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Exam 2 Flashcards

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1
Q

Common causes of impaired gas exchange (6)

A

Age
Smoking
Chronic and acute medical conditions
Brain injury
Prolonged immobility
Inhalation irritants

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2
Q

Diagnostics for Gas exchange problem (8)

A
  • Chest X-ray (detect TB)
  • CT Scan
  • Pulmonary Function Studies (usually reduced in COPD and restrictive diseases, old age)
  • Invasive (Bronchoscopy, laryngoscopy (larynx), mediastinoscopy (above sternum for tumors)
  • CBC
  • ABG
  • sputum (negative after 3 months of TB treatment)
  • BNP (rule out CHF)
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3
Q

Nursing Care and Patient education for Pulmonary Function tests (5)

A
  • Explain purpose and procedure to reduce anxiety-induced dyspnea
  • May need to withhold bronchodilators 4-6 hrs before the test
  • Patient should not smoke 6-8 hrs before test
  • Patient breathes through mouth (Nose clip to prevent air escaping through nose)
  • Assess patient for dyspnea or bronchospasm after procedure
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4
Q

4 Types of Pulmonary Function Studies

A

Forced vital capacity (FVC)- max amount of air that can be exhaled as quickly as possible after maximum inspiration. (decreased)

Forced expiratory volume (FEV)- max amount of air exhaled (decreased)

Peak expiratory flow rate (PEFR)- usually decreased

FRC (functional residual capacity) - the amount of air remaining in the lungs after normal expiration. (increased w/ air trapping i.e. emphysema)

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5
Q

Purpose of Bronchoscopy (5)

A
  • Diagnose and manage pulmonary disease
  • Help place or change endotracheal tube
  • Collect specimens
  • Removal of secretions not cleared by normal suctions
  • Stent placement (open up strictures in trachea and bronchus)
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6
Q

5 Potential complications after Bronchoscopy (and nursing care for each)

A
  • hypoxemia (maintain airway; give O2; monitor vitals q15 monitor for first two hrs)
  • aspiration (check for gag reflex (pt NPO till return), suction prn)
  • bleeding (hemoptysis)
  • infection
  • bronchospasm (indicated by stridor
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7
Q

Preparation for Bronchoscopy (4)

A
  • Explain procedure and verify consent given
  • Document patient allergies
  • Patient is NPO 4-8 hrs prior to procedure (and 2 hrs after until gag reflex returns) to prevent aspiration
  • Benzos or opioids given for sedation
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8
Q

Bronchoscopy: Benzocaine

Use
Complication
s/s of complication (3)
Treatment of complication (2)

A

Use: topical anesthetic used cautiously to numb oropharynx

Complication: methemoglobinemia (conversion of hemoglobin to methemoglobin which does not carry oxygen so leads to tissue hypoxia)—less likely with lidocaine

S/s: cyanosis after topical anesthetic, no response to supplemental oxygen, blood is chocolate-brown color

Treatment: oxygen and IV of 1% methylene blue

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9
Q

Acute findings of Impaired Gas exchange (8)

A

Tachypnea
Tachycardia
Accessory Muscle Use
Paradoxical chest movement (in on inspiration, out on expiration)
Pursed lip breathing
Pale skin
Adventitious Breath Sounds
Mucus/secretions

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10
Q

Chronic problems of impaired gas exchange (4)

A

Cyanosis
Clubbing of nails
Barrel chest (emphysema)
Orthopneic

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11
Q

Normal ABG values

pH
CO2
pO2
HCO3
O2 sat

A

pH: 7.35-7.45
CO2: 35-45 mm Hg
pO2: 80-100 mm Hg
HCO3: 21-28 mEq/L
O2 sat: 95-100%

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12
Q

ABGs: What do the following present as?

Respiratory Acidosis
Respiratory Alkalosis
Metabolic Acidosis
Metabolic Alkalosis

A

Respiratory Acidosis: pH < 7.35; CO2 > 45
Respiratory Alkalosis: pH > 7.45; CO2 < 35
Metabolic Acidosis: pH < 7.35; HCO3 < 21
Metabolic Alkalosis: pH > 7.45; HCO3 > 28

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13
Q

COPD: Basic Pathophysiology - 2

A

Chronic Bronchitis: airway problem due to inflammation of airway after exposure to irritants

Pulmonary emphysema: alveolar problem where lung elastic tissue loses ability to recoil after stretching

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14
Q

Risk factors for COPD (3)

A
  • cigarette smoking (esp 20 pack year)
  • Alpha1-antitrypsin deficiency ( ATT is normally in lungs and inhibits excess protease activity so protease only breaks down pollutants and not lungs but w/o ATT, protease breaks down lungs)
  • asthma
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15
Q

S/s of chronic bronchitis (5)

A
  • bronchospasm
  • copious sputum (leads to narrowed airways
  • thin/wasted
  • hypoxemia (low PaO2) and cyanosis
  • clubbing
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16
Q

Complications of COPD (6)

A
  • Hypoxemia (leads to polycythemia)
  • Acidosis (r/t CO2 retention and hyperinflation)
  • Respiratory infection (due to increased mucus; pneumonia and influenza vaccines important)
  • Cor pulmonale (right sided heart failure due to pulmonary disease leads to right ventricular hypertrophy and backup of blood into venous system; S/s: dependent edema)
  • Dysrhythmias (due to hypoxemia, drug effects, acidosis)
  • Respiratory Failure
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17
Q

S/s of emphysema (7)

