Nursing 207 Exam 1

Pharmacokinetics- Absorption

• Moving from the site of administration into bloodstream

• Factors that influence this: route of administration, ability of medication to dissolve, blood flow to the site of administration, body surface area, lipid solubility

Pharmacokinetics- Distribution and Metabolism

Distribution: movement of a medication from bloodstream to tissue/cells, membrane permeability, protein binding

Metabolism: The process that breaks down the drug, medications are metabolized into a less-potent or an inactive form, biotransformation occurs under the influence of enzymes that detoxify, break down, and remove active chemicals

Pharmacokinetics- Excretion

Removal of the drug from the body
Medications exit the body through the kidney, liver, bowel, lungs, and exocrine glands

Chemical makeup of medication determines the organ of excretion

Therapeutic Effect

Expected or predicted physiological response

Adverse effect

Unintended, undesirable, often unpredictable
Side effect: predictable, unavoidable secondary effect
Toxic effect: accumulation of medication in the bloodstream
Idiosyncratic reaction: overreaction of underreaction or different reaction from normal

Allergic reaction, medication interactions, medication tolerance, medication dependence

Allergic reaction: unpredictable response to a medication
Medication interactions: one medication modifies the action of another
Medication tolerance: more medication is required to achieve the same therapeutic effect
Medication dependence: physical, psychological

Enteral routes of medication

Oral: convenient, cost effective, avoid if drug impacted by the first pass effect
Sublingual & Buccal: bypasses the first pass effect, undergoes passive diffusion through the venous blood in oral cavity (bypasses portal hepatic vein portal vein), sublingual is more rapid absorption than buccal
Rectal: rectal mucosa is highly vascular (50% of it bypasses first-pass effect)

Parenteral routes of medications

Intravenous: bypasses first-pass effect
Intramuscular: ventrogluteal recommended
Subcutaneous: just below the dermis, absorption is slower, more sustained rate (due to less blood vessels), upper, outer arm or abdomen

Other medication routes

Ophthalmic: eyedrops
Transnasal: passive diffusion
Inhaled: absorbed rapidly
Transdermal: absorbed through the skin, ointments, gels, patches

NOT to be delegated by the RN

Teaching, assessment, planning, evaluating

3 phases of perioperative care

Pre-operative/Pre-anesthesia
Intraoperative
Postoperative/post-anesthesia-PACU and beyond

Preoperative phase

Nursing and anesthesia provider assessment
Planning care
Interventions to prepare for surgical procedure

Intraoperative phase

Phase that begins when the patient is wheeled into the OR and ends when transferred to immediate postoperative recovery area

Postoperative phase

Immediate postoperative period usually spent in PACU
PACU nursing care focused on recovery from general anesthesia, airway management, pain, and close observation of physiologic indicators

Purpose of surgery

Diagnosis, cure, palliative, prevention, exploration, cosmetic improvement

Types of surgery

Ambulatory: comes in, has surgery, and goes home on the same day
Same day: comes in for surgery, post-op admit
Inpatient: admitted to hospital, has surgery, stays post-op

Elective surgery

Improve quality of life (physically or psychologically)
General risks: bleeding, infection, anesthetic exposure
Relatively low mortality/morbidity risk

Semi-elective surgery

More time-sensitive than elective
Not required to be within 24 hours but should be a priority
Relative low morbidity and mortality risk

Urgent surgery

Surgery is required within 24 hours of diagnosis; done to prevent unnecessary complications that can occur with waiting

Emergency surgery

Cannot be delayed and must occur within 24hrs; ideally scheduled within 2hrs
Any delay may promote critical injury or systemic deterioration; required as a result of an urgent medical condition

Patient interview/history

1. Explore the patient’s understanding of the need for surgery to be performed

2. Ask about any previous surgeries and anesthetics

3. Ask about the patient’s family health history

4. Ask about current medication use, including prescription, OTC and herbal meds

5. Ask about medication allergies/intolerances

6. Ask about recreational drug use, abuse, addiction

7. Ask about tobacco use

8. Ask about the possibility of pregnancy and last menstrual period

Informed consent

1. Witness the patients signature

2. Act as patient advocate

Intraoperative phase nursing roles

Circulating nurse: not scrubbed, gown, and gloved and remain in unsterile field, records all nursing care
Scrub nurse: follow designated scrub procedure; are gowned/gloved in sterile attire; remain in sterile field
CRNA

