exam 3 Flashcards
Assessment of hematologic function
Health History:
Prior episodes of bleeding (epistaxis, tooth, gum, hematuria, menorrhagia, hematochezia, gastrointestinal bleeding and/or ulcers)
Prior blood clots, pulmonary emboli, miscarriages
Fatigue and weakness
Dyspnea, particularly dyspnea on exertion, orthopnea, shortness of breath
Prior radiation therapy (especially pelvic irradiation)
Prior chemotherapy
Hobbies/occupational/military exposure history (especially benzene, Agent Orange)
Diet history
Alcohol consumption
Use of herbal supplements
Concurrent medications
Family history/ethnicity
Physical assessment:
Skin:
Gray-tan or bronze skin color (especially genitalia, scars, exposed areas)
Ruddy complexion (face, conjunctiva, hands, feet)
Ecchymoses (i.e., bruises)
Petechiae
Rash
Bleeding (including around vascular lines, tubes)
Conjunctival hemorrhage
Pallor, especially in mucous membranes (including conjunctiva), nail beds, palate
Jaundice in mucous membranes (including conjunctiva), nail beds, palate
Oral cavity:
Petechiae in the buccal mucosa, gingiva, hard palate
Ulceration of oral mucosa
Infection, leukemia
Tongue: Smooth
Beefy red
Enlarged
Angular cheilosis (ulceration at corners of mouth)
Enlarged gums: hyperplasia
Enlarged size, firm and fixed vs. mobile and tender
Respiratory
Increased rate and depth of respirations; adventitious breath sounds
Cardiovascular: Distended neck veins, edema, chest pain on exertion, murmurs, gallops Hypotension (below baseline) Hypertension (above baseline) Severe anemia Polycythemia Genitourinary Hematuria Proteinuria
Musculoskeletal: Rib/sternal tenderness to palpation Back pain; tenderness to palpation over spine, loss of height, kyphosis Pain/swelling in knees, wrists, hands Enlarged spleen Enlarged liver Stool positive for occult blood
Central nervous system:
Cranial nerve dysfunction
Peripheral nerve dysfunction (especially sensory)
Visual changes, headache, alteration in mental status
Gynecologic:
Menorrhagia
Fever, chills, sweats, asthenia
Gerontologic considerations for hematologic function
Bone marrow’s ability to respond to need for blood cells may be decreased
Inability to perform hematopoiesis
More susceptible to myelosuppression effects of medications
hematologic studies
Hematologic Studies- hematopoietic, hemostasis, or reticuloendothelial system (blood and blood disorders)
two most common: CBC & peripheral blood smear
complete blood count (CBC)
RBC: Normal Adult
(female 4.2-5.4 male 4.7-6.1)
Red blood cell indices:
MCV: Normal adult 80-95dL
MCH: Normal adult 27-31pg/cell
MCHC: Normal Adult 32-36%
RDW: Normal Adult 11-14.5 %
Hgb: Normal Adult
(female 12-16 g/dL male 14-18 g/dL)
Hct: Normal Adults
(female 37-47% & Male 42-52%)
WBC: Normal Adults 5000-10,000/mm3 Neutrophils: Normal 50-70% of differential Segments: 38%–71% of total Bands: 0%–10% of total Eosinophils: Normal 0-7% Basophils: Normal 0-2% Lymphocytes: Normal 16-45% Monocytes: Normal 4-10%
Platelet: Normal Adults 150,000-400,000/mm3
Remember:
Hemoglobin – female and male have different numbers, magic number 10 – anemic
Less than 8 – provide blood transfusion
May be less after surgery- but watch the trend before transfusing
1 unit of blood at a time
White count-
Above 10- risk for infection
Focus on 10,000
Platelets-
150-400,000
Below 100- risk for bleeding
Bone marrow aspiration & biopsy
Diagnose and monitor blood cells and marrow diseases, including cancers
Monitor treatment of a disease
Hemochromatosis
Investigate a fever of unknown origin
Assess the quantity and quality cells produced
within the marrow
Nursing Care:
Physician explain procedure
Risks/benefits/alternatives
Informed Consent
Procedure: Skin cleaned using aseptic technique Local anesthesia Hollow core, large bore needle Aspirate marrow from bone (iliac crest or sternum)
Biopsy- iliac crest only
How to take care patient before, during, and after bone marrow aspiration and biopsy
Pre procedure Nursing management Consent Prone or side-lying position Patient education
Intra procedure Nursing management Sedation Patient education Test will last 20 mins Invasive procedure Education- side lateral position for aspiration Biopsy- use something quiz to get biopsy May see bleeding or drainage from sight for 8-12 hours Feel pressure during procedure, no pain though Outpatient, they will go home Pain meds, any warm redness from sight Pressure dressing Monitor dressing and bleeding
Post procedure Nursing management Control bleeding, Pain/discomfort Patient education Monitor bleeding Monitor S/S of infection Dressing
complications of bone marrow aspiration and biopsy
Hemorrhage Risk factors- coagulopathies myeloproliferative disorders aspirin and warfarin therapy thrombocytopenia Disseminated Intravascular Coagulation liver disease
Infection
Pain
Patient Education
Site may ache 1-2 days
Warm tub baths should be avoided for 24 hours
NSAIDs should be avoided r/t bleeding
Acetaminophen may be used as mild analgesic
Patient support
patho of anemias
Iron deficiency:
hypoproliferative (bone marrow)
When there is little to no iron left to transport to the bone marrow, iron deficient erythropoiesis begins.
Anemias in renal disease:
hypoproliferative (bone marrow)
When your kidneys are damaged, they produce less erythropoietin (EPO), a hormone that signals your bone marrow—the spongy tissue inside most of your bones—to make red blood cells (less RBC made)
Folic acid deficiency:
Folic acid, a B vitamin, is needed for the formation of heme, the pigmented, iron-containing portion of the hemoglobin in red blood cells (erythrocytes). A deficient intake of folic acid impairs the maturation of young red blood cells, which results in anemia
Vitamin B12 deficiency: lack of intrinsic factor
failure of gastric parietal cells to produce sufficient IF (a gastric protein secreted by parietal cells) to permit the absorption of adequate quantities of dietary vitamin B-12.