A
  • hyperinflation of lungs (flattened diaphragm)
  • tachypnea and dyspnea
  • barrel chest
  • orthopneic or tripod position (forward-bending posture w/ arms held forward)
  • hypercapnia (due to uncoordinated breathing; respiratory acidosis)
  • chronic hypoxia (leads to polycythemia i.e. increased RBC)
  • breath sounds: wheezes or reduced if airflow obstruction
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18
Q

Anti-inflammatory drugs for COPD

Corticosteroids (Beclomethasone, Prednisone)

5 patient education points

A
  • use daily b-c max effectiveness w/ 48-72 hrs of continued use
  • Side effects: increase risk for infections (Candida albicans in mouth; URI if around people w/ one)
  • avoid Risky activities (fragile BVs increase risk for bruising and petechiae)
  • do not stop abruptly stop drug b-c it suppresses adrenal production of essential corticosteroids
  • take with food to reduce risk for GI ulceration
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19
Q

Bronchodilators for COPD

SABA (albuterol) -1
LABA (arformoteral) -1
Anticholinergic (ipratropium) -3

A

SABA
- for acute relief

LABA
- for long term relief

Anticholinergic
- prevent COPD bronchospasm
- carry at all times
- S/s of overdose: blurred vision, eye pain, headache, nausea, palpitations, tremors, inability to sleep, dry mouth (increase fluids)

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20
Q

Other drugs for COPD

Mucolytics (Acetylcysteine, dornase alpha, guaifenesin) - 2
Oxygen - 2

A

Mucolytics (Acetylcysteine, dornase alpha, guaifenesin)
- thins secretions so easier to expectorate and cough up
- guaifenesin can raise cough threshold

Oxygen
- Usually oxygen flow of 2-4 L/min via nasal cannula or 40% via venturi mask
- ALL hypoxic patients should get oxygen therapy so SpO2 b/w 88-92%

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21
Q

COPD: nonpharmacological management of impaired gas exchange (5)

A
  • Positioning (HOB elevated, orthopneic )
  • Effective and controlled coughing ( scheduled coughing in morning, prior to bed, and at meals)
  • Exercise conditioning (2-3 times a week of walking; resistive breathing, isocapnic hyperventilation machine)
  • Suctioning (only if weak cough, pulmonary muscles or inability to expectorate)
  • Hydration ( 2L of fluid a day)
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22
Q

COPD: Weight loss prevention (8)

A
  • Collab w/ RDN for easy to chew and non-gas forming foods
  • High calorie, high protein
  • Plan biggest meal of day when pt most hunger and well rested
  • 4-6 small, frequent meals preferred to 3 large meals
  • Use breathing techniques and bronchodilators 30 minutes prior to meal to reduce bronchospasm
  • Avoid dry foods that stimulate coughing
  • Avoid caffeine that can increase urine output and lead to dehydration
  • Avoid drinking fluids before or during meals if early satiety
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23
Q

COPD: Improving Endurance

Patient Education (5)

A
  • Avoid rushing in morning b-c can increase dyspnea
  • Use energy conservation (plan and pace activities for best tolerance and minimum discomfort i.e. divide activities into smaller parts)
  • Avoid working w/ arms raised (raised arms reduce exercise tolerance b-c accessory muscles work to keep arms up instead of helping w/ breathing)
  • Do not talk during activities requiring energy (walking)
  • Avoid breath holding while performing any activity
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24
Q

COPD: Breathing Exercises

  • Diaphragmatic/ abdominal breathing
  • Pursed-lip breathing (2)
A

Diaphragmatic/ abdominal breathing
- Patient consciously increases movement of diaphragm while lying on back to relax abdomen

Pursed-lip breathing
- Mild resistance created by breathing through pursed lips to prolong exhalation and increase airway pressure
- Delays airway compression and reduces air trapping