Intraoperative nursing problems

Risk for infection, risk for perioperative positioning injury, risk for injury, risk for imbalanced body temperature

PACU

Assessment of patient
- vital signs including temp and pain
- level of consciousness
- pressure reading (ICU stuff)
- position of patient
- condition and color of skin
- neurovascular status
Condition of drainage tubes, catheters, amount & type of drainage
Muscular response & strength
Pupillary response
Fluid therapy
Physical and emotional comfort
Procedure specific assessment

Post OP Nursing problems

Ineffective airway clearance, altered tissue perfusion, pain, altered urinary elimination, nausea, risk for constipation, delayed surgical recovery/impaired skin integrity/risk for infection, psychosocial issues (body image disturbance; anxiety)

Post OP Care- Respiratory Focused

Consider positioning (HOB)
VS, O2 Sat, oxygen, suctioning
Effective coughing
Incentive spirometry
Turn Q2; early ambulation
Pain management

Post OP- Circulatory Focus

Decreased CO- BP, HR, pulses, skin color/temp
DVT
Pulmonary embolus
Monitor VS, leg exersices/knee bends, plantar/dorsiflexion, SCDs, ambulation, phlebitis assessment, monitor/protect wound

Post OP care- Acute pain

Pain increases as anesthesia wears off, interventions can be pharmacologic or non-pharmacologic

Post OP Care: Urinary Elimination

Complications: Urinary retention, UTI
Interventions: I/O output >30ml/hr
Assess urge to void
Palpate bladder
Encourage voiding
Obtain order for catheterization if no voiding within 6-8hrs after surgery
Examine quantity and quality of urine

Post OP Care: GI Elimination

Complications: Gas/distention, nausea, constipation, paralytic ileus, distended abd; high absent pitched BS; painful
Interventions:
Assess and treat nausea, gradually advance diet, monitor dietary intake, ambulation, hydration, monitor BS and BM each shift, privacy to use bathroom

Post OP Care: Wound Healing

Complications: Infection, assess pain, color, drainage, odor, consistency
Interventions: Assess risk, monitor would at least each shift, protect with appropriate dressing/keep clean and dry, infection control- aseptic tech during dressing change, nutrition increased CHO proteins, calories, vitamins, hydration

Skin integrity of wounds

Skin integrity: intact, normal skin
Impaired: skin layers that are interrupted by wounds
Wound: breach in the continuity of skin or mucus membrane
Ulcer: persistent breach in the continuity in skin or mucus membrane associated with cell death

Types of Wounds

Open: Incision, abrasion, laceration, crush, penetrating
Closed: Contusion, hematoma

Surgical wound classification: Clean Wound

uninfected wound in which minimal inflammation is encountered and the respiratory, alimentary, genital, and urinary tracts are not entered. Clean wounds are primarily closed wounds

Surgical wound classification: Clean contaminated

A surgical wound where the above mentioned systems have been entered. Wound shows no evidence of infection

Surgical wound classification: contaminated wound

Fresh accidental or surgical wound with a major break in sterile technique or a large amount of drainage from the GI tract. Contaminated wounds show evidence of inflammation. EX: stabbing victim

Surgical wound classification: Dirty or infected wound

Wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage

Primary intention for wound healing

Where the tissue surfaces have been approximated (closed) and there is little to no tissue loss
Characterized by the formation of granulation tissue and scarring. EX: closed surgical incision

Secondary intention for wound healing

Wound edges cannot or should not be approximated and us left to heal on its own
Heals from the bottom up
EX: pressure ulcer
These wounds take longer to heal, results in more scarring, more susceptible to infection

Tertiary intention of wound healing

A wound left open due to edema, debris, or infection. Wound is closed once issues are resolved or exudate to drain and then loosely closed with sutures, staples, or adhesive skin closures

