med surge theory

what is COPD

t

• Chronic obstructivbe pulmonary disease. respiratory disease that has persistant airflow obstruction

• mainly involves two processes
  Chronic bronchitis

  • 
    

Chronic bronchitis

• inflammation and excessive mucus production in teh bronchi

• ariwasys become sweollend and filled with mucus, narrowing the passage available for airflow

Emphysema

• destruction of alveolar walls and loss of lung elasticiyt

• lungs lose ability to recoil dyring expiration, resulting in air trapping

Why does air trapping occur

• lungs are elastice

• during expiration recoil helps push air out

• with emphysema

  • aveolar walls destroyed

  • recoil decreases

  • airways collpase more easily

  • air remains trapped

  • pt works harder to breahte

This explains several classic COPD findings:

Finding	Why it happens
Barrel chest	Chronic hyperinflation
Prolonged expiration	Difficulty moving air out
Pursed-lip breathing	Helps prevent premature airway collapse
Accessory muscle use	Increased work of breathing
Dyspnea	Air trapping and increased respiratory effort
Diminished breath sounds	Reduced airflow

why is there low oxgyen and high co2

Hypoxemia means decreaseed oxygen in arterial blood

Hypercapnia means increased carbon dioxide in arterial blood

Nursing priorities during an exacerbation

imagine pt with COPD develops sudden shortness of breath, a respiraroty rate of 34 and an spo2 of 85%

Priorities

• assess airways, breathing oxygenation and mental status

• position the pt upright often in high fowlers

• adminsiter and titrate oxygen according to orders and clinical condtion

• administer prescribed short acting bronchodilators

• reassess work of breathing lung sounds, cital signs, and response

• escelate immediately if pt has sever distress, delcniing consciousness, or signs of respiratory failure

Falling respiratory rate is not always improvement

• going from 36 to 8 is not alwasy great. might be fatigue

Inhalers and how they work

• primarily work by

  • relaxing smooth muslce, reducing inflammation, or both

• 
  

major medication classes (NOT needed for exam)

Class	Examples from your lecture	Mechanism and purpose
SABA — Short-acting beta₂ agonist	Albuterol	Stimulates beta₂ receptors → relaxes bronchial smooth muscle → rapid bronchodilation
LABA — Long-acting beta₂ agonist	Salmeterol	Same receptor mechanism, but provides prolonged bronchodilation for maintenance
SAMA — Short-acting muscarinic antagonist	Ipratropium	Blocks muscarinic receptors → reduces cholinergic bronchoconstriction
ICS — Inhaled corticosteroid	Fluticasone	Reduces airway inflammation; used in selected patients, generally in combination therapy
Combination inhalers	Advair, Combivent	Combine different mechanisms to improve symptom control

dry powder inhaler vs metered dose inhalers

Metered does inhaler

• release a measured aerosol dose using a propellant

dry powder inhaler

• uses pt inhalation to draw powdered medication into lungs

Feature	MDI	DPI
Medication form	Aerosol	Dry powder
Inhalation	Slow and deep	Fast, forceful, and deep
Coordination	Requires timing unless using spacer	Breath-actuated
Spacer	Often beneficial	Not used
Main limitation	Poor hand-breath coordination	Insufficient inspiratory effort

proper inhaltion tech for meteered dose inhaler

Metered-dose inhaler (MDI)

1. Remove the cap and shake the inhaler if required by the product.

2. Attach a spacer when appropriate.

3. Exhale fully, away from the inhaler.

4. Seal lips around the mouthpiece.

5. Begin inhaling slowly and press the canister once.

6. Continue inhaling slowly and deeply.

7. Hold breath for approximately 10 seconds if tolerated.

8. Exhale slowly.

9. Wait as directed before another puff.

10. Rinse mouth and spit after an inhaled corticosteroid.

proper tech for dry powder inhaler

Dry powder inhaler (DPI)

1. Open the device and load the dose according to manufacturer instructions.

2. Exhale fully away from the device.

3. Seal lips around the mouthpiece.

4. Inhale quickly, forcefully, and deeply.

5. Hold breath for approximately 10 seconds if tolerated.

6. Exhale away from the device.

7. Close the device.

8. Rinse mouth and spit if using an inhaled corticosteroid.

Nutritional needs of pt with COPD

Pt need more energy breathing becasue their respiratory msucles work hard to breathj

leads tto

• increased caloric expenditure

• weght loss and. uscle wasting

• fatigue during meals

• decreased appetite

• malnutrition and respiratory muscle weakness

inadequate diet leads to expeniture and fatigue

administration of oxygen to patients with copd

Target o2 range is 88-92

indicators that inhalres adminsted were effectivbe

Assessment	Before treatment	After effective treatment
Respiratory rate	Elevated	Moves toward patient's baseline
Wheezing	Present	May decrease
Dyspnea	Significant	Patient reports easier breathing
Accessory muscle use	Increased	Decreases
Breath sounds	Reduced airflow	Improved air movement
SpO₂	May be decreased	May improve
Heart rate	Often elevated from distress	May decrease as distress improves

changes in vitals over time and concerns related rto changes

Vital sign	Value	Interpretation
Blood pressure	160/96	Hypertension
Heart rate	130 bpm	Significant tachycardia
Respiratory rate	36/min	Severe tachypnea
Temperature	37.6°C	Slightly elevated
SpO₂	86% on room air	Hypoxemia

how vital signs change as respiratory failure develops

Early deterioration

Tachypnea, tachycardia, anxiety, restlessness, and increased accessory muscle use. The patient is working harder to compensate for impaired gas exchange.

