LO EXAM 2 Flashcards

Question

Pre op care 3) Pre op assessment: Risk factors Alcoholism

Answer 1

alters the effects of anesthesia (drinker might require more anesthesia than a non-drinker); pts with liver problems have a harder time getting rid of meds; if pt isn’t taking in “normal” amount of alcohol he/she might go thru DTs (Delirium tremens); alcoholics require more pain meds r/t poor coping skills (lack of coping skill may be the reason they drink in the first place) RN: monitor closely for signs of delirium tremens, response to anesthesia and analgesia, bleeding and wound compromise. Administer sup. nutrition as ordered, admin. Antagonist med with caution ( naloxone, flumazenil)

Answer 2

– increases risk of pulmonary complications (e.g., nicotine constricts blood vessels); excessive coughing ( chance of tearing open incisions; some cardiac and vascular surgeons will not do surgery until pt. stops smoking RN: monitoring closely for respiratory difficulties, encouraging C and DB, turning and early ambulation. Promote fluid intake 2500-3000ml to help liquify resp. secretions

Answer 3

Medications – if pt is on PRE-op meds (i.e., B/P, insulin, cholesterol, etc) he/she won’t get them POST-op if doctor doesn’t order them; nse/MD needs to know what kind, the dose, what time of day and how often the med/s are taken pt cannot bring meds in from home unless OK’ed by MD some meds may interact with anesthesia (i.e., some B/P meds, cardiac meds); Beta blockers ( the incidence of heart attacks and cardiovascular complications when they are given to pt from the time they have surgery – anesthesiologists have a protocol – Is the pt a candidate for beta blockers? assess pre-op meds to avoid potential drug interactions (e.g., if pt is on NSAID or aspirin pre-op he/she needs to stop taking it at least one week prior to surgery r/t bleeding complications); anticoagulants – have to stop Coumadin, switch to Heparin because it is much easier to reverse immediately if Dr has to. ask about ALL meds including OTC (Over The Counter), PRN and supplements

Answer 4

determines how familiar the pt is with surgery, hospital routines, etc.; a pt. who has never been hospitalized will need extra education (e.g., what the different rooms in hospital are for, how to fill out a menu, how to use the call light, how to ask for PRN meds, the visiting hours, etc.); determines if pt has had previous complications or family history of complications such as malignant hyperthermia - the body lacks the enzyme to breakdown certain drugs – anesthesia will cause the body’s temperature to rise to deadly levels (108-110°) – can give a drug (called Dyrenium [triamterene]) ahead of time to help person handle anesthetics.

Answer 5

– assess to prevent allergic/adverse reactions (e.g., uncontrollable shivering) to anesthesia, prep solutions (betadine), IV X ray contrast material, foods, latex, dressing materials (tapes, gauzes), drugs (a particular family of drugs may need to be avoided)

Answer 6

– assess for abnormalities PRIOR to surgery; abnormal cardiac status is responsible for 30% of peri-operative deaths (something the primary doctor is responsible for assessing); monitor all pts having surgery with EKG monitor ``` assess hx of: MI within the last 6 mo hx of high B/P not well-controlled CHF hx of arrhythmias (irregular heart rate) ```

Answer 7

gases used in surgery (usually start with IV meds then switch to gas) are exhaled so lungs need to be in good shape (don’t want a sick person going to surgery – anesthesiologist doesn’t want to have to suction mucus; coughing can tear open incisions and cause pt to refuse to C&DB which might lead to pneumonia); assess for clear lung sounds, lung capacity; some pts are sent for pulmonary function studies prior to surgery because if their lungs are not functioning well enough the anesthesiologist may never be able to extubate them – would need to use spinal anesthetic instead or cancel surgery

Answer 8

some anesthesia are eliminated via the kidneys, so need to assess if pt has chronic renal failure or poor kidney function; chronic constipation is common in elderly pts – might require more aggressive use of stool softeners or laxatives, etc post-op

Answer 9

poor nutrition interferes with wound healing therefore pt will be refused elective surgery unless their nutrition is reasonable; elderly and obese are the most commonly malnourished (r/t: don’t eat a lot of fruits and vegetables, possibly unable to shop regularly, etc)

Answer 10

assess to identify things that are major stressors for pt or if pt is having problems coping (e.g., job worries, childcare worries); assess if pt feeling positive or negative about procedure; assist with coping skills if possible

Answer 11

(might not see these in a nursing care plan pre-operatively, unless in hospital due to trauma and will have surgery soon) Knowledge Deficit - ask questions as to how long going to be laid up, is the incision going to show, etc. Anxiety – people cope differently Sleep Pattern Disturbance – used to admit pt the night before surgery to do lab workups, etc; but then the pt lost sleep worrying about surgery and being in a strange place. Ineffective Coping - pt coping with DX or with post-op issues; family coping with DX or with pt being out of commission

Answer 12

for pre-op to ( post-op complications and to ( pt’s understanding of surgery (e.g., why on certain drugs, why has to be off work, why may not be able to drive, why certain drugs are restricted, etc.)

