Nursing 2050 Exam 4

pH

Determines acid/base balance
Measure of Ions in Arterial Blood

High Blood pH

Low Concentration

Low Blood pH

High Concentration

CO2 Causes

Acidosis

HCO3

Alkalosis

Normal Body pH

7.35-7.45

Normal Blood CO2

35-45mmHg

Normal HCO3

22-26

Respiratory Acidosis

pH is low, and CO2 is high

Respiratory Alkalosis

pH is High, and CO2 is low

Metabolic Acidosis

pH is low, HCO3 is low

Metabolic Alkalosis

pH is high and HCO3 is High

Compensation

Processes to Return pH to normal levle

Respiratory Acidosis Compensation

Kidneys Increase levels of HCO3 to decrease pH to normal ranges
HCO3 Remains Elevated

Respiratory Alkalosis Compensation

Decrease HCO3 in the blood to push pH back into normal ranges

Metabolic Acidosis Compensation

Lungs Decrease CO2 levels in the blood
Done through Hyperventilation

Metabolic Alkalosis Compensation

Lungs increase CO2 in the blood
Done Through Hypoventilation
Most Difficult to compensate for as body requires oxygen and breathing can only be slowed so much

Kidney Compensation

More Difficult to accomplish than Lung Compensation
Can take days to see effects - 3-5 days for full compensation

Lung Compensation

Takes Minutes to Complete
Much quicker than kidneys

Causes of Respiratory Acidosis

Alveolar Hypoventilation
Opioid Overdose/CNS depression

S/S of Respiratory Acidosis

Bradypnea
Cyanosis
Decreased LOC
Cardiac Dysthymias (not a compensation)

Respiratory Acidosis Treatments

Intubation
O2 Therapy
Bronchodilation

Causes of Respiratory Alkalosis

Anxiety
Ventilator Settings

s/s of respiratory Alkalosis

Tachypnea
Excitement
Dizziness
Numbing

Treatment of Respiratory Alkalosis

Decrease Anxiety
Brown Paper Bag
Teaching on Full Breaths
Changing the Vent Settings

Causes of Metabolic Acidosis

Sepsis - release of lactic acid
DKA
Renal Diseases

Metabolic Acidosis S/S

Tachypnea
Kussumaul Breathing
Decreased LOC

Metabolic Acidosis Treatment

Treat Underlying Causes

Compensated vs Uncompensated

If it is an unbalanced CO2 to HCO3 but Blood pH is Between 7.35-7.45 it is compensated

Causes of Metabolic Alkalosis

Excessive: Vomiting, Diarrhea, Gastric Suctioning

Metabolic Alkalosis S/S

Bradypnea
Numbness
Tachycardia

Treatment of Metabolic Alkalosis

Antidiarrheals
Antiemetic
Replenish Fluids and Electrolytes

Phases of Perioperative Experience

Pre - intra and post

Preoperative Phase

Diagnosis with need of surgery - being on the table

Intraoperative Phase

On the table - PACU

Post operative phase

Leaving PACU - Stabilized and released by physician

Elective Surgery

Optional, Minimal Consequences if Not Performed
Out patient

Urgent Surgery

Surgery Needs to Take Place or Serious Consequences will occur
Inpatient

Emergent Surgery

Needs Performed ASAP
Inpatient
- Traumas Fall Here -

Obesity Complications/Risk Level

Difficulty Moving Patient
Poor Wound Healing
High Risk of CAD, Hypertension, Diabetes, Respiratory Complications
MILD TO MODERATE RISK

Old Age Complications/Risk

More Sensitive to Anesthetics
Poor Nutrition
Skin Break Down
MILD TO MODERATE RISK

Heart Disease Complications/Risk

Stressor on the Hearth
MI on table
Acute CHF
ICU may be needed to monitor Risk
MODERATE TO HIGH RISK

Bleeding Disorder Complications/Risk

Bleeds During Surgery
Clotting Issues Post OP
Could be caused by liver disease
HIGH RISK - REQUIRES TRANSFUSION

Pulmonary Disease Complications/Risk

More Difficult to manage airway
Lots of anesthetics are inhaled
High risk for Pnumonia
MODERATE TO HIGH RISK
- need pulmonologists signature before surgery -

Liver Disease Complications/Risks

Cannot metabolize anesthetics
Malnutrition from lack of protein
Bleeding Issues
MODERATE TO HIGH RISK

DM Complications/Risks

Slow Wound Healing - low glucose control
MODERATE RISK
- requires endocrinologists signature -

Signs of Cardiac or Pulmonary Compromise

Irregular Pulses
Edema
RR/O2 SAT
Lung Sounds
Heart Sounds
Weight Gain 2+LBS
JVD

Bowels and Surgery

Anesthetics and Opioids Slow Bowels

Type and Cross Match

Blood typing - Looks for Donor compatability
- ONLY GOOD FOR 48 HOURS -
Ensures blood can be replaced

EKG's

given to all patients over 40

CXR

ensures no pulmonary risks are present

Leukocytes

5-11k cml
-5 is immunosuppressed
11+ indicates infection, inflammation, allergy
13 - 14 is inflammation
17+ infection

Types of WBC's

Neutrophils - bacteria
Lymphocytes - Viral/Fungal
Eosinophils - Allergy

Erythrocytes

4-6 Million normal range
Concern if less than 4

Platelets - Thrombocytes

150k-400k
problem below 90k as clotting will not take place

Heme Levels

12-16 (f)
14-18 (m)
Transfusion not given unless less than 8
Hematocrit - 40-50% - low means Fluid Overload - high means deficit/dehydration

