Safety Anila Simon PhD-c, RN, CVRN, CMSRN AppleRN Classes

Safety

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Typewritten text

Anila Simon PhD-c, RN, CVRN, CMSRN AppleRN Classes

Environmental Safety- Fire safety

• Turn off oxygen and appliances in vicinity of fire• If fire occurs and client is on life support, maintain

respiratory status manually with Ambu bag until client ismoved

– Electrical safety• Use three-pronged electrical cords• Any electrical equipment brought in by client or family

must be inspected prior to use• Check all electrical cords and outlets for exposed, frayed,

damaged wires• If client receives electrical shock, turn off electricity

before touching client

- Fire safety• Turn off oxygen and appliances in vicinity of fire• If fire occurs and client is on life support, maintain


















Environmental Safety (continued)

– Radiation safety• Reduce exposure by limiting time spent near source,

increase distance as much as possible, use shieldingdevice

• Never touch dislodged radiation implants– Disposal of infectious wastes

• Handle all infectious materials as hazard• Dispose of all sharps immediately after use in closed,

puncture-resistant, approved disposal container– Physiological changes in older client—increase risk of

accidents






accidents






accidents






accidents

Measures to prevent falls• Assess client’s risk for falling• If client is at risk

– Move to room closer to nurses’ station– Alert all personnel of fall risk– Orient client to surroundings– Instruct client to ask for assistance when getting up– Explain call bell system and use bed and chair

alarms as necessary– Keep bed in lowest position– Keep side rails up if required– Keep personal belongings within reach– Provide adequate lighting

• Assess client’s risk for falling• If client is at risk









Restraints

• Must have physician’s prescription withspecifics about type of restraint, time frame foruse; must be renewed following agency policy

• Should not interfere with any treatments oraffect client’s health care

• Assess skin integrity and neurovascular statusevery 30 minutes; remove restraints at leastevery 2 hours










Poisons• Accidental poisoning common in toddlers, preschoolers,

young school-age children, so they must be protected• Older adults with diminished eyesight, impaired

memory may be at risk for accidental ingestion ofpoison

• Keep Poison Control Center phone number on phone orin view of phone

• If poisoning occurs,– Remove excess immediately,– identify type and amount if possible,– call Poison Control,– induce vomiting only if instructed by Poison Control,– go to emergency room if instructed by Poison Control

• Accidental poisoning common in toddlers, preschoolers,young school-age children, so they must be protected

• Older adults with diminished eyesight, impairedmemory may be at risk for accidental ingestion ofpoison











• A nurse is caring for a newly admitted clientwho has a documented history of falls. Whichof the following is the priority action by thenurse?

• A. Complete a fall-risk assessment.• B. Educate the client and family on fall risks.• C. Complete a physical assessment.• D. Survey the client’s belongings.

• A nurse is caring for a newly admitted clientwho has a documented history of falls. Whichof the following is the priority action by thenurse?

• A. Complete a fall-risk assessment.• B. Educate the client and family on fall risks.• C. Complete a physical assessment.• D. Survey the client’s belongings.

• A. CORRECT: The greatest risk to this client is injury due to a fall.Therefore, the priority action is to determine the client’s fall risk.This will guide the nurse in implementing appropriate safetymeasures.

• B. INCORRECT: It is important for family members to be aware ofthe client’s risk for falls. Providing instruction to the client andfamily is an appropriate nursing action, but this is not the priorityaction.

• C. INCORRECT: Completing a physical assessment will help toidentify further risk for injury and provide baseline physical data,but this is not the priority action.

• D. INCORRECT: Surveying the client’s belongings (glasses,medications, hearing aids, canes, walkers) may provide clues topotential fall risks. However, this is not the priority action.

• A. CORRECT: The greatest risk to this client is injury due to a fall.Therefore, the priority action is to determine the client’s fall risk.This will guide the nurse in implementing appropriate safetymeasures.

• B. INCORRECT: It is important for family members to be aware ofthe client’s risk for falls. Providing instruction to the client andfamily is an appropriate nursing action, but this is not the priorityaction.

• C. INCORRECT: Completing a physical assessment will help toidentify further risk for injury and provide baseline physical data,but this is not the priority action.

• D. INCORRECT: Surveying the client’s belongings (glasses,medications, hearing aids, canes, walkers) may provide clues topotential fall risks. However, this is not the priority action.

• A charge nurse is designating room assignments for clientswho will be admitted to the unit. Based on the nurse’sknowledge of fall prevention, which of the following clientsshould be assigned to the room closest to the nurses’station?

• A. A 43-year-old client who is postoperative following alaparoscopic cholecystectomy

• B. A 61-year-old client being admitted for telemetry to ruleout a myocardial infarction

• C. A 50-year-old client who is postoperative following anopen reduction internal fixation of the ankle

• D. A 79-year-old client who is postoperative following abelow-the-knee amputation

• A charge nurse is designating room assignments for clientswho will be admitted to the unit. Based on the nurse’sknowledge of fall prevention, which of the following clientsshould be assigned to the room closest to the nurses’station?

• A. A 43-year-old client who is postoperative following alaparoscopic cholecystectomy

• B. A 61-year-old client being admitted for telemetry to ruleout a myocardial infarction

• C. A 50-year-old client who is postoperative following anopen reduction internal fixation of the ankle

• D. A 79-year-old client who is postoperative following abelow-the-knee amputation

• A. INCORRECT: Although this client just had surgery, risk factors forfalls are low based on the client’s age and type of surgery.

• B. INCORRECT: Although this client is on telemetry, this client doesnot display as many risk factors as another client who is to beadmitted.

• C. INCORRECT: Although this client just had surgery, this client doesnot display as many risk factors as another client who is to beadmitted.

