Miscellaneous CPAN Topics Flashcards
Miscellanous CPAN Topics
What are the screening tools for OSA?
Berlin Questionnaire (limited application in preop)
STOP - BANG (excellent predictor of severe OSA but average predictor for diagnosis of OSA)
ASA OSA Checklist
Miscellanous CPAN Topics
How to score OSA using
STOP-Bang?
Miscellanous CPAN Topics
What is the STOP Bang scoring criteria for OSA?
0-2 Low risk OSA
3-4 Intermediate risk
5-8 High risk (includes male/BMI >35/ + neck circ)
Miscellanous CPAN Topics
What is the most advantageous position for a patient with OSA postoperatively?
Lateral recumbent
Avoid supine unless clinically indicated
Miscellanous CPAN Topics
When can diagnosed or suspected OSA patient can be safely discharged in Phase II?
No evidence of hypoxia or obstruction when patient is left undisturbed for 30 minutes
Miscellanous CPAN Topics
How many days before surgery should patient stop taking St. John’s Wort?
7 days
Herb same MOA as MAOIs/SSRIs/ antidepressant
Potentiates anesthetic effects
May affect BP
Miscellanous CPAN Topics
How many days before surgery should patient stop taking saw palmetto?
2 weeks
Increases urine flow, decrease urine frequency
May increase INR with warfarin
Miscellanous CPAN Topics
How many days before surgery should patient stop taking black cohosh?
2 weeks
Herb w/ estrogen, anti inflammatory effect
May cause hypotension, bradycardia
Miscellanous CPAN Topics
How many days before surgery should patient stop taking Gingko biloba?
2 weeks
Herb inhibits platelets and it is antioxidant
May potentiate anticoagulant effects
In general garlic, ginger, ginko increase risk of bleeding.
Miscellanous CPAN Topics
How many days before surgery should patient stop taking kava-kava?
24 hours
Herb a sedative hypnotic
Avoid use with benzo, etoh, barbiturates
DO NOT use with Parkinson’s medications
Miscellanous CPAN Topics
What is ephedra?
ephedra (from Chinese herb ma huang) contains ephedrine, an amphetamine-like compound closely related to adrenaline
It can cause tacyhcardia and elevated blood pressure, nausea and vomitting.
Reactions include heart attacks, strokes, seizures, and sudden deaths
The dangers of the herb ephedra. January 20, 2017
https://www.health.harvard.edu/staying-healthy/the-dangers-of-the-herb-ephedra
Miscellanous CPAN Topics
How much change in HGB/ HCT per 1 unit of PRBC (250cc, w/ RBCs + platelets)?
Hgb increase by 1 g/dL
Hct increase by 3%
Miscellanous CPAN Topics
How much change in platelet if given 1 pack = 50-300ml?
1 unit of platelets increases platelet concentration in the adult by 5000/mm(3) to 10,000/mm(3).
Platelet concentrate is usually suspended in 50ml plasma.
Miscellanous CPAN Topics
Patient is s/p wound debridement, febrile, with gross hemoglobinuria and flushed skin. Patient having which type of transfusion reaction:
anaphylactic
allergic
hemolytic
citrate intoxication
hemolytic
ABO-incompatibility precipitates hemolytic reaction thru aglutination of RBCs, which blocks patient’s capillaries and obstructs O2/blood flow to vital organs. Hemolysis of RBCs release hemoglobin into the plasma w/c plugs renal tubules.
Bleeding suggests patient receiived incompatible blood.
Miscellanous CPAN Topics
What is febrile non-hemolytic blood transfusion reaction?
Febrile reactions caused by sensitivity to leukocytes and plateles.
Symptoms does not occur as rapidly in hemolytic reactions
headache
chills
fever
backache
nausea
vomitting
Miscellanous CPAN Topics
What is anaphylactic blood transfusion reaction?
Anaphylactic reactions frequently seen in platelet transfusion. Patients with history of mod-severe allergic reaction benefits from pre-medication with histamine. Symptoms include
rash
pruritus
localized angioedema
urticaria (minor allergic reaction)
wheezing (more severe allergic reaction)
laryngeal edema (more severe allergic reaction)
hypotension (more severe allergic reactions)
Miscellanous CPAN Topics
What is lung injury transfusion reaction?
