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Question 1

Mechanical Bowel Preparation - rationale

Answer 1

To empty the intestines prior to the procedure, to provide a clear view of the bowel

Question 2

Mechanical Bowel Preparation

Answer 2

• Bowel prep may vary depending on doctor. For example, patients may be kept on clear liquids 1–2 days before procedure. Cathartic and/or enema given the night before. An alternative is to give 3L of polyethylene glycol on the evening before (250 mL glass every 15 minutes).
• Seven days before – stop NSAIDs (eg- Ibuprofen) Unless otherwise recommended by your Dr.
• Long acting insulin – recommend taking half the usual dose before procedure.
• Consult with your Dr about anti-coagulants in relation to heart failure and Diabetes.

Question 3

Mechanical Bowel Preparation - Nursing considerations

Answer 3

• Caution if used in people with diabetes, impaired kidney function, pre-existing electrolyte imbalance, congestive cardiac failure or the older person.
• Monitor the patient’s fluid balance by maintaining a strict FBC and electrolytes (especially potassium –cardiac arrhythmias/ arrest),
• Advise the patient to slow the drinking rate if nausea and bloating become severe,
• Preparation is considered complete when the patient is passing clear fluid from the bowel.

Question 4

Mechanical Bowel Preparation - After the procedure

Answer 4

• Be aware that patient may experience abdominal cramps caused by stimulation of peristalsis because the bowel is constantly inflated with air during procedure.
• Observe for rectal bleeding and signs of perforation (e.g. malaise, abdominal distension, tenesmus).
• Check vital signs.

Question 5

Surgical Fasting Times

Answer 5

• Liquids and solids empty by different mechanisms at different times.
• Clear liquids up to two hours prior to surgery
• Clear liquids e.g. water, juice without pulp, coffee/ tea without milk & soft drinks usuallyout of the stomach in 12mins.
• Enhanced recovery (ERAS) protocols for surgery may include the administration of 300to 400 mL of a carbohydrate drink ±proteins ±lipids up to two hours prior to anaesthesia.
• Solids up to four hours prior to surgery

Question 6

Bowel Cancer (Ca) - Prevalence

Answer 6

• Second most common in Australia•1/10 men
• Most common in over 50yo

:

Question 7

Bowel Cancer (Ca) - Risk factors

Answer 7

Age
Bowel diseases
Previous history
Lifestyle (overweight, red meat, alcohol, smoking)
Family history
Rare genetic disorders
polyps

Question 8

Bowel Cancer (Ca) - Symptoms

Answer 8

• Change in bowel habits
• Change of appearance or consistency
• Feeling of bowel not fully empty after bowel movement
• Abdominal pain and bloating
• Blood in stool
• Unexplained weight loss
• Weakness or fatigue
• Unexplained anaemia
• Rectal or anal pain
• Lump in rectum or anus

Question 9

Living with bowel cancer

Answer 9

• Depression
• Anxiety – upon leaving hospital and at-home management
• Finding simple tasks exhausting and decreased energy
• Conscious of more frequent bowel movements and in some cases fecal ooze
• Changes in body image can affect self-esteem and confidence
• Individual may fear death, suffering, pain or all the unknown things ahead
• Family members and caregivers often have these feelings too –losing their loved one

Question 10

Surgical complications -colectomy

Answer 10

• Bleeding
• Injury to adjacent organs
• splenic injury (risk factors increased age, obesity open vs lap previous abdosurgery)
• Small bowel and duodenal injury
• Pancreatic injury
• Gastric injury
• Major vessel injury
• Wound infection
• Incisional hernia
• Intestinal obstruction (ileus)
• Anastomotic leak
• Thromboembolic complication
• Cardiac/respiratory complications

Question 11

Congestive Cardiac Failure Patho

Answer 11

occurs when the heart is unable to pump oxygenated, nutrient rich blood out at a rate that meets the metabolic demands of the body, causing a back-up of blood in the venous circuit and leading to oedema.

