N403 Exam 4 - Fluids & Electrolytes, Oxygenation, & Perioperative

High flow nasal cannula

-Adjustable FiO2 (.21-1.0) with a modifiable flow up to 60 L/min Wide range of FiO2, can use on adults, children, and infants. FiO2 dependent on patient respiratory pattern and input flow. Risk for infection

The nurse has just witnessed her patient go into cardiac arrest. What priority interventions should the nurse perform at this time? (Select all that apply.) 1. Perform chest compressions. 2. Ask someone to bring the defibrillator to the room for immediate defibrillation. 3. Apply oxygen via nasal cannula. 4. Place the patient in the high Fowler's position. 5. Educate the family about the need for CPR.

1 and 2. Applying oxygen won't help the patient as he or she is not breathing. The patient needs to be supine for compressions to be effective. The family does need to be educated, but this is not the priority for the nurse at this time. The nurse could delegate this task to a member of the health care team who is not actively engaged in the resuscitation

A patient who returned from surgery 3 hours ago following a kidney transplant is reporting pain at a 7 on a scale of 0 to 10. The nurse has tried repositioning with no improvement in the patient's pain report. Unmanaged surgical pain can lead to which of the following problems? (Select all that apply.) 1. Delayed ambulation 2. Reduced ventilation 3. Catheter-associated urinary tract infection 4. Retained pulmonary secretions 5. Reduced appetite

1, 2, 4, 5. Unmanaged surgical pain can lead to delayed ambulation, reduced ventilation, retained pulmonary secretions, or reduced appetite. Unmanaged surgical pain is not associated with catheter-associated urinary tract infection.

An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.) 1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 3. Roller clamp wide open 4. Tubing kinked in bedrails 5. Circulatory overload

1, 2, 4. Factors that could slow an IV infusion even if the infusion pump is set correctly include increased pressure at the outflow site (e.g., infiltration) and compression of the tubing lumen (e.g., patient lying on the tubing or tubing kinked in bedrails).

An 85-year-old patient returns to the inpatient surgical unit after leaving the PACU. Which of the following place the patient at risk during surgery? (Select all that apply.) 1. Stiffened lung tissue 2. Reduced diaphragmatic excursion 3. Increased laryngeal reflexes 4. Reduced blood flow to kidneys 5. Increased cholinergic transmission

1, 2, 4. Older adults have stiffened lung tissue, reduced diaphragmatic excursion, and reduced blood flow to kidneys. Laryngeal reflexes are reduced, increasing risk for aspiration, and reduced cholinergic transmission puts them at risk for cognitive changes

The nurse is caring for a patient with an artificial airway. What are reasons to suction the patient? (Select all that apply.) 1. The patient has visible secretions in the airway. 2. There is a sawtooth pattern on the patient's EtCO2 monitor. 3. The patient has clear breath sounds. 4. It has been 3 hours since the patient was last suctioned. 5. The patient has excessive coughing.

1, 2, and 5. Clear breath sounds are normal and do not indicate the need for suctioning. Suctioning should be based upon assessment findings and not performed on a time-oriented basis

The nurse prepares a patient with type 2 diabetes for a surgical procedure. The patient weighs 112.7 kg (248 lb) and is 5 feet, 2 inches in height. Which factors increase this patient's risk for surgical complications? (Select all that apply.) 1. Obesity 2. Prolonged bleeding time 3. Delayed wound healing 4. Ineffective vital capacity 5. Immobility secondary to height

1, 3. Secondary to the physiological stress of surgery that increases cortisol levels in patients with type 2 diabetes, these patients are at risk for surgical complications. This patient is also obese, which increases surgical risk.

Which assessment questions should the nurse ask a preoperative patient preparing for surgery? (Select all that apply.) 1. "Are you experiencing any pain?" 2. "Do you exercise on a daily basis?" 3. "When do you regularly take your medications?" 4. "Do you have any medication allergies?" 5. "Do you use drugs and/or tobacco products?"

1, 4, 5. Although regular exercise and adherence to the medication regimen are important, for the preoperative patient, the nurse needs to focus on factors that impact the surgical experience.

A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights

1, 4. Hypokalemia causes bilateral skeletal muscle weakness, especially in the quadriceps, which creates a risk for falling. Hypokalemia also causes gastrointestinal smooth muscle weakness, which produces constipation

What assessments does a nurse make before hanging an intravenous (IV) fluid that contains potassium? (Select all that apply.) 1. Urine output 2. Arterial blood gases 3. Fullness of neck veins 4. Serum potassium laboratory value in EHR 5. Level of consciousness

1, 4. Increased potassium intake when potassium output is decreased or during hyperkalemia are major risks for hyperkalemia. Before increasing IV potassium intake, check to see that urine output is normal and that the serum potassium level in the health record is not above normal.

