TEST 1 - POWERPOINTS Flashcards
DEFINITION: art and science of treating diseases, injuries, and deformities by operation and instrumentation
SURGERY
4 PARTS OF Perioperative Nursing
- preoperative care
- intraoperative care
- post-anesthetic care
- post-operative care
5 PARTS OF PREOPERATIVE CARE
a) Client interview
b) Nursing assessment
c) Pre-op teaching
d) Legal preparation
e) Pre-op checklist
3 CONSIDERATION IN PRE-OP NURSING HISTORY
- Previous experiences with Sx (surgery) and anesthesia
- Allergies, meds, age, nutrition
- Past medical history
3 COMPONENTS OF PRE-OP PHYSICAL EXAM
- Mobility (side weaknesses)
- Systems: head to toe
- Lab work/test results
make sure results are back before surgery and abnormalities reported to physician
PRE-OP RISK FACTORS
- Meds
- Physical/mental impairments
- Mobility limitations (side weaknesses)
- Smoking, alcohol use, street drugs (risk of withdrawal symptoms)
- Occupation
- VS, Wt, Etc. (obesity-related healing complications such as dehiscence)
- Infection, nausea, fever
PRE-OP TEACHING (5 items)
- Food and fluid restrictions (npo)
- Medications, if any, permitted
- Any need for surgical site prep (surgeon specific)
- Written instructions
- Post-op expectations (tubes, mobility restrictions, pain management, choices e.g. IV, epidural, NG tube)
PRE-OP TEACHING: NUTRITION
3 CONSIDERATIONS
- Most surgeries require NPO after midnight
- Increase diet slowly
- Nausea is common—there are medications to help with this
PRE-OP TEACHING: AMBULATION
4 CONSIDERATIONS
- Ambulate early
- May have immbolizers, have to use assistive devices
- Leg exercises
- May have to wear antiembolism stockings postoperatively
PRE-OP TEACHING: BREATHING
3 CONSIDERATIONS
- Perform deep breathing and coughing exercises
- Splinting
- Use of incentive spirometer
PRE-OP TEACHING: GROOMING
5 CONSIDERATIONS
- Take a bath or shower morning of surgery
- Remove nail polish, artificial fingernails, hair clips, and jewellery before surgery
- Dentures and eyeglasses will be removed and stored during surgery
- Remove prosthetics
- No contact lenses permitted
PRE-OP TEACHING: MEDICATIONS
2 CONSIDERATIONS
- Take preoperative medication as ordered
- Stop taking prescribed medications, OTC medications, and herbal remedies as suggested by the physician, anaesthesiologist, or surgeon
PRE-OP TEACHING: PAIN CONTROL
2 CONSIDERATIONS
- Ask for pain medication as needed
2. Types of pain control (epidural, PCA)
INFORMED CONSENT
9 KEY COMPONENTS
- Name of procedure/surgery
- Description of procedure/surgery
- Person performing the procedure/surgery
- Benefits of procedure/surgery
- Potential risks and adverse effects of procedure/surgery
- Approximate length of time for procedure/surgery
- Approximate length of time needed for recovery
- Alternative treatments
- Consequences of refusing treatment
NURSE’S LEGAL ROLE WITH INFORMED CONSENT
act as a WITNESS to verify that the person who signed the consent is the client so named or the client’s legal guardian
NURSE’S ETHICAL ROLE WITH INFORMED CONSENT
act as the client’s advocate, ensures that the client understands the information and that the form has been signed and witnessed before the client receives preoperative medication
Begins immediately after surgery and continues until the client is discharged
POST-OP CARE
Postanesthesia discharge criteria
- Client awake (or baseline)
- Vital signs stable
- No excess bleeding or drainage
- No respiratory depression
- Oxygen saturation > above 90%
- Pain controlled
- Report given to receiving recipient (nurse from other units)
5th vital sign
Pain
DOCUMENTATION SAMPLE (POST-OP ASSESSMENT)
