The postoperative care nurse reviews the documentation from the ...

[strangeaffliction]

The postoperative care nurse reviews the documentation from the intraoperative phase and determines that several areas are missing. Which areas did the nurse identify as being missing from the intraoperative documentation?
 
  Select all that apply.
  A) Pain assessment
  B) Start and stop times of anesthesia
  C) Medication review
  D) Antibiotic infusion times
  E) Start and stop times of the procedure

Question 2

While receiving report from the operating room, the nurse learns that a client's surgical wound for gallbladder removal is classified as III. What could have caused this wound classification?
 
  Select all that apply.
  A) The alimentary tract was not entered.
  B) The wound is necrotic and infected.
  C) Gallbladder contents spilled into the surgical site.
  D) A break in sterility occurred during the surgery.
  E) The alimentary, respiratory, genital, or urinary tract was entered.

[Ahnyah]

Answer to Question 1

Answer: B, D, E

Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure. The pain assessment and medication review are documented during both the preoperative and postoperative assessments.

Answer to Question 2

Answer: C, D

An incision is classified as III-contaminated wound if gross spillage occurred. This classification is also identified if a major break in sterile technique occurred. An incision is classified as I-clean if the alimentary, respiratory, genital, and urinary tract are not entered. An incision is classified as IV-dirty, infected if the wound is necrotic and infected. An incision is classified as II-clean contaminated if there are no signs of infection but the alimentary, respiratory, genital, or urinary tracts were entered.