knowledge assessment III Flashcards
macronutritients
carbohydrates
fats
proteins
carbohydrates
1g=4 calories
45-65% of diet
simple carbohydrates
candy
fruit
milk
milk products
some breads
complex carbohydrates
grains
rice
pasta
marathon runners may
energy load with complex carbs to increase amount of energy available
why are carbs essential
source of energy
aid in physical activity
assist in brain function
assist in organ operation (intestinal health, elimination)
what kind of carb helps with elimination
grains
order that the body uses as first energy source to last
carbs
fats
protein
fats
1g=9 calories
20-35% of diet
lipids are composed of
steroids
triglycerides
phospholipids
hypertriglyceridemia
leads to CVD and hardening of arteries
saturated fats
solid at room temperature
ex. butter, cheeese
foods high in saturated fats lead to
higher incidence of heart disease, obesity, and cancer
unsaturated fats
liquid at room temperature
ex. olive oil, nuts, almonds, seeds
limits inclusions of saturated fats
cholesterol
animal related foods that are related to cholesterol
diets high in saturated fats or fat in general increase cholesterol
HDLs
- get them from olivie oil and other unsaturated fats
- allows us to keep arteries clear, balanced diet allows us to metabolize fat build up among arteries
- considered good cholesterol
LDLs
considered bad cholesterol
increase in LDLs are indicators of fats that people are consuming
why are fats essential
- surround and protect our organs
- important for cell growth
- necessary for hormone production
- help to form vit D (fat soluble vitamin that comes from sun)
proteins
1g= 4 calories
25-35% of diet
consists of essential amino acids and nonessential amino acids
essential amino acids
must be ingested as they canot be created by the human body
nonessential aminoacids
manufacture of metabolize in small quantities
why is protein essential
- assists with immunity/immune defense
- growth and development (affects ability to think, grow and function in infants)
- helps us regulate life processes
water
- lubricates joints
- assists with elimination
- essential for life
micronutrients
vitamins and minerals
vitamins
- enable body to facilitate or manage chemical functions or reactions throughout the body
- not a source of energy (only comes from macros)
fat soluble vitamins
vitamin A - carrots, orange or yellow foods
vitamin D - sun is a source of vitamin d, as well as eggs, and fish
vitamin E - almonds, peas, beet, greens
vitamin K - kale, spinach
water soluble vitamins
vitamin B - helps with production of RBCs and other important body functions (green leafy vegetables)
vitamin C - citrus sources
minerals include
- calcium
- potassium
- iron
- sodium
- magnesium
objective measures for assessing nutritional status
- weight/BMI
- weight change!
- primary medical diagnosis
- presence of comorbities
- anthropometric measures (height, weight, BMI)
- body circumfrences
- food histories and diaries
- lab values
body circumfrences
waist
arm
skin folds
food histories/diaries
- 24 hr recall
- food frequency questionairre
- food record (days-weeks long)
blood glucose
- important source of energy
- increase in glucose indicative of diabetes
- malabsorption
hemoglobin A1C
how body is utilizing glucose over 3 month period
iron
low = anemia
prealbumin
quick view of amount of protein stores we have in body
albumin
like A1C longer view of protein stores within body indicative of chronic illness in an individual
creatinine/BUN
- kidney function and ability to metabolize and excrete waste
- keto diets put high stress on kidneys
hemoglobin
- indicator of having adequate iron stores because we need iron to carry O2 throughout body on hemoglobin
- indicative of anemia
hematorcrit
production of RBCs and what is available
indicative of anemia
factors affecting nutritional needs
- culture/ethnicity
- age
- religious beliefs
- functional capacity
- socioeconomic status
- disease
- drug-interactions
infants need
increased calories where growth needs to occur and needs to occur fast
should underestimate effects of _____ on food
culture
religious beliefs can determine what
you can and cant eat
functional limitations and nutrition
chewing
swallowing
inability to self-feed
loss of taste or smell
supporting impaired swallowing
