Med-Surg 1 Exam 1

Stress

-inability to cope with perceived (real or imagined) demands or threats to one’s mental, emotional, or spiritual well-being

• state of worry, mental tension from demanding life situation

-stressors

• physiologic examples- acute pain, illness/injury, sleep deprivation, excessive noise, starvation, infection

• emotional/psychological examples- loss of child/spouse, fear, life changes, loss of home through fire, birth of baby, cancer diagnosis, caring for disabled child, marital issues

  • can be positive or negative

-women typically have more stress than men and more likely to seek help for stress-related symptoms (depression, anxiety)

• men morelikely to die from stress related illnesses

Stress Response

-very dependent on ones perception of the stress

• heavily affected by internal and external factors

• optimisum often play big part in response and coping capabilities

-internal

• examples: Age, health status, nutrition, sleep, resilience, optimism, hardiness

• hardiness- made up of commitment, control, and openness to change

-external

• Cultural and ethnic influence, timing/number of stressors, religious or spiritual influences, socioeconomic status

Pathophysiological Stress Response

-increased sympatetic nervous system activity

• heart- increased HR and stroke volume → increased CO

• blood vessels- peripheral vasocontriction → increased systolic BP and redistribution of blood to vital organs

• lungs- increased RR, shallow breathing

• adrenal medulla- increased epinephrine and norepinephrine → prolonged SNS response

• liver- glycogenolysis → increased blood glucose

• GI system- decreased secretions and peristalsis → decreased digestion

-commonly seen VS in stressed patients

• tachycardia, HTN

• increased RR

• increased mental awareness

• increased blood glucose

• symp NS aciton to fight or flight

Stress on Immune System

-Acute and chronic stress can cause immunosuppression

• decreased phagocytosis by neutrophils and monocytes

• decreased number and function of natural killer cells

• decreased lymphocyte proliferation

• Alters production of cytokines

-Worsen or increase risk for progression of immune related diseases (MS, RA, asthma, cancer) and infection

• stress can cause/be a compnonent in many disease processes- IBS, fatiure, lower back pain, mentraul irregularity, peptic ulcer dx, eating disorders, ED, etc.

-bidirectional link between brain and immune system (not fully understood)

Stress Outcomes

-illness

-disease- CV, atherosclerosis, HTN. can precipitate/worsen DM, asthma

-death- from long term diagnosis or accident/suicide

-declining cognitive function- forgetfullness, dreams, insomnia, memory decreased, impaired decision making

-behavior- withdrawn, drugs/alcohol excessively, decreased interest, eating habit changes

-infectionn- more likely to get

-telomere length (protective coatin gon end caps of chromosomes)- susceptible to stress, can accelerate the rate when cells age and earlier onset of age related dx (malingancy, osteoporosis, dimentia)

Coping Types

-problem-focused coping

• addresses the problem that is causing the stress

• ex. after failing an exam… meet with professor, tutoring, study groups, sleep

• ex. After cancer diagnosis… set up appointments, research, treatment approaches, lifestyle change, following medical plans/showing up for doctors, seek second opinion

-emotion-focused coping

• addresses the emotions felt when stress occurs

• ex. After failing an exam… crying, going for a run

• ex. After cancer diagnosis… support groups, spiritual resources

-more helpful depends on the patients goals- usually problem-focused but overall with combination of the two

Stress Nursing Care

Assess

• biggest concern

• how they normally experience stress, previous coping methods

• stress symptoms and support systems

• pysiological: Vital Signs (acute stress- HR up, RR up, BP up), weight change, eating habits, sweating, headaches, fidgeting, insomnia -> tired/fatigued, diarrhea

Identify

• when they will have issues coping

• spiritual problems

Implementation

• stress management strategies

  • box/relaxation breathing, journeling, meditation/yoga, spiritual practices, aroma therapy, art therapy, music therapy, exercise

Goals

• patient report decreased stress

• patient utilizes positive coping strategies

• free from complicaitons related to their stress

Teaching

• exercise

• relaxation techniques

• humor

• journaling

• social support

Sleep

-Definition: state in which a person lacks conscious awareness of environmental surroundings but can be easily aroused

• should get 7-8 hours a night

• if not easily aroused, considered unconsious

-Sleep influences mood, behavior, and some physical functions

• Memory

• Mood

• Hormone secretion

• Glucose metabolism

• Immune function

• Body Temperature

-Sleep Deprivation

• can result from not enough sleep or frequent awakenings (sleep fragmentation)

Insomnia

-Types

• acute < 3 months

• chronic > 3 months

-Contributing factors…

• poor sleep hygiene

• alcohol/drugs/medications- corticosteroids, stimulants, antidepressants, diuretics

• life stressors

• pain

• anxiety, depression

-S/S: difficulty falling asleep, prolonged nighttime wakings, early awakening, avoidance/resistance to scheduled bedtime, or inability to sleep without assistance

-treatment

• drug therapy- ambien, melatonin agoonists, antihistamines, antidepressants

  • helping to create the sleep onset and help with sleep maintainence so they can stay asleep

  • want patients to only use them for short-term use and must be educated on side-effects of medications

  • can still be impaired in the morning after waking up: don’t want them driving in the morning or things that require their attention

• CBT- cognitive behavioral therapy (first line)

Insomnia Nursing Care

-assessment

• sleep diary

• PMH- BPH, mental dealth issues (deprsssion, anxiety, PTSD), pain, meds, drugs, alcohol

-implementation (all addressed in CBT)

• sleep hygiene

• caffeine intake

• sleep medications

• education- go to bed same time every night, go to bed only when sleepy, no naps during the day, caffiene not <4-6 hrs before bed, no alcohol/stimulating activities before bed (exercise), have night time rountine

Obstructive Sleep Apnea (OSA)

Definition: partial or complete upper airway obstruction during sleep.

• Narrowing of air passage with muscle tone relaxation

• Tongues/soft palate falling backward and partially/completely obstructing pharynx

• 10-90 seconds resulting in hypoxemia and/or hypercapnia causing brief arousal

• long term have hypercapnia

-Risk factors: obesity (BMI >30), >65 yo, large neck circ, male, or postmenopausal women

-S/S: frequent arousals during sleep, insomnia, daytime sleepiness, or witnessed apneic episodes, oud snoring, AM headaches.