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25
Purpose of Pleural chest tube (3)
- Lung Re-Expansion - Drains Air/Blood from Pleural Space - Creates Negative Pressure
26
7 Nursing Care for patient w/ chest tube
- Inspect insertion site( eyelets of tube should not be visible; s/s of infection (redness, purulent drainage, excess bleeding)) - Palpate Insertion Site (may have subQ emphysema if puffiness or crackling - Ensure Intact Dressing at Site - Assess/reassess Respiratory Status (breathing, pulse ox, breath sounds) - Observe Trachea (tension pneumothorax if shifted) - Assess/reassess Pain (give meds and reposition) - Encourage Cough, Deep Breathing, Incentive Spirometry
27
9 Nursing Care for chest tube system
- Avoid kinks, Occlusions, or Loose Connections (should be straight) - Do NOT Strip/Milk Tubing - Keep Drainage System Below Level of Chest - Assess for “Tidaling” (water level rises inhalation and fall exhalation) - bubbling seen on exhalation, forceful cough, position changes (EXCESS BUBBLING = air leak) - Always have at least 2 cm of water to prevent air from returning to patient in water seal chamber - Limit clamping of a chest tube b-c will increase pressure in pleural space and may cause tension pneumothorax - No need to disconnect chest tube for transport - never let drainage come in contact w/ tubes (can cause tension pneumothorax)
28
9 Emergency Situations w/ Chest tube
- Tracheal Deviation - Sudden onset of increased dyspnea - O2 sat <90% - Drainage >70ml/hr (D) - Visible eyelets on chest tube - Chest tube falls out of the patient’s chest (first, cover the area with dry, sterile gauze) - Chest tube disconnects from the drainage system (first, put end of tube in a container of sterile water and keep below the level of the patient’s chest) - Drainage in tube stops (in the first 24 hours) - Drainage bloody after a couple days (drainage is always bloody in first few hrs)
29
Mantoux skin test Purpose Procedure Results
Purpose: screen for TB; diagnosis made w/ sputum culture Procedure: intradermal injection read after 48- 72 hrs Results: positive = induration (area of hardness) > 10 mm or > 5mm in immunocompromised
30
TB drugs: Isoniazid Nursing Care (4)
- Hepatotoxic so monitor labs/ urine for liver toxicity and limit alcohol use - Avoid antacids - take drug on an empty stomach (1 hour before or 2 hours after meals) to prevent slowing of GI absorption - Teach patients to take a daily multiple vitamin w/ B-complex vitamins b-c drug can deplete the body of this vitamin.
31
TB drugs: Rifampin Nursing Care (3)
- Hepatotoxic so monitor labs/ urine for liver toxicity and limit alcohol use - Warn patients to expect an orange-reddish staining of the skin and urine and all other secretions to have a reddish-orange tinge; also, soft contact lenses will become permanently stained - Women w/ oral contraceptives need additional method of contraception while taking this drug and for 1 month after stopping it because this drug reduces the effectiveness of OCs
32
TB drugs: Pyrazinamide Nursing Care (3)
- Hepatotoxic so monitor labs/ urine for liver toxicity and limit alcohol use - Drink at least 8 ounces of water when taking this tablet and Increase fluid intake to prevent uric acid from precipitating, making gout or kidney problems worse. - Photosensitivity (Teach patients to wear protective clothing, a hat, and sunscreen when going outdoors in the sunlight because the drug causes photosensitivity and greatly increases the risk for sunburn)
33
TB drugs: Ethambutol Nursing Care (3)
- Hepatotoxic so monitor labs/ urine for liver toxicity and limit alcohol use - Optic neuritis at high doses ( Instruct patients to report any changes in vision (reduced color vision, blurred vision, or reduced visual fields) immediately to HCP)-- Minor eye problems are usually reversed when the drug is stopped. - Instruct patients to drink at least 8 ounces of water when taking this drug and to increase fluid intake to prevent uric acid from precipitating, making gout or kidney problems worse.
34
risk factors for Diabetes (6)
- 1st relative w/ diabetes mellitus - Age 45 years or older - sedentary lifestyle - Hx of vascular disease, PCOS, gestational diabetes, pancreatitis, Cushing Syndrome, or given birth to an infant > 9 lb - Metabolic Syndrome (Central Obesity, Hyperlipidemia, Hypertension (uncontrolled), Hyperglycemia) - Lifetime of high-carb, high-sugar diet causes insulin to tire out
35
S/s of hyperglycemia (10)
- Polyuria (due to glycosuria) - Polydipsia (due to dehydration--s/s of dehydration: dry skin, rapid thready pulse, hypotension) - Polyphagia (due to starvation-- may have some weight loss) - Fatigue - kussmaul respirations (compensate for metabolic acidosis) - fruity breath - LOC changes (headache, seizures) - ketonuria - hot dry skin - blurry vision
36
Expected Glucose levels (what indicates problem?) Normal range Fasting glucose Oral glucose test Rapid glucose check Glycosated hemoglobin (HbA1C)
Normal Range (70-110) Fasting plasma glucose (FPG) - greater than 126mg/dL (8 hrs. after fasting, can have water while fasting) Oral glucose tolerance test (OGTT)- greater than 200mg/dL (2hrs after oral glucose test; pt fasts 10-12 hrs prior to test Rapid glucose check - Greater than 200md/dL (Finger prick; no fasting required) Glycosated hemoglobin (HbA1c) - Greater than 6.5 % (measures Average of blood glucose over 3 months, the lifespan of RBC b-c glucose binds to Hgb A)-- target <7% for diabetic
37
Oral antidiabetes: Biguanides (Metformin) Action (3) Side effects (2)
Action: - reduce glucose production by liver - increase sensitivity to insulin - delay carb absorption in intestines Side effect - GI effects (flatulence, anorexia, NV) - lactic acidosis (caution in AKI-- s/s myalgia, sluggishness, somnolence, hyperventilation)
38
Oral antidiabetes: Biguanides (Metformin) Nursing Care (4)
Nursing care - Take w/ food - Take vitamin B12 and folic acid supplements - Stop med 24-48 hrs before any radiographic test w/ iodine dye (restart 48 hrs after b-c can cause lactic acidosis from acute kidney injury - Avoid alcohol which can increase risk for lactic acidosis
39
