia; less adipose tissue; very cold in OR plus meds; pts on HTN meds--> could bottom out post op
the older surgical pt positioning complications r/t arthritis; decubiti/pressure ulcers; decreased subcu fat and reduced circ; twice as long to position, takes a team
drugs for care of the surgical pt neuromuscular blocking agents; anticholinergics; GI stimulants; sedatives/hypnotics; antianxiety agents; lots of drugs; cocktail during preop to prevent post op complications
nursing dx and interventions pre op deficient knowledge of surgery; fear; disturbed sleep pattern; ineffective coping; anticipatory grieving
sociocultural affiliation effect on surgical experience of client support; social network
team members not scrubbed circ nurse; anesthesiologist--> wear cover scrub jackets with long sleeves and protective eyewear; shoe covers
scrubbing up for surgery 3-5 min with broad spec ab; hands held higher than elbows; thoroughly drying; hands above wasit alcohol based; circ rn helps surgeon gown up; checks for tears; team wears sterile fluid resist gown, sterile gloves, eye protect or face shields
wrong patient errors JC 17%
wrong procedure JC 8%
wrong side JC 56%
other wrong site JC 19%
time out before surgery begings surgical team pauses to communicate about the specific pt and procedure; correct pt, med record, side/site, pt position, agreed procedure, right implants, correct equip, atbs; know advance directive
circulating nurse coordinates and oversees pt care in OR; sets up OR; flow; assists surg; sterile tech; docs events and findings; sponge count; communicates with fam
scrub nurse sets up sterile fields; drapes pt; hands supplies/equip and instruments to surgeon; sponge, sharps, instrument count; amount of irrig fluid and drugs used b4 and after surgery
specialty nurses in surgery assess, maintain and recommend DME supplies used in that specialty
major safety concerns of the operative experience positioning; equipment; maintain asepsis; assisting in wound closure
geriatic positioning considerations dry skin, loss of tugor and elasticity; disposed to hematomas, handle carefully; poor nutritional status; osteoporosis; arthritic changes; limited ROM; venostasis; resp problems(thicker, less elastic alveoli; COPD, asthma)
obese positioning considerations HTN, CV disease, diabetes, decreased periph circ; strain on joints and ligaments; trendelenberg-increased venous return; risk of aspiration
malnourished positioning considerations more susceptible to infection; thin, poor skin tugor; susceptible to venostasis and thrombus formation; prone and trendelenburg not tolerated well
supine position foam headrest, foam donut, pillow; most common position; arms at sides, palms turned towards patient or on armboards: palms turned down; never beyond ROM or >90 degrees
trendelenburg position modification of supine; exposure of lower ab/pelvic cavity; arms on armboards or at sides; when pt is hypotensive--> want head down
trendelenburg contraindicated increased intracranial pressure; increased intraocular pressure(glaucoma); increased thoracic pressure
reverse trendelenburg position padded footboard; head up, feet down; arms on armboards or at sides; consider venous pooling
lithotomy position many potential problems; legs suspended, pt on back; consider back pain, joint replacements, ROM; arms with armboards <90 degrees; or tucked at sides--> WATCH fingers; prevent neuro damage; raise and lower legs simultaneously; can cause HTN
neurological damage with lithotomy position most common- femoral nerve from acute flexion; fem or obturator from personnel or instruments; saphenous, tibial, common perineal from the stirrups
fracture table position unaffected leg is raised; abducted and supported in a padded leg rest
general anesthesia loss of all sensation; reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the CNS; involves a single agent or a combo of agents; combo of inhalation and IV injection is best for older adults and high risk pts
regional anesthesia temporary interruption of nerve impulses to and from a specific body area
concious sedation client still has ability to retain pt airway and respond to commands
older pts and anesthesia general not always the best because of the effects it may have on the rest of the body; higher risk for resp problems; wake up slower; higher risk for atelctasis or pneumo; diminished or absent bowel sounds; cant feed until these are heard
anesthesia chosen based on pt's fears; health issues; previous response to anesthesia; type of surgery
purpose of anesthesia block nerve trans; promote muscle relaxation and suppress reflexes
complications from general anesthesia overdose; unrecognized hypoventilation; complications of specific anesthetic agents; complications of intubation
overdose of anesthetic if pts metabolism and drum elim slower than expected(liver or kidney); toxicity; important to obtain accurate history about the pts ht, wt, liver and kidney function to determine the anesthetic type and dose
