Exam I

interrelated concepts for perioperative

safety, healthcare law, clinical judgement, infection, gas exchange , perfusion, pain, mobility, nutrition, elimination, tissue integrity, comfort, patient education, communication, stress and coping, fluid and electrolyte balance

patient preparation for the surgical experience

allergic reactions to anaesthia (malignment hyperthermia may happen- family member history of reactions)

allergies- strawberries/bananas (correlates to latex allergy), eggs/peanuts (correlates to propophol allergy), shellfish (correlates to iodine allergy)

PMH- procedures done, preop EKG if history of heart attack, obstructive sleep apnea, age, general health, social history, family history,

IV line present- big enough, two sites if needed, it works

bowel and bladder preparation- go to bathroom before

skin prep- chg baths, hair removal

NPO- decrease risk of aspiration

Labs- CBC, BUN/creatine, anemia (HNH), coags (PT/INR), chest xrays

understanding of surgery/informed consent form signed and in the chart

no jewelry, no dentures, clean skin/gown, no nail polish, undergarments off

blood/general surgery consent

head to toe assessment beforehand

right site/patient/surgery

patient teaching-getting out of bed after, incentive spirometer

medications- take BP meds, basal/long acting insulin (no short acting), respiratory(albuterol, ipratropium), seizure meds, chronic meds (hypothyroidism-thyroxine, prednisone/steroids)

DO NOT TAKE THESE medications- aspirin, warfarin, apixaban, Eliquis (any blood thinner), NSAIDS)

malignment hyperthermia

may happen under anesthsia, usually when there is family history

high temp

tachycardia

high CO2

dantrolene sodium- treats/prevents this condition

patient education prior to surgery

-tubes, drains, vascular access

-exercises that decrease respiratory complications

-excersies that decrease vascular complications

-importance of early ambulation

-specific post op restriction education

a 72 year old client with CAD, HTN, and a long smoking history is scheduled for abdominal surgery. the client says “i’m nervous and I dont really understand what to expect after surgery”

1. what are the top three pirorities- splinting with a pillow, use of incentive spirometer (pneumonia and analactisis (decrease in alveoli size) could occur without this)

2. what information should the nurse assess before surgery- lung sounds, chest pain, EKG, wheezing, SOB, COPD history, recent respiratory infections(cough/cold), allergies and previous reactions to anesthesia, post op instructions understanding, support system

consent for different scenerios

if they cant see- two witnesses can be present while they make an x on the paper

confused patient- power of attorney with paperwork

if the patient does not understand instructions to surgery what should the nurse do

assess anxiety of patients, ask what they are confused about to report to surgeon so they can explain procedure to patient

advanced directives

broad term

encapsulates power of attorney

power of attorney and reduces confusion for families

living will- make sure its in the chart, informt he surgeon

a nurse i preparing to administer ondansetron 4mg/2 mL IV push over 2 minutes. how many militiers should the nurse administer eveyr 15 seconds. round to one decimal place

0.25 mLs every 15 seconds

what is expected before a procedure starts

time out- right site, patient, and procedure, IV site, infusions into IV and when it was given, flammables in the room and anything to put it out (saline), things in the field

what could go wrong with skin integrity before, during and after positioning

risk reduction- their bmi, pain level, diabetes increases risk of neuropathy and slow healing wounds, older age, poor nutiriton, cad, pvd

positioning plan- protect bony prominences

ongoing assessment- before and after

prevention actions- padded band aids, positioning changes, prevent shearing and friction

clinical judgment- if redness appears see if its blanchable, reposition, protect or cover area, document it

the medictaion is available in an IV bag containing 1.5g in 100mL and infuses over 30 min

200mL/hr

general anesthsia

used for invasive surgical procedures

patient is fully unconscious

risk factors- malignant hyperthermia, aspiration, cardiac arrythmias, respiratory depression, hypotension, N/V, delayed awakening

nursing assessments- rr, respiratory effort, breath sounds, airway patency, level of consciousness, gag reflex, temp, hr, return of bowel and bladder function/I&Os/bowel sounds

regional anesthsia

-loss of sensation in specific body area by injecting local anesthetic along nerve pathways from the spinal cord. the patient remains conscious but is usually sedated. commonly used in labor and delivery or abdominal surgeries.

risk factors-

high spinoblock-respiratory paralysis/depression- occurs if it migrates up the spinal cord, causes decreased respiratory effort/ difficulty breathing, treat by elevating upper body to prevent upward migration

hypotension/bradycardia- caused by extensive vasodilation, anesthetic blocks sympathetic vasomotor nerves, pain, and motor nerve fibers, continue to monitor bp

injury to anesthetized areas-observe effected limbs and make sure sensation returns

discomfort at injection site/hematoma

nursing assessments- hr, rr, bp, motor function return, urinary distention, signs of high block

local anesthsia

give lidocaine

numbness to small local area

patient is awake

risks- local anesthetic toxicity (itching, redness, swelling: appears later-tremors, metallic taste in mouth, seizures), infection, bleeding

assessments- check procedure site, check for numbness, pain level, bleeding, signs of allergic reactions, toxicity signs

