role prep skin

cleansing a surgical wound

The outside is considered dirty The inside is considered clean

granulation tissue

The red area is the gradulation tissue Starting to heal from the bottle up They can have it red and it can be bumpy It should not hurt You can get pus in this phase

wound irrigation

Wound irrigation want to do it for debrevement fro the death skin Use sterile normal saline

NEGATIVE PRESSURE WOUND THERAPY

Wound vaccume to remove excess exudate or drainage It takes excess exudate it takes all the negative pressure so it suctions the gross stuff out The more blood flow you have the better the circulation is going to be

rule of nines

A system that assigns percentages to sections of the body, allowing calculation of the amount of skin surface involved in the burn area. Gives percent of what is burned Each limb calculate the full burns

classification of surgery

-Diagnostic -Ablative -Palliative -Reconstructive/Restorative -Procurement for transplant -Constructive -Cosmetic Abalative surgery- cardiac ablation, kill the tissue that is causing the cardiac fibulation Reconstructive surgery- facial, after impact of surgery Restorative- total knee replacement, Constructive- bring function back, repair of cleft palate

Phases of wound Repair

-Inflammatory phase: This phase begins with the body's initial response to wounding of the skin and lasts about 3 days. - -Proliferative phase: The purposes of this phase are to repair the defect; fill the wound bed with new tissue, called granulation tissue; and resurface the wound with skin. - -Granulation tissue: The new tissue created to fill the wound; this tissue is beefy red because of the many newly created blood vessels. Initally when there is wound healing there is a gradulation process Blood stops and it becomes red, it becomes inflamed Proliferative phase- it will fill with gradulation tussue Grandulation- new tissue is created

layers of the skin

2 major layers: a-epidermis b- dermis Epidermis is the top layer of the skin, the first layer The dermis is the one underneath - has hair folics and sweat folicals

Types of Dermatitis

Allergic contact dermatitis Irritant contact dermatitis Atopic Dermatitis Stasis dermatitis Seborrheic dermatitis Atopic demetiies- this is inflammation, starts when a child is young, result of sensitive skin Irriant-gasoline on the skin Will have an irritant Stasis- results as a when you do not move, there is no exercise Can have it on lower limb Seborrheic- dandrif, in the hair

cleaning around a drain

Around the drain you want to do inside out

cancer of the skin

Basal cell carcinoma - Squamous cell carcinoma - Malignant melanoma - Kaposi sarcoma -- Melanoma highly metastatic. Risk factors: genetic, UV light. Light skin races and over 60 Assess the lesion for: Location, size, color Surface features Asymetry of shape Border irregularity Color variation within one lesions Diameter greater than 6 mm Exudate presence and quality Chemotherapy, Biotherapy Types of biotherapy include immunotherapy (such as vaccines, cytokines, and some antibodies), gene therapy, and some targeted therapies. Targeted therapy CTLA-4 receptors Radiation for metastatic disease with systemic corticosteroids. Melanoma- is the most malignant, highly metastatic Risk factors include staying under the sun, tanning beds, over 60 years old ABCDE- the color changes, the asymmetry, it grows very fast, it diameter > 6mm, elevation Boarders are irregular Chemo therapy is treatment and radiation

fungal infections

Candidiasis ◦Caused by Candida albicans ◦Normally found on the skin, in the GI tract, and in the vagina ◦Candida albicans can change from a commensal organism to a pathogen ◦Local environment of moisture & warmth ◦Systemic administration of antibiotics ◦Diabetes mellitus ◦Immunosuppression Neoplastic diseases Over use of antibiotics, chemo, immunosuppressant Oral care is for candidas albicans There is a swish and swallow or a swish and spit Give them easy to chew food, do not give them hard food to swallow

burns

Capillary endothelial permeability changes resulting in lose of: üVascular fluid üElectrolytes üIncreased intracellular NA üDecreased potassium üIntracellular Ca (increased risk for myocardial infarct) üProtein ◦ Major burns >40% of body surface area üHypermetabolic Response (can last for up to 2 years) üCaused by an increased release of inflammatory cytokines üCan cause multiple organ dysfunction (especially Acute Kidney Injury) Burns- hypovolemic shock, septic shock and third spacing Prevention is priority Can get dehydration can occur Get hyperkalemia

