HNN124 Exam Revision

Pre-procedural assessment considerations

• Age-related considerations

  • Infants’ physiological functions are immature - therefore at risk during surgery

  • Surgical morbidity and mortality rates for ppl over 90 are higher than 70-75 age group

    • Complicated by chronic disease

• Social and cultural considerations

• Spiritual considerations

  • E.g. requesting to see a minster of religon before surgery, not allowing blood transfusions as part of treatment

• Psychosocial status

  • Assess degree or understanding + anxiety regarding procedure

  • Assess knowledge of procedure + expected outcomes

Pre-procedural physical assessment

• skin condition, pre-existing conditions, nutrition status, physical/mobility limitations

• Includes nursing/ medical hx + physical examination

  • medications, allergies

• Complete assessment performed at outpatient clinic during pre-admission visit

• On the day of surgery, conduct focused assessment to ensure current, accurate data

• Evaluate anxiety and fear level

Pre-procedural general survey

• Observe person's condition 

  • E.g. gait, assistance with mobility, skin temperature, level of consciousness + orientation, response to questions

• Skin (everywhere) – temperature, texture, integrity

• ROM – everywhere including oral cavity

• head + neck 

  • Assess if eye contact is maintained

  • Condition of scalp - e.g. alopecia or seborrheic dermatitis

  • Oral cavity - loose teeth, tongue. Mucous membranes

  • Lips and tongue, dentures, caps, bridges or crowns

  • Neck - strength of carotid pulses, palpate jugular veins, cervical lymph nodes

• Upper extremities 

  • Brachial + radial pulses - rate + character of pulse

  • Capillary refill

• Anterior and posterior chest + abdomen 

  • Inspect + palpate chest wall - note breathing pattern and expansion

  • Auscultate heart sounds

  • Anterior and posterior breath sounds - crackles, gurgles, wheezing

• Lower extremities 

  • Length and position of legs

  • Palpate bilateral strength of femoral, popliteal and pedal pulses

  • Capillary refill

Preoperative problem identification

• deficient knowledge caused by: pre-op preparation to decrease post-op risks

• anxiety caused by 

  • deficient knowledge

  • risk factors + anaesthesia

• fear caused by 

  • unknown

  • effects o

Intraoperative problem identification

• risk for perioperative positioning injury caused by:

  • oedema

  • ineffective tissue perfusion

  • impaired physical mobility

  • disturbed sensory perception

  • impaired skin integrity

• risk for injury caused by

  • physical, environmental, positional, chemical

  • fluid volume

  • cardiac output

• risk for infection caused by

  • invasive procedure

  • imbalanced nutrition

  • impaired skin/ tissue integrity

  • latex allergy

• hypothermia caused by

  • decreased metabolic rate

  • exposure to cool enviro

  • excess/ deficient fluid volume

• Common nursing identified problems pre-op

  • Deficient knowledge related to surgery

  • Anxiety and/ or fear

Postoperative problem identification

• ineffective airway clearance caused by 

  • anaesthesia (diminished cough reflex)

  • increased pulmonary ingestion

  • e.g. pneumonia, atelectasis, pulmonary embolism

• ineffective tissue perfusion (cardiopulmonary) caused by 

  • anaesthesia

  • position or immobility

• imbalanced nutrition (less than body req.) caused by: 

  • anaesthesia

  • surgical manipulation of intestines

  • fasting

  • e.g. GIT → N+V, constipation retention of tas

• urinary retention caused by 

  • anaesthesia

  • surgical manipulation of the bladder

  • e.g. UTI

• acute pain

• risk for infection 

  • e.g. dehiscence, evisceration

• low self-esteem 

  • altered body image + effects of surgery

  • dependence on others during recovery

Pre-op preparation (implementation)

• review surgery + prescribing practitioner orders

• obtain person’s hx, physical assessment, blood + urine specimens; notify prescribing practitioner of abnormal diagnostic test results

Pre-op checklist

Surgical consent form

• Nurse should verify that consent has been obtained

• Can identify problems when pt: 

  • Can't explain procedure/ identify risks

  • Signed the form over a year before surgery

  • Had unauthorised person sign consent form

  • Didn't sign consent form

  • Signed a form with incorrect surgical site/ incongruent procedure

Individual teaching

• Teaching pt + family is responsibility of multi-disc team

• Verify pt/family can describe reason for surgery, what will be done, side effects of anaesthesia + complications

• Nurse - plays role in relieving anxiety + reinforcing teaching regarding pre-op care

• Teaching aids should reinforce nurse's verbal instructions

Discharge planning - role of the nurse

• Communicating openly with pt's + family etc. + shared decision making

• Ensuring discharge summary has correct + relevant info

• Providing tailored patient education

• Ensuring discharge requirements are documented and met

 Role of the nurse in relation to therapeutic and professional communication

Registered Nurse

Therapeutic communication aims to build trust with the patients, encouraging them to express feelings and providing emotional support

• Active listening

• Empathy

• Open-ended questions

Professional communication is structured and goal-orientated when you interact with other healthcare workers. Both will help to better patient outcomes.

