Foundations Exam 3 Flashcards
What is the AORN?
Association of periOperative Registered Nurses; 1950s
What are some benefits of ambulatory surgery?
rapidly metabolizing anesthetics
cost-saving (less time in care setting)
reduce risk of HAIs
minimally invasive
What are the purposes of surgery? (8)
(A Curious Colorful Caterpillar Plays Pretty Rad Tunes) ablative constructive cosmetic curative palliative preventive reconstructive transplant
what are the different classifications for surgery?
1) seriousness (major, minor)
2) urgency (emergency, urgent, elective)
3) purposes (ablative, palliative, diagnostic, reconstructive, procurement, transplant, cosmetic)
Phases of surgery?
preoperative, intra-operative, postoperative,
what is the purpose of assessment during the preoperative phase?
to establish “normal” or baseline functioning to use as comparison during post-op phase to help recognize/prevent complications
what should be included in the pre-op assessment?
nursing hx (smoking, alcohol, pain, religion)
medical hx (allergies, meds, surgeries)
labs
risk factors
what are some of the risk factors for surgical complications?
age medical conditions nutrition sleep apnea medications/allergies immunocompetence fluid/electrolyte imbalance pregnancy personal habits (alcohol, smoking)
what are some specific surgical risk factors associated with age?
skin more prone to ulcers, tears delayed GI emptying increased risk for infection increased risk for confusion/delirium falls risk
what are some specific surgical risk factors associated with obesity?
embolus, atelectasis, pneumonia
poor wound healing (low blood supply)
dehiscence and evisceration
implications of anticoagulants before/during surgery?
must d/c at least 48 hours before surgery b/c alter normal clotting and increase risk of hemorrhage
implications of insulin before/during/after surgery?
the need for insulin changes post-op b/c stress, IV admin of insulin, and decreased nutritional intake decrease insulin requirements
implications of NSAIDS before/during/after surgery?
NSAIDs inhibit platelet aggregation and prolong bleeding times, increasing susceptibility to post-op bleeding
implications of ginseng and surgery?
Ginseng increases risk of hypoglycemia in patients on insulin therapy
ASA classes for surgical patients?
I: normally healthy II: mild symptomatic disease III: severe disease, not threatening IV: severe disease, constant threat to life V: not expected to survive w/o operation VI: brain dead, awaiting organ harvest I-III = ambulatory surgery candidate IV-VI = inpatient surgery only
preoperative teaching includes preparing patient for what?
expectations before, during, and after surgery
and physically prepping patient (NPO, jewelry, meds)
what is the nurses role in informed consent?
witnessing the signature, making sure patient is competent, making sure it’s signed by the right person, and assuring patient knows their right to refuse
different types of anesthesia?
general
conscious sedation
regional
local/topical
primary focus during intra-operative phase?
prevent injury/complications related to anesthesia, positioning, surgery, and equipment use
malignant hyperthermia
life-threatening complication related to anesthesia (genetic–hx important!)
s/s inc CO2, HR, RR, PVCs, unstable BP, cyanosis, mottling, muscle rigidity, late sign = 106-107 deg hyperthermia
recovery phase I
movement from OR to PACU
q15min assessment of airway, LOC, vitals, mobility, sensation, fluid balance, dressing (Aldrete score/post-anesthesia recovery score)
handoff communication
nursing focus on maintaining airway, respiratory, circulation, neurological functions and managing pain
recovery phase II
after ambulatory surgery
modified Aldrete score. need 8-10 to be discharged home. PARSAP scoring in addition to Aldrete. Need 18+ to go home.
t/f: never assume pain is incisional
true. always check for location, intensity, and character of pain.
pain
unpleasant, subjective sensory and emotional response to actual or potential tissue damage
pain control influences what other factors?
QOL, early mobilization, fewer hospitalizations, shorter length of stay, and decreased costs
nociception
process by which painful stimulus is transmitted to CNS and perceived as pain
the process of pain includes what phases?
transduction, transmission, perception, modulation
transduction
conversion of a painful stimuli into an action potential
transmission
action potential signals release of 2nd messengers into synapses to further the impulse to spinal cord, brainstem
perception
recognition of pain stimulus
modulation
body inhibits pain by releasing chemical messengers the send signal back to pain site
gate-control theory of pain
two painful stimuli cannot be transmitted at the same time, will compete for transmission, so painful stimuli can be blocked by other somatic stimuli (e.g. toe stubbing, rubbing example)
what stimulated the activation of the ANS and parasympatheic nervous system?
