COMPREHENSIVE EXAM REVIEW
1. Preoperative Care
a. Surgical Risk Factors, Current Medications, Data to Obtain in Health
History, & Physical/Psychosocial Assessment
i. Health History: Past surgical history and reactions, medications the
patient is taking. RED FLAG medications include: Anticoagulants:
Coumadin, Warfarin, Plavix, Aspirin, Heparin, Herbal Medications
that can thin your blood, and corticosteroids because they delay
wound healing.
ii. Psychosocial Assessment: You want your patient to feel as good as possible. It is
a fact supported by evidence that patients that enter surgery with poorer
attitudes experience poorer outcomes.
iii. Cultural/Spiritual Assessment: “Is there anything about your cultural or spiritual
background that I should know that could affect your surgery and care?”
iv. Physical Assessment: This will give us a baseline of information with
which to compare during and after surgery.
v. Labs: Hgb & Hct (H & H), platelets, PTT, aPTT, PT/INR, Blood Type & Cross, BUN,
and CR.
vi. Diagnostic Tests
b. Pre-operative Care
i. What medications are commonly used pre-op and why?
1. To reduce anxiety, pain, and the amount of anesthesia needed, i.e.
sedatives: atarax/vistaril (hydroxyzine), hypnotics: Ativan
(lorazepam), anxiolytics: versed(midazolam), analgesics:
morphine, Demerol (merperidine), fentanyl, dilaudid
(hydromorphone).
2. To decrease oral and gastric secretions, anticholinergics: atropine
(urecholine) and scopolamine.
3. To reduce nausea & vomiting: Phenergan (promethazine),
Zofran (Ondansetron), Reglan (Metoclopramide).
ii. What sort of precautions take precedence after giving pre-op medications?
1. Patient safety
2. Monitor status, i.e. vitals, affect
c. Preoperative Teaching
i. When should you do client teaching about the surgery and why?
1. BEFORE the operation. After surgery, patients are in too much
pain to care or be able to retain and understand.
ii. Why is client teaching important?
1. It helps the patient understand what to expect after surgery.
a. Be sure to explain equipment, tubes, drains, vascular
access, and the frequent monitoring for vital signs in
great detail.
2. It may help to comfort and prepare patients.
3. It reduces anxiety.
d. Informed Consent
i. When can the patient withdraw consent for surgery?
, 1. AT ANY TIME
ii. When should the informed consent form be signed? Who informs the
patient about the procedure, including its risks and benefits?
1. Before the surgery. The surgeon.
iii. What are the RN duties regarding informed consent?
1. Clarify as needed
2. Verify that the consent form has been signed and is on the chart
a. Witness the signature
e. Pre-op Checklist
i. A complete list of everything that must be done prior to surgery. Every
facility has their own list.
f. Marking of Surgical Site
i. Physician may write on the limb or spot that is to be removed to decrease
risk of error.
2. Intraoperative Care
a. Maintain safety
i. Different Types of Anesthesia & Possible Complications
1. General
Acts on CNS, produces loss of sensation, reflexes, and
consciousness.
a. Breathing, circulation, and temperature are not regulated
psychologically. The anesthesia provider controls this with
a ventilator.
b. Must be carefully monitored during surgery.
2. Regional
a. Blocks conduction of nerve impulses to a specific area.
b. Patient experiences a loss of sensation and motor
function to that area.
c. Examples: Spinal, epidural
3. Local
a. Used for minor procedures
b. Briefly disrupts sensory nerve impulse transmission
from specific boy area/region.
c. Patient remains conscious, able to follow instructions.
4. Procedural (Conscious) Sedation
a. Local or regional anesthesia plus IV sedation
b. Things to monitor:
i. Blood pressure
ii. O2 sat
iii. Heart rate and rhythm
5. What are some possible complications from local and
regional anesthesia?
a. Anaphylaxis
b. Incorrect delivery technique
, c. Systemic Absorption
d. Overdose
e. Local Complications
6. What are some possible complications from general anesthesia?
a. Overdose
b. Unrecognized hypoventilation
c. Problems with specific anesthetic agents
d. Intubation problems
e. Malignant Hyperthermia
b. Monitor for complications
i. Infection
ii. Fluid volume deficit or excess
iii. Injury r/t positioning
iv. Hypothermia
c. Malignant Hyperthermia.
i. It is an inherited disorder.
ii. Gathering past medical history and family history regarding this reaction
is vital pre-op.
iii. Body temp, muscle metabolism, and heat production increase rapidly,
progressively, and uncontrollably in response to stress and some anesthesia
meds.
iv. Symptoms: Tachycardia, tachypnea, fever, diaphoresis, muscle rigidity,
cyanosis, mottled skin, decreased urine output, hypotension, irregular
heart rate, and cardiac arrest.
v. Risk Factors
1. Bulky strong muscles
2. History of muscle cramps, muscle weakness and unexpected
temp elevation
3. Unexplained death of a family member accompanied by a febrile
response after anesthesia.
d. Provide assistance to the surgeon.
i. Scrub nurse: Does not have to be an LPN or RN, can be a tech. Sterile,
assists the team, hands instruments, counts sponges and needles.
ii. Circulating Nurse: MUST be a nurse. Not sterile, moves around. Verifies
patient identity, all pre-op orders have been done, consent is on the chart
and signed. Opens sterile equipment and supplies, documentation,
adjusts lights, and coordinates other departments and personnel,
including reporting off to the post-op nurse with the surgeon.
e. Nurses’ responsibility during surgery.
i. Setting up surgical field
ii. Pouring fluids
1. Do not cross the field.
2. NO SPLASHING.
iii. Specimen collection
3. Postoperative Care
a. What is the most important priority for the nurse in the immediate postop period?
