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Quiz on chapter 22/2

Terms in this set (89)

Termination of bleeding/ Begins as soon as the injury occurs.
hemostasis
An initial increase in the blood elements and water flow out of the blood vessel into space. Causes cardinal signs and symptoms of inflammation: erythema, heat, edema, pain, and tissue dysfunction
Inflammation phase
collagen formation occurs a glue like protein substance that adds tensile strength to the wound tissue. Appearance changes to an irregular, raised, purplish, immature scar. Wound dehiscence most frequently occurs during this phase
Reconstruction phase
Fibroblasts begin to exit the wound the wound continues to gain strength although healed wounds rarely return to the tissue had before surgery. Keloids may form during this phase
Maturation phase
Wound is made surgically with little tissue loss skin edges are close together. Minimal scarring results. It begins during the inflammatory phase of healing; in surgery, this is usually during closure of wound
Primary intention
Healing occurs when skin edges are not together or when pus has formed. If wound has purulent exudate, the surgeon provides a means for its release via drainage system or packing the wound. the necrotized tissue decomposes and escapes. The cavity begins to fill with granulation tissue. The amount of granulation tissue required depends on the size of the wound; scarring is greater in a larger wound
secondary intention
Occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together. Occurs when a contaminated wound is left open and sutured closed after the infection is controlled or primary wound becomes infected, is opened, allowing to granulate, and then sutured.
Tertiary intention
nutritional needs
fluids
rest and activity
Factors that affect healing
Perform thorough assessment
Assess IV site and fluids
medications
blood products administered
surgical site- dressing for drainage tube & exudate
Assess & control pain
ABC's, LOC, system review
Vital signs q 15min including GI
Temp must be assessed for hypo/hyperthermia
Immediate Post operative phase
age
Malnutrition
Obesity
impaired oxygenation
smoking
drugs
diabetes mellitus
radiation
wound stress
factors that affect wound healing
Vitals signs (q 15x4, q 30x4, q 1x4, then4hr until normal
IV incision site
any tubes
post operative orders
review body systems
post operative assessment
side-rails up and call light w/in reach
avoid pillow at the neck to prevent blocking of the tongue
lateral position or the HOB is elevated 45 degrees to avoid aspiration
Vomitus- record amount & description
Red or coffee ground emesis is indicative of GI bleeding. Report immediately
Later postoperative phase
shock
Incision
urinary function
venous stasis
level of consciousness (LOC)
motor status
assessment of the surgical patient
Rapid thready pulse
Declining BP
cool clammy skin
Cyanosis
Reduced urinary function
Narrowing pulse pressure
Restlessness
Hypovolemic shock/ hemorrhage shock
Administering oxygen per facility protocol or increase rate
raise patients legs above the level of the heart
Increase the rate of IV fluid administration
Notify anesthesia provider or the surgeon
Continue to assess the patient response to intervention
hypovolemic shock intervention
When are sutures and staples are generally removed
7-10
Fluids cells or other substances that have slowly exuded from cells or blood vessels through small pores or break in the cell membrane
Exudate
Removal of fluids from a body cavity wound or other sources of discharge by one or more methods may occur passively on it's own or with mechanical assistance
Drainage
Clear watery fluids that has been separated from its solids elements
Serous
Fluid that contains blood
Sanguineous
Thin and red composed of the serum and blood if the tissue is infected exudate/ drainage may be brown green purulant
Serosanguineous
How many mls in the first 24hrs should be treated as abnormal and reported immediately
300ml
System of tubing and other apparatus attached to the body remove fluid in airtight circuit that prevents environmental from entering the wound cavity
Closed drainage
Drainage that passes though an open ended tube into receptacle or out onto the dressing
Open drainage
Use of a pump or other mechanical device to help extract
Suction drainage
Function by applying negative pressure healing is facilitated by
Increased blood flow
Improved or increased fluid drainage
Enhance wound closure as the pressure draws the edges of the wound together
Removes fluid from the wound reducing local peripheral edema and improving circulation
Promotes formulation of granulation tissue
Drops bacteria level in wound
wound VAC
The invasion and multiplication of microorganisms such as bacteria, viruses, and parasites that are not normally present within the body. An infection may cause no symptoms and be subclinical, or it may cause symptoms and be clinically apparent.
