Med Surg 1 = Exam 1 Study Guide

13.1: Identify trade and generic names of medications

*Trade name - also referred to as the brand name, it is the manufacture's name for the medication. A trade name is for the sole use of the company that manufactures the medicine. The Trade name is identified by the ®, which is the registered symbol. *Generic name - also known as the official name of the medication. It is always the name underneath the Trade name (smaller print). [It is important to remember that a medication may be manufactured by different manufacturers but market it using a different trade name].

13.7 Compare metabolic acidosis with regard to causes, clinical manifestations, diagnosis, and management.

- Low pH <7.35- Low bicarbonate <22 mEq/L - Most commonly due to kidney injury. Manifestations: headache, confusion, drowsiness, increased respiratory rate and depth, decreased blood pressure, decreased cardiac output, dysrhythmias, shock; if decrease is slow, patient may be asymptomatic until bicarbonate is 15 mEq/L or less. Correct underlying problem, correct imbalance. -Bicarbonate may be administered. With acidosis, hyperkalemia may occur as potassium shifts out of cell - As acidosis is corrected, potassium shifts back into cell, potassium levels decrease. -Monitor potassium levels. Serum calcium levels may be low with chronic metabolic acidosis -Must be corrected before treating acidosis

13.4 Plan effective care of patients with the following imbalances: fluid volume deficit and fluid volume excess, sodium deficit (hyponatremia) and sodium excess (hypernatremia), and potassium deficit (hypokalemia) and potassium excess (hyperkalemia).

-Fluid Volume Excess: before the condition becomes severe, Interventions include promoting rest, restricting sodium intake, monitoring parenteral fluid therapy, and administering appropriate medications. Weigh patients daily, assess breath sounds regularly, monitor the degree of edema in extremities. Diuretics are prescribed when dietary restriction of sodium alone is insufficient to reduce edema by inhibiting the reabsorption of sodium and water by the kidneys. -Fluid Volume Deficit: monitors and measures fluid I&O at least every 8 hours, and sometimes hourly. observes for a weak, rapid pulse and orthostatic hypotension. Vital signs are closely monitored -Sodium deficit (hyponatremia): careful administration of sodium by mouth, nasogastric tube, or a parenteral route, restricting fluid, it may be necessary to administer small volumes of a hypertonic sodium solution with the goal of alleviating cerebral edema. monitors I&O as well as daily body weight. -Sodium excess (hypernatremia): Fluid losses and gains are carefully monitored in patients who are at risk for hypernatremia. The nurse should assess for abnormal losses of water or low water intake and for large gains of sodium and potassium deficit (hypokalemia) and potassium excess (hyperkalemia). Sodium deficit (hyponatremia) Serum sodium <135 mEq/L -(Loss of sodium, as in use of diuretics, loss of GI fluids, renal disease, and adrenal insufficiency. , the nurse encourages foods and fluids with high sodium content to control hyponatremia. it is safer to restrict fluid intake than to administer sodium. treatment for hyponatremia is careful administration of sodium by mouth, nasogastric tube, or a parenteral route). Sodium excess (hypernatremia) Serum sodium >145 mEq/L (Treatment of hypernatremia consists of a gradual lowering of the serum sodium level by the infusion of a hypotonic electrolyte solution).

19.3 Identify common post-operative problems and their management

-Hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood Oxygen is given by nasal cannula, facemask, or mechanical ventilation -Hypopharyngeal obstruction (elevate the patient head to open airway) -Hypotension and Shock, Hypertension and Dysrhythmia. -Hypertension and dysrhythmias are managed by treating the underlying causes. -Hemorrhage: Timely administration of IV fluids, blood, blood products, and medications that elevate blood pressure in case of shock. -Vomiting: the patient is turned to the side to prevent aspiration. cardiovascular stability, the nurse assesses the patient's level of consciousness; vital signs; cardiac rhythm; skin temperature, color, and moisture; and urine output - Pulmonary infection/hypoxia - Venous thromboembolism (VTE) (e.g., deep vein thrombosis [DVT], pulmonary embolism [PE]) - Hematoma or hemorrhage - Infection - Wound dehiscence or evisceration Serious potential VTE complications of surgery include DVT and PE - Low-molecular-weight or low-dose heparin and low-dose warfarin (Coumadin) are other anticoagulants that may be used - External pneumatic compression and anti-embolism stockings can be used alone or in combination with low-dose heparin. - The stress response that is initiated by surgery inhibits the thrombolytic (fibrinolytic) system, resulting in blood hypercoagulability. - Dehydration, low cardiac output, blood pooling in the extremities, and bed rest add to the risk of thrombosis formation. Although all postoperative patients are at some risk, factors such as a history of thrombosis, malignancy, trauma, obesity, indwelling venous catheters, and hormone use (e.g., estrogen) increase the risk. The first symptom of DVT may be a pain or cramp in the calf although many patients are asymptomatic. Initial pain and tenderness may be followed by a painful swelling of the entire leg, often accompanied by fever, chills, and diaphoresis - The benefits of early ambulation and leg exercises in preventing DVT cannot be overemphasized, and these activities are recommended for all patients, regardless of their risk. It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that can constrict vessels under the knees. Even prolonged "dangling" (having the patient sit on the edge of the bed with legs hanging over the side) can be dangerous and is not recommended in susceptible patients because pressure under the knees can impede circulation. Adequate hydration is also encouraged; the patient can be offered juices and water throughout the day to avoid dehydration. HEMATOMA - At times, concealed bleeding occurs beneath the skin at the surgical site. This hemorrhage usually stops spontaneously but results in clot (hematoma) formation within the wound. - If the clot is small, it will be absorbed and need not be treated. - If the clot is large, the wound usually bulges somewhat, and healing will be delayed unless the clot is removed. Several sutures are removed by the surgeon, the clot is evacuated, and the wound is packed lightly with gauze. Healing occurs usually by granulation, or a secondary closure may be performed. INFECTION - The creation of a surgical wound disrupts the integrity of the skin, bypassing the body's primary defense and protection against infection. Exposure of deep body tissues to pathogens in the environment places the patient at risk for infection of the surgical site, and a potentially life-threatening complication such as infection can increase the length of hospital stay, costs of care, and risk of further complications. - hospitals measure surgical site infections (SSIs) for the first 30 or 90 days following surgical procedures based on national standards. Overall there has been a 20% decrease in SSIs for a number of surgical procedures - Postoperative care of the wound centers on assessing the wound, preventing contamination and infection before wound edges have sealed, and enhancing healing. - Wound infection may not be evident until at least postoperative day 5. Most patients are discharged before that time, and more than half of wound infections are diagnosed after discharge, highlighting the importance of patient education regarding wound care. - Signs and symptoms of wound infection include increased pulse rate and temperature; an elevated white blood cell count; wound swelling, warmth, tenderness, or discharge; and increased incisional pain. Local signs may be absent if the infection is deep. Wound Dehiscence and Evisceration. - Wound dehiscence (disruption of surgical incision or wound) and evisceration (protrusion of wound contents) are serious surgical complications - Dehiscence and evisceration are especially serious when they involve abdominal incisions or wounds. These complications result from sutures giving way, from infection, or, more frequently, from marked distention or strenuous cough. - They may also occur because of increasing age, anemia, poor nutritional status, obesity, malignancy, diabetes, the use of steroids, and other factors in patients undergoing abdominal surgery. - When the wound edges separate slowly, the intestines may protrude gradually or not at all, and the earliest sign may be a gush of bloody (serosanguineous) peritoneal fluid from the wound. When a wound ruptures suddenly, coils of intestine may push out of the abdomen. The patient may report that "something gave way." The evisceration causes pain and may be associated with vomiting. ** If disruption of a wound occurs, the patient is placed in the low Fowler's position and instructed to lie quietly. These actions minimize protrusion of body tissues. The protruding coils of intestine are covered with sterile dressings moistened with sterile saline solution, and the surgeon is notified at once.

17.3 Describe considerations related to preoperative nursing care of older adult patients, patients who are obese, and patients with disabilities.

-Cardiac reserves are lower(at risk for hyperthermia, cold OR rooms), decreased cardiac output, diminished ability to respond to stress, slower heart recovery rate, increased BP - Respiratory: increase in residual lung volume, decrease in muscle strength, endurance, vital capacity, decreased cough efficiency -Renal and hepatic functions are depressed. - Gastrointestinal activity is likely to be reduced- Respiratory compromise. - Decreased subcutaneous fat; more susceptible to temperature changes. A lightweight cotton blanket is an appropriate cover when an older patient is moved to and from the OR but never replaces asking patients if they feel sufficiently warm and attending to their needs. - As the body ages, the ability to perspire decreases, leading to dry itchy skin that can become fragile and easily abraded - May need more time and multiple explanations to understand and retain what is communicated restrictions. ***** Ch. 11 page 197look at health care of older adults table 11.11 gerontological considerations OLDER ADULTS: - Less physiologic reserve (i.e. ability of an organ to return to normal after a disturbance in its equilibrium) than younger patients. - Respiratory + cardiac complications are leading causes of postoperative morbidity and mortality - cardiac reserves are lower, renal and hepatic functions are depressed, GI activity is reduced. Bariatric Patients: Obesity increases the risk and severity of complications associated with surgery. - During surgery, fatty tissues are especially susceptible to infection. Wound infections are more common in patients that are obese. - Obesity also increases technical and mechanical problems related to surgery, such as dehiscence (wound separation). - The patient with obesity tends to have shallow respirations when supine, increasing the risk of hypoventilation and postoperative pulmonary complications. - Certain physical characteristics found in patients who are obese impede intubation, such as short thick necks, large tongues, recessed chins, and redundant pharyngeal tissue. These characteristics are associated with increased oxygen demand and decreased pulmonary reserves. - The preoperative assessment looks for these characteristics as well as the presence of obstructive sleep apnea, frequently diagnosed in patients who are obese. Sleep apnea is treated with continuous positive airway pressure (CPAP). The use of CPAP should be incorporated throughout the perioperative period. Patients With Disabilities -Special considerations for patients with mental or physical disabilities include the need for appropriate assistive devices, modifications in preoperative education, and additional assistance with and attention to positioning or transferring. - Assistive devices include hearing aids, eyeglasses, braces, prostheses, and other devices.

13.2 Describe the role of the kidneys, lungs, and endocrine glands in regulating the body's fluid composition and volume.