thicken foods to help with people having a difficult time
NPO pts
alternative ways of feeding
older adults and nutrition
- functional capacities
- holding silverware
- arthritis
- swallowing issues
- loss of appetite
- loss of taste or smell
special diets
- soft (soft foods)
- clear liquid diets (usually post-op)
- full liquid diet (popsicles, water, juice)
- mechanical soft (soft in nature for those with issues swallowing, still recognizable
- pureed (unidentifiable)
- cardio diet
- renal diet
enteral
tube that goes directly into stomach
nasogastric
PEG tube
percutaneous endoscopy gastric tube
tube inserted directly into the stomach
more common in adults
G button
similar to PEG tube but is a little piece that sticks in above umbilical and doesn’t extend outward
Parenteral nutrition
TPN
food that is delivered through central line - surgically inserted and goes into top of the heart
nursing goals in the preoperative area
- quality improvement and EBP
- pt safety
- teamwork and collaboration
- effective communication and interactions
- nursing process to deliver timely assessment and interventions in all phases of surgery
- advocacy for a pt and pt family
- cost contaminent
how is surgery classified
- severity
- urgency
- purpose
surgical risk factors
- smoking
- age
- nutrition
- obesity
- obstructive sleep apnea
- immunosuppression
- fluid and electrolyte imbalance
- postop n/v
- postop urinary retention
- venous thromboembolism (VTE)
critical thinking for perioperative nursing
- integrate knowledge regarding pt’s specific situation and type of surgery along with previous experiences
- apply knowledge using PCC and partnering with pt to make clinical decisions
considerations in perioperative nursing
- use interpreters as needed
- accommodate religious and cultural needs; allow religious articles
- assess cultural preferences for pain medication
- may need to allow religious or cultural articles to be worn just before surgery
surgical site infection prevention
- minimize hair removal
- administer antibiotics
- maintain blood glucose, normothermia
- insert urinary catheter devices only when necessary and only as long as neccessary
pediatric surgery
- consider childs development level
- give child as many choices as possible
- keep parent child separation to a minimum
gerontological
cognitive, sensory, or physical impairments
increased time to dress
limit ROM
elective surgery
surgery that is no urgent or an emergency, pt can wait weeks to months out
ex. wisdom teeth
urgent surgery
can wait until pt’s health is unwavering but must be done within 1-2 days
emergent surgery
must be done immediately
diagnostic surgery
this would things like a biopsy or endoscopy
palliative surgery
done to improve comfort for incurable diagnoses
reconstructive/restorative surgery
reconstruction of tissue or restoration of tissue
ex. nose job, skin grafts
labs b4 surgery
- completed 1-2 weeks in advance of surgery
- CBC, CMP, bleeding times (PT, APTT), blood type and cross, UA
- CXR
EKG
components of surgical safety checklist (B4 surgery)
- confirmation of identity, site, procedure, and consent
- is site marked
- anesthesia and med check
- is pulse ox on pt and working
- does pt have allergy, aspiration risk or risk of > 500mL blood loss, 7ml/kg in children
components of surgical safety checklist (before skin incision)
- confirm team introduced themselves
- confirm name, procedure, and where incision will be made
- has antibiotic prophylaxis been given in last 60 minutes
- is essential imaging being displayed
- anticipated critical events
components of surgical safety checklist (before pt leaves OR)
- nurse confirms name of procedure, completion of tool counts
- specimen labeling
- whether any equipment problems need to be adressed
- key concerns for recovery
analysis and nursing diagnosis preop
- impaired airway clearance
- anxiety
- impaired skin integrity
- risk for infection
- acute pain
planning and outcome ID
- outcomes
- setting priorites
- teamwork and colloboration
implementation of surgery
- informed consent (must be done before pt receives sedation)
- privacy
preoperative teaching
- preop routines
- surgical procedures
- time of surgery
- post op unit and location of family during surgery and recovery
- anticipated post op montioring and therapies
- sensory preperation
