115 Exam study guide

Normal O2 values in ABG test

95%-100% Older adults: values may be slightly lower Decreased levels indicate possible impaired ability of hemoglobin to release oxygen to tissues.

Assessment of the respiratory system - Diagnostic Assessment - pulse oximetry, Bronchoscopy, pulmonary function tests - know all you need to know about these procedures (preparation, interpretations, interventions, and follow-up care).

Pulse Oximetry. Pulse oximetry identifies hemoglobin saturation with oxygen. Usually hemoglobin is almost 100% saturated with oxygen in superficial tissues. The pulse oximeter uses a wave of infrared light and a sensor placed on the patient's finger, toe, nose, earlobe, or forehead (Fig. 27-12). Ideal normal pulse oximetry values are 95% to 100%. Normal values are a little lower in older patients and in patients with dark skin. To avoid confusion with the PaO2 values from arterial blood gases, pulse oximetry readings are recorded as the SpO2 (peripheral arterial oxygen saturation) or SaO2. Causes for low readings include patient movement, hypothermia, decreased peripheral blood flow, ambient light (sunlight, infrared lamps), decreased hemoglobin, edema, and 509fingernail polish. When patients have any degree of impaired peripheral blood flow, the most accurate place to test oxygen saturation is on the forehead. Covering the sensor with a fingertip cut from a glove or changing its position may help accuracy if too much ambient light is present. Results lower than 91% (and certainly below 86%) are an emergency and require immediate assessment and treatment. When the SpO2 is below 85%, body tissues have a difficult time becoming oxygenated. An SpO2 lower than 70% is usually life threatening, but in some cases, values below 80% may be life threatening. Pulse oximetry is less accurate at lower values. Pulmonary Function Tests. Pulmonary function tests (PFTs) assess lung function and breathing problems. These tests measure lung volumes and capacities, flow rates, diffusion capacity, GAS EXCHANGE, airway resistance, and distribution of ventilation. The results are interpreted by comparing the patient's data with expected findings for age, gender, race, height, weight, and smoking status. The PFTs are useful in screening patients for lung disease even before the onset of manifestations. Repeated testing over time provides data that may be used to guide management (e.g., changes in lung function can support a decision to continue, change, or discontinue a specific therapy). Testing before surgery may identify patients at risk for lung complications after surgery. The most common reason for performing PFTs is to determine the cause of dyspnea. When performed while the patient exercises, PFTs help determine whether dyspnea is caused by lung or cardiac dysfunction or by muscle weakness. Patient Preparation. Explain the purpose of the tests, and advise the patient not to smoke for 6 to 8 hours before testing. Depending on the reasons for testing, bronchodilator drugs may be withheld for 4 to 6 hours before the test. The patient with breathing problems often fears further breathlessness and is anxious before these "breathing" tests. Help reduce anxiety by describing what will happen during and after the testing. Procedure. PFTs can be performed at the bedside or in the respiratory laboratory by a respiratory therapist or respiratory technician. The patient is asked to breathe through the mouth only. A nose clip may be used to prevent air from escaping. The patient performs different breathing maneuvers while measurements are obtained. Follow-up Care. Because many breathing maneuvers are performed during PFTs, assess the patient for increased dyspnea or bronchospasm after these studies. Document any drugs given during testing. A bronchoscopy is the insertion of a tube in the airways, usually as far as the secondary bronchi, to view airway structures and obtain tissue samples for biopsy or culture. It is used to diagnose and manage pulmonary diseases. Rigid bronchoscopy usually requires general anesthesia in the operating room. Flexible bronchoscopy can be performed in the intensive care unit (ICU) with low-dose sedation. A flexible bronchoscopy is used to evaluate the airway and to assist with placing or changing an endotracheal tube, collecting specimens, and diagnosing infections. It is often used for lung cancer staging and removal of secretions that are not cleared with normal suctioning procedures. Stents can be placed during bronchoscopy to open up strictures in the trachea and bronchus. Patient Preparation. Explain the procedure to the patient, and verify that consent for the procedure was obtained. Expected outcomes, risks, and benefits of the procedure must be discussed with the patient by the health care provider performing the procedure. Document patient allergies. Other tests before the procedure may include a complete blood count, platelet count, prothrombin time, electrolytes, and chest x-ray. The patient should be NPO for 4 to 8 hours before the procedure to reduce the risk for aspiration. Premedication with one of the benzodiazepines may be used to provide both sedation and amnesia. Opioids may also be used. Procedure. The procedure can be done in a bronchoscopy suite or at the ICU bedside. The bronchoscope is inserted through either the naris or the oropharynx. Maintain IV access, and continuously monitor the patient's pulse, blood pressure, 511respiratory rate, and oxygen saturation. Apply supplemental oxygen. Follow-up Care. Monitor the patient until the effects of the sedation have resolved and a gag reflex has returned. Continue to monitor vital signs, including oxygen saturation, and assess breath sounds every 15 minutes for the first 2 hours. Also assess for potential complications, including bleeding, infection, or hypoxemia.

Potassium (hypokalemia, hyperkalemia, & risk factors)

Any potassium imbalance—hypokalemia or hyperkalemia—must be corrected before surgery. 3.5-5.0 mEq/L, or 3.5-5.0 mmol/L Increased: Dehydration Kidney impairment Acidosis Cellular/tissue damage Hemolysis of the specimen Decreased: NPO status when potassium replacement is inadequate Excessive use of non-potassium-sparing diuretics Vomiting Malnutrition Diarrhea Alkalosis Elevated: Hyperkalemia; dehydration; kidney disease; acidosis; adrenal insufficiency; crush injuries Low: Hypokalemia; fluid overload; diuretic therapy; alkalosis; insulin administration; hyperaldosteronism Because potassium levels in the blood and interstitial fluid are so low, any change seriously affects physiologic activities. For example, a decrease in blood potassium of only 1 mEq/L (from 4 mEq/L to 3 mEq/L) is a 25% difference in total ECF potassium concentration. In contrast, a 1 mEq/L decrease in blood sodium level (from 130 mEq/L to 129 mEq/L) is, overall, a much smaller change (less than 1%) in total ECF sodium concentration. Hypokalemia is an ELECTROLYTE imbalance in which the serum potassium level is below 3.5 mEq/L (mmol/L). It can be life threatening because every body system is affected. Actual Potassium Deficits • Inappropriate or excessive use of drugs: • Diuretics • Digitalis • Corticosteroids • Increased secretion of aldosterone • Cushing's syndrome • Diarrhea • Vomiting • Wound drainage (especially gastrointestinal) • Prolonged nasogastric suction • Heat-induced excessive diaphoresis • Kidney disease impairing reabsorption of potassium • Nothing by mouthRelative Potassium Deficits • Alkalosis • Hyperinsulinism • Hyperalimentation • Total parenteral nutrition • Water intoxication • IV therapy with potassium-poor solutions Age is important because urine concentrating ability decreases with aging, which increases potassium loss. Older adults are more likely to use drugs that lead to potassium loss. Drugs, especially diuretics, corticosteroids, and beta-adrenergic agonists or antagonists, can increase potassium loss through the kidneys. Ask about prescription and over-the-counter drug use. In patients taking digoxin (Lanoxin, Novo-Digoxin image), hypokalemia increases the sensitivity of the cardiac muscle to the drug and may result in digoxin toxicity, even when the digoxin level is within the therapeutic range. Ask whether the patient takes a potassium supplement, such as potassium chloride (KCl), or eats foods that have high concentrations of potassium, such as bananas, citrus juices, raisins, and meat. The patient may not be taking the supplement as prescribed because of its unpleasant taste. Disease can lead to potassium loss. Ask about chronic disorders, recent illnesses, and medical or surgical interventions. A thorough nutrition history, including a typical day's food and beverage intake, helps identify patients at risk for hypokalemia. Respiratory changes occur because of respiratory muscle weakness resulting in shallow respirations. Thus respiratory status should be assessed first in any patient who might have hypokalemia. Assess the patient's breath sounds, ease of respiratory effort, color of nail beds and mucous membranes, and rate and depth of respiration. Musculoskeletal changes include skeletal muscle weakness. A stronger stimulus is needed to begin muscle contraction. A patient may be too weak to stand. Hand grasps are weak, and deep tendon reflexes may be reduced (hyporeflexia). Severe hypokalemia causes flaccid paralysis. Assess for muscle weakness and the patient's ability to perform ADLs. Cardiovascular changes are assessed by palpating the peripheral pulses. In hypokalemia, the pulse is usually thready and weak. Palpation is difficult, and the pulse is easily blocked with light pressure. The pulse rate can range from very slow to very rapid, and an irregular heartbeat (dysrhythmia) may be present. Measure blood pressure with the patient in the lying, sitting, and standing positions, because orthostatic (postural) hypotension occurs with hypokalemia. Neurologic changes from hypokalemia include altered mental status. The patient may have short-term irritability and anxiety followed by lethargy that progresses to acute confusion and coma as hypokalemia worsens. Behavioral changes caused by hypokalemia can occur quickly. The patient may be lethargic and unable to perform simple problem-solving tasks such as counting by threes. As hypokalemia progresses, confusion increases and coma may develop. Intestinal changes occur with hypokalemia because GI smooth muscle contractions are decreased, which leads to decreased peristalsis. Bowel sounds are hypoactive, and nausea, vomiting, constipation, and abdominal distention are common. Measure abdominal girth, and auscultate for bowel sounds in all four abdominal quadrants. Severe hypokalemia can cause the absence of peristalsis (paralytic ileus). Laboratory data confirm hypokalemia (serum potassium value below 3.5 mEq/L [mmol/L]). Hypokalemia causes ECG changes in the heart, including ST-segment depression, flat or inverted T waves, and increased U waves. Dysrhythmias can lead to death, particularly in older adults who are taking digoxin. image Interventions Interventions for hypokalemia focus on preventing potassium loss, increasing serum potassium levels, and ensuring patient safety. Drug and nutrition therapies help restore normal serum potassium levels. The priorities for nursing care of the patient with hypokalemia are (1) ensuring adequate oxygenation, patient safety for falls prevention, and prevention of injury from potassium administration and (2) monitoring the patient's response to therapy. Potassium is given IV for severe hypokalemia. The drug is available in different concentrations, and this drug carries a high alert warning as a concentrated electrolyte solution. Hyperkalemia is rare in people with normal kidney function. Most cases of hyperkalemia occur in hospitalized patients and in those undergoing medical treatment. Those at greatest risk are chronically ill patients, debilitated patients, and older adults (Table 11-8). TABLE 11-8 Common Causes of Hyperkalemia Actual Potassium Excesses • Overingestion of potassium-containing foods or medications: • Salt substitutes • Potassium chloride • Rapid infusion of potassium-containing IV solution • Bolus IV potassium injections • Transfusions of whole blood or packed cells • Adrenal insufficiency • Kidney failure • Potassium-sparing diuretics • Angiotensin-converting enzyme inhibitors (ACEIs)Relative Potassium Excesses • Tissue damage • Acidosis • Hyperuricemia • Uncontrolled diabetes mellitus

Electrolyte Imbalance - Electrolyte imbalance (hypo- & hyper-) the causes, risk factors, clinical manifestations, treatments/interventions - including diet, medications & appropriate teaching).

Changes in electrolyte, hematocrit, and hemoglobin levels often occur during the first 24 to 48 hours after surgery because of blood and fluid loss and the body's reaction to the surgical process. Fluid loss with minimal blood loss may cause elevated laboratory values. Such test results appear increased but actually are concentrated normal values. An indication of INFECTION is an increase in the band cells (immature neutrophils) in the white blood cell differential count, known as a "left-shift" or bandemia. The source of infection may be the respiratory system, urinary tract, surgical wound, or IV site. Obtain specimens for culture and sensitivity testing, and monitor the culture reports at 24, 48, and 72 hours. Notify the surgeon of positive culture results. (See Chapters 17 and 23 for information on infection.) 266 Arterial blood gas (ABG) tests may be needed for patients who have respiratory or cardiac disease, those undergoing mechanical ventilation after surgery, and those who had chest surgery. Review ABG results, and notify the surgeon of any acid-base imbalance or hypoxemia that indicates poor GAS EXCHANGE. Monitoring. Monitor the patient's oxygen saturation (SpO2) for adequacy of GAS EXCHANGE with pulse oximetry at least every hour or more often, according to the patient's condition. Patients who normally have a low PaO2, such as those with lung disease or older adults, are at higher risk for hypoxemia. An older adult is often prescribed low-dose oxygen therapy for the first 12 to 24 hours after surgery to reduce confusion from anesthesia and sedation (Sullivan, 2011). A patient who received moderate sedation with a benzodiazepine such as midazolam (Versed) or lorazepam (Ativan, Nu-Loraz image) may be overly sedated or have respiratory depression sufficient to need reversal with flumazenil (Romazicon) (Chart 16-4). Hypothermia after surgery causes shivering, which increases oxygen demand and can induce hypoxemia. Many rewarming methods can be used, although prevention is more important. The highest incidence of hypoxemia after surgery occurs on the second postoperative day. The body works best when FLUID AND ELECTROLYTE BALANCE is kept within a narrow range of normal. For example, no body system works well if 2 liters of blood volume are gained or lost. To keep conditions as close to normal as possible (known as homeostasis), the body has many control actions (known as homeostatic mechanisms) to prevent dangerous changes. Homeostasis requires that the body's volume and composition of FLUIDS remain within normal limits. Water (fluid) is the most common substance in the body, making up about 55% to 60% of total weight for healthy younger adults and 50% to 55% of total weight for healthy older adults. This water is divided into two main compartments (spaces)—the fluid outside the cells (extracellular fluid [ECF]); and the fluid inside the cells (intracellular fluid [ICF]). The ECF space is about one third (about 15 L) of the total body water. The ECF includes interstitial fluid (fluid between cells, sometimes called the "third space"); blood, lymph, bone, and connective tissue water; and the transcellular FLUIDS. Transcellular fluids are in special body spaces and include cerebrospinal fluid, synovial fluid, peritoneal fluid, and pleural fluid. ICF is about two thirds (about 25 L) of total body water. Fig. 11-1 shows normal total body water distribution. Water is needed to deliver dissolved nutrients, ELECTROLYTES, and other substances to all organs, tissues, and cells. In health, the volume of water in the fluid compartments remains within the normal range although the water moves constantly between compartments. Changes in either the amount of water or the amount of electrolytes in body FLUIDS can affect the functioning of all cells, tissues, and organs. For proper function, the volume of all body fluids and the types and amount of dissolved substances must be carefully balanced. Osmosis and filtration act together at the capillary membrane to maintain both extracellular fluid (ECF) and intracellular fluid (ICF) volumes within their normal ranges. The thirst mechanism is an example of how osmosis helps maintain homeostasis. The feeling of thirst is caused by the activation of cells in the brain that respond to changes in ECF osmolarity. 152These cells, so very sensitive to changes in ECF osmolarity, are called osmoreceptors. When a person loses body water but most of the particles remain, such as through excessive sweating, ECF volume is decreased and osmolarity is increased (is hypertonic). The cells in the thirst center shrink as water moves from the cells into the hypertonic ECF. The shrinking of these cells triggers a person's awareness of thirst and increases the urge to drink. Drinking replaces the amount of water lost through sweating and dilutes the ECF osmolarity, restoring it to normal. The thirst mechanism is less sensitive in older adults, increasing their risk for dehydration. Measured by subtracting the amount returned from the amount instilled. A rising blood osmolarity or a decreasing blood volume triggers the sensation of thirst. Sensations such as mouth dryness or the thought that a person has not had a drink recently also triggers the thirst drive. An adult takes in about 2300 mL of fluid daily from food and liquids. Fluid loss occurs through several routes (see Table 11-2). The kidney is the most important and the most sensitive water loss route because it is regulated and is adjustable. The volume of urine excreted daily varies depending on the amount of FLUID taken in and the body's need to conserve fluids. The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. This minimum volume is called the obligatory urine output. If the 24-hour urine output falls below the obligatory output amount, wastes are retained and can cause lethal electrolyte imbalances, acidosis, and a toxic buildup of nitrogen. The ability of the kidneys to make either concentrated or very dilute urine helps maintain FLUID BALANCE. The kidney works with various hormones to maintain fluid balance when extracellular fluid concentrations, volumes, or pressures change. Other normal water loss occurs through the skin, the lungs, and the intestinal tract. Water losses also can result from salivation, drainage from fistulas and drains, and GI suction. Water loss from the skin, lungs, and stool is called insensible water loss because there are no mechanisms to control this loss. In a healthy adult, insensible water loss is about 500 to 1000 mL/day. This loss increases greatly during thyroid crisis, trauma, burns, states of extreme stress, and fever. Insensible water loss also increases when the environment is hot and dry. Patients at risk for increased insensible water loss include those being mechanically ventilated, those with rapid respirations (tachypnea), and those undergoing continuous GI suctioning. Loss by sweating is variable and can reach a maximum rate of about 2 L/hr. Water loss through stool is normally minimal. However, this loss can increase greatly with severe diarrhea or excessive fistula drainage. If not balanced by intake, insensible loss can lead to severe dehydration and electrolyte imbalances. Hormonal Regulation of Fluid Balance Three hormones help control FLUID AND ELECTROLYTE BALANCE. These are aldosterone, antidiuretic hormone (ADH), and natriuretic peptide (NP). Aldosterone is a hormone secreted by the adrenal cortex whenever sodium levels in the extracellular fluid (ECF) are decreased. Aldosterone prevents both water and sodium loss. When aldosterone is secreted, it acts on the kidney nephrons, triggering them to reabsorb sodium and water from the urine back into the blood. This action increases blood osmolarity and blood volume. Aldosterone prevents excessive kidney excretion of sodium. It also helps prevent blood potassium levels from becoming too high. Antidiuretic hormone (ADH), or vasopressin, is released from the posterior pituitary gland in response to changes in blood osmolarity. The hypothalamus contains the osmoreceptors that are sensitive to changes in blood osmolarity. Increased blood osmolarity, especially an increase in the level of plasma sodium, results in a slight shrinkage of these cells and triggers ADH release from the posterior pituitary gland. Because the action of ADH retains just water, it only indirectly regulates electrolyte retention or excretion. ADH acts directly on kidney tubules and collecting ducts, making them more permeable to water only. As a result, more water is reabsorbed by these tubules and returned to the blood, decreasing blood osmolarity by making it more dilute. When blood osmolarity decreases with low plasma sodium levels, the osmoreceptors swell slightly and inhibit ADH release. Less water is then reabsorbed, and more is lost from the body in the urine. As a result, the amount of water in the extracellular fluid (ECF) decreases, bringing osmolarity up to normal. Natriuretic peptides (NPs) are hormones secreted by special cells that line the atria of the heart (atrial natriuretic peptide [ANP]) and the ventricles of the heart. (The peptide secreted by the heart ventricular cells is known as brain natriuretic peptide [BNP] because it was first discovered in the brain.) These peptides are secreted in response to increased blood volume and blood pressure, which stretch the heart tissue. NP binds to receptors in the nephrons, creating effects that are 154opposite of aldosterone. Kidney reabsorption of sodium is inhibited at the same time that glomerular filtration is increased, causing increased urine output. The outcome is decreased circulating blood volume and decreased blood osmolarity. Significance of Fluid Balance The Renin-Angiotensin II Pathway The human body requires FLUID AND ELECTROLYTE BALANCE, as well as a balance of acids and bases, for best function. The most important fluids to keep in balance are the blood volume (plasma volume) and the fluid inside the cells (intracellular fluid). Of these two, the most critical FLUID BALANCE to prevent death is maintaining blood volume at a sufficient level for blood pressure to remain high enough to ensure adequate perfusion and gas exchange of all organs and tissues. Balance of both water and electrolytes is needed for this very vital function. Because the kidney is a major regulator of water and sodium balance to maintain blood pressure and perfusion to all tissues and organs, the kidneys monitor blood pressure, blood volume, blood oxygen levels, and blood osmolarity (related to sodium concentration). When the kidneys sense that any one of these parameters is getting low, they begin to secrete a substance called renin that sets into motion a group of hormonal and blood vessel responses to ensure that blood pressure is raised back up to normal So, the triggering event is any change in the blood that indicates to the kidney that tissue and organ perfusion are at risk. Low blood pressure is a triggering event because when it gets too low, blood cannot flow through vessels into tissues and organs. Anything that reduces blood volume (e.g., dehydration, hemorrhage) below a critical level always lowers blood pressure. Low blood oxygen levels also are triggering events because with too little oxygen in the blood, even if the blood reaches the tissues and organs, it cannot supply the needed oxygen and the tissues and organs could die. A low blood sodium level also is a triggering event because sodium and water are closely linked. Where sodium goes, water follows. So, anything that causes the blood to have too little sodium prevents water from staying in the blood. The result is low blood volume with low blood pressure and poor tissue perfusion. An additional application of this pathway is related to management of hypertension (high blood pressure). Patients who have hypertension are often asked to limit their intake of sodium. The reason for this is that a high sodium intake raises the blood level of sodium, causing more water to be retained in the blood volume and raising blood pressure. Drug therapy for hypertension management may include diuretic drugs that increase the excretion of sodium so that less is present in the blood, resulting in a lower blood volume. Another class of drugs often used to manage blood pressure is the "ACE inhibitors." These drugs disrupt the renin-angiotensin II pathway by reducing the amount of angiotensin-converting enzyme (ACE) made so that less angiotensin II is present. With less angiotensin II, there is less vasoconstriction and reduced peripheral resistance, less aldosterone production, and greater excretion of water and sodium in the urine. All of these responses lead to decreased blood volume and blood pressure. Another class of drugs used to manage hypertension is the angiotensin receptor blockers (ARBs). These drugs disrupt the renin-angiotensin II pathway by blocking the receptors that bind with angiotensin II so that the tissues cannot respond to it and blood pressure is lowered. Electrolytes, or ions, are substances dissolved in body FLUID that carry an electrical charge. Cations have positive charges; anions have negative charges. Body fluids are electrically neutral, which means that the number of positive ions is balanced by an equal number of negative ions. However, the distribution of ions differs in the extracellular fluid (ECF) and the intracellular fluid Most ELECTROLYTES have different concentrations in the ICF and ECF. This concentration difference helps maintain membrane excitability and allows nerve impulse transmission. The normal ranges of electrolyte concentration are very narrow. So, even small changes in these levels can cause major problems. Electrolyte imbalances can occur in healthy people as a result of changes in fluid intake and output. These imbalances are usually mild and are easily corrected. Severe electrolyte imbalances with actual losses or retention of specific electrolytes are life threatening and can occur in any setting. People at greatest risk for severe imbalances are older patients, patients with chronic kidney or endocrine disorders, and those who are taking drugs that alter FLUID AND ELECTROLYTE BALANCE. All ill people are at some risk for electrolyte imbalances. ELECTROLYTE BALANCE occurs by matching the dietary intake of electrolytes with the kidney excretion or reabsorption of 161electrolytes. For example, the plasma level of potassium is maintained between 3.5 and 5.0 mEq/L (mmol/L). The high potassium level in foods such as meat and citrus fruit could increase the ECF potassium level and lead to major problems. In health, this does not occur because kidney excretion of potassium keeps pace with potassium intake and prevents major changes in the blood potassium level.