Infection
Obtain before the procedure begins
The patient is competent, agrees, and understands the procedure being performed
The surgeon explains, risks, benefits, consequences, and alternatives
The nurse role is usually to act as a witness
Should not be obtained if the person is disoriented, unconscious, mentally incompetent, or under the influence of sedatives
Informed consent
in the home setting
A handheld shower head can be used
Spray should be held approximately 12 inches from wound
If the force results in to much pressure a washcloth can be tied around the shower head to decrease the force
Irrogations
1+ Trace A barely perception pit (2mm)
2+ Mild A deeper pit(4 mm) with fairly normal contours, that rebounds in 10 to 15 seconds
3+ Moderate A deep Pitt (6mm) lasts for 30 seconds to more than 1 minute
4+ Severe An even deeper pit (8mm) with severe edema that possibly lasts as long as 2 to 5 minutes before rebounding
Pitting Edem scale
0 Absent pulse none felt
1+ thready pulse difficult to feel not palpable when only slight pressure applied
2+ weak pulse somewhat stronger than a thready pulse but not palpable when light pressure applied
3+ normal pulse easily felt but not palpable when moderate pressure applied
4+ bounding pulse feels full and springlike even under moderate pressure
Pulse Volume Variations
Wound layers separate
Patient may say that something has given way
It may result after periods of sneezing, coughing, or vomitting
It may be preceded by sesanguineous drainage
Patient remains in bed and NPO, be told not to cough, and be reassured.
The nurse places a warm moist sterile dressing over the area until the physician evaluates the site
The wound may be effectively covered with Steri-Strips or butterfly strips
Dehiscence
Abdominal organs protrude through an opened incision
Patient is to remain in bed NPO in low Fowlers with knees flexed, and the wound and contents should be covered with warm, sterile saline dressing
The surgeon is notified immediately
Provide emotional support and explain what has happened and what can be expected in the next phase of care
evisceration
removal of fluids from a body cavity, wound , or other source of discharge by one or more methods it may occur passively on its own or with mechanical assistance
Drainage
A drainage tube into the duct to maintain a free flow of bile until edema subsides
T tube
A normal bile drainage with color normally greenish brown thick and slightly blood tinged in the first 24hrs
250-500ml
Patient enters setting has surgical procedure and is discharge on the same day (e.g. breast biopsy, cataract, extraction, hemorrhoidectomy , scar revision)
Ambulatory
patient enters hospital undergoes surgery on the same day and remains for convalescence ( e.g. carotid endarterectomy, cholecystectomy, mastectomy, vaginal hysterectomy)
same day admit
patient is admitted to hospital undergoes surgery (surgery may occur on a day other than the day of admission) and remains in hospital for convalescence (e.g. amputation, heart transplant, laryngectomy, resection of aortic aneurysm)
inpatient
involves extensive reconstruction or alteration in the body parts , poses great risks to well being (e.g. coronary artery bypass, colon resection , gastric resection)
major
involves minimal alteration in body parts often designed to correct deformities, involves minimal risks compared with those of major procedures (e.g. cataract extraction , skin graft, tooth extraction)
minor
performed on basis of patient choice(e.g. bunionectomy, plastic surgery)
elective
Necessary for patient health
urgent
must be done immediately to save life or preserve function of body part
emergent
surgical exploration that allows physician to conform diagnosis may be removal of tissue for further diagnostic testing
diagnostic
excision or removal of Disease body part
ablative
surgery to relief or reduction of intensity of Disease symptoms will not produce cure
Palliative
restoration of function or appearance to traumatized or malfunctioning tissue
reconstructive
surgery that cures the problem or condition
curative
surgical procedure that prevents any problems or damage from occurring
Preventative
replacement of malfunctioning organs
transplant
Restoration of function lost or reduced as result of congenital anomalies
Constructive
alteration of personal appearance
cosmetic
Primary purpose is the mechanical debride a wound / ointment on dead tissue
wet to dry dressing
Patient understanding of conditions
visual changes such as diplopia (double vision)
changes in personality
changes in ability to think
Increased ICP assessment/ subjective data
changes in LOC (early sign of increased ICP)
Disorientation , restlessness, lethargy
changes in pupillary reaction (sluggish)Ipsilateral lesion is in one side pupil remains dilated in one side and is incapable of constriction
changes in BP widening pulse pressure
Vomiting and singulars hiccups are two objectives signs if increased ICP
increased ICP assessment / objectives
refers to the nurse role before surgery
preoperative
refers to the nurse role during surgery
intraoperative
refers to the nurse role after surgery
Postoperative
Pain Assessment
An evaluation of the factors that alleviate or exacerbate patient's pain
complex grouping of events that occurs because of multiple neurologic conditions brain tumor, hemorrhage, anoxic brain injury, or toxic or viral encephalopathies
Intracranial pressure (ICP)
lumbar puncture
sneezing
Coughing
Contraindicated to increase ICP
Elevate HOB 30 to 45 degrees to promote venous return
place the neck in neutral position not flexed or extended to promote venous drainage
instruct patient to avoid isometric or resistive exercise
restrictions fluid intake
have a Foley catheter in place due to large volume of urine produced oxygen before and after suctioning to avoid in PaCO2.