• morning ha from hypercapnia, BP, vasodilation of cerebral blood vessels

-Long term effects: over activation of SNS, HTN, DMII, dysrhythmias, coronary heart disease, arteriosclerosis, HF

-Diagnosis: Berlin or STOP-BANG questionnaires, and sleep study (Apnea Hypopnea Index=AHI, gold standard)

• questionaires identify patients at risk for sleep apnea

• for diagnosis apnic events look at over an hour: need >5 events of > 10 seconds per hours with 3-4% decrease in O2 saturation

-Severe apnea can have more than 30-50 apneic events per hour of sleep during sleep study.

OSA Nursing Care

-behavioral treatment

• Positional therapy- not sleeping on back or stomach- sleep on side and elevate the HOB

• encourage weight loss

• avoid medications that can contribute to insomnia

-medical devices

• CPAP (continual positive airway pressure)

• adherence is a challenge for patients

• adherence definition is 5 days a week for at least 4 hours per night (that amount of time can imporve sleep apnea SE)

-surgery

• often if diagnosed a early age will have these procedures

• UPPP/UP3- remove obstructive tissue

• GHAM- attachment of the muscular part of the tongue to the mandible to hold tongue down so it cannot fall back and obstruct the airway

Pain Definition

-3 main profressional definitions of pain that are very different

• pain is what the patient says it is

• A”n unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”

• “Pain may serve as a protective physiologic function”

• “The biopsychosocial model of pain includes the physiologic, affective, cognitive, behavior, and sociocultural dimensions of pain.”

Acute vs Chronic Pain

-Acute Pain

• Sudden onset

• Lasts < 3 months

  • Depends on normal healing

• Usually related to illness or surgery

• Symptoms- sympathetic NS- increased HR, BP, RR, restlessness, diaphoresis, anxiety, confusion/aggitagtion

-Chronic Pain- usually occurs after normal healing process is complete

• Gradual or sudden onset

• Origin/cause may be unknown

• Pain usually continues after normal recovery time is complete

• > 6 months

• Symptoms- depression, flat effect (minimal experession), lethary/fatigue, decreased activity participation, sedentary lifestyle, socially withdrawn

Nociceptive Pain Types (normal processing)

-somatic

• superficial- localized, skin, mucous membranes, sub q, tissues

• deep- diffuse, radiating, muscles, bones, tendons

-visceral- pain from visceral organs, localized or diffuse, often radiates

-pain processing

• transduction- conversion of nocious stimuli into electrical signal

• transmission- pain signal moves from peripheral to spinal cord and to the brain

• perception- reconition and definition- when brain recognizing and puts meaning to the pain

• modulation- when signal goes back down spinal cord, to inhibit or facilitate the effect of pain transmission

Neuopathic Pain Processing (Abnormal Processing)

-peripheral- pain along peripheral nerve due to nerve damage

-central- spinal lesions or CNS problems

-description

• burning, tingling, shooting, eletric shock-likeelectric

-causes

• diabetic neuropathy, nervous system infections (herpes-zoster)

Unrelieved Pain

-physical

• Weight loss

• Anorexia

• Infection

• Weakness/fatigue

-emotional

• depression

• anxiety

• sleep disturbances

-spiritual

• decreased quality of life

• hopelessness/distress

-financial

• unemployment

• lost productivity

Pain in Older Populations

-no report of pain does not mean it is not being experienced

-older adults can and should still recieve opioid pain medication

-many older results believe pain is a normal result of aging, when really it should not be

-assessing pain in older adult requires time and support

-Most common painful conditions: musculoskeletal (osteoarthritis, kyphosis, low back pain)

-High prevalence of pain, but undertreated

• use other words to report pain- aching, soreness

-Consequences: physical, emotional, social, spiritual

• With chronic pain: decreased mobility, falls, confusion, sleep issues, increased depression risk, socially isolated, decreased quality of life, hoplessness

Pain Assessment Barriers

-Misconception that pain is a normal part of aging process

-Fear of being a “burden” or complaining

-Fear of taking opioids

-Difficulty communicating needs

-Hearing/vision deficits

-Adapt pain assessment

• Use appropriate tools- correct pain scales for patient population in

• Unhurried

• Listen to how individual describes pain

Pain Assessment Best Practices

-ie. OLDCARTS but different method

-location- where is the pain

-quality- what kind of pain

-radiation- does it go anywhere else

-severity- of pain

-timing- when its worse

-Individualized

-Multimodal Approach:

• Medication- multiple types

  • pca pump

• Restorative therapies (PT, OT, physiotherapy, therapeutic exercise)

• Interventional procedures (epidural, nerve block)

• Behavioral health approaches

• Complementary and integrative health

-Multidisciplinary

• Treatments from one or more clinical disciplines

Biopsychosocial Approach to Pain Management

-Biological Factors

• pain generator

• precise diagnosis

• age

• injury

• illness/diagnosis

• neurologic

• genetic

• hormones obesity

-Psychological Factors

• mood/affect

• stress

• coping

• trauma

• childhood

-Social Factors

• cultural

• economics

• social support

• spirituality

• ethicnitiy

• educaiton

• bio/stigma

Pain Management Guideliens

-appropraite assessment for each patient populaiton

-appropriate treatment

-access to speciality care as needed

-recongize and treat pain promptly

-involve patients in the pain management plan

-reassess and adjust the pain management plan as needed

-monitor processes and outcomes of pain management

Non-Pharmacologic Interventions

• Massage

• Exercise

• Transcutaneous electrical nerve stimulation (TENS)

• Distraction

• Meditation

• Repositioning

• Adjust environment

• Heat/Cold therapy

-OFFER THESE SOME IN SIM

Non-Opioid Analgeics

• Available OTC

• Non-addictive

• Acetaminophen

• NSAIDs

  • Ibuprofen

  • Ketorolac

• Salicylates

  • Aspirin

-Main adverse effects:

• Acetaminophen:

  • Liver toxicity if more than 4 g/day

  • Avoid alcohol

• NSAIDs

  • GI bleed risk

  • CV risk

• Salicylates (aspirin)

  • Increased bleeding risk

Adjuvant Medications

-coritcosteroids- inflammation

-antidepressants- neuropathic pain

-antiseizure drugs- neuropathic pain

-muscle relaxants (SSRI’s, antidepressants, flexeril)- neuropathic, muscle spasms

-alpha 2 adrenergic agonist- neuropathic pain

-anesthetics- topical

Opioid Analgesics

-Types

• hydrocodone with acetaminophen (nroco)

• hydromorphone (dilaudid)

• morphine (MS Contin, Duramorph)

• Oxycodone extended release (OxyContin)

• Oxycodone with acetaminophen (Percocet)

Side Effects:

• constipation

• Sedation

• Resp depression

• RISK FOR FALLS!

