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Med Surg > Test 2 > Flashcards

Test 2 Flashcards

1
Q

Three phases of Perioperative care

A
  1. Pre-operative ( Home, Pre-anesthesia care)
  2. Intra-operative
  3. Post-operative periods (PACU, Post op inpatient care, Home Care)
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2
Q

What is the purpose of Preoperative Assessment and where does it take place?

A

Create a baseline, identify any surgical risk factors: problems with anesthesia, meds, sleep apnea, etc. Get med reconciliation, lab results, psychosocial assessment.
Can be done over phone or in person.

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3
Q

3 elements of consent

A
  1. Information: surgeon explains procedure, risks, concerns, alternatives.
  2. Voluntariness
  3. Competence
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4
Q

Pre-Op Meds - Atropine

Anticholinergics

A
  • Decrease pharyngeal secretions; reduces suction.
  • Reduce anxiety
    Reduce side effects of anesthetic agents.
  • Induce amnesia
  • Reduces gastric secretions
  • adult dose 0.4 mg IM; 30-60 minutes before anesthesia
    SIDE EFFECTS: tachycardia, fever, flushed
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5
Q

Anticholinergics

A

Atropine
Glycopyrrolate (Robinul) - similar to Atropine
Scopolamine- prevents nausea and decreases oral and respiratory secretions (patch behind ear).

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6
Q

Sedatives, hypnotic, anxiolytics

A
  • All are CNS depressants (degree depends on dose)
  • Subclass: benzodiazepines, barbiturates, non-benzodiazepine/ non-barbiturates.
  • Avoid taking other CNS depressants as they have an additive effect .
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7
Q

Benzodiazepines

A
  • Potentate GABA (gamaaminobutyric acid), an inhibitory neurotransmitter that results in CNS depression
  • Decrease anxiety, induce sedation, amnesiac effects.
  • Neuro - muscular relaxation
  • decreased muscle spasms
  • Midazolam (Versed)
  • Lorazepam (Ativan)
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8
Q

Opioids

A

CNS depressant
- Narcotic analgesics: relieves pain, decrease anxiety and causes sedation.
- Used to allay anxiety and diminish amount of anesthesia needed.
Morphine, fentanyl (Sublimaze), hydromorphone, hydrochloride (Dilaudid)

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9
Q

Proton Pump Inhibitors (PPI)

A
  • Omeprazole (Prilosec)
  • Prevents n/v and reflux
  • reduces acidity
  • Peptic ulcer disease prophylaxis
  • prevents stress ulcers
  • prevents aspiration
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10
Q

Antiemetics

A

Ondansetron (Zofran)
- Given before, during, after
- side effects: respiratory depression, lethargy
Metoclopramide (Reglan)
- Before and after surgery to increase gastric emptying
- reduces post op nausea

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11
Q

Antibiotics

A
  • Broad spectrum antibiotics
  • Decrease risk of post op wound infection
  • Given within 1 hr of incision being made and may be continued for 24 hrs post op.
  • *watch for allergies
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12
Q

Sentinal Event

A

An unexpected occurrence involving death or serious physical or psychological injury, or risk thereof (ex: death, fires, wrong site, something left inside, medication errors)

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13
Q

Serious reportable Event (Never events)

A

surgery on wrong body part, wrong patient; patient death associated with a fall, med error, or blood transfusion, surgical fires.

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14
Q

Circulating Nurse responsibilities

A
  • patient advocate
  • watches for break in sterile field
  • Enters all nursing documentation
  • monitor physiological/psychologic status
  • prep patient for transport to PACU or ICU
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15
Q

Intra operative Drugs

A
  • general anesthetics
  • regional anesthetics
  • local anesthetics
  • Monitored anesthesia care (MAC)
  • moderate sedation (former conscious sedation)
  • acupuncture
  • cryothermia
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16
Q

General Anesthetics

A

Anesthetize entire body

  • produce state of unconsciousness by depressing CNS and blocking pain stimuli in cerebral cortex; patient must be intubated
  • TIVA total intravenous anesthesia
  • Balanced anesthesia: combines drugs to complement induction and are used for general anesthesia
  • Inhalant (lungs), intravenous (kidneys/liver), or neuromuscular blocks
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17
Q

Steps of General Anesthesia

A
  1. Preinduction/sedation: (Versaid)- Relaxes body
  2. Induction: Short acting & NM block cause paralysis
  3. maintenance: Long acting, during surgical procedure.
  4. Emergence: Stop admin or reversal to wake right away.
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18
Q