Resulting from blood loss: trauma, medications, surgery
Hypoproliferative: Iron deficiency anemia Anemia in renal disease Megaloblastic Anemia in chronic disease Aplastic Anemia
Hemolytic:
Sickle Cell Anemia- inherited
Thalassemia’s- inherited
Immune hemolytic anemia’s
Blood loss:
Bleeding
Trauma
manifestations of anemias
Iron deficiency:Smooth, red, sore tongue
Brittle (sometimes spoon shaped) nails
Cracks at the corners of the mouth (Cheilitis)
Hx- multiple pregnancies, GI bleed, and Pica
Anemias in renal disease: Fatigue Increased cardiac output Reduced O2 utilization Decrease concentration and cognitive function
Folic acid deficiency: pale in mucous membranes,
Vitamin B12 deficiency: pernicious anemia- smooth red sore tongue, paresthesia in lower extremities (numbness & tingling)
Resulting from blood loss:
Tachycardia
Tachypnea, SOA
Dizziness
medical management and nursing interventions for anemias
Iron deficiency: Medical Management Identify cause (stool sample, colonoscopy) Inadequate intake of iron Inadequate storage of iron Abnormal loss of iron Prescribe supplements (oral or IV) Nursing Management Food sources – organ meats, meat, beans, leafy green vegetables Administer oral supplement Administer parenteral supplement
Anemias in renal disease: Medical Management Prescribe Epoetin alfa (IV or SQ 3x/week) and supplemental iron Monitor Hgb, Hct, iron and potassium Monitor BP Nursing Management Fatigue Angina Shortness of breath Monitor S/E of Epoetin (helps iron absorb)
Folic acid deficiency: Medical Management Prescribe folic acid (1mg/day) Nursing Management Food sources – liver, green vegetables Administer folic acid (IM or multivitamin)
Vitamin B12 deficiency:
Medical Management
Prescribe vitamin B12 replacement (oral, IM)
Nursing Management
Food sources – fortified soy milk
Administer vitamin B12 (oral when diet-related; monthly IM for pernicious anemia)
Educate re: pernicious anemia - lifelong treatment, risk of gastric cancer
Resulting from blood loss: Medical Management Identify cause Stop the bleeding Prescribe blood transfusion Prescribe iron supplements Nursing Management Monitor for bleeding Administer blood Administer iron supplement
assessment and diagnosis of anemia
Time to develop anemia Duration of the anemia Physical Assessment Metabolic requirements of the patient Other disorders/diseases present in the patient Family history
Iron Deficiency Anemia
Labs: low iron, ferritin levels, decreased MCV, increased RDW
Bone marrow aspiration
Occult blood stool sample
Megaloblastic Anemias Labs: increased MCV, increased RDW Bone marrow analysis Vitamin B12 level Folic acid level
Polycythemia
Causes:
Polycythemia Vera (PV): myeloid stem cell mechanisms out of control
Secondary polycythemia: Excessive production of erythropoietin
“thick blood”
Manifestation: HA, angina, dyspnea, claudication, blurred vision, pruritus
Risk for thrombosis and MI
Treatment: Phlebotomy (~ 500mL 1-2 times per week) Chemotherapy Antihistamines and Interferon alfa-2b for pruritus Allopurinol for gout attacks
Nursing Considerations: Educate patient of risk factors for thrombolytic complications Reduce risk of DVT Avoid iron supplements Tepid baths
Neutropenia
Causes: Decreased production of neutrophils Aplastic anemia (medications or toxins) Chemotherapy Radiation therapy Metastatic cancer Ineffective granulocytopoiesis Megaloblastic anemia Increased destruction of neutrophils Bacterial infection viral disease Immunologic disorders (SLE) Medication induced
Assessment
Neutrophil count < 2000/mm3
Routine CBC with differential
Treatment:
Treat underlying disease
Nursing: Assessment, prevention, and management of infection Educate r/t risk of infection Educate of s/s infection reverse isolation
thrombocytopenia
Causes:
Decreased platelet production
Increased platelet destruction
Increased platelet consumption
Assessment
Bleeding Precautions for platelets < 50,000
Risk of bleeding if platelets < 20,000
Bleeding and petechiae
Excessive bleeding after surgery or dental extraction
excessive menstrual bleeding
Spontaneous bleeding if platelets < 5,000
Treatment:
Prepare to administer FFP, PRBCs, Platelets, Vitamin K
Monitor lab work
Treat underlying disease
Nursing: Bleeding precaution Promote safety Educate r/t risk of hemorrhage Educate of s/s bleeding
difference between cellular and humoral immune response
Humoral:
B-cell quantification with monoclonal antibody
In vivo immunoglobulin synthesis with T-cell subsets
Specific antibody response
Total serum globulins and individual immunoglobulins (electrophoresis, immunoelectrophoresis, single radial immunodiffusion, nephelometry, & isohemagglutinin techniques
Cellular:
Total lymphocyte count
T-cell and T-cell-subset quantification with monoclonal antibody
Delayed hypersensitivity test
Cytokine production
Lymphocyte response to mitogens, antigens, and allogenic cells
Helper and suppressor T-cell functions
Humoral immunity secretes antibodies to fight against antigens, whereas cell-mediated immunity secretes cytokines and no antibodies to attack the pathogens
humoral immunity responses, B Cells produce antibodies after being activated by free antigens present in body fluids. In cell-mediated immunity responses, T cells attack infected body cells that display the antigens of pathogens on their surface.
Humoral immunity is also called antibody-mediated immunity. With assistance from helper T cells, B cells will differentiate into plasma B cells that can produce antibodies against a specific antigen. The humoral immune system deals with antigens from pathogens that are freely circulating, or outside the infected cells. Antibodies produced by the B cells will bind to antigens, neutralizing them, or causing lysis (dissolution or destruction of cells by a lysin) or phagocytosis.
Cellular immunity occurs inside infected cells and is mediated by T lymphocytes. The pathogen’s antigens are expressed on the cell surface or on an antigen-presenting cell. Helper T cells release cytokines that help activated T cells bind to the infected cells’ MHC-antigen complex and differentiate the T cell into a cytotoxic T cell. The infected cell then undergoes lysis.
body’s general allergic reactions and the stages of the allergic response
Allergic reaction:
Manifestation of tissue injury resulting from interaction between antigen & antibody
Body encounters allergens that are types of antigens
Body’s defenses recognize antigens as foreign
Series of events occurs in an attempt to render the invaders harmless, destroy them, and remove them from the body
Allergen triggers the B cell to make IgE antibody, which attaches to the mast cell. When that allergen reappears, it binds to the IgE and triggers the mast cell to release its chemicals.
Primary: Histamine Eosinophil chemotactic factor of anaphylaxis Platelet-activating factor Prostaglandins
Secondary:
Leukotrienes
Bradykinin
Serotonin
Environment (dust, pollen, mold, animal hair, etc.)
Food- nuts, seafood, eggs, peas, beans, milk
Proteins- foreign serum, vaccines
Latex
Medications- penicillin, sulfonamides, local anesthetics, salicylates
Inset bites/ stings
hypersensitivity
Abnormal heightened reaction to a stimulus of any kind Types of hypersensitivity reactions: 1 = Allergic Anaphylaxis and Atopy 2 = antiBody 3 = immune Complex 4 = Delayed
Type I- IgE mediated
Immediate onset (minutes): ingestion, inhalation, injection, or direct contact
IgE formation-histamine and leukotriene release
Manifestations: erythema, edema, pruritus, contraction of bronchial smooth muscle, increased mucous secretion
Example: Anaphylaxis, environmental (pollens)/ food allergy, insect stings, allergic conjunctivitis, allergic rhinitis (hay fever), atopic dermatitis (eczema), allergic asthma, hereditary angioedema, eosinophilia, urticaria (hives), maybe latex allergy
Type II-Antibody mediated
Fast onset (minutes – hours)
Cytotoxic reaction-antigen attach to cell- IgG, IgM, Macrophages attack antigen and self-cells; destroy (lyse) them (cellular lysis)
Cellular destruction by three mechanisms: (i) phagocytosis, (ii) complement-dependent cytotoxicity (CDC), and (iii) antibody-dependent cellular cytotoxicity (ADCC).
Example: Medication reactions (S/E), autoimmune blood transfusion hemolytic reactions, hemolytic disease, and hemolytic anemia, Good Pasture Syndrome, myasthenia gravis
Type III- Immune Complex mediated
Onset hours-days
Immune Complex –(Neutrophils, IgG, IgM)-deposited in small blood vessels of the skin (vasculitic), joints, kidneys (nephritis), lungs (extrinsic allergic alveolitis), systemic (serum sickness)
Vascular permeability, inflammation, fever, joint pain, rash, lymphadenopathy, hypotension, shock
Example: Systemic Lupus Erythematosus, serum sickness, Rheumatoid Arthritis, glomerulonephritis
Type IV- Delayed Type
Onset Delayed (24-72 hours after exposure)
Due to infectious agents, such as mycobacteria, protozoa and fungi
Sensitized T cells and macrophages – release lysosomes
Manifestations: edema, erythema, pruritus, ischemia, inflammation, and tissue damage
Example: Latex allergy (can turn into Type I), TB test and TB, contact dermatitis (latex, poison ivy), multiple sclerosis, transplant rejection
Assessment of Patients with Allergic Disorders
History, manifestations, & comprehensive allergy history
Diagnostic tests:
CBC: eosinophil count
Total serum IgE
Skin tests: prick, scratch, and intradermal
Two types of reactions: atopic and nonatopic
Atopic: (mediated by IgE)
Asthma, allergic rhinitis, atopic dermatitis
Familial
Nonatopic:
Lack genetic component
Latex
Anaphylaxis
Immediate release of IgE-mediated chemicals that produce a life-threatening reaction
Mild, moderate, and severe systemic reactions
Symptoms (Sudden onset. Progress in severity over minutes to hours.) Flushing Urticaria Angioedema Hypotension Bronchoconstriction
Causes
Foods
Peanuts, tree nuts (e.g., walnuts, pecans, cashews, almonds), shellfish (e.g., shrimp, lobster, crab), fish, milk, eggs, soy, wheat
Medications
Antibiotics, especially penicillin and sulfa antibiotics, allopurinol, radiocontrast agents, anesthetic agents (lidocaine, procaine), vaccines, hormones (insulin, vasopressin, adrenocorticotropic hormone), aspirin, nonsteroidal anti-inflammatory drugs
Other Pharmaceutical/Biologic Agents
Animal serums (tetanus antitoxin, snake venom antitoxin, rabies antitoxin), antigens used in skin testing
Insect Stings
Bees, wasps, hornets, yellow jackets, ants (including fire ants)
Latex
Medical and nonmedical products containing latex
prevention and management of allergic reactions/anaphylaxis
prevention:
Avoid potential allergens
If avoidance is impossible, get an epinephrine autoinjector.
