Care Case Study (1)-Perioperative Care
The nurse begins the preoperative assessment by taking vital signs. Which vital sign requires follow up by the nurse?
BP 160/88-it’s elevated (and requires further action by nurse)
Nurse reviews meds taken by pt. Pt states she is taking 2: hydrochlorothiazide (Hydrodiuril), a diuretic, and warfarin (Coumadin), an anticoagulant, every day for more than a year. What nursing action is most important?
Explain the need to withhold warfarin prior to surgery (anticoagulants increase risk for bleeding during surgery and postoperative period, so nurse must explain the need to withhold.
The nurse then reviews pt’s preoperative lab test results drawn earlier in the week? What serum lab value requires follow-up by nurse?
WBC of 14,000/mm^3- normal is 5-10,000/mm^3 increase can indicate onset of infection (C/I to surgery)-notify surgeon of abnormal lab value
Nurse talks with pt about what to expect the day of surgery and during immediate postop period. The nurse provides instructions regarding cough/deep breathing through mouth and exhale forcefully through pursed lips. What action should nurse implement?
demonstrate deep breathing and coughing technique again (Pt demonstrated incorrect technique)
When the nurse begins teaching about benefits of early mobilization following surgery, pt states, “oh, I know if I stayin bed very long I will get bedsores.” How should nurse respond?
Bedsores are one of many problems that can occur from prolonged bedrest-others–thrombus formation, constipation, atelectasis
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Nurse discusses postop pain management with pt and explains use of patient-controlled analgesia pump (PCA). Pt expresses fear that she might accidentally overdose herself, since she will be sleepy after surgery. How should nurse respond?
The pump has a control device that prevents you from taking too much medicine
While discussing postop pain management strategies with pt, nurse observes pt begins to cry. What action should nurse take?
quietly sit with pt-offering presence –caring therapeutic response,
After pt stops crying, she states, “My father was in so much pain before he died. Talking about pain brings back so many memories.” How should nurse respond?
it sounds like you went through a difficult time when your father died
Next week, pt arrives at surgery center 3hrs before scheduled surgery. Which question is most important for nurse to ask pt during admission interview?
“Have you had anything to eat/drink since midnight?” -ensure NPO for prescribed length of time before surgery critical to prevent vomiting/aspiration during surgery
After completing admission interview, the nurse reviews pt’s med record and notes surgical consent form is filled out but is not signed by client. What action should nurse take?
Ask pt if she has received sufficient info to sign consent form-Nurse may witness client’s signature if nurse determines that the client has been sufficiently informed of the necessary info
The nurse observes the word “yes” has been marked on pt’s left hip, and word “no” on her right hip. What action should nurse implement?
Confirm that the left hip is the site of scheduled surgery
Pt is transferred to stretcher and taken to the operating room. Nurse assists pt off stretcher and onto OR table. After gen. anesthesia is induced, the nurse positions pt for surgery. Which Nursing diagnosis has highest priority at this time?
Risk for perioperative-positioning injury–during surgery client may remain in one position for prolonged period. Nurse ensure protect from injury secondary to inappropriate positioning
Once OR team has assembled in room, the circulating nurse calls for a time out. What action should the nurse take during time out?
Review the scheduled procedure, site & client
Surgery is successfully completed w/o complications. Following surgery pt is admitted to PACU. The operative report indicates that pt had a left hip preplacement under gen anesthesia. The intial nursing assessment reveals pt is not responding to verbal stimuli. Vital 97.6F, P 88, R14, BP 130/70. What action should nurse implement first
Position client on side-during immediate post anesthesia, unconscious should be positioned on side to maintain open airway and promote drainage of secretions
While assessing pt, nurse observes surgical dressing on left hip, with no visible drainage. How should the nurse document this finding?
left hip dressing clean, dry, and intact–document is concise but thorough, provide a clear picture of the assessed data
Pt arrives on unit, IV is wide open. Her prescription 0.9% Normal Saline (75mL/hour alternating with ringer’s solution (lactated) at 75mL/hour. An infusion pump not immediately available, so nurse notes that the infusion tubing has a drop factor of 10drops/mL and resets the IV. At what rate should the IV infuse?
While nurse begins assessing pt, another nurse finds infusion pump and prepares a prescribed “now” dose of IV abx. Prescription is 2g cegazolin (Ancef), which arrives from the pharmacy diluted 100mL of normal saline and is to be administered over 30 minutes
The nurse continues the postop assessment. What action should nurse take to assess for atelectasis?
Auscultate client’s breath sounds-condition in which the alveoli collapse. Dull or absent sounds.
Nurse determines pt’s bowel sounds are hypoactive. What action should nurse implement in response to this finding?
Document the assessment finding in the chart-expected
During postop assessment, the nurse observes pt’s surgical site. The left hip dressing has a moderate amount of sanguineous drainage. What action(s) should nurse implement?
-observe linens under hip-nurse should inspect below surgical site for add’l drainage
– mark the amount of drainage on dressing-for later comparison
The nurse observes that the Hemovac drain is full of sanguineous drainage. What action should nurse implement first?
empty the drain and measure the amount of drainage-nurse should first empty the drain and measure, then compress drain to reestablish suction. Documentation of the findings and notification of the surgeon can then be done
Nurse notifies surgeon of wound drainage-what lab data is important for nurse to report to surgeon
Hgb & Hct (nurse reports the amount of drainage–> check for excessive blood loss. Surgeon needs to know info r/t blood volume)
Based on lab data, HCP prescribes 2U of packed RBC as soon as possible. Once 1st unit of packed RBC ready, the nurse obtains from blood bank. When the nurse enters pt’s room to begin the transfusion, the UAP is giving pt a partial bath. What action should nurse take
Hang transfusion of packed cells while UAP continues to complete the client’s personal care (transfuse of blood is higher priority-remainder of care can be delayed)
Pt is currently receiving Lactated Ringer’s solution IV at 75mL/hr. In transfusing 250mL unit of packed RBC, what action should nurse implement?
Stop IV solution and transfuse packed cells at 125 mL/hr via tubing connected to a bag of saline solution–packed RBC compatible with normal saline. The blood should be connected using special y-tubing and admin w/in 1 1/2 -2 hrs, no longer than 4 hours
Nurse assisting pt to bedside commode on the second postop day. Pt states “I’ve never had to depend on anyone before. I like to take care of myself. I feel helpless.” In response, nurse plans care for pt based on identification of which nursing diagnosis?
Situational low self-esteem
Nurse teaches pt safe transfer techniques and consults with the physical therapist to begin ambulation activities as soon as possible. What is the rationale for the inclusion of these actions in pt plan of care?
Increased mobility will promote an improved sense of control
After pt ambulates with PT, nurse prepares to change surgical dressing. While obtaining supplies the nurse reviews sterile procedure to be followed. At what step in the procedure should the nurse don sterile gloves?
Before cleansing hip incision.
While cleansing incision, nurse observes that the staples are intact, but a 2cm gap has opened at bottom of the incision. How should the nurse document this finding?
Small area of dehiscence at bottom of incision (unintentional opening in a surgical wound prior to healing)