MEd Surg Test 4: Hair, Skin, Nails, Burns, Operative Patients

seborrheic keratosis

-common in older ppl -rough, greasy, wartlike texture -commonly found on neck, face, upper trunk, & arms -removed only for cosmetic reasons or if becomes irritated form friction -cryosurgery or currettage

circumferential injury in full thickness wound

-completely surrounds an extremity or chest & blood flow & chest movement for breathing may be reduced by tight eschar -escharotomies or fasciotomies may be needed to relieve pressure & allow normal blood flow & breathing

Tzanck smear

-confirms viral infections -cells are examined under a microscope -Presence of multinucleated giant cells confirms viral infection, but not exact virus

moist heat (scald) injuries

-contact with hot liquids or steam -hot liquid spills or scalding hot water immersions

scabies

-contagious skin disease caused by mite infestation -transmitted by infected person or infested bedding -manifested by curved or rigid lines in the skin -itching becomes unbearable at night

comfort for sunburns

-cool baths -soothing lotions

comfort measures for eczema

-cool, moist compress -lukewarm baths decrease inflammation and can el[p debride crusts and scales

full thickness wounds

-damage extends into the lower layers of the dermis; underlying subQ tissue -leaves scar tissue (granulation)

eschar

-dead tissue that must slough off or be removed from the wound before healing can occur

GI changes from burns

-decreased blood flow in the GI -decreased peristalsis -paralytic ileus may develop -abdominal distention -curling's ulcer may develop within 24 hours after but less common from use of H2 histamine blockers and PPI

high risk pts for pressure ulcers

-decreased mental status -dependent mobility; any pt who requires assistance with turning and positioning -negative nitrogen balance -low protein levels -incontinence -diabetes -inadequate nutrition/hydration -peripheral vascular disease

deep partial thickness wound

-deeper into the skin with fewer healthy cells -rare blisters -soft and dry eschar -red and dry with white areas in deeper parts (dry because fewer blood vessels are patent) -blanches slowly or not at all -moderate edema -less pain than superficial because nerve endings are destroyed -heal 3-6 weeks with a scar -skin grafting can reduce healing time

second intention

-deeper tissue injuries or wounds with tissue loss -ex: chronic pressure ulcer or venous stasis ulcer -cavity like defect -requires gradual filling in of dead space with connective tissue -prolongs repair process

third intention

-delayed primary closure -wound left open to debride dead cells and tissues -wound is closed after inflammation has subsided

full thickness wound

-destruction of entire epidermis & dermis leaving no skin cells -does not regrow -require grafting -hard, dry, lethery eschar forms -severe edema under eschar -waxy white, deep red, yellow, brown, or black -thrombosed vessels may be visible beneath burn -avascular (w/o a blood supply) -reduced or absent sensation -healing is weeks to months

bedbugs (cimex lectularius)

-does not live on humans -feeds on human blood -extensive bits can cause anemia -insect bites -injects saliva containing an anitcoagulant -sucks blood for 3-10 min -resembles mosquito or flea bite -raised bite mark surrounded by a wheal -antihistamines can be used

granulation

-early; pale pink -progresses to beefy red -palpate wound -healthy; moist, slightly spongy texture -poor blood supply/stopped healing; dry, hard

when symptoms of pulmonary edema are present

-elevate head of bed to at least 45 degrees -apply humidified oxygen -notify burn team or rapid response team

s/e of acne med

-elevated liver function -dry, chapped lips -depression -teratogenic (birth defects)

superficial partial thickness wound

-entire epidermis and upper 3rd of the dermis -red and moist -blanch when pressure is applied -leakage of large amounts of plasma -blister formation -increased pain sensation -nerve endings are exposed -heal 10-21 days with no scar but minor pigment changes

surgical management of burns

-escharotomy or fasciotomy

deep full thickness wounds

-extend beyond the skin into underlying fascia and tissues -damage muscle, bone and tendons leaving them exposed -blackened and depressed wound -complete absence of sensation -need grafting and possible amputation if an extremity is involved

cysts

-firm, flesh-colored nodules that contain liquid or semisolid material -moves and indents on palpation

resuscitation phase

-first phase of a burn injury -begins at the onset of injury and continues 24-48 hours -priorities: 1. secure the airway 2. support circulation by fluid replacement 3. keep the patient comfortable with analgesics 4. prevent infection through careful wound care 5. maintain body temperature 6. provide emotional support

herpes simplex (HSV)

-most common viral infection of adults -virus remains in body dormant; pt has no symptoms -triggered by physical or psychological stressors -spread by direct contact between actively infective person and susceptible host

rule of nines

-most rapid method for calculating the size of a burn injury in adult patients whose weights are in normal proportion to their height

hourly urine output

-needs to be 0.5mL/kg (about 30mL/hr)

hydrophobic dressing

-non absorbent, waterproof -when wound is relatively free of drainage -protect ulcer form external contamination

diuretics

-not commonly used because don't increase CO in shock prevention -exception is electrical burn patients (use mannitol) but make sure urine output is adequate first

curettage & electrodesiccation

-not for melanoma -small lesions -scrape away lesion -places electric probe on wound destroying remaining tumor -

contact burns

-occur when hot metal, tar, or grease contacts the skin often leading to full-thickness injury

true electrical injury

-occurs when direct contact is made with an electrical source

Stevens-Johnson syndrome

-often drug induced immunologic skin reaction similar to TEN -lesions are widely distributed -pt has a mix of vesicles, erosions, and crusts -in severe involvement, pt could have resp problems, excessive fluid loss, acute kidney injury, blindness

basal cell carcinoma

-often go unnoticed -genetic predisposition, chronic irritation risk factors -sun exposure most common cause -pearly papule with a crater and rolled waxy borders -sun exposed areas

pts at risk for infection with wound

-older -WBC disorders -steroid therapy -wounds with compromised blood supply

radiation therapy

-older pts -those who are poor risk for surgery -melanoma is resistant to radiation

increased risk for death with burns

-older than 60 -burn greater than 40% TBSA -presence of inhalation injury

priority problems with pressure ulcers

-open wounds r/t vascular insufficiency and trauma -potential for infection and wound deterioration r/t insufficient wound management

treatment for anthrax

-oral antibiotics for 60 days -cipro -doxycycline for pts who have fever, lesions on head/neck, are pregnant, or have extensive edema: -antibiotics given IV followed by oral course for 60 days

epidermis

-outer layer of the skin made of epithelial cells -can grow back after a burn injury

keloid

-overgrowth of a scar with an excessive accumulation of collagen and ground substance. -common in dark-skinned ppl

a flap may have inadequate arterial perfusion if

-pale -delayed cap refill when blanched

drug therapy for supporting oxygenation

-paralytic drugs such as atracurium or vecuronium -these drugs make mechanical ventilation easier

immediately apply oxygen and notify rapid response team

-patient who is hoarse, has a brassy cough, drools or has difficulty swallowing or produces audible breath sounds on exhalation

demands immediate intubation

-patient with wheezing sounds that disappear

rule of nine

-perineal: 1 -head: 4.5 -arms: 4.5 -legs: 9 -chest/back: 18

pulmonary changes from burns

-possible respiratory failure -48-72 hours obstruction -alveolar edema up to 1 week -fibrinous membranes

Priority problems for patient after surgery

-potential for hypoxemia r/t effects of anesthesia, pain, opioid analgesics, & mobility -potential for wound infection & delayed healing r/t wound location, decreased mobility, drains & drainage, & tubes -Pain r/t surgical incision, positioning during surgery, & endotracheal (ET) tube irritation

actinic keratosis (cancer)

-premalignant lesions -small, dry, rough, yellow or brown scale -could progress to squamous cell carcinoma

Burow's solution

-promotes crust formation & healing -apply to viral lesions for 20 min 3x daily

functions of the skin

-protective barrier against injury and microbials -maintain fluid and electrolyte balance -excretory organ -sensory organ -activates vitamin D -physical identity

lichen planus

-purple, flat topped papules that itch -usually on wrists & inner surfaces of forearms

fluid resuscitation

-rapid infusion of IV fluids -needed to maintain sufficient blood volume for normal cardiac output, MAP (mean arterial pressure), & tissue oxygenation

toxic epidermal necrolysis (TEN)

-rare, acute drug reaction of the skin r -esulting in diffuse erythema and large blister formation -most common causes: chemo, sulfonamides, pyrazolones, barbiturates, antibiotics -occur at any age

pemphigus vulgaris

-rare, chronic, blistering, disease with high morbidity and mortality -autoimmune disorder mostly in middle to old age

signs of superficial thickness wound

-redness -mild edema -pain -increased sensitivity to heat occurs -desquamation (peeling of dead skin) 2-3 days after -heals 3-6 days w/o scar

surgical debridement

-removal of necrotic tissue -skin grafting -use of muscle flap to close wounds that cannot heal without it

"Don'ts" with burn victims

-remove burned clothing -apply ointments -breath, blow or cough on burn -break blisters -feed the person: possible surgery -immerse a severe burn -use a pillow under airway: keep them FLAT

emergency management: radiation burns

-remove patient from radiation source -if patient has been exposed to radiation from an unsealed source remove their clothing with tongs or lead gloves -if radioactive particles on skin send them to radiation decontamination center -help patient bathe/shower

examples of superficial partial thickness wound

-scalds, flames, brief contact with hot objects

examples of deep partial thickness wounds

-scalds, flames, prolonged contact with hot objects, tar, grease, chemicals

examples of full thickness wound

-scalds, flames, prolonged contact with hot objects, tar, grease, chemicals, electricity

given over the next 16 hours

-second half of volume being given

inadequate nutrition-high risk

-serum albumin level less than 3.5 g/dL -prealbumin level less than 19.5 mg/dL -poor daily intake -weight loss greater than 5% in 30 days or 10% in 180 days

postherpetic neuralgia

-severe pain persisting after shingles lesions have resolved -common in older pts

monitor ulcer/wound

-signs of infection -drainage -necrotic tissue -odor -frequency of dressing changes -measure wound size every 48 hrs -erythmia -swelling -elevated temp -elevated WBC count

stage 1 pressure ulcer

-skin intact -area red; does not blanch -for darker skinned pts; compare to adjacent limb

unstageable pressure ulcer

-skin loss full thickness -base completely covered with slough or eschar, obscuring true depth of wound

stage 4 pressure ulcer

-skin loss is full thickness -exposed or palpable muscle, tendon, or bone -often has tunneling -sinus tracts may develop -slough and eschar are often present

stage 3 pressure ulcer

-skin loss is full thickness -subQ tissue damaged or necrotic -bone, tendon, muscle are not exposed -varying depths -tunneling may or may not be present

stage 2 pressure ulcer

-skin not intact -partial thickness skin loss -superficial ulcer; abrasion, blister, shallow crater -bruising is NOT present

emergency management: flame burns

-smother the flames -remove smoldering clothing and all metal objects

MRSA

-spread by direct contact w/ infected skin or with infected objects -if infects a wound or gains access into the blood: -deep wound infection -sepsis -organ damage -death

folliculitis

-superfiscial infection involving only the upper portion of the follicle ]-usually caused by staph -rash is raised, red, small pustules

Priority problems for preoperative patients

1. Insufficient information about surgical experience r/t unfamiliarity w/ surgical procedures & prep. 2. Anxiety r/t new or unknown experience, possibility of pain, & possible surgical outcomes

proliferative (connective tissue repair) stage

-begins about 4th day -lasts 2-4 weeks -fibroblast cells stimulate secretion of collagen -scar tissue built by collagen and ground substance -new blood vessels form -epithelial cells grow over the granulation tissue bed

maturation (remodeling) stage

-begins as early as week 3 -scar tissue becomes thinner and paler -mature scar is firm and inelastic to touch

inflammatory (lag) phase

-begins at time of injury -lasts 3-5 days -local edema, pain, erythema, warmth

problems with partial thickness wounds

-blood vessel constriction reducing blood flow leading to deeper injury from hypoxia and ischemia -they can convert to full-thickness when tissue damage increases with infection, hypoxia or ischemia

nutritional stores of

-calories -protein -vitamins -minerals -water -vegetables -friut - whole grain

flash burns/external

-can occur when the electrical current jumps or "arcs" between two body surfaces

squamous cell carcinoma

-cancer of epidermis -potentially metastatic -firm nodule with crust -sun exposed areas

dry heat injuries

-caused by open flame -common are house fires and explosions

furnucles (boils)

-caused by staph -infection much deeper in follicle -large, sore looking, raised bump -more likely in hot, moist areas -hair-bearing skinfolds

SNS stress response

-changes in the cardiovascular, respiratory and GI system -everything increases

chemical burns

-chemicals directly contact the skin and epithelial tissues or are ingested -household cleaners -have toxic affects on the kidneys and liver

leprosy (hansens disease)

-chronic, contagious, systemic mycobacterial infection of the PNS with skin involvement. *Treatment -6-12 month course of multiple drug therapy

Assessing Skin

-clean surgical wound heals at skin level about 2 weeks -COMPLETE healing of tissues takes 6 months - 2 years -reduced healing: obese, diabetics, smokers, older, reduced immunity -Assess incisions at least q8h -Report to surgeon: redness/swelling around incision, excessive tenderness/pain, purulent/odorous drainage

General anesthesia- balanced

advantages • minimal disturbance to physiologic function • minimal side effects • can be used w/ older & high risk patients disadvantages • drug interactions can occur • pharmacologic effects unpredictable

In surgical safety checklist, what should nurse verbally confirm before pt leaves operating room

1. Name of procedure 2. Completion of instrument, sponge, & needle count 3. Specimen labeling 4. If there are any equipment problems that need addressing

Answer: a. c. d. The skin has many functions. It is a barrier mechanically, chemically, and thermally, allowing for acidic secretions to be expressed from the dermis, and acting as a moisture barrier for the body.

1. Name the functions of the skin. Select all that apply. a. Maintenance of a moisture barrier b. To allow alkalinic secretions to be excreted c. Protection against microorganisms d. To act as a mechanical barrier for the body tissues e. To take in proteins as nutrients for the body f. To take in fats as nutrients for the body

Classification of Burn Depth: Eschar

Superficial -NO Superficial Partial-Thickness -NO Deep Partial-Thickness -Yes, soft & dry Full-Thickness -Yes, hard & inelastic Deep Full-Thickness -Yes, hard & inelastic

Classification of Burn Depth: Blisters

Superficial -No Superficial Partial-Thickness -Yes Deep Partial-Thickness -Rare Full-Thickness -NO Deep Full-Thickness -NO

Classification of Burn Depth: Pain

Superficial -Yes Superficial Partial-Thickness -Yes Deep Partial-Thickness -Yes Full-Thickness -Yes/No Deep Full-Thickness -Absent

Classification of Burn Depth: Color

Superficial: Pink-Red Superficial Partial-Thickness: Pink-Red Deep Partial-Thickness: Red-White Full-Thickness: Black, Brown, white, red Deep Full-Thickness: Black

prophylactic antibiotic

Surgeon may order a _____ to be given right before/ during surgery to ↓risk for surgical site infection. It is given w/in 60 minutes before incision is made

advance directives or living will

Surgery does not provide an exception to a patient's ______

true or false an embolism is a blood clot that gets caught in your vein causing bloodflow issues

false: does not have to be blood, can be air or debris such as a broken piece of IV cath

true or false the area of skin to be surgically punctured must remain sterile

false: you will never get skin truly sterile

rete pegs.

fingers of epidermal tissue that project into dermis are called _______

topical glucocorticoid

fluticasone propionate cream

wide excision

for wider melanoma

herpetic whitlow

form of herpes simplex infection occuring on fingertips that were in contact with viral secretions -easily spread to pt.... WASH HANDS!

Nociceptors

free nerve endings located throughout the body

pedicle flap

full thickness flap of skin -raised and rotated to cover defect -one ege still intact to provide blood supply

Cryothermia anesthesia

advantages • reflexes remain intact • ↓ chance of adverse reactions, • ↓ intraoperative stress; disadvantages • no way to control depth of anesthesia • not used in long or extensive procedures, • may not be appropriate for anxious pt

type 2 HSV

genital herpes; also recurrent

hypnosis, hypnoanesthesia

advantages • reflexes remain intact disadvantages • requires patient cooperation • requires special training

Intravenous Anesthetics- methohexital sodium (brevital)

advantages •acts directly on CNS disadvantages •can induce bradycardia & hypotension

Intravenous Anesthetics- midazolam (versed)

advantages •induces amnesia around the event disadvantages •slower induction than other IV agents

The anesthesia provider

gives anesthetic drugs to induce & maintain anesthesia & delivers other drugs PRN to support pt during surgery.

if the Dr. refuses to re-explain to a pt who does not fully understand, what should the nurse do

go up the nurses chain of command

koebners phenomenon

greater risk for cancer development caused by injured skin

Wood's light Examination

handheld, long-wavelength ultraviolet light or Wood's light is sometimes used during a physical examination. Exposure of some skin infections produces a specific color such as blue-green or red.

whirlpool treatments

help remove dead tissue

what surgeries would pose a high risk for VTE (venous thromboembolism)

hip fx, total hip/knee

The Patient on Arrival Med Surg Unit After Discharge from PACU Temperature, Pulse, & BP

• Are these values w/in pt's baseline range? • Are these values significantly different from when pt was in PACU?

Malignant Hyperthermia (MH)

•An acute, life-threatening complication of certain drugs used for general anesthesia •Causes increased metabolism & Calcium levels in muscle cells leading to acidosis, cardiac dysrhythmias & high core body temp. •Can occur during induction (Succinylcholine—muscle relaxant) or hrs into procedure

mechanical debridment

• wounds are debrided & cleaned 1-2 x a day during hydrotherapy • remove loose, nonviable tissue using forceps, scissors, gauze, sponges

Hyperkalemia (increased serum potassium level)

• ↑ risk for dysrhythmias, esp w/ use of anesthesia.

Hypokalemia (decreased serum potassium level)

• ↑ risk for toxicity if taking digoxin • slows recovery from anesthesia, • ↑cardiac irritability.

Pressure-reduction devices

lower pressure below that of a standard hospital mattress or chair surface but do not reduce pressure consistently below the capillary closing pressure. These devices are effective for preventing pressure ulcers only when used together with a turning schedule and other skin care measures.

what puts pt's at risk for VTE

obesity, >40 yo, hx of cancer, decreased mobility, spinal cord injury, hx of VTE or PE, edema, oral contraceptivess, smoking, hx of decreased cardiac output

Cultures for bacterial infection

obtained from intact primary lesions (bullae, vesicles, or pustules), if possible.

Culture for Bacterial infection

obtained from intact primary lesions. *Express material from lesion *collect it with a cotton-tipped applicator *place material in bacterial culture medium specified by lab

linear lesion

occurring in a straight line

Nursing Actions Suspected DTI

off load, same as Stage I Constant assessment q shift

Nursing Actions Stage IV Pressure Ulcer

off load, same as Stage I and Stage II

Nursing Actions Stage III Pressure Ulcer

off load, same as Stage I; if depth pack wound space with dressing; low air loss mattress, wound care consult; possible surgical consult

Nursing Actions Stage II Pressure Ulcer

off load, same as Stage I; if incontinent don't use dressing use barrier creams on gluteal and hip areas

Nursing Actions Stage I Pressure Ulcer

off load, wedge, elevate heels off mattress, heel protectors, lotions, creams, specialty mattress

malpighian layers

older keratinocytes pushed upward & flattened to form stratified layers of epithelium

Post anesthesia care unit (PACU)

ongoing evaluation and stabilization of patients to anticipate, prevent, & manage complications after surgery.

Blackheads

open comedones

Stage III of general anesthesia

operative anesthesia, surgical anesthesia stage •begins w/ generalized muscle relaxation & ends w/ loss of reflexes & depression of vital functions •jaw is relaxed & breathing is quiet & regular •patient cannot hear, sensations are lost Nurse should •assist with intubation •place pt into operative position •prep scrub pt's skin over operative site

what are some musculoskeletal changes that occur with aging that increase surgical risks

osteoporosis/arthritis

Stratum corneum

outermost, strongest layer of epidermis --Large amount of keratin --Forms barrier that repels bacteria & foreign matter --Thickest in high-stress areas—soles & palms

○ Nonbullous Impetigo

§ Papules → vesicles → painless pustules with narrow erythematous border § Honey-colored exudate when lesions rupture, forming a crust on the ulcer-like base § Regional lymphadenopathy

Patient-Controlled Analgesia (PCA)

• An infusion pump, where IV sedation is administered • To a degree pt. is able to self- medicate by pressing a button

Medications that increase Surgical/ Postoperative Risk

• Antihypertensives • Tricyclic antidepressants • Anticoagulants • Nonsteroidal anti-inflammatory drugs (NSAIDs)

Health Promotion and Maintenance .

• Apply padding to OR bed to maintain pt's skin integrity. • Position pt comfortably & safely. • Apply warming blanket to maintain normal body temp

Bacterial Infection Therapeutic Management

• Appropriate hygiene • Topical / systemic antibiotics • Cool compresses- remove crusting with impetigo • Warm compresses- folliculitis

who is responsible for obtaining the informed consent

Doctor

anticholinergics benzodiazepine cholinergic dopamine blockers neuromuscular blockers opioids phenothiazine

Drug classes used as adjuncts to anesthesia include ___, __, ___, ___ ___, ___ ___, ___, & ___.

keratolytic

Drugs used to promote the shedding of old skin

Seborrheic dermatitis

Drugs used to treat oily skin would most likely be used for

Changes of Aging as Surgical Risk Factors Skin

Dry with ↓ subcutaneous fat = skin at ↑ risk for damage; slower skin healing ↑ risk for infection •Assess the patient's skin before surgery for lesions, bruises, and areas of ↓ circulation. Having baseline data helps detect changes and evaluate interventions. •Pad bony prominences. Padding can protect at-risk areas. •Use pressure-avoiding or pressure-reducing overlays, which prevent pressure ulcer formation by redistributing body weight. •Avoid applying tape to skin. Tape removal damages thin skin. •Teach pt to change position at least q2h- prevent ↓ blood flow to area & changes external pressure patterns.

Warm red area on the calf

During the postoperative client assessment, which skin condition discovered by the nurse requires an urgent response? A. Clubbing of the nail beds B. Cool extremities C. Café au lait spots D. Warm red area on the calf

Infection: the bacteria are invading viable tissue

Dx. based on clinical findings & appearance of S/sx's of infection: erythema, heat, edema, pain, purulent exudate

Dynamic pressure-reducing systems

Dynamic systems alternate inflation and deflation of the device through the use of electricity.

Central Pain Syndrome

General pain caused by damage of nerves in CNS --stroke, MS

General Anesthesia

Loss of sensation throughout body followed by loss of consciousness § Most nervous activity in the brain is depressed § Produces unconsciousness § Produces lack of responsiveness to painful stimuli § Provided best by balanced anesthesia (MH)

The most common forms of anesthesia used in North America

• general • regional • local anesthesia.

MH genetics

• genetic disorder w/ autosomal dominant pattern of inheritance. • Genetic predisposition at risk for complication from halothane, enflurane, isoflurane, desflurane, sevoflurane, & succinylcholine. • most common in young adults. • Males affected > females d/t differences in muscle mass. • Once hx of MH is known- muscle biopsy to determine risk. • Muscle biopsy- w/ caffeine halothane contracture test (CHCT) • "gold standard" for MH testing even though inherited. • No definitive genetic test identifies all at risk • can still have anesthesia & surgery; more precautions needed & different anesthetic agents

preventing ARDS with burns

• give positive end-expiratory pressure (PEEP) to augment ↓lung volume by providing a continuous positive pressure in airways & alveoli

The OR layout

• helps prevent infection by ↓ contaminants through air exchanges in room, maintaining recommended temp & humidity levels, & limiting traffic & activities in OR. • Safety straps used for pt, & operating bed locked in place. • Blankets or warming units used to prevent hypothermia, • interventions used to prevent skin breakdown.

homografts or allografts

• human skin obtained from a cadaver & provided through a skin bank • disadvantage: $750-1500 & risk of bloodborne pathogens

turgor

• indicates amt of skin elasticity. • Avoid mistaking dehydration for dry skin in older adult • always assess on forehead or chest, & also assess for other indicators of dehydration.

autografting

• involves taking healthy skin from an area of patient's intact skin & transplanting it to an excised burn wound

burn wound sepsis

• leading cause of death during the acute phase of recovery

synthetic dressings

• made of solid silicone & plastic membranes

Collagen

• main component of dermal tissue • protein formed by fibroblasts. • ↑ in areas of tissue injury & helps form scar tissue

Coughing & splinting

• may be performed along w/ deep breathing q1-2h after surgery. • to expel secretions, keep lungs clear, allow full aeration, & prevent pneumonia & atelectasis. • Splinting incision area provides support, promotes a feeling of security, & reduces pain during coughing.

pain relief with burns

• morphine (monitor resp & constipation) • anesthetic agents such as: • ketamine, pentobarbital sodium & nitrous oxide

Emergency Care of the Patient Experiencing an Opioid Overdose

• naloxone hydrochloride (Narcan) 1-2 mg IV. • Repeat q2-3 min up to 10 mg, depending on pt's response. • Maintain open airway. • Give O2 if hypoxia or resp < 10 • Have suction equipment available - can trigger vomiting • Continuously monitor VS & LOC for reversal of overdose. • Do not leave pt until fully responsive. • Assess for pain- reversal of opioid overdose also reverses analgesic effects. • Continue to monitor VS & LOC q10-15 min for 1st hour. Naloxone is eliminated from body more quickly than opioid, and may induce SE, incl. BP changes, tachycardia, & dysrhythmias. • Determine need for additional antagonist therapy

Assessing GI System

• nausea & vomiting COMMON • At risk: motion sickness, obese, opioid use • Zofran, meclizine • ABD surgery- intestinal peristalsis may be delayed at least 24 hrs • NG tubes: record color, consistency, & amt q8h

NPO

• no eating, drinking (including water), or smoking (nicotine stimulates gastric secretions). • Regardless of type of surgery & anesthesia planned, pt is NPO before surgery to ↓ risk of aspiration. • Failure to adhere= cancellation of surgery or ↑ risk for aspiration during/ after surgery.

Anxiety

• often causes restlessness & sleeplessness. • Pt may perceive surgery as threat to life & function. • Assess pt's level of anxiety. • Interventions such as teaching & communicating w/ pt before surgery, enabling pt to use previously successful coping mechanisms, & giving antianxiety drugs help ↓ anxiety. • Incorporate available support systems into plan of care.

opioid drugs

• only given IV in resuscitation phase because it won't relive pain IM or SQ & an overdose during fluid remobilization is reduced

epidermis

• outermost layer of skin • anchored to dermis by finger-like projections of dermal tissue (dermal papillae) • <1 mm thick, but is protective barrier between body & environment.

Neurologic status

• overall mental status, LOC, orientation, ability to follow commands. • baseline neurologic status • motor or sensory deficits. • patient who has been independent & oriented at home can be disoriented in hospital setting. (Ask Family) • RISK FOR FALLING • mental status, muscle strength, steadiness of gait, sense of independence • Document ability to ambulate & steadiness of gait as baseline data.

auto-contamination

• patients own normal flora overgrows & invades other body areas

Melanocytes

• pigment-producing cells found at basement membrane. •cells give color to skin & account for ethnic differences in skin tone. • Darker skin tones are not caused by ↑ numbers; rather, size of pigment granules (melanin) contained in each cell determines color.

jobst pressure garments

• prevent contractures & tight hypertrophic scars • stop venous stasis and edema • saves mobility • must be worn at least 23 hrs a day everyday until scar tissue is mature (12-24 months)

Preventing Injury Interventions

• prevent injury from positioning during surgery. • anesthesia & narrow OR bed= patient's normal defense mechanisms cannot guard against nerve or joint damage & muscle stretch or strain. • Pressure ulcers start developing during surgery • circulating nurse pads operating bed w/ foam & /or silicone gel pads & properly places grounding pads. • coordinates transfer to operating bed & helps pt to comfy position. • skin is assessed, esp. older patients- bruising/ injury, & extra padding is placed as indicated.

Infiltration (Field-Block) Anesthesia

-Direct injection into tissue immediate to surgical site -Blocks specific nerves near site

Nerve Block Anesthesia

-Direct injection into tissues that may be distant from surgical site -Affects nerve bundles supplying surgical area -Used to block sensation in a limb or large area of face

Induction of General Anesthesia

-IV drugs given 1st can slip the pt. off to sleep -Followed by inhaled drugs -help to maintain anesthesia -During shorter procedures (regional, conscious sedation) IV drugs may be used alone

biotherapy

-IV infusions -for melanomas that are stage 3 or higher -start at high dose and decrease

Breathing exercises after surgery

-If airway or ET tube in place, remove when extubation criteria has been met -help pt. cough and deep breath (w/ incision splinted) -urge pt. to cough, use incentive spirometer, and take deep breaths (every 1 - 2 hours)

Spinal Anesthesia

-Injected into CSF -Affects large, regional areas such as lower abd. & legs

Epidural Anesthesia

-Injected into epidural space of spinal canal -Used most often in labor and delivery

Assessment data of postoperative patients

-LOC -BP -pulse -temperature -O2 saturation -respiration -examine surgical areas- bleeding frequent VS q15-30 min x4 q4h for 24-48h

Nursing Interventions-- General Anesthesia

-MONITOR AIRWAY -Provide quiet environment during postop period -VS checks per hospital policy -orientation -Allay anxiety about shivering- warm blankets -Assess Pain frequently -Turn Cough Deep Breathe, movement of extremities unless contraindicated -Frequently discuss post-op & post-procedure plan, so family & pt. feel incl.

Inhalation Agents used with General Anesthesia

-Nitrous oxide "laughing gas" - only gas routinely used for general anesthesia -May be used in conjunction w/ other general anesthetics, ↓ doses of both (remember Malignant Hyperthermia) -Used for brief surgical & dental procedures

Risk for those in postoperative period

-Pneumonia -Cardiac arrest -Shock -Respiratory arrest -VTE -GI bleeding

Lidocaine (Xylocaine)

-SE are uncommon -Early symptom of toxicity - CNS excitement= irritability & confusion -If used as anesthetic agent for EGD or dental work, pt. may accidentally bite lip or chew on areas of the mouth before effect wears off -Effects the gag reflex -don't get up without help

Lidocaine (Xylocaine)

-SE uncommon -Early symptom of *toxicity* - *CNS excitement*= irritability & confusion -Anesthetic for EGD/ dental work, pt. bite lip/ chew on areas of mouth before effect wears off -Effects gag reflex -don't get up w/o help

Best Practice for Benzodiazepine Overdose

-Secure airway & IV access before starting benzodiazepine antagonist therapy -Prepare to administer flumazenil (Romazicon) 0.2mg to 1mg IV -Repeat drug q2-3 min up to 3mg PRN -Give O2 for hypoxia or resp < 10 breaths/min -suction equipment- flumazenil can trigger vomiting & drowsy pt. at risk for aspiration -Continuously monitor VS & LOC for reversal of overdose -Do NOT leave pt. until fully responsive -Continue to monitor VS & LOC q10-15min for 1st 2h b/c flumazenil is eliminated from body faster than benzodiazepine -Det. need for additional flumazenil therapy q1-2h after pt. becomes fully responsive -Observe pt. for tremors/ convulsions b/c flumazenil can lower seizure threshold -Assess IV site q shift b/c flumazenil can cause thrombophlebitis -Observe for SE (skin rash, hot flushes, dizziness, headache, sweating, dry mouth, blurred vision)

Nursing Interventions for Patients Receiving Local Anesthesia

-Teach pt. that area may be numb for several hrs -Teach pt. that ability to move may return before actual feeling returns -Teach to refrain from eating for 1 hr. postanesthesia or until sensation returns to oral cavity/throat -Teach to call for help before ambulating following anesthesia administration

Techniques for Applying Local Anesthesia

-Topical (surface) -Infiltration (field block) -Nerve block -Spinal -Epidural

Naloxone (Narcan)

-Used for Opioid Overdose -As a single dose, rapidly reverses effects of heroin OD -Injected or intranasal application -Approved for use by emergency personnel, family members & caregivers

Naloxone (Narcan)

-Used for Opioid Overdose -Single dose rapidly reverses effects of heroin OD -Injected or intranasal application -Approved for use by emergency personnel for family members & caregivers

first intention

-a wound without tissue loss -ex: clean laceration, surgical incision

hydrophilic dressing

-absorbent -draws in excessive drainage -preventing maceration

continuous dry dressings

-absorption -protection

drugs used for viral infections

-acyclovir (Zovirax) -valacyclovir (Valtrex) -famciclovir (Famvir)

interventions for burns (oxygenation)

-airway maintenance -promoting ventilation -monitor for gas exchange -oxygen therapy -drug therapy -positioning and deep breathing

difference between anthrax and insect bites/other skin lesions

-anthrax is painless -eschar forms regardless of treatment

Oxygen therapy after surgery

-apply oxygen tent, nasal cannula, or mask to eliminate inhaled anesthetic agents -after pt. is fully reactive & stable, raise head of bed

general management of all burns

-assess airway patency -administer oxygen as needed -cover patient w/ blanket -keep patient NPO -elevate extremities if no fractures are obvious -obtain VS -initiate IV line and begin fluid replacement -administer tentanus toxoid for prophylaxis -perform head to toe assessment

emergency management: electrical burns

-at scene separate patient from the electrical current -smother any flames that are present -initiate CPR -obtain ECG

health promotion in skin cancer

-avoid UV light (11am-4pm) -sunscreen, protective clothing -early detection -skin mapping

preventing MRSA

-avoid contact with ppl or objects that have it -WASH YOUR HANDS -shower not bathe

Mohs' surgery

-basal and squamous cell -sectioned in horizontal layers -each layer examined to determine presence of tumor cells

Pharmacologic Interruption of Pain Transmission

Pharmacological target areas • *Peripheral level*- NSAIDs • *CNS level* - opioids

Seizures

Phenobarbital (Luminal) is a sedative-hypnotic that is also prescribed for ___

The anesthesiologist

Physician who specializes in giving anesthetic agents.