• D. CORRECT: This client should be assigned to a room near thenurses’ station due to risk factors that include client’s age, mobility,and balance issues related to the surgery, and potential side effects,such as drowsiness, as a result of analgesic medication.

• A. INCORRECT: Although this client just had surgery, risk factors forfalls are low based on the client’s age and type of surgery.

• B. INCORRECT: Although this client is on telemetry, this client doesnot display as many risk factors as another client who is to beadmitted.

• C. INCORRECT: Although this client just had surgery, this client doesnot display as many risk factors as another client who is to beadmitted.

• D. CORRECT: This client should be assigned to a room near thenurses’ station due to risk factors that include client’s age, mobility,and balance issues related to the surgery, and potential side effects,such as drowsiness, as a result of analgesic medication.

Positions

Anila SimonApple RN Coaching

Learn Nursing International

Ergonomic principles

• Arrange for adequate assistance and usemechanical aids if assistance is not available

• Flex knees, keep feet wide apart, avoid twisting,use arms and legs (not the back)

• Position self close to client or object to be moved• Tighten abdominal and gluteal muscles in

preparation for move• Encourage client to assist in move as much as

possible





possible





possible





possible

• Hoyer lift• https://www.youtube.com/watch?v=JdvQp1O

KO0k

Positions• Burns of face and head: Elevated head of bed (HOB)• Mastectomy: Semi-Fowler’s position, with affected arm

elevated on pillow• Thyroidectomy: Semi-Fowler’s position• Liver biopsy: Supine, with right side of abdomen exposed during

procedure, right arm raised and extended over left shoulderbehind head; right side-lying position after procedure

• Nasogastric tube: Semi-Fowler’s position during irrigations andtube feedings

• Sengstaken-Blakemore and Minnesota tubes: HOB elevated toenhance lung expansion and reduce portal blood flow

• Chronic obstructive pulmonary disease: Sitting position, leaningforward, with arms over several pillows or overbed table

• Burns of face and head: Elevated head of bed (HOB)• Mastectomy: Semi-Fowler’s position, with affected arm


















Mastectomy:

Liver biopsy

• Laryngectomy: Semi-Fowler’s or Fowler’s position• Bronchoscopy: Semi-Fowler’s position• Thoracentesis: Sitting on edge bed, leaning over bedside

table, feet supported on stool or lying in bed on unaffectedside in Fowler’s position

• Amputation of lower extremity– First 24 hours, elevate foot of bed and support stump with

pillows, but not elevated• Cardiac catheterization

– Maintain bed rest postprocedure for 3 to 4 hours– Keep affected extremity straight with HOB elevated no higher

than 30 degrees• Congestive heart failure

– Client upright, with legs dangling over side of bed to decreasevenous return and lung congestion

• Peripheral arterial disease– Legs not elevated above level of heart

























Postural drainage: Lung segment being drained shouldbe in uppermost position

Thoracentesis

Thoracentesis

• Cataract surgery– Postoperatively, semi-Fowler’s to Fowler’s position

on back and nonoperative side• Autonomic dysreflexia :involuntary nervous

system overreacts- Spinal cord injury above T6– Elevate HOB to high Fowler’s position/sitting : to

cause the blood to flow to feet• Cerebral aneurysm

– Bed rest, with HOB semi-Fowler’s to Fowler’sposition

• Brain attack (stroke)– Hemorrhagic strokes, low Fowler’s position;

ischemic strokes, HOB flat






















• Craniotomy– Place on nonoperative side, semi-Fowler’s to Fowler’s

position, Head elevated 30 degrees for Supratentorialincision, head midline

• Increased intracranial pressure– Semi-Fowler’s to Fowler’s position, head midline

• Spinal cord injury– Immobilize, logroll

• Air embolism- Trendelenburg’s position on the left side

• Total hip replacement– Avoid extreme internal and external rotation and

adduction– Maintain abduction when supine or on nonoperative

side








side








side








side

Craniotomy

• A nurse is caring for a client after asupratentorial craniotomy. The nurse places asign above the client’s bed stating that theclient should be maintained in which of thefollowing positions?

• 1 Prone• 2 Supine• 3 Semi-Fowler’s• 4 Dorsal recumbent

• A nurse is caring for a client after asupratentorial craniotomy. The nurse places asign above the client’s bed stating that theclient should be maintained in which of thefollowing positions?

• 1 Prone• 2 Supine• 3 Semi-Fowler’s• 4 Dorsal recumbent

Tubes



Respiratory Tubes• Tracheostomy

– Single Lumen (no inner canula)– Double Lumen (with inner canula – can be removed, Clean

the outer surfaces in a circular motion )– Fenestration- holes to allow air flow between larynx and

trachea.– Fenestrated tube – before weaning off- allows speaking.– Non fenestrated – for mechanical ventillated pts

• Ambu bag and spare Trach kit - Always at bedside• Cuff pressure – max 20 mm hg.

– prevent aspiration– High pressure – tracheomalacia (erosion and dilation),

tracheoesophageal fistula, tracheal stenosis (Narrow lumen)• Cuff deflated before removing trach

• Tracheostomy– Single Lumen (no inner canula)– Double Lumen (with inner canula – can be removed, Clean


















Respiratory Tubes• Encourage cough and deep breathing• Ensure humidified oxygen flow

– water bottle attached to O2 flow -filled prn• Trach care q 8 hrs, Trach ties changed daily.

– Two people - one hold the trach in place.– There is a risk of tube dislodgement with replacing the ties. If no

assistant, place new ties before cutting and removing old ones.– use a commercially prepared tracheostomy dressing with a slit in

it.• Suction – hyper oxygenate before and after.

– The safe suction range for an adult is 100 to 120 mm Hg.– No more than 10 sec at a time– Suction when coming out- rotating movement– Limit each suctioning session to two to three attempts and allow

at least 1 min between.