Results from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill or eject blood.Diagnosed when LVEF < 40%

Question 12

Congestive Cardiac Failure Patho - Causes

Answer 12

• Myocardial disease
• (2/3 of all CHF –from fibrosis from IHD + AMI)
• Arrhythmias
• Valve disease
• Pericardial disease
• Congenital heart disease
• COPD (right sided HF)

Question 13

Determinants of Cardiac function

Answer 13

preload
afterload
contractility
heart rate

Question 14

preload

Answer 14

represent the stretch on the ventricles as a consequence of ventricular filling. (venous return relates directly to end diastolic volume) i.e intravascular blood volume

Question 15

Afterload

Answer 15

resistance downstream to the left ventricle which it has to overcome in order to eject blood from the heart. i.earterial vasoconstriction increases resistance

Question 16

Contractility

Answer 16

the force of contraction to ensure the adequate stroke volume is ejected. The degree of myocardial fibre shortening

Question 17

Captopril 50mg

• Indications
• Class
• Mechanism of Action:
• Nursing assessment(s) prior to the administration:
• Nursing assessment(s) after the administration:

Answer 17

Class: Antihypertensive, ACE inhibitor

Indications: hypertension, Heart Failure (+diuretic)

Mechanism of Action: highlyspecific competitive inhibitor of angiotensin I converting enzyme, theenzyme responsible for the conversion of angiotensin I to angiotensin II.:

Nursing assessment(s) prior to the administration: Check BP

Nursing assessment(s) after the administration: Monitor Serum potassium levels

Question 18

Potassium 1200mg

• Indications
• Class
• Mechanism of Action:
• Interactions
• Nursing assessment(s) prior to the administration:
• Nursing assessment(s) after the administration:

Answer 18

Indications: Treatment of all types o fpotassium deficiencies, particularly hypochloraemic or hypokalaemic alkalosis, associated with prolonged or intensive diuretic therapy, e.g. in hypertension,cardiac failure

Mechanism of Action: sustained release potassium supplement

Interactions: Span-K should be used with caution, if at all, in patients receiving drugs that increase serum potassium concentrations. These include potassium sparing diuretics, angiotensin convertingenzyme (ACE) inhibitors

Nursing assessment(s) prior to the administration: Know patient serum potassium with hold if > 5.5mmol/L

Nursing assessment(s) after the administration: Monitor Serum potassium levels

Question 19

Surgical risks for CCF

Answer 19

Heart failure is a major risk factor.
HF patients have substantially higher risks of postoperative mortality than those with coronary artery disease undergoing the same procedures

Patients with heart failure (HF) are at risk for hypotension, hypertension, and arrhythmias during surgery.

Due, in part, to the stress response induced by surgery, with release of catecholamines, steroids, and inflammatory mediators, which increase metabolic demand.

Question 20

ACE inhibitor and surgery

Answer 20

Generally oral antihypertensive medications should be continued up to the time of surgery,with few exceptions. taken with small sips of water on the morning of surgery.

However, we typically withhold angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) for a period of 24 hours prior to surgery.

Some anesthesiologists may prefer to withhold these medications on the morning of surgery based on concerns about possible hypotension particularly if significant perioperative fluid shifts are anticipated.

We suggest individualizing the decision to continue or discontinue ACE inhibitors based on the indications for the drug, the patient’s blood pressure, and the type of surgery and anesthesia planned.

Question 21

T2DM Pathophysiology

Answer 21

Chronic Progressive condition

Main problem is the body becomes resistant to the normal effects of insulin and/or the body loses the capacity to produce enough insulin in the pancreas to meet demand.

There is a decreased intracellular reaction to insulin causing a decreased uptake of glucose by the tissue

Causing an unchecked regulation of glucose production/release by the liver (gluconesis & Gluconeogenesis)

To overcome this there needs to be an increase in the amount of insulin secreted.

However if the beta cells cannot keep up with the increased demand for insulin, glucose level rises above normal level and T2DM develops.

