Exam 2 Flashcards
Common causes of impaired gas exchange (6)
Age
Smoking
Chronic and acute medical conditions
Brain injury
Prolonged immobility
Inhalation irritants
Diagnostics for Gas exchange problem (8)
- Chest X-ray (detect TB)
- CT Scan
- Pulmonary Function Studies (usually reduced in COPD and restrictive diseases, old age)
- Invasive (Bronchoscopy, laryngoscopy (larynx), mediastinoscopy (above sternum for tumors)
- CBC
- ABG
- sputum (negative after 3 months of TB treatment)
- BNP (rule out CHF)
Nursing Care and Patient education for Pulmonary Function tests (5)
- Explain purpose and procedure to reduce anxiety-induced dyspnea
- May need to withhold bronchodilators 4-6 hrs before the test
- Patient should not smoke 6-8 hrs before test
- Patient breathes through mouth (Nose clip to prevent air escaping through nose)
- Assess patient for dyspnea or bronchospasm after procedure
4 Types of Pulmonary Function Studies
Forced vital capacity (FVC)- max amount of air that can be exhaled as quickly as possible after maximum inspiration. (decreased)
Forced expiratory volume (FEV)- max amount of air exhaled (decreased)
Peak expiratory flow rate (PEFR)- usually decreased
FRC (functional residual capacity) - the amount of air remaining in the lungs after normal expiration. (increased w/ air trapping i.e. emphysema)
Purpose of Bronchoscopy (5)
- Diagnose and manage pulmonary disease
- Help place or change endotracheal tube
- Collect specimens
- Removal of secretions not cleared by normal suctions
- Stent placement (open up strictures in trachea and bronchus)
5 Potential complications after Bronchoscopy (and nursing care for each)
- hypoxemia (maintain airway; give O2; monitor vitals q15 monitor for first two hrs)
- aspiration (check for gag reflex (pt NPO till return), suction prn)
- bleeding (hemoptysis)
- infection
- bronchospasm (indicated by stridor
Preparation for Bronchoscopy (4)
- Explain procedure and verify consent given
- Document patient allergies
- Patient is NPO 4-8 hrs prior to procedure (and 2 hrs after until gag reflex returns) to prevent aspiration
- Benzos or opioids given for sedation
Bronchoscopy: Benzocaine
Use
Complication
s/s of complication (3)
Treatment of complication (2)
Use: topical anesthetic used cautiously to numb oropharynx
Complication: methemoglobinemia (conversion of hemoglobin to methemoglobin which does not carry oxygen so leads to tissue hypoxia)—less likely with lidocaine
S/s: cyanosis after topical anesthetic, no response to supplemental oxygen, blood is chocolate-brown color
Treatment: oxygen and IV of 1% methylene blue
Acute findings of Impaired Gas exchange (8)
Tachypnea
Tachycardia
Accessory Muscle Use
Paradoxical chest movement (in on inspiration, out on expiration)
Pursed lip breathing
Pale skin
Adventitious Breath Sounds
Mucus/secretions
Chronic problems of impaired gas exchange (4)
Cyanosis
Clubbing of nails
Barrel chest (emphysema)
Orthopneic
Normal ABG values
pH
CO2
pO2
HCO3
O2 sat
pH: 7.35-7.45
CO2: 35-45 mm Hg
pO2: 80-100 mm Hg
HCO3: 21-28 mEq/L
O2 sat: 95-100%
ABGs: What do the following present as?
Respiratory Acidosis
Respiratory Alkalosis
Metabolic Acidosis
Metabolic Alkalosis
Respiratory Acidosis: pH < 7.35; CO2 > 45
Respiratory Alkalosis: pH > 7.45; CO2 < 35
Metabolic Acidosis: pH < 7.35; HCO3 < 21
Metabolic Alkalosis: pH > 7.45; HCO3 > 28
COPD: Basic Pathophysiology - 2
Chronic Bronchitis: airway problem due to inflammation of airway after exposure to irritants
Pulmonary emphysema: alveolar problem where lung elastic tissue loses ability to recoil after stretching
Risk factors for COPD (3)
- cigarette smoking (esp 20 pack year)
- Alpha1-antitrypsin deficiency ( ATT is normally in lungs and inhibits excess protease activity so protease only breaks down pollutants and not lungs but w/o ATT, protease breaks down lungs)
- asthma
S/s of chronic bronchitis (5)
- bronchospasm
- copious sputum (leads to narrowed airways
- thin/wasted
- hypoxemia (low PaO2) and cyanosis
- clubbing
Complications of COPD (6)
- Hypoxemia (leads to polycythemia)
- Acidosis (r/t CO2 retention and hyperinflation)
- Respiratory infection (due to increased mucus; pneumonia and influenza vaccines important)
- Cor pulmonale (right sided heart failure due to pulmonary disease leads to right ventricular hypertrophy and backup of blood into venous system; S/s: dependent edema)
- Dysrhythmias (due to hypoxemia, drug effects, acidosis)
- Respiratory Failure
S/s of emphysema (7)
- hyperinflation of lungs (flattened diaphragm)
- tachypnea and dyspnea
- barrel chest
- orthopneic or tripod position (forward-bending posture w/ arms held forward)
- hypercapnia (due to uncoordinated breathing; respiratory acidosis)
- chronic hypoxia (leads to polycythemia i.e. increased RBC)
- breath sounds: wheezes or reduced if airflow obstruction
Anti-inflammatory drugs for COPD
Corticosteroids (Beclomethasone, Prednisone)
5 patient education points
- use daily b-c max effectiveness w/ 48-72 hrs of continued use
- Side effects: increase risk for infections (Candida albicans in mouth; URI if around people w/ one)
- avoid Risky activities (fragile BVs increase risk for bruising and petechiae)