Evaluating Effectivness of Pain Relief

-repeat assessment of pain

• Know the baseline pain

• Assess within 2 hours after intervention/medication

• Ask for patient’s verbal account

• Observe patient behavior

• Sedation scale

-adjust plan based on assessment

-discuss realistic pain goals with patient and family

-involve paitent, family, caregivers, and interprofessinoal team

Special Population: Patients who Cannot Self-Report Pain

those who cannot report pain: neurological deficits, intabated, unconcious, intellectual disability, stroke, TBI, demetia

-look for following as indicators of possible pain

• Behavior changes

• Psychological changes

• Cognitive changes

-Use of appropriate pain scale

• Individual with dementia

• Individual with cognitive impairment

• Tools based on facial expression, body movement/posture, and breathing pattern

Special Population: Substance Abuse/Addiction

-Opioid epidemic

-Healthcare provider may be reluctant to give opioid

no evidence addiction will be worsen by giving someone opioids to opioid addict

• sometimes unrelieved pain can cause more stress than providing medications (and can create higher risk for relapse)

-Pain assessment and management with dual diagnosis of pain and substance abuse is difficult

-Patients have the right to effective pain management

-Comprehensive pain assessment:

• Detailed history

• Physical exam

• Psychosocial assessment

• Diagnostic workup

-Treatment plan goals:

• Relieve pain

• Minimize withdrawal symptoms

-May require higher doses for relief

-Use a single opioid preferred

-Can still use nonopioid and adjuvant analgesics

-Can still use non-pharmacologic interventions

-Bring in the interprofessional team

-Examine biases, attitudes, and misconceptions of individuals with substance abuse problems

Nursing Role in Pain Management

• Assess ALL patients for pain

• Accept and respect patient’s self-report

• Do not rely on objective findings unless patient cannot self-report pain

• Understand that a uniform pain tolerance/threshold does not exist

• Do not assume to know where pain is coming from

• Do not attribute pain without an identifiable cause to psychologic causes

• Encourage patients to report pain

• Be timely when providing interventions

• Use a holistic approach

• Interprofessional collaboration

• Stay ahead of the pain (post-surgical patients)

• Educate patients and families

• Prevent/manage side effects of pain-relieving medications

• Reassess, reassess, reassess!

• Be patient with your patient (learn patient goals for pain)

Challenges to Pain Management

• Differentiate between:

  • Tolerance – need for increased dose

  • Physical dependence – ongoing exposure causes withdrawal when substance abruptly stopped/decreased; normal physiological response sometimes

  • Pseudoaddiction – inadequate pain control causes behaviors associated with addiction

    • Behaviors stop when pain is adequately relieved

    • Often labeled as “drug seeking”

  • Addiction – complex drive to take substance for unintended reasons

    • Older adults may be fearful

    • Education is key!

• Older adults have greater peak and longer duration of action with opioid medications

Palliative Care

-Holistic care of person with serious health related suffering from severe illness

• begins at the diagnosis of a serious illness

• improve quality of life to limit suffering, not curative (can occur with treatment)

• part of routine nursing care

-Goal: reduce burden of health-related suffering while improving quality of life.

• Pain and other physical sx relief

• Maximize quality of life

• Psychosocial and spiritual care

• Determine goals of care

• Neither hasten or postpone death

-Shown to improve quality of life, dec cost, and ease caregiver burden

-Examples: Dx- cancer patients recieving chemo, HF patients receiving meds/treatment, COPD, dementia, ESRD, ALS

Hospice Care

-Subcategory of palliative care- all hospice patients are palliative patients (not vice versa)

-Goal: help patient live as fully and comfortably as possible while dying with dignity. EOL care

• Symptom management

• Advance care planning

• Spiritual care

• Family support

-Two qualifying criteria:

• Patient must want services and agree to only hospice (no curative treatment- comfot measures only)

• Patient must be medically eligible (2 physicians certify <6 months to live)

5 Wishes for Hospice Care

1. Healthcare decision-maker

2. Treatments wanted/not wanted

3. Comfort wishes

4. How I want to be treated

5. What I want loved ones to know

EOL common legal documents

-advance directives- given in advance by a patient for decisions they want made if they cannot make decisions at some point in medical time (similar to living will) `

-AND (allow natural death)- aka DNR- avoid aggressive measures; does not mean do not treat

• no CPR

• sometimes see DNI- do not intubate

-combined directives- who makes medical decisions for them, kind of medical treatments they want, how comfortable they want to be, how they want to be treated (dignity, privacy of who will be present), anything they want their loved ones to know, funeral wishes, sometimes financials

-DPAHC (durable power of attorney for healthcare) (POA)- designates who makes decisions for them; activated when patient lacks the capacity to make their own decisions

• if not designated, goes to next of kin which varies by state

-living will- documents treatment preferences, EOL decisions (similar to advance directive)

-POLST (physician order for life-sustaining treatment)- order for life-sustaining treatment reflecting patient wishes via an order

• usually on paper to go with all providers even out of hospital to nursing home- order written for EMS to be able to follow

EOL Common Physical Manifestations

-expect to see many of these changes

-focus more on comfort feeding rather than for calories

• should not force them to eat

• anorexia, dehydration, n/v

-bowel patterns- constipation, decreased bowel sounds and motility, incontinence

• sometiems given stool soften and laxatives

-ora conditions- provide frequent oral care for comfort

• moist swabs and lip moisturizer

-delirium/restless- could be from meds, hypoxia, pain, urinary retention

• interventions- calming env, assess for reversable causes, medications,

-increased aspiration risks; diffculty swallowing

• offer small sips if safe, adjust medicaiton route with swallowing issues (transdermal, subcut, sublingual- options other than PO)

