Test 2 Flashcards
Define the perioperative period
preop, intra op and post op
Diagnostic surgery
diagnose and confirm
used to determine the seriousness of a condition.
biopsy
ablative surgery
remove diseased organ tissue extremity
cures a health problem
appy, amputation, AV node ablation
palliative surggery
to alleviate symptoms, but doesn’t cure
the underlying cause is still there but symptoms are relieved.
(bowel resection with bowel cancer)
reconstructive surgery
rebuild tissue and/or organs
usually done to improve physical appearance.
total joint, or skin graft, boob job.
constructive surgery
building tissue or organ that is absent
also done to improve physical appearance
cleft palate
transplant surgery
replace to restore function
heart, lung, tissue, kidney
incidental surgery
to do along with another surgery
remove at the same time as planned surgery, tends to be controversial
tying tubes during a Csection
appendectomy with bowel resection
Elective surgery
suggested surgery but can wait
done at a time when it is convenient for client and surgeon
knee surgery, bunions, cataract.
emergency surgery
surgery that must be done immediately
must be done ASAP to save pts life or ability to function; ruptured spleen, torn urethra, ruptured aneurysm, ect.
urgent surgery
necessary 1-2 days
may need to be admitted while waiting for surgery time.
(fx hip and CABG)
inpatient stay length
anything greater than 23 hours
patient begins recovery in the hospital and is sometimes admitted 24 hours prior to surgery
outpatient stay
anything less than 23 hours
pt will have surgery at hospital then go home once awake from anesthesia and VSS, how long pt stays depends upon the type of anesthesia what type of surgery and how fast they wake up (alertness), pain/nausea or other complications can lead to admission.
minor risk surgeries
minimal risk (skin lesion removals)
major risk
serious risk
heart bypass TJR
describe the perioperative assessment
looking at as much info as possible
age-elderly at increased risk because of comorbidities
tobacco- increases risk of pulmonary complications
ETOH- alters the effects of anesthesia
Medications-current meds anesthesia needs to know about, herbal products, avoiding potential drug interactions meds need to bed re-ordered post op.
Previous surgeries and Hospitalizations- familiarity and complications
Allergies- anesthesia, prep solution, pain meds
Vital signs-assess for abnormalities, know baseline
Resp- lung sounds, determine ability to exhale anesthetic agent
Elimination- baseline, anticolenergic effects of anesthesia increase risk of constipation and urinary rtn.
Nutrition- malnutrition interferes with wound healing
Coping and Stress- reduce anxiety, support system and discharge planning
Obesity- increases risk wound healing- dehiscence, evisceration, pneumonia, VTE, arrythmiss, heart failure, clotting risks.
Nursing diagnosis and Client goals with pre op
knowledge deficit
anxiety
sleep pattern disturbance
ineffective coping
client goals for pre op
for preop to decrease post op complications and to increase pts understanding of surgery
Informed consent r/t surgery
the surgery’s risks and complications have been explained so when patient signs they are signing informed consent.
surgeons responsibility to inform patient
the op permit is a legal document.
role of nurse with informed consent
advocate- want the patient to sign, but want the patient to be of sound mind and body before signing, nurse can request that the surgeon talk to patient before signing if patient doesn’t completely understand something
witness- that the correct pt signed the form and that said person is aware of what they are signing.
Student’s CANNOT be witnesses.
common preop diagnostic tests
lab work: CBC, lytes, BUN, Creat, PT, PTT
X-rays: CXR, MRI
EKGs
CBC
complete blood count
wbc, rbc, hemoglobin, platelets, hematocrit
looks for anemia, infection and platelet issues
electrolytes
up to 20 tests
i.e. potassium (abnormal potassium causes arrhythmias)
blood sugar
should be 60-100
looks for undiagnosed diabetes
BUN and creat
blood urea nitrogen and creatinine look at kidney function, some anesthetics are eliminated thru the kidneys so pt needs to have good kidney fx
PT and PTT
prothrombin time
partial thromboplastin time
looks at weather blood will clot or not and how long it takes
EKGs for preop
routinely done on anyone over age 40 anesthesiologist orders the test, hx of hypertension is one reason it is ordered r/t increased cardiac risk
preoperative interventions
client has medical clearance***
ordered labs, and other diagnostic tests, results are done and accessible
NPO status
pre-op meds are given- document
maybe a shower or scub ordered (hibbiclens)
usually no shaving- clip vs shave
enemas or golytely may be ordered preop
if needed tubes (catheters extra IVS, NG) inserted in OR
void before leaving for surgery
NPO status evidence
current evidence= clear liquids 2 hours before then NPO
Client teaching preop
alert and inform patient of the probability of having drains, tubes, and IVs and what precautions to take.