A nurse cares for a postoperative patient in the PACU. Upon assessment, the nurse finds the surgical dressing is saturated with serosanguineous drainage. Which interventions are a priority? (Select all that apply.) 1. Notify surgeon. 2. Maintain the intravenous fluid infusion. 3. Provide 2 L/min of oxygen via nasal cannula. 4. Monitor the patient's vital signs every 5 to 10 minutes. 5. Reinforce the dressing.

1, 5. The first two priorities are for the nurse to report to the surgeon immediately and to reinforce the dressing as needed. Maintaining intravenous fluids and monitoring vital signs are routine aspects of the patient's plan of care. Providing oxygen requires a prescription; the surgeon has to be notified for a prescription for oxygen

Nasal Cannula

1-6 L/min 24-44% flow delivered Safe, simple, inexpensive, disposable, does not impede eating or talking unable to use with nasal obstruction, dries mucous membranes, cause skin irritation around ears and nares, ineffective with mouth breathers

Which is the best intervention the nurse should implement to promote bowel function? 1. Early ambulation 2. Deep-breathing exercises 3. Repositioning on the left side 4. Lowering the head of the patient's bed

1. Early ambulation promotes peristalsis and thus the return of bowel function. Deep-breathing activities prevent the onset of respiratory complications. Positioning on the left side and low

A postoperative patient experiences tachypnea during the first hour of recovery. Which nursing intervention is a priority? 1. Elevate the head of the patient's bed. 2. Give ordered oxygen through a mask at 4 L/min. 3. Ask the patient to use an incentive spirometer. 4. Position the patient on one side with the face down and the neck slightly extended so that the tongue falls forward.

1. Elevating the head of the patient's bed is a quick intervention that does not require a prescription, but it will promote lung expansion and allow secretions to move via gravity. Administration of oxygen requires a prescription. While using the incentive spirometer expands the lungs, it would not be the first action as positioning the patient to breath effectively is necessary.

The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider? 1. New, vigorous bubbling in the water seal chamber. 2. Scant amount of sanguineous drainage noted on the dressing. 3. Clear but slightly diminished breath sounds on the right side of the chest. 4. Pain score of 2 one hour after the administration of the prescribed analgesic.

1. The bubbling in the water seal chamber can mean a new pneumothorax or tube dislodgment. The drainage could be related to the insertion procedure and is scant, so it does not require an immediate phone call to the provider. Answers 3 and 4 are expected findings for a patient with a chest tube

Match the nursing interventions on the left with the complication to be prevented on the right. An intervention may apply to more than one complication. Nursing Intervention 1. Offering glasses or hearing aid 2. Early ambulation 3. Strict aseptic technique 4. Deep breathing exercise 5. Hydration Complication a. Deep vein thrombosis b. Wound infection c. Delirium d. Atelectasis

1. c; 2. a, c; 3. b; 4. d; 5. a, d

Partial & Nonrebreather masks reservoir bag should always be partially inflated

10-15 L/min 60-90% useful for short periods, delivered increase FiO2, easily humidifies O2, does not dry mucous membranes Hot and confining, can irritate skin, tight seal necessary, interferes with talking and eating, bag may twist or kink

Communication between a nurse caring for a patient in the preoperative holding area and the circulating nurse in the operating room (OR) can best be enhanced by which of the following? (Select all that apply.) 1. Documenting assessment findings in the medical record 2. Using a standardized SBAR tool 3. Being responsive in using nonverbal communication techniques 4. Giving specific information to a transport technician 5. Listening to the OR nurse's questions

2, 3, 5. Documentation does not ensure clear communication of all findings and does not allow the OR nurse to raise questions. Giving information to another staff member to communicate important information is not acceptable in a hand-off. Using standardized tools designed for hand-offs and using communication skills will enhance communication.

Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention? (Select all that apply.) 1. SpO2 value of 95% 2. Retractions 3. Respiratory rate of 28 breaths per minute 4. Nasal flaring 5. Clubbing of fingers

2, 3, and 4 SpO2 of 95% is normal and requires no intervention. Clubbed fingers are an assessment finding associated with chronic hypoxia; this does not require immediate intervention

The nurse is performing tracheostomy care on a patient. What finding would indicate that the tracheostomy tube has become dislodged? 1. Clear breath sounds 2. Patient speaking to nurse 3. SpO2 reading of 96% 4. Respiratory rate of 18 breaths/minute

2. Patient phonation is a sign that the TT is not in its proper place. All the other findings are normal assessment findings

The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for further teaching? 1. "Pursed-lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles." 2. "When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus." 3. "I will ensure that I receive an influenza vaccine every year, preferably in the fall." 4. "I will look for a smoking-cessation support group in my neighborhood.

