Exam 2 Review

Ketorolac tromethamine (Toradol)

- Class: NSAIDs Nursing Implications: - Monitor for GI tolerance. GI bleeding, ulceration, and perforation can occur while taking this drug. - Monitor for kidney effects, especially in older adult, because decreased urine output, increased serum creatinine, hematuria, and proteinuria can occur.

Inserting an NG tube

1. Assemble supplies and check HCP prescription. 2. Assist the patient to high Fowler's position and elevate the head of the bed 45 degrees 3. Drape chest with bath towel or disposable pad. Prepare tape for taping tube to nose. Have emesis basin and tissues handy 4. Don exam gloves. Select best naris for tube insertion. 5. Measure the distance to insert tube by placing tip of tube at patient's nostril and extending to tip of ear lobe and then to tip of xyphoid process. Mark tube with an indelible marker or tape. 6. Lubricate tip of tube (at least 2″-4″) with water-soluble lubricant. 7. After selecting the appropriate nostril, ask patient to slightly extend head back against the pillow. Gently insert the tube into the nostril while directing the tube upward and backward along the floor of the nose. Patient may gag when tube reaches pharynx. (Provide tissues for tearing or watering of eyes. Offer comfort and reassurance to the patient.) 8. When pharynx is reached, instruct patient to flex chin to chest. Encourage patient to sip water through a straw or swallow even if no fluids are permitted. Advance tube in downward and backward direction when patient swallows (dry swallow or giving client sips of water). Stop when patient breathes. If gagging and coughing persist, stop advancing the tube and check placement of tube with tongue blade and flashlight. If tube is curled, straighten the tube and attempt to advance again. Keep advancing tube until pen marking /tape is reached. 9. Do not use force. Rotate tube if it meets resistance 10. Discontinue procedure and remove tube if there are signs of distress, such as gasping, coughing, cyanosis, and inability to speak or hum. 11. While keeping one hand on tube or temporarily securing with tape, determine that tube is in patient's stomach: a. Attach syringe to end of tube and aspirate a small amount of stomach contents. b. Measure the pH of aspirated fluid using pH paper or a meter (gastric content is 5 or less, color is green; pulmonary aspirate is 6 or greater and the color is white). c. Visualize aspirated contents, checking for color and consistency. d. Obtain radiograph (x-ray) of placement of tube (as ordered by HCP). 12. Secure tube with tape to patient's nose: a. Cut a 4″ piece of tape and split bottom 2″ or use packaged nose tape for NG tubes. b. Place unsplit end over bridge of patient's nose. c. Wrap split ends under tubing and up and over onto nose. Be careful not to pull tube too tightly against nose. 13. Clamp tube after flushing with 10 - 20 mL of water and cap; or attach tube to suction according to the HCP prescription. 14. Secure tube to patient's gown by using a rubber band and safety pin at the level of the shoulder. For additional support, tube can be taped onto patient's cheek using a piece of tape. If double-lumen tube (eg, Salem sump) is used, secure vent above stomach level. 15. Remove all equipment, lower the bed, and make the patient comfortable. Remove exam gloves and perform hand hygiene 16. Assist with or provide oral hygiene at every 2- to 4-hour interval. Lubricate the lips generously and clean nares and lubricate as needed. Offer analgesic throat lozenges or anesthetic spray for throat irritation if needed

What is ASA?

It is a PHYSICAL STATUS CLASSIFICATION SYSTEM, ranged from ASA I (the healthiest) to ASA VI (brain dead)

Define: Restorative Surgery

Performed to improve a patient's functional ability Examples: Total knee replacement Finger reimplantation

What would you do if the patient had an H/H of 8/23 pre-op?

"Hemoglobin and Hematocrit": Hb 8, Hct 23 ? low ? indicates anemia Monitor for dizziness, confusion, bleeding, tachycardia Continue to monitor hemoglobin, because you can transfuse blood when Hb 7 or less Contact doctor to put in order for blood transfusion Contact surgeon and anesthesiologist. They may delay surgery or allow blood transfusion

ASA VI

Declared brain-dead patient whose organs are being removed for donor purposes

PICC Nursing Considerations

- Any staff responsible for managing VADs need adequate training and must be competent. Know your facilities P&P! - Most facilities now have a Vascular Access Team that performs dressing changes and insert PICC lines & PIV - A catheter with the minimum number of ports or lumens essential for pt mgt. should be used - A PICC or midline is recommended for pts who need 1-6 weeks of access - Encourage pts to report any changes in their catheter site or any new discomfort - Assess sites connected to an infusion device at least every 8 hours for signs of infiltration, phlebitis, infection, pain, redness, swelling, induration, disruption of flow, or lack of blood return. - If a localized infection is suspected at the VAD insertion site, inform MD and a culture should be obtained - Know when the dressing should be changed at your facility and who changes it - For pt showering, the site, catheter and connecting devices are covered with an impermeable dressing and the dressing should be changed immediately after shower - All unused ports are clamped, capped and flushed - HD VADs should not be opened, flushed or used by non-dialysis staff, except in life-threatening emergencies - Except in life-threatening emergencies, TPN lines or ports are used exclusively for TPN and not accessed for (blood draws, piggyback meds or other fluids) - Know when the tubing and fluid should be changed in your facility - Keep manipulation of the VAD system to a minimum: Clean ports and hubs with alcohol prior to accessing - Prime all tubing, no air! - Cap intermittent infusions with a sterile cap when not in use! - Luer lock all connections - Use aseptic technique when accessing site! - If tubing is disconnected do not reuse, attach new tubing - Make sure IVPBs are labeled with initials, concentration and name of additive, date & time - Each lumen should flush and aspirate blood easily. If not, notify appropriate person