Patients who receive plasma-containing products, at risk for Transfusion-Related Acute Lung Injury. Symptoms include
noncardiogenic pulmonary edema
dyspnea
hypoxemia
fever
hypotension
Miscellanous CPAN Topics
What is citrate intoxication during blood transfusion?
Citrate intoxication d/t large amounts transfusion when blood is infused raplidly. Liver unable to metabolize citrate ions, that combine with calcium and cause calcium deficit symptoms such as tingling of the fingers, muscular cramps, and nervousness. If not corrected, cardiac dysrhythmias including ventricular fibrillation can occur. Treatment consists of slow IV administration of calcium gluconate, 1 g for every 1000 mL of blood the patient received. If calcium gluconate is unavailable, calcium chloride can be used, but this is more irritating to the veins.
Name cranial nerves I-VI
I – Olfactory: Sense of smell
II – Optic: Sight
III – Oculomotor: Pupil, upper eyelid, eye movements
IV – Trochlear: Downward/inward eye movement
V – Trigeminal: Sensation of cornea, cheek/lips, chin; control of biting and chewing muscles
VI – Abducens: Lateral eye movements
Name Cranial Nerves VII-XII
VII – Facial: Movement of facial muscles; taste
VIII – Acoustic: Equilibrium; hearing
IX – Glossopharyngeal: Swallowing muscles; taste
X – Vagus: Pharynx/larynx sensation; movement of soft palate
XI – Spinal accessory: Sternocleidomastoid, trapezius muscles
XII – Hypoglossal: Movement of tongue
Miscellanous CPAN Topics
Which cranial nerves are assessed after carodotid endarterectomy?
Facial (VII)
Glossopharyngeal (IX)
Vagus (X)
Spinal accessory (XI)
Hypoglossal (XII)
What is Cerebral Perfusion Pressure?
Brain perfusion calculated as
CPP=MAP - ICP
Normal range 70-100mmHg
Minimal adequate value @ 60mmHg
What is normal ICP?
Normal ICP 0 - 15 mmHg
Goal of care is to maintain ICP < 20 mmHg
Treatment starts when ICP > 20 mmHg
Patient with head trauma with intraparenchymal bolt in place. ICP 30-40 mm HG. Perianesthesia RN knows that cerebral hypoxia maybe aggravated by:
mannitol administration
raising HOB
hypercapnia
tachycardia
hypercapnia
What is autonomic dysreflexia?
Caused by spinal cord injury above T6.
Sudden dramatic BP elevation
May occur with spinal cord injury
Caused by massive sympathetic response to a noxious stimulus (e.g. full bladder, IV line insertion, fecal impaction)
Results to extreme hypertension, bradycardia, headache, and facial flushing, flushed skin above lesion, dry/ pale skin below lesion
Occurs to para/quadriplegic patient’s months or years after initial injury
What are other signs and symptoms of autonomic dysreflexia?
Changed in mental status
Pounding headache
Flushed skin above level of lesion, palor below level
What’s treatment for autonomic dysreflexia?
Straight cath to empty bladder
Elevate HOB
Administer antihypertensive
What is Virchow’s Triad ?
3 factors increase incidence of venous thrombosis:
hypercoagulability caused by alteration of platelet and clotting factors
venous stasis caused by incompetent venous valves
intimal (vessel) damage caused by trauma, IV infusions, and ischemia.
Miscellanous CPAN Topics
What are the signs and symptoms of cardiac tamponade?
BECK’S TRIAD:
Increased CVP
Muffled heart tones
Pulsus paradoxus (fall of SBP >10 mmHg upon inspiration)
What are other signs and symptoms of cardiac tamponade?
Tachycardia
Narrowing pulse pressure
JVD
Sudden cessation of drainage from mediastinal tube
What are the signs and symptoms of Right sided Heart Failure?