09:30 hrs: Received client from recovery awake and oriented x 3 spheres. Vital signs within normal limits. Client rates pain as a 1/10. Abdominal dressing dry and intact. Jackson pratt in situ (in place) draining sanguineous fluid. NG tube in situ and draining small amount of yellowish drainage. Foley catheter in situ and draining clear yellow urine, 350 cc in drainage bag. IV infusing well at 125 cc/hr of NS, 650 TBA (to be absorbed). IV site intact and patent. —————————————-MWalsh, RN
4 POST OP EXERCISES
- Deep breathing and coughing
- Turning, ambulation
- Incentive spirometer
- Leg exercises
8 CRITERIA FOR Ambulatory surgery discharge criteria
- All PACU discharge criteria met
- No IV narcotics for last 30 minutes
- Minimal nausea and vomiting
- Pain controlled
- Voided (if appropriate to surgical procedure/orders)
- Able to ambulate if age-appropriate and not contraindicated
- Responsible adult present to accompany client (not to drive home - sedatives can be in the body for up to 24 hours post-op)
- Discharge instructions given and understood
WHAT KIND OF WOUND? The skin is cut by a sharp object, usually a knife or razor. This type of wound may be deep, but will usually heal quickly.
INCISION
WHAT KIND OF WOUND?
This type of wound is caused by a jagged edge, the skin has been torn, rather than cut. This wound will take longer than an incised to heal and leave a scar.
LACERATION
WHAT KIND OF WOUND?
This type of wounds are caused by contact with a rough surface, the skin has been ground away. The wound is shallow, but the area damaged can be extensive. These wounds have the highest risk of contamination by foreign material and objects. Thus requiring extensive cleaning before dressing.
ABRASION
WHAT KIND OF WOUND?
Also commonly referred to as bruising, although the outer layer of skin may appear undamaged, there may have been extensive damage to underlying structures. Blood accumulates under the skin causing localised swelling.
CONTUSION
WHAT KIND OF WOUND?
Caused by sharp pointed objects. These wounds appear very small, however they are deep. Frequently structures that lie deep beneath the surface have been damaged.
PUNCTURE
What is the “healing ridge”? What complications could occur as a result of the body’s failure to form a healing ridge?
- an indicated ridge that normally forms deep to the skin along the length of a healing wound
- lack of a healing ridge can lead to wound dehiscence or infection.
primary purpose of wet-to-dry dressings is to _________ __________ a wound
mechanically debride
What is the purpose of wound packing?
- to debride the wound bed of dead tissue during healing
- to absorb the exudate
- to keep the sides of the wound from touching and mending together
What precautions must be implemented when packing a wound?
- moisten the packing material with a noncytotoxic solution such as normal saline
- never use cytotoxic solutions (eg. povidone-iodine) to pack a wound
- if using woven gauze, fluff it before packing it into the wound
- loosely pack wound
- do not let packing material drag or touch surrounding tissue before you put it in the wound
- fill all the wound dead space with packing material
- pack the wound until you reach the wound surface, never pack the wound higher
WHICH STAGE OF PRESSURE ULCER?
- Change in temperature (warmth or coolness)
- Tissue consistency (firm or boggy feel)
- Sensation (pain, itching)
- Persistent redness, blue or purple hues
I
WHICH STAGE OF PRESSURE ULCER?
- Partial-thickness skin loss
- Abrasion, blister or shallow crater
II
WHICH STAGE OF PRESSURE ULCER?
- Full-thickness skin loss
- Damage or necrosis of subcutaneous tissue
- Deep crater with or without undermining of adjacent tissue
III
WHICH STAGE OF PRESSURE ULCER?
