Exam 2 Flashcards
Preoperative
Begins when the decision
to have surgery is made
and ends with transfer
onto the Operating Room
(OR) bed
Intraoperative
Begins when pt is transferred onto the PR bed and ends with admission to the PACU
Post-operative
Begins when patients is admitted to the PACY and ends with a follow-up eval in clinic or home
Pre-op nursing interventions
Patient safety, manage nutrition and fluid-status (npo), prepare bowel if abdominal or pelvic surgery, prepare the skin, admin meds, maintain pre-op record, patient warming to prevent hypothermia, coordinate with family
Urinary post-op complications
-unable to void 8-10 hrs post op
-palpable bladder
-frequent, small amount of voiding
-pain in the suprapubic area
respiratory post-op complications
atelectasis and pneumonia
atelectasis
-dyspnea
-tachypnea
-dec. breath sounds
-asymm chest movement
-tachycardia
-increased restlessness
pneumonia
-rapid respirations
-shallow respirations
-fever
-wet breath sounds
-asymm chest movements
-productive cough
-hypoxia
-tachycardia
-leukocytosis
circulatory post-op complications
pulmonary embolism and hypovolemic shock
-monitor for fluid deficit or volume excess
-Foley needs at least 30mL/hr
-voiding at least 240 mL/8hr
-labs (HGB, HCT, lytes, Cr, BUN
-encourage PO fluid replacement
pulmonary embolism
-chest pain
-dyspnea
-increased resp. rate
-tachycardia
-increased anxiety
-diaphoresis
-dec. orientation
-dec. BP
-blood gas changes
hypovolemic shock
-dec urine
-dec BP
-weak pulse
-cool clammy
-restlessness
-increased bleeding
-increased thirst
-dec. CVP
wound post-op complications
infection, dehiscence, evisceration
infection
-redness
-purulent drainage
-fever
-tachycardia
-leukocytosis
dehiscence
-disruption of surgical incision/wound
-sutures give way (infection, distention, cough, older age, poor nutritional status)
-can be prevented by: abd. binder, pillow when coughing, using leg muscles not bd muscles
evisceration
-evidence of bowel through incision
-increased pain + vomiting
-moist NS dressings
-NPO
-will be returning to OR
G.I complications
gastric dilation, paralytic ileus
gastric dilation
-nausea and vomiting
-abd distention
paralytic ileus
-dec. bowel sounds
-no stool or flatus
-nausea
-vomiting
-abd distention
-abd tenderness
gastric dilation
-nausea + vomiting
-abd distention
on arrival to the med-surg unit, nurse must assess:
-pt’s appearance
-vital signs
-neuro
-cardiac
-respiratory
-CSMT
-surgical site
-toileting
-GI > bowel sounds > nausea
-pain level
-drains
-IVs
treatment of pulmonary issues
- early AMBULATION!
-must re-expand lungs
-turn, cough, deep breathe, I/S, acapella (“pickle”)
-clear secretions
-splinting of incision
-pain management
urinary retention
-anesthetics, anticholinergics, opioids
-abd. pelvic, hip surgeries= increased likelihood
-pt should void within 8 hours
-must be assessed on arrival to unit and freqently
-bladd scan and possible catheterization if cannot void
bowel function post-op
-constipation very common
-assess bowl sounds, monitor BMs, flatus, hiccups, burping, N/V, distention
-decreased mobility, oral intake, opioid analgesics
-irritation/gastric dilation
-manipulation of bowel, trauma
-best course: ambulation, turning/repositioning, prophylactic stool softeners, improved dietary intake
-no BM for 2-3 days = notify
VTE to DVT
-stress response from surgery makes blood hypercoagulable
-dehydration, low cardiac output
-immobility (blood pooling in extremities)
DVT!
