Med Surge Exam 1

HTN is more common in

-men
-african americans
-southern US

ABCS to control HTN

A: aspirin
B: BP control
C: cholesterol management
S: smoking cessation

normal BP

elevated BP

120-129/

stage 1 HTN

130-139/80-89

stage 2 HTN

\>140/\>90

primary HTN cause

idiopathic

how many HTN cases are primary HTN

20%

primary HTN risk factors

-high Na intake
-fast food
-alcohol
-smoking
-family history
-age
-genetics
-race

why is there so much Na in processed foods

it is used as a preservative so elderly and poor pts consume a lot of it

secondary HTN cause

-from another disease like kidney disease or sleep apnea
-side effects of drugs like steroids which cause fluid retention

brain damage from HTN

-hemorrhage
-stroke

eye damage from HTN

retinopathy

heart damage from HTN

-left ventricular hypertrophy
-chronic heart disease
-congestive heart failure

kidney damage from HTN

-renal failure
-proteinuria

what parts of the body does HTN affect

-organs
-extremities

how to diagnose HTN

-BP reading
-ECG
-CBC
-urinalysis
-fasting glucose
-electrolytes
-lipid profile

what to do if there is a disparity in BP reading in systolic and diastolic

the higher value determines the HTN level

white coat syndrome

BP increases at the hospital due to stress

how to get secondary HTN diagnosis

-Cr clearance
-urine albumin
-Ca
-uric acid
-plasma renin activity
-aldosterone measurement

lifestyle modifications for HTN

-weight loss
-eat fruits and veggies
-reduce Na
-increase activity
-DASH diet
-exercise

CDC Na recommendation

no more than 2300 mg per day (1 tsp)

DASH diet

dietary approach to stop HTN

exercise recommendations to reduce HTN

-150 mins per week
-mention CV issues to Dr

BP for HTN

what BP level does the WHO recommend drugs for

\>140/\>90

first line drugs for HTN

-thiazide diuretics
-CCBs
-ACE inhibitors
-ARBs

why are thiazide diuretics good for HTN

-impair Na absorption
-initial drug for people of African descent

why are CCBs good for HTN

-relax/widen blood vessels-slow HR
-initial drug for people of African descent

why are ACE inhibitors good for HTN

-stop RAAS stimulation
-first line drug for someone with a kidney injury

why are ARBs good for HTN

-stop RAAS stimulation
-first line drug for someone with a kidney injury

can you take ACE inhibitors and ARBs at the same time

no

what drug to take if you have HTN and heart disease

beta blocker

beta blocker side effect

erectile dysfunction

ace inhibitor side effect

dry cough

drug administration for stage 1 HTN

-prescribe 1 drug
-

drug administration for stage 2 HTN

-prescribe 2 drugs
-drop BP slowly so MAP is not lowered more than 10-20% at a time

factors that affect drug orders for HTN

-differing drug responses
-cost
-comorbidities
-drug interaction

what to focus on during HTN follow up

-Na/K levels
-BP goal

why is there poor treatment adherence for people with HTN

-no symptoms before med and then side effects post meds
-cost
-lack of pt education

strategies for HTN detection

pt outreach (barbershops for black men campaign)

malignant HTN adverse effects

-cerebral edema
-retinal hemorrhage
-acute renal damage

malignant HTN

\>180/\>120 (hypertensive crisis)

malignant HTN symptoms

-blurred vision
-headache
-confusion

malignant HTN treatment

lower BP slowly (10-20% per hour)

longterm malignant HTN goal

exceptions for gradually lowering BP for malignant HTN

-acute ischemic stroke (keep BP high)
-aortic dissection (lower quickly)
-hemorrhagic stroke (lower quickly)

preop

from when a person decides to have surgery until they are transferred to operating room bed

interop

form when in operating room until admitted into PACU

post op

form when in PACU until released from surgeon's care

emergent surgery

-need surgery immediately or death
-a lot of trauma patients
-life threatening if surgery is not done immediately
-only time you don't necessarily need consent for surgery

urgent surgery

patient needs prompt attention within 24-30 hours

examples of urgent surgeries

-acute cholecystitis
-kidney stones
-fractures
-drainage of abscess

required surgery

-patient needs to have surgery within weeks/months
-could lead to more serious health issues if not addressed

examples of required surgeries

-mass of breast
-skin lesion
-basal cell carcinoma
-prosthetic hyperplasia

elective surgery

patient should have surgery but failure to have surgery is not catastrophic

examples of elective surgeries

-hernia repair
-vaginal repair
-cyst
-lipoma

optional surgery

cosmetic surgeries

when do you need informed consent

for all nonemergent surgeries

who does informed consent protect

patient and physician

who gets the informed consent signed

the physician, but the nurse can witness it

when do you need informed consent from anesthesia

if it is anything more than local anesthesia

informed consent criteria

-voluntary
-freely given without coercion
-informed subject
-pt able to comprehend