- Full-thickness skin loss with extensive destruction, tissue necrosis
- Damage to muscle, bone, or supporting structures (tendon, joint capsule)
- Undermining and sinus tracts may be present
IV
Factors Affecting Wound Healing
- Tissue perfusion and oxygenation
- Nutritional status (obesity causes potential dehiscence)
- Infection
- Diabetes Mellitus
- Corticosteroid therapy
- Chemotherapy and radiation
- Age (comorbidities)
- Smoking (deoxygenation)
- Substance abuse, alcoholism
- Stress (physiological and psychological)
- Immunosuppression
- Systemic conditions (renal, hepatic disease, sepsis, cancer)
- Hematopoietic disorders
WHICH PHASE OF WOUND HEALING? Coagulation
Hemostasis phase
WHICH PHASE OF WOUND HEALING?
- ~ 3 days
- Leukocytes → clean up
- Macrophages → repair
Inflammatory stage
WHICH PHASE OF WOUND HEALING?
- 2-3 weeks
- Epithelialization
- new growth cells are created
Proliferative stage
WHICH PHASE OF WOUND HEALING?
- 1 year or more
- Collagen becomes stronger
- scar tissue forms
Remodeling stage
WHAT KIND OF WOUND?
- Dead tissue
- Usually has to be removed to enable healing
- Necrotic tissue (destruction)
- Black in colour
- Also common in stage III and IV pressure ulcers
BLACK
WHAT KIND OF WOUND?
- Death of subcutaneous fat tissue
- Muscle degeneration
- Yellow, cream-coloured, or gray necrotic slough, usually with purulent drainage
YELLOW
WHAT KIND OF WOUND?
granulation
RED
WHICH KIND OF DRESSING? (right on incision)
PRIMARY
WHICH KIND OF DRESSING? (on top of the primary)
SECONDARY
WHICH Intention of Wound Healing?
- Tissue is cleanly cut
- Staples or sutures
- Margins are reapproximated
- New capillary circulation bridges wound in 3-4 days
- Most susceptible to infection during the first 4 days
FIRST
WHICH Intention of Wound Healing?
- Occurs when a wound is left open
- Formation of granulation tissue from bottom
- Allowed to heal from the bottom up
- Eventual epithelialization from the sides
- Used for burns, infected wounds, deep pressure ulcers
SECONDARY
WHICH Intention of Wound Healing?
- Sometimes called delayed primary intention
- Surgical wounds left open for 3-5 days to allow edema or infection to diminish
- Then the wound edges are sutured or stapled closed
TERTIARY
6 Parts of Wound Inspection
- Colour, odour
- Edema
- Drains
- Exudate, amount
- Integrity
- Measure (length, width, depth)
ALWAYS Cleanse in a direction from ___________ contaminated area to ____________ contaminated
least
most
7 Characteristics of the Perfect Dressing
- Easily removed
- Removes excess exudate and toxins
- Provides thermal insulation
- Is free of particulates
- Allows gaseous exchange
- Protects from secondary infection
- Maintains humidity at a good level
Wound Documentation
- Appearance of dressing and wound:
- Colour
- Odour
- Drainage (amount, type)
- Wound characteristics
- Cleaning solution used
- Dressing material used to redress
- Client tolerance
DOCUMENTATION SAMPLE FOR WOUNDS
10:15 hrs: Removed serosanguineous soaked abdominal and 3 (4x4) dressings from right lower quadrant incision. Incision well approximated. Healing ridge present. Staples intact. Incision cleansed with normal saline and redressed with 3 dry (4x4s) and one abdominal dressing. Client tolerated procedure well.——————-MWalsh, RN
WOUND IRRIGATION: ____-_____ ml syringe with _____-_____ gauge needle = ~ ____-____ psi
30-35
18-19
8-11
When irrigating, all solution flows from ____________ contaminated to _____________ contaminated area
least
most
TRUE OR FALSE? cytotoxic solution should be used to moisten packing material
FALSE
use N/S because cytotoxic solution can cause irritation
When you have a drain and a suture line, which do you clean first?