Worsening respiratory failure

Increasing hypoxemia, respiratory fatigue, worsening CO₂ retention, confusion, and decreasing effectiveness of breathing.

Impending respiratory arrest

Decreased respiratory effort or rate despite ongoing distress, altered consciousness, weak respiratory effort, and possible hemodynamic instability. Requires immediate emergency response.

Interventions for shortness of breath

Priority	Intervention	Rationale
1	Assess airway, respiratory effort, RR, SpO₂, and mental status	Determines severity and whether emergency support is needed
2	Position in high Fowler's or tripod position	Improves diaphragmatic movement and lung expansion
3	Administer or titrate prescribed oxygen	Corrects hypoxemia
4	Administer prescribed short-acting bronchodilators	Relieves bronchoconstriction
5	Encourage pursed-lip breathing when appropriate	Prolongs expiration and reduces airway collapse
6	Reassess respiratory status and response to treatment	Determines effectiveness and need for escalation

why does pursed lip breathing help

pt with emphsema lose elastic recoul. making airways more likely to collapse during expiration

pursed lips create mild positve expiratory pressure, helping keep airwasys open long

this allows more air to escape, reducing air trapping and potentially decreasing dyspnea

what happens in pneumonia

infection of lung tissue that causes inflammation in alveoli and surroudnign structures

normally alveoli are filled with air allowing oxygen to diffuse into pulmonary capillaries

inflammation causes fluid, inflammatory cells and someties pus to accumulate inside teh alveoli

priority action when a pneumonia pt complains of increasing shortness of breath despite oxygen

• assess pt’s airway and breathing, including respiratory rate, work of breathing, spO2, mental status, and whetehr the o2 delivery system is functioning

• position pt upright if you can and escelate in pt has signs of severe respiratory distress

signs that exacerbation is improving

• decreased respiratory

  • from 33 to 20

• decreased work o fbreathing

  • less accessory muslce use, tripof positioning, retractions

• improved oxygenation

  • spo2 moes toward pt target, often 88-92

• improved lung sounds

• decreased dyspnea

  • breathing is easier

• improved mental status

  • less confusion drowziness

• improved activityu tolerance

• improving ABGs

Wheezing occurs when air moves through narrowed airways. If airflow becomes severely reduced, wheezing can disappear even though the patient is deteriorating.

A patient with very diminished breath sounds, worsening hypoxemia, exhaustion, or altered mental status requires immediate assessment.

vesicular breath sounds

• what you want to hear

Location: Most peripheral lung fields.

Sound: Soft, low-pitched, gentle rustling or blowing.

Inspiration vs. expiration: Inspiration is longer and louder than expiration.

Normal finding: Yes, over most lung tissue.

bronchial breath sounds

Location: Normally heard over the trachea.

Sound: Loud, harsh, high-pitched, tubular.

Inspiration vs. expiration: Expiration is longer and often louder than inspiration.

Normal finding: Yes, over the trachea; abnormal over peripheral lung fields.

caused by lung consolidatoin

what causes lung consolidation

1. Fluid or pus (pneumonia): The alveoli fill with inflammatory fluid and cellular debris, creating consolidation. This is a classic cause of bronchial breath sounds in peripheral lung fields.

2. Blood (pulmonary hemorrhage): Blood fills the alveoli, increasing tissue density and improving sound transmission.

3. Other causes of consolidation: Cells or other material replace air within the alveoli, producing similar findings.

what is the relationship between hemoglobin and oxygen saturation

• oxygen saturation and oxygen carrying capacity are not the same thing

• Hgb binds oxygen and transports throughout body

• SpO2 measures estimated percentage of availbable hemoglobing binding sites occupied by oxygen

• hemoglobin concentration measures how much hgb is available to carry oxygen

high hgb can partially compensate for reduced satruation by increasing amt of oxygen carrying protein, but does not correct hypoxemia, high hgb can increase blood viscosity as well

