Circulating Nurse – not a part of sterile field

- Pt. safety
- Verify consent & aseptic techniques
- Pt. position, vital signs, assessing
- Count all instruments/sponges to make sure the pt. gets closed so nothing gets left
- Keeps family informed on how pt. and surgery is going
- She calls for time-out (checking to make sure we are doing surgery on correct part of
body)
- Works with anesthesiologist to ensure pt. is well oxygenated & perfused
- Gives report to PACU nurse

Scrub Role – part of sterile field

- Scrubs in
- She stands next to surgeon and handles instruments
- Counts instruments prior to surgery

Surgeon – a part of sterile field

- Open, perform surgery, close

Registered Nurse First Assistant

- Assistant to the surgeon
- Learns to cut and stitch patient

Anesthesiologist
- Keeps pt. stable
- Responsible for oxygenation & perfusion
- Monitor vitals, airway, breathing, circulation

Older adults @ increased risk for complications

Surgical Environment
Unrestricted Zone – not part of sterile field (ex. Circulating nurse)
Semi-restricted zone – ex. Anesthesiologist @ head of patient
Restricted zone – sterile field

Intraoperative Complications
- Anesthesia awareness
- Nausea, vomiting
- Anaphylaxis
- Hypoxia, respiratory complications
- Hypothermia
 - Malignant hyperthermia (genetic disorder, life threatening, calcium ions increase
inside muscle cells, results in high CO2, low O2, metabolic and respiratory acidosis)
o Early sign: tachypnea, tachycardia, cardiac arrythmias, hyperkalemia (peak T
waves), muscular rigidity
o Late sign: Elevated temp, when this happens it’s hard to get patient back,
typically will be in vegetative state
- Infection
- Disseminated intravascular coagulations (DIC)
o Pt. bleeding thru every hole in their body (eyes, ears, nose, mouth, IV Site)

Types of Anesthesia (pg. 1345)

- General – loss of consciousness, sensation, reflexes (gag, blink, GI, GU)
o Bladder function will be lost, signals/impulses will not be received, bladder
will retain fluid with risk of bursting. Catheter must be placed
o Pt must be NPO 8-12hrs prior to surgery for risk of aspiration
o Cardiac irregularities/decreased cardiac output are a risk

- regional – loss of sensation to a portion of the body (more than just the desired site)
o Ex. – epidural
o Complications: hypotension, hypothermia, injury to spinal cord, respiratory
paralysis, spinal headaches

- Local – loss of sensation @ desired site

o Complications – rash, hives, potential anaphylactic reaction

- Moderate/Conscious Sedation – given IV

o Depressed level of consciousness but can be woken easily
o Complications – aspiration, decreased LOC, hypoxemia, respiratory
depression

Nursing Interventions
- Reduce anxiety, positioning injuries, latex exposure, patient advocate, monitor and
manage potential complications

POSTOPERATIVE

Nurse will assess vitals, LOC, Respiratory (airway and breathing), cardiac, pain management,
urine output (1-2ml / kg/ hr), bowels
- Q15min for the 1st hour
- Q30min for the 2nd hour
- Hourly for four hours
 - Q4hr after that
Complications of Post-Op (pg. 1354)

- Atelectasis (collapse of alveoli with increased mucous secretions) caused by

inadequate lung expansion
- Pneumonia (inflammation of alveoli involving 1 or several lobes of the lungs)
- Hypoxemia
- Pulmonary embolism
- Hemorrhage
- Hypovolemic shock
- Thrombophlebitis
- Muscle weakness
- Paralytic ileus
- Abdominal distension
- Nausea/vomiting
Why do you get an ostomy?
Non-functional colon
Disease ex.: Diverticulosis, cancer, chrons disease, IBS, congenital defects

Stoma is red, shiny, beefy, moist

Has no nerve endings (no feeling)

Ileostomy – in the ileum; stoma will be at right lower quadrant of body; stool will be liquidy;
constant; minimal odor; stool contains digestive enzymes which will burn and damage skin and
can also cause electrolyte imbalance; requires continuous use of protective appliance

Cecostomy – very close to the appendix; liquidy stool; right lower quadrant; requires
continuous use of protective appliance

Ascending colostomy – liquidy stool; odor; requires continuous use of protective appliance

Transverse colostomy – close to the umbilicus; stool is more mushy bc some water is
reabsorbed; no control (constant); malodorous; requires continuous use of protective appliance

Descending colostomy – left upper quadrant; fluid has been extracted; stool will be increasingly
solid; frequency can be regulated (can schedule it because it wont be constant); odors can be
controlled (diet: parsley, mint, buttermilk, probiotics); may not have to use the protective
appliance all the time due to regulation; educate everything they eat, they’ll see in the bag
(avoid cabbage, beans, anything that is really gasy); pt may tend to have constipation so
irrigation of the colostomy may be needed, tubing will be inserted to the stoma and pt will sit
on toilet (or lay on left side if immobile);