Suture line - least contaminated - always clean first
DOCUMENTATION SAMPLE FOR SUTURE REMOVAL
21:00 hrs: 10 interrupted sutures removed as per orders. Incision cleansed with NS. No puffiness noted. Small reddened area at proximal end. 5 ½ inch steri-strips applied. Client tolerated well. —————————————M. Walsh, RN
STAPLE REMOVAL
If there is concern that the wound is going to re-open, remove every ____________ staple to evaluate healing before removing all
second
SUTURE REMOVAL - TRUE OR FALSE?
Remove suture and pull contaminated stitch/knot through the tissues
FALSE
never pull contaminated suture through tissue
2 Types of Wound Infection
- Aerobic wound infection
* Anaerobic wound infection
8 SIGNS AND SYMPTOMS OF WOUND INFECTION
- Localized inflammation
- Tenderness
- Warmth, odour
- Purulent drainage
- Chills
- Malaise
- ↑ WBC
- Fever
WHICH TYPE OF CULTURE?
- AIR
- Grow in superficial wounds exposed to the air
- Use culture tube with swab and transport medium for culture
AEROBIC
WHICH TYPE OF CULTURE?
- NO AIR
- Grow deep within body cavities, where oxygen is not normally present
- Use culture tube with swab, tube contain carbon dioxide or nitrogen gas
ANAEROBIC
INDICATES SUPERFICIAL SWABBING - NERDS
N Non-healing E Exudate R Red & bleeding D Debris S Smell
INDICATES DEEP SWABBING - STONES
S Size is bigger T Temperature increases O Os (probes or exposed) - opening, eg. bone N New breakdown E Exudate, erythema, edema S Smell
Cultures are done to ____________ organisms within an infection in order to _________ it appropriately
identify
treat
C&S
culture and sensitivity
3 REASONS TO OBTAIN A CULTURE?
- If topical treatment not effective
- If wound is not progressing toward healing as expected
- If systemic treatment required for deep infection (fever, chills, malaise, WBC)
To obtain a culture, swab the __________ looking tissue in the wound bed
healthiest
TRUE OR FALSE?
CULTURE PUS, SLOUGH, OR ESCHAR
FALSE
4 CAUSES OF ULCERS:
- Incontinence
* Friction and shear
* Immobility
* Poor nutrition (lack of adipose tissue)
Complications of Wound Healing
- Hemorrhage
- Infection
- Dehiscence
- Evisceration
- Fistula formation
DEFINITION: Separation or opening of wound layers
Dehiscence
DEFINITION: Separation of wound layers with the protrusion of abdominal organs through the wound layers
Evisceration
DEFINITION: Soft, pink, fleshy projection of tissue that forms during the healing process in a wound not healing by primary intention
Granulation tissue
DEFINITION: Termination of bleeding by mechanical or chemical means or by the coagulation process of the body
Hemostasis
DEFINITION: An overgrowth of scar tissue at the site of skin injury, such as a wound or surgical incision
Keloid
DEFINITION: Scab or dry crust that results from excoriation of the skin
Eschar
DEFINITION: Process by which epidermal cells migrate over the wound’s surface to close the top of the wound (cell growth occurring)
Epithelialization
DEFINITION: Redness or inflammation of the skin or mucous membranes, result of dilation and congestion of superficial capillaries, blanching and non-blanching
Erythema
DEFINITION: Injury to the surface of the skin or other part of the body caused by scratching or abrasion
Excoriation
DEFINITION: Any fluid that has been extruded from a tissue or its capillaries, more specifically because of injury or inflammation
High in protein and white blood cells
Exudate
DEFINITION: finely dissolved drug particles in a liquid medium must be shaken. when left standing, particles settle to bottom of container; not used intravenously
SUSPENSION
DEFINITION: clear fluid containing water and alcohol; usually has sweetener added
ELIXIR
DEFINITION: special coatings or ingredients that control how fast the drug is released from the pill into your body. This may allow you to take certain medications only once or twice a day, instead of more often
EXTENDED RELEASE
Appropriate to crush:
LARGE TABLETS THAT ARE DIFFICULT TO SWALLOW
Never crush:
- Capsules
- Enteric-coated
- Long-acting
- Slow-release
When is it appropriate to halve a tablet or caplet?