-RR changes- talk with family through and comfort

• terminal secretions- ‘death rattle’ as secretions get stuck in throat and cannot be cleared; can give medications- morphine, etc

• dyspnea, cough

-myoclonus- from meds and dx progression

-pain- assess for nonverbals (grimacing, muscle tension, HR, RR, BP)

• goal is comfort- decreasing pain

-skin changes- fragile; encourage repositioning; increased risk for pressure injuries; breakdown

-urinary and bowel incontinence- sometimes retention; decreased output

-weakness/fatigue- dx progression, meds, not eating much; less response as death gets closer

EOL Comfort Measures

• comfort

• pain relief

• oral care

• family support

• spiritual care

-look at verbal and nonverbal indicators to treat pain proactively

-repositioning, oral and skin care

-help take care of the fmaily, explain/educate them things are normal at EOL

• encourage their time, touch, talking with the patient

EOL Care and Documentation

Documentation- some hospital policies vary on this topic

• time of death- actual and pronouncement time

• provider, family,a nd staff notification

• post-mortem care

• coroner case?

• orgran procurement organization (ORO) (PA: Gift of Life and CORE)

• funeral home information

• body disposition- follow where it goes

• belongings

Surgery Types

Performed

• diagnosis- to confirm a disease; minimally invasive- biopsy, endoscopy

• cure- elimiative or repair a pathology- appendectomy

• palliative- to relieve symptoms without curing, colostomy for bowel obstruction, for pain

• prevention- to prevent future disease- remove cancerous mole on skin

• cosmetic improvement- to restore function/appearance (breast reconstruction after cancer)

• exploration- to find out extent of the disease- exploratory laporatomy

Surgical setting

• elective- planned surgery, not immedately life threatening- knee replacement

• emergency- requires immediate intervention- trauma, appendectomy

• inpatient- require hospitalization

• same-day

• ambulatory- do not need hospitalization; outpatient; minimally invasive- knee replacement, endoscopy

Suffix

• ectomy- removal

• lysis- destruction

• orrhaphy- repair/suture

• osocpy- look at, visualize, observe

• ostomy- hole, opening

• otomy- incision, cut into- tracheotomy

• plasty- repair/reconstruct

Pre-op Assessment Goals

-give overall picture of patient and determine key safety and findings to be aware of for surgery

-lecture today mainly focuses on elective surgeries- when there is time to do all of these things

Components:

1. Establish baseline data- Need baseline data to compare pre-op state to intra op and post op

2. Assess psychological and physiologic risks- So that we can help patient cope positively, manage stress, and to know risk factors for the surgery

3. Verify surgical readiness- Identify surgical site, correct patient and procedure

4. Review medications, diagnostics, and health history- Affect the outcome of the surgery; share findings with healthcare provider

5. Address cultural, educational, and informational needs- Ensure patient knows what they need to to support informed decision making before and after surgery

Pre-Op Psychological Assessment

-stress response may have positive or negative affect

• stress could make patients more prepared for their surgery or the opposite where they cannot absorb education you are giving them

-potential or actual stressors

• Situational changes

• Concerns with the unknown

• Concerns with body image

• Experiences

• Need for information

-Anxiety- a normal survival mechanism, can impair cognition, decision making, and coping ability

• provide education to reduce

• identify anything needed for more information and tell physician about needed education

• remember cultural and religious beliefs that could increase their anxiety

  -ie. JW cannot recieve blood products

  -ie. Jewish cannot recieve certain foods, modesty concerns

  -ie. Muslims- prefer same gender care providers, modesty concerns, prayer times

  -ie. Hindu- family involvement and rituals

  -ie. Natives- natural remedies/treatments

  -ie. Amish- family and community support

  -ie. Asian- family-centered decision making

-fear of… death, pain/discomfort, mutation or altered body image, disruption of life functioning

-hope- can be strongest coping mechanism in these scenarios

Pre-Op health history and medications

-lots of information gathering

• health problems or surgeries

• hospitalizations- reasoning, acute infections

• menstraul and obstetric history

• FMH- hereditary dx; anesethia concerns; hypremalignant hyperthermia

• current medications- may need dose adjustments pre-op pahse

• OTC medications

• substance use

Pre-Op Common Medications requiring adjustment

antidepressants- can potentiate the effects of sedation

• usually stopped before surgery

-antihypertensives- can cause hypotension; continued to surgery

• puts patients at risk for shock and hypotension during surgery

-insulin/anti-diabetics- continued until day of surgery

• during surgery have decreased oral intake- at risk for hypoglycemia and also hyperglycemia from stress

• monitor glucose closely

-antiplatelets and coagulants- often stopped pre-op phase bc of bleeding risk

• depends on what medications

• Aspirin stopped 7 days pre-op unless for cardiac surgery

• longer term ones- elequis, suralto, warfarin- need inpatient admission so they can be bridged to short acting anticoagulant until surgery (heparin ex.) so it can be stopped a few hours before surgery

-diuretics

-corticosteroids

-follow healthcare provider order, know all of these meds may need adjustment pre-op

Pre-Op Allergies

-drug intolerance- unpleasant side effects; non life threating

• n/v/d

-allergy- anaphylaxis

• decreased BP, increased HR, bronchospasms

• specifically looking for antibioitcs as they are given prophylactically

-nondrug allergy/hypersenstivity

• specific worry to surgery- latex, iodine, CHG

• latex allergy risk higher in healthcare workers, those who work in rubber factory, contact dermatitis/urticaria, aresol reactions, reaction hx, hay fever, asthma, some food allergies (egg, avacados, bananas)

  • know general idea for exam of who is at higher risk

Pre-OP ROS

CV:

• Looking for: HTN, angia, dys, HF, MI, clotting disorders

• tests- EKG, Coag studies

• DVT/PE risks

Resp

• Upper resp infections- bronchospasm increase/secretions

• COPD/OSA- increased risk for complications intra-op and post-op

• stop smoking 6 weeks prior to surgery; use nicotine patch; includes vaping

• may get ABG or pul function test done if having COPD/OSA/asthma

Neuro

• need baseline to know expectations post-op

• assess emergence delirium- short term neurological change- restless, agitation, thrashing, violent, change in orientation