PCA pump

how is it delivered: IV when the patient presses a button

given for moderate to severe pain

nursing assessments: IV patency, rr, bp, level of consciousness, pain, sedation, O2

patient teaching: how to use it, when to use it (press the button when first signs of pain show), don’t get up by yourself, early ambulation with assistance, incentive spirometer, coughing and deep breathing with splinting if abdominal

risks: over sedation, respiratory depression, N/V, constipation

PASERO-opioid induced sedation scale

S= sleep and easy to arouse ACCEPTABLE

1=awake and alert, ACCEPTABLE

2=slightly drowsy, easily aroused, ACCEPTABLE

3= frequently drowsy, arousable, drifts off to sleep during conversation, UNACCEPTABLE

4= somnolent, minimal or no response to verbal and physical stimulation, UNACCEPTABLE

a pateitn is receving morphine via PCA with a basal rate of 1.5mL/hr. the concdntration of the emdication is 1mg/mL. the patient can also receive a demand dose of 0.5 mL every 10 minutes. what is the max dose per hour

4.5 mL/hr

epidural analgesia

-narcotics are infused into the peridural space through an indwelling catheter. administration may be at a continuous basal infusion rate or self administered within programmed limits

-major lower surgeries from abdomen below

-reduces systemic opioid use

-risks: respiratory depression, infection at insertion site(redness, purulent drainage), hypotension, motor weakness

-monitor- rr, bp, signs of infection, pain level, sedation

REPORT HEADACHE- could be sign of serous fluid leak (put alot of pressure and fluids to fix this)

scheduled/prn IV opioids

given to patients by request

used for acute postop pain within 24-48 hours of surgery

limited abuse, targets breakthrough pain, fast onset, easy administration

risks- may cause constipation, respiratory depression, sedation, nausea

assessments: level of consciousness, bowel function,

post operative drains (jackson pratt)

jackson pratt- closed suction medical device used as a post operative drain for collecting bodily fluid

nursing considerations- measure amount of drainage and quality, color, monitor site for signs of infection, make sure the tube is working with no kinks or clogs, can be secured to patients gown, make sure the suction is on (squeeze to maintain suction)

paralytic ileus

cues- pain, bloating, n/v, abdominal distention/tenderness, decreased bowel sounds, cramping, hiccups

system assessment- tenderness, bowel sounds, last bowel movement, passing gas?, diet toleration, n/v, distention, pain level, O2, lung sounds, rr (pressure on lungs could lead to limited breathing)

Labs to monitor- ABG, electrolytes

nursing interventions- antiemetic for n/v, opioids for the pain, encourage ambulation, increased fluids, see if they can take in clear liquids

treatments- ng tube for decompression

tissue integrity after surgery

how often to assess skin after surgery- at least every 8 hours

when should the nurse be concerned about serosanguineous drainage (bloody with yellowed tinge)- beyond the 5th day after surgery ( still note if its two days after)

post op complications

PE- chest pain, dyspnea, tachycardia, increased rr, diaphoresis, low level of consciousness, hypotension

hypovolemic shock- lose too much fluid, decrease bp/urine output, cool clammy skin, increase thirst

pneumonia- fever, rapid respirations, shallow respirations, wet breath sounds

urinary retention- no void8-10 hours postop, palpate bladder, super pubic pain

atelectasis- dyspnea, tachypnea, decreased breath sounds tachycardia, asymmetrical chest expansion, increased restlessness

infection- redness, purulent drainage

paralytic ileus-

dehiscence- separation of incision

evisceration- evidence of bowel through incision site causing pain

post op labs

cbc

BMP- electrolytes, BUN/creatine,

ABG

coagluation studies- platalets, PT/INR, PTT

blood transfusion reactions

mild allergic- itching, hives, flushing

febrile nonhemolytic- fever, chills, headache

acute hemolytic- fever, chills, low back pain, hypotension, tachycardia

TACO (transfusion associated circulatory overload)- dyspnea, crackles, hypertension, fluid overload

what should you do when a transfusion reaction happens

stop the transfusion if suspected

maintain iv access with normal saline and new tubing per policy

reassess the patient and obtain vital signs

notify the provider and follow facility blood bank protocol

an infant is brought to the hospital with forceful emesis. which disorder does the nurse suspect

pyloric stenosis

pyloric stenosis

cues: projectile vomit, hungry after vomit after feeds, dry mucous membranes, irritability, crying with no tears

potential complications: dehydration, weight loss, constipation, metabolic alkalosis, electrolyte imbalance, hypoactive bowels, decreased urine output, tachycardia, low bp

parasitotic waves prior to vomiting

diagnosed with abdominal ultrasound and increase urine specific gravity in labs to tell if they are dehydrated

olive shaped mass on palpation in the upper right quadrant from thickening of muscle between stomach and intestines causing a blockage/obstruction

interventions: give fluids, monitor vitals and I&O’s, try advanced feeds and see if they tolerate Pedialyte to hopefully move them up to full strength of just milk, low intermittent suction, can feed baby as early as 6 hours after surgery even if bowel sounds aren’t present, emesis is expected after surgery. HAVE TO HAVE SURGERY