Wear medical identification which lists allergens.
Management:
Oxygen as needed
Epinephrine (1:1000 dilution) IM preferred (See Chart 37-3, pg. 1067)
Manage airway (bronchodilators, corticosteroids)
Adjuncts: antihistamines & corticosteroids
IV fluids (NS), volume expanders, vasopressors
Transfer to ED
Watch for delayed reaction 4-8 hours after initial allergic reaction
Rheumatic Disease
Encompass autoimmune, degenerative, inflammatory, & systemic conditions
Affect the joints, muscles, and soft tissues
Problems caused by rheumatic diseases include:
Limitations in mobility and activities of daily living
Pain and fatigue
Altered self-image
Sleep disturbances
Systemic effects that can lead to organ failure and death
Commonly manifest the clinical features of arthritis (inflammation of a joint) & pain
Marked by periods of remission and exacerbation
Classifications:
Monoarticular or polyarticular
Inflammatory or noninflammatory
Three distinct characteristics: Inflammation: Autoimmunity: hallmark of rheumatologic disease Degeneration Manifestations: Secondary process to inflammation Pain Joint swelling Limited movement Stiffness Weakness Fatigue
Nursing Process: The Care of the Patient with a Rheumatic Disorder
Assessment:
Current and past symptoms: fatigue, weakness, pain, stiffness, fever, or anorexia
Effects of symptoms on the patient’s lifestyle and self-image
Psychological and mental status, social support system, comply with treatment regimen, and manage self-care
Pain:
Provide comfort measures
Administer anti-inflammatory analgesic
Fatigue:
Explain energy conserving techniques
Facilitate development of activity/rest schedule
Impaired physical mobility:
Assess for need of PT/OT
Encourage independence in mobility
Self-care deficit:
Assist in identifying self-care deficits
Provide assistive devices
Consult with community agencies
Disturbed body image:
Assist to identify elements of control over disease
Encourage verbalization of feelings
Ineffective coping:
Identify areas of life affected by disease
Develop plan for managing symptoms and enlisting support of family and friends to promote daily function
Complications secondary to medications:
Perform periodic clinical assessment and laboratory evaluation
Provide education about correct self-administration, potential side effects, and importance of monitoring
Counsel regarding methods to reduce side effects and manage symptoms
Administer medications in modified doses as prescribed if complications occur
Rheumatoid Arthritis
usually affects joints symmetrically, may initially begin in a couple of joints only, and most frequently attacks the wrists, hands, elbows, shoulders, knees, and ankles
Manifestation:
Symmetric joint
Pain, Swelling, Warmth, Erythema
Morning stiffness
Testing: ESR, CRP: elevated RBC decreased ANA positive Arthrocentesis shows cloudy, milky, dark yellow fluid
Treatment:
NSAIDs, COX-2 inhibitors, disease-modifying antirheumatic drugs (DMARDs)
Systemic Lupus Erythematosus (SLE)
SLE is an autoimmune disorder wherein immune complexes form and deposit in the basement membranes of capillaries, causing manifestations in the skin, joints, serous membranes, renal, hematologic and neurologic systems.
Remissions and exacerbations of Manifestations: Fatigue Myalgia /arthralgia Photosensitivity/rash Neurologic/behavioral changes Pericarditis/ pleuritis Renal disease Oral ulcers Erythrocyte Sedimentation Rate (ESR), Antinuclear Antibody (ANA), creatinine elevated CBC-anemia or thrombocytopenia weight loss
Treatment- Multiple Medications Corticosteroids (topical and oral) NSAIDs Glucocorticoids Immunosuppressive agents
Nursing Consideration
Fatigue. Impaired skin integrity. Body image disturbance
Avoid exposure to sun & UV light
Diet to prevent HTN, atherosclerosis
gout
Monosodium urate crystals deposit in joints; Tophi
swollen and inflamed joints, masses of uric acid (tophi), uric acid crystals
Manifestations:
Acute pain, redness, swelling, warmth of affected joint
Triggers: Alcohol, trauma, diet, medications, stress, illness
food to avoid:
fatty fish, shell fish, red meat, eggs, caffeine, white flour, yeast, alcohol, leafy green veggies, cake, pastries, sugars
Testing: polarized light microcopy pf synovial fluid, Serum uric Acid level
Treatment Xanthine oxidase inhibitor (Allopurinol) Uricosuric agents (Probenecide) NSAIDs Colchicine
Nursing Care: Rest joint Apply ice Avoid aspirin, stress, ETOH, trauma, food high in purines Drink plenty of fluids
fibromyalgia
Manifestations
Chronic pain, Diffuse musculoskeletal achiness, Morning stiffness, Fatigue, Sleep disturbances, Functional impairment, Weight gain, Mood disturbances, Chemical sensitivity, dysmenorrhea,
Dx by manifestations
Widespread pain index (WPI)
& symptom severity score
Symptoms present for at least
3 months
No other disorder to explain
the pain
Treatment NSAIDs TCA (Amitriptyline, Nortriptyline) Muscle relaxants (Cyclobenzaprine) AEDs (Gabapentin, Pregabalin) Antidepressants
Nursing Care
Exercise
Cognitive therapy
Medication regimen
Management of Patients with Oncologic Disorders
Treatment Goals
Cure- complete eradication of malignant disease
Control- prolonged survival and containment of cancer cell growth
Palliation- relief of symptoms associated with the disease and improvement of quality of life
Treatment Approaches
Surgery- diagnostic surgery (biopsy), treatment, prophylactic surgery, palliative surgery, reconstructive surgery
Radiation
Chemotherapy
Preop care:
Emotional support. Education (consistent information)
RN is patient advocate & liaison
Post-op care:
Complications (dehiscence, fluid/electrolyte imbalances, organ dysfunction)
Wound care, pain management, activity, nutrition & medication teaching
Surgery combined w/radiation & chemotherapy
post-op complications:
Infection & impaired wound healing & development of VTE
Altered pulmonary & renal function
Discharge: Community resources (American Cancer Society)
radiation therapy
Treatment Goals
Cure- Thyroid carcinomas, cancers of the cervix
Control- reduce tumor size to facilitate surgical resection
Prophylactically- prevent spread of the primary cancer to a distance area
Palliative- relieve the symptoms of metastatic disease
Administration
Teletherapy- external-beam radiation e.g. EBRT (GammaKnife)
Brachytherapy- internal radiation implantation (vagina, abdomen, pleura, breast, prostate)- LDR (low dose), HDR (high dose)
Toxicity Early, systemic, late effects Altered skin integrity Alterations in oral mucosa Affect QOL, overall health
Side Effects- localized
Alopecia, Erythema, Desquamation, Potentially Ulceration, Hyperpigmentation
Stomatitis, Xerostomia, change in or loss of taste
Mucositis, anorexia, nausea, vomiting, and diarrhea
Anemia, Leukopenia, Thrombocytopenia
Radiation precautions- Time, Distance, & Shielding private room w/notice on door staff wear dosimeter badges no pregnant staff members assigned no children or pregnant visitors limit visits to 30 min. daily stay 6 feet away If internal implant dislodged: Pick up w/metal forceps. Place in lead-lined container Contact radiation safety officer & go to occupational health
Protect skin and oral mucosa
Avoid ointment, lotion, powder on treated area
Gently cleanse with mild soap using fingertips instead of washcloth
Do not remove temporary skin markings
Electric razors only
Avoid constrictive clothing
Avoid sun exposure, health lamps, head pads, ice packs
Gentle oral hygiene
Chemotherapy
Technique for administration
Administered in the hospitals, outpatient center, or home setting
Right atrial silastic catheters, Implanted venous access device or PICC
Prevention of extravasation
Hypersensitivity reactions- Type I
Discontinue medication immediately
Initiate emergency procedures
Aspirate any remaining drug from the extravasation site
Toxicity
Gastrointestinal system, Hematopoietic system, Renal system, Cardiopulmonary system, Reproductive system, Neurologic system, cognitive impairment, and Fatigue
management: Assessing Fluid and Electrolyte Balance Assessing Cognitive Status Modifying Risks for Infection and Bleeding Preventing Nausea and Vomiting Managing Cognitive Changes Managing Fatigue Protecting Caregivers
phases of care for the surgical patient and the types of surgical approaches
The preoperative phase begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room (OR) bed.