• Encourage cough and deep breathing• Ensure humidified oxygen flow





















Tracheostomy• Assess respirations, bilateral breath sounds

– Placement is confirmed by chest x-ray (1 to 2 cm above carina)– Assess placement by auscultating both sides of chest while

manually ventilating client with Ambu bag• Monitor arterial blood gas (ABG) levels and pulse oximetry• Oral care Q 2, Resp. assess Q 4, cuff pressure Q8• Maintain semi-Fowler’s to high Fowler’s position• Suction PRN, hyper oxygenating first• Communication means (writing pad/pictures)• Tracheostomy Suction• Trecheostomy Care

• Assess respirations, bilateral breath sounds– Placement is confirmed by chest x-ray (1 to 2 cm above carina)– Assess placement by auscultating both sides of chest while






Chest Tube• Description

– Used to remove abnormal accumulations of air and fluids frompleural space

– 3 chambers – collection, water seal, suction• Collection chamber (to collect drainage)

– Drainage should not be more than 100 mL/hr• Water-seal chamber (2 cm water- tidaling)

– Water should oscillate with client’s respirations– If continuous bubbling in chamber, physician should be notified– Fluctuation in the water seal chamber stops if the tube is

obstructed, if a dependent loop exists, if the suction is notworking properly, or if the lung has re expanded

• Suction control chamber– Allows suction to create negative pressure – low wall suction

• Description– Used to remove abnormal accumulations of air and fluids from

pleural space– 3 chambers – collection, water seal, suction

• Collection chamber (to collect drainage)– Drainage should not be more than 100 mL/hr

• Water-seal chamber (2 cm water- tidaling)– Water should oscillate with client’s respirations– If continuous bubbling in chamber, physician should be notified– Fluctuation in the water seal chamber stops if the tube is















Chest Tube• What to report

– Drainage more than 100 mL/hr– Bright red drainage,– Drainage amounts that increase suddenly– Continuous vigorous bubbling in water seal chamber

(leak). Iintermittent bubbling is OK- drainage ofpneumothorax

• In suction control chamber – a gentle continuousbubbling of water is acceptable.

• Absence of bubbling in suction chamber shouldbe noted (not enough suction)

• What to report– Drainage more than 100 mL/hr– Bright red drainage,– Drainage amounts that increase suddenly– Continuous vigorous bubbling in water seal chamber












• Suction control chamber (with water)– Water should be gently bubbling continuously– If vigorous bubbling occurs, notify physician

• Dry suction system (no water)– Absence of bubbling in suction chamber should be noted– Suction applied via wall suction source

• Interventions– Monitor drainage in collection chamber– Monitor for fluctuation of fluid level in water-seal

chamber, with respirations– If bubbling and no movement, and not working properly,

further assessment required– Monitor for gentle bubbling in suction chamber
















• Maintain drainage system below chest level (12 inches)• Assess, monitor respiratory status• Do not milk or strip chest tubes without physician’s

prescription• Maintain occlusive dressings and two rubber-tipped clamps,

hemostats at bedside at all times in case tube comes out ofchest or out of drainage system

• Have client perform Valsalva’s maneuver when chest tuberemoved

• If chest tube disconnects from chest drainage system, insertchest tube into bottle of sterile water or clamp at end of tubenear disconnection, close to client

• If chest tube pulled out of chest accidentally, pinch skinopening together, apply occlusive dressing, tape, notifyphysician



















Nasogastric Tubes• Purpose

– Decrease risk of aspiration– Decompress stomach after abdominal surgery– Provide enteral feedings

• Intubation procedures– Place client in high Fowler’s position– Measure tube from tip of nose to earlobe to xiphoid

process to determine length of insertion– Lubricate tube with water-soluble jelly– Instruct client to bend head forward– Insert tube into nostril, advance backward– Have client take sips of water, advancing tube while he or

she swallows– When in place, tape appropriately

• Purpose– Decrease risk of aspiration– Decompress stomach after abdominal surgery– Provide enteral feedings












Irrigation• Should be performed every 4 hours as prescribed

– Assess placement of tube prior to irrigation– Gently instill 30 to 50 mL of water or NS, according to

agency policy, with irrigation syringe– Pull back syringe plunger to withdraw fluid to check

patency; repeat if tube remains sluggish• Removal of nasogastric tube

– Client should take deep breath and hold; breath-holding minimizes the risk of aspirating spilled gastriccontents

– Remove tube slowly.

• Should be performed every 4 hours as prescribed– Assess placement of tube prior to irrigation– Gently instill 30 to 50 mL of water or NS, according to















Gastrointestinal Tube Feedings• Types of tubes

– Nasogastric: Nose to stomach– Nasoduodenal, nasojejunal: Nose to duodenum or

jejunum– Gastrostomy: Stomach– Jejunostomy: Jejunum

• Types of administration– Bolus, continuous, cyclical

• Administration of feedings– Assess placement and bowel sounds; if absent, hold

feeding, notify physician– Assess residual amount before initiating feeding; hold

feeding if residual more than 100 mL or amount specifiedby agency

• Types of tubes– Nasogastric: Nose to stomach– Nasoduodenal, nasojejunal: Nose to duodenum or


















Gastrointestinal Tube Feedings• Precautions

– Always assess tube placement, residual, bowel soundsprior to feeding

– Change container and tubing every 24 hours– Administer feeding at prescribed rate on pump or via

gravity flow– Flush with 30 to 50 mL of water or NS before and after

feeding; account for amount in intake and outputrecord

• Prevention of complications– Diarrhea

• Use fiber-containing solutions• Administer solution slowly at room temperature

• Precautions– Always assess tube placement, residual, bowel sounds

prior to feeding– Change container and tubing every 24 hours– Administer feeding at prescribed rate on pump or via

















Gastrointestinal Tube Feedings• Aspiration

– Verify tube placement– Do not administer feeding if residual more than 100 mL or

amount specified by agency, physician– Keep head of bed (HOB) elevated

• Clogged tube– Use liquid forms of medication– Flush tube with 30 to 50 mL water or NS before and after

medication administration and bolus feedings• Vomiting

– Administer feedings slowly– Do not allow air to enter tube– Elevate HOB

• Aspiration– Verify tube placement– Do not administer feeding if residual more than 100 mL or















Nasoenteric Tube

• Tube inserted nasally to stomach – thenpassed to intestine via persiatlsis.