Right side unable to pump venous blood adequately into pulmonary circulation, results to swelling, abdominal bloating, ascites, weight gain, jugular venous distention, and dependent pitting edema.
What are the signs and symptoms of Left sided Heart Failure?
Left side unable to pump blood into the systemic circulation, results to accumulation of blood into the lungs, manifested by crackles, wheezes, weakness, fatigue, cough, and orthopnea.
Extra heart sounds heard R and L ventricular failure d/t filling patterns in a noncompliant ventricle.
What are common signs and symptoms of ICP increase complication?
Hypertension
Bradycardia
Respiratory disturbances
Miscellaneous CPAN Topics
What is intracranial hypertension?
ICP > 20 to 25 mm Hg or higher for > 5 minutes
Clinical manifestations include:
headache
deterioration in LOC (indicator of brain injury)
alterations in motor function
pupillary size
reactivity to light
Early changes in LOC may include restlessness, confusion, agitation, irritability, and progress to lethargy.
Mischellaneous CPAN Topics
What is Cushings Triage?
Cushing’s response is a physiologic response (compensatory) to increasing ICP in efforts to provide adequate CPP.
Rising systolic blood pressure
Widening pulse pressure (> 40 to 60 systolic/diastolic difference)
Declining heart rate toward bradycardia
Alterations in spontaneous respiratory pattern leading to irregular respirations
Loss of this compensatory response is termed Cushing’s triad : hypertension with widening pulse pressure, bradycardia, and irregular respirations. Cushing’s triad is a clinical presentation of deterioration of brainstem function; brain herniation may have already occurred.
Miscellanous CPAN Topics
What the s/s of brain herniation?
decreased LOC
changes in pupillary response
decorticate or decerebrate posturing
hemiplegia
impaired brainstem reflexes such as corneal or gag
alterations in vital signs/Cushing’s triad
Unilateral pupillary dilation is the earliest and most indicative clinical signs of brain herniation.
Treatment is craniectomry, excision of lesion/ hematoma, EVD
What does Cushings Triage indicate?
Brain edema or herniation
Requires capnography in addition to pulse oximetry
Miscellaneous CPAN Topics
What is Addisonian’s crisis?
decreased secretion of cortisol and aldosterone d/t autoimmune reaction, infection, congenital, that results to:
dehydration
n & v
muscular weakness
hypotension followed by fever
marked flaccidity of the extremities
hyponatremia
hyperkalemia (d/t aldosterone deficiency)
azotemia
shock
Dexamethasone is drug of choice because it does not interfere with tests
Miscellaneous CPAN Topics
What is pheochromocytoma?
usually a benign ** tumor** in the adrenal gland that causes hyperfunction and results in severe symptoms
Increase in catecholamine secretion (epinephrine/ norepinephrine)
Results to:
Severe hypertension, tachycardia, palpitations
Hyperglycemia
Hypermetabolism, weight loss
Nausea, Abdominal pain
Irritability, diaphoresis
Miscellaneous CPAN Topics
What is the treatment for pheochromocytoma?
Adrenalectomy
Miscellanous CPAN Topics
What are the post-op considerations for pheochromocytoma?
Monitor BP closely! Can have rebound hypotension post-adrenalectomy and may require vasopressors. Will need cortisol replacement
What are classifications of renal failure?
PRERENAL – volume depletion, volume shifts, vascular compromise (MH, AAA)
INTRARENAL – Occurs within the renal tissue (Glomerulonephritis, acute tubular necrosis, etc.)
POSTRENAL – Renal stone, outlet obstruction (back-flow of pressure into kidney causes damage)
Miscellanous CPAN Topics
What is SIADH?
Body producing too much Vasopresin (anti diuretic hormoe)
Miscellanous CPAN Topics
What causes SIADH?
SIADH can be caused by various factors, including:
* Certain medications (e.g., chemotherapy drugs, opioids)
* Lung cancer
* Brain tumors
* Head trauma
* Hypothyroidism
Miscellanous CPAN Topics
What are the symptoms of SIADH?