, i. Close observation and monitoring of patient during emerging from
anesthesia. Initial and ongoing assessment occurs until patient is
transferred.
1. Respiratory Assessment
a. Use your ABCs. Airway, Breathing, Circulation. A Patent
airway is the number one most important priority. Patent
airway ensures adequate gas exchange.
b. Check o2 sat, should be between 92-100. If it goes below, apply
oxygen.
c. Monitor rate, pattern, and depth of breathing.
d. Listen to breath sounds.
e. Monitor for use of accessory muscles.
f. Snoring, stridor and other adventitious lung sounds can
alert you that something isn’t right.
2. Cardiovascular Assessment
a. Monitor vital sins every 15 minutes.
b. Listen to heart sounds.
c. Cardiac monitoring requires interpreting from the nurse.
d. Peripheral vascular assessment is done to check for
tissue perfusion and adequate gas exchange. Monitor
for VTE.
e. If you suspect a DVT, check:
i. Peripheral pulses
ii. Color and temp of extremities
iii. Sensation in extremities
iv. Capillary refill
3. Neurologic Assessment
a. Cerebral Functioning:
i. Determining the patient’s level of consciousness.
Are they restless, lethargic, irritated, and oriented to
person, place, and time?
ii. Where do they fall on the Glasgow Come scale? 15 is
best, 7 is comatose.
iii. Motor and sensory assessment, can they move
each extremity?
4. Urinary Assessment
a. Check for urinary retention. Less than 30ml/hour is too
little and can indicate hypovolemia or another renal
problem. Anesthesia may delay control of urination, so it’s
important to palpate bladder, watch output, or use a bladder
scanner to check for the amount of residual urine. You may
need to straight cath.
5. GI Assessment
a. Postoperative nausea/vomiting common and managed
with an antiemetic.
b. Peristalsis may be delayed up to 24 hours.
c. Monitor for bowel sounds.
d. The best indicator of bowel activity is the passing of
flatus or stool.
6. Skin Assessment
1. Preoperative Care
a. Surgical Risk Factors, Current Medications, Data to Obtain in Health
History, & Physical/Psychosocial Assessment
i. Health History: Past surgical history and reactions, medications the
patient is taking. RED FLAG medications include: Anticoagulants:
Coumadin, Warfarin, Plavix, Aspirin, Heparin, Herbal Medications
that can thin your blood, and corticosteroids because they delay
wound healing.
ii. Psychosocial Assessment: You want your patient to feel as good as possible. It is
a fact supported by evidence that patients that enter surgery with poorer
attitudes experience poorer outcomes.
iii. Cultural/Spiritual Assessment: “Is there anything about your cultural or spiritual
background that I should know that could affect your surgery and care?”
iv. Physical Assessment: This will give us a baseline of information with
which to compare during and after surgery.
v. Labs: Hgb & Hct (H & H), platelets, PTT, aPTT, PT/INR, Blood Type & Cross, BUN,
and CR.
vi. Diagnostic Tests
b. Pre-operative Care
i. What medications are commonly used pre-op and why?
1. To reduce anxiety, pain, and the amount of anesthesia needed, i.e.
sedatives: atarax/vistaril (hydroxyzine), hypnotics: Ativan
(lorazepam), anxiolytics: versed(midazolam), analgesics:
morphine, Demerol (merperidine), fentanyl, dilaudid
(hydromorphone).
2. To decrease oral and gastric secretions, anticholinergics: atropine
(urecholine) and scopolamine.
3. To reduce nausea & vomiting: Phenergan (promethazine),
Zofran (Ondansetron), Reglan (Metoclopramide).
ii. What sort of precautions take precedence after giving pre-op medications?
1. Patient safety
2. Monitor status, i.e. vitals, affect
c. Preoperative Teaching
i. When should you do client teaching about the surgery and why?
1. BEFORE the operation. After surgery, patients are in too much
pain to care or be able to retain and understand.
ii. Why is client teaching important?
1. It helps the patient understand what to expect after surgery.
a. Be sure to explain equipment, tubes, drains, vascular
access, and the frequent monitoring for vital signs in
great detail.
2. It may help to comfort and prepare patients.
3. It reduces anxiety.
d. Informed Consent
i. When can the patient withdraw consent for surgery?
, 1. AT ANY TIME
ii. When should the informed consent form be signed? Who informs the
patient about the procedure, including its risks and benefits?
1. Before the surgery. The surgeon.
iii. What are the RN duties regarding informed consent?