Question 22

T2DM Risk factors - modifiable

Answer 22

Weight
Sedentary lifestyle
diet
HTN
Apple shaped body

Question 23

T2DM Risk factors - Non –modifiable

Answer 23

• A family history of diabetes
• ATSI background
• Age
• Over 55 years of age - the risk increases as we age
• Are over 45 years of age and are overweight
• Are over 35 years of age and are from an Aboriginal or Torres Strait Islander background
• Are a woman who has given birth to a child over 4.5 kgs, or had gestational diabetes when pregnant, or had a condition known as Polycystic Ovarian Syndrome.

Question 24

T2DM Symptoms / Clinical manifestations

Answer 24

Polyphagia
Polyuria
Polydipsia

Question 25

Polyphagia

Answer 25

results from cell deprivation of nutrients as glucose is not entering the cells in sufficient amounts which stimulates increased food intake

Question 26

Polyuria

Answer 26

the osmotic effect of glucose in the urine draws water from the bloodstream increasing production of urine

Question 27

Polydipsia

Answer 27

the water being lost from the body in the urine leads to dehydration which triggers increased thirst in an attempt to rehydrate the cells

Question 28

Metformin 1000mg

• Indications
• Class
• Mechanism of Action:
• Interactions
• Nursing assessment(s) prior to the administration:
• Nursing assessment(s) after the administration:

Answer 28

Class: oral hypoglycaemic agent

Indications:
Biguinadeused in T2DM not controlled by diet and exercise

Mechanism of Action:
It causes an increased peripheral uptake of glucose by increasing the biological efficiency of available exogenous or endogenous insulin.
The mode of action of metformin may be linked to an increase of insulin sensitivity.
It does not stimulate insulin release but does require the presence of insulin to exert its antihyperglycaemic effect.

Possible mechanisms of action include inhibition of gluconeogenesis in the liver, delay in glucose absorption from the gastrointestinal tract and an increase in peripheral uptake of glucose

Nursing considerations:
Type 2 diabetic patients with heart failure are at an increased risk of hypoperfusion and possible renal insufficiency.
Renal insufficiency is a risk factor for systemic accumulation of metformin and consequently lactic acidosis.
Careful monitoring of renal function is recommended when metforminis used in patients with cardiac failure.
Elective major surgery (discontinue 48 hr pre-surgery; may restart ≥ 48 hrs post-surgery if renal function normal)
monitor serum vitB12(pre treatment, 6mths, annually)

Question 29

Surgical risk for obesity and diabetes

Answer 29

Obese patients have a higher risk of surgical and anaesthetic complications (BMI over 30) and post operative wound infections

Obesity stresses the cardiac and pulmonary systems and makes access to the surgical site and anaesthesia administration more difficult.

Some inhaled anaesthetic agents are absorbed and stored in adipose tissue, and therefore leave the body more slowly prolonging recovery/wakening times.

Diabetes mellitus is also associated with increased risk of perioperative infection and postoperative cardiovascular morbidity and mortality and longer hospital stays.

Persistent hyperglycemia is a risk factor for endothelial dysfunction, postoperative sepsis, impaired wound healing, and cerebral ischemia.

Surgery and general anaesthesia cause a increase in stress response which alters glucose metabolism.

Key aspect of the perioperative management is glycemic control through close monitoring, adequate fluid and caloric repletion, and judicious use of insulin

Question 30

Vascular access for surgery

Answer 30

Arterial Lines-
indicated when precise continuous BP monitoring is required, especially during periods of fluid volume, cardiac output and blood pressure instability. when frequent blood sampling is required

Radial artery
most common as the ulnar artery provides additional supply to extremities if the radial artery become compromised.

Other sites:
Brachial, femoral, dorsalis pedis arteries

Nursing responsibilities:
Needs to be referenced to phelbastatic axis (level of heart) may need to be moved every time patient is repositioned
transducer zeroed every shift.
Correlated with NIBP to ensure accuracy start of every shift
Pressure bag check
Waveform interpretation and BP monitoring
Limb observations for adequate circulation to fingers/hand and site inspection hourly (dressing, bleeding)
Blood sampling technique

Question 31

Fluid resuscitation

Answer 31

Crystalloids solution-
are solutions of electrolytes and sterile water that may be isotonic, hypotonic, or hypertonic with respect to plasma. (hartmannsor plasmalyte)

