midterm Flashcards
(192 cards)
1
Q
nursing role in preoperative phase
A
Obtain health information
Determine pt’s expectations about procedure
Provide & clarify information about procedure
Assess pt’s emotional state & readiness
Provide discharge planning and postoperative teaching
2
Q
preoperative assessment
A
before surgery to determine if there are any changes (baseline)
3
Q
what is included in preoperative assessment
A
health assessment
history (medical conditions & current health challenges, previous surgeries, family history)
medications (herbal & vitamins)
substance use
allergies
4
Q
purpose of preoperative screening
A
baseline, see if anything is happening to cause complications
5
Q
common preoperative screening tests
A
Urine analysis, checking how the kidneys are working, UTIs,
chest xray (see if anything present that will make the surgery difficult),
CBC (complete blood count),
CPT (electrolytes and glucose),
INR PTT (how fast you can form clots) = important to know to determine if your body can clot to help the healing process,
ECG (checking out heart to make sure the heart is strong),
creatinine & gfr (tell us how the kidneys are functioning),
liver function tests
6
Q
preoperative teaching
A
Nutrition (NPO – reduce the risk of aspiration & post-op nausea)(increase diet slowly),
breathing (deep breathing & coughing = important to facilitate lung expansion, encourages the gas exchange, and mucus movement, incentive spirometer, splinting to avoid damage incision),
grooming (special soap, shower, shaving if necessary, nails, polish, jewerly, dentures),
medications (what can they take day off – will be provided instructions),
pain control (what kind of pain they should expect, letting them know about pain management),
dressings & drains & tubes (what are they going to wake up with),
safety (call bell in reach, letting them know it may be difficult to get out of bed),
preoperative information (where they should park, where can family wait, how long it should take),
ambulation (compression stockings, leg exercises, mobilizing early = prevents the body from decom the muscles quickly)
7
Q
informed consent
A
getting enough information to make a decision
8
Q
aspects of informed consent
A
- voluntary consent
- capacity to consent
- properly informing pt
- advocating for pt
- barries/ethical complications: language barriers, refuses
9
Q
intraoperative phase
A
multi-disipline team
10
Q
postoperative phase
A
post anaesthesic care unit (PACU)
11
Q
what is the PACU
A
unit where the pt is under close and constant observation to make sure they are returning to normal physiological functioning (VS machine & IV ready)
12
Q
initial post operative assessment
A
airway (patent, adventitious sounds?)
breathing (regular & easy)
circulation (VSS, warn & dry to touch, oozing/bleeding at site)
disability/neurological (LOC/cognition/orientation)
13
Q
neurological postoperative complications
A
emergence delirium, delayed awakening
14
Q
emergence delirium
A
acute confusion state during recovery from anesthesia
CAM test
safety
neurological assessments
bedrails
15
Q
respiratory postop complications
A
obstruction, hypoxemia (atelectasis, pulmonary edema, aspiration), hypoventilation (breathing that is too shallow or too slow to meet the needs of the body = body’s carbon dioxide level rises.
16
Q
cardio postop complications
A
hypotension, hypertension, dysrhythmias, DVT/PE, syncope, fluid & electrolyte imbalances (hypokalemia, overload)
17
Q
GI postop complications
A
N & V (PONV = postop nausea & vomiting)
slowed GI motility
altered patterns of food intake
18
Q
urinary postop complications
A
low urine output
acute urinary retention
19
Q
integumentary postop complications
A
impaired wound healing
infections
20
Q
temperature post op complications
A
hypothermia, fever
21
Q
pain & discomfort postop
A
presence of internal devices, mobilization, incision
22
Q
discharge instructions
A
Care of wound site & dressings
Bathing recommendations
Activities allowed & prohibited
Dietary restrictions or modifications
Symptoms to be reported
Follow-up care
23
Q
purpose of MSE
A
overview of functioning, monitor changes over time, provides snapshot of how that person in that moment (holistic)
24
Q
appearance
A
clothes, hair, tattoos, ethnicity, cultural background, piercings, age
25
behaviour
eye contact, gait, mobility, cooperation, attitude, dismissive, psychomotor activity, agitation
26
affect
physical representation of mood, reflection of thoughts & feelings (congruent/incongruent)
27
euthymic
as expected
28
speech
rhythm, volume, tone, pace
29
thought form
how they think
30
circumstantial
they eventually get to the point, give unnecessary details
31
tangential
never get to the point, keep talking about nothing to do with the point
32
flight of ideas
non goal directed, "takes off" from topic at hand, change topics quickly
33
loose associations
disintegration of meaningful connections between ideas occur, transitions b/w topics not logical connections b/w ideas
34
thought blocking
involuntary interruption of thought & speech
35
derailment
speech begins again after thought blocking
36
word salad
extreme form of loosened associations to the point the words have no connection to one another
37
thought content
what they are thinking
38
delusions
persecutory, grandiose, jealously, religious, obsession, phobias, ideas of reference
39
ideas of reference
false beliefs that random or irrelevant occurrences in the world directly relate to onesel
40
perception
hallucinations (auditory, tactile, visual, gustatory, olfactory, somatic)
41
cognitive functioning
memory, LOC, concentration, attention span, orientation
42
insight/judgement
insight = if they get whats going on, they understand the situation they are in
judgement = decision-making
43
shock
failure of circulatory system to maintain adequate perfusion of vital organs
44
if there is inadequate tissue perfusion...