- do not stop abruptly stop drug b-c it suppresses adrenal production of essential corticosteroids
- take with food to reduce risk for GI ulceration
Bronchodilators for COPD
SABA (albuterol) -1
LABA (arformoteral) -1
Anticholinergic (ipratropium) -3
SABA
- for acute relief
LABA
- for long term relief
Anticholinergic
- prevent COPD bronchospasm
- carry at all times
- S/s of overdose: blurred vision, eye pain, headache, nausea, palpitations, tremors, inability to sleep, dry mouth (increase fluids)
Other drugs for COPD
Mucolytics (Acetylcysteine, dornase alpha, guaifenesin) - 2
Oxygen - 2
Mucolytics (Acetylcysteine, dornase alpha, guaifenesin)
- thins secretions so easier to expectorate and cough up
- guaifenesin can raise cough threshold
Oxygen
- Usually oxygen flow of 2-4 L/min via nasal cannula or 40% via venturi mask
- ALL hypoxic patients should get oxygen therapy so SpO2 b/w 88-92%
COPD: nonpharmacological management of impaired gas exchange (5)
- Positioning (HOB elevated, orthopneic )
- Effective and controlled coughing ( scheduled coughing in morning, prior to bed, and at meals)
- Exercise conditioning (2-3 times a week of walking; resistive breathing, isocapnic hyperventilation machine)
- Suctioning (only if weak cough, pulmonary muscles or inability to expectorate)
- Hydration ( 2L of fluid a day)
COPD: Weight loss prevention (8)
- Collab w/ RDN for easy to chew and non-gas forming foods
- High calorie, high protein
- Plan biggest meal of day when pt most hunger and well rested
- 4-6 small, frequent meals preferred to 3 large meals
- Use breathing techniques and bronchodilators 30 minutes prior to meal to reduce bronchospasm
- Avoid dry foods that stimulate coughing
- Avoid caffeine that can increase urine output and lead to dehydration
- Avoid drinking fluids before or during meals if early satiety
COPD: Improving Endurance
Patient Education (5)
- Avoid rushing in morning b-c can increase dyspnea
- Use energy conservation (plan and pace activities for best tolerance and minimum discomfort i.e. divide activities into smaller parts)
- Avoid working w/ arms raised (raised arms reduce exercise tolerance b-c accessory muscles work to keep arms up instead of helping w/ breathing)
- Do not talk during activities requiring energy (walking)
- Avoid breath holding while performing any activity
COPD: Breathing Exercises
- Diaphragmatic/ abdominal breathing
- Pursed-lip breathing (2)
Diaphragmatic/ abdominal breathing
- Patient consciously increases movement of diaphragm while lying on back to relax abdomen
Pursed-lip breathing
- Mild resistance created by breathing through pursed lips to prolong exhalation and increase airway pressure
- Delays airway compression and reduces air trapping
Purpose of Pleural chest tube (3)
- Lung Re-Expansion
- Drains Air/Blood from Pleural Space
- Creates Negative Pressure
7 Nursing Care for patient w/ chest tube
- Inspect insertion site( eyelets of tube should not be visible; s/s of infection (redness, purulent drainage, excess bleeding))
- Palpate Insertion Site (may have subQ emphysema if puffiness or crackling
- Ensure Intact Dressing at Site
- Assess/reassess Respiratory Status (breathing, pulse ox, breath sounds)
- Observe Trachea (tension pneumothorax if shifted)
- Assess/reassess Pain (give meds and reposition)
- Encourage Cough, Deep Breathing, Incentive Spirometry
9 Nursing Care for chest tube system
- Avoid kinks, Occlusions, or Loose Connections (should be straight)
- Do NOT Strip/Milk Tubing
- Keep Drainage System Below Level of Chest
- Assess for “Tidaling” (water level rises inhalation and fall exhalation)
- bubbling seen on exhalation, forceful cough, position changes (EXCESS BUBBLING = air leak)
- Always have at least 2 cm of water to prevent air from returning to patient in water seal chamber
- Limit clamping of a chest tube b-c will increase pressure in pleural space and may cause tension pneumothorax
- No need to disconnect chest tube for transport
- never let drainage come in contact w/ tubes (can cause tension pneumothorax)
9 Emergency Situations w/ Chest tube
- Tracheal Deviation
- Sudden onset of increased dyspnea
- O2 sat <90%
- Drainage >70ml/hr (D)
- Visible eyelets on chest tube
- Chest tube falls out of the patient’s chest (first, cover the area with dry, sterile gauze)
- Chest tube disconnects from the drainage system (first, put end of tube in a container of sterile water and keep below the level of the patient’s chest)
- Drainage in tube stops (in the first 24 hours)
- Drainage bloody after a couple days (drainage is always bloody in first few hrs)
Mantoux skin test
Purpose
Procedure
Results
Purpose: screen for TB; diagnosis made w/ sputum culture
Procedure: intradermal injection read after 48- 72 hrs
Results: positive = induration (area of hardness) > 10 mm or > 5mm in immunocompromised
TB drugs: Isoniazid
Nursing Care (4)
- Hepatotoxic so monitor labs/ urine for liver toxicity and limit alcohol use
- Avoid antacids
- take drug on an empty stomach (1 hour before or 2 hours after meals) to prevent slowing of GI absorption
- Teach patients to take a daily multiple vitamin w/ B-complex vitamins b-c drug can deplete the body of this vitamin.