prophylactic treatment for DVT
-SCDs/TED hose
-prophylactic anticoagulants (ex: low dose heparin or enoxaprin)
-ambulation
-hourly leg exercises
-adequate hydration
wound infection
-s/sx: increased in pulse, temp, WBC
-wound swelling, warmth, tenderness, discharge
-local signs may be absent if incision is deep
-may not be present until at least 5 days PO
wound infection risk factors
-contamination
-foreign body
-faulty suturing technique
-debilitation
-dehydration
-malnutrition
-drains/foreign material
-advanced age
-obesity
-Diabetes mellitus
Tx of wound infections
-insertion of drain or wound vac
-I+D procedure
-culture
-antibiotics
-wound care will be in place
managing drains
-allows escape of blood and serous fluids
-some have suction (JP,hemovac, wound-vac)
-gravity
-must carefully record I/Os
-may have to flush tubing per orders
-multiple drains must be labeled
managing the dressing
-monitor drainage (outline)
-1st drsg change done by surgeon
-nurse performs subsequent dressing changes
-wound assessment (aprox. of edges, integrity of sutures or staples)
-redness, warmth, swelling, unusual tenderness, or drainage
Surgical categories
-elective
-urgent
-required
-emergent
-optional
emergent class of surgery
-life threatning
-immediate attention
-severe bleeding
-bladder or intestional obstruction
-fractured skull
-GSW or stab wounds
-extensive burns
urgent class of surgery
-requires prompt attention
-within 24-30 hours
-acute gallbladder infection
-kidney stones
-certain fractures (hip)
required class surgery
-pt. needs to have surgery
-plan within a few weeks/months
-thyroid
-cataracts
-prostate resection
-BPH
Elective class surgery
-pt should have surgery
-failure to have surgery will not be catastrophic
-hernia repair
optional class surgery
-decision rests with patient
-personal preference
-cosmetic surgery
Gerontologic considerations for surgery
-anesthesia can lead to dysregulation of physiology
-cardiac reserves are lower, renal and hepatic function is depressed, GI activity is reduced
-decrease in subq fat = more susceptible to temp changes and skin damage
-memory and cognition are more vulnerable
bariatric patient surgery considerations
-increased adipose tissue can delay wound healing and increase risk of infection
-higher weight has increased risk for joint replacement failure
-higher risk of obstructive sleep apnea = intubation and postop complications
disability patient surgery considerations
-needs assistive devices: hearing aids, glasses, protheses, technology
-may need modification in preoperative education
-may need special positioning to prevent pain and injury
-any respiratory impairment from MS etc. may cause intubation anesthesia complications
informed consent: role of surgeon
-name, type, reason for surgery
-name of the surgeon
-reason surgery will benefit pt. + risks
-all alternative options to surgery
-potential outcomes if surgery not performed
-consent for anesthesia
-consent for blood products
informed consent: role of the nurse
-ensure pt. has all information + understands
-no psychoactive medication before informed consent
-place signed consent in prominent place in the pts. record + accompanies pt. to OR
pre-op assessment questionnaire
-verify name/DOB
-vital signs
-allergies
-assess pain, nut. status. mobility
-psych status
-spiritual and cultural considerations
-medications- OTC vs. Herbal
-last oral intake?
-personal or family hx of malignant hyperthermia
-alcohol/substance use/tobacco use
-special considerations
-informed consent done?
-physical assessment
pre-op check-list
-lab work
-radiologic orders
-remove all metal and piercings, nail polish
-surgical site is prepped and marked per orders
-insert IV
-IV fluids, antibiotics, anxiolytics, antiemetics, preemptive analgesia
-bowel/bladder prep (have pt. void)
-prepare for transfer to OR, beside report with OR nursing staff
pre-op nursing interventions
-pt safety
-manage nut. and fluid status
-prepare bowel if abd. or pelvic surgery
-prepare the skin
-admin meds
-pt. warming to prevent hypothermia
-coordinate with family
circulating RN-non sterile
-OR manager
-supply management
-assists with positioning pt.
-documenter
-assists with counting
-verifies informed consent
-initiates the “time out”
time out
-is this the right patient
-is it the correct location
-is it the correct procedure
general anesthesia
requires intubation
regional anesthesia
spinal, epidural
moderate sedation
combo of benzodiazepine and narcotic
monitored anesthesia care (MAC)
combo of local and light sedation (pt breathes on own)
local anesthesia
its local idk
common adverse effects of anesthesia
-hypotension
-headache
-delirium
-hypothermia
-nausea, vomiting
-anxiety
-shivering
complications of anesthesia
-anaphylaxis
-hypoxia
-malignant hyperthermia
-seizure
-resp. arrest
-cardiac arrest
-stroke
-nerve damage, hematoma, abscess
-anesthesia awareness (rare)
what is malignant hyperthermia
-rare, genetic muscular disorder induced by anesthetic agents
-hypermetabolic state > sustained muscular contractions
-reaction begins soon after exposure
s/sx of malignant hyperthermia
-tachycardia (above 150)
-skeletal muscle rigidity (early sign)
-tetanus-like movement of the jaw “lock jaw”
-dark brown urine from muscle breakdown
-hyperthermia ** late sign
-increased CO2
-HTN
tx of malignant hyperthermia
dantrolene (muscle relaxant), cooling pt.
