Exam 1 Flashcards
What are the three phases of operative nursing?
PO, IO, POP
- preop
-intraoperative
Post op
What test/ exams need to be completed or examined during the pre- op phase?
- Physical exam
- medical and surgical history
- labs
-pre-op teaching
-informed consent
Why is it important to do a complete physical exam before surgery?
To establish the patients baseline so if something happens they are able to assess and intervene
What is implied consent and when is it used?
It is used only in emergent situations where consent cannot be obtained
What is the job of the circulation nurses?
- patient safety
- documentation
- initiates time outs
What is the role of the scrub nurse/ tech?
- sterility
- handing instruments to surgeon/ FA
What is anesthesia responsible for?
- medication
- pt. Vitals
What is that main priority in the post op phase?
- vitals signs (A, B, C’s)
- hand off report
What does the nurse need to observe before the patient is free to b e discharged?
- active bowel sounds
- Gag reflex ( if intubated during surgery)
- patient needs to be able to pee w/o catheter
- pain must be controlled by oral pain meds
What is the lateral recovery position used for?
- to prevent the tongue from obstructing the airway and helps to prevent choking, reduce the risk of aspiration, and promote adequate breathing
What is isotonic solutions like lactated ringers or 0.9% NS used for?
Vascular fluid volume deficit or risk for fluid volume overload r/t renal or cardiac disorders
What are hypotonic solutions used for such as 0.45% NS?
Treats interstitial and intracelluar dehydration, hypernatremia, maintenance fluid
What are hypertonic solutions such as 3% NS used to treat?
Hyponatremia and pulmonary edema
Ignore
What are the S+S of fluid excess volume?
- bounding pulse
- weight gain
- edema
- crackles in the lungs
- increased BP
What are the S+S of a fluid volume deficit?
- dry mucous membranes
-poor skin turgor - increased HR and RR
- decreased cap refill
-orthostatic hypotension - increased body temp
What labs do you have to watch in volume deficit and excess
- hematocrit
- serum sodium
- BUN
- plasma and urine osmolality
What causes sodium deficiency (hyponatremia)?
- GI loss
- heart failure
-Inappropriate SIADH syndrome
What causes sodium excess (hypernatermia)?
E, DI, CS
- excess oral sodium intake
- Na+ retention due to corticosteroids
- H2O loss due to diabetes insipidus
What are the clinical manifestations of hyponatremia due to FVD?
I, IHR, OH, WP
- irritability
- increased HR
- orthostatic hypotension
- weak pulses
What are the clinical manifestations of hyponatremia due to FVE?
H, MS, WG, IBP
- headache
- muscle spams
- weight gain
- increased BP
What are the clinical manifestations of hypernatremia due to FVD?
- increased thirst
- agitation
- weakness
- increased HR
What are the clinical manifestations of hypernatremia due to FVE?
- restlessness
- agitation
- twitching
What are the severe clinical manifestations of Na+ imbalance?
Seizure, coma, and vomiting
What labs/ assessments should be monitored in pts with Na+ imbalance ?
- daily weight
- I and O’s
- LOC
- HR, BP, and pulses
- edema
- muscle strength
What are the safety precautions that she be put in place for pts with Na+ imbalance?
- fall precautions
- seizure precaution
What are possible treatments for pts with hyponatremia?
- IV normal saline
- IV 0.3% sodium chloride
What are possible treatments for pts with hypernatremia ?
- change diet
- loop diuretics
What does potassium (K+) play a big role in?
Muscles including the heart
What are causes of hypokalcemia?
- GI loss
- meds: loop + thiazide diuretics, corticosteroids
- inadequate K+ intake ( ex. NPO, diet low in K+)
- increased blood glucose = decreased K+
What are causes of hyperkalemia ?
- renal dysfunction
- meds: ACE, ARBs, K+ sparing diuretics, NSAIDS, spiranalactone, beta blockers
- excess K+ intake ( K+ replacement IV/PO)
What are clinical manifestations for hypo and hyperkalemia?
- muscle weakness
- twitching
- Cardiac dysrhythmia
- Decreased LOC
- decreased reflexes
- paresthesia
- N/V
When administering K+ what should the nurse NEVER do?
Causes heart cessation
- never slam K+
- never bolus
- never exceed infusion rate of 10mEq/L
How is hypokalemia reversed?
- ## IV infusion to replace
How is hyperkalemia reversed?
Increased K+ excretion
- kayexalate ( causes pt to excrete K+ in the form of stool)
- loop thiazide ( diuretic)
- dialysis
- insulin
- albuterol
- calcium
What labs/ assessments need to monitored in pt’s with a potassium imbalance?
- ECG
- pulses
- IV ( K+ is a vein irritant, check pts IV for redness, swelling, pain, etc.)
- decreased UO
What is the cause of hypocalcemia?
HP, HPT, CAU
- hypoparathyroidism
- hyperphosphatemia
- serum albumin
- Chronic alcohol use
- loop diuretics
What is the cause of hypercalcemia?
- hyperparathyroidism
- cancers (breast, kidney, lung, bone metastasis)
- prolonged immobility
- meds: thiazides, calcium supplements, calcium based antacids ( tums)
What are the clinical manifestations of hypocalcemia?
T, C+T, N+T, DBP, ECGC
- tetany
- chvostek and trousseau’s
- numbness + tingling
- decreased BP
- ECG changes
What are the clinical manifestations of hypercalcemia?
