Medical Surgical Nursing

Describe factors that influence surgical outcomes.
Identify the role of the licensed practical nurse/licensed vocational nurse (LPN/LVN) in each perioperative phase.
Explain the role of the LPN/LVN in obtaining informed patient consent.
Develop a teaching plan to enhance learning for the older preoperative patient.
Identify nursing interventions used for common postoperative patient needs.
Describe how to evaluate effectiveness of nursing interventions.
List signs and symptoms of common postoperative complications.
List the criteria for ambulatory discharge.
Describe the role of the home health care nurse in caring for postoperative patients.

VOCABULARY
Fill in the blank.
1. _____________ are physicians who perform surgical procedures.
2. The three surgical phases are referred to collectively by the term _____________.
3. The _____________ phase begins with the decision to have surgery and ends with transfer of the patient to the operating room.
4. The _____________ phase begins when the patient is transferred to the operating room and ends when the patient is admitted to the perianesthesia care unit (PACU).
5. The _____________ phase begins with the admission of the patient to the PACU and continues until the patient’s recovery is completed.
6. _____________ is the period when an anesthetic is first given until full anesthesia is reached.
7. An _____________ agent is a medication (such as narcotics, muscle relaxants, or antiemetics) used with the primary anesthetic agents.
8. The sudden bursting open of a wound’s edges that may be preceded by an increase in serosanguineous drainage is referred to as ___________.
9. _____________ are physicians who administer anesthesia.
10 _____________ causes a loss of sensation and allows the surgical procedure to be done safely.
11. _____________ occurs from hypoventilation or mucous obstruction that prevents some alveoli from opening and being fully ventilated.
12. _____________ is the removal of necrotic and infected tissue.
13. _____________ is a body temperature that is below normal range.
14. _____________ is the viscera spilling out of the abdomen.
15. A _____________ is an advance practice registered nurse certified to provide anesthetics to surgical patients.

SURGERY URGENCY LEVELS
Match the surgery urgency level to the appropriate definition or example. The level may be used more than once.
1. _____ Surgery needed when any delay jeopardizes the patient’s life or limb
2. _____ Fracture repair
3. _____ Surgery needed within 24 to 30 hours
4. _____ Extremity emboli
5. _____ Surgery planned and scheduled without immediate time constraints
6. _____ Surgery done at request of the patient
7. _____ Hernia repair
8. _____ Rhinoplasty
9. _____ Infected gallbladder
10. _____ Cosmetic surgery 1. Optional
2. Elective
3. Urgent
4. Emergency

NOURISHING THE SURGICAL PATIENT
Find the seven errors and insert the correct information.
Healing requires increased vitamin A for collagen formation, vitamin B12 for blood clotting, and magnesium for tissue growth, skin integrity, and cell-mediated immunity. Carbohydrates are essential for controlling fluid balance and manufacturing antibodies and white blood cells. Hypoalbuminemia, a low urine albumin, impedes the return of interstitial fluid to the venous return system, decreasing the risk of shock. A serum zinc level is a useful measure of protein status.

COMPLICATION PREVENTION
Indicate whether the statement is true or false and correct the false statement.
1. _____ All medications that patients are taking must be reviewed preoperatively.
2. _____ Most anticoagulants, such as warfarin (Coumadin), do not need to be stopped before surgery.
3. _____ Patients with diabetes who take insulin may be told to take half of their normal insulin dose on the day of surgery.
4. _____ One method to prevent wrong site surgery is for the nurse to mark the site before surgery begins.
5. _____ If a patient is on chronic oral steroid therapy, the steroid therapy cannot be abruptly stopped when the patient is nil per os (NPO; nothing by mouth).
6. _____ Blood glucose monitoring for patients who are diabetic is ordered on admission to the surgical unit.
7. _____ Chronic oral steroid therapy should be continued via the parenteral route if the patient is NPO.
8. _____ Circulatory collapse can develop if steroids are not stopped abruptly.
9. _____ Indwelling urinary catheters are not a source of infection for a surgical patient.
10. _____ Intermittent pneumatic compression devices can cause blood clots.

PERIOPERATIVE NURSING DIAGNOSES AND OUTCOMES

Write a patient objective (goal) for each nursing diagnosis.
Preoperative
1. Anxiety or Fear related to potential change in body image, hospitalization, pain, loss of control, and uncertainties surrounding surgery

2. Deficient Knowledge related to lack of previous experience with surgical routines and procedures

Intraoperative
3. Risk for Injury related to perioperative positioning, chemicals, electrical equipment, and effect of being anesthetized

4. Risk for Impaired Skin Integrity related to chemicals, positioning, and immobility

Postoperative
5. Acute Pain related to tissue damage from surgery, muscle spasms, nausea, or vomiting

6. Risk for Infection related to inadequate primary defenses from surgical wound

__________
__________
__________

CRITICAL THINKING
Read the case study and answer the questions.
Mrs. Vell, age 74, is scheduled for a total hip replacement because of osteoarthritis. She is seen in the preadmission testing department 2 weeks before surgery.
1. Why is Mrs. Vell being seen in preadmission testing?