• After tube inserted into stomach –pt in rightside position (to pass tube through pyloricsphincter). Then pt repositioned side to sideevery 2 hrs.

• Placement verified by X ray• Measure abdominal girth routienly










Urinary and Renal Tubes

• Types of urinary catheters– Urinary catheter, ureteral tubes, nephrostomy tubes

• Routine urinary catheter care– Maintain collection bag below level of bladder

• Ureteral and nephrostomy tubes– Never clamp tube; maintain patency– Monitor strict intake and output– Irrigate only with physician’s prescriptions, using strict

aseptic technique (5 ml max)













Wound drainage

• Measure and record every shift• JP drain and Hemovac- maintain pressure after

emptying the bulb• Penrose drain – dressing changes• T-Tube – bile drainage

– Keep T-tube below level of surgical wound– Up to 500 ml expected first 24 hrs– About 200 ml in 2-3 days– D/C home ? - Clamping schedule- before and after

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• A nurse is preparing to perform endotrachealsuctioning for a client. Which of the following areappropriate guidelines for the nurse to follow? (Selectall that apply.)

• A. Apply suction while withdrawing the catheter.• B. Perform suctioning on a routine basis, every 2 to 3

hr• C. Maintain medical asepsis during suctioning• D. Use a new catheter for each suctioning attempt.• E. Limit suctioning to two to three attempts.

• A nurse is preparing to perform endotrachealsuctioning for a client. Which of the following areappropriate guidelines for the nurse to follow? (Selectall that apply.)

• A. Apply suction while withdrawing the catheter.• B. Perform suctioning on a routine basis, every 2 to 3

hr• C. Maintain medical asepsis during suctioning• D. Use a new catheter for each suctioning attempt.• E. Limit suctioning to two to three attempts.

• A. CORRECT: The nurse should apply suction pressure onlywhile withdrawing the catheter, not while inserting it.

• B. INCORRECT: The nurse should not suction routinely,because suctioning is not without risk. It can cause mucosaldamage, bleeding, and bronchospasm.

• C. INCORRECT: Endotracheal suctioning requires surgicalasepsis.

• D. CORRECT: The nurse should not reuse the suctioncatheter unless an inline suctioning system is in place.

• E. CORRECT: To prevent hypoxemia, the nurse should limiteach suctioning session to two to three attempts and allowat least 1 min between passes for ventilation andoxygenation.

• A. CORRECT: The nurse should apply suction pressure onlywhile withdrawing the catheter, not while inserting it.

• B. INCORRECT: The nurse should not suction routinely,because suctioning is not without risk. It can cause mucosaldamage, bleeding, and bronchospasm.

• C. INCORRECT: Endotracheal suctioning requires surgicalasepsis.

• D. CORRECT: The nurse should not reuse the suctioncatheter unless an inline suctioning system is in place.

• E. CORRECT: To prevent hypoxemia, the nurse should limiteach suctioning session to two to three attempts and allowat least 1 min between passes for ventilation andoxygenation.

• A nurse is delivering an enteral feeding to a client who hasan NG tube in place for intermittent feedings. When thenurse pours water into the syringe after the formula drainsfrom the syringe, the client asks the nurse why the water isnecessary. Which of the following is an appropriateresponse by the nurse?

• A. “Water helps clear the tube so it doesn’t get clogged.”• B. “Flushing helps make sure the tube stays in place.”• C. “This will help you get enough fluids.”• D. “Adding water makes the formula less concentrated.”

• A nurse is delivering an enteral feeding to a client who hasan NG tube in place for intermittent feedings. When thenurse pours water into the syringe after the formula drainsfrom the syringe, the client asks the nurse why the water isnecessary. Which of the following is an appropriateresponse by the nurse?

• A. “Water helps clear the tube so it doesn’t get clogged.”• B. “Flushing helps make sure the tube stays in place.”• C. “This will help you get enough fluids.”• D. “Adding water makes the formula less concentrated.”

• A. CORRECT: Flushing the tube after instilling the feedinghelps keep the NG tube patent by clearing any excessformula from the tube so that it doesn’t clump and clog thetube.

• B. INCORRECT: Tape or a securing device, not flushing thetube with water, helps maintain the position of the NGtube.

• C. INCORRECT: If the client requires additional fluids, thesmall amount the nurse uses for flushing the NG tube willnot be adequate.

• D. INCORRECT: If the formula is supposed to be lessconcentrated, the dietary staff will prepare it according tothe client’s prescription before the nurse instills it.

• A. CORRECT: Flushing the tube after instilling the feedinghelps keep the NG tube patent by clearing any excessformula from the tube so that it doesn’t clump and clog thetube.

• B. INCORRECT: Tape or a securing device, not flushing thetube with water, helps maintain the position of the NGtube.

• C. INCORRECT: If the client requires additional fluids, thesmall amount the nurse uses for flushing the NG tube willnot be adequate.

• D. INCORRECT: If the formula is supposed to be lessconcentrated, the dietary staff will prepare it according tothe client’s prescription before the nurse instills it.