The main symptoms of SIADH include:
* Hyponatremia
* High urine concentration
* Excessive thirst
* Headache
* Nausea
* Confusion
* Seizures (in severe cases)
Treatment is fluid restriction
Miscellaneous CPAN Topics
What is diabetis insipidus?
lack of ADH w/c leads to volume depletion and hypernatremia
common in transnasal transsphenoidal surgery (TSS) or traumatic brain injury (TBI)
polyuria (a symptom) is uop >300ml/hour x 2 hours or more
hypernatremia leads to a water shift from intracellular to extracellular
Treatment is to replace ADH with desmopressin and H2O loss w/ NaCl
What is steal syndrome?
Steal syndrome: complication due to fistula formation can lead to ischemia
Miscellaneous CPAN Topics
What is thyroid storm?
Thyroid storm is a rare, life-threatening condition caused by a sudden and drastic overproduction of thyroid hormones, leading to a hypermetabolic state and potentially causing fever, confusion, and other severe symptoms.
Miscellaneous CPAN Topics
What are the causes of thyroid storm?
Untreated or poorly controlled hyperthyroidism, which can be triggered by:
* Infections: Especially severe infections like pneumonia or sepsis.
* Trauma: Major injuries or surgery.
* Stress: Emotional or physical stress.
* Medications: Certain medications, like radioactive iodine therapy for Graves’ disease.
* Thyroid surgery
Miscellanous CPAN Topics
What are the symptoms of thyroid storm?
Fever (over 100.5°F)
Tachycardia
Hypertension
Confusion, delirium, and agitation: Changes in mental status, including disorientation and restlessness.
Nausea, vomiting, and diarrhea
Tremors and shaking
Sweating: Excessive perspiration.
Coma: In severe cases, loss of consciousness.
Jaundice
Bulging eyeballs
Compared to MH, thyroid storm does not have muscle ridgidity
What are the signs and symptoms of steal syndrome?
Pallor
Diminished pulses
Pain distal to new graft site
Miscellaneous CPAN Topics
What causes peroneal nerve damage?
Peroneal nerve damage, often leading to foot drop, can be caused by trauma, compression, or certain medical conditions, including knee injuries, fibula fractures, tight casts, prolonged bedrest, or nerve compression from tumors or cysts.
How to assess peroneal nerve damage?
Peroneal nerve assessment:
Sensory: touch lateral side of great toe, medial side of second digit
Motor: dorsiflex ankle, hyperextend great toe
Miscellanous CPAN Topics
What is the most common complication of tonsillectomy and adenoidectomy?
postoperative bleeding
indication of bleeding - frequent swallowing, clearing of the throat, and vomiting of dark blood
cardinal symptoms of hemorrhage - decreased blood pressure, tachycardia, pallor, and restlessness - notify surgeon
Miscellanous CPAN Topics
What is fat embolism?
droplet-like particles of fat enter bloodstream and block blood vessels
95% of cases involve pelvic fractures or long bones
S/S include:
difficulty breathing (initial symptom)
mental state changes (d/t affecting brain, can lead to seizure)
petechial rash
https://my.clevelandclinic.org/health/diseases/23995-fat-embolism-syndrome. 04.04.2025
Miscellanous CPAN Topics
What are the components of malpractice?
Duty
Breach of duty
Causation
Damages
Which of the following oxygen delivery devices offers the highest concentration of oxygen (FiO2)?
Venturi mask
Partial non-rebreather mask
Non-rebreather mask
Simple face mask
Non-rebreather FiO2 of close to 80-95%
Venturi mask 24-55%
Simple face mask 40-60%
Partial rebreather mask 60-75%
A patient with severe COPD requires both humidification of oxygen and a tightly controlled flow rate. Which of the following would be the best choice for oxygen therapy?
Venturi mask
Partial non-rebreather mask
Non-rebreather mask
Simple face mask
Venturi mask allows well-controlled titration of FiO2 and humidification.
Which of the following would be an unexpected complication seen in a patient with a newly created tracheostomy?
