1
Q
3 inpatient surgical procedures
A
- ) emergent- Immediately
- ) urgent- schedule ASAP
- ) elective
2
Q
outpatient surgical procedures
A
- most often elective
- not acute
- Ex: cataract removal, hernia repair
3
Q
pre-operative period Rn role
A
- begins when pt scheduled for surgery
- physical/mental assessment
- blood donations
- informed consent (signing)
- teaching
- discharge planning
4
Q
pre-operative teaching
A
•pain control •breathing/spirometer •ROM •anti-embolism •diet •invasive devices •anti-anxiety *demonstrate and then have pt state understanding and demonstrate
5
Q
intra-operative period Rn role
A
- monitor for resp. depression
- maintain body temp
- equipment count
6
Q
biggest concern of opioids/sedatives
A
•respiratory depression
*reverse w/ Narcan
7
Q
hypothermia during surgery
A
•increases chance of surgical/wound infection
•alters metabolism of meds
*why need to give pt warm blanket
8
Q
malignant hyperthermia
A
•life-threatening complication of exposure anesthetics •tachycardia/pnea •elevated body temp •muscle rigidity •skin mottling •cyanosis •myobloinuria (muscle protein in urine) •rise in tidal CO2 and decrease in O2 sat *tx w/ cold IV and Dantrolene
9
Q
post-operative Rn role
A
- evaluate/stabilize pt
- prevent complications (ABC priority)
- determine readiness for discharge (ambulate/fluids/VS)
10
Q
post-op complications
A
- airway obstruction
- hypoxia (day 2)
- hypovolemic schock (massive loss circulating blood)
- paralytic ileus
- wound dehiscence or evisceration
- DVT
11
Q
general anesthesia
A
•reversible loss of consciousness induced by inhibiting neuronal impulses in CNS
•causes analgesia, amnesia, unconsciousness, and loss of reflexes/tone
•used for major surgery or requiring major muscle rlx
*usually balanced- inhaled, IV, & adjuncts
12
Q
local anesthesia
A
- loss of sensation w/o loss of consciousness
- motor fxn may/may not be affected
- topical, local infiltration, or regional
- often supplemented w/ sedative, opioid analgesics, hypnotics
- risk for aspiration low b/c cough/gag reflex intact
13
Q
regional anesthesia
A
- blocks multiple peripheral nerves in specific body region
- field
- nerve
- spinal
- epidural
14
Q
moderate (conscious) sedation
A
- IV delivery of sedative, hypnotic, opioid drugs to reduce LOC for minor procedures w/o pt having discomfort
- pt responds to verbal stimuli, retains reflexes, and is easily aroused
- pt maintains airway
- often used for burn debridement
15
Q
major components of body fluid
A
1.) intracellular (ICF)- ⅔
2.) extracellular (ECF)- ⅓
•ECF includes intravascular and interstitial
•fluid can move b/t
16
Q
hypotonic ECF
A
- osmolarity of less than 270 mOsm/L
- fluid into cells (lyse)
- 0.5% NS
17
Q
hypertonic ECF
A
- osmolarity of greater than 300 mOsm/L
- fluid out of cells (crenation)
- 1.5% NS or 3% NS
18
Q
isotonic ECF
A
- osmolarity of 270-300 mOsm/L
* 0.9% NS
19
Q
major causes of fluid/electrolyte imbalances
A
- renal/GI/cardiac dysfunction/losses
- hemorrhage
- third spacing (ascites/burns)
- intake
- fever
- hormones
20
Q
aldosterone
A
•excreted by the cortex of the adrenal gland in response to low Na+ levels
•prevents sodium and water loss
*RETAIN fluid (FVD)
21
Q
anti-diuretic hormone (ADH)
A
•Produced in the posterior pituitary
•acts on kidneys to make kidneys reabsorb more water so that the body retains more fluid
*RETAIN fluid (FVD)
22
Q
natriuretic peptides (NPs)
A
•released in response to barorecptors in the heart or vascular system detecting increased blood volume
*LOSE fluid (FVE)
23
Q
renin-angiotension system
A
- in response to low BP, blood volume, blood O2, and blood osmolarity kidneys excrete renin
- renin activates angiotension I, which is converted to angiotension II (active form) by ACE
24
Q
3 fxns of angiotension II
A
- vasoconstrictor
- causes nephrons to contract, decreasing UOP
- causes kidneys to release aldosterone
25
an ACE inhibitor would be classified as...