what does it mean to inform the subject

-discuss procedure, risk, benefits
-offer to answer questions
-allow pt to refuse

who can't sign informed consent

-someone who can't comprehend it
-minor

points of emphasis for surgery prep

-past adverse anesthesia effects
-meds they are on
-allergies
-PMH/PSH
-substance abuse
-nutritional status

meds to pay attention to during surgery prep

-garlic (impairs coagulation)
-ginseng (increases coagulation)
-aspirin
-warfarin (impairs coagulation

allergies to pay attention to during surgery prep

-latex
-fish (iodine)

why do we pay attention to obesity during surgery prep

increases evisceration risk

preop diagnostic tests

-CBC, lytes, UA
-EKG
-chest x ray
-type and screen / type and cross
-pregnancy tests
-H and H
-WBCs
-urinalysis

steps for deep breathing/coughing

-sitting position
-splint incision
-deep breaths x3
-quick deep breath
-strong cough
-repeat x3

how to use incentive spirometer

-sit edge or raise HOB as far as possible
-place mouthpiece in mouth, seal lips around
-breathe in as slowly and deeply as possible
-raise piston to yellow indicator
-hold breath for 5 seconds
-allow piston to fall
-repeat 10 times/hr while awake
-use yellow indicator to indicate\= best effort
-after 10 breaths, cough while splinting incision

foot exercises to improve venous flow

-point toes to head and foot of bed
-repeat five times on each foot

leg exercises for circulation

-bend knee and raise it toward chest
-straighten leg and hold for 5 seconds
-lower to bed

ankle exercises for circulation

rotate ankle

devices for circulation

-SCDs
-TED hose

rational for early mobility/turning

-good for circulation
-reduces pressure ulcers
-helps GI tract
-reduce atrophy
-helps respiratory
-shown to decrease hospitalization stay

NG tube drain

-goes thru nose into stomach
-hooked up to suction to drain stomach contents

chest tube drain

for any kind of thoracic surgery where you think there will be bleeding into pleural space

JP drain

causes suction for drainage at surgical site

hemovac drain

suction for ortho cases

penrose drain

-often used for abscesses
-not really used anymore bc not a closed system

pain management

-teach about pain communication in preop
-explain pain scale in preop
-pain is subjective so the pain scale is specific to pt
-we don't want to play catch up with pain
-addiction does not typically happen for short term pain relief

physical effects of pain

-increased BP
-impaired mobility
-impaired respiration

PCA pump

-pt controlled analgesia
-pt cannot overdose
-keep monitoring respiratory closely
-not appropriate for pts that are cognitively impaired
-don't let pt's family member give dose
-don't give dose yourself
-if pt can't use PCA pump correctly you need to get an order for a different type of pain medication
-if pt leaves unit with PCA pump, the pump is discontinued

NPO before surgery rules

-usually NPO after midnight for AM surgery
-no gum/hard candy

NPO purpose

-promotes gastric emptying
-decreases risk of aspiration

day of surgery tasks

-confirm preop checklist completed
-record baseline vitals
-check pt's ID and allergy wrist band
-pt is to wear hospital gown, no underwear
-remove nail polish, makeup, all jewelry
-remove dentures/bridges
-remove eyeglasses, hearing aids unless pt needs them to communicate with anesthesia/OR personnel prior to anesthesia
-pt should void prior to leaving for OR

preop meds

-may be ordered "on call for OR"
-used to relieve anxiety and facilitate anesthesia
-if med is ordered that effects cognitive ability, make sure surgical and anesthesia consents are signed prior to administration
-antiemetic may be given to prevent nausea from anesthesia
-eye drops may be ordered prior to eye surgery

what to verify before operation

-correct person
-correct site
-correct procedure

how to prevent wrong site, wrong procedure, wrong person

-preop verification
-mark procedure site
-time out

unrestricted OR zone

can wear street clothes

semi restricted OR zone

must wear scrubs and surgical cap

restricted OR zone

must wear scrubs, surgical cap, mask

who on the surgical team is sterile

The surgeon, assistants to the surgeon, and the scrub team

who on the surgical team is non sterile

nurse anesthetist, anesthesiologist, circulating nurse, radiology technicians, medical device representative, and additional staff

general anesthesia

-inhalation
-monitored anesthesia care

regional anesthesia

-epidural (slower)
-spinal (rapid)

local anesthesia

causes the loss of sensation in a limited area by injecting an anesthetic solution near that area

positioning considerations during surgery

-prevent hyperextension of extremities
-prevent pressure on nerve
-prevent circulation occlusion
-padding to prevent pressure ulcers