Infectious ds. + pre/intra/post op mgmt Flashcards
what is preoperative phase
begins when decision to proceed w/ surgical intervention is made
- ends w/ transfer of patient onto OR bed
what is intraoperative phase
begins when patient is transferred onto OR bed
- ends w/ admission to PACU (post anesthesia care unit)
what is postoperative phase
begins with admission of patient to PACU
-ends w/ follow up evaluation in clinical setting or home
what are the 3 reasons for surgery
1) facilitating a diagnoses, cure, or repair
2) reconstructive, cosmetic, or palliative (stage 4 metastatic bowel ca -> comfort)
3) rehabilitative
what is the degree of urgency for surgery based on? (5)
emergent (ER -> OR life or death, ex: fracture skull, gun shot)
urgent (wait until OR room open, stable, ex: closed fractures)
required (ex: hernia repair, cataracts)
elective (ex: repair of scars, huge quality of life improvement)
optional (cosmetic)
describe preadmission testing
- prior to arrival for surgery
- includes: admission date (demographics, health history, other information pertinent to the surgical procedure), begins discharge planning by assessing patient’s need for post operative care
what is the included in pre-op assessment (day of)
health hx
meds/ax
nutritional/fluid status
dentition (what can be removed)
respiratory and cardiovascular status (older: chest X-ray, cardiac: ECG)
hepatic/renal function (metabolic panel)
endocrine function (blood glucose)
immune function (WBC)
previous meds used
psychosocial factors
spiritual/cultural beliefs
meds that can affect surgical experiences
anticoagulants (should be stopped before sx depending on surgery/how long)
opioids (pain harder to control if higher tolerance)
diuretics, phenothiazines, tranquilizers (interactions w/ anesthesia)
antibiotics (educate about taking correct antibiotic dose)
anticonvulsants
OTC/herbals
corticosteroids
insulin
thyroid hormone
who should obtain informed consent
surgeon w/ nurse as witness
who should obtain anesthesia consent
anesthesiologist or CRNA
describe process of informed consent
- should be in writing before non emergent surgery
- legal mandate
- surgeon must explain the procedure, benefits, risks, complications, etc.
- nurse clarifies information and witnesses signature
- consent accompanies patient to OR
when is a informed consent valid
only when signed BEFORE administering psychoactive premedication
- next of kin if emergent situation
what are prep-op nursing interventions
- providing psychosocial interventions (reduce anxiety, decrease fear, respect culture, spiritual, and religious beliefs)
- maintain patient safety
- manage nutrition, fluids
- prepare bowel (endoscopy procedure)
- prepare skin (occurs in OR, shaving, CHG bath night before)
what is included in pre-op checklist?
chest xray: potential issues w/ respiratory
ECG: cardiac issues, no exposure to radiation for pregnant women
Labs: metabolic panel, PT/INR, PTT, blood type, blood transfusion consent, CBC
consent signed: mark surgical site when patient is awake
NPO status
what is the recommended time for NPO
8 hours strict NPO prior to surgery
what are the immediate pre-op actions
- patient changes into gown, mouth inspected, jewelry removed, valuables stored in secure place
- administer pre-anesthetic medication (low dose)
- maintaining preoperative record
- transporting patient to presurgical area
- attending to family needs
what are some pre-op patient education performed by nurse/doc
- deep breathing, coughing, incentive spirometry, splinting
- mobility, active body movement
- pain management
- cognitive coping strategies
- instructions for patients undergoing ambulatory surgery (ambulatory pain pumps/drains, activity orders, coagulation concerns, follow up instructions - normal vs. abnormal)
team members of intraop phase
patient
anesthesiologist (physician) or CRNA
surgeon
nurses
surgical tech
registered nurse first assistants or certified surgical technologists
what are the 3 zones for surgical environment to prevent infection
1) unrestricted zone: street clothes allowed (lobby)
2) semi restricted zone: scrub clothes and caps (new, clean)
3) scrub clothes, shoe covers, caps, and masks (OR) goggles
what is part of surgical asepsis rules to prevent infection
sterile field, gowns, gloves, equipment
sterile and unsterile team
1 foot distance surrounding sterile field
- if breached, area is contaminated
what are the environmental controls to prevent infection
negative pressure
what are some intra-operative complications
- anesthesia awareness
- nausea, vomiting
- anaphylaxis (difficult to identify)
- hypotension (difficult to identify)
- hypoxia, respiratory complications
- hypothermia
- malignant hyperthermia
- infection: longer surgery = increased chance of infection
types of anesthesia (4)
1) general
2) conscious sedation
3) regional
4) local
describe general anesthesia
inhalation, intravenous
- paralytic
describe conscious sedation
intravenous
- quick procedures, airway intact, joint dislocations
describe regional
can be combined with general
