Therapeutic Procedures: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of therapeutic procedures in order to:
- Assess the client response to recovery from local, regional or general anesthesia
- Apply knowledge of related nursing procedures and psychomotor skills when caring for clients undergoing therapeutic procedures
- Educate client about treatments and procedures
- Educate client about home management of care (tracheostomy and ostomy)
- Use precautions to prevent further injury when moving a client with a musculoskeletal condition (e.g., log-rolling, abduction pillow)
- Monitor the client before, during, and after a procedure/surgery (e.g., casted extremity)
- Monitor effective functioning of therapeutic devices (e.g., chest tube, drainage tubes, wound drainage devices, continuous bladder irrigation)
- Provide preoperative and postoperative education
- Provide preoperative care
- Provide intraoperative care
- Manage client during and following a procedure with moderate sedation
Anesthesia is categorized as local, regional, conscious sedation, and general anesthesia. Whenever possible local and regional anesthesia are used rather than general anesthesia because general anesthesia places the client at greater risk for complications.
The types of local and regional anesthesia include:
- A topical anesthesia such as lidocaine or benzocaine is used for less invasive procedures as well as prior to the administration of a local anesthetic for procedures such as the removal of a skin lesion. These same topical agents are used to decrease localized pain such as the pain associated with a burn.
- A local anesthetic such as lidocaine or tetracaine is injected into the affected area for minor surgical procedures such as suturing a clean, open wound.
- A nerve block entails the injection of an anesthetic into the area around nerves and groups of nerves. Some nerve blocks are referred to as minor nerve blocks when they are only introduced to anesthetize to a single nerve; others are referred to as a major nerve block when they are introduced into a plexus or groups of nerves; and still more are referred to as a field block which is a subcutaneous injection of local anesthesia into the area around the intended area to be anesthetized.
- A Beir's block is the administration of an intravenous regional anesthetic into a limb vein that has subjected to the temporary interruption of circulation to the area with a tourniquet to localize the intended effect of the anesthetic to the tissues and nerves in the area that is getting the procedure or surgical intervention.
- Spinal anesthesia, also referred to as subarachnoid anesthesia, is the injection of a local anesthetic into the subarachnoid area around the spinal cord after the performance of a lumbar puncture. The sites for the administration of this anesthesia range from L2 to S1. A low spinal anesthesia, also referred to a saddle block or a caudal block, is typically used for rectal surgeries and this anesthesia is delivered above T9, a mid spinal anesthetic is administered above the level of the naval to T10 and this type of spinal anesthesia can be used for procedures such as the removal of an infected appendix, and a high spinal anesthetic is done between T4 and the level of the nipples. This type of spinal anesthesia is often used for a C section.
- Transwound anesthesia, also referred to as transincision anesthesia, entails the administration of a local anesthetic using a multilumen catheter that is surgically placed into the area that will be treated.
- Epidural anesthesia, also referred to as peridural anesthesia, entails the administration of a local anesthetic is into the epidural space outside of the dura mater of the spinal cord. This type of anesthesia is used for chest and abdominal surgeries.
- Conscious sedation, which is often used for endoscopic examinations and procedures, involves the intravenous administration of a narcotic such as midazolam, diazepam or morphine which are intended to decrease the client's awareness, to increase pain tolerance and to induce amnesia. Although this type of anesthesia has more complications and risks than local anesthesia, it is less problematic than general anesthesia.
- General anesthesia produces analgesia, amnesia, sleep and muscular relaxation, but it also produces unconsciousness, and the lack of life protective reflexes such as the gag and cough reflexes. This lose places the client at risk for respiratory problems, therefore, continuous monitoring of the client is necessary. General anesthesia can be administered with a medical gas or an intravenous transfusion of an anesthetizing agent.
The stages of general anesthesia are:
- Stage 1 - The Induction Stage: During this stage the client begins to lose consciousness and feel the analgesic effects of the general anesthesia, however, the client is not yet affected with amnesia.
- Stage 2 - The Excitement Stage: This stage is characterized with irregular respirations, an irregular cardiac rhythm, uncontrollable muscular activity, and, at times, vomiting. Because of these risks, the duration of this stage of general anesthesia is minimized to the greatest extent possible.
- Stage 3 - The Surgical Anesthesia Stage: The client is totally unconscious, the pupils are dilated, the client is in the maximum state of analgesia and amnesia; they are experiencing a deep yet artificial sleep; there is total muscular relaxation, and the client is vulnerable because they are without any protective gag, laryngeal or cough reflexes.