Drugs used during each step of General Anesthesia

A
  1. Preinduction: Benzodiazepines, Opioids, Antibiotics, Aspiration prophylaxis(Reglan, Zantac, Transderm)
  2. Induction: Benzodiazepines, Opioids, Barbituarates, hypnotics, volatile gases.
  3. Maintenance: Benzodiazepines, Opioids, barbiturates, hypnotics, volatile gases, neuromuscular blocking agents
  4. Emergence: Reversal Agents (Anticholinesterases: Prostigmin, Opiod antagonists: Narcan, Benzodiazepine antabonists: Romazicon), supplemental opioids, antiemetics.
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19
Q

Types of General Anesthesia Meds

A
  • Intravenous: barbiturate- thiopental (Pentothat) rapid induction; nonbarbuturate hypnotics- etomidate (Amidate) and propofol (Diprivan)
  • Inhalation: volatile liquids– isoflurane (Forane); desflurane (Suprane), sevoflurane (Ultane)
  • Gaseous Agents: nitrous oxide-potentiate volatile agents speeding induction; reduce total dose; good analgesic potency.
  • Neuromuscular Blocking Agents: facilitate intubation and promote neuromuscular relaxation (paralysis) succinylcholine (Anectine), vecuronium (Norcuron), rocuronium (Zemuron)
  • Reversal: anticholinesterase agents: neostigmine, pyridostigmine.
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20
Q

Types of Regional Anesthesia

A

Spinal: local anesthetic injected into subarachnoid space, involves lower half of body, does not affect consciousness
Epidural: local anesthetic injected into epidural space at T, L, or S.
Caudal - epidural space but in sacral canal
Peripheral nerve block: anesthetizes individual nerves or nerve plexuses
IV regional extremity block: injected into vein to anesthetize limb.

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21
Q

Local Anesthetics

A
  • Topical: applied directly to area to be desensitized. Numbs skin; lidocain cream.
  • Infiltration: injection of local anesthetic into skin or subcut tissue.
  • Field Block: infiltration of anesthetic into area around incision.
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22
Q

Monitored Anesthesia Care (MAC) aka Twilight

A
  • Combination: Propofol, Versaid, Fentanyl
  • Provides anxiolysis, amnesia and analgesia while avoiding a depth of sedation that would require respiratory support.
  • speeds postop recovery and lessens anesthetic risks
  • Physician supervision always required
  • Dedicated monitor for Pt.
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23
Q

Malignant hyperthermia

A
  • catastrophic event
  • Rigidity of skeletal muscles that can result in death. It occurs in susceptible people when they are exposed to certain anesthetic agents.
  • Treat with Dantrolene(Dantrium)- slows metabolism, reduces muscle contraction, and mediates the catabolic processes.
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24
Q

PACU tasks

A

Post Anesthetic Care Unit

  • Airway, Breathing, Circulation
  • LOC
  • Dressings, drains, catheters, IVs
  • Bleeding, Urinary output
  • Get pain under control
  • Temp
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25
Q

4 phases of wound healing

A
  1. Vascular Response: vessels constrict to keep bacteria out and stop bleeding, fibrin meshwork, platelet aggregation.
  2. Inflammatory response: helps to limit bacterial effects and setup environment for tissue repair.
  3. Proliferative Phase: Collagen deposition, epithelialization, granulation tissue depostition, form new blood vessesls.
  4. Maturation Phase (longterm phase): Remodel scar, up to 1 yr or longer, capillaries begin to disappear, scar thins and turns white.
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26
Q

3 Types of Healing

A
  1. Primary: Surgical incision healing
  2. Secondary: Heals from inside out; left open
  3. Tertiary: A primary that opened up or got an infection
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27
Q

Types of pain

A
  1. Cutaneous: skin and subcut tissue; localized; sharp, stinging. Specific part of body.
  2. Somatic: Less receptors; not as localized; not sharp; muscles, bones, ligaments; dull; poorly localized.
  3. Visceral: Deep; pain of body organs; dull, defuse, vague pain. Ex Cholecystitis, Appendicitis.
  4. Referred Pain: Related w/ visceral, organ has no pain sensors; transfers pain to another part body. Ex: Jaw pain from heart attack.
  5. Phantom Limb Pain: Amputations, continue to sense pain after nerve severed.
  6. Neuropathic: caused by damage to nerve fibers; numbness, burn, stab/pin & needles. Ex. Diabetics.
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28
Q

Ceiling Effect

A

Increasing the dose beyond an upper limit provides no greater analgesia. Ex: Aspirin, Tylenol, NSAIDS.
No ceiling on Opioids

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29
Q

Pain control: Tolerance

A

Tolerance occurs when the person no longer responds to the drug in the way that person initially responded.

30
Q

Pain control: Dependence

A

Physical dependence is an expected physiologic response to ongoing exposure to pharmacologic agents, manifested by a withdrawal syndrome that occurs when blood levels of the drug are abruptly decreased

31
Q

Pain control: Addiction

A

A Psychological dependence. A complex neurobiologic condition characterized by aberrant behaviors.