- postop activity resumption
- pain relief
- rest
- feelings
acute care implementation
- minimizing risk for infection
- maintianing normal fluid and electrolyte balance
- preventing bowel incontinence and contamination
prep day of surgery
- hygreine
- prep of hair and removal of cosmetics
- removal of prosthesis
- safeguadring valuables
- preparing bowel and bladder
- vital signs
- prevention of DVT
- admin of preop meds
- documentation and hand-off
- eliminating wrong site and wrong procedure surgery
preop orders
- food and fluid restrictions
- meds to take and meds to hold (insulin, antihypertensives, anticoag’s, fish oil, ASA, vitamin E)
- smoking cessation
- no alcohol
- anticoag’s when to hold
- no shaving
- bowel prep if needed
day of surgery guidelines
- know type and nature of any previous surgery
- ID factors and conditions increasing pt risk
- know rationale for and extent of current surgery
- ensure pt has signed consent form
- complete preop checklist
- admin pain-relief therapies according to a pt’s perioperative needs
- restrict pt activity after admin of preoperative and postoperative sedatives to minimize the risk for pt falls
pt states incorrect procedure, site, date, or time of surgery
provide correct information verbally and in writing for pt and caregiver
pt incorrectly performs on of the postoperative exercises
- explain and demonstrate correct way
- explain important of the postoperative exercise as it pertains to pt recovery
- instruct pt to repeat demo
post-op exercises
- coughing and deep breathing
- incentive spirometer
- early ambulation
- turning and positioning
- splinting
proplyactic antibitocs
given as close to time of incision as possible
vancomycin may be given up to 2 hrs before incision because of longer infusion times
discontinued
recording and reporting of surgery
-document
- report any abnormal findings or concerns to surgical teams
- record disposition of pt valuables and belongings
- report lack of signed and witnessed consent form or failure of patient to maintain NPO status and action taken
preanesthesia care unit (PCU)
- presurgical care unit
- holding area
PCU nurses
members of OR staff
common procedures
circulating nurse
- nonsterile member of surgical team
- maintains pt safety
- supervises conduct of scrub tech/nurse
- knowing pertinent info about pt and verifying it is the correct pt on table
- positioning pt
- managing the room including supplies, equipment, lighting, and documentation
- ensures no break in sterile field
- initiates counts
scrub nurse
- RN
- surgical technologist
- maintains sterile field
- assists surgeon by handing sterile instruments, sutures, and supplies
- pt safety
- counts
- sterile
RNFA
monitor pt vital signs during procedures, if complications arise, RNFA acts with surgeon to stabilize pt
- sterile
intraoperative nursing diagnosis
- impaired airway clearance
- risk for DVT
- risk for perioperative positioning injury
- risk for impaired skin integrity
- risk for latex allergy
PACU
post anesthesia care unit
safety guidelines
- all items used within sterile field must be sterile
- gowns used by scrub personnel msut be sterile before donning (sterile from chest to shoulders to table level, sleeves 2 inches above elbows)
- sterile personnel must keep hands in view above waist level and below neckline to avoid contamination
- when wearing a sterile gown, do not fold arms with hands tucked in the axillary region
- sterile-draped tables are sterile only at table level
- all personnel moving around or within a sterile field must maintain sterility
- unsterile personnel must stay 12 niches away from sterile field
- group all sterile supplies and equipment around the sterile draped patient
9.unsterile people must avoid reached over sterile field - scrubbed people remain close to sterile field when changing position turn face to face or back to back
immediate post op recovery (phase I)
- hand-off
- family communication
- pt assessment
- airway
- passero opioid induced sedation scale (POSS)
- efficacy safety score
- discharge from PACU
recovery in ambulatory surgery
- begins after pt stabilize and no longer requires close monitoring
- fast-track surgery: ambulatory surgery pts can bypass phase I and immediately enter phase II in recovery area
- pt monitoring continues