PACU
-can remain in unit 1-6 hrs before discharge
-discharge = home, med-surg unit, ICU, other facility
-GOAL = provide care until patient has recovered from anesthesia effects
process in PACU
-pt arrives with anesthesia provider +team
-PACU rn connects pt. to monitors + obtains vitals
-PACU rn gets report from anesthesia provider
-PACU rn completes thorough assessment, continuous monitoring
PACU nursing
-head-to-toe
-frequent monitoring of: RR, SPO2, RR, BP, skin color, dressings, drains, LOC, CSMT (when applicable)
-ensures IV fluids are infusing per orders
-assesses effects of anesthesia agents
-assesses for post-op complications
-provides comfort and pain relief
immediate post-op complications
-airway
-cardiovascular
-pain and anxiety
-nausea and vomiting
immediate airway complications
-hypoxia or hypercapnia
-hypopharyngeal obstruction
hypoxia or hypercapnia
s/sx: RR and depth, ease of resp, O2 sat, breath sounds
tx: administer supplemental O2, identify underlying cause
hypopharyngeal obstruction
-choking, noisy/irregular resp, dec. SPO2
-movement of the thorax doesn’t mean air is moving
tx: tilting head back and jaw forward (opens airways), may need to admin oral/nasal airway
assessment + management of hypotension and shock in the PACU
-loss of fluids or plasma, hypoventilation, medications
-must replace fluids, pt. at risk for hypovolemic shock
-blood loss (>500cc)
-report: systolic BP <90 or downward trend of 5mmhg/q15 min
-promote normothermia
assessing for hemorrhage
-always look under blankets, gown!
-apprehension
-rapid thready pulse
-disorientation
-restlessness
-oliguria
-cold, pale skin
-increase pulse + RR
-dec. cardiac output (dec. BP, Hgb, Hct)
-hypothermic
treatment of hemorrhage
-blood transfusion
-determine the cause
-always inspect surgical site
-if bleeding from surgical site = hold pressure
-reinforce drsg
-internal needs to return to OR
neurologic complications
-stroke
-delayed emergence
-emergence delirium
s/sx of stroke
facial droop; PERRLA not intact; unilateral weakness or flaccidity, aphasia; change in LOC; dysarthria; visual changes; numbness/tingling; balance/coordination
s/sx of delayed emergence
prolonged sedation; lack of response to stimuli
s/sx of emergence delirium
agitation; hyperactivity; thrashing; kicking; looks like a night terror
pain, anxiety, post-op nausea/vomiting
-utilize a wide variety of pharmacologic and nonpharmacologic therapies
-psychosocial support
-family/visitor support when possible
-heated blankets, ice packs, music etc.
-popsicles
leaving the PACU
-stable vital signs
-orientation to baseline
-uncompromised pulmonary function
-urine output 30mL/hr
-pulse ox reading >93%
-N+V under control
-pain control
-anesthesia discharge
what’s included in a CBC?
-RBC
-Hgb
-Hct
-WBC
-Platelets
pathology of anemia
-decreased RBC (production, destruction, bleeding)
-decreased Hgb = dec. oxygen delivered to tissues
-impairs body’s ability for gas exchange
what happens after blood donation?
-tested for diseases
-blood type is determined
-ABO and Rh system
-Rh antigen = present in 85%
autologous donation
-patient’s own blood collected and stored
-pre-op 4-6 weeks before surgery
-iron supplementation
-prevention of viral infections and transfusion reactions
-discarded if not used
1 unit whole = how much blood and anticoagulant?
450 mL of blood and 50 mL of anticoagulant
pre-transfusion assessment
-history of past reactions?