PICC Lines

- Catheters placed in large blood vessels of people who require frequent access to the vascular system - Indicated for patients with limited peripheral vascular access or need for long-term vascular access - Central catheters inserted into a vein in the arm - Inserted @ BS by specially trained RN - Can be used for a prolonged period of time (can be used up to a year) - Ex. long chemotherapy regimens, extended antibiotic therapy or total parenteral nutrition - Less risk of infection than subclavian lines, internal jugular lines or femoral lines - Less risk of pneumothorax- Inserted in a peripheral vein - Cephalic, basilic or brachial vein - Advanced through increasingly larger veins, toward the heart until the tip rests in the distal superior vena cava - The basilic vein is the primary preferred insertion site via Antecubital space - Brachial access requires ultrasound guidance to avoid arterial or nerve access; allow visual inspection, assessment of size and location of vessel - PICC should be placed in patients using maximum sterile barrier by a specially trained nurse, in patient's room, outpatient area or the patient's home (use of a portable unit) - Catheter tip location should be determined by x-ray prior to initiation of prescribed therapy (distal superior vena cava and the right atrium junction)

Ibuprofen (Motrin, Amersol, Novoprofen)

- Class: NSAIDs Nursing Implications: - Monitor upper GI tolerance of medication; this drug can be given with food or milk to decrease irritation of the stomach. - Monitor coagulation studies (PT, aPTT) and assess for signs of bleeding or delayed clotting so early detection can lead to avoidance of complications.

Oxycodone hydrochloride and acetaminophen (Percocet, Endocet, Oxycocet)

- Class: Opioids Nursing Implications: - Monitor blood pressure and respiratory status because hypotension and respiratory depression can occur. - Monitor GI motility because constipation when taking this drug is common and interventions may be indicated.

Oxycodone hydrochloride and aspirin (Percodan, Endodan, Oxycodan)

- Class: Opioids Nursing Implications: - Monitor for GI tolerance and function because the aspirin component of this drug can irritate the stomach. - Constipation and GI bleeding can occur. - Monitor coagulation studies (PT, aPTT) because the aspirin component of this drug may influence bleeding times and other coagulation study results.

Butorphanol tartrate (Stadol)

- Class: Opioids Nursing Implications: - Monitor neurologic status and for changes in level of consciousness because this medication can cause increased intracranial pressure. - Monitor for respiratory depression.

Morphine sulfate (Epimorph, Statex), and Hydromorphone hydrochloride (Dilaudid)

- Class: Opioids Nursing Implications: - Monitor respiratory rate and blood pressure because respiratory depression can be severe and require medical intervention. - Monitor GI motility and urine output because constipation and urinary retention can occur.

Codeine sulfate, codeine phosphate (Paveral)

- Class: Opioids Nursing Implications: - Monitor respiratory status because respiratory depression can occur. - Monitor GI motility because constipation when taking this drug is common and interventions may be indicated.

PICC Complications

- Infiltration of the IV line - Loss of patency: catheter occlusion - Definition of patency: ability to Infuse through the catheter & Aspirate blood from the catheter - Tissue necrosis when drugs are injected into infiltrated IV sites - Thrombophlebitis of the vein - Injection of air embolism - Serious adverse drug reactions such as hypotension, cardiac arrhythmias, and cardiac arrest - Allergic reaction to the medication - Venous thrombosis - Pain at the IV site

PICC: Intermittent Infusions of Medications

- Most facilities only allow RNs to administer IV medications - The patient is placed in a comfortable position - Explain the procedure and name of drug to be administered - Instruct pt to alert you immediately if he/she has unusual feelings or discomfort after medication administration - Check IV patency to insure that the line is intact and not leaking - Review MD order; Check 5 rights; check 2 identifiers - Check med label for date - Review med administration guidelines for specific drug - Verify that that particular med can be administered on the unit you are working on and if you have the qualifications to administer that particular drug - Wash hands - Calculate and prepare drug according to drug administration guidelines - Assemble necessary equipment, verify if emergency equipment needed - Inspect catheter and insertion site. - Assess pain. - Change dressing and clean according to institution policies. - Clean the injection caps prior to using. - Flushing is important. Ensure the injection cap is intact after flushing. - Determine the amount of time over which the drug should be delivered according to the physician's order and/or the IV drug administration guidelines. - Usually given with an IV pump and most IV pumps are set in mL per hour, not mL per minute (know how to do both) - Document - If reverting to a primary IV line, the health care professional must be sure to reset the IV flow rate to the correct hourly rate that is ordered for the IV fluids - Know how to convert to saline lock

Flushing a PICC

- Preservative-free 0.9 % sodium chloride - *A 10mL or larger syringe MUST be used(psi = pounds per square inch of approx. 7) - *Catheter burst pressure is 25 - 40 psi - A 1mL syringe exerts >300 psi; 3mL > 25 psi - Procedures regarding aspiration (to assess patency) vary greatly: done as per agency policy

SASH

- Saline - Administer Medication - Saline - Heparin Amount of saline and Heparin is per hospital policy: suggestion: - 5 ml NS - Medication - 5ml NS - 3 ml Heparin (100U/ml)

PICC Considerations

- Sterile dressing changes - Routine saline flushes - Catheter may break - Activity restriction - Restrictions in blood sampling