Signs and symptoms of pneomonia

Finding	Why it occurs
Fever and chills	Inflammatory response to infection
Productive cough	Secretions and inflammatory exudate in the airways
Crackles	Air moving through or reopening fluid-affected small airways
Bronchial breath sounds over affected lung tissue	Consolidated lung transmits airway sounds more effectively
Tachypnea	Compensation for impaired oxygenation
Tachycardia	Response to fever, hypoxemia, and physiological stress
Dyspnea	Impaired gas exchange and increased work of breathing
Pleuritic chest pain	Inflammation involving the pleura
Fatigue and weakness	Systemic illness and increased metabolic demand
Confusion	Can reflect infection, hypoxemia, or delirium, particularly in older adults

assessment findings that indicate pneomonia is resolving

Assessment	Improvement looks like
Temperature	Fever resolves
Respiratory rate	Returns toward normal
SpO₂	Improves or requires less supplemental oxygen
Work of breathing	Decreased accessory muscle use
Lung sounds	Improving air movement; crackles may diminish
Cough	Less frequent or less productive
Sputum	Decreasing amount and purulence
Heart rate	Returns toward baseline
Mental status	Improved alertness and orientation
WBC	Trends toward normal if initially elevated
Activity tolerance	Less fatigue and dyspnea with activity

which findings are most important for pneomonia

improvements in oxygenation and work of breathing are especially important

A patient initially requires 4 L/min of oxygen to maintain SpO₂ of 93%. Two days later, they maintain 95% on 1 L/min.

This suggests improving oxygenation.

interventions to decrease shortness of breath: initial priority and easiest action

• high fowlers is easiest

Intervention	Rationale
High Fowler's positioning	Improves lung expansion
Supplemental oxygen as prescribed	Corrects hypoxemia
Encourage coughing and deep breathing	Mobilizes secretions
Incentive spirometry when appropriate	Encourages sustained inspiration and lung expansion
Encourage hydration when appropriate	Helps maintain secretion clearance
Administer prescribed antibiotics	Treats bacterial infection
Bronchodilators when indicated	Relieve associated bronchospasm
Mobilization as tolerated	Improves ventilation and secretion clearance
Monitor SpO₂, RR, and lung sounds	Evaluates respiratory status

position with good lung down!

Gravity directs blood flow to dependent lung, improving ventialtion, also helps pull away bad stuff from bad lung

key things for pneomonia

Study-guide topic	Key takeaway
Worsening dyspnea despite oxygen	Immediately assess airway, breathing, SpO₂, and respiratory effort; escalate if unstable
Hemoglobin vs. SpO₂	Hemoglobin = carrying capacity; SpO₂ = percentage saturated
Pneumonia symptoms	Fever, cough, crackles, tachypnea, dyspnea, pleuritic pain
Resolving pneumonia	Improving oxygenation, decreased respiratory effort, resolving fever
Easiest initial intervention	Position upright in high Fowler's while assessing and supporting breathing

ekg/ecg

records electrical activity of the heart not the mechanical pumping itself

normal ekg wave

Component	Normal value	Electrical activity	What's happening physiologically?
P wave	<0.12 sec	Atrial depolarization	The SA node has initiated an impulse that spreads through the atria. Atrial muscle cells become electrically activated, triggering atrial contraction shortly afterward and pushing blood into the ventricles.
PR interval	0.12–0.20 sec	Electrical conduction from atria toward ventricles	The impulse travels through the atria and AV node, where it is briefly delayed, then through the His-Purkinje system. This delay allows the ventricles more time to fill before contracting.
QRS complex	<0.12 sec	Ventricular depolarization	The electrical impulse spreads through the ventricular myocardium, triggering ventricular contraction shortly afterward. Pressure rises, eventually opening the aortic and pulmonary valves and ejecting blood.
ST segment	Normally near baseline	Ventricles remain largely depolarized	Ventricular muscle cells are in the plateau phase of their action potentials. The ventricles are mechanically contracting and ejecting blood during much of this period.
T wave	No single fixed duration	Ventricular repolarization	Ventricular muscle cells restore their electrical resting state. Ventricular relaxation follows, pressure falls, and the ventricles enter diastole.
QT interval	Heart-rate dependent	Ventricular depolarization through repolarization	Represents the total electrical activation and recovery period of the ventricles, encompassing much of ventricular systole.

what is ventricular tachycardia (v-tach)

• occures when rapid electricla impusles orginate in teh ventricles rather than following normal condiction through SA nose

• Recognition

  • usually rapid rate, often aroudn 150-250 bpm

  • wide QRS complexes, trypically .12 seconds or longer

  • often regular

  • p waves mauy be absent, difficult to see, or dissociated from QRS complexs

why is V-tach dangerous

• when ventricles beat extremely quickly they have less time to fill with blood

• can cause

  • decreased stroke volume adn cardiac output

  • hypotension

  • reduced cerebral perfusion

  • loss of consciousness

  • progression to cardiac arrest

what to do if there is vtach on the monitor

• assess responsivenss, breathing, and pulse immediately

• No pulse

  • begin CPR, activate code response adn defib as soon as possible

• if pulse

  • assess BP, mental status, chest pain, shock, and signs of heart failure

  • Unstable

    • urgen synchronized cardioversion for regular monomorphic VT, with emergency team support