TB drugs: Rifampin
Nursing Care (3)
- Hepatotoxic so monitor labs/ urine for liver toxicity and limit alcohol use
- Warn patients to expect an orange-reddish staining of the skin and urine and all other secretions to have a reddish-orange tinge; also, soft contact lenses will become permanently stained
- Women w/ oral contraceptives need additional method of contraception while taking this drug and for 1 month after stopping it because this drug reduces the effectiveness of OCs
TB drugs: Pyrazinamide
Nursing Care (3)
- Hepatotoxic so monitor labs/ urine for liver toxicity and limit alcohol use
- Drink at least 8 ounces of water when taking this tablet and Increase fluid intake to prevent uric acid from precipitating, making gout or kidney problems worse.
- Photosensitivity (Teach patients to wear protective clothing, a hat, and sunscreen when going outdoors in the sunlight because the drug causes photosensitivity and greatly increases the risk for sunburn)
TB drugs: Ethambutol
Nursing Care (3)
- Hepatotoxic so monitor labs/ urine for liver toxicity and limit alcohol use
- Optic neuritis at high doses ( Instruct patients to report any changes in vision (reduced color vision, blurred vision, or reduced visual fields) immediately to HCP)– Minor eye problems are usually reversed when the drug is stopped.
- Instruct patients to drink at least 8 ounces of water when taking this drug and to increase fluid intake to prevent uric acid from precipitating, making gout or kidney problems worse.
risk factors for Diabetes (6)
- 1st relative w/ diabetes mellitus
- Age 45 years or older
- sedentary lifestyle
- Hx of vascular disease, PCOS, gestational diabetes, pancreatitis, Cushing Syndrome, or given birth to an infant > 9 lb
- Metabolic Syndrome (Central Obesity, Hyperlipidemia, Hypertension (uncontrolled), Hyperglycemia)
- Lifetime of high-carb, high-sugar diet causes insulin to tire out
S/s of hyperglycemia (10)
- Polyuria (due to glycosuria)
- Polydipsia (due to dehydration–s/s of dehydration: dry skin, rapid thready pulse, hypotension)
- Polyphagia (due to starvation– may have some weight loss)
- Fatigue
- kussmaul respirations (compensate for metabolic acidosis)
- fruity breath
- LOC changes (headache, seizures)
- ketonuria
- hot dry skin
- blurry vision
Expected Glucose levels (what indicates problem?)
Normal range
Fasting glucose
Oral glucose test
Rapid glucose check
Glycosated hemoglobin (HbA1C)
Normal Range (70-110)
Fasting plasma glucose (FPG) - greater than 126mg/dL (8 hrs. after fasting, can have water while fasting)
Oral glucose tolerance test (OGTT)- greater than 200mg/dL (2hrs after oral glucose test; pt fasts 10-12 hrs prior to test
Rapid glucose check - Greater than 200md/dL (Finger prick; no fasting required)
Glycosated hemoglobin (HbA1c) - Greater than 6.5 % (measures Average of blood glucose over 3 months, the lifespan of RBC b-c glucose binds to Hgb A)– target <7% for diabetic
Oral antidiabetes: Biguanides (Metformin)
Action (3)
Side effects (2)
Action:
- reduce glucose production by liver
- increase sensitivity to insulin
- delay carb absorption in intestines
Side effect
- GI effects (flatulence, anorexia, NV)
- lactic acidosis (caution in AKI– s/s myalgia, sluggishness, somnolence, hyperventilation)
Oral antidiabetes: Biguanides (Metformin)
Nursing Care (4)
Nursing care
- Take w/ food
- Take vitamin B12 and folic acid supplements
- Stop med 24-48 hrs before any radiographic test w/ iodine dye (restart 48 hrs after b-c can cause lactic acidosis from acute kidney injury
- Avoid alcohol which can increase risk for lactic acidosis
Oral antidiabetes: Sulfonylureas (Glipizide)
Action (2)
Side effects (2)
Nursing Care (2)
Action
- stimulates insulin release from pancreas to decrease blood glucose
- increase tissue sensitivity to insulin
Side effects
- hypoglycemia
- disulfiram effect (do not use alcohol)
Nursing care
- avoid with sulfa allergy
- give 30 minutes before mealsd
Non-insulin injectable: Amylin Analog (Pramlintide)
Action
Side effect
Nursing Care (3)
Action: suppress glucagon secretion to control postprandial rise in glucose
Side effect: hypoglycemia
Nursing care
- Give subQ right before any major meal
- Do not give if client hypoglycemia unawareness, noncompliance, or poor adherence to treatment regimen or SMBG
- Give 5 cm/ 2 in away from any insulin injection given at same time
SubQ Insulin: Rapid Acting (aspart, lispro)
Onset
Peak
Nursing Care (2)
Onset: 15 min
Peak: 30 min - 1.5 hr
Nursing Care
- used w/ longer-acting
- meal must be eaten at time of injection
SubQ Insulin: Short Acting (regular)
Onset
Peak
Nursing Care (2)
Onset: 30 min
Peak: 2-5 hr
Nursing Care
- covers insulin needs for meal within 30-60 minutes
- only insulin that can be given via IV (usually for DKA in ICU)
SubQ Insulin: Intermediate Acting (NPH, Novolin 70/30)
Onset
Peak
Nursing Care (3)
Onset: 1.5 hr
Peak: 4-12 hr
Nursing Care
- covers insulin needs b/w meals or overnight
- can be combined w/ rapid or short acting insulin (ALWAYS PULL UP SHORTER ACTING ONE FIRST TO AVOID CONTAMINATION)
- appears white and cloudy
SubQ Insulin: Long Acting (glargine, detemir)
Onset
Peak
Nursing Care (3)
Onset: 1-4 hr
Peak: none
Nursing Care
- give once daily at same time each day
- never mix with another insulin
- never give IV (always give subQ)
Insulin storage (3)
- Always have insulin on hand (esp if traveling)
- Can store at room temp for 30 days
- Can store longer in refrigerator
5 things to know before giving insulin
- Type of insulin plus onset, peak
- Blood glucose level
- Food that will be given
- s/s of hypoglycemia
- Always document site of injection
3 Complications of Insulin therapy (and prevention)
What are they?