1. Clarify as needed
2. Verify that the consent form has been signed and is on the chart
a. Witness the signature
e. Pre-op Checklist
i. A complete list of everything that must be done prior to surgery. Every
facility has their own list.
f. Marking of Surgical Site
i. Physician may write on the limb or spot that is to be removed to decrease
risk of error.
2. Intraoperative Care
a. Maintain safety
i. Different Types of Anesthesia & Possible Complications
1. General
Acts on CNS, produces loss of sensation, reflexes, and
consciousness.
a. Breathing, circulation, and temperature are not regulated
psychologically. The anesthesia provider controls this with
a ventilator.
b. Must be carefully monitored during surgery.
2. Regional
a. Blocks conduction of nerve impulses to a specific area.
b. Patient experiences a loss of sensation and motor
function to that area.
c. Examples: Spinal, epidural
3. Local
a. Used for minor procedures
b. Briefly disrupts sensory nerve impulse transmission
from specific boy area/region.
c. Patient remains conscious, able to follow instructions.
4. Procedural (Conscious) Sedation
a. Local or regional anesthesia plus IV sedation
b. Things to monitor:
i. Blood pressure
ii. O2 sat
iii. Heart rate and rhythm
5. What are some possible complications from local and
regional anesthesia?
a. Anaphylaxis
b. Incorrect delivery technique
, c. Systemic Absorption
d. Overdose
e. Local Complications
6. What are some possible complications from general anesthesia?
a. Overdose
b. Unrecognized hypoventilation
c. Problems with specific anesthetic agents
d. Intubation problems
e. Malignant Hyperthermia
b. Monitor for complications
i. Infection
ii. Fluid volume deficit or excess
iii. Injury r/t positioning
iv. Hypothermia
c. Malignant Hyperthermia.
i. It is an inherited disorder.
ii. Gathering past medical history and family history regarding this reaction
is vital pre-op.
iii. Body temp, muscle metabolism, and heat production increase rapidly,
progressively, and uncontrollably in response to stress and some anesthesia
meds.
iv. Symptoms: Tachycardia, tachypnea, fever, diaphoresis, muscle rigidity,
cyanosis, mottled skin, decreased urine output, hypotension, irregular
heart rate, and cardiac arrest.
v. Risk Factors
1. Bulky strong muscles
2. History of muscle cramps, muscle weakness and unexpected
temp elevation
3. Unexplained death of a family member accompanied by a febrile
response after anesthesia.
d. Provide assistance to the surgeon.
i. Scrub nurse: Does not have to be an LPN or RN, can be a tech. Sterile,
assists the team, hands instruments, counts sponges and needles.
ii. Circulating Nurse: MUST be a nurse. Not sterile, moves around. Verifies
patient identity, all pre-op orders have been done, consent is on the chart
and signed. Opens sterile equipment and supplies, documentation,
adjusts lights, and coordinates other departments and personnel,
including reporting off to the post-op nurse with the surgeon.
e. Nurses’ responsibility during surgery.
i. Setting up surgical field
ii. Pouring fluids
1. Do not cross the field.
2. NO SPLASHING.
iii. Specimen collection
3. Postoperative Care
a. What is the most important priority for the nurse in the immediate postop period?
, i. Close observation and monitoring of patient during emerging from
anesthesia. Initial and ongoing assessment occurs until patient is
transferred.
1. Respiratory Assessment
a. Use your ABCs. Airway, Breathing, Circulation. A Patent
airway is the number one most important priority. Patent
airway ensures adequate gas exchange.
b. Check o2 sat, should be between 92-100. If it goes below, apply
oxygen.
c. Monitor rate, pattern, and depth of breathing.
d. Listen to breath sounds.
e. Monitor for use of accessory muscles.
f. Snoring, stridor and other adventitious lung sounds can
alert you that something isn’t right.
2. Cardiovascular Assessment
a. Monitor vital sins every 15 minutes.
b. Listen to heart sounds.
c. Cardiac monitoring requires interpreting from the nurse.
d. Peripheral vascular assessment is done to check for
tissue perfusion and adequate gas exchange. Monitor
for VTE.
e. If you suspect a DVT, check:
i. Peripheral pulses
ii. Color and temp of extremities
iii. Sensation in extremities
iv. Capillary refill
3. Neurologic Assessment
a. Cerebral Functioning:
i. Determining the patient’s level of consciousness.
Are they restless, lethargic, irritated, and oriented to
person, place, and time?
ii. Where do they fall on the Glasgow Come scale? 15 is
best, 7 is comatose.
iii. Motor and sensory assessment, can they move
each extremity?
4. Urinary Assessment
a. Check for urinary retention. Less than 30ml/hour is too
little and can indicate hypovolemia or another renal
problem. Anesthesia may delay control of urination, so it’s
important to palpate bladder, watch output, or use a bladder
scanner to check for the amount of residual urine. You may
need to straight cath.
5. GI Assessment
a. Postoperative nausea/vomiting common and managed
with an antiemetic.
b. Peristalsis may be delayed up to 24 hours.
c. Monitor for bowel sounds.
d. The best indicator of bowel activity is the passing of
flatus or stool.
6. Skin Assessment
