351 Test #1: MedSurg

speciality practice of med-surg nursing

* Promote, restore, or maintain optimal health for patients > age 18
* Nurses must have knowledge, skills, & attitudes (KSAs) to be:
* Care coordinators
* Transition managers
* Caregivers
* Patient educators
* Leaders
* Advocates for the patient and family
* Locations: skilled nursing facilities, hospitals, ambulatory clinics, patient’s home

Quality and Safety Education for Nurses (QSEN)

* Patient-centered care
* Safety
* Teamwork and interprofessional collaboration
* Evidence-based practice
* Quality improvement
* Informatics and technology

Patient-centered care

* The patient or designee (person who makes decisions on behalf of the patient) is source of control and full partner (QSEN, 2011)
* Cultural competence
* Family-centered care
* Respect for patients’ values, preferences, and expressed needs
* Interdisciplinary
* Teamwork
* Care coordination
* Transitional care
* Access

Safety

* The ability to keep the patient and staff free from harm and minimize errors in care
* The Joint Commission (hospital compliance): A Culture of Safety
* National Patient Safety Goals
* Requires a culture of safety: blame-free approach
* Serious (sentinel) events must be reported.

Common causes of harm and error

* Lack of clear communication
* Lack of attentiveness
* Lack of clinical judgment
* Errors in medication admin.
* Inadequate prevention of complications

Teamwork and interprofessional collaboration

* Function effectively within interprofessional health care teams, fostering open communication, mutual respect, and shared decision-making (QSEN, 2011)
* Includes:
* Ethics for interprofessional practice - Mutual respect & shared values
* Knowledge of role responsibilities (ours and others)
* Communication (including strategies such as SBAR)
* Teamwork – relationship-building values

Teamwork nursing process

assessing, analyzing, planning, implementing, evaluating

Delegation

* Process of transferring a selected nursing task or activity to a competent UAP (unlicensed assistive personnel): nurse tech, medical assistant 
* The nurse is always accountable for the task/activity delegated!
* Not necessarily the actions, just the fact that you delegated the task

Delegation requires:

* Supervision
* Guidance or direction, evaluation, and follow-up by the nurse to ensure a task/activity is performed appropriately
* There are some tasks that nurses cannot delegate to nursing assistants: assessment and evaluation (assessment of pain, evaluation of intervention), education, unstable patients (right circumstance) 


* Nursing assistants can only gather data

Five rights of delegation

right task, circumstance, person, communication, supervision

RNs can’t delegate

pain level

Evidence-based practice

* Integration of the best current evidence and practices to make decisions about patient care
* Considers patient preferences and values
* Considers one’s own clinical expertise for delivery of optimal health care

Quality improvement

* Indicators (data) used to monitor care outcomes and develop solutions to change and improve care
* Models
* PDSA

Informatics and technology is used to:

communicate, manage knowledge, prevent errors, and support decision making

Development of clinical judgment

Nursing process + Tanner’s Model of Clinical Judgment (patterns of noticing, interpreting, responding, and reflecting)

Can use the NCSBN Clinical Judgment Measurement Model: considers the context of your patients

1. Recognize clues: assessment
2. Analyze clues: assessment
3. Prioritize hypotheses : nursing diagnosis (patient’s biggest problem)
4. Generate solutions: plan
5. Take action: implementation
6. Evaluate outcomes: evaluation

Critical thinking

The skill of using logic and reasoning to identify the strengths and weaknesses of alternative health care solutions, conclusions, or approaches to clinical or practice problems

Clinical reasoning

The process by which nurses collect cues, process the information, come to an understanding of a patient problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process

Clinical judgment

The skill of recognizing cues about a clinical situation, generating and weighing hypotheses, taking action, and evaluating outcomes for the purpose of arriving at a satisfactory clinical outcome. Clinical judgment is the observed outcome of two unobserved underlying mental processes, critical thinking and decision making

Acid-base balance

* Maintenance of arterial blood pH between 7.35 and 7.45
* Acidosis (DKA) and alkalosis (basic)

Cellular regulation

* Cell growth, replication, and differentiation
* Benign (non-cancerous) /Malignant (cancerous) cell growth
* Healthy People 2030 goal to reduce cancer risk