How can it be prevented?
Hypoglycemia
- prevent w/ sliding scale checks
Lipoatrophy (uneven tissue) and Lipohypertrophy (lumps of fatty tissue)
- prevent by rotating sites within same area of body to also prevent change in absorption rates
Dawn phenomenon
- 5-6am rise in glucose due to cortisol release
- Prevention: Check blood glucose at bedtime and adjust insulin accordingly
Patient Education for Insulin pump (2)
- take off for baths and swimming
- change needle q2-3 days to prevent infection
Diabetic Neuropathy: Autonomic Symptoms (4)
Affects nerve conduction of
▪ Heart (exercise intolerance, painless MI, altered left ventricular function, syncope)
▪ GI (gastroparesis, reflux, early satiety) – promote motility w/ metoclopramide
▪ GU (urinary retention, decreased bladder sensation)
▪ Masks hypoglycemia and traditional indicators of heart attack (chest, back, or jaw pain)
Diabetic Nephropathy: Interventions (4)
- Report output < 30 mL/ hr
- Urinalysis, BUN, microalbumin, blood creatinine levels taken yearly
- Avoid soda, alcohol, and toxic levels of NSAIDs and acetaminophen
- Consume 2-3 L/day of fluid from food, beverages w/ artificial sweetener, and drink adequate water
Chronic Complications of Diabetes: Microvascular (6)
- Retinopathy (blurry vision -> blindness)- leading cause of blindness
- Nephropathy (kidney dysfunction and increased permeability)
- Neuropathy (nerve dysfunction)- Fingers, toes, feet; autonomic; Tingling, numbness, prickly
- Sexual dysfunction (Male- ED or retrograde ejaculation; Female- decreased libido, dyspareunia)
- periodontal disease
- integumentary disorders (infections, poor wound healing, patchy color changes, sclerosing)
Basic Pathophysiology of Diabetic Chronic Complications (2)
- Hyperglycemia thickens membranes in vital organs
- Decreased blood perfusion to vessels cause tissue hypoxia and ischemia
Chronic Complications of Diabetes: Macrovascular (2)
Cardiovascular disease- Higher risk for MI, hyperlipidemia, hypertension
Cerebrovascular disease- Stroke
S/s of hypoglycemia (9)
- Tremors and lack of coordination
- restless and irritability
- Blurred vision (temporary)
- Seizures -> coma
- Excessive hunger
- Cold, clammy skin
- Pallor
- CNS decline (headache, confusion, fatigue, drowsiness, depression, dizziness, slurred speech)
- SNS activation (tachycardia, diaphoresis, nervousness, palpitations)
Patient Education Diabetes: Foot care (11)
- Trim nails trimmed straight across w/ clippers or emery board
- Inspect and wash feet daily with mild soap and warm water
- Test water temperature with the arms or a thermometer before washing feet.
- Do not soak the feet.
- Pat feet dry gently, especially between the toes,
- Avoid lotions between toes to decrease excess moisture and prevent infection.
- Use mild foot powder (powder with cornstarch) on sweaty feet.
- Do not use commercial remedies for the removal of calluses or corns (can increase risk for tissue injury and infection)
- Separate overlapping toes with cotton or lamb’s wool.
- Do not use hot water bottles or heating pads to warm feet. (use socks)
- Avoid prolonged sitting, standing, and crossing of legs.
Patient Education Diabetes: Footwear (7)
- Avoid open-toe, open-heel shoes
- Leather shoes are preferred to plastic.
- Wear shoes that fit correctly.
- Wear slippers with soles
- Do not go barefoot.
- Wear clean, absorbent socks or stockings that are made of cotton or wool
- Wear socks at night if the feet get cold.
