Mod 1 Flashcards
In the immediate postoperative period what is the first-line route of administration of analgesic delivery?
IV
What can be applied directly over the injection site prior to painful needle sticks?
Local anesthetic such as EMLA and L.M.A.X. ( lidocaine 4%)
What is the difference between tropical and transdermal drug delivery?
Transdermal requires drug absorption into the systemic circulation and tropical agents produce effects on the tissue immediately
How are intranspinal analgesic delivered?
By inserting a needle into the subarachnoid space or epidural space and injecting the analgesic agent or treading a catheter through a needle and taping it in place
When are temporary epidural catheters for acute pain management removed?
After 2-4 days
What is the most common opioids administered intraspinally?
Morphine
Fentanyl
Hydromorphone (dilaudid)
And are combined with a local anesthetic, most often ropivacaine (Naropin) or bupivavaine (marcaine)
What is the difference between opioid tolerant and opioid naïve?
Opioid naive: patients who are not chronically receiving opioid analgesics on a daily basis; and
Opioid tolerant: patients who are chronically receiving opioid analgesics on a daily basis.
What is authorized advent controlled analgesia?
When a patient is unable to use the PCA equipment a nurse or capable family member is authorized to manage the pain using the PCA
What is considered one of the safest and best tolerated analgesic agents?
Acetaminophen (Tylenol)
What is the most serious complication when taken acetaminophen?
Hepatotoxicity ( liver damage)
What is the primary underlying mechanism of NSAID (aspirin, IBUPROFEN and naproxen)?
Gastric ulceration and reduction in the GI productive prostaglandins
Administer small does for short time
What are the unwanted side effects of opioids?
Constipation, nausea, sedation and respiratory depression
What is the goal of titration?
Is to use the smallest does that provides satisfactory pain relief with the fewest adverse effects
What is the first sign of withdrawal?
Diaphoresis (sweating)
What is the recommended approach for treatment of pain in all types of pain and all age groups?
Multimodal analgesia
Equal analgesia
Equianalgesia
What is a normal response that occurs with repeated administration of an opioid for 2 or more weeks
Physical dependence
Sensitivity to pain is known as what?
Hyperalgesia
OHI is a result of what?
Changes in the central and peripheral nervous system that produces increased transmission of nociceptive signals
What is the opioid is the standard to which all other opioids are compared?
Morphine
Morphine is a hydrophilic drug which accounts for what?
It’s slow onset and long duration
What does hydrophilic mean?
Readily absorbed in aqueous solution
Fentanyl (sublimaze) is lipophilic opioid and as such it has what kind of onset and duration?
A fast onset and short duration
How often should a fentanyl duragesic be changed?
48 to 72 hours
What do you need to be careful of when it comes to a fentanyl transdermal patch?
The application of heat because it speeds up absorption of the transdermal fentanyl which can lead to life threatening respiratory depression
What medication has been removed or severely restricted on hospital formularies for the treatment of pain in efforts to improve patient safety?
Meperidine (Demerol)
What are the most common adverse effects of opioids?
Constipation, nausea, vomiting, pruritus and sedation
Respiratory depression is less common but most feared
In postop patients ileus can become a major complication
What is given to reverse significant opioid induced respiratory depression?
Naloxone (narcan)
When giving narcan for respiratory depression what should you do?
It should be diluted and titration led very slowly to prevent severe pain, hypertension, tachycardia, ventricular dysthymias, pulmonary edema and cardiac arrest
0.4 mg of naloxone and 10 mls of NS administer 0.5 ml over 2 min
What are first line analgesic agents for neuropathic pain?
Anticonvulsants (anti seizure drugs) gabapentin (neurontin) and pregabalin (lyrica)
What contains the highest amount of water?
Muscle
Skin
Blood
Body fluids are contained in what compartments?
Intracellular space (fluid in the cells) Extra cellular space (fluid outside the cells)
What is third space fluid shift?
Loss of the ECF into space that does not contribute to equilibrium between the ICF and the ECF
What is early evidence of third space fluid shift?
Decrease urine output despite adequate fluid intake
Other S/S that indicate intravascular fluid volume deficit FVD are: Increased HR Decreased BP Decreased central venous pressure Edema Increased body weight Imbalanced intake and output
Third space fluid shift occurs in patients who have what?
Hypocalcemia Decreased iron intake Severe liver disease Alcoholism Malabsorption Immobility Burns Cancer
What is the usual daily urine volume in the adult?