2. Patients need to make sure that they are adequately hydrated in order to liquefy secretions, making it easier to expectorate. Fluids should not be limited or else the mucus will become too thick. All the other answers indicate an understanding of the discharge plan

The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first? 1. Start oxygen at 2 L/min via nasal cannula. 2. Elevate the head of the bed to 45 degrees. 3. Encourage the patient to use the incentive spirometer. 4. Notify the health care provider.

2. The HOB needs to be elevated to help increase lung expansion and ease work of breathing. Also this makes it easier for the patient to expectorate.

The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate does the nurse program into the infusion pump? 1. 100 mL/hr 2. 125 mL/hr 3. 167 mL/hr 4. 200 mL/hr

2. To infuse 500 mL in 4 hours, set the rate at 125 mL/hr. (500 divided by 4 = 125)

An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new onset of crackles in the lung bases. What is the priority action? 1. Notify a health care provider. 2. Decrease the IV flow rate. 3. Lower the head of the bed. 4. Discontinue the IV site.

2. When an IV fluid is infusing, monitor for excess infusion. Crackles in the lung bases are an indication of ECV excess. For patient safety, the IV flow rate must be decreased immediately. Then notify the health care provider

When delegating input and output (I&O) measurement to assistive personnel, the nurse instructs them to record what information for ice chips? 1. Two-thirds of the volume 2. One-half of the volume 3. One-quarter of the volume 4. Two times the volume

2. When ice chips melt, their water volume is one-half the volume of the ice chips. The water volume should be recorded as intake.

CPAP & BIPAP

21-100% avoids use of artificial airway, successfully treats obstructive sleep apnea nasal pillows/face masks can cause skin breakdown, claustrophobia in some patients.

Venturi Mask

24-50% A face mask and reservoir bag device that delivers specific concentrations of oxygen by mixing oxygen with inhaled air. (low constant O2) Mask and humidity may irritate skin, interrupts eating and drinking, specific flow rate must be followed

Which assessment does the nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? 1. Dryness of mucous membranes 2. Skin turgor 3. Fullness of neck veins when supine 4. Fullness of neck veins when upright

3. ECV deficit involves decreased vascular and interstitial volume. One way to assess vascular volume is to examine the fullness of neck veins when an individual is supine. With normal ECV, neck veins are full when the individual is supine. With ECV deficit, they are flat.

A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and HCO3 - , 24. How does the nurse interpret these laboratory values? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. The pH is abnormally low, which indicates acidosis. The PaCO2 is high, which indicates respiratory acidosis. The HCO3 - is in the normal range, which indicates an acute respiratory acidosis that has not had time for renal compensation. The low PaO2 and the severe dyspnea and wheezing are consistent with this interpretation.

Which postoperative intervention best prevents atelectasis? 1. Use of intermittent compression stockings 2. Heel-toe flexion 3. Use of the incentive spirometer 4. Abdominal splinting when coughing

3. Use of the incentive spirometer expands the lungs, thus preventing the onset of atelectasis. Heel-toe flexion and the use of intermittent compression stockings prevent the onset of deep vein thrombosis. Abdominal splinting keeps pressure on abdominal incisions to prevent pain during coughing and wound dehiscence.

How many mL in an oz?

30 mL

Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply.) 1. Initiate oxygen therapy via nasal cannula. 2. Perform nasotracheal suctioning of a patient. 3. Educate the patient about the use of an incentive spirometer. 4. Assist with care of an established tracheostomy tube. 5. Reposition a patient with a chest tube.

4 and 5. Assistive personnel (AP) are not allowed to initiate oxygen therapy, provide education, or perform NT suctioning on a patient. They are allowed to assist the nurse in performing tracheostomy tube care and with repositioning patients

The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first? 1. Apply a warm, moist compress. 2. Aspirate the infusing fluid from the VAD. 3. Report the situation to the health care provider. 4. Discontinue the intravenous infusion.

4. Pain and redness at a VAD site are indicators of phlebitis. When phlebitis occurs, the infusion must be stopped and the VAD removed as the highest priority.

How many mL in a teaspoon?