Removing an NGT

1. Assemble supplies and check HCP order. a. perform hand hygiene b. check patient's ID band for two identifiers. c. provide privacy. d. Explain procedure to patient. e. Place patient in semi-Fowler's position. f. Don gloves. 2. Assess patient to determine presence of bowel sounds. Discontinue suction and separate tube from suction. Unpin tube from patient's gown and carefully remove adhesive tape from patient's nose. 3. Clear tubing by attaching syringe to tube and clear with 20 mL of water. Follow with a bolus of air. 4. Instruct patient to take a deep breath and hold it. 5. Clamp tube with fingers by doubling tube on itself. Remove tube while patient holds breath. Coil the tube in a disposable towel as you remove from the patient. 6. Dispose of tube per agency policy. Remove gloves and discard. Perform hand hygiene 7. Offer oral care to patient and facial tissue to blow nose. Lower the bed and assist the patient to a position of comfort as needed. 8.Don gloves and measure the amount of nasogastric drainage in the collection device and record on output flow record, subtracting irrigant fluids if necessary. Add solidifying agent to nasogastric drainage according to hospital policy. 9. Remove gloves and perform hand hygiene

Emergency Care of the Patient With Surgical Wound Evisceration

1. Contact surgeon immediately or Rapid Response Team to bring any needed supplies into the patient's room. 2. Provide reassurance and support to ease the patient's anxiety. If possible, stay with the patient and instruct him or her to remain in bed. 3. Using sterile technique, unfold a sterile towel to create a sterile field. 4. Open an irrigation set and place the basin and syringe on the sterile field. 5. Open several large abdominal dressings and place them on the sterile field. 6. Put on the sterile gloves and place one or two of the large abdominal dressings into the basin to saturate them with warm saline solution. 7. Place the moistened dressings over the exposed viscera. Then place a sterile, waterproof drape over the dressings to prevent the sheets from getting wet. 8. If saline is not immediately available, cover the wound with gauze and moisten with sterile saline when available. 9. Do not attempt to reinsert the protruding organ or viscera. Assess for manifestations of shock and document vital signs. Place the patient in a supine position with the hips and knees bent. Raise the head of the bed 15 to 20 degrees. Continue assessing the patient, including vital signs assessment every 5 to 10 minutes until the surgeon arrives. Keep dressings continuously moist by adding warmed sterile saline to the dressing as often as necessary. Do not let the dressing become dry. When the surgeon arrives, report finding and interventions. Document the incident, the activity in which the patient was engaged at the time of the incident, assessment, and interventions taken. If necessary, prepare the patient for emergency surgery; start an IV infusion as ordered. Don't allow the patient to have anything by mouth to decrease the risk of aspiration if surgery is planned. Special Consideration: Best treatment is prevention. If a postoperative patient is at risk for poor healing, encourage adequate supply of protein, vitamins, and calories. Monitor dietary intake, identify deficiencies, and discuss with the surgeon and the dietitian.

Maintaining a PICC

1. Perform hand hygiene and don gloves. 2. Assess IV site and surrounding area for signs of infection (i.e. erythema, tenderness, edema and drainage). 3. Check clamps and access caps are tightly locked 4. Assess securement device site for stability, cleanliness, and intact dressing. 5. Cleanse the female Luer cap vigorously with an antimicrobial swab for 15 - 30 seconds. 6. Allow to dry for 30 seconds. 7. Attach the syringe to the Luer , push and twist until it is tight. Unclamp catheter. 8. Check for blood return or according to the agency policy. 9. Inject or irrigate solution of 0.9% preservative-free sodium chloride slowly; flush with minimum force using a pulsatile motion until syringe is almost empty. Rationale: This action creates turbulence for catheter cleansing. 10. For medication administration, refer to ATI central caths - PICC 11. Flush non-used catheter ports every 8 to 12 hours using push-pause technique 12. Remove syringe and clamp the catheter, 13. Check all clamps and caps to ensure they are tightly locked. 14. Place discarded equipment in appropriate receptacle. Place syringe in sharps container. 15. Remove gloves and perform hand hygiene.

Preparing IV partial fill to a continuous IV

1. Select the correct tubing & correct supplies and assemble all other necessary supplies. 2. Determine compatibility of partial fill (or "piggy-back") solution to primary solution. If a PCA is in use, determine compatibility with that medication. 3. Review the IVPB (including the 5 rights) and attach the secondary tubing. You may purge the tubing with the medication; or use the back-flush method to purge the secondary line with fluid from the primary bag. 4. Assure that no air is in the secondary tubing. 5. Demonstrate correct mechanics of IVPB infusion by controlling roller clamp or setting the pump to assure proper rate. 6. Monitor infusion for 1-3 minutes to assure proper administration 7. Discuss documentation

Preparing IV Partial Fill to an IID. Using SAS(H).

1. Select the correct tubing & correct supplies. 2. Assemble all other necessary supplies. 3. Flush IID with proper solution (this will generally be normal saline before medication administration). 4. Prepare the IVPB and attach the secondary tubing. Use back-flush method to purge the secondary line if the agency uses a flush bag system. Perform appropriate flush when attaching the IV line to an IID: - Place needleless cannula into proper port - Flush appropriate amount of saline (as indicated by agency) & assess for complications - Inject solution slowly (approximate 1 - minim/sec) 5. Attach the tubing to the IID. Prior to attaching the line, change the needleless cannula to the primary line to ensure sterility of the cannula. 6. Demonstrate correct mechanics of IVPB infusion. 7. Flush IID after infusion. 8. Discuss documentation.

