Adult Health Final Exam Study Guide

Adult Health Final Exam Study Guide Surgical: Pre/Postop assessment and interventions, safety in the OR  Assessment of the preoperative patient  Overall goal is to  Gather data to identify risk factors and plan c ...

Adult Health Final Exam Study Guide Surgical: Pre/Postop assessment and interventions, safety in the OR  Assessment of the preoperative patient  Overall goal is to  Gather data to identify risk factors and plan care to ensure patient safety  Baseline data for comparison  Psychologic status/coping strategies  Physiologic factors contributing to risk  Identify and document surgical site  Prescription medications, OTC, herbals  Laboratory results  Cultural and ethic factors  Pt adequately informed  Assess pts emotional status and readiness for surgery  Subjective data  Psychosocial assessment  Decrease stress: use common language  Anxiety: lack of knowledge  Common fears: death, mutilation, disability, pain, body image, anesthesia  Health history  LMP, family hx, meds, allergies, ROS  Ask questions about each system for history of issues and current issues  Medications  Prescription  OTC (and herbals)  Astragalus and Ginseng: increase BP  Garlic, Vitamin E, Ginkgo, Fish Oil: Bleeding  Kava and Valerian: Sedation  In general, stop herbals 2-3 weeks prior to surgery  Objective data (T 17-3 to 17-5)  Physical exam  Based on this, a physical status rating is assigned  Diagnostic tests and labs  EKG, CBC, chest X-Ray PT, PTT, INR, liver function  Allergies  What is their reaction?  Screen for latex allergy  Risk factors: long-term multiple exposures to latex products, history of hay fever, asthma, allergies to certain foods such as avocado, potatoes, or bananas (latexfood syndrome)  Nursing management of the preop patient (T 17-6/7) Preoperative teaching  Void prior to surgery  No make-up  ID band on patient  Hospital gown  Valuables  Dentures, contacts, glasses removed  We have a check list that must be completed before procedure is performed  NPO status (smoking goes with it - increases HCL)  Liquid and Food Intake Fasting Period  clear liquid: 2 hours  breast milk: 4 hours  nonhuman milk: 6 hours  light meal: 6 hours  regular or heavy meal: 8 hours (or more)  Sensory: what they will see, hear, feel  Procedural: what to bring, when/where to be  Process: flow of surgery, family waiting  Other: deep breathing, coughing, moving postop, PCA, immobilizer, cast, epidural  Ambulatory surgery: care at home  Special considerations (for the elderly)  Many surgical procedures are on patients older than 65  ↑ risk in surgery and post-op complications  Many have chronic diseases  Altered cognition & senses (document baseline)  More intense reactions (emotional) to surgery  May have physical decline and loss of health  Usually involves several providers (primary, hospitalist, surgeon)  Upon admission of a patient to the PACU, the nurse’s priority assessment is  Respiratory adequacy  Consent  We don’t always need consent (in cases of emergency), but whenever possible we get it.  The person performing the procedure is responsible for attaining consent  Care in the operating room  Physical environment  pre-operative area (holding area)  surgical suite (operating room)  Controlled geographically, environmentally, & aseptically  Air flow control and filters for dust control  Positive air pressure: prevents air flowing in from hall  UV light: decreases microorganisms in air  Limited surfaces  Restricted traffic area – why?  To avoid contamination and infection  Near the PACU, ICU, and ED  Surgical team RN  Prepares OR for pt before they go in  Meet pt  The advocate for pt during surgery 1. Safety, privacy, dignity, confidentiality 2. Communicate with patient 3. Physical care  Final assessment prior to surgery  Scrub nurse (sterile)!  Prepares instrument table, remains in the sterile area of the OR, passes instruments to surgeon and assistants  Circulating nurse (nonsterile)!  