med surg 1 - exam 1 Flashcards
What is acute pain?
- commonly associated with a specific injury
- usually decreasing as healing occurs
- can last from seconds to 6 months
What is chronic pain?
- Constant or intermittent pain that persists beyond expected healing time
- Seldom can be attributed to specific cause or injury
- Lasts for longer than 6 month
- Chronic pain can be disabling and lead to anxiety and depression
What are the opiate administration and effects?
- must be given frequently enough and in large enough doses to be effective
- given orally have been found to provide a more consistent serum level than those given IM
- Opioid agonists are found to be more responsive to nociceptive pain vs neuropathic pain. For neuropathic pain-antidepressants and antiseizure medications are recommended as first line agents
- can be given orally, IV, subcutaneous, intraspinal, intranasal, rectal, transdermal
- Start low go slow- tolerance to the respiratory depressant effects increases if the dose is increased slowly
Constipation ~ increase intake of fluid and fiber - Mild laxative and stool softener should be administered on a schedule.
Severe constipation ~ give a stimulating cathartic agent like dulcolax or rectal suppositories
What are side effects of opiates?
- respiratory depression and sedation (risk increases with age)
- Nausea and vomiting
(Usually occurs several hours after injections
Can be avoided by giving fluids and antiemetics) - Constipation
(Common post-op and in cancer patients
Bowel regimen should be started when opioids are started)
-Pruritis
(Very common with opioids, not a true allergy_
What are the opiate considerations?
- Primarily metabolized in the liver and excreted by kidneys
- Untreated hypothyroidism may be more susceptible
- Hyperthyroidism may require larger doses relief
- Elderly patients may be more susceptible
What is tolerance?
- The need for increasing doses of opioids to achieve the same therapeutic effect
- Develops in almost all patients who are taking opioids for an extended period
- Levels off after the first few weeks of treatment
- If develop a tolerance for one drug, may get relief by switching to another opioid
- Tolerance does not equal addiction
- Patient may develop symptoms of physical dependence when opioids are discontinued, but actual addiction is rare
What is addiction?
- Is a behavioral pattern characterized by a compulsion to take the substance
- Fear of becoming addicted is a common cause for inadequate treatment
- Addiction from therapeutic use of opioid is negligible
- Many may however develop a tolerance
What is the purpose of a pre-op assessment?
- Obtain health information, including drug and food allergies
- Provide and clarify information about the surgery and anesthesia
- Assess emotional state and readiness
- Determine expectations
- Identify risk factors
- Plan care to ensure patient safety
The main types of abnormal drainage:
- Sanguineous-Deeper wounds involving thicker layers of tissue are more likely to produce sanguineous drainage, or thicker red blood.
- Hemorrhagic Hemorrhage occurs if there’s been damage to an artery or vein.
- Purulent milky texture and is gray, yellow, or green odor as well
- Seroprulent
normal types of drainage?
- Serosanguinous drainage is thin, like water. It usually has a light red or pink tinge, though it may look clear in some cases. Its appearance depends on how much clotted red blood is mixed with serum.
- Serous drainage is thin and clear, it’s serum. This is typical when the wound is healing, but the inflammation around the injury is still high.
What would the nurse do first if the patient hasn’t voided in 9 hours post op? Least invasive to most invasive?
- Bladder scan
- insert straight Cath
Post-op urinary interventions?
Monitor urine output
Adequate hydration
Remove urinary catheter when no longer indicated
Normal positioning for elimination
Bladder scan/straight catheter per orders
What do you assess in regards to a wound?
Surgical site infection (SSI)
Accumulation of fluid in the wound
Dehiscence
Note drainage color, consistency, and amount, how much drainage is appropriate per hour?
Assess effect of position changes on wound/drain tube drainage
Signs/symptoms of infection
Ordered prophylactic antibiotics
Maintain glycemic control
Normal potassium
3.5 - 5
normal BUN level
10-20
normal creatine levels
0.7-1.4
normal magnesium levels
1.3 - 2.3
normal hemoglobin male
13-18
normal hemoglobin female
12-16
normal HCT male
42-52%
normal HCT female
35-47%
normal WBC
4,500 - 11,000
normal Platelets
150,000 - 450,000
What can the Unlicensed Healthcare Worker assist with?
- reinforce teaching
- take vital signs
- assist with meals
What does frequent vital signs include?
ECG
What are the must knows with SCDs?
- provide compression for blood return to the heart
- Calf warm swollen painful –emergency!!! The client needs to be up and ambulating as soon as possible, if possible.
- At risk for development of clot
What are the early signs and symptoms of Hypoxemia?
agitation and confusion
When do you know your interventions are successful?
Assess breath sounds and vital signs
What does the post-op nursing assessment consist of?