3 types: nerve blocks, epidural, spinal
what is nerve blocks regional anesthesia
injection into anatomical nerve site 6-24 hours
- can be continous
what is epidural regional anesthesia
injected into the epidural space, delayed onset, continuous infusion
what is spinal regional anesthesia
injected into dural sac, immediate relief, limited timeline +2 hours
what is considered local anesthsia
lidocaine
how do you protect patient from injury
- patient id
- correct informed consent
- verification of records of health history, exam
- results of diagnostic tests
- allergies (including latex)
- monitoring, modifying physical environment
- safety measures (grounding of equipment, restraints, not leaving sedated patient)
- verification, accessibility of blood
- verifying surgical site marked
describe nursing management in the PACU
- provide care for patient until patient has recovered from effects of anesthesia (resumption of motor and sensory function, oriented, stable VS, shows no evidence of hemorrhage or other complications of surgery)
- vital to perform frequent assessment of patient (airway, breathing, circulation, neurological/temp,, incisions/drains/tubes/pumps, GI/diet, pain - always assess)
outpatient post op vs. inpatient post op
outpatient
- more detailed discharge planning (written, verbal instructions to a responsible adult who will accompany patient)
- no driving for 24 hours (never discharge alone)
inpatient
- more detailed assessment (Resp., pain, LOC, general discomfort)
- can use stronger pain medications (IV)
what is the primary consideration of airway..BC maintenance
necessary to maintain ventilation, oxygenation
- provides supplemental oxygen as indicated
- assess breathing
- keep HOB 15-30 degrees unless contraindicated
- suction set up at bedside
- if vomiting, turn to side
- head and jaw positioning to open airway
what is the primary consideration of AB..circulation
monitor all indicators of cardiovascular status
- assess all IV sites
- potential for hTN, shock
- potential for hemorrhage
- potential for HTN, dysrhythmias
s/sx of hypotension/shock state
- pallor
- cool, moist skin
- rapid respirations
- cyanosis
- rapid, weak, thread pulse
- decreasing pulse pressure
- low bp
- concentrated urine
how to manage pain and anxiety post op
- assess patient comfort
- control of environment: quiet, low lights, noise level
- administer analgesics as indicated; usually short acting opioids IV (follow up 1 hour)
- family visit, dealing with family anxiety
how to manage n/v post op
- intervene at first indication of nausea
- medications (zofran, compazine, Benadryl)
- assessment of postoperative nausea, vomiting risk, prophylactic treatment
what are the 5 drain types we learned
- Jackson pratt
- Penrose (latex tubes)
- Hemovac
- PICO (disposable negative pressure vacs)
- Wound Vacs (little bit different)
what is the purpose of post-op dressings
(sterile, healing environment)
- provide healing environment
- absorb drainage
- splint or immobilize
- protect
- promote homeostasis
- promote patient’s physical and mental comfort
- first dressings change is almost always done by the surgical team
what are some post surgical complications
- pulmonary infection/hypoxia
(inventions: incentive spirometer, deep breathing/walking) - deep vein thrombosis/PE
(manage with WTE prophylaxis) - hematoma/hemorrhage
- infection
(eliminate lines, post op Abx) - wound dehiscence or evisceration (dehiscence- opens back up)
what are some final post op considerations
- activity order
OOB (out of bed), NWB (non-weight bearing) - diet/fluid orders
- pain/reassessment
- urinary retention (intermittent catheterization)
- GI peristalsis
what is inflammation
protective, coordinate response of the body to an injurious agent
- proportional to the extent of tissue injury
- walls off the area of injury, prevents spread of the injurious agent, and directs the body defense
- can be acute or chronic
- “itis”
what are the 5 cardinal signs of acute inflammation
heat
redness
pain
swelling
loss of function
3 main stages of acute inflammation
1) vascular permeability
2) cellular chemotaxis
3) systemic responses
what are the outcomes of acute inflammation
- resolution
- healing proliferation of connective tissue (scar)
- chronic inflammation
describe vascular permeability
- inflammatory mediators such as histamine & bradykinins cause dilation and increased permeability of the blood vessel
- fluids, WBC, or macrophages, and platelets to move out to the site of injury or infection
- fluid moving out of the blood vessels to the injured tissues causes swelling, dilution of the toxin and a decrease in pH (pus/purulent, transudate serosanguinous)
describe chemotaxis
- a chemical signal attracts platelets and other WBCs to the site of injury
- margination: WBC’s line up along the endothelium in the area of inflammation in a process
- includes cytokines: TNF, interleukins, C-reactive proteins (good mark of inflammation)
5 types of WBCs
- neutrophils: “first responders”, acute inflammation
- lymphocytes: small WBC carrying out activities of the immune system