Chronic Obstructive Pulmonary Disease (COPD) - Chronic Bronchitis + Emphysema - Physical assessment findings

Chronic obstructive pulmonary diseases (COPD) include emphysema and chronic bronchitis. Although these are separate disorders with different pathologic processes, many patients with emphysema also have chronic bronchitis at the same time chronic obstructive pulmonary disease (COPD). Emphysema. The two major changes that occur with emphysema are loss of lung elasticity and hyperinflation of the lung (see Fig. 30-1). These changes result in dyspnea and the need for an increased respiratory rate. In the healthy lung, enzymes called proteases are present to destroy and eliminate particulates and organisms inhaled during breathing. If these proteases are present in higher-than-normal levels, they damage the alveoli and the small airways by breaking down elastin. Over time, alveolar sacs lose their elasticity and the small airways collapse or narrow. Some alveoli are destroyed, and others become large and flabby, with less area for GAS EXCHANGE. An increased amount of air is trapped in the lungs. Causes of air trapping are loss of elastic recoil in the alveolar walls, overstretching and enlargement of the alveoli into air-filled spaces called bullae, and collapse of small bronchioles. These changes greatly increase the work of breathing. The hyperinflated lung flattens the diaphragm (Fig. 30-7), weakening the effectiveness of this muscle. As a result, the patient with emphysema needs to use accessory muscles in the neck, chest wall, and abdomen to inhale and exhale. This increased effort increases the need for oxygen, making the patient have an "air hunger" sensation. Inhalation starts before exhalation is completed, resulting in an uncoordinated breathing pattern. GAS EXCHANGE is affected by the increased work of breathing and the loss of alveolar tissue. Although some alveoli enlarge, the curves of alveolar walls decrease and less surface area is available for gas exchange. Often the patient adjusts by increasing the respiratory rate, so arterial blood gas (ABG) values may not show gas exchange problems until the patient has advanced disease. Then carbon dioxide is produced faster than it can be eliminated, resulting in carbon dioxide retention and chronic respiratory acidosis (see Chapter 12). The patient with late-stage emphysema also has a low arterial oxygen (PaO2) level because it is difficult for oxygen to move from diseased alveoli into the blood. 558 Emphysema is classified as panlobular, centrilobular, or paraseptal depending on the pattern of destruction and dilation of the gas-exchanging units (acini) (see Fig. 30-1). Each type can occur alone or in combination in the same lung. Most are associated with smoking or chronic exposure to other inhaled particles such as wood smoke and biomass fuels (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2014). Chronic Bronchitis. Bronchitis is an INFLAMMATION of the bronchi and bronchioles caused by exposure to irritants, especially cigarette smoke. The irritant triggers inflammation, vasodilation, mucosal edema, congestion, and bronchospasm. Bronchitis affects only the airways, not the alveoli. Chronic INFLAMMATION increases the number and size of mucus glands, which produce large amounts of thick mucus. The bronchial walls thicken and impair airflow. This thickening, along with excessive mucus, blocks some of the smaller airways and narrows larger ones. Mucus provides a breeding ground for organisms and leads to chronic infection. Chronic bronchitis impairs airflow and GAS EXCHANGE because mucus plugs and infection narrow the airways. As a result, the PaO2 level decreases (hypoxemia) and the arterial carbon dioxide (PaCO2) level increases (respiratory acidosis). Cigarette smoking is the greatest risk factor for COPD. The patient with a 20-pack-year history or longer often has early-stage COPD with changes in pulmonary function tests (PFTs). The inhaled smoke triggers the release of excessive proteases in the lungs. These enzymes break down elastin, the major component of alveoli. By impairing the action of cilia, smoking also inhibits the cilia from clearing the bronchi of mucus, cellular debris, and fluid. General appearance can provide clues about respiratory status and energy level. Observe weight in proportion to height, posture, mobility, muscle mass, and overall hygiene. The patient with increasingly severe COPD is thin, with loss of muscle mass in the extremities, although the neck muscles may be enlarged. He or she tends to be slow moving and slightly stooped. The person often sits in a forward-bending posture with the arms held forward, a position known as the orthopneic or tripod position (Fig. 30-8). When dyspnea becomes severe, activity intolerance may be so great that bathing and general grooming are neglected. Respiratory changes occur as a result of obstruction, changes in chest size, and fatigue. Inspect the chest and assess the breathing rate and pattern. The patient with respiratory muscle fatigue breathes with rapid, shallow respirations and may have an abnormal breathing pattern in which the abdominal wall is sucked in during inspiration or may use accessory muscles in the abdomen or neck. During an acute exacerbation, the respiratory rate could be as high as 40 to 50 breaths/min and requires immediate medical attention. As respiratory muscles become fatigued, respiratory movement is jerky and appears uncoordinated. Check the patient's chest for retractions and for asymmetric chest expansion. The patient with emphysema has limited diaphragmatic movement (excursion) because the diaphragm is flattened and below its usual resting state. Chest vibration (fremitus) is often decreased and the chest sounds hyperresonant on percussion because of trapped air. Auscultate the chest to assess the depth of inspiration and any abnormal breath sounds. Wheezes and other abnormal sounds often occur on inspiration and expiration, although crackles are usually not present. Reduced breath sounds are common, especially with emphysema. Note the pitch and location of the sound and the point in the respiratory cycle at which the sound is heard. A silent chest may indicate serious airflow obstruction or pneumothorax. 561 Assess the degree of dyspnea using a Visual Analog Dyspnea Scale (VADS), which is a straight line with verbal anchors at the beginning and end of a 100-mm line (Fig. 30-9). Ask the patient to place a mark on the line to indicate his or her perceived breathing difficulty. Document the response, and use this scale to determine the therapy effectiveness and pace the patient's activities. Examine the patient's chest for the presence of a "barrel chest" (see Fig. 30-3). With a barrel chest, the ratio between the anteroposterior (AP) diameter of the chest and its lateral diameter is 1 : 1 rather than the normal ratio of 1 : 1.5, as a result of lung overinflation and diaphragm flattening. The patient with chronic bronchitis often has a cyanotic, or blue-tinged, dusky appearance and has excessive sputum production. Assess for cyanosis, delayed capillary refill, and finger clubbing (Fig. 30-10), which indicate chronically decreased arterial oxygen levels. Cardiac changes occur as a result of the anatomic changes associated with COPD. Assess the patient's heart rate and rhythm. Check for swelling of the feet and ankles (dependent edema) or other manifestations of right-sided heart failure. Examine nail beds and oral mucous membranes. In late-stage emphysema the patient may have pallor or cyanosis and is usually underweight.

Nursing interventions - Diaphragmatic breathing, Care of a patient with thick, tenacious secretions

Interventions. Most patients with COPD use nonsurgical management to improve or maintain GAS EXCHANGE. Surgical management requires that the patient meet strict criteria. Nonsurgical Management. Nursing management for patients with COPD focuses on airway maintenance, monitoring, breathing techniques, positioning, effective coughing, oxygen therapy, exercise conditioning, suctioning, hydration, and use of a vibratory positive-pressure device. A nursing priority is to teach the patient how to be a partner in COPD management by participating in therapies to improve GAS EXCHANGE and by adhering to prescribed drug therapy. Before any intervention, assess the breathing rate, rhythm, depth, and use of accessory muscles. The accessory muscles are less efficient than the diaphragm, and the work of breathing increases. Determine whether any factors are contributing to the increased work of breathing, such as respiratory infection. Airway maintenance is the most important focus of interventions to improve GAS EXCHANGE. needed for patients in respiratory failure. Breathing Techniques. Diaphragmatic or abdominal and pursed-lip breathing may be helpful for managing dyspneic episodes. Teach the patient to use these techniques, shown in Chart 30-10, during all activities to reduce the amount of stale air in the lungs and manage dyspnea. Teach these techniques when the patient has less dyspnea. In diaphragmatic breathing, the patient consciously increases movement of the diaphragm. Lying on the back allows the abdomen to relax. Breathing through pursed lips creates mild resistance, which prolongs exhalation and increases airway pressure. This technique delays airway compression and reduces air trapping. Pursed-lip breathing can be used during diaphragmatic or abdominal breathing. Positioning. Placing the patient in an upright position with the head of the bed elevated can help alleviate dyspnea by increasing chest expansion and keeping the diaphragm in the 563proper position to contract. This position conserves energy by supporting the patient's arms and upper body. Assist the patient who can tolerate sitting in a chair out of bed for 1-hour periods 2 or 3 times a day. This position also helps move secretions. Effective Coughing. Coughing effectively can improve GAS EXCHANGE by helping increase airflow in the larger airways. The patient with COPD often has difficulty with removal of secretions, which results in poor gas exchange and oxygenation. Excessive mucus also increases the risk for respiratory infections. Controlled coughing is helpful in removing excessive mucus. Teach the patient to cough on arising in the morning to eliminate mucus that collected during the night. Coughing to clear mucus before mealtimes may make meals more pleasant. Coughing before bedtime may help clear lungs for a less interrupted night's sleep. For effective coughing, teach the patient to sit in a chair or on the side of a bed with feet placed firmly on the floor. Instruct him or her to turn the shoulders inward and to bend the head slightly downward, hugging a pillow against the stomach. The patient then takes a few breaths, attempting to exhale more fully. After the third to fifth breath (in through the nose, out through pursed lips), instruct him or her to take a deeper breath and bend forward slowly while coughing 2 or 3 times ("mini-coughs") from the same breath. On return to a sitting position, the patient takes a comfortably deep breath. The entire coughing procedure is repeated at least twice. Oxygen Therapy. Oxygen is prescribed for relief of hypoxemia and hypoxia. The need for oxygen therapy and its effectiveness can be determined by arterial blood gas (ABG) values and oxygen saturation by pulse oximetry. The patient with COPD may need an oxygen flow of 2 to 4 L/min via nasal cannula or up to 40% via Venturi mask. Ensure that there are no open flames or other combustion hazards in rooms in which oxygen is in use. More information on oxygen therapy is found in Chapter 28. In the past, the patient with COPD was thought to be at risk for extreme hypoventilation with oxygen therapy because of a decreased drive to breathe as blood oxygen levels rose. However, this concern has not been shown to be evidence-based and has been responsible for ineffective management of hypoxia in patients with COPD. All hypoxic patients, even those with COPD and hypercarbia, should receive oxygen therapy at rates appropriate to reduce hypoxia and bring SpO2 levels up between 88% and 92% Suctioning. Perform suctioning only when needed—not on a routine schedule. For the patient with a weak cough, weak pulmonary muscles, and inability to expectorate effectively, perform nasotracheal suctioning. Assess the patient for dyspnea, tachycardia, and dysrhythmias during the procedure. Assess for improved breath sounds after suctioning.

Fluid Imbalance - Dehydration: Signs and symptoms Risk factors Prevention of dehydration Assessment of older adult client

Fasting before and during surgery, the loss of fluid during the procedure, and the type and amount of blood or fluid given affect the patient's fluid and electrolyte balance after surgery. Fluid volume deficit or fluid volume overload may occur after surgery. Sodium, potassium, chloride, and calcium imbalances also may result, as may changes in other electrolyte levels. Fluid and electrolyte imbalances occur more often in older or debilitated patients and in those with health problems such as diabetes mellitus, Crohn's disease, or heart failure. Intake and output measurement is part of the operative record and is reported by the circulating nurse to the PACU nurse. Record any intake or output, including IV fluid intake, vomitus, urine, wound drainage, and nasogastric (NG) tube drainage. You must know the total intake and output from both the OR and the PACU to assess fluid balance accurately and to complete the 24-hour intake and output record. Hydration status is assessed in the PACU and the medical-surgical unit. To determine hydration status, inspect the color and moisture of mucous membranes; the turgor, texture, and "tenting" of the skin (test over the sternum or forehead of an older patient); the amount of drainage on dressings; and the presence of axillary sweat. Measure and compare total output (e.g., NG tube drainage, urine output, wound drainage) with total intake to identify a possible fluid imbalance. Consider insensible fluid loss, such as sweat, when reviewing total output. Continue to assess intake and output as long as the patient is at risk for fluid imbalances. Some facilities require intake and output to be measured if the patient receives IV fluids or has a catheter, drains, or an NG tube. In addition, patients who have heart disease or kidney disease may need a longer period of intake and output measurement. IV fluids are closely monitored to promote fluid and electrolyte balance. Isotonic solutions such as lactated Ringer's (LR), 0.9% sodium chloride (normal saline), and 5% dextrose with lactated Ringer's (D5/LR) are used for IV fluid replacement in the PACU. After the patient returns to the medical-surgical unit, the type and rate of IV infusions are based on need. Control of urination may return immediately after surgery or may not return for hours after general or regional anesthesia. The effects of preoperative drugs (especially atropine), anesthetic agents, or manipulation during surgery can cause urine retention. Assess for urine retention by inspection, palpation, and percussion of the lower abdomen for bladder distention or by the use of a bladder scanner (see Chapter 65). Assessment may be difficult to perform after lower abdominal surgery. Urine retention is common early after surgery and requires intervention, such as intermittent (straight) catheterization, to empty the bladder. When the patient has an indwelling urinary (Foley) catheter, assess the urine for color, clarity, and amount. If the patient is voiding, assess the frequency, amount per void, and any manifestations. Urine output should be close to the total intake for a 24-hour period. Consider sweat, vomitus, or diarrhea stools as sources of output. Report a urine output of less than 30 mL/hr (240 mL per 8-hour nursing shift) to the surgeon. Decreased urine output may indicate hypovolemia or renal complications In dehydration, fluid intake or retention is less than what is needed to meet the body's fluid needs, resulting in a FLUID volume deficit, especially a plasma volume deficit. It is a condition rather than a disease and can be caused by many factors (Table 11-3). Dehydration may be an actual decrease in total body water caused by either too little intake of fluid or too great a loss of fluid. It also can occur without an actual loss of total body water, such as when water shifts from the plasma into the interstitial space. This condition is called relative dehydration. Mild dehydration is very common among healthy adults and is corrected or prevented easily by matching fluid intake with fluid output. Teach all patients to drink more fluids, especially water, whenever they engage in heavy or prolonged physical activity or live in dry climates or at higher altitudes. Beverages with caffeine can increase fluid loss, as can drinks containing alcohol; thus these beverages should not be used to prevent or treat dehydration. Moderate to severe dehydration is more likely to occur in people who are unable to obtain fluids without help, such as some older adults. Dehydration in older adults in long-term care facilities can be prevented with programs that include routinely offering residents fluids every hour or two during the day and when administering medications. The most obvious changes occur in the cardiovascular and integumentary systems. Cardiovascular changes are good indicators of hydration status because of the relationship between plasma fluid volume and blood pressure. Heart rate increases in an attempt to maintain blood pressure with less blood volume. Peripheral pulses are weak, difficult to find, and easily blocked with light pressure. The blood pressure also decreases, as does the pulse pressure, with a greater decrease in the systolic blood pressure. Hypotension is more severe with the patient in the standing position than in the sitting or lying position (orthostatic or postural hypotension). Because the blood pressure with the patient standing may be much lower than in other positions, first measure blood pressure with the patient lying down, then sitting, and finally standing. (These measures are also called "ortho checks" or "ortho changes.") As the blood pressure decreases when changing position, the person may not have sufficient blood flow to the brain, causing the sensations of light-headedness and dizziness. This problem increases the risk for falling, especially among older adults. Neck veins are normally distended when a patient is in the supine position, and hand veins are distended when lower than the level of the heart. Neck veins normally flatten when the patient moves to a sitting position. With dehydration, neck and hand veins are flat, even when the neck and hands are not raised above the level of the heart. Respiratory changes include an increased rate because the decreased blood volume reduces perfusion and oxygenation. The increased respiratory rate is a compensatory mechanism that attempts to maintain oxygen delivery when perfusion is decreased. Skin changes can indicate dehydration. Assess the skin and mucous membranes for color, moisture, and turgor. In older patients, this information is less reliable because of poor skin turgor resulting from the loss of elastic tissue and increased skin dryness from the loss of tissue FLUID with aging. Assess skin turgor by checking: • How easily the skin over the back of the hand and arm can be gently pinched between the thumb and the forefinger to form a "tent" • How soon the pinched skin resumes its normal position after release In dehydration, skin turgor is poor, with the tent remaining for minutes after pinching the skin. The skin is dry and scaly. Patient-Centered Care image Assess skin turgor in an older adult by pinching the skin over the sternum or on the forehead, rather than the back of the hand (Fig. 11-8). With aging, the skin loses elasticity and tents on hands and arms even when the person is well hydrated. FIG. 11-8 Examining the skin turgor of an older patient. 157 In dehydration, oral mucous membranes are not moist. They may be covered with a thick, sticky coating and may have cracks and fissures. The surface of the tongue may have deep furrows. This manifestation may not be accurate for assessing dehydration in patients taking drugs that have the side effect of dry mouth. Neurologic changes with dehydration include changes in mental status and temperature with reduced blood flow in the brain. Confusion is more common among older adults and may be the first indication of a FLUID imbalance. Check to determine whether the patient is alert and oriented. Chapter 41 provides more information about assessment of mental status. The patient with dehydration often has a low-grade fever, and fever can also cause dehydration. A patient with a temperature higher than 102° F (39° C) for longer than 6 hours is especially at risk because the increased body temperature increases the rate at which FLUID is lost. For every degree (Celsius) increase in body temperature above normal, a minimum of an additional 500 mL of body fluid is lost. Kidney changes in dehydration affect urine volume and concentration. Monitor urine output, comparing total output with total fluid intake and daily weights. The urine may be concentrated, with a specific gravity greater than 1.030. The color is dark amber and has a strong odor. Urine output below 500 mL/day for any patient without kidney disease is cause for concern. Use daily weights to assess fluid loss. Weight loss over a half pound per day is fluid loss.

