NUR 340 Final Exam
Aseptic technique - answer practiced as each surgical item is opened and placed on the
instrument table
-practiced in OR to prevent infection
-implemented through the creation and maintenance of a sterile field
-center of sterile field is the surgical incision
scrubbing method for surgery - answer fingers to elbows
national patient safety goods - answer universal protocol followed to prevent wrong site,
wrong procedure, and wrong surgery
-patient safety checklist
-identify two pt identifiers
-improve staff communication (report test and diagnostic procedure)
- use medications safely
-prevent infection- hand-washing
-use universal protocol to prevent mistakes in surgery( site is marked by surgeon with pt
involvement)
surgical care improvement project - answer focused on improving surgical care by
reducing complications from surgery
-implemented in holding area:
drug administration
patient warming
application of sequential compression
AORN - answersurgical time out
verify correct site surgery
preoperative assessment - answeridentify risk factors and plan care to ensure pt safety
throughout surgical experience
intraoperative assessment - answerensure patient is tolerating surgery and has
uncompromised airway system
-report any changes in vital signs and monitor blood loss + urine output
-position pts correctly and ensure right to privacy
postoperative assesment - answer-Airway
-Breathing
,-Circulation
Hearing first sense to return to unconscious pt
informed consent - answer-adequate disclosure of diagnosis, nature and purpose of
treatment, risks & benefits, probability of successful outcome availability, prognosis if
treatment not instituted
voluntary
supine position - answermost commonly used during surgery easy access to heart,
abdomen, breat
lithotomy position - answerpelvic organ surgery
prone position - answereasy for back surgery
general anesthesia causes what to dilate - answerperipheral vessels
preventing hypothermia - answer-may apply thermal warming blanket to patient to
maintain body temperature
can cause:
impaired wound healing
adverse cardiac events
altered drug metabolism
coagulopathies
monitored anesthesia care - answerused for diagnostic or therapeutic procedures
performed in or outside of the OR
moderate sedation - answerused for procedures performed outside of the OR
general anesthesia - answertechnique of choice for patients who are having surgical
procedures that are of significant duration, require skeletal muscle relaxation, require
uncomfortable operative positions because of location of the incision site, require
control of ventilation
IV or inhalation administration or balanced
dissociative anesthesia - answerinterrupts associative brain pathways while blocking
sensory pathways- pt may appear catatonic, amnesic and experiences profound
analgesia that lasts into postoperative period
-ketamine common example
,ketamine - answerused in asthmatic pt undergoing surgery because it promotes
bronchodilation and in trauma pts requiring surgery
because it increases HR and helps maintain cardiac output
-CAN CAUSE HALLUCINATIONS
local anesthesia - answer-topical
-ophthalmic
-nebulized
-injectable
interrupt nerve impulses by altering flow of sodium into nerve cells through cell
membranes
regional anesthesia - answerex lidocaine
applied to specific area of body does NOT require sedation or loss of consciousness
ex spinal/epidural anesthesia
spinal anesthesia - answerinvolves injection of a local anesthetic into cerebrospinal fluid
found in the subarachnoid space usually below level of L2
epidural anesthesia - answerinvolves injection of a local anesthetic into the epidural
space via the thoracic or lumbar approach
most reliable indicator of pain - answerself report
not always possible PACU - answerlook for restlessness, changes in vitals diaphoresis
identify location of pain
nursing diagnosis for patient experiencing pain - answeracute pain related to
inflammation/injury in surgical area
IV opioids - answermost rapid relief
sustained relief - answerPCA, epidural catheters, regional anesthetic blockade
first 48 hours or longer for pain - answeropioids
opioids/NSAID may be used to provide lowest dose of medication and decrease side
effects
regeneration - answerreplacement of lost cell and tissues with cells of the same type
, repair - answerlost cells being replaced by connective tissue
repair is more common
normal healing - answer-drainage depends on type of surgery
-initially sanguineous-->sero sanguineous--> serous
-slightly crusted along incision line- pink color, slight swelling, puffiness
-keep assessing site periodically
-need diet high in protein, carbs, vitamins, moderate fat intake
-do not touch area
-give antibiotics prophylactically
primary intention - answerwound margins are neatly approx
initial phase: 3-5 days: edges of incision are aligned and sutured in place; the incision
fills with blood, blood clot forms, and platelets release growth factors to begin in healing
process; acute inflammatory reaction occurs
granulation 5 days to 4 weeks: components include proliferating fibroblasts, proliferating
capillary sprouts, various types WBCs, exudate, and loos, semifluid, ground substance
maturation phase/scar contraction 7 days to several months: collagen fibers are further
organized and remodeling process occurs; active movement of the mypfibroblasts
causes contraciton of healing area, helping to close the defect and bring the skin edges
closer together
fibroblasts - answerimmature connective tissue cells that migrate into the healing site
and secrete collagen (begin to "knit wound together" in time the collagen is organized
and restructured to strengthen the healing site)
secondary intention - answerwounds may have irregular edges that cannot be
approximated
-inflammatory reaction may be greater than in primary healing; this results in more
debris, cells, and exudate
-debris may have to be cleaned away before healing can occur
-wound remains open; granulation takes place from the edges inward and from the
bottom upward until the defect is filled
tertiary intention - answerhealing occurs with delayed suturing of a wound in which two
layers of granulation tissue are sutured together
-contaminated wound is left open and sutured closed after the infection is controlled
-usually results in a larger and deeper scar
dehiscence - answerseparation and disruption of previously joined wound edges
-usually occurs when a primary healing site bursts open