Checks and balances system in the body: when the body senses too much fluid being retained or too much lost, body will try to normalize it thru - baroreceptors (increase cardiac rate, conduction, contractility) - RAAS (cause vasoconstriction to occur, increasing arterial perfusion pressure and stimulate thirst) - ADH - antidiuretic hormone (help either hold on to or get rid of more fluid, helps with sodium balance) - Natriuetic peptide (is a hormone that when your body senses that there is an increase in fluid volume, it is gonna release this hormone to help flush out extra fluid volume, easy way for providers to identify if someone is having an episode of heart failure bc natriuetic peptide levels will be elevated bc more fluid that body senses, the more the hormone is released)

11.2 Identify the meanings of standard abbreviations used in medication administration

Different folder, under abbreviations.

18.4 Identify adverse effects of surgery and anesthesia.

The surgical patient is subject to several risks. Potential intraoperative complications include anesthesia awareness, nausea and vomiting, anaphylaxis, hypoxia, hypothermia, and malignant hyperthermia. Targeted areas include surgical site infections as well as cardiac, respiratory, and venous thromboembolic complications. Anesthesia Awareness - It is important to discuss concerns about intraoperative awareness with patients preoperatively so that they realize that only general anesthesia is meant to create a state of oblivion. All other forms of anesthesia will eliminate pain, but sensation of pushing and pulling tissues may still be recognized and they may hear conversations among the operative team. In many cases, patients may be able to respond to questions and involve themselves in the discussion. This is normal and is not what is referred to as anesthesia awareness. - Unintended intraoperative awareness refers to a patient becoming cognizant of surgical interventions while under general anesthesia and then recalling the incident. Neuromuscular blocks, sometimes required for surgical muscle relaxation, intensify the fear of the patient experiencing awareness because they are then unable to communicate during the episode. The frequency of anesthesia awareness is 0.1% to 0.2% of general anesthesia patients, equivalent to about 30,000 cases per year in the United States. - Indications of the occurrence of anesthesia awareness include an increase in the blood pressure, rapid heart rate, and patient movement. However, hemodynamic changes can be masked by paralytic medication, beta-blockers, and calcium channel blockers, thus the awareness may remain undetected. Premedication with amnesic agents and avoidance of muscle paralytics except when essential help to preclude its occurrence. Nausea and Vomiting - Nausea and vomiting, or regurgitation, may affect patients during the intraoperative period. If gagging occurs, the patient is turned to the side, the head of the table is lowered, and a basin is provided to collect the vomitus. Suction is used to remove saliva and vomited gastric contents. The advent of new anesthetic agents has reduced the incidence; however, there is no single way to prevent nausea and vomiting. - In some cases, the anesthesiologist or CRNA administers antiemetics preoperatively or intraoperatively to counteract possible aspiration. If the patient aspirates vomitus, an attack with severe bronchial spasms and wheezing is triggered. Pneumonitis and pulmonary edema can subsequently develop, leading to extreme hypoxia. Increasing medical attention is being paid to silent regurgitation of gastric contents (not related to preoperative fasting times), which occurs more frequently than previously realized. The volume and acidity of the aspirate determine the extent of damage to the lungs. Patients may be given citric acid and sodium citrate (Bicitra), a clear, nonparticulate antacid to increase gastric fluid pH or a histamine-2 (H2) receptor antagonist such as cimetidine (Tagamet), ranitidine (Zantac), or famotidine (Pepcid) to decrease gastric acid production (Rothrock, 2014). Anaphylaxis - Any time the patient comes into contact with a foreign substance, there is potential for an anaphylactic reaction. Because medications are the most common cause of anaphylaxis, intraoperative nurses must be aware of any patient allergies as well as the type and method of anesthesia used including specific agents. An anaphylactic reaction can occur in response to many medications, latex, or other substances. The reaction may be immediate or delayed. Anaphylaxis can be a life-threatening reaction. - Latex allergy—the sensitivity to natural rubber latex products—has become more prevalent, creating the need for alert responsiveness among health care professionals. The allergy exhibits with urticaria, asthma, rhinoconjunctivitis, and anaphylaxis. If patients state that they have allergies to latex, even if they are wearing latex in their clothing, treatment must be latex free. In the OR, many products are latex free with the notable exception of softer latex catheters. Surgical cases should use latex-free gloves in anticipation of a possible allergy, and if no allergy is present, then personnel can switch to other gloves after the case starts if desired. - Fibrin sealants are used in various surgical procedures, and cyanoacrylate tissue adhesives are used to close wounds without the use of sutures. These sealants have been implicated in allergic reactions and anaphylaxis. Although these reactions are rare, the nurse must be alert to the possibility and observe the patient for changes in vital signs and symptoms of anaphylaxis when these products are used. Hypoxia and Other Respiratory Complications - Inadequate ventilation, occlusion of the airway, inadvertent intubation of the esophagus, and hypoxia are significant potential complications associated with general anesthesia. Many factors can contribute to inadequate ventilation. Respiratory depression caused by anesthetic agents, aspiration of respiratory tract secretions or vomitus, and the patient's position on the operating table can compromise the exchange of gases. - Anatomic variation can make the trachea difficult to visualize and result in insertion of the artificial airway into the esophagus rather than into the trachea. In addition to these dangers, asphyxia caused by foreign bodies in the mouth; spasm of the vocal cords; relaxation of the tongue; or aspiration of vomitus, saliva, or blood can occur. - Brain damage from hypoxia occurs within minutes; therefore, vigilant monitoring of the patient's oxygenation status is a primary function of the anesthesiologist or CRNA and the circulating nurse. Peripheral perfusion is checked frequently, and pulse oximetry values are monitored continuously. Hypothermia - During anesthesia, the patient's temperature may fall. (esp low BMI and older adults) - Glucose metabolism is reduced, and as a result, metabolic acidosis may develop. This condition is called hypothermia and is indicated by a core body temperature that is lower than normal (36.6°C [98°F] or less). - Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open body wounds or cavities, decreased muscle activity, advanced age, or the pharmaceutical agents used (e.g., vasodilators, phenothiazines, general anesthetic medications). - Hypothermia can depress neuronal activity and decrease cellular oxygen requirements below the minimum levels normally required for continued cell viability. As a result, it is used to protect function during some surgical procedures (e.g., carotid endarterectomy, cardiopulmonary bypass) - Unintentional hypothermia needs to be avoided. If it occurs, it must be minimized or reversed. If hypothermia is intentional, the goal is safe return to normal body temperature. Environmental temperature in the OR can temporarily be set at 25°C to 26.6°C (78°F to 80°F). IV and irrigating fluids are warmed to 37°C (98.6°F). Wet gowns and drapes are removed promptly and replaced with dry materials, because wet materials promote heat loss. Warm air blankets and thermal blankets can also be used on the areas not exposed for surgery, and minimizing the area of the patient that is exposed will help maintain core temperature. Whatever methods are used to rewarm the patient, warming must be accomplished gradually, not rapidly. Conscientious monitoring of core temperature, urinary output, ECG, blood pressure, arterial blood gas levels, and serum electrolyte levels is required. Malignant Hyperthermia - Malignant hyperthermia is a rare inherited muscle disorder that is chemically induced by anesthetic agents. - This disorder can be triggered by myopathies, emotional stress, heatstroke, neuroleptic malignant syndrome, strenuous exercise exertion, and trauma. It occurs in 1 in 50,000 to 100,000 adults. Mortality from malignant hyperthermia had been reported to be as high as 70%; however, with prompt recognition and rapid treatment, it has fallen to less than 10%. - Susceptible people include those with strong and bulky muscles, a history of muscle cramps or muscle weakness and unexplained temperature elevation, and an unexplained death of a family member during surgery that was accompanied by a febrile response.

13.4 Plan effective care of patients with the following imbalances: fluid volume deficit and fluid volume excess, sodium deficit (hyponatremia) and sodium excess (hypernatremia), and potassium deficit (hypokalemia) and potassium excess (hyperkalemia). FVD (fluid volume deficit) and FVE (fluid volume excess)

