Adults 1 - Exam 1

Operative phases

• Preoperative: Decision for surgery is made, transfer patient to OR bed

• Operative: in OR bed, admission to PACU

• Postoperative: in PACU, post-surgery in clinic or home

Surgical classification

• Emergent – requires immediate action, can’t be delayed; severe bleeding, bladder or intestinal obstruction, fractured skull, gunshot, stab wounds, burns​

• Urgent – requires prompt attention, 24-36 hours; closed fractures, infected wounds, ELAP​

• Required – needs to have surgery, weeks-months; BPH, thyroid, cataracts​

• Elective – should have surgery, not catastrophic; repair of scars, hernia, vaginal repair, cosmetic surgery

• Can be a combination – i.e. lumpectomy with breast augmentation​​

​

Preoperative management/elements

Goal: prevent complications, promote healing, and return to healthy state

• Pre-admission testing​

  • Admission data (health history, demographics)​

  • Forms (consent)​

  • Diagnostic testing (labs)​

• Admission​

  • Identify patient​

  • Verify consent​

  • Review lab data​

  • Conduct baseline assessment​

  • Insert peripheral IV​

• What should the patient expect?​

  • Understanding of pre-operative prep​

  • Beginning of discharge planning​

Surgical risk factors

• Age – very young and very old​

• Nutrition – obesity and malnutrition​

• Fluid and electrolytes – dehydration/hypovolemia increase surg risk d/t imbalances of calcium, mag, K, phos​

• Cardiac conditions – angina, MI, HTN, HF; little risk if well controlled​

• Coag disorders – can lead to severe bleeding, hemorrhage, shock​

• URI and COPD are exacerbated by general anesthesia ​

• Renal disease – impacts lyte balance​

• Diabetes – risk for poor wound healing​

• Liver disease - impairs the liver’s ability to detoxify medications used during surgery to produce prothrombin or to metabolize nutrients for wound healing.​

Gerontologic consideration: post op

• Cardiac and respiratory: low reserves​

• Gastrointestinal: decreased motility​

• Neurological: post-op/ICU delirium​

• Renal and hepatic: depressed organfunction​

• Integumentary: decreased subcutaneousfat, fragile, more susceptible totemperature changes​

Drugs/medications that increasesurgical risk

• Anticoagulants – increase bleeding time​

• Tranquilizers – risk for hypotension​

• Heroin – decreases CNS response​

• Antibiotics – may be incompatible with anesthetics​

• Diuretics – can precipitate lyte imbalance​

• Steroids​

• OTC herbal preparations​

• Vitamin E​

Informed consent

• Who is involved?​

  • Surgeon: ​explains and answers questions; risks, benefits, complications​​

• Nurse: acts as witness and obtains signature​

  • can witness and verify, does not obtain!​

• patient​

• caregiver/family member*​

• Patient must be:​

  • mentally capable​

  • consented prior to sedative medication

    • Psychiatric patients-can refuse treatment unless court states they unable to make decisions for themselves ​

    • Mentally capable: 18+ ​

    • Telephone consent requires 2 nurses​​

Preoperative patient education

• What will recovery look like?​

  • Instructions: verbal, written

  • Devices needed following surgery​

  • Mobility and range-of-motion exercises​

  • SCDs, coughing and deep breathing, incentive spirometry​

    • Deep-breathing, coughing and IS: prevent atelectasis and PNA

    • Sequential compression device: prevent venous stasis of blood and to facilitate venous blood return​

• How will pain be managed?​

  • Some pain is expected and normal​

  • Multi-modal pain management, may include PCA​

• Cognitive coping strategies​

  • Relaxation, distraction, guided imagery​

  • Goal is to relieve anxiety, decrease fear​

• Ensure understanding of surgical interventions

Preoperative checklist​

• Identification bracelet​

• Allergy bracelet​

• Verify NPO and IV status

  • NPO, 6-8 hrs prior to invasive surgery, 3 hours prior to local anesthetic, IV fluids​, IV big enough for blood products if needed

  • I/O: make sure to void prior, enemas (if needed), indwelling catheter​​​

• Appropriate forms completed

  • Informed Consent, Blood, Laboratory, Diagnostic Tests​

  • EKG, CXR, blood type/screen and cross match​​

• Past medical history

  • RF: Bleeding disorders, DM, Heart Disease, OSA, Respiratory infections, liver/ renal disease, Chronic Respiratory disease, HIV​​

• Physical exam​

• Remove make-up, jewelry, dentures, glasses/contacts​

• Identify and mark surgical site​

• Prepare surgical site

  • clean with antiseptic/antibac soap, shave as prescribed​​

• Administer medications (antibiotics, etc.)

  • meds: keep pt in bed, side rails up​​

Immediate pre-op nursing interventions​

• Patient changes into gown, hair covered, mouthinspected, jewelry removed, valuables stored in asecure place​

• Administering pre-anesthetic medication​

  • antibiotics: peak in bloodstream beforeincision​

• Maintaining pre-operative record​

  • complete the pre-op checklist ​

• Transporting patient to presurgical area​

  • pre-op warming to prevent hypothermia ​

• Attending to family needs​

The surgical team

• Patient

  • Patient: culture diversity: certain cultures the head is considered sacred so they should be able to wear their own surgical cap​

    Medications: JW: no blood products​​

• Surgeon​

• Registered nurse first assist (RNFA)​

• CRNA, anesthesiologist

• Nurse​

  • Circulating: patient advocate​

    • Verifies consent, surgical pause, monitors aseptic practice ​

    • Travels through many OR rooms ​

  • Scrub ​

    • Monitors hand hygiene, sterilization field, surgical instructions, medication into field​

    • COUNTING: making sure nothing is left in patient (cotton balls, towels, etc.)​

Surgical asepsis

• Gowns​

  • Sterile in front from chest to the level ofthe sterile field ​

  • Sleeves from 2 inches above elbow tocuff ​

• Sterile drapes​

  • Positioned from front to back ​

• Items​

  • Dropped in from package to preserve sterility

  • Cleanse finger nails and then surgical scrub for 3-6 min and then rinse then go to surgical suite to don sterile gloves​

• Field​

  • 1 foot around sterile field must be maintained​

  • Breached = contaminated ​

  • Prepared as close to time of use ​

Surgical Time-out

A final safety check performed immediately before a procedure (skin incision) to prevent wrong patient, wrong procedure, and wrong site surgery.​