The intraoperative phase begins when the patient is transferred onto the OR bed and ends with admission to the PACU. Intraoperative nursing responsibilities involve acting as scrub nurse, circulating nurse, or registered nurse first assistant.
The postoperative phase begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home.
Surgical interventions can be describe based on purpose:
Facilitating a diagnosis (a diagnostic procedure such as biopsy, exploratory laparotomy, or laparoscopy)
Curative (e.g., excision of a tumor or an inflamed appendix), or repair (e.g., multiple wound repair).
Reconstructive or cosmetic (such as mammoplasty or a facelift)
Palliative (to relieve pain or correct a problem—such as debulking a tumor to achieve comfort, or removal of a dysfunctional gallbladder).
Rehabilitative (e.g., total joint replacement surgery to correct crippling pain or progression of degenerative osteoarthritis.)
Surgery can also be classified based upon the degree of urgency involved: emergent, urgent, required, elective, and optional
preop:
Preop assessment
Patient demographics and health history (including medication profile)
Consent (page 422, Chart 17-2)
Diagnostic (CT, MRI, X-rays, ECG, etc.)
Laboratory tests (CBC, BMP, PT, PTT, UA, etc.)
Education– the patient is educated not only on expectations of the procedure and outcomes, but also on the post operative plan of care. How will the paient prepare for the procedure, What will the patient need before/during/after, what medications can they expect to take, what will follow up look like, what activities will they be doing, what sort of support should they plan to have, etc.
postop:
Nursing management of the post operative patient (Page 463-464, Chart 19-4).
During the first 24 hours after surgery, nursing care of the hospitalized patient on the medical-surgical unit involves continuing to help the patient recover from the effects of anesthesia, frequently assessing the patient’s physiologic status, monitoring for complications, managing pain, and implementing measures designed to achieve the long-range goals of independence with self-care, successful management of the therapeutic regimen, discharge to home, and full recovery.
In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding are primary concerns.
gerontologic considerations for surgery
The hazards of surgery for older adults are proportional to the number and severity of comorbidities and the nature and duration of the operative procedure.
Older adult patients have less physiologic reserve (i.e., the ability of an organ to return to normal after a disturbance in its equilibrium) than younger patients. Cardiac reserves are lower, renal and hepatic functions are depressed, and gastrointestinal activity is likely to be reduced. See Table 11-1 for additional age-related changes.
Respiratory and cardiac complications are the leading causes of postoperative morbidity and mortality in older adults.
possible Dx after surgery
Risk for ineffective airway clearance related to depressed respiratory function, pain, and bed rest
Acute pain related to surgical incision
Decreased cardiac output related to shock or hemorrhage
Risk for activity intolerance related to generalized weakness secondary to surgery
Impaired skin integrity related to surgical incision and drains
Ineffective thermoregulation related to surgical environment and anesthetic agents
Risk for imbalanced nutrition, less than body requirements related to decreased intake and increased need for nutrients secondary to surgery
Risk for constipation related to effects of medications, surgery, dietary change, and immobility
Risk for urinary retention related to anesthetic agents
Risk for injury related to surgical procedure/positioning or anesthetic agents
Anxiety related to surgical procedure
Deficient knowledge related to wound care, dietary restrictions, activity recommendations, medications, follow-up care, or signs and symptoms of complications in preparation for discharge
surgical asepsis
Surgical asepsis prevents the contamination of surgical wounds.
The patient’s natural skin flora or a previously existing infection may cause postoperative wound infection. Rigorous adherence to the principles of surgical asepsis by OR personnel is basic to preventing surgical site infections.
All surgical supplies, instruments, needles, sutures, dressings, gloves, covers, and solutions that may come in contact with the surgical wound or exposed tissues must be sterilized before use.
Traditionally, the surgeon, surgical assistants, and nurses prepared themselves by scrubbing their hands and arms with antiseptic soap and water; however, this practice is being challenged by research investigating the optimal length of time to scrub and the best preparation to use.
Surgical team members wear long-sleeved, sterile gowns and gloves. Head and hair are covered with a cap, and a mask is worn over the nose and mouth to minimize the possibility that bacteria from the upper respiratory tract will enter the wound.
During surgery, only personnel who have scrubbed, gloved, and gowned touch sterilized objects. Nonscrubbed personnel refrain from touching or contaminating anything sterile.
An area of the patient’s skin larger than that requiring exposure during the surgery is meticulously cleansed, and an antiseptic solution is applied. If hair removal needs to take place and this was unable to be performed before the patient arrived in the OR suite, this is done immediately before the procedure with electric clippers (not shaved) to minimize the risk of infection. The remainder of the patient’s body is covered with sterile drapes.
All practitioners involved in the intraoperative phase have a responsibility to provide and maintain a safe environment.
basic principles:
All materials in contact with the surgical wound or used within the sterile field must be sterile.
Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile; contact with unsterile objects at any point renders a sterile area contaminated.
Gowns of the surgical team are considered sterile in front from the chest to the level of the sterile field. The sleeves are also considered sterile from 2 in above the elbow to the stockinette cuff.
Sterile drapes are used to create a sterile field (see Fig. 18-2). Only the top surface of a draped table is considered sterile. During draping of a table or patient, the sterile drape is held well above the surface to be covered and is positioned from front to back. Items are dispensed to a sterile field by methods that preserve the sterility of the items and the integrity of the sterile field.
After a sterile package is opened, the edges are considered unsterile. Sterile supplies, including solutions, are delivered to a sterile field or handed to a scrubbed person in such a way that the sterility of the object or fluid remains intact.
The movements of the surgical team are from sterile to sterile areas and from unsterile to unsterile areas. Scrubbed people and sterile items contact only sterile areas; circulating nurses and unsterile items contact only unsterile areas. Sterile areas must be kept in view during movement around the area. At least a 1-ft distance from the sterile field must be maintained to prevent inadvertent contamination.
Whenever a sterile barrier is breached, the area must be considered contaminated. A tear or puncture of the drape permitting access to an unsterile surface underneath renders the area unsterile. Such a drape must be replaced. Every sterile field is constantly monitored and maintained.
Items of doubtful sterility are considered unsterile. Sterile fields are prepared as close as possible to the time of use.
Proper draping exposes only the surgical site, which decreases the risk of infection.