1 to 2 L
1500 ml per day output
What are the chief solute a in sweat?
Sodium, chloride and potassium
How much approximate fluid is lost through the skin as insensible perspiration?
500 ml/day
Lungs normally eliminate water vapor at a rate of what?
300 mls per day
What is the normal intake?
2500 mls
Water 1000 mls
Food 1300
Water of oxidation 200
How much water is lost through stools?
200 mls
What is the best indicator of I/Os?
Daily weights
1 oz is how many mls?
30 mls
What is osmolality?
It is the concentration of fluid that affects the movement of water between fluid compartments by osmosis
What is the normal BUN?
10-20 mg/dl
What are factors that increase BUN?
Decreased renal function GI bleed Dehydration Increased protein intake Fever Sepsis
Decreased BUN End stage liver disease Low protein diet Starvation Conditions with expanded fluid volume
What is the normal creatinine labs?
0.7-1.4 mg/dl
Why is creatinine a better indicator of renal function?
Because it does not very with protein intake and metabolic state
What is the normal hematocrit labs?
42%-52% for males
35%-47% for females
What conditions increase and decrease hematocrit?
Increase:
Dehydration
Polycythemia
Decrease:
Over hydration
Anemia
When does FVD or hypovolemia occur?
When the loss of ECF volume exceeds the intake of fluid
What causes FVD hypovolemia?
Vomiting diarrhea GI suctioning Sweating Third space fluid shifting Diabetes insipidus
What are the signs and symptoms of FVD hypovolemia
Acute weight loss Slow skin turgor Oliguria Concentrated urine Prolonged capillary refill Low BP low CVP Flattened neck veins Dizziness Confusion Elevated pulse Sunken eyes Muscle cramps Cool clammy skin Pale skin
What are the signs and symptoms of FVE hypervolemia?
Acute weight gain Peripheral edema Ascites Distended neck veins Crackles SOB Bounding pulse Cough Increased respiratory rate
What are contributing factors to potassium deficit hypokalemia?
Diarrhea Vomiting Gastric suctioning Corticosteroid administration Diuretic Bulimia Starvation
What are S/S of potassium deficit hypokalemia?
Fatigue Anorexia Nausea Vomiting Muscle weakness Polyuria Decreased bowel motility Ventricular a systole fibrillation Paresthesias Leg cramps Low BP Ileus Hypoactive reflexes
What will you see on an ECG with potassium deficit hypokalemia?
Flattened T waves, prominent U waves, ST depression, prolonged intervals
What will you see on an ECG with potassium excess hyperkalemia?
Tall tented T waves, prolonged PR intervals and QRS duration, absent p waves,ST depression
When is a fluid challenge test done?
When the health care provider need to determine whether the depressed renal function is caused by reduced renal blood flow secondary to FVD or from acute tubular necrosis from prolonged FVD
1L of fluid is how much weight?
1 kg or 2.2 lbs
What would you use dextrose 5% in water for?
Fluid loss
Hypernatremia
Special consideration:
Not for long term use
Becomes hypotonic when dextrose metabolizes
Don’t use for resuscitation; can cause hyperglycemia
Use caution in renal and cardiac disease
0.9% sodium chloride NS is used for what?
Shock Hyponatremia Blood transfusion Resuscitation Fluid challenge Metabolic alkalosis Hypercalcemia Patients with diabetic ketoacidosis
Don’t use on patients with heart failure, edema, hyernatremia; can lead to overload
How is peripheral edema monitored?
By measuring the circumstances of the extremity with tape marked in millimeters
What is the most abundant electrolyte in the ECF?
Sodium
What are normal concentration of sodium?
135-145 mEq/l
Hyponatremia cause the cell to do what?
Swell as water is pulled in from ECF
Hypernatremia causes cells to shrink
To maintain potassium Balance what must be functioning and why?
The renal system because 80% of the potassium excreted daily leaves the body by way of the kidneys
What are sources of potassium?
Fruit juice Bananas Melons Citrus fruit Fresh and frozen vegetables Lean meat Milk Wholegrains Avocado Chocolate Nuts
If an infusion pump is not used to administer potassium what could happen?
If someone does an IV push or intramuscularly it could replace the potassium too quickly and stop the heart
A patient with a potassium infusion has less than 20 mls per hour for 2 consecutive hours what should you do?
Stop the infusion
No pee no K
When should increased potassium levels be anticipated?