FVD (fluid volume deficit) - essentially body losing more volume than it is taking in - losing electrolytes as well - May occur alone or in combination with other imbalances - Loss of extracellular fluid exceeds intake ratio of water ---- Electrolytes lost in same proportion as they exist in normal body fluids - Dehydration (only losing water, which cause sodium levels to rise) ---- Not the same as FVD Loss of water alone, with increased serum sodium levels if you look at lab values of pt with FVD = you're gonna see, low volume, low electrolytes. if you look at lab values of pt with dehydration = volume is gonna be low but serum sodium levels will be increased/high CAUSES OF FVD - Abnormal fluid losses ---- Vomiting, diarrhea, excessive sweating, GI suctioning, athletes training excessively - Decreased intake ---- Nausea, lack of access to fluids (not taking in enough fluids to meet needs of their output) ----- stomach bug, pregnant woman experiencing pregnancy related nausea, cancer pt who has undergone chemo and has chemo induced nausea ----- pts who are not independent and are relying on someone else to provide them with their food and fluid intake such as young children (infants, toddlers, preschool age children) do not have ability to get fluid when they are feeling thirsty, pt's with mobility impairments who cannot get up on their own and get the things that they need, Older adults = decreased mobility, other developmental needs. - Third-space fluid shifts (too much fluid is moving from intravascular space, within those blood vessels and they're moving out to interstitial areas) - issue: when fluid is moving from vascular space, overwhelming cardiovascular system which can cause decreased cardiac output, pt is gonna have hypotension, and most likely manifesting thru edema, lot of swelling fluid filled areas) ---- Due to burns, ascites - Additional causes ---- Diabetes insipidus, adrenal insufficiency, hemorrhage (losing large amounts of blood volume all at once) Clinical Manifestations of FVD - Can develop rapidly - Severity depends on degree of loss - Acute weight loss - ↓ skin turgor - oliguria (small amounts of urine production) - concentrated urine - capillary filling time prolonged - low CVP - ↓ BP - flattened neck veins - dizziness, weakness - thirst - confusion - ↑ pulse - muscle cramps - sunken eyes - nausea - increased temperature - cool, clammy, pale skin HOW TO THINK: pt is exhibiting signs of FVD: dizzy, lightheaded, BP is low. How can I support them in a safety aspect? and what physiological interventions do they need? Fluid Volume Deficit—Nursing Management - I&O at least every 8 hours, sometimes hourly - Daily weight (best indicator of fluid volume status) - Vital signs closely monitored (if you monitor i+o every hour, also check vital signs every hour) - Skin and tongue turgor, mucosa, urine output, mental status (even more important in older adult bc typical manifestations may not be present and may jump to confusion or delirium, know baseline to see if it is an acute jump in mental status) ( think about: is tongue tenting? dry and dehydrated? is urine concentrated, color?) - Measures to minimize fluid loss (if you have someone who is losing fluid bc of excessively high temp, are we medicating w antipyretics? are we keeping room cooler?if respirations are increased, what're we doing to calm those respirations down?) - Administration of oral fluids (first line of defense for managing fluid volume deficit, always want to start unless contraindicated) (ex. pt has post op nausea, implementing antiemetic and giving round the clock to keep nausea at bay so that they can tolerate oral fluids) - Administration of parenteral fluids (if oral fluids is not enough or contraindicated) FVE (fluid volume excess) - Isotonic expansion of the ECF caused by the abnormal retention of water and sodium in approximately the same proportions in which they normally exist in the ECF - Secondary to an increase in the total body sodium content CAUSES of FVE - Due to fluid overload or diminished homeostatic mechanisms ex. pt having a surgical procedure and during surgery given too much IV fluids = body cannot compensate/overcome that, pt begins manifesting symptoms of FVE or body cannot regulate appropriately, thinking about baroreceptors, RAAS, ADH. mechanisms are not up to par and cant quite keep up with and regulate fluid volume overload or excess - Heart failure, kidney injury, cirrhosis of liver (pumping mechanism isn't working adequately) (chronic renal failure = kidneys cannot get rid of fluid = buildup) (cirrhosis of liver = third spacing occurs a lot, all the extra fluid volume gets pushed out. Can have FVD and FVE = too much fluid but has moved out of vascular system and makes it appear as FVD) - Contributing factors: Consumption of excessive amounts of table salt or other sodium salts - Excessive administration of sodium-containing fluids (if using hypertonic solution that has high sodium concentration, water follows salt) CLINICAL MANIFESTATIONS OF FVE (opposite fo FVD) - edema - distended neck veins - crackles from text: - Acute weight gain - peripheral edema and ascites - distended jugular veins - crackles - elevated CVP - shortness of breath - ↑ BP - bounding pulse and cough - ↑ respiratory rate - ↑ urine output Fluid Volume Excess—Nursing Management - I&O and daily weights; assess lung sounds, edema, other symptoms (FVD will not have adventitious lung sounds) - Monitor responses to medications—diuretics (pull extra fluid out of body) and parenteral fluids - Promote adherence to fluid restrictions, patient teaching related to sodium and fluid restrictions (limit x amount in 24 hours, everything they eat or drink includes water and IV fluids = VERY STRICT) - Monitor, avoid sources of excessive sodium, including medications (ex. do not add any salt to food) - Promote rest as an intervention body is going thru hard workload

13.9 Interpret arterial blood gas measurements

ABG's. Know the different lab value range. PH = 7.35 - 7.45 PaCo2 = 35 - 45 mm Hg HCO3= 22 - 26 mEq/L PaO2= 80 - 100 mm/Hg Sodium = 135 -145 mEq/l Potassium = 3.5 - 5.0 mEq/L Chloride = 98 - 106 mEq/L Bicarbonate = 24 - 31 mEq/L Calcium = 8.5 - 10.5 mg/dL Phosphorus = 2.5 - 4.5 Mg/dL Magnesium = 1.8 - 3.0 mg/dL BUN/CR R- respiratory O- opposite M- metabolic E- equal -Metabolic Acidosis= ↓ pH and ↓ HCo3 (bicarb) -Metabolic Alkalosis= ↑ pH and ↑ HCo3 -Respiratory Acidosis= ↓ pH and ↑ PCo2 (carbon dioxide) -Respiratory Alkalosis= ↑ pH and ↓ PCo2

19.1 Describe the responsibilities of the post-anesthesia care nurse in the prevention of immediate postoperative complications.

What are the priority right after post-op? -Stable airway (respiratory). -Assess? auscultating chest, chest rise and fall... Intervention: apply oxygen, raising the bed... Outcome: clear lung sound to auscultation, oxygen level within normal limit... Respiratory status is important because pulmonary complications are among the most frequent and serious problems encountered by the surgical patient. The nurse monitors for airway patency and any signs of laryngeal edema. The quality of respirations, including depth, rate, and sound, is assessed regularly. Chest auscultation verifies that breath sounds are normal (or abnormal) bilaterally, and the findings are documented as a baseline for later comparisons. The nurse assesses the patient's pain level using a verbal or visual analog scale and assesses the characteristics of the pain. The patient's appearance, pulse, respirations, blood pressure, skin color (adequate or cyanotic), and skin temperature (cold and clammy, warm and moist, or warm and dry) are clues to cardiovascular function. When the patient arrives in the clinical unit, the surgical site is assessed for bleeding, type and integrity of dressings, and drains. The nurse also assesses the patient's mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. These serious causes must be investigated and excluded before other causes are pursued. From text: The nursing management objectives for the patient in the PACU are to provide care until the patient has recovered from the effects of anesthesia (e.g., until resumption of motor and sensory functions), is oriented, has stable vital signs, and shows no evidence of hemorrhage or other complications Assessing the Patient The major goals for the patient include optimal respiratory function, relief of pain, optimal cardiovascular function, increased activity tolerance, unimpaired wound healing, maintenance of body temperature, and maintenance of nutritional balance - Further goals include resumption of usual pattern of bowel and bladder elimination, identification of any perioperative positioning injury, acquisition of sufficient knowledge to manage self-care after discharge, and absence of complications. Frequent, skilled assessments of the patient's airway, respiratory function, cardiovascular function, skin color, level of consciousness, and ability to respond to commands are the cornerstones of nursing care in the PACU. - Vital signs are observed and recorded, as well as level of consciousness. The nurse performs and documents a baseline assessment, then checks the surgical site for drainage or hemorrhage and makes sure that all drainage tubes and monitoring lines are connected and functioning. The nurse checks any intravenous (IV) fluids with the goal of maintaining a euvolumic state - Medications currently infusing are checked, verifying that they are infusing at the correct dosage and rate. - After the initial assessment, vital signs are monitored and the patient's general physical status is assessed and documented at least every 15 minutes. - The nurse must be aware of any pertinent information from the patient's history that may be significant (e.g., patient is deaf or hard of hearing, has a history of seizures, has diabetes, or is allergic to certain medications or to latex). - Administration of the patient's postoperative analgesic medications is a top priority in order to provide pain relief before it becomes severe and facilitate early ambulation. ** Following surgery, patients who had ketamine as anesthesia must be placed in a quiet, darkened area of the PACU Maintaining a Patent Airway - The primary objective in the immediate postoperative period is to maintain ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). - Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation). Besides administering supplemental oxygen as prescribed, the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds. - Patients who have experienced prolonged anesthesia usually are unconscious, with all muscles relaxed. This relaxation extends to the muscles of the pharynx. When the patient lies on their back, the lower jaw and the tongue fall backward and the air passages become obstructed. This is called hypopharyngeal obstruction. - Signs of occlusion include choking; noisy and irregular respirations; decreased oxygen saturation scores; and, within minutes, a blue, dusky color (cyanosis) of the skin. Because movement of the thorax and the diaphragm does not necessarily indicate that the patient is breathing, the nurse needs to place the palm of the hand at the patient's nose and mouth to feel the exhaled breath. ** The treatment of hypopharyngeal obstruction involves tilting the head back and pushing forward on the angle of the lower jaw, as if to push the lower teeth in front of the upper teeth. This maneuver pulls the tongue forward and opens the air passages. - If the teeth are clenched, the mouth may be opened manually but cautiously with a padded tongue depressor. The head of the bed is elevated 15 to 30 degrees unless contraindicated, and the patient is closely monitored to maintain the airway as well as to minimize the risk of aspiration. If vomiting occurs, the patient is turned to the side to prevent aspiration and the vomitus is collected in the emesis basin. Mucus or vomitus obstructing the pharynx or the trachea is suctioned with a pharyngeal suction tip or a nasal catheter introduced into the nasopharynx or oropharynx to a distance of 15 to 20 cm (6 to 8 in). Maintaining Cardiovascular Stability - To monitor cardiovascular stability, the nurse assesses the patient's level of consciousness; vital signs; cardiac rhythm; skin temperature, color, and moisture; and urine output. - The nurse also assesses the patency of all IV lines. - The primary cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and dysrhythmias. - In patients who are critically ill, have significant comorbidity, or have undergone riskier procedures, additional monitoring may have been done in the OR and will continue in the PACU. These may include central venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output. - Hypotension and Shock Hypotension can result from blood loss, hypoventilation, position changes, pooling of blood in the extremities, or side effects of medications and anesthetics. - Shock, which is one of the most serious postoperative complications, can result from hypovolemia and decreased intravascular volume. Types of shock are classified as hypovolemic, cardiogenic, neurogenic, anaphylactic, and septic. The classic signs of hypovolemic shock (the most common type of shock) are pallor; cool, moist skin; rapid breathing; cyanosis of the lips, gums, and tongue; rapid, weak, thready pulse; narrowing pulse pressure; low blood pressure; and concentrated urine. Relieving Pain and Anxiety -The nurse in the PACU monitors the patient's physiologic status, manages pain, and provides psychological support in an effort to relieve the patient's fears and concerns. The nurse checks the medical record for special needs and concerns of the patient. Opioid analgesic medications are given mostly by IV in the PACU. - IV opioids provide immediate pain relief and are short acting, thus minimizing the potential for drug interactions or prolonged respiratory depression while anesthetics are still active in the patient's system. - family members may visit as well to make patient feel more secure Controlling Nausea and Vomiting - Nausea and vomiting occur in about 10% of patients in the PACU. The nurse should intervene at the patient's first report of nausea to control the problem rather than wait for it to progress to vomiting ** safety alert: At the slightest indication of nausea, the patient is turned completely to one side to promote mouth drainage and prevent aspiration of vomitus, which can cause asphyxiation and death. The risk of PONV ranges from approximately 10% in the PACU to 30% in the first 24 hours of postoperative care - Risks include general anesthesia, female gender, nonsmoker, history of PONV, and history of motion sickness. - Surgical risks are increased with PONV due to an increase in intra-abdominal pressure, elevated central venous pressure, the potential for aspiration, increased heart rate, and systemic blood pressure, which increase the risk of myocardial ischemia and dysrhythmias. - Patients are at increased risk of dehydration, electrolyte disturbances, aspiration, and wound dehiscence. Postoperative pain is increased as well. OLDER ADULTS: Immediate postoperative care for the older adult is the same as for any surgical patient; however, additional support is given if cardiovascular, pulmonary, or renal function is impaired. - With careful monitoring, it is possible to detect cardiopulmonary deficits before signs and symptoms are apparent. - Changes associated with the aging process, the prevalence of chronic diseases, alteration in fluid and nutrition status, and the increased use of medications result in the need for postoperative vigilance. - Nurses should keep in mind that older adults may have slower recovery from anesthesia due to the prolonged time it takes to eliminate sedatives and anesthetic agents - Postoperative confusion and delirium may occur in up to half of all older patients. Determining Readiness for Postanesthesia Care Unit Discharge - A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. NURSING INTERVENTIONS LIST: 1. Assess breathing and administer supplemental oxygen, if prescribed. - Assessment provides a baseline and helps identify signs and symptoms of respiratory distress early. 2. Monitor vital signs and note skin warmth, moisture, and color. - A careful baseline assessment helps identify signs and symptoms of shock early. 3. Assess the surgical site and wound drainage systems. Connect all drainage tubes to gravity or suction as indicated and monitor closed drainage systems. - Assessment provides a baseline and helps identify signs and symptoms of hemorrhage early. 4. Assess level of consciousness, orientation, and ability to move extremities. - These parameters provide a baseline and help identify signs and symptoms of neurologic complications. 5. Assess pain level; pain characteristics (location, quality); and timing, type, and route of administration of the last dose of analgesic. - Assessment provides a baseline of current pain level and assesses effectiveness of pain management strategies. 6. Administer analgesic medications as prescribed and assess their effectiveness in relieving pain. - Administration of analgesic agents helps decrease pain. 7. Place the call light, emesis basin, ice chips (if allowed), and bedpan or urinal within reach. - Attending to these needs provides for comfort and safety. 8. Position the patient to enhance comfort, safety, and lung expansion. - This promotes safety and reduces risk of postoperative complications. 9. Assess IV sites for patency and infusions for correct rate and solution. - Assessing IV sites and infusions helps detect phlebitis and prevents errors in rate and solution type. 10. Assess urine output in closed drainage system or use bladder scanner to detect distention. - Assessment provides a baseline and helps identify signs of urinary retention. 11. Reinforce the need to begin deep breathing and leg exercises. - These activities help prevent complications related to immobility (e.g., atelectasis, VTE). 12. Provide information to the patient and family. - Patient education helps decrease the patient's and family's anxiety.

