Med Surge EXAM 1

Reason for Surgery

Reason for Surgery

• diagnostic (trying to figure whats wrong)

• palliative (surgery to make PT more comfortable)

• cosmetic (plastic surgery)

Urgency of Surgery

• elective (PT choice)

• urgent (get to surgery soon)

• emergent (immediate)

Physical Stresses of Surgery

• resistance to infection is lowered

• organ function may be altered sue to manipulation

Psychological Stresses of Surgery

• fear

• pain

• anxiety

• loss of control

• body image

• alterations in ADL

Surgical Risk

• what to assess

• age

• nutritional status

• fluid & electrolyte balance

• medications

• general health status

Perioperative Nursing

prepare PT for surgery

Perianesthesia Nursing

care in the pre op area & discharge

Pre-op Phase

begins when decision for surgical intervention is made & ends with transfer of PT → to the operating room

What does the nurse do in the Pre-Op Phase

• PT history

• physical Exam

• PT medications

• Labs & Diagnostic tests

• teaching

Immediately Pre-Op

• baseline vital signs

• record loose teeth/remove dentures

• remove nail polish

• have PT void

• administer pre-op meds (if ordered)

• elevate side rails

Possbile Pre-Op meds

• anti-anxiety

  • Diazepam

• sedative

  • Midazolam

• analgesic

  • morphine sulfate

• anticholinergic

• H2 receptor Antagonist

Intra-Op Phase

• begins when PT is admitted/transferred to surgery

• ends when PT is admitted to PACU

Factors of Intra-Op care

• safety

• positioning

  • correct alignment

  • PT cannot move position for the whole surgery

• documentation

• surgical environment

  • traffic control

  • infection control

  • sterilization of supplies

• preventing inadvertent hypothermia

what do we want to prevent

• universal protocol

• wrong site

• wrong procedure

• wrong PT

ASA Classifications

• 1-6

1. healthy

2. 1 medical problem

3. severe systemic disease

5. not expected to survive w/o surgery

6. organ harvest

What is Anesthesia Induction?

the point @ which anesthesia initiated

Types of Anesthesia

• general anesthesia

• PT is completely under/unconscious

• HIGHEST RISK

• breathing tube is hooked up to a machine that breathes for the PT

• PT IS NOT in control

Types of Anesthesia

• Types of Regional Anesthesia

numbs a large part of the body

• Spinal

• Epidural

• Peripheral Nerve Blocks

• IV

• infiltration block

IV Anesthesia

• MAC

• administered by anesthesia provider

• PT maintains own airway

• many types of agents are available

IV Anesthesia

• Mederate Sedation

• administered by a non-anesthesia provider who has received special training

• PT can maintain their own highway

• limited agents ava

General Anesthesia Definition

• controlled loss of conciseness

• muscle relaxation

• protective reflexes lost

• sedation & analgesia

• IV, Inhalation, Narcotics

• HIGHEST RISK

General Anesthesia Potential Complications

• CNS

• emergency delirium

• delayed emergence (Pt is NOT waking up when they are supposed to)

General Anesthesia Potential Complications

• Cardiovascular

• hypotension

• dysrhythmias

• MI

General Anesthesia Potential Complications

• Hyperthermia

temp less than 95

Anesthetic Agents

• Opioids

• Morphine

• Fentanyl

• Sufentanyl

• Hydromorphone (Dilaudid)

• Meperidine (Demerol)

What is the opioid antagonist

Naloxone (narcan)

Anesthetic Agents

• Benzodiazepines

Sedatives

• diazepam (valium)

• midazolam (versed)

• lorazepam (ativan)

What is Malignant Hyperthermia?

disease that causes a fast rise in body temperature & severe muscle contractions

MH Triggering Agents

• Inhalation Agents

• halothane

• isoflurane

• desflurane

• sevoflurane

• succinylcholine (muscle relaxant)

MH signs & symptoms

• muscle rigidity

• tachycardia & dysrhythmias

• cutaneous changes

• tachypnea

• pyrexia (increase temp.)

Management of MH Crisis

• discontinue anesthesia

• administer 100% oxygen

• administer Dantrolene ASAP

  • PT cooling

Post-Op Phase

• begins with admission of PT to the recovery are

• ends with a follow-up evaluation in clinical setting setting or home

What do you monitor in the PACU

• airway, O2

• vitals signs

• LOC

• I & O

• Pain & Comfort

• Dressings

• Labs

• S/S of anesthesia complications

• S/S of surgery/procedure complications

• Anesthesia Report (what happened in pre-op)

Post-Op Handoff

obtain report from PACU nurse

• type of anesthesia

• PT allergies

• type of surgical procedure

• PT condition

• Status of vitals

• type & amt of IV fluid

• type of meds administered

• any incisions, dressings, tubes/drains, catheters

• estimated blood loss (EBL)

What is first priority in Post-Op care?