unrecognized hypoventilation failure to exchange gases adequately may lead to cardiac arrest, perm brain damage and death
complications of intubation broken/injured teeth caps; swollen lip, vocal cord trauma; surgeon needs to be in OR during intub in case a trach is needed
malignant hyperthermia clinical manisfestations tachycardia; dysrhythmias; muscle rigidity; hypotension; tachypnea; skin mottling; cyanosis; elevated temp >111.2; potentially fatal
malignant hyperthermia genetics autosomal dominant; more common in young males; if known pts history pt can have a muscle biopsy to determine whether they are at risk; survival dependent on early diagnosis and actions of the surgical team
treatment of malignant hyperthermia possible with dantrolene, a skeletal muscle relaxant
spinal anesthesia non invansive; non generalized; wont have as many resp and GI issues as you have with generalized
neuro side effects/complications of gen anesthetic agents excessive sedation- delayed awakening
respiratory side effects/complications of gen anesthetic agents laryngospasm, hypoxia, hypercarbia
cardio side effects/complications of gen anesthetic agents hypotension; tachycardia; arrhythmias; fluid/electrolytes imbalances
other side effects/complications of gen anesthetic agents restlessness; N/V
CNS side effects/complications of REGIONAL anesthetic agents stimulation- hyperactivity, excitement, seizures, followed by CNS depression
cardio side effects/complications of REGIONAL anesthetic agents hypotension; arrhythmias
spinal side effects/complications of REGIONAL anesthetic agents headache, urinary retention
nursing diagnosis intraoperative phase risk for aspiration; ineffective protection; impaired skin integrity;risk for perioperative positioning injury; risk for imabalanced body temp; ineffective tissue perfusion; risk for deficient fluid volume
nursing responsibilities of care of the intraoperative client nurse anesthetist observes for adverse effects intraoperatively; circ nurse runs the room; scrub nurse works with the dr
PACU(postanesthesia care unit) allows for ongoing evaluation and stabilization of pts to anticipate, prevent, and treat complications after surgery; circ nurse and anesthesia provider give PACU nurse a verbal hand off report
upon admission to PACU pt should be immediately placed in side lying position with head to side
admitted to PACU assess airway and gas exchanged; cont monitor spO2 >95%; RR <10= shock, acidosism pain; all wrpas/bandages assessed for bleeding, drainage and then hourly thereafter;
all post op pts at risk for pnemo, shock, cardiac/ resp arrest; dvt; hemmorrhage
PACU nursing assessment- respiratory pt airway; rate, pattern and depth of breathing; accessory muscle use; snoring and stridor
PACU nursing assessment- cardio vital signs; heart sounds; cardiac monitoring
PACU nursing assessment- neuro cerebral functioning; motor and sensory
PACU nursing assessment- others I &O; hydration status; IV fluids; acid-based balance; renal urinary retention, other output sources; N/V and <peristalsis
NG tube inserted during surgery to decompress and drain the stomach; promote GI rest; allow the lower GI tract to heal; provide an enteral feeding route; monitor any gastric bleeding; prevent intestinal obstruction; assess drained material every 8 hr; do not move or irrigate tube w/o order
PACU nursing functions respiratory; LOC, TPR, O2 sat; BP, output; examine surgical area for bleeding; discharge from PACU--> vital signs every 15 min x4; then every 30 min, 2 hrs and then 4 hrs x 24-48 hrs
post op risks airway obstruction; shock; cardiac arrest; resp arrest; DVT; GI bleeding; pain
pre-op diet NPO
post op diet nutrition withheld until bowel sounds and no N/V; diet progresses slowly- ice chips, H2O, clear, full liquids, regular; by drs orders only
nutritional modifications to promote optimal wellness in surgical pts protein and calories for healing; low-fat, high fiber diets contraindicated; failure to use GI tract for > 4 or 5 days can result in atrophy of intestinal mucosa leading to risk for infection
nursing diagnosis for post-op pt acute pain; risk for infection; risk for imbalanced fluid volume; nausea; ineffective protection; delayed surgical recovery
impaired gas exchange interventions airway maintenance; positioning the pt in a side lying position or turning head to side to prevent aspiration; encourage breathing exercises; encourage mobilizations as soon as possible
impaired skin integrity interventions nursing assessment of the surgical area; dressings-first change usually done by surgeon; drains- provide exit route for air, blood, and bile as well as help prevent deep infections and abscess formation during healing
ineffective wound healing can be seen between 5th and 10th days after surgery; dehiscence or evisceration
dehiscence a partial or complete separation of the outer wound layers