ANS: stress (fight/flight)
PSNS: continuous, severe, deep pain
sympathetic responses to pain
dilate respiratory tubes, increase HR, peripheral vasoconstriction, increase BGC, diaphoresis, increased muscle tension, pupil dilation, decreased GI motility
parasympathetic responses to pain
pallor (blood to vital organs), muscle tension (fatigue), decreased HR & BP (vagal stimulation), rapid/irregular breathing (bodys defenses fail under prolonged stress)
behavioral responses to pain
body movements: clenched teeth, guarding, bent posture, grimacing, crying, moaning, restlessness, frequent requests for nurse
lack of pain expression does not mean patient is not experiencing pain
types of pain
acute, chronic, chronic episodic, cancer, inferred pathological, idiopathic
acute pain
protective identifiable cause limited tissue damage, emotional response seen with injury or surgery lasts up to 6 months
chronic pain
lasts longer than 6 mo lasts longer than expected recovery time in response to progressive illness may not have visible injury (neuropathic) no adaptive purpose frequently results in depression
physiological factors influencing pain
age
fatigue
genes
neurological function
social factors influencing pain
attention
previous experience
family or social support
spiritual factors
psychological factors influencing pain
anxiety
coping style
cultural factors (expectations, roles, ideas about healing/suffering, etc.)
burning, crushing, piercing, sharp are examples of what kind of words that describe pain?
sensory words
agonizing, exhausting, miserable, punishing are examples of what kind of words that describe pain?
affective words
what is the goal of pain management?
anticipate and prevent pain, not treat it
what are some non-pharmacologic interventions for pain?
cognitive-behavioral
physical
CAM
cutaneous stimulation for pain
TENS
massage
what does TENS stand for?
transcutaneous electrical nerve stimulation
what are some pharmacologic interventions for pain?
analgesics (opioid, non-opioid, adjuvants) PCA (patient-controlled) perineurial local anesthetic infusion topical analgesics local/regional analgesics
what are some benefits of PCA?
safe (avoids peaks, troughs)
patient in control
relief does not depend on nurse availability
decreases anxiety and medication use
describe perineurial local anesthetic infusion
anesthetic agent infused through un-sutured catheter placed at surgical site
what are some considerations with local anesthetics?
prolonged use may lead to “caine allergy”
what are some considerations for caring for patients with epidural infusions?
prevent catheter displacement maintain catheter function prevent infection (q24h tube change) monitor for respiratory depression prevent complications (itching, nausea) maintain urinary/bowel function
guidelines for use of analgesics
1) know patient’s previous response to analgesics
2) select proper med when have multiple orders
3) know accurate dosage
4) assess right time, interval for admin
pain relief ladder
1) start with non-opioids such as NSAIDs, acetaminophen, +/- adjuvants
2) if persists/develops to mild-moderate pain, use opioids +/- non-opioids and adjuvants
3) if persists/develops to severe pain, use higher dose of opioids +/- non-opioids and adjuvants
cautions with analgesic use
avoid use of multiple opioids, esp. w/ elderly
avoid IM analgesics, esp. in elderly
what is used for long-term management of chronic pain?
fentanyl patches, morphine, and hydro-morphone
and
SR formulatons ATC
what is a benefit of IV analgesics?
quicker acting
patient barriers to effective pain management
fear of addiction
worries about side effects
“noble” suffering
need to suffer to earn healing
provider barriers to effective pain mangement
inadequate pain assessment skills
addiction concerns
fear of legal repercussions
thinks pain is part of aging process (false)
differences between physical dependence, addiction, and tolerance
dependence: withdrawal symptoms w/ stop
addiction: disease. impaired control, cravings
tolerance: over time requires more to achieve same effects
palliative care vs. hospice
palliative care helps coordinate care and live life fully
hospice is end of life care (quality of life over quantity of time)
allodynia
sensation of pain in response to a normally non-painful stimulus
analgesia
absence of pain in response to a normally painful stimulus
dysthesia
unpleasant but normal sensation, either spontaneous or evoked
unpleasant, normal
paresthesia
abnormal but not unpleasant sensation, spontaneous or evokes
not-unpleasant, abnormal
neuroalgesia
pain in distribution of nerve or nerves
hyper/hypoalgesia
increased or decreased response to normally painful stimuli
pain threshold vs. tolerance
threshold = minimal experience of pain tolerance = greatest level of pain
nociceptive pain state
evidenced by painful stimulus
pain localized to area of stimulus damage
inflammatory pain state
evidence of inflammation
redness, swelling, heat
neuropathic pain state
evidence of sensory or nerve damage
burning, tingling, shock-like pain, paresthesias or dysthesias
dysfunctional/centralized pain state
pain without detectable pathology; evidence of increased amplification and/or decreased inhibition
pain mechanisms include…
nociceptive transduction peripheral sensitization exotic activity central sensitization central disinhibition
what to acquire about during nursing assessment for pain?
intensity
location
quality
modifying factors
what to observe for during nursing assessment for pain?
level of distress movement posture consistency with story vitals TOUCH/physical exam
pain red flags include…
outside expected location
out or proportion with diagnosis
“something’s not right”
multimodal management of pain
M = medications I = interventions P = PT S = pSychoSocial
treatment of nociceptive pain
opioids
NSAIDS
acetaminophen
antidepressants (TCAs)
treatment of inflammatory pain
steroids
NSAIDs
COX2 inhibitors
treatment of neuropathic pain
CCBs
sodium channel blockers
treatment of dysfunctional/centralized pain
SNRI antidepressants
CCBs