• PMH-MS, Parkinson’s

GI

• renal function BUN, creatinine)- drug metabolism; anesthesia done mostly by kidneys

• voiding issues

• pregnancy test just in case

Hepatic

• iver function- medication metabolism; dx can decrease clotting capabilities

• coagulation

Skin

• pressure injury; skin issues

• how wounds will heal post-op

-MS

• some anesthesia positioning if patients have some patho

• spinal- if patient cannot flex lower lumbar spine (kyphosis) makes spinal anesthesia hard; cervical spine issues

Endocrine

• DM- to see blood sugar monitoring; ensure it is diagnosed (can have delayed wound healing and increased risk for infection)

• adjust insulin levels

• thyroid- affects metabolic rate; check with provider about taking medication

Immunospressants- slow wound healing, increase risk for infections

Fluid and Electrolytes- may need replaced if given bowel prep or other medications (diuretics)

• n/v/d, medications

Nutrition

• obesity vs very thin

• excess stress on heart and lungs

• obestiy can make anesthesia adiministration different, can decrease ability to get to surgical site

  • lower recovery from anesthesia, can still be deficient in nutreints

• caffiene intake- how much has been had (spinal anesthesia can create headaches vs confused from caffeiene headache)

Pre-Op Diagnostic Studies

Test	Assessment
Albumin	Nutrition status
ABG, pulse oximetry	Resp and metabolic function, oxygenation status
CXR	Lung problems, cardiac enlargement, HF
CBC	Anemia, immune status, infection
ECG	Heart disease, dysrhythmias
BMP Electrolytes Glucose BUN, creatinine	Metabolic status, renal function, diuretic SE Metabolic status, diabetes Renal function
Human chorionic gonadotropin (hCG)	Pregnancy status
Liver function tests	Liver status
PT, PTT, INR, PLT	Coagulation status
Pulmonary function studies	Pulmonary status
Type and crossmatch	Blood available for replacement
Urinalysis	Renal status, hydration, UTI
Test or culture for communicable disease	Presence of communicable disease

Pre-Op Cultural and Gerontological Considerations

Cultural Considerations

• view of pain- past experience

• ability to express needs- preferences

• family involvement-

  • part of culture where family aids in decision making process?

  • hispanic women may defer decisions to family members completely

  • provide respectful care and ensure informed consent

• blood transfusions

• use of medical interpreter when providing care to patients that do not speak English

  • document use and preferences of patients to other members of healthcare team

Older Adults

• sometimes need family involvement for 2nd person to recieve information

  • vision and heating decificts

  • decreased or slow thought process or cognitive ability

• increased complicaiton from surgery risk from comorbidity (ie. HF, COPD) 

• Sometimes very resistant to elective surgery (think they will end up in a nursing home)

• provide lots of education- cna be easily overwhlmeing

• caregiver support

Pre-Op Teaching

Right to know- assess pateint understanding while filling in gaps

• Increases patient satisfaction

• Reduces fear, anxiety, and stress

• May decrease complications, length of hospitalization, and recovery time after d/c.

Time limitation

• Highest priority

  • what is higest priority for patient if they do not know anything about surgery, infection prevention guidelines, surgery prep (bowels, shower, wash site, mark site for surgery, etc)

  • educate prevention for after surgery- turn/cough deep breath, ambulate early, pain management

• Focus on safety

• Provide written material

Pre-Op Teaching

Sensory

• Hear, smell, and feel during surgery

• what OR and process will be like

Procedural

• Specific details about procedures

Process

• General flow of what will happen

Caregivers

-18.7 in book

Pre-Op Teaching

-turn, cough, deep breathe- to prevent pneumonia

• sometimes contraindications- if having tonsilectomy or craniotomy

• early ambulaiton

-tubing, drains, monitoring devices, or special equipment

• incentive spirometer- to prevent infection in lungs (pneumonia)

  • alveoli collapse during

• PCA pump- patient controlled analgesic: patient has button to give themself dose of medication for bolus also have basal rate always going

  • have CO2 monitor on to ensure they do not give themself too much

-surgery specific info

• ie. Knee replacement- use walker, do not bend knee entirely, etc.

• ie. Open heart surgery- wake up in ICU, pain, breathing tube

-NPO guidelines

• 8-6-2- can have regular meals 8 hours before surgery, light meals 6 hours before surgery, and clear liquids 2 hours before surgery

-ambulatory surgery info- anything to help decrease patient anxiety, where/when to show up, necessary preparation

Pre-Op Informed Consent

-surgeon responsbility to obtain

• nurse can sign as a witness to verify patient has informed consent and understanding

• advocate for patient. If they do not understand education

-nurses: witness signature, verify patient understanding, advocate for patient

-requirements

• adequate disclosure- should know a lot about the procedure- diagnosis, risks to have/not have, sucessful/unsuccessful outcomes, other options,

• understanding/comprehension- msut be done free of sedatives

• cannot be persuasive or cooerced; given voluntarily

  • if <18, unconcious, consent given by parent/legal gaurdian or next of kin

-can be true medical emergency that overrides informed consent- to retain life or limb

Pre-Op Surgery Day Prep

-complete checklist and documentation to ensure everything is complete before transfer to OR

• informed consent must be taken with them in the chart (paper or online )

• confirm patient, site,

• may take glasses or hear aids to OR depending on hospital

• SBAR transport to OR and help ensure family ahs somewhere to go

Steps:

• Complete final pre-op teaching, verify understanding

• Review and complete pre-op orders, checklist, and documentation

• Verify informed consent is signed and included in chart

• Confirm correct patient, procedure, and surgical site marking

• Obtain baseline VS

• Ensure proper skin preparation

• Ensure patient is wearing appropriate surgical attire

• Remove jewelry, dentures, protheses, glasses/contacts, and nail polish/artificial nails as indicated