Airway

• note: rate, depth, rhythm

What to assess Post- Op

• respiratory

• rate & pattern

• breath sounds

• PT color

• use of accessory muscle

• oxygen status/pulse ox

Post Op Potential Complications

• respiratory

• atelectasis

• pneumonia

• embolus

Post-Op Nurs. Intervention

• respiratory

• Turn PT

• cough & deep breathing exercises

• maintain hydration

• early ambulation

• incentive spirometer

Incentive Spirometer

Breathing device to achieve maximal ventilation

• device measures respiratory flow & induces the PT to take a deep breath & hold for several seconds

• Position → sitting or semi fowlers

• 5-10 times every hr

What to assess Post- Op

• Circulatory

• vitals

• skin temp

• peripheral vascular assessment

• check for bleeding

Potential Complications

• Post Op Potential Complications

Thrombophlebitis

Post-Op Nurs. Intervention

• Circulatory

prevent by…

• leg exercises while in bed

• early ambulation

• TED stockings

• low dose heparin

  • sequential hose

What to assess Post- Op

• Neurological

• LOC (AAOx3)

• ability to obey verbal commands

• motor & sensory

What to assess Post- Op

• Renal/Urinary System

• I & O recording

• foley catheter (report output of <30 cc/hr)

What to assess Post- Op

• GI

• nausea/vomiting

• peristalsis (due to anesthesia)

• bowel sounds

• BM

• paralytic ileus

• NG tube drainage

Post-Op Nurs. Intervention

• GI

• Isopropyl Alcohol → for vomiting

  • NG tube → to decompress stomach/promote rest/allow GI tract to heal

What to assess Post- Op

• Pain

• scale of 0-10

Post-Op Nurs. Intervention

• Pain

• administer pain meds

  • oral/IV/IM

• Patient Controlled Analgesia (PCA)

• Document → reassess → document

Common Pain Meds

• opioid meds…

• Morphine

• Hydromorphone (Dilaudid)

• Codeine

• Oxycodone & ASA

• Oxycodone & acetaminophen

Common Pain Meds

• NSAIDS

• Ketorolac (Toradol)

• Ibuprofen (Motrin)

Post-Op Care

• mobilization

• sit up in bed & dangle legs (post-op night)

• OOB next day

  • is bases on physician order

Post-Op Care

• Diet

progress from NPO → liquids → soft → house diet as tolerated

• per physician orders

Approx. how long does it take a clean surgical wound to heal itself

2 weeks

Post-Op drainage

• sanguineous

• serosanguineous

• serous

Dehiscence

separation of wound edges

• organs stay inside

Evisceration

wound opens

• protrusion of bowels

• EMERGENCY

Different Drains

• Penrose

• Jackson- Pratt

• Hemovac

• T-tube

Who is the first dressing preformed by?

the physician

How do we prevent wound complications?

• splint incision when coughing

• monitor for signs of infection, malnutrition, dehydration

5 rights of Delegation

1. right task

2. right circumstances

3. right person

4. right supervision

5. right communication

Acute

an illness with an abrupt onset & short course

• ex: broken arm

Chronic

an illness that persists for a long period of time & a continuing disease process

• ex: diabetes, arthritis

What are the 3 levels of care

• emergent

• urgent

• non-urgent

Key factors to consider before delegating

• potential for harm?

• complexity of task?

• amt of problem solving needed?

• unpredictability of outcome?

• level of interaction required with PT?

What can an RN do?

• ALL MEDS

• admission assessment

• blood products

• care plan

• PT teaching

• UNSTABLE PT’s

• acute diseases

What can an LPN do?

• vitals

• uncomplicated skills

• STABLE PT’s

• chronic diseases

• Oral/IM/SQ/patches/inhalers

What can a UAP do?

