General CPAN Study Flashcards
CN VII assessment s/p thyroidectomy
- Facial Nerve
- Grimace and wrinkle forhead
HELLP Syndrome
Hemolysis
Elevated Liver enzymes
Low Platelets
How to assess Ulnar Nerve with pt experiencing entrapment decompression
Sensory: touch tip of pinky finger
Motor: abduct all fingers (spread out)
Primary drug of choice for epidurals in pregnant women
Ropivacaine
- rapid onset of sensory loss.
- less motor blockage
- helps pain control for 12 hours
How do you position a patient s/p tonsillectomy?
Semi-prone or SIMS
Elements needed to define malpractice
4 D’s:
- Duty of care:
- Dereliction of duty: (did not give good care)
- Direct causation
- Damages
What is intentional tort?
Consequences of actions that can be reasonably foreseen, violate duty, or cause injury. Intent to do wrong.
What are the types and examples of intentional torts?
- Assault: place person in fear of being touched
- Battery: touch without permission
- False Imprisonment: unjustified detention
- Surgery without consent is an example of what?
Battery
Wrongfully putting a patient on restraints is an example of what?
False imprisonment
Practicing outside of staffing ratios is considered what?
Patient abandonment
Speaking negatively or critically of a patient and their beliefs is considered what?
Defamation of character.
- How should RN respond to coworker who is speaking negatively and critically about a patient?
Professionally address the coworker about unprofessional behavior.
Staffing recommendations for Phase 1
2 RNS:
- 1 competent RN in Phase 1
- The second RN should be able to directly hear a call and be able to assist immediately.
- Both RNs give care in the same room/unit.
- Must have immediate access and direct line of sight when providing pt care.
- Same applies during “on-call”
Phase I - 1:2 (1 RN to 2 patients)
- 1 stable unconscious patient over 8YO and 1 conscious stable patient
- 2 conscious stable patients
- 2 conscious patients < or 8YO with parent or support staff present
PACU Phase 1:
1:1 (1 RN : 1 patient)
- At time of admission until critical elements met.
- Unstable airway and/or unstable hemodynamically
- Unconscious pt under 8YO
- Isolation patients when possible
Phase 1 - Two RNs to one patient (2:1)
- One critically ill, unstable patient.
- ex. (1 RN drawing labs or monitoring VS, while other RN giving blood products)
Staffing recommendations for Phase II
Two competent personnel:
- 1 RN competent in Phase II
- Second person should be able to directly hear a call for assistance and be immediately available to assist (Ex. Med-Surg LPN)
Phase II - 1:3 nurse to patient ratio
> 8YO or <8YO with family present
Phase II - 1:2
- New admission
- < 8YO without family or support staff
Phase II - (1:1)
- Unstable patient requiring transfer to higher level of care
- return to PACU
Autonomic nervous system consists of what two systems?
- Sympathetic Nervous System
- Parasympathetic Nervous System
Sympathetic Nervous System
- Adrenergic Response
- “Fight or Flight”
Parasympathetic Nervous System
- Cholinergic Response
- “Rest and Digest”
Dopamine (Intropin) - what does low dose, intermediate dose, and high dose do?
- Adrenergic receptor drug
- Low dose- 2-5mcg/kg/min: increases renal profusion
- Intermediate 5-10 mcg/kg/min: increased HR
- High dose >10mcg/kg/min: vasoconstriction—> increased BP
4 ways heat is lost from the body.
- Radiation (40-60%) - Electromagnetic energy loss
- Convection (25-35%) - Cold Room (air currents)
- Conduction (10%) - cold solid surface
- Evaporation (25%) - Breath or moist skin or open abdomen
What is the goal of anesthetic pharmacology?
To provide unconsciousness (anesthesia), pain relief (analgesia), loss of memory (amnesia), and muscle paralysis.
Risk factors associated with PONV
Patient specific
- female
- < 50 years old
- Nonsmoker
- Hx of PONV
- Hx of motion sickness
Surgery related
- laparoscopy
- gynecological
- cholecystectomy
Dopamine (Intropin)
- contractility of the heart is increased without change in after load (total peripheral resistance) - which leads to increase in cardiac output.