-cardiac issues, pulmonary, vascular disease
-baseline vital signs
-resp assessment
-cardiac assessment-fluid volume status
-skin + sclera
pre-transfusion procedure
-ensure order and type crossmatch
-ensure informed consent
-explain procedure + special attention to reaction symptoms
-ensure 20 gauge IV or larger
-filter tubing for blood admin
-baseline vitals
blood pre-transfusion
-must be started within 30 min
-2 RNs must verify ABO group, RH type, pt identification, expiration time
-check blood for bubbles, color, cloudiness
actual infusion
-no faster than 5mL/min for first 15 min
-observe carefully for first 15-30 min
-may increase rate after 15 min
-must finish infusion in 4 hours
-continuous observation
only 2 units via same tubing
symptoms of transfusion reaction
-restlessness
-hives
-N/V
-back/torso pain
-SOB
-flushing
-fever
-hematuria
post-transfusion
-obtain last set of vitals
-dispose of materials
-document
-monitor for response and effectiveness
febrile nonhemolytic reaction
-most common accounts for 90% of reaction
-caused by antibodies to donor leukocytes
-non life threatening
-stop transfusion and notify
s/sx of febrile nonhemolytic reaction
chills follow by fever, and muscle stiffness, headache, tachycardia
acute hemolytic reaction
-MOST DANGEROUS
-occurs when donor blood is incompatible with recipient blood
s/sx of acute hemolytic reaction
chills, fever, tachycardia, constricting chest pain, hypotension, hemoglobinuria, lumbar pain
tx of acute hemolytic reaction
-stop transfusion immediately
-maintain blood volume, renal profusion, manage DIC
allergic transfusion reaction
-1-3% of transfusions
-caused by sensitivity to a plasma protein in the donor blood
-s/sx: hives, itching, flushing
-tx: antihistamines
-may resume transfusion unless severe
what to do if you notice a transfusion reaction
-stop the transfusion, maintain IV line with NS through new IV tubing
-assess pt carefully
-notify provider and blood bank
-send the blood container and tubing to the blood bank for repeat typing and culutre
-obtain blood and urine samples from pt
-document!
transfusion associated circulatory overload
-hypervolemia
-likely to happen in pt’s w/ inc. circulatory volume
-may be prevented by slow administration
-diuretics may be administered after transfusion
-oxygen and morphine for severe dyspnea
s/sx of TACO
dyspnea, tachycardia, anxiety, JVD, crackles, inc. BP
transfusion related acute lung injury (TRALI)
-potentially fatal idiosyncratic reaction-develops within 2-6 hours after transfusion
-all components can cause it, but most likely is plasma
-most common cause of transfusion related death
-involves antigens in donor’s plasma that react to recipients blood
-abrupt onset: SOB, hypoxia, fever, hypotension, pulmonary edema
what is shock?
circulatory failure that leads to hypoperfusion which leads to clotting cascade and death
key symptoms of shock
tachycardia, hypotension, anxiety, restlessness, inc. resp rate, cyanosis, dec. urine output, cold, clammy, mottled skin
measuring/monitoring shock and perfusion
-ABGs = can see metabolic acidosis
-lactate levels: elevated = tissue damage
-CBC: anemia, infection, coagulopathies
-Urine output (30mL/hr)
-MAP and pusle pressure
-BMP: glucose, lytes, BUN, Cr
compensatory shock findings
-HR >100
-inc. resp.
