Exam 1 Study guide Flashcards
Review consent form process, roles of the nurse vs physician
Consent**- The responsibility of the person providing the service Surgeon Anesthetist NOT nurse; nurse is witness
3 conditions for consent
Adequate disclosure – diagnosis, treatment plan, risks, outcome probability, alternatives, prognosis if tx not instituted
Clear understanding (before sedation)
Voluntary
Prep roles of the nurse vx physician
Preoperative teaching**- Education
Also the responsibility of the person providing the service
Surgeon: Surgical procedure and follow-up care (Often delegated)
Anesthetist: Anesthesia protocols.
Nursing: Pre and post-op expectations/procedures.
preparation (clothing, jewelry, shaving, bathing, glasses, dentures, etc),
environment of the OR,
transferring from area to area (preop, OR, pacu, floor/discharge),
IV initiation,
procedure,
pain,
surgical site,
understanding/questions about the procedure.
Reasons for a Post-operative-patient to be restless or confused are:
Delayed emergence
Check liver and kidney function
Delirium
anethesia, medications, respiratory
Hypothermia-how can we warm the patient?
Warm blankets
Bear hugger
Post-operative-patient restless, confused-nursing interventions to take and priority actions (ABCs)
Assessments: Airway - Try stimulation, O2 Breathing Circulation Neurologic- Can use stimulation Genitourinary Surgical Site- **Don’t take off 1st dressing** Surgeon does this. Nurse can reinforce dressing Pain Fluid and electrolyte status
Prevention and Treatment:
Know at risk groups – (Elderly – lower immune system, comorbidities)
Create safe environment
Careful patient and family history (Previously confused? – GET a baseline!)
Ongoing observation
Reversal agents
(Narcan – opioids, Romazicon – versed (antianxiety), Fresh frozen plasma - warfarin)
Careful use of pain medication-sedation, confusion
Medications to manage withdrawal symptoms - Adivan
Think about electrolytes – (Low Na+ ->cerebral edema)
Keep patient warm
Which meds can the nurse administer preop vs anesthesia? In the preoperative chapter of the med-surgical textbook
Preoperative Medications
Drugs and purposes T 17-8
Antibiotics - Prevent Postoperative infection
cefazolin
Anticholinergics – reduce oral and respiratory secetions, provide sedation, prevent N/V
scopolamine
Antidiabetics –Stabilize blood glucose (Insulin)
Antiemetics – prevent N/V, increase gastric emptying
ondansetron (Zofran) or metoclopramide (Reglan)
Benzodiazepines – reduce anxiety, induce sedation, amnesic effects
midazolam (Versed)
Beta blockers – manage HTN
labetalol
Histamine receptor antagonists – decrease HCL acid secretion, increase pH, decrease gastric volume
ranitidine (Zantac)
Opioids – relieve pain during preoperative procedures
morphine, dilaudid, fentanyl
Nursing precautions when a patient is NPO and receiving insulin.
Dextrose IV
- communicate with pre-op nurse – tell that given insulin; have dextrose IV drip running because don’t want to have them shut off pump accidently
- Look at glucose trends…if trending down let surgeon know and may say give lower dose or hold
Urinary complications
Includes:
Infection
Retention
Low output
Low output:
minimal accept urinary output 0.5 ml/kg/hr or 30 mL
First 24 hours, 800 ml to 1500 ml of urinary output is expected.
Most void 6 to 8 hours after surgery.
What do you do if there is a low urinary output?
Bladder scanner
Yes to bladder full -> straight catheter
No to bladder full -> fluid bolus, check creatinine
Common causes of low uop is third spacing (edema), low volume, sepsis, heart failure, obstruction, and medication harm.
Treatment:
NS fluid bolus X 2-if low on volume/fluid-usually the first intervention
Diuretic-will pull fluid from third spacing/edema and back into the vascular space
Dialysis
Urinary output nursing care-interventions- (including calculation)
Prevention and Treatment: Monitor I & O Cautious use of pain meds in high risk Avoid catheter if possible Males- stand to void Fluid challenge
Calculation of Fluid Gain or Loss: 1 L of water = 2.2lb (1 kg) 240 ml (8 oz) = 0.5 lb (0.24 kg)
A patient receiving diuretics loses 4.4 lb (2 kg). How much fluid has he lost?
