Foundations Midterm J2 😊 (operative care, informed consent, inflammatory bowel disease, HTN, pneumothorax/hemothorax, palliative care)

Surgical Safety Checklist (SSC)

- Informed consent

- Preop Education

- Health Hx including hx smoking, pregnancy, diagnostic screenings r/t procedure

- Allergies

- Head-to-toe Assessment

- Baseline VS, height, weight

- Skin prep PRN

- NPO

- Medications - home meds & preop meds

- Remove items including jewelry, dentures, make-up, mail polish, glasses/contacts, hearing aids, artificial limbs

- psychosocial support

- Consider age-related risks for older clients

Operative Care - Preoperative

Surgical Care Improvement Project

- If antibiotics are prescribed, should be given 1hr prior to incision and stopped within 24hr after the surgery

- Prepare surgical site according to recommended guidelines: remove dirt. hair (with clippers), or bacteria

- Client may shower with aseptic agent prior to surgery

Who is at risk of developing infections?

Operative Care - Intraoperative

Begins when the client is transferred to the operating table. Ends when the client is transferred to the PACU.

Anesthesia

- General

- Regional

- Local

- Moderate or conscious sedation

Nursing Team members

- Scrub Nurse: Ensure utensils are sterile and ready for use, assisting surgeon PRN

- Circulating Nurse: Coordinates care, Verifies consent forms, Assists anesthesiologist PRN, Client safety/monitoring/positioning, maintains sterility, Documents, Confirms counting supplies used during surgery

13 principles of Sterile Technique

1. Only sterile items are used within the sterile field.

2. Sterile persons are gowned and gloved.

3. Tables are sterile only at table level

4. Sterile persons touch only sterile items or areas. Unsterile persons touch only unsterile items or areas.

5. Unsterile persons avoid reaching over sterile field. Sterile persons avoid leaning over unsterile areas.

6. Edges of anything that encloses sterile content are considered unsterile.

7. Unsterile persons avoid sterile areas.

8. Sterile field is created as close as possible to the time of use.

9. Sterile areas are continuously kept in view.

10. Sterile persons keep well within sterile area.

11. Sterile persons keep contact with sterile areas to a minimum.

12. Microorganisms must be kept to irreducible minimum.

13. Destruction of integrity of microbial barriers results in contamination.

Operative Care - postoperative

Focus on safety & physiologic systems. Patent airway is a priority.

Immediate assessment of vital signs and repeated frequently to ensure stability

- Every 5-15 mins x 1hr

- Every 4hr x 24 hr

- Warming blankets, forced air warming until for hypothermia.

Enhanced Recovery After Surgery (ERAS)

- Getting the client up and moving early (mobility)

- Providing fluids and food early (nutrition)

- Using mild analgesics (pain)

- Managing any nausea or vomiting as soon as possible

- Discontinuing IV fluids early or in a sensible timeframe

- Continue ed started preoperatively

- PACU: Aldrete post anesthesia score

- Incentive spirometer

- Deep breathing and coughing

- Frequent turning

- Respiratory complications (suctioning, nebulizer, PEEP/IPPD if ventilated)

- Intake and output

- Pain management

- Monitor incision site

- Resume home medications if ordered

- Teaching

hand-off report

I - Introduction

• Introduce yourself & your role and job (include the client)

P - Patient

• Identifiers, age, pronouns, gender, sex assigned at birth, & location

A - Assessment

• Present chief complaint, vital signs, manifestations, & diagnosis

S - Situation

• Current status, including code status, level of uncertainty, recent changes, & response to treatment

S - Safety

• Critical lab values, SES factors, allergies, & alerts (falls, isolation)

B - Background

• Comorbidities, previous episodes, current Rx, & family history

A - Actions

• What actions were taken or are required? Provide brief rationale.

T - Timing

• Level of urgency & explicit timing & prioritization of actions

O - Ownership

• Who is responsible (nurse, doctor, team)? (Include client & caregiver

responsibilities).

N - Next

• What will happen next? Anticipated changes? What is the plan? Are there contingency plans?

Common Nursing Concerns - Postoperative

- Risk for constipation

- Risk for infection

- Acute Urinary Retention

- Nausea and Vomiting

- Postoperative Cognitive Dysfunction

- Venous Thromboembolism/PE

- Hypotension/Hypovolemia

- Atelectasis

- Wound Infection

- Wound Dehiscence

- Ileus

- Oliguria or Acute Kidney Injury

- Pain

What complications are you assessing for?