- eosinophils: allergic reactions
- basophils: chronic infections (cancer)
- monocytes: long life span, chronic inflammation
describe shifts
shifts: neutrophils mature vs. immature
- Left shift: more young (band cells) -> severe
- Right shift: resolved, mature neutrophils
what is systemic response (acute inflammation)
result from the action of inflammatory mediators released from WBCs
- results in fever, pain, malaise, lymphadenopathy
describe fever (systemic response)
- microbial organisms, bacterial products, and cytokines all act as pyrogens
- pyrogens activate prostaglandins to RESET the hypothalamic temperature-regulating center in the brain to a higher level
- higher body temperature increased the efficiency of WBCs in their defense of the body
- cure: antipyretic agent = drug that brings down fever (Tylenol, Motrin)
describe histamine release (systemic response)
- inflammatory mediator released from basophils, platelets, and mast cells in response to trauma, immune responses, or other inflammatory mediators
- sneezing, rhinorrhea (runny nose), eye tearing, sinus inflammation, and pharyngeal irritation are consequences of histamine release in the URT
- medications: benadryl
describe lymhadenopathy
- enlargement of lymph nodes caused by inflammatory processes (depends on location)
describe lymph nodes
- small bean-sized masses of tissue located in various regions of the body, including the neck, axillary regions, central thoracic region, inguinal areas, and gastrointestinal tract
- responsible of the production of lymphocytes
what is chronic inflammation
inflammatory process that “gets stuck” with resolution resulting in tissue damage, more inflammation, more damage
what are the causes of chronic inflammation
- microorganisms
- viruses, parasites, and fungi
- autoimmune
- other
what are distinctive patterns of chronic inflammation
- development of granulomas (tuberculosis)
- delays wound healing leading to chronic wounds (more prone to bed sore, pressure injuries)
what is normal wound healing
not all cells are regenerate
- 3 phases: inflammation, proliferation (granulation tissue forms: beefy, red, healing about to occur), wound contraction and remodeling
what are the 3 processes for wound healing
1) primary: edges approximated, lacks significant bacterial contamination, minimal loss of tissue and a “small” scar (ex: surgical incisions)
2) secondary: larger tissue detect to fill, can be partial or full thickness, takes longer to heal, more likely to scar (ex: road rash, skin arm, heal from group up)
3) tertiary: wound with a large gap of missing tissue that has been contaminated, closed once contamination has been resolved (ex: group up injury, PI with eschar)
what factors affect wound healing
- nutrition (protein, vitamins, fats and carbohydrates)
- blood flow and oxygen delivery (septic shock)
- immune system (comorbidities: prone to infection, drugs)
- infections
what are types of dysfunctional wound healing
dehiscence (wound reopens)
keloids
fistulas (chronic bladder infection)
contractures (trigger finger, carpal tunnel syndrome)
adhesions (GI tracts, trigger: surgical lysis of adhesion)
pathogens
specific microorganisms that are capable of causing infectious disease; categorized as viruses, bacteria, fungi, and parasites
host
describe the human or animal invaded and colonized by a pathogen
colonization
indicates that a pathogen is living within the host, but does not mean infection exists
infection
describes the invasion, colonization, and multiplication of pathogens within the host; diagnosed when there is isolation of a pathogen or evidence of its presence and pathogen-related host symptoms
virulence
disease-producing potential of an organism
- severity of infection os virulence of the pathogen and strength of host defenses
reservoir
source of a pathogenic organism that may or may not be suffering from the disease caused by the pathogen
fomites
environmental objects acting as a reservoirs of microorganisms
incidence
number of new cases of infection within a population
prevalence
number of active ongoing cases of infection at any given time
endemic
incidence and prevalence are relatively stable
epidemic
abrupt increase in the incidence of disease within a geographic region
pandemic
global spread of a specific disease
what is an example of normal flora vs. pathogens
hospital acquired infections vs. community acquired infections (100% preventable, PI, CAUTI)
types of microorganisms
bacteria, viruses, fungi (immunocompromised), parasites, prions
what are the different portals of entry
skin
respiratory tract/mucosa
GI tract: CDIFF
GU tract: UTI
blood-blood
maternal-fetal transmission
5 stages of infection
incubation period
prodromal stage
acute stage
convalescent stage
resolution phase
describe diagnosis of infection
history and symptoms and physical findings
- wbc
- gram stain (bacteria)
- culture (blood, urine, wound, sputum) (2 vials, done before antibiotic to detect bacteria)
- biopsy
- antibody titer (serology)
- polymerase chain reaction (PCR) detects genetic material