• Apply allergy identification if applicable

• Encourage patient to void before transport

• Handoff and Transport to OR

• Family and Caregiver support

Pre-Op Medications

-send down with chart, given 60 minutes before surgical incision

-scopalimine patches- behind the ear, given to patients at higher risk for n/v

Class	Drug	Purpose
Antibiotics	Cefazolin	Prevent post-op infection
Anticholinergics	Atropine glycopyrrolate Scopolamine	Dec oral and resp secretions Dec vagal activation Prevent N/V Provide sedation
Antihyperglycemics	Insulin	Stabilize BG
Antiemetics	Ondansetron (Zofran)	Prevent N/V
Benzodiazepines	Diazepam Lorazepam Midazolam	Dec anxiety, induce sedation, amnesic effects
B-Blockers	Labetolol	Manage HTN
Histamin (H2)-receptor antagonists	Famotidine	Dec HCl acid secretion, inc pH, dec gastric volume
Opioids	Fentanyl Morphine	Relieve pain during preoperative procedures

Post-Op Care

-phase 1 PACU- stabilize patient, manage immediate risks (airway obstruction, hypoxia, bleeding, hemodynamic instability)

• immediate post-anesthesia period, ECG/continuous moitoring

• most likely to have Resp/Cardiac decomp in this phase

• Prioirty- airway patency and respiration

• goal- prep for Phase 2, inpatient unit, or ICU

-phase 2- look at ambulation, apin control, discharge from PACU

• Po opioid, no excessive drainage, PO fluids start, have voided if going to extended unit (sometimes leave before voiding and call if ont done in 8 hours- if low worry of area)

• be able to ambulate

• fast tracking- bypass phase 1

• goal- prep for extended observation, home, or extended care

-extended care/observation- combined phase 1/2

• used at a lot of small hospitals; stay in same place through each one

• different criteria in different hospitals- Aldredi/PADSS scoring systems to leave phase 1 (return to baselines (LOC, hemodynamically stable (HR/RR close to baseline), minimal surgical site drainage, pain managed/planned

-blneded levels of care- various levels of carein the same place

PACU Post-Op Assessment Pt 1

-1st check is airway patency to ensure it is open

• assessed often; airway patency and artificial airway

• stridor, laningual edema, laningual spasm- monitor airway/breathing ot identify signs of hypoxemia ot intervene whats causing it

-Breathing

• RR and quality- hypoventilation

• breath sounds- encourage cough and deep breathing when awoken

• supplemental oxygen

• pulse Ox and capnography

-circulation

• BP early and often

• ECG moinitoring

• peripheral pulses

• capillary refill

• skin color and termpature

• bleeding signs- decreased BP and increased HR

• cardiac tamponade, PE, dysrhythmias

• HTN (treat underlying cause before with medications such as labetolol), anxiety, bladder distension (palpate, scan), pain

PACU Post-Op Assessment Pt 2

-neurologic

• LOC/ Glasgow Coma Scale

• Orientation- ask questions

• Sensory and motor status

• Pupil size, equality and reaction

• report ability to move extremities, assymetircal findings to providor

• remember hearing is one of first senses to return- can often hear what is being said

  • can hear when reorienting them; do it even when do not look like they aren’t awake

• spinal/epidural- may have impaired sensorineural deficits

  • assess slow return; return should be distal to proximal (toes to thigh)

-Fluid Balance

• Intake (IV fluids)- review intake intraoperatively

• Output (urine and NG)

• Estimated blood loss (EBL)

• bladder scan >600 → straight cath

• blood/fluid loss signs- tachy, hypotension, pallor, restlessness

PACU Post-Op Assessments Pt 3

-GI

• ausc bowel sounds, assess abdominal distension

• n/v- treat nausea with zofran before becomes vomitting (common from anesthesia side effect)

• NG tube- follow orders, I/Os, color of fluid (normal is green)

-Surgical Site

• assess REEDA for dressing- clean,dry intact, vs blood, can have small amounts of blood, watch for hemorrhage risk

Pain- early and often assessment/treatments

• expect incisional pain but other pain could be complications and is not expected

• ie. Headache from GI surgery- HTN crisis?

Laboratory/Diagnostic tests

• could have serial labs or H&H to ensure no bleeding or electrolyte, complicaitons

• review results of ordered exams

Clinical Unit Post-Op Care

-time of return- when assessing patient after they come back from PACU-> not always stable after leaving

-ABC’s- highest priority is airway patency

-VS and LOC (neuro status)- watch trends from baseline and PACU to now

-pain- past meds, PCA bolus numbers?, PO/IV, n/v

• educate patients to ask for pain meds before in lots of pain, can splint incision with pillow/balnket when needing to cough or turn

-wound/drain- REEDA- intact w/o excessive output

-dressings

-n/v management

-urine output- if not voiding do bladder scan after 4-6 hours if >600 straight Cath with an order

-safety- 2 bedrails up, bed in lowest position, call bell in place (can use), fall alarm if high fall risk- socks, blanket, wrist band

-psychological status/family supports

-post-op orders- diet orders, laxatives, SCD (risk for DVT/PE), incentive spirometer (risk for pneumonia), T/R, IV fluids if NPO, I/Os

Common Potential Post-Op Complications

Neuropsychological

• delerium, fever, hypothermia, pain, post-op dysfunction

-GI

• delayed gastric emptying, dissension/flatulence, hiccups, n/v, post-op ileus

-GU- urinary retention

-urinary

• infection, retention

-respiratory

• actelectasis, hypoxemia

-CV-

• dysrhymias, hemorrhage, HTN, superficial thrombophlebitis, venous thromboembolism (DVT, PE)

-integumentary

• dehiscence, hematoma, infection

-fluid and electrolytes

• acid-base disorders, electrolyte imbalances, fluid deficit, fluid overload

-wound- infection, dehiscence

Preventing Potential Post-Op Complications

-respiratory- atelectasis

• Position changes

• Incentive spirometer

• Turn, Cough, and Deep breathing

• Early ambulation

-CV

• Oxygen therapy and fluids for hypotension

• Remove cause of hypertension

• Early ambulation, SCD’s, and antiplatelet/anticoagulation medication

-Neurological

• assess oxygenation first

• promote orientation

-Pain

• multimodal approach

• complementary therapies

-Temperature

• oxygen therapy

• passive/active warming

-GI

• manage n/v

• bowel protocols

• early ambulation

-GU

• techniques to encourage voiding

• straight catheterization

-Wound

• dressing changes

Discharge Teaching

-ambulatory surgery

• Provided to patient and caregiver

• Specific to type of surgery and anesthesia used; should have full sensation before discharge