Compare metabolic alkalosis with regard to causes, clinical manifestations, diagnosis, and management.

- High pH >7.45 -High bicarbonate >26 mEq/L. Most commonly due to vomiting or gastric suction. -May also be due to medications, especially long-term diuretic use. -Hypokalemia will produce alkalosis. -Manifestations: symptoms related to decreased calcium, respiratory depression, tachycardia, symptoms of hypokalemia. -Correct underlying disorder, supply chloride to allow excretion of excess bicarbonate, restore fluid volume with sodium chloride solutions

13.8 Compare respiratory alkalosis with regard to causes, clinical manifestations, diagnosis, and management.

- High pH >7.45 -PaCO2 <35 mm/Hg -Always due to hyperventilation. Manifestations: lightheadedness, inability to concentrate, numbness and tingling, sometimes loss of consciousness. -Correct cause of hyperventilation

13.3 Identify the effects of aging on fluid and electrolyte regulation.

-Increased sensitivity to fluid and electrolyte changes in older patients. Slowness in filling of veins of the hands and feet become more useful in detecting FVD. - Clinical manifestations of imbalance may be subtle (different than presenting manifestations in comparison to normal adult. EX: normal signs of dehydration in normal adult: increased sense of thirst. Older adults: may not have that same thirst mechanism and instead they may start to have confusion and delirium) - Fluid deficit may cause delirium - Decreased cardiac reserve (cardiac output is not as efficient, decreased ability for contractility) - Reduced renal function (may cause them to hold on to extra fluid) - Dehydration is common in older adults (must modify plan of care to meet needs of the older adult) - Age-related thinning of the skin and loss of strength and elasticity

17.2 Describe a comprehensive preoperative assessment to identify pertinent health and surgical risk factors.

-Initiates the nursing process. -Admission data: demographics, health history, other information pertinent to the surgical procedure. -Verifies completion of preoperative diagnostic testing. -Begins discharge planning by assessing patient's need for postoperative care. A lot of testing is done before the patient even goes to the hospital - preop assessment or lab work (renal, electrolytes), physical, diagnostic testing such as CAT scan, x-ray, EKG). immediate planning and implementing discharge planning, even before the surgery. ASSESSMENT: goal of assessment is to prevent post op complications. - Health history and physical exam. - Medications and allergies(certain medications can place patient at risk for post op complications)(do they have allergies to: latex? anesthetics? iodine? medication used post op?). -Nutritional, fluid status(poor nutrition=poor healing)(hypo/hyper volemic)(NPO= to prevent aspiration during surgery)(Bowel prep=for bowel surgery=additional monitoring=to maintain normal fluid status). (losing fluid=losing electrolytes such as potassium that could alter cardiovascular status). -Dentition: (what're their teeth like? missing or loose teeth? can be a problem during intubation)(any infections in their mouth? = increased risk for cardiovascular infections) -Drug or alcohol use(excessive use of either = negative impact to heal properly = post op complications) -Respiratory and cardiovascular status(chronic respiratory - asthma or COPD - may need additional monitoring). -Hepatic, renal function(we need to know the medication, anesthetic agents, is patients able to metabolize and excrete from body). (if impaired hepatic/renal function= toxic build up= post op complications) From the text: - Before any surgical treatment is initiated, a health history is obtained, a physical examination is performed during which vital signs are noted, and a baseline is established for future comparisons). - The nurse should ask about any allergies and comorbid conditions that may affect anesthesia. - During the physical examination, many factors that have the potential to affect the patient undergoing surgery are considered, such as joint mobility. Genetic considerations are also taken into account during assessment to prevent complications with anesthesia - Asking the patient about use of prescription and over-the-counter (OTC) medications, including herbal and other supplements provides useful information. Activity and functional levels should be determined, including that involving regular aerobic exercise. - Known allergies to drugs, foods, and latex could avert an anaphylactic response. Patients may have early manifestations of a latex allergy and be unaware of this. If a patient states that he or she is allergic to kiwi, avocado, or banana, or cannot blow up balloons, there may be an association with an allergy to latex. **A latex allergy can manifest as a rash, asthma, or anaphylactic shock. Nutritional and Fluid Status - Optimal nutrition is an essential factor in promoting healing and resisting infection and other surgical complications. - Assessment of a patient's nutritional status identifies factors that can affect the patient's surgical course, such as obesity, weight loss, malnutrition, deficiencies in specific nutrients, metabolic abnormalities, and the effects of medications on nutrition. Nutritional needs may be determined by measurement of body mass index and waist circumference - Any nutritional deficiency should be corrected before surgery to provide adequate protein for tissue repair. - Assessment of a patient's hydration status is also essential. Dehydration, hypovolemia, and electrolyte imbalances can lead to significant problems in patients with comorbid medical conditions or in older adults. - The depletion of fluids and electrolytes following bowel preparation, especially when combined with prolonged fasting, can result in dehydration and chemical imbalances, even among healthy surgical patients. Any identified fluid and electrolyte imbalances should be corrected prior to surgery. Dentition - Dental caries, dentures, and partial plates are particularly significant to the anesthesiologist or CRNA, because decayed teeth or dental prostheses may become dislodged during intubation and occlude the airway. This is especially important for older patients as well as those who may not have regular dental care. The condition of the mouth is also important because any bodily infection, even in the mouth, can be a source of postoperative infection. Drug or Alcohol Use - Ingesting even moderate amounts of alcohol prior to surgery can weaken a patient's immune system and increase the likelihood of developing postoperative complications. - In addition, the use of illicit drugs and alcohol may impede the effectiveness of some medications. Because acutely intoxicated people are susceptible to injury, surgery is postponed if possible. If emergency surgery is required, local, spinal, or regional block anesthesia is used for minor surgery. - In an emergency, to prevent vomiting and potential aspiration, a nasogastric tube is inserted before general anesthesia is given. - Research suggests that patients who have more than two drinks of alcohol per day in the 2 weeks prior to surgery have more complications, longer hospital stays, and more days in ICU postoperatively. People who have a substance abuse problem may deny or attempt to hide it. In such situations, the nurse who is obtaining the patient's health history needs to ask frank questions with patience, care, and a nonjudgmental attitude. Such questions should include asking whether the patient has had two drinks per day or more on a regular basis in the 2 weeks prior to surgery. Respiratory Status - The patient is educated about breathing exercises and the use of an incentive spirometer, if indicated, to achieve optimal respiratory function prior to surgery. - The potential compromise of ventilation during all phases of surgical treatment necessitates a proactive response to respiratory infections. Surgery is usually postponed for elective cases if the patient has a respiratory infection. - Patients with underlying respiratory disease (e.g., asthma, chronic obstructive pulmonary disease) are assessed carefully for current threats to their pulmonary status. Patients also need to be assessed for comorbid conditions and age-related changes that may affect respiratory function. - Patients who smoke are urged to stop 30 days before surgery to significantly reduce pulmonary and wound healing complications. - Preoperative smoking cessation interventions can be effective in changing smoking behavior and reducing the incidence of postoperative complications. Patients who smoke are more likely to experience poor wound healing, a higher incidence of SSI, and complications that include VTE and pneumonia. Cardiovascular Status - Patient preparation for surgical intervention includes ensuring that the cardiovascular system can support the oxygen, fluid, and nutritional needs of the perioperative period. - If the patient has uncontrolled hypertension, surgery may be postponed until the blood pressure is under control. - At times, surgical treatment can be modified to meet the cardiac tolerance of the patient. For example, in a patient with obstruction of the descending colon and coronary artery disease, a temporary simple colostomy may be performed rather than a more extensive colon resection that would require a prolonged period of anesthesia. Hepatic and Renal Function - The presurgical goal is optimal function of the liver and urinary systems so that medications, anesthetic agents, body wastes, and toxins are adequately metabolized and removed from the body. The liver, lungs, and kidneys are the routes for elimination of drugs and toxins. - The liver is important in the biotransformation of anesthetic compounds. Disorders of the liver may substantially affect how anesthetic agents are metabolized. Acute liver disease is associated with high surgical mortality; preoperative improvement in liver function is a goal. Careful assessment may include various liver function tests. - The kidneys are involved in excreting anesthetic medications and their metabolites; therefore, surgery is contraindicated if a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems. - Exceptions include surgeries performed as lifesaving measures, surgery to enable easier access for dialysis, or those necessary to improve urinary function (e.g., obstructive uropathy or hydronephrosis). Endocrine Function - The patient with diabetes who is undergoing surgery is at risk for both hypoglycemia and hyperglycemia. - Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin. - Hyperglycemia, which can increase the risk of surgical wound infection, may result from the stress of surgery, which can trigger increased levels of catecholamine. - Other risks are acidosis and glucosuria. Although the surgical risk in the patient with controlled diabetes is no greater than in the patient without diabetes, strict glycemic control (80 to 110 mg/dL) leads to better outcomes. - Frequent monitoring of blood glucose levels is important before, during, and after surgery. - Patients who have received corticosteroids are at risk for adrenal insufficiency. The use of corticosteroids for any purpose during the preceding year must be reported to the anesthesiologist or CRNA and surgeon. The patient is monitored for signs of adrenal insufficiency. - Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis (with hyperthyroid disorders) or respiratory failure (with hypothyroid disorders). The patient with an associated history of a thyroid disorder is assessed preoperatively. Immune Function - An important function of the preoperative assessment is to determine the presence of infection or allergies. - Routine laboratory tests used to detect infection include the white blood count (WBC) and the urinalysis. Surgery may be postponed in the presence of infection. It is important to identify and document any sensitivity to medications and past adverse reactions. - The patient is asked to identify any substances that precipitated previous allergic reactions, including medications, blood transfusions, contrast agents, latex, and food products, and to describe the signs and symptoms produced by these substances. - Immunosuppression is common with corticosteroid therapy, organ transplantation, radiation therapy, chemotherapy, and disorders affecting the immune system, such as acquired immunodeficiency syndrome and leukemia. The mildest symptoms or slightest temperature elevation must be investigated. Previous Medication Use - A medication history is obtained because of the possible interactions with medications that might be given during surgery and the effects of any of these medications on the patient's perioperative course. - Any medications the patient is using or has used in the past are documented, including OTC preparations and herbal agents, as well as the frequency with which they are used. Many medications have an effect on physiologic functions; interactions of such medications with anesthetic agents can cause serious problems, such as hypotension and circulatory collapse. Aspirin, a common OTC medication that inhibits platelet aggregation, should be prudently discontinued 7 to 10 days before surgery; otherwise, the patient may be at increased risk for bleeding. - Any use of aspirin or other OTC medications is noted in the patient's medical record and conveyed to the anesthesiologist or CRNA and surgeon. The anesthesia provider evaluates the potential effects of prior medication therapy, considering the length of time the patient has used the medication, the physical condition of the patient, and the nature of the proposed surgery. The possible adverse interactions of some medications require the nurse to assess and document the patient's use of prescription medications, OTC medications (especially aspirin), herbal agents, and the frequency with which medications are used. The nurse must clearly communicate this information to the anesthesiologist or CRNA.