Pre op and Post op care



Preop Care• Assessment of risk factors is one of the major aspects

of preoperative care.• Infection (risk of sepsis)• Anemia (malnutrition, oxygenation, healing impact)• Hypovolemia from dehydration or blood loss

(circulatory compromise)• Electrolyte imbalance through inadequate diet or

disease process (dysrhythmias)• Age (older adults are at greater risk because of

decreased liver and kidney function due to age, andthe use of multiple prescribed medications)

• Pregnancy (fetal risk with anesthesia)

• Assessment of risk factors is one of the major aspectsof preoperative care.

• Infection (risk of sepsis)• Anemia (malnutrition, oxygenation, healing impact)• Hypovolemia from dehydration or blood loss

















Preop Care Risk• Respiratory disease (COPD, pneumonia, asthma)• Cardiovascular disease (cerebrovascular accident, heart

failure, myocardial infarction, hypertension, dysrhythmias)• Diabetes mellitus (decreased intestinal motility, altered

blood glucose levels, delayed healing)• Liver disease (altered medication metabolism and increased

risk for bleeding)• Kidney disease (altered elimination and medication

excretion)• Endocrine disorders (hypo/hyperthyroidism, Addison’s

disease, Cushing’s syndrome)• Immune system disorders (allergies, immunocompromised)

• Respiratory disease (COPD, pneumonia, asthma)• Cardiovascular disease (cerebrovascular accident, heart


















Preop Care Risk• Coagulation defect (increased risk of bleeding)• Malnutrition (delayed healing)• Obesity (pulmonary complications due to

hypoventilation, impact on anesthesia, elimination,and wound healing)

• Certain medications (antihypertensives,anticoagulants, NSAIDs, tricyclic antidepressants,herbal medications, over-the-counter medications)

• Substance use (tobacco, alcohol)• Family history (malignant hyperthermia)• Allergies (latex, anesthetic agents)

• Coagulation defect (increased risk of bleeding)• Malnutrition (delayed healing)• Obesity (pulmonary complications due to












Perioperative Care• Obtaining informed consent• Nutrition : NPO as prescribed• Avoid cigarette smoking for 24 hr preop• Stop herbal meds – risk of bleeding• Elimination : Void immediately before surgery• Bowel prep if needed (laxative, emema)• Surgical site

• Hair should be shaved or clipped with electric clippers orchemical depilatory to prevent traumatizing the skin andincreasing the risk for infection.

• Preoperative checklist

• Obtaining informed consent• Nutrition : NPO as prescribed• Avoid cigarette smoking for 24 hr preop• Stop herbal meds – risk of bleeding• Elimination : Void immediately before surgery• Bowel prep if needed (laxative, emema)• Surgical site









Pre op check• Give Preoperative medications : Sedative? Fall risk- Pt

in bed with side rails up• Prophylactic antibiotics are administered 1 hr prior to

surgical incision.• Pt already on Beta-blocker? Give a dose prior to

surgery to prevent a cardiac event and mortality.• Cover the client with lightweight cotton blanket heated

in a warmer to prevent hypothermia.• Hypothermia increases the chance for

– surgical wound infections,– alters metabolism of medication,– causes coagulation problems and cardiac dysrhythmias.

• Give Preoperative medications : Sedative? Fall risk- Ptin bed with side rails up

• Prophylactic antibiotics are administered 1 hr prior tosurgical incision.

• Pt already on Beta-blocker? Give a dose prior tosurgery to prevent a cardiac event and mortality.

• Cover the client with lightweight cotton blanket heatedin a warmer to prevent hypothermia.

• Hypothermia increases the chance for– surgical wound infections,– alters metabolism of medication,– causes coagulation problems and cardiac dysrhythmias.











Diagnostic Procedures• Urinalysis – ruling out of infection• Blood type and cross match – transfusion readiness• CBC – infection/immune status• Hgb and Hct – fluid status, anemia• Pregnancy test – fetal risk of anesthesia• Clotting studies (PT, INR, aPTT, platelet count)• Electrolyte levels – electrolyte imbalances• Serum creatinine and BUN – renal status• ABGs – oxygenation status• Chest x-ray – heart and lung status• 12-lead ECG – baseline heart rhythm, dysrhythmias,

history of cardiac disease, performed on all clients olderthan 40 years

• Urinalysis – ruling out of infection• Blood type and cross match – transfusion readiness• CBC – infection/immune status• Hgb and Hct – fluid status, anemia• Pregnancy test – fetal risk of anesthesia• Clotting studies (PT, INR, aPTT, platelet count)• Electrolyte levels – electrolyte imbalances• Serum creatinine and BUN – renal status• ABGs – oxygenation status• Chest x-ray – heart and lung status• 12-lead ECG – baseline heart rhythm, dysrhythmias,






Pre operative Care– Preoperative client teaching

• Inform client that requesting opioid medications(narcotics) postoperatively will not make him or hera drug addict

• Postoperative pain control techniques (medications,immobilization, patient-controlled analgesia, pumps,splinting)

• Demonstration and importance of range-of-motionexercises and early ambulation for prevention ofthrombi and respiratory complications

– Preoperative client teaching• Inform client that requesting opioid medications

(narcotics) postoperatively will not make him or hera drug addict











Pre operative Care– Preoperative client teaching

• Purpose of antiembolism stockings andpneumatic compression devices to preventdeep-vein thrombosis

• Invasive devices (drains, catheters, IV lines)• Postoperative diet• Demonstration and importance of splinting,

coughing, and deep breathing• Use of the incentive spirometer• Early ambulation

– Preoperative client teaching• Purpose of antiembolism stockings and

pneumatic compression devices to preventdeep-vein thrombosis











Using IncentiveSpirometryUsing IncentiveSpirometry

Perioperative CareExplanation

– Toddler : Immediately prior to surgery, give a briefand simple explanation

– Preschoolers: give a brief and simple explanation,play therapy

– School age : Age appropriate but completeexplanation, use pictures, dolls and videos.

– Adolescents: Privacy is extremely important. Clearexplanation.

