Therapeutic Procedures (Nursing)

by Diana Shenefield, PhD

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    00:01 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.

    00:23 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.

    00:34 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.

    01:47 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.

    03:34 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.

    04:01 We always want to orient our patients to their environment, so that’s a definite yes.

    04:06 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.

    05:50 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.

    06:19 So knowing that that’s what a 5-year-old will do, you would pick that answer.

    06:24 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.

    06:50 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.

    07:18 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.

    07:27 They also need to know what are the side effects, what are the risks of having this procedure.

    07:33 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.

    07:47 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.

    07:58 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.

    08:39 We have to make sure that we are teaching our patient.

    08:41 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.

    09:14 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.

    09:54 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 to happen.

    11:22 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.

    12:08 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.

    12:30 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.

    16:38 Go through and answer lots of questions every day, and good luck.

    About the Lecture

    The lecture Therapeutic Procedures (Nursing) by Diana Shenefield, PhD is from the course Physiological Integrity (Nursing). It contains the following chapters:

    • Therapeutic Procedures
    • Questions
    • Patient Teaching
    • Assessing the Patient
    • Positioning

    Included Quiz Questions

    1. Serous drainage
    2. Red, hard skin
    3. Purulent drainage
    4. Warm, tender skin
    1. Increasing restlessness
    2. A negative Homan’s sign
    3. Hypoactive bowel sounds in all four quadrants
    4. Blood pressure of 110/70 and a pulse of 86 beats/min
    1. On the nonoperative side with legs abducted.
    2. Side-lying on the operative side.
    3. Side-lying with the affected leg internally rotated.
    4. Side-lying with the affected leg externally rotated.
    1. Supine, with the amputated limb supported with pillows.
    2. Prone.
    3. Reverse Trendelenburg.
    4. Supine with the amputated limb flat on the bed.

    Author of lecture Therapeutic Procedures (Nursing)

     Diana Shenefield, PhD

    Diana Shenefield, PhD

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