decreased O2 at cellular level --> switch from aerobic to anaerobic cellular metabolism --> accumulation of waste products --> cell death
45
what is the waste prodcut that builds up for inadequate tissue perfusion
lactic acid
46
tissue perfusion means
continuous delivery of an adequate blood supply containing oxygen, nutrients, and hormones to the body's tissues and organs
47
different shocks
cardiogenic, hypovolemic, septic, anaphylactic, neurogenic
48
which shocks are considered distributive
septic, anaphylactic, neurogenic
49
distributive means
maldistribution of blood flow
fluid is in the wrong space, not in the vessels, total fluid volume is normal just in wrong space
50
distributive shock causes
widespread vasodilation
51
cardiogenic shock
happens when your heart cannot pump enough blood and oxygen to the brain and other vital organs
52
causes of cardiogenic shock
MI, blunt force trauma, cardiomyopathy
53
clinical manifestations of cardiogenic shock
CV: tachycardia, hypotension, narrowed pulse pressure, cool clammy, pallor, peripheral hypoperfusion
RESP: tacypnea, pulmonary congestion
RENAL: decreased urine output, Na H2O retention (edema)
NEURO: anxiety, LOC, confusion
54
hypovolemic shock
loss of intravascular fluid volume by either ABSOLUTE VOLUME LOSS or RELATIVE VOLUME LOSS
remaining volume unable to meet O2 needs
55
absolute volume loss examples
external bleeding, vomiting, diarrhea, excessive sweating
56
relative volume loss examples
internal bleeding, fluid shifts, burns
57
clinical manifestations of hypovolemic shock
CV: tachycardia, hypotension, cool clammy, peripheral hypoperfusion
RESP: tachypnea
RENAL: decreased urine output
NEURO: agitation, confusion, anxiety, LOC
58
body can compensate for up to 15%, greater than 30% body begins to fail (T/F)
TRUE
59
neurogenic shock
massive vasodilation without SNS activation, blocked
blocked = no increase HR
can occur within 30 mins of injury last up to 6 weeks
60
clinical manifestations neurogenic
hypotension, bradycardia, inability to regulate temp = hypothermic
61
anaphylactic shock
IMMUNE SYSTEM OVERLOAD, IMMEDIATE REACTION CAUSING LEAKING FROM VASCULAR SPACE TO INTERSTITIAL SPACE
hypersensitivity reaction to a sensitizing substance (immediate reaction causes massive vasodilation, release of vasoactive mediators, increase in cap permeability == fluid leaks from vascular space into interstitial space
62
clinical manifestations for anaphylactic shock
NEURO: anxiety & sense of impending doom
AIRWAY: swelling, swollen tongue
BREATHING: tachypnea, dyspnea
CIRC: hypotension, tachycardia
SKIN: rashes, hives
GI: N & V
63
what needs to be involved to be classified as anaphylaxis
2 systems (neuro & skin)
64
septic shock
presence of sepsis with hypotension despite resuscitation and resulting hypoperfusion
65
infections that can lead to sepsis
UTI, pneumonia, wounds
66
clinical manifestations of sepsis
RESP: tachypnea
CV: tachycardia, hypotension, warm & flush THEN cool & mottled, initially have fever then become cool
GU: decreased urine output
NEURO: confusion, altered mental status
67
change in LOC is #1 manifestation in elderly people regarding sepsis
TRUE
68
compensatory stage of shock
compensatory mechanisms maintain BP & cardiac output within a normal to low range
norepinephrine & epi released, vasoconstriction & tachycardia, BP & perfusion to vital organs maintained
69
progressive stage of shock
prolonged vasoconstriction (SNS working hard)
reduced supply O2 blood
switch to anaerobic metabolism & build up of lactic acid
microcirculation dilates
decrease BP, venous return
tissue hypoxia
70
refractory stage of shock