Electrolyte Concerns

Ca and K - concerns about electrical rhythms in the heath - concerns about bp
BMP (chempannel)

Creatinine - Kidney Funciton

Range 0.6-1.2
Tells if patient can excrete drugs

ALT

A Liver Test
Liver Enzyme Test - also AST and AFT

Meds which are not held before surgery

Thyroid Medications
some hormonal medications
Endocrine Medications

All Patients Are shaven before surgery

usually done by assistive personel

CHG baths

Kills Exterior STAFF bacteria
done 3 days prior to surgery
Neck Down (Exclude Genital Areas)

Prosthetics/Jewlrey

All Must Be Removed before Surgery
(if it can be removed it needs to be)
Wedding bands must be removed

Informed Consent

Nurse must be able to say the patient was knowledgeable (not that they know what they are consenting to)
Consents for Surgery, to Receive Blood, and Anastasia

Pre Op Sequence

Informed Consent - Give Meds - Labs on Chart -Patient Urinates - 4 rails up for transport - report to circulating nurse

Types of Anesthesia

Local, Regional, General, Moderate Conscious Sedation

Local Anesthesia

Blocks Nerve Impulses at the Cite
Wear Gloves

Regional Anesthetics

Loss of Sensation to an Area by Injecting Along a Nerve Pathway
Epidurals
Watch for: Hypotension, Respiratory Paralysis, Risk for Falls

General Anesthetics

Total Loss of Consciousness
Three Phases - Induction, Maintenance, Emergence

Moderate Conscious Sedation

Happy Drugs
Short Term Surgical Diagnostic Use
Patient can Maintain Airway
Resuscitation Equipment Must be Near

Scrub Nurses

Set Up Instruments for Surgery
Know what Surgery is taking Place
Know How the Surgeon Likes the Room
Responsible for Clean Up
Responsible for Scrubbing in - Sterile
Monitor Sterility
Second Set of Eyes on Vital Signs
RN or LPN

Circulating Nurses

Maintains Safe and Comfortable Environment
Not Sterile
Fixes item issues which are not sterile
Initiates Time Out's Before and During Surgery
Responsible for Patient Experience - Patient Care - Care Plan - Patient Precautions
Assist Anesthesiologist - Pull Meds - Label Specimens
Count Tools Before, During, and After Surgery

RNFA

Certification
Watch for Complications - Monitor Vital Signs
Close Wounds - identify bleeds - Cauterize or Suture Wounds - Apply Dressings
Assess Patient during procedure

Operating Room Technicians

Set up and Clean up
Scrubbed in
ID Sterile Breaks
Manipulate Tools

Medical Team Members

Surgeon
Surgical Assistant
Anesthesiologist
Anesthetist
Technical Representative
CRNA - works under Anesthesiologist
Perfusionist

PACU Management

Airway, Breathing, Manage Circulation, Pain and Nausea/Vomiting Control, Temperature Control, Family Management

Managing Airway

Artificial Airway - Extubated out of Surgery - put in if unable to maintain own airway
Proper Positioning - Elevate HOB - Place on their Side

Managing Breathing

Administer oxygen at High Flow Rates
4L+ needs humidified
Assess Lungs
Position for Ventilation
Pulmonary Toilet

Managing Circulation

Monitor Pulse and BP every 15 minutes
Assess for Shock - HR >120 - Hypotension

Pain and Nausea

IV Pain control
N/V Antiemetics - IV

Temperature Control

Cold in OR
People Shiver
Assess for Malignant Hyperthermia

Malignant Hyperthermia

Hypermetabolic State which affects Skeletal Muscles when Triggered by Anastasia
Tachycardia, Tachypnea, Arrythmias, Hyperkalemia, Muscle Rigidity
Temp 103+
Organ Failure

Family Management

Update Family, and Allow them to briefly visit

Discharge from PACU

Stable, A&Ox3, Clear Own Airway, Bedside Report

Post OP care

Validate Stability, RN takes vital signs, Follow Physicians Orders, Give Foods and Fluids, Ambulation, Urination and Bowel Movement, Pain Control.
Stability First Priority

Discharge Teaching

Print of sheets
Teach Necessary Skills
Teach about abnormal Findings

Assess for Complications

Bleeding from Wounds
Call physician if saturated within 15 minutes
Infection
Dehiscence
Hernias
Pneumonia
Constipation

Follow-up

Appointments/Checkups

Bowel Impaction

Constipation
S/S - inability to pass stool
Obstructions can require
Bradycardia, need Cardiac Monitor
Remove impactions by hand if necessary

Diarrhea

Acute 1-2 days
Persistent 2-4 weeks

Diarrhea Causes

GI bugs
Prolonged Emotion Distress
IBS
Crons
Duodenal Ulcer

Diarrhea Complications

Elderly and Infants
High Fevers
Blood in Stool
Abdominal Pain

Flatulence

Causes Abdominal Pain, Fullness, Cramping
Contributing Factors, Diet, Medications, Surgery, Immobailization
Tx - avoid bad foods, movement, gasx

Hemorrhoids

Internal or External Engorged Veins
Pain with thrombosis, or internal protruding

Hemorrhoid Causes

Venous Pressure
Pregnancy
Heart Failure
CLD

Hemorrhoid Tx

diet, fluids, stool softeners,

Fecal Incontinence

Inability to control Passage of Feces
Passive - unaware of passage of liquid Feces
Urge - urge is present, but gone by time toilet is reached

Fecal Incontinence Causes

Nerve Damage
Weak Pelvic Floor Muscle
Immobility

Fecal Incontinence Implications

Skin Irritation and poor self esteem
Skin Breakdown
Social Isolation

C-Diff

Contact Isolation