5 mL

Place the following steps for discontinuing intravenous (IV) access in the correct order: 1. Perform hand hygiene and apply gloves. 2. Explain procedure to patient. 3. Remove IV site dressing and tape. 4. Use two identifiers to ensure correct patient. 5. Stop the infusion and clamp the tubing. 6. Carefully check the health care provider's order. 7. Clean the site, withdraw the catheter, and apply pressure

6, 4, 2, 1, 5, 3, 7. A health care provider's order is necessary before discontinuing IV access, unless there is a complication such as infiltration or phlebitis. Identifying the patient and explaining the procedure are performed before hand hygiene and glove application in order to maintain clean gloves. Removing the site dressing before stopping the infusion and then withdrawing the catheter keeps the VAD patent without forming a clot that could embolize during catheter withdrawal.

Simple Face Mask

6-12 L/min: 35-50% Advantages: -useful for short periods of time such as patient transportation Disadvantages: -contradicted in patients who retain CO2 -may feel claustrophobia -therapy interrupted with eating or drinking -increased risk to aspirate

The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the steps in order. 1. Apply suction. 2. Assist patient to semi-Fowler's or high Fowler's position, if able. 3. Advance catheter through nares and into trachea. 4. Have patient take deep breaths. 5. Lubricate catheter with water-soluble lubricant. 6. Apply sterile gloves. 7. Perform hand hygiene 8. Withdraw catheter

7, 2, 6, 4, 5, 3, 1, 8.

Oxymizer oxygen-conserving cannula

8 L/min 30-50% flow delivered long term O2 usage, use at home, increase O2 concentration and lower flow cannula cannot be cleaned, more expensive than standard cannula

Jackson-pratt drains

A Jackson-Pratt (JP) drain is used to remove fluids that build up in areas of your body after surgery or when you have an infection. The JP drain is made up of 2 parts: A thin rubber tube; A soft round squeeze bulb maintain bulb suction, empty Qshift, label each bulb for accurate recording

Franz studies acid-base balance. Which two organs are responsible for acid excretion, which helps maintain acid-base balance? A. Lungs and kidneys B. Kidneys and liver C. Bladder and bowel D. Lungs and bladder

A. The lungs excrete carbonic acid. The kidneys excrete metabolic acids.

Mrs. Neuhausen's type 2 diabetes puts her at risk for impaired wound healing and increased susceptibility to infection. A. True B. False

A. True Diabetes increases the patient's susceptibility to infection and impairs wound healing from altered glucose metabolism and associated circulatory impairment. Stress of surgery often results in hyperglycemia.

Labs and Diagnostics for Pulse Ox

ABG RBC, Hgb, Hct BNP (brain natriuretic peptide) WBC Sputum sample chest x-ray ct scan pulmonary function tests (spirometer) broncoscopy

Removal list for surgery

All jewelry/body piercing All clothing Tampon Dentures Contact lens/glasses Hairclips/bobby pins Hearing aids

Procedures that require a time out

Amniocenteses Bone Marrow Aspiration Bronchoscopy Cardioversion Central line placement Chest tube - "YES" CircumcisionsClosed reduction procedure - "YES" Epidural placementJoint aspirations - "YES" Lumbar puncture Paracentisis PICC line placement Thoracentisis - "YES" Tracheotomy

Pulse Oximetry

An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds. 95% or above unless COPD --> 88-90%

What is included in informed surgical consent

An explanation of the need for the procedure An explanation of the steps involved and what the surgery entails An explanation of the potential risks An explanation of the expected results An explanation of alternative treatments

Output

Any fluid that comes out of the body Urine, emesis/vomit, NG tube drainage, blood on dressings, urine on incontinent pads, wound drainage, chest tube drainage etc..

Intake

Any fluid that goes into the body Liquid medications, IV, drinks, NG tube flushes, continuous bladder irrigation, water pitchers etc.. **Ice chips are recorded at half volume. 100 mL of ice chips = 50 mL liquid

Nurse Responsibility during Preoperative Phase

Assess clients emotional/physical status Assess clients risk factors Coordinate diagnostic studies Obtain consents and initiate preoperative checklist Assess clients teaching/learning needs Initiate perioperative care plan

A COPD patient asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic? a. Your disease affects your heart, and not enough blood is being pumped b. Your disease doesn't send enough oxygen to your fingers C. Your disease will be helped if you pursed-lip breathe d. Your disease often makes patients lose mental status

B

A COPD patient is receiving 2 L/min of oxygen. Which oxygen device is most appropriate? a. Simple face mask b. Nasal cannula C. Non-rebreather mask d. Partial non-rebreather mask