celllular ischemia & necrosis progresses = organ failure & death
cycle of inadequate tissue perfusion is not interrupted
71
medical management for shock
oxygen & ventilation (admin O2 & patent airway)
fluid resuscitation (admin IV fluids, monitor BP & output, monitor cardiovascular system)
drugs (vasopressors)
nutrition (enteral & parenteral)
72
medical management for cardiogenic shock
- thrombolytic therapy
- angioplasty/CABG/IABP
- admin inotropes & vasopressors
73
medical management of hypovolemic
fluid resuscitation (maintain BP & output)
treat cause
74
medical management of septic
blood cultures
IV antibiotics & fluid resuscitation
monitor glucose & insulin (hyperglycemia)
monitoring labs (lactic acid)
75
neurogenic shock medical management
spinal stability
admin vasopressors & atropine
treatment dependent on cause
76
anaphylactic shock medical management
admin epi & fluid resuscitation
antihistamines & H2 blockers & glucocorticosteroids
maintaining airway
77
nursing assessment & management of shock
Assess ABCs
Comprehensive physiological assessment (Thorough head to toe)
Vital signs
Lab data (CBC, electrolytes, lactic acid levels, blood gases, liver enzymes, renal function (are they being perfused?)
Intake & output (min amount = 30cc/hr)
Personal hygiene
Emotional support & comfort (Holistic care, Utilize BCCNM 6 core concepts & principles)
78
what is a blood transfusion
admin of blood & blood products to temp support pt
79
what are the components of blood transfusion
whole blood, platelets, packed red blood cells, albumin or plasma
80
blood group antigens (A & B) are on RBC membranes (T/F)
T
81
what are the blood groups
A, B, AB, O
82
blood group A
A antigens on the red blood cells with anti-B antibodies in the plasma
83
blood group B
B antigens with anti-A antibodies in the plasma
84
blood group AB
both A and B antigens, but no antibodies
85
blood group O
no antigens, but both anti-A and anti-B antibodies in the plasma
86
what blood can be given to almost anyone in emergencies
O RhD negative blood (O-)
87
rh factor
refers to 3rd antigen thats also on RBC membranes
88
blood admin procedure
Venous access required to administer blood products
Positive identification of blood donor & recipient (double check with 2 licensed individuals – RN & RN)
Vital signs before transfusion
Remain with pt for first 15 mins or 50mL of transfusion (Likely when transfusion reaction occurs (acute hemolytic))
Reassess vital signs and increase rate per policy/orders
Periodically observe pt throughout & up to one hr after transfusion
89
acute hemolytic reaction cause
multiple transfusions (6 units), incompatible blood
90
clinical manifestations of acute hemolytic
hypotension, tachycardia, tachypnea, abdominal pain, back pain, fever, jaundice, occurs first 15mins
91
interventions for acute hemolytic
support BP
fluids
vasopressors
stop transfusion
92
febrile reaction cause
sensitization to donor
93
clincal manifestations of febrile reaction
chills, cold, overall feeling not well, muscle aches, flushed, increase temp by 1 degree
94
interventions for febrile reaction
antipyretics
stop transfusions
95
cause of allergic reaction to blood
sensitivity to donor plasma protein
96
clinical manifestation of allergic reaction to blood
hives, redness, skin issues, itchy
anaphylaxis (N & V, bronchoconstriction)
97
allergic reaction interventions to blood
antihistamines, epi, fluids
98
circulatory overload reaction
fluid administered faster than circulating system tolerates
99
clinical manifestations of circulatory overload reaction
SOB, crackles, increased work of breathing, tachycardia, tachypnea
100
