The term used for before surgery?
What is the nurses responsibility for this term?
Educator, advocate and health promotion.
What is the term used during surgery?
What is the nurses responsibility for this term
Safety and advocacy.
What is the term used after surgery?
What is the nurses responsibility for this term?
On going evaluation and stabilization of clients, prevention of post-op complications.
What are these things:
1. Diagnostic: exploratory laparotomy.
2. Curative: fibroid tumors-hysterectomy.
3. Restorative: hip replacement.
4. Palliative surgery makes the client more comfortable. Does not cure, ex. suprapubic catheter.
5. Cosmetic surgery reconstructs the skin and underlying structures, ex. scar revision.
Purpose of surgery
When would you collect these things:
-Hx and data collection.
-Drugs and substance use (look for withdrawls)
-Medical hx, including cardiac and pulmonary hx (specifically comorbities ex. DM and CAD).
-Previous surgeries and anasthesia.
-Blood donations (this will tell you if they may have a disease like HIV)
Collaborative management assessment
What are these things?
-Chronic illness-inc. risk
-Prior surgical experiences-ex. anesthesia rx.
-Type of surgical procedure-ex. exploratory laparotomy inc. risk for paralytic ileus.
Risk factors based on assessment
What are these things:
-Baseline vital signs.
-Focus on problem areas identified by the clients hx on all body systems affected by the surgical procedures.
-Report any abnormal assessment findings to the surgeon.
Physical Assessment/Clinical Manifestations
What is the common NRS Dx for pt's who are preoperative?
Lack of knowledge secondary to lack of surgical experience.
Who is responsible for obtaining a signed consent before sedation is given and surgery is performed?
The nurse is responsible for making sure pt is NPO b/f surgery, what happens if pt eats?
Surgery get CX and by eating increases the risk for pt to have aspiration.
Can pt still take his meds even if he is NPO b/f his surgery?
Consult the physician and anesthesia for instructions, especially for meds for DM, CAD, glaucoma, anticonvulsants, antihypertensives, anticoagulants, antidepressants, or corticosteroids.
Why are bowel or intestinal preperation performed b/f surgery?
to prevent injury to the colon and to reduce the number of intestinal bacteria. An enema or laxative may be ordered by the physician.
Name things that you would teach the pt for postoperative.
-Breathing excerises, incentive spirometry, coughing and splinting, leg procedures and exercises, antiembolism stockings, and elastic wraps, early ambulation, and rang of motion exercises.
Name 5 things the nurse would do for anxiety prevention b/f surgery?
1. Preoperative teaching.
2. Encouraging communication.
3. Promoting rest.
4. Using distraction.
5. Teaching family and significant others.
If some one has come bk from surgery and had anesthesia what are the two high risk patients the nurse should really look out for?
-Those with liver and kidney disease.
Induced state of partial or total loss of sensation, occurring with or without loss of consciousness. Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and in some instances achieve a controlled level of unconsciousness.
-Reversible loss of consciousness.
-State can be achieved by a single agent or a combination of agents.
-Central nervous system is depressed resulting in analgesia, amnesia and unconsciousness with loss of muscle tone and reflexes.
-With this the nurse needs to consider emotional/psychological effects which include the fear of being put to sleep.
Name the two types of General anesthesia and info about them.
1. Inhalation-Intake and excretion of anesthetic gas or vapor to the lungs through a mask.
2. Intravenous Injection- injected through an IV line disposed in the blood.
How long does recovery take when given general anesthesia?
Recovery depends on type of agent, length of time client is anesthetized and if a reversal agent is used.
What are possible responses to general anesthesia?
Retching, vomiting, restlessness and changes in the ability to control body temperature.
What are some interventions we might use when some one went through general aneshthesia?
Suction equipment, warmth and O2.
What is the biggest complication from general anesthesia?
This is the biggest complication from general anesthesia.
Marked by a rapid rise in body temperature, increase in serum calcium and potassium, signs of increased muscle metabolism (muscle proteins detected in the urine) and rigidity. Can be life-threatening.
Name 5 complications of General anesthesia.
1. Malignant hyperthermia
3. Complications of specific anesthetic agents.
4. Unrecognized hypoventilation.
5. Complications of intubation.
This is caused by a local or regional anesthesia:
Secondary to the interruption of the sensory nerve impulse transmission from a specific body area or region.
Name 4 things that local or regional anesthesia does to the body.
2. Motor function may be affected.
3. Client remains conscious and able to follow instructions.
4. Gag and cough reflexes remain intact.
What type of agents are used on the pt before the have a local or regional anesthesia?
Sedatives, opioid analgesics, or hypnotics.