Surgical Sign In and Sign Out

Fill in

Protecting patient from injury

• Patient identification​

• Correct informed consent ​

• Verification of records ​

• Accessibility of blood​

• Allergies ​

  • Latex​

• Physical environment ​

• Safety measures​

  • Grounding equipment, restraints​

• Anxiety​

  • Lights dimmed, music ​

• Patient advocate ​

  • Emotional, physical comfort ​

  • Privacy, comfort, and dignity

Position positioning

• Position dictated by procedure​

• Typically proceeds anesthesia​

• Consider patient comfort​

• Position to not compress or obstruct ​

  • Respirations ​

  • Vascular supply​

  • Nerves​

• Light restraint in case of excitement​

Anesthetic agents

• General anesthesia ​

  • Provides analgesia and amnesia​

  • Induces unconsciousness

  • depresses CNS in effort to provide analgesia, amnesia, and induce unconsciousness​

  • Can be given by IV, inhalation, or both​

  • Propofol: milky and burns in veins, sedation instantly, no gag reflex-so will need intubation, titrate to still breathing, can lead to hypotension​

    Risk: Cardiovascular and respiratory depression​

    SE: nausea - NPO for risk for aspiration​​

• Moderate (conscious) sedation​

  • Blocks patient pain & reduces anxiety ​

  • Used for diagnostic or therapeutic procedures.​

• Regional anesthetic ​

  • Spinal: CSF one time dose ​

  • Epidural: continuous infusion through catheter, epidural space​

  • Peripheral Nerve Block​

• Local anesthetic

Intraoperative complications

• Anesthesia Awareness

• N/V

• Anaphylaxis

• Respiratory complications

• Hypothermia: want to return to baseline w/ warming blankets, warming IV fluids

• Malignant hyperthermia

Anesthesia awareness​

• General anesthesia​

  • should be in complete oblivion​

• Other anesthesia​

  • Feel pressure/pushing, eliminate pain​

• Unintended awareness​

  • Neuromuscular blocks not able to communicate​

  • Increase in BP, HR, and movement​

  • Monitor EEG with brain waves​

Malignant hyperthermia​

• Severe adverse reaction to drugs used in anesthesia

• Temp >40 C​

• Genetic component​

• Presents with markedly elevated temperature, muscle rigidity or spasms, tachycardia, rapid and shallow breathing

  • Rapid shallow breathing → low oxygen, high CO2​​

• Can occur during or shortly after anesthesia​

• Requires immediate treatment with dantrolene

  • only known antidote, is an IV muscle relaxant​​

• If untreated, can lead to rhabdomyolysis, hyperkalemia, organ failure​

Nausea and vomiting​

• Risk factors​

  • female gender​

  • age less then 50​

  • opioid administration​

• Will present with gagging​

  • turn patient to the side ​

  • suction needs to be used​

• Antiemetic administration​

Why is this important to avoid? Vomiting can turn into Bronchial spasm/wheezing can turn into hypoxia: Aspiration pneumonia to develop​

​

Hypothermia

• Defined by core body temperature lower than normal

  • Less than 36.6C/98F​

  • Glucose metabolism is reduced, leads to metabolic acidosis​​

• Risk factors:​

  • Cardiovascular events​

  • SSIs​

  • Bleeding​

  • Delayed arousal from anesthesia​

  • Advanced age​

• Can occur due to OR environment/interventions

  • low temp in OR, infusions of cold fluids, inhalation of cold gases, open body wounds/cavities, decreased muscle activity, medications (vasodilators, phenothiazines, general anesthesia medications)​

  • Can depress neuron activity, decrease cellular oxygen requirements below minimum levels normally required for cell viability; can be used as a protective function during some surgical procedures (certain cardiovascular procedures – carotid endarterectomy and cardiopulmonary bypass)​

• Monitor core temp, urine output, ECG, BP, ABGs, lytes​

• If occurring unintentionally, needs to be minimized/reversed​

  • Temporarily increase OR temperature​

  • Infuse/irrigate with warmed fluids​

  • Replace wet gowns/drapes with dry material​

  • Warm air/thermal blankets in non-operative areas of patient​

Anaphylaxis

• Life-threatening reaction to anesthesia or latex

  • ​Muscle relaxants: 69.2%

  • Latex: 12.1%

  • Antibiotics: 8%

  • Hypnotic: 3.7%

  • Colloids: 2.7%

  • Opioids: 1.4%

  • Other: 2.9%

• Treat with epinephrine​

Respiratory Complications

• Complications include:​

  • Inadequate ventilation: could be caused by respiratory depression, aspiration, positioning; all compromise gas exchange​​

  • Occlusion of the airway: c/b (complicated by) foreign bodies in mouth, spasm of vocal chords, relaxation of tongue, aspiration​​

  • Inadvertent intubation of the esophagus: anatomic variation can make trachea difficult to visualize, result in insertion to esophagus rather than trachea​​

  • Hypoxia: brain damage within minutes

• Monitoring is responsibility of anesthesiologist/CRNA and circulating nurse​

  • Includes frequent peripheral perfusion checks and capnography monitoring​

• Vigilant monitoring of oxygenation status​

  • Peripheral perfusion assessment​

  • Capnography

    • measures end-tidal CO2 = amount of CO2 in exhaled air

    • provides instantaneous information about CO2 production, pulmonary perfusion, and respiratory patterns that detect hypoventilation and apnea​​

Postoperative assessment

• Patient may go to PACU​

• Assess vital signs (HR, BP, RR, O2, temp)​

• LOC​

• skin color and condition​

• dressing location and condition​

• IV fluids​

• Drainage tubes​

• Position​

PACU

Initial handoff — from the anesthesia care team to PACU​

​PACU care is typically divided into two phases. ​

• Phase I emphasizes ensuring the patient's full recovery from anesthesia and return of vital signs to near baseline. ​

• Phase II recovery focuses on preparing patients for hospital discharge, including education regarding the surgeon's postoperative instructions and any prescribed discharge medications.​

Report from OR: what we need to know?