- Stage 4 - The Emergence Stage: During this stage of anesthesia the client begins to return to their preanesthesia state. Prior to the client's full return to their preanesthesia state, the client may be agitated, confused, tachycardic, and experience some shivering and changes in terms of their blood pressure. The client is still at risk for complications during this stage.
For this reason, the client is continuously monitored in terms of their blood pressure, pulse oximetry, cardiac rhythm, and temperature in order to determine whether or not the client is affected with malignant hyperthermia which can occur when some medical gases are used. The artificial airway remains in place and managed by the nurse until the client is able to spontaneously and safely breathe on their own with the return of the gag, cough and laryngeal reflexes.
All forms and types of anesthesia have risks. As stated previously, local and regional anesthesia have less risks than conscious sedation and conscious sedation has less risks and complications than general anesthesia.
The expected outcomes post anesthesia include the client's return to their preanesthesia state and without any complications.
The complications of local anesthesia, such as that done by a dentist, are typically associated with an over dosage or too rapid administration of the anesthetizing medication. Mild and moderate complications can include excitability, seizures, central nervous system depression, respiratory and/or cardiac distress and collapse.
Regional anesthesia can include complications such a headache, injection site soreness, infection, bleeding, hematoma, decreased urination, hypotension, nausea, vomiting and nerve damage as well as complications which may or may not vary in terms of the site that was used. For example, a pneumothorax, hoarseness of the voice, ptosis, temporary or permanent weakness or paralysis can occur.
Conscious sedation is associated with complications such as agitation, uncontrollable muscular activity, respiratory distress, respiratory arrest, unstable vital signs, cerebral hypoxia. The nurse must insure that the crash cart and other resuscitative equipment is readily available for use when indicated.
Conscious sedative is rapid in terms of its actions and it is relatively rapid in terms of the client's return to their preanesthesia state, however, the client remains a risk for complications and at risk for falls and other accidents until they have fully recovered.
General anesthesia can lead to mild and very serious complications such as a sore throat from the artificial airway, fatigue, dizziness, damage to dentition as the result of the placement of an artificial airway, myocardial infarction, serious malignant hyperthermia, a cerebrovascular accident, respiratory depression, hypoxia, cardiac arrest, respiratory arrest, coma and death.
Applying a Knowledge of Related Nursing Procedures and Psychomotor Skills When Caring for Clients Undergoing Therapeutic Procedures and Educating the Client about Treatments and Procedures
Nurses apply their knowledge of nursing procedures and psychomotor skills and abilities as they care for clients who are undergoing therapeutic procedures, including surgical procedures. Each of these procedures can be found in the facility specific policies and procedures as well as in standards of care and reliable, current and accurate nursing textbooks. The details about these psychomotor procedures are well beyond the scope of this NCLEX RN review, so we suggest that you review and reference nursing procedures in your current nursing textbooks.
Other than mentioning the necessity for nurses to follow established standards of care and facility policies and procedures relating to the many nursing procedures, nurses must perform procedures with physical and emotional jeopardy in mind. Clients must be properly identified using two unique identifiers, the orders for the procedure must be complete and appropriate, the client must have a complete informed consent, and the preparation of the client must be completed prior to the procedure to prevent physical jeopardy. The nurse must explain the procedure to the client and maintain the client's psychological and emotional safety.
As fully discussed and detailed in the section entitled "Discussing Treatment Options and Decisions with the Client: Informed Consent", all clients have the legal and ethical right to accept or reject all treatments and procedures as based on their full understanding of the treatment or procedure, its benefits, its risks, and any alternatives to the particular treatment or procedure. Except with extreme emergencies, education and informed consent are mandatory. Consents can be an implicit consent, an explicit consent and an opt out consent.
Complete education about treatments and procedures should minimally include the purpose of the procedure, who will be performing the procedure, the benefits of the procedure or treatment, the risks and complications associated with it, and alternative options to the procedure or treatment that the client may want to consider.
When client education cannot be provided to the client because they are not competent enough to understand it because they are a minor, unconscious, developmentally incapacitated, or not mentally competent, this education is provided to the parent, spouse, legal guardian, the legal durable power of attorney for healthcare decisions, or the healthcare surrogate or proxy.
Many clients are discharged from an acute care facility to the home. Some of these clients may have the assistance of a home care agency when they meet the criteria for home care and others do not. As the lengths of stay in acute care facilities decrease, the client and/or family may have to manage their care of their own. For example, a client may have to manage an ostomy, take care of and dress a surgical wound, and also care for and suction a tracheostomy tube and even a mechanical ventilator.
