Our next topic is Therapeutic Procedures.
So be thinking about in your mind what are
therapeutic procedures you do as a nurse?
And what kind of policies and procedures go
along with those? And what kind of interventions?
What kind of preplanning, and what kind of
monitoring goes along with that? This falls
under the topic of reduction of risk.
Again, with NCLEX we know we've got to keep our patients
safe, and reduction of risk is a big part
of what we do as nurses, not only are we caring
for our patients, but we're keeping them safe.
My name is Diana Shenefield, let’s get started.
So what are we going to be talking about under
this topic? We are going to be talking about
therapeutic procedures. Again, when caring
for your patient undergoing a therapeutic
procedure, we know we need to assess responses,
we need to assess their recovery, and we need
to watch for potential complications, and
we need to diminish the risk of harm to our
patients. Our learning outcomes is to
apply our knowledge related to nursing process.
Again, that is a common theme that you are
going to hear throughout all of these videos,
but also throughout your nursing career, as
we need to keep our patients safe and reduce
risk. We also need to know how to monitor
our patients, during and after procedures,
and again in the back of our minds know, and
anticipate for possible complications. So
our first question we are going to look at
is you're a nurse caring for a patient who underwent
a surgical repair of a detached retina in
the right eye. So think about detached retina,
and what you have learned about that, and
what kind of precautions and what kind of
procedures would this patient be going through.
Which of the following interventions should
the nurse perform? Again, sometimes they are
going to ask what should you do, they are
going to ask you what is your first priority,
so make sure you know what the question is
asking you. So, are we going to place the
patient in a prone position? So again, you've
got to remember, what's prone, supine, lateral,
so make sure you are running those positions
through your mind. You are going to approach
the patient from the left side. Again reread
the question and you know that the detached
retina was in the right eye. Are you going
to encourage deep breathing and coughing?
So, normally we would do that for our patients,
but again, what's different about a detached
retina? Are you going to discourage bending down?
So are you going to discourage the patient
from bending down? Are you going to orient
the patient to his environment? And F, are
you going to administer a stool softener?
So we know with detached retina we don’t
want a lot of pressure. So as you are going
through and you are looking at these interventions,
which ones are going to reduce pressure? Are
you going to place the patient in a prone
position? That’s face down. No, because
that’s going to cause increase pressure
in the eye, so you want to mark that one out.
Are you going to approach the patient from
the left side? If you think about the right
side being covered with a bandage, then yes,
you are going to want to come from the left
side, so you are going to pick B. What about
C? Encourage deep breathing and coughing. Again,
we would do that for our patients that
are post-op, but what about our detached retina?
We don’t want them coughing, we don’t
want them bearing down, so you would not pick
C. What about D? Discourage bending down.
That is true. You don’t want them bending
down. So again be thinking about each question,
and each answer. What is it asking and how
does it fit? This is one of those questions
that select all that apply. So a lot of times
you can go through, and on each answer kind
of give yourself a true or false kind of quiz
to help you pick the right one. What about
E? Orient the patient to his environment.
That should be one that you are always picking.
We always want to orient our patients to their
environment, so that’s a definite yes.
And what about administer a stool softener? That
would be a definite yes. We don’t want the
patient bearing down and being constipated.
So again, know what a detached retina is,
know what’s special about that, and then
be able to answer your true and false for
each of the answers. We have a 5-year-old
patient who just returned from the OR after
having a tonsillectomy. If you work on the
pediatric unit or in post-op, we do lots of
tonsillectomies. So in your mind,
what makes this question
different? One, it’s a 5-year-old, so when
they talk about pediatric patients, you want
to make sure you know your growth and development.
And then a tonsillectomy, what part of the
body and what is happening? And a tonsillectomy,
again is the removal of the tonsils. So we
have a 5-year-old who has had their tonsils removed.
The nurse is preparing to perform a post-op
assessment. They've come back from surgery,
what do you need to be watching for? And what
are going to be signs and symptoms of bleeding?
We know when tonsils are taken out that it
is prone for bleeding. It’s a big problem
if they bleed, because patients can bleed
almost to the point of death by losing blood
through the tonsils. So as a nurse, how would
I know a 5-year-old is bleeding too much?
Are they going to tell you? Well according
to growth and development, probably not. So
what are the signs and symptoms that you need
to know as a nurse? A, is there going to be
frequent clearing of the throat? B, breathing
through the mouth? C, frequent swallowing?