-cold, clammy skin, slow cap refill
-dec. urine output
-mental: confused or agitated
-acid-base balance: respiratory alkalosis
progressive shock findings
-BP: sys<100, <65 map, requires fluids resucitation to support blood pressure
-HR >150
-skin: mottling, petechia, very slow cap refill
-minimal to no urinary output
-acid-base balance: metabolic acidosis
irreversible shock findings
-bp require mechanical or pharm support
-HR: erratic
-skin: jaundice
-urinary output: requires dialysis + anuric
-mental: unconscious
-acid-base balance: profound acidosis
-MODS
-death is likely to occur
early signs of shock
-systolic bp <100 or drop of 40mmhg or more from baseline
-MAP less than 65 and narrowing pulse pressure
-resp. rate greater than 22
-chances in LOC, reduced urinary output
-skin changes: mottling, prolonged cap refill
-lab values: lactic acid, elevated sodium, elevated glucose, blood cx
vasoactive medications
-used when fluid therapy alone does not maintain a MAP >65
-require continuous monitoring and never stop it abruptly
-central line preferred, extravasation, necrosis of distal extremities
hypovolemic shock
-empty tank/pipes
-fluid replacement
-oxygenation
-potential vasoactive medications
-can be caused be external fluid loss or internal fluid shifts (burns, hemorrhage, ascites, surgery)
cardiogenic shock
-pump malfunction
-dec. CO
-caused by MI/cardiac arrhythmias, valve stenosis, medication overdose, lyte imbalances
-chest pain/SOB/sweating
-fluid replacement but never rapid bolus
-correct underlying cause
-monitor labs, BP/MAP, I/Os
obstructive shock
-clogged pipes
-decreased cardiac function by noncardiac factor
-caused by: PE, cardiac tamponade, tension pneumo
-s/sx: hypotension, tachycardia, chest pain, tachypnea/dyspnea, hypoxia
-needle decompression if tension pneumo
distributive shock
-pipe malfunction
-excessive vasodilation
-caused by sepsis, spinal cord injury, anaphylaxsis
-loss of sympathetic tone or biochemical mediators that cause vasodilation
=
neurogenic distributive shock
-damage to nervous system (loss of sympathetic tone)
-causes: SCI above T6, spinal anesthesia complications, guillain-barre syndrome, other causes of nervous system damage
-s/sx: dry, warm skin (SQ vasodilation)
neurogenic shock managemnt
-support cardiovascular and neurologic functioning (fluid replacement+vasoactive meds to maintain MAP and manage bradycardia)
-treat underlying cause
-if pt. receives spinal or epidural anesthesia, elevate HOB at least 30 degrees to prevent spread of anesthetic agent up the spinal cord
-monitor closely for VTE because of increase pooling of blood
anaphylactic distributive shock
-severe allergic reaction
-s/sx 2-30 min: can sometimes manifest hours later, HA, lightheadedness, N/V/abd pain, pruitis
-recognition: erythema, generalized flushing, pruitis, dyspnea, laryngeal/angioedema, bronchospasm, stridor, hypotension
anaphylactic distributive shock management
-rapid recognition and response: remove causative agent, remove items around swollen extremities, elevated legs
-IM epinephrine, IV diphenhydramine
-Supp. O2
-fluid therapy/vasoactive meds
-intubation for resp. arrest
-CPR for cardiac arrest
distributive shock: sepsis and septic shock
-most common type of distributive shock
-bloodstream, lungs, urinary tract
-systemic inflammatory response syndrome results in hypoperfusion, mirrors stages of shock
-fever, elevated WBC, flushed skin, bounding pulses, elevated RR, mental status changes
risk factors for distributive shock: sepsis and septic shock
-large open wounds
-invasive devices
-age (older adults, children)
-immunosuppression
-type 2 diabetes mellitus
-malnutrition
-recent surgery
medical management of septic shock
-early recognition
-obtain lab work (lactate, CBC, Cr, BG, BUN)
-removal of all invasive devices in suspected pts
initiate abx therapy (broad spectrum first, then targeted once culture results come back
-fluid theraoy
-vasoactive medications for MAP >65
-nutritional therapy
healthcare associated infections
-central line assocaited bloodstream infections
-catheter-associated urinary tract infections
-pneumonia (due to ventilator)
-1/31 hospitalized pts. affected by an HAI at any one time
-increased mortality/length of stay
-many are preventible
-MRSA, C.diff, vancomycin resistant enterococci (VRE)
-carpapenem-resistant enterobacteriaceae (CRE)
-multi-drug resistant gram-negative rods (MDR-GNR)
HA pneumonia
-develops 48 hours or more after admission to facility
-most common HAI
-high mortality
-usually bacterial
-caused by inhilitation of organisms, aspiration of secretions, contaminated respiratory equipment
preventing pneumonia
-hand hygiene
-proper use of standard precautions
-turn,cough,deep breathe
-incentive spirometry
-early ambulation
-hydration
-oral care
CLABSI prevention
-hand hygiene prior to insertion
-avoid femoral vein if possible
-maximum sterile barrier precautions
-chlorhecidine for skin prep
-use of checklist
bloodstream infection prevention
-hand hygiene prior to handling catheter
-scrub the hub for 15 sec
-assess the site
-maintain closed system if possible
-dont get the site wet
-change tubing and drsg per facility protocol
-wear gloves
CDC appropriate recommendations for urinary catheter use
-acute urinary retention or bladder outlet obstruction
-need for accurate measurement of urine output in critically ill pts.