General post-op nursing care - positioning/turning of surgical patient, breathing exercises, coughing, leg exercises and early ambulation.

Leg Exercises 1. Lie in bed with the head of your bed elevated to about 45 degrees. 2. Beginning with your right leg, bend your knee, raise your foot off the bed, and hold this position for a few seconds. 3. Extend your leg by unbending your knee, and lower the leg to the bed. 4. Repeat this sequence four more times with your right leg; then perform this same exercise five times with your left leg. Exercise No. 2 1. Beginning with your right leg, point your toes toward the bottom of the bed. 2. With the same leg, point your toes up toward your face. 3. Repeat this exercise several times with your right leg; then perform this same exercise with your left leg. Exercise No. 3 1. Beginning with your right leg, make circles with your ankle, first to the left and then to the right. 2. Repeat this exercise several times with your right leg; then perform this same exercise with your left leg. Exercise No. 4 1. Beginning with your right leg, bend your knee and push the ball of your foot into the bed or floor until you feel your calf and thigh muscles contracting. 2. Repeat this exercise several times with your right leg; then perform this same exercise with your left leg. Breathing exercises include deep, or diaphragmatic, breathing to enlarge the chest cavity and expand the lungs. After you demonstrate and explain the technique, urge the patient to practice deep breathing. For patients with chronic lung disease or limited chest expansion, as seen in older patients because of the aging process, expansion breathing exercises are useful. For the patient having chest surgery, expansion breathing exercises strengthen accessory muscles and are started before surgery. Expansion breathing after surgery during chest physiotherapy (percussion, vibration, postural drainage) may help loosen secretions and maintain an adequate air exchange. Incentive spirometry is another way to encourage the patient to take deep breaths. Its purpose is to promote complete lung expansion and to prevent pulmonary problems. Deep (Diaphragmatic) Breathing 1. Sit upright on the edge of the bed or in a chair, being sure that your feet are placed firmly on the floor or a stool. (After surgery, deep breathing is done with the patient in Fowler's position or in semi-Fowler's position.) 2. Take a gentle breath through your mouth. 3. Breathe out gently and completely. 4. Then take a deep breath through your nose and mouth, and hold this breath to the count of five. 5. Exhale through your nose and mouth. Expansion Breathing 1. Find a comfortable upright position, with your knees slightly bent. (Bending the knees decreases tension on the abdominal muscles and decreases respiratory resistance and discomfort.) 2. Place your hands on each side of your lower rib cage, just above your waist. 3. Take a deep breath through your nose, using your shoulder muscles to expand your lower rib cage outward during inhalation. 4. Exhale, concentrating first on moving your chest, then on moving your lower ribs inward, while gently squeezing the rib cage and forcing air out of the base of your lungs. Splinting of the Surgical Incision 1. Unless coughing is contraindicated, place a pillow, towel, or folded blanket over your surgical incision and hold the item firmly in place. 2. Take three slow, deep breaths to stimulate your cough reflex. 3. Inhale through your nose, and then exhale through your mouth. 4. On your third deep breath, cough to clear secretions from your lungs while firmly holding the pillow, towel, or folded blanket against your incision. Coughing and splinting may be performed along with deep breathing every 1 to 2 hours after surgery. The purposes of coughing are to expel secretions, keep the lungs clear, allow full aeration, and prevent pneumonia and atelectasis. Coughing may be uncomfortable for the patient, but when performed correctly, it should not harm the incision. Splinting (i.e., holding) the incision area provides support, promotes a feeling 231of security, and reduces pain during coughing Patients at greater risk for VTE: • Are obese • Are older than 40 years • Have cancer • Have decreased mobility or are immobile • Have a spinal cord injury • Have a history of VTE, DVT, PE, varicose veins, or edema • Are taking oral contraceptives 232 • Smoke • Have decreased cardiac output • Have hip fracture or total hip or total knee surgery Always assess for VTE before surgery. Sudden swelling in one leg is a common physical finding of VTE caused by DVT. A patient may feel a dull ache in the calf area that becomes worse with ambulation. A careful assessment and timely intervention may prevent the potentially fatal complication of pulmonary embolism. Because surgical-related VTE can be prevented, prophylaxis is required by the Surgical Care Improvement Project (SCIP) core measures (see Table 14-1). All patients should be evaluated for VTE risk based on history, type and duration of surgery, and expected time of immobilization after surgery. VTE prophylaxis may involve devices and drug therapy, depending on a specific patient's evaluated risk. Devices may be used during and after surgery along with leg exercises and early ambulation to promote venous return. Specific interventions depend on the patient's risk factors Antiembolism stockings (TED or Jobst stockings) and elastic (Ace) wraps provide graduated compression of the legs, starting at the end of the foot and ankle. Measure the patient's leg length and circumference before ordering the stocking size. Elastic wraps are used when the legs are too large or too small for the stockings. Assist the patient in applying the stockings or wraps, and ensure that they are neither too loose (are ineffective) nor too tight (inhibit blood flow). They need to be worn properly and should be removed 1 to 3 times per day for 30 minutes for skin inspection and skin care. Pneumatic compression devices enhance venous blood flow by providing intermittent periods of compression on the legs. Measure the patient's legs, and order the correct size. Place the boots on the patient's legs, and then set and check the compression pressures (usually 35-55 mm Hg). Unless these devices are applied properly, there is no benefit Mobility soon after surgery (early ambulation) has many cardiovascular and other benefits. It stimulates intestinal motility, enhances lung expansion, mobilizes secretions, promotes venous return, prevents joint rigidity, and relieves pressure. For most types of surgery, teach the patient to turn at least every 2 hours after surgery while confined to bed. Teach patients how 233to use the bed siderails safely for turning and how to protect the surgical wound by splinting when turning. Assure patients that assistance and pain drugs will be given as needed to reduce any anxiety and pain they may have with this activity. For certain surgical procedures, such as some brain, spinal, and orthopedic procedures, the surgeon may prescribe turning restrictions. Ask the surgeon about other interventions to prevent complications of immobility in patients with turning restrictions. During teaching before surgery, inform the patient of anticipated turning restrictions. Most patients are allowed and encouraged to get out of bed the day of or the day after surgery. Assist the patient into a chair or with ambulation after the surgery, the next day, or when the surgeon specifies. If a patient must remain in bed, help him or her turn, deep breathe, and perform leg exercises at least every 2 hours to prevent complications from immobility.

Effects of herbal supplements taken preoperatively

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Infectious Respiratory Problems - Pneumonia: Risk factors?

Pneumonia is a common complication of COPD, especially among older adults. Patients who have excessive secretions or who have artificial airways are at increased risk for respiratory tract infections. Teach patients to avoid crowds, and stress the importance of receiving a pneumonia vaccination and a yearly influenza vaccine. Pneumonia image Pathophysiology Pneumonia is excess fluid in the lungs resulting from an inflammatory process. The INFLAMMATION is triggered by many infectious organisms and by inhalation of irritating agents. The INFLAMMATION occurs in the interstitial spaces, the alveoli, and often the bronchioles. The process begins when organisms penetrate the airway mucosa and multiply in the alveolar spaces. White blood cells (WBCs) migrate to the area of INFECTION, causing local capillary leak, edema, and exudate. These fluids 589collect in and around the alveoli, and the alveolar walls thicken. Both events seriously reduce GAS EXCHANGE and lead to hypoxemia, interfering with oxygenation and possibly leading to death. Red blood cells (RBCs) and fibrin move into the alveoli, and capillary leak spreads the infection to other areas of the lung. If the organisms move into the bloodstream, septicemia results; if the infection extends into the pleural cavity, empyema (a collection of pus in the pleural cavity) results. The fibrin and edema stiffen the lung, reducing compliance and decreasing the vital capacity. Alveolar collapse (atelectasis) further reduces the ability of the lung to oxygenate the blood moving through it. As a result, arterial oxygen levels fall, causing hypoxemia. Pneumonia may occur as lobar pneumonia with consolidation (solidification, lack of air spaces) in a segment or an entire lobe of the lung or as bronchopneumonia with diffusely scattered patches around the bronchi. The extent of lung involvement depends on the host defenses. Bacteria multiply quickly in a person whose immune system is compromised. Tissue necrosis results when an abscess forms and perforates the bronchial wall. Risk Factors for Pneumonia Community-Acquired Pneumonia • Is an older adult • Has never received the pneumococcal vaccination or received it more than 5 years ago • Did not receive the influenza vaccine in the previous year • Has a chronic health problem or other coexisting condition that reduces immune responses • Has recently been exposed to respiratory viral or influenza infections • Uses tobacco or alcohol or is exposed to high amounts of secondhand smoke Health Care-Acquired Pneumonia • Is an older adult • Has a chronic lung disease • Has presence of gram-negative colonization of the mouth, throat, and stomach • Has an altered level of consciousness • Has had a recent aspiration event • Has presence of endotracheal, tracheostomy, or nasogastric tube • Has poor nutritional status • Has immunocompromised status (from disease or drug therapy) • Uses drugs that increase gastric pH (histamine [H2] blockers, antacids) or alkaline tube feedings • Is currently receiving mechanical ventilation (ventilator-associated pneumonia [VAP])

Assessment of Respiration, Cardiovascular, Peripheral vascular, GI, Renal system for postoperative patient...Airway, Breathing, Circulation

The Patient on Arrival at the Medical-Surgical Unit After Discharge from the Postanesthesia Care Unit Airway • Is it patent? • Is the neck in proper alignment? Breathing • What is the quality and pattern of the breathing? • What is the respiratory rate and depth? • Is the patient using accessory muscles to breathe? • Is the patient receiving oxygen? At what setting? What is the pulse oximetry reading? Mental Status • Is the patient awake, able to be aroused, oriented, and aware? • Does the patient respond to verbal stimuli? Surgical Incision Site • How is it dressed? • Review the amount of drainage on the dressing immediately. • Is there any bleeding or drainage under the patient? • Are any drains present? • Are the drains set properly (e.g., compressed if they should be compressed, not kinked, patient not lying on them)? • How much drainage is present in the drainage container? Temperature, Pulse, and Blood Pressure • Are these values within the patient's baseline range? • Are these values significantly different from when the patient was in the postanesthesia care unit (PACU)? Intravenous Fluids • What type of solution is infusing and with what additives? • How much solution was remaining on arrival? • How much solution infused in the transport time from PACU? • At what rate is the infusion supposed to be set? Is it? Other Tubes • Is there a nasogastric or intestinal tube? • What is the color, consistency, and amount of drainage? • Is suction applied to the tube if ordered? Is the suction setting correct? • Is there a Foley catheter? • Is the Foley draining properly? • What is the color, clarity, and volume of urine output? During the postoperative period, all patients remain at risk for pneumonia, shock, cardiac arrest, respiratory arrest, CLOTTING and venous thromboembolism (VTE), and GI bleeding. These serious complications can be prevented or the consequences reduced with collaborative care. Nursing observations and interventions are part of critical rescue management for patient safety and quality care. Respiratory System. When the patient is admitted to the PACU, immediately assess for a patent airway and adequate GAS EXCHANGE. Although some patients may be awake and able to speak, talking is not a good indicator of adequate gas exchange. An artificial airway, such as an endotracheal tube 259(ET), a nasal trumpet, or an oral airway, may be in place. If the patient is receiving oxygen, document the type of delivery device and the concentration or liter flow of the oxygen. Continuously monitor pulse oximetry for oxygen saturation (SpO2) while the patient is in the PACU. The SpO2 should be above 95% (or at the patient's presurgery baseline). Assess the rate, pattern, and depth of breathing to determine adequacy of GAS EXCHANGE. A respiratory rate of less than 10 breaths per minute may indicate anesthetic- or opioid analgesic-induced respiratory depression. Rapid, shallow respirations may signal shock, cardiac problems, increased metabolic rate, or PAIN. Listen to the lungs over all lung fields to assess breath sounds. Also check symmetry of breath sounds and chest wall movement. If, for example, the patient has an ET tube, it could move down into the right bronchus and prevent left lung expansion. In this case, lung sounds on the left are absent or decreased and only the right chest wall rises and falls with breathing. Perform ongoing inspection of the chest wall for accessory muscle use, sternal retraction, and diaphragmatic breathing. These manifestations may indicate an excessive anesthetic effect, airway obstruction, or paralysis, which could result in hypoxia. Listen for snoring and stridor (a high-pitched crowing sound). Snoring and stridor occur with airway obstruction resulting from tracheal or laryngeal spasm or edema, mucus in the airway, or blockage of the airway from edema or tongue relaxation. When neuromuscular blocking agents are retained, the patient has muscle weakness, which could impair GAS EXCHANGE. Indicators of muscle weakness include the inability to maintain a head lift, weak hand grasps, and an abdominal breathing pattern. If the patient returns to an inpatient unit, complete an initial assessment on arrival (see Chart 16-2) and then continue to assess for respiratory depression or hypoxemia. Listen to the lungs to check for effective expansion and for abnormal breath sounds. Check the lungs at least every 4 hours during the first 24 hours after surgery and then every 8 hours, or more often, as indicated. Older patients, smokers, and patients with a history of lung disease are at greater risk for respiratory complications after surgery and need more frequent assessment (Sullivan, 2011). Obese patients are also at high risk for respiratory complications. Cardiovascular System. Vital signs and heart sounds are assessed on admission to the PACU and then at least every 15 minutes until the patient's condition is stable. Automated blood pressure cuffs and cardiac monitoring assist in continuous assessment. Review vital signs after surgery for trends, and compare them with those taken before surgery. Report blood pressure changes that are 25% higher or lower than values obtained before surgery (or a 15- to 20-point difference, systolic or diastolic) to the anesthesia provider or the surgeon. Decreased blood pressure and pulse pressure and abnormal heart sounds indicate possible cardiac depression, fluid volume deficit, shock, hemorrhage, or the effects of drugs (see Chapters 11 and 37). Bradycardia could indicate an anesthesia effect or hypothermia. Older patients are at risk for hypothermia because of age-related changes in the hypothalamus (the temperature regulation center), low levels of body fat, and coolness of the OR suite (Sullivan, 2011; Touhy & Jett, 2014). An increased pulse rate could indicate hemorrhage, shock, or PAIN. Cardiac monitoring is maintained until the patient is discharged from the PACU. For patients at risk for dysrhythmias, monitoring may continue either on telemetry units or on general medical-surgical units. In assessing the vital signs of a patient who is not being monitored continuously, compare the rate, rhythm, and quality of the apical pulse with the rate, rhythm, and quality of a peripheral pulse, such as the radial pulse. A pulse deficit (a difference between the apical and peripheral pulses) could indicate a dysrhythmia. Peripheral vascular assessment needs to be performed because anesthesia and positioning during surgery (e.g., the lithotomy position for genitourinary procedures) may impair the peripheral circulation and contribute to CLOTTING and venous thromboembolism (VTE), especially deep vein thrombosis (DVT). Compare distal pulses on both feet for pulse quality, observe the color and temperature of extremities, evaluate sensation and motion, and determine the speed of capillary refill. Palpable pedal pulses indicate adequate circulation and perfusion of the legs. In adherence with The Joint Commission's Surgical Care Improvement Project (SCIP) core measures for prevention of inappropriate CLOTTING and VTE, continue the prophylactic measures initiated before surgery (Myles, 2012). Although these measures vary in type (e.g., drug therapy with anticoagulants or antiplatelet drugs, sequential compression devices, antiembolic stockings or elastic wraps, early ambulation) depending on the patient's specific risk factors and the type and extent of surgery, any preventive strategies started before surgery are usually needed for at least the first 24 hours after surgery. Reassess the patient's risk for CLOTTING and VTE and the effectiveness of the preventive strategies daily. Assess the feet and legs for redness, pain, warmth, and swelling, which may occur with DVT. Foot and leg assessment may be performed once during a nursing shift or once daily depending on the patient's risk for complications and the facility's or agency's policy. (See Chapters 14 and 36 for more information on prevention of inappropriate CLOTTING and VTE.) Neurologic System. Cerebral functioning and the level of consciousness or awareness must be assessed in all patients who have received general anesthesia (Table 16-2) or any type of sedation. Observe for lethargy, restlessness, or irritability, and test coherence and orientation. Determine awareness by observing responses to calling the patient's name, touching the patient, and giving simple commands such as "Open your eyes" and "Take a deep breath." Eye opening in response to a command indicates wakefulness or arousability but not necessarily awareness. Determine the degree of orientation to person, place, and time by asking the conscious patient to answer questions such as "What is your name?" (person), "Where are you?" (place), and "What day is it?" (time). On the medical-surgical nursing unit, assess the level of consciousness every 4 to 8 hours or as indicated by the patient's condition and the facility's policy. Motor function and sensory function after general anesthesia are altered and must be assessed. General anesthesia depresses all voluntary motor function. Regional anesthesia alters the motor and sensory function of only part of the body. (See Chapter 15 for more information on anesthesia.) Motor and sensory function after spinal and epidural anesthesia are profoundly affected and critical to assess. Assess the level of sensation loss remaining by lightly pricking the patient's skin with a needle or pin and having the patient indicate when the sensation feels sharp rather than dull (just pressure). Evaluate motor function by asking the patient to move each extremity. The patient who had epidural or spinal anesthesia remains in the PACU until sensory function (feeling) and voluntary motor movement of the legs have returned (see Table 16-2). Also assess the strength of each limb, and compare the results on both sides. Test for the return of sympathetic nervous system tone by gradually elevating the patient's head and monitoring for hypotension. Begin this evaluation after the patient's sensation has returned to at least the spinal dermatome level of T10. An unchanged wet or damp dressing is a source of INFECTION. Change dressings using aseptic technique until the sutures or staples are removed Control of urination may return immediately after surgery or may not return for hours after general or regional anesthesia. The effects of preoperative drugs (especially atropine), anesthetic agents, or manipulation during surgery can cause urine retention. Assess for urine retention by inspection, palpation, and percussion of the lower abdomen for bladder distention or by the use of a bladder scanner (see Chapter 65). Assessment may be difficult to perform after lower abdominal surgery. Urine retention is common early after surgery and requires intervention, such as intermittent (straight) catheterization, to empty the bladder. When the patient has an indwelling urinary (Foley) catheter, assess the urine for color, clarity, and amount. If the patient is voiding, assess the frequency, amount per void, and any manifestations. Urine output should be close to the total intake for a 24-hour period. Consider sweat, vomitus, or diarrhea stools as sources of output. Report a urine output of less than 30 mL/hr (240 mL per 8-hour nursing shift) to the surgeon. Decreased urine output may indicate hypovolemia or renal complications. (See Chapter 65 for kidney/urinary assessment.) Gastrointestinal System. Postoperative nausea and vomiting (PONV) are among the most common reactions after surgery. Many patients who receive general anesthesia have some form of GI upset within the first 24 hours after surgery; however, some patients are more at risk than others (Tinsley & Barone, 2013). Patients with a history of motion sickness are more likely to develop nausea and vomiting after surgery. Obese patients may be at risk because many anesthetics are retained by fat cells and remain in the body longer. Abdominal surgery and the use of opioid analgesics reduce intestinal peristalsis after surgery. These problems increase the risk for prolonged nausea and vomiting after surgery. Preventive drug therapy, often started in the preoperative period, is effective in reducing the incidence. Drugs often used are a serotonin antagonist such as ondansetron (Zofran), a sedating H1 histamine antagonist such as dimenhydrinate (Dramamine), and an anticholinergic agent such as scopolamine. PONV can stress and irritate abdominal and GI wounds, increase intracranial pressure in patients who had head and neck surgery, elevate intraocular pressure in patients who had eye surgery, and increase the risk for aspiration. Assess the patient continuously for PONV. Often patients have nausea as the head of the bed is raised early after surgery. Help reduce this distressing symptom by having the patient in a side-lying position before raising the head slowly. Intestinal peristalsis may be delayed because of prolonged anesthesia time, the amount of bowel handling during surgery, and opioid analgesic use. In the PACU and later on the medical-surgical unit, assess for the return of peristalsis. Patients who are recovering from abdominal surgery often have decreased or no peristalsis for at least 24 hours. This problem may persist for several days for those who have GI surgery. Listen for bowel sounds in all four abdominal quadrants and at the umbilicus. If NG suction is being used, turn off the suction before listening to prevent mistaking the sound of the suction for bowel sounds. The presence of active bowel sounds usually indicates return of peristalsis; however, the absence of bowel sounds does not confirm a lack of peristalsis. The best indicator of intestinal activity is the passage of flatus or stool (Massey, 2012). Abdominal cramping along with distention denotes trapped, nonmoving gas—not peristalsis. Decreased peristalsis occurs in patients who have a paralytic ileus. The abdominal wall is distended with no visible intestinal movement. Assess for the manifestations of paralytic ileus (distended abdomen, abdominal discomfort, vomiting, no passage of flatus or stool). In some patients, bowels sounds can be heard even when a true paralytic ileus is present. The passage of flatus or stool is the best indicator of resolution of a paralytic ileus. The surgeon inserts a drain into or close to the wound if more than a minimal amount of drainage is expected. A Penrose drain (a single-lumen, soft, open, latex tube) is a gravity-type drain under the dressing. Drainage on the dressing is expected with open tube drains but is not expected with closed drainage systems. Assess closed-suction drains, such as Hemovac, Vacu-Drain, and Jackson-Pratt drains, for maintenance of suction. Specialty drains, such as a T-tube, may be placed for specific drainage purposes. For example, a T-tube drains bile after a cholecystectomy. Chronic wounds or wounds that heal by delayed primary intention are drained with a negative pressure wound device Positioning. In the PACU, immediately position the patient in a semi-Fowler's position unless contraindicated. If the patient cannot have the head of the bed raised, either place him or her in a side-lying position or turn the head to the side to prevent aspiration. Oxygen Therapy. Hypoxemia is prevented and managed with oxygen therapy. Apply oxygen by face tent, nasal cannula, or mask to eliminate inhaled anesthetic agents, increase oxygen levels, raise the level of consciousness, and reduce confusion. After the patient is fully reactive and stable, raise the head of the bed to promote respiratory function. For some patients, oxygen therapy may continue through the second day after surgery. When hypoxemia occurs despite preventive care, interventions such as respiratory treatments and mechanical ventilation may be used to manage the cause of the hypoxemia. Breathing Exercises. After the patient regains the gag and cough reflexes and meets the agency's criteria for extubation (if intubated), remove the airway or ET tube. Usual extubation criteria include the ability to raise and hold the head up and evidence of thoracic breathing. Help the patient splint the incision, cough, and deep breathe to promote GAS EXCHANGE and eliminate anesthetic agents Perform mouth care after removing secretions. Movement. Assist the patient out of bed and to ambulate as soon as possible to help remove secretions and promote ventilation. Even when the patient has had extensive surgery, the expectation may be to get out of bed the day of or the first day after surgery. If this is not possible, assist him or her to turn at least every 2 hours (side to side) and ensure that breathing exercises and leg exercises are performed (see Charts 14-5 and 14-6 in Chapter 14). Early ambulation reduces the risk for pulmonary complications, especially after abdominal, pelvic, or spinal surgery. It increases circulation to extremities and reduces the risk for CLOTTING and venous thromboembolism (VTE), especially deep vein thrombosis (DVT). The patient may resist getting up, but you must stress the importance of activity to prevent complications. When indicated, offer pain medication 30 to 45 minutes before he or she gets out of bed.