* diuretic
* lowers BP b/c blocks production of angiotension II
* commonly used for mild HTN
26
fluid-volume deficit (FVD)
* hypovolemia and dehydration
* tachy/thready
* increased hemoconcentration
* hyperthermia, hyPOtension, confusion, oliguria
* increased serum osm, Hct, Hgb, urine specific gravity
* HYPERNATREMIA
* tx w/ fluid (PO pref.)
27
hypovolemia vs/ dehydration
•hypovolemia is fluid and electrolyte loss, while dehydration is just fluid loss
28
hypovolemic shock
* decreased oxygen to organ/pressure to organ
* complication of FVD
* tx w/ O2, fluids, vasoconstrictors (increase central flow first)
29
hemoconcentration
•decrease in the volume of plasma in relation to # of RBCs
•increase in concentration of circulating RBCs
•increases in Hct, Hgb, electrolytes, and urine specific gravity
*expected in endurance athletes
30
fluid volume excess (FVE)
* hypervolemia or over-hydration
* tachy/bounding
* weight gain/crackles/edema
* hyPERtension
* decreased hemoconcentration, Hgb, Hct, serum osm
* HYPONATREMIA
* tx w/ Na+, diuretics, O2
31
expected serum Na+ levels
* 135-145 mEq/L
| * imbalances cause NEURO problems (influences conduction rates)
32
hypernatremia
* Na+ > 145 mEq/L
* due to increased Na+ or excessive water loss
* hypertonic serum (crenation)
* dehydration
* tx w/ hypo/iso IV
33
hyponatremia
* Na+ < 135 mEq/L
* due to decreased Na+ or excessive water concentration in relation to sodium
* hypotonic serum (lyse)
* over-hydration
* tx w/ hyper IV, ACE inhibitors, diuretics
34
expected K+ levels
* 3.5-5.0 mEq/L
| * imbalances cause CARDIAC problems
35
hyperkalemia
* K+ > 5.0 mEq/L
* due to increased K+ intake, K+ out of cells (diabetes/tumor lysis), salt sub.
* EKG shows peaked T waves
* tx w/ decreased K+ intake, Kayexalate (K+ in stool), diuretics
36
hypokalemia
```
•K+ < 3.5 mEq
•results from decreased intake, movement of K+ into cells (insulin high), Lasix (furosimide) cause K+ loss
*key s/s is fluttering chest
•EKG shows inverted T waves
•tx w/ PO K+ (never bolus)
```
37
expected Ca2+ levels
* 9.0-10.5 mg/dL
| * imbalances cause SKELETAL MUSCLE problems
38
hypocalcemia
* Ca2+ < 9.0 mg/dL
* bradycardia, hypotension, hyper bowel
* muscle cramps (SPASMS)
* risk of seizure/fall
* Trousseau's sign- wrist spasm with BP cuff
* Chvostek's sign- cheek muscle twitch when tap
39
hypercalcemia
```
•Ca2+ > 10.5 mg/dL
•lethargy, paresthesia b/c less sensitive to normal stimuli
•mscl WEAKNESS
•causes faster clotting time
*high risk for DVT
```
40
expected phosphorus level
* 3.0-4.5 mg/dL
| * imbalances cause SKELETAL MUSCLE problems
41
hyphosphatemia
* phos < 3.0 mg/dL
* same as HYPERCALCEMIA
* muscle weakness
42
hyperphasphatemia
* phos > 4.5 mg/dL
* same as HYPOCALCEMIA
* muscle spasms
43
phosphorus food sources
* fish
* chicken
* beef
* pork
* organ meats
* nuts
* whole grains
44
expected Mg2+ levels
* 1.3-2.1 mEq/L
| * abnormalities involve DTRs
45
hypomagnesemia
* Mg2+ < 1.3 mEq
* HYPERACTIVE DTRs
* occurs in conjunction w/ hypocalcemia (spasm)
* tetany, seizure, psychoses
46
hypermagnesemia
```
•Mg2+ > 2.1 mEq/L
•HYPOACTIVE DTRs
•occurs in conjunction w/ hypercalcemia (weakness)
•coma, bradycardia, hypotension
*use of laxatives poses major risk
```
47
use of laxatives risk
* hypermagnesemia
| * hypokalemia
48
normal Hgb values
•m: 14-18 g/dL
•f: 12-16 g/dL
*hemochromatosis- too much Hgb
49
normal Hct values
•m: 50-57 ml/dL (50-54%)
•f: 37-48 ml/dL (37-48%)
*% of packed RBC/dL of blood
50
normal RBC values
•m: 4.7-6.0 million/uL
•f: 4.2-5.4 million/uL
*4.5-6
*polycythemia vera- too many RBCs
51
anemia
•abnormally low RBCs, Hgb, and/or hematocrit
•results in diminished O2 carrying capacity and deliver to tissues/organs
*goal of tx is to restore/maintain adequate tissue oxygenation
52
anemia causes
* blood loss
* inadequate RBC production (hypoproliferative)
* increased RBC destruction (hemolytic)
* Fe, folic acit, erythropoietin, and/or B12 deficiency
53
s/s anemia