The routine administration of hyperoxia (high levels of oxygen) is not recommended to reduce surgical site infections
Environmental Controls
Floors and horizontal surfaces are cleaned between cases with detergent, soap, and water or a detergent-germicide.
Sterilized equipment is inspected regularly to ensure optimal operation and performance.
All equipment that comes into direct contact with the patient must be sterile.
Sterilized linens, drapes, and solutions are used. Instruments are cleaned and sterilized in a unit near the OR. Individually wrapped sterile items are used when additional individual items are needed.
Airborne bacteria are a concern.
To decrease the amount of bacteria in the air, standard OR ventilation provides 15 air exchanges per hour, at least 3 of which are fresh air
A room temperature of 20°C to 24°C (68°F to 73°F), humidity between 30% and 60%, and positive pressure relative to adjacent areas are maintained.
Staff members shed skin scales, resulting in about 1000 bacteria-carrying particles (or colony-forming units [CFUs]) per cubic foot per minute. With the standard air exchanges, air counts of bacteria are reduced to 50 to 150 CFUs per cubic foot per minute. Systems with high-efficiency particulate air (HEPA) filters are needed to remove particles larger than 0.3 μm.
Unnecessary personnel and physical movement may be restricted to minimize bacteria in the air and achieve an OR infection rate no greater than 3% to 5% in clean, infection-prone surgery.
Even using all precautions, wound contamination may inadvertently occur. Constant surveillance and conscientious technique in carrying out aseptic practices are necessary to reduce the risk of contamination and infection.
Wound Infection and wound dehiscence
The creation of a surgical wound disrupts the integrity of the skin, bypassing the body’s primary defense and protection against infection.
Exposure of deep body tissues to pathogens in the environment places the patient at risk for infection of the surgical site, and a potentially life-threatening complication such as infection can increase the length of hospital stay, costs of care, and risk of further complications.
Multiple factors place the patient at potential risk for infection.
Type of the wound
Surgical wounds are classified according to the degree of contamination. (Table 19-5 defines the classification of surgical wounds)
Patient-related factors include age, nutritional status, diabetes, smoking, obesity, remote infections, endogenous mucosal microorganisms, altered immune response, length of preoperative stay, and severity of illness
Factors related to the surgical procedure include the method of preoperative skin preparation, surgical attire of the team, method of sterile draping, duration of surgery, antimicrobial prophylaxis, aseptic technique, factors related to surgical technique, drains or foreign material, OR ventilation, length of procedure, and exogenous microorganisms.
Other risk factors for wound sepsis include wound contamination, foreign body, faulty suturing technique, devitalized tissue, hematoma, debilitation, dehydration, malnutrition, anemia, obesity, shock, duration of surgical procedure, and associated disorders (e.g., diabetes)
Efforts to prevent wound infection are directed at reducing risks.
Postoperative care of the wound centers on:
assessing the wound
preventing contamination
infection before wound edges have sealed
enhancing healing
Wound infection may not be evident until at least postoperative day 5. Most patients are discharged before that time, and more than half of wound infections are diagnosed after discharge, highlighting the importance of patient education regarding wound care
S/S of wound infection
Increased pulse rate
Elevated temperature
Elevated white blood cell count
Wound swelling, warmth, tenderness, or discharge/drainage
Increased incisional pain.
Local signs may be absent if the infection is deep.
Management
Intensive medical and nursing care is essential if the patient is to survive.
When a wound infection is diagnosed in a surgical incision, the surgeon may remove one or more sutures or staples and, using aseptic precautions, separate the wound edges with a pair of blunt scissors or a hemostat. Once the incision is opened, a drain is inserted. If the infection is deep, an incision and drainage procedure may be necessary.
Antimicrobial therapy and a wound care regimen are also initiated.
Wound Dehiscence and Evisceration are serious surgical complications (see Fig. 19-6).
Wound dehiscence (disruption of surgical incision or wound)
Evisceration (protrusion of wound contents)
Dehiscence and evisceration are especially serious when they involve abdominal incisions or wounds. These complications result from sutures giving way, from infection, or, more frequently, from marked distention or strenuous cough. They may also occur because of increasing age, anemia, poor nutritional status, obesity, malignancy, diabetes, the use of steroids, and other factors in patients undergoing abdominal surgery. When the wound edges separate slowly, the intestines may protrude gradually or not at all, and the earliest sign may be a gush of bloody (serosanguineous) peritoneal fluid from the wound. When a wound ruptures suddenly, coils of intestine may push out of the abdomen. The patient may report that “something gave way.” The evisceration causes pain and may be associated with vomiting. p. 474
wound healing- incisions
First-Intention Healing Wounds made aseptically with a minimum of tissue destruction that are properly closed heal with little tissue reaction by first intention (primary union). When wounds heal by first-intention healing, granulation tissue is not visible and scar formation is minimal.
Often covered with a dry sterile dressing. If a cyanoacrylate tissue adhesive (LiquiBand) has been used to close the incision without sutures, a dressing is contraindicated.
Second-Intention Healing Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been approximated.
When an abscess is incised, it collapses partly, but the dead and dying cells forming its walls are still being released into the cavity. For this reason, a drainage tube or gauze packing is inserted into the abscess pocket to allow drainage to escape easily.
Gradually, the necrotic material disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue. The cells surrounding the capillaries change their round shape to become long, thin, and intertwined to form a scar (cicatrix). Healing is complete when skin cells (epithelium) grow over these granulations. This method of repair is referred to as healing by granulation, and it takes place whenever pus is formed or when loss of tissue has occurred for any reason.
When the postoperative wound is to be allowed to heal by secondary intention, it is usually packed with saline-moistened sterile dressings and covered with a dry sterile dressing.
Third-Intention Healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are re-sutured later, thus bringing together two opposing granulation surfaces. This results in a deeper and wider scar. These wounds are also packed postoperatively with moist gauze and covered with a dry sterile dressing
parenteral fluid therapy
Fluid and electrolyte balance is a necessary component for life in the maintenance of homeostasis.
If unable to take PO/no other route available, fluids are administered by IV (intravenous access).
Goals include:
Provide water, electrolytes, and nutrients to meet daily requirements
To replace water and correct electrolyte deficits
To administer medications and blood products
types of IV fluids
Isotonic Fluids
Use: hydration or fluid loss
Alert: Do not use in clients with HTN, cardiac disease, or renal disease (may cause Fluid Volume Excess, HTN, Hypernatremia)
NS (0.9% normal saline), of note this is the only fluid that can be used when administering blood products
LR (Lactated Ringers)
Contains NA,K, CA++, & CL
D5W (is considered both isotonic and hypotonic- at base is isotonic but in effect is hypotonic because the glucose is rapidly metabolized and the water has a hypotonic effect-must be carefully used and monitored.
Hypotonic Fluids
Use: treat intracellular dehydration, such as diabetic ketoacidosis & hypernatremia. Use in clients with HTN, cardiac disease, or renal disease (may cause Fluid Volume Deficient, decrease BP)
1/2NS (0.45% sodium chloride)
Hypertonic Fluids
Use: For severe hyponatremia, edema, burns, or ascites
Alert: may cause intravascular fluid volume overload and pulmonary edema
Monitor closely in ICU setting for 3% NS
D50 (50% dextrose in water), D10W (Dextrose 10% in water)
3% saline
Isotonic Solutions “Stay where I put it!” HypOtonic Solutions “Go Out of the vessel (into cells)” HypErtonic Solutions “Enter the vessel”
complications with IV
Systemic
Fluid overload
S/S: moist crackles, cough, restlessness, distended neck veins, edema, weight gain, dyspnea, rapid/shallow respirations, increased blood pressure, increased central venous pressure.
Treatment: stopping infusion or decreasing the rate, monitoring vital signs frequently, assessing breath sounds, placing the patient in a high fowlers position, notifying the provider
Air Embolism
most often associated with central venous catheters and related to the size/rate of embolus
S/S: palpitations, dyspnea, continued coughing, jugular venous distention, wheezing, cyanosis, hypotension, weak/rapid pulse, altered mental status; and/or chest, shoulder, or low back pain.