Oral antidiabetes: Sulfonylureas (Glipizide) Action (2) Side effects (2) Nursing Care (2)
Action - stimulates insulin release from pancreas to decrease blood glucose - increase tissue sensitivity to insulin Side effects - hypoglycemia - disulfiram effect (do not use alcohol) Nursing care - avoid with sulfa allergy - give 30 minutes before mealsd
40
Non-insulin injectable: Amylin Analog (Pramlintide) Action Side effect Nursing Care (3)
Action: suppress glucagon secretion to control postprandial rise in glucose Side effect: hypoglycemia Nursing care - Give subQ right before any major meal - Do not give if client hypoglycemia unawareness, noncompliance, or poor adherence to treatment regimen or SMBG - Give 5 cm/ 2 in away from any insulin injection given at same time
41
SubQ Insulin: Rapid Acting (aspart, lispro) Onset Peak Nursing Care (2)
Onset: 15 min Peak: 30 min - 1.5 hr Nursing Care - used w/ longer-acting - meal must be eaten at time of injection
42
SubQ Insulin: Short Acting (regular) Onset Peak Nursing Care (2)
Onset: 30 min Peak: 2-5 hr Nursing Care - covers insulin needs for meal within 30-60 minutes - only insulin that can be given via IV (usually for DKA in ICU)
43
SubQ Insulin: Intermediate Acting (NPH, Novolin 70/30) Onset Peak Nursing Care (3)
Onset: 1.5 hr Peak: 4-12 hr Nursing Care - covers insulin needs b/w meals or overnight - can be combined w/ rapid or short acting insulin (ALWAYS PULL UP SHORTER ACTING ONE FIRST TO AVOID CONTAMINATION) - appears white and cloudy
44
SubQ Insulin: Long Acting (glargine, detemir) Onset Peak Nursing Care (3)
Onset: 1-4 hr Peak: none Nursing Care - give once daily at same time each day - never mix with another insulin - never give IV (always give subQ)
45
Insulin storage (3)
- Always have insulin on hand (esp if traveling) - Can store at room temp for 30 days - Can store longer in refrigerator
46
5 things to know before giving insulin
- Type of insulin plus onset, peak - Blood glucose level - Food that will be given - s/s of hypoglycemia - Always document site of injection
47
3 Complications of Insulin therapy (and prevention) What are they? How can it be prevented?
Hypoglycemia - prevent w/ sliding scale checks Lipoatrophy (uneven tissue) and Lipohypertrophy (lumps of fatty tissue) - prevent by rotating sites within same area of body to also prevent change in absorption rates Dawn phenomenon - 5-6am rise in glucose due to cortisol release - Prevention: Check blood glucose at bedtime and adjust insulin accordingly
48
Patient Education for Insulin pump (2)
- take off for baths and swimming - change needle q2-3 days to prevent infection
49
Diabetic Neuropathy: Autonomic Symptoms (4)
Affects nerve conduction of ▪ Heart (exercise intolerance, painless MI, altered left ventricular function, syncope) ▪ GI (gastroparesis, reflux, early satiety) -- promote motility w/ metoclopramide ▪ GU (urinary retention, decreased bladder sensation) ▪ Masks hypoglycemia and traditional indicators of heart attack (chest, back, or jaw pain)
50
Diabetic Nephropathy: Interventions (4)
* Report output < 30 mL/ hr * Urinalysis, BUN, microalbumin, blood creatinine levels taken yearly * Avoid soda, alcohol, and toxic levels of NSAIDs and acetaminophen * Consume 2-3 L/day of fluid from food, beverages w/ artificial sweetener, and drink adequate water
51
Chronic Complications of Diabetes: Microvascular (6)
- Retinopathy (blurry vision -> blindness)- leading cause of blindness - Nephropathy (kidney dysfunction and increased permeability) - Neuropathy (nerve dysfunction)- Fingers, toes, feet; autonomic; Tingling, numbness, prickly - Sexual dysfunction (Male- ED or retrograde ejaculation; Female- decreased libido, dyspareunia) - periodontal disease - integumentary disorders (infections, poor wound healing, patchy color changes, sclerosing)
52
Basic Pathophysiology of Diabetic Chronic Complications (2)
- Hyperglycemia thickens membranes in vital organs - Decreased blood perfusion to vessels cause tissue hypoxia and ischemia
53
Chronic Complications of Diabetes: Macrovascular (2)
Cardiovascular disease- Higher risk for MI, hyperlipidemia, hypertension Cerebrovascular disease- Stroke
54
S/s of hypoglycemia (9)
- Tremors and lack of coordination - restless and irritability - Blurred vision (temporary) - Seizures -> coma - Excessive hunger - Cold, clammy skin - Pallor - CNS decline (headache, confusion, fatigue, drowsiness, depression, dizziness, slurred speech) - SNS activation (tachycardia, diaphoresis, nervousness, palpitations)
55
Patient Education Diabetes: Foot care (11)
- Trim nails trimmed straight across w/ clippers or emery board - Inspect and wash feet daily with mild soap and warm water - Test water temperature with the arms or a thermometer before washing feet. - Do not soak the feet. - Pat feet dry gently, especially between the toes, - Avoid lotions between toes to decrease excess moisture and prevent infection. - Use mild foot powder (powder with cornstarch) on sweaty feet. - Do not use commercial remedies for the removal of calluses or corns (can increase risk for tissue injury and infection) - Separate overlapping toes with cotton or lamb’s wool. - Do not use hot water bottles or heating pads to warm feet. (use socks) - Avoid prolonged sitting, standing, and crossing of legs.
56
Patient Education Diabetes: Footwear (7)
- Avoid open-toe, open-heel shoes - Leather shoes are preferred to plastic. - Wear shoes that fit correctly. - Wear slippers with soles - Do not go barefoot. - Wear clean, absorbent socks or stockings that are made of cotton or wool - Wear socks at night if the feet get cold.
57
Patient Education Diabetes: Exercise (5)
- less insulin needed if exercising - Exercise (150/min/week at least 3 sessions a week) - Only exercise if glucose b/w 80-250 mg/dL (check glucose prior to exercise) - Do not exercise if ketones in urine - Consume carbohydrate snack prior to exercise IF 1 hr since last eating and high-intensity exercise planned
58
Patient Education Diabetes: Illness (5)