Vital signs!!
- Airway
- –Patency
- –Artificial airway
- Breathing
- –RR and quality
- –Breath sounds
- –Supplemental oxygen
- –Pulse oximetry and capnography
- Circulation
- –ECG monitoring
- –Vital signs
- –Peripheral pulses
- –Capillary refill
- –Skin color and temperature
- Neurologic
- –LOC/ Glasgow Coma Scale
- –Orientation
- –Sensory and motor status
- –Pupil size and reaction
- Genitourinary
- –Intake (IV fluids)
- –Output (urine and NG)
- –Estimated blood loss (EBL)
- Gastrointestinal
- –Bowel sounds
- –NG—Verify placement to suction or clamped
- –Nausea
- Surgical site
- –Dressing
- –Pain
- –Incisional
- Other
- –Laboratory and diagnostic tests
- –Review results of ordered exams
Vital signs and trends??? What is normal???
- a small drop in blood pressure is normal.
- Know the trends of your patient
- get a baseline for your patient
- look at post-op lab results
What is malignant hyperthermia?
- Rare metabolic disorder, hyperthermia with rigidity of skeletal muscles
- Autosomal dominant trait
- Inherited hyper-metabolism of skeletal muscle resulting in altered control of intracellular calcium
- Often occurs with exposure to succinylcholine, especially in conjunction with inhalation agents
- Usually occurs under general anesthesia but may also occur in recovery
- Tachycardia, Tachypnea, Hypercarbia, Ventricular dysrhythmias
** Rise in body temperature NOT an early sign
- Can result in cardiac arrest and death
***Dantrolene for reversal
- ***Body temp of 105 or greater
- ***Be aware of previous family history of Malignant Hyperthermia report to doctors
Surgical asepsis rules
- Center of sterile field is site of surgical incision
- Only sterilized items in sterile field
- Protective equipment:
Face shields, caps, gloves, aprons, and eyewear
What do registered nurse first assistant do?
Handles tissue, uses instruments, provides exposure to surgical site, assists with homeostasis, performs suturing
What are benzodiazepines?
- class of psychoactive drugs
- acts as a sedative - slowing down the bodies functions and are used for both sleeping problems and anxiety. They work by increasing the effect of a brain chemical called GABA
What are some of the names of benzodiazepines?
lorazepam
alprazolam
diazepam
conazepam
What are side effects of benzos?
- drowsiness
- lightheadness
- confusion
- unsteakiness
- dizziness
- slurred speech
- muscle weakness
- memory problems
What do opioids do?
Sedation and analgesia
Induction and maintenance intraoperatively
Pain management postoperatively
Respiratory depression
What is albumin? What does it? What does a low albumin indicate?
- is a protein made by your liver.
- Albuminhelps keep fluid in your bloodstream so it doesn’t leak into other tissues.
- It is also carries various substances throughout your body, including hormones, vitamins, and enzymes.
- Lowalbuminlevels can indicate a problem with your liver or kidneys) If you have alower albumin level, you may have malnutrition, problems with wound healing,
What is hemoglobin?
oxygen-carrying protein
What is hematocrit?
percentage of red blood cells in your blood
What do you need to talk about with the patient about respiratory before a surgery?
- recent airway infections
- History of dyspnea, coughing, or hemoptysis reported to operative team
- COPD or asthma
What are the safety considerations for surgery?
Surgical time-out, confirm name, BD, surgical procedure and site, and consent
When is oxygen used for COPD patients?
when their O2 is less than 90% during sleep, rest, and exertion
What does pursed lip breathing do?
- the purpose is to prolong exhalation, which prevents bronchiolar collapse and air trapping.
- It helps to slow respiratory rate and easy to learn.
- Gives pt more control over their breathing.
- To teach, have pt breath in slowly and deeply through nose, then blow out through pursed lips, like your whistling. - We want exhalation to be 3 times as long as inhalation.
- Practice 8-10 repetitions 3-4 times a day
What does long term O2 therapy do for COPD patients?
Improves: Survival Exercise capacity Cognitive performance Sleep in hypoxemic patients
What are the complications of oxygen therapy for COPD pts?
Combustion CO2 narcosis O2 toxicity Absorption atelectasis Infection
What are the clinical manifestations for COPD?
- develops slowly
- chronic cough or sputum production
- dyspnea
- exposure to risk factors
- chest breathing
- use of accessory and intercostal muscles
- inefficient breathing
- wheezing and chest tightness
- underweight with anorexia
- prolonged expiratory phase
- decreased breath sounds
- barrel chest
What are the typical ABG levels for later stage COPD?
Low PaO2
↑ PaCO2
↓ pH
↑ Bicarbonate
What kind of diet is needed for COPD patients?