Treatment: Immediately clamping the cannula (replacing a leaking or open infusion system), placing the patient on their left side in the Trendelenburg position, assessing vital signs and breath sounds, and administering oxygen.
Infection
S/S: abrupt temperature elevation after initiation of the IV solution, backache, headache, increased pulse and/or respirations, nausea and vomiting, diarrhea, chills and shaking, and general malaise. Additionally, erythema, edema, induration or drainage at the insertion site.
Treatment: Varies significantly based on the severity from local involvement to sepsis. Focus on prevention.
Careful hand hygiene
Strict aseptic technique
Firmly anchoring the cannula
Examine the catheter for cracks, leaks, or cloudiness
Inspect IV site with assessments and use
Disinfect injection/access ports
Removing the IV at the first sign of local inflammation, contamination, or complication
Replace peripheral IV cannula per policy
Follow policy regarding replacement of solution bags, tubings, medication sets
Local Complications
Infiltration
Unintentional administration of a nonvesicant solution into surrounding tissue
Occurs when the IV cannula dislodges or perforates the wall of the vein
Characterized by edema around insertion site, leakage of fluids from the insertion site, discomfort or coolness in the area of infiltration, and decrease in flow rate.
Interventions: stop the infusion, discontinue the IV catheter, apply sterile dressing, elevated the extremity, a warm or cool compress may be applied to the site depending on what was infiltrated.
Extravasation
Similar, to infiltration- unintentional vesicant solution into the surrounding tissue
Phlebitis
Inflammation of a vein
Can be related to chemical, mechanical, or bacterial causes, often more than 1 cause.
Interventions: discontinue the IV, restart IV in another location using aseptic technique and the appropriate sized cannula for the vein, anchor the cannula well, assess/monitor frequently; apply a warm moist compress to the site.
Thrombophlebitis
Presence of a clot plus inflammation in the vein.
Characterized by localized pain, redness, warmth, and swelling around the insertion site or along the path of the vein; immobility of the extremity r/t discomfort and swelling, sluggish flow rate, fever, malaise, and leukocytosis.
Interventions: Discontinue infusion, apply cold compress first then followed by warm compress, elevated extremity, restart IV in opposite extremity. If concerned for thrombophlebitis- IV line should NOT be flushed. The catheter should be cultured the area cleaned with alcohol.
Hematoma
When blood leaks into the tissues surrounding the IV site
Characterized by ecchymosis, immediate swelling at the site, and leakage of blood at the insertion site.
Interventions-remove the needle or cannula, apply light pressure with dry dressing, ice may be applied for the first 24hours to avoid extension of hematoma, elevated the extremity, frequent neurovascular monitoring
Clotting and Obstruction
Characterized decreased flow rate, blood backing into the tubing.
Interventions-discontinue IV and restart in a new location, main focus is related to prevention.
Venous Access
Peripheral devices
PIV- For short-term access (up to 96 hours)
Midline- Rarely used because of growing popularity of PICCs;
When access is needed for longer than 1 month or when vesicant medications are involved
Central devices
PICC- For medium-term access
(up to 6 months) and especially for
antibiotics, TPN, chemotherapy,
transfusions, and frequent blood sampling
Non-Tunneled central catheter- For short-term access when PIV is not suitable, and especially for resuscitation and central venous pressure monitoring; When access is required for more than a few days (use a tunneled catheter instead)
Tunneled central catheter- For frequent long-term access, and especially for TPN, transfusions, and frequent blood sampling Can be used when PICC line is contraindicated or not possible; When access of shorter duration is required (consider an implantable port if access is to be less frequent)
Implantable port- For infrequent access on a long-term basis or when lifestyle concerns make one of the other options less appealing; When venous access is regularly required (frequent needle pokes would be uncomfortable for the patient)
total parenteral nutrition (TPN)
TPN Nutritional Content carbohydrates proteins fats vitamins minerals and electrolytes Who makes TPN- a pharmacist with special training to make the solution according to your lab results, weight, health conditions, and other factors. Can be done at hospital or at home. Goal- Correct or prevent malnutrition Reasons- digestive systems either can't absorb or can't tolerate food eaten by mouth
An interdisciplinary nutrition team, if available, should monitor patients. Weight, CBC, electrolytes, and BUN should be monitored often (eg, daily for inpatients). Plasma glucose should be monitored every 6 h until patients and glucose levels become stable. Fluid intake and output should be monitored continuously. When patients become stable, blood tests can be done much less often.
Liver function tests should be done. Plasma proteins (eg, serum albumin, possibly transthyretin or retinol-binding protein), prothrombin time, plasma and urine osmolality, and calcium, magnesium, and phosphate should be measured twice/wk. Changes in transthyretin and retinol-binding protein reflect overall clinical status rather than nutritional status alone. If possible, blood tests should not be done during glucose infusion.
Full nutritional assessment (includingBMI calculationandanthropometric measurements) should be repeated at 2-wk intervals
Complications Catheter infection Pneumothorax Air embolism Clotted catheter Hyper (Hypo) glycemia Blood clots Fluid overload Mineral imbalances
Benefits
Return to a healthy weight
Nutritional repletion while resting the bowel
Get better condition before surgery
Nutritional support after surgery to aid in healing
For children nutrition is extremely important for growth and development. TPN can help.
Indications
Insufficient oral or enteral intake
Impaired ability to ingest or absorb food orally or enterally
Patient unwilling or unable to ingest adequate nutrients
Prolonged pre- or post-operative nutritional needs
Cancer
Crohn’s disease
Ischemic bowel disease
GI surgery
Bowel obstruction
Temporary depletion
Small bowel can’t absorb nutrients well
The patient needs to “rest” the bowel in order to help it heal
Severe weight loss
Short bowel syndrome
Prolonged diarrhea
Get a patient in better health in preparation for surgery
Nursing management Central venous access devices Monitor blood glucose q 6 h Monitor I & O, weight, CBC, electrolytes, BUN, liver function, prothrombin time Prevent infection Monitor S/S of complications
Iv assessment
Type Site Date Size Patency Condition of the site
cancer
Encompasses a large group of disorders with many different causes, manifestations, treatments, and prognoses.
Second leading cause of death in the U.S.
Causes
Genetics and familial factors
Life style factors
Environmental exposures (physical and chemical agents
Viruses and bacteria
Hormonal agents
Prevention
Primary-Focuses risk reduction, immunizations
Secondary-Focuses on screening and early detection
Tertiary-Focuses on monitoring for and preventing recurrence of the primary cancer as well as secondary malignancies.
Diagnosis-
Based on physiologic and functional changes
Determine presence/extent of disease
Identify possible metastatic disease
Evaluate function of body systems
Tissue sample for confirmation, staging and grading
Staging- Determines Size Existence of local invasion Lymph node involvement Metastasis
Grading-
Pathologic classification of tumor cells
Type of cells and characteristics
Grade I- IV
Goals of care Medical Management- surgery, chemo, radiation Nursing role- Education Symptom management Comfort Advocate Monitoring and prevention of complications Nursing diagnosis (Chart 15-7) Complications Infection Typical s/s may be absent r/t decreased circulating WBCs and diminished local inflammatory response. Fever may be the only sign. Septic Shock Life threatening complication Bleeding and Thrombocytopenia Decrease in circulating platelets often related to bone marrow suppression after some types of chemo/radiation
hair, skin, and nails
Skin
Epidermis
Outermost layer-forms a protective layer that can repel pathogens and prevent excessive fluid loss
Contains melanin-gives skin and hair its color
Contains Merkel cells- not fully understood but sensory?