When the is an over dose of local or regional anesthesia what are the signs to look for?
respiratory depression and sedation
Name 4 complications of local or regional anesthesia.
2. Incorrect delivery technique
3. Systemic absorption
What S&S should the nurse look for with complications of local or regional anesthesia.
Assess for CNS stimulation, CNSand cardiac depression, metallic taste, nausea and vomiting, tremors, seizures, increased pulse, respirations, and bp.
What are the treatments for complications of local or regional anesthesia?
1. **Establish an open airway.************
2. Give O2.
3. Notify the surgeon.
4. Fast-Acting barbiturate is usual treatment.
If toxic rx is untreated, unconsciousness, hypotension, apnea, cardiac arrest, and death may result.
IV delivery of sedative, hypnotic, and opioid drugs reduces the level of consciousness but allows the client to maintain a patent airway and to respond to verbal commands.
When pt is in a conscious sedation what is the nurses role?
Assessment of airway, level of consciousness, oxygen saturation, electrocardiographic status, and vital signs are monitored every 15-30 minutes.
Name 3 interventions for risk for perioperative positioning injuries.
1. Proper body position
2. Risk for pressure ulcer formation
3. Prevention of obstruction of circulation, respieation, and nerve conduction.
Ongoing evaluation and stabilization of clients to anticipate, prevent and treat complications after surgery.
Usually located close to the surgical suite.
Recovery room AKA PACU.
What kind of nurse is skilled in the care of clients with multiple medical and surgical problems that can occur following a surgical procedure.
A PACU nurse AKA recovery room nurse.
After a patient has had what done should you assess for:
-motor and sensory assessment.
After an epidural or spinal anesthesia.
What is an example of a command you would ask a patient to assess for motor fx?
Simple commands, ask pt to move extremities.
While pt is going through the return of the sympathetic nervous system tone what position should they be in and what should you assess for?
Gradually elevate head and monitor for hypotension.
The effects of drugs, anesthetic agents, or manipulation during surgery can cause urine what?
1. Why is peristalsis delayed post surgery?
2. Pt's who have abdominal surgery often have decreased peristalsis for at least how long?
Can you irrigate a nasogastric tube after gastric surgery with out an order?
No, you need an order from the surgeon
A partial or complete separation of the outer wound layers, sometimes described as a splitting open of the wound. Wound heals from the bottom up.
A total separation of all wound layers and protrusion of internal organs through the open wound requires surgical intervention.
Dressings and drains, including casts and plastic bandages, must be assessed for bleeding or other drainage when?
On admission to the PACU (recovery room)
and hourly thereafter.
In what situation should a nurse have a patient in a side-lying position or turning his or her head to the side to prevent aspiration?
When there is an impaired gas exchange.
When a patient has an impaired gas exchange what are a couple interventions a nurse should do?
1. Encourage deep breathing exercises.
2. Encourage mobilization as soon as possible to help remove secretions and promote lung expansion.
Provide and exit route for air, blood, and bile as well as help prevent deep infections and abscess formation during healing.
1. Acute pain can activate what?
2. When that happens what are symptoms of the patient?
2. Restlessness, increased HR, BP, RR, dilated pupils and sweating.
Name three interventions for hypoxemia.
1. Maintain airway patency and breathing pattern.
2. Prevention of hypothermia.
3. Maintenance of oxygen therapy as prescribed.
Name the 3 sources of pain.
2. Visceral-organ pain like an MI
3. Neuropathic-pain from the CNS
Is a state of adaptation in which exposure to a drug induces changes in its effect over time.
This is a chronic neurobiologic disease characterized by:
impaired control over drug use
compulsive drug use
continued use despite harm
occurs over time, not a result of one hospital stay
During an assessment you ask what questions about the location of the pain.
localized, projected, radiating, or referred
Name the three types of analgesics that are for relieving pain.
Acetylsalicylic acid, acetaminophen, and non-steroidal anti-imflammatory drug (NSAIDS) like motrin, aleve, tramadol.
These are examples of what type of drug?
Codeine, hydrocodone, oxycodone, morphine, hydromorpnone, fentanyl, methadone, tramadol, and meperidine are examples of what type of drug?
Name a few side effects of opioid analgesics
Nausea, vomiting, constipation, sedation and respiratory depression.
Antiepileptic drugs, tricyclic antidepressants and topical meds are examples of what type of drug?
Instead of pain drugs what can we do for the pt?
apply heat, cold pressure
What are some things they do that are invasive to help with pain?
spinal cord stimulation
What is the purpose of inflammation and immunity?
Is to neutralize, eliminate or destroy invading organism or the antigen.
Provides immediate, short term protection against the effects of tissue injury and foreign proteins.