They may provide more specific & peripheral pain relief.

Why are selevtive COX-2 inhibitors often prescribed over aspirin?

balanced lowered

With ___ anesthesia, the dose of inhalation anesthetic can be ___, this making the procedure safer for the patient.

Local Anesthetics

Work by blocking Na channels -Temporarily suspending nerve conduction & preventing pain signals from reaching the CNS -Temporarily diminishing sensation & muscle activity --Locals often results in loss of sensation to a small, limited area -Often called Na channel blockers -Other agents sometimes added to increase duration or effectiveness --Epinephrine

true or false when preparing a pt's skin for a surgical procedure you should always go over the area with antiseptic twice

false

Ingestion

what is the first step in pharmacokinetics?

what is a direct blood donation

when a family member donates specifically for pt

what is autologous blood donation

when a pt donates their own blood for their procedure

under the tongue

where are sublingual medications administered?

Spinal Subarachnoid space

where would an intrathecal injection of morphine be adminstered?

vitamin D

which vitamin is synthesized by the skin

They are more efficacious than other analgesics

why are opioids often used for pain relief following tooth extractions?

diffuse

widespread, involving most the body with intervening areas of normal skin; generalized

serpiginous lesion

with wavy borders, resembling a snake

normal hemoglobin

women: 12-16 men: 14-18

normal hematocrit

women: 37-47% men: 42-52%

candida albicans

yeast infection -common areas include: -perineum -vagina -axillae -under breasts -in mouth (thrush)

antimigraine agent.

zolmitriptan (Zomig)

Rosacea Exacerbation

· Sunlight, stress, ↑ temperature · Agents that dilate facial blood vessels (alcohol) · Gender: women more often affected

Topical enzyme preparations

Proteolytic action on thick, adherent eschar causes breakdown of denatured protein and more rapid separation of necrotic tissue.

Intense itching

Pruritis

psoriasis vulgaris

-most common type -thick, reddened papules covered by silvery white scales -sharply defined -bilateral distribution over body most common sites: -scalp -elbows -trunk -sacrum -outside surfaces of limbs

Glucocorticoids

1st-line drugs for allergic rhinitis

how many units are usually donated for autologous donation

2-4

Dehiscence

"splitting open of a wound"

Furuncles

(boils) are also caused by Staphylococcus, but the infection is much deeper in the follicle (Fig. 27-7). This larger, sore-looking, raised bump may or may not have a pustular "head" at its point. Furuncles are more likely to occur in areas of heat and moisture, such as in the hair-bearing skinfold areas.

*Third intention scar

(delayed closure)—high risk for infection with a resultant scar *significant tx before it will close- eviseration, etc. * leave open & pack- heal itself from inside out *bigger scar *NO pressure- it will open up.

*Second intention scar

(granulation) and contraction—a deeper tissue injury/wound * think about pressure ulcers. *can open back up

Stratum corneum

(horny layer) outermost skin

What considerations do you take when a pt has an order for TED hose

* measure length and circumference of legs before ordering to ensure correct size * remove 1-3 times a day for 30 minutes * inspect skin and provide skin care upon removal

before signing an informed consent, what should the pt understand

* nature and reason for the surgery * who will be present and performing * alternatives * risks of procedure and anesthesia

What should the nurse do if the pt refuses the procedure

* teach the risks of refusing * notify PCP * DOCUMENT

Sunburn

*1st-degree or superficial burn *Excessive exposure to UV light injures dermis, stimulating inflammatory response that dilates capillaries, leading to redness, tenderness, edema, & occasional blister formation. *When large areas of body are sunburned, systemic inflammatory symptoms, such as headache, nausea, & fever, may be produced. *Erythema & pain begin w/in a few hrs after sunburn has occurred & increase in intensity for 1 - 2 days before subsiding. *Management is directed toward promoting comfort & includes cool baths & soothing lotions, such as bland lubricants or refrigerated moisturizing lotions. *Antibiotic ointments are used only if blistering of skin causes infection. If pain severe, topical corticosteroids & NSAIDs may reduce inflammation temporarily.

Esters

-Cocaine was 1st used for medical procedures -Others: §- Procaine (Novocain) §- Benzocaine (Solarcaine) §- Tetracaine (Cetacaine

Interventions: Acne Vulgaris

*Avoid oil-based cosmetics/ hair products *Administer & teach how to use medications ordered *Use humectant moisturizer *Clean BID w/ soap & H2O *Avoid picking & squeezing *Use noncomedogenic sunscreen with SPF 30 *Use topical meds daily (4-6 weeks for results) *Shave gently- don't use dull razors *Isotretinoin- don't get pregnant- birth defects *Emotional support §Wash hands after eating greasy food

dandruff

*Caused by excessive oil, not dryness. *Severe inflammatory _____ can extend to eyebrows, face & neck. *If severe not treated = hair loss

MONITORING THE WOUND With Tissue Loss Observations- Systemic Response

*Check for the presence or absence of elevated body temperature or WBCs or positive blood culture Check temperature daily; if elevated, check WBCs & blood culture To detect bacteremia

Viral Skin Infections

*Childhood infections* · Varicella (chickenpox) · rubeola (measles) · rubella (German measles) *Adult infections* · Herpes zoster (shingles) · herpes simplex (cold sores & genital lesions)

Xerosis (Dryness)

*Common problem among older clients *Fine flaking of the stratum corneum (outer most skin layer) *Generalized pruritus often occurs w/dry skin *Scratching can result in secondary skin lesions, excoriations, lichenification and infection hot water, harsh soaps wind cold sunlight central heating

Pruritis- Pt Care

*Cool sleeping environment is helpful *Apply moisturizers after bath *Fingernails should be trimmed short *Herbal teas to promote sleep *Balneotherapy is a therapeutic bath using colloidal oatmeal that can provide temp relief *Drug therapy: antihistamines or steroids *Occlusion dx- put steroidal on dry skin and then dx on top = INCREASED effects, so no steroid cream under a dx.

Alterations in nail color Blue

*Diffuse blue discoloration that blanches with pressure -Respiratory failure -Methemoglobinuria -Venous stasis disease (toenails)

Alterations in nail color Yellow-brown

*Diffuse yellow to brown discoloration -Jaundice -Peripheral lymphedema -Bacterial or fungal infections of nail -Psoriasis -Diabetes -Cardiac failure -tobacco stains, nail polish, or dyes -Long-term tetracycline therapy -Normal aging (yellow-gray color) *Vertical brown banding extending from the proximal nail fold distally -Normal finding in dark-skinned pts -Nevus or melanoma of nail matrix in light-skinned patients

Vancomycin (Lyphocin, Vancocin) 500 mg IV every 6 hr

*Ensure that IV access is patent. If extravasated, drug is highly tissue damaging *Administer drug over at least 60 min and never as a bolus or by IV push. When given more rapidly, drug causes hypotension, dysrhythmias, and histamine release. *Observe patient for widespread flushing. Drug triggers a histamine release causing "red man syndrome." *Check IV site at least every 2 hr for a change in blood return, redness or pain, or the feeling of hard or "cordlike" veins above the site. Drug is irritating to veins & can trigger thrombophlebitis. *Ask the patient about any diarrhea or presence of watery stools. Drug changes the intestinal flora and can lead to pseudomembranous colitis.

Three Layers of Skin

*Epidermis *Dermis *Subcutaneous

Inflammatory Skin Conditions Nonspecific Eczematous Dermatitis

*Evolution of lesions from vesicles to weeping papules and plaques. Lichenification occurs in chronic disease. *Oozing, crusting, fissuring, excoriation, or scaling may be present. *Itching is common. *Anywhere on the body; localized eczema commonly involves the hands or feet.

Alterations in nail color White

*Horizontal white banding or areas of opacity -Chronic liver or kidney disease (hypoalbuminemia) *Generalized pallor of nail beds= -Shock -Anemia -Early arteriosclerotic changes (toenails) -Myocardial infarction

Partial-Thickness Wounds

*Involve damage to epidermis & upper layers of dermis (more superficial) *These wounds heal by re-epithelialization w/in 5-7 days *Skin injury is followed immediately by local inflammation *Inflammatory response causes formation of fibrin clot which stimulates cell division & new skin cells form *New skin cells may appear as small, pink bumps (in wound bed) at injury site- resurfacing

MONITORING THE WOUND With Tissue Loss Observations- Wound Size

*Measure wound size at greatest length and width using a disposable paper tape measure or, for asymmetric ulcers, by tracing the wound onto a piece of plastic film or sheeting (plastic template) *Compare all subsequent measurements against the initial measurement Assess at least q week, usually every 48-72 hr To detect increase in wound size and depth

Salicylates • Prototype drug: aspirin (ASA)

*Mechanism of Action* - inhibits prostaglandin synthesis • anticoagulant, antipyretic, anti-inflammatory, & analgesic *Adverse effects* - w/ high doses may cause GI distress & bleeding (EC available) • May increase action of oral hypoglycemic agents

Opioid (Narcotic) Agonist Prototype drug: Morphine (Astramorph PF, Duramorph)

*Mechanism of Action*- interacts w/ mu & kappa receptor sites *Primary use*- for analgesia & pre-anesthesia --to relieve SOB assoc. w/heart failure/ pul. edema --acute chest pain assoc. w/MI *Adverse effects* --resp. depression, sedation, n/v, --pruritus, urinary retention, --vasodilation = orthostatic hypotension, ↓peristalsis, constipation

Opioid (Narcotic) Agonist Prototype drug: Morphine (Astramorph PF, Duramorph)

*Mechanism of Action*--interacts w/ mu & kappa receptor sites *Primary use* --analgesia & pre-anesthesia --relieve SOB assoc. w/heart failure/pul. edema --acute chest pain assoc. w/MI *Adverse effects* --resp. depression, sedation, n/v, --pruritus, urinary retention, --vasodilation = orthostatic hypotension, ↓peristalsis, constipation

Salicylates • Prototype drug: aspirin (ASA)

*Mechanism of Action*: • inhibits prostaglandin synthesis • anticoagulant, antipyretic, anti-inflammatory, & analgesic *Adverse effects*: • w/ high doses - GI distress & bleeding (EC available) • May ↑ action of oral hypoglycemic agents

tretinoin (Avita, Retin-A, Trentin-X)

*Mechanism of Action*: ↓ comedone formation & ↑ extrusion of comedones *Primary use*: early tx & control of mild- moderate acne vulgaris *Adverse effects*: very high doses when used for leukemias can cause bone pain, fever, headache, n/v, rash, stomatitis, pruritus, sweating & ocular disorders --will PEEL --photosensitive

IV General Anesthesia o Prototype drug: Propofol (Diprivan)

*Mechanism of action* --induction & maintenance of general anesthesia § Almost immediate action, effective for conscious sedation § Emergence is rapid, few SE § Has anti-emetic effect *Adverse effects* --apnea, resp. depression, hypotension *Serious adverse effects* § Propofol infusion syndrome (PIF) - domino effect of metabolic dysfunctions § Contraindicated in those w/ egg/ soybean hypersensitivity § Cautious use in w/ cardiac or resp. impairment § Cautious use w/ CNS depressants

Gaseous agent Prototype drug: *Nitrous Oxide*

*Mechanism of action*- analgesia w/o loss of consciousness § Commonly used w/other surgical anesthetic agents § Administered w/ mask, combined w/ O2 § Establish an IV in case emergency meds needed

Opioid Antagonists Prototype drug: naloxone (Narcan)

*Mechanism of action*- blocks both mu & kappa receptors *Primary use*- administered IV to reverse resp. depression & other acute symptoms of opioid addiction/ overdose -Used to tx. postop opioid depression -*Keep resuscitative equipment accessible* (O2, IV fluids, vasopressors) *Adverse effects* -has minimal toxicity --reversal of effects of opioids = rapid loss of analgesia --Increased BP, tremors, hyperventilation, n/v, drowsiness

IV General Anesthesia o Prototype drug: *propofol* (Diprivan)

*Mechanism of action*- induction & maintenance of general anesthesia § Almost immediate action, effective for conscious sedation § Emergence is rapid, few SE § Has anti-emetic effect *Adverse effects*- apnea, resp. depression, hypotension *Serious adverse effects* § Propofol infusion syndrome (PIF) - domino effect of metabolic dysfunctions § Contraindicated in those w/ egg/ soybean hypersensitivity § Cautious use in w/ cardiac or resp. impairment § Cautious use w/ CNS depressants

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) • Prototype drug: *ibuprofen* (Motrin)

*Mechanism of action*- inhibit cyclooxygenase (COX 1 & 2) & prevent formation of prostaglandins *Primary use*- for mild-moderate pain, as antipyretic & to ↓ inflammation *Adverse effects*- GI upset, acute renal failure

permethrin (Acticin, Elimite, Nix)

*Mechanism of action*- kills head & crab lice & mites & eradicate their ova *Primary use* cream or lotion. 1% lotion- lice; 5% lotion - mites *Adverse effects*- few systemic effects - · Local reactions- pruritus, rash, transient tingling, burning, stinging, erythema, edema

Selective COX-2 Inhibitors • Prototype drug: celecoxib (Celebrex)

*Mechanism of action*- prevents synthesis of inflammatory prostaglandins, selective for COX-2 *Primary use*- to relieve pain, inflammation *Adverse effects*- mild & related to GI • GI bleed, abd. pain, diarrhea, dyspepsia, nausea

Triptans • Prototype drug: sumatriptan (Imitrex)

*Mechanism of action*- serotonin agonists- constricting intracranial vessels *Primary use*- Abort migraines w/ or w/o auras, subcut. acts in 10-20 min *Adverse effects*- cardiac ischemia in person's w/ no cardiac hx, GI upset

Amide Prototype drug: lidocaine (Xylocaine)

*Mechanism of action*: -Designed for short surgical procedures requiring local anesthesia -Injectable local anesthetic acts by blocking Na channels = blocking pain impulses -Administered IV, IM or subcut. to tx. dysrhythmias -Topical form available **WITHOUT PRESERVATIVES**-- infections

Opioid Antagonists Prototype drug: naloxone (Narcan)

*Mechanism of action*: blocks both mu & kappa receptors *Primary use* -administered IV to reverse resp. depression & other acute symptoms of opioid addiction/overdose -Used to tx. postop opioid depression -Keep resuscitative equipment accessible (O2, IV fluids, vasopressors) *Adverse effects*: -has minimal toxicity -reversal of effects of opioids = rapid loss of analgesia --Increased BP, tremors, hyperventilation, n/v, drowsiness

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) • Prototype drug: ibuprofen (Motrin)

*Mechanism of action*: inhibit cyclooxygenase (COX 1 & 2) & prevent formation of prostaglandins *Primary use*: for mild-moderate pain, as antipyretic & to ↓ inflammation *Adverse effects*: GI upset, acute renal failure

Selective COX-2 Inhibitors • Prototype drug: celecoxib (Celebrex)

*Mechanism of action*: prevents synthesis of inflammatory prostaglandins, selective for COX-2 *Primary use*: relieve pain, inflammation *Adverse effects*: mild & related to GI • GI bleed, abd. pain, diarrhea, dyspepsia, nausea

Triptans • Prototype drug: sumatriptan (Imitrex)

*Mechanism of action*: serotonin agonists- constricting intracranial vessels *Primary use*: Abort migraines w/ or w/o auras, subcut. acts in 10-20 min *Adverse effects*: may produce cardiac ischemia in person's w/ no cardiac hx, GI upset

Treatment For Opioid Dependence

*Methadone maintenance* • Doesn't cure- avoids withdrawal sx • Oral methadone- opioid doesn't cause euphoria • Tx may continue for many mos & yrs

Drugs as Adjuncts to Surgery Preoperatively

*Opioids* (Morphine) counteract pain after surgery (usually postop) *Anticholinergics* (Atropine) dry secretions & suppress bradycardia caused by some anesthetics *Sedative-hypnotics* (Ativan, Valium) reduce fear, anxiety or pain

Skin Assessment Techniques for Patients with Darker Skin Pallor

*Pallor in people with dark skin = mucous membranes an ash-gray color. *If lips & nail beds not heavily pigmented, paler than normal *good lighting to assess for absence of underlying red tones that normally give heavily pigmented skin a healthy glow. *With generalized decreased blood flow brown skin = yellow-brown very dark brown = ash gray.

Shave biopsy

*Removal of only portion of skin elevated above surrounding tissue. *A scalpel or razor blade is moved parallel to skin surface to remove tissue specimen. *usually indicated for superficial or raised lesions.

Stages of General Anesthesia

*Stage I*: Loss of pain *Stage II*: Excitement and hyperactivity *Stage III*: Surgical anesthesia *Stage IV*: Paralysis of the medulla

Esters

-Cocaine was first used for medical procedures -Others: §- Procaine (Novocain) §- Benzocaine (Solarcaine) §- Tetracaine (Cetacaine

Topical (Surface) Anesthesia

-Creams, sprays, suppositories -Drops and lozenges --Applied to mucous membranes

Linezolid (Zyvox) 400-600 mg orally or IV every 8-12 hr

*Take blood pressure at least every 4 hr, especially for anyone who has HTN. Drug constricts blood vessels and may trigger hypertensive crisis. *Check IV site at least every 2 hr for a change in blood return, redness or pain, or the feeling of hard or "cordlike" veins above the site. Drug is irritating to veins and can trigger thrombophlebitis. *Ask the patient about any diarrhea or presence of watery stools. Drug changes the intestinal flora and can lead to pseudomembranous colitis. *Observe for increased bruising or oozing of blood from gums or at injection sites. Drug reduces platelet and red blood cell numbers, increasing the risk for bleeding.

Alterations in nail color Red

*Thin, dark red vertical lines 1-3 mm long (splinter hemorrhages) -Bacterial endocarditis -Trichinosis -Trauma to the nail bed -Normal finding in some patients *Red discoloration of he lunula -Cardiac insufficiency *Dark red nail beds -Polycythemia vera

therapies for psoriasis

*Topical -corticosteroids; anti-inflammatory; suppress cell division -tar preparations; suppress cell division; reduce inflammation *UV light therapy *Systemic therapy -biologic agents -discontinue and notify Dr immediately if signs of infection occur *Emotional support -use of touch significant for pts with psoriasis; DO NOT wear gloves; conveys acceptance

Anti-migraine Agents

*Triptans*: sumatriptan (Imitrex) --• Serotonin agonists --• Constrict certain intracranial vessels *Ergot alkaloids* --• Serotonin agonists --• Interact w/ adrenergic, dopaminergic, & serotonin receptors --• Used for those who are unresponsive to triptans

Clindamycin (Cleocin) 150-300 mg orally every 6 hr or 300-600 mg IM or IV 2-4 times daily

*When given IV, administer slowly (over 30-60╯min). Rapid administration can induce shock and cardiac arrest. *Check liver function tests. Drug can induce liver damage. *Ask the patient about any diarrhea or presence of watery stools Drug changes the intestinal flora & can lead to pseudomembranous colitis

Venous stasis leading to thromboembolism (VTE)

*a group of disorders that includes DVT & PE *potential but avoidable complication of surgery. *These problems can lead to a pulmonary embolus (PE) if blood clot breaks off & travels to lungs.

Vitamin D

*activated in epidermis by UV light *distributed by blood to intestinal tract *promotes uptake of dietary calcium

Skin Palpation

*confirms size of lesions & determines whether they are flat or slightly raised. *skin temperature, dryness, scarring, lichenification, edema

Centrally acting drugs

*drugs that exert directly w/in the brain & spinal cord *Any analgesic drug that has a central effect bypasses the nociceptor level --Acetaminophen- centrally acting nonopiod analgesic

Centrally acting drugs

*exert directly w/in brain & spinal cord *Any analgesic drug w/ central effect bypasses nociceptor level --Acetaminophen- centrally acting nonopiod analgesic

what requirements must be met for autologous donation

*infection free * Hgb must be >11 * must have a prescription

Acute paronychia

*inflammation of skin around nail often occurs with torn cuticle or ingrown toenail. *If immunosuppressed pt, a staphylococcal infection is probable.

layers of the skin

*largest organ of body *protective environment *homeostasis

why does diet affect surgical risk

*poor diet=poor healing *protein and vitamin C needed for wound healing

Acne neonatorum

*response to maternal androgens *avoid squeezing/picking the pimples *Wash affected area w/water, avoid lotions/ soaps w/ fragrance

Main concerns for perioperative nurse

*safety & advocacy for pt during surgery. -Pt at risk for infection, impaired skin integrity, increased anxiety, altered body temperature, injury related to positioning & other hazards.

A∂ fibers

*thinly wrapped in myelin (a fatty substance that speeds up nerve transmission) *Signal sharp , well-defined pain

C fibers

*unmyelinated *carry nerve impulses more slowly & conduct dull, poorly localized pain

Inhalation Agents used with General Anesthesia

-*Nitrous oxide* "laughing gas" - only gas routinely used for general anesthesia -May be used in conjunction w/ other general anesthetics, ↓ doses of both (Malignant Hyperthermia) -Used for brief surgical & dental procedures

clock method to assess wound

-12 o'clock towards head -6 o'clock toward feet -length is always 12-6 -width is always 9-3 -depth is deepest portion to skin level

prevention of dry skin (xerosis)

-20 min soak in warm bath; or moist towels if cannot bathe, follow with lotion -use a humidifier -take bath or shower every other day -use tepid water -use fat based, nonalkaline soap; not deoderant soap -rinse soap thouroghly from skin -add bath oils at end of bath; avoid falls -pat dry rather than rub -avoid tight clothing -daily fluid intake of 3000 mL unless contraindicated -no rubbing alcohol, astringents, or other drying agents -avoid caffeine & alcohol consumption

after injury 48-72 hours later

-24hrs later fluid remobilization when capillary leak stops -diuretic stage 48-72 hours after & fluid goes back into intravascular space -hypokalemia from diuresis

reposition immobile patients

-30 degree rule; elevated, not rested on mattress -turn and reposition at least every 2 hours

upper airway edema becomes pronounced

-8-12 hours after the beginning of fluid resuscitation and often require nasal or oral intubation

Assessment When Neuromuscular Blocking Agents Are Used

-Baseline neuro assessment before neuromuscular blocking agents given --A&O, dementia, stroke -Anesthesia will monitor peripheral nerve stimulation during procedure -Neuromuscular blockage should be DC'd ASAP after surgery is completed -Postneuro assessment & continuous monitoring

Classification of Local Anesthetics

-Classified by their chemical structures -Two major classes - · Esters - · Amides -Some miscellaneous agents that are not esters or amides

vascular changes resulting from burn injury

-fluid shift leaking fluid into interstitial space also known as "third spacing" or capillary leak syndrome -decreases BP & blood volume -causes edema, acid base imbalances, weight gain -hypovolemia, metabolic acidosis, hyperkalemia, hyponatremia

palmoplantar pustulosis (PPP)

-form of psoriasis that causes pustules on the palms and soles of feet

encourage pt to eat

-frequent high protein snacks -vitamin and mineral substances if needed

given in the first 8 hours

-half of the total volume being given -occurs at time of injury (ex: accident at 8am, get to ED at 10am, infuse now over 6hours)

superficial thickness wounds

-have the least damage because the epidermis is the only part of the skin injured -caused by prolonged exposure to low intensity heat or short exposure to high intensity heat (sunburn, flash burns)

urticaria

-hives -red or white edematous papules or plaques of various size -usually caused by exposure to allergens that release histamines in dermal tissue - blood vessel dilation & leakage of plasma proteins form lesions or wheals.

pressure ulcer prevention

-identification of high risk patients -intervetions using pressure relief-reducing devices

emergency management: chemical burns

-if dry chemicals are present on skin or clothing, DO NOT WET THEM -brush off dry chemicals -remove patients clothing -ascertain the type of chemical causing the burn -do not attempt to neutralize the chemical

herpes zoster (shingles) (vericella zoster)

-immunosuppression caused by reactivation of the dormant chicken pox virus in pts who have previously had chicken pox -minor irritation to severe deep pain -usually lasts several weeks -complications -full thickness necrosis -bells palsy -eye infection (scaring if gets in eye) -vaccine; Zostavax

escharotomy

-incision through burn eschar relieves pressure caused by constricting force of fluid under circumferential burns on extremity or chest & improves circulation -incisions are made along length of extremity & into subcutaneous tissue

cardiac changes from burns

-increased HR -decreased CO until 18-36 hrs after & increase after fluid resusitation

metabolic changes from burns

-increased metabolism so high needs of oxygen and calories -increased core body temperature

Laboratory Assessment

-increased test results common (more concentrated) in 1st 24-48 hrs post-surgery -bandemia = increased WBC differential- indicates infection "left-shift" -ABG tests: for resp or cardiac disease -Urine/kidney tests: urinalysis, creatinine, urine electrolyte levels

cutaneous anthrax

-infection caused by spores of Bacillus anthracis -common risk factor is contact with an infected animal -farm workers -vets -tannery and wool workers -may be confined to skin or systemic

aggravating factors for psoriasis

-infections -hormonal changes -stress -drugs -obesity -presence of other diseases

cellulitis

-inflammation of the skin cells -either staph or strep -involves deeper connective tissue

compensatory response to burns

-inflammatory response and the SNS stress response

fluid resuscitation of the burn patient

-initiate & maintain at least 1 large bore IV in area of intact skin or central venous line -coordinate w/ physician to determine amt of volume to be infused in 1st 24 hrs -1st half in 8 hrs 2nd half in 16 -assess IV access site, infusion rate & infused volume qh -monitor VS hourly -assess urine output hourly -assess for fluid overload -monitor additional body fluid output hourly

factors determining inhalation injury or airway obstruction

-injured in a closed space -extensive burns or with burns on face -intra-oral charcoal on teeth and gums -unconscious at time of injury -have singed scalp hair, nasal hairs, eyelids or eyelashes -coughing up carbonaceous sputum -hoarseness or brassy cough -use of accessory muscles of stridor -poor oxygenation or ventilation -edema, erythrema and ulceration of airway mucosa -wheezing, bronchospasm

partial thickness wound

-involves the entire epidermis -can be superficial or deep

melanoma

-irregularly shaped -red, white , and blue tones -risk factors: genetic predisposition, excessive UV exposure, presence of one or more precursor lesion resembling unusual moles -highly metastatic -survival depends on early diagnosis and treatment

promote mobility to prevent contractures

-keep patient in neutral body position w/ minimal flexion -ROM at least 3 x a day -ambulation ASAP after fluid shifts have resolved -pressure dressings

subcutaneous tissue/hypodermis

-lies below the dermis and varies in thickness -basement membrane separates this from the dermis -with this burned in deep burns bones, tendons, and muscles may be exposed

psoriasis

-lifelong scaling disorder with underlying dermal inflammation -no cure -cell division is speeded up so cells are shed every 4-5 days (normal is 28 days)

ECG

-ll pts over a certain age (40-45) or hx of heart issues

assess wounds for

-location -size -color -extent of tissue involvement -cell types in wound -exudate -condition of surrounding tissue -presence of foreign bodies

considerations of older adults with fluid resuscitation

-may be a complicating factor w/ cardiac diseases like HF and MI -may use drugs that increase CO or strengthen contraction with fluid (dopamine, digoxin)

partial thickness wounds

-more superficial -damage to the epidermis and upper layers of dermis -immediate local inflammation -heal by re-epithelialization -about 5-7 days -faster if hydrated, oxygenated, few microorganisms

pressure ulcer

-most common in hips, sacrum, and ankles

hypovolemic shock

-most common shock with burns is

steroid therapy

-suppresses inflammation -must taper off use; cant just stop abruptly -CANNOT cure inflammation; just relieves it -NEVER apply to potentially infected skin or face. suppresses local immune response and can worsen infection. makes pt more vulnerable to steroid effects

The surgical team consists of

-surgeon -one or more surgical assistants -anesthesia provider -the OR nursing staff. -Perioperative, or OR nurses include the holding area nurse, circulating nurse, scrub nurse or a non-nurse "scrub person," & specialty nurse.

examples of deep full thickness wounds

-tar -grease -flames -electrical -chemical

dermis

-thicker than the epidermis made of collagen, fibrous connective tissue, and elastic fibers -has blood vessels, sensory nerves, hair follicles, lymph vessels, sebaceous glands, sweat glands -can regrow ONLY if some dermis is present

inflammatory response

-triggers healing in the injured tissues -causes blood vessels to leak and WBCs to release chemicals -causes signs of the first 24-48 hours seen

burns larger than 35% TBSA

-use of urine output and VS to guide resuscitation aren't as adequate so invasive monitoring is needed

fasciotomy

-used if pressure remains elevated after a escharotomy -deeper incision extending through the fascia

Vacuum-assisted wound closure (VAC) negative pressure wound therapy (NPWT)

-used successfully to reduce/ close chronic ulcers by removing fluids or infectious materials from wound & enhancing formation of granulation tissue. -Requires that a suction tube be covered by a special sponge & sealed in place. -foam dressing changed q 48-72 hrs & not < 3x weekly. -continuous low-level negative pressure applied through suction tube. -should not be used in areas where skin cancer is located. -do not use if on anticoagulants or have exposed nerves, blood vessels or organs

exfoliative psoriasis

-very eruptive and inflammatory form of disease with generalized erythema and scaling -examine for signs of dehydration and hypothermia or hyperthermia r/t severe inflammatory reaction -can have reduced fluid volume through evaporative water loss from the skin surface

growth of anthrax

-vesicle appears -lesion may itch -often resembles insect bite -within a few days; vesicle becomes hemorrhagic and sinks inward -are of necrosis and ulceration begins -tissue around wound swells and can become swollen -eschar forms

Promoting sleep with itching

-wearing mittens or splints at night can help prevent inadvertent scratching during sleep. -A cool sleeping environment along with comfort measures such as a cool shower and application of moisturizers may help promote sleep. -moisturizers may help promote sleep. -Additional measures such as using sleep-promoting herbal teas or sedating antihistamines at bedtime

electrical injuries

-when an electrical current enters the body -results from electrical energy being converted to heat energy -"can't" let go, entrance wound and exit wound -occur in 3 ways: thermal, flash, true electrical

thermal burns

-when clothes ignite from heat or flames produced by electrical sparks

radiation injuries

-when exposed to large doses of radioactive material -common with therapeutic radiation

eczema

-when the cause of inflammatory rash is unknown

Chart pg 11

...

On the surgery safety checklist, what should be confirmed before the skin incision?

