Exam #1 Flashcards
What is immunity?
The bodies specific response to a foreign antigen or organism
What is the purpose of the immune system?
To fight off foreign bodies that can infect our body
What type of cells fight off infection?
WBC
What instances can raise WBC?
Infections or trauma
When a WBC response is triggered what is also triggered?
Inflammatory response
What type of diseases attack your own healthy tissues?
Autoimmune diseases
What occurs in the body with a hypersensitivity?
It is when your body has a inappropriate response to specific antigens
What are some examples of hypersensitivities?
Peanut, dog, cat, pollen, latex
What happens inside the body with a primary deficiency disesease?
Improper development of the immune system
How do you get a primary deficiency disease?
Through genetics/inheritance
Changing of genetic make up
What are some examples of primary deficiency diseases?
Sickle Cell, HIV/Aids
What is a secondary deficiency?
a disease that is developed later in life and is a result of a primary disease
What is an example of a secondary disease and how it develops?
A person with HIV has a supressed immune system gets Pneumonia
The pneumonia is the secondary disease
Can secondary diseases alter genetic make up?
Yes
What parts of the body do rheumatic diseases effect?
Muscles, bones, ligaments, and joints
In rheumatoid arthritis is inflammation primary or secondary?
Primary
In rheumatoid arthritis what happens if the inflammation of the body is controlled?
The patient will get relief because the inflammation is what is causing the problems in the first place
In degenerative diseases what happens to the patients condition if inflammation is controlled?
Swelling will go down but their underlying condition/symptoms will still be present
What is an autoimmune disease?
A disease that attacks your own healthy tissues
In what rheumatic disease is inflammation secondary?
Degenerative, osteoarthritis
In what diseases is inflammation primary?
Autoimmune rheumatic diseases such as lupus, MS and Rheumatoid arthritis
What are some examples of rheumatic degenerative disorders?
Osteoporosis and osteoarthritis
Is osteoarthritis and osteoporosis inflammatory or non inflammatory?
Non inflammatory
What occurs in the body in patients with osteoarthritis?
The Cartlidge that protects the joint and allows smooth movements is worn down to the point that bones are rubbing on each other
What occurs in the body for patient with osteoporosis?
Their body is not regulating calcitonin and estrogen properly which prevents their bones from keeping the calcium they need to be strong
What are the differences between rheumatoid arthritis and osteoarthritis?
RA is an inflammatory disease while OA is noninflammatory
RA is bilateral where OA can be unilateral
Morning stiffness for RA can take between 30 up to an hour to go away whereas OA is better in less than 30 minutes
What is happening to the cartilage and synovial membrane in RA?
Cartilage is still in tact but the synovial sac is inflamed
What is happening to the cartilage and synovial membrane in OA?
Thinned cartilage but the synovial membrane is fine
Does RA or OA have crepitus?
OA
Does RA improve or worsen with use?
May improve
Does OA improve or worsen with use?
Worsens
Is RA or OA systemic?
RA
What is RA?
A chronic progressive systemic inflammatory disease that affects tissues and joints
How does RA damage joints?
Inflammation in the synovial sacs form growths called pannus that narrow the joint space causing pain, damage, and decreased ROM
Where does RA typically start and where does it go from there?
Starts in hands first and then goes on the knee and spine
What are some non systemic symptoms of RA?
Bone erosion, erythema, immobilization, contractures, deformities
What is erythema?
Warmth of the joint
What are some systemic symptoms of RA?
Anemia, anorexia, fatigue, depression, vasculitis, pericarditis, kidney disease, Sjögren’s syndrome, and Raynauds
What is anemia?
This occurs when you have a drop in your hemoglobin and hematocrit
Why is anemia bad?
Because you will not have enough hemoglobin to carry oxygen to your body
What are some symptoms of anemia?
Fatigue, weakness, SOB, pale skin, head ache, cold hands/feet, dizziness, irregular heartbeat, chest pain
What is vasculitis?
Inflammation of the blood vessels
What are symptoms of vasculitis?