High-calorie, high-protein diet is recommended
Eat five to six small meals to avoid bloating and early satiety
Avoid foods that require a great deal of chewing
Exercises and treatments 1 hour before and after eating
Rest at least 30 minutes before eating
Avoid exercise for 1 hour before and after eating
Use bronchodilator
What is sinusitis?
- inflammation around the nasal cavities
- mucus irritation
- usually viral; 5-10% bacterial
What are the symptoms of sinusitis?
- pain
- purulent nasal drainage
- nasal obstruction
- congestion
- fever
- malaise
What are the goals for COPD patients?
Prevention of disease progression
Ability to perform ADLs
Relief from symptoms
No complications related to COPD
Knowledge and ability to implement long-term regimen
Overall improved quality of life
Return to baseline respiratory function
Demonstrate an effective rate, rhythm, and depth of respirations
Experience clear breath sounds
Maintain clear airway by effective coughing
Feeling of being rested
Improvement in sleep pattern
Awareness of need to seek medical attention
Behaviors minimizing risk of infection
No infection
What are the interventions taken for COPD patients?
- teach pursed lip breathing
- teach HUFF coughing
- teach flutter mucus clearing
- enforce a healthy diet
- ADLs
What is epistaxis?
nose bleed
anterior bleeding - 90%
posterior bleeding - older adults with other health problems
What is the treatment for epistaxis?
Lean head forward, if not stop within 15 minutes, seek help
Nasal tampon
Epinephrine
Packing for posterior bleeds, balloon- only for 2-3 days
Monitor LOC, heart rate & rhythm, RR, O2 sat, issues with breathing or swallowing-requires immediate intervention by RN if 02 sat is dropping
Pain medicine and antibiotics needed
Teach no vigorous nose blowing, no NSAIDs, no lifting or straining for 4-6 weeks
What are the types of allergic rhinitis?
episodic
intermittent
persistent
What are the manifestations of epistaxis?
Sneezing Watery eyes Itchy eyes and nose Altered sense of smell Thin, watery nasal d/c Nasal congestion Pale, boggy turbinate headache
What do you teach to patients with allergic rhinitis?
avoid triggers - first thing and most important
Drug therapies to reduce inflammation?
Nasal corticosteroids
H-antihistamines-first generation (diphenhydramine) second generation- cetirizine (Zyrtec) loratadine (Claritin) fexofenadine (allegra)
Decongestants-pseudophedrine (Sudafed) promotes vasoconstriction, reduces nasal congestion
Leukotriene receptor antagonists
These can help patients with allergic rhinitis
What is acute viral rhinitis?
common cold
What is flail chest?
2 or more adjacent ribs in 2 or more places with loss of chest wall stability, paradoxical movement of chest wall, respiratory distress
Diagnostic testing
How do you manage to flail chest?
Adequate airway and ventilation
Oxygen therapy
Analgesia
Surgical fixation
What is a pulmonary embolism?
Blockage of one or more pulmonary arteries by thrombus, fat or air embolus, or tumor tissue
Obstructs alveolar perfusion
Most commonly affects lower lobes
- blood clot in the lungs
What is a pulmonary embolism most commonly from?
DVT
Clinical manifestations of pulmonary embolism?
Deep vein thrombosis Immobility or reduced mobility Surgery History of DVT Malignancy Obesity Oral contraceptives/ hormones Smoking Heart failure Pregnancy/delivery Clotting disorders Atrial fibrillation Central venous catheters Fractured long bones
What are the common tests to determine a pulmonary embolism
Most common: Spiral helical CT scan
D-dimer: elevated with any clot degradation, false negatives with small PE
Troponin levels: proteins in skeletal and heart muscle that regulate contraction. Elevated levels indicate damage to the muscle cells
Arterial blood gases - pH, HCO3, CO2
Ventilation perfusion scan
ECG/EKG
Nursing care for patients with a pulmonary embolism
Prevention:
Sequential compression devices
Early ambulation
Prophylactic anticoagulation
Supportive care: Oxygen → mechanical ventilation Pulmonary toilet ~ NOW called Pulmonary hygiene Semi-Fowler’s position Frequent assessments of VS to react to changes IV access Fluids, diuretics, analgesics Monitor laboratory results Emotional support and reassurance
Drug therapy
Anticoagulation
Fibrinolytic agents
Surgical therapy
pulmonary embolectomy for massive PE
IVC filter
What is a thoracentesis?
Removing fluid for diagnostic or therapeutic purposes
Needle inserted into intercostal space
Max amount to drain at one time is 1000-1200 ml of fluid to avoid hypotension, hypoxemia, or rapid re-expansion of pulmonary edema
When a thoracentesis occurs what S&S should you report?
pneumothorax, tension pneumothorax, and pleural fluid re-accumulation.