- Can be broken either using a gloved hand or a cutting device
- Tablets must be pre-scored
What important aspects must be considered when preparing and administering medications to the pediatric population?
- Liquid forms are preferable
- Mixing with sweet tasting substances (except honey)
- Don’t mix with essential food item
- Use calibrated items to measure accurately
Where can topical medications be applied?
- Skin
- Mucous membranes:
- Eyes
- Ears
- Nose
- Vaginal
- Rectal
- sublingual
What are the adverse effects of administering otic medications that are not at room temperature?
failure to install ear drops or irrigating fluid at room temperature may cause vertigo or nausea
How would you recognize that the client is experiencing rebound effect with nasal instillation?
patient is unable to breathe easily through nasal passages and mucosa appears swollen, and congestion is unrelieved
S & S of dysphagia
- abnormal volitional coughing
- drooling
- one-sided drooping
- red face
- pain while swallowing
- hoarseness
- unexpected weight loss
- feeling of food stuck in throat
- recurring chest infections
- difficulty completing a meal
Nursing Responsibilities WITH MED ADMIN
Know the drug’s purpose, normal dosage and route, common side effects, time of onset and peak action, and nursing implications
WHICH FORM OF MEDICATION?
- Handheld devices
- Disperses med through an aerosol spray, mist, or fine powder
- Penetrates lung airways
- Alveolar-capillary network absorbs medication rapidly
Metered-dose Inhalers (MDI)
WHICH FORM OF MEDICATION?
- Do not contain propellant
- Client’s inhaled breath pulls drug into the airway
- Do not shake
- Has an external counter
- Some require a rotation to load drug, others require insertion of a capsule or a disk
Dry Powder Inhaler (DPI)
WHICH FORM OF MEDICATION?
- Process of adding medications or moisture to inspired air
- May improve clearance of pulmonary secretions
- Inhaled into the tracheobronchial tree and possible into the bloodstream via alveoli
Small-Volume Nebulizers
WHICH FORM OF MEDICATION?
Most sensitive organ to apply medication
OPTHALMIC MEDICATION
TRUE OR FALSE? Conjunctival sac is much less sensitive therefore more appropriate site for medication instillation
TRUE
Nursing Considerations with Ophthalmic Medications
- Must warm medication prior to giving if kept in the fridge
- Position client supine or head slightly hyperextended
- Wipe clean from inner to outer canthus if crusts or drainage are present
Nursing Considerations with Otic Medications
- Must instill the medication at room temperature
- Position client either side-lying or sitting with head tilted
- Pull the pinna in appropriate direction r/t age of client
- If wax has become impacted, ear irrigation may be needed
- Client must remain in side-lying position 5-10 minutes post instillation
Nursing Considerations with Ear Irrigations
- If impacted with cerumen, may have to administer 1-2 gtts of mineral oil bid x 2-3 days prior to the irrigation
- If vegetable matter is occluding, do not irrigate
- Fill 50cc syringe
Nursing Considerations with Nasal Administrations
- Client should remain in supine position x 5 minutes post delivery
- Assess for rebound effect
Nursing Considerations with Vaginal Medications
- Insert application 5-7cm
- Persist with treatment even during menstruation
- Ask pt to remain in lithotomy position for 10 minutes
- Always use water-soluble lubricant with suppository insertion
Nursing Considerations with Rectal Medications
- Ask client to remain on side x 5 minutes
- Insert ~ 4 inches for adults, ~2 inches for infants/children
- Suppositories may be administered through a colostomy
Common med admin errors:
- Inaccurate prescribing
- Giving the wrong drug, route, time interval
- Giving extra doses
- Failing to give drug