13.6 Explain the roles of the lungs, kidneys in maintaining acid--base balance.

-Kidneys regulate Bicarbonate ion concentration and Regulation of ECF volume and osmolality by selective retention and excretion of body fluids. Regulation of pH of the ECF by retention of hydrogen ions Excretion of metabolic wastes and toxic substance. -Lungs control CO2 (lungs can compensate longer than the kidneys

13.8 Compare respiratory acidosis with regard to causes, clinical manifestations, diagnosis, and management.

-Low pH <7.35. -PaCO2 >42 mm/Hg. -Always due to respiratory problem with inadequate excretion of CO2. -With chronic respiratory acidosis, body may compensate, may be asymptomatic. *Symptoms may include suddenly increased pulse, respiratory rate, and BP; mental changes; feeling of fullness in head. -Potential increased intracranial pressure. -Treatment aimed at improving ventilation

13.2 Describe the role of the kidneys, lungs, and endocrine glands in regulating the body's fluid composition and volume.

-Lungs:The lungs normally eliminate water vapor (insensible loss) at a rate of approximately 300 mL every day -Kidneys: Vital to the regulation of fluid and electrolyte balance -Endocrine Glands: Increased secretion of aldosterone causes sodium retention (and thus water retention) and potassium loss. Conversely, decreased secretion of aldosterone causes sodium and water loss and potassium retention. GAIN - Healthy people gain fluids by drinking and eating - Not just liquids, also includes foods high in liquid content and concentration (ex. watermelon = considered solid but due to high water content, needs to be kept in mind in regards to fluid intake.) - Daily I+O of water are equal (in healthy adult) - however much taken into body expect as output = EQUAL fluid volume deficit / excess occurs when there is an imbalance in intake and output LOSS - Kidney: urine output of 1mL/kg/hr generally speaking, you want adult to have urine output of 30 mL/kg/hr in order to be sufficient. In close monitoring, must calculate based on weight. - Skin loss: sensible due to sweating and insensible due to fever, exercise, and burns - Lungs: 300 mL everyday, greater with increased RR (pt w respiratory issue, something that causes them to have increased respirations = fluid loss can be even greater) - GI tract: large losses due to diarrhea and fistulas (large wounds can also cause fluid loss. ex: wound vac) Kidneys: allow for retention and/or excretion of fluids depending on the specific needs of the body - help maintain a normal electrolyte balance as well as maintaining pH in the body - plays a major role in excreting waste thru the body Lungs: a person loses fluid thru their lungs on a normal basis but can change based on conditions (increased respirations, continuous cough, mechanical ventilation) - help maintain acid/base balance Endocrine system: pituitary gland, adrenals, parathyroid: help hold on to/get rid of fluid, maintain balance

17.5 Describe preoperative nursing measures that decrease 1 the risk for infection and other postoperative complications.