B

A CVA patient has developed bronchitis and has a HR-105, BP -156/90, RR-30. What is the priority nursing diagnosis? a. Risk for skin breakdown b. Impaired gas exchange C. Activity intolerance d. Risk for infection

B

A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis? a. Atelectasis affects only those with chronic conditions such as emphysema b. Do breathing exercises every hour to prevent atelectasis C. If i develop atelectasis, I will get a chest tube to drain excess fluid d. Hyperventilation will open up my alveoli, preventing atelectasis

B

An older adult patient is at risk for infection due to decreased immunity. Which best addresses infection prevention? a. Inform the patient to finish the entire dose of their antibiotics b. Encourage the patient to stay up-to-date on all vaccinations C. Schedule patient to get annual TB skin testing d. Create an exercise routine to run 45 minute every day

B

Mr. Perry Burke is a 51-year-old African-American patient on the medical-surgical unit for management of chronic bronchitis that has turned into pneumonia. He works in a paper mill factory where he inhales sawdust and chemicals on a daily basis. Working in an industrial environment causes his lungs to be constantly irritated and inflamed. Mr. Burke's respiratory rate as determined by Cyrus is 42 breaths/min. This means that he is experiencing apnea. A. True B. False

B. False Apnea is the absence of breath sounds. Tachypnea is more than 20 breaths/min

Franz is a first-semester nursing student who struggles with the concepts associated with electrolyte and acid-base balance. He knows that he needs to get a handle on these concepts because they are the foundation of understanding pathophysiology and as a nurse he will be responsible for understanding and interpreting laboratory reports so he may deliver the best patient care possible. Franz reviews the concepts of fluid, electrolyte, and acid-base balance as he studies for his midterm examination. Franz learns that hyperkalemia may be the result of chronic diarrhea. A. True B. False

B. False Chronic diarrhea causes hypokalemia, a loss of potassium.

Franz knows that hypercalcemia and hypermagnesemia increase neuromuscular excitability. A. True B. False

B. False Hypocalcemia and hypomagnesemia increase neuromuscular excitability. Hypercalcemia and hypermagnesemia cause decreased neuromuscular excitability.

Types of Patient Controlled Analgesia

Bolus doses Demand doses Continuous doses Lockout intervals 4-hour max doses

A RN explains the alveoli function to a patient with COPD. Which information about the alveoli's function is true? a. Store 02 b. Produces hemoglobin C. Carries out gas exchange d. Regulates tidal volume

C

A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect as a result? a. Increase in diastolic filling time b. Decrease in hemoglobin level C. Decrease in cardiac output d. Increase in stroke volume

C

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older adult patient? a. Discontinue the humidification device to keep excess fluid from the lungs b. Monitor oxygen saturation, and frequently auscultate the lung bases C. Assist the patient to cough, turn, and deep breathe every 2 hours d. Decrease fluid intake to 300ml a shift

C

Brittany checks Mrs. Neuhausen's blood sugar, which is 210 mg/dL, using the fingerstick method. In addition to being concerned about her blood sugar level, for which other postsurgical condition that can decrease tissue healing should Brittany monitor Mrs. Neuhausen? A. Shock B. Myocardial infarction C. Fluid and electrolyte imbalance D. Sensory deficit

C Hyperglycemia can cause an adrenocortical stress response in which the body retains sodium and water and loses potassium within the first 2 to 5 days following surgery. A patient who is hypovolemic or who has serious postoperative electrolyte alterations is at risk for decreased tissue healing and increased infection.

Mr. Perry Burke is a 51-year-old African-American patient on the medical-surgical unit for management of chronic bronchitis that has turned into pneumonia. He works in a paper mill factory where he inhales sawdust and chemicals on a daily basis. Working in an industrial environment causes his lungs to be constantly irritated and inflamed. Cyrus is the nursing student assigned to Mr. Burke. After reviewing his care plan, the health care provider's orders, and the nursing notes from the previous shift, Cyrus enters Mr. Burke's room Cyrus finds Mr. Burke restless, agitated, and confused. His pulse is 102 beats/min, and respirations are 42 breaths/min and shallow. He is sitting up in bed grasping the side rails and trying to catch his breath. He is most likely experiencing which of the following conditions? A. Hyperventilation B. Hypoventilation C. Hypoxia D. Dysrhythmia

C Hypoxia is the decreased diffusion of oxygen from the alveoli to the blood, as in pneumonia. Signs and symptoms of hypoxia include apprehension, restlessness, inability to concentrate, decreased level of consciousness, dizziness, and behavioral changes. Vital sign changes include increased pulse rate and rate and depth of respiration

Who is at risk? (respiratory)