Answer 13

means the surgery’s risks and complications have been explained, so when pt signs they are signing their “informed” consent It is the SURGEON’S responsibility to inform pt (prefer to have a family member present to reinforce info) the op-permit is a legal document – has doctors name on it and the name of the procedure nse has advocate role – want the pt to sign, but want pt to be of sound mind and body before signing nse can request that surgeon talk to pt before signing if pt doesn’t completely understand something nse can act as witness that the correct pt signed the form and that said person is aware of what they are signing student CANNOT be a witness

Answer 14

ordered and looked over by general practitioner/internist/family doc who give OK to have surgery or not Lab Work can include: CBC (looks for anemia, infection, platelet issues, etc); purple tubes Electrolytes (up to 20 tests, sometimes called a Chem 7 or Chem 12); red tube Potassium (abnormal potassium causes arrhythmias) Blood Sugar (looks for undiagnosed diabetes) BUN (Blood Urea Nitrogen) and Creatinine (looks at kidney function – some anesthetics are eliminated thru the kidneys so pt needs to have good kidney function) Coagulation Studies such as PT (Prothrombin Time) and PTT (Partial Thromboplastin Time) (tells if pt’s blood will clot or not) ; blue top tube X-rays may include several different types of tests such as X rays MRI Angiograms PET Scans Ultra sounds EKGs – 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 Sometimes the surgeon can pull up the result info from his/her computer; or can have “hard copies” of the actual tests sent to him/her

Answer 15

Pre-op Intervention – Responsibility of nurse – sometimes shared with secretary; pt shows up for surgery 1-2 hours early for these reasons: To make sure pt have medical clearance and that hospital has documents IN HAND To make sure labs, X rays, EKG results are in chart To make sure pt complied with NPO ordered for at least 6-8 hours (preferably overnight) prior to surgery; nse asks pt “When was the last time you had anything to eat or drink?” If pre-op meds are ordered (usually by anesthesiologist because those meds benefit the anesthesiologist, not the surgeon), nse makes sure meds are given and documented as ordered; nowadays pre-op meds are given by anesthesiologist via IV in holding area or OR because it is safer to administer meds at that time (previously, meds were given in holding area, so if surgery was running late, the anesthesiologist had to play guessing games as to how much more medication to give or not give); used to give pt. meds to make them drowsy before going into surgery, but not anymore because we need pt to be able to identify themselves, any allergies they have, and the area of their body that is to be operated on There may be a shower or scrub with antimicrobial soap ordered; pt usually showers at home (some pts need to be supervised so a scrub will be done at the facility) Tell pt that no shaving is done prior to surgery; IF it is done at all it is done in the OR after the pt is anesthetized to reduce risk of infection; shaving nicks provide entry access to microbes, increasing risk of infection; To make sure bowel prep is done if ordered; pt usually does this at home, but some surgeons order a cleansing or fleets enema to be done the morning of surgery AFTER the pt is in the OR and has received medication (although the pt may not be completely anesthetized) any tubes such as NG (nasogastric) and catheters are inserted TED hose and SCDs (Sequential Compression Devices) are applied and documented preoperatively

Answer 16

this is done BEFORE the pt even has an IV inserted; nse tells/teaches pt: When you wake up in PACU (post-anesthesia care unit) you might have tubes coming out of you such as O2, IV, drain tubes, NG tube, etc. Nse stresses to pt after transfer from PACU to room “DO NOT GET UP WITHOUT NURSE’s HELP!” Nse tells family that too. (Families sometimes try to help, but don’t realize the dangers of the patient falling or ripping out tubes that are attached to poles and bed.) Nse explains to pt that he/she will need to take deep breaths after surgery (PO2 goes up with deep breaths) and will need to cough to keep lungs clear after surgery Nse explains that TED hose might be put on pre-operatively or that they may wake up with SCDs on their legs post-operatively Nse teaches pt how to do post-op leg exercises to increase circulation and decrease post-op complications (blood clots) Nse tells pt that he/she will be getting up to walk with assistance on that first day/evening to decrease post-op complications Nse explains that pain meds are PRN and that meds won’t come automatically because not all pt experience pain (may be r/t local block) and/or pt experience pain differently, nse teaches pt how to ask for pain meds and how to rate pain

Answer 17

``` Anticoagulant/ platelet inhibitors Antidepressants (particularly monoamine, and oxide inhibitors) Antibiotics Anti hypertensive Herbal supplements Immunosuppressant Diuretics ```

Answer 18

May cause intra op and. Post op hemorrhage RN: closely monitor for bleeding Assess PT/ PTT/INR VALUES

Answer 19

Increase hypotensive effect of anesthesia | RN: closely monitor BP

Answer 20

May cause apnea and resp. paralysis | RN: monitor respiration

Answer 21

Increase hypotensive effects of Anesthesia | RN: closely monitor BP

Answer 22

Prolonged effects of anesthesia, increase risk of bleeding and increase BP RN: should be d/cd at least 2 weeks pre op.

Answer 23

Increase risk of infection and hypothermia | RN: monitor CBC w/diff for leukoplakia. Monitor wound healing, document dose of medication and time of last dose taken

Answer 24

May least to fluid and electrolyte imbalance producing altered cardiovascular response and resp. depression RN: monitor I and O, electrolytes. Assess cardio and resp. status.

Answer 25

the care of the client before surgery (called pre-op), during surgery (called intra-op) and after surgery (called post-op). The duration of each period depends upon the situation; a person is in the “post-op” period until he/she is back to his/her normal “baseline” level, which can mean sometime after leaving the hospital (some pts never fully recover [i.e. hip fx])

Answer 26

``` Surgon First assist Anesthesiologist or nurse anesthetist Holding area nurse Circulating nurse Scrub nurse ```

Answer 27

is responsible for all judgment in pt care; might be assisted by another surgeon – they are equal partners; one surgeon (gyn) would do the hysterectomy while the other surgeon (urologist) repairs/hoists the bladder