Pre-op. patient/family education

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

Magnesium (hypomagnesemia & hypermagnesemia)

1.3-2.1 mEq/L Elevated: Hypermagnesemia; kidney disease; hypothyroidism; adrenal insufficiency Low: Hypomagnesemia; malnutrition; alcoholism; ketoacidosis It is important for skeletal muscle contraction, carbohydrate metabolism, generation of energy stores, vitamin activation, blood coagulation, and cell growth. Magnesium regulation occurs through the kidney and the intestinal tract although the exact mechanisms are not known. When blood magnesium levels are low, ingested magnesium is rapidly absorbed and kidney excretion of magnesium stops. When blood magnesium levels are high, little magnesium is absorbed from food and kidney magnesium excretion increases. It is most often caused by decreased absorption of dietary magnesium or increased kidney magnesium excretion. Table 11-12 lists the specific causes of hypomagnesemia. TABLE 11-12 Common Causes of Magnesium Imbalance Hypomagnesemia • Malnutrition • Starvation • Diarrhea • Steatorrhea • Celiac disease • Crohn's disease • Drugs (diuretics, aminoglycoside antibiotics, cisplatin, amphotericin B, cyclosporine) • Citrate (blood products) • Ethanol ingestionHypermagnesemia • Increased magnesium intake: • Magnesium-containing antacids and laxatives • IV magnesium replacement • Decreased kidney excretion of magnesium resulting from kidney disease image The effects of hypomagnesemia are caused by increased membrane excitability and the accompanying serum calcium and potassium imbalances. Excitable membranes, especially nerve cell membranes, may depolarize spontaneously. Neuromuscular changes are caused by increased nerve impulse transmission. Normally, magnesium inhibits nerve impulse transmission at synapse areas. Decreased levels increase impulse transmission from nerve to nerve or from nerve to skeletal muscle. The patient has hyperactive deep tendon reflexes, numbness and tingling, and painful muscle contractions. Positive Chvostek's and Trousseau's signs may be present because hypomagnesemia may occur with hypocalcemia (see the earlier discussion of these assessment signs of neuromuscular changes on p. 168 in the Hypocalcemia section). The patient may have tetany and seizures as hypomagnesemia worsens. Intestinal changes are from decreased intestinal smooth muscle contraction. Reduced motility, anorexia, nausea, constipation, and abdominal distention are common. A paralytic ileus may occur when hypomagnesemia is severe. Interventions for hypomagnesemia aim to correct the imbalance and manage the specific problem that caused it. In addition, because hypocalcemia often occurs with hypomagnesemia, interventions also aim to restore normal serum calcium levels. Drugs that promote magnesium loss, such as high-ceiling (loop) diuretics, osmotic diuretics, aminoglycoside antibiotics, and drugs containing phosphorus, are discontinued. Magnesium is replaced intravenously with magnesium sulfate (MgSO4) when hypomagnesemia is severe. Assess deep tendon reflexes at least hourly in the patient receiving IV magnesium to monitor effectiveness and prevent hypermagnesemia. If hypocalcemia is also present, drug therapy to increase serum calcium levels is prescribed. Magnesium is a membrane stabilizer. Most manifestations of hypermagnesemia occur as a result of reduced membrane excitability. They usually are not apparent until serum magnesium levels exceed 4 mEq/L. Cardiac changes include bradycardia, peripheral vasodilation, and hypotension. These problems become more severe as serum magnesium levels increase. ECG changes show a prolonged PR interval with a widened QRS complex. Bradycardia can be severe, and cardiac arrest is possible. Hypotension is also severe, with a diastolic pressure lower than normal. Patients with severe hypermagnesemia are in grave danger of cardiac arrest. Central nervous system changes result from depressed nerve impulse transmission. Patients may be drowsy or lethargic. Coma may occur if the imbalance is prolonged or severe. Neuromuscular changes include reduced or absent deep tendon reflexes. Voluntary skeletal muscle contractions become progressively weaker and finally stop. Hypermagnesemia has no direct effect on the lungs; however, when the respiratory muscles are weak, respiratory insufficiency can lead to respiratory failure and death. Interventions for hypermagnesemia focus on reducing the serum level and correcting the underlying problem that caused the imbalance. All oral and parenteral magnesium is discontinued. When kidney failure is not present, giving magnesium-free IV fluids can reduce serum magnesium levels. High-ceiling (loop) diuretics such as furosemide (Lasix, Furoside image) can 172further reduce serum magnesium levels. When cardiac problems are severe, giving calcium may reverse the cardiac effects of hypermagnesemia.

Phosphate (hypophosphatemia & hyperphosphatemia)

3.0-4.5 mg/dL Elevated: Hypermagnesemia; kidney disease; hypothyroidism; adrenal insufficiency Low: Hypomagnesemia; malnutrition; alcoholism; ketoacidosis Phosphorus is needed for activating vitamins and enzymes, forming energy supplies, and assisting in cell growth and metabolism. It also functions in acid-base balance and calcium homeostasis. Phosphorus balance and calcium balance are intertwined. Plasma levels of calcium and phosphorus exist in a balanced, reciprocal relationship, which means that when you multiply the two values, the product remains constant. Therefore a change in the level of serum phosphorus results in an equal and opposite change in the level of serum calcium (and vice versa). The regulation of ECF phosphorus occurs through the activity of parathyroid hormone (PTH). Increased PTH levels cause a net loss of phosphorus. Reduced PTH levels enhance kidney reabsorption of phosphorus, resulting in increased plasma levels of phosphorus. Common Causes of Phosphorus Imbalance Hypophosphatemia • Malnutrition • Starvation • Use of aluminum hydroxide-based antacids • Use of magnesium-based antacids • Hyperparathyroidism • Hypercalcemia • Kidney failure • Malignancy • Hyperglycemia • Hyperalimentation • Respiratory alkalosis • Uncontrolled diabetes mellitus • Alcohol abuseHyperphosphatemia • Decreased kidney excretion resulting from kidney disease • Tumor lysis syndrome • Increased intake of phosphorus • Hypoparathyroidism Because phosphorus and calcium are inter-related, decreases in serum phosphorus levels cause increases in serum calcium levels. image Assessment Manifestations of hypophosphatemia are most apparent in the cardiac, musculoskeletal, hematologic, and central nervous systems. Cardiac changes include weak contractility, decreased stroke volume, and decreased cardiac output. Peripheral pulses are slow, difficult to find, and easy to block. Prolonged hypophosphatemia causes progressive but reversible cardiac muscle damage. Musculoskeletal changes include weak skeletal muscles that may progress to acute muscle breakdown (rhabdomyolysis). With profound muscle weakness, respiratory efforts are ineffective, leading to respiratory failure. Assess for muscle strength, and observe respiratory effort. The manifestations of chronic hypophosphatemia are most evident in the skeletal system. Bone density is decreased, which leads to fractures. Assess the patient for unusual lumps or depressions over bony areas that indicate bone fractures. Central nervous system changes are not apparent until hypophosphatemia is severe. These first appear as irritability and may progress to seizure activity followed by coma. image Interventions Drugs that promote phosphorous loss (e.g., antacids, osmotic diuretics, calcium supplements) are discontinued. Oral replacement of phosphorus along with a vitamin D supplement may correct moderate hypophosphatemia. IV phosphorus is given only when serum phosphorus levels fall below 1 mg/dL and the patient has serious manifestations. Infuse IV phosphorus slowly because the problems caused by hyperphosphatemia are equally serious. Nutrition therapy involves increasing the intake of phosphorus-rich foods while decreasing the intake of calcium-rich foods. Collaborate with the dietitian to teach the patient and family which foods to eat and which to avoid. Causes of increased serum phosphorus levels include kidney disease, certain cancer treatments, increased phosphorus intake, and hypoparathyroidism. Table 11-11 lists common causes of hyperphosphatemia.

Calcium (hypocalcemia & hypercalcemia)

9.0-10.5 mg/dL Elevated: Hypercalcemia; hyperthyroidism; hyperparathyroidism Low: Hypocalcemia; vitamin D deficiency; hypothyroidism; hypoparathyroidism; kidney disease; excessive intake of phosphorus-containing foods and drinks Calcium enters the body by dietary intake and absorption through the intestinal tract. Dairy products are common foods high in calcium. Absorption of dietary calcium requires the active form of vitamin D. Calcium is stored in the bones. When more calcium is needed, parathyroid hormone (PTH) is released from the parathyroid glands. PTH increases serum calcium levels by: • Releasing free calcium from bone storage sites (bone resorption of calcium) • Stimulating vitamin D activation to help increase intestinal absorption of dietary calcium • Inhibiting kidney calcium excretion • Stimulating kidney calcium reabsorption When excess calcium is present in plasma, PTH secretion is inhibited and the secretion of thyrocalcitonin (TCT), a hormone secreted by the thyroid gland, is increased. TCT causes the plasma calcium level to decrease by inhibiting bone resorption of calcium, inhibiting vitamin D-associated intestinal uptake of calcium, and increasing kidney excretion of calcium in the urine. Hypocalcemia is an ELECTROLYTE imbalance in which a total serum calcium (Ca2+) level is below 9.0 mg/dL or 2.25 mmol/L. Calcium is an excitable membrane stabilizer, regulating depolarization and the generation of action potentials. It decreases sodium movement across excitable membranes, slowing the rate of depolarization. Low serum calcium levels increase sodium movement across excitable membranes, allowing depolarization to occur more easily and at inappropriate times. Hypocalcemia is caused by many chronic and acute conditions, as well as medical or surgical treatments. Table 11-9 lists causes of hypocalcemia. Acute hypocalcemia results in the rapid onset of life-threatening manifestations. Chronic hypocalcemia occurs slowly over time, and excitable membrane manifestations may not be severe because the body has adjusted to the gradual reduction of serum calcium levels. TABLE 11-9 Common Causes of Hypocalcemia Actual Calcium Deficits • Inadequate oral intake of calcium • Lactose intolerance • Malabsorption syndromes: • Celiac sprue • Crohn's disease • Inadequate intake of vitamin D • End-stage kidney disease • Diarrhea • Steatorrhea • Wound drainage (especially gastrointestinal)Relative Calcium Deficits • Hyperproteinemia • Alkalosis • Calcium chelators or binders • Citrate • Mithramycin • Penicillamine • Sodium cellulose phosphate (Calcibind) • Aredia • Acute pancreatitis • Hyperphosphatemia • Immobility • Removal or destruction of parathyroid glands Actual calcium loss (a reduction in total body calcium) occurs when the absorption of calcium from the GI tract slows or when calcium is lost from the body. Relative calcium loss causes total body calcium amounts to remain normal while serum calcium levels are low. Assess the nutrition history for the risk for hypocalcemia. Ask the patient about his or her intake of dairy products and whether he or she takes a calcium supplement regularly. One indicator of hypocalcemia is a report of frequent, painful muscle spasms ("charley horses") in the calf or foot during rest or sleep. Ask about a history of recent orthopedic surgery or bone healing. Endocrine disturbances and treatments are risk factors for hypocalcemia. A history of thyroid surgery, therapeutic irradiation of the upper middle chest and neck area, or a recent anterior neck injury increases the risk for hypocalcemia. Most manifestations of acute hypocalcemia are caused by overstimulation of the nerves and muscles. Neuromuscular changes often occur first in the hands and feet. Paresthesias occur at first, with sensations of tingling and numbness. If hypocalcemia continues or worsens, muscle twitching or painful cramps and spasms occur. Tingling may also affect the lips, nose, and ears. These problems may signal the onset of neuromuscular overstimulation and tetany (Crawford & Harris, 2012). Assess for hypocalcemia by testing for Trousseau's and Chvostek's signs. To test for Trousseau's sign, place a blood pressure cuff around the upper arm, inflate the cuff to greater than the patient's systolic pressure, and keep the cuff inflated for 1 to 4 minutes. Under these hypoxic conditions, a positive Trousseau's sign occurs when the hand and fingers go into spasm in palmar flexion (Fig. 11-13). To test for Chvostek's sign, tap the face just below and in front of the ear (over the facial nerve) to trigger facial twitching of one side of the mouth, nose, and cheek Cardiovascular changes involve heart rate and ECG changes. The heart rate may be slower or slightly faster than normal, with a weak, thready pulse. Severe hypocalcemia causes severe hypotension and ECG changes of a prolonged ST interval and a prolonged QT interval. 169 Intestinal changes include increased peristaltic activity. Auscultate the abdomen for hyperactive bowel sounds. The patient may report painful abdominal cramping and diarrhea. Skeletal changes are common with chronic hypocalcemia. Calcium leaves bone storage sites, causing a loss of bone density (osteoporosis). The bones are less dense, more brittle, and fragile and may break easily with slight trauma. Vertebrae become more compact and may bend forward, leading to an overall loss of height. Drug therapy for hypocalcemia includes direct calcium replacement (oral and IV) and drugs that enhance the absorption of calcium, such as vitamin D. When hypocalcemia is a result of hyperphosphatemia, aluminum hydroxide may help raise serum calcium levels. When neuromuscular manifestations are troublesome, drugs that decrease nerve and muscle responses also may be used. Nutrition therapy involves a high-calcium diet for patients with mild hypocalcemia and for those who are at continuing risk for hypocalcemia. Collaborate with the dietitian to assist the patient in selecting calcium-rich foods. Environmental management for safety is needed because the excitable membranes of the nervous system and the skeletal system are overstimulated in hypocalcemia. Reduce stimulation by keeping the room quiet, limiting visitors, adjusting the lighting, and using a soft voice. Use seizure precautions for the patient with hypocalcemia (see Chapter 42). Keep emergency equipment (e.g., oxygen, suction) at the bedside. Injury prevention strategies are needed because the patient with long-standing calcium loss may have brittle, fragile bones that fracture easily and cause little pain. Hypercalcemia is an ELECTROLYTE imbalance in which the total serum calcium level is above 10.5 mg/dL or 2.62 mmol/L. Even small increases above normal have severe effects. Although the effects of hypercalcemia occur first in excitable tissues, all systems are affected. The excitable tissues affected most by hypercalcemia are the heart, skeletal muscles, nerves, and intestinal smooth muscles. TABLE 11-10 Common Causes of Hypercalcemia Actual Calcium Excesses • Excessive oral intake of calcium • Excessive oral intake of vitamin D • Kidney failure • Use of thiazide diureticsRelative Calcium Excesses • Hyperparathyroidism • Malignancy • Hyperthyroidism • Immobility • Use of glucocorticoids • Dehydration developed slowly. Cardiovascular changes are the most serious and life-threatening problems of hypercalcemia. Mild hypercalcemia at first causes increased heart rate and blood pressure. Severe or prolonged calcium imbalance depresses electrical conduction, slowing heart rate. Measure pulse rate and blood pressure, and observe for indications of poor tissue blood flow, such as cyanosis and pallor. Examine ECG tracings for dysrhythmias, especially a shortened QT interval. Hypercalcemia allows blood clots to form more easily whenever blood flow is poor. Blood clotting is more likely in the lower legs, the pelvic region, areas where blood flow is blocked by internal or external constrictions, and areas where venous obstruction occurs. Assess for slowed or impaired blood flow. Measure and record calf circumferences with a soft tape measure. Assess the feet for temperature, color, and capillary refill to determine the blood flow to and from the area. Neuromuscular changes include severe muscle weakness and decreased deep tendon reflexes without paresthesia. The patient may be confused and lethargic. Intestinal changes are first reflected as decreased peristalsis. Constipation, anorexia, nausea, vomiting, and abdominal distention and pain are common. Bowel sounds are hypoactive or absent. Assess abdominal size by measuring abdominal girth with a soft tape measure in a line circling the abdomen at the umbilicus. Interventions for hypercalcemia focus on reducing serum calcium levels through drug therapy, rehydration, and, depending on the cause and severity, dialysis. Cardiac monitoring is also important. Drug therapy involves preventing increases in calcium, as well as drugs to lower calcium levels. IV solutions containing calcium (e.g., Ringer's lactate) are stopped. Oral drugs containing calcium or vitamin D (e.g., calcium-based antacids) are discontinued. FLUID volume replacement can help restore normal serum calcium levels. IV normal saline (0.9% sodium chloride) is usually given because sodium increases kidney excretion of calcium. 170 Thiazide diuretics are discontinued and are replaced with diuretics that enhance the excretion of calcium, such as furosemide (Lasix, Furoside image). Calcium chelators (calcium binders) help lower serum calcium levels. Such drugs include plicamycin (Mithracin) and penicillamine (Cuprimine, Pendramine image). Drugs to prevent hypercalcemia include agents that inhibit calcium resorption from bone, such as phosphorus, calcitonin (Calcimar), bisphosphonates (etidronate), and prostaglandin synthesis inhibitors (aspirin, NSAIDs). Cardiac monitoring of patients with hypercalcemia is needed to identify dysrhythmias and decreased cardiac output. Compare recent ECG tracings with the patient's baseline tracings. Especially look for changes in the T waves and the QT interval and changes in rate and rhythm.