Converting IV to saline lock

1. Verify the client using two identifiers. 2. Prime extension tubing with normal saline syringe. Don gloves. 3. Don gloves. Assess that IV is infusing and there are no signs of phlebitis or infiltration. 4. Turn off IV. 5. Disconnect IV tubing and attach extension tubing. A 2x2 gauze can be placed under IV by the site to catch drops from IV tubing disconnect 6. Redress the IV site with transparent dressing and tape. 7. Prep injection port with alcohol (it is the pressure and friction applied that produce the antimicrobial effect.) 8. Insert/connect syringe to injection port and gently flush with saline (amount of saline is determined by the hospital policy). Assess IV insertion site for tissue swelling or pain when injecting saline (pain or swelling could be a sign of infiltration). 9. Disconnect syringe and discard in appropriate trash/sharps container. 10. Remove and discard gloves. Document flush in MAR.

Discontinuing IV

1. Verify the client using two identifiers. Turn off infusion. 2. Don gloves. 3. Loosen transparent dressing and tape. Alcohol swabs can be used to loosen dressing to prevent skin tears. 4. Stabilize IV catheter while removing dressing and tape. 5. Hold sterile gauze (2"x2") and remove IV catheter carefully. Observe catheter for breakage and ensure it is intact. 6. Quickly press sterile gauze pad over venipuncture site and hold firmly until bleeding stops.(holds pressure for 2 -3 min) 7. Apply sterile gauze pad and tape it in place. Remove gloves.

Irrigating an NGT connected to suction

1.Assemble supplies and check HCP order. a. perform hand hygiene b. check patient's ID band for two identifiers. c. provide privacy. d. Explain procedure to patient. e. Place patient in semi-Fowler's position. f. Don gloves. 2. Determine NG tube placement 3. Pour irrigating solution into container. Draw up 20 - 30 mL solution (or amount ordered by the HCP) into syringe 4. Clamp NG tube near connection site. If needed, disconnect tube from suction apparatus and place on disposable pad or towel, or hold both tubes upright in nondominant hand 5. Place tip of syringe in tube. If Salem sump or double-lumen tube is used, make sure that syringe tip is placed in drainage port and not in blue air vent. Hold syringe upright and gently insert the irrigant (or allow solution to flow in by gravity if agency policy indicates). Do not force solution into tube. 6. If unable to irrigate tube, reposition patient and attempt irrigation again. Inject 10 to 20 mL of air and aspirate again. Check with HCP or follow agency policy, if repeated attempts to irrigate tube fail 7. After irrigant has been instilled, observe for return flow of NG drainage into available container. Alternately, the nurse may reconnect the NG tube to suction and observe the return drainage as it drains into the suction container. Inject air into blue air vent after irrigation is complete. Position the blue air vent above the patient's stomach 8. Measure and record amount and description of irrigant and returned solution if measured at this time. 9. Rinse equipment if it will be reused. Label with the date, patient's name, room number, and purpose. Remove gloves and perform hand hygiene 10. Lower the bed. Assist the patient to a position of comfort. Perform hand hygiene.

Regulating IV Infusion Flow Rate

1.Check manufacturer's drip rate calibration on administration set package. 2.Check physician's order for amount of fluid to be delivered per unit of time, i.e. 100 mL/hr. 3. Calculate the flow rate 4. Adjust tubing clamp until the chamber drips the desired number of drips per minutes (15 second increment)

IV Assessment

1.Check the IV solution and rate with the physician's order. 2. Check the functioning of IV infusion (drip rate, disconnections, leaks). 3.Check the IV bag and tubing for signs of leaking. Also check the IV tubing for kinks, disconnection and the tubing label for expiration. 4. Don gloves. Assess IV site for signs of infiltration, and phlebitis. Remove gloves. 5. Check the "take" or left in bag (LIB) of the IV bag.

Changing gown with IV

1.Untie back of gown and remove gown from unaffected arm. 2.Support arm with IV and slip gown down arm to IV tubing. 3. Place clean gown over client's chest and abdomen. 4. Remove IV bag from hook and slip sleeve over bag, keeping bag above client's arm (prevents backflow of blood into tubing).

Changing a new IV solution bag

1.Verify IV solution order with the MAR. Verify the client using two identifiers. 2.Check the solution bag for leaking, color and expiration. Apply label with type of solution, patient's name and date, time and initial of the nurse. 3. If using an infusion pump," pause" the device. If using gravity infusion, close the roller clamp on the IV administration set. 4. Carefully remove the cap on the entry site of the new IV solution bag and expose the site, taking care not to touch the exposed entry site. 5. Lift the empty IV bag off IV pole and invert it. Quickly remove the spike from the old IV bag, being careful not to contaminate it. Discard old IV bag. 6. Using a twisting and pushing motion, insert the administration set spike into the entry site of the new IV bag. Hang the new IV bag to the IV pole. 7. If using the infusion pump, re-program the pump with amount of solution and verify the flow rate and "START" the infusion pump. 8. If using gravity infusion, slowing open the roller clamp and adjust the drops to the correct rate. 9. Document in the MAR about hanging the IV bag.

Regulating IV Infusion Flow Rate via an infusion pump

1.Verify the client using two identifiers. Check the IV solution and rate with the physician's order. Explain use of the infusion pump to the client. 2.Prepare the IV and tubing as stated in "Preparing the Infusion System" 3. Load the tubing to the infusion pump as recommended by the manufacturer. Latch the device. 4. Open regulating clamp to the administration set. 5. Turn the device ON. 6. Set the device parameters for operation: infusion rate, volume to be infused, etc.