1. All team members have introduced themselves by name & role 2. Pt's name, procedure, where incision will be made 3. ABT prophylaxis been given w/in last 60 mins

Expansion Breathing

1. Comfortable upright position, w/ knees slightly bent. (Bending knees ↓ tension on abd muscles & ↓ resp resistance & discomfort.) 2. Place hands on each side of lower rib cage, just above waist. 3. Deep breath through nose, using shoulder muscles to expand lower rib cage outward during inhalation. 4. Exhale, concentrating 1st on moving chest, then on moving lower ribs inward, while gently squeezing rib cage & forcing air out of base of lungs.

surgery safety checklist: before induction of anesthesia

1. Has pt confirmed identity, site, procedure, & consent 2. Is site marked 3. Is anesthesia machine & medications check complete 4. Is pulse oximeter on pt & functioning 5. Does pt have allergy, airway or aspiration risk, risk of >500mL blood loss (7 mL/kg in child)

In thesurgical safety checklist, what should nursing staff be concerned with before skin incision?

1. Has sterility been confirmed 2. Are there any equipment concerns

Splinting of the Surgical Incision

1. Place pillow, towel, or folded blanket over surgical incision & hold firmly in place. 2. Take 3 slow, deep breaths to stimulate cough reflex. 3. Inhale through nose, & then exhale through mouth. 4. On 3rd deep breath, cough while firmly holding pillow, towel, or folded blanket against incision.

Priority problems for patients during surgery are:

1. Potential for injury r/t improper positioning 2. Potential for infection r/t invasive procedures 3. Potential for hypoventilation r/t anesthesia, pain, ↓ resp effort

Deep (Diaphragmatic) Breathing

1. Sit upright on edge of bed/ chair, feet firmly on floor/ stool. (After surgery, done w/ pt in Fowler's or semi-Fowler's position.) 2. Gentle breath through mouth. 3. Breathe out gently & completely. 4. Deep breath through nose & mouth, - hold to count of 5. 5. Exhale through nose & mouth.

In surgical safety checklist, what should surgeon be aware of before skin incision?

1. What are critical/non-routine steps 2. How long will this take 3. Anticipated blood loss

what are 5 reasons for surgery

1. diagnostic-find out whats going on 2. curative- solve a problem 3. restorative- improve function 4. palliative- provide comfort 5. cosmetic

Ramsay sedation scale for post sedation consciousness

1. pt anxious & agitated/ restless 2. pt cooperative oriented & tranquil (calm not agitated) 3. pt responds quickly but only to commands 4. pt exhibits brisk response to • light tapping on forehead between eyebrows (glabella) • loud noise • responds slowly to commands 5. pt exhibits sluggish response to light tapping or loud auditory stimulus 6. patient exhibits no response (not conscious). **RSS at intervals until full consciousness achieved.

amide-type local anesthetic

13. bupivacaine (Exparel, Marcaine, Sensorcaine)

inhaled drugs

14. enflurane (Ethrane)

Answer: a. b. e. f. Eccrine glands are particularly found on the forehead, the soles of the feet, the palms of the hands, and the axilla.

16. Eccrine glands are found on which body areas the most? Select all that apply. 17. a. b. c. d. e. f. Forehead Soles of the feet Back Buttocks Palms of the hands Axilla

amide-type local anesthetic

17. articaine (Septocaine, Zorcaine)

Answer: c. Only the soles and the palms are absent of hair follicles.

18. Which area(s) of the skin do not have hair follicles? a. The abdomen & the back. b. The scalp c. The soles and the palms d. The buttocks

intravenous drugs adjuncts to anesthesia

18. fentanyl (Sublimaze)

Answer: b. Melanocytes near the hair shaft determine what color the hair coming out of the follicle is.

19. Hair color is determined by what part of the skin? a. The carotenoids b. The melanocytes c. The location on the body d. The age of the skin

Answer: a. The arrector pili muscles are activated when the temperature falls, producing classic "goose bumps"

20. The arrector pili muscles are activated when what happens to the skin? a. A fall in temperature b. A rise in temperature c. An increase in sweat d. Fear

adjuncts to anesthesia

20. ketamine (Ketalar)

Answer: b. d. Both cold weather and illness will slow the rate of growth of the nails, which normally grow about 0.1 mm per day.

21. Nail growth is slowed by what? Select all that apply. a. Hot weather b. Illness c. Increased protein in the diet d. Cold weather e. Increased sweating f. Application of nail polish

inhaled drugs.

21. isoflurane (Forane)

Answer: c. A lesion can be cultured and sensitivities to certain antibiotics can be determined so as to find out which antibiotics might be helpful in treating the infection. Only one culture need be taken and the wound must not be cleansed before obtaining the culture.

22. The doctor asks the nurse to obtain a culture and sensitivity on a lesion. What does the nurse understand about this procedure? a.It must be done on at least two sites two hours apart. b. It is generally useless because it only shows skin organisms. c. It can tell what antibiotics might be helpful when treating the lesion. d. The wound must be thoroughly cleansed before obtaining the culture and sensitivities.

when are preadmission labs drawn

24 hours-28 days

epinephrine

24. prolongs duration of local anesthetic agents

Epidural

27. type of anesthetic most commonly used in obstetrics during labor & delivery

isoflurane (Forane)

32. most widely used inhalation agent

Psoralens

4. Oral or topical agents that produce a photosensitive reaction when exposed to UV light, as in the case of psoriasis treatment

how long can PRBC's be stored

40 days or 10 years if frozen

fluid resuscitation formula

4mL x kg x %of burns (crystalloid only LR)

Answer: d. The degree of sensitivity of an area of skin depends on the density of receptors in the skin tissue.

6. The sensitivity of the skin depends upon what? a. The age of the client b. The gender of the client c. The density of receptors in the skin d. The thickness of the skin

when does the last autologous donation have to be done by

72 hours prior to surgery

itch-scratch-itch cycle

Pts try to relieve itching by scratching or rubbing skin, which further stimulates itch receptors

certified registered nurse anesthetist (CRNA)

RN with additional education & credentials who delivers anesthetic agents under supervision of an anesthesiologist, surgeon, dentist, or podiatrist.

Answer: d. Vitamin D is manufactured in the skin in response to exposure to sunshine. The other vitamins need to be ingested by the gastrointestinal system.

A client is deficient in a vitamin that is manufactured in the skin. What vitamin is deficient? a. Vitamin A b. Folic acid c. Vitamin C d. Vitamin D

Apply an antibiotic ointment and place a sterile dressing on the incision.

A client who has had an excisional biopsy of a skin lesion in the same-day surgery unit is ready for discharge. Which nursing activity will the nurse assign to an LPN/LVN working with this client? A. Teach the client about signs of incisional infection. B. Instruct the client about how to do dressing changes. C. Apply an antibiotic ointment and place a sterile dressing on the incision. D. Complete the written discharge instructions for the long-term care facility.

Cultures for viral infection (Herpes)

A cotton-tipped applicator is used to obtain vesicle fluid from intact lesion. These are placed on ice immediately after collected and then transported to lab.

Cultures for viral infections

A cotton-tipped applicator is used to obtain vesicle fluid from intact lesions. Tubes are placed on ice for transport to the lab.

Answer: c. d. e. Tests for fungal infections of the skin include a Wood's lamp examination, a fungal culture, and a KOH (potassium hydroxide) smear. Bacterial cultures and white blood counts will not show the presence of skin fungi and a blood culture for fungi is likely to be negative.

A fungal infection is suspected. What tests can be done to determine the presence of a fungal infection of the skin? Check all that apply. a. Bacterial culture and sensitivities. b. Blood culture for fungi c. Fungal culture d. Wood's light examination e. Potassium hydroxide exam f. White blood count

To prolong clotting times

A health care provider see an order for aspirin 325mg once daily. The health care provider knows this medication is given at this dose level for what reason?

Increased risk of Reye's Syndrome

A mother asks why ASA should not be given to children & teens. The appropriate reaction by the health care provider is based on the actions of ASA, which can cause ______

Classification of Burn Depth: Grafts Required

Superficial -NO Superficial Partial-Thickness -NO Deep Partial-Thickness -Can be used if healing is prolonged Full-Thickness -Yes Deep Full-Thickness -Yes

Bethanechol (Urecholine)

A parasympathomimetic sometimes administered to stimulate smooth muscle of bowel & urinary tract following surgery.

The patient will soon experience a migraine

A pt comes to the ER with a migraine. The health care provider knows that the patient may have an aura prior to the onset of a headache. What does the aura indicate about the patient?

Depressed respiration

A pt comes to the ER with and OD of morphine. what would the priority nursing assessment include?

scabies

A skin disorder caused by mites

Punch biopsy

A small, circular, cutting instrument, or "punch," ranging in diameter from 2 to 6 mm, is used. After the site is injected with a local anesthetic, a small plug of tissue is cut and removed. The site may be closed with one or two sutures

Psoriasis

A strong genetic predisposition has been recognized in at least 30% of cases, and several genes appear to be involved in expression of the disease. It is likely that the disorder is multifactorial, in that a genetic predisposition exists but environmental factors influence disease occurrence, disease severity, and response to different treatments. Always ask about a family history when assessing the patient with psoriasis.

annular

Ringlike w/ raised borders around flat, clear centers of normal skin

asymmetry of shape

ABCDE: What is A?

border irregularity

ABCDE: What is B?

color variation within one lesion

ABCDE: What is C?

diameter > 6 mm

ABCDE: What is D?

Evolving or changing in any feature (shape, size, color, elevation, itching, bleeding, or crusting)

ABCDE: What is E?

Static pressure-reducing systems

Static devices made of gel, water, foam, or air are in a constant state of inflation that distributes the patient pressure load over a larger area and reduces the pressure experienced by any particular area.

surface or regional

Because local anesthesia is not always applied to small areas of the body, some local anesthetic treatments are more accurately called __ anesthesia.

5 Layers of Epidermis

Stratum corneum Stratum lucidum Stratum granulosum Stratum spinosum Stratum basale: deepest

Aspirin

ASA is an abbreviation that refers to ?

Dermabrasion

Abrasive removal of the facial epidermis and portion of the dermis followed by healing by second intention Moderate to severe acne scar Deep wrinkling Multiple actinic keratoses Hyperpigmentation (postinflammatory or after the use of estrogens) Hypertrophic scarring Altered skin pigmentation Acne flare Wound infection (rare)

Malignant hyperthermia

Acute life threatening complication of certain drugs used for general anesthesia. •Begins w/ skeletal muscle exposed to specific agents causing ↑ Ca levels in muscle cells & ↑ muscle metabolism. •leads to acidosis, cardiac dysrhythmias, ↑ body temp. •Manifestations include: •tachycardia, dysrhythmias, muscle rigidity especially jaw & upper chest, hypotension, tachypnea, skin mottling, cyanosis, myoglobinuria. •↑ in end tidal CO2 level w/ ↓ in O2 sat. •Early indication sinus tachycardia. •Extreme ↑ temp high as 111 late sign. •Dantrolene sodium- skeletal muscle relaxant drug of choice for intervention

parasympathetic stimulation

Adrenergic blockers produce a response similar to that of ____ ?

Nursing Safety Priority Action Alert

After gastric surgery, do not move or irrigate the NG tube unless prescribed by surgeon

Preventing Hypoxemia Interventions

Airway Maintenance • oral airway if doesn't have one. • oral airway pulls tongue forward & holds down to prevent obstruction. • If pt had oral surgery or clenched teeth, large tongue, or upper airway obstruction insert nasal airway (nasal trumpet) • keep manual reasuscitation bag & emergency equipment for intubation or tracheostomy close Monitoring • SPO2 q hour

antiinflammatory, antipyretic

All nonsteroidal anti-inflammatory drugs (NSAIDs) have ___ & ___ activity as well as analgesic properties.

iodine products or shellfish

Allergies to _____ or _____ indicate a risk for a reaction to the agents used to clean the surgical area.

Cultures for fungal infection

Always wear gloves. Using a tongue blade, gently scrape cells from skin lesions into a clean container and send to lab.

Stage I of general anesthesia

Analgesia, sedation, relaxation stage • begins with induction & ends with loss of consciousness • patient feels drowsy & dizzy has ↓ sensation to pain & is amnesic, hearing is exaggerated. Nurse should: • close operating room doors • dim lights & control traffic • position pt securely w/ safety belts • avoid external stimuli • keep discussions about pt to minimum

cryothermia

Anesthesia w/ use of cold [ice] to ↓ surface temp of site

Hypnosis or hypnoanesthesia

Anesthesia which induces a passive, trancelike state

The surgical assistant

Another surgeon, physician (resident or intern) or an advanced practice nurse, physician assistant, certified registered nurse first assistant (CRNFA), or surgical tech.

Nitrous Oxide-Inhalation Gaseous Drug Adverse effects:

§ At low doses, very few SE § At higher doses, could cause anxiety, excitement, combativeness § N/V

In surgical safety checklist, what should anesthetist be aware of before skin incision

Are there any pt specific concerns

Wet-to-damp saline moistened gauze

As with the wet-to-dry technique, necrotic debris is mechanically removed but with less trauma to healing tissue.

ABCDE features associated w/ skin cancer:

Asymmetry of shape Border irregularity Color variation w/in 1 lesion Diameter > 6 mm Evolving or changing in any feature (shape, size, color, elevation, itching, bleeding, or crusting)

identity, correct side & site, correct patient position, agreement on proposed procedure

At a minimum, the patient's _____ , _____, _____, & ______ must be verified by all members of surgical team.

○ Bullous Impetigo

§ Fever § Red macules & bullous eruptions on an erythematous base § Regional lymphadenopathy

Classification of Burn Depth: Healing time

Superficial -3-6 days Superficial Partial-Thickness -2 weeks Deep Partial-Thickness -2-6 weeks Full-Thickness -weeks - months Deep Full-Thickness -weeks - months

room temperature

Bacterial and fungal specimens can remain at __________ until being transported to the lab.

Propionbacterium acne

Bacterial overgrowth of _____

General Anesthesia Stage 4 (Danger)

Begins w/ depression of vital functions & ends w/ resp failure, cardiac arrest, & possible death. • Prepare & assist in tx of cardiac & /or pulmonary arrest. • Document occurrence in pt's chart. • Teamwork & preparedness help ↓ injuries & compl. & promote possibility of desired outcome for pt. • Respiratory muscles are paralyzed; apnea occurs. • Pupils are fixed and dilated.

General Anesthesia Stage 1 (Analgesia and Sedation, Relaxation)

Begins w/ induction & ends w/ loss of consciousness. • Close operating room doors, dim the lights, & control traffic in the operating room. • Avoiding external stimuli in environment promotes relaxation. • Patient feels drowsy & dizzy, has ↓ sensation to pain, & is amnesic. • Position patient securely w/ safety belts. • Using safety measures in stage 1 prepares for stage 2. • Hearing is exaggerated. -Keep discussions about pt to a minimum. • Being sensitive to pt maintains dignity.

The intraoperative period

Begins when pt enters surgical suite & ends at time of transfer to PACU, same-day surgery unit, or ICU

Intraoperative Care

Begins when the patient enters the surgical suite & ends at the time of transfer to the postanesthesia recovery area.

General Anesthesia Stage 3 (Operative Anesthesia, Surgical Anesthesia)

Begins with generalized muscle relaxation & ends w/ loss of reflexes & depression of vital functions. • Assist the anesthesiologist or CRNA w/ intubation. • Helps promote smooth intubation & prevent injury. The jaw is relaxed, & breathing is quiet & regular. • Place patient into operative position. • Prep (scrub) pt's skin over operative site. • performing procedures ASAP minimizes anesthesia time The patient cannot hear. • Sensations (i.e., to pain) are lost.

Should not be applied to an open wound

Benzocaine

antidepressant

Besides an antimigraine agent, what is another use for amitriptyline?

Bacterial Infections Laboratory & Diagnostic Tests

Blood cultures- cellulitis w/ lymphangitic streaking & all orbital/ periorbital cellulitis

○ Staphylococcal scaled skin syndrome

§ Fever Flattish bullae- rupture w/in hrs= red, weeping surface

what cardiovascular findings should be reported during preop assessment

CAD, MI within 6 months, angina, HTN, dysrhythmias, hx of DVT

Trauma

Can include trauma from a healing surgical incision to a grossly healing, draining pressure ulcer

Mechanical trauma & thermal injury

Categories of injury that a patient can incur during MIS & robotic surgery

Drugs as Adjuncts to Surgery: Neuromuscular Blocking Agents

Cause paralysis w/o loss of consciousness § w/o general anesthesia, pt. awake w/o ability to move § Resp. muscles = skeletal muscles § Neuromuscular blocking agents require pt. to be intubated & receive mechanical ventilation

○ Cellulitis

§ Fever § Erythema § Pain § Edema § Warmth at site of skin disruption § Regional lymphadenopathy

CAUSES OF IMPAIRED WOUND HEALING Impaired Cellular Proliferation: Systemic

Cause: • Aging • Chronic stress • Nutritional deficiencies: • Calories • Protein • Vitamins • Minerals • Water Impaired oxygenation: • Pulmonary insufficiency • Heart failure • Hypovolemia Cirrhosis Uremia Prolonged hypothermia Coagulation disorders Cytotoxic drugs Mechanism: Impaired cellular proliferation and collagen synthesis Decreased wound contraction

CAUSES OF IMPAIRED WOUND HEALING Altered Inflammatory Response: Local

Cause: • Arteriosclerosis • Diabetes • Vasculitis • Thrombosis • Venous Insufficiency • Lymphedema • Pharmacologic vasoconstriction • Irradiated tissue • Crush Injuries • Primary closure under tension Mechanism: •Reduced local tissue circulation, resulting in ischemia, impaired leukocytic response to wounding, and increased probability of wound infection

CAUSES OF IMPAIRED WOUND HEALING Impaired Cellular Proliferation: Local

Cause: • Wound infection Foreign body Necrotic tissue Repeated injury or irritation Movement of wound (e.g., across a joint) Wound desiccation or maceration Mechanism: Prolonged inflammatory response, which can result in low tissue oxygen tension and further tissue destruction

CAUSES OF IMPAIRED WOUND HEALING Altered Inflammatory Response: Systemic

Cause: • Leukemia • Prolonged administration of high-dose • anti-inflammatory drugs: • Corticosteroids • Aspirin Mechanism: •Systemic inhibition of leukocytic response, resulting in impaired host resistance to infection

Pruritus

Caused by stimulation of itch-specific nerve fibers at dermal-epidermal junction *Is a subjective symptom like pain *may become worse at night ◦ Poor hydration, ↑ skin temp., perspiration, emotional stress *Systemic diseases, such as liver & venous disorders *Liver disease often ↑ buildup of bilirubin in skin, which stimulates itch receptors. *too little or too much blood flow to an area (especially feet & legs).

topical corticosteroids

Caution patients not to apply to potentially infected skin lesions anywhere on the body, but especially on the face. These agents suppress the local immune response and can worsen the infection. The skin on the face is thinner and absorbs topical steroids more quickly, making the patient more vulnerable to steroid side effects.

Answer: c. Langerhans cells are specialized skin cells involved in cell-mediated immunity.

Cells of the skin considered important in cell- mediated immunity are what? a. Islet cells b. B cells c. Langerhans cells d. T-helper cells

MONITORING THE WOUND Without Tissue Loss Observations (using first postoperative dressing change as baseline)

Check for presence/ absence of increased: *Localized tenderness *Swelling of incision line *Erythema of incision line >1cm on each side of wound *Localized heat Assess At least q24hr until sutures or staples removed To detect cellulitis (bacterial infections)*

MONITORING THE WOUND With Tissue Loss Observations- Wound Margins

Check for the presence or absence of: Erythema and swelling extending outward >1╯cm from wound margins Increased tenderness at wound margins At least every 24╯hr or at each dressing change To detect wound infection*

MONITORING THE WOUND With Tissue Loss Observations- Ulcer Base

Check for the presence or absence of: Necrotic tissue (loose or adherent) Foul odor from wound when dressing is changed Note the frequency of dressing changes or dressing reinforcements owing to drainage At least every 24╯hr To detect the need for débridement or the response to treatment (necrotic tissue) and to detect local wound infection (frequent dressing changes and foul odor)

Interventions: Acne Neonatorus

§ Instruct to avoid squeezing & picking § Wash affected areas daily *Avoid soaps with fragrances & lotions

Problems that increase the surgical risk or increase the risk for complications after surgery: Medical History

Chronic lung problems, asthma, emphysema, & chronic bronchitis: ↓ elasticity of the lungs = ↓gas exchange = ↓ tissue oxygenation.

Postoperative Period

Completion of surgery & transfer of pt to either PACU, same-day surgery (SDS) unit (ambulatory care unit), or ICU mark beginning of the ________. It continues after the pt's condition is stabilized & discharged.

Informed Consent

Consent implies that pt has sufficient info to understand: • The nature of & reason for surgery • Who will be performing surgery & whether others will be present during the procedure • All available options & risks assoc. w/ each option • Risks assoc w/ surgical procedure & its potential outcomes • Risks assoc. w/ use of anesthesia

bioterrorism

Consider the possibility of _____ whenever lesions consistent with cutaneous anthrax appear in patients who do not have a history of exposure to infected animals.

Preoperative Teaching Checklist

Consider these items when planning individualized preoperative teaching for pts & families: • Fears & anxieties • Surgical procedure • Preop routines (NPO, blood samples, showering) • Invasive procedures (lines, catheters) • Coughing, turning, deep breathing • Incentive spirometer • How to use • How to tell when used correctly • Lower extremity exercises • Stockings & pneumatic compression devices • Early ambulation • Splinting • Pain management

Administering Regularly Scheduled Meds.

Consult the medical physician & anesthesia provider for instructions about drugs, such as those taken for diabetes, cardiac disease, glaucoma, regularly scheduled anticonvulsants, antihypertensives, anticoagulants, antidepressants, or corticosteroids

If you believe that the patient has not been adequately informed

Contact surgeon & request that s/he see pt for further clarification. Document this action in the medical record.

Classification of Burn Depth: Edema

Superficial -Mild Superficial Partial-Thickness -Mild-Moderate Deep Partial-Thickness -Moderate Full-Thickness -Severe Deep Full-Thickness - Absent

Nursing Safety Priority Drug Alert

Do not confuse Toradol w/ Tramadol (a drug used for central anesthesia)

Stage IV of general anesthesia

Danger stage •begins w/ depression of vital functions & ends w/ resp. failure, cardiac arrest, & death •resp. muscles paralyzed, apnea occurs •pupils fixed & dilated Nurse should •prepare for & assist in treatment of cardiac & pulmonary arrest

Changes of Aging as Surgical Risk Factors Cardiovascular System

Decreased cardiac output •Determine normal activity levels, & note when pt tires. •Knowing limits helps prevent fatigue. Increased BP •Decreased peripheral circulation Monitor vital signs, peripheral pulses, and capillary refill. •Having baseline data helps detect deviations.

Excisional biopsy

Deep incisions are made & then sutured after the specimen is removed.

Classification of Burn Injury & Burn Center Referral Criteria Moderate Burns

Deep partial-thickness burns 15%-25% TBSA Full-thickness burns 2%-10% TBSA No burns of eyes, ears, face, hands, feet, or perineum No electrical burns No inhalation injury No complicated additional injury Patient is younger than 60 years and has no chronic cardiac, pulmonary, or endocrine disorder. Pts should receive emergency care at scene & be transferred to special expertise hospital or burn center.

Classification of Burn Injury & Burn Center Referral Criteria Minor Burns

Deep partial-thickness burns less than 15% TBSA Full-thickness burns less than 2% TBSA No burns of eyes, ears, face, hands, feet, or perineum No electrical burns No inhalation injury No complicated additional injury Pt < 60 yrs & no chronic cardiac, pulmonary, or endocrine disorder Pts should receive emergency care at scene & be taken to hospital ED. Special expertise hospital or burn center not necessary.

Fibroblasts

Dermal cells that form collagen, & ground substance

Comorbidities For Decreased Tissue Repair

Diabetes, HTN, artherosclerotic disease, Autoimmunie Disorders, Medication, stress, smoking

Endogenous Opioids

Endorphins, dynorphins, enkephalins • Neurotransmitters produced by CNS that can modify sensory information, interrupting pain transmission (can affect pain message carried by Substance P) • May be affected by other neurotransmitters

Superficial-thickness wounds

Epidermis is the only layer effected

Side effects of increased HR & BP Hx of cardiac condtions Vital signs

Epinephrine is often added to a local anesthetic. The nurse must monitor for which factors when caring for the patient due to receive epinephrine in his anesthetic?

It should never be taken during pregnancy

Ergotamine is a Category X drug, which means what about the drug?

Blepharoplasty

Excision of bulging fat& redundant skin of periorbital area with primary closure Bags under the eyes Hematoma Ectropion Corneal injury Visual loss (rare) Wound infection (rare)

Breast Reduction (Reduction Mammoplasty)

Excision of excessive breast tissue & skin w/ primary closure Hypertrophy of breast tissue caused by elevated hormone levels, endocrine abnormalities, or obesity Weight of large breasts can contribute to back pain Hematoma or hemorrhage Nipple, areola, and skin flap necrosis Wound infection Fat necrosis Wound dehiscence

Stage II of general anesthesia

Excitement, delirium stage • begins w/ loss of consciousness & ends w/ relaxation, regular breathing, & loss of eyelid reflex • pt may have irregular breathing, ↑ muscle tone, & involuntary movement of extremities • laryngospasm or vomiting may occur • pt is susceptible to external stimuli; Nurse should • avoid auditory & physical stimuli • protect extremities • assist with suctioning • stay with patient

Radical

Extensive surgery beyond the area obviously involved; is directed at finding a root cause • Radical prostatectomy • Radical hysterectomy

Naloxone (Narcan)

For an overdose of opiates, what would the health care provider need to have on hand to counteract the effects?

CONSIDERATIONS FOR OLDER ADULTS

For older adult, a rapid return to level of orientation before surgery may not be realistic. Preop drugs & anesthetics delay older pt's return of orientation

expansion breathing exercises

For patients with chronic lung disease or limited chest expansion, as seen in older patients because of the aging process, ______ are useful. -For pt having chest surgery, these exercises strengthen accessory muscles & are started before surgery. -may be used after surgery during chest physiotherapy (percussion, vibration, postural drainage) _to help loosen secretions & maintain an adequate air exchange.

Answer: a. b. d. f. The dermis contains the nerve supply to the skin. It also contains fibroblasts, mast cells, and macrophages for immunity and the sweat glands. The dermis contains the collagen and elastin that gives skin its elasticity and substance.

Functions of the dermis include the following. Select all that apply. a. Nerve supply to the skin b. Contains fibroblasts, mast cells, and macrophages c. Provides a moisture barrier d. Contains sweat glands e. Provides a radiant barrier f. Contains collagen and elastin

in doses at least 21 days apart.

Halothane hepatitis can be prevented by using halothane

Amides

Have largely replaced Esters—producing less SE & longer duration of action

Answer: b. The blood flow to the skin controls the amount of heat that is lost from the skin. The ambient temperature plays a lesser role in the amount of heat lost from the skin.

Heat loss from the skin is dependent upon what? a. The number of sebaceous glands in the skin b. The blood flow to the skin c. The number of hair follicles in the skin d. The ambient temperature

Conscious Sedation

IV delivery of sedation, hypnotic, & opioid drugs reduces LOC but allows client to maintain a patent airway and respond to verbal commands (pt. will be very sleepy) •Commonly used drugs: diazepam (Valium), midazolam (Versed), fentanyl (Sublimase), propofol (Diprivan) •Credentialed nurses may deliver conscious sedation (under anesthesia supervision)

Bier Block

IV injection of anesthetic into an extremity following mechanical exsanguination with a tourniquet, providing analgesia & a bloodless surgical site

Nursing Safety Priority Critical Rescue

If the O2 saturation drops below 95% (or presurgical baseline), notify surgeon or anesthesia provider. If it drops by 10 percentage points and you are certain it is an accurate measure, call the RRT

Positioning after surgery

Immediately position in a semi-Fowler's position unless contraindicated. If the pt. cannot have head of bed raised, place in a side lying position or turn head to side to prevent aspiration

Atropic Dermatitis (eczema) Pathophysiology

Reactions d/t allergies ○ usually food • Eggs, wheat, milk, p-nuts ○ Environmental triggers • Molds, dust mites, cat dander ○ High/low temperatures ○ Perspiring/ scratching/ skin irritants ○ Stress Encounter antigen- stimulates interleukins= inflammatory process Skin itches- scratching- then rash

○ Folliculitis

Red, raised, haired follicles

Anxiety

In addition to its use as an injected anesthetic, what is lorazepam (Ativan) also used to treat?

IV anesthesia

In administering general anesthetics using balanced anesthesia, the nurse would expect which medication to be administered first?

Changes of Aging as Surgical Risk Factors Musculoskeletal System

Increased incidence of deformities related to osteoporosis or arthritis •Assess the patient's mobility. •Teach turning and positioning. •Encourage ambulation. •Interventions help prevent complications of immobility. •Place on falls precautions, if indicated. •Safety measures help prevent injury.

Breast Augmentation (Augmentation Mammoplasty)

Insertion of synthetic breast-shaped implants through a skin incision Inadequate breast volume or contour Hematoma or hemorrhage Wound infection (with gram-positive organisms) Phlebitis

Complications of Local or Regional Anesthesia

Interventions include • establishing an open airway • giving oxygen & notifying the surgeon. • Fast-acting barbiturate needed for tx. • If untreated= unconsciousness, hypotension, apnea, cardiac arrest, & death • Cardiac arrest- rare complication of spinal anesthesia. • Epinephrine prophylactic- cardiac arrest in pts who develop sudden, unexplained bradycardia. Local complications include • edema & inflammation- early . • Abscess formation, tissue necrosis, gangrene- later. • Abscesses r/t contamination during injection of agent. • Necrosis & gangrene r/t prolonged blood vessel constriction in injected area.

Impaired Skin Integrity & Impaired Tissue Integrity

Interventions to reduce complications include: •Plastic adhesive drape •Skin closures, sutures and staples, non-absorbable sutures •Insertion of drains •Application of dressing •Transfer of client from the operating room table to a stretcher using lift sheet/roller board

Risk for Perioperative Positioning Injury

Interventions: •Proper body positioning •Risk for pressure ulcer formation •Assess skin condition for padding needs •Prevention of issues r/t circulatory obstruction, resp obstruction & nerve conduction •Consider DVT formation, position of straps, protecting airway, placement of padding/pillows •Who protects the airway? •Surgical table safety precautions •Pads on OR Table (foam, gel) •Grounding pads •Straps

pruritis

Itching associated with dry, scaly skin

sensation, consciousness

Local anesthesia is loss of ___ to a small area without loss of ___

amides, esters

Local anesthetics are classified by their chemical structures; the 2 major classes are ___ & ___

Preoperative drugs

May be prescribed regardless of type of anesthesia. Drugs ↓ anxiety, promote relaxation, ↓ nasal & oral secretions, prevent laryngospasm, ↓ vagal-induced bradycardia, inhibit gastric secretions, & ↓ amount of anesthetic needed for induction & maintenance of anesthesia.

Distraction

May be used as intervention for anxiety, esp. in 24 hrs immediately before surgery. Listening to music may ↓ anxiety, or watching television, reading, or visiting w/ family.

Gaseous agent Prototype drug: Nitrous Oxide

Mechanism of action --analgesia w/o loss of consciousness § Commonly used w/other surgical anesthetic agents § Administered w/ mask, combined w/ O2 § Establish an IV in case emergency meds needed

Amide Prototype drug: lidocaine (Xylocaine)

Mechanism of action: § Designed for short surgical procedures requiring local anesthesia § Injectable local anesthetic, acts by blocking Na channels = blocking pain impulses § Administered IV, IM or subcut. to tx. dysrhythmias § Topical form available **WITHOUT PRESERVATIVES**

Acne Description

Most Common skin condition in childhood *Infants & adolescents

Braden scale for predicting pressure ulcer risk

Most commonly used skin risk assessment tool P. 439 *Helps nurse to assess & document using: ◦ Sensory impairment ◦ Moisture ◦ Activity ◦ Mobility ◦ Nutrition ◦ Friction & shear

Benzoyl Peroxide (Clearsil, Fostex)

NOT used to promote shedding of old skin

Salicyclic acid (Salex, Neutrogena)

NOT useful for minor insect bites

nociceptor (peripheral tissue)

NSAIDs act by inhibiting pain mediators at the ___ level.

Regional Anesthesia

Nerve block Bier block Spinal anesthesia Epidural anesthesia

Increased anxiety r/t pain or procedures

Nitrous oxide can be administered safely in patients with ____?