- Illness and stress can increase glucose levels so continue insulin even if not eating - Monitor blood glucose q2-4 hrs - Monitor urine for ketones q3-4 hrs or if blood glucose > 240 mg/dL - Drink 8-12 oz (240-260 mL) of sugar-free, non caffeinated liquid every hr OR Drink fluids w/ sugar if blood glucose low - Meet carb needs w/ soft food or liquids 6-8 times a day (Soft foods: custard, cream soup, gelatin, graham crackers)
59
Patient Education Diabetes: Nutrition (7)
- watch protein levels if kidney involved (aim for 15-20% of diet) - Eat at regular times and do not skip meals - eat consistent amounts of food - Avoid alcohol - Increase fiber for carb metabolism and cholesterol control - artificial sweeteners encouraged - Low fat diet but include omega-3 fatty acids in diet
60
Treatment for hypoglycemia If conscious (3) If unconscious (2)
If responsive - Simple Carbohydrates (6 crackers, 2 graham crackers, 4 oz fruit juice, 4 oz 2% milk; glucose tablets) - repeat if hypoglycemia persists - If hypoglycemia resolved and next meal > 1 hr away, take snack w/ carb and protein If unresponsive or seizing - 1 amp (50ml) dextrose 50% (D5W) IV push or 1mg glucagon SQ - place lateral to prevent aspiration
61
Acute Complications of Diabetes (When to call HCP) - 8
- Presence of moderate to large urine ketones or ketonuria for more than 24 hr - Blood glucose > 250 mg/dL that does not resolve with treatment - Fever > 38.6° C (101.5° F), does not respond to acetaminophen, or lasts more than 24 hr - Feeling disoriented or confused - Experiencing rapid breathing - Persistent NVD - Inability to tolerate liquids - Illness >2 days
62
Hyperglycemic-hyperosmolar state (HHS) and Diabetic Ketoacidosis (DKA) 2 things they have in common 2 differences Treatment for both (3)
both have insulin deficiency and very high glucose levels (> 300) DKA primarily type 1 DM and has ketonuria. HHS primarily type 2 DM and has severe dehydration Treatment: ICU, NS fluids, IV insulin
63
8 patient indications for TPN
- cannot tolerate enteral nutrition - extensive burn injuries - poor wound healing - specific GI disease (UC, Crohns, GI fistula) - hepatic failure - pancreatitis - malignant diseases - malnourished
64
Nursing Care for TPN (5)
- monitor glucose (risk for hyperglycemia w/ TPN; risk for hypoglycemia if no TPN) - If TPN stops, give D10 to prevent hypoglycemia - Monitor labs (albumin, prealbumin) - regularly assess IV b-c risk for phlebitis/ infection w/ high glucose - prevent hypoglycemia by call pharmacy prior to bag running out
65
Difference b/w the following surgeries - Elective - Urgent - Emergent
Elective - Can be scheduled to correct nonacute problem Urgent - Must be performed in 24-48 hrs b-c life threatening if not Emergent - Life-threatening so surgery ASAP
66
5 safety tools in perioperative care
- SBAR (Situation, Background, Assessment, Recommendation) - Surgical Safety Checklist ( prior to person receiving anesthesia ) - TeamSTEPPs (Team Strategies and Tools to Enhance Performance and Patient Safety)- involves teamwork, communication, collaboration, and safety - SCIP (Surgical Care Improvement Project) - National Patient Safety goals (NPSG)
67
5 National Patient Safety goals (NPSG)
Correct patient Correct procedure Correct site and side Correct site marking Intentional pause before surgery (time out
68
8 SCIP (Surgical Care Improvement Project) Data elements
- Antibiotics given within 1 hour prior to surgical incision.(Vancomycin and Fluoroquinolones=2 hours) - Prophylactic antibiotics should be discontinued within 24 hours of anesthesia end time (48 hours for CABG patients) (Reason for continuing antibiotics > 24 hours after anesthesia end time (48 hours for CABG patients) must have a physician documented infection) - Appropriate hair removal (clippers vs razor) - Normal patient temperature (36.0 C or greater) within 30 minutes prior to or 15 minutes after anesthesia end time - If beta blocker in hx, must continue day before surgery/ day of surgery AND post op day 1/post op day 2 (If not given, contraindications must be documented) - VTE (DVT) prophylaxis must be applied/administered within 24 hours prior to anesthesia start time or 24 hours after anesthesia end-time. - Foley discontinued by post-op day 2 or obtain physician order for specific reason to continue foley. - Cardiac Surgery patients require Controlled Postoperative Blood Glucose levels less than or equal to 180 within 18-24 hours after anesthesia end time
69
Preoperative Phase: Medical History (2)
- Medical history (including renal, musculoskeletal, cardiac, pulmonary dz.) b-c these can increase risk for complications - hx of prostheses (do not place electrocautery pads on these area)
70
Preoperative Phase: surgical History (3)
- Prior surgical procedures and how these were tolerated (previous complications, may increase anxiety) - Prior experience with anesthesia (e.g., difficulty being aroused after surgery, ongoing nausea and vomiting) - Prior experience with postsurgical pain control
71
Preoperative Phase: allergies (2)
- Latex allergy cross sensitivity w/ avocado, banana, kiwi, strawberry allergies - Propofol allergy cross sensitivity w/ egg, peanut, and soy allergy
72
Preoperative Phase: social and family history (5)
- Family History- (malignant hyperthermia, cancer, bleeding disorder) - Prescription drugs/OTC - Complementary/alternative practices (herbals, folk remedies) - Alcohol - DT if abrupt withdrawal - Substance abuse, tobacco use, marijuana use - smoking can increase risk for pulmonary complications
73
Malignant Hyperthermia Pathophysiology Onset Treatment
Patho: Acute, life-threatening complication begins when skeletal muscle is exposed to specific agent (halothane -flurane, succinylcholine); poor thermoregulation increases calcium in muscles Onsets: can be immediate or delayed (even after end of anesthesia) Treatment: Dantrolene
74
Malignant Hyperthermia Signs and Symptoms (8)
- High temperatures (late sign > 111.2 F) - Dysrhythmias - Tachycardia - Muscle rigidity (jaw and upper chest) - Hypotension - Cyanosis - skin mottling - tachypnea
75
Malignant Hyperthermia Diagnostic changes (5)
- hypercalcemia - hyperkalemia - metabolic acidosis - rise in end tidal CO2 (decreased O2) - most sensitive indicator) - myoglobinuria (muscle protein in urine- brown or colored urine)
76
Preoperative Care: lab testing (6)