Fever, headache, general body pain, hypertension, MI, stroke, nose bleeds, blood cough
What is pericarditis?
Inflammation around the heart
What does the patient feel when they have pericarditis?
Pain on inhalation but not on exhale
What can pericarditis be confused with?
heart attack / cardiac arrest
What should you in relation to the kidneys in RA patients?
Monitor creatinine, BUN, and urine output
What is Sjögren’s syndrome?
Any gland that produces xxxx goes dry….dry mouth and dry eyes
What is raynuads syndrome?
Blood vessels constrict in the hand and makes finger turn blue/pale and makes them numb
Why would a physician order an x ray for a RA patient?
To look for bone erosion and deformities
What labs are ran for a potential RA patient?
Rheumatoid factor, CBC, H and H, ESR, BMP, Liver enzymes
What does a rheumatoid factor show?
Looks for antibodies in the connective tissues
Why would a CBC test be ran on a RA patient?
Their immune systems are lowered so they are looking for possible infection
Why would physicians run a ESR on a potential RA patient?
to look for excessive inflammation
Why would a physician run a BMP on a potential RA patient?
To monitor for dehydration, electrolytes , BUN, and Creatinine
Why would a physician run a liver enzymes on a RA patient?
To get baseline numbers on to compare once starting RA medications….RA medications can affect the liver
What are goals of treatment for RA patients?
Decrease pain, inflammation, and slow the progression
What procedure can be done to help alleviate pain and restore function from RA?
Artherocentesis
What is a artherocentesis?
This a procedure where a physician will insert a large needle into a synovial sac and drain of the excess fluid
What medication is used during Arthrocentesis?
Lidocaine to numb the area
What is another term used for Arthrocentesis?
Joint aspiration
What education should you give to a post op Arthrocentesis patient?
Labs may be drawn, ice the site, don’t use heat, look for drainage, watch the swelling, and rest for 24 hours
What should RA patients do at home to improve their condition?
Take medications, rest, ROM exercises, ICE, heat, PT, OT, support groups, and self care
What are the risk factors for RA?
Women, age 30-60, having Epstein bar virus, genetics, physical / mental stress
What are you looking for in an immunity assessment in relation to physical assessment?
Hair and skin….rashes, lesions, erythema, hair loss, hair thinning, photosensitivity, dyshphagia, void patterns, stool or urine characteristics
What is lupus?
A chronic progressive system inflammatory autoimmune disease that causes organs and systems to fail due to remissions and exacerbations
What is occurring in relation to WBC in lupus?
The WBC are attacking healthy tissues
What are the risk factors for lupus?
Women, 30-45, African Americans, Asians, Hispanics, native Americans, native Hawaiians
Clinical manifestations of lupus?
Fever, pain in several joints (mimics RA?), fatigue due to anemia, weakness, amenorrhea, oliguria, anorexia, butterfly rash, photosensitivity, systemic issues
What can trigger lupus exacerbation?
Any stress to the body such as child birth, drugs, uv light
What systemic issues arise in lupus patients?
Alopecia,amonorhea pancytopenia, LOC, pleural effusion, lupus nephritis, pericarditis, raynauds syndrome
What is amenorrhea?
Irregular menstrual cycle
What is oliguria?
Decreased urine output
What does butterfly fly rash look like?
Dry, scaly, raised red rash on the face
What is alopecia?
Patchy hair loss
How can lupus cause changes in a patients LOC
Confusion, irritability, headaches, seizures, decrease sodium
What does pancytopenia mean?
Decrease in all blood cells which included anemia, neutropenia, thrombocytopenia
What is anemia?
Decreased RBC
What is neutropenia?
Decreased WBC
What is thrombocytopenia?
Decreased platelets
What is a pleural effusion?
Build of fluid between the lungs and heart
What does pleural effusion look like?
Wet cough, chest paints, SOB
What is lupus nephritis?
Damage to kidneys due to lupus effects
What are symptoms of lupus nephritis?