COPD Smokers Sleep Apnea Asthma Pneumonia Chest Trauma Older patients Atrial Fibrillation Immobility Anemia Heart Failure Anxiety Postoperative Ascites

Hyperkalemia

Causes: Diabetic ketoacidosis, metabolic acidosis, salt substitutes, kidney failure, dehydration, potassium sparing diuretics s/s: muscle weakness, cramps, tingling, paresthesia (numbness prickling), when someone has a burn (initially) cells are lysed and k+ increase in cell. tx: cardiac monitor, furosemide, kayexalate, iv dextrose then insulin, decrease potatoes and cantalope

Hypocalcemia

Causes: Diarrhea, Vit D deficiency, lack of weight baring exercise, hypoparathyroidism s/s: Chvostek signs (facial spasm), Trousseus signs (hand wrist spasm) tx: calcium supplements, increase intake of Ca rich foods like broccoli, dairy, oranges, (sunlight too)

Hypokalemia

Causes: GI losses, NG tube suctioning, vomiting s/s: dysrhythmias, ileus (no peristalsis) in GI tract tx: potassium supplements

Hypercalcemia

Causes: Hyperparathyroidism, prolonged immobilization, dehydration, corticosteroids, bone cancers. s/s: constipation, decreased deep tendon reflexes, kidney stones, lethargy, weakness, dysrhythmias --> heart block tx: fluids, normal saline, calcitonin, limit oral intake of calcium, possibly dialysis

Hypomagnesemia

Causes: malnutrition, GI losses, Diuretics, alcohol abuse s/s: neuromuscular excitability, dysrhythmias, tachycardia, hypertension, increased deep tendon reflexes, tremors, seizures tx: supplements, deep green leafy vegetables

Hypermagnesemia

Causes: renal disease, excess antacids, excess laxatives s/s: hypotension, bradycardia, lethargy, muscle weakness, cardiac arrest, decrease in deep tendon reflexes tx: furosemide, calcium

Hemovac

Closed wound drainage system connected to a suction. note drainage, color, amount, and empty Qshift

What needs to be correct for informed consent

Correct patient Correct physician or surgeon Correct operation or procedure Correct operative site/side/level Correct marking of operative site/side/level with the word "yes" or an "x" Correct spelling of physicians name Absolutely NO abbreviations used on informed consent

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia? a. Elevated blood pressure b. Increased pulse rate C. Restlessness d. Cyanosis

D

Which term is used to describe gas exchange through the alveolar capillary membrane? a. Ventilation b. Surfactant C. Perfusion d. Diffusion

D

Franz learns the difference between Chvostek's and Trousseau's signs. A positive Chvostek's sign elicits which of the following? A. Bilateral muscle weakness in the quadriceps B. Bilateral muscle weakness of the respiratory muscles C. Carpal spasm with hypoxia D. Contraction of facial muscles when a facial nerve is tapped

D A positive Chvostek's sign is the contraction of facial muscles when the facial nerve is tapped. A positive Trousseau's sign is a carpal spasm with hypoxia.

FVE Labs

Decrease BUN Decrease Hematocrit Decrease in Serum osmolality Increase in BNP possible Increase in Urine specific gravity

Hypoxia (late signs)

Decrease LOC bradypnea dysrhythmias bradycardia hypotension cyanosis

When is Procedural pause/"Time Out" used

During All operative and other invasive procedures that expose patients to more than minimal risk Also used for procedures done in the OR and/or in non-OR settings such as ER, bedside, treatment labs, ones that involve puncture of the skin, insertion of instrument, or foreign material in the body

Mr. Perry Burke is a 51-year-old African-American patient on the medical-surgical unit for management of chronic bronchitis that has turned into pneumonia. He works in a paper mill factory where he inhales sawdust and chemicals on a daily basis. Working in an industrial environment causes his lungs to be constantly irritated and inflamed. Mr. Burke's condition is causing the clinical sign of shortness of breath. Shortness of breath is referred to as _______________.

Dyspnea Dyspnea is shortness of breath often found in hypoxia.

Hypernatremia

Excess sodium intake or dehydration Agitation, confusion, seizures, muscle weakness, cramps, GI upset, dry flushed skin Restrict sodium intake, increase h20, hypotonic IV solutions (sodium chloride 0.45%), diuretics, furosemide GO SLOWLY or you can cause cerebral edema/seizures

Na+

Fluid Balance, Nerve & Muscle Function 135-145

Isotonic Solution

For dehydrated patient normal saline lactated ringers D5 NS

Respiratory Key Function

Gas exchange by capillaries and alveoli

Mr. Perry Burke is a 51-year-old African-American patient on the medical-surgical unit for management of chronic bronchitis that has turned into pneumonia. He works in a paper mill factory where he inhales sawdust and chemicals on a daily basis. Working in an industrial environment causes his lungs to be constantly irritated and inflamed. Mr. Burke coughs up bloody sputum that Cyrus sends to the laboratory. Bloody sputum is referred to as ____________.