Psoriasis

Chronic, relapsing, proliferative skin disorder T cell immune- mediated skin disease Scaly, thick, silvery, elevated lesions, usually on the scalp, elbows, or knees. üShows evidence of dermal and epidermal thickening üEpidermal turnover goes from 26 to 30 days to 3 to 4 days üCells do not have time to mature or adequately keratinize Topical therapy: corticosteroids followed by warm moist dressings to increase absoption. Tar preparation to the skin: ointments, lotions, gels and shampoo Anthralin plus coal tar bathsand UV lights Calcipotiene (vit D ) regulates skin division UV radiation( decreases skin growth rate) Systemic: oral vit A (can cause birth defects) Immunospurresive Emotional support There is a lot of skin, because when people have psoriasis their skin is being produced very fast The extra skin causes red patches, some times itchy or painful Topical steroids to give to them to help with inflammation

Dehiscence

Dehiscence- separation of the incision site at coughing to blow out the stitches, obese patients and diabetics patietns are more at risk

keloids

Elevated, rounded, and firm Clawlike margins that extend beyond the original site of injury Excessive collagen formation during dermal connective tissue repair Common in darkly pigmented skin types and burn scars Type III collagen is increased Keloids- it is elevated scar that has not healed properly It extends the boarders of the wound They do not regress Risk factors is younger age, younger than 30 Earpeiercingis high risk

frostbites

Frost bites- are due to burn of skin that is from the cold Treat it like a burn First degree will see edema And frost bite with second is blisters and edema and skin necrosis Skin turns blue- is third Will see no pain and will feel cold, and edema- this is fourth degree Want to elevate limb, do not put compressive dressing If there is infection may want to do topical antibiotics

burns

Give humified oxygen Assess breath sounds Worry about hypovolemic shock Worry about intestional layer The burn is stress on the body

burn impairments

Increased thermal regulation ◦Persistent tachycardia ◦Hypercapnia ◦Body wasting Immunological Responses ◦Increased susceptibility to fatal systemic wound sepsis ◦Additional risk for those who have an autoimmune disorder Water Loss ◦Cannot regulate evaporative water loss Increased water loss (liters can be lost) Increase risk of infection If you lose the skin then you have nothing to protect you from infection

Lupus Erythematosus

Inflammatory, autoimmune disease with cutaneous manifestations ◦Discoid lupus erythematosus ◦Restricted to the skin ◦Photosensitivity ◦Butterfly pattern over the nose and cheeks ◦Systemic lupus erythematosus This is autoimmune This means the body attacks itself Critical sign is butterfly rash The patient can have severe fatigue, joint swelling, hair loss Give anti-inflammatory to decrease the pain and steroids to decrease inflammation

Pruritus (itching)

Most common symptom of primary skin disorders Itch is carried by specific unmyelinated C-nerve fibers and is triggered by a number of itch mediators The CNS can modulate the itch response Pain stimuli at lower intensities can induce itching Chronic itching can result in infections and scarring due to persistent scratching Itching- they have dermitis or ceryasis Cut the finger nails If they have pruiritis so that it decrases infection

nursing safety

Nursing safety- checking her arm band Time out- they stop everything and go over the patient history, what side of the arm or leg Where the disease is located

obtaining a wound culture

Obtain wound culture, you obtain it before you do any cleaning

Stasis Dermatitis

Occurs in the legs as a result of the following: Venous stasis Edema Vascular trauma ◦Sequence of events: ◦Erythema ◦Pruritus ◦Scaling ◦Petechiae Ulcerations (around ankle and tibia) Caused by venous insuffiency Obese, diabetic, older people, this can be part of the result of skin break down Itching, hyperpigmentation, pruritis

herpes simplex virus

Oral is type 1 Genetical is type 2 Up to 20 days is incubation This is dormant and then it if there is sun or stress or some sexual activity then you can have resufrance Tell them abstence because can spread Zovirax is treatment

burns

Partial-thickness burns ◦First degree ◦ ◦ ◦ Superficial and deep partial ◦Second degree Full-thickness burns ◦Third degree "Rule of nines" Contracture Partial is when the rule is red The full thickness is the whole body The rule of 9's- is how they calculate what percentage is burns Secure airway always and organ profusion Worry about body temperature Worry about hypothermia and infection There is no thermoregulation

other drains

Pen roses need a pen so that it will prevent coming into the skin Cover the pen rose with a 4x4 Put the safety pin at the level of the skin It is not sutured at the site then it will go back to the skin JP- hemovack make sure that you have negative pressure

primary wound healing

Primary- has a suture, it is nice and neat and everything comes together The two end of the skins are together Want a wound to heal slowly Primary can take 2 weeks

secondary wound healing

Secondary is a lot of tissue loss The two ends don't come together as fast as the primary healing This healing process is much longer Secondary can take months