A client is 2 hours postoperative right total knee replacement due to arthritis. They have had 2 mg morphine IVP every 30 minutes for a total of 8 mg and 2 tablets of Percocet 10 mg/325 mg 15 minutes prior to discharge from PACU. Pain 3/10. The right hip dressing is dry and intact. 2+ pedal pulse. Wiggles toes on right foot. IV lactated Ringer's at 50 mL/hr in left hand

An 18-year-old patient who is unconscious and hypotensive and who has

sustained serious injury in an MVA in brought to the ED via ambulance. Which is

true of the treatment for this patient?

a. Next of kin needs to be notified prior to treatment beginning

b. Advanced directive and durable power of attorney should be reviewed

prior to treatment

c. The life-threatening injuries warrant immediate emergent treatment

d. The client can be treated after consent is given

C

The ostomy nurse is educating the client about how to

empty their ostomy pouch. Which of the following

actions by the client indicates that psychomotor learning

has taken place?

1. The client states how often the ostomy pouch should

be emptied

2. The client demonstrates emptying the ostomy pouch

3. The client writes the steps of how to empty the

ostomy pouch on a piece of paper

4. The client states they understand how to empty their

ostomy pouch

2

Informed consent

1. The provider obtains informed consent.

Explains procedure, risks, benefits, alternatives, and consequences of refusal.

2. The nurse's role is to:

Witness the signature

Ensure the client is competent

Ensure the client signs voluntarily

Verify understanding

Notify the provider if the client has question

3. The nurse does NOT:

Explain the procedure in detail for consent

Obtain the consent for the provider

4. Emergencies

Implied consent applies if the client is unconscious and treatment is life-saving.

Hypertension Definition & Epidemiology

- SBP >130 mm Hg OR DBP >80 mm Hg

- Confirmed on 2 readings at least 2 weeks apart

- 40% of U.S. Adults treated for hypertension

- Causes >40,000 deaths yearly

- Lifestyle changes are essential to prevent cardiovascular disease

Essential Primary Hypertension

most common type and is not caused by an existing health problem

Secondary Hypertension

Caused by:

- Kidney Disease

- Endocrine disorders (Cushing's, aldosteronism, pheochromocytoma)

- Brain disorders

- Medications (steroids, estrogen, sympathomimetics)

- Pregnancy

Treatment:

- Remove underlying cause

Untreated HTN can cause damage to...

Heart, Brain, Eyes, Kidneys

Higher BP --> Higher complication risk

BP Regulation Mechanisms

1. Baroreceptors: Located in carotid sinus, aorta, LV. Adjust HR and vessel tone.

2. Kidney fluid regulation

- Retain fluid if hypotensive

- Excrete fluid if hypertensive

3. RAAS system

- Angiotensin II --> vasoconstriction

- Aldosterone --> sodium/fluid retention

4. Vascular autoregulation

- Maintains tissue perfusion

Health Promotion & Prevention of HTN

- BMI

Essential Hypertension risk factors

- Genetics

- High Sodium Intake

- Obesity (BMI >25)

- Physical inactivity

- Smoking

- Hyperlipidemia

- Diabetes

- Alcohol excess

- African American ethnicity

- Age >60 / postmenopause

- Stress

Secondary Hypertension risk factors

- Kidney disease

- Cushing's disease

- Primary aldosteronism

- Pheochromocytoma

- Brain tumors/encephalitis

- Medications

- Pregnancy

Clinical Manifestations of HTN

Often asymptomatic

Possible findings:

- Headaches

- Facial flushing

- Dizziness/fainting

- Visual changes

- Retinal damage

BP Classification

Expected:

Assessments & Diagnostics HTN

Physical assessment:

- Check both arms

- Sitting & standing

- Correct cuff size

Labs (NOT diagnostic but supportive)

- BUN/Creatinine --> kidney disease

- Corticoids --> Cushing's

- Glucose/cholesterol --> vascular risk

Diagnostic procedures

- ECG --> LV hypertrophy (tall R waves)

- Chest X-ray --> cardiomegaly

Diuretics for HTN

Thiazide: hydrochlorothiazide

Loop: Furosemide

Potassium-sparing: spironolactone

Nursing actions:

- Monitor potassium: thiazide/loop-hypokalemia, potassium sparing-hyperkalemia

- Watch: muscle weakness, irregular pulse, dehydration

Teaching:

- Take last dose before 6 PM

- Increase potassium if not potassium sparing

- Keep follow-up appointments

Calcium channel blockers for HTN

Verapamil, amlodipine, diltiazem

Effects: Vasodilation --> lower BP

Nursing: Monitor BP/pulse, risk hypotension

Teaching:

- avoid grapefruit juice

- high-fiber diet for constipation

- Report irregular pulse

ACE inhibitors for HTN

Lisinopril, enalapril

Effects: Prevent angiotensin II formation

Key adverse effects:

- persistent cough

- angioedema

- Hypotension

- Possible HF or kidney complications

ARBs for HTN

Losartan, valsartan

Key:

- alternative if ACE cough occurs

- can cause hyperkalemia

- Monitor for angioedema

HTN nutrition guidelines

- Sodium

HTN lifestyle changes

- weight loss

- exercise >3x weekly

- Smoking cessation

- Stress reduction (yoga, massage)

Hypertensive crisis

Signs:

- BP >180/120

- severe headache

- Blurred vision

- Dizziness

- Epistaxis

- Disorientation

Nursing actions

- IV antihypertensives (nitroprusside, nicardipine, labetalol)

- Lower BP 20-21% in the first hour

- Monitor BP q5-15 min

- Neuro assessment

- ECG monitoring

Digestion Locations

Mouth: carbohydrates, fat

Stomach: Protein, carbohydrates, fat

Small intestine: carbohydrates, fat, protein, nucleic acids

GI Anatomy and Physiology

Lower gastrointestinal

- small intestine has "brush border" plasms rich lining

- chyme reaches large intestine or colon

- colon has bacterial flora that break down fibers and synthesize vitamins

- rectum expels water, dead bacteria, and food residue

Bristol Stool Form Scale

-Type 1: separate hard lumps like nuts (difficult to pass)

-Type 2: sausage shaped but lumpy

-Type 3: like sausage but with cracks on surface

-Type 4: like a sausage or snake, smooth and soft

-Type 5: soft blobs with clear-cut edges (passed easily)

-Type 6: fluffy pieces with ragged edges, a mushy stool

-Type 7: watery, no solid pieces (entirely liquid)

Inflammatory Bowel Diseases

- Chron's disease

- Ulcerative colitis

- Diverticulitis

Chron's disease

Idiopathic, chronic inflammatory process

- Probable genetic factors - IBD1, CARD15, IL23R, and others have been found

- Probable environmental factors - tobacco, diet, or fatty foods

Affects any part of the GI tract from mouth to anus

- 30% involve the small bowel, particularly the terminal ileum

- 20% involve the colon

- 45% involve both the small bowel and colon

Periods of symptomatic, unpredictable relapse and remission

Believed to be the result of an imbalance between proinflammatory mediators - chronic inflammation from T-cell activation leading to tissue injury

Crohn's Disease - clinical presentation

- Abd pain

- Diarrhea

- Intestinal fistuilization or obstruction

- Rectal bleeding

- Fever

- Weight loss, anorexia

- Nausea, vomiting

- Malnutrition, vitamin deficiencies

- Generalized fatigability

- Bone loss

- Psychosocial issues (depression, anxiety, coping difficulty) --> pediatric patients may also experience psychological issues regarding quality of life and body image

- Growth failure in pediatric patients: may precede gastrointestinal symptoms by years

Crohn's disease - Diagnosis

Based on clinical presentation and diagnostic tests

Lab tests

- Nonspecific - used more for facilitating disease management

- CBC count

- Chemistry panel

- Liver function tests

- Inflammatory markers

- Stool studies

- Serologic tests

Procedures

- Endoscopic visualization and biopsy

- Colonoscopy, ileocolonoscopic

- Small bowel endoscopy

- Interventional radiology: for percutaneous drainages of abscesses

Imaging studies

- CT scans

- Barium contrast studies

- CT enterorrhaphy or MR enterography

- MRI of the pelvis

- Abdominal and/or endoscopic ultrasonography

- Nuclear imaging

Ulcerative Colitis

A diffuse, nonspecific inflammatory disease whose etiology is unknown

Involves the large bowel, occasionally may involve the terminal ileum

Causes

- Environmental: NSAID use, psychosocial stress, smoking, milk-product consumption