As previously mentioned, discharge planning should begin no later than the day of the admission so that the client can get all the community resources and all the teaching that they need to successfully manage their care in the home.
In addition to teaching the client information within the cognitive domain of learning, they are also taught the psychomotor aspects of their self care. For example, the client will be taught about medical asepsis and surgical techniques and they will also be taught to properly suction themselves and change a surgical wound dressing, which are cognitive and psychomotor domains of learning, respectively.
Cognitive domain learning needs can be met with a discussion and written material that the client can take home with them and psychomotor domain learning needs should be met with step by step demonstration, practice and return demonstration. Pictures and videos of these steps should be provided to the client for their further review and reference when they leave the facility to return home. Additionally, the spouse or other care givers should also be taught as indicated.
Some musculoskeletal injuries, such as a spinal fracture or possible spinal fracture or injury and a fracture of the hip, require that the nurse provide special measures to prevent further injury when moving these clients. For example, log rolling is used for clients who have a spinal fracture and an abduction pillow is used for clients who have a fractured hip.
Nurses assess and monitor the client before, during, and after a procedure or a surgery.
The assessment and monitoring of the client prior to a procedure and surgery is necessary in order to insure that the procedure or surgery is appropriate for the client and also to substantiate that the client is physically and psychologically ready, prepared and safe for the specific treatment or procedure.
For example, a client who is scheduled for a bronchoscopy must be monitored and assessed in terms of their maintenance of their NPO status for a minimum of 6 hours prior to the procedure, their vital signs, their respiratory status, their pulse oximetry, and the client responses to the intramuscular or intravenous administration of atropine that is given to the client prior to the procedure in order to decrease the amount of respiratory secretions.
During the procedure, such as a diagnostic bronchoscopy, the client is continuously monitored in terms of their vital signs, and they are placed on continuous cardiac monitoring, blood pressure monitoring, and pulse oximetry monitoring.
After the procedure, the client is monitored in terms of their physical status including their vital signs, pulse oximetry, and respiratory system functioning in addition to the assessment and monitoring of the vocal cords functioning since the pharynx and vocal cords are anesthetized with nebulized or aerosol lidocaine prior to the passing of the bronchoscope.
Similarly, the client with a fracture must also be monitored and assessed prior to, during and after the application of a cast.
Prior to the casting of the extremity, the client is assessed and monitored in terms of their vital signs, level of pain, the proper alignment of the limb, the peripheral pulses of the limb and the color and warmth of the affected limb.
During the procedure, the client continues to be monitored for the limb's proper alignment and the adequacy of the peripheral circulation. After the procedure, the client is monitored and assessed in terms of their level of pain, vital signs, swelling, and the lack of an external pressure on the limb as the result of the cast which can lead to a serious limb losing complication of casting that is referred to as compartment syndrome.
Information about the monitoring and assessment of clients prior to, during and after surgical procedures will be discussed below in the sections entitled "Providing Preoperative Care", "Providing Intraoperative Care" and "Managing the Client During and Following a Procedure with Moderate Sedation".
Medical devices such as chest tubes, drainage tubes, wound drainage devices and continuous bladder irrigation systems must be monitored in a continuous manner to insure that they are functioning correctly. When it appears that a therapeutic device is not functioning properly, the nurse will apply trouble shooting measures and when these corrective measures and interventions are not successful, the nurse will remove the device and replace it with a device that is functioning correctly and effectively.
Nurses monitor for tube and catheter kinks, other obstructions and accidental disconnections and then intervene appropriately; and they will monitor a chest tube for bubbling and intervene appropriately when it appears that the chest tube is not functioning effectively.
Preoperative and postoperative education ultimately focuses on the assurance of a safe and effective surgery and the prevention of any complications and poor sequelae.
Preoperative patient and family education should include complete information about all of the preoperative procedures and interventions that will be done prior to their surgery.
The elements of these preoperative procedures and interventions that the client should be knowledgeable about minimally include the purpose of and the procedures relating to:
- The complete physical assessment and medical history that are done prior to the surgery
- The laboratory and other diagnostic tests what will be done prior to the surgery
- Medications and anesthesia that will be administered prior to the surgery
- The medical markings of the surgical site that must be done prior to the surgery
- The informed consent and the elements of the informed consent including the benefits, risks and alternatives related to the planned surgical procedure
- Special preoperative preparation including shaving and an enema, for example
- The preoperative checklist and its components
- The removal of valuables and prosthetics, including dentures, and their safe keeping
- How pain will be managed
During the preoperative period of time, the client is also taught about the various exercises and routines that they should practice during the preoperative period of time so that the client is able to effectively perform these exercises and routines after surgery when they may be in pain and still under the effects of their general anesthesia.