Patient Education Diabetes: Exercise (5)
- less insulin needed if exercising
- Exercise (150/min/week at least 3 sessions a week)
- Only exercise if glucose b/w 80-250 mg/dL (check glucose prior to exercise)
- Do not exercise if ketones in urine
- Consume carbohydrate snack prior to exercise IF 1 hr since last eating and high-intensity exercise planned
Patient Education Diabetes: Illness (5)
- Illness and stress can increase glucose levels so continue insulin even if not eating
- Monitor blood glucose q2-4 hrs
- Monitor urine for ketones q3-4 hrs or if blood glucose > 240 mg/dL
- Drink 8-12 oz (240-260 mL) of sugar-free, non caffeinated liquid every hr OR Drink fluids w/ sugar if blood glucose low
- Meet carb needs w/ soft food or liquids 6-8 times a day (Soft foods: custard, cream soup, gelatin, graham crackers)
Patient Education Diabetes: Nutrition (7)
- watch protein levels if kidney involved (aim for 15-20% of diet)
- Eat at regular times and do not skip meals
- eat consistent amounts of food
- Avoid alcohol
- Increase fiber for carb metabolism and cholesterol control
- artificial sweeteners encouraged
- Low fat diet but include omega-3 fatty acids in diet
Treatment for hypoglycemia
If conscious (3)
If unconscious (2)
If responsive
- Simple Carbohydrates (6 crackers, 2 graham crackers, 4 oz fruit juice, 4 oz 2% milk; glucose tablets)
- repeat if hypoglycemia persists
- If hypoglycemia resolved and next meal > 1 hr away, take snack w/ carb and protein
If unresponsive or seizing
- 1 amp (50ml) dextrose 50% (D5W) IV push or 1mg glucagon SQ
- place lateral to prevent aspiration
Acute Complications of Diabetes (When to call HCP) - 8
- Presence of moderate to large urine ketones or ketonuria for more than 24 hr
- Blood glucose > 250 mg/dL that does not resolve with treatment
- Fever > 38.6° C (101.5° F), does not respond to acetaminophen, or lasts more than 24 hr
- Feeling disoriented or confused
- Experiencing rapid breathing
- Persistent NVD
- Inability to tolerate liquids
- Illness >2 days
Hyperglycemic-hyperosmolar state (HHS) and Diabetic Ketoacidosis (DKA)
2 things they have in common
2 differences
Treatment for both (3)
both have insulin deficiency and very high glucose levels (> 300)
DKA primarily type 1 DM and has ketonuria.
HHS primarily type 2 DM and has severe dehydration
Treatment: ICU, NS fluids, IV insulin
8 patient indications for TPN
- cannot tolerate enteral nutrition
- extensive burn injuries
- poor wound healing
- specific GI disease (UC, Crohns, GI fistula)
- hepatic failure
- pancreatitis
- malignant diseases
- malnourished
Nursing Care for TPN (5)
- monitor glucose (risk for hyperglycemia w/ TPN; risk for hypoglycemia if no TPN)
- If TPN stops, give D10 to prevent hypoglycemia
- Monitor labs (albumin, prealbumin)
- regularly assess IV b-c risk for phlebitis/ infection w/ high glucose
- prevent hypoglycemia by call pharmacy prior to bag running out
Difference b/w the following surgeries
- Elective
- Urgent
- Emergent
Elective
- Can be scheduled to correct nonacute problem
Urgent
- Must be performed in 24-48 hrs b-c life threatening if not
Emergent
- Life-threatening so surgery ASAP
5 safety tools in perioperative care
- SBAR (Situation, Background, Assessment, Recommendation)
- Surgical Safety Checklist ( prior to person receiving anesthesia )
- TeamSTEPPs (Team Strategies and Tools to Enhance Performance and Patient Safety)- involves teamwork, communication, collaboration, and safety
- SCIP (Surgical Care Improvement Project)
- National Patient Safety goals (NPSG)
5 National Patient Safety goals (NPSG)
Correct patient
Correct procedure
Correct site and side
Correct site marking
Intentional pause before surgery (time out
8 SCIP (Surgical Care Improvement Project) Data elements
- Antibiotics given within 1 hour prior to surgical incision.(Vancomycin and Fluoroquinolones=2 hours)
- Prophylactic antibiotics should be discontinued within 24 hours of anesthesia end time (48 hours for CABG patients) (Reason for continuing antibiotics > 24 hours after anesthesia end time (48 hours for CABG patients) must have a physician documented infection)
- Appropriate hair removal (clippers vs razor)
- Normal patient temperature (36.0 C or greater) within 30 minutes prior to or 15 minutes after anesthesia end time
- If beta blocker in hx, must continue day before surgery/ day of surgery AND post op day 1/post op day 2 (If not given, contraindications must be documented)
- VTE (DVT) prophylaxis must be applied/administered within 24 hours prior to anesthesia start time or 24 hours after anesthesia end-time.
- Foley discontinued by post-op day 2 or obtain physician order for specific reason to continue foley.
- Cardiac Surgery patients require Controlled Postoperative Blood Glucose levels less than or equal to 180 within 18-24 hours after anesthesia end time
Preoperative Phase: Medical History (2)
- Medical history (including renal, musculoskeletal, cardiac, pulmonary dz.) b-c these can increase risk for complications
- hx of prostheses (do not place electrocautery pads on these area)
Preoperative Phase: surgical History (3)
- Prior surgical procedures and how these were tolerated (previous complications, may increase anxiety)
- Prior experience with anesthesia (e.g., difficulty being aroused after surgery, ongoing nausea and vomiting)
- Prior experience with postsurgical pain control
Preoperative Phase: allergies (2)
- Latex allergy cross sensitivity w/ avocado, banana, kiwi, strawberry allergies
- Propofol allergy cross sensitivity w/ egg, peanut, and soy allergy
Preoperative Phase: social and family history (5)