Preparing the IV infusion system

1.Verify the type & amount of solution with physician's order. Check expiration date. 2. Label the IV container with client's identification, solution type, date, time and initials of the nurse. 3. Select IV tubing appropriate for infusion device. 4. Inspect IV bag carefully for tears or leaks by applying gentle pressure to bag. 5. Hold the IV bag up to examine for discoloration, cloudiness or particulate matter. 6. Hang the IV bag to the IV pole. Close tubing roller clamp. 7. Remove plastic protector from tubing spike, keeping the spike portion sterile. 8. Inserting tubing spike into the bag port. 9. Squeeze the drip chamber until chamber is partially full. 10.Open the roller clamp to prime the tubing. 11. Invert and tap Y injection sites to remove air as tubing primes. 12. Close the tubing clamp when primed. 13. Put protective cap on the tip of tubing if removed. 14. Label the IV tubing with date, time and initials of the nurse.

A nurse is discontinuing an IV infusion. For which of the following reasons is it important to verify and document the integrity and condition of the IV catheter? A. A broken-off catheter tip indicates the risk for an embolus B. Catheter erosion indicates that it was left in place too long C. Blood within the catheter could indicate clot formation D. Discoloration of the catheter could be a sign of phlebitis

A. A broken-off catheter tip indicates the risk for an embolus Reasoning: The tip of the catheter can break off, thus creating an embolus. To limit the movement of the embolus, the nurse should apply a tourniquet high on the extremity where the IV line was located and notify the provider immediately

A nurse is performing an nasogastric intubation. Which of the following actions should the nurse take immediately after inserting the tube to the predetermined length? A. Inspect the oropharynx with a penlight and a tongue blade B. Obtain an x-ray examination of the chest and abdomen C Tape and tube securely in place with a tube holder device. D. Aspirate gastric contents.

A. Inspect the oropharynx with a penlight and a tongue blade Reasoning: After insertion, the nurse should immediately inspect the oropharynx to check for kinks and to ensure that the tube is not coiled.

A nurse has just inserted a PIV catheter for a continuous infusion. To secure the catheter, the nurse should... A. Leave the connection between the hub and tubing uncovered. B. Wrap tape around the circumference of the patient's arm C. tape the IV catheter's hub securely to the patient's skin D. Place a piece of paper tape over the insertion site

A. Leave the connection between the hub and tubing uncovered. Reasoning: This makes it possible to replace the tubing without removing the dressing.

A nurse is caring for a patient who has a newly inserted NGT. Which of the following methods is appropriate for verifying the initial placement? A. X-ray examination of the chest and abdomen B. Auscultation of injected air C. pH measurement of gastric aspirate D. Color of gastric contents

A. X-ray examination of the chest and abdomen Reasoning: X-ray examination is the gold standard for confirming the initial placement of an NGT

Risk Factors for Increased Surgical Complications

Age • Older than 65 years Medications • Antihypertensives • Tricyclic antidepressants • Anticoagulants • Nonsteroidal anti-inflammatory drugs (NSAIDs) • Immunosuppressives Medical History • Decreased immunity • Diabetes • Pulmonary disease • Cardiac disease • Hemodynamic instability • Multi-system disease • Coagulation defect or disorder • Anemia • Dehydration • Infection • Hypertension • Hypotension • Any chronic disease Prior Surgical Experiences • Less-than-optimal emotional reaction • Anesthesia reactions or complications • Postoperative complications Health History • Malnutrition or obesity • Drug, tobacco, alcohol, or illicit substance use or abuse • Altered coping ability • Herbal use Family History • Malignant hyperthermia • Cancer • Bleeding disorder • Anesthesia reactions or complications Type of Surgical Procedure Planned • Neck, oral, or facial procedures (airway complications) • Chest or high abdominal procedures (pulmonary complications) • Abdominal surgery (paralytic ileus, venous thromboembolism)

What would you do if you found a new irregular heart beat in your pre-op patient?

Auscultate heart for any other irregularities, murmurs Review EKG for a history of atrial fibrillation Contact pre-op nurse and physician

When checking for nasogastric tube placement, the nurse should conduct which of the following procedures? A. Instill 20 mL of air into the tube and listen for a whooshing sound? B. Aspirate stomach contents and check the pH C. Aspirate stomach contents and check their color D. Auscultate lung sounds

B. Aspirate stomach contents and check the pH Reasoning: Checking the pH of stomach contents is the recommended method for checking tube placement

A nurse initiating a peripheral IV infusion punctures the skin and selected vein and observes blood return in the flashback chamber of the IV catheter. Which of the following actions should the nurse perform next? A. Secure the catheter to the skin with a transparent dressing B. Lower the catheter until it is almost flush with the skin C. Advance the catheter about 1/4 inch into the vein. D. Remove the stylet slowly from the lumen of the catheter

B. Lower the catheter until it is almost flush with the skin Reasoning: Lowering the angle and then advancing the catheter slightly facilitates full penetration of the wall of the vein, thus placing the catheter within the vein's lumen and making it easy to advance the catheter off the stylet.