• Care of incision(s) and dressings

• Symptoms that should be reported

• s/s of infection- redness, warmth, swelling, drainage, green, foul smelling, lots

• Where and when to return for follow-up care

• Hygiene and showering recommendations

• Activities allowed/prohibited, resuming activities

• Diet restriction/modifications

-reasons to seek help after discharge

• Answers to questions

• Unrelieved pain, inc incisional pain

• Questions about medications

• Wound drainage and/or bleeding

• Increased drainage from a drainage device

• Fever > 100.4°F

Inflammation and Infection

-inflammation- sequential reaction to cell injury (infection and/or heat, radiation, trauma, chemicals, allergens, autoimmune reaction)

• inflammation always there with infection but infection not always having inflammation (inflammation normal part of healing but can look like infection)

• inflammation signs: serous drainage, erythema at site, temperature at site, normal healing response

Types of inflammation

• acute- healing within 2-3 weeks of intension; no residual damage; ex. anaphylacis, burns, appendicitis, allergic reaction

• subacute- acute but lasts slightly longer; weeks to months

• chronic- weeks to months to years

  • Injurious agent continues to persist with repeated injury and inflammation to tissue

  • ex. asthma, COPD, cirrhosis, diverticultuus, RA, TB, most autoimmune dx

infection- invasion of tissues or cells by microorganisms (bacteria, fungi, viruses)

• signs- purulent drainage (from dead WBC and bacteria), erythema more intense and in streaks, fever, elevated WBC

Wound Healing

-last stage in inflammatory response

-tissue regeneration- replacement of lost cells and tissues with cells of same type; depends on cell type

• some tissues regenerate rapidly but some regenerate slowly

• some do not regenerate at all and must go through tissue repair

• labile cells- constantly divding -ex. Skin, bone marrow, mucous membranes, lymphoid tissue (spleen, tonsils)

• stable cells- regenerate when injured; slower regeneration -ex. Pancreas, liver, kidney, bone

-Tissue repair- replacement with connective tissue

• most common and more complex

• occurs by primary, seconday or teritary intention

• permanent cells- do not divide; heal with scar tissue  -ex. muscles, neurons (replaced with glial cells- support and protect but do not help in nerve pulses; allow some neuroplasticity), cardiac muscle

Wound Healing: Tissue Repair

-primary- wounds from surgical incisions

• simple- straight incision, neat, approximated edges

• not trauma usually unless straight line with like clean edges

• could take days to months to heal; least scarring

• heal in initial -> granulation -> scar contracture phases

  • inital- 3-5 days; approximation of edges; migration of epithelial cells; clot meshwork for capillary growth

  • gramulation- 5d-4wks; migration of fibroblasts; collagen secretion; wound fragility; capillary bud abundance

  • scar contracture- 7d-months; remodel of collagen; scar strengthens

• ie appendectomy incision

-secondary- wounds from trauma, ulceration, infection; large tissue loss

• edges cannot be approximated

• can be debris, which may need cleaned before healing can take place

• greater defect with this; more scar formation

• granulation tissue prominent

-tertiary- large contaminated wounds left open to allow for graulation or infection control

• leave larger, deeper scar with large initial opening that closes later

Clean vs Contaminated Wounds

-clean wounds

• primary intention usually; cleansing

• clean them by removing debris/bacteria, excess drainage- blood or serous

• close with closure device- suture, staples, steri strips, skin glue

• dressing to keep wound moist- supports cell growth and reduces tissue damage

• protect from trauma, friction, further injury

-Contaminated wounds

• secondary or tertiary usually

• higher infection risk bc of debris, microorganisms, dead cells

• want to first convert to clean wound by cleaning and irrigating

• debridemenet- get rid of necroic tissue so that wound can heal

• absorptive dressing

• hydrocolloid- inclusive dressing that maintains moisture and helps with autolytic (self) debridement

Granulation Tissue

-needed in all wound healing, primarily seen in secondary intention wounds

-healthy tissue that fills in tissue that was lost from wound

-granulation tissue- formation of vascular and connective tissue

-picture B on slide 9- cobblestone looking red appearance (not shiny)

Delayed Wound Healing Factors!!!!!!!

-advanced age- decreased circulation and slower collagen production

-anemia- decreased oxygenation

-corticosteroids- can decrease granulation tissue, suppress inflammation, and delay healing

-diabetics- poor circulation, weaker immune system, elevated blood glucose -> infection risk

-inadequate blood supply/poor circulation

-infection

-friction/shear- damage good tissue that has formed

-poor nutrition- decreased vitamins, zinc, and protein that help with tissue repair and collagen formation

-obese- more adipose tissue that has poorer blood supply, less oxygen and less nutrient delivery to a wound

-compromised immune system- increased risk for infection, delayed wound healing

-smoking decreases oxygen delivery

Wound Healing Complications

-infection signs- purulent drainage, VS changes- tachy, decreased BP, increased temp; swelling, increased WBC, pain

• surgical wounds- show signs within 4-5 days post-op

• contaminated wounds- show signs within 2-3 days

-dehiscence (top left)- partial or complete separation of wound edges

• increase risk- those with infection, obesity, poor nutrition, excess strain (for bowel movements), weak granulation tissue from secondary/tertiary, slight separation is concerning

-evisceration- when internal organs protrude through wound opening; medical emergency

• with occurance- cover area with sterile, saline soaked gauze, place patient in position not causing more strain on the area, notify provider immediately

-fistula- abnormal tube like connection b/t two organs or b/t an organ and the skin

• result from poor wound healing, infeciton, inflammation

-keloid (top right)- excessive scar tissue formation beyond wound

-contraction- formed after burns; common on joints

-adhesion- bands of scar tissue; band tissues together; more common after abdominal or pelvic surgery

• can cause pain or bowel obstruction

-hypertrophic scars- excessive collagen production; raised scar stays within wound border

-excess granulation tissue (bottom right)- when graulation tissue grow above wound surface which delay epithelization and closure