Individual teaching

• Nurse - plays role in relieving anxiety + reinforcing teaching regarding pre-op care

Prepare peri-operative procedures and spinal precautions

• Risks that need to be considered pre-procedurally to manage care 

  • Age

  • comorbid conditions/ medical problems

  • lifestyle: nutrition; smoking/ alcohol/ substance abuse

  • pregnancy

  • diabetes

  • medications

  • cognitive problems

• Ask patient questions - test their understanding e.g. what the procedure name means to them

• Identify patients correctly

• Use medicines safely 

  • Before a procedure, label all medicines (e.g. medicines in syringes, cups and basins)

  • Be aware or patients who take medicines to thin their blood

  • Record + pass correct info about patient's medicines 

    • Find out what meds they're taking + compare to new medicines

    • Give education about medicine

    • Ensure they bring up to date list of medicines when visiting a doctor

• Identify patient safety risks E.g. falls + reduce risk for suicide

• Prevent mistakes in surgery 

  • Ensure correct surgery done on correct patient

  • Mark correct place on patient's body where surgery is to be done

  • Pause before surgery - prevent mistakes'

Perform peri-operative procedures and spinal precautions

• Instrument nurse: establishes + maintains the safety, efficiency and integrity of the sterile field throughout the surgical or invasive procedure

• circulating nurse: coordinates + directs the activities of intra-op environment during the surgical procedure; supports scrub nurse + gathers additional equipment if needed

• anaesthetic nurse: prepares equipment and the person for anaesthesia; assists anaesthetist in all phases of anaesthesia

Post- op monitoring

• Consider: surgery type, anaesthetic type

• Includes: 

  • Vital signs

  • State of consciousness

  • Pain and comfort

  • Nausea

  • Wound + drains

  • Catheters

  • IV fluids and site

  • Fluid balance

  • Postoperative limb and chest physio

Devices that prevent post-op complications/ pain

Principles of respiratory management

• Airway maintenance: keep airway clear using suction/ intubation

• Ventilation support: e.g. oxygen therapy or mechanical ventilation

• Monitoring: pulse oximetry, ABGs, capnography (monitoring of CO2 conc. in resp. gas)

• Lung expansion: encourage deep breathing, proper positioning and incentive spirometry to prevent lung collapse

• Preventing complications: use chest physiotherapy, ensure hydration and control infection

• Medications: such as bronchodilators, corticosteroids and antibiotics

• Patient education: teach breathing techniques + encourage smoking cessation

Three fundamental respiratory management techniques

• optimise gas flow 

  • Sit them up, support with pillows

  • Do a pain assessment

  • Guedel airways

  • Nasal/oral/ oral endotracheal/ tracheostomy tubes

• What therapeutic substances can improve the person's respiratory function + oxygenation? 

  • Oxygen therapy

  • Through a nebulizer/ metered inhaler/ spacer (aimed at dilating airways)/

• Mobilising secretions 

  • Strategies: appropriate positioning, chest physiotherapy, percussion, Yankauer sucker, hydration,

Prepare, provide and document oxygen therapy

• oxygen is used to treat hypoxia or any condition that could cause it

• standard ward flow is 15L oxygen 

• nasal prongs maximum 4-6L minutes

• simple face masks at least 5L/ min

• more than 8L requires Venturi mask

Respiratory management (Assessment)

• patient history, respiratory status, auscultation of lungs, monitoring oxygen saturation,

physical examination

• inspect effort, distress, positioning, chest configuration, cyanosis, oedema, clubbing

• Chest palpation related to compromised ventilation 

  • Vocal fremitus: palpable vibration felt on a patient's chest wall when they speak, caused by sound vibrations from the vocal cords that are transmitted through the lungs

  • Displacement of the trachea

• Percussion: Hyper-resonance, dull tone, changes in density of the lungs + surrounding tissues

• Auscultation 

  • Adventitious breath sounds: abnormal noises beyond typical breathing 

    • e.g. fine/ coarse crackles, sibilant/ sonorous wheezes, pleural friction rub, stridor)

factors affecting oxygenation

• age 

  • older ppl - req increased effort to expand lungs + more susceptible to respiratory infection 

    • due to decreased cilia activity

• environmental + lifestyle factors 

  • smoke, smog, dust, asbestos, toxic chemicals at home/work

  • significant physical/ emotional stress

  • over/ underweight

• diseases 

  • COPD - airways are blocked

  • diffusion defects

• circulatory influences 

  • ventilation-perfusion mismatching: imbalance between ventilation + perfusion

• haemoglobin alterations

Respiratory management (Problem identification)

Ineffective airway clearance

• obstruction (by tongue, secretion, foreign object) or by oedema of the larynx

• partial occlusion of bronchi / bronchioles by infection

Impaired gas exchange

• Occurs when adequate oxygen doesn't enter arterial blood OR CO2 isn't removed from the venous blood

Decreased cardiac output

• Impairs oxygen delivery to the tissues

• May be a factor in impaired gas exchange

Ineffective tissue perfusion

• May be widespread (e.g. decreased CO)

• or confined to one or more tissues or organs of the body

• CO + tissue perfusion likely to be experiencing: 

  • oedema of lower extremities + lungs

  • Fatigue

  • Activity intolerance

other problems:

• Deficient knowledge

• Activity intolerance (impact of illness on person's ability to perform ADL)

• Insomnia

• Imbalanced nutrition

• Acute pain

• Anxiety

Respiratory management (planning)

• sets goals 

  • e.g. improving oxygenation, clearing airway, preventing complications

Intervention to improve oxygen uptake and delivery

Administer oxygen

• % of oxygen in inspired air is fraction of inspired oxygen (FIO2) 

  • Expressed as % 

    • Normal atmospheric air has FIO2 of 21%

  • Supplemental O2 delivery systems can increase FIO2 to anywhere from 24% to nearly 100%

  • 78% of inspired air is nitrogen 

    • Keeps alveoli open (just by occupying space)

Complications/ hazards of oxygen administration

• Those with chronic pulmonary disease assoc w CO2 retention (hypercapnia) (e.g. COPD) can become insensitive to CO2 levels to drive their RR 

  • May depend on chronic low O2 blood level (hypoxaemia) to stimulate respiratory drive