C- steroids to help with inflammation

The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the health care provider's prescriptions. Which of the following medications would the nurse expect to be prescribed? A.Broad Spectrum antibiotic B.Antidiarrheal C.Corticosteroid Opioid analgesic

skin infections

V CHIPS V-CHIPS *V* = Varicella *C* = Cutaneous Diptheria *H* = Herepes Zoster *I* = Impetigo *P* = Pediculosis *S* = Scabies Skin infection It is important to teach the young generation to not play with it or squeeze it Put warm compresses on it And keep it as dry and intact as possible May need to put topical antibiotic

Infections & Warts

Viral infections ◦ Herpes zoster, Herpes simplex and varicella Warts ◦Benign lesions caused by the human papillomavirus (HPV) ◦Diagnosed by visualization ◦Condylomata acuminata Venereal warts HPV - causes this They are not itching Cryotherapy, can cut them, or use "bettlejuice"

Changing a Sterile Dressing: Dry, Wet/Damp-to-Dry

Wet to dry- this means that the patient goes from debrebment You take a 4x4 with normal saline and then you apply it to the site and then apply it with the dry and tape it down It is used to help prevent infection and to take the dead skin off Use sterile saline Will delay healing because it takes both dead and healthy tissue off

abscesses

vAnorectal abscess v vBrain abscess v vHepatic abscess v vLung abscess v vPancreatic abscess Hyperglycemia- due to stress that will increase the level of cortisol Absecess- going to see sign with anoretctal- Brain- will see visual and neurological deficits Hepatic absesses will have pain on right upper quadrent Have pulatic pain Pancreatic- complication of alcohol drinking, see alcohol drinking, usually due to pancreatitic May see antibiotics and surgical drainage

assessment wounds

•Emergency setting •After stabilizing the client's condition (ABCs) •Then check wound for bleeding •Abrasion: superficial with little bleeding •Laceration: sometimes bleeds profusely •Puncture: bleeding amount dependent on depth and size of wound •May require tetanus shot (if not within 5 years) •Stable setting •Assess client's wound to determine level of healing •Wound appearance •Character of wound drainage •Drains Wound closures If the patient starts bleeding then you hold pressure Check the Abc's Want to assess what kind of bleeding Check vital signs and call physician Abrasion- partial thickness of the skin, due to skin damage at the surgical area During epidermis Laseration is cut can be dermis or epidermis

D

■A client had a colostomy surgery and is learning how to care for the skin around the stoma. Which information should the nurse include in the teaching plan for this client? ■A-"Cut an opening about ⅓ inch (0.85 cm) larger than the stomal pattern." ■B-"Avoid the use of soap and other irritating agents." ■C-"Eat yogurt and drink buttermilk and parsley." ■D-"Empty the pouch before it is one-third full."

A, B and E They do not urinate excessive amoints

■A client has a kidney transplant. The nurse should monitor for which assessment findings associated with rejection of the transplant? Select all that apply. ■ ■A-Fever ■B- Oliguria ■C- jaundice ■D-Polydipsia E-Weight gain

A- keep skin dry and intact

■A client is scheduled to receive irradiation to the chest wall after a tumor was removed from the client's lung. Which information will the nurse emphasize when teaching skin care to the client? ■A-Keeping the skin dry to protect it from excoriation ■B-Using skin lotion twice daily to keep the skin supple ■C-Massaging the skin four times a day to increase circulation ■D-Washing the area frequently to remove desquamated cells

A- because first degree only effects the outter layer Second degree is blistering/ dermis Third degree - effect the deep layers, there is no pain, the color will look black Fourth- is chemical or electrical- very deep, muscle and bone s

■A client was admitted with a burn injury caused by a quick heat flash. The nurse examined the skin and noticed erythema and mild swelling. What type of burn does the nurse suspect? ■A-First-degree burn ■B-Third-degree burn ■C-Fourth-degree burn D-Second-degree burn