Mediastinal subcutaneous emphysema
Pleural effusion
Pneumothorax
Feeling of shortness of breath despite adequate oxygenation
Pleural effusion NOT anticipated
Complications include:
subcutaneous emphysema, pneumothorax,
hemorrhage,
post-placement obstruction.
Patients report SOB despite adequate oxygenation d/t smaller diameter and anxiety
In a patient experiencing laryngospasm, the nurse would expect to find which of the following after doing a complete respiratory assessment?
Patient states that it is hard to breathe and is visibly dyspneic
Audible wheezes and use of accessory muscles
Pink, frothy sputum
Inspiratory stridor with tracheal tug
A patient experiencing laryngospasm represents a clinical emergency in which the vocal cords are partially or fully closed. Although it would be hard for the patient to breathe, he or she would not be able to speak in the event of a true laryngospasm. The other items listed are more representative of bronchospasm . A patient experiencing laryngospasm may not be moving any air and may not even experience stridor. In the event of partial laryngospasm, high-pitched stridor, tracheal tub, and patient anxiety or agitation are common
What is the rule for maintenance iv fluid administration?
First 10kg = 4 mL/kg/hr
Next 10kg = 2mL/kg/hr
Weight > 20kg = 1ml/kg/hr
What is the rule for maintenance iv fluid administration?
First 10kg = 4 mL/kg/hr
Next 10kg = 2mL/kg/hr
Weight > 20kg = 1ml/kg/hr
In a patient who has undergone pectoralis major pedicle flap procedure, the perianesthesia nurse will suspect failure of the graft if the flap became:
cool and bluish
cool and grey
warm and grey
warm and bluish
cool and bluish
Which of the following nursing actions is contraindicated in patients with a laryngeal mask airway in place?
- tactile stimulation to assess neurological responses
- application of noninvasive BP cuff and EKG electrodes
- auscultating anterior breath and heart sounds
- attaching t-pice with 40% humidified O2
tactile stimulation to assess neurological responses
After successful recovery from malignant hyperthermia crisis, patient reports muscle tightness and weakness in the forearm, as well as severe pain with finger movement. The patient’s forearms are pale and the skin is tight. The perianesthesia nurse priority intervention is to:
- elevate the arms above the level of the heart to assist venous return
- reassure the patient that this is normal side effect of dantrolene
- apply ice packs to the patient’s forearms to decrease swelling
- maintain the patient’s arm in neutral position
maintain the patient’s arm in neutral position
How many nurses to care for the following: awake and crying 5 year old; an intubated patient unconscious with spontaneous breathing; 2 awake and stable patients; a patient entring PACU?
4
Patient s/p breast mastectomy and TRAM flap reveals pale, cool flap that does not bleed when stuck with a needle. Perianesthesia nurse suspects:
venous thrombosis
arterial thrombosis
vasoconstriction
vasodilation
arterial thrombosis
Patient with history of malignant hyperthermia can safely receive?
succinylcholine
nitrous oxide
sevoflurane
isolfurane
nitrous oxide
Miscellaneouos CPAN Topics
What are the different types of shock?
Hypovolemic
* d/t hemorrhagic loss that decreases vascular filling pressure
Cardiogenic
* d/t inadequate contractility of cardiac muscle d/t blunt cardiac injury or MI
Obstructive
* d/t obstruction of the great vessels of the heart (e.g. tension pneumothorax and cardiac tamponade)
Distributive = Vasogenic
* causes vascular system abnormality and SIRS activation (e.g. neurogenic d/t spinal cord injuries, anaphylactic, septic)
Miscellaneous CPAN Topics
What is the treatment for patient’s with blood loss hemorrhage (hypovolemic shock)?
3:1 rule
Replace with 3 mL crystalloid for each 1 mL of blood loss
What is spinal shock?
Spinal shock is a form of neurogenic shock characterized by loss of motor, sensory, autonomic, and reflex activity below the level of lesion.
Miscellaneous CPAN Topics
What are the possible causes of neurogenic shock?