Clotting

* A complex, multi-step process by which blood forms a protein-based structure (clot)
* Thrombosis or embolus (increased clotting)
* DVT, PE, blood clot 
* Prolonged internal or external bleeding (decreased ability to clot)
* hemorrhage

Cognition

* Reasoning/Learning/memory
* May be intact/adequate, or impaired
* Delirium: acute, common in hospitals 
* Dementia: prolonged, progressive 
* Depression: prolonged, can look similar to dementia 
* All seen in geriatrics and can appear similar 
* Decreased blood sugar can cause LOC changes

Comfort

emotional/physical, pain

Elimination: constipation/diarrhea

* Excretion of waste from the body (GI/Urinary)
* Continence versus incontinence
* Dysfunction of kidneys, bowels (GI), enlarged prostate (BPH)

Fluid and electrolyte balance

* Fluid volume excess or deficit (diuretics) 
* Hypokalemia, hyperkalemia, etc.

Gas exchange

* Inadequate transportation of oxygen to cells and carbon dioxide away from cells
* Ventilation & Diffusion (is oxygen reaching the blood?)

Glucose regulation

* type II diabetes, tumor 
* Maintenance of optimal blood glucose levels

Immunity

* Overactive: crohn's disease (autoimmune)
* Inactive: HIV
* Protection from illness or disease
* Active immunity/passive immunity

Infection

invasion of pathogens in the body

Inflammation

* Response to cellular injury, allergy, or invasion of pathogens
* Acute (sprained ankle) vs. Chronic (ulcerative colitis) 
* Local vs. Systemic

Mobility

* Dependent on central and peripheral nervous system & musculoskeletal system
* Aka “Functional Ability”
* Consider patients’ baselines in assessment

Nutrition

* ill-fitting dentures, stomach flu, Crohn’s disease- malnutrition 
* Process of ingesting and using food to maintain optimal body function
* Proteins, carbohydrates, fats, vitamins, minerals

Pain

* Unpleasant sensory or motor experience
* Acute vs. Persistent/Chronic Pain

Perfusion

* cast that’s too tight-obstructs blood flow 
* Adequate arterial blood flow through peripheral tissues (peripheral perfusion)
* Blood pumped by the heart to oxygenate major body organs (central perfusion)

Sensory perception

* Receiving & interpreting sensory input
* Vision, hearing, smell, taste, touch

Sexuality

“Physiological, emotional, social aspects of well-being related to intimacy, self concept, and role relationships.”

Tissue integrity: pressure ulcer, wound, rash

* Intactness of structure and function of integument and mucous membranes
* Intact versus impaired

priority concepts for a perioperative patient

gas exchange, pain

interrelated concepts for a perioperative patient

infection, tissue integrity

Hemoglobin women values

12-16 g/dL

Hemoglobin men levels

14-18 g/dL

Hematocrit women values

37-47%

Hematocrit men values

42-52%

AB+ blood is the

universal recipient

O- is the

universal donor

\+blood

have Rh

\-blood

don’t have Rh

aPTT

* 30-60 seconds
* Patients receiving anticoagulant therapy: 1.5-2.5 times control value in seconds

PT

* 11-12.5 seconds; 85-100%
* Full anticoagulant therapy: >1.5-2 times control value; 20-30%
* INR: 0.8-1.1

Platelet count for adults-elderly

150,000-400,000/ mm3

Perioperative assessment: pre-op history

* Review of systems (ROS) (head-toe assessment as a history)
* Medical history
* Surgical history
* Social history (alcohol, drugs, nicotine) 
* Psychological status and support (who is going to help them at home)
* Cultural or spiritual needs (food requests or needs, see them chaplin, want a certain gender of care provider, may not accept blood products, how anxious the patient is)

Perioperative assessment: increased risk

* Age older than 65
* Medications: immunosuppressants, NSAIDs
* Medical history: cardiopulmonary disease, impaired immunity, active infection, DM, coagulation disorder, obesity, substance use/abuse, any chronic disease
* Prior surgical experiences: anesthesia reactions/complications, post-operative complications
* Type of planned procedure: head/neck surgery (airway occlusion), chest procedure (atelectasis-risk for pneumonia), abdominal surgery (paralytic ileus and DVT)