evisceration a total separation of all wound layers and protrusion of internal organs through the open wound
factors that influence perception of pain age, gender, sociocultural, genetics
nociceptive pain somatic pain; visceral pain; normal processing of pain; sharp, burning; somatic- dull, aching; visceral- diffuse, cramping, stabbing
neuropathic pain abnormal pain processing; results from nerve injury; burning shooting stabbing pins and needles ; shocklike, burning, fiery, numbness
pharm and comp/alt therapies for acute pain non-opoid analgesics; NSAIDS, opoid analgesics; adjuvant analgesics; positioning; massage; relax and diversion techniques
chronic pain onset is gradual; longer than 3 months duration; persistent, mild to severe in intestiny; accompanied by depression, fatigue, decrease in function
prevention, treatment of opoid side effects constipation, N/V, sedation/confusion; respiratory depression
QSEN competencies patient-centered care; teamwork and collaboration; evidence-based practice; quality improvement; safety; informatics
what percentage of adults in the USA are over age 65? 13%; fastest growing population is >85
gerontology broad term use to define the study of aging
generalist RN Prep in geriatics 2.2 million practicing RNs; <1% are certified in gerontological nursing; 34% of BSN programs have a required course in geriatics
psychosocial changes of aging retirement; social isolation; sexuality; housing and environment; death; longer you live the more losses you have to cope with; high percentage of older adults are depressed; a lot of older adults are negative (cant change what is);often overlooked
young old 65 to 74
middle old 75 to 84
old old 85 to 99
elite old ages 100 or older; fast growing segment
fraility a clinical syndrome; unitentional weight loss; weakness; exhaustion; slowed physical activity including walking; risk for adverse outcomes
physiological changes of older adult perception of well-being defines quality of life; older pts concept of health revolves around how they perceive their ability to function; nurses need to be cognizant of normal age-related changes; not all physio changes are patho
ageism discrimination based on age; age discrimination employee act of ADEA 1967; stereotyping and prejudice against older persons
stereotyping of older dults disabled; sick, senile, senseless, sexless, physically unattractive, rigid, unfriendly, confused and forgetful; refrain from "elderspeak"
age-related physio changes atrophic gastritis; decreased ADH response; decreased hepatic metabolism; decreased muscle mass; decreased body water; decreased cerebral blood flow
atrophic gastritis--> B12 deficiency--> dementia
decreased ADH response--> increased dehydration risk
decreased hepatic metabolism--> drug toxicity/polypharmacy
decreased muscle mass--> digitalis toxicity/polyparm
decreased body water--> increased dehydration risk
decreased cerebral blood flow--> syncope--> falls
health concerns of the older adult SPICES; nutrition; mobility; safety; stress and loss; polypharm; mental/behavioral health; neglect and abuse
SPICES Sleep disorders; Problems with eating, feeding; Incontinence; Confusion; Evidence of falls; Skin breakdown
caring for older adults is COMPLEX the array and number of chronic illnesses facing older adults is only expected to increase with longevity
caring for older adults is CHALLENGING given the demand for skilled health care providers in geriatrics which far exceeds the capcity of current geriatric nurses and other health professionals
causes of older adult malnutrition diminished sense of taste and smell; tooth loss and poorly fitting dentures; economics; inappropriate or imbalanced nutrition; logistics, access; loneliness
malnutrition: symptoms lethargy; generalized weakness; an unintentional weight loss of more than 5% of body weight in 1 month
nursing nutritional assessment of older adults: SCALES Saddness or mood changes; Cholesterol, high; Albumin, low; Loss of gain of weight; Eating problems; Shopping and food prep problems
dysphagia-behaviors difficulty or discomfort swallowing; sensation is something is stuck in the throat; coughing with intake of food, fluids; excessive throat clearing; gurgling voice, drooling, food or fluid coming out of nose when swallowing; pocketing of food in the mouth
nutrition imbalance over 65 years initially subject to weight gain and obesity-intake remains the same, but expenditure decreases
nutrition imbalance older old are subject to weight loss and malnutrition, decreased intake
"at risk" older adults adults with advanced age and/or complex illness should be considered at increased risk to develop adverse response and complications related to medications, treatments, geriatric syndromes
at risk older adults assessed for functional, cognitive status; pain; geriatric syndromes including presence of urinary incontinence, pressure ulcers, delirium, fall risk