Scrub tech  Surgeon and assistants  Registered nurse first assistant  Anesthesia care provider  Anesthesiologist and/or nurse anesthetist  Nursing management of pt during surgery  Before surgery  Final assessment & support  Know about cultural values and spiritual beliefs  Review physical assessment  Chart review  Admitting the patient: ID process, CAM (complementary and alternative meds), questions, confirm NPO status, valuables, preoperative meds (30-60 minutes), hair cover  During surgery  Room preparation (sterile field, equipment)  Transferring the patient  Scrubbing, gowning & gloving  Basic aseptic technique T 18-3  Assisting the ACP  Positioning: alignment, bony prominences, thoracic expansion, blood flow, privacy, pt history  Preparing the surgical site  Preventing hypothermia  Can cause: impaired wound healing, adverse cardiac events, altered drug metabolism, coagulopathies, surgical infection  Use thermal warming blanket  Patient safety  Use a grounding pad on a well vascularized muscle mass to prevent a fire  Grounding pads prevent burn injury  Special considerations (elderly)  May have varying and unique reactions to anesthesia  May have trouble communicating and/or following directions Integumentary problems: protection is key (positioning to prevent injury)  Unexpected/catastrophic events  Anaphylactic reaction  Most severe form of allergic reaction  Life-threatening pulmonary and circulatory complications  Hypotension, tachycardia, bronchospasm, possibly pulmonary edema  Anesthetic agents, antibiotics and latex are responsible for many perioperative allergic reactions  Treatment: maintain airway, oxygen, IV access, epinephrine, respiratory treatment, Benadryl, steroids, treat hypotension with fluids and epi  One of the national patient safety goals  Safety considerations  Universal Protocol: prevents wrong site, wrong procedure, or the wrong person  Called a surgical time-out  performed just before the procedure is started to verify patient identity, surgical procedure, and surgical site  Classification of anesthesia  General: loss of sensation with loss of consciousness  Phases of general:  Pre-induction  Prepping anesthesia/patient  Induction  Administering by IV or inhalation  Maintenance  Continue to administer to maintain surgical stage  Emergence  Discontinue administration of anesthesia to return them to their basic state  Drugs used in general/adjuncts  Neuromuscular blocking agents paralyzes whole body  used to make the muscle flaccid  opioids we worry about decrease rr  Benzos same thing if we give too much  Local: loss of sensation to a small area without loss of consciousness  Topical, injected, nebulized  Regional: loss of sensation to a region of the body without loss of consciousness  Spinal  Epidural  We are responsible of the care of the epidural cath  We never change epidural dressing, we just care for it  MAC: sedatives and opioids, no inhalation agents, patients breathe without assistance (used with local and regional)  * MAC = monitored anesthesia care  Moderate sedation: usually outside of OR, no ACP needed  Malignant hyperthermia is an inherited disorder of skeletal muscle that predisposes susceptible individuals to a life threatening adverse reaction upon exposure to some inhalation anesthetics and the skeletal muscle relaxant succinylcholine.  Symptoms  Tachycardia/Dysrhythmias  Tachypnea  Hypercarbia  Too much CO2 in blood stream (from hypoventilation)  Rise in body temperature to 105 degrees or higher (not an early sign)  Dark brown urine  Myoglobinuria- muscle breaking down into urine  kidney can get damaged  Muscle ache without an obvious cause, such as exercise or injury  Muscle rigidity and stiffness  Assessment  MH is often discovered after a patient is given anesthesia during surgery.  There may be a family history of malignant hyperthermia or unexplained death during anesthesia, therefore, assess for history of personal or family problems with anesthesia  The person may have a fast and often irregular heart rate.  Since it is genetic, ask ―has your family had any issues with anesthesia?