Focused preoperative physical assessment: cardiopulmonary

* Hypotension/hypertension 
* Bradycardia, tachycardia, dysrhythmia
* Chest pain 
* Dyspnea or tachypnea
* Pulse ox

Focused preoperative physical assessment: infection

* Fever, increased WBC
* Wounds, respiratory, or urinary symptoms

Focused preoperative physical assessment: contraindications for surgery

* Increased PT, INR, or aPTT
* May not even do surgery if these numbers are out of range 
* Coagulation issues-inability to create clots after surgery 
* Hypo/hyperkalemia 
* Positive pregnancy test
* Recent PO intake (within 6 hours)

Focused preoperative physical assessment: conditions to evaluate further

* Change in mental status
* Vomiting
* Rash
* Recent anticoagulants

Pre-op planning short-term outcomes

* The patient will demonstrate improvement in symptoms
* The patient will describe/demonstrate appropriate self-care strategies (to be used during post-op period)

Pre-op planning long-term outcomes

The patient will not experience any complications (of the surgery)

Perioperative implementation

pre-op teaching and anticipatory guidance

Perioperative implementation: prevent complications

* DVT (use SCDs-creates blood flow pumping motion), atelectasis (incentive spirometer (breath in) -bacteria can grow-pneumonia), paralytic ileus, early \*ambulation prevents these things 
* Splitting helps with abdominal surgeries, holding a pillow to the chest to prevent pain 
* Initially give meds on a scheduled basis to reach a therapeutic dose even if they are PRN

Perioperative planning for patient teaching

\*focus on early ambulation-prevents pressure ulcers, constipation

Perioperative implementation: informed consent by the surgeon

1. Nature of procedure
2. Risks and benefits
3. Reasonable alternatives
4. Assessment of the patient’s understanding

Perioperative implementation: informed consent by the nurse

* Verify form is signed
* May serve as witness to patient’s signature 
* Is NOT witnessing that the patient understands
* Client confused about surgery: request surgeon

Post-op assessment: respiratory complications

atelectasis: listen to lung sounds (diminished, popping sounds), ask about dyspnea, O2 sats (low), elevated RR

Post-op assessment: cardiovascular complications

* VTE (warm skin, intermittent claudication-pain while walking), dysrhythmias or HF, hypo/hypertension, sepsis, SOB with PE
* HF right-sided: edema, left-sided: fluid in the lungs 
* Skin assessment, turn every 2 hrs
* Blood pressure measurements
* Check wound drains

Post-op assessment: neurologic complications

* CVA, cognitive decline
* Neuro status assessment 
* CVA: paralysis on one side of the body 
* Changes in vision

Post-op assessment: neuromuscular complications

* nerve damage
* Monofilament test (lost of sensation, tingling)
* Slower reflexes

Post-op assessment: GI complications

* stress ulcer (not caused by H.pylori, surgery causes physiologic stresser), paralytic ileus (intestines are paralyzed, peristalsis isn’t working, type of bowel obstruction, causes N/V)
* Constipated, incontinence 
* PPI given to treat stress ulcer 
* Paralytic ileus: nausea, won’t eat, not having BM because nothing is moving through

Post-op assessment: renal/GU complications

* AKI (elevated creatinine or BUN-lab results, may require dialysis), acute urinary retention (medications we give), electrolyte imbalance (medications, IV fluids, dehydration)
* Concentrated urine, not voiding 
* Potassium- EKG effects 

Post-op assessment: skin complications

* pressure injuries, wound infection or dehiscence (separation of approximated wound edges) 
* Skin assessment, non-blanchable redness, purulent drainage

Post-op focused assessment

PACU and then Med-Surg unit: make sure to get a full set of vitals and orient them to their room, how they would ask for help, who is taking care of them

Post-op focused assessment: neuro status

* Awake, arousable, oriented, aware?
* Are peripheral pulses palpable?

Post-op focused assessment: respiratory status

* Airway patent?
* RR and depth? LS CTA?
* Use of accessory muscles?
* O2 Sat? Setting and method of oxygen delivery?
* Incentive Spirometer?