Sodium (hyponatremia, hypernatremia, & risk factors)

90 yr or younger: 136-145 mEq/L, or 136-145 mmol/L Older than 90 yr: 132-146 mEq/L, or 132-146 mmol/L Increased: Cardiac failure or kidney impairment Hypertension Excessive amounts of IV fluids containing sodium chloride Edema Dehydration (hemoconcentration) Decreased: Nasogastric drainage Vomiting or diarrhea Excessive use of laxatives or diuretics Excessive amounts of IV fluids containing water Syndrome of inappropriate antidiuretic hormone (SIADH) Elevated: Hypernatremia; dehydration; kidney disease; hypercortisolism Low: Hyponatremia; fluid overload; liver disease; adrenal insufficiency Sodium (Na+), a mineral, is the major cation (positively charged particle) in the extracellular fluid (ECF) and maintains ECF osmolarity. Sodium levels of the ECF are high (136 to 145 mEq/L [mmol/L]), and the intracellular fluid (ICF) sodium levels are low (about 14 mEq/L [mmol/L]). Keeping this difference in sodium levels is vital for skeletal muscle contraction, cardiac contraction, and nerve impulse transmission. Sodium levels and movement influence water balance because "where sodium goes, water follows." The ECF sodium level determines whether water is retained, excreted, or moved from one fluid space to another. To maintain electrical balance, the sodium (a cation) level within body FLUIDS must be matched by an equal number of anions (negatively charged substances). When this balance is present, the fluid is electrically neutral. Changes in plasma sodium levels seriously change fluid volume and the distribution of other ELECTROLYTES. Sodium enters the body through the ingestion of many foods and fluids. Foods with the highest sodium levels are those that are processed or preserved, such as smoked or pickled foods, snack foods, and many condiments. Foods lowest in sodium include fresh fish and poultry and most fresh vegetables and fruit. Despite variation in sodium intake from one day to the next, the blood sodium level usually remains within the normal range. Serum sodium balance is regulated by the kidney under the influences of aldosterone, antidiuretic hormone (ADH), and natriuretic peptide (NP), as described on p. 153. Low serum sodium levels inhibit the secretion of ADH and NP and trigger aldosterone secretion. Together these compensatory actions increase serum sodium levels by increasing kidney reabsorption of sodium and enhancing kidney loss of water. High serum sodium levels inhibit aldosterone secretion and directly stimulate secretion of ADH and NP. Together these hormones increase kidney excretion of sodium and kidney reabsorption of water. Hyponatremia is an ELECTROLYTE imbalance in which the serum sodium (Na+) level is below 136 mEq/L (mmol/L). Sodium imbalances often occur with a fluid imbalance because the same hormones regulate both sodium and water balance. The problems caused by hyponatremia occur from two changes—reduced excitable membrane depolarization and cellular swelling. Excitable cell membrane depolarization depends on high extracellular fluid (ECF) levels of sodium being available to cross cell membranes and move into cells in response to a stimulus. Hyponatremia makes depolarization slower so that excitable membranes are less excitable. With hyponatremia, the osmolarity of the ECF is lower than that of the intracellular fluid (ICF). As a result, water moves into the cell, causing swelling. Even a small amount of swelling can reduce cell function. Larger amounts of swelling can make the cell burst (lysis) and die. Many conditions and drugs can lead to hyponatremia (Table 11-5). A common cause of low sodium levels is the prolonged use and overuse of diuretics, especially in older adults. When these drugs are used to manage FLUID overload, sodium is lost along with the extra water. Hyponatremia can result from the loss of total body sodium, the movement of sodium from the blood to other fluid spaces, or the dilution of serum sodium from excessive water in the plasma. The manifestations of hyponatremia are caused by its effects on excitable cellular activity. The cells especially affected are those involved in cerebral, neuromuscular, intestinal smooth muscle, and cardiovascular functions. Cerebral changes are the most obvious problems of hyponatremia. Behavioral changes result from cerebral edema and increased intracranial pressure. Closely observe and document the patient's behavior, level of consciousness, and mental status. A sudden onset of acute confusion or increased confusion is often seen in older adults who have low serum sodium levels. When sodium levels become very low, seizures, coma, and death may occur (McGraw, 2012). Neuromuscular changes are seen as general muscle weakness. Assess the patient's neuromuscular status during each nursing shift for changes from baseline. Deep tendon reflexes diminish, and muscle weakness is worse in the legs and arms. Test arm muscle strength by having the patient squeeze your hand. 162Another way to test arm muscle strength is to have the patient flex his or her arms against the chest and keep them flexed while you attempt to pull them away from the chest. Test leg muscle strength by having the patient push both feet against a flat surface Intestinal changes include increased motility, causing nausea, diarrhea, and abdominal cramping. Assess the GI system by listening to bowel sounds and observing stools. Bowel sounds are hyperactive, with rushes and gurgles over the splenic flexure and in the lower left quadrant. Bowel movements are frequent and watery. Cardiovascular changes are seen as changes in cardiac output. The cardiac responses to hyponatremia with hypovolemia (decreased plasma volume) include a rapid, weak, thready pulse. Peripheral pulses are difficult to palpate and are easily blocked with light pressure. Blood pressure is decreased, and the patient may have severe orthostatic hypotension, leading to light-headedness or dizziness. The central venous pressure is low. When hyponatremia occurs with hypervolemia (FLUID overload), cardiac changes include a full or bounding pulse with normal or high blood pressure. Peripheral pulses are full and difficult to block; however, they may not be palpable if edema is present. When hyponatremia occurs with a fluid deficit, IV saline infusions are prescribed to restore both sodium and fluid volume. Severe hyponatremia may be treated with small-volume infusions of hypertonic saline, most often 3% saline (Schreiber, 2013b) although 5% saline can be used for extreme hyponatremia. These infusions are delivered using a controller to prevent accidental increases in infusion rate. Monitor the infusion rate and the patient's response. When hyponatremia occurs with FLUID excess, drug therapy includes giving drugs that promote the excretion of water rather than sodium, such as conivaptan (Vaprisol) or tolvaptan (Samsca). Drug therapy for hyponatremia caused by inappropriate secretion of antidiuretic hormone (ADH) may include lithium and demeclocycline (Declomycin). Assess hourly for signs of excessive fluid loss, potassium loss, and increased sodium levels. Nutrition therapy can help restore sodium balance in mild hyponatremia. Collaborate with the registered dietitian (RD) to teach the patient about which foods to increase in the diet. Common Causes of Hypernatremia Actual Sodium Excesses • Hyperaldosteronism • Kidney failure • Corticosteroids • Cushing's syndrome or disease • Excessive oral sodium ingestion • Excessive administration of sodium-containing IV fluidsRelative Sodium Excesses • Nothing by mouth • Increased rate of metabolism • Fever • Hyperventilation • Infection • Excessive diaphoresis • Watery diarrhea • Dehydration Nervous system changes start with altered cerebral function. Assess the patient's mental status for attention span and cognitive function. In hypernatremia with normal or decreased FLUID volumes, the patient may have a short attention span and be agitated or confused. When hypernatremia occurs with fluid overload, the patient may be lethargic, drowsy, stuporous, and even comatose. Skeletal muscle changes vary with the degree of sodium increases. Mild rises cause muscle twitching and irregular muscle contractions. As hypernatremia worsens, the muscles and nerves are less able to respond to a stimulus and muscles become progressively weaker. Late, the deep tendon reflexes are reduced or absent. Muscle weakness occurs bilaterally and has 163no specific pattern. Observe for twitching in muscle groups. Assess muscle strength by having the patient perform handgrip and arm flexion against resistance as described on pp. 161-162. Assess deep tendon reflexes by lightly tapping the patellar (knee) tendons and Achilles (heel) tendons with a reflex hammer and measuring the movement. Cardiovascular changes include decreased contractility because high sodium levels slow the movement of calcium into the heart cells. Measure blood pressure and the rate and quality of the apical and peripheral pulses. Pulse rate and blood pressure may be normal, above normal, or below normal, depending on the FLUID volume and how rapidly the imbalance occurred. Pulse rate is increased in patients with hypernatremia and hypovolemia. Peripheral pulses are difficult to palpate and are easily blocked. Hypotension and severe orthostatic (postural) hypotension are present, and pulse pressure is reduced. Patients with hypernatremia and hypervolemia have slow to normal bounding pulses. Peripheral pulses are full and difficult to block. Neck veins are distended, even with the patient in the upright position. Blood pressure, especially diastolic blood pressure, is increased. Interventions used when sodium levels become life threatening include hemodialysis. Priorities for nursing care of the patient with hypernatremia include monitoring his or her response to therapy and ensuring patient safety by preventing hyponatremia and dehydration. Drug therapy is used to restore FLUID balance when hypernatremia is caused by fluid loss. Isotonic saline (0.9%) and dextrose 5% in 0.45% sodium chloride are most often prescribed (Schreiber, 2013a). Although the dextrose 5% in 0.45% sodium chloride is hypertonic in the IV bag, once it is infused, the glucose is rapidly metabolized and the fluid is really hypotonic. Hypernatremia caused by poor kidney excretion of sodium requires drug therapy with diuretics that promote sodium loss, such as furosemide (Lasix, Furosideimage) or bumetanide (Bumex). Assess the patient hourly for symptoms of excessive losses of fluid, sodium, or potassium.

Assessment of surgical patient in the PACU

After surgery, the patient is taken to the postanesthesia care unit (PACU) usually for 1 to 2 hours before returning to the hospital room or discharge area. The length of stay in the PACU depends on the type of surgery, the type of anesthesia, any complications, and the patient's responses. Phase I care occurs immediately after surgery, most often in a PACU, although care in an ambulatory care unit is becoming common. For those patients who have very complicated procedures or many serious health problems, phase I care may occur in an intensive care unit (ICU). The length of time the patient remains at a phase I level of observation depends on his or her health status, the surgical procedure, anesthesia type, and rate of progression to complete alertness and hemodynamic stability. It can range from less than 1 hour to days. This level features very close monitoring of the airway, vital signs, and indicators of recovery that varies from every 5 to 15 minutes initially. The time between assessments gradually increases as the patient progresses toward recovery. The purpose of a postanesthesia care unit (PACU) (recovery room) is the ongoing evaluation and stabilization of patients to anticipate, prevent, and manage complications after surgery. Physical Assessment/Clinical Manifestations. Assess the patient, and record data on a PACU flow chart record (Fig. 16-1). Assessment data include level of consciousness, temperature, pulse, respiration, oxygen saturation, and blood pressure. Examine the surgical area for bleeding. Monitor vital signs as often as your facility's policy states, the patient's condition warrants, and the surgeon prescribes. Once the patient is discharged from the PACU, vital signs are measured as prescribed or as often as the patient's condition indicates. image Nursing Safety Priority image Action Alert Respiratory assessment is the most critical assessment to perform after surgery for any patient who has undergone general anesthesia or moderate sedation or has received sedative or opioid drugs. . The health care team determines the patient's readiness for discharge from the PACU by the presence of a recovery score rating of 9 to 10 on the recovery scale (see Fig. 16-1). Other criteria for discharge (e.g., stable vital signs; normal body temperature; no overt bleeding; return of gag, cough, and swallow reflexes; the ability to take liquids; and adequate urine output) may be specific to the facility. After you determine that all criteria have been met, the patient is discharged by the anesthesia provider to the hospital unit or to home. If an anesthesia provider has not been involved, which may be the case with local anesthesia or moderate sedation, the surgeon or nurse discharges the patient once the discharge criteria have been met. Assessment continues from the PACU to the intensive care or medical-surgical nursing unit. If the patient is to be discharged from the PACU to home, assessment and any needed nursing care are continued by home care nurses or by the patient or family members after health teaching. When the patient is transferred to an inpatient unit, complete an initial assessment on arrival

Risk factors for surgery -medications, age, presence of other diseases

Age • Older than 65 years Older patients are at increased risk for complications from both anesthesia and surgery (Doerflinger, 2009). The normal aging process decreases immune system functioning and delays wound healing. The frequency of chronic illness increases in older patients. Gas exchange is more profoundly affected by general anesthetic agents and by opioid analgesics. Age-related changes in kidney and liver function may delay the elimination of anesthetic and analgesic agents, increasing the risk for adverse reactions Medications • Antihypertensives • Tricyclic antidepressants • Anticoagulants • Nonsteroidal anti-inflammatory drugs (NSAIDs) 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 Family History • Malignant hyperthermia • Cancer • Bleeding disorder 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)

Foods high in potassium, low in potassium.

Almost all foods contain potassium. It is highest in meat, fish, and many (but not all) vegetables and fruits. It is lowest in eggs, bread, and cereal grains. Typical potassium intake is about 2 to 20 g/day. Despite heavy potassium intake, the healthy adult keeps plasma potassium levels within the narrow range of normal values.

Types of anesthesia - general, local, conscious sedation. Benefits/Risks of each type

Anesthesia reduces or temporarily eliminates SENSORY PERCEPTION. Anesthesia delivery is a precise science. It requires the skill of an anesthesiologist, a certified registered nurse anesthetist (CRNA) working under the direction of an anesthesiologist or another physician, or an anesthesiologist assistant (AA—similar to a physician assistant working under the direction of an anesthesiologist). Anesthesia is an induced state of partial or total loss of SENSORY PERCEPTION, with or without loss of consciousness. The purpose of anesthesia is to block nerve impulse transmission, suppress reflexes, promote muscle relaxation, and, in some cases, achieve a controlled level of unconsciousness. Anesthesia providers use a separate anesthesia record for documentation Patient health problems are factors in the selection and dose of anesthetic. Selection is also influenced by: • Type and duration of the procedure • Area of the body having surgery • Safety issues to reduce injury, such as airway management • Whether the procedure is an emergency • Options for management of pain after surgery • How long it has been since the patient ate, had any liquids, or had any drugs • Patient position needed for the surgical procedure • Whether the patient must be alert enough to follow instructions during surgery • The patient's previous responses and reactions to anesthesia The categories rank patients in a range from a totally healthy patient (P1 ranking) to a patient who is brain dead (P6 ranking) Inhalation Most controllable method Induction and reversal accomplished with pulmonary ventilation Must be used in combination with other agents for painful or prolonged procedures Limited muscle relaxant effects Postoperative nausea and shivering common Intravenous Rapid and pleasant induction Low incidence of postoperative nausea and vomiting Must be metabolized and excreted from the body for complete reversal Contraindicated in presence of liver or kidney disease Increased cardiac and respiratory depression Balanced Minimal disturbance to physiologic function Can be used with older and high-risk patients Drug interactions can occur Regional or Local Gag and cough reflexes stay intact Allows participation and cooperation by the patient Less disruption of physical and emotional body functions No way to control agent after administration Increased nervous system stimulation (overdose)Not practical for extensive procedures because of the amount of drug that would be required to maintain anesthesia General anesthesia is a reversible loss of consciousness induced by inhibiting neuronal impulses in several areas of the central nervous system (CNS). This state can be achieved with a single agent or a combination of agents. General anesthesia depresses the CNS, resulting in analgesia (pain relief or pain suppression), amnesia (memory loss of the surgery), and unconsciousness, with loss of muscle tone and reflexes. The patient is unconscious and has no SENSORY PERCEPTION. General anesthesia is used most often in surgery of the head, neck, upper torso, and abdomen. The speed of emergence (recovery from the anesthesia) depends on the anesthetic agent, the duration of anesthesia administration, and whether a reversal agent is used. Retching, vomiting, and restlessness may occur during emergence, although not all patients have these responses. Complications can range from minor (e.g., sore throat) to death. Improvement in anesthesia delivery and surgical techniques has resulted in a decline in anesthesia-related deaths, even among higher-risk patients. Although the anesthesia provider has the main responsibility for monitoring patient responses during surgery, the circulating nurse also remains alert for changes in the patient's condition. Malignant hyperthermia (MH), an inherited muscle disorder, is an acute, life-threatening complication of certain drugs used for general anesthesia. Local or regional anesthesia briefly disrupts sensory nerve impulse transmission from a specific body area or region, thus reducing SENSORY PERCEPTION in a limited area. Motor function may or may not be affected. The patient remains conscious and can follow instructions. The gag and cough reflexes remain intact, and the risk for aspiration is low. This type of anesthesia may be supplemented with sedatives, opioid analgesics, or hypnotics to reduce anxiety and increase comfort. The OR nurse provides the patient with information, directions, and emotional support before, during, and after the procedure. Local Anesthesia. Local anesthesia is delivered topically (applied to the skin or mucous membranes of the area to be anesthetized) and by local infiltration (injected directly into the tissue around an incision, wound, or lesion). Sometimes when the term local is used, it means any form of anesthesia that is not general or monitored anesthesia. Regional Anesthesia. Regional anesthesia is a type of local anesthesia that blocks multiple peripheral nerves and reduces SENSORY PERCEPTION in a specific body region. It can be used under a variety of conditions and surgeon and patient preferences. It is often used when pain management after surgery is enhanced by regional anesthesia, such as after a total knee replacement. If the patient has eaten and the surgery is an emergency, it may be possible to perform surgery with the patient under regional anesthesia to decrease the risk for aspiration. Regional anesthesia includes field block, nerve block, spinal, and epidural Field block A series of injections around the operative field Most commonly used for chest procedures, hernia repair, dental surgery, and some plastic surgeries Nerve block Injection of the local anesthetic agent into or around one nerve or group of nerves in the involved area Most commonly used for limb surgery or to relieve chronic pain Spinal anesthesia Injection of an anesthetic agent into the cerebrospinal fluid in the subarachnoid space (see Fig. 15-9) Most commonly used for lower abdominal, pelvic, hip, and knee surgery Epidural anesthesia Injection of an agent into the epidural space (see Fig. 15-9) Most commonly used for anorectal, vaginal, perineal, hip, and lower extremity surgeries Complications of local or regional anesthesia are related to patient sensitivity to the anesthetic agent (anaphylaxis), incorrect delivery technique, systemic absorption, and overdose. The nurse observes for central nervous system (CNS) stimulation followed by CNS and cardiac depression, which are indications of a systemic toxic reaction. The nurse also assesses for restlessness, excitement, incoherent speech, headache, blurred vision, metallic taste, nausea, tremors, seizures, and increased pulse, respiration, and blood pressure. Interventions include establishing an open airway, giving oxygen, and notifying the surgeon. Usually a fast-acting barbiturate is needed for treatment. If the toxic reaction is untreated, unconsciousness, hypotension, apnea, cardiac arrest, and death may result. Cardiac arrest may occur as a rare complication of spinal anesthesia. Epinephrine is given to prevent cardiac arrest in patients who develop sudden, unexplained bradycardia. Local early complications include edema and inflammation. Abscess formation, tissue necrosis, and/or gangrene may occur later. Abscesses result from contamination during injection of the agent. Necrosis and gangrene may occur as a result of prolonged blood vessel constriction in the injected area. Moderate sedation (conscious sedation) is the IV delivery of sedative, hypnotic, and opioid drugs to reduce SENSORY PERCEPTION but allow the patient to maintain a patent airway. The amnesia action is short, and the patient has a rapid return to ADLs. Etomidate (Amidate), diazepam (Valium, Vivol image, Novo-Dipam image), midazolam (Versed), fentanyl (Sublimaze), alfentanil (Alfenta), propofol (Diprivan), and morphine sulfate are the most commonly used drugs. Moderate sedation is used to reduce the level of consciousness during endoscopy, cardiac catheterization, closed fracture reduction, cardioversion, and other short procedures. Formerly known as conscious sedation. IV delivery of hypnotic, sedative, and opioid drugs to reduce LOC. Allows patient to maintain an airway and to respond to verbal commands.

anti-inflammatory, i.e, corticosteroids, Fluticasone

Anti-inflammatories All of these drugs help improve bronchiolar airflow by decreasing the inflammatory response of the mucous membranes in the airways. They do not cause bronchodilation. Corticosteroids Disrupt production pathways of inflammatory mediators. The main purpose is to prevent an asthma attack caused by inflammation or allergies (controller drug). Fluticasone (Flovent) 50 mcg by MDI twice daily; 100-250 mcg by DPI dailyTeach patient to use the drug daily, even when no symptoms are present.Maximum effectiveness requires continued use for 48-72 hr and depends on regular use.Teach patient to use good mouth care and to check mouth daily for lesions or drainage.Drug reduces local immunity and increases the risk for local infections, especially Candida albicans (yeast).Teach patient to not use this drug as a reliever drug.Drug has slow onset of action and does not relieve symptoms.Teach patient the correct technique for using the MDI or DPI.Correct technique is essential to getting the drug to the site of action.