Answer 28

cannot function alone; they scrub-in and have their hands “in the pie” with the surgeon; can be more than one person scrubbing in depending on how involved the case is; don’t make the incision, but help with tying off bleeders, may hold retractors, tie off sutures could be a surgical resident (a general surgery resident or a surgical resident specializing in that particular area) could be a med student could be a PA (physician’s assistant) – some surgeons hire PA to help with surgery could be a nse (RN) could be an OR Tech, Scrub Tech, Scrub Nse hired by the hospital

Answer 29

has a lot of responsibility maintaining the pt; administers anesthesia; monitor VS, record meds and VS; usually sit at head of OR table behind drape (reduces risk of infection) – can’t see surgery so depend on surgeon to let them know when surgery is almost finished;

Answer 30

does not go in the OR at all – works in the holding area; checks the OR-permit and has pt mark surgical area on body with a special pen containing indelible purple ink (doesn’t wash off skin with surgical scrub); assesses pt’s anxiety, name they go by, any allergies pt has, etc.; looks at pre-op check-off list; calls anesthesia to let him/her know that pt is there and ready; sometimes starts the IV; may assist with anesthesia block given in holding area; hands pt over to anesthesiologist who takes pt to OR; then escorts pt’s family to waiting room area

Answer 31

is an RN who sets up the NON-sterile OR room while pt is being seen by the anesthesiologist – nse has a card that lists all the equipment/supplies the surgeon needs/wants available for the surgery; he/she maintains supplies; checks the safety of the equipment; makes sure the cauterize equipment is grounded; catheterizes pt if ordered; positions (with help if needed) pt, decides if pt is positioned OK, then gives the go-ahead for surgery and then documents the position; helps anesthesiologist with intubation if needed; gets meds for anesthesiologist (because anesthesia do not have access to Pyxis) if needed; if pt is biopsied, makes sure specimen is labeled and gets to lab ASAP; does all the outside the OR communicating – takes Dr’s calls/pages, lets family know how pt is doing; watches for breaks in sterile technique – their word is LAW! – anything below waist level is considered contaminated; keep written track of who comes and goes in surgery – if one doc is relieved by another, etc

Answer 32

usually isn’t a nse, but can be an LPN (in some small hospitals); AKA the OR Technician or Scrub Technician; set up the sterile field – handle all sterile supplies; hand the surgeon/first assist the surgical instruments/supplies; need to anticipate surgeons needs; cleans the tissue and blood off the instruments as doc/first assist hands them back; gets sutures ready, count instruments/supplies before and after use and account for each; in charge of throwing away soiled supplies – the surgeon does not throw anything away; there are actual Scrub Tech programs offered now (take exam and get certified)

Answer 33

Traffic flow needs to be controlled There are FOUR different Zones in the OR – OR is usually off on a wing somewhere or on a separate floor and the whole area is considered protective The Protective Area includes the Holding Area where only the pt and their limited family members are allowed The Clean Area – thru a door beyond the holding area; scrubs must be worn in this area; this is where all the clean supplies are kept The OR Room – is considered a STERILE area; all doors are closed to it; people cannot wander in and out of that area The Dirty Area – where used equipment/instruments are placed to be cleaned Employees street clothes are removed and replaced by Surgical Scrubs, booties and caps; a mask must on when in OR room Any personnel who will be touching anything sterile must do a surgical scrub (long scrub first thing in the AM – 10 minutes; short ones throughout the rest of the day between surgical pts – 3 minutes) Scrubbed personnel cannot wear any jewelry or watches (jewelry harbors microbes and increases risk of infection to pt) Pt is totally covered in several layers of sterile drapes (a sterile place for surgeon to set instruments); wears cap; only the surgical site is exposed thru a hole in the sterile drape Anterior waist to chin is considered the only sterile area; anything behind the scrubbed person, below the waist or above the chin is considered contaminated Identify the pt, the pt identifies the area of body to be worked on by initialing or X ing it; the surgeon also initials the surgical area of body The OR staff does a Time Out prior to making the incision to make sure everything is identified, correct, OK and ready to go The pt gets strapped to the OR table to keep him/her from falling off; if using arm boards, arms are also strapped to keep arm from falling off and being injured Instrument and sponge counts are done; scrub tech and circulating nurse documents if a sponge went out with a specimen to the lab

Answer 34

such as 10 minute scrub in the morning, maintaining the sterile field, pt identification, pt positioning, are all done for patient safety

Answer 35

General Regional Conscious sedation/ analgesia Local

Answer 36

is reversible, unconscious state characterized by amnesia (pt does not remember anything), and also analgesia (pt doesn’t experience pain), depression of reflexes, muscle relaxation, and homeostasis (maintain profusion, B/P, etc.); can be done with IV drugs, inhalation drugs – almost all are started with IV drugs then switched to inhalation (most common is nitrous oxide) and used in combination with IV drugs – called Balanced Anesthesia

Answer 37

is reversible loss of sensation in a specific region or area of the body when a local anesthetic is injected; anesthesia blocks the nerves (technically, a spinal is a nerve block); these include spinals, epidurals, caudal (lower down on the spine for anesthetizing the perineum for episiotomies), peripheral nerve blocks; used for a lot of OB procedures; dentist will block a whole area when working on more than one tooth at a time; pt is awake and responds to verbal stimulation