Wound healing process: Hemostasis & inflammatory phases

Begins within minutes of injury and lasts 3-6 days
Hemostasis: Combination of vasoconstriction & fibrin clot formation
Inflammation process: warmth, erythema, edema, pain at site
Cells involved: platelets, neutrophils, monocytes
Goal: arrest bleeding, remove dead tissue & foreign bodies, stimulate next phase of healing

Wound healing process: Proliferative phase

Lasts from 3 or 4 day post injury to about day 21 post injury
Collagen, a whiteish protein substance that adds tensile strength to the wound, is synthesized
Granulation tissue develops (appears as healthy, beefy red tissue)
Eschar forms (scab) and is made from dried plasma proteins and dead cells

Wound healing process: Maturation & Remodeling stage

Lasts from day 21 post injury to 1-2 years post injury
Collagen continues to be synthesized to build tensile strength
Mature scar is formed
Abnormal scarring occurs when an abnormal amount of collagen forms resulting in a hypertrophic scar (keloid)

Pressure Injury Assessment

Anatomical Location: Where is is, use landmarks & directions to define locations
EX: rash noted in right inguinal area extending from midpoint laterally to the iliac crest
Dimensions: Measure how big, no comparison to fruits, vegetables or coins, use millimeters or centimeters
Periwound skin and wound edges: what’s around it, ecchymosed (bruise) erthematous (red) indurated (firm) edematous (swollen)

Staging Pressure Ulcers: Stage 1

Skin is intact, skin does not blanch, area main be painful, firm, soft, warmer or cooler, considered reversible
Intervention: hydrocolloids, skin sealants, moisturizers

Staging Pressure Ulcers: Stage 2

Skin is visibly damaged and NOT intact with partial loss of the dermis, no subq fatty tissue will be visible.
Wound may be opened with superficial red/pink opened ulcer or may have the formation of an opened or closed blister
Interventions: Transparent films (tegaderm), hydrocolloids, absorptive dressings

Staging Pressure Ulcers: Stage 3

Skin is visibly damaged and not intact with full loss of the skin tissue
May see the subq fatty tissue, wound edges may be rolled away
Bone, tendon and muscle not visible
Interventions: Collagens, wound fillers, packing, debriding agents (autolytic or enzymatic)

Staging Pressure Ulcers: Stage 4

Skin is visibly damaged with FULL loss of skin tissue that will expose bone, muscle, tendon, and ligaments
Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling
Interventions: Collagens, wound fillers, alginates, packing, debriding agents (autolytic or enzymatic)

Staging Pressure Ulcers: Unstageable

Slough (yellowish or tan) or eschar (brownish black) is covering a full thickness ulcer
You can’t assess the actual depth of the wound because of the slough or eschar covering the ulcer

Staging Pressure Ulcers: Deep Tissue Injury

Presents as purplish pr blackish areas over skin that is intact. The fatty tissue below is injured. Also, may look like a black blister area. It may feel heavy or spongy

Prevention of pressure ulcers

Keep skin dry, clean
Clean linens
Turn every 2 hours
Watch for friction and shear activities

Assessment: Braden Scale

Categories: sensory, moisture, activity, mobility, nutrition, and friction and shear
9 or less: very high risk of developing a pressure injury
19-23: no risk

Tetanus Injection

Minor: unknown or more than 10 years ago → give
Last tetanus within 10 years → not needed
Other wounds or bites: unknown or more than 5 years ago → give
Within 5 years → not needed

Lesions

Bulla: circumscribed collection of free fluid > 1cm
Macule: circular flat discoloration <1cm brown, blue, red, or hypopigmented
Nodule: Circular, elevated, solid lesion >1 cm
Patch: circumscribed, flat discoloration > 1cm
Papule: Superficial solid elevated, <0.5cm, color varies
Plaque: Superficial elevated solid flat topped lesion, >1cm
Pustule: vesicle containing puss (inflammatory cells)
Vesicle: Circular collection of free fluid < 1cm
Wheal: Edematous, transitory, plaque, may last few hours
Scale: Epidermal thickening consists of flakes of plates of compacted
Crust: Dried serum or exudate on skin
Fissure: crack or split