  • stable

    • monitoring, IV access, 12-lead ECG when feasible and ordered antiarrhythmic treatment.

sinus tachycardia

• SA node is firing faster than normal

How to recognize

• heart rate

  • greater than 100 bpm

• rhthm

  • regular

• P waves

  • present, one before each QRS

• PR interval

  • 0.12-0.20

• QRS

  • usually narrow, under 0.12

looks like nomral sinus rhthym except is faster

why does sinus tachycardia occur

• often response to another problem rather than primary primary problme itsel

Common causes

• fever or infection

• dehydration or hypovolemia

• pain or anxjety

• hypoxemia

• anemia

• hemorrhage

• pulmonary embolism

• myocardial ischemia

what is priority concern for sinus tachycardia

Treating underlying cause

at higher heart rate, ventricles have less time to fill, stroke volume may decrease, myocardial oxygen deman increases, coronary perfusion time decreases

Nursing interventions for sinus tachycardia

Asses vitals, BP, SpO2, temp, pain, perfusion, and possible causes

what is atrial fibrillation (A-fib)

• Atrial fibrillation occurs when the atria experience chaotic electrical activity rather than coordinated depolarization; instead of one organized impulse originating from the SA node, multiple disorganized impulses activate the atria

• What happens in the heart

  • normally, atria contract in a coordinated manner

  • during a-fib

  • atria fibrillate rather than contract effectively

  • organized P waves disappear

  • the AV node conducts impulses irregularly

  • the ventricular rhythm becomes irregularly irregular

how to recognize A-fib

Feature	Atrial fibrillation
Heart rate	Variable; can be rapid or controlled
Rhythm	Irregularly irregular
P waves	No distinct, consistent P waves
PR interval	Cannot be measured reliably
QRS	Usually narrow unless another conduction abnormality exists

why is A-fib dangerous

• decreased cardiac output

  • atria loses coordinated contraction, sometimes called atrial kick

  • can reduced ventricular filling and cardica output, especially in patients iwth impaired ventricular relazation

• stroke risk

  • becasue the atria are not contracting effectively, blood can stagnate, particularly in the left atrial appendage

  • this can increase risk of thrombus formation

  • a clot can dislodge, travel through the arterial circulation, and cause and ischemic stroke

Treatment for A-fib

Treatment goal	Examples
Control ventricular rate	Metoprolol, diltiazem, sometimes digoxin
Restore or maintain sinus rhythm	Cardioversion, selected antiarrhythmics, catheter ablation
Prevent thromboembolic stroke	Warfarin or a direct oral anticoagulant when indicated

Warferin teaching for patients with A-fib

wafarin is an anticoagulant used to reduce risk of thrombboembolic stroke in selected patients wiht a-fib

it works by inhibiting vitamin k-dependant clotting factor syntehsis

does not directly dissolve existing lcots

teaching

Teaching	Why?
Monitor INR regularly	Determines anticoagulation intensity
Typical INR goal 2.0–3.0 for A-fib	Balances clot prevention with bleeding risk
Maintain consistent vitamin K intake	Sudden dietary changes can affect INR
Report unusual bleeding or bruising	May indicate excessive anticoagulation
Avoid starting NSAIDs without medical advice	Increased bleeding risk
Discuss new medications and supplements	Many interactions affect warfarin
Use a soft toothbrush and electric razor	Helps reduce bleeding injuries
Do not stop warfarin independently	Stopping can increase thromboembolic risk
Avoid warfarin during pregnancy	Can cause fetal harm

ischemia

The myocardium is receiving inadequate oxygen rich blood

injury

acute myocardial damage is occuring

infarction

Myocardial tissue has undergone irreversible cell death

EKG changes indicateing ischemia

ST sesfment depression can indicate myocardial ischemia, it may be seein with NSTEMI, unstable angina or demand ischemia, among other causes

EKG changes indicating acute injury

ST segmetn elevatoin in an apporpriate pattern can indicate acute myocardial injry, including a STEMI

this requires urgent evaluation for cornary arter occlusion

EKG changes indicating Infarction

Pathologial Q waves can indicate prior mysocardial infarction adn scar tissue

they may also develop during an evloling MI, althoubh not every infarction produces Q waves

what about T wave inversions

Can indicate myocardial ischemia, although it is not specific to ischemia

acute coranory suynromes may produce evolving changes over tiem, so serial ECGs are important

Condition	EKG finding
Ischemia	ST depression
Injury	ST elevation
Infarction	Pathological Q waves, potentially with ST/T-wave changes

Nursing priority: New ischemic EKG changes accompanied by chest pain, dyspnea, diaphoresis, or instability require immediate assessment, urgent provider notification, and a 12-lead ECG/chest pain protocol as appropriate.