Can inflammation occur without invasion by organisms?
Yes, inflammation does not always mean there is an infection.
What stage of inflammation is this?
(Vascular) change in blood vessels (seconds to minutes)
Phase I constriction
Phase II hyperemia and edema (increased blood flow, plasma).
What stage of inflammation is this?
(cellular exudate hours after invasion) neutrophilia, pus.
First line of defense, phagocytosis, they mature in 12-14 days. It is involved in inflammation.
Important in the immediate in inflammation response and phagocytosis. Predominantly in the liver and spleen, long life spans months to years.
These things are stimulated by what?
pollen and food
-stem cells in the bone marrow
-Migrate into secondary lymphoid tissue (spleen, lymph nodes, tonsil and Peyer's patches of the intestinal tract) where the mature completely.
-Provides long lasting immunity (memory cells)
-Antibodies are called immunoglobulins and gamma globulins.
-Neutralize, eliminate or destroy the antigen.
-Transferable from person to person.
Acquiring Antibody Mediated Immunity
Helps protect the body by differentiating self from non-self cells, non-self cells most easily recognized by cell-mediated immunity are CA cells and those self cells infected by organisms that live within host cells (RBC's).
*************Its function is to protect against CA cells and viruses, responsible for delayed hypersensitivity and transplant rejection.
Cell-Mediated Immunity (t-cells)
What are these types of?
Natural killer cells
Types of T-Cells
Because the elderly has fewer B-lymphocytes what does this increase the chances of?
Because elderly have few T-Lymphocytes what does this increase their chances of having?
a congenital disorder that causes the absence of serum Igs they can give them antibodies.
X linked Agammaglobinemia of Burton
A congenital disorder that causes the absence of cell-mediated immunity. They can have a thymus transplant.
Di George's Syndrome
HIV is classified according to clinical conditions and CD4+ counts what is the norm count?
800-1000 CD4+ cells/mm3 of blood
What is the top 2 ways a healthcare worker gets HIV?
1. needle stick.
2. infected through exposure of non-intact skin and mucous membranes to blood and body fluids.
What is the name of the CA HIV patients can get?
Kaposi's sarcoma, and malignant lymphomas
they can also have endocrine complications
What is the name of the antibody test done to see if pt has HIV? (ELISA). What is the test confirmed by?
Enzyme-Linked Immunosorbent Assay
1. This test monitors disease progression in HIV?
2. This test determines presence of HIV?
1. Viral load
2. Viral culture
These are nrs dx related to what disease?
-chronic low self esteem
-disturbed thought processes
-impaired skin integrity
Is an altered immunologic reaction to an antigen and it results in a pathologic immune response upon re-exposure to the antigen.
-This type of hypersensitivity is characterized by the production of IgE after exposure to an antigen.
-caused by release of histamine.
-Re-exposure produce severe allergic reaction.
-Symptoms last about 10 minutes.
-Peak 1-2 minutes.
Clinical Manifestations of what type of hypersensitivity?
GI tract, the skin and the respiratory tract
-Angioedema (cutaneous swelling)
-Nasal and conjunctival discharge.
Target tissues are those that contain a large amount.
Anaphylaxis of what type of hypersensitivity?
-rapid, systemic affecting multiple organs simultanously.
Interventions for systemic anaphylaxis
Name 9 things
1. Establish airway
2. Epinephrine 0.3-0.5ml
3. Antihistamine to treat angioedema/uticaria
4. Oxygen at 2-6 L/min
5. Aminophylline for bronchospasms it is a steroid pt needs to stay 24 hours.
7. Pulse ox
8. Suction available
9. CPR may be necessary
What type of hypersensitivity is this?
-Antibody reacts with antigen on surface cells
-Most common IgG and IgM
-Involves activation of complement
Hemolytic anemia (rapid break down of RBC) involves antibodies produced against RBC.
-Transfusion reactions involves antibodies produced against donor blood cells.
-erythroblastosis Fetalis involves maternal antibodies produced against fetal blood cells. ( Mom RH+ and Infant RH- Moms body thinks baby is foriegn and when she has a second baby it will die. They give the mom rogan.
Type II AKA cytotoxic
What would you consider to do with a Type II (cytotoxic) response?
Plasmapheriesis to remove autoantibodies
What type of hypersensitivity is this?
-Antigens cause immune complexes to form in the blood.
-Not organ specific, activates complement and mast cell degranulation-tissue and capillary damage.
serum sickness, glomerulnephritis, systemic lupus erythematous, rheumatoid arthritis.
This is people who have antigen-antibody rx.
Type III (immune complex rx)
treatment is chemo, steroid, ASA
This type of hypersensitivity does not involve antibodies, mediated by sensitized T lymphocytes.