Impetigo

Skin condition that is highly contagious
Found on the face, hands, arms, and the legs
S/S: Itchy, painful red blisters or bumps that spreads, the lesion can leak fluid that is honey colored (strep) or clear/pus (staph)
Treatment: topical or oral antibiotics, remove the crust prior to applying antibiotic ointment with warm water and antibacterial soap

Cellulitis

Cause: infection by group A beta-hemolytic strep or staph that affects the subcutaneous tissue and dermis
S/S: a tender, warm, erythematous, swollen area, which is usually well demarcated, fever, chills
Diagnosis: Gram stain and culture of skin tissue
Treatment: IV or oral antibiotic therapy depending on severity

Herpes Zoster (shingles)

Acute unilateral and segmental inflammation of certain nerve roots, usually appearing in adults over age 40

Cause: results from the varicella zoster virus that also causes chicken pox
S/S: Fever and malaise are onset, 2-4 days later there is severe pain, pruritus, and paresthesia (burning, itching, tingling)
Treatment: Calamine lotion, pain meds

Intertrigo

Superficial inflammatory skin condition of the skins flexural surfaces, promoted or irritated by warm temps, friction, moisture, maceration, and poor ventilation
Treatment: Topical using an anti-fungal cream

Scabies

Caused by an infestation of the skin by the human itch mite. It burrows into the upper layer of the skin where it lives and lays its eggs
Causes: sexually active individuals, presence of many children in the household, poor housing
S/S: skin rash with itching, burrows in skin with grayish-white or skin colored lines on skin surface
Treatment: Contact precautions, scabicidal agent and antimicrobial agent

Abscess

Appears swollen, pus-filled lump under the surface of the skin
Treatment: treated with antibiotics, may be lanced and drained

Melanoma

Most aggressive type of skin cancer, melanocytes turn cancerous

Nail Problems: Subungual hematoma

Bleeding and bruising under the nail caused by an injury to the blood vessel under the nail bed
Reduce swelling: elevate the affected extremity and icing the area for 20 minutes at a time
OTC pain meds can relieve discomfort
Nail trephination: small hole made in the nail where the blood is pooled, allowing it to drain

Nail problems: paronychia

Inflammation of the skin around a finger or toenail
Treatment: soak affected digit in warm water several times daily (3-4x daily), antibiotics is severe

Eye Vocabulary

Myopia: near sighted
Hyperopia: far sighted
Astigmatism: imperfect eye curvature
Presbyopia: normal loss of accommodation with age

Extraocular problems

Hordeolum: sty
Chalazion: chronic inflammatory granuloma of sebaceous gland
Blepharitis: chronic bilateral inflammation of the lid margin
Conjunctivitis: infection of the eye (pink eye)
Keratitis: infection of the cornea

Cataracts

Opacity in lens with gradual vision loss
Caused by aging, drugs, diabetes, trauma, smoking, UV, inflammation
Pathophysiology: altered metabolic processes in len caused by water accumulation and changes in lens fiber structure altering transparency

Cataract preoperative phase

Give anti-inflammatory and pupillary dilating drops
- mydriatic: alpha-adrenergic agonist = dilation
- cycloplegic: anticholinergic = paralysis of accommodation and dilation
- drug alert: patients wear dark glasses to reduce photophobia; monitor for systemic toxicity (tachycardia and CNS effects)

Cataracts postoperative phase

Discharged after sedation wears off
Medications: antibiotic and corticosteroids drops
Activity restrictions: avoid IOP such as bending =, stooping, coughing, or lifting
Nighttime shielding
Follow up for visual acuity; may or may not need glasses/lenses

Retinopathy

Microvascular damage to the retina; blurred vision; progressive loss of vision
Most common with hypertension or diabetes
Diabetic retinopathy
- nonproliferative: loss of vision
- proliferative: advanced disease; severe vision loss
- treatment: laser photocoagulation
Hypertensive retinopathy
- swelling of optic disc & nerve
- treatment: lower BP to restore vision