‖  Tests  Blood clotting studies, Chem-20, including CPK (creatinine phosphokinase, a muscle protein destroyed during the acute illness)  Genetic testing to look for defects in a specific gene  Muscle biopsy  Urine myoglobin (muscle protein)  Treatment  Prompt detection essential to survivability  Wrapping the patient in a cooling blanket can help reduce fever and the risk of serious complications  Drugs such as dantrolene, lidocaine, or a beta-blocker drug can help with heart rhythm problems  Dantrolene- slows metabolism, reduces muscle contraction  highly specific in terms of dosing. Dosing occurs in stages and is the primary medication in MH  To preserve kidney function during an episode, you must get fluids through a vein and by mouth, as well as certain medications  Postoperative care  Nursing management of the post op patient  Main Focus  Protecting the patient  Preventing complications  PACU  Post Anesthesia Care Unit for patient’s immediate recovery period  Care in PACU General anesthesia – Phase I (typically)  Ecg and more intense monitoring- goal is to prepare patient for transfer to phase II or inpatient  Fast-tracking  PACU Phase I Bypass – direct to Phase II  Generally, for ambulatory surgery patients who will be discharged home  Which patient is ready for discharge from phase 1 PACU care to the clinical unit?  Awake, vital signs stable, dressing is dry and intact, no respiratory depression, SpO2 is 92%  Priority assessment: ABC’s  Priority Care: monitoring and managing respiratory and circulatory function, pain, temperature, and the surgical site  Key Element: Oxygenation  Pulse oximetry  Assessment of each body system in PACU  Common respiratory complications post op  Signs of inadequate oxygenation  In absence of any other reason for restlessness, agitation, etc think oxygen! Airway obstruction  Usually caused by the patient’s tongue  Treatment is to reposition  Other causes  No matter the issue, if it is a respiratory problem, give oxygen  Retained thick secretions: treatment – cough if able, if not then suction  Laryngospasm: treatment - positive pressure (bag them), IV muscle relaxant, steroids  Laryngeal edema: treatment - steroids  Atelectasis  Most common cause of postop hypoxemia  Cough and deep breath to prevent  10 times every hour while awake  Pulmonary Edema: accumulation of fluid in the alveoli from fluid overload, left ventricular failure, prolonged airway obstruction, sepsis, aspiration  Signs and symptoms: crackles, decreased O2 sat  Treatment: diuretics, treat the cause  U can tell its working by having more UO, maybe decrease crackles, increased o2 sat  Aspiration: gastric contents in the lungs  Signs and symptoms: tachypnea, bronchospasm, decreased O2 sat  Prevention is goal, BUT, if it happens, treatment is to support airway however is needed and antibiotics  Can proceed to respiratory failure!  Aspiration pneumonia is very hard to treat when the gastric contents get into lung  Bronchospasm: closure of small airways  Signs and symptoms: wheezing, SOB  treatment – nebulizer treatment and treat the cause (such as aspiration)  Hypoventilation: decreased RR or effort, usually due to CNS depression, poor muscle tone (anesthetic agents), mechanical restriction, pain  Signs and symptoms: shallow respirations, decreased RR (except in pain) Treatment – treat the cause (reverse neuromuscular blockade, reverse opioid if it is severe, loosen binders/dressings/casts)  Proper patient positioning  Lateral ―recovery‖ position  Once conscious – supine position  Pneumonia  Due to mucous plugs from hypoventilation, recumbent position, ineffective coughing, history of smoking, irritation from intubation and inhaled anesthetic agents  Atelectasis may progress to pneumonia without intervention when microorganisms grow in the stagnant mucus and an infection develops  Nursing process: Respiratory  Assessment: airway patency, chest symmetry, and depth, rate, and character of respirations, pulse oximetry, breath sounds, sputum  Nsg interventions - proper positioning (HOB ↑), oxygen, deep breathing/coughing, Incentive Spirometer (same of cough/deep breath), reposition q 1-2 hr  Potential Cardiovascular problems  Hypotension  S&S: disorientation, loss of consciousness, chest pain, oliguria, hypoxemia  Treatment critical to avoid organ ischemia and/or infarction: OXYGEN first, then assess to find cause, usually unreplaced fluid and blood loss – may lead to hypovolemic shock  Replace fluid with IV bolus, make sure BP reading is accurate  Hypertension  Results from sympathetic nervous system stimulation from pain, anxiety, bladder distention, or respiratory compromise  Treatment: Fix the cause (pain meds, assist to void, etc), or medicate with antihypertensives  Dysrhythmias  Often results from hypoxemia, hypercapnia, alterations in electrolyte imbalance, circulatory instability, preexisting heart disease, hypothermia, pain, surgical stress, anesthetic agents  Treatment: fix the