2. What preadmission testing may be done?

3. What teaching should the nurse do in preadmission testing?

4. What are the responsibilities of the admitting nurse to prepare Mrs. Vell for surgery?

5. What is the role of the holding area nurse?

6. What is a role of the licensed practical nurse/licensed vocational nurse in the operating room?

7. What are the two prioritized primary responsibilities of the perianesthesia care nurse?

8. Explain why postoperative care for this patient includes pain control, deep breathing and coughing, leg exercises, activity, and leg abduction.

REVIEW QUESTIONS—CONTENT REVIEW
Choose the best answer unless directed otherwise.

1. Which of the following is a licensed practical nurse/licensed vocational nurse patient care role in the preoperative phase?
1. Obtaining preoperative orders
2. Explaining the surgical procedure
3. Offering emotional support
4. Providing informed consent
2. When the patient’s signature is witnessed by the nurse on the surgical consent, which of the following does the nurse’s signature indicate?
1. The nurse obtained informed consent.
2. The nurse provided informed consent.
3. The nurse answered all surgical procedure questions.
4. The nurse verified that the patient signed the consent.
3. Which of the following is an intraoperative outcome for a patient undergoing an inguinal hernia repair?
1. Verbalizes fears.
2. Maintains skin integrity.
3. Demonstrates leg exercises.
4. Explains deep-breathing exercises.
4. Which of the following is a discharge criterion from the perianesthesia care unit for a patient after surgery?
1. Oxygen saturation is above 90%.
2. Oxygen saturation is below 90%.
3. The patient has voided.
4. Intravenous narcotics have been given less than 30 minutes earlier.
5. Which of the following are discharge criteria from ambulatory surgery that would allow the patient to be discharged following surgery? Select all that apply.
1. Is able to drive self home
2. Has a landline home telephone
3. Understands discharge instructions
4. Has received intravenous narcotics 20 minutes prior
5. Will be released to a responsible adult
6. Plans to rest for 24 hours

REVIEW QUESTIONS—TEST PREPARATION
Choose the best answer unless directed otherwise.
6. The nurse is caring for a patient in the preoperative period who, even after verbalizing concerns and having questions answered, states, “I know I am not going to wake up after surgery.” Which of the following actions should the nurse take?
1. Reassure the patient everything will be all right.
2. Inform the registered nurse.
3. Explain the national surgery death rate.
4. Ask family to comfort the patient.
7. The nurse understands that which of the following is the reason that long-term steroid therapy cannot be abruptly stopped? Select all that apply.
1. Higher steroid levels are needed during stress.
2. Malignant hyperthermia will result.
3. Hypertensive crisis will occur.
4. Respiratory failure will occur.
5. Circulatory collapse may result.
8. The nurse is to provide preoperative teaching for a 74-year-old patient. Which of the following actions should the nurse take to improve learning? Select all that apply.
1. Allow patient increased time to respond.
2. Determine readiness to learn.
3. Present one idea at a time
4. Speak in a high tone.
5. Use blue and green color brochures.
6. Use medical terminology.
9. The nurse is teaching a postoperative patient about complications. Which of the following would the nurse explain might be prevented with early postoperative ambulation? Select all that apply.
1. Increased peristalsis
2. Coughing
3. Pneumonia
4. Evisceration
5. Deep vein thrombosis
6. Paralytic ileus
10. Which of the following actions should the nurse take to maintain patient safety when ambulating a patient for the first time postoperatively?
1. Use one person to assist the patient.
2. Use two people to assist the patient.
3. Encourage the patient to stand quickly.
4. Give narcotic 15 minutes before ambulation.
11. The nurse is caring for a patient with a bowel resection. Which of the following would indicate that the patient’s gastrointestinal tract is resuming normal function?
1. Firm abdomen
2. Excessive thirst
3. Presence of flatus
4. Absent bowel sounds
12. The patient is sitting at the bedside and states, “Oh, my stomach is tearing open.” Which of the following actions is a priority for the nurse to take when dehiscence occurs?
1. Have patient sit upright in a chair.
2. Decrease rate of intravenous fluids.
3. Have patient lie down.
4. Obtain a sterile suture set.
13. The nurse is assisting the patient to use an incentive spirometer. Which of the following actions by the patient indicates that the patient needs further teaching on how to use the spirometer?
1. Taking two normal breaths before use
2. Inhaling deeply to reach target
3. Sitting upright before use
4. Exhaling to reach target
14. After surgery, the nurse notes that the patient’s urine is dark amber and concentrated. Which of the following does the nurse understand may be the reason for this?
1. The sympathetic nervous system saves fluid in response to stress of surgery.
2. The sympathetic nervous system diureses fluid in response to stress of surgery.
3. The parasympathetic nervous system saves fluid in response to stress of surgery.
4. The parasympathetic nervous system diureses fluid in response to stress of surgery.
15. The patient develops a low-grade fever 18 hours postoperatively and has diminished breath sounds. Which of the following actions is most appropriate for the nurse to take to prevent complications? Select all that apply.
1. Administer antibiotics.
2. Encourage coughing and deep breathing.
3. Administer acetaminophen (Tylenol).
4. Decrease fluid intake.
5. Ambulate patient as ordered.
6. Monitor output.
16. The nurse explains how to use an incentive spirometer to a patient who is to have surgery. Mark the area where the incentive spirometer will help prevent atelectasis postoperatively.