Benzoyl peroxide with erythromycin (Benzamycin)

OTC medication for acne

Role of the Nurse: Drug Therapy for Acne-related Disorders

Obtain thorough history --onset of acne; tx's used & effects --determine pregnancy status* --allergies, current meds · Assess face, anterior & post. Thorax (Wear gloves)

Answer: d. Oil in the skin is produced by the sebaceous glands. Eccrine glands produce sweat; Langerhans cells are involved in cell-mediated immunity; apocrine glands produce sweat that is potentially malodorous.

Oil is produced in the skin by what glands? a. Eccrine glands b. Apocrine glands c. Langerhans glands d. Sebaceous glands

Considerations for older adults

Older adults are at particular risk for skin tears and pressure ulcers because of the presence of age-related skin changes. Progressive flattening of cells at the dermal-epidermal junction predisposes older people to skin tears from mechanical shearing forces, such as the removal of tape and friction from tightly applied restraints. In addition, skin moisture and irritation from incontinence combined with friction over bony prominences can lead to partial-thickness skin destruction and pressure ulcer formation. Patients with cognitive impairments may not readily report discomfort from inadequate pressure relief. If pressure is unrelieved, tissue destruction progresses to full-thickness injury.

Simple

Only the most overtly affected areas involved in the surgery • Simple/partial mastectomy

CNS, nociceptor

Opioids act w/in the _____, whereas NSAIDs act at the _____ level.

pain following surgery

Opioids are sometimes given as adjunctive medications to counteract ___ ___ ___.

Assess Neurologic System

Order of return to consciousness after general anesthesia: 1. Muscular irritability 2. Restlessness or delirium 3. Recognition of pain 4. Ability to reason & control behavior Order of return motor & sensory after local/regional anesthesia: 1.Sense of touch 2.Sense of pain 3.Sense of warmth 4.Sense of cold 5.Ability to move

antibiotics, oral contraceptives

Other than keratolytic agents, 2 classes of drugs that offer some protection against acne

keratin plug

Outermost layer of skin (stratum corneum) sheds at follicular opening

Carpal Tunnel Syndrome

Pain d/t nerve compression in the wrist, thumb, & fingers

Carpal Tunnel Syndrome

Pain d/t nerve compression in wrist, thumb, & fingers

intractable pain

Pain not easy to relieve -adjuvant analagesics -co-analgesics

intractable pain

Pain that is not easy to relieve -adjuvant analagesics -co-analgesics

NSAIDs

Painful disorders having a strong inflammatory component, such as arthritis, are treated most effectively with what?

Stage II Pressure Ulcer

Partial thickness loss of dermis ○ presenting as a shallow open ulcer w/ a red pink wound bed, without slough. ○ May present as an intact or open/ruptured serum-filled blister ○ This stage should not be used to describe skin tears, tape burns, perineal dermatitis, mac

Classification of Burn Injury & Burn Center Referral Criteria Major Burns

Partial-thickness burns > 25% TBSA Full-thickness burns > 10% Any burn involving eyes, ears, face, hands, feet, perineum Electrical injury Inhalation injury Patient > 60 yrs Burn complicated w/ other injuries (e.g., fractures) Patient has cardiac, pulmonary, or other chronic metabolic disorders Pts who meet any one of the criteria for a major burn should receive emergency care at scene & be transferred to special expertise hospital or burn center ASAP

psychosocial support

Patients have ranked _____ as most important part of preop teaching. The informed, educated pt is better able to anticipate in events & maintain self-control & is thus ↓ anxious.

Nutritional Status Older Adults

Poor nutrition d/t chronic illness, diuretic or laxative use, poor dietary habits, anorexia, lack of motivation, financial limitations Indications of poor fluid or nutritional status: • Brittle nails • Muscle wasting • Dry or flaky skin, decreased skin turgor, hair changes • Orthostatic (postural) hypotension • ↓serum protein levels & abnormal serum electrolyte values

Preventing Hypoventilation Interventions

Prevent injury resulting from anesthesia. • continuous monitoring of breathing, circulation, & cardiac rhythms; • BP & HR recordings q5min • continuous presence of anesthesia provider during case.

Papules

Primary Lesions; small, firm, elevated lesions less than 1 cm (elevated moles, warts)

Erosions

Primary lesions *wider than fissures but involve only epidermis *often associated w/ vessicles, bullae, or pustules

Plaques

Primary lesions: elevated, plateau-like patches more than 1 cm that do not extend into the lower skin layers

Vesicles

Primary lesions; blisters filled with clear fluid, less than 1 cm in diameter

Wheals

Primary lesions; elevated, irregularly shaped, transient areas of dermal edema (insect bites)

Nodules

Primary lesions; elevated, marble-like lesions more than 1 cm wide and deep

Macules

Primary lesions; flat lesions of less than 1 cm; moles/freckles; most often brown, white or red

Patches

Primary lesions; macules larger than 1cm in diameter

Pustules

Primary lesions; vesicles filled with cloudy or purulent fluid (acne and acute impetigo)

Major

Procedure of greater risk; usually longer & more extensive than a minor procedure • Mitral valve replacement • Pancreas transplant • Lymph node dissection

Minor

Procedure without significant risk; often done with local anesthesia Incision and drainage (I&D) • Implantation of a venous access device (VAD) • Muscle biopsy

Functions of Skin

Protection, homeostasis (water balance) temp. regulation, sensory organ, vitamin synthesis, psychosocial

Changes of Aging as Surgical Risk Factors Respiratory System

Reduced vital capacity Loss of lung elasticity •Teach coughing and deep-breathing exercises. •Pulmonary exercises help prevent pulmonary complications Decreased oxygenation of blood •Monitor respirations and breathing effort. •Having baseline data helps detect deviations.

Hypnosis/Hypnoanesthesia Anesthesia Advantages

Reflexes remain intact

Rhytidectomy (Facelift)

Removal of excess skin and tissue from the face at the level of the hairline followed by primary closure Excessive wrinkling or sagging of facial skin Hematoma or hemorrhage Facial nerve damage (temporary or permanent) Wound infection Ecchymosis and edema (temporary) Skin necrosis Hair loss

Rhinoplasty

Removal of excessive cartilage and tissue from the nose with correction of septal defects if indicated Disproportionate anatomy Post-traumatic nasal deformity Difficulty breathing through the nose Hematoma or hemorrhage Ecchymosis and edema (temporary) Wound infection (with gram-positive organisms) Septal perforation Minor skin irritation

Nursing Safety Priority Action Alert

Respiratory assessment is the most critical assessment to perform after surgery for any pt. who has undergone general anesthesia, moderate sedation, or has received sedative or opioid drugs

Crusts and oozing

Secondary lesions; are composed of dried serum or pus on the skin beneath which liquid debris may accumulate; crusts frequently result from broken vessicles, bullae, or pustules

Lichentification

Secondary lesions; are thickened areas of epidermis with accentuated skin markings. They are caused by chronic rubbing and scratching

Atrophy

Secondary lesions; characterized by thinning of skin surface w/ loss of skin markings *skin is translucent & paper-like (striae or "stretch marks")

Ulcers

Secondary lesions; deep erosions that extend beneath the epidermis and involve the dermis and sometimes the subcutaneous fat

Fissures

Secondary lesions; linear cracks in the epidermis, which often extend into the dermis (athlete's foot)

Scales

Secondary lesions; visibly thickened stratum corneum; appear dry and usually whitish; most often seen with papules and plaques

Changes of Aging as Surgical Risk Factors Neurologic System

Sensory deficits •Orient the patient to the surroundings. Slower reaction time •Allow extra time for teaching the patient. •An individualized preop. teaching plan is developed based on pt's orientation & any neurologic deficits. Decreased ability to adjust to changes in surroundings •Provide for the patient's safety. •Safety measures help prevent falls and injury.

Preventing Pressure Ulcers:: Skin care

Skin Care • Perform a daily inspection of the patient's entire skin. • Document and report any manifestations of skin infection. • Use moisturizers daily on dry skin, and apply when skin is damp. • Keep moisture from prolonged contact with skin: • Dry areas where two skin surfaces touch, such as the axillae and under the breasts. • Place absorbent pads under areas where perspiration collects. • Use moisture barriers on skin areas where wound drainage or incontinence occurs. • Do not massage bony prominences. • Humidify the room.

Answer: b. c. d. e. Skin color is determined by the melanin, carotenoids, oxygenated blood in arterioles, and deoxygenated blood in the venules.

Skin color is determined by what? Select all that apply. a. Sebaceous glands b. Melanin c. Carotenoids d. Oxygenated Blood e. Deoxygenated Blood f. Lymph fluid

Answer: a. b. d. e. Skin sensation involves detection of pressure, light touch, vibration and pain. Moisture is not a part of skin sensation and proprioception is the ability to detect where a body part is in space without looking at it.

Skin sensation involves which of the following types? a. Pressure b. Light touch c. Moisture d. Vibration e. Pain f. Proprioception

Moisture-retentive dressing

Spontaneous separation of necrotic tissue is promoted by autolysis.

Stage III

Stage of general anesthesia (surgical anesthesia) b/c it is the stage in which most surgery occurs.

Minimally invasive surgery (MIS)

Surgery performed in body cavity or body area through 1+ endoscopes; can correct problems, remove organs, take tissue for biopsy, re-route blood vessels & drainage systems • Arthroscopy • Tubal ligation • Hysterectomy • Lung lobectomy • Coronary artery bypass • Cholecystectomy

SCIP

Surgical Care Improvement Project: a project to reduce & eliminate preventable surgical complications

who mandates the requirement of an informed consent

TJC-The Joint Commission

reddened areas

Teach all nursing care personnel and family members not to massage _____ directly because this action can damage capillary beds and increase tissue necrosis.

opioid (narcotic) & nonopioid (nonnarcotic)

The 2 general classes of pain medicine are ___ & ___.

infiltration (or field blocks)

The direct injection of a local anesthetic into tissue immediate to a surgical site is called ___ anesthesia.

Answer: The epidermis is thinnest on the eyelids, followed by the back of the hand, the fingertips and the soles of the feet in that order.

The epidermis is thinnest on what body area? a. The eyelids b. The fingertips c. The soles of the feet d. The back of the hand

stop, prevent

The goals of pharmacotherapy for migraines are to ___ the migraine in progess & to ___ the migraines from occuring.

"I have been working in my garden for several hours every day."

The home health nurse is doing an intake assessment on a client who had a recent shave biopsy of a basal cell carcinoma located on the client's cheek. Which statement by the client may indicate the greatest need for client teaching? A. "Every morning, I check the biopsy site for signs of infection." B. "I have been cleaning my face with soap and water." C. "My appetite is improving lately." D. "I have been working in my garden for several hours every day."

Culture for fungal infections

Using a tongue blade, gently scrape scales from the skin lesions into a clean container and send to the laboratory for culture. Container may be kept at room temperature.

Bathe the client, and apply a protective barrier to skin folds and perineum.

The nurse identifies the priority problem of skin breakdown related to poor hygiene in a long-term care client who has areas of skin breakdown in the skin folds and the perineal area. Which intervention will be best for the RN to delegate to the nursing assistant? A. Check the client's skin weekly for areas of redness or breakdown. B. Teach the client and family about the importance of good hygiene in skin folds. C. Evaluate the client's ability to provide skin hygiene independently. D. Bathe the client, and apply a protective barrier to skin folds and perineum.

Place the viral culture tubes for a client with possible herpes zoster infection on ice, and send them to the laboratory.

The nurse in the outpatient clinic is caring for four clients who require cultures of skin lesions. Which action will the nurse take first? A. Add potassium hydroxide to the specimen to check for a possible fungal infection, and inspect it under the microscope. B. Soak the crust of a possible bacterial lesion with normal saline. C. Instruct the client who has had a punch biopsy about wound care. D. Place the viral culture tubes for a client with possible herpes zoster infection on ice, and send them to the laboratory.

Preventing Hypoxemia Planning: Expected Outcomes.

The pt is expected to attain/ maintain optimal lung expansion & breathing patterns after surgery as indicated by: • Partial pressure of arterial oxygen (Pao2) within normal range • Partial pressure of arterial carbon dioxide (Paco2) WNR • Oxygen saturation values WNR

Psoriasis

The nurse is assessing a client and observes multiple small pits in all of the client's fingernails. The nurse suspects that the client may have which condition? A. Cystic fibrosis B. Iron deficiency anemia C. Isolated periods of severe malnutrition D. Psoriasis

Answer: c. The hypodermis or subcutaneous layer contains fat, which is important in insulation for the body.

The part of the skin that provides the most insulation from the hot and cold is what? a. Epidermis b. Dermis c. Hypodermis d. Langerhans cells

Presence of one of the ABCD features

The nurse is aware that which characteristic of a skin lesion warrants further examination by a dermatologist or surgeon? A. 1-mm ecchymotic area on the upper extremity B. Presence of one of the ABCD features C. Dark red color D. Round and raised appearance

Nursing Safety Priority Drug Alert

Usual dosage for hydromorphone is much smaller (about 1/5 to 1/10) than of morphine

Answer: c. d. The fingers and the face have the highest density of receptors and are considered the most sensitive parts of the body.

The parts of the body considered highly sensitive include the following. Select all that apply. a. Soles of the feet b. The back c. The fingers d. The face e. The abdomen f. The buttocks

Preventing Hypoventilation Planning: Expected Outcomes

The pt is expected to be free of damaging events r/t hypoventilation as indicated by: • Maintenance of SaO2, PaO2, & blood pH WNL • VS WNL • Return to presurgical level of cognitive function

"I use a tanning bed to avoid the sun's harmful rays."

The nurse is instructing the client on skin and sun protection. Which statement by the client indicates the need for further teaching? A. "My skin is better protected from the sun because I am dark skinned." B. "Sunscreen should be applied liberally." C. "I use a tanning bed to avoid the sun's harmful rays." D. "My sunglasses are UVA and UVB protected."

Preventing Injury Planning: Expected Outcomes.

The patient is expected to be free of injury as indicated by: • Adequate capillary refill & peripheral pulses in all ext • Peripheral sensation & motor function after surgery = before surgery • Absence of skin rednes or open skin areas • Absence of bruising

Sedation/ relaxation

The primary reason that nitrous oxide is used in short surgical procedures is that it provides _____.

Body image counseling

The nurse is teaching the client about postoperative care following oral cancer surgery. Because of damage to the epidermis, what topic does the nurse plan to discuss with the client? A. Body image counseling B. Respiratory protection C. Self-suctioning D. Tobacco cessation education

Checks the oral mucosa

The nurse notices yellowing at the corners of the sclera in the African-American client admitted for hepatitis. What does the nurse do next? A. Palpates the liver B. Checks the oral mucosa C. Examines the client's hair D. Monitors pulse oximetry

"How is this affecting you?"

The older adult female client asks the nurse, "Why is my hair thinning?" After assuring the client that this is a normal sign of aging, what is the nurse's best follow-up response? A. "How does this make you feel?" B. "How is this affecting you?" C. "Wear a hat outside to stay warm." D. "You could wear a wig."

Get help and lift the client.

The older adult immobile client has "sunk" to the bottom of the bed. What will the nurse do first? A. Gently pull the client up. B. Get help and lift the client. C. Look for broken skin areas. D. Pad the bony prominences.

Answer: d. The epidermal layer or epidermis is the outer layer of the skin. Deep to that is the dermis, then the hypodermis, which is also called the subcutaneous tissue.

The outermost layer of the skin is called what? a. The hypodermis b. The dermis c. The subcutaneous layer d. The epidermal layer

Preventing Infection Planning: Expected Outcomes.

The pt is expected to have an uninfected surgical wound(s). Indicators include: • Wound edges closed & not excessively red or swollen • Wound is free from purulent drainage • WBC counts remain at expected levels after surgery • Pt is afebrile

Answer: c. e. The thickest areas of the hypodermis are located on the back and the buttocks.

The thickest areas of hypodermis are located where? Select all that apply a. Back of the hand b. Sole of the feet c. Back d. Fingertips e. Buttocks f. Calves

continuous wet gauze

The wound surface is continually bathed with a wetting agent of choice, promoting dilution of viscous exudate and softening of dry eschar.

intracranial vessels, orally, parenterally, nasally

Triptans are 5-HT-selective & are thought to act by constricting _____ _____. The may be administered ___, ___ or ___.

triptans, ergot alkaloids, serotonin

Two major drug classes used for migraine headaches include ___ & ____ _____. Both of these are ___ agonists.

what are the most common preadmission labs

UA, type and cross, CBC, Hgb, Hct, PT, PTT, INR, electrolytes, serum creatinine, BUN, pregnancy test, x-ray, EKG

Opioid use

Use of opioids or other analgesics for pain management may mask or increase severity of symptoms of anesthesia reaction. Therefore give these drugs w/ caution, esp. in the PACU when pt's condition not stable

Nitrous Oxide-Inhalation Gaseous Drug Adverse effects:

§ Low doses- very few SE § Higher doses- anxiety, excitement, combativeness § N/V

Ice

Viral culture tubes are placed on _______ immediately after specimens are obtained and are transported to the lab ASAP

retinoids

Vitamin A-like compounds providing resistance to bacterial infection by reducing oil production and the occurrence of clogged pores

restlessness or anxiety

What is a potential adverse effect from local anesthetics?

Succinylcholine (Anectine, Quelicin)

What is the major depolarizing neuromuscular blocker used during surgery?

cause vasoconstriction of cranial arteries

What is the mechanism of action of sumatriptan (Imitrex) and other triptans?

Answer: c. The apocrine glands are not well understood. They do not function until puberty.

What is true of the apocrine glands? They are the most important glands in a. sweating. b. They have the highest concentration in infancy. c. They do not function until puberty. d. They release oil onto the skin.

GI bleeding

When a health care provider is asked to explain why acetaminophen is used more often than aspirin, the response is that ASA can cause ______.

Nursing Safety Priority Critical Rescue

When a surgical wound evisceration occurs, 1 nurse tends to pt while another nurse immediately notifies surgeon

no anti-inflammatory activity

When asked why NSAIDs are better than acetaminophen for arthritis, the health care provider responds, "Compared to aspirin, acetaminophen has ___."

Answer: a. During excessive heat, sweat is produced by the eccrine glands in the skin. Eccrine glands are located in most skin areas, including the scalp and axillary area.

When heat is excessive, sweat is produced by what glands? a. Eccrine glands b. Endocrine glands c. Axillary glands d. Scalp glands

A multicolored lesion is present on the client's thigh.

When the nurse is assessing the skin of an older adult client, which of these data will be most important to report to the physician? A. A multicolored lesion is present on the client's thigh. B. Liver spots are present on both hands. C. Cherry hemangiomas are scattered on the client's back. D. The skin on the extremities is paper thin.

nonpharmocologic techniques

When used concurrently with traditional medications, ___ ___ may result in fewer drug-related adverse effects and allow for lower doses of medications.

Administer an antihistamine to a client who is describing pruritus.

Which activity for the long-term care client does the nurse plan to assign to the LPN/LVN? A. Develop a care plan for a client who has blisters caused by herpes zoster. B. Administer an antihistamine to a client who is describing pruritus. C. Teach a client how to self-assess for changes in skin lesions. D. Perform a baseline skin assessment for a newly admitted client.

to increase the effectiveness of the anesthetic in regions that have extensive local infection of abscesses

Why is an alkaline substance such as Sodium hydroxide sometimes added to a vial of anesthetic solution?

"Administration of local anesthetic agents may cause burning."

While providing teaching to the client undergoing excisional biopsy, which statement will the nurse include? A. "Administration of local anesthetic agents may cause burning." B. "The biopsy results will be available within 2 hours of the procedure." C. "The dressing must remain in place for the first 48 hours." D. "Redness and swelling at the puncture site are expected."

Asymmetry, border, color, diameter, evolving

Which method will the nurse use to assess skin lesions for cancer? A. American Cancer Society Skin Assessment B. Asymmetry, border, color, diameter, evolving C. Dermatologist skin review D. Size, location, and inflammation

Five clustered circumscribed lesions on the chest

Which nursing documentation is correct in describing multiple lesions with well-defined borders that are located in one area? A. Clustered round lesions to the chest B. Five clustered circumscribed lesions on the chest C. Five diffuse circinate lesions on the chest D. Several lesions in one area that have well-defined borders

Inhalation

Which of the following is NOT a major route for applying local anesthetics? Epidural Spinal Nerve Block Inhalation

Ibuprofen (Advil)

Which of the following would be used to treat mild to moderate pain due to inflammation? oxycodone (OxyContin) meperidine (Demerol) Ibuprofen (Advil) acetaminophen (Tylenol)

Pitting edema

Which skin condition will the emergency department nurse assess first? A. Localized redness to the surgical site B. Pitting edema C. Poor skin turgor D. Red bony prominences

Methadone (Dolophine)

___ is commonly given to heroin addicts during treatment of their drug dependence

anxiety, fatigue, depression positive attitudes, support from health care providers

____, ____, & ____ can increase the perception of pain. _____ & ____ may reduce the perception of pain

Surgeon

_____ is responsible for having the consent form signed before sedation is given & before surgery is performed. • Nurse not responsible for providing detailed information about the surgical procedure. Clarify facts presented by physician & dispel myths that pt or family may have about surgical experience. Verify consent form signed, & witness signature, not that pt is informed.

nevus (mole)

a benign growth of the pigment-forming cells. These lesions are classified according to their location within the layers of the skin.

Psilocybin

a hallucinogen

Treatment of respiratory depression

a health care provider knows that therapeutic effects of opiates do NOT include

Dehiscence

a partial/ complete separation of outer wound layers, "splitting open of the wound"

Surgeon

a physician who assumes responsibility for surgical procedure & any surgical judgments about pt.

Acne

a progressive disorder that manifests as several types of skin lesions, including noninflammatory comedones (blackheads and whiteheads), inflammatory papules, pustules, and cysts. These lesions are usually present only on the face and upper trunk.

eczema

a skin disorder with symptoms resembling an allergic reaction is called atopic dermatitis or ____

what surgeries may require the pre-administration of GoLYTELY

abdominal, pelvic, perineal, perianal, colonoscopy

Vacudrain

accordian-type closed drain sutured in place w/ suture that seals area when drain is removed.

hyperbaric oxygen

administer O2 under high pressure, raising tissue O2 concentration -costly -60-90 min -100% O2 w/ pressure higher than atmosphere -enhances the ability of white blood cells to kill bacteria and reduce swelling

Calcipotriene (Dovonex)

adminsitered topically for psoriaris

Regional or Local anesthesia

advantages • gag and cough reflexes stay intact, allows participation & cooperation by pt • ↓ disruption of physical & emotional body function • ↓ chance of sensitivity to agent • ↓ intraoperative stress disadvantages • difficult to administer to uncooperative/ upset pt • no way to control after administration • absorbs rapidly into blood & causes cardiac ↓ or overdose • ↑ nervous system stimulation (overdose) • not practical for extensive procedures b/c of amt of drug required to maintain

e. antimigraine agent.

ergotamine tartrate (Ergostat)

Redness

erythema

General anesthesia- Intravenous

advantages •rapid & pleasant induction •↓incidence of postop nausea & vomiting •requires ↓equipment disadvantages •must be metabolized & excreted from body for complete reversal •contraindicated in presence of liver or kidney disease •↑ cardiac & respiratory depression •retained by fat cells

Inhalation anesthetics- halothane (fluothane)

advantages •rapid & smooth induction •↓incidence of postop N&V •↓irritating to resp. tract than other inhalation agents disadvantages •shivering common postop •can induce malignant hyperthermia •hypotension & bradycardia may occur •can ↑ dysrhythmias •can cause permanent liver damage (rare)

Intravenous Anesthetics- propofol (diprivan)

advantages •rapid induction & recovery disadvantages •can cause pain at injection site •may induce propofol infusion syndrome •severe metabolic acidosis •rhabdomyolysis •hyperkalemia •kidney injury •cardiovascular collapse

Intravenous Anesthetics- thiopental sodium (penthothal)

advantages •rapid induction & recovery disadvantages •can depress respiratory & cardiac functions

Opioids- sufentanil (sufenta)

advantages •rapid induction & recovery disadvantages •can induce prolonged respiratory depression

Neuromuscular blockers- succinylcholine

advantages •rapid induction & recovery disadvantages •causes fasciculations on induction •can cause malignant hyperthermia in conjunction w/ inhalation anesthetics

Inhalation anesthetics- desflurane (suprane)

advantages •rapid induction & recovery disadvantages •may ↑ HR & ↓ BP during induction •can induce malignant hyperthermia

Neuromuscular blockers •cisatracurium (nimbex) •atracurium (tracrium) •mivacurium (mivacron) •vecuronium (norcuron)

advantages •rapid induction & recovery disadvantages •temporarily paralyzes muscles, does NOT block sensation

Inhalation anesthetics- enflurane (ethrane)

advantages •rapid induction & recovery •less likely to induce dysrhythmias disadvantages •respiratory depression may occur, •hypotension may occur •can induce malignant hyperthermia •lowers seizure threshold

Intravenous Anesthetics- ketamine (ketalar)

advantages •rapid induction & recovery •protective reflexes remain intact; disadvantages •stimulates cardiovascular responses •dissociative emergence reactions •can induce N&V

Intravenous Anesthetics- etomidate (amidae)

advantages •rapid induction & recovery •useful for short procedures •little hang over effect disadvantages •can cause pain at injection site, •laryngospasms (rare)

Inhalation anesthetics- nitrous oxide

advantages •rapid induction & recovery •useful for short procedures •when used w/ other agents ↓required concentration of them •minimal cardiovascular & resp. depression disadvantages •relatively weak anesthetic agent •may produce hypoxia if concentration is ↑ •needs addition of other agents for longer procedures

Inhalation anesthetics- sevoflurane (ultane)

advantages •rapid induction and recovery •induces additional muscle relaxation disadvantages can induce kidney impairment (rare)

General anesthesia-- Inhalation

advantages •most controllable method •induction & reversal accomplished w/ pulmonary ventilation •few side effects disadvantages •must be used in combination w/ other agents for painful or prolonged procedures, •limited muscle relaxant effects, •postop nausea & shivering common

Inhalation anesthetics- isoflurane (forane)

advantages •rapid induction & recovery •induces additional muscle relaxation disadvantages •respiratory depression possible •irritating odor

Opioids- remifentanil (ultiva)

advantages- effective at very low doses

Opioids- fentanyl (sublimaze)

advantages- outstanding analgesia, anesthesia (epidural)

Opioids- alfentanil (alfenta)

advantages- rapid induction & recovery

what factors increase surgical risks

age, medications, medical hx, prior surgical experience, health hx, family hx, type of procedure

universal

all areas of the body involved, with no areas of normal-appearing skin

antimigraine agent.

amitriptyline (Elavil)

capillary closing pressure

amount of pressure needed to occlude skin capillary blood flow, in the area at risk. The normal capillary closing pressure ranges from 12 to 32 mm Hg. An effective pressure-relieving device is one that keeps tissue pressure below the capillary closing pressure to ensure adequate tissue perfusion and oxygenation.

Crotamiton (Eurax)

an alternative scabicide to lindane (Kwell) available by prescription as a 10% scream

primary lesions

an initial reaction to a problem that alters one of the structural components of the skin.

what type of medication is midazolam (versed)

anxiolytic

eletrical stimulation

application of low-voltage current to increase blood vessel growth and promote granulation -delivered in pulses -tingling sensation -1 hr a day *not used w/ pts who have a pcemaker or wound over heart

Topical growth factors

are biologically active substances that stimulate cell movement and growth. These factors are deficient in chronic wounds, and topical application is currently being studied as a way to stimulate wound healing. For example, platelet-derived growth factor (PDGF) stimulates the movement of fibroblasts into the wound space. Use of this and other growth factors has been found to be more successful in clean, surgically débrided chronic wounds

secondary lesions

are changes in the appearance of the primary lesion.

psoriatic agent

etanercept (Enbrel)

how often can a pt donate for autologous blood donation

every 3 days

Acne Vulgaris

avoid oil-based cosmetics, hair products ○ Cleanse skin twice daily w/mild soap & water ○ Topical meds. used daily. May take 4-6 wks. to see results ○ Teach boys to shave gently, avoid using dull razors so as not to irritate further Avoid picking/squeezing pimples, use sunscreen

acne & acne-related agent

azalaic acid (Azelex, Finacea)

Degenerative Disk Disease

back pain d/t damage of nerves entering/ exiting spinal cord

Nonabsorbable sutures

become encapsulated in tissue during healing process & remain in tissue unless removed.

respiration rate

before administering an opioid, which of the following should be checked?

Preoperative

before surgery: from scheduling of appt until going in to OR

ester-like local anesthetic

benzocaine (Americanine, Anbesol, Solarcaine)

sunburn/ minor irriation agent

benzocaine (Solarcaine)

acne & acne-related agent

benzoyl perozied (Clearasil, Fostex)

Vascular changes or markings classified as Normal

birthmarks cherry angiomas spider angiomas venous stars.

Vascular changes or markings are classified as Abnormal

bleeding into the tissue is abnormal and results in purpuric lesions (bleeding under the skin that may progress from red to purple to brownish yellow), petechiae, and ecchymosis.

Vascular changes or markings classified as Abnormal

bleeding into tissue is abnormal & results in purpuric lesions (may progress from red to purple to brownish yellow), petechiae ecchymosis.

what is the action of anticholinergic agents and one example

blocks acetylcholine in the CNS and PNS which relaxes muscles and helps pt relax: atropine

serosanguineous exudate

blood tinged amber fluid consisting of serum and RBC -normal for first 48 hours after injury -sudden increase in amount precedes dehiscence in first intention wounds

diabetic neuropathy

burning or stabbing pain in hands & feet of pts suffering from diabetes

what is a "time out" in regards to surgery

every one "shuts up" and one person verbally verifies pt identity, correct side and site, correct pt position, and agreement of proposed procedure before incision

hirsutism

excessive growth of body hair or hair growth in abnormal body areas

Why should fall precautions be implemented for a pt who has taken GoLYTELY

can cause exhaustion, dehydration, electrolyte imbalances which affect pt's ambulatory status

do not massage reddened areas

can damage capillary beds and increase tissue necrosis

Which of the pt's routine medications are always taken unless a physician specifically says not to

cardiac medications

type 1 HSV

cause classic recurring cold sore

a. nociceptor pain

caused by injury to tissues

Hypertension, atherosclerotic disease

causes problems with circulation/edema that compromise wound healing

b. neuropathic pain

central pain syndrome

what respiratory findings should be reported during preop assessment

chronic respiratory problems, smoking

circinate

circular

what is the nurses responsibility pertaining to the informed consent

clarify, verify, witness

what device should be used for hair removal prior to surgery and why

clippers, reduces the likelihood of injury from razor

Whiteheads

closed comedones

Jackson Pratt

closed drainage system

Hemovac

closed drainage system sutured in place w/ suture that seals area when drain is removed.

Chronic paronychia

common inflammation that persists for months. People at risk: men & women w/ frequent exposure to water, such as homemakers, bartenders, laundry workers, & nurses.