Contains Langerhans cells-cutaneous immune reactions
Dermis
Largest portion of the skin, provides strength and structure
Contains blood and lymph vessels, nerves, sweat and sebaceous glands, and hair roots
Subcutaneous
Inner most layer, primarily adipose and connective tissue- which provides cushion between skin layers and the muscles and bones
Protects vascular and nerve structures
Promotes mobility
Insulates- important in thermoregulation
Functions of skin Protection Sensation Fluid Balance Temperature regulation Vitamin production (Vit D) Immune response
Hair
Present over entire body except soles and palms
Serves different functions based on location
Filters debris (eye lashes)
Provides insulation (thermoregulation)
Nails
Protection
normal aging changes in skin
Cherry angiomas (bright red “moles”)
Diminished hair, especially on scalp and pubic area
Dyschromias (color variations)
Solar lentigo (liver spots)
Melasma (dark discoloration of the skin)
Lentigines (freckles)
Neurodermatitis (itchy spots)
Seborrheic keratoses (crusty brown “stuck-on” patches)
Spider angiomas (see Fig. 49-3)
Telangiectasias (red marks on skin caused by stretching of the superficial blood vessels)
Wrinkles
Xerosis (dryness)
Xanthelasma (yellowish waxy deposits on upper and lower eyelids)
primary and secondary lesions
Primary Lesions
MACULE, PATCH
Flat, nonpalpable skin color change (color may be brown, white, tan, purple, red)
Macule: <1 cm; circumscribed border
Patch: >1 cm; may have irregular border
Freckles, flat moles, petechia, rubella, vitiligo, port wine stains, ecchymosis
PAPULE, PLAQUE
Elevated, palpable, solid mass with a circumscribed border
Plaque may be coalesced papules with flat top
Papule: <0.5 cm
Plaque: >0.5 cm
Papules: Elevated nevi, warts, lichen planus
Plaques: Psoriasis, actinic keratosis
NODULE, TUMOR
Elevated, palpable, solid mass that extends deeper into the dermis than a papule
Nodule: 0.5–2 cm; circumscribed
Tumor: >1–2 cm; tumors do not always have sharp borders
Nodules: Lipoma, squamous cell carcinoma, poorly absorbed injection, dermatofibroma
Tumors: Larger lipoma, carcinoma
VESICLE, BULLA
Circumscribed, elevated, palpable mass containing serous fluid
Vesicle: <0.5 cm
Bulla: >0.5 cm
Vesicles: Herpes simplex/zoster, varicella, poison ivy, second-degree burn (blister)
Bulla: Pemphigus, contact dermatitis, large burn blisters, poison ivy, bullous impetigo
WHEAL
Elevated mass with transient borders; often irregular; size and color vary
Caused by movement of serous fluid into the dermis; does not contain free fluid in a cavity (e.g., as a vesicle does)
Urticaria (hives), insect bites
PUSTULE
Pus-filled vesicle or bulla
Acne, impetigo, furuncles, carbuncles
CYST
Encapsulated fluid-filled or semisolid mass in the subcutaneous tissue or dermis
Sebaceous cyst, epidermoid cysts
Secondary Lesions
EROSION
Loss of superficial epidermis that does not extend to dermis; depressed, moist area
Ruptured vesicles, scratch marks
ULCER
Skin loss extending past epidermis; necrotic tissue loss; bleeding and scarring possible
Stasis ulcer of venous insufficiency, pressure ulcer
FISSURE
Linear crack in the skin that may extend to dermis
Chapped lips or hands, tinea pedis
SCALES
Flakes secondary to desquamated, dead epithelium that may adhere to skin surface; color varies (silvery, white); texture varies (thick, fine)
Dandruff, psoriasis, dry skin, pityriasis rosea
CRUST
Dried residue of serum, blood, or pus on skin surface
Large, adherent crust is a scab
Residue left after vesicle rupture: impetigo, herpes, eczema
SCAR (CICATRIX) Skin mark left after healing of a wound or lesion; represents replacement by connective tissue of the injured tissue Young scars: Red or purple Mature scars: White or glistening Healed wound or surgical incision
KELOID
Hypertrophied scar tissue secondary to excessive collagen formation during healing; elevated, irregular, red
Greater incidence among African Americans
Keloid of ear piercing or surgical incision
ATROPHY
Thin, dry, transparent appearance of epidermis; loss of surface markings; secondary to loss of collagen and elastin; underlying vessels may be visible
Aged skin, arterial insufficiency
LICHENIFICATION
Thickening and roughening of the skin or accentuated skin markings that may be secondary to repeated rubbing, irritation, scratching
skin lesion
Vary in size, shape, cause
Type and appearance
Primary lesions
Initial lesions
Characteristic of disease
Secondary lesions
Results from changes in primary lesions; scratching, trauma, infections, wound healing
document: Color Redness, heat, pain, swelling Size and location Patterns of eruptions Distribution of lesions
pruritis
Itching- creams help
Allergic- Benadryl, antihistamines
Metabolic-
Rash
Gotta know what is causing this
Keep nails short and clean
herpes zoster (shingles)
Caused by Varicella
Assessment
Careful H & P
Diagnoses Impaired Comfort Acute Pain Risk for Infection Social Isolation-zoster virus
Plan
Relieve pain
Reduce/avoid complications
Interventions Medications – antivirals, analgesics, corticosteroids Dressings as needed Proper hand hygiene Evaluation
Stress and illness can bring this on
Hallmark: pain along dermatome followed by an eruption of an itchy rash , one sided
Can be spread to other people
Contact precautions
Can go blind in the eye if it is in that area
Can get this more than once
Lasts a few weeks
Start antivirals ASAP
Analgesics and corticosteroids
Dressing over it to keep from scratching and shedding virus
herpes simplex
Type 1- (cold sore or fever blister)
Highly contagious (razors, towels, dishes)
Incubation 2-12 days
Activated sunlight, wind, cold, flu/infections, stress, heavy alcohol use
50-80% of the population by 30 years old
Type 2
Vesicular and ulcerative lesions genital and anal area
Early symptoms: burning, itching, increased sensitivity or tingling sensation-may occur several days prior to appearance of lesions
Lesions progress to vesicles, then yellow crusts, then healing skin
Antivirals-acyclovir and valacyclovir
contact dermatitis
H & P
Diagnoses
Impaired comfort
Impaired Skin Integrity
Anxiety
Plan
Identify cause
Soothe/heal skin
Prevent infection
Interventions
Medications – barrier creams, topical corticosteroids
Evaluation
psoriasis
H & P
Diagnoses
Impaired Skin Integrity
Disturbed Body Image
Impaired Comfort
Plan
Slow the rapid turnover of epidermis
Interventions
Stress management
Regular skin care routine
Medications – topical (corticosteroids and non-steroidals), phototherapy, systemic (cytotoxic, biologic agents)
Evaluation
Skin care most important
Warm baths, gently exfoliate off epidermal cells, apply immolates and hydrate skin
Prevent exacerbations
UVB phototherapy
skin tumors
Benign vs Malignant
Skin cancer prevention: Minimize sun exposure Use sunscreen Avoid tanning beds/booths Check skin regularly
A - asymmetry B - border uneven C - color D - Diameter E - evolving
melanoma
H & P
Biopsy
Diagnoses
Fear
Acute pain
Readiness for enhanced Self-Health Management
Plan
Surgical excision
Interventions Medications Stage II-III = high-dose interferon Stage III-IV = monoclonal antibodies, chemotherapy Pain management Psychological support
Evaluation
Education on prevention
Hats, sunglasses, appropriate clothing, sun screen
Cancer
Chronic sun exposure
Dark red, blue, irregular border, itchy, rapid growth, can ulcerate and bleed
Chemo cream
assessment of musculoskeletal function
Health History Common symptoms Pain Altered sensation Gerontologic consideration Past health, Social & Family history
Physical Assessment: Posture Scoliosis Kyphosis Lordosis
Gait- Smoothness and Rhythm
Bone Integrity- Deformities and Alignment
