x Peri-Op (IV, Fluids) Flashcards
Drop Factor?
size of drop.
Macro Drip - 10gtts/min
Micro Drip - 60gtts/min
Blood tubing - 15gtts/min
If IV rate is 80ml/hr or slower, using what size tubing?
Micro Drip tubing
If IV rate is 81ml/hr and UP, use
Macro Drip tubing
1L = ?ml
1000ml
IV RATE formula
ml / hr
DRIP RATE formula
RATE/Time (minutes) x GTT factor/1 = gtts/min
READ p107 - 114 (Burke)
and chpt 7,9,10,12,13
debridement
Removal of necrotic tissue
Chemical - collagenase
mechanical - wet to dry dressing
Types of Anesthesia
Topical
Local
Regional
Epidural
Topical Anesthesia
spray or paste of lidocaine to numb skin
Local Anesthesia
inject lidocaine into subq and underlying tissue as well as the skin
Regional Anesthesia
Lidocaine injection into a nerve plexus to numb a region or limb
Epidural Anesthesia
Lidocaine injection into spinal region between vertebrae to numb areas called dermatomes (on dura mater)
Spinal goes right into spinal column and last longer.
how does Lidocaine work?
Sodium Channel Blocker - strips impulse of pain going to brain
why do patients shiver after anesthesia?
muscle tone and movement generate heat. Anesthesia paralyzes the muscles. The body will shiver because muscles were not generating any heat.
Complications of blood transfusions
- Transfusion reaction/Allergic Reaction (hives, itching, swelling)
- Bacteremia/Sepsis (sudden chills, back ache, fever)
- In too rapidly, Hypervolemia (fluid overload)
- Blood is citrated to prevent clotting? Treated w NaCitrate or citric acid
What blood product would hemophiliacs need?
Cryoprecipitate (fibrinogen & multiple clotting factors)
Cryoprecipitate is a source of fibrinogen. Fibrinogen is vital to blood clotting. It is usually used in the treatment of patients with reduced levels of, or poorly functioning, fibrinogen with clinical bleeding, an invasive procedure or trauma.
How long can you hand an IV before changing? Bag Tubing TPN tubing IV site
Bag - 24hrs
Tubing - 3 days
TPN tubing - 24 hrs
IV site - 3 days
(no IV on side of mastectomy, fistula)
PIC line
Peripherally Inserted Catheter
tip ends near aorta
Always X-ray to confirm placement
How long do blood bags last?
3 months
READ p 107 - 114, 321, 480
.
check glucose when?
p. 200
ac + hs (before meals, hour of sleep)
Debulking
removing large peices of cancer to de-bulk tumor.
not therapeutic, merely Palliative (only for comfort)
Palliative
not going to heal, but only to increase comfort
Who obtains Consent?
person performing procedure. Nurse can sign as a witness
Presumed Consent
99% of people want to live. Surgeon can make life saving decision if patient is not able and there is no family available.
Incentive Spirometer
suck air out. Exercise deep breathing
in stress, what is released in body, what are effects to blood
Epinephrine - vital signs affected
Cortisol - decrease immune response
BOTH raise blood sugar
Extravesation (signs, symptoms, treat)
passage or escape into tissue of antineoplastic chemotherapeutic drugs.
Signs and symptoms may be sudden onset of localized pain at an injection site, sudden redness or extreme pallor at an injection site, or loss of blood return in an IV needle. Tissue slough and necrosis may occur if the condition is severe.
Nursing responsibilities include maintaining the patient IV line, elevating the affected area, applying ice packs, and notifying the physician of the need for antidote
Infiltration (signs, symptoms, treat)
- the movement of a needle or cannula from within a vessel into the surrounding tissue.
symptoms are a slowed flow of fluids, swelling, pallor, coolness of the skin, and discomfort in the area
Treatment
Thrombophlebitis (signs, symptoms, treat)
inflammation of a vein located just below the skin’s surface. The inflammation is due to a blood clot.
Causes
This condition may occur after injury to the vein. Or it may occur after having an intravenous (IV) line or catheter. If you have a high risk of this condition, you may develop it for no apparent reason.
Symptoms Skin redness, inflammation, tenderness, or pain along a vein just below the skin Warmth of the area Limb pain Hardening of the vein
Treatment
- Goals:reduce pain and inflammation and prevent complications.
- Wear support stockings, if your leg is affected
- Keep the affected leg or arm raised above heart level
- Apply a warm compress to the area
- remove IV line
Medicines that may be prescribed include:
Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation
Painkillers
If deeper clots (deep vein thrombosis) are also present, your provider may prescribe medicines to thin your blood. These medicines are called anticoagulants. Antibiotics are prescribed if you have an infection.