what is sinus bradycardia

occurs when SA node fires fewer than 60 times per minute

Feature	Sinus bradycardia
Heart rate	Under 60 beats/min
Rhythm	Regular
P waves	Present before every QRS
PR interval	0.12–0.20 sec
QRS	Usually narrow

is bradycardia always dangerous

No. bradycardia can be normal in healthy, well conditions indiciduals or during sleep

BUT

does the pt have adequate perfusion

Nursing interventions for symptomatic bradycardia

1. Assess airway, breathing, pulse, BP, mental status, and perfusion.

2. Call for immediate assistance if unstable.

3. Apply cardiac monitoring, obtain IV access, and support oxygenation when needed.

4. Prepare to administer atropine, according to the ACLS protocol or provider orders.

5. Prepare for transcutaneous pacing or other advanced treatments if atropine is ineffective.

administration of diabetic miedications the morning of surgery

Biggest concern is hypoglycemia while the pt is NPO (nothing by mouth)

normally, pt eat carbohydrates that riase their blood glucose, it pt takes insulin or certain oral diabetes medications but doesnt eat, their blood glucose can fall dangerously low. bnecaue your body ztill needs insulin, and srugery increases glucose beacsue of stress.

however, wihtholding all diabetes medications can also cause hyperglycemia, so teh nurse follows the perioperative medication plan rather than making blanket decisions.

Medication	Typical morning-of-surgery approach	Why?
Rapid-acting insulin (lispro, aspart)	Usually hold the routine mealtime dose while NPO; correction insulin may still be ordered	No meal is being consumed
Short-acting regular insulin	Hold scheduled nutritional doses while NPO; follow correction orders	Prevent hypoglycemia
Long-acting basal insulin (glargine, detemir, degludec)	Usually continue at a reduced or individualized dose	Prevent excessive hyperglycemia and ketosis
NPH insulin	Often give a reduced morning dose	Has an intermediate peak that can cause hypoglycemia
Sulfonylureas (glipizide, glyburide)	Usually hold on surgery day	Stimulate insulin secretion even without food
Metformin	Often held on surgery day; follow the perioperative plan	Discussed below
SGLT2 inhibitors (empagliflozin, dapagliflozin)	Typically stop 3 days before surgery; ertugliflozin 4 days	Risk of euglycemic diabetic ketoacidosis
GLP-1 medications (semaglutide, dulaglutide)	Individualized plan based on aspiration risk and current guidance	May delay gastric emptying

nursing priorities for diabetes pre-op

Nursing priorities

1. Check the patient's blood glucose before surgery.

2. Confirm NPO status and the last time they ate.

3. Review which diabetes medications were taken.

4. Follow the anesthesia or perioperative medication orders.

5. Report significant hypoglycemia, hyperglycemia, or discrepancies in the medication plan.

Metformin before surgery

pt is NPO so does not need glucose

what should nurse do with metformin before surgery

For an exam question in which the patient is NPO and scheduled for surgery that morning, the expected response is commonly to hold metformin according to perioperative orders.

If the patient has already taken it, notify the appropriate perioperative team rather than independently canceling the procedure.

In current practice, some protocols allow metformin to continue for selected low-risk procedures, so the actual order and clinical situation matter.

Preoperative labs: which ones should be reported

Lab	Typical reference range	Why it matters before surgery
Hemoglobin	Approximately 12–17.5 g/dL, varies by sex/lab	Low Hgb means reduced oxygen-carrying capacity and possible anemia or blood loss
Hematocrit	Approximately 36–53%	Helps evaluate anemia, blood loss, or hemoconcentration
Platelets	150,000–400,000/µL	Low levels increase bleeding risk
INR (not on anticoagulants)	Approximately 0.8–1.2	Elevated INR may indicate increased bleeding risk
aPTT	Approximately 25–35 seconds	Prolongation may indicate anticoagulant effect or coagulation abnormalities
Potassium	3.5–5.0 mEq/L	Low or high potassium can cause dangerous dysrhythmias
Sodium	135–145 mEq/L	Significant abnormalities can affect neurological function
Creatinine	Approximately 0.6–1.3 mg/dL	Helps evaluate renal function and medication clearance
Glucose	Depends on clinical context	Severe hypo- or hyperglycemia increases perioperative risk
WBC	Approximately 4,000–11,000/µL	Elevation may indicate infection or inflammation

labs to be reported Hgb

Lab	Typical reference range	Why it matters before surgery
Hemoglobin	Approximately 12–17.5 g/dL, varies by sex/lab	Low Hgb means reduced oxygen-carrying capacity and possible anemia or blood loss

Hematocrit labs to be reported

Lab	Typical reference range	Why it matters before surgery
Hematocrit	Approximately 36–53%	Helps evaluate anemia, blood loss, or hemoconcentration

platelet labs to be reported

Lab	Typical reference range	Why it matters before surgery
Platelets	150,000–400,000/µL	Low levels increase bleeding risk