Noninfectious Lower Respiratory Problems - Asthma - Inflammation + Bronchospasm - Asthmatic emergency

Asthma is often a chronic condition in which reversible airflow obstruction in the airways occurs intermittently (Fig. 30-1). Airway obstruction occurs by INFLAMMATION and by airway tissue sensitivity (hyperresponsiveness) that leads to bronchoconstriction. Inflammation obstructs the airway lumens (i.e., the insides) (Fig. 30-2). Airway hyperresponsiveness and constriction of bronchial smooth muscle narrow the airways from the outside. Airway inflammation and sensitivity can trigger bronchiolar constriction, and many people with asthma have both problems. Severe airway obstruction impairs GAS EXCHANGE and can be fatal. At least 3400 deaths 549from acute asthma occur in the United States each year Although asthma is classified into types based on what triggers the attacks, the effect on GAS EXCHANGE is the same. INFLAMMATION of the mucous membranes lining the airways is a key event in triggering an asthma attack. It occurs in response to the presence of specific allergens; general irritants such as cold air, dry air, or fine airborne particles; microorganisms; and aspirin and other NSAIDs. Increased airway sensitivity (hyperresponsiveness) can occur with exercise, with an upper respiratory illness, and for unknown reasons. When asthma is well controlled, the airway changes are temporary and reversible. With poor control, chronic INFLAMMATION can lead to airway damage and altered CELLULAR REGULATION with enlargement of the bronchial epithelial cells 550and changes in the bronchial smooth muscle. When asthma attacks are frequent, even exposure to low levels of the triggering agent or event may stimulate an attack. Inflammation triggers asthma for some people when allergens bind to specific antibodies (especially immunoglobulin E [IgE]). These antibodies are attached to tissue mast cells and white blood cells (WBCs) called basophils, which are filled with chemicals that can start local inflammatory responses (see Chapters 17 and 20). Some chemicals, such as histamine, start an immediate inflammatory response, which can be blocked by drugs like diphenhydramine (Benadryl). Others, such as leukotriene and eotaxin, are slower and cause later, prolonged inflammatory responses, which can be blocked by drugs like montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo). Chemicals also attract more WBCs (eosinophils, macrophages, basophils) to the area, which then continue the responses of blood vessel dilation and capillary leak, leading to mucous membrane swelling and increased mucus production (McCance et al., 2014). These responses narrow the lumens even more, which then interferes with airflow and GAS EXCHANGE. INFLAMMATION can also occur through general irritation rather than allergic responses. Bronchospasm is a narrowing of the bronchial tubes by constriction of the smooth muscle around and within the bronchial walls. It can occur when small amounts of pollutants or respiratory viruses stimulate nerve fibers, causing constriction of bronchial smooth muscle. If an inflammatory response is stimulated at the same time, the chemicals released during INFLAMMATION also trigger constriction. Severe bronchospasm alone, especially in smaller bronchioles, can profoundly limit airflow to the alveoli and greatly reduce GAS EXCHANGE. Aspirin and other NSAIDs can trigger asthma in some people, although this response is not a true allergy. It results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways. Gastroesophageal reflux disease (GERD) can trigger asthma in some people, who then have more asthma manifestations at night (Global Initiative for Asthma [GINA], 2014). GERD allows highly acidic stomach contents to enter the airway and make the pre-existing tissue sensitivity worse. Status Asthmaticus. Status asthmaticus is a severe, life-threatening acute episode of airway obstruction that intensifies once it begins and often does not respond to usual therapy. The patient arrives in the emergency department with extremely labored breathing and wheezing. Use of accessory muscles for breathing and distention of neck veins are observed. If the condition is not reversed, the patient may develop pneumothorax and cardiac or respiratory arrest. IV fluids, potent systemic bronchodilators, steroids, epinephrine, and oxygen are given immediately to reverse the condition. Prepare for emergency intubation. Sudden absence of wheezing indicates complete airway obstruction and requires a tracheotomy. When breathing improves, management is similar to that for any patient with asthma.

Common drug therapy - focus on mechanism of action (purpose) and side effect(s) of bronchodilator, i.e., short- & long-acting beta agonists: - Short acting agonist - Albuteral (Proventil) - Long acting beta agonist -Salmeterol (Serevent)

Bronchodilators Cause bronchodilation through relaxing bronchiolar smooth muscle by binding to and activating pulmonary beta2 receptors. Short-Acting Beta2 Agonist (SABA) Primary use is a fast-acting reliever (rescue) drug to be used either during an asthma attack or just before engaging in activity that usually triggers an attack. Albuterol (Proventil, Ventolin) 1-2 inhalations every 4-6 hr (90 mcg/ inhaled dose) Excessive use causes systemic symptoms, especially tachycardia. Teach patients to carry drug with them at all times.The drug can stop or reduce life-threatening bronchoconstriction, which can occur anytime.Teach patient to monitor heart rate.Excessive use causes systemic symptoms, especially tachycardia.When taking this drug with other inhaled drugs, teach patient to use this drug at least 5 minutes before the other inhaled drugs.The bronchodilation effect of the drug allows better penetration of the other inhaled drugs.Teach patient the correct technique for using the MDI or DPI.Correct technique is essential to getting the drug to the site of action. Long-Acting Beta2 Agonist (LABA) Causes bronchodilation through relaxing bronchiolar smooth muscle by binding to and activating pulmonary beta2 receptors. Onset of action is slow with a long duration. Primary use is prevention of an asthma attack. Salmeterol (Serevent) 2 inhalations every 12 hr (25 mcg/inhalation with MDI) (50 mcg/inhalation with DPI) Teach patient to shake inhaler (MDI) well before using.Drug separates easily.Teach patient to not use this drug as a reliever drug.Drug has slow onset of action and does not relieve symptoms.Teach patient the correct technique for using the MDI or DPI.Correct technique is essential to getting the drug to the site of action.

Electrocardiogram for hypokalemia and hyperkalemia

Cardiovascular changes are the most severe problems from hyperkalemia and are the most common cause of death in patients with hyperkalemia. Cardiac manifestations include bradycardia, hypotension, and ECG changes of tall, peaked T waves, prolonged PR intervals, flat or absent P waves, and wide QRS complexes. As serum potassium levels rise, ectopic beats may appear. Complete heart block, asystole, and ventricular fibrillation are life-threatening complications of severe hyperkalemia. Cardiovascular changes are assessed by palpating the peripheral pulses. In hypokalemia, the pulse is usually thready and weak. Palpation is difficult, and the pulse is easily blocked with light pressure. The pulse rate can range from very slow to very rapid, and an irregular heartbeat (dysrhythmia) may be present. Measure blood pressure with the patient in the lying, sitting, and standing positions, because orthostatic (postural) hypotension occurs with hypokalemia.

cholinergic antagonist - Ipratropium (Atrovent)

Cholinergic Antagonist Causes bronchodilation by inhibiting the parasympathetic nervous system, allowing the sympathetic system to dominate, releasing norepinephrine that activates beta2 receptors. Purpose is to both relieve and prevent asthma. Ipratropium (Atrovent, Apo-Ipravent) 2-4 inhalations 4-6 times daily (18 mcg/inhalation)If patient is to use this as a reliever drug, teach him or her to carry it at all times.The drug can stop or reduce life-threatening bronchoconstriction, which can occur anytime.Teach patient to shake MDI well before using.Drug separates easily.Teach patient to increase daily fluid intake.Drug causes mouth dryness.Teach patient to observe for and report blurred vision, eye pain, headache, nausea, palpitations, tremors, inability to sleep.These are systemic symptoms of overdose and require intervention.Teach patient the correct technique for using the MDI or DPI.Correct technique is essential to getting the drug to the site of action.

Nursing interventions (particularly teaching)

Combination drug therapy is the most effective method of treating TB and preventing transmission. Active TB is treated with 597a combination of drugs to which the organism is sensitive. Therapy continues until the disease is under control. The use of multiple-drug regimens destroys organisms as quickly as possible and reduces the emergence of drug-resistant organisms. First-line therapy uses isoniazid (INH) and rifampin (Rifadin) throughout the therapy; pyrazinamide is added for the first 2 months (Chart 31-5). This protocol shortens the therapy from 6 to 12 months to 6 months. Ethambutol (Myambutol) is the recommended fourth drug in first-line therapy. These drugs are now available in two-drug or three-drug combinations. One example is Rifater, which combines isoniazid, pyrazinamide, and rifampin. Variations of the first-line drugs along with other drug types are used when the patient does not tolerate the standard first-line therapy. Nursing interventions focus on patient teaching for drug therapy adherence and INFECTION control. Strict adherence to the prescribed drug regimen is crucial for suppressing the disease. Thus your major role is teaching the patient about drug therapy and stressing the importance of taking each drug regularly, exactly as prescribed, for as long as it is prescribed. Provide accurate information in multiple formats, such as pamphlets, videos, and drug-schedule worksheets. To determine whether the patient understands how to take the drugs, ask him or her to describe the treatment regimen, side effects, and when to call the health care agency and physician. The TB drugs may cause the patient to have nausea. Teach him or her to prevent nausea by taking the daily dose at bedtime. Antiemetics may also prevent this problem. Instruct him or her to eat a well-balanced diet that includes foods that are rich in iron, protein, and vitamins C and B. Collaborate with the registered dietitian for specialized needs. The patient with TB has reduced physical stamina and also has concerns about the disease prognosis. Offer a positive outlook for the patient who adheres to the drug regimen. Tell him or her that fatigue will diminish as the treatment progresses. With current resistant strains of TB, however, emphasize that not taking the drugs as prescribed could lead to an infection that is drug resistant. Some multidrug-resistant TB (MDR TB) strains are emerging as extensively drug-resistant (XDR TB). MDR TB is an INFECTION that resists INH and rifampin. XDR TB is resistant not only to the first-line anti-tuberculosis drugs but also to the second-line antibiotics, including the fluoroquinolones and at least one of the aminoglycosides. In 2011, there were over 690,000 cases of MDR TB worldwide with 9% being XDR TB. The most common cause of MDR TB and XDR TB is mismanagement of drug therapy, either from inappropriate selection or use of antibiotics (WHO, 2013). Patients with acquired immune deficiency syndrome (AIDS) also often have MDR TB (CDC, 2013a). Drug therapy for MDR TB and XDR TB is more limited than standard first-line therapy and requires higher doses for longer periods. A new drug combination of bedaquiline, pyrazinamide, and moxifloxacin (Sirturo) was approved in 2012 to treat multidrug-resistant TB. Another drug, delaminid (OPC-67683), is in clinical trials When teaching the patient and family with either MDR TB or XDR TB, stress that it is the organism, not the patient, that is drug resistant. So a person who acquires the INFECTION and develops TB from a person who is infected with a resistant strain of bacillus will also have drug-resistant disease. Thus teaching infection control strategies is a priority and should be constantly reinforced. E. Amoxicillin (Amoxil); take this drug with food or milk Other care issues for the patient with TB include teaching about INFECTION prevention and what to expect about disease monitoring and participating in activities. TB is often treated outside the acute care setting, with the patient convalescing in the home setting. Airborne Precautions are not necessary in this setting because family members have already been exposed; however, all members of the household need to undergo TB testing. Teach the patient to cover the mouth and nose with a tissue when coughing or sneezing, to place used tissues in plastic bags, and to wear a mask when in contact with crowds until the drugs suppress infection. Tell the patient that sputum specimens are needed usually every 2 to 4 weeks once drug therapy is initiated. When the results of three consecutive sputum cultures are negative, the patient is no longer infectious and may return to former employment. Remind him or her to avoid exposure to any inhalation irritants because these can cause further lung damage. The hospitalized patient with active TB is placed on Airborne Precautions (see Chapter 23) in a well-ventilated room that has at least six exchanges of fresh air per minute. All health care workers must use a personal respirator when caring for the patient. When hand and clothing contamination is a risk, use Standard Precautions with appropriate contact protection (i.e., gowns and gloves). In accordance with The Joint Commission's NPSGs, perform handwashing before and after patient care. Precautions are discontinued when the patient is no longer infectious.

Treatment recommendations - the step system

Drug Therapy. Pharmacologic management of adults with asthma is based on the step category for severity and treatment (see Charts 30-2 and 30-3) (GINA, 2014). Control therapy drugs are drugs used to reduce airway sensitivity (responsiveness) to prevent asthma attacks from occurring. They are used every day, regardless of symptoms. Reliever drugs (also called "rescue drugs") are those used to actually stop an attack once it has started. Some patients may need drug therapy only during an asthma episode. For others, daily drugs are needed to keep asthma episodic rather than a more frequent problem. This therapy involves the use of bronchodilators and various drug types to reduce INFLAMMATION. Some drugs reduce the asthma response, and other drugs actually prevent the response. Combination drugs are two agents from different classes combined together for better response.

Prevention of electrolyte imbalances (potassium, sodium)

Health teaching is key to the prevention of hyperkalemia and the early detection of complications. The teaching plan includes diet, drugs, and recognition of the manifestations of hyperkalemia. Collaborate with the dietitian to teach the patient and family about which foods to avoid (those high in potassium). Instruct the patient and family to read the labels on drug and food packages to determine the potassium content. Warn them to avoid salt substitutes, which contain potassium.

Diuretics - furosemide

Hypernatremia caused by poor kidney excretion of sodium requires drug therapy with diuretics that promote sodium loss, such as furosemide (Lasix, Furosideimage) or bumetanide (Bumex). Assess the patient hourly for symptoms of excessive losses of fluid, sodium, or potassium Diuretics that increase the kidney excretion of potassium can cause hypokalemia, especially high-ceiling (loop) diuretics (e.g., furosemide [Lasix, Furoside image] and bumetanide [Bumex]) and the thiazide diuretics.

Can you be sick and do surgery?

No one who has an open wound, cold, or any INFECTION should participate in surgery.

Teaching regarding isoniazid and rifampin.

Isoniazid: Teach the patient to take the drug on an empty stomach (1 hour before or 2 hours after meals) and to avoid antacids.Food and antacids slow or prevent absorption of the drug from the GI tract.Teach the patient to take a daily multiple vitamin that contains the B-complex vitamins while on this drug.Drug can deplete the body of this vitamin.Remind the patient to avoid drinking alcoholic beverages while on this drug.The drug can cause liver damage. This effect is potentiated by alcohol. Rifampin: Teach the patient to expect the drug to stain the skin and urine and expect all other secretions to have a reddish orange tinge; also, soft contact lenses will become permanently stained.This is an expected and harmless side effect of the drug and will clear some time after the patient stops taking the drug.Teach women using oral contraceptives to use an additional method of contraception while taking this drug and for 1 month after stopping the drug.This drug reduces the effectiveness of oral contraceptives, increasing the risk for an unplanned pregnancy.Remind the patient to avoid drinking alcoholic beverages while on this drug.The drug can cause liver damage. This effect is potentiated by alcohol.Teach the patient to report darkening of the urine, a yellow appearance to the skin or whites of the eyes, and an increased tendency to bruise or bleed.These manifestations may indicate liver toxicity or failure.Ask the patient about all other drugs in use.This drug interacts with many drugs.

Lab Profile: Preoperative Assessment - what should be communicated to surgeon

Laboratory tests before surgery provide baseline data about the patient's health and help predict potential complications. The patient scheduled for surgery in an ambulatory surgical center or admitted to the hospital on the morning of or day before surgery may have preadmission testing (PAT) performed from 24 hours to 28 days before the scheduled surgery. These test results are usually valid unless there has been a change in the patient's condition that warrants repeated testing or the patient is taking drugs that can alter laboratory values (e.g., warfarin [Coumadin], aspirin, diuretics). The most common tests include: • 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 Urinalysis is performed to assess for abnormal substances in the urine such as protein, glucose, blood, and bacteria. If kidney disease is suspected or if the patient is older, the physician may request other tests to determine the type and degree of disease present. Report electrolyte imbalances or other abnormal results to the anesthesia team and the surgeon before surgery. Hypokalemia (decreased serum potassium level) increases the risk for toxicity if the patient is taking digoxin, slows recovery from anesthesia, and increases cardiac irritability. Hyperkalemia (increased serum potassium level) increases the risk for dysrhythmias, especially with the use of anesthesia. The OR nurse reviews the most recent laboratory findings and test results to inform the surgical team about the patient's health and to alert them for potential problems. These results are usually obtained within 24 to 48 hours before surgery for hospitalized patients and within 4 weeks for ambulatory surgery patients. The nurse reports all abnormal findings or results to the surgeon and anesthesia provider. Laboratory values greater than or less than the normal range are potentially life threatening during surgery (see Chapter 14). For example, if the hemoglobin level is less than 10 g/dL, oxygen transport and GAS EXCHANGE are reduced, affecting the amount and type of anesthesia used.

Leukotriene modifiers - Montelukast (Singulair)

Leukotriene Modifier Blocks the leukotriene receptor, preventing the inflammatory mediator from stimulating inflammation. Purpose is to prevent asthma attack triggered by inflammation or allergens. Montelukast (Singulair) 10 mg orally dailyTeach patient to use the drug daily, even when no symptoms are present.Drug has slow onset of action for asthma prevention and is most effective when taken consistently.Teach patient not to decrease the dose of or stop taking any other asthma drugs unless instructed by the health care professional.This drug is for long-term asthma control and does not replace other drugs, especially corticosteroids and reliever (rescue) drugs.

Malignant hyperthermia - who is at risk, signs & symptoms, interventions

Malignant hyperthermia (MH), an inherited muscle disorder, is an acute, life-threatening complication of certain drugs used for general anesthesia. It is characterized by many problems, including poor THERMOREGULATION. The reaction begins in skeletal muscle exposed to the drugs, causing increased calcium levels in muscle cells and increased muscle metabolism. Serum calcium and potassium levels are increased, as is the metabolic rate, leading to acidosis, cardiac dysrhythmias, and a high body temperature. Onset of MH may occur immediately after anesthesia induction, several hours into the procedure, or even after the anesthetic has been terminated. Manifestations are caused by increased muscle calcium level and the greatly increased body metabolism. These include tachycardia, dysrhythmias, muscle rigidity (especially of the jaw and upper chest), hypotension, tachypnea, skin mottling, cyanosis, and myoglobinuria (presence of muscle proteins in the urine). The most sensitive 247indication is an unexpected rise in the end-tidal carbon dioxide level with a decrease in oxygen saturation and tachycardia. Extremely elevated temperature, as high as 111.2° F (44° C), is a late sign of MH. Survival depends on early diagnosis and the immediate actions of the entire surgical team. Dantrolene sodium, a skeletal muscle relaxant, is the drug of choice along with other interventions Monitor patients for the cluster of elevated end-tidal carbon dioxide level, decreased oxygen saturation, and tachycardia related to malignant hyperthermia. If these changes begin, alert the surgeon and anesthesia provider immediately. When the patient has a known history or risk for MH, treatment with dantrolene can begin before, during, and after surgery to prevent it. Chart 15-1 lists best practices for care of the patient with MH. The AORN recommends that all operating rooms have a dedicated MH cart containing drugs for management (normal saline, dantrolene, sodium bicarbonate, insulin, 50% dextrose, lidocaine, and calcium chloride), a protocol card listing interventions, and the MH hotline number. Additional nursing support is needed during this true perioperative emergency. MH is a genetic disorder with an autosomal dominant pattern of inheritance. The patient with a genetic predisposition for MH is at risk for this complication from halothane, enflurane, isoflurane, desflurane, sevoflurane, and succinylcholine. This rare problem is most common in young adults. Males are affected more often than females (despite the autosomal dominant pattern of inheritance) because of gender differences in muscle mass. The muscle biopsy tested with the caffeine halothane contracture test (CHCT) is still considered the most commonly used MH testing even though this disorder is inherited and only five centers are approved to perform the test Emergency Care of the Patient with Malignant Hyperthermia • Stop all inhalation anesthetic agents and succinylcholine. • If an endotracheal tube (ET) is not already in place, intubate immediately. • Ventilate the patient with 100% oxygen, using the highest possible flow rate. • Administer dantrolene sodium (Dantrium) IV at a dose of 2 to 3 mg/kg. • If possible, terminate surgery. If termination is not possible, continue surgery using anesthetic agents that do not trigger malignant hyperthermia (MH). • Assess arterial blood gases (ABGs) and serum chemistries for metabolic acidosis and hyperkalemia. • If metabolic acidosis is evident by ABG analysis, administer sodium bicarbonate IV. • If hyperkalemia is present, administer 10 units of regular insulin in 50 mL of 50% dextrose IV. • Use active cooling techniques: ▪ Administer iced saline (0.9% NaCl) IV at a rate of 15 mL/kg every 15 minutes as needed. ▪ Apply a cooling blanket over the torso. ▪ Pack bags of ice around the patient's axillae, groin, neck, and head. ▪ Lavage the stomach, bladder, rectum, and open body cavities with sterile iced normal saline. • Insert a nasogastric tube and a rectal tube. • Monitor core body temperature to assess effectiveness of interventions and to avoid hypothermia. • Monitor cardiac rhythm by electrocardiography (ECG) to assess for dysrhythmias. • Insert a Foley catheter to monitor urine output. • Treat any dysrhythmias that do not resolve on correction of hyperthermia and hyperkalemia with antidysrhythmic agents other than calcium channel blockers. • Administer IV fluids at a rate and volume sufficient to maintain urine output above 2 mL/kg/hr. • Monitor urine for presence of blood or myoglobin. • If urine output falls below 2 mL/kg/hr, consider using osmotic or loop diuretics, depending on the patient's cardiac and kidney status. • Contact the Malignant Hyperthermia Association of the United States (MHAUS) hotline for more information regarding treatment: (800) 644-9737. • Transfer the patient to the intensive care unit (ICU) when stable. • Continue to monitor the patient's temperature, ECG, ABGs, electrolytes, creatine kinase, coagulation studies, and serum and urine myoglobin levels until they have remained normal for 24 hours. • Instruct the patient and family about testing for MH risk. • Refer the patient and family to the Malignant Hyperthermia Association of the United States at (800) 986-4287 or www.mhaus.org. • Report the incident to the North American Malignant Hyperthermia Registry at the Malignant Hyperthemia Association of the United States: (800) 644-9737.