Joint Function- Range-of-motion, Deformity, Stability, tenderness, & Nodular formation
skin- edema, temp, color
neuromuscular status 5 ps pain pulse pallor paresthesia paralysis
gerontologic considerations with musculoskeletal system
Bone
Gradual progressive loss of bone mass
Bones fragile and prone to fracture
Muscles
Diminish in size
Loss of strength and flexibility
Joints
Progressive cartilage deterioration
Stiffness, reduced flexibility and pain
Ligaments
Lax ligaments
Weakness
diagnostic eval of musculoskeletal system
Imaging Procedure- X-ray, Computed tomography (CT), Magnetic resonance imaging (MRI), Arthrography
Bone Densitometry- Bone Mineral Density (BMD)- determined by Dual-energy x-ray absorptiometry (DXA, DEXA)
Bone Scan- metastatic and primary bone tumor
Arthroscopy
Other- Arthrocentesis, Electromyography, Biopsy
FRAX - fracture risk assessment tool
a tool that predicts a patient’s 10-year risk of fracturing a hip or other major bone, which includes the spine, forearm, or shoulder
nursing management:
Prepare the Patient (Before and after)- Position, Allergies
Education- Procedure, S/S of infection
Monitor and Document- Neurovascular status
Administer Analgesic Agent
athrography
Indications
Joint pain
Joint disease
Preparation
Assess for contraindications
Allergies
Nursing Implications Compression bandage Rest joint 12 hours after Mild analgesia, ice Clicking/cracking nose normal for 24-48 hours after
done in OR only
looking into joints
bone density
Indications
Bone Mineral Density (BMD)
Predicts risk of fracture
Preparation
Assess for contraindications
Nursing Implications
Not much
low BD = easily fractured
bone scan
Indications
Bone tumor
(primary and metastatic)
Osteomyelitis
Degenerative bone disease
Preparation
Assess for contraindications
Assess for allergies
Nursing Implications
Flushing, warm feeling
Drink fluids
arthroscopy
Indications
Diagnosing joint disorders
Treat tears
Preparation
NPO
Nursing Implications
Ice, compression, elevation
Neurovascular assessment
Pain management
arthrocentesis
Indications
Examine synovial fluid
Remove fluid
Preparation
Hair removal
Nursing Implications
Ice 24-48 hours after
Electromyography (EMG)
Indications
Muscle weakness, pain, disability
Neuromuscular disorders
Peripheral nerve disorders
(carpal tunnel)
Preparation
Consent
Assess for use of anticoagulants,
skin infection
Avoid lotions, creams day of test
Nursing Implications
Warm compresses after
prep management (musculoskeletal)
Providing patient education
Pre-op assessment (nurse, dr, anesth.)
eval. CV, respiratory, renal and liver function
risk factors of DVT
neurovascular status
Mobility -(HIP PRECAUTIONS - post op total hip-can’t bend past 90 degrees, don’t internally rotate-wedge pillow b/w legs in hospital, don’t cross legs, raise toilet—all can predispose to dislocation of new hip)
Positioning – post op knee-NEVER pillow under knee, Check Continuous passive motion device (CPM) settings, slightly elevate heels off bed
Activities after surgery-PT
Preventing infection
intraoperative management (musculoskeletal)
Blood loss management
Reinfusion devices- collects blood that’s lost during surgery, filters out cells and debris and it can be reinfused back if Hgb is low; 200-500 ml of drainage in first 24 hours on reinfusion device – after 24 hours 50 ml every hours or less
Monitor estimated blood loss (EBL) closely
Adherence to sterile procedures
Prevent infection
Culture of joint during surgery
May be helpful in identifying subsequent infections
total hip arthroplasty
Replacement of a severely damaged hip with an artificial joint Indication- OA acetabular dysplasia, RA, AVN, traumatic injury
Nursing Interventions Preventing DVT Preventing infection Managing Pain Assessing for Hemorrhage Assessing neurovascular status (5 Ps) Pain Pallor Pulse Paresthesia Paralysis Promoting Ambulation
education:
Keep the knees apart at all times.
Put a pillow between the legs when sleeping.
Never cross the legs when seated.
Avoid bending forward when seated in a chair.
Avoid bending forward to pick up an object on the floor.
Use a high-seated chair and a raised toilet seat.
Do not flex the hip to put on clothing such as pants, stockings, socks, or shoes. Positions to avoid after total hip replacement are shown in the illustrations.
abduction, neutral rotation and flexion of less than 90 degrees
total knee arthroplasty
Replacement of a severely damaged knee with an artificial joint
Indication
Severe pain
Functional disabilities
Nursing Interventions Preventing DVT Preventing infection Managing Pain Assessing for Hemorrhage Assessing neurovascular status (5 Ps) Pain Pallor Pulse Paresthesia Paralysis Promoting Ambulation
low back pain
Assessment/Diagnostic Findings Acute vs. Chronic Radiculopathy? Sciatica? Gait, general observation, spinal mobility, reflexes, strength, sensation Neurologic testing Diagnostic Procedures (Chart 41-1)
Medical Management
Analgesics (NSAIDS, muscle relaxant)
Rest - avoid twisting, bending, lifting, reaching
Change positions frequently – limit sitting to 20-50 min
Thermal therapy
Spinal manipulation
Assessment
H & P
Diagnoses
Acute Pain
Impaired physical mobility
Activity intolerance
Plan
Management of causes
Pain management
Improved mobility
Interventions
Pharm and non-pharm pain management
Body mechanics
(Chart 41-2)
Lumbar flexion
(pillows between knees)
Exercise program
Weight reduction
Evaluation
osteoporosis
Reduced bone mass
Resorption > Formation
=> porous, brittle, fragile
Deterioration of bone matrix
Diminished bone architectural strength
biggest problem is fractures
bone density test
high risk: slender female caucasian alcohol smoker steroid use Genetics Age Nutrition Physical Exercise Lifestyle Medication women after menopause
ACCESS alcohol use corticosteroid use calcium low estrogen low smoking sedentary lifestyle
treatment for osteoporosis
Pharmacologic Therapy- Calcium and Vitamin D Supplements and Bisphosphonates (alendronate, risedronate, ibandronate)
Fracture Management- Surgically joint replacement, Open/Closed reduction with internal fixation (Osteoporotic compression fractures of vertebrae are managed conservatively)
Prevention is the best action!
osteomalacia
Inadequate Mineralization-
The skeleton softens and weakens => Spinal Kyphosis/ Rickets and Bowed Legs
soft bones due to calcium loss
O shaped extremities
patho:
Vitamin D Deficiency
Decrease Calcium Absorption/ Increased Calcium Loss
Risk Factors- GI disorders, Liver and Kidney diseases, Hyperparathyroidism, Malnutrition
Medical Management- Reduce discomfort and pain, Underlying cause correction
vitamin D and calcium sources
D Fatty fish - tuna, mackerel, and salmon Beef liver Cheese Egg yolks Foods fortified with vitamin D - some dairy products, orange juice, soy milk, and cereals
calcium
Spinach, Kale, Okra, Collards
Soybeans
White beans
Fish - sardines, salmon, perch, and rainbow trout
Foods fortified with calcium - some orange juice, oatmeal, and breakfastcereal
osteomyelitis
infection to bone!!
Hematogenous spread
Trauma or surgical instrumentation
Assessment/Diagnostic Findings X-ray, bone scan, MRI Increased WBCs Elevated ESR Wound/blood culture
Management
Pharm – antibiotics IV (3-6 weeks)
Surgery – debridement
Wound irrigations
prevention
Postpone elective orthopedics surgery if client has infection (UTI, URI, etc.)
Surgical environment
Prophylactic antibiotics
Urinary catheters and drains only as needed; remove ASAP
Aseptic wound care
Assessment
H & P
Diagnoses
Acute Pain
Impaired physical mobility
Plan
Pain management
Improved mobility
Interventions
Immobilization (keep infection localized)
Analgesics
Elevate extremity
Activity restrictions so do ROM on joints above and below affected joint
Evaluation