Dobutamine (Dobutrex)
- Stimulates Beta 1(heart)
- Increases cardiac output with minimal effect on BP, heart rate, and systemic vascular resistance (afterload)
- useful for patients recovering from cardiopulmonary bypass surgery.
- stimulates Beta 2 - bronchodilator
Epinephrine (Adrenalin)
- vasopressor - causes vasoconstriction
- increases myocardial and cerebral blood flow and may improve ROSC during CPR.
- give 1mg IV q3-5min for adult during cardiac arrest.
- can be given through ET tube
- acts in all adrenergic receptors
-ionotropic and chronotropic - lipolysis
- does not perfuse kidneys
What is the max dose of Lidocaine 0.5% (5mg/ml) a patient can have?
5mg/kg per day.
The inhalation agent that is most likely to induce airway spasm
Desflurane
The perianesthesia nurse knows that the primary function of moderate sedation is to provide:
A. Mood alteration
B. Controlled unconsciousness
C. Diminished reflexes m
D. Dependent respiration
A. Mood alteration
After receiving a depolarizing muscle relaxant, the patient may develop complications when there is a deficiency in plasma levels of:
A. Pseudocholinesterase
B. Catecholamines
C. Cortisol
D. Calcium
A. Pseudocholinesterase
Drains: anesthesia considerations for special populations: patients with pre-existing conditions
For interstitial fluid replacement, it is best to use:
A. Blood
B. Hydroxyethel starch
C. Plasma
D. An isotonic solution
D. Isotonic solution
A patient is scheduled for a bronchoscopy. The perianesthesia nurse is aware that midazolam hydrochloride will be used for sedation because it:
A. Has a slow onset of action
B. Decreases coughing and gagging
C. Has long lasting effects effects
D. Depressed the cardiovascular system
B. Decreases coughing and gagging
A patient is admitted to the PACU following a left carotid endarterectomy. While assessing the patients neuro status, the perianesthesia nurse notes that the patient cannot move the tongue from side to side. The perianesthesia nurse suspects involvement of cranial nerve:
A. V.
B. VII
C. X
D. XII
C. X - vagus nerve
Drains p. 90
A patient is being treated for MH. The perianesthesia nurse recognizes which of the following drugs is contraindicated?
A. Moraine
B. Sodium Bicarbonate
C. Procainamide
D. Diltiazem
D. Diltiazem
Drains: p. 117-118
A patient arrives in PACU with minimal response to verbal stimuli and respirations of 6. The pt received dialysis 3mg Ontario, and naloxone 0.2mg IV was given as ordered in the PACU. The perianesthesia nurse would consider repeating the dose again in:
A. 1 minute
B. 3 minutes
C. 10 minutes
D. 20 minutes
B. 3 minutes
The perianesthesia nurse suspects a type IV latex allergy in a patient exhibiting:
A. Tachyphylaxis
B. Erythema
C. Hypotension
D. Bronchospasm
B. Erythema
Which cranial nerves are assessed following carotid endarterectomy surgery?
A. Facial, olfactory, oculomotor, trigeminal
B. Facial, glossopharyngeal, vagus, hypoglossopharyngeal.
C. Oculomotor, acoustic, olfactory, trigeminal
D. Vagus, olfactory, glossopharyngeal, hypoglossopharyngeal
B. Facial, glossopharyngeal, vagus, hypoglossopharyngeal
The neurosurgeon orders monitoring of cerebral perfusion pressure (CPP). The perianesthesia nurse understands that CPP is calculated by:
A. MAP+CVP
B. DBP-CVP
C. SBP-ICP
D. MAP-ICP
D. MAP-ICP
Drains p. 97
A patient has received a right satellite ganglion block. The perianesthesia nurse notes the right eyelid is droopy and pupil is constricted, the left pupil is dilated. These symptoms are indicative of:
Horner’s syndrome
In elderly patients, the preferred treatment for hypotension induced by spinal anesthesia is
Titrated dosing of ephedrine
Drain’s p. 262-277
On admission to the PACU following a splenectomy, a patient who’s is 75kg with a pulmonary artery catheter exhibits a PA pressure of 24/12. A short time later, the perianesthesia nurse obtains a reading of 25/0, and notes a burst of trigeminal lasting 30seconds. The most appropriate action is to:
Notify the physician of possible catheter malposition.