Hemoptysis Hemoptysis is bloody sputum that often accompanies respiratory illnesses such as pneumonia.

FVE S/S

Hypertension Bounding pulses Jugular vein distension Edema Portal Hypertension (liver)

Fluid Volume Excess

Hypervolemia - overhydration Kidney disease, heart failure, corticosteroids, liver disease

FVD S/S

Hypotension Tachycardia Weak thready pulses Headaches Weakness Fatigue

Fluid Volume Deficit

Hypovolemia - dehydration Dehydration, diarrhea, vomiting, high RR, diaphoresis, exercising when hot, caffeine, alcohol

Ca+

Important for bone and teeth formation, nerve and muscle function, clotting, activation of platelets, and part of coagulation cascade 9-10.5

FVD Labs

Increased BUN Increased Hematocrit Increased Sodium

Documentation review

Informed consent Blood transfusion consent Sterilization/hysterectomy consent Observer consent Refusal to remove jewelry waiver H&PLab Report Diagnostics Surgery checklist

Hypotonic

Inside the cell is dehydrated, water needs to go in half normal saline quarter normal saline D5W (Dextrose 5% in water)

When is "time out" mandatory?

Is always MANDATORY for all surgical/invasive procedures All surgical/invasive procedures DO NOT require surgical marking Note: Single organ or bilateral procedure do not need to be marked with "yes"

Immediate interventions post op

Keep patient side-lying unless contraindicated, in which case you turn the head to the side Keep client warm Reinforce dressings PRN Assess level of comfort Assess for hemorrhage Maintain hydration/electrolyte balance

Hypoxemia

Low O2 at the Blood level

Hypoxia

Low O2 at the Tissue level

Mg

Maintain normal nerve and muscle function 1.2-3.1

Revocation of informed consent

May be considered to have continuing force and effect until the patient revokes the consent or until circumstances change

Franz studies the difference between metabolic acidosis and alkalosis. _____________ _____________ increases blood HCO3.

Metabolic Alkalosis Metabolic alkalosis occurs from a direct increase of base HCO3 or a decrease of metabolic acid, which increases blood HCO3 by releasing it from its buffering function.

S/S of Oxygen Toxicity

Nasal Congestion Substernal Pain Nonproductive cough headache n/v fatigue sore throat

Urgent Surgery

Patient is still stable but needs to be removed Example would be a cancerous tumor that needs to be removed

Clients at surgical risk

Previous cardiac history Diabetes mellitus Respiratory diseases Bleeding/circulation disorders Altered metabolism/fever Immunocompromised Liver disease Drug abuse Chronic pain elderly clients

K+

Regulate heartbeat, ensure muscle and nerve function, synthesize protein and metabolize carbs 3.5-5

Postoperative risks

Respiratory depression Hemorrhage Hypothermia Aspiration from emesis Ineffective airway clearance of secretions Laryngospasm

Hypoxia (early signs)

Restlessness irritability dyspnea accessory musle use nasal flaring adventitious lung sounds tachycardia tachypnea hypertension pale pallor

Reconstructive/Restorative Surgery

Restorative: Restores function or structure to damaged or malfunctioning tissue ex: remove breasts d/t breast cancer (restorative) but has breast reconstruction (reconstructive)

Pre-Operative phase process requires RN to:

Review documentation Assess and interview the patient Administer preop medications Educate client and family regarding procedure

Hypertonic

Sodium chloride 3% dehydrate the cells, too much water in the cell

antihemolytic stockings

Special stockings used to help prevent swelling and blood clots and aide circulation, also called elastic stockings TED Stockings

Sleep Apnea

Stops breathing during sleep ten times in an hour for 5 seconds or more

Emergency Surgery

Surgery needed immediately for patient to live. ex: ruptured appendicitis, car accident w/ hemorrhaging

Elective Care Urgency

There is time to plan for it, not super urgent

Why is universal protocol: procedural pause "Time Out" needed?

To ensure patient safety and consistency in care of all patients who undergo operative invasive procedures To prevent wrong person, wrong procedure, or wrong site/side procedures or operations

Constructive surgery

To restore function in congenital abnormalities. e.g., Cleft palate repair.