Use hypothermia blanket to control body temperature increase body VS q2h if patient has increased ICP
nursing intervention increased ICP
Age- because of slower response to physiological changes such as temp. variations, cardiovascular shifts, respiratory needs, & renal function.
Physical condition- patient in good health have smoother and faster recovery compared to patient with coexisting health problems
Nutritional factor- stressful condition such as recovering from surgery requires for energy-producing nutrient. consider patient ethnic Background, culture, religious, and socioeconomic background when choosing high energy-producing nutrient
Psychosocial needs:
Socioeconomic and cultural needs
factors that affect the individual ability to tolerate surgery
Increased peristalsis, kidney function, circulation, metabolism, micturition, mental alertness from increased oxygenation to brain, and rate& depth of breathing
Prevention of abdominal distention & gas pain, atelectasis & hypostatic pneumonia, constipation, loss of muscle tone, paralytic ileum, thrombophlebitis, urinary retention
Promotion of flatus and restoration of nitrogen balance
effects of early postoperative ambulation
Rectum temp less than 96F or oral less than 95 F
Warm blanket may be used to increase the patient body temperature
Convective warming- uses disposable cover inflated with warm air from a heating unit placed over the patient warm air passes out through out the underside, so warm air is moving constantly
postoperative hypothermia
Anticoagulant, antihypertensive, corticosteroids, diuretics, herbal therapies, insulin, and Nsaids
Drugs needed to stop before surgery
Anti seizures
cardiac medications
insulin- if withhold, nurse should monitor patient blood glucose pre and postoperatively
common meds that are not stopped before surgery
includes wound care guidelines/dressing, symptoms to be reported and return demonstration by the patient caregiver.
Medications action and possible side effects
Dietary restrictions or modifications
Activities allowed and prohibited
When to call the HCP
Where and when to return for follow-up care
postoperative/ discharge teaching
Patient must be mobile, alert and proof of self care
Pain and nausea must be controlled
Must be near the same level of functionality
Patient my not drive at the time of discharge
Ambulatory surgery discharge
Early and frequent ambulation and leg exercise
Use od antiembolism stockings and pneumatic compression devices
External sequential compression device (SCD)
How to avoid venous stasis
If patient is unable to give a consent in the case of emergency efforts are made to locate family members to assume the responsibility in the absence of a spouse, the role may be passed to another legally identified individuals
In medical emergencies the surgeon may legally perform the surgery if patient is incompetent, the legally appointed individual provides the consent
If family objects to a surgery the physician believes is essential, q court order may have to be obtained
Advance directive
P-palliative/ provocative
Q- Quality sharp, burning, tingling
R- Region
S-Severity pain scale, FLACC, PQRST
T-Time when, how ling
Pains assessment
Use to assess pain as young as two months old. Score from 0-2(total score 10)
F-face
L-leg
A-activity
C-color/consolability
C-cry
FLACC
Helpful in assessment of pain in children Scale 0-5
Wong-baker faces pain rating scale
Pain medication is effective if taken at the onset of pain
When do you give pain medications
Should be provided 1 to 2 days before surgery, when anxiety is n to as high
preoperative teaching
every 2-4 hours in the first 24 hours
frequency of wound assessment
meds are absorbed within the GI tract
Enternal
through the skin or mucous membrane
percutaneous
routes other than digestive system route. Usually given with a needle and syringe
parenteral
check for gag reflex after NPO or surgery
postoperative nursing intervention prior to any oral administration
pain that is less than 6 months and usually an indication of something
acute pain
Changing medications and administration schedule may provide effective pain control
unrelieved pain can be resolved by
Information that is provided by the patient
Symptoms or subjective cues are other term for subjective data
Subjective data
Are observable or measurable signs
Signs or objectives cues are the other terms for objective data
Objective data
Bright red in vomit
Vomit that looks like coffee-ground
Black or tarry stool
Dark blood mixed with stool
S/S of upper GI bleed
Black or tarry stool
Dark blood mixed with stool
Stool mixed or coated with bright red blood
S/S of lower GI bleed
check 3-5 minutes
Postoperative bowel sound check
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