You are receiving your patient from OR, what do you need from anesthesia to take care of your patient

• Name, gender, age ​

• Language barrier​

• Allergies ​

• Medical comorbidities ​

• Surgical procedure performed ​

• OR total time ​

• Anesthesia used/reversal agent ​

• Estimated fluid/blood loss​

• Last set of vitals​

• Surgery complications​

  • Anesthesia ​

  • Surgical ​

• Immediate post-op plan​

  • Pain management​

  • Reversals ​

  • Vent settings ​

• Location of visitors/family​

PACU nursing management

1. report baseline admission

2. ABCs

3. Cardiovascular status

4. Neuro status

5. Incisions/tubes/drains

6. F/E

7. Renal status

8. Pain

9. Transfer

Post-operative: respiratory assessment

• Monitor vital signs​

• Assess airway patency, ensure adequate ventilation​

• Maintain clear airway​

• Coughing​

• Deep breathing​

• Suction secretions as needed​

• Observe chest movement for symmetry, use of accessory muscles​

• Monitor pulse ox, ETCO2 as prescribed​

• Monitor for signs of respiratory distress, atelectasis, pneumonia,pulmonary edema​

Post-operative: respiratory complications

• Hypoxemia​

  • Inadequate concentration of oxygen in arterial blood, due toshallow breathing ​

  • Assessment: restlessness, dyspnea, diaphoresis, tachycardia,HTN, cyanosis, low pulse ox​

  • Monitor, notify, administer O2​

  • Encourage deep breathing and coughing , IS​

  • Turn position and encourage ambulation​

• Atelectasis​

  • 1-2 days, collapsed alveoli, result of not deep breathing, coughing,or immobility​

  • Pneumonia​

  • develop 3-5 days, result of infection, aspiration, or immobility ​

  • Assessment: dyspnea, increased RR, crackles, temp, cough andchest pain​

• Interventions: lung sounds, q2 turning, deep breathing, coughing, IS,chest physiotherapy, postural drainage, fluid, suction​

Postoperative: Cardiovascular Assessment

• Assess circulation

  • ​skin color, peripheral pulses, cap refill, absence of edema, paresthesias​

• Monitor vital signs​

• Monitor for bleeding​

• Monitor for cardiac dysrhythmias​

• Monitor for thrombophlebitis​

• Encourage SCD use/early ambulation​

• Monitor for major complications​

  • Hemorrhage: Loss of large amounts of blood externally or internally in a short amount of time ​​​

  • shock: Loss of circulatory fluid volume, caused by hemorrhage

    • Indicators of Shock: pallor, cool, moist skin, rapid respirations, cyanosis, rapid, weak thready pulse, decreasing pulse pressure, hypotension, oliguria​

    • Interventions: IV fluids, blood

​Thrombophlebitis

• Inflammation of a vein, often accompanied by clot formation​

  • Legs most commonly affected​

• Assessment:​

  • Vein inflammation​

  • Aching/ cramping​

  • Vein feels hard and cord-like​

  • Tender to touch​

  • Elevated temperature​

• Interventions to Prevent:​

  • Monitor for swelling, inflammation, pain, tenderness, venous distension,cyanosis ​

  • Notify surgeon​

  • Elevate 30 degrees with no pressure on popliteal area​

  • Anti-embolism stockings, remove twice a day for washing and to look atlegs, SCD’s

    • Anti embolism stockings, remove at shift change ​​

  • Passive ROM, q2 hours, early ambulation​

  • No dangling legs​

  • Anticoagulants as prescribed

    • heparin, enoxaparin ​​

Postoperative: musculoskeletal assessment

• Movement of extremities ​

• Positioning and restrictions, q2 turning​

• Ambulating progression​

  • Dangle at bedside prior to sitting up ​

• Low-fowlers, unless contraindicated ​

  • Increase size of thorax for lungexpansion​

• Avoid supine until gag reflex returned ​

Postoperative: neurological assessment

• Assess level of consciousness​

• Frequent periodic attempts to wake patient ​

• Orient to environment​

• Speak in soft tone, filter out noises ​

• Maintain body temperature ​

• Prevent heat loss ​

• Warm blankets and room temperature​

• Monitor for signs of hypothermia ​

Postoperative: Integumentary Assessment

• Skin assessment​

  • Surgical site​

  • Drains​

  • Wound dressings​

  • Other areas impacted by surgical positioning​

• Assess for evidence of infection: Fever​, Surgical site/wound

• Other areas – surgical positioning may have affected bony prominences or others​

• Check for redness, abrasions, breakdown​

• Drains should be patent; removed when drainage becomes insignificant; record as I/Os​

• Dressings changed as prescribed, keep dry and intact, note amt of bleeding or drainage, odor, intactness of sutures/staples, color​

Risk factors for Wound healthing

• Age: less resilient tissues​

• Hemorrhage: dead cells lead to infection​

• Hypovolemia/temp: vasoconstriction for blood and nutrients, poor perfusion​

• Local Factors: ​

  • Edema: reduces blood supply​

  • Inadequate dressing technique: too tight or too lose ​

  • Nutritional Deficient: protein ​

  • Oxygen Deficient: lung/ cardio function​

• Medications:​

  • Corticosteroids: impair normal inflammatory response ​

  • Anticoagulants: risk for bleeding/ hemorrhage​​

• Systemic Disorders: shock, acidosis, hypoxia, kidney injury, immunosuppression

• Wound Stressors: vomiting, Valsalva, heavy coughing, straining ​

Wound infection: Assessment and interventions

• Assessment

  • Fever, chills​

  • Warm, tender, painful, inflamed site​

  • Edematous skin and tight sutures​

  • Elevated WBC​

  • REEDA: redness, erythema, ecchymoses, drainage, and approximation ​

• Interventions​

  • Monitor temperature​

  • Monitor incision site suture line​

  • Patency of drainage, assess color, amount and consistency​

  • Maintain asepsis, dressing and wound irrigation ​

  • Wound cultures and sensitivity, blood cultures & sensitivity​

  • Antibiotics ​

• Caused by poor aseptic technique, contaminated wound before surgery, 3-6 days after and purulent conditions​

• Poor client conditions: DM, immunocompromised​

Wound complications (+ interventions)

• Dehiscence​

  • Separation of wound edges at suture line, 6-8 days​

  • Assessment: drainage, opened edges, underlying tissues through wound​

• Evisceration​

  • Protrusion of the internal organs, 6-8 days after​

  • Assessment: serosanguinous fluid from dry wound, loops of bowel through wound, patient states popping sensation after coughing or turning​

  • EMERGENCY!​

• Interventions​

  • Call for help ​

  • Stay with client​

  • Low-fowlers position with knees bent​

  • Cover wound with sterile dressing, normal saline​

  • VS and monitor for shock ​

• Interventions for Evisceration:

  • 1. Call for help; ask that the surgeon be notified and that needed supplies be brought to the client’s room. ​

    2. Stay with the client. ​

    3. While waiting for supplies to arrive, place the client in a low-Fowler’s position with the knees bent. ​

    4. Cover the wound with a sterile normal saline dressing and keep the dressing moist. ​

    5. Take vital signs and monitor the client closely for signs of shock. ​

    6. Prepare the client for surgery as necessary. ​

    7. Document the occurrence, actions taken, and the client’s response. ​

Postoperative; Gastrointestinal assessment ​

• Nausea and vomiting, monitor I/O’s​

  • Side lying position and suction equipment readyand at bedside​

• Patency, placement, and drainage of NG tube​

• Monitor for abdominal distention​

• Monitor for passage of flatus and return of bowel sounds​

• Oral care, every 2 hours​

• Maintain NPO status until gag reflex, peristalsis returns​

• NPO—> Ice chips and water—> clear liquid—> regulardiet, as tolerated​

Postoperative GI complication

• Constipation - abnormal infrequent passage of stool ​

  • Resumes a solid diet post op, and fail to pass stool in 48hours​

  • Assessment ​

    • Absence of bowel movement​

    • Bowel distention​

    • Anorexia, headache, nausea ​

  • Interventions​

    • Assess bowel sounds​

    • Fluid intake up to 3000 mL/day​

    • Early ambulation​

    • Consumption of fiber foods​

    • Privacy and adequate time ​

    • Medications: stool softeners, laxatives ​

• Paralytic ileus - failure of appropriate forward movement ofbowel contents​

  • Result of anesthetic medications or manipulation of bowelduring surgery​

  • Assessment​

    • Vomiting postoperatively​

    • Abdominal distention​

    • Absence of bowel sounds, bowel movement or flatulence ​

    • Interventions​

    • Monitor I/O’s​

    • Maintain NPO until bowel sounds return​

    • Maintain patency of NG tube ​

    • Encourage ambulation​

    • IV fluids or parenteral nutrition​

    • Medications: increase gastric motility and secretions​

    • Try to treat non-operatively with NG tube/bowel rest​​

Postoperative: renal system

• Monitor IV fluid administration​

• Assess for fluid and electrolyteimbalances​

• Record I/Os

  • Output should be at least 30mL/hour​

• Assess urinary system​

• Bladder distension​

• Urine output​

• Foley catheter removal

• No foley present: Void within 6-8 hours, At least 200 mL​​

Postoperative: Renal complications

• What is it?​

  • Involuntary accumulation of urine in the bladder, result of loss of muscle tone, 6-8 hrs post surgery​

  • Caused by effects of anesthetic or opioid analgesic​

• Assessment​

  • Inability to void​

  • Restlessness and diaphoresis ​

  • Lower abdominal pain​

  • Distended bladder​

  • Hypertension​

  • Percussion – sounds like a drum​

• Intervention​

  • Monitor for voiding​

  • Assess by palpation for distention, bladder scan​

  • Ambulation if prescribed​

  • Fluid intake, unless contraindicated ​

  • Assist to void, stand, privacy, warm water​

  • After all noninvasive techniques, notify HCP​

  • Straight catheter, Foley insertion ​

Postop: Pain management

• Review type of anesthetic used, preoperative medications,analgesics in the post-anesthesia period​

• Conduct pain assessment​

  • Patient report and physical exam

  • Type, location, pain level: numerical 1-10, unable to rate the pain use a descriptor scale or faces ​

  • Monitor for objective data related to pain, such as facial expressions, body gestures, increased pulse rate, increased blood pressure, and increased respirations. ​​

• Assess effectiveness of analgesic after 30-60 minutes of admin​

• Monitor RR, BP, HR, O2 sat, LOC​

• Provide patient education on PCA use​

• Multi-modal approach, include non-pharmacological interventions

  • provision of distraction, relaxation techniques, guided imagery, comfort measures, positioning, backrubs, heat or cold therapy, and a quiet and restful environment

• Consider cultural and spiritual practices ​​

Outpatient surgery or direct discharge interventions​

• Discharge assessment​

• Discharge planning​

  • Availability of caregiver​

    • Contact information ​

    • Can’t drive​

• Pharmacy phone​

  • Prescriptions ​

• Follow up care​

  • S/s to be reported​

  • Where and when to go ​

• Care of incision​

• Side effects of medication ​

Body fluids

• A solution (think chemistry!) is a combination of:

  • Solvent: fluid

  • Solutes: particles

• Body fluid is in two fluid compartments:

  • Intracellular space: the fluid within cells • 2/3 of the body fluid is intracellular fluid (ICF)

• Extracellular space: the fluid outside of the cells

  • 1/3 of the body fluid is extracellular fluid (ECF)

  • ECF can located in the intravascular, interstitial, or intracellular fluid spaces

• Body fluid moves between ICF and ECF to maintain equilibrium​

Second spacing: edema

• Excess accumulation of fluid in the interstitial space/body (edema)

  • Localized: traumatic injury, local inflammatory process, or burns

  • Generalized (anasarca): cardiac, renal, liver failure

Third spacing

• Fluid accumulates with membrane-bound spaced in the body

• Examples: Peritoneal cavity (ascites) or Pleural space (pleural effusion)

• Early identification: decreased urine output despite adequate intake

• Also: increased body weight with symptoms of hypovolemia

Regulation of body fluids (pressures)

• Hydrostatic pressure: the pressure exerted on the walls of the blood vessels (out of vessel)

• Osmotic pressure: the pressure exerted by the solutes within the plasma (into vessel, through plasma proteins)

• These forces opposed each other at every capillary membrane and balance each other out in healthy conditions

Fluid replacement

• Replacing a deficit of fluid in the body will be determined by what type of fluid was lost

  • Colloids: a fluid consisting of a nonsoluble substance distributed within a solvent

    • Blood loss can be replaced with colloids; or treat low protein and large fluid shifts

    • Examples: whole blood, albumin, dextran

  • Fluid loss from hypovolemia can be replaced with crystalloids

    • Examples: normal saline (NaCl 0.9%); half normal saline (NaCl

Tonicity

• Tonicity: the ability of solutes to cause an osmotic driving force that promotes water movement from one compartment to another

  • How the solution affects the movement of water into or out of cells

  • How strong a solution is at pulling water across a cell membrane.