Colloid solutions
are human plasma derivatives (eg, human albumin, fresh frozen plasma [FFP]) or semisynthetic preparations (gelofusion)
There is no evidence that colloid solutions are superior to balanced electrolyte solutions. However, some clinicians prefer to use colloids in selected patients or situations in attempts to expand microvascular volume with minimal capillary leakage, thereby minimizing edema formation and the total quantity of administered fluid

Blood products 
(RBC) are used to replace intraoperative blood loss when a transfusion threshold is met,

moderately invasive surgery, we administer 1 to 2 L of a balanced electrolyte solution if the procedure does not incur significant fluid shifts or blood loss.
This 1 to 2 L of fluid is typically administered during surgery, over a period of 30 minutes to two hours.
A smaller fluid volume is appropriate in patients with a history of heart failure or chronic obstructive pulmonary disease.

Question 32

Fluid Overload

Answer 32

Pulmonary oedema is the accumulation of fluid within pulmonary interstitial spaces and ultimately within the alveoli.

The excess fluid occurs as a result of changes in pressure within the pulmonary vessels or from changes in vascular permeability

Pulmonary capillary pressure exceeds plasma oncotic pressure and forces fluid into the alveoli, interfering with gas exchange.

Cardiogenic pulmonary oedema is associated with heart failure

Question 33

Signs and Symptoms of pulmonary oedema (APO)

Answer 33

↓ SpO2
Dyspnoea (SOB)
Tachycardia
Tachypnoeic
↓ LOC
Cyanosis
Crackles on auscultation
Prink frothy sputum
Sense of impending doom

Question 34

Treatment for fluid overload

Answer 34

Supplemental oxygen
Mechanical ventilation
High fowlers positioning
Calm reassurance
Morphine
Diuretics – reduces pulmonary capillary pressures and systemic vascular resistance
Medications to improve contractility may also be required
Manage cause

Question 35

Stoma/ wound management

Answer 35

• Patient adaptation-ADL’s in 6-8 weeks, no heavy lifting, psychological support, identify coping mechanism
• Colostomy care
• Assess stoma and surrounding skin:
• Pink stoma - healthy; pale - anaemic; dusky blue - necrotic
• Mild to moderate swelling - till 2-3 weeks is normal; moderate to severe swelling -obstruction of stoma
• Small amount of oozing - normal; moderate to large bleeding -coagulation problem or GI bleed
• Wash stoma with mild soap & water
• Use of skin barrier
• Use of pouch - leave ¼ of skin around the stoma
• Colostomy irrigations
• Regulate bowel function
• Treat constipation

Question 36

Living with a colostomy bag

Answer 36

• Negative change in body image
• Physical, emotional, mental, social, sexual and economic
• Fear of rejection from partner due to change in body image, as well as, smell and physical appearance•Low fiber and soft diet
• Post-Op discomfort from some foods
• Nuts, seeds and fibrous foods can lead to blockage and infection
• Most people return to their normal diet

Question 37

Patient Controlled Analgesia -PCA

Answer 37

• Used to manage post operative and chronic pain
• PCA pump permits the patient to self administer bolus doses of opioid analgesic medication.
• The pump then delivers a pre-set amount of medication (usually Intravenously but can be via SC or epidural route)
• Can have a continuous infusion (basal rate or background) and still allow additional bolus doses of medication
• The pump is an electronically controlled by a timing device. (lock out) time prevents/reduces risk of overdose.
• PCA use usually means patients require less pain medication and achieve better pain relief than those treated by the standard prn plan

Question 38

Redivac drain - Indication:

Answer 38

To allow the escape of blood or serous fluid that can otherwise serve as a culture medium for bacteria.

With closed drain systems the use of gentle, constant suction enhances drainage of these fluids and collapses the skin flaps against the underlying tissue thus removing dead space.

Question 39

Redivac Drain - Nursing responsibilities

Answer 39

:* Measure output FBC – amount, colour, consistency

• Check suction patency
• Check surgical dressing for bloody ooze.
• Excessive drainage should be reported
• Change drain when full (aseptic technique)