- Family History- (malignant hyperthermia, cancer, bleeding disorder)
- Prescription drugs/OTC
- Complementary/alternative practices (herbals, folk remedies)
- Alcohol - DT if abrupt withdrawal
- Substance abuse, tobacco use, marijuana use - smoking can increase risk for pulmonary complications
Malignant Hyperthermia
Pathophysiology
Onset
Treatment
Patho: Acute, life-threatening complication begins when skeletal muscle is exposed to specific agent (halothane -flurane, succinylcholine); poor thermoregulation increases calcium in muscles
Onsets: can be immediate or delayed (even after end of anesthesia)
Treatment: Dantrolene
Malignant Hyperthermia
Signs and Symptoms (8)
- High temperatures (late sign > 111.2 F)
- Dysrhythmias
- Tachycardia
- Muscle rigidity (jaw and upper chest)
- Hypotension
- Cyanosis
- skin mottling
- tachypnea
Malignant Hyperthermia
Diagnostic changes (5)
- hypercalcemia
- hyperkalemia
- metabolic acidosis
- rise in end tidal CO2 (decreased O2) - most sensitive indicator)
- myoglobinuria (muscle protein in urine- brown or colored urine)
Preoperative Care: lab testing (6)
- Urinalysis (protein, glucose, blood, bacteria, pregnancy)
- Blood type and screen
- CBC
- PT, aPTT, INR, platelet count (clotting studies)
- Electrolytes (CMP or BMP)
- Creatinine, BUN
5 Options for handling blood loss
- Autologous (by patient few weeks prior to surgery)- eliminates transfusion reactions and risk for bloodborne disease
- Directed blood donation (from family member or friend)
- Limit number and amount of blood samples before surgery
- stimulate RBC production w/ Supplements (iron, folic acid, vitamin B12, vitamin C) or Epoetin Alfa
- Intraoperative cell salvage (suction, wash, and filter blood back into body)- No limits to amount and no risk for bloodborne disease
Preoperative Care: Imaging/Diagnostics testing (3)
- Chest X-ray (identify pneumonia, TB, HF, cardiomyopathy if hx of respiratory problems)
- Electrocardiogram/EKG (if hx of cardiac disease or > 40 yrs)
- CT/MRI- May be done for back surgery
Preoperative Care: Cardiovascular and respiratory Assessment finding to report (7)
- Chest pain
- Irregular heart rate
- Hypotension or hypertension
- Heart rate <60 or >100 beats/min
- Shortness of breath, dyspnea, tachypnea
- Pulse oximetry reading of less than 94%
- Presence of implantable cardiovascular devices such as a pacemaker or implantable cardioverter defibrillator (ICD)
Preoperative Care: S/s of infection to report (7)
- Fever
- Purulent sputum
- Increased white blood cell count
- Dysuria or cloudy, foul-smelling urine
- Any red, swollen, draining IV or wound site
- vomiting
- rash
Preoperative care: Labs that may contraindicate surgery (4)
- Hypokalemia (digoxin toxicity, slower recovery from anesthesia, cardiac irritability)
- hyperkalemia (dysrhythmias)
- Positive pregnancy test result (or patient report of actual or possible pregnancy)
- Increased prothrombin time (PT), international normalized ratio (INR), or activated partial thromboplastin time (aPTT)
Preoperative Care: Neurologic (2)
- Minimum is assessment of coping skills, mental health history and note about recent behavioral changes
- report changes in mental status
Preoperative Care: Medications increase risk for complication (5)
- Antihypertensives
- Tricyclic antidepressants
- NSAIDs
- Immunosuppressive drugs
- Anticoagulants (hold days before procedure)
Preoperative Care: Nutrition and Diet (4)
- usually NPO (no clear liquid <2 hrs, no food < 6 hr) to prevent risk for aspiration
- No eating, drinking, smoking (increases gastric secretions), chewing gum or oral meds
- may give drugs for some conditions (Beta blockers, respiratory, anticonvulsants, antihypertensives) w/ sip of water
- may continue subQ insulin to prevent DKA (other antidiabetics are held)
Preoperative Care: Integumentary (4)
- shower or bath w/ antiseptic
- Clipping of hair with electric clippers (no razor)
- surgeon must mark site while patient conscious
- large bore IV placed (for meds and blood if necessary in emergencies)
Preoperative Care: Conditions that increase risk for complications (4)
- Age: > 65 yrs
- Malnutrition or Obesity
- Conditions (Diabetes, hemodynamic instability, dehydration; any chronic conditions)
- Impaired coping
Preoperative Care: Intestinal preparation
Purpose
Interventions (3)
Purpose: prevents injury to colon and decrease intestinal bacteria
Interventions
- enema until clear (fall risk)
- laxatives
- bowel prep
Informed Consent
Surgeon role
Nurse Role (3)
Surgeon role
- explain procedure and get informed consent prior to procedure
Nurse role
- sign as a witness to the signature on consent (not to patient’s understanding)
- clarify facts as needed
- not responsible for providing detailed info about procedure
Informed Consent
Variations (5)
- Pts who cannot write (sign w/ X and two witnesses)
- Pt w/o competence (legal guardian, POA or Court appointed advocate gives consent)
- Pt w/ blindness (can sign w/ two witnesses)
- Pt w/ hearing impairment or different language (can sign w/ qualified translator and another witness)
- Life threatening (can’t give consent, unable to contact person with medical power of attorney-written consultation with 2 independent HCP required)– does not override living wills/ advance directives
Postoperative Care: Respiratory Complications
Risk Factors (4)
- elderly
- lung disease
- benzos
- hypothermia
Postoperative Care: Respiratory
Complications (6)
- Atelectasis
- pneumonia
- PE (result of DVT)
- Laryngeal Edema
- Pulmonary Edema
- ventilator dependence
Postoperative Care: Respiratory Complications