D, sleeping for long intervals? E, pulse rate
of 98 beats per minute? Or F, blood-red vomit?
Again, you got to know your growth and development.
Frequent clearing of the throat. You want
to pick that one. When patients have blood
running down the back of their throat, they
are going to try clearing their throat, so
pick that one. Breathing through the mouth.
Now you have a 5-year-old. Lot of times
5-year-olds breathe through the mouth. Is
that a sign and symptom of bleeding? No, so
you don’t want to pick that one. Frequent
swallowing. That kind of goes back
with the clearing of the throat. A lot of
times children will swallow, swallow, swallow.
So knowing that that’s what a 5-year-old
will do, you would pick that answer.
Sleeping for long intervals. 5-year-olds after they've
had surgery, yes they will sleep. So you don’t
want to pick that one. A Pulse rate of 98.
If you don’t know what a normal pulse rate
for a 5-year-old is, you might want to pick
this one because you are thinking “Oh, that’s
too fast.” But in reality, a 5-year-old, the a
pulse rate of 98 is ok. So you wouldn’t
want to pick that. And then blood-red vomit.
That’s an easy one.
That usually happens after the child has been
swallowing a lot of blood. So again,
you got to know growth and development, and
you got to know what’s happening, disease
process or surgical process, and then go through
each of the answers, and think it through
to yourself, and answer true or false. So,
the nurse, what do I need to know for this
topic? You know that the nurse is responsible
to educate their patients about their treatments.
We need to make sure that our patients understand
what it is they are going to have done, what
the procedures are going to entail, and what
kind of recovery there is going to be.
They also need to know what are the side effects,
what are the risks of having this procedure.
We also need to make sure that we are monitoring
before, during, and after. We have to monitor
pre and post-op patients. Again, whether we
are the ones doing the procedures or not.
We have to be able to know what the patient's
baseline is, and then what could happen afterwards,
and what we are monitoring for. And then we
have to understand proper positioning.
Some procedures, there is no position that
is specific but a lot of our procedures have
specific positioning, and so we need to understand
just like on the question of the patient that
had the detached retina. Normally somebody
has surgery, if they want to lay on their
belly it's okay. But we need to know our disease
processes so that we know which patients are
allowed to do that, and which are not. In
patient teaching, we need to make sure that
the patient understands, again, one, if they
are going to sign a consent, that they understand
exactly what’s going to happen to them, not that
you kind of just assume because everybody
knows that when you have your tonsils taken
out, what that means. We can’t assume that.
We have to make sure that we are teaching
What are we going to be watching for? Are
they going to get medicines before, to help
with the anxiety? Are they going to get medicines
afterwards? Are they going to go home right
after the procedure, or do they need to spend
a night in the hospital? Does somebody need
to drive them home after the procedure? Did
they think that once the procedure was done
that they could just drive themselves home?
All of those things are our responsibilities
as nurses to make sure that our patients know
exactly what’s going to be happening to
them before, during, and after. And then provide
education for what is going to happen at home.
Once they leave our facility, they are no
more in front of us but we are responsible,
to make sure that they know what medicines
that they need to take, what medicines they
need to stop taking. When do they call the
physician if there is a problem, and what
problem? If we don’t tell them that if you
start coughing up blood after a tonsillectomy,
that that’s not normal, they may think “Well,
I just had surgery, bleeding must not be too
bad.” And patients can get into a lot of
trouble. So as nurses, we need to make sure
that once they leave our visual sight that
they know how to take care of themselves at
home or take care of their children. We need
to assess the patient before procedure.
You know, what is their baseline assessment?
What is their baseline vital sign?
Again, what is their history? And did I do a good history?
Are they smokers? Again, a lot of time patients won’t volunteer that, but
we know that smoking has a big effect on a lot
of our anesthetics, a lot of our medications,
and a lot of our procedures, so what is the
baseline? And then what is their admitting
information? Do they know? Have they had this
procedure before? Is this new? Did a family
member have this procedure and have good or
bad results? What kind of information are
they coming in with? And what condition does
the patient come in with? Is this an elective
procedure? Or is this a procedure that could
be lifesaving? What is their anxiety level?
Do they need a medication to help with anxiety?