cause, antidysrhythmic medications  Fluid and electrolyte imbalances  Hypokalemia (urinary and GI tract losses)  Monitor lab values  Fluid retention  Fluid overload  Fluid deficits  0.5 mL/kg/hr urine output  VTE (venous thromboembolism)  Stress response ↑ platelet production, general anesthesia causes peripheral vasodilation possible damaging vascular lining  May form in legs due to inactivity, body position, pressure  May lead to pulmonary embolism  Prevention is best: Low Molecular Weight Heparin, ICD, exercises  Exercises Dorsiflexion, plantar flexion, quad flexion, foot circles, and hip and knee movements  Syncope  May indicate ↓ cardiac output, fluid deficits, defects in cerebral perfusion  Often postural hypotension when pt ambulates  Make position changes slowly  Nursing assessment  Frequent monitoring of vital signs  Compare to pre- and intra- operative numbers  Cardiac monitoring  Skin color, temperature and moisture  EARLY AMBULATION IS THE MOST SIGNFICANT GENERAL NURSING MEASURE TO PREVENT POSTOPERATIVE COMPLICATIONS  Why?  Increases muscle tone  Stimulates circulation  prevents VTE  speeds wound healing  Increases vital capacity and maintains normal respiratory function  Also improves GI and urinary tract function  To promote effective coughing, deep breathing, and ambulation in the postoperative patient, what is the most important for the nurse to do?  Provide adequate and regular pain medication.  Potential Neurologic/Psychologic problems  Emergence delirium  Waking up restless, agitated, disorientated, thrashing, shouting  Suspect hypoxia, but could be pain, bladder distention, anesthetic medications, ET tube  Assess respiratory status, give oxygen if needed, assess for other causes and fix, sedation may help agitation if no cause can be found  Usually time limited and will resolve before PACU discharge  Delayed emergence  Prolonged drug action  Normal awakening can be predicted by ACP based on what was given and when during surgery  Usually resolve spontaneously with time  Benzodiazepines and opioids can be reversed  Keep patient safe during both delayed emergence and emergence delirium  Postoperative cognitive dysfunction  Decline in cognitive function for weeks to months after surgery, almost always in older patients  Risk factors: age, duration of anesthesia, complications and infections are related to the development of POCD  Delirium in general  Most common in the older patient, but can occur at any age Multiple potential causes: fluid and electrolyte imbalances, hypoxemia, drugs, sleep deprivation or overload, pain, UTIs  Treatment  Maintain physiological function  Fluid and electrolyte balance  Adequate nutrition  Adequate sleep  Pain management  Proper bowel and bladder function  Early mobilization  Use of clocks, calendars, photos to keep pt oriented  Anxiety and depression  Grieving for lost body parts or functions, decreased independence, poor prognosis  Alcohol withdrawal delirium  Results from withdrawal of alcohol  Restlessness, insomnia, nightmares, irritability, auditory or visual hallucinations  Anticipate and treat with medications, quiet/calm environment, avoid restraints and IV lines  Assessment  Level of consciousness  Orientation  Memory and ability to follow commands  Pupils  Sleep/wake cycle  Sensory & motor status  Determine differences from preop status  Problems  For all problems, address factors that are known to contribute to the condition  Listen and talk to your patient, offer explanations and reassurance, encourage presence and assistance from caregiver, discuss expectations for discharge  Keep in mind the most common cause of restlessness in the PACU is hypoxemia!  Pain and discomfort  Assessment  Patient’s self-report is the single most reliable indicator of pain - SUBJECTIVE  If not verbal, then look for restlessness, changes in vital signs, diaphoresis  Nurses are required to implement effective pain management strategies for anyone in pain  Restlessness usually indicates hypoxemia rather than pain  Interventions  Pharmacological therapies  Potential alterations in temperature  Hypothermia (T below 96.8)  Assessment – Temperature, skin assessment  Warm IV fluids, active rewarming (warm blankets, forced air warmers)  Monitor body temp q 30 min when using device Fever  Encourage airway clearance with cough and deep breathing or