Prevention (8)
- Breathing exercises (expansion breathing, diaphragmatic breathing)
- Incentive spirometry (seal lips, inhale, hold 3-5 sec, exhale to promote lung expansion)
- Coughing and splinting (w/ bath blanket or pillow) q1-2 hrs (contraindicated in some surgeries)
- give older adult low dose oxygen first 12-24 hrs
- monitor O2, lung sounds q2-4 hrs for first 24 hr
- positioning (side lying or semi fowlers)
- suction PRN
- early ambulation (lung expansion; turn q2h)
Postoperative Care: Respiratory
Signs of complications (5)
- If RR <10 breaths/min, may be anesthetic or opioid analgesic-induced respiratory depression
- If rapid, shallow respirations, may be shock, cardiac problems, pain, increased metabolic rate
- stridor or snoring may be due to airway obstruction
- accessory muscle use may be excess anesthesia, airway obstruction, paralysis
- spO2 < 95%
Postoperative Care: Neurologic
Complications (4)
- cerebral infarction
- cognitive decline
- epidural hematoma
- infection (meningitis)
Postoperative Care: Neurologic Complications
Prevention/Interventions (2)
- assess LOC, awareness, motor/sensation, DTRs
- If received sedation or general anesthesia in ambulatory setting, need another adult to drive them home
Postoperative Care: Neurologic
Signs of Complications (4)
- Eye opening to command = arousability and wakefulness but not aware
- back pain while coughing or straining = may be epidural hematoma
- occipital headache = postdural puncture headache)
- nuchal rigidity, high fever, acute confusion = meningitis
Postoperative Care: GI
Complications (4)
- Nausea/vomiting (risk for increased ICP or IOP, abdominal irritation, aspiration)
- GI ulcers/bleeding
- paralytic ileus (due to anesthetics, bowel handling during surgery, opioids, or SNS excitation from stress)
- Constipation (due to anesthesia, opioids, decreased activity, decreased oral intake
Postoperative Care: Nausea and Vomiting
Prevention/ treatment (2)
- give medication (ondansetron and dexamethasone)
- Positioning (side-lying position, raise HOB)
Postoperative Care: Paralytic Ileus
Prevention/ Treatment (7)
- auscultate bowel sounds ( no bowel sounds or flatus = ileus)
- NGT insertion to decompress stomach
- hydration (dehydration can decrease GI motility)
- early ambulation (stimulates intestinal motility)
- non opioid pain management
- alvimopan – accelerates the time for GI recovery after some GI surgeries
- metoclopramide- promotes peristalsis via stimulation of GI motility
Postoperative Care: Constipation
Prevention/Treatment (4)
- increased fiber
- enemas
- mild laxatives and bulk forming agents
- hydration
Postoperative Care: GI Complications
Signs of Complications (3)
- Absence of bowel sounds = hypomotility
- Abdominal cramping & distention = trapped, nonmoving gas NOT peristalsis
- No passage of stool or flatus = paralytic ileus
Postoperative Care: Cardiovascular
Complications (6)
- Dysrhythmias
- Hypo/hypertension (widened pulse pressure
- Heart Failure
- Hypovolemic Shock
- DVT
- Sepsis
Postoperative Care: Cardiovascular
Prevention/ Intervention (2)
- daily assessment of distal pulses (swelling, quality, color, temperature, sensation)
- Report BP changes 25% change (or 15-20 point difference) from baselines
Postoperative Care: Cardiovascular
Signs of Complications (4)
- Decreased BP, pulse pressure, abnormal heart signs = cardiac depression, fluid volume deficit, shock, hemorrhage, effects of drugs
- Increased pulses = hemorrhage, shock, pain
- Pulse deficit (difference b/w apical and other pulses) = dysrhythmia
- Bradycardia = hypothermia, anesthesia effect
Postoperative Care: Neuromuscular
Complications (3)
Prevention
Complications
- Hyper/Hypothermia
- Nerve damage/paralysis
- Joint Contractures
Prevention
- early ambulation (prevents joint rigidity)
Postoperative Care: Kidney/Urinary
Complications (5)
- Acute kidney injury (AKI)
- Acute urinary retention
- Electrolyte imbalance
- Kidney stone formation
- Urinary tract infection
Postoperative Care: Kidney/Urinary
Signs of complication (2)
- Urinary retention may be from pre-op drugs (atropine), anesthetics, manipulation during surgery
- Report urine output of <30 mL/hr (may indicate hypovolemia or renal complications)
Postoperative Care: Integumentary
Complications (4)
- Pressure injuries
- Skin rashes/contact allergies
- Wound infection
- Impaired wound healing b/w 5-10 days (Evisceration or Dehiscence)
Postoperative Care: Integumentary
Prevention (5)
- check dressing and drainage (color, amount, consistency, odor)
- change dressing w/ aseptic technique
- splint incision to prevent evisceration or dehiscence
- early ambulation (relieves pressure)
- assess site prn or every shift for warmth, redness, drainage
Postoperative Care: Integumentary
Signs of complication (3)
- Large amount of sanguineous drainage = poor clotting and internal bleeding
- Serosanguineous drainage after 5th day or increased amount = dehiscence sign
- redness or swelling around incision, excess tenderness or pain on palpation, purulent odorous drainage = surgical site infection
Postoperative Care: Integumentary
Risk factors for poor wound healing (4)
- decreased potassium, vitamin C and B, iron, zinc
- low protein and negative nitrogen balance
- obesity (fatty tissue has less nutrients, collage, and BVs)
- malnutrition (s/s: low albumin; muscle wasting, brittle nails, poor skin turgor, Orthostatic hypotension, dry and dull hair and skin)
Postoperative care: VTE
S/s
Intervention (5)
S/s: sudden swelling or dull ache in calf of one leg
Prevention
- Antiembolism stockings (TED Hose) and Sequential Compression Devices (SCD)