• Tonicity of IV Solutions

  • Isotonic solution: Has the same number of particles as inside the cell → water movement is balanced.

  • Hypotonic solution: Has fewer particles than inside the cell → water moves into the cell → cell becomes swollen

  • Hypertonic solution: Has more particles than inside the cell → water moves out of the cell → cell becomes small

Hypovolemia (what/causes)

• Fluid volume deficit (FVD) occurs when a loss of ECF volume exceeds the intake of fluid

  • Dehydration is FVD from just water loss; there are other types

• Causes: Vomiting, diarrhea, GI suctioning, third-space shifts, Hemorrhage, Homeostatic mechanisms such as ADH disorder

Hypovolemia (FVD) (lab findings + assessment)

• Labs: Everything increases due to a lack of water

  • Increased BUN and Cr levels

  • Increased serum osmolality

  • Increased hematocrit

  • Changes in electrolytes, including an increased serum sodium level

  • Increased urine specific gravity

• Assessment (decrease in almost everything)

  • Weak, thready pulse, diminished

  • Decreased BP, ortho hypotension

  • Flat neck veins

  • Decreased RR, dyspnea

  • Decreased U/O

  • Decreased skin turgor, dry

Hypovolemia (FVD): management/treatment

• IF LOSS IS SEVERE OR IF PATIENT IS UNABLE TO DRINK, PROVIDE IV fluids (isotonic)

• MEDICAL TREATMENT AS INDICATED TO PREVENT further losses

• Monitor I and Os (hourly output)

• Monitor electrolyte levels

• Identify the cause and expected additional losses

• Monitor vital signs (BP going up, HR going down), LOC, Lung sounds

• Monitor for improvement or other symptoms

Hypervolemia (what, causes)

• Fluid volume excess (FVE) occurs from an expansion of ECF volume due to abnormal retention of sodium and water

• Causes: Increase in sodium content (typically), Excessive fluids or excess intake of sodium, Conditions: heart failure, kidney dysfunction, cirrhosis of the liver

Hypervolemia (FVE): labs and assessment

• Labs: everything deceases, too much water to particle

  • Decreased BUN level

  • Decreased serum osmolality

  • Decreased hematocrit

  • Decreased serum sodium level

  • Decreased urine specific

• Assessment: increase in findings

  • Bounding, increased pulse

  • Elevated blood pressure

  • Distended neck veins; JVD

  • Increased RR, crackles, SOB

  • Altered LOC

  • Pitting edema, pale cool skin

  • Possible increased UO, decreased if kidney damage

  • Liver enlargement, ascites

Hypervolemia (FVE): management/treatment

• Prevent further overload, restrict fluid and sodium intake

• medical tx as indicated to increase UO: Diuretics

• Monitor I and Os: daily weight

• Monitor electrolyte levels

• Identify cause: Need to know to prevent worsening

• Monitor vital signs, LOC, lung sounds

• Monitor for improvement or other symptoms

• Prepare for dialysis if indicated, kidney failure/disease

What is sodium?

• Most abundant electrolyte in ECF

• Primary determinant of ECF volume and osmolality

• Major role in water distribution control (water follows sodium)

• Regulated by ADH, thirst, and reninangiotensin-aldosterone system (RASS)

• Usually, a loss of salt leads to a loss of water

  • Salt gain leads to water gain!!

• Provides the electrochemical state needed for muscle contraction and nerve impulses

Hyponatremia

• Low sodium levels: Definition: Na+ less than 135 mEq/L

• Can be acute or chronic

  • Acute causes: fluid volume overload leads to a water imbalance; results in dilutional hyponatremia. Also, certain medications, hormone imbalances

  • Chronic cases: usually seen in outpatient setting; less serious

• Exercise induced: due to extreme temperatures, excess loss of sodium through perspiration

Symptoms of hyponatermia

SALT LOSS

• Stupor/coma/confusion

• Anorexia

• Lethargy

• Tendon reflex decreases

• Limp muscles

• Ortho hypoTN

• Seizure/HA

• Stomach cramps

• Others: irritability, difficulty concentrating, NV, S+S of FVE fluid overload, Cerebral swelling

Management of Hyponatremia

• First identify the cause:

  • H&P (hx and physical) focused neurological exam, identify s/s, review lab results, current med list, IV infusion

• Treating the underlying condition will bring the sodium levels back to normal

• Water restriction! - less water = higher sodium conc.

• Replace sodium, if needed

  • Sodium replacement PO, if able

  • Hypertonic IV if needed

    • Cannot replace faster than 12 mEq/L per 24 hours

• Medication adjustments

• Close monitoring of fluid balance: Daily weights, I&O, labs, patient safety

Hypernatremia (what, causes)

• High sodium levels: Definition: Na+ more than 145 mEq/L

• From a gain of sodium, retention of more sodium than water

  • The body can usually compensate for increased PO intake

  • HYPERTONIC SOLUTIONS or body lost the ability to be THIRSTY/can not verbalize thirst

  • Cells shrink d/t water being pulled into bloodsteam (out of cells)

• Seen in patients with:

  • Fluid deprivation with loss of thirst; very old; very young

  • Hypertonic solutions: enteral feeding or IV fluid

  • Hormonal imbalances

  • Kidney disease

Hypernatremia: S+S

• Thirst – Changes in mental status, ranging from drowsiness, restlessness, confusion and lethargy to seizures and coma

• Symptoms of fluid volume deficit (FVD): tachycardia, orthostatic hypotension, decreased urine output, thirst, dry mouth

• Na >145 mEq/L

• Neurological Changes

Hypernatremia tx/management

• Gradually lower the sodium with slow infusion of hypotonic or isotonic IV solution • ½ NS (preferred); D5W • Decrease Na+ level at about 1 mEq/L per hour

• Monitor I&O

• Assess for, or manage, the cause

  • Medications, thirst, fever • Monitor for neurologic changes

• Restlessness, disorientation, lethargy

• Restrict sodium intake

How to read tonicity?