Surgical removal (phlebectomy), stripping, or sclerotherapy of the affected vein are occasionally needed to treat large varicose veins or to prevent further episodes of thrombophlebitis in high-risk patients.
When choosing an IV site, where do you start?
Distal
PICC line vs Central Line vs Implanted Ports
PICC line goes in through Central Line to top of aorta. Xray to check.
Central/Implanted ports?
Both are central lines
PICC up to 1 yr
Port over a year
Issue w IV in anticubital?
Can bend arm
How does Insulin affect BS?
Lowers it
How does glucagon affect BS?
Raises
TPN
Total parenteral nutrition
what is the only instance an LPN can work with a main line?
Dialysis unit
Lactated Ringers
isotonic sulations (same concentration as Plasma)
Sepsis
Infection of blood
Symptoms: shaking, backache, chills
Crystalloid
Solutes dissolved in water
Isotonic
normal saline (NS), plasma, D5W (dextrose 5% in H20), Ringers solution
Hypotonic
fewer dissolved solids that plasma, 0.45% NaCL, 5% Dextrose
Hypertonic
more concentrated than body fluid. D10W, 20% Dextrose
Packed cells
RBC , plasma removed
Fresh Frozen plasma
used by hemophiliacs. manage coagulapathies, Vit K, ANTIDOTE for warfarin
Albumin
Main protein in blood. If not enough protein, fluid leaks into tissue (Kwarshiorkor Edema)
In an emergency, we don’t have to cross match what blood products?
Fresh Frozen Plasm, Albumin, Platelets. Only necessary in packed RBC or regular blood.
Blood subsitutes
emulsion
PFCs (per flouro carbons)
HBOC (Hemoglobin based Oxygen carriers)
How high should IV bag be placed for gravity infusion?
18 - 24” above infusion site
what is the problem with Anticubital IV?
can’t bend arm.
Glucagon vs Glycogen
Glucagon causes the liver to convert stored glycogen into glucose, which is released into the bloodstream. High blood glucose levels stimulate the release of insulin. Insulin allows glucose to be taken up and used by insulin-dependent tissues.
Aplastic Anemia
body stops making RBC.
treatment: stem cell or marrow transplant
Wounds:
Primary, Secondary, Tertiary
PRIMARY: Wound edges approximated
SECONDARY: would allowed to close from bottom up
TERTIARY: Initially had primary, abscess formed and had to reopen and left to heal secondarily.
Elders at risk for
- post/op ICU dementia
- wound healing
- renal/hepatic functions- clear meds
- may not get fever -infection
Obese at risk for
- UP pneumonia
- dehiscence of wound
- thrombophlebitis
Dehiscence
Wound pops open. Cover w saline gauze and call doc
Evisceration
Organs etc come out of open wound
When choosing IV sites
Start distal and slowly move proximal
Problem w antecubital IV
Can’t bend arm
Patient on TPN at risk for
Hyperglycemia
Have patient cough/deep breathe because
Prevent post op Pneumonia
Expand lungs and increase deep breathing
Treatment of DVT to prevent pulmonary embolus
- TED hose
- ankle/leg exercises
- SCD (Venodyne Boots) Sequential Compression Device (change in pressure to promote circulation)
If therapy is painful, can you pre-medicate patient?
Yes
- physical therapy
- ambulated
- dressing changes
- painful re positioning
Who obtains Informed Consent?
What is nurse role?
- Person performing procedure
- Nurse as a witness only.
protects nurse, physician, facility
Perioperative nursing care
period immediately before, during and after surgery
Inpatient surgery
admission to hospital
Ambulatory (outpatient) surgery
local or general anesthesia but allowed to return home without assistance.