Breathing and Coughing with return Demo preop- keeps lungs clear after surgery and patients are more likely to do what they are taught preop
antiembolism devices- SCDs TEDs
early ambulation- MUST WALK WITH ASSISTANCE POSTOP
nurse teaches about prn pain meds that patient needs to ask for and rate pain.
Surgeon
responsible for all judgment in pt care, may be assisted by another surgeon they are equal partners,
First assist
usually a resident, can be an RN, assists with surgery.
can not function alone
med student, PA/NP, OR tech, scrub tech
Anesthesiologist or CRNA
monitors labs, vitals, monitors patient, administers anesthesia, records meds and vitals signs.
holding area nurse
starts IV, marks surgical site, has consents signed, assesses anxiety and allergies, looks at preop check list, does not go into OR, escorts patients family to holding area
circulating nurse
RN for patient in the operating room.
concerned with client safety, advocates for patient.
sets up non sterile OR room while patient is being seen by anesthesia.
positions patient and placeses catheter. gives the go ahead for surgery.
watches for breaks in sterile technique.
Scrub Nurse
sets up sterile field. OR tech or scrub tech. sets up sterile field, handles all sterile supplies. hands instruments to the surgeon or first assist.
Methods to ensure client safety during OR
traffic flow controlled
surgical scrubs worn (not worn in public)
surgical gown- sterile gown, covers arms and caps
no jewelry by scrubbed persons
sterile drapes and clothing
pt identification- name birthdate 2 identifiers
positioning with documentation
universal protocol “time out” what surgery, who the patient is and marks on body.
sponge and instrument counts
List OR protocols and why they are done
10 minute scrub in the morning maintaining sterile field pt identification pt positioning ALL done for patient safety
Anesthesia definition
is an artificially inducted state of partial or total loss of sensation, occurring with or without Loss Of Consciousness
General anesthesia
reversible, unconscious state characterized by amnesia (pt doesn’t remember anything), analgesia (pt doesn’t experience pain) and depression of reflexes (diaphragm) muscle relaxation and homeostasis (maintaining profusion, B/P etc., can be done with IV drugs and inhalation drugs.
when a combination is used its called balanced anesthesia
Regional anesthesia
reversible loss of sensation in a specific region or area of the body when a local anesthetic is injected, anesthesia blocks the nerve. these include spinals, epidurals, caudal, peripheral nerve blocks.
pt is awake and responds to verbal stimulation
Monitored Anesthesia Care (MAC)
area is infiltrated with an anesthetic block or local at a particular site AND the patient is getting IV drugs (by anesthesiologist) to make them unaware.
Deeper than conscious sedation- patient doesn’t respond to verbal commands
Conscious sedations
drug induced depression of consciousness during which patient responds purposely to verbal stimuli. level up from MAC, pt keeps own airway open. CV function is maintained. commonly used for endo, colonoscopy procedures
Local anesthesia
least amount of anesthesia, smaller than regional.
infiltrate the area with anesthetic but no sedation will occur.
used for dental, and derm procedures
pre anesthetic meds
given to a pt before anesthesia, mostly for anxiety.