-delayed response (hours-days)
-ex. PPD for TB
Type IV (cell mediated)
This type of hypersensitivity is continous "turned on" state of cell
-Inappropriate stimulation of normal cell surface receptor by autoantibody.
-ex. graves disease (hyperthyroidism)
-Interventions are surgical removal or radiate the thyroid. and immunosuppression of autoantibodies.
Type V (stimulatory)
This is an example of autoimmunity this is when all connective tissue becomes hard, there is no cure.
Inappropriate immune response it is the breakdown of tolerance-antibodies are directed against healthy, normal cells.
List 2 examples
1. Rheumatiod arithritis
2. Rheumatic fever
What are the interventions for autoimmunity?
1. Anti-inflammatory drugs
2. Immunosuppressive drugs
3. Symptomatic treatment
Is Osteoarthritis inflammatory or non-inflammatory?
What type of people do you see this in mostly?
What joints does it typically effect?
weight bering joints
Clinical manifestations of what disease?
-pain and stiffness in one or more joints (usually wgt bearing joints)
-Joint enlargement (heberden's and Bouchard's nodes
What is the treatment for Osteoarthritis?
-minimize inflammation but preserve ROM (rest and exercise the joint)
-Analgesics and anti-inflammatory drugs. ex. celebrex
-surgery (joint replacement)
Chronic systemic inflammatory disease that causes degenertion of connective tissue. Primarily effects the synovial joints. Autoimmune phenomenon development of self-destructive antibodies called Rheumatoid Factors which persist in the joint capsule inflammation and destruction of the tissue.
Clinical manifestations of what disease:
-fever, fatigue, body aches, and joint swelling.
-joint tenderness and stiffness greater in the morning.
-Extra-synovial nodules over the elbows and fingers.
This electrolyte is a major cation in the extracellular fluid and is responsible for maintaining extracellular fluid osmolarity.
This electrolyte is responsible for skeletal muscle and cardiac contraction, nerve impulse transmission.
What symptoms will a patient have when they have hypernatremia?
It causes shift of fluid out of the cells and then causes neuromuscular irritability.
The function of this electrolyte functions include the regulation of protein synthesis, glucose use and storage, and maintenance of action potential in excitable membranes.
this electrolytes levels in the blood and interstitial fluid are very low, so change seriously affects physiologic activities.
If an ng tube is in the pt what electrolyte should be infusing b/c the tube is sucking it out?
What is the treatment for hyperkalemia and how does it work?
Kayexalate and it pulls potassiumbk in to the gut and then the person poops it out.
What is the max infusion rate with potassium?
5-10 mEq/hr the rate should never exceed 20 mEq/hr under any circumstances.
What does blood do when calcium levels are too high or too low?
Too high your blood can clot
Too low you can bleed
This electrolyte is and important maintenance of bone strength and density activation of enzymes or reactions, skeletal and cardiac muscle contraction, nerve impulse transmission, and blood clotting?
If a pt has hypocalcemia what are they at risk for and what should you do to help prevent it?
Seizures and keep the environment stress free.
If a pt has diarrhea and they are not absorbing potassium what type of monitor do you need to put them on?
What symptoms do you get with hypophosphatemia?
-Musculoskeletal (acute muscle breakdown, or rhabdomyolyis)
Problems caused by hyperphosphatemia center on the hypocalcemia that results when serum phosphorus levels increase.
What electrolyte is usually off when you are an alcoholic b/c they are usually malnourished?
What electrolyte is responsible for this:
-Skeletal muscle contraction
-adenosine triphosphate formation
-B-complex vitamin activation
-DNA and protein synthisis
-Extracellular magnesium regulates blood coagulation and skeletal muscle contractility
This imbalance causes increased membrane excitability and the accompanying serum calcium and potassium imbalances.
With this electrolyte imbalance excitable membranes may not respond to any stimulus.
What types of things would we ask/assess for, for fluid and electrolyte balance?
-Physical assessment-assess for hydration
-Psychosocial assessment-psychological factors that may effect balance.
-Diagnostic assessment-laboratory assessment.
Occurs when fluid intake is less than needed to meet the body's fluid needs, resulting in a fluid volume deficit.
What is an expected lab finding for some one who is dehydrated?
In the absence of hemmorrhage, overall hemo-concentration.
When some one is dehydrated what 2 organs will take over as a compensatory mechanism?
heart it pumps faster so HR will increase, person may develop CHF. and kidneys but they usually take days to respond.
One of the risks of dehydration is decreased cardiac output the HR will increase, what does this put you at risk for?
This is an expression of the balance b/t co2, regulated by the lungs and bicarbonate regulated by the kidneys.