DR, IBP, ECGC, BP, PU, D
- depressed reflexes
- increased BP
- ECG changes
- bone pain
- polyuria
- dehydration
What reverses hypocalcemia?
- increase calcium intake
- adequate hydration
What reverses hypercalcemia?
- limit foods high in calcium
- avoid IV solutions that contain calcium (ex. LR)
- weight bearing exercises
What causes hypomagnesemia?
GIFL, CAU, MAS, IUO, HGLY, PPI
- GI tract fluid losses
- chronic alcohol use
- malabsorption syndromes
- increased UO
- hyperglycemia
- PPIs
What causes hypermagnesemia?
A, IVM, RF, MBD, TLS
- antacids
- IV magnesium
- renal failure
- metastic bone disease
- tumor lysis syndrome
- hypothyroidism
What are the clinical manifestations of hypomagnesemia?
C, MC, T, S, HATR, C+T, IBP+P
- confusion
- muscle cramps
- tremor
- seizures
- hyperactive tendon reflex
- chvostek and trousseau’s
- increased BP and pulse
What causes hypermagnesemia?
L, D, MW, D/ATR, DP+BP, N/V
- lethargy
- drowsiness
- muscle weakness
- decreased/ absent tendon reflexes
- decreased pluses and BP
- N and V
What are the interventions for hypermagnesemia?
IV calcium gluconate
What is the primary level of prevention for cancer prevention?
- smoking cessation
- decreased or elimination of alcohol use
- sunscreen 15- 30 SPF or higher
- promote healthy behaviors
What are the warning signs of cancer?
CAUTION
- Change in bladder and bowel habits
- A sore that doesn’t heal
- Thickening or lump in the breast or elsewhere
- Indigestion or difficulty swelling
- Obvious change in wart or mole
- Nagging cough or hoarseness
What is magnesium used primarily for treating ?
- reflexes and lowers risk for seizures
What is the main diagnostic tool for looking for cancer?
PET scan
What other diagnostic tools are used to find/ diagnosis cancer?
- biopsy
- lab tests
- radiography
- colonoscopy’s
- bronchial wash
How are cancers classified
TNM
- Turmeric size and invasiveness
- Node - prescience or absence spread to regional lymph node
- Metastasis
What does a high score on the TNM classification test signify?
The worse the prognosis
What is chemotherapy?
- systemic or localized cytotoxic medication to kill of rapid dividing cells
What other rapid dividing cells does chemotherapy kill off?
- GI
- bone marrow
- skin, hair, and nails
What are the main safety concerns with patients being treated by chemo?
- their bodily secretions are still toxic 48 hours after treatment
What should the nurse educate the chemo patient on 48 hours after treatment?
- use separate toilet or double flush
- replace toothbrush
- abstain from se x
- ALL body secretions are poisonous 48 hours after treatment
What is the common route for chemotherapy to be administered?
- IV
- central venous access device ( CVAD)
What is a potential complication of chemo being administered IV?
Infiltration because chemo is a vesicant that can cause tissue damage and loss opening the risk for infection
What is protocol for peripheral IV extravasation?
- stop the infusion immediately
- contact HCP
- leave IV in place
- do not flush but pull back
- specific chemos have an antidote
What is protocol for a central line extravasation?
- stop the infusion
- pull drug back from the line
-leave the line in place - contact HCP
What is external radiation therapy?
Radiation to a specific body part marked by radiology
What are some safety concerns for pt’s receiving external radiation therapy?
- gently clean with water and mild soap (no scents)
- avoid powders, lotions, or creams unless Rx
- avoid sun exposure
What are some safety concerns for pt’s receiving internal radiation?
- they radioactive after treatment
- they must have a limited amount of visitors
- nurses must wear lead aprons and cluster care
What is internal radiation therapy ?
Sealed radiative implants into the tumor or nearby the tumor
Which therapy doesnt leave the pt radioactive after treatment?
External radiation therapy
What are the adverse effects of chemo and radiation therapy?
- bone marrow suppression
- anorexia
- nausea
-vomiting
Infection - alopecia
- leukopenia
- reproductive problems
How does bone marrow suppression affect the WBCs?
- increase risk for infection
How does bone marrow suppression affect the platelets?
Increases risk for bleeding
How does bone marrow suppression affect the RBCs?
Increased risk for severe anemia
What are some nursing interventions that can be put into place to prevent bone marrow suppression from effecting the WBCs?
EIS, AI, APT
- enhance immune system through diet, rest, and handwashing
- avoid infection by implementing neutropenic precautions
- asses the pt’s temp daily
What are some nursing interventions that can be put into place to prevent bone marrow suppression from effecting the platelets?
Avoiding risky behaviors such as use of an electric razor, stool softeners, IM injections, aspirin products
What are some nursing interventions that can be put into place to prevent bone marrow suppression from effecting the RBCs?
- increase RBC count by iron rich foods, blood transfusions, and EPO
- may need o2
What should the patient report immediately to the HCP?
BTS, UexB, UB
- black tarry stool
- unexplained bruising
- uncontrolled bleeding
How can the nurse prevent stomatitis or mucotitis
- oral hygiene
- soft or bland high protein food @ room temp
- straw for liquids
- rinse mouth with water and saline topical anesthetic
How is pain managed in cancer pt’s?
- NSAIDs for moderate to severe pain
- antidepressants and anti-seizure drugs fr neuropathic pain
What is the most reliable measure of fluid status?
- daily weights
What is IS used for?
- lung expansion