interventions for circulatory overload
diuretics inbetween units of blood
slow down infusion rate
O2 PRN
101
sepsis reaction cause
contaminated product (bacterial infected blood)
102
clinical manifestations of sepsis reaction
hot, flushed
febrile
hypotension
103
interventions for sepsis reactino to blood
supportive therapy for sepsis
blood cultures
antibiotics
fluids
104
massive blood transfusion reaction
hypothermic (due to blood being in fridge)
105
transfusion related acute lung injury
leading cause of death
respiratory distress
1-6 hrs
106
response to acute transfusion reaction
Stop transfusion
Maintain patent IV line with NS
Notify blood bank & primary HCP
Recheck ID & tags
Monitor VS & UO
Treat symptoms per orders
Send tags & tubing to blood bank
Collect patient blood & urine samples per policy
Document transfusion reaction per policy
107
voluntary admission
pt agrees to hospitalization & treatment
108
involuntary admission
not willing to accept hospitalization & treatment
109
process for voluntary admission
Adults 16 yrs & older
Requires person to voluntarily seek admission
Physician/psychiatrist must agree to admission
Pt may discharge themselves from hospital at any time
110
form 1
request for admission
111
form 2
consent for treatment
112
process for involuntary admission
Medical certificate signed by a dr (form 4.1 (48hrs) & 4.2 (1 month))
Police (section 28)
Judge/court order
Section 22 (medical system) of MHA
113
criteria for involuntary admission
Pt must be suffering from mental disorder that srsly impairs pts ability to react appropriately to environment
Pt requires treatment in or through a designated facility
Pt requires care, supervision, & control in or through a designated faculty to prevent the pt’s substantial mental or physical deterioration or for pt’s own protection or protection of others
Pt not suitable as voluntary pt
114
forms for involuntary admission
form 4s (4.1, 4.2)
form 5
115
form 4s
medical certificates
need both signed & complated within 48 hr
116
form 5
consent for treatment
can be signed by director or designate if pt not sign
117
Recent changes in form 4
NPs can now involuntarily admit to designated facility for up to 48hrs (form 4.1)
Involuntary admission must be authorized by 2nd person, called director or designate
118
Legally, involuntary psychiatric admission can’t begin until the form 4.1 is fully complete is fully complete and signed by director
T
119
one certificate (4.1)
48 hrs
120
Two certificates (forms 4.1 & 4.2)
1 month
121
First renewal (form 6)
1 month
122
Second renewal (form 6)
3 months
123
Third renewal
6 months
Any subsequent renewals are for 6 months
124
form 13
NOTIFICATION TO INVOLUNTARY PATIENT
OF RIGHTS UNDER THE MENTAL HEALTH ACT
125
when does form 13 need to be filled out
When person is 1st admitted as involuntary pt
Following transfer to another facility
Whenever renewal certificate (form 6) is completed
When pt status changes (voluntary --> involuntary)
126
form 15
nomination of near relative
allows a patient to nominate someone to receive notice of the their admission, discharge and any application they make to the review panel.
127
form 16
notification to near relative
ADMISSION OF INVOLUNTARY PATIENT
includes rights information of involuntary pt
128
form 17
notification to near relative
discharge involuntary pt
129
Who participates at review panel hearing
Review panel (physician member, legal member, community member)
Pt
Pt representative
Case presenter from facility (physician)
Other representative for facility
Witnesses for pt &/or facility
130
How frequently can a person request a review panel?