In a life-threatening situation in which every effort has been made to contact the person with medical power of attorney

consent desired, not essential. In place of written/ oral consent, written consultation by at least 2 physicians not associated w/ case

Surgical team

consists of surgeon, one or more surgical assistants, anesthesia provider, OR nursing staff, perioperative or OR nurses including holding area nurse, circulating nurse, scrub nurse, non nurse scrub person, specialty nurse

Cyclosporine

contraindicated in conjunction with phototherapy for the tx of psoriasis

purulent exudate

creamy yellow pus- staph greenish blue pus/fruity odor- pseudomonas beige pus/fishy odor- proteus brownish pus/fecal odor- usually occurs after intestinal surgery

what type of surgery is an appendectomy

curative

what can be done with blood that is suctioned from pt during surgery

cycled and recycled back into pt

why do you want your pt to cough after surgery

expel secretions, keep the lungs clear, allow full aeration, prevent pneumonia and atelectasis

contact dermatitis

exposure to perfume, cosmetics, detergents, or latex is associated with ____

Sunburn

exposure-type injury

rhytidectomy

facelift

Physical Therapy

daily whirlpool treatments along with dressing changes for débridement can help remove dead tissue. The ulcerated area is immersed in or saturated with warm tap water that contains an antibacterial cleansing agent. Continuous agitation of the water loosens the debris and washes away exudate and particles. During treatment, the ulcer surface is cleansed with a gauze pad. After treatment, the therapist or wound specialist often uses instruments to trim away any obvious bits of dead tissue that are still loosely attached to the ulcer surface.

what is the action of H2 histamine blockers and two examples

decrease gastric secretions: cimetidine (tagamet), ranitidine (zantac)

what are some renal/urinary changes that occur with aging that increase surgical risks

decreased blood flow to the kidneys, reduced ability to excrete waste, decreased GFR, nocturia

what are some cardiovascular changes that occur with aging that increase surgical risks

decreased cardiac output, increased BP, decreased peripheral circulation

Tretinoin (Avita, Retin-A)

decreases comedone formation & increases extrusion of comedones from the skin

Autoimmune disorders (lupus or scleroderma)

decreases the body's ability to fight off infection and delay wound healing

Stratum basale

deepest layer of epidermis -Supplies new cells to epidermis

Local anesthesia

delivered topically (applied to skin or mucous membranes) & local infiltration (injected into tissue)

what type of surgery is a biopsy

diagnostic

Absorbable sutures

digested over time by body enzymes.

apocrine sweat glands

direct contact with hair follicle, mostly in axillae, nipple areola, periumbilicus, and perineal body areas, cause body odor due to skin bacteria and secretions.

inhaled drugs

droperidol (Inapsine)

what are some skin changes that occur with aging that increase surgical risks

dry, less subcutaneous fat, slower healing

visceral pain

dull, throbbing, or aching pain

Intraoperative

during surgery: from entrance in to OR until leaving OR

What is pre-op nursing role?

educate, advocate, promote health * prepare pt * validate, clarify, reinforce information

What level of urgency is cataract removal surgery

elective

what are the levels of urgency regarding surgery

elective, urgent, emergent

what level of urgency is surgery for hemorrhage

emergent

Skin substitues

engineered products that aid in the temporary or permanent closure of different types of wounds. These products vary widely in design and application and are used mainly for surgically débrided wounds, such as a fullthickness pressure ulcer before reconstruction with skin grafts or muscle flaps (

what drug can be given prior to surgery to promote RBC production

epogen

NSAID

ibuprofen (Advil, Motrin)

post op graft sites are

immobilized for 3-5 days -encourage elevation and complete rest of area -movement prohibited -monitor graft -remove dressing after 24-48 hrs -keep dry -promote air circulation

Why is assessment of kidney function important before surgery

impairment inhibits drugs/anesthetic agent excretion and can cause toxicity

Impregnated gauze dressing

impregnated w/ NS, petrolatum, iodoform placed directly on wound. less trauma little pain upon removal must have dressing on top of it Aquaphor

Vascular changes or markings are classified as Normal

include birthmarks, cherry angiomas, spider angiomas, and venous stars.

why would an older pt be at risk for falls after surgery

increased confusion, agitation, anxiety, medication

blanching

indicates color changes relates to blood vessel dilation rather than tissue damage or inflammation

teratogenic

inducement of birth defects

what is the action of pre-op sedatives and one example

induces sedation by reducing irritability or excitement: hydroxyzine (atarax, vistiril)

what is the action of pre-op hypnotics and one example

induces sleep: lorazepam (ativan)

The Joint Commission's NPSGs require that you provide information about

informed consent, dietary restrictions, specific preparation for surgery (bowel & skin preparations), exercises after surgery, & plans for pain management to promote patients' participation & help achieve expected outcome.

Sodium

inhaled general anesthetics produce their effect by preventing the flow of _____ into neurons of the CNS

The middle layers of epidermis

innermost to outermost -Stratum spinosum -Stratum granulosum -Stratum lucidum

which of the pt's routine medications are most always held or reduced prior to surgery

insulin, hyperglycemic medications

Why would you avoid garlic prior to surgery

interferes w/ clotting

Cellulitis

is a generalized infection with either Staphylococcus or Streptococcus and involves deeper connective tissue. can occur as a result of secondary bacterial infection of an open wound, or it may be unrelated to skin trauma.

Folliculitis

is a superficial infection involving only the upper portion of the follicle and is usually caused by Staphylococcus. The rash is raised and red and usually shows small pustules.

Electrical stimulation

is the application of a low-voltage current to a wound area to increase blood vessel growth and promote granulation. This treatment is usually performed by a certified wound care specialist. A single electrode can be applied directly to a wound through a sterile dressing, or multiple electrodes can be applied around a wound. The voltage is delivered in "pulses" that may cause the patient to feel a "tingling" sensation. Usually electrical stimulation is performed for 1 hour a day, five to seven days a week. This form of treatment is not used with patients who have a pacemaker or who have a wound over the heart.

Diabetes

is the single most prevalent co-morbidity in pt's requiring chronic wound care

drug for fungal infections

ketoconazole (Nizoral)

what are some ways to prevent VTE

leg exercises, immediate mobility, TED hose, SCD's (sequential compression devices)

pilonidal cyst

lesion of the sacral area that often has a sinus track extending into deeper tissue structures. As this cyst fills or becomes infected, it can become tender. An incision and drainage can be performed, but the cyst is likely to refill. The cure for this cyst is surgical removal, and the area heals by second intention, which may take 4 to 8 weeks.

coalesced

lesions that merge with one another and appear confluent

pediculosis

lice -capitis = head lice -corpris = body lice -pubis = pubic, crab lice -itching most common symptom -more common in women -secondary infection can arise from scratching treatment: -chemical killing with sprays, creams, shampoos

thickened

lichenfied

amide-type local anesthetic

lidocaine (Anestacon, Dilocaine, Xylocaine)

laser specialty nurse or laser nurse coordinator

light amplification by stimulated emission of radiation gives off a high powered beam of light that cuts tissue more cleanly than scalpel blades. Process creates intense heat rapidly clots blood vessels or tissue and turns target tissue into vapor. All personnel must observe safety measures.

cryosurgery

liquid nitrogen causing cancerous cell death

succinylcholine (Anectine, Quelicin)

major depolarizing neuromuscular blocker

Specialty Nurse

may be in charge of particular type of surgical specialty including orthopedic, cardiac, ophthalmologic. Assesses, maintains, and recommends equipment, instruments, and supplies used.

Lidocaine

may be prescribed for cardiac dysrthymias

Dystrophic (abnormal appearing) nails

may occur with a serious systemic illness or local skin disease involving the epidermal keratinocytes.

Patients who cannot write

may sign with an X, which must be witnessed by 2 persons.

NSAID

meloxicam (Mobic)

c. opioid; high effectiveness

meperidine (Demerol)

Rheumatoid arthritis & certain cancers

methotrexate may be used to tx psoriasis and ____

Intravenous drugs adjuncts to anesthesia

midazolam (Versed)

Surgical assistant

might be another surgeon such as a resident or intern or advanced practice nurse, physician assistant, certified registered nurse first assistant (CRNFA) or surgical tech. Under direction of the surgeon & within legal scope of practice for each state. Assistant may hold retractors, suction the wound, cut tissue, suture, dress wounds

"Do's" with minor & major burns

minor: • cool water NOT ICE • cover • protect • up to date on tetanus major: • stop drop & roll • smother & douse

nitrous oxide

most abused anesthetic agent

Lidocaine

most commonly used injectible local anesthetic

benzocaine

most commonly used topical anesthetics

what are the requirements if a pt is signing with an "x"

must have 2 witnesses

d. opiod blocker

naloxone (Evzio, Narcan)

d. opiod blocker

naltrexone (ReVia, Trexan)

NSAID

naprozen sodium (Aleve, Anaprox)

Opiates

natural substances from opium · 9-14% morphine · 0.8-2.5% codeine

Opiates

natural substances from opium --9-14% morphine --0.8-2.5% codeine

maintenance of positive...

nitrogen: intake of 30-35 cal/kg daily protein intake of 1.25 to 1.5 g/kg/day

What is NPO and why is the pt put on this prior to surgery

no eating, no drinking, no gum, no smoking: increases the risk for aspiration

Adjuvant analgesics

not typically analgesics- can provide relief for specific types of pain *antiseizure drugs* -Carbamazepine (Tegretol)- trigeminal neuralgia -Valporic Acid (Depakene)- pain d/t migraines -Gabapentin (Neurontin)- postherpetic neuralgia -Pregabalin (Lyrica)- fibromyalgia, postherpetic neuralgia, diabetic neuropathy

Adjuvant analgesics

not typically classified as analgesics, but can provide relief for specific types of pain -antiseizure drugs -Carbamazepine (Tegretol)- trigeminal neuralgia -Valporic Acid (Depakene)- pain d/t migraines -Gabapentin (Neurontin)- postherpetic neuralgia -Pregabalin (Lyrica)- fibromyalgia, postherpetic neuralgia, diabetic neuropathy

Dry Gauze Dressing

not used in wounds that require a moist env. or when removal of dry dressing will cause pain/bleeding of healthy tissue *mostly used as a wrap.

What is the immediate action of the nurse when an electrolyte imbalance is found and why

notify anesthesia team and surgeon. MUST be corrected before surgery

Nonsurgical Management of Burns

o IV fluids o Monitoring patient response to fluid therapy o Drug therapy

IV General Anesthetics

o Opioid: Fentanyl (Sublimaze) o Benzodiazepines: diazepam (Valium), lorazepam (Ativan), midazolam (Versed)

Opioids

o Opioids offer superior analgesia o Combining Fentanyl (Sublimaze) w/ droperidol (Inapsine) an antipsychotic agent, will produce *neuroleptanalgesia* --Pts conscious, but insensitive to pain --sensory overload when recovering o Premixed combo of the 2 agents is *Innovar*

Opioids

o Opioids offer superior analgesia o Combining Fentanyl (Sublimaze) w/ droperidol (Inapsine) an antipsychotic agent, will produce neuroleptanalgesia o Pts are conscious, but insensitive to pain --sensory overload when recovering o Premixed combo of the 2 agents is Innovar

General Anesthetics: Intravenous

o Opioids, benzodiazepines, & misc. agents o Rapidly induce unconsciousness o Used in combo w/inhalation agents § Greater analgesia & muscle relaxation than inhalation alone § Balanced anesthesia

b. opioid; moderate effectiveness

oxycodone (OxyContin, Oxecta)

c. opioid; high effectiveness

oxymorphone (Opana)

postsurgical pain

pain after a surgical procedure

postherpetic neuralgia

pain brought on by herpes & herpes-related viruses or outbreak of shingles

intractable cancer pain

pain d/t progressive or metastatic spread of cancer

why are opiod analgesics given in regards to surgery and one example

pain management: morphine

phantom limb pain

pain occurring in some pts after a limb is amputated

diascopy

painless technique that eliminates erythema caused by increased blood flow to the skin.

what type of surgery is a tumor reduction

palliative

local signs of infection

partial thickness injury to full thickness • ulceration of healthy skin at burn site • redness & nodules on uninvolved skin & vesicular lesions on involved • edema of healthy skin around wound • excessive wound drainage • pale, boggy, dry or crusted granulation tissue • sloughing of grafts • wound breakdown after closure • odor

intractable, adjuvant analgesics, co-analgesics

patients with ___, or pain that is not easy to relieve, may require additional therapy. In this case, ____ or ___ may be used, which can provide relief for specific types of pain

scabicide/ pediculicide

permethrin (Elimite)

Surgeon

physician who assumes responsibility for the surgical procedure & any judgments about the patient.

Anesthesiologist

physician who specializes in giving anesthetic agents. monitors level of anesthesia with EEG, cardiopulmonary function with ECG, pulse oximetry, end tidal carbon dioxide, ABGs, hemodynamic, capnography, vital signs, intake & output

neuropathic pain

postherpetic neuralgia

Contaminated:

presence of bacteria on the wound surface but are not invading

Colonization:

presence of bacteria that are multiplying on the wound surface but are not invading

adjunct to anesthesia

promethazine (Phenergan)

intravenous drugs

propofol (Diprivan)

antimigraine agent.

propranolol (Inderal)

antihistamines

provide some relief from itching

itching

pruritus

rhinoplasty

reconsrtuction of nose

what are some respiratory changes that occur with aging that increase surgical risks

reduced vital capacity, loss of lung elasticity, decreased O2 in the blood

Certified registered nurse anesthetist (CRNA)

registered nurse with additional education & credentials who delivers anesthetic agents under supervision of anesthesiologist, surgeon, dentist, or podiatrist

Autologous blood transfusion

reinfusing pt's own blood- may be used for surgery.

Debridement

removal of infected or dead tissue

during the preop physical assessment, what should the nurse do when abnormalities are found

report findings to surgeon/anesthesia and DOCUMENT

A positive nitrogen balance

requires an intake of 30 to 35 calories per kilogram of body weight daily with a protein intake of 1.25 to 1.5 g/kg/day. Up to 2 g/kg/day of protein may be needed when nutritional deficits are severe or protein loss is ongoing.

what type of surgery is a total knee replacement

restorative

*First intention scar

resulting in a thin scar (60%)

Incontinence

results in prolonged contact of the skin with such substances as urea, bacteria, yeast, and enzymes carried in urine and feces. These substances are irritants that destroy the integrity of the skin's barrier, predisposing that patient to skin breakdown. Excessive moisture macerates intact skin, further increasing the risk for breakdown

neuropathic pain

sciatica

how do you properly use incentive spirometer and what is the goal of using it

seal lips tightly around mouthpiece, inhale, hold breath for 3-5 seconds: goal is to increase lung volume

undermining

separation of the skin layers at the wound margins form the underlying granulation tissue

clustered lesions

several lesions group together

Perioperative nursing staff

several roles during surgery depending on their education, experience, skill, & job responsibilities

somatic pain

sharp, localized pain

Trigeminal neuralgia

shooting pain in upper neck & jaw

What is difference between simple, radical, & minimally invasive surgery (MIS)

simple-only & involved area radical-extensive surgery beyond obviously involved area MIS-use of endoscopes & laparoscopes

Petechiae

small, reddish purple lesions that do not fade or blanch when pressure is applied. Indicate ↑capillary fragility. Often occur in lower extremities w/ stasis dermatitis, a condition usually seen in patients who have chronic venous insufficiencies.

why is it important for surgical team to be aware of prosthetics

so that the Bovi pad (grounds electrical current) will not be placed on it

fluid resuscitation

started at time of injury not at time of hospital ex: injury at 8am but get to hospital at 10 IV infusion needs to be over 6 hours and not 8 hours

Androgenous hormones

stimulate sebaceous gland proliferation & sebum production in 12-16yr olds

wound VAC

suction tube uses negative pressure to enhance formation of granulation tissue

acne & acne-related agent

sulfacetamide sodium (Cetamide, Klaron)

In an emergency

telephone or telegram authorization acceptable & should be followed up w/ written consent ASAP. # of witnesses (usually two) & type of documentation vary

IV, Inhaled

the 2 major ways to induce general anesthesia are by using ___ drugs & __ drugs.

consciousness

the goal of general anesthesia is to provide a rapid & complete loss of ___

sensation total analgesia consciousness, memory, body movement

the goal of general anesthesia is to provide a rapid & complete loss of ___. Signs of general anesthesia include ___ ___, and loss of ___ .___, & ___

tension, migraine, aura

the most common type of headache when muscles of the head & neck become very tight is the ____ headache. the most painful type of headache is the ____, which is characterized by throbbing or pulsating pain sometimes preceeded by a/an ___.

dermatophyte infections

tinea is used followed by the location description -tinea pedis = athletes foot -tinea manus = involves hands -tinea cruris = jock itch -tinea capitis = involves head -tinea corporis = involves rest of body

why is it important to obtain preop vital signs

to determine a baseline

psoriasis pruritis dermatitis

topical glucocorticoids are a common tx for

inflammatory papules

topical metronidazole (*MetroCream*, *MetroGel*) is used to tx rosacea. Extensive use would be indicated for ____

Evisceration

total separation of all wound layers & protrusion of internal organs

Evisceration

total separation of all wound layers & protrusion of internal organs through open wound

Nursing Safety Priority Action Alert

unless surgeon prescribes pillow support, place no pillows under knees, & do not raise knee gatch, b/c this position could restrict circulation & increase risk for VTE

when does discharge planning begin and with what people

upon admission: pt, family, D/C planner, resource officer, social services

what level of urgency is surgery for GI obstruction

urgent

severe depression & suicidal tendencies diabetics treated with oral agents seizures tx with carbamazepine pregnancy

use of isotretinoin (Accutane) is contraindicated in patients with

Lidocaine (Xylocaine)

used as a local anesthetic and an antidsyrhythmic

Alginates

used in wounds w/large amt. of exudate, support autolytic debridement ○ Used for pressure ulcers, diabetic ulcers, infected wound/venous stasis ulcers ○ Dressing change can vary from q12h to q4 d ○ Should be left on wound until saturated *expect edudate

Wet to dry dressing

used to debride wound mechanically

Hydrocolloids

used to protect skin that may have drainage ○ Fluid from wound pulled into dressing ○ Dressing becomes gel-like, protects surrounding skin (ex. DuoDerm) ○ Designed to be left in place for 7 days

OR nurse

uses clinical decision making skills, develops a plan of nursing care, coordinates care delivery to patient and their family members

circumscribed lesion

well-defined with sharp borders

restlessness/ anxiety

what is a potential SE of nitrous oxide

Informed consent

§ The surgeon is responsible for obtaining signed consent before sedation is given and surgery is performed § The nurse's role is to clarify facts presented by the physician and dispel myths that the client/family may have about surgery § The nurse serves as a witness to the signature, NOT to the fact that the pt. is informed § Implies • Pt voluntarily signed the form • Pt. understands the procedure • Pt understands who will be performing procedure • Pt knows the options/risks, possible outcomes • Pt. knows risks assoc. w/anesthesia § Patients may sign with "X" § In emergency, telephone authorization is acceptable § Special permits required for some procedures

Drugs as Adjuncts to Surgery Preoperatively

· *Opioids* (Morphine) counteract pain after surgery (usually postop) · *Anticholinergics* (Atropine) dry secretions & suppress bradycardia caused by some anesthetics · *Sedative-hypnotics* (Ativan, Valium) reduce fear, anxiety or pain

Factors Associated w/ Acne Vulgaris

· *Seborrhea*: overproduction of sebum by oil glands · Abnormal formation of keratin blocks oil glands · *Androgens*: stimulate sebum production · Most common OTC *benzoyl peroxide* (Clearasil, Benzalin, Triaz) · *Tretinoin* (Retin-A) - older drug · *Oral contraceptives* w/ ethinyl estradiol & norgestimate · Antibiotics sometimes used in combo w/ acne meds · Isotretinoin (Accutane)

Dermis

· 2nd layer; 95% of thickness · Foundation for hair & nails · Nerve endings, oil glands, sweat glands, blood vessels

Subcutaneous

· 3rd layer; composed of adipose tissue · Cushions, insulates, provides source of energy · NOT considered when measuring skin layers

Chemical Sunscreens

· Absorb the spectrum of UV light · Include those that contain benzophenone for protection against UVA rays · Cinnamates, p-aminobenzoic acid (PABA) work against UVB rays

· Management of Minor Burns

· Addressing symptoms w/soothing lotions · rest · Prevention of dehydration · Topical anesthetics: benzocaine (Solarcaine), lidocaine (Xylocaine), tetracaine HCL (Pontocaine) · Aloe vera- natural therapy for minor skin irritations/ burns

Assessment When Neuromuscular Blocking Agents Are Used

· Baseline neuro assessment before neuromuscular blocking agents given --A&O, dementia, stroke · Anesthesia will monitor peripheral nerve stimulation during procedure · Neuromuscular blockage should be DC'd ASAP after surgery is completed · Postneuro assessment & continuous monitoring

Role of the Nurse: Scabicide & Pediculicide Therapy

· Before assessing pt, don gloves · Assess pt's hair & skin for lice, nits or scabies · Assess axilla, neckline, hairline, groin, beltline areas · Obtain thorough health history: onset of symptoms; possible exposure to others · Do not use/ use cautiously in pregnant/ lactating women & young children o Use only after other agents have been unsuccessful · Follow application instructions · Wear gloves when applying medication · Cleanse & dry lesions & surrounding areas prior to application · Educate on cleaning all bed linen, clothing & towels that child may have used

Pharmacotherapy of Acne and Rosacea

· Benzoyl peroxide --Keratolytic—dries & sheds outer layer of epidermis · Retinoids (tretinoin) --Reduce oil production & clogged pores --Do not use if patient is pregnant --Common reaction is sensitivity to sunlight · Antibiotics · Oral contraceptives

Pharmocotherapy for Viral Skin Infections

· Childhood infections: treat lesions & for discomfort · Adult infections: topical or oral antiviral therapy w/ acyclovir (Zovirax)

Psoriasis

· Chronic skin disorder · Red patches of skin covered w/flaky, silver-colored scales (plaques) · May be genetic immune reaction · Causes extremely fast skin-turnover rate · Plaques are shed rapidly · Underlying skin is inflamed & irritated

Drug Therapy with Isotretrinoin (Accutane)

· Contraindicated w/ hx. of *depression, suicidal ideation, pregnancy* (6 mo)- 2 forms of birth control · Have pt. sign consent regarding understanding of suicidal risks prior to tx. · Obtain preg. test in all female pts. of childbearing years · *very photosensitive* · liver profile every month (4-6 months)

Sunburn

· First degree burn --s/sx's: erythema, intense pain, n/v, chills, HA · Best tx is prevention --Sunscreens, physical protection

Pharmacotherapy of Psoriasis

· Goal : ↓erythema, plaques, & scales to improve appearance · No pharmacological cure

Causes of Skin Disorders

· Infectious · Inflammatory · Neoplastic

Lice (Pediculus)

· Infest areas w/ hair · Lay eggs & leave debris called nits · Transmitted by infected clothing or personal contact

Dermatitis

· Inflammatory skin disorder—pain, redness, & pruritus · *Atopic / eczema*- Chronic; genetic predisposition · *Contact*- Hypersensitivity response · *Seborrheic* newborns & teenagers after puberty · *Stasis*- Sign of poor venous circulation

Dermatologic Signs & Symptoms

· May be reflective of disease processes occurring elsewhere in body · Abnormalities in skin color, sizes, types, character of surface lesions, skin turgor & moisture -May have potential systemic causes - § Skin turgor - § Pruritus - § Erythema

Fungal Skin Infections

· Occur in warm, moist areas of skin · Tinea pedis (athlete's foot) · tinea cruris (jock itch) · tinea capitis (ringworm of scalp) · tinea unguium (nails) · generally mild- Treated w/topical antifungals · *Fungal infections of skin & mucous membranes of immunocompromised are serious*- Require oral or parenteral antifungals

Epidermis

· Outermost layer; 5% of thickness · Melanocytes in deeper layers · Secretes dark pigment melanin -Helps protect skin from UV rays

Rosacea

· Progressive disorder · Onset between 30- 50 yrs old · Characteristic symptoms --o Small papules w/o pus --o Flushed face around nose & cheeks --o Soft tissues of nose may swell--rhinophyma

Pharmacotherapy w/Scabicides and Pediculicides

· Scabicides kill mites · Peduclicides kill lice · Treatment of choice for lice & scabies is permethrin (Nix) · Others are pyrethrins (RID) & malathion (Ovide) · Lindane (Kwell) is used only after other treaments fail · Potential to cause serious *nervous system toxicity*

Skin Cells

· Supplied by stratum basale --Deepest epidermal layer · Old cells damaged or lost by normal wear · New cells migrate up through layers --Flattened & covered w/ water—insoluble material · Takes 3 wks for new cell to reach skin surface · Pigment determined by amt of melanin --Protects skin from UV in sunlight

Topical Therapies for Psoriasis

· Topical corticosteroids --Tazarotene (Tazorac), salicylic acid (Neutrogena) · Topical immunomodulators (TIMs): --Suppress immune system · Retinoid-like compounds

Systemic Therapies for Psoriasis

· When topical drugs fail · Methotrexate (Trexall, others) is most commonly prescribed · Cylcosporine (Sandimmune, Neoral) immunosuppressive agent- severe conditions · Biologic therapies Alefacept (amevive), adalimumab (Humira), others

Mites (Sarcoptes scabiei)

· cause scabies · Female borrows into skin & lays eggs · Causes intense itching · Common areas of infection: fingers, extremities, trunk, axillary & gluteal folds, pubic area · Spread by contact w/upholstery & linens

*Topical glucocorticoids*

· most effective tx. for *dermatitis* · Relieve local inflammation & itching · Adverse effects w/ LONG-term use- Irritation, redness, *thinning of skin* · Available in creams, lotions, solution, gels, pads

Bacterial Skin Infections

· occur when there is a break in skin's defenses · 2 most common: staphylococcus & strepto-coccus · Many are mild & self-limiting—tx'd w/topical antibiotics · Serious skin infections- deep or systemic: p.o./ parenteral ABT

Fungal Skin Infections Tinea

• (fungal infection that can occur on any part of the body) ○ Tinea capitis: ringworm, scalp ○ Tx: topical antifungal creams ○ Child may return to daycare/school once tx. has begun. Family members may need to be treated also. Wash sheets/cloths in hot water to decrease spread.

Combination Opioid & Nonnarcotic Analgesics

• 2 classes of drugs work synergistically to relieve pain • Opioid dose can be kept low to avoid narcotic-related SE • Imperative to realize: some combination products may raise drug levels to unacceptable limits (Ex- tylenol in Norco added to a PRN tylenol tablet) • Vicodin (hydrocodone 5 mg.: acetaminophen 500 mg) • Perococet (oxycodone hydrochloride 4.5 mg; acetaminophen 325 mg)

Combination Opioid & Nonnarcotic Analgesics

• 2 classes of drugs work synergistically to relieve pain • Opioid- low dose to avoid narcotic-related SE • Imperative to realize: some combination products may raise drug levels to unacceptable limits (Ex- tylenol in Norco added to a PRN tylenol tablet) • Vicodin (hydrocodone 5 mg.: acetaminophen 500 mg) • Perococet (oxycodone hydrochloride 4.5 mg; acetaminophen 325 mg)

Scabies

• A contagious skin disease caused by mite infestations that burrowed into outer skin layers • Itching is defined as "unbearable" • Transmitted by close (hand-to-hand) contact or infested bedding, very contagious • Manifested by curved or linear ridges in skin • Examine skin between fingers & on palms • Infestation is confirmed by scraping of a lesion & examining under a microscope (to look for mite) • Scabicides include Kwell, Acticin, Ascabiol • Launder clothes & personal items w/ hot water/detergent • Close contacts should be monitored for infestation

General Anesthesia

• A reversible loss of consciousness • can be accomplished by: inhalation, IV or a combination of the two. • CNS is depressed, resulting in analgesia, amnesia & unconsciousness, with loss of muscle tone/reflexes • Older pts. w/heart, lung, kidney, liver issues may not be cleared for general anesthesia

Skin Cancer

• Actinic keratoses • Basal cell carcinoma • Squamous cell carcinoma Melanomas—highly metastatic; survival depends on early diagnosis/tx

Safe & Effective Care Environment

• Advanced directive • Pt can explain what surgery is being done & why. • If not consistent w/ documentation, notify surgeon & request speak to pt • Use at least 2 identifiers (not room/ bed number) • Ensure pt is wearing proper identification. • Ensure pt not asked to sign consent or any other legal document after preop drugs given. • After pt has received preop drugs, keep siderails up & bed in low position. • Communicate to surgeon & anesthesia personnel any physical or lab change that may alter pt's response to drugs, anesthesia, or surgery.

History and data collection

• Age • Drugs/substance use/herbal • Medical hx., including cardiac and pulmonary, DM • Previous surgery/anesthesia • Blood donations • D/C planning

Safe and Effective Care Environment

• All entering OR wearing proper OR attire for role. • Observe for & inform OR personnel of any break in sterile field or sterile technique. • Use two identifiers to check identity of pt. • Report to surgeon any discrepancy between what type of surgery the pt says is going to be performed & what informed consent form indicates. • Review preop checklist & informed consent forms. • Highlight any known allergies. • Apply grounding pads as needed. • Complete any needed skin prep. • accurate "sharps" & sponge count w/ scrub nurse tech

Intraoperative Nursing Interventions

• Allow patients to retain eyeglasses, dentures, & hearing aids until anesthesia has begun. • Use small pillow under pt's head if head & neck are normally bent slightly forward. • Lift pts into position to prevent shearing on fragile skin. • Position arthritic & artificial joints carefully to prevent postop pain & discomfort from strain on those joints. • Pad bony prominences to prevent pressure sores. • Provide extra padding for patients w/↓peripheral circluation. • Warming devices to prevent hypothermia. • Cover pt's head & feet. • Warm IV & irrigation fluids • Follow strict aseptic technique. • Carefully monitor I&O, including blood loss.

Venous Thromboembolism VTE

• Always assess for VTE before surgery. • Sudden swelling in 1 leg • Dull ache in calf area that becomes worse w/ ambulation. • Careful assessment & timely intervention prevent fatal PE • Surgical-related VTE can be prevented • All pts evaluated for VTE risk • VTE prophylaxis: devices & drug therapy

Insufflation

• An important part of MIS for abd surgery, pelvic surgery, & surgery in some other body cavity areas is injecting gas or air into the cavity before surgery to separate organs & improve visualization. • This may contribute to complications & patient discomfort. • 1 factor considered when deciding whether to perform a procedure by traditional "open" surgery or by endoscopy.

Problems that increase the surgical risk or increase the risk for complications after surgery: Medical History

• Ask about cardiac disease b/c complications from anesthesia occur more often in pts w/ cardiac problems • A patient w/ a hx of rheumatic heart disease- antibiotics before surgery. • Cardiac problems that ↑ surgical risks • coronary artery disease, angina, myocardial infarction (MI) w/in 6 mos before surgery, heart failure, hypertension, & dysrhythmias. • Impair pt's ability to withstand hemodynamic changes & alter response to anesthesia. • Risk for an MI during surgery is higher in patients w/ heart problems. • Patients w/ cardiac disease - perioperative therapy w/ beta-blocking drugs

Physiological Integrity

• Ask pt when was last time had anything to eat or drink. • Assess pt for tachycardia, ↑ end-tidal CO2 level, & ↑ body temp as indicators of malignant hyperthermia. • Maintain malignant hyperthermia cart. • Monitor pt's airway, LOC, O2 sat, ECG, & VS during & immediately after moderate sedation. • Assess all skin areas & document findings before transferring pt to PACU

Preventing Infection Interventions

• Assess risk for infection • identify pts w/ pre-existing health problems- diabetes mellitus, immune deficiency, obesity, & kidney disease. • Perform skin prep, protect pt's exposure to cross-contamination, keep traffic to a minimum, & administer antimicrobial prophylaxis. • Sterile surgical technique & use protective drapes, skin closures, & dressings to ↓complications & promote wound healing. • When a wound is already infected or at ↑ risk for infection- antibiotics used directly in wound by irrigation or by placing drug directly into surgical site before wound closure.

Wound Management of Pressure Ulcers 2/4

• Assess the ulcer for presence of necrotic tissue and amount of exudates. • Assess and document the condition of the skin surrounding the pressure ulcer in terms of color, temperature, texture, moisture, and appearance. • Remove or trim loose bits of tissue (may be done by a certified wound care specialist, physical therapist, advanced practice nurse, or other as specified by the agency and the state's nurse practice act).

Pressure Ulcers

• At risk d/t positoning during surgery, prolonged contact with damp surgical linens, & contact w/ unpadded surfaces. • increases length of stay & complications • address early!

Respiratory System Complications of Surgery

• Atelectasis • Pneumonia • PE (pulmonary embolism) • Laryngeal edema • Ventilator dependence • Pulmonary edema

Atropic Dermatitis (eczema) Description

• Atopy family (with asthma & allergic rhinitis) • Chronic w/ relapse/ remit • Extreme itching, inflamed, reddened, swollen skin • Psychological distress d/t itching & self-image • Difficulty sleeping d/t itching

Assessing GI System

• BS in 4 quadrants & umbilicus. • If NG suction-turn off to hear • active BS = peristalsis • absence of BS does not = no peristalsis. • best indicator = passage of flatus or stool. • Abd cramping + distention = trapped, nonmoving gas—not peristalsis.

Skin Care: Fungal Infections

• Bathe daily with an antibacterial soap • Remove any pustules/crust gently (do not squeeze pustules) • Apply warm compresses twice a day to furuncles or areas of cellulitis • May apply astringent compresses (Burrow's solution) to viral lesions • Avoid constricting garments that may irritate • Avoid excessive moisture, occlusive dressings • Position for optimal air circulation

Intraoperative Autologous Blood Salvage & Transfusion

• Be aware of cell-processing method to be used. • Make sure that collection containers labeled for pt. • Assist w/ sterile setup as necessary. • Assist w/ processing & reinfusing procedures as needed. • Document transfusion process. • Monitor pt's VS during transfusion procedure.