older adults and the acute care setting poses riskf or adverse events delirium, dehydration, malnutrition, health-care associate infections, urinary incontinence, falls
older adults and restorative care: types of ongoing care continues recovery from acute illness; addresses chronic conditions that affect daily functioning
older adults and restorative care: goal to regain or improve prior level of independence, ADLs, instrumental ADLs; discharge planning starts the minute they are admited
consequences of malnutrition infection; pressure ulcers; anemia; impaired cognition; hip fractures; most are reversible; poor healing skin conditions
nursing diagnoses for older adult nutrition swallowing, impaired; self-care deficit, feeding; deficient fluid volume; nutrition imabalnce less or more; failure to thrive, adult; dentition
goals for older adult nutrition pt will demonstrate improved ability to swallow within the next 48 hrs AEB ability to clear throat after intake; pt will be able to swllow without chocking within the next 3 meals offered;
nursing interventions for older adult nutrition determine food pref; remove unpleasant stimuli; maintain good oral hygiene, correct temp of foods; arrange meal when fam visits; pain relieved; small frequent meals; consider meds; community dining
benefits of regular exercise decreased risk for falls; increased mobility; increased quality of sleep; reduced/maintained weight; improved well-being and self-esteem; fewer depression symptoms; improved longevity; reduced risk for diabetes and cardiovascular disease
safety risks for older adults in hospital risk for falls and injury; skin breakdown; dehydration; delirium; HAIs; becoming incontinent; polypharm
factors that increase accident likelihood presbyopia; reduced sense of touch; decreased reaction time; periphral neuropathy; arthritis
fall prevention and safety home modification; exercise; greater predictor of falls/history of falls; tai chi
frequent sources of stress older adults rapid enviro changes; changes in lifestyle; acute or chronic illness; loss of significant others; financial hardships; relocation stress syndrome
drug use and misuse polypharm; may not be able to tolerate standard dosage of drugs; physio changes from aging can affect absorption, distribution, metabolism, and excretion of drugs from the body; start low and go slow
how to assess decisional capacity is pt able to ID problems recognize options, make decisions, and provide the rationale supporting the decisions; mini mental status exam(MMSE)
mild cognitive impairment state of cog functioning that is below defined norms; does not meet criteria for dementia; memory complaint by another person; measurable memory impairment via standard assess tests; norm overall thinking and cognitive functioning; ability to perform ADLs
The 3 D's dementia, depression and delirium
dementia irreversible, progressive, mental, cognitive deterioration; loss of memory, orientation, attention, language judgement and reasoning; personality changes, agitation, delusion, hallucinations may result
depression reversible; 20% of older adults; cognitive impairment; cerebral dysfunction; treatment generally includes drug therapy and psychotherapy
delirium reversible confused state usually related to physio cause; acute; fluctuation in mood, cognition; disorentation; hallucinations; often seen among older adults in an unfamiliar setting
four types of dementia alzheimers; vascular; diffuse lewy body disease, frontotemporal
alzheimers disease loss of memoryl agnosia; apraxia
agnosia dont recognize objects and persons
apraxia inability to perform familiar tasts
vascular dementia causes- thromboemboli, ischemia, hemmorrhage to brain abrupt onset; symptoms similar to stroke(CVA)
diffuse lewy body disease auditory/visual hallucinations; fluctuating cognition; parkinsonian motor symptoms appear early in disease; increased sensitivity to antipsychotics(haldol)
frontotemporal dementia slow progression; incontinence early symptom; poor hygiene; repetitive behaviors; lack of social tact; lack of sexual inhibition
elder mistreatment neglect; physical abuse; emotional abuse; financial abuse
restraints device or drug that prohibits pt from moving freely; always prescribed by health care provider; ethical concern
nursing diagnoses for older adult confusion, fatigue, immobility, self-care deficit; powerlessness; risk for falls
nursing outcomes/goals adequate nutrition; provide safe care-prevent falls, safe med admin; mental/behavioral health; encourage independence, self care
the older population is growing and diversifying the older pop is very ethnically diverse and is growing; by 2030, 25% of older pop will be minorities
localized pain pain confined to the site of origin
projected pain pain along a specific nerve or nerves
radiating pain diffuse pain around the site of origin that is not well localized
referred pain pain received in an area distant from the site of painful stimuli
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