Med Surge EXAM 1

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
4. \
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

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

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

*

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

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)