Answer 38

area is infiltrated with an anesthetic block or local at a particular site (usually by the surgeon for example for hemorrhoid surgery) and the pt is getting IV drugs (by the anesthesiologist) to make them unaware (deeper than conscious sedation, pt doesn’t respond to verbal stimulation) of what is going on – pt is deeply sedated; pt probably has some sort of oral airway device in place; anesthesiologist monitor VS and may give other medications such as muscle relaxers

Answer 39

drug induced depression of consciousness during which pt respond purposely to verbal stimuli; level up from MAC; pt keeps own airway open; cardiovascular function is maintained; commonly used for endoscopy, colonoscopy procedures; Reversal drug: Narcan

Answer 40

least amount of anesthesia; infiltrate the area with anesthetic but no sedation will occur; used for stitches, burning off warts; one tooth removal

Answer 41

PRE ANESTHETIC MED: Given to pt for several reasons; sedation, reducing anxiety, increase comfort, decrease N/V, gastric acidity, and infection Types: versed- decrease anxiety, promote anesthesia Opioids- pain relief Anticholinergics- inhabitants, decreasing secretions POST ANESTHESIA: Analgesics- opioids for sever pain Antiemetic - Zofran for N/V Cardiac- Atrophine if pt bradycardia

Answer 42

great skeletomuscular relaxer; the “I don’t care” drug; takes longer to wear off

Answer 43

most commonly used, gives more amnesia, the “I don’t remember anything” drug

Answer 44

may give to pt so there is less pain post-op because drugs are already in system; ( B/P; helps with muscle relaxation

Answer 45

dry up secretions (so anesthesiologist doesn’t have to use suction/( chances of pt aspirating); used to give in pre-op, but now given in OR so pt doesn’t feel the dryness; these drugs ( h/r, urinary retention, makes vision fuzzy, constipation; two types used: Atropine – Robinul –

Answer 46

High Risk For Injury (intra-op)– r/t adverse effects of anesthesia or r/t intra-op positioning or r/t immobilization, etc Impaired Skin Intergrity – for any pt. with an incision, central line, IV’s, etc. Impaired Tissue Intergrity - surgery involves moving/removing organs, cutting tissues, dissecting parts, etc. High Risk of Impaired Gas Exchange (mostly for anesthesiologist) – if giving a short-acting barbiturate that acts for 5-10 minutes and anesthesia runs into problems intubating there is a risk for impaired gas exchange; if the pt is extubated too soon and can’t breathe on own there is a risk for impaired gas exchange Fluid Volume Deficit – pt is NPO overnight but the kidneys still work, the pt still sweats, etc. which ( fluid volume in body and the pt goes into surgery with a fluid volume deficit; don’t want the pt ending up with fluid volume deficit after surgery so pt is given IV fluids (bag holds 1000-mL – usually infused 125mL/hr on normal non-surgical pt) High Risk for Infection – r/t incision – cannot sterilize skin; lots of instruments (hemostats, sutures, drains, etc.) going in and out of the pt Fear and Powerlessness (pre-op and intra-op) – happens before the pt is given the “I don’t care” drugs; r/t what is going to happen, the fact that once surgery gets started it’s too late to stop, am I going to wake up in surgery, and fearful of the anesthesia, wearing hospital gown, putting trust into staff, etc.

Answer 47

PACU (Post Anesthesia Care Unit) used to be called the “recovery room”; are staffed by different nses than the Pre-op and OR nses; is in the OR Suite Level of anxiety before surgery – if the pt went in calm the pt will probably come out calm; if went in anxious will probably come out of it anxious Type and length of surgical procedure – most outpatient surgeries last 1-1 ½ hour; some inpatient surgeries last 4-5 hours; the longer the surgery the higher the risk of immobility, blood clots, atelectasis, fluid build up in lungs, etc. Location of incision/s, drain/s, skin grafts – know where they are so can check on ALL of them Past reactions of anesthetics – shivering, ( B/P, etc. Respiratory status – pt is usually extubated (done in OR) by the time they reach PACU, but not always Any joint or limb immobility – is pt arm/shoulder not supposed to be moved?; are there special positioning limitations?; Primary language - the pt may not understand English and therefore won’t respond to nse directions Hard of hearing – does pt wear hearing aides (don’t wear them into OR – nse needs to get them) Visual problems – does pt wear glasses/contacts? Any OR complications - anything that made surgery go longer than expected (trouble breathing, scar tissue, unexpected bleeding)