Preoperative teaching

Type of surgery and what to expect (reinforces MD teaching) Frequent vital signs in PACU Pain management/comfort measures Resuming diet & physical activity Postoperative exercisesDrains, tubes, gadgets, O2 Return to room? ICU? Visitors

Mrs. Charlene Neuhausen is a 59-year-old Caucasian woman who underwent a double mastectomy and breast reconstruction for breast cancer. During the surgery the surgeon also removed several malignant lymph nodes. Diagnostics indicate that Mrs. Neuhausen has no other metastasis at this time. She has been transferred to the medical-surgical unit for recovery where she is resting comfortably. Brittany is the nursing student assigned to Mrs. Neuhausen. She performs an admission history and notes Mrs. Neuhausen's history of type 2 diabetes and asthma. Brittany takes Mrs. Neuhausen's vital signs: temperature 98.9° F, blood pressure 152/74 mm Hg, pulse 68 beats/min and regular, and respirations 20 breaths/min on room air. Mrs. Neuhausen rates her pain as 3 out of 10 on a scale of 0 to 10. Mrs. Neuhausen's double mastectomy to remove cancerous breast tissue is considered an___________surgical procedure, and the surgical purpose of the breast reconstruction is considered ______________.

Urgent, Cosmetic Urgent surgical procedures are necessary for the patient's health to prevent additional problems such as the spread of cancer. Removal of cancerous tissue or tumors is considered urgent. Cosmetic procedures such as breast reconstruction are performed to improve personal appearance.

What do you assess postop

VS, respiratory, cardiac status, peripheral circulation, neurological, LOC, IV therapy, N/V, pain level, motor ability, sensory, skin, temperature regulation, positioning, wound, I&Os

7-Step process of a "time out"

Verify correct patient Verify correct operation/procedure Verify site/side/level (if applicable) Verify surgical marking with the word "Yes" on operative site/side/level (if applicable) Verify that the surgical marking is visible after draping Verify correct implants/special equipment Verify that prophylactic antibiotic is administered 30-60 minutes before incision

Penrose Drain

a flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing Safety pin/irrigate per order PRN

Sensible losses

can be measured and include fluid lost during urination, defecation, and wounds

Insensible losses

cannot be measured or seen and include fluid lost from evaporation through the skin and as water vapor from the lungs during respiration, sweating, etc..

Montgomery Straps

easily removable straps that stay in place to facilitate dressing removal special adhesive strips that are applied when dressings must be changed frequently at the surgical site Strips of tape with eyelets

Ablative Surgery

excision or removal of diseased body part

Foley Catheter

indwelling catheter inserted through the urethra and into the bladder that includes a collection system allowing urine to be drained into a bag; the catheter can remain in place for an extended period note color, clarity, amount, odor Qshift

Phlebitis

inflammation of a vein

Extravasation

leakage from a vessel into the tissue. Medication taht infiltrates and causes tissue sloughing

Osmosis

movement of water across a semipermeable membrane

Nursing Diagnosis Ineffective Airway Clearance

r/t thick secretions AEB coughing Q30 min with copious amounts of green sputum/phlegm o Patient will cough Q1 hr with moderate amount of white sputum/phlegm

Nursing Diagnosis Impaired Gas Exchange

r/t thick secretions, decrease ventilation space or fluid in lungs [multiple causes] AEB PO-85% on 4L NC o Plan: Patient will have PO-92% on 2L by end of the shift with RR of o Always cluster Pulse ox, with RR, with breathing method

Procurement for transplant

removal of organs and/or tissues from a person pronounced brain dead for transplantation into another person

Palliative Surgery

surgery that is performed to relieve pain or other symptoms but not to cure ex: cancer has spread but removal of tumor to prolong a patient's life

Cosmetic surgery

surgical procedures used for cosmetic purposes only ex: eye lift, face lift, forehead lifts, liposuction, collagen injections, rhinoplasty

Osmolality

the concentration of solutes in body fluids. normal range 275-295

Hyponatremia

too little sodium in the blood N/V, diuretics, kidney failure, heart failure, tap water enemas confusion, decreased LOC, fatigue, lethargy, N/V, headaches, seizures Hypertonic solutions (sodium chloride 3%) Full strength or normal saline sodium tablets

Nursing Diagnosis Ineffective Tissue Perfusion

· r/t fluid in lungs AEB peripheral cyanosis o Patient will have no peripheral cyanosis by in 4 hours.

Nursing Diagnosis Activity Intolerance

· r/t shortness of breath AEB patient with dyspnea after ambulating to the restroom. o Patient will be able to perform ADLs at baseline without dyspnea by discharge