use of IS  Chest x-ray may be taken, as well as cultures of wound, sputum, urine, or blood – depending on the suspected cause  Antibiotics AFTER the cultures have been obtained  If over 103⁰F, antipyretic drugs and cooling blanket might be used   Gastrointestinal problems  Nausea and vomiting (PONV)  Assess: ask pt if they feel nauseated, assess vomit if it occurs, assess abdomen for distention or bowel sounds  N/V interventions  Antiemetic or prokinetic drugs  Prevent aspiration (gag reflex)  Pt usually NPO after bowel surgery until bowel sounds return (IV fluids provide hydration)  NG tube may be used to decompress the stomach  Mouth care  Progress diet from clear liquids as tolerated when allowed Hematology  White blood count  Not an indicator of infection  Indicator of physiological stress!!!  If the WBC is elevated, it means that the body is undergoing some sort of physiological stress  Physiologic stress can be caused by injuries, hospitalizations, surgeries  If the WBC is low, the level indicates an inability to deal with stressors = immunosuppression  If WBC is normal and you’re typically low d/t being immunosuppressed, it could mean infection  The WBC differential  must equal 100  Red blood count  Low = Anemia  High = Polycythemia  Composed of hemoglobin (carries oxygen) and hematocrit (percentage of RBC’s in relation to blood volume)  Hemoglobin and hematocrit levels typically higher in males vs femals Normal lab values Normal Range Platelets 150,000-400,000 RBC F: 3.8-5.1 M: 4.3-5.7 HCT F: 35-47% M: 39-50% HGB F: 11.7-16 M: 13.2-17.3 WBC 4,000-11,000  Anemia  What is it?  Anemia develops when you don’t have enough robust, healthy red blood cells to carry oxygen throughout your body. The blood cells may lack enough hemoglobin, the protein that gives blood its red color, or there may be a lack of overall blood volume. It can occur in women, men, and children and is linked to some illnesses.  Clinical manifestations  Caused by the body’s response to tissue hypoxia  Manifestations vary based on rate of development, severity of anemia, presence of co-existing disease.  Hemoglobin (Hgb) levels are used to determine the severity of anemia.  Early manifestations  none  Mild manifestations  Mild (Hgb 10-12): palpitations, exertional dyspnea, mild fatigue  Moderate manifestations  (Hgb 6-10): increased palpitations, dyspnea, roaring in the ears, fatigue  Severe manifestations  Severe (Hgb <6): pallor, jaundice, icteric conjunctiva and sclera, glossitis, smooth tongue, tachycardia, tachypnea, dyspnea at rest, vertigo, irritability, and more…  Keep in mind, S&S will be similar so symptom management will be similar, but treating the CAUSE might be different  General treatments of anemia  Blood transfusions, drug therapy (vitamin supplements), volume replacement, oxygen therapy, dietary changes, energy management (alternate periods of rest and activity as tolerated), prioritize activities  Nursing interventions  Correct physiologic status deficits (e.g., chemotherapy-induced anemia) as priority items.  Monitor cardiorespiratory response to activity (e.g., tachycardia, dysrhythmias, dyspnea, diaphoresis, pallor, respiratory rate) to evaluate activity intolerance.  Assist the patient in assigning priority to activities to accommodate energy levels to promote tolerance for important activities. Assist with regular physical activities (e.g., ambulation, transfers, personal care) to minimize fatigue and risk of injury from falls.  Encourage alternate rest and activity periods to provide activity without tiring the patient.  Limit number of visitors and interruptions by visitors to provide rest periods  Arrange physical activities to reduce competition for oxygen supply to vital functions (e.g., avoid activity immediately after meals).  Instruct the patient/caregiver to recognize signs and symptoms of fatigue that require reduction in activity to promote self-care.  