Answer 48

``` post-op pt goes to PACU to be assessed to ensure that pt is safe enough (not going to run into complications) to either be discharged or admitted to med/surgical unit for recovery; assessments include: Vital signs Dressings/ drains/ bleeding Gag reflex Airway patency Adequate respirations Peripheral circulation LOC Pain medication Nausea and vomiting ```

Answer 49

VS are done q15 min; based on a point system as to whether or not pt can be released from PACU; (covert bleeding is bleeding that cannot be seen – internal, which is a reason for taking VS q15 min – if B/P is ( the pt may have internal bleeding)

Answer 50

bleeding that can be seen; nse looks at dressing and all around dressing site (depending on where the incision is, bleeding may drip down underneath pt); orthopaedic surgeries tend to bleed a lot; nse doesn’t ( (change) dressing in PACU, but may reinforce it, so surgeon can assess blood loss, etc.; normally dressing are not saturated in PACU; assess drainage amount – shouldn’t fill up in PACU; Dr puts type of drain in based on expected amount of drainage in 24° (if not a lot of drainage is expected the doc will put in a JP drain which holds about 150mL, if a lot of drainage is expected then doc will put in a Hemovac drain which holds about 400mL); nse can empty drains in PACU if filling up fast – measure, document and notify surgeon; drainage could be from a lot of irrigation fluid (looks watery); some MD want to do the first dressing ( and write orders to leave it alone

Answer 51

pt needs to be able to handle secretions/be able to swallow (nse can see pt swallowing secretions); do not want pt to drink until gag reflex returns

Answer 52

pt needs to be able to breathe on own; if pt is snoring there is a partial airway obstruction – reposition head (chin up); if pt sounds gurgly – needs to be suctioned; if pt is awake enough nse has pt cough – pt will cough up secretions and swallow them showing that gag reflex has returned and doesn’t need suctioning

Answer 53

each pt has suction, O2 equipment, etc available at bedside; pt usually comes from surgery on O2 (usually via nasal canula, but sometimes a mask) and with a pulse Ox on (pt needs to maintain O2 sats above 92%); nse asks pt to take deep breaths to ( O2 sats.

Answer 54

- pt may be positioned in surgery in such a way that his/her circulation is compromised – especially to his/her lower extremities; nse needs to pull blanket up and check for capillary refill, warmth, color, etc.; pt may be too out of it at first to be able to wiggle toes.

Answer 55

pt will have IV running post-op; PACU nse sets up IV tubing and pump per ordered rate; IV won’t be D/C’d (discontinued) until pt is ready to be discharged from hospital;

Answer 56

level of consciousness; pt cannot leave PACU until he/she is alert enough to breathe on his/her own, put a call light on, respond to his/her name, etc.; some pts come to PACU very alert, some take a long time to wake up

Answer 57

pain meds are given in PACU if needed; not every pt needs pain meds in PACU (some have blocks that are keeping them comfortable); if give something for pain, nse keeps pt in PACU long enough to assess if med was effective, if pt got nauseated from drug, if the drug effected the pt’s respiratory rate and/or B/P, etc.

Answer 58

from effects of anesthesia, etc. (those drugs hit the vomiting center in the brain and cause “quick” vomiting, unlike the “flu” type of nausea/vomiting that may come on very slowly- have a basin ready and handy [not just the little emesis pan because that may be overfilled quickly]); not every anesthesiologist gives antiemetics in OR; if needed nse medicates pt in PACU for N&V f consciousness; pt cannot leave PACU until he/she is alert enough to breathe on his/her own, put a call light on, respond to his/her name, etc.; some pts come to PACU very alert, some take a long time to wake up

Answer 59

these Nsg Dx are not just for PACU, but fit in throughout the hospital stay; when prioritizing Nsg Dx Urinating comes 1st, then Effective Airway Clearance Impaired Gas Exchange – pt needs to C & DB, impaired gas exchange is usually for the first 24° post-op Impaired Physical Mobility – NOT a pt having trouble walking to bathroom r/t painful incision – it IS the pt who requires crutches, has had an amputation, has to wear a brace, etc.; intervention: might want to have brace close to bed, have pt put brace on before ambulating; teach pt home safety such as no loose rugs to slip on Risk for Injury – could be at risk for injury r/t mental status – accidentally pulls out drain, foley, IV; falls out of bed; Impaired Skin Intergrity – any incision/IV means pt has impaired skin integrity Pain – High Risk for Urinary Retention – general anesthetics, neuromuscular blocking agents, muscle relaxants, narcotic, anticholinergics can and do cause urinary retention; almost all post-op inpatients have an order that reads “catheterize q4-6° prn for inability to urinate”; need to have pt urinate (at 30mL/hr) by 4-6° post-op – very important; (when ranking priority – urinating ranks higher than effective airway clearance) Ineffective Airway Clearance – C & DB, use Incentive Spirometer (IS) 10 X hr (at every commercial) – if hearing the balls going up stop in and give pt “atta-girl/boy”; assess lung sounds – if clear then goal has been met; heavy smokers have gunky sounding lungs Fluid Volume Deficit – IV’s are kept running because pt is often too sleepy to feel like eating and drinking much; try ice chips, pop; start with cold items first, so pt doesn’t burn self while still mentally/physically impaired; IV are kept running until pt can take fluids well – drinking and keeping fluids down – 8-16 oz in an hour’s time; once pt taking in adequate fluids convert IV to hep-lock/saline-lock – IV stays in place just in case a med needs to be given; If pt had GI surgery; doc wants to know if bowel sounds are heard, then can start on progressive diet if ordered Constipation – r/t anesthesia, narcotic, ( mobility, ( fluid intake, ( food intake; most pt are on some sort of stool softener; pt doesn’t have to have a BM before going home, so do teaching on ways to ( fiber and fluids in diet Knowledge Deficit – a very common Nsg Dx; knowledge deficit about post-op period or post-op home care – teach pt about constipation (foods to eat to prevent it); not to play with incision and to keep it dry, when and where to go to get stitches out or that stitches will dissolve on their own

Answer 60

C & DB and IS – Maintain Suction and other Drainage tubing – Changing Dressings and Other Incisional Care Measure Drainage – Administer Analgesia – Client and Family Teaching – Prevention of infection: Care of wound: Diet: Drugs: Progressive activity and restrictions: Discharge Planning –

Answer 61

shallow coughs are not effective; use IS; pillow splint incisions; get pt up to bathroom ASAP

Answer 62

assess Hemovac, JP, NG tube; if pt is supposed to be hooked up and suction on - make sure everything is working properly

Answer 63