A patient recovering from gastric surgery remains NPO and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes? A. Allow the patient to suck on ice chips B. Provide frequent mouth care C. Apply petroleum jelly to the patient's naris D. Offer throat lozenges for the patient to use

B. Provide frequent mouth care Reasoning: Frequent mouth care (brushing teeth, oral swab) is a nursing intervention that prevents mucous membranes from becoming dry and irritated

A patient in early stage renal failure is prescribed an infusion of 0.45% sodium chloride. This type of solution is appropriate because it.... A. pulls fluid from the cells and increases vascular volume B. dilutes extracellular fluid and rehydrates the cells C. replaces extracellular volume and maintains intravascular volume D. draws fluid into blood vessels and reduces interstitial compartments

B. dilutes extracellular fluid and rehydrates the cells Reasoning: Infusing a hypotonic solution such as 0.45% sodium chloride moves fluid into the cells, thus enlarging and rehydrating them

A nurse should recognize that nasogastric intubation is indicated to relieve gastric distention for which of the following patients? A. A 6-year-old child who drank a toxic substance B. A 60-year-old patient admitted with gastrointestinal hemorrhage C. A 40-year-old patient with a postoperative bowel obstruction D. A 20-year old patient with malabsorption syndrome

C. A 40-year-old patient with a postoperative bowel obstruction Reasoning: A nasogastric tube should be placed for decompression for the removal of secretions. This will assist in relieving abdominal distention

A nurse finds a patient's IV insertion site is red, warm, and slightly edematous. Which of the following actions should the nurse perform first? A. Check for blood return B. Elevate the extremity C. Discontinue the IV line D. Apply warm, moist heat

C. Discontinue the IV line Reasoning: The patient has classic signs of phlebitis, an inflammation of the vein. The IV line must be discontinued immediately to reduce the risk of thrombophlebitis and embolism

A nurse is removing an IV catheter form a patient whose IV infusion has been discontinued. Which of the following actions is appropriate? A. Apply firm pressure over the vein B. Leave the roller clamp slightly open C. Pull the catheter straight back from the insertion site D. Lift the hub slightly upward away from the skin

C. Pull the catheter straight back from the insertion site Reasoning: With the catheter stabilized and using a slow, steady movement, the nurse should withdraw the catheter straight back and away from the insertion site, making sure to keep the hub parallel to the skin

During report, a nurse is informed that a patient has a nasogastric tube connected to continuous suction. The nurse should recognize that this patient must have which of the following types of tube? A. Levin B. Sengstaken-Blakemore C. Salem Sump D. Ewald

C. Salem Sump Reasoning: A Salem sump is the only type of tube tat allows for continuous suction. The tube has two lumens; one removes gastric contents and the other serves as an air vent. The vent allows air to enter the stomach, allowing the tube to float freely and prevent damage to the gastric mucosa

What would you do if the pre-op patient's blood pressure is 178/100?

Contact the surgeon and anesthesiologist Administer anti-anxiety medications Give patient teaching about the procedure Note: For surgeries, high blood pressures are actually easier to manage because the medications used during surgery will lower the blood pressure

A nurse who has just initiated an IV infusion explains to the patient that complications are possible and that she will monitor the infusion regularly. The nurse should teach the patient that which of the following findings is an indication of early infiltration? A. Moisture B. Bruising C. Tingling D. Coolness

D. Coolness Reasoning: Coolness is a classic sign of infiltration, along with swelling, pallor, and possibly tenderness. Infiltration is a leakage of IV solution out of the intravascular compartment into the surrounding tissue

A nurse has just initiated a new peripheral IV infusion with 5% dextrose in water for continuous infusion. How often should the nurse plan to replace the primary infusion tubing? A. Every 24 hours B. Every 48 hours C. Every 72 hours D. Every 96 hours

D. Every 96 hours Reasoning: THE CDC and the Infusion Nurses' Society recommend changing the IV tubing no more than every 96 hours unless the tubing has been contaminated, punctured, or obstructed

Which of the following is an important nursing action when converting an IV infusion to a saline lock? A. Open the roller clamp of the primary infusion to prime the saline lock B. Apply pressure with a syringe to clear resistance in the IV catheter C. Attach secondary tubing to allow mobility D. Flush the IV catheter to confirm patency

D. Flush the IV catheter to confirm patency Reasoning: It is essential to attach the primed saline lock adapter to the extension tubing and to flush the tubing with normal saline to confirm patency

A nurse is caring for a patient who has a NGT connected to suction. Which of the following should indicate to the nurse that the tube has become occluded? A. Active bowel sounds B. Passing flatus C. Increase in gastric secretions D. Patient's report of nausea

D. Patient's report of nausea Reasoning: Tubes connected to suction decompress the gastrointestinal tract. This is needed when peristalsis is absent. If gastric secretions are unable to move through the GI tract and if the NGT is unable to evacuate the stomach due to an occlusion, nausea and vomiting will result.

Concept 25: SENSORY PERCEPTION

Definition: A complex physiologic process that allows humans to interact efficiently within the environment. The ability to perceive stimulation through sensory organs. Resources: Ignatavicius chapters (8th ed.) 46,47,48. Giddens Ch 25, ATI units on Sensory disorders.

CONCEPT 25: INFECTION

Definition: The invasion and multiplication of microorganisms in body tissues, which may be clinically unapparent or result in local cellular injury due to competitive metabolism, toxins, intracellular replication or antigen-antibody response. Readings: Giddens: Concept 25: Ignatavicius Chap. 23 (may omit bioterrorism agents on p. 429).

CONCEPT 16: GAS EXCHANGE

Definition: the process by which oxygen is transported to cells and carbon dioxide is transported from cells. Resources: Review Ignatavicius chapter 27 Review this chapter (as needed) and read all boxes, tables except 27-1 and 27-6 (only FEV1 will be covered). Read Ignatavicius chapter 28) Read Table 28-1; Charts 28-2, 28-3, 28-4, 28-5 Read Ignatavicius chapter 30 Asthma and COPD pp. 563-581 Read Ignatavicius chapter 31 Pneumonia, TB pp. 598-611 Read Ignatavicius chapter 39 Table 39-2 only Read Ignatavicius chapter 40 Anemia pp 813-816; chart 40-8; blood transfusion admin 832-836 ATI Nursing Care of Clients with Respiratory Disorders.