  • Excessive O2 administration may obliterate hypoxic drive --> apnoea

• O2 toxicity: may be caused from prolonged administration of high FIO2 (>50% for >2hrs) 

  • Damage to lung tissue + prod severe resp difficulties

Interventions to increase cardiac output + tissue perfusion

Manage fluid balance

• If congestive heart failure present: 

  • Fluid intake is restricted - prevent oedema + circulatory overload

  • Sodium intake limited (Sodium promotes fluid retention)

• Diuretics may be given to increase fluid excretion by kidneys 

  • Should be given before mid-afternoon so sleep isn't affected

• Monitor fluid I&O + daily weights

Activity restrictions + assistance with ADLs

• Purpose of assisting --> decrease oxygen demands of body 

  • Tolerance may be slowly increased through cardiac rehab program

Proper positioning

• Done to increase fluid load to heart 

  • Decrease development of pulmonary oedema

• Venous system can pool blood (when assisted with gravity) 

  • 'venous capacitance' (aka pooling effect) is increased when head + upper body is elevated, legs are in dependent position

• Supine position may be detrimental for person with congestive heart failure

Administer medications

• Diuretics: affects renal tubules → increased water excretion → lowers BP + cardiac workload

• Cardiac glycosides: increases force of cardiac contraction + slows HR

• Inotropic agents: increases force of cardiac contraction

• Antihypertensives: lowers BP → decreases workload

• Nitrates: dilates coronary arteries + peripheral vessels → increase cardiac O2 supply → decrease cardiac workload

• Vasodilators: widens vascular system to improve blood flow + reduce BP

Interventions to address associated respiratory problem

Lifestyle + activity adaptations

3 general purposes:

• Minimise energy + oxygen consumption

  • Complete bed rest is often NOT the best option

• Lifestyle adaptations aimed at reducing factors contributing to disease process:

  • Removal of allergens

  • Stopping smoking

  • Control modifiable risk factors for heart disease

• Modification of cardiac risk factors:

  • Stop smoking

  • Dietary alterations + weight control

  • Control of diabetes + hypertension

  • Exercise + stress management

Encourage dietary + nutritional modifications

• Usually include: reduction of sodium, total fat and cholesterol intake

• Person receiving inadequate nutrient intake from poor appetite/ severe dyspnoea will need help in finding ways to increase intake

Promote comfort

• Pain related to tissue ischaemia is best relieved by --> improving O2 delivery to tissues while reducing oxygen demand 

  • Rest the affected tissue e.g. rest the leg/arm

  • May involve positioning legs lower than heart level (elevating them often makes pain worse)

• Heart pain related to iscahemia (angina pectoris) should be dealt with first and foremost by resting

Complementary therapies

• Meditation + yoga produce relaxation + calmness

Explain and demonstrate the role of the nurse in relation to chest physiotherapy

Collaboration

• working with physiotherapists to develop + adjust patient care plans

Assessment

• conducting initial assessments and monitoring patients’ progress during therapy

Patient Education

• informing patients about the benefits of physiotherapy and teaching prescribed exercises

Support

• assisting patients physically during therapy sessions and providing emotional support

Documentation

• recording patients’ responses to therapy and ensuring CoC

Rehabilitation (more detail later)

Chest physiotherapy (rehabilitation techniques)

Teach effective coughing

• Should be preceded by slow, deep breaths 

  • E.g. huffing:  delivering a series of short, forceful exhalations

• Intent is to raise sputum to level where it can be coughed out

• Assisting person to sitting position will increase effectiveness of the cough

Initiate postural drainage + chest physiotherapy

• Intended to promote the drainage of secretions from the lungs

• Accompanied by percussion or vibration applied to chest wall to loosen secretions

Administer medications

• Assist in airway clearance e.g. expectorants, mucolytics and bronchodilators

Monitor environmental and lifestyle conditions

• e.g. Smoking

Introduce artificial airways

• Guedel's airway 

  • Maintains the tongue away from posterior oropharynx in unconscious person

  • Essential to choose correct size --> too large may cause occlusion; too small may compress tongue + stimulate vomit

• Endotracheal tubes: bypass the upper airway structures 

  • Passed beyond vocal cords into trachea

  • Nutritional care 

    • Providing entera feeding / total parenteral nutrition

Suction the airway

• May be necessary to clear secretions the person cannot remove by coughing 

  • Especially important when endotracheal/ tracheostomy tube is present --> coughing is impaired by these devices

• Nasotracheal or endotracheal suctioning

Properly position person

• Help them breath

• Tripod position

Teach controlled-breathing exercises

• Improve breathing efficiency

• E.g. pursed-lip breathing 

  • Involved forced exhalation against pursed lips

• Deep breathing exercises: encourage slow, deep breaths 

  • (instead of rapid, shallow, breathing) --> May be present in restrictive lung disease or anxious people

• Incentive spirometry: measures volume of air displaced by moving float ball/ similar device up a column

Manage chest-drainage systems

• removing accumulations of air + fluid from pleural space (improve breathing patterns)

Recognise requirements of escalation of care and basic life support algorithm

DRSABCD

• Danger, response, send for help, airway, breathing, compressions, defibrilator

Escalation of care requirements

• Assessment: regularly monitor vital signs and use clinical judgment to identify pt deterioration

• Recognising deterioration be aware of early warning signs, such as confusion or changes in VS, and utilise scoring systems like Early Warning Scores (EWS)

• Initiating protocols: follow established escalation protocols, notify a physician or activate emergency response teams as necessary

• Communication: ensure effective handover + keep patient’s family informed about changes in condition
  Emergency interventions