Fluid build up, decreased urine output, increased BP, increased creatinine, peripheral edema
What does pericarditis feel like for the patient?
Pain on inhalation but not on exhale
How is a diagnosis of lupus made?
Combination of H and P, skin biopsy, and labs
What skin is removed for testing?
The lesions or rashes
What labs are looked at for lupus?
Antinuclear antibody, rheumatoid factor, erhyrocyte sedimentation rate, basic metabolic panel, complete blood count, UA
What does the ANA/ antinuclear antibody lab show?
Shows the number of antibodies present for ????
What does the RF lab do in relation to lupus?
Helps determine if the patient has RA or Lupus
What does the UA look for in lupus patients?
Looks at BUN and creatinine levels to determine kidney function
What does the CBC look for in lupus patients?
WBC, H and H, and Platelets
What is the goal when treating lupus patients?
Prevent organ damage, reduce exacerbations, pain control, and reduce the disease effects that come with lupus
What education should be give to patients with lupus?
Inspect skin, avoiding prolonged sun exposure, wearing long sleeves, brimmed hats, sun block of 30 spf or higher, mild soaps with no perfume, avoid skin drying agents like make up and powders , and support groups
What does the antigen do on a blood cell?
It is the key for what can be accepted by that blood cell
What does the antibody do in a blood cell?
It prevents that blood type from being accepted by the body
What happens if a patient gets the wrong blood type?
Agglination
What happens during agglutination? ?
The persons receives the wrong combination for antigen and antibody….the body then clumps of these cells
Who is agglutination most common in?
Patients receiving many units of blood
What is a autologous infusion?
An infusion do with your own donated blood
What are some good medications to give pre transfusion to reduce the speed and effects of agglutination?
Benadryl, Tylenol,
What type of saline is used when transfusing blood?
Normal 0.9 saline
What is added to a IV line when infusing blood?
A filter
What should be done between infusing each unit of blood?
Changing the IV tubing????
What lab is run to determine patient blood type?
Type and screen
When would it be a good idea to use a transfusion warmer?
Patients with problems of thermoregulation or in patients that are receiving many units of blood
What is the max time a unit of blood can be infused for?
4 hours
What blood type is the universal donor?
O blood
What is the universal acceptor blood type?
AB
What are the types of blood transfusion reactions?
Febrile, hemolytic, and allergic
What are the symptoms of a febrile blood reaction?
Chills, fever, headache, flushing, tachycardia, and increased anxiety
What are symptoms of an allergic reaction during a blood transfusion?
Mild…Hives, pruritis, facial flushing, SOB, bronchospasms, anxiety
What are the symptoms of a hemolytic transfusion reaction?
Low back pain, hypotension, tachycardia, fever, chills, chest pain, tachypnea, homoglobinuria, may be immoderate onset
What should you do if patient exhibits any type of reaction to a blood transfusion?
Stop infusion, notify physician, change iv tubing, treat symptoms, administer o2, epi, and fluids as needed, recheck blood type being infused with type and screen results
What should you do for blood transfusion reaction in relation to hemolytic reactions?
Obtain 2 blood samples distal to infusion site, obtain UA testing for hemoglobinuria, monitor fluid and electrolyte balance (BMP), evaluate serum calcium levels
What is the purpose of priming blood infusion with saline?
If you do not prim tubing with saline the blood cells become shredded
What is added to IV tubing during a blood transfusion to prevent clots from reaching the patient?
Filter chamber
What is multiple sclerosis?
A chronic progressive autoimmune disease that causes demyelination of the myelin that surround the axon of the neuron
What causes demyelination of the myelin in MS?
Inflammation
Why is demyelination of the myelin bad?
It distorts the message from your brain telling your organs and muscles what to do
What are risk factors for MS?
Genetics, developmental changes, environmental changes such as cold climates, women, ages 15 - 45
What are the symptoms of MS?
Muscle weakness, spasticity, pain, fatigue, vision changes, spastic bladder, decreased sexual function, gait changes, intention tremors, parenthesis, dysarthria, dysphasia, cognitive changes
What vision changes can someone with MS have?