A, B, C, E Should ambulate that evening

■A nurse provides care to a client following a subtotal thyroidectomy. Which interventions should the nurse implement? Select all that apply. ■A-Assessing for frequent swallowing ■B-Ambulating the client the evening of surgery ■C-Assessing for facial spasms, apprehension, or tingling of the lips, fingers, or toes ■D-Instructing the client to support the head and maintain the neck in a flexed position ■E-Ensuring that oxygen, suction equipment, and a tracheostomy tray are at the bedside

Postoperative Physical assessment

■Airway and respiration ■Circulation ■Temperature control ■Fluid and electrolyte balance ■Neurological functions ■Skin integrity and condition of the wound ■GU/GI function ■Comfort Neurological function- assess the cranial nerves, purla Once they wake up they should know where they are asses AOx3 GI function asses bowel sounds- 2 days or 24 hours should hear something

preoperative phase

■Assessment -History -Risk Factors (fever, purulent sputum, dysuria, cloudy urine, draining wound, increased white blood cell) -Medications -Allergies -Smoking habits -Alcohol consumption -Pregnancy -Cultural and spiritual factors Physical assessment Check the arm band, make sure the surgical consent form is signed, check allergy band What medications that have been given, NPO for at least 12 hours, can take the cardiac meds with a little sip of water Respitortory system is assessed before surgery, circulatory system check heart rate and pulses Check pedial pulses and radial pulses Check skin for turgor, pressure ulcer, and check for dehydration Check allergies that they may have If patient is over 50 they need clearance from the heart doctor Check kidney function- BUN and creatine, check intake and output to show how well the patient is functioning Tells how well the kidney can excrete medication

from the book

■Chapter 14: Care of Preoperative Patients ■Chapter 15: Care of Intraoperative Patients ■Chapter 16: Care of Postoperative Patients

NURSES ROLE

■Circulating Nurse -Endotracheal intubation -Administering blood products -Monitors sterile technique and safe OR -Assists the surgeon/surgical team by operating nonsterile equipment -Verifies sponge and instrument count -Maintains accurate and complete written records ■Scrub Nurse -Maintains sterile field during surgical procedure -Assists with applying sterile drapes -Hands instruments and other sterile supplies to surgeon -Counts sponges and instruments

kidney transplant

■Definition of Surgery: Removal of the diseased kidney and replacing it with a live or cadaver (dead) kidney that functions better ■Option for patients in end stage renal disease most commonly ■Candidates are placed on national waiting list one they are dependent on dialysis or have glomerular filtration rate of less than 20 mL/min (normal 90-120). Take it from cavader or live person

Restorative Proctocolectomy with Ileo Pouch-Anal Anastomosis (RPC-IPAA)

■Definition of Surgery: a Two Step Procedure- 1. Removal of the colon and most of rectum + create an internal pouch called j-pouch connected to anus, outside abdominal skin a temporary ileostomy is created to help with healing of internal pouch. 2. Loop ileostomy is closed and outside pouch is taken away. ■There is usually about 1 to 2 months between steps, so it is two separate surgeries. Gold Standard surgery for Ulcerative Colitis

amputation

■Definition: Removal of a part of the body -Most common: above the knee and below the knee -Other: toes, feet, fingers, hands and arms ■Causes: -Peripheral vascular disease, 80% (75% of these are clients with diabetes) -Trauma -Congenital deformities -Malignant tumors -Infection ■Complications: hemorrhage, infection, phantom limb pain, neuroma and flexion contractures Amputation is cutting off the limb They always want you to know about the contractors

thyroidectomy

■Definition: complete or partial removal of thyroid gland ■Performed when there is persistent hyperthyroidism -Grave's Disease ■Partial removal is the preferred intervention Removal of the thyroid

dressing changing

■Dressings have multiple purposes: ■ ■To keep the wound free from: contamination ■Absorb drainage yet prevent overdrying of the wound bed ■Protect the periwound tissue ■Treat infection ■ Aid in the debridement of the wound. Dressing changes, to keep the changes clean Dry dressing, wet to dry dressing Canassesfor infection, or bleeding with dressing changes

A- start o2 because if there is hypotension then there is not enough o2 and then start IV fluid 02 increase the oxygenation