INR labs to be reported

Lab	Typical reference range	Why it matters before surgery
INR (not on anticoagulants)	Approximately 0.8–1.2	Elevated INR may indicate increased bleeding risk

aPTT labs to be reported

Lab	Typical reference range	Why it matters before surgery
aPTT	Approximately 25–35 seconds	Prolongation may indicate anticoagulant effect or coagulation abnormalities

Potassium labs to be reported

Lab	Typical reference range	Why it matters before surgery
Potassium	3.5–5.0 mEq/L	Low or high potassium can cause dangerous dysrhythmias

sodium labs to be reported

Lab	Typical reference range	Why it matters before surgery
Sodium	135–145 mEq/L	Significant abnormalities can affect neurological function

creatinine labs to be reported

Lab	Typical reference range	Why it matters before surgery
Creatinine	Approximately 0.6–1.3 mg/dL	Helps evaluate renal function and medication clearance

gliucose labs to be reported

Lab	Typical reference range	Why it matters before surgery
Glucose	Depends on clinical context	Severe hypo- or hyperglycemia increases perioperative risk

WBC labs to be reported

Lab	Typical reference range	Why it matters before surgery
WBC	Approximately 4,000–11,000/µL	Elevation may indicate infection or inflammation

Priority lab to report

Potassium

PCA for postoperative pain management

PCA stands for patient controlled anelgesia

allows pt to administer a prescribed dose of IV pain medication, usually an opiod such as morphine or hydromorphone, by pressing a button

Setting	Meaning
Basal rate	Continuous medication infusion, whether or not the patient presses the button
Bolus or demand dose	Medication administered when the patient presses the button
Lockout interval	Minimum time before another demand dose can be delivered
mL/hour	Volume of medication solution infused each hour
Maximum dose limit	Maximum medication allowed during a specified period, if programmed

nursing considerations for PCS button

• ONLY THE PT presses the button, family members and staff should not activate demand doses for them

• assess pain and whether the PCA is providing relife

• monitor respiratory rate, sedation, SpO2 and BP

• verify medication concetration adn pump settings against the order

• monitor for nasuea, itching, constipation, urinary retentoin and respiratroy depression

Exam takeaway: The lockout interval prevents repeated doses too close together, but it does not eliminate the risk of opioid overdose.

pre/post op care interpretation of o2 saturation

spo2 measuers estimated perfentage of hemoglibin binding sites occupied by o2

does not measure amt of hemoglobin

95–100%	Usually normal for a healthy adult
92–94%	May indicate reduced oxygenation; assess clinical context
90–91%	Concerning in many patients
Below 90%	Significant hypoxemia requiring prompt assessment and intervention

Priority actions when receving a pt from teh PACU

PACU stands for post anesthesia care unit

when pt returns from PACU your immediate priopiryt is identifying complications from anesthesia or srugery

1. Airway and breathing

Check airway patency, respiratory rate and depth, SpO₂, lung sounds, and work of breathing. Assess for residual anesthesia or opioid-related respiratory depression.

2. Circulation

Check BP, HR, skin perfusion, peripheral pulses, and signs of hemorrhage or shock.

3. Level of consciousness

Determine whether the patient is awake, oriented, and responding appropriately.

4. Surgical site, drains, and lines

Assess dressings, bleeding, drain output, IV fluids, Foley output, and device function.

5. Pain, nausea, and ongoing recovery

Assess pain, review PCA settings, provide prescribed symptom management, and implement complication-prevention measures.

when can pt resume eating after surgery

depensd on pt condition adn postoperative orders

Assessment	Why it matters
Awake and able to swallow	Reduces aspiration risk
Nausea and vomiting	May indicate intolerance
Abdominal distention	Could suggest ileus or obstruction
Abdominal pain	Worsening or severe pain may indicate complications
Flatus or bowel movements	Useful signs of returning bowel function, but not always required before feeding
Surgical orders	Determine permitted diet and progression

General surgery

once pt is sufficiently awake, can protext theri airway and has no contraindications, oral intake may often resume realtively early

you should asses for nasuea, comiting and swallowing safety

Bowel surgery

However, modern enhanced recovery protocols frequently recommend early oral intake after uncomplicated bowel surgery, sometimes within 24 hours, as tolerated.

what is postoperative ileus

temporary reduction or cessation of intestinal motility after surgery

possible findings include ditention, nuasea, vomiting, and inabiliyt to tolerate food

TAKEAWAY: do not automatically feed a pt who has sings of ileu or bowl obstruction ubt also remember that waiting for bowel sounds or flatus is not universally required after uncomplicated bowel surgery

orthostatic vital sings and orthostatic hypotension

hypotension occurs when blod pressure drops significantly after a person moves from lying down to standing

when a person stands up gravity casues blood to pool in lwoer extremities,

temporarily decerases venous return to heart

Normally, baroreceptors detect the decrease in blood pressure and trigger a sympathetic response:

1. Heart rate increases.

2. Blood vessels constrict.

3. Blood pressure is maintained.

If the body cannot compensate adequately, blood pressure drops and the patient may become dizzy or faint.

technique for orthostatic hypotension

What indicates orthostatic hypotension?