Remove airway obstruction

• Complete airway obstruction is characterised by inability to speak/cough 

  • Victim may raise hands to throat, appear very anxious

Initiate CPR (cardiopulmonary resuscitation)

• Cardiac/ respiratory arrests require artificial support of circulation + ventilation

Pharmacological acute pain management

• analgesics:

  • non-opioids: acetaminophen and NSAIDS for mild-moderate pain

  • opioids: for moderate to severe pain (with careful monitoring)

  • adjuvants: antidepressants + anticonvulsants for neuropathic pain

• routes: orally, IV or regionally

• multimodal: combines different medications for improved relief

  • preferred method for providing post-op pain management 

  • Involves the use of meds from diff drug classes targeting diff pain pathways to control pain 

  • With the goal of using fewer or ideally eliminating need for opioids

• monitoring: regular pain assessments + side effect

• pt education: inform about medications + safe usage

• Trying to avoid morphine + opioids --> due to addictive properties + unwanted side effects

Non-pharmacological acute pain management

• Physical:

  • heat/ cold therapy, physical therapy,

• Cognitive-behavioural 

  • Meditation music, relaxation, distraction, mindfulness

• acupuncture + massage (alternative for relaxation + pain relief)

• environmental modifications: create calming enviro to enhance comfort

Nurse’s role in acute pain management

• Pain management goal: relieving pain while ensuring that side effects are kept to a minimum

Assessment

• Regularly assess effectiveness of pain management interventions by monitoring  pain levels, functional abilities, and overall patient satisfaction

Problem identifiation

• pain

• anxiety etc.

Planning

• Modify pain management plan as necessary based on the evaluation findings and any changes in the patient’s condition

Implementation

• non-pharm./ pharm. interventions

Patient’s role in pain management

• Provide feedback about effectiveness of pain management strategies – what worked/ didn’t work

• Actively communicate changes in pain levels/ new symptoms during treatment

Describe, perform and document pain assessment in the post-procedural context

• PQRST or COLDSPA

  • Provocation, quality, region, severity, time

  • Character, onset, location, duration, severity, pattern, associated factors

• Once patient can communicate (anaesthesia wears off), nurse can consider using:

  • Numerical pain rating scale (0-10)

  • Wong Baker scale

Prepare, perform and document parenteral analgesia

Prepare

• Pt identity, medical hx, current pain level

• Obtain prescribed analgesic + gather supplies (syringe, alcohol swabs, gloves)

  • 6 rights: Time, dosage, medication, patient, route, documentation

• Prepare medication by cleaning vial, drawing up correct dosage, ensuring no air bubbles

Perform

• Position comfortable + select appropriate site

  • IM: deltoid, ventro-gluteal 

  • Subcutaneous: abdominal, thigh

• Clean site

• Administer injection

Documentation

• Pt info, medication details, time of administration

• Record patient’s pre- and post-administration pain levels and any observed responses or side effects

Subcutaneous

• Fat + connective tissue

• Risks: 

  • Bruising

  • Pain

  • Swelling

  • Infection

  • Redness

  • Local reactions

  • Fibrosis

  • abcess

Intramuscular

• Muscle

• More blood flow + more absorption

.	Absorption	Angle of insertion	Site	Needle size	Volume to be injected
Subcutaneous - fat + connective tissue	Slower	45º	Abdominal	25-27g	~2ml
Intramuscular - muscle	Faster (more blood flow to muscles)	90º	Deltoid Ventrogluteal	23-25g	~5ml

Explain the pathophysiology of fluid and electrolyte imbalanceFluid imbalance:

• Types:  hypovolemia (decreased fluid volume) and hypervolemia (increased fluid volume)

• Causes: fluid loss (e.g. vomiting, diarrhoea) or retention (e.g. heart or renal failure)

• Mechanisms: changes in osmotic gradients and hormonal regulation (e.g. aldosterone, ADH)

Electrolyte imbalance:

• Types: hyponatremia (low sodium), hypokalaemia (low potassium) and hyper- vice versa

• Causes: decreased intake, increased losses (e.g. urine, sweat)n or shifts between compartments

• Mechanisms: disruption of cellular function and hormonal regulation (e.g. PTH for calcium)

Consequences

• CVS issues

• Muscle dysfunction

• Neurological symptoms

• Respiratory distress

• Electrolyte: compound that when dissolved in water or another solvent forms or dissociates into ions 

  • Electrically charged particles

• Provide inorganic chemicals - for cellular reactions and control mechanisms

• Have special physiological functions in the body that: 

  • Neuromuscular irritability

  • Maintain body fluid osmolarity

  • Regulate acid-base balance

  • Distribute body fluids between the fluid compartments

• Measured in terms of their electrical combining 

  • Quantities of cations and anions (expressed as millimoles per litre mmol/L)

• Produce either positively charged ions (cations) or negatively charged ions (anions) 

  • Critical regulators in the distribution of body fluid

• Electrolytes in body fluid are sodium (Na+), potassium (K+), calcium (Ca2+), magnesium (Mg2+)

-tonic definitions

• Isotonic: equal solute concentration; no net water movement

• Hypertonic: higher solute concentration; water moves out of cell

• Hypotonic: lower solute concentration; water moves into cells

Sodium

• Function: maintains fluid balance, facilitates nerve transmission and supports muscle contraction

• Sources: table salt, processed foods, meats, dairy products

Potassium (K+)

• Function: regulates cellular function, supports nerve transmission, maintains CVS health

• Sources: rich in bananas, oranges, potatoes, spinach, avocados and legumes

Calcium (CO2+)

• Function: essential for bone health, muscle contraction, nerve transmission, blood clotting

• Sources: dairy products, leafy greens, almonds, tofu, fortified foods

Magnesium (Mg2+)

• Functions: acts as a cofactor for enzymatic reactions, regulates muscle + nerve function, supports bone health

• Sources: present in whole grains, nuts, seeds, legumes and green leafy vegetables

Diffusion

Diffusion: particles move across permeable membrane

• rate is influenced by size of molecule, concentration, temperature of solution, 

  • and electrical charge: +ve ions pulled towards -ve ions etc.