– Adults : complete information

Explanation– Toddler : Immediately prior to surgery, give a brief

and simple explanation– Preschoolers: give a brief and simple explanation,

play therapy– School age : Age appropriate but complete

explanation, use pictures, dolls and videos.– Adolescents: Privacy is extremely important. Clear

explanation.– Adults : complete information











Slide 12

POST OP CARE

Postoperative CareImmediate postoperative stage

• Assess, monitor airway – adequate ventilation?secretions ?respirations ?signs of respiratory distress?

• Assess for symmetry of breath sounds and chest wallmovement.

• Absent breath sounds on the left may indicate theendotracheal tube has migrated down the rightmainstem bronchus or there is a pneumothorax.

• Snoring or stridor (a high pitch crowing type sound)may indicate poor oxygen exchange.

Immediate postoperative stage• Assess, monitor airway – adequate ventilation?

secretions ?respirations ?signs of respiratory distress?• Assess for symmetry of breath sounds and chest wall

movement.• Absent breath sounds on the left may indicate the

endotracheal tube has migrated down the rightmainstem bronchus or there is a pneumothorax.












Slide 14

Postoperative CareImmediate postoperative stage

• Assess, monitor for bleeding• Orient to environment• Apply warm blankets and prescribed oxygen if shivering• Assess and monitor surgical site, drains, wound• Assess, monitor for signs of hypocalcemia,

hyperglycemia, metabolic or respiratory acidosis oralkalosis

• Assess, monitor for return of bowel sounds

Immediate postoperative stage• Assess, monitor for bleeding• Orient to environment• Apply warm blankets and prescribed oxygen if shivering• Assess and monitor surgical site, drains, wound• Assess, monitor for signs of hypocalcemia,









Slide 15

Risk Factors for PostoperativeComplications

• Immobility (respiratory compromise, DVT, pressureulcer)

• Anemia (blood loss, inadequate/decreasedoxygenation, and healing factors)

• Hypovolemia (tissue perfusion)• Hypothermia (risk of surgical wound infection,

altered absorption of medication, coagulopathy,and cardiac dysrhythmia)

• Cardiovascular diseases (fluid overload, deep-veinthrombosis, arrhythmia)
















Risk Factors for PostoperativeComplications

• Respiratory disease (respiratory compromise)• Immune disorder (risk for infection, delayed

healing)• Diabetes mellitus (gastroparesis, delayed wound

healing)• Coagulation defect (increased risk of bleeding)• Malnutrition (delayed healing)• Obesity (wound healing, dehiscence,evisceration)










Older adult

• Age-related respiratory, cardiovascular, and renalchanges necessitate special attention to thepostoperative recovery of older adults.

• Older adult clients are more susceptible to coldtemperatures– additional warm blankets in the PACU may be

required.

• Responses to medications and anesthetics maydelay return of orientation postoperatively.



required.




required.




required.


Older Adults

• Age-related physiologic changes (decreased liver andkidney function) can affect response to and eliminationof postoperative medications.– Monitor the client for appropriate response and possible

adverse effects.• Older adults perspire less, which leads to dry, itchy skin

that becomes fragile and easily abraded.– The use of paper tape for wound dressings may be

appropriate, as well as lifting precautions.• Older adults may be at risk for delayed wound healing

because of possible compromised nutrition.
















Postoperative Care– Immediate postoperative stage

• Unless contraindicated, place client in lowFowler’s position.

• Avoid supine positioning until pharyngeal reflexeshave returned

• If comatose or semicomatose, position on sidewith oral airway in place

• Turn client to side-lying position if vomitingoccurs

• Do not put pillows under knees or elevate theknee gatch on the bed (decreases venous return).

– Immediate postoperative stage• Unless contraindicated, place client in low

Fowler’s position.• Avoid supine positioning until pharyngeal reflexes

have returned• If comatose or semicomatose, position on side

with oral airway in place• Turn client to side-lying position if vomiting

occurs• Do not put pillows under knees or elevate the

knee gatch on the bed (decreases venous return).













Slide 20

Postoperative Care (continued)• Expect client to void in 6 to 8 hours postoperatively• Assess pain

– type of anesthetic used, and preoperative medication, andwhether client received pain medication in postanesthesiaperiod

– If opioid has been prescribed, assess client every 30minutes for pain relief and respiratory rate and effort

• Reinforce wound with sterile dressing PRN; notifyphysician if bleeding occurs from site

• Maintain NPO status until gag reflex and peristalsisreturn

• Expect client to void in 6 to 8 hours postoperatively• Assess pain















Slide 21

Malignant hyperthermia

• Genetic disorder• Combination of anesthetic agents (the muscle

relaxant succinylcholine and inhalation agentssuch as halothanes) triggers uncontrolled skeletalmuscle contractions – leading to hyperthermia

• Hyper metabolic condition causing an alterationin calcium activity in muscle cells (muscle rigidity,hyperthermia, and damage to the central nervoussystem).

• Always check for family history.














• Tachycardia is a first manifestation.• Other signs: Dysrhythmias, muscle rigidity,

hypotension, tachypnea, skin mottling,cyanosis and protein in urine.

• can quickly lead to a potentially fatalhyperthermia.

• Elevated temperature is a late manifestation –rising 1° to 2° C (2° to 4° F) every 5 min.