-Providing patient education. -Deep breathing, coughing, and incentive spirometry. -Mobility and active body movement - Pain management. -Cognitive coping strategies. -Education for patients undergoing ambulatory surgery From the text: A wide range of interventions are used to prepare the patient physically and psychologically and to maintain safety. - Beginning with the nursing history and physical examination, listing of medications taken routinely, history of allergies, and surgical and anesthetic histories, the patient's overall health status and level of experience and understanding may be established. Providing Patient Education - Each patient's education is individualized, with consideration for any unique concerns or learning needs. Multiple education strategies should be used (e.g., verbal, written, return demonstration), depending on the patient's needs and abilities. - Preoperative education is initiated as soon as possible, beginning in the physician's office, in the clinic, or at the time of PAT when diagnostic tests are performed. - Frequently, education sessions are combined with various preparation procedures to allow for an easy and timely flow of information. - Telling the patient that preoperative medication will cause relaxation before the operation is not as effective as also noting that the medication will act quickly and may result in lightheadedness, dizziness, and drowsiness. Knowing what to expect will help the patient anticipate these reactions and attain a superior degree of relaxation. - One goal of preoperative nursing care is to educate the patient how to promote optimal lung expansion and resulting blood oxygenation after anesthesia. The patient assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and how to exhale slowly. After practicing deep breathing several times, the patient is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough deeply in the lungs - The nurse or respiratory therapist also demonstrates how to use an incentive spirometer, a device that provides measurement and feedback related to breathing effectiveness Mobility and Active Body Movement - The goals of promoting mobility postoperatively are to improve circulation, prevent venous stasis, and promote optimal respiratory function. The patient should be taught that early and frequent ambulation postoperatively, as tolerated, will help prevent complications. - The nurse explains the rationale for frequent position changes after surgery and then shows the patient how to turn from side to side and how to assume the lateral position without causing pain or disrupting intravenous (IV) lines, drainage tubes, or other equipment. Any special position the patient needs to maintain after surgery (e.g., adduction or elevation of an extremity) is discussed, as is the importance of maintaining as much mobility as possible despite restrictions. Reviewing the process before surgery is helpful, because the patient may be too uncomfortable or drowsy after surgery to absorb new information. Pain Management A pain assessment should include differentiation between acute and chronic pain. A pain intensity scale should be introduced and explained to the patient to promote more effective postoperative pain management. - Preoperative patient education also needs to include the difference between acute and chronic pain so that the patient is prepared to differentiate acute postoperative pain from a chronic condition such as back pain. Preoperative pain assessment and education for the older patient may require additional attention. - Postoperatively, medications are given to relieve pain and maintain comfort without suppressing respiratory function. The patient is instructed to take the medication as frequently as prescribed during the initial postoperative period for pain relief. Anticipated methods of administration of analgesic agents for inpatients include patient-controlled analgesia (PCA), epidural catheter bolus or infusion, or patient-controlled epidural analgesia (PCEA). - A patient who is expected to go home will likely receive oral analgesic agents. These methods are discussed with the patient before surgery, and the patient's interest and willingness to use them are assessed. Preoperative Instructions to Prevent Postoperative Complications - Diaphragmatic Breathing - Coughing - Leg Exercises - Turning to the side - Getting out of bed Cognitive Coping Strategies - Cognitive strategies may be useful for relieving tension, overcoming anxiety, decreasing fear, and achieving relaxation. Examples of general strategies include: Imagery: The patient concentrates on a pleasant experience or restful scene. Distraction: The patient thinks of an enjoyable story or recites a favorite poem or song. Optimistic self-recitation: The patient recites optimistic thoughts ("I know all will go well"). Music: The patient listens to soothing music (an easy-to-administer, inexpensive, noninvasive intervention). - Several researchers have reported that individualized nurse-delivered interventions reduce anxiety levels and are highly valued by patients Education for Patients Undergoing Ambulatory Surgery - Preoperative education for the same-day or ambulatory surgical patient comprises all previously discussed patient education as well as collaborative planning with the patient and family for discharge and follow-up home care. The major difference in outpatient preoperative education is the environment. - Preoperative education content may be presented in a group class, in a media presentation, at PAT, or by telephone in conjunction with the preoperative interview. In addition to answering questions and describing what to expect, the nurse tells the patient when and where to report, what to bring (insurance card, list of medications and allergies), what to leave at home (jewelry, watch, medications, contact lenses), and what to wear (loose-fitting, comfortable clothes; flat shoes). The nurse in the surgeon's office may initiate education before the perioperative telephone contact. - During the final preoperative telephone call, education is completed or reinforced as needed and last-minute instructions are given. The patient is reminded not to eat or drink for a specified period of time preoperatively. Providing Psychosocial Interventions - Reducing Anxiety and Decreasing Fear - Respecting Cultural, Spiritual, and Religious Beliefs Maintaining Patient Safety Protecting patients from injury is one of the major roles of the perioperative nurse. - Identify patients correctly - Improve staff communication - Use medicines safely - Use alarms safely - Prevent infection - Identify patient safety risks - Prevent mistakes in surgery Managing Nutrition and Fluids - The purpose of withholding food and fluid before surgery is to prevent aspiration. Until recently, fluid and food were restricted preoperatively overnight and often longer. The American Society of Anesthesiologists reviewed this practice and made new recommendations for people undergoing elective surgery who are otherwise healthy. - Specific recommendations depend on the age of the patient and the type of food eaten. For example, adults may be advised to fast for 8 hours after eating fatty food and 4 hours after ingesting milk products. - Healthy patients are allowed clear liquids up to 2 hours before an elective procedure. Preparing the Bowel Enemas are not commonly prescribed preoperatively unless the patient is undergoing abdominal or pelvic surgery. - In this case, a cleansing enema or laxative may be prescribed the evening before surgery and may be repeated the morning of surgery. The goals of this preparation are to allow satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by fecal material. - Unless the condition of the patient presents some contraindication, the toilet or bedside commode, rather than the bedpan, is used for evacuating the enema if the patient is hospitalized during this time. In addition, antibiotics may be prescribed to reduce intestinal flora. Preparing the Skin - The goal of preoperative skin preparation is to decrease bacteria without injuring the skin. If the surgery is not performed as an emergency, most health care facilities and ambulatory surgical centers have implemented antiseptic skin cleansing protocols. There is an ongoing debate as to the efficacy of skin protocols in preventing SSIs, particularly when the patient is instructed to carry out the preparation independently at home prior to surgery. - Generally, hair is not removed preoperatively unless the hair at or around the incision site is likely to interfere with the operation. If hair must be removed, electric clippers are used for safe hair removal before transferring the patient to the OR. To ensure the correct site, the surgical site is typically marked by the patient and the surgeon prior to the procedure. Immediate Preoperative Nursing Interventions - Immediately prior to the procedure, the patient changes into a hospital gown that is left untied and open in the back. The patient with long hair may braid it, remove hairpins, and cover the head completely with a disposable paper cap. The mouth is inspected, and dentures or plates are removed. If left in the mouth, these items could easily fall to the back of the throat during induction of anesthesia and cause respiratory obstruction. - Jewelry is not worn to the OR; wedding rings and jewelry or body piercings should be removed to prevent injury. If a patient objects to removing a ring, some institutions allow the ring to be securely fastened to the finger with tape. All articles of value, including assistive devices, dentures, glasses, and prosthetic devices, are given to family members or are labeled clearly with the patient's name and stored in a safe and secure place according to the institution's policy. All patients (except those with urologic disorders) should void immediately before going to the OR. This is particularly important in promoting visibility of anatomy and continence during low abdominal surgery. Urinary catheterization is performed in the OR only as necessary. Administering Preanesthetic Medication - The use of preanesthetic medication is minimal with ambulatory or outpatient surgery. If prescribed, it is usually given in the preoperative holding area. If a preanesthetic medication is given, the patient is kept in bed with the side rails raised, because the medication can cause lightheadedness or drowsiness. During this time, the nurse observes the patient for any untoward reaction to the medications. The immediate surroundings are kept quiet to promote relaxation, and some facilities use soft classical music - Often, surgery is delayed or schedules change, and it becomes impossible to request that a medication be given at a specific time. In these situations, the preoperative medication is prescribed "on call to OR." The nurse can have the medication ready to administer as soon as a call is received from the OR staff. It usually takes 15 to 20 minutes to prepare the patient for the OR. If the nurse gives the medication before attending to the other details of preoperative preparation, the patient will have at least partial benefit from the preoperative medication and will have a smoother anesthetic and operative course. Maintaining the Preoperative Record - Preoperative checklists contain critical elements that must be checked and verified preoperatively. The nurse completes the preoperative checklist. The completed medical record (with the preoperative checklist and verification form) accompanies the patient to the OR with the surgical consent form attached, along with all laboratory reports and nurses' records. Any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the medical record. Expected Patient Activities in the Preoperative Phase of Care - Relief of anxiety, evidenced when the patient: - Discusses with the anesthesiologist, or CRNA concerns related to types of anesthesia and induction - Verbalizes an understanding of the preanesthetic medication and general anesthesia - Discusses last-minute concerns with the nurse or physician - Discusses financial concerns with the social worker, when appropriate - Requests visit with spiritual advisor, when appropriate - Appears relaxed when visited by health care team members Decreased fear, evidenced when the patient: -Discusses fears with health care professionals or a spiritual advisor, or both -Verbalizes an understanding of any expected bodily changes, including expected duration of bodily changes Understanding of the surgical intervention, evidenced when the patient: -Participates in preoperative preparation as appropriate (i.e., bowel preparation, shower) -Demonstrates and describes exercises that he or she is expected to perform postoperatively -Reviews information about postoperative care -Accepts preanesthetic medication, if prescribed -Remains in bed once premedicated -Relaxes during transportation to the operating room or unit -States rationale for use of side rails Discusses postoperative expectations CRNA, certified registered nurse anesthetist

18.2 Specify the principles of surgical asepsis.

-Surgical environment: -Unrestricted zone: street clothes allowed -Semi restricted zone: scrub cloths and caps.-Restricted zone: scrub clothes, shoes covers, caps and mask. -Surgical asepsis -Environmental control -Proper draping exposes only the surgical site, which decreases the risk of infection. From the text: - Warming the patient, which may begin in the preoperative phase of surgery, is continued or initiated during the perioperative stage. Maintaining normothermia has been linked to improved patient outcomes, such as enhanced healing, lower infection rates, decreased pain intensity, and reduced malaise. - To help decrease microbes, the surgical area is divided into three zones: 1. the unrestricted zone, where street clothes are allowed; 2. the semirestricted zone, where attire consists of scrub clothes and caps; 3. restricted zone, where scrub clothes, shoe covers, caps, and masks are worn. The surgeons and other surgical team members wear additional sterile clothing and protective devices during surgery. - All surgical supplies, instruments, needles, sutures, dressings, gloves, covers, and solutions that may come in contact with the surgical wound or exposed tissues must be sterilized before use - Surgical team members wear long-sleeved, sterile gowns and gloves. Head and hair are covered with a cap, and a mask is worn over the nose and mouth to minimize the possibility that bacteria from the upper respiratory tract will enter the wound. During surgery, only personnel who have scrubbed, gloved, and gowned touch sterilized objects. Nonscrubbed personnel refrain from touching or contaminating anything sterile. - An area of the patient's skin larger than that requiring exposure during the surgery is meticulously cleansed, and an antiseptic solution is applied. If hair removal needs to take place and this was unable to be performed before the patient arrived in the OR suite, this is done immediately before the procedure with electric clippers (not shaved) to minimize the risk of infection. The remainder of the patient's body is covered with sterile drapes. Environmental Controls - Floors and horizontal surfaces are cleaned between cases with detergent, soap, and water or a detergent-germicide. Sterilized equipment is inspected regularly to ensure optimal operation and performance. All equipment that comes into direct contact with the patient must be sterile. Sterilized linens, drapes, and solutions are used. Instruments are cleaned and sterilized in a unit near the OR. Individually wrapped sterile items are used when additional individual items are needed. - Airborne bacteria are a concern. To decrease the amount of bacteria in the air, standard OR ventilation provides 15 air exchanges per hour, at least 3 of which are fresh air. A room temperature of 20°C to 24°C (68°F to 73°F), humidity between 30% and 60%, and positive pressure relative to adjacent areas are maintained. Basic Guidelines for Maintaining Surgical Asepsis All practitioners involved in the intraoperative phase have a responsibility to provide and maintain a safe environment. Adherence to aseptic practice is part of this responsibility. The basic principles of aseptic technique follow (AORN, 2014): - All materials in contact with the surgical wound or used within the sterile field must be sterile. Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile; contact with unsterile objects at any point renders a sterile area contaminated. - Gowns of the surgical team are considered sterile in front from the chest to the level of the sterile field. The sleeves are also considered sterile from 2 in above the elbow to the stockinette cuff. - Sterile drapes are used to create a sterile field. Only the top surface of a draped table is considered sterile. During draping of a table or patient, the sterile drape is held well above the surface to be covered and is positioned from front to back. - Items are dispensed to a sterile field by methods that preserve the sterility of the items and the integrity of the sterile field. After a sterile package is opened, the edges are considered unsterile. Sterile supplies, including solutions, are delivered to a sterile field or handed to a scrubbed person in such a way that the sterility of the object or fluid remains intact. - The movements of the surgical team are from sterile to sterile areas and from unsterile to unsterile areas. Scrubbed people and sterile items contact only sterile areas; circulating nurses and unsterile items contact only unsterile areas. - Movement around a sterile field must not cause contamination of the field. Sterile areas must be kept in view during movement around the area. At least a 1-ft distance from the sterile field must be maintained to prevent inadvertent contamination. - Whenever a sterile barrier is breached, the area must be considered contaminated. A tear or puncture of the drape permitting access to an unsterile surface underneath renders the area unsterile. Such a drape must be replaced. - Every sterile field is constantly monitored and maintained. Items of doubtful sterility are considered unsterile. Sterile fields are prepared as close as possible to the time of use. - The routine administration of hyperoxia (high levels of oxygen) is not recommended to reduce surgical site infections.