- Urinalysis (protein, glucose, blood, bacteria, pregnancy) - Blood type and screen - CBC - PT, aPTT, INR, platelet count (clotting studies) - Electrolytes (CMP or BMP) - Creatinine, BUN
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5 Options for handling blood loss
- Autologous (by patient few weeks prior to surgery)- eliminates transfusion reactions and risk for bloodborne disease - Directed blood donation (from family member or friend) - Limit number and amount of blood samples before surgery - stimulate RBC production w/ Supplements (iron, folic acid, vitamin B12, vitamin C) or Epoetin Alfa - Intraoperative cell salvage (suction, wash, and filter blood back into body)- No limits to amount and no risk for bloodborne disease
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Preoperative Care: Imaging/Diagnostics testing (3)
- Chest X-ray (identify pneumonia, TB, HF, cardiomyopathy if hx of respiratory problems) - Electrocardiogram/EKG (if hx of cardiac disease or > 40 yrs) - CT/MRI- May be done for back surgery
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Preoperative Care: Cardiovascular and respiratory Assessment finding to report (7)
* Chest pain * Irregular heart rate * Hypotension or hypertension * Heart rate <60 or >100 beats/min * Shortness of breath, dyspnea, tachypnea * Pulse oximetry reading of less than 94% * Presence of implantable cardiovascular devices such as a pacemaker or implantable cardioverter defibrillator (ICD)
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Preoperative Care: S/s of infection to report (7)
* Fever * Purulent sputum * Increased white blood cell count * Dysuria or cloudy, foul-smelling urine * Any red, swollen, draining IV or wound site * vomiting * rash
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Preoperative care: Labs that may contraindicate surgery (4)
* Hypokalemia (digoxin toxicity, slower recovery from anesthesia, cardiac irritability) * hyperkalemia (dysrhythmias) * Positive pregnancy test result (or patient report of actual or possible pregnancy) * Increased prothrombin time (PT), international normalized ratio (INR), or activated partial thromboplastin time (aPTT)
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Preoperative Care: Neurologic (2)
- Minimum is assessment of coping skills, mental health history and note about recent behavioral changes - report changes in mental status
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Preoperative Care: Medications increase risk for complication (5)
* Antihypertensives * Tricyclic antidepressants * NSAIDs * Immunosuppressive drugs * Anticoagulants (hold days before procedure)
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Preoperative Care: Nutrition and Diet (4)
- usually NPO (no clear liquid <2 hrs, no food < 6 hr) to prevent risk for aspiration - No eating, drinking, smoking (increases gastric secretions), chewing gum or oral meds - may give drugs for some conditions (Beta blockers, respiratory, anticonvulsants, antihypertensives) w/ sip of water - may continue subQ insulin to prevent DKA (other antidiabetics are held)
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Preoperative Care: Integumentary (4)
- shower or bath w/ antiseptic - Clipping of hair with electric clippers (no razor) - surgeon must mark site while patient conscious - large bore IV placed (for meds and blood if necessary in emergencies)
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Preoperative Care: Conditions that increase risk for complications (4)
- Age: > 65 yrs - Malnutrition or Obesity - Conditions (Diabetes, hemodynamic instability, dehydration; any chronic conditions) - Impaired coping
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Preoperative Care: Intestinal preparation Purpose Interventions (3)
Purpose: prevents injury to colon and decrease intestinal bacteria Interventions - enema until clear (fall risk) - laxatives - bowel prep
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Informed Consent Surgeon role Nurse Role (3)
Surgeon role - explain procedure and get informed consent prior to procedure Nurse role - sign as a witness to the signature on consent (not to patient's understanding) - clarify facts as needed - not responsible for providing detailed info about procedure
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Informed Consent Variations (5)
- Pts who cannot write (sign w/ X and two witnesses) - Pt w/o competence (legal guardian, POA or Court appointed advocate gives consent) - Pt w/ blindness (can sign w/ two witnesses) - Pt w/ hearing impairment or different language (can sign w/ qualified translator and another witness) - Life threatening (can’t give consent, unable to contact person with medical power of attorney-written consultation with 2 independent HCP required)-- does not override living wills/ advance directives
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Postoperative Care: Respiratory Complications Risk Factors (4)
- elderly - lung disease - benzos - hypothermia
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Postoperative Care: Respiratory Complications (6)
- Atelectasis - pneumonia - PE (result of DVT) - Laryngeal Edema - Pulmonary Edema - ventilator dependence
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Postoperative Care: Respiratory Complications Prevention (8)
- Breathing exercises (expansion breathing, diaphragmatic breathing) - Incentive spirometry (seal lips, inhale, hold 3-5 sec, exhale to promote lung expansion) - Coughing and splinting (w/ bath blanket or pillow) q1-2 hrs (contraindicated in some surgeries) - give older adult low dose oxygen first 12-24 hrs - monitor O2, lung sounds q2-4 hrs for first 24 hr - positioning (side lying or semi fowlers) - suction PRN - early ambulation (lung expansion; turn q2h)
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Postoperative Care: Respiratory Signs of complications (5)
- If RR <10 breaths/min, may be anesthetic or opioid analgesic-induced respiratory depression - If rapid, shallow respirations, may be shock, cardiac problems, pain, increased metabolic rate - stridor or snoring may be due to airway obstruction - accessory muscle use may be excess anesthesia, airway obstruction, paralysis - spO2 < 95%