When extensive tissue trama has occurred
Burns
Crushing
Severe infection
Lysis of malignant cells after chemotherapy
When potassium levels are dangerously high over ( over 7mEq/l) what is Necessary to administer?
IV calcium gluconate
Although calcium gluconate is not injectable what do you want to monitor for as a result of the rapid IV administration?
Blood pressure to detect hypotension
When monitoring patients for hyperkalemia where should the pulse be taken?
Apical
What is the normal total calcium level?
8.6-10.2 mg/dl
Hypocalcemia is common in what patients?
Patients with renal failure because these patients have elevated serum phosphate levels
What is the most characteristics manifestation of hypocalcemia and hypomagnesemia?
Tentany
What is chvostek’s sign?
A twitching of muscles enervated by facial nerve when the region that is about 2 cm anterior the earlobe is tapped
What is trousseau sign?
Can be elicited by inflating a blood pressure cuff on the upper arm to about 20 mm HG above systolic pressure with in 2-5 min there is carpal spams
What may occur because hypocalcemia increases irritability or the central nervous system as well as peripheral nerves
Seizures
Acute symptomatic hypocalcemia is life threatening and requires prompt treatment with IV administration of what?
Calcium salt
What should calcium be deluted with so it doesn’t cause cardiac arrest?
D5W and administered as slow as a IV blouse or a slow IV infusion using a pump
What foods are high in calcium?
Milk products Green leafy vegetables Canned salmon Sardines Fresh oysters
Anaphylactic shock
Circulatory shock state resulting from a severe allergic reaction producing an overwhelming systemic vasodilation and relative hypovolemia
Hypovolemic shock
Shock state resulting from decreased intravascular volume due to fluid loss
Neurogenic shock
Shock states resulting from loss of sympathetic tone causing relative hypovolemia
Septic shock
Circulatory shock states resulting from overwhelming infection causing hypovolemia
Systemic inflammatory response syndrome (SIRS)
Overwhelming inflammatory response in the absence of infection causing relative hypovolemia and decreased tissues perfusion
Shock
A clinical syndrome that results from inadequate tissue perfusion creating an imbalance between the delivery of and requirement for oxygen and nutrients that support cellular function
What response is common in all types of shock?
Hypoperfusion of tissue
Hypermetabolism
Activation of the inflammatory response
What must the mean arterial Pressure (MAP) exceed for cells to receive oxygen and nutrients?
65 mm HG
What is cardiac output?
Is the product of stroke volume the amount of blood ejected from the left ventricle durning systole
How is peripheral resistance determined?
By the diameter of the arterioles
What is the equation to find the MAP?
Means arterial= cardiac output X peripheral resistance
How do the kidneys regulate BP?
By releasing renin
What are the stages of shock?
Compensatory stage 1
Progressive stage 2
Irreversible stage 3
Chances is survival increase when shock is identified and aggressively treated within how many hours?
6 hours
Especially septic shock
What happens in the compensatory stage of shock?
The BP will remain WNL vasoconstriction will increase the heat rate, stimulation of sympathetic nervous system release catecholamines ( epinephrine/ norepinephrine). The body shunts blood to the brain, heart and lungs causing the skin to become cool and pale bowel sound to be hypo active, and urine out put to decrease
What are the nursing intervention for shock?
IV fluids and oxygen labs ( base deficit and lactic acid levels) blood glucose and serum sodium levels will be elevated
Monitor trends in vital signs
How is pulse pressure calculated?
By subtracting the diastolic measurement from the systolic measurement
What happens during progressive stage shock?
BP can no longer compensate the MAP falls below normal limits
Patients are clinically hypotensive( systolic
What happens in irreversible (or refractory) stage of shock?
The organ damage is so severe that the patient does not respond to treatment and cannot survive
What should be done to manage all types of shocks in all stages?
Support of respiratory function
Fluid replacement
Vasoactive medications to restore vasomotor tone and cardiac function
Nutritional support
What are the types of guild provided to a shock patient?
Crystalstalloids and colloids
Isotonic crystalloid solution are often selected because they contain the same concentration of electrolytes as extracellular fluid (may cause interstitial edema)
Colloids are used to treat hypoperfusion and may cause anaphylactic reaction and patients must be monitored closely
What is a normal central venous pressure?
4 to 12 mm HG or cm H2O
What is the most common shock?