CONCEPT 24: TISSUE INTEGRITY

Definition: the state structurally intact and physiologically functioning epithelial tissues and mucous membrane Resources: Giddens, Chapter 24, (p. 248-257). Ignatavicius, chapter 24 & 25. Focus on lesion types, dressings, wound vac and exemplars (fungal infections, skin CA, psoriasis, bacterial infections, viral infections). Ignatavicius, ch 25; review pressure ulcers and staging Common infections: Ch 23 Common inflammations ATI Unit 11 Pre, intra, and post operative care: Ignatavicius, chapters 14, 15, 16. ATI Med-Surg Unit 14,

Define: Radical Surgery

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

Nursing Focus on the Older Adult Best Practice in Postoperative Skin Care

Improve perfusion to the wound to promote wound healing: • Keep the patient adequately hydrated to maintain cardiac output. • Keep the airway patent and provide adequate oxygenation. • Keep the patient's oxygen saturation on pulse oximetry at greater than 93%. • Use strict aseptic technique (e.g., IV or other catheters, indwelling urethral catheter, wound). • Promote adequate sleep and rest periods throughout the day. • If necessary, administer drugs to combat pain and sleeplessness. • Provide rest periods throughout the day. • Control the patient's room temperature. • Place the patient on a safety program to prevent falls if indicated. • Maintain the patient's psychosocial health. • Maintain personal hygiene. • Protect fragile skin. • Minimize the use of tape on the skin. • Use hypoallergenic tape or Montgomery straps. • Change dressings as soon as they become wet. • Lift the patient during transfer or repositioning.

PICC dressing

Looks like this net but covers a catheter in the arm, chest, or groin (not the knee)

ASA V

Moribund patient who is not expected to survive without the operation Examples include (but not limited to): - Ruptured abdominal/thoracic aneurysm - Massive trauma - Intracranial bleed with mass effect - Ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction

ASA I

Normal healthy patient Example: Healthy, nonsmoking, no or minimal alcohol use

Define: Diagnostic Surgery

Performed to determine the origin and cause of a disorder or the cell type for cancer Examples: Breast biopsy Exploratory laparotomy Arthroscopy

Define: Simple Surgery

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

What would you do if the patient states they had an episode of new chest pain yesterday?

Order 12 lead EKG Continue to monitor them Acquire troponin levels Call surgeon and anesthesiologist to update them

Define: Palliative Surgery

Performed to relieve symptoms of a disease process but does not cure Examples: Colostomy Nerve root resection Tumor debulking Ileostomy

Define: Curative Surgery

Performed to resolve a health problem by repairing or removing the cause Examples: Cholecystectomy Appendectomy Hysterectomy

ASA II

Patient with mild systemic disease Mild diseases only without substantive functional limitations Examples include (but not limited to): - Current smoker - Social alcohol drinker - Pregnancy - Obesity (30 < BMI < 40) - Well-controlled DM/HTN - Mild lung disease

ASA III

Patient with severe systemic disease Substantive functional limitations One or more moderate-to-severe diseases Examples include (but not limited to): - Poorly controlled DM or HTN - COPD - Morbid obesity (BMI ≥40) - Active hepatitis - Alcohol dependence or abuse - Implanted pacemaker - Moderate reduction of ejection fraction - ESRD undergoing regularly scheduled dialysis - Premature infant PCA <60 weeks - History (>3 months) of MI, CVA, TIA, or CAD/stents

ASA IV

Patient with severe systemic disease that is a constant threat to life Examples include (but not limited to): - Recent (<3 months) MI, CVA, TIA, or CAD/stents - Ongoing cardiac ischemia - Severe valve dysfunction - Severe reduction of ejection fraction - Sepsis - DIC - ARD - ESRD not undergoing regularly scheduled dialysis

Define: Cosmetic Surgery

Performed primarily to alter or enhance personal appearance Examples: Liposuction Revision of scars Rhinoplasty Blepharoplasty

What would you do if the patient only had a 22 G PIV in the right hand pre-op?

Place an IV with a large gauge in the forearm or other large vein

Define: Elective Surgery

Planned for correction of a nonacute problem Examples: Cataract removal Hernia repair Hemorrhoidectomy Total joint replacement

Define: Minimally Invasive Surgery (MIS)

Surgery performed in a body cavity or body area through one or more endoscopes; can correct problems, remove organs, take tissue for biopsy, re-route blood vessels and drainage systems; is a fast-growing and ever-changing type of surgery Examples: Arthroscopy Tubal ligation Hysterectomy Lung lobectomy Coronary artery bypass Cholecystectomy

What would you do if your renal pre-op patient has a K+ of 6.0?

Put them on dialysis (which takes 4 hours). Call the surgical department to keep them updated and delay the surgery.

Define: Transplant

Replacing malfunctioning structures Examples: Kidney transplant Heart transplant Liver transplant

Define: Emergent Surgery

Requires immediate intervention because of life-threatening consequences Examples: Gunshot or stab wound Severe bleeding Abdominal aortic aneurysm Compound fracture Appendectomy

Define: Urgent Surgery

Requires prompt intervention; may be life threatening if treatment is delayed more than 24-48 hrs Examples: Intestinal obstruction Bladder obstruction Kidney or ureteral stones Bone fracture Eye injury Acute cholecystitis

CONCEPT: PICC

Resources: Guidelines to Prevent Catheter-Related Blood Stream Infections. Iggy pp. 205-6, Tables 13-2, 13-3, 13-4, 13-5.