in physicians office, free standing ambulatory surgery center, or in hospital suites
Patient has right to refuse up to ??? before surgery
20min
Types of surgery
Diagnostic Ablative Constructive Reconstructive Palliative (comfort only, no healing) Transplant
Malnutrition surgical risk factors
UP rise for adverse outcome
UP risk for impaired wound healing, infection, sepsis
Dehydration/Elec Balance surgical risk factor
UP risk for thrombophlebitis
UP risk for clotting
UP risk for cardio instability/dysrhytmia/heart failure
Cardiovascular disorders surgical risk factor
UP risk for cardio instability
HYPOVOLEMIC shock (insuff blood flow to organs)
HYPOTENSION
DVT (cramping in calves, hurts when dorsaflex)
venous thrombosis
pulmonary embolism (does NOT make lung sounds)
stroke
fluid volume overload
edema(peripheral)
lung sounds
Alcoholism surgical risk factor
-DTs (hallucinations) (Delerium Tremens)
(treat w Benzodiazapene)
-seizures
Universal Protocol
to reduce wrong site, wrong procedure, wrong person
- procedure verification
- Mark area (while pnt awake)
- “Time Out” to ensure right client, right site, right procedure
PTT test
PTT: Partial thromboplastin time
coagulation
PT test
PT: Prothrombin Time
coagulation
Diagnostic Tests
- CBC: complete blood count
- Serum Electrolytes
- Coagulation: PT & PTT
- Urinalysis: to rule out UTI/pregnancy
- Chest Xray: baseline for size/shape, condition of heart/lungs
- ECG: Electrocardiogram (for those undergoing general anestesia, older than 40, or history of cardiovascular disease. Identify cardiac status
- Blood glucose levels (esp diabetic ptn)
During Skin Prep, any moles, warts, rashes, lesions within surgical site are recorded and put back in place after surgery.
.
Who pay attention to I&O during surgery
circulating nurse
Splinting is used when ?
To prevent injury or splitting of stitches etc after surgery in abdominal area.
Holding pillow against stomach when coughing
Splinting is used when ?
To prevent injury or splitting of stitches etc after surgery in abdominal area.
No coughing after what surgeries?
Neuro Surgery
Eye
Hernia
Coughing encouraged why?
To prevent post-op pneumonia
CPM
Continuous Passive Motion
Machine that moved your joints for you. I.e let after knee surgery
PACU
Post Anestesia Care Unit
Malignant Hyperthermia
Idiosyncratic reaction to Anestesia
Potentially fatal rise in body temp
Genetic
The Surgical Team
Surgeon
Surgical Assistant (physician, RN, PA, or trained LPN)
Anesthesiologist
CRNA( cert RN anesthetist, administered Anestesia and responsible for clients well being)
Circulating Nurse (coordinates and manages activities)
Scrub Nurse (handles tools)
Stages of General Anestesia
Induction : drug administered, airway checked, skin prep
Maintenance: surgical incision and almost to end of procedure
Emergence: client awakened, tube removed
Conscious Sedation drug and rescue med
Analgesic and amnesiac effect
Opioids: morphine sulfate, fentanyl (sublimaze)
Sedative: Diazepam (valium), Midazolam (versed)
Reversal Med: Naloxone hydrochloride (Narcan), Flumazenil (romazicon)
How long is the surgical scrub?
5-10min
anything body part removed from patient goes where?
the lab for testing
any question asking which symptom is most concerning always go with ….
respiratory
Wound Healing: Primary Intention
edges are approximated (staples/sutures), heals quickly, little scarring
Secondary Intention
large, gaping, irregular. would allowed to heal on its own from bottom up
Tertiary Intention
Initially Secondary itention then got infected
3 phases of wound healing
Inflammatory
Proliferative
Remodeling
Exudite
wound drainage
Types of wound drainage
Serous - clear, yellow serum (thin, yellow)
Sanguineous - serum and RBC (thick reddish)
Purulent - Pus (WBC, tissue debris, bacteria)
Wound Drainage Devices
Penrose Tube - rubber tube (gravity)
Jackson Pratt - grenade looking (light suction)
Hemovac - cylinder with springs (heavy suction)
Wet-Dry (Negative Pressure)? - black foam taped onto wound.
Atelectasis
incomplete expansion of collapse of lung tissue
prevent w early ambulation and spriometer
Homan’s Sign
pain in calves on Dorsiflextion of food. (indicates DVT)
Signs of Pulmonary Embolism
dyspnea sudden chest pain diaphoresis (sweating) anxiety restlessness rapid respiration and pulse dysrythmia cough cyanosis NO LUNG SOUNDS
Signs Hemmorage
restlessness, anxiety
UP heart rate, same BP
NSAID
Non steroidal anti-inflammatory drug
class of drugs that provides analgesic (pain-killing) and antipyretic (fever-reducing) effects, and, in higher doses, anti-inflammatory effects.