rules of contamination: results in 24h, 48h, 72h
describe treatments for infection
- prevention
- antimicrobial
- issues with resistance
what is mainly associated with staphylococcus infections (causes)
hospital acquired pneumonia
MRSA
rheumatic fever
glomerulonephritis (kidney failure)
strept throat
cure: amoxicillin
Important GI bacteria
-salmonella
-escherichia coli (found in normal flora)
-campylobacter (uncooked raw meat, oral transmission)
-cholera (third world countries)
describe influenza
-viruses possess surface antigens known as hemagglutinin and neuraminidase that facilitate entry into respiratory cells and enhance release of viral particles
- transmitted primarily through droplet and aerosols
- most severe breakouts: influenza A
- less severe breakouts: influenza B
- treatment: tamaflu (expensive, decreases severity by 1 day)
what is candidiasis
candida fungus: normal flora found on skin, GI tract, and vaginal tract (pathogenic when overgrowth)
- danger to immunocompromised (overwhelming sepsis)
describe amebiasis and giardiasis
waterborne protozoan infections contracted by consuming contaminated water or food containing cyst stage of parasite
- sx: nausea, vomiting, intense abdominal pain, tenderness, copious diarrhea of watery stool, sometimes with blood
describe Creutzfeldt Jakob
rare but fatal degenerative neurological disease caused by prion (progressive death of brain’s nerve cells)
- spongiform appearance of the brain tissue
describe immunity
distinguishes between self and non self
antigens
non-self substances are the targets of the immune systemi
innate immunity
first and immediate defense
- body’s natural barriers, normal flora, WBCs, and protective enzymes and chemicals
adaptive immunity
occurs after innate immunity
- developed after exposure to antigens
- act rapidly, specifically, destructively, and with memory(!) for every individual antigen encountered
main types of cells in adaptive immunity
b lymphocyte immune (B cell immunity)
- phagocytosis of bacteria
t lymphocyte immunity (T cell immunity)
- quicker than B cell
- CD4 and CD8, killer T cells
active acquired adaptive immunity
obtained through exposure to an antigen or through immunization (vaccine)
- individual synthesizes specific immunoglobulins against the antigen
passive acquired adaptive immunity
injection of remanufactured immunoglobulins
- hep B immunoglobin and immunoglobulins in breast milk (from another human) ex: covid
anergy panels
t skin test
antibody titers
used to confirm adequate tests used to confirm adequate immune protection against a particular antigen by measuring IgM and IgG immunoglobulins
allergy testing
skin testing
serology testing: measures presence of IgE
types of hypersensitivity reactions (4)
type 1: immediate hypersensitivity
type 2: cytotoxic hypersensitivity
type 3: immune complex disorders
type 4: delayed hypersensitivity
type 1 immediate hypersensitivity
- allergy/ anaphylaxis
- airway constriction recognized within 30m-1h
- cure: epi-pen (delays reaction)
type 2 cytotoxic hypersensitivity
- cell destruction and phagocytosis
- blood transfusion reactions: slow administration
type 3 immune complex
- body forms antibodies against itself
- systemic lupus erythematous
- rheumatoid arthritis
type 4 delayed hypersensitivity
- delayed response to the antigen
- contact dermatitis
- rejection of transplanted tissue (touching someone/something)
describe systemic lupus erythematosus
chronic multi-system, autoimmune disease characterized by exacerbations and remissions
- body recognizes self as antigen
- kidney disease/HTN, pulmonary fibrosis
- treamtments: aimed at reducing inflammation (NSAIDS, steroids, chemotaxis
describe rheumatoid arthritis
chronic, immune complex, autoimmune inflammatory disease
- attacks its own synovial tissue
- destruction of cartilage, bone, tendons, and ligaments
- sx: fever, malaise, fatigue, permanent damage
- treatment: anti-inflammatory, biologics
what are the 2 types of immunodeficiency diorders
congenital (primary): genetically linked, most are x-linked and affect males
acquired (secondary): disorders causing immunosuppression (leukemia, lymphomas, HIV)
describe human immunodeficiency virus infection (HIV)
acute infection followed by asymptomatic period
- acquired immune deficiency syndrome (AIDS)
- no cell mediated response
- something else is taking immune system out (auto = self)
- asymptomatic for 6 months - 10 years (latent period)
- development of opportunistic infections (pneumocystitis carinii pneumonia, toxoplasmosis)
- karposi sarcoma (epidermal metastatic disease)
what are the route of transmissions of HIV
- sexual: semen and vaginal secretions
- blood
- transplacenta: only if open wound in baby’s mouth
- breast milk
- organ transplants
- saliva (into open wounds)
HIV antibody testing (4)
- post seroconversion ( 2 weeks - 6 months)
- ELISA
- Western Blot test
- OTC tests
treatment for HIV
- HIV pre-exposure prophylaxis
- antiretroviral medications (reverse transcriptase inhibitors, protease inhibitors, agents that block the initial entry of HIV into CD4 cells)