After a person is certified and after each renewal
131
How does a person request a review panel
Pt fills out form 7
Nurse faxes it to review panel office
Review panel must occur within 14 days of request
132
Review panel must occur within 14 days of request
TRUE
133
Extended leave is
Type of leave for involuntary pt for a period greater than 14 days
134
pt still remains invountary on extended leave
TRUE
135
Form 20 / section 37 of MHA
allows an involuntary patient to leave the hospital and live in the community
Hospital dr needs to write an order in chart for leave
Hospital continues to have responsibility for treatment, care, health and safety of pt while on leave, when responsibility for pt has been assumed by a community physician
136
Conditions for extended leave
Pt needs to be cooperative with a list of regulations that are outlined by attending dr (medication adherence, follow up with MHT, housing, no substances)
Pt must understand (have insight)
You need to have adequate supports in community
Pt needs to be actively monitored for adherence
Extended leave may last for as long as person certified
137
Unauthorized absence
Involuntary pt leaves hospital without permission (AWOL)
138
Nurses responsibility for AWOL
Notify police
Notify security
Notify most responsible physician (MRP)
Notify charge nurse
Notify ED (triage)
Contact pt residence / family
Documentation
Complete PSLS (patient safety learning support)
139
ASKING ABOUT SUICIDE IS AN INTERVENTION & FIRST STEP OF PREVENTION!
TRUE
140
Suicide is the
voluntary & intentional act of killing oneself
Experiences, family factors, perceptions
141
Suicide attempt
Expecting to die, but survived
142
Suicidal behaviour
Any act of suicide despite the outcome
143
Suicidal ideation
Thought (passive = considering/thinking or active = plan, decided)
Thinking about & planning one’s own death
60% of people experiencing suicidal ideation had their first suicide attempt within the 1st year of ideation onset
Risk factor!
144
Para suicide
Attempt without intention to die (self-harm, that mimic suicide, intent not to die but accidental death can occur)
145
Self-harm
NOT a suicide attempt
People self-harm for a variety of reasons (A way to communicate needs or wants (Deep need to help pain), Need of often for attention or care, Self-punishment, May relieve or release certain emotions & feelings)
If the purpose of self-harm is not achieved it can lead to escalation in behaviour
Do not ignore or minimize behaviour
146
Risk factors: vulnerable population
Mental illness
Indigenous without cultural identity (X3 higher)
Incarcerated
Physical illness
Male
LGBT+
147
Risk factors: historical factors
Previous history of a suicide attempt (increased in first 90 days after hospital)
Family history of suicide
Family history of abuse or trauma
Early childhood loss
History of impulsivity
148
Risk factors: current factors
Mental illness
Substance use
Personality type
Stressful life events
School or work problems
Socioeconomic disadvantages
Social isolation
Attitudes/beliefs about suicide
149
Warning signs
Behavioural
Verbal
Emotional
Physical
150
Behavioural cues of suicide
Making final arrangements = Will
Stockpiling means = Pills
Family dr visit without reason
Increased/decreased substance use
Depressive symptoms
Uncharacteristic behavioural changes = Increase in mood
Changes in self-care
Withdrawal or acting out
151
Emotional cues suicide
Sad or despondent
Hopeless/helpless
Lonely
Guilty
Boredom
Self-hate
Extreme mood changes = Rage, agitation, anxiety
152
Verbal cues suicide
Direct statement of intent
Suicidal fantasies
Indirect statements
Discussing or joking about death or suicide
Saying goodbye out of context
153
Physical cues
Physical health complaints = Pain!!, drastic weight loss, diagnosed with something terminal or life long
Change/loss in sex interest
Sleep disturbances
Increased energy
154
Protective factors
Married with dependent children
Intact social supports
Religious affiliations or faith
Absence of depression or substance use
Access to medical/mental health resources
Good impulse control
Good problem-solving & coping mechanisms
155
interventions for suicide
hospitalization, protection
safety planning
encourage communication
promote self esteem
treat physical problems related to suicide
antidepressants
ECT
education
156
pain
Unpleasant sensory & emotional experience associated with actual or potential tissue damage, or described in terms of such damage
157
Gate theory: Neural mechanism in which pain is perceived includes:
Transduction
Transmission
Perception
Modulation
158
Transduction
Unpleasant stimulus causes cell damage with release of sensitizing chemicals (prostaglandins, bradykinin, serotonin, histamine)
Chemicals active nociceptors and generate action potential
159
Transmission
Action potential continues from:
Site of injury to spinal cord
Spinal cord to brainstem & thalamus
Thalamus to cortex for processing
160
Perception
Conscious experience of pain
161
Modulation
Neurons originating in brainstem descend to spinal cord & release substances (endogenous opioids) that inhibit nociceptive impulses
162
Pain assessment
O = onset (when did this pain start? How long have you been having this pain?)