We know as nurses that the more anxious a
patient is, the more their heart rate goes
up, their respiratory rate goes up, their
blood pressure goes up, and it doesn’t always
give us a clear baseline. So is there something
that we need to be assessing? And does there
need to be a signed consent? What procedures
need signed consents? We know if it’s invasive,
there has to be a signed consent. But knowing
that a patient can refuse the procedure at
any point in time, whether they've signed
the consent or not. So making sure that our
patients understand, so that when they go
for that procedure, or when you as the nurse
perform that procedure, you can have a clear
mind that they know exactly what’s going
And then assessing the patient during. If
you are there during the procedure, whether
it’s you performing it or whether it’s a
physician performing it, or a radiologist,
whoever is performing it. Is there things
you need to watch for?
In the OR, nurses that work in the OR are very
aware that they need to watch for malignant
hyperthermia. That if a family member has
had that problem, or if they haven’t had
that problem, is there something that could be
a risk factor for this patient? What about
risk of respiratory failure? Any patient that
I’m doing a procedure on, whether they have
respiratory problems or not, if I’m giving
them medications or I’m doing any kind of
procedure that is going to interfere with
their breathing, then a risk of respiratory
failure is real, and I need to be watching
that during the procedure.
What if I’m giving them medications like for conscious sedation?
Again, am I depressing their respiratory status?
Am I depressing their gag reflex?
All of those are things that I need to understand about each procedure,
so that I can monitor my patient during that procedure.
And then always looking for unplanned complications.
When we do procedures, depending on what the
procedure is, in the back of our minds, again,
we always need to be thinking what is the
worst that could happen. What do I need to
be watching for, that maybe the physician
isn’t watching for because they are doing
the procedure? What do I need to be monitoring
for? So for positioning, some of the examples
that come to mind, and again this isn't an
exhaustive list, there is lots of different
positions that we put our patients in for
different reasons. But don’t forget about
sideline, to help with drainage of secretions.
If your patient is like under conscious sedation
or you've reduced their gag reflex, you want
to make sure that you have them on the side
so that they don’t choke on their secretions.
What about head elevated to increase venous
return and allow for maximum lung expansion.
We automatically do that when a patient is
having difficulty breathing, we increase the
head of the bed up. But think through those
things on how can I position the patient that’s
going to have the best results. Elevation
of limps to reduce swelling. You have a broken
leg, a broken arm, or you have an edema for
some reason. We know
if we lift that extremity, it's
going to decrease swelling. Again, that’s
a position that we are putting our patient
in for optimal results. Prone position to ease hip problems.
Again not every patient, you have a 80-year-old
that’s having trouble with hip expansion.
You are probably not going to just flip him
over on their stomach, but a lot of times,
we insist that patients lay on their back
or they lay sitting up on their bed, when
sometimes prone position is going to allow
for the best hip extension. So again, be thinking
through positions. Is there contraindications
to a position? Or is that position going to
help with a therapeutic procedure or just
for comfort? And then assessing that patient
after. Whether again it’s you, that did
the procedure or whether a physician did the
procedure, we need to monitor our patients
after the procedure. Most of the times they
don’t just get up and walk out. There has
to be some kind of monitoring afterwards.
So again, looking for airway, breathing,
circulation, the big three at the beginning.
But then monitoring pain. Did the position
cause pain because of osteoarthritis, or because
of a chronic back pain? Or did the procedure
itself cause pain? We want to make sure we
are addressing that and that we are treating
pain the best that we can. Also complications
before or after the treatment. Was there bleeding?
Was there an injury because of a position?
Did the patient get a skin tear because they
were older and as we were moving them on and
off the table. So again, watching for all
those complications. Don’t forget about
the gut. Anytime you do anything with the
gut, did we stop the gut from working? And, are
we are looking at an ileus? That’s something
that needs to be monitored afterwards.
And then again, big discharge teaching and
follow up afterwards. Do our patients understand
what’s going to happen once they leave the
hospital? What signs and symptoms should they
be watching for? What medications should they
or should they not be taking? Can they be
taking their herbal medications? What happens
if they start smoking as soon as they leave
the hospital? Is that going to have an effect
on the procedure or the medications? Again,
we need to do a lot of good teaching and make
sure that we document that teaching. So in
closing, assess, assess, assess. Know your
patient before procedure, watch them during,
and then monitor afterwards and be ready to
identify any risks that might happen, any
complications. And know what to do to act
on those complications. What the nurse needs
to do to intervene? And make sure that you
are following the nursing process. And make
sure that you are giving your patient the
best education possible, so that you feel
comfortable when they leave your facility
that they know how to take care of themselves.
Make sure you are studying those NCLEX books.
Go through and answer lots of questions
every day, and good luck.