■During post-operative care, the nurse finds that a client has hypotension. Which priority intervention does the nurse expects to begin? ■A-Starting O 2 therapy ■B-Inspecting the surgical incision ■C-Administration of IV fluid boluses ■D-Administration of vasoconstrictive agents

intraoperative

■General anesthesia -Immobile, quiet client, doesn't recall procedure -Endotracheal intubation ■Risks of general anesthesia -Cardiovascular depression or irritability -Respiratory depression -Liver and kidney damage ■Regional anesthesia -Loss of sensation in an area of the body ■Risks of regional anesthesia -Infiltrative anesthesia -Injury due to positioning ■Local anesthesia -Loss of sensation at the desired site -Common for minor procedures in ambulatory surgery ■Conscious sedation -Depressed level of consciousness, amnesia -Client able to respond, maintain own airway -Nurses need to be competent in caring for clients General anesthia means that the patient is completely sleeping Intubation occurs- because the patient is not breathing Being dependent on it, pneumonia, vocal cord paralysis, malignant hyperthermia It is due to inhaled anthestic and it is due to inhaled, it can cause muscle rigidity Dantroline is IV and give the patient ice packs LocAL anthesthia is only effecting one part of the body Concious sedation- they are partically awake, but they cant do anything, it is twilight They are breathing on their own

RPC-IPAA Post-Operative Instructions

■HESI Nursing Safety Priority: Assess stoma frequently!!! -Stoma should be pinkish to bright red. If stoma looks pale, bluish, or dark report findings to health care provider immediately. ■Parenteral ATB are given within 1 hour of surgical opening -Based on current best evidence and Joint Commission's National Patient Safety Goals ■Patients are placed on NPO status after surgery and have a NG tube to help with suction -NG tube removed after 1 to 2 days and diet is slowly changed if pt is able to tolerate it ■Have pt drink lots of fluids to help start drainage ■Inflammation of stoma is treated with metronidazole (Flagyl), an anti-fungal med for 7 to 10 days ■Diet -Avoid foods that cause odors or gas = cabbage, asparagus, and beans -Eliminate foods that cannot be well digested = nuts and corn ■Ileostomy may lead to altered body image, especially in middle age men - important to suggest pt attends support groups to help deal with body image and psychosocial aspects while they have the pouch Empty bag when 1/3rd full

RPC-IPAA Pre-Operative Instructions

■Health care provider (HCP) explains that temporary pouch/stoma will be made on abdomen prior to surgery ■HCP explains with the ileostomy functions as: -Loop of ileum is placed through abdominal wall to drain fecal matter into a pouch/ bag system that is protected through a wafer container that protects the skin from the stool portion ■HCP should have a wound care/ostomy specialist consult with patient before surgery ■Patients are NO longer required to have enemas or go through bowel prep antibiotics before the surgery -Because it does not seem to affect surgical site infections Any type of procedure that include ileostomy or colostomy Need to asses stomach "beefy red stoma" is good Turning blue need to alart the physician Discourgae gassy food or garlic Beans,cabageandesparguscan cause gas

complication of wound healing

■Hemorrhage -Externally -Internally ■Hematoma ■Infection ■Dehiscence Evisceration Hemorrage is bleeding Pietchae will be around the area when there is hemorrhage that is internal Will see hypotension, tachy and monitoring H and H Dehiscence- separation of the incision site at coughing to blow out the stitches, obese patients and diabetics patietns are more at risk Evisceration- this is when your organs are protruding out

post operative phase

■Immediate postop recovery -Report is given to nurse receiving client in post anesthesia care unit (PACU) ■Anesthesia used, fluids lost, replaced, and any complications ■VS q 15mins ■Thorough focused physical assessment ■Monitor and maintain airway, respiratory, circulatory, neurological status, and pain ■Post anesthesia Recovery Score (PARS) identifies when clients are ready to be discharged from PACU ■Surgeon's responsibility to report to family members about client's condition Get a full report, check the patients vitals, check respiratoru rate, lungs, heart rate, and lungs Check the ABC's Want to check for signs of bleeding or infection Going to have some bleeding, but if they have bright red and there is a lot, soaking the compresses every 1 hour This is concerning Do not develop a contracture Cardiac catherization, lay flat for 6-12 hours The patient want to asses if the patient is having pain Want to ask If they can go to the bathroom The goal is to prevent respiratory issues, can do passive or active ROM, SCD- to prevent DVT Cough and deep breathe, ambulate, incentive spirometer If they have abdomen- then they need to splint

complication prevention

■Maintain respiratory function -Turn, cough, and deep breathe q2hr -Incentive spirometer ■Prevent circulatory complications -Apply SCDs or TED hose -Encourage early ambulation -Administer anticoagulants as prescribed ■Rest and comfort -Administer pain meds as prescribed -Positioning Pain medication- sign of pain is increased blood pressure, guarding, they will not move or eat They need to give pain medication to make sure that can get better Worry about respiration so have vital signs before giving vital signs