The components of this preoperative education should include:
- Splinting the incisional site
- Coughing and deep breathing exercises
- The use of the incentive spirometer
- Performing stress and relaxation techniques
- The use of patient controlled analgesia devices (PCA)
- The use of compression hose and sequential compression devices
- In and out of bed exercises including active leg exercises
Postoperative education should include the reinforcement of and coaching the client in terms of all of the components of preoperative exercises and routines as listed above in addition to how to care for the surgical wound and any alterations of the normal bodily anatomy such as caring for an ostomy, for example.
In addition to the extensive client and family education components described immediately above in the section entitled "Providing Preoperative and Postoperative Education", the following roles and responsibilities are done by the registered nurse during the preoperative period of time. Many of these roles and procedures are documented on the facility specific Preoperative Checklist to insure that no elements of this preoperative care are overlooked and not done. Some of the components of the Preoperative Checklist include things that are done by the registered nurse and others are done by other members of the health care team but all are validated by the registered nurse as done and complete.
Preoperative care can include:
- A complete physical assessment and medical history
- Obtaining and assessing laboratory diagnostic test data
- Preparing the client for other diagnostic tests, such as a chest +x-ray, and assessing the results of these other diagnostic tests
- The administration of ordered preoperative medications
- The nursing role in terms of the informed consent and the validation of the informed consent
- Special preoperative preparation including shaving and an enema, for example
- The removal of valuables and prosthetics, including dentures, and their safe keeping
Registered nurses assume different roles and responsibilities during the intraoperative phase of the perioperative process. For example, a registered nurse may be assigned to fulfill the role of the scrub nurse, the circulating nurse or the registered nurse first assistant.
The scrub nurse assists the surgeon during the operative procedure; the circulating nurse assesses the client, maintains aseptic technique and also maintains the safety of the client and the comfort of the environment. The registered nurse as the first assistant assists the surgeon in terms of advanced skills such as cutting tissue and controlling bleeding, as stated by the Association of Perioperative Nurses (AORN).
The role of the circulating nurse cannot be delegated to an unlicensed assistive person or the licensed practical nurse. As stated by the Association of Perioperative Nurses (AORN), the role of the circulating nurse is within the exclusive scope of practice for the registered nurse. The role of the scrub person, however, can be delegated to the licensed practical nurse and an unlicensed assistive staff person such as a surgical technologist under the supervision of the registered nurse. Lastly, the role of the first assistant is assumed only by a registered nurse with the advanced training and education necessary to perform competently in this capacity.
Some of the elements of nursing care during the intraoperative phase of the perioperative process include:
- Positioning of the client: The correct positioning of the client is based on the need for the surgeon to be able to fully visualize the operative area and the need to prevent the complications that can result from client positioning including skin breakdown and/or damage as the result of pressure, friction and shearing, nerve damage, and postoperative joint pain. The most common position that is used for surgical procedures is the supine position; for this position, the nurse will pad and protect pressure points such as the head, sacrum, coccyx, olecranon and scapula.
- Preparing and maintaining the sterile field: As fully discussed and detailed in the section entitled "Using Appropriate Technique to Set up a Sterile Field and Maintaining Asepsis", nurses set up, maintain and add to the sterile field during the intraoperative phase. Whenever the sterile field becomes contaminated with an inadvertent action, the entire sterile field and its contents are promptly discarded because the sterile field is no longer sterile. The entire set up must be redone from the very beginning. Nurses also add to the sterile fields during surgery when they open and place the needed supplies for the particular surgical procedure.
- Counting and rectifying sponges, sharps and other instruments: Nurses count sponges, sharps and other instruments used during the surgical procedure in order to insure that no foreign bodies are inadvertently left within the client's bodily cavities. The scrub nurse, or tech, in addition to the circulating registered nurse are responsible and accountable for the final sponge and instrument counts at the end of the surgical procedure.
- Continuously assessing and monitoring the client: Nurses are also responsible for continuously assessing and monitoring the client in terms of their vital signs, responses to anesthesia, their ECG readings, their pulse oximetry, their loss of blood, their intravenous fluid intake and their output, their laboratory values and their pulmonary artery, arterial and venous pressures.