Retinal Detachment

Separation of retina and underlying epithelium; fluid accumulation between layers
Causes: breaks or holes (spontaneous) or tears (aging)
Manifestations: photopsia (light flashes), floaters, and cobweb/hairnet or ring in field of vision
Surgical therapy: seal retinal breaks by inflammation/adhesion or scar
- Laser photocoagulation: inflammation
- Cryopexy: freezing → scar
- Scleral buckling: band placed around globe (silicone implant)
Postoperative considerations: bedrest/activity restrictions, medications (analgesia and topical), patient education, decrease anxiety

Age-related macular degeneration

Irreversible central vision loss in the United States for people over 60
Two forms:
- Dry (nonexudative): atrophy of macular cells, slow, progressive, painless loss of vision
- Wet (exudative): most severe; abnormal blood vessels develop in or near macula, rapid onset of vision loss
Risk factors: family history
Acute vision loss, blurred or darkened vision, scotomas (blind spots) and metamorphopsia (visual distortion)

Age-related macular degeneration care

Interprofessional care
- Medications injected every 4 to 6 weeks into vitreous cavity to stop new vessel formation and slow vision loss
- Photodynamic therapy uses dye and laser to damage abnormal blood vessels
- Nutrition: vitamin C and E; beta-carotene, zinc, lutein (green leafy veggies and fatty fish), whole grains
- Smoking cessation

Drusen Spots

small yellow deposits of fatty proteins (lipids) that accumulate under the retina

Glaucoma

Aqueous production (inflow) and aqueous reabsorption (outflow) must be balanced to maintain IOP
Outflow occurs at angle where iris meets cornea
Inflow > Outflow → increased IOP = permanent loss of vision
Types:
- Primary open angle glaucoma: outflow of aqueous decreased; drainage channels clogged → optic nerve damage (22-32mmHg)
- Angle-closure glaucoma: reduced outflow from angle closure. Sudden onset, pain, color halos around lights, pressure greater than 50 (normal 10-21mmHg)

Glaucome care

POAG: drugs to control, argon laser trabeculoplasty
AACG: ocular emergency, miotics and hyperosmotic agents, laser peripheral or surgical iridotomy

Chronic conditions: follow therapy plan and follow-up recommendations, accurate information about disease and treatments, anti-glaucoma drugs

Inner Ear Problems

Vestibular labyrinth → vertigo
Auditory labyrinth → sensorineural hearing loss and tinnitus

Menieres disease

Accumulation of endolymph in membranous labyrinth; progressive
Unknown cause
Occurs in age 30-60 years; women more than men
Excess fluid and pressure → hearing and balance problems
Lasts hours → days; several times/year; variable

Menieres disease treatment

Diagnostic tests: audiogram, glycerol test, vestibular tests
No cure; treatments to reduce symptoms
Between attacks use diuretics, corticosteroids, low-sodium diet, and stress reduction
Surgical intervention: decompression, vestibular nerve section, ablation of labyrinth

Hearing loss

Conductive- external and middle ear (decrease sound intensity and/or distortion)
Sesorineural- inner ear (distortion or faintness of sound alter ability to understand speech complete hearing loss)
Central- impaired auditory pathways in the brain (problems understanding the meaning of words heard)
Age 65-74: 25% with hearing loss
Age 75 and older: 50% hearing loss

Conductive hearing loss

Sound transmission to inner ear impaired
Patient actually hear better in noisy environment
Caused by: otitis media with effusion, impacted cerumen, perforation of TM, otosclerosis, narrowing of the external auditory canal

Sensorineural hearing loss

results in ability to hear sound but unable to understand speech
can lead to misunderstanding by others
sounds muffled; difficult to understand, especially high-pitched sounds
hearing aids make sounds louder but not clearer
Caused by: impairment of the inner ear, vestibulocochlear nerve damage, congenital and hereditary factors, noise exposure, aging, menieres disease, trauma, ototoxicity

Central and functional hearing loss

Central: problem in CNS; unable to interpret sound
Functional: can be psychologically or emotionally related

Cochlear Implant

bypasses damaged area & directly activates the cranial nerve 8
external microphone, speech processor, transmitter, electrodes, cover entire range of frequencies, provide sound, improve lip reading, improve sense of security, decrease isolation