QUESTIONS AND ANSWERS GRADED A+
Vital Signs - ✔✔Drop 20mmHg Systolic or 10mmHg Diastolic - faintness, blurred vision,
dizziness, syncope
✔✔HR - Orthostatic Vital Signs - ✔✔Variations HR helpful determining casue orthostatic
Hypotension
Tachycardic - dehydration / volume depletion
✔✔Medical Record Reviews - ✔✔Follow guidelines in documentation - legal document -
evidence of events occurred or treatment given
✔✔Quality Documentation (5 important characteristics) - ✔✔1. Factual
2. Accurate
3. Complete
4. Current
5. Organized
✔✔Nonverbal Communication (5 characteristics) - ✔✔1. Personal Appearance
2. Posture & Gait
3. Facial Expression
4. Eye Contact
5. Gestures
✔✔NPO - ✔✔Nothing By Mouth
6-8 hours before surgery
✔✔Universal Protocol (Guidelines) - ✔✔1. Created to prevent wrong site, wrong
procedure, wrong person surgeries
2. The Joint Commission (TJC)
✔✔Universal Protocol (Components) - ✔✔Involve Patient
Items needed for procedure
Verify correct procedure, correct patient , correct site
✔✔Time Out - ✔✔@ Start of Procedure
"Huddle"
✔✔Anesthesia Risks - ✔✔Respiratory & Circulatory
Aspiration if NPO not followed
✔✔Anesthesia - Careful Steps - ✔✔Stay at Pt side
never leave unattended sedated PT
, Noise levels keep minimum
Hearing last sense lost
Noises increase anxiety
✔✔Skin Cleansing Prep - ✔✔Shower
Isolated Scrub - antibacterial/antimicrobial
Surgical Scrub Prep - prevent contamination incision
Circular Pattern, scrub moving outward circles
2-3 minutes
✔✔Post Operative - Coughing - ✔✔Coughing Contraindicated after brain, spinal, eye
surgery - increases intracranial pressure
✔✔Diaphragmatic Breathing - ✔✔Also called - pursed lip breathing
30 deep breaths hourly
hands over incision site
✔✔Controlled Coughing - ✔✔Consecutive coughs remove mucus more effectively than
one forceful cough
✔✔Incentive Spirometry (Why and Who?) - ✔✔helps improve function lungs
used for at risk of atelectasis, pneumonia, chronic smokers, older adults, prolonged bed
rest
✔✔Incentive Spirometry (How) - ✔✔Semi Fowler
Fowler
repeat pattern 10 breaths every 1/2 hours
Goal - increased inspired volume at least 100ml each breath
✔✔Leg Exercises (Why?) - ✔✔Prevent risk skin breakdown, pressure ulcers, VTE, DVT
✔✔VTE - ✔✔Venous Thromboembolism
post operative complication
due to immobility
blood clot in vein
✔✔DVT - ✔✔Deep Vein Thrombosis
complication lower extremities
✔✔Immobility (What should you not do and why?) - ✔✔Do NOT rub legs - may disrupt
clot formed and cause embolus (clot travels and lodges in vessel)
✔✔Pneumatic Compression Device (Purpose) - ✔✔Prevent Thrombus formation
Improve Venous Return to heart
Prevent pooling blood in leg veins - causes vein distention and dependent edema