• feeding

• basic hygiene

• basic skills

• STABLE PT’s

• chronic diseases

• ambulation

RN’s CAN delegate

• Stable PT’s

• requirements within caregivers job description

• when adequate supervision is available

• within skill & competency of caregiver

• minimal potential for harm

Factors to Consider when assigning rooms to PT’s

• bed availability

• LOC

• PT acuity

• Age/gender/special needs

• medical diagnosis

• infectious disease

• staffing

• attending physician

Factors to Consider when deciding which PT to see first

• ABC’s & PT safety

• PT Acuity

• Acute vs Chronic

• Onset vs Expected Manifestations

Normal Lab

• RBC

3.6-3.8 million/mm3

Normal Lab

• Hemoglobin

• male = 14-17.3g/dL

• female = 11.7-15.5 g/dL

Normal Lab

• Hematocrit

• male = 42% - 52%

• female = 36%-48%

Normal Lab

• WBC’s

4,500 - 11,000/cubic mm3

Normal Lab

• PLT

150,000 - 450,000

Normal Bleeding Time

3-8 minutes

what are the 3 Clotting Studies?

• PT

• PTT

• INR

What is an ESR Rate?

aka Sed Rate

• tells you how much inflammation is in the body

• normal rate <30 mm/hr

Hematologic System Diagnostic Studies

• CT

• MRI

• Bone Marrow Biopsy

  • Lymph Node Biopsy

Bone Marrow Biopsy Procedure

• lasts 5-10 min

• PT is sedated

• procedure is sterile

Bone Marrow Biopsy Prep

• Prep PT

• talk to PT about anxiety/pain

• education ( what to expect/feel)

• lay PT in prone, side-lying, or supine

Bone Marrow Biopsy Post Care

• apply pressure for 5-10 min

• cover w/ sterile dressing

• wear bandage for 24 hrs

• No tub bath or shower for 24 hr

• check for infection

• prevent bleeding

Aplastic Anemia

Bone marrow isn’t producing enough

• pancytopenia (↓ RBC, ↓WBC, ↓PLT)

Prevent complications from…

• hypoxia

• infection

• hemorrhage

Aplastic Anemia Nursing Care

• Neuro Assessment

• Good Handwashing

• avoid invasive procedure

• prevent problems immobility

• bleeding precautions

• increase fluid & fiber

What is Polycythemia?

Increase in # of RBC

Primary Polycythemia

chronic myleoproliferative disorder arising from chromosomal mutation in stem cell

• ↑ RBC, ↑WBC, ↑PLT, ↑ blood viscosity, ↑blood volume

Secondary Polycythemia

Hypoxia stimulates erythropoietin in kidneys

• ↑ RBC production

Secondary Polycythemia Complications

CVA, MI, PE

Polycythemia Clinical Manifestations

• headache

• dizziness

• dyspnea

• angina

• intermittent claudication

• weakness

• L.upper abdominal pain

Polycythemia Collaborative Care

• HYDRATION THERAPY

• small frequent meals

• avoid iron

• avoid tight-fitting clothing

• avoid citrus with meals (↑ absorption of iron)

• reduce blood vol & viscosity

• ambulate to decrease thrombus formation

• avoid extreme temp changes

Thrombocytopenia

Reduction in PLT

• <50,000 → risk for spontaneous

• <5,000 → risk for massive GI hemorrhage or CNS bleed

Mnemonic “RANDI”

Razor → electric

Aspirin → NO

Needle → small gauge

Decrease → needle sticks

Injury → prevent

Neutropenia

↓ WBC

• neutrophils = primary phagocytic cell

• ↓ neutrophils = ↓ immune response

Neutropenia Diagnostic Studies

ANC <1000 = @ risk for bacterial infection

ANC 500-1000 = moderate risk for bacterial infection

ANC <500 = severe risk for bacterial infection (EMERGENCY)

• peripheral blood smear

  • assess for immature cell

• Bone Marrow biopsy & aspiration

Neutropenia Collaborative Care

• PT teaching for fighting infection

• STRICT hand- washing

• be alert for minor complaints that may indicate infection

• private room

• avoid fresh fruits/veg/flowers

• no sick visitors

Leukemia

accumulation of immature cells due to loss of regulation in cell division

• Prob w/ WBC

• WBC overproduce

• WBC block & overcrowd bone marrow

• RBC & PLT are NOT being made properly

Leukemia Clinical Manifestations

• anemia

• thrombocytopenia

• neutropenia

Leukemia Nursing Care

• administer meds

  • help PT develop coping strategies

• assess lab reports for effects of drugs

Lymphoma

• Hodgkins

malignant condition caused by proliferation of abnormal, multinucleated cells (Reed- Sternberg cells) located in lymph nodes

Lymphoma

• Non-Hodgkins

malignant neoplasm of the immune system (B & T cells)