• Normal saline: 0.9% NaCl - Isotonic

• If the first number is above 0.9% than it is hypertonic; if it is below, it is hypotonic

• 5% Dextros + water is isotonic

  • Dextros + non-water is usually hypertonic, but as the body metabolizes it, it becomes isotonic

• When/what

  • For burns, use isotonic: never want to shrink or swell cells on the burn patient, but they are probably dehydrated

  • For dehydration, use isotonic

  • Hypertonic could cause crackles in the lungs

  • The best way to monitor is I&Os and daily weight (do at consistant time)

Osteoarthritis (what, RF, S+S, Assessment, Management)

• What: Breakdown of the articular cartilage leading to damage of the underlying bone

  • Osteophytes form in joint space, narrowing space for movement, leading to progressive degeneration

• Risk factors: older age, female gender, obesity, labor-intensive occupations, sports activities

• Manifestations

  • Pain, hard and bony

  • Stiffness

  • Functional impairment

  • Aggravated by movement

  • Relieved by rest

  • If morning stiffness is present, it is brief (~30 minutes)

  • Most often impacts weight-bearing joints – hips, knees, cervical spine, lumbar spine

  • Bony growths: Heberden: distal, Bouchard: proximal

• Assessment:

  • Crepitus over the joint

  • Mild joint effusion due to inflammation

  • No systemic manifestations

  • If already diagnosed, blood tests and exam of joint fluid are not necessary

  • On x-ray: decreased joint space and osteophyte formation, subchondral (under joint) bones may appear thickened

• Management

  • Decrease pain and stiffness (symptom management)

  • Maintain/improve joint motility

  • Exercise: preserve joint, warm pack: pre-exercise, Ice pack: post-exercise

  • Weight loss

  • OT/PT → show what exercises to do

  • Orthotic devices and walking aids

  • Complementary therapies (massages/breathing)

  • Medication: NSAIDs (not always for older adults), steroids

  • Severe OA may require total arthroplasty

Arthroplasty

• Replacing a joint surgical with an artificial joint

• Common joints are hip and knee

• Indicated for extensive damage, pain, or severely limited function as a result of osteoarthritis, osteonecrosis, RA, or congenital malformation

• Nursing interventions: required surgery for quality of life, referred to as elective in practice

  • Positioning

  • Incision care

  • Pain management

  • Early ambulation

  • Patient education

  • Monitor for post-op complications

    • DVT, PE, shock, infection, PNA, dislocation

Osteoporosis (what, RF, S+S, assessment, prevention, management, Nursing intervention)

• Low quantity: Bone resorption (clast) > bone formation (blast) = thinning

• Can lead to compression fractures in the thoracic and lumbar spine, and fractures in the hips and wrist

• Age-related loss begins after the peak bone mass is achieved

• Risk factors: small frame, female gender, ethnicity, aromatase inhibitor use (low estrogen), nutritional factors, some autoimmune diseases, steroid use, immobility, diabetes • Onset in men is about a decade later than in women

  • opposite of OA - affects thin people

• S+S: Low bone mineral density on Dual-energy x-ray absorptiometry (DEXA) scan, Rounding of upper back, Dowagers hump, Osteoporotic fracture, Otherwise, asymptomatic

• Assessment: X-ray will show radiolucency if there has been significant demineralization, otherwise not detectable. Dual-energy x-ray absorptiometry (DEXA) scan provides BMD of the spine and hips, reported as T-scores

• Prevention:

  • Balanced diet high in calcium and vitamin D

  • Use of calcium supplements to ensure adequate calcium intake

  • Regular weight-bearing exercises: 20 to 30 minutes a day

  • Weight training

• Management:

  • Pharmacological therapy to improve bone density

  • Fractures of the hip are managed with replacement

  • The compression fraction of the spine may be managed conservatively

• Nursing intervention: Promote understanding of disease and treatment

  • Manage complications: Pain relief, improved bowel elimination, injury prevention

Osteomalacia (what, assessment, management)

• Inadequate mineralization of the bone caused by a deficiency in activated vitamin D

  • Quality of bone is poor, rather than a lack of quantity

• Results in softened and weakened bones

• Assessment:

  • X-ray will show generalized demineralization of the bone and can show a compression fracture

  • Lab studies: low calcium, low phosphorus, and moderately elevated alkaline phosphatase - helps bone growth (body overcompensating)

  • Bone biopsy will show increased osteoid, which is a demineralized, cartilaginous bone matrix, aka “pre-bone”

    • starts making bone but does not harden = pre-bone

• Management:

  • If possible, the underlying cause should be treated • Supplemental calcium and vitamin D

  • Exposure to sunlight

  • If the cause is kidney disease, activated form of vitamin D (calcitriol) is prescribed

  • If the cause is dietary, the changes recommended are the same as those for osteoporosis

  • Orthopedic deformities may need braces or surgery

Pagets disease (what, why, S+S, assessment, management)

• Primary proliferation of osteoclasts followed by compensatory increase in osteoblasts, osteoblasts trying to compenstate

• Leads to pathologic fractures • Structural bowing of the legs

• Most commonly affects skull, femur, tibia, pelvic bones, and vertebrae

• Idiopathic - no understanding of why

• S+S

  • Often asymptomatic

  • Femur and tibia tend to bow

  • Spine is bent forward and rigid

  • Bone may be tender and warm to palpation

  • Pain described as mild to moderate, deep, achy, increased with weight bearing

• Assessment:

  • increases alkaline phosphatase

  • Normal calcium levels (different from osteomalacia)

  • Demineralization and bone overgrowth in a characteristic mosaic pattern on X-ray

  • Diagnosed with x-ray/bone scan/bone biopsy may be indicated

• Managment

  • NSAIDs

  • Calcium w/ Vitamin D

  • Biophosphonates (alendronate)

Alendronate (fosamax)

• Action: slows the activity of osteoclasts

• Use: Osteoporosis and Paget’s disease

• Complications: GI upset (N/V), pill-induced esophagitis

• Nursing interventions: monitor serum calcium levels (normal: 9-11mg/dL)

• Education:

  • Full glass of water on an empty stomach

  • Sit up for 30 mins after administration

  • Weight-bearing exercise

  • Calcium + vitamin D

Osteomyelitis (what, types, cause, assessment, management, nursing interventions)

• Infection of the bone resulting in inflammation,,necrosis, and now bone formation

• 3 classifications:

  • Hematogenous: blood borne

  • Contiguous-focus: surgery

  • Vascular insufficiency: diabetes, PVD

• >50% are caused by S. aureus, increasingly MRSA • Can extend to adjacent soft tissues and joints

• The bone abscess forms if not treated promptly (chronic osteomyelitis)