* tachy, hypotension, HF
* pallor, cold, brittle nails
* weakness, fatigue
* dyspnea, decreased O2 on exertion
* somnolence, forgetfullness, dizziness
54
Hgb levels in mild anemia
•10-14 g/dL
55
Hgb levels in moderate anemia
•8-10 g/dL
56
Hgb levels in severe anemia
• < 8 g/dL
| * < 10 g/dL when clinical manifestations show
57
hemolytic anemia
* due to excessive destruction of RBCs (or SCD)
* splenomegaly and jaundice
* followed by acceleration of erythropoises
* response to trauma, infection, chemical exposure, autoimmune rxns
58
tx hemolytic anemia
* steriods
* spenectomy
* chemo
* plasma exchange
* immuno-suppressant agents
59
iron-deficiency anemia (IDA)
* due to inadequate intake, most common in children, adolescents, and preggo
* due to blood loss is common in older adults
* menstruating women can develop secondary to menorrhagia
* Hgb < 8 g/dL
* Fe level 10 micrograms/dL
* TIBC increase (trying to signal more iron to come)
60
IDA tx
* encourage intake
* PO iron supplement (w/ OJ or vit C to absorb best)
* Iron dextran- IM
* transfusion packed RBCs
* discontinue anti-acids, coffee, tea b/c impair Fe absorption
61
pernicius anemia
* due to vit B12 (cobalamin) deficiency
* lack of intrinsic factor found in GI mucosa, which is necessary for B12 (extrinsic factor) absorption
* low Hgb, Hct, cobalamin, and RBC
* weakness/fatigue
* jaundice
* memory/personality changes
* paresthesia
62
pernicius anemia tx
•parenteral/intranasal admin of B12
63
folic acid deficiency anemia
* decreased RBC, Hgb caused by impaired production r/t decreased folate level
* higher risk if poor nutrition, malabsorption syndromes (Crohn's), anticonvulsant/oral contraceptive use, alcoholism, anorexic
64
iron food sources
* red/organ meat
* leafy greens
* egg yolks
* almonds
* legumes
* dried fruit
65
vit B12 food sources
* meat/poultry
* eggs
* milk products
* fortified cereals
66
folic acid food sources
* beans/legumes
* citrus fruits/juice
* fortified bread, cereals, pasta, etc
67
homologous blood transfusion
•from another donor
68
autologous blood transfusion
* pt blood collected in anticipation of future transfusion
* donated 5 wks- 72 hrs prior to elective surgery
* eliminates risk of alloimmunization (immune response to antigens)
69
whole blood transfusion
* used for massive blood loss
| * pt needs O2-carrying capacity and vol. increase
70
packed RBC transfusion
* whole blood with ⅔ of plasma removed
* used for severe anemia or moderate blood loss
* less danger of fluid overload
* transfusion of choice
* should not exceed 4 hrs transfusing
71
fresh-frozen plasma transfusion
* anti coagulated clear liquid portion of blood separated from whole blood by centrifugation
* used to reverse excessive anticoagulation
* used for clotting factor deficiencies associated w/ hemorrhagic tendency
72
administering transfusion priorities
* ensure type and Rx order
* make sure no allergy, hx rxn, etc
* cross match before getting from blood bank
* verify blood and pt #
* infuse w/ NS (NOT meds)
* remain w/ pt for first 15 min
73
hemolytic transfusion rxn
* chills, fever, urticaria (rash), tach, pain/tight chest, SOB, cloudy urine
* stop blood (keep NS)
74
febrile transfusion rxn
* sudden fever/chills, headache, flushing, anxiety, muscle pain
* give antipyretics (avoid aspirin)
75
bacterial (sepsis) rxn
•rapid onset of hypotension, fever, chills, vomit, diarrhea, and shock
stop transfusion and treat septicemia (abx, IV fluid, vasopressors, steroids)
76
allergic transfusion rxn
* antihistamine admin 15-30 min prior to transfusion to prevent
* s/s: urticaria, edema of face, asthma attack, flushing/itching
* tx: stop transfusion and KVO w/ NS
77
circulatory overload transfusion rxn
* higher risk if have renal/cardiac insufficiencies
* s/s: cough, dyspnea, headache, hypertension, tach, JVD
* tx: pt upright, O2 therapy, diuretics, morphine
78
pancytopenia
•low RBC, WBC, and platelets
79
cerebral vascular accident (CVA)