P = provoking/palliating (what makes it better/worse?)
Q = quality
R = radiation/region (does it radiate anywhere else in the body?) (where is this pain located?)
S = severity (pain scale = #0-10, faces, words (mild, moderate, severe)
T = treatment/timing
U = understanding/impact on pt (what do you think is causing your pain? How is this pain impacting you?)
V = value (how does this pain impact your life)
163
Nonverbal behaviours pani
Facial expressions = Communication barrier, confused, stroke, nonverbal, delirium
Vocalization
Body movements
Social interactions
Mood
Sleep
164
Analgesic ladder
Used to help determine what to use to manage pain
Opioids = codeine (mild to moderate pain) used with acetaminophen
Moderate to severe pain = hydromorphone, morphine
Adjuvant = primary use may not used for pain but used with opioid/nonopioids to reduce pain = Work on different pain pathways to increase analgesic properties
165
Mild pain
Nonopioids (NSAIDs, acetaminophen)
166
Mild to moderate pain
Nonopioids & opioids (codeine, oxycodone)
167
Moderate to severe pain
Opioids (morphine, hydromorphone, fentanyl)
168
Adjuvant analgesic therapy
Anti-depressants (tricyclics, lower dose to have analgesic properties)
Anti-seizure agents (neuropathic pain = diabetes)
Muscle relaxant (muscle spasms & neuropathic)
Anesthetics
Cannabinoids
Corticosteroids (reduction in edema & inflammation = reduce pain)
169
Nociceptive pain
- type of pain caused by damage to body tissue.
- feels sharp, aching, or throbbing.
- caused by an external injury, like stubbing your toe, having a sports injury, or a dental procedure.
commonly experience nociceptive pain in the musculoskeletal system, which includes the joints, muscles, skin, tendons, and bone
Ability to process pain, intact nervous system
170
manifestations of nociceptive pain
Somatic = bones/joints: localized, throbbing, aching
Visceral = organs, obstruction, tumour
171
treatment for nocicpetive pain
Non-opioid & opioid medications
172
neuropathic pain
Abnormal processing due to damage, difficult to treat, result of injury to nervous system (difficult to treat)
173
manifestations neuropathic pain
Burning, shock-like, electric, intense, long lasting, short
174
treatment neuropathic pain
Gabapentin
- antidepressants, anticonvulsants
Pain ladder
175
Acute pain
Sudden onset, normal time of healing expected, worse in beginning and gradually get better over healing process (labour, post-op, cuts, sprains, fracture, angina)
176
manifestation acute pain
Tachycardia, tachypnea, hypertension, pallor, diaphoretic, agitated, annoyed, anxious
177
treatment acute pain
Opioids & nonopioids
Pain ladder
178
Persistent pain
Gradual onset continues past time of normal healing (episodic health change, depression, anxiety)
179
manifestations of persistent pain
Accompany anxiety, depression (internal), fatigue, changes in affect, ADLs,
180
treatment persistent pain
Pain ladder
181
1 goal per care plan?
YES
182
illusions
perception that occurs when a sensory stimulus is present but is incorrectly perceived and misinterpreted, such as hearing the wind as someone crying
183
SBAR documentation tool
Situation, Background, Assessment, Recommendation
Used to transfer pts between units
184
What is the PSLS?
Completed after any unusual occurrence (eg. med error, falls, staff harm, unexpected deaths); used for educational and quality assurance
185
SOAP charting
Subjective, objective, assessment, plan
186
what is the MHA and why is it important?
ensures people with mental health disorders receive tx when they are not willing to do it
provides criteria & procedure for involuntary admission & tx
187
what are the 5 conditions for extended leave?
1. pt needs to be cooperative with a list of outlined regulations from physician
2. pt must have insight to understand
3. adequate community supports
4. actively monitored for adherence
5. extended leave may last for as long as the person is certified
188
What type of blood can a person with AB blood type receive?
all blood type
189
What type of blood can a person with type A blood receive?
type A or type O
190
What type of blood can a person with O type blood receive?
O positive or O negative blood types
191
acute hemolytic reaction description
Antibodies in the recipient's serum react with antigens on the donor's RBCs that causes agglutination of cells resulting in blood flow being blocked to tissues.
192