Assessment for Skin Infection

• Because most skin infections are contagious, take precautions to prevent the spread of infection • Culture purulent material; obtain blood cultures • Obtain Tzanck's smear and viral culture (test for Herpes virus) • Test for fungal infections with potassium hydroxide (KOH)

General Anesthesia Stage 2 (Excitement, Delirium)

• Begins w/ loss of consciousness & ends w/ relaxation, regular breathing, & loss of eyelid reflex. • Avoid auditory & physical stimuli. • Sensory stimuli can contribute to pt's response. • Patient may have irregular breathing, increased muscle tone, & involuntary movement of extremities • Protect the extremities. -Safety measures prevent injury. • Laryngospasm or vomiting may occur. • Assist anesthesiologist/ CRNA w/ suctioning • Adequate suctioning of vomitus- prevent aspiration. • Patient is susceptible to external stimuli. • Stay with patient. • Staying with the patient is emotionally supportive.

Pain Transmission

• Begins when nociceptor receptors are stimulated • Nociceptor stimulation (somatic/ visceral) • Pain impulse for either are sent to spinal cord by way of: -- • *A∂ fibers*— signal sharp, well-defined pain signals -- • *C fibers*— conduct dull, poorly localized pain signals

Pain Transmission

• Begins when nociceptor receptors are stimulated • Nociceptor stimulation (somatic/visceral) • Pain impulse for either are sent to spinal cord by way of: -- • *A∂ fibers*— signal sharp, well-defined pain signals -- • *C fibers*— conduct dull, poorly localized pain signals

POTENTIAL EFFECTS OF HERBS

• Black cohosh- Bradycardia, hypotension, joint pains • Bloodroot- Bradycardia, dysrhythmia, dizziness, impaired vision, intense thirst • Boneset- Liver toxicity, mental changes, respiratory problems • Coltsfoot- Fever, liver toxicity • Dandelion- Interactions with diuretics, increased concentration of lithium or potassium • Ephedra- Headache, dizziness, insomnia, tachycardia, hypertension, anxiety, irritability, dry mouth • Feverfew- Interference with blood-clotting mechanisms

Opioid Antagonists

• Block opioid activity • Compete for access to opioid receptors • Reverse symptoms of addiction, toxicity & overdose • Naxalone (Narcan) • Also used to diagnose overdose

Opioid Antagonists

• Block opioid activity • Compete for access to opioid receptors • Reverse symptoms of addiction, toxicity & overdose • Naxalone (Narcan) may be used to reverse symptoms of opioid addiction, toxicity & overdose • Also used to diagnose overdose

Problems that increase the surgical risk or increase the risk for complications after surgery: Blood donation

• Blood donation for surgery can be made by pt (autologous donations) a few weeks just before surgery. • eliminates transfusion reactions & ↓ risk for acquiring bloodborne disease. • can donate own blood up to 5 weeks before surgery if infection free, hemoglobin level > 11 g/dL (110 g/L), & have physician's prescription. • Patients w/ cardiac disease -additional clearance from cardiologist before making autologous donation. • Physician may prescribe supplemental Fe before 1st donation. • Autologous donations can be made as often as q3d • Usually a total of 2-4 units are donated. • Last donation cannot be made w/in 72 hrs before surgery. • Family & friends donate (directed blood donation) if blood types compatible

Intestinal Preparation

• Bowel or intestinal preparations performed to prevent injury to colon & ↓ # of intestinal bacteria • Enema/ laxative (Golytely)

System Assessment

• Cardiovascular • Respiratory • Renal/urinary • Neuro • Musculoskeletal • Nutritional • Psychosocial

Preventing Injury Interventions

• Care modified to reduce complications r/t spec. positions. • lithotomy position- leg swelling, pain in legs or back, ↓foot pulses, ↓sensation from compression of peroneal nerve. • Ensure proper padding & position changes at regular intervals. • continually check pulses & cap. refill below pressure pts. • Throughout the surgery, prevents obstruction of circulation, resp, or nerve conduction caused by tight straps, poorly placed pads & pillows, or position of bed.

Role of the Nurse: Nonopioid Analgesics

• Careful monitoring of pt's condition & providing education • Thorough assessment for hypersensitivity, bleeding disorders • Thorough assessment for gastric ulcers, severe renal/hepatic disease • Obtain lab tests on renal and liver function • Pain assessment • Monitor for SE • Monitor for ototoxicity

Herpes Zoster/Shingles

• Caused by reactivation of dormant varicella-zoster virus in clients who have had chickenpox • Multiple lesions occur in a segmental distribution on skin area innervated by infected nerve • Eruptions can last several weeks ○ Discomfort varies form minor irritation & itching to severe, deep pain ○ Postherpetic neuralgia can occur after lesions have resolved • Vaccine: (Zostavax subcut.) Given to pts. >60 who do not currently have shingles...however FDA has approved it for >50 • Shingles is contagious to people who have not previously had chickenpox and have not been vaccinated against the disease Airborne precautions: use of gloves & good handwashing is sufficient to prevent spread

Assess for & report other clinical conditions that may need to be evaluated by a physician or advanced practice nurse before proceeding with the surgical plans, including:

• Change in mental status • Vomiting • Rash • Recent administration of an anticoagulant drug

Kidney/Urinary Assessment

• Changes r/t cellular debris, ↓kidney blood flow • Myoglobin released from damaged muscle, circulates to kidney • Assess kidney function by monitoring BUN, serum creatinine, serum sodium levels. • Urine color, odor, presence of particles/foam • ↓urine output

Migraine Headaches

• Characterized by throbbing/pulsating pain • Sometimes preceded by an aura • Goal: to stop migraines/prevent occurrence • Triggers: --• MSG, red wine, perfumes, food additives, caffeine, chocolate, aspartame, pickled foods, beer, wine, aged cheeses • Drug therapy is most effective if begun before migraine has reached a severe level

Physiological Integrity

• Check documentation for procedure performed on 1 of a paired organ/extremity clearly indicates which organ/ extremity is involved. • Ensure dentures & any other personal items removed from pt before transferred to surgical suite.

Skin Assessment Techniques for Patients with Darker Skin Jaundice

• Check for yellow tinge to oral mucous membranes, esp. hard palate. • Examine sclera nearest to iris rather than corners of eye

Older Adults: Consideration for Preoperative Care

• Chronic illness • Malnutrition • Impaired self-care ability • Allergies • Inadequate support systems • Stress from surgery/anesthesia • Cardiopulmonary complications after surgery • Mental status changes • Risk for falls

Problems that increase the surgical risk or increase the risk for complications after surgery: Medical History

• Chronic illnesses • a patient w/ systemic lupus erythematosus- additional drugs to offset stress of surgery. • A patient w/ diabetes - more extensive bowel prep b/c of decreased intestinal motility. • An infection- treated before surgery.

Resuscitation Phase of the Burn Injury Vascular Changes Resulting from Burn Injury

• Circulatory disruption occurs immediately after burn injury • Initially vasoconstriction occurs. • Vasodilation follows • Fluid shift: 3rd spacing or capillary leak syndrome, usually occurs in 1st 12 hrs & can continue 24-36 hrs. • Capillaries become permeable in response to stress • A continuous leak of plasma from vascular space into interstitial space • Loss of blood, fluids & proteins...↓blood vol. & BP • Leakage of fluid & lytes from vascular space continues, causing edema • Fluid shift w/ wt. gain occurs in 1st 12 hrs. & continues for 24-36 hrs.

Preventing Pressure Ulcers: Skin Cleaning

• Clean the skin as soon as possible after soiling occurs and at routine intervals. • Use a mild, heavily fatted soap or gentle commercial cleanser for incontinence. • Use tepid rather than hot water. • In the perineal area, use a disposable cleaning cloth that contains a skin barrier agent. • While cleaning, use the minimum scrubbing force necessary to remove soil. • Gently pat rather than rub the skin dry. • Do not use powders or talcs directly on the perineum. • After cleansing, apply a commercial skin barrier to those areas in frequent contact with urine or feces.

Wound Management of Pressure Ulcers 3/4

• Cleanse the ulcer with saline or a prescribed solution (after diluting it as per manufacturer's directions or prescriber's instructions). • Rinse and dry the ulcer surface. • In collaboration with the certified wound care specialist, select and apply the dressing materials most appropriate for the volume of wound drainage

Evaluate care of preop pt based on identified pt problems. The expected outcomes include that pt:

• States understanding of informed consent & preop procedures • Demonstrates postop exercises & techniques • Has reduced anxiety

Pre-op Client Prep

• Client should remove clothing/wear hospital gown • Valuables should remain with family member or be locked up • Tape rings in place if they can't be removed • Remove all pierced jewelry • Client wears ID band/allergy band Dentures, prosthetic devices, hearing aids, contact lenses, fingernail polish, artificial nails must be removed

Balanced Anesthesia

• Combo of IV drugs & inhalation agents • Combo used to provide hypnosis, amnesia, analgesia, muscle relaxation, & reduced reflexes w/ minimal disturbance of physiologic function

Skin Assessment Techniques for Patients with Darker Skin Inflammation

• Compare affected area w/ nonaffected area for increased warmth. • Examine skin of affected area to determine whether it's shiny or taut or pits w/ pressure. • Compare skin color of affected area w/ same area on opposite side of body. • Palpate affected area & compare it w/ unaffected area to determine whether texture is different (affected area may feel hard or "woody").

Skin Assessment Techniques for Patients with Darker Skin Skin bleeding

• Compare affected area w/ same area on unaffected side for swelling or skin darkening. • If pt has thrombocytopenia, petechiae may be present on oral mucosa or conjunctiva.

Naloxone (Narcan) • Role of the Nurse: Opioid Antagonist Therapy

• Continue careful monitoring of pt's condition • Esp respiratory status • Have resuscitative equipment available

Full-Thickness Wounds

• Damage extends into lower layers of dermis & underlying subQ tissue • Most of epithelial cells at base have been destroyed- wont see pink bumps anymore • Re-epithelialization cannot be major healing process now- can't wait. • Removal of damaged tissue results in a defect that must be filled w/ granulation tissue in order to heal. • Contraction develops in healing process- takes longer, health, lots of air, pressure off the area. *Not a stable process.

Medical Hx that increases Surgical/ Postoperative Risk

• Decreased immunity • Diabetes • Pulmonary disease • Cardiac disease • Hemodynamic instability • Multisystem disease • Coagulation defect or disorder • Anemia • Dehydration • Infection • Hypertension • Hypotension • Any chronic disease

A chest x-ray

• Determines size & shape of heart, lungs, & major vessels • provides evidence of presence of pneumonia or TB. • Provides baseline data in case of complications. • Emergency surgery • results assist in selecting anesthesia.

Purposes of Surgery

• Diagnostic - determines origin and cause of disorder • Curative - resolves health problem by repairing or removing cause • Restorative - improves patient's functional ability • Palliative - relieves symptoms of disease process, but does not cure Cosmetic - alters/enhances personal appearance

Regional or Local Anesthesia Disdvantages

• Difficult to administer to an uncooperative or upset patient • No way to control agent after administration • Absorbs rapidly into blood & causes cardiac depression (hypotension) or overdose • Increased nervous system stimulation (overdose) • Not practical for extensive procedures b/c of amt of drug required to maintain anesthesia

General Anesthesia Balanced Disdvantages

• Drug interactions can occur • Pharmacologic effects on the body may be unpredictable

Mixed opioid agonist-antagonist

• Drugs that occupy one receptor & block (or have no effect) on the other • pentazocine (Talwin) • butorphanol (Stadol) • buprenorphine (Buprenex)

Treatment of Skin Cancer

• Drugs: topical chemo with 5-fluorouracil, systemic chemo agents, interferon • Radiation therapy • Immunotherapy • Surgical management ○ Cryosurgery ○ Curettage/ electrodissection ○ Excision

Nociceptive Pain

• Due to injury to tissues • Sharp, localized (*somatic pain*) or • Dull, throbbing, aching (*visceral pain*) • Usually responds well to conventional pain-relief meds. • nociceptor= activation of receptor nerve endings that receive/ transmit pain signals to CNS

Nociceptive Pain

• Due to injury to tissues • Sharp, localized (somatic pain) or • Dull, throbbing, aching (visceral pain) • Usually responds well to conventional pain-relief meds. • Somatic Pain- sharp, localized sensations • Visceral Pain- generalized dull & internal throbbing/ aching • nociceptor= activation of receptor nerve endings that receive/ transmit pain signals to CNS

Elastic fibers

• Elasticity of skin depends on both amt & quality of _____ , which are scattered among collagen fibers. •major component = elastin.

Psychosocial Integrity

• Encourage pt to express concerns about surgical procedure or its possible outcome. • Communicate pt preferences or fears about anesthesia to anesthesia provider. • Preserve the patient's privacy & dignity by keeping body exposure to a minimum. • Stay w/ pt during induction of anesthesia. • Communicate info about pt's status to waiting family members. • Ensure that pt's advance directives are honored

Role of the Nurse Migraine Headaches

• Encourage pt. to take medication when symptoms occur rather than waiting • Report chest pain, tightness, dyspnea • Encourage food diary • *Seek medical advice before planning to become pregnant* • nonpharmacological pain management: quiet, darkened room, cool cloth to head

Role of the Nurse Migraine Headaches

• Encourage pt. to take medication when symptoms occur rather than waiting • Report chest pain, tightness, dyspnea • Encourage food diary • Seek medical advice before planning to become pregnant • Use nonpharmacological pain management: quiet, darkened room, cool cloth to head)

Bowel Preparations

• Enema is a stressful procedure • Repeated enemas = electrolyte imbalance, fluid volume imbalances, vagal stimulation, & postural (orthostatic) hypotension. • Enemas cause severe anorectal discomfort in pts w/ hemorrhoids. • Some have potent laxatives (polyethylene glycol electrolyte solution [GoLYTELY]) instead of enemas, esp. older patients. • Bowel preps can be exhausting, & must take safety precautions to PREVENT FALLS.

Preventing Pressure Ulcers: Nutrition

• Ensure a fluid intake between 2000 and 3000╯mL/day. • Help the patient maintain an adequate intake of protein and calories.

Preoperative Chart Review

• Ensure all documentation, preoperative procedures, and orders are complete • Check the surgical consent form and others for completeness • Document allergies/reactions • Document height and weight • Ensure results of all lab and diagnostic tests are on the chart • Document and report any abnormal results Report special needs and concerns

National Patient Safety Goals and Informed Consent

• Ensure correct site is selected and wrong site is avoided • Licensed independent practitioner marks site, involving patient if possible • "Time out" procedure adopted by most facilities

Full-thickness wounds

• Entire epidermis & dermis, leaving no skin cells for re-growth, the skin cannot heal on its own, requires grafting • Deep-Full thickness wounds • Extend beyond skin leaving muscle, tendons & bones exposed

Partial-thickness wounds

• Epidermis & varying depths of dermis • Can range from superficial partial-thickness to deep partial- thickness

Skin Assessment Techniques for Patients with Darker Skin Cyanosis

• Examine lips & tongue for gray color. • Examine nail beds, palms, & soles for blue tinge. • Examine conjunctiva for pallor.

Pre-op Teaching For Parents

• Explain what to expect and what is expected • Reinforce any teaching necessary • Purpose of special equipment/procedures • Possible presence during anesthesia induction/recovery

Before surgery, pt is expected to have manageable anxiety as indicated by consistently demonstrating these behaviors:

• Expressing a ↓ level of anxiety • Absence of body language indicators of anxiety • hand wringing • facial tension • restlessness, • dilated pupils • sweating • ↑BP & Pulse

Opioid Agonist: Fentanyl

• Fentanyl transdermal system (Duragesic patch) • Provides longer lasting relief in mod-severe chronic pain • Fentanyl (Lazanda) nasal spray • Fentanyl lozenge (Oralet, Actiq) • Fentanyl tablet (Fentora, Onsolis) • Fentanyl sublingual (Abstral) • Buccal Fentanyl: management of breakthrough cancer pain (given to pts. who already have a tolerance for opioid therapy)

Assess for and report any signs or symptoms of infection, including:

• Fever • Purulent sputum • Dysuria or cloudy, foul-smelling urine • Any red, swollen, draining IV or wound site • Increased white blood cell count

Bacterial Infections

• Folliculitis: superficial infection involving only the upper portion of the follicle • Furuncles: much deeper infection in the follicle (boils) • Cellulitis: generalized infection with either Staph/Strep involving deeper connective tissue • Folliculitis—red, raised rash w/small pustules • Faruncle--boil • Cellulitis • Methicillin-resistant Staphylococcus Aureus (MRSA) • Easily spread to other parts of the body or other people by direct contact with infected skin and by contact with infected articles (shared towels, sheets, athletic equipment) • Skin problems range from mild folliculitis to extensive furuncles • Does not respond to antibacterial soaps or most types of topical and many oral antibiotics

Nonopioid Analgesics

• For fever, inflammation & analgesia • For mild - moderate pain assoc. w/ inflammation • NSAIDs & a few centrally acting drugs- Acetaminophen (Tylenol)

Fungal Infections

• Fungal infections (Dermatophyte infections) can differ in lesion appearance, location, & species of infecting organism • Tinea is used to describe a fungal infection (this term is followed by the location) ◦ Ex. Tinea pedis: fungal infection of foot ◦ Ex. Tinea cruris: fungal infection of groin—jock itch ◦ Ex. Tinea capitis: fungal infection of head ◦ Ex. Tinea corporis: fungal infection of rest of body--ringworm

Fungal Infections

• Fungal infections occur when infecting organism comes onto contact with impaired skin of a susceptible host • Most are spread by direct contact • Tinea capitis/tinea coporis can be transmitted by inanimate objects (combs, hats, pillowcases)

Regional or Local Anesthesia Advantages

• Gag & cough reflexes stay intact • Allows participation and cooperation by the patient • Less disruption of physical & emotional body functions • Decreased chance of sensitivity to the agent • Decreased intraoperative stress

POTENTIAL EFFECTS OF HERBS

• Garlic- Hypotension, blood-clotting inhibition, potentiation of diabetes drugs • Ginseng- Headache, anxiety, insomnia, hypertension, tachycardia, asthma attacks, postmenopausal bleeding • Goldenseal- Vasoconstriction • Hawthorn- Hypotension • Kava- Damage to the eyes, skin, liver, and spinal cord from long-term use

Preoperative Care—Pediatrics

• Geared to child's developmental level • Includes psychosocial & physical prep • If possible a visit to area of care • Videotapes/DVDs may be helpful • Handling of stethoscopes, gowns, masks may be helpful • Assurance that parent will be in attendance if possible

Atropic Dermatitis (eczema) Therapeutic Management

• Good skin hydration • Topical corticosteroids/immunomodulators • Antihistamines • Antibiotics d/t secondary infection

Specific Considerations When Planning Care for the Older Preoperative Patient

• Greater incidence of chronic illness • Greater incidence of malnutrition • More allergies • Increased incidence of impaired self-care abilities • Inadequate support systems • Decreased ability to withstand stress of surgery & anesthesia • Increased risk for cardiopulmonary complications after surgery • Risk for a change in mental status when admitted (related to unfamiliar surroundings, change in routine, drugs) • Increased risk for a fall & resultant injury

Robotic technology

• Gynecologic, urologic, & cardiovascular procedures • Consists of several components: console, surgical arm cart, & video cart. • Inserts required instruments & positions articulating arms • Breaks scrub & performs surgery while sitting at console. • A 3-D view of patient's anatomy provides surgeon w/ precise control & dexterity. • Vision cart holds monitors, cameras, & recorder equip.

Cardiovascular Complications of Surgery

• HTN • Hypotension • Hypovolemic shock • Dysrhythmias • Venous thromboembolism (VTE), DVT -Heart failure -Sepsis -Disseminated intravascular coagulation (DIC) -Anemia -Anaphylaxis

The Patient on Arrival Med Surg Unit After Discharge from PACU Surgical Incision Site

• How is it dressed? • Review amt of drainage on dressing immediately. • any bleeding or drainage under pt? • Any drains present? • Are drains set properly (compressed if should be, not kinked, pt not lying on them)? • How much drainage is present in drainage container?

As part of the cardiopulmonary assessment, take and record vital signs; report:

• Hypotension or hypertension • Heart rate less than 60 or more than 120 beats/min • Irregular heart rate • Chest pain • Shortness of breath or dyspnea • Tachypnea • Pulse oximetry reading of less than 94%

Neuromuscular Complications of Surgery

• Hypothermia • Hyperthermia • Nerve damage and paralysis • Joint contractures

Assessing Fluid, Electrolyte, and Acid-Base Balance

• I&O • Hydration status- color & moisture of mucous membranes, turgor, • IV fluids monitored • ABGs- acid-base balance -NG tubes/ vomit- loss of acid = alkalosis

Wound Management of Pressure Ulcers 4/4

• If possible, avoid positioning the patient on the pressure ulcer. • Re-position at least every 1 to 2 hours to prevent ulcer extension or generation of additional pressure ulcers. • Use prescribed pressure-relieving and pressure-reducing devices and techniques as described in Chart 27-2.

Wound Management of Pressure Ulcers 1/4

• If ulcer is covered, remove old dressings/coverings daily (unless the dressing type is to remain in place until it loosens naturally). • Measure wound size at greatest length and width using a disposable paper tape measure or, for asymmetric ulcers, by tracing the wound onto a piece of plastic film of sheeting (plastic template) at least daily. • Compare all subsequent measurements against the initial measurement.

Assessing Respiratory System

• Immediately assess patent airway & adequate gas exchange -- -talking- not a good indicator • document type & delivery device of O2 & Liters • continuously monitor pulse ox: > 95% or pt's baseline • rate, pattern, depth of breathing -- <10= anesthetic or opioid induced rep depression -- rapid/ shallow= shock, cardiac problems, increased metabolic rate, pain • all lung fields for breath sounds & chest wall movement -- accessory muscle use -- sternal retraction -- diaphragmatic breating -- anesthetic effect, airway obstuction, paralysis = hypoxia • check lungs at least q4h during 1st 24h after surgery • Assess risks: older, smoker, lung disease, obese

Assess for and report signs or symptoms that could contraindicate surgery, including:

• Increased prothrombin time (PT), international normalized ratio (INR), or activated partial thromboplastin time (aPTT) • Hypokalemia or hyperkalemia • Patient report of possible pregnancy or positive pregnancy test

anesthesia "negative sensation."

• Induced state of partial/ total loss of sensation, occurring w/ or w/o loss of consciousness. • Block nerve impulse transmission, suppress reflexes, promote muscle relaxation, achieve a controlled LOC • Separate anesthesia record for documentation. • most metabolized by liver & excreted by kidneys. • Liver/ kidney impairment ↑ effects & risk for toxicity. • Interactions between anesthetics & other drugs

Administration of General Anesthesia

• Inhalation: intake & excretion of anesthetic gas/vapor to the lungs through mask • IV injection: barbiturates, ketamine, and propofol through the blood • Balanced: combo of inhalation + IV injection • Adjuncts to general anesthetic agents: hypnotics, opioid analgesics, neuromuscular blocking agents

Physical Assessment

• Inspect entire body (back of head, back of ears, nares, bony prominences, areas prone to moisture) • general skin appearance • malnutrition - looks can be deceiving • overall cleanliness- IMPORTANT to skin breakdown • loss of mobility/ROM- has PT been ordered

Skin assessment

• Insurers deny coverage when pts develop skin breakdown/ pressure ulcers during perioperative period. • Assess pt's skin for signs of breakdown, open sores, areas that receive excessive pressure during surgical procedure, & document • Communicate to circulating nurse so precautions can be taken to prevent injury.

Acute pain

• Intense • Occurring over a brief period of time - from injury until tissue repair

Acute pain

• Intense • Occurring over a brief period of time - from injury until tissue repair

The Patient on Arrival Med Surg Unit After Discharge from PACU Airway

• Is it patent? • Is neck in proper alignment?

The Patient on Arrival Med Surg Unit After Discharge from PACU Mental Status

• Is pt awake, able to be aroused, oriented, & aware? • Does pt respond to verbal stimuli?

Emergency Care of the Patient with Malignant Hyperthermia (2/2)

• Lavage stomach, bladder, rectum, & open body cavities w/ sterile iced NS • Insert NG tube & rectal tube. • Monitor core temp- effectiveness, avoid hypothermia. • Monitor cardiac rhythm ECG for dysrhythmias. • Insert a Foley catheter to monitor urine output. • Treat dysrhythmias that don't resolve on correction of hyperthermia & hyperkalemia w/ antidysrhythmic agents other than Ca channel blockers. • Monitor urine for blood or myoglobin. • Administer IV fluids to maintain urine output > 2mL/kg/hr. ---If urine output falls < 2mL/kg/hr- osmotic or loop • Transfer patient to ICU when stable. • Continue to monitor pt's temp, ECG, ABGs, electrolytes, creatine kinase, coagulation studies, & serum & urine myoglobin levels until normal for 24h. • Instruct pt & family about testing for MH risk.

Prior Surgical Experiences that increase Surgical/ Postoperative Risk

• Less-than-optimal emotional reaction • Anesthesia reactions or complications • Postoperative complications

The anesthesia provider monitors the patient during surgery by assessing & monitoring:

• Level of anesthesia (by using a peripheral nerve stimulator or EEG bispectral analysis) • Cardiopulmonary function (ECG monitoring, pulse ox., end-tidal CO2 monitoring, ABGs, & hemodynamic monitoring via arterial lines & /or pulmonary artery catheters) • Capnography (monitors ventilation for non-intubated pts) • Vital signs • I & O

Laboratory Assessment

• UA • Blood type/crossmatch • CBC or Hct/Hgb. • Clotting studies • Electrolyte levels • Serum creatinine level • Pregnancy tests, Chest x-ray, ECG

POTENTIAL EFFECTS OF HERBS

• Licorice- Hyperkalemia, hypernatremia • Lobelia- Hearing and vision problems • Motherwort- Increased anticoagulation • Nettle- Hypokalemia • Senna- Potentiation of digoxin • St. John's wort- Antidepressant, photosensitivity • Valerian root- Mild sedative or tranquilizer effect, hepatotoxicity

Family History that increases Surgical/ Postoperative Risk

• Malignant hyperthermia • Cancer • Bleeding disorder

Nutritional Status Obese Patient

• Malnourished d/t imbalanced diet. • ↑ risk for poor wound healing d/t excessive adipose (fatty) tissue. • Fatty tissue- few blood vessels, little collagen, & ↓ nutrients, all needed for wound healing. • Stresses heart & ↓lung volumes • Pts need ↑ doses of drugs & may retain longer after surgery.

Health History that increases Surgical/ Postoperative Risk

• Malnutrition or obesity • Drug, tobacco, alcohol, or illicit substance use or abuse • Altered coping ability

Nonpharmacological Techniques for Pain Management

• May be used alone or as an adjunct to pharmacotherapy • May allow for lower doses/fewer SE • relax muscles, strengthen coping abilities, generally improve quality of life --• Massage --• Heat/cold packs --• Relaxation therapy --• Art/music therapy --• Imagery --• Therapeutic or physical touch --• TENS (transcutaneous electrical nerve stimulation)

Treatment For Opioid Dependence

• Methadone maintenance initiated for opioid dependence • Does not cure but avoids withdrawal symptoms • Oral methadone- opioid that does not cause euphoria • Tx may continue for many mos & yrs

General Anesthesia Balanced Advantages

• Minimal disturbance to physiologic function • Minimal side effects • Can be used with older and high-risk patients

Role of the Nurse: Opioid Therapy

• Monitor VS, esp resp & pulse oximetry • Monitor for orthostatic hypotension • Assess bowel sounds, monitor BMs • Monitor for pruritus • Assess for changes in LOC/ neuro status • Assess for urinary retention • Monitor for pain relief & PCA effectiveness

Role of the Nurse: Opioid Therapy

• Monitor VS, esp resp & pulse oximetry • Monitor for orthostatic hypotension • Assess bowel sounds, monitor BMs • Monitor for pruritus • Assess for changes in LOC/ neuro status • Assess for urinary retention • Monitor for pain relief and PCA effectiveness

Role of the Nurse: Nonopioid Analgesics

• Monitor pt's condition & provide education • Assess for *hypersensitivity*, *bleeding disorders*, *gastric ulcers*, *severe renal/hepatic disease* • Lab tests: renal & liver function • Pain assessment • Monitor for SE, *ototoxicity*

General Anesthesia Inhalation Advantages

• Most controllable method • Induction and reversal accomplished w/ pulmonary ventilation • Few side effects

Malignant hyperthermia (MH)

• Most sensitive indication - unexpected ↑ in end-tidal CO2 level w/ a ↓ in O2 saturation. • Another early indication is sinus tachycardia. • Extremely ↑ temperature, as high as 111.2° F - late sign • Survival depends on early dx & actions of surgical team. • Time is crucial when MH is diagnosed. • Dantrolene sodium- a skeletal muscle relaxant • For known history or risk, can be tx before, during, & after surgery w/ dantrolene prophylaxis

General Anesthesia Intravenous Disdvantages

• Must be metabolized & excreted from body for complete reversal • Contraindicated in presence of liver or kidney disease • Increased cardiac & respiratory depression • Retained by fat cells

General Anesthesia Inhalation Disdvantages

• Must be used in combination with other agents for painful or prolonged procedures • Limited muscle relaxant effects • Postoperative nausea & shivering common

The Patient on Arrival Med Surg Unit After Discharge from PACU Other Tubes

• NG or intestinal tube? • What is color, consistency, & amt of drainage? • Is suction applied to tube if ordered? Is setting correct? • Foley catheter? • Is Foley draining properly? • What is color, clarity, & volume of urine output?

Implementing Dietary Restrictions

• NPO 6-8 hrs. before surgery • NPO ↓the risk of aspiration • Failure to adhere = cancellation of surgery or ↑ risk for aspiration

Opioids (Opiate)

• Natural or synthetic morphine-like substances responsible for reducing moderate to severe pain • "narcotic" which means -produce s/sxs of analgesia & CNS depression • Exert their actions (analgesia) by interacting with 4 major types of receptors in the body.

Type of Surgical Procedures (Planned) that increase Surgical/ Postoperative Risk

• Neck, oral, or facial procedures (airway complications) • Chest or high abdominal procedures (pulmonary complications) • Abdominal surgery (paralytic ileus, venous thromboembolism)

Substance P

• Neurotransmitter • Passes on pain message from spinal cord to next set of neurotransmitters • A critical factor as to whether pain signal reaches brain

Endogenous Opioids

• Neurotransmitters produced by CNS that can modify sensory information, interrupting pain transmission (can affect pain message carried by Substance P) • May be affected by other neurotransmitters *Endorphins, dynorphins, enkephalins*

Cryothermia Anesthesia Disdvantages

• No way to control depth of anesthesia • Not used in long or extensive procedures • May not be appropriate for an anxious patient

Problems that increase the surgical risk or increase the risk for complications after surgery: Older patients

• Normal aging process decreases immune system functioning & delays wound healing. • Frequency of chronic illness • Reductions of muscle mass & body water increase risk for dehydration

Burns

• Nursing Interventions: ○ Strict I&O ○ Strict weights daily ○ Monitor electrolytes until WNL ○ Monitor child's temperature, maintain a neutral room temp. ○ Administer tetanus vaccine if needed Perform dressing changes, med. application as ordered

Burns Nursing Interventions

• Nursing interventions include fluid resuscitation, wound care, prevention of infection, restoration of function. • Burn infections are treated w/antibiotics specific to the causative agent. • If invasive burn damage occurs, surgery may be necessary

Patients at greater risk for VTE:

• Obese • Older than 40 years • cancer • ↓ mobility or are immobile • spinal cord injury • Hx of VTE, PE, varicose veins, or edema • taking oral contraceptives • Smoke • ↓ cardiac output • hip fx/ total hip/ total knee surgery

Patient at Risk for Venous Thromboembolism (VTE)

• Obese patients • Age 40 or older • History of cancer • Decreased mobility or immobile • Spinal cord injury • History of VTE, PE, varicose veins, edema • Oral contraceptives • Smoking • History of decreased cardiac output • Hip fracture, total hip/knee surgery

Physical Assessment

• Obtain baseline VS • Focus on problem areas identified by client's hx. on all body systems affected by the surgical procedure • Report any abnormal assessment findings to the surgeon/anesthesiologist

Maintaining hydration assists in healing and decreases the risk of development of additional wounds

• Often once IV is DC'd, hydration is forgotten • Offering pts. fluids on a regular basis assists in maintaining hydration

Minimally invasive surgery (MIS)

• Once used only for minor procedures & joint surgery • preferred technique for cholecystectomy, cardiac surgery, splenectomy, & spinal surgery. • being used for cancer surgeries, such as removal of lung lobe (lobectomy) or entire lung (pneumonectomy) & colectomy. • involves making 1+ small incisions & placing endoscope into opening. An endoscope is a tube that allows viewing & manipulation of internal body areas. Some also magnify view.