* disruption in the cerebral blood flow secondary to ischemia from thrombosis, hemorrhage, or embolism
* aka: stroke, cerebral infarction, or brain attack
80
hemorrhagic CVA
* occur secondary to ruptured artery or aneurysm
* prognosis poor b/c of amt ischemia and increased ICP caused by collection of blood
* prognosis better if stroke caught early, bleeding ceased, and clot evacuated
81
thrombotic CVA
•occurs secondary to development of blood clot on an atherosclerotic plaque in a cerebral artery
•clot gradually shuts off artery and causes ischemia distal to occlusion
•symptoms evolve over period of hrs-days (often preceded by TIA)
*occlusive
82
embolic CVA
•occur secondary to embolus traveling from another part of body to cerebral artery
•brain blood distal to occlusion immediately shut off, causing loc to occur
*occlusive
83
transient ischemic attack (TIA)
* mini stroke (warning stroke)
* caused by thrombotic clot but blockage is temporary
* sx occur rapidly but last 1-5 minutes
* warning signs almost same as stroke
* usually no permanent damage
84
reversible ischemic neurological deficit (RIND)
* caused by thrombotic clot, but blockage temporary
| * similar to TIA, but lasts longer (up to 24 hrs)
85
recombinant tissue plasminogen activator (rtPA)
•thrombolytic NZ (Activase)
•can be used to reverse ischemic stroke (thrombolitic/embolitic) if given w/ 3-4.5 hrs of initial sx
•contraindicated if hemorrhagic stroke or pt on anticoagulants
•have to rule out hemorrhagic stroke w/ MRI before initiating
*only used for clot in brain (not used for DVT)
86
AEDs for CVA
* phenytoin (Dilantin), gabapentin (Neurontin)
* usually only if patient develops seizures
* gabapentin may be given for paresthetic pain in affected extremity
87
antiplatelets
* low dose ASA-acetylsalicylic acid (aspirin) given within 24-48 hrs. following a stroke to prevent further clot formation
* Give within 4.5 hrs. of initial symptoms
88
anticoagulates
* controversial tx for CVA
* high risk of intracerebral hemorrhage
* Heparin, enoxaparin (Lovenox), warfarin (Coumadin)
89
CVA complications
* dysphagia
* aspiration
* unilateral neglect
* anosognosia- don't recognize impairments
90
left hem CVA possible abnormalities
* language, math, and analytic thinking
* expressive, receptive, global aphasia
* agnosia- inability to recognize objects
* alexia- reading diff.
* agraphia- writing diff.
* hemianopsia, hemiplegia, hemiparesis
91
right hem CVA possible abnormalities
•spatial/depth perception
•proprioception
judgment/impulse control
•hemianopsia, hemiplegia, hemiparesis
92
homonymous hemianopsia
* visual field loss on same side of both eyes
* left: due to abrasion on right side of brain (has visual pathways for left hemifield of both eyes)
* right: due to abrasion on left side of brain (has visual pathways for right hemifield of both eyes)
93
cerebrum damage
contralateral impact
94
cerebellar damage
ipsilateral impact
95
FAST
* facial drooping
* arm weakness
* slurred speech (dysarthria)
* time- call 911
96
ICP increase
•due to blood from hemorrhage, cerebral edema
•causes hyperthermia b/c pressure on thalamus, widening of pulse pressure, decreased HR
*normal: 10-15 mmHg
97
seizure
* abrupt, abnormal, excessive, and uncontrolled electrical discharge of neurons within the brain
* may cause alterations in LOC, motor/sensory ability, and/or behavior
* can be generalized, partial, or unclassified
98
primary (idiopathic) epilepsy
* chronic recurring abnormal brain electrical activity
* dx based on hx and labs to rule out other causes
* considered a syndrome
* due to imbalance of nts (GABA)
99
generalized seizure
* involves both hemispheres
* tonic-clonic
* tonic
* clonic
* absence
* myoclonic
* atonic
100
tonic-clonic (grand mal) seizure
•may (rarely) begin with aura (altered sense)
•begins w/ tonic episode (stiff muscles) and loc
•clonic episode (muscle jerk) follows tonic
•clonic phase followed by postictal phase
*lasts 2-5 min
101