ANS: approx 2L
Weight losses of more than 1-2 lb per day is usually due to water loss
Malignant Hyperthermia-know what it is, etiology, manifestations, medical treatments, nursing care discussed.
rapid rise in temperature, 105 F degrees, or 40.5 C
Usually happens intra-operatively but CAN HAPPEN IN POST-OP
Susceptibility
rare
Genetic components
Stress, trauma, heat
S&S
Hyperthermia (NOT the 1st sign)
Muscle rigidity
Causes
Altered control of Ca++ increased metabolism of skeletal muscle (contractures) elevated temperature hypoxemia lactic acidosis hemodynamic/cardiac alterations death
Trigger
Succinylcholine
Inhalation Agents
Treatment Early detection is critical ICE! IV dantrolene (Dantrium) Slows metabolism and reduces muscle contractions
Prevention - Obtain family history
Anaphylactic Reaction-know what it is, etiology, manifestations, medical treatments, nursing care discussed.
Severe allergic reaction
May be masked by anesthesia, Blood products, antibiotics, anesthetics, plasma expanders, latex
Anything administered via IV can cause an allergic reaction
Clinical manifestations: pulmonary edema, bronchospasms, tachycardia, hypotension.
Treatment: Discontinue what is running, oxygen, epinephrine IM, benadryl (diphenhydramine), corticosteroids, albuterol, fluids
Nursing assessments pre-op priority, what we discussed.
Pre-Op Assessments
Goal is to gather data to identify risk factors and plan care to ensure patient safety
Baseline data for comparison
Health history LMP Family health history Medications Allergies - Latex (Risk factors: long-term multiple exposures to latex products, history of hay fever, asthma, allergies to certain foods such as avocado, potatoes, or bananas (latex-food syndrome)), Previous anesthesia ASK: What is your reaction?? Systems Review - Ask questions about each system for history of issues and current issues
Psychologic status/coping strategies Psychosocial assessment Decrease stress: use common language Anxiety: lack of knowledge Common fears: death, mutilation, disability, pain, body image, anesthesia
Physiologic factors contributing to risk
ASA classification system
American Society of Anestheisiologists
P1/ASA1 (healthy) to P6/ASA6 (brain dead/organ donation)
Identify and document surgical site
medications
Prescription
OTC, including herbals
Astragalus and Ginseng: increase BP
Garlic, Vitamin E, Ginkgo, Fish Oil: Bleeding
Kava and Valerian: Sedation
In general - stop herbals 2-3 weeks prior to surgery
Laboratory results
Nursing assessments post-op priority, what we discussed.
Post-Op Assessments Airway- Try stimulation, O2 Breathing Circulation Neurologic - Can use stimulation Genitourinary Surgical Site (**Don’t take off 1st dressing**; Surgeon does this; Nurse can reinforce dressing) Pain Fluid and electrolyte status
If a patient is vomiting postoperatively, what can the nurse do? Pharmacological vs nonpharmacological
Nausea, vomiting is common after anesthesia
GI rest until BS resume, nausea subsides
Treatment
Zofran to prevent N/V
Promethazine (Phenergan), chlorpromazine (Thorazine), Prochlorperazine (Compazine), hydroxyzine (Vistaril) to treat
Watch sedation levels, watch bp
What if they start vomiting, how do you protect their airway?
Turn on side
suction
Surgical wound complications include:
Hemorrhage
Infection
Dehiscence – splitting/bursting of a wound
Evisceration – protrusion of the internal organs (usually abdominal) through an incision
Evisceration tx – sterile gauze w/NS or sterile water over organ & notify HCP; check vitals
Wound care surgical-nursing care and discharge instructions:
Care
Check drains, adjacent tissue, dressings
Watch BP, trend H&H-bleeding
Clean technique with dressing change-infection control!
Wound support in stress areas - Pillow for cough and deep breathing
Prophylactic antibiotics
Discharge Instructions Activities What can pt do/not do? (like heavy lifting) Diet (high protein for wound healing) Wound/Incisional Care Meds- new, old, when to resume When to call, and when not to What to worry about (S/S infection) What not to worry about Who to call When, where to return for follow up Other information as needed
Potassium
3.5-5.0
98% of K+ is intracellular
Important in
a. Neuromuscular function
b. Cardiac function
c. Intracellular osmolality
d. Promotes cellular growth
Diet is the source of K+
Kidneys are primary route of K+ loss(90%)
Factors that cause Na retention cause K loss and vice versa
The ability of the kidneys to conserve K is weak even when body stores are depleted
Factors that move K into cells
a. Insulin
b. Alkalosis
c. B-Adrenergic stimulation (catecholamine release, Coronary ischemia, DT.s)
d. Rapid cell building
Factors that move K out of cells
a. Acidosis
b. Trauma