Nutrition

• One of the most understated/undervalued components • Proteins are necessary for the matrix that forms tissue granulation • Vits. (A, D, E, K, C, and B) necessary for wound healing • Comprehensive nutritional assessment should be done for nonhealing/chronic wounds/debilitated pt. w/pressure ulcer

Chronic Pain

• Over 6 months duration • Interferes w/ ADLs • Usually results in feelings of helplessness/hopelessness

Psychosocial Integrity

• Pace interview to match learning needs & style of individual pt. • Encourage pt to express feelings regarding surgical procedure or possible outcome. • Explain & provide written information for all diagnostic procedures, restrictions, & follow-up care to pt & family. • Communicate to surgeon & anesthesia personnel concerns/ fears pt has.

Preventing Pressure Ulcers: Positioning

• Pad contact surfaces with foam, silicon gel, air pads, or other pressure-relieving pads. • Do not keep the head of the bed elevated above 30 degrees to prevent shearing. • Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or her. • When positioning a patient on his or her side, do not position directly on the trochanter. • Reposition an immobile patient at least every 2 hours while in bed and at least every 1 hour while sitting in a chair. • Do not place a rubber ring or donut under the patient's sacral area. • When moving an immobile patient from a bed to another surface, use a designated slide board well lubricated with talc or use a mechanical lift. • Place pillows or foam wedges between two bony surfaces. • Keep the patient's skin directly off plastic surfaces. • Keep the patient's heels off the bed surface using bed pillow under ankles.

Prevention of Peroneal Nerve Complications (Foot Drop)

• Pad knees and ankles. • Maintain minimal external rotation of the hips. • Support the lower extremities. • Be careful not to overtighten leg straps.

Prevention of Brachial Plexus Complications (Paralysis, Loss of Sensation in Arm and Shoulder)

• Pad the elbow if tucked at the side. • Avoid excessive abduction. • Secure arm firmly on a padded armboard, positioned at shoulder level, & extended < 90 degrees.

GI Complications of Surgery

• Paralytic ileus (few/ absent BS, distended abd, abd discomfort, vomiting, no flatus or stool) • GI ulcers and bleeding

Burns Pathopyhsiology

• Pathophysiology follows same path as w/adults • At first, vasodilatation. Then leaking of water, electrolytes and protein into the vasculature, causing edema

Pharmacologic Interruption of Pain Transmission

• Pharmacological target areas • Peripheral level- NSAIDs • CNS level- opioids

Prevention of Joint Complications (Stiffness, Pain, Inflammation, Limited Motion)

• Place a pillow or foam padding under bony prominences. • Maintain pt's extremities in good anatomical alignment. • Slightly flex joints & support w/ pillows, trochanter rolls, or pads.

Prevention of Medial or Ulnar Nerve Complications (Hand Weakness, Claw Hand)

• Place the safety strap above or below the nerve locations.

Prevention of Tibial Nerve Complications (Loss of Sensation on the Plantar Surface of the Foot)

• Place the safety strap above the ankle. • Do not place equipment on lower extremities. • Urge OR personnel to avoid leaning on pt's lower ext.

Preparing the Client

• Possible placement of tubes, drains & vascular access devices • Teaching about postop procedures & exercises: • Breathing exercises, incentive spirometry, coughing & splinting • Leg exercises/procedures, anti-embolism stockings, pneumatic compression devices, ambulation, ROM exercises

Anxiety Interventions

• Preoperative teaching • Encouraging communication • Promoting rest • Using distraction • Teaching/including family and significant others

The patient with a pressure ulcer is expected to demonstrate progress to complete wound healing and not develop new pressure ulcers. Indicators include:

• Presence of granulation, re-epithelialization, and scar tissue formation • Decreased wound size • Absence of new pressure ulcers

Skin Complications of Surgery

• Pressure ulcers • Wound infection • Wound dehiscence • Wound evisceration • Skin rashes/contact allergies

Problems that increase the surgical risk or increase the risk for complications after surgery: Previous surgical procedures and anesthesia

• Previous experiences-may↑ anxiety • Ask about experience w/ anesthesia & allergies. • Family medical history & problems with anesthetics • Povidoneiodine (e.g., Betadine) for skin cleansing contains same allergens found in shellfish. Pts allergic to shellfish may have reaction to povidone-iodine. • Patient w/ allergy to bananas & other fruits may also have a latex sensitivity or allergy.

Circulating Nurse

• Protects the patient's privacy • Ensures the patient's safety • Monitors traffic in room • Assesses amt of urine & blood loss • Reports findings to surgeon & anesthesia provider • Ensures that surgical team maintain sterile technique & a sterile field • Anticipates pt's & surgical team's needs, providing supplies & equipment • Communicates info about the pt's status to family members during long or unique procedures • Documents care, events, interventions, & findings

Preventing Hypoventilation Evaluation: Outcomes

• Pt safely anesthetized w/o complications • NO injury r/t surgical positioning or equipment • Free of skin/ tissue contamination during surgery • Free of skin tears, bruises, redness, abrasion, or maceration • Maintains normal body temp

Changes Resulting From Burn Injury

• Pulmonary • Cardiac • GI (Curling's ulcer) • Metabolic • Immunologic

Problems that increase the surgical risk or increase the risk for complications after surgery: Medical History

• Pulmonary complications: older patients, pts w/ chronic resp problems, smokers d/t smoking- or age-related lung changes • ↑ chest rigidity & loss of lung elasticity reduce anesthetic excretion. • Smoking ↑ blood level of carboxyhemoglobin (carbon monoxide on oxygen-binding sites of the hemoglobin molecule), which ↓ O2 delivery to organs. • Action of cilia in pulmonary mucous membranes ↓ = retained secretions & predisposes to infection (pneumonia) & atelectasis (collapse of alveoli). • Atelectasis ↓ gas exchange & causes intolerance of anesthesia.

Complications of local or regional anesthesia

• R/T patient sensitivity to anesthetic (anaphylaxis), incorrect delivery technique, systemic absorption, & overdose. • Observe CNS stimulation followed by CNS & cardiac depression- signs of a systemic toxic reaction. • Assess for restlessness, excitement, incoherent speech, headache, blurred vision, metallic taste, nausea, vomiting, tremors, seizures, & increased pulse, respirations, & BP

General Anesthesia Intravenous Advantages

• Rapid and pleasant induction • Low incidence of postoperative nausea & vomiting • Requires little equipment

Opioid Receptors

• Receptors: mu, kappa, delta , nociceptin • For pain management, mu & kappa receptors are most important • delta connected w/ emotional & affective components of pain experience

Preoperative Medication

• Reduce anxiety • Promote relaxation • Reduce pharyngeal secretions • Prevent laryngospasm • Inhibit gastric secretions • Decrease amount of anesthetic needed for induction/maintenance of anesthesia

Increased use of "bloodless surgery" & minimally invasive surgery provides alternatives for patients w/ religious or medical restrictions to blood transfusions.

• Reduce need for transfusion during & after surgery. • Techniques used • limiting blood samples before surgery • Stimulating patient's own RBC production w/ epoetin alpha (Epogen, Procrit) before, during, & after surgery. • Supplemental Fe, folic acid, vitamin B12, & vitamin C before surgery to help RBC formation. • Newer equipment & surgical techniques = ↓ blood loss • recycling blood suctioned during surgery & immediately transfusing it back into patient. • Assess, monitor, teach, & support patient during bloodless surgery process.

Cryothermia Anesthesia Advantages

• Reflexes remain intact • Decreases chance of adverse reactions • Decreased intraoperative stress

Surgical procedures that are site-specific, such as left, right, or bilateral

• Require patient identification before surgery. • Site is marked by licensed independent practitioner & involves patient. • Practitioner is accountable & should be present during procedure. • Before starting procedure, facilities use "time-out" to verify correct site.

Hypnosis/Hypnoanesthesia Anesthesia Disadvantages

• Requires patient cooperation • Requires special training

Opioid Agonists Adverse Effects:

• Resp. depression • Sedation • n/v • Physical/psychological dependence • Urinary retention • Constipation

Opioid Agonists Adverse Effects:

• Resp. depression • Sedation • n/v • Physical/psychological dependence • Urinary retention • Constipation

Neuropathic Pain

• Results from injury to nerves • Burning, shooting, numbing • More difficult to manage w/conventional pain meds.

Bacterial Infection Pathophysiology

• S. aures & group A beta-hemolytic streptococci ○ Normal flora of skin • Nonbullous impetigo follows skin trauma or secondary bacterial infection • Both types of impetigo from toxin from S. aures • Folliculitis from occulsions of hair follicle • Cellulitis- localized infection usually from skin trauma • Staphylococcal scaled skin syndrome- infection with S. aureus that produces a toxin- causes exfoliation ○ Abrupt onset ○ Diffuse erythema ○ Skin tenderness

• Pathophysiology of Burn Injury

• Severity determined by how much of BSA is involved & depth of burn injury • Superficial thickness • Partial thickness • Full thickness • Deep full thickness • Degree of tiss. damage r/t what agent caused burn, temp. of heat source & how long skin exposed. • Differences in skin thickness in different areas of body can affect burn depth

Skin Assessment

• Size & depth of injury • % of total BSA affected • "Rule of nines" using multiples of 9% of total BSA

Gerontologic Considerations

• Skin tears • Thinning of the skin especially along lower legs and forearms • Senile purpura: type of hemorrhage under the skin due to thinner, more fragile bl. vess. Often occurs along with skin tears A greater number of comorbidities results in prolonged wound healing(poor cardiac output, ht. failure, DM, PVD, poor nutrition

Medication: Co-Morbidities for Decreased Tissue Repair

• Steroids decreases the effectiveness of the immune system by delaying white blood cell migration and fibroblasts, thus impacting the inflammatory phase of wound healing • Steroid use delays collagen synthesis, the regeneration of bl. vess. and epithelialization necessary for building healthy tissue • Methotrexate (chemo. drug) decreases the effectiveness of the immune system by bone marrow suppression and anemia

Emergency Care of the Patient with Malignant Hyperthermia (1/2)

• Stop all inhalation anesthetic agents & succinylcholine. • If endotracheal tube not already in place, intubate immediately. • Ventilate pt w/ 100% O2, using highest possible flow rate. • Administer dantrolene sodium (Dantrium) IV 2-3 mg/ kg. • Administer 100% O2. • If possible, terminate surgery. If not, continue using anesthetic agents that do not trigger MH • Assess ABGs & serum chemistries for metabolic acidosis & hyperkalemia. • metabolic acidosis- sodium bicarbonate IV. • hyperkalemia -10u reg insulin in 50mL 50% dextrose IV. • Use active cooling techniques: • Iced saline (0.9% NaCl) IV 15mL/kg q15min PRN • Cooling blanket over the torso. • Pack bags of ice around pt's axillae, groin, neck, & head.

Stress: Co-Morbidity

• Stress causes a release of glucocorticoids, reducing the production of cytokines, an essential component to the inflammatory process; thus inflammation becomes suppressed • Wound healing begins with inflammation, so if inflammation is delayed so is wound healing • Minimizing the pts stress level will promote the progression of wound healing (pain causes stress too)

Snoring or stridor

• Stridor: high-pitched crowing sounds • Occur w/ airway obstruction resulting from tracheal/ laryngeal spasm or edema, mucus in airway, blockage of airway

Pain Assessment

• Subjective experience for pts • Numerical scales & surveys assist in assessment & standardize perceptions • Effective pharmacotherapy depends on it • Assessment of degree of pain • Determining/understanding underlying disorders causing pain

Pain Assessment

• Subjective experience for pts • Numerical scales & surveys assist in assessment & standardize perceptions • Effective pharmacotherapy depends on it • Assessment of degree of pain • Determining/understanding underlying disorders causing the pain

Prevention of Radial Nerve Complications (Wrist Drop)

• Support the wrist with padding. • Be careful not to overtighten wrist straps.

Nutritional status Malnutrition

• Surgery ↑ metabolic rate & depletes K+, vitamin C, & B vitamins, all needed for wound healing & blood clotting. • ↓ serum protein levels slow recovery. • (-) nitrogen balance- from depleted protein stores. • ↑ risk for skin breakdown, delayed wound healing, possible dehiscence or evisceration, dehydration, & sepsis.

Physiological Integrity

• Teach pts about dietary restrictions & preop preparations. • Teach pt specific interventions to perform after surgery to prevent complications (incision splinting, deep-breathing exercises, ROM exercises)

Smoking: Co-Morbidity for Decreased Tissue Repair

• The association between cig. smoking and delayed wound healing is a common phenomenon • Nicotine, carbon monoxide and hydrogen cyanide impact the normal rate of healing The overall effect is slower healing

Infection

• The process of organisms invading and destroying cells Wounds can be: contaminated, colonized and infected

Skin Preparation

• The skin- 1st line of defense against infection; a break in the barrier ↑ risk for infection • Shower using antiseptic solution • Shaving as a procedure before surgery is viewed as controversial (institution specific)

surgical scrub

• The surgeon, all assistants, & scrub nurse perform after putting on a mask & before putting on sterile gown & gloves. • Does not make hands & forearms sterile. • When performed correctly, it reduces # of organisms from hands, arms, & nails.

Migraine Headaches

• Throbbing/pulsating pain • Sometimes preceded by an aura • *Goal*: stop/ prevent migraines • *Triggers*: MSG, red wine, perfumes, food additives, caffeine, chocolate, aspartame, pickled foods, beer, wine, aged cheeses • Drug therapy most effective if begun *before* migraine gets severe

Problems that increase the surgical risk or increase the risk for complications after surgery: Drugs and substance use

• Tobacco use increases risk for pulmonary complications • Excessive alcohol & illicit substance use can alter patient's responses to anesthesia & pain medication. • Withdrawal of alcohol before surgery may lead to delirium tremens. • Prescription & OTC drugs may also affect how the patient reacts to the operative experience. • Adverse effects can occur with use of some herbs

Opioid Dependence

• Tolerance & physical dependence develops very quickly • When attempting to d/c, withdrawal symptoms can be very uncomfortable • To feel "normal" must continue w/ opioid • Withdrawal symptoms last from 7d - yrs • Potential for physical & psychological dependence

Opioid Dependence

• Tolerance & physical dependence develops very quickly • When attempting to d/c, withdrawal symptoms can be very uncomfortable • To feel "normal" they must continue with opioid • Withdrawal symptoms can last from 7d - years • Potential for physical and psychological dependence

Anti-migraine Agents

• Triptans: sumatriptan (Imitrex) --• Serotonin agonists --• Act by constricting certain intracranial vessels • Ergot alkaloids --• Serotonin agonists --• Interact w/adrenergic, dopaminergic, and serotonin receptors --• Used for those who are unresponsive to triptans

Herpes Simplex Virus

• Type 1 herpes simplex virus: classic recurring cold sore • Type 2 herpes simplex virus: genital herpes • After 1st infection, virus dormant in a nerve ganglia; no symptoms • Recurrence of HSV infection is triggered by stressors • Virus can be spread by direct contact between an actively infected person and susceptible host • Auto-inoculation can occur: the transfer of either viral type from one part of the body to another • Herpetic whitlow—a form of herpes simplex infection occurring on fingertips of medical personnel who have come in contact w/ viral or resp. secretions, can easily be spread to pts.

The most common tests include:

• Urinalysis • Blood type & screen • CBC or Hgb level & Hct • Clotting studies (PT, INR, aPTT, platelet count) • Electrolyte levels • Serum creatinine & BUN levels • Depending on female patient's age & nature of procedure- pregnancy test

Kidney/Urinary Complications of Surgery

• Urinary tract infection • Acute urinary retention • Electrolyte imbalances • Acute kidney injury (AKI) • Stone formation

Nonopioid Analgesics

• Used for fever, inflammation & analgesia • Used for mild - moderate pain assoc. w/ inflammation • Include NSAIDs, acetaminophen, & a few centrally acting drugs such as Acetaminophen (Tylenol)

Tension Headaches

• Usually self-limiting • Caused in general by stress, muscles of head/neck become tight • Can be effectively tx'd. w/OTC analgesics (ASA, ibuprofen, acetaminophen)

The Patient on Arrival Med Surg Unit After Discharge from PACU Breathing

• What is quality & pattern of breathing? • What is resp rate & depth? • Is the pt receiving O2? what setting? What's the pulse ox result?

The Patient on Arrival Med Surg Unit After Discharge from PACU Intravenous Fluids

• What type of solution is infusing & w/ what additives? • How much solution was remaining on arrival? • How much solution infused in transport time from PACU? • At what rate is infusion supposed to be set?

Candida albicans

• Yeast infection: common superficial fungal infection of skin/mucous membranes • Risk factors: immunosuppression, long-term antibiotics, DM, obesity • Prevention: keeping skin-folds dry/clean, turning/positioning to enhance airflow, meticulous skin care and when infection present...use of topical antifungals • Inspect skin folds daily, change pt. gowns whenever they become moist

Cuticle

• a layer of keratin at nail fold • attaches the nail plate to soft tissue of nail fold. • The nail body is translucent, & pinkish hue reflects a rich blood supply beneath nail surface. Nail growth & appearance are often altered during systemic disease or serious illness.

General anesthesia

• a reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of CNS • Single or a combination of agents. • Depresses CNS, resulting in analgesia, amnesia, & unconsciousness, w/ loss of muscle tone & reflexes. • Pt is unconscious & unaware. • Used most often in surgery of head, neck, upper torso, & abdomen, or when pts cannot cooperate.

Opioid agonist drugs:

• activate mu & kappa receptors • Fentanyl (Sublimase), codeine, hydromorphone (Dilaudid), morphine • Produce analgesia • Many important effects other than analgesia: -- • Suppresses cough reflex -- • Slows the motility of the GI tract for severe diarrhea -- • Sedation (may be therapeutic or a determined SE) -- • Euphoria, intense relaxation (abuse potential)

Opioid agonist drugs:

• activate mu & kappa receptors • Fentanyl (Sublimase), codeine, hydromorphone (Dilaudid), morphine • Produce analgesia • Many important effects other than analgesia: -- • Suppresses cough reflex -- • Slows the motility of the GI tract for severe diarrhea -- • Sedation (may be therapeutic or a determined SE) -- • Euphoria, intense relaxation (abuse potential)

Keratinocytes

• actual skin cells • Produces Keratin • 28-45 days to move fr basement membrane to skin surface

burn patient transport criteria

• adults have greater than 5% full thickness burn • children 14 years old and under • partial or full thickness burns of face, eyes, ears, hands, feet or genitalia • circumferential burns • chemical or high voltage electrical burns • smoke inhalation injury w/ external burns

Kidney function

• affects excretion of drugs & waste products, incl. anesthetic & analgesic agents. • Kidney function ↓ = fluid & electrolyte balance altered, esp. in older pts. • Ask about urinary frequency, dysuria, nocturia, difficulty starting urine flow, & oliguria. • Appearance & odor of urine. • Usual fluid intake & degree of continence. • Kidney or urinary problems- consult w/ physician about further workup. • Kidney impairment ↓ excretion of drugs & anesthetic agents. • Scopolamine (Buscopan ), morphine, other opioids, & barbiturates often cause confusion, disorientation, apprehension, & restlessness

systemic signs of infection

• altered LOC • changes in VS (tachycardia, tachypnea, hypotension, temp instability) • increased fluid for maintenance of urine output • hemodynamic instability • oliguria • GI dysfunction • hyperglycemia • thrombocytopenia • high or low WBC count • metabolic acidosis • hypoxemia

Malignant hyperthermia (MH)

• an acute, life-threatening complication of certain drugs used for general anesthesia. • Begins in skeletal muscle exposed to specific agents, causing ↑ Ca levels in muscle cells & ↑ muscle metabolism. • Serum Ca & K levels are ↑, as is metabolic rate, leading to acidosis, cardiac dysrhythmias, & ↑ body temp • Clinical features reflect ↑ muscle Ca level & greatly ↑ body metabolism. • Manifestations include tachycardia, dysrhythmias, muscle rigidity (especially of the jaw & upper chest), hypotension, tachypnea, skin mottling, cyanosis, & myoglobinuria (presence of muscle proteins in the urine).

Unrecognized hypoventilation

• anesthesia-induced complication. • Failure to exchange gases adequately = cardiac arrest, permanent brain damage, death. • Monitoring standards • end-tidal CO2 monitor- confirm CO2 in pt's expired gas • breathing system disconnect monitor- detect break in breathing circuit equipment.

hydrotherapy

• application of water for treatment • common w/ wounds is showers but not baths

eccrine sweat glands

• arise from epithelial cells • found over entire body • odorless • important for temperature regulation.

Nails

• fingers & toes have cosmetic value & are useful for grasping & scraping. • extensions of keratin-producing epidermal layers of skin. • The white, crescent-shaped portion of nail at lower end of nail plate is called lunula & is location of the nail matrix, where nail keratin is formed & nail growth begins • Fingernail replacement requires 3 to 4 months. • Toenail replacement may take up to 12 months.

Assessing Cardiovascular System

• assess VS & heart sounds q15 min until stable • use automated BP cuffs & cardiac monitoring • report BP changes 25% difference than baseline before surgery • Decreased BP & pulse pressure & abnormal heart sounds = possible cardiac depression, fluid volume deficit, shock, hemorrhage, effects of drugs • bradycardia= anesthesia effect or hypothermia • older adults increased risk d/t changes in hypothalamus, low levels body fat, coolness of OR • increased pulse= hemorrhage, shock, pain • cardiac monitoring continues until discharge • compare distal pulses, capillary refill, sensation of extremities • pulse deficit = dysrhythmia

Assessing Kidney/Urinary System

• assess for urinary retention (inspection, palpation, percussion) or bladder scanner • output should be equal to total intake for 24hr period • report output < 30mL/hr= hypovolemia/ renal comp. • intervention: straight cath

Moisture content of skin

• assessed by noting thickness & consistency of secretions.

nursing priority with wound care

• assessing wound, providing wound care, & preventing infection

Factors that predispose to wound contamination & surgical site infection

• bacteria in hair follicles • disruption of normal protective mechanisms of skin, & nicks in & skin. • Shaving creates potential for infection. • Electrical clippers & depilatories for hair removal • If shaving necessary, use disposable sterile supplies & aseptic principles immediately before start of procedure.

Health standards require that all members of surgical team and & support personnel in surgical suite:

• be free of communicable diseases. • No one who has an open wound, cold, or any infection should participate in surgery.

rehabilitative phase of burn injury

• begins w/ wound closure & ends when pt returns to their highest level of functioning • provide psychosocial support for pt & family • lots of home care teaching • provide resources

Opioid antagonist drugs:

• block mu & kappa receptors • Naloxone (Narcan)

Local or regional anesthesia

• briefly disrupts sensory nerve impulse transmission from body area/ region. • Motor function may/ may not be affected. •Pt remains conscious & can follow instructions. • Gag & cough reflexes intact- risk for aspiration ↓ . • Often supplemented w/ sedatives, opioid analgesics, or hypnotics to ↓ anxiety & ↑comfort.

surgical scrub

• broad-spectrum, surgical antimicrobial solution • Plain or antimicrobial soap is used for washing hands immediately before • Vigorous rubbing from fingertips to elbow. • continues for 3-5 min, followed by rinse. • During rinse, hands & arms positioned so that water runs off, rather than up or down, arms • After personnel enter OR w/ hands held higher than elbows & thoroughly dry hands & forearms w/ sterile towel. • assisted into sterile gown ("gowning") & puts on sterile gloves ("gloving"). • alcohol-based agents may/ may not require use of water. • • wash & dry hands w/ soap & water before applying to hands & forearms, rubbing thoroughly until dry.

Intubation complications

• broken or injured teeth & caps • swollen lip • vocal cord trauma • May be difficult d/t anatomic variance or disease presence • Improper neck extension during intubation = injury. • Surgeon should be in OR during intubation in case tracheostomy needed • ET placement causes tracheal irritation & edema • sore throat after surgery.

-priority nursing intervention in the acute phase is to assess:

• cardiovascular & resp. systems -to maintain these systems & to identify or prevent complications

8-24 hours

• clean wound every _____ & apply antimicrobial agents each time

biosynthetic wound dressings

• combination of biosynthetic & synthetic material • biobrane commonly used & made of nylon fabric w/ silicone & collagen

Respiratory status

• considers age, smoking history (incl. exposure to secondhand smoke), & any chronic illness. • Observe patient's posture; respiratory rate, rhythm, & depth; overall respiratory effort; & lung expansion. • Document any clubbing of the fingertips or cyanosis. • Auscultate lungs for abnormal breath sounds (crackles, wheezes, rubs).

Cardiovascular status

• critical to assess- 30% of surgery-related deaths. • Check for HTN- often undiagnosed, & can affect response to surgery. Cardiac assessment includes: • listening to heart sounds- rate, regularity, & abnormalities. • Ask if pt has ever had a venous thromboembolism (VTE). • Examine pt's hands & feet for temp, color, peripheral pulses, cap refill, & edema. Report any problems (absent peripheral pulses, pitting edema, cardiac symptoms, chest pain, SOB, dyspnea) to physician

sebaceous glands

• distributed over entire skin surface except for palms & soles of feet. • Produce sebum which is bacteriostatic, lubricates skin & reduces water loss.

Epidermis

• does not have own blood supply • receives nutrients by diffusion from dermal layer

needs to be addressed before discharge

• early pt assessment • financial assessment • evaluation of family resources • weekly discharge planning meeting • psychological referral • patient and family teaching (home care) • designation of principal learners • development of teaching plan • training for wound care • rehab referral • home assessment (on site visit) • medical equipment • public health nursing referral • evaluation of community resources • visit to referral agency • re-entry programs for school or work environment • long term care placement • environmental interventions • auditory testing • speech therapy • prosthetic rehab

Skin Prep

• embarrassing or uncomfortable, esp if site is in a sensitive or private body area. • Provide warm, comfortable, & private environment during procedure. • 1st step to ↓ risk for surgical site infection

Pneumatic compression devices

• enhance venous blood flow by providing intermittent periods of compression on legs. • Measure pt's legs, & order correct size. • Place boots on pt's legs, & then set & check compression pressures (35-55 mm Hg). • Antiembolism stockings may be worn with boots & may ↓ some uncomfortable sensations (itching, sweating, heat)

Musculoskeletal status

• problems w/ positioning during & after surgery. • patients w/ arthritis- able to assume surgical positions; have discomfort after surgery from prolonged joint immobilization. • Shape & length of neck & shape of chest cavity- interfere w/ resp & cardiac function or require special positioning during surgery. • Hx of joint replacement • exact location of prostheses. • During surgery- electrocautery pads, not placed on/ near area of prosthesis.

Keratin

• produced by keratinocytes • makes horny layer waterproof

Incentive spirometry

• promote complete lung expansion • Pt must be able to seal lips tightly around mouthpiece, inhale spontaneously, & hold breath for 3 - 5 sec. for effective lung expansion. • Seeing a light move up a column or a bellows expanding reinforces & motivates pt to continue performance.

Melanin

• protects skin from damage by UV light. • People w dark skin less likely to develop sunburn • Freckles, birthmarks, & age spots caused by patches of in skin. •UV light stimulates its production •production ↑ in areas that have endocrine changes or inflammation.

DX tests to monitor nut. status:

• protein levels, albumin & pre-albumin (pre-albumin is most sensitive when monitoring TPN) • Albumin: 3.5-5.0 g/dL • Pre-Albumin: 15-36 mg/dL • Pre-albumin helps to determine whether ↓ in albumin is due to dietary intake or some organic issue independent of dietary intake.

ground substance

• protein lubricant formed by fibroblasts • surrounds dermal cells & fibers • contributes to skin's normal suppleness & turgor.

Antiembolism stockings (TED or Jobst stockings) & elastic (Ace) wraps

• provide graduated compression of legs, starting at end of foot & ankle. • Measure leg length & circumference before ordering • Elastic wraps when legs too large/ small for stockings. • Removed 1-3 x day for 30 min for skin inspection & care.

Overdose of anesthetic

• pt's metabolism & drug elimination slower than expected • more likely in older pts or those w/ liver/ kidney problems. • Other drugs (antihypertensives) also alter metabolism- interactions between anesthetic & pt's regular drugs. • Accurate info about pt's ht, wt, & medical hx, esp. liver & kidney function, vital in determining anesthetic type & dosage. • Death during surgery more often r/t pre-existing health problems than anesthetic overdose.

Readiness for discharge from PACU

• recovery score 9-10 • stable VS • normal body temp • no overt bleeding • return of gag, cough & swallow reflexes • ability to take liquids • adequate urine output

early grafting

• reduces time patients are at risk for infection & sepsis

begins at admission

• rehabilitation efforts • discharge planning

debridement

• removal of eschar & other cellular debris

for large area burns and autografting

• repeat removal of skin from same donor site w/ time allowed inbetween • meshing split thickness skin grafts to allow small graft to cover a larger area, slower healing

Scrub Nurses/ persons

• set up sterile table, drape pt, hand sterile supplies, sterile equipment, & instruments to surgeon & assistant. • anticipate which instruments & types of sutures surgeon will need. • maintains accurate count of sponges, sharps, & instruments & amts of irrigation fluid & drugs used.

basal cells

• skin cells capable of cell division • located close to basement membrane & continuously divide to make new cells

heterografts or xenografts

• skin obtained from another species • commonly used is pig skin

Discharge planning

• starts before surgery. • Assess pt's home environment, self-care capabilities, support systems, & anticipate postop needs before surgery. • Older & dependent adults-transportation referrals to & from physician's office or surgical setting. • Home care nurse- monitor recovery & provide instructions. • Pts w/ few support systems-follow-up care at home. • Some patients- planned direct admission to rehab center for PT after surgery, esp. joint replacement. • Shortened hospital stays- adequate d/c planning to achieve desired outcomes after surgery.

Mobility

• stimulates intestinal motility • enhances lung expansion • mobilizes secretions • promotes venous return • prevents joint rigidity • relieves pressure.

acute phase of burn injury

• this phase begins about 36-48 hours after injury & lasts until wound closure is complete

Opioid Agonist: *Fentanyl*

• transdermal system (Duragesic patch) • Provides longer lasting relief in mod-severe chronic pain • nasal spray (Lazanda) • lozenge (Oralet, Actiq) • tablet (Fentora, Onsolis) • sublingual (Abstral) • Buccal: management of breakthrough cancer pain (given to pts. who already have a tolerance for opioid therapy)

Best Practice for Postoperative Hand-off Report

• type & extent of surgical procedure • Type of anesthesia & time pt. was under anesthesia • Tolerance of anesthesia & surgical procedure • Allergies (especially latex/drugs) & any health problems or pathologic conditions • O2 saturation, Status of VS & core body temp • Type & amount of IV fluids & drugs administered • Estimated blood loss (EBL) & I&O • Intraoperative complications • Preop drugs & pt. response • Primary language, sensory impairments, communication difficulties • Anxiety level before anesthesia • Preoperative/intraoperative resp functions • Location/type of incisions, dressings, catheters, tubes, drains, or packing • Relevant intraoperative positioning & Joint or limb immobility while in OR

nursing priorities with minimizing infection

• use aseptic technique, provide a safe environment, monitor for early detection of infection

biologic dressing

• used for temporary wound coverage & closure • can be skin or membranes obtained from others • promotes healing & prepares for grafting

neuromuscular blocking drugs

• used in patients receiving mechanical ventilation to ↓ O2 consumption • atracurium

Dressing and Drains

•Assess all dressings/drains/casts/ace drsgs. immediately post-op •Assess for drainage, bleeding (usually q 15-30 min. PACU) •Upon return to floor, q VS assessment or prn •Each assessment, monitor for drainage & record amt, color, consistency & odor •If drainage present, mark site & monitor for progression •Check underneath dressing •Monitor for circulation/ sensation

Psychosocial Assessment Coping Ability

•Assess coping mechanisms used by pt under similar situations •Ask open-ended questions about pt's feelings about entire surgical experience. Factors that influence coping •age; previous surgical or sickrole experiences; & emotional & physical signs of fear, anxiety, or discomfort.