Within 3 minutes of standing:

• Systolic BP decreases by 20 mmHg or more, or

• Diastolic BP decreases by 10 mmHg or more.

heart rate up by twenty

lab findings indicating orthostatic hypotension

Lab finding	Possible explanation
Elevated BUN-to-creatinine ratio	May suggest dehydration or reduced renal perfusion
Elevated sodium	May accompany water deficit
Elevated Hgb/Hct	Can suggest hemoconcentration from dehydration
Low Hgb/Hct	May suggest anemia or blood loss
Low potassium	Can accompany vomiting or diuretic use

Nursing interventions

• Assist the patient to sit or lie down.

• Implement fall precautions.

• Assess HR, BP, symptoms, hydration status, and possible bleeding.

• Review fluid balance and medications such as diuretics and antihypertensives.

• Notify the provider about significant findings and administer ordered fluids or other treatments as appropriate.

what is a DVT

blood clot that forms in a deep vein, most commonly in legs

why does a DVT form

thre major factors that promote clot formation

• Venous stasis

  • blood moves too slowly, such as during prolonged bed rest or after surgery

• endothelial injury

  • damage to inner lining of a blood vessel

• hypercoagulability

  • blood has an increased tendency to clot, such as with cancer, pregnancy or certain inherity disorders

Signs and sympotms of a DVT

• unilateral leg swelling

• pain or tenderness, often in calf

• warmth and redness

• sometiems no symptoms at all

The biggest concern is that part of the clot can break off, travel through the venous circulation, and lodge in a pulmonary artery, causing a pulmonary embolism (PE).

Sudden dyspnea, chest pain, tachycardia, hypoxemia, or collapse in a patient with suspected DVT requires immediate evaluation for PE.

what is heperain therapy

heparin is an anitcoagulant, prevents blood clots from getting larger

does not dissolve existing clot

Mechanism

enhances activity of antithrombin, a naturally occuring portein that inhibnits clotting factors

why give heperain to someone who already has a DVT

• prevents blood clot from growin while body gradually breaks down the clot

nursing considerations for heparin therapy

• monitor for bleeding: brusing hematuria, black stools, bleeding gums, and unexpecrted hypotension

• monitor hemoglobin, and hematocrit for possibel blood loss

• monitor platelet counts for heparin induced thrombocytopenia (HIT)

• assess for symptoms of pulmonary embolism

• verify infusion rate and ordered laboratory monitoring

what is heparin induced thrombocytopenia

• immune mediated complcation in which antibiodies activate platelets

• causes platelet consumption adn can paradoxically lead to new dangerous blood clots despit a falling platelet count

• a platelt decrease of 50% or more is concerning even if platelet count remians within normal range

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warferin therapy how it owrks and is monitored

• oral anticoagulant

• interferes with bodys ability to produce certain clottin gfactors

• inhibits vitamin K reducing activation of vitamin K dependent clotting factors

  • II,VII,IX. and X

• because existing clotting factors must be cleared from circulation, warferin takes several days to produce its full anticoagulatn effect

why might heparin and warferin be given together

• for acute DVT treatment with warferin, pt genearlly receive an immediately acting anticoagulant such as heparin while warferin becoems therapeutic

• called bridging

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how is warferin monitored

• using PT/INR

  • PT

    • prothrombin time

  • INR

    • international normalized ratio

NR	Meaning
Below 2.0	Often insufficient anticoagulation for DVT treatment
2.0–3.0	Typical therapeutic range
Above 3.0	Increased bleeding risk as INR rises

nursing considerations for warferin

• monitor INR as ordered

• assess for bleeding

• monitor for medicatoin interactions

• teach consisten vitamin K intake

• ensrue pt understatns the importance of taking warferin consistently

• avoidd pregnany while taking warferin becasue it can cause fetal harm

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labs to monitor for wafarin and heparin

Medication	Primary monitoring	Important additional labs
Unfractionated heparin (IV)	aPTT or anti-Xa	CBC, platelets, Hgb/Hct
Warfarin	PT/INR	CBC, Hgb/Hct
Low-molecular-weight heparin (enoxaparin)	Usually no routine aPTT monitoring	CBC, platelets, creatinine; anti-Xa in selected patients

what is aPTT

activated partial thromboplastin time

A typical normal aPTT is approximately 25–35 seconds, depending on the laboratory.

Why does heparin increase aPTT?

Unfractionated heparin works differently from warfarin.