Blurred vision, diplopia, scotomas, nystagmus
What is diplopia?
Double vision
What is scotomas?
Changes in peripheral vision
What is nystagmus?
Involuntary eye movement
What symptoms does someone with a spastic bladder have?
Incontinence
What may MS patients have to do at home to relieve their bladder problems?
In and out catheter
What gait changes may you suspect in a MS patient?
Not picking up their feet completely
What are intentional tremors?
Tremors when the patient is trying to do something
What is parenthesis?
Numbness and tingling
What is dysarthria?
Slurred speech
What is dysphagia?
Difficult swallowing
What is someone with dysphagia at risk for?
Aspiration
What is aspiration?
Inhaling foreign object into the airway
What cognitive changes might you see in a patient with MS?
Depression, delirium, attention span issues, and early onset dementia
How can you differentiate between MS and Parkinson’s?
When walking Parkinson’s patients shuffle their feet while MS patients drag them
What are the differences between MS and ALS?
MS have episodes of remission and exacerbations
MS has muscle spasticity where as ALS has Muscle atrophy
MS does not impact the respiratory system where as ALS does
MS causes body tremors where as ALS causes facial/tongue twitching
What happens when ALS reaches the lungs?
Death
What can be done to help diagnose MS?
Lumbar puncture and MRI of brain and spine
What do they do during a lumbar puncture?
The physician will remove some CSF from the low back and test the fluid
What must a patient do after having a lumbar puncture done?
Lay flat until physician says its okay for them to sit up
What should the nurse do if the patient experiences a headache upon sitting up after a lumbar puncture?
Lay them back down and notify the provider
What does a headache mean after sitting up in lumbar puncture patients?
That their is leak of CSF somewhere in the spine
What is the goal of treatment in patients with MS?
Delay progression, manage symptoms, and treat exacerbations
What education should be given to a MS patient?
Avoid rigorous activity, avoid extreme temps, plan activities, alternate eye patch??, toileting schedule, PT, OT, ST, eliminate things that could cause falls
Why should you alternate eye patch in MS patients?
To help treat the diplopia
What is perioperative nursing?
Nursing that starts from scheduling and sometimes after discharge
What is considered pre operative?
From scheduling to transfer to surgical suite
What is considered intraoperative?
Entering to the surgical suite up until the transfer to post anesthesia care unit (PACU)
What is considered post operative?
From PACU to surgeons release..sometimes extending past discharge
What is considered the number one priority in the perioperative setting?
Safety
What are patients at risk for while in a perioperative setting?
Infection, impaired skin, ineffective thermoregulation, self care deficit, DVT, cardiac events
What considerations should you have for a surgical patient?
Comfort, nutrition, sensory, interaction, education
What nutritional considerations should you keep in mind for surgical patients?
NPO status, hydration status, eating enough to promote healing
What elimination considerations should you keep in mind for surgical patients?
Surgery often slows down elimination for both urine or stool
What sensory considerations should you keep in mind for surgical patients?
Nerve blocks, lidocaine, opioid high
What human interaction considerations should you keep in mind for surgical patients?
Anxiety and disturbed body image
What learning considerations should you keep in mind for surgical patients?
They may not be fully informed or educated about procedure, their condition, and what post surgery will be like
What are the “reasons” for an operation?
Diagnostic, Curative, restorative, palliative, and cosmetic
What is considered a curative surgery?
Removal of cancer mass or removal of a problematic organ
What is considered a diagnostic surgery?
When a biopsy is taken
What is considered a restorative surgery?
Something that can improve functional ability but does not cure the issue
What is considered a cosmetic surgery
something done to help only with appearance
What is considered a palliative surgery?
Reduce suffering or support quality of life….how does this differ from restorative???
What are the different level of urgency for surgeries?
Elective, urgent, emergent
What is an elective procedure?
A procedure that a patient may need but does not threaten their life
What is an urgent procedure?
A procedure than can wait until the patient is medically stable …
What is an emergent procedure?