Nasogastric Tube Drainage

•Assess drained material q8h. or q shift •Normal NG drainage is yellowish-green •Red drainage- new blood •Brown liquid- old blood •Do not move/irrigate NG after gastric surgery w/o order from surgeon

Fluid, Electrolyte & Acid-Base Balance Assessment

•Assess skin for hydration status •Assess input (IV fluid, type of IV fluid) •Assess output (NG tube, urine, wound drainage) •Assess acid-base balance (NG tube, vomitus, ABG results)

Nurse Interventions Following Conscious Sedation

•Assessment of airway •LOC •Oxygen saturation •ECG status •VS q 15-30 min.

Risk for Infection Interventions

•Auto-contamination of burn wound from client's own normal flora •Cross-contamination of burn wound from external environment •Drug Therapy •Isolation therapy •Secondary prevention/early detection •Surgical management to remove infected burned tissue

Laboratory Assessment

•Before surgery -baseline data about pt's health & predict potential complications •preadmission testing (PAT) - 24h - 28 days before surgery •Test results usually valid unless a change in pt's condition warrants repeated testing or pt is taking drugs that can alter lab values (warfarin [Coumadin], aspirin, diuretics). •Some facilities have time limits for tests, esp. pregnancy testing or any that would require altering surgical plan. •Choice of lab testing before surgery varies & depends on pt's age, medical history, & type of anesthesia planned

Fluid Re-Mobilization

•Begins about 24 hrs. after injury when capillary leak stops & lose permeability •Fluid shifts from interstitial to intravascular space & edema is ↓ •Bl. vol. ↑ = increased bl. flow & diuresis (↑urine output, ↓specific gravity) •Body wt. returns to normal as edema ↓ •Hypokalemia & Hyponatremia occur

Acute Phase of Burn Injury

•Begins about 36-48 hrs. after injury & lasts until wound closure is complete •Care directed toward continued assessment & maintenance of all systems & healing processes •Burn wound sepsis is a serious complication of burn injury •Infection is leading cause of death during this phase

Postoperative Period

•Begins with completion of surgery & transfer to PACU, ambulatory care unit, or ICU

Acute Pain Intervention

•Better pain relief w/ a combo of pain relieving interventions: -• ice -• positioning -• massage -• relaxation techniques -• diversion •Pt. who has optimal pain control- better able to cooperate w/ therapies/exercises

Local Anesthesia

•Briefly disrupts sensory nerve impulse transmission from specific body area/region •Delivered topically and by local infiltration •Patient remains conscious, able to follow instructions, cough & gag reflex remains intact

• Surgical Scrubbing

•Broad-spectrum, surgical antimicrobial solution •Vigorous rubbing that creates friction used from fingertips to elbow •Scrub continues for 3 to 5 min

Management of evisceration

•CALL FOR HELP: instruct person to get surgeon or RRT •stay w/ pt. •cover wound w/ nonadherent dressing pre-moistened w/ warmed NS (if unavailable moisten sterile gauze/towels in irrigation tray w/ sterile saline) •DO NOT attempt to reinsert protruding organ/viscera •While caring for wound, note pt. response & assess for shock •Place pt. in supine position w/ hips & knees bent •Raise head of bed 15-20° •Take VS & document •Provide support/reassurance •Continue assessing q5-10min until surgeon arrives •Keep dressings moist by adding warmed sterile saline •When surgeon arrives, report •Document incident

Other Complications From General Anesthesia--Anesthesia Overdose

•Can occur when metabolism/drug elimination are slower than expected •Occurs in pts. who are older or have liver/kidney problems •Complications can develop when anesthetics interact with pts. regular meds.

Gastrointestinal Assessment

•Changes in GI function expected •↓blood flow & sympathetic stimulation during early phase cause reduced GI motility, paralytic ileus, abd. distention •GI bleeding •Initiate precautions for Curling's Ulcer—cimetidine (Tagament) a Histamine 2 blocker

Resuscitation: Early Phase of Burn Injury

•Continues for 24-46 hrs. •Goals of management: • Secure airway • Support circulation—fl. replacement • Prevent infection • Maintain body temp • Provide emotional support

Emergency Care of the Patient with Surgical Wound Evisceration

•Cover w/ non-adherent dressing (saline sterile dressing) •Notify surgeon •Do not attempt to reinsert protruding organ or viscera •Pt. in supine position w/ hips/knees bent •VS ASAP •Keep dressings moist •When surgeon arrives fully document (time of incident, your actions, your assessments)

Full Thickness Burn

•Destruction of entire epidermis & dermis •Skin does NOT re-grow

Injuries to the Respiratory System

•Direct airway injury (table 26-3, p. 474) •Changes in resp. pattern •Carbon monoxide poisoning •"cherry red color" •Thermal injury •edema •Smoke poisoning •Pulmonary fluid overload •External factors

Acute Pain; Chronic Pain

•Drug therapy -Opioids •Complementary & alternative therapy •Environmental changes for client comfort/sleep •Early surgical excision under anesthesia to ↓ pain from daily debridement at bedside or during hydrotherapy

Cardiovascular Assessment

•VS (report BP that is out of range from pt's norms) •Heart sounds •Cardiac monitoring •Peripheral vascular assessment •Monitor for VTE

Psychosocial Assessment Anxiety/ Fear

•Extent of reactions varies- type of surgery, perceived effects of surgery & potential outcome, & pt's personality. •Threat to life, body image, self-esteem, self-concept, lifestyle. •Fear death, pain, helplessness, change in role or work status, diagnosis of life-threatening conditions, possible disabling or crippling effects •Affects ability to learn, cope, & cooperate w/ teaching & operative procedures. •Influences amt & type of anesthetic needed & may slow recovery. •Severe preop anxiety appears to ↑ degree of pain Signs of anxiety •anger, crying, restlessness, profuse sweating, increased pulse rate, palpitations, sleeplessness, diarrhea, & urinary frequency

•Drug Therapy

•Give opioids w/ caution in PACU •When drugs for pain used in PACU, usually given in small IV amts.

Cardiovascular Assessment

•Hypovolemic shock common cause of death in early phase in pts w/ serious injuries • VS • Cardiac status, esp. in cases of electrical burn injuries -ECG changes

Moderate sedation (conscious sedation)

•IV delivery of sedative, hypnotic, & opioid drugs to reduce LOC but allow pt to maintain patent airway & respond to verbal commands. •Amnesia action- short. •Most common drugs; etomidate, diazepam, midazolam, fentanyl, alfentanil, propofol, morphine sulfate. •Used for endoscopy, cardiac catheterization, closed fracture reduction, cardioversion, other short procedures

Best Practice in Postoperative Skin Care

•Improve perfusion to wound to promote healing •Conserve pt's energy •Place pt. on safety program to prevent falls •Use strict aseptic technique in caring for breaks in integument •Maintain pt's psychosocial health •Protect fragile skin

Malignant Hyperthermia (MH) Clinical Features

•Increased muscle calcium levels, potassium & greatly increased metabolism leads to acidosis •S/Sxs: Tachycardia (early sign), hypotension, cyanosis(increased CO2 & decreased O2), muscle rigidity, tachypnea and myoglobinuria •Most sensitive indication is unexpected rise in the end-tidal CO2 level w/decrease in O2 sat. •Late sign is extremely elevated temp. as high as 111.2 F •Dantrolen sodium, a muscle relaxant is drug of choice along with other interventions.

Assessment Specifics for Pain

•Increased pulse/BP/resp •Profuse diaphoresis •Restlessness •Confusion (in older adults) •Wincing, moaning, crying •Assess for pain on 0-10 pain scale •Consider culture, roles, lifestyles

anesthesia

•Induced state of partial or total loss of sensation, occurring with/without LOC •Used to block nerve impulse transmission, suppress reflexes, promote muscle relaxation

Wound Care Management

•Interventions for debridement (removal of exudate & necrotic tissue) include: -Mechanical debridement BID by hydrotherapy through tub/shower water tx -Enzymatic debridement by autolysis or application of enzyme agents, such as collagenase (Santyl)

Neurologic System Cerebral functioning

•LOC, lethargy, restlessness, irritability, purposeful movements •all pts who received general anesthesia

Regional Anesthesia

•Local anesthesia, blocks multiple peripheral nerves in specific body region. •Used when general anesthesia cannot be used Types: •field block •nerve block •spinal anesthesia •epidural anesthesia

Fluid, Electrolyte and Acid-Base Balance

•Loss of fluid during procedure, type & amt. of fluid/blood given affect F&E balance after surgery, NPO status •Na, Cl, K & Ca imbalances result from procedure •Older/debilitated pts. & children may be affected more often with F&E imbalances

Nasogastric Tube Drainage

•May be inserted during surgery to decompress/drain stomach •promote GI rest •allow lower GI tract to heal •provide enteral feeding route •monitor gastric bleeding •prevent intestinal obstruction

Nursing Care During Wound Dehiscence

•May follow forceful coughing, vomiting, straining or when not splinting surgical incision •Calm patient •Apply sterile saline (nonadherent) dressing to wound •VS •Notify surgeon •Instruct pt. to bend knees, avoid coughing

Constipation

•May occur after surgery as result of anesthesia, analgesia (opioids), decreased activity, decreased oral intake •Assessment: Abdominal q shift/prn, inspection, auscultation, palpation, percussion •Monitor BMs (record last BM) & stay accurate/up-to-date •Mild laxative, stool softeners, enemas, ↑ dietary fiber

Assessment of Overmedication

•Monitor VS, esp. BP/resp rate & LOC •Complications include: resp. depression, hypotension, n/v, constipation •Opioid antagonist: naloxone (Narcan) - reverse effects of opioid depression •VS will be taken upon arrival to floor & then q 15-30 min. until pt. becomes stable

Nasogastric Tubes

•Most common: Salem tube, a double-lumen tube w/ air vent to keep tube from grabbing intestinal mucosa •Less common: Levin tube, a single-lumen tube w/ no vent •To promote drainage, suction (usually low) is applied to NG tube

Gastrointestinal System

•Nausea & vomiting common following surgery •Assess for return of peristalsis, if abd. surgery •Peristalsis delayed b/c of long anesthesia time, amount of bowel handling during surgery & opioid analgesic use •Abd. surgery- decreased peristalsis for at least 24 hrs.

Skin Assessment

•Normal wound healing •2-3 wks appears healed; is not complete up to 2 yrs, until scar is strengthened •Ineffective wound healing: most often between 5th -10th days after surgery

Management of Burn Injury

•Obtain time & place of injury •Obtain source & cause of injury •Obtain details regarding how burn occurred & what transpired until help arrived •Obtain health hx. including pre-existing conditions, ht.,wt. & age

Minimally invasive surgery

•Only for minor procedures & joint surgery. •Cholecystectomy, cardiac surgery, splenectomy, spinal surgery & some cancer surgeries. •Lobectomy, pneumonectomy, colectomy. •It reduces surgery time, smaller incisions, reduced blood loss, faster recovery time, less pain

Phases of wound healing

◦ Inflammatory phase ◦ Fibroblastic, or connective tissue repair phase ◦ Maturation or remodeling phase (up to a year) ◦ See page 433, table 25-1

Post-op Pain Control After Return to Floor

•Opioid analgesics - either scheduled or on-demand: -•Morphine •hydromorphone (Dilaudid) •ketorolac (Toradol) •meperidine(Demerol) •codeine, oxycodone w/aspirin(Percodan) •oxycodone w/acetaminophen(Percocet) •Hydrocodone (Lortab) •w/ acetaminophen (Norco) •IV Pain Medication •PCA pump (morphine, meperidine, hydromorphone) -•Usually 24-48 hrs. post-op •"Around-the-clock" administration more effective than "on demand" •Epidural analgesia -•preservative free morphine (Duramorph) •bupivacaine (Marcaine)

Discomfort Pain Assessment

•Pain assessment is started by PACU nurse •This info r/t floor nurse, who begins own assessment of pain •Is it subjective or objective? •Pain r/t: •Surgical wound •Tissue manipulation •Drains •Positioning during surgery •Pt's experience w/ surgical pain

Respiratory

•Patent airway, adequate gas exchange •Note artificial airway when applicable •Rate, pattern, depth of breathing •Breath sounds •Accessory muscle use •Snoring & stridor •Resp. depression or hypoxia

Penrose Drain

•Penrose drain (single-lumen, soft, open latex tube)—a gravity-type drain •placed into external aspect of incision & drains directly onto dressing &skin around incision.

Assessment Initiated in PACU

•Physical assessment & clinical manifestations •Assess respiration •Examine surgical area for bleeding •Monitor VS •Assess for readiness to D/C once criteria have been met •Pt. will be very sleepy, should waken frequently, deep breathe, cough, watch O2 sats

Environment of the Operating Room

•Preparation of surgical suite, team safety •Layout •Health and hygiene of surgical team •Surgical attire •Surgical scrub

Langerhan's cells

•Present in skin, engulf foreign substances (antigens) that invade body when skin is injured. •These cells alert immune system to presence of invader.

General Anesthesia Complications: Intubation Complications

•Problems may include chipped/broken teeth, swollen lip, injured vocal cord •Tracheal irritation, edema, sore throat •Improper neck extension may cause injury •Unrecognized hypoventilation •Overdose

Resuscitative Vascular Change Results of fluid shift

•Profound imbalance of: • Fluid, electrolytes and acid base • Hyperkalemia • Hyponatremia • Hemoconcentration with hypovolemia • Decreased urine output • Elevated specific gravity

Epidural Anesthesia

•Provided by anesthesia intermittently or by continuous infusion (thru catheter left in place after epidural anesthesia) •Drugs: fentanyl (Sublimaze), preservative-free Morphine(Duramorph), bupivacaine (Marcaine) •Assessment for overmedication include: o Monitor VS o Monitor for resp. depression, hypotension, n/v, constipation

PACU Recovery Room

•Purpose is to provide ongoing evaluation & stabilization of clients to anticipate, prevent & treat complications after surgery. •Is usually located close to surgical suite •The Joint Commission's NPSGs require circulating nurses & anesthesia providers give PACU nurses verbal hand-off reports

Circulating nurses or circulators

•Responsible for coordinating all activities w/in that particular OR. •Sets up OR & supplies including blood products & diagnostic support. •All anticipated equipment gathered & inspected by circulator to make certain safe & functional before surgery •makes up bed with gel pads, safety straps, armboards, heating pads under sheets or disposable warming blankets over pt. •If no holding nurse, assumes responsibilities of that nurse •If a holding nurse, also greet pt & reviews findings w/ holding area nurse.

Stages of General Anesthesia

•Stage 1: analgesia, sedation, relaxation •Stage 2: excitement, delirium •Stage 3: operative anesthesia, surgical anesthesia •Stage 4: danger •Emergence—recovery from anesthesia

Dressing the Burn Wound

•Standard wound dressings •Biologic dressings: -Homograft—human skin -Heterograft—skin from other species -Amniotic membrane -Cultured skin -Artificial skin •Biosynthetic dressings •Synthetic dressings

Malignant Hyperthermia Response to S/Sx's

•Stop administration of the anesthetic agent •Intubate if not already intubated •Ventilate with 100% oxygen •Infuse IV Dantrolene •Use cooling techniques, monitoring body temp •Monitor heart rhythm, intervene as necessary •Monitor protein and urinary output •End surgery ASAP •Pt will be admitted to ICU when stable

Emergency care of malignant hyperthermia

•Stop all inhalation & succinylcholine •intubate immediately & ventilate w/ 100% O2 •administer dantrium •administer 100% O2 •terminate surgery if possible •assess ABGs & chemistries for metabolic acidosis & hyperkalemia •if present -sodium bicarbonate, •if hyperkalemia - regular insulin •active cooling techniques

Members of the Surgical Team

•Surgeon •Surgical assistant •Anesthesiologist •Certified registered nurse anesthetist (CRNA) •Holding area nurse •Circulating nurse •Scrub nurse •Surgical technologist (ORT's) •Operating room technician

Surgical Management Burn Wound

•Surgical excision is done w/in 5 days after injury to excise very thin layers of necrotic burn surface; a bed of healthy dermis or subcut. fat is then reached •For wound covering by autograft, skin from remote unburned area of body is transplanted to cover burn wound

•Drug therapy for infection prevention:

•Tetanus toxoid, tetanus immunoglobulin •Topical antibiotics (Silvadene, Flamazine, Sulfamylon) •Systemic antibiotics

Renal/Urinary System

•The effects of drugs, anesthetic agents, manipulation during surgery can cause urine retention •Assess for bladder distention (palpation, bladder scanner) •Consider other sources of output- sweat, vomit, diarrhea •Report a urine output of < 30 ml/hr •↓urine output could signal hypovolemia •One of most sensitive indicators of vascular volume loss is decreased urine output <30 ml/hr

Cultural Awareness

•The trauma of burn injury often triggers sickle cell crisis in pts who have it & those that carry the trait •The decreased fl., circulation and resp. functions following burn can trigger sickle cell crisis

Circulating nurse

•When pt ready to be moved to OR assists w/ pt transfer, protecting bony areas w/ extra padding. •May assist w/ insert foley catheter, apply grounding pad, test equipment, prep scrub surgical site before pt is draped w/ sterile drapes. •Protects privacy, safety, monitors traffic in room, assesses amount of urine & blood loss, reports findings to surgeon & anesthesia provider, ensures surgical team maintain sterile technique & sterile field, anticipates needs, communicates information about patient's status to family member, documents care events interventions findings. •May record drugs, blood components given. Counts sponges, sharps

Management of dehiscence

•apply a sterile nonadherent/saline dressing •notify surgeon •instruct pt. to bend the knees and avoid coughing •wound is left open and treated

Neurologic System Motor & sensory

•assessment important after epidural or spinal anesthesia •Level of sensation loss: test w/ sharp object

Drugs given through epidural catheter

•fentanyl (Sublimaze) •preservative-free morphine (Duramorph) •bupivacaine (Marcaine)

Hair

•follicles located in dermal layer of skin but actually extensions of epidermal layer •within each follicle, a round column of keratin forms shaft •This keratin is stronger than skin keratin • stressors can alter growth.

signs of fluid overload

•formation of dependent edema •engorged neck veins •rapid, thready pulse •presence of lung crackles or wheezes on auscultation

Movement after surgery

•get the pt. out of bed & ambulating ASAP •if unable to get out of bed, turn at least q2 hrs •ambulation ↓ risk for pulmonary complications, aids circulation

Neurologic System Return of sympathetic nervous system tone

•gradually elevate head & monitor for hypotension

Dermis

•has capillaries & lymph vessels for exchange of O2 & heat •sensory nerves- touch, pressure, pain, itch

Regional anesthesia- epidural anesthesia

•injection of an agent into epidural space •used for anorectal, vaginal, perineal, hip, lower extremity surgeries

Regional anesthesia- spinal anesthesia

•injection of anesthetic into cerebrospinal fluid in subarachnoid space •used for lower abdominal, pelvic, hip, knee surgery

Regional anesthesia- nerve block

•injection of lock anesthetic into or around 1 nerve or group of nerves in involved area •used for limb surgery or to relieve chronic pain

subcutaneous fat (adipose tissue)

•innermost layer of skin, lying over muscle & bone. •cells serve as energy reserve •cells act as heat insulators •absorb shock & protect against injury •distribution varies w/ body area, age, & gender. •Many blood vessels go through fatty layer & extend into dermal layer, forming capillary networks that supply nutrients & remove wastes.

Dermis (corium):

•layer above fat layer •connective tissue that contains NO cells •composed of collagen & elastic fibers that give skin flexibility & strength.

Psychosocial Assessment

•level of anxiety •coping ability •support systems.

Comfort measures

•positioning: turn q2h, use of pillows, joint support, ambulation •massage: gentle or stiff joints/sore back, smooth/gentle strokes (DO NOT massage calves; can loosen clots) •relaxation •diversion: used during acute episodes (i.e. dressing changes)

Teaching plan for the pt./family after surgery

•prevention of infection: HAND WASHING •care & assessment of surgical wound •management of drains or catheters •nutrition therapy: proteins, calories, vitamin C •pain management •drug therapy: proper dose/frequency •progressive increase in activity

Stages of general anesthesia speed of emergence

•recovery from anesthesia depends on type of anesthetic agent, length of time anesthetized, whether reversal agent used. •retching, vomiting, restlessness •Suction equipment must be available to prevent aspiration. •shivering, rigidity, slight cyanosis may occur d/t change in body's temp control. -Provide warm blankets, radiant light, & O2

General anesthesia

•reversible LOC induced by inhibiting neuronal impulses in several areas of CNS. •Depresses CNS resulting in analgesia, amnesia, unconsciousness w/ loss of muscle tone & reflexes. •Patient is unconscious & unaware. •Most often used in surgery of head, neck , upper torso, & abd & pt who cannot cooperate

Regional anesthesia- field block

•series of injections around operative field •used for chest procedures, hernia repair, dental surgery, & some plastic surgery

Scrub Nurse Operating room tech surgical tech certified surgical tech

•set up sterile table, drape patient, hand sterile supplies, sterile equipment, instruments to surgeon. •Knowledge allows to anticipate which instruments & types of sutures which reduces duration of anesthesia for pt. •maintains accurate count of sponges, sharps, instruments & amounts of irrigation fluid & drugs used.

T-tube

•shaped like letter T. •put in place after bile duct surgery to drain bile while duct is healing. •tube drains into bag attached to body.

Neurologic System Motor Function

•simple commands; moving extremities on command, strength of each limb, symmetry of limbs

Holding area nurse

•work in operating suites that have a pre-surgical holding area next to main OR. •Coordinates & manages care •greets patient on arrival •reviews medical record •preoperative check list •verifies operative consent forms signed •documents risk assessment. •Assesses pt's physical & emotional status •gives emotional support •answers questions

Metabolic Changes

•↑ secretions of catecholamines, antidiuretic hormone, aldosterone, cortisol •↑ core body temperature as response to temperature regulation by hypothalamus

Changes of Aging as Surgical Risk Factors Renal/Urinary System

↓ blood flow to kidneys •MonitorI&O Reduced ability to excrete waste •Assess overall hydration ↓ in glomerular filtration rate •Monitor electrolyte status. •Ongoing assessment helps detect fluid & electrolyte imbalances & ↓ renal function. Nocturia common •Assist frequently with toileting needs, esp. at night. •Frequent toileting helps prevent incontinence & falls.

Bacterial Infections Nursing Interventions

○ Administer antibiotics- topical or systemic ○ Soak impetiginous lesions with cool compresses or Burrow solutions to remove crusts before applying ointments ○ Teach family about administration, care of rash, importance of cleanliness, hygiene & keeping nails short & clean ○ Impetigo- remove from school or daycare not necessary unless weeping or widespread ○ Prevent transmission of nosocomial MRSA w/ isolation ○ With scaled skin syndrome- apply soothing ointments as the skin heals, & avoid corticosteroids

Acne Risk Factors

○ Adolescence/ preadolescence ○ Male gender ○ Oily complexion ○ Cushings syndrome/ other disease with increased androgens

Atropic Dermatitis (eczema) Nursing Interventions

○ Avoid hot water ○ Avoid skin / hair products w/ perfumes, dyes, fragrances ○ Bathe BID in warm H20 w/ mild soap ○ Slightly pat dry- dont rub ○ Topical ointments ○ Fragrance-free moisturizer over topical meds multiple x a day § Vaseline/ /generic petrolium ○ Avoid clothing made of synthetic fabrics & wool ○ Cut fingernails & keep clean ○ Prevent from scratching § Bedtime histamines ○ Behavior modification

Atropic Dermatitis (eczema) Risk Factors

○ Family hx dermatitis, allergic rhinitis, asthma ○ Hx of asthma/ allergic rhinitis Food/ environmental allergies

Bacterial Infection Health History

○ Hx of skin disruption: Cut, scrape, insect/ spider bite, body piercing

Acne Health History

○ Oily face/ scalp ○ Acne lesions (& increase before periods) ○ Family hx ○ Medications- corticosteroids, androgens, lithium, phenytoin, isoniazid ○ Hx endocrine d/o

Acne Physical Examination

○ Open & closed comedones ○ Inflammatory papules ○ Pustules ○ Nodules ○ Cysts ○ Hypertrophic scarring ○ Oily skin/hair

Bacterial Infection Risk Factors

○ Poor hygiene ○ CA-MRSA § Turf burns § Towel sharing § Team sports § Daycare or outdoor camps ○ Folliculitis § Prolonged contact with contaminated water § Maceration § A moist environment § Use of emollient products

Atropic Dermatitis (eczema) Laboratory & Diagnostic Tests

○ Serum Ig E levels ↑ Skin prick allergy testing: for food / environmental allergy

Therapeutic Management of: Acne Vulgaris

○ Skin cleansing ○ Medications- benzoyl peroxide, salicylic acid, retinoids, topical/ oral antibiotics ○ Isotretinoin (Accutane) - severe cases

Atropic Dermatitis (eczema) Health History

○ Wiggling, scratching ○ Dry skin ○ Scratch marks ○ Disrupted sleep irritability

Atropic Dermatitis (eczema) Physical Examination

○ Wiggling, scratching ○ Dry, scaly, flaky skin ○ Hypertrophy, lichenification ○ Dry lesions/ weepy papules or vesicles ○ Rash distribution § <2 yrs □ Face, scalp, wrists, extensor surfaces arms/ legs § older children □ Flexor areas mostly (can be anywhere) ○ Erythema, warmth (secondary bacterial infection) ○ Areas of hyperpigmentation/. Hypopigmentation ○ Sxs of allergic rhinitis Wheezing r/t asthma

Candidiasis

○ may occur in diaper area ○ Change diapers frequently ○ Gently wash diaper area w/soft cloth, avoid harsh soaps ○ Avoid wipes that contain fragrance/preservatives ○ Allow air to get to area, may go diaperless ○ Avoid rubber pants

Bacterial Infection Description

○Bullous & nonbullous impetigo, Folliculitis, cellulitis ○ Self-limited- rarely severe Staphylococcal scaled skin syndrome ○Community-acquired methicillin-resistance Staphylococcus aureus CA-MRSA ○Skin or soft tissue infection ○Cellulitis or abscess

Arterial Ulcer

◦ Arterial Insufficiency Ulcers are caused by arteriosclerosis which leads to insufficient oxygenation of skin & underlying tissues. This injures & affected tissues & causes wounds. ◦ Wounds are very dry, painful, pt. likes to sit up w/ legs dangling ◦ Hair loss & shiny skin ◦ Pallor with elevation ◦ Dependent rubor ◦ dangle- pink/red

Pressure Ulcer Interventions

◦ Daily inspection of skin, skin washed w/ soap & water, creams/lotions used to moisturize, barrier ointment whenever incontinence is present, absorbent pads/ garments changed after each incontinence ◦ Reddened areas are never massaged

Wound Assessment

◦ Document initial assessment, including location, size, color, extent of tiss. involvement, exudate, condition of surrounding tissue ◦ Assess/document wound at ea. dressing change ◦ Assess/document for blanching(area lightens with pressure) ◦ Types of wound exudate, p. 443 ◦ Record location & size using mm/cms. ◦ Measure depth as distance from deepest portion of wound to skin level ◦ Inspect wound margins for inflammation extending beyond area of injury ◦ Inspect for eschar (black, brown or gray)necrotic tissue ◦ Assess for odor

◦ Venous System Determinants in Circulation

◦ Edema ◦ Hemosiderin staining: RBCs become trapped in interstitial tissues; breakdown of heme, or iron, into tissue itself ◦ Venous Insufficiency: Doppler tests using US to measure venous congestion or regurgitation (a direct result of incompetent valves)

Unstageable Pressure Ulcer

◦ Full thickness tiss loss ◦ The base of ulcer is completely covered by slough (yellow, tan, gray, green or brown) &/or eschar (tan, brown or black) in wound bed. (Slough usually soft, eschar is hard) ◦ The true depth of wound is obscured

Stage IV Pressure Ulcer

◦ Full thickness tiss loss w/exposed bone, tendon or muscle. ○ Slough or eschar may be present on some parts of wound bed. ○ Often include undermining & tunneling ◦ Exposed bone/tendon is visible or directly palpable. ◦ Monitor for undermining (tissue damage that occurs under healthy appearing skin surrounding ulcer

Stage I Pressure Ulcer

◦ Intact skin w/non-blancheable redness of a localized area usually over a boney prominence. ○ Darkly pigmented skin may not have visible blanching; its color may differ from surrounding skin ◦ Area may be painful, firm, soft, warmer/ cooler as compared to adjacent tiss. May be difficult to detect with dark skin tones

Factors Contributing to Pressure Ulcers

◦ Limited mobility ◦ Sensory impairment ◦ Friction & shear ◦ Excessive skin moisture ◦ Nutritional status ◦ Incontinence ◦ Prolonged contact of the skin with urea, bacteria, yeast & enzymes carried in urine/feces

Risk Factors That Impact Wound Healing

◦ Nutrition & Hydration ◦ Infection ◦ Comorbidities ◦ Medications ◦ Stress ◦ Glucose control & diabetic management ◦ Smoking ◦ Gerontological considerations &comorbidities

Venous Insufficiency

◦ Occurs as a result of prolonged venous hypertension that stretches veins & damages valves ◦ Valvular damage can lead to a backup of blood & further venous HTN ◦ Results: edema, ↓ tiss. perfusion ◦ In time, stasis results in venous stasis ulcers, edema & cellulitis

Types of Wounds

◦ Pressure ulcers-area of localized damage caused by ischemia because of pressure ◦ Surgical incision-the cutting of/or into body tissues/organs as part of an operation ◦ Venous ulcers-are lesions that develop in the lower extremities from chronic venous insufficiency ◦ Arterial ulcers(ischemic ulcers)-occur d/t severe tiss. ischemia and are extremely painful ◦ Diabetic ulcers-results from damaged nerves, metabolic changes and peripheral artery disease changes

Pressure Ulcer Interventions: Positioning

◦ Pressure-relief devices: specialty beds, mattress replacements, wedges ◦ Pt. positioned at HOB at 30 degrees (applies to side-lying, also) ◦ If lying in this position is a problem, may prop pt at >90 with pillows at back to get pressure off sacrum ◦ Positioning in w/c ◦ Prevention of heel ulcers ◦ Pt should be on individualized schedule turning

Risk Factors Affecting The Rate of Wound Healing

◦ The vascular component to healing is most essential of all components; wo it, no phase/hope of healing can occur ◦ Vascular circulation consists of: ○ Macrocirculation ○ Microcirculation ◦ Vascular system delivers O2, leukocytes, macrophages, prostaglandins, growth factors...all contribute to healing process

Diabetic Ulcer

◦ There is a chain of events that lead to development of a diabetic foot ulcer. ◦ In general, most common precipitating event is trauma to foot of a person w/diabetes. ◦ Ex: irritation to foot caused by poorly-fitting shoes, calluses left untreated, trimming of toenail, burn injury to foot, cut (laceration) of foot ◦ Penetrating injury to foot from a sharp object, insect bite to foot ◦ 2 other conditions that predispose diabetic patient to develop foot ulcers: ◦ Peripheral neuropathy ◦ Peripheral vascular disease

Suspected Deep Tissue Injury (DTI)

◦ This area may present as painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue ◦ Purple or maroon localized area of discolored intact skin or blood-filled blister d/t damage of underlying soft tiss from pressure and/or shear.

Venous Ulcer

◦ Ulcers caused by increased pressure of blood in the veins of the lower leg. ◦ This causes fluid to ooze out of the veins beneath the skin. ◦ This causes swelling, thickening and damage to the skin. ◦ The damaged skin may eventually break down to form a shallow ulcer. ◦ See Lower Extremity Ulcers, p. 721

Stage III Pressure Ulcer

◦Full thickness tiss loss. ○ Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. ○ Slough may be present but does not obscure the depth of tiss loss. ○ May include undermining/tunneling ◦The bridge of nose, ear, occipital & malleolus do not have subcut. tiss. & stage III ulcers can be shallow.