32
Q

Pain control: Rescue dose for break-through pain

A

When pain breaks through before next scheduled dose. Utilize a different drug to get the person by. Ex: alternating tylenol and motrin.

33
Q

Equianalgesia

A

A dose of one analgesic that is approximately equivalent in pain relieving effects to a given dose of another analgesic.

34
Q

Types of Analgesia

A 
Opioid (Narcotics): strongest
Narcotic agonist/antagonists: Moderate
NSAIDS: Cox1 and Cox2
Prostaglandin synthesis inhibitors
Salicylates
Tylenol
35
Q

Adjuvant Agents

A

Treatment that enhances existing med regimen; pharm agent added to a drug to increase the effect.
Not designed for pain meds

36
Q

Adjuvant Agent: Tricyclic antidepressants

A

Elavil- chronic pain

37
Q

Adjuvant Agent: Anxiolytics

A

Valium - relieve muscle spasm

38
Q

Adjuvant Agent: corticosteroids

A

decrease inflammation

39
Q

Adjuvant Agent: Anticonvulsants

A

gabapentin (Neurontin) or pregabalin (Lyrica): neuropathic pain

40
Q

Cholecystitis

A

Inflammation of gall bladder

S&S: Rt upper quad pain, referred pain; back or rt shoulder; epigastric pain; increased WBC; fever.

41
Q

Cholelithiasis

A

Presence of stones

42
Q

Cholangitis

A

Inflammation of bile duct

43
Q

Inracapsular Hip Fracture

A

Located in the joint capsule @ head of femur.

44
Q

Extracapsular Hip Fracture

A

Located outside of capsule where it meets acetabulum.

45
Q

Stages of Bone Healing

A

Stage 1: inflammatory stage: Form hematoma, helps stabilize fracture. 1-3 days.
Stage 2: fibrocartilage formation, 3-14 days
Stage 3: Callus formation, 2-6 weeks
Stage 4: Ossification, 3 wks- 6 mo.

46
Q

Fat embolis: complication after hip fracture

A

A process by which fat tissue passes into the bloodstream and lodges within a blood vessel.

47
Q

Cast Syndrome (Superior Mesenteric Artery Syndrome)

A

Happens with a spica cast; cast around waist. Edema causes pressure against artery and intestines. leads to necrosis of the bowel.

48
Q

Cast Care

A
  • neurovascular assessment
  • assessment for areas of pain of “hot spots” under the cast
  • With hip spica: assess for SMA syndrome: nausea, vomiting, bloating.
49
Q

Reasons for traction

A
  1. Help reduce muscle spasms

2. Help align bone

50
Q

Nociception

A

physiologic process by which information about tissue damage is communicated from the peripheral to the central nervous system (CNS)

51
Q

4 phases of Nociception

A

o Transduction is the conversion of a mechanical, thermal, or chemical stimulus into a neuronal action potential.
o Transmission is the movement of pain impulses from the site of transduction to the brain.
o Perception occurs when pain is recognized, defined, and assigned meaning by the individual experiencing the pain. The brain is necessary for pain perception.
o Modulation involves the activation of descending neurochemical pathways that exert inhibitory or facilitatory effects on the transmission of pain.

52
Q

Comprehensive pain assessment:

A

describing the onset, duration, characteristics, pattern, location, intensity, quality, and associated symptoms such as anxiety and depression. The patient’s beliefs, expectations, and goals for pain management are also assessed.

53
Q

What are the 3 categories that pain meds are divided into?

A

Pain medications generally are divided into three categories: nonopioids, opioids, and adjuvant (coanalgesic) drugs.
o Mild pain often can be relieved using nonopioids
o Moderate to severe pain usually requires an opioid.
o Neuropathic pain often requires adjuvant drug therapy alone or in combination with an opioid or another class of analgesics. Treatment is typically augmented with adjuvant therapies including tricyclic antidepressants, antiseizure drugs, and α2-adrenergic agonists.

54
Q

Characteristics of nonopioids.

A
  • Nonopioids are characterized by an analgesic ceiling, lack of ability to produce tolerance or dependence, and availability without a prescription.
  • Nonopioid pain medications include acetaminophen, aspirin, and NSAIDs.
  • NSAIDs are associated with a number of side effects including bleeding tendencies, gastrointestinal (GI) ulcers and bleeding, and renal and CNS dysfunction.
55
Q

Characteristics of opioids.