Loop Colostomy:
- Bulky stoma
- Created when there has been trauma to the colon
- Difficult to manage bc it has two openings
o One proximal which is draining the stool, closest to the ascending colon
o One distal which is inactive and draining mucus

Divided Colostomy:
- Two edges of the bowel brought out into the abdominal wall separate from each
other
- Proximal end: colostomy
- Distal: mucus
- Used when spillage of feces into the distal end needs to be avoided
Double Barreled Colostomy:
- Proximal and distal loops are sutured together and are brought up onto the
abdominal wall
- May be temporary or permanent

Final:
Chapter 47 – bowel elimination (25-30questions, includes ostomy, constipation, diarrhea,
enemas, fecal impaction) (when to change bag, wafer, wafer cut dimensions, stoma color)
- Stoma color – red, beefy, shiny, moist
- Expect fecal material to start coming thru ostomy after 48-72hrs
- Low fiber diet 4-6 weeks or occlusion will occur
- Sewing of stoma to skin so be gentle upon cleaning
- New stoma pt. will have self image problems, lack of knowledge
- Pt with new ostomy needs small meals, low fiber, plenty of fluids, avoid foods that
are gassy
- Stoma trace ¼ - 1/8 larger than the stoma for wafter dimensions
- Odor help – buttermilk, mint, parsley
- Stoma Care: empty bag when ½ or 1/3 full; peristoma care is everytime you change
bag
- Never give enteric coated meds, they wont dissolve
- Outcomes: Bag Care, well attached to skin
- Enema – pt. reporting cramps, slow down enema, place pt on left side, leg flexed,
barium enema (white fluid that is given to pt to take xrays, fluid needs to be
eliminated, pt must drink a lot of fluids to remove barium)
- Chronic constipation – increase fluids (8-10 glasses of 8oz), fiber, exercise,

Chapter 22&23 - Legal and Ethics (2-4 questions)

- Informed consent (preop)
- Autonomy – protect patient & their privacy; make their own decisions re care
- See something wrong, do something (report)
- Negligence: nurse is practicing out of scope
- Malpractice: Pt. sustained injury due to nurse was practicing out of scope
- Assault – verbal threat
- Battery – physical injury
- Prevent legal claim, nurse should work within scope of practice (Nurse Practice Act)

Chapter 50 – perioperative
 - Pre- signed consent, labs, vitals, any preop meds, IV on pt., assess what surgery
they’re having, ask if they’ve been NPO, ask about medications
- Circulating nurse – count instruments, position pt. (padding), keep family informed,
call time outs
- PACU Nurse – Assess ABC
- Prevent complications of a clot – SCDs

Pain Management (nonverbal pain, priority [cannot do anything without assessing], ask for pain
medication before pain worsens or previous dose completely wears off)

Older Adult (complication aware or perioperatively)

- Anxious, hypothermia, respiratory distress, decreased immune system

Fluid & Electrolyte // Acid-Base

- Hypertonic: (shrink the cell) 3%, 5%, 10% normal saline
- Isotonic: Normal Saline (0.9%)
- Hypotonic: (swell the cell) Normal Saline < .9%
- Fluid overload: weight gain, bounding pulse, tachycardia, high bp, crackles in lungs,
difficulty breathing, pitting edema
- Fluid Volume Deficit: hypovolemia, dehydration, weight loss, hypotension, pulse is
weak and thready, tachycardia, tachypnea, tongue is dry, less urinary output
- Potassium: cardiac sensitive
o Hypo: flattened T wave, prominent U wave, cause: diuretics & laxatives, low
K effects muscles (weakness to heart and respiratory muscles), shallow
respirations, alkalosis
o Hyper: tall T waves, causes hyperactivity of the muscles, diarrhea, acidosis
- Low calcium = high Deep tendon reflexes
- ABG test for acid base levels
- Respiratory Acidosis = hypo-ventilating (retaining acid) like COPD, kyphosis, lordosis,
scoliosis, after anesthesia or opioid usage after surgery

Blood transfusion
Two RN to check blood
Need 18 gauge needle, normal saline (2 bags), Y tubing, primary tubing
Infusion run 4 hrs
Blood needs to be administered within 30 minutes of receiving it
Obtain baseline vital signs, urinary output, listen to lungs

Nursing process – 8 questions (assessment = gathering data, organize, document) (planning =

discuss/create expected outcomes w/ patient) (evaluation = reassess to see if outcomes are
achieved)

Delegation
- Do not delegate to LPN
 o New assessment
o education
- Can delegate from already started care plan
- Delegate to UAP after first time: Ambulation, vitals on stable pt., bathing, changing,
feeding when no swallow precautions, monitor intake/output, collection of urine,
stool, blood (accuchecks)

No sleep questions