Drains p. 287-311
The most common triggering agents of a malignant hyperthermia crisis are:
Halothane and succinylcholine
The most common cause of bradycardia among pediatric patients in the PACU is
Hypoxia
Calcium channel blockers
End in “pine” (amlodipine, nifedipine, felodipine
Primarily for HTN and Angine
Works on vascular smooth muscle, widens coronary and peripheral arteries - decreased afterload (decreased SVR)
Non dihydropyridines - work on cardiac myocytes and nodal tissue
- decreases O2 demand of myocardium
- helpful in angina not related to heart failure
- primarily for hypertension, angina, dysthythmias (verapamil, Diltiazem)
- helpful in treating AV modal dysrhythmias.
Calcium channel blockers
End in “pine” (amlodipine, nifedipine, felodipine
Primarily for HTN and Angine
Works on vascular smooth muscle, widens coronary and peripheral arteries - decreased afterload (decreased SVR)
Non dihydropyridines - work on cardiac myocytes and nodal tissue
- decreases O2 demand of myocardium
- helpful in angina not related to heart failure
- primarily for hypertension, angina, dysthythmias (verapamil, Diltiazem)
- helpful in treating AV modal dysrhythmias.
If patient is taking Verapamil, and end up having MH crisis, can you give Dantrolene?
No. Verapamil has bad interaction with Dantrolene.
- causes severe life threatening hyperkalemia.
-
Calcium channel blockers - contraindications
Contraindicated in 2 and 3rd degree heart lock.
- do not give with grapefruit juice. Increases its effectiveness.
Nipride/Nitropress (Nitroprusside Sodium)
Vasodilator - releases cyanide
- watch for signs of cyanide poisoning. Skin rash, flushing, burns show dark through skin, abdominal pain, nausea.
Apresoline/hydralazine
- vasodilators
- can stimulate Beta-1
- Increase in HR, BP, Renin (fluid retention)
- usually given with Beta Blvoker
- headache and tachycardia significantly higher
Demerol is a narcotic contraindicated with which type of drug?
(Mondoamine oxidase inhibitors) MAOI
- drugs used to treat depression and other nervous system disorders
- hypertension, tachycardia, fever
Fentanyl
Push slowly, rapid IV injection may trigger bronchial contraction and chest wall rigidity.
Naloxone (narcan)
- adult and PEDS dose: 1mcg/kg (0.01mg/kg) IV
- repeat every 5-10min as needed
- lasts 30-45 minutes
- monitor for return of respiratory depression
Naltrexone
- given to people who are withdrawing from narcotics, addictions
- reduces dopamine reward for opioids and alcohol, and most addictive behaviors.
- Hold 72 hours before surgery*
- can take as needed
Benzodiazepines negative side effect
Respiratory depression - suppresses midbrain ability to detect CO2
- examples: Diazepam, lorazepam, midazolam
Flumazenil ( Romazicon)
- benzodiazepine reversal
- contraindications: do not give with pts taking seizure medications
Succinylcholine
- depolarizing muscle relaxant - paralytic
- primarily for induction to facilitate intubation
- metabolized by Pseudocholinesterase
- rapid onset: 1 min, duration: 5-10min -
- adverse reactions: bradycardia, increased intraocular pressure, hyperkalemia, oxygen depletion
- contraindicated: glaucoma patients, MH family Hx, degenerative neuromuscular disorders, people with Pseudocholinesterase deficiency
- no reversal agent
Drugs contraindicated with glaucoma
- succinylcholine - increases intraocular pressure
- atropine
- glycopyrolate (Robinol)
Non- depolarizing muscle relaxant
- Acetylcholine antagonist - blocks acetylcholine
- all work slower thank Succs
- used to maintain paralysis
- rocuronium is the fastest from all of them
- Meds: rocuronium, vecuronium, atracurium, cistarrscurium
What is anticholinesterases?