A procedure that must be done or the patient will die
What is the degree of risk for operations?
Minor or major
What are the extents of surgery?
Simple, radical, or minimally invasive
What is a minimally invasive surgery?
A procedure that uses specialized instruments that either go into a natural orifices or use very small incisions
What is a simple procedure?
Only removing part of an organ
What is a radical procedure?
Removing all of the organ
How far out must patients not have solids from surgical procedure?
8 hours
How far out must patients not have liquids?
2 hours
What is on the pre op check list?
Accurate patient identifiers, last know oral intake, psychosocial support, 18 gauge preferred or 20 gauge IV, base line imaging is done, base line labs are done, patient voids before giving pre op meds, consent is signed before giving any mental altering meds, the DR has marked the correct procedure site, OR check list is complete in the front of chart, pre op meds are given, and side rails up
What should be removed before a patient goes into surgery?
Jewelry, dentures, bridges, nail polish, clothing, contact lenses,
What should be done to the skin before surgery?
Chlorhexidine aka CHG bath
When should on the call to OR meds be given?
When the CRNA/Anesthesiologist calls…it will be 30 minutes before the procedure will begin
What are advance directives?
A legal document that the patient has made stating what they wish to be done if they can not make decisions for themselves
What status should be noted before procedures?
DNR, DNI, Full code
What should you not do once you give hypnotics to a patient?
Leave them alone
Why would baseline imaging be done before a procedure?
To see what needs to be operated on and have something to compare to after surgery to see if there is improvement or not post op
Why would baseline labs be done before a surgery?
To see if they will have delay clotting times or have something to compare WBC with in relation to infection
What labs will be run before a procedure?
CBC, CMP or BMP, Type and Screen, Clotting Factors, and UA
What does a CBC lab show?
RBC, WBC, Platelets
Why would a CBC be ran before a procedure?
To look a their RBC, WBC, and platelets
Why would you need to know what a patients RBC is before a procedure?
RBC shows hemoglobin and hematocrit….if these value are low then you know if they need a blood transfusion before or if they will need the transfusion during the procedure
Why do you need to know WBC count before a procedure?
You need the WBC count first determine if they have a infection prior to surgery but also have a baseline number to compare to post surgery
Why would you need to know a platelet count before surgery
Your platelets are responsible for clotting and if you do not have enough platelets then you run the risk of bleeding out
Why would you run a BMP/CMP before a procedure?
To determine their kidney/liver function, blood sugar, electrolyte, and hydration status
Why is kidney/liver function important to know before surgery?
The anesthesiologist or CRNA needs to know the level of function of these organs because these organ metabolize the anesthetics
Why would you need to know a patients blood sugar before a procedure?
Having a controlled blood sugar helps the body fight off infection also your patients most likely will not have eaten anything which will likely have their blood sugar low
What should you take into consideration with diabetic patient at are NPO and schedule insulin?
Check their blood sugar before giving the insulin…the patient is fasted therefore will likely have a normal blood sugar level..if the patient is coming the day of surgery make sure that their blood sugar is in a acceptable range because they may have taken their scheduled insulin while fasted and put their blood sugar below an acceptable level
What medications should you be most concerned about before a patient comes to have their procedure done?
Anti diabetic medications, anticoagulants, antiplatelets, antihypotensives
Why would a type and screen be run before a procedure?
So that the patients blood type is known just in case of an emergency during the procedure where they need an immediate transfusion
What are the clotting studies that are ran?
INR, APTT, Anti Xa
Why are clotting studies ran before a procedure?
To determine their ability to clot up and stop bleeding….if their ability to stop bleeding is hindered too much they run the risk of bleeding out during a procedure
Why is a chest x ray done before a procedure?
Do look at overall lung health and to check for pneumonia
Why is an EKG/ECG performed before a procedure?
Surgery is stressful on the body and a abnormal heart function could lead to cardiac arrest also to have a baseline to compare to post op
In what patient population is a ekg/ecg performed before surgery?
