Midterm 1 - Pre-Intra-Post Op - N&V - Hyperemesis Gravidarum - PUD- IBD Flashcards
Informed Consent: RN’s role
Advocate for Pt
Validating consent
Assessing capacity
May ask Pt to sign
May witness Pt signing
Clarifies the Pt’s understanding and that they have all the info
Ensure Pt has not had psychoactive meds prior to signing consenting
Consent is valid if…
- Given freely - No coercion
- Pt is competent
- Should be in writing, but does not have to be
- Pt should be able to understand (consider lifespan)
Consent is required when…
Treatment is/involves:
- Invasive
- Radiation
- Risk
- Sedation
Who can sign a consent?
- 19+
- Mentally capable
- Surrogate if not of age or competent
- Emancipated minor
- Emergency-surgeon or physician if life-saving
- Child under the Infant’s Act
Who can NOT sign a consent?
- Incompetent-not capable
- Not autonomous
- Cognitively impaired, mentally ill, neurologically incapacitated
- Unable to understand (language barrier)
Consent assessments
Assess:
- Capacity
- Age
- LOC - teach back
- Cognitive ability
Perioperative phases
- PreOperative
- IntraOperative
- PostOperative
PreOperative Nursing Assessments
- Physical
- Health Hx (fluid &nutritional status, vitamin & mineral levels, dentition - inutubation is aggressive and you can loose teeth)
- Emotional
- Support Systems (getting to and from Sx)
- Risk Factors
- Previous surgeries
- Meds
- Allergies
- Pain tolerance & hx
- Occupation, literacy & education
PreOp Cardiovascular
Pacemaker? Stent? HTN? Coagulation > Warfarin? PVD? Cardiac PmHx?
Dx:
- ECG, platelets, coagulation & liver fx (coagulation factors production)
PreOp Respiratory
Resp Sounds Fluid overload Pulmonary edema Pneumonia s+s Comorbidities? Smoking??? > 4-6 weeks no smoking preop is ideal > affects wound healing
PreOp Neurological
Epilepsy Depression Anxiety Stroke or TIA Hx Mental Status Bleeding disorders
Nursing Diagnosis related to PreOp
- At risk of infection due to the PreOp findings as evidenced by WBC count
- Actual Anxiety and fear preop due to…
- Knowledge deficit r/t complexity of treatment as evidenced by Pt’s lack of knowledge about follow-up care
- Adverse physical response to anesthetics, medications as evidenced by…
Sx Risk Factors
- Age (old & young)
- Nutrition, dentition
- Obesity (dehiscence, hypoventilation, might need bigger doses - at risk for OD)
- Immune compromised (HIV/AIDS, chemo, steroids)
- Fluid & electrolyte status - K+!!!! If elevated arrhthmias
- Pregnancy - different meds & fluid status depending on stage
- Illicit drug use
- Smoking - higher risk of clots, infection, poor healing
- Psychiatric/delirium Hx
- Other Meds (insulin, anti-coags, withdrawal)
- Bleeding disorders
- Diabetes
- Heart Disease
- Respiratory disease or infection
- Hepatic disease
- Comorbidities
- Chronic pain
IntraOperative Complications
Nausea and vomitting Anaphylaxis Hypoxia and respiratory complications Hypothermia Malignant Hyperthermia DIC (disseminated intravascular coagulation)
Nursing goals in the intraoperative period?
- Reduce anxiety
- Prevent position injury
- Maintain Pt safety - maintain sterility
- Pt advocate
- Avoid complications
IntraOp: How to protect Pt from injury?
- Pt identification
- Correct informed consent
- Verify medical records of health hx
- Allergies
- Monitor physical environment
- Verification and accessibility of blood
General Anaesthetics
Drugs that induce a state in which the CNS is altered so that degrees of pain relief, depression of consciousness, skeletal and reflex reduction are produced.