• Terminate surgery• ›› Dantrolene (Dantrium) is a muscle relaxant

to treat the condition• ›› 100% oxygen, arterial blood gases• ›› Infuse iced IV 0.9% sodium chloride• ›› Apply a cooling blanket, ice to axillae, groin,

neck and head, iced lavage










Pneumonia and Atelectasis– Description

• Pneumonia: Inflammation of alveoli occurring 3to 5 days postoperatively

• Atelectasis: Collapse of alveoli, most commonpostoperative complication, 1 to 3 dayspostoperatively

– Assessment• Dyspnea, tachypnea, crackles over affected

lung area, fever, productive cough, chest pain

– Description• Pneumonia: Inflammation of alveoli occurring 3

to 5 days postoperatively• Atelectasis: Collapse of alveoli, most common

postoperative complication, 1 to 3 dayspostoperatively













Pneumonia and Atelectasis– Interventions

• Encourage client to breathe deeply,cough, use incentive spirometer

– Prevention• Cough and deep breath, IS,• Reposition every 2 hr• ambulate early and regularly.

– Interventions• Encourage client to breathe deeply,

cough, use incentive spirometer– Prevention

• Cough and deep breath, IS,• Reposition every 2 hr• ambulate early and regularly.







Hypoxia

– Description• Inadequate concentration of oxygen in arterial

blood– Assessment

• Restlessness, dyspnea, hypertension,tachycardia, diaphoresis, cyanosis

– Interventions• Encourage client to breathe deeply, cough, use

incentive spirometer


blood– Assessment





blood– Assessment





blood– Assessment




Pulmonary Embolism– Description

• Embolus blocking pulmonary artery, disrupting bloodflow to one or more lung lobes

– Assessment• Dyspnea, sudden sharp chest or upper abdominal pain,

cyanosis, tachycardia, hypotension (shock)– Interventions

• Notify physician STAT• Monitor vital signs• Administer oxygen and medications as prescribed

– Prevention• Turning and early Ambulation• TEDS and SCD

– Description• Embolus blocking pulmonary artery, disrupting blood

flow to one or more lung lobes– Assessment

• Dyspnea, sudden sharp chest or upper abdominal pain,cyanosis, tachycardia, hypotension (shock)

– Interventions• Notify physician STAT• Monitor vital signs• Administer oxygen and medications as prescribed












Hemorrhage– Description

• Loss of large amount of blood externally or internally inshort time

– Assessment• Restlessness, weak rapid pulse, hypotension, cool

clammy skin, oliguria– Interventions

• Apply pressure to site of bleeding• Notify physician STAT• Monitor vital signs• Administer oxygen as prescribed• Administer IV fluids, blood as prescribed

– Description• Loss of large amount of blood externally or internally in

short time– Assessment

• Restlessness, weak rapid pulse, hypotension, coolclammy skin, oliguria

– Interventions• Apply pressure to site of bleeding• Notify physician STAT• Monitor vital signs• Administer oxygen as prescribed• Administer IV fluids, blood as prescribed









Slide 29

Shock– Description

• Loss of circulatory fluid volume; often secondary tohemorrhage

– Assessment• Restlessness, weak and rapid pulse, hypotension, cool

clammy skin, oliguria– Interventions

• If shock develops, elevate legs• Monitor, assess vital signs, level of consciousness, intake

and output, skin• Administer oxygen as prescribed• Administer IV fluids, blood, colloid solutions as

prescribed

– Description• Loss of circulatory fluid volume; often secondary to

hemorrhage– Assessment

• Restlessness, weak and rapid pulse, hypotension, coolclammy skin, oliguria

– Interventions• If shock develops, elevate legs• Monitor, assess vital signs, level of consciousness, intake


prescribed






prescribed






prescribed

Thrombophlebitis• Inflammation of vein, accompanied by clot formation• Assessment

– Positive Homans’ sign– Aching or cramping pain, tender to touch, Fever

• Interventions– Assess leg(s) for swelling, inflammation, pain, tenderness,

cyanosis– Elevate extremity 30 degrees without pressure in popliteal

space. SCD, TEDS, Ambulte– Passive range of motion every 2 hours– Do not allow client to dangle legs– Instruct client not to sit in one position for lengthy period– Administer heparin sodium or warfarin (Coumadin)

• Inflammation of vein, accompanied by clot formation• Assessment















Urinary Retention– Description

• Involuntary accumulation of urine in bladder– Assessment

• Inability to void, lower abdominal pain, distended bladder,hypertension, tympany sound on percussion of bladder

– Interventions• Strict intake and output• Assess for distended bladder• Encourage ambulation• Provide privacy for voiding• Pour warm water over perineum, run water for client to hear to

promote voiding• Catheterize as prescribed

– Description• Involuntary accumulation of urine in bladder

– Assessment• Inability to void, lower abdominal pain, distended bladder,

hypertension, tympany sound on percussion of bladder– Interventions

• Strict intake and output• Assess for distended bladder• Encourage ambulation• Provide privacy for voiding• Pour warm water over perineum, run water for client to hear to












Constipation– Description

• Abnormal infrequent passage of stool– Assessment

• Abdominal distention, absence of bowel movements,anorexia, headache, nausea

– Interventions• Encourage fluid intake up to 3000 mL/day unless

contraindicated• Encourage early ambulation• Encourage consumption of high-fiber foods unless

contraindicated• Administer stool softeners and laxatives as prescribed

– Description• Abnormal infrequent passage of stool

– Assessment• Abdominal distention, absence of bowel movements,

anorexia, headache, nausea– Interventions

• Encourage fluid intake up to 3000 mL/day unlesscontraindicated

• Encourage early ambulation• Encourage consumption of high-fiber foods unless














Paralytic Ileus– Description

• Failure of appropriate forward movement of bowelcontents

– Assessment• Nausea, vomiting immediately postoperatively,

abdominal distention, absence of bowel movements,bowel sounds or flatus

– Interventions• Maintain NPO status until bowel sounds return• Strict intake and output• Maintain patency of nasogastric tube if in place• Encourage ambulation• Administer IV fluids, parenteral nutrition, medications as

prescribed

– Description• Failure of appropriate forward movement of bowel

contents– Assessment

• Nausea, vomiting immediately postoperatively,abdominal distention, absence of bowel movements,bowel sounds or flatus


prescribed





prescribed





prescribed

Wound Infection– Description

• Infection caused by poor aseptic technique orcontaminated wound before surgical exploration; occurs3 to 6 days postoperatively