- Immune dysfunction

- Likely genetic predisposition

Ulcerative Colitis - Clinical Presentation

- Rectal bleeding

- Frequent stools

- Mucous discharge from the rectum

- Tenesmus (occasionally)

- Lower abdominal pain

- Severe dehydration

- Severe diarrhea and cramps

- Fever

- Leukocytosis

- Abdominal distention

- Tachycardia

- Significant abdominal tenderness

- Weight loss

Grades

- mild: bleeding per rectum

Ulcerative Colitis - Diagnosis

Based on clinical presentation and diagnostic tests

Lab tests

- Serologic markers

- CBC count

- Comprehensive metabolic panel

- Inflammatory markers (ESR, CRP)

- Stool assays

Procedures

- Endoscopy & biopsy

Nutrition for IBD

- Provide nutrients in forms the pt can tolerate

- Diet is based on pt's specific disease process & triggers

During an exacerbation - low residue, high-protein, high-calorie diet with vitamin & mineral supplementation

- Fluid & electrolyte imbalances are corrected with IV fluids or oral replacement fluids

- Enteral nutrition can be prescribed if pt is reluctant to eat

- Parenteral nutrition is not used unless enteral nutrition is ineffective or contraindicated (TPN more expensive)

IBD Therapy - similar for UC and CD

Complementary therapies

- Vitamin C

- Herbs like flaxseed

- Yoga, hypnosis, breathing exercises

Antibiotics & prebiotics

- Metronidazole, ciprofloxacin, rifaximin

- Commensal E. coli, lactobacillus species

Antidiarrheal & antiperistaltic agents

Animo salicylate medications & corticosteroids to reduce inflammation

Immunomodulators & biologic agents to alter immune responce & prevent relapsagents

Surgery when treatments not effective

Differential features of Ulcerative colitis & Crohn's disease

crohns-

• Can affect any part of the digestive tract from the mouth to the anus (small intestine and the colon).

• Strictures (narrowing), abscesses, and fistulas (abnormal tunnels between organs/skin).

• Rectal bleeding is less common

• malabsorption weight loss are more frequent.

• surgery can remove damaged sections, but the disease frequently recurs

Ulcerative colitis -

• Limited strictly to the colon and rectum (large intestine).

• Severe bleeding, toxic megacolon, and a higher long-term risk of colorectal cancer.

• bloody diarrhea

• Removing the entire colon and rectum can cure the condition.

Complications of IBD

Fluid & electrolyte imbalances

Hemorrhage/perforation

Abscess formation

Toxic megacolon

Malabsorption

Nonmechanical bowel obstruction

Fistulas

Colorectal cancer

Extraintestinal complications

Osteoporosis

Role of the Nurse in GI disorders

Assessment

Environmental factors

Health promotion to decrease GI conditions

- Avoid intake of substances that cause or exacerbate diarrhea

- Avoid nicotine

Safety considerations

Applying the nursing process in GI disorders

Address pain

Asses for GI bleed

Monitor and promote nutrition/fluid intake

Education

Monitor labs including CBC

Consult dietitian

GI disorders

GI health depends on many psychological and physical components

- limited stress

- No alcohol or smoking or illegal drug use

- Healthy diet

- Early diagnosis of GI such as cancer or liver disease

From oral health to healthy bowel habits, each part is important

Exercise and stress reduction can prevent serious GI issues

Ventilation

- The process of inhaling oxygen into the lungs and exhaling CO2 from the lungs

- May be impaired by the unavailability of oxygen, or any disorder affecting the conducting airways, lungs, or respiratory muscles

Transport

- The availability of Hgb and its ability to carry oxygen from alveoli to cells for metabolism & to carry CO2 produced by cellular metabolism from cells to alveoli to be eliminated

- May be impaired when an insufficient # of quality RBC is available to carry oxygen, or when the amount of Hgb in the blood is low

Perfusion

- The ability of blood to transport oxygen-containing hemoglobin cells & return CO2 containing hemoglobin to the alveoli

- May be impaired by decreased cardiac output, thrombi, emboli, vessel narrowing, vasoconstriction, or blood loss

What is a Pneumothorax?