-pyloromyotomy- make incision in muscle, wont need an ostomy

evaluation: hydration status, weight gain,

hirschsprungs

cues: don’t pass meconium after birth, ribbon like stools(flat, because there’s an obstruction and the stool passes around it )

diagnostics: rectal biopsy (take tissue sample and find agangliotic cells)

treatment: have to do a bowel resection to take it out (temporary ostomy)

needs nerve cells to move everything through GI tract, part fo the GI tract is agangliotic cells, so you dont have parastalsis so nothing is moving

peptic ulcer disease

cues: alot of caffeine, alot of NSAIDS,

diagnostics: EGD(visulize stomach, esophagus, and duodenum)

treatment: antibiotics, high protone pump inhibitors, sucrafate

GERD

cues: burning pain after eating, sour taste, belching, relief after antacids, more common in those who are obese(diaphragm pushed up), irritability, crying during and after feeds, arched back and coughing(babies in reflux),

diagnostics: upper endoscopy, stool antigens test to rule out H pylori, pH monitoring, barium swallow test(drink barium and go under imaging to see where it goes in the body)

signs to expect: tachycardia, high rr, pain, cough a lot (adults), apnea(babies)

don’t eat three big meals, space them out

stay upright after eating

treatment: Laparoscopic Nissen Fundoplication (LNF):- bypass, take upper portion of stomach and wrap around the lower end of the esophagus

effectiveness: no pain when eating

which medication would be used to manage gastroesophageal reflux disease in a 6 month old

omeprazole

antibiotics are used to manage which conditions

hirschsprungs and peptic ulcer disease

when is the best time to administer sucralfate

before each meal

what is an adverse reaction/side effect of pantoprazole and amoxicillin

c diff

apnea may be a manifestation of which disorder

GERD

whihc would the nurse include in the teaching of a patient prescvribed pantoprazole

take before breakfast

which diagnostic test would be used to diagnose pyloric stenosis

ultrasound

esophagogastroduodenoscopy (EGD)

description: uses an endoscope to directly visualize the esophagus, stomach, duodenum. it helps detect ulcers, H.pylori, mucosal inflammation, blockages.

signs a patient needs an egd- weight loss, bloody emesis, pain after eating

pre procedure- npo status, left side lying, mouth gaurd to keep mouth open for endoscope

after procedure- sore throat(chew gum or candy), horse voice, assess for gag reflex before they eat or drink, cant drive after, check vitals

risks- could aspirate, or choke, no aspirin or blood thinners

hematemesis

bloody vomit

melana

dark tarry stools

advancing feeds

if a baby comes in nasuea/vomitting/diahrea

1. pedialyte only

2. half strength= half pedialyte, half formula/breastmilk

3. full strength= formula/breastmilk only

enterocolitis

inflmation in GI tract

if it is imflammed enough perforation may occur

may see fever, pain, guarding of abdomen, hard/distended abdomen

what is the bodys main source of energy

carbs

bulimia nervosa is at risk for elwectrolyte imbalance especially the followijng electrolytes

chlorine and potassium

celiac disease is

an autoimmune disorder triggered by gluten

carbphydrates

primary source of fuel and energy;provide fiber and glucose; protein and fat metabolism;brain an nervous systme function

protein

facilittates grwoth, maintanece and repair of tissues; backup energy source; supports immune system

fats

necessary for growth and development; transmission of nerve impulse and memory;

celiac disease

chronic autoimmune disorder, issues with absorption, can be hereditary

gluten(protein found in grains) triggers immune system to attack cilia and they become flat

diagnostics: diagnosed with blood test(ttga and ema) and endoscopy biopsy.

signs and symptoms: anorexia, weight loss, constipation, abdominal bloating, pain, fatty stools, headaches, tiredness, bone pain, itchy skin rash, n/v, slowed growth, delayed puberty

treatments: gluten free diet

complications: anemia, infertility, weak and brittle bones

CELIAC CRISIS: Acute severe episodes of profuse watery diarrhea and vomiting.

may be precipitated by: infections, prolonged fluid and electrolyte depletion, emotional disturbance

most concerned about: fluid and electrolyte imbalance

treatments: potassium, cardiac monitoring, ondansetron(for the nausea), IV meds, fluids, accurate I&O’s

anorexia nervosa

not eating

psychotherapy/ cognitive behavioral therapy

bulimia nervosa

binge eating followed by extensive exercise, vomiting, laxatives, diuretics, etc.

-often skips meals in public and binges in private, perfectionism, low self esteem, body dysmorphia, dental erosion

priority interventions- ekg and give IV potassium, monitor during meals, don’t weigh after meals, don’t give IV fluids during meals(encourage oral intake)

most important concept: fluid and electrolytes