- NDMR reversal agents
- acts on skeletal muscle and parasympathetic nervous system
- typically combines with muscarinic antagonist (anticholinergic) like glycopyrolate, or atropine
What is Sugammadex?
- NDMR reversal agents
- only works with rocuronium, or vecuronium.
What is anticholinergic syndrome
- elderly are susceptible
- confused, agitated, hyperactive,
- pick things on the blanket.
- drugs: glycopyrrolate (robinol), atropine, scopalamine
Which block is common for shoulder procedures?
Interscslene - brachial plexus blocks
- for shoulder procedures
Most common complication with interscalene blocks?
- Horner’s Syndrome
- phrenic nerve paresis common
What are the s/s of Horner’s Syndrome?
- signs on the same side as the block
- miosis: constricted pupil
- ptosis: droopy eyelid
-anhidrosis: decreased swelling
What are complications with supraclavicular block?
- pneumothorax
- phrenic nerve paresis less common
Complications with axillary block
- hematoma
- maintain elevation of affected limb
- observe for changes in circulation and neurological status
What is a retrobulbar block?
- Injection at base of lower lid or behind eyeball
- complications:
What is a retrobulbar block?
- Injection at base of lower lid or behind eyeball
- complications:
What is LAST?
Local Anesthetic Systemic Toxicity
- high serum levels of local anesthetic
What is the max dose for Amides?
5mg/kg per day
What are the s/s of LAST?
What are the two types of non cardiogenic pulmonary edema?
POPE TYPE 1 & POPE TYPE 2
What is the most common type of non-cardiogenic pulmonary edema?
POPE Type 1
What is the difference between POPE Type 1 and Type 2?
Pope Type 1
- upper airway obstruction/edema (
- eg. Laryngospasm, epiglottis, strangulation/hanging.
- High inspiratory pressure
- Most Common
POPE Type 2
- after a chronic obstruction is relieved
-eg. Tonsillectomy, adenoidectomy, airway tumor.
- Chronic obstruction produces something like PEEP. (increases end-expiratory lung volume/pressure.
- Relief of obstruction feels like negative pressure.
When would you see the oxyhemoglobin disassociation curve shift to the left?
When a patient is hypothermic
What are s/s of bronchospasm, and how would you treat?
S/s: wheezing, using accessory muscles
Tx: give Beta 2 such as Albuterol or aminophylline
What are s-s of laryngospasm and how do you treat?
S/s: high pitched crowing, rocking chest movement
If pt is awake: have pt cough to get rid of secretions/foreign body, suction
If not awake: give 100% O2 Positive pressure ventilation, suction
Worst case scenario is to paralyze and intubate.
What are s/s of pulmonary edema
- Dyspnea, that worsens when pt lays down
- pink frothy sputum
- circumoral cyanosis
- tachycardic
What causes cardiogenoc pulmonary edema?
- back up of blood returning from the lungs to the heart, excess fluid leaking from blood vessels into lung tissue.
- causes: congestive heart failure - (L sided heart failure)
- MI
- Atrial Stenosis, Mitral Stenosis
What are normal values for ABG interpretations?
pH: 7.35-7.45
CO2: 35-45
HCO3: 22-26
Respiratory Acidosis: causes and treatment
- caused by decreased ventilation
- treat with ventilation
Respiratory Alkalosis- causes and treatment
- caused by hyperventilation
- treat with sedation or decreased ventilation
Metabolic Acidosis - causes and treatment
- mostly caused by ischemic tissue (cardiac arrest, sepsis, ketoacidosis, renal failure)
- treat with HCO3
Metabolic alkalosis- causes and treatment
- caused by acid loss (excess vomiting), diuretics (potassium loss= Hydrogen Ion Loss)
- Too much HCO3 in IVF
- treat cause
Breathing patterns accosicated with increased ICP (Cushing’s syndrome)
What are extubation criteria?
What are some causes for ST elevation?
- injury, occlusion of one or more coronary artery
- emergent revascularization needed
What are causes of ST depression?