- Managing and maintaining the client's drains, catheters and tubes: Nurses manage and maintain the client's lines, drains, tubes and catheters such as their intravenous catheters, urinary drainage catheters and nasogastric tubes to suction, as indicated.
All members of the surgical team also participate in a mandatory "time out" before surgery that aims to prevent surgical medical errors such as wrong patient surgery, wrong procedure, and wrong site surgery.
According to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), time outs are done after surgical site marking is done, after all verification procedures are complete and all questions and concerns have been addressed and resolved. Time outs are done immediately prior to the beginning of the invasive procedure and:
- "A designated member of the team starts the time-out.
- The time-out is standardized.
- The time-out involves the immediate members of the procedure team: the individual performing the procedure, anesthesia providers, circulating nurse, operating room technician, and other active participants who will be participating in the procedure from the beginning.
- All relevant members of the procedure team actively communicate during the time-out.
- During the time- time-out, the team members agree, at a minimum, on the following:
- correct patient identity
- procedure to be done
- correct site
- When the same patient has two or more procedures: If the person performing the procedure changes, another time-out needs to be performed before starting each procedure.
- Document the completion of the time-out. The organization determines the amount and type of documentation." (JCAHO, 2016)
The American Association of Moderate Sedation Nurses (AAMSN) Position Statement on the Role of the Registered Nurse in the Management of Patients Receiving Conscious Sedation for Short-Term Therapeutic, Diagnostic, or Surgical Procedures states:
"AAMSN teaches the position that registered nurses trained and experienced in critical care, emergency and/or peri-anesthesia specialty areas may be given the responsibility of administration and maintenance of moderate or conscious sedation in the presence, and by the order, of a physician. The registered nurse has the knowledge and experience with medications used and skills to assess, interpret and intervene in the event of complications. This registered nurse is an asset to the physician and enhances the quality of care provided to the patient.
Because of the importance assigned to the task of monitoring the patient who is receiving conscious sedation, a second nurse or associate is required to assist the physician with those procedures that are complicated either by the severity of the patient's illness and/or the complex technical requirements associated with advanced diagnostic and therapeutic procedures.
The registered nurse will be knowledgeable and familiar with their institution's guidelines as well as the Joint Commission for Accreditation of Health Care Organizations (JCAHO), American Association of Nurse Anesthetists and the American Society of Anesthesiologists for patient monitoring, drug administration, and protocols for dealing with potential complications or emergency situations during and after sedation."
The procedure for moderate sedation, according to the Policy and Procedure on Conscious Sedation/Analgesia for Adults is as follows:
The Administration Phase
- Administer pharmacological agents under direct supervision of responsible physician. Begin administration of sedative or analgesic drugs only when responsible physician is present.
- Continuously observe and document patient responses to conscious sedation/analgesia:
- ECG, BP, and oxygen saturation every five minutes
- Auscultation of breath sounds and observation of respiratory depth and rate every five minutes
- Level of sedation and mental status every five minutes
- Skin color and condition every 10 minutes
- Pain rating every 10 minutes
- Provide reassurance and emotional support throughout the procedure.
- Inform the physician immediately of adverse response or any significant changes in baseline parameters.
- Maintain continuous IV access.
- Perform emergency management procedures if necessary.
Note: Determining some of the monitoring parameters as frequently as outlined above may not be possible during some procedures. For example, if the purpose of conscious sedation/analgesia is to help the patient remain as still as possible, frequent inflation of the BP cuff may stimulate the patient and prove to be counterproductive. In these cases, close observation and monitoring of other parameters is invaluable.
The Recovery Phase
- Continue mechanical monitoring: ECG, BP, oxygen saturation.
- Assess and document vital signs, skin condition, level of sedation and mental status, and pain every 15 minutes for at least 60 minutes after the last sedative or analgesic drug dose is given and until discharge criteria is met.
- Maintain IV access for at least 60 minutes after last sedative and analgesic drug dose is given and until discharge criteria are met.
- Review discharge instructions - http://prc.coh.org/html/Paserosedation.htm
- Changes/Abnormalities in Vital Signs
- Diagnostic Tests
- Laboratory Values
- Potential For Alterations in Body Systems
- Potential for Complications of Diagnostic Tests/Treatments/ Procedures
- Potential for Complications from Surgical Procedures and Health Alterations
- System Specific Assessments
- Therapeutic Procedures (Currently here)