– Assessment• Fever, chills, warm, tender, painful, inflamed incision

site, elevated white blood cell count– Interventions

• Monitor temperature, vital signs• Monitor incision site for signs of infection• Maintain patency of drains, assessing drainage• Change dressings as prescribed• Administer antibiotics as prescribed

– Description• Infection caused by poor aseptic technique or

contaminated wound before surgical exploration; occurs3 to 6 days postoperatively














Wound Dehiscence– Description

• Separation of wound edges from suture line– Assessment

• Increased drainage, open wound edges, appearance ofunderlying tissue through wound

– Interventions• Place in low Fowler’s position, with knees bent, if

abdominal incision• Cover wound with sterile normal saline dressing• Notify physician• Administer antiemetics if abdominal incision to prevent

vomiting, strain on incision• Instruct client to splint abdominal incision when coughing

– Description• Separation of wound edges from suture line

– Assessment• Increased drainage, open wound edges, appearance of

underlying tissue through wound– Interventions

• Place in low Fowler’s position, with knees bent, ifabdominal incision

• Cover wound with sterile normal saline dressing• Notify physician• Administer antiemetics if abdominal incision to prevent














Ambulatory Surgery– General criteria for client discharge

• Alert and oriented• Has voided• Has no respiratory distress• Ambulates, swallows, coughs• Experiencing minimal pain, bleeding• Has no vomiting• Has someone to take home; physician has signed release

– Discharge teaching• Performed prior to procedure taking place• Both verbal and written instructions in primary language• Instructions about activity, medications, postoperative

complications

– General criteria for client discharge• Alert and oriented• Has voided• Has no respiratory distress• Ambulates, swallows, coughs• Experiencing minimal pain, bleeding• Has no vomiting• Has someone to take home; physician has signed release


complications



complications



complications

• A nurse is caring for a client who is scheduled foran exploratory laparotomy. The client’stemperature is 39° C (102.2° F) orally. Which ofthe following is an appropriate action by thenurse?

• A. Inform the surgeon of the elevatedtemperature.

• B. Transfer the client to the preoperative unit.• C. Apply ice packs to the client’s groin.• D. Encourage the client to increase intake of clear

liquids.

• A nurse is caring for a client who is scheduled foran exploratory laparotomy. The client’stemperature is 39° C (102.2° F) orally. Which ofthe following is an appropriate action by thenurse?

• A. Inform the surgeon of the elevatedtemperature.

• B. Transfer the client to the preoperative unit.• C. Apply ice packs to the client’s groin.• D. Encourage the client to increase intake of clear

liquids.

• A. CORRECT: An appropriate action by the nurse isimmediately notifying the surgeon of the elevatedtemperature to determine if cancelling the surgery isnecessary due to an underlying infection.

• B. INCORRECT: Transferring the client to the preoperativeunit is not an appropriate nursing action when there is apossible underlying infection.

• C. INCORRECT: Applying ice packs to the client’s groin is notan appropriate action by the nurse for a temperature of 39°C (102.2° F). Instead, administer acetaminophen (Tylenol).

• D. INCORRECT: Increasing intake of clear liquids is not anappropriate action by the nurse because the client shouldbe NPO for at least 2 hr before surgery.

• A. CORRECT: An appropriate action by the nurse isimmediately notifying the surgeon of the elevatedtemperature to determine if cancelling the surgery isnecessary due to an underlying infection.

• B. INCORRECT: Transferring the client to the preoperativeunit is not an appropriate nursing action when there is apossible underlying infection.

• C. INCORRECT: Applying ice packs to the client’s groin is notan appropriate action by the nurse for a temperature of 39°C (102.2° F). Instead, administer acetaminophen (Tylenol).

• D. INCORRECT: Increasing intake of clear liquids is not anappropriate action by the nurse because the client shouldbe NPO for at least 2 hr before surgery.

• A nurse is obtaining informed consent for a client whois having a paracentesis. Which of the following areappropriate nursing actions? (Select all that apply.)

• A. Explain to the client the purpose of having theprocedure.

• B. Inform the client of risks to having the procedure.• C. Ensure the client understood the information about

the procedure.• D. Witness the client signing the informed consent

form.• E. Determine if the client is mentally capable of

understanding the reason for the procedure.

• A nurse is obtaining informed consent for a client whois having a paracentesis. Which of the following areappropriate nursing actions? (Select all that apply.)

• A. Explain to the client the purpose of having theprocedure.

• B. Inform the client of risks to having the procedure.• C. Ensure the client understood the information about

the procedure.• D. Witness the client signing the informed consent

form.• E. Determine if the client is mentally capable of

understanding the reason for the procedure.

• A. INCORRECT: The provider should explain thepurpose of the procedure.

• B. INCORRECT: The provider should inform the client ofrisks to having the procedure.

• C. CORRECT: Ensuring the client understood theinformation about the procedure is an appropriatenursing action.

• D. CORRECT: Witnessing the client signing the informedconsent is an appropriate nursing action.

• E. CORRECT: Determining if the client is mentallycapable to sign the informed consent is an appropriatenursing action.

• A. INCORRECT: The provider should explain thepurpose of the procedure.

• B. INCORRECT: The provider should inform the client ofrisks to having the procedure.

• C. CORRECT: Ensuring the client understood theinformation about the procedure is an appropriatenursing action.

• D. CORRECT: Witnessing the client signing the informedconsent is an appropriate nursing action.

• E. CORRECT: Determining if the client is mentallycapable to sign the informed consent is an appropriatenursing action.

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Safety Anila Simon PhD-c, RN, CVRN, CMSRN AppleRN Classes