  • move with conc gradient

osmosis

osmosis: solvent moves across membrane to an area where there is a higher concentration of solute that can’t pass through the membrane

• osmotic pressure: force created when 2 solutions of diff. conc. are separated by selectively permeable membrane

• rate is influenced by net movement of water + semipermeability of membrane

active transport

active transport: cell membrane MOVES molecules/ ions against electrochemical gradient (and against conc gradient)

• must be carrier + ATP inside the cell membrane

hydrostatic pressure (HSP)

hydrostatic pressure (HSP): force of fluid pressing outward against blood vessel wall; drives fluid out of the blood vessel

• HSP of arterial end of capillary bed = HSP venous end x2 

  • fluid + solutes go from arterial → interstitial space

• force is influenced by: force by which heart pumps, rate of blood flow, arterial + venous BP

filtration

filtration: movement of fluid through semi-permeable membrane from area with higher HSP → area with low HSP creates outward gain of fluid in the interstitial spaces

• governed by presence of a greater HSP in arterial end cap. than interstitial spaces

• body achieves total fluid balance when excess fluid + solutes remaining in interstitial spaces are returned to intravasc. compartment by lymphatic

colloid osmotic pressure

colloid osmotic pressure: movement of fluid between intravasc. and interstit. compartments

• colloids: protein or diffusible substance

• crystalloids: intravenous fluids composed of small molecules (e.g. salts, sugars) that can pass through cell membranes easily

  • used to expand extracell. fluid volume. Typically iso-, hypo- or hyper-tonic. 

  • Effective for hydration, electrolyte replacement, maintaining fluid balance 

• based on no. of solute particles on the conc. side + presence of semipermeable membrane

• created by solutes / colloids in plasma

Principles of fluid and electrolyte management

• Assessment: regularly evaluate patient’s fluid and electrolyte status through clinical signs, vital signs, intake and output monitoring and lab tests

• Fluid + electrolyte replacement: use oral or intravenous solutions for fluid and electrolyte replenishment, choosing the right type based on specific imbalance

• Understanding physiological principles: recognise roles of osmolarity + hormonal regulation in fluid and electrolyte balance

• Prevention of complications: avoid rapid corrections of imbalances and educate patients on recognising signs of disturbances

Role of the nurse in relation to altered fluid and electrolyte status using the nursing process

• Assessment: conduct comprehensive assessments that include pt hx, physical examination, lab values, monitoring or I+O to identify issues (e.g. dehydration, oedema, electrolyte imbalances)

• Problem identification: recognise specific problems or risk factors related to fluid and electrolyte imbalances. Common issues might include:

  • Excessive fluid loss/ gain

  • Electrolyte deficits or excesses

  • Impaired ability to regulate fluid and electrolyte balance

  • Risk for complications related to fluid overload or dehydration

• Planning

• Implementation: carry out interventions aimed at addressing identified problems (e.g. administering fluids/ electrolytes), educating patient about fluid management, monitoring for signs of complications

Evaluation: continuously assess effectiveness of interventions to determine if identified problems are being resolved or if further action is required

Prepare parenteral fluid and electrolyte administration

Indications	Risks	Nursing considerations
Restoring blood volume Dehydration Fluid maintenance	Allergies (esp penicillin) Infection @ insertion site Extravasation: when the drug goes outside of the vein Infiltration: fluid flowing into tissue surrounding the vein Signs: blanched, cool, pain/ burning at site, swelling, tightness Phlebitis: inflammation of vein wall Signs: pain, inflammation, heat, swelling + redness, tracks up the vein Cellulitis: hospital-acquired infection of tissues surrounding insertion site Signs: warm/ hotness, swelling, possible malaise + febrility	Drug compatibility → fluids and other drugs ANTT Education Sensitivities → wound swab etc. Labelling correctly

• Assess pt needs + select appropriate solution (crystalloids or colloids)

• Gather necessary supploes, perform hand hygiene, prepare IV site with an aseptic technique

Perform parenteral fluid and electrolyte administration

• Insert IV catheter , connect + prime IV set, begin infusion at prescribed rate. 

• Changing the IV bag:

  • don’t let the old bag empty entirely - to prevent air entering drip chamber + line

  • when bag has ~50 mL of fluid remaining, stop flow of solution

• prepare to change bag when there’s about an hour’s worth of fluid remaining in old bag

Document parenteral fluid and electrolyte administration

• solution bag changes

• discontinuation of fluid order

• appearance of IV site

• type + amount of fluid infused

• infusion rate

• person’s response to procedure

• abnormal findings

Principles of wound management

• TIMERS

  • Tissue

  • Infection/ inflammation

  • Moisture

  • Edge of wound

  • Regeneration

  • Social factors

Pathophysiology of diabetes and health outcomes

diabetes can damage:

• large blood vessels (aka macrovascular complications) —> heart attack, stroke, circulation problems in lower limbs + feet

• small blood vessels (aka microvascular complications) —> problems in eyes, kidneys, nerves (e.g. in feet, sexual function)

• body, skin, teeth, gut, gums

large blood vessels

• main cause of damage to LBV in ppl with diabetes is atherosclerosis

• atherosclerosis: occurs when plaque - made up of cholesterol, other blood fats + substances - builds up inside the wall of the blood vessels 