Inflammatory Disorders

◦The most various types of dermatitis ◦The common inflammatory disorders of the skin are dermatitis or eczema ◦There are disorders are generally characterized by: ◦Pruritus ◦Lesions with indistinct borders Epidermal changes Eczema- walks hand and hand with allergies It itches

Amputation: Post-Op

■Mark bleeding and drainage of on the dressing ■Evaluate phantom limb pain--you may need to explain this sensation· ■Elevate the residual limb on for the first 24 hours to help with edema -Do this only for 24 hours to prevent hip contractures ■Maintain surgical dressing and compression bandage to reduce swelling, minimize the pain and mold the residual limb in preparation for a prosthesis ■Use mild soap and water to clean the suture and dry completely ■If prescribed, massage the skin to the suture line. This mobilizes the scar and prevents it adherence to underlying bone ■Preparing for the prosthesis: instruct patient to gently push the residual limb against pillows and progress to firmer surfaces ■Encourage verbalization of the loss of limb and identify coping mechanisms *do elevate the limb initially for the first 24 hours to prevent contractors Going to wrap the remaining limb of the patient Ask if it is an arm or a leg Want them to start pushing on things As they start pushing on hard surfaces they get used to the prosthesis of it

Phases of wound Repair

■Maturation phase: This last phase of wound healing is known as the remodeling phase and can last up to a year. -In this phase, collagen continues to be deposited and remodeled, and scar tissue is formed and strengthens. •Scar- that will always be there •The gradulation tissue is healed but the remodeling occurs •Last phase

surgical risk factors

■Medications ■ Medical history Medication worry about blood thinner with sugery because they can bleed out Insulin- can cause hyper or hypoglycemia during surgery If they take the regular insulin then they can take get hypoglycemia if they are not eating Hypetensive medications- take vital signs then if they are within normal limits then give the medication If not then hold the medication Anti-depression- can decrease CNS and cause a decrease in respiratory With anesthetics as well, the patient can have increase is respitory with depressants anti-coagulents- NSAID this can cause bleeding Medical history- diabetes, hypertension, cardiac conditions, pulmonary issues, anemia (more increase risk of bleeding)

Thyroidectomy Post-Op Instructions

■Monitor for respiratory distress ■At the bedside have tracheostomy set, oxygen and suction kit ■Maintain semi-fowler position ■Monitor surgical site for edema and signs of bleeding ■Check the dressing anteriorly and at the back of the neck ■Assess level of hoarseness, limit talking ■Avoid neck flexion and stress on the suture line (support neck while moving) ■Monitor for laryngeal nerve damage: airway obstruction, dysphonia, high pitched voice, stridor, dysphagia and restlessness ■Monitor for signs of hypocalcemia and tetany -Wrist spasm,numbness and tingling of face and extremities, positive Chvostek's sign, positive Trousseau's sign, seizures, cardiac dysrhythmias -caused by trauma to the parathyroid gland -Prepare to administer calcium gluconate Monitor for thyroid storm

Post-Op Instructions Con't

■Patient is on 2-3 immunosuppressive drugs for life -Immunosuppressive medications ■Corticosteroids (prednisone), anti-lymphocyte preparations, monoclonal antibodies, cyclosporin A, Prograft -Need to monitor for complications from immunosuppression such as infection, anemia, malignancy, hyperlipidemia, hypertension, bone disease, nephrotoxicity, neurotoxicity, glucose intolerance, nausea, impaired wound healing, hyeperuricemia, hyperkalemia, and hypomagnesium ■Monitor for rejection -Indicated by a rise in serum creatinine -Acute rejection symptoms- ■The patient may develop fever, tenderness over graft site, edema, weight gain, gross hematuriea, decreased urine output, and/or hypertension ■Area over the transplanted kidney may feel firm on palpation -Treatment for acute rejection- ■High doses of corticosteroids and optimizing immunosuppression