Aseptic technique - answer practiced as each surgical item is opened and placed on the
instrument table
-practiced in OR to prevent infection
-implemented through the creation and maintenance of a sterile field
-center of sterile field is the surgical incision
scrubbing method for surgery - answer fingers to elbows
national patient safety goods - answer universal protocol followed to prevent wrong site,
wrong procedure, and wrong surgery
-patient safety checklist
-identify two pt identifiers
-improve staff communication (report test and diagnostic procedure)
- use medications safely
-prevent infection- hand-washing
-use universal protocol to prevent mistakes in surgery( site is marked by surgeon with pt
involvement)
surgical care improvement project - answer focused on improving surgical care by
reducing complications from surgery
-implemented in holding area:
drug administration
patient warming
application of sequential compression
AORN - answersurgical time out
verify correct site surgery
preoperative assessment - answeridentify risk factors and plan care to ensure pt safety
throughout surgical experience
intraoperative assessment - answerensure patient is tolerating surgery and has
uncompromised airway system
-report any changes in vital signs and monitor blood loss + urine output
-position pts correctly and ensure right to privacy
postoperative assesment - answer-Airway
-Breathing
,-Circulation
Hearing first sense to return to unconscious pt
informed consent - answer-adequate disclosure of diagnosis, nature and purpose of
treatment, risks & benefits, probability of successful outcome availability, prognosis if
treatment not instituted
voluntary
supine position - answermost commonly used during surgery easy access to heart,
abdomen, breat
lithotomy position - answerpelvic organ surgery
prone position - answereasy for back surgery
general anesthesia causes what to dilate - answerperipheral vessels
preventing hypothermia - answer-may apply thermal warming blanket to patient to
maintain body temperature
can cause:
impaired wound healing
adverse cardiac events
altered drug metabolism
coagulopathies
monitored anesthesia care - answerused for diagnostic or therapeutic procedures
performed in or outside of the OR
moderate sedation - answerused for procedures performed outside of the OR
general anesthesia - answertechnique of choice for patients who are having surgical
procedures that are of significant duration, require skeletal muscle relaxation, require
uncomfortable operative positions because of location of the incision site, require
control of ventilation
IV or inhalation administration or balanced
dissociative anesthesia - answerinterrupts associative brain pathways while blocking
sensory pathways- pt may appear catatonic, amnesic and experiences profound
analgesia that lasts into postoperative period
-ketamine common example
,ketamine - answerused in asthmatic pt undergoing surgery because it promotes
bronchodilation and in trauma pts requiring surgery
because it increases HR and helps maintain cardiac output
-CAN CAUSE HALLUCINATIONS
local anesthesia - answer-topical
-ophthalmic
-nebulized
-injectable
interrupt nerve impulses by altering flow of sodium into nerve cells through cell
membranes
regional anesthesia - answerex lidocaine
applied to specific area of body does NOT require sedation or loss of consciousness
ex spinal/epidural anesthesia
spinal anesthesia - answerinvolves injection of a local anesthetic into cerebrospinal fluid
found in the subarachnoid space usually below level of L2
epidural anesthesia - answerinvolves injection of a local anesthetic into the epidural
space via the thoracic or lumbar approach
most reliable indicator of pain - answerself report
not always possible PACU - answerlook for restlessness, changes in vitals diaphoresis
identify location of pain
nursing diagnosis for patient experiencing pain - answeracute pain related to
inflammation/injury in surgical area
IV opioids - answermost rapid relief
sustained relief - answerPCA, epidural catheters, regional anesthetic blockade
first 48 hours or longer for pain - answeropioids
opioids/NSAID may be used to provide lowest dose of medication and decrease side
effects
regeneration - answerreplacement of lost cell and tissues with cells of the same type
, repair - answerlost cells being replaced by connective tissue
repair is more common
normal healing - answer-drainage depends on type of surgery
-initially sanguineous-->sero sanguineous--> serous
-slightly crusted along incision line- pink color, slight swelling, puffiness
-keep assessing site periodically
-need diet high in protein, carbs, vitamins, moderate fat intake
-do not touch area
-give antibiotics prophylactically
primary intention - answerwound margins are neatly approx
initial phase: 3-5 days: edges of incision are aligned and sutured in place; the incision
fills with blood, blood clot forms, and platelets release growth factors to begin in healing
process; acute inflammatory reaction occurs
granulation 5 days to 4 weeks: components include proliferating fibroblasts, proliferating
capillary sprouts, various types WBCs, exudate, and loos, semifluid, ground substance
maturation phase/scar contraction 7 days to several months: collagen fibers are further
organized and remodeling process occurs; active movement of the mypfibroblasts
causes contraciton of healing area, helping to close the defect and bring the skin edges
closer together
fibroblasts - answerimmature connective tissue cells that migrate into the healing site
and secrete collagen (begin to "knit wound together" in time the collagen is organized
and restructured to strengthen the healing site)
secondary intention - answerwounds may have irregular edges that cannot be
approximated
-inflammatory reaction may be greater than in primary healing; this results in more
debris, cells, and exudate
-debris may have to be cleaned away before healing can occur
-wound remains open; granulation takes place from the edges inward and from the
bottom upward until the defect is filled
tertiary intention - answerhealing occurs with delayed suturing of a wound in which two
layers of granulation tissue are sutured together
-contaminated wound is left open and sutured closed after the infection is controlled
-usually results in a larger and deeper scar
dehiscence - answerseparation and disruption of previously joined wound edges
-usually occurs when a primary healing site bursts open