Robotic Surgery

Minimally Invasive and Robotic Surgery Minimally invasive surgery (MIS) is a common practice and now is the preferred technique for many types of surgery, including cholecystectomy, cardiac surgery, splenectomy, and spinal surgery. It is even being used for cancer surgeries, such as the removal of a lung lobe (lobectomy) or even the entire lung (pneumonectomy) and colectomy. Benefits of MIS include reduced surgery time for some surgeries, smaller incisions, reduced blood loss, faster recovery time, and less pain after surgery. During MIS, one or more small incisions is made in the surgical area and an endoscope (a tube that allows viewing and manipulation of internal body areas) is placed through the opening (Fig. 15-4). These instruments may be rigid, semirigid, or flexible and may have self-contained light sources. Endoscopes have different names and shapes for different surgical purposes. For example, laparoscopes are used for abdominal surgery, arthroscopes are used for joint surgery, and ureteroscopes are used for urinary tract surgery. An important part of MIS for abdominal surgery, pelvic surgery, and surgery in some other body cavity areas is injecting gas or air into the cavity before the surgery to separate organs and improve visualization. This injection is known as insufflation and may contribute to complications and patient discomfort. This factor is considered when deciding whether to perform a procedure by traditional surgery or by endoscopy. Robotic technology takes MIS to a new level and is changing how surgery is performed and how the OR is organized. Many gynecologic, urologic, and cardiovascular procedures are being performed by using robotics. The robotic system consists of a console, surgical arm cart, and video cart (Fig. 15-5). The surgeon first inserts the required instruments and positions the articulating arms; he or she then breaks scrub and performs the surgery while sitting at the console. A three-dimensional (3-D) view of the patient's anatomy allows precise control and dexterity. The vision cart holds the monitors, cameras, and recorder equipment. This new technology requires a perioperative robotics nurse specialist who teaches patients and family and trains members of the surgical team. Mechanical trauma and thermal injury are two types of injury that a patient can incur during MIS and robotic surgery (Ulmer, 2010). Both MIS and robotic surgery are limited by the cost of special equipment, OR settings, and the lengthy training and practice periods for the surgeon to become proficient in even one procedure using these methods.

Physical assessment findings?

Physical Assessment/Clinical Manifestations. Observe the general appearance. Many patients with pneumonia have flushed cheeks and an anxious expression. The patient may have chest pain or discomfort, myalgia, headache, chills, fever, cough, tachycardia, dyspnea, tachypnea, hemoptysis, and sputum production. Severe chest muscle weakness also may be present from sustained coughing. Observe the patient's breathing pattern, position, and use of accessory muscles. The hypoxic patient may be uncomfortable in a lying position and will sit upright, balancing with the hands 592("tripod position"). Assess the cough and the amount, color, consistency, and odor of sputum produced. Crackles are heard with auscultation when fluid is in interstitial and alveolar areas, and breath sounds may be diminished. Wheezing may be heard if INFLAMMATION or exudate narrows the airways. Bronchial breath sounds are heard over areas of density or consolidation. Fremitus is increased over areas of pneumonia, and percussion is dulled. Chest expansion may be diminished or unequal on inspiration. In evaluating vital signs, compare the results with baseline values. The patient with pneumonia is often hypotensive with orthostatic changes as a result of vasodilation and dehydration, especially the older adult. A rapid, weak pulse may indicate hypoxemia, dehydration, or impending sepsis and shock. Dysrhythmias may occur as a result of cardiac tissue hypoxia.

IV potassium - nursing considerations

Potassium is a severe tissue irritant and is never given by IM or subcutaneous injection. Tissues damaged by potassium can become necrotic, causing loss of function and requiring surgery. IV potassium solutions irritate veins and cause phlebitis. Check the prescription carefully to ensure that the patient receives the correct amount of potassium. Assess the IV site hourly, and ask the patient whether he or she feels burning or pain at the site. Drug Alert A dilution no greater than 1 mEq of potassium to 10 mL of solution is recommended for IV administration. The maximum recommended infusion rate is 5 to 10 mEq/hr; this rate is never to exceed 20 mEq/hr under any circumstances. In accordance with National Patient Safety Goals (NPSGs), potassium is not given by IV push to avoid causing cardiac arrest. Action Alert If infiltration of solution containing potassium occurs, stop the IV solution immediately, remove the venous access, and notify the health care provider or Rapid Response Team. Document these actions along with a complete description of the IV site.

Risk factors for complications of surgery, and anesthesia -pneumonia, clots, urinary retention, etc.

Prevention of Brachial Plexus Complications (Paralysis, Loss of Sensation in Arm and Shoulder) • Pad the elbow if tucked at the side. • Avoid excessive abduction. • Secure the arm firmly on a padded armboard, positioned at shoulder level, and extended less than 90 degrees. Prevention of Radial Nerve Complications (Wrist Drop) • Support the wrist with padding. • Be careful not to overtighten wrist straps. Prevention of Medial or Ulnar Nerve Complications (Hand Weakness, Claw Hand) • Place the safety strap above or below the nerve locations. Prevention of Peroneal Nerve Complications (Foot Drop) • Pad knees and ankles. • Maintain minimal external rotation of the hips. • Support the lower extremities. • Be careful not to overtighten leg straps. Prevention of Tibial Nerve Complications (Loss of Sensation on the Plantar Surface of the Foot) • Place the safety strap above the ankle. • Do not place equipment on lower extremities. • Urge operating room (OR) personnel to avoid leaning on the patient's lower extremities. Prevention of Joint Complications (Stiffness, Pain, Inflammation, Limited Motion) • Place a pillow or foam padding under bony prominences. • Maintain the patient's extremities in good anatomic alignment. • Slightly flex joints and support with pillows, trochanter rolls, or pads. Surgical wound INFECTIONS interfere with recovery, delay wound healing, contribute to rising health care costs, and are a source of nosocomial infections. Respiratory System Complications • Atelectasis • Pneumonia • Pulmonary embolism (PE) • Laryngeal edema • Ventilator dependence • Pulmonary edema Cardiovascular Complications • Hypertension • Hypotension • Hypovolemic shock • Dysrhythmias • Venous thromboembolism (VTE), especially deep vein thrombosis (DVT) • Heart failure • Sepsis • Disseminated intravascular coagulation (DIC) • Anemia • Anaphylaxis Skin Complications • Pressure ulcers • Wound infection • Wound dehiscence • Wound evisceration • Skin rashes or contact allergies Gastrointestinal Complications • Paralytic ileus • Gastrointestinal ulcers and bleeding Neuromuscular Complications • Hypothermia • Hyperthermia • Nerve damage and paralysis • Joint contractures Kidney/Urinary Complications • Urinary tract infection • Acute urinary retention • Electrolyte imbalances • Acute kidney injury (AKI) • Stone formation

Community-Based care - focus on health teaching.

Self-Management Education. Teach the patient to follow the drug regimen exactly as prescribed and always to have a supply on hand. Teach about side effects and ways of reducing them to promote adherence. Remind him or her that the disease is usually no longer contagious after drugs have been taken for 2 to 3 consecutive weeks and clinical improvement is seen; however, he or she must continue with the prescribed drugs for 6 months or longer as prescribed. Directly observed therapy (DOT), in which a health care professional watches the patient 599swallow the drugs, may be indicated in some situations. This practice leads to more treatment successes, fewer relapses, and less drug resistance. The patient who has weight loss and severe lethargy should gradually resume usual activities. Proper nutrition is needed to prevent INFECTION recurrence. To help with concerns about the contagious aspect of the INFECTION, provide the patient with information about TB. A key to preventing transmission is identifying those in close contact with the infected person so that they can be tested and treated if needed. Identified contacts are assessed with a TB test and possibly a chest x-ray to determine infection status. Multidrug therapy may be indicated as a preventive strategy for heavily exposed individuals or for those who have other health problems that reduce the immune response.

Skin preparation for surgery?

Skin assessment is important. Many insurers have denied coverage to hospitals for care provided to patients who develop skin breakdown or pressure ulcers during the perioperative period. Assess the patient's skin for signs of breakdown, open sores, or areas that may be exposed to excessive pressure during the surgical procedure, and document these findings. Communicate this information to the circulating nurse so that precautions can be taken to prevent injury. The skin is the body's first line of defense against INFECTION. A break in this barrier increases the risk for infection, especially for older patients. Skin preparation before surgery is the first step to reduce the risk for surgical site infection (AORN, 2014d). One or two days before the scheduled surgery, the surgeon may ask the patient to shower using an antiseptic solution. Instruct the patient to be especially careful to clean well around the proposed surgical site. If the patient is hospitalized before surgery, showering and cleaning are repeated the night before surgery or in the morning before transfer to the surgical suite. This cleaning reduces contamination of the surgical field and reduces the number of organisms at the site. Remove any soil or debris from the surgical site and surrounding areas. Factors that predispose to wound contamination and surgical site INFECTION (SSI) include bacteria found in hair follicles, disruption of the normal protective mechanisms of the skin, and nicks in the skin. Shaving of hair creates the potential for infection. Hair clipping with electrical clippers and depilatories are to be used for hair removal as required by The Joint Commission's NPSGs (Tanner et al., 2011). This type of skin 229preparation is part of the Surgical Care Improvement Project's (SCIP) core measures for SCIP Inf-6 (see Table 14-1). The Centers for Disease Control and Prevention (CDC) recommends that if shaving is necessary, the hair should be removed using disposable sterile supplies and aseptic principles immediately before the start of the surgical procedure. If needed, shaving is performed in the treatment room, the holding area of the operating suite, or the operating room (OR). Fig. 14-3 shows areas of hair removal for various surgical procedures.

Surgical Care Improvement Project (SCIP) - what is included, who is responsible

Some complications are predictable and are considered preventable or "never events." As a result, The Joint Commission (TJC) has partnered with other groups and agencies and developed a plan for the reduction and eventual elimination of preventable surgical complications known as the Surgical Care Improvement Project (SCIP). Implementation of these core measures is now mandatory for patient safety. The current plan focuses on INFECTION prevention, prevention of serious cardiac events, and prevention of venous thromboembolism (VTE) (also known as deep vein thrombosis [DVT]). Ten specific core measures have been identified as actions required for prevention of these complications in patients identified as at risk. Table 14-1 provides an overview of these core measures areas. (The numbers associated with the core measures are not always chronologic, indicating that some areas are still in development.) The preoperative areas of responsibility for these core measures and their prevention strategies are highlighted in the appropriate areas of this chapter. In addition, some core measures also are discussed in patient care chapters most associated with the complication. In response to the ongoing health care delivery changes and the use of multiple settings, nurses have modified their interventions, remaining focused on patient care before (preoperative), during (intraoperative), and after (postoperative) surgery. Together, these time periods are known as the perioperative experience. SCIP Infection-1 (SCIP Inf-1)Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision The purpose is to use short-duration antibiotics to establish bactericidal blood and tissue levels by the time the surgical incision is made. SCIP Infection-2 (SCIP Inf-2)Prophylactic Antibiotic Selection for Surgical Patients The purpose is to ensure that prophylactic antibiotics are used for patients who are at increased risk for surgical site infections. The guidelines for risk and for the exact antibiotic to be used are specific to each type of surgical procedure and follow evidence-based published recommendations. SCIP Infection-3 (SCIP Inf-3)Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time The purpose is to ensure that prophylactic antibiotic therapy provides benefit without risk. Prolonged prophylactic antibiotic therapy has not been shown to increase benefit and is known to increase the risk for C. difficile infection and the development of microorganisms that are resistant to antimicrobial drugs. SCIP Infection-4 (SCIP Inf-4)Cardiac Surgery Patients with Controlled 6 AM Postoperative Blood Glucose (Applies to cardiac surgery patients only) The purpose is to avoid hyperglycemia (which is defined as blood glucose levels above 200 mg/dL and is associated with increased complications and mortality) in cardiac surgery patients, especially patients undergoing coronary artery bypass graft surgery and patients with diabetes who are having cardiac surgery. SCIP Infection-6 (SCIP Inf-6)Surgery Patients with Appropriate Hair Removal The purpose is to avoid hair removal procedures, specifically shaving, that cause skin abrasions and increase the risk for surgical site infections. If hair must be removed from the surgical site, removal is performed with electric clippers or chemical depilatories. SCIP Infection-9 (SCIP Inf-9)Urinary Catheter Removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with Day of Surgery Being Day Zero The purpose is to avoid urinary catheter-associated urinary tract infections, which increase with longer duration indwelling catheters. It is unacceptable to have an indwelling urinary catheter in place longer than 48 hours after surgery unless there is a documented specific and medically validated reason for it. SCIP Infection-10 (SCIP Inf-10)Surgery Patients with Perioperative Temperature Management The purpose is to prevent prolonged hypothermia, which is associated with impaired wound healing, serious cardiac complications, altered drug metabolism, coagulation problems, and a higher incidence of surgical site infections. Temperature must be measured within 15 minutes from the end of anesthesia administration. Intentional hypothermia must be documented. SCIP CARD-2Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period The purpose is to ensure that patients with specific medical conditions receive beta-blocker therapy before surgery and continue the therapy in the immediate postoperative period. This evidence-based action has resulted in a significant reduction in coronary events, cardiovascular mortality, and overall mortality. SCIP Venous thromboembolism-1 (SCIP VTE-1)Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered The purpose is to reduce the complications from postoperative venous thromboembolism (VTE). Surgery is a major risk factor responsible for VTE formation and subsequent pulmonary embolism. Although VTE prophylaxis is effective, it is underused. Specific preoperative and postoperative VTE prophylaxis strategies are recommended on the basis of patient risk, type and duration of surgery, and extent of expected postoperative immobilization. SCIP Venous thromboembolism-2 (SCIP VTE-2)Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery The purpose is to reduce the complications from postoperative venous thromboembolism (VTE), particularly among patients undergoing the types of surgeries in which the risk is highest.

Laboratory Assessment - know all you need to know about sputum culture and tuberculin test (Mantoux test)

Sputum culture confirms the diagnosis. Enhanced TB cultures and automated mycobacterial cultures require 1 to 4 weeks to determine a positive or negative result. After drugs are started, sputum samples are obtained again to determine therapy effectiveness. Cultures are usually negative after 3 months of effective treatment. The tuberculin test (Mantoux test) is the most commonly used reliable screening test of TB infection. A small amount (0.1 mL) of purified protein derivative (PPD) is placed intradermally in the forearm. An area of induration (localized swelling with hardness of soft tissue), not just redness, measuring 10 mm or greater in diameter 48 to 72 hours after injection indicates exposure to and possible INFECTION with TB (Fig. 31-3). If possible, the site is re-evaluated after 72 hours because the incidence of false-negative readings is greater at 48 hours. A positive reaction does not mean that active disease is present but indicates exposure to TB or the presence of inactive (dormant) disease. A reaction of 5 mm or greater is considered positive in people with HIV infection. A reduced skin reaction or a negative skin test does not rule out TB disease or infection of the very old or anyone who is severely immunocompromised. Failure to have a skin response because of reduced immune function when INFECTION is present is called anergy.

Preventing pneumonia?

Teach patients to avoid crowds, and stress the importance of receiving a pneumonia vaccination and a yearly influenza vaccine. Preventing Pneumonia • Know whether you are at risk for pneumonia (older than 65 years, have a chronic health problem [especially a respiratory problem], or have limited mobility and are confined to a bed or chair during your waking hours). • Have the annual influenza vaccine after discussing appropriate timing of the vaccination with your primary health care provider. • Discuss the pneumococcal vaccine with your primary health care provider, and have the vaccination as recommended. • Avoid crowded public areas during flu and holiday seasons. • If you have a mobility problem, cough, turn, move about as much as possible, and perform deep-breathing exercises. • If you are using respiratory equipment at home, clean the equipment as you have been taught. • Avoid indoor pollutants, such as dust, secondhand (passive) smoke, and aerosols. • If you do not smoke, do not start. • If you smoke, seek professional help on how to stop (or at least decrease) your habit. • Be sure to get enough rest and sleep on a daily basis. • Eat a healthy, balanced diet. • Drink at least 3 liters (quarts) of nonalcoholic fluids each day (unless fluid restrictions are needed because of another health problem).

Patient and family teaching - know the steps to obtain a peak expiratory flow rate.

Teach the patient to assess asthma severity at least daily with a peak flow meter (Fig. 30-4) and to adjust drugs according to his or her personal asthma action plan to manage INFLAMMATION and bronchospasms to prevent or relieve manifestations. Chart 30-4 describes the correct method to use the peak flow meter. The patient first establishes a baseline or "personal best" peak expiratory flow (PEF) by measuring his or her PEF twice daily for 2 to 3 weeks when asthma is well controlled and recording the results. This way, the patient will know when his or her peak flow is reduced to the point that more drugs are needed or that 553emergency assistance is needed. When the patient has established a "personal best," all other readings are compared with this value. Some meters are color-coded to help the patient interpret the results. Green zone readings are at least 80% of or above the "personal best." This is the ideal range for asthma control and indicates that no increases in drug therapy are needed. Yellow is a range between 50% and 80% of personal best. When a patient has a reading in this range, he or she needs to use the prescribed reliever drug. Within a few minutes after using the reliever drug, another PEF reading should be made to determine whether the reliever drug is working. Frequent readings in the yellow zone or increasing use of reliever drugs indicates the need to reassess the asthma plan for the need to change controller drugs. Red is a range below 50% of the patient's personal best, indicating serious respiratory obstruction. Using a Peak Flow Meter • Set the peak flowmeter at zero. • Use a standing position, without leaning or supporting yourself on anything, if possible. • Take as deep a breath as you can. • Place the mouthpiece of the meter in your mouth, taking care to wrap your lips tightly around it. • Blow your breath out through the mouthpiece as hard and as fast as you are able. (If you cough, sneeze, or have any type of interruption while you exhale, reset the meter and perform the test again.) • Reset and perform the test two additional times. • The highest reading of the three is your current peak flow rate. • Keep a record or graph of your peak flow rates and examine these for trends.