Kidney Transplant Post-Operative Instructions

■Patient should not use any illegal drugs before or after transplantation ■Close monitoring of hemodynamic and respiratory statuses, I&Os, electrolyte balance, and daily weights are vital in initial postoperative period ■Diuresis is common and fluid replacement becomes necessary -Increased or excessive production of urine ■A Jackson-Pratt drain may be placed after surgery, next to kidney, to collect lymph fluid Drain is removed when drainage is less than 100mL per day There is the risk of rejection Is pain, fever, will see decrease urine output, and weight gain may get a rash Give them more steroids

Thyroidectomy Pre-Op Instructions

■Pre-Op: -Obtain vitals, weight, electrolyte levels, and asses for hypoglycemia -Instruct the patient how to perform coughing and deep-breathing exerceis and how to support the neck in post-op when coughing and moving -Administer antithyroid medications, propranolol, iodides and glucocorticoids to prevent thyroid storm Pre-op cough and deep breathe And let them know if they have tingling in their face Because if after surgery then they will have calcium imbalance in the parathyroid Watch for positive chrostchek is check, and trusso- is the arm tenses up when the blood pressure cuff is put on, inflate cuff above systolic and wait 3 minutes, if you see any flextion then it's a positive trussos The chrochesk Is tapping on the cheek

process of wound healing

■Primary intention ■ ■Secondary intention ■ -Scar tissue

classifications of surgery

■Seriousness -Major -Minor ■Urgency -Elective -Urgent -Emergency Big review of surgeries we know Cardiac catherization, epidural hematomaia- is urgent Emergency- appendectomy, compound factor, bleeding Total knee replacement, caderact- elective

surgical risk factors

■Smoking - respiratory problems, poor wound healing ■Age- very young, very old ■Nutrition- protein or vitamin deficiency increases risk for complications ■Obesity- increased risk for post-op atelectasis ■Obstructive Sleep Apnea- analgesics and general anesthesia relax the upper airway and may worsen OSA ■Immunosuppression ■DVT •Anyone who goes under any type of surgery they can have complication •People who are smoking •Very old- they can have a higher effect of anesthia or heart, they have decreased recovery factors, increased healing time, it takes them longer to heal Infants there bodies are small, they have a narrow therapeutic index it can cause a big drug effect, there bodies are not as developed Airway, malignant hypothermia- they will be cold Protien helps with wound healing Obesity increase the complication of atalectsis There is a lot of pressure of them laying on their chest

A, B, C Increased intracranial pressure

■The nurse is teaching a client who underwent a hypophysectomy for hyperpituitarism about self-management. Which actions performed by the client could cause complications on the second post-operative day? Select all that apply. ■A-Nose blowing ■B-Tooth brushing ■C-Bending forward ■D-Breathing through the mouth E-Lying in a semi-Fowler position

D-non oozing means that you do not need to clean it because its dry and intact

■The nurse teaches a nursing student about the discharge instructions to be given to a post-operative client. Which statement made by the nursing student indicates the nurse needs to intervene? ■A-"I should teach the client about using topical antibiotics." ■B- "I should teach the client about how to change wound dressings." ■C-"I should instruct the client about signs and symptoms of an infection." ■D-"I should instruct the client that the non-oozing wound should be cleaned with saline solution."

Pre-Op: Informed Consent

■The patient's or guardian's written consent for the surgery is a vital portion of preoperative care. ■By law, the physician who will perform the procedure must explain the risks and benefits of the surgery, along with other treatment options. ■The nurse is often the person who actually witnesses the patient's signature on the consent form. ■The patient must understands everything he or she has been told ■Patients who are mentally impaired, heavily sedated, or critically ill are not considered legally able to give consent. -Next of kin (spouse, adult child, adult sibling, or person with medical power of attorney ) may act as a surrogate and sign the consent form. ■Children under age 18 must have a parent or guardian sign. Informed consent- just the doctor and the patient sign it You observe it

Postoperative assessment

■Thorough focused assessment on arrival ■VS q 1hr for the first 4hrs, then every 4hrs ■Document assessment -Physical assessment -VS -Level of consciousness -Condition of dressings and drains -IV fluid status -Urinary output measurements -Comfort level -Pain Want to check vital signs as often as possible Patient that goes to surgery may have too much IV or too much replacement Monitor their urine output