- post op teaching/written instructions
- postop n/v
- discharge scoring system (PADSS)
assessment post op
throughout pt eyes
airway and respiration
circulation
temp control (malignant hyperthermia)
fluid and electrocyte balance
ROS
acute care recovery
- maintain respiratory function
- prevent circulatory complications
- promoting early mobility
- achieving rest and comfort
- temp regulation
- preventing infection
- maintaining neuro function
implement restorative and continuning care
prepare for discharge
provide pt education
make referrals
coughing and deep breathing are sometimes contraindicated for
brain, spinal, head, neck, or eye surgery
pts who are severly obese sometimes have
more improved lung function and vital capacity in reverse trendelenburg or side-lying position
immediately report any signs of
venous thromboemoblism to HCP
PACU care
- first 1-2 hrs most critical
- assessments must be timely, knowledgable and accurate
- aldrete score
- ambulatory or inpatient surgery requires same assessments
post op assessment
- receive pt and report (anesthesia and circulating nurse, reconnect any attachments)
- airway (check breathing) - turn on side if possible, head to side
- circulation (color, pulses, cap refill <3 seconds)
- VS q 5-15 minutes
- gag reflex
- call by name/attempt to arouse (orient and encourage coughing)
- monitor wound, dressing (mark drainage)
- monitor output devices (urinary catheter, NGT)
- IV site (redness, swelling, edema, leakage, pain, warmth, fluids, rate
- pain and n/v
- oral care
complications of surgery
- aspiration/pneumonia
- atelectasis (can be prevented by incentive spirometer
- DVT/PE/renal failure
- hypovolemia
- N/V/constipation
- evisceration
- hemorrhage
- paralytic ileus
- infection
gerontological
- require longer recovery period
- assess for post op delirium and mental status changes
- post op pain tends to be undertreated in older adults
home care
- post op exercises, home modifications
- make referrals if necessary
- ambulatory center pts must be accompanied
anatomy of the skin
composed of epidermis, dermal layer/dermis, and subq layer from most superficial to least
epidermis
- 1st layer of skin
- offers body significant layer of protection
- outer layer
- varies in thickness which is part of normal process of aging
- made of dead skin cells that shed about every 2 weeks
dermis
- varies in thickness
- soles and palms of feet and hands
- eyelids - least amount of thickness
- collagen and elastic tissue compose the dermis which give skin firm complexion
subq layer
- fat (helps temperature regulation)
- blood vessels (injury to subq tissue, bloody supply causes brusing)
muscle layer
- most metabolically active layer of skin
- most vulnerable area to ischemic injury
- ischemic injury indicates limited ability for healing as blood flow isn’t reaching the tissue causing tissue to die
pressure injuries are caused by
bony prominences and pressure exerted by the bed is creating ischemia and skin breakdown
interventions for pressure injuries
- ambulation
- ROM
- turning and repositioning q2hrs
- nutrition
normal skin changes
- structures change related to epidermal thickness/thinness and nature of subq fat
- skin is more easily damaged
- circulation can be compromised
strategies to maintain healthy skin
- nutrition (protein!!!, vitamin C)
- hydration
- bathing and lubcrication (lotion)
- increasing activity ASAP
- avoiding sun or using proper protection
- managing pruritic skin (itchy skin)
descriptive qualities of wounds
- open, closed
- chornic, acute
- cause of wound
- severity
- cleanliness
- colonized
- superficial
- partial or full thickness
open wounds
- abraisions
- burns
- incisions
- lacerations
closed wounds
- abscesses
- contusions
acute/chronic wound
length of time
cause of wounds
wounds that are potentially intentional or unintentional
ex. gunshot wounds
sevirity of wound
- superficial
- penetrating (goes through multiple layers of skin)
- perforation (perforating of organs)
cleanliness of wound
- clean wound: no debris, minimal risk of infection
- contaminated wound: debris, high risk of infection
- infected wound
- clean contaminated wounds (association with surgical wounds)
colonized wounds
MRSA is likely candidate for colonized wound
superficial wounds
on outside surface
partial thickness