benzodiazepine
in the family of anti anxiety drugs- all these drugs end in lam or pam
Ativan
valium
versed
opioids and narcotics
may give to pt so there is less pain post-op because drugs are already in system
decreases B/P
helps with muscle relaxation
anticholinergic antagonist
dry up secretions to decrease aspiration
given in or
increase HR urinary retention and constipation
Atropine and Robinul-
post anesthesia meds
analgesics- opioids if severe
antiemetics- Zofran and Phenergan
cardiac- atropine for bradycardia and hypotension
Nursing dx for intra-op
airway clearance skin integrity risk for injury risk for aspiration altered elimination fluid volume deficit powerlessness
info given to PACU from OR (report)
what type of anesthesia what surgery any drains any significant pre-op/intra op events rxn to anesthesia resp status hearing or other impairments estimated blood loss
Balanced anesthesia
several different drugs used at once:
versed- alters LOC
IV anesthesia- used to start anesthesia short-acting barbiturates (induction
Neuromuscular blocking agents- for muscle relaxation during surgery- paralyze muscles
Opioids and Narcotics- help with muscle relaxation decrease BP, pain management post op
inhalation anesthetics- nitrous oxide most common
anti emetics- Zofran/Phenergan use after surgery so pt is less nauseated in PACU
Nursing assessments/interventions in PACU
VS Dressings, Drains, Bleeding Return of gag reflex airway patency- suctioning (intervention adequate respirations- O2 (interventions) peripheral circulation fluid volume- IV fluids rate LOC- pt must breath on his or her own to leave PACU Pain N&V
Common Nursing Dx post op
Impaired gas exchange impaired physical mobility risk for injury impaired skin integrity pain high risk for urinary retention ineffective airway clearance fluid volume deficit constipation knowledge deficit
What is ranked higher for post op nursing diagnosis, high risk for urinary retention or ineffective airway clearance?
High risk for Urinary retention- UO must be at least ml/hr by- 4-6 hrs post op. VERY important.
Airway clearance is cough and deep breathing. different that airway patency
Nursing assessments and interventions post op
Resp exercises cough and deep breath use incision splinting for coughing to ease pain.
maintain suction and other drainage tubing
dressings (drainage and changes) and other incisional care
describe drainage- sanguineous, serosanguineous, purulent
analgesia- pain relief
client family teaching
progressive activity and restrictions
D/C planning* starts at admission
Post op meds
stool softeners and laxatives- narcotics cause constipation, anticholinergic effects of anesthesia
vitamins- to aid in healing
anticoagulants- decrease risk of DVT r/t bed rest and decreased mobility
Abx- decrease risk of infection especially ortho and neuro
pain meds
Colace
stool softener (usually given BID)
Peri-Colace
stool softener with gentle laxative added usually given BID
Milk of Magnesia
laxative- not given to people with real failure because their kidneys cant handle the Mag
Miralax
laxative that pulls fluid from intestine- can be used as a colon prep
Metamucil
a bulk laxative- not usually given post op because bulk doesn’t help the decreased peristalsis caused by narcotics and anesthesia
Heparin or Lovenox
subQ low dose
used for risk of DVTS
Muscle relaxants
used for ortho (back and Knee) and neuro surgery
Anti-spasmodic
urinary pt to keep bladder from being irritable
hormones
after hysterectomy
Post op Pain management
3 types of pain control
PRN
PCA
Epidural
PRN meds
advantage
disadvantage
most common- pt has to ask for these- injectable or oral
Advantages- pt doesn’t get over medicated. pt doesn’t get them if they don’t need or want them.
Disadvantages- pt has to wait for them while nurse prepares to give them. pain levels can build up to intolerable level while patient waits
PCA (patient controlled analgesia)
Advantage
Disadvantage
Pump with large syringe (30ml) full of narcotic- Hydromorphone or morphine MD determines amount
pt pushes button for dose
advantage- dosing is immediate- pt is in control
disadvantage- not necessarily easier for nurse. doesn’t save time, pt has to be physically and mentally able to push button. dosing is small and controlled. hooked to running IV
families will push button.
Epidural
advantage and disadvantage
catheter is put in patients back by anesthesiologist during surgery. drug is analgesic not anesthetic- doesn’t remove all of the pain.
advantage- excellent pain control
disadvantages- numbs the lower abdominal area- causes difficulty with urination- pt will need a foley
invasive procedure- risk for infection
Lab tests pre op and post op
WBC Hgb Hct platelets CBC sodium potassium BG
WBC
4-10 thousand
Platelets
150-400 thousand
Hemoglobin (Hgb)
female/ male
Female 12-14
Male 14-16
sodium (Na+)
135-150
Potassium (K+)
3.5-5
muscle and heart contraction
Hematocrit (Hct)
male/female
35-47 percent females
42-52 percent males
Blood sugar
60-100
SCD/TEDs
compress to increase venous return because patients are not mobile so DVTs are not formed
Incentive spirometer
Expand lungs/ alveoli
cough and deep breath to prevent pneumonia
use pillow splinting
Atelectasis
lungs not fully expanded
Ileus
cause- usually from handling the bowel during surgery, anesthesia (anticholinergic effects), electrolyte imbalance, intraperitoneal infection
prevention- early ambulation, increase activity, pain meds- pain doesn’t interfere with mobility but they do cause constipation by slowing peristalsis
treatment- NG tube for nausea
colenergic meds- stool softeners, and stimulators
IV fluids and electrolytes
Assess bowel sounds and measure distension
Acute Blood Loss Anemia Defining characteristics
Could be r/t surgery/trauma
peripheral blood vessels constrict (trying to bring what O2 carrying blood is left back to organs)
normocytic ( RBCs are normal size and shape)
normochromic (RBCs are normal color)
Tachycardia- trying to pump more blood because O2 demand is high
H&H (hematocrit and Hemoglobin are normal in early stages- then drop drastically.