Know MD orders; some surgeons don’t want anyone to ( dressing until they do it; some will say ( dressing PRN (if looks like it falling off, if tape gets loose, if it gets wet from incontinence, shower, etc); most dressing (’s are just changing the dressing – don’t clean it or put anything on it (Betadine, neosporin, etc) like we used to; teach pt about incision care

Answer 64

measure and document (amount and description) the drainage from drains, emesis, urine output (would like to see 150mL each time pt voids post-op), NG tube drainage

Answer 65

Assess and provide pain meds as needed and document

Answer 66

things the pt needs to know before going home Prevention of infection: how to care for wound Diet care and medications

Answer 67

keep incision uncovered/open to air(bacteria prefer dark, moist, warm places), dry (no ointment – anaerobic bacteria love ointment); although incision shouldn’t have drainage after 24° post-op, some drainage is expected for 3-4° after drain tube is pulled; if there is no drain, the pt is allowed to shower; pt cannot soak in bath, hot tub, go swimming, etc until incision is totally healed (NO SCAB present)

Answer 68

high fiber (bran flakes, fruits with skin on, prune juice, apple juice or cider) prevents constipation; get plenty of fluids, protein

Answer 69

pt may go home with Rx for pain meds, muscle relaxers, Lovenox, iron supplements, etc.; narcotic might have Tylenol already in it; teach pt about their Rx and about pain meds – don’t take more than 4000mg of Tylenol in a 24° period

Answer 70

pt can get up and do a little more each day post-op; MD will decide when pt can go back to work; will need to see pt in office to give clearance; may give pt restrictions on lifting/carrying, going up and down stairs, etc.; if travelling the pt needs to stop, get out of car and walk around q1-2° to prevent blood clots

Answer 71

begins when pt is ADMITTED to hospital; don’t wait until last minute – might need to set up PT, home care, may need home care equipment (shower chair, walker) and those things take time to organize

Answer 72

some pts will go home on these meds Stool Softeners and Laxatives (Lehne pp. 904-910)- Colace: stool softener (usually given BID) Peri-Colace: a stool softener with a gentle laxative added (usually given BID) Milk of Magnesia: laxative (not given to people with renal failure because their kidneys can’t hand the magnesium) Miralax: a laxative that pulls fluid from intestine – can be used as a prep for colonoscopy Fleets Enema: Dulcolax Suppository: Metamucil: a bulk laxative; not usually given post-op because bulk doesn’t help the (’ed peristalsis caused by narcotics Vitamins/Minerals/Iron/Calcium/Theragran M – vitamins and minerals to aid in healing Anticoagulants – Heparin or Lovenox (subQ low dose) / aspirin for pts that may be on bedrest or other risks for DVT. Antibiotics – orthopaedic and neurosurgery pts usually get antibiotics (don’t want infection in bone or brain); may give two doses in a short period of time (e.g. at start of surgery and at end of surgery); might have more antibiotics ordered for when admitted to med/surg floor after PACU Other Meds that might be specific to type of surgery include: Muscle Relaxants – used for ortho (e.g. back, knee) or neuro surgery Anti-spasmodic – urinary pt to keep bladder from being irritable Hormones – for hysterectomy GI Drugs – for certain GI surgeries

Answer 73

PRN pain medication PCA pain pump Epidural pain pump

Answer 74

are the most common; pt has to ask for these; injectable or oral Advantages: pt doesn’t get overmedicated; pt doesn’t get them if he/she doesn’t want or need them Disadvantages: pt has to wait for them while nse prepares to give them; pain levels can (/build up to intolerable level while pt waits

Answer 75

Patient Controlled Analgesia: pump with large syringe (30mL) full of narcotic (morphine, Dilaudid); MD determines amount – may want pt to be able to get “X” number of mg of drug q6, q10, or q20 min. (there is a lockout device); nse gets pump set up, signs out narcotic, (’s IV tubing (special tubing for PCA); pt pushes button and automatically gets dose Advantages: dosing is immediate; pt is in control Disadvantages: not necessarily easier for nse – doesn’t save time; pt has to be physically and mentally able to push button; will not work for kids or confused pts; has to be hooked up to running IV (not a hep-lock); no sense using this if no more than 2-3 doses needed – would waste a whole vial for just a couple of doses; family thinks they should push button for pt even when pt doesn’t ask for it

Answer 76

catheter is put in pt’s back; has to be put in by anesthesiologist during surgery; the drug put in the epidural is an analgesic not anesthetic; doesn’t remove all the pain Disadvantages: it numbs the lower abdominal area which can cause difficulty with urination (pt will need a foley); it is an invasive procedure creating another possibility for infection Pain Pump – vial or container filled with local anesthetic with tubing that connects to a catheter that has been inserted into a stab incision by the surgeon (placed exactly where they want it – where they think the pt will have the most pain); the pump is spring loaded, automatically delivers small amount of anesthetic to pt over several hours (set for 48°, 72°, or five days – usually don’t want for five days r/t risk of infection) Advantages: pt goes home with pain pump; not hooked to electric so pt can move easily; pain control lasts for a long time post-op; makes it easier for MDs to manage pain therefore ( more outpatient surgeries; it’s loaded with a local anesthetic not a narcotic so pt doesn’t get respiratory depression Disadvantages: pt has to pull catheter out and may be too squeamish to do so

Answer 77

the reason we are concerned with anemias is because anemias can ALL major organ systems in the body (e.g., CHF can be secondary to anemia – there is not enough O2 getting to the heart, the heart works harder, gets tired and fails to work anymore; lack of O2 to the brain causes mental slowness, etc.); MDs must treat the CAUSE of anemia, not just the anemia.

Answer 78

is an abnormally low number of circulating RBC, low hemoglobin concentration, or both. Anemia is a symptom of an underlying disorder Lack of O2 to the cells and the consequences that follow

Answer 79

male 14-18; female 12-14; hemoglobin is protein in RBC that binds/attaches O2 to iron atoms; hemoglobin carries the O2 around the body; if hemoglobin levels drop that means the body is not able to carry around enough O2.

Answer 80

can be any number of things/a combo of things; three major include: Inadequate Production – Increased Destruction Blood Loss

Answer 81

Altered hemoglobin synthesis – pt is having trouble making enough hemoglobin because their body is lacking something (happens with iron deficiency – can’t make good hemoglobin if you don’t have enough iron) Altered DNA synthesis – can’t replicate RBC because there is a problem with DNA (happens with Vit B12 deficiency and folic acid deficiency) Bone Marrow can fail – fails to make blood cells (RBC, WBC and platelets) and causes aplastic anemia; people die from this Increased RBC Loss or Destruction – ``` happens with acute or chronic blood loss; most people know when they are having an acute blood loss, but chronic blood loss may go undetected for a while (occult blood) – the body bleeds internally r/t cancer in the intestine, stomach ulcers, etc happens with ( hemolysis of RBC – could be r/t sickle cell (the liver/spleen see that the RBC are not shaped properly and destroys them), or (-hemolytic strep infection (the toxins produced from that bacteria destroy RBC) ``` certain other infections can ( RBC production