  • causes blood vessels to narrow + reduces blood flow to organs + other parts of body

  • if plaque breaks, can form blood clot that can block blood supply to organs and other parts of body 

    • wounds need blood to heal

Insulin and glucagon balance

• high blood sugar

→ insulin release from pancreas → stimulates glucose uptake (glucose turns into glycogen

Type 1 VS Type 2 diabetes

Features	Type 1 diabetes	Type 2 diabetes
	5-10% of diabetes cases	87% of all diabetes cases
Onset (rapid or slow?)	rapid (often abrupt) - relieved when insulin given	slow (gradual, often over year) - some ppl don’t have symptoms, can remain undiagnosed for yea
Pathophysiology	Insulin deficiency due to autoimmune destruction of beta cells	Cells become resistant to insulin, inadequate insulin secretion by pancreas
Risk factors	family hx, genetics, autoimmune diseases	family hx, obesity, sedentary, lifestyle, age, ethnicity, hypertension over 40s in white population; over 25s in south asian population overweight - can stop insulin from working
Common age at onset	childhood/ adolescence (usually <30 y.o)	adulthood (usually >40 y.o increasingly seen in younger ages)
Symptoms leading to diagnosis	polyuria, polydipsia (excessive thirst), weight loss, fatigue, rapid onset of symptoms, thrush/ genital itching. slow wounding healing, blurred vision (glucose builds up in lens of eye), hunger (triggered by body seeking energy), ketonuria (ketones in urine), dry mouth + itchy skin	Polyuria, polydipsia, fatigue, slow onset, often detected incidentally, blurred vision, slow healing, thrush, hunger, dry mouth + itchy skin
Long term symptoms	Increased risk of kidney disease, retinopathy, neuropathy, cardiovascular disease. yeast infection (yeast feeds on glucose) slow healing cuts + sores, pain + numbness in feet + legs (from nerve damage)	Same complications as type 1, but also increased risk due to late diagnosis.
Treatment/ management	Insulin injections, blood sugar monitoring, diet, exercise	Lifestyle changes, oral medications, possibly insulin, blood sugar monitoring, resensitising receptors with drugs
Does insulin have to be provided?	Yes, always	Not always; may eventually be needed if oral medications aren't enough
Prevention	Can’t be prevented	Can often be prevented or delayed with external changes

Factors that may influence wound healing

• Age

• Body type

  • Obesity 🡪 fatty tissue has poor blood supply

  • Emaciation (very thin) 🡪 lack of oxygen + nutritional stores

  • Malnutrition 🡪 reduces humoral + cell-mediated factors => immunocompromise => impairing wound healing + increasing infection risk

• Nutrition

• Oxygenation

  • Decreased arterial O2 => synthesis of collagen + formation of epithelial cells 

  • Anaemia decreases oxygen delivery to tissues + interferes with tissue repair

• Chronic disease

• Other: smoking, repeated trauma (onto wound), infection, maceration

Hyperglycaemia: high BGL damages blood vessels + impairs immune response

Long term effects of hyperglycaemia

• Neuropathy: loss of sensation increases risk of unnoticed wounds.

• Vascular damage: impaired circulation leads to poor oxygenation and delayed healing

• infection risk: high glucose levels promote bacterial growth + worsen infection outcomes (slow healing)

Role of the nurse in relation to the principles of wound management using the nursing process

Assessment 

• TIMERS

• Collect data about the wound (size, type, depth, exudate, infection), overall pt heath (e.g. nutrition + circulation)

Problem identification

• Identify key issues affecting wound healing (e.g. impaired circulation, risk of infection, delayed healing due to diabetes)

Planning

• Develop a care plan with goals (e.g. reducing wound size, preventing infection) 

• Select appropriate interventions (e.g. dressings, medication, lifestyle changes)

Implementation

• Perform wound care, apply dressings, monitor for complications, educate patient on home care

Evaluation

• Monitor healing progress, reassess problems + modify care plan if needed

Types of wound dressing for types of wounds

Perform the donning of sterile gloves and explain when sterile gloves are indicated.

• Check date + integrity of the glove packaging prior to opening sterile glove in a package onto a clean surface

• Open up glove packet

• Place dominant hand into glove – only touch distal portion of cuff (the inside)

• Use dominant gloved hand to put glove onto other hand (DON’T TOUCH OUTSIDE AREA USING DOM HAND)

Prepare wound dressing

• ***Provide analgesia prior to dressing

• PPE

  • Gown

  • Sterile gloves

  • Normal gloves (to remove the dressing depending on nature of wound + hospital policy)

• Equipment

  • Surgical dressing pack

  •  Dressing equipment (alginate, sterile scissors if needed)

  • Sterile solution

  • Sodium chloride to irrigate

Perform wound dressing

• Hand hygiene

• Set up dressing pack + all sterile equipment

• Remove old dressing

• Put on sterile gloves

• Clean wound (from cleanest to dirtiest area)

• Assess wound – does the packing material need to be cut?