- Air in the pleural space --> causes lung collapse

- Happens when air leaks from lung or chest wall into pleural cavity

- Medical emergency! Requires immediate intervention

Pathophysiology of Pneumothorax

Normally

- Pleural space has negative pressure --> keeps lungs expanded

With Pneumothorax

- Air enters pleural space

- Pressure becomes positive

- Lung collapses --> ⬇️ oxygenation

Air enters via

- chest trauma

- Ruptured blebs/bullae in lung

Traumatic Pneumothorax

Cause: Rib fracture, stab/gunshot wound, blunt trauma, pressure changes (flying/diving)

Subtypes

- Open pneumothorax: "sucking chest wound", air freely moves in/out

- Iatrogenic pneumothorax: Caused by procedures (central line placement, thoracentesis, biopsy, mechanical ventilation)

Spontaneous Pneumothorax

Primary (PSP)

- no underlying lung disease

- Common in tall thin young males, smokers

- Cause: Ruptured blebs, lung inflammation/oxidative stress

Secondary (SSP)

- Due to lung disease: COPD most common, TB, CF, cancer, covid

Tension Pneumothorax

Emergency!!

- Air trapped --> cannot escape

- Pressure builds each breath

- Causes: Mediastinal shift, decreased cardiac output, respiratory failure

Classic signs:

- Hypotension

- Distended neck veins

- Tracheal deviation

- Cyanosis

Pneumothorax risk factors

- Smoking (tobacco/cannabis)

- Tall thin body type

- COPD or lung disease

- Trauma

- Pressure changes (diving/flying)

- Mechanical ventilation

- Environmental exposures (pollution, smoke)

Aging considerations pneumothorax

- Slightly lower O2 saturation normal (93-94%)

- Reduced lung elasticity

- Higher energy needed to breathe

Common pneumothorax symptoms

- Sudden chest pain

- Shortness of breath

- Tachypnea

- Tachycardia

- Hypoxia

Pneumothorax assessment findings

- Asymmetrical chest expansion

- reduced or absent lung sounds

- Hyperresonant percussion

- reduced tactile fremitus

- severe hypotension

- JVD

- Cyanosis

- Tracheal deviation (late)

Pneumothorax diagnostics

Most common --> Chest x-ray

Other tests - CT scan, ultrasound, E-FAST in trauma

Nursing priorities pneumothorax

ABC's first

- Airway

- Breathing

- Circulation

Monitor

- O2 saturation

- Breath sounds

- VS

- Chest symmetry

- Signs of shock

Pneumothorax nursing interventions

- Semi or high-fowlers position

- Oxygen therapy

- Pain control

- Prepare for: needle decompression, chest tube insertion

Chest tube management

Placement

- Needle decompression: 2nd intercostal space

- Chest tube: Usually 5th intercostal space

Nursing Care

- Keep drainage system below chest

- Monitor: drainage amount/type, air leaks, breath sounds, pain, fever

- Encourage coughing/deep breathing

Pneumothorax treatments

- Needle decompression (emergency)

- Chest tube drainage

- high-flow oxygen

- pleurodesis (prevent recurrence)

- Surgery if recurrent/severe

What is a hemothorax?

Blood in the pleural space

- Usually caused by chest trauma

- Causes both respiratory compromise (lung compression) and hemodynamic compromise (blood loss)

- Life threatening emergency requiring immediate intervention

Pathophysiology of hemothorax

Respiratory effects

- lung compression

- Reduced lung expansion

- Hypoxia

Circulatory Effects

- Blood loss --> hypovolemia

- Decreased preload and cardiac output

- Increased pulmonary vascular resistance

- Severe cases can lead to shock, cardiac arrest, or death

Hemothorax causes

Traumatic (most common)

- Motor vehicle collisions

- Rib fractures

- Gunshot or stab wounds

- Blunt chest trauma

Iatrogenic (procedure related)

- Central line placement

- Thoracentesis

- Chest tube insertion

- Thoracic surgery

Spontaneous (less common)

- Bleeding disorders (hemophilia, thrombocytopenia)

- Anticoagulant therapy (heparin, warfarin)

- Genetic or vascular conditions

Hemothorax risk factors

- Trauma (largest risk)