A

• Opioids are the strongest analgesics available. Opioids produce their pain-relieving effects by binding to receptors in the CNS, inhibiting the transmission of nociceptive input from the periphery to the CNS.
• Common side effects of opioids include constipation, nausea, vomiting, sedation, respiratory depression, and pruritus.
• Concerns about sedation and respiratory depression are two of the most common fears associated with opioids.
o Sedation is usually seen in opioid-naive patients in the treatment of acute pain.
o Patients most at risk for respiratory depression include those who are opioid naive, are elderly, have underlying lung disease, have a history of sleep apnea, or are receiving other CNS depressants.

56
Q

Adjuvant Analgesic Therapy

A
  • Adjuvant analgesic medications are used alone or in conjunction with opioid and nonopioid analgesics. They include antidepressants, anticonvulsants, α-adrenergic agonists, and corticosteroids.
  • Tricyclic antidepressants enhance the descending inhibitory system and are effective for a variety of pain syndromes, especially neuropathic pain syndromes.
  • Antiseizure drugs affect both peripheral nerves and the CNS, and are effective for neuropathic pain and prophylactic treatment of migraine headaches.
  • Clonidine (Catapres) and tizanidine (Zanaflex) are the most widely used 2-adrenergic agonists and may be used for chronic headache and neuropathic pain.
  • Corticosteroids, including dexamethasone (Decadron), prednisone, and methylprednisolone (Medrol), are used for management of acute and chronic cancer pain, pain resulting from spinal cord compression, and inflammatory joint pain syndromes.
  • Ketamine (Ketalar) is an NMDA receptor antagonist that is potentially useful for blocking mechanisms that lead to or sustain central sensitization.
57
Q

Multimodal treatment examples

A

Antiseizure drugs, tricyclic antidepressants, SNRIs, transdermal lidocaine, and α2-adrenergic agonists will be used for multimodal treatment when opioid analgesics alone do not control neuropathic pain

58
Q

perioperative period

A

This period in the health care continuum includes the time before surgery (the preoperative period), the time spent during the actual surgical procedure (the intraoperative period), and the period after the surgery is completed (the postoperative period)

59
Q

Holding Area

A

conduct the preprocedure verification, assess the patient, and mark the procedure site before transferring the patient into the OR for surgery.
• Procedures such as inserting intravenous (IV) catheters and arterial lines and removing casts may occur here.

60
Q

A balanced technique- General anesthetics

A

using adjunctive drugs to complement the induction, is the most common approach used for general anesthesia.
• Nearly all routine general anesthetics begin with an IV induction agent.

61
Q

Inhalation agents

A

o Administered by an endotracheal tube, a laryngeal mask airway, or a tracheostomy and enter the body via the lung alveoli.
o Complications of inhalation anesthesia include coughing, laryngospasm, bronchospasm, increased secretions, and respiratory depression.

62
Q

Regional anesthesia

A

uses a local anesthetic and is injected near a central nerve (e.g., spinal) or group of nerves (e.g., plexus) that innervate a site distal to the point of injection.
o Spinal and epidural anesthesia are types of regional anesthesia.
o When spinal or epidural anesthesia is used, the patient can remain fully conscious, receive MAC, or choose general anesthesia

63
Q

Surgical Time Out

A

During a surgical time-out, the surgery team will stop all activities right before the procedure to verify the patient identification, surgical procedure, and surgical site. Proper identification will be accomplished by asking the patient to state name, birth date, and operative procedure and location. In addition, the surgical team will compare the hospital ID number with the patient’s own ID band and chart.

64
Q

flumazenil (Romazicon)

A

To reverse severe benzodiazepine-induced respiratory depression, the nurse would administer flumazenil

65
Q

naloxone (Narcan)

A

Naloxone would reverse opioid-induced respiratory depression.

66
Q

The most common cause of postoperative hypoxemia

A

Atelectasis, which occurs as a result of retained secretions or decreased respiratory excursion.

67
Q

Postoperative cognitive dysfunction (POCD)

A

is almost exclusively seen in the older surgical patient and describes a decline in cognitive function (e.g., memory, ability to concentrate) for weeks and months after surgery.

68
Q

The most common cause of postoperative agitation

A

Hypoxemia

69
Q

most common postoperative complications

A

Postoperative nausea and vomiting remain the most common postoperative complications. Risk factors that contribute to their development include gender (female), history of motion sickness or previous postoperative nausea and vomiting, anesthetics or opioids, and duration and type of surgery. treated with the use of antiemetic or prokinetic drugs. Oral fluids should be given only as indicated in the PACU

70
Q

Low urine output (800 to 1500 ml) in the first 24 hours after surgery

A

may be expected, regardless of fluid intake. This low output is caused by increased aldosterone and ADH secretion resulting from the stress of surgery, fluid restriction before surgery, and fluid loss through surgery, drainage, and diaphoresis.

71
Q

Ketamine (Ketalar)

A

Used in asthmatic patients because it promotes bronchodilation
Used in trauma patients because increase HR and cardiac output

Med Surg (20 decks)

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