Post-op focused assessment: cardiovascular status

* BP/HR within baseline range?
* Values different than in (PACU)?
* VTE prophylaxis?

Post-op focused assessment: GI/GU status

* Post-Op N/V (PONV)?
* Urine output?

Post-op focused assessment: derm status

* Pressure ulcers? Redness?
* Check coccyx to see if there are pressure ulcers when the patient stands up or is transferred

Post-op focused assessment: surgical incision status

* Dressing? Drainage? Swelling?
* Bleeding/drainage under patient?
* Drains present? Quantity in container? Positioned properly & draining?

Post-op focused assessment: IV fluid status

* Type? Additives?
* How much solution remaining?
* Rate of infusion? Ordered rate?

Post-op focused assessment: other tube status

* NG or intestinal tube?
* Drainage color, consistency, and amount?
* Suction ordered?
* Foley? Draining properly?
* Urine color, clarity, and volume?

Post-op focused assessment: general status

lab results

post-op assessment: drains

* A. Penrose: acts like a wick, used for a day 
* B. T-tube
* C. Jackson-Pratt (JP): creating a vacuum and patients go home with them, teach how to track output, have to squeeze before you plug it in again 
* D. Hemovac: greater volume for larger spaces, suction vacuum, maintain pressure, record volume and type of fluid

Post-op assessment: monitoring for complications of spinal or epidural anesthesia: paralysis and loss of sensation in the legs

* Respiratory depression
* Hypotension
* Post-dural puncture headache (spinal headache)-leak of cerebrospinal fluid, increased pressure in the brain, lie flat to resolve

Post-op planning and interventions: addressing and preventing complications

outcome: patient is free of post-op complications

post-op planning/interventions: improve gas exchange

* Incentive spirometer
* Walking around 
* Cough, deep breath, turn

post-op planning/interventions: prevent wound infection/delayed wound healing

* Drain
* Cleaning dressing 
* Increase protein intake to promote healing
* Increase hydration

post-op planning/interventions: promote peristalsis

* Walking around 
* Stool softeners
* Fiber diet
* May have to wait around for body to work on its own or put in an NG tube

post-op planning/interventions: manage pain

* Pain meds 
* Music, dancing, acupuncture 
* Pain assessment

post-op planning/interventions: prevent venous thromboembolus

* SCD
* Compression socks
* Walking around 
* SQ heparin

post-op planning/interventions: manage urinary retention and constipation

* Diuretic 
* Catheter 
* Laxative
* may have to wait around for body to keep working again, parasympathetic NS needs to start again

post-op planing and implementation: moderate sedation, ED

Outcome: the patient will be free of symptoms of medication overdose

Opioids

* Prepare to administer naloxone hydrochloride (Narcan); may need to be repeated
* Have suction available
* Assess pain level, as naloxone reverses analgesic effect of opioids

Benzodiazepine: ativan

* Prepare to administer flumazenil (Romazicon); may need to repeat PRN
* Monitor for S/E of flumazenil: dizziness, HA, dry mouth, blurred vision

Opioids and benzodiazepines:

* Half-life is longer of drug than reversal agent: may need to give several doses 
* Monitor and support airway
* Administer O2 if hypoxia or RR

post-op planning/implementation: discharge teaching

* Outcome: the patient will demonstrate or restate ways to safely care for self at home
* Pain management
* Drug therapy with reconciliation of postoperative drugs
* SAFETY (e.g., understanding who to contact in case of complications, progressive increase in activity, needed assistive devices)
* Continuation of interventions to prevent post-op complications
* Management of drains or catheters
* Nutrition therapy
* Follow-up with the surgeon

glucose normal adults ranges

74-106 mg/dL

glycoslyated hemoglobin normal ranges

good diabetic control:

diabetes typically occurs in

Native American populations with an education less than high school and family income in poverty

diabetes assessment: risk factors

* First degree relative with DM
* Physically inactive
* High risk ethnic populations
* African American, Hispanic American, American Indian, Pacific Islander

diabetes assessment: history

* Gestational diabetes mellitus
* Infants more likely to have diabetes later in life
* Higher infant birth weight 
* Vascular disease
* HTN