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Postoperative Care: Neurologic Complications (4)
- cerebral infarction - cognitive decline - epidural hematoma - infection (meningitis)
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Postoperative Care: Neurologic Complications Prevention/Interventions (2)
- assess LOC, awareness, motor/sensation, DTRs - If received sedation or general anesthesia in ambulatory setting, need another adult to drive them home
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Postoperative Care: Neurologic Signs of Complications (4)
- Eye opening to command = arousability and wakefulness but not aware - back pain while coughing or straining = may be epidural hematoma - occipital headache = postdural puncture headache) - nuchal rigidity, high fever, acute confusion = meningitis
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Postoperative Care: GI Complications (4)
- Nausea/vomiting (risk for increased ICP or IOP, abdominal irritation, aspiration) - GI ulcers/bleeding - paralytic ileus (due to anesthetics, bowel handling during surgery, opioids, or SNS excitation from stress) - Constipation (due to anesthesia, opioids, decreased activity, decreased oral intake
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Postoperative Care: Nausea and Vomiting Prevention/ treatment (2)
- give medication (ondansetron and dexamethasone) - Positioning (side-lying position, raise HOB)
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Postoperative Care: Paralytic Ileus Prevention/ Treatment (7)
- auscultate bowel sounds ( no bowel sounds or flatus = ileus) - NGT insertion to decompress stomach - hydration (dehydration can decrease GI motility) - early ambulation (stimulates intestinal motility) - non opioid pain management - alvimopan – accelerates the time for GI recovery after some GI surgeries - metoclopramide- promotes peristalsis via stimulation of GI motility
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Postoperative Care: Constipation Prevention/Treatment (4)
- increased fiber - enemas - mild laxatives and bulk forming agents - hydration
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Postoperative Care: GI Complications Signs of Complications (3)
- Absence of bowel sounds = hypomotility - Abdominal cramping & distention = trapped, nonmoving gas NOT peristalsis - No passage of stool or flatus = paralytic ileus
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Postoperative Care: Cardiovascular Complications (6)
- Dysrhythmias - Hypo/hypertension (widened pulse pressure - Heart Failure - Hypovolemic Shock - DVT - Sepsis
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Postoperative Care: Cardiovascular Prevention/ Intervention (2)
- daily assessment of distal pulses (swelling, quality, color, temperature, sensation) - Report BP changes 25% change (or 15-20 point difference) from baselines
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Postoperative Care: Cardiovascular Signs of Complications (4)
- Decreased BP, pulse pressure, abnormal heart signs = cardiac depression, fluid volume deficit, shock, hemorrhage, effects of drugs - Increased pulses = hemorrhage, shock, pain - Pulse deficit (difference b/w apical and other pulses) = dysrhythmia - Bradycardia = hypothermia, anesthesia effect
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Postoperative Care: Neuromuscular Complications (3) Prevention
Complications - Hyper/Hypothermia - Nerve damage/paralysis - Joint Contractures Prevention - early ambulation (prevents joint rigidity)
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Postoperative Care: Kidney/Urinary Complications (5)
- Acute kidney injury (AKI) - Acute urinary retention - Electrolyte imbalance - Kidney stone formation - Urinary tract infection
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Postoperative Care: Kidney/Urinary Signs of complication (2)
- Urinary retention may be from pre-op drugs (atropine), anesthetics, manipulation during surgery - Report urine output of <30 mL/hr (may indicate hypovolemia or renal complications)
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Postoperative Care: Integumentary Complications (4)
- Pressure injuries - Skin rashes/contact allergies - Wound infection - Impaired wound healing b/w 5-10 days (Evisceration or Dehiscence)
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Postoperative Care: Integumentary Prevention (5)
- check dressing and drainage (color, amount, consistency, odor) - change dressing w/ aseptic technique - splint incision to prevent evisceration or dehiscence - early ambulation (relieves pressure) - assess site prn or every shift for warmth, redness, drainage
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Postoperative Care: Integumentary Signs of complication (3)
- Large amount of sanguineous drainage = poor clotting and internal bleeding - Serosanguineous drainage after 5th day or increased amount = dehiscence sign - redness or swelling around incision, excess tenderness or pain on palpation, purulent odorous drainage = surgical site infection
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Postoperative Care: Integumentary Risk factors for poor wound healing (4)
- decreased potassium, vitamin C and B, iron, zinc - low protein and negative nitrogen balance - obesity (fatty tissue has less nutrients, collage, and BVs) - malnutrition (s/s: low albumin; muscle wasting, brittle nails, poor skin turgor, Orthostatic hypotension, dry and dull hair and skin)
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Postoperative care: VTE S/s Intervention (5)
S/s: sudden swelling or dull ache in calf of one leg Prevention - Antiembolism stockings (TED Hose) and Sequential Compression Devices (SCD) - Anticoagulants (enoxaparin, heparin) - Leg Exercises (practice prior to procedure) - Early ambulation (stimulates venous return) - do not place pillows under knees b-c reduces circulation
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Patient preparation for Intraoperative (6)