Sickle Cell Disease/Anemia defining characteristics
High risk for Infection- sickle cells damage the spleen.
thrombotic crisis can occur- deformed RBCs are caught in capillaries and form clots leading to ischemia
avoid stress- triggers a crisis.
Hydroxyurea drug used during crisis- makes RBCs more flexible.
Ischemia can lead to acute chest pain and all over pain in the body- especially in joints
increased WBCs seen
Vitamin B12 deficiency anemia defining characteristics
can be r/t lack of intrinsic factor (helps absorb vit. B12) after a stomach or ilium resection
Seeking early treatment is important because neurological symptoms happen with this anemia (paresthesia and loss of balance) if treated before 6mo of onset these are reversible.
IM or intranasal vit B12 for treatment on monthly basis because pills won’t work for people who lack intrinsic factor
Painful Tongue, smooth red and inflamed
Folic Acid Deficiency anemia defining characteristics
r/t chronic malnourishment
r/t ETOH abuse
Causes birth defects in baby if inadequate intake during pregnancy (neurological problems)
symptoms develop gradually
Diet high in green leafy veggies, fortified cereals and meats
Aplastic anemia
increased infection rates pancytopenia- All blood parts affected- RBCs, WBCs, Platelets Bone marrow failure result of chemo HIV Bleeding tendencies
Iron (Fe) deficiency anemia
Common in elderly
Cheilosis- brittle nails
PICA appetite- paper, chalk, Ice, things that are not food.
Most prevalent form of nutritional anemia in the world, effects the poorest
Results from inadequate intake of Iron so body cant make good Hgb
Hematologic disorders anemias GFHP
Activity and Exercise
Anemia is not
A condition itself- it is a SYMPTOM of something else going on
Anemia Definition
abnormally low number of circulating RBCs, hemoglobin concentration, or both.
this results in a lack of O2 to cells and tissues
Causes of Anemia
inadequate production of RBCs Increased destruction (nutrition, meds, depression of bone marrow) (aplastic) Blood loss (acute and chronic) insufficient or defective Hgb (sickle cell)
Affects all major organs if severe because of decreased O2 carrying capacity of RBCs
Anemia Categorized by cause (4)
Blood loss
Nutritional
Hemolytic
bone marrow failure/Suppression
Blood loss anemia
Acute: surgery/ trauma. Symptomatic- fatigue
normochromic and normocytic RBCs
Chronic: blood loss (colon Cancer). depletes iron stores.
less symptomatic because the body compensates. Hypochromic and microcytic RBCs
Nutritional anemia’s
and what their cells look like
Iron Deficiency Anemia- inhibition of Hgb synthesis. microcytic and hypochromic RBCs
Vitamin B12 Anemia-inhibition of DNA synthesis (cell multiplications) Macrocytic, misshaped RBCs with short life span
Folic Acid deficiency anemia- Fragile megaloblastic cells, large and immature RBCs, r/t not enough intake higher demands with pregnancy and chemo therapy
Hemolytic anemia
Sickle cell anemia- hereditary, chronic, stress and increased demands of O2 cause crisis. most common in African Americans
Aplastic anemia
more rare than other types of anemia bone marrow failure usually r/t chemo radiation, exposure to chemicals, virus and meds problems with anemia- RBC problems with infection- WBC problems with clotting- Platelets. Everything in the blood is low
Pancytopenia
every part of the blood is affected. RBC, WBC and Platelets. r/t aplastic anemia
General signs and symptoms of anemia
pale skin,mucus membranes, conjunctiva, nail beds because blood needs to go to organs
increased HR and RR- compensatory need more O2 and circulation.