What would you do if your patient had an INR of 3.2 pre-op?

Stop blood thinners (need to be stopped at least 3 days before surgery) Review CBC, PT, PTT Administer vitamin K (if warfarin-induced INR) Contact surgeon and anesthesiologist. Likely the surgery will be post-poned

What would you do if the patient stated they took aspirin and Eliquis yesterday?

Stop blood thinners (need to be stopped at least 3 days before surgery) Review CBC, PT, PTT Contact surgeon and anesthesiologist. Likely the surgery will be post-poned

What would you do if the pre-op patient's blood sugar with a hx of DMII is 70?

The normal glucose range for DMII: 80-120 (so the blood sugar is too low) Administer D5NS Recheck blood sugar q15 minutes until stable Contact surgeon and anesthesiologist

What would you do if the pre-op patient's blood pressure is 90/60?

Understand what the baseline is for this patient Look for cause of blood pressure being this level Monitor medications which may lower BP VS: heart rate, respiration rate Monitor for s/s: dizziness, confusion Administer IV fluids Contact surgeon and anesthesiologist with updates Note: Low blood pressure is imperative to treat pre-op since medications used during surgery will lower the blood pressure

Flushing technique

push-pause method to create turbulence (swirling effect) within the catheter --> moves residue of fibrin, medications, lipids, other adherents to catheter lumen

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 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 Assess for and report other clinical conditions that may need further evaluation before proceeding with the surgical plans, including: • Change in mental status • Vomiting • Rash • Recent administration of an anticoagulant drug

Nonpharmacologic Interventions to Reduce Postoperative Pain and Promote Comfort

• Find a general position of comfort for the patient. • Use ice to reduce and prevent swelling as indicated. • Cushion and elevate painful areas; avoid tension or pressure on these areas. • Control or remove noxious stimuli. • Provide adequate rest to increase pain tolerance. • Encourage the patient's participation in diversional activities. • Instruct the patient in relaxation techniques; use audio recordings or CDs and breathing exercises. • Provide opportunities for meditation. • Help the patient stimulate sensory nerve endings near the painful areas to inhibit ascending pain impulses. • Help the patient stimulate the area contralateral (opposite) to the painful area.

Assess and determine functionality of any implantable cardiovascular devices:

• Pacemaker • Implantable cardioverter defibrillators (ICDs)

Emergency Care of the Patient Experiencing an Opioid Overdose

• Prepare to administer naloxone hydrochloride (Narcan)* in an initial dose of 0.4 mg-2 mg IV. • If the desired degree of improvement in respiratory functions is not obtained, it may be repeated at 2- to 3-minute intervals up to 10 mg as needed, depending on the patient's response. • Naloxone may be administered IV, IM, subcutaneously or intranasal spray. IV is most rapid onset and is recommended in emergency situations. • Maintain an open airway. • Give oxygen if hypoxia is present or if respirations are below 10 breaths/min. • Have suction equipment available because naloxone can trigger vomiting and a drowsy patient is at risk for aspiration. • Continuously monitor vital signs and level of consciousness for opioid reversal every 10-15 minutes for the first hour. Naloxone is eliminated from the body more quickly than is the opioid; and it may induce side effects, including blood pressure changes, tachycardia, and dysrhythmias. • Do not leave the patient until he or she is fully responsive. • Assess the patient for pain because reversal of the opioid also reverses the analgesic effects. • Determine the need for additional antagonist therapy 1 hour after the patient initially becomes fully responsive. *There are other opioid antagonists; however, naloxone hydrochloride is most often indicated for complete or partial reversal of opioid depression induced by natural and synthetic opioids. It is also indicated for suspected or known adult and opioid overdose in the postoperative period.

Emergency Care of the Patient Experiencing a Benzodiazepine Overdose

• Secure the airway and IV access before starting benzodiazepine antagonist therapy. • Prepare to administer flumazenil* (Romazicon) in a dose of 0.2 mg to 1 mg IV (recommended for IV only). • Repeat drug every 2 to 3 minutes up to 3 mg, as needed, depending on the patient's response. • Give oxygen if hypoxia is present or if respirations are below 10 breaths/min. • Have suction equipment available because flumazenil can trigger vomiting and a drowsy patient is at risk for aspiration. • Continuously monitor vital signs and level of consciousness for reversal of overdose. • Do not leave the patient until he or she is fully responsive. • Continue to monitor the patient's vital signs and level of consciousness every 10 to 15 minutes for the first 2 hours because flumazenil is eliminated from the body more quickly than is the benzodiazepine. • Determine the need for additional flumazenil therapy 1 to 2 hours after the patient initially becomes fully responsive. • Observe the patient for tremors or convulsions because flumazenil can lower the seizure threshold in patients who have seizure disorders. • Assess the IV site every shift because flumazenil can cause thrombophlebitis at the injection site. • Observe the patient for side effects of flumazenil, including skin rash, hot flushes, dizziness, headache, sweating, dry mouth, and blurred vision. The incidence of these side effects increases with higher total doses of flumazenil. *There are other benzodiazepine antagonists; however, flumazenil is used most often to manage adult complete or partial reversal of the sedative effects of benzodiazepine in cases in which general anesthesia was induced and or maintained with benzodiazepines, sedation was produced with benzodiazepines for diagnostic procedures, or in management of benzodiazepine overdose.