c. Exercise
d. Digoxin-like drugs
e. B-adrenergic blocking drugs (Inderal)
Hyperkalemia: Causes, manifestations, treatment
Causes
a. Increased intake
b. Impaired renal excretion
c. Shift from inside cell
d. Blood transfusions
e. Severe infection (Acidosis -> H+ getting into cell and forcing K+ out)
f. Drugs (K sparing diuretics, ACE inhibitors)
Leads to
a. Leg cramps, weakness, paralysis
b. Bradycardias, VT, Arrest (watch peaked T waves)**
c. Abdominal cramping/diarrhea
Treatment
a. K+ restriction
b. Diuretics, dialysis, Kayexalate
c. IV insulin
d. Calcium gluconate
hypokalemia: causes, manifestations, treatment
Causes
a. Abnormal losses (Kidneys or GI tract)
b. Aldosterone release (retains Na, loses K)
c. Magnesium deficiency (stimulates renin release aldosterone release)
d. Diarrhea, laxative abuse, vomiting, ileostomy drainage
e. Metabolic alkalosis can cause a shift into the cells
f. Rapid formation of cells
Manifestations
a. Weakness or paralysis of muscles including diaphragm
b. Decreased GI motility
c. ST segment depression**
d. Ventricular dysrhythmias**
Treatment
K+ supplements (hold if UOP (urinary output) inadequate-notify the provider)
magnesium
1.8-2.2
Function
i. important for many processes in the body, including regulating muscle and nerve function, blood sugar levels, and blood pressure and making protein, bone, and DNA
Mg acts directly on the myoneural junction
- neuromuscular excitability is profoundly affected by changes in Mg levels
- Hypermagnesemia depresses neuromuscular and CNS functions
- Hypomagnesemia neuromuscular and CNS hyperirritability. Can cause cardiac dysrhythmias-Torsades de pointes!**
Ca, K, and Mg should be assessed together
- All three affect cardiac dysrhythmias
- Imbalances often mistaken for Ca imbalances
- Mg and K have correlating balances
High K = low Mg, Low K = High Mg
So always check the other if one off
replace Mg first!
hypermagnesemia: causes, manifestations, treatment (management)
Cause - Occurs only with increase in intake accompanied by renal insufficiency (failure)
Manifestations
- Lethargy, drowsiness, nausea and vomiting
- Loss of deep tendon reflexes, somnolence, respiratory and cardiac arrest
Management
- Prevention
- IV Calcium chloride or calcium gluconate
a. Calcium gluconate is easier on pt - Increase UOP (urine output) or dialysis
hypomagnesemia: causes, manifestations, treatment
Causes
- Prolonged fasting or starvation
- Chronic alcoholism
- Fluid loss from the GI tract decreased absorption of Mg
- Prolonged parenteral nutrition without Mg supplementation
- Many diuretics**
- High glucose levels
Manifestations
- Confusion, hyperactive deep tendon reflexes, tremors and seizures
- Cardiac dysrhythmias-Torsades de pointes!**
- Clinical hypomagnesemia resemble hypocalcemia
Treatment
- Oral supplementation/ intake (green leafy vegetables, nuts, bananas, oranges, peanut butter, chocolate)
- Parenteral IV or IM replacement for severe cases
a. too rapid can lead to cardiac or respiratory arrest!!
Fluid volume deficit
Causes: diarrhea, hemorrhage, polyuria, inadequate intake
Treatment:
Correct underlying cause
Replace both water and electrolytes (NS, LR)
Replace blood if needed
Technically, Fluid Volume Deficit is NOT Dehydration
Dehydration = Loss of water only without sodium
Fluid volume overload (excess)
Causes: Excessive intake (IV too fast) abnormal retention (heart failure, renal failure), fluid shifts (changes intravascular fluid)
Treatment:
Goal: To remove fluid without abnormal changes in electrolytes or osmolality (diuretics**, fluid restriction, Na+ restriction)
Thoracentesis or paracentesis if ascites or pleural effusion present
Thoracentesis – draining (with a needle) the thoracic cavity (around lungs)
Paracentesis – draining (with a needle) the peritoneum (abdomen)
fluid volume overload/deficit nursing assessments
I&O Urine specific gravity (1.010 -1.025) Solute concentration in urine CV changes (BP, JVD, Pulse quality, lung sounds) Respiratory changes (rate, crackles, SOB) Neurologic changes (cerebral edema) Daily weights (1 kg = 1 L) Skin turgor Monitor IVs, NGs, etc.
hypertension management and nursing care
- Check body systems first – pain, anxiety levels, full bladder, or respiratory compromise
- Fix the cause (pain meds, assist to void, etc.)
- Or medicate w/antihypertensives (Pharmacologic therapy)
Figure out what you want to effect…
Cardiac output:
a. Heart rate – think beta-adrenergic inhibition (beta blockers) - Metoprolol (B1 selective)
b. Systemic volume – think diuretics - Furosemide, Aldactone (watch K+)
Systemic Vascular Resistance – think vasodilators (ACE, ARB, CCB)
a. ACE – lisinopril
b. ARB – losartan
c. CCB – amylodipine (think Very Nice Drugs)
3. Nitrates