• Pack under the edge of the skin (edges first)

  • Packing should be BELOW skin level – otherwise will grow abnormally

• Put film on top

Suture/ staple removal

Prepare suture/ staple removal

• Equipment: stitch cutter (like a hook blade) OR staple remover 

Perform suture/ staple removal

• HH + gloves

• Get dressing pack + saline

• Clean the cut - using saline + tweezers

• Grab tweezers + scissors (sutures) OR staple removers + sharps bin (staples

• Sutures: pull the suture up using tweezers, slide underneath + cut with scissors

• Staples: slide under the staple, press down, discard in sharps bin

• Clean again

Principles of post procedural gastrointestinal management

• Monitoring: VS, pain, GI function for complications

• Manage pain: medications (avoiding ones that cause constipation)

• Gradually reintroduce fluids + food as tolerated

• Prevent complications: e.g. N+V, constipation

  • Interventions such as positioning + medication

Educate: pt on post-op care, diet + signs of complications

Role of the nurse in relation to post procedural gastrointestinal management using the nursing process

Assessment

• Collect data: VS, bowel sounds, abdominal distension, pain levels, fluid/ nutritional intake

  • Complications e.g. N+V or bleeding

Problem identification

• Common presenting symptoms: constipation, diarrhoea, N+V

• Infection

• Pressure injuries

• Pain

• Impaired GI motility

• Dehydration

• Disorders (more info later)

Planning

• create goals e.g. relieving pain, ensuring adequate hydration + nutrition, preventing complications (e.g. aspiration + constipation)
  Implementation

• interventions such as administering prescribed analgesics, gradually reintroducing fluids + food, managing nausea, positioning pt (reduce discomfort + pressure injuries)

Evaluation

• reassess patient’s condition to determine effectiveness of interventions, monitor progress in bowel function recovery + adjust care plan as needed

Disorders of the GIT

• Peptic ulcer disease: break/ ulceration in mucosal lining of the lower oesophagus, stomach or duodenum

  • Damages lining

• Inflammatory bowel disease: inflammatory conditions of the bowel

• Appendicitis: inflammation of the appendix

Prepare NGT

Equipment

• NGT

• lubricant

• catheter tip syringe (to aspirate)

• drainage bag

• nose stickers (to hold the NGT)

Indications	Risks	Nursing Considerations
Bowel obstruction → decompresses Remove nasogastric contents to alleviate symptoms of nausea and vomiting Reset bowel after surgery Diagnostic purposes Provide feeding/medication for people who have difficulty swallowing, are unresponsive or have had neck or oral surgery	If it’s in lung Pressure sores Hygiene Distress of patient - may pull it out Perforation → pain + discomfort Trauma - e.g. nose bleed	Nostrils: blocked? deviated septum? anatomical differences? Don’t put it in a blocked nostril Patient education and consent

Perform NGT

1. Wear gloves

2. Measure from tip of nose to ear, to xiphoid process. Note length/number

3. Attach end to catheter needle

4. Lubricant

5. Put it in from nose, keep pushing in until noted length

6. Sticker it to nose

7. Aspirate to check it’s in stomach

8. Kink/fold it (so it doesn’t leak) and remove from needle and attach to drainage bag

Post insertion

• X ray and aspirate to ensure it’s in tight spot

• PH test

Document NGT

• Type + size of NGT used

• Confirmation of placement + length of tube (from nares to hub)

• Amount of aspirate and its nature, including pH

• Type of apparatus connected (e.g. suction + pressure setting, gravity drain)

• Person’s response to procedure

Prepare stoma assessment + appliance change

Indications	Risks	Nursing Considerations (for position)
Cancer (bowel or colorectal) Obstruction Birth defect Bowel resection	Damaged skin integrity Irritation (from adhesive) infeection	Location of disease Practicality Preserve muscle

• Equipment

  • Kidney pan (leakage)

  • Clean pouch

  • Stoma measuring guide

  • Ostomy scissors (to cut the guide)

  • Clean gloves

  • Adhesive remover

  • Bluey

  • Locker bags

Perform stoma appliance change

• Wear apron and gloves

• clean area, remove any leaked feces

• remove old bag

• measure NEW stoma, cut it to fit.

• Stick it on

• Close bag

Document stoma assessment/ appliance change

• each stomal assessment

• alteration in stomal size

• change in colour (pallor/ cyanosis → indicative of altered circulation)

• presence + degree of skin irritation

• amount + type of drainage and/ or effluent

• skills learnt by pt

• bleeding of stoma 

  • altered circulation

  • diminished or increased drainage

    • consistency

Pathophysiology + signs/ symptoms of a post procedural wound

Post-procedural wound

• hemostasis: clot formation to stop bleeding

• inflammatory phase: white blood cells clean wound 🡪 redness + swelling

• proliferative phase: granulation tissue forms as new blood vessels and collagen develop

• remodelling phase: collagen reorganises to strengthen the wound

Signs and symptoms

• redness (erythema)

• swelling

• fever - high temp

• drainage 

  • clear - doesn’t indicate infection. may mean other things

  • yellow, murky - usually indicative of bacterial infection

  • green - pseudomonas infection of a wound (treated differently)

• lots of pain

• foul odour

• non-healing

Pathophysiology + signs/ symptoms of a chest infection

• community acquired: can occur from organisms entering (strep + flu bacteria/virus)

• ventilator acquired: bacteria/ organisms/ etc that enter tube can grow → cause pneumonia infection 

  • device connected to tube delivering O2 to pt

• aspiration (acquired): common for pt who vomit - can aspirate it into lungs (open epiglottis)

• infection is inside alveoli 🡪 alveolar tissue inflames + leaks fluid 🡪 air goes DOWN, but is blocked by fluid 🡪 blocks entering of oxygen + exiting of CO2

signs + symptoms

• dyspnoea (SOB)

• chest pain

• cough - body trying to eject fluid

• fever - infection

What is antimicrobial stewardship?

Antimicrobial stewardship: careful use of antimicrobials to prevent bugs from developing resistance

Role of the nurse in antimicrobial stewardship

• Assessment: evaluate patients for infection and review medical histories to ensure appropriate antimicrobial use

  • Make sure you always check if the patient has their allergies recorded and encourage patients/parents to report side effects promptly.