involves some layers of skin
full thickness
involves all layers of skin
phases of wound healing
- hemostasis (immediate-3days)
- inflammatory phase (1-3 days)
- cellular proliferation (4-21 days)
- wound remodeling (3 weeks-12 months)
hemostasis
- immediate - 3 days
- the body’s reaction to wounding is to stop the bleeding: construction of blood vessels
- occurs within minutes
- vasoconstriction starts first, then platelets arrive, fibrin matrix forms, and then a scab
inflammatory phase
- 1-3 days
- focuses on destroying bacteria and removing debris - essentially preparing the wound bed for growth of new tissue
- triggers inflammatory cascade; heat, pain, redness, and swelling
- essential for growth of new tissue and prepares wound bed for growth
cellular proliferation
- 4-21 days
- rebuilding phase (begins in 4-21 days)
- granulation tissue forms
- wound contracture (wound edges mobilize to reduce the size of the wound)
wound remodeling
- 3 weeks - 12 months
- excess collagen degrades and wound contraction begins to peak
primary intention
- process wherby an incision or open wound is immediately close (usually elective surgery incision)
- skin edges are clean, low, and healing occurs quick
- approximation of wound edges
- no drainage
- no evidence of infection
- prescence of palpable healing ridge along the incision by 5th operative day
secondary intention
- formulation of granulation tissue
- location, dimension, depth of tunneling, appearance of wound base, status of surrounding tissue
- approximation of wound edges
- process whereby an open wound closes by tissue formation (granulation tissue) with subsequent wound contraction and reepithelialization
- most complex traumatic infeciton or disease induced wounds are closed by secondary intention
third intention
- process whereby a wound is temporarily left open to be closed at a later day (4-7 days) using a primary closure technique
- may be used when a skin graft is needed or to wait for a reduction in swelling or infection
factors affecting wound healing
- primary: infection, ischemia
- secondary: immobility, nutrition/hydration/protein!/vitamin C, hygeine, systemic/chronic illness, smoking, cholesterol, decreased sensation, circulation, and cognition, necrosis, excess bleeding, pressure, fever, meds, lifestyle, tattooing, excessive cleaning
components of wound assessment
- anatomic location
- type of wound
- wound bed
- wound edges and periwound skin
- width and diameter of wound/ size and depth
- wound closures
- pain
wound bed
- granulation tissue
- epithelial tissue
- closed/resurfaced wound
- slough
- necrotic tissue
- exudate or drainage
- wound colors
slough
yellow or white strings or thick clumps
necrotic tissue (eschar)
black, brown, or tan firmly adheres to wound bed
exudate or drainage
note volume, color, odor, consistency of exudate
serous wound drainage
- clear fluid typically appearing during the inflammatory stage of wound healing
- clear, thin, watery
- causing swelling of area and impeding healing
serosanguinous
- most common type of wound drainage that is thin and watery fluid that is pink in color due to presence of small amounts of RBCs
- secreted by open wound in response to tissue damage
sanguineous
fresh bloody drainage produced from deep wounds during inflammatory stage of wound healing
purulent
a sign of infection that can be white, yellow, or brown, and slightly thick in texture
wound colors
- black necrotic tissue
- green drainage with redness and inflammation
- muscle tissue exposed
- redness and whiteness
wound edges and periwound skin
- flat, red, moist, closed
- note condition of skin around the wound
signs of inflammation/infection
- induration
- temp elevation
- erythema
- edema
wound closures
- sutures
- staples
- steristrips
- dermabond adhesive
- palpation of wound for swelling/tenderness, fluid accumulation
assessment for pressure ulcers in darker people
- color of intact dark skin often remains unchanged (does not blanch) when pressure is applied over a bony prominence
- palpate area for temperature changes
types of wound treatments
- jackson pratt
- penrose
- hemovac
- wound vac
penrose
inserted within wound to removed excess fluid
hemovac
compress and help remove excess fluid or blood
wound vac
reduces size of wound and is inserted into skin to help reduce size