- acute spinal cord injury
- paraplegic or quadriplegic and have a full bladder
- brain concussion or contusion of the basal regions of the brain
- spinal cord injury above T6
3 & 4 can be direct cause of loosing sympathetic vasomotor tone
Miscellaneous CPAN Topics
What are the cascade of events in neurogenic shock?
increase vascular capacity => decreases mean systemic pressure => decreases venous return to the heart => sympathetic nervous system causes vasoconstriction to maintain vascular tone => lost of sympathetic enervation => parasympathetic nerves dominate causing vascular dilation (or venous pooling)
Miscellaneous CPAN Topics
How does neurogenic shock compare to hypovolemic shock?
The clinical presentation in neurogenic shock is different from that in hypovolemic shock even though the blood pressure is low. The patient is frequently bradycardic, and the skin is warm, dry, and flushed. Hemodynamic monitoring reveals a decrease in cardiac output as a result of a decrease in resistance in arteriolar vasculature and also a decrease in venous tone.
Miscellaneous CPAN Topics
What are the 2 phases of septic shock?
First phase or hyperdynamic response - high cardiac output and a low systemic vascular resistance
Second or hypodynamic response - low cardiac output and an extremely high systemic vascular resistance (classic shock picture)
First & Second phases known as early shock when patient’s skin is pink, warm, and dry because of the increased cardiac output and peripheral vasodilation. This progresses to fluid leaks from vascular compartment, and patient develops relative hypovolemia with decreasing cardiac output and increasing peripheral vasoconstriction.
Clinical manifestations of late shock are cold and clammy skin, decreased cardiac output, severe hypotension, and extreme vasoconstriction.
C4 level (and higher) injury likely to need mechanical ventilation d/t phrenic nerve involvement.
Miscellaneous CPAN Topics
Care for patients with C3, C4, C5 procedures
If the surgical procedure involves C3, C4, or C5, respiratory movements should be monitored because the diaphragm muscle is innervated by the spinal outflow from these vertebrae. The patient with this nerve deficit has a lack of diaphragmatic excursion and shortness of breath and uses the intercostal and accessory muscles in breathing. If these symptoms appear, oxygen should be administered, and assistance in ventilation may be necessary.
Miscellaneous CPAN Topics
What is the neurological assessment for patient who had a halo traction?
Patients in halo traction should be monitored for any deficiency in the sixth cranial (abducens) nerve. Any decrease in the lateral movement of the eye is indicative of injury to the abducens nerve.
Miscellaneous CPAN Topics
Arterial vs. Venous Thrombosis in microvascular tissue transfer
Arterial Thrombosis - pale cool flap that does not bleed when stuck with a needle
Venous Thrombosis - congested warm mottled flap that continuously oozes dark blood. Venous thrombosis is more commonly encountered but is not an immediate threat.
Any change in skin color from the normal baseline assessments that indicate imminent occlusion should be reported to the surgeon immediately.
Miscellanous CPAN Topics
What is Beck’s Triad?
increased CVP
muffled heart tones
pulsus paradoxus (sbp drops by 10% or more during inspiration)
Signs and symptoms of cardiac tampondade
Miscellaneous CPAN Topics
What are physiologic signs of cocaine stimulant abuse?
changes in temperature regulation
pupil dilation
tachycardia
cardiac arrhythmias
diaphoresis
nausea
anxiety
Abuse can cause psychosis, hallucination, restlesness, agitation
Miscellanous CPAN Topics
What are the symptoms of cocaine stimulant withdrawal?
depression
tiredness
insomnia
unpleasant dreams
increased appetite
decreased cognition, and movement
Unlike ETOH or benzo, stimulant withdrawal is not life-threatening.
Miscellaneous CPAN Topics
Shoulder pain after thoracotomy or VATS (video assisted thoracic surgery)
Shoulder pain on one side can occur after both thoracotomy and VATS and is thought to be primarily referred pain of diaphragmatic irritation transmitted by phrenic nerve afferents. Other factors to consider include patient position during the surgery and whether a major bronchus transection occurred. Shoulder pain occurs even when the patient receives TEA, so the patient may require anti-inflammatory drugs with or without opioids. Shoulder pain is usually temporary and is often resolved completely by the second postoperative day.