1) Potassium 2) Magnesium 3)Sodium 4) Calcium

1) Hypo/hyperkalemia 2) Hypo/hypermagnesemia 3) Hypo/hypernatremia 4) Hypo/hypercalcemia

10.5: State the ten "rights" of safe medication administration

1. Right client 2. Right medication 3. Right dose 4. Right route 5. Right time 6. Right documentation 7. Right indication 8. Right to know 9. Right to refuse 10. Right response

Potential Adverse Effects of Surgery and Anesthesia

Anesthesia and surgery disrupt all major body systems. Although most patients can compensate for surgical trauma and the effects of anesthesia, all patients are at risk during the operative procedure. These risks include the following: - Allergic reactions -Anesthesia awareness -Cardiac dysrhythmia from electrolyte imbalance or adverse effect of anesthetic agents -Myocardial depression, bradycardia, and circulatory collapse -Central nervous system agitation, seizures, and respiratory arrest -Oversedation or undersedation -Agitation or disorientation, especially in older adult patients -Hypoxemia or hypercarbia from hypoventilation and inadequate respiratory support during anesthesia -Laryngeal trauma, oral trauma, and broken teeth from difficult intubation -Hypothermia from cool operating room temperatures, exposure of body cavities, and impaired thermoregulation secondary to anesthetic agents -Hypotension from blood loss or adverse effect of anesthesia -Infection -Thrombosis from compression of blood vessels or stasis -Malignant hyperthermia secondary to adverse effect of anesthesia -Nerve damage and skin breakdown from prolonged or inappropriate positioning -Electrical shock or burns -Laser burns -Drug toxicity, faulty equipment, and other types of human error

NURSING PROCESS The Patient During Surgery

Assessment Nursing assessment of the intraoperative patient involves obtaining data from the patient and the patient's medical record to identify factors that can affect care. These serve as guidelines for an individualized plan of patient care. - The intraoperative nurse uses the focused preoperative nursing assessment documented on the patient record. This includes assessment of physiologic status (e.g., health-illness level, level of consciousness), psychosocial status (e.g., anxiety level, verbal communication problems, coping mechanisms), physical status (e.g., surgical site, skin condition, and effectiveness of preparation; mobility of joints), and ethical concerns. Diagnosis NURSING DIAGNOSES Based on the assessment data, major nursing diagnoses may include the following: - Anxiety related to surgical or environmental concerns - Risk of latex allergy response due to possible exposure to latex in OR environment - Risk for perioperative positioning injury related to positioning in the OR - Risk for injury related to anesthesia and surgical procedure - Risk for compromised human dignity related to general anesthesia or sedation COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Based on the assessment data, potential complications may include the following: -Anesthesia awareness -Nausea and vomiting -Anaphylaxis -Hypoxia -Unintentional hypothermia -Malignant hyperthermia -Infection Planning and Goals The major goals for care of the patient during surgery include: -reduced anxiety -absence of latex exposure -absence of positioning injuries -freedom from injury -maintenance of the patient's dignity -absence of complications Nursing Interventions REDUCING ANXIETY The OR environment can seem cold, stark, and frightening to the patient, who may be feeling isolated and apprehensive. Introducing yourself, addressing the patient by name warmly and frequently, verifying details, providing explanations, and encouraging and answering questions provide a sense of professionalism and friendliness that can help the patient feel safe and secure. - Attention to physical comfort (warm blankets, padding, and position changes) helps the patient feel more comfortable. Telling the patient who else will be present in the OR, how long the procedure is expected to take, and other details helps the patient prepare for the experience and gain a sense of control. REDUCING LATEX EXPOSURE Patients with latex allergies require early identification and communication to all personnel about the presence of the allergy according to standards of care for patients with latex allergy PREVENTING PERIOPERATIVE POSITIONING INJURY The patient's position on the operating table depends on the surgical procedure to be performed as well as the patient's physical condition The patient should be in as comfortable a position as possible, whether conscious or unconscious. The operative field must be adequately exposed. An awkward anatomical position, undue pressure on a body part, or the use of stirrups or traction should not obstruct the vascular supply. Respiration should not be impeded by pressure of arms on the chest or by a gown that constricts the neck or chest. Nerves must be protected from undue pressure. Improper positioning of the arms, hands, legs, or feet can cause serious injury or paralysis. Shoulder braces must be well padded to prevent irreparable nerve injury, especially when the Trendelenburg position is necessary. Precautions for patient safety must be observed, particularly with older adults, patients who are thin or obese, and those with a physical deformity. The patient may need light restraint before induction in case of excitement. The usual position for surgery, called the dorsal recumbent position, is flat on the back. Both arms are positioned at the side of the table: one with the hand placed palm down and the other carefully positioned on an armboard to facilitate IV infusion of fluids, blood, or medications. This position is used for most abdominal surgeries, except for surgery of the gallbladder or pelvis PROTECTING THE PATIENT FROM INJURY Verifying information, checking the medical record for completeness, and maintaining surgical asepsis and an optimal environment are critical nursing responsibilities. Verification that all the required documentation is completed is an important function of the intraoperative nurse. SERVING AS PATIENT ADVOCATE The patient undergoing general anesthesia or moderate sedation experiences temporary sensory or perceptual alteration or loss, and has an increased need for protection and advocacy. Patient advocacy in the OR entails maintaining the patient's physical and emotional comfort, privacy, rights, and dignity. Patients, whether conscious or unconscious, should not be subjected to excess noise, inappropriate conversation, or, most of all, derogatory comments. Banter in the OR should not include comments about the patient's physical appearance, job, personal history, and so forth. MONITORING AND MANAGING POTENTIAL COMPLICATIONS It is the responsibility of the surgeon and the anesthesiologist or CRNA to monitor and manage complications. However, intraoperative nurses also play an important role. Being alert to and reporting changes in vital signs, cardiac dysrhythmias, symptoms of nausea and vomiting, anaphylaxis, hypoxia, hypothermia, and malignant hyperthermia and assisting with their management are important nursing functions. Expected patient outcomes may include: -Exhibits low level of anxiety while awake during the intraoperative phase of care -Has no symptoms of latex allergy -Remains free of perioperative positioning injury -Experiences no unexpected threats to safety -Has dignity preserved throughout OR experience -Is free of complications (e.g., nausea and vomiting, anaphylaxis, hypoxia, hypothermia, malignant hyperthermia, or deep vein thrombosis) or experiences successful management of adverse effects of surgery and anesthesia should they occur

19.7 Identify assessment parameters and interventions appropriate for the early detection of post-operative complications

Assessment (Compare to pre op or baseline). -Respiratory -Pain -Mental status/LOC -General discomfort (pain associated with intubation? prolonged immobility?) -Primary consideration: necessary to maintain ventilation, oxygenation(assess respiratory rate, drive and effort) -Provide supplemental oxygen as indicated. -Assess breathing by placing hand near face to feel movement of air - Keep head of bed elevated 15 to 30 degrees unless contraindicated. -May require suctioning - If vomiting occurs, turn patient to side. -Monitor all indicators of cardiovascular status - Assess all IV lines - Potential for hypotension, shock - Potential for hemorrhage - Potential for hypertension, dysrhythmias. Refer to Table 19-4 Signs to look for: post op hemorrhage or hypovolemic shock. Have they lost too much volume? fluid or blood? - Pallor - Cool, moist skin - Rapid respirations - Cyanosis - Rapid, weak, thread pulse - Decreasing pulse pressure - Low blood pressure - Concentrated urine. Interventions: - Assess patient comfort - Control of environment: quiet, low lights, noise level - Administer analgesics as indicated; usually short-acting opioids IV - Family visit, dealing with family anxiety - Intervene at first indication of nausea- Medications - Assessment of postoperative nausea, vomiting risk, prophylactic treatment -Decreased physiologic reserve-Monitor carefully, frequently -Increased confusion -Dosage -Hydration -Increased likelihood of postoperative confusion, delirium -Hypoxia, hypotension, hypoglycemia -Reorient as needed -Pain Interventions: PREVENTING RESPIRATORY COMPLICATIONS -

17.4 Identify legal and ethical considerations related to obtaining informed consent for surgery.

INFORMED CONSENT(autonomous decision to undergo surgical procedure, no coercion) -Should be in writing before nonemergent surgery (no surgical consent only when life is on the line). -Legal mandate. -Surgeon must explain the procedure, benefits, risks, complications, etc. -Nurse clarifies information and witnesses signature -Consent is valid ONLY when signed before administering psychoactive premedication (patient has extreme anxiety and takes a benzo, after medication informed consent is not valid). -Consent accompanies patient to OR - Voluntary and written informed consent from the patient is necessary before nonemergent surgery can be performed to protect the patient from unsanctioned surgery and protect the surgeon from claims of an unauthorized operation or battery. Consent is a legal mandate, but it also helps the patient to prepare psychologically, because it helps to ensure that the patient understands the surgery to be performed - The nurse may ask the patient to sign the consent form and witness the signature; however, it is the SURGEON'S responsibility to provide a clear and simple explanation of what the surgery will entail prior to the patient giving consent. - The surgeon must also inform the patient of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and if the patient requests additional information, the nurse notifies the physician. The nurse ascertains that the consent form has been signed before administering psychoactive premedication, because consent is not valid if it is obtained while the patient is under the influence of medications that can affect judgment and decision-making capacity. Consent forms should be written in easily understandable words and concepts to facilitate the consent process and should use other strategies and resources as needed to help the patient understand the content. - Asking patients to describe in their own words the surgery they are about to have promotes nurses' understanding of patients' comprehension. Voluntary Consent Valid consent must be freely given, without coercion. Patient must be at least 18 years of age (unless an emancipated minor), a physician must obtain consent, and a professional staff member must witness patient's signature.