debridement
throroughly cleaning wound and removing all hyperkeratotic (thickened skin or callous), infected and nonviable (necrotic or dead) tissue, foriegn debris, and residual material from dressings
kinds of debridement
- mechanical
- autolytic (hydrocolloidal)
- chemical (dakin’s)
- sharp/surgical
- maggots
skin grafts
a piece of healthy skin removed from one area of body to repair damaged or missing skin somewhere else on your body
flaps
healthy skin tissue that is partly detached and moved to cover nearby wound
hyperbaric therapy
chamber in which pt breathes 100% pure oxygen under increased pressure, the combination of hgih pressure and pure O2 drives the life giving o2 into bloodstream at very high concentration so it can spread into tissues and fight illness
complications of wound healing
- hemorrhage
- hematoma
- infection
- dehiscence
- eviseration
- fistula
hemorrhage
- direct pressure
- elevate limb
- tourniquet
- ice cold water
- evaluate blood loss through weighing gauze
hematoma
- collection of blood, usually clotted outside of a blood vessel that may occur becaus eof an injury to the wall of a blood vessel allowing blood to leak out into tissues where it does not belong
- damaged blood vessel may be an artery, vein, or capillary; the bleeding may be very tiny with just a dot of blood or it can be large and cause significant blood loss
- it is a type of internal bleeding that is either clotted or is forming clots
dehisence
a partial or complete separation of the wound edges
evisceration
- protrusion of internal viscera through a wound
- prevent by spliting
- immediate measures: apply sterile saline, sterile dressing and call HCP
- constricts BF so it interfers with adequate perfusion
fistula
- abnormal connection between 2 body parts such as an organ and blood vessel or another structure
- usually result of injury or surgery
pressure injury formation
- related to pressure intensity
- ischemia
- blanching
- pressure duration
- tissue toleration
common locations of wounds
- occipital
- scapula
- shoulder
- backbone
- spine
- elbows
- knees
- heels
- ankles
- behind ears
risk factors for pressure injury development
- impaired sensory perception
- alterations in LOC
- impaired mobility
- shear
- friction
actions for prevention of DTI
- early ambulation
- turning and repositioning
- lower HOB to prevent shearing and friction
- maintain hydration and moisture
- assess sensory perception
braden scale
- optimal predictive efficacy (66.7%)
- sensory perception, skin moisture, physical activity, mobility, nutrition, friction/shear
stage 1
- non-blanchable redness
- intact epidermis
- reversible with interventions
- injury is superficial and present clinically as an abrasion, blister, or shallow crater
- may include changes in skin temp, tissue consistency, sensation, non-blanching erythema
nonblanching
skin redness that doesn’t turn white when pressed
stage II
- partial thickness loss of skin layers
- involves epidermis but not completely through the dermis
- blister or broken skin
- presenting as a shallow open injury with a red-pink wound bed, without slough or bruising
- injury presents clinically as a deep crater with or without undermining of adjacent tissue
stage III
- full thickness tissue loss
- extends throuhg dermis to subq tissue
- shallow crater
- subq fat may be visible but no bone, tendon, or muscle exposed
undermining
caused by erosion under wound edges resulting large wound with small opening, much like an iceberg what you see on surface is not indicative of what lies below
tunneling
cause by destruction of facial planes which results in narrow passageway
stage IV
- deep tissue destruction
- extends through subq tissue to fascia
- may involve muscle layers, joints, or bone
- deep crater
- full-thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structure (such as tendon or joint capsules)
- undermining and sinus tracts may be associated
- slough or eschar might be present
unstageable
- obsured full-thcikness skin and tissue loss
- cannot determine the extent of damage because it is obscured by slough or eschar
malignant hyperthermia
severe reaction from drugs used for anesthesia causing dangerously high body temperatures, muscle spams and rigidity, rapid heart rate, and more
treated with dantrolene