Patients over 40 or patients with a past heart history
Why would a UA be done before a procedure?
To see if a women is unknowingly pregnant….anesthesia and the operation could harm the child
How far out from the procedure should patients stop taking Antiplatelets and anticoagulation medications?
2-3 days before the procedure
What do you do if you feel like the patient is not adequately informed about their procedure?
Call the provider and chart it.
What if you discover a critical or out of range lab result?
Call the prover and chart it
What does adequate disclosure of diagnosis mean?
The patient should know the purpose, risk, probability of success, and prognosis before treatment
What does understanding and comprehension mean?
The patient must understand the procedure and be drug free when signing the consent
What does consent given voluntarily mean?
The patient was not persuaded into doing the procedure
How old must you be to sign a consent?
18
When can parent sign for their children?
When the child is dependent on them
What two mental states should the patient be to sign consent?
AAO and competent
When can a consent be bypassed?
When the circumstance are life threatening and the patient can’t sign or if the person that can sign is not present
What are some symptoms of a latex allergy?
Urticaria,rhinorrhea , bronchospasms, compromised respiratory system
What allergies common correlate with latex allergy
Bananas, kiwi, avocado
What does Urticaria mean?
Rash or hives
What does rhinorrhea mean?
Runny nose
What allergy other than latex should you be aware of prior to surgery?
Drug and iodine?
What allergy is correlated with iodine allergy?
Shell fish
Who’s at most risk for a latex allergy?
Spina bifida, urogenital issues, spinal cord injury, health care providers, people who under go many operations
What is spina bifida?
The spine protruding from the skin
What is the urogenital system?
Organs of the reproductive and urinary system
Why should post op teaching be done during pre op?
Because the patient is sober and not under any drugs at that point
What pre op teaching might you talk about?
The surgery, sensations, pain management, ambulation, TCDB, Spirometer, and exercises
When should vitals be done pre and post op?
Xxx
When do severe reactions usually take place when administering blood?
Within the first 15 minutes or 50mL
How long should blood take to infuse?
Between 2 and 4 hours
what is a timeout?
correct patient, site, surgery, allergy, and surgical site marked
types of sedation…429 and 430 moderate sedation
xxxxx
What are the human needs considerations for perioperative care?
Comfort, nutrition, elimination, sensory, human interaction, and learning
What is dehiscence?
When the wound has separated and is exposing layers under the skin
What is evisceration?
Viscera is exposed or intestines are showing
What is the acronym coach used for?
charting body fluids
What does the acronym COACH stand for?
Color, Odor, Amount, Consistency, How is the patient tolerating
What is the acronym REEDA used for?
Assessing the surgical site
What does REEDA mean?
Redness…Edema…Ecchymosis…Drainage…Approximation
What is a pulmonary embolism?
A clot that is found in one of the pulmonary arteries
What are the symptoms of a PE?
Chest pain, dyspnea, tachycardia, anxiety, diaphoresis, blood gas changes, increases respiration rate, increased anxiety, decreased BP, decreased orientation
What is urinary retention?
When you are holding excessive amounts of urine
What are symptoms of urinary retention?
Unable to urinate for 8-10 hours post op
Palpable bladder
Frequent small voids
Pain in the suprapubic area
What is pneumonia?
Fluid in the alveoli
What are the symptoms of pneumonia?
Rapid shallow respirations, fever, wet breath sounds, asymmetrical chest movement, productive cough, hypoxia, tachycardia
What is atelectasis ?
Dyspnea, tachypnea, decreased breath sounds, aysmetrical chest movement, tachycardia, increased restlessness
What is gastric dilation?
Sudden and severe distention caused by a build up of fluid and gas
What are the symptoms of gastric dilation?
Nausea and vomiting and
Abd distention
What is a paralytic ileus?
condition where the motor activity of the bowel is impaired, usually without the presence of a physical obstruction
What are paralytic ileus symptoms
Decreased bowel sounds, no stool, no gas, nausea, vomiting, abd distention, abd tenderness
What to do if patient is having a PE?