  • Encourage patients/parents to report side effects promptly.

• Education: inform patients about responsible antibiotic use and adherence to prescriptions

  • Help patients/families to understand the importance of avoiding unnecessary antibiotics – for example, explain that antibiotics don't work for viral infections like the flu.

• Collaboration: work with healthcare teams to select, dose and monitor antimicrobial therapies based on guidelines

  • Ask the medical team what the antibiotics are being used for if the indication has not been documented on the medication chart to avoid miscommunication.

• Monitoring: track patient responses to treatment and adjust as necessary

  • Doctors sometimes miss ceasing treatment in a timely way. It is OK to ask: "how many more days of antibiotics are expected?"

• Data collection: help gather information on antimicrobial use and resistance to improve practice

  • Ensure that the appropriate tests (e.g. urine specimen, blood cultures) are taken before antibiotics are commenced when possible.

Role of the nurse in infection prevention and control

• Adherence to protocols: follow HH, PPE, aseptic techniques

• Environmental cleaning: maintain cleanliness in pt areas and ensure proper sterilisation of equipment

• Patient education: teach infection prevention practice to Pt + families

• Surveillance: monitor patients for signs of infection + report outbreaks

Reporting + documentation: document infection rates + interventions for tracking effectiveness

Role of the nurse in relation to pre-procedural infection prevention and control

Assessment

• Evaluate pt hx, existing skin integrity 

• Wound assessment

Problem identification

• Identify risks (e.g. compromised immunity or lack of patient education)

Planning

• Develop a care plan with interventions like administering prophylactic antibiotics

  • prophylactic antibiotics: prevent infection

• education pt on hygiene + preparation

Implementation

• use HH + PPE

• prepare surgical site aseptically

• administer any antibiotics as needed

Evaluation

• monitor patient’s understanding

• reassess surgical site for signs for infection

Role of the nurse in relation to post-procedural infection prevention and control

Assessment

• monitor VS, pain, signs of infection at surgical site

Problem identification

• identify risks such as impaired skin integrity + inadequate wound care

Planning

• create a care plan outlining infection prevention strategies + wound care instructions

Implementation

• educate patient on proper wound care

• ensure sterile techniques during dressing changes

Evaluation

• regularly reassess surgical site for infection signs + evaluate effectiveness of patient education

Prepare + perform antibiotic infusion

Prepare:

• vial

• bevelled needle (for vial)

• 10ml syringe

• WFI 10 ml

• 100 ml N/saline (blue side = spike, white side = drug)

• line for pump

• blue label

• x2 swab (for vial + IV site)

Perform

• prepare WFI + antibiotic in preparation room beforehand 

  • not bedside

1. clean drug insertion on IV bag

2. draw drug → syringe → IV bag

3. put drug label on

4. follow iv process

Prepare + perform antibiotic push

Prepare

• vial

• bevelled needle (for vial)

• x2 swab (for vial + IV site)

• WFI

• 10 ml N/S ampoule

• syringe x2 10 ml

• ~label sticker

Perform

• prepare stuff in treatment room first 

  • draw up WFi

  • clean vial + take out drug/water

1. check patency → flush/drawback 

   • drawback THEN flush

2. 10 mls ⇒ 2-3 mls/ minute 

   • do slowly

   • too fast might ⇒ seizure, itchiness

pathophysiological responses associated with grief and loss

• stress overload

  • increased cortisol => fatigue + illness (immune suppression)

• fatigue + insomnia: grief disrupts sleep patterns => exhaustion / difficulty sleeping

• appetite changes: grief => loss of appetite/ overeating

• cardiac effects: chest pain/ tightness

psychological responses associated with grief and loss

• shock + denial: e.g. initial numbness/ disbelief

• anger + guilt

• sadness + depression: affecting daily life and interests

• acceptance and healing: gradual adjustment to the reality of loss => more manageable emotions over time

role of the nurse in relation to grief + loss (for a GRIEVING person)

• assessment → to differentiate healthy grieving from at-risk

• problem identification

• planning → clarify expected outcomes when planning care for the grieving person

• implementation → understand person, counselling, support, support groups

• evaluation → follow their own time schedule

Explain and demonstrate the role of the nurse in relation to end-of-life care using the nursing process

assessment

• pt’s awareness of terminal nature of illness

• assess support systems + history of previous positive coping skills

• physical/ emotional status

• presence of advance directives for health care decisions

• unfinished business expressed by patient or family

problem identification

• powerlessness + hopelessness

• risk of harm to self

planning

• schedule time to be available to the patient

• balance the person’s need for independence + their need for assistance

• respect the person’s confidentiality

• answer questions + provide factual information to pt + family

implementation

• communicate a caring attitude

• EOL care

• learning needs of patient and family

  • physiological needs

  • promoting comfort

  • hospice/ home care

  • psychosocial/ spiritual needs

  • family support

questions to consider asking to maintain cultural sensitivity

• 'What should I know about you to help me take care of you the best I can?'

• 'What do you find the most distressing at present?'

• 'What is most important to you in relation to your care?'

• 'Who else (or what else) will be affected by what’s happening with your health?'

• 'Who would you like to be involved to help support you?'

• 'What do you think about the time ahead?'

• offer to contact clergy

Describe self-care strategies to support yourself, and other nurses, when working with patients experiencing grief and loss.

lifestyle/ personal

• embrace the outdoors

• move your body

• connect with loved ones

• prioritise quality sleep

• unleash your creativity

• practice self-compassion

• honour your pt in a way that aligns w your beliefs

external resources

• support, education + assistance in coping w the death of patients

• use peer support

• trained professional

• identify and cope w burnout