- Anticoagulation therapy

- Thoracic procedures

- Bleeding disorders

- Older age (may present subtly) --> Higher risk of complications, may require more intensive monitoring, reduced physiologic reserve, symptoms may appear later

Hemothorax Clinical manifestations

Respiratory findings

- SOB (dyspnea)

- Tachypnea

- Decreased or absent breath sounds

- Dull percussion over affected area

Circulatory/Shock signs

- Hypotension

- Tachycardia

- Cool, clammy skin

- Anxiety

Additional signs

- Chest pain

- Chest asymmetry

- Hypoxia

- Mediastinal shift (late, serious sign)

- Neck veins often flat (unlike tension pneumothorax)

Hemothorax diagnostics

Primary test --> chest x-ray

Other tests: ultrasound, CT scan, ABG's

Hemothorax immediate nursing priorities

Always prioritize ABC's

Initial actions

- Administer high-flow oxygen

- Continuous pulse oximetry

- Cardiac monitoring

- Insert two large-bore IVs --> possible need for blood transfusion

- Prepare for chest tube placement

Hemothorax treatment overview

Goal = remove blood and re-expand lung

Typical treatments:

- Chest tube drainage (thoracostomy)

- IV fluids or blood transfusion

- Oxygen therapy

- Surgery if bleeding persists

Chest tube size often

- 28-32 french

Hemothorax nursing care - assessment, intervention, teaching

Assessment

- Respiratory distress

- Breath sounds

- VS

- Signs of shock

- chest symmetry

- Pain level

Interventions

- Semi or high-fowlers position

- Oxygen therapy

- Pain control

- Prepare for chest tube insertion

- Monitor drainage system closely

Client teaching

- Injury prevention

- Medication safety (esp anticoagulants)

- Deep breathing exercises

- Early mobility when stable

Key differences from pneumothorax

Hemothorax

- Blood in pleural space

- Dull percussion

- Signs of blood loss/shock

Pneumothorax

- Air in pleural space

- Hyperresonant percussion

- More air-related respiratory compromise

Purpose of Chest Tubes

Chest tubes are inserted to:

- Drain air, blood, or fluid

- Re-establish negative pressure

- Promote lung re-expansion

- Restore intrapleural pressure

Removed when

- Lung re-expands

- Drainage stops

Chest tube Three chamber Drainage System

1. Collection chamber

- Collects drainage

- Measure & document output

2. Water seal chamber

- Acts as one-way valve

- Prevents air from re-entering pleural space

- Fill to 2 cm (minimum; follow manufacturer)

- Expected findings: Tidaling (rise and fall with breathing), intermittent bubbling if removing air (during coughing/exhaling)

- Abnormal: Continuous bubbling = air leak, no tidaling = obstruction OR lung re-expansion

3. Suction control chamber

- Wet suction: water level determines suction, usually -20 cm H2O, gentle bubbling expected

- Dry suction: dial set to prescribed suction (often -20), no bubbling expected

Indications for Chest Tube

- Pneumothorax

- Hemothorax

- Pleural effusion

- Empyema

- Post thoracotomy or open-heart surgery

Chest tube safety rules

Do NOT

- Clamp routinely

- Strip tubing

- Milk tubing

Clamp only if

- Ordered

- During system change

- During air leak evaluation

At bedside ALWAYS

- Oxygen

- Sterile water

- Occlusive dressing

- two hemostats

Chest tube expected vs unexpected findings

Expected

- Tidaling in water seal

- Gentle bubbling in suction chamber (wet system)

- Drainage increases with coughing

- System below chest

unexpected Report Immediately

- SaO2 <90%

- Sudden stop in drainage in first 24 hr

- Continuous bubbling in water seal

- Visible chest tube eyelets

- Signs of tension pneumothorax

Complications chest tube

Air leak: continuous bubbling in water seal

Accidental discontinuation: instruct client to exhale/cough, place tube end in sterile water, notify provider

Accidental removal: Cover with dry sterile gauze, apply occlusive dressing, call provider/rapid response

Tension Pneumothorax (emergency): tracheal division, absent breath sounds, JVD, cyanosis, respiratory distress

Accidental chest tube removal

1. Apply sterile occlusive dressing

2. Instruct client to exhale/cough

3. Notify provider/rapid response

4. monitor respiratory status

Expected findings in chest tube drainage system

Correct:

- Gentle constant bubbling in suction chamber

- Rise and fall in water seal with respiration

Incorrect:

- Continuous bubbling in water seal (air leak)

- Exposed sutures

- System at chest level (must be below)

Palliative Care - Attributes and criteria

◦ State of the art treatment tailored to the individual

◦ Support for the family and/or caregivers

◦ Interdisciplinary team approach

◦ Optimal assessment & management of physical & psychological

symptoms

◦ Eliciting and advocating for the wishes & preferences of patients and

developing a comprehensive and individualized plan of care

◦ Assisting patients in advance care planning including the delegation

of a surrogate decision-maker, clarifying values, preferences, &

beliefs in advanced directives, and out of hospital orders for life-

sustaining treatment with the completion of appropriate documents

specific to each state

◦ Promoting effective communication among patient, families, &

members of the interdisciplinary team

◦ Promoting continuity of care and care coordination across transitions

of care

Hospice Care

Care of an individual who cannot be cured or chooses not to be treated

Client anticipated to have 6 or fewer months to live (National Institute

of Aging, 2021, p. 3,7)

Care provided at home, facility, or nursing home

Respite care

Comfort care

Palliative sedation

Palliative Care

Physical, Psychological & psychiatric aspects of care

◦ Fatigue

◦ Sleep

◦ Nutrition

◦ Elimination

◦ Pain

◦ Mood and affect

◦ Anxiety

◦ Stress and coping

Structure & process of care

◦ Health care quality

◦ Caregiving

◦ Care coordination

Social aspects of care

◦ Family dynamics

◦ Development

Cultural & spiritual needs

Cultural affiliations can affect how clients view illnesses, which includes the end of life.

Cultural assessments

◦ View of end-of-life care

◦ Cultural rituals

Spiritual assessments

◦ Religious staff

◦ HOPE

Therapeutic communication

◦ Open-ended questions

HOPE tool for spiritual assessment

Hope

◦ What gives you a sense of hope, peace, or strength?

Organized

◦ Do you have a religion you belong to? Is your religion important to

you?

Personal spirituality and practices

◦ What are your personal spiritual beliefs? What spiritual practices

are most helpful for you?

Effects on medical care and end of life issues

◦ Has your illness interfered with the ability to do things that give

your life meaning and a sense of purpose? What spiritual practices

should we know about when we care for you?

End of Life - Expected findings

Early Stage:

◦ Loss of mobility

◦ Decrease ability/desire to eat or drink

◦ Cognitive changes - delirium or increased

sleeping

Middle Stage:

◦ Continued decline in mental status, increased

sleeping

◦ Noisy respirations - "death rattle"

Late Stage:

◦ Apnea

◦ Fever

◦ Mottling

Breathing and Respirations at the end of life

Dyspnea: shortness of breath

Retention of secretions in the

respiratory tract, also known

as "death rattle"

Cheyne-Stokes respirations:

an irregular respiratory rate

fluctuating between several

quick breaths and periods of

apnea

Pain at the end of life

Experienced by nearly 60% of

older adult hospice clients

who have cancer

Occurs as a result of nerve

injury, organs being stretched

and compressed, and/or bone

pain

Temperature at the end of life

◦ Ability of the nervous system to regulate body

temperature diminishes, causing clients to

experience both increased and decreased

temperature.

◦ Also caused by infection, cancer, and cancer

therapy.

◦ Mottling occurs hours or days before death, with

the upper and lower extremities becoming cool to

the touch. Mottling occurs as result of the heart's

inability to pump blood effectively, leading to

decreased blood perfusion throughout the body.

Vision and hearing at end of life

Clients may experience hallucinations or report

hearing and seeing those who have already died.

End of life - Nursing care/interventions

Pain control: Pharmacological & Nonpharmalogical methods

Dyspnea: Administer opioids& bronchodilators, administer oxygen at 2-3 L

Skin interventions: Incontinent care and change sheets PRN, apply lotion to the clients skin, turn and reposition every 2 hours. Pressure relief mattress PRN, wound care PRN

GI interventions: offer favorite foods and drinks, small, frequent meals are recommended, never force a client to eat, anorexia is a natural part of the dying process

Constipation: Hydration, medications, increased fiber

Fatigue: provide assistive devices such as commodes, shower chairs, & performing bathing, assess underlying cause for fatigue such as depression or dehydration