-perioperative use for selected surgical procedures
-to assist in healing of open sacral or perineal wounds in incontinent pts.
-pts. who require prolonged immbolization
-improve comfort for end of life care
proper foley care and maintenance
-regular foley and perineal care using soap and water
-ensure tubing is without kinks/loops
-maintain drainage bag below the level of the bladder
-keep bag off of the floor
-maintain the seal
-empty the bag regularly
-secure after insertion
-proper specimen collection
-remove asap!
COVID-19
-droplets, exhaled aerosols (breathing, speaking, coughing, sneezing)
-can remain indoors for hours
Zika
-bites of infected mosquito
-can cause microcephaly in infants infected in the womb
-avoid travel to high-risk areas
Ebola
-direct contact w/ blood or fluids, breast milk/semen
-avoid contact with fluids until the virus is gone from everything
infectious diseases that require droplet precautions
-influenza
-rubella
-mumps
-meningitis
infectious diseases that require airborne precautions
-TB
-covid-19
infectious diseases that require contact precautions
-MDR-GNR
-C-diff.
-MRSA
-Ebola
Anything skin
genomics
The study of the interaction of all genes in the human genome
genome
Complete set of genetic instructions
genotype
Genetic structure and variations that we inherit from parents
phenotype
physical, biochemical, and physiologic genetic makeup that
generates our physical presentation
epigenetics
changes in the expression of a gene due to environmental
exposure; personal health activity
pharmacogenetics
Study of safety and efficacy of medication admin based
on a person’s genotype
DNA
-code tells our cells how to make proteins
-Complete set of DNA = genome (~20,000 genes and 23 pairs of chromosomes)
-each nucleotide contains sugar, phosphate group and nitrogen base (4 types)
nitrogen bases
-Adenine (A)
-Thymine (T)
-Cytosine (C)
-Guanine (G)
A with T and G with C
mutations + DNA damage
-mutations are permanent changes in DNA
-diseases such as cystic fibrosis, sickle cell, cancer, heart disease +
genes + chromosomes
-genes are arranged in chromosomes
-each cell has 46 chromosome pairs (except eggs and sperm (23))
-of the 23 chromosomes: 22 are autosomes, and 1 sex chromosome
down syndrome
-not typically inherited
-Three copies of the 21 chromosome
-can lead to cardiac defects, thyroid, muscular tone issues, cognitive function, eyes, motor skills
autosomal dominant inheritance
child has inherited a mutation in a gene that gives them a higher chance of developing a condition compared with someone without mutation (50% chance per child)
autosomal recessive inheritance
one mutated gene is inherited from each parents. Parents each carry one mutated gene and one normal gene (parent does not have disease) (50% chance child is carrier, 25% chance not affected/affected)
X-linked inheritance
-genetic conditions associated w/ mutations in genes on the X chrmosome
-can be recessive or dominant pattern
-if a male carries the mutation they will be affecyed with the dieases becasue he only has 1 X chromosome
most common x-linked recessive inheritance situation
-female carrier (x-linked recessive)
-50% chance of passing mutation to son (would have disease)
-50% chance of passing to daughter who would be a carrier like the mother
multifactorial inheritance
-birth defects, heart disease, cancer, osteroarthritis, diabetes, neural tube defects
-may see clusters in families, but nor predictable pattern of inheritance
genetic screening
-used when no signs/symptoms of a disorder
-estimate whether an individual’s risk of having of having a condition is increased/decreased compared with risk of similar population
-can be false positives or false negatives
genetic testing
-used w/ signs and symptoms
-used to confirm or rule out certain conditions
-can also help to confirm or rule out certain conditions
-can also help inform a persons’ chance of developing a condition and passing down to a child
-can be performed before birth or during life