Angina and Fatigue- night cramps- lack of O2, Bone pain- marrow working harder, ischemia
DOE and SOB- r/t lack of O2
Cerebral hypoxia
Heart Failure
Signs of circulatory shock with rapid blood loss- low BP tachy, decreased LOC and Urine Output
Cerebral Hypoxia
general symptom of anemia, HA dizziness, dim vision, possible stroke r/t anemia
Explain fluid movement during acute blood loss anemia
shifts from tissue and interstitial space to vascular space to try and increase BP
Hct and Hgb ratio
1:3
1 being Hgb,3 Hct
i.e.
12:36
Nutritional Anemia in general
Megaloblastic anemia
affect RBC formation (vitamin B12 and folate play a big role in RBC development and Iron plays a big role in Heme Group development)
Caused by inadequate diet, increased need (pregnancy and chemo), malabsorption (r/t alcoholism or gastric bypass), and GI disorders
Symptoms of Iron Deficiency anemia
Nails- brittle
Mouth- Cheilosis cracks in the corner of mouth
Tongue- smooth and sore
Eating habits- PICA, hungry for things that aren’t food
Treatment for Fe deficiency Anemia
Iron supplement- oral tabs
increased absorption if taken with Vit C
don’t take with milk or tums/milk of mag because calcium decreases absorption as well as Bran
Vitamin B12 deficiency anemia symptoms
gradual onset of neuro problems- numbness, tingling, paresthesia, lose sense of balance
tongue- beefy sore smooth red
mouth- chielosis- cracked
Treatment for Vit B12 Anemia
EARLY INTERVENTION- treated early
Folic Acid deficiency anemia symptoms
develop gradually.
NO NEURO SYPMOTOMS- that’s only B12
Palor, general weakness
treatments of folic acid deficiency anemia
eating greens, whole grains, meat
taking supplements- especially prenatal vitamins during pregnancy.
Hemolytic Anemia causes
what do the cells look like
premature breakdown of RBCs
normocytic and normochromic RBCs but immature BCs won’t last a long time. bone marrow tries to keep up by pumping out more
Intrinsic- inside RBC- Sickle cell
Extrinsic- Outside RBC- chemo, bacteria, infection, trauma, radiation
Treatment of Hemolytic anemia
treat what is CAUSING the problem
Sickle Cell anemia signs and symptoms
Pain. fatigue increased WBC couth Sustained erection Angina/MI Stroke/ TIA pallor jaundice- r/t spleen breaking down so many RBC irritable decreased circulation ischemia
treatment of sickle cell anemia
meds- hydroxyurea- increase production of Hgb, makes RBC more flexible
Transplant- Bone marrow- brings in more healthy RBC making stem cells.
pain management- during crisis- r/t thrombo crisis.
aplastic anemia signs and symptoms
vary with severity pallor fatigue HA DOE Tachy bleeding*** HF
Treatment of aplastic anemia
remove causative agent, blood transfusions, BMT
Diagnostic tests for anemias
CBC
Iron levels and TIBC (total iron binding capacity- transferrin levels)
Serum ferritin- another iron test
sickle cell test- screening for sickle cell
BM examination- biopsy
CBC includes what
WBC
RBC
Platelets
RBC distribution, width, size, shape
CBC with Diff means all different kinds of WBC are identified
Iron overdose is toxic to
young children
Iron teaching
don’t take with calcium or bran
it may need to be taken for a long time
vitamin C increases absorption
Nursing diagnosis for anemias
pain
fatigue
decreased tissue perfusion
activity intolerance
Intradermal injections
Used for TB and other skin tests 25-29 g 1/4-5/8" needle 5-15 degree angle with bevel up- no aspiration or massage inner forearm or upper back
Subcutaneous injections
Used for Heparin, Lovenox, and Insulin 25-31g needles 1/2-5/8" needle 45-90 degree angle- no aspiration abdomen, upper outer arms, upper outer thighs, and outer back
Intramuscular injections
Used for Immunizations and B-12 20-25 g needles depending on site Deltoid- 5/8-1" Vastus lateralus- 5/8-1.5" Dorsal gluteal- 1-3" Ventrogluteal- SAFEST SITE- 1.5-2.5" Can airlock to prevent leaking into SubQ- aspirate except for immunizations
Z track
Used for Iron and injections that can be damaging to the skin
dorsogluteal and ventrogluteal can use 1.5” needle- may need larger if patient is obese
90 degree angle with skin pulled to the side.