postical phase
* period of confusion, fatigue, agitation, and lethargy following a tonic-clonic seizure
* lasts up to an hour
102
absence seizure
* most common in children
* loc lasting few sec
* blank staring
* automatisms
* return to baseline after seizure
103
automatisms
* involuntary behavior
* lip smacking
* eye fluttering
* picking at clothes
104
myoclonic seizure
* generalized
* brief jerking/stiffening of extremities (sym/asym)
* lasts for few seconds
105
atonic (akinetic) seizure
* few second period of muscle tone loss
* followed by period of confusion (postictal)
* frequently results in falling
* most resistant to drug therapy
106
complex partial seizure
* automatisms
* loc for 1-3 min
* amnesia possible prior to and after seizure
* temporal lobe usually involved
107
simple partial seizure
* consciousness maintained
* unusual sensations- aura, deja vu
* autonomic abnormalities (HR, flushing, epigastric discomfort)
* unilateral extremity movement
108
unclassified (idiopathic seizure)
* occur fo no known reason
| * account for ½ of all seizure activities
109
seizure risks
* increased physical activity
* stress
* hyperventilation
* fatigue
* excessive caffeine/etoh intake
* flashing lights
* chemical exposure
110
hyperventilation
* CO2 decrease (alkalosis- basic)
* Vasoconstriction b/c low CO2 (and pH) causes CSF to signal vasoconstriction (seizure)
* decrease in ICP
* too much O2 b/c no CO2 to compete w/ for Hgb site
111
nursing interventions during seizure
* PRIORITY: keep pt from injury
* maintain airway (be ready to suction)
* ease pt to floor
* turn pt on side
* remove loose items
* don't retrain/put object in mouth
112
status epilepticus
•prolonged seizure activity occurring over 30-min time frame
•decreased O2
•inability brain to return to normal fxn
*require immediate tx to proven loss of brain fxn, organ failure, dysrhythmias, etc
113
anticonvulsants (AEDs)
•tx to control seizures to some degree
•pt often requires combo for control
•doses adjusted to achieve therapeutic blood levels with least amount of side effects
•oral hygiene important when taking
*CANNOT be stopped abruptly
•educate pt on drug/food interactions (GF juice)
114
diazepam (Valium)
* acute seizure tx to prevent progression into status epileptics
* anti-convulsant, anti-anxiety, BZD, and skeletal muscle relaxer
* give 4 mg over 2 min (slow IV push)
115
lorazepam (Ativan)
* acute seizure tx to prevent progression into status epileptics
* anti-anxiety, BZD, and anti-convulsant
* give 4 mg over 2 min (slow IV push)
116
phenytoin (Dilantin)
* acute seizure tx to prevent progression into status epileptics (loading dose)
* anti-convulsant and anti-dysrhythmic
* AED for maintenance therapy
* decreases effectiveness of warfarin and oral contraceptives
117
EEG testing for seizure
* hyperventilation- rapid deep breathing
* photic stimulation- strobe light flashes
* sleep- temporal lobe epilepsy
118
MACHINE mnemonic
```
•causes of hyperkalemia
Meds (ACE, steroids, beta blockers)
Acidosis
Cellular destruction (burns, trauma)
Hypoaldosteronism, hemolysis
Intake- excessive
Nephrons- renal failure
Excretion- impaired
```
119
6 L's mnemonic
```
•signs of hypokalemia
Lethargy
Lethal cardia arrhythmia
Limp muscles
Leg cramps
Low, shallow respirations
Less stool (constipation)
```
120
FRIED mnemonic
```
•signs of hypernatremia
Fever
Restless
Increased BP
Edema
Decreased UOP
```
121
MURDER mnemonic
```
•signs of hyperkalemia
Muscle weakness
Urine- oliguria/anuria
Respiratory distress
Decreased cardiac contractility
EKG changes (peaked T waves)
Reflexes hyper or hypo
```
122
GRAPHIC IDEA mnemonic
```
•causes of hypokalemia
GI losses
Renal losses
Aldosterone excess
Periodic Paralysis
Hypothermia
Insulin excess
Cushing syndrom
Insufficient intake
Diuretics
Elevated beta adrenergic activity
Alkalosis
```
123
K-BANK mnemonic
```
•K+ increasing agents
K-sparing diuretic
Beta Blocker
ACE Inhibitor
NSAID
K supplement
```