- ischemia
- hypokalemia, cardiac ischemia, digitalis toxicity,
- treatment: beta blockers, schedule revascularization - cath lab
SVT - what is it, how to you treat stable and unstable?
Narrow complex QRS HR> 170
Stable: vagal stim (cough, or valsalva), ice on neck, give adenosine.
Unstable: sync cardioversion
What cranial nerve are you assessing when looking for pupil constriction?
Cranial nerve III- ocular motor
Normal ICP
0-15
- Below 20 is ok
How to calculate Cerebral Perfusion Pressure (CPP) and what is normal value?
MAP-ICP= CPP
Normal- 70-100
In PACU= minimum is 60
The kidney site for acid-base regulation, hydrogen ion secretion, and bicarbonate reabsorption is:
-Glomerulus
- Proximal tubule
- Distal Tubule
- Loop of Henle
- Distal Tubule:
Which herbal prolong anesthesia?
St. John’s Wort
- also Valerian and Ginkgo
Which herbal can cause liver damage if pt is given propofol?
Kava Kava
Where does the exposure control plan for bloodborne pathogens requirement originate?
Occupational Safety and Health Administration (OSHA)
A patient s/p oral maxillofacial surgery, what do you make sure before discharging?
Include instructions on how to clear secretions or remove vomitus while remaining in IMF. Pt should also be taught how to use the suction catheter
Define Assault
An attempt or threat that causes a person to fear physical touch or injury
Define Battery
The unauthorized touching of an individuals body
What are the 4 required elements in order to prove malpractice?
- Duty
- Breach of Duty
- Causation
- Damages
What is STOP- BANG and what scores are for low risk, intermediate risk, and high risk?
S- Snoring?
T- Tired upon awakening?
O - Observed - stop breathing/choking/gasping during sleep?
P - Pressure - HTN?
B- BMI >35
A- Age older than 50
N- Neck size - > 40cm or 16in?
G- Gender? - Male?
TOTAL SCORE
- Low risk (0-2)
- intermediate risk (3-5)
- high risk (>or= 6)
Define “Failure to Capture/Pace”
Pacer is firing but there is no response from the heart.
- fractured or dislodged lead
- battery failure
- acidosis/hyperkalemia (7meq or higher)
Define “failure to sense” and what do you do?
Pacer is failing to sense the cardiac cycle
- pacer spikes in the ST segments
- possibly initiating ventricular arrhythmias
- poorly placed leads
- increase sensitivity
What are the phases in the Nursing Process?
- ADIPIE
Assessment
Diagnosis
Identification of outcomes
Planning
Implementation
Evaluation
What medications do you anticipate will be ordered for your patient with a-fib?
- digitalis
- verapamil
- quinidine
- atrial pacing
- ablation or cardioversion
A-fib is common after cardiac surgery, amidoarone can be given for new onset afib
- Diltiazem or metoprolol
- cardioversion if unstable
What are Proparacaine drops used for?
To numb the eye for optic procedures
What medication in the patients med list would make flumazenil a contraindication?
Siezure medications
What medication for glaucoma should you ask the patient to hold prior to cataract surgery?
Pilocarpine - cholinergic agent that causes pupil constriction
How is a patient with chicken pox transported to pediatric floor after surgery?
Chickenpox is airborne. So we implement standard, contact, and airborne precautions. We do reverse iso when transporting
The patient received a massive blood transfusion. What electrolyte is is likely low?
Calcium
If hyperkalemia is present, reduce levels with glucose, insulin and furosomide
Why is epinephrine added to local anesthesia?
To prolong effectiveness
What is definition of anemia?
Decrease in RBC. That corresponds with low hgb and hct
After thyroidectomy you touch the patients cheek, and it twitches. What does that indicate? What is it called?
It indicates hypocalcemia and it’s called Chvostek’s sign
Pt has entrapment decompression, how do you assess the ulnar nerve?
Abduct all 5 fingers (spread them out) and with resistance. Test sensation of both 4th (lateral side) and 5th digits
Lab values for DIC
Low platelets
Low fibrinogen
Positive d fimer
Prolonged/ elevated PT/PTT