Answer 82

Pale Skin, MM, Conjunctiva, Nail Beds pale/pallor – isn’t always a good indicator unless the nse knows the pt well because each person has a different complexion/skin tone – too hard to judge who is and who isn’t pale MM (mucus mucosa) – an anemic pt will have pale MM Conjunctiva – should be red, not pale pink Nail Beds – ( Heart and Respiratory Rate – because of the anemia pt is not circulating enough O2 - the heart pumps faster which makes the pt breathe faster to keep up with the heart Angina (chest pain) – especially with severe anemia; chest pain secondary to the heart working hard, but not effectively Fatigue – pt feels tired, exhausted DOE (dyspnea on exertion) – SOB when trying to do activities such as walking up stairs/hill Night Cramps – (not reliable Sx); leg cramps Cerebral Hypoxia – lack of sufficient O2 to the brain which results in headaches, dizziness, dim-fuzzy vision Heart Failure – if severe enough anemia - pt develops heart failure; pt may have enough circulating blood volume, but not enough RBC to carry O2 to the heart – can’t just give pt blood because pt would then end up with fluid overload, need to give the pt a diuretic to ( fluid volume and at the same time give the pt Packed RBC Circulatory Shock with Rapid Blood Loss – pt’s B/P ( (r/t blood loss), pulse ( (r/t heart beating faster trying to pump blood to body), pt gets dizzy and loses consciousness (r/t lack of O2), can usually see bleeding (pt was shot, stabbed, lying in a pool of blood, etc)

Answer 83

these are some of the more common ones CBC – Complete Blood Count; measures how many RBCs, WBCs, gives hematocrit %, hemoglobin %, gets into the indices about color, shapes, sizes, etc. Hematocrit (Hct) measures the portion of blood volume made up of RBC – normal for men = 40-45%, normal for women = 36-48%); when go to give blood you are tested for Hct, not Hgb – can’t give blood if Hct is too low Hemoglobin (Hgb) is protein in RBC that binds/attaches O2 to iron atoms – normal for men = 14-18, normal for women = 12-14 Iron Levels and TIBC (Total Iron Binding Capacity)- iron deficiency is the most common cause of anemia so pt is tested for iron levels; TIBC measures how much iron a person can hold inside his/her body – deficiency usually occur with chronic iron deficiency anemia Serum Ferritin – another iron test; some pts absorb too much iron or have problems carrying iron, or person has too many RBCs (pt has blood taken and thrown away as much as once a week or so) Sickle Cell Test – screens to see if a person has sickle cell; usually done on babies and kids Bone Marrow Examination – if iron levels are good, pt is eating well and taking vitamins, but hemoglobin is still off the MD will order red marrow examination (can look for cancers)

Answer 84

there are different meds for different anemias Hydroxyurea for Sickle Cell – specific for sickle cell; some pts are on it for life, some only periodically when ill with a cold (not oxygenating well) Vit B12 SubQ or IM, intranasal – pills are given to vegetarian; persons lacking the intrinsic factor are given injections (SUBQ or IM) or intranasal meds; injections are given 1 X month; intranasal are usually given every week – doesn’t work for everyone Lifelong Treatment Needed – if lack of intrinsic factor, the injections are given to pt for rest of their life Folic Acid - prenatal vitamins – found in prenatal vitamins; pregnant women, alcoholics and sickle cell disease people need folic acid; can get individual folic acid pills; different preparations of prenatal vitamins – MD’s preference Iron – things to teach pt include: Green or black tarry stools – pt’s with GI bleed have similar looking stools Absorption – iron is absorbed better on an empty stomach, but better tolerated with food (try it without food first, if upset then take with food) iron is absorbed better when taken with Vitamin C (take with OJ) iron competes with some receptors sites (e.g., calcium) so don’t take iron with milk or antacids ( dietary iron – pt should eat more meats, fortified cereals, eggs, dairy high in iron Diarrhea or Constipation – constipation is more common, but either can occur Take for months – anemias are not fixed quickly; need to take supplements for months so body can replenish iron stores OTC/Rx – some iron supplements need prescriptions, some don’t; some are tolerated better than others Toxic – too much iron is toxic to children (can kill);

Answer 85

not making enough RBC

Answer 86

getting rid of RBC faster than body should; destruction of RBC in less than 120 days (technically blood loss is Increase Destruction, but we think of blood loss a quick thing, not as the destruction of RBC in less than 120 days)

Answer 87

acute:hemorrhage (GI bleed)-loses a whole bunch of blood at once. when a hemorrhage occurs the circulating blood volume decreases , decrease BP, so fluid shifts from the interstitial space to the bloodstream to try to stabilize or raise B/P RBC are normocytic (normal size and shape) and normochromic (normal color) RBCs Chronic – (can also partially be due to nutrition); most people don’t know they have this type of blood loss; usually caused by heavy menstrual periods, intestinal/colon cancer; depletion of iron stores in the body (the bone marrow is still trying to make RBC but the body doesn’t have enough iron left to make – the body loses the blood taking the iron that is normally recycled with it); RBCs are microcytic (smaller than normal) and hypochromic (pale) RBCs which = iron deficiencies

Answer 88

Complete Blood Count; measures how many RBCs, WBCs, gives hematocrit %, hemoglobin %, look for MCV and RDW (about color, shapes, sizes,) MCV- microcytic RDW-

Answer 89

measures the portion of blood volume made up of RBC – normal for men = 40-45%, normal for women = 36-48%); when go to give blood you are tested for Hct, not Hgb – can’t give blood if Hct is too low

Answer 90

is protein in RBC that binds/attaches O2 to iron atoms – normal for men = 14-18, normal for women = 12-14

Answer 91

TIBC measures how much iron a person can hold inside his/her body – deficiency usually occur with chronic iron deficiency anemia

Answer 92

another iron test, malnutrition

Answer 93

screens to see if a person has sickle cell; usually done on babies and kids. Looks for HBS gene

Answer 94

DX OF Aplastic anemia. if iron levels are good, pt is eating well and taking vitamins, but hemoglobin is still off the MD will order red marrow examination (aspirated BM)

Answer 95

Affect RBC formation (erythropoiesis) - Vit. B12 and Folate play a big role in RBC development. Cause: inadequate diet, increase need, malabsorption, GI disorders Types: iron deficiency anemia, Vitamin B Deficiency anemia , and folic acid anemia

Answer 96