• Assessment:

  • Acute:

    • X-ray, bone scan, MRI

    • Leukocytosis, elevated ESR

    • Only 50% of wounds cultured are positive

  • Chronic:

    • X-ray, bone scan

    • ESR and WBC are normal (body adapting), possible anemia

• Management:

  • Primary prevention

    • Delay elective orthopedic surgery if patient has an infection

    • Sterile technique during surgery

    • Prophylactic antibiotics

    • Prompt drain removal

    • Aseptic postoperative wound care

  • Antibiotic therapy

    • Long term

  • Debridement - the removal of dead tissue

    • Sloth - yellow dead tissue

    • Escar - brown dead tissue

• Nursing interventions

  • 1. pain relief

  • 2. improve physical mobility

  • 3. control infectious process

  • 4. promote home, community-based, and transitional care (visiting nurse)

Osteomyelitis - Clinical manifestations for each type

1. Hematogenous: sudden onset, septic symptoms

2. Contiguous-focus: no septic-like picture; surface overlying bone will be swollen, warm, painful to touch (more localized)

3. Chronic osteomyelitis: nonhealing fracture, impaired immune response, a foot ulcer >2cm is highly suspicious for osteomyelitis

Septic Arthritis

• Infection of the joint

• Risk factors: older age, diabetes, RA, skin infection, alcoholism, history of joint surgery, IV drug use

• Overall mortality rate for single joint infection is 11% (d/t comorbities)

• S+S:

  • Warm, painful, swollen joint

  • Decreased ROM

  • Chills, fever, leukocytosis

  • About half of all cases involve the knee joint

• Assessment:

  • infectous work up

  • Aspiration, examination, and culture of synovial fluid (for pathogens)

  • CT/MRI

  • Bone scan

• Management

  • Prompt treatment is vital

  • Broad-spectrum IV antibiotics (6-8 week tx, usually through PICC line)

  • Aspirate synovial fluid periodically

  • Therapeutic aspiration (removing fluid)

  • Splinting

  • Pain relief

  • Progressive ROM exercises

    • Potential for joint fibrosis

  • Assess for recurrence

• Nursing interventions: same as osteomyelitis

  • Pain relief

  • Improve physical mobility

  • Control infectious process

  • Promote home, community-based, and transitional care

Types of soft tissue injury

• Contusion: soft bone (intense bruising)

• Strain: muscle or tendon

• Sprain: ligament or supporting muscle fiber around joint

• Dislocation: articular surfaces of joint

• Subluxation: partial/incomplete dislocation

Management of soft tissue injury

1. RICE: rest, ice, compression, elevation

2. Immobilization

Types of fractures

1. closed/simple - does not break through skin

2. open/compound/complex - breaks though skin

3. intra-articular - involves joint

Manifestations of fracture

• loss of function

• shortening

• edema

• deformity (twisting common in hip)

• crepitus

• ecchymosis (bruise)

Fracture assessment

• Health history, comorbidities

• Pain

• VS, respiratory status (breaking bown can cause fat embolism), LOC, and signs and symptoms of shock (depending on severity)

• Neurovascular assessment of affected extremity

• Bowel and bladder elimination; bowel sounds, I&O (hip fracture)

• Skin condition • Anxiety and coping

Fracture management

• Immediately immobilize

• Wounds with open fractures should be covered; do not attempt to reduce the fracture

• Fracture reduction: realignment of the bone to anatomic position with followed application of immobilization

  • Closed reduction: manual traction

  • Open reduction: surgical approach (urgent surgery)

  • Delayed reduction (wait, for reason)

• Immobilization following reduction

  • External fixation: bandages, cast

  • Internal fixation: plates and screws

Fracture - Nursing interventions

• Elevation

• Monitor for neurovascular compromise (6 Ps)

• Monitor for normal elimination (hip fracture)

• Isometric and muscle setting exercises

• Encourage participation in ADLs

• Pain management

• Patient education

• Wound care for open fractures

RF for poor fracture healing

• usually takes: 3-12 weeks

• Age >40

• bone loss

• tobacco use

• comorbidities (diabetes, usually)

• corticosteriods

• NSAIDs

• Extensive local trauma (more severe = longer to heal)

• Inadequate immobilization (especially after realignment)

• Infection (if open, especially)

• Local malignancy

• Malignancy

• Premature weight bearing

• AVN - avascular necrosis (bone dying d/t lack of blood supply)

Fracture complications

• Acute

  • Shock

  • Fat embolism

  • Compartment syndrome

  • DVT, PE

  • DIC - Disseminated intravascular coagulation

    • Widespread clots, using up all of the clotting factors, leads to hemorrhaging

  • Infection

  • Loss of bladder control (hip fracture)

  • Hemorrhage (particularly with hip fracture)

• Chronic

  • Delayed union (slowed healing)

  • Malunion (healing incorrectly)

  • Nonunion (complete failure to heal)

  • AVN of the bone

  • Complex regional pain syndrome (CRPS)

  • Heterotopic ossification (benign bone growth in atypical location)

Casts, Splints, and Braces - Assessment

• Assess injury and treat any lacerations or wounds

• Assess for neurovascular status (6 Ps)

  • Pain (FIRST)

  • Pulse (lessness) (last)

  • Pallor

  • Parethesia (second)

  • Paraysis (last)

  • Poikilothermia (temp - cold compared to other extermites)

Compartment Syndrome

• Increased pressure within a compartment impairs blood flow and compromises tissue viability

  • Causes: Cast, overexercise, fracture

• Often occurs in the extremities, such as the forearm, lower leg, and thigh

• Assessment:

  • Pain: intense, disproportionate to the injury or condition

  • Pallor: pale skin, reduced capillary refill

  • Pulselessness: diminished or absent pulses distal to the affected compartment

  • Paresthesia: numbness or tingling

  • Poikilothermia (temp - cold compared to other extermites)

  • Paralysis: muscle weakness or loss of function

• Compartment swelling: taut, shiny skin with potential blistering

• 6 Ps, notify immediately if suspected, analgesics, monitor for worsening symptoms

• In severe cases, fasciotomy (surgical decompression) may be necessary to relieve pressure

• DO NOT elevate the extremity higher than heart, should be at heart level, but to prevent compartment syndrome = elevate