Ibuprofen, Aspirin, Diclofenac, Naproxen, Meloxicam, Celecoxib, Indometacin, Ketorolac, Ketoprofen, Nimesulide, Etoricoxib, Piroxicam, Nabumetone, Mefenamic acid, Loxoprofen, Salicylic acid, Diclofenac sodium, Carprofen, Naproxen sodium, Aceclofenac, Etodolac, Flurbiprofen, Sulindac, Phenylbutazone, Dexketoprofen, Oxaprozin, Lornoxicam, Tenoxicam, Diclofenac/Misoprostol, Benzydamine, Flunixin, Diflunisal, Dexibuprofen, Valdecoxib, Etofenamate, Tiaprofenic acid, Phenazone, Felbinac, Salsalate, Deracoxib, Nepafenac, Diclofenac potassium, Bromfenac, Tolfenamic acid, Fenoprofen, Tolmetin, Lumiracoxib, Fenbufen, Diclofenac epolamine, Suprofen
For wound healing, what diet is encouraged?
protein and vit C
After major surgery, how often do you assess patient?
every 15min (first hour)
if stable, every 30 min (for 2 hrs)
then every hour (for 4 hrs)
what drug given to build up blood before a surgery
Erythropoetin
Epogen
Autolugus Donor
Donating your own blood in advance of your surgery
Cell saver
using blood suctioned from surgery. it’s washed and given back to you.
Who is most at risk for Pneumonia
Elderly
pts under General Anestesia
PCA
Patient controlled analgesic
most common post op infection
staph aureus
Teratogenic
any drug causing birth defects
Anticholinergic
- Dry out secretions
- causes difficulty swallowing d/t dry mouth
- affects peristaltic action of esophogus
block the action of the neurotransmitter acetylcholine in the brain. They are used to treat diseases like asthma, incontinence, gastrointestinal cramps, and muscular spasms. They are also prescribed for depression and sleep disorders. The drugs help to block involuntary movements of the muscles associated with these diseases. They also balance the production of dopamine and acetylcholine in the body. Anticholinergics can also be used to treat certain types of toxic poisoning, and are sometimes used as an aid to anesthesia.
DRY up secretions
Perfusion
blood coming out of vessel into area
Eschemia
blood leaving area
Venous stasis
pooling of blood
Penrose tube
gravity drainage
Who cannot be on immunosuppressants
HIV, cancer, hep
Signs of someone losing blood (lacking O2)
restlessness
tachycardia
Who can sign a consent form?
sober adult (over 18)
emancipated minor
married minor
in emergency, next of kin
Bovie Cautery
seal blood vessels not cut.
How do they know you need an apendectomy
Rebound tenderness @ McBurney’s point
Toradol
one of strongest NSAIDs. good weaning drug for opiates
If receiving transplant, must take suppressants. What are the times when you don’t need suppressants?
- transplant from an identical twin
- Cornea transplant
Paralytic Illeus
all bowel movement ceases
auscultate for bowel sounds
4min per quadrant
Gall bladder surgery diet
avoid concentrated fats
miss out on fat soluble vits (ADEK)
Steatorhea
fluffy, fatty stool
Laproscopic surgery
- less invasive
- easier recovery
- open surgery
- insufflate belly w CO2 gas. (after surgery, trapped gas can cause pain)
PACU
Post Anestesia Care Unit
ptn monitered q15min
nurse ratio: adult 1:2, pedi 1:1
Post Op, 1st surgical dressing changed by ?
surgeon
Warming Blankets
Bear Hugger (blows hot air)
How would the nurse treat an evisceration?
- place saline soaked guaze. don’t press, just place on it.
- call Dr STAT
After what surgeries should you NOT encourage coughing
Gluacoma, Cataract, (eye), hernia
after hip replacement surgery, what do you restrict
- adduction
- 90* flexion, legs should be straight (sit/stand on high stool)
How do you monitor drainage of wound
-draw circle around drainage and check to see if it spreads
Post Op Pneumonia
-hypostasis of secretions
Adhesion
when tissues stick together during healing
an abnormal union of membranous surfaces due to inflammation or injury
Perioperative: Phases or Surgery
PRE-OPERATIVE: perform tests, attempt to limit preoperational anxiety and may include the preoperative fasting.
INTRA-OPERATIVE: begins when the patient is transferred to the operating room bed and ends with the transfer of a patient to the postanesthesia care unit (PACU). During this period the patient is monitored, anesthetized, prepped, and draped, and the operation is performed. Nursing activities during this period focus on safety, infection prevention, and physiological response to anesthesia. Radiation therapy and blood salvage may also be performed during this time. AND COUNTING SUPPLIES
POST-OPERATIVE: The postoperative period begins after the transfer to the PACU (Post Anesthesia Care Unit) and terminates with the resolution of the surgical sequelae. It is quite common for this period to end outside of the care of the surgical team. It is uncommon to provide extended care past the discharge of the patient from the PACU.