Universal Precations/Time Out procedure

The Joint Commission (TJC) has developed a Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery, and the Association of periOperative Registered Nurses has developed recommendations based on this protocol (AORN, 2014r). The nurse asks the patient about any allergies and determines whether autologous blood was donated. A special allergy bracelet on the patient's wrist and the medical record must be verified with what has been communicated. Surgical procedures that are site-specific, such as left, right, or bilateral, require patient identification before surgery. As required by The Joint Commission's NPSGs, to ensure the correct site is selected and the wrong site is avoided, the site is marked by a licensed independent practitioner and, whenever possible, involves the patient. The surgeon is accountable and should be present during the procedure. The nurse is an important part of this safety measure. Before starting the operative procedure, facilities use a "time-out" procedure to verify the correct site, patient, and procedure. The perioperative nurse is in a position of ensuring these safety measures are implemented immediately before the procedure is started (Association of periOperative Registered Nurses [AORN], 2014c). The "time-out" involves the participation of all members of the procedure team including the surgeon, anesthesia provider, circulating nurse, scrub person, and any other active participants

Skin assessment - complications of surgical incision healing and appropriate nursing care when suspect infection or excessive bleeding

The patient is expected to have an uninfected surgical wound or wounds. Indicators include: • Wound edges are closed and not excessively red or swollen • Wound is free from purulent drainage • White blood cell counts remain at expected levels after surgery • Patient is afebrile Assess the risk for INFECTION by identifying patients with health problems such as diabetes mellitus, immunodeficiency, obesity, and kidney disease. The nurse performs the prescribed skin preparation, protects against cross-contamination, keeps traffic to a minimum, and administers prescribed antimicrobial prophylaxis. Surgery increases risk for wound complications (e.g., incisional tears, lacerations), infection, and loss of body fluids. Sterile surgical technique and the use of protective drapes, skin closures, and dressings reduce complications and promote wound healing. When a wound is already infected or is at high risk for infection, antibiotics may be used directly in the wound before wound closure. A pressure dressing may be applied to prevent poor CLOTTING and bleeding. One or more drains (see Chapter 16) may be inserted to remove secretions and fluids around the surgical area. These secretions, if not drained, slow healing and promote bacterial growth, which could result in wound INFECTION The clean surgical wound regains TISSUE INTEGRITY (heals) at skin level in about 2 weeks in the absence of trauma, connective tissue disease, malnutrition, or the use of some drugs, such as steroids. Smokers and patients who are older, obese, or have diabetes or whose immunity is reduced have delayed wound healing. Complete tissue integrity (healing) of all layers within the surgical wound may take 6 months to 2 years. The physical health and age of the patient, size and 264location of the wound, and stress on the wound all affect healing time. Head and facial wounds heal more quickly than abdominal and leg wounds because of the better blood flow to the head and neck. Normal Wound Healing. During the first few days of normal wound healing, the incised tissue regains blood supply and begins to bind together. Fibrin and a thin layer of epithelial cells seal the incision. After 1 to 4 days, epithelial cells continue growing in the fibrin and strands of collagen begin to fill in the wound gaps. This process continues for 2 to 3 weeks. At that time, TISSUE INTEGRITY appears regained; however, healing is not complete for up to 2 years, until the scar is strengthened Assess the TISSUE INTEGRITY of the incision on a regular basis, at least every 8 hours, for redness, increased warmth, swelling, tenderness or PAIN, and the type and amount of drainage. Some drainage, changing from sanguineous (bloody) to serosanguineous to serous (serum-like, or yellow), is normal during the first few days. Serosanguineous drainage continuing beyond the fifth day after surgery or increasing in amount instead of decreasing alerts you to the possibility of dehiscence (discussed below), and the surgeon should be notified. Crusting on the incision line is normal, as is a pink color to the line itself, which is caused by inflammation from the surgical procedure. Slight swelling under the sutures or staples is also normal. Redness or swelling of or around the incision line, excessive tenderness or pain on palpation, and purulent or odorous drainage indicate wound INFECTION and must be reported to the surgeon. Impaired Wound Healing. Impaired wound healing with loss of TISSUE INTEGRITY may be caused by INFECTION, distention, stress at the surgical site, and health problems that cause delayed wound healing (e.g., diabetes). Wound dehiscence is a partial or complete separation of the outer wound layers, sometimes described as a "splitting open of the wound." Evisceration is the total separation of all wound layers and protrusion of internal organs through the open wound (Fig. 16-2). Both of these problems occur most often between the fifth and tenth days after surgery. Wound separation occurs more often in obese patients and those with diabetes, immune deficiency, or malnutrition or who are using steroids. Dehiscence or evisceration may follow forceful coughing, vomiting, or straining and when not splinting the surgical site during movement. The patient may state, "Something popped" or "I feel as if I just split open." Large amounts of sanguineous drainage may indicate poor CLOTTING and possible internal bleeding

Physical assessment findings - symptoms commonly associated with asthma.

The patient with mild to moderate asthma may have no manifestations between asthma attacks. During an acute episode, common manifestations are an audible wheeze and increased respiratory rate. At first, the wheeze is louder on exhalation. When INFLAMMATION occurs with asthma, coughing may increase. The patient may use accessory muscles to help breathe during an attack. Observe for muscle retraction at the sternum and the suprasternal notch and between the ribs. The patient with long-standing, severe asthma may have a "barrel chest," caused by air trapping (Fig. 30-3). The anteroposterior (AP) diameter (diameter between the front and the back of the chest) 552increases with air trapping, giving the chest a rounded rather than an oval shape. The normal chest is about 1.5 times as wide as it is deep. In severe, chronic asthma, the AP diameter may equal or exceed the lateral diameter. Compare the AP diameter of the chest with the lateral diameter. Chronic air trapping also flattens the diaphragm and increases the space between the ribs. Along with an audible wheeze, the breathing cycle is longer with prolonged exhalation and requires more effort. The patient may be unable to speak more than a few words between breaths. Hypoxia occurs with severe attacks. Pulse oximetry shows hypoxemia (poor blood oxygen levels). Examine the oral mucosa and nail beds for cyanosis. Other indicators of hypoxemia include changes in the level of cognition or consciousness and tachycardia. The most accurate tests for measuring airflow in asthma are the pulmonary function tests (PFTs) using spirometry (O'Laughlen & Rance, 2012). Baseline PFTs are obtained for all patients diagnosed with asthma. The most important PFTs for a patient with asthma are the forced vital capacity (FVC), the forced expiratory volume in the first second (FEV1), and the peak expiratory flow (PEF), sometimes called peak expiratory rate flow (PERF). Definitions of PFTs are listed in Chapter 27. A decrease in either the FEV1 or the PEF (PERF) of 15% to 20% below the expected value for age, gender, and size is common for the patient with asthma. Asthma is diagnosed when these values increase by 12% or more after treatment with bronchodilators. Airway responsiveness is tested by measuring the PEF and FEV1 before and after the patient inhales the drug methacholine, which induces bronchospasm in susceptible people. The patient with mild to moderate asthma may have no manifestations between asthma attacks. During an acute episode, common manifestations are an audible wheeze and increased respiratory rate. At first, the wheeze is louder on exhalation. When INFLAMMATION occurs with asthma, coughing may increase. The patient may use accessory muscles to help breathe during an attack. Observe for muscle retraction at the sternum and the suprasternal notch and between the ribs. The patient with long-standing, severe asthma may have a "barrel chest," caused by air trapping (Fig. 30-3). The anteroposterior (AP) diameter (diameter between the front and the back of the chest) 552increases with air trapping, giving the chest a rounded rather than an oval shape. The normal chest is about 1.5 times as wide as it is deep. In severe, chronic asthma, the AP diameter may equal or exceed the lateral diameter. Compare the AP diameter of the chest with the lateral diameter. Chronic air trapping also flattens the diaphragm and increases the space between the ribs. Along with an audible wheeze, the breathing cycle is longer with prolonged exhalation and requires more effort. The patient may be unable to speak more than a few words between breaths. Hypoxia occurs with severe attacks. Pulse oximetry shows hypoxemia (poor blood oxygen levels). Examine the oral mucosa and nail beds for cyanosis. Other indicators of hypoxemia include changes in the level of cognition or consciousness and tachycardia.

Informed consent - know all you need to know about informed consent (purpose, role of nurses and surgeon).

The patient's readiness for surgery is critical to the outcome. Preoperative care focuses on preparing the patient for the surgery and ensuring patient safety. This care includes education and any intervention needed before surgery to reduce anxiety and complications and to promote patient cooperation in procedures after surgery. Use adult teaching and learning principles in teaching patients and families before surgery. Validate, clarify, and reinforce information the patient has received from the surgeon or other members of the surgical team. In addition, during the nursing assessment before surgery, problems may be identified that warrant further patient assessment or intervention before the procedure. As required by The Joint Commission's National Patient Safety Goals (NPSGs), communication and collaboration with the surgical team are essential so that correct actions are taken to achieve the desired outcome. The patient needs to know what to expect during and after surgery and participate in his or her recovery as indicated by consistently demonstrating these behaviors: • Explaining in his or her own words the purpose and expected results of the planned surgery • Asking questions when a term or procedure is not known • Adhering to the NPO requirements • Stating an understanding of preoperative preparations (e.g., skin preparation, bowel preparation) • Demonstrating correct use of exercises and techniques to be used after surgery for the prevention of complications (e.g., splinting the incision, using an incentive spirometer, performing leg exercises, ambulating as early as permitted) Consent implies that the patient has sufficient information to understand: • The nature of and reason for surgery • Who will be performing the surgery and whether others will be present during the procedure (e.g., students) • All available options and the risks associated with each option • The risks associated with the surgical procedure and its potential outcomes • The risks associated with the use of anesthesia The surgeon is responsible for having the consent form signed before sedation is given and before surgery is performed. You, as a nurse, are not responsible for providing detailed information about the surgical procedure. Rather, your role is to clarify facts that have been presented by the surgeon and dispel myths that the patient or family may have about the surgical experience. You verify that the consent form is signed, and you serve as a witness to the signature, not to the fact that the patient is informed

Pre-Op Assessment - client with medical history, allergies, cardio/pulmonry history, musculoskeletal status, etc.

The preoperative period begins when the patient is scheduled for surgery and ends at the time of transfer to the surgical suite. As a nurse, you will function as an educator, an advocate, and a promoter of health. As part of the cardiopulmonary assessment, take and record vital signs; report: ▪ Hypotension or hypertension ▪ Heart rate less than 60 or more than 120 beats/min ▪ Irregular heart rate ▪ Chest pain ▪ Shortness of breath or dyspnea ▪ Tachypnea ▪ Pulse oximetry reading of less than 94% 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 to be evaluated by a physician or advanced practice nurse before proceeding with the surgical plans, including: ▪ Change in mental status ▪ Vomiting ▪ Rash ▪ Recent administration of an anticoagulant drug Data collection about the patient before surgery begins in various settings (e.g., the surgeon's office, the preadmission or admission office, the inpatient unit, the telephone, the Internet). Use privacy to increase the patient's comfort with the interview process. Anesthesia and surgery are both physical and emotional stressors. Collect these data: • Age • Use of tobacco, alcohol, or illicit substances, including marijuana • Current drugs • Use of complementary or alternative practices, such as herbal therapies, folk remedies, or acupuncture • Medical history • Prior surgical procedures and how these were tolerated • Prior experience with anesthesia, pain control, and management of nausea or vomiting • Autologous or directed blood donations • Allergies, including sensitivity to latex products • General health • Family history • Type of surgery planned • Knowledge about and understanding of events during the perioperative period • Adequacy of the patient's support system Drugs and substance use may affect patient responses to surgery. Tobacco use increases the risk for pulmonary complications because of changes to the lungs, blood vessels, and chest cavity. Alcohol and illicit substance use can alter the patient's responses to anesthesia and pain medication. Withdrawal of alcohol before surgery may lead to delirium tremens. Prescription and over-the-counter drugs may also affect how the patient reacts to the operative experience. Adverse effects can occur with the use of some herbs. Thus asking about and documenting past and current use of herbs or botanicals are important. Medical history is important to obtain because many chronic illnesses increase surgical risks and need to be considered when planning care. For example, a patient with systemic lupus erythematosus may need additional drugs to offset the stress of the surgery. A patient with diabetes may need a more extensive bowel preparation because of decreased intestinal motility. An INFECTION may need to be treated before surgery. Ask the patient specifically about cardiac problems because complications from anesthesia occur more often in patients with cardiac problems (Johnson, 2011). A patient with a history of rheumatic heart disease may be prescribed antibiotics before surgery. Cardiac problems that increase surgical risks include coronary artery disease, angina, myocardial infarction (MI) within 6 months before surgery, heart failure, hypertension, and dysrhythmias. These problems impair the patient's ability to withstand hemodynamic changes and alter the response to anesthesia. The risk for an MI during surgery is higher in patients who have heart problems. Patients with cardiac disease may require perioperative therapy with beta-blocking drugs, as recommended by core measures for SCIP CARD-2 (see Table 14-1). Pulmonary complications during or after surgery are more likely to occur in older patients, those with chronic respiratory 220problems, and smokers because of smoking- or age-related lung changes (Doerflinger, 2009). Increased chest rigidity and loss of lung elasticity reduce anesthetic excretion. Smoking increases the blood level of carboxyhemoglobin (carbon monoxide on oxygen-binding sites of the hemoglobin molecule), which decreases oxygen delivery to organs. Action of cilia in pulmonary mucous membranes decreases, which leads to retained secretions and predisposes the patient to INFECTION (pneumonia) and atelectasis (collapse of alveoli). Atelectasis reduces gas exchange and causes intolerance of anesthesia. It is also a common problem after general anesthesia. Chronic lung problems such as asthma, emphysema, and chronic bronchitis also reduce the elasticity of the lungs, which reduces gas exchange. As a result, patients with these problems have reduced tissue oxygenation. Previous surgical procedures and anesthesia affect the patient's readiness for surgery. Previous experiences, especially with complications, may increase anxiety about the scheduled surgery. Ask about the patient's experience with anesthesia and all allergies. These data provide information about tolerance of and possible fears about the use of anesthesia. The family medical history and problems with anesthetics may indicate possible reactions to anesthesia, such as malignant hyperthermia (see Chapter 15). An allergy to certain substances alerts you to a possible reaction to anesthetic agents or to substances that are used before or during surgery. For example, povidone-iodine (e.g., Betadine) used for skin cleansing contains the same allergens found in shellfish. Patients who are allergic to shellfish may have an adverse reaction to povidone-iodine. The patient with an allergy to avocados, bananas, strawberries, and other fruits may also have a latex sensitivity or allergy. Patients who have an egg, peanut, or soy allergy may have a reaction to propofol (Diprivan), which is an anesthetic agent often used in the induction and maintenance of anesthesia (MDConsult, 2012). Blood donation for surgery can be made by the patient (autologous donations) a few weeks just before the scheduled surgery date. Then, if blood is needed during or after surgery, an autologous blood transfusion can be given. This practice eliminates transfusion reactions and reduces the risk for acquiring bloodborne disease. Specific patient criteria, which may vary by surgical type and patient health problem, must be met to qualify for autologous transfusion. Discharge planning is started before surgery. Assess the patient's home environment, self-care capabilities, and support systems and anticipate postoperative needs before surgery. All patients, regardless of how minor the procedure or how often they have had surgery, should have discharge planning. The preoperative patient may be any age, with a health status that varies from well to debilitated. Perform a complete assessment before surgery to obtain baseline data. Use this information to identify current health problems, potential complications related to anesthesia, and risk for complications that may occur after surgery. Begin the assessment by obtaining a complete set of vital signs. You may need to obtain vital signs several times at different time intervals for accurate baseline values. Also assess for anxiety, which could increase blood pressure, pulse, and respiratory rate. Document these findings as part of the overall assessment. The number of serious problems (morbidity) and death (mortality) during or after surgery is higher in older and chronically ill patients Cardiovascular status is critical to assess because cardiac problems are associated with many surgery-related deaths. Check the patient for hypertension, which is common, is often undiagnosed, and can affect the response to surgery. Cardiac assessment includes listening to heart sounds for rate, regularity, and abnormalities. Ask whether the patient has ever had a venous thromboembolism (VTE). Examine the patient's hands and feet for temperature, color, peripheral pulses, capillary refill, and edema. Report any problems (e.g., absent peripheral pulses, pitting edema, cardiac manifestations, chest pain, shortness of breath, and dyspnea) to the surgeon for further assessment and evaluation. Respiratory status considers age, smoking history (including exposure to secondhand smoke), and any chronic illness (Doerflinger, 2009). Obese patients may have undiagnosed respiratory problems such as obstructive sleep apnea (OSA), which can lead to complications from anesthesia (Graham et al., 2011). Observe the patient's posture; respiratory rate, rhythm, and depth; overall respiratory effort; and lung expansion. Document any clubbing of the fingertips (swelling at the base of the nail beds caused by a chronic lack of oxygen) or cyanosis. Auscultate the lungs to assess for any abnormal breath sounds (crackles, wheezes, rubs). Kidney function affects the excretion of drugs and waste products, including anesthetic and analgesic agents. If kidney function is reduced, fluid and electrolyte balance can be altered, 222especially in older patients. Ask about problems such as urinary frequency, dysuria (painful urination), nocturia (awakening during nighttime sleep because of a need to void), difficulty starting urine flow, and oliguria (scant amount of urine). Ask the patient about the appearance and odor of the urine. Assess the patient's usual fluid intake and degree of continence. If the patient has kidney or urinary problems, consult with the physician about further workup. Kidney impairment decreases the excretion of drugs and anesthetic agents. As a result, drug responses may be prolonged. Scopolamine (Buscopan image), morphine, other opioids, benzodiazepines, and barbiturates often cause confusion, disorientation, apprehension, and restlessness when given to patients with decreased kidney function. Neurologic status includes the patient's overall mental status, level of consciousness, orientation, and ability to follow commands. This information is needed before planning preoperative teaching and care after surgery. A problem in any of these areas affects the type of care needed during the surgical experience. Determine the patient's baseline neurologic status to be able to identify changes that may occur later. Also assess for any motor or sensory deficits. Musculoskeletal status problems may interfere with positioning during and after surgery. For example, patients with arthritis may be able to assume surgical positions but have discomfort after surgery from prolonged joint immobilization. Other anatomic features, such as the shape and length of the neck and the shape of the chest cavity, may interfere with respiratory and cardiac function or require special positioning during surgery. Nutrition status, especially malnutrition and obesity, can increase surgical risk. Surgery increases metabolic rate and depletes potassium, vitamin C, and B vitamins, all of which are needed for wound healing and blood clotting. In poorly nourished patients, decreased serum protein levels slow recovery. Negative nitrogen balance may result from depleted protein stores. This problem increases the risk for skin breakdown, delayed wound healing, possible dehiscence or evisceration (see Chapter 16), dehydration, and sepsis. Indications of poor fluid or nutrition status include: • Brittle nails • Muscle wasting • Dry or flaky skin, decreased skin turgor, and hair changes (e.g., dull, sparse, dry) • Orthostatic (postural) hypotension • Decreased serum protein levels and abnormal serum electrolyte values The obese patient is often malnourished because of an imbalanced diet. Obesity increases the risk for poor wound healing because of excessive adipose (fatty) tissue. Fatty tissue has few blood vessels, little collagen, and decreased nutrients, all of which are needed for wound healing. Obesity stresses the heart and reduces the lung volumes, which can affect the surgery and recovery. Obese patients may need larger drug doses and may retain them longer after surgery.

TB - Assessment - clinical manifestations

Tuberculosis (TB) is a highly communicable disease caused by Mycobacterium tuberculosis. It is one of the most common bacterial INFECTIONS worldwide (CDC, 2014c). The organism is transmitted via aerosolization (i.e., an airborne route) (Fig. 31-2). When a person with active TB coughs, laughs, sneezes, whistles, or sings, droplets are airborne and may be inhaled by others. Far more people are infected with the bacillus than actually develop active TB. Physical Assessment/Clinical Manifestations. The patient with TB has progressive fatigue, lethargy, nausea, anorexia, weight loss, irregular menses, and a low-grade fever. Manifestations may have been present for weeks or months. Night sweats may occur with the fever. A cough with mucopurulent sputum, which may be streaked with blood, is present. Chest tightness and a dull, aching chest pain occur with the cough. Ask about, assess for, and document the presence of any of these manifestations to help with diagnosis, to establish a baseline, and to plan nursing interventions. Chest examination does not provide conclusive evidence of TB. Dullness with percussion may be heard over the involved lung fields, as may bronchial breath sounds, crackles, and increased transmission of spoken or whispered sounds. Partial obstruction of a bronchus from the disease or compression by lymph nodes may produce localized wheezing.

Complications from benzocaine spray

number) before a bronchoscopy. Benzocaine spray as a topical anesthetic to numb the oropharynx is used cautiously, if at all. This agent may induce a condition called methemoglobinemia, which is the conversion of normal hemoglobin to methemoglobin (Wesley, 2014). Methemoglobin is an altered iron state that does not carry oxygen, resulting in tissue hypoxia. Other topical anesthetic sprays, such as lidocaine, appear less likely to induce this problem. The normal blood level of methemoglobin is less than 1%. When this level increases, tissue GAS EXCHANGE is reduced. Cyanosis occurs with methemoglobin levels between 10% and 20%, and death can occur when levels reach 50% to 70%. Suspect methemoglobinemia if a patient becomes cyanotic after receiving a topical anesthetic, if he or she does not respond to supplemental oxygen, and if blood is a characteristic chocolate-brown in color. It can be reversed with oxygen and IV injection of 1% methylene blue (1 to 2 mg/kg).