Instead of reducing the liver's production of clotting factors, heparin enhances the activity of antithrombin.

measures how long it takes blood to clot through the intrinsic and common coagulatoin pathways

heparin prolongs this time

40-70 seconds is therapeutic rang

what is INR

warferin prolongs PT (prothrombin time), whihc is standerdized ad INR (international normalized ratio)

PT measures the time, in seconds, for plasma to form a fibrin clot after tissue factor and calcium are added in the laboratory.

low molecular weight heprarin versus unfractionated heparin

eature	Unfractionated heparin	LMWH (enoxaparin)
Mechanism	Enhances antithrombin; inhibits IIa and Xa	Enhances antithrombin; predominantly inhibits Xa
Administration	IV infusion or subcutaneous injection	Usually subcutaneous
Duration	Shorter acting	Longer acting
Monitoring	aPTT or anti-Xa for therapeutic IV use	Usually no routine aPTT
Dose response	Less predictable	More predictable
Kidney impairment	Often preferred in severe renal impairment	Requires renal assessment and possible dose adjustment
Reversal	Protamine	Protamine only partially reverses its activity
Home use	Less convenient	Commonly used at home

patient teaching enoxaparin ijections

• Wash hands and check the prescribed dose.

• Select an abdominal injection site at least 2 inches from the umbilicus, avoiding bruises, scars, and irritated areas.

• Rotate injection sites.

• Clean the skin and allow it to dry.

• Pinch a fold of skin and insert the needle into the subcutaneous tissue, typically at 90 degrees for a standard prefilled syringe.

• Inject the medication as instructed, remove the needle, and dispose of the syringe in a sharps container.

do not massage or rub injection site afterwar it can cause bruising

• Take injections at the prescribed times.

• Do not double doses if one is missed; contact the care team for instructions.

• Watch for bleeding, bruising, black stools, or blood in urine.

• Avoid aspirin and NSAIDs unless approved by the prescriber.

• Keep follow-up appointments for CBC and renal function monitoring.

• Seek emergency care for sudden chest pain, shortness of breath, coughing blood, or fainting.

nursing care for patient with dvt

• Assess swelling, warmth, tenderness, and color of the affected leg.

• Measure leg circumference consistently to monitor changes.

• Elevate the affected leg for comfort when appropriate.

• Administer prescribed anticoagulation.

• Monitor for bleeding.

• Encourage early ambulation once anticoagulation is effective and the patient is clinically stable, as appropriate.

• Do not massage the affected leg.

• Do not apply sequential compression devices directly over an affected limb with known acute DVT unless specifically directed by the treating team.

what is acute coranary syndrome

• occurs when blood flow through a coronary artery suddenly decreases, depriving part of the heart muscle of oxygen

• heart requires constant supply of oxygen, because it is constantly contracting

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what is stable angina

• stable angina is predictbale chest discomfort casued by a temporary imabalnace between myoscardial oxygen suppply and deman

• for ex

  • pt with coronary artery disease might experience chest pain while climbing stairs

  • during excersie

    • hr increases

    • myocardial contractility increases

    • heart requires more oxygen

    • narrowed coronary artery cannot increase blood flow sufficiently

    • myocardium becomes ischemic, producing chest discomcfort

nursing priority when pt with stable angina complains of chest pain with activity

• stop activity and have pt rest

• asses pain location, severity, quality, duration adn radiation

• assess vital signs, BP, HR, RR and SpO2

• administer prescribed sublingual nitroglycerin if appropriate and BP is adequate

• reassess the pt sympotms and vital sings

• if pain persists, unusual or occurs at rest, activate the appropriate chest-pain or emergency response protocol becaseu ACS may be developing

what labs are indicative of myocardial infarction

when myocardial cells are damaged, intracellular proteins are released into the bloodstream

Lab	What it indicates	Importance
Cardiac troponin I or T	Myocardial cell injury	Most important and cardiac-specific biomarker used for diagnosing MI
CK-MB	Muscle injury, particularly cardiac muscle	Less specific than troponin; occasionally useful in selected circumstances
Myoglobin	Muscle injury	Rises early but is not cardiac-specific; not routinely used to diagnose MI

troponin

• porotein involved in muscle contraction

• cardiac tropomnin I and T are found in cardiac muscle cells when those cells are injured, troponin enters blood

• elevated troponin does not necessarily mean pt is having an MI.

  • physicians look for rise or fall in troponin with evidence of ischemia such as symptoms. ECG changes or imaging findingd

• serial troponins

  • troponin may not be elevated immediately after symptoms begin

  • blood samples are collected at specified intervals to identify whether levesl are rising or fallin

nitroglycerin

• nitrate vasodilator used to relieve angina

• how it works

  • converted to nitric oxide, —> relaxes smooth muslce

• venodilation

• veins dilate

• more blood to remain in venous circulation

• decreased preload

• reduced ventricular wall tension

• reduced myocardial oxygen demand

nitroglycerin teaching

• at onset of angina stp activity and lie down

• place one tablet under tongue and allow it to dissolve or use prescribend sublingual spray

• not not chew or swallow

• if pain not relieved in 5 minutes, call 911

• additional doess may be taken every 5 minutes up to three totoal according to prescription instructions

• do not drive to hospital