Used for:
- Deep muscle relaxation
- Loss of consciousness during surgery
Inhaled anaesthetics
Volatile liquids or gases that are vaporized in O2
IV anaesthetics
Used for induction or maintenance of general anaesthesia, amnesia and as an adjunct to inhalation
Types of Anaesthesia
General anaesthetics - propofol
Sedatives-hypnotics - barbiturates and benzodiazepines
Narcotics - morphine sulfate, fentanyl and surfentanyl
Neuromuscular Junction Blockers - succinylcholine
Benzodiazepines
- Sedative-hypnotic drug
- Anxiolytic
- Ability to depress activity in the CNS (GABA)
- Calming effect in the CNS
- Anticonvulsant
- ETOH withdrawal prevention
Antiacids drug interactions
Adsorption - decreases the ability of absorption of other drugs
Chemical - inactivation of other drugs
Increased stomach pH - may increase absorption of basic drugs over acidic drugs
Increased urinary pH- may increase the excretion of acidic drugs and decrease the basic drugs
Antidiarrheals types
- Adsorbents - act by coating the GI walls and binding to the causative agent to promote its excretion
- Anticholinergic - slows peristalsis by decreasing the rhythmic contractions and smooth muscle tone
- Probiotics - replenish bacteria and normal flora
- Opiates - decrease bowel motility, increasing the time of transit of food in the GI tract increasing its absorption ( H2O and lytes)
Antiemetics types
- Anticholinergic (scopolamine): motion sickness, secretion reduction, N&V
- Antihistamines H1 (dimenhydrinate & diphenhydramine): motion sickness, non productive cough, sedation, rhinitis, allergy, N&V
- Neuroleptic (prochlorperazine): psychotic disorders, N&V (dopamine blocker)
- Prokinetic (metoclopramide): delayed gastric emptying, GERD, N&V
- Serotonin blocker (ondansetran): N&V associated with postop and chemo CA
- Tetrahydrocannaboids (THC): N&V with CA chemo, anorexia and weight loss in AIDS
Recovery room nurse’s assessments
Q15min skilled focused assessments Airway maintenance Preventing hypoxemia & hypercapnia Cardiovascular stabilization Managing acute pain Controlling nausea & vomiting postop Relieving anxiety
PCA Assessments
Pain level VS Sedation? Respiratory Fx SE - N&V, pruritus Insertion site assessm Bladder Fx Motor Fx Sensory Fx
PCA: Patient Controlled Analgesia
Effective way to control pain Increases Pt’s feeling of control Less dose than IM route Pt needs to be cognitively aware Needs a functioning IV Lock-out system so Pt can not overdose Only Pt can press button - NOT family Teaching pre-op is essential
PostOp Exercises
- Early ambulation
- Pain management - cautions with sedation or hypotension
- Just don’t ask Pt if exercise was done, do it with them :)
- Refer to pre-op teaching of postop exercises and why
Fluid Volume Overload S&S
JVD Increased BP Adventitious LS Extra heart sounds (S3) Resp distress Bounding pulse Peripheral edema Rapid weight gain
Monitor I&O and VS
Complications of N&V
Aspiration Dehydration Malnutrition Disruption of surgical site Metabolic disturbances Increased ICP Stress/Anxiety
N&V: Non-Pharmacological Interventions
- Gentle diet
- Ginger, peppermint
- Relaxation, music, distraction
- Cool cloths
- Positioning
- Aromatherapy?
Hyperemesis Gravidarum: s+s & complications
Dehydration
Malnutrition (can lead to Wernicke’s encephalopathy)
Metabolic disorders (Ketosis)
Stress and extreme fatigue
Fetal Growth Restriction
DVT r/t increased Hematocrit and immobility
Hyperemesis Gravidarum Tx
IV Rehydration
- Electrolytes
- B1 (thiamine), B6 (pyridoxine)
- TPN in severe cases, PICC lines used
Medication:
- Antiemetics (promethazine)
- folic acid thiamine, iron
- LMWH (dalteparin)
Pediatrics: N and V, Diarrhea
Immature kidneys - less concentrated urine
Infants and children become dehydrated FAST
Dehydration becomes a medical emergency > can lead to kidney failure, cardiac collapse, death
Pediatrics: N and V, Diarrhea Assessments
Dry mouth < urine Weight loss Diarrhea: watery? bloody? Sunken fontanelles in babies Loss of tears Sunken eyes Rapid, deep resps (acidosis) Cold extremities Rapid weak pulse Cyanosis Loss of skin turgor
IBD Management
- Reduce inflammation
- Suppress inappropriate Immune responses
- Rest the bowel (food, diet, Sx intervention)
- Correct fluid and electrolytes
- Nutritional therapy
- Prevent complications - fistulas, ulcerations, toxic megacolon
Steroids Side effects
- increased blood glucose
- decrease IR — >increasing risk of infection
- decreased inflammatory response
- decreased wound healing
- weight gain/facial swelling
- increased risk of ulcers
- electrolyte disorders
- mood disorders
Steroids: Nursing considerations
- monitor for potencial hyperglycemia
- give oral steroids with food if possible
- monitor for signs of infection
- Monitor for skin breakdown (poor wound healing)
- Monitor electrolytes
- Monitor for mood or behavioural changes