Pressure Injuries

-primary nursing responsibility

• assess wounds and manage wound care (thorough skin assessment with admission, transfer, and routinely in hospital)

• identify patients at risk

• Implementation of pressure ulcer prevention strategies

  • T/R- reposition

  • nutrition

  • moisture management

  • pressure redistribution

  • reduce friction/sheer

Pressure Injury Prevention

-assessment

-nutrition

• encourage eating adequate amounts

• Vit C, protein, zinc

• if NPO- enteral, parenteral (IV, TPN)

-mobility- do early; up to chair, early ambulation, walking in hallways

-reduce friction and shear

• use transfer device to limit; pad, draw sheet, transfer device

-reduce pressure

-reduce moisture- moisture barrier

• change linens, dry with naths, powder in skin folds

Pressure Injury Risk Factors

-advanced age

-anemia

-cognitive impairment

-ciricitcally ill, in critical setting

-diabetes

-fever

-friction

-hip fracture

-immobility

-incontinence, extensive surgical procedure

-low diastolic BP <60mmHg

-major trauma

-malnourishment

-MS prblems

-neurologic disorders

-PVD

-spinal cord injury

Braden Scale

-used for predicting pressure sore risks

• scores <18 is at risk for pressure ulcers

• less than 12 generally high risk

-help with: heels up, OOB, early/drinking

Pressure Injuries

-stage 1 and 2- partial thickness injuries

• 1- non blanchable erythema with intect skin; often over bony prominence; sometimes changes in sensation, temp, firmness preceding visual changes

• 2- some exposed dermis; blister; wound bed viable, pink/red and moist; no slough or granulation tissue

-stage 3 and 4- full thickness

• 3- subcutanrous fat may be visible; graulation and rolled owund edges often; slough/eschar sometimes; undermining and tunneling sometimes present

• 4- full thickness and tissue loss; involves muscle, tendon, ligament, cartilage, or bone; sometimes slough/eschar; often undermining and tunneling

-stages 2-3 are considered contaminated and colonized with bacteria

-unstagable- depth cannot be determined

Wound Assessment

-location, type measurement

-REEDA

-wound bed tissue, odor

-wound margins

-lab tests

-characeristics of wound drainage

-drains- assessment; serous, serous sanginous, sanginous

• odor, amount, consistency, trends important

• note significant changes

-surrounding tissue

-wound closures

-s/s of infection and associated sx (pain, loss of function, etc.)

Assessment of Patients with Dark Skin

-look for darker tone

-use natural light

-assess skin for temperature, pain, itchy, boggy tissue

• boggy- phsyical texture difference where tissue is soft, spongy, mushy, or squishy to the touch

Wound Management

-purpose

• proctect clean wound to promote normal healing

• cleaning a wound to remove dirt and debris

• prevent and treat infection

-dressings

• do not need to know all types (many)

• dressing used for protection, hemostasis, absorption and debridement

  • wounds need moisture to heal

  • if granulating or rempithelization- want moisture to help induce healing

  • protect from trauma so granulation tissue is not damaged

Pressure Injury Management

-documentation

• PUSH tool (pressure ulcer scale for healing- manages pressure progress and healing of injuries)

• pictures into EHR

-resdistributing pressure- off redness/injury

-clean with saline only

-cover wounds with proper dressing

Dressing Changes

-assess need for analgesic and administer beforehand

-cleanse with noncytotoxic solution: saline

-change or repinforce when wet/per order

• when wet, soiled, needs

Wound Management

-types of debridement

• autolytic- natural with possible topical treatments; wound debrides itself

• biologic (larval therapy)- use living organisms (maggots)

• conservative sharp- scapal or sharp tool to debride

• enzymatic/chemical- topical drug to dissolve necrosis or tissue

• mechanical- wet to dry dressing; wound irrigation with certain PSI

• surgical- done in OR

-negative pressure wound therapy- use wound vaccum; mechanism not fully understood; pulls excess fluid away and reduces bacterial load of a wound

-hyperbaric oxygen therapy

-psychological implications- can be hard to cope with and look at; distressing

Multidisciplinary Interventions

-drug therapy

• antibiotics- infection control

• corticosteroids- help with healing

• anti-inflammatory and antipyretic agents- help with fever

  • ensure adequate hydration and removal of wet clothing

  • can use cooling blankets, coldpacks, skin/oral care

-dietary consult- monitor/assess nutrition status, start parental therapy if NPO (TPN)

• ensure adequate protein, Vitamin C zinc intake

• important to know how many calories need with wound 30-35 calories/kg/day; protein 1.25-1.5 g/kg/day (nearly double normal)

• encourage eating of meat, eggs, dairy, and leafy greens so protein and vitamins are gotten

-infection control- educate on handwashing and universal precautions

-WOCN consult- involved in care to ensure needs are met with adequate dressing change orders; helpful with pressure injuries

-RICE- rest, ice, compression, elevation of wounds

• -rest gives body time to get oxygen, nutrients and time to heal

• ice during initial trauma to decrease swelling and congestion in wound

• compression decreases swelling and congestion around wound

• elevation above heart to decrease swelling

Wound Care Evaluation

-record and report both implementation and progress towards expected outcomes

• want healing of pressure injury or intact skin with no further breakdown

-patient education

• regarding infection prevention and readiness for discharge if ready to care for wound themself

• Need family to get education too?

-readiness for discharge

Patient Teaching

-dressing changes- how to or have someone who can after discharge

• perform hand hygiene beforehand to prevent infection

• remind of antibiotic rules- finish everything, SE- common and severe, drug/food interactions

• review abnormal healing- contraction, adhesion, secondary infection and when to notify provider

-psychological health- encourage adequate sleep and minimize stress to quicken healing

• sleep

• stress

-nutrition

-observing wound

• infection

• abnormal wound healing

• healing can take 4-6 weeks

Wound and NGT Skills

-REEDA to assess surgical incision

• redness

• edema

• ecchymosis

• discharge

• approximation

-COCA for drainage assessment

• color

• odor

• consistency

• amount

-Wound Measurement

1. length- head to toe

2. width- side to side

3. clock method for tunneling/undermining

-Drainage Types

• serous- clear watery

• serossanguineous- pink watery

• sanguineous- bloody

• purulent- thick drainage with infection