Casts, Splints, and Braces - Education

• Impact of injury on ADLs and IADLs

• Physician order for activity, exercise, and rest

• Techniques for cast drying

• Pain management

• Care for minor skin irritation (hair dryer, DO NOT use object)

• Signs and symptoms to report (infection)

• Required follow-up care

• Cast removal and after care

Amputation

• May be congenital or traumatic or caused by conditions such as progressive peripheral vascular disease, infection, malignant tumor, trauma

• Performed to control pain or disease process, improve function, and improve quality of life

• Assessment:

  • Neurovascular and functional status

  • Signs and symptoms of infection

  • Nutritional status

  • Concurrent health problems

  • Psychological status, grief, and coping - especially if not planned

• Nursing interventions

  • pain relief

  • wound care

  • resolving grief and enhancing body image

  • promoting independent self-care

  • Assisting patient to achieve physical mobility

• Complications

  • acute

    • Postoperative hemorrhage

    • Infection

    • Poor wound healing/skin breakdown

  • Chronic

    • Phantom limb pain

    • Joint contracture - joint so stiff it cannot move (prevented by lying in prone position (correct alignment) - multiple times a day for 20-30 mins)

      • If above the knee, avoid sitting for too long, do not use a pillow to support

Types of heart failure

• Left ventricular failure: most common

• Right ventricular failure: often a result of left ventricular failure

• Systolic failure (HFrEF): problem with contraction and ejection

• Diastolic failure (HFpEF): problem with relaxing and filling

Left sided-heart failure

• left side failure = lung symptoms

• S+S:

  • Dyspnea

  • Orthopnea (cannot lay flat - how many pillows do you use?)

  • Paroxysmal Nocturnal Dyspnea

  • Low organ profusion + hypoxia

  • Crackle lungs sounds - alveoli fill with fluid

  • Pink frothy sputum (must identify if it’s lungs or heart)

  • Hypoxemic Ischemic Encephalopathy

    • lack of O2 = Mental symptoms (like dementia)

• Lab: BNP - hormone that release d/t stressed out heart

  • over 400 = heart problem, normal = 100

Right sided Heart failure

• right side of heart fails = rest of body symptoms

• S+S:

  • increased jugular vein pressure

  • Peripheral Venous Congestion

  • Hepatomegaly (enlarged liver)

  • Renal failure, Azotemia (high amounts of waste)

  • Peripheral Edema (dependent parts) - second spacing

  • Acites - 3rd spacing (worse)

• Typically bc left side of heart fails first

Risk factors for heart failure

Older age, cigarette smoking, obesity, poorly managed diabetes (hyperglycemia), Metabolic syndrome (combo of insulin resistance, obesity, increased B), Chronic kidney disease

Systolic heart failure

Heart inability to squeeze, ejection fracture >40% (normal = 55-70%)

HFrEF = heart failure with reduced EF = systolic heart failure

Tend to heart S3 gallop

Diastolic heart failure

The heart's inability to refill/relax in order to refill

• S+S of heart failure with normal EF (55-70%)

HFpEF = heart failure with normal EF = diastolic heart failure

Tend to heart S4 gallop

Diagnosing heart failure

• History and physical assessment

• Comorbidities, ROS and exam findings

• Echocardiogram – EF, ventricle sizes

• Chest x-ray

• EKG

• Labs – cardiac enzymes, BNP

• Stress test

• Cardiac catheterization

Clinical manifestations of: congestion

• congestion (wet lungs)

• Dyspnea, orthopnea, paroxysmal nocturnal dyspnea

• Cough

• Crackles not clearing with cough

• Rapid weight gain (+2 lbs/day, +5 lbs/week)

• Dependent edema

• Abdominal boating

• Ascites

• JVD

• Sleep disturbances

• Fatigue

clinical manifestations of: poor perfusion/low cardiac output

• Decreases exercise intolerance

• Muscle wasting/weight loss (not eating enough)

• weakness

• anorexia, N

• Lightheadedness

• Confusion, AMS (altered metal status)

• Tachycardia at rest

• Oliguria recumbent nocturia

• Cool, vasoconstricted extremities

• Pallor, cyanosis

Congestive heart failure

• Pulmonary congestion occurs due to diastolic failure

• Pulmonary venous blood volume and pressure increases in lungs, forcing fluid into pulmonary tissue and alveoli, causing pulmonary edema and impaired gas exchange

• Clinical manifestations include dyspnea, cough, crackles, low oxygen saturation, “extra” heart sound (S3, “ventricular gallop”) due to abnormal ventricular filling

Management of heart failure

• Identify precipitating risk factors and if possible, eliminate

• Encourage verbalization of how patient is feeling about lifestyle changes necessary for management (might greive old lifestyle)

• Educate patient on medication regimen, may include digoxin, diuretics, ACEI, beta blockers, and vasodilators

• Advise on when to notify provider of medication side effects, OTC medication use, and inability to take medications (do not take NSAIDS)

• Enrollment in a cardiac rehabilitation program (slowly become more active)

• Advise avoidance of large amounts of caffeine and committing to a lowsodium, low-fat, low-cholesterol diet

• Provide list of potassium-rich foods if taking potassium-depleting diuretics

• Educate on fluid restriction if prescribed

• Instruct to balance periods of activity and rest, and avoid isometric activities that can increase pressure on heart

• Instruct to monitor weight daily and report signs of fluid retention (edema, weight gain

Goals of therapy: heart failure

• Improve cardiac function

• Reduce symptoms

• Improve functional status

• Stabilize condition and lower risk of hospitalization

• Delay progression of heart failure and extend life expectancy

• Promote lifestyle that is conducive to cardiac health

Gerontologic considerations: heart failure

• May present with atypical signs/symptoms

  • Fatigue, weakness, and somnolence

• Decreased renal function

  • Resistant to diuretics

  • More sensitive to changes in volume

• Administration of diuretics to older men requires nursing surveillance for bladder distention

  • Urethral obstruction from an enlarged prostate gland

  • Foley indications

Hypertension - What, RF, stages

• Chronic elevated BP

• Can lead to Heart disease, kidney damage, stroke

• RF: age, genetcis, lifestyle, medical conditions, meds

• Stages: use whichever number is higher

  • Normal: <120/ <80

  • Elevated: 120-129/<80

  • Stage 1: 130-139/ or 80-89

  • Stage 2: >140/ or >90

  • HyperTN crisis: >180/ or >120

• Lifestyle modifications 1-3 months before medication reg