Exam #1 Study Review Week 1 Flashcards
Informed consent: what is your role as a nurse
To witness the clients consent
And make sure that they are NPO before midnight
Only the providers job to obtain the consent
General anesthesia
Loss of sensation
Loss of consciousness
Local Anesthesia
Fully awake
Loss of sensation to localized area
Ex: stitches
Monitored anesthesia
Decreased responsiveness
May need airway support
Ex: getting a colonoscopy
Regional anesthesia
Loss of sensation to body
Without loss of consciousness
Ex: epidural
Anaphylactic reaction (signs and symptoms)
Hypotension
Tachycardia
Bronchospasm
Pulmonary edema
Anaphylactic reaction: nursing intervention
Protect airway
Give epinephrine
Malignant Hyperthermia manifestations
Increase HR, Decreased BP, dysrhythmia
increased respiratory rate, hypoxia, hypercapnia
Muscle rigidity
Myoglobinuria
Hyperthermia= late sign (bp low)
Malignant hyperthermia Nursing interventions
Stop anesthetic
Protect airway
Dantrolene
IV fluid
Initiate cooling measures
What to do immediately after patient gets out of surgery
Listen to lungs
ABCs = Airway, breathing, circulation
What to do for respiratory depression
Promote coughing and deep breathing
Positioning
O2 therapy
Incentive spirometer
Reversing agent for morphine (opioids)
Naloxone
Reversing agent for Benzodiazepine
Flumazenil
Signs of deep vein thrombosis (Venous thromboembolism)
Edema, redness, and warmth
Calf tenderness or pain
Penrose drain
(Looks like a pen)
Is a straight flexible tube that drains fluid from surgery site onto a sponge pad not a regular gauze
Jackson Pratt drain
(Bulb looking drain)
This device is used to drain fluids that might collect under or near the incision where the surgeon cut your skin
Hemovac Drain
Placed under ur skin during surgery
Removes any blood or other fluids that might build up in the area
Post Op : possible GI complications
Might have nausea
Paralytic ileus: Hypoactive or Absent bowel sounds
GI complications interventions
Nausea: Antiemetic, NGT to decompress stomach, oral care
Paralytic ileus: ambulation, prokinetic agent, NGT to decompress stomach
Dehiscence and Evisceration Nursing Actions
Position patient to supine position with knees flexed
Soak gauze with sterile saline and place on opening to prevent bacteria and infection
Notify surgeon
Make sure patient does not cough
Peripheral IV access
Antecubital
Back of hand
Central venous IV access
Subclavian vein
Jugular vein
Central Line: client education when removing
Tell patient to hold breath and bear down
Use sterile technique when changing IV
(Change dressing with normal gloves then switch to sterile procedure when putting a new dressing back on)
IV complications: Infiltration
Edema and discomfort around site
Fluid leaking from site
Stop infusion, elevate extremity and apply warm or cold compress
IV complication: Phlebitis
Redness, tenderness, pain
Possible red streak and/or palpable cord
stop infusion, use warm compress to relieve pain
Blood transfusion parameters
Need a second nurse to verify vital signs, blood, and allergies
Stay with patient for first 15-30 min of transfusion
Once blood product is received you have 30 min to begin transfusion and up to 4 hours to transfuse
Acute hemolytic reaction
Increase Respiratory rate, dyspnea
Increased Heart rate
Decreased blood pressure
Low back pain
Hemoglobinuria
Acute hemolytic reaction nursing actions
Stop infusion and remove blood tubing
Initiate normal saline with new tubing
Monitor vital signs and treat symptoms
Notify the provider
Allergic transfusion reaction
Mild itching, urticaria, flushing
Anaphylactic: bronchospasm, hypotension, shock
Allergic transfusion reaction nursing action
Stop transfusion and remove tubing
Administer normal saline
Administer antihistamine
Administer epinephrine, vasopressin, corticosteroids, Oxygen for anaphylaxis reaction, and start CPR if needed
Blood types
If patient has positive blood they can receive both positive and negative blood
If negative then patient can only receive negative blood
Hypovolemia
tachypnea
Weakness
Dry mouth
hematocrit levels: high
blood osmolality: high
Hypervolemia
Crackles, cough, dyspnea
JVD - jugular distended veins
Bounding pulse
Hypertension
Edema
Hypokalemia
Flattened T wave
Hypoactive bowel sounds
Dysrhythmia (for both high and low)
never push IV potassium, very hard on veins (can cause phlebitis)
Hyperkalemia
T waves become peaked
Diarrhea
Hyperactive bowel sounds- bowel is too tight
administer sodium polystyrene sulfonate
Foods high in potassium
Dried peaches
Raisins
Oranges
Bananas
Skin of potatoes
Hyponatremia
Can cause seizure, coma, and death
- deep tendon reflex
isotonic solution are the best
Hypocalcemia
Tetany, tingling around mouth or fingers
Chvostecks sign —> facial twitching when touched by finger
Trousseaus sign —> hand and finger spasm
Hypercalcemia
Renal cálculo and kidney stones
What solution to give for hypernatremia
Dextrose 5% in water
Order of what to do client having infiltration
Stop the infusion
Remove catheter
Apply sterile dressing
Elevate extremity
Apply warm or cold compress