13.4 Plan effective care of patients with the following imbalances: fluid volume deficit and fluid volume excess, sodium deficit (hyponatremia) and sodium excess (hypernatremia), and potassium deficit (hypokalemia) and potassium excess (hyperkalemia). sodium deficit (hyponatremia) and sodium excess (hypernatremia)

NORMAL 135-145 mEq/L Sodium Deficit (Hyponatremia) Serum sodium less than <135 mEq/L ( FVD bc they lose fluid and sodium ) Acute - Result of fluid overload of a surgical patient (neurological issues or of concern) Chronic - Seen outside of hospital setting, longer duration, less serious neurologic sequelae (chronic kidney issues, liver issues) Exercise associated - More common in women of small stature, extreme temperatures, excessive fluid intake, prolonged exercise Causes and Clinical Manifestations of Hyponatremia Causes: Imbalance of water, losses by vomiting, diarrhea, sweating, diuretics, adrenal insufficiency, certain medications, SIADH Manifestations: poor skin turgor, dry mucosa, headache, decreased salivation, decreased blood pressure, nausea, abdominal cramping, neurologic changes ALL ABOUT ANTICIPATING PT'S NEEDS BEFORE ISSUE BECOMES SEVERE MANAGEMENT OF HYPONATREMIA - Treat underlying condition (Know root cause) (ex: pt has SIADH, if not corrected antidiuretic hormone issue, you end up chasing the hyponatremia) - Sodium replacement (May be used: hypertonic solution such as 3% sodium chloride; hypertonic solutions may cause sodium levels to rise rapidly; must be given slowly and pts neurological status must be closely monitored) - Water restriction - Medication (such as sodium chloride tablets to increase levels) - Assessment: I&O, daily weight, lab values, CNS changes - Encourage dietary sodium (add extra table salt for example) - Monitor fluid intake - Effects of medications (diuretics, lithium) (teach pts about medications causing excessive fluid and electrolyte loss, signs + symptoms teaching) Sodium Excess (Hypernatremia) Serum sodium greater than >145 mEq/L - Occurs in patients with normal fluid volume, FVD, FVE (depends on if we are losing water and salt together or if we are losing water, such as during dehydration, and causing sodium levels to rise) - Most affected are very old, very young, and cognitively impaired (these are the patients that we worry about who cannot get normal intake of fluids, they do not have the ability to get up and get it, or no thirst response) Causes and Clinical Manifestations of hypernatremia Causes: fluid deprivation, excess sodium administration, diabetes insipidus, heat stroke, hypertonic IV solutions Manifestations: thirst; elevated temperature THIRST: easy way to think about it: you went to movies and had an entire bucket of salty popcorn, the rest of the night you cannot get enough water bc of your increased salt intake. Management of Hypernatremia - Gradual lowering of serum sodium level via infusion of hypotonic electrolyte solution (hypotonic solution like 0.3% or 0.45% sodium chloride to help slowly pull out excess sodium) - Diuretics (when we lose fluid, sodium follows) - Assessment for abnormal loss of water and low water intake (what is cause?) - Assess for over-the-counter sources of sodium (tell me diet, medications, etc) - Monitor for CNS changes (most important to monitor neurologic changes, at risk for seizures and changes of levels of consciousness)

13.4 Plan effective care of patients with the following imbalances: fluid volume deficit and fluid volume excess, sodium deficit (hyponatremia) and sodium excess (hypernatremia), and potassium deficit (hypokalemia) and potassium excess (hyperkalemia). potassium deficit (hypokalemia) and potassium excess (hyperkalemia)

Normal 3.5 - 5 meq/L Potassium Deficit (Hypokalemia) Below-normal serum potassium <3.5 mEq/L - remember: majority of potassium is intracellular - responsible for controlling muscular function (skeletal and cardiac) - sensitive to minor changes for example: a potassium level of 3.0 has a significant impact on a patient but if we were talking about sodium where 135-145 is normal, 130 might not be as impactful. potassium is measured diff and has a big impact when it is altered slightly, on the high or low range. - majority of potassium leaves thru renal system which is why pts w impaired renal function are at extremely high risk for potassium imbalances. rest is thru GI system (vomiting, gi suctioning, diarrhea) - May occur with normal potassium levels: when alkalosis is present a temporary shift of serum potassium into cells occurs CAUSES AND CLINICAL MANIFESTATIONS OF HYPOKALEMIA Causes: GI losses, medications (diuretics specifically loop diuretics such as Lasix), prolonged intestinal suctioning (during bowel surgery), recent ileostomy, tumor of the intestine, alterations of acid-base balance, poor dietary intake, hyperaldosteronism Manifestations: - ECG changes and dysrhythmias (cardiac muscle=muscle weakness) (most severe manifestations) (prolonged low potassium = close cardiac monitoring bc of potential of cardiac arrest) - dilute urine - excessive thirst - fatigue - anorexia - muscle weakness - decreased bowel motility - paresthesias (pins and needles) Management of Hypokalemia - Potassium replacement: Increased dietary potassium or IV for severe deficit (may be prescribed a potassium chloride pill or an elixir) (IV= requires continuous monitoring, can NEVER be given IV Push and never intramuscularly: IM bc potassium levels will rise too quickly ONLY IV PIGGYBACK is allowed, on an infusion pump never administered by gravity) - Monitor ECG for changes (should be on continuous cardiac monitoring) - Monitor ABGs (if issue is bc of acid base imbalance) - Monitor patients receiving digitalis for toxicity (pts who take digoxin - can cause hypokalemia) - Monitor for early signs and symptoms (if we pick up on signs of muscle cramps and weakness we can avoid issue or prevent issue before full blown cardiac changes) - Administer IV potassium only after adequate urine output has been established (renal system plays a huge role in regulation of potassium) Potassium Excess (Hyperkalemia) *does not occur as often as hypokalemia Serum potassium greater than >5.0 mEq/L - Seldom occurs in patients with normal renal function (usually w renal impairments, potassium starts to build up) - Increased risk in older adults - Cardiac arrest is frequently associated Causes and clinical manifestations of hyperkalemia Causes: Impaired renal function, rapid administration of potassium (opposite effect), hypoaldosteronism, medications, tissue trauma, acidosis Manifestations: Cardiac changes and dysrhythmias, muscle weakness, paresthesias, anxiety, GI manifestations Management of hyperkalemia - Monitor ECG, assess labs, monitor I&O, obtain apical pulse - Limitation of dietary potassium and dietary teaching (salt substitutes typically have a high potassium content in them) - Administration of cation exchange resins (Kayexalate) - Emergent care: IV calcium gluconate, IV sodium bicarbonate, IV regular insulin and hypertonic dextrose IV, beta-2 agonists, dialysis - Administer IV slowly and with an infusion pump some pts who have really high potassium levels may require dialysis, get all the waste out and bring potassium levels down in order to avoid cardiac arrest

13.5 Describe the cause, clinical manifestations, management, and nursing interventions for the following imbalances: calcium deficit (hypocalcemia) and calcium excess (hypercalcemia)

Normal level: 8.5 - 10.5 mg/dL Calcium is responsible for nerve impulses, helps regulate muscle contractions (includes cardiac muscles) Hypocalcemia - Serum level less than 8.6 mg/dL, must be considered in conjunction with serum albumin level - Serum calcium level controlled by parathyroid hormone and calcitonin - Causes: hypoparathyroidism, malabsorption, osteoporosis, pancreatitis, alkalosis, transfusion of citrated blood, kidney injury, medications - Manifestations: (neuro changes) tetany, circumoral numbness, paresthesias, hyperactive DTRs (deep tendon reflexes) (hypocalcemia causes HYPERactive DTRs), positive Trousseau sign, Chvostek sign, seizures, respiratory symptoms of dyspnea and laryngospasm, abnormal clotting, anxiety. Management of Hypocalcemia - IV of calcium gluconate for emergent situations (if tetany, positive Chvostek and Trosseau signs) (must be monitored extremely carefully, if the medication were to get out of vein and go into surrounding tissue, has a high risk of extravasation, meaning break down surrounding tissue.) - Seizure precautions - Oral calcium and vitamin D supplements (when not severe) - Exercises to decrease bone calcium loss - Patient teaching related to diet and medications (add into diet to combat hypocalcemia) Hypercalcemia - Serum level greater than 10.5 mg/dL - Hypercalcemia crisis has high mortality - Causes: malignancy (bone cancer) and hyperparathyroidism, bone loss related to immobility (lose a lot of fluid = concentrate calcium in vascular system and make it higher), diuretics pt w bone cancer = make sure to monitor calcium levels Clinical manifestations: - polyuria (increased urination) - thirst - muscle weakness - intractable nausea - abdominal cramps - severe constipation - diarrhea - peptic ulcer - bone pain - ECG changes and dysrhythmias (most significant) Management of Hypercalcemia ultimate goal is to get as much of that calcium out of the body, excreted thru urine as quickly as possible. - Treat underlying cause - Administer IV fluids, furosemide, phosphates, calcitonin, bisphosphonates - Increase mobility - Encourage fluids - Dietary teaching, fiber for constipation - Ensure safety (important for all electrolyte imbalances but due to underlying causes such as bone cancer, if pt falls, bones are brittle and may break horribly)

Preoperative Phase

Preadmission Testing 1. Initiates initial preoperative assessment 2. Initiates education appropriate to patient's needs 3. Involves family in interview 4. Verifies completion of preoperative diagnostic testing 5. Verifies understanding of surgeon-specific preoperative orders (e.g., bowel preparation, preoperative shower) 6. Discusses and reviews advance directive document 7. Begins discharge planning by assessing patient's need for postoperative transportation and care Admission to Surgical Center 1. Completes preoperative assessment 2. Assesses for risks for postoperative complications 3. Reports unexpected findings or any deviations from normal 4. Verifies that operative consent has been signed 5. Coordinates patient education and plan of care with nursing staff and other health team members 6. Reinforces previous education 7. Explains phases in perioperative period and expectations 8. Answers patient's and family's questions In the Holding Area 1. Identifies patient 2. Assesses patient's status, baseline pain, and nutritional status 3. Reviews medical record 4. Verifies surgical site and that it has been marked per institutional policy 5. Establishes IV line 6. Administers medications if prescribed 7. Takes measures to ensure patient's comfort 8. Provides psychological support 9. Communicates patient's emotional status to other appropriate members of the health care team

Know normal values for sodium, potassium, magnesium, calcium, BUN/Cr, pH, CO2, and HCO3 levels

Sodium = 135 - 145 mEq/l Potassium = 3.5 - 5.0 mEq/L Chloride = 98 - 106 mEq/L Bicarbonate = 24 - 31 mEq/L Calcium = 8.5 - 10.5 mg/dL Phosphorus 2.5 - 4.5 mg/dL Magnesium = 1.8 - 3.0 mg/dL BUN 10-20 CR 0.6-1.2 PH= 7.35 -7.45 PCO2 = 35-45 mm Hg HCO3 = 22-26 mEq/L PaO2 = 80 - 100 mm/Hg