- ID band (name, hospital number, birthdate) - Removal of clothing (may leave underwear and socks for some surgeries, dentures, jewelry, piercings - Removal of prosthetics (limbs, eyes) - Removal of all metal (i.e., hairclips, pins) - can cause burns w/ electrical current - Nail polish/artificial nails (at least one clean) - Empty bladder - to prevent incontinence or overdistention
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What items should be transitioned w/ client to OR? (4)
- Ensure patient is wearing ID band - Use two patient identifiers - Complete pre-op checklist - Signed Consent Form
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Purpose of the following drugs in preoperative care: Anxiolytics (midazolam) - 1 Sedatives (hydroxyzine) & Hypnotics (Lorazepam) - 1 Opioids - 1
Anxiolytics (midazolam) - Reduce anxiety Sedatives (hydroxyzine) and Hypnotics (Lorazepam) - Promote relaxation Opioids - Decrease amount of anesthetic needed for induction and maintenance
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Purpose of the following drugs in preoperative care: Anticholinergics (atropine) - 3 H2 Histamine blockers-cimetidine, ranitidine - 1
Anticholinergics (atropine) - Reduce nasal and oral secretions - Prevent laryngospasm - Reduce vagal-induced bradycardia H2 Histamine blockers-cimetidine, ranitidine - Inhibit gastric secretion
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Things included in post-op hand off (7)
- Type and extent of surgical procedure - Anesthetics (type and length) - Health history (inc. allergies, communication or sensory impairments, conditions) - Complications (esp respiratory function, intraoperative blood loss) - VS/I&O/IV/Blood products/Medication - Incisions/dressings/tubes/drains - Joint/limb immobility (intra and postoperative
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Postoperative care: I And O Input Output Hydration status (2)
Input: oral fluids, IV fluids Output: Urine, vomitus, NGT drainage, wound drainage Hydration Status: - best way for them is I &O b-c difficult to weigh - check mucous membranes, skin texture and turgor, axillary sweat
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Postoperative care: NGT Purposes (4)
- Decompress stomach - Promote GI rest so lower GI tract to heal - monitor gastric bleeding - prevent intestinal obstruction
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Postoperative care: NGT Decompression Nursing care (4)
- Do not administer feeding through NGT (decompression) - Secure NGT to patient’s gown - Semi-fowler’s position - turn off suctioning prior to auscultating bowel sounds
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Postoperative care: NGT Drainage colors (3)
- Normal drainage = greenish yellow - Red or pink drainage = active bleeding - Brown drainage w/ coffee ground appearance = old bleeding
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Postoperative care: Drains and Dressings Purpose (2) Expectations (2) Nursing Care (2)
Purpose - remove fluid, air, blood, bile - prevent deep infection and abscess formation Expectations - drainage goes from sanguineous to serosanguineous to serous - surgeon changes first dressing Nursing Care - circle, date, time drainage on dressings - secure drains to pt's gown and not sheet or mattress
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Nonverbal indicators of pain (5)
- Increased pulse, BP, RR - Profuse sweating - Restlessness - Confusion (older adults) - Grimacing, wincing, moaning, crying
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Postoperative care: pain management (3)
- plan activities around timing of analgesia - PCA w/ morphine sulfate, hydromorphone hydrochloride, oxycodone w/ acetaminophen, ketorolac - nonpharmacological (diversional, reposition, relaxation, massage (no massage for calves b-c PE risk))
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Emergency Care for Benzo Overdose (6)
- Secure the airway and IV access - Administer oxygen as prescribed if hypoxia is present or RR< 10 - give flumazanil (repeat q2-3 mins as needed up to 3 mg) - Have suction equipment available b-c flumazenil can trigger vomiting or lower seizure threshold - Do not leave the patient until fully responsive. - monitor vital signs and LOC every 10 to 15 minutes for the first 2 hours b-c flumazenil is eliminated quicker than benzodiazepines.
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Flumazenil Use Side effects (7)
Use: Benzo overdose Side effects - tremors or convulsions (lowers seizure threshold in those with seizure disorders) - thrombophlebitis at IV site - skin rash - hot flushes or sweating - dizziness/headache - dry mouth - blurred vision
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Emergency Care for Opioid Overdose (9)
- IV naloxone hydrochloride when possible (other routes available if no IV access) - Maintain an open airway. - repeat naloxone q2- to 3-minute intervals if needed - Administer oxygen if hypoxia is present or if RR < 10 breaths/min. - Have suction equipment b-c naloxone can trigger vomiting - monitor vital signs and LOC every 10 to 15 minutes for the first hour b-c naloxone is eliminated quicker than opioids - Watch for naloxone side effects i.e. blood pressure changes, tachycardia, and dysrhythmias. - Do not leave the patient until he or she is fully responsive. - Assess the patient for breakthrough pain because reversal of the opioid also reverses the analgesic effects.
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Postoperative care: Dehiscence (4)
- Apply sterile non-adherent dressing or saline dressing to the wound - Notify surgeon - Instruct to bend knees - Avoid coughing
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Postoperative Care: Evisceration (8)
- Ask someone to notify Surgeon b-c SURGICAL EMERGENCY - Stay with patient and calm them - Do not attempt to reinsert the organ - Cover wound with pre-moistened saline non-adherent dressing or Moisten sterile gauze with sterile saline (STERILE TECHNIQUE) - Keep dressings moist (do not let dressing dry out) - Place supine position with hip and knees bent - HOB elevated 15-20 degrees - Pt NPO until issue resolved
Concepts 2
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