Sit them up, apply oxygen, reassure client, call rapid response
How frequently are vitals done on a patient after surgery and when does the spacing between sets increase?
Q15 until patient wakes up and then every 4 hours after that
What is malignant hypothermia?
A condition that is set off by anesthesia where the patients body temperature increases up to 107 degrees
What are risk factors for malignant hyperthermia?
Men and genetics
What are symptoms of malignant hyperthermia?
Temp up to 107 degrees F
Dyspnea
Tachycardia
Tachypnea
Hypotension
Restlessness
Metabolic Acidosis
Elevated Ca and K
Cyanosis
Muscle rigidity in jaw and upper chest
Skin mottling
What are the interventions for Malignant Hyperthermia?
Dantrolene Sodium, cooling blanket, and ice applied to groins, armpits, etc
What labs will be looked at for a malignant hypothermia patient?
ABG….pH level, CO2, and O2
BMP for Ca and K
When can Malignant Hyperthermia happen?
From the surgical suite up to 24 hours post op
What are symptoms of OD?
Xxxx
What is a JP drain?
A bulb like drain that sits deeper in the wound and uses negative pressure to pull internal drainage out
What is a hemavac drain?
A spring loaded circular drain that pulls blood using negative pressure
What is a Penrose drain?
Soft flexible latex tube that drains fluid away from wound
How to brace your incision?
Brace against a pillow or push hands toward the incision reducing stretch on the incision site
How to breath for TCDB exercise?
3 slow breaths in through nose and on third breath cough to remove secretions
What does a circulatory nurse do?
Deals with patient advocacy and privacy
Sterile Continuity
Padding Boney proms
Traffic control
In charge of time out
Verifies consent
What does the scrub nurse do?
Sterile
Hands items to surgeon
Instrument count
Setting up sterile field
Pays attention to irrigation, urine, and blood lose
What is sanguineous drainage?
Bloody and normal for 1-2 days
What is serousanguineous?
Blood and water which is normal for 2 to 5 days
If it last longer Than 5 days the patient may be dehiscing
What is serous?
Clear drainage
What is purulent drainage?
Thick, yellow, creamy
What are symptoms of pulmonary embolism?
Anxiety, SOB, Cyanosis, Chest Pain, increased RR, Increased HR, decrease in SPO2, decrease in BP
How can you prevent PE?
Blood thinners, smoking cessation, exercise, ambulation, not sitting for prolonged periods, hydration, healthy, weight, not using oral contraceptives
What are symptoms of DVT?
Swelling, pain in the area of the clot, erythema, discoloration of skin around the site of the clot
What are the risk factors for DVT and PE?
Obesity, Age, Cancer, oral contraceptives, pregnancy, smoking, diabetes, HF, varicose veins, hypertension
What do you do if patient is having PE?
Raise head of bead, apply oxygen, encourage slow deep breaths and call rapid response
How to prevent respiratory complications?
Monitor vitals, TCDB, coughing, Incentive spirometry, turning in bed, getting out of bed, early ambulation, hydration, and monitoring response to analgesics
What post op assessments should be performed immediately after surgery/
Vital signs, pulse ox monitoring, tele monitoring, skin color, temperature, LOC, Position, surgical site
How long will the patient be NPO after surgery?
Until bowel sounds are auscultated
What meds can be given in pre op?
Hydroxyzine, lorazepam, midazolam, atropine
What are signs and symptoms of opioid OD?
Loss of consciousness, pinpoint pupils, breathing difficulty, respiratory arrest, choking, cyanosis, unresponsive to loud/shaking/painful stimuli
What are symptoms of benzodiazepine overdose?
Impaired mental status, confusion, slurred speech, slow breathing, respiratory arrest, coma
What shoulda nurse do during a OD?
Once a OD is determined, call rapid response, administer antidote, apply oxygen, suction airway of secretions if needed, monitor vital signs, apply cardiac monitor, keep patient on their side to decrease risk of aspiration, monitor fluid and electrolytes,