- Anticoagulants (enoxaparin, heparin)
- Leg Exercises (practice prior to procedure)
- Early ambulation (stimulates venous return)
- do not place pillows under knees b-c reduces circulation
Patient preparation for Intraoperative (6)
- ID band (name, hospital number, birthdate)
- Removal of clothing (may leave underwear and socks for some surgeries, dentures, jewelry, piercings
- Removal of prosthetics (limbs, eyes)
- Removal of all metal (i.e., hairclips, pins) - can cause burns w/ electrical current
- Nail polish/artificial nails (at least one clean)
- Empty bladder - to prevent incontinence or overdistention
What items should be transitioned w/ client to OR? (4)
- Ensure patient is wearing ID band
- Use two patient identifiers
- Complete pre-op checklist
- Signed Consent Form
Purpose of the following drugs in preoperative care:
Anxiolytics (midazolam) - 1
Sedatives (hydroxyzine) & Hypnotics (Lorazepam) - 1
Opioids - 1
Anxiolytics (midazolam)
- Reduce anxiety
Sedatives (hydroxyzine) and Hypnotics (Lorazepam)
- Promote relaxation
Opioids
- Decrease amount of anesthetic needed for induction and maintenance
Purpose of the following drugs in preoperative care:
Anticholinergics (atropine) - 3
H2 Histamine blockers-cimetidine, ranitidine - 1
Anticholinergics (atropine)
- Reduce nasal and oral secretions
- Prevent laryngospasm
- Reduce vagal-induced bradycardia
H2 Histamine blockers-cimetidine, ranitidine
- Inhibit gastric secretion
Things included in post-op hand off (7)
- Type and extent of surgical procedure
- Anesthetics (type and length)
- Health history (inc. allergies, communication or sensory impairments, conditions)
- Complications (esp respiratory function, intraoperative blood loss)
- VS/I&O/IV/Blood products/Medication
- Incisions/dressings/tubes/drains
- Joint/limb immobility (intra and postoperative
Postoperative care: I And O
Input
Output
Hydration status (2)
Input: oral fluids, IV fluids
Output: Urine, vomitus, NGT drainage, wound drainage
Hydration Status:
- best way for them is I &O b-c difficult to weigh
- check mucous membranes, skin texture and turgor, axillary sweat
Postoperative care: NGT
Purposes (4)
- Decompress stomach
- Promote GI rest so lower GI tract to heal
- monitor gastric bleeding
- prevent intestinal obstruction
Postoperative care: NGT Decompression
Nursing care (4)
- Do not administer feeding through NGT (decompression)
- Secure NGT to patient’s gown
- Semi-fowler’s position
- turn off suctioning prior to auscultating bowel sounds
Postoperative care: NGT
Drainage colors (3)
- Normal drainage = greenish yellow
- Red or pink drainage = active bleeding
- Brown drainage w/ coffee ground appearance = old bleeding
Postoperative care: Drains and Dressings
Purpose (2)
Expectations (2)
Nursing Care (2)
Purpose
- remove fluid, air, blood, bile
- prevent deep infection and abscess formation
Expectations
- drainage goes from sanguineous to serosanguineous to serous
- surgeon changes first dressing
Nursing Care
- circle, date, time drainage on dressings
- secure drains to pt’s gown and not sheet or mattress
Nonverbal indicators of pain (5)
- Increased pulse, BP, RR
- Profuse sweating
- Restlessness
- Confusion (older adults)
- Grimacing, wincing, moaning, crying
Postoperative care: pain management (3)
- plan activities around timing of analgesia
- PCA w/ morphine sulfate, hydromorphone hydrochloride, oxycodone w/ acetaminophen, ketorolac
- nonpharmacological (diversional, reposition, relaxation, massage (no massage for calves b-c PE risk))
Emergency Care for Benzo Overdose (6)
- Secure the airway and IV access
- Administer oxygen as prescribed if hypoxia is present or RR< 10
- give flumazanil (repeat q2-3 mins as needed up to 3 mg)
- Have suction equipment available b-c flumazenil can trigger vomiting or lower seizure threshold
- Do not leave the patient until fully responsive.
- monitor vital signs and LOC every 10 to 15 minutes for the first 2 hours b-c flumazenil is eliminated quicker than benzodiazepines.
Flumazenil
Use
Side effects (7)
Use: Benzo overdose
Side effects
- tremors or convulsions (lowers seizure threshold in those with seizure disorders)
- thrombophlebitis at IV site
- skin rash
- hot flushes or sweating
- dizziness/headache
- dry mouth
- blurred vision
Emergency Care for Opioid Overdose (9)
- IV naloxone hydrochloride when possible (other routes available if no IV access)
- Maintain an open airway.
- repeat naloxone q2- to 3-minute intervals if needed
- Administer oxygen if hypoxia is present or if RR < 10 breaths/min.
- Have suction equipment b-c naloxone can trigger vomiting
- monitor vital signs and LOC every 10 to 15 minutes for the first hour b-c naloxone is eliminated quicker than opioids
- Watch for naloxone side effects i.e. blood pressure changes, tachycardia, and dysrhythmias.
- Do not leave the patient until he or she is fully responsive.
- Assess the patient for breakthrough pain because reversal of the opioid also reverses the analgesic effects.
Postoperative care: Dehiscence (4)
- Apply sterile non-adherent dressing or saline dressing to the wound
- Notify surgeon
- Instruct to bend knees
- Avoid coughing
Postoperative Care: Evisceration (8)
- Ask someone to notify Surgeon b-c SURGICAL EMERGENCY
- Stay with patient and calm them
- Do not attempt to reinsert the organ
- Cover wound with pre-moistened saline non-adherent dressing or Moisten sterile gauze with sterile saline (STERILE TECHNIQUE)
- Keep dressings moist (do not let dressing dry out)
- Place supine position with hip and knees bent
- HOB elevated 15-20 degrees
- Pt NPO until issue resolved