Kidney Transplant Pre-Op Instructions

■Treatment before surgery -Immunologic studies ■In-depth tissue typing ■Blood typing ■Human leukocyte antigen (HLA) ■Patient education -The procedure -Care after the surgery -Compliance of medication regiment post-op -In-depth patient assessment Coordination of diagnostic tests The HLA is the protiens in the humans that are responsible for regulation of immune system BUN and creatine is what we are watching and we also watch for potassium

sutures

■Types of wound closures. ■Sutures are used to bring the edges of a wound together in order to speed wound healing and reduce scar formation. •Depends on the physician Steri-strips- the patient is open to abdomen They need to know how to care At least 48 hours, do not pull the strips off let them fall by themselves If they are itching or if the sides roll up then you can cut the sides that are rolled up Do not need to clean this as a nurse, need to make sure that it is dry Need to retape on skin when the sides turn And do not itch it

laboratory assessment

■Urinalysis ■• Blood type and screen ■• Complete blood count or hemoglobin level and hematocrit ■• Clotting studies (prothrombin time [PT], international normalized ratio [INR], activated partial thromboplastin time [aPTT], platelet count) ■• Electrolyte levels ■• Serum creatinine and blood urea nitrogen levels ■• Depending on a female patient's age and the nature of the planned procedure, a pregnancy test may also be needed in the urine checking for protein, glucose, blood Cloudy urine Blood type should be test, they should have coombs test that is indirect test Check indirect hemoglobin- if this patient is having low H and H then they will bleed more The H and H needs to be close to normal or normal PT (12-15) /INR (1-2) PTT (25-35) Platelet normal level is 150-450,000 If the platelet level is lower then 150 is thrombocyopnia Want you to detect low platelet is thrombocytopenia Worry about too much clotting is thrombocytosis- this is when it is over 450,000 Worry about clotting and worry about stroke and DVT Female patients need to do pregnancy test before sending patient to surgery

Intraoperative Phase

■Usually 2 roles for the RN in the OR -Circulating nurse, must be an RN -Scrub nurse, can be an RN, surgical technician -Advanced practice nurse (CRNA) PTT- is heparin PT/INR- cumadin or warfarin When you check heparin that is IV then you need to make sure that it is continuing to get into the value You want to question and worry about short acting because it last longer It has a faster effect compared to the long acting is a longer insulin The endocrinologist will adjust the long acting insulin There is 2 roles of the nurse. There is a circulating nurse that does documentation and monitoring how the room is working, document the blood loss And the scrub nurse she is the one that is in the sterile field, she hands the insturments to the doctor

types of dressing

■WOCN Recommendations -Use a dressing that maintains moist environment - -Use topical dressings as determined by assessment - -Choose dressing that keeps surrounding intact - -Choose dressing that controls exudate - Eliminate wound dead space by packing the wound(V.A.C.)

UNEXPECTED OUTCOMES AND UNRELATED INTERVENTIONS

■WOUND APPEARS INFLAMMED OR TENDER, DRAINAGE INCREASED AND ODOR IS PURULENT ■ ■PATIENT REPORTS INCREASE PAIN ■ ■NEGATIVE PRESSURE SEAL HAS BROKEN Increase pain If the negative seal breaks then it can introduce bacteria Then you call the wound doctor if the wound vaccume breaks

B- because can increase intracranial pressure

■Which instruction given by the nurse ensures good healing in a client recovering after surgical removal of the pituitary gland by endoscopic transnasal approach? ■A-"Decrease fluid intake." ■B-"Increase high-fiber food intake." ■C-"Bend over from the waist to pick up fallen objects." ■D-"Brush teeth regularly with a medium-bristle brush."

scleroderma

◦Facial skin becomes very tight ◦Fingers become tapered and flexed; nails and fingertips can be lost from atrophy ◦Mouth may not open completely 50% of patients die within 5 years

scleroderma

◦Sclerosis of the skin that can progress to the internal organs ◦The disease is associated with several antibodies ◦Lesions exhibit massive deposits of collagen with inflammation, vascular changes, and capillary dilation ◦Skin is hard, hypopigmented, taut, and tightly connected to underlying tissue Muscle rigidity- its hardening and tightening of the skin Someones this can mimic raynauds disease This can occur with cold and the fingers become cold and numb It can effect the lungs and heart and if not treated right away can be life threatening Give vasodilators to help with oxygenation Also give immunosuppressors- relieve the signs and symptoms