``` Most common type of anemia. - results in fewer # RBCs that are - microcytic(small), hypochromic (pale) Cause: chronic bleeding Malabsorption Pregnancy GI inflammation Hemorrhoid CA SX:brittle, spoon shaped nails, cheilosis, smooth sore tongue, pica(eat dirt) TX: diet, po iron supplements Food: spinach, beef, cereals ```

Answer 97

Deficiency in Vit B causes Impaired RBC devision and maturation of the cell nucleus. RBCs are macrocyclic ( large), fragile, short life span and misshaped SX: for Vit B12 def- gradual onset of neural problems: Paresthesias in extremities ( numbness/tingling), Proprioception, impaired balance, Sore beefy tongue, cheilosis Tx: early intervention to prevent neural problem Pernicious anemia- fail to absorb dietary Vit B 12 due to lack of intrinsic factors Occure sin pt who have ileac resection, loss of pancreatic secretions,chronic gastritis (ETOH), strict vegetarian. TX: IM supplement Vit B12 , increase meat egg, dairy, IM Vit B12 sup.

Answer 98

Fragile megaloblastic RBC (lg and immature) Cause: chronic malnutrition, ETOH, increase need( pregnant/ chemo), elderly, growing children s SX: (not as severe as Vit B12) Pallor, progressive weak eland fatigue, SOB, Palpation, glossitis(red tongu), cheilosis,diarrhea TX: diet, supplements Sources: green leafy veg, meat, fruit, cereal

Answer 99

Characterized by premature breakdown of RBC within circulation Aplastic anemia Normocytic and normochromic- Most RBC look normal they just don't last long Cause: intrinsic (inside RBC) or extrinsic (outside RBC) Tx: treat the cause Types: Sickle cell anemia

Answer 100

Hereditary, chronic hemolytic anemia RBC are crescent shaped due to abn form of hemoglobin within RBC, most common among people of African descent. DX: sickle cell test- HBS gene.

Answer 101

``` Priapism Pallor Jaundice Irritaility Decreased circulation Occulusion Ischemia Infarction ```

Answer 102

RBC's get stuck, clot, decreased 02 to the area, severe pain. Fever and intense pain, swelling of extremeties due to ischemia. Factors for crisis: Hypoxia, low enviornmental or body temp, excessive exercise, anesthesia, dehydration, infection, acidosis. Treatment- meds like hydroxurea, transplanting cells, and managing the pain of the ischemia

Answer 103

bone marrow failure resulting in pancytopenia. The bone marrow is replaced by fat. Causes are idopathic in 50% of cases. Other causes can be: virus, radiation, chemo (most common), benzene, arsenic / rat poison, nitrogen mustard, chloramphenicol, HIV, Hep B. Symptoms vary with severity: Pallor, fatigure, headache, dyspnea on exertion, tachycardia, heart failure. Treatment is to remove the causative agent, blood transfusions or try a bone marrow transplant, but that may not always work.

Answer 104

``` Impaired gas exchange Activity Intolerance Pain Impaired tissue per fusion knowledge deficit Coping ```

LO EXAM 2 Flashcards

(128 cards)