Hypovolemic shock
What is hypovolemic shock caused by?
By external fluid loss, as in traumatic blood loss slot by internal fluid shifts as in severe dehydration , severe edema or ascites
When does cardio genie shock occur?
When the hearts ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues
Why should a fluid bolus never be given rapidly?
Because administration in patients with cardiac failure may result in acute pulmonary edema
(Infants and elderly)
When does circulatory shock occur?
When intravascular volume pools in the peripheral blood vessels
What cause septic shock ( warm shock)?
Widespread infection or sepsis
What are S/S of SIRS?
Temp: >100.4 or 90pm
RR: > 20 breaths per min
WBC: > 12,000 cells/mm
What is neurogenic shock?
Vasodilation occurs as a result of a loss of balance between parasympathetic and sympathetic stimulation
What is neurologic shock caused by?
Spinal cord injury
Spinal anesthesia
Or other nervous system damage
What cause anaphylactic shock?
Severe allergic reaction when patients who have already produced antibodies to a foreign substance develop a systematic antigen antibody reaction
What are the sings and symptoms of anaphylactic shock?
Headache Lightheaded Nausea Vomiting Acute abdominal pain Pruritus Impeding doom Generalized flushing Difficulty breathing Bronchi spasm Cardiac dysthymias Hypotension
What are normal blood glucose levels?
70-110
What are the stages of general anesthesia?
Stage 1: beginning anesthesia
Stage 2: excitement
Stage 3: surgical anesthesia
Stage 4: medullary depression
What might the. Patient experience in stage 1 of anesthesia?
As the patient. Breathes in the anesthetic mixture, warmth, dizziness and feeling of detachment may be experienced. The patient may have ringing, roaring or buzzing in there ears.
what is Stage II of anesthesia characterized by?
characterized by variously by struggling, shouting, talking, singing, laughing, or crying is often avoided if anesthetic administered smoothly & quickly. Pupils dilate, but contract if exposed to light, pulse is rapid, & respiration may be irreg. Pt should not be touched except restraint is needed. (Restraint should never be placed over operative site as this increases circulation to that area & increases potential for bleeding)
when is stage III of anesthesia reached?
is reached by continued administration of anesthetic vapor or gas. The patient is unconscious & lies quietly on the table. Pupils are small but contract when exposed to light. Respirations are regular, pulse rate & volume are normal, skin pink or slightly flushed.
When is stage IV of anesthesia reached?
this stage is reached when too much anesthesia has been administered. Respirations are shallow, pulse is weak & thready, pupils are dilated & no longer respond to light. Cyanosis develops, & without intervention, death rapidly follows. If this stage develops, anesthesia is discontinued immediately & CPR is initiated to prevent death.
what is Malignant hyperthermia?
a rare inherited muscle disorder that is chemically induced by anesthetic agents.
what are the initial symptoms of Malignant hyperthermia?
Tachycardia (>150) is often the earliest sign, along with Sympathetic nervous stimulation that lead to ventricular dysrhythmia, hypotension, decreased cardiac output, oliguria (decreased output), & later, cardiac arrest. With abnormal transport of Ca, rigidity or tetanus like movements occur, often in the jaw. The rise in temp can increase 1-2 C (2-4 F) q 5 minutes. The core body temp can reach or exceed 42 C (104 F) in a short time & must be Properly monitored & recorded
what can you give for Malignant hyperthermia?
Dantrolene sodium (Dantrium)
Diazepam (valium, dizac)
Amnesia; hypnotic; preoperative medication. Good sedation. Prolonged duration. Residual effects for 20-90 hr; increased effect with alcohol.
Kertamine (ketalar)
induction, occasional maintenance (IV or IM). Short acting; patient maintains airway; good in small children and burn patients. Large doses may cause hallucinations and respiratory depression. Need darkened, quiet room for recovery; often used in trauma cases.
Midazolam (versed)
Hypnotic; anxiolytic; sedation; often used as adjunct to induction. Excellent amnesia; water soluble (nopain with IV injection); short acting. Slower induction than thiopental. Often used for amnesia with insertion of invasive monitors or regional anesthesia.
Profofol (diprivan)
Induction and maintenance; sedation with regional anesthesia or MAC. Comes in a glass bottle and is milky white. Rapid onset; awakening in 4-8 min. May cause pain when injected. Short elimination half life 34-64 min
what medications may mask presence of infection by impairing normal inflammatory response?
corticosteroids