Types of anemia  Hemorrhagic  Slow/internal  harder to detect  Fast  easy to detect  Diagnose – fast (blood); slow (serial H&H’s – at least 3 showing sequential drop)  Treatment  Replace BLOOD volume to prevent shock  NS, Dextran, Hetastarch, Albumin, LR for volume  RBCs for O2 Carrying ability  Identify source of bleeding and control  Oral or parenteral Fe  Vitamin deficiency  Something needed to make RBCs or Hemoglobin, or needed for absorption is missing  Iron, B12, folate, ferritin, intrinsic factor, and more  Diagnosed with blood test for any of these  Iron deficiency anemia  DX  Decreased H&H  Decreased serum iron  Increased TIBC  Measures the body’s capacity to bind iron  Body tries to compensate for less iron by increasing the binding capacity  Evaluation for GI/GU bleeding-stool, quiac test, endoscopy, colonoscopy  Bone marrow bx if nothing else shows up  Remember, a problem with blood cells MIGHT mean a problem with the bone marrow in the absence of another clear cause  collaborative care  goal  treat underlying disease (could be decreased intake or decreased absorption)  Increase intake of iron  oral Fe  need 150-200mg every day  Best absorbed in acidic environment - give with OJ or Vitamin C one hour before meals if tolerated. Otherwise give with food Undiluted liquid Fe may stain teeth (use straw)  May cause GI upset, heartburn, constipation/diarrhea  Causes stools to turn black – tell the patient   parenteral iron supplements  Use for malabsorption states, intolerance to PO, poor pt adherence  IM  May stain skin (use separate needles for withdrawing and injecting)  Leave .5 mL air bubble in syringe to clear it  Give deep IM using Z-track  Do not rub  IV Fe should not be mixed with other meds and tubing should be flushed well before and after. Monitor during infusion—risk of allergic reaction  transfusion of packed RBCs  Vitamin B12 deficiency  Megaloblastic anemia  DX  RBCs large and abnormal shape  Fragile cell membrane  Gastric analysis  intrinsic factor  Gastroscopy with biopsy  Schilling test (radioactive B12 given and B12 measured in urine)  Treatment  Parenteral or intranasal administration of cobalamin - for life  Increase in dietary cobalamin does not correct the anemia  Has to be parenteral or inter-nasal  Still important to emphasize adequate dietary intake to maintain overall good nutrition  Pt will die in 1-3 years without treatment  Folic acid (B9) deficiency  Megaloblastic anemia  negative)  Treatment  Replacement therapy PO (May need larger doses in malabsorption states but usually 1 mg per day)  Encourage dietary food intake  Nursing Care  Look at the care plan posted for anemia and fatigue  Sickle cell anemia  Typical patient is asymptomatic, except during sickling episodes  Symptoms may include  Pain and swelling  Pallor of mucous membranes  Jaundice  May receive prophylactic abx to prevent infections  Treatment Nursing and Collaborative Management  Alleviate Sx  Minimize end organ damage  Promptly treat serious sequelae  Teach patient about:  Avoiding high altitudes  Good fluid intake  Immunizations  Treat infections promptly  In the hospital  Give oxygen  Rest—DVT prophylaxis  SCDs, ted HOSE  Fix fluid and electrolyte imbalance  Transfusion therapy—Aggressive RBC exchange  PAIN management! —continuous pain meds, opioids, PCA.  They are often opioid-tolerant and require increased doses of medication than usual  Acquired hemolytic anemia  Caused by extrinsic factors: RBCs normal - damage caused by external factors  DX  Blood smear: schistocytes (helmet cells)  due to shearing mechanical destruction  Treatment  Supportive care until cause can be identified and removed  Steroids  Blood replacement  Splenectomy  Worry about bleeding  Aplastic anemia  Treatment  Find cause and treat – if possible  Provide support until pancytopenia reverses  Prevent complications of infection and/or bleeding  70% fatal  Stem cell transplant  Immunosuppressive therapy  Anemia Thalassemia  DX  Blood smear  Darker RBCs are normal cells from transfusion  Note small (microcytic), pale (hypochromic), abnormally-shaped red blood cells. These are associated with thalassemia major.  Treatment  None for T-minor T-major  Blood transfusions (but not to normal levels)  They can become iron overloaded  Chelation (removes iron from blood) to reduce iron overloading from transfusions – medications do this  Splenectomy – enlarged because RBCs are sequestered there (spleen is trying to get abnormal cells out of circulation)  Pt may be at risk for bleeding after these  Cardiac complications contribute to early death  From iron overload, pulmonary disease, and hypertension  Hepatitis C in older patients due to transfusions  No effective drug therapy  Hematopoietic stem cell transplantation only cure